Formulary (List of Drugs)

Transcription

1 PLEASE READ: This document contains information about the drugs we cover in this plan. This formulary is up-to-date through its publication date, February 1, Formulary (List of Drugs) Effective February 2018 IL_BCCHP _RX_FORMULARY18

2 WHEN YOU NEED TO CONTACT MEMBER SERVICES Our goal is to serve your health care needs through all of life s changes. If you have any questions, our team stands ready to help. Call (TTY/TDD: 711) We are open 24 hours a day, seven (7) days a week. The call is free. Website Write Blue Cross Community Health Plans c/o Member Services P.O. Box 3418 Scranton, PA

3 What is the Blue Cross Community Health Plans (the Plan ) drug list? The drug list (sometimes called a formulary) is a list showing the drugs that can be covered by the plan. The drugs listed will be covered as long as you: Have a medical need for them Fill the medication s at an in-network pharmacy Follow the other plan rules For more information on how to fill your medication s, please review your Member Handbook. What will I pay? You do not pay for covered drugs. Can the drug list change? Yes, it can change. Coverage may change if: A new, less expensive generic drug becomes available New information about a drug shows it to be unsafe or less effective You will be told in writing when the drug list does change. How do I the drug list? There are two ways to find your drug in the list beginning on page Category The list of covered drugs that begins on page 1 gives you information about the drugs covered by Blue Cross Community Health Plans. If you have trouble finding your drug in the list, turn to the Index that begins at the back of this book. The first column of the chart has the name of the drug. Brand name drugs are capitalized (e.g., CIPRO) and generic drugs are listed in lower-case italics (e.g. ciprofloxacin). - The information in the column tells you if Blue Cross Community Health Plans has any rules for covering your drug. The drugs are listed in categories, or groups, based on the type of medical conditions they treat. (For example, drugs d to treat a heart condition are listed under Cardiovascular Agents). If you know what your drug is d for, look for the group in the drug list. Then, look under that group for your drug. 2. Alphabetical Listing Look for your drug in the at the back of this book. Next to your drug, you will see the page number where you can find coverage information. i

4 What are generic drugs? A generic drug is approved by the Food and Drug Administration (FDA) as having the same active ingredient as the brand name drug, but often costs less. The plan covers both brand name drugs and generic drugs. Are there any limits on my coverage? Added conditions or limits on some covered drugs may include: Prior Authorization: You or your doctor may need to get approval before you fill your medication s. If you do not get approval, the plan may not cover the drug. Quantity Limits: For certain drugs, the plan limits the amount that will be covered. Step Therapy: In some cases, the plan requires you to first try certain drugs before another drug can be covered. For example, if Drug A and Drug B both treat your medical condition, the plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, the plan will then cover Drug B. You can find out if your drug has any added conditions or limits by looking at the list that begins on page 1. You will find our contact information below, and the date we last updated the list, on the front and back cover pages. Does the plan pay for over-the-counter (OTC) drugs? Yes, the plan pays for certain OTC drugs with a valid medication from your doctor, and you may get those at no cost. Generic products are to be prescribed and given out when available. These products are to be filled at a plan network pharmacy and for quantities up to a 30-day supply. What if my drug is not on the drug list? Contact Member Services and ask if your drug is covered. If you learn that the plan does not cover your drug, you have two options: Talk to your doctor to decide if you should first try a different drug on our list before you request an exception. Ask Member Services about making an exception to cover your drug. Send in a statement from your doctor backing your request. We must decide within 24 hours of getting your doctor s statement. We usually only approve requests for exceptions if the other drugs included on our list or the added limits would make your treatment less effective and/or would be harmful to your health. Which drug categories are not covered by the plan drug list? The following drug categories are not covered by your plan: ii Anorexia, weight loss, or weight gain drugs Bulk chemicals Cosmetic enhancing drugs Diagnostic agents Drug Efficacy Study Implementation (DESI) that are classified as ineffective Experimental and investigational drugs Erectile dysfunction drugs prescribed to treat impotence Fertility drugs General anesthetic drugs Over-the-counter products not otherwise included on the plan s drug list Surgical supply/medical devices Medications considered unreasonable, unnecessary, and/or excessive according to the standards of Medicaid, clinical practice guidelines, and FDA labeling.

5 For More Information For more details about your plan s drug coverage, please review your Member Handbook and other plan materials. If you have any questions, please call Member Services at: (TTY/TDD 711). We are available 24 hours a day, seven (7) days a week.the call is free. For Language Assistance Interpreter Services We can arrange for someone to help you speak with us in any language. These services are free. If your doctor does not speak your language, we can arrange for a translator to help you. Please call Member Services at the number above. Hearing and Vision Problems For our members with hearing problems, we offer TTY/TDD service free of charge. The line is open 24 hours a day/seven day a week at 711. Other Languages and Formats You can get this document in Spanish, or speak with someone about this information in other languages for free. Call (TTY/TDD: 711). The call is free. You can also call Member Services, toll-free, to request this information in other alternative formats such as Braille, large print and other forms. Call Toll Free: (TTY/TDD: 711). We are available 24 hours a day, seven (7) days a week. The call is free. iii

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7 ANTI-INFECTIVE DRUGS PENICILLINS AMOXICILLIN amoxicillin (trihydrate) chew tab 125 mg $0 (2) AMOXICILLIN amoxicillin (trihydrate) chew tab 250 mg $0 (2) amoxicillin (trihydrate) cap 250 mg $0 (1) amoxicillin (trihydrate) cap 500 mg $0 (1) amoxicillin (trihydrate) for susp 125 mg/5ml $0 (1) amoxicillin (trihydrate) for susp 200 mg/5ml $0 (1) amoxicillin (trihydrate) for susp 250 mg/5ml $0 (1) amoxicillin (trihydrate) for susp 400 mg/5ml $0 (1) amoxicillin (trihydrate) tab 875 mg $0 (1) amoxicillin & k clavulanate for susp mg/5ml $0 (1) amoxicillin & k clavulanate for susp mg/5ml $0 (1) (Augmentin) amoxicillin & k clavulanate for susp mg/5ml $0 (1) amoxicillin & k clavulanate for susp mg/5ml (Augmentin $0 (1) es-600) amoxicillin & k clavulanate tab mg $0 (1) amoxicillin & k clavulanate tab mg (Augmentin) $0 (1) amoxicillin & k clavulanate tab mg (Augmentin) $0 (1) AMPICILLIN ampicillin cap 500 mg $0 (2) dicloxacillin sodium cap 250 mg $0 (1) dicloxacillin sodium cap 500 mg $0 (1) PENICILLIN V POTASSIUM penicillin v potassium for soln $0 (2) 125 mg/5ml PENICILLIN V POTASSIUM penicillin v potassium for soln $0 (2) 250 mg/5ml penicillin v potassium tab 250 mg $0 (1) penicillin v potassium tab 500 mg $0 (1) CEPHALOSPORINS cefaclor cap 250 mg $0 (1) cefaclor cap 500 mg $0 (1) cefadroxil cap 500 mg $0 (1) cefadroxil for susp 250 mg/5ml $0 (1) cefadroxil for susp 500 mg/5ml $0 (1) cefadroxil tab 1 gm $0 (1) 1

8 cefdinir cap 300 mg $0 (1) cefdinir for susp 125 mg/5ml $0 (1) cefdinir for susp 250 mg/5ml $0 (1) cefprozil for susp 125 mg/5ml $0 (1) cefprozil for susp 250 mg/5ml $0 (1) cefprozil tab 250 mg $0 (1) cefprozil tab 500 mg $0 (1) ceftriaxone sodium for inj 250 mg $0 (1) ceftriaxone sodium for inj 500 mg $0 (1) ceftriaxone sodium for inj 1 gm $0 (1) ceftriaxone sodium for inj 2 gm $0 (1) cefuroxime axetil tab 250 mg $0 (1) cefuroxime axetil tab 500 mg $0 (1) cephalexin cap 250 mg (Keflex) $0 (1) cephalexin cap 500 mg (Keflex) $0 (1) cephalexin for susp 125 mg/5ml $0 (1) cephalexin for susp 250 mg/5ml $0 (1) MACROLIDES azithromycin for susp 100 mg/5ml (Zithromax) $0 (1) azithromycin for susp 200 mg/5ml (Zithromax) $0 (1) azithromycin tab 250 mg (Zithromax) $0 (1) QL (60 tablets/180 days) azithromycin tab 500 mg (Zithromax) $0 (1) QL (60 tablets/180 days) azithromycin tab 600 mg (Zithromax) $0 (1) QL (60 tablets/180 days) CLARITHROMYCIN clarithromycin for susp 125 mg/5ml $0 (2) CLARITHROMYCIN clarithromycin for susp 250 mg/5ml $0 (2) clarithromycin tab 250 mg $0 (1) clarithromycin tab 500 mg (Biaxin) $0 (1) TETRACYCLINES demeclocycline hcl tab 150 mg $0 (1) doxycycline hyclate cap 50 mg $0 (1) doxycycline hyclate cap 100 mg (Vibramycin) $0 (1) doxycycline hyclate tab 20 mg $0 (1) doxycycline hyclate tab 100 mg $0 (1) doxycycline monohydrate cap 50 mg $0 (1) doxycycline monohydrate cap 100 mg (Monodox) $0 (1) 2

9 doxycycline monohydrate for susp 25 mg/5ml (Vibramycin) $0 (1) doxycycline monohydrate tab 50 mg $0 (1) doxycycline monohydrate tab 75 mg $0 (1) doxycycline monohydrate tab 100 mg $0 (1) minocycline hcl cap 50 mg (Minocin) $0 (1) minocycline hcl cap 75 mg $0 (1) minocycline hcl cap 100 mg (Minocin) $0 (1) minocycline hcl tab 50 mg $0 (1) minocycline hcl tab 75 mg $0 (1) minocycline hcl tab 100 mg $0 (1) FLUOROQUINOLONES ciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml) (Cipro) $0 (1) ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml) $0 (1) (Cipro) ciprofloxacin hcl tab 250 mg (base equiv) (Cipro) $0 (1) ciprofloxacin hcl tab 500 mg (base equiv) (Cipro) $0 (1) ciprofloxacin hcl tab 750 mg (base equiv) $0 (1) LEVOFLOXACIN levofloxacin oral soln 25 mg/ml $0 (2) levofloxacin tab 250 mg (Levaquin) $0 (1) levofloxacin tab 500 mg (Levaquin) $0 (1) levofloxacin tab 750 mg (Levaquin) $0 (1) SULFADIAZINE sulfadiazine tab 500 mg $0 (2) AMINOGLYCOSIDES neomycin sulfate tab 500 mg $0 (1) paromomycin sulfate cap 250 mg $0 (1) tobramycin nebu soln 300 mg/5ml (Tobi) $0 (1) QL (56 ampules/56 days), SP TUBERCULOSIS ethambutol hcl tab 100 mg (Myambutol) $0 (1) ethambutol hcl tab 400 mg (Myambutol) $0 (1) isoniazid tab 100 mg $0 (1) 90 isoniazid tab 300 mg $0 (1) 90 PRIFTIN rifapentine tab 150 mg $0 (2) pyrazinamide tab 500 mg $0 (1) rifabutin cap 150 mg (Mycobutin) $0 (1) rifampin cap 150 mg (Rifadin) $0 (1) 3

10 rifampin cap 300 mg $0 (1) FUNGAL INFECTIONS fluconazole for susp 10 mg/ml (Diflucan) $0 (1) fluconazole for susp 40 mg/ml (Diflucan) $0 (1) fluconazole tab 50 mg (Diflucan) $0 (1) fluconazole tab 100 mg (Diflucan) $0 (1) fluconazole tab 150 mg (Diflucan) $0 (1) fluconazole tab 200 mg (Diflucan) $0 (1) flucytosine cap 250 mg (Ancobon) $0 (1) flucytosine cap 500 mg (Ancobon) $0 (1) griseofulvin microsize susp 125 mg/5ml $0 (1) griseofulvin microsize tab 500 mg $0 (1) griseofulvin ultramicrosize tab 125 mg (Gris-peg) $0 (1) griseofulvin ultramicrosize tab 250 mg (Gris-peg) $0 (1) itraconazole cap 100 mg (Sporanox) $0 (1) QL (120 capsules/30 days) ketoconazole tab 200 mg $0 (1) NOXAFIL posaconazole tab delayed release 100 mg $0 (2) PA, 90 NOXAFIL posaconazole susp 40 mg/ml $0 (2) PA, 90 nystatin tab unit $0 (1) terbinafine hcl tab 250 mg (Lamisil) $0 (1) QL (90 tablets/365 days) voriconazole for susp 40 mg/ml (Vfend) $0 (1) PA voriconazole tab 50 mg (Vfend) $0 (1) PA voriconazole tab 200 mg (Vfend) $0 (1) PA 4 VIRAL INFECTIONS Cytomegalovirus valganciclovir hcl tab 450 mg (base equivalent) (Valcyte) $0 (1) 90 Hepatitis BARACLUDE entecavir oral soln 0.05 mg/ml $0 (2) 90 entecavir tab 0.5 mg (Baraclude) $0 (1) 90 entecavir tab 1 mg (Baraclude) $0 (1) 90 EPCLUSA sofosbuvir-velpatasvir tab mg $0 (2) PA, SP lamivudine tab 100 mg (hbv) (Epivir hbv) $0 (1) 90 MAVYRET glecaprevir-pibrentasvir tab mg $0 (2) PA, SP ribavirin cap 200 mg (Rebetol) $0 (1) SP SOVALDI sofosbuvir tab 400 mg $0 (2) PA, SP

11 ZEPATIER elbasvir-grazoprevir tab mg $0 (2) PA, SP Herpes acyclovir cap 200 mg (Zovirax) $0 (1) acyclovir susp 200 mg/5ml (Zovirax) $0 (1) acyclovir tab 400 mg (Zovirax) $0 (1) acyclovir tab 800 mg (Zovirax) $0 (1) valacyclovir hcl tab 500 mg (Valtrex) $0 (1) valacyclovir hcl tab 1 gm (Valtrex) $0 (1) HIV/AIDS abacavir sulfate soln 20 mg/ml (base equiv) (Ziagen) $0 (1) QL (960 mls/30 days), 90 abacavir sulfate tab 300 mg (base equiv) (Ziagen) $0 (1) QL (60 tablets/30 days) abacavir sulfate-lamivudine tab mg (Epzicom) $0 (1) QL (30 tablets/30 days) abacavir sulfate-lamivudine-zidovudine tab mg $0 (1) QL (60 tablets/30 days) (Trizivir) APTIVUS tipranavir cap 250 mg $0 (2) QL (120 capsules/30 days), 90 APTIVUS tipranavir oral soln 100 mg/ml $0 (2) QL (4 bottles/30 days), 90 atazanavir sulfate cap 150 mg (base equiv) (Reyataz) $0 (1) QL (30 capsules/30 days), 90 atazanavir sulfate cap 200 mg (base equiv) (Reyataz) $0 (1) QL (60 capsules/30 days), 90 atazanavir sulfate cap 300 mg (base equiv) (Reyataz) $0 (1) QL (30 capsules/30 days), 90 ATRIPLA efavirenz-emtricitabine-tenofovir df tab $0 (2) QL (30 tablets/30 days), mg CRIXIVAN indinavir sulfate cap 200 mg $0 (2) QL (270 capsules/30 days), 90 CRIXIVAN indinavir sulfate cap 400 mg $0 (2) QL (180 capsules/30 days), 90 DESCOVY emtricitabine-tenofovir alafenamide fumarate tab $0 (2) QL (30 tablets/30 days), mg didanosine delayed release capsule 200 mg (Videx ec) $0 (1) QL (30 capsules/30 days) didanosine delayed release capsule 250 mg (Videx ec) $0 (1) QL (30 capsules/30 days) didanosine delayed release capsule 400 mg (Videx ec) $0 (1) QL (30 capsules/30 days) EDURANT rilpivirine hcl tab 25 mg (base equivalent) $0 (2) QL (30 tablets/30 days), 90 efavirenz cap 50 mg (Sustiva) $0 (1) QL (90 capsules/30 days), 90 efavirenz cap 200 mg (Sustiva) $0 (1) QL (60 capsules/30 days), 90 EMTRIVA emtricitabine caps 200 mg $0 (2) QL (30 capsules/30 days), 90 EMTRIVA emtricitabine soln 10 mg/ml $0 (2) QL (720 mls/30 days), 90 5

12 fosamprenavir calcium tab 700 mg (base equiv) (Lexiva) $0 (1) QL (120 tablets/30 days), 90 GENVOYA elvitegrav-cobic-emtricitab-tenofov af tab $0 (2) QL (30 tablets/30 days), mg INTELENCE etravirine tab 25 mg $0 (2) QL (120 tablets/30 days), 90 INTELENCE etravirine tab 100 mg $0 (2) QL (60 tablets/30 days), 90 INTELENCE etravirine tab 200 mg $0 (2) QL (60 tablets/30 days), 90 INVIRASE saquinavir mesylate cap 200 mg $0 (2) QL (300 capsules/30 days), 90 INVIRASE saquinavir mesylate tab 500 mg $0 (2) QL (120 tablets/30 days), 90 ISENTRESS raltegravir potassium packet for susp 100 mg $0 (2) QL (60 packets/30 days), 90 (base equiv) ISENTRESS raltegravir potassium tab 400 mg (base equiv) $0 (2) QL (60 tablets/30 days), 90 ISENTRESS raltegravir potassium chew tab 25 mg (base $0 (2) QL (180 tablets/30 days), 90 equiv) ISENTRESS raltegravir potassium chew tab 100 mg (base $0 (2) QL (180 tablets/30 days), 90 equiv) ISENTRESS HD raltegravir potassium tab 600 mg (base equiv) $0 (2) QL (60 tablets/30 days), 90 KALETRA lopinavir-ritonavir tab mg $0 (2) QL (180 tablets/30 days), 90 KALETRA lopinavir-ritonavir tab mg $0 (2) QL (120 tablets/30 days), 90 lamivudine oral soln 10 mg/ml (Epivir) $0 (1) QL (4 bottles/30 days) lamivudine tab 150 mg (Epivir) $0 (1) QL (30 tablets/30 days) lamivudine tab 300 mg (Epivir) $0 (1) QL (30 tablets/30 days) lamivudine-zidovudine tab mg (Combivir) $0 (1) QL (60 tablets/30 days) LEXIVA fosamprenavir calcium susp 50 mg/ml (base equiv) $0 (2) QL (8 bottles/30 days), 90 lopinavir-ritonavir soln mg/5ml (80-20 mg/ml) (Kaletra) $0 (1) QL (480 mls/30 days) nevirapine tab er 24hr 100 mg (Viramune xr) $0 (1) QL (90 tablets/30 days) nevirapine tab er 24hr 400 mg (Viramune xr) $0 (1) QL (30 tablets/30 days) nevirapine tab 200 mg (Viramune) $0 (1) QL (60 tablets/30 days) NORVIR ritonavir cap 100 mg $0 (2) QL (180 capsules/30 days), 90 NORVIR ritonavir tab 100 mg $0 (2) QL (180 tablets/30 days), 90 NORVIR ritonavir oral soln 80 mg/ml $0 (2) QL (2 bottles/30 days), 90 PREZISTA darunavir ethanolate susp 100 mg/ml (base equiv) $0 (2) QL (2 bottles/30 days), 90 PREZISTA darunavir ethanolate tab 75 mg (base equiv) $0 (2) QL (300 tablets/30 days), 90 PREZISTA darunavir ethanolate tab 150 mg (base equiv) $0 (2) QL (180 tablets/30 days), 90 PREZISTA darunavir ethanolate tab 600 mg (base equiv) $0 (2) QL (60 tablets/30 days), 90 PREZISTA darunavir ethanolate tab 800 mg (base equiv) $0 (2) QL (30 tablets/30 days), 90 6

13 RESCRIPTOR delavirdine mesylate tab 100 mg $0 (2) QL (90 tablets/30 days), 90 RESCRIPTOR delavirdine mesylate tab 200 mg $0 (2) QL (180 tablets/30 days), 90 REYATAZ atazanavir sulfate oral powder packet 50 mg (base $0 (2) QL (240 packets/30 days), 90 equiv) SELZENTRY maraviroc tab 25 mg $0 (2) QL (240 tablets/30 days), 90 SELZENTRY maraviroc tab 75 mg $0 (2) QL (60 tablets/30 days), 90 SELZENTRY maraviroc tab 300 mg $0 (2) QL (120 tablets/30 days), 90 stavudine cap 15 mg (Zerit) $0 (1) QL (60 capsules/30 days) stavudine cap 20 mg (Zerit) $0 (1) QL (60 capsules/30 days) stavudine cap 30 mg (Zerit) $0 (1) QL (60 capsules/30 days) stavudine cap 40 mg (Zerit) $0 (1) QL (60 capsules/30 days) SUSTIVA efavirenz tab 600 mg $0 (2) QL (30 tablets/30 days), 90 SUSTIVA efavirenz cap 50 mg $0 (2) QL (90 tablets/30 days), 90 SUSTIVA efavirenz cap 200 mg $0 (2) QL (60 tablets/30 days), 90 tenofovir disoproxil fumarate tab 300 mg (Viread) $0 (1) QL (30 tablets/30 days), 90 TIVICAY dolutegravir sodium tab 10 mg (base equiv) $0 (2) QL (60 tablets/30 days), 90 TIVICAY dolutegravir sodium tab 25 mg (base equiv) $0 (2) QL (60 tablets/30 days), 90 TIVICAY dolutegravir sodium tab 50 mg (base equiv) $0 (2) QL (60 tablets/30 days), 90 TRUVADA emtricitabine-tenofovir disoproxil fumarate tab $0 (2) QL (30 tablets/30 days), mg TRUVADA emtricitabine-tenofovir disoproxil fumarate tab $0 (2) QL (30 tablets/30 days), mg TRUVADA emtricitabine-tenofovir disoproxil fumarate tab $0 (2) QL (30 tablets/30 days), mg TRUVADA emtricitabine-tenofovir disoproxil fumarate tab $0 (2) QL (30 tablets/30 days), mg VIDEX didanosine for soln 2 gm $0 (2) QL (1200 mls/30 days), 90 VIDEX didanosine for soln 4 gm $0 (2) QL (1200 mls/30 days), 90 VIRACEPT nelfinavir mesylate tab 250 mg $0 (2) QL (270 tablets/30 days), 90 VIRACEPT nelfinavir mesylate tab 625 mg $0 (2) QL (120 tablets/30 days), 90 VIRAMUNE nevirapine susp 50 mg/5ml $0 (2) QL (5 bottles/30 days), 90 VIREAD tenofovir disoproxil fumarate oral powder 40 mg/gm $0 (2) QL (4 bottles/30 days), 90 VIREAD tenofovir disoproxil fumarate tab 150 mg $0 (2) QL (30 tablets/30 days), 90 VIREAD tenofovir disoproxil fumarate tab 200 mg $0 (2) QL (30 tablets/30 days), 90 VIREAD tenofovir disoproxil fumarate tab 250 mg $0 (2) QL (30 tablets/30 days), 90 VIREAD tenofovir disoproxil fumarate tab 300 mg $0 (2) QL (30 tablets/30 days), 90 zidovudine cap 100 mg (Retrovir) $0 (1) QL (180 capsules/30 days) 7

14 zidovudine syrup 10 mg/ml (Retrovir) $0 (1) QL (8 bottles/30 days) zidovudine tab 300 mg $0 (1) QL (60 tablets/30 days) Influenza oseltamivir phosphate cap 30 mg (base equiv) (Tamiflu) $0 (1) QL (40 capsules/120 days) oseltamivir phosphate cap 45 mg (base equiv) (Tamiflu) $0 (1) QL (20 capsules/120 days) oseltamivir phosphate cap 75 mg (base equiv) (Tamiflu) $0 (1) QL (20 capsules/120 days) oseltamivir phosphate for susp 6 mg/ml (base equiv) (Tamiflu) $0 (1) QL (360 mls/120 days) RELENZA DISKHALER zanamivir aero powder breath activated 5 mg/blister $0 (2) QL (20 disks/120 days) MALARIA atovaquone-proguanil hcl tab mg (Malarone) $0 (1) QL (30 tablets/90 days) atovaquone-proguanil hcl tab mg (Malarone) $0 (1) QL (30 tablets/90 days) CHLOROQUINE PHOSPHATE chloroquine phosphate tab $0 (2) mg chloroquine phosphate tab 500 mg $0 (1) 90 DARAPRIM pyrimethamine tab 25 mg $0 (2) hydroxychloroquine sulfate tab 200 mg (Plaquenil) $0 (1) 90 MEFLOQUINE HCL mefloquine hcl tab 250 mg $0 (2) 90 PRIMAQUINE PHOSPHATE primaquine phosphate tab 26.3 mg (15 mg base) $0 (2) WORM INFECTIONS ALBENZA albendazole tab 200 mg $0 (2) BILTRICIDE praziquantel tab 600 mg $0 (2) ivermectin tab 3 mg (Stromectol) $0 (1) OTHER ANTI-INFECTIVES atovaquone susp 750 mg/5ml (Mepron) $0 (1) clindamycin hcl cap 75 mg (Cleocin) $0 (1) clindamycin hcl cap 150 mg (Cleocin) $0 (1) clindamycin hcl cap 300 mg (Cleocin) $0 (1) clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) $0 (1) (Cleocin pediatric gr) dapsone tab 25 mg $0 (1) 90 dapsone tab 100 mg $0 (1) 90 linezolid for susp 100 mg/5ml (Zyvox) $0 (1) QL (600 mls/180 days) linezolid tab 600 mg (Zyvox) $0 (1) QL (56 tablets/180 days) metronidazole cap 375 mg (Flagyl) $0 (1) 8

