Cigna-HealthSpring CarePlan (Medicare-Medicaid Plan) 2018 List of Covered Drugs (Formulary)

Transcription

1 Cigna-HealthSpring CarePlan (Medicare-Medicaid Plan) 2018 List of Covered Drugs (Formulary) This is a list of drugs that members can get in Cigna-HealthSpring CarePlan. H8423_18_56471f v Cigna-HealthSpring CarePlan is a health plan that contracts with both Medicare and Texas Medicaid to provide benefits of both programs to enrollees. v The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you. v Benefits may change on January 1 of each year. v You can always check Cigna-HealthSpring CarePlan s up-to-date List of Covered Drugs online at v Limitations and restrictions may apply. For more information, call Cigna-HealthSpring CarePlan Member Services or read the Cigna-HealthSpring CarePlan Member Handbook. v If you speak English, language assistance services, free of charge, are available to you. Call Member Services at (TTY: 7-1-1), 7 days a week, 8 a.m. to 8 p.m. Central Time. The call is free. Si habla inglés, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 7-1-1), los 7 días de la semana, de 8 a.m. a 8 p.m., hora del Centro. La llamada es gratuita. v You can get this document for free in other formats, such as large print, braille, or audio. Call Member Services at (TTY: 7-1-1), 7 days a week, 8 a.m. to 8 p.m. Central Time. The call is free. v You can request to receive this document in Spanish or an alternate format, now and in the future by calling Member Services at (TTY: 7-1-1), 7 days a week, 8 a.m. to 8 p.m. Central Time. Updated 08/01/2018 For more recent information or other questions, please contact Cigna-HealthSpring CarePlan at (TTY: 7-1-1), 7 days a week, 8 a.m. to 8 p.m. Central Time, or visit HPMS Approved Formulary File Submission ID 18087, Version Number 14? If you have questions, please call Cigna-HealthSpring CarePlan at (TTY: 7-1-1), 7 days a week, 8 a.m. to 8 p.m. Central Time. The call is free. For more information, visit I

2 Frequently Asked Questions (FAQ) Find answers here to questions you have about this List of Covered Drugs. You can read all of the FAQ to learn more, or look for a question and answer. 1. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the Drug List for short.) The drugs on the List of Covered Drugs that starts on page 1 are the drugs covered by Cigna-HealthSpring CarePlan. These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as network pharmacies. Cigna-HealthSpring CarePlan will cover all medically necessary drugs on the Drug List if: your doctor or other prescriber says you need them to get better or stay healthy, and you fill the prescription at a Cigna-HealthSpring CarePlan network pharmacy. Cigna-HealthSpring CarePlan may have additional steps to access certain drugs (see question #5 below). You can also see an up-to-date list of drugs that we cover on our website at or call Member Services at (TTY: 7-1-1), 7 days a week, 8 a.m. to 8 p.m. Central Time. 2. Does the Drug List ever change? Yes. Cigna-HealthSpring CarePlan may add or remove drugs on the Drug List during the year. Generally, the Drug List will only change if: a cheaper drug comes along that works as well as a drug on the Drug List now, or we learn that a drug is not safe. We may also change our rules about drugs. For example, we could: Decide to require or not require prior approval for a drug. (Prior approval is permission from Cigna-HealthSpring CarePlan before you can get a drug.) Add or change the amount of a drug you can get (called quantity limits ). Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.) (For more information on these drug rules, see page III.)? If you have questions, please call Cigna-HealthSpring CarePlan at (TTY: 7-1-1), 7 days a week, 8 a.m. to 8 p.m. Central Time. The call is free. For more information, visit II

3 We will tell you when a Medicare Part D drug you are taking is removed from the Drug List. We will also tell you when we change our rules for covering a Medicare Part D drug. Questions 3, 4, and 7 below have more information on what happens when the Drug List changes. You can always check Cigna-HealthSpring CarePlan s up to date Drug List online at You can also call Member Services to check the current Drug List at (TTY: 7-1-1), 7 days a week, 8 a.m. to 8 p.m. Central Time. 3. What happens when a cheaper drug comes along that works as well as a drug on the Drug List now? If you are taking a Medicare Part D drug that is removed beca a cheaper drug that works just as well comes along, we will tell you. We will tell you at least 60 days before we remove it from the Drug List or when you ask for a refill. Then you can get a 60-day supply of the drug before the change to the Drug List is made. We will mail you a letter explaining the change and tell you the next steps to take to switch to a different drug. 4. What happens when we find out a drug is not safe? If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we will take it off the Drug List right away. We will also send you a letter telling you that. If you have any questions after being notified of the change, you should contact the doctor who prescribed the drug for you. 5. Are there any restrictions or limits on drug coverage? Or are there any required actions to take in order to get certain drugs? Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases you must do something before you can get the drug. For example: Prior approval (or prior authorization): For some drugs, you or your doctor or other prescriber must get approval from Cigna-HealthSpring CarePlan before you fill your prescription. If you don t get approval, Cigna-HealthSpring CarePlan may not cover the drug. Quantity limits: Sometimes Cigna-HealthSpring CarePlan limits the amount of a drug you can get. Step therapy: Sometimes Cigna-HealthSpring CarePlan requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn t work for you, then we will cover the second.? If you have questions, please call Cigna-HealthSpring CarePlan at (TTY: 7-1-1), 7 days a week, 8 a.m. to 8 p.m. Central Time. The call is free. For more information, visit III

4 You can find out if your drug has any additional requirements or limits by looking in the tables on pages You can also get more information by visiting our website at We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. You can ask for an exception from these limits. Please see question 11 for more information on exceptions. If you are in a nursing home or other long-term care facility and need a drug that is not on the Drug List, or if you cannot easily get the drug you need, we can help. We will cover a 31-day emergency supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new Cigna-HealthSpring CarePlan member. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. Please see question 11 for more information about exceptions. 6. How will you know if the drug you want has limitations or if there are required actions to take to get the drug? The List of Covered Drugs on page 1 has a column labeled. 7. What happens if we change our rules on how we cover some drugs? For example, if we add prior authorization (approval), quantity limits, and/or step therapy restrictions on a drug. We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions on a drug. We will tell you at least 60 days before the restriction is added or when you next ask for a refill. Then, you can get a 60-day supply of the drug before the change to the Drug List is made. This gives you time to talk to your doctor or other prescriber about what to do next. 8. How can you find a drug on the Drug List? There are two ways to find a drug: You can search alphabetically (if you know how to spell the drug), or You can search by medical condition. To search alphabetically, go to the Alphabetical Listing section. You can find it on page 109. This section has a list of all the drugs in this book. The drug names are in the first column of the list with the page number across from each name.? If you have questions, please call Cigna-HealthSpring CarePlan at (TTY: 7-1-1), 7 days a week, 8 a.m. to 8 p.m. Central Time. The call is free. For more information, visit IV

5 To search by medical condition, find the section labeled List of drugs by medical condition on page 1. The drugs in this section are grouped into categories depending on the type of medical conditions they are d to treat. For example, if you have a heart condition, you should look in the category, Cardiovascular Agents. That is where you will find drugs that treat heart conditions. 9. What if the drug you want to take is not on the Drug List? If you don t see your drug on the Drug List, call Member Services at (TTY: 7-1-1), 7 days a week, 8 a.m. to 8 p.m. Central Time and ask about it. If you learn that Cigna-HealthSpring CarePlan will not cover the drug, you can do one of these things: Ask Member Services for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or You can ask the health plan to make an exception to cover your drug. Please see question 11 for more information about exceptions. 10. What if you are a new Cigna-HealthSpring CarePlan member and can t find your drug on the Drug List or have a problem getting your drug? We can help. We may cover a temporary 30-day supply of your drug during the first 90 days you are a member of Cigna-HealthSpring CarePlan. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. We will cover a 30-day supply of your drug if: you are taking a drug that is not on our Drug List, or health plan rules do not let you get the amount ordered by your prescriber, or the drug requires prior approval by Cigna-HealthSpring CarePlan, or you are taking a drug that is part of a step therapy restriction. If you live in a nursing home or other long-term care facility, you may refill your prescription for as long as 98 days. You may refill the drug multiple times during your first 98 days in the plan. This gives your prescriber time to change your drugs to ones on the Drug List or ask for an exception. We will cover a temporary 30-day supply of your drug if an unexpected move happens. For example, if you are released from the hospital to go home or to a nursing home and you are not able to get your medicine.? If you have questions, please call Cigna-HealthSpring CarePlan at (TTY: 7-1-1), 7 days a week, 8 a.m. to 8 p.m. Central Time. The call is free. For more information, visit V

6 11. Can you ask for an exception to cover your drug? Yes. You can ask Cigna-HealthSpring CarePlan to make an exception to cover a drug that is not on the Drug List. You can also ask us to change the rules on your drug. For example, Cigna-HealthSpring CarePlan may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more. Other examples: You can ask us to drop step therapy restrictions or prior approval requirements. 12. How long does it take to get an exception? First, we must get a statement from your prescriber supporting your request for an exception. After we get the statement, we will give you a decision on your exception request within 72 hours. If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, we will give you a decision within 24 hours of getting your prescriber s supporting statement. 13. How can you ask for an exception? To ask for an exception, call Member Services. A Member Services Representative will work with you and your provider to help you ask for an exception. 14. What are generic drugs? Generic drugs are made up of the same active ingredients as brand name drugs. They usually cost less than the brand name drug and usually don t have well-known names. Generic drugs are approved by the Food and Drug Administration (FDA). Cigna-HealthSpring CarePlan covers both brand name drugs and generic drugs. 15. What are OTC drugs? OTC stands for over-the-counter. Cigna-HealthSpring CarePlan covers some OTC drugs when they are written as prescriptions by your provider. You can read the Cigna-HealthSpring CarePlan Drug List to see what OTC drugs are covered.? If you have questions, please call Cigna-HealthSpring CarePlan at (TTY: 7-1-1), 7 days a week, 8 a.m. to 8 p.m. Central Time. The call is free. For more information, visit VI

7 16. Does Cigna-HealthSpring CarePlan cover OTC non-drug products? Cigna-HealthSpring CarePlan covers some OTC non-drug products when they are written as prescriptions by your provider. You can read the Cigna-HealthSpring CarePlan Drug List to see what OTC non-drug products are covered. 17. What is your copay? As a Cigna-HealthSpring CarePlan member, you have no copays for prescription and OTC drugs as long as you follow Cigna-HealthSpring CarePlan s rules. 18. What are drug tiers? Tiers are groups of drugs on our Drug List. All tiers have no copay. Tier 1 drugs are generic drugs. Tier 2 drugs are brand name drugs.? If you have questions, please call Cigna-HealthSpring CarePlan at (TTY: 7-1-1), 7 days a week, 8 a.m. to 8 p.m. Central Time. The call is free. For more information, visit VII

8 List of Covered Drugs The list of covered drugs that begins on the next page gives you information about the drugs covered by Cigna-HealthSpring CarePlan. If you have trouble finding your drug in the list, turn to the Index that begins on page 109. The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g., BYSTOLIC) and generic drugs are listed in lower-case italics (e.g., alendronate). The information in the necessary actions, column tells you if Cigna-HealthSpring CarePlan has any rules for covering your drug. Abbreviation Explanation B/D (Part B/Part D) PA (Prior Authorization) QL (Quantity Limits) ST (Step Therapy) MC (Medicaid Covered) (Non-Extended Day Supply) This drug might be covered under Medicare Part B instead of Medicare Part D. More information might be needed for Cigna-HealthSpring CarePlan to decide which plan should cover it. This drug requires prior authorization. This drug has quantity limits. This drug has step therapy requirements. Non-Part D Drugs, or OTC items that are covered by Medicaid This drug is only available as a 30-day supply or less. Note: The "MC" next to a drug means the drug is not a Part D drug. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are getting Extra Help to pay for your prescriptions, you will not get any Extra Help to pay for these drugs. These drugs also have different rules for appeals. An appeal is a formal way of asking us to review a coverage decision and to change it if you think we made a mistake. For example, we might decide that a drug that you want is not covered or is no longer covered by Medicare or Texas Medicaid. If you or your doctor disagrees with our decision, you can appeal. To ask for instructions on how to appeal, call Member Services at (TTY: 7-1-1), 7 days a week, 8 a.m. to 8 p.m. Central Time. You can also read the Member Handbook to learn how to appeal a decision.? If you have questions, please call Cigna-HealthSpring CarePlan at (TTY: 7-1-1), 7 days a week, 8 a.m. to 8 p.m. Central Time. The call is free. For more information, visit VIII

9 List of Drugs by Medical Condition The drugs in this section are grouped into categories depending on the type of medical conditions they are d to treat. For example, if you have a heart condition, you should look in the category, Cardiovascular Agents. That is where you will find drugs that treat heart conditions. What the drug Name of drug Analgesics (Drugs that Relieve Pain) Analgesics acephen $0(Tier 1) MC acetaminophen tabs 325mg $0(Tier 1) MC butalbital/acetaminophen/caffeine caps $0(Tier 1) QL (180 per 30 days) PA butalbital/acetaminophen/caffeine tabs 325mg; 50mg; 40mg $0(Tier 1) QL (180 per 30 days) PA butalbital/aspirin/caffeine caps $0(Tier 1) QL (180 per 30 days) PA capacet $0(Tier 1) QL (180 per 30 days) PA childrens mapap rapid tabs $0(Tier 1) MC ed-apap $0(Tier 1) MC esgic $0(Tier 1) QL (180 per 30 days) PA gnp arthritis pain relief $0(Tier 1) MC junior mapap $0(Tier 1) MC mapap acetaminophen extrastrength $0(Tier 1) MC mapap arthritis pain $0(Tier 1) MC mapap childrens susp, tbdp $0(Tier 1) MC mapap pm $0(Tier 1) MC mapap caps, chew, liqd, tabs $0(Tier 1) MC margesic $0(Tier 1) QL (180 per 30 days) PA pain & fever $0(Tier 1) MC pain & fever childrens chew 80mg $0(Tier 1) MC pain & fever childrens soln $0(Tier 1) MC pain & fever extra strength $0(Tier 1) MC pain & fever infants $0(Tier 1) MC pain reliever pm extra strength $0(Tier 1) MC q-pap extra strength $0(Tier 1) MC q-pap tabs $0(Tier 1) MC qc arthritis pain relief $0(Tier 1) MC zebutal caps 325mg; 50mg; 40mg $0(Tier 1) QL (180 per 30 days) PA Nonsteroidal Anti-inflammatory Drugs all day relief $0(Tier 1) MC aspirin ec tbec 325mg $0(Tier 1) MC aspirin low dose chew 81mg $0(Tier 1) MC aspirin tabs 325mg $0(Tier 1) MC aspirin tbec 325mg $0(Tier 1) MC celecoxib caps 400mg $0(Tier 1) QL (30 per 30 days) celecoxib caps 100mg, 200mg, 50mg $0(Tier 1) QL (60 per 30 days) childrens ibuprofen susp 100mg/5ml $0(Tier 1) MC congestion relief $0(Tier 1) MC diclofenac potassium $0(Tier 1) apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 1

10 Name of drug What the drug diclofenac sodium dr $0(Tier 1) diclofenac sodium er $0(Tier 1) diflunisal tabs 500mg $0(Tier 1) enteric coated aspirin $0(Tier 1) MC etodolac er $0(Tier 1) etodolac caps, tabs $0(Tier 1) fenoprofen calcium caps 400mg $0(Tier 1) fenoprofen calcium tabs $0(Tier 1) flurbiprofen tabs $0(Tier 1) gnp ibuprofen junior strength $0(Tier 1) MC gnp ibuprofen tabs $0(Tier 1) MC goodsense ibuprofen childrens $0(Tier 1) MC goodsense ibuprofen infants $0(Tier 1) MC goodsense ibuprofen junior strength $0(Tier 1) MC goodsense ibuprofen tabs $0(Tier 1) MC goodsense naproxen sodium $0(Tier 1) MC ibu-200 $0(Tier 1) MC ibu-drops $0(Tier 1) MC ibu-drops infants $0(Tier 1) MC ibuprofen childrens $0(Tier 1) MC ibuprofen caps $0(Tier 1) MC ibuprofen susp 100mg/5ml $0(Tier 1) ibuprofen susp 100mg/5ml $0(Tier 1) MC ibuprofen tabs 400mg, 600mg, 800mg $0(Tier 1) ibuprofen tabs 200mg $0(Tier 1) MC ibu tabs 600mg, 800mg $0(Tier 1) infants ibuprofen $0(Tier 1) MC ketoprofen caps 50mg, 75mg $0(Tier 1) meclofenamate sodium caps $0(Tier 1) meloxicam tabs $0(Tier 1) QL (30 per 30 days) migraine formula $0(Tier 1) MC nabumetone tabs $0(Tier 1) naproxen dr $0(Tier 1) naproxen sodium tabs 275mg, 550mg $0(Tier 1) naproxen susp, tabs $0(Tier 1) oxaprozin $0(Tier 1) piroxicam caps $0(Tier 1) qc ibuprofen caps $0(Tier 1) MC qc naproxen sodium $0(Tier 1) MC salsalate tabs $0(Tier 1) sm ibuprofen tabs $0(Tier 1) MC sulindac tabs $0(Tier 1) tolmetin sodium $0(Tier 1) Opioid Analgesics, Long-acting buprenorphine hcl inj 0.3mg/ml $0(Tier 1) QL (150 per 30 days) apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 2

11 Name of drug What the drug DURAMORPH $0(Tier 2) QL (180 per 30 days) fentanyl $0(Tier 1) QL (10 per 30 days) infumorph 200 $0(Tier 1) QL (200 per 30 days) infumorph 500 $0(Tier 1) QL (200 per 30 days) levorphanol tartrate tabs $0(Tier 1) QL (120 per 30 days) methadone hcl intensol $0(Tier 1) QL (500 per 30 days) METHADONE HCL INJ $0(Tier 2) QL (150 per 30 days) methadone hcl conc $0(Tier 1) QL (500 per 30 days) methadone hcl oral soln 10mg/5ml $0(Tier 1) QL (450 per 30 days) methadone hcl oral soln 5mg/5ml $0(Tier 1) QL (600 per 30 days) methadone hcl tabs 10mg $0(Tier 1) QL (120 per 30 days) methadone hcl tabs 5mg $0(Tier 1) QL (180 per 30 days) morphine sulfate er tbcr $0(Tier 1) QL (90 per 30 days) morphine sulfate inj 0.5mg/ml, 1mg/ml $0(Tier 1) QL (180 per 30 days) XTAMPZA ER $0(Tier 2) QL (60 per 30 days) Opioid Analgesics, Short-acting acetaminophen/codeine phosphate tabs 300mg; 30mg $0(Tier 1) QL (360 per 30 days) acetaminophen/codeine soln $0(Tier 1) QL (2700 per 30 days) acetaminophen/codeine tabs 300mg; 60mg $0(Tier 1) QL (180 per 30 days) acetaminophen/codeine tabs 300mg; 15mg, 300mg; 30mg $0(Tier 1) QL (360 per 30 days) ascomp/codeine $0(Tier 1) QL (180 per 30 days) PA butalbital/acetaminophen/caffeine/codeine $0(Tier 1) QL (180 per 30 days) PA butalbital/aspirin/caffeine/codeine $0(Tier 1) QL (180 per 30 days) PA butorphanol tartrate nasal soln $0(Tier 1) QL (5 per 30 days) butorphanol tartrate inj 2mg/ml $0(Tier 1) QL (240 per 30 days) butorphanol tartrate inj 1mg/ml $0(Tier 1) QL (480 per 30 days) endocet tabs 325mg; 10mg $0(Tier 1) QL (180 per 30 days) endocet tabs 325mg; 7.5mg $0(Tier 1) QL (240 per 30 days) endocet tabs 325mg; 2.5mg, 325mg; 5mg $0(Tier 1) QL (360 per 30 days) fentanyl citrate oral transmucosal lpop 200mcg, 400mcg, $0(Tier 1) QL (120 per 30 days) PA 600mcg fentanyl citrate oral transmucosal lpop 1200mcg, 1600mcg, 800mcg $0(Tier 1) QL (120 per 30 days) PA fentanyl citrate inj 1000mcg/20ml, 100mcg/2ml, $0(Tier 1) B/D 2500mcg/50ml, 250mcg/5ml hydrocodone bitartrate/acetaminophen soln 325mg/15ml; $0(Tier 1) QL (2700 per 30 days) 7.5mg/15ml hydrocodone bitartrate/acetaminophen tabs 300mg; 10mg, $0(Tier 1) QL (180 per 30 days) 300mg; 7.5mg hydrocodone bitartrate/acetaminophen tabs 300mg; 5mg, $0(Tier 1) QL (360 per 30 days) 325mg; 2.5mg hydrocodone/acetaminophen tabs 325mg; 10mg, 325mg; $0(Tier 1) QL (180 per 30 days) 7.5mg hydrocodone/acetaminophen tabs 325mg; 5mg $0(Tier 1) QL (360 per 30 days) apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 3

12 Name of drug What the drug hydrocodone/ibuprofen $0(Tier 1) QL (150 per 30 days) hydromorphone hcl dosette $0(Tier 1) hydromorphone hcl liqd $0(Tier 1) QL (1200 per 30 days) hydromorphone hcl inj 10mg/ml, 1mg/ml, 2mg/ml, 4mg/ml, $0(Tier 1) 50mg/5ml hydromorphone hcl tabs 8mg $0(Tier 1) QL (120 per 30 days) hydromorphone hcl tabs 2mg, 4mg $0(Tier 1) QL (180 per 30 days) ibudone tabs 5mg; 200mg $0(Tier 1) QL (150 per 30 days) lorcet $0(Tier 1) QL (360 per 30 days) lorcet hd $0(Tier 1) QL (180 per 30 days) lorcet plus tabs 325mg; 7.5mg $0(Tier 1) QL (180 per 30 days) lortab tabs 325mg; 10mg, 325mg; 7.5mg $0(Tier 1) QL (180 per 30 days) lortab tabs 325mg; 5mg $0(Tier 1) QL (360 per 30 days) morphine sulfate inj 150mg/30ml, 15mg/ml, 25mg/ml, $0(Tier 1) 50mg/ml, 5mg/ml morphine sulfate inj 2mg/ml $0(Tier 1) QL (1260 per 30 days) morphine sulfate inj 1mg/ml $0(Tier 1) QL (180 per 30 days) morphine sulfate inj 10mg/ml $0(Tier 1) QL (200 per 30 days) morphine sulfate inj 8mg/ml $0(Tier 1) QL (250 per 30 days) morphine sulfate inj 4mg/ml $0(Tier 1) QL (630 per 30 days) morphine sulfate oral soln 100mg/5ml $0(Tier 1) QL (180 per 30 days) morphine sulfate oral soln 20mg/5ml $0(Tier 1) QL (300 per 30 days) morphine sulfate oral soln 10mg/5ml $0(Tier 1) QL (700 per 30 days) MORPHINE SULFATE TABS 15MG, 30MG $0(Tier 2) QL (120 per 30 days) nalbuphine hcl inj 10mg/ml $0(Tier 1) QL (180 per 30 days) nalbuphine hcl inj 20mg/ml $0(Tier 1) QL (90 per 30 days) oxycodone hcl caps, conc $0(Tier 1) QL (120 per 30 days) oxycodone hcl soln $0(Tier 1) QL (1200 per 30 days) oxycodone hcl tabs 10mg, 15mg, 20mg, 5mg $0(Tier 1) QL (120 per 30 days) oxycodone hcl tabs 30mg $0(Tier 1) QL (90 per 30 days) oxycodone/acetaminophen tabs 325mg; 10mg $0(Tier 1) QL (180 per 30 days) oxycodone/acetaminophen tabs 325mg; 7.5mg $0(Tier 1) QL (240 per 30 days) oxycodone/acetaminophen tabs 325mg; 2.5mg, 325mg; 5mg $0(Tier 1) QL (360 per 30 days) oxycodone/aspirin tabs 325mg; 4.835mg $0(Tier 1) QL (180 per 30 days) oxycodone/ibuprofen $0(Tier 1) QL (28 per 30 days) reprexain tabs 10mg; 200mg $0(Tier 1) QL (150 per 30 days) TALWIN $0(Tier 2) tramadol hcl tabs $0(Tier 1) QL (240 per 30 days) tramadol hydrochloride/acetaminophen $0(Tier 1) QL (240 per 30 days) vicodin es tabs 300mg; 7.5mg $0(Tier 1) QL (180 per 30 days) vicodin hp tabs 300mg; 10mg $0(Tier 1) QL (180 per 30 days) vicodin tabs 300mg; 5mg $0(Tier 1) QL (360 per 30 days) xylon $0(Tier 1) QL (150 per 30 days) apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 4

13 What the drug Name of drug Anesthetics (Drugs that Decrease Feeling and Awareness) Local Anesthetics glydo $0(Tier 1) lidocaine hcl jelly $0(Tier 1) lidocaine hcl viscous $0(Tier 1) lidocaine hcl gel 2% $0(Tier 1) lidocaine hcl inj 0.5%, 1%, 1.5%, 2%, 4% $0(Tier 1) lidocaine hcl external soln 4% $0(Tier 1) lidocaine hcl mouth/throat soln 4% $0(Tier 1) lidocaine viscous $0(Tier 1) lidocaine/prilocaine crea $0(Tier 1) lidocaine oint 5% $0(Tier 1) QL (120 per 30 days) lidocaine ptch 5% $0(Tier 1) QL (90 per 30 days) PA Anti-Addiction/Substance Ab Treatment Agents (Drugs that Treat Addiction Problems) Alcohol Deterrents/Anti-craving acamprosate calcium dr $0(Tier 1) disulfiram tabs $0(Tier 1) Opioid Dependence Treatments buprenorphine hcl/naloxone hcl $0(Tier 1) QL (90 per 30 days) PA buprenorphine hcl inj 0.3mg/ml $0(Tier 1) QL (150 per 30 days) buprenorphine hcl subl 2mg, 8mg $0(Tier 1) QL (90 per 30 days) PA naltrexone hcl tabs $0(Tier 1) SUBOXONE FILM $0(Tier 2) QL (90 per 30 days) PA ZUBSOLV SUBL 0.7MG; 0.18MG $0(Tier 2) QL (30 per 30 days) PA ZUBSOLV SUBL 1.4MG; 0.36MG, 11.4MG; 2.9MG, $0(Tier 2) QL (90 per 30 days) PA 2.9MG; 0.71MG, 5.7MG; 1.4MG, 8.6MG; 2.1MG Opioid Reversal Agents naloxone hcl inj 0.4mg/ml, 2mg/2ml, 4mg/10ml $0(Tier 1) NARCAN LIQD $0(Tier 2) QL (4 per 30 days) Smoking Cessation Agents buproban $0(Tier 1) QL (60 per 30 days) bupropion hcl sr tb12 150mg $0(Tier 1) QL (60 per 30 days) CHANTIX CONTINUING MONTH PAK $0(Tier 2) QL (336 per 365 days) CHANTIX STARTING MONTH PAK $0(Tier 2) QL (336 per 365 days) CHANTIX TABS 0.5MG, 1MG $0(Tier 2) QL (336 per 365 days) NICODERM CQ $0(Tier 1) MC nicorelief gum $0(Tier 1) MC NICORETTE $0(Tier 1) MC NICORETTE MINI $0(Tier 1) MC NICORETTE STARTER KIT $0(Tier 1) MC nicotine polacrilex gum, lozg $0(Tier 1) MC nicotine transdermal system step 1 $0(Tier 1) MC nicotine transdermal system step 2 $0(Tier 1) MC nicotine transdermal system step 3 $0(Tier 1) MC nicotine transdermal system kit $0(Tier 1) MC apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 5

14 What the drug $0(Tier 1) MC Name of drug nicotine transdermal system pt24 14mg/24hr, 21mg/24hr, 7mg/24hr NICOTROL INHALER $0(Tier 2) QL (1008 per 90 days) NICOTROL NS $0(Tier 2) QL (30 per 30 days) Antibacterials (Drugs that Treat Infection from Bacteria) Aminoglycosides amikacin sulfate inj 1gm/4ml, 500mg/2ml $0(Tier 1) gentak oint $0(Tier 1) gentamicin sulfate pediatric $0(Tier 1) gentamicin sulfate/0.9% sodium chloride inj 0.8mg/ml; 0.9%, 0.9mg/ml; 0.9%, 1.2mg/ml; 0.9%, 1.4mg/ml; 0.9%, 1.6mg/ml; 0.9%, 1mg/ml; 0.9%, 2mg/ml; 0.9% $0(Tier 1) gentamicin sulfate crea, external oint, ophthalmic oint, $0(Tier 1) ophthalmic soln gentamicin sulfate inj 10mg/ml, 40mg/ml $0(Tier 1) isotonic gentamicin inj 0.8mg/ml; 0.9% $0(Tier 1) neomycin sulfate $0(Tier 1) neomycin/polymyxin b sulfates $0(Tier 1) paromomycin sulfate $0(Tier 1) streptomycin sulfate inj 1gm $0(Tier 1) tobramycin sulfate ophthalmic soln $0(Tier 1) tobramycin sulfate inj 1.2gm, 10mg/ml, 80mg/2ml $0(Tier 1) tobramycin soln 0.3% $0(Tier 1) TOBREX OINT $0(Tier 2) ZYLET $0(Tier 2) Antibacterials, Other ak-poly-bac $0(Tier 1) alcohol prep pads $0(Tier 1) baciim $0(Tier 1) bacitracin zinc oint $0(Tier 1) MC bacitracin/neomycin/polymyxin oint $0(Tier 1) MC bacitracin/polymyxin b $0(Tier 1) bacitracin inj, ophthalmic oint $0(Tier 1) bacitracin external oint $0(Tier 1) MC BACTROBAN NASAL $0(Tier 2) chloramphenicol sodium succinate $0(Tier 1) clindacin etz pledgets $0(Tier 1) clindacin-p $0(Tier 1) clindamax gel $0(Tier 1) clindamycin $0(Tier 1) clindamycin hcl caps $0(Tier 1) clindamycin phosphate add-vantage inj 900mg/6ml $0(Tier 1) clindamycin phosphate in d5w $0(Tier 1) clindamycin phosphate crea, gel, lotn, external soln, swab $0(Tier 1) apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 6

15 Name of drug What the drug clindamycin phosphate inj 150mg/ml, 300mg/2ml, 600mg/4ml, $0(Tier 1) 900mg/6ml clindamycin/sodium chloride $0(Tier 1) colistimethate sodium $0(Tier 1) daptomycin inj 500mg $0(Tier 1) B/D lincomycin hcl inj $0(Tier 1) linezolid inj $0(Tier 1) linezolid susr $0(Tier 1) QL (1800 per 30 days) linezolid tabs $0(Tier 1) QL (60 per 30 days) methenamine hippurate $0(Tier 1) metronidazole in nacl 0.79% $0(Tier 1) metronidazole vaginal $0(Tier 1) metronidazole crea, gel, inj, lotn, tabs $0(Tier 1) mupirocin calcium $0(Tier 1) mupirocin crea, oint $0(Tier 1) neo-polycin $0(Tier 1) neo-polycin hc $0(Tier 1) neomycin/bacitracin/polymyxin $0(Tier 1) neomycin/polymyxin/bacitracin zinc $0(Tier 1) neomycin/polymyxin/bacitracin/hydrocortisone $0(Tier 1) neomycin/polymyxin/gramicidin $0(Tier 1) neomycin/polymyxin/hydrocortisone ophthalmic susp 1%; $0(Tier 1) 3.5mg/ml; 10000unit/ml nitrofurantoin macrocrystals $0(Tier 1) nitrofurantoin monohydrate $0(Tier 1) nitrofurantoin monohydrate/macrocrystals $0(Tier 1) nitrofurantoin susp $0(Tier 1) polycin $0(Tier 1) polymyxin b sulfate/trimethoprim sulfate $0(Tier 1) polymyxin b sulfate inj $0(Tier 1) povidone-iodine oint, soln $0(Tier 1) MC PRIMSOL $0(Tier 2) rosadan $0(Tier 1) silver sulfadiazine crea $0(Tier 1) SSD $0(Tier 2) SYNERCID INJ 350MG; 150MG $0(Tier 2) tigecycline $0(Tier 1) trimethoprim sulfate/polymyxin b sulfate $0(Tier 1) trimethoprim tabs $0(Tier 1) triple antibiotic plus oint 500unit/gm; 5mg/gm; 10000unit/gm; $0(Tier 1) MC 10mg/gm triple antibiotic oint 400unit/gm; 3.5mg/gm; 5000unit/gm, $0(Tier 1) MC 400unit/gm; 5mg/gm; 5000unit/gm TYGACIL $0(Tier 2) apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 7

16 Name of drug What the drug vancomycin $0(Tier 1) vancomycin hcl in dextrose $0(Tier 1) vancomycin hcl caps 125mg $0(Tier 1) QL (40 per 10 days) vancomycin hcl caps 250mg $0(Tier 1) QL (80 per 10 days) vancomycin hcl inj 0.9%; 1gm/200ml, 1000mg, 10gm, $0(Tier 1) 5000mg, 500mg, 750mg vancomycin hydrochloride/sodium chloride inj 0.9%; $0(Tier 1) 750mg/150ml vandazole $0(Tier 1) XIFAXAN TABS 200MG $0(Tier 2) QL (9 per 30 days) PA XIFAXAN TABS 550MG $0(Tier 2) QL (90 per 30 days) PA Beta-lactam, Cephalosporins cefaclor er tb12 500mg $0(Tier 1) cefaclor caps $0(Tier 1) cefaclor susr 125mg/5ml, 250mg/5ml, 375mg/5ml $0(Tier 1) cefadroxil $0(Tier 1) CEFAZOLIN SODIUM/DEXTROSE INJ 2GM; 3% $0(Tier 2) cefazolin sodium inj 10gm, 1gm/50ml; 4%, 1gm, 500mg $0(Tier 1) CEFAZOLIN INJ 2GM/100ML; 4% $0(Tier 2) cefdinir $0(Tier 1) cefepime $0(Tier 1) cefepime/dextrose $0(Tier 1) cefixime $0(Tier 1) cefotaxime sodium inj 1gm, 2gm, 500mg $0(Tier 1) cefoxitin sodium inj 10gm, 1gm, 2gm $0(Tier 1) cefpodoxime proxetil $0(Tier 1) cefprozil $0(Tier 1) CEFTAZIDIME/DEXTROSE $0(Tier 2) ceftazidime inj 1gm, 2gm, 6gm $0(Tier 1) ceftriaxone in iso-osmotic dextrose $0(Tier 1) ceftriaxone sodium inj 10gm, 1gm, 250mg, 2gm, 500mg $0(Tier 1) cefuroxime axetil tabs $0(Tier 1) cefuroxime sodium inj 1.5gm, 7.5gm, 750mg, 75gm $0(Tier 1) cephalexin caps 250mg, 500mg $0(Tier 1) cephalexin susr, tabs $0(Tier 1) SUPRAX SUSR 500MG/5ML $0(Tier 2) tazicef inj 1gm, 2gm, 6gm $0(Tier 1) TEFLARO $0(Tier 2) Beta-lactam, Other AZACTAM IN ISO-OSMOTIC DEXTROSE INJ 1GM/50ML; 0, 2GM/50ML; 0 $0(Tier 2) AZACTAM INJ 1GM, 2GM $0(Tier 2) aztreonam inj 1gm $0(Tier 1) aztreonam inj 2gm $0(Tier 1) apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 8

17 What the drug Name of drug cefotetan $0(Tier 1) imipenem/cilastatin $0(Tier 1) INVANZ $0(Tier 2) meropenem $0(Tier 1) meropenem/sodium chloride $0(Tier 1) Beta-lactam, Penicillins amoxicillin/clavulanate potassium $0(Tier 1) amoxicillin/clavulanate potassium er $0(Tier 1) amoxicillin chew 125mg, 250mg $0(Tier 1) amoxicillin caps, susr, tabs $0(Tier 1) ampicillin $0(Tier 1) ampicillin sodium inj $0(Tier 1) ampicillin-sulbactam $0(Tier 1) AUGMENTIN SUSR 125MG/5ML; 31.25MG/5ML $0(Tier 2) BICILLIN L-A INJ UNIT/2ML, $0(Tier 2) UNIT/4ML, UNIT/ML dicloxacillin sodium $0(Tier 1) nafcillin sodium inj 10gm, 1gm, 2gm $0(Tier 1) nafcillin sodium inj 2gm $0(Tier 1) oxacillin sodium inj 10gm, 1gm, 2gm $0(Tier 1) penicillin g potassium inj unit, unit $0(Tier 1) penicillin v potassium $0(Tier 1) PFIZERPEN INJ 20MU, UNIT $0(Tier 2) piperacillin sodium/ tazobactam sodium $0(Tier 1) piperacillin sodium/tazobactam sodium $0(Tier 1) piperacillin/tazobactam $0(Tier 1) ZOSYN INJ 5%; 2GM/50ML; 0.25GM/50ML, 5%; 3GM/50ML; 0.375GM/50ML, 5%; 4GM/100ML; 0.5GM/100ML $0(Tier 2) Macrolides AZASITE $0(Tier 2) azithromycin pack $0(Tier 1) azithromycin inj 500mg $0(Tier 1) azithromycin susr 100mg/5ml $0(Tier 1) QL (150 per 30 days) azithromycin susr 200mg/5ml $0(Tier 1) QL (75 per 30 days) azithromycin tabs 250mg, 500mg $0(Tier 1) QL (12 per 28 days) azithromycin tabs 600mg $0(Tier 1) QL (60 per 30 days) clarithromycin er $0(Tier 1) QL (60 per 30 days) clarithromycin susr $0(Tier 1) clarithromycin tabs $0(Tier 1) QL (42 per 14 days) e.e.s. 400 tabs $0(Tier 1) ery $0(Tier 1) ERY-TAB $0(Tier 2) ERYPED 400 $0(Tier 2) ERYTHROCIN LACTOBIONATE INJ 500MG $0(Tier 2) apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 9

18 Name of drug What the drug erythrocin stearate tabs 250mg $0(Tier 1) erythromycin base $0(Tier 1) erythromycin ethylsuccinate susr, tabs $0(Tier 1) erythromycin gel, oint, pads $0(Tier 1) erythromycin soln 2% $0(Tier 1) ilotycin oint $0(Tier 1) KETEK $0(Tier 2) QL (20 per 30 days) ZMAX $0(Tier 2) QL (60 per 30 days) Quinolones AVELOX INJ $0(Tier 2) BAXDELA $0(Tier 2) BESIVANCE $0(Tier 2) CILOXAN OINT $0(Tier 2) CIPRO HC $0(Tier 2) CIPRODEX $0(Tier 2) ciprofloxacin er tb mg; 0 $0(Tier 1) QL (14 per 14 days) ciprofloxacin er tb24 500mg; 0 $0(Tier 1) QL (3 per 3 days) ciprofloxacin hcl soln, tabs $0(Tier 1) ciprofloxacin i.v.-in d5w $0(Tier 1) ciprofloxacin inj, susr $0(Tier 1) levofloxacin in d5w $0(Tier 1) levofloxacin inj, oral soln $0(Tier 1) levofloxacin tabs $0(Tier 1) QL (30 per 30 days) moxifloxacin hydrochloride/sodium hydrochloride $0(Tier 1) moxifloxacin hcl inj $0(Tier 1) moxifloxacin hcl tabs $0(Tier 1) QL (30 per 30 days) moxifloxacin hydrochloride soln $0(Tier 1) ofloxacin ophthalmic soln, otic soln $0(Tier 1) ofloxacin tabs 300mg, 400mg $0(Tier 1) VIGAMOX $0(Tier 2) Sulfonamides BLEPHAMIDE $0(Tier 2) BLEPHAMIDE S.O.P. $0(Tier 2) sodium sulfacetamide soln $0(Tier 1) sulfacetamide sodium/prednisolone sodium phosphate $0(Tier 1) sulfacetamide sodium lotn, soln $0(Tier 1) sulfadiazine tabs $0(Tier 1) sulfamethoxazole/trimethoprim $0(Tier 1) sulfamethoxazole/trimethoprim ds $0(Tier 1) sulfatrim pediatric $0(Tier 1) Tetracyclines demeclocycline hcl tabs $0(Tier 1) doxy 100 $0(Tier 1) doxycycline hyclate caps, inj $0(Tier 1) doxycycline hyclate tabs 100mg, 20mg $0(Tier 1) apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 10

19 What the drug Name of drug doxycycline monohydrate caps 100mg, 50mg, 75mg $0(Tier 1) QL (60 per 30 days) doxycycline monohydrate tabs $0(Tier 1) doxycycline susr $0(Tier 1) minocycline hcl caps, tabs $0(Tier 1) mondoxyne nl $0(Tier 1) QL (60 per 30 days) morgidox 1x100mg caps $0(Tier 1) morgidox 1x50mg $0(Tier 1) morgidox 2x100mg caps $0(Tier 1) tetracycline hydrochloride $0(Tier 1) Anticonvulsants (Drugs that Control Seizures) Anticonvulsants, Other APTIOM TABS 200MG, 400MG, 800MG $0(Tier 2) QL (30 per 30 days) APTIOM TABS 600MG $0(Tier 2) QL (60 per 30 days) BRIVIACT ORAL SOLN $0(Tier 2) QL (1200 per 30 days) BRIVIACT INJ $0(Tier 2) QL (600 per 30 days) BRIVIACT TABS 100MG $0(Tier 2) QL (120 per 30 days) BRIVIACT TABS 10MG, 25MG, 50MG, 75MG $0(Tier 2) QL (60 per 30 days) FYCOMPA TABS $0(Tier 2) QL (30 per 30 days) FYCOMPA SUSP $0(Tier 2) QL (720 per 30 days) levetiracetam er tb24 750mg $0(Tier 1) QL (120 per 30 days) levetiracetam er tb24 500mg $0(Tier 1) QL (180 per 30 days) levetiracetam inj, oral soln, tabs $0(Tier 1) magnesium sulfate in d5w $0(Tier 1) B/D POTIGA $0(Tier 2) QL (90 per 30 days) PA roweepra $0(Tier 1) roweepra xr tb24 750mg $0(Tier 1) QL (120 per 30 days) roweepra xr tb24 500mg $0(Tier 1) QL (180 per 30 days) SPRITAM TB3D 750MG $0(Tier 2) QL (120 per 30 days) SPRITAM TB3D 1000MG, 250MG, 500MG $0(Tier 2) QL (60 per 30 days) Calcium Channel Modifying Agents CELONTIN CAPS 300MG $0(Tier 2) ethosuximide $0(Tier 1) LYRICA SOLN $0(Tier 2) QL (900 per 30 days) LYRICA CAPS 225MG, 300MG $0(Tier 2) QL (60 per 30 days) LYRICA CAPS 100MG, 150MG, 200MG, 25MG, 50MG, $0(Tier 2) QL (90 per 30 days) 75MG zonisamide $0(Tier 1) Gamma-aminobutyric Acid (GABA) Augmenting Agents clonazepam odt tbdp 1mg $0(Tier 1) QL (120 per 30 days) clonazepam odt tbdp 2mg $0(Tier 1) QL (300 per 30 days) clonazepam odt tbdp 0.125mg, 0.25mg, 0.5mg $0(Tier 1) QL (90 per 30 days) apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 11

20 Name of drug What the drug clonazepam tabs 1mg $0(Tier 1) QL (120 per 30 days) clonazepam tabs 2mg $0(Tier 1) QL (300 per 30 days) clonazepam tabs 0.5mg $0(Tier 1) QL (90 per 30 days) DIASTAT ACUDIAL GEL 10MG $0(Tier 2) QL (20 per 30 days) DIASTAT ACUDIAL GEL 20MG $0(Tier 2) QL (40 per 30 days) DIASTAT PEDIATRIC GEL 2.5MG $0(Tier 2) QL (5 per 30 days) diazepam rectal gel gel 10mg $0(Tier 1) QL (20 per 30 days) diazepam rectal gel gel 20mg $0(Tier 1) QL (40 per 30 days) diazepam rectal gel gel 2.5mg $0(Tier 1) QL (5 per 30 days) DIAZEPAM GEL 20MG $0(Tier 2) QL (40 per 30 days) diazepam gel 10mg $0(Tier 1) QL (20 per 30 days) diazepam gel 2.5mg $0(Tier 1) QL (5 per 30 days) divalproex sodium dr $0(Tier 1) divalproex sodium er $0(Tier 1) divalproex sodium csdr $0(Tier 1) gabapentin caps 100mg $0(Tier 1) QL (180 per 30 days) gabapentin caps 300mg, 400mg $0(Tier 1) QL (270 per 30 days) gabapentin soln $0(Tier 1) QL (2160 per 30 days) gabapentin tabs 800mg $0(Tier 1) gabapentin tabs 600mg $0(Tier 1) QL (180 per 30 days) GABITRIL TABS 12MG $0(Tier 2) QL (120 per 30 days) GABITRIL TABS 16MG $0(Tier 2) QL (90 per 30 days) ONFI SUSP $0(Tier 2) QL (480 per 30 days) ONFI TABS 10MG $0(Tier 2) QL (60 per 30 days) ONFI TABS 20MG $0(Tier 2) QL (60 per 30 days) phenobarbital elix $0(Tier 1) QL (1500 per 30 days) phenobarbital tabs 100mg, 15mg, 16.2mg, 30mg, 32.4mg, $0(Tier 1) QL (120 per 30 days) 60mg, 64.8mg, 97.2mg primidone tabs $0(Tier 1) SABRIL TABS $0(Tier 2) QL (180 per 30 days) PA SABRIL PACK $0(Tier 2) QL (200 per 30 days) PA tiagabine hydrochloride tabs 4mg $0(Tier 1) tiagabine hydrochloride tabs 12mg $0(Tier 1) QL (120 per 30 days) tiagabine hydrochloride tabs 2mg $0(Tier 1) QL (240 per 30 days) tiagabine hydrochloride tabs 16mg $0(Tier 1) QL (90 per 30 days) valproate sodium inj $0(Tier 1) valproic acid caps, soln $0(Tier 1) vigabatrin $0(Tier 1) QL (200 per 30 days) PA Glutamate Reducing Agents felbamate tabs $0(Tier 1) felbamate susp $0(Tier 1) apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 12

21 What the drug Name of drug lamotrigine er $0(Tier 1) lamotrigine odt $0(Tier 1) lamotrigine chew, tabs $0(Tier 1) topiramate cpsp, tabs $0(Tier 1) TROKENDI XR CP24 100MG, 25MG, 50MG $0(Tier 2) QL (30 per 30 days) TROKENDI XR CP24 200MG $0(Tier 2) QL (60 per 30 days) Sodium Channel Agents BANZEL SUSP $0(Tier 2) QL (2400 per 30 days) PA BANZEL TABS 400MG $0(Tier 2) QL (240 per 30 days) PA BANZEL TABS 200MG $0(Tier 2) QL (60 per 30 days) PA carbamazepine er $0(Tier 1) carbamazepine chew, susp, tabs $0(Tier 1) DILANTIN CAPS 30MG $0(Tier 2) epitol $0(Tier 1) fosphenytoin sodium $0(Tier 1) oxcarbazepine $0(Tier 1) PEGANONE TABS 250MG $0(Tier 2) phenytoin infatabs $0(Tier 1) phenytoin sodium extended $0(Tier 1) phenytoin sodium inj $0(Tier 1) phenytoin chew, susp $0(Tier 1) VIMPAT INJ, ORAL SOLN $0(Tier 2) QL (1200 per 30 days) VIMPAT TABS $0(Tier 2) QL (60 per 30 days) Antidementia Agents (Drugs that Help with Memory Loss) Antidementia Agents, Other ergoloid mesylates tabs $0(Tier 1) PA NAMZARIC CP24 $0(Tier 2) QL (30 per 30 days) NAMZARIC C4PK $0(Tier 2) QL (56 per 365 days) Cholinesterase Inhibitors donepezil hcl tabs 23mg, 5mg $0(Tier 1) QL (30 per 30 days) donepezil hcl tabs 10mg $0(Tier 1) QL (60 per 30 days) donepezil hcl tbdp 5mg $0(Tier 1) QL (30 per 30 days) donepezil hcl tbdp 10mg $0(Tier 1) QL (60 per 30 days) donepezil hydrochloride tabs 5mg $0(Tier 1) QL (30 per 30 days) donepezil hydrochloride tabs 10mg $0(Tier 1) QL (60 per 30 days) galantamine hydrobromide er $0(Tier 1) QL (30 per 30 days) galantamine hydrobromide soln $0(Tier 1) QL (200 per 30 days) galantamine hydrobromide tabs $0(Tier 1) QL (60 per 30 days) rivastigmine tartrate $0(Tier 1) QL (60 per 30 days) rivastigmine transdermal system $0(Tier 1) QL (30 per 30 days) N-methyl-D-aspartate (NMDA) Receptor Antagonist memantine hcl titration pak $0(Tier 1) QL (49 per 28 days) PA apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 13

