MetroPlus Health Plan Formulary. (Prescription Drug Guide)

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2 MetroPlus Health Plan 2018 Formulary (Prescription Drug Guide) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on July 1. For more recent information or other questions, please contact MetroPlus Health Plan Member Services, at (TTY: 711), 8am-8pm, Monday-Saturday, or visit Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. This document includes list of the drugs for our plan. For an updated formulary, please contact us. You must use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2019, and from time to time during the year. What is the MetroPlus Health Plan Formulary? A formulary is a list of covered drugs selected by MetroPlus Health Plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. MetroPlus Health Plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a MetroPlus network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Certificate of Coverage. Can the Formulary change? Generally, if you are taking a drug on our formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued I

3 access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. To get updated information about the drugs covered by MetroPlus Health Plan, please contact us. Our contact information appears on the front and back cover pages. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular. If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 110. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. II

4 MetroPlus Formulary The formulary that begins on the next page provides coverage information about the drugs covered by MetroPlus Health Plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 110. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., DURAMORPH)) and generic drugs are listed in lower-case italics (e.g., endocet). The information in the Requirements/Limits column tells you if MetroPlus Health Plan has any special requirements for coverage of your drug. : MetroPlus requires your physician to get prior authorization for certain drugs. This means you will need to get approval from MetroPlus before you fill your prescriptions. If you don t get approval, MetroPlus may not cover the drug. ST: In some cases, MetroPlus 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, MetroPlus may not cover Drug B unless you try Drug A first. If Drug A does not work for you, MetroPlus will then cover Drug B. **: If you do not go through the step therapy process, prior authorization is required for this drug. QL: For certain drugs, MetroPlus limits the amount of the drug that MetroPlus will cover. For example, MetroPlus provides one unit per day per prescription for pantoprazole. This may be in addition to a standard one month or three month supply. OTC: This drug is not available over the counter. III

5 EXCH_CVSC 3T NY4 STND eff 07/01/2018 Drug Name ANALGESICS COX-2 INHIBITORS celecoxib cap 50 1 celecoxib cap celecoxib cap celecoxib cap GOUT allopurinol tab allopurinol tab colchicine tab colchicine w/ probenecid tab probenecid tab ULORIC TAB 40MG 3 ST; ** ULORIC TAB 80MG 3 ST; ** NON-OPIOID ANALGESICS butalbital-acetaminophen-caffeine cap 50-1 QL (48 caps / 25 days) butalbital-acetaminophen-caffeine cap 50-1 QL (48 caps / 25 days) butalbital-acetaminophen-caffeine tab 50-1 QL (48 tabs / 25 days) butalbital-aspirin-caffeine cap QL (48 caps / 25 days) margesic cap 1 QL (48 caps / 25 days) tencon tab QL (48 tabs / 25 days) NSAIDS, COMBINATIONS diclofenac w/ misoprostol tab delayed 1 release diclofenac w/ misoprostol tab delayed 1 release NSAIDS diclofenac potassium tab 50 1 diclofenac sodium tab delayed release 25 1 diclofenac sodium tab delayed release 50 1 diclofenac sodium tab delayed release 75 1 diclofenac sodium tab er 24hr etodolac cap etodolac cap etodolac tab etodolac tab Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 1

6 etodolac tab er 24hr etodolac tab er 24hr etodolac tab er 24hr fenoprofen calcium cap fenoprofen calcium tab flurbiprofen tab 50 1 flurbiprofen tab ibuprofen susp 100 /5ml 1 ibuprofen tab ibuprofen tab ibuprofen tab ketoprofen cap 50 1 ketoprofen cap 75 1 ketoprofen cap er 24hr ketorolac tromethamine im inj 60 /2ml 1 (30 /ml) ketorolac tromethamine inj 15 /ml 1 ketorolac tromethamine inj 30 /ml 1 ketorolac tromethamine tab 10 1 QL (20 tabs / 25 days) meclofenamate sodium cap 50 1 meclofenamate sodium cap mefenamic acid cap meloxicam susp 7.5 /5ml 1 meloxicam tab meloxicam tab 15 1 nabumetone tab nabumetone tab naproxen dr tab naproxen dr tab naproxen sodium tab naproxen sodium tab naproxen susp 125 /5ml 1 naproxen tab naproxen tab naproxen tab oxaprozin tab piroxicam cap 10 1 piroxicam cap 20 1 sulindac tab sulindac tab tolmetin sodium cap tolmetin sodium tab tolmetin sodium tab OPIOID AGONIST/ANTAGONIST buprenorphine hcl-naloxone hcl sl tab (base equiv) 1 QL (90 tabs / 25 days) - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 2

7 buprenorphine hcl-naloxone hcl sl tab QL (90 tabs / 25 days) (base equiv) SUBOXONE MIS 2-0.5MG 2 QL (90 units / 25 days) SUBOXONE MIS 4-1MG 2 QL (90 units / 25 days) SUBOXONE MIS 8-2MG 2 QL (90 units / 25 days) SUBOXONE MIS 12-3MG 2 QL (60 units / 25 days) ZUBSOLV SUB QL (90 units / 25 days) ZUBSOLV SUB QL (90 units / 25 days) ZUBSOLV SUB QL (90 units / 25 days) ZUBSOLV SUB QL (90 units / 25 days) ZUBSOLV SUB QL (60 units / 25 days) ZUBSOLV SUB QL (30 units / 25 days) OPIOID ANALGESICS acetaminophen w/ codeine soln /5ml acetaminophen w/ codeine tab acetaminophen w/ codeine tab acetaminophen w/ codeine tab QL (2700 ml / 25 days), ST; Subject to initial 7- day limit QL (400 tabs / 25 days), ST; Subject to initial 7- day limit QL (360 tabs / 25 days), ST; Subject to initial 7- day limit QL (180 tabs / 25 days), ST; Subject to initial 7- day limit 1 QL (48 caps / 25 days) butalbital-acetaminophen-caff w/ cod cap butorphanol tartrate nasal soln 10 /ml 1 QL (2 bottles / 25 days) CAPITAL/COD SUS /5 3 QL (2700 ml / 25 days), ST; Subject to initial 7- day limit codeine sulfate tab 15 1 QL (42 tabs / 25 days), ST; Subject to initial 7- day limit codeine sulfate tab 30 1 QL (42 tabs / 25 days), ST; Subject to initial 7- day limit codeine sulfate tab 60 1 QL (42 tabs / 25 days), ST; Subject to initial 7- day limit EMBEDA CAP MG 3 QL (60 caps / 25 days), ST EMBEDA CAP MG 3 QL (60 caps / 25 days), ST EMBEDA CAP 50-2MG 3 QL (30 caps / 25 days), ST EMBEDA CAP MG 3 QL (30 caps / 25 days), ST - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 3

8 EMBEDA CAP MG 3 QL (30 caps / 25 days), ST EMBEDA CAP 100-4MG 3, ST; High Strength Requires endocet tab QL (360 tabs / 25 days), ST; Subject to initial 7- day limit endocet tab QL (360 tabs / 25 days), ST; Subject to initial 7- day limit endocet tab QL (240 tabs / 25 days), ST; Subject to initial 7- day limit endocet tab QL (180 tabs / 25 days), ST; Subject to initial 7- day limit fentanyl citrate lozenge on a handle 200 mcg 1 QL (120 lozenges / 25 days), fentanyl citrate lozenge on a handle 400 mcg 1 QL (120 lozenges / 25 days), fentanyl citrate lozenge on a handle 600 mcg 1 QL (120 lozenges / 25 days), fentanyl citrate lozenge on a handle 800 mcg 1 QL (120 lozenges / 25 days), fentanyl citrate lozenge on a handle 1200 mcg 1 QL (120 lozenges / 25 days), fentanyl citrate lozenge on a handle 1600 mcg 1 QL (120 lozenges / 25 days), fentanyl td patch 72hr 12 mcg/hr 1 QL (10 patches / 25 days), ST fentanyl td patch 72hr 25 mcg/hr 1 QL (10 patches / 25 days), ST fentanyl td patch 72hr 50 mcg/hr 1, ST; High Strength Requires fentanyl td patch 72hr 75 mcg/hr 1, ST; High Strength Requires fentanyl td patch 72hr 100 mcg/hr 1, ST; High Strength Requires hydrocodone-acetaminophen soln QL (2700 ml / 25 days), /15ml ST; Subject to initial 7- day limit hydrocodone-acetaminophen soln /15ml hydrocodone-acetaminophen tab QL (2700 ml / 25 days), ST; Subject to initial 7- day limit 1 QL (360 tabs / 25 days), ST; Subject to initial 7- day limit - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 4

9 hydrocodone-acetaminophen tab QL (240 tabs / 25 days), ST; Subject to initial 7- day limit hydrocodone-acetaminophen tab QL (180 tabs / 25 days), ST; Subject to initial 7- day limit hydrocodone-acetaminophen tab QL (180 tabs / 25 days), ST; Subject to initial 7- day limit HYDROMORPHON SUP 3MG 3 QL (120 suppositories / 25 days), ST; Subject to initial 7-day limit hydromorphone hcl liqd 1 /ml 1 QL (600 ml / 25 days), ST; Subject to initial 7- day limit hydromorphone hcl tab 2 1 QL (180 tabs / 25 days), ST; Subject to initial 7- day limit hydromorphone hcl tab 4 1 QL (150 tabs / 25 days), ST; Subject to initial 7- day limit hydromorphone hcl tab 8 1 QL (60 tabs / 25 days), ST; Subject to initial 7- day limit hydromorphone hcl tab er 24hr deter 8 1 QL (30 tabs / 25 days), ST hydromorphone hcl tab er 24hr deter 12 1 QL (30 tabs / 25 days), ST hydromorphone hcl tab er 24hr deter 16 1 QL (30 tabs / 25 days), ST hydromorphone hcl tab er 24hr deter 32 1, ST; High Strength Requires HYSINGLA ER TAB 20 MG 2 QL (30 tabs / 25 days), ST HYSINGLA ER TAB 30 MG 2 QL (30 tabs / 25 days), ST HYSINGLA ER TAB 40 MG 2 QL (30 tabs / 25 days), ST HYSINGLA ER TAB 60 MG 2 QL (30 tabs / 25 days), ST HYSINGLA ER TAB 80 MG 2 QL (30 tabs / 25 days), ST HYSINGLA ER TAB 100 MG 2, ST; High Strength Requires HYSINGLA ER TAB 120 MG 2, ST; High Strength Requires - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 5

10 levorphanol tartrate tab 2 1 QL (120 tabs / 25 days), ST; Subject to initial 7- day limit lortab tab QL (180 tabs / 25 days), ST; Subject to initial 7- day limit methadone con 10/ml 1 QL (60 ml / 25 days), ST; (generic of Methadone Intensol, indicated for pain) methadone hcl conc 10 /ml 1 QL (30 ml / 25 days); (indicated for opioid addiction) methadone hcl soln 5 /5ml 1 QL (450 ml / 25 days), ST methadone hcl soln 10 /5ml 1 QL (300 ml / 25 days), ST methadone hcl tab 5 1 QL (90 tabs / 25 days), ST methadone hcl tab 10 1 QL (60 tabs / 25 days), ST methadone hcl tab for oral susp 40 1 QL (9 tabs / 25 days) methadose tab 40 1 QL (9 tabs / 25 days) MORPHINE SUL SUP 30MG 2 QL (90 supp / 25 days), ST; Subject to initial 7- day limit morphine sulfate beads cap er 24hr 30 1 QL (30 caps / 25 days), ST morphine sulfate beads cap er 24hr 45 1 QL (30 caps / 25 days), ST morphine sulfate beads cap er 24hr 60 1 QL (30 caps / 25 days), ST morphine sulfate beads cap er 24hr 75 1 QL (30 caps / 25 days), ST morphine sulfate beads cap er 24hr 90 1 QL (30 caps / 25 days), ST morphine sulfate beads cap er 24hr 120 1, ST; High Strength Requires morphine sulfate cap er 24hr 10 1 QL (60 caps / 25 days), ST morphine sulfate cap er 24hr 20 1 QL (60 caps / 25 days), ST morphine sulfate cap er 24hr 30 1 QL (60 caps / 25 days), ST morphine sulfate cap er 24hr 50 1 QL (30 caps / 25 days), ST morphine sulfate cap er 24hr 60 1 QL (30 caps / 25 days), ST - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 6

11 morphine sulfate cap er 24hr 80 1 QL (30 caps / 25 days), ST morphine sulfate cap er 24hr 100 1, ST; High Strength Requires morphine sulfate oral soln 10 /5ml 1 QL (900 ml / 25 days), ST; Subject to initial 7- day limit morphine sulfate oral soln 20 /5ml 1 QL (675 ml / 25 days), ST; Subject to initial 7- day limit morphine sulfate oral soln 100 /5ml (20 1 QL (135 ml / 25 days), /ml) ST; Subject to initial 7- day limit morphine sulfate suppos 5 1 QL (180 suppositories / 25 days), ST; Subject to initial 7-day limit morphine sulfate suppos 10 1 QL (180 suppositories / 25 days), ST; Subject to initial 7-day limit morphine sulfate suppos 20 1 QL (120 supp / 25 days), ST; Subject to initial 7-day limit morphine sulfate tab 15 1 QL (180 tabs / 25 days), ST; Subject to initial 7- day limit morphine sulfate tab 30 1 QL (90 tabs / 25 days), ST; Subject to initial 7- day limit morphine sulfate tab er 15 1 QL (90 tabs / 25 days), ST morphine sulfate tab er 30 1 QL (90 tabs / 25 days), ST morphine sulfate tab er 60 1, ST; High Strength Requires morphine sulfate tab er 100 1, ST; High Strength Requires morphine sulfate tab er 200 1, ST; High Strength Requires nalbuphine hcl inj 10 /ml 1 nalbuphine hcl inj 20 /ml 1 NUCYNTA ER TAB 50MG 2 QL (60 tabs / 25 days), ST NUCYNTA ER TAB 100MG 2 QL (60 tabs / 25 days), ST NUCYNTA ER TAB 150MG 2, ST; High Strength Requires NUCYNTA ER TAB 200MG 2, ST; High Strength Requires - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 7

12 NUCYNTA ER TAB 250MG 2, ST; High Strength Requires NUCYNTA TAB 50MG 2 QL (120 tabs / 25 days), ST; Subject to initial 7- day limit NUCYNTA TAB 75MG 2 QL (90 tabs / 25 days), ST; Subject to initial 7- day limit NUCYNTA TAB 100MG 2 QL (60 tabs / 25 days), ST; Subject to initial 7- day limit oxycodone hcl cap 5 1 QL (180 caps / 25 days), ST; Subject to initial 7-day limit oxycodone hcl conc 100 /5ml (20 /ml) 1 QL (90 ml / 25 days), ST; Subject to initial 7- day limit oxycodone hcl soln 5 /5ml 1 QL (900 ml / 25 days), ST; Subject to initial 7- day limit oxycodone hcl tab 5 1 QL (180 tabs / 25 days), ST; Subject to initial 7- day limit oxycodone hcl tab 10 1 QL (180 tabs / 25 days), ST; Subject to initial 7- day limit oxycodone hcl tab 15 1 QL (120 tabs / 25 days), ST; Subject to initial 7- day limit oxycodone hcl tab 20 1 QL (90 tabs / 25 days), ST; Subject to initial 7- day limit oxycodone hcl tab 30 1 QL (60 tabs / 25 days), ST; Subject to initial 7- day limit oxycodone hcl tab er 12hr deter 10 1 QL (60 tabs / 25 days), ST oxycodone hcl tab er 12hr deter 15 1 QL (60 tabs / 25 days), ST oxycodone hcl tab er 12hr deter 20 1 QL (60 tabs / 25 days), ST oxycodone hcl tab er 12hr deter 30 1 QL (60 tabs / 25 days), ST oxycodone hcl tab er 12hr deter 40 1, ST; High Strength Requires oxycodone hcl tab er 12hr deter 60 1, ST; High Strength Requires oxycodone hcl tab er 12hr deter 80 1, ST; High Strength Requires - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 8

13 oxycodone w/ acetaminophen soln /5ml 1 QL (1800 ml / 25 days), ST; Subject to initial 7- day limit oxycodone w/ acetaminophen tab QL (360 tabs / 25 days), ST; Subject to initial 7- day limit oxycodone w/ acetaminophen tab QL (360 tabs / 25 days), ST; Subject to initial 7- day limit oxycodone w/ acetaminophen tab QL (240 tabs / 25 days), ST; Subject to initial 7- day limit oxycodone w/ acetaminophen tab QL (180 tabs / 25 days), ST; Subject to initial 7- day limit oxycodone-aspirin tab QL (360 tabs / 25 days), ST; Subject to initial 7- day limit oxycodone-ibuprofen tab QL (28 tabs / 25 days), ST; Subject to initial 7- day limit OXYCONTIN TAB 10MG CR 2 QL (60 tabs / 25 days), ST OXYCONTIN TAB 15MG CR 2 QL (60 tabs / 25 days), ST OXYCONTIN TAB 20MG CR 2 QL (60 tabs / 25 days), ST OXYCONTIN TAB 30MG CR 2 QL (60 tabs / 25 days), ST OXYCONTIN TAB 40MG CR 2, ST; High Strength Requires OXYCONTIN TAB 60MG CR 2, ST; High Strength Requires OXYCONTIN TAB 80MG CR 2, ST; High Strength Requires oxymorphone hcl tab 5 1 QL (180 tabs / 25 days), ST; Subject to initial 7- day limit oxymorphone hcl tab 10 1 QL (90 tabs / 25 days), ST; Subject to initial 7- day limit oxymorphone hcl tab er 12hr 5 1 QL (60 tabs / 25 days), ST oxymorphone hcl tab er 12hr QL (60 tabs / 25 days), ST oxymorphone hcl tab er 12hr 10 1 QL (60 tabs / 25 days), ST - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 9

14 oxymorphone hcl tab er 12hr 15 1 QL (60 tabs / 25 days), ST oxymorphone hcl tab er 12hr 20 1, ST; High Strength Requires oxymorphone hcl tab er 12hr 30 1, ST; High Strength Requires oxymorphone hcl tab er 12hr 40 1, ST; High Strength Requires PRIMLEV TAB 5-300MG 3 QL (360 tabs / 25 days), ST; Subject to initial 7- day limit PRIMLEV TAB QL (240 tabs / 25 days), ST; Subject to initial 7- day limit PRIMLEV TAB MG 3 QL (180 tabs / 25 days), ST; Subject to initial 7- day limit tramadol hcl tab 50 1 QL (180 tabs / 25 days), ST; Subject to initial 7- day limit tramadol hcl tab er 24hr QL (30 tabs / 25 days), ST tramadol hcl tab er 24hr 200 1, ST; High Strength Requires tramadol hcl tab er 24hr 300 1, ST; High Strength Requires xylon tab QL (50 tabs / 25 days), ST; Subject to initial 7- day limit OPIOID RTIAL AGONISTS BELBUCA MIS 75MCG 2 QL (60 films / 25 days), ST BELBUCA MIS 150MCG 2 QL (60 films / 25 days), ST BELBUCA MIS 300MCG 2 QL (60 films / 25 days), ST BELBUCA MIS 450MCG 2 QL (60 films / 25 days), ST BELBUCA MIS 600MCG 2, ST; High Strength Requires Prior Auth BELBUCA MIS 750MCG 2, ST; High Strength Requires Prior Auth BELBUCA MIS 900MCG 2, ST; High Strength Requires Prior Auth buprenorphine hcl sl tab 2 (base equiv) 1 QL (90 tabs / 25 days); Must obtain approval after the initial fill - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 10

15 buprenorphine hcl sl tab 8 (base equiv) 1 QL (90 tabs / 25 days); Must obtain approval after the initial fill SALICYLATES aspirin chw 81 0 QL (100 tabs / 30 days); OTC; $0 copay-age and gender restrictions apply aspirin low tab 81 ec 0 QL (100 tabs / 30 days); OTC; $0 copay-age and gender restrictions apply diflunisal tab ANTI-INFECTIVES ANTI-BACTERIALS - MISCELLANEOUS KETEK TAB 300MG 3 KETEK TAB 400MG 3 MONUROL K GRANULES 3 neomycin sulfate tab paromomycin sulfate cap streptomycin sulfate for inj 1 gm 1 SULFADIAZINE TAB 500MG 3 tinidazole tab tinidazole tab tobramycin nebu soln 300 /5ml 1 QL (280 ml / 28 days), ANTI-INFECTIVES - MISCELLANEOUS ALBENZA TAB 200MG 2 ALINIA SUS 100/5ML 2 ALINIA TAB 500MG 2 atovaquone susp 750 /5ml 1 aztreonam for inj 1 gm 1 aztreonam for inj 2 gm 1 BILTRICIDE TAB 600MG 3 CAYSTON INH 75MG 3 QL (84 vials / 28 days), clindamycin hcl cap 75 1 clindamycin hcl cap clindamycin hcl cap clindamycin palmitate hcl for soln 75 1 /5ml (base equiv) dapsone tab 25 1 dapsone tab daptomycin for iv soln DARAPRIM TAB 25MG 3 doripenem for iv infusion doripenem for iv infusion ivermectin tab Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 11

16 linezolid for susp 100 /5ml 1 linezolid tab methenamine hippurate tab 1 gm 1 metronidazole cap metronidazole tab metronidazole tab NEBUPENT INH 300MG 3 nitrofurantoin macrocrystalline cap 25 1 ; High Risk Medications require for members age 65 and older nitrofurantoin macrocrystalline cap 50 1 ; High Risk Medications require for members age 65 and older nitrofurantoin macrocrystalline cap ; High Risk Medications require for members age 65 and older nitrofurantoin monohydrate macrocrystalline cap ; High Risk Medications require for members age 65 and older PENTAM 300 INJ 300MG 3 praziquantel tab PRIMSOL SOL 50MG/5ML 2 SIVEXTRO INJ 200MG 3 SIVEXTRO TAB 200MG 3 sulfamethoxazole-trimethoprim susp /5ml 1 sulfamethoxazole-trimethoprim tab sulfamethoxazole-trimethoprim tab trimethoprim tab vancomycin hcl cap QL (80 caps / 14 days), ST; ** vancomycin hcl cap QL (80 caps / 14 days), ST; ** XIFAXAN TAB 200MG 2 XIFAXAN TAB 550MG 2 ANTIFUNGALS amphotericin b for inj 50 1 BIO-STATIN CAP BIO-STATIN CAP CRESEMBA CAP 186 MG 3 fluconazole for susp 10 /ml 1 - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 12

17 fluconazole for susp 40 /ml 1 fluconazole tab 50 1 fluconazole tab fluconazole tab fluconazole tab griseofulvin microsize susp 125 /5ml 1 griseofulvin microsize tab griseofulvin ultramicrosize tab griseofulvin ultramicrosize tab itraconazole cap NOXAFIL SUS 40MG/ML 2 NOXAFIL TAB 100MG 2 nystatin oral powder 1 nystatin tab unit 1 SPORANOX SOL 10MG/ML 2 terbinafine hcl tab voriconazole for susp 40 /ml 1 voriconazole tab 50 1 voriconazole tab ANTIMALARIALS atovaquone-proguanil hcl tab atovaquone-proguanil hcl tab chloroquine phosphate tab chloroquine phosphate tab COARTEM TAB MG 3 mefloquine hcl tab PRIMAQUINE TAB 26.3MG 3 quinine sulfate cap ANTIRETROVIRAL AGENTS abacavir sulfate soln 20 /ml (base 1 QL (900 ml / 30 days) equiv) abacavir sulfate tab 300 (base equiv) 1 QL (60 tabs / 30 days) APTIVUS CAP 250MG 2 QL (120 caps / 30 days) APTIVUS SOL 2 QL (300 ml / 30 days) atazanavir sulfate cap 150 (base equiv) 1 QL (30 caps / 30 days) atazanavir sulfate cap 200 (base equiv) 1 QL (60 caps / 30 days) atazanavir sulfate cap 300 (base equiv) 1 QL (30 caps / 30 days) CRIXIVAN CAP 200MG 2 QL (450 caps / 30 days) CRIXIVAN CAP 400MG 2 QL (180 caps / 30 days) didanosine delayed release capsule QL (30 caps / 30 days) didanosine delayed release capsule QL (30 caps / 30 days) didanosine delayed release capsule QL (30 caps / 30 days) didanosine delayed release capsule QL (30 caps / 30 days) EDURANT TAB 25MG 2 QL (60 tabs / 30 days) efavirenz cap 50 1 QL (90 caps / 30 days) - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 13

18 efavirenz cap QL (90 caps / 30 days) efavirenz tab QL (30 tabs / 30 days) EMTRIVA CAP 200MG 2 QL (30 caps / 30 days) EMTRIVA SOL 10MG/ML 2 QL (680 ml / 28 days) fosamprenavir calcium tab 700 (base 1 QL (120 tabs / 30 days) equiv) FUZEON INJ 90MG 3 QL (60 vials / 30 days) INTELENCE TAB 25MG 2 QL (120 tabs / 30 days) INTELENCE TAB 100MG 2 QL (120 tabs / 30 days) INTELENCE TAB 200MG 2 QL (60 tabs / 30 days) INVIRASE CAP 200MG 2 QL (300 caps / 30 days) INVIRASE TAB 500MG 2 QL (120 tabs / 30 days) ISENTRESS CHW 25MG 2 QL (180 tabs / 30 days) ISENTRESS CHW 100MG 2 QL (180 tabs / 30 days) ISENTRESS HD TAB 600MG 2 QL (60 tabs / 30 days) ISENTRESS POW 100MG 2 QL (60 packets / 30 days) ISENTRESS TAB 400MG 2 QL (120 tabs / 30 days) lamivudine oral soln 10 /ml 1 QL (900 ml / 30 days) lamivudine tab QL (60 tabs / 30 days) lamivudine tab QL (30 tabs / 30 days) LEXIVA SUS 50MG/ML 2 QL (1680 ml / 30 days) nevirapine susp 50 /5ml 1 QL (1200 ml / 30 days) nevirapine tab QL (60 tabs / 30 days) nevirapine tab er 24hr QL (90 tabs / 30 days) nevirapine tab er 24hr QL (30 tabs / 30 days) NORVIR CAP 100MG 2 QL (360 caps / 30 days) NORVIR SOL 80MG/ML 2 QL (480 ml / 30 days) NORVIR TAB 100MG 2 QL (360 tabs / 30 days) PREZISTA SUS 100MG/ML 2 QL (400 ml / 30 days) PREZISTA TAB 75MG 2 QL (300 tabs / 30 days) PREZISTA TAB 150MG 2 QL (180 tabs / 30 days) PREZISTA TAB 600MG 2 QL (60 tabs / 30 days) PREZISTA TAB 800MG 2 QL (30 tabs / 30 days) REYATAZ POW 50MG 2 QL (180 packets / 30 days) ritonavir tab QL (360 tabs / 30 days) SELZENTRY SOL 20MG/ML 2 QL (1840 ml / 30 days) SELZENTRY TAB 25MG 2 QL (240 tabs / 30 days) SELZENTRY TAB 75MG 2 QL (60 tabs / 30 days) SELZENTRY TAB 150MG 2 QL (60 tabs / 30 days) SELZENTRY TAB 300MG 2 QL (120 tabs / 30 days) stavudine cap 15 1 QL (60 caps / 30 days) stavudine cap 20 1 QL (60 caps / 30 days) stavudine cap 30 1 QL (60 caps / 30 days) stavudine cap 40 1 QL (60 caps / 30 days) - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 14

19 tenofovir disoproxil fumarate tab QL (30 tabs / 30 days) TIVICAY TAB 10MG 2 QL (60 tabs / 30 days) TIVICAY TAB 25MG 2 QL (60 tabs / 30 days) TIVICAY TAB 50MG 2 QL (60 tabs / 30 days) TYBOST TAB 150MG 2 QL (30 tabs / 30 days) VIDEX SOL 2GM 2 QL (1200 ml / 30 days) VIDEX SOL 4GM 2 QL (1200 ml / 30 days) VIRACEPT TAB 250MG 2 QL (300 tabs / 30 days) VIRACEPT TAB 625MG 2 QL (120 tabs / 30 days) VIRAMUNE SUS 50MG/5ML 2 QL (1200 ml / 30 days) VIREAD POW 40MG/GM 2 QL (240 gm / 30 days) VIREAD TAB 150MG 2 QL (30 tabs / 30 days) VIREAD TAB 200MG 2 QL (30 tabs / 30 days) VIREAD TAB 250MG 2 QL (30 tabs / 30 days) ZERIT SOL 1MG/ML 2 QL (2400 ml / 30 days) zidovudine cap QL (180 caps / 30 days) zidovudine syrup 10 /ml 1 QL (1800 ml / 30 days) zidovudine tab QL (60 tabs / 30 days) ANTIRETROVIRAL COMBINATION AGENTS abacavir sulfate-lamivudine tab QL (30 tabs / 30 days) abacavir sulfate-lamivudine-zidovudine tab 1 QL (60 tabs / 30 days) ATRIPLA TAB 2 QL (30 tabs / 30 days) COMPLERA TAB 2 QL (30 tabs / 30 days) DESCOVY TAB 200/25 2 QL (30 tabs / 30 days) EVOTAZ TAB QL (30 tabs / 30 days) GENVOYA TAB 2 QL (30 tabs / 30 days) KALETRA TAB MG 2 QL (240 tabs / 30 days) KALETRA TAB MG 2 QL (120 tabs / 30 days) lamivudine-zidovudine tab QL (60 tabs / 30 days) lopinavir-ritonavir soln /5ml 1 QL (390 ml / 30 days) (80-20 /ml) ODEFSEY TAB 2 QL (30 tabs / 30 days) PREZCOBIX TAB QL (30 tabs / 30 days) STRIBILD TAB 2 QL (30 tabs / 30 days) TRIUMEQ TAB 2 QL (30 tabs / 30 days) TRUVADA TAB QL (30 tabs / 30 days) TRUVADA TAB QL (30 tabs / 30 days) TRUVADA TAB QL (30 tabs / 30 days) TRUVADA TAB QL (30 tabs / 30 days) ANTITUBERCULAR AGENTS cycloserine cap ethambutol hcl tab ethambutol hcl tab isoniazid syrup 50 /5ml 1 - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 15

20 isoniazid tab isoniazid tab SER GRA 4GM 3 PRIFTIN TAB 150MG 2 pyrazinamide tab rifabutin cap RIFAMATE CAP 2 rifampin cap rifampin cap RIFATER TAB 2 SIRTURO TAB 100MG 3 TRECATOR TAB 250MG 2 ANTIVIRALS acyclovir cap acyclovir susp 200 /5ml 1 acyclovir tab acyclovir tab adefovir dipivoxil tab 10 1 BARACLUDE SOL.05MG/ML 2 entecavir tab entecavir tab 1 1 EPCLUSA TAB QL (28 tabs / 28 days), EPIVIR HBV SOL 5MG/ML 2 famciclovir tab famciclovir tab famciclovir tab HARVONI TAB MG 3 QL (28 tabs / 28 days), lamivudine tab 100 (hbv) 1 oseltamivir phosphate cap 30 (base 1 QL (40 caps / 90 days) equiv) oseltamivir phosphate cap 45 (base 1 QL (20 caps / 90 days) equiv) oseltamivir phosphate cap 75 (base 1 QL (20 caps / 90 days) equiv) oseltamivir phosphate for susp 6 /ml 1 QL (300 ml / 90 days) (base equiv) PEGASYS INJ 3 QL (4 injections / 28 days), PEGASYS INJ 180MCG/M 3 QL (4 injections / 28 days), PEGASYS INJ PROCLICK 3 QL (4 injections / 28 days), REBETOL SOL 40MG/ML 3 - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 16

21 RELENZA MIS DISKHALE 2 QL (2 inhalers / 90 days) ribasphere cap ribasphere tab ribasphere tab ribasphere tab ribavirin cap ribavirin tab rimantadine hydrochloride tab SOVALDI TAB 400MG 3 QL (28 tabs / 28 days),, ST valacyclovir hcl tab 1 gm 1 valacyclovir hcl tab valganciclovir hcl for soln 50 /ml (base 1 equiv) valganciclovir hcl tab 450 (base 1 equivalent) VOSEVI TAB 3 QL (28 tabs / 28 days), ZETIER TAB MG 3 QL (28 tabs / 28 days),, ST CEPHALOSPORINS cefaclor cap cefaclor cap CEFACLOR ER TAB 500MG 2 cefaclor for susp 125 /5ml 1 cefaclor for susp 250 /5ml 1 cefaclor for susp 375 /5ml 1 cefadroxil cap cefadroxil for susp 250 /5ml 1 cefadroxil for susp 500 /5ml 1 cefadroxil tab 1 gm 1 cefdinir cap cefdinir for susp 125 /5ml 1 cefdinir for susp 250 /5ml 1 cefditoren pivoxil tab 200 (base 1 equivalent) cefditoren pivoxil tab 400 (base 1 equivalent) cefepime hcl for inj 1 gm 1 cefepime hcl for inj 2 gm 1 cefixime for susp 100 /5ml 1 cefixime for susp 200 /5ml 1 cefpodoxime proxetil for susp 50 /5ml 1 cefpodoxime proxetil for susp 100 /5ml 1 cefpodoxime proxetil tab Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 17

22 cefpodoxime proxetil tab cefprozil for susp 125 /5ml 1 cefprozil for susp 250 /5ml 1 cefprozil tab cefprozil tab ceftazidime for inj 2 gm 1 ceftibuten cap ceftibuten for susp 180 /5ml 1 CEFTIN SUS 125/5ML 2 CEFTIN SUS 250/5ML 2 ceftriaxone sodium for inj 1 gm 1 ceftriaxone sodium for inj 2 gm 1 ceftriaxone sodium for inj 10 gm 1 ceftriaxone sodium for inj ceftriaxone sodium for inj ceftriaxone sodium for iv soln 1 gm 1 ceftriaxone sodium for iv soln 2 gm 1 cefuroxime axetil tab cefuroxime axetil tab cephalexin cap cephalexin cap cephalexin cap cephalexin for susp 125 /5ml 1 cephalexin for susp 250 /5ml 1 cephalexin tab cephalexin tab SUPRAX CAP 400MG 2 SUPRAX CHW 100MG 2 SUPRAX CHW 200MG 2 SUPRAX SUS 500/5ML 2 tazicef inj 1gm 1 tazicef inj 2gm 1 tazicef inj 6gm 1 ERYTHROMYCINS/MACROLIDES azithromycin for susp 100 /5ml 1 azithromycin for susp 200 /5ml 1 azithromycin powd pack for susp 1 gm 1 azithromycin tab azithromycin tab azithromycin tab clarithromycin for susp 125 /5ml 1 clarithromycin for susp 250 /5ml 1 clarithromycin tab clarithromycin tab clarithromycin tab er 24hr Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 18

23 DIFICID TAB 200MG 2 e.e.s. 400 tab ery-tab tab 250 ec 1 ery-tab tab 333 ec 1 ery-tab tab 500 ec 1 ERYPED SUS 400/5ML 2 erythrocin tab erythromycin ethylsuccinate for susp /5ml erythromycin ethylsuccinate tab erythromycin tab erythromycin tab erythromycin w/ delayed release particles 1 cap 250 FLUOROQUINOLONES ciprofloxacin for oral susp 250 /5ml 1 (5%) (5 gm/100ml) ciprofloxacin for oral susp 500 /5ml (10%) (10 gm/100ml) 1 ciprofloxacin hcl tab 100 (base equiv) 1 ciprofloxacin hcl tab 250 (base equiv) 1 ciprofloxacin hcl tab 500 (base equiv) 1 ciprofloxacin hcl tab 750 (base equiv) 1 ciprofloxacin-ciprofloxacin hcl tab er 24hr (base eq) ciprofloxacin-ciprofloxacin hcl tab er 24hr (base eq) FACTIVE TAB 320MG 3 levofloxacin oral soln 25 /ml 1 levofloxacin tab levofloxacin tab levofloxacin tab moxifloxacin hcl tab 400 (base equiv) 1 PENICILLINS amoxicillin & k clavulanate chew tab amoxicillin & k clavulanate chew tab amoxicillin & k clavulanate for susp /5ml amoxicillin & k clavulanate for susp /5ml amoxicillin & k clavulanate for susp /5ml amoxicillin & k clavulanate for susp /5ml amoxicillin & k clavulanate tab Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 19

24 amoxicillin & k clavulanate tab amoxicillin & k clavulanate tab amoxicillin & k clavulanate tab er 12hr amoxicillin (trihydrate) cap amoxicillin (trihydrate) cap amoxicillin (trihydrate) chew tab amoxicillin (trihydrate) chew tab amoxicillin (trihydrate) for susp /5ml amoxicillin (trihydrate) for susp /5ml amoxicillin (trihydrate) for susp /5ml amoxicillin (trihydrate) for susp /5ml amoxicillin (trihydrate) tab amoxicillin (trihydrate) tab ampicillin cap ampicillin cap ampicillin for susp 125 /5ml 1 ampicillin for susp 250 /5ml 1 AUGMENTIN SUS 125/5ML 2 dicloxacillin sodium cap dicloxacillin sodium cap penicillin v potassium for soln 125 /5ml 1 penicillin v potassium for soln 250 /5ml 1 penicillin v potassium tab penicillin v potassium tab TETRACYCLINES avidoxy tab demeclocycline hcl tab demeclocycline hcl tab doxycycline hyclate cap 50 1 doxycycline hyclate cap doxycycline hyclate tab 20 1 doxycycline hyclate tab doxycycline monohydrate cap 50 1 doxycycline monohydrate cap 75 1 doxycycline monohydrate cap doxycycline monohydrate cap doxycycline monohydrate for susp 25 1 /5ml doxycycline monohydrate tab 50 1 doxycycline monohydrate tab 75 1 doxycycline monohydrate tab Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 20

25 minocycline hcl cap 50 1 minocycline hcl cap 75 1 minocycline hcl cap minocycline hcl tab 50 1 minocycline hcl tab 75 1 minocycline hcl tab morgidox cap 1x100 1 tetracycline hcl cap tetracycline hcl cap ANTINEOPLASTIC AGENTS ALKYLATING AGENTS BICNU INJ 100MG 2 busulfan inj 6 /ml 1 CYCLOPHOSPH CAP 25MG 2 CYCLOPHOSPH CAP 50MG 2 cyclophosphamide cap 25 1 cyclophosphamide cap 50 1 cyclophosphamide for inj 1 gm 1 cyclophosphamide for inj 2 gm 1 cyclophosphamide for inj dacarbazine for inj dacarbazine for inj EMCYT CAP 140MG 2 GLEOSTINE CAP 5MG 2 GLEOSTINE CAP 10MG 2 GLEOSTINE CAP 40MG 2 GLEOSTINE CAP 100MG 2 GLIADEL WAF 7.7MG 2 HEXALEN CAP 50MG 2 ifosfamide for inj 1 gm 1 ifosfamide iv inj 1 gm/20ml (50 /ml) 1 ifosfamide iv inj 3 gm/60ml (50 /ml) 1 LEUKERAN TAB 2MG 2 melphalan tab 2 1 TEMODAR INJ 100MG 3 temozolomide cap 5 3 temozolomide cap 20 3 temozolomide cap temozolomide cap temozolomide cap temozolomide cap ANTHRACYCLINES daunorubicin hcl inj 5 /ml (base equiv) 1 DAUNOXOME INJ 2MG/ML 2 doxorubicin hcl for inj Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 21

26 doxorubicin hcl for inj 50 1 doxorubicin hcl inj 2 /ml 1 doxorubicin hcl liposomal inj (for iv 1 infusion) 2 /ml epirubicin hcl iv soln 50 /25ml (2 1 /ml) epirubicin hcl iv soln 200 /100ml (2 1 /ml) idarubicin hcl iv inj 5 /5ml (1 /ml) 1 idarubicin hcl iv inj 10 /10ml (1 /ml) 1 idarubicin hcl iv inj 20 /20ml (1 /ml) 1 ANTIBIOTICS bleomycin sulfate for inj 15 unit 1 bleomycin sulfate for inj 30 unit 1 mitomycin for iv soln 5 1 mitomycin for iv soln 20 1 mitomycin for iv soln 40 1 ANTIMETABOLITES adrucil inj 2.5g/50m 1 adrucil inj 500/10ml 1 ALIMTA INJ 100MG 2 ALIMTA INJ 500MG 2 ARRANON INJ 5MG/ML 2 azacitidine for inj capecitabine tab QL (120 tabs / 30 days), capecitabine tab QL (300 tabs / 30 days), cladribine iv soln 10 /10ml (1 /ml) 1 clofarabine iv soln 1 /ml 1 cytarabine inj 20 /ml 1 cytarabine inj pf 20 /ml 1 cytarabine inj pf 100 /ml 1 decitabine for inj 50 3 DEPOCYT INJ 50MG/5ML 2 floxuridine for inj 0.5 gm 1 fludarabine phosphate for inj 50 1 fludarabine phosphate inj 25 /ml 1 fluorouracil iv soln 1 gm/20ml (50 /ml) 1 fluorouracil iv soln 2.5 gm/50ml (50 1 /ml) fluorouracil iv soln 5 gm/100ml (50 /ml) 1 fluorouracil iv soln 500 /10ml (50 1 /ml) gemcitabine hcl for inj 1 gm 1 gemcitabine hcl for inj 2 gm 1 - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 22

