IEHP Medi-Cal Formulary Maintenance Drug List

Transcription

1 IEHP Medi-Cal Formulary Maintenance Drug List The following formulary medications may be approvable up to a three-month supply. FDA-approved generic products must be used if available. Brand name products may be covered through the prior authorization process. ACARBOSE ACARBOSE 25 MG TABLET ACARBOSE ACARBOSE 50 MG TABLET ACARBOSE ACARBOSE 100 MG TABLET ACETAZOLAMIDE ACETAZOLAMIDE 125 MG TABLET ACETAZOLAMIDE ACETAZOLAMIDE 250 MG TABLET ACETAZOLAMIDE ACETAZOLAMIDE 500 MG CAPSULE ER ACYCLOVIR ACYCLOVIR 200 MG CAPSULE ACYCLOVIR ACYCLOVIR 200 MG/5ML ORAL SUSP ACYCLOVIR ACYCLOVIR 400 MG TABLET ACYCLOVIR ACYCLOVIR 800 MG TABLET ALBUTEROL SULFATE ALBUTEROL SULFATE 2.5 MG/0.5 VIAL-NEB ALBUTEROL SULFATE ALBUTEROL SULFATE 8 MG TAB ER 12H ALBUTEROL SULFATE ALBUTEROL SULFATE 2.5 MG/3ML VIAL-NEB ALBUTEROL SULFATE ALBUTEROL SULFATE 2 MG/5 ML SYRUP ALBUTEROL SULFATE ALBUTEROL SULFATE 1.25MG/3ML VIAL-NEB ALBUTEROL SULFATE ALBUTEROL SULFATE 0.63MG/3ML VIAL-NEB ALBUTEROL SULFATE ALBUTEROL SULFATE 4 MG TAB ER 12H ALDACTAZIDE SPIRONOLACTONE/HYDROCHLOROTHIAZIDE 50 MG-50MG TABLET ALENDRONATE SODIUM ALENDRONATE SODIUM 10 MG TABLET ALENDRONATE SODIUM ALENDRONATE SODIUM 35 MG TABLET ALENDRONATE SODIUM ALENDRONATE SODIUM 40 MG TABLET ALENDRONATE SODIUM ALENDRONATE SODIUM 70 MG TABLET ALLOPURINOL ALLOPURINOL 100 MG TABLET ALLOPURINOL ALLOPURINOL 300 MG TABLET AMIODARONE HCL AMIODARONE HCL 200 MG TABLET AMITRIPTYLINE HCL AMITRIPTYLINE HCL 100 MG TABLET AMITRIPTYLINE HCL AMITRIPTYLINE HCL 50 MG TABLET AMITRIPTYLINE HCL AMITRIPTYLINE HCL 75 MG TABLET AMITRIPTYLINE HCL AMITRIPTYLINE HCL 150 MG TABLET AMITRIPTYLINE HCL AMITRIPTYLINE HCL 10 MG TABLET AMITRIPTYLINE HCL AMITRIPTYLINE HCL 25 MG TABLET AMLODIPINE BESYLATE AMLODIPINE BESYLATE 10 MG TABLET AMLODIPINE BESYLATE AMLODIPINE BESYLATE 2.5 MG TABLET AMLODIPINE BESYLATE AMLODIPINE BESYLATE 5 MG TABLET AMLODIPINE BESYLATE- BENAZEPRIL AMLODIPINE BESYLATE/BENAZEPRIL HCL 10 MG-20MG CAPSULE AMLODIPINE BESYLATE- BENAZEPRIL AMLODIPINE BESYLATE/BENAZEPRIL HCL 10 MG-40MG CAPSULE 255_FormularyMaintenance_February2016 Page 1 of 26

2 AMLODIPINE BESYLATE- BENAZEPRIL AMLODIPINE BESYLATE/BENAZEPRIL HCL 2.5MG-10MG CAPSULE AMLODIPINE BESYLATE- BENAZEPRIL AMLODIPINE BESYLATE/BENAZEPRIL HCL 5 MG-10 MG CAPSULE AMLODIPINE BESYLATE- BENAZEPRIL AMLODIPINE BESYLATE/BENAZEPRIL HCL 5 MG-20 MG CAPSULE AMLODIPINE BESYLATE- BENAZEPRIL AMLODIPINE BESYLATE/BENAZEPRIL HCL 5 MG-40 MG CAPSULE AMPHETAMINE SALT COMBO AMPHETAMINE SALT COMBO AMPHETAMINE SALT COMBO AMPHETAMINE SALT COMBO AMPHETAMINE SALT COMBO DEXTROAMPHETAMINE SULF- SACCHARATE/AMPHETAMINE SULF-ASPARTATE 10 MG TABLET DEXTROAMPHETAMINE SULF- SACCHARATE/AMPHETAMINE SULF-ASPARTATE 7.5 MG TABLET DEXTROAMPHETAMINE SULF- SACCHARATE/AMPHETAMINE SULF-ASPARTATE 30 MG TABLET DEXTROAMPHETAMINE SULF- SACCHARATE/AMPHETAMINE SULF-ASPARTATE 20 MG TABLET DEXTROAMPHETAMINE SULF- SACCHARATE/AMPHETAMINE SULF-ASPARTATE 12.5 MG TABLET AMPHETAMINE SALT COMBO DEXTROAMPHETAMINE SULF- SACCHARATE/AMPHETAMINE SULF-ASPARTATE 15 MG TABLET ANASTROZOLE ANASTROZOLE 1 MG TABLET ANTI-DIARRHEAL LOPERAMIDE HCL 1 MG/5 ML LIQUID APIDRA INSULIN GLULISINE 100/ML VIAL APIDRA SOLOSTAR INSULIN GLULISINE 100/ML INSULN PEN ARMOUR THYROID THYROID,PORK 30 MG TABLET ARMOUR THYROID THYROID,PORK 60 MG TABLET ARMOUR THYROID THYROID,PORK 90 MG TABLET ARMOUR THYROID THYROID,PORK 300 MG TABLET ARMOUR THYROID THYROID,PORK 180 MG TABLET ARMOUR THYROID THYROID,PORK 120 MG TABLET ARMOUR THYROID THYROID,PORK 15 MG TABLET ARMOUR THYROID THYROID,PORK 240 MG TABLET ASMANEX MOMETASONE FUROATE 220MCG(60) AER POW BA ASMANEX MOMETASONE FUROATE 220MCG 120 AER POW BA ASMANEX MOMETASONE FUROATE 220MCG(30) AER POW BA ASMANEX MOMETASONE FUROATE 110MCG(30) AER POW BA ASPIRIN-DIPYRIDAMOLE ER ASPIRIN/DIPYRIDAMOLE 25MG-200MG CPMP 12HR ATENOLOL ATENOLOL 25 MG TABLET 255_FormularyMaintenance_February2016 Page 2 of 26

3 ATENOLOL ATENOLOL 50 MG TABLET ATENOLOL ATENOLOL 100 MG TABLET ATENOLOL- CHLORTHALIDONE ATENOLOL/CHLORTHALIDONE 100MG-25MG TABLET ATENOLOL- CHLORTHALIDONE ATENOLOL/CHLORTHALIDONE 50 MG-25MG TABLET ATORVASTATIN CALCIUM ATORVASTATIN CALCIUM 40 MG TABLET ATORVASTATIN CALCIUM ATORVASTATIN CALCIUM 20 MG TABLET ATORVASTATIN CALCIUM ATORVASTATIN CALCIUM 10 MG TABLET ATORVASTATIN CALCIUM ATORVASTATIN CALCIUM 80 MG TABLET ATROPINE SULFATE ATROPINE SULFATE 1 % DROPS ATROPINE SULFATE ATROPINE SULFATE 1 % OINT. (G) ATROVENT HFA IPRATROPIUM BROMIDE 17MCG HFA AER AD AZATHIOPRINE AZATHIOPRINE 50 MG TABLET AZELASTINE HCL AZELASTINE HCL 137 MCG SPRAY/PUMP AZOPT BRINZOLAMIDE 1 % DROPS SUSP AZURETTE DESOGESTREL-ETHINYL ESTRADIOL/ETHINYL ESTRADIOL 21-5 TABLET BACLOFEN BACLOFEN 20 MG TABLET BACLOFEN BACLOFEN 10 MG TABLET BALZIVA NORETHINDRONE-ETHINYL ESTRADIOL TABLET BD ULTRA-FINE PEN NEEDLE PEN NEEDLE, DIABETIC 31 GX5/16" DIS NEEDLE BD ULTRA-FINE PEN NEEDLE PEN NEEDLE, DIABETIC 29 G X1/2" DIS NEEDLE BENAZEPRIL HCL BENAZEPRIL HCL 5 MG TABLET BENAZEPRIL HCL BENAZEPRIL HCL 40 MG TABLET BENAZEPRIL HCL BENAZEPRIL HCL 10 MG TABLET BENAZEPRIL HCL BENAZEPRIL HCL 20 MG TABLET BENAZEPRIL HCL-HCTZ BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE 20-25MG TABLET BENAZEPRIL- HYDROCHLOROTHIAZIDE BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE MG TABLET BENAZEPRIL- HYDROCHLOROTHIAZIDE BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE MG TABLET BENAZEPRIL- HYDROCHLOROTHIAZIDE BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE MG TABLET BETAXOLOL HCL BETAXOLOL HCL 0.5 % DROPS BETIMOL TIMOLOL 0.25 % DROPS BETIMOL TIMOLOL 0.5 % DROPS BETOPTIC S BETAXOLOL HCL 0.25 % DROPS SUSP BRIMONIDINE TARTRATE BRIMONIDINE TARTRATE 0.15 % DROPS 255_FormularyMaintenance_February2016 Page 3 of 26