15 metronidazole tab 250 mg (Flagyl) $0 (1) metronidazole tab 500 mg (Flagyl) $0 (1) sulfamethoxazole-trimethoprim susp mg/5ml $0 (1) sulfamethoxazole-trimethoprim tab mg (Bactrim) $0 (1) sulfamethoxazole-trimethoprim tab mg (Bactrim ds) $0 (1) trimethoprim tab 100 mg $0 (1) vancomycin hcl cap 125 mg (Vancocin hcl) $0 (1) vancomycin hcl cap 250 mg (Vancocin hcl) $0 (1) XIFAXAN rifaximin tab 200 mg $0 (2) PA, QL (9 tablets/30 days) XIFAXAN rifaximin tab 550 mg $0 (2) PA, QL (60 tablets/30 days), 90 ZYVOX linezolid for susp 100 mg/5ml $0 (2) QL (4 bottles/180 days) IMMUNIZING AGENTS SYNAGIS palivizumab im soln 50 mg/0.5ml $0 (2) PA, SP SYNAGIS palivizumab im soln 100 mg/ml $0 (2) PA, SP CANCER DRUGS ACTIMMUNE interferon gamma-1b inj 100 mcg/0.5ml ( unit/0.5ml) $0 (2) PA, QL (12 vials/28 days), SP, 90 AFINITOR everolimus tab 2.5 mg $0 (2) PA, QL (30 tablets/30 days), SP AFINITOR everolimus tab 5 mg $0 (2) PA, QL (30 tablets/30 days), SP AFINITOR everolimus tab 7.5 mg $0 (2) PA, QL (30 tablets/30 days), SP AFINITOR everolimus tab 10 mg $0 (2) PA, QL (30 tablets/30 days), SP AFINITOR DISPERZ everolimus tab for oral susp 2 mg $0 (2) PA, QL (60 tablets/30 days), SP AFINITOR DISPERZ everolimus tab for oral susp 3 mg $0 (2) PA, QL (90 tablets/30 days), SP AFINITOR DISPERZ everolimus tab for oral susp 5 mg $0 (2) PA, QL (60 tablets/30 days), SP ALKERAN melphalan tab 2 mg $0 (2) SP anastrozole tab 1 mg (Arimidex) $0 (1) 90 bexarotene cap 75 mg (Targretin) $0 (1) PA, SP bicalutamide tab 50 mg (Casodex) $0 (1) SP capecitabine tab 150 mg (Xeloda) $0 (1) PA, SP 9

16 capecitabine tab 500 mg (Xeloda) $0 (1) PA, SP COTELLIC cobimetinib fumarate tab 20 mg (base equivalent) $0 (2) PA, QL (63 tablets/28 days), SP CYCLOPHOSPHAMIDE cyclophosphamide cap 25 mg $0 (2) SP CYCLOPHOSPHAMIDE cyclophosphamide cap 50 mg $0 (2) SP CYTARABINE cytarabine inj 20 mg/ml $0 (2) exemestane tab 25 mg (Aromasin) $0 (1) 90 flutamide cap 125 mg $0 (1) SP hydroxyurea cap 500 mg (Hydrea) $0 (1) SP IBRANCE palbociclib cap 75 mg $0 (2) PA, QL (21 capsules/28 days), SP IBRANCE palbociclib cap 100 mg $0 (2) PA, QL (21 capsules/28 days), SP IBRANCE palbociclib cap 125 mg $0 (2) PA, QL (21 capsules/28 days), SP imatinib mesylate tab 100 mg (base equivalent) (Gleevec) $0 (1) PA, QL (90 tablets/30), SP imatinib mesylate tab 400 mg (base equivalent) (Gleevec) $0 (1) PA, QL (60 tablets/30 days), SP KISQALI ribociclib succinate tab 200 mg (base equiv) $0 (2) PA, QL (63 tablets/28 days), SP KISQALI FEMARA 200 DOSE ribociclib tab 200 mg & letrozole tab 2.5 mg therapy pack KISQALI FEMARA 400 DOSE ribociclib tab 200 mg & letrozole tab 2.5 mg therapy pack KISQALI FEMARA 600 DOSE ribociclib tab 200 mg & letrozole tab 2.5 mg therapy pack LENVIMA 10 MG DAILY DOSE lenvatinib cap therapy pack 10 mg (10 mg daily dose) LENVIMA 14 MG DAILY DOSE lenvatinib cap therapy pack 10 & 4 mg (14 mg daily dose) LENVIMA 18 MG DAILY DOSE lenvatinib cap therapy pack 10 & 4 (2) mg (18 mg daily dose) LENVIMA 20 MG DAILY DOSE lenvatinib cap therapy pack 10 (2) mg (20 mg daily dose) LENVIMA 24 MG DAILY DOSE lenvatinib cap therapy pack 10 (2) & 4 mg (24 mg daily dose) LENVIMA 8 MG DAILY DOSE lenvatinib cap therapy pack 4 (2) mg (8 mg daily dose) $0 (2) PA, QL (91 tablets/28 days), SP $0 (2) PA, QL (91 tablets/28 days), SP $0 (2) PA, QL (91 tablets/28 days), SP $0 (2) PA, QL (30 capsules/30 days), SP $0 (2) PA, QL (60 capsules/30 days), SP $0 (2) PA, QL (90 capsules/30 days), SP $0 (2) PA, QL (60 capsules/30 days), SP $0 (2) PA, QL (90 capsules/30 days), SP $0 (2) PA, QL (60 capsules/30 days), SP 10

17 letrozole tab 2.5 mg (Femara) $0 (1) 90 LEUCOVORIN CALCIUM leucovorin calcium tab 10 mg $0 (2) LEUCOVORIN CALCIUM leucovorin calcium tab 15 mg $0 (2) leucovorin calcium tab 5 mg $0 (1) leucovorin calcium tab 25 mg $0 (1) LEUKERAN chlorambucil tab 2 mg $0 (2) SP LUPRON DEPOT (1-MONTH) leuprolide acetate for inj kit $0 (2) PA, SP 3.75 mg LUPRON DEPOT (1-MONTH) leuprolide acetate for inj kit $0 (2) PA, SP 7.5 mg LUPRON DEPOT (3-MONTH) leuprolide acetate (3 month) for $0 (2) PA, SP inj kit mg LUPRON DEPOT (3-MONTH) leuprolide acetate (3 month) for $0 (2) PA, SP inj kit 22.5 mg LUPRON DEPOT (4-MONTH) leuprolide acetate (4 month) for $0 (2) PA, SP inj kit 30 mg LUPRON DEPOT (6-MONTH) leuprolide acetate (6 month) for $0 (2) PA, SP inj kit 45 mg LYNPARZA olaparib cap 50 mg $0 (2) PA, QL (480 capsules/30 days), SP LYNPARZA olaparib tab 100 mg $0 (2) PA, QL (120 tablets/30 days) LYNPARZA olaparib tab 150 mg $0 (2) PA, QL (120 tablets/30 days) megestrol acetate susp 40 mg/ml $0 (1) megestrol acetate tab 20 mg $0 (1) megestrol acetate tab 40 mg $0 (1) MEKINIST trametinib dimethyl sulfoxide tab 0.5 mg (base equivalent) MEKINIST trametinib dimethyl sulfoxide tab 2 mg (base equivalent) melphalan tab 2 mg (Alkeran) $0 (1) $0 (2) PA, QL (90 tablets/30 days), SP $0 (2) PA, QL (30 tablets/30 days), SP mercaptopurine tab 50 mg $0 (1) SP METHOTREXATE SODIUM methotrexate sodium inj $0 (2) 250 mg/10ml (25 mg/ml) methotrexate sodium tab 2.5 mg (base equiv) $0 (1) MYLERAN busulfan tab 2 mg $0 (2) SP NEXAVAR sorafenib tosylate tab 200 mg (base equivalent) $0 (2) PA, QL (120 tablets/30 days), SP RUBRACA rucaparib camsylate tab 200 mg (base equivalent) $0 (2) PA, QL (120 tablets/30 days), SP 11

18 RUBRACA rucaparib camsylate tab 250 mg (base equivalent) $0 (2) PA, QL (120 tablets/30 days), SP RUBRACA rucaparib camsylate tab 300 mg (base equivalent) $0 (2) PA, QL (120 tablets/30 days), SP RYDAPT midostaurin cap 25 mg $0 (2) PA, QL (240 capsules/30 days), SP SPRYCEL dasatinib tab 20 mg $0 (2) PA, QL (90 tablets/30 days), SP SPRYCEL dasatinib tab 50 mg $0 (2) PA, QL (30 tablets/30 days), SP SPRYCEL dasatinib tab 70 mg $0 (2) PA, QL (30 tablets/30 days), SP SPRYCEL dasatinib tab 80 mg $0 (2) PA, QL (30 tablets/30 days), SP SPRYCEL dasatinib tab 100 mg $0 (2) PA, QL (30 tablets/30 days), SP SPRYCEL dasatinib tab 140 mg $0 (2) PA, QL (30 tablets/30 days), SP STIVARGA regorafenib tab 40 mg $0 (2) PA, QL (84 tablets/28 days), SP SUTENT sunitinib malate cap 12.5 mg (base equivalent) $0 (2) PA, QL (90 capsules/30 days), SP SUTENT sunitinib malate cap 25 mg (base equivalent) $0 (2) PA, QL (30 capsules/30 days), SP SUTENT sunitinib malate cap 37.5 mg (base equivalent) $0 (2) PA, QL (30 capsules/30 days), SP SUTENT sunitinib malate cap 50 mg (base equivalent) $0 (2) PA, QL (30 capsules/30 days), SP tamoxifen citrate tab 10 mg (base equivalent) $0 (1) 90 tamoxifen citrate tab 20 mg (base equivalent) $0 (1) 90 TARCEVA erlotinib hcl tab 25 mg (base equivalent) $0 (2) PA, QL (60 tablets/30 days), SP TARCEVA erlotinib hcl tab 100 mg (base equivalent) $0 (2) PA, QL (30 tablets/30 days), SP TARCEVA erlotinib hcl tab 150 mg (base equivalent) $0 (2) PA, QL (30 tablets/30 days), SP TASIGNA nilotinib hcl cap 150 mg (base equivalent) $0 (2) PA, QL (120 capsules/30 days), SP 12

19 TASIGNA nilotinib hcl cap 200 mg (base equivalent) $0 (2) PA, QL (120 capsules/30 days), SP temozolomide cap 5 mg (Temodar) $0 (1) PA, SP temozolomide cap 20 mg (Temodar) $0 (1) PA, SP temozolomide cap 100 mg (Temodar) $0 (1) PA, SP temozolomide cap 140 mg (Temodar) $0 (1) PA, SP temozolomide cap 180 mg (Temodar) $0 (1) PA, SP temozolomide cap 250 mg (Temodar) $0 (1) PA, SP tretinoin cap 10 mg $0 (1) PA, SP VOTRIENT pazopanib hcl tab 200 mg (base equiv) $0 (2) PA, QL (120 tablets/30 days), SP XALKORI crizotinib cap 200 mg $0 (2) PA, QL (60 capsules/30 days), SP XALKORI crizotinib cap 250 mg $0 (2) PA, QL (60 capsules/30 days), SP XTANDI enzalutamide cap 40 mg $0 (2) PA, QL (120 capsules/30 days), SP ZELBORAF vemurafenib tab 240 mg $0 (2) PA, QL (240 tablets/30 days), SP ZYTIGA abiraterone acetate tab 250 mg $0 (2) PA, QL (120 tablets/30 days), SP ZYTIGA abiraterone acetate tab 500 mg $0 (2) PA, QL (60 tablets/30 days), SP HORMONES, DIABETES AND RELATED DRUGS CORTICOSTEROIDS budesonide delayed release particles cap 3 mg (Entocort ec) $0 (1) CORTISONE ACETATE cortisone acetate tab 25 mg $0 (2) DEXAMETHASONE dexamethasone soln 0.5 mg/5ml $0 (2) dexamethasone elixir 0.5 mg/5ml $0 (1) dexamethasone tab 0.5 mg $0 (1) dexamethasone tab 0.75 mg $0 (1) dexamethasone tab 1.5 mg $0 (1) dexamethasone tab 4 mg $0 (1) dexamethasone tab 6 mg $0 (1) fludrocortisone acetate tab 0.1 mg $0 (1) 90 hydrocortisone tab 5 mg (Cortef) $0 (1) 13

20 hydrocortisone tab 10 mg (Cortef) $0 (1) hydrocortisone tab 20 mg (Cortef) $0 (1) methylprednisolone tab therapy pack 4 mg (21) (Medrol dosepak) $0 (1) methylprednisolone tab 4 mg (Medrol) $0 (1) methylprednisolone tab 8 mg (Medrol) $0 (1) methylprednisolone tab 16 mg (Medrol) $0 (1) methylprednisolone tab 32 mg (Medrol) $0 (1) prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base) $0 (1) (Pediapred) prednisolone sod phosphate oral soln 15 mg/5ml (base equiv) $0 (1) prednisolone syrup 15 mg/5ml (usp solution equivalent) $0 (1) PREDNISONE prednisone tab 50 mg $0 (2) PREDNISONE prednisone oral soln 5 mg/5ml $0 (2) prednisone tab 1 mg $0 (1) prednisone tab 2.5 mg $0 (1) prednisone tab 5 mg $0 (1) prednisone tab 10 mg $0 (1) prednisone tab 20 mg $0 (1) MALE HORMONES danazol cap 50 mg $0 (1) danazol cap 100 mg $0 (1) danazol cap 200 mg $0 (1) 14 testosterone cypionate im inj in oil 100 mg/ml (Depotestosterone) $0 (1) QL (10 mls/28 days) testosterone cypionate im inj in oil 200 mg/ml (Depotestosterone) $0 (1) QL (10 mls/28 days) testosterone enanthate im inj in oil 200 mg/ml $0 (1) QL (1 vial/28 days) ESTROGENS COMBIPATCH estradiol-norethindrone ace td pttw $0 (2) mg/day COMBIPATCH estradiol-norethindrone ace td pttw $0 (2) mg/day estradiol & norethindrone acetate tab mg (Activella) $0 (1) 90 estradiol & norethindrone acetate tab mg (Activella) $0 (1) 90 estradiol tab 0.5 mg (Estrace) $0 (1) 90 estradiol tab 1 mg (Estrace) $0 (1) 90 estradiol tab 2 mg (Estrace) $0 (1) 90

21 estradiol td patch twice weekly mg/24hr (Vivelle-dot) $0 (1) QL (8 patches/30 days), 90 estradiol td patch twice weekly mg/24hr (Vivelle-dot) $0 (1) QL (8 patches/30 days), 90 estradiol td patch twice weekly 0.05 mg/24hr (Vivelle-dot) $0 (1) QL (8 patches/30 days), 90 estradiol td patch twice weekly mg/24hr (Vivelle-dot) $0 (1) QL (8 patches/30 days), 90 estradiol td patch twice weekly 0.1 mg/24hr (Vivelle-dot) $0 (1) QL (8 patches/30 days), 90 estradiol td patch weekly mg/24hr (Climara) $0 (1) QL (4 patches/30 days), 90 estradiol td patch weekly mg/24hr (37.5 mcg/24hr) $0 (1) QL (4 patches/30 days), 90 (Climara) estradiol td patch weekly 0.05 mg/24hr (Climara) $0 (1) QL (4 patches/30 days), 90 estradiol td patch weekly 0.06 mg/24hr (Climara) $0 (1) QL (4 patches/30 days), 90 estradiol td patch weekly mg/24hr (Climara) $0 (1) QL (4 patches/30 days), 90 estradiol td patch weekly 0.1 mg/24hr (Climara) $0 (1) QL (4 patches/30 days), 90 ESTROPIPATE estropipate tab 0.75 mg $0 (2) 90 ESTROPIPATE estropipate tab 1.5 mg $0 (2) 90 ESTROPIPATE estropipate tab 3 mg $0 (2) 90 norethindrone acetate-ethinyl estradiol tab 1 mg-5 mcg $0 (1) 90 PREMPRO conjugated estrogen-medroxyprogest acetate tab mg PREMPRO conjugated estrogen-medroxyprogest acetate tab mg PREMPRO conjugated estrogen-medroxyprogest acetate tab mg PROGESTINS medroxyprogesterone acetate tab 2.5 mg (Provera) $0 (1) medroxyprogesterone acetate tab 5 mg (Provera) $0 (1) medroxyprogesterone acetate tab 10 mg (Provera) $0 (1) megestrol acetate susp 625 mg/5ml (Megace es) $0 (1) $0 (2) 90 $0 (2) 90 $0 (2) 90 norethindrone acetate tab 5 mg (Aygestin) $0 (1) 90 progesterone im in oil 50 mg/ml $0 (1) progesterone micronized cap 100 mg (Prometrium) $0 (1) 90 progesterone micronized cap 200 mg (Prometrium) $0 (1) 90 BIRTH CONTROL desogest-eth estrad & eth estrad tab /0.01 mg(21/5) $0 (1) QL (28 tablets/21 days), 90 (Mircette) desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg (Desogen) $0 (1) QL (28 tablets/21 days), 90 drospirenone-ethinyl estradiol tab mg (Yasmin 28) $0 (1) QL (28 tablets/21 days), 90 ELLA ulipristal acetate tab 30 mg $0 (2) QL (3 tablets/365 days) 15

22 ethynodiol diacetate & ethinyl estradiol tab 1 mg-50 mcg $0 (1) QL (28 tablets/21 days), 90 KYLEENA levonorgestrel releasing iud 17.5 mcg/day (19.5 mg $0 (2) total) levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg $0 (1) QL (28 tablets/21 days), 90 levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg $0 (1) QL (28 tablets/21 days), 90 levonorgestrel tab 1.5 mg $0 (3) QL (3 tablets/365 days) levonorgestrel-eth estra tab / / mg-mcg $0 (1) QL (28 tablets/21 days), 90 medroxyprogesterone acetate im susp 150 mg/ml (Depo-provera $0 (1) QL contrac) MIRENA levonorgestrel releasing iud 20 mcg/day (52 mg total) $0 (2) 90 NEXPLANON etonogestrel subdermal implant 68 mg $0 (2) 90 norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg (Loestrin $0 (1) QL (28 tablets/21 days), 90 1/20-21) norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg $0 (1) QL (28 tablets/21 days), 90 (Loestrin 1.5/30-21) norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg $0 (1) QL (28 tablets/21 days), 90 (Loestrin fe 1/20) norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg (Orthocyclen) $0 (1) QL (28 tablets/21 days), 90 norgestimate-eth estrad tab / / mg-mcg $0 (1) QL (28 tablets/21 days), 90 (Ortho tri-cyclen lo) norgestimate-eth estrad tab / / mg-mcg $0 (1) QL (28 tablets/21 days), 90 (Ortho tri-cyclen) NUVARING etonogestrel-ethinyl estradiol va ring $0 (2) QL (1 ring/21 days), mg/24hr PARAGARD INTRAUTERINE COP copper iud $0 (2) 90 PLAN B ONE-STEP levonorgestrel tab 1.5 mg $0 (3) QL (3 tablets/365 days) SKYLA levonorgestrel releasing iud 14 mcg/day (13.5 mg total) $0 (2) 90 XULANE norelgestromin-ethinyl estradiol td ptwk mcg/24hr LUPRON DEPOT-PED (1-MONTH leuprolide acetate for inj pediatric kit 7.5 mg LUPRON DEPOT-PED (1-MONTH leuprolide acetate for inj pediatric kit mg LUPRON DEPOT-PED (1-MONTH leuprolide acetate for inj pediatric kit 15 mg LUPRON DEPOT-PED (3-MONTH leuprolide acetate (3 month) for inj pediatric kit mg LUPRON DEPOT-PED (3-MONTH leuprolide acetate (3 month) for inj pediatric kit 30 mg DIABETES 16 $0 (2) QL (4 patches/21 days), 90 $0 (2) PA, SP $0 (2) PA, SP $0 (2) PA, SP $0 (2) PA, SP $0 (2) PA, SP

23 acarbose tab 25 mg (Precose) $0 (1) QL (180 tablets/30 days), 90 acarbose tab 50 mg (Precose) $0 (1) QL (180 tablets/30 days), 90 acarbose tab 100 mg (Precose) $0 (1) QL (90 tablets/30 days), 90 ALOGLIPTIN alogliptin benzoate tab 6.25 mg (base equiv) $0 (2) QL (30 tablets/30 days), ST, 90 ALOGLIPTIN alogliptin benzoate tab 12.5 mg (base equiv) $0 (2) QL (30 tablets/30 days), ST, 90 ALOGLIPTIN alogliptin benzoate tab 25 mg (base equiv) $0 (2) QL (30 tablets/30 days), ST, 90 ALOGLIPTIN/METFORMIN HCL alogliptin-metformin hcl tab mg ALOGLIPTIN/METFORMIN HCL alogliptin-metformin hcl tab mg ALOGLIPTIN/PIOGLITAZONE alogliptin-pioglitazone tab mg ALOGLIPTIN/PIOGLITAZONE alogliptin-pioglitazone tab mg ALOGLIPTIN/PIOGLITAZONE alogliptin-pioglitazone tab mg ALOGLIPTIN/PIOGLITAZONE alogliptin-pioglitazone tab mg ALOGLIPTIN/PIOGLITAZONE alogliptin-pioglitazone tab mg ALOGLIPTIN/PIOGLITAZONE alogliptin-pioglitazone tab mg $0 (2) QL (60 tablets/30 days), ST, 90 $0 (2) QL (60 tablets/30 days), ST, 90 $0 (2) QL (30 tablets/30 days), ST, 90 $0 (2) QL (30 tablets/30 days), ST, 90 $0 (2) QL (30 tablets/30 days), ST, 90 $0 (2) QL (30 tablets/30 days), ST, 90 $0 (2) QL (30 tablets/30 days), ST, 90 $0 (2) QL (30 tablets/30 days), ST, 90 glimepiride tab 1 mg (Amaryl) $0 (1) QL (60 tablets/30 days), 90 glimepiride tab 2 mg (Amaryl) $0 (1) QL (60 tablets/30 days), 90 glimepiride tab 4 mg (Amaryl) $0 (1) QL (60 tablets/30 days), 90 glipizide tab er 24hr 2.5 mg (Glucotrol xl) $0 (1) QL (60 tablets/30 days), 90 glipizide tab er 24hr 5 mg (Glucotrol xl) $0 (1) QL (90 tablets/30 days), 90 glipizide tab er 24hr 10 mg (Glucotrol xl) $0 (1) QL (60 tablets/30 days), 90 glipizide tab 5 mg (Glucotrol) $0 (1) QL (120 tablets/30 days), 90 glipizide tab 10 mg (Glucotrol) $0 (1) QL (120 tablets/30 days), 90 GLUCAGON EMERGENCY KIT glucagon (rdna) for inj kit 1 mg $0 (2) QL (6 pens/365 days) glyburide micronized tab 1.5 mg (Glynase) $0 (1) QL (120 tablets/30 days), 90 glyburide micronized tab 3 mg (Glynase) $0 (1) QL (60 tablets/30 days), 90 glyburide micronized tab 6 mg (Glynase) $0 (1) QL (60 tablets/30 days), 90 17

24 glyburide tab 1.25 mg $0 (1) QL (60 tablets/30 days), 90 glyburide tab 2.5 mg $0 (1) QL (60 tablets/30 days), 90 glyburide tab 5 mg $0 (1) QL (120 tablets/30 days), 90 glyburide-metformin tab mg $0 (1) QL (120 tablets/30 days), 90 glyburide-metformin tab mg (Glucovance) $0 (1) QL (120 tablets/30 days), 90 glyburide-metformin tab mg (Glucovance) $0 (1) QL (120 tablets/30 days), 90 metformin hcl tab er 24hr 500 mg (Glucophage xr) $0 (1) QL (120 tablets/30 days), 90 metformin hcl tab er 24hr 750 mg (Glucophage xr) $0 (1) QL (60 tablets/30 days), 90 metformin hcl tab 500 mg (Glucophage) $0 (1) QL (120 tablets/30 days), 90 metformin hcl tab 850 mg (Glucophage) $0 (1) QL (90 tablets/30 days), 90 metformin hcl tab 1000 mg (Glucophage) $0 (1) QL (60 tablets/30 days), 90 nateglinide tab 60 mg (Starlix) $0 (1) QL (120 tablets/30 days), 90 nateglinide tab 120 mg (Starlix) $0 (1) QL (90 tablets/30 days), 90 pioglitazone hcl tab 15 mg (base equiv) (Actos) $0 (1) QL (30 tablets/30 days), 90 pioglitazone hcl tab 30 mg (base equiv) (Actos) $0 (1) QL (30 tablets/30 days), 90 pioglitazone hcl tab 45 mg (base equiv) (Actos) $0 (1) QL (30 tablets/30 days), 90 TOLAZAMIDE tolazamide tab 250 mg $0 (2) QL (90 tablets/30 days), 90 VICTOZA liraglutide soln pen-injector 18 mg/3ml (6 mg/ml) $0 (2) QL (3 pens/30 days), ST, 90 DIABETES - INSULINS Rapid-Acting Insulins HUMALOG insulin lispro soln cartridge 100 unit/ml $0 (2) QL (45 mls/30 days), 90 HUMALOG insulin lispro inj 100 unit/ml $0 (2) QL (45 mls/30 days), 90 HUMALOG JUNIOR KWIKPEN insulin lispro soln pen-injector $0 (2) QL (45 mls/30 days), unit/ml HUMALOG KWIKPEN insulin lispro soln pen-injector 100 unit/ $0 (2) QL (45 mls/30 days), 90 ml HUMALOG KWIKPEN insulin lispro soln pen-injector 200 unit/ $0 (2) QL (24 mls/30 days), 90 ml NOVOLOG insulin aspart inj 100 unit/ml $0 (2) QL (45 mls/30 days), 90 NOVOLOG FLEXPEN insulin aspart soln pen-injector 100 unit/ $0 (2) QL (45 mls/30 days), 90 ml NOVOLOG PENFILL insulin aspart soln cartridge 100 unit/ml $0 (2) QL (45 mls/30 days), 90 Short-Acting Insulins HUMULIN R insulin regular (human) inj 100 unit/ml $0 (3) QL (45 mls/30 days), 90 NOVOLIN R insulin regular (human) inj 100 unit/ml $0 (3) QL (45 mls/30 days), 90 NOVOLIN R RELION insulin regular (human) inj 100 unit/ml $0 (3) QL (45 mls/30 days), 90 18