27 gemcitabine hcl for inj gemcitabine hcl inj 1 gm/26.3ml (38 1 /ml) (base equiv) gemcitabine hcl inj 2 gm/52.6ml (38 1 /ml) (base equiv) gemcitabine hcl inj 200 /5.26ml (38 1 /ml) (base equiv) mercaptopurine tab 50 1 methotrexate sodium for inj 1 gm 1 methotrexate sodium inj 50 /2ml (25 1 /ml) methotrexate sodium inj 250 /10ml (25 1 /ml) methotrexate sodium inj pf 50 /2ml (25 1 /ml) methotrexate sodium inj pf 100 /4ml 1 (25 /ml) methotrexate sodium inj pf 200 /8ml 1 (25 /ml) methotrexate sodium inj pf 250 /10ml 1 (25 /ml) methotrexate sodium inj pf 1000 /40ml 1 (25 /ml) NIPENT INJ 10MG 2 TABLOID TAB 40MG 2 ANTIMITOTIC, TAXOIDS ABRAXANE INJ 100MG 2 DOCEFREZ INJ 20MG 2 docetaxel for inj conc 20 /ml 1 docetaxel for inj conc 80 /4ml (20 1 /ml) DOCETAXEL INJ 20/0.5ML 2 DOCETAXEL INJ 20MG/2ML 2 DOCETAXEL INJ 80MG/2ML 2 DOCETAXEL INJ 80MG/8ML 2 DOCETAXEL INJ 140/7ML 2 DOCETAXEL INJ 160/8ML 2 DOCETAXEL INJ 160/16ML 2 DOCETAXEL INJ 200MG/20 2 DOCETAXEL INJ NON-ALCO 2 docetaxel soln for iv infusion 20 /2ml 1 docetaxel soln for iv infusion 80 /8ml 1 docetaxel soln for iv infusion 160 /16ml 1 paclitaxel iv conc 30 /5ml (6 /ml) 1 paclitaxel iv conc 100 /16.7ml (6 1 /ml) paclitaxel iv conc 150 /25ml (6 /ml) 1 - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 23

28 paclitaxel iv conc 300 /50ml (6 /ml) 1 ANTIMITOTIC, VINCA ALKALOIDS vinblastine sulfate inj 1 /ml 1 vincasar pfs inj 1/ml 1 vincristine sulfate iv soln 1 /ml 1 vinorelbine tartrate inj 10 /ml (base 1 equiv) vinorelbine tartrate inj 50 /5ml (10 1 /ml) (base equiv) BIOLOGIC RESPONSE MODIFIERS ERBITUX INJ 100MG 3 ERBITUX INJ 200MG 3 ERIVEDGE CAP 150MG 3 QL (30 caps / 30 days), FARYDAK CAP 10MG 3 FARYDAK CAP 15MG 3 FARYDAK CAP 20MG 3 GAZYVA INJ 25MG/ML 3 IBRANCE CAP 75MG 3 QL (21 caps / 28 days), IBRANCE CAP 100MG 3 QL (21 caps / 28 days), IBRANCE CAP 125MG 3 QL (21 caps / 28 days), KADCYLA INJ 100MG 3 KADCYLA INJ 160MG 3 KEYTRUDA INJ 100MG/4M 3 KEYTRUDA SOL 50MG 3 LYNRZA CAP 50MG 3 QL (480 caps / 30 days), LYNRZA TAB 100MG 3 QL (180 tabs / 30 days), LYNRZA TAB 150MG 3 QL (120 tabs / 30 days), RYDAPT CAP 25MG 3 QL (224 caps / 28 days), ZEJULA CAP 100MG 3 QL (90 caps / 30 days), ZOLINZA CAP 100MG 3 QL (120 caps / 30 days), HORMONAL ANTINEOPLASTIC AGENTS anastrozole tab 1 1 bicalutamide tab 50 1 exemestane tab 25 1 FARESTON TAB 60MG 2 FASLODEX INJ 250/5ML 2 - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 24

29 flutamide cap letrozole tab leuprolide acetate inj kit 5 /ml 3 LUPR DEP-PED INJ 3M 30MG 3 LUPR DEP-PED INJ 7.5MG 3 LUPR DEP-PED INJ 11.25MG 3 LUPR DEP-PED INJ 15MG 3 LUPRON DEPOT INJ 3.75MG 3 LUPRON DEPOT INJ 7.5MG 3 LUPRON DEPOT INJ 11.25MG 3 LUPRON DEPOT INJ 22.5MG 3 LUPRON DEPOT INJ 30MG 3 LUPRON DEPOT INJ 45MG 3 LYSODREN TAB 500MG 2 megestrol acetate susp 40 /ml 1 megestrol acetate tab 20 1 megestrol acetate tab 40 1 nilutamide tab tamoxifen citrate tab 10 (base equivalent) 1 $0 copay for women > 35 years for the primary prevention of breast cancer tamoxifen citrate tab 20 (base equivalent) 1 $0 copay for women > 35 years for the primary prevention of breast cancer XTANDI CAP 40MG 3 QL (120 caps / 30 days), ZYTIGA TAB 250MG 3 QL (120 tabs / 30 days), ZYTIGA TAB 500MG 3 QL (60 tabs / 30 days), KINASE INHIBITORS AFINITOR DIS TAB 2MG 3 QL (60 tabs / 30 days), AFINITOR DIS TAB 3MG 3 QL (90 tabs / 30 days), AFINITOR DIS TAB 5MG 3 QL (60 tabs / 30 days), AFINITOR TAB 2.5MG 3 QL (30 tabs / 30 days), AFINITOR TAB 5MG 3 QL (30 tabs / 30 days), AFINITOR TAB 7.5MG 3 QL (30 tabs / 30 days), AFINITOR TAB 10MG 3 QL (30 tabs / 30 days), - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 25

30 ALECENSA CAP 150MG 3 QL (240 caps / 30 days), BOSULIF TAB 100MG 3 QL (90 tabs / 30 days), BOSULIF TAB 400MG 3 QL (30 tabs / 30 days), BOSULIF TAB 500MG 3 QL (30 tabs / 30 days), CALQUENCE CAP 100MG 3 QL (60 caps / 30 days), CAPRELSA TAB 100MG 3 QL (60 tabs / 30 days), CAPRELSA TAB 300MG 3 QL (30 tabs / 30 days), COMETRIQ KIT 60MG 3 QL (1 kit / 28 days), COMETRIQ KIT 100MG 3 QL (1 kit / 28 days), COMETRIQ KIT 140MG 3 QL (1 kit / 28 days), ICLUSIG TAB 15MG 3 QL (60 tabs / 30 days), ICLUSIG TAB 45MG 3 QL (30 tabs / 30 days), IDHIFA TAB 50MG 3 QL (30 tabs / 30 days), IDHIFA TAB 100MG 3 QL (30 tabs / 30 days), imatinib mesylate tab 100 (base equivalent) 3 QL (90 tabs / 30 days), imatinib mesylate tab 400 (base equivalent) 3 QL (60 tabs / 30 days), IMBRUVICA CAP 70MG 3 QL (30 caps / 30 days), IMBRUVICA CAP 140MG 3 QL (120 caps / 30 days), IMBRUVICA TAB 140MG 3 QL (30 tabs / 30 days), IMBRUVICA TAB 280MG 3 QL (30 tabs / 30 days), IMBRUVICA TAB 420MG 3 QL (30 tabs / 30 days), IMBRUVICA TAB 560MG 3 QL (30 tabs / 30 days), INLYTA TAB 1MG 3 QL (180 tabs / 30 days), INLYTA TAB 5MG 3 QL (120 tabs / 30 days), JAKAFI TAB 5MG 3 QL (60 tabs / 30 days), - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 26

31 JAKAFI TAB 10MG 3 QL (60 tabs / 30 days), JAKAFI TAB 15MG 3 QL (60 tabs / 30 days), JAKAFI TAB 20MG 3 QL (60 tabs / 30 days), JAKAFI TAB 25MG 3 QL (60 tabs / 30 days), LENVIMA CAP 8 MG 3 QL (60 caps / 30 days), LENVIMA CAP 10 MG 3 QL (30 caps / 30 days), LENVIMA CAP 14 MG 3 QL (60 caps / 30 days), LENVIMA CAP 18 MG 3 QL (90 caps / 30 days), LENVIMA CAP 20 MG 3 QL (60 caps / 30 days), LENVIMA CAP 24 MG 3 QL (90 caps / 30 days), MEKINIST TAB 0.5MG 3 QL (90 tabs / 30 days), MEKINIST TAB 2MG 3 QL (30 tabs / 30 days), NEXAVAR TAB 200MG 3 QL (120 tabs / 30 days), SPRYCEL TAB 20MG 3 QL (90 tabs / 30 days), SPRYCEL TAB 50MG 3 QL (30 tabs / 30 days), SPRYCEL TAB 70MG 3 QL (30 tabs / 30 days), SPRYCEL TAB 80MG 3 QL (30 tabs / 30 days), SPRYCEL TAB 100MG 3 QL (30 tabs / 30 days), SPRYCEL TAB 140MG 3 QL (30 tabs / 30 days), STIVARGA TAB 40MG 3 QL (84 tabs / 28 days), SUTENT CAP 12.5MG 3 QL (30 caps / 30 days), SUTENT CAP 25MG 3 QL (30 caps / 30 days), SUTENT CAP 37.5MG 3 QL (30 caps / 30 days), SUTENT CAP 50MG 3 QL (30 caps / 30 days), - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 27

32 TAFINLAR CAP 50MG 3 QL (120 caps / 30 days), TAFINLAR CAP 75MG 3 QL (120 caps / 30 days), TARCEVA TAB 25MG 3 QL (60 tabs / 30 days), TARCEVA TAB 100MG 3 QL (30 tabs / 30 days), TARCEVA TAB 150MG 3 QL (30 tabs / 30 days), TYKERB TAB 250MG 3 QL (180 tabs / 30 days), VOTRIENT TAB 200MG 3 QL (120 tabs / 30 days), XALKORI CAP 200MG 3 QL (60 caps / 30 days), XALKORI CAP 250MG 3 QL (60 caps / 30 days), ZELBORAF TAB 240MG 3 QL (240 tabs / 30 days), ZYDELIG TAB 100MG 3 QL (60 tabs / 30 days), ZYDELIG TAB 150MG 3 QL (60 tabs / 30 days), ZYKADIA CAP 150MG 3 QL (150 caps / 30 days), MISCELLANEOUS bexarotene cap 75 3 DROXIA CAP 200MG 2 DROXIA CAP 300MG 2 DROXIA CAP 400MG 2 hydroxyurea cap MATULANE CAP 50MG 2 mitoxantrone hcl inj conc 20 /10ml (2 /ml) 3 mitoxantrone hcl inj conc 25 /12.5ml (2 3 /ml) mitoxantrone hcl inj conc 30 /15ml (2 3 /ml) ONCASR INJ 750/ML 3 PHOTOFRIN INJ 75MG 2 QUADRAMET INJ 2 THERACYS INJ 2 TICE BCG INJ 2 tretinoin cap 10 1 TRISENOX INJ 12MG/6ML 2 TRISENOX SOL 10MG/10M 2 - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 28

33 UVADEX INJ 20MCG/ML 2 VISTOGARD K 10GM 2 PLATINUM-BASED AGENTS carboplatin iv soln 50 /5ml 1 carboplatin iv soln 150 /15ml 1 carboplatin iv soln 450 /45ml 1 carboplatin iv soln 600 /60ml 1 cisplatin inj 50 /50ml (1 /ml) 1 cisplatin inj 100 /100ml (1 /ml) 1 cisplatin inj 200 /200ml (1 /ml) 1 oxaliplatin for iv inj 50 1 oxaliplatin for iv inj oxaliplatin iv soln 50 /10ml 1 oxaliplatin iv soln 100 /20ml 1 PROTECTIVE AGENTS amifostine for inj dexrazoxane for inj dexrazoxane for inj leucovorin calcium for inj 50 1 leucovorin calcium for inj leucovorin calcium for inj leucovorin calcium for inj leucovorin calcium for inj leucovorin calcium tab 5 1 leucovorin calcium tab 10 1 leucovorin calcium tab 15 1 leucovorin calcium tab 25 1 mesna inj 100 /ml 1 MESNEX TAB 400MG 2 TOPOISOMERASE INHIBITORS CAMPTOSAR INJ 300/15ML 2 etoposide cap 50 1 etoposide inj 100 /5ml (20 /ml) 1 irinotecan hcl inj 40 /2ml (20 /ml) 1 irinotecan hcl inj 100 /5ml (20 /ml) 1 irinotecan hcl inj 500 /25ml (20 /ml) 1 TENIPOSIDE INJ 50MG/5ML 2 toposar inj 20/ml 1 toposar inj 100/5ml 1 topotecan hcl for inj 4 1 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ANTINEOPLASTIC, BCL-2 INHIBITORS VENCLEXTA TAB 10MG 3 VENCLEXTA TAB 50MG 3 VENCLEXTA TAB 100MG 3 - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 29

34 VENCLEXTA TAB START PK 3 CARDIOVASCULAR ACE INHIBITOR COMBINATIONS amlodipine besylate-benazepril hcl cap amlodipine besylate-benazepril hcl cap amlodipine besylate-benazepril hcl cap amlodipine besylate-benazepril hcl cap amlodipine besylate-benazepril hcl cap amlodipine besylate-benazepril hcl cap benazepril & hydrochlorothiazide tab benazepril & hydrochlorothiazide tab benazepril & hydrochlorothiazide tab benazepril & hydrochlorothiazide tab captopril & hydrochlorothiazide tab captopril & hydrochlorothiazide tab captopril & hydrochlorothiazide tab captopril & hydrochlorothiazide tab enalapril maleate & hydrochlorothiazide tab enalapril maleate & hydrochlorothiazide tab fosinopril sodium & hydrochlorothiazide tab fosinopril sodium & hydrochlorothiazide tab lisinopril & hydrochlorothiazide tab lisinopril & hydrochlorothiazide tab lisinopril & hydrochlorothiazide tab moexipril-hydrochlorothiazide tab Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 30

35 moexipril-hydrochlorothiazide tab moexipril-hydrochlorothiazide tab quinapril-hydrochlorothiazide tab quinapril-hydrochlorothiazide tab quinapril-hydrochlorothiazide tab trandolapril-verapamil hcl tab er trandolapril-verapamil hcl tab er trandolapril-verapamil hcl tab er trandolapril-verapamil hcl tab er ACE INHIBITORS benazepril hcl tab 5 1 benazepril hcl tab 10 1 benazepril hcl tab 20 1 benazepril hcl tab 40 1 captopril tab captopril tab 25 1 captopril tab 50 1 captopril tab enalapril maleate tab enalapril maleate tab 5 1 enalapril maleate tab 10 1 enalapril maleate tab 20 1 fosinopril sodium tab 10 1 fosinopril sodium tab 20 1 fosinopril sodium tab 40 1 lisinopril tab lisinopril tab 5 1 lisinopril tab 10 1 lisinopril tab 20 1 lisinopril tab 30 1 lisinopril tab 40 1 moexipril hcl tab moexipril hcl tab 15 1 perindopril erbumine tab 2 1 perindopril erbumine tab 4 1 perindopril erbumine tab 8 1 quinapril hcl tab 5 1 quinapril hcl tab 10 1 quinapril hcl tab 20 1 quinapril hcl tab 40 1 ramipril cap ramipril cap Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 31

36 ramipril cap 5 1 ramipril cap 10 1 trandolapril tab 1 1 trandolapril tab 2 1 trandolapril tab 4 1 ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone tab 25 1 eplerenone tab 50 1 ALPHA BLOCKERS doxazosin mesylate tab 1 1 doxazosin mesylate tab 2 1 doxazosin mesylate tab 4 1 doxazosin mesylate tab 8 1 prazosin hcl cap 1 1 prazosin hcl cap 2 1 prazosin hcl cap 5 1 terazosin hcl cap 1 (base equivalent) 1 terazosin hcl cap 2 (base equivalent) 1 terazosin hcl cap 5 (base equivalent) 1 terazosin hcl cap 10 (base equivalent) 1 ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS amlodipine besylate-olmesartan medoxomil 1 tab 5-20 amlodipine besylate-olmesartan medoxomil 1 tab 5-40 amlodipine besylate-olmesartan medoxomil 1 tab amlodipine besylate-olmesartan medoxomil 1 tab amlodipine besylate-valsartan tab amlodipine besylate-valsartan tab amlodipine besylate-valsartan tab amlodipine besylate-valsartan tab amlodipine-valsartan-hydrochlorothiazide 1 tab amlodipine-valsartan-hydrochlorothiazide 1 tab amlodipine-valsartan-hydrochlorothiazide 1 tab amlodipine-valsartan-hydrochlorothiazide 1 tab amlodipine-valsartan-hydrochlorothiazide 1 tab Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 32

37 BYVALSON TAB 5-80MG 3 candesartan cilexetil-hydrochlorothiazide 1 tab candesartan cilexetil-hydrochlorothiazide 1 tab candesartan cilexetil-hydrochlorothiazide 1 tab irbesartan-hydrochlorothiazide tab irbesartan-hydrochlorothiazide tab losartan potassium & hydrochlorothiazide 1 tab losartan potassium & hydrochlorothiazide 1 tab losartan potassium & hydrochlorothiazide 1 tab olmesartan medoxomil-hydrochlorothiazide 1 tab olmesartan medoxomil-hydrochlorothiazide 1 tab olmesartan medoxomil-hydrochlorothiazide 1 tab olmesartan-amlodipine-hydrochlorothiazide 1 tab olmesartan-amlodipine-hydrochlorothiazide 1 tab olmesartan-amlodipine-hydrochlorothiazide 1 tab olmesartan-amlodipine-hydrochlorothiazide 1 tab olmesartan-amlodipine-hydrochlorothiazide 1 tab telmisartan-amlodipine tab telmisartan-amlodipine tab telmisartan-amlodipine tab telmisartan-amlodipine tab telmisartan-hydrochlorothiazide tab telmisartan-hydrochlorothiazide tab telmisartan-hydrochlorothiazide tab valsartan-hydrochlorothiazide tab valsartan-hydrochlorothiazide tab Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 33

38 valsartan-hydrochlorothiazide tab valsartan-hydrochlorothiazide tab valsartan-hydrochlorothiazide tab ANGIOTENSIN II RECEPTOR ANTAGONISTS candesartan cilexetil tab 4 1 candesartan cilexetil tab 8 1 candesartan cilexetil tab 16 1 candesartan cilexetil tab 32 1 EDARBI TAB 40MG 3 ST; ** EDARBI TAB 80MG 3 ST; ** eprosartan mesylate tab irbesartan tab 75 1 irbesartan tab irbesartan tab losartan potassium tab 25 1 losartan potassium tab 50 1 losartan potassium tab olmesartan medoxomil tab 5 1 olmesartan medoxomil tab 20 1 olmesartan medoxomil tab 40 1 telmisartan tab 20 1 telmisartan tab 40 1 telmisartan tab 80 1 valsartan tab 40 1 valsartan tab 80 1 valsartan tab valsartan tab ANTIARRHYTHMICS amiodarone hcl tab amiodarone hcl tab disopyramide phosphate cap disopyramide phosphate cap dofetilide cap 125 mcg (0.125 ) 3 dofetilide cap 250 mcg (0.25 ) 3 dofetilide cap 500 mcg (0.5 ) 3 flecainide acetate tab 50 1 flecainide acetate tab flecainide acetate tab mexiletine hcl cap mexiletine hcl cap mexiletine hcl cap MULTAQ TAB 400MG 3 NORCE CAP 100MG CR 2 - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 34

39 NORCE CAP 150MG CR 2 pacerone tab pacerone tab procainamide hcl inj 100 /ml 1 propafenone hcl cap er 12hr propafenone hcl cap er 12hr propafenone hcl cap er 12hr propafenone hcl tab propafenone hcl tab propafenone hcl tab sorine tab 80 1 sorine tab sorine tab sorine tab sotalol hcl (afib/afl) tab 80 1 sotalol hcl (afib/afl) tab sotalol hcl (afib/afl) tab sotalol hcl tab 80 1 sotalol hcl tab sotalol hcl tab sotalol hcl tab ANTILIPEMICS, BILE ACID RESINS cholestyramine light powder 4 gm/dose 1 cholestyramine light powder packets 4 gm 1 cholestyramine powder 4 gm/dose 1 cholestyramine powder packets 4 gm 1 colestipol hcl granule packets 5 gm 1 colestipol hcl granules 5 gm 1 colestipol hcl tab 1 gm 1 prevalite pow 4gm 1 WELCHOL K 3.75GM 2 WELCHOL TAB 625MG 2 ANTILIPEMICS, CHOLESTEROL ABSORPTION INHIBITOR ezetimibe tab 10 1 ANTILIPEMICS, FIBRATES fenofibrate cap 50 1 fenofibrate cap fenofibrate micronized cap 43 1 fenofibrate micronized cap 67 1 fenofibrate micronized cap fenofibrate micronized cap fenofibrate micronized cap fenofibrate tab 48 1 fenofibrate tab 54 1 fenofibrate tab Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 35

40 fenofibrate tab gemfibrozil tab ANTILIPEMICS, HMG-COA REDUCTASE INHIBITORS/COMBINATIONS ezetimibe-simvastatin tab ezetimibe-simvastatin tab ezetimibe-simvastatin tab ezetimibe-simvastatin tab ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS atorvastatin calcium tab 10 (base equivalent) 1 $0 copay for members age 40 through 75 atorvastatin calcium tab 20 (base equivalent) 1 $0 copay for members age 40 through 75 atorvastatin calcium tab 40 (base 1 equivalent) atorvastatin calcium tab 80 (base 1 equivalent) fluvastatin sodium cap 20 1 $0 copay for members age 40 through 75 fluvastatin sodium cap 40 1 $0 copay for members age 40 through 75 fluvastatin sodium tab er 24 hr 80 1 $0 copay for members age 40 through 75 LIVALO TAB 1MG 3 LIVALO TAB 2MG 3 LIVALO TAB 4MG 3 lovastatin tab 10 1 $0 copay for members age 40 through 75 lovastatin tab 20 1 $0 copay for members age 40 through 75 lovastatin tab 40 1 $0 copay for members age 40 through 75 pravastatin sodium tab 10 1 $0 copay for members age 40 through 75 pravastatin sodium tab 20 1 $0 copay for members age 40 through 75 pravastatin sodium tab 40 1 $0 copay for members age 40 through 75 pravastatin sodium tab 80 1 $0 copay for members age 40 through 75 rosuvastatin calcium tab 5 1 $0 copay for members age 40 through 75 rosuvastatin calcium tab 10 1 $0 copay for members age 40 through 75 rosuvastatin calcium tab 20 1 rosuvastatin calcium tab Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 36

41 simvastatin tab 5 1 $0 copay for members age 40 through 75 simvastatin tab 10 1 $0 copay for members age 40 through 75 simvastatin tab 20 1 $0 copay for members age 40 through 75 simvastatin tab 40 1 $0 copay for members age 40 through 75 simvastatin tab 80 1 ST; ** ANTILIPEMICS, MISCELLANEOUS niacin tab er 500 (antihyperlipidemic) 1 niacin tab er 750 (antihyperlipidemic) 1 niacin tab er 1000 (antihyperlipidemic) 1 ANTILIPEMICS, OMEGA-3 FATTY ACIDS omega-3-acid ethyl esters cap 1 gm 1 VASCE CAP 0.5GM 2 VASCE CAP 1GM 2 ANTILIPEMICS, PCSK9 INHIBITORS PRALUENT INJ 75MG/ML 3 QL (2 injections / 28 days), PRALUENT INJ 150MG/ML 3 QL (2 injections / 28 days), RETHA INJ 140MG/ML 3 QL (2 syringes / 28 days), RETHA PUSH INJ 420/3.5 3 QL (1 cartridge / 28 days), RETHA SURE INJ 140MG/ML 3 QL (2 pens / 28 days), BETA-BLOCKER/DIURETIC COMBINATIONS atenolol & chlorthalidone tab atenolol & chlorthalidone tab bisoprolol & hydrochlorothiazide tab bisoprolol & hydrochlorothiazide tab bisoprolol & hydrochlorothiazide tab metoprolol & hydrochlorothiazide tab metoprolol & hydrochlorothiazide tab metoprolol & hydrochlorothiazide tab nadolol & bendroflumethiazide tab nadolol & bendroflumethiazide tab propranolol & hydrochlorothiazide tab Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 37

42 propranolol & hydrochlorothiazide tab BETA-BLOCKERS acebutolol hcl cap acebutolol hcl cap atenolol tab 25 1 atenolol tab 50 1 atenolol tab betaxolol hcl tab 10 1 betaxolol hcl tab 20 1 bisoprolol fumarate tab 5 1 bisoprolol fumarate tab 10 1 BYSTOLIC TAB 2.5MG 3 BYSTOLIC TAB 5MG 3 BYSTOLIC TAB 10MG 3 BYSTOLIC TAB 20MG 3 carvedilol tab carvedilol tab carvedilol tab carvedilol tab 25 1 labetalol hcl tab labetalol hcl tab labetalol hcl tab metoprolol succinate tab er 24hr 25 1 (tartrate equiv) metoprolol succinate tab er 24hr 50 1 (tartrate equiv) metoprolol succinate tab er 24hr (tartrate equiv) metoprolol succinate tab er 24hr (tartrate equiv) metoprolol tartrate tab 25 1 metoprolol tartrate tab 50 1 metoprolol tartrate tab nadolol tab 20 1 nadolol tab 40 1 nadolol tab 80 1 pindolol tab 5 1 pindolol tab 10 1 propranolol hcl cap er 24hr 60 1 propranolol hcl cap er 24hr 80 1 propranolol hcl cap er 24hr propranolol hcl cap er 24hr propranolol hcl oral soln 20 /5ml 1 propranolol hcl oral soln 40 /5ml 1 propranolol hcl tab Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 38

43 propranolol hcl tab 20 1 propranolol hcl tab 40 1 propranolol hcl tab 60 1 propranolol hcl tab 80 1 timolol maleate tab 5 1 timolol maleate tab 10 1 timolol maleate tab 20 1 CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS amlodipine besylate-atorvastatin calcium 1 tab amlodipine besylate-atorvastatin calcium 1 tab amlodipine besylate-atorvastatin calcium 1 tab amlodipine besylate-atorvastatin calcium 1 tab 5-10 amlodipine besylate-atorvastatin calcium 1 tab 5-20 amlodipine besylate-atorvastatin calcium 1 tab 5-40 amlodipine besylate-atorvastatin calcium 1 tab 5-80 amlodipine besylate-atorvastatin calcium 1 tab amlodipine besylate-atorvastatin calcium 1 tab amlodipine besylate-atorvastatin calcium 1 tab amlodipine besylate-atorvastatin calcium 1 tab CALCIUM CHANNEL BLOCKERS afeditab tab 30 cr 1 afeditab tab 60 cr 1 amlodipine besylate tab 2.5 (base 1 equivalent) amlodipine besylate tab 5 (base 1 equivalent) amlodipine besylate tab 10 (base 1 equivalent) CARDIZEM LA TAB 120MG 2 cartia xt cap 120/24hr 1 cartia xt cap 180/24hr 1 cartia xt cap 240/24hr 1 cartia xt cap 300/24hr 1 diltiazem hcl cap er 12hr 60 1 diltiazem hcl cap er 12hr 90 1 diltiazem hcl cap er 12hr Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 39

44 diltiazem hcl cap er 24hr diltiazem hcl cap er 24hr diltiazem hcl cap er 24hr diltiazem hcl coated beads cap er 24hr diltiazem hcl coated beads cap er 24hr diltiazem hcl coated beads cap er 24hr diltiazem hcl coated beads cap er 24hr diltiazem hcl coated beads cap er 24hr diltiazem hcl extended release beads cap 1 er 24hr 120 diltiazem hcl extended release beads cap 1 er 24hr 180 diltiazem hcl extended release beads cap 1 er 24hr 240 diltiazem hcl extended release beads cap 1 er 24hr 300 diltiazem hcl extended release beads cap 1 er 24hr 360 diltiazem hcl extended release beads cap 1 er 24hr 420 diltiazem hcl tab 30 1 diltiazem hcl tab 60 1 diltiazem hcl tab 90 1 diltiazem hcl tab felodipine tab er 24hr felodipine tab er 24hr 5 1 felodipine tab er 24hr 10 1 isradipine cap isradipine cap 5 1 matzim la tab 180/24 1 matzim la tab 240/24 1 matzim la tab 300/24 1 matzim la tab 360/24 1 matzim la tab 420/24 1 nicardipine hcl cap 20 1 nicardipine hcl cap 30 1 nifedical xl tab 30 1 nifedical xl tab 60 1 nifedipine tab er 24hr 30 1 nifedipine tab er 24hr 60 1 nifedipine tab er 24hr Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 40

45 nifedipine tab er 24hr osmotic release 90 1 nimodipine cap 30 1 nisoldipine tab er 24hr nisoldipine tab er 24hr 17 1 nisoldipine tab er 24hr 20 1 nisoldipine tab er 24hr nisoldipine tab er 24hr 30 1 nisoldipine tab er 24hr 34 1 nisoldipine tab er 24hr 40 1 taztia xt cap 120/24 1 taztia xt cap 180/24 1 taztia xt cap 240/24 1 taztia xt cap 300/24 1 taztia xt cap 360/24 1 verapamil hcl cap er 24hr verapamil hcl cap er 24hr verapamil hcl cap er 24hr verapamil hcl cap er 24hr verapamil hcl cap er 24hr verapamil hcl cap er 24hr verapamil hcl cap er 24hr verapamil hcl tab 40 1 verapamil hcl tab 80 1 verapamil hcl tab verapamil hcl tab er verapamil hcl tab er verapamil hcl tab er DIGITALIS GLYCOSIDES digoxin oral soln 0.05 /ml 1 digoxin tab 125 mcg (0.125 ) 1 digoxin tab 250 mcg (0.25 ) 1 LANOXIN TAB MG 2 LANOXIN TAB MG 2 DIRECT RENIN INHIBITORS/COMBINATIONS TEKTURNA TAB 150MG 3 ST; ** TEKTURNA TAB 300MG 3 ST; ** DIURETICS acetazolamide cap er 12hr acetazolamide sodium for inj acetazolamide tab acetazolamide tab ALDACTAZIDE TAB 50/50 2 amiloride & hydrochlorothiazide tab Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 41

46 amiloride hcl tab 5 1 bumetanide tab bumetanide tab 1 1 bumetanide tab 2 1 chlorothiazide tab chlorothiazide tab chlorthalidone tab 25 1 chlorthalidone tab 50 1 chlorthalidone tab DIURIL SUS 250/5ML 3 DYRENIUM CAP 50MG 3 DYRENIUM CAP 100MG 3 ethacrynate sodium for inj 50 1 ethacrynic acid tab 25 1 furosemide oral soln 8 /ml 1 furosemide oral soln 10 /ml 1 furosemide tab 20 1 furosemide tab 40 1 furosemide tab 80 1 hydrochlorothiazide cap hydrochlorothiazide tab hydrochlorothiazide tab 25 1 hydrochlorothiazide tab 50 1 indapamide tab indapamide tab methazolamide tab 25 1 methazolamide tab 50 1 methyclothiazide tab 5 1 metolazone tab metolazone tab 5 1 metolazone tab 10 1 spironolactone & hydrochlorothiazide tab spironolactone tab 25 1 spironolactone tab 50 1 spironolactone tab torsemide tab 5 1 torsemide tab 10 1 torsemide tab 20 1 torsemide tab triamterene & hydrochlorothiazide cap triamterene & hydrochlorothiazide cap triamterene & hydrochlorothiazide tab Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 42

47 triamterene & hydrochlorothiazide tab MISCELLANEOUS clonidine hcl tab clonidine hcl tab clonidine hcl tab clonidine hcl td patch weekly 0.1 /24hr 1 clonidine hcl td patch weekly 0.2 /24hr 1 clonidine hcl td patch weekly 0.3 /24hr 1 ENTRESTO TAB 24-26MG 2 ENTRESTO TAB 49-51MG 2 ENTRESTO TAB MG 2 guanfacine hcl tab 1 1 guanfacine hcl tab 2 1 hydralazine hcl tab 10 1 hydralazine hcl tab 25 1 hydralazine hcl tab 50 1 hydralazine hcl tab methyldopa tab methyldopa tab midodrine hcl tab midodrine hcl tab 5 1 midodrine hcl tab 10 1 minoxidil tab minoxidil tab 10 1 phenoxybenzamine hcl cap 10 1 RANEXA TAB 500MG 2 ST; ** RANEXA TAB 1000MG 2 ST; ** reserpine tab reserpine tab NITRATES ISORDIL TAB 40MG 2 isosorbide dinitrate tab 5 1 isosorbide dinitrate tab 10 1 isosorbide dinitrate tab 20 1 isosorbide dinitrate tab 30 1 isosorbide dinitrate tab er 40 1 isosorbide mononitrate tab 10 1 isosorbide mononitrate tab 20 1 isosorbide mononitrate tab er 24hr 30 1 isosorbide mononitrate tab er 24hr 60 1 isosorbide mononitrate tab er 24hr minitran dis 0.1/hr 1 minitran dis 0.2/hr 1 minitran dis 0.4/hr 1 - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 43

48 minitran dis 0.6/hr 1 NITRO-DUR DIS 0.3MG/HR 2 NITRO-DUR DIS 0.8MG/HR 2 nitroglycerin cap er 9 1 nitroglycerin lingual aerosol 400 mcg/spray 1 nitroglycerin sl tab nitroglycerin sl tab nitroglycerin sl tab nitroglycerin td patch 24hr 0.1 /hr 1 nitroglycerin td patch 24hr 0.2 /hr 1 nitroglycerin td patch 24hr 0.4 /hr 1 nitroglycerin td patch 24hr 0.6 /hr 1 nitroglycerin tl soln 0.4 /spray (400 1 mcg/spray) PULMONARY ARTERIAL HYPERTENSION ADCIRCA TAB 20MG 3 QL (60 tabs / 30 days),, ST ADEMS TAB 0.5MG 3 QL (90 tabs / 30 days), ADEMS TAB 1.5MG 3 QL (90 tabs / 30 days), ADEMS TAB 1MG 3 QL (90 tabs / 30 days), ADEMS TAB 2.5MG 3 QL (90 tabs / 30 days), ADEMS TAB 2MG 3 QL (90 tabs / 30 days), epoprostenol sodium for inj epoprostenol sodium for inj LETAIRIS TAB 5MG 3 QL (30 tabs / 30 days), LETAIRIS TAB 10MG 3 QL (30 tabs / 30 days), OPSUMIT TAB 10MG 3 QL (30 tabs / 30 days), ORENITRAM TAB 0.25MG 3 ORENITRAM TAB 0.125MG 3 ORENITRAM TAB 1MG 3 ORENITRAM TAB 2.5MG 3 ORENITRAM TAB 5MG 3 REMODULIN INJ 1MG/ML 3 REMODULIN INJ 2.5MG/ML 3 REMODULIN INJ 5MG/ML 3 REMODULIN INJ 10MG/ML 3 sildenafil citrate iv soln 10 /12.5ml (base equivalent) 3 - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 44

49 sildenafil citrate tab 20 3 QL (90 tabs / 30 days), TRACLEER TAB 32MG 3 QL (112 tabs / 28 days), TRACLEER TAB 62.5MG 3 QL (60 tabs / 30 days), TRACLEER TAB 125MG 3 QL (60 tabs / 30 days), TYVASO START SOL 0.6MG/ML 3 QL (28 ampules / 28 days), UPTRAVI TAB 200/800 3 UPTRAVI TAB 200MCG 3 UPTRAVI TAB 400MCG 3 UPTRAVI TAB 600MCG 3 UPTRAVI TAB 800MCG 3 UPTRAVI TAB 1000MCG 3 UPTRAVI TAB 1200MCG 3 UPTRAVI TAB 1400MCG 3 UPTRAVI TAB 1600MCG 3 VENTAVIS SOL 10MCG/ML 3 QL (270 ml / 30 days), VENTAVIS SOL 20MCG/ML 3 QL (270 ml / 30 days), CENTRAL NERVOUS SYSTEM ANTIANXIETY ALPRAZOLAM CON 1 MG/ML 2 QL (120 ml / 25 days) alprazolam orally disintegrating tab QL (90 tabs / 25 days) alprazolam orally disintegrating tab QL (90 tabs / 25 days) alprazolam orally disintegrating tab 1 1 QL (90 tabs / 25 days) alprazolam orally disintegrating tab 2 1 QL (60 tabs / 25 days) alprazolam tab QL (90 tabs / 25 days) alprazolam tab QL (90 tabs / 25 days) alprazolam tab 1 1 QL (90 tabs / 25 days) alprazolam tab 2 1 QL (60 tabs / 25 days) lorazepam conc 2 /ml 1 QL (150 ml / 25 days) lorazepam tab QL (150 tabs / 25 days) lorazepam tab 1 1 QL (150 tabs / 25 days) lorazepam tab 2 1 QL (150 tabs / 25 days) meprobamate tab meprobamate tab oxazepam cap 10 1 QL (120 caps / 25 days) oxazepam cap 15 1 QL (120 caps / 25 days) oxazepam cap 30 1 QL (120 caps / 25 days) ANTICONVULSANTS APTIOM TAB 200MG 3 - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 45

50 APTIOM TAB 400MG 3 APTIOM TAB 600MG 3 APTIOM TAB 800MG 3 BANZEL SUS 40MG/ML 3 BANZEL TAB 200MG 3 BANZEL TAB 400MG 3 carbamazepine cap er 12hr carbamazepine cap er 12hr carbamazepine cap er 12hr carbamazepine chew tab carbamazepine susp 100 /5ml 1 carbamazepine tab carbamazepine tab er 12hr carbamazepine tab er 12hr carbamazepine tab er 12hr CELONTIN CAP 300MG 3 clonazepam tab clonazepam tab 1 1 clonazepam tab 2 1 clorazepate dipotassium tab QL (120 tabs / 25 days) clorazepate dipotassium tab QL (120 tabs / 25 days) clorazepate dipotassium tab 15 1 QL (120 tabs / 25 days) diazepam con 5/ml 1 QL (240 ml / 25 days) diazepam inj 5 /ml 1 diazepam oral soln 1 /ml 1 QL (1200 ml / 25 days) diazepam tab 2 1 QL (120 tabs / 25 days) diazepam tab 5 1 QL (120 tabs / 25 days) diazepam tab 10 1 QL (120 tabs / 25 days) divalproex sodium cap delayed release sprinkle divalproex sodium tab delayed release divalproex sodium tab delayed release divalproex sodium tab delayed release divalproex sodium tab er 24 hr divalproex sodium tab er 24 hr epitol tab ethosuximide cap ethosuximide soln 250 /5ml 1 felbamate susp 600 /5ml 1 felbamate tab felbamate tab FYCOM SUS 0.5MG/ML 2 FYCOM TAB 2MG 2 - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 46

51 FYCOM TAB 4MG 2 FYCOM TAB 6MG 2 FYCOM TAB 8MG 2 FYCOM TAB 10MG 2 FYCOM TAB 12MG 2 gabapentin cap gabapentin cap gabapentin cap gabapentin oral soln 250 /5ml 1 gabapentin tab gabapentin tab lamotrigine orally disintegrating tab 25 1 lamotrigine orally disintegrating tab 50 1 lamotrigine orally disintegrating tab lamotrigine orally disintegrating tab lamotrigine tab 25 1 lamotrigine tab 25 (35) starter kit 1 lamotrigine tab 25 (42) & 100 (7) 1 starter kit lamotrigine tab 25 (84) & 100 (14) 1 starter kit lamotrigine tab lamotrigine tab lamotrigine tab lamotrigine tab chewable dispersible 5 1 lamotrigine tab chewable dispersible 25 1 lamotrigine tab disint 25 (14) & 50 1 (14) & 100 (7) kit lamotrigine tab disint 25 (21) & 50 1 (7) titration kit lamotrigine tab disint 50 (42) (14) titration kit lamotrigine tab er 24hr 25 1 lamotrigine tab er 24hr 50 1 lamotrigine tab er 24hr lamotrigine tab er 24hr lamotrigine tab er 24hr lamotrigine tab er 24hr levetiracetam oral soln 100 /ml 1 levetiracetam tab levetiracetam tab levetiracetam tab levetiracetam tab levetiracetam tab er 24hr Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 47

52 levetiracetam tab er 24hr LYRICA CAP 25MG 3 ST; ** LYRICA CAP 50MG 3 ST; ** LYRICA CAP 75MG 3 ST; ** LYRICA CAP 100MG 3 ST; ** LYRICA CAP 150MG 3 ST; ** LYRICA CAP 200MG 3 ST; ** LYRICA CAP 225MG 3 ST; ** LYRICA CAP 300MG 3 ST; ** LYRICA SOL 20MG/ML 3 ST; ** ONFI SUS 2.5MG/ML 3 ONFI TAB 10MG 3 ONFI TAB 20MG 3 oxcarbazepine susp 300 /5ml (60 1 /ml) oxcarbazepine tab oxcarbazepine tab oxcarbazepine tab PEGANONE TAB 250MG 3 phenobarbital elixir 20 /5ml 1 phenobarbital tab 15 1 phenobarbital tab phenobarbital tab 30 1 phenobarbital tab phenobarbital tab 60 1 phenobarbital tab phenobarbital tab phenobarbital tab phenytoin chew tab 50 1 phenytoin sodium extended cap phenytoin sodium extended cap phenytoin sodium extended cap phenytoin susp 125 /5ml 1 primidone tab 50 1 primidone tab SABRIL TAB 500MG 3 QL (180 tabs / 30 days), tiagabine hcl tab 2 1 tiagabine hcl tab 4 1 tiagabine hcl tab 12 1 tiagabine hcl tab 16 1 topiramate sprinkle cap 15 1 topiramate sprinkle cap 25 1 topiramate tab 25 1 topiramate tab 50 1 topiramate tab Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 48

53 topiramate tab valproate sodium oral soln 250 /5ml 1 (base equiv) valproic acid cap vigabatrin powd pack QL (180 packets / 30 days), VIMT SOL 10MG/ML 3 VIMT TAB 50MG 3 VIMT TAB 100MG 3 VIMT TAB 150MG 3 VIMT TAB 200MG 3 zonisamide cap 25 1 zonisamide cap 50 1 zonisamide cap ANTIDEMENTIA donepezil hydrochloride orally 1 disintegrating tab 5 donepezil hydrochloride orally 1 disintegrating tab 10 donepezil hydrochloride tab 5 1 donepezil hydrochloride tab 10 1 donepezil hydrochloride tab 23 1 ergoloid mesylates tab 1 1 galantamine hydrobromide cap er 24hr 8 1 galantamine hydrobromide cap er 24hr 16 1 galantamine hydrobromide cap er 24hr 24 1 galantamine hydrobromide oral soln 4 1 /ml galantamine hydrobromide tab 4 1 galantamine hydrobromide tab 8 1 galantamine hydrobromide tab 12 1 memantine hcl cap er 24hr 7 1 ; applies for members less than 30 years of age memantine hcl cap er 24hr 14 1 ; applies for members less than 30 years of age memantine hcl cap er 24hr 21 1 ; applies for members less than 30 years of age memantine hcl cap er 24hr 28 1 ; applies for members less than 30 years of age - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 49