22 What the drug Name of drug memantine hcl tabs 10mg $0(Tier 1) QL (60 per 30 days) PA memantine hcl tabs 5mg $0(Tier 1) QL (90 per 30 days) PA memantine hydrochloride er $0(Tier 1) QL (30 per 30 days) PA memantine hydrochloride soln $0(Tier 1) QL (300 per 30 days) PA NAMENDA XR $0(Tier 2) QL (30 per 30 days) PA NAMENDA XR TITRATION PACK $0(Tier 2) QL (56 per 365 days) PA Antidepressants (Drugs that Help with a Depressed Mood) Antidepressants, Other bupropion hcl er $0(Tier 1) QL (60 per 30 days) bupropion hcl sr tb12 100mg, 150mg, 200mg $0(Tier 1) QL (60 per 30 days) bupropion hcl xl $0(Tier 1) QL (30 per 30 days) bupropion hcl tabs 100mg $0(Tier 1) QL (120 per 30 days) bupropion hcl tabs 75mg $0(Tier 1) QL (180 per 30 days) maprotiline hcl $0(Tier 1) QL (90 per 30 days) mirtazapine odt $0(Tier 1) QL (30 per 30 days) mirtazapine tabs $0(Tier 1) QL (30 per 30 days) nefazodone hcl $0(Tier 1) QL (60 per 30 days) trazodone hcl $0(Tier 1) TRINTELLIX $0(Tier 2) QL (30 per 30 days) ST Monoamine Oxidase Inhibitors EMSAM $0(Tier 2) QL (30 per 30 days) MARPLAN $0(Tier 2) QL (180 per 30 days) phenelzine sulfate $0(Tier 1) tranylcypromine sulfate $0(Tier 1) SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitor citalopram hydrobromide soln $0(Tier 1) QL (600 per 30 days) citalopram hydrobromide tabs 10mg $0(Tier 1) citalopram hydrobromide tabs 40mg $0(Tier 1) QL (30 per 30 days) citalopram hydrobromide tabs 20mg $0(Tier 1) QL (60 per 30 days) desvenlafaxine er $0(Tier 1) QL (30 per 30 days) duloxetine hcl cpep 20mg, 60mg $0(Tier 1) QL (60 per 30 days) duloxetine hcl cpep 30mg $0(Tier 1) QL (90 per 30 days) escitalopram oxalate soln $0(Tier 1) QL (600 per 30 days) escitalopram oxalate tabs 5mg $0(Tier 1) QL (30 per 30 days) escitalopram oxalate tabs 10mg $0(Tier 1) QL (60 per 30 days) escitalopram oxalate tabs 20mg $0(Tier 1) QL (90 per 30 days) FETZIMA $0(Tier 2) QL (30 per 30 days) ST FETZIMA TITRATION PACK $0(Tier 2) QL (56 per 365 days) ST fluoxetine dr $0(Tier 1) QL (4 per 28 days) fluoxetine hcl caps 20mg $0(Tier 1) QL (120 per 30 days) fluoxetine hcl caps 10mg $0(Tier 1) QL (30 per 30 days) fluoxetine hcl caps 40mg $0(Tier 1) QL (60 per 30 days) fluoxetine hcl soln $0(Tier 1) QL (600 per 30 days) fluoxetine hcl tabs 20mg $0(Tier 1) QL (120 per 30 days) apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 14

23 What the drug Name of drug fluoxetine hcl tabs 10mg $0(Tier 1) QL (30 per 30 days) fluoxetine caps 20mg $0(Tier 1) QL (120 per 30 days) fluoxetine caps 10mg $0(Tier 1) QL (30 per 30 days) fluvoxamine maleate er $0(Tier 1) QL (60 per 30 days) fluvoxamine maleate tabs 25mg, 50mg $0(Tier 1) QL (30 per 30 days) fluvoxamine maleate tabs 100mg $0(Tier 1) QL (90 per 30 days) olanzapine/fluoxetine $0(Tier 1) QL (30 per 30 days) paroxetine hcl er tb mg $0(Tier 1) QL (30 per 30 days) paroxetine hcl er tb24 25mg, 37.5mg $0(Tier 1) QL (60 per 30 days) paroxetine hcl tabs 10mg $0(Tier 1) QL (30 per 30 days) paroxetine hcl tabs 30mg, 40mg $0(Tier 1) QL (60 per 30 days) paroxetine hcl tabs 20mg $0(Tier 1) QL (90 per 30 days) PAXIL SUSP $0(Tier 2) QL (900 per 30 days) ST PRISTIQ $0(Tier 2) QL (30 per 30 days) sertraline hcl conc $0(Tier 1) QL (300 per 30 days) sertraline hcl tabs 50mg $0(Tier 1) QL (120 per 30 days) sertraline hcl tabs 25mg $0(Tier 1) QL (30 per 30 days) sertraline hcl tabs 100mg $0(Tier 1) QL (60 per 30 days) venlafaxine hcl $0(Tier 1) QL (90 per 30 days) venlafaxine hcl er cp mg $0(Tier 1) QL (30 per 30 days) venlafaxine hcl er cp24 150mg $0(Tier 1) QL (60 per 30 days) venlafaxine hcl er cp24 75mg $0(Tier 1) QL (90 per 30 days) VIIBRYD $0(Tier 2) QL (30 per 30 days) ST VIIBRYD STARTER PACK $0(Tier 2) QL (30 per 30 days) ST Tricyclics amitriptyline hcl tabs $0(Tier 1) PA amoxapine $0(Tier 1) clomipramine hcl caps $0(Tier 1) PA desipramine hcl tabs $0(Tier 1) imipramine hcl tabs $0(Tier 1) PA nortriptyline hcl caps, soln $0(Tier 1) perphenazine/amitriptyline $0(Tier 1) PA protriptyline hcl $0(Tier 1) trimipramine maleate caps $0(Tier 1) PA Antiemetics (Drugs that Prevent or Treat Naa and Vomiting) Antiemetics, Other dimenhydrinate tabs $0(Tier 1) MC formula em $0(Tier 1) MC meclizine hcl tabs 12.5mg, 25mg $0(Tier 1) meclizine hcl tabs 12.5mg $0(Tier 1) MC phenadoz $0(Tier 1) phenergan supp $0(Tier 1) promethazine hcl plain $0(Tier 1) PA promethazine hcl supp $0(Tier 1) promethazine hcl syrp, tabs $0(Tier 1) PA apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 15

24 What the drug Name of drug promethegan $0(Tier 1) scopolamine $0(Tier 1) QL (10 per 30 days) TRANSDERM-SCOP $0(Tier 2) QL (10 per 30 days) travel sickness $0(Tier 1) MC Emetogenic Therapy Adjuncts ALOXI INJ 0.25MG/5ML $0(Tier 2) B/D aprepitant caps 40mg $0(Tier 1) QL (1 per 30 days) B/D aprepitant caps 125mg $0(Tier 1) QL (2 per 28 days) B/D aprepitant caps 80mg $0(Tier 1) QL (4 per 28 days) B/D aprepitant caps 0 $0(Tier 1) QL (6 per 28 days) B/D dronabinol $0(Tier 1) QL (60 per 30 days) PA EMEND SUSR $0(Tier 2) QL (6 per 28 days) B/D granisetron hcl inj $0(Tier 1) B/D granisetron hcl tabs $0(Tier 1) QL (30 per 30 days) B/D ondansetron hcl oral soln $0(Tier 1) QL (450 per 30 days) B/D ondansetron hcl inj 40mg/20ml, 4mg/2ml $0(Tier 1) ondansetron hcl tabs 24mg $0(Tier 1) QL (15 per 30 days) B/D ondansetron hcl tabs 4mg, 8mg $0(Tier 1) QL (90 per 30 days) B/D ondansetron odt $0(Tier 1) QL (90 per 30 days) B/D palonosetron hydrochloride $0(Tier 1) B/D SANCUSO $0(Tier 2) QL (4 per 28 days) Antifungals (Drugs that treat Infections with Fungus) Antifungals ABELCET $0(Tier 2) PA AMBISOME $0(Tier 2) PA amphotericin b inj $0(Tier 1) PA anti-fungal powder $0(Tier 1) MC antifungal aero, crea $0(Tier 1) MC CANCIDAS $0(Tier 2) PA caspofungin acetate $0(Tier 1) PA ciclodan $0(Tier 1) ciclopirox nail lacquer $0(Tier 1) ciclopirox olamine crea $0(Tier 1) ciclopirox sham, susp $0(Tier 1) clotrimazole anti-fungal $0(Tier 1) MC clotrimazole/betamethasone dipropionate $0(Tier 1) clotrimazole external crea 1% $0(Tier 1) clotrimazole external crea 1% $0(Tier 1) MC clotrimazole vaginal crea 1% $0(Tier 1) MC clotrimazole lozg $0(Tier 1) clotrimazole soln 1% $0(Tier 1) clotrimazole soln 1% $0(Tier 1) MC econazole nitrate crea $0(Tier 1) fluconazole in dextrose inj 56mg/ml; 200mg/100ml, 56mg/ml; 400mg/200ml $0(Tier 1) apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 16

25 What the drug Name of drug fluconazole in nacl $0(Tier 1) fluconazole susr, tabs $0(Tier 1) flucytosine caps $0(Tier 1) FUNGOID TINCTURE SOLN $0(Tier 1) MC griseofulvin microsize $0(Tier 1) griseofulvin ultramicrosize tabs 125mg, 250mg $0(Tier 1) itraconazole caps $0(Tier 1) QL (120 per 30 days) PA ketoconazole crea, sham, tabs $0(Tier 1) miconazole 7 supp $0(Tier 1) MC miconazole nitrate external crea, vaginal crea, supp $0(Tier 1) MC miconazole crea $0(Tier 1) MC naftifine hcl $0(Tier 1) naftifine hydrochloride $0(Tier 1) NAFTIN GEL $0(Tier 2) NATACYN $0(Tier 2) NOXAFIL SUSP $0(Tier 2) QL (600 per 30 days) PA NOXAFIL TBEC $0(Tier 2) QL (96 per 30 days) PA nyamyc $0(Tier 1) nystatin/triamcinolone $0(Tier 1) nystatin crea, oint, powd, susp, tabs $0(Tier 1) nystop $0(Tier 1) qc tolnaftate $0(Tier 1) MC sm miconazole 7 crea $0(Tier 1) MC SPORANOX SOLN $0(Tier 2) PA terbinafine hcl crea $0(Tier 1) MC terbinafine hcl tabs $0(Tier 1) QL (90 per 365 days) terconazole $0(Tier 1) tioconazole-1 $0(Tier 1) MC tolnaftate crea, powd $0(Tier 1) MC voriconazole inj $0(Tier 1) PA voriconazole susr $0(Tier 1) QL (300 per 30 days) PA voriconazole tabs $0(Tier 1) QL (90 per 30 days) PA zazole crea 0.8% $0(Tier 1) zazole supp $0(Tier 1) ZEASORB-AF POWD $0(Tier 1) MC Antigout Agents (Drugs that Treat or Prevent Gout) Antigout Agents allopurinol sodium $0(Tier 1) allopurinol tabs $0(Tier 1) colchicine caps $0(Tier 1) QL (60 per 30 days) colchicine tabs 0.6mg $0(Tier 1) QL (120 per 30 days) MITIGARE $0(Tier 2) QL (60 per 30 days) apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 17

26 What the drug Name of drug probenecid/colchicine $0(Tier 1) probenecid tabs $0(Tier 1) ULORIC $0(Tier 2) QL (30 per 30 days) ST Antimigraine Agents (Drugs that Treat Migraine Headaches) Ergot Alkaloids dihydroergotamine mesylate inj $0(Tier 1) QL (30 per 28 days) ergotamine tartrate/caffeine $0(Tier 1) QL (40 per 28 days) MIGERGOT $0(Tier 2) QL (20 per 28 days) Serotonin (5-HT) 1b/1d Receptor Agonists naratriptan hcl $0(Tier 1) QL (9 per 30 days) rizatriptan benzoate $0(Tier 1) QL (12 per 30 days) rizatriptan benzoate odt $0(Tier 1) QL (12 per 30 days) sumatriptan succinate refill inj 6mg/0.5ml $0(Tier 1) QL (4 per 30 days) sumatriptan succinate refill inj 4mg/0.5ml $0(Tier 1) QL (8 per 30 days) sumatriptan succinate tabs $0(Tier 1) QL (9 per 30 days) sumatriptan succinate inj 6mg/0.5ml $0(Tier 1) QL (4 per 30 days) sumatriptan succinate inj 4mg/0.5ml $0(Tier 1) QL (8 per 30 days) sumatriptan soln $0(Tier 1) QL (12 per 30 days) Antimyasthenic Agents (Drugs d for Problems with Muscle Weakness and Fatigue) Parasympathomimetics GUANIDINE HCL $0(Tier 2) pyridostigmine bromide er $0(Tier 1) pyridostigmine bromide tabs $0(Tier 1) REGONOL INJ 10MG/2ML $0(Tier 2) Antimycobacterials (Drugs that Treat Infection with Fungus and Bacteria) Antimycobacterials, Other dapsone tabs $0(Tier 1) rifabutin $0(Tier 1) Antituberculars CAPASTAT SULFATE $0(Tier 2) cycloserine $0(Tier 1) ethambutol hcl tabs $0(Tier 1) isoniazid inj, syrp, tabs $0(Tier 1) PASER $0(Tier 2) PRIFTIN $0(Tier 2) pyrazinamide tabs $0(Tier 1) rifampin caps, inj $0(Tier 1) RIFATER $0(Tier 2) SIRTURO $0(Tier 2) QL (188 per 365 days) PA TRECATOR $0(Tier 2) Antineoplastics (Drugs that Treat Cancer) Alkylating Agents BENDEKA $0(Tier 2) QL (8 per 21 days) B/D BICNU $0(Tier 2) B/D apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 18

27 Name of drug What the drug busulfan $0(Tier 1) B/D BUSULFEX $0(Tier 2) B/D cyclophosphamide caps $0(Tier 1) B/D cyclophosphamide inj 1gm, 500mg $0(Tier 1) B/D cyclophosphamide inj 2gm $0(Tier 1) B/D dacarbazine inj 100mg, 200mg $0(Tier 1) B/D EVOMELA $0(Tier 2) PA GLEOSTINE $0(Tier 2) HEXALEN $0(Tier 2) ifosfamide $0(Tier 1) B/D KISQALI FEMARA 200 DOSE $0(Tier 2) QL (49 per 28 days) PA KISQALI FEMARA 400 DOSE $0(Tier 2) QL (70 per 28 days) PA KISQALI FEMARA 600 DOSE $0(Tier 2) QL (91 per 28 days) PA LEUKERAN $0(Tier 2) MATULANE $0(Tier 2) melphalan hydrochloride $0(Tier 1) B/D MUSTARGEN $0(Tier 2) B/D thiotepa inj 15mg $0(Tier 1) PA TREANDA INJ 100MG $0(Tier 2) B/D TREANDA INJ 180MG/2ML $0(Tier 2) QL (4 per 21 days) B/D TREANDA INJ 45MG/0.5ML $0(Tier 2) QL (6 per 21 days) B/D TREANDA INJ 25MG $0(Tier 2) QL (8 per 21 days) B/D VALCHLOR $0(Tier 2) QL (60 per 30 days) PA YONDELIS $0(Tier 2) PA ZANOSAR $0(Tier 2) B/D Antiandrogens bicalutamide $0(Tier 1) QL (30 per 30 days) ERLEADA $0(Tier 2) QL (120 per 30 days) PA flutamide $0(Tier 1) nilutamide $0(Tier 1) QL (60 per 30 days) XTANDI $0(Tier 2) QL (120 per 30 days) PA YONSA $0(Tier 2) QL (120 per 30 days) PA ZYTIGA TABS 250MG $0(Tier 2) QL (120 per 30 days) PA apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 19

28 Name of drug What the drug ZYTIGA TABS 500MG $0(Tier 2) QL (60 per 30 days) PA Antiangiogenic Agents POMALYST $0(Tier 2) QL (21 per 28 days) PA REVLIMID CAPS 15MG, 20MG, 25MG $0(Tier 2) QL (21 per 28 days) PA REVLIMID CAPS 10MG, 2.5MG, 5MG $0(Tier 2) QL (28 per 28 days) PA THALOMID CAPS 100MG, 150MG, 50MG $0(Tier 2) QL (28 per 28 days) PA THALOMID CAPS 200MG $0(Tier 2) QL (56 per 28 days) PA Antiestrogens/Modifiers EMCYT $0(Tier 2) FARESTON $0(Tier 2) QL (30 per 30 days) FASLODEX INJ 250MG/5ML $0(Tier 2) QL (30 per 30 days) B/D SOLTAMOX $0(Tier 2) tamoxifen citrate tabs $0(Tier 1) Antimetabolites adrucil inj 2.5gm/50ml, 500mg/10ml, 5gm/100ml $0(Tier 1) B/D ALIMTA $0(Tier 2) PA ARRANON $0(Tier 2) cladribine $0(Tier 1) B/D clofarabine $0(Tier 1) B/D cytarabine aqueous $0(Tier 1) B/D cytarabine inj 100mg/ml, 20mg/ml $0(Tier 1) B/D DROXIA $0(Tier 2) ELITEK $0(Tier 2) B/D fluorouracil inj 1gm/20ml, 2.5gm/50ml, 500mg/10ml, $0(Tier 1) B/D 5gm/100ml FOLOTYN $0(Tier 2) B/D gemcitabine $0(Tier 1) B/D gemcitabine hcl inj 200mg, 2gm $0(Tier 1) B/D gemcitabine hcl inj 1gm $0(Tier 1) B/D gemcitabine hydrochloride inj 1.5gm/15ml, 1gm/10ml, $0(Tier 1) B/D 200mg/2ml, 2gm/20ml hydroxyurea caps $0(Tier 1) LONSURF TABS 6.14MG; 15MG $0(Tier 2) QL (100 per 28 days) PA LONSURF TABS 8.19MG; 20MG $0(Tier 2) QL (80 per 28 days) PA mercaptopurine tabs $0(Tier 1) NIPENT $0(Tier 2) B/D apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 20

29 Name of drug What the drug PURIXAN $0(Tier 2) QL (300 per 30 days) PA TABLOID $0(Tier 2) VYXEOS $0(Tier 2) B/D Antineoplastics, Other ABRAXANE $0(Tier 2) PA adriamycin inj 2mg/ml $0(Tier 1) B/D amifostine $0(Tier 1) B/D azacitidine $0(Tier 1) B/D BELEODAQ $0(Tier 2) PA bleomycin sulfate $0(Tier 1) B/D BORTEZOMIB $0(Tier 2) QL (14 per 21 days) PA carboplatin $0(Tier 1) B/D cisplatin $0(Tier 1) B/D COSMEGEN $0(Tier 2) B/D dactinomycin $0(Tier 1) B/D daunorubicin hcl inj 5mg/ml $0(Tier 1) B/D DAUNORUBICIN HYDROCHLORIDE $0(Tier 2) B/D decitabine $0(Tier 1) dexrazoxane $0(Tier 1) B/D DOCEFREZ INJ 20MG $0(Tier 2) B/D docetaxel inj 140mg/7ml, 160mg/16ml, 160mg/8ml, 200mg/10ml, 200mg/20ml, 20mg/2ml, 20mg/ml, 80mg/4ml, 80mg/8ml $0(Tier 1) B/D doxorubicin hcl liposome $0(Tier 1) B/D doxorubicin hcl inj 10mg, 2mg/ml, 50mg $0(Tier 1) B/D epirubicin hcl inj 200mg/100ml, 50mg/25ml $0(Tier 1) B/D ERWINAZE $0(Tier 2) QL (60 per 28 days) B/D ETHYOL $0(Tier 2) B/D fludarabine phosphate $0(Tier 1) B/D FUSILEV $0(Tier 2) HALAVEN $0(Tier 2) PA idarubicin hcl inj 10mg/10ml $0(Tier 1) B/D irinotecan $0(Tier 1) B/D irinotecan hcl $0(Tier 1) B/D irinotecan hydrochloride inj 40mg/2ml $0(Tier 1) B/D ISTODAX $0(Tier 2) PA ISTODAX (OVERFILL) $0(Tier 2) PA IXEMPRA KIT $0(Tier 2) B/D JEVTANA $0(Tier 2) PA KISQALI $0(Tier 2) QL (63 per 28 days) PA LARTRUVO $0(Tier 2) PA apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 21

30 Name of drug What the drug leucovorin calcium tabs $0(Tier 1) leucovorin calcium inj 100mg, 350mg, 500mg, 50mg $0(Tier 1) levoleucovorin calcium $0(Tier 1) levoleucovorin inj 175mg/17.5ml, 250mg/25ml, 50mg $0(Tier 1) lipodox $0(Tier 1) B/D lipodox 50 $0(Tier 1) B/D LYNPARZA TABS 100MG, 150MG $0(Tier 2) QL (120 per 30 days) PA mesna $0(Tier 1) B/D MESNEX $0(Tier 2) mitomycin inj 20mg, 5mg $0(Tier 1) B/D mitomycin inj 40mg $0(Tier 1) B/D mitoxantrone hcl inj 2mg/ml $0(Tier 1) B/D NERLYNX $0(Tier 2) QL (180 per 30 days) PA NINLARO $0(Tier 2) QL (3 per 28 days) PA ODOMZO $0(Tier 2) QL (30 per 30 days) PA ONCASPAR $0(Tier 2) B/D oxaliplatin inj 100mg/20ml, 50mg/10ml $0(Tier 1) B/D oxaliplatin inj 100mg, 50mg $0(Tier 1) B/D paclitaxel inj 100mg/16.7ml, 150mg/25ml, 300mg/50ml, $0(Tier 1) B/D 30mg/5ml PORTRAZZA $0(Tier 2) QL (100 per 21 days) PA PROLEUKIN $0(Tier 2) B/D romidepsin $0(Tier 1) PA RUBRACA $0(Tier 2) QL (120 per 30 days) PA RYDAPT $0(Tier 2) QL (224 per 28 days) PA SYLATRON $0(Tier 2) QL (4 per 28 days) PA SYNRIBO $0(Tier 2) QL (28 per 28 days) PA TRISENOX $0(Tier 2) B/D VELCADE $0(Tier 2) QL (14 per 21 days) PA VENCLEXTA STARTING PACK $0(Tier 2) QL (84 per 365 days) PA VENCLEXTA TABS 100MG $0(Tier 2) QL (120 per 30 days) PA VENCLEXTA TABS 50MG $0(Tier 2) QL (30 per 30 days) PA VENCLEXTA TABS 10MG $0(Tier 2) QL (60 per 30 days) PA apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 22

31 Name of drug What the drug VERZENIO $0(Tier 2) QL (60 per 30 days) PA vinblastine sulfate inj 1mg/ml $0(Tier 1) B/D vincasar pfs $0(Tier 1) B/D vincristine sulfate $0(Tier 1) B/D vinorelbine tartrate $0(Tier 1) B/D ZEJULA $0(Tier 2) QL (90 per 30 days) PA ZOLINZA $0(Tier 2) QL (120 per 30 days) Aromatase Inhibitors, 3rd Generation anastrozole tabs $0(Tier 1) QL (30 per 30 days) exemestane $0(Tier 1) QL (60 per 30 days) letrozole $0(Tier 1) QL (30 per 30 days) Enzyme Inhibitors etoposide inj 100mg/5ml, 1gm/50ml, 500mg/25ml $0(Tier 1) B/D KYPROLIS $0(Tier 2) B/D toposar inj 100mg/5ml, 1gm/50ml, 500mg/25ml $0(Tier 1) B/D topotecan hcl inj 4mg $0(Tier 1) Molecular Target Inhibitors AFINITOR DISPERZ TBSO 5MG $0(Tier 2) QL (112 per 28 days) PA AFINITOR DISPERZ TBSO 2MG, 3MG $0(Tier 2) QL (56 per 28 days) PA AFINITOR TABS 2.5MG, 5MG, 7.5MG $0(Tier 2) QL (28 per 28 days) PA AFINITOR TABS 10MG $0(Tier 2) QL (56 per 28 days) PA ALECENSA $0(Tier 2) QL (240 per 30 days) PA ALIQOPA $0(Tier 2) QL (3 per 28 days) PA ALUNBRIG TBPK $0(Tier 2) QL (60 per 365 days) PA ALUNBRIG TABS 30MG $0(Tier 2) QL (180 per 30 days) PA ALUNBRIG TABS 180MG, 90MG $0(Tier 2) QL (30 per 30 days) PA BOSULIF TABS 100MG $0(Tier 2) QL (120 per 30 days) PA BOSULIF TABS 400MG, 500MG $0(Tier 2) QL (30 per 30 days) PA CABOMETYX TABS 20MG, 60MG $0(Tier 2) QL (30 per 30 days) PA apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 23

32 Name of drug What the drug CABOMETYX TABS 40MG $0(Tier 2) QL (60 per 30 days) PA CALQUENCE $0(Tier 2) QL (60 per 30 days) PA CAPRELSA TABS 300MG $0(Tier 2) QL (30 per 30 days) PA CAPRELSA TABS 100MG $0(Tier 2) QL (60 per 30 days) PA COMETRIQ KIT 0 $0(Tier 2) QL (112 per 28 days) PA COMETRIQ KIT 0 $0(Tier 2) QL (56 per 28 days) PA COMETRIQ KIT 20MG $0(Tier 2) QL (84 per 28 days) PA COTELLIC $0(Tier 2) QL (63 per 28 days) PA ERIVEDGE $0(Tier 2) QL (28 per 28 days) PA FARYDAK $0(Tier 2) QL (6 per 21 days) PA GILOTRIF $0(Tier 2) QL (30 per 30 days) PA IBRANCE $0(Tier 2) QL (21 per 28 days) PA ICLUSIG TABS 45MG $0(Tier 2) QL (30 per 30 days) PA ICLUSIG TABS 15MG $0(Tier 2) QL (60 per 30 days) PA IDHIFA $0(Tier 2) QL (30 per 30 days) PA imatinib mesylate $0(Tier 1) QL (60 per 30 days) PA IMBRUVICA TABS $0(Tier 2) QL (30 per 30 days) PA IMBRUVICA CAPS 140MG $0(Tier 2) QL (120 per 30 days) PA IMBRUVICA CAPS 70MG $0(Tier 2) QL (30 per 30 days) PA INLYTA $0(Tier 2) QL (120 per 30 days) PA IRESSA $0(Tier 2) QL (30 per 30 days) PA JAKAFI $0(Tier 2) QL (60 per 30 days) PA apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 24

33 Name of drug What the drug LENVIMA 10 MG DAILY DOSE $0(Tier 2) QL (30 per 30 days) PA LENVIMA 14 MG DAILY DOSE $0(Tier 2) QL (60 per 30 days) PA LENVIMA 18 MG DAILY DOSE $0(Tier 2) QL (90 per 30 days) PA LENVIMA 20 MG DAILY DOSE $0(Tier 2) QL (60 per 30 days) PA LENVIMA 24 MG DAILY DOSE $0(Tier 2) QL (90 per 30 days) PA LENVIMA 8 MG DAILY DOSE $0(Tier 2) QL (60 per 30 days) PA LYNPARZA CAPS 50MG $0(Tier 2) QL (448 per 28 days) PA MEKINIST TABS 2MG $0(Tier 2) QL (30 per 30 days) PA MEKINIST TABS 0.5MG $0(Tier 2) QL (90 per 30 days) PA NEXAVAR $0(Tier 2) QL (120 per 30 days) PA SPRYCEL $0(Tier 2) QL (30 per 30 days) PA STIVARGA $0(Tier 2) PA SUTENT $0(Tier 2) QL (28 per 28 days) PA TAFINLAR $0(Tier 2) QL (120 per 30 days) PA TAGRISSO $0(Tier 2) QL (30 per 30 days) PA TARCEVA TABS 100MG, 150MG $0(Tier 2) QL (30 per 30 days) PA TARCEVA TABS 25MG $0(Tier 2) QL (60 per 30 days) PA TASIGNA CAPS 150MG, 200MG $0(Tier 2) QL (112 per 28 days) PA TASIGNA CAPS 50MG $0(Tier 2) QL (420 per 30 days) PA TYKERB $0(Tier 2) QL (180 per 30 days) PA VOTRIENT $0(Tier 2) QL (120 per 30 days) PA XALKORI $0(Tier 2) QL (60 per 30 days) PA ZALTRAP $0(Tier 2) QL (40 per 28 days) PA apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 25

34 What the drug Name of drug ZELBORAF $0(Tier 2) QL (240 per 30 days) PA ZYDELIG $0(Tier 2) QL (60 per 30 days) PA ZYKADIA $0(Tier 2) QL (140 per 28 days) PA Monoclonal Antibody/Antibody-Drug Conjugate ARZERRA $0(Tier 2) B/D AVASTIN $0(Tier 2) PA BAVENCIO $0(Tier 2) PA BESPONSA $0(Tier 2) PA CYRAMZA $0(Tier 2) PA DARZALEX $0(Tier 2) PA EMPLICITI $0(Tier 2) PA ERBITUX $0(Tier 2) PA GAZYVA $0(Tier 2) PA HERCEPTIN INJ 150MG $0(Tier 2) B/D HERCEPTIN INJ 440MG $0(Tier 2) PA IMFINZI $0(Tier 2) PA KADCYLA $0(Tier 2) PA KEYTRUDA $0(Tier 2) PA MYLOTARG $0(Tier 2) PA OPDIVO INJ 240MG/24ML $0(Tier 2) QL (48 per 28 days) PA OPDIVO INJ 100MG/10ML, 40MG/4ML $0(Tier 2) QL (80 per 28 days) PA PERJETA $0(Tier 2) PA RITUXAN $0(Tier 2) PA RITUXAN HYCELA $0(Tier 2) PA TECENTRIQ $0(Tier 2) QL (20 per 21 days) PA UNITUXIN $0(Tier 2) PA VECTIBIX INJ 100MG/5ML, 400MG/20ML $0(Tier 2) PA YERVOY INJ 50MG/10ML $0(Tier 2) PA YERVOY INJ 200MG/40ML $0(Tier 2) QL (80 per 21 days) PA Retinoids bexarotene $0(Tier 1) PANRETIN $0(Tier 2) TARGRETIN GEL $0(Tier 2) QL (60 per 30 days) tretinoin caps 10mg $0(Tier 1) Antiparasitics (Drugs that Treat Infections with Parasites) Anthelmintics ALBENZA $0(Tier 2) BILTRICIDE $0(Tier 2) apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 26

35 What the drug Name of drug ivermectin tabs $0(Tier 1) praziquantel tabs $0(Tier 1) Antiprotozoals ALINIA SUSR $0(Tier 2) QL (150 per 30 days) ALINIA TABS $0(Tier 2) QL (20 per 30 days) atovaquone $0(Tier 1) atovaquone/proguanil hcl $0(Tier 1) chloroquine phosphate tabs $0(Tier 1) COARTEM $0(Tier 2) QL (24 per 30 days) DARAPRIM $0(Tier 2) QL (90 per 30 days) hydroxychloroquine sulfate tabs $0(Tier 1) mefloquine hcl $0(Tier 1) NEBUPENT $0(Tier 2) QL (6 per 28 days) B/D PENTAM 300 $0(Tier 2) PRIMAQUINE PHOSPHATE TABS $0(Tier 2) quinine sulfate caps 324mg $0(Tier 1) QL (42 per 7 days) Pediculicides/Scabicides gnp lice treatment liqd $0(Tier 1) MC lindane lotn, sham $0(Tier 1) malathion $0(Tier 1) permethrin crea $0(Tier 1) Antiparkinson Agents (Drugs d for Parkinson s Disease) Anticholinergics benztropine mesylate inj $0(Tier 1) benztropine mesylate tabs $0(Tier 1) PA trihexyphenidyl hcl $0(Tier 1) PA Antiparkinson Agents, Other amantadine hcl caps, syrp, tabs $0(Tier 1) entacapone $0(Tier 1) QL (240 per 30 days) tolcapone $0(Tier 1) Dopamine Agonists APOKYN INJ 30MG/3ML $0(Tier 2) QL (60 per 30 days) PA bromocriptine mesylate caps, tabs $0(Tier 1) NEUPRO $0(Tier 2) QL (30 per 30 days) pramipexole dihydrochloride $0(Tier 1) QL (90 per 30 days) pramipexole dihydrochloride er tb mg, 3.75mg, 3mg, $0(Tier 1) 4.5mg pramipexole dihydrochloride er tb mg, 0.75mg, 1.5mg $0(Tier 1) ropinirole hcl $0(Tier 1) Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors carbidopa/levodopa $0(Tier 1) carbidopa/levodopa er $0(Tier 1) carbidopa/levodopa odt $0(Tier 1) carbidopa/levodopa/entacapone $0(Tier 1) QL (30 per 30 days) QL (90 per 30 days) apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 27

36 What the drug Name of drug carbidopa tabs $0(Tier 1) RYTARY $0(Tier 2) ST Monoamine Oxidase B (MAO-B) Inhibitors rasagiline mesylate tabs $0(Tier 1) QL (30 per 30 days) selegiline hcl caps, tabs $0(Tier 1) Antipsychotics (Drugs that Control or Prevent Psychotic Behavior) 1st Generation/Typical chlorpromazine hcl inj, tabs $0(Tier 1) compro $0(Tier 1) fluphenazine decanoate inj $0(Tier 1) fluphenazine hcl conc, elix, inj, tabs $0(Tier 1) haloperidol decanoate inj $0(Tier 1) haloperidol lactate $0(Tier 1) haloperidol conc, tabs $0(Tier 1) loxapine succinate caps 25mg, 50mg $0(Tier 1) loxapine succinate caps 10mg, 5mg $0(Tier 1) QL (120 per 30 days) loxapine caps 25mg, 50mg $0(Tier 1) loxapine caps 10mg, 5mg $0(Tier 1) QL (120 per 30 days) molindone hydrochloride $0(Tier 1) perphenazine tabs $0(Tier 1) pimozide $0(Tier 1) prochlorperazine edisylate inj $0(Tier 1) prochlorperazine maleate tabs $0(Tier 1) prochlorperazine supp 25mg $0(Tier 1) thioridazine hcl tabs 100mg, 10mg, 25mg, 50mg $0(Tier 1) thiothixene caps 10mg, 1mg, 2mg, 5mg $0(Tier 1) trifluoperazine hcl tabs $0(Tier 1) 2nd Generation/Atypical ABILIFY MAINTENA $0(Tier 2) QL (1 per 28 days) aripiprazole odt $0(Tier 1) QL (60 per 30 days) aripiprazole tabs $0(Tier 1) QL (30 per 30 days) aripiprazole soln $0(Tier 1) QL (900 per 30 days) ARISTADA INJ 441MG/1.6ML $0(Tier 2) QL (1.6 per 30 days) ARISTADA INJ 662MG/2.4ML $0(Tier 2) QL (2.4 per 30 days) ARISTADA INJ 882MG/3.2ML $0(Tier 2) QL (3.2 per 30 days) ARISTADA INJ 1064MG/3.9ML $0(Tier 2) QL (3.9 per 60 days) FANAPT TITRATION PACK $0(Tier 2) QL (16 per 365 days) ST FANAPT TABS 1MG, 2MG, 4MG $0(Tier 2) QL (60 per 30 days) ST FANAPT TABS 10MG, 12MG, 6MG, 8MG $0(Tier 2) QL (60 per 30 days) ST GEODON INJ $0(Tier 2) QL (6 per 30 days) INVEGA SUSTENNA INJ 39MG/0.25ML $0(Tier 2) QL (0.25 per 28 days) INVEGA SUSTENNA INJ 78MG/0.5ML $0(Tier 2) QL (0.5 per 28 days) INVEGA SUSTENNA INJ 117MG/0.75ML $0(Tier 2) QL (0.75 per 28 days) apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 28

37 Name of drug What the drug INVEGA SUSTENNA INJ 156MG/ML $0(Tier 2) QL (1 per 28 days) INVEGA SUSTENNA INJ 234MG/1.5ML $0(Tier 2) QL (1.5 per 28 days) INVEGA TRINZA INJ 273MG/0.875ML $0(Tier 2) QL (0.88 per 90 days) INVEGA TRINZA INJ 410MG/1.315ML $0(Tier 2) QL (1.32 per 90 days) INVEGA TRINZA INJ 546MG/1.75ML $0(Tier 2) QL (1.75 per 90 days) INVEGA TRINZA INJ 819MG/2.625ML $0(Tier 2) QL (2.63 per 90 days) LATUDA TABS 120MG, 20MG, 40MG, 60MG $0(Tier 2) QL (30 per 30 days) ST LATUDA TABS 80MG $0(Tier 2) QL (60 per 30 days) ST NUPLAZID $0(Tier 2) QL (60 per 30 days) PA olanzapine $0(Tier 1) QL (30 per 30 days) olanzapine odt $0(Tier 1) QL (30 per 30 days) paliperidone er tb24 1.5mg, 3mg $0(Tier 1) QL (30 per 30 days) ST paliperidone er tb24 9mg $0(Tier 1) QL (30 per 30 days) ST paliperidone er tb24 6mg $0(Tier 1) QL (60 per 30 days) ST quetiapine fumarate $0(Tier 1) QL (60 per 30 days) quetiapine fumarate er tb24 150mg, 200mg $0(Tier 1) QL (30 per 30 days) quetiapine fumarate er tb24 300mg, 400mg, 50mg $0(Tier 1) QL (60 per 30 days) REXULTI $0(Tier 2) QL (30 per 30 days) RISPERDAL CONSTA INJ 12.5MG, 25MG, 37.5MG $0(Tier 2) QL (2 per 28 days) RISPERDAL CONSTA INJ 50MG $0(Tier 2) QL (2 per 28 days) risperidone m-tab tbdp 4mg $0(Tier 1) QL (120 per 30 days) risperidone m-tab tbdp 0.5mg, 1mg, 2mg, 3mg $0(Tier 1) QL (60 per 30 days) risperidone odt tbdp 4mg $0(Tier 1) QL (120 per 30 days) risperidone odt tbdp 0.25mg, 0.5mg, 1mg, 2mg, 3mg $0(Tier 1) QL (60 per 30 days) risperidone soln $0(Tier 1) QL (240 per 30 days) risperidone tabs 4mg $0(Tier 1) QL (120 per 30 days) risperidone tabs 0.25mg, 0.5mg, 1mg, 2mg, 3mg $0(Tier 1) QL (60 per 30 days) SAPHRIS $0(Tier 2) QL (60 per 30 days) VRAYLAR CPPK $0(Tier 2) QL (14 per 365 days) ST VRAYLAR CAPS $0(Tier 2) QL (30 per 30 days) ST ziprasidone hcl $0(Tier 1) QL (60 per 30 days) ZYPREXA RELPREVV INJ 405MG $0(Tier 2) QL (1 per 28 days) ZYPREXA RELPREVV INJ 210MG $0(Tier 2) QL (2 per 28 days) ZYPREXA RELPREVV INJ 300MG $0(Tier 2) QL (2 per 28 days) Treatment-Resistant clozapine odt tbdp 12.5mg, 25mg $0(Tier 1) apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 29

38 What the drug Name of drug clozapine odt tbdp 200mg $0(Tier 1) QL (120 per 30 days) clozapine odt tbdp 150mg $0(Tier 1) QL (180 per 30 days) clozapine odt tbdp 100mg $0(Tier 1) QL (270 per 30 days) clozapine tabs 25mg, 50mg $0(Tier 1) clozapine tabs 200mg $0(Tier 1) QL (120 per 30 days) clozapine tabs 100mg $0(Tier 1) QL (270 per 30 days) VERSACLOZ $0(Tier 2) QL (540 per 30 days) Antispasticity Agents (Drugs d for Muscle Jerks or Twitches) Antispasticity Agents baclofen tabs $0(Tier 1) dantrolene sodium caps $0(Tier 1) tizanidine hcl caps, tabs $0(Tier 1) Antivirals (Drugs that Treat Infection with Virs) Anti-cytomegalovirus (CMV) Agents cidofovir $0(Tier 1) FOSCAVIR INJ 6000MG/250ML $0(Tier 2) ganciclovir inj 500mg/10ml, 500mg $0(Tier 1) B/D valganciclovir $0(Tier 1) valganciclovir hydrochlorde $0(Tier 1) ZIRGAN $0(Tier 2) Anti-hepatitis B (HBV) Agents adefovir dipivoxil $0(Tier 1) QL (30 per 30 days) BARACLUDE SOLN $0(Tier 2) QL (630 per 30 days) entecavir $0(Tier 1) QL (30 per 30 days) EPIVIR HBV SOLN $0(Tier 2) INTRON A W/DILUENT INJ 18MU $0(Tier 2) INTRON A W/DILUENT INJ 10MU, 50MU $0(Tier 2) INTRON A INJ 18MU, UNIT/ML $0(Tier 2) INTRON A INJ 10MU/ML, 10MU, 50MU $0(Tier 2) lamivudine tabs 100mg $0(Tier 1) TYZEKA $0(Tier 2) QL (30 per 30 days) PA Anti-hepatitis C (HCV) Agents, Direct Acting Agents EPCLUSA $0(Tier 2) QL (28 per 28 days) PA HARVONI $0(Tier 2) QL (28 per 28 days) PA VOSEVI $0(Tier 2) QL (30 per 30 days) PA Anti-hepatitis C (HCV) Agents, Other PEGASYS PROCLICK $0(Tier 2) QL (2 per 28 days) PA PEGASYS INJ 180MCG/0.5ML $0(Tier 2) QL (2 per 28 days) PA apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 30

39 Name of drug What the drug PEGASYS INJ 180MCG/ML $0(Tier 2) QL (4 per 28 days) PA ribavirin caps 200mg $0(Tier 1) QL (168 per 28 days) ribavirin tabs 200mg $0(Tier 1) QL (168 per 28 days) Anti-HIV Agents, Integrase Inhibitors (INSTI) BIKTARVY $0(Tier 2) QL (30 per 30 days) GENVOYA $0(Tier 2) QL (30 per 30 days) ISENTRESS PACK $0(Tier 2) QL (180 per 30 days) ISENTRESS TABS $0(Tier 2) QL (60 per 30 days) ISENTRESS CHEW 25MG $0(Tier 2) QL (180 per 30 days) ISENTRESS CHEW 100MG $0(Tier 2) QL (180 per 30 days) JULUCA $0(Tier 2) QL (30 per 30 days) TIVICAY TABS 10MG, 25MG $0(Tier 2) QL (60 per 30 days) TIVICAY TABS 50MG $0(Tier 2) QL (60 per 30 days) VITEKTA $0(Tier 2) QL (30 per 30 days) Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI) COMPLERA $0(Tier 2) QL (30 per 30 days) EDURANT $0(Tier 2) QL (30 per 30 days) efavirenz caps 200mg $0(Tier 1) QL (60 per 30 days) efavirenz caps 50mg $0(Tier 1) QL (90 per 30 days) efavirenz tabs $0(Tier 1) QL (30 per 30 days) INTELENCE TABS 25MG $0(Tier 2) QL (120 per 30 days) INTELENCE TABS 100MG, 200MG $0(Tier 2) QL (60 per 30 days) nevirapine er tb24 400mg $0(Tier 1) QL (30 per 30 days) nevirapine er tb24 100mg $0(Tier 1) QL (90 per 30 days) nevirapine susp $0(Tier 1) QL (1200 per 30 days) nevirapine tabs $0(Tier 1) QL (60 per 30 days) ODEFSEY $0(Tier 2) QL (30 per 30 days) RESCRIPTOR TABS 200MG $0(Tier 2) QL (180 per 30 days) RESCRIPTOR TABS 100MG $0(Tier 2) QL (270 per 30 days) STRIBILD $0(Tier 2) QL (30 per 30 days) SUSTIVA TABS $0(Tier 2) QL (30 per 30 days) SUSTIVA CAPS 200MG $0(Tier 2) QL (60 per 30 days) SUSTIVA CAPS 50MG $0(Tier 2) QL (90 per 30 days) SYMFI $0(Tier 2) QL (30 per 30 days) SYMFI LO $0(Tier 2) QL (30 per 30 days) VIRAMUNE SUSP $0(Tier 2) QL (1200 per 30 days) Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI) abacavir sulfate/lamivudine/zidovudine $0(Tier 1) QL (60 per 30 days) abacavir/lamivudine $0(Tier 1) QL (30 per 30 days) abacavir tabs $0(Tier 1) QL (60 per 30 days) apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 31

40 Name of drug What the drug abacavir soln $0(Tier 1) QL (960 per 30 days) CIMDUO $0(Tier 2) QL (30 per 30 days) DESCOVY $0(Tier 2) QL (30 per 30 days) didanosine $0(Tier 1) QL (30 per 30 days) EMTRIVA CAPS $0(Tier 2) QL (30 per 30 days) EMTRIVA SOLN $0(Tier 2) QL (680 per 28 days) lamivudine/zidovudine $0(Tier 1) QL (60 per 30 days) lamivudine soln 10mg/ml $0(Tier 1) QL (900 per 30 days) lamivudine tabs 300mg $0(Tier 1) QL (30 per 30 days) lamivudine tabs 150mg $0(Tier 1) QL (60 per 30 days) RETROVIR IV INFUSION $0(Tier 2) stavudine solr $0(Tier 1) QL (2400 per 30 days) stavudine caps $0(Tier 1) QL (60 per 30 days) tenofovir disoproxil fumarate $0(Tier 1) QL (30 per 30 days) TRIUMEQ $0(Tier 2) QL (30 per 30 days) TRUVADA $0(Tier 2) QL (30 per 30 days) VIDEX EC CPDR 125MG $0(Tier 2) QL (30 per 30 days) VIDEX PEDIATRIC $0(Tier 2) QL (1200 per 30 days) VIREAD POWD $0(Tier 2) QL (240 per 30 days) VIREAD TABS $0(Tier 2) QL (30 per 30 days) ZERIT SOLR $0(Tier 2) QL (2400 per 30 days) ZIAGEN SOLN $0(Tier 2) QL (960 per 30 days) zidovudine syrp $0(Tier 1) QL (1680 per 28 days) zidovudine caps $0(Tier 1) QL (180 per 30 days) zidovudine tabs $0(Tier 1) QL (60 per 30 days) Anti-HIV Agents, Other ATRIPLA $0(Tier 2) QL (30 per 30 days) FUZEON $0(Tier 2) QL (60 per 30 days) ISENTRESS HD $0(Tier 2) QL (60 per 30 days) SELZENTRY SOLN $0(Tier 2) QL (1610 per 26 days) SELZENTRY TABS 300MG $0(Tier 2) QL (120 per 30 days) SELZENTRY TABS 25MG $0(Tier 2) QL (240 per 30 days) SELZENTRY TABS 150MG, 75MG $0(Tier 2) QL (60 per 30 days) TROGARZO $0(Tier 2) B/D TYBOST $0(Tier 2) QL (30 per 30 days) Anti-HIV Agents, Protease Inhibitors APTIVUS CAPS $0(Tier 2) QL (120 per 30 days) APTIVUS SOLN $0(Tier 2) QL (285 per 28 days) atazanavir sulfate caps 150mg $0(Tier 1) QL (30 per 30 days) atazanavir sulfate caps 300mg $0(Tier 1) QL (30 per 30 days) apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 32

41 Name of drug What the drug atazanavir sulfate caps 200mg $0(Tier 1) QL (60 per 30 days) atazanavir caps 150mg $0(Tier 1) QL (30 per 30 days) atazanavir caps 300mg $0(Tier 1) QL (30 per 30 days) atazanavir caps 200mg $0(Tier 1) QL (60 per 30 days) CRIXIVAN CAPS 400MG $0(Tier 2) QL (180 per 30 days) CRIXIVAN CAPS 200MG $0(Tier 2) QL (270 per 30 days) EVOTAZ $0(Tier 2) QL (30 per 30 days) fosamprenavir calcium $0(Tier 1) QL (120 per 30 days) INVIRASE TABS $0(Tier 2) QL (120 per 30 days) INVIRASE CAPS $0(Tier 2) QL (300 per 30 days) KALETRA SOLN $0(Tier 2) QL (480 per 30 days) KALETRA TABS 200MG; 50MG $0(Tier 2) QL (120 per 30 days) KALETRA TABS 100MG; 25MG $0(Tier 2) QL (300 per 30 days) LEXIVA TABS $0(Tier 2) QL (120 per 30 days) LEXIVA SUSP $0(Tier 2) QL (1575 per 28 days) lopinavir/ritonavir $0(Tier 1) QL (480 per 30 days) NORVIR CAPS, PACK, TABS $0(Tier 2) QL (360 per 30 days) NORVIR SOLN $0(Tier 2) QL (480 per 30 days) PREZCOBIX $0(Tier 2) QL (30 per 30 days) PREZISTA SUSP $0(Tier 2) QL (400 per 30 days) PREZISTA TABS 150MG $0(Tier 2) QL (180 per 30 days) PREZISTA TABS 75MG $0(Tier 2) QL (210 per 30 days) PREZISTA TABS 800MG $0(Tier 2) QL (30 per 30 days) PREZISTA TABS 600MG $0(Tier 2) QL (60 per 30 days) REYATAZ PACK $0(Tier 2) QL (180 per 30 days) REYATAZ CAPS 150MG, 300MG $0(Tier 2) QL (30 per 30 days) REYATAZ CAPS 200MG $0(Tier 2) QL (60 per 30 days) ritonavir $0(Tier 1) QL (360 per 30 days) VIRACEPT TABS 625MG $0(Tier 2) QL (120 per 30 days) VIRACEPT TABS 250MG $0(Tier 2) QL (270 per 30 days) Anti-influenza Agents oseltamivir phosphate caps 30mg $0(Tier 1) QL (112 per 365 days) oseltamivir phosphate caps 45mg, 75mg $0(Tier 1) QL (56 per 365 days) oseltamivir phosphate susr $0(Tier 1) QL (700 per 365 days) rimantadine hcl $0(Tier 1) TAMIFLU CAPS 30MG $0(Tier 2) QL (112 per 365 days) apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 33