4 BRIMONIDINE TARTRATE BRIMONIDINE TARTRATE 0.2 % DROPS BROMOCRIPTINE MESYLATE BROMOCRIPTINE MESYLATE 5 MG CAPSULE BROMOCRIPTINE MESYLATE BROMOCRIPTINE MESYLATE 2.5 MG TABLET BUDESONIDE BUDESONIDE 1 MG/2 ML AMPUL-NEB BUDESONIDE BUDESONIDE 0.25MG/2ML AMPUL-NEB BUDESONIDE BUDESONIDE 0.5 MG/2ML AMPUL-NEB BUMETANIDE BUMETANIDE 0.5 MG TABLET BUMETANIDE BUMETANIDE 1 MG TABLET BUMETANIDE BUMETANIDE 2 MG TABLET BUPROPION HCL BUPROPION HCL 100 MG TABLET BUPROPION HCL BUPROPION HCL 75 MG TABLET BUPROPION HCL SR BUPROPION HCL 100 MG TABLET ER BUPROPION HCL SR BUPROPION HCL 200 MG TABLET ER BUPROPION XL BUPROPION HCL 150 MG TAB ER 24H BUPROPION XL BUPROPION HCL 300 MG TAB ER 24H BUSPIRONE HCL BUSPIRONE HCL 5 MG TABLET BUSPIRONE HCL BUSPIRONE HCL 30 MG TABLET BUSPIRONE HCL BUSPIRONE HCL 15 MG TABLET BUSPIRONE HCL BUSPIRONE HCL 10 MG TABLET BUSPIRONE HCL BUSPIRONE HCL 7.5 MG TABLET CALCITONIN-SALMON CALCITONIN,SALMON,SYNTHETIC 200/SPRAY SPRAY/PUMP CALCITRIOL CALCITRIOL 0.25 MCG CAPSULE CALCITRIOL CALCITRIOL 0.5 MCG CAPSULE CALCIUM ACETATE CALCIUM ACETATE 667 MG TABLET CALCIUM ACETATE CALCIUM ACETATE 667 MG CAPSULE CAMRESE LEVONORGESTREL/ETHINYL ESTRADIOL AND ETHINYL ESTRADIOL (84) TBDSPK 3MO CAPTOPRIL CAPTOPRIL 12.5 MG TABLET CAPTOPRIL CAPTOPRIL 25 MG TABLET CAPTOPRIL CAPTOPRIL 50 MG TABLET CAPTOPRIL CAPTOPRIL 100 MG TABLET CARAFATE SUCRALFATE 1 G/10 ML ORAL SUSP CARBAMAZEPINE CARBAMAZEPINE 200 MG CPMP 12HR CARBAMAZEPINE CARBAMAZEPINE 300 MG CPMP 12HR CARBAMAZEPINE CARBAMAZEPINE 200 MG TABLET CARBAMAZEPINE CARBAMAZEPINE 100 MG/5ML ORAL SUSP CARBAMAZEPINE CARBAMAZEPINE 100 MG CPMP 12HR CARBAMAZEPINE CARBAMAZEPINE 100 MG TAB CHEW CARBAMAZEPINE ER CARBAMAZEPINE 200 MG TAB ER 12H CARBAMAZEPINE ER CARBAMAZEPINE 400 MG TAB ER 12H CARBIDOPA-LEVODOPA CARBIDOPA/LEVODOPA 10MG-100MG TABLET CARBIDOPA-LEVODOPA CARBIDOPA/LEVODOPA 25MG-100MG TABLET 255_FormularyMaintenance_February2016 Page 4 of 26

5 CARBIDOPA-LEVODOPA CARBIDOPA/LEVODOPA 25MG-250MG TABLET CARBIDOPA-LEVODOPA CARBIDOPA/LEVODOPA 50MG-200MG TABLET ER CARNITOR SF LEVOCARNITINE 100 MG/ML SOLUTION CARVEDILOL CARVEDILOL MG TABLET CARVEDILOL CARVEDILOL 25 MG TABLET CARVEDILOL CARVEDILOL 12.5 MG TABLET CARVEDILOL CARVEDILOL 6.25 MG TABLET CAZIANT DESOGESTREL-ETHINYL ESTRADIOL 7 DAYS X 3 TABLET CHEMSTRIP K URINE ACETONE TEST,STRIPS STRIP CHILDREN'S IBUPROFEN IBUPROFEN 100 MG/5ML ORAL SUSP CHLOROQUINE PHOSPHATE CHLOROQUINE PHOSPHATE 250 MG TABLET CHLOROQUINE PHOSPHATE CHLOROQUINE PHOSPHATE 500 MG TABLET CHLOROTHIAZIDE CHLOROTHIAZIDE 250 MG TABLET CHLOROTHIAZIDE CHLOROTHIAZIDE 500 MG TABLET CHLORTHALIDONE CHLORTHALIDONE 25 MG TABLET CHLORTHALIDONE CHLORTHALIDONE 50 MG TABLET CHOLESTYRAMINE CHOLESTYRAMINE (WITH SUGAR) 4 G POWD PACK CHOLESTYRAMINE LIGHT CHOLESTYRAMINE/ASPARTAME 4 G POWDER CHOLESTYRAMINE LIGHT CHOLESTYRAMINE/ASPARTAME 4 G POWD PACK CILOSTAZOL CILOSTAZOL 100 MG TABLET CILOSTAZOL CILOSTAZOL 50 MG TABLET CIMETIDINE CIMETIDINE 200 MG TABLET CIMETIDINE CIMETIDINE 300 MG TABLET CIMETIDINE CIMETIDINE 400 MG TABLET CIMETIDINE CIMETIDINE 800 MG TABLET CIMETIDINE CIMETIDINE HCL 300 MG/5ML SOLUTION CITALOPRAM CITALOPRAM HYDROBROMIDE 10 MG/5 ML SOLUTION CITALOPRAM HBR CITALOPRAM HYDROBROMIDE 10 MG TABLET CITALOPRAM HBR CITALOPRAM HYDROBROMIDE 20 MG TABLET CITALOPRAM HBR CITALOPRAM HYDROBROMIDE 40 MG TABLET CLONAZEPAM CLONAZEPAM 0.5 MG TABLET CLONAZEPAM CLONAZEPAM 1 MG TABLET CLONAZEPAM CLONAZEPAM 2 MG TABLET CLONIDINE CLONIDINE 0.1MG/24HR PATCH TDWK CLONIDINE CLONIDINE 0.3MG/24HR PATCH TDWK CLONIDINE CLONIDINE 0.2MG/24HR PATCH TDWK CLONIDINE HCL CLONIDINE HCL 0.1 MG TABLET CLONIDINE HCL CLONIDINE HCL 0.2 MG TABLET CLONIDINE HCL CLONIDINE HCL 0.3 MG TABLET CLONIDINE HCL ER CLONIDINE HCL 0.1 MG TAB ER 12H CLOPIDOGREL CLOPIDOGREL BISULFATE 75 MG TABLET COLCHICINE COLCHICINE 0.6 MG CAPSULE 255_FormularyMaintenance_February2016 Page 5 of 26

6 COLCHICINE COLCHICINE 0.6 MG TABLET COMBIVENT RESPIMAT IPRATROPIUM BROMIDE/ALBUTEROL SULFATE MCG MIST INHAL CREON LIPASE/PROTEASE/AMYLASE CAPSULE DR CREON LIPASE/PROTEASE/AMYLASE K CAPSULE DR CREON LIPASE/PROTEASE/AMYLASE K CAPSULE DR CREON LIPASE/PROTEASE/AMYLASE 12K-38K-60 CAPSULE DR CREON LIPASE/PROTEASE/AMYLASE 6K-19K-30K CAPSULE DR CROMOLYN SODIUM CROMOLYN SODIUM 20 MG/2 ML AMPUL-NEB CYANOCOBALAMIN INJECTION CYANOCOBALAMIN (VITAMIN B-12) 1000MCG/ML VIAL CYCLOGYL CYCLOPENTOLATE HCL 0.5 % DROPS CYCLOPENTOLATE HCL CYCLOPENTOLATE HCL 1 % DROPS CYCLOPENTOLATE HCL CYCLOPENTOLATE HCL 2 % DROPS CYPROHEPTADINE HCL CYPROHEPTADINE HCL 2 MG/5 ML SYRUP CYPROHEPTADINE HCL CYPROHEPTADINE HCL 4 MG TABLET DAPSONE DAPSONE 100 MG TABLET DAPSONE DAPSONE 25 MG TABLET DEPO-PROVERA MEDROXYPROGESTERONE ACETATE 400 MG/ML VIAL DESIPRAMINE HCL DESIPRAMINE HCL 25 MG TABLET DESIPRAMINE HCL DESIPRAMINE HCL 50 MG TABLET DESIPRAMINE HCL DESIPRAMINE HCL 100 MG TABLET DESIPRAMINE HCL DESIPRAMINE HCL 10 MG TABLET DESIPRAMINE HCL DESIPRAMINE HCL 150 MG TABLET DESIPRAMINE HCL DESIPRAMINE HCL 75 MG TABLET DESMOPRESSIN ACETATE DESMOPRESSIN ACETATE 0.1 MG TABLET DESMOPRESSIN ACETATE DESMOPRESSIN ACETATE 0.2 MG TABLET DESOGESTREL-ETHINYL ESTRADIOL DESOGESTREL-ETHINYL ESTRADIOL TABLET DEXMETHYLPHENIDATE HCL DEXMETHYLPHENIDATE HCL 2.5 MG TABLET DEXMETHYLPHENIDATE HCL DEXMETHYLPHENIDATE HCL 5 MG TABLET DEXMETHYLPHENIDATE HCL DEXMETHYLPHENIDATE HCL 10 MG TABLET DEXMETHYLPHENIDATE HCL ER DEXMETHYLPHENIDATE HCL 5 MG CPBP DEXMETHYLPHENIDATE HCL ER DEXMETHYLPHENIDATE HCL 15 MG CPBP DEXMETHYLPHENIDATE HCL ER DEXMETHYLPHENIDATE HCL 20 MG CPBP _FormularyMaintenance_February2016 Page 6 of 26