25 Intermediate-Acting Insulins HUMALOG MIX 50/50 insulin lispro protamine & lispro inj 100 $0 (2) QL (45 mls/30 days), 90 unit/ml (50-50) HUMALOG MIX 50/50 KWIKPEN insulin lispro prot & lispro sus $0 (2) QL (45 mls/30 days), 90 pen-inj 100 unit/ml (50-50) HUMALOG MIX 75/25 insulin lispro prot & lispro inj 100 unit/ml $0 (2) QL (45 mls/30 days), 90 (75-25) HUMALOG MIX 75/25 KWIKPEN insulin lispro prot & lispro sus $0 (2) QL (45 mls/30 days), 90 pen-inj 100 unit/ml (75-25) HUMULIN N insulin nph (human) (isophane) inj 100 unit/ml $0 (3) QL (45 mls/30 days), 90 HUMULIN N KWIKPEN insulin nph (human) (isophane) susp $0 (3) QL (45 mls/30 days), 90 pen-injector 100 unit/ml HUMULIN 70/30 insulin nph isophane & regular human inj 100 $0 (3) QL (45 mls/30 days), 90 unit/ml (70-30) HUMULIN 70/30 KWIKPEN insulin nph & regular susp pen-inj $0 (3) QL (45 mls/30 days), unit/ml (70-30) NOVOLIN N insulin nph (human) (isophane) inj 100 unit/ml $0 (3) QL (45 mls/30 days), 90 NOVOLIN N RELION insulin nph (human) (isophane) inj 100 unit/ml NOVOLIN 70/30 insulin nph isophane & regular human inj 100 unit/ml (70-30) NOVOLIN 70/30 RELION insulin nph isophane & regular human inj 100 unit/ml (70-30) NOVOLOG MIX 70/30 insulin aspart prot & aspart (human) inj 100 unit/ml (70-30) NOVOLOG MIX 70/30 PREFILL insulin aspart prot & aspart sus pen-inj 100 unit/ml (70-30) Basal Insulins BASAGLAR KWIKPEN insulin glargine soln pen-injector 100 unit/ml $0 (3) QL (45 mls/30 days), 90 $0 (3) QL (45 mls/30 days), 90 $0 (3) QL (45 mls/30 days), 90 $0 (2) QL (45 mls/30 days), 90 $0 (2) QL (45 mls/30 days), 90 $0 (2) QL (45 mls/30 days), 90 THYROID REGULATION levothyroxine sodium tab 25 mcg (Synthroid) $0 (1) 90 levothyroxine sodium tab 50 mcg (Synthroid) $0 (1) 90 levothyroxine sodium tab 75 mcg (Synthroid) $0 (1) 90 levothyroxine sodium tab 88 mcg (Synthroid) $0 (1) 90 levothyroxine sodium tab 100 mcg (Synthroid) $0 (1) 90 levothyroxine sodium tab 112 mcg (Synthroid) $0 (1) 90 levothyroxine sodium tab 125 mcg (Synthroid) $0 (1) 90 levothyroxine sodium tab 137 mcg (Synthroid) $0 (1) 90 levothyroxine sodium tab 150 mcg (Synthroid) $0 (1) 90 19

26 levothyroxine sodium tab 175 mcg (Synthroid) $0 (1) 90 levothyroxine sodium tab 200 mcg (Synthroid) $0 (1) 90 levothyroxine sodium tab 300 mcg (Synthroid) $0 (1) 90 liothyronine sodium tab 5 mcg (Cytomel) $0 (1) 90 liothyronine sodium tab 25 mcg (Cytomel) $0 (1) 90 liothyronine sodium tab 50 mcg (Cytomel) $0 (1) 90 methimazole tab 5 mg (Tapazole) $0 (1) 90 methimazole tab 10 mg (Tapazole) $0 (1) 90 propylthiouracil tab 50 mg $0 (1) 90 thyroid tab 30 mg (1/2 grain) (Armour thyroid) $0 (1) 90 thyroid tab 60 mg (1 grain) (Armour thyroid) $0 (1) 90 thyroid tab 90 mg (1 1/2 grain) (Armour thyroid) $0 (1) 90 GROWTH HORMONE OMNITROPE somatropin for inj 5.8 mg $0 (2) PA, SP, 90 OTHER HORMONES AND RELATED DRUGS ALENDRONATE SODIUM alendronate sodium tab 40 mg $0 (2) QL (30 tablets/30 days) alendronate sodium tab 5 mg $0 (1) QL (30 tablets/30 days), 90 alendronate sodium tab 10 mg $0 (1) QL (30 tablets/30 days), 90 alendronate sodium tab 35 mg $0 (1) QL (4 tablets/28 days), 90 alendronate sodium tab 70 mg (Fosamax) $0 (1) QL (4 tablets/28 days), 90 cabergoline tab 0.5 mg $0 (1) calcitonin (salmon) nasal soln 200 unit/act $0 (1) 90 calcitriol cap 0.25 mcg (Rocaltrol) $0 (1) 90 calcitriol cap 0.5 mcg (Rocaltrol) $0 (1) 90 calcitriol oral soln 1 mcg/ml (Rocaltrol) $0 (1) 90 desmopressin acetate nasal soln 0.01% (refrigerated) (Ddavp) $0 (1) 90 desmopressin acetate nasal spray soln 0.01% (Ddavp) $0 (1) 90 desmopressin acetate nasal spray soln 0.01% (refrigerated) $0 (1) 90 desmopressin acetate tab 0.1 mg (Ddavp) $0 (1) 90 desmopressin acetate tab 0.2 mg (Ddavp) $0 (1) 90 levocarnitine oral soln 1 gm/10ml (10%) (Carnitor) $0 (1) 90 levocarnitine tab 330 mg (Carnitor) $0 (1) 90 LUPRON DEPOT-PED (1-MONTH leuprolide acetate for inj pediatric kit 7.5 mg $0 (2) PA, SP 20

27 LUPRON DEPOT-PED (1-MONTH leuprolide acetate for inj $0 (2) PA, SP pediatric kit mg LUPRON DEPOT-PED (1-MONTH leuprolide acetate for inj $0 (2) PA, SP pediatric kit 15 mg METHERGINE methylergonovine maleate tab 0.2 mg $0 (2) NITYR nitisinone tab 2 mg $0 (2) 90 NITYR nitisinone tab 5 mg $0 (2) 90 NITYR nitisinone tab 10 mg $0 (2) 90 octreotide acetate inj 50 mcg/ml (0.05 mg/ml) (Sandostatin) $0 (1) PA, QL (90 mls/30 days), SP, 90 octreotide acetate inj 100 mcg/ml (0.1 mg/ml) (Sandostatin) $0 (1) PA, QL (90 mls/30 days), SP, 90 octreotide acetate inj 200 mcg/ml (0.2 mg/ml) (Sandostatin) $0 (1) PA, QL (90 mls/30 days), SP, 90 octreotide acetate inj 500 mcg/ml (0.5 mg/ml) (Sandostatin) $0 (1) PA, QL (30 vials/30 days), SP octreotide acetate inj 1000 mcg/ml (1 mg/ml) (Sandostatin) $0 (1) PA, QL (30 vials/30 days), SP raloxifene hcl tab 60 mg (Evista) $0 (1) 90 STIMATE desmopressin acetate nasal soln 1.5 mg/ml $0 (2) 90 TYMLOS abaloparatide subcutaneous soln pen-injector 3120 mcg/1.56ml HEART AND CIRCULATORY DRUGS $0 (2) PA, QL (1 pen/30 days), SP, 90 ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITORS AND COMBINATIONS benazepril & hydrochlorothiazide tab mg $0 (1) 90 benazepril & hydrochlorothiazide tab mg (Lotensin hct) $0 (1) 90 benazepril & hydrochlorothiazide tab mg (Lotensin hct) $0 (1) 90 benazepril & hydrochlorothiazide tab mg (Lotensin hct) $0 (1) 90 benazepril hcl tab 5 mg $0 (1) 90 benazepril hcl tab 10 mg $0 (1) 90 benazepril hcl tab 20 mg (Lotensin) $0 (1) 90 benazepril hcl tab 40 mg (Lotensin) $0 (1) 90 captopril tab 12.5 mg $0 (1) 90 captopril tab 25 mg $0 (1) 90 captopril tab 50 mg $0 (1) 90 captopril tab 100 mg $0 (1) 90 CAPTOPRIL/HYDROCHLOROTHIA captopril & hydrochlorothiazide tab mg $0 (2) 90 21

28 CAPTOPRIL/HYDROCHLOROTHIA captopril & $0 (2) 90 hydrochlorothiazide tab mg CAPTOPRIL/HYDROCHLOROTHIA captopril & $0 (2) 90 hydrochlorothiazide tab mg CAPTOPRIL/HYDROCHLOROTHIA captopril & $0 (2) 90 hydrochlorothiazide tab mg enalapril maleate & hydrochlorothiazide tab mg $0 (1) 90 enalapril maleate & hydrochlorothiazide tab mg (Vaseretic) $0 (1) 90 enalapril maleate tab 2.5 mg (Vasotec) $0 (1) 90 enalapril maleate tab 5 mg (Vasotec) $0 (1) 90 enalapril maleate tab 10 mg (Vasotec) $0 (1) 90 enalapril maleate tab 20 mg (Vasotec) $0 (1) 90 fosinopril sodium & hydrochlorothiazide tab mg $0 (1) 90 fosinopril sodium & hydrochlorothiazide tab mg $0 (1) 90 fosinopril sodium tab 10 mg $0 (1) 90 fosinopril sodium tab 20 mg $0 (1) 90 fosinopril sodium tab 40 mg $0 (1) 90 lisinopril & hydrochlorothiazide tab mg (Zestoretic) $0 (1) 90 lisinopril & hydrochlorothiazide tab mg (Zestoretic) $0 (1) 90 lisinopril & hydrochlorothiazide tab mg (Zestoretic) $0 (1) 90 lisinopril tab 2.5 mg (Zestril) $0 (1) 90 lisinopril tab 5 mg (Prinivil) $0 (1) 90 lisinopril tab 10 mg (Prinivil) $0 (1) 90 lisinopril tab 20 mg (Prinivil) $0 (1) 90 lisinopril tab 30 mg (Zestril) $0 (1) 90 lisinopril tab 40 mg (Zestril) $0 (1) 90 moexipril hcl tab 7.5 mg $0 (1) 90 moexipril hcl tab 15 mg $0 (1) 90 moexipril-hydrochlorothiazide tab mg $0 (1) 90 moexipril-hydrochlorothiazide tab mg $0 (1) 90 moexipril-hydrochlorothiazide tab mg $0 (1) 90 perindopril erbumine tab 2 mg $0 (1) 90 perindopril erbumine tab 4 mg (Aceon) $0 (1) 90 perindopril erbumine tab 8 mg (Aceon) $0 (1) 90 quinapril hcl tab 5 mg (Accupril) $0 (1) 90 quinapril hcl tab 10 mg (Accupril) $0 (1) 90 22

29 quinapril hcl tab 20 mg (Accupril) $0 (1) 90 quinapril hcl tab 40 mg (Accupril) $0 (1) 90 quinapril-hydrochlorothiazide tab mg (Accuretic) $0 (1) 90 quinapril-hydrochlorothiazide tab mg (Accuretic) $0 (1) 90 quinapril-hydrochlorothiazide tab mg (Accuretic) $0 (1) 90 ramipril cap 1.25 mg (Altace) $0 (1) 90 ramipril cap 2.5 mg (Altace) $0 (1) 90 ramipril cap 5 mg (Altace) $0 (1) 90 ramipril cap 10 mg (Altace) $0 (1) 90 trandolapril tab 1 mg $0 (1) 90 trandolapril tab 2 mg (Mavik) $0 (1) 90 trandolapril tab 4 mg $0 (1) 90 ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARBS) AND COMBINATIONS irbesartan tab 75 mg (Avapro) $0 (1) QL (30 tablets/30 days), 90 irbesartan tab 150 mg (Avapro) $0 (1) QL (30 tablets/30 days), 90 irbesartan tab 300 mg (Avapro) $0 (1) QL (30 tablets/30 days), 90 irbesartan-hydrochlorothiazide tab mg (Avalide) $0 (1) QL (30 tablets/30 days), 90 irbesartan-hydrochlorothiazide tab mg (Avalide) $0 (1) QL (30 tablets/30 days), 90 losartan potassium & hydrochlorothiazide tab mg $0 (1) QL (30 tablets/30 days), 90 (Hyzaar) losartan potassium & hydrochlorothiazide tab mg $0 (1) QL (30 tablets/30 days), 90 (Hyzaar) losartan potassium & hydrochlorothiazide tab mg $0 (1) QL (30 tablets/30 days), 90 (Hyzaar) losartan potassium tab 25 mg (Cozaar) $0 (1) QL (60 tablets/30 days), 90 losartan potassium tab 50 mg (Cozaar) $0 (1) QL (60 tablets/30 days), 90 losartan potassium tab 100 mg (Cozaar) $0 (1) QL (30 tablets/30 days), 90 valsartan tab 40 mg (Diovan) $0 (1) QL (60 tablets/30 days), 90 valsartan tab 80 mg (Diovan) $0 (1) QL (60 tablets/30 days), 90 valsartan tab 160 mg (Diovan) $0 (1) QL (60 tablets/30 days), 90 valsartan tab 320 mg (Diovan) $0 (1) QL (30 tablets/30 days), 90 valsartan-hydrochlorothiazide tab mg (Diovan hct) $0 (1) QL (30 tablets/30 days), 90 valsartan-hydrochlorothiazide tab mg (Diovan hct) $0 (1) QL (30 tablets/30 days), 90 valsartan-hydrochlorothiazide tab mg (Diovan hct) $0 (1) QL (30 tablets/30 days), 90 valsartan-hydrochlorothiazide tab mg (Diovan hct) $0 (1) QL (30 tablets/30 days), 90 valsartan-hydrochlorothiazide tab mg (Diovan hct) $0 (1) QL (30 tablets/30 days), 90 23

30 BETA BLOCKERS AND COMBINATIONS acebutolol hcl cap 200 mg $0 (1) 90 acebutolol hcl cap 400 mg $0 (1) 90 atenolol & chlorthalidone tab mg (Tenoretic 50) $0 (1) 90 atenolol & chlorthalidone tab mg (Tenoretic 100) $0 (1) 90 atenolol tab 25 mg (Tenormin) $0 (1) 90 atenolol tab 50 mg (Tenormin) $0 (1) 90 atenolol tab 100 mg (Tenormin) $0 (1) 90 betaxolol hcl tab 10 mg $0 (1) 90 betaxolol hcl tab 20 mg $0 (1) 90 bisoprolol & hydrochlorothiazide tab mg (Ziac) $0 (1) 90 bisoprolol & hydrochlorothiazide tab mg (Ziac) $0 (1) 90 bisoprolol & hydrochlorothiazide tab mg (Ziac) $0 (1) 90 bisoprolol fumarate tab 5 mg $0 (1) 90 bisoprolol fumarate tab 10 mg $0 (1) 90 carvedilol tab mg (Coreg) $0 (1) 90 carvedilol tab 6.25 mg (Coreg) $0 (1) 90 carvedilol tab 12.5 mg (Coreg) $0 (1) 90 carvedilol tab 25 mg (Coreg) $0 (1) 90 labetalol hcl tab 100 mg $0 (1) 90 labetalol hcl tab 200 mg $0 (1) 90 labetalol hcl tab 300 mg $0 (1) 90 metoprolol & hydrochlorothiazide tab mg (Lopressor hct) $0 (1) 90 metoprolol & hydrochlorothiazide tab mg $0 (1) 90 metoprolol succinate tab er 24hr 25 mg (tartrate equiv) (Toprol xl) $0 (1) 90 metoprolol succinate tab er 24hr 50 mg (tartrate equiv) (Toprol xl) $0 (1) 90 metoprolol succinate tab er 24hr 100 mg (tartrate equiv) (Toprol $0 (1) 90 xl) metoprolol succinate tab er 24hr 200 mg (tartrate equiv) (Toprol $0 (1) 90 xl) metoprolol tartrate tab 25 mg $0 (1) 90 metoprolol tartrate tab 50 mg (Lopressor) $0 (1) 90 metoprolol tartrate tab 100 mg (Lopressor) $0 (1) 90 METOPROLOL/HYDROCHLOROTHI metoprolol & $0 (2) 90 hydrochlorothiazide tab mg nadolol tab 20 mg (Corgard) $0 (1) 90 24

31 nadolol tab 40 mg (Corgard) $0 (1) 90 nadolol tab 80 mg (Corgard) $0 (1) 90 propranolol hcl tab 10 mg $0 (1) 90 propranolol hcl tab 20 mg $0 (1) 90 propranolol hcl tab 40 mg $0 (1) 90 propranolol hcl tab 60 mg $0 (1) 90 propranolol hcl tab 80 mg $0 (1) 90 PROPRANOLOL/HYDROCHLOROTH propranolol & hydrochlorothiazide tab mg $0 (2) 90 CALCIUM CHANNEL BLOCKERS AND COMBINATIONS amlodipine besylate tab 2.5 mg (Norvasc) $0 (1) 90 amlodipine besylate tab 5 mg (Norvasc) $0 (1) 90 amlodipine besylate tab 10 mg (Norvasc) $0 (1) 90 amlodipine besylate-benazepril hcl cap mg $0 (1) 90 amlodipine besylate-benazepril hcl cap 5-10 mg (Lotrel) $0 (1) 90 amlodipine besylate-benazepril hcl cap 5-20 mg (Lotrel) $0 (1) 90 amlodipine besylate-benazepril hcl cap 5-40 mg $0 (1) 90 amlodipine besylate-benazepril hcl cap mg (Lotrel) $0 (1) 90 amlodipine besylate-benazepril hcl cap mg (Lotrel) $0 (1) 90 amlodipine besylate-valsartan tab mg (Exforge) $0 (1) QL (30 tablets/30 days), 90 amlodipine besylate-valsartan tab mg (Exforge) $0 (1) QL (30 tablets/30 days), 90 amlodipine besylate-valsartan tab mg (Exforge) $0 (1) QL (30 tablets/30 days), 90 amlodipine besylate-valsartan tab mg (Exforge) $0 (1) QL (30 tablets/30 days), 90 diltiazem hcl cap er 12hr 60 mg $0 (1) 90 diltiazem hcl cap er 24hr 120 mg $0 (1) 90 diltiazem hcl cap er 24hr 180 mg $0 (1) 90 diltiazem hcl cap er 24hr 240 mg $0 (1) 90 diltiazem hcl coated beads cap er 24hr 120 mg (Cardizem cd) $0 (1) 90 diltiazem hcl coated beads cap er 24hr 180 mg (Cardizem cd) $0 (1) 90 diltiazem hcl coated beads cap er 24hr 240 mg (Cardizem cd) $0 (1) 90 diltiazem hcl coated beads cap er 24hr 300 mg $0 (1) 90 diltiazem hcl extended release beads cap er 24hr 120 mg (Tiazac) diltiazem hcl extended release beads cap er 24hr 180 mg (Tiazac) $0 (1) 90 $0 (1) 90 25

32 diltiazem hcl extended release beads cap er 24hr 240 mg $0 (1) 90 (Tiazac) diltiazem hcl extended release beads cap er 24hr 300 mg $0 (1) 90 (Tiazac) diltiazem hcl extended release beads cap er 24hr 360 mg $0 (1) 90 (Tiazac) diltiazem hcl extended release beads cap er 24hr 420 mg $0 (1) 90 (Tiazac) diltiazem hcl tab 30 mg (Cardizem) $0 (1) 90 diltiazem hcl tab 60 mg (Cardizem) $0 (1) 90 diltiazem hcl tab 90 mg $0 (1) 90 diltiazem hcl tab 120 mg (Cardizem) $0 (1) 90 felodipine tab er 24hr 2.5 mg $0 (1) 90 felodipine tab er 24hr 5 mg $0 (1) 90 felodipine tab er 24hr 10 mg $0 (1) 90 nifedipine cap 10 mg (Procardia) $0 (1) 90 nifedipine tab er 24hr 30 mg (Adalat cc) $0 (1) 90 nifedipine tab er 24hr 60 mg (Adalat cc) $0 (1) 90 nifedipine tab er 24hr 90 mg (Adalat cc) $0 (1) 90 nifedipine tab er 24hr osmotic release 30 mg (Procardia xl) $0 (1) 90 nifedipine tab er 24hr osmotic release 60 mg (Procardia xl) $0 (1) 90 nifedipine tab er 24hr osmotic release 90 mg (Procardia xl) $0 (1) 90 verapamil hcl cap er 24hr 100 mg (Verelan pm) $0 (1) 90 verapamil hcl cap er 24hr 120 mg (Verelan) $0 (1) 90 verapamil hcl cap er 24hr 180 mg (Verelan) $0 (1) 90 verapamil hcl cap er 24hr 200 mg (Verelan pm) $0 (1) 90 verapamil hcl cap er 24hr 240 mg (Verelan) $0 (1) 90 verapamil hcl cap er 24hr 300 mg (Verelan pm) $0 (1) 90 verapamil hcl cap er 24hr 360 mg (Verelan) $0 (1) 90 verapamil hcl tab er 120 mg (Calan sr) $0 (1) 90 verapamil hcl tab er 180 mg (Calan sr) $0 (1) 90 verapamil hcl tab er 240 mg (Calan sr) $0 (1) 90 verapamil hcl tab 40 mg $0 (1) 90 verapamil hcl tab 80 mg (Calan) $0 (1) 90 verapamil hcl tab 120 mg (Calan) $0 (1) 90 CHEST PAIN 26

33 ISOSORBIDE DINITRATE ER isosorbide dinitrate tab er 40 mg $0 (2) 90 isosorbide dinitrate tab 5 mg (Isordil titradose) $0 (1) 90 isosorbide dinitrate tab 10 mg $0 (1) 90 isosorbide dinitrate tab 20 mg $0 (1) 90 isosorbide dinitrate tab 30 mg $0 (1) 90 isosorbide mononitrate tab er 24hr 30 mg $0 (1) 90 isosorbide mononitrate tab er 24hr 60 mg $0 (1) 90 isosorbide mononitrate tab er 24hr 120 mg $0 (1) 90 isosorbide mononitrate tab 10 mg $0 (1) 90 isosorbide mononitrate tab 20 mg $0 (1) 90 nitroglycerin cap er 2.5 mg $0 (1) 90 nitroglycerin cap er 6.5 mg $0 (1) 90 nitroglycerin cap er 9 mg $0 (1) 90 nitroglycerin sl tab 0.3 mg (Nitrostat) $0 (1) 90 nitroglycerin sl tab 0.4 mg (Nitrostat) $0 (1) 90 nitroglycerin sl tab 0.6 mg (Nitrostat) $0 (1) 90 nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur) $0 (1) 90 nitroglycerin td patch 24hr 0.2 mg/hr (Nitro-dur) $0 (1) 90 nitroglycerin td patch 24hr 0.4 mg/hr (Nitro-dur) $0 (1) 90 nitroglycerin td patch 24hr 0.6 mg/hr (Nitro-dur) $0 (1) 90 CHOLESTEROL LOWERING atorvastatin calcium tab 10 mg (base equivalent) (Lipitor) $0 (1) QL (30 tablets/30 days), 90 atorvastatin calcium tab 20 mg (base equivalent) (Lipitor) $0 (1) QL (30 tablets/30 days), 90 atorvastatin calcium tab 40 mg (base equivalent) (Lipitor) $0 (1) QL (30 tablets/30 days), 90 atorvastatin calcium tab 80 mg (base equivalent) (Lipitor) $0 (1) QL (30 tablets/30 days), 90 cholestyramine light powder packets 4 gm $0 (1) 90 cholestyramine light powder 4 gm/dose (Questran light) $0 (1) 90 cholestyramine powder packets 4 gm (Questran) $0 (1) 90 cholestyramine powder 4 gm/dose (Questran) $0 (1) 90 choline fenofibrate cap dr 45 mg (fenofibric acid equiv) (Trilipix) $0 (1) QL (60 tablets/30 days), 90 choline fenofibrate cap dr 135 mg (fenofibric acid equiv) (Trilipix) $0 (1) QL (30 tablets/30 days), 90 colestipol hcl granule packets 5 gm (Colestid flavored) $0 (1) 90 colestipol hcl granules 5 gm (Colestid) $0 (1) 90 colestipol hcl tab 1 gm (Colestid) $0 (1) 90 fenofibrate micronized cap 43 mg $0 (1) QL (60 capsules/30 days), 90 27