54 memantine hcl oral solution 2 /ml 1 ; applies for members less than 30 years of age memantine hcl tab 5 1 ; applies for members less than 30 years of age memantine hcl tab 5 (28) & 10 (21) titration pak 1 ; applies for members less than 30 years of age memantine hcl tab 10 1 ; applies for members less than 30 years of age NAMENDA XR CAP TITRATIO 2 ; applies for members less than 30 years of age rivastigmine tartrate cap rivastigmine tartrate cap 3 1 rivastigmine tartrate cap rivastigmine tartrate cap 6 1 ANTIDEPRESSANTS amitriptyline hcl tab 10 1 QL (150 tabs / 25 days); QL applies to members age 65 and older amitriptyline hcl tab 25 1 QL (60 tabs / 25 days); QL applies to members age 65 and older amitriptyline hcl tab 50 1 QL (30 tabs / 25 days); QL applies to members age 65 and older amitriptyline hcl tab 75 1 ; Members 65 and older subject to amitriptyline hcl tab ; Members 65 and older subject to amitriptyline hcl tab ; Members 65 and older subject to amoxapine tab 25 1 QL (90 tabs / 25 days); QL applies to members age 65 and older amoxapine tab 50 1 QL (90 tabs / 25 days); QL applies to members age 65 and older amoxapine tab QL (90 tabs / 25 days); QL applies to members age 65 and older amoxapine tab QL (60 tabs / 25 days); QL applies to members age 65 and older bupropion hcl tab Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 50

55 bupropion hcl tab bupropion hcl tab er 12hr bupropion hcl tab er 12hr bupropion hcl tab er 12hr bupropion hcl tab er 24hr bupropion hcl tab er 24hr citalopram hydrobromide oral soln 10 1 /5ml citalopram hydrobromide tab 10 (base 1 equiv) citalopram hydrobromide tab 20 (base 1 equiv) citalopram hydrobromide tab 40 (base 1 equiv) desipramine hcl tab 10 1 QL (90 tabs / 25 days); QL applies to members age 65 and older desipramine hcl tab 25 1 QL (90 tabs / 25 days); QL applies to members age 65 and older desipramine hcl tab 50 1 QL (90 tabs / 25 days); QL applies to members age 65 and older desipramine hcl tab 75 1 QL (60 tabs / 25 days); QL applies to members age 65 and older desipramine hcl tab QL (30 tabs / 25 days); QL applies to members age 65 and older desipramine hcl tab QL (30 tabs / 25 days); QL applies to members age 65 and older desvenlafaxine succinate tab er 24hr 25 (base equiv) 1 ST; (generic of Pristiq) ** desvenlafaxine succinate tab er 24hr 50 (base equiv) 1 ST; (generic of Pristiq) ** desvenlafaxine succinate tab er 24hr 100 (base equiv) 1 ST; (generic of Pristiq) ** doxepin hcl cap 10 1 QL (90 caps / 25 days); QL applies to members age 65 and older doxepin hcl cap 25 1 QL (90 caps / 25 days); QL applies to members age 65 and older doxepin hcl cap 50 1 QL (90 caps / 25 days); QL applies to members age 65 and older - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 51

56 doxepin hcl cap 75 1 QL (60 caps / 25 days); QL applies to members age 65 and older doxepin hcl cap QL (30 caps / 25 days); QL applies to members age 65 and older doxepin hcl cap QL (30 caps / 25 days); QL applies to members age 65 and older doxepin hcl conc 10 /ml 1 QL (450 ml / 25 days); QL applies to members age 65 and older duloxetine hcl cap 20 1 duloxetine hcl cap 30 1 duloxetine hcl cap 60 1 EMSAM DIS 6MG/24HR 3 EMSAM DIS 9MG/24HR 3 EMSAM DIS 12MG/24H 3 escitalopram oxalate soln 5 /5ml (base 1 equiv) escitalopram oxalate tab 5 (base 1 equiv) escitalopram oxalate tab 10 (base 1 equiv) escitalopram oxalate tab 20 (base 1 equiv) FETZIMA CAP 20MG 3 FETZIMA CAP 40MG 3 FETZIMA CAP 80MG 3 FETZIMA CAP 120MG 3 FETZIMA CAP TITRATIO 3 fluoxetine hcl cap 10 1 fluoxetine hcl cap 20 1 fluoxetine hcl cap 40 1 fluoxetine hcl solution 20 /5ml 1 fluoxetine hcl tab 10 1 (generic Sarafem not covered) fluoxetine hcl tab 20 1 (generic Sarafem not covered) imipramine hcl tab 10 1 QL (120 tabs / 25 days); QL applies to members age 65 and older imipramine hcl tab 25 1 QL (120 tabs / 25 days); QL applies to members age 65 and older imipramine hcl tab 50 1 QL (60 tabs / 25 days); QL applies to members age 65 and older - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 52

57 imipramine pamoate cap 75 1 QL (30 caps / 25 days); QL applies to members age 65 and older imipramine pamoate cap QL (30 caps / 25 days); QL applies to members age 65 and older imipramine pamoate cap ; Members 65 and older subject to imipramine pamoate cap ; Members 65 and older subject to maprotiline hcl tab 25 1 maprotiline hcl tab 50 1 maprotiline hcl tab 75 1 MARPLAN TAB 10MG 3 mirtazapine orally disintegrating tab 15 1 mirtazapine orally disintegrating tab 30 1 mirtazapine orally disintegrating tab 45 1 mirtazapine tab mirtazapine tab 15 1 mirtazapine tab 30 1 mirtazapine tab 45 1 nefazodone hcl tab 50 1 nefazodone hcl tab nefazodone hcl tab nefazodone hcl tab nefazodone hcl tab nortriptyline hcl cap 10 1 QL (150 caps / 25 days); QL applies to members age 65 and older nortriptyline hcl cap 25 1 QL (60 caps / 25 days); QL applies to members age 65 and older nortriptyline hcl cap 50 1 QL (30 caps / 25 days); QL applies to members age 65 and older nortriptyline hcl cap 75 1 ; Members 65 and older subject to nortriptyline hcl soln 10 /5ml 1 QL (750 ml / 25 days); QL applies to members age 65 and older paroxetine hcl tab 10 1 paroxetine hcl tab 20 1 paroxetine hcl tab 30 1 paroxetine hcl tab 40 1 paroxetine hcl tab er 24hr paroxetine hcl tab er 24hr Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 53

58 paroxetine hcl tab er 24hr phenelzine sulfate tab 15 1 protriptyline hcl tab 5 1 QL (90 tabs / 25 days); QL applies to members age 65 and older protriptyline hcl tab 10 1 QL (60 tabs / 25 days); QL applies to members age 65 and older sertraline hcl oral concentrate for solution 1 20 /ml sertraline hcl tab 25 1 sertraline hcl tab 50 1 sertraline hcl tab tranylcypromine sulfate tab 10 1 trazodone hcl tab 50 1 trazodone hcl tab trazodone hcl tab trazodone hcl tab trimipramine maleate cap 25 1 QL (60 caps / 25 days); QL applies to members age 65 and older trimipramine maleate cap 50 1 QL (60 caps / 25 days); QL applies to members age 65 and older trimipramine maleate cap QL (30 caps / 25 days); QL applies to members age 65 and older TRINTELLIX TAB 5MG 3 ST; ** TRINTELLIX TAB 10MG 3 ST; ** TRINTELLIX TAB 20MG 3 ST; ** venlafaxine hcl cap er 24hr 37.5 (base 1 equivalent) venlafaxine hcl cap er 24hr 75 (base 1 equivalent) venlafaxine hcl cap er 24hr 150 (base 1 equivalent) venlafaxine hcl tab 25 1 venlafaxine hcl tab venlafaxine hcl tab 50 1 venlafaxine hcl tab 75 1 venlafaxine hcl tab venlafaxine hcl tab er 24hr 37.5 (base 1 equivalent) venlafaxine hcl tab er 24hr 75 (base 1 equivalent) venlafaxine hcl tab er 24hr 150 (base 1 equivalent) - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 54

59 VIIBRYD KIT STARTER 3 ST; ** VIIBRYD TAB 10MG 3 ST; ** VIIBRYD TAB 20MG 3 ST; ** VIIBRYD TAB 40MG 3 ST; ** ANTIRKINSONIAN AGENTS amantadine hcl cap amantadine hcl syrup 50 /5ml 1 amantadine hcl tab APOKYN INJ 10MG/ML 3 benztropine mesylate tab benztropine mesylate tab 1 1 benztropine mesylate tab 2 1 bromocriptine mesylate cap 5 (base 1 equivalent) bromocriptine mesylate tab 2.5 (base equivalent) 1 carbidopa & levodopa orally disintegrating 1 tab carbidopa & levodopa orally disintegrating 1 tab carbidopa & levodopa orally disintegrating 1 tab carbidopa & levodopa tab carbidopa & levodopa tab carbidopa & levodopa tab carbidopa & levodopa tab er carbidopa & levodopa tab er carbidopa tab 25 1 carbidopa-levodopa-entacapone tabs carbidopa-levodopa-entacapone tabs carbidopa-levodopa-entacapone tabs carbidopa-levodopa-entacapone tabs carbidopa-levodopa-entacapone tabs carbidopa-levodopa-entacapone tabs entacapone tab pramipexole dihydrochloride tab pramipexole dihydrochloride tab pramipexole dihydrochloride tab pramipexole dihydrochloride tab pramipexole dihydrochloride tab 1 1 pramipexole dihydrochloride tab Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 55

60 pramipexole dihydrochloride tab er 24hr pramipexole dihydrochloride tab er 24hr pramipexole dihydrochloride tab er 24hr pramipexole dihydrochloride tab er 24hr pramipexole dihydrochloride tab er 24hr 3 1 pramipexole dihydrochloride tab er 24hr pramipexole dihydrochloride tab er 24hr rasagiline mesylate tab 0.5 (base 1 equiv) rasagiline mesylate tab 1 (base equiv) 1 ropinirole hydrochloride tab ropinirole hydrochloride tab ropinirole hydrochloride tab 1 1 ropinirole hydrochloride tab 2 1 ropinirole hydrochloride tab 3 1 ropinirole hydrochloride tab 4 1 ropinirole hydrochloride tab 5 1 selegiline hcl cap 5 1 selegiline hcl tab 5 1 tolcapone tab trihexyphenidyl hcl elixir 0.4 /ml 1 trihexyphenidyl hcl tab 2 1 trihexyphenidyl hcl tab 5 1 ANTIPSYCHOTICS aripiprazole oral solution 1 /ml 1 aripiprazole orally disintegrating tab 10 1 aripiprazole orally disintegrating tab 15 1 aripiprazole tab 2 1 aripiprazole tab 5 1 aripiprazole tab 10 1 aripiprazole tab 15 1 aripiprazole tab 20 1 aripiprazole tab 30 1 ARISTADA INJ 441MG/1. 2 ARISTADA INJ 662MG/2 2 ARISTADA INJ 882MG/3 2 ARISTADA INJ 1064MG 2 chlorpromazine hcl tab 10 1 chlorpromazine hcl tab Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 56

61 chlorpromazine hcl tab 50 1 chlorpromazine hcl tab chlorpromazine hcl tab clozapine orally disintegrating tab clozapine orally disintegrating tab 25 1 clozapine orally disintegrating tab clozapine orally disintegrating tab clozapine orally disintegrating tab clozapine tab 25 1 clozapine tab 50 1 clozapine tab clozapine tab fluphenazine hcl elixir 2.5 /5ml 1 fluphenazine hcl oral conc 5 /ml 1 fluphenazine hcl tab 1 1 fluphenazine hcl tab fluphenazine hcl tab 5 1 fluphenazine hcl tab 10 1 haloperidol decanoate im soln 50 /ml 1 haloperidol decanoate im soln 100 /ml 1 haloperidol lactate oral conc 2 /ml 1 haloperidol tab haloperidol tab 1 1 haloperidol tab 2 1 haloperidol tab 5 1 haloperidol tab 10 1 haloperidol tab 20 1 LATUDA TAB 20MG 2 ST; ** LATUDA TAB 40MG 2 ST; ** LATUDA TAB 60MG 2 ST; ** LATUDA TAB 80MG 2 ST; ** LATUDA TAB 120MG 2 ST; ** loxapine succinate cap 5 1 loxapine succinate cap 10 1 loxapine succinate cap 25 1 loxapine succinate cap 50 1 NUPLAZID TAB 17MG 3 olanzapine orally disintegrating tab 5 1 olanzapine orally disintegrating tab 10 1 olanzapine orally disintegrating tab 15 1 olanzapine orally disintegrating tab 20 1 olanzapine tab olanzapine tab 5 1 olanzapine tab olanzapine tab 10 1 olanzapine tab Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 57

62 olanzapine tab 20 1 paliperidone tab er 24hr paliperidone tab er 24hr 3 1 paliperidone tab er 24hr 6 1 paliperidone tab er 24hr 9 1 perphenazine tab 2 1 perphenazine tab 4 1 perphenazine tab 8 1 perphenazine tab 16 1 quetiapine fumarate tab 25 1 quetiapine fumarate tab 50 1 quetiapine fumarate tab quetiapine fumarate tab quetiapine fumarate tab quetiapine fumarate tab quetiapine fumarate tab er 24hr 50 1 quetiapine fumarate tab er 24hr quetiapine fumarate tab er 24hr quetiapine fumarate tab er 24hr quetiapine fumarate tab er 24hr REXULTI TAB 0.5MG 3 ST; ** REXULTI TAB 0.25MG 3 ST; ** REXULTI TAB 1MG 3 ST; ** REXULTI TAB 2MG 3 ST; ** REXULTI TAB 3MG 3 ST; ** REXULTI TAB 4MG 3 ST; ** risperidone orally disintegrating tab risperidone orally disintegrating tab risperidone orally disintegrating tab 1 1 risperidone orally disintegrating tab 2 1 risperidone orally disintegrating tab 3 1 risperidone orally disintegrating tab 4 1 risperidone soln 1 /ml 1 risperidone tab risperidone tab risperidone tab 1 1 risperidone tab 2 1 risperidone tab 3 1 risperidone tab 4 1 SAPHRIS SUB 2.5MG 3 ST; ** SAPHRIS SUB 5MG 3 ST; ** SAPHRIS SUB 10MG 3 ST; ** thioridazine hcl tab 10 1 thioridazine hcl tab 25 1 thioridazine hcl tab Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 58

63 thioridazine hcl tab thiothixene cap 1 1 thiothixene cap 2 1 thiothixene cap 5 1 thiothixene cap 10 1 trifluoperazine hcl tab 1 (base 1 equivalent) trifluoperazine hcl tab 2 (base 1 equivalent) trifluoperazine hcl tab 5 (base 1 equivalent) trifluoperazine hcl tab 10 (base 1 equivalent) ziprasidone hcl cap 20 1 ziprasidone hcl cap 40 1 ziprasidone hcl cap 60 1 ziprasidone hcl cap 80 1 ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine-dextroamphetamine cap er 1 QL (90 caps / 25 days) 24hr 5 amphetamine-dextroamphetamine cap er 1 QL (90 caps / 25 days) 24hr 10 amphetamine-dextroamphetamine cap er 1 QL (30 caps / 25 days) 24hr 15 amphetamine-dextroamphetamine cap er 1 QL (30 caps / 25 days) 24hr 20 amphetamine-dextroamphetamine cap er 1 QL (30 caps / 25 days) 24hr 25 amphetamine-dextroamphetamine cap er 1 QL (30 caps / 25 days) 24hr 30 amphetamine-dextroamphetamine tab 5 1 QL (90 tabs / 25 days) amphetamine-dextroamphetamine tab QL (90 tabs / 25 days) amphetamine-dextroamphetamine tab 10 1 QL (90 tabs / 25 days) amphetamine-dextroamphetamine tab 1 QL (90 tabs / 25 days) 12.5 amphetamine-dextroamphetamine tab 15 1 QL (60 tabs / 25 days) amphetamine-dextroamphetamine tab 20 1 QL (60 tabs / 25 days) amphetamine-dextroamphetamine tab 30 1 QL (30 tabs / 25 days) atomoxetine hcl cap 10 (base equiv) 1 atomoxetine hcl cap 18 (base equiv) 1 atomoxetine hcl cap 25 (base equiv) 1 - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 59

64 atomoxetine hcl cap 40 (base equiv) 1 atomoxetine hcl cap 60 (base equiv) 1 atomoxetine hcl cap 80 (base equiv) 1 atomoxetine hcl cap 100 (base equiv) 1 dexmethylphenidate hcl cap er 24 hr 5 1 QL (60 caps / 25 days) dexmethylphenidate hcl cap er 24 hr 10 1 QL (60 caps / 25 days) dexmethylphenidate hcl cap er 24 hr 15 1 QL (60 caps / 25 days) dexmethylphenidate hcl cap er 24 hr 20 1 QL (60 caps / 25 days) dexmethylphenidate hcl cap er 24 hr 25 1 QL (30 caps / 25 days) dexmethylphenidate hcl cap er 24 hr 30 1 QL (30 caps / 25 days) dexmethylphenidate hcl cap er 24 hr 35 1 QL (30 caps / 25 days) dexmethylphenidate hcl cap er 24 hr 40 1 QL (30 caps / 25 days) dexmethylphenidate hcl tab QL (120 tabs / 25 days) dexmethylphenidate hcl tab 5 1 QL (120 tabs / 25 days) dexmethylphenidate hcl tab 10 1 QL (60 tabs / 25 days) dextroamphetamine sulfate cap er 24hr 5 1 QL (120 caps / 25 days) dextroamphetamine sulfate cap er 24hr 10 1 QL (120 caps / 25 days) dextroamphetamine sulfate cap er 24hr 15 1 QL (60 caps / 25 days) dextroamphetamine sulfate oral solution 5 1 QL (1,200 ml / 25 days) /5ml dextroamphetamine sulfate tab 5 1 QL (120 tabs / 25 days) dextroamphetamine sulfate tab 10 1 QL (120 tabs / 25 days) guanfacine hcl tab er 24hr 1 (base 1 ST; ** equiv) guanfacine hcl tab er 24hr 2 (base 1 ST; ** equiv) guanfacine hcl tab er 24hr 3 (base 1 ST; ** equiv) guanfacine hcl tab er 24hr 4 (base 1 ST; ** equiv) methamphetamine hcl tab 5 1 QL (150 tabs / 25 days) methylphenidate hcl cap er 10 (cd) 1 QL (60 caps / 25 days) methylphenidate hcl cap er 20 (cd) 1 QL (60 caps / 25 days) methylphenidate hcl cap er 24hr 20 1 QL (60 caps / 25 days) (la) methylphenidate hcl cap er 24hr 30 (la) 1 QL (60 caps / 25 days) - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 60

65 methylphenidate hcl cap er 24hr 40 1 QL (30 caps / 25 days) (la) methylphenidate hcl cap er 24hr 60 1 QL (30 caps / 25 days) (la) methylphenidate hcl cap er 30 (cd) 1 QL (60 caps / 25 days) methylphenidate hcl cap er 40 (cd) 1 QL (30 caps / 25 days) methylphenidate hcl cap er 50 (cd) 1 QL (30 caps / 25 days) methylphenidate hcl cap er 60 (cd) 1 QL (30 caps / 25 days) methylphenidate hcl chew tab QL (180 chew tabs / 25 days) methylphenidate hcl chew tab 5 1 QL (180 chew tabs / 25 days) methylphenidate hcl chew tab 10 1 QL (180 chew tabs / 25 days) methylphenidate hcl soln 5 /5ml 1 QL (1800 ml / 25 days) methylphenidate hcl soln 10 /5ml 1 QL (900 ml / 25 days) methylphenidate hcl tab 5 1 QL (180 tabs / 25 days) methylphenidate hcl tab 10 1 QL (180 tabs / 25 days) methylphenidate hcl tab 20 1 QL (90 tabs / 25 days) methylphenidate hcl tab er 10 1 QL (90 tabs / 25 days) methylphenidate hcl tab er 20 1 QL (90 tabs / 25 days) methylphenidate hcl tab er 24hr 18 1 QL (60 tabs / 25 days) methylphenidate hcl tab er 24hr 27 1 QL (60 tabs / 25 days) methylphenidate hcl tab er 24hr 36 1 QL (60 tabs / 25 days) methylphenidate hcl tab er 24hr 54 1 QL (30 tabs / 25 days) methylphenidate hcl tab er osmotic release 1 QL (60 tabs / 25 days) (osm) 18 methylphenidate hcl tab er osmotic release 1 QL (60 tabs / 25 days) (osm) 27 methylphenidate hcl tab er osmotic release 1 QL (60 tabs / 25 days) (osm) 36 methylphenidate hcl tab er osmotic release 1 QL (30 tabs / 25 days) (osm) 54 VYVANSE CAP 10MG 2 VYVANSE CAP 20MG 2 VYVANSE CAP 30MG 2 VYVANSE CAP 40MG 2 VYVANSE CAP 50MG 2 VYVANSE CAP 60MG 2 VYVANSE CAP 70MG 2 VYVANSE CHW 10MG 2 VYVANSE CHW 20MG 2 VYVANSE CHW 30MG 2 VYVANSE CHW 40MG 2 VYVANSE CHW 50MG 2 VYVANSE CHW 60MG 2 zenzedi tab QL (120 tabs / 25 days) - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 61

66 zenzedi tab QL (120 tabs / 25 days) zenzedi tab 15 1 QL (60 tabs / 25 days) zenzedi tab 20 1 QL (60 tabs / 25 days) zenzedi tab 30 1 QL (30 tabs / 25 days) HYPNOTICS BELSOMRA TAB 5MG 2 ST; ** BELSOMRA TAB 10MG 2 ST; ** BELSOMRA TAB 15MG 2 ST; ** BELSOMRA TAB 20MG 2 ST; ** doxylamine succinate tab 25 1 OTC eszopiclone tab 1 1 QL (15 tabs / 25 days) eszopiclone tab 2 1 QL (15 tabs / 25 days) eszopiclone tab 3 1 QL (15 tabs / 25 days) ROZEREM TAB 8MG 3 QL (15 tabs / 25 days), ST; ** temazepam cap QL (15 caps / 25 days) temazepam cap 15 1 QL (15 caps / 25 days) temazepam cap QL (15 caps / 25 days) temazepam cap 30 1 QL (15 caps / 25 days) zaleplon cap 5 1 QL (15 caps / 25 days) zaleplon cap 10 1 QL (15 caps / 25 days) zolpidem tartrate tab 5 1 QL (15 tabs / 25 days) zolpidem tartrate tab 10 1 QL (15 tabs / 25 days) zolpidem tartrate tab er QL (15 tabs / 25 days) zolpidem tartrate tab er QL (15 tabs / 25 days) MIGRAINE almotriptan malate tab QL (12 tabs / 25 days) almotriptan malate tab QL (12 tabs / 25 days) dihydroergotamine mesylate inj 1 /ml 1 dihydroergotamine mesylate nasal spray 4 1 QL (8 units / 25 days) /ml eletriptan hydrobromide tab 20 (base 1 QL (12 tabs / 25 days) equivalent) eletriptan hydrobromide tab 40 (base 1 QL (12 tabs / 25 days) equivalent) ergotamine w/ caffeine tab frovatriptan succinate tab 2.5 (base 1 QL (18 tabs / 25 days) equivalent) naratriptan hcl tab 1 (base equiv) 1 QL (12 tabs / 25 days) naratriptan hcl tab 2.5 (base equiv) 1 QL (12 tabs / 25 days) rizatriptan benzoate oral disintegrating tab 1 QL (18 tabs / 25 days) 5 (base eq) rizatriptan benzoate oral disintegrating tab 1 QL (18 tabs / 25 days) 10 (base eq) rizatriptan benzoate tab 5 (base equivalent) 1 QL (18 tabs / 25 days) - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 62

67 rizatriptan benzoate tab 10 (base 1 QL (18 tabs / 25 days) equivalent) sumatriptan nasal spray 5 /act 1 QL (24 sprays / 25 days) sumatriptan nasal spray 20 /act 1 QL (12 sprays / 25 days) sumatriptan succinate inj 6 /0.5ml 1 QL (12 vials / 25 days) sumatriptan succinate solution autoinjector 4 /0.5ml 1 QL (18 syringes / 25 days) sumatriptan succinate solution autoinjector 6 /0.5ml 1 QL (12 units / 25 days) sumatriptan succinate solution cartridge 4 1 QL (18 syringes / 25 /0.5ml days) sumatriptan succinate solution cartridge 6 1 QL (12 units / 25 days) /0.5ml sumatriptan succinate solution prefilled 1 QL (12 units / 25 days) syringe 6 /0.5ml sumatriptan succinate tab 25 1 QL (12 tabs / 25 days) sumatriptan succinate tab 50 1 QL (12 tabs / 25 days) sumatriptan succinate tab QL (12 tabs / 25 days) zolmitriptan orally disintegrating tab QL (12 tabs / 25 days) zolmitriptan orally disintegrating tab 5 1 QL (12 tabs / 25 days) zolmitriptan tab QL (12 tabs / 25 days) zolmitriptan tab 5 1 QL (12 tabs / 25 days) ZOMIG SPR 2.5MG 3 QL (12 sprays / 25 days) ZOMIG SPR 5MG 3 QL (12 sprays / 25 days) MISCELLANEOUS buspirone hcl tab 5 1 buspirone hcl tab buspirone hcl tab 10 1 buspirone hcl tab 15 1 buspirone hcl tab 30 1 clomipramine hcl cap 25 1 QL (150 caps / 25 days); QL applies to members age 65 and older clomipramine hcl cap 50 1 QL (150 caps / 25 days); QL applies to members age 65 and older clomipramine hcl cap 75 1 QL (90 caps / 25 days); QL applies to members age 65 and older fluvoxamine maleate cap er 24hr Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 63

68 fluvoxamine maleate cap er 24hr fluvoxamine maleate tab 25 1 fluvoxamine maleate tab 50 1 fluvoxamine maleate tab GUANIDINE TAB 125MG 3 lithium carbonate cap lithium carbonate cap lithium carbonate cap lithium carbonate tab lithium carbonate tab er lithium carbonate tab er LITHIUM SOL 8MEQ/5ML 3 MESTINON SYP 60MG/5ML 2 NUEDEXTA CAP 20-10MG 2 pimozide tab 1 1 pimozide tab 2 1 pyridostigmine bromide tab 60 1 pyridostigmine bromide tab er riluzole tab 50 1 SAVELLA MIS TITR K 3 SAVELLA TAB 12.5MG 3 SAVELLA TAB 25MG 3 SAVELLA TAB 50MG 3 SAVELLA TAB 100MG 3 tetrabenazine tab QL (240 tabs / 30 days), tetrabenazine tab 25 3 QL (120 tabs / 30 days), MULTIPLE SCLEROSIS AGENTS AMPYRA TAB 10MG 3 QL (60 tabs / 30 days), AUBAGIO TAB 7MG 2 QL (30 tabs / 30 days), AUBAGIO TAB 14MG 2 QL (30 tabs / 30 days), AVONEX KIT 30MCG 3 QL (4 injections / 28 days),, ST AVONEX PEN KIT 30MCG 3 QL (4 injections / 28 days),, ST AVONEX PREFL KIT 30MCG 3 QL (4 injections / 28 days),, ST BETASERON INJ 0.3MG 2 QL (14 injections / 28 days), COXONE INJ 40MG/ML 2 QL (12 syringes / 28 days), GILENYA CAP 0.5MG 2 QL (30 caps / 30 days), - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 64

69 glatiramer acetate soln prefilled syringe 20 2 QL (30 injections / 30 /ml days), glatiramer acetate soln prefilled syringe 40 2 QL (12 syringes / 28 /ml days), PLEGRIDY INJ 3 QL (1 carton / 28 days),, ST PLEGRIDY INJ PEN 3 QL (1 carton / 28 days),, ST PLEGRIDY INJ STARTER 3 QL (1 kit / 28 days),, ST PLEGRIDY PEN INJ STARTER 3 QL (1 pack / 28 days),, ST REBIF INJ 22/0.5 2 QL (12 syringes / 28 days), REBIF INJ 44/0.5 2 QL (12 syringes / 28 days), REBIF REBIDO INJ 22/0.5 2 QL (12 syringes / 28 days), REBIF REBIDO INJ 44/0.5 2 QL (12 syringes / 28 days), REBIF REBIDO INJ TITRATN 2 QL (1 box / 28 days), REBIF TITRTN INJ CK 2 QL (1 box / 28 days), TECFIDERA CAP 120MG 2 QL (14 caps / 7 days), TECFIDERA CAP 240MG 2 QL (60 caps / 30 days), TECFIDERA MIS STARTER 2 QL (1 kit / 30 days), TYSABRI INJ 300/15ML 3 QL (1 vial / 28 days), MUSCULOSKELETAL THERAPY AGENTS baclofen tab 10 1 baclofen tab 20 1 carisoprodol tab ; High Risk Medications require for members age 65 and older carisoprodol tab ; High Risk Medications require for members age 65 and older chlorzoxazone tab cyclobenzaprine hcl tab 5 1 ; High Risk Medications require for members age 65 and older cyclobenzaprine hcl tab ; High Risk Medications require for members age 65 and older - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 65

70 cyclobenzaprine hcl tab 10 1 ; High Risk Medications require for members age 65 and older dantrolene sodium cap 25 1 dantrolene sodium cap 50 1 dantrolene sodium cap metaxalone tab ; High Risk Medications require for members age 65 and older metaxalone tab ; High Risk Medications require for members age 65 and older methocarbamol tab ; High Risk Medications require for members age 65 and older methocarbamol tab ; High Risk Medications require for members age 65 and older orphenadrine citrate inj 30 /ml 1 orphenadrine citrate tab er 12hr ; High Risk Medications require for members age 65 and older tizanidine hcl cap 2 (base equivalent) 1 tizanidine hcl cap 4 (base equivalent) 1 tizanidine hcl cap 6 (base equivalent) 1 tizanidine hcl tab 2 (base equivalent) 1 tizanidine hcl tab 4 (base equivalent) 1 NARCOLEPSY/CATAPLEXY armodafinil tab 50 1 armodafinil tab armodafinil tab armodafinil tab modafinil tab modafinil tab XYREM SOL 500MG/ML 2 PSYCHOTHERAPEUTIC-MISC acamprosate calcium tab delayed release CHANTIX K 0.5& 1MG 0 $0 limited to 2 treatment cycles/year - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 66

71 CHANTIX K 1MG 0 $0 limited to 2 treatment cycles/year CHANTIX TAB 0.5MG 0 $0 limited to 2 treatment cycles/year CHANTIX TAB 1MG 0 $0 limited to 2 treatment cycles/year disulfiram tab disulfiram tab naloxone hcl inj 0.4 /ml 1 naloxone hcl inj 4 /10ml 1 naloxone hcl soln cartridge 0.4 /ml 1 naloxone hcl soln prefilled syringe 2 1 /2ml naltrexone hcl tab 50 1 NARCAN SPR 2 nicorelief gum 4 mint 0 OTC; $0 limited to 2 treatment cycles/year nicotine pol loz 4 mint 0 OTC; $0 limited to 2 treatment cycles/year nicotine polacrilex gum 2 0 OTC; $0 limited to 2 treatment cycles/year nicotine polacrilex gum 4 0 OTC; $0 limited to 2 treatment cycles/year nicotine polacrilex lozenge 2 0 OTC; $0 limited to 2 treatment cycles/year nicotine td patch 24hr 7 /24hr 0 OTC; $0 limited to 2 treatment cycles/year nicotine td patch 24hr 14 /24hr 0 OTC; $0 limited to 2 treatment cycles/year nicotine td patch 24hr 21 /24hr 0 OTC; $0 limited to 2 treatment cycles/year NICOTROL INH 0 QL (max 168 days / year); $0 limited to 2 treatment cycles/year NICOTROL NS SPR 10MG/ML 0 QL (max 168 days / year); $0 limited to 2 treatment cycles/year sm nicotine dis 7/24hr 0 OTC; $0 limited to 2 treatment cycles/year sm nicotine dis 14/24h 0 OTC; $0 limited to 2 treatment cycles/year sm nicotine dis 21 0 OTC; $0 limited to 2 treatment cycles/year ENDOCRINE AND METABOLIC ANDROGENS methyltestosterone cap Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 67

72 testosterone cypionate im inj in oil /ml testosterone cypionate im inj in oil /ml testosterone enanthate im inj in oil /ml testosterone td gel 10/act (2%) 1 testosterone td gel 25 /2.5gm (1%) 1 ANTIDIABETICS, ALPHA-GLUCOSIDASE INHIBITORS acarbose tab 25 1 acarbose tab 50 1 acarbose tab miglitol tab 25 1 miglitol tab 50 1 miglitol tab ANTIDIABETICS, AMYLIN ANALOGS SYMLINPEN 60 INJ 1000MCG 3 SYMLNPEN 120 INJ 1000MCG 3 ANTIDIABETICS, BIGUANIDE metformin hcl tab metformin hcl tab metformin hcl tab metformin hcl tab er 24hr metformin hcl tab er 24hr metformin hcl tab er 24hr osmotic metformin hcl tab er 24hr osmotic ANTIDIABETICS, BIGUANIDE/ SULFONYLUREA COMBINATIONS glipizide-metformin hcl tab glipizide-metformin hcl tab glipizide-metformin hcl tab glyburide-metformin tab ; High Risk Medications require for members age 65 and older glyburide-metformin tab ; High Risk Medications require for members age 65 and older glyburide-metformin tab ; High Risk Medications require for members age 65 and older ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 INHIBITORS alogliptin benzoate tab 6.25 (base equiv) 1 - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 68

73 alogliptin benzoate tab 12.5 (base equiv) 1 alogliptin benzoate tab 25 (base equiv) 1 JANUVIA TAB 25MG 2 JANUVIA TAB 50MG 2 JANUVIA TAB 100MG 2 TRADJENTA TAB 5MG 2 ANTIDIABETICS, DOMINE RECEPTOR AGONISTS CYCLOSET TAB 0.8MG 3 ANTIDIABETICS, DPP-4 INHIBITOR COMBINATIONS JANUMET TAB MG 2 JANUMET TAB JANUMET XR TAB MG 2 JANUMET XR TAB JANUMET XR TAB JENTADUETO TAB JENTADUETO TAB JENTADUETO TAB JENTADUETO TAB XR 2 ANTIDIABETICS, INCRETIN MIMETIC AGENTS OZEMPIC INJ 2/1.5ML 2 TANZEUM INJ 30MG 3 TANZEUM INJ 50MG 3 TRULICITY INJ 0.75/0.5 2 TRULICITY INJ 1.5/0.5 2 VICTOZA INJ 18MG/3ML 2 ANTIDIABETICS, INSULIN APIDRA INJ SOLOSTAR 2 APIDRA INJ U BASAGLAR KWIKPEN 2 FIASP FLEX INJ TOUCH 2 FIASP INJ 100/ML 2 HUMALOG INJ 100/ML 3 HUMALOG KWIK INJ 100/ML 3 HUMALOG KWIK INJ 200/ML 3 HUMALOG MIX INJ 50/50 3 HUMALOG MIX INJ 50/50KWP 3 HUMALOG MIX INJ 75/25KWP 3 HUMALOG MIX SUS 75/25 3 HUMULIN INJ 70/30 3 OTC HUMULIN INJ 70/30KWP 3 OTC HUMULIN N INJ U OTC HUMULIN N INJ U-100KWP 3 OTC HUMULIN R INJ U OTC HUMULIN R INJ U Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 69

74 LEVEMIR INJ 2 LEVEMIR INJ FLEXTOUC 2 NOVOLIN INJ 70/30 2 OTC;RELION not covered NOVOLIN N INJ U OTC;RELION not covered NOVOLIN R INJ U OTC;RELION not covered NOVOLOG INJ 100/ML 2 NOVOLOG INJ FLEXPEN 2 NOVOLOG INJ PENFILL 2 NOVOLOG MIX INJ 70/30 2 NOVOLOG MIX INJ FLEXPEN 2 TRESIBA FLEX INJ 100UNIT 2 TRESIBA FLEX INJ 200UNIT 2 ANTIDIABETICS, INSULIN SENSITIZER pioglitazone hcl tab 15 (base equiv) 1 pioglitazone hcl tab 30 (base equiv) 1 pioglitazone hcl tab 45 (base equiv) 1 ANTIDIABETICS, INSULIN SENSITIZER/BIGUANIDE COMBINATION pioglitazone hcl-metformin hcl tab pioglitazone hcl-metformin hcl tab ANTIDIABETICS, INSULIN SENSITIZER/SULFONYLUREA COMBINATION pioglitazone hcl-glimepiride tab pioglitazone hcl-glimepiride tab ANTIDIABETICS, MEGLITINIDE nateglinide tab 60 1 nateglinide tab repaglinide tab repaglinide tab 1 1 repaglinide tab 2 1 ANTIDIABETICS, MEGLITINIDE/BIGUANIDE COMBINATION repaglinide-metformin hcl tab repaglinide-metformin hcl tab ANTIDIABETICS, SODIUM-GLUC CO-TRANSPOR2 INHIB (SGLT2) COMBO INVOKAMET TAB MG 2 INVOKAMET TAB INVOKAMET TAB INVOKAMET TAB INVOKAMET XR TAB MG 2 INVOKAMET XR TAB Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 70

75 INVOKAMET XR TAB INVOKAMET XR TAB XIGDUO XR TAB XIGDUO XR TAB 5-500MG 2 XIGDUO XR TAB MG 2 XIGDUO XR TAB MG 2 XIGDUO XR TAB ANTIDIABETICS, SODIUM-GLUC CO-TRANSPOR2 INHIB (SGLT2)/DPP-4 INHIBITOR COMBINATIONS QTERN TAB 10MG/5MG 2 ANTIDIABETICS, SODIUM-GLUCOSE COTRANSPORTER2(SGLT2) INHIB FARXIGA TAB 5MG 2 FARXIGA TAB 10MG 2 INVOKANA TAB 100MG 2 INVOKANA TAB 300MG 2 JARDIANCE TAB 10MG 3 ST; ** JARDIANCE TAB 25MG 3 ST; ** ANTIDIABETICS, SULFONYLUREA glimepiride tab 1 1 glimepiride tab 2 1 glimepiride tab 4 1 glipizide tab 5 1 glipizide tab 10 1 glipizide tab er 24hr glipizide tab er 24hr 5 1 glipizide tab er 24hr 10 1 glyburide micronized tab ; High Risk Medications require for members age 65 and older glyburide micronized tab 3 1 ; High Risk Medications require for members age 65 and older glyburide micronized tab 6 1 ; High Risk Medications require for members age 65 and older glyburide tab ; High Risk Medications require for members age 65 and older - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 71

76 glyburide tab ; High Risk Medications require for members age 65 and older glyburide tab 5 1 ; High Risk Medications require for members age 65 and older BISPHOSPHONATES alendronate sodium oral soln 70 /75ml 1 alendronate sodium tab 5 1 alendronate sodium tab 10 1 alendronate sodium tab 35 1 alendronate sodium tab 40 1 alendronate sodium tab 70 1 FOSAMAX + D TAB ST; ** FOSAMAX + D TAB ST; ** ibandronate sodium tab 150 (base 1 equivalent) pamidronate disodium for inj 30 1 pamidronate disodium for inj 90 1 pamidronate disodium iv soln 3 /ml 1 pamidronate disodium iv soln 9 /ml 1 risedronate sodium tab 5 1 risedronate sodium tab 30 1 risedronate sodium tab 35 1 risedronate sodium tab risedronate sodium tab delayed release 35 1 zoledronic acid inj conc for iv infusion 4 3 /5ml zoledronic acid iv soln 5 /100ml 3 CALCIUM RECEPTOR AGONISTS SENSIR TAB 30MG 3 SENSIR TAB 60MG 3 QL (60 tabs / 30 days), SENSIR TAB 90MG 3 QL (120 tabs / 30 days), CHELATING AGENTS CHEMET CAP 100MG 3 DEPEN TITRA TAB 250MG 3 FERRIPROX SOL 100MG/ML 3 FERRIPROX TAB 500MG 3 JADENU SPRKL GRA 90MG 3 JADENU SPRKL GRA 180MG 3 JADENU SPRKL GRA 360MG 3 - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 72

77 JADENU TAB 90MG 3 JADENU TAB 180MG 3 JADENU TAB 360MG 3 kionex sus 15gm/60 1 sodium polystyrene sulfonate oral susp 15 1 gm/60ml sodium polystyrene sulfonate rectal susp 1 30 gm/120ml trientine hcl cap CONTRACEPTIVES altavera tab 0 alyacen tab 1/35 0 alyacen tab 7/7/7 0 amethia tab 0 amethyst tab 90-20mcg 0 apri tab 0 aranelle tab 0 ashlyna tab 0 aviane tab 0 azurette tab 28 day 0 BALCOLTRA TAB camila tab caziant pak 0 chateal tab 0.15/30 0 cryselle-28 tab 28 tabs 0 cyclafem tab 1/35 0 cyclafem tab 7/7/7 0 dasetta tab 1/35 0 dasetta tab 7/7/7 0 delyla tab DEPO-SQ PROV INJ QL (4 inj / 300 days) drospirenone-ethinyl estrad-levomefolate 0 tab drospirenone-ethinyl estrad-levomefolate 0 tab drospirenone-ethinyl estradiol tab elinest tab 0 ELLA TAB 30MG 0 emoquette tab 0 enpresse-28 tab 0 enskyce tab 0 errin tab ethynodiol diacetate & ethinyl estradiol tab mcg falmina tab 0 - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 73

78 fayosim tab 0 gianvi tab gildess fe tab 1.5/30 0 gildess fe tab 1/20 0 gildess tab 1.5/30 0 gildess tab 1/20 0 heather tab introvale tab 0 jolessa tab 0 jolivette tab junel 1.5/30 tab 0 junel 1/20 tab 0 junel fe tab 1.5/30 0 junel fe tab 1/20 0 kariva tab 28 day 0 kelnor tab 1/35 0 kurvelo tab 0.15/30 0 KYLEENA IUD 19.5MG 0 QL (1 / 300 days) larin tab 1.5/30 0 leena tab 0 lessina tab 0 levonest tab 0 levonorg-eth est tab (84) & eth 0 est tab 0.01(7) levonorgestrel & ethinyl estradiol (91-day) 0 tab levonorgestrel & ethinyl estradiol tab mcg levora-28 tab 0.15/30 0 LILETTA IUD 52MG 0 QL (1 / 300 days) LO LOESTRIN TAB 0 loryna tab low-ogestrel tab 0 lutera tab 0 marlissa tab 0.15/30 0 medroxyprogesterone acetate im susp QL (4 inj / 300 days) /ml medroxyprogesterone acetate im susp 0 QL (4 inj / 300 days) prefilled syr 150 /ml mibelas 24 chw fe 0 MIRENA IUD SYSTEM 0 QL (1 / 300 days) mono-linyah tab mononessa tab 0 myzilra tab 0 NATAZIA TAB 0 necon tab 0.5/ Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 74