7 DEXMETHYLPHENIDATE HCL ER DEXMETHYLPHENIDATE HCL 30 MG CPBP DEXMETHYLPHENIDATE HCL ER DEXMETHYLPHENIDATE HCL 40 MG CPBP DEXMETHYLPHENIDATE HCL ER DEXMETHYLPHENIDATE HCL 10 MG CPBP DEXTROAMPHETAMINE SULFATE DEXTROAMPHETAMINE SULFATE 5 MG TABLET DEXTROAMPHETAMINE SULFATE DEXTROAMPHETAMINE SULFATE 5 MG CAPSULE ER DEXTROAMPHETAMINE SULFATE DEXTROAMPHETAMINE SULFATE 10 MG CAPSULE ER DEXTROAMPHETAMINE SULFATE DEXTROAMPHETAMINE SULFATE 10 MG TABLET DEXTROAMPHETAMINE SULFATE ER DEXTROAMPHETAMINE SULFATE 15 MG CAPSULE ER DEXTROAMPHETAMINE- AMPHET ER DEXTROAMPHETAMINE- AMPHET ER DEXTROAMPHETAMINE- AMPHET ER DEXTROAMPHETAMINE- AMPHET ER DEXTROAMPHETAMINE- AMPHET ER DEXTROAMPHETAMINE- AMPHET ER DEXTROAMPHETAMINE SULF- SACCHARATE/AMPHETAMINE SULF-ASPARTATE 10 MG CAP ER 24H DEXTROAMPHETAMINE SULF- SACCHARATE/AMPHETAMINE SULF-ASPARTATE 15 MG CAP ER 24H DEXTROAMPHETAMINE SULF- SACCHARATE/AMPHETAMINE SULF-ASPARTATE 20 MG CAP ER 24H DEXTROAMPHETAMINE SULF- SACCHARATE/AMPHETAMINE SULF-ASPARTATE 25 MG CAP ER 24H DEXTROAMPHETAMINE SULF- SACCHARATE/AMPHETAMINE SULF-ASPARTATE 30 MG CAP ER 24H DEXTROAMPHETAMINE SULF- SACCHARATE/AMPHETAMINE SULF-ASPARTATE 5 MG CAP ER 24H DEXTROAMPHETAMINE- AMPHETAMINE DEXTROAMPHETAMINE SULF- SACCHARATE/AMPHETAMINE SULF-ASPARTATE 5 MG TABLET DIGOXIN DIGOXIN 0.125/2.5 SOLUTION DIGOXIN DIGOXIN 125 MCG TABLET DIGOXIN DIGOXIN 250 MCG TABLET DILANTIN PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE DILATRATE-SR ISOSORBIDE DINITRATE 40 MG CAPSULE ER DILTIAZEM 12HR ER DILTIAZEM HCL 60 MG CAP ER 12H DILTIAZEM 12HR ER DILTIAZEM HCL 90 MG CAP ER 12H DILTIAZEM 12HR ER DILTIAZEM HCL 120 MG CAP ER 12H 255_FormularyMaintenance_February2016 Page 7 of 26

8 DILTIAZEM 24HR CD DILTIAZEM HCL 120 MG CAP ER 24H DILTIAZEM 24HR CD DILTIAZEM HCL 180 MG CAP ER 24H DILTIAZEM 24HR CD DILTIAZEM HCL 240 MG CAP ER 24H DILTIAZEM 24HR CD DILTIAZEM HCL 300 MG CAP ER 24H DILTIAZEM 24HR CD DILTIAZEM HCL 360 MG CAP ER 24H DILTIAZEM ER DILTIAZEM HCL 360 MG CAPSULE ER DILTIAZEM ER DILTIAZEM HCL 420MG CAPSULE ER DILTIAZEM HCL DILTIAZEM HCL 60 MG TABLET DILTIAZEM HCL DILTIAZEM HCL 90 MG TABLET DILTIAZEM HCL DILTIAZEM HCL 30 MG TABLET DILTIAZEM HCL DILTIAZEM HCL 120 MG TABLET DILT-XR DILTIAZEM HCL 180 MG CAP ER DEG DILT-XR DILTIAZEM HCL 240 MG CAP ER DEG DILT-XR DILTIAZEM HCL 120 MG CAP ER DEG DISULFIRAM DISULFIRAM 250 MG TABLET DISULFIRAM DISULFIRAM 500 MG TABLET DIURIL CHLOROTHIAZIDE 250 MG/5ML ORAL SUSP DIVALPROEX SODIUM DIVALPROEX SODIUM 500 MG TABLET DR DIVALPROEX SODIUM DIVALPROEX SODIUM 250 MG TABLET DR DIVALPROEX SODIUM DIVALPROEX SODIUM 125 MG CAP SPRINK DIVALPROEX SODIUM DIVALPROEX SODIUM 125 MG TABLET DR DIVALPROEX SODIUM ER DIVALPROEX SODIUM 250 MG TAB ER 24H DIVALPROEX SODIUM ER DIVALPROEX SODIUM 500 MG TAB ER 24H DONEPEZIL HCL DONEPEZIL HCL 5 MG TABLET DONEPEZIL HCL DONEPEZIL HCL 10 MG TABLET DONEPEZIL HCL ODT DONEPEZIL HCL 10 MG TAB RAPDIS DONEPEZIL HCL ODT DONEPEZIL HCL 5 MG TAB RAPDIS DORZOLAMIDE HCL DORZOLAMIDE HCL 2 % DROPS DORZOLAMIDE-TIMOLOL DORZOLAMIDE HCL/TIMOLOL MALEATE /1 DROPS DOXAZOSIN MESYLATE DOXAZOSIN MESYLATE 1 MG TABLET DOXAZOSIN MESYLATE DOXAZOSIN MESYLATE 2 MG TABLET DOXAZOSIN MESYLATE DOXAZOSIN MESYLATE 4 MG TABLET DOXAZOSIN MESYLATE DOXAZOSIN MESYLATE 8 MG TABLET DOXEPIN HCL DOXEPIN HCL 75 MG CAPSULE DOXEPIN HCL DOXEPIN HCL 10 MG CAPSULE DOXEPIN HCL DOXEPIN HCL 100 MG CAPSULE DOXEPIN HCL DOXEPIN HCL 150 MG CAPSULE DOXEPIN HCL DOXEPIN HCL 25 MG CAPSULE DOXEPIN HCL DOXEPIN HCL 50 MG CAPSULE DULOXETINE HCL DULOXETINE HCL 60 MG CAPSULE DR DULOXETINE HCL DULOXETINE HCL 20 MG CAPSULE DR DULOXETINE HCL DULOXETINE HCL 30 MG CAPSULE DR DYRENIUM TRIAMTERENE 50 MG CAPSULE EDECRIN ETHACRYNIC ACID 25 MG TABLET 255_FormularyMaintenance_February2016 Page 8 of 26

9 EFFER-K POTASSIUM BICARBONATE/CITRIC ACID 10 MEQ TABLET EFF EFFER-K POTASSIUM BICARBONATE/CITRIC ACID 20 MEQ TABLET EFF EFFER-K POTASSIUM BICARBONATE/CITRIC ACID 25 MEQ TABLET EFF ELIQUIS APIXABAN 2.5 MG TABLET ELIQUIS APIXABAN 5 MG TABLET ENALAPRIL MALEATE ENALAPRIL MALEATE 10 MG TABLET ENALAPRIL MALEATE ENALAPRIL MALEATE 2.5 MG TABLET ENALAPRIL MALEATE ENALAPRIL MALEATE 20 MG TABLET ENALAPRIL MALEATE ENALAPRIL MALEATE 5 MG TABLET ENULOSE LACTULOSE 10 G/15 ML SOLUTION ERGOCALCIFEROL (VITAMIN D2) ERGOCALCIFEROL (VITAMIN D2) UNIT CAPSULE ESCITALOPRAM OXALATE ESCITALOPRAM OXALATE 10 MG TABLET ESCITALOPRAM OXALATE ESCITALOPRAM OXALATE 20 MG TABLET ESCITALOPRAM OXALATE ESCITALOPRAM OXALATE 5 MG TABLET ESTRACE ESTRADIOL 0.01 % CREAM/APPL ESTRADIOL ESTRADIOL 0.06MG/24H PATCH TDWK ESTRADIOL ESTRADIOL 2 MG TABLET ESTRADIOL ESTRADIOL 1 MG TABLET ESTRADIOL ESTRADIOL 0.5 MG TABLET ESTRADIOL ESTRADIOL 0.1MG/24HR PATCH TDSW ESTRADIOL ESTRADIOL 0.05MG/24H PATCH TDWK ESTRADIOL ESTRADIOL.075MG/24H PATCH TDWK ESTRADIOL ESTRADIOL 0.1MG/24HR PATCH TDWK ESTRADIOL ESTRADIOL.075MG/24H PATCH TDSW ESTRADIOL ESTRADIOL.0375MG/24 PATCH TDWK ESTRADIOL ESTRADIOL.0375MG/24 PATCH TDSW ESTRADIOL ESTRADIOL.025MG/24H PATCH TDWK ESTRADIOL ESTRADIOL.025MG/24H PATCH TDSW ESTRADIOL ESTRADIOL 0.05MG/24H PATCH TDSW ESTROGEN & METHYLTESTOSTERONE ESTROGENS,ESTERIFIED/METHYLTESTOSTERONE TABLET ESTROGEN- METHYLTESTOSTERONE ESTROGENS,ESTERIFIED/METHYLTESTOSTERONE MG TABLET ETHOSUXIMIDE ETHOSUXIMIDE 250 MG/5ML SOLUTION ETHOSUXIMIDE ETHOSUXIMIDE 250 MG CAPSULE ETODOLAC ETODOLAC 200 MG CAPSULE ETODOLAC ETODOLAC 300 MG CAPSULE ETODOLAC ETODOLAC 400 MG TABLET ETODOLAC ETODOLAC 500 MG TABLET FAMOTIDINE FAMOTIDINE 20 MG TABLET 255_FormularyMaintenance_February2016 Page 9 of 26