34 fenofibrate micronized cap 67 mg (Lofibra) $0 (1) QL (30 capsules/30 days), 90 fenofibrate micronized cap 134 mg (Lofibra) $0 (1) QL (30 capsules/30 days), 90 fenofibrate micronized cap 200 mg (Lofibra) $0 (1) QL (30 capsules/30 days), 90 fenofibrate tab 48 mg (Tricor) $0 (1) QL (60 tablets/30 days), 90 fenofibrate tab 54 mg (Lofibra) $0 (1) QL (60 tablets/30 days), 90 fenofibrate tab 145 mg (Tricor) $0 (1) QL (30 tablets/30 days), 90 fenofibrate tab 160 mg $0 (1) QL (30 tablets/30 days), 90 gemfibrozil tab 600 mg (Lopid) $0 (1) QL (60 tablets/30 days), 90 lovastatin tab 10 mg $0 (1) QL (60 tablets/30 days), 90 lovastatin tab 20 mg $0 (1) QL (60 tablets/30 days), 90 lovastatin tab 40 mg $0 (1) QL (60 tablets/30 days), 90 PRALUENT alirocumab subcutaneous soln pen-injector 75 mg/ ml PRALUENT alirocumab subcutaneous soln pen-injector 150 mg/ml 28 $0 (2) PA, QL (2 pens/28 days), SP, 90 $0 (2) PA, QL (2 pens/28 days), SP, 90 pravastatin sodium tab 10 mg $0 (1) QL (45 tablets/30 days), 90 pravastatin sodium tab 20 mg (Pravachol) $0 (1) QL (45 tablets/30 days), 90 pravastatin sodium tab 40 mg (Pravachol) $0 (1) QL (45 tablets/30 days), 90 pravastatin sodium tab 80 mg (Pravachol) $0 (1) QL (30 tablets/30 days), 90 REPATHA evolocumab subcutaneous soln prefilled syringe 140 mg/ml REPATHA SURECLICK evolocumab subcutaneous soln autoinjector 140 mg/ml $0 (2) PA, QL (2 syringes/28 days), SP, 90 $0 (2) PA, QL (2 syringes/28 days), SP, 90 rosuvastatin calcium tab 5 mg (Crestor) $0 (1) QL (30 tablets/30 days), 90 rosuvastatin calcium tab 10 mg (Crestor) $0 (1) QL (30 tablets/30 days), 90 rosuvastatin calcium tab 20 mg (Crestor) $0 (1) QL (30 tablets/30 days), 90 rosuvastatin calcium tab 40 mg (Crestor) $0 (1) QL (30 tablets/30 days), 90 simvastatin tab 5 mg (Zocor) $0 (1) QL (30 tablets/30 days), 90 simvastatin tab 10 mg (Zocor) $0 (1) QL (30 tablets/30 days), 90 simvastatin tab 20 mg (Zocor) $0 (1) QL (30 tablets/30 days), 90 simvastatin tab 40 mg (Zocor) $0 (1) QL (30 tablets/30 days), 90 FLUID RETENTION acetazolamide cap er 12hr 500 mg (Diamox) $0 (1) 90 acetazolamide tab 125 mg $0 (1) 90 acetazolamide tab 250 mg $0 (1) 90 amiloride & hydrochlorothiazide tab 5-50 mg $0 (1) 90

35 amiloride hcl tab 5 mg $0 (1) 90 bumetanide tab 0.5 mg (Bumex) $0 (1) 90 bumetanide tab 1 mg (Bumex) $0 (1) 90 bumetanide tab 2 mg (Bumex) $0 (1) 90 CHLOROTHIAZIDE chlorothiazide tab 250 mg $0 (2) 90 chlorothiazide tab 500 mg $0 (1) 90 chlorthalidone tab 25 mg $0 (1) 90 chlorthalidone tab 50 mg $0 (1) 90 furosemide oral soln 10 mg/ml $0 (1) 90 furosemide tab 20 mg (Lasix) $0 (1) 90 furosemide tab 40 mg (Lasix) $0 (1) 90 furosemide tab 80 mg (Lasix) $0 (1) 90 hydrochlorothiazide cap 12.5 mg (Microzide) $0 (1) 90 hydrochlorothiazide tab 12.5 mg $0 (1) 90 hydrochlorothiazide tab 25 mg $0 (1) 90 hydrochlorothiazide tab 50 mg $0 (1) 90 indapamide tab 1.25 mg $0 (1) 90 indapamide tab 2.5 mg $0 (1) 90 metolazone tab 2.5 mg $0 (1) 90 metolazone tab 5 mg $0 (1) 90 metolazone tab 10 mg $0 (1) 90 spironolactone & hydrochlorothiazide tab mg (Aldactazide) $0 (1) 90 spironolactone tab 25 mg (Aldactone) $0 (1) 90 spironolactone tab 50 mg (Aldactone) $0 (1) 90 spironolactone tab 100 mg (Aldactone) $0 (1) 90 torsemide tab 5 mg $0 (1) 90 torsemide tab 10 mg (Demadex) $0 (1) 90 torsemide tab 20 mg (Demadex) $0 (1) 90 torsemide tab 100 mg $0 (1) 90 triamterene & hydrochlorothiazide cap mg (Dyazide) $0 (1) 90 triamterene & hydrochlorothiazide tab mg (Maxzide-25) $0 (1) 90 triamterene & hydrochlorothiazide tab mg (Maxzide) $0 (1) 90 HEART RHYTHM amiodarone hcl tab 200 mg $0 (1) 90 disopyramide phosphate cap 100 mg (Norpace) $0 (1) 90 29

36 disopyramide phosphate cap 150 mg (Norpace) $0 (1) 90 dofetilide cap 125 mcg (0.125 mg) (Tikosyn) $0 (1) 90 dofetilide cap 250 mcg (0.25 mg) (Tikosyn) $0 (1) 90 dofetilide cap 500 mcg (0.5 mg) (Tikosyn) $0 (1) 90 flecainide acetate tab 50 mg $0 (1) 90 flecainide acetate tab 100 mg $0 (1) 90 flecainide acetate tab 150 mg $0 (1) 90 mexiletine hcl cap 150 mg $0 (1) 90 mexiletine hcl cap 200 mg $0 (1) 90 mexiletine hcl cap 250 mg $0 (1) 90 propafenone hcl tab 150 mg $0 (1) 90 propafenone hcl tab 225 mg $0 (1) 90 propafenone hcl tab 300 mg $0 (1) 90 quinidine gluconate tab er 324 mg $0 (1) 90 QUINIDINE SULFATE quinidine sulfate tab 200 mg $0 (2) 90 QUINIDINE SULFATE quinidine sulfate tab 300 mg $0 (2) 90 sotalol hcl tab 80 mg (Betapace) $0 (1) 90 sotalol hcl tab 120 mg (Betapace) $0 (1) 90 sotalol hcl tab 160 mg (Betapace) $0 (1) 90 sotalol hcl tab 240 mg $0 (1) 90 OTHER HEART RELATED DRUGS ADCIRCA tadalafil tab 20 mg (pah) $0 (2) PA, QL (60 tablets/30 days), SP, 90 clonidine hcl tab 0.1 mg (Catapres) $0 (1) 90 clonidine hcl tab 0.2 mg (Catapres) $0 (1) 90 clonidine hcl tab 0.3 mg (Catapres) $0 (1) 90 clonidine hcl td patch weekly 0.1 mg/24hr (Catapres-tts-1) $0 (1) 90 clonidine hcl td patch weekly 0.2 mg/24hr (Catapres-tts-2) $0 (1) 90 clonidine hcl td patch weekly 0.3 mg/24hr (Catapres-tts-3) $0 (1) 90 DIGOXIN digoxin oral soln 0.05 mg/ml $0 (2) 90 digoxin tab 125 mcg (0.125 mg) (Lanoxin) $0 (1) 90 digoxin tab 250 mcg (0.25 mg) (Lanoxin) $0 (1) 90 doxazosin mesylate tab 1 mg (Cardura) $0 (1) QL (30 tablets/30 days), 90 doxazosin mesylate tab 2 mg (Cardura) $0 (1) QL (30 tablets/30 days), 90 doxazosin mesylate tab 4 mg (Cardura) $0 (1) QL (30 tablets/30 days), 90 30

37 doxazosin mesylate tab 8 mg (Cardura) $0 (1) QL (60 tablets/30 days), 90 ENTRESTO sacubitril-valsartan tab mg $0 (2) PA, QL (60 tablets/30 days), 90 ENTRESTO sacubitril-valsartan tab mg $0 (2) PA, QL (60 tablets/30 days), 90 ENTRESTO sacubitril-valsartan tab mg $0 (2) PA, QL (60 tablets/30 days), 90 EPINEPHRINE HCL epinephrine inj 30 mg/30ml $0 (2) guanfacine hcl tab 1 mg $0 (1) 90 guanfacine hcl tab 2 mg $0 (1) 90 hydralazine hcl tab 10 mg $0 (1) 90 hydralazine hcl tab 25 mg $0 (1) 90 hydralazine hcl tab 50 mg $0 (1) 90 hydralazine hcl tab 100 mg $0 (1) 90 methyldopa tab 250 mg $0 (1) 90 methyldopa tab 500 mg $0 (1) 90 METHYLDOPATE HCL methyldopate hcl inj 250 mg/5ml $0 (2) midodrine hcl tab 2.5 mg $0 (1) midodrine hcl tab 5 mg $0 (1) midodrine hcl tab 10 mg $0 (1) minoxidil tab 2.5 mg $0 (1) 90 minoxidil tab 10 mg $0 (1) 90 PAPAVERINE HCL papaverine hcl inj 30 mg/ml $0 (2) phenoxybenzamine hcl cap 10 mg (Dibenzyline) $0 (1) prazosin hcl cap 1 mg (Minipress) $0 (1) 90 prazosin hcl cap 2 mg (Minipress) $0 (1) 90 prazosin hcl cap 5 mg (Minipress) $0 (1) 90 sildenafil citrate tab 20 mg (Revatio) $0 (1) PA, QL (90 tablets/30 days), SP, 90 terazosin hcl cap 1 mg $0 (1) QL (30 capsules/30 days), 90 terazosin hcl cap 2 mg $0 (1) QL (30 capsules/30 days), 90 terazosin hcl cap 5 mg $0 (1) QL (30 capsules/30 days), 90 terazosin hcl cap 10 mg $0 (1) QL (60 capsules/30 days), 90 TRACLEER bosentan tab 62.5 mg $0 (2) PA, QL (60 tablets/30 days), SP, 90 31

38 32 TRACLEER bosentan tab 125 mg $0 (2) PA, QL (60 tablets/30 days), SP, 90 ANAPHYLAXIS EPINEPHRINE epinephrine solution auto-injector 0.15 mg/0.3ml (1:2000) EPINEPHRINE epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000) RESPIRATORY AGENTS ANTIHISTAMINES carbinoxamine maleate soln 4 mg/5ml $0 (1) carbinoxamine maleate tab 4 mg $0 (1) cetirizine hcl oral soln 1 mg/ml (5 mg/5ml) $0 (1) cetirizine hcl tab 5 mg $0 (3) cetirizine hcl tab 10 mg $0 (3) chlorpheniramine maleate tab 4 mg $0 (3) clemastine fumarate tab 1.34 mg (1 mg base equiv) $0 (3) cyproheptadine hcl syrup 2 mg/5ml $0 (1) cyproheptadine hcl tab 4 mg $0 (1) desloratadine tab 5 mg (Clarinex) $0 (1) diphenhydramine hcl cap 25 mg $0 (3) diphenhydramine hcl cap 50 mg $0 (1) diphenhydramine hcl liquid 12.5 mg/5ml $0 (3) diphenhydramine hcl tab 25 mg $0 (3) fexofenadine hcl susp 30 mg/5ml (6 mg/ml) $0 (3) fexofenadine hcl tab 60 mg $0 (3) fexofenadine hcl tab 180 mg $0 (3) levocetirizine dihydrochloride tab 5 mg $0 (1) loratadine syrup 5 mg/5ml $0 (3) loratadine tab 10 mg $0 (3) promethazine hcl suppos 12.5 mg $0 (1) promethazine hcl suppos 25 mg $0 (1) promethazine hcl syrup 6.25 mg/5ml $0 (1) promethazine hcl tab 12.5 mg $0 (1) promethazine hcl tab 25 mg $0 (1) promethazine hcl tab 50 mg $0 (1) NASAL PRODUCTS $0 (2) QL (4 pens/1 prescription) $0 (2) QL (4 pens/1 prescription)

39 azelastine hcl nasal spray 0.1% (137 mcg/spray) $0 (1) QL (2 bottles/30 days) FLUNISOLIDE flunisolide nasal soln 25 mcg/act (0.025%) $0 (2) QL (3 bottles/30 days) fluticasone propionate nasal susp 50 mcg/act $0 (1) QL (1 inhaler/30 days) phenylephrine hcl tab 10 mg $0 (3) saline nasal spray 0.65% $0 (3) COUGH/COLD/ALLERGY acetylcysteine inhal soln 10% $0 (1) acetylcysteine inhal soln 20% $0 (1) BROHIST D brompheniramine & phenylephrine tab 4-10 mg $0 (3) brompheniramine & phenylephrine elixir mg/5ml $0 (3) dextromethorphan-guaifenesin liquid mg/5ml $0 (3) diphenhydramine-phenylephrine liq mg/5ml $0 (3) guaifenesin liquid 100 mg/5ml $0 (3) guaifenesin-codeine soln mg/5ml $0 (3) ME phenylephrine w/ dm-gg liqd mg/5ml $0 (3) phenylephrine-guaifenesin tab mg $0 (3) PHENYLEPHRINE/GUAIFENESIN phenylephrine-guaifenesin $0 (2) liqd mg/5ml ( mg/ml) promethazine w/ codeine syrup mg/5ml $0 (1) ME RELHIST BP brompheniramine & phenylephrine tab 4-10 mg $0 (3) RU-HIST D brompheniramine & phenylephrine tab 4-10 mg $0 (3) sodium chloride soln nebu 0.9% $0 (1) sodium chloride soln nebu 3% $0 (1) sodium chloride soln nebu 7% (Hyper-sal) $0 (1) sodium chloride soln nebu 10% $0 (1) TRIAMINIC NIGHT TIME COLD diphenhydraminephenylephrine syrup mg/5ml $0 (3) ASTHMA/COPD albuterol sulfate soln nebu 0.083% (2.5 mg/3ml) $0 (1) QL (125 containers/30 days), 90 albuterol sulfate soln nebu 0.5% (5 mg/ml) $0 (1) QL (60 mls/30 days), 90 albuterol sulfate soln nebu 0.63 mg/3ml (base equiv) $0 (1) QL (125 containers/30 days), 90 albuterol sulfate soln nebu 1.25 mg/3ml (base equiv) $0 (1) QL (125 containers/30 days), 90 albuterol sulfate syrup 2 mg/5ml $0 (1) 90 33

40 ARNUITY ELLIPTA fluticasone furoate aerosol powder breath $0 (2) QL (30 blisters/30 days), 90 activ 100 mcg/act ARNUITY ELLIPTA fluticasone furoate aerosol powder breath $0 (2) QL (30 blisters/30 days), 90 activ 200 mcg/act ATROVENT HFA ipratropium bromide hfa inhal aerosol $0 (2) QL (2 inhalers/30 days), mcg/act budesonide inhalation susp 0.25 mg/2ml (Pulmicort) $0 (1) QL (2 packages/30 days), 90 budesonide inhalation susp 0.5 mg/2ml (Pulmicort) $0 (1) QL (2 packages/30 days), 90 budesonide inhalation susp 1 mg/2ml (Pulmicort) $0 (1) QL (60 mls/30 days), 90 COMBIVENT RESPIMAT ipratropium-albuterol inhal aerosol $0 (2) QL (2 inhalers/30 days), 90 soln mcg/act cromolyn sodium soln nebu 20 mg/2ml $0 (1) QL (240 mls/30 days), 90 FLOVENT DISKUS fluticasone propionate aer pow ba 50 mcg/ blister FLOVENT DISKUS fluticasone propionate aer pow ba 100 mcg/blister FLOVENT DISKUS fluticasone propionate aer pow ba 250 mcg/blister FLOVENT HFA fluticasone propionate hfa inhal aero 44 mcg/ act (50/valve) FLOVENT HFA fluticasone propionate hfa inhal aer 110 mcg/ act (125/valve) FLOVENT HFA fluticasone propionate hfa inhal aer 220 mcg/ act (250/valve) 34 $0 (2) AL, PA, QL (1 inhaler/30 days), 90 $0 (2) AL, PA, QL (1 inhaler/30 days), 90 $0 (2) AL, PA, QL (4 inhalers/30 days), 90 $0 (2) AL, PA, QL (1 inhaler/30 days), 90 $0 (2) AL, PA, QL (1 inhaler/30 days), 90 $0 (2) AL, PA, QL (2 inhalers/30 days), 90 FLUTICASONE PROPIONATE/SA fluticasone-salmeterol aer $0 (2) QL (1 inhaler/30 days), 90 powder ba mcg/act FLUTICASONE PROPIONATE/SA fluticasone-salmeterol aer $0 (2) QL (1 inhaler/30 days), 90 powder ba mcg/act FLUTICASONE PROPIONATE/SA fluticasone-salmeterol aer $0 (2) QL (1 inhaler/30 days), 90 powder ba mcg/act ipratropium bromide inhal soln 0.02% $0 (1) QL (150 vials/30 days), 90 ipratropium-albuterol nebu soln (3) mg/3ml $0 (1) QL (180 containers/30 days), 90 montelukast sodium chew tab 4 mg (base equiv) (Singulair) $0 (1) QL (30 tablets/30 days), 90 montelukast sodium chew tab 5 mg (base equiv) (Singulair) $0 (1) QL (30 tablets/30 days), 90 montelukast sodium oral granules packet 4 mg (base equiv) $0 (1) QL (30 packets/30 days), 90 (Singulair) montelukast sodium tab 10 mg (base equiv) (Singulair) $0 (1) QL (30 tablets/30 days), 90 QVAR beclomethasone diprop inhal aero soln 40 mcg/act (50/ valve) $0 (2) AL, PA, QL (2 containers/30 days), 90

41 QVAR beclomethasone diprop inhal aero soln 80 mcg/act (100/ valve) SEREVENT DISKUS salmeterol xinafoate aer pow ba 50 mcg/ dose (base equiv) SPIRIVA HANDIHALER tiotropium bromide monohydrate inhal cap 18 mcg (base equiv) SYMBICORT budesonide-formoterol fumarate dihyd aerosol mcg/act SYMBICORT budesonide-formoterol fumarate dihyd aerosol mcg/act $0 (2) AL, PA, QL (2 containers/30 days), 90 $0 (2) QL (60 blisters/30 days), 90 $0 (2) QL (30 capsules/30 days), 90 $0 (2) AL, PA, QL (1 inhaler/30 days), 90 $0 (2) AL, PA, QL (1 inhaler/30 days), 90 terbutaline sulfate tab 2.5 mg $0 (1) 90 terbutaline sulfate tab 5 mg $0 (1) 90 theophylline soln 80 mg/15ml $0 (1) 90 theophylline tab er 12hr 100 mg $0 (1) 90 theophylline tab er 12hr 200 mg $0 (1) 90 theophylline tab er 12hr 300 mg $0 (1) 90 theophylline tab er 12hr 450 mg $0 (1) 90 theophylline tab er 24hr 400 mg $0 (1) 90 theophylline tab er 24hr 600 mg $0 (1) 90 VENTOLIN HFA albuterol sulfate inhal aero 108 mcg/act (90mcg base equiv) $0 (2) QL (3 inhalers/30 days), 90 OTHER RESPIRATORY DRUGS KALYDECO ivacaftor tab 150 mg $0 (2) PA, QL (60 tablets/30 days), SP, 90 KALYDECO ivacaftor packet 50 mg $0 (2) PA, QL (56 packets/28 days), SP, 90 KALYDECO ivacaftor packet 75 mg $0 (2) PA, QL (56 packets/28 days), SP, 90 PULMOZYME dornase alfa inhal soln 1 mg/ml $0 (2) SP, 90 GASTROINTESTINAL DRUGS LAXATIVES bisacodyl tab delayed release 5 mg $0 (3) docusate sodium cap 100 mg $0 (3) docusate sodium cap 250 mg $0 (3) docusate sodium liquid 150 mg/15ml $0 (3) FLEET LIQUID GLYCERIN SUP glycerin enema adult 5.4 gm/ average delivered dose $0 (3) 35

42 glycerin suppos 1 gm $0 (3) glycerin suppos 2 gm $0 (3) KONSYL psyllium powder 60.3% $0 (3) KONSYL psyllium powder 71.67% $0 (3) KONSYL-D psyllium powder 52.3% $0 (3) lactulose solution 10 gm/15ml $0 (1) 90 magnesium citrate soln $0 (3) METAMUCIL MULTIHEALTH FIB psyllium powder 55.46% $0 (3) METAMUCIL MULTIHEALTH FIB psyllium powder 63% $0 (3) METAMUCIL SMOOTH TEXTURE psyllium powder 63% $0 (3) PEDIA-LAX glycerin liquid suppos 2.8 gm (2.7 ml) $0 (3) peg 3350-kcl-sod bicarb-nacl for soln 420 gm (Nulytely/flavor $0 (1) pack) peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm (Golytely) $0 (1) peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm (Colyteflavor packs) $0 (1) polyethylene glycol 3350 oral powder $0 (1) psyllium powder 28.3% $0 (3) psyllium powder 30% $0 (3) psyllium powder 30.9% $0 (3) psyllium powder 48.57% $0 (3) psyllium powder 58.6% $0 (3) psyllium powder 95% $0 (3) sennosides tab 8.6 mg $0 (3) ANTIDIARRHEALS bismuth subsalicylate susp 262 mg/15ml $0 (3) diphenoxylate w/ atropine tab mg (Lomotil) $0 (1) loperamide hcl cap 2 mg $0 (1) loperamide hcl liq 1 mg/5ml (0.2 mg/ml) $0 (3) loperamide hcl tab 2 mg $0 (3) ANTACIDS alum & mag hydroxide-simethicone susp mg/5ml $0 (3) alum & mag hydroxide-simethicone susp mg/5ml $0 (3) calcium carbonate (antacid) chew tab 500 mg $0 (3) calcium carbonate (antacid) chew tab 750 mg $0 (3) 36

43 calcium carbonate (antacid) chew tab 1000 mg $0 (3) magnesium oxide tab 400 mg $0 (3) ULCER/GERD CIMETIDINE HCL cimetidine hcl soln 300 mg/5ml $0 (2) 90 cimetidine tab 200 mg $0 (1) 90 cimetidine tab 300 mg $0 (1) 90 cimetidine tab 400 mg $0 (1) 90 cimetidine tab 800 mg $0 (1) 90 dicyclomine hcl cap 10 mg (Bentyl) $0 (1) 90 dicyclomine hcl oral soln 10 mg/5ml $0 (1) 90 dicyclomine hcl tab 20 mg $0 (1) 90 famotidine for susp 40 mg/5ml (Pepcid) $0 (1) 90 famotidine tab 10 mg $0 (3) 90 famotidine tab 20 mg (Pepcid) $0 (1) 90 famotidine tab 40 mg (Pepcid) $0 (1) 90 glycopyrrolate tab 1 mg (Robinul) $0 (1) 90 glycopyrrolate tab 2 mg (Robinul forte) $0 (1) 90 hyoscyamine sulfate elixir mg/5ml $0 (1) 90 hyoscyamine sulfate soln mg/ml $0 (1) 90 hyoscyamine sulfate tab disint mg (Anaspaz) $0 (1) 90 hyoscyamine sulfate tab er 12hr mg (Levbid) $0 (1) 90 hyoscyamine sulfate tab sl mg (Levsin/sl) $0 (1) 90 hyoscyamine sulfate tab mg (Levsin) $0 (1) 90 lansoprazole cap delayed release 15 mg (Prevacid) $0 (1) QL (60 Capsules/30 days; 120 Days Supply/365 Days), 90 lansoprazole cap delayed release 30 mg (Prevacid) $0 (1) QL (60 Capsules/30 days; 120 Days Supply/365 Days), 90 misoprostol tab 100 mcg (Cytotec) $0 (1) 90 misoprostol tab 200 mcg (Cytotec) $0 (1) 90 NIZATIDINE nizatidine oral soln 15 mg/ml $0 (2) 90 nizatidine cap 150 mg $0 (1) 90 nizatidine cap 300 mg $0 (1) 90 37

44 omeprazole cap delayed release 20 mg $0 (1) QL (60 Capsules/30 days; 120 Days Supply/365 Days), 90 omeprazole cap delayed release 40 mg $0 (1) QL (60 Capsules/30 days; 120 Days Supply/365 Days), 90 pantoprazole sodium ec tab 20 mg (base equiv) (Protonix) $0 (1) QL (60 Tablets/30 days; 120 Days Supply/365 Days), 90 pantoprazole sodium ec tab 40 mg (base equiv) (Protonix) $0 (1) QL (60 Tablets/30 days; 120 Days Supply/365 Days), 90 ranitidine hcl syrup 15 mg/ml (75 mg/5ml) $0 (1) 90 ranitidine hcl tab 75 mg $0 (3) 90 ranitidine hcl tab 150 mg (Zantac) $0 (1) 90 ranitidine hcl tab 300 mg (Zantac) $0 (1) 90 sucralfate tab 1 gm (Carafate) $0 (1) 90 NAUSEA AND VOMITING fructose-dextrose-phosphoric acid oral soln $0 (3) meclizine hcl tab 12.5 mg $0 (1) meclizine hcl tab 25 mg $0 (1) ondansetron hcl oral soln 4 mg/5ml (Zofran) $0 (1) QL (300 mls/30 days) ondansetron hcl tab 4 mg (Zofran) $0 (1) QL (30 tablets/30 days) ondansetron hcl tab 8 mg (Zofran) $0 (1) QL (30 tablets/30 days) ondansetron hcl tab 24 mg $0 (1) QL (1 tablet/30 days) ondansetron orally disintegrating tab 4 mg (Zofran odt) $0 (1) QL (30 tablets/30 days) ondansetron orally disintegrating tab 8 mg (Zofran odt) $0 (1) QL (30 tablets/30 days) prochlorperazine maleate tab 5 mg (base equivalent) $0 (1) 90 prochlorperazine maleate tab 10 mg (base equivalent) $0 (1) 90 prochlorperazine suppos 25 mg $0 (1) DIGESTIVE ENZYMES CREON pancrelipase (lip-prot-amyl) dr cap unit CREON pancrelipase (lip-prot-amyl) dr cap unit CREON pancrelipase (lip-prot-amyl) dr cap unit CREON pancrelipase (lip-prot-amyl) dr cap unit $0 (2) 90 $0 (2) 90 $0 (2) 90 $0 (2) 90 38