79 necon tab 1/35 0 necon tab 1/ NECON TAB 10/ NEXPLANON IMP 68MG 0 QL (1 / 300 days) nikki tab nora-be tab norethindrone & ethinyl estradiol-fe chew 0 tab mcg norethindrone ace-ethinyl estradiol-fe tab mcg (24) norethindrone tab norgestimate & ethinyl estradiol tab mcg norgestimate-eth estrad tab / / mcg norgestimate-eth estrad tab / / mcg nortrel tab 0.5/35 0 nortrel tab 1/35 0 nortrel tab 7/7/7 0 NUVARING MIS 0 QL (13 / 300 days) ocella tab ogestrel tab 0 orsythia tab 0 RAGARD IUD T380A 0 QL (1 unit / 300 days) pirmella tab 1/35 0 pirmella tab 7/7/7 0 portia-28 tab 0 previfem tab 0 quasense tab 0 reclipsen tab 0 rivelsa tab 0 SKYLA IUD 13.5MG 0 QL (1 / 300 days) sprintec 28 tab 28 day 0 sronyx tab 0 syeda tab take action tab OTC TAYTULLA CAP 0 tilia fe tab 0 tri-linyah tab 0 tri-sprintec tab 0 trinessa tab 0 trivora-28 tab 0 velivet pak 0 vestura tab viorele tab 0 - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 75

80 wera tab 0.5/35 0 xulane dis zarah tab zenchent fe chw zenchent tab 0 zovia 1/35e tab 0 ENDOMETRIOSIS danazol cap 50 1 danazol cap danazol cap SYNAREL SOL 2MG/ML 2 ENZYME REPLACEMENTS CERDELGA CAP 84MG 3 QL (60 caps / 30 days), CYSTADANE POW 3 CYSTAGON CAP 50MG 3 CYSTAGON CAP 150MG 3 KUVAN POW 100MG 3 KUVAN POW 500MG 3 KUVAN TAB 100MG 3 miglustat cap QL (90 caps / 30 days), ORFADIN CAP 2MG 3 ORFADIN CAP 5MG 3 ORFADIN CAP 10MG 3 ORFADIN CAP 20MG 3 ORFADIN SUS 4MG/ML 3 ZAVESCA CAP 100MG 3 QL (90 caps / 30 days), ESTROGENS CLIMARA PRO DIS WEEKLY 2 DUAVEE TAB ENJUVIA TAB 0.3MG 3 ; High Risk Medications require for members age 65 and older ENJUVIA TAB 0.9MG 3 ; High Risk Medications require for members age 65 and older ENJUVIA TAB 0.45MG 3 ; High Risk Medications require for members age 65 and older - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 76

81 ENJUVIA TAB 0.625MG 3 ; High Risk Medications require for members age 65 and older estradiol & norethindrone acetate tab estradiol & norethindrone acetate tab estradiol tab ; High Risk Medications require for members age 65 and older estradiol tab 1 1 ; High Risk Medications require for members age 65 and older estradiol tab 2 1 ; High Risk Medications require for members age 65 and older estradiol td patch twice weekly 0.1 /24hr 1 ; High Risk Medications require for members age 65 and older estradiol td patch twice weekly 0.05 /24hr estradiol td patch twice weekly /24hr estradiol td patch twice weekly /24hr estradiol td patch twice weekly /24hr 1 ; High Risk Medications require for members age 65 and older 1 ; High Risk Medications require for members age 65 and older 1 ; High Risk Medications require for members age 65 and older 1 ; High Risk Medications require for members age 65 and older estradiol td patch weekly 0.1 /24hr 1 ; High Risk Medications require for members age 65 and older estradiol td patch weekly 0.05 /24hr 1 ; High Risk Medications require for members age 65 and older - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 77

82 estradiol td patch weekly 0.06 /24hr 1 ; High Risk Medications require for members age 65 and older estradiol td patch weekly /24hr 1 ; High Risk Medications require for members age 65 and older estradiol td patch weekly /24hr 1 ; High Risk Medications require for members age 65 and older estradiol td patch weekly /24hr 1 ; High Risk (37.5 mcg/24hr) Medications require for members age 65 and older estradiol vaginal cream 0.1 /gm 1 estropipate tab ; High Risk Medications require for members age 65 and older estropipate tab ; High Risk Medications require for members age 65 and older estropipate tab 3 1 ; High Risk Medications require for members age 65 and older jinteli tab 1-5mcg 1 MENEST TAB 0.3MG 3 ; High Risk Medications require for members age 65 and older MENEST TAB 0.625MG 3 ; High Risk Medications require for members age 65 and older MENEST TAB 1.25MG 3 ; High Risk Medications require for members age 65 and older MENEST TAB 2.5MG 3 ; High Risk Medications require for members age 65 and older mimvey lo tab mimvey tab Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 78

83 norethindrone acetate-ethinyl estradiol tab mcg PREMARIN TAB 0.3MG 3 ; High Risk Medications require for members age 65 and older PREMARIN TAB 0.9MG 3 ; High Risk Medications require for members age 65 and older PREMARIN TAB 0.45MG 3 ; High Risk Medications require for members age 65 and older PREMARIN TAB 0.625MG 3 ; High Risk Medications require for members age 65 and older PREMARIN TAB 1.25MG 3 ; High Risk Medications require for members age 65 and older PREMARIN VAG CRE 0.625MG 3 yuvafem tab 10mcg 1 FERTILITY REGULATORS CHOR GONADOT INJ 10000UNT 3 clomiphene citrate tab 50 1 GONAL-F INJ 450UNIT 3 QL (10 vials / 30 days), GONAL-F INJ 1050UNIT 3 QL (5 vials / 30 days), GONAL-F RFF INJ 75UNIT 3 QL (60 vials / 30 days), GONAL-F RFF INJ 300/0.5 3 QL (15 cartridges / 30 days), GONAL-F RFF INJ 450/ QL (10 cartridges / 30 days), GONAL-F RFF INJ 900/1.5 3 QL (5 cartridges / 30 days), OVIDREL INJ 3 GLUCOCORTICOIDS cortisone acetate tab 25 1 DEXAMETHASON CON 1MG/ML 2 dexamethasone elixir 0.5 /5ml 1 dexamethasone soln 0.5 /5ml 1 dexamethasone tab dexamethasone tab Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 79

84 dexamethasone tab 1 1 dexamethasone tab dexamethasone tab 2 1 dexamethasone tab 4 1 dexamethasone tab 6 1 fludrocortisone acetate tab hydrocortisone tab 5 1 hydrocortisone tab 10 1 hydrocortisone tab 20 1 MEDROL TAB 2MG 2 methylprednisolone tab 4 1 methylprednisolone tab 8 1 methylprednisolone tab 16 1 methylprednisolone tab 32 1 methylprednisolone tab therapy pack 4 1 (21) prednisolone sod phosph oral soln /5ml (5 /5ml base) prednisolone sod phosphate oral soln 15 1 /5ml (base equiv) prednisolone sodium phosphate oral soln 1 25 /5ml (base eq) prednisolone syrup 15 /5ml (usp 1 solution equivalent) PREDNISONE CON 5MG/ML 2 prednisone oral soln 5 /5ml 1 prednisone tab 1 1 prednisone tab prednisone tab 5 1 prednisone tab 10 1 prednisone tab 20 1 prednisone tab 50 1 prednisone tab therapy pack 5 (21) 1 prednisone tab therapy pack 5 (48) 1 prednisone tab therapy pack 10 (21) 1 prednisone tab therapy pack 10 (48) 1 GLUCOSE ELEVATING AGENTS GLUCAGON KIT 1MG 2 ORAL GLUCOSE REPLACEMENT 2 OTC HUMAN GROWTH HORMONES HUMATROPE INJ 5MG 3 HUMATROPE INJ 6MG 3 HUMATROPE INJ 12MG 3 HUMATROPE INJ 24MG 3 NORDITROPIN INJ 5/1.5ML 3 NORDITROPIN INJ 10/1.5ML 3 - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 80

85 NORDITROPIN INJ 15/1.5ML 3 NORDITROPIN INJ 30/3ML 3 MISCELLANEOUS cabergoline tab calcitonin (salmon) nasal soln 200 unit/act 1 FORTEO SOL 600/2.4 3 QL (2.4 ml / 28 days),, ST INCRELEX INJ 40MG/4ML 3 octreotide acetate inj 50 mcg/ml (0.05 /ml) 3 QL (90 ml / 30 days), octreotide acetate inj 100 mcg/ml (0.1 /ml) 3 QL (90 ml / 30 days), octreotide acetate inj 200 mcg/ml (0.2 /ml) 3 QL (225 ml / 30 days), octreotide acetate inj 500 mcg/ml (0.5 /ml) 3 QL (90 ml / 30 days), octreotide acetate inj 1000 mcg/ml (1 /ml) 3 QL (45 ml / 30 days), OSPHENA TAB 60MG 2 PROLIA SOL 60MG/ML 3 QL (60 / 24 weeks), raloxifene hcl tab 60 1 $0 copay for women > 35 years for the primary prevention of breast cancer SAMSCA TAB 15MG 3 SAMSCA TAB 30MG 3 SOMATULINE INJ 60/0.2ML 3 QL (1 injection / 28 days), SOMATULINE INJ 90/0.3ML 3 QL (1 injection / 28 days), SOMATULINE INJ 120/.5ML 3 QL (1 injection / 28 days), SOMAVERT INJ 10MG 3 QL (30 vials / 30 days), SOMAVERT INJ 15MG 3 QL (30 vials / 30 days), SOMAVERT INJ 20MG 3 QL (30 vials / 30 days), SOMAVERT INJ 25MG 3 QL (30 vials / 30 days), SOMAVERT INJ 30MG 3 QL (30 vials / 30 days), PHOSPHATE BINDER AGENTS calcium acetate (phosphate binder) cap 667 (169 ca) 1 - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 81

86 calcium acetate (phosphate binder) tab FOSRENOL POW 750MG 3 FOSRENOL POW 1000MG 3 lanthanum carbonate chew tab (elemental) lanthanum carbonate chew tab (elemental) lanthanum carbonate chew tab (elemental) sevelamer carbonate packet 0.8 gm 1 sevelamer carbonate packet 2.4 gm 1 sevelamer carbonate tab VELPHORO CHW 500MG 3 PROGESTINS CRINONE GEL 4% VAG 2 CRINONE GEL 8% VAG 2 LUNETA KIT LUNETA KIT medroxyprogesterone acetate tab medroxyprogesterone acetate tab 5 1 medroxyprogesterone acetate tab 10 1 norethindrone acetate tab 5 1 progesterone micronized cap progesterone micronized cap THYROID AGENTS levothyroxine sodium tab 25 mcg 1 levothyroxine sodium tab 50 mcg 1 levothyroxine sodium tab 75 mcg 1 levothyroxine sodium tab 88 mcg 1 levothyroxine sodium tab 100 mcg 1 levothyroxine sodium tab 112 mcg 1 levothyroxine sodium tab 125 mcg 1 levothyroxine sodium tab 137 mcg 1 levothyroxine sodium tab 150 mcg 1 levothyroxine sodium tab 175 mcg 1 levothyroxine sodium tab 200 mcg 1 levothyroxine sodium tab 300 mcg 1 levoxyl tab 25mcg 1 levoxyl tab 50mcg 1 levoxyl tab 75mcg 1 levoxyl tab 88mcg 1 levoxyl tab 100mcg 1 levoxyl tab 112mcg 1 levoxyl tab 125mcg 1 levoxyl tab 137mcg 1 - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 82

87 levoxyl tab 150mcg 1 levoxyl tab 175mcg 1 levoxyl tab 200mcg 1 liothyronine sodium tab 5 mcg 1 liothyronine sodium tab 25 mcg 1 liothyronine sodium tab 50 mcg 1 methimazole tab 5 1 methimazole tab 10 1 propylthiouracil tab 50 1 SYNTHROID TAB 25MCG 2 SYNTHROID TAB 50MCG 2 SYNTHROID TAB 75MCG 2 SYNTHROID TAB 88MCG 2 SYNTHROID TAB 100MCG 2 SYNTHROID TAB 112MCG 2 SYNTHROID TAB 125MCG 2 SYNTHROID TAB 137MCG 2 SYNTHROID TAB 150MCG 2 SYNTHROID TAB 175MCG 2 SYNTHROID TAB 200MCG 2 SYNTHROID TAB 300MCG 2 THYROLAR-1 TAB 60MG 3 THYROLAR-1/2 TAB 30MG 3 THYROLAR-1/4 TAB 15MG 3 THYROLAR-2 TAB 120MG 3 THYROLAR-3 TAB 180MG 3 unithroid tab 25mcg 1 unithroid tab 50mcg 1 unithroid tab 75mcg 1 unithroid tab 88mcg 1 unithroid tab 100mcg 1 unithroid tab 112mcg 1 unithroid tab 125mcg 1 unithroid tab 200mcg 1 unithroid tab 300mcg 1 VASOPRESSINS desmopressin acetate nasal soln 0.01% 1 (refrigerated) desmopressin acetate nasal spray soln % desmopressin acetate nasal spray soln % (refrigerated) desmopressin acetate tab desmopressin acetate tab GASTROINTESTINAL ANTICHOLINERGICS - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 83

88 CUVPOSA SOL 1MG/5ML 2 dicyclomine hcl cap 10 1 dicyclomine hcl oral soln 10 /5ml 1 dicyclomine hcl tab 20 1 ed-spaz tab hyoscyamine sulfate tab hyoscyamine sulfate tab disint hyoscyamine sulfate tab er 12hr hyoscyamine sulfate tab sl methscopolamine bromide tab methscopolamine bromide tab 5 1 nulev tab oscimin sr tab oscimin sub oscimin tab symax-sl sub ANTIEMETICS AKYNZEO CAP QL (2 caps / 21 days) ANZEMET TAB 50MG 3 QL (6 tabs / 21 days) ANZEMET TAB 100MG 3 QL (6 tabs / 21 days) aprepitant capsule 40 1 QL (3 caps / 180 days) aprepitant capsule 80 1 QL (4 caps / 21 days) aprepitant capsule QL (2 caps / 21 days) aprepitant capsule therapy pack 80 & QL (2 packs / 21 days) compro sup 25 1 dronabinol cap QL (60 caps / 25 days) dronabinol cap 5 1 QL (60 caps / 25 days) dronabinol cap 10 1 QL (60 caps / 25 days) EMEND SUS 125MG 3 QL (6 kits / 21 days) granisetron hcl tab 1 1 QL (12 tabs / 21 days) meclizine hcl tab meclizine hcl tab 25 1 metoclopramide hcl soln 5 /5ml (10 1 /10ml) (base equiv) metoclopramide hcl tab 5 (base 1 equivalent) metoclopramide hcl tab 10 (base 1 equivalent) ondansetron hcl oral soln 4 /5ml 1 QL (200 ml / 21 days) ondansetron hcl tab 4 1 QL (18 tabs / 21 days) ondansetron hcl tab 8 1 QL (18 tabs / 21 days) ondansetron hcl tab 24 1 QL (2 tabs / 21 days) ondansetron orally disintegrating tab 4 1 QL (18 tabs / 21 days) ondansetron orally disintegrating tab 8 1 QL (18 tabs / 21 days) phenadoz sup Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 84

89 prochlorperazine maleate tab 5 (base 1 equivalent) prochlorperazine maleate tab 10 (base 1 equivalent) prochlorperazine suppos 25 1 promethazine hcl suppos promethazine hcl suppos 25 1 promethazine hcl syrup 6.25 /5ml 1 ; High Risk Medications require for members age 65 and older promethazine hcl tab ; High Risk Medications require for members age 65 and older promethazine hcl tab 25 1 ; High Risk Medications require for members age 65 and older promethazine hcl tab 50 1 ; High Risk Medications require for members age 65 and older promethegan sup promethegan sup 25 1 promethegan sup 50 1 SANCUSO DIS 3.1MG 3 QL (2 patches / 21 days) scopolamine td patch 72hr 1 /3days 1 trimethobenzamide hcl cap ; High Risk Medications require for members age 65 and older VARUBI INJ 2 VARUBI TAB 90MG 2 H2-RECEPTOR ANTAGONISTS cimetidine hcl soln 300 /5ml 1 cimetidine tab cimetidine tab cimetidine tab cimetidine tab famotidine for susp 40 /5ml 1 famotidine tab 20 1 famotidine tab 40 1 nizatidine cap nizatidine cap nizatidine oral soln 15 /ml 1 - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 85

90 ranitidine hcl cap ranitidine hcl cap ranitidine hcl syrup 15 /ml (75 /5ml) 1 ranitidine hcl tab ranitidine hcl tab INFLAMMATORY BOWEL DISEASE APRISO CAP 0.375GM 2 balsalazide disodium cap budesonide delayed release particles cap 3 1 CANASA SUP 1000MG 2 colocort ene DIPENTUM CAP 250MG 3 mesalamine enema 4 gm 1 mesalamine rectal enema 4 gm & cleanser 1 wipe kit sulfasalazine tab sulfasalazine tab delayed release IRRITABLE BOWEL SYNDROME WITH CONSTITION AMITIZA CAP 8MCG 2 AMITIZA CAP 24MCG 2 LINZESS CAP 72MCG 2 LINZESS CAP 145MCG 2 LINZESS CAP 290MCG 2 IRRITABLE BOWEL SYNDROME WITH DIARRHEA alosetron hcl tab 0.5 (base equiv) 1 alosetron hcl tab 1 (base equiv) 1 LAXATIVES CLENPIQ SOL 0 $0 copay for members age 50 through 74 enulose sol 10gm/15 1 gavilyte-c sol 1 gavilyte-g sol 1 gavilyte-h kit 0 $0 copay for members age 50 through 74 gavilyte-n sol flav pk 1 generlac sol 10gm/15 1 GOLYTELY SOL 2 lactulose solution 10 gm/15ml 1 MOVIPREP SOL 0 $0 copay for members age 50 through 74; Tier 2 for all others OSMOPREP TAB 1.5GM 3 peg 3350-kcl-na bicarb-nacl-na sulfate for 1 soln 236 gm - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 86

91 peg 3350-kcl-na bicarb-nacl-na sulfate for 1 soln 240 gm peg 3350-kcl-sod bicarb-nacl for soln gm polyethylene glycol 3350 oral packet 1 polyethylene glycol 3350 oral powder 1 PREPOPIK K 0 $0 copay for members age 50 through 74 SUPREP BOWEL SOL PREP KIT 0 $0 copay for members age 50 through 74; Tier 3 for all others MISCELLANEOUS anti-diarrhe tab 2 1 OTC CARAFATE SUS 1GM/10ML 3 diphenoxylate w/ atropine liq /5ml diphenoxylate w/ atropine tab loperamide hcl cap 2 1 misoprostol tab 100 mcg 1 misoprostol tab 200 mcg 1 MOTOFEN TAB MOVANTIK TAB 12.5MG 2 MOVANTIK TAB 25MG 2 SUCRAID SOL 8500/ML 3 sucralfate tab 1 gm 1 ursodiol cap ursodiol tab ursodiol tab NCREATIC ENZYMES CREON CAP 3000UNIT 2 CREON CAP 6000UNIT 2 CREON CAP 12000UNT 2 CREON CAP 24000UNT 2 CREON CAP 36000UNT 2 VIOKACE TAB 2 VIOKACE TAB ZENPEP CAP 2 ZENPEP CAP 3000UNIT 2 ZENPEP CAP 5000UNIT 2 ZENPEP CAP 10000UNT 2 ZENPEP CAP 15000UNT 2 ZENPEP CAP 20000UNT 2 ZENPEP CAP 25000UNT 2 ZENPEP CAP 40000UNT 2 PROTON PUMP INHIBITORS - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 87

92 DEXILANT CAP 30MG DR 3 QL (90 caps / 365 days), ST; ** DEXILANT CAP 60MG DR 3 QL (90 caps / 365 days), ST; ** esomepra mag cap 20 dr 1 QL (90 caps / 365 days); OTC esomeprazole magnesium cap delayed release 20 (base eq) 1 QL (90 caps / 365 days), ST esomeprazole magnesium cap delayed release 40 (base eq) 1 QL (90 caps / 365 days), ST lansoprazole cap 15 dr 1 QL (90 caps / 365 days); OTC lansoprazole cap delayed release 15 1 QL (90 caps / 365 days) lansoprazole cap delayed release 30 1 QL (90 caps / 365 days) NEXIUM 24HR CAP 20MG 1 QL (90 caps / 365 days); OTC NEXIUM 24HR TAB 20MG 1 QL (90 tabs / 365 days); OTC omepra/bicar cap QL (90 caps / 365 days); OTC omeprazole cap delayed release 10 1 QL (90 caps / 365 days) omeprazole cap delayed release 20 1 QL (90 caps / 365 days) omeprazole cap delayed release 40 1 QL (90 caps / 365 days) omeprazole magnesium cap dr 20.6 (20 base equiv) 1 QL (90 caps / 365 days); OTC OMEPRAZOLE TAB 20MG 1 QL (90 tabs / 365 days); OTC pantoprazole sodium ec tab 20 (base 1 QL (90 tabs / 365 days) equiv) pantoprazole sodium ec tab 40 (base 1 QL (90 tabs / 365 days) equiv) rabeprazole sodium ec tab 20 1 QL (90 tabs / 365 days) RECTAL,CORTICOSTEROIDS procto-pak cre 1% 1 proctosol hc cre 2.5% 1 GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl tab er 24hr 10 1 CARDURA XL TAB 4MG 3 ST; ** CARDURA XL TAB 8MG 3 ST; ** CIALIS TAB 2.5MG 2 QL (30 tabs / 25 days), CIALIS TAB 5MG 2 QL (30 tabs / 25 days), dutasteride cap dutasteride-tamsulosin hcl cap finasteride tab Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 88

93 RAFLO CAP 4MG 2 ST; ** RAFLO CAP 8MG 2 ST; ** tamsulosin hcl cap CONTRACEPTIVES CONCEPTROL GEL 4% 0 OTC ENCARE SUP 100MG 0 OTC GYNOL II GEL 3% 0 OTC SHUR-SEAL GEL 2% 0 OTC TODAY SPONGE MIS 0 OTC VCF VAGINAL AER CONTRACP 0 OTC VCF VAGINAL MIS CONTRACP 0 OTC MISCELLANEOUS bethanechol chloride tab 5 1 bethanechol chloride tab 10 1 bethanechol chloride tab 25 1 bethanechol chloride tab 50 1 ELMIRON CAP 100MG 3 flavoxate hcl tab phenazopyridine hcl tab potassium citrate tab er 5 meq (540 ) 1 potassium citrate tab er 10 meq (1080 ) 1 potassium citrate tab er 15 meq (1620 ) 1 URINARY ANTISSMODICS darifenacin hydrobromide tab er 24hr (base equiv) darifenacin hydrobromide tab er 24hr 15 1 (base equiv) MYRBETRIQ TAB 25MG 3 ST; ** MYRBETRIQ TAB 50MG 3 ST; ** oxybutynin chloride syrup 5 /5ml 1 oxybutynin chloride tab 5 1 oxybutynin chloride tab er 24hr 5 1 oxybutynin chloride tab er 24hr 10 1 oxybutynin chloride tab er 24hr 15 1 tolterodine tartrate cap er 24hr 2 1 tolterodine tartrate cap er 24hr 4 1 tolterodine tartrate tab 1 1 tolterodine tartrate tab 2 1 TOVIAZ TAB 4MG 2 TOVIAZ TAB 8MG 2 trospium chloride cap er 24hr 60 1 trospium chloride tab 20 1 VESICARE TAB 5MG 3 ST; ** VESICARE TAB 10MG 3 ST; ** VAGINAL ANTI-INFECTIVES - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 89

94 CLEOCIN SUP 100MG 2 clindamycin phosphate vaginal cream 2% 1 GYNAZOLE-1 CRE 2% 3 metronidazole vaginal gel 0.75% 1 miconazole 1 kit % 1 OTC miconazole 3 kit 4% 1 OTC miconazole 3 kit combo pk 1 miconazole 3 sup miconazole 7 cre tube/kit 1 OTC terconazole vaginal cream 0.4% 1 terconazole vaginal suppos 80 1 vandazole gel 0.75% 1 zazole cre 0.8% 1 zazole sup 80 1 HEMATOLOGIC ANTICOAGULANTS ARGATROBAN INJ 125/125 3 argatroban inj 250 /2.5ml (concentrate 1 for iv infusion) ARGATROBAN INJ 250/250 3 ELIQUIS TAB 2.5MG 2 ELIQUIS TAB 5MG 2 enoxaparin sodium inj 30 /0.3ml 1 enoxaparin sodium inj 40 /0.4ml 1 enoxaparin sodium inj 60 /0.6ml 1 enoxaparin sodium inj 80 /0.8ml 1 enoxaparin sodium inj 100 /ml 1 enoxaparin sodium inj 120 /0.8ml 1 enoxaparin sodium inj 150 /ml 1 enoxaparin sodium inj 300 /3ml 1 fondaparinux sodium subcutaneous inj /0.5ml fondaparinux sodium subcutaneous inj 5 1 /0.4ml fondaparinux sodium subcutaneous inj /0.6ml fondaparinux sodium subcutaneous inj 10 1 /0.8ml FRAGMIN INJ 2500/0.2 3 FRAGMIN INJ 5000/0.2 3 FRAGMIN INJ 7500/0.3 3 FRAGMIN INJ 10000/ML 3 FRAGMIN INJ 12500UNT 3 FRAGMIN INJ 15000UNT 3 FRAGMIN INJ 18000UNT 3 FRAGMIN INJ 95000UNT 3 - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 90

95 heparin sodium (porcine) inj 1000 unit/ml 1 heparin sodium (porcine) inj 5000 unit/ml 1 heparin sodium (porcine) inj unit/ml 1 heparin sodium (porcine) inj unit/ml 1 heparin sodium (porcine) pf inj unit/0.5ml jantoven tab 1 1 jantoven tab jantoven tab 2 1 jantoven tab 3 1 jantoven tab 4 1 jantoven tab 5 1 jantoven tab 6 1 jantoven tab jantoven tab 10 1 PRADAXA CAP 75MG 3 PRADAXA CAP 110MG 3 PRADAXA CAP 150MG 3 warfarin sodium tab 1 1 warfarin sodium tab 2 1 warfarin sodium tab warfarin sodium tab 3 1 warfarin sodium tab 4 1 warfarin sodium tab 5 1 warfarin sodium tab 6 1 warfarin sodium tab warfarin sodium tab 10 1 XARELTO STAR TAB 15/20MG 2 XARELTO TAB 10MG 2 XARELTO TAB 15MG 2 XARELTO TAB 20MG 2 HEMATOPOIETIC GROWTH FACTORS ARANESP INJ 10MCG 3 ARANESP INJ 25MCG 3 ARANESP INJ 40MCG 3 ARANESP INJ 60MCG 3 ARANESP INJ 100MCG 3 ARANESP INJ 150MCG 3 ARANESP INJ 200MCG 3 ARANESP INJ 300MCG 3 ARANESP INJ 500MCG 3 NEULASTA INJ 6MG/0.6M 3 QL (2 injections / 28 days), NEULASTA KIT 6MG/0.6M 3 QL (2 injections / 28 days), PROCRIT INJ 2000/ML 3 - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 91

96 PROCRIT INJ 3000/ML 3 PROCRIT INJ 4000/ML 3 PROCRIT INJ 10000/ML 3 PROCRIT INJ 20000/ML 3 PROCRIT INJ 40000/ML 3 PROMACTA TAB 12.5MG 3 QL (30 tabs / 30 days), PROMACTA TAB 25MG 3 QL (30 tabs / 30 days), PROMACTA TAB 50MG 3 QL (60 tabs / 30 days), PROMACTA TAB 75MG 3 QL (60 tabs / 30 days), ZARXIO INJ 300/0.5 3 ZARXIO INJ 480/0.8 3 MISCELLANEOUS anagrelide hcl cap anagrelide hcl cap 1 1 cilostazol tab 50 1 cilostazol tab FIRAZYR INJ 30MG/3ML 3 pentoxifylline tab er tranexamic acid iv soln 1000 /10ml 1 (100 /ml) tranexamic acid tab PLATELET AGGREGATION INHIBITORS aspirin-dipyridamole cap er 12hr BRILINTA TAB 60MG 2 BRILINTA TAB 90MG 2 clopidogrel bisulfate tab 75 (base 1 equiv) clopidogrel bisulfate tab 300 (base 1 equiv) dipyridamole tab 25 1 ; High Risk Medications require for members age 65 and older dipyridamole tab 50 1 ; High Risk Medications require for members age 65 and older dipyridamole tab 75 1 ; High Risk Medications require for members age 65 and older prasugrel hcl tab 5 (base equiv) 1 - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 92

97 prasugrel hcl tab 10 (base equiv) 1 ZONTIVITY TAB 2.08MG 2 IMMUNOLOGIC AGENTS BIOLOGIC DISEASE-MODIFYING AGENTS ACTEMRA INJ 80MG/4ML 3 QL (5 vials / 28 days),, ST ACTEMRA INJ 162/0.9 3 QL (4 syringes / 28 days),, ST ACTEMRA INJ 200/10ML 3 QL (4 vials / 14 days),, ST ACTEMRA INJ 400/20ML 3 QL (2 vials / 14 days),, ST ENBREL INJ 25/0.5ML 3 QL (8 syringes / 28 days), ENBREL INJ 25MG 3 QL (8 syringes / 28 days), ENBREL INJ 50MG/ML 3 QL (8 syringes / 28 days), ENBREL MINI INJ 50MG/ML 3 QL (8 cartridges / 28 days), ENBREL SRCLK INJ 50MG/ML 3 QL (8 syringes / 28 days), HUMIRA INJ 10MG/0.2 3 QL (2 injections / 28 days), HUMIRA KIT 20MG/0.4 3 QL (2 injections / 28 days), HUMIRA KIT 40MG/0.8 3 QL (4 injections / 28 days), HUMIRA PEN INJ CROHNS 3 QL (6 pens / 28 days), HUMIRA PEN INJ PSORIASI 3 QL (4 pens / 28 days), KEVZARA INJ 150/ QL (2 syringes / 4 weeks), KEVZARA INJ 200/ QL (2 syringes / 4 weeks), ORENCIA CLCK INJ 125MG/ML 3 QL (4 syringes / 28 days),, ST ORENCIA INJ 50/0.4 3 QL (4 syringes / 28 days),, ST ORENCIA INJ 87.5/0.7 3 QL (4 syringes / 28 days),, ST ORENCIA INJ 125MG/ML 3 QL (4 syringes / 28 days),, ST ORENCIA INJ 250MG 3 QL (1000 / 4 weeks),, ST SIMPONI ARIA SOL 50MG/4ML 3 QL (200 / 8 weeks),, ST - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 93

98 SIMPONI INJ 50/0.5ML 3 QL (1 injection / 28 days),, ST SIMPONI INJ 100MG/ML 3 QL (1 injection / 28 days),, ST STELARA INJ 45MG/0.5 3 QL (1 syringe / 84 days), STELARA INJ 90MG/ML 3 QL (1 syringe / 56 days), XELJANZ TAB 5MG 3 QL (60 tabs / 30 days),, ST DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) hydroxychloroquine sulfate tab leflunomide tab 10 1 leflunomide tab 20 1 methotrexate sodium tab 2.5 (base 1 equiv) OTEZLA TAB 10/20/30 3 QL (55 tabs / 28 days), OTEZLA TAB 30MG 3 QL (60 tabs / 30 days), IMMUNOGLOBULIN HYQVIA INJ HYQVIA INJ HYQVIA INJ HYQVIA INJ HYQVIA INJ IMMUNOMODULATORS ALFERON N INJ 5MU/ML 3 INTRON A INJ 10MU 3 INTRON A INJ 18MU 3 INTRON A INJ 25MU 3 INTRON A INJ 50MU 3 POMALYST CAP 1MG 3 QL (21 caps / 21 days), POMALYST CAP 2MG 3 QL (21 caps / 21 days), POMALYST CAP 3MG 3 QL (21 caps / 21 days), POMALYST CAP 4MG 3 QL (21 caps / 21 days), REVLIMID CAP 2.5MG 3 QL (28 caps / 28 days), REVLIMID CAP 5MG 3 QL (28 caps / 28 days), REVLIMID CAP 10MG 3 QL (28 caps / 28 days), - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 94

99 REVLIMID CAP 15MG 3 QL (21 caps / 28 days), REVLIMID CAP 20MG 3 QL (21 caps / 28 days), REVLIMID CAP 25MG 3 QL (21 caps / 28 days), THALOMID CAP 50MG 3 QL (28 caps / 28 days), THALOMID CAP 100MG 3 QL (28 caps / 28 days), THALOMID CAP 150MG 3 QL (56 caps / 28 days), THALOMID CAP 200MG 3 QL (56 caps / 28 days), IMMUNOSUPPRESSANTS azathioprine tab 50 1 cyclosporine modified cap 25 1 cyclosporine modified cap 50 1 cyclosporine modified cap cyclosporine modified oral soln 100 /ml 1 gengraf cap 25 1 gengraf cap gengraf sol 100/ml 1 mycophenolate mofetil cap mycophenolate mofetil for oral susp /ml mycophenolate mofetil tab mycophenolate sodium tab dr (mycophenolic acid equiv) mycophenolate sodium tab dr (mycophenolic acid equiv) RAMUNE SOL 1MG/ML 2 sirolimus tab sirolimus tab 1 1 sirolimus tab 2 1 tacrolimus cap tacrolimus cap 1 1 tacrolimus cap 5 1 ZORTRESS TAB 0.5MG 2 ZORTRESS TAB 0.25MG 2 ZORTRESS TAB 0.75MG 2 VACCINES ACTHIB INJ 0 $0 copay for members age 18 and younger ADACEL INJ 0 AFLURIA INJ Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 95

100 AFLURIA INJ PF BEXSERO INJ 0 BOOSTRIX INJ 0 COMVAX INJ 0 $0 copay for members age 18 and younger DAPTACEL INJ 0 $0 copay for members age 18 and younger DIP/TET PED INJ 25-5LFU 0 $0 copay for members age 18 and younger ENGERIX-B INJ 10/0.5ML 0 ENGERIX-B INJ 20MCG/ML 0 FLUAD INJ FLUBLOK QUAD INJ FLUBLOK SOL FLUCLVX QUAD INJ FLULAVAL QUA INJ FLUVIRIN INJ FLUZONE HD INJ PF FLUZONE QUAD INJ GARDASIL 9 INJ 0 GARDASIL INJ 0 HAVRIX INJ 720UNIT 0 HAVRIX INJ 1440UNIT 0 HEPLISAV-B INJ 20MCG 0 HIBERIX SOL 10MCG 0 $0 copay for members age 18 and younger INFANRIX INJ 0 $0 copay for members age 18 and younger IPOL INJ INACTIVE 0 $0 copay for members age 18 and younger KINRIX INJ 0 $0 copay for members age 18 and younger M-M-R II INJ 0 MENACTRA INJ 0 MENHIBRIX INJ 0 $0 copay for members age 18 and younger MENOMUNE INJ A/C/Y/W 0 MENVEO INJ 0 PEDIARIX INJ 0.5ML 0 $0 copay for members age 18 and younger PEDVAX HIB INJ 0 $0 copay for members age 18 and younger PENTACEL INJ 0 $0 copay for members age 18 and younger PNEUMOVAX 23 INJ 25/0.5 0 PREVNAR 13 INJ 0 - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 96

101 PROQUAD INJ 0 $0 copay for members age 18 and younger RECOMBIVA HB INJ 5MCG/0.5 0 RECOMBIVA HB INJ 10MCG/ML 0 RECOMBIVA-HB INJ 40MCG/ML 0 ROTARIX SUS 0 $0 copay for members age 18 and younger ROTATEQ SOL 0 $0 copay for members age 18 and younger SHINGRIX INJ 50MCG 0 $0 copay for members age 19 and older TENIVAC INJ 5-2LF 0 $0 copay for members age 19 and older TET/DIP TOX INJ 2-2 LF 0 $0 copay for members age 19 and older TRUMENBA INJ 0 TWINRIX INJ 0 $0 copay for members age 19 and older VAQTA INJ 25/0.5ML 0 VAQTA INJ 50UNT/ML 0 VARIVAX INJ 0 ZOSTAVAX INJ 0 $0 copay for members age 19 and older MEDICAL DEVICES CONTRACEPTIVES CAYA DPR 0 QL (1 / 300 days) FC2 FEMALE MIS CONDOM 0 OTC FEMCAP MIS 22MM 0 QL (1 / 300 days) FEMCAP MIS 26MM 0 QL (1 / 300 days) FEMCAP MIS 30MM 0 QL (1 / 300 days) OMNIFLEX DPR 0 QL (1 / 300 days) WIDE-SEAL DPR KIT 60 0 QL (1 / 300 days) WIDE-SEAL DPR KIT 65 0 QL (1 / 300 days) WIDE-SEAL DPR KIT 70 0 QL (1 / 300 days) WIDE-SEAL DPR KIT 75 0 QL (1 / 300 days) WIDE-SEAL DPR KIT 80 0 QL (1 / 300 days) WIDE-SEAL DPR KIT 85 0 QL (1 / 300 days) WIDE-SEAL DPR KIT 90 0 QL (1 / 300 days) WIDE-SEAL DPR KIT 95 0 QL (1 / 300 days) DIABETIC SUPPLIES ALCOH-WIPE MIS 12"X12" 2 ALCOHOL PREP WIPES AND SWABS 2 OTC BLOOD GLUCOSE CALIBRATION SOLUTION 2 OTC FREESTYLE BLOOD GLUCOSE TEST KITS 2 OTC FREESTYLE BLOOD GLUCOSE TEST STRIPS 2 QL (204 Test Strips / 25 days); OTC - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 97

102 GLUCOSE URINE TEST STRIPS 2 OTC INSULIN PEN NEEDLES 2 OTC INSULIN PEN NEEDLES/SYRINGES 2 OTC KETONE URINE TEST STRIPS 2 OTC LANCETS 2 OTC LANCING DEVICE 2 OTC MISC LANCETS 2 OTC SHARPS CONTAINER 2 OTC URINE GLUCOSE MONITORING SUPPLIES 2 OTC URINE TEST STRIPS 2 OTC MISCELLANEOUS ADULT RESPIRATORY MASK 2 ADULT RESPIRATORY MASK 2 OTC HUMATROPEN MIS FOR 6MG 2 OTC HUMATROPEN MIS FOR 12MG 2 OTC HUMATROPEN MIS FOR 24MG 2 OTC NORDIPEN 5 MIS DEVICE 2 NORDIPEN DEL MIS SYSTEM 2 OTC PEDIATRIC RESPIRATORY MASK 2 PEDIATRIC RESPIRATORY MASK 2 OTC NUTRITIONAL/SUPPLEMENTS ELECTROLYTES fluor-a-day dro $0 applies for ages 5 and under FLUORABON DRO 0 $0 applies for ages 5 and under fluoritab chw 0.5 f 0 $0 applies for ages 5 and under fluoritab chw 0.25 f 0 $0 applies for ages 5 and under fluoritab chw flura-drops dro 0.25 f 0 $0 applies for ages 5 and under flura-drops dro $0 applies for ages 5 and under k-effervesce tab 25meq ef 1 klor-con 8 tab 8meq er 1 klor-con 10 tab 10meq er 1 KLOR-CON M15 TAB 15MEQ ER 2 klor-con m20 tab 20meq er 1 ludent chw 0.5 f 0 $0 applies for ages 5 and under ludent chw 0.25 f 0 $0 applies for ages 5 and under ludent chw 1 f 1 - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 98

103 LURIDE DRO 0.5MG/ML 0 $0 applies for ages 5 and under nafrinse chw 1 f 1 potassium chloride cap er 8 meq 1 potassium chloride cap er 10 meq 1 potassium chloride microencapsulated crys 1 er tab 10 meq potassium chloride microencapsulated crys 1 er tab 20 meq potassium chloride oral soln 10% (20 1 meq/15ml) potassium chloride oral soln 20% (40 1 meq/15ml) potassium chloride tab er 8 meq (600 ) 1 potassium chloride tab er 10 meq 1 potassium chloride tab er 20 meq ( ) sodium chloride flush iv soln 0.9% 1 sodium chloride inj 2.5 meq/ml (14.6%) 1 sodium fluoride chew tab 0.5 f (from 1.1 naf) 0 $0 applies for ages 5 and under sodium fluoride chew tab 0.25 f (from 0.55 naf) 0 $0 applies for ages 5 and under sodium fluoride chew tab 1 f (from naf) sodium fluoride soln 0.5 /ml f (from $0 applies for ages 5 /ml naf) and under sodium fluoride tab 0.5 f (from $0 applies for ages 5 naf) and under sodium fluoride tab 1 f (from naf) IV REPLACEMENT SOLUTIONS sodium chloride inj 0.9% 1 sodium chloride inj 0.45% 1 sodium chloride inj 3% 1 sodium chloride inj 5% 1 sodium chloride iv soln 0.9% 1 VITAMINS BABY SUPER DRO DAILY D3 0 OTC;$0 applies for ages 65 and older BIO-D-MULSIO LIQ 400/0.4 0 OTC; $0 applies for ages 65 and older bio-d-mulsio liq 400unit 0 OTC; $0 applies for ages 65 and older calcitriol cap 0.5 mcg 1 calcitriol cap 0.25 mcg 1 calcitriol oral soln 1 mcg/ml 1 - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 99