10 FAMOTIDINE FAMOTIDINE 40 MG TABLET FAMOTIDINE FAMOTIDINE 10 MG TABLET FAMOTIDINE FAMOTIDINE 40MG/5ML ORAL SUSP FELODIPINE ER FELODIPINE 10 MG TAB ER 24H FELODIPINE ER FELODIPINE 2.5 MG TAB ER 24H FELODIPINE ER FELODIPINE 5 MG TAB ER 24H FENOFIBRATE FENOFIBRATE NANOCRYSTALLIZED 145MG TABLET FENOFIBRATE FENOFIBRATE,MICRONIZED 67 MG CAPSULE FENOFIBRATE FENOFIBRATE,MICRONIZED 200 MG CAPSULE FENOFIBRATE FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET FENOFIBRATE FENOFIBRATE 54 MG TABLET FENOFIBRATE FENOFIBRATE 160 MG TABLET FENOFIBRATE FENOFIBRATE,MICRONIZED 134MG CAPSULE FENOFIBRIC ACID FENOFIBRIC ACID (CHOLINE) 135 MG CAPSULE DR FENOFIBRIC ACID FENOFIBRIC ACID (CHOLINE) 45 MG CAPSULE DR FINASTERIDE FINASTERIDE 5 MG TABLET FLOVENT DISKUS FLUTICASONE PROPIONATE 50 MCG BLST W/DEV FLOVENT DISKUS FLUTICASONE PROPIONATE 100 MCG BLST W/DEV FLOVENT DISKUS FLUTICASONE PROPIONATE 250 MCG BLST W/DEV FLOVENT HFA FLUTICASONE PROPIONATE 110 MCG AER W/ADAP FLOVENT HFA FLUTICASONE PROPIONATE 220 MCG AER W/ADAP FLOVENT HFA FLUTICASONE PROPIONATE 44 MCG AER W/ADAP FLUDROCORTISONE ACETATE FLUDROCORTISONE ACETATE 0.1 MG TABLET FLUNISOLIDE FLUNISOLIDE 25 MCG SPRAY FLUOR-A-DAY SODIUM FLUORIDE 2.5 MG/ML DROPS FLUORIDE SODIUM FLUORIDE 0.25(0.55) TAB CHEW FLUORIDE SODIUM FLUORIDE 0.5(1.1)MG TAB CHEW FLUORITAB SODIUM FLUORIDE 1MG(2.2MG) TAB CHEW FLUOXETINE HCL FLUOXETINE HCL 10 MG TABLET FLUOXETINE HCL FLUOXETINE HCL 20 MG/5 ML SOLUTION FLUOXETINE HCL FLUOXETINE HCL 40 MG CAPSULE FLUOXETINE HCL FLUOXETINE HCL 10 MG CAPSULE FLUOXETINE HCL FLUOXETINE HCL 20 MG TABLET FLUOXETINE HCL FLUOXETINE HCL 20 MG CAPSULE FLUTAMIDE FLUTAMIDE 125 MG CAPSULE FLUTICASONE PROPIONATE FLUTICASONE PROPIONATE 50 MCG SPRAY SUSP FOCALIN XR DEXMETHYLPHENIDATE HCL 25 MG CPBP FOCALIN XR DEXMETHYLPHENIDATE HCL 35 MG CPBP FOLIC ACID FOLIC ACID 0.4 MG TABLET FOLIC ACID FOLIC ACID 1 MG TABLET FUROSEMIDE FUROSEMIDE 20 MG TABLET FUROSEMIDE FUROSEMIDE 40 MG TABLET 255_FormularyMaintenance_February2016 Page 10 of 26

11 FUROSEMIDE FUROSEMIDE 40MG/5ML SOLUTION FUROSEMIDE FUROSEMIDE 80 MG TABLET FUROSEMIDE FUROSEMIDE 10 MG/ML SOLUTION GABAPENTIN GABAPENTIN 600 MG TABLET GABAPENTIN GABAPENTIN 800 MG TABLET GABAPENTIN GABAPENTIN 400 MG CAPSULE GABAPENTIN GABAPENTIN 100 MG CAPSULE GABAPENTIN GABAPENTIN 300 MG CAPSULE GEMFIBROZIL GEMFIBROZIL 600 MG TABLET GIANVI ETHINYL ESTRADIOL/DROSPIRENONE (24) TABLET GLIMEPIRIDE GLIMEPIRIDE 1 MG TABLET GLIMEPIRIDE GLIMEPIRIDE 2 MG TABLET GLIMEPIRIDE GLIMEPIRIDE 4 MG TABLET GLIPIZIDE GLIPIZIDE 10 MG TABLET GLIPIZIDE GLIPIZIDE 5 MG TABLET GLIPIZIDE ER GLIPIZIDE 5 MG TAB ER 24 GLIPIZIDE ER GLIPIZIDE 2.5 MG TAB ER 24 GLIPIZIDE ER GLIPIZIDE 10 MG TAB ER 24 GLIPIZIDE-METFORMIN GLIPIZIDE/METFORMIN HCL MG TABLET GLIPIZIDE-METFORMIN GLIPIZIDE/METFORMIN HCL 5 MG-500MG TABLET GLIPIZIDE-METFORMIN GLIPIZIDE/METFORMIN HCL MG TABLET GLYBURIDE GLYBURIDE 1.25 MG TABLET GLYBURIDE GLYBURIDE 2.5 MG TABLET GLYBURIDE GLYBURIDE 5 MG TABLET GLYBURIDE-METFORMIN HCL GLYBURIDE/METFORMIN HCL MG TABLET GLYBURIDE-METFORMIN HCL GLYBURIDE/METFORMIN HCL MG TABLET GLYBURIDE-METFORMIN HCL GLYBURIDE/METFORMIN HCL 5 MG-500MG TABLET GUANFACINE HCL GUANFACINE HCL 1 MG TABLET GUANFACINE HCL GUANFACINE HCL 2 MG TABLET HOMATROPAIRE HOMATROPINE HBR 5 % DROPS HUMALOG INSULIN LISPRO 100/ML CARTRIDGE HUMALOG INSULIN LISPRO 100/ML VIAL HUMALOG KWIKPEN U-100 INSULIN LISPRO 100/ML INSULN PEN HUMALOG MIX INSULIN LISPRO PROTAMINE & INSULIN LISPRO 50-50/ML VIAL HUMALOG MIX KWIKPEN INSULIN LISPRO PROTAMINE & INSULIN LISPRO 50-50/ML INSULN PEN HUMALOG MIX INSULIN LISPRO PROTAMINE & INSULIN LISPRO 75-25/ML VIAL 255_FormularyMaintenance_February2016 Page 11 of 26

12 HUMALOG MIX KWIKPEN INSULIN LISPRO PROTAMINE & INSULIN LISPRO 75-25/ML INSULN PEN HUMULIN 70/30 KWIKPEN INSULIN NPH HUMAN ISOPHANE/INSULIN REGULAR, HUMAN 70-30/ML INSULN PEN HUMULIN INSULIN NPH HUMAN ISOPHANE/INSULIN REGULAR, HUMAN 70-30/ML VIAL HUMULIN N INSULIN NPH HUMAN ISOPHANE 100/ML VIAL HUMULIN N KWIKPEN INSULIN NPH HUMAN ISOPHANE 100/ML (3) INSULN PEN HUMULIN R INSULIN REGULAR, HUMAN 100/ML VIAL HUMULIN R U-500 INSULIN REGULAR, HUMAN 500/ML VIAL HYDRALAZINE HCL HYDRALAZINE HCL 25 MG TABLET HYDRALAZINE HCL HYDRALAZINE HCL 50 MG TABLET HYDRALAZINE HCL HYDRALAZINE HCL 10 MG TABLET HYDRALAZINE HCL HYDRALAZINE HCL 100 MG TABLET HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE 12.5 MG TABLET HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE 25 MG TABLET HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE 50 MG TABLET HYDROCORTISONE HYDROCORTISONE 10 MG TABLET HYDROCORTISONE HYDROCORTISONE 20 MG TABLET HYDROCORTISONE HYDROCORTISONE 5 MG TABLET HYDROXYCHLOROQUINE SULFATE HYDROXYCHLOROQUINE SULFATE 200 MG TABLET HYDROXYUREA HYDROXYUREA 500 MG CAPSULE IBUPROFEN IBUPROFEN 400 MG TABLET IBUPROFEN IBUPROFEN 600 MG TABLET IBUPROFEN IBUPROFEN 200 MG TABLET IBUPROFEN IBUPROFEN 200 MG CAPSULE IBUPROFEN IBUPROFEN 800 MG TABLET IMIPRAMINE HCL IMIPRAMINE HCL 10 MG TABLET IMIPRAMINE HCL IMIPRAMINE HCL 25 MG TABLET IMIPRAMINE HCL IMIPRAMINE HCL 50 MG TABLET INDAPAMIDE INDAPAMIDE 2.5 MG TABLET INDAPAMIDE INDAPAMIDE 1.25 MG TABLET INVOKAMET CANAGLIFLOZIN/METFORMIN HCL 50MG-500MG TABLET INVOKAMET CANAGLIFLOZIN/METFORMIN HCL MG TABLET INVOKAMET CANAGLIFLOZIN/METFORMIN HCL MG TABLET INVOKAMET CANAGLIFLOZIN/METFORMIN HCL MG TABLET INVOKANA CANAGLIFLOZIN 100 MG TABLET INVOKANA CANAGLIFLOZIN 300 MG TABLET 255_FormularyMaintenance_February2016 Page 12 of 26

13 IPRATROPIUM BROMIDE IPRATROPIUM BROMIDE 0.2 MG/ML SOLUTION IRBESARTAN IRBESARTAN 150 MG TABLET IRBESARTAN IRBESARTAN 75 MG TABLET IRBESARTAN IRBESARTAN 300 MG TABLET ISONIAZID ISONIAZID 100 MG TABLET ISONIAZID ISONIAZID 300 MG TABLET ISONIAZID ISONIAZID 50 MG/5 ML SOLUTION ISORDIL ISOSORBIDE DINITRATE 40 MG TABLET ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE 10 MG TABLET ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE 20 MG TABLET ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE 30 MG TABLET ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE 40 MG TABLET ER ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE 5 MG TABLET ISOSORBIDE MONONITRATE ISOSORBIDE MONONITRATE 30 MG TAB ER 24H ISOSORBIDE MONONITRATE ISOSORBIDE MONONITRATE 60 MG TAB ER 24H ISOSORBIDE MONONITRATE ISOSORBIDE MONONITRATE 120 MG TAB ER 24H ISOSORBIDE MONONITRATE ISOSORBIDE MONONITRATE 10 MG TABLET ISOSORBIDE MONONITRATE ISOSORBIDE MONONITRATE 20 MG TABLET JANUMET SITAGLIPTIN PHOSPHATE/METFORMIN HCL 50MG-500MG TABLET JANUMET SITAGLIPTIN PHOSPHATE/METFORMIN HCL MG TABLET JANUMET XR SITAGLIPTIN PHOSPHATE/METFORMIN HCL 50MG-500MG TBMP 24HR JANUMET XR SITAGLIPTIN PHOSPHATE/METFORMIN HCL MG TBMP 24HR JANUMET XR SITAGLIPTIN PHOSPHATE/METFORMIN HCL MG TBMP 24HR JANUVIA SITAGLIPTIN PHOSPHATE 50 MG TABLET JANUVIA SITAGLIPTIN PHOSPHATE 100 MG TABLET JANUVIA SITAGLIPTIN PHOSPHATE 25 MG TABLET JINTELI NORETHINDRONE ACETATE-ETHINYL ESTRADIOL 1MG-5MCG TABLET JUNEL FE NORETHINDRONE ACETATE-ETHINYL ESTRADIOL/FERROUS FUMARATE (21) TABLET JUNEL FE NORETHINDRONE ACETATE-ETHINYL ESTRADIOL/FERROUS FUMARATE 1MG-20(21) TABLET KETO-DIASTIX REAGENT URINE GLUC-ACET COMB.TST,STRIP STRIP LABETALOL HCL LABETALOL HCL 300 MG TABLET LABETALOL HCL LABETALOL HCL 100 MG TABLET LABETALOL HCL LABETALOL HCL 200 MG TABLET LACTULOSE LACTULOSE 10 G/15 ML SOLUTION LAMOTRIGINE LAMOTRIGINE 100 MG TABLET LAMOTRIGINE LAMOTRIGINE 150 MG TABLET 255_FormularyMaintenance_February2016 Page 13 of 26