45 CREON pancrelipase (lip-prot-amyl) dr cap unit ZENPEP pancrelipase (lip-prot-amyl) dr cap unit ZENPEP pancrelipase (lip-prot-amyl) dr cap unit ZENPEP pancrelipase (lip-prot-amyl) dr cap unit ZENPEP pancrelipase (lip-prot-amyl) dr cap unit ZENPEP pancrelipase (lip-prot-amyl) dr cap unit ZENPEP pancrelipase (lip-prot-amyl) dr cap unit OTHER GASTROINTESTINAL DRUGS balsalazide disodium cap 750 mg (Colazal) $0 (1) $0 (2) 90 $0 (2) 90 $0 (2) 90 $0 (2) 90 $0 (2) 90 $0 (2) 90 $0 (2) 90 calcium acetate (phosphate binder) cap 667 mg (169 mg ca) $0 (1) 90 calcium acetate (phosphate binder) tab 667 mg (Eliphos) $0 (1) 90 CANASA mesalamine suppos 1000 mg $0 (2) cromolyn sodium oral conc 100 mg/5ml (Gastrocrom) $0 (1) 90 KINEVAC sincalide for inj 5 mcg $0 (2) lactulose (encephalopathy) solution 10 gm/15ml $0 (1) 90 MESALAMINE DR mesalamine tab delayed release 800 mg $0 (2) mesalamine enema 4 gm $0 (1) metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) $0 (1) metoclopramide hcl tab 5 mg (Reglan) $0 (1) metoclopramide hcl tab 10 mg (Reglan) $0 (1) 90 simethicone chew tab 80 mg $0 (3) simethicone susp 40 mg/0.6ml $0 (3) sulfasalazine tab delayed release 500 mg (Azulfidine en-tabs) $0 (1) 90 sulfasalazine tab 500 mg (Azulfidine) $0 (1) 90 ursodiol cap 300 mg (Actigall) $0 (1) 90 ursodiol tab 250 mg (Urso 250) $0 (1) 90 ursodiol tab 500 mg (Urso forte) $0 (1) 90 GENITOURINARY DRUGS URINARY TRACT INFECTIONS nitrofurantoin macrocrystalline cap 25 mg (Macrodantin) $0 (1) 39

46 nitrofurantoin macrocrystalline cap 50 mg (Macrodantin) $0 (1) nitrofurantoin macrocrystalline cap 100 mg (Macrodantin) $0 (1) nitrofurantoin monohydrate macrocrystalline cap 100 mg $0 (1) (Macrobid) nitrofurantoin susp 25 mg/5ml (Furadantin) $0 (1) URINARY TRACT SPASMS bethanechol chloride tab 5 mg (Urecholine) $0 (1) bethanechol chloride tab 10 mg (Urecholine) $0 (1) bethanechol chloride tab 25 mg (Urecholine) $0 (1) bethanechol chloride tab 50 mg (Urecholine) $0 (1) oxybutynin chloride syrup 5 mg/5ml $0 (1) QL (600 mls/30 days), 90 oxybutynin chloride tab er 24hr 5 mg (Ditropan xl) $0 (1) QL (30 tablets/30 days), 90 oxybutynin chloride tab er 24hr 10 mg (Ditropan xl) $0 (1) QL (60 tablets/30 days), 90 oxybutynin chloride tab er 24hr 15 mg (Ditropan xl) $0 (1) QL (60 tablets/30 days), 90 oxybutynin chloride tab 5 mg $0 (1) QL (120 tablets/30 days), 90 VAGINAL PRODUCTS clindamycin phosphate vaginal cream 2% (Cleocin) $0 (1) clotrimazole vaginal cream 2% $0 (3) estradiol vaginal tab 10 mcg (Vagifem) $0 (1) 90 metronidazole vaginal gel 0.75% (Metrogel-vaginal) $0 (1) miconazole nitrate vaginal cream 2% $0 (3) terconazole vaginal cream 0.4% (Terazol 7) $0 (1) terconazole vaginal cream 0.8% $0 (1) terconazole vaginal suppos 80 mg $0 (1) tioconazole vaginal oint 6.5% $0 (3) OTHER GENITOURINARY DRUGS alfuzosin hcl tab er 24hr 10 mg (Uroxatral) $0 (1) QL (30 tablets/30 days), 90 finasteride tab 5 mg (Proscar) $0 (1) QL (30 tablets/30 days), 90 phenazopyridine hcl tab 100 mg (Pyridium) $0 (1) phenazopyridine hcl tab 200 mg (Pyridium) $0 (1) pot & sod citrates w/ cit ac soln mg/5ml $0 (1) potassium citrate & citric acid powder pack mg $0 (1) potassium citrate & citric acid soln mg/5ml $0 (1) potassium citrate tab er 5 meq (540 mg) (Urocit-k 5) $0 (1) potassium citrate tab er 10 meq (1080 mg) (Urocit-k 10) $0 (1) 40

47 potassium citrate tab er 15 meq (1620 mg) (Urocit-k 15) $0 (1) sodium chloride irrigation soln 0.9% $0 (1) sodium citrate & citric acid soln mg/5ml (Shohls solution $0 (1) modi) tamsulosin hcl cap 0.4 mg (Flomax) $0 (1) QL (60 capsules/30 days), 90 CENTRAL NERVOUS SYSTEM DRUGS ANXIETY alprazolam tab 0.25 mg (Xanax) $0 (1) QL (120 tablets/30 days) alprazolam tab 0.5 mg (Xanax) $0 (1) QL (120 tablets/30 days) alprazolam tab 1 mg (Xanax) $0 (1) QL (120 tablets/30 days) alprazolam tab 2 mg (Xanax) $0 (1) QL (90 tablets/30 days) buspirone hcl tab 5 mg $0 (1) buspirone hcl tab 10 mg $0 (1) buspirone hcl tab 15 mg $0 (1) buspirone hcl tab 30 mg $0 (1) chlordiazepoxide hcl cap 5 mg $0 (1) QL (120 capsules/30 days) chlordiazepoxide hcl cap 10 mg $0 (1) QL (120 capsules/30 days) chlordiazepoxide hcl cap 25 mg $0 (1) QL (120 capsules/30 days) clorazepate dipotassium tab 3.75 mg $0 (1) QL (90 tablets/30 days) clorazepate dipotassium tab 7.5 mg (Tranxene t) $0 (1) QL (90 tablets/30 days) clorazepate dipotassium tab 15 mg $0 (1) QL (120 tablets/30 days) diazepam conc 5 mg/ml $0 (1) QL (240 mls/30 days) diazepam tab 2 mg (Valium) $0 (1) QL (120 tablets/30 days) diazepam tab 5 mg (Valium) $0 (1) QL (120 tablets/30 days) diazepam tab 10 mg (Valium) $0 (1) QL (120 tablets/30 days) HYDROXYZINE HCL hydroxyzine hcl im soln 25 mg/ml $0 (2) hydroxyzine hcl syrup 10 mg/5ml $0 (1) hydroxyzine hcl tab 10 mg $0 (1) hydroxyzine hcl tab 25 mg $0 (1) hydroxyzine hcl tab 50 mg $0 (1) hydroxyzine pamoate cap 25 mg (Vistaril) $0 (1) hydroxyzine pamoate cap 50 mg (Vistaril) $0 (1) lorazepam conc 2 mg/ml $0 (1) QL (150 mls/30 days) lorazepam tab 0.5 mg (Ativan) $0 (1) QL (90 tablets/30 days) lorazepam tab 1 mg (Ativan) $0 (1) QL (90 tablets/30 days) 41

48 lorazepam tab 2 mg (Ativan) $0 (1) QL (150 tablets/30 days) DEPRESSION amitriptyline hcl tab 10 mg $0 (1) 90 amitriptyline hcl tab 25 mg (Elavil) $0 (1) 90 amitriptyline hcl tab 50 mg $0 (1) 90 amitriptyline hcl tab 75 mg $0 (1) 90 amitriptyline hcl tab 100 mg $0 (1) 90 amitriptyline hcl tab 150 mg $0 (1) 90 bupropion hcl tab er 12hr 100 mg (Wellbutrin sr) $0 (1) QL (60 tablets/30 days), 90 bupropion hcl tab er 12hr 150 mg (Wellbutrin sr) $0 (1) QL (60 tablets/30 days), 90 bupropion hcl tab er 12hr 200 mg (Wellbutrin sr) $0 (1) QL (60 tablets/30 days), 90 bupropion hcl tab er 24hr 150 mg (Wellbutrin xl) $0 (1) QL (30 tablets/30 days), 90 bupropion hcl tab er 24hr 300 mg (Wellbutrin xl) $0 (1) QL (30 tablets/30 days), 90 bupropion hcl tab 75 mg $0 (1) QL (60 tablets/30 days), 90 bupropion hcl tab 100 mg $0 (1) QL (120 tablets/30 days), 90 citalopram hydrobromide oral soln 10 mg/5ml $0 (1) QL (600 mls/30 days), 90 citalopram hydrobromide tab 10 mg (base equiv) (Celexa) $0 (1) QL (30 tablets/30 days), 90 citalopram hydrobromide tab 20 mg (base equiv) (Celexa) $0 (1) QL (30 tablets/30 days), 90 citalopram hydrobromide tab 40 mg (base equiv) (Celexa) $0 (1) QL (30 tablets/30 days), 90 doxepin hcl cap 10 mg $0 (1) 90 doxepin hcl cap 25 mg $0 (1) 90 doxepin hcl cap 50 mg $0 (1) 90 doxepin hcl cap 75 mg $0 (1) 90 doxepin hcl cap 100 mg $0 (1) 90 doxepin hcl cap 150 mg $0 (1) 90 doxepin hcl conc 10 mg/ml $0 (1) 90 duloxetine hcl enteric coated pellets cap 20 mg (base eq) $0 (1) QL (60 capsules/30 days), 90 (Cymbalta) duloxetine hcl enteric coated pellets cap 30 mg (base eq) $0 (1) QL (90 capsules/30 days), 90 (Cymbalta) duloxetine hcl enteric coated pellets cap 60 mg (base eq) $0 (1) QL (60 capsules/30 days), 90 (Cymbalta) escitalopram oxalate soln 5 mg/5ml (base equiv) $0 (1) QL (600 mls/30 days), 90 escitalopram oxalate tab 5 mg (base equiv) (Lexapro) $0 (1) QL (30 tablets/30 days), 90 escitalopram oxalate tab 10 mg (base equiv) (Lexapro) $0 (1) QL (30 tablets/30 days), 90 escitalopram oxalate tab 20 mg (base equiv) (Lexapro) $0 (1) QL (30 tablets/30 days), 90 42

49 fluoxetine hcl cap 10 mg (Prozac) $0 (1) QL (30 capsules/30 days), 90 fluoxetine hcl cap 20 mg (Prozac) $0 (1) QL (120 capsules/30 days), 90 fluoxetine hcl solution 20 mg/5ml $0 (1) QL (600 mls/30 days), 90 fluvoxamine maleate tab 25 mg $0 (1) QL (30 tablets/30 days), 90 fluvoxamine maleate tab 50 mg $0 (1) QL (30 tablets/30 days), 90 fluvoxamine maleate tab 100 mg $0 (1) QL (90 tablets/30 days), 90 imipramine hcl tab 10 mg (Tofranil) $0 (1) 90 imipramine hcl tab 25 mg (Tofranil) $0 (1) 90 imipramine hcl tab 50 mg (Tofranil) $0 (1) 90 mirtazapine orally disintegrating tab 15 mg (Remeron soltab) $0 (1) QL (30 tablets/30 days), 90 mirtazapine orally disintegrating tab 30 mg (Remeron soltab) $0 (1) QL (30 tablets/30 days), 90 mirtazapine orally disintegrating tab 45 mg (Remeron soltab) $0 (1) QL (30 tablets/30 days), 90 mirtazapine tab 15 mg (Remeron) $0 (1) QL (30 tablets/30 days), 90 mirtazapine tab 30 mg (Remeron) $0 (1) QL (30 tablets/30 days), 90 mirtazapine tab 45 mg (Remeron) $0 (1) QL (30 tablets/30 days), 90 nortriptyline hcl cap 10 mg (Pamelor) $0 (1) 90 nortriptyline hcl cap 25 mg (Pamelor) $0 (1) 90 nortriptyline hcl cap 50 mg (Pamelor) $0 (1) 90 nortriptyline hcl cap 75 mg (Pamelor) $0 (1) 90 paroxetine hcl tab 10 mg (Paxil) $0 (1) QL (30 tablets/30 days), 90 paroxetine hcl tab 20 mg (Paxil) $0 (1) QL (30 tablets/30 days), 90 paroxetine hcl tab 30 mg (Paxil) $0 (1) QL (60 tablets/30 days), 90 paroxetine hcl tab 40 mg (Paxil) $0 (1) QL (30 tablets/30 days), 90 sertraline hcl oral conc 20 mg/ml (Zoloft) $0 (1) QL (300 mls/30 days), 90 sertraline hcl tab 25 mg (Zoloft) $0 (1) QL (30 tablets/30 days), 90 sertraline hcl tab 50 mg (Zoloft) $0 (1) QL (30 tablets/30 days), 90 sertraline hcl tab 100 mg (Zoloft) $0 (1) QL (60 tablets/30 days), 90 trazodone hcl tab 50 mg $0 (1) 90 trazodone hcl tab 100 mg $0 (1) 90 trazodone hcl tab 150 mg $0 (1) 90 venlafaxine hcl cap er 24hr 37.5 mg (base equivalent) (Effexor $0 (1) QL (30 capsules/30 days), 90 xr) venlafaxine hcl cap er 24hr 75 mg (base equivalent) (Effexor xr) $0 (1) QL (90 capsules/30 days), 90 venlafaxine hcl cap er 24hr 150 mg (base equivalent) (Effexor xr) $0 (1) QL (30 capsules/30 days), 90 43

50 venlafaxine hcl tab 25 mg $0 (1) QL (90 tablets/30 days), 90 venlafaxine hcl tab 37.5 mg $0 (1) QL (90 tablets/30 days), 90 venlafaxine hcl tab 50 mg $0 (1) QL (90 tablets/30 days), 90 venlafaxine hcl tab 75 mg $0 (1) QL (90 tablets/30 days), 90 venlafaxine hcl tab 100 mg $0 (1) QL (90 tablets/30 days), 90 PSYCHOTIC AND BIPOLAR DISORDERS ABILIFY MAINTENA aripiprazole im for er susp prefilled $0 (2) QL (1 syringe/28 days), ST syringe 300 mg ABILIFY MAINTENA aripiprazole im for er susp prefilled $0 (2) QL (1 syringe/28 days), ST syringe 400 mg ABILIFY MAINTENA aripiprazole im for extended release susp $0 (2) QL (1 syringe/28 days), ST 300 mg ABILIFY MAINTENA aripiprazole im for extended release susp $0 (2) QL (1 syringe/28 days), ST 400 mg aripiprazole oral solution 1 mg/ml $0 (1) QL (150 mls/30 days), 90 aripiprazole tab 2 mg (Abilify) $0 (1) QL (30 tablets/30 days), 90 aripiprazole tab 5 mg (Abilify) $0 (1) QL (30 tablets/30 days), 90 aripiprazole tab 10 mg (Abilify) $0 (1) QL (30 tablets/30 days), 90 aripiprazole tab 15 mg (Abilify) $0 (1) QL (30 tablets/30 days), 90 aripiprazole tab 20 mg (Abilify) $0 (1) QL (30 tablets/30 days), 90 aripiprazole tab 30 mg (Abilify) $0 (1) QL (30 tablets/30 days), 90 ARISTADA aripiprazole lauroxil im er susp prefilled syr 441 mg/1.6ml ARISTADA aripiprazole lauroxil im er susp prefilled syr 662 mg/2.4ml ARISTADA aripiprazole lauroxil im er susp prefilled syr 882 mg/3.2ml ARISTADA aripiprazole lauroxil im er susp prefilled syr 1064 mg/3.9ml $0 (2) QL (1 syringe/28 days), ST, 90 $0 (2) QL (1 syringe/28 days), ST, 90 $0 (2) QL (1 syringe/28 days), ST, 90 $0 (2) QL (1 syringe/56 days), ST, 90 clozapine orally disintegrating tab 25 mg (Fazaclo) $0 (1) QL (60 tablets/30 days) clozapine orally disintegrating tab 100 mg (Fazaclo) $0 (1) QL (60 tablets/30 days) clozapine tab 25 mg (Clozaril) $0 (1) QL (90 tablets/30 days) clozapine tab 50 mg $0 (1) QL (90 tablets/30 days) clozapine tab 100 mg (Clozaril) $0 (1) QL (270 tablets/30 days) clozapine tab 200 mg $0 (1) QL (120 tablets/30 days) fluphenazine decanoate inj 25 mg/ml $0 (1) FLUPHENAZINE HCL fluphenazine hcl elixir 2.5 mg/5ml $0 (2) 90 44

51 FLUPHENAZINE HCL fluphenazine hcl oral conc 5 mg/ml $0 (2) 90 fluphenazine hcl tab 1 mg $0 (1) 90 fluphenazine hcl tab 2.5 mg $0 (1) 90 fluphenazine hcl tab 5 mg $0 (1) 90 fluphenazine hcl tab 10 mg $0 (1) 90 haloperidol decanoate im soln 50 mg/ml (Haldol decanoate 50) $0 (1) haloperidol decanoate im soln 100 mg/ml (Haldol decanoate 100) $0 (1) haloperidol lactate oral conc 2 mg/ml $0 (1) 90 haloperidol tab 0.5 mg $0 (1) 90 haloperidol tab 1 mg $0 (1) 90 haloperidol tab 2 mg $0 (1) 90 haloperidol tab 5 mg $0 (1) 90 haloperidol tab 10 mg $0 (1) 90 haloperidol tab 20 mg $0 (1) 90 INVEGA SUSTENNA paliperidone palmitate im extendedrelease $0 (2) QL (1 kit/28 days), ST susp 39 mg/0.25ml INVEGA SUSTENNA paliperidone palmitate im extendedrelease $0 (2) QL (1 kit/28 days), ST susp 78 mg/0.5ml INVEGA SUSTENNA paliperidone palmitate im extend-release $0 (2) QL (1 kit/28 days), ST susp 117 mg/0.75ml INVEGA SUSTENNA paliperidone palmitate im extendedrelease $0 (2) QL (1 kit/28 days), ST susp 156 mg/ml INVEGA SUSTENNA paliperidone palmitate im extendedrelease $0 (2) QL (1 kit/28 days), ST susp 234 mg/1.5ml LATUDA lurasidone hcl tab 20 mg $0 (2) QL (30 tablets/30 days), ST, 90 LATUDA lurasidone hcl tab 40 mg $0 (2) QL (30 tablets/30 days), ST, 90 LATUDA lurasidone hcl tab 60 mg $0 (2) QL (30 tablets/30 days), ST, 90 LATUDA lurasidone hcl tab 80 mg $0 (2) QL (60 tablets/30 days), ST, 90 LATUDA lurasidone hcl tab 120 mg $0 (2) QL (30 tablets/30 days), ST, 90 LITHIUM lithium oral solution 8 meq/5ml $0 (2) 90 lithium carbonate cap 150 mg (Lithium carbonate) $0 (1) 90 lithium carbonate cap 300 mg $0 (1) 90 lithium carbonate cap 600 mg (Lithium carbonate) $0 (1) 90 45

52 lithium carbonate tab er 300 mg (Lithobid) $0 (1) 90 lithium carbonate tab er 450 mg $0 (1) 90 lithium carbonate tab 300 mg $0 (1) 90 loxapine succinate cap 5 mg $0 (1) 90 loxapine succinate cap 10 mg $0 (1) 90 loxapine succinate cap 25 mg $0 (1) 90 loxapine succinate cap 50 mg $0 (1) 90 olanzapine for im inj 10 mg (Zyprexa) $0 (1) QL (90 vials/30 days), 90 olanzapine orally disintegrating tab 5 mg (Zyprexa zydis) $0 (1) QL (30 tablets/30 days), 90 olanzapine orally disintegrating tab 10 mg (Zyprexa zydis) $0 (1) QL (30 tablets/30 days), 90 olanzapine orally disintegrating tab 15 mg (Zyprexa zydis) $0 (1) QL (30 tablets/30 days), 90 olanzapine orally disintegrating tab 20 mg (Zyprexa zydis) $0 (1) QL (30 tablets/30 days), 90 olanzapine tab 2.5 mg (Zyprexa) $0 (1) QL (30 tablets/30 days), 90 olanzapine tab 5 mg (Zyprexa) $0 (1) QL (30 tablets/30 days), 90 olanzapine tab 7.5 mg (Zyprexa) $0 (1) QL (30 tablets/30 days), 90 olanzapine tab 10 mg (Zyprexa) $0 (1) QL (30 tablets/30 days), 90 olanzapine tab 15 mg (Zyprexa) $0 (1) QL (30 tablets/30 days), 90 olanzapine tab 20 mg (Zyprexa) $0 (1) QL (30 tablets/30 days), 90 perphenazine tab 2 mg $0 (1) 90 perphenazine tab 4 mg $0 (1) 90 perphenazine tab 8 mg $0 (1) 90 perphenazine tab 16 mg $0 (1) 90 quetiapine fumarate tab 25 mg (Seroquel) $0 (1) QL (90 tablets/30 days), 90 quetiapine fumarate tab 50 mg (Seroquel) $0 (1) QL (90 tablets/30 days), 90 quetiapine fumarate tab 100 mg (Seroquel) $0 (1) QL (90 tablets/30 days), 90 quetiapine fumarate tab 200 mg (Seroquel) $0 (1) QL (90 tablets/30 days), 90 quetiapine fumarate tab 300 mg (Seroquel) $0 (1) QL (60 tablets/30 days), 90 quetiapine fumarate tab 400 mg (Seroquel) $0 (1) QL (60 tablets/30 days), 90 RISPERIDONE ODT risperidone orally disintegrating tab $0 (2) QL (60 tablets/30 days), mg risperidone orally disintegrating tab 0.5 mg (Risperdal m-tab) $0 (1) QL (60 tablets/30 days), 90 risperidone orally disintegrating tab 1 mg (Risperdal m-tab) $0 (1) QL (60 tablets/30 days), 90 risperidone orally disintegrating tab 2 mg (Risperdal m-tab) $0 (1) QL (60 tablets/30 days), 90 risperidone orally disintegrating tab 3 mg (Risperdal m-tab) $0 (1) QL (60 tablets/30 days), 90 risperidone orally disintegrating tab 4 mg (Risperdal m-tab) $0 (1) QL (120 tablets/30 days), 90 46

53 risperidone soln 1 mg/ml (Risperdal) $0 (1) QL (480 mls/30 days), 90 risperidone tab 0.25 mg (Risperdal) $0 (1) QL (120 tablets/30 days), 90 risperidone tab 0.5 mg (Risperdal) $0 (1) QL (120 tablets/30 days), 90 risperidone tab 1 mg (Risperdal) $0 (1) QL (120 tablets/30 days), 90 risperidone tab 2 mg (Risperdal) $0 (1) QL (120 tablets/30 days), 90 risperidone tab 3 mg (Risperdal) $0 (1) QL (60 tablets/30 days), 90 risperidone tab 4 mg (Risperdal) $0 (1) QL (120 tablets/30 days), 90 thioridazine hcl tab 10 mg $0 (1) 90 thioridazine hcl tab 25 mg $0 (1) 90 thioridazine hcl tab 50 mg $0 (1) 90 thioridazine hcl tab 100 mg $0 (1) 90 thiothixene cap 1 mg $0 (1) 90 thiothixene cap 2 mg $0 (1) 90 thiothixene cap 5 mg $0 (1) 90 thiothixene cap 10 mg $0 (1) 90 trifluoperazine hcl tab 1 mg (base equivalent) $0 (1) 90 trifluoperazine hcl tab 2 mg (base equivalent) $0 (1) 90 trifluoperazine hcl tab 5 mg (base equivalent) $0 (1) 90 trifluoperazine hcl tab 10 mg (base equivalent) $0 (1) 90 ziprasidone hcl cap 20 mg (Geodon) $0 (1) QL (60 capsules/30 days), 90 ziprasidone hcl cap 40 mg (Geodon) $0 (1) QL (60 capsules/30 days), 90 ziprasidone hcl cap 60 mg (Geodon) $0 (1) QL (60 capsules/30 days), 90 ziprasidone hcl cap 80 mg (Geodon) $0 (1) QL (60 capsules/30 days), 90 SLEEP AIDS estazolam tab 1 mg $0 (1) QL (30 tablets/30 days) estazolam tab 2 mg $0 (1) QL (30 tablets/30 days) eszopiclone tab 1 mg (Lunesta) $0 (1) QL (30 tablets/30 days) eszopiclone tab 2 mg (Lunesta) $0 (1) QL (30 tablets/30 days) eszopiclone tab 3 mg (Lunesta) $0 (1) QL (30 tablets/30 days) PHENOBARBITAL phenobarbital tab 15 mg $0 (2) 90 PHENOBARBITAL phenobarbital tab 30 mg $0 (2) 90 PHENOBARBITAL phenobarbital tab 60 mg $0 (2) 90 PHENOBARBITAL phenobarbital tab 100 mg $0 (2) 90 phenobarbital elixir 20 mg/5ml $0 (1) 90 PHENOBARBITAL SODIUM phenobarbital sodium inj 65 mg/ml $0 (2) 47