42 What the drug Name of drug TAMIFLU CAPS 45MG, 75MG $0(Tier 2) QL (56 per 365 days) TAMIFLU SUSR 6MG/ML $0(Tier 2) QL (700 per 365 days) Antiherpetic Agents acyclovir sodium inj 50mg/ml $0(Tier 1) B/D acyclovir caps, susp, tabs $0(Tier 1) acyclovir oint $0(Tier 1) QL (30 per 30 days) DENAVIR $0(Tier 2) QL (5 per 30 days) famciclovir tabs $0(Tier 1) QL (60 per 30 days) trifluridine $0(Tier 1) valacyclovir hcl $0(Tier 1) QL (30 per 30 days) ZOVIRAX CREA $0(Tier 2) QL (5 per 30 days) Anxiolytics (Drugs d to Relieve Stress or Anxiety) Anxiolytics, Other buspirone hcl tabs $0(Tier 1) doxepin hcl caps, conc $0(Tier 1) PA Benzodiazepines alprazolam odt tbdp 2mg $0(Tier 1) QL (150 per 30 days) alprazolam odt tbdp 0.25mg, 0.5mg, 1mg $0(Tier 1) QL (90 per 30 days) alprazolam tabs 2mg $0(Tier 1) QL (150 per 30 days) alprazolam tabs 0.25mg, 0.5mg, 1mg $0(Tier 1) QL (90 per 30 days) clorazepate dipotassium tabs 15mg $0(Tier 1) QL (180 per 30 days) clorazepate dipotassium tabs 3.75mg, 7.5mg $0(Tier 1) QL (90 per 30 days) diazepam inj 5mg/ml $0(Tier 1) diazepam oral soln 1mg/ml $0(Tier 1) QL (1200 per 30 days) diazepam tabs 10mg, 2mg, 5mg $0(Tier 1) QL (120 per 30 days) lorazepam intensol $0(Tier 1) QL (150 per 30 days) lorazepam conc $0(Tier 1) QL (150 per 30 days) lorazepam inj 2mg/ml, 4mg/ml $0(Tier 1) lorazepam tabs 2mg $0(Tier 1) QL (150 per 30 days) lorazepam tabs 0.5mg, 1mg $0(Tier 1) QL (90 per 30 days) oxazepam $0(Tier 1) QL (120 per 30 days) Bipolar Agents (Drugs that Regulate Severe Mood Changes due to Bipolar Disorder) Mood Stabilizers lithium carbonate er $0(Tier 1) lithium carbonate caps, tabs $0(Tier 1) Blood Glucose Regulators (Drugs d to Control Blood Sugar Levels) Antidiabetic Agents acarbose $0(Tier 1) QL (90 per 30 days) BYDUREON $0(Tier 2) QL (4 per 28 days) BYDUREON BCISE $0(Tier 2) QL (4 per 28 days) BYDUREON PEN $0(Tier 2) QL (4 per 28 days) BYETTA INJ 5MCG/0.02ML $0(Tier 2) QL (1.2 per 30 days) BYETTA INJ 10MCG/0.04ML $0(Tier 2) QL (2.4 per 30 days) CYCLOSET $0(Tier 2) QL (180 per 30 days) FARXIGA $0(Tier 2) QL (30 per 30 days) apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 34

43 Name of drug What the drug glimepiride tabs 2mg $0(Tier 1) QL (120 per 30 days) glimepiride tabs 1mg $0(Tier 1) QL (240 per 30 days) glimepiride tabs 4mg $0(Tier 1) QL (60 per 30 days) glipizide er tb24 5mg $0(Tier 1) QL (120 per 30 days) glipizide er tb24 2.5mg $0(Tier 1) QL (240 per 30 days) glipizide er tb24 10mg $0(Tier 1) QL (60 per 30 days) glipizide xl tb24 5mg $0(Tier 1) QL (120 per 30 days) glipizide xl tb24 2.5mg $0(Tier 1) QL (240 per 30 days) glipizide xl tb24 10mg $0(Tier 1) QL (60 per 30 days) glipizide/metformin hcl tabs 2.5mg; 500mg, 5mg; 500mg $0(Tier 1) QL (120 per 30 days) glipizide/metformin hcl tabs 2.5mg; 250mg $0(Tier 1) QL (240 per 30 days) glipizide tabs 10mg $0(Tier 1) QL (120 per 30 days) glipizide tabs 5mg $0(Tier 1) QL (60 per 30 days) GLYXAMBI $0(Tier 2) QL (30 per 30 days) INVOKAMET $0(Tier 2) QL (60 per 30 days) INVOKAMET XR $0(Tier 2) QL (60 per 30 days) INVOKANA $0(Tier 2) QL (30 per 30 days) JANUMET $0(Tier 2) QL (60 per 30 days) JANUMET XR TB MG; 100MG, 500MG; 50MG $0(Tier 2) QL (30 per 30 days) JANUMET XR TB MG; 50MG $0(Tier 2) QL (60 per 30 days) JANUVIA $0(Tier 2) QL (30 per 30 days) JARDIANCE $0(Tier 2) QL (30 per 30 days) JENTADUETO $0(Tier 2) QL (60 per 30 days) JENTADUETO XR TB24 5MG; 1000MG $0(Tier 2) QL (30 per 30 days) JENTADUETO XR TB24 2.5MG; 1000MG $0(Tier 2) QL (60 per 30 days) metformin hcl er tb24 (generic for Glucophage XR) 500mg $0(Tier 1) QL (120 per 30 days) metformin hcl er tb24 (generic for Glucophage XR) 750mg $0(Tier 1) QL (60 per 30 days) metformin hcl er tb24 (generic for Fortamet) 1000mg, 500mg $0(Tier 1) QL (60 per 30 days) metformin hcl tabs 500mg $0(Tier 1) QL (150 per 30 days) metformin hcl tabs 1000mg $0(Tier 1) QL (60 per 30 days) metformin hcl tabs 850mg $0(Tier 1) QL (90 per 30 days) miglitol $0(Tier 1) QL (90 per 30 days) nateglinide $0(Tier 1) QL (90 per 30 days) OZEMPIC $0(Tier 2) QL (3 per 28 days) pioglitazone hcl $0(Tier 1) QL (30 per 30 days) pioglitazone hcl/metformin hcl $0(Tier 1) QL (90 per 30 days) repaglinide tabs 0.5mg, 1mg $0(Tier 1) QL (120 per 30 days) repaglinide tabs 2mg $0(Tier 1) QL (240 per 30 days) RIOMET $0(Tier 2) QL (750 per 30 days) SYMLINPEN 120 $0(Tier 2) QL (10.8 per 28 days) PA SYMLINPEN 60 $0(Tier 2) QL (6 per 30 days) PA SYNJARDY $0(Tier 2) QL (60 per 30 days) SYNJARDY XR TB24 10MG; 1000MG, 25MG; 1000MG $0(Tier 2) QL (30 per 30 days) SYNJARDY XR TB MG; 1000MG, 5MG; 1000MG $0(Tier 2) QL (60 per 30 days) apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 35

44 Name of drug What the drug TRADJENTA $0(Tier 2) QL (30 per 30 days) TRULICITY $0(Tier 2) QL (2 per 28 days) VICTOZA $0(Tier 2) QL (9 per 30 days) XIGDUO XR TB24 10MG; 1000MG, 10MG; 500MG, $0(Tier 2) QL (30 per 30 days) 2.5MG; 1000MG, 5MG; 500MG XIGDUO XR TB24 5MG; 1000MG $0(Tier 2) QL (60 per 30 days) Glycemic Agents GLUCAGEN HYPOKIT $0(Tier 2) QL (4 per 30 days) GLUCAGON EMERGENCY KIT $0(Tier 2) QL (4 per 30 days) PROGLYCEM $0(Tier 2) Insulins HUMALOG $0(Tier 2) HUMALOG JUNIOR KWIKPEN $0(Tier 2) HUMALOG KWIKPEN $0(Tier 2) HUMALOG MIX 50/50 $0(Tier 2) HUMALOG MIX 50/50 KWIKPEN $0(Tier 2) HUMALOG MIX 75/25 $0(Tier 2) HUMALOG MIX 75/25 KWIKPEN $0(Tier 2) HUMULIN 70/30 $0(Tier 2) HUMULIN 70/30 KWIKPEN $0(Tier 2) HUMULIN N $0(Tier 2) HUMULIN N KWIKPEN $0(Tier 2) HUMULIN R $0(Tier 2) HUMULIN R U-500 (CONCENTRATED) $0(Tier 2) HUMULIN R U-500 KWIKPEN $0(Tier 2) LANTUS $0(Tier 2) LANTUS SOLOSTAR $0(Tier 2) LEVEMIR $0(Tier 2) LEVEMIR FLEXTOUCH $0(Tier 2) SOLIQUA 100/33 $0(Tier 2) QL (18 per 30 days) ST TOUJEO MAX SOLOSTAR $0(Tier 2) TOUJEO SOLOSTAR $0(Tier 2) TRESIBA FLEXTOUCH $0(Tier 2) XULTOPHY 100/3.6 $0(Tier 2) QL (15 per 30 days) ST Blood Products/Modifiers/Volume Expanders (Drugs d to Stop Bleeding, Replace Blood, or Break-Up a Clot) Anticoagulants COUMADIN TABS $0(Tier 2) enoxaparin sodium inj 40mg/0.4ml $0(Tier 1) QL (12 per 90 days) enoxaparin sodium inj 60mg/0.6ml $0(Tier 1) QL (18 per 90 days) enoxaparin sodium inj 120mg/0.8ml, 80mg/0.8ml $0(Tier 1) QL (24 per 90 days) enoxaparin sodium inj 100mg/ml, 150mg/ml, 300mg/3ml $0(Tier 1) QL (30 per 90 days) enoxaparin sodium inj 30mg/0.3ml $0(Tier 1) QL (9 per 90 days) fondaparinux sodium inj 5mg/0.4ml $0(Tier 1) QL (12 per 90 days) fondaparinux sodium inj 2.5mg/0.5ml $0(Tier 1) QL (15 per 90 days) apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 36

45 Name of drug What the drug fondaparinux sodium inj 7.5mg/0.6ml $0(Tier 1) QL (18 per 90 days) fondaparinux sodium inj 10mg/0.8ml $0(Tier 1) QL (24 per 90 days) heparin sodium/d5w $0(Tier 1) heparin sodium/nacl 0.45% inj 50unit/ml; 0.45% $0(Tier 1) heparin sodium/nacl 0.9% inj 2unit/ml; 0.9% $0(Tier 1) heparin sodium/sodium chloride 0.9% $0(Tier 1) heparin sodium/sodium chloride 0.9% premix $0(Tier 1) heparin sodium inj 10000unit/ml, 1000unit/ml, 20000unit/ml, $0(Tier 1) 2000unit/ml, 2500unit/ml, 5000unit/0.5ml, 5000unit/ml jantoven $0(Tier 1) PRADAXA $0(Tier 2) QL (60 per 30 days) SAVAYSA $0(Tier 2) QL (30 per 30 days) warfarin sodium tabs $0(Tier 1) XARELTO STARTER PACK $0(Tier 2) QL (102 per 365 days) XARELTO TABS 20MG $0(Tier 2) QL (30 per 30 days) XARELTO TABS 15MG $0(Tier 2) QL (60 per 30 days) XARELTO TABS 10MG $0(Tier 2) QL (90 per 90 days) Blood Formation Modifiers anagrelide hydrochloride $0(Tier 1) ARANESP ALBUMIN FREE INJ 500MCG/ML $0(Tier 2) QL (1 per 21 days) PA ARANESP ALBUMIN FREE INJ 60MCG/0.3ML $0(Tier 2) QL (1.2 per 28 days) PA ARANESP ALBUMIN FREE INJ 150MCG/0.3ML $0(Tier 2) QL (1.2 per 28 days) PA ARANESP ALBUMIN FREE INJ 10MCG/0.4ML, $0(Tier 2) QL (1.6 per 28 days) PA 40MCG/0.4ML ARANESP ALBUMIN FREE INJ 200MCG/0.4ML $0(Tier 2) QL (1.6 per 28 days) PA ARANESP ALBUMIN FREE INJ 25MCG/0.42ML $0(Tier 2) QL (1.68 per 28 days) PA ARANESP ALBUMIN FREE INJ 100MCG/0.5ML $0(Tier 2) QL (2 per 28 days) PA ARANESP ALBUMIN FREE INJ 300MCG/0.6ML $0(Tier 2) QL (2.4 per 28 days) PA ARANESP ALBUMIN FREE INJ 25MCG/ML, 40MCG/ML $0(Tier 2) QL (4 per 28 days) PA ARANESP ALBUMIN FREE INJ 100MCG/ML, 200MCG/ML, 300MCG/ML, 60MCG/ML $0(Tier 2) QL (4 per 28 days) PA LEUKINE INJ 250MCG $0(Tier 2) PA MOZOBIL $0(Tier 2) QL (9.6 per 30 days) NEUMEGA $0(Tier 2) PA PROCRIT INJ 10000UNIT/ML, 2000UNIT/ML, $0(Tier 2) QL (12 per 28 days) PA 3000UNIT/ML, 4000UNIT/ML PROCRIT INJ 20000UNIT/ML $0(Tier 2) QL (12 per 28 days) PA PROCRIT INJ 40000UNIT/ML $0(Tier 2) QL (6 per 28 days) PA apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 37

46 What the drug Name of drug PROMACTA $0(Tier 2) QL (30 per 30 days) PA ZARXIO $0(Tier 2) PA Hemostasis Agents tranexamic acid inj $0(Tier 1) tranexamic acid tabs $0(Tier 1) QL (30 per 28 days) Platelet Modifying Agents aspir-low $0(Tier 1) MC aspirin ec low dose $0(Tier 1) MC aspirin low dose chew 81mg $0(Tier 1) MC aspirin/dipyridamole $0(Tier 1) QL (60 per 30 days) aspirin chew 81mg $0(Tier 1) MC aspirin tbec 81mg $0(Tier 1) MC BRILINTA $0(Tier 2) QL (60 per 30 days) childrens aspirin $0(Tier 1) MC cilostazol $0(Tier 1) clopidogrel tabs 300mg $0(Tier 1) QL (2 per 365 days) clopidogrel tabs 75mg $0(Tier 1) QL (30 per 30 days) prasugrel $0(Tier 1) QL (30 per 30 days) Cardiovascular Agents (Drugs that Affect the Heart and Blood Vessels) Alpha-adrenergic Agonists clonidine hcl tabs $0(Tier 1) clonidine hcl ptwk 0.1mg/24hr, 0.2mg/24hr $0(Tier 1) QL (4 per 28 days) clonidine hcl ptwk 0.3mg/24hr $0(Tier 1) QL (8 per 28 days) midodrine hcl $0(Tier 1) Alpha-adrenergic Blocking Agents phenoxybenzamine hydrochloride $0(Tier 1) prazosin hcl caps $0(Tier 1) Angiotensin II Receptor Antagonists BENICAR $0(Tier 2) QL (30 per 30 days) ST BENICAR HCT $0(Tier 2) QL (30 per 30 days) ST candesartan cilexetil $0(Tier 1) QL (30 per 30 days) candesartan cilexetil/hydrochlorothiazide $0(Tier 1) QL (30 per 30 days) EDARBI $0(Tier 2) ST EDARBYCLOR $0(Tier 2) ST ENTRESTO $0(Tier 2) QL (60 per 30 days) irbesartan $0(Tier 1) QL (30 per 30 days) irbesartan/hydrochlorothiazide $0(Tier 1) QL (30 per 30 days) losartan potassium/hydrochlorothiazide tabs 12.5mg; 100mg, $0(Tier 1) QL (30 per 30 days) 25mg; 100mg losartan potassium/hydrochlorothiazide tabs 12.5mg; 50mg $0(Tier 1) QL (60 per 30 days) losartan potassium tabs 100mg $0(Tier 1) QL (30 per 30 days) losartan potassium tabs 25mg, 50mg $0(Tier 1) QL (60 per 30 days) olmesartan medoxomil/hydrochlorothiazide $0(Tier 1) QL (30 per 30 days) olmesartan medoxomil tabs $0(Tier 1) QL (30 per 30 days) apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 38

47 Name of drug What the drug telmisartan $0(Tier 1) QL (30 per 30 days) telmisartan/amlodipine $0(Tier 1) QL (30 per 30 days) telmisartan/hydrochlorothiazide $0(Tier 1) QL (30 per 30 days) valsartan $0(Tier 1) QL (30 per 30 days) valsartan/hydrochlorothiazide $0(Tier 1) QL (30 per 30 days) Angiotensin-converting Enzyme (ACE) Inhibitors benazepril hcl/hydrochlorothiazide tabs 10mg; 12.5mg, 20mg; $0(Tier 1) QL (30 per 30 days) 25mg, 5mg; 6.25mg benazepril hcl/hydrochlorothiazide tabs 20mg; 12.5mg $0(Tier 1) QL (60 per 30 days) benazepril hcl tabs $0(Tier 1) QL (60 per 30 days) captopril/hydrochlorothiazide $0(Tier 1) captopril tabs 100mg, 50mg $0(Tier 1) captopril tabs 12.5mg, 25mg $0(Tier 1) QL (90 per 30 days) enalapril maleate/hydrochlorothiazide $0(Tier 1) QL (60 per 30 days) enalapril maleate tabs $0(Tier 1) QL (60 per 30 days) fosinopril sodium $0(Tier 1) QL (60 per 30 days) fosinopril sodium/hydrochlorothiazide $0(Tier 1) QL (120 per 30 days) lisinopril/hydrochlorothiazide tabs 12.5mg; 20mg $0(Tier 1) QL (120 per 30 days) lisinopril/hydrochlorothiazide tabs 12.5mg; 10mg, 25mg; $0(Tier 1) QL (60 per 30 days) 20mg lisinopril tabs $0(Tier 1) QL (60 per 30 days) moexipril hcl $0(Tier 1) moexipril/hydrochlorothiazide tabs 12.5mg; 7.5mg $0(Tier 1) QL (30 per 30 days) moexipril/hydrochlorothiazide tabs 12.5mg; 15mg, 25mg; $0(Tier 1) QL (60 per 30 days) 15mg perindopril erbumine $0(Tier 1) QL (60 per 30 days) quinapril hcl $0(Tier 1) QL (60 per 30 days) quinapril/hydrochlorothiazide tabs 12.5mg; 10mg $0(Tier 1) QL (30 per 30 days) quinapril/hydrochlorothiazide tabs 12.5mg; 20mg, 25mg; $0(Tier 1) QL (60 per 30 days) 20mg ramipril $0(Tier 1) QL (60 per 30 days) trandolapril tabs 1mg $0(Tier 1) QL (30 per 30 days) trandolapril tabs 2mg, 4mg $0(Tier 1) QL (60 per 30 days) Antiarrhythmics amiodarone hcl tabs $0(Tier 1) amiodarone hcl inj 50mg/ml, 900mg/18ml $0(Tier 1) dofetilide $0(Tier 1) QL (60 per 30 days) flecainide acetate $0(Tier 1) lidocaine hcl inj 10mg/ml, 20mg/ml $0(Tier 1) mexiletine hcl $0(Tier 1) MULTAQ $0(Tier 2) QL (60 per 30 days) pacerone tabs 100mg, 200mg, 400mg $0(Tier 1) propafenone hcl $0(Tier 1) propafenone hcl er $0(Tier 1) quinidine sulfate tabs $0(Tier 1) apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 39

48 Name of drug What the drug sorine $0(Tier 1) sotalol hcl $0(Tier 1) sotalol hcl (af) $0(Tier 1) sotalol hydrochloride (af) tabs 80mg $0(Tier 1) sotalol hydrochloride tabs 120mg $0(Tier 1) Beta-adrenergic Blocking Agents acebutolol hcl caps $0(Tier 1) atenolol/chlorthalidone $0(Tier 1) atenolol tabs $0(Tier 1) betaxolol hcl tabs 10mg, 20mg $0(Tier 1) bisoprolol fumarate $0(Tier 1) bisoprolol fumarate/hydrochlorothiazide $0(Tier 1) BYSTOLIC TABS 10MG, 2.5MG, 5MG $0(Tier 2) QL (30 per 30 days) BYSTOLIC TABS 20MG $0(Tier 2) QL (60 per 30 days) BYVALSON $0(Tier 2) QL (30 per 30 days) carvedilol $0(Tier 1) carvedilol phosphate $0(Tier 1) QL (30 per 30 days) COREG CR $0(Tier 2) QL (30 per 30 days) labetalol hcl inj, tabs $0(Tier 1) metoprolol succinate er $0(Tier 1) QL (60 per 30 days) metoprolol tartrate inj, tabs $0(Tier 1) metoprolol/hydrochlorothiazide $0(Tier 1) nadolol/bendroflumethiazide $0(Tier 1) QL (30 per 30 days) nadolol tabs 20mg, 40mg, 80mg $0(Tier 1) pindolol tabs $0(Tier 1) propranolol hcl er $0(Tier 1) propranolol hcl inj, oral soln, tabs $0(Tier 1) propranolol hydrochloride tabs 60mg $0(Tier 1) propranolol/hydrochlorothiazide $0(Tier 1) timolol maleate tabs 10mg, 20mg, 5mg $0(Tier 1) Calcium Channel Blocking Agents afeditab cr $0(Tier 1) QL (60 per 30 days) amlodipine besylate/benazepril hydrochloride caps 10mg; $0(Tier 1) QL (30 per 30 days) 20mg, 10mg; 40mg amlodipine besylate/benazepril hydrochloride caps 2.5mg; $0(Tier 1) QL (60 per 30 days) 10mg, 5mg; 10mg, 5mg; 20mg, 5mg; 40mg amlodipine besylate/valsartan $0(Tier 1) QL (30 per 30 days) amlodipine besylate tabs 2.5mg $0(Tier 1) QL (120 per 30 days) amlodipine besylate tabs 10mg $0(Tier 1) QL (30 per 30 days) amlodipine besylate tabs 5mg $0(Tier 1) QL (60 per 30 days) amlodipine/olmesartan medoxomil $0(Tier 1) QL (30 per 30 days) amlodipine/valsartan/hctz $0(Tier 1) QL (30 per 30 days) AZOR $0(Tier 2) QL (30 per 30 days) ST cartia xt $0(Tier 1) dilt-xr $0(Tier 1) apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 40

49 Name of drug What the drug diltiazem cd $0(Tier 1) diltiazem hcl er cp24 120mg, 180mg, 240mg, 300mg, 420mg $0(Tier 1) diltiazem hcl er cp12, tb24 $0(Tier 1) diltiazem hcl tabs $0(Tier 1) diltiazem hcl inj 100mg, 125mg/25ml, 25mg/5ml, 50mg/10ml $0(Tier 1) felodipine er $0(Tier 1) QL (60 per 30 days) isradipine $0(Tier 1) matzim la $0(Tier 1) nicardipine hcl caps, inj $0(Tier 1) nifedical xl $0(Tier 1) QL (60 per 30 days) nifedipine er tb24 90mg $0(Tier 1) QL (30 per 30 days) nifedipine er tb24 30mg, 60mg $0(Tier 1) QL (60 per 30 days) nimodipine caps 0; 30mg $0(Tier 1) nisoldipine er tb24 20mg, 30mg, 40mg $0(Tier 1) nisoldipine er tb24 17mg, 25.5mg, 34mg, 8.5mg $0(Tier 1) QL (30 per 30 days) taztia xt cp24 120mg, 180mg, 240mg, 300mg $0(Tier 1) verapamil hcl er cp24 100mg, 120mg, 180mg, 240mg, 300mg $0(Tier 1) QL (30 per 30 days) verapamil hcl er cp24 200mg $0(Tier 1) QL (60 per 30 days) verapamil hcl er tbcr $0(Tier 1) verapamil hcl sr cp24 360mg $0(Tier 1) QL (30 per 30 days) verapamil hcl inj, tabs $0(Tier 1) Cardiovascular Agents, Other atropine sulfate inj 0.5mg/5ml $0(Tier 1) CORLANOR $0(Tier 2) QL (60 per 30 days) PA DEMSER $0(Tier 2) digitek tabs 0.25mg $0(Tier 1) PA digitek tabs 0.125mg $0(Tier 1) QL (30 per 30 days) digoxin inj 0.25mg/ml $0(Tier 1) PA digoxin tabs 250mcg $0(Tier 1) PA digoxin tabs 125mcg $0(Tier 1) QL (30 per 30 days) digox tabs 250mcg $0(Tier 1) PA digox tabs 125mcg $0(Tier 1) QL (30 per 30 days) LANOXIN PEDIATRIC $0(Tier 2) PA NORTHERA CAPS 200MG, 300MG $0(Tier 2) QL (180 per 30 days) PA NORTHERA CAPS 100MG $0(Tier 2) QL (90 per 30 days) PA pentoxifylline er $0(Tier 1) PRALUENT $0(Tier 2) PA RANEXA $0(Tier 2) QL (60 per 30 days) TEKTURNA $0(Tier 2) QL (30 per 30 days) TEKTURNA HCT $0(Tier 2) QL (30 per 30 days) Diuretics, Carbonic Anhydrase Inhibitors acetazolamide $0(Tier 1) acetazolamide sodium $0(Tier 1) apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 41

50 Name of drug What the drug methazolamide $0(Tier 1) Diuretics, Loop bumetanide inj, tabs $0(Tier 1) ethacrynate sodium $0(Tier 1) furosemide inj, oral soln, tabs $0(Tier 1) torsemide tabs $0(Tier 1) Diuretics, Potassium-sparing amiloride hcl tabs $0(Tier 1) amiloride/hydrochlorothiazide $0(Tier 1) spironolactone/hydrochlorothiazide $0(Tier 1) spironolactone tabs $0(Tier 1) triamterene/hydrochlorothiazide $0(Tier 1) Diuretics, Thiazide chlorothiazide $0(Tier 1) chlorothiazide sodium $0(Tier 1) chlorthalidone tabs 25mg, 50mg $0(Tier 1) hydrochlorothiazide caps, tabs $0(Tier 1) indapamide tabs $0(Tier 1) metolazone $0(Tier 1) Dyslipidemics, Fibric Acid Derivatives fenofibrate micronized caps 134mg, 200mg $0(Tier 1) QL (30 per 30 days) fenofibrate micronized caps 67mg $0(Tier 1) QL (60 per 30 days) fenofibrate caps 130mg, 150mg $0(Tier 1) QL (30 per 30 days) fenofibrate caps 43mg, 50mg $0(Tier 1) QL (60 per 30 days) fenofibrate tabs 145mg, 160mg $0(Tier 1) QL (30 per 30 days) fenofibrate tabs 48mg, 54mg $0(Tier 1) QL (60 per 30 days) fenofibric acid dr cpdr 135mg $0(Tier 1) QL (30 per 30 days) fenofibric acid dr cpdr 45mg $0(Tier 1) QL (60 per 30 days) gemfibrozil tabs $0(Tier 1) QL (60 per 30 days) Dyslipidemics, HMG CoA Reductase Inhibitors atorvastatin calcium $0(Tier 1) QL (30 per 30 days) CRESTOR $0(Tier 2) QL (30 per 30 days) ST LIVALO $0(Tier 2) QL (30 per 30 days) ST lovastatin tabs 10mg, 20mg $0(Tier 1) QL (30 per 30 days) lovastatin tabs 40mg $0(Tier 1) QL (60 per 30 days) pravastatin sodium $0(Tier 1) QL (30 per 30 days) rosuvastatin calcium $0(Tier 1) QL (30 per 30 days) simvastatin tabs $0(Tier 1) QL (30 per 30 days) Dyslipidemics, Other cholestyramine light $0(Tier 1) cholestyramine pack, powd $0(Tier 1) colestipol hcl $0(Tier 1) ezetimibe $0(Tier 1) QL (30 per 30 days) ezetimibe/simvastatin $0(Tier 1) QL (30 per 30 days) niacin er tbcr 500mg $0(Tier 1) QL (30 per 30 days) apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 42

51 What the drug Name of drug niacin er tbcr 1000mg, 750mg $0(Tier 1) QL (60 per 30 days) niacin tabs 100mg, 500mg, 50mg $0(Tier 1) MC niacin tbcr 500mg $0(Tier 1) MC niacor $0(Tier 1) omega-3-acid ethyl esters $0(Tier 1) QL (120 per 30 days) prevalite $0(Tier 1) REPATHA $0(Tier 2) QL (3 per 30 days) PA REPATHA PUSHTRONEX SYSTEM $0(Tier 2) QL (3.5 per 30 days) PA REPATHA SURECLICK $0(Tier 2) QL (3 per 30 days) PA VASCEPA CAPS 1GM $0(Tier 2) QL (120 per 30 days) VASCEPA CAPS 0.5GM $0(Tier 2) QL (240 per 30 days) WELCHOL $0(Tier 2) ZETIA $0(Tier 2) QL (30 per 30 days) ST Vasodilators, Direct-acting Arterial/Venous BIDIL $0(Tier 2) QL (180 per 30 days) isosorbide dinitrate er $0(Tier 1) isosorbide dinitrate tabs 10mg, 20mg, 30mg, 5mg $0(Tier 1) isosorbide mononitrate $0(Tier 1) isosorbide mononitrate er $0(Tier 1) minitran $0(Tier 1) QL (30 per 30 days) nitroglycerin lingual soln $0(Tier 1) nitroglycerin transdermal $0(Tier 1) QL (30 per 30 days) nitroglycerin inj 5mg/ml $0(Tier 1) nitroglycerin subl 0.3mg, 0.4mg, 0.6mg $0(Tier 1) Vasodilators, Direct-acting Arterial hydralazine hcl inj, tabs $0(Tier 1) minoxidil tabs $0(Tier 1) Central Nervous System Agents (Drugs that Affect the Nervous System) Attention Deficit Hyperactivity Disorder Agents, Amphetamines amphetamine/dextroamphetamine cp24 2.5mg; 2.5mg; 2.5mg; 2.5mg, 3.75mg; 3.75mg; 3.75mg; 3.75mg, 5mg; 5mg; 5mg; 5mg, 7.5mg; 7.5mg; 7.5mg; 7.5mg amphetamine/dextroamphetamine cp mg; 1.25mg; 1.25mg; 1.25mg, 6.25mg; 6.25mg; 6.25mg; 6.25mg amphetamine/dextroamphetamine tabs 1.25mg; 1.25mg; 1.25mg; 1.25mg, 1.875mg; 1.875mg; 1.875mg; 1.875mg, 2.5mg; 2.5mg; 2.5mg; 2.5mg, 3.125mg; 3.125mg; 3.125mg; 3.125mg, 3.75mg; 3.75mg; 3.75mg; 3.75mg, 7.5mg; 7.5mg; 7.5mg; 7.5mg $0(Tier 1) $0(Tier 1) $0(Tier 1) QL (30 per 30 days) QL (60 per 30 days) QL (60 per 30 days) amphetamine/dextroamphetamine tabs 5mg; 5mg; 5mg; 5mg $0(Tier 1) QL (90 per 30 days) dextroamphetamine sulfate er cp24 15mg $0(Tier 1) QL (120 per 30 days) dextroamphetamine sulfate er cp24 5mg $0(Tier 1) QL (60 per 30 days) apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 43

52 Name of drug What the drug dextroamphetamine sulfate er cp24 10mg $0(Tier 1) QL (90 per 30 days) dextroamphetamine sulfate soln $0(Tier 1) QL (1800 per 30 days) dextroamphetamine sulfate tabs 10mg $0(Tier 1) QL (180 per 30 days) dextroamphetamine sulfate tabs 5mg $0(Tier 1) QL (60 per 30 days) Attention Deficit Hyperactivity Disorder Agents, Nonamphetamines atomoxetine caps 100mg, 60mg, 80mg $0(Tier 1) QL (30 per 30 days) atomoxetine caps 10mg, 18mg, 25mg, 40mg $0(Tier 1) QL (60 per 30 days) clonidine hcl er $0(Tier 1) QL (120 per 30 days) dexmethylphenidate hcl $0(Tier 1) QL (60 per 30 days) metadate er tbcr 20mg $0(Tier 1) QL (90 per 30 days) methylphenidate hcl er tb24 18mg $0(Tier 1) QL (120 per 30 days) methylphenidate hcl er tb24 27mg, 54mg $0(Tier 1) QL (30 per 30 days) methylphenidate hcl er tb24 36mg $0(Tier 1) QL (60 per 30 days) methylphenidate hcl er tbcr 18mg $0(Tier 1) QL (120 per 30 days) methylphenidate hcl er tbcr 10mg, 27mg, 54mg $0(Tier 1) QL (30 per 30 days) methylphenidate hcl er tbcr 36mg $0(Tier 1) QL (60 per 30 days) methylphenidate hcl er tbcr 20mg $0(Tier 1) QL (90 per 30 days) methylphenidate hcl sr $0(Tier 1) QL (90 per 30 days) methylphenidate hcl tabs $0(Tier 1) QL (90 per 30 days) Central Nervous System, Other HETLIOZ $0(Tier 2) QL (30 per 30 days) PA NUEDEXTA $0(Tier 2) QL (60 per 30 days) riluzole $0(Tier 1) tetrabenazine tabs 25mg $0(Tier 1) QL (120 per 30 days) PA tetrabenazine tabs 12.5mg $0(Tier 1) QL (90 per 30 days) PA Fibromyalgia Agents LYRICA CR TB24 330MG $0(Tier 2) QL (60 per 30 days) LYRICA CR TB24 165MG, 82.5MG $0(Tier 2) QL (90 per 30 days) Multiple Sclerosis Agents AMPYRA $0(Tier 2) QL (60 per 30 days) PA AVONEX $0(Tier 2) QL (4 per 28 days) PA AVONEX PEN $0(Tier 2) QL (4 per 28 days) PA BETASERON $0(Tier 2) QL (14 per 28 days) PA COPAXONE INJ 40MG/ML $0(Tier 2) QL (12 per 28 days) PA COPAXONE INJ 20MG/ML $0(Tier 2) QL (30 per 30 days) PA apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 44

53 What the drug Name of drug GILENYA $0(Tier 2) QL (30 per 30 days) PA REBIF $0(Tier 2) QL (6 per 28 days) PA REBIF REBIDOSE $0(Tier 2) QL (6 per 28 days) PA REBIF REBIDOSE TITRATION PACK $0(Tier 2) QL (4.2 per 28 days) PA REBIF TITRATION PACK $0(Tier 2) QL (4.2 per 28 days) PA TECFIDERA STARTER PACK $0(Tier 2) QL (120 per 365 days) PA TECFIDERA CPDR 120MG $0(Tier 2) QL (14 per 30 days) PA TECFIDERA CPDR 240MG $0(Tier 2) QL (60 per 30 days) PA TYSABRI $0(Tier 2) QL (15 per 28 days) PA Dental and Oral Agents (Drugs that Relieve or Prevent Problems of the Mouth) Dental and Oral Agents chlorhexidine gluconate oral rinse $0(Tier 1) chlorhexidine gluconate soln $0(Tier 1) oralone dental paste $0(Tier 1) paroex $0(Tier 1) periogard $0(Tier 1) pilocarpine hcl tabs 7.5mg $0(Tier 1) pilocarpine hydrochloride $0(Tier 1) triamcinolone acetonide dental paste $0(Tier 1) Dermatological Agents (Drugs d for Skin Problems) Dermatological Agents acitretin $0(Tier 1) PA acne medication 10 $0(Tier 1) MC acne medication 5 $0(Tier 1) MC ammonium lactate crea, lotn $0(Tier 1) amnesteem $0(Tier 1) avita $0(Tier 1) QL (45 per 30 days) PA benzoyl peroxide wash liqd 10%, 5% $0(Tier 1) MC benzoyl peroxide gel 10%, 2.5%, 5% $0(Tier 1) MC benzoyl peroxide foam $0(Tier 1) MC blue gel gel 2% $0(Tier 1) MC calcipotriene crea, oint $0(Tier 1) QL (120 per 30 days) calcipotriene soln $0(Tier 1) QL (60 per 30 days) calcitrene $0(Tier 1) QL (120 per 30 days) calcitriol oint 3mcg/gm $0(Tier 1) QL (800 per 30 days) capsaicin crea 0.025% $0(Tier 1) MC apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 45

54 Name of drug What the drug claravis $0(Tier 1) coats aloe creme $0(Tier 1) MC coats aloe gelly $0(Tier 1) MC coats aloe moisturizing lotion $0(Tier 1) MC coleman botanicals insectrepellent $0(Tier 1) MC coleman insect repellent/high & dry $0(Tier 1) MC coleman skinsmart insect repellent $0(Tier 1) MC curity gauze pads 2"x2" $0(Tier 1) cutter backwoods $0(Tier 1) MC cutter backwoods dry $0(Tier 1) MC cutter lemon eucalyptus $0(Tier 1) MC diclofenac sodium gel 1% $0(Tier 1) QL (1000 per 30 days) diclofenac sodium transdermal soln 1.5% $0(Tier 1) QL (1050 per 30 days) doxepin hydrochloride $0(Tier 1) DR SMITHS DIAPER $0(Tier 1) MC dr smiths diaper rash spray $0(Tier 1) MC ELIDEL $0(Tier 2) QL (100 per 90 days) erythromycin/benzoyl peroxide $0(Tier 1) fluorouracil crea 5% $0(Tier 1) fluorouracil crea 0.5% $0(Tier 1) fluorouracil external soln 2%, 5% $0(Tier 1) hemorrhoidal supp 88.7%; 0.25% $0(Tier 1) MC imiquimod crea $0(Tier 1) QL (12 per 30 days) isotretinoin caps $0(Tier 1) lidocaine crea 5% $0(Tier 1) MC major-prep hemorrhoidal oint 14%; 74.9%; 0.25% $0(Tier 1) MC methoxsalen caps $0(Tier 1) moisturel therapeutic $0(Tier 1) MC myorisan $0(Tier 1) natrapel 12-hour tick & insect repellent continuous spray $0(Tier 1) MC off deep woods $0(Tier 1) MC off deep woods dry $0(Tier 1) MC off deep woods sportsmen aero $0(Tier 1) MC off deep woods sportsmen liqd 25% $0(Tier 1) MC pain relieving cream $0(Tier 1) MC PICATO GEL 0.05% $0(Tier 2) QL (2 per 56 days) PICATO GEL 0.015% $0(Tier 2) QL (3 per 56 days) podofilox soln $0(Tier 1) REGRANEX $0(Tier 2) QL (15 per 30 days) PA repel hunters formula $0(Tier 1) MC repel lemon eucalyptus insect repellent $0(Tier 1) MC repel sportsmen $0(Tier 1) MC repel sportsmen dry $0(Tier 1) MC repel sportsmen max aero $0(Tier 1) MC apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 46

55 What the drug Name of drug SANTYL $0(Tier 2) sawyer premium insect repellent $0(Tier 1) MC selenium sulfide lotn $0(Tier 1) tacrolimus oint 0.03%, 0.1% $0(Tier 1) QL (100 per 90 days) tazarotene crea $0(Tier 1) QL (120 per 30 days) TAZORAC GEL $0(Tier 2) QL (100 per 30 days) TAZORAC CREA $0(Tier 2) QL (120 per 30 days) tretinoin microsphere $0(Tier 1) PA tretinoin microsphere pump $0(Tier 1) PA tretinoin crea 0.025%, 0.05%, 0.1% $0(Tier 1) QL (45 per 30 days) PA tretinoin gel 0.01%, 0.025%, 0.05% $0(Tier 1) QL (45 per 30 days) PA ultrathon insect repellent 8 $0(Tier 1) MC UVADEX $0(Tier 2) B/D vitamin a & d oint 15.5%; 53.4% $0(Tier 1) MC white petrolatum $0(Tier 1) MC z-bum $0(Tier 1) MC zenatane $0(Tier 1) zinc oxide oint 20% $0(Tier 1) MC ZYCLARA $0(Tier 2) QL (56 per 30 days) ZYCLARA PUMP CREA 2.5% $0(Tier 2) QL (15 per 30 days) ZYCLARA PUMP CREA 3.75% $0(Tier 2) QL (56 per 30 days) Electrolytes/Minerals/Metals/Vitamins (Drugs d to Replace Nutrients, Minerals, and Electrolytes) Electrolyte/Mineral Replacement AMINOSYN 7%/ELECTROLYTES $0(Tier 2) B/D AMINOSYN 8.5%/ELECTROLYTES $0(Tier 2) B/D AMINOSYN II 8.5%/ELECTROLYTES $0(Tier 2) B/D apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 47

56 What the drug Name of drug AMINOSYN II INJ 107.6MEQ/L; 1490MG/100ML; $0(Tier 2) 1527MG/100ML; 1050MG/100ML; 1107MG/100ML; 750MG/100ML; 450MG/100ML; 990MG/100ML; 1500MG/100ML; 1575MG/100ML; 258MG/100ML; 447MG/100ML; 1083MG/100ML; 795MG/100ML; 50MEQ/L; 600MG/100ML; 300MG/100ML; 405MG/100ML; 750MG/100ML, 50.3MEQ/L; 695MG/100ML; 713MG/100ML; 490MG/100ML; 517MG/100ML; 350MG/100ML; 210MG/100ML; 462MG/100ML; 700MG/100ML; 735MG/100ML; 120MG/100ML; 209MG/100ML; 505MG/100ML; 371MG/100ML; 31.3MEQ/L; 280MG/100ML; 140MG/100ML; 189MG/100ML; 350MG/100ML, 61.1MEQ/L; 844MG/100ML; 865MG/100ML; 595MG/100ML; 627MG/100ML; 425MG/100ML; 255MG/100ML; 561MG/100ML; 850MG/100ML; 893MG/100ML; 146MG/100ML; 253MG/100ML; 614MG/100ML; 450MG/100ML; 33.3MEQ/L; 340MG/100ML; 170MG/100ML; 230MG/100ML; 425MG/100ML, 71.8MEQ/L; 993MG/100ML; 1018MG/100ML; 700MG/100ML; 738MG/100ML; 500MG/100ML; 300MG/100ML; 660MG/100ML; 1000MG/100ML; 1050MG/100ML; 172MG/100ML; 298MG/100ML; 722MG/100ML; 530MG/100ML; 38MEQ/L; 400MG/100ML; 200MG/100ML; 270MG/100ML; 500MG/100ML AMINOSYN M INJ 65MEQ/L; 448MG/100ML; $0(Tier 2) 343MG/100ML; 40MEQ/L; 448MG/100ML; 105MG/100ML; 252MG/100ML; 329MG/100ML; 252MG/100ML; 3MEQ/L; 140MG/100ML; 154MG/100ML; 3.5MMOLE/L; 13MEQ/L; 300MG/100ML; 147MG/100ML; 40MEQ/L; 182MG/100ML; 56MG/100ML; 31MG/100ML; 280MG/100ML AMINOSYN-HBC $0(Tier 2) B/D AMINOSYN-PF $0(Tier 2) B/D AMINOSYN-PF 7% $0(Tier 2) B/D AMINOSYN-RF $0(Tier 2) B/D B/D B/D apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 48

57 What the drug Name of drug AMINOSYN INJ 148MEQ/L; 1280MG/100ML; $0(Tier 2) 980MG/100ML; 1280MG/100ML; 300MG/100ML; 720MG/100ML; 940MG/100ML; 720MG/100ML; 400MG/100ML; 440MG/100ML; 5.4MEQ/L; 860MG/100ML; 420MG/100ML; 520MG/100ML; 160MG/100ML; 44MG/100ML; 800MG/100ML, 90MEQ/L; 1100MG/100ML; 850MG/100ML; 35MEQ/L; 1100MG/100ML; 260MG/100ML; 620MG/100ML; 810MG/100ML; 624MG/100ML; 340MG/100ML; 380MG/100ML; 5.4MEQ/L; 750MG/100ML; 370MG/100ML; 460MG/100ML; 150MG/100ML; 44MG/100ML; 680MG/100ML bprotected pedia iron $0(Tier 1) MC cal-mag-zinc-d $0(Tier 1) MC calcet petites $0(Tier 1) MC calci-chew $0(Tier 1) MC calcitrate $0(Tier 1) MC calcium + d3 $0(Tier 1) MC calcium 500 +d3 $0(Tier 1) MC calcium 500 +d tabs 500mg; 400unit $0(Tier 1) MC calcium 500+d high potency $0(Tier 1) MC calcium 500+d3 $0(Tier 1) MC calcium 500+d tabs $0(Tier 1) MC calcium 500/d chew $0(Tier 1) MC calcium 500/d tabs 200unit; 500mg $0(Tier 1) MC calcium 500/vitamin d3 $0(Tier 1) MC calcium 600 $0(Tier 1) MC calcium 600 high potency $0(Tier 1) MC calcium 600 with vitamin d $0(Tier 1) MC calcium 600+d $0(Tier 1) MC calcium 600+d high potency $0(Tier 1) MC calcium 600+d plus minerals chew 600mg; 400unit; 1mg; $0(Tier 1) MC 50mg; 1.8mg; 250mcg; 7.5mg calcium 600+d plus minerals tabs $0(Tier 1) MC calcium 600+d3 $0(Tier 1) MC calcium 600+d3 plus minerals chew $0(Tier 1) MC calcium 600-d $0(Tier 1) MC calcium 600/vitamin d $0(Tier 1) MC calcium 600/vitamin d3 $0(Tier 1) MC calcium carbonate/d3 $0(Tier 1) MC calcium carbonate/vitamin d $0(Tier 1) MC calcium carbonate chew 500mg $0(Tier 1) MC calcium carbonate susp $0(Tier 1) MC calcium carbonate tabs 1250mg, 600mg $0(Tier 1) MC calcium citrate + d $0(Tier 1) MC B/D apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 49

58 Name of drug What the drug calcium citrate + d3 max imum $0(Tier 1) MC calcium citrate + d3 maximum $0(Tier 1) MC calcium citrate malate/vitamin d $0(Tier 1) MC calcium citrate maximum/vitamin d $0(Tier 1) MC calcium citrate plus/magnesium $0(Tier 1) MC calcium citrate w/d $0(Tier 1) MC calcium citrate+d $0(Tier 1) MC calcium citrate+d3 $0(Tier 1) MC calcium citrate/vitamin d3 tabs $0(Tier 1) MC calcium citrate/vitamin d tabs 315mg; 200unit, 315mg; $0(Tier 1) MC 250unit calcium citrate tabs 200mg $0(Tier 1) MC calcium extra d3 $0(Tier 1) MC calcium for women $0(Tier 1) MC calcium gluconate tabs 500mg $0(Tier 1) MC calcium high potency $0(Tier 1) MC calcium high potency + vitamin d $0(Tier 1) MC calcium oyster shell $0(Tier 1) MC calcium plus vitamin d3 tabs $0(Tier 1) MC calcium+d3 $0(Tier 1) MC calcium/c/d $0(Tier 1) MC calcium/d tabs $0(Tier 1) MC calcium/magnesium/zinc tabs mg; mg; 5mg, $0(Tier 1) MC 333mg; 133mg; 5mg calcium/vitamin d3 tabs 250mg; 125unit $0(Tier 1) MC calcium/vitamin d caps 600mg; 400unit $0(Tier 1) MC calcium/vitamin d tabs 200unit; 500mg, 500mg; 200unit, $0(Tier 1) MC 500mg; 400unit, 600mg; 200unit, 600mg; 400unit calcium tabs 500mg, 600mg $0(Tier 1) MC caltrate 600+d plus minerals tabs $0(Tier 1) MC caltrate 600+d3 soft chews $0(Tier 1) MC caltrate 600+d tabs 600mg; 800unit $0(Tier 1) MC CARBAGLU $0(Tier 2) PA centamin $0(Tier 1) MC centratex $0(Tier 1) MC chewable calcium chew $0(Tier 1) MC citracal + d3 maximum $0(Tier 1) MC citracal maximum $0(Tier 1) MC CLINIMIX 2.75%/DEXTROSE 5% $0(Tier 2) B/D CLINIMIX 4.25%/DEXTROSE 10% $0(Tier 2) B/D CLINIMIX 4.25%/DEXTROSE 20% $0(Tier 2) B/D CLINIMIX 4.25%/DEXTROSE 25% $0(Tier 2) B/D CLINIMIX 4.25%/DEXTROSE 5% $0(Tier 2) B/D CLINIMIX 5%/DEXTROSE 15% $0(Tier 2) B/D CLINIMIX 5%/DEXTROSE 20% $0(Tier 2) B/D apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 50