14 LAMOTRIGINE LAMOTRIGINE 200 MG TABLET LAMOTRIGINE LAMOTRIGINE 25 MG TABLET LAMOTRIGINE LAMOTRIGINE 25 MG TB CHW DSP LAMOTRIGINE LAMOTRIGINE 5 MG TB CHW DSP LANSOPRAZOLE LANSOPRAZOLE 15 MG CAPSULE DR LANSOPRAZOLE LANSOPRAZOLE 30 MG CAPSULE DR LANTUS INSULIN GLARGINE,HUMAN RECOMBINANT ANALOG 100/ML VIAL LANTUS SOLOSTAR INSULIN GLARGINE,HUMAN RECOMBINANT ANALOG 100/ML (3) INSULN PEN LATANOPROST LATANOPROST % DROPS LEENA NORETHINDRONE-ETHINYL ESTRADIOL TABLET LEFLUNOMIDE LEFLUNOMIDE 10 MG TABLET LEFLUNOMIDE LEFLUNOMIDE 20 MG TABLET LEVALBUTEROL CONCENTRATE LEVALBUTEROL HCL 1.25MG/0.5 VIAL-NEB LEVALBUTEROL HCL LEVALBUTEROL HCL 1.25MG/3ML VIAL-NEB LEVALBUTEROL HCL LEVALBUTEROL HCL 0.31MG/3ML VIAL-NEB LEVALBUTEROL HCL LEVALBUTEROL HCL 0.63MG/3ML VIAL-NEB LEVETIRACETAM LEVETIRACETAM 100 MG/ML SOLUTION LEVETIRACETAM LEVETIRACETAM 1000 MG TABLET LEVETIRACETAM LEVETIRACETAM 250 MG TABLET LEVETIRACETAM LEVETIRACETAM 500 MG TABLET LEVETIRACETAM LEVETIRACETAM 750 MG TABLET LEVOBUNOLOL HCL LEVOBUNOLOL HCL 0.5 % DROPS LEVOCARNITINE LEVOCARNITINE 330 MG TABLET LEVONORG-ETH ESTRAD ETH ESTRAD LEVONORGESTREL/ETHINYL ESTRADIOL AND ETHINYL ESTRADIOL (84) TBDSPK 3MO LEVORA-28 LEVONORGESTREL-ETHINYL ESTRADIOL TABLET LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 25 MCG TABLET LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 100 MCG TABLET LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 88 MCG TABLET LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 75 MCG TABLET LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 50 MCG TABLET LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 300 MCG TABLET LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 175MCG TABLET 255_FormularyMaintenance_February2016 Page 14 of 26

15 LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 150 MCG TABLET LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 137 MCG TABLET LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 112 MCG TABLET LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 125 MCG TABLET LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 200 MCG TABLET LIOTHYRONINE SODIUM LIOTHYRONINE SODIUM 25 MCG TABLET LIOTHYRONINE SODIUM LIOTHYRONINE SODIUM 5 MCG TABLET LIOTHYRONINE SODIUM LIOTHYRONINE SODIUM 50 MCG TABLET LISINOPRIL LISINOPRIL 20 MG TABLET LISINOPRIL LISINOPRIL 5 MG TABLET LISINOPRIL LISINOPRIL 30 MG TABLET LISINOPRIL LISINOPRIL 2.5 MG TABLET LISINOPRIL LISINOPRIL 10 MG TABLET LISINOPRIL LISINOPRIL 40 MG TABLET LISINOPRIL-HCTZ LISINOPRIL/HYDROCHLOROTHIAZIDE MG TABLET LISINOPRIL-HCTZ LISINOPRIL/HYDROCHLOROTHIAZIDE 20-25MG TABLET LISINOPRIL- HYDROCHLOROTHIAZIDE LISINOPRIL/HYDROCHLOROTHIAZIDE MG TABLET LOPERAMIDE LOPERAMIDE HCL 2 MG CAPSULE LOPERAMIDE LOPERAMIDE HCL 2 MG TABLET LOSARTAN POTASSIUM LOSARTAN POTASSIUM 100 MG TABLET LOSARTAN POTASSIUM LOSARTAN POTASSIUM 25 MG TABLET LOSARTAN POTASSIUM LOSARTAN POTASSIUM 50 MG TABLET LOSARTAN- HYDROCHLOROTHIAZIDE LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE MG TABLET LOSARTAN- HYDROCHLOROTHIAZIDE LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE 100MG-25MG TABLET LOSARTAN- HYDROCHLOROTHIAZIDE LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE MG TABLET LOVASTATIN LOVASTATIN 20 MG TABLET LOVASTATIN LOVASTATIN 40 MG TABLET LOVASTATIN LOVASTATIN 10 MG TABLET LOW-OGESTREL NORGESTREL-ETHINYL ESTRADIOL MG TABLET MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE ACETATE 10 MG TABLET 255_FormularyMaintenance_February2016 Page 15 of 26

16 MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE ACETATE 150 MG/ML VIAL MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE ACETATE 2.5 MG TABLET MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE ACETATE 5 MG TABLET MEGESTROL ACETATE MEGESTROL ACETATE 800MG/20ML ORAL SUSP MELOXICAM MELOXICAM 15 MG TABLET MELOXICAM MELOXICAM 7.5 MG TABLET MENEST ESTROGENS,ESTERIFIED 1.25 MG TABLET MENEST ESTROGENS,ESTERIFIED 2.5 MG TABLET MENEST ESTROGENS,ESTERIFIED MG TABLET MENEST ESTROGENS,ESTERIFIED 0.3 MG TABLET MESTINON PYRIDOSTIGMINE BROMIDE 60 MG/5 ML SYRUP MESTINON PYRIDOSTIGMINE BROMIDE 180 MG TABLET ER METAPROTERENOL SULFATE METAPROTERENOL SULFATE 10 MG TABLET METAPROTERENOL SULFATE METAPROTERENOL SULFATE 10 MG/5 ML SYRUP METAPROTERENOL SULFATE METAPROTERENOL SULFATE 20 MG TABLET METFORMIN HCL METFORMIN HCL 1000 MG TABLET METFORMIN HCL METFORMIN HCL 500 MG TABLET METFORMIN HCL METFORMIN HCL 850 MG TABLET METFORMIN HCL ER METFORMIN HCL 500 MG TAB ER 24H METFORMIN HCL ER METFORMIN HCL 750 MG TAB ER 24H METHIMAZOLE METHIMAZOLE 10 MG TABLET METHIMAZOLE METHIMAZOLE 5 MG TABLET METHOTREXATE METHOTREXATE SODIUM 2.5 MG TABLET METHYLDOPA METHYLDOPA 250 MG TABLET METHYLDOPA METHYLDOPA 500 MG TABLET METHYLDOPA- HYDROCHLOROTHIAZIDE METHYLDOPA/HYDROCHLOROTHIAZIDE 250MG-15MG TABLET METHYLDOPA- HYDROCHLOROTHIAZIDE METHYLDOPA/HYDROCHLOROTHIAZIDE 250MG-25MG TABLET METHYLPHENIDATE ER METHYLPHENIDATE HCL 10 MG TABLET ER METHYLPHENIDATE ER METHYLPHENIDATE HCL 18 MG TAB ER 24 METHYLPHENIDATE ER METHYLPHENIDATE HCL 20 MG TABLET ER METHYLPHENIDATE ER METHYLPHENIDATE HCL 27 MG TAB ER 24 METHYLPHENIDATE ER METHYLPHENIDATE HCL 36 MG TAB ER 24 METHYLPHENIDATE ER METHYLPHENIDATE HCL 54 MG TAB ER 24 METHYLPHENIDATE HCL METHYLPHENIDATE HCL 10 MG TABLET 255_FormularyMaintenance_February2016 Page 16 of 26

17 METHYLPHENIDATE HCL METHYLPHENIDATE HCL 20 MG TABLET METHYLPHENIDATE HCL METHYLPHENIDATE HCL 5 MG TABLET METIPRANOLOL METIPRANOLOL 0.3 % DROPS METOPROLOL SUCCINATE METOPROLOL SUCCINATE 200 MG TAB ER 24H METOPROLOL SUCCINATE METOPROLOL SUCCINATE 25 MG TAB ER 24H METOPROLOL SUCCINATE METOPROLOL SUCCINATE 100 MG TAB ER 24H METOPROLOL SUCCINATE METOPROLOL SUCCINATE 50 MG TAB ER 24H METOPROLOL TARTRATE METOPROLOL TARTRATE 100 MG TABLET METOPROLOL TARTRATE METOPROLOL TARTRATE 25 MG TABLET METOPROLOL TARTRATE METOPROLOL TARTRATE 50 MG TABLET MEXILETINE HCL MEXILETINE HCL 150 MG CAPSULE MEXILETINE HCL MEXILETINE HCL 200 MG CAPSULE MEXILETINE HCL MEXILETINE HCL 250 MG CAPSULE MICROGESTIN NORETHINDRONE ACETATE-ETHINYL ESTRADIOL MG TABLET MICROGESTIN NORETHINDRONE ACETATE-ETHINYL ESTRADIOL 1MG-20MCG TABLET MINOXIDIL MINOXIDIL 2.5 MG TABLET MINOXIDIL MINOXIDIL 10 MG TABLET MIRTAZAPINE MIRTAZAPINE 45 MG TAB RAPDIS MIRTAZAPINE MIRTAZAPINE 7.5 MG TABLET MIRTAZAPINE MIRTAZAPINE 45 MG TABLET MIRTAZAPINE MIRTAZAPINE 30 MG TAB RAPDIS MIRTAZAPINE MIRTAZAPINE 15 MG TABLET MIRTAZAPINE MIRTAZAPINE 15 MG TAB RAPDIS MIRTAZAPINE MIRTAZAPINE 30 MG TABLET MISOPROSTOL MISOPROSTOL 100 MCG TABLET MISOPROSTOL MISOPROSTOL 200 MCG TABLET MONONESSA NORGESTIMATE-ETHINYL ESTRADIOL TABLET MONTELUKAST SODIUM MONTELUKAST SODIUM 10 MG TABLET MONTELUKAST SODIUM MONTELUKAST SODIUM 4 MG TAB CHEW MONTELUKAST SODIUM MONTELUKAST SODIUM 5 MG TAB CHEW MYCOPHENOLATE MOFETIL MYCOPHENOLATE MOFETIL 250 MG CAPSULE MYCOPHENOLATE MOFETIL MYCOPHENOLATE MOFETIL 500 MG TABLET NAPROXEN NAPROXEN 125 MG/5ML ORAL SUSP NAPROXEN NAPROXEN 500 MG TABLET NAPROXEN NAPROXEN 250 MG TABLET NAPROXEN NAPROXEN 375 MG TABLET 255_FormularyMaintenance_February2016 Page 17 of 26