54 PHENOBARBITAL SODIUM phenobarbital sodium inj 130 mg/ $0 (2) ml phenobarbital tab 16.2 mg $0 (1) 90 phenobarbital tab 32.4 mg $0 (1) 90 phenobarbital tab 64.8 mg $0 (1) 90 phenobarbital tab 97.2 mg $0 (1) 90 temazepam cap 15 mg (Restoril) $0 (1) QL (30 capsules/30 days) temazepam cap 30 mg (Restoril) $0 (1) QL (30 capsules/30 days) zaleplon cap 5 mg (Sonata) $0 (1) QL (30 capsules/30 days) zaleplon cap 10 mg (Sonata) $0 (1) QL (30 capsules/30 days) zolpidem tartrate tab 5 mg (Ambien) $0 (1) QL (30 tablets/30 days) zolpidem tartrate tab 10 mg (Ambien) $0 (1) QL (30 tablets/30 days) HYPERACTIVITY/NARCOLEPSY amphetamine-dextroamphetamine cap er 24hr 5 mg (Adderall xr) $0 (1) AL, PA, QL (30 capsules/30 days) amphetamine-dextroamphetamine cap er 24hr 10 mg (Adderall xr) amphetamine-dextroamphetamine cap er 24hr 15 mg (Adderall xr) amphetamine-dextroamphetamine cap er 24hr 20 mg (Adderall xr) amphetamine-dextroamphetamine cap er 24hr 25 mg (Adderall xr) amphetamine-dextroamphetamine cap er 24hr 30 mg (Adderall xr) $0 (1) AL, PA, QL (30 capsules/30 days) $0 (1) AL, PA, QL (30 capsules/30 days) $0 (1) AL, PA, QL (30 capsules/30 days) $0 (1) AL, PA, QL (30 capsules/30 days) $0 (1) AL, PA, QL (30 capsules/30 days) amphetamine-dextroamphetamine tab 5 mg (Adderall) $0 (1) AL, PA, QL (60 tablets/30 days) amphetamine-dextroamphetamine tab 7.5 mg (Adderall) $0 (1) AL, PA, QL (60 tablets/30 days) amphetamine-dextroamphetamine tab 10 mg (Adderall) $0 (1) AL, PA, QL (60 tablets/30 days) amphetamine-dextroamphetamine tab 12.5 mg (Adderall) $0 (1) AL, PA, QL (60 tablets/30 days) amphetamine-dextroamphetamine tab 15 mg (Adderall) $0 (1) AL, PA, QL (60 tablets/30 days) amphetamine-dextroamphetamine tab 20 mg (Adderall) $0 (1) AL, PA, QL (90 tablets/30 days) 48

55 amphetamine-dextroamphetamine tab 30 mg (Adderall) $0 (1) AL, PA, QL (60 tablets/30 days) caffeine citrate oral soln 60 mg/3ml (10 mg/ml base equiv) $0 (1) dexmethylphenidate hcl cap er 24 hr 5 mg (Focalin xr) $0 (1) AL, PA, QL (30 capsules/30 days) dexmethylphenidate hcl cap er 24 hr 10 mg (Focalin xr) $0 (1) AL, PA, QL (30 capsules/30 days) dexmethylphenidate hcl cap er 24 hr 15 mg (Focalin xr) $0 (1) AL, PA, QL (30 capsules/30 days) dexmethylphenidate hcl cap er 24 hr 20 mg (Focalin xr) $0 (1) AL, PA, QL (30 capsules/30 days) dexmethylphenidate hcl cap er 24 hr 30 mg (Focalin xr) $0 (1) AL, PA, QL (30 capsules/30 days) dexmethylphenidate hcl cap er 24 hr 40 mg (Focalin xr) $0 (1) AL, PA, QL (30 capsules/30 days) dexmethylphenidate hcl tab 2.5 mg (Focalin) $0 (1) AL, PA, QL (60 tablets/30 days) dexmethylphenidate hcl tab 5 mg (Focalin) $0 (1) AL, PA, QL (60 tablets/30 days) dexmethylphenidate hcl tab 10 mg (Focalin) $0 (1) AL, PA, QL (60 tablets/30 days) guanfacine hcl tab er 24hr 1 mg (base equiv) (Intuniv) $0 (1) QL (30 tablets/30 days) guanfacine hcl tab er 24hr 2 mg (base equiv) (Intuniv) $0 (1) QL (30 tablets/30 days) guanfacine hcl tab er 24hr 3 mg (base equiv) (Intuniv) $0 (1) QL (30 tablets/30 days) guanfacine hcl tab er 24hr 4 mg (base equiv) (Intuniv) $0 (1) QL (30 tablets/30 days) methylphenidate hcl cap er 10 mg (cd) $0 (1) AL, PA, QL (30 capsules/30 days) methylphenidate hcl cap er 20 mg (cd) $0 (1) AL, PA, QL (30 capsules/30 days) methylphenidate hcl cap er 30 mg (cd) $0 (1) AL, PA, QL (30 capsules/30 days) methylphenidate hcl cap er 40 mg (cd) $0 (1) AL, PA, QL (30 capsules/30 days) methylphenidate hcl cap er 50 mg (cd) $0 (1) AL, PA, QL (30 capsules/30 days) methylphenidate hcl cap er 60 mg (cd) $0 (1) AL, PA, QL (30 capsules/30 days) 49

56 methylphenidate hcl cap er 24hr 20 mg (la) (Ritalin la) $0 (1) AL, PA, QL (30 capsules/30 days) methylphenidate hcl cap er 24hr 30 mg (la) (Ritalin la) $0 (1) AL, PA, QL (60 capsules/30 days) methylphenidate hcl cap er 24hr 40 mg (la) (Ritalin la) $0 (1) AL, PA, QL (30 capsules/30 days) METHYLPHENIDATE HCL ER methylphenidate hcl tab er 24hr 18 mg METHYLPHENIDATE HCL ER methylphenidate hcl tab er 24hr 27 mg METHYLPHENIDATE HCL ER methylphenidate hcl tab er 24hr 36 mg METHYLPHENIDATE HCL ER methylphenidate hcl tab er 24hr 54 mg methylphenidate hcl tab er osmotic release (osm) 18 mg (Concerta) methylphenidate hcl tab er osmotic release (osm) 27 mg (Concerta) methylphenidate hcl tab er osmotic release (osm) 36 mg (Concerta) methylphenidate hcl tab er osmotic release (osm) 54 mg (Concerta) $0 (2) AL, PA, QL (30 tablets/30 days), 90 $0 (2) AL, PA, QL (30 tablets/30 days), 90 $0 (2) AL, PA, QL (60 tablets/30 days), 90 $0 (2) AL, PA, QL (30 tablets/30 days), 90 $0 (1) AL, PA, QL (30 tablets/30 days) $0 (1) AL, PA, QL (30 tablets/30 days) $0 (1) AL, PA, QL (60 tablets/30 days) $0 (1) AL, PA, QL (30 tablets/30 days) methylphenidate hcl tab er 10 mg $0 (1) AL, PA, QL (90 tablets/30 days) methylphenidate hcl tab 5 mg (Ritalin) $0 (1) AL, PA, QL (90 tablets/30 days) methylphenidate hcl tab 10 mg (Ritalin) $0 (1) AL, PA, QL (90 tablets/30 days) methylphenidate hcl tab 20 mg (Ritalin) $0 (1) AL, PA, QL (90 tablets/30 days) modafinil tab 100 mg (Provigil) $0 (1) PA, QL (30 tablets/30 days) modafinil tab 200 mg (Provigil) $0 (1) PA, QL (30 tablets/30 days) MULTIPLE SCLEROSIS AMPYRA dalfampridine tab er 12hr 10 mg $0 (2) PA, QL (60 tablets/30 days), SP, 90 AUBAGIO teriflunomide tab 7 mg $0 (2) PA, QL (30 tablets/30 days), SP, 90 50

57 AUBAGIO teriflunomide tab 14 mg $0 (2) PA, QL (30 tablets/30 days), SP, 90 AVONEX interferon beta-1a im prefilled syringe kit 30 mcg/0.5ml AVONEX interferon beta-1a for im inj kit 30mcg (33mcg(6.6 mu)/vial) $0 (2) PA, QL (1 kit/28 days), SP, 90 $0 (2) PA, QL (4 vials/28 days), SP, 90 AVONEX PEN interferon beta-1a im auto-injector kit $0 (2) PA, QL (1 kit/28 days), SP, mcg/0.5ml EXTAVIA interferon beta-1b for inj kit 0.3 mg $0 (2) PA, QL (14 vials/28 days), SP, 90 glatiramer acetate soln prefilled syringe 20 mg/ml (Copaxone) $0 (1) PA, QL (30 syringes/30 days), SP glatiramer acetate soln prefilled syringe 40 mg/ml (Copaxone) $0 (1) PA, QL (12 syringes/28 days), SP, 90 OTHER CENTRAL NERVOUS SYSTEM DRUGS acamprosate calcium tab delayed release 333 mg $0 (1) 90 bupropion hcl (smoking deterrent) tab er 12hr 150 mg (Zyban) $0 (1) QL (180 days/365 days) CHANTIX varenicline tartrate tab 0.5 mg (base equiv) $0 (2) QL (180 days/365 days) CHANTIX varenicline tartrate tab 1 mg (base equiv) $0 (2) QL (180 days/365 days) CHANTIX CONTINUING MONTH varenicline tartrate tab 1 mg $0 (2) QL (180 days/365 days) (base equiv) CHANTIX STARTING MONTH PA varenicline tartrate tab $0 (2) QL (180 days/365 days) 0.5 mg x 11 & tab 1 mg x 42 pack disulfiram tab 250 mg (Antab) $0 (1) 90 disulfiram tab 500 mg (Antab) $0 (1) 90 donepezil hydrochloride orally disintegrating tab 5 mg $0 (1) QL (30 tablets/30 days), 90 donepezil hydrochloride orally disintegrating tab 10 mg $0 (1) QL (30 tablets/30 days), 90 donepezil hydrochloride tab 5 mg (Aricept) $0 (1) QL (30 tablets/30 days), 90 donepezil hydrochloride tab 10 mg (Aricept) $0 (1) QL (30 tablets/30 days), 90 naltrexone hcl tab 50 mg $0 (1) nicotine polacrilex gum 2 mg $0 (3) QL (180 days/365 days) nicotine polacrilex gum 4 mg $0 (3) QL (180 days/365 days) nicotine td patch 24hr 7 mg/24hr $0 (3) QL (180 days/365 days) nicotine td patch 24hr 14 mg/24hr $0 (3) QL (180 days/365 days) nicotine td patch 24hr 21 mg/24hr $0 (3) QL (180 days/365 days) pimozide tab 1 mg (Orap) $0 (1) 90 pimozide tab 2 mg (Orap) $0 (1) 90 51

58 VIVITROL naltrexone for im extended release susp 380 mg $0 (2) SP XYREM sodium oxybate oral solution 500 mg/ml $0 (2) PA, QL (3 bottles/30 days), SP PAIN RELIEF DRUGS NON-NARCOTIC DRUGS acetaminophen cap 500 mg $0 (3) acetaminophen chew tab 80 mg $0 (3) acetaminophen chew tab 160 mg $0 (3) acetaminophen disintegrating tab 80 mg $0 (3) acetaminophen liquid 160 mg/5ml $0 (3) acetaminophen soln 160 mg/5ml $0 (3) acetaminophen suppos 120 mg $0 (3) acetaminophen susp 80 mg/0.8ml $0 (3) acetaminophen susp 160 mg/5ml $0 (3) acetaminophen tab 325 mg $0 (3) acetaminophen tab 500 mg $0 (3) aspirin chew tab 81 mg $0 (3) 90 aspirin tab delayed release 81 mg $0 (3) 90 aspirin tab delayed release 325 mg $0 (3) 90 aspirin tab 325 mg $0 (3) 90 butalbital-acetaminophen tab mg $0 (1) QL (180 tablets/30 days) butalbital-acetaminophen-caffeine cap mg (Fioricet) $0 (1) QL (180 capsules/30 days) butalbital-acetaminophen-caffeine cap mg $0 (1) QL (180 capsules/30 days) butalbital-acetaminophen-caffeine tab mg (Esgic) $0 (1) QL (180 tablets/30 days) butalbital-aspirin-caffeine cap mg (Fiorinal) $0 (1) QL (180 capsules/30 days) salsalate tab 500 mg $0 (1) 90 salsalate tab 750 mg $0 (1) 90 NARCOTIC DRUGS acetaminophen w/ codeine soln mg/5ml $0 (1) ME, QL (2700 mls/30 days) acetaminophen w/ codeine tab mg (Tylenol/codeine) $0 (1) ME, QL (360 tablets/30 days) acetaminophen w/ codeine tab mg (Tylenol/codeine #3) $0 (1) ME, QL (360 tablets/30 days) acetaminophen w/ codeine tab mg (Tylenol/codeine #4) $0 (1) ME, QL (180 tablets/30 days) ACETAMINOPHEN/CAFFEINE/DI acetaminophen-caffeinedihydrocodeine cap mg $0 (2) ME, QL (300 capsules/30 days) 52

59 BUNAVAIL buprenorphine-naloxone buccal film mg $0 (2) QL (60 films/30 days) (base equiv) BUNAVAIL buprenorphine-naloxone buccal film mg $0 (2) QL (60 films/30 days) (base equiv) BUNAVAIL buprenorphine-naloxone buccal film mg (base $0 (2) QL (60 films/30 days) equiv) buprenorphine hcl sl tab 2 mg (base equiv) $0 (1) QL (15 tablets/90 days) buprenorphine hcl sl tab 8 mg (base equiv) $0 (1) QL (15 tablets/90 days) buprenorphine hcl-naloxone hcl sl tab mg (base equiv) $0 (1) QL (60 tablets/30 days) buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv) $0 (1) QL (60 tablets/30 days) butalbital-acetaminophen-caff w/ cod cap mg $0 (1) ME, QL (180 capsules/30 days) butalbital-aspirin-caff w/ codeine cap mg (Fiorinal/ codeine #3) $0 (1) ME, QL (180 capsules/30 days) codeine sulfate tab 15 mg (Codeine sulfate) $0 (1) ME, QL (180 tablets/30 days) codeine sulfate tab 30 mg (Codeine sulfate) $0 (1) ME, QL (180 tablets/30 days) codeine sulfate tab 60 mg (Codeine sulfate) $0 (1) ME, QL (180 tablets/30 days) fentanyl td patch 72hr 12 mcg/hr (Duragesic) $0 (1) ME, QL (15 patches/30 days) fentanyl td patch 72hr 25 mcg/hr (Duragesic) $0 (1) ME, QL (15 patches/30 days) fentanyl td patch 72hr 50 mcg/hr (Duragesic) $0 (1) ME, QL (15 patches/30 days) fentanyl td patch 72hr 75 mcg/hr (Duragesic) $0 (1) ME, QL (15 patches/30 days) fentanyl td patch 72hr 100 mcg/hr (Duragesic) $0 (1) ME, QL (15 patches/30 days) hydrocodone-acetaminophen soln mg/15ml (Hycet) $0 (1) ME, QL (3600 mls/30 days) hydrocodone-acetaminophen tab mg $0 (1) ME, QL (360 tablets/30 days) hydrocodone-acetaminophen tab mg (Norco) $0 (1) ME, QL (180 tablets/30 days) hydrocodone-acetaminophen tab mg (Norco) $0 (1) ME, QL (360 tablets/30 days) hydrocodone-acetaminophen tab mg (Norco) $0 (1) ME, QL (180 tablets/30 days) hydromorphone hcl liqd 1 mg/ml (Dilaudid) $0 (1) ME, QL (1440 mls/30 days) hydromorphone hcl tab 2 mg (Dilaudid) $0 (1) ME, QL (180 tablets/30 days) hydromorphone hcl tab 4 mg (Dilaudid) $0 (1) ME, QL (180 tablets/30 days) hydromorphone hcl tab 8 mg (Dilaudid) $0 (1) ME, QL (180 tablets/30 days) meperidine hcl tab 50 mg $0 (1) ME, QL (240 tablets/30 days) meperidine hcl tab 100 mg (Demerol) $0 (1) ME, QL (240 tablets/30 days) MORPHINE SULFATE morphine sulfate inj 8 mg/ml $0 (2) ME MORPHINE SULFATE morphine sulfate tab 15 mg $0 (2) ME, QL (240 tablets/30 days) MORPHINE SULFATE morphine sulfate tab 30 mg $0 (2) ME, QL (180 tablets/30 days) 53

60 MORPHINE SULFATE morphine sulfate suppos 5 mg $0 (2) ME MORPHINE SULFATE morphine sulfate suppos 10 mg $0 (2) ME MORPHINE SULFATE morphine sulfate suppos 20 mg $0 (2) ME MORPHINE SULFATE morphine sulfate suppos 30 mg $0 (2) ME morphine sulfate oral soln 10 mg/5ml $0 (1) ME, QL (2700 mls/30 days) morphine sulfate oral soln 20 mg/5ml $0 (1) ME, QL (1350 mls/30 days) morphine sulfate oral soln 100 mg/5ml (20 mg/ml) $0 (1) ME, QL (270 mls/30 days) morphine sulfate tab er 15 mg (Ms contin) $0 (1) ME, QL (90 tablets/30 days) morphine sulfate tab er 30 mg (Ms contin) $0 (1) ME, QL (90 tablets/30 days) morphine sulfate tab er 60 mg (Ms contin) $0 (1) ME, QL (90 tablets/30 days) morphine sulfate tab er 100 mg (Ms contin) $0 (1) ME, QL (90 tablets/30 days) morphine sulfate tab er 200 mg (Ms contin) $0 (1) ME, QL (90 tablets/30 days) oxycodone hcl conc 100 mg/5ml (20 mg/ml) $0 (1) ME, QL (270 mls/30 days) oxycodone hcl soln 5 mg/5ml $0 (1) ME, QL (5400 mls/30 days) oxycodone hcl tab 5 mg (Roxicodone) $0 (1) ME, QL (360 tablets/30 days) oxycodone hcl tab 10 mg $0 (1) ME, QL (180 tablets/30 days) oxycodone hcl tab 15 mg (Roxicodone) $0 (1) ME, QL (180 tablets/30 days) oxycodone hcl tab 20 mg $0 (1) ME, QL (180 tablets/30 days) oxycodone hcl tab 30 mg (Roxicodone) $0 (1) ME, QL (180 tablets/30 days) oxycodone w/ acetaminophen tab mg (Percocet) $0 (1) ME, QL (360 tablets/30 days) oxycodone w/ acetaminophen tab mg (Percocet) $0 (1) ME, QL (240 tablets/30 days) oxycodone w/ acetaminophen tab mg (Percocet) $0 (1) ME, QL (180 tablets/30 days) oxycodone-aspirin tab mg $0 (1) ME, QL (360 tablets/30 days) OXYCODONE/ACETAMINOPHEN oxycodone w/ $0 (2) ME, QL (1800 mls/30 days) acetaminophen soln mg/5ml PROBUPHINE IMPLANT KIT buprenorphine hcl subdermal $0 (2) implant 74.2 mg (base equiv) SUBOXONE buprenorphine hcl-naloxone hcl sl film mg $0 (2) QL (60 films/30 days) (base equiv) SUBOXONE buprenorphine hcl-naloxone hcl sl film 4-1 mg $0 (2) QL (60 films/30 days) (base equiv) SUBOXONE buprenorphine hcl-naloxone hcl sl film 8-2 mg $0 (2) QL (60 films/30 days) (base equiv) SUBOXONE buprenorphine hcl-naloxone hcl sl film 12-3 mg $0 (2) QL (60 films/30 days) (base equiv) tramadol hcl tab 50 mg (Ultram) $0 (1) ME, QL (240 tablets/30 days) ZUBSOLV buprenorphine hcl-naloxone hcl sl tab mg (base eq) 54 $0 (2) QL (60 tablets/30 days)

61 ZUBSOLV buprenorphine hcl-naloxone hcl sl tab mg (base eq) ZUBSOLV buprenorphine hcl-naloxone hcl sl tab mg (base eq) ZUBSOLV buprenorphine hcl-naloxone hcl sl tab mg (base eq) ZUBSOLV buprenorphine hcl-naloxone hcl sl tab mg (base eq) $0 (2) QL (60 tablets/30 days) $0 (2) QL (60 tablets/30 days) $0 (2) QL (60 tablets/30 days) $0 (2) QL (60 tablets/30 days) RHEUMATOID AND OSTEOARTHRITIS celecoxib cap 50 mg (Celebrex) $0 (1) AL, QL (60 capsules/30 days), ST, 90 celecoxib cap 100 mg (Celebrex) $0 (1) AL, QL (60 capsules/30 days), ST, 90 celecoxib cap 200 mg (Celebrex) $0 (1) AL, QL (60 capsules/30 days), ST, 90 celecoxib cap 400 mg (Celebrex) $0 (1) AL, QL (30 capsules/30 days), ST, 90 diclofenac potassium tab 50 mg $0 (1) QL (120 tablets/30 days), 90 diclofenac sodium gel 1% (Voltaren) $0 (1) QL (200 grams/30 days) diclofenac sodium tab delayed release 50 mg $0 (1) QL (120 tablets/30 days), 90 diclofenac sodium tab delayed release 75 mg $0 (1) QL (60 tablets/30 days), 90 diclofenac sodium tab er 24hr 100 mg $0 (1) QL (60 tablets/30 days), 90 ENBREL etanercept for subcutaneous inj 25 mg $0 (2) PA, QL (8 vials/28 days), SP, 90 ENBREL etanercept subcutaneous soln prefilled syringe 25 mg/0.5ml ENBREL etanercept subcutaneous soln prefilled syringe 50 mg/ml ENBREL SURECLICK etanercept subcutaneous solution autoinjector 50 mg/ml $0 (2) PA, QL (8 syringes/28 days), SP, 90 $0 (2) PA, QL (4 syringes/28 days), SP, 90 $0 (2) PA, QL (4 syringes/28 days), SP, 90 flurbiprofen tab 50 mg $0 (1) QL (180 tablets/30 days), 90 flurbiprofen tab 100 mg $0 (1) QL (90 tablets/30 days), 90 HUMIRA adalimumab prefilled syringe kit 10 mg/0.2ml $0 (2) PA, QL (2 syringes/28 days), SP, 90 HUMIRA adalimumab prefilled syringe kit 20 mg/0.4ml $0 (2) PA, QL (2 syringes/28 days), SP, 90 HUMIRA adalimumab prefilled syringe kit 40 mg/0.8ml $0 (2) PA, QL (2 syringes/28 days), SP, 90 55

62 HUMIRA PEDIATRIC CROHNS D adalimumab prefilled syringe kit 40 mg/0.8ml $0 (2) PA, QL (3 syringes/180 days), SP, 90 HUMIRA PEN adalimumab pen-injector kit 40 mg/0.8ml $0 (2) PA, QL (2 pens/180 days), SP, 90 HUMIRA PEN-CROHNS DISEASE adalimumab pen-injector kit 40 mg/0.8ml HUMIRA PEN-PSORIASIS STAR adalimumab pen-injector kit 40 mg/0.8ml $0 (2) PA, QL (6 pens/180 days), SP, 90 $0 (2) PA, QL (4 pens/28 days), SP, 90 ibuprofen cap 200 mg $0 (3) 90 ibuprofen susp 100 mg/5ml $0 (1) QL (1000 mls/30 days) ibuprofen tab 200 mg $0 (3) 90 ibuprofen tab 400 mg $0 (1) QL (120 tablets/30 days), 90 ibuprofen tab 600 mg $0 (1) QL (150 tablets/30 days), 90 ibuprofen tab 800 mg $0 (1) QL (120 tablets/30 days), 90 indomethacin cap er 75 mg $0 (1) QL (60 capsules/30 days), 90 indomethacin cap 25 mg $0 (1) QL (90 capsules/30 days), 90 indomethacin cap 50 mg $0 (1) QL (60 capsules/30 days), 90 ketoprofen cap 50 mg $0 (1) QL (180 capsules/30 days), 90 ketoprofen cap 75 mg $0 (1) QL (120 capsules/30 days), 90 ketorolac tromethamine tab 10 mg $0 (1) QL (20 tablets/30 days) leflunomide tab 10 mg (Arava) $0 (1) 90 leflunomide tab 20 mg (Arava) $0 (1) 90 meloxicam tab 7.5 mg (Mobic) $0 (1) QL (60 tablets/30 days), 90 meloxicam tab 15 mg (Mobic) $0 (1) QL (30 tablets/30 days), 90 nabumetone tab 500 mg $0 (1) QL (120 tablets/30 days), 90 nabumetone tab 750 mg $0 (1) QL (60 tablets/30 days), 90 naproxen sodium tab 220 mg $0 (3) 90 naproxen sodium tab 275 mg $0 (1) QL (150 tablets/30 days), 90 naproxen sodium tab 550 mg (Anaprox ds) $0 (1) QL (90 tablets/30 days), 90 naproxen tab ec 375 mg (Ec-naprosyn) $0 (1) QL (120 tablets/30 days), 90 naproxen tab ec 500 mg (Ec-naprosyn) $0 (1) QL (90 tablets/30 days), 90 naproxen tab 250 mg $0 (1) QL (150 tablets/30 days), 90 naproxen tab 375 mg $0 (1) QL (120 tablets/30 days), 90 naproxen tab 500 mg (Naprosyn) $0 (1) QL (90 tablets/30 days), 90 56