104 cholecalciferol cap 400 unit 0 OTC; $0 applies for ages 65 and older CITRANATAL CAP HARMONY 2 CITRANATAL CAP MEDLEY 2 CITRANATAL MIS 2 CITRANATAL MIS 90 DHA 2 CITRANATAL MIS B-CALM 2 CITRANATAL K ASSURE 2 CITRANATAL K DHA 2 CITRANATAL TAB BLOOM 2 CITRANATAL TAB RX 2 cyanocobalamin inj 1000 mcg/ml 1 d3 kids chw 400unit 0 OTC; $0 applies for ages 65 and older D-VI-SOL LIQ 400UNIT 0 OTC; $0 applies for ages 65 and older DDROPS BOOST LIQ 600/ OTC; $0 applies for ages 65 and older doxercalciferol cap 0.5 mcg 1 doxercalciferol cap 1 mcg 1 doxercalciferol cap 2.5 mcg 1 elite-ob tab 1 ergocalciferol cap unit 1 folic acid tab 1 1 folic acid tab 400 mcg 0 QL (100 tabs / 30 days); OTC; $0 copay for women ages 55 and under folic acid tab 800 mcg 0 QL (100 tabs / 30 days); OTC; $0 copay for women ages 55 and under MEPHYTON TAB 5MG 2 multi-vit/fe dro /fl multi-vit/fl dro 0.5/ml 1 multi-vit/fl dro multivit/fl chw multivit/fl chw multivit/fl chw 1 1 mvc-fluoride chw 1 1 paricalcitol cap 1 mcg 1 paricalcitol cap 2 mcg 1 paricalcitol cap 4 mcg 1 pedia d-vite dro 400unit 0 OTC; $0 applies for ages 65 and older prenatabs rx tab 1 pyridoxine hcl tab 25 1 OTC - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 100

105 pyridoxine hcl tab 50 1 OTC sm vitamin d tab 400unit 0 OTC; $0 applies for ages 65 and older tri-vit/fe dro /fl tri-vit/fl dro tri-vit/fl dro virt-vite tab forte 1 vit a/c/d/fl dro VITAMIN D2 TAB 400UNIT 0 OTC; $0 applies for ages 65 and older VITAMIN D3 LIQ 1000UNIT 0 OTC; $0 applies for ages 65 and older VITAMIN D3 LIQ 1200UNIT 0 OTC; $0 applies for ages 65 and older OPHTHALMIC ANTI-INFECTIVE/ANTI-INFLAMMATORY bacitracin-polymyxin-neomycin-hc ophth 1 oint 1% BLEPHAMIDE OIN S.O.P. 2 BLEPHAMIDE SUS OP 2 neomycin-polymyxin-dexamethasone 1 ophth oint 0.1% neomycin-polymyxin-dexamethasone 1 ophth susp 0.1% neomycin-polymyxin-hc ophth susp 1 sulfacetamide sodium-prednisolone ophth 1 soln (0.25)% TOBRADEX OIN % 2 TOBRADEX ST SUS tobramycin-dexamethasone ophth susp % ANTI-INFECTIVES AZASITE SOL 1% 3 bacitracin ophth oint 500 unit/gm 1 bacitracin-polymyxin b ophth oint 1 BESIVANCE SUS 0.6% 3 CILOXAN OIN 0.3% OP 2 ciprofloxacin hcl ophth soln 0.3% 1 erythromycin ophth oint 5 /gm 1 gatifloxacin ophth soln 0.5% 1 gentamicin sulfate ophth oint 0.3% 1 gentamicin sulfate ophth soln 0.3% 1 levofloxacin ophth soln 0.5% 1 MOXEZA SOL 0.5% 2 moxifloxacin hcl ophth soln 0.5% (base 1 equiv) - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 101

106 NATACYN SUS 5% OP 2 neomycin-polymy-gramicid op sol unt-/ml ofloxacin ophth soln 0.3% 1 polycin oin op 1 polymyxin b-trimethoprim ophth soln unit/ml-0.1% sulfacetamide sodium ophth oint 10% 1 sulfacetamide sodium ophth soln 10% 1 tobramycin ophth soln 0.3% 1 TOBREX OIN 0.3% OP 2 trifluridine ophth soln 1% 1 ZIRGAN GEL 0.15% 3 ANTI-INFLAMMATORIES ACUVAIL SOL 0.45% 2 ALREX SUS 0.2% 3 bromfenac sodium ophth soln 0.09% (base 1 equiv) (once-daily) bromfenac sodium ophth soln 0.09% (base 1 equivalent) dexamethasone sodium phosphate ophth 1 soln 0.1% diclofenac sodium ophth soln 0.1% 1 DUREZOL EMU 0.05% 2 FLAREX SUS 0.1% OP 2 fluorometholone ophth susp 0.1% 1 flurbiprofen sodium ophth soln 0.03% 1 FML FORTE SUS 0.25% OP 2 FML OIN 0.1% OP 2 ILEVRO DRO 0.3% OP 2 ketorolac tromethamine ophth soln 0.4% 1 ketorolac tromethamine ophth soln 0.5% 1 LOTEMAX GEL 0.5% 3 LOTEMAX OIN 0.5% 3 LOTEMAX SUS 0.5% 3 MAXIDEX SUS 0.1% OP 2 NEVANAC SUS 0.1% 2 PRED MILD SUS 0.12% OP 2 PRED SOD PHO SOL 1% OP 2 prednisolone acetate ophth susp 1% 1 VEXOL SUS 1% OP 3 ANTIALLERGICS ALOCRIL SOL 2% 3 ALOMIDE SOL 0.1% OP 3 azelastine hcl ophth soln 0.05% 1 ST BEPREVE DRO 1.5% 3 ST - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 102

107 cromolyn sodium ophth soln 4% 1 EMADINE SOL 0.05% OP 3 ST epinastine hcl ophth soln 0.05% 1 ST ketotif fum dro 0.025%op 1 OTC LASTACAFT SOL 0.25% 2 ST olopatadine hcl ophth soln 0.1% (base 1 ST equivalent) olopatadine hcl ophth soln 0.2% (base 1 ST equivalent) ZEO DRO 0.7% 2 ANTIGLAUCOMA apraclonidine hcl ophth soln 0.5% (base 1 equivalent) AZOPT SUS 1% OP 2 betaxolol hcl ophth soln 0.5% 1 BETIMOL SOL 0.5% 3 BETIMOL SOL 0.25% 3 BETOPTIC-S SUS 0.25% OP 2 bimatoprost ophth soln 0.03% 1 brimonidine tartrate ophth soln 0.2% 1 brimonidine tartrate ophth soln 0.15% 1 carteolol hcl ophth soln 1% 1 COMBIGAN SOL 0.2/0.5% 2 dorzolamide hcl ophth soln 2% 1 dorzolamide hcl-timolol maleate ophth soln /ml latanoprost ophth soln 0.005% 1 levobunolol hcl ophth soln 0.5% 1 LUMIGAN SOL 0.01% 2 ST; ** metipranolol ophth soln 0.3% 1 PHOSPHOLINE SOL 0.125%OP 3 pilocarpine hcl ophth soln 1% 1 SIMBRINZA SUS 1-0.2% 2 timolol maleate ophth gel forming soln 1 0.5% timolol maleate ophth gel forming soln % timolol maleate ophth soln 0.5% 1 timolol maleate ophth soln 0.25% 1 TIMOPTIC OCU SOL 0.5% OP 2 TIMOPTIC OCU SOL 0.25% OP 2 TRAVATAN Z DRO 0.004% 2 ST; ** ZIOPTAN DRO % 3 ST; ** MISCELLANEOUS atropine sulfate ophth soln 1% 1 CYSTARAN SOL 0.44% 3 - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 103

108 LACRISERT MIS 5MG OP 3 naphazoline hcl ophth soln 0.1% 1 phenylephrine hcl ophth soln 2.5% 1 phenylephrine hcl ophth soln 10% 1 RESTASIS EMU 0.05% 2 tropicamide ophth soln 0.5% 1 tropicamide ophth soln 1% 1 OTHER IRRIGATION SOLUTIONS physiolyte sol 1 tis-u-sol sol 1 RESPIRATORY ANAPHYLAXIS TREATMENT AGENTS epinephrine solution auto-injector (generic of Adrenaclick) /0.3ml (1:1000) epinephrine solution auto-injector (generic of Adrenaclick) /0.15ml (1:1000) EPIPEN 2-K INJ 0.3MG 2 EPIPEN-JR INJ 2-K 2 ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ANORO ELLIPT AER QL (1 package / 25 days) BEVESPI AER 9-4.8MCG 2 QL (1 package / 25 days) COMBIVENT AER QL (2 inhalers / 25 days) ipratropium-albuterol nebu soln (3) 1 QL (6 boxes / 25 days) /3ml ANTICHOLINERGICS INCRUSE ELPT INH 62.5MCG 2 QL (1 package / 25 days) ipratropium bromide inhal soln 0.02% 1 QL (5 boxes / 25 days) ipratropium bromide nasal soln 0.03% (21 1 mcg/spray) ipratropium bromide nasal soln 0.06% (42 1 mcg/spray) SPIRIVA AER 1.25MCG 2 QL (1 package / 25 days) SPIRIVA CAP HANDIHLR 2 QL (1 package / 25 days) SPIRIVA SPR 2.5MCG 2 QL (1 package / 25 days) TUDORZA PRES AER 400/ACT 3 QL (1 package / 25 days) ANTIHISTAMINE COMBINATIONS - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 104

109 DYMISTA SPR QL (1 package / 25 days) ANTIHISTAMINES all day allg cap 10 1 OTC all day allg chw 10 1 OTC allergy relf tab 10 1 OTC allergy tab 10 1 OTC arbinoxa sol 4/5ml 1 azelastine hcl nasal spray 0.1% (137 1 QL (2 bottles / 25 days) mcg/spray) azelastine hcl nasal spray 0.15% (205.5 mcg/spray) 1 QL (2 bottles / 25 days) brompheniramine tannate chew tab 12 1 carbinoxamine maleate tab 4 1 cetirizine hcl chew tab 5 1 OTC cetirizine hcl tab 5 1 OTC cetirizine hcl tab 10 1 OTC cetirizine sol 1/ml 1 OTC CLARINEX SYP 0.5MG/ML 3 ST clemastine fumarate tab ; High Risk Medications require for members age 65 and older cyproheptadine hcl syrup 2 /5ml 1 cyproheptadine hcl tab 4 1 desloratadine tab 5 1 ST desloratadine tab orally disintegrating ST desloratadine tab orally disintegrating 5 1 ST diphenhydramine hcl elixir 12.5 /5ml 1 diphenhydramine hcl inj 50 /ml 1 fexofenadine hcl tab 60 1 OTC fexofenadine hcl tab OTC fexofenadine sus 30/5ml 1 OTC hydroxyzine hcl syrup 10 /5ml 1 ; High Risk Medications require for members age 65 and older hydroxyzine hcl tab 10 1 ; High Risk Medications require for members age 65 and older hydroxyzine hcl tab 25 1 ; High Risk Medications require for members age 65 and older - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 105

110 hydroxyzine hcl tab 50 1 ; High Risk Medications require for members age 65 and older levocetirizine dihydrochloride soln /5ml (0.5 /ml) levocetirizine dihydrochloride tab 5 1 loratadine cap 10 1 OTC loratadine syp 5/5ml 1 OTC BETA AGONISTS albuterol sulfate soln nebu 0.5% (5 1 QL (60 ml / 25 days) /ml) albuterol sulfate soln nebu 0.63 /3ml 1 QL (5 boxes / 25 days) (base equiv) albuterol sulfate soln nebu 0.083% (2.5 1 QL (5 boxes / 25 days) /3ml) albuterol sulfate soln nebu 1.25 /3ml 1 QL (5 boxes / 25 days) (base equiv) albuterol sulfate syrup 2 /5ml 1 albuterol sulfate tab 2 1 albuterol sulfate tab 4 1 albuterol sulfate tab er 12hr 4 1 albuterol sulfate tab er 12hr 8 1 BROVANA NEB 15MCG 3 QL (2 boxes / 25 days) levalbuterol hcl soln nebu 0.31 /3ml 1 QL (300 ml / 25 days) (base equiv) levalbuterol hcl soln nebu 0.63 /3ml 1 QL (300 ml / 25 days) (base equiv) levalbuterol hcl soln nebu 1.25 /3ml 1 QL (300 ml / 25 days) (base equiv) levalbuterol hcl soln nebu conc QL (45 ml / 25 days) /0.5ml (base equiv) metaproterenol sulfate syrup 10 /5ml 1 metaproterenol sulfate tab 10 1 metaproterenol sulfate tab 20 1 PERFOROMIST NEB 20MCG 2 QL (2 boxes / 25 days) PROAIR HFA AER 2 QL (2 inhalers / 25 days) PROAIR RESPI AER 2 QL (2 packages / 25 days) SEREVENT DIS AER 50MCG 3 QL (60 inhalations / 25 days) STRIVERDI AER 2.5MCG 2 QL (1 package / 25 days) terbutaline sulfate tab terbutaline sulfate tab 5 1 COLD/COUGH - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 106

111 benzonatate cap benzonatate cap cheratussin syp /5 1 hydrocodone w/ homatropine syrup /5ml hydrocodone w/ homatropine tab NORTUSS-EX LIQ /5 2 prometh vc sol plain 1 prometh vc/ syp codeine 1 promethazine w/ codeine syrup /5ml promethazine-dm syrup /5ml 1 pseudoephed-bromphen-dm syrup /5ml tussigon tab TUZISTRA XR SUS 3 LEUKOTRIENE MODIFIERS zileuton tab er 12hr LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium chew tab 4 (base 1 equiv) montelukast sodium chew tab 5 (base 1 equiv) montelukast sodium oral granules packet 4 1 (base equiv) montelukast sodium tab 10 (base 1 equiv) zafirlukast tab 10 1 zafirlukast tab 20 1 MAST CELL STABILIZERS cromolyn sodium soln nebu 20 /2ml 1 QL (2 boxes / 25 days) MISCELLANEOUS acetylcysteine inhal soln 10% 1 acetylcysteine inhal soln 20% 1 DALIRESP TAB 250MCG 3 DALIRESP TAB 500MCG 3 KALYDECO K 50MG 3 QL (60 packets / 30 days), KALYDECO K 75MG 3 QL (60 packets / 30 days), KALYDECO TAB 150MG 3 QL (60 tabs / 30 days), ORKAMBI TAB QL (112 tabs / 28 days), ORKAMBI TAB QL (112 tabs / 28 days), - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 107

112 sodium chloride soln nebu 0.9% 1 sodium chloride soln nebu 3% 1 sodium chloride soln nebu 7% 1 sodium chloride soln nebu 10% 1 SYMDEKO TAB QL (56 tabs / 28 days), NASAL STEROIDS flunisolide nasal soln 25 mcg/act (0.025%) 1 QL (3 containers / 25 days) fluticasone propionate nasal susp 50 mcg/act 1 QL (1 container / 25 days) fluticasone spr 50mcg 1 QL (1 container / 25 days); OTC OMNARIS SPR 3 QL (1 package / 25 days) rhinocort sus allergy 1 QL (1 bottle / 25 days); OTC triamcinolone acetonide nasal aerosol suspension 55 mcg/act 1 QL (1 bottle / 25 days); OTC STEROID INHALANTS ASMANEX 30 AER 110MCG 2 QL (2 inhalers / 25 days) ASMANEX 30 AER 220MCG 2 QL (4 inhalers / 25 days) ASMANEX 60 AER 220MCG 2 QL (2 inhalers / 25 days) ASMANEX 120 AER 220MCG 2 QL (1 inhaler / 25 days) ASMANEX HFA AER 100 MCG 2 QL (1 inhaler / 25 days) ASMANEX HFA AER 200 MCG 2 QL (1 inhaler / 25 days) budesonide inhalation susp 0.5 /2ml 1 QL (2 boxes / 25 days) budesonide inhalation susp 0.25 /2ml 1 QL (3 boxes / 25 days) budesonide inhalation susp 1 /2ml 1 QL (1 box / 25 days) QVAR AER 40MCG 2 QL (2 packages / 25 days) QVAR AER 80MCG 2 QL (2 packages / 25 days) STEROID/BETA-AGONIST COMBINATIONS ADVAIR DISKU AER 100/50 2 QL (1 package / 25 days) ADVAIR DISKU AER 250/50 2 QL (1 package / 25 days) ADVAIR DISKU AER 500/50 2 QL (1 package / 25 days) ADVAIR HFA AER 45/21 2 QL (1 package / 25 days) ADVAIR HFA AER 115/21 2 QL (1 package / 25 days) - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 108

113 ADVAIR HFA AER 230/21 2 QL (1 package / 25 days) BREO ELLIPTA INH QL (1 package / 25 days) BREO ELLIPTA INH QL (1 package / 25 days) SYMBICORT AER QL (1 package / 25 days) SYMBICORT AER QL (1 package / 25 days) XANTHINES theochron tab 100 cr 1 theochron tab 200 cr 1 theochron tab 300 cr 1 theophylline soln 80 /15ml 1 theophylline tab er 12hr theophylline tab er 24hr theophylline tab er 24hr TOPICAL DERMATOLOGY, ACNE ACANYA GEL % 3 ST; ** acne cleansi bar 10% 1 OTC acne medicat gel 5% 1 OTC ACNE MEDICAT LOT 5% 1 OTC ACNE MEDICAT LOT 10% 1 OTC adapalene cream 0.1% 1 ; applies for members age 35 and older adapalene gel 0.1% 1 ; applies for members age 35 and older adapalene gel 0.3% 1 ; applies for members age 35 and older adapalene lotion 0.1% 1 ; applies for members age 35 and older adapalene-benzoyl peroxide gel % 1 ST amnesteem cap 10 1 amnesteem cap 20 1 amnesteem cap 40 1 avita cre 0.025% 1 ; applies for members age 35 and older avita gel 0.025% 1 ; applies for members age 35 and older - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 109

114 AZELEX CRE 20% 3 ST; ** BENZIQ GEL 5.25% 2 ST BENZIQ LS GEL 2.75% 2 ST benziq wash liq 5.25% 1 OTC BENZOYL PER GEL 2.5% 1 OTC benzoyl per gel 10% 1 OTC benzoyl per liq 5% wash 1 OTC benzoyl per liq 10% wash 1 OTC benzoyl per lot 6% 1 OTC benzoyl peroxide gel 5% 1 OTC benzoyl peroxide-erythromycin gel 5-3% 1 bp foaming liq wash 10% 1 ST bp gel gel 10% 1 OTC bp wash liq 2.5% 1 ST bp wash liq 5% 1 OTC bpo-5 wash liq 5% 1 OTC claravis cap 10 1 claravis cap 20 1 claravis cap 30 1 claravis cap 40 1 clean&clear cre 10% 1 OTC CLEAR PORE LIQ 3.5% 1 OTC clearplex x gel 10% 1 ST CLINDACIN KIT C 1% 3 clindacin mis etz 1% 1 clindamycin phosph-benzoyl peroxide 1 (refrig) gel 1.2 (1)-5% clindamycin phosphate foam 1% 1 clindamycin phosphate gel 1% 1 clindamycin phosphate lotion 1% 1 clindamycin phosphate soln 1% 1 clindamycin phosphate-benzoyl peroxide 1 gel 1-5% creamy face liq wash 4% 1 OTC EPIDUO FORTE GEL % 3 ST ery pad 2% 1 erythromycin gel 2% 1 erythromycin soln 2% 1 myorisan cap 10 1 myorisan cap 20 1 myorisan cap 40 1 oscion clnsr lot 6% 1 ST sulfacetamide sodium lotion 10% (acne) 1 targetd acne cre 2.5% 1 OTC - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 110

115 tretinoin cream 0.1% 1 ; applies for members age 35 and older tretinoin cream 0.05% 1 ; applies for members age 35 and older tretinoin cream 0.025% 1 ; applies for members age 35 and older tretinoin gel 0.01% 1 ; applies for members age 35 and older tretinoin gel 0.05% 1 ; applies for members age 35 and older tretinoin gel 0.025% 1 ; applies for members age 35 and older DERMATOLOGY, ACTINIC KERATOSIS FLUOROPLEX CRE 1% 3 fluorouracil cream 0.5% 1 fluorouracil cream 5% 1 fluorouracil soln 2% 1 fluorouracil soln 5% 1 imiquimod cream 5% 1 PICATO GEL 0.05% 3 PICATO GEL 0.015% 3 DERMATOLOGY, ANTIBIOTICS ALTABAX OIN 1% 3 ST bacitracin oin 500/gm 1 OTC CENTANY AT KIT 2% 3 ST CORTISPORIN CRE 0.5% 3 ST CORTISPORIN OIN 1% 3 ST gentamicin sulfate cream 0.1% 1 gentamicin sulfate oint 0.1% 1 IV PREP WIPE D 2 mupirocin oint 2% 1 silver sulfadiazine cream 1% 1 ssd cre 1% 1 SULFAMYLON CRE 85MG/GM 3 triple antib oin 1 OTC DERMATOLOGY, ANTIFUNGALS anti-fungal pow 1% 1 OTC antifungal cre 1% 1 OTC antifungal cre 2% 1 OTC ath foot spr aer 1% 1 OTC - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 111

116 butenafine hcl cream 1% 1 OTC ciclopirox gel 0.77% 1 ST ciclopirox olamine cream 0.77% (base 1 ST equiv) ciclopirox olamine susp 0.77% (base 1 ST equiv) ciclopirox shampoo 1% 1 ciclopirox solution 8% 1 clotrimazole cre 1% 1 OTC clotrimazole cream 1% 1 ST clotrimazole soln 1% 1 clotrimazole soln 1% 1 OTC clotrimazole w/ betamethasone cream % clotrimazole w/ betamethasone lotion % cruex aer 2% 1 OTC econazole nitrate cream 1% 1 ST ERTACZO CRE 2% 3 EXELDERM CRE 1% 3 ST; ** EXELDERM SOL 1% 3 ST; ** JUBLIA SOL 10% 3 ketoconazole cream 2% 1 ST ketodan aer 2% 1 ST LAMISIL ADV GEL 1% 1 OTC LAMISIL AT SPR 1% 1 OTC LOTRIMIN AF AER 2% 1 OTC LOTRIMIN ULT CRE 1% 1 OTC MENTAX CRE 1% 3 miconazorb pow af 2% 1 OTC naftifine hcl cream 1% 1 ST naftifine hcl cream 2% 1 ST nyamyc pow ST nystatin cream unit/gm 1 ST nystatin oint unit/gm 1 ST nystatin-triamcinolone cream unit/gm-% nystatin-triamcinolone oint unit/gm-% nystop pow ST oxiconazole nitrate cream 1% 1 ST OXISTAT LOT 1% 3 ST terbinafine cre 1% 1 OTC tolnaftate aerosol pow 1% 1 OTC tolnaftate soln 1% 1 OTC triple paste oin af 2% 1 OTC - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 112

117 DERMATOLOGY, ANTIPRURITIC doxepin hcl cream 5% 1 QL (90 grams / 25 days), ST; ** DERMATOLOGY, ANTIPSORIATICS acitretin cap 10 1 acitretin cap acitretin cap 25 1 calcipotriene cream 0.005% 1 calcipotriene oint 0.005% 1 calcipotriene soln 0.005% (50 mcg/ml) 1 calcitriol oint 3 mcg/gm 1 COSENTYX INJ 150MG/ML 3 QL (1 box / 28 days), COSENTYX PEN INJ 300DOSE 3 QL (1 box / 28 days), methoxsalen rapid cap MOP CAP 10MG 3 tazarotene cream 0.1% 1 TAZORAC CRE 0.05% 2 TAZORAC GEL 0.1% 2 TAZORAC GEL 0.05% 2 DERMATOLOGY, ANTISEBORRHEICS ketoconazole shampoo 2% 1 selenium sulfide lotion 2.5% 1 DERMATOLOGY, CORTICOSTEROIDS alclometasone dipropionate cream 0.05% 1 QL (120g / 25 days) alclometasone dipropionate oint 0.05% 1 QL (120g / 25 days) alphatrex gel 0.05% 1 QL (120g / 25 days) amcinonide cream 0.1% 1 QL (120g / 25 days) amcinonide lotion 0.1% 1 QL (120mL / 25 days) AMCINONIDE OIN 0.1% 2 QL (120g / 25 days) betamethasone dipropionate augmented 1 QL (120g / 25 days) cream 0.05% betamethasone dipropionate augmented 1 QL (120g / 25 days) gel 0.05% betamethasone dipropionate augmented 1 QL (120mL / 25 days) lotion 0.05% betamethasone dipropionate augmented oint 0.05% 1 QL (120g / 25 days) betamethasone dipropionate cream 0.05% 1 QL (120g / 25 days) betamethasone dipropionate lotion 0.05% 1 QL (120mL / 25 days) betamethasone dipropionate oint 0.05% 1 QL (120g / 25 days) betamethasone valerate aerosol foam 0.12% 1 betamethasone valerate cream 0.1% (base 1 QL (120g / 25 days) equivalent) betamethasone valerate lotion 0.1% (base 1 QL (120mL / 25 days) equivalent) - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 113

118 betamethasone valerate oint 0.1% (base equivalent) 1 QL (120g / 25 days) calcipotriene-betamethasone dipropionate 1 oint % clobetasol propionate cream 0.05% 1 QL (120g / 25 days) clobetasol propionate foam 0.05% 1 clobetasol propionate gel 0.05% 1 QL (120g / 25 days) clobetasol propionate lotion 0.05% 1 QL (120mL / 25 days) clobetasol propionate oint 0.05% 1 QL (120g / 25 days) clobetasol propionate shampoo 0.05% 1 clobetasol propionate soln 0.05% 1 clobetasol propionate spray 0.05% 1 clocortolone pivalate cream 0.1% 1 QL (120g / 25 days) CORDRAN 24X3 TAP 4MCG/CM 3 desonide cream 0.05% 1 QL (120g / 25 days) desonide lotion 0.05% 1 QL (120mL / 25 days) desonide oint 0.05% 1 QL (120g / 25 days) desoximetasone cream 0.05% 1 QL (120g / 25 days) desoximetasone cream 0.25% 1 QL (120g / 25 days) desoximetasone gel 0.05% 1 QL (120g / 25 days) desoximetasone oint 0.05% 1 QL (120g / 25 days) desoximetasone oint 0.25% 1 QL (120g / 25 days) diflorasone diacetate cream 0.05% 1 QL (120g / 25 days) diflorasone diacetate oint 0.05% 1 QL (120g / 25 days) fluocinolone acetonide cream 0.01% 1 fluocinolone acetonide cream 0.025% 1 QL (120g / 25 days) fluocinolone acetonide oil 0.01% (body oil) 1 fluocinolone acetonide oil 0.01% (scalp oil) 1 fluocinolone acetonide oint 0.025% 1 QL (120g / 25 days) fluocinolone acetonide soln 0.01% 1 fluocinonide cream 0.1% 1 QL (120g / 25 days) fluocinonide cream 0.05% 1 QL (120g / 25 days) fluocinonide gel 0.05% 1 QL (120g / 25 days) fluocinonide oint 0.05% 1 QL (120g / 25 days) fluocinonide soln 0.05% 1 flurandrenolide cream 0.05% 1 QL (120g / 25 days) flurandrenolide lotion 0.05% 1 QL (120mL / 25 days) flurandrenolide oint 0.05% 1 QL (120g / 25 days) fluticasone propionate cream 0.05% 1 QL (120g / 25 days) fluticasone propionate lotion 0.05% 1 QL (120mL / 25 days) fluticasone propionate oint 0.005% 1 QL (120g / 25 days) halobetasol propionate cream 0.05% 1 QL (120g / 25 days) halobetasol propionate oint 0.05% 1 QL (120g / 25 days) HALOG CRE 0.1% 3 QL (120g / 25 days) HALOG OIN 0.1% 3 QL (120g / 25 days) hydrocortisone butyrate cream 0.1% 1 QL (120g / 25 days) - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 114

119 hydrocortisone butyrate hydrophilic lipo 1 QL (120g / 25 days) base cream 0.1% hydrocortisone butyrate oint 0.1% 1 QL (120g / 25 days) hydrocortisone butyrate soln 0.1% 1 hydrocortisone cream 1% 1 hydrocortisone cream 2.5% 1 hydrocortisone lotion 2.5% 1 hydrocortisone oint 1% 1 hydrocortisone oint 2.5% 1 hydrocortisone valerate cream 0.2% 1 QL (120g / 25 days) hydrocortisone valerate oint 0.2% 1 QL (120g / 25 days) lokara lot 0.05% 1 QL (120mL / 25 days) mometasone furoate cream 0.1% 1 QL (120g / 25 days) mometasone furoate oint 0.1% 1 QL (120g / 25 days) mometasone furoate solution 0.1% (lotion) 1 QL (120mL / 25 days) prednicarbate cream 0.1% 1 QL (120g / 25 days) prednicarbate oint 0.1% 1 QL (120g / 25 days) scalacort lot 2% 1 triamcinolone acetonide aerosol soln /gm triamcinolone acetonide cream 0.1% 1 triamcinolone acetonide cream 0.5% 1 triamcinolone acetonide cream 0.025% 1 triamcinolone acetonide lotion 0.1% 1 triamcinolone acetonide lotion 0.025% 1 triamcinolone acetonide oint 0.1% 1 triamcinolone acetonide oint 0.5% 1 triamcinolone acetonide oint 0.025% 1 triderm cre 0.1% 1 DERMATOLOGY, LOCAL ANESTHETICS lidocaine hcl gel 2% 1 QL (30gm / 25 days) lidocaine hcl soln 4% 1 QL (50mL / 25 days) lidocaine-prilocaine cream % 1 QL (30gm / 25 days) lidocaine-prilocaine cream kit % 1 pramox gel 1% 1 SYNERA DIS 70-70MG 3 QL (2 patches / 25 days) DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE ABREVA CRE 10% 1 OTC acyclovir oint 5% 1 AVAGE CRE 0.1% 3 CONDYLOX GEL 0.5% 3 DENAVIR CRE 1% 3 ST diclofenac sodium gel 1% 1 QL (500g / 25 days) ELIDEL CRE 1% 2 ST; ** lactic acid (ammonium lactate) cream 12% 1 - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 115

120 lactic acid (ammonium lactate) lotion 10% 1 lactic acid (ammonium lactate) lotion 12% 1 OXSORALEN LOT 1% 3 podofilox soln 0.5% 1 RECTIV OIN 0.4% 3 tacrolimus oint 0.1% 1 ST; ** tacrolimus oint 0.03% 1 ST; ** TARGRETIN GEL 1% 3 VEREGEN OIN 15% 3 DERMATOLOGY, ROSACEA FINACEA AER 15% 2 FINACEA GEL 15% 2 metronidazole cream 0.75% 1 metronidazole gel 0.75% 1 metronidazole gel 1% 1 metronidazole lotion 0.75% 1 MIRVASO GEL 0.33% 3 rosadan cre 0.75% 1 DERMATOLOGY, SCABICIDES AND PEDICULIDES EURAX CRE 10% 3 EURAX LOT 10% 3 lice treatmt lot 1% 1 OTC lice trtmnt liq 1% 1 OTC lindane lotion 1% 1 lindane shampoo 1% 1 malathion lotion 0.5% 1 permethrin cream 5% 1 SKLICE LOT 0.5% 3 ST spinosad susp 0.9% 1 ULESFIA LOT 5% 3 ST DERMATOLOGY, WOUND CARE AGENTS REGRANEX GEL 0.01% 3 SANTYL OIN 250/GM 3 sodium chloride irrigation soln 0.9% 1 MOUTH/THROAT/DENTAL AGENTS cevimeline hcl cap 30 1 chlorhexidine gluconate soln 0.12% 1 clotrimazole troche 10 1 lidocaine hcl laryngotracheal soln 4% 1 lidocaine hcl viscous soln 2% 1 nystatin susp unit/ml 1 oralone dent pst 0.1% 1 periogard sol 0.12% 1 pilocarpine hcl tab 5 1 pilocarpine hcl tab Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 116

121 triamcinolone acetonide dental paste 0.1% 1 OTIC acetic acid 2% in aluminum acetate otic 1 soln acetic acid otic soln 2% 1 CIPRO HC SUS OTIC 3 CIPRODEX SUS % 2 CORTISPORIN SUS -TC OTIC 3 fluocinolone acetonide (otic) oil 0.01% 1 hydrocortisone w/ acetic acid otic soln 1-1 2% neomycin-polymyxin-hc otic soln 1% 1 neomycin-polymyxin-hc otic susp /ml unit/ml-1% ofloxacin otic soln 0.3% 1 - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over The Counter ** - Applies if Step is Not Met 117

122 Index 8 8-MOP CAP 10MG A abacavir sulfate-lamivudine-zidovudine tab abacavir sulfate-lamivudine tab abacavir sulfate soln 20 /ml (base equiv)...13 abacavir sulfate tab 300 (base equiv)...13 ABRAXANE INJ 100MG...23 ABREVA CRE 10% acamprosate calcium tab delayed release ACANYA GEL % acarbose tab acarbose tab acarbose tab acebutolol hcl cap acebutolol hcl cap acetaminophen w/ codeine soln /5ml...3 acetaminophen w/ codeine tab acetaminophen w/ codeine tab acetaminophen w/ codeine tab acetazolamide cap er 12hr acetazolamide sodium for inj acetazolamide tab acetazolamide tab acetic acid 2% in aluminum acetate otic soln acetic acid otic soln 2% acetylcysteine inhal soln 10% acetylcysteine inhal soln 20% acitretin cap acitretin cap acitretin cap acne cleansi bar 10% acne medicat gel 5% ACNE MEDICAT LOT 10% ACNE MEDICAT LOT 5% ACTEMRA INJ 162/ ACTEMRA INJ 200/10ML...93 ACTEMRA INJ 400/20ML...93 ACTEMRA INJ 80MG/4ML...93 ACTHIB INJ...95 ACUVAIL SOL 0.45% acyclovir cap acyclovir oint 5% acyclovir susp 200 /5ml...16 acyclovir tab acyclovir tab ADACEL INJ...95 adapalene-benzoyl peroxide gel % adapalene cream 0.1% adapalene gel 0.1% adapalene gel 0.3% adapalene lotion 0.1% ADCIRCA TAB 20MG...44 adefovir dipivoxil tab ADEMS TAB 0.5MG...44 ADEMS TAB 1.5MG...44 ADEMS TAB 1MG...44 ADEMS TAB 2.5MG...44 ADEMS TAB 2MG...44 adrucil inj 2.5g/50m...22 adrucil inj 500/10ml...22 ADULT RESPIRATORY MASK...98 ADVAIR DISKU AER 100/ ADVAIR DISKU AER 250/ ADVAIR DISKU AER 500/ ADVAIR HFA AER 115/ ADVAIR HFA AER 230/ ADVAIR HFA AER 45/ afeditab tab 30 cr...39 afeditab tab 60 cr...39 AFINITOR DIS TAB 2MG...25 AFINITOR DIS TAB 3MG...25 AFINITOR DIS TAB 5MG...25 AFINITOR TAB 10MG...25 AFINITOR TAB 2.5MG...25 AFINITOR TAB 5MG...25 AFINITOR TAB 7.5MG...25 AFLURIA INJ AFLURIA INJ PF AKYNZEO CAP ALBENZA TAB 200MG...11 albuterol sulfate soln nebu 0.083% (2.5 /3ml)

123 albuterol sulfate soln nebu 0.5% (5 /ml) albuterol sulfate soln nebu 0.63 /3ml (base equiv) albuterol sulfate soln nebu 1.25 /3ml (base equiv) albuterol sulfate syrup 2 /5ml albuterol sulfate tab albuterol sulfate tab albuterol sulfate tab er 12hr albuterol sulfate tab er 12hr alclometasone dipropionate cream 0.05% alclometasone dipropionate oint 0.05% ALCOH-WIPE MIS ALCOHOL PREP WIPES AND SWABS...97 ALDACTAZIDE TAB 50/ ALECENSA CAP 150MG...26 alendronate sodium oral soln 70 /75ml...72 alendronate sodium tab alendronate sodium tab alendronate sodium tab alendronate sodium tab alendronate sodium tab ALFERON N INJ 5MU/ML...94 alfuzosin hcl tab er 24hr ALIMTA INJ 100MG...22 ALIMTA INJ 500MG...22 ALINIA SUS 100/5ML...11 ALINIA TAB 500MG...11 all day allg cap all day allg chw allergy relf tab allergy tab allopurinol tab allopurinol tab almotriptan malate tab almotriptan malate tab ALOCRIL SOL 2% alogliptin benzoate tab 12.5 (base equiv)...69 alogliptin benzoate tab 25 (base equiv)...69 alogliptin benzoate tab 6.25 (base equiv)...68 ALOMIDE SOL 0.1% OP alosetron hcl tab 0.5 (base equiv).86 alosetron hcl tab 1 (base equiv)...86 alphatrex gel 0.05% ALPRAZOLAM CON 1 MG/ML...45 alprazolam orally disintegrating tab alprazolam orally disintegrating tab alprazolam orally disintegrating tab alprazolam orally disintegrating tab alprazolam tab alprazolam tab alprazolam tab alprazolam tab ALREX SUS 0.2% ALTABAX OIN 1% altavera tab...73 alyacen tab 1/ alyacen tab 7/7/ amantadine hcl cap amantadine hcl syrup 50 /5ml...55 amantadine hcl tab amcinonide cream 0.1% amcinonide lotion 0.1% AMCINONIDE OIN 0.1% amethia tab...73 amethyst tab 90-20mcg...73 amifostine for inj amiloride & hydrochlorothiazide tab amiloride hcl tab amiodarone hcl tab amiodarone hcl tab AMITIZA CAP 24MCG...86 AMITIZA CAP 8MCG...86 amitriptyline hcl tab amitriptyline hcl tab amitriptyline hcl tab amitriptyline hcl tab amitriptyline hcl tab amitriptyline hcl tab amlodipine-valsartan-hydrochlorothiazide tab amlodipine-valsartan-hydrochlorothiazide tab amlodipine-valsartan-hydrochlorothiazide 119

124 tab amlodipine-valsartan-hydrochlorothiazide tab amlodipine-valsartan-hydrochlorothiazide tab amlodipine besylate-atorvastatin calcium tab amlodipine besylate-atorvastatin calcium tab amlodipine besylate-atorvastatin calcium tab amlodipine besylate-atorvastatin calcium tab amlodipine besylate-atorvastatin calcium tab amlodipine besylate-atorvastatin calcium tab amlodipine besylate-atorvastatin calcium tab amlodipine besylate-atorvastatin calcium tab amlodipine besylate-atorvastatin calcium tab amlodipine besylate-atorvastatin calcium tab amlodipine besylate-atorvastatin calcium tab amlodipine besylate-benazepril hcl cap amlodipine besylate-benazepril hcl cap amlodipine besylate-benazepril hcl cap amlodipine besylate-benazepril hcl cap amlodipine besylate-benazepril hcl cap amlodipine besylate-benazepril hcl cap amlodipine besylate-olmesartan medoxomil tab amlodipine besylate-olmesartan medoxomil tab amlodipine besylate-olmesartan medoxomil tab amlodipine besylate-olmesartan medoxomil tab amlodipine besylate-valsartan tab amlodipine besylate-valsartan tab amlodipine besylate-valsartan tab amlodipine besylate-valsartan tab amlodipine besylate tab 10 (base equivalent)...39 amlodipine besylate tab 2.5 (base equivalent)...39 amlodipine besylate tab 5 (base equivalent)...39 amnesteem cap amnesteem cap amnesteem cap amoxapine tab amoxapine tab amoxapine tab amoxapine tab amoxicillin (trihydrate) cap amoxicillin (trihydrate) cap amoxicillin (trihydrate) chew tab amoxicillin (trihydrate) chew tab amoxicillin (trihydrate) for susp 125 /5ml...20 amoxicillin (trihydrate) for susp 200 /5ml...20 amoxicillin (trihydrate) for susp 250 /5ml...20 amoxicillin (trihydrate) for susp 400 /5ml...20 amoxicillin (trihydrate) tab amoxicillin (trihydrate) tab amoxicillin & k clavulanate chew tab amoxicillin & k clavulanate chew tab amoxicillin & k clavulanate for susp /5ml...19 amoxicillin & k clavulanate for susp /5ml...19 amoxicillin & k clavulanate for susp /5ml...19 amoxicillin & k clavulanate for susp /5ml

125 amoxicillin & k clavulanate tab amoxicillin & k clavulanate tab amoxicillin & k clavulanate tab amoxicillin & k clavulanate tab er 12hr amphetamine-dextroamphetamine cap er 24hr amphetamine-dextroamphetamine cap er 24hr amphetamine-dextroamphetamine cap er 24hr amphetamine-dextroamphetamine cap er 24hr amphetamine-dextroamphetamine cap er 24hr amphetamine-dextroamphetamine cap er 24hr amphetamine-dextroamphetamine tab amphetamine-dextroamphetamine tab amphetamine-dextroamphetamine tab amphetamine-dextroamphetamine tab amphetamine-dextroamphetamine tab amphetamine-dextroamphetamine tab amphetamine-dextroamphetamine tab amphotericin b for inj ampicillin cap ampicillin cap ampicillin for susp 125 /5ml...20 ampicillin for susp 250 /5ml...20 AMPYRA TAB 10MG...64 anagrelide hcl cap anagrelide hcl cap anastrozole tab ANORO ELLIPT AER anti-diarrhe tab anti-fungal pow 1% antifungal cre 1% antifungal cre 2% ANZEMET TAB 100MG...84 ANZEMET TAB 50MG...84 APIDRA INJ SOLOSTAR...69 APIDRA INJ U APOKYN INJ 10MG/ML...55 apraclonidine hcl ophth soln 0.5% (base equivalent) aprepitant capsule aprepitant capsule aprepitant capsule aprepitant capsule therapy pack 80 & APRISO CAP 0.375GM...86 apri tab...73 APTIOM TAB 200MG...45 APTIOM TAB 400MG...46 APTIOM TAB 600MG...46 APTIOM TAB 800MG...46 APTIVUS CAP 250MG...13 APTIVUS SOL...13 aranelle tab...73 ARANESP INJ 100MCG...91 ARANESP INJ 10MCG...91 ARANESP INJ 150MCG...91 ARANESP INJ 200MCG...91 ARANESP INJ 25MCG...91 ARANESP INJ 300MCG...91 ARANESP INJ 40MCG...91 ARANESP INJ 500MCG...91 ARANESP INJ 60MCG...91 arbinoxa sol 4/5ml ARGATROBAN INJ 125/ ARGATROBAN INJ 250/ argatroban inj 250 /2.5ml (concentrate for iv infusion)...90 aripiprazole orally disintegrating tab aripiprazole orally disintegrating tab aripiprazole oral solution 1 /ml...56 aripiprazole tab aripiprazole tab aripiprazole tab aripiprazole tab aripiprazole tab aripiprazole tab ARISTADA INJ 1064MG...56 ARISTADA INJ 441MG/