18 NAPROXEN SODIUM NAPROXEN SODIUM 220 MG TABLET NAPROXEN SODIUM NAPROXEN SODIUM 275 MG TABLET NAPROXEN SODIUM NAPROXEN SODIUM 550 MG TABLET NECON NORETHINDRONE-ETHINYL ESTRADIOL TABLET NECON NORETHINDRONE-ETHINYL ESTRADIOL 1 MG-35MCG TABLET NECON NORETHINDRONE-ETHINYL ESTRADIOL TABLET NECON NORETHINDRONE-ETHINYL ESTRADIOL 7 DAYS X 3 TABLET NECON NORETHINDRONE-MESTRANOL 1 MG-50MCG TABLET NEFAZODONE HCL NEFAZODONE HCL 50 MG TABLET NEFAZODONE HCL NEFAZODONE HCL 250 MG TABLET NEFAZODONE HCL NEFAZODONE HCL 150 MG TABLET NEFAZODONE HCL NEFAZODONE HCL 100 MG TABLET NEFAZODONE HCL NEFAZODONE HCL 200 MG TABLET NEXIUM 24HR ESOMEPRAZOLE MAGNESIUM 22.3 MG CAPSULE DR NIACIN NIACIN 250 MG CAPSULE ER NIACIN NIACIN 500 MG CAPSULE ER NIACIN ER NIACIN 1000 MG TAB ER 24H NIACIN ER NIACIN 750 MG TAB ER 24H NIACOR NIACIN 500 MG TABLET NIFEDIPINE NIFEDIPINE 10 MG CAPSULE NIFEDIPINE NIFEDIPINE 20 MG CAPSULE NIFEDIPINE ER NIFEDIPINE 60 MG TABLET ER NIFEDIPINE ER NIFEDIPINE 90 MG TAB ER 24 NIFEDIPINE ER NIFEDIPINE 30 MG TABLET ER NIFEDIPINE ER NIFEDIPINE 30 MG TAB ER 24 NIFEDIPINE ER NIFEDIPINE 60 MG TAB ER 24 NIFEDIPINE ER NIFEDIPINE 90 MG TABLET ER NITRO-BID NITROGLYCERIN 2 % OINT. (G) NITROSTAT NITROGLYCERIN 0.3 MG TAB SUBL NITROSTAT NITROGLYCERIN 0.4 MG TAB SUBL NITROSTAT NITROGLYCERIN 0.6 MG TAB SUBL NORETHINDRONE NORETHINDRONE 0.35 MG TABLET NORTRIPTYLINE HCL NORTRIPTYLINE HCL 75 MG CAPSULE NORTRIPTYLINE HCL NORTRIPTYLINE HCL 50 MG CAPSULE NORTRIPTYLINE HCL NORTRIPTYLINE HCL 25 MG CAPSULE NORTRIPTYLINE HCL NORTRIPTYLINE HCL 10 MG CAPSULE NORTRIPTYLINE HCL NORTRIPTYLINE HCL 10 MG/5 ML SOLUTION NOVOLIN INSULIN NPH HUMAN ISOPHANE/INSULIN REGULAR, HUMAN 70-30/ML VIAL NOVOLIN N INSULIN NPH HUMAN ISOPHANE 100/ML VIAL NOVOLIN R INSULIN REGULAR, HUMAN 100/ML VIAL NOVOLOG INSULIN ASPART 100/ML CARTRIDGE NOVOLOG INSULIN ASPART 100/ML VIAL NOVOLOG FLEXPEN INSULIN ASPART 100/ML INSULN PEN 255_FormularyMaintenance_February2016 Page 18 of 26

19 NOVOLOG MIX INSULIN ASPART PROTAMINE HUMAN/INSULIN ASPART 70-30/ML INSULN PEN NOVOLOG MIX INSULIN ASPART PROTAMINE HUMAN/INSULIN ASPART 70-30/ML VIAL NUVARING ETONOGESTREL/ETHINYL ESTRADIOL MG VAG RING O-CAL FA PRENATAL VITAMINS WITH CALCIUM/FERROUS FUMARATE/FOLIC ACID 66-1MG TABLET OCELLA ETHINYL ESTRADIOL/DROSPIRENONE 0.03MG-3MG TABLET OGESTREL NORGESTREL-ETHINYL ESTRADIOL 0.5 MG-50 TABLET OMEPRAZOLE OMEPRAZOLE 40 MG CAPSULE DR OMEPRAZOLE OMEPRAZOLE 20 MG TABLET DR OMEPRAZOLE OMEPRAZOLE 10 MG CAPSULE DR OMEPRAZOLE OMEPRAZOLE 20 MG CAPSULE DR OXCARBAZEPINE OXCARBAZEPINE 600 MG TABLET OXCARBAZEPINE OXCARBAZEPINE 150 MG TABLET OXCARBAZEPINE OXCARBAZEPINE 300 MG TABLET OXCARBAZEPINE OXCARBAZEPINE 300 MG/5ML ORAL SUSP OXYBUTYNIN CHLORIDE OXYBUTYNIN CHLORIDE 5 MG TABLET OXYBUTYNIN CHLORIDE ER OXYBUTYNIN CHLORIDE 10 MG TAB ER 24 OXYBUTYNIN CHLORIDE ER OXYBUTYNIN CHLORIDE 15 MG TAB ER 24 OXYBUTYNIN CHLORIDE ER OXYBUTYNIN CHLORIDE 5 MG TAB ER 24 PANTOPRAZOLE SODIUM PANTOPRAZOLE SODIUM 20 MG TABLET DR PANTOPRAZOLE SODIUM PANTOPRAZOLE SODIUM 40 MG TABLET DR PAROXETINE HCL PAROXETINE HCL 20 MG TABLET PAROXETINE HCL PAROXETINE HCL 30 MG TABLET PAROXETINE HCL PAROXETINE HCL 10 MG TABLET PAROXETINE HCL PAROXETINE HCL 40 MG TABLET PENTOXIFYLLINE PENTOXIFYLLINE 400 MG TABLET ER PHENOBARBITAL PHENOBARBITAL 32.4 MG TABLET PHENOBARBITAL PHENOBARBITAL 64.8 MG TABLET PHENOBARBITAL PHENOBARBITAL 15 MG TABLET PHENOBARBITAL PHENOBARBITAL 60 MG TABLET PHENOBARBITAL PHENOBARBITAL 97.2MG TABLET PHENOBARBITAL PHENOBARBITAL 16.2 MG TABLET PHENOBARBITAL PHENOBARBITAL 100 MG TABLET PHENOBARBITAL PHENOBARBITAL 20 MG/5 ML ELIXIR PHENOBARBITAL PHENOBARBITAL 30 MG TABLET PHENYTOIN PHENYTOIN 125 MG/5ML ORAL SUSP PHENYTOIN PHENYTOIN 50 MG TAB CHEW PHENYTOIN SODIUM EXTENDED PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE 255_FormularyMaintenance_February2016 Page 19 of 26

20 PHOSPHOLINE IODIDE ECHOTHIOPHATE IODIDE % DROPS PILOCARPINE HCL PILOCARPINE HCL 1 % DROPS PILOCARPINE HCL PILOCARPINE HCL 2 % DROPS PILOCARPINE HCL PILOCARPINE HCL 4 % DROPS PIOGLITAZONE HCL PIOGLITAZONE HCL 30 MG TABLET PIOGLITAZONE HCL PIOGLITAZONE HCL 45 MG TABLET PIOGLITAZONE HCL PIOGLITAZONE HCL 15 MG TABLET PNV 29-1 PRENATAL VITS WITH CALCIUM #76/IRON,CARBONYL/FOLIC ACID 29 MG-1 MG TABLET POTASSIUM CHLORIDE POTASSIUM CHLORIDE 10 MEQ CAPSULE ER POTASSIUM CHLORIDE POTASSIUM CHLORIDE 10 MEQ TAB ER PRT POTASSIUM CHLORIDE POTASSIUM CHLORIDE 10 MEQ TABLET ER POTASSIUM CHLORIDE POTASSIUM CHLORIDE 20 MEQ TAB ER PRT POTASSIUM CHLORIDE POTASSIUM CHLORIDE 20MEQ/15ML LIQUID POTASSIUM CHLORIDE POTASSIUM CHLORIDE 40MEQ/15ML LIQUID POTASSIUM CHLORIDE POTASSIUM CHLORIDE 8 MEQ CAPSULE ER POTASSIUM CHLORIDE POTASSIUM CHLORIDE 8 MEQ TABLET ER PRAMIPEXOLE DIHYDROCHLORIDE PRAMIPEXOLE DI-HCL 0.75 MG TABLET PRAMIPEXOLE DIHYDROCHLORIDE PRAMIPEXOLE DI-HCL 1 MG TABLET PRAMIPEXOLE DIHYDROCHLORIDE PRAMIPEXOLE DI-HCL 1.5 MG TABLET PRAMIPEXOLE DIHYDROCHLORIDE PRAMIPEXOLE DI-HCL MG TABLET PRAMIPEXOLE DIHYDROCHLORIDE PRAMIPEXOLE DI-HCL 0.25 MG TABLET PRAMIPEXOLE DIHYDROCHLORIDE PRAMIPEXOLE DI-HCL 0.5 MG TABLET PRAVASTATIN SODIUM PRAVASTATIN SODIUM 10 MG TABLET PRAVASTATIN SODIUM PRAVASTATIN SODIUM 20 MG TABLET PRAVASTATIN SODIUM PRAVASTATIN SODIUM 40 MG TABLET PRAVASTATIN SODIUM PRAVASTATIN SODIUM 80 MG TABLET PRAZOSIN HCL PRAZOSIN HCL 1 MG CAPSULE PRAZOSIN HCL PRAZOSIN HCL 2 MG CAPSULE PRAZOSIN HCL PRAZOSIN HCL 5 MG CAPSULE PREMARIN ESTROGENS, CONJUGATED MG/G CREAM (G) PREMARIN ESTROGENS, CONJUGATED 0.9 MG TABLET PREMARIN ESTROGENS, CONJUGATED 1.25 MG TABLET PREMARIN ESTROGENS, CONJUGATED 0.45MG TABLET PREMARIN ESTROGENS, CONJUGATED 0.3 MG TABLET PREMARIN ESTROGENS, CONJUGATED MG TABLET 255_FormularyMaintenance_February2016 Page 20 of 26