59 Name of drug What the drug CLINIMIX 5%/DEXTROSE 25% $0(Tier 2) B/D CLINIMIX E 2.75%/DEXTROSE 10% $0(Tier 2) B/D CLINIMIX E 4.25%/DEXTROSE 10% $0(Tier 2) B/D CLINIMIX E 4.25%/DEXTROSE 25% $0(Tier 2) B/D CLINIMIX E 5%/DEXTROSE 25% $0(Tier 2) B/D CLINIMIX N14G30E $0(Tier 2) B/D CLINIMIX N9G15E $0(Tier 2) B/D CLINISOL SF 15% $0(Tier 2) B/D coral calcium caps 100unit; 185mg; 50mg $0(Tier 1) MC corvite 150 tabs 100mcg; 120mg; 5mg; 20mcg; 700mcg; $0(Tier 1) MC 150mg; 300mcg; 10mg; 10mg; 25mg corvite fe tabs 160mg; 5mg; 1000unit; 10mg; 15mg; 1mg; $0(Tier 1) MC 150mg; 10mg; 25mg cvs calcium 600 & vitamind3 $0(Tier 1) MC cvs calcium 600+d $0(Tier 1) MC cvs calcium chewables 600plus $0(Tier 1) MC cvs calcium citrate + d $0(Tier 1) MC cvs calcium citrate+d/magnesium tabs 250mg; 125unit; $0(Tier 1) MC 0.5mg; 40mg; 0.5mg; 0.25mg; 3.75mg cvs electrolyte solution $0(Tier 1) MC cvs iron $0(Tier 1) MC cvs magnesium tabs $0(Tier 1) MC cvs pediatric electrolyte $0(Tier 1) MC cvs pediatric electrolyte freezer pops $0(Tier 1) MC cvs selenium $0(Tier 1) MC cvs slow release iron $0(Tier 1) MC cvs zinc $0(Tier 1) MC DEXTROSE 10%/NACL 0.45% $0(Tier 2) B/D dextrose 5% /electrolyte #48 viaflex $0(Tier 1) B/D DEXTROSE 10% $0(Tier 2) B/D DEXTROSE 10%/NACL 0.2% $0(Tier 2) B/D DEXTROSE 2.5%/NACL 0.45% $0(Tier 2) B/D DEXTROSE 20% $0(Tier 2) B/D DEXTROSE 25% INJ 250MG/ML $0(Tier 2) B/D DEXTROSE 30% $0(Tier 2) B/D DEXTROSE 40% $0(Tier 2) B/D DEXTROSE 5% $0(Tier 2) DEXTROSE 5%/LACTATED RINGERS $0(Tier 2) B/D DEXTROSE 5%/NACL 0.2% $0(Tier 2) DEXTROSE 5%/NACL 0.225% $0(Tier 2) DEXTROSE 5%/NACL 0.3% $0(Tier 2) DEXTROSE 5%/NACL 0.33% $0(Tier 2) DEXTROSE 5%/NACL 0.45% $0(Tier 2) DEXTROSE 5%/NACL 0.9% $0(Tier 2) DEXTROSE 50% $0(Tier 2) B/D apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 51

60 Name of drug What the drug DEXTROSE 70% $0(Tier 2) duofer $0(Tier 1) MC enfalyte $0(Tier 1) MC enfamil enfalyte soln 45meq/l; 33meq/l; 25meq/l; 50meq/l $0(Tier 1) MC enlyte $0(Tier 1) MC eq calcium 500+d $0(Tier 1) MC eq calcium 600+d $0(Tier 1) MC eq calcium citrate+d $0(Tier 1) MC eq slow-release iron $0(Tier 1) MC eql calcium citrate w/vitamin d $0(Tier 1) MC eql calcium/vitamin d tabs $0(Tier 1) MC eql pediatric electrolyte soln 35meq/l; 20gm/l; 5gm/l; 20meq/l; 45meq/l, 35meq/l; 25gm/l; 20meq/l; 45meq/l; 7.8mg/l $0(Tier 1) ezfe 200 $0(Tier 1) MC fe c tab $0(Tier 1) MC feosol bifera $0(Tier 1) MC feosol tabs 200mg $0(Tier 1) MC fer-in-sol soln $0(Tier 1) MC fer-iron $0(Tier 1) MC ferate tabs 27mg $0(Tier 1) MC fergon tabs 240mg $0(Tier 1) MC feriva 21/7 $0(Tier 1) MC ferivafa $0(Tier 1) MC ferralet 90 $0(Tier 1) MC ferraplus 90 $0(Tier 1) MC ferretts $0(Tier 1) MC ferretts ips $0(Tier 1) MC ferrex 150 $0(Tier 1) MC ferrex 150 forte $0(Tier 1) MC ferric x-150 $0(Tier 1) MC ferrimin 150 $0(Tier 1) MC ferrocite $0(Tier 1) MC ferrous fumarate 324 $0(Tier 1) MC ferrous gluconate tabs 240mg, 324mg $0(Tier 1) MC ferrous sulfate elix, syrp, tbcr, tbec $0(Tier 1) MC ferrous sulfate soln 15mg/ml $0(Tier 1) MC ferrous sulfate tabs 325mg $0(Tier 1) MC ferrousul $0(Tier 1) MC floriva liqd 0.25mg/ml; 400unit/ml $0(Tier 1) MC fluoride chew 0.25mg, 1.1mg, 2.2mg $0(Tier 1) fluoritab chew 0.5mg, 1mg $0(Tier 1) focalgin dss $0(Tier 1) MC FREAMINE HBC 6.9% $0(Tier 2) B/D FREAMINE III $0(Tier 2) B/D apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 52 MC

61 Name of drug What the drug fusion $0(Tier 1) MC fusion plus $0(Tier 1) MC gnp calcium 500 +d3 $0(Tier 1) MC gnp calcium 600 +d3 $0(Tier 1) MC gnp calcium 600 +d3/minerals chew 600mg; 800unit; 1mg; $0(Tier 1) MC 40mg; 0; 0; 1.8mg; 250mcg; 7.5mg gnp calcium citrate +d3 $0(Tier 1) MC gnp calcium citrate+d3 maximum $0(Tier 1) MC gnp calcium tabs 600mg $0(Tier 1) MC gnp iron tbcr $0(Tier 1) MC gnp iron tabs 200mg $0(Tier 1) MC gnp pediatric electrolyte soln 35meq/l; 20gm/l; 5gm/l; 20meq/l; 45meq/l, 35meq/l; 25gm/l; 20meq/l; 45meq/l gnp therapeutic-m tabs 90mg; 0; 30mcg; 150mcg; 40mg; 10mg; 7.5mg; 400unit; 50mcg; 2mg; 12mcg; 9mg; 400mcg; 100mg; 2mg; 20mg; 5mcg; 31mg; 28mcg; 7.5mg; 150mcg; 6mg; 3.4mg; 2mg; 10mcg; 75mcg; 70mcg; 10mcg; 3mg; 60unit; 5000unit; 15mg $0(Tier 1) $0(Tier 1) gnp vitamin c drops $0(Tier 1) MC h-e-b oral electrolyte solution $0(Tier 1) MC hemocyte $0(Tier 1) MC hemocyte plus $0(Tier 1) MC hemocyte-f tabs $0(Tier 1) MC HEPATAMINE $0(Tier 2) B/D hm calcium 600 & vitamin d3 $0(Tier 1) MC hm calcium d plus minerals $0(Tier 1) MC hm calcium vitamin d3 $0(Tier 1) MC hm calcium citrate + vitamin d $0(Tier 1) MC hm calcium/vitamin d $0(Tier 1) MC hm calcium/vitamin d/minerals $0(Tier 1) MC hm iron $0(Tier 1) MC hm iron slow release $0(Tier 1) MC hm pediatric electrolyte $0(Tier 1) MC hm selenium $0(Tier 1) MC hm zinc $0(Tier 1) MC i.l.x. b-12 $0(Tier 1) MC icar pediatric $0(Tier 1) MC icar-c $0(Tier 1) MC iferex 150 $0(Tier 1) MC infed $0(Tier 1) MC iron 27 $0(Tier 1) MC iron high-potency tabs $0(Tier 1) MC iron slow release tbcr 45mg $0(Tier 1) MC iron tabs 256mg, 27mg, 325mg, 65mg $0(Tier 1) MC irospan 24/6 $0(Tier 1) MC apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 53 MC MC

62 Name of drug What the drug k-sol soln 10% $0(Tier 1) KABIVEN $0(Tier 2) B/D KCL 0.075%/D5W/NACL 0.45% $0(Tier 2) B/D KCL 0.15%/D5W/NACL 0.2% $0(Tier 2) B/D kcl 0.15%/d5w/nacl 0.225% inj 5%; 20meq/l; 0.225% $0(Tier 1) B/D kcl 0.15%/d5w/nacl 0.45% inj 5%; 20meq/l; 0.45% $0(Tier 1) B/D KCL 0.15%/D5W/NACL 0.9% $0(Tier 2) B/D KCL 0.3%/D5W/NACL 0.45% $0(Tier 2) B/D kcl 0.3%/d5w/nacl 0.9% $0(Tier 1) B/D klor-con $0(Tier 1) klor-con 10 $0(Tier 1) klor-con 8 $0(Tier 1) klor-con m10 $0(Tier 1) klor-con m20 $0(Tier 1) klor-con sprinkle $0(Tier 1) kp calcium 600+d tabs 600mg; 800unit $0(Tier 1) MC kp calcium citrate+d $0(Tier 1) MC kp ferrous gluconate $0(Tier 1) MC kp ferrous sulfate $0(Tier 1) MC LACTATED RINGERS VIAFLEX $0(Tier 2) B/D LACTATED RINGERS INJ 3MEQ/L; 109MEQ/L; $0(Tier 2) B/D 28MEQ/L; 4MEQ/L; 130MEQ/L liquid calcium/vitamin d $0(Tier 1) MC ludent $0(Tier 1) mag-tab sr $0(Tier 1) MC magnesium 27 $0(Tier 1) MC magnesium elemental $0(Tier 1) MC magnesium l-lactate dihyrate $0(Tier 1) MC magnesium sulfate inj 20gm/500ml, 2gm/50ml, 40gm/1000ml, $0(Tier 1) B/D 4gm/100ml, 4gm/50ml, 50% magnesium tabs 250mg, 500mg $0(Tier 1) MC monocal $0(Tier 1) MC myferon 150 $0(Tier 1) MC NEPHRAMINE $0(Tier 2) B/D nephron fa $0(Tier 1) MC NORMOSOL -R $0(Tier 2) B/D NORMOSOL-M IN D5W $0(Tier 2) B/D NORMOSOL-R $0(Tier 2) B/D NORMOSOL-R IN D5W $0(Tier 2) B/D nu-iron 150 $0(Tier 1) MC nu-mag $0(Tier 1) MC NUTRILYTE II $0(Tier 2) B/D NUTRILYTE INJ 2.03MEQ/ML; 0.25MEQ/ML; 1.68MEQ/ML; 0.25MEQ/ML; 0.4MEQ/ML; 2.03MEQ/ML; 1.25MEQ $0(Tier 2) apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 54 B/D

63 Name of drug What the drug oceanic selenium $0(Tier 1) MC oralyte $0(Tier 1) MC oralyte freezer pops $0(Tier 1) MC orazinc caps 220mg $0(Tier 1) MC orazinc tabs $0(Tier 1) MC os-cal calcium + d3 $0(Tier 1) MC os-cal extra d3 $0(Tier 1) MC osteo-poretical $0(Tier 1) MC oysco 500 $0(Tier 1) MC oysco 500+d tabs $0(Tier 1) MC oyst-cal-d 500 $0(Tier 1) MC oyster calcium $0(Tier 1) MC oyster shell calcium + d3 $0(Tier 1) MC oyster shell calcium + vitamin d $0(Tier 1) MC oyster shell calcium 250+d $0(Tier 1) MC oyster shell calcium 500 $0(Tier 1) MC oyster shell calcium d tabs 500mg; 125unit $0(Tier 1) MC oyster shell calcium 500+d $0(Tier 1) MC oyster shell calcium 500/d $0(Tier 1) MC oyster shell calcium plusvitamin d $0(Tier 1) MC oyster shell calcium+d $0(Tier 1) MC oyster shell calcium/d3 $0(Tier 1) MC oyster shell calcium/d tabs 250mg; 125unit, 500mg; 200unit $0(Tier 1) MC oyster shell calcium/magnesium $0(Tier 1) MC oyster shell calcium/vitamin d tabs 200unit; 500mg, 250mg; $0(Tier 1) MC 125unit; 0, 500mg; 200unit, 500mg; 400unit oyster shell calcium tabs 500mg $0(Tier 1) MC oystercal-d tabs 400unit; 500mg $0(Tier 1) MC pedialyte advanced care soln 35meq/l; 16gm/l; 20meq/l; 45meq/l; 7.8mg/l, 6.3meq/237ml; 4.7meq/237ml; 10.6meq/237ml; 0 $0(Tier 1) MC pedialyte freezer pops $0(Tier 1) MC pedialyte singles soln 7meq/200ml; 5.3gm/200ml; 4meq/200ml; 9meq/200ml; 1.6mg/200ml, 8.3meq/240ml; 7.1meq/240ml; 4.7gm/240ml; 1.2gm/240ml; 4.7meq/240ml; 10.6meq/240ml $0(Tier 1) MC pedialyte soln 2.1meq/59ml; 1.5gm/59ml; 1.2meq/59ml; 2.7meq/59ml; 0.5mg/59ml, 35meq/l; 20gm/l; 5gm/l; 20meq/l; 45meq/l, 35meq/l; 25gm/l; 20meq/l; 45meq/l; 7.8mg/l, 35meq/l; 30meq/l; 25gm/l; 20meq/l; 45meq/l $0(Tier 1) pediatric electrolyte freeze pops $0(Tier 1) MC pediatric electrolyte freezer pops soln 35meq/1000ml; $0(Tier 1) MC 25gm/1000ml; 20meq/1000ml; 45meq/1000ml pediatric electrolyte/zinc $0(Tier 1) MC MC apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 55

64 What the drug Name of drug pediatric electrolyte soln 35meq/l; 20gm/l; 20meq/l; 45meq/l, $0(Tier 1) 35meq/l; 20gm/l; 5gm/l; 20meq/l; 45meq/l, 35meq/l; 25gm/l; 20meq/l; 45meq/l, 35meq/l; 25gm; 20meq/l; 45meq/l; 7.8mg/l, 35meq/l; 30meq/l; 20gm/l; 5gm/l; 20meq/l; 45meq/l, 35meq/l; 30meq/l; 25gm/l; 20meq/l; 45meq/l, 35meq/l; 30meq/l; 25gm/l; 5gm/l; 20meq/l; 45meq/l PERIKABIVEN $0(Tier 2) B/D phospho-trin 250 neutral $0(Tier 1) MC phosphorous $0(Tier 1) MC PLENAMINE $0(Tier 2) B/D poly-iron 150 $0(Tier 1) MC polysacc iron 150 complex $0(Tier 1) MC potassium chloride /sodium chloride $0(Tier 1) B/D potassium chloride cr tbcr 10meq $0(Tier 1) potassium chloride er cpcr $0(Tier 1) potassium chloride er tbcr 10meq, 20meq, 8meq $0(Tier 1) potassium chloride sr tbcr 8meq $0(Tier 1) POTASSIUM CHLORIDE/DEXTROSE/LACTATED $0(Tier 2) B/D RINGERS potassium chloride/dextrose/sodium chloride $0(Tier 1) B/D POTASSIUM CHLORIDE/DEXTROSE INJ 5%; 20MEQ/L $0(Tier 2) B/D potassium chloride/dextrose inj 5%; 40meq/l $0(Tier 1) B/D potassium chloride/sodium chloride inj 20meq/l; 0.45%, $0(Tier 1) B/D 20meq/l; 0.9%, 40meq/l; 0.9% potassium chloride pack, oral soln $0(Tier 1) potassium chloride inj 10meq/100ml, 20meq/100ml, 2meq/ml, $0(Tier 1) B/D 40meq/100ml potassium citrate er $0(Tier 1) PREMASOL $0(Tier 2) B/D PROCALAMINE $0(Tier 2) B/D profe $0(Tier 1) MC proferrin es $0(Tier 1) MC PROSOL $0(Tier 2) B/D qc calcium 600 +d3 $0(Tier 1) MC ra calcium 600 $0(Tier 1) MC ra calcium 600/vit d/minerals $0(Tier 1) MC ra calcium citrate plus vitamin d-3 $0(Tier 1) MC ra central-vite womens mature $0(Tier 1) MC ra high potency iron tabs 27mg $0(Tier 1) MC ra natural magnesium $0(Tier 1) MC ra pediatric electrolyte freezer pops $0(Tier 1) MC ra pediatric electrolyte soln 35meq/l; 25gm/l; 20meq/l; 45meq/l; 7.8mg/l, 35meq/l; 30meq/l; 20gm/l; 5gm/l; 20meq/l; 45meq/l, 35meq/l; 30meq/l; 25gm/l; 20meq/l; 45meq/l $0(Tier 1) ra selenium natural $0(Tier 1) MC MC apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 56 MC

65 Name of drug What the drug ra slow release iron tbcr 45mg $0(Tier 1) MC ra zinc tabs 50mg $0(Tier 1) MC RINGERS INJECTION $0(Tier 2) B/D sb pediatric electrolyte $0(Tier 1) MC se-tan plus $0(Tier 1) MC selenium tbcr $0(Tier 1) MC selenium tabs 200mcg, 50mcg $0(Tier 1) MC slow fe tbcr 142mg $0(Tier 1) MC slow release iron tbcr 45mg, 47.5mg $0(Tier 1) MC slow-mag tbec $0(Tier 1) MC slow-release iron $0(Tier 1) MC sm balanced b-50 $0(Tier 1) MC sm calcium 500/vitamin d3 $0(Tier 1) MC sm calcium 600+d3 $0(Tier 1) MC sm calcium 600/vitamin d $0(Tier 1) MC sm calcium citrate w/vitamin d3 $0(Tier 1) MC sm calcium citrate+ w/vitamin d $0(Tier 1) MC sm calcium soft chews chew 500mg; 200unit; 40mcg $0(Tier 1) MC sm calcium/magnesium/zinc tabs 333mg; 133mg; 5mg $0(Tier 1) MC sm calcium/vitamin d $0(Tier 1) MC sm complete advanced formula $0(Tier 1) MC sm complete senior formula $0(Tier 1) MC sm complete tabs 120mg; 0; 40mcg; 100mg; 10mg; 72mg; 120mcg; 2mg; 16mcg; 400unit; 18mg; 400mcg; 60mg; 40mg; 4mg; 40mg; 5mcg; 50mg; 48mg; 25mcg; 80mg; 150mcg; 6mg; 5.1mg; 4mg; 60mcg; 10mcg; 75mcg; 70mcg; 10mcg; 4.5mg; 60unit; 3500unit; 15mg $0(Tier 1) sm iron slow release tbcr 142mg $0(Tier 1) MC sm iron tabs 325mg $0(Tier 1) MC sm magnesium $0(Tier 1) MC sm multiple vitamins essential $0(Tier 1) MC sm multiple vitamins/iron $0(Tier 1) MC sm oyster shell calcium/vitamin d3 $0(Tier 1) MC sm oyster shell calcium/vitamin d tabs 500mg; 400unit $0(Tier 1) MC sm pediatric electrolyte $0(Tier 1) MC sm selenium $0(Tier 1) MC sm slow release iron $0(Tier 1) MC sm vit c/rose hips $0(Tier 1) MC sm vitamin b-12 $0(Tier 1) MC sm vitamin b-6 $0(Tier 1) MC sm vitamin c chew 500mg $0(Tier 1) MC sm vitamin c tabs 1000mg, 250mg $0(Tier 1) MC sm vitamin e blended $0(Tier 1) MC sm vitamin e caps 1000unit, 200unit, 400unit $0(Tier 1) MC sm zinc $0(Tier 1) MC apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 57 MC

66 Name of drug What the drug sodium bicarbonate partial fill $0(Tier 1) sodium bicarbonate inj 4.2%, 7.5%, 8.4% $0(Tier 1) SODIUM CHLORIDE 0.45% INJ $0(Tier 2) SODIUM CHLORIDE INJ 0.9%, 2.5MEQ/ML, 3%, 5% $0(Tier 2) sodium citrate/citric acid $0(Tier 1) MC sodium fluoride chew 0.5mg, 1mg $0(Tier 1) sodium fluoride chew 1mg $0(Tier 1) MC sodium fluoride soln 0.5mg/ml $0(Tier 1) MC SODIUM LACTATE INJ 5MEQ/ML $0(Tier 2) B/D super calcium d3 $0(Tier 1) MC super calcium 600+d 400 $0(Tier 1) MC super calcium 600+d3 400 $0(Tier 1) MC super calcium tabs 600mg $0(Tier 1) MC support liqd $0(Tier 1) MC TANDEM $0(Tier 1) MC tandem plus $0(Tier 1) MC taron forte $0(Tier 1) MC tgt calcium + vitamin d3 $0(Tier 1) MC th calcium $0(Tier 1) MC th calcium 600 with vitamin d $0(Tier 1) MC th calcium 600/vitamin d $0(Tier 1) MC th calcium citrate/vitamin d $0(Tier 1) MC th iron $0(Tier 1) MC th oyster shell calcium/vitamin d $0(Tier 1) MC th zinc $0(Tier 1) MC therapeutic liquid $0(Tier 1) MC theratrum complete tabs 60mg; 0; 30mcg; 150mcg; 162mg; 10mg; 72mg; 400unit; 120mcg; 2mg; 6mcg; 18mg; 400mcg; 150mcg; 250mcg; 100mg; 2mg; 20mg; 5mcg; 108mg; 80mg; 2mg; 1.7mg; 2mg; 10mcg; 75mcg; 20mcg; 10mcg; 1.5mg; 30unit; 5000unit; 25mcg; 15mg $0(Tier 1) totalday multiple $0(Tier 1) MC TPN ELECTROLYTES $0(Tier 2) B/D TRAVASOL INJ 52MEQ/L; 1760MG/100ML; 880MG/100ML; 34MEQ/L; 1760MG/100ML; 372MG/100ML; 406MG/100ML; 526MG/100ML; 492MG/100ML; 492MG/100ML; 526MG/100ML; 356MG/100ML; 356MG/100ML; 390MG/100ML; 34MG/100ML; 152MG/100ML $0(Tier 2) B/D tricitrates soln $0(Tier 1) MC TROPHAMINE $0(Tier 2) B/D wee care $0(Tier 1) MC zinc 15 $0(Tier 1) MC zinc gluconate tabs 100mg, 30mg, 50mg $0(Tier 1) MC zinc sulfate caps $0(Tier 1) MC apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 58 MC

67 Name of drug What the drug zinc sulfate tabs 220mg $0(Tier 1) MC zinc-220 $0(Tier 1) MC zinc mouth/throat lozg 10mg $0(Tier 1) MC zinc oral lozg 100mg; 50mg; 500unit; 15mg $0(Tier 1) MC zinc tabs 30mg, 50mg $0(Tier 1) MC Electrolyte/Mineral/Metal Modifiers CHEMET $0(Tier 2) CUPRIMINE $0(Tier 2) DEPEN TITRATABS $0(Tier 2) JADENU $0(Tier 2) JADENU SPRINKLE $0(Tier 2) kionex $0(Tier 1) SAMSCA TABS 15MG $0(Tier 2) QL (30 per 30 days) PA SAMSCA TABS 30MG $0(Tier 2) QL (60 per 30 days) PA sodium polystyrene sulfonate powd, oral susp $0(Tier 1) sodium polystyrene sulfonate rectal susp 30gm/120ml $0(Tier 1) sps $0(Tier 1) SYPRINE $0(Tier 2) trientine hydrochloride $0(Tier 1) VELTASSA $0(Tier 2) Phosphate Binders AURYXIA $0(Tier 2) QL (360 per 30 days) calcium acetate caps $0(Tier 1) calcium acetate tabs 667mg $0(Tier 1) PHOSLYRA $0(Tier 2) RENVELA PACK $0(Tier 2) QL (180 per 30 days) RENVELA TABS $0(Tier 2) QL (540 per 30 days) VELPHORO $0(Tier 2) QL (180 per 30 days) apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 59

68 Name of drug Vitamins a thru z advanced tabs 60mg; 0; 30mcg; 200mg; 0; 10mg; 20mg; 0; 72mg; 400unit; 35mcg; 0.5mg; 6mcg; 18mg; 400mcg; 50mg; 0; 0; 2.3mg; 20mg; 5mcg; 25mcg; 80mg; 150mcg; 2mg; 1.7mg; 2mg; 0; 75mcg; 0; 10mcg; 45mcg; 55mcg; 10mcg; 1.5mg; 30unit; 3500unit; 11mg, 60mg; 0; 30mcg; 200mg; 10mg; 20mg; 72mg; 400unit; 35mcg; 0.5mg; 6mcg; 18mg; 400mcg; 50mg; 2.3mg; 20mg; 5mcg; 25mcg; 80mg; 150mcg; 2mg; 1.7mg; 2mg; 75mcg; 10mcg; 45mcg; 55mcg; 10mcg; 1.5mg; 30unit; 3500unit; 11mg, 60mg; 0; 30mcg; 200mg; 10mg; 72mg; 400unit; 35mcg; 0.5mg; 6mcg; 18mg; 400mcg; 50mg; 2.3mg; 20mg; 5mcg; 20mg; 25mcg; 80mg; 150mcg; 2mg; 1.7mg; 75mcg; 2mg; 10mcg; 45mcg; 55mcg; 10mcg; 1.5mg; 30unit; 3500unit; 11mg, 90mg; 0; 30mcg; 200mg; 10mg; 72mg; 400unit; 35mcg; 0.9mg; 6mcg; 18mg; 500mcg; 250mcg; 300mcg; 100mg; 2.3mg; 20mg; 5mcg; 109mg; 25mcg; 80mg; 150mcg; 2mg; 1.7mg; 150mcg; 2mg; 10mcg; 45mcg; 55mcg; 10mcg; 1.5mg; 30unit; 3500unit; 11mg What the drug $0(Tier 1) a thru z select 50+ advanced formula $0(Tier 1) MC a thru z select advanced tabs 60mg; 0; 30mcg; 220mg; 10mg; $0(Tier 1) MC 20mg; 72mg; 500unit; 45mcg; 0.5mg; 25mcg; 400mcg; 250mcg; 300mcg; 50mg; 2.3mg; 20mg; 5mcg; 30mcg; 80mg; 150mcg; 3mg; 1.7mg; 2mg; 150mcg; 10mcg; 45mcg; 55mcg; 1.5mg; 50unit; 2500unit; 11mg a thru z select ultimate womens $0(Tier 1) MC a thru z select tabs 60mg; 0; 30mcg; 220mg; 10mg; 20mg; 72mg; 500unit; 45mcg; 0.5mg; 25mcg; 400mcg; 100mcg; 250mcg; 300mcg; 50mg; 2.3mg; 20mg; 5mcg; 30mcg; 80mg; 3mg; 1.7mg; 150mcg; 2mg; 10mcg; 45mcg; 55mcg; 1.5mg; 50unit; 2500unit; 11mg, 90mg; 0; 30mcg; 220mg; 10mg; 72mg; 500unit; 45mcg; 0.9mg; 25mcg; 500mcg; 150mcg; 250mcg; 300mcg; 50mg; 2.3mg; 20mg; 5mcg; 30mcg; 80mg; 3mg; 1.7mg; 150mcg; 2mg; 10mcg; 45mcg; 55mcg; 1.5mg; 50unit; 2500unit; 11mg $0(Tier 1) MC a thru z ultimate mens $0(Tier 1) MC a $0(Tier 1) MC abaneu-sl $0(Tier 1) MC abc plus senior adults 50+ $0(Tier 1) MC acerola c 500 $0(Tier 1) MC actical $0(Tier 1) MC advanced stress formula/zinc $0(Tier 1) MC alba-lybe nr $0(Tier 1) MC animal chews chew 60mg; 0; 400unit; 4.5mcg; 300mcg; 10mg; 1.05mg; 1.2mg; 0; 1.05mg; 15unit; 1998unit $0(Tier 1) apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 60 MC MC

69 What the drug Name of drug animal shapes/iron $0(Tier 1) MC animal shapes chew 60mg; 0; 4.5mcg; 400unit; 300mcg; $0(Tier 1) MC 13.5mg; 1.05mg; 1.2mg; 1.05mg; 15unit; 2500unit apatate forte $0(Tier 1) MC apetex $0(Tier 1) MC apetigen $0(Tier 1) MC apetigen-plus $0(Tier 1) MC aquadeks chew, liqd $0(Tier 1) MC aqueous vitamin d infants $0(Tier 1) MC aqueous vitamin e $0(Tier 1) MC ascorbic acid powd $0(Tier 1) MC ascorbic acid tabs 250mg, 500mg $0(Tier 1) MC b complex/c tabs 300mg; 150mg; 10mg; 50mg; 5mg; 10.2mg; $0(Tier 1) MC 15mg b complex/folic acid $0(Tier 1) MC b complex caps $0(Tier 1) MC b complex tabs 6mcg; 0.4mg; 20mg; 10mg; 2mg; 1.7mg; $0(Tier 1) MC 1.2mg b-12 dots $0(Tier 1) MC b-12 tr $0(Tier 1) MC b-12 tbcr $0(Tier 1) MC b-12 subl 2500mcg $0(Tier 1) MC b-12 tabs 1000mcg, 100mcg, 500mcg, 50mcg $0(Tier 1) MC b-1 tabs 100mg, 250mg $0(Tier 1) MC b-2 $0(Tier 1) MC b-6 tabs 100mg, 50mg $0(Tier 1) MC b-complex formula 1 $0(Tier 1) MC b-complex plus vitamin c tabs 300mg; 150mg; 10mg; 50mg; 5mg; 10.2mg; 15mg $0(Tier 1) MC b-complex w/c tabs 300mg; 50mg; 10mg; 5mg; 10.2mg; 15mg $0(Tier 1) MC b-complex with b-12 $0(Tier 1) MC b-complex/c tabs 300mg; 50mg; 10mg; 5mg; 10.2mg; 15mg $0(Tier 1) MC b-complex caps 5mg; 1mcg; 400mcg; 60mg; 20mg; 0.5mg; 3mg; 3mg; 60mg, 5mg; 1mcg; 60mg; 20mg; 0.5mg; 3mg; 3mg; 60mg $0(Tier 1) MC b-complex tabs 6mcg; 400mcg; 20mg; 2mg; 1.7mg; 1.5mg $0(Tier 1) MC b12 $0(Tier 1) MC b6 natural $0(Tier 1) MC bacmin tabs 500mg; 150mcg; 25mg; 0.1mg; 3mg; 50mcg; 27mg; 1mg; 50mg; 50mg; 5mg; 100mg; 25mg; 20mg; 50mcg; 20mg; 30unit; 5000unit; 22.5mg $0(Tier 1) balance b-100 $0(Tier 1) MC balance b-50 $0(Tier 1) MC balanced b-100 tabs 100mcg; 100mg; 100mcg; 100mcg; 100mg; 100mg; 100mg; 100mg; 100mg; 100mg; 100mg $0(Tier 1) MC apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 61 MC

70 What the drug Name of drug balanced b-50 complex tabs $0(Tier 1) MC balanced b-50 tabs 50mcg; 50mg; 50mcg; 100mcg; 50mg; $0(Tier 1) MC 50mg; 50mg; 50mg; 50mg; 50mg; 50mg bee zee $0(Tier 1) MC beta carotene caps 25000unit $0(Tier 1) MC biocal $0(Tier 1) MC biosupp $0(Tier 1) MC biotin 5000 $0(Tier 1) MC biotin/maximum strength $0(Tier 1) MC biotin caps 2500mcg, 5000mcg $0(Tier 1) MC biotin tabs 1000mcg, 300mcg $0(Tier 1) MC biovol $0(Tier 1) MC bprotected multi-vite $0(Tier 1) MC bprotected pedia d-vite $0(Tier 1) MC bprotected pedia tri-vite $0(Tier 1) MC c 1000 $0(Tier 1) MC c 1000/bioflavonoids/rosehips $0(Tier 1) MC c 250 tabs $0(Tier 1) MC c 500 tabs $0(Tier 1) MC c complex $0(Tier 1) MC c-1000 $0(Tier 1) MC c-1000 prolonged release $0(Tier 1) MC c-1000/rose hips tabs 1000mg; 37mg $0(Tier 1) MC c-250 tabs $0(Tier 1) MC c-500 $0(Tier 1) MC c-500 prolonged release $0(Tier 1) MC c-500/rose hips tabs 500mg; 37mg $0(Tier 1) MC c-chewable chew 500mg $0(Tier 1) MC calcidol $0(Tier 1) MC centravites 50 plus tabs 60mg; 0; 30mcg; 220mg; 0; 10mg; 0; 1000unit; 50mcg; 0.5mg; 25mcg; 400mcg; 250mcg; 300mcg; 50mg; 2.3mg; 20mg; 5mcg; 20mg; 30mcg; 80mg; 150mcg; 3mg; 1.7mg; 2mg; 0; 45mcg; 19mcg; 10mcg; 1.5mg; 50unit; 2500unit; 11mg $0(Tier 1) centrum adults $0(Tier 1) MC centrum kids complete chew 60mg; 0; 45mcg; 108mg; 10mg; $0(Tier 1) MC 20mcg; 2mg; 6mcg; 400unit; 400mcg; 18mg; 40mg; 1mg; 20mg; 50mg; 10mcg; 150mcg; 2mg; 1.7mg; 20mcg; 1.5mg; 30unit; 3500unit; 15mg centrum silver adult 50+ $0(Tier 1) MC centrum silver ultra womens $0(Tier 1) MC MC apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 62

71 What the drug Name of drug centrum silver tabs 60mg; 0; 30mcg; 220mg; 10mg; 72mg; $0(Tier 1) 500unit; 45mcg; 0.5mg; 25mcg; 400mcg; 0; 0; 50mg; 2.3mg; 20mg; 5mcg; 20mg; 30mcg; 80mg; 150mcg; 3mg; 1.7mg; 2mg; 150mcg; 10mcg; 45mcg; 55mcg; 1.5mg; 50unit; 2500unit; 11mg centrum specialist heart $0(Tier 1) MC centrum ultra mens $0(Tier 1) MC centrum ultra womens $0(Tier 1) MC centrum chew $0(Tier 1) MC centrum liqd 0; 60mg/15ml; 300mcg/15ml; 400unit/15ml; 25mcg/15ml; 6mcg/15ml; 0; 150mcg/15ml; 9mg/15ml; 2mg/15ml; 25mcg/15ml; 20mg/15ml; 10mg/15ml; 0; 2mg/15ml; 1.7mg/15ml; 0; 1.1mg/15ml; 1300unit/15ml; 30unit/15ml; 3mg/15ml $0(Tier 1) cerovite advanced formula $0(Tier 1) MC cerovite jr $0(Tier 1) MC certa plus tabs 90mg; 0; 30mcg; 10mg; 200mg; 72mg; 400unit; 35mcg; 0.9mg; 6mcg; 18mg; 500mcg; 250mcg; 300mcg; 100mg; 2.3mg; 20mg; 5mcg; 109mg; 25mcg; 80mg; 150mcg; 2mg; 1.7mg; 2mg; 150mcg; 10mcg; 45mcg; 55mcg; 10mcg; 1.5mg; 30unit; 3500unit; 11mg $0(Tier 1) MC certavite senior/antioxidant nutrients $0(Tier 1) MC certavite/antioxidants $0(Tier 1) MC chewable vitamin c chew 500mg, 500mg; 0 $0(Tier 1) MC chewable vite childrens $0(Tier 1) MC chewable vite with iron/childrens $0(Tier 1) MC childrens chewable multivitamin $0(Tier 1) MC childrens chewable vitamin $0(Tier 1) MC childrens chewable vitamins/iron chew 400unit; 4.5mcg; 15mg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 60mg; 1.05mg; 15unit; 2500unit childrens chewable vitamins chew 400unit; 4.5mcg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 60mg; 1.05mg; 15unit; 2500unit, 60mg; 4.5mcg; 0.3mg; 13.5mg; 0; 1.2mg; 0; 2500unit; 400unit; 15unit $0(Tier 1) $0(Tier 1) citranatal bloom $0(Tier 1) MC citrus calcium +d $0(Tier 1) MC companion $0(Tier 1) MC compete $0(Tier 1) MC complete $0(Tier 1) MC complex b-100 tbcr 100mcg; 100mg; 100mg; 100mcg; $0(Tier 1) MC 200mcg; 100mg; 100mg; 100mg; 100mg; 100mg; 100mg corvita $0(Tier 1) MC corvite $0(Tier 1) MC corvite free $0(Tier 1) MC MC apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 63 MC MC MC

72 Name of drug What the drug cranberry urinary comfort $0(Tier 1) MC cvs b complex plus c $0(Tier 1) MC cvs b-1 $0(Tier 1) MC cvs b-12 liqd, tabs $0(Tier 1) MC cvs b1 $0(Tier 1) MC cvs b6 $0(Tier 1) MC cvs balanced b-100 tabs 100mcg; 100mg; 100mcg; 400mcg; $0(Tier 1) MC 100mg; 100mg; 100mg; 100mg cvs balanced b-50 $0(Tier 1) MC cvs beta carotene $0(Tier 1) MC cvs biotin high potency $0(Tier 1) MC cvs biotin caps 5000mcg $0(Tier 1) MC cvs calcium $0(Tier 1) MC cvs calcium/magnesium/zinc $0(Tier 1) MC cvs childrens chewable complete chew 60mg; 0; 40mcg; 100mg; 2mg; 6mcg; 400unit; 18mg; 400mcg; 20mg; 20mg; 10mg; 100mg; 150mcg; 2mg; 1.7mg; 1.5mg; 30unit; 5000unit; 15mg $0(Tier 1) cvs childrens chewable multivitamin/iron $0(Tier 1) MC cvs daily multiple $0(Tier 1) MC cvs daily multiple for men $0(Tier 1) MC cvs daily multiple for women $0(Tier 1) MC cvs daily multiple for women 50+ $0(Tier 1) MC cvs daily multiple plus iron/calcium/zinc $0(Tier 1) MC cvs gummy dinos chew 30mg; 75mcg; 5mg; 200unit; 38mg; $0(Tier 1) MC 5mcg; 200mcg; 20mcg; 40mcg; 1mg; 20unit; 2000unit; 2.5mg cvs hair/skin/nails $0(Tier 1) MC cvs spectravite adult 50+ tabs $0(Tier 1) MC cvs spectravite advanced formula $0(Tier 1) MC cvs spectravite senior tabs 60mg; 0; 30mcg; 150mcg; 220mg; 10mg; 20mg; 72mg; 500unit; 45mcg; 0.5mg; 25mcg; 400mcg; 250mcg; 300mcg; 50mg; 2.3mg; 20mg; 5mcg; 30mcg; 80mg; 150mcg; 3mg; 1.7mg; 2mg; 10mcg; 45mcg; 55mcg; 1.5mg; 50unit; 2500unit; 11mg $0(Tier 1) cvs spectravite ultra health mens $0(Tier 1) MC cvs spectravite ultra mens health $0(Tier 1) MC cvs spectravite ultra women $0(Tier 1) MC cvs spectravite ultra womens health $0(Tier 1) MC cvs spectravite ultra womens health senior $0(Tier 1) MC cvs super b complex/c $0(Tier 1) MC cvs vitamin a $0(Tier 1) MC cvs vitamin b-12 tr $0(Tier 1) MC cvs vitamin b-12 tabs 2000mcg $0(Tier 1) MC cvs vitamin b-2 $0(Tier 1) MC cvs vitamin b12 tabs $0(Tier 1) MC apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 64 MC MC

73 Name of drug What the drug cvs vitamin c tabs $0(Tier 1) MC cvs vitamin e caps 1000unit, 400unit $0(Tier 1) MC d-vi-sol $0(Tier 1) MC d-vita $0(Tier 1) MC daily combo multi vitamin tabs 60mg; 450mg; 6mcg; 400unit; 0.4mg; 27mg; 20mg; 10mg; 2mg; 1.7mg; 1.5mg; 5000unit; 30unit; 15mg $0(Tier 1) daily multiple vitamin/iron tabs 3mcg; 250mg; 30mg; 2mg; $0(Tier 1) MC 0.5mg; 5mg; 75mg; 5mg daily multiple vitamins tabs 50mg; 7mg; 1mcg; 400unit; $0(Tier 1) MC 20mg; 1mg; 2.5mg; 2mg; 5000unit daily multiple vitamin tabs 60mg; 0; 45mg; 10mg; 400unit; $0(Tier 1) MC 6mcg; 400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 30unit; 3000unit daily value multivitamin $0(Tier 1) MC daily vitamin formula+ir on $0(Tier 1) MC daily vitamin formula+iron tabs 60mg; 13mg; 10mg; 400unit; $0(Tier 1) MC 6mcg; 18mg; 400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 15unit; 5000unit daily vitamin formula+minerals tabs 50mg; 1mg; 15.8mg; 400unit; 5mcg; 1mcg; 4.5mg; 10mg; 1mg; 20mg; 11.6mg; 150mcg; 1mg; 2.5mg; 5mcg; 2mg; 5000unit; 3.75mg $0(Tier 1) daily vitamin tabs 60mg; 0; 20mg; 400unit; 6mcg; 400mcg; $0(Tier 1) MC 20mg; 2mg; 1.7mg; 1.5mg; 15unit; 5000unit daily vite multivitamin/iron $0(Tier 1) MC daily vite with iron $0(Tier 1) MC daily vite tabs 60mg; 10mg; 400unit; 6mcg; 20mg; 2mg; 1.7mg; 1.5mg; 30unit; 5000unit, 60mg; 6mcg; 0.4mg; 20mg; 10mg; 2mg; 1.7mg; 1.5mg; 5000unit; 400unit; 30unit $0(Tier 1) MC daily-vite/iron/beta-carotene $0(Tier 1) MC daily-vite tabs 60mg; 0; 45mg; 0; 10mg; 0; 400unit; 6mcg; 400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 30unit; 3000unit, 60mg; 400unit; 6mcg; 400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 5000unit $0(Tier 1) MC dekas essential caps $0(Tier 1) MC dekas plus caps, liqd $0(Tier 1) MC dialyvite 800/iron $0(Tier 1) MC dialyvite 800 tabs $0(Tier 1) MC dino-life $0(Tier 1) MC dino-life w extra c $0(Tier 1) MC e-400 $0(Tier 1) MC e-oil $0(Tier 1) MC e400 mixed $0(Tier 1) MC elfolate plus $0(Tier 1) MC endur-acin tbcr 250mg, 500mg $0(Tier 1) MC endur-c/rose hips $0(Tier 1) MC MC MC apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 65

74 What the drug Name of drug eq complete multivitamin adults 50+ tabs 60mg; 0; 30mcg; $0(Tier 1) 220mg; 10mg; 20mg; 72mg; 500unit; 45mcg; 0.5mg; 25mcg; 400mcg; 250mcg; 300mcg; 50mg; 2.3mg; 20mg; 5mcg; 30mcg; 80mg; 150mcg; 3mg; 1.7mg; 2mg; 0; 10mcg; 45mcg; 55mcg; 150mcg; 1.5mg; 50unit; 2500unit; 11mg eq complete multivitamin adults under 50 $0(Tier 1) MC eq one daily womens health $0(Tier 1) MC eql b complex 50 tabs $0(Tier 1) MC eql b-6 $0(Tier 1) MC eql one daily mens health formula $0(Tier 1) MC eql one daily womens $0(Tier 1) MC eql vitamin b-12 $0(Tier 1) MC eql vitamin b-12 tr $0(Tier 1) MC eql vitamin c/rose hips $0(Tier 1) MC eql vitamin c tabs $0(Tier 1) MC eql vitamin e $0(Tier 1) MC ergocalciferol soln $0(Tier 1) MC escavite $0(Tier 1) MC escavite d $0(Tier 1) MC escavite lq $0(Tier 1) MC essentia $0(Tier 1) MC essential balance tabs 120mg; 30mcg; 100mg; 10mg; 36mg; 400unit; 120mcg; 2mg; 6mcg; 9mg; 400mcg; 250mcg; 100mg; 2mg; 20mg; 5mcg; 77mg; 40mg; 150mcg; 2mg; 1.7mg; 2mg; 150mcg; 10mcg; 25mcg; 25mcg; 10mcg; 1.5mg; 50unit; 3000unit; 25mcg; 15mg $0(Tier 1) fabb $0(Tier 1) MC flintstones complete chew 0; 40mcg; 10mg; 100mg; 400unit; 38mg; 2mg; 6mcg; 18mg; 400mcg; 20mg; 15mg; 100mg; 150mcg; 2mg; 1.7mg; 60mg; 1.5mg; 3000unit; 30unit; 12mg, 60mg; 0; 40mcg; 100mg; 10mg; 38mg; 2mg; 6mcg; 18mg; 400mcg; 20mg; 15mg; 100mg; 150mcg; 2mg; 1.7mg; 10mg; 1.5mg; 3000unit; 400unit; 30unit; 12mg $0(Tier 1) MC flintstones plus extra c $0(Tier 1) MC flintstones/my first $0(Tier 1) MC floriva plus soln 32mg/ml; 3mcg/ml; 1mg/ml; 400unit/ml; 2mcg/ml; 5unit/ml; 29.7mcg/ml; 2mg/ml; 0.4mg/ml; 0.6mg/ml; 0.25mg/ml; 0.5mg/ml; 1150unit/ml $0(Tier 1) MC floriva chew 75mg; 0; 40mcg; 600unit; 1mg; 6mcg; 262mcg; 0; 15mg; 1.8mg; 1.5mg; 0.25mg; 1.3mg; 20unit; 2000unit; 5mg, 75mg; 40mcg; 600unit; 1mg; 6mcg; 100mcg; 162mcg; 15mg; 1.8mg; 1.5mg; 0.5mg; 1.3mg; 20unit; 2000unit; 5mg, 75mg; 40mcg; 600unit; 1mg; 6mcg; 100mcg; 162mcg; 15mg; 1.8mg; 1.5mg; 1mg; 1.3mg; 20unit; 2000unit; 5mg $0(Tier 1) folbee ar $0(Tier 1) MC MC apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 66 MC MC

75 Name of drug What the drug folic acid inj $0(Tier 1) MC folic acid tabs 1mg $0(Tier 1) MC folitab 500 $0(Tier 1) MC foltabs 800 $0(Tier 1) MC fortavit caps $0(Tier 1) MC fosfree $0(Tier 1) MC fruit c 500 $0(Tier 1) MC fruity c $0(Tier 1) MC fruity chewables multivitamin $0(Tier 1) MC full spectrum b/vitamin c $0(Tier 1) MC gnp b-12 $0(Tier 1) MC gnp biotin $0(Tier 1) MC gnp century active performance $0(Tier 1) MC gnp century adults 50+ senior tabs 60mg; 0; 30mcg; 220mg; 10mg; 20mg; 72mg; 500unit; 45mcg; 0.5mg; 25mcg; 400mcg; 250mcg; 300mcg; 50mg; 2.3mg; 20mg; 5mcg; 30mcg; 80mg; 150mcg; 3mg; 1.7mg; 2mg; 150mcg; 10mcg; 45mcg; 55mcg; 1.5mg; 50unit; 2500unit; 11mg gnp century cardio healthformula tabs 90mg; 0; 30mcg; 40mg; 10mg; 7.5mg; 400unit; 50mcg; 2mg; 12mcg; 9mg; 400mcg; 100mg; 2mg; 20mg; 5mcg; 31mg; 28mcg; 7.5mg; 150mcg; 6mg; 3.4mg; 2mg; 150mcg; 10mcg; 75mcg; 70mcg; 10mcg; 3mg; 60unit; 5000unit; 15mg gnp century mature tabs 60mg; 0; 30mcg; 220mg; 10mg; 72mg; 500unit; 45mcg; 0.5mg; 25mcg; 400mcg; 250mcg; 300mcg; 50mg; 2.3mg; 20mg; 5mcg; 20mg; 30mcg; 80mg; 150mcg; 3mg; 1.7mg; 2mg; 150mcg; 10mcg; 45mcg; 55mcg; 1.5mg; 50unit; 2500unit; 11mg $0(Tier 1) $0(Tier 1) $0(Tier 1) gnp century ultimate mens complete $0(Tier 1) MC gnp century ultimate womens complete $0(Tier 1) MC gnp century ultimate womens senior formula $0(Tier 1) MC gnp century tabs 60mg; 0; 30mcg; 200mg; 10mg; 20mg; 72mg; 400unit; 35mcg; 0.5mg; 6mcg; 18mg; 400mcg; 50mg; 2.3mg; 20mg; 5mcg; 25mcg; 80mg; 150mcg; 2mg; 1.7mg; 2mg; 75mcg; 10mcg; 45mcg; 55mcg; 10mcg; 1.5mg; 30unit; 3500unit; 11mg, 60mg; 0; 30mcg; 200mg; 10mg; 72mg; 400unit; 35mcg; 0.5mg; 6mcg; 18mg; 400mcg; 50mg; 2.3mg; 20mg; 5mcg; 20mg; 25mcg; 80mg; 150mcg; 2mg; 1.7mg; 2mg; 75mcg; 10mcg; 45mcg; 55mcg; 10mcg; 1.5mg; 30unit; 3500unit; 11mg $0(Tier 1) gnp childrens chewables w/extra c $0(Tier 1) MC gnp childrens chewables/extra c $0(Tier 1) MC gnp childrens chewables/iron $0(Tier 1) MC gnp essential one daily tabs 60mg; 0; 75mg; 10mg; 400unit; 6mcg; 400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 30unit; 5000unit $0(Tier 1) apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 67 MC MC MC MC MC