63 piroxicam cap 10 mg (Feldene) $0 (1) QL (60 capsules/30 days), 90 piroxicam cap 20 mg (Feldene) $0 (1) QL (30 capsules/30 days), 90 sulindac tab 150 mg $0 (1) QL (60 tablets/30 days), 90 sulindac tab 200 mg $0 (1) QL (60 tablets/30 days), 90 MIGRAINE HEADACHES rizatriptan benzoate oral disintegrating tab 5 mg (base eq) $0 (1) QL (18 tablets/30 days) (Maxalt-mlt) rizatriptan benzoate oral disintegrating tab 10 mg (base eq) $0 (1) QL (18 tablets/30 days) (Maxalt-mlt) rizatriptan benzoate tab 5 mg (base equivalent) (Maxalt) $0 (1) QL (18 tablets/30 days) rizatriptan benzoate tab 10 mg (base equivalent) (Maxalt) $0 (1) QL (18 tablets/30 days) sumatriptan succinate inj 6 mg/0.5ml (Imitrex) $0 (1) QL (12 vials/30 days) sumatriptan succinate solution cartridge 6 mg/0.5ml (Imitrex $0 (1) QL (6 packages/30 days) statdose ref) sumatriptan succinate tab 25 mg (Imitrex) $0 (1) QL (18 tablets/30 days) sumatriptan succinate tab 50 mg (Imitrex) $0 (1) QL (18 tablets/30 days) sumatriptan succinate tab 100 mg (Imitrex) $0 (1) QL (18 tablets/30 days) GOUT allopurinol tab 100 mg (Zyloprim) $0 (1) 90 allopurinol tab 300 mg (Zyloprim) $0 (1) 90 colchicine w/ probenecid tab mg $0 (1) 90 probenecid tab 500 mg $0 (1) 90 NEUROMUSCULAR DRUGS SEIZURES APTIOM eslicarbazepine acetate tab 200 mg $0 (2) 90 APTIOM eslicarbazepine acetate tab 400 mg $0 (2) 90 APTIOM eslicarbazepine acetate tab 600 mg $0 (2) 90 APTIOM eslicarbazepine acetate tab 800 mg $0 (2) 90 BANZEL rufinamide susp 40 mg/ml $0 (2) 90 BANZEL rufinamide tab 200 mg $0 (2) 90 BANZEL rufinamide tab 400 mg $0 (2) 90 BRIVIACT brivaracetam tab 10 mg $0 (2) 90 BRIVIACT brivaracetam tab 25 mg $0 (2) 90 BRIVIACT brivaracetam tab 50 mg $0 (2) 90 BRIVIACT brivaracetam tab 75 mg $0 (2) 90 BRIVIACT brivaracetam tab 100 mg $0 (2) 90 57

64 BRIVIACT brivaracetam oral soln 10 mg/ml $0 (2) 90 BRIVIACT brivaracetam iv soln 50 mg/5ml $0 (2) carbamazepine chew tab 100 mg $0 (1) 90 carbamazepine susp 100 mg/5ml (Tegretol) $0 (1) 90 carbamazepine tab er 12hr 100 mg (Tegretol-xr) $0 (1) 90 carbamazepine tab er 12hr 200 mg (Tegretol-xr) $0 (1) 90 carbamazepine tab er 12hr 400 mg (Tegretol-xr) $0 (1) 90 carbamazepine tab 200 mg (Tegretol) $0 (1) 90 CARBATROL carbamazepine cap er 12hr 100 mg $0 (2) 90 CARBATROL carbamazepine cap er 12hr 200 mg $0 (2) 90 CARBATROL carbamazepine cap er 12hr 300 mg $0 (2) 90 CELONTIN methsuximide cap 300 mg $0 (2) 90 CEREBYX fosphenytoin sodium inj 100 mg/2ml (phenytoin $0 (2) equiv) CEREBYX fosphenytoin sodium inj 500 mg/10ml (phenytoin $0 (2) equiv) clonazepam orally disintegrating tab mg $0 (1) QL (90 tablets/30 days), 90 clonazepam orally disintegrating tab 0.25 mg $0 (1) QL (90 tablets/30 days), 90 clonazepam orally disintegrating tab 0.5 mg $0 (1) QL (90 tablets/30 days), 90 clonazepam orally disintegrating tab 1 mg $0 (1) QL (90 tablets/30 days), 90 clonazepam orally disintegrating tab 2 mg $0 (1) QL (60 tablets/30 days), 90 clonazepam tab 0.5 mg (Klonopin) $0 (1) QL (90 tablets/30 days), 90 clonazepam tab 1 mg (Klonopin) $0 (1) QL (90 tablets/30 days), 90 clonazepam tab 2 mg (Klonopin) $0 (1) QL (60 tablets/30 days), 90 DEPACON valproate sodium inj 100 mg/ml $0 (2) DEPAKENE valproic acid cap 250 mg $0 (2) 90 DEPAKENE valproate sodium oral soln 250 mg/5ml (base $0 (2) 90 equiv) DEPAKOTE divalproex sodium tab delayed release 125 mg $0 (2) 90 DEPAKOTE divalproex sodium tab delayed release 250 mg $0 (2) 90 DEPAKOTE divalproex sodium tab delayed release 500 mg $0 (2) 90 DEPAKOTE ER divalproex sodium tab er 24 hr 250 mg $0 (2) 90 DEPAKOTE ER divalproex sodium tab er 24 hr 500 mg $0 (2) 90 DEPAKOTE SPRINKLES divalproex sodium cap delayed release sprinkle 125 mg DIAZEPAM RECTAL GEL diazepam rectal gel delivery system 2.5 mg 58 $0 (2) 90 $0 (2) QL (2 packs/30 days)

65 DIAZEPAM RECTAL GEL diazepam rectal gel delivery system $0 (2) QL (2 packs/30 days) 10 mg DIAZEPAM RECTAL GEL diazepam rectal gel delivery system $0 (2) QL (2 packs/30 days) 20 mg DILANTIN phenytoin sodium extended cap 30 mg $0 (2) 90 DILANTIN phenytoin sodium extended cap 100 mg $0 (2) 90 DILANTIN INFATABS phenytoin chew tab 50 mg $0 (2) 90 DILANTIN-125 phenytoin susp 125 mg/5ml $0 (2) 90 divalproex sodium cap delayed release sprinkle 125 mg $0 (1) 90 (Depakote sprinkles) divalproex sodium tab delayed release 125 mg (Depakote) $0 (1) 90 divalproex sodium tab delayed release 250 mg (Depakote) $0 (1) 90 divalproex sodium tab delayed release 500 mg (Depakote) $0 (1) 90 divalproex sodium tab er 24 hr 250 mg (Depakote er) $0 (1) 90 divalproex sodium tab er 24 hr 500 mg (Depakote er) $0 (1) 90 ethosuximide cap 250 mg (Zarontin) $0 (1) 90 ethosuximide soln 250 mg/5ml (Zarontin) $0 (1) 90 felbamate susp 600 mg/5ml (Felbatol) $0 (1) 90 felbamate tab 400 mg (Felbatol) $0 (1) 90 felbamate tab 600 mg (Felbatol) $0 (1) 90 FELBATOL felbamate susp 600 mg/5ml $0 (2) 90 FELBATOL felbamate tab 400 mg $0 (2) 90 FELBATOL felbamate tab 600 mg $0 (2) 90 FYCOMPA perampanel susp 0.5 mg/ml $0 (2) 90 FYCOMPA perampanel tab 2 mg $0 (2) 90 FYCOMPA perampanel tab 4 mg $0 (2) 90 FYCOMPA perampanel tab 6 mg $0 (2) 90 FYCOMPA perampanel tab 8 mg $0 (2) 90 FYCOMPA perampanel tab 10 mg $0 (2) 90 FYCOMPA perampanel tab 12 mg $0 (2) 90 gabapentin cap 100 mg (Neurontin) $0 (1) QL (720 capsules/30 days), 90 gabapentin cap 300 mg (Neurontin) $0 (1) QL (240 capsules/30 days), 90 gabapentin cap 400 mg (Neurontin) $0 (1) QL (180 capsules/30 days), 90 gabapentin oral soln 250 mg/5ml (Neurontin) $0 (1) QL (1500 mls/30 days), 90 59

66 gabapentin tab 600 mg (Neurontin) $0 (1) QL (120 tablets/30 days), 90 gabapentin tab 800 mg (Neurontin) $0 (1) QL (90 tablets/30 days), 90 GABITRIL tiagabine hcl tab 2 mg $0 (2) 90 GABITRIL tiagabine hcl tab 4 mg $0 (2) 90 GABITRIL tiagabine hcl tab 12 mg $0 (2) 90 GABITRIL tiagabine hcl tab 16 mg $0 (2) 90 KEPPRA levetiracetam tab 250 mg $0 (2) 90 KEPPRA levetiracetam tab 500 mg $0 (2) 90 KEPPRA levetiracetam tab 750 mg $0 (2) 90 KEPPRA levetiracetam tab 1000 mg $0 (2) 90 KEPPRA levetiracetam oral soln 100 mg/ml $0 (2) 90 KEPPRA levetiracetam inj 500 mg/5ml (100 mg/ml) $0 (2) KEPPRA XR levetiracetam tab er 24hr 500 mg $0 (2) 90 KEPPRA XR levetiracetam tab er 24hr 750 mg $0 (2) 90 LAMICTAL lamotrigine tab 25 mg $0 (2) 90 LAMICTAL lamotrigine tab 100 mg $0 (2) 90 LAMICTAL lamotrigine tab 150 mg $0 (2) 90 LAMICTAL lamotrigine tab 200 mg $0 (2) 90 LAMICTAL CHEWABLE DISPERS lamotrigine tab chewable $0 (2) 90 dispersible 5 mg LAMICTAL CHEWABLE DISPERS lamotrigine tab chewable $0 (2) 90 dispersible 25 mg LAMICTAL ODT lamotrigine tab disint 25 mg (21) & 50 mg (7) $0 (2) titration kit LAMICTAL ODT lamotrigine tab disint 50 mg (42)- 100 mg(14) $0 (2) titration kit LAMICTAL ODT lamotrigine tab disint 25 (14) & 50 mg (14) & $0 (2) 100 mg (7) kit LAMICTAL ODT lamotrigine orally disintegrating tab 25 mg $0 (2) 90 LAMICTAL ODT lamotrigine orally disintegrating tab 50 mg $0 (2) 90 LAMICTAL ODT lamotrigine orally disintegrating tab 100 mg $0 (2) 90 LAMICTAL ODT lamotrigine orally disintegrating tab 200 mg $0 (2) 90 LAMICTAL STARTER/NOT TAKI lamotrigine tab 25 mg (42) & 100 mg (7) starter kit LAMICTAL STARTER/TAKING C lamotrigine tab 25 mg (84) & 100 mg (14) starter kit LAMICTAL STARTER/TAKING V lamotrigine tab 25 mg (35) starter kit $0 (2) $0 (2) $0 (2) 60

67 LAMICTAL XR lamotrigine tab er 24hr 25 mg (21) & 50 mg (7) $0 (2) titration kit LAMICTAL XR lamotrigine tab er 24hr 25 (14) & 50 mg (14) & $0 (2) 100 mg(7) kit LAMICTAL XR lamotrigine tab er 24hr 50 (14) & 100 mg(14) & $0 (2) 200 mg(7) kit LAMICTAL XR lamotrigine tab er 24hr 25 mg $0 (2) 90 LAMICTAL XR lamotrigine tab er 24hr 50 mg $0 (2) 90 LAMICTAL XR lamotrigine tab er 24hr 100 mg $0 (2) 90 LAMICTAL XR lamotrigine tab er 24hr 200 mg $0 (2) 90 LAMICTAL XR lamotrigine tab er 24hr 250 mg $0 (2) 90 LAMICTAL XR lamotrigine tab er 24hr 300 mg $0 (2) 90 lamotrigine tab chewable dispersible 5 mg (Lamictal chewable di) $0 (1) 90 lamotrigine tab chewable dispersible 25 mg (Lamictal chewable $0 (1) 90 di) lamotrigine tab 25 mg (Lamictal) $0 (1) 90 lamotrigine tab 100 mg (Lamictal) $0 (1) 90 lamotrigine tab 150 mg (Lamictal) $0 (1) 90 lamotrigine tab 200 mg (Lamictal) $0 (1) 90 LEVETIRACETAM levetiracetam in sodium chloride iv soln $0 (2) 500 mg/100ml LEVETIRACETAM levetiracetam in sodium chloride iv soln $0 (2) 1000 mg/100ml LEVETIRACETAM levetiracetam in sodium chloride iv soln $0 (2) 1500 mg/100ml levetiracetam oral soln 100 mg/ml (Keppra) $0 (1) 90 levetiracetam tab er 24hr 500 mg (Keppra xr) $0 (1) 90 levetiracetam tab er 24hr 750 mg (Keppra xr) $0 (1) 90 levetiracetam tab 250 mg (Keppra) $0 (1) 90 levetiracetam tab 500 mg (Keppra) $0 (1) 90 levetiracetam tab 750 mg (Keppra) $0 (1) 90 levetiracetam tab 1000 mg (Keppra) $0 (1) 90 MYSOLINE primidone tab 50 mg $0 (2) 90 MYSOLINE primidone tab 250 mg $0 (2) 90 NEURONTIN gabapentin oral soln 250 mg/5ml $0 (2) QL (1500 mls/30 days), 90 NEURONTIN gabapentin cap 100 mg $0 (2) QL (720 capsules/30 days), 90 61

68 NEURONTIN gabapentin cap 300 mg $0 (2) QL (240 capsules/30 days), 90 NEURONTIN gabapentin cap 400 mg $0 (2) QL (180 capsules/30 days), 90 NEURONTIN gabapentin tab 600 mg $0 (2) QL (120 tablets/30 days), 90 NEURONTIN gabapentin tab 800 mg $0 (2) QL (90 tablets/30 days), 90 ONFI clobazam suspension 2.5 mg/ml $0 (2) QL (480 mls/30 days), 90 ONFI clobazam tab 10 mg $0 (2) QL (60 tablets/30 days), 90 ONFI clobazam tab 20 mg $0 (2) QL (60 tablets/30 days), 90 oxcarbazepine susp 300 mg/5ml (60 mg/ml) (Trileptal) $0 (1) 90 oxcarbazepine tab 150 mg (Trileptal) $0 (1) 90 oxcarbazepine tab 300 mg (Trileptal) $0 (1) 90 oxcarbazepine tab 600 mg (Trileptal) $0 (1) 90 OXTELLAR XR oxcarbazepine tab er 24hr 150 mg $0 (2) 90 OXTELLAR XR oxcarbazepine tab er 24hr 300 mg $0 (2) 90 OXTELLAR XR oxcarbazepine tab er 24hr 600 mg $0 (2) 90 PEGANONE ethotoin tab 250 mg $0 (2) 90 PHENYTEK phenytoin sodium extended cap 200 mg $0 (2) 90 PHENYTEK phenytoin sodium extended cap 300 mg $0 (2) 90 phenytoin chew tab 50 mg (Dilantin infatabs) $0 (1) 90 phenytoin sodium extended cap 100 mg (Dilantin) $0 (1) 90 phenytoin sodium extended cap 200 mg (Phenytek) $0 (1) 90 phenytoin sodium extended cap 300 mg (Phenytek) $0 (1) 90 phenytoin susp 125 mg/5ml (Dilantin-125) $0 (1) 90 primidone tab 50 mg (Mysoline) $0 (1) 90 primidone tab 250 mg (Mysoline) $0 (1) 90 QUDEXY XR topiramate cap er 24hr sprinkle 25 mg $0 (2) 90 QUDEXY XR topiramate cap er 24hr sprinkle 50 mg $0 (2) 90 QUDEXY XR topiramate cap er 24hr sprinkle 100 mg $0 (2) 90 QUDEXY XR topiramate cap er 24hr sprinkle 150 mg $0 (2) 90 QUDEXY XR topiramate cap er 24hr sprinkle 200 mg $0 (2) 90 SABRIL vigabatrin tab 500 mg $0 (2) SP, 90 SABRIL vigabatrin powd pack 500 mg $0 (2) SP, 90 SPRITAM levetiracetam tab disintegrating soluble 250 mg $0 (2) 90 SPRITAM levetiracetam tab disintegrating soluble 500 mg $0 (2) 90 62

69 SPRITAM levetiracetam tab disintegrating soluble 750 mg $0 (2) 90 SPRITAM levetiracetam tab disintegrating soluble 1000 mg $0 (2) 90 TEGRETOL carbamazepine tab 200 mg $0 (2) 90 TEGRETOL carbamazepine susp 100 mg/5ml $0 (2) 90 TEGRETOL-XR carbamazepine tab er 12hr 100 mg $0 (2) 90 TEGRETOL-XR carbamazepine tab er 12hr 200 mg $0 (2) 90 TEGRETOL-XR carbamazepine tab er 12hr 400 mg $0 (2) 90 TOPAMAX topiramate tab 25 mg $0 (2) 90 TOPAMAX topiramate tab 50 mg $0 (2) 90 TOPAMAX topiramate tab 100 mg $0 (2) 90 TOPAMAX topiramate tab 200 mg $0 (2) 90 TOPAMAX SPRINKLE topiramate sprinkle cap 15 mg $0 (2) 90 TOPAMAX SPRINKLE topiramate sprinkle cap 25 mg $0 (2) 90 TOPIRAMATE ER topiramate cap er 24hr sprinkle 25 mg $0 (2) 90 TOPIRAMATE ER topiramate cap er 24hr sprinkle 50 mg $0 (2) 90 TOPIRAMATE ER topiramate cap er 24hr sprinkle 100 mg $0 (2) 90 TOPIRAMATE ER topiramate cap er 24hr sprinkle 150 mg $0 (2) 90 TOPIRAMATE ER topiramate cap er 24hr sprinkle 200 mg $0 (2) 90 topiramate sprinkle cap 15 mg (Topamax sprinkle) $0 (1) 90 topiramate sprinkle cap 25 mg (Topamax sprinkle) $0 (1) 90 topiramate tab 25 mg (Topamax) $0 (1) 90 topiramate tab 50 mg (Topamax) $0 (1) 90 topiramate tab 100 mg (Topamax) $0 (1) 90 topiramate tab 200 mg (Topamax) $0 (1) 90 TRILEPTAL oxcarbazepine susp 300 mg/5ml (60 mg/ml) $0 (2) 90 TRILEPTAL oxcarbazepine tab 150 mg $0 (2) 90 TRILEPTAL oxcarbazepine tab 300 mg $0 (2) 90 TRILEPTAL oxcarbazepine tab 600 mg $0 (2) 90 TROKENDI XR topiramate cap er 24hr 25 mg $0 (2) 90 TROKENDI XR topiramate cap er 24hr 50 mg $0 (2) 90 TROKENDI XR topiramate cap er 24hr 100 mg $0 (2) 90 TROKENDI XR topiramate cap er 24hr 200 mg $0 (2) 90 valproate sodium oral soln 250 mg/5ml (base equiv) (Depakene) $0 (1) 90 valproic acid cap 250 mg (Depakene) $0 (1) 90 vigabatrin powd pack 500 mg (Sabril) $0 (1) SP, 90 63

70 VIMPAT lacosamide tab 50 mg $0 (2) 90 VIMPAT lacosamide tab 100 mg $0 (2) 90 VIMPAT lacosamide tab 150 mg $0 (2) 90 VIMPAT lacosamide tab 200 mg $0 (2) 90 VIMPAT lacosamide iv inj 200 mg/20ml (10 mg/ml) $0 (2) VIMPAT lacosamide oral solution 10 mg/ml $0 (2) 90 ZARONTIN ethosuximide cap 250 mg $0 (2) 90 ZARONTIN ethosuximide soln 250 mg/5ml $0 (2) 90 ZONEGRAN zonisamide cap 25 mg $0 (2) 90 ZONEGRAN zonisamide cap 100 mg $0 (2) 90 zonisamide cap 25 mg (Zonegran) $0 (1) 90 zonisamide cap 50 mg $0 (1) 90 zonisamide cap 100 mg (Zonegran) $0 (1) 90 PARKINSON'S DISEASE amantadine hcl cap 100 mg $0 (1) 90 amantadine hcl syrup 50 mg/5ml $0 (1) 90 benztropine mesylate tab 0.5 mg $0 (1) 90 benztropine mesylate tab 1 mg $0 (1) 90 benztropine mesylate tab 2 mg $0 (1) 90 bromocriptine mesylate tab 2.5 mg (base equivalent) (Parlodel) $0 (1) 90 carbidopa & levodopa tab er mg (Sinemet cr) $0 (1) 90 carbidopa & levodopa tab er mg (Sinemet cr) $0 (1) 90 carbidopa & levodopa tab mg (Sinemet) $0 (1) 90 carbidopa & levodopa tab mg (Sinemet) $0 (1) 90 carbidopa & levodopa tab mg (Sinemet) $0 (1) 90 carbidopa tab 25 mg (Lodosyn) $0 (1) 90 DUOPA carbidopa-levodopa enteral susp mg/ml $0 (2) 90 entacapone tab 200 mg (Comtan) $0 (1) 90 pramipexole dihydrochloride tab mg (Mirapex) $0 (1) 90 pramipexole dihydrochloride tab 0.25 mg (Mirapex) $0 (1) 90 pramipexole dihydrochloride tab 0.5 mg (Mirapex) $0 (1) 90 pramipexole dihydrochloride tab 0.75 mg (Mirapex) $0 (1) 90 pramipexole dihydrochloride tab 1 mg (Mirapex) $0 (1) 90 pramipexole dihydrochloride tab 1.5 mg (Mirapex) $0 (1) 90 ropinirole hydrochloride tab 0.25 mg (Requip) $0 (1) 90 64

71 ropinirole hydrochloride tab 0.5 mg (Requip) $0 (1) 90 ropinirole hydrochloride tab 1 mg (Requip) $0 (1) 90 ropinirole hydrochloride tab 2 mg (Requip) $0 (1) 90 ropinirole hydrochloride tab 3 mg (Requip) $0 (1) 90 ropinirole hydrochloride tab 4 mg (Requip) $0 (1) 90 ropinirole hydrochloride tab 5 mg (Requip) $0 (1) 90 selegiline hcl cap 5 mg (Eldepryl) $0 (1) 90 selegiline hcl tab 5 mg $0 (1) 90 trihexyphenidyl hcl elixir 0.4 mg/ml $0 (1) 90 trihexyphenidyl hcl tab 2 mg $0 (1) 90 trihexyphenidyl hcl tab 5 mg $0 (1) 90 MUSCLE RELAXANTS baclofen tab 10 mg $0 (1) 90 baclofen tab 20 mg $0 (1) 90 CHLORZOXAZONE chlorzoxazone tab 500 mg $0 (2) cyclobenzaprine hcl tab 5 mg $0 (1) cyclobenzaprine hcl tab 10 mg $0 (1) dantrolene sodium cap 25 mg (Dantrium) $0 (1) dantrolene sodium cap 50 mg (Dantrium) $0 (1) dantrolene sodium cap 100 mg $0 (1) methocarbamol tab 500 mg (Robaxin) $0 (1) methocarbamol tab 750 mg (Robaxin-750) $0 (1) orphenadrine citrate tab er 12hr 100 mg $0 (1) tizanidine hcl tab 2 mg (base equivalent) $0 (1) QL (180 tablets/30 days), 90 tizanidine hcl tab 4 mg (base equivalent) (Zanaflex) $0 (1) QL (180 tablets/30 days), 90 OTHER NEUROMUSCULAR DRUGS BOTOX onabotulinumtoxina for inj 100 unit $0 (2) PA pyridostigmine bromide tab 60 mg (Mestinon) $0 (1) riluzole tab 50 mg (Rilutek) $0 (1) 90 SUPPLEMENTS VITAMINS ASCORBIC ACID ascorbic acid inj 500 mg/ml $0 (2) ascorbic acid tab 500 mg $0 (3) cholecalciferol cap 1000 unit $0 (3) cholecalciferol cap 2000 unit $0 (3) 65

72 cholecalciferol cap 5000 unit $0 (3) cholecalciferol cap unit $0 (3) cholecalciferol cap unit $0 (3) cholecalciferol oral liquid 400 unit/ml $0 (3) cholecalciferol tab 400 unit $0 (3) cholecalciferol tab 1000 unit $0 (3) cholecalciferol tab 2000 unit $0 (3) cholecalciferol tab unit $0 (3) cyanocobalamin inj 1000 mcg/ml $0 (1) cyanocobalamin tab er 1000 mcg $0 (3) cyanocobalamin tab 100 mcg $0 (3) cyanocobalamin tab 250 mcg $0 (3) cyanocobalamin tab 500 mcg $0 (3) cyanocobalamin tab 1000 mcg $0 (3) DECARA cholecalciferol cap unit $0 (3) 66 ergocalciferol cap unit $0 (1) 90 folic acid tab 400 mcg $0 (3) folic acid tab 800 mcg $0 (3) 90 folic acid tab 1 mg $0 (1) 90 folic acid-vitamin b6-vitamin b12 tab mg $0 (1) folic acid-vitamin b6-vitamin b12 tab mg (Folgard rx) $0 (1) folic acid-vitamin b6-vitamin b12 tab mg $0 (1) iron combination cap $0 (1) iron polysacch complex-vit b12-fa cap mg $0 (1) iron-docusate-b12-folic acid-c-e-cu-biotin tab mg $0 (1) (Hematron-af) iron-folic acid-vit c-vit b6-vit b12-zinc tab mg (Corvite $0 (1) 150) MEPHYTON phytonadione tab 5 mg $0 (2) niacin cap er 250 mg $0 (3) niacin cap er 500 mg $0 (3) niacin tab er 250 mg $0 (3) niacin tab er 500 mg $0 (3) niacin tab er 750 mg $0 (3) niacin tab 100 mg $0 (3) niacin tab 500 mg $0 (3)