21 PREMPHASE PREMPRO PREMPRO PREMPRO ESTROGENS, CONJUGATED/MEDROXYPROGESTERONE ACETATE (14) TABLET ESTROGENS, CONJUGATED/MEDROXYPROGESTERONE ACETATE TABLET ESTROGENS, CONJUGATED/MEDROXYPROGESTERONE ACETATE MG TABLET ESTROGENS, CONJUGATED/MEDROXYPROGESTERONE ACETATE MG TABLET PREMPRO ESTROGENS, CONJUGATED/MEDROXYPROGESTERONE ACETATE MG TABLET PRENATAL PRENATAL VITS WITH CALCIUM #96/FERROUS FUMARATE/FOLIC ACID 27MG-0.8MG TABLET PRENATAL LOW IRON PRENATAL VITS WITH CALCIUM #74/FERROUS FUMARATE/FOLIC ACID 27 MG-1 MG TABLET PRENATAL PLUS PRENATAL VITS WITH CALCIUM #72/FERROUS FUMARATE/FOLIC ACID 27 MG-1 MG TABLET PRENATAL VITAMINS PRENATAL VIT W-CA,FE,FA(<1 MG) TABLET PRENATAL VITAMINS PRENATAL VITAMINS WITH CALCIUM/FERROUS FUMARATE/FOLIC ACID 27MG-0.8MG TABLET PRENATAL VITAMINS PRENATAL VITAMINS WITH CALCIUM/FERROUS FUMARATE/FOLIC ACID 28MG-0.8MG TABLET PRETAB PRENATAL VITS WITH CALCIUM #78/FERROUS FUMARATE/FOLIC ACID 29 MG-1 MG TABLET PREVACID 24HR LANSOPRAZOLE 15 MG CAPSULE DR PRILOSEC OTC OMEPRAZOLE MAGNESIUM 20 MG TABLET DR PRIMAQUINE PRIMAQUINE PHOSPHATE 26.3 MG TABLET PRIMIDONE PRIMIDONE 250 MG TABLET PRIMIDONE PRIMIDONE 50 MG TABLET PROBENECID PROBENECID 500 MG TABLET PROPAFENONE HCL PROPAFENONE HCL 225 MG TABLET PROPAFENONE HCL PROPAFENONE HCL 300 MG TABLET PROPAFENONE HCL PROPAFENONE HCL 150 MG TABLET PROPAFENONE HCL ER PROPAFENONE HCL 325 MG CAP ER 12H PROPAFENONE HCL ER PROPAFENONE HCL 425 MG CAP ER 12H PROPAFENONE HCL ER PROPAFENONE HCL 225 MG CAP ER 12H PROPRANOLOL HCL PROPRANOLOL HCL 120 MG CAP SA 24H PROPRANOLOL HCL PROPRANOLOL HCL 40MG/5ML SOLUTION PROPRANOLOL HCL PROPRANOLOL HCL 60 MG TABLET PROPRANOLOL HCL PROPRANOLOL HCL 60 MG CAP SA 24H PROPRANOLOL HCL PROPRANOLOL HCL 80 MG TABLET 255_FormularyMaintenance_February2016 Page 21 of 26

22 PROPRANOLOL HCL PROPRANOLOL HCL 40 MG TABLET PROPRANOLOL HCL PROPRANOLOL HCL 20 MG/5 ML SOLUTION PROPRANOLOL HCL PROPRANOLOL HCL 160 MG CAP SA 24H PROPRANOLOL HCL PROPRANOLOL HCL 10 MG TABLET PROPRANOLOL HCL PROPRANOLOL HCL 20 MG TABLET PROPRANOLOL HCL ER PROPRANOLOL HCL 80 MG CAP SA 24H PROPYLTHIOURACIL PROPYLTHIOURACIL 50 MG TABLET PULMICORT FLEXHALER BUDESONIDE 180 MCG AER POW BA PULMICORT FLEXHALER BUDESONIDE 90 MCG AER POW BA PYRAZINAMIDE PYRAZINAMIDE 500 MG TABLET PYRIDOSTIGMINE BROMIDE PYRIDOSTIGMINE BROMIDE 60 MG TABLET QUASENSE LEVONORGESTREL-ETHINYL ESTRADIOL TBDSPK 3MO QUINIDINE GLUCONATE QUINIDINE GLUCONATE 324 MG TABLET ER QVAR BECLOMETHASONE DIPROPIONATE 80 MCG AER W/ADAP QVAR BECLOMETHASONE DIPROPIONATE 40 MCG AER W/ADAP RABEPRAZOLE SODIUM RABEPRAZOLE SODIUM 20 MG TABLET DR RANITIDINE HCL RANITIDINE HCL 15 MG/ML SYRUP RANITIDINE HCL RANITIDINE HCL 150 MG TABLET RANITIDINE HCL RANITIDINE HCL 300 MG TABLET RANITIDINE HCL RANITIDINE HCL 75 MG TABLET RENAGEL SEVELAMER HCL 400 MG TABLET RENAGEL SEVELAMER HCL 800 MG TABLET RENVELA SEVELAMER CARBONATE 800 MG TABLET RHEUMATREX METHOTREXATE SODIUM 2.5 MG TAB DS PK RIDAURA AURANOFIN 3 MG CAPSULE RIVASTIGMINE RIVASTIGMINE TARTRATE 1.5 MG CAPSULE RIVASTIGMINE RIVASTIGMINE TARTRATE 6 MG CAPSULE RIVASTIGMINE RIVASTIGMINE TARTRATE 3 MG CAPSULE RIVASTIGMINE RIVASTIGMINE TARTRATE 4.5 MG CAPSULE ROPINIROLE HCL ROPINIROLE HCL 0.25 MG TABLET ROPINIROLE HCL ROPINIROLE HCL 0.5 MG TABLET ROPINIROLE HCL ROPINIROLE HCL 1 MG TABLET ROPINIROLE HCL ROPINIROLE HCL 2 MG TABLET ROPINIROLE HCL ROPINIROLE HCL 3 MG TABLET ROPINIROLE HCL ROPINIROLE HCL 4 MG TABLET ROPINIROLE HCL ROPINIROLE HCL 5 MG TABLET SELEGILINE HCL SELEGILINE HCL 5 MG CAPSULE SELEGILINE HCL SELEGILINE HCL 5 MG TABLET SEREVENT DISKUS SALMETEROL XINAFOATE 50 MCG BLST W/DEV SERTRALINE HCL SERTRALINE HCL 100 MG TABLET SERTRALINE HCL SERTRALINE HCL 50 MG TABLET SERTRALINE HCL SERTRALINE HCL 25 MG TABLET SERTRALINE HCL SERTRALINE HCL 20 MG/ML ORAL CONC 255_FormularyMaintenance_February2016 Page 22 of 26

23 SF 5000 PLUS SODIUM FLUORIDE 1.1 % CREAM (G) SIMVASTATIN SIMVASTATIN 10 MG TABLET SIMVASTATIN SIMVASTATIN 20 MG TABLET SIMVASTATIN SIMVASTATIN 40 MG TABLET SIMVASTATIN SIMVASTATIN 5 MG TABLET SIMVASTATIN SIMVASTATIN 80 MG TABLET SODIUM CHLORIDE SODIUM CHLORIDE 5 % DROPS SODIUM CHLORIDE SODIUM CHLORIDE 5 % OINT. (G) SODIUM FLUORIDE SODIUM FLUORIDE 0.5 MG/ML DROPS SOTALOL SOTALOL HCL 240 MG TABLET SOTALOL SOTALOL HCL 80 MG TABLET SOTALOL SOTALOL HCL 160 MG TABLET SOTALOL SOTALOL HCL 120 MG TABLET SPIRONOLACTONE SPIRONOLACTONE 25 MG TABLET SPIRONOLACTONE SPIRONOLACTONE 50 MG TABLET SPIRONOLACTONE SPIRONOLACTONE 100 MG TABLET SPIRONOLACTONE-HCTZ SPIRONOLACTONE/HYDROCHLOROTHIAZIDE 25 MG-25MG TABLET SRONYX LEVONORGESTREL-ETHINYL ESTRADIOL TABLET STRATTERA ATOMOXETINE HCL 10 MG CAPSULE STRATTERA ATOMOXETINE HCL 100 MG CAPSULE STRATTERA ATOMOXETINE HCL 18 MG CAPSULE STRATTERA ATOMOXETINE HCL 25 MG CAPSULE STRATTERA ATOMOXETINE HCL 40 MG CAPSULE STRATTERA ATOMOXETINE HCL 60 MG CAPSULE STRATTERA ATOMOXETINE HCL 80 MG CAPSULE SUCRALFATE SUCRALFATE 1 G TABLET SULFASALAZINE SULFASALAZINE 500 MG TABLET SULFASALAZINE DR SULFASALAZINE 500 MG TABLET DR TAMOXIFEN CITRATE TAMOXIFEN CITRATE 10 MG TABLET TAMOXIFEN CITRATE TAMOXIFEN CITRATE 20 MG TABLET TAMSULOSIN HCL TAMSULOSIN HCL 0.4 MG CAP ER 24H TAZTIA XT DILTIAZEM HCL 120 MG CAPSULE ER TAZTIA XT DILTIAZEM HCL 180 MG CAPSULE ER TAZTIA XT DILTIAZEM HCL 240 MG CAPSULE ER TAZTIA XT DILTIAZEM HCL 300 MG CAPSULE ER TEGRETOL XR CARBAMAZEPINE 100 MG TAB ER 12H TERAZOSIN HCL TERAZOSIN HCL 5 MG CAPSULE TERAZOSIN HCL TERAZOSIN HCL 1 MG CAPSULE TERAZOSIN HCL TERAZOSIN HCL 10 MG CAPSULE TERAZOSIN HCL TERAZOSIN HCL 2 MG CAPSULE TERBUTALINE SULFATE TERBUTALINE SULFATE 2.5 MG TABLET TERBUTALINE SULFATE TERBUTALINE SULFATE 5 MG TABLET THEO-24 THEOPHYLLINE ANHYDROUS 100 MG CAP ER 24H THEO-24 THEOPHYLLINE ANHYDROUS 200 MG CAP ER 24H 255_FormularyMaintenance_February2016 Page 23 of 26