126 ARISTADA INJ 662MG/ ARISTADA INJ 882MG/ armodafinil tab armodafinil tab armodafinil tab armodafinil tab ARRANON INJ 5MG/ML...22 ashlyna tab...73 ASMANEX 120 AER 220MCG ASMANEX 30 AER 110MCG ASMANEX 30 AER 220MCG ASMANEX 60 AER 220MCG ASMANEX HFA AER 100 MCG ASMANEX HFA AER 200 MCG aspirin-dipyridamole cap er 12hr aspirin chw aspirin low tab 81 ec...11 atazanavir sulfate cap 150 (base equiv)...13 atazanavir sulfate cap 200 (base equiv)...13 atazanavir sulfate cap 300 (base equiv)...13 atenolol & chlorthalidone tab atenolol & chlorthalidone tab atenolol tab atenolol tab atenolol tab ath foot spr aer 1% atomoxetine hcl cap 100 (base equiv)...60 atomoxetine hcl cap 10 (base equiv)...59 atomoxetine hcl cap 18 (base equiv)...59 atomoxetine hcl cap 25 (base equiv)...59 atomoxetine hcl cap 40 (base equiv)...60 atomoxetine hcl cap 60 (base equiv)...60 atomoxetine hcl cap 80 (base equiv)...60 atorvastatin calcium tab 10 (base equivalent)...36 atorvastatin calcium tab 20 (base equivalent)...36 atorvastatin calcium tab 40 (base equivalent)...36 atorvastatin calcium tab 80 (base equivalent)...36 atovaquone-proguanil hcl tab atovaquone-proguanil hcl tab atovaquone susp 750 /5ml...11 ATRIPLA TAB...15 atropine sulfate ophth soln 1% AUBAGIO TAB 14MG...64 AUBAGIO TAB 7MG...64 AUGMENTIN SUS 125/5ML...20 AVAGE CRE 0.1% aviane tab...73 avidoxy tab avita cre 0.025% avita gel 0.025% AVONEX KIT 30MCG...64 AVONEX PEN KIT 30MCG...64 AVONEX PREFL KIT 30MCG...64 azacitidine for inj AZASITE SOL 1% azathioprine tab azelastine hcl nasal spray 0.1% (137 mcg/spray) azelastine hcl nasal spray 0.15% (205.5 mcg/spray) azelastine hcl ophth soln 0.05% AZELEX CRE 20% azithromycin for susp 100 /5ml...18 azithromycin for susp 200 /5ml...18 azithromycin powd pack for susp 1 gm 18 azithromycin tab azithromycin tab azithromycin tab AZOPT SUS 1% OP aztreonam for inj 1 gm...11 aztreonam for inj 2 gm...11 azurette tab 28 day...73 B BABY SUPER DRO DAILY D bacitracin-polymyxin-neomycin-hc ophth oint 1% bacitracin-polymyxin b ophth oint

127 bacitracin oin 500/gm bacitracin ophth oint 500 unit/gm baclofen tab baclofen tab BALCOLTRA TAB balsalazide disodium cap BANZEL SUS 40MG/ML...46 BANZEL TAB 200MG...46 BANZEL TAB 400MG...46 BARACLUDE SOL.05MG/ML...16 BASAGLAR KWIKPEN...69 BELBUCA MIS 150MCG...10 BELBUCA MIS 300MCG...10 BELBUCA MIS 450MCG...10 BELBUCA MIS 600MCG...10 BELBUCA MIS 750MCG...10 BELBUCA MIS 75MCG...10 BELBUCA MIS 900MCG...10 BELSOMRA TAB 10MG...62 BELSOMRA TAB 15MG...62 BELSOMRA TAB 20MG...62 BELSOMRA TAB 5MG...62 benazepril & hydrochlorothiazide tab benazepril & hydrochlorothiazide tab benazepril & hydrochlorothiazide tab benazepril & hydrochlorothiazide tab benazepril hcl tab benazepril hcl tab benazepril hcl tab benazepril hcl tab BENZIQ GEL 5.25% BENZIQ LS GEL 2.75% benziq wash liq 5.25% benzonatate cap benzonatate cap benzoyl per gel 10% BENZOYL PER GEL 2.5% benzoyl per liq 10% wash benzoyl per liq 5% wash benzoyl per lot 6% benzoyl peroxide-erythromycin gel 5-3% benzoyl peroxide gel 5% benztropine mesylate tab benztropine mesylate tab benztropine mesylate tab BEPREVE DRO 1.5% BESIVANCE SUS 0.6% betamethasone dipropionate augmented cream 0.05% betamethasone dipropionate augmented gel 0.05% betamethasone dipropionate augmented lotion 0.05% betamethasone dipropionate augmented oint 0.05% betamethasone dipropionate cream 0.05% betamethasone dipropionate lotion 0.05% betamethasone dipropionate oint 0.05% betamethasone valerate aerosol foam 0.12% betamethasone valerate cream 0.1% (base equivalent) betamethasone valerate lotion 0.1% (base equivalent) betamethasone valerate oint 0.1% (base equivalent) BETASERON INJ 0.3MG...64 betaxolol hcl ophth soln 0.5% betaxolol hcl tab betaxolol hcl tab bethanechol chloride tab bethanechol chloride tab bethanechol chloride tab bethanechol chloride tab BETIMOL SOL 0.25% BETIMOL SOL 0.5% BETOPTIC-S SUS 0.25% OP BEVESPI AER 9-4.8MCG bexarotene cap BEXSERO INJ...96 bicalutamide tab BICNU INJ 100MG...21 BILTRICIDE TAB 600MG...11 bimatoprost ophth soln 0.03% BIO-D-MULSIO LIQ 400/ bio-d-mulsio liq 400unit...99 BIO-STATIN CAP BIO-STATIN CAP

128 bisoprolol & hydrochlorothiazide tab bisoprolol & hydrochlorothiazide tab bisoprolol & hydrochlorothiazide tab bisoprolol fumarate tab bisoprolol fumarate tab bleomycin sulfate for inj 15 unit...22 bleomycin sulfate for inj 30 unit...22 BLEPHAMIDE OIN S.O.P BLEPHAMIDE SUS OP BLOOD GLUCOSE CALIBRATION SOLUTION...97 BOOSTRIX INJ...96 BOSULIF TAB 100MG...26 BOSULIF TAB 400MG...26 BOSULIF TAB 500MG...26 bp foaming liq wash 10% bp gel gel 10% bpo-5 wash liq 5% bp wash liq 2.5% bp wash liq 5% BREO ELLIPTA INH BREO ELLIPTA INH BRILINTA TAB 60MG...92 BRILINTA TAB 90MG...92 brimonidine tartrate ophth soln 0.15% brimonidine tartrate ophth soln 0.2% 103 bromfenac sodium ophth soln 0.09% (base equiv) (once-daily) bromfenac sodium ophth soln 0.09% (base equivalent) bromocriptine mesylate cap 5 (base equivalent)...55 bromocriptine mesylate tab 2.5 (base equivalent)...55 brompheniramine tannate chew tab BROVANA NEB 15MCG budesonide delayed release particles cap budesonide inhalation susp 0.25 /2ml budesonide inhalation susp 0.5 /2ml budesonide inhalation susp 1 /2ml 108 bumetanide tab bumetanide tab bumetanide tab buprenorphine hcl-naloxone hcl sl tab (base equiv)...2 buprenorphine hcl-naloxone hcl sl tab 8-2 (base equiv)...3 buprenorphine hcl sl tab 2 (base equiv)...10 buprenorphine hcl sl tab 8 (base equiv)...11 bupropion hcl tab bupropion hcl tab bupropion hcl tab er 12hr bupropion hcl tab er 12hr bupropion hcl tab er 12hr bupropion hcl tab er 24hr bupropion hcl tab er 24hr buspirone hcl tab buspirone hcl tab buspirone hcl tab buspirone hcl tab buspirone hcl tab busulfan inj 6 /ml...21 butalbital-acetaminophen-caffeine cap butalbital-acetaminophen-caffeine cap butalbital-acetaminophen-caffeine tab butalbital-acetaminophen-caff w/ cod cap butalbital-aspirin-caffeine cap butenafine hcl cream 1% butorphanol tartrate nasal soln 10 /ml...3 BYSTOLIC TAB 10MG...38 BYSTOLIC TAB 2.5MG...38 BYSTOLIC TAB 20MG...38 BYSTOLIC TAB 5MG...38 BYVALSON TAB 5-80MG...33 C cabergoline tab calcipotriene-betamethasone dipropionate oint % calcipotriene cream 0.005% calcipotriene oint 0.005%

129 calcipotriene soln 0.005% (50 mcg/ml) calcitonin (salmon) nasal soln 200 unit/act...81 calcitriol cap 0.25 mcg...99 calcitriol cap 0.5 mcg...99 calcitriol oint 3 mcg/gm calcitriol oral soln 1 mcg/ml...99 calcium acetate (phosphate binder) cap 667 (169 ca)...81 calcium acetate (phosphate binder) tab CALQUENCE CAP 100MG...26 camila tab CAMPTOSAR INJ 300/15ML...29 CANASA SUP 1000MG...86 candesartan cilexetil-hydrochlorothiazide tab candesartan cilexetil-hydrochlorothiazide tab candesartan cilexetil-hydrochlorothiazide tab candesartan cilexetil tab candesartan cilexetil tab candesartan cilexetil tab candesartan cilexetil tab capecitabine tab capecitabine tab CAPITAL/COD SUS /5...3 CAPRELSA TAB 100MG...26 CAPRELSA TAB 300MG...26 captopril & hydrochlorothiazide tab captopril & hydrochlorothiazide tab captopril & hydrochlorothiazide tab captopril & hydrochlorothiazide tab captopril tab captopril tab captopril tab captopril tab CARAFATE SUS 1GM/10ML...87 carbamazepine cap er 12hr carbamazepine cap er 12hr carbamazepine cap er 12hr carbamazepine chew tab carbamazepine susp 100 /5ml...46 carbamazepine tab carbamazepine tab er 12hr carbamazepine tab er 12hr carbamazepine tab er 12hr carbidopa-levodopa-entacapone tabs carbidopa-levodopa-entacapone tabs carbidopa-levodopa-entacapone tabs carbidopa-levodopa-entacapone tabs carbidopa-levodopa-entacapone tabs carbidopa-levodopa-entacapone tabs carbidopa & levodopa orally disintegrating tab carbidopa & levodopa orally disintegrating tab carbidopa & levodopa orally disintegrating tab carbidopa & levodopa tab carbidopa & levodopa tab carbidopa & levodopa tab carbidopa & levodopa tab er carbidopa & levodopa tab er carbidopa tab carbinoxamine maleate tab carboplatin iv soln 150 /15ml...29 carboplatin iv soln 450 /45ml...29 carboplatin iv soln 50 /5ml...29 carboplatin iv soln 600 /60ml...29 CARDIZEM LA TAB 120MG...39 CARDURA XL TAB 4MG...88 CARDURA XL TAB 8MG...88 carisoprodol tab carisoprodol tab carteolol hcl ophth soln 1% cartia xt cap 120/24hr...39 cartia xt cap 180/24hr...39 cartia xt cap 240/24hr...39 cartia xt cap 300/24hr...39 carvedilol tab carvedilol tab

130 carvedilol tab carvedilol tab CAYA DPR...97 CAYSTON INH 75MG...11 caziant pak...73 cefaclor cap cefaclor cap CEFACLOR ER TAB 500MG...17 cefaclor for susp 125 /5ml...17 cefaclor for susp 250 /5ml...17 cefaclor for susp 375 /5ml...17 cefadroxil cap cefadroxil for susp 250 /5ml...17 cefadroxil for susp 500 /5ml...17 cefadroxil tab 1 gm...17 cefdinir cap cefdinir for susp 125 /5ml...17 cefdinir for susp 250 /5ml...17 cefditoren pivoxil tab 200 (base equivalent)...17 cefditoren pivoxil tab 400 (base equivalent)...17 cefepime hcl for inj 1 gm...17 cefepime hcl for inj 2 gm...17 cefixime for susp 100 /5ml...17 cefixime for susp 200 /5ml...17 cefpodoxime proxetil for susp 100 /5ml...17 cefpodoxime proxetil for susp 50 /5ml...17 cefpodoxime proxetil tab cefpodoxime proxetil tab cefprozil for susp 125 /5ml...18 cefprozil for susp 250 /5ml...18 cefprozil tab cefprozil tab ceftazidime for inj 2 gm...18 ceftibuten cap ceftibuten for susp 180 /5ml...18 CEFTIN SUS 125/5ML...18 CEFTIN SUS 250/5ML...18 ceftriaxone sodium for inj 10 gm...18 ceftriaxone sodium for inj 1 gm...18 ceftriaxone sodium for inj ceftriaxone sodium for inj 2 gm...18 ceftriaxone sodium for inj ceftriaxone sodium for iv soln 1 gm...18 ceftriaxone sodium for iv soln 2 gm...18 cefuroxime axetil tab cefuroxime axetil tab celecoxib cap celecoxib cap celecoxib cap celecoxib cap CELONTIN CAP 300MG...46 CENTANY AT KIT 2% cephalexin cap cephalexin cap cephalexin cap cephalexin for susp 125 /5ml...18 cephalexin for susp 250 /5ml...18 cephalexin tab cephalexin tab CERDELGA CAP 84MG...76 cetirizine hcl chew tab cetirizine hcl tab cetirizine hcl tab cetirizine sol 1/ml cevimeline hcl cap CHANTIX K 0.5& 1MG...66 CHANTIX K 1MG...67 CHANTIX TAB 0.5MG...67 CHANTIX TAB 1MG...67 chateal tab 0.15/ CHEMET CAP 100MG...72 cheratussin syp / chlorhexidine gluconate soln 0.12%..116 chloroquine phosphate tab chloroquine phosphate tab chlorothiazide tab chlorothiazide tab chlorpromazine hcl tab chlorpromazine hcl tab chlorpromazine hcl tab chlorpromazine hcl tab chlorpromazine hcl tab chlorthalidone tab chlorthalidone tab chlorthalidone tab chlorzoxazone tab cholecalciferol cap 400 unit cholestyramine light powder 4 gm/dose...35 cholestyramine light powder packets 4 gm...35 cholestyramine powder 4 gm/dose

131 cholestyramine powder packets 4 gm..35 CHOR GONADOT INJ 10000UNT...79 CIALIS TAB 2.5MG...88 CIALIS TAB 5MG...88 ciclopirox gel 0.77% ciclopirox olamine cream 0.77% (base equiv) ciclopirox olamine susp 0.77% (base equiv) ciclopirox shampoo 1% ciclopirox solution 8% cilostazol tab cilostazol tab CILOXAN OIN 0.3% OP cimetidine hcl soln 300 /5ml...85 cimetidine tab cimetidine tab cimetidine tab cimetidine tab CIPRODEX SUS % ciprofloxacin-ciprofloxacin hcl tab er 24hr 1000 (base eq)...19 ciprofloxacin-ciprofloxacin hcl tab er 24hr 500 (base eq)...19 ciprofloxacin for oral susp 250 /5ml (5%) (5 gm/100ml)...19 ciprofloxacin for oral susp 500 /5ml (10%) (10 gm/100ml)...19 ciprofloxacin hcl ophth soln 0.3% ciprofloxacin hcl tab 100 (base equiv)...19 ciprofloxacin hcl tab 250 (base equiv)...19 ciprofloxacin hcl tab 500 (base equiv)...19 ciprofloxacin hcl tab 750 (base equiv)...19 CIPRO HC SUS OTIC cisplatin inj 100 /100ml (1 /ml).29 cisplatin inj 200 /200ml (1 /ml).29 cisplatin inj 50 /50ml (1 /ml)...29 citalopram hydrobromide oral soln 10 /5ml...51 citalopram hydrobromide tab 10 (base equiv)...51 citalopram hydrobromide tab 20 (base equiv)...51 citalopram hydrobromide tab 40 (base equiv)...51 CITRANATAL CAP HARMONY CITRANATAL CAP MEDLEY CITRANATAL MIS CITRANATAL MIS 90 DHA CITRANATAL MIS B-CALM CITRANATAL K ASSURE CITRANATAL K DHA CITRANATAL TAB BLOOM CITRANATAL TAB RX cladribine iv soln 10 /10ml (1 /ml)...22 claravis cap claravis cap claravis cap claravis cap CLARINEX SYP 0.5MG/ML clarithromycin for susp 125 /5ml...18 clarithromycin for susp 250 /5ml...18 clarithromycin tab clarithromycin tab clarithromycin tab er 24hr clean&clear cre 10% clearplex x gel 10% CLEAR PORE LIQ 3.5% clemastine fumarate tab CLENPIQ SOL...86 CLEOCIN SUP 100MG...90 CLIMARA PRO DIS WEEKLY...76 CLINDACIN KIT C 1% clindacin mis etz 1% clindamycin hcl cap clindamycin hcl cap clindamycin hcl cap clindamycin palmitate hcl for soln 75 /5ml (base equiv)...11 clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5% clindamycin phosphate-benzoyl peroxide gel 1-5% clindamycin phosphate foam 1% clindamycin phosphate gel 1% clindamycin phosphate lotion 1% clindamycin phosphate soln 1% clindamycin phosphate vaginal cream 2%...90 clobetasol propionate cream 0.05% clobetasol propionate foam 0.05%

132 clobetasol propionate gel 0.05% clobetasol propionate lotion 0.05% clobetasol propionate oint 0.05% clobetasol propionate shampoo 0.05% clobetasol propionate soln 0.05% clobetasol propionate spray 0.05% clocortolone pivalate cream 0.1% clofarabine iv soln 1 /ml...22 clomiphene citrate tab clomipramine hcl cap clomipramine hcl cap clomipramine hcl cap clonazepam tab clonazepam tab clonazepam tab clonidine hcl tab clonidine hcl tab clonidine hcl tab clonidine hcl td patch weekly 0.1 /24hr...43 clonidine hcl td patch weekly 0.2 /24hr...43 clonidine hcl td patch weekly 0.3 /24hr...43 clopidogrel bisulfate tab 300 (base equiv)...92 clopidogrel bisulfate tab 75 (base equiv)...92 clorazepate dipotassium tab clorazepate dipotassium tab clorazepate dipotassium tab clotrimazole cre 1% clotrimazole cream 1% clotrimazole soln 1% clotrimazole troche clotrimazole w/ betamethasone cream % clotrimazole w/ betamethasone lotion % clozapine orally disintegrating tab clozapine orally disintegrating tab clozapine orally disintegrating tab clozapine orally disintegrating tab clozapine orally disintegrating tab clozapine tab clozapine tab clozapine tab clozapine tab COARTEM TAB MG...13 codeine sulfate tab codeine sulfate tab codeine sulfate tab colchicine tab colchicine w/ probenecid tab colestipol hcl granule packets 5 gm...35 colestipol hcl granules 5 gm...35 colestipol hcl tab 1 gm...35 colocort ene COMBIGAN SOL 0.2/0.5% COMBIVENT AER COMETRIQ KIT 100MG...26 COMETRIQ KIT 140MG...26 COMETRIQ KIT 60MG...26 COMPLERA TAB...15 compro sup COMVAX INJ...96 CONCEPTROL GEL 4%...89 CONDYLOX GEL 0.5% COXONE INJ 40MG/ML...64 CORDRAN 24X3 TAP 4MCG/CM cortisone acetate tab CORTISPORIN CRE 0.5% CORTISPORIN OIN 1% CORTISPORIN SUS -TC OTIC COSENTYX INJ 150MG/ML COSENTYX PEN INJ 300DOSE creamy face liq wash 4% CREON CAP 12000UNT...87 CREON CAP 24000UNT...87 CREON CAP 3000UNIT...87 CREON CAP 36000UNT...87 CREON CAP 6000UNIT...87 CRESEMBA CAP 186 MG...12 CRINONE GEL 4% VAG...82 CRINONE GEL 8% VAG...82 CRIXIVAN CAP 200MG...13 CRIXIVAN CAP 400MG...13 cromolyn sodium ophth soln 4% cromolyn sodium soln nebu 20 /2ml 128

133 cruex aer 2% cryselle-28 tab 28 tabs...73 CUVPOSA SOL 1MG/5ML...84 cyanocobalamin inj 1000 mcg/ml cyclafem tab 1/ cyclafem tab 7/7/ cyclobenzaprine hcl tab cyclobenzaprine hcl tab cyclobenzaprine hcl tab cyclophosphamide cap cyclophosphamide cap cyclophosphamide for inj 1 gm...21 cyclophosphamide for inj 2 gm...21 cyclophosphamide for inj CYCLOPHOSPH CAP 25MG...21 CYCLOPHOSPH CAP 50MG...21 cycloserine cap CYCLOSET TAB 0.8MG...69 cyclosporine modified cap cyclosporine modified cap cyclosporine modified cap cyclosporine modified oral soln 100 /ml...95 cyproheptadine hcl syrup 2 /5ml cyproheptadine hcl tab CYSTADANE POW...76 CYSTAGON CAP 150MG...76 CYSTAGON CAP 50MG...76 CYSTARAN SOL 0.44% cytarabine inj 20 /ml...22 cytarabine inj pf 100 /ml...22 cytarabine inj pf 20 /ml...22 D D-VI-SOL LIQ 400UNIT d3 kids chw 400unit dacarbazine for inj dacarbazine for inj DALIRESP TAB 250MCG DALIRESP TAB 500MCG danazol cap danazol cap danazol cap dantrolene sodium cap dantrolene sodium cap dantrolene sodium cap dapsone tab dapsone tab DAPTACEL INJ...96 daptomycin for iv soln DARAPRIM TAB 25MG...11 darifenacin hydrobromide tab er 24hr 15 (base equiv)...89 darifenacin hydrobromide tab er 24hr 7.5 (base equiv)...89 dasetta tab 1/ dasetta tab 7/7/ daunorubicin hcl inj 5 /ml (base equiv)...21 DAUNOXOME INJ 2MG/ML...21 DDROPS BOOST LIQ 600/ decitabine for inj delyla tab demeclocycline hcl tab demeclocycline hcl tab DENAVIR CRE 1% DEPEN TITRA TAB 250MG...72 DEPO-SQ PROV INJ DEPOCYT INJ 50MG/5ML...22 DESCOVY TAB 200/ desipramine hcl tab desipramine hcl tab desipramine hcl tab desipramine hcl tab desipramine hcl tab desipramine hcl tab desloratadine tab desloratadine tab orally disintegrating desloratadine tab orally disintegrating desmopressin acetate nasal soln 0.01% (refrigerated)...83 desmopressin acetate nasal spray soln 0.01%...83 desmopressin acetate nasal spray soln 0.01% (refrigerated)...83 desmopressin acetate tab desmopressin acetate tab desonide cream 0.05% desonide lotion 0.05% desonide oint 0.05% desoximetasone cream 0.05% desoximetasone cream 0.25% desoximetasone gel 0.05% desoximetasone oint 0.05%

134 desoximetasone oint 0.25% desvenlafaxine succinate tab er 24hr 100 (base equiv)...51 desvenlafaxine succinate tab er 24hr 25 (base equiv)...51 desvenlafaxine succinate tab er 24hr 50 (base equiv)...51 DEXAMETHASON CON 1MG/ML...79 dexamethasone elixir 0.5 /5ml...79 dexamethasone sodium phosphate ophth soln 0.1% dexamethasone soln 0.5 /5ml...79 dexamethasone tab dexamethasone tab dexamethasone tab dexamethasone tab dexamethasone tab dexamethasone tab dexamethasone tab DEXILANT CAP 30MG DR...88 DEXILANT CAP 60MG DR...88 dexmethylphenidate hcl cap er 24 hr dexmethylphenidate hcl cap er 24 hr dexmethylphenidate hcl cap er 24 hr dexmethylphenidate hcl cap er 24 hr dexmethylphenidate hcl cap er 24 hr dexmethylphenidate hcl cap er 24 hr dexmethylphenidate hcl cap er 24 hr dexmethylphenidate hcl cap er 24 hr dexmethylphenidate hcl tab dexmethylphenidate hcl tab dexmethylphenidate hcl tab dexrazoxane for inj dexrazoxane for inj dextroamphetamine sulfate cap er 24hr dextroamphetamine sulfate cap er 24hr dextroamphetamine sulfate cap er 24hr dextroamphetamine sulfate oral solution 5 /5ml...60 dextroamphetamine sulfate tab dextroamphetamine sulfate tab diazepam con 5/ml...46 diazepam inj 5 /ml...46 diazepam oral soln 1 /ml...46 diazepam tab diazepam tab diazepam tab diclofenac potassium tab diclofenac sodium gel 1% diclofenac sodium ophth soln 0.1% diclofenac sodium tab delayed release diclofenac sodium tab delayed release diclofenac sodium tab delayed release diclofenac sodium tab er 24hr diclofenac w/ misoprostol tab delayed release diclofenac w/ misoprostol tab delayed release dicloxacillin sodium cap dicloxacillin sodium cap dicyclomine hcl cap dicyclomine hcl oral soln 10 /5ml...84 dicyclomine hcl tab didanosine delayed release capsule didanosine delayed release capsule didanosine delayed release capsule didanosine delayed release capsule DIFICID TAB 200MG...19 diflorasone diacetate cream 0.05% diflorasone diacetate oint 0.05% diflunisal tab digoxin oral soln 0.05 /ml...41 digoxin tab 125 mcg (0.125 )...41 digoxin tab 250 mcg (0.25 )...41 dihydroergotamine mesylate inj 1 /ml...62 dihydroergotamine mesylate nasal spray 4 /ml

135 diltiazem hcl cap er 12hr diltiazem hcl cap er 12hr diltiazem hcl cap er 12hr diltiazem hcl cap er 24hr diltiazem hcl cap er 24hr diltiazem hcl cap er 24hr diltiazem hcl coated beads cap er 24hr diltiazem hcl coated beads cap er 24hr diltiazem hcl coated beads cap er 24hr diltiazem hcl coated beads cap er 24hr diltiazem hcl coated beads cap er 24hr diltiazem hcl extended release beads cap er 24hr diltiazem hcl extended release beads cap er 24hr diltiazem hcl extended release beads cap er 24hr diltiazem hcl extended release beads cap er 24hr diltiazem hcl extended release beads cap er 24hr diltiazem hcl extended release beads cap er 24hr diltiazem hcl tab diltiazem hcl tab diltiazem hcl tab diltiazem hcl tab DIP/TET PED INJ 25-5LFU...96 DIPENTUM CAP 250MG...86 diphenhydramine hcl elixir 12.5 /5ml diphenhydramine hcl inj 50 /ml diphenoxylate w/ atropine liq /5ml...87 diphenoxylate w/ atropine tab dipyridamole tab dipyridamole tab dipyridamole tab disopyramide phosphate cap disopyramide phosphate cap disulfiram tab disulfiram tab DIURIL SUS 250/5ML...42 divalproex sodium cap delayed release sprinkle divalproex sodium tab delayed release divalproex sodium tab delayed release divalproex sodium tab delayed release divalproex sodium tab er 24 hr divalproex sodium tab er 24 hr DOCEFREZ INJ 20MG...23 docetaxel for inj conc 20 /ml...23 docetaxel for inj conc 80 /4ml (20 /ml)...23 DOCETAXEL INJ 140/7ML...23 DOCETAXEL INJ 160/16ML...23 DOCETAXEL INJ 160/8ML...23 DOCETAXEL INJ 20/0.5ML...23 DOCETAXEL INJ 200MG/ DOCETAXEL INJ 20MG/2ML...23 DOCETAXEL INJ 80MG/2ML...23 DOCETAXEL INJ 80MG/8ML...23 DOCETAXEL INJ NON-ALCO...23 docetaxel soln for iv infusion 160 /16ml...23 docetaxel soln for iv infusion 20 /2ml...23 docetaxel soln for iv infusion 80 /8ml...23 dofetilide cap 125 mcg (0.125 )...34 dofetilide cap 250 mcg (0.25 )...34 dofetilide cap 500 mcg (0.5 )...34 donepezil hydrochloride orally disintegrating tab donepezil hydrochloride orally disintegrating tab donepezil hydrochloride tab donepezil hydrochloride tab donepezil hydrochloride tab doripenem for iv infusion doripenem for iv infusion dorzolamide hcl-timolol maleate ophth soln /ml dorzolamide hcl ophth soln 2% doxazosin mesylate tab

136 doxazosin mesylate tab doxazosin mesylate tab doxazosin mesylate tab doxepin hcl cap doxepin hcl cap doxepin hcl cap doxepin hcl cap doxepin hcl cap doxepin hcl cap doxepin hcl conc 10 /ml...52 doxepin hcl cream 5% doxercalciferol cap 0.5 mcg doxercalciferol cap 1 mcg doxercalciferol cap 2.5 mcg doxorubicin hcl for inj doxorubicin hcl for inj doxorubicin hcl inj 2 /ml...22 doxorubicin hcl liposomal inj (for iv infusion) 2 /ml...22 doxycycline hyclate cap doxycycline hyclate cap doxycycline hyclate tab doxycycline hyclate tab doxycycline monohydrate cap doxycycline monohydrate cap doxycycline monohydrate cap doxycycline monohydrate cap doxycycline monohydrate for susp 25 /5ml...20 doxycycline monohydrate tab doxycycline monohydrate tab doxycycline monohydrate tab doxylamine succinate tab dronabinol cap dronabinol cap dronabinol cap drospirenone-ethinyl estrad-levomefolate tab drospirenone-ethinyl estrad-levomefolate tab drospirenone-ethinyl estradiol tab DROXIA CAP 200MG...28 DROXIA CAP 300MG...28 DROXIA CAP 400MG...28 DUAVEE TAB duloxetine hcl cap duloxetine hcl cap duloxetine hcl cap DUREZOL EMU 0.05% dutasteride-tamsulosin hcl cap dutasteride cap DYMISTA SPR DYRENIUM CAP 100MG...42 DYRENIUM CAP 50MG...42 E e.e.s. 400 tab econazole nitrate cream 1% ed-spaz tab EDARBI TAB 40MG...34 EDARBI TAB 80MG...34 EDURANT TAB 25MG...13 efavirenz cap efavirenz cap efavirenz tab eletriptan hydrobromide tab 20 (base equivalent)...62 eletriptan hydrobromide tab 40 (base equivalent)...62 ELIDEL CRE 1% elinest tab...73 ELIQUIS TAB 2.5MG...90 ELIQUIS TAB 5MG...90 elite-ob tab ELLA TAB 30MG...73 ELMIRON CAP 100MG...89 EMADINE SOL 0.05% OP EMBEDA CAP 100-4MG...4 EMBEDA CAP MG...3 EMBEDA CAP MG...3 EMBEDA CAP 50-2MG...3 EMBEDA CAP MG...3 EMBEDA CAP MG...4 EMCYT CAP 140MG...21 EMEND SUS 125MG...84 emoquette tab...73 EMSAM DIS 12MG/24H...52 EMSAM DIS 6MG/24HR...52 EMSAM DIS 9MG/24HR...52 EMTRIVA CAP 200MG...14 EMTRIVA SOL 10MG/ML...14 enalapril maleate & hydrochlorothiazide tab enalapril maleate & hydrochlorothiazide tab

137 enalapril maleate tab enalapril maleate tab enalapril maleate tab enalapril maleate tab ENBREL INJ 25/0.5ML...93 ENBREL INJ 25MG...93 ENBREL INJ 50MG/ML...93 ENBREL MINI INJ 50MG/ML...93 ENBREL SRCLK INJ 50MG/ML...93 ENCARE SUP 100MG...89 endocet tab endocet tab endocet tab endocet tab ENGERIX-B INJ 10/0.5ML...96 ENGERIX-B INJ 20MCG/ML...96 ENJUVIA TAB 0.3MG...76 ENJUVIA TAB 0.45MG...76 ENJUVIA TAB 0.625MG...77 ENJUVIA TAB 0.9MG...76 enoxaparin sodium inj 100 /ml...90 enoxaparin sodium inj 120 /0.8ml..90 enoxaparin sodium inj 150 /ml...90 enoxaparin sodium inj 300 /3ml...90 enoxaparin sodium inj 30 /0.3ml...90 enoxaparin sodium inj 40 /0.4ml...90 enoxaparin sodium inj 60 /0.6ml...90 enoxaparin sodium inj 80 /0.8ml...90 enpresse-28 tab...73 enskyce tab...73 entacapone tab entecavir tab entecavir tab ENTRESTO TAB 24-26MG...43 ENTRESTO TAB 49-51MG...43 ENTRESTO TAB MG...43 enulose sol 10gm/ EPCLUSA TAB EPIDUO FORTE GEL % epinastine hcl ophth soln 0.05% epinephrine solution auto-injector 0.15 /0.15ml (1:1000) epinephrine solution auto-injector 0.3 /0.3ml (1:1000) EPIPEN-JR INJ 2-K EPIPEN 2-K INJ 0.3MG epirubicin hcl iv soln 200 /100ml (2 /ml)...22 epirubicin hcl iv soln 50 /25ml (2 /ml)...22 epitol tab EPIVIR HBV SOL 5MG/ML...16 eplerenone tab eplerenone tab epoprostenol sodium for inj epoprostenol sodium for inj eprosartan mesylate tab ERBITUX INJ 100MG...24 ERBITUX INJ 200MG...24 ergocalciferol cap unit ergoloid mesylates tab ergotamine w/ caffeine tab ERIVEDGE CAP 150MG...24 errin tab ERTACZO CRE 2% ery-tab tab 250 ec...19 ery-tab tab 333 ec...19 ery-tab tab 500 ec...19 ery pad 2% ERYPED SUS 400/5ML...19 erythrocin tab erythromycin ethylsuccinate for susp 200 /5ml...19 erythromycin ethylsuccinate tab erythromycin gel 2% erythromycin ophth oint 5 /gm erythromycin soln 2% erythromycin tab erythromycin tab erythromycin w/ delayed release particles cap escitalopram oxalate soln 5 /5ml (base equiv)...52 escitalopram oxalate tab 10 (base equiv)...52 escitalopram oxalate tab 20 (base equiv)...52 escitalopram oxalate tab 5 (base equiv)...52 esomepra mag cap 20 dr...88 esomeprazole magnesium cap delayed release 20 (base eq)...88 esomeprazole magnesium cap delayed release 40 (base eq)...88 estradiol & norethindrone acetate tab 133

138 estradiol & norethindrone acetate tab estradiol tab estradiol tab estradiol tab estradiol td patch twice weekly /24hr...77 estradiol td patch twice weekly /24hr...77 estradiol td patch twice weekly 0.05 /24hr...77 estradiol td patch twice weekly /24hr...77 estradiol td patch twice weekly 0.1 /24hr...77 estradiol td patch weekly /24hr...78 estradiol td patch weekly /24hr (37.5 mcg/24hr)...78 estradiol td patch weekly 0.05 /24hr...77 estradiol td patch weekly 0.06 /24hr...78 estradiol td patch weekly /24hr...78 estradiol td patch weekly 0.1 /24hr 77 estradiol vaginal cream 0.1 /gm...78 estropipate tab estropipate tab estropipate tab eszopiclone tab eszopiclone tab eszopiclone tab ethacrynate sodium for inj ethacrynic acid tab ethambutol hcl tab ethambutol hcl tab ethosuximide cap ethosuximide soln 250 /5ml...46 ethynodiol diacetate & ethinyl estradiol tab 1-50 mcg...73 etodolac cap etodolac cap etodolac tab etodolac tab etodolac tab er 24hr etodolac tab er 24hr etodolac tab er 24hr etoposide cap etoposide inj 100 /5ml (20 /ml).29 EURAX CRE 10% EURAX LOT 10% EVOTAZ TAB EXELDERM CRE 1% EXELDERM SOL 1% exemestane tab ezetimibe-simvastatin tab ezetimibe-simvastatin tab ezetimibe-simvastatin tab ezetimibe-simvastatin tab ezetimibe tab F FACTIVE TAB 320MG...19 falmina tab...73 famciclovir tab famciclovir tab famciclovir tab famotidine for susp 40 /5ml...85 famotidine tab famotidine tab FARESTON TAB 60MG...24 FARXIGA TAB 10MG...71 FARXIGA TAB 5MG...71 FARYDAK CAP 10MG...24 FARYDAK CAP 15MG...24 FARYDAK CAP 20MG...24 FASLODEX INJ 250/5ML...24 fayosim tab...74 FC2 FEMALE MIS CONDOM...97 felbamate susp 600 /5ml...46 felbamate tab felbamate tab felodipine tab er 24hr felodipine tab er 24hr felodipine tab er 24hr FEMCAP MIS 22MM...97 FEMCAP MIS 26MM...97 FEMCAP MIS 30MM...97 fenofibrate cap fenofibrate cap fenofibrate micronized cap fenofibrate micronized cap fenofibrate micronized cap fenofibrate micronized cap fenofibrate micronized cap

139 fenofibrate tab fenofibrate tab fenofibrate tab fenofibrate tab fenoprofen calcium cap fenoprofen calcium tab fentanyl citrate lozenge on a handle 1200 mcg...4 fentanyl citrate lozenge on a handle 1600 mcg...4 fentanyl citrate lozenge on a handle 200 mcg...4 fentanyl citrate lozenge on a handle 400 mcg...4 fentanyl citrate lozenge on a handle 600 mcg...4 fentanyl citrate lozenge on a handle 800 mcg...4 fentanyl td patch 72hr 100 mcg/hr...4 fentanyl td patch 72hr 12 mcg/hr...4 fentanyl td patch 72hr 25 mcg/hr...4 fentanyl td patch 72hr 50 mcg/hr...4 fentanyl td patch 72hr 75 mcg/hr...4 FERRIPROX SOL 100MG/ML...72 FERRIPROX TAB 500MG...72 FETZIMA CAP 120MG...52 FETZIMA CAP 20MG...52 FETZIMA CAP 40MG...52 FETZIMA CAP 80MG...52 FETZIMA CAP TITRATIO...52 fexofenadine hcl tab fexofenadine hcl tab fexofenadine sus 30/5ml FIASP FLEX INJ TOUCH...69 FIASP INJ 100/ML...69 FINACEA AER 15% FINACEA GEL 15% finasteride tab FIRAZYR INJ 30MG/3ML...92 FLAREX SUS 0.1% OP flavoxate hcl tab flecainide acetate tab flecainide acetate tab flecainide acetate tab floxuridine for inj 0.5 gm...22 FLUAD INJ FLUBLOK QUAD INJ FLUBLOK SOL FLUCLVX QUAD INJ fluconazole for susp 10 /ml...12 fluconazole for susp 40 /ml...13 fluconazole tab fluconazole tab fluconazole tab fluconazole tab fludarabine phosphate for inj fludarabine phosphate inj 25 /ml...22 fludrocortisone acetate tab FLULAVAL QUA INJ flunisolide nasal soln 25 mcg/act (0.025%) fluocinolone acetonide (otic) oil 0.01% fluocinolone acetonide cream 0.01%.114 fluocinolone acetonide cream 0.025% 114 fluocinolone acetonide oil 0.01% (body oil) fluocinolone acetonide oil 0.01% (scalp oil) fluocinolone acetonide oint 0.025% fluocinolone acetonide soln 0.01% fluocinonide cream 0.05% fluocinonide cream 0.1% fluocinonide gel 0.05% fluocinonide oint 0.05% fluocinonide soln 0.05% fluor-a-day dro FLUORABON DRO...98 fluoritab chw 0.25 f...98 fluoritab chw 0.5 f...98 fluoritab chw fluorometholone ophth susp 0.1% FLUOROPLEX CRE 1% fluorouracil cream 0.5% fluorouracil cream 5% fluorouracil iv soln 1 gm/20ml (50 /ml)...22 fluorouracil iv soln 2.5 gm/50ml (50 /ml)...22 fluorouracil iv soln 500 /10ml (50 /ml)...22 fluorouracil iv soln 5 gm/100ml (50 /ml)...22 fluorouracil soln 2% fluorouracil soln 5% fluoxetine hcl cap

140 fluoxetine hcl cap fluoxetine hcl cap fluoxetine hcl solution 20 /5ml...52 fluoxetine hcl tab fluoxetine hcl tab fluphenazine hcl elixir 2.5 /5ml...57 fluphenazine hcl oral conc 5 /ml...57 fluphenazine hcl tab fluphenazine hcl tab fluphenazine hcl tab fluphenazine hcl tab flura-drops dro flura-drops dro 0.25 f...98 flurandrenolide cream 0.05% flurandrenolide lotion 0.05% flurandrenolide oint 0.05% flurbiprofen sodium ophth soln 0.03% flurbiprofen tab flurbiprofen tab flutamide cap fluticasone propionate cream 0.05%..114 fluticasone propionate lotion 0.05%..114 fluticasone propionate nasal susp 50 mcg/act fluticasone propionate oint 0.005% fluticasone spr 50mcg fluvastatin sodium cap fluvastatin sodium cap fluvastatin sodium tab er 24 hr FLUVIRIN INJ fluvoxamine maleate cap er 24hr fluvoxamine maleate cap er 24hr fluvoxamine maleate tab fluvoxamine maleate tab fluvoxamine maleate tab FLUZONE HD INJ PF FLUZONE QUAD INJ FML FORTE SUS 0.25% OP FML OIN 0.1% OP folic acid tab folic acid tab 400 mcg folic acid tab 800 mcg fondaparinux sodium subcutaneous inj 10 /0.8ml...90 fondaparinux sodium subcutaneous inj 2.5 /0.5ml...90 fondaparinux sodium subcutaneous inj 5 /0.4ml...90 fondaparinux sodium subcutaneous inj 7.5 /0.6ml...90 FORTEO SOL 600/ FOSAMAX + D TAB FOSAMAX + D TAB fosamprenavir calcium tab 700 (base equiv)...14 fosinopril sodium & hydrochlorothiazide tab fosinopril sodium & hydrochlorothiazide tab fosinopril sodium tab fosinopril sodium tab fosinopril sodium tab FOSRENOL POW 1000MG...82 FOSRENOL POW 750MG...82 FRAGMIN INJ 10000/ML...90 FRAGMIN INJ 12500UNT...90 FRAGMIN INJ 15000UNT...90 FRAGMIN INJ 18000UNT...90 FRAGMIN INJ 2500/ FRAGMIN INJ 5000/ FRAGMIN INJ 7500/ FRAGMIN INJ 95000UNT...90 FREESTYLE BLOOD GLUCOSE TEST KITS...97 FREESTYLE BLOOD GLUCOSE TEST STRIPS...97 frovatriptan succinate tab 2.5 (base equivalent)...62 furosemide oral soln 10 /ml...42 furosemide oral soln 8 /ml...42 furosemide tab furosemide tab furosemide tab FUZEON INJ 90MG...14 FYCOM SUS 0.5MG/ML...46 FYCOM TAB 10MG...47 FYCOM TAB 12MG...47 FYCOM TAB 2MG...46 FYCOM TAB 4MG...47 FYCOM TAB 6MG...47 FYCOM TAB 8MG...47 G gabapentin cap