76 Name of drug What the drug gnp little ones childrens $0(Tier 1) MC gnp mega multi for men $0(Tier 1) MC gnp mega multi for women $0(Tier 1) MC gnp one daily maximum $0(Tier 1) MC gnp one daily mens health 50+ $0(Tier 1) MC gnp one daily plus iron tabs 60mg; 75mg; 10mg; 400unit; 6mcg; 18mg; 400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 30unit; 5000unit $0(Tier 1) gnp one daily womens health 50+ $0(Tier 1) MC gnp therapeutic-m tabs 90mg; 0; 30mcg; 150mcg; 10mg; 40mg; 7.5mg; 400unit; 50mcg; 2mg; 12mcg; 9mg; 400mcg; 100mg; 2mg; 20mg; 5mcg; 31mg; 28mcg; 7.5mg; 150mcg; 6mg; 3.4mg; 2mg; 10mcg; 75mcg; 70mcg; 10mcg; 3mg; 60unit; 5000unit; 15mg $0(Tier 1) MC gnp vitamin a caps 10000unit $0(Tier 1) MC gnp vitamin b-1 $0(Tier 1) MC gnp vitamin b-12 $0(Tier 1) MC gnp vitamin b-12 prolonged release $0(Tier 1) MC gnp vitamin b-6 tabs 100mg $0(Tier 1) MC gnp vitamin c pr $0(Tier 1) MC gnp vitamin c w/rose hips tabs 500mg; 37mg $0(Tier 1) MC gnp vitamin c/rose hips $0(Tier 1) MC gnp vitamin c chew 500mg; 0 $0(Tier 1) MC gnp vitamin c tabs $0(Tier 1) MC gnp vitamin e water dispersible $0(Tier 1) MC gnp vitamin e caps 200unit, 400unit $0(Tier 1) MC gnp zoochews gummies $0(Tier 1) MC gummi bear multivitamin/mineral $0(Tier 1) MC halls defense vitamin c drops $0(Tier 1) MC hard nails $0(Tier 1) MC healthy kids gummies $0(Tier 1) MC hm complete $0(Tier 1) MC hm complete 50+ $0(Tier 1) MC hm complete 50+ womens ultimate $0(Tier 1) MC hm complete women $0(Tier 1) MC hm hair/skin/nails $0(Tier 1) MC hm niacin tr $0(Tier 1) MC hm one daily essential $0(Tier 1) MC hm one daily womens $0(Tier 1) MC hm one daily/iron $0(Tier 1) MC hm vitamin b complex/vitamin c $0(Tier 1) MC hm vitamin b100 complex $0(Tier 1) MC hm vitamin b12 $0(Tier 1) MC hm vitamin b12 tr $0(Tier 1) MC hm vitamin b50 complex $0(Tier 1) MC apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 68 MC

77 What the drug Name of drug hm vitamin b6 $0(Tier 1) MC hm vitamin c tr $0(Tier 1) MC hm vitamin c/rose hips tabs 0; 1000mg; 0; 0, 0; 500mg; 0; 0 $0(Tier 1) MC hm vitamin c chew 500mg; 0 $0(Tier 1) MC hm vitamin c tabs 1000mg, 500mg $0(Tier 1) MC hm vitamin e caps 400unit $0(Tier 1) MC honey bears $0(Tier 1) MC icaps areds formula $0(Tier 1) MC icaps mv $0(Tier 1) MC integra $0(Tier 1) MC integra f $0(Tier 1) MC integra plus $0(Tier 1) MC iron 100/c $0(Tier 1) MC iron supplement childrens $0(Tier 1) MC iron tabs 27mg $0(Tier 1) MC just d $0(Tier 1) MC kobee $0(Tier 1) MC kp adults 50+ daily formula tabs 60mg; 0; 30mcg; 0; 150mcg; 220mg; 0; 10mg; 0; 72mg; 500unit; 45mg; 0.5mg; 25mcg; 400mcg; 250mcg; 300mcg; 50mg; 2.3mg; 20mg; 5mcg; 20mg; 30mcg; 80mg; 0; 150mcg; 3mg; 1.7mg; 2mg; 0; 10mcg; 45mcg; 55mcg; 1.5mg; 50unit; 2500unit; 11mg $0(Tier 1) kp b complex/c $0(Tier 1) MC kp niacin $0(Tier 1) MC kp vitamin b-12 $0(Tier 1) MC kp vitamin b-6 $0(Tier 1) MC kp vitamin e $0(Tier 1) MC l-methyl-b6-b12 $0(Tier 1) MC life pack mens $0(Tier 1) MC life pack womens $0(Tier 1) MC liquid b12 $0(Tier 1) MC lysiplex plus liqd $0(Tier 1) MC mega multiple w/chelated minerals $0(Tier 1) MC mega multivitamin for men $0(Tier 1) MC mega multivitamin for women $0(Tier 1) MC meijer c $0(Tier 1) MC MEPHYTON $0(Tier 1) MC meribin $0(Tier 1) MC mtx support $0(Tier 1) MC multi complete/iron $0(Tier 1) MC multi vitamin daily $0(Tier 1) MC multi-day plus iron $0(Tier 1) MC multi-delyn/iron $0(Tier 1) MC MC apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 69

78 What the drug Name of drug multi-vit/fluoride soln 35mg/ml; 400unit/ml; 2mcg/ml; $0(Tier 1) 8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.25mg/ml; 0.5mg/ml; 5unit/ml; 1500unit/ml, 35mg/ml; 400unit/ml; 2mcg/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.5mg/ml; 0.5mg/ml; 5unit/ml; 1500unit/ml multi-vit/iron/fluoride soln 35mg/ml; 400unit/ml; 10mg/ml; $0(Tier 1) 8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.25mg/ml; 0.5mg/ml; 5unit/ml; 1500unit/ml multi-vitamin daily $0(Tier 1) MC multi-vitamin hp/minerals $0(Tier 1) MC multi-vitamin/fluoride drops $0(Tier 1) MC multi-vitamin/fluoride/iron soln 35mg/ml; 400unit/ml; 10mg/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.25mg/ml; 0.5mg/ml; 5unit/ml; 1500unit/ml multi-vitamin/minerals tabs 60mg; 160mg; 6mcg; 18mg; 0.4mg; 150mcg; 100mg; 20mg; 125mg; 2mg; 1.7mg; 1.2mg; 5000unit; 400unit; 15mg $0(Tier 1) $0(Tier 1) multi-vitamin/multi-mineral adult/high potency $0(Tier 1) MC multi-vitamins $0(Tier 1) MC multi-vitamin tabs 60mg; 0; 30mcg; 10mg; 400unit; 6mcg; $0(Tier 1) MC 400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 30unit; 5000unit multilex $0(Tier 1) MC multilex-t&m tabs 150mg; 10mg; 400unit; 1mg; 7.5mcg; 15mg; 5mg; 1mg; 100mg; 0.15mg; 2mg; 10mg; 15mg; 5.5unit; 10000unit; 1.5mg $0(Tier 1) MC multiple vitamin/minerals/no iron $0(Tier 1) MC multiple vitamins plain $0(Tier 1) MC multiple vitamins/iron chew 60mg; 4.5mcg; 400unit; 15mg; $0(Tier 1) MC 0.3mg; 13.5mg; 1.04mg; 1.2mg; 1.05mg; 2500unit; 15unit multiple vitamins/iron tabs 60mg; 0; 10mg; 400unit; 6mcg; 18mg; 400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 30unit; 5000unit, 60mg; 400unit; 6mcg; 18mg; 400mcg; 20mg; 10mg; 2mg; 1.7mg; 1.5mg; 30unit; 5000unit $0(Tier 1) MC multiple vitamins tabs 60mg; 0; 10mg; 400unit; 400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 30unit; 5000unit, 60mg; 0; 400unit; 6mcg; 400mcg; 20mg; 10mg; 2mg; 1.7mg; 1.5mg; 30unit; 5000unit, 60mg; 0; 6mcg; 400mcg; 20mg; 10mg; 2mg; 1.7mg; 1.5mg; 30unit; 5000unit; 400unit, 60mg; 20mg; 8mcg; 1.7mg; 1.5mg; 5000unit; 400unit; 30unit, 60mg; 400unit; 6mcg; 400mcg; 20mg; 10mg; 2mg; 1.7mg; 1.5mg; 30unit; 5000unit $0(Tier 1) multivitamin & mineral $0(Tier 1) MC MC MC MC MC MC apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 70

79 Name of drug multivitamin adults 50+ tabs 60mg; 0; 30mcg; 220mg; 0; 10mg; 500unit; 45mcg; 0.5mg; 25mcg; 400mcg; 250mcg; 300mcg; 50mg; 2.3mg; 20mg; 5mcg; 20mg; 30mcg; 80mg; 150mcg; 3mg; 1.7mg; 2mg; 150mcg; 10mcg; 45mcg; 55mcg; 1.5mg; 50unit; 2500unit; 11mg What the drug $0(Tier 1) multivitamin with fluoride chew $0(Tier 1) multivitamin with fluoride soln 35mg/ml; 400unit/ml; $0(Tier 1) 2mcg/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.25mg/ml; 0.5mg/ml; 5unit/ml; 1500unit/ml, 35mg/ml; 400unit/ml; 2mcg/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.5mg/ml; 0.5mg/ml; 5unit/ml; 1500unit/ml multivitamin/fluoride chew 60mg; 400unit; 4.5mcg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 0; 0.25mg; 1.05mg; 2500unit; 15unit, 60mg; 400unit; 4.5mcg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 0; 0.5mg; 1.05mg; 2500unit; 15unit, 60mg; 400unit; 4.5mcg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 0; 1mg; 1.05mg; 2500unit; 15unit $0(Tier 1) my-vitalife $0(Tier 1) MC natural c/rose hips tabs 1000mg $0(Tier 1) MC natural vitamin e caps 1000unit, 400unit $0(Tier 1) MC nephro-vite $0(Tier 1) MC nephro-vite rx tabs 60mg; 300mcg; 10mg; 6mcg; 1mg; 20mg; $0(Tier 1) MC 10mg; 1.7mg; 1.5mg nephrocaps caps 100mg; 150mcg; 5mg; 6mcg; 1mg; 20mg; $0(Tier 1) MC 10mg; 1.7mg; 1.5mg nephronex liqd $0(Tier 1) MC niacin er cpcr 250mg $0(Tier 1) MC niacin er tbcr 500mg $0(Tier 1) MC niacin pr $0(Tier 1) MC niacin sr cpcr 250mg $0(Tier 1) MC niacin tr cpcr 250mg $0(Tier 1) MC niacin tr tbcr 250mg, 500mg $0(Tier 1) MC niacin cpcr 250mg $0(Tier 1) MC niacin tabs 100mg, 250mg, 500mg $0(Tier 1) MC no iron multiple vitamin/minerals $0(Tier 1) MC nutricap $0(Tier 1) MC nutrivit $0(Tier 1) MC ocutabs $0(Tier 1) MC ocutabs/lutein $0(Tier 1) MC omnicap $0(Tier 1) MC once daily/iron $0(Tier 1) MC once daily tabs 50mg; 1mcg; 20mg; 1mg; 1mg; 2.5mg; 2mg; $0(Tier 1) MC 5000unit; 400unit oncovite $0(Tier 1) MC one daily complete $0(Tier 1) MC MC apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 71 MC MC

80 Name of drug What the drug one daily for men 50+ advanced $0(Tier 1) MC one daily for women $0(Tier 1) MC one daily for women 50+a dvanced $0(Tier 1) MC one daily maximum $0(Tier 1) MC one daily mens tabs 90mg; 0; 30mcg; 210mg; 120mcg; 2mg; 3mg; 400mcg; 0.6mg; 120mg; 2mg; 16mg; 5mg; 99mg; 1.7mg; 105mcg; 1.2mg; 3500unit; 18mcg; 400unit; 45unit; 20mcg; 15mg $0(Tier 1) one daily multivitamin adult tabs 60mg; 400unit; 6mcg; $0(Tier 1) MC 0.4mg; 20mg; 2mg; 1.7mg; 1.5mg; 5000unit one daily multivitamin/iron $0(Tier 1) MC one daily plus iron tabs 60mg; 75mg; 10mg; 400unit; 6mcg; $0(Tier 1) MC 18mg; 400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 30unit; 5000unit one daily plus minerals tabs 50mg; 19mg; 400unit; 5mcg; 1mcg; 150mcg; 4.5mg; 10mg; 1mg; 20mg; 1mg; 10mg; 1mg; 2.5mg; 5mcg; 2mg; 5000unit; 3.75mg $0(Tier 1) MC one daily womens 50 plus $0(Tier 1) MC one daily womens 50+ $0(Tier 1) MC one daily/iron/calcium $0(Tier 1) MC one daily/minerals tabs 50mg; 125mg; 1mg; 3mcg; 100mcg; 150mcg; 5mg; 20mg; 1mg; 1.7mg; 1.5mg; 10unit; 5000unit; 400unit $0(Tier 1) one daily tabs 60mg; 0; 6mcg; 400mcg; 20mg; 10mg; 2mg; $0(Tier 1) MC 1.7mg; 1.5mg; 5000unit; 400unit; 30unit one-a-day essential $0(Tier 1) MC one-a-day mens 50+ advantage tabs 60mg; 0; 30mcg; 120mg; $0(Tier 1) MC 15mg; 700unit; 180mcg; 2mg; 25mcg; 400mcg; 120mg; 300mcg; 100mg; 4mg; 20mg; 20mcg; 150mcg; 6mg; 3.4mg; 90mcg; 110mcg; 4.5mg; 22.5unit; 2500unit; 22.5mg one-a-day teen advantage for her $0(Tier 1) MC one-a-day teen advantage for him $0(Tier 1) MC one-a-day womens formula $0(Tier 1) MC one-daily multi vitamins $0(Tier 1) MC peridin-c $0(Tier 1) MC plain niacin tabs 500mg $0(Tier 1) MC poly vitamin $0(Tier 1) MC poly-vi-flor/iron chew 0; 10mg; 200mcg; 0; 0; 0; 0.5mg; 0; 0; $0(Tier 1) MC 0; 0 poly-vi-flor/iron susp $0(Tier 1) MC poly-vi-flor chew 0; 200mcg; 0; 0; 0; 0.25mg; 0; 0; 0; 0, 0; 200mcg; 0; 0; 0; 0.5mg; 0; 0; 0; 0, 0; 200mcg; 0; 0; 0; 1mg; 0; 0; 0; 0 $0(Tier 1) MC poly-vi-flor susp $0(Tier 1) MC poly-vita drops soln 35mg/ml; 400unit/ml; 2mcg/ml; 8mg/ml; $0(Tier 1) MC 0.4mg/ml; 0.6mg/ml; 0.5mg/ml; 5unit/ml; 1500unit/ml apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 72 MC MC

81 What the drug Name of drug poly-vita/iron drops soln 35mg/ml; 400unit/ml; 10mg/ml; $0(Tier 1) 8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.5mg/ml; 5unit/ml; 1500unit/ml polyvitamin/iron soln 35mg/ml; 400unit/ml; 10mg/ml; $0(Tier 1) 8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.5mg/ml; 5unit/ml; 1500unit/ml polyvitamin soln 35mg/ml; 2mcg/ml; 8mg/ml; 0.4mg/ml; $0(Tier 1) 0.6mg/ml; 0.5mg/ml; 1500unit/ml; 400unit/ml; 5unit/ml, 35mg/ml; 400unit/ml; 2mcg/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.5mg/ml; 5unit/ml; 1500unit/ml prevent $0(Tier 1) MC protectiron $0(Tier 1) MC pure c 500 $0(Tier 1) MC pureway-c $0(Tier 1) MC pyridoxine hcl tabs $0(Tier 1) MC qc calcium/minerals/vitamin d $0(Tier 1) MC qc maximum daily multivitamin/multimineral $0(Tier 1) MC quflora fe $0(Tier 1) MC quflora fe pediatric $0(Tier 1) MC quflora gummies $0(Tier 1) MC quflora pediatric $0(Tier 1) MC quintabs-m tabs 0; 30mcg; 30mg; 300mg; 30mg; 0.2mg; 30mcg; 50unit; 400unit; 400mcg; 15mg; 2mg; 100mg; 150mcg; 30mg; 30mg; 35mcg; 30mg; 5000unit; 7.5mg $0(Tier 1) ra b-complex $0(Tier 1) MC ra b-complex with b-12 $0(Tier 1) MC ra b-complex/vitamin c tr $0(Tier 1) MC ra balanced b-100 $0(Tier 1) MC ra balanced b-50 tabs 50mcg; 50mg; 50mg; 50mcg; 400mcg; $0(Tier 1) MC 50mcg; 50mg; 50mg; 50mg; 50mg; 50mg ra biotin caps $0(Tier 1) MC ra calcium 600 plus vitamin d-3 $0(Tier 1) MC ra calcium/boron $0(Tier 1) MC ra calcium/magnesium/zinc/copper $0(Tier 1) MC ra hi cal $0(Tier 1) MC ra high potency iron tabs 27mg $0(Tier 1) MC ra iron $0(Tier 1) MC ra magnesium $0(Tier 1) MC ra niacin $0(Tier 1) MC ra one daily energy formula $0(Tier 1) MC ra one daily essential $0(Tier 1) MC ra one daily maximum $0(Tier 1) MC ra oyster shell calcium/vitamin d $0(Tier 1) MC ra vitamin a caps 10000unit $0(Tier 1) MC ra vitamin b-1 $0(Tier 1) MC MC apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 73 MC MC MC

82 Name of drug What the drug ra vitamin b-12 tr tbcr 1000mcg $0(Tier 1) MC ra vitamin b-12 tabs 100mcg $0(Tier 1) MC ra vitamin b-6 $0(Tier 1) MC ra vitamin b12 $0(Tier 1) MC ra vitamin c tr tbcr 1000mg; 25mg, 500mg $0(Tier 1) MC ra vitamin c/acerola $0(Tier 1) MC ra vitamin c/rose hips $0(Tier 1) MC ra vitamin c chew 500mg; 0 $0(Tier 1) MC ra vitamin c tabs 250mg, 500mg $0(Tier 1) MC ra vitamin e caps 400unit $0(Tier 1) MC rabano yodado $0(Tier 1) MC rena-vite $0(Tier 1) MC renal vitamin $0(Tier 1) MC renal-vite $0(Tier 1) MC reno caps $0(Tier 1) MC risacal-d $0(Tier 1) MC sb vitamin c $0(Tier 1) MC scooby-doo one a day $0(Tier 1) MC senior tabs $0(Tier 1) MC sentry $0(Tier 1) MC sentry adults under 50 $0(Tier 1) MC sentry senior $0(Tier 1) MC siderol tabs $0(Tier 1) MC slo-niacin tbcr 250mg, 500mg $0(Tier 1) MC sm b-complex $0(Tier 1) MC sm b-complex/vitamin c $0(Tier 1) MC sm chewable c $0(Tier 1) MC sm chewable vitamin c $0(Tier 1) MC sm complete 50+ $0(Tier 1) MC sm complete 50+ ultimate womens $0(Tier 1) MC sm complete tabs 60mg; 0; 30mcg; 200mg; 10mg; 72mg; 400unit; 35mcg; 0.5mg; 6mcg; 18mg; 400mcg; 50mg; 2.3mg; 20mg; 5mcg; 20mg; 25mcg; 80mg; 150mcg; 2mg; 1.7mg; 2mg; 75mcg; 10mcg; 45mcg; 55mcg; 10mcg; 1.5mg; 30unit; 3500unit; 11mg $0(Tier 1) sm hair/skin/nails $0(Tier 1) MC sm niacin cr $0(Tier 1) MC sm one daily womens $0(Tier 1) MC sm super b complex-vitamin c $0(Tier 1) MC sm vitamin b-1 $0(Tier 1) MC sm vitamin b1 $0(Tier 1) MC sm vitamin b100 complex $0(Tier 1) MC sm vitamin b12 $0(Tier 1) MC sm vitamin b12 tr $0(Tier 1) MC sm vitamin b6 $0(Tier 1) MC apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 74 MC

83 Name of drug What the drug sm vitamin c tr $0(Tier 1) MC sm vitamin c/rose hips $0(Tier 1) MC sm vitamin c tabs 1000mg, 500mg $0(Tier 1) MC sm vitamin e caps 400unit $0(Tier 1) MC stress b/zinc tabs 500mg; 45mcg; 70mg; 20mg; 3mg; 12mcg; $0(Tier 1) MC 400mcg; 100mg; 5mg; 10mg; 10mg; 30unit; 23.9mg stress formula w/iron $0(Tier 1) MC stress formula/iron tabs 500mg; 45mcg; 12mcg; 27mg; $0(Tier 1) MC 400mcg; 100mg; 20mg; 5mg; 10mg; 15mg; 30unit stress formula/zinc tabs 500mg; 45mcg; 3mg; 12mcg; 400mcg; 100mg; 20mg; 5mg; 10mg; 15mg; 30unit; 23.9mg, 600mg; 45mg; 3mg; 12mcg; 400mcg; 100mg; 20mg; 5mg; 10mg; 15mg; 30unit; 23.9mg $0(Tier 1) MC stress formula tabs 500mg; 45mcg; 12mcg; 400mcg; 100mg; 20mg; 3mg; 10mg; 10mg; 30unit, 500mg; 45mcg; 12mcg; 400mcg; 100mg; 20mg; 5mg; 10mg; 15mg; 30unit $0(Tier 1) strovite forte tabs $0(Tier 1) MC strovite one $0(Tier 1) MC super b complex maxi $0(Tier 1) MC super b with c $0(Tier 1) MC super biotin caps $0(Tier 1) MC super quints b-50 $0(Tier 1) MC super thera vite m $0(Tier 1) MC superplex-t $0(Tier 1) MC support-500 $0(Tier 1) MC tab-a-vite maximum $0(Tier 1) MC tab-a-vite w/beta carotene $0(Tier 1) MC tab-a-vite/iron $0(Tier 1) MC tab-a-vite tabs 60mg; 400unit; 6mcg; 400mcg; 20mg; 2mg; $0(Tier 1) MC 1.7mg; 0; 1.5mg; 5000unit th b 100 complex $0(Tier 1) MC th b complex/iron/vitamin c/vitamin e $0(Tier 1) MC th complete multi $0(Tier 1) MC th complete multi 50+ $0(Tier 1) MC th daily multiple vitamins $0(Tier 1) MC th daily multiple vitamins/iron $0(Tier 1) MC th premium daily multiple $0(Tier 1) MC th theradex-m $0(Tier 1) MC th vitamin b 50/b-complex $0(Tier 1) MC th vitamin b-12 $0(Tier 1) MC th vitamin b-6 $0(Tier 1) MC th vitamin b1 $0(Tier 1) MC th vitamin b12 $0(Tier 1) MC th vitamin b12 er $0(Tier 1) MC th vitamin c $0(Tier 1) MC apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 75 MC

84 Name of drug What the drug th vitamin c/rose hips/bioflavonoids $0(Tier 1) MC th vitamin e/d-alpha $0(Tier 1) MC th vitamin e caps 200unit, 400unit $0(Tier 1) MC thera m plus $0(Tier 1) MC thera-m tabs 120mg; 15mcg; 44mg; 10mg; 7.5mg; 400unit; 15mcg; 2mg; 9mcg; 18mg; 400mcg; 100mg; 5mg; 30mg; 31mg; 7.5mg; 150mcg; 3mg; 3.4mg; 15mcg; 10mcg; 3mg; 30unit; 5500unit; 15mg, 90mg; 0; 30mcg; 150mcg; 40mg; 7.5mg; 26mcg; 2mg; 9mcg; 400mcg; 150mcg; 18mg; 100mg; 3.5mg; 32mcg; 20mg; 5mcg; 10mg; 31mg; 7.5mg; 3mg; 3.4mg; 21mcg; 2mg; 3mg; 10mcg; 10mcg; 5000unit; 400unit; 30unit; 28mcg; 15mg, 90mg; 0; 30mcg; 30mg; 10mg; 50mcg; 2mg; 12mcg; 400unit; 9mg; 400mcg; 100mg; 2mg; 20mg; 5mcg; 23mg; 28mcg; 7.5mg; 7mg; 150mcg; 6mg; 3.4mg; 6mg; 150mcg; 10mcg; 75mcg; 70mcg; 10mcg; 3mg; 60unit; 5000unit; 15mg $0(Tier 1) thera-tabs $0(Tier 1) MC therapeutic-m/lutein $0(Tier 1) MC thera tabs 90mg; 30mcg; 9mcg; 400mcg; 20mg; 10mg; 3mg; $0(Tier 1) MC 3.4mg; 3mg; 5000unit; 400unit; 30unit theratrum complete 50 plus tabs 60mg; 0; 30mcg; 150mcg; 200mg; 10mg; 72mg; 400unit; 150mcg; 2mg; 25mcg; $0(Tier 1) MC 400mcg; 250mcg; 300mcg; 100mg; 2mg; 20mg; 5mcg; 48mg; 10mcg; 80mg; 150mcg; 3mg; 1.7mg; 2mg; 75mcg; 20mcg; 1.5mg; 45unit; 10mcg; 3500unit; 15mg theratrum complete tabs 60mg; 0; 30mcg; 150mcg; 162mg; 0; 10mg; 0; 400unit; 120mcg; 2mg; 6mcg; 18mg; 400mcg; 250mcg; 300mcg; 100mg; 2mg; 20mg; 5mcg; 109mg; 25mcg; 80mg; 72mg; 150mcg; 2mg; 1.7mg; 2mg; 0; 10mcg; 75mcg; 20mcg; 10mcg; 1.5mg; 30unit; 3500unit; 15mg, 60mg; 0; 30mcg; 150mcg; 162mg; 10mg; 72mg; 400unit; 120mcg; 2mg; 6mcg; 18mg; 400mcg; 150mcg; 250mcg; 100mg; 2mg; 20mg; 5mcg; 108mg; 80mg; 2mg; 1.7mg; 2mg; 10mcg; 75mcg; 20mcg; 10mcg; 1.5mg; 30unit; 5000unit; 25mcg; 15mg $0(Tier 1) therems $0(Tier 1) MC therems-h $0(Tier 1) MC therems-m $0(Tier 1) MC thiamine hcl tabs 100mg $0(Tier 1) MC thrivite 19 $0(Tier 1) MC total b/c $0(Tier 1) MC tri-vi-flor susp $0(Tier 1) MC tri-vi-sol soln 35mg/ml; 400unit/ml; 750unit/ml $0(Tier 1) MC tri-vit/fluoride/iron $0(Tier 1) MC MC MC apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 76

85 Name of drug What the drug tri-vit/fluoride soln 35mg/ml; 400unit/ml; 0.5mg/ml; $0(Tier 1) MC 1500unit/ml tri-vitamin soln 35mg/ml; 400unit/ml; 1500unit/ml $0(Tier 1) MC tri-vita soln 35mg/ml; 400unit/ml; 1500unit/ml $0(Tier 1) MC $0(Tier 1) MC unicomplex-m tabs 60mg; 60mg; 10mg; 400unit; 2mg; 6mcg; 18mg; 400mcg; 1mg; 20mg; 0; 45mg; 150mcg; 5mg; 2mg; 1.7mg; 0; 1.5mg; 30unit; 5000unit; 15mg v-c forte $0(Tier 1) MC vic-forte $0(Tier 1) MC vita-bee/c $0(Tier 1) MC vitalee $0(Tier 1) MC vitalets childrens chew 40mg; 0; 150mcg; 80mg; 5mg; 3mcg; 200unit; 10mg; 200mcg; 20mg; 0.1mg; 10mg; 60mg; 1mg; 0.85mg; 0.75mg; 15unit; 2500unit; 0.8mg vitalets chew 40mg; 0; 150mcg; 80mg; 3mcg; 200unit; 10mg; 200mcg; 20mg; 0.1mg; 10mg; 5mg; 60mg; 1mg; 0.85mg; 0.75mg; 2500unit; 15unit; 0.8mg $0(Tier 1) $0(Tier 1) vitamin a caps 10000unit, 8000unit $0(Tier 1) MC vitamin b 6 $0(Tier 1) MC vitamin b complex-c $0(Tier 1) MC vitamin b complex tabs 10mg; 10mg; 0.2mg; 2mg; 1.5mg, $0(Tier 1) MC 2mcg; 15mg; 5mg; 2mg; 2mg; 2mg vitamin b-12 cr $0(Tier 1) MC vitamin b-12 er $0(Tier 1) MC vitamin b-12 tr tbcr 1000mcg, 2000mcg $0(Tier 1) MC vitamin b-12 subl 2500mcg $0(Tier 1) MC vitamin b-12 tabs 1000mcg, 100mcg, 250mcg, 500mcg $0(Tier 1) MC vitamin b-1 tabs 100mg, 250mg, 50mg $0(Tier 1) MC vitamin b-2 $0(Tier 1) MC vitamin b-6 tabs 100mg, 25mg, 50mg $0(Tier 1) MC vitamin b-complex tabs 83mg; 5mcg; 20mg; 1mg; 2mg; 3mg $0(Tier 1) MC vitamin b1 $0(Tier 1) MC vitamin b12 tr $0(Tier 1) MC vitamin b12 tabs $0(Tier 1) MC vitamin b6 tabs 100mg, 50mg $0(Tier 1) MC vitamin c drops lozg 60mg; 0 $0(Tier 1) MC vitamin c sr cpcr $0(Tier 1) MC vitamin c tr cpcr $0(Tier 1) MC vitamin c tr tbcr 1500mg, 500mg $0(Tier 1) MC vitamin c/rose hips tr tbcr 1000mg, 500mg, 500mg; 0 $0(Tier 1) MC vitamin c/rose hips tabs 1000mg, 1000mg; 0, 500mg, 500mg; $0(Tier 1) MC 0, 500mg; 10mg vitamin c chew 0; 500mg; 0; 0; 0; 0, 250mg, 500mg, 500mg; 0 $0(Tier 1) MC vitamin c powd, syrp, tbcr $0(Tier 1) MC vitamin c liqd 500mg/5ml $0(Tier 1) MC apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 77 MC MC

86 Name of drug What the drug vitamin c tabs 1000mg, 250mg, 500mg $0(Tier 1) MC vitamin d3 liqd 400unit/ml $0(Tier 1) MC vitamin d caps 50000unit $0(Tier 1) MC vitamin d liqd $0(Tier 1) MC vitamin e blend caps 400unit $0(Tier 1) MC vitamin e high potency $0(Tier 1) MC vitamin e water dispersible $0(Tier 1) MC vitamin e water soluble $0(Tier 1) MC vitamin e-400 $0(Tier 1) MC vitamin e/d-alpha $0(Tier 1) MC vitamin e/d-alpha natural caps 400unit $0(Tier 1) MC vitamin e/dl-alpha caps 400unit $0(Tier 1) MC vitamin e caps 1000unit, 100unit, 200unit, 400unit $0(Tier 1) MC vitamin e oil $0(Tier 1) MC vitamin k1 inj 10mg/ml $0(Tier 1) MC vitamins & minerals $0(Tier 1) MC vitamins for hair tabs 400mcg; 100mg; 250mg; 2mg; 6mcg; 18mg; 400mcg; 125mg; 150mcg; 5mg; 100mg; 15mg vitatrum tabs 90mg; 0; 30mcg; 200mg; 10mg; 109mg; 72mg; 400unit; 35mcg; 0.9mg; 6mcg; 18mg; 500mcg; 250mcg; 300mcg; 100mg; 2.3mg; 20mg; 5mcg; 25mcg; 80mg; 150mcg; 2mg; 1.7mg; 2mg; 150mcg; 10mcg; 45mcg; 55mcg; 10mcg; 1.5mg; 30unit; 3500unit; 11mg $0(Tier 1) $0(Tier 1) vitrum 50+ senior multi $0(Tier 1) MC vol-nate $0(Tier 1) MC vol-plus $0(Tier 1) MC vol-tab rx $0(Tier 1) MC VP-PNV-DHA $0(Tier 2) womens daily formula $0(Tier 1) MC womens daily formula/folic acid/calcium/iron $0(Tier 1) MC womens one daily $0(Tier 1) MC yelets teenage formula $0(Tier 1) MC zoo friends $0(Tier 1) MC Gastrointestinal Agents (Drugs that Treat Issues of the Stomach, Bowels, and Gallbladder) Antispasmodics, Gastrointestinal anaspaz $0(Tier 1) atropine sulfate inj 0.25mg/5ml, 0.4mg/0.5ml, 0.5mg/5ml, $0(Tier 1) 1mg/ml, 8mg/20ml dicyclomine hcl caps, soln $0(Tier 1) dicyclomine hydrochloride tabs $0(Tier 1) ed-spaz tbdp $0(Tier 1) glycopyrrolate inj 0.2mg/ml, 0.4mg/2ml, 1mg/5ml, 4mg/20ml $0(Tier 1) glycopyrrolate tabs 1mg, 2mg $0(Tier 1) hyoscyamine sulfate odt $0(Tier 1) hyoscyamine sulfate elix, subl, tabs, tbdp $0(Tier 1) apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 78 MC MC

87 Name of drug What the drug methscopolamine bromide tabs $0(Tier 1) nulev $0(Tier 1) oscimin $0(Tier 1) propantheline bromide tabs $0(Tier 1) Gastrointestinal Agents, Other acid gone susp $0(Tier 1) MC acid reducer maximum strength $0(Tier 1) MC ACTIDOSE/SORBITOL LIQD 50GM/240ML; 0 $0(Tier 1) MC almacone double strength $0(Tier 1) MC almacone chew 200mg; 200mg; 25mg $0(Tier 1) MC almacone susp $0(Tier 1) MC aluminum hydroxide susp 320mg/5ml $0(Tier 1) MC antacid calcium extra st rength $0(Tier 1) MC antacid calcium regular strength $0(Tier 1) MC antacid extra strength chew 750mg $0(Tier 1) MC antacid maximum strength $0(Tier 1) MC antacid plus anti-gas relief $0(Tier 1) MC anti-diarrheal tabs $0(Tier 1) MC anu-med $0(Tier 1) MC bisacodyl ec tbec 5mg $0(Tier 1) MC biscolax $0(Tier 1) MC bismatrol $0(Tier 1) MC bismatrol maximum strength $0(Tier 1) MC cal-gest antacid $0(Tier 1) MC calcium antacid $0(Tier 1) MC calcium antacid extra strength $0(Tier 1) MC chewable antacid $0(Tier 1) MC cromolyn sodium conc 100mg/5ml $0(Tier 1) diphenoxylate/atropine $0(Tier 1) docqlace caps 100mg $0(Tier 1) MC docusol kids $0(Tier 1) MC dok $0(Tier 1) MC enemeez mini $0(Tier 1) MC enemeez plus $0(Tier 1) MC fiber tabs $0(Tier 1) MC fiber-lax $0(Tier 1) MC FLEET PEDIATRIC $0(Tier 1) MC gas relief $0(Tier 1) MC gas relief extra strength caps $0(Tier 1) MC gas relief maximum strength chew $0(Tier 1) MC GATTEX $0(Tier 2) QL (30 per 30 days) PA gnp antacid anti-gas $0(Tier 1) MC gnp masanti maximum strength $0(Tier 1) MC gnp masanti regular strength $0(Tier 1) MC apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 79

88 Name of drug What the drug hm magnesium tabs 250mg $0(Tier 1) MC infants gas relief susp 20mg/0.3ml $0(Tier 1) MC infants simethicone susp 20mg/0.3ml $0(Tier 1) MC kao-tin $0(Tier 1) MC laxative supp $0(Tier 1) MC loperamide hcl caps $0(Tier 1) loperamide hcl liqd, susp $0(Tier 1) MC magnesium oxide tabs 241.3mg, 400mg, 420mg $0(Tier 1) MC magnesium caps 500mg $0(Tier 1) MC metoclopramide hcl inj, oral soln, tabs $0(Tier 1) mi-acid gas relief $0(Tier 1) MC mi-acid maximum strength $0(Tier 1) MC mi-acid susp $0(Tier 1) MC milk of magnesia concentrate $0(Tier 1) MC milk of magnesia susp 400mg/5ml, 7.75% $0(Tier 1) MC mintox maximum strength $0(Tier 1) MC mytab gas $0(Tier 1) MC mytab gas max str $0(Tier 1) MC natural fiber therapy $0(Tier 1) MC OSMOPREP $0(Tier 2) peptic relief chew 262mg $0(Tier 1) MC pink bismuth chew 262mg $0(Tier 1) MC qc anti-diarrheal $0(Tier 1) MC reguloid $0(Tier 1) MC RELISTOR INJ 8MG/0.4ML $0(Tier 2) QL (11.2 per 28 days) PA RELISTOR INJ 12MG/0.6ML $0(Tier 2) QL (16.8 per 28 days) PA rulox susp 200mg/5ml; 200mg/5ml; 20mg/5ml $0(Tier 1) MC senexon $0(Tier 1) MC senna lax $0(Tier 1) MC senna tabs 8.6mg $0(Tier 1) MC simethicone caps 180mg $0(Tier 1) MC sm antacid/antigas $0(Tier 1) MC sm anti-diarrheal tabs $0(Tier 1) MC sodium bicarbonate tabs 325mg, 650mg $0(Tier 1) MC stimulant laxative $0(Tier 1) MC stool softener caps 100mg $0(Tier 1) MC th antacid regular strength $0(Tier 1) MC TRULANCE $0(Tier 2) QL (30 per 30 days) ursodiol caps, tabs $0(Tier 1) Histamine2 (H2) Receptor Antagonists cimetidine hcl soln $0(Tier 1) cimetidine tabs $0(Tier 1) famotidine premixed $0(Tier 1) apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 80

89 Name of drug What the drug famotidine inj 200mg/20ml, 20mg/2ml, 40mg/4ml $0(Tier 1) famotidine tabs 20mg, 40mg $0(Tier 1) famotidine tabs 10mg $0(Tier 1) MC nizatidine caps $0(Tier 1) ranitidine 150 maximum strength $0(Tier 1) MC ranitidine 75 $0(Tier 1) MC ranitidine hcl caps, syrp $0(Tier 1) ranitidine hcl inj 150mg/6ml, 50mg/2ml $0(Tier 1) ranitidine hcl tabs 150mg, 300mg $0(Tier 1) ranitidine maximum strength $0(Tier 1) MC Irritable Bowel Syndrome Agents alosetron hydrochloride tabs 0.5mg $0(Tier 1) QL (60 per 30 days) PA alosetron hydrochloride tabs 1mg $0(Tier 1) QL (60 per 30 days) PA AMITIZA $0(Tier 2) QL (60 per 30 days) LINZESS $0(Tier 2) QL (30 per 30 days) VIBERZI $0(Tier 2) QL (60 per 30 days) PA Laxatives bisacodyl ec tbec 5mg $0(Tier 1) MC constulose $0(Tier 1) cvs laxative dietary supplement $0(Tier 1) MC docqlace caps 100mg $0(Tier 1) MC docusate sodium & senna stimulant laxative/stool softener $0(Tier 1) MC docusol plus mini-enema $0(Tier 1) MC dok plus $0(Tier 1) MC enema ready-to- enem 7gm/118ml; 19gm/118ml $0(Tier 1) MC enulose $0(Tier 1) fiber laxative caps $0(Tier 1) MC gavilyte-c $0(Tier 1) gavilyte-g $0(Tier 1) gavilyte-n/flavor pack $0(Tier 1) generlac $0(Tier 1) gnp enema $0(Tier 1) MC lactulose soln $0(Tier 1) milk of magnesia susp 400mg/5ml $0(Tier 1) MC MOVIPREP $0(Tier 2) peg 3350/electrolytes $0(Tier 1) peg 3350 pack $0(Tier 1) MC peg-3350/electrolytes $0(Tier 1) peg-3350/nacl/na bicarbonate/kcl $0(Tier 1) peg3350 $0(Tier 1) MC phillips tabs $0(Tier 1) MC polyethylene glycol 3350 powd 0 $0(Tier 1) polyethylene glycol 3350 powd 0 $0(Tier 1) MC sani-supp adult $0(Tier 1) MC apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 81

90 What the drug Name of drug sani-supp pediatric $0(Tier 1) MC senexon-s $0(Tier 1) MC senna plus $0(Tier 1) MC senna-lax $0(Tier 1) MC sennalax-s $0(Tier 1) MC senna tabs 8.6mg $0(Tier 1) MC stool softener caps 100mg, 240mg $0(Tier 1) MC SUPREP BOWEL PREP KIT $0(Tier 2) trilyte $0(Tier 1) Protectants CARAFATE SUSP $0(Tier 2) misoprostol $0(Tier 1) sucralfate tabs $0(Tier 1) Proton Pump Inhibitors esomeprazole magnesium cpdr 20mg $0(Tier 1) MC esomeprazole magnesium cpdr 20mg, 40mg $0(Tier 1) QL (60 per 30 days) esomeprazole sodium $0(Tier 1) gnp omeprazole $0(Tier 1) MC heartburn treatment 24 hour cpdr 15mg $0(Tier 1) MC lansoprazole cpdr 15mg $0(Tier 1) MC omeprazole magnesium cpdr 20.6mg $0(Tier 1) MC omeprazole tbec $0(Tier 1) MC omeprazole cpdr $0(Tier 1) QL (60 per 30 days) pantoprazole sodium tbec $0(Tier 1) QL (60 per 30 days) Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment (Drugs d to Replace or Change Bodily Enzymes) Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment ADAGEN $0(Tier 2) PA ALDURAZYME $0(Tier 2) PA BUPHENYL TABS $0(Tier 2) PA CEREZYME $0(Tier 2) B/D CREON CPEP UNIT; 24000UNIT; 76000UNIT, 15000UNIT; 3000UNIT; 9500UNIT, UNIT; 36000UNIT; UNIT, 30000UNIT; 6000UNIT; 19000UNIT, 60000UNIT; 12000UNIT; 38000UNIT $0(Tier 2) CYSTADANE $0(Tier 2) CYSTAGON $0(Tier 2) ELAPRASE $0(Tier 2) PA FABRAZYME $0(Tier 2) B/D KUVAN $0(Tier 2) PA LUMIZYME $0(Tier 2) PA miglustat $0(Tier 1) QL (90 per 30 days) NAGLAZYME $0(Tier 2) PA ORFADIN $0(Tier 2) sodium phenylbutyrate powd, tabs $0(Tier 1) PA apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 82

91 Name of drug What the drug VPRIV $0(Tier 2) PA ZAVESCA $0(Tier 2) QL (90 per 30 days) ZENPEP CPEP UNIT; 25000UNIT; 79000UNIT, 14000UNIT; 3000UNIT; 10000UNIT, UNIT; 40000UNIT; UNIT, 24000UNIT; 5000UNIT; 17000UNIT, 42000UNIT; 10000UNIT; 32000UNIT, 63000UNIT; 15000UNIT; 47000UNIT, 84000UNIT; 20000UNIT; 63000UNIT $0(Tier 2) Genitourinary Agents (Drugs that Treat Problems of the Urinary Tract) Antispasmodics, Urinary darifenacin hydrobromide er $0(Tier 1) QL (30 per 30 days) ENABLEX $0(Tier 2) QL (30 per 30 days) ST flavoxate hcl $0(Tier 1) MYRBETRIQ $0(Tier 2) QL (30 per 30 days) oxybutynin chloride er tb24 10mg, 5mg $0(Tier 1) QL (30 per 30 days) oxybutynin chloride er tb24 15mg $0(Tier 1) QL (60 per 30 days) oxybutynin chloride tabs $0(Tier 1) QL (120 per 30 days) oxybutynin chloride syrp $0(Tier 1) QL (600 per 30 days) tolterodine tartrate $0(Tier 1) QL (60 per 30 days) tolterodine tartrate er $0(Tier 1) QL (30 per 30 days) VESICARE $0(Tier 2) QL (30 per 30 days) Benign Prostatic Hypertrophy Agents alfuzosin hcl er $0(Tier 1) QL (30 per 30 days) doxazosin mesylate tabs 1mg, 2mg, 4mg $0(Tier 1) QL (30 per 30 days) doxazosin mesylate tabs 8mg $0(Tier 1) QL (60 per 30 days) dutasteride/tamsulosin hydrochloride $0(Tier 1) QL (30 per 30 days) dutasteride caps $0(Tier 1) QL (30 per 30 days) finasteride tabs 5mg $0(Tier 1) QL (30 per 30 days) tamsulosin hcl $0(Tier 1) QL (60 per 30 days) terazosin hcl caps 1mg, 2mg, 5mg $0(Tier 1) terazosin hcl caps 10mg $0(Tier 1) QL (60 per 30 days) Genitourinary Agents, Other bethanechol chloride tabs $0(Tier 1) ELMIRON $0(Tier 2) phenazopyridine hcl tabs 100mg, 200mg $0(Tier 1) phenazopyridine hydrochloride tabs 200mg $0(Tier 1) phenazopyridine hydrocholride $0(Tier 1) Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) (Drugs that Control or Replace Hormones Associated with the Adrenal Gland) Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) a-hydrocort inj 100mg $0(Tier 1) a-methapred inj 40mg $0(Tier 1) ala-cort crea 1% $0(Tier 1) alclometasone dipropionate $0(Tier 1) augmented betamethasone dipropionate $0(Tier 1) apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 83

92 What the drug Name of drug betamethasone dipropionate crea, lotn, oint $0(Tier 1) betamethasone valerate crea, foam, lotn, oint $0(Tier 1) clobetasol propionate e $0(Tier 1) clobetasol propionate emollient $0(Tier 1) clobetasol propionate crea, foam, gel, oint, sham, soln $0(Tier 1) clodan $0(Tier 1) cormax scalp application $0(Tier 1) cortisone acetate tabs 25mg $0(Tier 1) DEPO-MEDROL INJ 20MG/ML $0(Tier 2) desonide lotn, oint $0(Tier 1) desoximetasone crea, gel, oint $0(Tier 1) dexamethasone intensol $0(Tier 1) dexamethasone sodium phosphate inj 10mg/ml, 120mg/30ml, $0(Tier 1) 20mg/5ml, 4mg/ml dexamethasone elix, soln $0(Tier 1) dexamethasone tabs 0.5mg, 0.75mg, 1.5mg, 1mg, 2mg, 4mg, $0(Tier 1) 6mg fludrocortisone acetate tabs $0(Tier 1) fluocinolone acetonide body $0(Tier 1) fluocinolone acetonide scalp $0(Tier 1) fluocinolone acetonide crea 0.01%, 0.025% $0(Tier 1) fluocinolone acetonide oint 0.025% $0(Tier 1) fluocinolone acetonide soln 0.01% $0(Tier 1) fluocinonide crea, gel, oint, soln $0(Tier 1) fluticasone propionate crea 0.05% $0(Tier 1) fluticasone propionate oint 0.005% $0(Tier 1) halobetasol propionate $0(Tier 1) hydrocortisone butyrate (lipid) $0(Tier 1) hydrocortisone butyrate (lipophilic) $0(Tier 1) hydrocortisone butyrate crea, oint, soln $0(Tier 1) hydrocortisone in absorbase $0(Tier 1) hydrocortisone valerate $0(Tier 1) hydrocortisone/aloe crea 0; 1% $0(Tier 1) MC hydrocortisone external crea 1%, 2.5% $0(Tier 1) hydrocortisone external crea 0.5%, 1% $0(Tier 1) MC hydrocortisone rectal crea 1%, 2.5% $0(Tier 1) hydrocortisone lotn 2.5% $0(Tier 1) hydrocortisone oint 1%, 2.5% $0(Tier 1) hydrocortisone oint 0.5%, 1% $0(Tier 1) MC hydrocortisone tabs 10mg, 20mg, 5mg $0(Tier 1) lokara $0(Tier 1) MEDROL TABS 2MG $0(Tier 2) methylprednisolone acetate inj 40mg/ml, 80mg/ml $0(Tier 1) methylprednisolone dose pack tbpk $0(Tier 1) methylprednisolone sodiumsuccinate inj 125mg, 40mg $0(Tier 1) apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 84

93 What the drug Name of drug methylprednisolone tabs $0(Tier 1) mometasone furoate crea 0.1% $0(Tier 1) mometasone furoate oint 0.1% $0(Tier 1) mometasone furoate soln 0.1% $0(Tier 1) prednicarbate oint $0(Tier 1) prednisolone sodium phosphate oral soln 15mg/5ml, $0(Tier 1) 25mg/5ml, 5mg/5ml prednisolone soln $0(Tier 1) prednisone intensol $0(Tier 1) prednisone soln, tbpk $0(Tier 1) prednisone tabs 10mg, 1mg, 2.5mg, 20mg, 50mg, 5mg $0(Tier 1) procto-med hc $0(Tier 1) procto-pak $0(Tier 1) proctosol hc $0(Tier 1) proctozone-hc $0(Tier 1) SOLU-CORTEF $0(Tier 2) texacort soln 2.5% $0(Tier 1) triamcinolone acetonide crea 0.025%, 0.1%, 0.5% $0(Tier 1) triamcinolone acetonide inj 40mg/ml $0(Tier 1) triamcinolone acetonide lotn 0.025%, 0.1% $0(Tier 1) triamcinolone acetonide oint 0.025%, 0.1%, 0.5% $0(Tier 1) trianex $0(Tier 1) triderm crea 0.1% $0(Tier 1) TRIPTODUR $0(Tier 2) QL (1 per 168 days) PA Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) (Drugs that Control or Replace Hormones Associated with the Pituitary Gland) Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) CHORIONIC GONADOTROPIN $0(Tier 2) PA desmopressin acetate inj, tabs $0(Tier 1) desmopressin acetate nasal soln $0(Tier 1) QL (15 per 30 days) GENOTROPIN $0(Tier 2) PA GENOTROPIN MINIQUICK INJ 0.2MG $0(Tier 2) PA GENOTROPIN MINIQUICK INJ 0.4MG, 0.6MG, 0.8MG, $0(Tier 2) PA 1.2MG, 1.4MG, 1.6MG, 1.8MG, 1MG, 2MG INCRELEX $0(Tier 2) PA NOVAREL $0(Tier 2) PA PREGNYL W/DILUENT BENZYL ALCOHOL/NACL $0(Tier 2) PA STIMATE SOLN $0(Tier 2) Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) (Drugs that Control or Replace Sex Hormones) Anabolic Steroids ANADROL-50 $0(Tier 2) PA oxandrolone tabs 2.5mg $0(Tier 1) QL (120 per 30 days) PA apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 85