24 THEO-24 THEOPHYLLINE ANHYDROUS 300 MG CAP ER 24H THEO-24 THEOPHYLLINE ANHYDROUS 400 MG CAP ER 24H THEOPHYLLINE THEOPHYLLINE ANHYDROUS 400 MG TABLET ER THEOPHYLLINE THEOPHYLLINE ANHYDROUS 80 MG/15ML SOLUTION THEOPHYLLINE ANHYDROUS THEOPHYLLINE ANHYDROUS 100 MG TAB ER 12H THEOPHYLLINE ANHYDROUS THEOPHYLLINE ANHYDROUS 200 MG TAB ER 12H THEOPHYLLINE ANHYDROUS THEOPHYLLINE ANHYDROUS 300 MG TAB ER 12H THEOPHYLLINE ANHYDROUS THEOPHYLLINE ANHYDROUS 450 MG TAB ER 12H TILIA FE NORETHINDRONE ACETATE-ETHINYL ESTRADIOL/FERROUS FUMARATE TABLET TIMOLOL MALEATE TIMOLOL MALEATE 0.25 % DROPS TIMOLOL MALEATE TIMOLOL MALEATE 0.5 % SOL-GEL TIMOLOL MALEATE TIMOLOL MALEATE 0.5 % DROPS TIMOLOL MALEATE TIMOLOL MALEATE 0.25 % SOL-GEL TIZANIDINE HCL TIZANIDINE HCL 2 MG TABLET TIZANIDINE HCL TIZANIDINE HCL 4 MG TABLET TOLTERODINE TARTRATE TOLTERODINE TARTRATE 1 MG TABLET TOLTERODINE TARTRATE TOLTERODINE TARTRATE 2 MG TABLET TOLTERODINE TARTRATE ER TOLTERODINE TARTRATE 2 MG CAP ER 24H TOLTERODINE TARTRATE ER TOLTERODINE TARTRATE 4 MG CAP ER 24H TOPIRAMATE TOPIRAMATE 50 MG TABLET TOPIRAMATE TOPIRAMATE 100 MG TABLET TOPIRAMATE TOPIRAMATE 15 MG CAP SPRINK TOPIRAMATE TOPIRAMATE 200 MG TABLET TOPIRAMATE TOPIRAMATE 25 MG CAP SPRINK TOPIRAMATE TOPIRAMATE 25 MG TABLET TRAVATAN Z TRAVOPROST % DROPS TRAVOPROST TRAVOPROST (BENZALKONIUM) % DROPS TRAZODONE HCL TRAZODONE HCL 100 MG TABLET TRAZODONE HCL TRAZODONE HCL 150 MG TABLET TRAZODONE HCL TRAZODONE HCL 300 MG TABLET TRAZODONE HCL TRAZODONE HCL 50 MG TABLET TRIAMTERENE-HCTZ TRIAMTERENE/HYDROCHLOROTHIAZIDE 75 MG-50MG TABLET TRIAMTERENE- HYDROCHLOROTHIAZID TRIAMTERENE/HYDROCHLOROTHIAZIDE MG CAPSULE TRIAMTERENE- HYDROCHLOROTHIAZID TRIAMTERENE/HYDROCHLOROTHIAZIDE MG TABLET TRINESSA NORGESTIMATE-ETHINYL ESTRADIOL 7DAYSX3 28 TABLET 255_FormularyMaintenance_February2016 Page 24 of 26

25 TRIVORA-28 LEVONORGESTREL-ETHINYL ESTRADIOL TABLET TROPICAMIDE TROPICAMIDE 0.5 % DROPS TROPICAMIDE TROPICAMIDE 1 % DROPS TUDORZA PRESSAIR ACLIDINIUM BROMIDE 400 MCG AER POW BA URSODIOL URSODIOL 250 MG TABLET URSODIOL URSODIOL 300 MG CAPSULE VALACYCLOVIR VALACYCLOVIR HCL 1000 MG TABLET VALACYCLOVIR VALACYCLOVIR HCL 500 MG TABLET VALPROIC ACID VALPROIC ACID 250 MG CAPSULE VALPROIC ACID VALPROIC ACID (AS SODIUM SALT) (VALPROATE SODIUM) 250 MG/5ML SOLUTION VALSARTAN VALSARTAN 320 MG TABLET VALSARTAN VALSARTAN 40 MG TABLET VALSARTAN VALSARTAN 160 MG TABLET VALSARTAN VALSARTAN 80 MG TABLET VALSARTAN- HYDROCHLOROTHIAZIDE VALSARTAN/HYDROCHLOROTHIAZIDE MG TABLET VALSARTAN- HYDROCHLOROTHIAZIDE VALSARTAN/HYDROCHLOROTHIAZIDE MG TABLET VALSARTAN- HYDROCHLOROTHIAZIDE VALSARTAN/HYDROCHLOROTHIAZIDE MG TABLET VALSARTAN- HYDROCHLOROTHIAZIDE VALSARTAN/HYDROCHLOROTHIAZIDE MG TABLET VALSARTAN- HYDROCHLOROTHIAZIDE VALSARTAN/HYDROCHLOROTHIAZIDE 320MG-25MG TABLET VENLAFAXINE HCL VENLAFAXINE HCL 75 MG TABLET VENLAFAXINE HCL VENLAFAXINE HCL 50 MG TABLET VENLAFAXINE HCL VENLAFAXINE HCL 37.5 MG TABLET VENLAFAXINE HCL VENLAFAXINE HCL 100 MG TABLET VENLAFAXINE HCL VENLAFAXINE HCL 25 MG TABLET VENLAFAXINE HCL ER VENLAFAXINE HCL 150 MG CAP ER 24H VENLAFAXINE HCL ER VENLAFAXINE HCL 150 MG TAB ER 24 VENLAFAXINE HCL ER VENLAFAXINE HCL 225 MG TAB ER 24 VENLAFAXINE HCL ER VENLAFAXINE HCL 37.5 MG CAP ER 24H VENLAFAXINE HCL ER VENLAFAXINE HCL 37.5 MG TAB ER 24 VENLAFAXINE HCL ER VENLAFAXINE HCL 75 MG CAP ER 24H VENLAFAXINE HCL ER VENLAFAXINE HCL 75 MG TAB ER 24 VENTOLIN HFA ALBUTEROL SULFATE 90 MCG HFA AER AD VERAPAMIL ER VERAPAMIL HCL 240 MG CAP24H PEL 255_FormularyMaintenance_February2016 Page 25 of 26

26 VERAPAMIL ER PM VERAPAMIL HCL 300 MG CAP24H PCT VERAPAMIL ER PM VERAPAMIL HCL 100 MG CAP24H PCT VERAPAMIL ER PM VERAPAMIL HCL 200 MG CAP24H PCT VERAPAMIL HCL VERAPAMIL HCL 240 MG TABLET ER VERAPAMIL HCL VERAPAMIL HCL 40 MG TABLET VERAPAMIL HCL VERAPAMIL HCL 180 MG TABLET ER VERAPAMIL HCL VERAPAMIL HCL 180 MG CAP24H PEL VERAPAMIL HCL VERAPAMIL HCL 120 MG TABLET ER VERAPAMIL HCL VERAPAMIL HCL 120 MG TABLET VERAPAMIL HCL VERAPAMIL HCL 120 MG CAP24H PEL VERAPAMIL HCL VERAPAMIL HCL 80 MG TABLET VOLTAREN DICLOFENAC SODIUM 1 % GEL (GRAM) WARFARIN SODIUM WARFARIN SODIUM 2 MG TABLET WARFARIN SODIUM WARFARIN SODIUM 6 MG TABLET WARFARIN SODIUM WARFARIN SODIUM 5 MG TABLET WARFARIN SODIUM WARFARIN SODIUM 7.5 MG TABLET WARFARIN SODIUM WARFARIN SODIUM 4 MG TABLET WARFARIN SODIUM WARFARIN SODIUM 2.5 MG TABLET WARFARIN SODIUM WARFARIN SODIUM 10 MG TABLET WARFARIN SODIUM WARFARIN SODIUM 1 MG TABLET WARFARIN SODIUM WARFARIN SODIUM 3 MG TABLET XARELTO RIVAROXABAN 15 MG TABLET XARELTO RIVAROXABAN 20 MG TABLET ZENCHENT FE NORETHINDRONE-ETHINYL ESTRADIOL/FERROUS FUMARATE (21) TAB CHEW ZONISAMIDE ZONISAMIDE 100 MG CAPSULE ZONISAMIDE ZONISAMIDE 25 MG CAPSULE ZONISAMIDE ZONISAMIDE 50 MG CAPSULE ZOVIA 1-35E ETHYNODIOL DIACETATE-ETHINYL ESTRADIOL 1 MG-35MCG TABLET ZOVIA 1-50E ETHYNODIOL DIACETATE-ETHINYL ESTRADIOL 1 MG-50MCG TABLET 255_FormularyMaintenance_February2016 Page 26 of 26