141 gabapentin cap gabapentin cap gabapentin oral soln 250 /5ml...47 gabapentin tab gabapentin tab galantamine hydrobromide cap er 24hr galantamine hydrobromide cap er 24hr galantamine hydrobromide cap er 24hr galantamine hydrobromide oral soln 4 /ml...49 galantamine hydrobromide tab galantamine hydrobromide tab galantamine hydrobromide tab GARDASIL 9 INJ...96 GARDASIL INJ...96 gatifloxacin ophth soln 0.5% gavilyte-c sol...86 gavilyte-g sol...86 gavilyte-h kit...86 gavilyte-n sol flav pk...86 GAZYVA INJ 25MG/ML...24 gemcitabine hcl for inj 1 gm...22 gemcitabine hcl for inj gemcitabine hcl for inj 2 gm...22 gemcitabine hcl inj 1 gm/26.3ml (38 /ml) (base equiv)...23 gemcitabine hcl inj 200 /5.26ml (38 /ml) (base equiv)...23 gemcitabine hcl inj 2 gm/52.6ml (38 /ml) (base equiv)...23 gemfibrozil tab generlac sol 10gm/ gengraf cap gengraf cap gengraf sol 100/ml...95 gentamicin sulfate cream 0.1% gentamicin sulfate oint 0.1% gentamicin sulfate ophth oint 0.3% gentamicin sulfate ophth soln 0.3% GENVOYA TAB...15 gianvi tab gildess fe tab 1/ gildess fe tab 1.5/ gildess tab 1/ gildess tab 1.5/ GILENYA CAP 0.5MG...64 glatiramer acetate soln prefilled syringe 20 /ml...65 glatiramer acetate soln prefilled syringe 40 /ml...65 GLEOSTINE CAP 100MG...21 GLEOSTINE CAP 10MG...21 GLEOSTINE CAP 40MG...21 GLEOSTINE CAP 5MG...21 GLIADEL WAF 7.7MG...21 glimepiride tab glimepiride tab glimepiride tab glipizide-metformin hcl tab glipizide-metformin hcl tab glipizide-metformin hcl tab glipizide tab glipizide tab glipizide tab er 24hr glipizide tab er 24hr glipizide tab er 24hr GLUCAGON KIT 1MG...80 GLUCOSE URINE TEST STRIPS...98 glyburide-metformin tab glyburide-metformin tab glyburide-metformin tab glyburide micronized tab glyburide micronized tab glyburide micronized tab glyburide tab glyburide tab glyburide tab GOLYTELY SOL...86 GONAL-F INJ 1050UNIT...79 GONAL-F INJ 450UNIT...79 GONAL-F RFF INJ 300/ GONAL-F RFF INJ 450/ GONAL-F RFF INJ 75UNIT...79 GONAL-F RFF INJ 900/ granisetron hcl tab griseofulvin microsize susp 125 /5ml...13 griseofulvin microsize tab griseofulvin ultramicrosize tab griseofulvin ultramicrosize tab guanfacine hcl tab

142 guanfacine hcl tab guanfacine hcl tab er 24hr 1 (base equiv)...60 guanfacine hcl tab er 24hr 2 (base equiv)...60 guanfacine hcl tab er 24hr 3 (base equiv)...60 guanfacine hcl tab er 24hr 4 (base equiv)...60 GUANIDINE TAB 125MG...64 GYNAZOLE-1 CRE 2%...90 GYNOL II GEL 3%...89 H halobetasol propionate cream 0.05%.114 halobetasol propionate oint 0.05% HALOG CRE 0.1% HALOG OIN 0.1% haloperidol decanoate im soln 100 /ml...57 haloperidol decanoate im soln 50 /ml...57 haloperidol lactate oral conc 2 /ml..57 haloperidol tab haloperidol tab haloperidol tab haloperidol tab haloperidol tab haloperidol tab HARVONI TAB MG...16 HAVRIX INJ 1440UNIT...96 HAVRIX INJ 720UNIT...96 heather tab heparin sodium (porcine) inj unit/ml...91 heparin sodium (porcine) inj 1000 unit/ml...91 heparin sodium (porcine) inj unit/ml...91 heparin sodium (porcine) inj 5000 unit/ml...91 heparin sodium (porcine) pf inj 5000 unit/0.5ml...91 HEPLISAV-B INJ 20MCG...96 HEXALEN CAP 50MG...21 HIBERIX SOL 10MCG...96 HUMALOG INJ 100/ML...69 HUMALOG KWIK INJ 100/ML...69 HUMALOG KWIK INJ 200/ML...69 HUMALOG MIX INJ 50/ HUMALOG MIX INJ 50/50KWP...69 HUMALOG MIX INJ 75/25KWP...69 HUMALOG MIX SUS 75/ HUMATROPE INJ 12MG...80 HUMATROPE INJ 24MG...80 HUMATROPE INJ 5MG...80 HUMATROPE INJ 6MG...80 HUMATROPEN MIS FOR 12MG...98 HUMATROPEN MIS FOR 24MG...98 HUMATROPEN MIS FOR 6MG...98 HUMIRA INJ 10MG/ HUMIRA KIT 20MG/ HUMIRA KIT 40MG/ HUMIRA PEN INJ CROHNS...93 HUMIRA PEN INJ PSORIASI...93 HUMULIN INJ 70/ HUMULIN INJ 70/30KWP...69 HUMULIN N INJ U HUMULIN N INJ U-100KWP...69 HUMULIN R INJ U HUMULIN R INJ U hydralazine hcl tab hydralazine hcl tab hydralazine hcl tab hydralazine hcl tab hydrochlorothiazide cap hydrochlorothiazide tab hydrochlorothiazide tab hydrochlorothiazide tab hydrocodone-acetaminophen soln /15ml...4 hydrocodone-acetaminophen soln /15ml...4 hydrocodone-acetaminophen tab hydrocodone-acetaminophen tab hydrocodone-acetaminophen tab hydrocodone-acetaminophen tab hydrocodone w/ homatropine syrup /5ml hydrocodone w/ homatropine tab hydrocortisone butyrate cream 0.1%.114 hydrocortisone butyrate hydrophilic lipo 138

143 base cream 0.1% hydrocortisone butyrate oint 0.1% hydrocortisone butyrate soln 0.1% hydrocortisone cream 1% hydrocortisone cream 2.5% hydrocortisone lotion 2.5% hydrocortisone oint 1% hydrocortisone oint 2.5% hydrocortisone tab hydrocortisone tab hydrocortisone tab hydrocortisone valerate cream 0.2%.115 hydrocortisone valerate oint 0.2% hydrocortisone w/ acetic acid otic soln 1-2% hydromorphone hcl liqd 1 /ml...5 hydromorphone hcl tab hydromorphone hcl tab hydromorphone hcl tab hydromorphone hcl tab er 24hr deter hydromorphone hcl tab er 24hr deter hydromorphone hcl tab er 24hr deter hydromorphone hcl tab er 24hr deter HYDROMORPHON SUP 3MG...5 hydroxychloroquine sulfate tab hydroxyurea cap hydroxyzine hcl syrup 10 /5ml hydroxyzine hcl tab hydroxyzine hcl tab hydroxyzine hcl tab hyoscyamine sulfate tab hyoscyamine sulfate tab disint hyoscyamine sulfate tab er 12hr hyoscyamine sulfate tab sl HYQVIA INJ HYQVIA INJ HYQVIA INJ HYQVIA INJ HYQVIA INJ HYSINGLA ER TAB 100 MG...5 HYSINGLA ER TAB 120 MG...5 HYSINGLA ER TAB 20 MG...5 HYSINGLA ER TAB 30 MG...5 HYSINGLA ER TAB 40 MG...5 HYSINGLA ER TAB 60 MG...5 HYSINGLA ER TAB 80 MG...5 I ibandronate sodium tab 150 (base equivalent)...72 IBRANCE CAP 100MG...24 IBRANCE CAP 125MG...24 IBRANCE CAP 75MG...24 ibuprofen susp 100 /5ml...2 ibuprofen tab ibuprofen tab ibuprofen tab ICLUSIG TAB 15MG...26 ICLUSIG TAB 45MG...26 idarubicin hcl iv inj 10 /10ml (1 /ml)...22 idarubicin hcl iv inj 20 /20ml (1 /ml)...22 idarubicin hcl iv inj 5 /5ml (1 /ml)...22 IDHIFA TAB 100MG...26 IDHIFA TAB 50MG...26 ifosfamide for inj 1 gm...21 ifosfamide iv inj 1 gm/20ml (50 /ml)...21 ifosfamide iv inj 3 gm/60ml (50 /ml)...21 ILEVRO DRO 0.3% OP imatinib mesylate tab 100 (base equivalent)...26 imatinib mesylate tab 400 (base equivalent)...26 IMBRUVICA CAP 140MG...26 IMBRUVICA CAP 70MG...26 IMBRUVICA TAB 140MG...26 IMBRUVICA TAB 280MG...26 IMBRUVICA TAB 420MG...26 IMBRUVICA TAB 560MG...26 imipramine hcl tab imipramine hcl tab imipramine hcl tab imipramine pamoate cap imipramine pamoate cap imipramine pamoate cap imipramine pamoate cap

144 imiquimod cream 5% INCRELEX INJ 40MG/4ML...81 INCRUSE ELPT INH 62.5MCG indapamide tab indapamide tab INFANRIX INJ...96 INLYTA TAB 1MG...26 INLYTA TAB 5MG...26 INSULIN PEN NEEDLES...98 INSULIN PEN NEEDLES/SYRINGES...98 INTELENCE TAB 100MG...14 INTELENCE TAB 200MG...14 INTELENCE TAB 25MG...14 INTRON A INJ 10MU...94 INTRON A INJ 18MU...94 INTRON A INJ 25MU...94 INTRON A INJ 50MU...94 introvale tab...74 INVIRASE CAP 200MG...14 INVIRASE TAB 500MG...14 INVOKAMET TAB INVOKAMET TAB INVOKAMET TAB INVOKAMET TAB MG...70 INVOKAMET XR TAB INVOKAMET XR TAB INVOKAMET XR TAB INVOKAMET XR TAB MG...70 INVOKANA TAB 100MG...71 INVOKANA TAB 300MG...71 IPOL INJ INACTIVE...96 ipratropium-albuterol nebu soln (3) /3ml ipratropium bromide inhal soln 0.02% ipratropium bromide nasal soln 0.03% (21 mcg/spray) ipratropium bromide nasal soln 0.06% (42 mcg/spray) irbesartan-hydrochlorothiazide tab irbesartan-hydrochlorothiazide tab irbesartan tab irbesartan tab irbesartan tab irinotecan hcl inj 100 /5ml (20 /ml)...29 irinotecan hcl inj 40 /2ml (20 /ml)...29 irinotecan hcl inj 500 /25ml (20 /ml)...29 ISENTRESS CHW 100MG...14 ISENTRESS CHW 25MG...14 ISENTRESS HD TAB 600MG...14 ISENTRESS POW 100MG...14 ISENTRESS TAB 400MG...14 isoniazid syrup 50 /5ml...15 isoniazid tab isoniazid tab ISORDIL TAB 40MG...43 isosorbide dinitrate tab isosorbide dinitrate tab isosorbide dinitrate tab isosorbide dinitrate tab isosorbide dinitrate tab er isosorbide mononitrate tab isosorbide mononitrate tab isosorbide mononitrate tab er 24hr isosorbide mononitrate tab er 24hr isosorbide mononitrate tab er 24hr isradipine cap isradipine cap itraconazole cap ivermectin tab IV PREP WIPE D J JADENU SPRKL GRA 180MG...72 JADENU SPRKL GRA 360MG...72 JADENU SPRKL GRA 90MG...72 JADENU TAB 180MG...73 JADENU TAB 360MG...73 JADENU TAB 90MG...73 JAKAFI TAB 10MG...27 JAKAFI TAB 15MG...27 JAKAFI TAB 20MG...27 JAKAFI TAB 25MG...27 JAKAFI TAB 5MG...26 jantoven tab jantoven tab jantoven tab jantoven tab jantoven tab

145 jantoven tab jantoven tab jantoven tab jantoven tab JANUMET TAB JANUMET TAB MG...69 JANUMET XR TAB JANUMET XR TAB JANUMET XR TAB MG...69 JANUVIA TAB 100MG...69 JANUVIA TAB 25MG...69 JANUVIA TAB 50MG...69 JARDIANCE TAB 10MG...71 JARDIANCE TAB 25MG...71 JENTADUETO TAB JENTADUETO TAB JENTADUETO TAB JENTADUETO TAB XR...69 jinteli tab 1-5mcg...78 jolessa tab...74 jolivette tab JUBLIA SOL 10% junel 1/20 tab...74 junel 1.5/30 tab...74 junel fe tab 1/ junel fe tab 1.5/ K k-effervesce tab 25meq ef...98 KADCYLA INJ 100MG...24 KADCYLA INJ 160MG...24 KALETRA TAB MG...15 KALETRA TAB MG...15 KALYDECO K 50MG KALYDECO K 75MG KALYDECO TAB 150MG kariva tab 28 day...74 kelnor tab 1/ KETEK TAB 300MG...11 KETEK TAB 400MG...11 ketoconazole cream 2% ketoconazole shampoo 2% ketodan aer 2% KETONE URINE TEST STRIPS...98 ketoprofen cap ketoprofen cap ketoprofen cap er 24hr ketorolac tromethamine im inj 60 /2ml (30 /ml)...2 ketorolac tromethamine inj 15 /ml...2 ketorolac tromethamine inj 30 /ml...2 ketorolac tromethamine ophth soln 0.4% ketorolac tromethamine ophth soln 0.5% ketorolac tromethamine tab ketotif fum dro 0.025%op KEVZARA INJ 150/ KEVZARA INJ 200/ KEYTRUDA INJ 100MG/4M...24 KEYTRUDA SOL 50MG...24 KINRIX INJ...96 kionex sus 15gm/ klor-con 10 tab 10meq er...98 klor-con 8 tab 8meq er...98 KLOR-CON M15 TAB 15MEQ ER...98 klor-con m20 tab 20meq er...98 kurvelo tab 0.15/ KUVAN POW 100MG...76 KUVAN POW 500MG...76 KUVAN TAB 100MG...76 KYLEENA IUD 19.5MG...74 L labetalol hcl tab labetalol hcl tab labetalol hcl tab LACRISERT MIS 5MG OP lactic acid (ammonium lactate) cream 12% lactic acid (ammonium lactate) lotion 10% lactic acid (ammonium lactate) lotion 12% lactulose solution 10 gm/15ml...86 LAMISIL ADV GEL 1% LAMISIL AT SPR 1% lamivudine-zidovudine tab lamivudine oral soln 10 /ml...14 lamivudine tab 100 (hbv)...16 lamivudine tab lamivudine tab lamotrigine orally disintegrating tab lamotrigine orally disintegrating tab lamotrigine orally disintegrating tab

146 ...47 lamotrigine orally disintegrating tab lamotrigine tab lamotrigine tab lamotrigine tab lamotrigine tab lamotrigine tab 25 (35) starter kit.47 lamotrigine tab 25 (42) & 100 (7) starter kit...47 lamotrigine tab 25 (84) & 100 (14) starter kit...47 lamotrigine tab chewable dispersible lamotrigine tab chewable dispersible lamotrigine tab disint 25 (14) & 50 (14) & 100 (7) kit...47 lamotrigine tab disint 25 (21) & 50 (7) titration kit...47 lamotrigine tab disint 50 (42)- 100 (14) titration kit...47 lamotrigine tab er 24hr lamotrigine tab er 24hr lamotrigine tab er 24hr lamotrigine tab er 24hr lamotrigine tab er 24hr lamotrigine tab er 24hr LANCETS...98 LANCING DEVICE...98 LANOXIN TAB MG...41 LANOXIN TAB MG...41 lansoprazole cap 15 dr...88 lansoprazole cap delayed release lansoprazole cap delayed release lanthanum carbonate chew tab 1000 (elemental)...82 lanthanum carbonate chew tab 500 (elemental)...82 lanthanum carbonate chew tab 750 (elemental)...82 larin tab 1.5/ LASTACAFT SOL 0.25% latanoprost ophth soln 0.005% LATUDA TAB 120MG...57 LATUDA TAB 20MG...57 LATUDA TAB 40MG...57 LATUDA TAB 60MG...57 LATUDA TAB 80MG...57 leena tab...74 leflunomide tab leflunomide tab LENVIMA CAP 10 MG...27 LENVIMA CAP 14 MG...27 LENVIMA CAP 18 MG...27 LENVIMA CAP 20 MG...27 LENVIMA CAP 24 MG...27 LENVIMA CAP 8 MG...27 lessina tab...74 LETAIRIS TAB 10MG...44 LETAIRIS TAB 5MG...44 letrozole tab leucovorin calcium for inj leucovorin calcium for inj leucovorin calcium for inj leucovorin calcium for inj leucovorin calcium for inj leucovorin calcium tab leucovorin calcium tab leucovorin calcium tab leucovorin calcium tab LEUKERAN TAB 2MG...21 leuprolide acetate inj kit 5 /ml...25 levalbuterol hcl soln nebu 0.31 /3ml (base equiv) levalbuterol hcl soln nebu 0.63 /3ml (base equiv) levalbuterol hcl soln nebu 1.25 /3ml (base equiv) levalbuterol hcl soln nebu conc 1.25 /0.5ml (base equiv) LEVEMIR INJ...70 LEVEMIR INJ FLEXTOUC...70 levetiracetam oral soln 100 /ml...47 levetiracetam tab levetiracetam tab levetiracetam tab levetiracetam tab levetiracetam tab er 24hr levetiracetam tab er 24hr levobunolol hcl ophth soln 0.5% levocetirizine dihydrochloride soln 2.5 /5ml (0.5 /ml) levocetirizine dihydrochloride tab 5 142

147 levofloxacin ophth soln 0.5% levofloxacin oral soln 25 /ml...19 levofloxacin tab levofloxacin tab levofloxacin tab levonest tab...74 levonorg-eth est tab (84) & eth est tab 0.01(7)...74 levonorgestrel & ethinyl estradiol (91- day) tab levonorgestrel & ethinyl estradiol tab mcg...74 levora-28 tab 0.15/ levorphanol tartrate tab levothyroxine sodium tab 100 mcg...82 levothyroxine sodium tab 112 mcg...82 levothyroxine sodium tab 125 mcg...82 levothyroxine sodium tab 137 mcg...82 levothyroxine sodium tab 150 mcg...82 levothyroxine sodium tab 175 mcg...82 levothyroxine sodium tab 200 mcg...82 levothyroxine sodium tab 25 mcg...82 levothyroxine sodium tab 300 mcg...82 levothyroxine sodium tab 50 mcg...82 levothyroxine sodium tab 75 mcg...82 levothyroxine sodium tab 88 mcg...82 levoxyl tab 100mcg...82 levoxyl tab 112mcg...82 levoxyl tab 125mcg...82 levoxyl tab 137mcg...82 levoxyl tab 150mcg...83 levoxyl tab 175mcg...83 levoxyl tab 200mcg...83 levoxyl tab 25mcg...82 levoxyl tab 50mcg...82 levoxyl tab 75mcg...82 levoxyl tab 88mcg...82 LEXIVA SUS 50MG/ML...14 lice treatmt lot 1% lice trtmnt liq 1% lidocaine-prilocaine cream %..115 lidocaine-prilocaine cream kit % lidocaine hcl gel 2% lidocaine hcl laryngotracheal soln 4% 116 lidocaine hcl soln 4% lidocaine hcl viscous soln 2% LILETTA IUD 52MG...74 lindane lotion 1% lindane shampoo 1% linezolid for susp 100 /5ml...12 linezolid tab LINZESS CAP 145MCG...86 LINZESS CAP 290MCG...86 LINZESS CAP 72MCG...86 liothyronine sodium tab 25 mcg...83 liothyronine sodium tab 50 mcg...83 liothyronine sodium tab 5 mcg...83 lisinopril & hydrochlorothiazide tab lisinopril & hydrochlorothiazide tab lisinopril & hydrochlorothiazide tab lisinopril tab lisinopril tab lisinopril tab lisinopril tab lisinopril tab lisinopril tab lithium carbonate cap lithium carbonate cap lithium carbonate cap lithium carbonate tab lithium carbonate tab er lithium carbonate tab er LITHIUM SOL 8MEQ/5ML...64 LIVALO TAB 1MG...36 LIVALO TAB 2MG...36 LIVALO TAB 4MG...36 lokara lot 0.05% LO LOESTRIN TAB...74 loperamide hcl cap lopinavir-ritonavir soln /5ml (80-20 /ml)...15 loratadine cap loratadine syp 5/5ml lorazepam conc 2 /ml...45 lorazepam tab lorazepam tab lorazepam tab lortab tab loryna tab losartan potassium & hydrochlorothiazide tab

148 losartan potassium & hydrochlorothiazide tab losartan potassium & hydrochlorothiazide tab losartan potassium tab losartan potassium tab losartan potassium tab LOTEMAX GEL 0.5% LOTEMAX OIN 0.5% LOTEMAX SUS 0.5% LOTRIMIN AF AER 2% LOTRIMIN ULT CRE 1% lovastatin tab lovastatin tab lovastatin tab low-ogestrel tab...74 loxapine succinate cap loxapine succinate cap loxapine succinate cap loxapine succinate cap ludent chw 0.25 f...98 ludent chw 0.5 f...98 ludent chw 1 f...98 LUMIGAN SOL 0.01% LUNETA KIT LUNETA KIT LUPR DEP-PED INJ 11.25MG...25 LUPR DEP-PED INJ 15MG...25 LUPR DEP-PED INJ 3M 30MG...25 LUPR DEP-PED INJ 7.5MG...25 LUPRON DEPOT INJ 11.25MG...25 LUPRON DEPOT INJ 22.5MG...25 LUPRON DEPOT INJ 3.75MG...25 LUPRON DEPOT INJ 30MG...25 LUPRON DEPOT INJ 45MG...25 LUPRON DEPOT INJ 7.5MG...25 LURIDE DRO 0.5MG/ML...99 lutera tab...74 LYNRZA CAP 50MG...24 LYNRZA TAB 100MG...24 LYNRZA TAB 150MG...24 LYRICA CAP 100MG...48 LYRICA CAP 150MG...48 LYRICA CAP 200MG...48 LYRICA CAP 225MG...48 LYRICA CAP 25MG...48 LYRICA CAP 300MG...48 LYRICA CAP 50MG...48 LYRICA CAP 75MG...48 LYRICA SOL 20MG/ML...48 LYSODREN TAB 500MG...25 M M-M-R II INJ...96 malathion lotion 0.5% maprotiline hcl tab maprotiline hcl tab maprotiline hcl tab margesic cap...1 marlissa tab 0.15/ MARPLAN TAB 10MG...53 MATULANE CAP 50MG...28 matzim la tab 180/ matzim la tab 240/ matzim la tab 300/ matzim la tab 360/ matzim la tab 420/ MAXIDEX SUS 0.1% OP meclizine hcl tab meclizine hcl tab meclofenamate sodium cap meclofenamate sodium cap MEDROL TAB 2MG...80 medroxyprogesterone acetate im susp 150 /ml...74 medroxyprogesterone acetate im susp prefilled syr 150 /ml...74 medroxyprogesterone acetate tab medroxyprogesterone acetate tab medroxyprogesterone acetate tab mefenamic acid cap mefloquine hcl tab megestrol acetate susp 40 /ml...25 megestrol acetate tab megestrol acetate tab MEKINIST TAB 0.5MG...27 MEKINIST TAB 2MG...27 meloxicam susp 7.5 /5ml...2 meloxicam tab meloxicam tab melphalan tab memantine hcl cap er 24hr memantine hcl cap er 24hr memantine hcl cap er 24hr

149 memantine hcl cap er 24hr memantine hcl oral solution 2 /ml..50 memantine hcl tab memantine hcl tab memantine hcl tab 5 (28) & 10 (21) titration pak...50 MENACTRA INJ...96 MENEST TAB 0.3MG...78 MENEST TAB 0.625MG...78 MENEST TAB 1.25MG...78 MENEST TAB 2.5MG...78 MENHIBRIX INJ...96 MENOMUNE INJ A/C/Y/W...96 MENTAX CRE 1% MENVEO INJ...96 MEPHYTON TAB 5MG meprobamate tab meprobamate tab mercaptopurine tab mesalamine enema 4 gm...86 mesalamine rectal enema 4 gm & cleanser wipe kit...86 mesna inj 100 /ml...29 MESNEX TAB 400MG...29 MESTINON SYP 60MG/5ML...64 metaproterenol sulfate syrup 10 /5ml metaproterenol sulfate tab metaproterenol sulfate tab metaxalone tab metaxalone tab metformin hcl tab metformin hcl tab metformin hcl tab metformin hcl tab er 24hr metformin hcl tab er 24hr metformin hcl tab er 24hr osmotic metformin hcl tab er 24hr osmotic methadone con 10/ml...6 methadone hcl conc 10 /ml...6 methadone hcl soln 10 /5ml...6 methadone hcl soln 5 /5ml...6 methadone hcl tab methadone hcl tab methadone hcl tab for oral susp 40.6 methadose tab methamphetamine hcl tab methazolamide tab methazolamide tab methenamine hippurate tab 1 gm...12 methimazole tab methimazole tab methocarbamol tab methocarbamol tab methotrexate sodium for inj 1 gm...23 methotrexate sodium inj 250 /10ml (25 /ml)...23 methotrexate sodium inj 50 /2ml (25 /ml)...23 methotrexate sodium inj pf 1000 /40ml (25 /ml)...23 methotrexate sodium inj pf 100 /4ml (25 /ml)...23 methotrexate sodium inj pf 200 /8ml (25 /ml)...23 methotrexate sodium inj pf 250 /10ml (25 /ml)...23 methotrexate sodium inj pf 50 /2ml (25 /ml)...23 methotrexate sodium tab 2.5 (base equiv)...94 methoxsalen rapid cap methscopolamine bromide tab methscopolamine bromide tab methyclothiazide tab methyldopa tab methyldopa tab methylphenidate hcl cap er 10 (cd) 60 methylphenidate hcl cap er 20 (cd) 60 methylphenidate hcl cap er 24hr 20 (la)...60 methylphenidate hcl cap er 24hr 30 (la)...60 methylphenidate hcl cap er 24hr 40 (la)...61 methylphenidate hcl cap er 24hr 60 (la)...61 methylphenidate hcl cap er 30 (cd) 61 methylphenidate hcl cap er 40 (cd) 61 methylphenidate hcl cap er 50 (cd) 61 methylphenidate hcl cap er 60 (cd) 61 methylphenidate hcl chew tab methylphenidate hcl chew tab methylphenidate hcl chew tab

150 methylphenidate hcl soln 10 /5ml...61 methylphenidate hcl soln 5 /5ml...61 methylphenidate hcl tab methylphenidate hcl tab methylphenidate hcl tab methylphenidate hcl tab er methylphenidate hcl tab er methylphenidate hcl tab er 24hr methylphenidate hcl tab er 24hr methylphenidate hcl tab er 24hr methylphenidate hcl tab er 24hr methylphenidate hcl tab er osmotic release (osm) methylphenidate hcl tab er osmotic release (osm) methylphenidate hcl tab er osmotic release (osm) methylphenidate hcl tab er osmotic release (osm) methylprednisolone tab methylprednisolone tab methylprednisolone tab methylprednisolone tab methylprednisolone tab therapy pack 4 (21)...80 methyltestosterone cap metipranolol ophth soln 0.3% metoclopramide hcl soln 5 /5ml (10 /10ml) (base equiv)...84 metoclopramide hcl tab 10 (base equivalent)...84 metoclopramide hcl tab 5 (base equivalent)...84 metolazone tab metolazone tab metolazone tab metoprolol & hydrochlorothiazide tab metoprolol & hydrochlorothiazide tab metoprolol & hydrochlorothiazide tab metoprolol succinate tab er 24hr 100 (tartrate equiv)...38 metoprolol succinate tab er 24hr 200 (tartrate equiv)...38 metoprolol succinate tab er 24hr 25 (tartrate equiv)...38 metoprolol succinate tab er 24hr 50 (tartrate equiv)...38 metoprolol tartrate tab metoprolol tartrate tab metoprolol tartrate tab metronidazole cap metronidazole cream 0.75% metronidazole gel 0.75% metronidazole gel 1% metronidazole lotion 0.75% metronidazole tab metronidazole tab metronidazole vaginal gel 0.75%...90 mexiletine hcl cap mexiletine hcl cap mexiletine hcl cap mibelas 24 chw fe...74 miconazole 1 kit %...90 miconazole 3 kit 4%...90 miconazole 3 kit combo pk...90 miconazole 3 sup miconazole 7 cre tube/kit...90 miconazorb pow af 2% midodrine hcl tab midodrine hcl tab midodrine hcl tab miglitol tab miglitol tab miglitol tab miglustat cap mimvey lo tab mimvey tab minitran dis 0.1/hr...43 minitran dis 0.2/hr...43 minitran dis 0.4/hr...43 minitran dis 0.6/hr...44 minocycline hcl cap minocycline hcl cap minocycline hcl cap minocycline hcl tab minocycline hcl tab minocycline hcl tab minoxidil tab minoxidil tab

151 MIRENA IUD SYSTEM...74 mirtazapine orally disintegrating tab mirtazapine orally disintegrating tab mirtazapine orally disintegrating tab mirtazapine tab mirtazapine tab mirtazapine tab mirtazapine tab MIRVASO GEL 0.33% MISC LANCETS...98 misoprostol tab 100 mcg...87 misoprostol tab 200 mcg...87 mitomycin for iv soln mitomycin for iv soln mitomycin for iv soln mitoxantrone hcl inj conc 20 /10ml (2 /ml)...28 mitoxantrone hcl inj conc 25 /12.5ml (2 /ml)...28 mitoxantrone hcl inj conc 30 /15ml (2 /ml)...28 modafinil tab modafinil tab moexipril-hydrochlorothiazide tab moexipril-hydrochlorothiazide tab moexipril-hydrochlorothiazide tab moexipril hcl tab moexipril hcl tab mometasone furoate cream 0.1% mometasone furoate oint 0.1% mometasone furoate solution 0.1% (lotion) mono-linyah tab mononessa tab...74 montelukast sodium chew tab 4 (base equiv) montelukast sodium chew tab 5 (base equiv) montelukast sodium oral granules packet 4 (base equiv) montelukast sodium tab 10 (base equiv) MONUROL K GRANULES...11 morgidox cap 1x morphine sulfate beads cap er 24hr morphine sulfate beads cap er 24hr morphine sulfate beads cap er 24hr morphine sulfate beads cap er 24hr morphine sulfate beads cap er 24hr morphine sulfate beads cap er 24hr morphine sulfate cap er 24hr morphine sulfate cap er 24hr morphine sulfate cap er 24hr morphine sulfate cap er 24hr morphine sulfate cap er 24hr morphine sulfate cap er 24hr morphine sulfate cap er 24hr morphine sulfate oral soln 100 /5ml (20 /ml)...7 morphine sulfate oral soln 10 /5ml...7 morphine sulfate oral soln 20 /5ml...7 morphine sulfate suppos morphine sulfate suppos morphine sulfate suppos morphine sulfate tab morphine sulfate tab morphine sulfate tab er morphine sulfate tab er morphine sulfate tab er morphine sulfate tab er morphine sulfate tab er MORPHINE SUL SUP 30MG...6 MOTOFEN TAB MOVANTIK TAB 12.5MG...87 MOVANTIK TAB 25MG...87 MOVIPREP SOL...86 MOXEZA SOL 0.5% moxifloxacin hcl ophth soln 0.5% (base equiv) moxifloxacin hcl tab 400 (base equiv)...19 MULTAQ TAB 400MG...34 multi-vit/fe dro /fl multi-vit/fl dro

152 multi-vit/fl dro 0.5/ml multivit/fl chw multivit/fl chw multivit/fl chw mupirocin oint 2% mvc-fluoride chw mycophenolate mofetil cap mycophenolate mofetil for oral susp 200 /ml...95 mycophenolate mofetil tab mycophenolate sodium tab dr 180 (mycophenolic acid equiv)...95 mycophenolate sodium tab dr 360 (mycophenolic acid equiv)...95 myorisan cap myorisan cap myorisan cap MYRBETRIQ TAB 25MG...89 MYRBETRIQ TAB 50MG...89 myzilra tab...74 N nabumetone tab nabumetone tab nadolol & bendroflumethiazide tab nadolol & bendroflumethiazide tab nadolol tab nadolol tab nadolol tab nafrinse chw 1 f...99 naftifine hcl cream 1% naftifine hcl cream 2% nalbuphine hcl inj 10 /ml...7 nalbuphine hcl inj 20 /ml...7 naloxone hcl inj 0.4 /ml...67 naloxone hcl inj 4 /10ml...67 naloxone hcl soln cartridge 0.4 /ml.67 naloxone hcl soln prefilled syringe 2 /2ml...67 naltrexone hcl tab NAMENDA XR CAP TITRATIO...50 naphazoline hcl ophth soln 0.1% naproxen dr tab naproxen dr tab naproxen sodium tab naproxen sodium tab naproxen susp 125 /5ml...2 naproxen tab naproxen tab naproxen tab naratriptan hcl tab 1 (base equiv)..62 naratriptan hcl tab 2.5 (base equiv)...62 NARCAN SPR...67 NATACYN SUS 5% OP NATAZIA TAB...74 nateglinide tab nateglinide tab NEBUPENT INH 300MG...12 necon tab 0.5/ necon tab 1/ necon tab 1/ NECON TAB 10/ nefazodone hcl tab nefazodone hcl tab nefazodone hcl tab nefazodone hcl tab nefazodone hcl tab neomycin-polymy-gramicid op sol unt-/ml neomycin-polymyxin-dexamethasone ophth oint 0.1% neomycin-polymyxin-dexamethasone ophth susp 0.1% neomycin-polymyxin-hc ophth susp neomycin-polymyxin-hc otic soln 1%.117 neomycin-polymyxin-hc otic susp 3.5 /ml unit/ml-1% neomycin sulfate tab NEULASTA INJ 6MG/0.6M...91 NEULASTA KIT 6MG/0.6M...91 NEVANAC SUS 0.1% nevirapine susp 50 /5ml...14 nevirapine tab nevirapine tab er 24hr nevirapine tab er 24hr NEXAVAR TAB 200MG...27 NEXIUM 24HR CAP 20MG...88 NEXIUM 24HR TAB 20MG...88 NEXPLANON IMP 68MG...75 niacin tab er 1000 (antihyperlipidemic)...37 niacin tab er 500 (antihyperlipidemic)...37 niacin tab er 750 (antihyperlipidemic) 148

153 ...37 nicardipine hcl cap nicardipine hcl cap nicorelief gum 4 mint...67 nicotine polacrilex gum nicotine polacrilex gum nicotine polacrilex lozenge nicotine pol loz 4 mint...67 nicotine td patch 24hr 14 /24hr...67 nicotine td patch 24hr 21 /24hr...67 nicotine td patch 24hr 7 /24hr...67 NICOTROL INH...67 NICOTROL NS SPR 10MG/ML...67 nifedical xl tab nifedical xl tab nifedipine tab er 24hr nifedipine tab er 24hr nifedipine tab er 24hr nifedipine tab er 24hr osmotic release nikki tab nilutamide tab nimodipine cap NIPENT INJ 10MG...23 nisoldipine tab er 24hr nisoldipine tab er 24hr nisoldipine tab er 24hr nisoldipine tab er 24hr nisoldipine tab er 24hr nisoldipine tab er 24hr nisoldipine tab er 24hr NITRO-DUR DIS 0.3MG/HR...44 NITRO-DUR DIS 0.8MG/HR...44 nitrofurantoin macrocrystalline cap nitrofurantoin macrocrystalline cap nitrofurantoin macrocrystalline cap nitrofurantoin monohydrate macrocrystalline cap nitroglycerin cap er nitroglycerin lingual aerosol 400 mcg/spray...44 nitroglycerin sl tab nitroglycerin sl tab nitroglycerin sl tab nitroglycerin td patch 24hr 0.1 /hr..44 nitroglycerin td patch 24hr 0.2 /hr..44 nitroglycerin td patch 24hr 0.4 /hr..44 nitroglycerin td patch 24hr 0.6 /hr..44 nitroglycerin tl soln 0.4 /spray (400 mcg/spray)...44 nizatidine cap nizatidine cap nizatidine oral soln 15 /ml...85 nora-be tab NORDIPEN 5 MIS DEVICE...98 NORDIPEN DEL MIS SYSTEM...98 NORDITROPIN INJ 10/1.5ML...80 NORDITROPIN INJ 15/1.5ML...81 NORDITROPIN INJ 30/3ML...81 NORDITROPIN INJ 5/1.5ML...80 norethindrone & ethinyl estradiol-fe chew tab mcg...75 norethindrone ace-ethinyl estradiol-fe tab 1-20 mcg (24)...75 norethindrone acetate-ethinyl estradiol tab mcg...79 norethindrone acetate tab norethindrone tab norgestimate-eth estrad tab / / mcg...75 norgestimate-eth estrad tab / / mcg...75 norgestimate & ethinyl estradiol tab mcg...75 NORCE CAP 100MG CR...34 NORCE CAP 150MG CR...35 nortrel tab 0.5/ nortrel tab 1/ nortrel tab 7/7/ nortriptyline hcl cap nortriptyline hcl cap nortriptyline hcl cap nortriptyline hcl cap nortriptyline hcl soln 10 /5ml...53 NORTUSS-EX LIQ / NORVIR CAP 100MG...14 NORVIR SOL 80MG/ML...14 NORVIR TAB 100MG...14 NOVOLIN INJ 70/ NOVOLIN N INJ U NOVOLIN R INJ U NOVOLOG INJ 100/ML...70 NOVOLOG INJ FLEXPEN

154 NOVOLOG INJ PENFILL...70 NOVOLOG MIX INJ 70/ NOVOLOG MIX INJ FLEXPEN...70 NOXAFIL SUS 40MG/ML...13 NOXAFIL TAB 100MG...13 NUCYNTA ER TAB 100MG...7 NUCYNTA ER TAB 150MG...7 NUCYNTA ER TAB 200MG...7 NUCYNTA ER TAB 250MG...8 NUCYNTA ER TAB 50MG...7 NUCYNTA TAB 100MG...8 NUCYNTA TAB 50MG...8 NUCYNTA TAB 75MG...8 NUEDEXTA CAP 20-10MG...64 nulev tab NUPLAZID TAB 17MG...57 NUVARING MIS...75 nyamyc pow nystatin-triamcinolone cream unit/gm-% nystatin-triamcinolone oint unit/gm-% nystatin cream unit/gm nystatin oint unit/gm nystatin oral powder...13 nystatin susp unit/ml nystatin tab unit...13 nystop pow O ocella tab octreotide acetate inj 1000 mcg/ml (1 /ml)...81 octreotide acetate inj 100 mcg/ml (0.1 /ml)...81 octreotide acetate inj 200 mcg/ml (0.2 /ml)...81 octreotide acetate inj 500 mcg/ml (0.5 /ml)...81 octreotide acetate inj 50 mcg/ml (0.05 /ml)...81 ODEFSEY TAB...15 ofloxacin ophth soln 0.3% ofloxacin otic soln 0.3% ogestrel tab...75 olanzapine orally disintegrating tab olanzapine orally disintegrating tab olanzapine orally disintegrating tab olanzapine orally disintegrating tab olanzapine tab olanzapine tab olanzapine tab olanzapine tab olanzapine tab olanzapine tab olmesartan-amlodipinehydrochlorothiazide tab olmesartan-amlodipinehydrochlorothiazide tab olmesartan-amlodipinehydrochlorothiazide tab olmesartan-amlodipinehydrochlorothiazide tab olmesartan-amlodipinehydrochlorothiazide tab olmesartan medoxomilhydrochlorothiazide tab olmesartan medoxomilhydrochlorothiazide tab olmesartan medoxomilhydrochlorothiazide tab olmesartan medoxomil tab olmesartan medoxomil tab olmesartan medoxomil tab olopatadine hcl ophth soln 0.1% (base equivalent) olopatadine hcl ophth soln 0.2% (base equivalent) omega-3-acid ethyl esters cap 1 gm...37 omepra/bicar cap omeprazole cap delayed release omeprazole cap delayed release omeprazole cap delayed release omeprazole magnesium cap dr 20.6 (20 base equiv)...88 OMEPRAZOLE TAB 20MG...88 OMNARIS SPR OMNIFLEX DPR...97 ONCASR INJ 750/ML...28 ondansetron hcl oral soln 4 /5ml...84 ondansetron hcl tab ondansetron hcl tab