94 Name of drug What the drug oxandrolone tabs 10mg $0(Tier 1) QL (60 per 30 days) PA Androgens ANDROXY $0(Tier 2) PA danazol caps $0(Tier 1) testosterone cypionate inj $0(Tier 1) testosterone enanthate inj $0(Tier 1) QL (5 per 30 days) testosterone pump $0(Tier 1) QL (300 per 30 days) PA testosterone gel 25mg/2.5gm, 50mg/5gm $0(Tier 1) QL (300 per 30 days) PA Estrogens ALORA $0(Tier 2) QL (8 per 28 days) PA altavera tabs 0.03mg; 0.15mg $0(Tier 1) alyacen 1/35 $0(Tier 1) alyacen 7/7/7 $0(Tier 1) amethia $0(Tier 1) QL (91 per 91 days) amethia lo $0(Tier 1) QL (91 per 91 days) apri $0(Tier 1) aranelle $0(Tier 1) ashlyna $0(Tier 1) QL (91 per 91 days) aubra $0(Tier 1) aviane $0(Tier 1) azurette $0(Tier 1) balziva $0(Tier 1) bekyree $0(Tier 1) blisovi fe 1.5/30 $0(Tier 1) blisovi fe 1/20 $0(Tier 1) briellyn $0(Tier 1) camrese $0(Tier 1) QL (91 per 91 days) camrese lo $0(Tier 1) QL (91 per 91 days) caziant $0(Tier 1) cesia $0(Tier 1) chateal $0(Tier 1) cryselle-28 $0(Tier 1) cyclafem 1/35 $0(Tier 1) cyclafem 7/7/7 $0(Tier 1) cyred $0(Tier 1) dasetta 1/35 $0(Tier 1) dasetta 7/7/7 $0(Tier 1) daysee $0(Tier 1) QL (91 per 91 days) DELESTROGEN INJ 10MG/ML $0(Tier 2) delyla $0(Tier 1) DEPO-ESTRADIOL INJ 5MG/ML $0(Tier 2) desogestrel/ethinyl estradiol $0(Tier 1) elinest $0(Tier 1) emoquette $0(Tier 1) apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 86

95 Name of drug What the drug enpresse-28 $0(Tier 1) enskyce tabs 0.15mg; 30mcg $0(Tier 1) estarylla $0(Tier 1) estradiol valerate inj $0(Tier 1) estradiol oral tabs $0(Tier 1) PA estradiol vaginal tabs $0(Tier 1) QL (18 per 28 days) estradiol ptwk $0(Tier 1) QL (4 per 28 days) PA estradiol pttw $0(Tier 1) QL (8 per 28 days) PA ESTRING $0(Tier 2) QL (1 per 90 days) ethynodiol diacetate/ethinyl estradiol tabs 50mcg; 1mg $0(Tier 1) falmina $0(Tier 1) FEMRING $0(Tier 2) QL (1 per 90 days) femynor $0(Tier 1) fyavolv tabs 2.5mcg; 0.5mg $0(Tier 1) PA gildagia $0(Tier 1) gildess 1.5/30 $0(Tier 1) gildess 1/20 $0(Tier 1) gildess fe 1.5/30 $0(Tier 1) gildess fe 1/20 $0(Tier 1) introvale $0(Tier 1) QL (91 per 91 days) isibloom $0(Tier 1) jevantique lo $0(Tier 1) PA jolessa $0(Tier 1) QL (91 per 91 days) juleber $0(Tier 1) junel 1.5/30 $0(Tier 1) junel 1/20 $0(Tier 1) junel fe 1.5/30 $0(Tier 1) junel fe 1/20 $0(Tier 1) kariva $0(Tier 1) kelnor 1/35 $0(Tier 1) kelnor 1/50 $0(Tier 1) kimidess $0(Tier 1) kurvelo $0(Tier 1) larin 1.5/30 $0(Tier 1) larin 1/20 $0(Tier 1) larin fe 1.5/30 $0(Tier 1) larin fe 1/20 $0(Tier 1) larissia $0(Tier 1) lessina $0(Tier 1) levonest $0(Tier 1) levonorgestrel and ethinyl estradiol tabs 0; 0 $0(Tier 1) QL (91 per 91 days) levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg, 0; 0, $0(Tier 1) 20mcg; 0.1mg levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg, 0; 0 $0(Tier 1) QL (91 per 91 days) levora 0.15/30-28 $0(Tier 1) apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 87

96 Name of drug What the drug low-ogestrel $0(Tier 1) lutera $0(Tier 1) marlissa $0(Tier 1) melodetta 24 fe $0(Tier 1) MENEST $0(Tier 2) PA MENOSTAR $0(Tier 2) QL (4 per 28 days) PA mibelas 24 fe $0(Tier 1) microgestin 1.5/30 $0(Tier 1) microgestin 1/20 $0(Tier 1) microgestin fe $0(Tier 1) microgestin fe 1.5/30 $0(Tier 1) mili $0(Tier 1) MINIVELLE $0(Tier 2) QL (8 per 28 days) PA mono-linyah $0(Tier 1) myzilra $0(Tier 1) necon 0.5/35-28 $0(Tier 1) necon 1/35 $0(Tier 1) necon 1/50-28 $0(Tier 1) necon 10/11-28 $0(Tier 1) necon 7/7/7 $0(Tier 1) norethindrone acetate/ethinyl estradiol/ferrous fumarate tabs $0(Tier 1) norethindrone acetate/ethinyl estradiol tabs 20mcg; 1mg $0(Tier 1) norethindrone acetate/ethinyl estradiol tabs 2.5mcg; 0.5mg $0(Tier 1) PA norgestimate/ethinyl estradiol $0(Tier 1) nortrel 0.5/35 (28) $0(Tier 1) nortrel 1/35 $0(Tier 1) nortrel 7/7/7 $0(Tier 1) ogestrel $0(Tier 1) orsythia $0(Tier 1) philith $0(Tier 1) pimtrea $0(Tier 1) pirmella 1/35 $0(Tier 1) pirmella 7/7/7 $0(Tier 1) portia-28 $0(Tier 1) PREMARIN CREA, INJ $0(Tier 2) PREMARIN TABS 0.3MG, 0.45MG, 0.625MG, 0.9MG, $0(Tier 2) QL (30 per 30 days) PA 1.25MG previfem $0(Tier 1) quasense $0(Tier 1) QL (91 per 91 days) reclipsen tabs 0.15mg; 0.03mg $0(Tier 1) setlakin $0(Tier 1) QL (91 per 91 days) sprintec 28 $0(Tier 1) sronyx $0(Tier 1) tarina fe 1/20 $0(Tier 1) tilia fe $0(Tier 1) apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 88

97 Name of drug What the drug tri-estarylla $0(Tier 1) tri-legest fe $0(Tier 1) tri-linyah $0(Tier 1) tri-mili $0(Tier 1) tri-previfem $0(Tier 1) tri-sprintec $0(Tier 1) tri-vylibra $0(Tier 1) trinessa $0(Tier 1) trivora-28 $0(Tier 1) tydemy $0(Tier 1) velivet $0(Tier 1) vienva $0(Tier 1) viorele $0(Tier 1) vyfemla $0(Tier 1) vylibra $0(Tier 1) wera $0(Tier 1) yuvafem $0(Tier 1) QL (18 per 28 days) zenchent $0(Tier 1) zovia 1/35e $0(Tier 1) zovia 1/50e $0(Tier 1) Progesterone Agonists/Antagonists ELLA $0(Tier 2) MAKENA INJ 275MG/1.1ML $0(Tier 2) PA Progestins camila $0(Tier 1) deblitane $0(Tier 1) DEPO-PROVERA INJ 400MG/ML $0(Tier 2) QL (10 per 28 days) econtra ez $0(Tier 1) MC errin $0(Tier 1) fallback solo $0(Tier 1) MC heather $0(Tier 1) hydroxyprogesterone caproate inj 1.25gm/5ml $0(Tier 1) PA jencycla $0(Tier 1) jolivette $0(Tier 1) levonorgestrel tabs 1.5mg $0(Tier 1) MC lyza $0(Tier 1) MAKENA INJ 250MG/ML $0(Tier 2) PA medroxyprogesterone acetate tabs $0(Tier 1) medroxyprogesterone acetate inj $0(Tier 1) QL (1 per 90 days) megestrol acetate tabs $0(Tier 1) PA megestrol acetate susp 40mg/ml $0(Tier 1) PA my way $0(Tier 1) MC nora-be $0(Tier 1) norethindrone acetate tabs $0(Tier 1) norethindrone tabs $0(Tier 1) apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 89

98 What the drug Name of drug norlyroc $0(Tier 1) opcicon one-step $0(Tier 1) MC progesterone caps $0(Tier 1) sharobel $0(Tier 1) Selective Estrogen Receptor Modifying Agents raloxifene hydrochloride $0(Tier 1) QL (30 per 30 days) Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) (Drugs that Replace Thyroid Hormone) Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) levothyroxine sodium tabs $0(Tier 1) LEVOXYL TABS 100MCG, 112MCG, 125MCG, 137MCG, 150MCG, 175MCG, 200MCG, 25MCG, 50MCG, 75MCG, 88MCG $0(Tier 2) liothyronine sodium inj, tabs $0(Tier 1) SYNTHROID TABS $0(Tier 2) THYROLAR-1 $0(Tier 2) THYROLAR-1/2 $0(Tier 2) THYROLAR-1/4 $0(Tier 2) THYROLAR-2 $0(Tier 2) THYROLAR-3 $0(Tier 2) UNITHROID $0(Tier 2) Hormonal Agents, Suppressant (Adrenal) (Drugs that Decrease Levels of Hormones Associated with the Adrenal Glands) Hormonal Agents, Suppressant (Adrenal) LYSODREN $0(Tier 2) Hormonal Agents, Suppressant (Pituitary) (Drugs that Decrease Thyroid Stimulating Hormone Production) Hormonal Agents, Suppressant (Pituitary) cabergoline $0(Tier 1) QL (16 per 28 days) ELIGARD INJ 30MG $0(Tier 2) QL (1 per 120 days) PA ELIGARD INJ 45MG $0(Tier 2) QL (1 per 180 days) PA ELIGARD INJ 7.5MG $0(Tier 2) QL (1 per 30 days) PA ELIGARD INJ 22.5MG $0(Tier 2) QL (1 per 90 days) PA FIRMAGON INJ 80MG $0(Tier 2) QL (1 per 28 days) B/D FIRMAGON INJ 120MG $0(Tier 2) QL (4 per 365 days) B/D leuprolide acetate inj $0(Tier 1) PA LUPRON DEPOT (1-MONTH) $0(Tier 2) QL (1 per 30 days) PA LUPRON DEPOT (3-MONTH) $0(Tier 2) QL (1 per 84 days) PA LUPRON DEPOT (4-MONTH) $0(Tier 2) QL (1 per 112 days) PA LUPRON DEPOT (6-MONTH) $0(Tier 2) QL (1 per 168 days) PA LUPRON DEPOT-PED (1-MONTH) $0(Tier 2) QL (1 per 30 days) PA apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 90

99 Name of drug What the drug LUPRON DEPOT-PED (3-MONTH) $0(Tier 2) QL (1 per 84 days) PA octreotide acetate inj 1000mcg/ml, 100mcg/ml, 200mcg/ml, $0(Tier 1) PA 50mcg/ml octreotide acetate inj 500mcg/ml $0(Tier 1) PA SANDOSTATIN LAR DEPOT $0(Tier 2) PA SIGNIFOR $0(Tier 2) QL (60 per 30 days) PA SOMATULINE DEPOT INJ 60MG/0.2ML $0(Tier 2) QL (0.2 per 28 days) PA SOMATULINE DEPOT INJ 90MG/0.3ML $0(Tier 2) QL (0.3 per 28 days) PA SOMATULINE DEPOT INJ 120MG/0.5ML $0(Tier 2) QL (0.5 per 28 days) PA SOMAVERT $0(Tier 2) QL (30 per 30 days) PA SYNAREL $0(Tier 2) PA TRELSTAR MIXJECT INJ 22.5MG $0(Tier 2) QL (1 per 168 days) PA TRELSTAR MIXJECT INJ 3.75MG $0(Tier 2) QL (1 per 28 days) PA TRELSTAR MIXJECT INJ 11.25MG $0(Tier 2) QL (1 per 84 days) PA TRELSTAR INJ 3.75MG $0(Tier 2) QL (1 per 28 days) PA TRELSTAR INJ 11.25MG $0(Tier 2) QL (1 per 84 days) PA Hormonal Agents, Suppressant (Thyroid) (Drugs that Lower Thyroid Hormone Levels) Antithyroid Agents methimazole tabs 10mg, 5mg $0(Tier 1) propylthiouracil tabs $0(Tier 1) Immunological Agents (Drugs d for Prevention of Disease and Infection or can Affect the Immune System) Angioedema Agents CINRYZE $0(Tier 2) QL (100 per 30 days) PA FIRAZYR $0(Tier 2) QL (18 per 30 days) PA RUCONEST $0(Tier 2) QL (8 per 30 days) PA Immune Suppressants ASTAGRAF XL CP24 0.5MG, 1MG $0(Tier 2) PA ASTAGRAF XL CP24 5MG $0(Tier 2) PA AZASAN $0(Tier 2) PA azathioprine inj, tabs $0(Tier 1) PA cyclosporine modified $0(Tier 1) PA apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 91

100 Name of drug What the drug cyclosporine caps, inj $0(Tier 1) PA ENBREL MINI $0(Tier 2) QL (8 per 28 days) PA ENBREL SURECLICK $0(Tier 2) QL (8 per 28 days) PA ENBREL INJ 25MG/0.5ML $0(Tier 2) QL (4.08 per 28 days) PA ENBREL INJ 25MG, 50MG/ML $0(Tier 2) QL (8 per 28 days) PA ENVARSUS XR TB MG, 1MG $0(Tier 2) PA ENVARSUS XR TB24 4MG $0(Tier 2) PA gengraf $0(Tier 1) PA hecoria $0(Tier 1) PA HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK INJ 0 $0(Tier 2) QL (4 per 365 days) PA HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK INJ 40MG/0.8ML, 80MG/0.8ML $0(Tier 2) QL (6 per 365 days) PA HUMIRA PEN $0(Tier 2) QL (4 per 28 days) PA HUMIRA PEN-CROHNS DISEASESTARTER $0(Tier 2) QL (12 per 365 days) PA HUMIRA PEN-PSORIASIS STARTER $0(Tier 2) QL (8 per 365 days) PA HUMIRA INJ 10MG/0.1ML, 10MG/0.2ML, 20MG/0.2ML, 20MG/0.4ML $0(Tier 2) QL (2 per 28 days) PA HUMIRA INJ 40MG/0.4ML, 40MG/0.8ML $0(Tier 2) QL (4 per 28 days) PA KINERET $0(Tier 2) QL (20.1 per 30 days) PA methotrexate sodium inj 100mg/4ml, 1gm/40ml, 1gm, $0(Tier 1) 200mg/8ml, 250mg/10ml, 50mg/2ml methotrexate tabs $0(Tier 1) mycophenolate mofetil caps, inj, tabs $0(Tier 1) PA mycophenolate mofetil susr $0(Tier 1) PA mycophenolic acid dr $0(Tier 1) PA NULOJIX $0(Tier 2) QL (150 per 30 days) PA PROGRAF INJ $0(Tier 2) PA RAPAMUNE SOLN $0(Tier 2) PA REMICADE $0(Tier 2) PA RENFLEXIS $0(Tier 2) PA SANDIMMUNE SOLN $0(Tier 2) PA sirolimus tabs $0(Tier 1) PA tacrolimus caps 0.5mg, 1mg, 5mg $0(Tier 1) PA apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 92

101 Name of drug What the drug TORISEL $0(Tier 2) QL (4 per 28 days) B/D XATMEP $0(Tier 2) PA ZORTRESS TABS 0.5MG $0(Tier 2) QL (120 per 30 days) PA ZORTRESS TABS 0.25MG, 0.75MG $0(Tier 2) QL (60 per 30 days) PA Immunizing Agents, Passive ATGAM $0(Tier 2) PA GAMMAKED INJ 1GM/10ML $0(Tier 2) B/D GAMMAKED INJ 10GM/100ML, 2.5GM/25ML, $0(Tier 2) B/D 20GM/200ML, 5GM/50ML GAMUNEX-C INJ 1GM/10ML $0(Tier 2) B/D GAMUNEX-C INJ 10GM/100ML, 2.5GM/25ML, $0(Tier 2) B/D 20GM/200ML, 40GM/400ML, 5GM/50ML THYMOGLOBULIN $0(Tier 2) B/D VARIZIG INJ 125UNIT $0(Tier 2) QL (12 per 30 days) Immunomodulators ACTEMRA INJ 162MG/0.9ML $0(Tier 2) QL (3.6 per 28 days) PA ACTEMRA INJ 200MG/10ML, 400MG/20ML, 80MG/4ML $0(Tier 2) QL (40 per 28 days) PA ACTIMMUNE $0(Tier 2) PA ARCALYST $0(Tier 2) PA BENLYSTA INJ 120MG $0(Tier 2) QL (30 per 28 days) PA BENLYSTA INJ 400MG $0(Tier 2) QL (9 per 28 days) PA ILARIS $0(Tier 2) QL (2 per 28 days) PA leflunomide tabs $0(Tier 1) QL (30 per 30 days) RIDAURA $0(Tier 2) SIMULECT $0(Tier 2) B/D SYNAGIS $0(Tier 2) PA Vaccines ACTHIB INJ 0 $0(Tier 2) ADACEL $0(Tier 2) QL (0.5 per 365 days) BCG VACCINE $0(Tier 2) BEXSERO $0(Tier 2) BOOSTRIX $0(Tier 2) QL (0.5 per 365 days) CERVARIX $0(Tier 2) COMVAX $0(Tier 2) DAPTACEL INJ 23MCG/0.5ML; 15LF/0.5ML; 5LF/0.5ML $0(Tier 2) DIPHTHERIA/TETANUS TOXOIDS ADSORBED PEDIATRIC $0(Tier 2) apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 93

102 What the drug Name of drug ENGERIX-B INJ 10MCG/0.5ML $0(Tier 2) QL (3 per 365 days) B/D ENGERIX-B INJ 20MCG/ML $0(Tier 2) QL (8 per 365 days) B/D GARDASIL $0(Tier 2) QL (1.5 per 365 days) GARDASIL 9 $0(Tier 2) QL (1.5 per 365 days) HAVRIX INJ 1440ELU/ML, 720ELU/0.5ML $0(Tier 2) HEPLISAV-B $0(Tier 2) QL (3 per 365 days) B/D HIBERIX $0(Tier 2) IMOVAX RABIES (H.D.C.V.) $0(Tier 2) B/D INFANRIX $0(Tier 2) IPOL INACTIVATED IPV $0(Tier 2) IXIARO $0(Tier 2) KINRIX $0(Tier 2) M-M-R II $0(Tier 2) QL (2 per 365 days) MENACTRA $0(Tier 2) MENHIBRIX $0(Tier 2) MENOMUNE-A/C/Y/W-135 $0(Tier 2) MENVEO $0(Tier 2) PEDIARIX $0(Tier 2) PEDVAX HIB INJ 7.5MCG/0.5ML $0(Tier 2) PROQUAD $0(Tier 2) QL (2 per 365 days) QUADRACEL $0(Tier 2) RABAVERT $0(Tier 2) B/D RECOMBIVAX HB $0(Tier 2) QL (3 per 365 days) B/D ROTARIX $0(Tier 2) ROTATEQ SOLN $0(Tier 2) SHINGRIX $0(Tier 2) QL (2 per 999 days) STAMARIL $0(Tier 2) QL (1 per 999 days) TENIVAC $0(Tier 2) QL (0.5 per 28 days) TETANUS/DIPHTHERIA TOXOIDS-ADSORBED $0(Tier 2) TETANUS/DIPHTHERIA TOXOIDS-ADSORBED ADULT $0(Tier 2) TRUMENBA $0(Tier 2) TWINRIX $0(Tier 2) TYPHIM VI $0(Tier 2) VAQTA $0(Tier 2) VARIVAX $0(Tier 2) QL (1 per 365 days) VARIZIG INJ 125UNIT/1.2ML $0(Tier 2) QL (12 per 30 days) VAXCHORA $0(Tier 2) YF-VAX $0(Tier 2) ZOSTAVAX $0(Tier 2) QL (1 per 999 days) Inflammatory Bowel Disease Agents (Drugs that Treat Inflammation of the Bowels) Aminosalicylates APRISO $0(Tier 2) QL (120 per 30 days) balsalazide disodium $0(Tier 1) LIALDA $0(Tier 2) QL (120 per 30 days) mesalamine enem, kit $0(Tier 1) apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 94

103 What the drug Name of drug Glucocorticoids budesonide cpep 3mg $0(Tier 1) colocort $0(Tier 1) hydrocortisone enem 100mg/60ml $0(Tier 1) Sulfonamides sulfasalazine tabs, tbec $0(Tier 1) Metabolic Bone Disease Agents (Drugs that Treat Weak Bones) Metabolic Bone Disease Agents alendronate sodium tabs 10mg, 40mg, 5mg $0(Tier 1) QL (30 per 30 days) alendronate sodium tabs 35mg, 70mg $0(Tier 1) QL (4 per 28 days) BINOSTO $0(Tier 2) calcitonin-salmon soln $0(Tier 1) QL (3.7 per 30 days) calcitriol caps 0.25mcg, 0.5mcg $0(Tier 1) calcitriol inj 1mcg/ml $0(Tier 1) calcitriol oral soln 1mcg/ml $0(Tier 1) doxercalciferol caps 2.5mcg $0(Tier 1) QL (120 per 30 days) doxercalciferol caps 1mcg $0(Tier 1) QL (240 per 30 days) doxercalciferol caps 0.5mcg $0(Tier 1) QL (90 per 30 days) doxercalciferol inj $0(Tier 1) etidronate disodium $0(Tier 1) FORTEO INJ 600MCG/2.4ML $0(Tier 2) QL (2.4 per 28 days) PA ibandronate sodium tabs $0(Tier 1) QL (1 per 28 days) MIACALCIN INJ $0(Tier 2) pamidronate disodium $0(Tier 1) B/D paricalcitol caps 4mcg $0(Tier 1) QL (60 per 30 days) paricalcitol caps 1mcg, 2mcg $0(Tier 1) QL (90 per 30 days) PROLIA $0(Tier 2) QL (1 per 180 days) risedronate sodium tabs 150mg $0(Tier 1) QL (1 per 30 days) risedronate sodium tabs 30mg, 5mg $0(Tier 1) QL (30 per 30 days) risedronate sodium tabs 35mg $0(Tier 1) QL (4 per 28 days) SENSIPAR TABS 90MG $0(Tier 2) QL (120 per 30 days) SENSIPAR TABS 30MG $0(Tier 2) QL (60 per 30 days) SENSIPAR TABS 60MG $0(Tier 2) QL (60 per 30 days) XGEVA $0(Tier 2) QL (1.7 per 28 days) PA zoledronic acid inj 5mg/100ml $0(Tier 1) QL (100 per 365 days) B/D zoledronic acid inj 4mg/5ml $0(Tier 1) QL (15 per 21 days) B/D zoledronic acid inj 4mg $0(Tier 1) QL (3 per 21 days) B/D Miscellaneous Therapeutic Agents (Other Drugs) Miscellaneous Therapeutic Agents accu-chek guide strp $0(Tier 1) MC apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 95

104 Name of drug What the drug active 1st blood lancets 30g/easy twist cap $0(Tier 1) MC advocate lancing device $0(Tier 1) MC aerovent plus holding chamber/collapsible $0(Tier 1) MC assure prism multi test strips $0(Tier 1) MC bd autoshield duo 30g x 3/16" $0(Tier 1) MC bd eclipse syringe/1ml/30gx1/2" $0(Tier 1) QL (200 per 30 days) bd insulin syringe safetyglide/1ml/29g x 1/2" $0(Tier 1) QL (200 per 30 days) bd insulin syringe ultrafine/0.3ml/31g x 5/16" $0(Tier 1) QL (200 per 30 days) bd insulin syringe ultrafine/0.5ml/30g x 1/2" $0(Tier 1) QL (200 per 30 days) bd insulin syringe ultrafine/1ml/31g x 5/16" $0(Tier 1) QL (200 per 30 days) bd pen needle/mini/ultrafine/31g x 3/16" $0(Tier 1) QL (200 per 30 days) bd pen needle/nano/ultra fine/32g x 4mm $0(Tier 1) QL (200 per 30 days) bd pen needle/ultrafine/29g x 12.7mm $0(Tier 1) QL (200 per 30 days) bd safetyglide 27g x 5/8" $0(Tier 1) QL (200 per 30 days) blood glucose test strips premium $0(Tier 1) MC caretouch lancing device with ejector $0(Tier 1) MC caretouch twist lancets 30g $0(Tier 1) MC CARNITOR INJ $0(Tier 2) B/D clever choice anti-staticvalved holding chamber/adult large $0(Tier 1) MC clever choice anti-staticvalved holding chamber/medium $0(Tier 1) MC clever choice anti-staticvalved holding chamber/small $0(Tier 1) MC compact space chamber/anti-static $0(Tier 1) MC compact space chamber/anti-static/large mask $0(Tier 1) MC compact space chamber/anti-static/medium mask $0(Tier 1) MC compact space chamber/anti-static/small mask $0(Tier 1) MC cvs lancets ultra-thin 30g $0(Tier 1) MC drug mart unilet micro thin lancets 33g $0(Tier 1) MC easy mini eject lancing device $0(Tier 1) MC FERRIPROX $0(Tier 2) PA fifty50 unilet lancets 33g $0(Tier 1) MC flexichamber $0(Tier 1) MC flexichamber adult mask/small $0(Tier 1) MC flexichamber child mask/large $0(Tier 1) MC flexichamber child mask/small $0(Tier 1) MC fomepizole $0(Tier 1) fora d40/g31 blood glucose test strips $0(Tier 1) MC fora lancets $0(Tier 1) MC fora lancing device/clearcap $0(Tier 1) MC fora tn'g/tn'g voice blood glucose test strips $0(Tier 1) MC freestyle precision neo blood glucose test strips $0(Tier 1) MC glucose meter test strips advanced $0(Tier 1) MC gnp easy touch glucose test strips $0(Tier 1) MC h-e-b incontrol lancets micro thin 33g $0(Tier 1) MC iglucose blood glucose test strips $0(Tier 1) MC infinity voice strp $0(Tier 1) MC apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 96

105 Name of drug What the drug inspirachamber/large $0(Tier 1) MC INTRALIPID INJ 20GM/100ML, 30GM/100ML $0(Tier 2) B/D KORLYM $0(Tier 2) QL (120 per 30 days) PA LACTATED RINGERS IRRIGATION $0(Tier 2) lancets $0(Tier 1) MC levocarnitine inj, oral soln, tabs $0(Tier 1) LIPOSYN III INJ 1.2GM/100ML; 2.5GM/100ML; 10GM/100ML, 1.2GM/100ML; 2.5GM/100ML; 20GM/100ML $0(Tier 2) microlet next $0(Tier 1) MC mm easy touch glucose test strips $0(Tier 1) MC multi-lancet device 2 $0(Tier 1) MC NATPARA $0(Tier 2) QL (2 per 28 days) PA novofine 30gx8mm $0(Tier 1) QL (200 per 30 days) novofine 31 $0(Tier 1) QL (200 per 30 days) novofine 32gx6mm $0(Tier 1) QL (200 per 30 days) novofine autocover 30gx8mm $0(Tier 1) QL (200 per 30 days) novotwist 30gx8mm $0(Tier 1) QL (200 per 30 days) novotwist 32gx5mm $0(Tier 1) QL (200 per 30 days) NUTRILIPID $0(Tier 2) B/D one-way valved expiratorymouthpiece/disposable $0(Tier 1) MC one-way valved inspiratory mouthpiece/disposable $0(Tier 1) MC panda mask large $0(Tier 1) MC panda mask medium $0(Tier 1) MC panda mask small $0(Tier 1) MC pantothenic acid $0(Tier 1) MC pediatric medium mask $0(Tier 1) MC pediatric mouthpiece/disposable $0(Tier 1) MC pediatric panda mask $0(Tier 1) MC pediatric small mask $0(Tier 1) MC pharmacist choice no coding blood glucose test strips $0(Tier 1) MC pharmacist choice ultra thin lancets 33g $0(Tier 1) MC PHYSIOLYTE $0(Tier 2) PHYSIOSOL IRRIGATION $0(Tier 2) premium blood glucose test strips $0(Tier 1) MC pro comfort lancets 30g $0(Tier 1) MC pro comfort lancets 31g $0(Tier 1) MC prodigy safety lancets $0(Tier 1) MC px advanced lancing device $0(Tier 1) MC px lancets ultra thin 28g $0(Tier 1) MC qc unilet lancets 33g/micro thin $0(Tier 1) MC readylance safety lancets/21g/2.2mm $0(Tier 1) MC readylance safety lancets/23g/1.8mm $0(Tier 1) MC apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 97 B/D

106 What the drug Name of drug readylance safety lancets/26g/1.8mm $0(Tier 1) MC readylance safety lancets/28g/1.8mm $0(Tier 1) MC relion premier blood glucose test strips $0(Tier 1) MC relion prime blood glucose test strips $0(Tier 1) MC RINGERS IRRIGATION $0(Tier 2) sidestream pediatric facemask $0(Tier 1) MC sidestream pediatric facemask/tucker the turtle $0(Tier 1) MC silicone mask for breatherite chamber/pediatric $0(Tier 1) MC SODIUM CHLORIDE 0.9% $0(Tier 2) SODIUM CHLORIDE 0.9% $0(Tier 2) sterile water irrigation $0(Tier 1) sterile water irrigation plastic bottle $0(Tier 1) suspendol-s $0(Tier 1) MC techlite pen needles/31g x 6 mm $0(Tier 1) QL (200 per 30 days) techlite pen needles/31g x 8mm $0(Tier 1) QL (200 per 30 days) techlite pen needles/32g x 4mm $0(Tier 1) QL (200 per 30 days) techlite pen needles/32g x 6mm $0(Tier 1) QL (200 per 30 days) techlite pen needles/32g x 8mm $0(Tier 1) QL (200 per 30 days) thyrosafe $0(Tier 1) MC TIS-U-SOL $0(Tier 2) true metrix self monitoring blood glucose strips $0(Tier 1) MC unilet lancets micro-thin33g $0(Tier 1) MC unilet lancets super-thin30g $0(Tier 1) MC unilet lancets ultra-thin 28g $0(Tier 1) MC unistik pro safety lancet 21g $0(Tier 1) MC unistik pro safety lancet 25g $0(Tier 1) MC unistik pro safety lancet 28g $0(Tier 1) MC unistik touch safety lancets 21g $0(Tier 1) MC unistik touch safety lancets 23g $0(Tier 1) MC unistik touch safety lancets 28g $0(Tier 1) MC unistik touch safety lancets 30g $0(Tier 1) MC V-GO 20 $0(Tier 2) V-GO 30 $0(Tier 2) V-GO 40 $0(Tier 2) verasens blood glucose test strips $0(Tier 1) MC vortex holding chamber/mask/toddler/lady bug $0(Tier 1) MC vortex valved holding chamber $0(Tier 1) MC Ophthalmic Agents (Drugs that Relieve or Prevent Eye Problems) Ophthalmic Prostaglandin and Prostamide Analogs bimatoprost $0(Tier 1) QL (5 per 30 days) COMBIGAN $0(Tier 2) latanoprost soln $0(Tier 1) QL (5 per 30 days) LUMIGAN $0(Tier 2) QL (5 per 30 days) ST TRAVATAN Z $0(Tier 2) QL (5 per 30 days) ZIOPTAN $0(Tier 2) QL (30 per 30 days) apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 98

107 Name of drug What the drug Ophthalmic Agents, Other akwa tears $0(Tier 1) MC artificial tears oint 15%; 83% $0(Tier 1) MC artificial tears soln 1.4% $0(Tier 1) MC atropine sulfate ophthalmic soln 1% $0(Tier 1) CYSTARAN $0(Tier 2) QL (60 per 28 days) PA eye drops soln 0.05% $0(Tier 1) MC eye irrigating solution $0(Tier 1) MC eye wash soln 99.05% $0(Tier 1) MC FRESHKOTE $0(Tier 1) MC ISOPTO TEARS $0(Tier 1) MC LACRISERT $0(Tier 2) liquitears $0(Tier 1) MC lubricant eye drops soln 0.4%; 0.3% $0(Tier 1) MC lubricating plus eye drops $0(Tier 1) MC lubrifresh p.m. $0(Tier 1) MC MURO 128 SOLN $0(Tier 1) MC naphazoline hcl $0(Tier 1) natural balance tears soln 0.1%; 0.3% $0(Tier 1) MC natures tears soln 0.1%; 0.3% $0(Tier 1) MC opti-clear $0(Tier 1) MC proparacaine hcl $0(Tier 1) puralube oint 15%; 85% $0(Tier 1) MC REFRESH CELLUVISC $0(Tier 1) MC REFRESH LACRI-LUBE $0(Tier 1) MC refresh optive mega-3 $0(Tier 1) MC REFRESH PLUS $0(Tier 1) MC RESTASIS $0(Tier 2) QL (60 per 30 days) sodium chloride oint 5% $0(Tier 1) MC sodium chloride ophthalmic soln 5% $0(Tier 1) MC tropicamide $0(Tier 1) ultra lubricant eye drops $0(Tier 1) MC Ophthalmic Anti-allergy Agents ALOCRIL $0(Tier 2) azelastine hcl ophthalmic soln 0.05% $0(Tier 1) cromolyn sodium soln 4% $0(Tier 1) epinastine hcl $0(Tier 1) olopatadine hcl $0(Tier 1) QL (5 per 30 days) olopatadine hydrochloride $0(Tier 1) QL (2.5 per 30 days) PAZEO $0(Tier 2) QL (2.5 per 30 days) Ophthalmic Anti-inflammatories bromfenac $0(Tier 1) dexamethasone sodium phosphate ophthalmic soln 0.1% $0(Tier 1) diclofenac sodium ophthalmic soln 0.1% $0(Tier 1) apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 99

108 What the drug Name of drug DUREZOL $0(Tier 2) eye itch relief $0(Tier 1) MC fluorometholone $0(Tier 1) flurbiprofen sodium $0(Tier 1) ILEVRO $0(Tier 2) ketorolac tromethamine $0(Tier 1) LOTEMAX $0(Tier 2) neomycin/polymyxin/dexamethasone $0(Tier 1) PRED MILD $0(Tier 2) PRED-G $0(Tier 2) PRED-G S.O.P. $0(Tier 2) prednisolone acetate $0(Tier 1) prednisolone sodium phosphate ophthalmic soln 1% $0(Tier 1) PROLENSA $0(Tier 2) TOBRADEX OINT $0(Tier 2) tobramycin/dexamethasone $0(Tier 1) Ophthalmic Antiglaucoma Agents acetazolamide er $0(Tier 1) apraclonidine $0(Tier 1) AZOPT $0(Tier 2) betaxolol hcl soln 0.5% $0(Tier 1) brimonidine tartrate $0(Tier 1) carteolol hcl $0(Tier 1) dorzolamide hcl $0(Tier 1) QL (10 per 30 days) dorzolamide hcl/timolol maleate $0(Tier 1) QL (10 per 30 days) levobunolol hcl soln 0.5% $0(Tier 1) metipranolol $0(Tier 1) PHOSPHOLINE IODIDE SOLR 0.125% $0(Tier 2) pilocarpine hcl soln 1%, 2%, 4% $0(Tier 1) SIMBRINZA $0(Tier 2) timolol maleate soln 0.25%, 0.5% $0(Tier 1) Otic Agents (Drugs that Relieve or Prevent Ear Problems) Otic Agents acetasol hc $0(Tier 1) acetic acid $0(Tier 1) acetic acid/aluminum acetate soln 2%; 0 $0(Tier 1) COLY-MYCIN S $0(Tier 2) CORTISPORIN-TC $0(Tier 2) ear drops soln 6.5% $0(Tier 1) MC earwax treatment drops $0(Tier 1) MC fluocinolone acetonide ear drops $0(Tier 1) fluocinolone acetonide oil 0.01% $0(Tier 1) hydrocortisone/acetic acid $0(Tier 1) neomycin/polymyxin/hc $0(Tier 1) apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 100

109 What the drug $0(Tier 1) Name of drug neomycin/polymyxin/hydrocortisone soln 1%; 3.5mg/ml; 10000unit/ml neomycin/polymyxin/hydrocortisone otic susp 1%; 3.5mg/ml; $0(Tier 1) 10000unit/ml Respiratory Tract/Pulmonary Agents (Drugs that are d for Breathing Problems) Anti-inflammatories, Inhaled Corticosteroids ADVAIR DISKUS $0(Tier 2) QL (60 per 30 days) ADVAIR HFA $0(Tier 2) QL (12 per 30 days) ARNUITY ELLIPTA $0(Tier 2) QL (30 per 30 days) BREO ELLIPTA $0(Tier 2) QL (60 per 30 days) budesonide nasal spray susp 32mcg/act $0(Tier 1) MC budesonide nasal spray susp 32mcg/act $0(Tier 1) QL (17.2 per 30 days) budesonide susp 0.25mg/2ml, 0.5mg/2ml, 1mg/2ml $0(Tier 1) QL (120 per 30 days) B/D FLOVENT DISKUS AEPB 250MCG/BLIST $0(Tier 2) QL (240 per 30 days) FLOVENT DISKUS AEPB 100MCG/BLIST, 50MCG/BLIST $0(Tier 2) QL (60 per 30 days) FLOVENT HFA AERO 44MCG/ACT $0(Tier 2) QL (10.6 per 30 days) FLOVENT HFA AERO 110MCG/ACT $0(Tier 2) QL (12 per 30 days) FLOVENT HFA AERO 220MCG/ACT $0(Tier 2) QL (24 per 30 days) flunisolide soln 0.025% $0(Tier 1) QL (50 per 30 days) fluticasone propionate susp 50mcg/act $0(Tier 1) MC fluticasone propionate susp 50mcg/act $0(Tier 1) QL (16 per 30 days) mometasone furoate susp 50mcg/act $0(Tier 1) QL (34 per 30 days) NASONEX $0(Tier 2) QL (34 per 30 days) ST triamcinolone acetonide aero 55mcg/act $0(Tier 1) MC Antihistamines aceta-gesic tabs 325mg; 12.5mg $0(Tier 1) MC acetaminophen/diphenhydramine $0(Tier 1) MC ALA-HIST IR $0(Tier 1) MC ALA-HIST PE $0(Tier 1) MC all day allergy childrens soln 5mg/5ml $0(Tier 1) MC all day allergy-d $0(Tier 1) MC all day allergy tabs $0(Tier 1) MC aller-chlor $0(Tier 1) MC allergy relief d-24 $0(Tier 1) MC allergy relief tabs 10mg $0(Tier 1) MC allergy tabs 10mg, 4mg $0(Tier 1) MC azelastine hcl nasal soln 0.1%, 0.15% $0(Tier 1) QL (30 per 25 days) banophen caps, liqd $0(Tier 1) MC BROTAPP $0(Tier 1) MC cetirizine hcl allergy childrens $0(Tier 1) MC cetirizine hcl childrens allergy soln $0(Tier 1) MC cetirizine hcl/pseudoephedrine hcl er $0(Tier 1) MC cetirizine hcl chew, tabs $0(Tier 1) MC childrens allergy $0(Tier 1) MC childrens loratadine $0(Tier 1) MC apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 101

110 Name of drug What the drug chlorphen sr $0(Tier 1) MC complete allergy medicine caps $0(Tier 1) MC dallergy liqd 1mg/ml; 2.5mg/ml $0(Tier 1) MC dallergy tabs 1mg; 5mg $0(Tier 1) MC desloratadine $0(Tier 1) QL (30 per 30 days) dimaphen childrens $0(Tier 1) MC diphenhist caps, liqd $0(Tier 1) MC diphenhydramine hcl caps $0(Tier 1) MC diphenhydramine hcl inj 50mg/ml $0(Tier 1) diphenhydramine hydrochloride $0(Tier 1) MC ed a-hist pse $0(Tier 1) MC ed a-hist liqd, tabs $0(Tier 1) MC ed chlorped d $0(Tier 1) MC ed chlorped jr $0(Tier 1) MC ed chlorped liqd $0(Tier 1) MC fexofenadine hcl childrens allergy $0(Tier 1) MC fexofenadine hcl tabs 180mg, 60mg $0(Tier 1) MC gnp all day allergy $0(Tier 1) MC gnp allergy tabs 4mg $0(Tier 1) MC gnp dayhist allergy $0(Tier 1) MC gnp loratadine $0(Tier 1) MC histex pd liqd 0.938mg/ml $0(Tier 1) MC histex syrp $0(Tier 1) MC levocetirizine dihydrochloride tabs $0(Tier 1) QL (30 per 30 days) levocetirizine dihydrochloride soln $0(Tier 1) QL (300 per 30 days) LODRANE D $0(Tier 1) MC lohist-d $0(Tier 1) MC loratadine childrens $0(Tier 1) MC loratadine hives relief $0(Tier 1) MC loratadine-d 12hr $0(Tier 1) MC loratadine-d 24hr $0(Tier 1) MC loratadine tabs $0(Tier 1) MC m-hist pd $0(Tier 1) MC NASOPEN PE $0(Tier 1) MC night time sleep aid $0(Tier 1) MC nohist-lq $0(Tier 1) MC POLY-HIST PD $0(Tier 1) MC qc loratadine allergy relief $0(Tier 1) MC qc loratadine-d $0(Tier 1) MC RESCON TABS $0(Tier 1) MC ru-hist d $0(Tier 1) MC rymed $0(Tier 1) MC rynex pe $0(Tier 1) MC rynex pse $0(Tier 1) MC siladryl allergy $0(Tier 1) MC apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 102

111 Name of drug What the drug silphen cough $0(Tier 1) MC sm allergy 4 hour $0(Tier 1) MC sm allergy relief liqd $0(Tier 1) MC sm allergy relief tabs 1.34mg $0(Tier 1) MC sm lorata-dine d $0(Tier 1) MC sm loratadine syrp $0(Tier 1) MC sm sleep aid $0(Tier 1) MC sudogest sinus & allergy $0(Tier 1) MC triprolidine hcl liqd 0.625mg/ml $0(Tier 1) MC triprolidine hydrochloride $0(Tier 1) MC vanaclear pd $0(Tier 1) MC VANAHIST PD $0(Tier 1) MC Antileukotrienes montelukast sodium chew, pack, tabs $0(Tier 1) QL (30 per 30 days) zafirlukast $0(Tier 1) QL (60 per 30 days) Bronchodilators, Anticholinergic ATROVENT HFA $0(Tier 2) QL (25.8 per 30 days) COMBIVENT RESPIMAT $0(Tier 2) QL (8 per 30 days) INCRUSE ELLIPTA $0(Tier 2) QL (30 per 30 days) ipratropium bromide/albuterol sulfate $0(Tier 1) QL (540 per 30 days) B/D ipratropium bromide nasal soln $0(Tier 1) QL (30 per 30 days) ipratropium bromide inhalation soln $0(Tier 1) QL (300 per 30 days) B/D Bronchodilators, Sympathomimetic albuterol sulfate er $0(Tier 1) albuterol sulfate syrp, tabs $0(Tier 1) albuterol sulfate nebu 0.5% $0(Tier 1) QL (180 per 30 days) B/D albuterol sulfate nebu 0.083%, 0.63mg/3ml, 1.25mg/3ml $0(Tier 1) QL (360 per 30 days) B/D albuterol tabs $0(Tier 1) ANORO ELLIPTA $0(Tier 2) QL (60 per 30 days) epinephrine hcl inj 1mg/10ml, 1mg/ml, 30mg/30ml $0(Tier 1) epinephrine inj $0(Tier 1) QL (2 per 30 days) EPIPEN 2-PAK $0(Tier 2) QL (2 per 30 days) EPIPEN-JR 2-PAK $0(Tier 2) QL (2 per 30 days) levalbuterol tartrate hfa $0(Tier 1) QL (30 per 30 days) metaproterenol sulfate syrp, tabs $0(Tier 1) PERFOROMIST $0(Tier 2) QL (120 per 30 days) B/D PROAIR HFA $0(Tier 2) QL (17 per 30 days) PROAIR RESPICLICK $0(Tier 2) QL (2 per 30 days) S2 $0(Tier 1) MC SEREVENT DISKUS $0(Tier 2) QL (60 per 30 days) terbutaline sulfate inj, tabs $0(Tier 1) VENTOLIN HFA $0(Tier 2) QL (36 per 30 days) Cystic Fibrosis Agents CAYSTON $0(Tier 2) QL (84 per 56 days) PA apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 103

112 Name of drug What the drug KALYDECO $0(Tier 2) QL (60 per 30 days) PA ORKAMBI $0(Tier 2) QL (120 per 30 days) PA PULMOZYME $0(Tier 2) QL (150 per 30 days) B/D TOBI PODHALER $0(Tier 2) QL (1568 per 365 days) tobramycin nebu 300mg/5ml $0(Tier 1) QL (280 per 56 days) B/D Mast Cell Stabilizers cromolyn sodium aers 5.2mg/act $0(Tier 1) MC cromolyn sodium nebu 20mg/2ml $0(Tier 1) QL (240 per 30 days) B/D Phosphodiesterase Inhibitors, Airways Disease aminophylline inj $0(Tier 1) DALIRESP TABS 500MCG $0(Tier 2) QL (30 per 30 days) PA DALIRESP TABS 250MCG $0(Tier 2) QL (60 per 365 days) PA THEO-24 $0(Tier 2) theophylline cr tb12 100mg, 200mg $0(Tier 1) theophylline er tb12, tb24 $0(Tier 1) Pulmonary Antihypertensives ADEMPAS $0(Tier 2) QL (90 per 30 days) PA LETAIRIS $0(Tier 2) QL (30 per 30 days) PA OPSUMIT $0(Tier 2) QL (30 per 30 days) PA REMODULIN $0(Tier 2) B/D sildenafil tabs $0(Tier 1) QL (90 per 30 days) PA TRACLEER $0(Tier 2) QL (60 per 30 days) PA VENTAVIS $0(Tier 2) QL (270 per 30 days) PA Pulmonary Fibrosis Agents ESBRIET CAPS $0(Tier 2) QL (270 per 30 days) PA ESBRIET TABS 267MG $0(Tier 2) QL (270 per 30 days) PA ESBRIET TABS 801MG $0(Tier 2) QL (90 per 30 days) PA OFEV $0(Tier 2) QL (60 per 30 days) PA Respiratory Tract Agents, Other acetylcysteine soln $0(Tier 1) B/D alahist cf $0(Tier 1) MC apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 104

113 Name of drug What the drug alahist dm liqd 2mg/5ml; 15mg/5ml; 7.5mg/5ml $0(Tier 1) MC all-nite cold & flu nighttime relief $0(Tier 1) MC aprodine tabs $0(Tier 1) MC ARALAST NP INJ 1000MG, 500MG $0(Tier 2) B/D benzonatate $0(Tier 1) MC bromfed dm $0(Tier 1) MC bromphen/pseudoephedrine hcl/dextromethorphan hbr $0(Tier 1) MC BROTAPP DM $0(Tier 1) MC cheratussin ac syrp $0(Tier 1) MC chest congestion relief $0(Tier 1) MC chest congestion relief pe $0(Tier 1) MC childrens silfedrine $0(Tier 1) MC chlo tuss liqd 12.5mg/5ml; 1mg/5ml; 30mg/5ml $0(Tier 1) MC codeine/guaifenesin soln $0(Tier 1) MC cough dm $0(Tier 1) MC cough syrup $0(Tier 1) MC deconex dmx tabs 17.5mg; 385mg; 10mg $0(Tier 1) MC deconex ir tabs 385mg; 10mg $0(Tier 1) MC deep sea nasal spray $0(Tier 1) MC delsym cough + chest congestion dm $0(Tier 1) MC delsym cough + chest congestion dm childrens $0(Tier 1) MC delsym cough + cold daytime $0(Tier 1) MC delsym cough + cold nighttime childrens $0(Tier 1) MC delsym cough childrens $0(Tier 1) MC DELSYM SUER $0(Tier 1) MC dextromethorphan polistirex $0(Tier 1) MC dextromethorphan/guaifenesin/phenylephrine $0(Tier 1) MC dimaphen dm cold & cough $0(Tier 1) MC ed a-hist dm $0(Tier 1) MC ed bron gp $0(Tier 1) MC endacof-dm liqd $0(Tier 1) MC extra action cough $0(Tier 1) MC flowtuss $0(Tier 1) MC gnp tussin $0(Tier 1) MC gnp tussin dm $0(Tier 1) MC guaifenesin ac syrp $0(Tier 1) MC guaifenesin er tb mg $0(Tier 1) MC guaifenesin/codeine soln $0(Tier 1) MC guaifenesin/pseudoephedrine hydrochloride $0(Tier 1) MC histex-dm $0(Tier 1) MC histex-pe $0(Tier 1) MC hycofenix $0(Tier 1) MC hydrocodone bitartrate/chlorpheniramine maleate/pse $0(Tier 1) MC hydrocodone bitartrate/homatropine methylbromide $0(Tier 1) MC hydrocodone polistirex/chlorpheniramine polistirex $0(Tier 1) MC apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 105

114 Name of drug What the drug hydromet $0(Tier 1) MC iosat $0(Tier 1) MC kidkare cough/cold $0(Tier 1) MC lohist-dm $0(Tier 1) MC lortuss dm liqd 15mg/5ml; 6.25mg/5ml; 30mg/5ml $0(Tier 1) MC lortuss ex liqd 10mg/5ml; 100mg/5ml; 30mg/5ml $0(Tier 1) MC lortuss lq $0(Tier 1) MC M-END DMX $0(Tier 1) MC m-hist dm $0(Tier 1) MC mapap cold formula multi-symptom $0(Tier 1) MC mapap sinus maximum strength congestion and pain $0(Tier 1) MC MUCINEX $0(Tier 1) MC mucinex chest congestion childrens $0(Tier 1) MC mucinex childrens cold cough & sore throat $0(Tier 1) MC mucinex childrens multi-symptom cold $0(Tier 1) MC MUCINEX CHILDRENS MULTI-SYMPTOM COLD & $0(Tier 1) MC FEVER mucinex congestion & cough childrens $0(Tier 1) MC mucinex cough childrens $0(Tier 1) MC MUCINEX COUGH FOR KIDS PACK $0(Tier 1) MC MUCINEX D $0(Tier 1) MC MUCINEX D MAXIMUM STRENGTH $0(Tier 1) MC MUCINEX DM $0(Tier 1) MC MUCINEX DM MAXIMUM STRENGTH TB12 60MG; $0(Tier 1) MC 1200MG mucinex dm maximum strength tb12 60mg; 1200mg $0(Tier 1) MC mucinex fast-max cold & sinus tabs $0(Tier 1) MC MUCINEX FAST-MAX COLD FLU& SORE THROAT $0(Tier 1) MC LIQD mucinex fast-max cold flu& sore throat tabs $0(Tier 1) MC mucinex fast-max day time/night time misc 650mg/20ml; $0(Tier 1) MC 20mg/20ml; 25mg/20ml; 400mg/20ml; 10mg/20ml mucinex fast-max day/night maximum strength $0(Tier 1) MC mucinex fast-max dm max $0(Tier 1) MC mucinex fast-max night time cold & flu liqd $0(Tier 1) MC mucinex fast-max severe cold liqd, tabs $0(Tier 1) MC mucinex fast-max severe congestion & cough tabs $0(Tier 1) MC MUCINEX FOR KIDS PACK 100MG $0(Tier 1) MC mucinex maximum strength $0(Tier 1) MC mucinex multi-symptom cold day/night pack $0(Tier 1) MC mucinex multi-symptom cold night time childrens $0(Tier 1) MC mucinex sinus-max pressure & pain tabs $0(Tier 1) MC mucinex stuffy nose & cold childrens $0(Tier 1) MC mucus relief $0(Tier 1) MC mucus-er $0(Tier 1) MC apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 106

115 Name of drug What the drug mucusrelief sinus $0(Tier 1) MC nasal decongestant spray $0(Tier 1) MC nasal decongestant syrp $0(Tier 1) MC night time multi-symptom cold/flu relief caps $0(Tier 1) MC NINJACOF $0(Tier 1) MC NINJACOF-A $0(Tier 1) MC ninjacof-xg $0(Tier 1) MC nohist-dm $0(Tier 1) MC organ-i nr $0(Tier 1) MC pain relief sinus pe daytime $0(Tier 1) MC pediatric cough/cold $0(Tier 1) MC phenylephrine hcl/pyrilamine maleate $0(Tier 1) MC poly hist forte tabs 7.5mg; 10mg $0(Tier 1) MC POLY-HIST DM $0(Tier 1) MC poly-vent dm $0(Tier 1) MC poly-vent ir $0(Tier 1) MC PROLASTIN-C $0(Tier 2) B/D promethazine vc/codeine $0(Tier 1) MC promethazine-dm $0(Tier 1) MC promethazine/codeine $0(Tier 1) MC pseudoephedrine hcl tabs 30mg $0(Tier 1) MC RESCON DM $0(Tier 1) MC RESCON-GG $0(Tier 1) MC RESPAIRE-30 $0(Tier 1) MC ribavirin solr 6gm $0(Tier 1) B/D robafen $0(Tier 1) MC robafen cf multi-symptom cold $0(Tier 1) MC robafen cough $0(Tier 1) MC robafen dm $0(Tier 1) MC robafen dm cough clear $0(Tier 1) MC robafen dm cough/chest congestion $0(Tier 1) MC rynex dm $0(Tier 1) MC siltussin dm das $0(Tier 1) MC siltussin sa $0(Tier 1) MC siltussin-dm $0(Tier 1) MC sm nasal spray 12 hour $0(Tier 1) MC sm tussin dm $0(Tier 1) MC sm tussin dm cough/chest congestion $0(Tier 1) MC stahist ad $0(Tier 1) MC sudogest $0(Tier 1) MC sudogest 12 hour $0(Tier 1) MC sudogest pe $0(Tier 1) MC TRELEGY ELLIPTA $0(Tier 2) QL (60 per 30 days) tussin dm clear $0(Tier 1) MC tussin dm syrp $0(Tier 1) MC apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 107

116 What the drug Name of drug tussin dm liqd 10mg/5ml; 100mg/5ml $0(Tier 1) MC TUSSIONEX PENNKINETIC EXTENDED RELEASE $0(Tier 1) MC SUER 8MG/5ML; 10MG/5ML tussionex pennkinetic extended release suer 8mg/5ml; $0(Tier 1) MC 10mg/5ml VANACOF $0(Tier 1) MC VANACOF DM $0(Tier 1) MC vanatab ac $0(Tier 1) MC vanatab dm $0(Tier 1) MC virtussin a/c $0(Tier 1) MC virtussin dac $0(Tier 1) MC XOLAIR $0(Tier 2) QL (6 per 28 days) PA ZEMAIRA $0(Tier 2) B/D ZONATUSS $0(Tier 1) MC ZUTRIPRO $0(Tier 1) MC Skeletal Muscle Relaxants (Drugs that Relax Muscle Cramps or Stiff Muscles) Skeletal Muscle Relaxants cyclobenzaprine hcl tabs 10mg, 5mg $0(Tier 1) QL (90 per 30 days) PA methocarbamol tabs $0(Tier 1) PA orphenadrine citrate er $0(Tier 1) QL (60 per 30 days) PA Sleep Disorder Agents (Drugs that help with Sleep Problems) GABA Receptor Modulators temazepam $0(Tier 1) QL (60 per 365 days) zaleplon $0(Tier 1) QL (30 per 30 days) zolpidem tartrate tabs $0(Tier 1) QL (30 per 30 days) PA Sleep Disorders, Other armodafinil $0(Tier 1) QL (30 per 30 days) PA modafinil $0(Tier 1) QL (30 per 30 days) PA ROZEREM $0(Tier 2) QL (30 per 30 days) SILENOR $0(Tier 2) QL (30 per 30 days) XYREM $0(Tier 2) QL (540 per 30 days) PA apply; B/D = Drug covered under Medicare Part B or Part D; = Non-Extended Day Supply; MC = Non-Part D order, except when special circumstances or situations prohibit mailing a particular medication to your home. 108

117 Index Drug Name Page # a thru z advanced 60 a thru z select 60 a thru z select 50+ advanced formula 60 a thru z select advanced 60 a thru z select ultimate womens 60 a thru z ultimate mens 60 a abacavir 31 abacavir sulfate/lamivudine/zidovudine 31 abacavir/lamivudine 31 abaneu-sl 60 abc plus senior adults ABELCET 16 ABILIFY MAINTENA 28 ABRAXANE 21 acamprosate calcium dr 5 acarbose 34 accu-chek guide 95 acebutolol hcl 40 acephen 1 acerola c aceta-gesic 101 acetaminophen 1 acetaminophen/codeine 3 acetaminophen/codeine phosphate 3 acetaminophen/diphenhydramine 101 acetasol hc 100 acetazolamide 41 acetazolamide er 100 acetazolamide sodium 41 acetic acid 100 acetic acid/aluminum acetate 100 acetylcysteine 104 acid gone 79 acid reducer maximum strength 79 acitretin 45 acne medication acne medication 5 45 ACTEMRA 93 ACTHIB 93 actical 60 ACTIDOSE/SORBITOL 79 ACTIMMUNE 93 active 1st blood lancets 30g/easy twist cap 96 acyclovir 34 acyclovir sodium 34 ADACEL 93 Drug Name Page # ADAGEN 82 adefovir dipivoxil 30 ADEMPAS 104 adriamycin 21 adrucil 20 ADVAIR DISKUS 101 ADVAIR HFA 101 advanced stress formula/zinc 60 advocate lancing device 96 aerovent plus holding chamber/collapsible 96 afeditab cr 40 AFINITOR 23 AFINITOR DISPERZ 23 a-hydrocort 83 ak-poly-bac 6 akwa tears 99 ala-cort 83 alahist cf 104 alahist dm 105 ALA-HIST IR 101 ALA-HIST PE 101 alba-lybe nr 60 ALBENZA 26 albuterol 103 albuterol sulfate 103 albuterol sulfate er 103 alclometasone dipropionate 83 alcohol prep pads 6 ALDURAZYME 82 ALECENSA 23 alendronate sodium 95 alfuzosin hcl er 83 ALIMTA 20 ALINIA 27 ALIQOPA 23 all day allergy 101 all day allergy childrens 101 all day allergy-d 101 all day relief 1 aller-chlor 101 allergy 101 allergy relief 101 allergy relief d all-nite cold & flu nighttime relief 105 allopurinol 17 allopurinol sodium 17 almacone 79 almacone double strength 79 ALOCRIL 99 ALORA

118 Drug Name Page # alosetron hydrochloride 81 ALOXI 16 alprazolam 34 alprazolam odt 34 altavera 86 aluminum hydroxide 79 ALUNBRIG 23 alyacen 1/35 86 alyacen 7/7/7 86 amantadine hcl 27 AMBISOME 16 a-methapred 83 amethia 86 amethia lo 86 amifostine 21 amikacin sulfate 6 amiloride hcl 42 amiloride/hydrochlorothiazide 42 aminophylline 104 AMINOSYN 49 AMINOSYN 7%/ELECTROLYTES 47 AMINOSYN 8.5%/ELECTROLYTES 47 AMINOSYN II 48 AMINOSYN II 8.5%/ELECTROLYTES 47 AMINOSYN M 48 AMINOSYN-HBC 48 AMINOSYN-PF 48 AMINOSYN-PF 7% 48 AMINOSYN-RF 48 amiodarone hcl 39 AMITIZA 81 amitriptyline hcl 15 amlodipine besylate 40 amlodipine besylate/benazepril 40 hydrochloride amlodipine besylate/valsartan 40 amlodipine/olmesartan medoxomil 40 amlodipine/valsartan/hctz 40 ammonium lactate 45 amnesteem 45 amoxapine 15 amoxicillin 9 amoxicillin/clavulanate potassium 9 amoxicillin/clavulanate potassium er 9 amphetamine/dextroamphetamine 43 amphotericin b 16 ampicillin 9 ampicillin sodium 9 ampicillin-sulbactam 9 AMPYRA 44 Drug Name Page # ANADROL anagrelide hydrochloride 37 anaspaz 78 anastrozole 23 ANDROXY 86 animal chews 60 animal shapes 61 animal shapes/iron 61 ANORO ELLIPTA 103 antacid calcium extra st rength 79 antacid calcium regular strength 79 antacid extra strength 79 antacid maximum strength 79 antacid plus anti-gas relief 79 anti-diarrheal 79 antifungal 16 anti-fungal powder 16 anu-med 79 apatate forte 61 apetex 61 apetigen 61 apetigen-plus 61 APOKYN 27 apraclonidine 100 aprepitant 16 apri 86 APRISO 94 aprodine 105 APTIOM 11 APTIVUS 32 aquadeks 61 aqueous vitamin d infants 61 aqueous vitamin e 61 ARALAST NP 105 aranelle 86 ARANESP ALBUMIN FREE 37 ARCALYST 93 aripiprazole 28 aripiprazole odt 28 ARISTADA 28 armodafinil 108 ARNUITY ELLIPTA 101 ARRANON 20 artificial tears 99 ARZERRA 26 ascomp/codeine 3 ascorbic acid 61 ashlyna 86 aspirin 1 aspirin

119 Drug Name Page # aspirin ec 1 aspirin ec low dose 38 aspirin low dose 1 aspirin low dose 38 aspirin/dipyridamole 38 aspir-low 38 assure prism multi test strips 96 ASTAGRAF XL 91 atazanavir 33 atazanavir sulfate 32 atenolol 40 atenolol/chlorthalidone 40 ATGAM 93 atomoxetine 44 atorvastatin calcium 42 atovaquone 27 atovaquone/proguanil hcl 27 ATRIPLA 32 atropine sulfate 41 atropine sulfate 78 atropine sulfate 99 ATROVENT HFA 103 aubra 86 augmented betamethasone dipropionate 83 AUGMENTIN 9 AURYXIA 59 AVASTIN 26 AVELOX 10 aviane 86 avita 45 AVONEX 44 AVONEX PEN 44 azacitidine 21 AZACTAM 8 AZACTAM IN ISO-OSMOTIC 8 DEXTROSE AZASAN 91 AZASITE 9 azathioprine 91 azelastine hcl 99 azelastine hcl 101 azithromycin 9 AZOPT 100 AZOR 40 aztreonam 8 azurette 86 b complex 61 b complex/c 61 b complex/folic acid 61 b-1 61 Drug Name Page # b12 61 b b-12 dots 61 b-12 tr 61 b-2 61 b-6 61 b6 natural 61 baciim 6 bacitracin 6 bacitracin zinc 6 bacitracin/neomycin/polymyxin 6 bacitracin/polymyxin b 6 baclofen 30 bacmin 61 BACTROBAN NASAL 6 balance b balance b balanced b balanced b balanced b-50 complex 62 balsalazide disodium 94 balziva 86 banophen 101 BANZEL 13 BARACLUDE 30 BAVENCIO 26 BAXDELA 10 BCG VACCINE 93 b-complex 61 b-complex formula 1 61 b-complex plus vitamin c 61 b-complex w/c 61 b-complex with b b-complex/c 61 bd autoshield duo 30g x 3/16" 96 bd eclipse syringe/1ml/30gx1/2" 96 bd insulin syringe safetyglide/1ml/29g x 96 1/2" bd insulin syringe ultrafine/0.3ml/31g x 96 5/16" bd insulin syringe ultrafine/0.5ml/30g x 1/2" 96 bd insulin syringe ultrafine/1ml/31g x 5/16" 96 bd pen needle/mini/ultrafine/31g x 3/16" 96 bd pen needle/nano/ultra fine/32g x 4mm 96 bd pen needle/ultrafine/29g x 12.7mm 96 bd safetyglide 27g x 5/8" 96 bee zee 62 bekyree 86 BELEODAQ 21 benazepril hcl

120 Drug Name Page # benazepril hcl/hydrochlorothiazide 39 BENDEKA 18 BENICAR 38 BENICAR HCT 38 BENLYSTA 93 benzonatate 105 benzoyl peroxide 45 benzoyl peroxide wash 45 benztropine mesylate 27 BESIVANCE 10 BESPONSA 26 beta carotene 62 betamethasone dipropionate 84 betamethasone valerate 84 BETASERON 44 betaxolol hcl 40 betaxolol hcl 100 bethanechol chloride 83 bexarotene 26 BEXSERO 93 bicalutamide 19 BICILLIN L-A 9 BICNU 18 BIDIL 43 BIKTARVY 31 BILTRICIDE 26 bimatoprost 98 BINOSTO 95 biocal 62 biosupp 62 biotin 62 biotin biotin/maximum strength 62 biovol 62 bisacodyl ec 79 bisacodyl ec 81 biscolax 79 bismatrol 79 bismatrol maximum strength 79 bisoprolol fumarate 40 bisoprolol fumarate/hydrochlorothiazide 40 bleomycin sulfate 21 BLEPHAMIDE 10 BLEPHAMIDE S.O.P. 10 blisovi fe 1.5/30 86 blisovi fe 1/20 86 blood glucose test strips premium 96 blue gel 45 BOOSTRIX 93 BORTEZOMIB 21 Drug Name Page # BOSULIF 23 bprotected multi-vite 62 bprotected pedia d-vite 62 bprotected pedia iron 49 bprotected pedia tri-vite 62 BREO ELLIPTA 101 briellyn 86 BRILINTA 38 brimonidine tartrate 100 BRIVIACT 11 bromfed dm 105 bromfenac 99 bromocriptine mesylate 27 bromphen/pseudoephedrine 105 hcl/dextromethorphan hbr BROTAPP 101 BROTAPP DM 105 budesonide 95 budesonide 101 budesonide nasal spray 101 bumetanide 42 BUPHENYL 82 buprenorphine hcl 2 buprenorphine hcl 5 buprenorphine hcl/naloxone hcl 5 buproban 5 bupropion hcl 14 bupropion hcl er 14 bupropion hcl sr 5 bupropion hcl sr 14 bupropion hcl xl 14 buspirone hcl 34 busulfan 19 BUSULFEX 19 butalbital/acetaminophen/caffeine 1 butalbital/acetaminophen/caffeine/codeine 3 butalbital/aspirin/caffeine 1 butalbital/aspirin/caffeine/codeine 3 butorphanol tartrate 3 BYDUREON 34 BYDUREON BCISE 34 BYDUREON PEN 34 BYETTA 34 BYSTOLIC 40 BYVALSON 40 c c 1000/bioflavonoids/rosehips 62 c c c complex

121 Drug Name Page # c c-1000 prolonged release 62 c-1000/rose hips 62 c c c-500 prolonged release 62 c-500/rose hips 62 cabergoline 90 CABOMETYX 23 calcet petites 49 calci-chew 49 calcidol 62 calcipotriene 45 calcitonin-salmon 95 calcitrate 49 calcitrene 45 calcitriol 45 calcitriol 95 calcium 50 calcium + d3 49 calcium 500 +d 49 calcium 500 +d3 49 calcium 500/d 49 calcium 500/vitamin d3 49 calcium 500+d 49 calcium 500+d high potency 49 calcium 500+d3 49 calcium calcium 600 high potency 49 calcium 600 with vitamin d 49 calcium 600/vitamin d 49 calcium 600/vitamin d3 49 calcium 600+d 49 calcium 600+d high potency 49 calcium 600+d plus minerals 49 calcium 600+d3 49 calcium 600+d3 plus minerals 49 calcium 600-d 49 calcium acetate 59 calcium antacid 79 calcium antacid extra strength 79 calcium carbonate 49 calcium carbonate/d3 49 calcium carbonate/vitamin d 49 calcium citrate 50 calcium citrate + d 49 calcium citrate + d3 max imum 50 calcium citrate + d3 maximum 50 calcium citrate malate/vitamin d 50 calcium citrate maximum/vitamin d 50 Drug Name Page # calcium citrate plus/magnesium 50 calcium citrate w/d 50 calcium citrate/vitamin d 50 calcium citrate/vitamin d3 50 calcium citrate+d 50 calcium citrate+d3 50 calcium extra d3 50 calcium for women 50 calcium gluconate 50 calcium high potency 50 calcium high potency + vitamin d 50 calcium oyster shell 50 calcium plus vitamin d3 50 calcium/c/d 50 calcium/d 50 calcium/magnesium/zinc 50 calcium/vitamin d 50 calcium/vitamin d3 50 calcium+d3 50 cal-gest antacid 79 cal-mag-zinc-d 49 CALQUENCE 24 caltrate 600+d 50 caltrate 600+d plus minerals 50 caltrate 600+d3 soft chews 50 camila 89 camrese 86 camrese lo 86 CANCIDAS 16 candesartan cilexetil 38 candesartan cilexetil/hydrochlorothiazide 38 capacet 1 CAPASTAT SULFATE 18 CAPRELSA 24 capsaicin 45 captopril 39 captopril/hydrochlorothiazide 39 CARAFATE 82 CARBAGLU 50 carbamazepine 13 carbamazepine er 13 carbidopa 28 carbidopa/levodopa 27 carbidopa/levodopa er 27 carbidopa/levodopa odt 27 carbidopa/levodopa/entacapone 27 carboplatin 21 caretouch lancing device with ejector 96 caretouch twist lancets 30g 96 CARNITOR

122 Drug Name Page # carteolol hcl 100 cartia xt 40 carvedilol 40 carvedilol phosphate 40 caspofungin acetate 16 CAYSTON 103 caziant 86 c-chewable 62 cefaclor 8 cefaclor er 8 cefadroxil 8 CEFAZOLIN 8 cefazolin sodium 8 CEFAZOLIN SODIUM/DEXTROSE 8 cefdinir 8 cefepime 8 cefepime/dextrose 8 cefixime 8 cefotaxime sodium 8 cefotetan 9 cefoxitin sodium 8 cefpodoxime proxetil 8 cefprozil 8 ceftazidime 8 CEFTAZIDIME/DEXTROSE 8 ceftriaxone in iso-osmotic dextrose 8 ceftriaxone sodium 8 cefuroxime axetil 8 cefuroxime sodium 8 celecoxib 1 CELONTIN 11 centamin 50 centratex 50 centravites 50 plus 62 centrum 63 centrum adults 62 centrum kids complete 62 centrum silver 63 centrum silver adult centrum silver ultra womens 62 centrum specialist heart 63 centrum ultra mens 63 centrum ultra womens 63 cephalexin 8 CEREZYME 82 cerovite advanced formula 63 cerovite jr 63 certa plus 63 certavite senior/antioxidant nutrients 63 certavite/antioxidants 63 Drug Name Page # CERVARIX 93 cesia 86 cetirizine hcl 101 cetirizine hcl allergy childrens 101 cetirizine hcl childrens allergy 101 cetirizine hcl/pseudoephedrine hcl er 101 CHANTIX 5 CHANTIX CONTINUING MONTH PAK 5 CHANTIX STARTING MONTH PAK 5 chateal 86 CHEMET 59 cheratussin ac 105 chest congestion relief 105 chest congestion relief pe 105 chewable antacid 79 chewable calcium 50 chewable vitamin c 63 chewable vite childrens 63 chewable vite with iron/childrens 63 childrens allergy 101 childrens aspirin 38 childrens chewable multivitamin 63 childrens chewable vitamin 63 childrens chewable vitamins 63 childrens chewable vitamins/iron 63 childrens ibuprofen 1 childrens loratadine 101 childrens mapap rapid tabs 1 childrens silfedrine 105 chlo tuss 105 chloramphenicol sodium succinate 6 chlorhexidine gluconate 45 chlorhexidine gluconate oral rinse 45 chloroquine phosphate 27 chlorothiazide 42 chlorothiazide sodium 42 chlorphen sr 102 chlorpromazine hcl 28 chlorthalidone 42 cholestyramine 42 cholestyramine light 42 CHORIONIC GONADOTROPIN 85 ciclodan 16 ciclopirox 16 ciclopirox nail lacquer 16 ciclopirox olamine 16 cidofovir 30 cilostazol 38 CILOXAN 10 CIMDUO

123 Drug Name Page # cimetidine 80 cimetidine hcl 80 CINRYZE 91 CIPRO HC 10 CIPRODEX 10 ciprofloxacin 10 ciprofloxacin er 10 ciprofloxacin hcl 10 ciprofloxacin i.v.-in d5w 10 cisplatin 21 citalopram hydrobromide 14 citracal + d3 maximum 50 citracal maximum 50 citranatal bloom 63 citrus calcium +d 63 cladribine 20 claravis 46 clarithromycin 9 clarithromycin er 9 clever choice anti-staticvalved holding 96 chamber/adult large clever choice anti-staticvalved holding 96 chamber/medium clever choice anti-staticvalved holding 96 chamber/small clindacin etz pledgets 6 clindacin-p 6 clindamax 6 clindamycin 6 clindamycin hcl 6 clindamycin phosphate 6 clindamycin phosphate add-vantage 6 clindamycin phosphate in d5w 6 clindamycin/sodium chloride 7 CLINIMIX 2.75%/DEXTROSE 5% 50 CLINIMIX 4.25%/DEXTROSE 10% 50 CLINIMIX 4.25%/DEXTROSE 20% 50 CLINIMIX 4.25%/DEXTROSE 25% 50 CLINIMIX 4.25%/DEXTROSE 5% 50 CLINIMIX 5%/DEXTROSE 15% 50 CLINIMIX 5%/DEXTROSE 20% 50 CLINIMIX 5%/DEXTROSE 25% 51 CLINIMIX E 2.75%/DEXTROSE 10% 51 CLINIMIX E 4.25%/DEXTROSE 10% 51 CLINIMIX E 4.25%/DEXTROSE 25% 51 CLINIMIX E 5%/DEXTROSE 25% 51 CLINIMIX N14G30E 51 CLINIMIX N9G15E 51 CLINISOL SF 15% 51 clobetasol propionate 84 Drug Name Page # clobetasol propionate e 84 clobetasol propionate emollient 84 clodan 84 clofarabine 20 clomipramine hcl 15 clonazepam 12 clonazepam odt 11 clonidine hcl 38 clonidine hcl er 44 clopidogrel 38 clorazepate dipotassium 34 clotrimazole 16 clotrimazole anti-fungal 16 clotrimazole/betamethasone dipropionate 16 clozapine 30 clozapine odt 29 COARTEM 27 coats aloe creme 46 coats aloe gelly 46 coats aloe moisturizing lotion 46 codeine/guaifenesin 105 colchicine 17 coleman botanicals insectrepellent 46 coleman insect repellent/high & dry 46 coleman skinsmart insect repellent 46 colestipol hcl 42 colistimethate sodium 7 colocort 95 COLY-MYCIN S 100 COMBIGAN 98 COMBIVENT RESPIMAT 103 COMETRIQ 24 compact space chamber/anti-static 96 compact space chamber/anti-static/large 96 mask compact space chamber/anti-static/medium 96 mask compact space chamber/anti-static/small 96 mask companion 63 compete 63 COMPLERA 31 complete 63 complete allergy medicine 102 complex b compro 28 COMVAX 93 congestion relief 1 constulose 81 COPAXONE

124 Drug Name Page # coral calcium 51 COREG CR 40 CORLANOR 41 cormax scalp application 84 cortisone acetate 84 CORTISPORIN-TC 100 corvita 63 corvite 63 corvite corvite fe 51 corvite free 63 COSMEGEN 21 COTELLIC 24 cough dm 105 cough syrup 105 COUMADIN 36 cranberry urinary comfort 64 CREON 82 CRESTOR 42 CRIXIVAN 33 cromolyn sodium 79 cromolyn sodium 99 cromolyn sodium 104 cryselle CUPRIMINE 59 curity gauze pads 2"x2" 46 cutter backwoods 46 cutter backwoods dry 46 cutter lemon eucalyptus 46 cvs b complex plus c 64 cvs b1 64 cvs b-1 64 cvs b cvs b6 64 cvs balanced b cvs balanced b cvs beta carotene 64 cvs biotin 64 cvs biotin high potency 64 cvs calcium 64 cvs calcium 600 & vitamind3 51 cvs calcium 600+d 51 cvs calcium chewables 600plus 51 cvs calcium citrate + d 51 cvs calcium citrate+d/magnesium 51 cvs calcium/magnesium/zinc 64 cvs childrens chewable complete 64 cvs childrens chewable multivitamin/iron 64 cvs daily multiple 64 cvs daily multiple for men 64 Drug Name Page # cvs daily multiple for women 64 cvs daily multiple for women cvs daily multiple plus iron/calcium/zinc 64 cvs electrolyte solution 51 cvs gummy dinos 64 cvs hair/skin/nails 64 cvs iron 51 cvs lancets ultra-thin 30g 96 cvs laxative dietary supplement 81 cvs magnesium 51 cvs pediatric electrolyte 51 cvs pediatric electrolyte freezer pops 51 cvs selenium 51 cvs slow release iron 51 cvs spectravite adult cvs spectravite advanced formula 64 cvs spectravite senior 64 cvs spectravite ultra health mens 64 cvs spectravite ultra mens health 64 cvs spectravite ultra women 64 cvs spectravite ultra womens health 64 cvs spectravite ultra womens health senior 64 cvs super b complex/c 64 cvs vitamin a 64 cvs vitamin b12 64 cvs vitamin b cvs vitamin b-12 tr 64 cvs vitamin b-2 64 cvs vitamin c 65 cvs vitamin e 65 cvs zinc 51 cyclafem 1/35 86 cyclafem 7/7/7 86 cyclobenzaprine hcl 108 cyclophosphamide 19 cycloserine 18 CYCLOSET 34 cyclosporine 92 cyclosporine modified 91 CYRAMZA 26 cyred 86 CYSTADANE 82 CYSTAGON 82 CYSTARAN 99 cytarabine 20 cytarabine aqueous 20 dacarbazine 19 dactinomycin 21 daily combo multi vitamin 65 daily multiple vitamin

125 Drug Name Page # daily multiple vitamin/iron 65 daily multiple vitamins 65 daily value multivitamin 65 daily vitamin 65 daily vitamin formula+ir on 65 daily vitamin formula+iron 65 daily vitamin formula+minerals 65 daily vite 65 daily vite multivitamin/iron 65 daily vite with iron 65 daily-vite 65 daily-vite/iron/beta-carotene 65 DALIRESP 104 dallergy 102 danazol 86 dantrolene sodium 30 dapsone 18 DAPTACEL 93 daptomycin 7 DARAPRIM 27 darifenacin hydrobromide er 83 DARZALEX 26 dasetta 1/35 86 dasetta 7/7/7 86 daunorubicin hcl 21 DAUNORUBICIN HYDROCHLORIDE 21 daysee 86 deblitane 89 decitabine 21 deconex dmx 105 deconex ir 105 deep sea nasal spray 105 dekas essential 65 dekas plus 65 DELESTROGEN 86 DELSYM SUER 105 delsym cough + chest congestion dm 105 delsym cough + chest congestion dm 105 childrens delsym cough + cold daytime 105 delsym cough + cold nighttime childrens 105 delsym cough childrens 105 delyla 86 demeclocycline hcl 10 DEMSER 41 DENAVIR 34 DEPEN TITRATABS 59 DEPO-ESTRADIOL 86 DEPO-MEDROL 84 DEPO-PROVERA 89 Drug Name Page # DESCOVY 32 desipramine hcl 15 desloratadine 102 desmopressin acetate 85 desogestrel/ethinyl estradiol 86 desonide 84 desoximetasone 84 desvenlafaxine er 14 dexamethasone 84 dexamethasone intensol 84 dexamethasone sodium phosphate 84 dexamethasone sodium phosphate 99 dexmethylphenidate hcl 44 dexrazoxane 21 dextroamphetamine sulfate 44 dextroamphetamine sulfate er 43 dextromethorphan polistirex 105 dextromethorphan/guaifenesin/phenylephrin 105 e DEXTROSE 10%/NACL 0.45% 51 dextrose 5% /electrolyte #48 viaflex 51 DEXTROSE 10% 51 DEXTROSE 10%/NACL 0.2% 51 DEXTROSE 2.5%/NACL 0.45% 51 DEXTROSE 20% 51 DEXTROSE 25% 51 DEXTROSE 30% 51 DEXTROSE 40% 51 DEXTROSE 5% 51 DEXTROSE 5%/LACTATED RINGERS 51 DEXTROSE 5%/NACL 0.2% 51 DEXTROSE 5%/NACL 0.225% 51 DEXTROSE 5%/NACL 0.3% 51 DEXTROSE 5%/NACL 0.33% 51 DEXTROSE 5%/NACL 0.45% 51 DEXTROSE 5%/NACL 0.9% 51 DEXTROSE 50% 51 DEXTROSE 70% 52 dialyvite dialyvite 800/iron 65 DIASTAT ACUDIAL 12 DIASTAT PEDIATRIC 12 DIAZEPAM 12 diazepam 34 diazepam rectal gel 12 diclofenac potassium 1 diclofenac sodium 46 diclofenac sodium 99 diclofenac sodium dr 2 diclofenac sodium er 2 117

126 Drug Name Page # dicloxacillin sodium 9 dicyclomine hcl 78 dicyclomine hydrochloride 78 didanosine 32 diflunisal 2 digitek 41 digox 41 digoxin 41 dihydroergotamine mesylate 18 DILANTIN 13 diltiazem cd 41 diltiazem hcl 41 diltiazem hcl er 41 dilt-xr 40 dimaphen childrens 102 dimaphen dm cold & cough 105 dimenhydrinate 15 dino-life 65 dino-life w extra c 65 diphenhist 102 diphenhydramine hcl 102 diphenhydramine hydrochloride 102 diphenoxylate/atropine 79 DIPHTHERIA/TETANUS TOXOIDS 93 ADSORBED PEDIATRIC disulfiram 5 divalproex sodium 12 divalproex sodium dr 12 divalproex sodium er 12 DOCEFREZ 21 docetaxel 21 docqlace 79 docqlace 81 docusate sodium & senna stimulant 81 laxative/stool softener docusol kids 79 docusol plus mini-enema 81 dofetilide 39 dok 79 dok plus 81 donepezil hcl 13 donepezil hydrochloride 13 dorzolamide hcl 100 dorzolamide hcl/timolol maleate 100 doxazosin mesylate 83 doxepin hcl 34 doxepin hydrochloride 46 doxercalciferol 95 doxorubicin hcl 21 doxorubicin hcl liposome 21 Drug Name Page # doxy doxycycline 11 doxycycline hyclate 10 doxycycline monohydrate 11 DR SMITHS DIAPER 46 dr smiths diaper rash spray 46 dronabinol 16 DROXIA 20 drug mart unilet micro thin lancets 33g 96 duloxetine hcl 14 duofer 52 DURAMORPH 3 DUREZOL 100 dutasteride 83 dutasteride/tamsulosin hydrochloride 83 d-vi-sol 65 d-vita 65 e.e.s e e400 mixed 65 ear drops 100 earwax treatment drops 100 easy mini eject lancing device 96 econazole nitrate 16 econtra ez 89 ed a-hist 102 ed a-hist dm 105 ed a-hist pse 102 ed bron gp 105 ed chlorped 102 ed chlorped d 102 ed chlorped jr 102 ed-apap 1 EDARBI 38 EDARBYCLOR 38 ed-spaz 78 EDURANT 31 efavirenz 31 ELAPRASE 82 elfolate plus 65 ELIDEL 46 ELIGARD 90 elinest 86 ELITEK 20 ELLA 89 ELMIRON 83 EMCYT 20 EMEND 16 emoquette 86 EMPLICITI

127 Drug Name Page # EMSAM 14 EMTRIVA 32 ENABLEX 83 enalapril maleate 39 enalapril maleate/hydrochlorothiazide 39 ENBREL 92 ENBREL MINI 92 ENBREL SURECLICK 92 endacof-dm 105 endocet 3 endur-acin 65 endur-c/rose hips 65 enema ready-to- 81 enemeez mini 79 enemeez plus 79 enfalyte 52 enfamil enfalyte 52 ENGERIX-B 94 enlyte 52 enoxaparin sodium 36 enpresse enskyce 87 entacapone 27 entecavir 30 enteric coated aspirin 2 ENTRESTO 38 enulose 81 ENVARSUS XR 92 e-oil 65 EPCLUSA 30 epinastine hcl 99 epinephrine 103 epinephrine hcl 103 EPIPEN 2-PAK 103 EPIPEN-JR 2-PAK 103 epirubicin hcl 21 epitol 13 EPIVIR HBV 30 eq calcium 500+d 52 eq calcium 600+d 52 eq calcium citrate+d 52 eq complete multivitamin adults eq complete multivitamin adults under eq one daily womens health 66 eq slow-release iron 52 eql b complex eql b-6 66 eql calcium citrate w/vitamin d 52 eql calcium/vitamin d 52 eql one daily mens health formula 66 Drug Name Page # eql one daily womens 66 eql pediatric electrolyte 52 eql vitamin b eql vitamin b-12 tr 66 eql vitamin c 66 eql vitamin c/rose hips 66 eql vitamin e 66 ERBITUX 26 ergocalciferol 66 ergoloid mesylates 13 ergotamine tartrate/caffeine 18 ERIVEDGE 24 ERLEADA 19 errin 89 ERWINAZE 21 ery 9 ERYPED ERY-TAB 9 ERYTHROCIN LACTOBIONATE 9 erythrocin stearate 10 erythromycin 10 erythromycin base 10 erythromycin ethylsuccinate 10 erythromycin/benzoyl peroxide 46 ESBRIET 104 escavite 66 escavite d 66 escavite lq 66 escitalopram oxalate 14 esgic 1 esomeprazole magnesium 82 esomeprazole sodium 82 essentia 66 essential balance 66 estarylla 87 estradiol 87 estradiol valerate 87 ESTRING 87 ethacrynate sodium 42 ethambutol hcl 18 ethosuximide 11 ethynodiol diacetate/ethinyl estradiol 87 ETHYOL 21 etidronate disodium 95 etodolac 2 etodolac er 2 etoposide 23 EVOMELA 19 EVOTAZ 33 exemestane

128 Drug Name Page # extra action cough 105 eye drops 99 eye irrigating solution 99 eye itch relief 100 eye wash 99 ezetimibe 42 ezetimibe/simvastatin 42 ezfe fabb 66 FABRAZYME 82 fallback solo 89 falmina 87 famciclovir 34 famotidine 81 famotidine premixed 80 FANAPT 28 FANAPT TITRATION PACK 28 FARESTON 20 FARXIGA 34 FARYDAK 24 FASLODEX 20 fe c tab 52 felbamate 12 felodipine er 41 FEMRING 87 femynor 87 fenofibrate 42 fenofibrate micronized 42 fenofibric acid dr 42 fenoprofen calcium 2 fentanyl 3 fentanyl citrate 3 fentanyl citrate oral transmucosal 3 feosol 52 feosol bifera 52 ferate 52 fergon 52 fer-in-sol 52 fer-iron 52 feriva 21/7 52 ferivafa 52 ferralet ferraplus ferretts 52 ferretts ips 52 ferrex ferrex 150 forte 52 ferric x ferrimin FERRIPROX 96 Drug Name Page # ferrocite 52 ferrous fumarate ferrous gluconate 52 ferrous sulfate 52 ferrousul 52 FETZIMA 14 FETZIMA TITRATION PACK 14 fexofenadine hcl 102 fexofenadine hcl childrens allergy 102 fiber laxative 81 fiber tabs 79 fiber-lax 79 fifty50 unilet lancets 33g 96 finasteride 83 FIRAZYR 91 FIRMAGON 90 flavoxate hcl 83 flecainide acetate 39 FLEET PEDIATRIC 79 flexichamber 96 flexichamber adult mask/small 96 flexichamber child mask/large 96 flexichamber child mask/small 96 flintstones complete 66 flintstones plus extra c 66 flintstones/my first 66 floriva 52 floriva 66 floriva plus 66 FLOVENT DISKUS 101 FLOVENT HFA 101 flowtuss 105 fluconazole 17 fluconazole in dextrose 16 fluconazole in nacl 17 flucytosine 17 fludarabine phosphate 21 fludrocortisone acetate 84 flunisolide 101 fluocinolone acetonide 84 fluocinolone acetonide 100 fluocinolone acetonide body 84 fluocinolone acetonide ear drops 100 fluocinolone acetonide scalp 84 fluocinonide 84 fluoride 52 fluoritab 52 fluorometholone 100 fluorouracil 20 fluorouracil

129 Drug Name Page # fluoxetine 15 fluoxetine dr 14 fluoxetine hcl 14 fluphenazine decanoate 28 fluphenazine hcl 28 flurbiprofen 2 flurbiprofen sodium 100 flutamide 19 fluticasone propionate 84 fluticasone propionate 101 fluvoxamine maleate 15 fluvoxamine maleate er 15 focalgin dss 52 folbee ar 66 folic acid 67 folitab FOLOTYN 20 foltabs fomepizole 96 fondaparinux sodium 36 fora d40/g31 blood glucose test strips 96 fora lancets 96 fora lancing device/clearcap 96 fora tn'g/tn'g voice blood glucose test strips 96 formula em 15 fortavit 67 FORTEO 95 fosamprenavir calcium 33 FOSCAVIR 30 fosfree 67 fosinopril sodium 39 fosinopril sodium/hydrochlorothiazide 39 fosphenytoin sodium 13 FREAMINE HBC 6.9% 52 FREAMINE III 52 freestyle precision neo blood glucose test 96 strips FRESHKOTE 99 fruit c fruity c 67 fruity chewables multivitamin 67 full spectrum b/vitamin c 67 FUNGOID TINCTURE 17 furosemide 42 FUSILEV 21 fusion 53 fusion plus 53 FUZEON 32 fyavolv 87 FYCOMPA 11 Drug Name Page # gabapentin 12 GABITRIL 12 galantamine hydrobromide 13 galantamine hydrobromide er 13 GAMMAKED 93 GAMUNEX-C 93 ganciclovir 30 GARDASIL 94 GARDASIL 9 94 gas relief 79 gas relief extra strength 79 gas relief maximum strength 79 GATTEX 79 gavilyte-c 81 gavilyte-g 81 gavilyte-n/flavor pack 81 GAZYVA 26 gemcitabine 20 gemcitabine hcl 20 gemcitabine hydrochloride 20 gemfibrozil 42 generlac 81 gengraf 92 GENOTROPIN 85 GENOTROPIN MINIQUICK 85 gentak 6 gentamicin sulfate 6 gentamicin sulfate pediatric 6 gentamicin sulfate/0.9% sodium chloride 6 GENVOYA 31 GEODON 28 gildagia 87 gildess 1.5/30 87 gildess 1/20 87 gildess fe 1.5/30 87 gildess fe 1/20 87 GILENYA 45 GILOTRIF 24 GLEOSTINE 19 glimepiride 35 glipizide 35 glipizide er 35 glipizide xl 35 glipizide/metformin hcl 35 GLUCAGEN HYPOKIT 36 GLUCAGON EMERGENCY KIT 36 glucose meter test strips advanced 96 glycopyrrolate 78 glydo 5 GLYXAMBI

130 Drug Name Page # gnp all day allergy 102 gnp allergy 102 gnp antacid anti-gas 79 gnp arthritis pain relief 1 gnp b gnp biotin 67 gnp calcium 53 gnp calcium 500 +d3 53 gnp calcium 600 +d3 53 gnp calcium 600 +d3/minerals 53 gnp calcium citrate +d3 53 gnp calcium citrate+d3 maximum 53 gnp century 67 gnp century active performance 67 gnp century adults 50+ senior 67 gnp century cardio healthformula 67 gnp century mature 67 gnp century ultimate mens complete 67 gnp century ultimate womens complete 67 gnp century ultimate womens senior formula 67 gnp childrens chewables w/extra c 67 gnp childrens chewables/extra c 67 gnp childrens chewables/iron 67 gnp dayhist allergy 102 gnp easy touch glucose test strips 96 gnp enema 81 gnp essential one daily 67 gnp ibuprofen 2 gnp ibuprofen junior strength 2 gnp iron 53 gnp lice treatment 27 gnp little ones childrens 68 gnp loratadine 102 gnp masanti maximum strength 79 gnp masanti regular strength 79 gnp mega multi for men 68 gnp mega multi for women 68 gnp omeprazole 82 gnp one daily maximum 68 gnp one daily mens health gnp one daily plus iron 68 gnp one daily womens health gnp pediatric electrolyte 53 gnp therapeutic-m 53 gnp therapeutic-m 68 gnp tussin 105 gnp tussin dm 105 gnp vitamin a 68 gnp vitamin b-1 68 gnp vitamin b Drug Name Page # gnp vitamin b-12 prolonged release 68 gnp vitamin b-6 68 gnp vitamin c 68 gnp vitamin c drops 53 gnp vitamin c pr 68 gnp vitamin c w/rose hips 68 gnp vitamin c/rose hips 68 gnp vitamin e 68 gnp vitamin e water dispersible 68 gnp zoochews gummies 68 goodsense ibuprofen 2 goodsense ibuprofen childrens 2 goodsense ibuprofen infants 2 goodsense ibuprofen junior strength 2 goodsense naproxen sodium 2 granisetron hcl 16 griseofulvin microsize 17 griseofulvin ultramicrosize 17 guaifenesin ac 105 guaifenesin er 105 guaifenesin/codeine 105 guaifenesin/pseudoephedrine hydrochloride 105 GUANIDINE HCL 18 gummi bear multivitamin/mineral 68 HALAVEN 21 halls defense vitamin c drops 68 halobetasol propionate 84 haloperidol 28 haloperidol decanoate 28 haloperidol lactate 28 hard nails 68 HARVONI 30 HAVRIX 94 healthy kids gummies 68 heartburn treatment 24 hour 82 heather 89 h-e-b incontrol lancets micro thin 33g 96 h-e-b oral electrolyte solution 53 hecoria 92 hemocyte 53 hemocyte plus 53 hemocyte-f 53 hemorrhoidal 46 heparin sodium 37 heparin sodium/d5w 37 heparin sodium/nacl 0.45% 37 heparin sodium/nacl 0.9% 37 heparin sodium/sodium chloride 0.9% 37 heparin sodium/sodium chloride 0.9% 37 premix 122

131 Drug Name Page # HEPATAMINE 53 HEPLISAV-B 94 HERCEPTIN 26 HETLIOZ 44 HEXALEN 19 HIBERIX 94 histex 102 histex pd 102 histex-dm 105 histex-pe 105 hm calcium 600 & vitamin d3 53 hm calcium d plus minerals 53 hm calcium vitamin d3 53 hm calcium citrate + vitamin d 53 hm calcium/vitamin d 53 hm calcium/vitamin d/minerals 53 hm complete 68 hm complete hm complete 50+ womens ultimate 68 hm complete women 68 hm hair/skin/nails 68 hm iron 53 hm iron slow release 53 hm magnesium 80 hm niacin tr 68 hm one daily essential 68 hm one daily womens 68 hm one daily/iron 68 hm pediatric electrolyte 53 hm selenium 53 hm vitamin b complex/vitamin c 68 hm vitamin b100 complex 68 hm vitamin b12 68 hm vitamin b12 tr 68 hm vitamin b50 complex 68 hm vitamin b6 69 hm vitamin c 69 hm vitamin c tr 69 hm vitamin c/rose hips 69 hm vitamin e 69 hm zinc 53 honey bears 69 HUMALOG 36 HUMALOG JUNIOR KWIKPEN 36 HUMALOG KWIKPEN 36 HUMALOG MIX 50/50 36 HUMALOG MIX 50/50 KWIKPEN 36 HUMALOG MIX 75/25 36 HUMALOG MIX 75/25 KWIKPEN 36 HUMIRA 92 Drug Name Page # HUMIRA PEDIATRIC CROHNS 92 DISEASE STARTER PACK HUMIRA PEN 92 HUMIRA PEN-CROHNS 92 DISEASESTARTER HUMIRA PEN-PSORIASIS STARTER 92 HUMULIN 70/30 36 HUMULIN 70/30 KWIKPEN 36 HUMULIN N 36 HUMULIN N KWIKPEN 36 HUMULIN R 36 HUMULIN R U-500 (CONCENTRATED) 36 HUMULIN R U-500 KWIKPEN 36 hycofenix 105 hydralazine hcl 43 hydrochlorothiazide 42 hydrocodone bitartrate/acetaminophen 3 hydrocodone bitartrate/chlorpheniramine 105 maleate/pse hydrocodone bitartrate/homatropine 105 methylbromide hydrocodone polistirex/chlorpheniramine 105 polistirex hydrocodone/acetaminophen 3 hydrocodone/ibuprofen 4 hydrocortisone 84 hydrocortisone 95 hydrocortisone butyrate 84 hydrocortisone butyrate (lipid) 84 hydrocortisone butyrate (lipophilic) 84 hydrocortisone in absorbase 84 hydrocortisone valerate 84 hydrocortisone/acetic acid 100 hydrocortisone/aloe 84 hydromet 106 hydromorphone hcl 4 hydromorphone hcl dosette 4 hydroxychloroquine sulfate 27 hydroxyprogesterone caproate 89 hydroxyurea 20 hyoscyamine sulfate 78 hyoscyamine sulfate odt 78 i.l.x. b ibandronate sodium 95 IBRANCE 24 ibu 2 ibu ibudone 4 ibu-drops 2 ibu-drops infants 2 123