155 ondansetron hcl tab ondansetron orally disintegrating tab ondansetron orally disintegrating tab ONFI SUS 2.5MG/ML...48 ONFI TAB 10MG...48 ONFI TAB 20MG...48 OPSUMIT TAB 10MG...44 ORAL GLUCOSE REPLACEMENT...80 oralone dent pst 0.1% ORENCIA CLCK INJ 125MG/ML...93 ORENCIA INJ 125MG/ML...93 ORENCIA INJ 250MG...93 ORENCIA INJ 50/ ORENCIA INJ 87.5/ ORENITRAM TAB 0.125MG...44 ORENITRAM TAB 0.25MG...44 ORENITRAM TAB 1MG...44 ORENITRAM TAB 2.5MG...44 ORENITRAM TAB 5MG...44 ORFADIN CAP 10MG...76 ORFADIN CAP 20MG...76 ORFADIN CAP 2MG...76 ORFADIN CAP 5MG...76 ORFADIN SUS 4MG/ML...76 ORKAMBI TAB ORKAMBI TAB orphenadrine citrate inj 30 /ml...66 orphenadrine citrate tab er 12hr orsythia tab...75 oscimin sr tab oscimin sub oscimin tab oscion clnsr lot 6% oseltamivir phosphate cap 30 (base equiv)...16 oseltamivir phosphate cap 45 (base equiv)...16 oseltamivir phosphate cap 75 (base equiv)...16 oseltamivir phosphate for susp 6 /ml (base equiv)...16 OSMOPREP TAB 1.5GM...86 OSPHENA TAB 60MG...81 OTEZLA TAB 10/20/ OTEZLA TAB 30MG...94 OVIDREL INJ...79 oxaliplatin for iv inj oxaliplatin for iv inj oxaliplatin iv soln 100 /20ml...29 oxaliplatin iv soln 50 /10ml...29 oxaprozin tab oxazepam cap oxazepam cap oxazepam cap oxcarbazepine susp 300 /5ml (60 /ml)...48 oxcarbazepine tab oxcarbazepine tab oxcarbazepine tab oxiconazole nitrate cream 1% OXISTAT LOT 1% OXSORALEN LOT 1% oxybutynin chloride syrup 5 /5ml...89 oxybutynin chloride tab oxybutynin chloride tab er 24hr oxybutynin chloride tab er 24hr oxybutynin chloride tab er 24hr oxycodone-aspirin tab oxycodone-ibuprofen tab oxycodone hcl cap oxycodone hcl conc 100 /5ml (20 /ml)...8 oxycodone hcl soln 5 /5ml...8 oxycodone hcl tab oxycodone hcl tab oxycodone hcl tab oxycodone hcl tab oxycodone hcl tab oxycodone hcl tab er 12hr deter 10.8 oxycodone hcl tab er 12hr deter 15.8 oxycodone hcl tab er 12hr deter 20.8 oxycodone hcl tab er 12hr deter 30.8 oxycodone hcl tab er 12hr deter 40.8 oxycodone hcl tab er 12hr deter 60.8 oxycodone hcl tab er 12hr deter 80.8 oxycodone w/ acetaminophen soln /5ml...9 oxycodone w/ acetaminophen tab oxycodone w/ acetaminophen tab oxycodone w/ acetaminophen tab

156 oxycodone w/ acetaminophen tab OXYCONTIN TAB 10MG CR...9 OXYCONTIN TAB 15MG CR...9 OXYCONTIN TAB 20MG CR...9 OXYCONTIN TAB 30MG CR...9 OXYCONTIN TAB 40MG CR...9 OXYCONTIN TAB 60MG CR...9 OXYCONTIN TAB 80MG CR...9 oxymorphone hcl tab oxymorphone hcl tab oxymorphone hcl tab er 12hr oxymorphone hcl tab er 12hr oxymorphone hcl tab er 12hr oxymorphone hcl tab er 12hr oxymorphone hcl tab er 12hr oxymorphone hcl tab er 12hr oxymorphone hcl tab er 12hr OZEMPIC INJ 2/1.5ML...69 P pacerone tab pacerone tab paclitaxel iv conc 100 /16.7ml (6 /ml)...23 paclitaxel iv conc 150 /25ml (6 /ml)...23 paclitaxel iv conc 300 /50ml (6 /ml)...24 paclitaxel iv conc 30 /5ml (6 /ml)...23 paliperidone tab er 24hr paliperidone tab er 24hr paliperidone tab er 24hr paliperidone tab er 24hr pamidronate disodium for inj pamidronate disodium for inj pamidronate disodium iv soln 3 /ml 72 pamidronate disodium iv soln 9 /ml 72 pantoprazole sodium ec tab 20 (base equiv)...88 pantoprazole sodium ec tab 40 (base equiv)...88 RAGARD IUD T380A...75 paricalcitol cap 1 mcg paricalcitol cap 2 mcg paricalcitol cap 4 mcg paromomycin sulfate cap paroxetine hcl tab paroxetine hcl tab paroxetine hcl tab paroxetine hcl tab paroxetine hcl tab er 24hr paroxetine hcl tab er 24hr paroxetine hcl tab er 24hr SER GRA 4GM...16 ZEO DRO 0.7% pedia d-vite dro 400unit PEDIARIX INJ 0.5ML...96 PEDIATRIC RESPIRATORY MASK...98 PEDVAX HIB INJ...96 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm...86 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm...87 peg 3350-kcl-sod bicarb-nacl for soln 420 gm...87 PEGANONE TAB 250MG...48 PEGASYS INJ...16 PEGASYS INJ 180MCG/M...16 PEGASYS INJ PROCLICK...16 penicillin v potassium for soln 125 /5ml...20 penicillin v potassium for soln 250 /5ml...20 penicillin v potassium tab penicillin v potassium tab PENTACEL INJ...96 PENTAM 300 INJ 300MG...12 pentoxifylline tab er PERFOROMIST NEB 20MCG perindopril erbumine tab perindopril erbumine tab perindopril erbumine tab periogard sol 0.12% permethrin cream 5% perphenazine tab perphenazine tab perphenazine tab perphenazine tab phenadoz sup phenazopyridine hcl tab phenelzine sulfate tab phenobarbital elixir 20 /5ml...48 phenobarbital tab phenobarbital tab phenobarbital tab

157 phenobarbital tab phenobarbital tab phenobarbital tab phenobarbital tab phenobarbital tab phenoxybenzamine hcl cap phenylephrine hcl ophth soln 10% phenylephrine hcl ophth soln 2.5% phenytoin chew tab phenytoin sodium extended cap phenytoin sodium extended cap phenytoin sodium extended cap phenytoin susp 125 /5ml...48 PHOSPHOLINE SOL 0.125%OP PHOTOFRIN INJ 75MG...28 physiolyte sol PICATO GEL 0.015% PICATO GEL 0.05% pilocarpine hcl ophth soln 1% pilocarpine hcl tab pilocarpine hcl tab pimozide tab pimozide tab pindolol tab pindolol tab pioglitazone hcl-glimepiride tab pioglitazone hcl-glimepiride tab pioglitazone hcl-metformin hcl tab pioglitazone hcl-metformin hcl tab pioglitazone hcl tab 15 (base equiv)...70 pioglitazone hcl tab 30 (base equiv)...70 pioglitazone hcl tab 45 (base equiv)...70 pirmella tab 1/ pirmella tab 7/7/ piroxicam cap piroxicam cap PLEGRIDY INJ...65 PLEGRIDY INJ PEN...65 PLEGRIDY INJ STARTER...65 PLEGRIDY PEN INJ STARTER...65 PNEUMOVAX 23 INJ 25/ podofilox soln 0.5% polycin oin op polyethylene glycol 3350 oral packet...87 polyethylene glycol 3350 oral powder..87 polymyxin b-trimethoprim ophth soln unit/ml-0.1% POMALYST CAP 1MG...94 POMALYST CAP 2MG...94 POMALYST CAP 3MG...94 POMALYST CAP 4MG...94 portia-28 tab...75 potassium chloride cap er 10 meq...99 potassium chloride cap er 8 meq...99 potassium chloride microencapsulated crys er tab 10 meq...99 potassium chloride microencapsulated crys er tab 20 meq...99 potassium chloride oral soln 10% (20 meq/15ml)...99 potassium chloride oral soln 20% (40 meq/15ml)...99 potassium chloride tab er 10 meq...99 potassium chloride tab er 20 meq (1500 )...99 potassium chloride tab er 8 meq (600 )...99 potassium citrate tab er 10 meq (1080 )...89 potassium citrate tab er 15 meq (1620 )...89 potassium citrate tab er 5 meq (540 )...89 PRADAXA CAP 110MG...91 PRADAXA CAP 150MG...91 PRADAXA CAP 75MG...91 PRALUENT INJ 150MG/ML...37 PRALUENT INJ 75MG/ML...37 pramipexole dihydrochloride tab pramipexole dihydrochloride tab pramipexole dihydrochloride tab pramipexole dihydrochloride tab

158 pramipexole dihydrochloride tab pramipexole dihydrochloride tab 1.55 pramipexole dihydrochloride tab er 24hr pramipexole dihydrochloride tab er 24hr pramipexole dihydrochloride tab er 24hr pramipexole dihydrochloride tab er 24hr pramipexole dihydrochloride tab er 24hr pramipexole dihydrochloride tab er 24hr pramipexole dihydrochloride tab er 24hr pramox gel 1% prasugrel hcl tab 10 (base equiv)..93 prasugrel hcl tab 5 (base equiv)...92 pravastatin sodium tab pravastatin sodium tab pravastatin sodium tab pravastatin sodium tab praziquantel tab prazosin hcl cap prazosin hcl cap prazosin hcl cap PRED MILD SUS 0.12% OP prednicarbate cream 0.1% prednicarbate oint 0.1% prednisolone acetate ophth susp 1%.102 prednisolone sodium phosphate oral soln 25 /5ml (base eq)...80 prednisolone sod phosphate oral soln 15 /5ml (base equiv)...80 prednisolone sod phosph oral soln 6.7 /5ml (5 /5ml base)...80 prednisolone syrup 15 /5ml (usp solution equivalent)...80 PREDNISONE CON 5MG/ML...80 prednisone oral soln 5 /5ml...80 prednisone tab prednisone tab prednisone tab prednisone tab prednisone tab prednisone tab prednisone tab therapy pack 10 (21)...80 prednisone tab therapy pack 10 (48)...80 prednisone tab therapy pack 5 (21)...80 prednisone tab therapy pack 5 (48)...80 PRED SOD PHO SOL 1% OP PREMARIN TAB 0.3MG...79 PREMARIN TAB 0.45MG...79 PREMARIN TAB 0.625MG...79 PREMARIN TAB 0.9MG...79 PREMARIN TAB 1.25MG...79 PREMARIN VAG CRE 0.625MG...79 prenatabs rx tab PREPOPIK K...87 prevalite pow 4gm...35 previfem tab...75 PREVNAR 13 INJ...96 PREZCOBIX TAB PREZISTA SUS 100MG/ML...14 PREZISTA TAB 150MG...14 PREZISTA TAB 600MG...14 PREZISTA TAB 75MG...14 PREZISTA TAB 800MG...14 PRIFTIN TAB 150MG...16 PRIMAQUINE TAB 26.3MG...13 primidone tab primidone tab PRIMLEV TAB MG...10 PRIMLEV TAB 5-300MG...10 PRIMLEV TAB PRIMSOL SOL 50MG/5ML...12 PROAIR HFA AER PROAIR RESPI AER probenecid tab procainamide hcl inj 100 /ml...35 prochlorperazine maleate tab 10 (base equivalent)...85 prochlorperazine maleate tab 5 (base equivalent)...85 prochlorperazine suppos PROCRIT INJ 10000/ML...92 PROCRIT INJ 2000/ML...91 PROCRIT INJ 20000/ML...92 PROCRIT INJ 3000/ML...92 PROCRIT INJ 4000/ML

159 PROCRIT INJ 40000/ML...92 procto-pak cre 1%...88 proctosol hc cre 2.5%...88 progesterone micronized cap progesterone micronized cap PROLIA SOL 60MG/ML...81 PROMACTA TAB 12.5MG...92 PROMACTA TAB 25MG...92 PROMACTA TAB 50MG...92 PROMACTA TAB 75MG...92 promethazine-dm syrup /5ml promethazine hcl suppos promethazine hcl suppos promethazine hcl syrup 6.25 /5ml..85 promethazine hcl tab promethazine hcl tab promethazine hcl tab promethazine w/ codeine syrup /5ml promethegan sup promethegan sup promethegan sup prometh vc/ syp codeine prometh vc sol plain propafenone hcl cap er 12hr propafenone hcl cap er 12hr propafenone hcl cap er 12hr propafenone hcl tab propafenone hcl tab propafenone hcl tab propranolol & hydrochlorothiazide tab propranolol & hydrochlorothiazide tab propranolol hcl cap er 24hr propranolol hcl cap er 24hr propranolol hcl cap er 24hr propranolol hcl cap er 24hr propranolol hcl oral soln 20 /5ml...38 propranolol hcl oral soln 40 /5ml...38 propranolol hcl tab propranolol hcl tab propranolol hcl tab propranolol hcl tab propranolol hcl tab propylthiouracil tab PROQUAD INJ...97 protriptyline hcl tab protriptyline hcl tab pseudoephed-bromphen-dm syrup /5ml pyrazinamide tab pyridostigmine bromide tab pyridostigmine bromide tab er pyridoxine hcl tab pyridoxine hcl tab Q QTERN TAB 10MG/5MG...71 QUADRAMET INJ...28 quasense tab...75 quetiapine fumarate tab quetiapine fumarate tab quetiapine fumarate tab quetiapine fumarate tab quetiapine fumarate tab quetiapine fumarate tab quetiapine fumarate tab er 24hr quetiapine fumarate tab er 24hr quetiapine fumarate tab er 24hr quetiapine fumarate tab er 24hr quetiapine fumarate tab er 24hr quinapril-hydrochlorothiazide tab quinapril-hydrochlorothiazide tab quinapril-hydrochlorothiazide tab quinapril hcl tab quinapril hcl tab quinapril hcl tab quinapril hcl tab quinine sulfate cap QVAR AER 40MCG QVAR AER 80MCG R rabeprazole sodium ec tab raloxifene hcl tab ramipril cap ramipril cap ramipril cap

160 ramipril cap RANEXA TAB 1000MG...43 RANEXA TAB 500MG...43 ranitidine hcl cap ranitidine hcl cap ranitidine hcl syrup 15 /ml (75 /5ml)...86 ranitidine hcl tab ranitidine hcl tab RAFLO CAP 4MG...89 RAFLO CAP 8MG...89 RAMUNE SOL 1MG/ML...95 rasagiline mesylate tab 0.5 (base equiv)...56 rasagiline mesylate tab 1 (base equiv)...56 REBETOL SOL 40MG/ML...16 REBIF INJ 22/ REBIF INJ 44/ REBIF REBIDO INJ 22/ REBIF REBIDO INJ 44/ REBIF REBIDO INJ TITRATN...65 REBIF TITRTN INJ CK...65 reclipsen tab...75 RECOMBIVA-HB INJ 40MCG/ML...97 RECOMBIVA HB INJ 10MCG/ML...97 RECOMBIVA HB INJ 5MCG/ RECTIV OIN 0.4% REGRANEX GEL 0.01% RELENZA MIS DISKHALE...17 REMODULIN INJ 10MG/ML...44 REMODULIN INJ 1MG/ML...44 REMODULIN INJ 2.5MG/ML...44 REMODULIN INJ 5MG/ML...44 repaglinide-metformin hcl tab repaglinide-metformin hcl tab repaglinide tab repaglinide tab repaglinide tab RETHA INJ 140MG/ML...37 RETHA PUSH INJ 420/ RETHA SURE INJ 140MG/ML...37 reserpine tab reserpine tab RESTASIS EMU 0.05% REVLIMID CAP 10MG...94 REVLIMID CAP 15MG...95 REVLIMID CAP 2.5MG...94 REVLIMID CAP 20MG...95 REVLIMID CAP 25MG...95 REVLIMID CAP 5MG...94 REXULTI TAB 0.25MG...58 REXULTI TAB 0.5MG...58 REXULTI TAB 1MG...58 REXULTI TAB 2MG...58 REXULTI TAB 3MG...58 REXULTI TAB 4MG...58 REYATAZ POW 50MG...14 rhinocort sus allergy ribasphere cap ribasphere tab ribasphere tab ribasphere tab ribavirin cap ribavirin tab rifabutin cap RIFAMATE CAP...16 rifampin cap rifampin cap RIFATER TAB...16 riluzole tab rimantadine hydrochloride tab risedronate sodium tab risedronate sodium tab risedronate sodium tab risedronate sodium tab risedronate sodium tab delayed release risperidone orally disintegrating tab risperidone orally disintegrating tab risperidone orally disintegrating tab risperidone orally disintegrating tab risperidone orally disintegrating tab risperidone orally disintegrating tab risperidone soln 1 /ml...58 risperidone tab risperidone tab risperidone tab

161 risperidone tab risperidone tab risperidone tab ritonavir tab rivastigmine tartrate cap rivastigmine tartrate cap rivastigmine tartrate cap rivastigmine tartrate cap rivelsa tab...75 rizatriptan benzoate oral disintegrating tab 10 (base eq)...62 rizatriptan benzoate oral disintegrating tab 5 (base eq)...62 rizatriptan benzoate tab 10 (base equivalent)...63 rizatriptan benzoate tab 5 (base equivalent)...62 ropinirole hydrochloride tab ropinirole hydrochloride tab ropinirole hydrochloride tab ropinirole hydrochloride tab ropinirole hydrochloride tab ropinirole hydrochloride tab ropinirole hydrochloride tab rosadan cre 0.75% rosuvastatin calcium tab rosuvastatin calcium tab rosuvastatin calcium tab rosuvastatin calcium tab ROTARIX SUS...97 ROTATEQ SOL...97 ROZEREM TAB 8MG...62 RYDAPT CAP 25MG...24 S SABRIL TAB 500MG...48 SAMSCA TAB 15MG...81 SAMSCA TAB 30MG...81 SANCUSO DIS 3.1MG...85 SANTYL OIN 250/GM SAPHRIS SUB 10MG...58 SAPHRIS SUB 2.5MG...58 SAPHRIS SUB 5MG...58 SAVELLA MIS TITR K...64 SAVELLA TAB 100MG...64 SAVELLA TAB 12.5MG...64 SAVELLA TAB 25MG...64 SAVELLA TAB 50MG...64 scalacort lot 2% scopolamine td patch 72hr 1 /3days...85 selegiline hcl cap selegiline hcl tab selenium sulfide lotion 2.5% SELZENTRY SOL 20MG/ML...14 SELZENTRY TAB 150MG...14 SELZENTRY TAB 25MG...14 SELZENTRY TAB 300MG...14 SELZENTRY TAB 75MG...14 SENSIR TAB 30MG...72 SENSIR TAB 60MG...72 SENSIR TAB 90MG...72 SEREVENT DIS AER 50MCG sertraline hcl oral concentrate for solution 20 /ml...54 sertraline hcl tab sertraline hcl tab sertraline hcl tab sevelamer carbonate packet 0.8 gm...82 sevelamer carbonate packet 2.4 gm...82 sevelamer carbonate tab SHARPS CONTAINER...98 SHINGRIX INJ 50MCG...97 SHUR-SEAL GEL 2%...89 sildenafil citrate iv soln 10 /12.5ml (base equivalent)...44 sildenafil citrate tab silver sulfadiazine cream 1% SIMBRINZA SUS 1-0.2% SIMPONI ARIA SOL 50MG/4ML...93 SIMPONI INJ 100MG/ML...94 SIMPONI INJ 50/0.5ML...94 simvastatin tab simvastatin tab simvastatin tab simvastatin tab simvastatin tab sirolimus tab sirolimus tab sirolimus tab SIRTURO TAB 100MG...16 SIVEXTRO INJ 200MG...12 SIVEXTRO TAB 200MG...12 SKLICE LOT 0.5% SKYLA IUD 13.5MG...75 sm nicotine dis 14/24h...67 sm nicotine dis

162 sm nicotine dis 7/24hr...67 sm vitamin d tab 400unit sodium chloride flush iv soln 0.9%...99 sodium chloride inj 0.45%...99 sodium chloride inj 0.9%...99 sodium chloride inj 2.5 meq/ml (14.6%)...99 sodium chloride inj 3%...99 sodium chloride inj 5%...99 sodium chloride irrigation soln 0.9%..116 sodium chloride iv soln 0.9%...99 sodium chloride soln nebu 0.9% sodium chloride soln nebu 10% sodium chloride soln nebu 3% sodium chloride soln nebu 7% sodium fluoride chew tab 0.25 f (from 0.55 naf)...99 sodium fluoride chew tab 0.5 f (from 1.1 naf)...99 sodium fluoride chew tab 1 f (from 2.2 naf)...99 sodium fluoride soln 0.5 /ml f (from 1.1 /ml naf)...99 sodium fluoride tab 0.5 f (from 1.1 naf)...99 sodium fluoride tab 1 f (from 2.2 naf)...99 sodium polystyrene sulfonate oral susp 15 gm/60ml...73 sodium polystyrene sulfonate rectal susp 30 gm/120ml...73 SOMATULINE INJ 120/.5ML...81 SOMATULINE INJ 60/0.2ML...81 SOMATULINE INJ 90/0.3ML...81 SOMAVERT INJ 10MG...81 SOMAVERT INJ 15MG...81 SOMAVERT INJ 20MG...81 SOMAVERT INJ 25MG...81 SOMAVERT INJ 30MG...81 sorine tab sorine tab sorine tab sorine tab sotalol hcl (afib/afl) tab sotalol hcl (afib/afl) tab sotalol hcl (afib/afl) tab sotalol hcl tab sotalol hcl tab sotalol hcl tab sotalol hcl tab SOVALDI TAB 400MG...17 spinosad susp 0.9% SPIRIVA AER 1.25MCG SPIRIVA CAP HANDIHLR SPIRIVA SPR 2.5MCG spironolactone & hydrochlorothiazide tab spironolactone tab spironolactone tab spironolactone tab SPORANOX SOL 10MG/ML...13 sprintec 28 tab 28 day...75 SPRYCEL TAB 100MG...27 SPRYCEL TAB 140MG...27 SPRYCEL TAB 20MG...27 SPRYCEL TAB 50MG...27 SPRYCEL TAB 70MG...27 SPRYCEL TAB 80MG...27 sronyx tab...75 ssd cre 1% stavudine cap stavudine cap stavudine cap stavudine cap STELARA INJ 45MG/ STELARA INJ 90MG/ML...94 STIVARGA TAB 40MG...27 streptomycin sulfate for inj 1 gm...11 STRIBILD TAB...15 STRIVERDI AER 2.5MCG SUBOXONE MIS 12-3MG...3 SUBOXONE MIS 2-0.5MG...3 SUBOXONE MIS 4-1MG...3 SUBOXONE MIS 8-2MG...3 SUCRAID SOL 8500/ML...87 sucralfate tab 1 gm...87 sulfacetamide sodium-prednisolone ophth soln (0.25)% sulfacetamide sodium lotion 10% (acne) sulfacetamide sodium ophth oint 10% sulfacetamide sodium ophth soln 10% SULFADIAZINE TAB 500MG...11 sulfamethoxazole-trimethoprim susp 158

163 /5ml...12 sulfamethoxazole-trimethoprim tab sulfamethoxazole-trimethoprim tab SULFAMYLON CRE 85MG/GM sulfasalazine tab sulfasalazine tab delayed release sulindac tab sulindac tab sumatriptan nasal spray 20 /act...63 sumatriptan nasal spray 5 /act...63 sumatriptan succinate inj 6 /0.5ml.63 sumatriptan succinate solution autoinjector 4 /0.5ml...63 sumatriptan succinate solution autoinjector 6 /0.5ml...63 sumatriptan succinate solution cartridge 4 /0.5ml...63 sumatriptan succinate solution cartridge 6 /0.5ml...63 sumatriptan succinate solution prefilled syringe 6 /0.5ml...63 sumatriptan succinate tab sumatriptan succinate tab sumatriptan succinate tab SUPRAX CAP 400MG...18 SUPRAX CHW 100MG...18 SUPRAX CHW 200MG...18 SUPRAX SUS 500/5ML...18 SUPREP BOWEL SOL PREP KIT...87 SUTENT CAP 12.5MG...27 SUTENT CAP 25MG...27 SUTENT CAP 37.5MG...27 SUTENT CAP 50MG...27 syeda tab symax-sl sub SYMBICORT AER SYMBICORT AER SYMDEKO TAB SYMLINPEN 60 INJ 1000MCG...68 SYMLNPEN 120 INJ 1000MCG...68 SYNAREL SOL 2MG/ML...76 SYNERA DIS 70-70MG SYNTHROID TAB 100MCG...83 SYNTHROID TAB 112MCG...83 SYNTHROID TAB 125MCG...83 SYNTHROID TAB 137MCG...83 SYNTHROID TAB 150MCG...83 SYNTHROID TAB 175MCG...83 SYNTHROID TAB 200MCG...83 SYNTHROID TAB 25MCG...83 SYNTHROID TAB 300MCG...83 SYNTHROID TAB 50MCG...83 SYNTHROID TAB 75MCG...83 SYNTHROID TAB 88MCG...83 T TABLOID TAB 40MG...23 tacrolimus cap tacrolimus cap tacrolimus cap tacrolimus oint 0.03% tacrolimus oint 0.1% TAFINLAR CAP 50MG...28 TAFINLAR CAP 75MG...28 take action tab tamoxifen citrate tab 10 (base equivalent)...25 tamoxifen citrate tab 20 (base equivalent)...25 tamsulosin hcl cap TANZEUM INJ 30MG...69 TANZEUM INJ 50MG...69 TARCEVA TAB 100MG...28 TARCEVA TAB 150MG...28 TARCEVA TAB 25MG...28 targetd acne cre 2.5% TARGRETIN GEL 1% TAYTULLA CAP...75 tazarotene cream 0.1% tazicef inj 1gm...18 tazicef inj 2gm...18 tazicef inj 6gm...18 TAZORAC CRE 0.05% TAZORAC GEL 0.05% TAZORAC GEL 0.1% taztia xt cap 120/ taztia xt cap 180/ taztia xt cap 240/ taztia xt cap 300/ taztia xt cap 360/ TECFIDERA CAP 120MG...65 TECFIDERA CAP 240MG...65 TECFIDERA MIS STARTER...65 TEKTURNA TAB 150MG

164 TEKTURNA TAB 300MG...41 telmisartan-amlodipine tab telmisartan-amlodipine tab telmisartan-amlodipine tab telmisartan-amlodipine tab telmisartan-hydrochlorothiazide tab telmisartan-hydrochlorothiazide tab telmisartan-hydrochlorothiazide tab telmisartan tab telmisartan tab telmisartan tab temazepam cap temazepam cap temazepam cap temazepam cap TEMODAR INJ 100MG...21 temozolomide cap temozolomide cap temozolomide cap temozolomide cap temozolomide cap temozolomide cap tencon tab TENIPOSIDE INJ 50MG/5ML...29 TENIVAC INJ 5-2LF...97 tenofovir disoproxil fumarate tab terazosin hcl cap 10 (base equivalent)...32 terazosin hcl cap 1 (base equivalent)...32 terazosin hcl cap 2 (base equivalent)...32 terazosin hcl cap 5 (base equivalent)...32 terbinafine cre 1% terbinafine hcl tab terbutaline sulfate tab terbutaline sulfate tab terconazole vaginal cream 0.4%...90 terconazole vaginal suppos testosterone cypionate im inj in oil 100 /ml...68 testosterone cypionate im inj in oil 200 /ml...68 testosterone enanthate im inj in oil 200 /ml...68 testosterone td gel 10/act (2%)...68 testosterone td gel 25 /2.5gm (1%) 68 TET/DIP TOX INJ 2-2 LF...97 tetrabenazine tab tetrabenazine tab tetracycline hcl cap tetracycline hcl cap THALOMID CAP 100MG...95 THALOMID CAP 150MG...95 THALOMID CAP 200MG...95 THALOMID CAP 50MG...95 theochron tab 100 cr theochron tab 200 cr theochron tab 300 cr theophylline soln 80 /15ml theophylline tab er 12hr theophylline tab er 24hr theophylline tab er 24hr THERACYS INJ...28 thioridazine hcl tab thioridazine hcl tab thioridazine hcl tab thioridazine hcl tab thiothixene cap thiothixene cap thiothixene cap thiothixene cap THYROLAR-1/2 TAB 30MG...83 THYROLAR-1/4 TAB 15MG...83 THYROLAR-1 TAB 60MG...83 THYROLAR-2 TAB 120MG...83 THYROLAR-3 TAB 180MG...83 tiagabine hcl tab tiagabine hcl tab tiagabine hcl tab tiagabine hcl tab TICE BCG INJ...28 tilia fe tab...75 timolol maleate ophth gel forming soln 0.25% timolol maleate ophth gel forming soln 0.5% timolol maleate ophth soln 0.25% timolol maleate ophth soln 0.5% timolol maleate tab timolol maleate tab

165 timolol maleate tab TIMOPTIC OCU SOL 0.25% OP TIMOPTIC OCU SOL 0.5% OP tinidazole tab tinidazole tab tis-u-sol sol TIVICAY TAB 10MG...15 TIVICAY TAB 25MG...15 TIVICAY TAB 50MG...15 tizanidine hcl cap 2 (base equivalent)...66 tizanidine hcl cap 4 (base equivalent)...66 tizanidine hcl cap 6 (base equivalent)...66 tizanidine hcl tab 2 (base equivalent)...66 tizanidine hcl tab 4 (base equivalent)...66 TOBRADEX OIN % TOBRADEX ST SUS tobramycin-dexamethasone ophth susp % tobramycin nebu soln 300 /5ml...11 tobramycin ophth soln 0.3% TOBREX OIN 0.3% OP TODAY SPONGE MIS...89 tolcapone tab tolmetin sodium cap tolmetin sodium tab tolmetin sodium tab tolnaftate aerosol pow 1% tolnaftate soln 1% tolterodine tartrate cap er 24hr tolterodine tartrate cap er 24hr tolterodine tartrate tab tolterodine tartrate tab topiramate sprinkle cap topiramate sprinkle cap topiramate tab topiramate tab topiramate tab topiramate tab toposar inj 100/5ml...29 toposar inj 20/ml...29 topotecan hcl for inj torsemide tab torsemide tab torsemide tab torsemide tab TOVIAZ TAB 4MG...89 TOVIAZ TAB 8MG...89 TRACLEER TAB 125MG...45 TRACLEER TAB 32MG...45 TRACLEER TAB 62.5MG...45 TRADJENTA TAB 5MG...69 tramadol hcl tab tramadol hcl tab er 24hr tramadol hcl tab er 24hr tramadol hcl tab er 24hr trandolapril-verapamil hcl tab er trandolapril-verapamil hcl tab er trandolapril-verapamil hcl tab er trandolapril-verapamil hcl tab er trandolapril tab trandolapril tab trandolapril tab tranexamic acid iv soln 1000 /10ml (100 /ml)...92 tranexamic acid tab tranylcypromine sulfate tab TRAVATAN Z DRO 0.004% trazodone hcl tab trazodone hcl tab trazodone hcl tab trazodone hcl tab TRECATOR TAB 250MG...16 TRESIBA FLEX INJ 100UNIT...70 TRESIBA FLEX INJ 200UNIT...70 tretinoin cap tretinoin cream 0.025% tretinoin cream 0.05% tretinoin cream 0.1% tretinoin gel 0.01% tretinoin gel 0.025% tretinoin gel 0.05% tri-linyah tab...75 tri-sprintec tab...75 tri-vit/fe dro /fl tri-vit/fl dro tri-vit/fl dro triamcinolone acetonide aerosol soln 161

166 0.147 /gm triamcinolone acetonide cream 0.025% triamcinolone acetonide cream 0.1%.115 triamcinolone acetonide cream 0.5%.115 triamcinolone acetonide dental paste 0.1% triamcinolone acetonide lotion 0.025% triamcinolone acetonide lotion 0.1%..115 triamcinolone acetonide nasal aerosol suspension 55 mcg/act triamcinolone acetonide oint 0.025%.115 triamcinolone acetonide oint 0.1% triamcinolone acetonide oint 0.5% triamterene & hydrochlorothiazide cap triamterene & hydrochlorothiazide cap triamterene & hydrochlorothiazide tab triamterene & hydrochlorothiazide tab triderm cre 0.1% trientine hcl cap trifluoperazine hcl tab 10 (base equivalent)...59 trifluoperazine hcl tab 1 (base equivalent)...59 trifluoperazine hcl tab 2 (base equivalent)...59 trifluoperazine hcl tab 5 (base equivalent)...59 trifluridine ophth soln 1% trihexyphenidyl hcl elixir 0.4 /ml...56 trihexyphenidyl hcl tab trihexyphenidyl hcl tab trimethobenzamide hcl cap trimethoprim tab trimipramine maleate cap trimipramine maleate cap trimipramine maleate cap trinessa tab...75 TRINTELLIX TAB 10MG...54 TRINTELLIX TAB 20MG...54 TRINTELLIX TAB 5MG...54 triple antib oin triple paste oin af 2% TRISENOX INJ 12MG/6ML...28 TRISENOX SOL 10MG/10M...28 TRIUMEQ TAB...15 trivora-28 tab...75 tropicamide ophth soln 0.5% tropicamide ophth soln 1% trospium chloride cap er 24hr trospium chloride tab TRULICITY INJ 0.75/ TRULICITY INJ 1.5/ TRUMENBA INJ...97 TRUVADA TAB TRUVADA TAB TRUVADA TAB TRUVADA TAB TUDORZA PRES AER 400/ACT tussigon tab TUZISTRA XR SUS TWINRIX INJ...97 TYBOST TAB 150MG...15 TYKERB TAB 250MG...28 TYSABRI INJ 300/15ML...65 TYVASO START SOL 0.6MG/ML...45 U ULESFIA LOT 5% ULORIC TAB 40MG...1 ULORIC TAB 80MG...1 unithroid tab 100mcg...83 unithroid tab 112mcg...83 unithroid tab 125mcg...83 unithroid tab 200mcg...83 unithroid tab 25mcg...83 unithroid tab 300mcg...83 unithroid tab 50mcg...83 unithroid tab 75mcg...83 unithroid tab 88mcg...83 UPTRAVI TAB 1000MCG...45 UPTRAVI TAB 1200MCG...45 UPTRAVI TAB 1400MCG...45 UPTRAVI TAB 1600MCG...45 UPTRAVI TAB 200/ UPTRAVI TAB 200MCG...45 UPTRAVI TAB 400MCG...45 UPTRAVI TAB 600MCG...45 UPTRAVI TAB 800MCG...45 URINE GLUCOSE MONITORING SUPPLIES...98 URINE TEST STRIPS

167 ursodiol cap ursodiol tab ursodiol tab UVADEX INJ 20MCG/ML...29 V valacyclovir hcl tab 1 gm...17 valacyclovir hcl tab valganciclovir hcl for soln 50 /ml (base equiv)...17 valganciclovir hcl tab 450 (base equivalent)...17 valproate sodium oral soln 250 /5ml (base equiv)...49 valproic acid cap valsartan-hydrochlorothiazide tab valsartan-hydrochlorothiazide tab valsartan-hydrochlorothiazide tab valsartan-hydrochlorothiazide tab valsartan-hydrochlorothiazide tab valsartan tab valsartan tab valsartan tab valsartan tab vancomycin hcl cap vancomycin hcl cap vandazole gel 0.75%...90 VAQTA INJ 25/0.5ML...97 VAQTA INJ 50UNT/ML...97 VARIVAX INJ...97 VARUBI INJ...85 VARUBI TAB 90MG...85 VASCE CAP 0.5GM...37 VASCE CAP 1GM...37 VCF VAGINAL AER CONTRACP...89 VCF VAGINAL MIS CONTRACP...89 velivet pak...75 VELPHORO CHW 500MG...82 VENCLEXTA TAB 100MG...29 VENCLEXTA TAB 10MG...29 VENCLEXTA TAB 50MG...29 VENCLEXTA TAB START PK...30 venlafaxine hcl cap er 24hr 150 (base equivalent)...54 venlafaxine hcl cap er 24hr 37.5 (base equivalent)...54 venlafaxine hcl cap er 24hr 75 (base equivalent)...54 venlafaxine hcl tab venlafaxine hcl tab venlafaxine hcl tab venlafaxine hcl tab venlafaxine hcl tab venlafaxine hcl tab er 24hr 150 (base equivalent)...54 venlafaxine hcl tab er 24hr 37.5 (base equivalent)...54 venlafaxine hcl tab er 24hr 75 (base equivalent)...54 VENTAVIS SOL 10MCG/ML...45 VENTAVIS SOL 20MCG/ML...45 verapamil hcl cap er 24hr verapamil hcl cap er 24hr verapamil hcl cap er 24hr verapamil hcl cap er 24hr verapamil hcl cap er 24hr verapamil hcl cap er 24hr verapamil hcl cap er 24hr verapamil hcl tab verapamil hcl tab verapamil hcl tab verapamil hcl tab er verapamil hcl tab er verapamil hcl tab er VEREGEN OIN 15% VESICARE TAB 10MG...89 VESICARE TAB 5MG...89 vestura tab VEXOL SUS 1% OP VICTOZA INJ 18MG/3ML...69 VIDEX SOL 2GM...15 VIDEX SOL 4GM...15 vigabatrin powd pack VIIBRYD KIT STARTER...55 VIIBRYD TAB 10MG...55 VIIBRYD TAB 20MG...55 VIIBRYD TAB 40MG...55 VIMT SOL 10MG/ML...49 VIMT TAB 100MG...49 VIMT TAB 150MG...49 VIMT TAB 200MG...49 VIMT TAB 50MG

168 vinblastine sulfate inj 1 /ml...24 vincasar pfs inj 1/ml...24 vincristine sulfate iv soln 1 /ml...24 vinorelbine tartrate inj 10 /ml (base equiv)...24 vinorelbine tartrate inj 50 /5ml (10 /ml) (base equiv)...24 VIOKACE TAB...87 VIOKACE TAB viorele tab...75 VIRACEPT TAB 250MG...15 VIRACEPT TAB 625MG...15 VIRAMUNE SUS 50MG/5ML...15 VIREAD POW 40MG/GM...15 VIREAD TAB 150MG...15 VIREAD TAB 200MG...15 VIREAD TAB 250MG...15 virt-vite tab forte VISTOGARD K 10GM...29 vit a/c/d/fl dro VITAMIN D2 TAB 400UNIT VITAMIN D3 LIQ 1000UNIT VITAMIN D3 LIQ 1200UNIT voriconazole for susp 40 /ml...13 voriconazole tab voriconazole tab VOSEVI TAB...17 VOTRIENT TAB 200MG...28 VYVANSE CAP 10MG...61 VYVANSE CAP 20MG...61 VYVANSE CAP 30MG...61 VYVANSE CAP 40MG...61 VYVANSE CAP 50MG...61 VYVANSE CAP 60MG...61 VYVANSE CAP 70MG...61 VYVANSE CHW 10MG...61 VYVANSE CHW 20MG...61 VYVANSE CHW 30MG...61 VYVANSE CHW 40MG...61 VYVANSE CHW 50MG...61 VYVANSE CHW 60MG...61 W warfarin sodium tab warfarin sodium tab warfarin sodium tab warfarin sodium tab warfarin sodium tab warfarin sodium tab warfarin sodium tab warfarin sodium tab warfarin sodium tab WELCHOL K 3.75GM...35 WELCHOL TAB 625MG...35 wera tab 0.5/ WIDE-SEAL DPR KIT WIDE-SEAL DPR KIT WIDE-SEAL DPR KIT WIDE-SEAL DPR KIT WIDE-SEAL DPR KIT WIDE-SEAL DPR KIT WIDE-SEAL DPR KIT WIDE-SEAL DPR KIT X XALKORI CAP 200MG...28 XALKORI CAP 250MG...28 XARELTO STAR TAB 15/20MG...91 XARELTO TAB 10MG...91 XARELTO TAB 15MG...91 XARELTO TAB 20MG...91 XELJANZ TAB 5MG...94 XIFAXAN TAB 200MG...12 XIFAXAN TAB 550MG...12 XIGDUO XR TAB XIGDUO XR TAB MG...71 XIGDUO XR TAB XIGDUO XR TAB MG...71 XIGDUO XR TAB 5-500MG...71 XTANDI CAP 40MG...25 xulane dis xylon tab XYREM SOL 500MG/ML...66 Y yuvafem tab 10mcg...79 Z zafirlukast tab zafirlukast tab zaleplon cap zaleplon cap zarah tab ZARXIO INJ 300/ ZARXIO INJ 480/ ZAVESCA CAP 100MG...76 zazole cre 0.8%...90 zazole sup ZEJULA CAP 100MG...24 ZELBORAF TAB 240MG

169 zenchent fe chw zenchent tab...76 ZENPEP CAP...87 ZENPEP CAP 10000UNT...87 ZENPEP CAP 15000UNT...87 ZENPEP CAP 20000UNT...87 ZENPEP CAP 25000UNT...87 ZENPEP CAP 3000UNIT...87 ZENPEP CAP 40000UNT...87 ZENPEP CAP 5000UNIT...87 zenzedi tab zenzedi tab zenzedi tab zenzedi tab zenzedi tab ZETIER TAB MG...17 ZERIT SOL 1MG/ML...15 zidovudine cap zidovudine syrup 10 /ml...15 zidovudine tab zileuton tab er 12hr ZIOPTAN DRO % ziprasidone hcl cap ziprasidone hcl cap ziprasidone hcl cap ziprasidone hcl cap ZIRGAN GEL 0.15% zoledronic acid inj conc for iv infusion 4 /5ml...72 zoledronic acid iv soln 5 /100ml...72 ZOLINZA CAP 100MG...24 zolmitriptan orally disintegrating tab zolmitriptan orally disintegrating tab zolmitriptan tab zolmitriptan tab zolpidem tartrate tab zolpidem tartrate tab zolpidem tartrate tab er zolpidem tartrate tab er ZOMIG SPR 2.5MG...63 ZOMIG SPR 5MG...63 zonisamide cap zonisamide cap zonisamide cap ZONTIVITY TAB 2.08MG...93 ZORTRESS TAB 0.25MG...95 ZORTRESS TAB 0.5MG...95 ZORTRESS TAB 0.75MG...95 ZOSTAVAX INJ...97 zovia 1/35e tab...76 ZUBSOLV SUB ZUBSOLV SUB ZUBSOLV SUB ZUBSOLV SUB ZUBSOLV SUB ZUBSOLV SUB ZYDELIG TAB 100MG...28 ZYDELIG TAB 150MG...28 ZYKADIA CAP 150MG...28 ZYTIGA TAB 250MG...25 ZYTIGA TAB 500MG

170 166

171