132 Drug Name Page # ibuprofen 2 ibuprofen childrens 2 icaps areds formula 69 icaps mv 69 icar pediatric 53 icar-c 53 ICLUSIG 24 idarubicin hcl 21 IDHIFA 24 iferex ifosfamide 19 iglucose blood glucose test strips 96 ILARIS 93 ILEVRO 100 ilotycin 10 imatinib mesylate 24 IMBRUVICA 24 IMFINZI 26 imipenem/cilastatin 9 imipramine hcl 15 imiquimod 46 IMOVAX RABIES (H.D.C.V.) 94 INCRELEX 85 INCRUSE ELLIPTA 103 indapamide 42 INFANRIX 94 infants gas relief 80 infants ibuprofen 2 infants simethicone 80 infed 53 infinity voice 96 infumorph infumorph INLYTA 24 inspirachamber/large 97 integra 69 integra f 69 integra plus 69 INTELENCE 31 INTRALIPID 97 INTRON A 30 INTRON A W/DILUENT 30 introvale 87 INVANZ 9 INVEGA SUSTENNA 28 INVEGA TRINZA 29 INVIRASE 33 INVOKAMET 35 INVOKAMET XR 35 INVOKANA 35 Drug Name Page # iosat 106 IPOL INACTIVATED IPV 94 ipratropium bromide 103 ipratropium bromide/albuterol sulfate 103 irbesartan 38 irbesartan/hydrochlorothiazide 38 IRESSA 24 irinotecan 21 irinotecan hcl 21 irinotecan hydrochloride 21 iron 53 iron 69 iron 100/c 69 iron iron high-potency 53 iron slow release 53 iron supplement childrens 69 irospan 24/6 53 ISENTRESS 31 ISENTRESS HD 32 isibloom 87 isoniazid 18 ISOPTO TEARS 99 isosorbide dinitrate 43 isosorbide dinitrate er 43 isosorbide mononitrate 43 isosorbide mononitrate er 43 isotonic gentamicin 6 isotretinoin 46 isradipine 41 ISTODAX 21 ISTODAX (OVERFILL) 21 itraconazole 17 ivermectin 27 IXEMPRA KIT 21 IXIARO 94 JADENU 59 JADENU SPRINKLE 59 JAKAFI 24 jantoven 37 JANUMET 35 JANUMET XR 35 JANUVIA 35 JARDIANCE 35 jencycla 89 JENTADUETO 35 JENTADUETO XR 35 jevantique lo 87 JEVTANA 21 jolessa

133 Drug Name Page # jolivette 89 juleber 87 JULUCA 31 junel 1.5/30 87 junel 1/20 87 junel fe 1.5/30 87 junel fe 1/20 87 junior mapap 1 just d 69 KABIVEN 54 KADCYLA 26 KALETRA 33 KALYDECO 104 kao-tin 80 kariva 87 KCL 0.075%/D5W/NACL 0.45% 54 KCL 0.15%/D5W/NACL 0.2% 54 kcl 0.15%/d5w/nacl 0.225% 54 kcl 0.15%/d5w/nacl 0.45% 54 KCL 0.15%/D5W/NACL 0.9% 54 KCL 0.3%/D5W/NACL 0.45% 54 kcl 0.3%/d5w/nacl 0.9% 54 kelnor 1/35 87 kelnor 1/50 87 KETEK 10 ketoconazole 17 ketoprofen 2 ketorolac tromethamine 100 KEYTRUDA 26 kidkare cough/cold 106 kimidess 87 KINERET 92 KINRIX 94 kionex 59 KISQALI 21 KISQALI FEMARA 200 DOSE 19 KISQALI FEMARA 400 DOSE 19 KISQALI FEMARA 600 DOSE 19 klor-con 54 klor-con klor-con 8 54 klor-con m10 54 klor-con m20 54 klor-con sprinkle 54 kobee 69 KORLYM 97 kp adults 50+ daily formula 69 kp b complex/c 69 kp calcium 600+d 54 kp calcium citrate+d 54 Drug Name Page # kp ferrous gluconate 54 kp ferrous sulfate 54 kp niacin 69 kp vitamin b kp vitamin b-6 69 kp vitamin e 69 k-sol 54 kurvelo 87 KUVAN 82 KYPROLIS 23 labetalol hcl 40 LACRISERT 99 LACTATED RINGERS 54 LACTATED RINGERS IRRIGATION 97 LACTATED RINGERS VIAFLEX 54 lactulose 81 lamivudine 30 lamivudine 32 lamivudine/zidovudine 32 lamotrigine 13 lamotrigine er 13 lamotrigine odt 13 lancets 97 LANOXIN PEDIATRIC 41 lansoprazole 82 LANTUS 36 LANTUS SOLOSTAR 36 larin 1.5/30 87 larin 1/20 87 larin fe 1.5/30 87 larin fe 1/20 87 larissia 87 LARTRUVO 21 latanoprost 98 LATUDA 29 laxative 80 leflunomide 93 LENVIMA 10 MG DAILY DOSE 25 LENVIMA 14 MG DAILY DOSE 25 LENVIMA 18 MG DAILY DOSE 25 LENVIMA 20 MG DAILY DOSE 25 LENVIMA 24 MG DAILY DOSE 25 LENVIMA 8 MG DAILY DOSE 25 lessina 87 LETAIRIS 104 letrozole 23 leucovorin calcium 22 LEUKERAN 19 LEUKINE 37 leuprolide acetate

134 Drug Name Page # levalbuterol tartrate hfa 103 LEVEMIR 36 LEVEMIR FLEXTOUCH 36 levetiracetam 11 levetiracetam er 11 levobunolol hcl 100 levocarnitine 97 levocetirizine dihydrochloride 102 levofloxacin 10 levofloxacin in d5w 10 levoleucovorin 22 levoleucovorin calcium 22 levonest 87 levonorgestrel 89 levonorgestrel and ethinyl estradiol 87 levonorgestrel/ethinyl estradiol 87 levora 0.15/ levorphanol tartrate 3 levothyroxine sodium 90 LEVOXYL 90 LEXIVA 33 LIALDA 94 lidocaine 5 lidocaine 46 lidocaine hcl 5 lidocaine hcl 39 lidocaine hcl jelly 5 lidocaine hcl viscous 5 lidocaine viscous 5 lidocaine/prilocaine 5 life pack mens 69 life pack womens 69 lincomycin hcl 7 lindane 27 linezolid 7 LINZESS 81 liothyronine sodium 90 lipodox 22 lipodox LIPOSYN III 97 liquid b12 69 liquid calcium/vitamin d 54 liquitears 99 lisinopril 39 lisinopril/hydrochlorothiazide 39 lithium carbonate 34 lithium carbonate er 34 LIVALO 42 l-methyl-b6-b12 69 LODRANE D 102 Drug Name Page # lohist-d 102 lohist-dm 106 lokara 84 LONSURF 20 loperamide hcl 80 lopinavir/ritonavir 33 loratadine 102 loratadine childrens 102 loratadine hives relief 102 loratadine-d 12hr 102 loratadine-d 24hr 102 lorazepam 34 lorazepam intensol 34 lorcet 4 lorcet hd 4 lorcet plus 4 lortab 4 lortuss dm 106 lortuss ex 106 lortuss lq 106 losartan potassium 38 losartan potassium/hydrochlorothiazide 38 LOTEMAX 100 lovastatin 42 low-ogestrel 88 loxapine 28 loxapine succinate 28 lubricant eye drops 99 lubricating plus eye drops 99 lubrifresh p.m. 99 ludent 54 LUMIGAN 98 LUMIZYME 82 LUPRON DEPOT (1-MONTH) 90 LUPRON DEPOT (3-MONTH) 90 LUPRON DEPOT (4-MONTH) 90 LUPRON DEPOT (6-MONTH) 90 LUPRON DEPOT-PED (1-MONTH) 90 LUPRON DEPOT-PED (3-MONTH) 91 lutera 88 LYNPARZA 22 LYNPARZA 25 LYRICA 11 LYRICA CR 44 lysiplex plus 69 LYSODREN 90 lyza 89 magnesium 54 magnesium 80 magnesium

135 Drug Name Page # magnesium elemental 54 magnesium l-lactate dihyrate 54 magnesium oxide 80 magnesium sulfate 54 magnesium sulfate in d5w 11 mag-tab sr 54 major-prep hemorrhoidal 46 MAKENA 89 MAKENA 89 malathion 27 mapap 1 mapap acetaminophen extrastrength 1 mapap arthritis pain 1 mapap childrens 1 mapap cold formula multi-symptom 106 mapap pm 1 mapap sinus maximum strength congestion 106 and pain maprotiline hcl 14 margesic 1 marlissa 88 MARPLAN 14 MATULANE 19 matzim la 41 meclizine hcl 15 meclofenamate sodium 2 MEDROL 84 medroxyprogesterone acetate 89 mefloquine hcl 27 mega multiple w/chelated minerals 69 mega multivitamin for men 69 mega multivitamin for women 69 megestrol acetate 89 meijer c 69 MEKINIST 25 melodetta 24 fe 88 meloxicam 2 melphalan hydrochloride 19 memantine hcl 14 memantine hcl titration pak 13 memantine hydrochloride 14 memantine hydrochloride er 14 MENACTRA 94 M-END DMX 106 MENEST 88 MENHIBRIX 94 MENOMUNE-A/C/Y/W MENOSTAR 88 MENVEO 94 MEPHYTON 69 Drug Name Page # mercaptopurine 20 meribin 69 meropenem 9 meropenem/sodium chloride 9 mesalamine 94 mesna 22 MESNEX 22 metadate er 44 metaproterenol sulfate 103 metformin hcl 35 metformin hcl er 35 METHADONE HCL 3 methadone hcl intensol 3 methazolamide 42 methenamine hippurate 7 methimazole 91 methocarbamol 108 methotrexate 92 methotrexate sodium 92 methoxsalen 46 methscopolamine bromide 79 methylphenidate hcl 44 methylphenidate hcl er 44 methylphenidate hcl sr 44 methylprednisolone 85 methylprednisolone acetate 84 methylprednisolone dose pack 84 methylprednisolone sodiumsuccinate 84 metipranolol 100 metoclopramide hcl 80 metolazone 42 metoprolol succinate er 40 metoprolol tartrate 40 metoprolol/hydrochlorothiazide 40 metronidazole 7 metronidazole in nacl 0.79% 7 metronidazole vaginal 7 mexiletine hcl 39 m-hist dm 106 m-hist pd 102 MIACALCIN 95 mi-acid 80 mi-acid gas relief 80 mi-acid maximum strength 80 mibelas 24 fe 88 miconazole 17 miconazole 7 17 miconazole nitrate 17 microgestin 1.5/30 88 microgestin 1/

136 Drug Name Page # microgestin fe 88 microgestin fe 1.5/30 88 microlet next 97 midodrine hcl 38 MIGERGOT 18 miglitol 35 miglustat 82 migraine formula 2 mili 88 milk of magnesia 80 milk of magnesia 81 milk of magnesia concentrate 80 minitran 43 MINIVELLE 88 minocycline hcl 11 minoxidil 43 mintox maximum strength 80 mirtazapine 14 mirtazapine odt 14 misoprostol 82 MITIGARE 17 mitomycin 22 mitoxantrone hcl 22 mm easy touch glucose test strips 97 M-M-R II 94 modafinil 108 moexipril hcl 39 moexipril/hydrochlorothiazide 39 moisturel therapeutic 46 molindone hydrochloride 28 mometasone furoate 85 mometasone furoate 101 mondoxyne nl 11 monocal 54 mono-linyah 88 montelukast sodium 103 morgidox 1x100mg 11 morgidox 1x50mg 11 morgidox 2x100mg 11 morphine sulfate 3 morphine sulfate 4 morphine sulfate er 3 MOVIPREP 81 moxifloxacin hydrochloride/sodium 10 hydrochloride moxifloxacin hcl 10 moxifloxacin hydrochloride 10 MOZOBIL 37 mtx support 69 MUCINEX 106 Drug Name Page # mucinex chest congestion childrens 106 mucinex childrens cold cough & sore throat 106 mucinex childrens multi-symptom cold 106 MUCINEX CHILDRENS MULTI- 106 SYMPTOM COLD & FEVER mucinex congestion & cough childrens 106 mucinex cough childrens 106 MUCINEX COUGH FOR KIDS 106 MUCINEX D 106 MUCINEX D MAXIMUM STRENGTH 106 MUCINEX DM 106 MUCINEX DM MAXIMUM STRENGTH 106 mucinex fast-max cold & sinus 106 MUCINEX FAST-MAX COLD FLU& 106 SORE THROAT mucinex fast-max day time/night time 106 mucinex fast-max day/night maximum 106 strength mucinex fast-max dm max 106 mucinex fast-max night time cold & flu 106 mucinex fast-max severe cold 106 mucinex fast-max severe congestion & 106 cough MUCINEX FOR KIDS 106 mucinex maximum strength 106 mucinex multi-symptom cold day/night pack 106 mucinex multi-symptom cold night time 106 childrens mucinex sinus-max pressure & pain 106 mucinex stuffy nose & cold childrens 106 mucus relief 106 mucus-er 106 mucusrelief sinus 107 MULTAQ 39 multi complete/iron 69 multi vitamin daily 69 multi-day plus iron 69 multi-delyn/iron 69 multi-lancet device 2 97 multilex 70 multilex-t&m 70 multiple vitamin/minerals/no iron 70 multiple vitamins 70 multiple vitamins plain 70 multiple vitamins/iron 70 multi-vit/fluoride 70 multi-vit/iron/fluoride 70 multi-vitamin 70 multivitamin & mineral 70 multivitamin adults

137 Drug Name Page # multi-vitamin daily 70 multi-vitamin hp/minerals 70 multivitamin with fluoride 71 multivitamin/fluoride 71 multi-vitamin/fluoride drops 70 multi-vitamin/fluoride/iron 70 multi-vitamin/minerals 70 multi-vitamin/multi-mineral adult/high 70 potency multi-vitamins 70 mupirocin 7 mupirocin calcium 7 MURO MUSTARGEN 19 my way 89 mycophenolate mofetil 92 mycophenolic acid dr 92 myferon MYLOTARG 26 myorisan 46 MYRBETRIQ 83 mytab gas 80 mytab gas max str 80 my-vitalife 71 myzilra 88 nabumetone 2 nadolol 40 nadolol/bendroflumethiazide 40 nafcillin sodium 9 naftifine hcl 17 naftifine hydrochloride 17 NAFTIN 17 NAGLAZYME 82 nalbuphine hcl 4 naloxone hcl 5 naltrexone hcl 5 NAMENDA XR 14 NAMENDA XR TITRATION PACK 14 NAMZARIC 13 naphazoline hcl 99 naproxen 2 naproxen dr 2 naproxen sodium 2 naratriptan hcl 18 NARCAN 5 nasal decongestant 107 nasal decongestant spray 107 NASONEX 101 NASOPEN PE 102 NATACYN 17 Drug Name Page # nateglinide 35 NATPARA 97 natrapel 12-hour tick & insect repellent 46 continuous spray natural balance tears 99 natural c/rose hips 71 natural fiber therapy 80 natural vitamin e 71 natures tears 99 NEBUPENT 27 necon 0.5/ necon 1/35 88 necon 1/ necon 10/ necon 7/7/7 88 nefazodone hcl 14 neomycin sulfate 6 neomycin/bacitracin/polymyxin 7 neomycin/polymyxin b sulfates 6 neomycin/polymyxin/bacitracin zinc 7 neomycin/polymyxin/bacitracin/hydrocortis 7 one neomycin/polymyxin/dexamethasone 100 neomycin/polymyxin/gramicidin 7 neomycin/polymyxin/hc 100 neomycin/polymyxin/hydrocortisone 7 neomycin/polymyxin/hydrocortisone 101 neo-polycin 7 neo-polycin hc 7 NEPHRAMINE 54 nephrocaps 71 nephron fa 54 nephronex 71 nephro-vite 71 nephro-vite rx 71 NERLYNX 22 NEUMEGA 37 NEUPRO 27 nevirapine 31 nevirapine er 31 NEXAVAR 25 niacin 43 niacin 71 niacin er 42 niacin er 71 niacin pr 71 niacin sr 71 niacin tr 71 niacor 43 nicardipine hcl

138 Drug Name Page # NICODERM CQ 5 nicorelief 5 NICORETTE 5 NICORETTE MINI 5 NICORETTE STARTER KIT 5 nicotine polacrilex 5 nicotine transdermal system 5 nicotine transdermal system step 1 5 nicotine transdermal system step 2 5 nicotine transdermal system step 3 5 NICOTROL INHALER 6 NICOTROL NS 6 nifedical xl 41 nifedipine er 41 night time multi-symptom cold/flu relief 107 night time sleep aid 102 nilutamide 19 nimodipine 41 NINJACOF 107 NINJACOF-A 107 ninjacof-xg 107 NINLARO 22 NIPENT 20 nisoldipine er 41 nitrofurantoin 7 nitrofurantoin macrocrystals 7 nitrofurantoin monohydrate 7 nitrofurantoin monohydrate/macrocrystals 7 nitroglycerin 43 nitroglycerin lingual 43 nitroglycerin transdermal 43 nizatidine 81 no iron multiple vitamin/minerals 71 nohist-dm 107 nohist-lq 102 nora-be 89 norethindrone 89 norethindrone acetate 89 norethindrone acetate/ethinyl estradiol 88 norethindrone acetate/ethinyl 88 estradiol/ferrous fumarate norgestimate/ethinyl estradiol 88 norlyroc 90 NORMOSOL -R 54 NORMOSOL-M IN D5W 54 NORMOSOL-R 54 NORMOSOL-R IN D5W 54 NORTHERA 41 nortrel 0.5/35 (28) 88 nortrel 1/35 88 Drug Name Page # nortrel 7/7/7 88 nortriptyline hcl 15 NORVIR 33 NOVAREL 85 novofine 30gx8mm 97 novofine novofine 32gx6mm 97 novofine autocover 30gx8mm 97 novotwist 30gx8mm 97 novotwist 32gx5mm 97 NOXAFIL 17 NUEDEXTA 44 nu-iron nulev 79 NULOJIX 92 nu-mag 54 NUPLAZID 29 nutricap 71 NUTRILIPID 97 NUTRILYTE 54 NUTRILYTE II 54 nutrivit 71 nyamyc 17 nystatin 17 nystatin/triamcinolone 17 nystop 17 oceanic selenium 55 octreotide acetate 91 ocutabs 71 ocutabs/lutein 71 ODEFSEY 31 ODOMZO 22 OFEV 104 off deep woods 46 off deep woods dry 46 off deep woods sportsmen 46 ofloxacin 10 ogestrel 88 olanzapine 29 olanzapine odt 29 olanzapine/fluoxetine 15 olmesartan medoxomil 38 olmesartan medoxomil/hydrochlorothiazide 38 olopatadine hcl 99 olopatadine hydrochloride 99 omega-3-acid ethyl esters 43 omeprazole 82 omeprazole magnesium 82 omnicap 71 ONCASPAR

139 Drug Name Page # once daily 71 once daily/iron 71 oncovite 71 ondansetron hcl 16 ondansetron odt 16 one daily 72 one daily complete 71 one daily for men 50+ advanced 72 one daily for women 72 one daily for women 50+a dvanced 72 one daily maximum 72 one daily mens 72 one daily multivitamin adult 72 one daily multivitamin/iron 72 one daily plus iron 72 one daily plus minerals 72 one daily womens 50 plus 72 one daily womens one daily/iron/calcium 72 one daily/minerals 72 one-a-day essential 72 one-a-day mens 50+ advantage 72 one-a-day teen advantage for her 72 one-a-day teen advantage for him 72 one-a-day womens formula 72 one-daily multi vitamins 72 one-way valved 97 expiratorymouthpiece/disposable one-way valved inspiratory 97 mouthpiece/disposable ONFI 12 opcicon one-step 90 OPDIVO 26 OPSUMIT 104 opti-clear 99 oralone dental paste 45 oralyte 55 oralyte freezer pops 55 orazinc 55 ORFADIN 82 organ-i nr 107 ORKAMBI 104 orphenadrine citrate er 108 orsythia 88 os-cal calcium + d3 55 os-cal extra d3 55 oscimin 79 oseltamivir phosphate 33 OSMOPREP 80 osteo-poretical 55 Drug Name Page # oxacillin sodium 9 oxaliplatin 22 oxandrolone 85 oxaprozin 2 oxazepam 34 oxcarbazepine 13 oxybutynin chloride 83 oxybutynin chloride er 83 oxycodone hcl 4 oxycodone/acetaminophen 4 oxycodone/aspirin 4 oxycodone/ibuprofen 4 oysco oysco 500+d 55 oyst-cal-d oyster calcium 55 oyster shell calcium 55 oyster shell calcium + d3 55 oyster shell calcium + vitamin d 55 oyster shell calcium 250+d 55 oyster shell calcium oyster shell calcium d 55 oyster shell calcium 500/d 55 oyster shell calcium 500+d 55 oyster shell calcium plusvitamin d 55 oyster shell calcium/d 55 oyster shell calcium/d3 55 oyster shell calcium/magnesium 55 oyster shell calcium/vitamin d 55 oyster shell calcium+d 55 oystercal-d 55 OZEMPIC 35 pacerone 39 paclitaxel 22 pain & fever 1 pain & fever childrens 1 pain & fever extra strength 1 pain & fever infants 1 pain relief sinus pe daytime 107 pain reliever pm extra strength 1 pain relieving cream 46 paliperidone er 29 palonosetron hydrochloride 16 pamidronate disodium 95 panda mask large 97 panda mask medium 97 panda mask small 97 PANRETIN 26 pantoprazole sodium 82 pantothenic acid

140 Drug Name Page # paricalcitol 95 paroex 45 paromomycin sulfate 6 paroxetine hcl 15 paroxetine hcl er 15 PASER 18 PAXIL 15 PAZEO 99 pedialyte 55 pedialyte advanced care 55 pedialyte freezer pops 55 pedialyte singles 55 PEDIARIX 94 pediatric cough/cold 107 pediatric electrolyte 56 pediatric electrolyte freeze pops 55 pediatric electrolyte freezer pops 55 pediatric electrolyte/zinc 55 pediatric medium mask 97 pediatric mouthpiece/disposable 97 pediatric panda mask 97 pediatric small mask 97 PEDVAX HIB 94 peg peg 3350/electrolytes 81 peg peg-3350/electrolytes 81 peg-3350/nacl/na bicarbonate/kcl 81 PEGANONE 13 PEGASYS 30 PEGASYS PROCLICK 30 penicillin g potassium 9 penicillin v potassium 9 PENTAM pentoxifylline er 41 peptic relief 80 PERFOROMIST 103 peridin-c 72 PERIKABIVEN 56 perindopril erbumine 39 periogard 45 PERJETA 26 permethrin 27 perphenazine 28 perphenazine/amitriptyline 15 PFIZERPEN 9 pharmacist choice no coding blood glucose 97 test strips pharmacist choice ultra thin lancets 33g 97 phenadoz 15 Drug Name Page # phenazopyridine hcl 83 phenazopyridine hydrochloride 83 phenazopyridine hydrocholride 83 phenelzine sulfate 14 phenergan 15 phenobarbital 12 phenoxybenzamine hydrochloride 38 phenylephrine hcl/pyrilamine maleate 107 phenytoin 13 phenytoin infatabs 13 phenytoin sodium 13 phenytoin sodium extended 13 philith 88 phillips 81 PHOSLYRA 59 PHOSPHOLINE IODIDE 100 phosphorous 56 phospho-trin 250 neutral 56 PHYSIOLYTE 97 PHYSIOSOL IRRIGATION 97 PICATO 46 pilocarpine hcl 45 pilocarpine hcl 100 pilocarpine hydrochloride 45 pimozide 28 pimtrea 88 pindolol 40 pink bismuth 80 pioglitazone hcl 35 pioglitazone hcl/metformin hcl 35 piperacillin sodium/ tazobactam sodium 9 piperacillin sodium/tazobactam sodium 9 piperacillin/tazobactam 9 pirmella 1/35 88 pirmella 7/7/7 88 piroxicam 2 plain niacin 72 PLENAMINE 56 podofilox 46 poly hist forte 107 poly vitamin 72 polycin 7 polyethylene glycol POLY-HIST DM 107 POLY-HIST PD 102 poly-iron polymyxin b sulfate 7 polymyxin b sulfate/trimethoprim sulfate 7 polysacc iron 150 complex 56 poly-vent dm

141 Drug Name Page # poly-vent ir 107 poly-vi-flor 72 poly-vi-flor/iron 72 poly-vita drops 72 poly-vita/iron drops 73 polyvitamin 73 polyvitamin/iron 73 POMALYST 20 portia PORTRAZZA 22 potassium chloride 56 potassium chloride /sodium chloride 56 potassium chloride cr 56 potassium chloride er 56 potassium chloride sr 56 POTASSIUM CHLORIDE/DEXTROSE 56 POTASSIUM 56 CHLORIDE/DEXTROSE/LACTATED RINGERS potassium chloride/dextrose/sodium 56 chloride potassium chloride/sodium chloride 56 potassium citrate er 56 POTIGA 11 povidone-iodine 7 PRADAXA 37 PRALUENT 41 pramipexole dihydrochloride 27 pramipexole dihydrochloride er 27 prasugrel 38 pravastatin sodium 42 praziquantel 27 prazosin hcl 38 PRED MILD 100 PRED-G 100 PRED-G S.O.P. 100 prednicarbate 85 prednisolone 85 prednisolone acetate 100 prednisolone sodium phosphate 85 prednisolone sodium phosphate 100 prednisone 85 prednisone intensol 85 PREGNYL W/DILUENT BENZYL 85 ALCOHOL/NACL PREMARIN 88 PREMASOL 56 premium blood glucose test strips 97 prevalite 43 prevent 73 Drug Name Page # previfem 88 PREZCOBIX 33 PREZISTA 33 PRIFTIN 18 PRIMAQUINE PHOSPHATE 27 primidone 12 PRIMSOL 7 PRISTIQ 15 pro comfort lancets 30g 97 pro comfort lancets 31g 97 PROAIR HFA 103 PROAIR RESPICLICK 103 probenecid 18 probenecid/colchicine 18 PROCALAMINE 56 prochlorperazine 28 prochlorperazine edisylate 28 prochlorperazine maleate 28 PROCRIT 37 procto-med hc 85 procto-pak 85 proctosol hc 85 proctozone-hc 85 prodigy safety lancets 97 profe 56 proferrin es 56 progesterone 90 PROGLYCEM 36 PROGRAF 92 PROLASTIN-C 107 PROLENSA 100 PROLEUKIN 22 PROLIA 95 PROMACTA 38 promethazine hcl 15 promethazine hcl plain 15 promethazine vc/codeine 107 promethazine/codeine 107 promethazine-dm 107 promethegan 16 propafenone hcl 39 propafenone hcl er 39 propantheline bromide 79 proparacaine hcl 99 propranolol hcl 40 propranolol hcl er 40 propranolol hydrochloride 40 propranolol/hydrochlorothiazide 40 propylthiouracil 91 PROQUAD

142 Drug Name Page # PROSOL 56 protectiron 73 protriptyline hcl 15 pseudoephedrine hcl 107 PULMOZYME 104 puralube 99 pure c pureway-c 73 PURIXAN 21 px advanced lancing device 97 px lancets ultra thin 28g 97 pyrazinamide 18 pyridostigmine bromide 18 pyridostigmine bromide er 18 pyridoxine hcl 73 qc anti-diarrheal 80 qc arthritis pain relief 1 qc calcium 600 +d3 56 qc calcium/minerals/vitamin d 73 qc ibuprofen 2 qc loratadine allergy relief 102 qc loratadine-d 102 qc maximum daily 73 multivitamin/multimineral qc naproxen sodium 2 qc tolnaftate 17 qc unilet lancets 33g/micro thin 97 q-pap 1 q-pap extra strength 1 QUADRACEL 94 quasense 88 quetiapine fumarate 29 quetiapine fumarate er 29 quflora fe 73 quflora fe pediatric 73 quflora gummies 73 quflora pediatric 73 quinapril hcl 39 quinapril/hydrochlorothiazide 39 quinidine sulfate 39 quinine sulfate 27 quintabs-m 73 ra balanced b ra balanced b ra b-complex 73 ra b-complex with b ra b-complex/vitamin c tr 73 ra biotin 73 ra calcium ra calcium 600 plus vitamin d-3 73 Drug Name Page # ra calcium 600/vit d/minerals 56 ra calcium citrate plus vitamin d-3 56 ra calcium/boron 73 ra calcium/magnesium/zinc/copper 73 ra central-vite womens mature 56 ra hi cal 73 ra high potency iron 56 ra high potency iron 73 ra iron 73 ra magnesium 73 ra natural magnesium 56 ra niacin 73 ra one daily energy formula 73 ra one daily essential 73 ra one daily maximum 73 ra oyster shell calcium/vitamin d 73 ra pediatric electrolyte 56 ra pediatric electrolyte freezer pops 56 ra selenium natural 56 ra slow release iron 57 ra vitamin a 73 ra vitamin b-1 73 ra vitamin b12 74 ra vitamin b ra vitamin b-12 tr 74 ra vitamin b-6 74 ra vitamin c 74 ra vitamin c tr 74 ra vitamin c/acerola 74 ra vitamin c/rose hips 74 ra vitamin e 74 ra zinc 57 rabano yodado 74 RABAVERT 94 raloxifene hydrochloride 90 ramipril 39 RANEXA 41 ranitidine 150 maximum strength 81 ranitidine ranitidine hcl 81 ranitidine maximum strength 81 RAPAMUNE 92 rasagiline mesylate 28 readylance safety lancets/21g/2.2mm 97 readylance safety lancets/23g/1.8mm 97 readylance safety lancets/26g/1.8mm 98 readylance safety lancets/28g/1.8mm 98 REBIF 45 REBIF REBIDOSE 45 REBIF REBIDOSE TITRATION PACK

143 Drug Name Page # REBIF TITRATION PACK 45 reclipsen 88 RECOMBIVAX HB 94 REFRESH CELLUVISC 99 REFRESH LACRI-LUBE 99 refresh optive mega-3 99 REFRESH PLUS 99 REGONOL 18 REGRANEX 46 reguloid 80 relion premier blood glucose test strips 98 relion prime blood glucose test strips 98 RELISTOR 80 REMICADE 92 REMODULIN 104 renal vitamin 74 renal-vite 74 rena-vite 74 RENFLEXIS 92 reno caps 74 RENVELA 59 repaglinide 35 REPATHA 43 REPATHA PUSHTRONEX SYSTEM 43 REPATHA SURECLICK 43 repel hunters formula 46 repel lemon eucalyptus insect repellent 46 repel sportsmen 46 repel sportsmen dry 46 repel sportsmen max 46 reprexain 4 RESCON 102 RESCON DM 107 RESCON-GG 107 RESCRIPTOR 31 RESPAIRE RESTASIS 99 RETROVIR IV INFUSION 32 REVLIMID 20 REXULTI 29 REYATAZ 33 ribavirin 31 ribavirin 107 RIDAURA 93 rifabutin 18 rifampin 18 RIFATER 18 riluzole 44 rimantadine hcl 33 RINGERS INJECTION 57 Drug Name Page # RINGERS IRRIGATION 98 RIOMET 35 risacal-d 74 risedronate sodium 95 RISPERDAL CONSTA 29 risperidone 29 risperidone m-tab 29 risperidone odt 29 ritonavir 33 RITUXAN 26 RITUXAN HYCELA 26 rivastigmine tartrate 13 rivastigmine transdermal system 13 rizatriptan benzoate 18 rizatriptan benzoate odt 18 robafen 107 robafen cf multi-symptom cold 107 robafen cough 107 robafen dm 107 robafen dm cough clear 107 robafen dm cough/chest congestion 107 romidepsin 22 ropinirole hcl 27 rosadan 7 rosuvastatin calcium 42 ROTARIX 94 ROTATEQ 94 roweepra 11 roweepra xr 11 ROZEREM 108 RUBRACA 22 RUCONEST 91 ru-hist d 102 rulox 80 RYDAPT 22 rymed 102 rynex dm 107 rynex pe 102 rynex pse 102 RYTARY 28 S2 103 SABRIL 12 salsalate 2 SAMSCA 59 SANCUSO 16 SANDIMMUNE 92 SANDOSTATIN LAR DEPOT 91 sani-supp adult 81 sani-supp pediatric 82 SANTYL

144 Drug Name Page # SAPHRIS 29 SAVAYSA 37 sawyer premium insect repellent 47 sb pediatric electrolyte 57 sb vitamin c 74 scooby-doo one a day 74 scopolamine 16 selegiline hcl 28 selenium 57 selenium sulfide 47 SELZENTRY 32 senexon 80 senexon-s 82 senior tabs 74 senna 80 senna 82 senna lax 80 senna plus 82 senna-lax 82 sennalax-s 82 SENSIPAR 95 sentry 74 sentry adults under sentry senior 74 SEREVENT DISKUS 103 sertraline hcl 15 se-tan plus 57 setlakin 88 sharobel 90 SHINGRIX 94 siderol 74 sidestream pediatric facemask 98 sidestream pediatric facemask/tucker the 98 turtle SIGNIFOR 91 siladryl allergy 102 sildenafil 104 SILENOR 108 silicone mask for breatherite 98 chamber/pediatric silphen cough 103 siltussin dm das 107 siltussin sa 107 siltussin-dm 107 silver sulfadiazine 7 SIMBRINZA 100 simethicone 80 SIMULECT 93 simvastatin 42 sirolimus 92 Drug Name Page # SIRTURO 18 slo-niacin 74 slow fe 57 slow release iron 57 slow-mag 57 slow-release iron 57 sm allergy 4 hour 103 sm allergy relief 103 sm antacid/antigas 80 sm anti-diarrheal 80 sm balanced b sm b-complex 74 sm b-complex/vitamin c 74 sm calcium 500/vitamin d3 57 sm calcium 600/vitamin d 57 sm calcium 600+d3 57 sm calcium citrate w/vitamin d3 57 sm calcium citrate+ w/vitamin d 57 sm calcium soft chews 57 sm calcium/magnesium/zinc 57 sm calcium/vitamin d 57 sm chewable c 74 sm chewable vitamin c 74 sm complete 57 sm complete 74 sm complete sm complete 50+ ultimate womens 74 sm complete advanced formula 57 sm complete senior formula 57 sm hair/skin/nails 74 sm ibuprofen 2 sm iron 57 sm iron slow release 57 sm loratadine 103 sm lorata-dine d 103 sm magnesium 57 sm miconazole 7 17 sm multiple vitamins essential 57 sm multiple vitamins/iron 57 sm nasal spray 12 hour 107 sm niacin cr 74 sm one daily womens 74 sm oyster shell calcium/vitamin d 57 sm oyster shell calcium/vitamin d3 57 sm pediatric electrolyte 57 sm selenium 57 sm sleep aid 103 sm slow release iron 57 sm super b complex-vitamin c 74 sm tussin dm

145 Drug Name Page # sm tussin dm cough/chest congestion 107 sm vit c/rose hips 57 sm vitamin b1 74 sm vitamin b-1 74 sm vitamin b100 complex 74 sm vitamin b12 74 sm vitamin b sm vitamin b12 tr 74 sm vitamin b6 74 sm vitamin b-6 57 sm vitamin c 57 sm vitamin c 75 sm vitamin c tr 75 sm vitamin c/rose hips 75 sm vitamin e 57 sm vitamin e 75 sm vitamin e blended 57 sm zinc 57 sodium bicarbonate 58 sodium bicarbonate 80 sodium bicarbonate partial fill 58 SODIUM CHLORIDE 58 sodium chloride 99 SODIUM CHLORIDE 0.9% 98 SODIUM CHLORIDE 0.45% 58 SODIUM CHLORIDE 0.9% 98 sodium citrate/citric acid 58 sodium fluoride 58 SODIUM LACTATE 58 sodium phenylbutyrate 82 sodium polystyrene sulfonate 59 sodium sulfacetamide 10 SOLIQUA 100/33 36 SOLTAMOX 20 SOLU-CORTEF 85 SOMATULINE DEPOT 91 SOMAVERT 91 sorine 40 sotalol hcl 40 sotalol hcl (af) 40 sotalol hydrochloride 40 sotalol hydrochloride (af) 40 spironolactone 42 spironolactone/hydrochlorothiazide 42 SPORANOX 17 sprintec SPRITAM 11 SPRYCEL 25 sps 59 sronyx 88 Drug Name Page # SSD 7 stahist ad 107 STAMARIL 94 stavudine 32 sterile water irrigation 98 sterile water irrigation plastic bottle 98 STIMATE 85 stimulant laxative 80 STIVARGA 25 stool softener 80 stool softener 82 streptomycin sulfate 6 stress b/zinc 75 stress formula 75 stress formula w/iron 75 stress formula/iron 75 stress formula/zinc 75 STRIBILD 31 strovite forte 75 strovite one 75 SUBOXONE 5 sucralfate 82 sudogest 107 sudogest 12 hour 107 sudogest pe 107 sudogest sinus & allergy 103 sulfacetamide sodium 10 sulfacetamide sodium/prednisolone sodium 10 phosphate sulfadiazine 10 sulfamethoxazole/trimethoprim 10 sulfamethoxazole/trimethoprim ds 10 sulfasalazine 95 sulfatrim pediatric 10 sulindac 2 sumatriptan 18 sumatriptan succinate 18 sumatriptan succinate refill 18 super b complex maxi 75 super b with c 75 super biotin 75 super calcium 58 super calcium d3 58 super calcium 600+d super calcium 600+d super quints b super thera vite m 75 superplex-t 75 support 58 support

146 Drug Name Page # SUPRAX 8 SUPREP BOWEL PREP KIT 82 suspendol-s 98 SUSTIVA 31 SUTENT 25 SYLATRON 22 SYMFI 31 SYMFI LO 31 SYMLINPEN SYMLINPEN SYNAGIS 93 SYNAREL 91 SYNERCID 7 SYNJARDY 35 SYNJARDY XR 35 SYNRIBO 22 SYNTHROID 90 SYPRINE 59 tab-a-vite 75 tab-a-vite maximum 75 tab-a-vite w/beta carotene 75 tab-a-vite/iron 75 TABLOID 21 tacrolimus 47 tacrolimus 92 TAFINLAR 25 TAGRISSO 25 TALWIN 4 TAMIFLU 33 tamoxifen citrate 20 tamsulosin hcl 83 TANDEM 58 tandem plus 58 TARCEVA 25 TARGRETIN 26 tarina fe 1/20 88 taron forte 58 TASIGNA 25 tazarotene 47 tazicef 8 TAZORAC 47 taztia xt 41 TECENTRIQ 26 TECFIDERA 45 TECFIDERA STARTER PACK 45 techlite pen needles/31g x 6 mm 98 techlite pen needles/31g x 8mm 98 techlite pen needles/32g x 4mm 98 techlite pen needles/32g x 6mm 98 techlite pen needles/32g x 8mm 98 Drug Name Page # TEFLARO 8 TEKTURNA 41 TEKTURNA HCT 41 telmisartan 39 telmisartan/amlodipine 39 telmisartan/hydrochlorothiazide 39 temazepam 108 TENIVAC 94 tenofovir disoproxil fumarate 32 terazosin hcl 83 terbinafine hcl 17 terbutaline sulfate 103 terconazole 17 testosterone 86 testosterone cypionate 86 testosterone enanthate 86 testosterone pump 86 TETANUS/DIPHTHERIA TOXOIDS- 94 ADSORBED TETANUS/DIPHTHERIA TOXOIDS- 94 ADSORBED ADULT tetrabenazine 44 tetracycline hydrochloride 11 texacort 85 tgt calcium + vitamin d3 58 th antacid regular strength 80 th b 100 complex 75 th b complex/iron/vitamin c/vitamin e 75 th calcium 58 th calcium 600 with vitamin d 58 th calcium 600/vitamin d 58 th calcium citrate/vitamin d 58 th complete multi 75 th complete multi th daily multiple vitamins 75 th daily multiple vitamins/iron 75 th iron 58 th oyster shell calcium/vitamin d 58 th premium daily multiple 75 th theradex-m 75 th vitamin b 50/b-complex 75 th vitamin b1 75 th vitamin b12 75 th vitamin b th vitamin b12 er 75 th vitamin b-6 75 th vitamin c 75 th vitamin c/rose hips/bioflavonoids 76 th vitamin e 76 th vitamin e/d-alpha

147 Drug Name Page # th zinc 58 THALOMID 20 THEO theophylline cr 104 theophylline er 104 thera 76 thera m plus 76 thera-m 76 therapeutic liquid 58 therapeutic-m/lutein 76 thera-tabs 76 theratrum complete 58 theratrum complete 76 theratrum complete 50 plus 76 therems 76 therems-h 76 therems-m 76 thiamine hcl 76 thioridazine hcl 28 thiotepa 19 thiothixene 28 thrivite THYMOGLOBULIN 93 THYROLAR-1 90 THYROLAR-1/2 90 THYROLAR-1/4 90 THYROLAR-2 90 THYROLAR-3 90 thyrosafe 98 tiagabine hydrochloride 12 tigecycline 7 tilia fe 88 timolol maleate 40 timolol maleate 100 tioconazole-1 17 TIS-U-SOL 98 TIVICAY 31 tizanidine hcl 30 TOBI PODHALER 104 TOBRADEX 100 tobramycin 6 tobramycin 104 tobramycin sulfate 6 tobramycin/dexamethasone 100 TOBREX 6 tolcapone 27 tolmetin sodium 2 tolnaftate 17 tolterodine tartrate 83 tolterodine tartrate er 83 Drug Name Page # topiramate 13 toposar 23 topotecan hcl 23 TORISEL 93 torsemide 42 total b/c 76 totalday multiple 58 TOUJEO MAX SOLOSTAR 36 TOUJEO SOLOSTAR 36 TPN ELECTROLYTES 58 TRACLEER 104 TRADJENTA 36 tramadol hcl 4 tramadol hydrochloride/acetaminophen 4 trandolapril 39 tranexamic acid 38 TRANSDERM-SCOP 16 tranylcypromine sulfate 14 TRAVASOL 58 TRAVATAN Z 98 travel sickness 16 trazodone hcl 14 TREANDA 19 TRECATOR 18 TRELEGY ELLIPTA 107 TRELSTAR 91 TRELSTAR MIXJECT 91 TRESIBA FLEXTOUCH 36 tretinoin 26 tretinoin 47 tretinoin microsphere 47 tretinoin microsphere pump 47 triamcinolone acetonide 85 triamcinolone acetonide 101 triamcinolone acetonide dental paste 45 triamterene/hydrochlorothiazide 42 trianex 85 tricitrates 58 triderm 85 trientine hydrochloride 59 tri-estarylla 89 trifluoperazine hcl 28 trifluridine 34 trihexyphenidyl hcl 27 tri-legest fe 89 tri-linyah 89 trilyte 82 trimethoprim 7 trimethoprim sulfate/polymyxin b sulfate 7 tri-mili

148 Drug Name Page # trimipramine maleate 15 trinessa 89 TRINTELLIX 14 triple antibiotic 7 triple antibiotic plus 7 tri-previfem 89 triprolidine hcl 103 triprolidine hydrochloride 103 TRIPTODUR 85 TRISENOX 22 tri-sprintec 89 TRIUMEQ 32 tri-vi-flor 76 tri-vi-sol 76 tri-vit/fluoride 77 tri-vit/fluoride/iron 76 tri-vita 77 tri-vitamin 77 trivora tri-vylibra 89 TROGARZO 32 TROKENDI XR 13 TROPHAMINE 58 tropicamide 99 true metrix self monitoring blood glucose 98 strips TRULANCE 80 TRULICITY 36 TRUMENBA 94 TRUVADA 32 tussin dm 107 tussin dm clear 107 TUSSIONEX PENNKINETIC 108 EXTENDED RELEASE TWINRIX 94 TYBOST 32 tydemy 89 TYGACIL 7 TYKERB 25 TYPHIM VI 94 TYSABRI 45 TYZEKA 30 ULORIC 18 ultra lubricant eye drops 99 ultrathon insect repellent 8 47 unicomplex-m 77 unilet lancets micro-thin33g 98 unilet lancets super-thin30g 98 unilet lancets ultra-thin 28g 98 unistik pro safety lancet 21g 98 Drug Name Page # unistik pro safety lancet 25g 98 unistik pro safety lancet 28g 98 unistik touch safety lancets 21g 98 unistik touch safety lancets 23g 98 unistik touch safety lancets 28g 98 unistik touch safety lancets 30g 98 UNITHROID 90 UNITUXIN 26 ursodiol 80 UVADEX 47 valacyclovir hcl 34 VALCHLOR 19 valganciclovir 30 valganciclovir hydrochlorde 30 valproate sodium 12 valproic acid 12 valsartan 39 valsartan/hydrochlorothiazide 39 vanaclear pd 103 VANACOF 108 VANACOF DM 108 VANAHIST PD 103 vanatab ac 108 vanatab dm 108 vancomycin 8 vancomycin hcl 8 vancomycin hcl in dextrose 8 vancomycin hydrochloride/sodium chloride 8 vandazole 8 VAQTA 94 VARIVAX 94 VARIZIG 93 VARIZIG 94 VASCEPA 43 VAXCHORA 94 v-c forte 77 VECTIBIX 26 VELCADE 22 velivet 89 VELPHORO 59 VELTASSA 59 VENCLEXTA 22 VENCLEXTA STARTING PACK 22 venlafaxine hcl 15 venlafaxine hcl er 15 VENTAVIS 104 VENTOLIN HFA 103 verapamil hcl 41 verapamil hcl er 41 verapamil hcl sr

149 Drug Name Page # verasens blood glucose test strips 98 VERSACLOZ 30 VERZENIO 23 VESICARE 83 V-GO V-GO V-GO VIBERZI 81 vic-forte 77 vicodin 4 vicodin es 4 vicodin hp 4 VICTOZA 36 VIDEX EC 32 VIDEX PEDIATRIC 32 vienva 89 vigabatrin 12 VIGAMOX 10 VIIBRYD 15 VIIBRYD STARTER PACK 15 VIMPAT 13 vinblastine sulfate 23 vincasar pfs 23 vincristine sulfate 23 vinorelbine tartrate 23 viorele 89 VIRACEPT 33 VIRAMUNE 31 VIREAD 32 virtussin a/c 108 virtussin dac 108 vita-bee/c 77 vitalee 77 vitalets 77 vitalets childrens 77 vitamin a 77 vitamin a & d 47 vitamin b 6 77 vitamin b complex 77 vitamin b complex-c 77 vitamin b1 77 vitamin b-1 77 vitamin b12 77 vitamin b vitamin b-12 cr 77 vitamin b-12 er 77 vitamin b12 tr 77 vitamin b-12 tr 77 vitamin b-2 77 vitamin b6 77 Drug Name Page # vitamin b-6 77 vitamin b-complex 77 vitamin c 77 vitamin c drops 77 vitamin c sr 77 vitamin c tr 77 vitamin c/rose hips 77 vitamin c/rose hips tr 77 vitamin d 78 vitamin d3 78 vitamin e 78 vitamin e blend 78 vitamin e high potency 78 vitamin e water dispersible 78 vitamin e water soluble 78 vitamin e/d-alpha 78 vitamin e/d-alpha natural 78 vitamin e/dl-alpha 78 vitamin e vitamin k1 78 vitamins & minerals 78 vitamins for hair 78 vitatrum 78 VITEKTA 31 vitrum 50+ senior multi 78 vol-nate 78 vol-plus 78 vol-tab rx 78 voriconazole 17 vortex holding chamber/mask/toddler/lady 98 bug vortex valved holding chamber 98 VOSEVI 30 VOTRIENT 25 VP-PNV-DHA 78 VPRIV 83 VRAYLAR 29 vyfemla 89 vylibra 89 VYXEOS 21 warfarin sodium 37 wee care 58 WELCHOL 43 wera 89 white petrolatum 47 womens daily formula 78 womens daily formula/folic 78 acid/calcium/iron womens one daily 78 XALKORI

150 Drug Name Page # XARELTO 37 XARELTO STARTER PACK 37 XATMEP 93 XGEVA 95 XIFAXAN 8 XIGDUO XR 36 XOLAIR 108 XTAMPZA ER 3 XTANDI 19 XULTOPHY 100/ xylon 4 XYREM 108 yelets teenage formula 78 YERVOY 26 YF-VAX 94 YONDELIS 19 YONSA 19 yuvafem 89 zafirlukast 103 zaleplon 108 ZALTRAP 25 ZANOSAR 19 ZARXIO 38 ZAVESCA 83 zazole 17 z-bum 47 ZEASORB-AF 17 zebutal 1 ZEJULA 23 ZELBORAF 26 ZEMAIRA 108 zenatane 47 zenchent 89 ZENPEP 83 ZERIT 32 ZETIA 43 ZIAGEN 32 zidovudine 32 zinc 59 zinc zinc gluconate 58 zinc oxide 47 zinc sulfate 58 zinc ZIOPTAN 98 ziprasidone hcl 29 ZIRGAN 30 ZMAX 10 zoledronic acid 95 ZOLINZA 23 Drug Name Page # zolpidem tartrate 108 ZONATUSS 108 zonisamide 11 zoo friends 78 ZORTRESS 93 ZOSTAVAX 94 ZOSYN 9 zovia 1/35e 89 zovia 1/50e 89 ZOVIRAX 34 ZUBSOLV 5 ZUTRIPRO 108 ZYCLARA 47 ZYCLARA PUMP 47 ZYDELIG 26 ZYKADIA 26 ZYLET 6 ZYPREXA RELPREVV 29 ZYTIGA

151 All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including HealthSpring Life & Health Insurance Company, Inc. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. Updated 08/01/2018. For more information or other questions, please contact Cigna-HealthSpring CarePlan at (TTY: 7-1-1), 7 days a week, 8 a.m. to 8 p.m. Central Time, or visit