73 NIACIN TR niacin tab er 1000 mg $0 (3) thiamine hcl tab 50 mg $0 (3) thiamine hcl tab 100 mg $0 (3) MULTIVITAMINS b-complex w/ c & folic acid cap 1 mg (Nephrocaps) $0 (1) b-complex w/ c & folic acid tab $0 (1) b-complex w/ c & folic acid tab 1 mg (Nephro-vite rx) $0 (1) b-complex w/ c & folic acid tab 5 mg $0 (1) EQ MULTIVITAMINS ADULT GU multiple vitamins w/ minerals $0 (3) chew tab FOLBEE PLUS CZ b-complex w/ c-biotin-minerals & folic acid $0 (2) tab 5 mg multiple vitamin tab $0 (3) multiple vitamins w/ iron tab $0 (3) multiple vitamins w/ minerals & fa tab 1.25 mg (Corvite) $0 (1) multiple vitamins w/ minerals cap $0 (1) multiple vitamins w/ minerals tab (Strovite forte) $0 (1) pediatric multiple vitamin w/ c & fa chew tab $0 (3) pediatric multiple vitamin w/ minerals & c drops 45 mg/ml $0 (3) PRESERVISION AREDS 2 + MU multiple vitamins w/ minerals $0 (3) cap TRI-VI-SOL pediatric vitamins adc drops 750 unit-400 $0 (3) unit-35 mg/ml VITAMIN B-COMPLEX 100 b-complex vitamin inj $0 (2) MINERALS AND ELECTROLYTES calcium carbonate tab 1250 mg (500 mg elemental ca) $0 (3) calcium carbonate-cholecalciferol tab 500 mg-200 unit $0 (3) calcium carbonate-cholecalciferol tab 600 mg-400 unit $0 (3) calcium carbonate-vitamin d tab 250 mg-125 unit $0 (3) calcium carbonate-vitamin d tab 500 mg-200 unit $0 (3) calcium carbonate-vitamin d tab 600 mg-400 unit $0 (3) calcium citrate tab 950 mg (200 mg elemental ca) $0 (3) fe fum-iron polysacch complex-fa-b cmplx-c-zn-mn-cu cap $0 (1) (Tandem plus) fe fumarate w/ b12-vit c-fa-ifc cap mg $0 (1) fe fumarate-vit c-vit b12-fa cap 460 (151 fe) mg $0 (1) ferrous fumarate-fa-b complex-c-zn-mg-mn-cu tab mg $0 (1) 67

74 ferrous fumarate-folic acid tab mg $0 (1) ferrous sulfate tab ec 325 mg (65 mg fe equivalent) $0 (3) ferrous sulfate tab 325 mg (65 mg elemental fe) $0 (3) 68 K-PHOS potassium phosphate monobasic tab 500 mg $0 (2) 90 MAGNESIUM CHLORIDE magnesium chloride inj 200 mg/ml $0 (2) magnesium oxide tab 400 mg (241.3 mg elemental mg) $0 (1) oral electrolyte solution $0 (3) pot bicarbonate & chloride effer tab 25 meq $0 (1) 90 pot phos monobasic w/sod phos di & monobas tab $0 (1) mg (K-phos neutral) potassium bicarbonate effer tab 25 meq $0 (1) 90 POTASSIUM CHLORIDE potassium chloride oral soln 20% (40 $0 (2) 90 meq/15ml) potassium chloride cap er 8 meq (Micro-k) $0 (1) 90 potassium chloride cap er 10 meq (Micro-k) $0 (1) 90 POTASSIUM CHLORIDE ER potassium chloride tab er 8 meq $0 (2) 90 (600 mg) potassium chloride microencapsulated crys er tab 10 meq $0 (1) 90 potassium chloride microencapsulated crys er tab 20 meq $0 (1) 90 potassium chloride oral soln 10% (20 meq/15ml) $0 (1) 90 potassium chloride powder packet 20 meq $0 (1) 90 potassium chloride tab er 8 meq (600 mg) $0 (1) 90 potassium chloride tab er 10 meq (K-tab) $0 (1) 90 SODIUM FLUORIDE sodium fluoride tab 1 mg f (from 2.2 mg $0 (2) 90 naf) sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf) $0 (1) 90 sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf) $0 (1) 90 sodium fluoride chew tab 1 mg f (from 2.2 mg naf) $0 (1) 90 sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf) $0 (1) 90 OTHER SUPPLEMENTS FISH OIL ULTRA omega-3 fatty acids cap 1400 mg $0 (3) OCEAN BLUE MINICAPS OMEGA omega-3 fatty acids cap $0 (3) 350 mg OMEGA POWER omega-3 fatty acids cap 1050 mg $0 (3) OMEGA-3 omega-3 fatty acids cap 1400 mg $0 (3) OMEGA-3 IQ omega-3 fatty acids chew tab 240 mg $0 (3) OMEGA omega-3 fatty acids cap 1050 mg $0 (3)

75 omega-3 fatty acids cap 500 mg $0 (3) omega-3 fatty acids cap 435 mg $0 (3) omega-3 fatty acids cap 1000 mg $0 (3) omega-3 fatty acids cap 1200 mg $0 (3) omega-3 fatty acids cap delayed release 1000 mg $0 (3) omega-3 fatty acids cap delayed release 1200 mg $0 (3) PRO NUTRIENTS OMEGA 3 omega-3 fatty acids cap delayed release mg $0 (3) BLOOD MODIFYING DRUGS ADVATE antihemophilic factor rahf-pfm for inj 250 unit $0 (2) PA, SP ADVATE antihemophilic factor rahf-pfm for inj 500 unit $0 (2) PA, SP ADVATE antihemophilic factor rahf-pfm for inj 1000 unit $0 (2) PA, SP ADVATE antihemophilic factor rahf-pfm for inj 1500 unit $0 (2) PA, SP ADVATE antihemophilic factor rahf-pfm for inj 2000 unit $0 (2) PA, SP ADVATE antihemophilic factor rahf-pfm for inj 3000 unit $0 (2) PA, SP ADVATE antihemophilic factor rahf-pfm for inj 4000 unit $0 (2) PA, SP ADYNOVATE antihemophilic factor recomb pegylated for inj 250 unit ADYNOVATE antihemophilic factor recomb pegylated for inj 500 unit ADYNOVATE antihemophilic factor recomb pegylated for inj 750 unit ADYNOVATE antihemophilic factor recomb pegylated for inj 1000 unit ADYNOVATE antihemophilic factor recomb pegylated for inj 1500 unit ADYNOVATE antihemophilic factor recomb pegylated for inj 2000 unit ADYNOVATE antihemophilic factor recomb pegylated for inj 3000 unit ALPHANATE/VON WILLEBRAND antihemophilic factor/vwf (human) for inj 250 unit ALPHANATE/VON WILLEBRAND antihemophilic factor/vwf (human) for inj 500 unit ALPHANATE/VON WILLEBRAND antihemophilic factor/vwf (human) for inj 1000 unit ALPHANATE/VON WILLEBRAND antihemophilic factor/vwf (human) for inj 1500 unit ALPHANATE/VON WILLEBRAND antihemophilic factor/vwf (human) for inj 2000 unit $0 (2) PA, SP $0 (2) PA, SP $0 (2) PA, SP $0 (2) PA, SP $0 (2) PA, SP $0 (2) PA, SP $0 (2) PA, SP $0 (2) PA, SP $0 (2) PA, SP $0 (2) PA, SP $0 (2) PA, SP $0 (2) PA, SP 69

76 ALPHANINE SD coagulation factor ix for inj 500 unit $0 (2) PA, SP ALPHANINE SD coagulation factor ix for inj 1000 unit $0 (2) PA, SP ALPHANINE SD coagulation factor ix for inj 1500 unit $0 (2) PA, SP anagrelide hcl cap 0.5 mg (Agrylin) $0 (1) 90 anagrelide hcl cap 1 mg $0 (1) 90 ARANESP ALBUMIN FREE darbepoetin alfa soln prefilled $0 (2) PA, SP syringe 10 mcg/0.4ml ARANESP ALBUMIN FREE darbepoetin alfa soln prefilled $0 (2) PA, SP syringe 25 mcg/0.42ml ARANESP ALBUMIN FREE darbepoetin alfa soln prefilled $0 (2) PA, SP syringe 40 mcg/0.4ml ARANESP ALBUMIN FREE darbepoetin alfa soln prefilled $0 (2) PA, SP syringe 60 mcg/0.3ml ARANESP ALBUMIN FREE darbepoetin alfa soln prefilled $0 (2) PA, SP syringe 100 mcg/0.5ml ARANESP ALBUMIN FREE darbepoetin alfa soln prefilled $0 (2) PA, SP syringe 150 mcg/0.3ml ARANESP ALBUMIN FREE darbepoetin alfa soln prefilled $0 (2) PA, SP syringe 200 mcg/0.4ml ARANESP ALBUMIN FREE darbepoetin alfa soln prefilled $0 (2) PA, SP syringe 300 mcg/0.6ml ARANESP ALBUMIN FREE darbepoetin alfa soln prefilled $0 (2) PA, SP syringe 500 mcg/ml ARANESP ALBUMIN FREE darbepoetin alfa soln inj 25 mcg/ $0 (2) PA, SP ml ARANESP ALBUMIN FREE darbepoetin alfa soln inj 40 mcg/ $0 (2) PA, SP ml ARANESP ALBUMIN FREE darbepoetin alfa soln inj 60 mcg/ $0 (2) PA, SP ml ARANESP ALBUMIN FREE darbepoetin alfa soln inj 100 mcg/ $0 (2) PA, SP ml ARANESP ALBUMIN FREE darbepoetin alfa soln inj 200 mcg/ $0 (2) PA, SP ml ARANESP ALBUMIN FREE darbepoetin alfa soln inj 300 mcg/ $0 (2) PA, SP ml aspirin-dipyridamole cap er 12hr mg (Aggrenox) $0 (1) 90 BEBULIN factor ix complex for inj unit $0 (2) PA, SP BENEFIX coagulation factor ix (recombinant) for inj kit 250 unit $0 (2) PA, SP BENEFIX coagulation factor ix (recombinant) for inj kit 500 unit $0 (2) PA, SP BENEFIX coagulation factor ix (recombinant) for inj kit 1000 unit $0 (2) PA, SP 70

77 BENEFIX coagulation factor ix (recombinant) for inj kit 2000 $0 (2) PA, SP unit BENEFIX coagulation factor ix (recombinant) for inj kit 3000 $0 (2) PA, SP unit BRILINTA ticagrelor tab 60 mg $0 (2) PA, QL (60 tablets/30 days), 90 BRILINTA ticagrelor tab 90 mg $0 (2) PA, QL (60 tablets/30 days), 90 cilostazol tab 50 mg $0 (1) 90 cilostazol tab 100 mg $0 (1) 90 clopidogrel bisulfate tab 75 mg (base equiv) (Plavix) $0 (1) 90 clopidogrel bisulfate tab 300 mg (base equiv) (Plavix) $0 (1) COAGADEX coagulation factor x (human) for inj 250 unit $0 (2) PA, SP COAGADEX coagulation factor x (human) for inj 500 unit $0 (2) PA, SP dipyridamole tab 25 mg $0 (1) 90 dipyridamole tab 50 mg $0 (1) 90 dipyridamole tab 75 mg $0 (1) 90 ELIQUIS apixaban tab 2.5 mg $0 (2) PA, QL (60 tablets/30 days), 90 ELIQUIS apixaban tab 5 mg $0 (2) PA, QL (120 tablets/30 days), 90 enoxaparin sodium inj 30 mg/0.3ml (Lovenox) $0 (1) QL (30 syringes/365 days) enoxaparin sodium inj 40 mg/0.4ml (Lovenox) $0 (1) QL (30 syringes/365 days) enoxaparin sodium inj 60 mg/0.6ml (Lovenox) $0 (1) QL (30 syringes/365 days) enoxaparin sodium inj 80 mg/0.8ml (Lovenox) $0 (1) QL (30 syringes/365 days) enoxaparin sodium inj 100 mg/ml (Lovenox) $0 (1) QL (30 syringes/365 days) enoxaparin sodium inj 120 mg/0.8ml (Lovenox) $0 (1) QL (30 syringes/365 days) enoxaparin sodium inj 150 mg/ml (Lovenox) $0 (1) QL (30 syringes/365 days) enoxaparin sodium inj 300 mg/3ml (Lovenox) $0 (1) QL (30 vials/365 days) FIRAZYR icatibant acetate inj 30 mg/3ml (base equivalent) $0 (2) PA, QL (6 syringes/30 days), SP HELIXATE FS antihemophilic factor (recombinant) for inj kit 250 unit HELIXATE FS antihemophilic factor (recombinant) for inj kit 500 unit HELIXATE FS antihemophilic factor (recombinant) for inj kit 1000 unit $0 (2) PA, SP $0 (2) PA, SP $0 (2) PA, SP 71

78 HELIXATE FS antihemophilic factor (recombinant) for inj kit $0 (2) PA, SP 2000 unit HELIXATE FS antihemophilic factor (recombinant) for inj kit $0 (2) PA, SP 3000 unit HEMOFIL M antihemophilic factor (human) for inj 250 unit $0 (2) PA, SP HEMOFIL M antihemophilic factor (human) for inj 500 unit $0 (2) PA, SP HEMOFIL M antihemophilic factor (human) for inj 1000 unit $0 (2) PA, SP HEMOFIL M antihemophilic factor (human) for inj 1700 unit $0 (2) PA, SP HUMATE-P antihemophilic factor/vwf (human) for inj $0 (2) PA, SP unit HUMATE-P antihemophilic factor/vwf (human) for inj $0 (2) PA, SP unit HUMATE-P antihemophilic factor/vwf (human) for inj $0 (2) PA, SP unit IXINITY coagulation factor ix (recombinant) for inj 500 unit $0 (2) PA, SP IXINITY coagulation factor ix (recombinant) for inj 1000 unit $0 (2) PA, SP IXINITY coagulation factor ix (recombinant) for inj 1500 unit $0 (2) PA, SP KOATE antihemophilic factor (human) for inj 250 unit $0 (2) PA, SP KOATE antihemophilic factor (human) for inj 500 unit $0 (2) PA, SP KOATE antihemophilic factor (human) for inj 1000 unit $0 (2) PA, SP KOATE-DVI antihemophilic factor (human) for inj 250 unit $0 (2) PA, SP KOATE-DVI antihemophilic factor (human) for inj 500 unit $0 (2) PA, SP KOATE-DVI antihemophilic factor (human) for inj 1000 unit $0 (2) PA, SP KOGENATE FS antihemophilic factor (recombinant) for inj kit 250 unit KOGENATE FS antihemophilic factor (recombinant) for inj kit 500 unit KOGENATE FS antihemophilic factor (recombinant) for inj kit 1000 unit KOGENATE FS antihemophilic factor (recombinant) for inj kit 2000 unit KOGENATE FS antihemophilic factor (recombinant) for inj kit 3000 unit KOGENATE FS BIO-SET antihemophilic factor (recombinant) for inj kit 250 unit KOGENATE FS BIO-SET antihemophilic factor (recombinant) for inj kit 500 unit KOGENATE FS BIO-SET antihemophilic factor (recombinant) for inj kit 1000 unit $0 (2) PA, SP $0 (2) PA, SP $0 (2) PA, SP $0 (2) PA, SP $0 (2) PA, SP $0 (2) PA, SP $0 (2) PA, SP $0 (2) PA, SP 72

79 KOGENATE FS BIO-SET antihemophilic factor (recombinant) $0 (2) PA, SP for inj kit 2000 unit KOGENATE FS BIO-SET antihemophilic factor (recombinant) $0 (2) PA, SP for inj kit 3000 unit LMD 10% DEXTROSE 5% dextran 40 inj 10% in d5w $0 (2) MONOCLATE-P antihemophilic factor (human) for inj kit 1000 $0 (2) PA, SP unit MONOCLATE-P antihemophilic factor (human) for inj kit 1500 $0 (2) PA, SP unit MONONINE coagulation factor ix for inj 1000 unit $0 (2) PA, SP NEUPOGEN filgrastim soln prefilled syringe 300 mcg/0.5ml $0 (2) SP NEUPOGEN filgrastim soln prefilled syringe 480 mcg/0.8ml $0 (2) SP (600 mcg/ml) NEUPOGEN filgrastim inj 300 mcg/ml $0 (2) SP NEUPOGEN filgrastim inj 480 mcg/1.6ml (300 mcg/ml) $0 (2) SP pentoxifylline tab er 400 mg $0 (1) 90 PROFILNINE factor ix complex for inj 500 unit $0 (2) PA, SP PROFILNINE factor ix complex for inj 1000 unit $0 (2) PA, SP PROFILNINE factor ix complex for inj 1500 unit $0 (2) PA, SP PROFILNINE SD factor ix complex for inj 500 unit $0 (2) PA, SP PROFILNINE SD factor ix complex for inj 1000 unit $0 (2) PA, SP PROFILNINE SD factor ix complex for inj 1500 unit $0 (2) PA, SP RECOMBINATE antihemophilic factor (recombinant) for inj $0 (2) PA, SP unit RECOMBINATE antihemophilic factor (recombinant) for inj $0 (2) PA, SP unit RECOMBINATE antihemophilic factor (recombinant) for inj $0 (2) PA, SP unit RECOMBINATE antihemophilic factor (recombinant) for inj $0 (2) PA, SP unit RECOMBINATE antihemophilic factor (recombinant) for inj $0 (2) PA, SP unit RIXUBIS coagulation factor ix (recombinant) for inj 250 unit $0 (2) PA, SP RIXUBIS coagulation factor ix (recombinant) for inj 500 unit $0 (2) PA, SP RIXUBIS coagulation factor ix (recombinant) for inj 1000 unit $0 (2) PA, SP RIXUBIS coagulation factor ix (recombinant) for inj 2000 unit $0 (2) PA, SP RIXUBIS coagulation factor ix (recombinant) for inj 3000 unit $0 (2) PA, SP tranexamic acid tab 650 mg (Lysteda) $0 (1) warfarin sodium tab 1 mg (Coumadin) $0 (1) 90 73

80 warfarin sodium tab 2 mg (Coumadin) $0 (1) 90 warfarin sodium tab 2.5 mg (Coumadin) $0 (1) 90 warfarin sodium tab 3 mg (Coumadin) $0 (1) 90 warfarin sodium tab 4 mg (Coumadin) $0 (1) 90 warfarin sodium tab 5 mg (Coumadin) $0 (1) 90 warfarin sodium tab 6 mg (Coumadin) $0 (1) 90 warfarin sodium tab 7.5 mg (Coumadin) $0 (1) 90 warfarin sodium tab 10 mg (Coumadin) $0 (1) 90 XARELTO rivaroxaban tab 10 mg $0 (2) QL (35 tablets/365 days), 90 XARELTO rivaroxaban tab 15 mg $0 (2) PA, QL (60 tablets/30 days), 90 XARELTO rivaroxaban tab 20 mg $0 (2) PA, QL (30 tablets/30 days), 90 XARELTO STARTER PACK rivaroxaban tab starter therapy $0 (2) PA, QL (51 tablets/30 days) pack 15 mg & 20 mg XYNTHA antihemophilic factor recombinant paf for inj kit 250 $0 (2) PA, SP unit XYNTHA antihemophilic factor recombinant paf for inj kit 500 $0 (2) PA, SP unit XYNTHA antihemophilic factor recombinant paf for inj kit 1000 $0 (2) PA, SP unit XYNTHA antihemophilic factor recombinant paf for inj kit 2000 $0 (2) PA, SP unit XYNTHA SOLOFUSE antihemophilic factor recombinant paf for $0 (2) PA, SP inj kit 250 unit XYNTHA SOLOFUSE antihemophilic factor recombinant paf for $0 (2) PA, SP inj kit 500 unit XYNTHA SOLOFUSE antihemophilic factor recombinant paf for $0 (2) PA, SP inj kit 1000 unit XYNTHA SOLOFUSE antihemophilic factor recombinant paf for $0 (2) PA, SP inj kit 2000 unit XYNTHA SOLOFUSE antihemophilic factor recombinant paf for $0 (2) PA, SP inj kit 3000 unit ZARXIO filgrastim-sndz soln prefilled syringe 300 mcg/0.5ml $0 (2) SP ZARXIO filgrastim-sndz soln prefilled syringe 480 mcg/0.8ml $0 (2) SP TOPICAL DRUGS EYE Anti-infectives BACITRACIN bacitracin ophth oint 500 unit/gm $0 (2) 74

81 bacitracin-polymyxin b ophth oint $0 (1) ciprofloxacin hcl ophth soln 0.3% (Ciloxan) $0 (1) erythromycin ophth oint 5 mg/gm $0 (1) GENTAK gentamicin sulfate ophth oint 0.3% $0 (2) gentamicin sulfate ophth soln 0.3% $0 (1) levofloxacin ophth soln 0.5% $0 (1) NATACYN natamycin ophth susp 5% $0 (2) neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin $0 (1) neomycin-polymy-gramicid op sol mg-unt-mg/ $0 (1) ml (Neosporin) ofloxacin ophth soln 0.3% (Ocuflox) $0 (1) polymyxin b-trimethoprim ophth soln unit/ml-0.1% $0 (1) (Polytrim) sulfacetamide sodium ophth soln 10% (Bleph-10) $0 (1) tobramycin ophth soln 0.3% (Tobrex) $0 (1) trifluridine ophth soln 1% (Viroptic) $0 (1) Steroids and Combination Products bacitracin-polymyxin-neomycin-hc ophth oint 1% $0 (1) DEXAMETHASONE SODIUM PHOS dexamethasone sodium $0 (2) phosphate ophth soln 0.1% fluorometholone ophth susp 0.1% (Fml liquifilm) $0 (1) neomycin-polymyxin-dexamethasone ophth oint 0.1% (Maxitrol) $0 (1) neomycin-polymyxin-dexamethasone ophth susp 0.1% (Maxitrol) $0 (1) prednisolone acetate ophth susp 1% (Pred forte) $0 (1) PREDNISOLONE SODIUM PHOSP prednisolone sodium $0 (2) phosphate ophth soln 1% sulfacetamide sodium-prednisolone ophth soln (0.25)% $0 (1) tobramycin-dexamethasone ophth susp % (Tobradex) $0 (1) Glaucoma ALPHAGAN P brimonidine tartrate ophth soln 0.1% $0 (2) 90 apraclonidine hcl ophth soln 0.5% (base equivalent) (Iopidine) $0 (1) betaxolol hcl ophth soln 0.5% $0 (1) 90 brimonidine tartrate ophth soln 0.2% $0 (1) 90 carteolol hcl ophth soln 1% $0 (1) 90 dorzolamide hcl ophth soln 2% (Trusopt) $0 (1) 90 dorzolamide hcl-timolol maleate ophth soln mg/ml (Cosopt) $0 (1) 90 75

82 latanoprost ophth soln 0.005% (Xalatan) $0 (1) QL (1 bottle/30 days), 90 levobunolol hcl ophth soln 0.5% (Betagan) $0 (1) 90 pilocarpine hcl ophth soln 1% (Isopto carpine) $0 (1) 90 pilocarpine hcl ophth soln 2% (Isopto carpine) $0 (1) 90 pilocarpine hcl ophth soln 4% (Isopto carpine) $0 (1) 90 timolol maleate ophth soln 0.25% (Timoptic) $0 (1) 90 timolol maleate ophth soln 0.5% (Timoptic) $0 (1) 90 Other Eye Products artificial tear ophth solution $0 (3) ATROPINE SULFATE atropine sulfate ophth soln 1% $0 (2) 90 ATROPINE SULFATE atropine sulfate ophth oint 1% $0 (2) 90 azelastine hcl ophth soln 0.05% $0 (1) cromolyn sodium ophth soln 4% $0 (1) cyclopentolate hcl ophth soln 0.5% (Cyclogyl) $0 (1) 90 cyclopentolate hcl ophth soln 1% (Cyclogyl) $0 (1) 90 cyclopentolate hcl ophth soln 2% (Cyclogyl) $0 (1) 90 diclofenac sodium ophth soln 0.1% $0 (1) FLURBIPROFEN SODIUM flurbiprofen sodium ophth soln $0 (2) 0.03% ketorolac tromethamine ophth soln 0.4% (Acular ls) $0 (1) ketorolac tromethamine ophth soln 0.5% (Acular) $0 (1) ketotifen fumarate ophth soln 0.025% (base equiv) $0 (3) proparacaine hcl ophth soln 0.5% $0 (1) tetracaine hcl ophth soln 0.5% $0 (1) tetrahydroz-dextran-peg-povidone ophth soln % $0 (3) EAR acetic acid otic soln 2% $0 (1) carbamide peroxide 6.5% otic soln $0 (3) hydrocortisone w/ acetic acid otic soln 1-2% $0 (1) neomycin-polymyxin-hc otic soln 1% $0 (1) neomycin-polymyxin-hc otic susp 3.5 mg/ml unit/ml-1% $0 (1) ofloxacin otic soln 0.3% (Floxin otic) $0 (1) MOUTH AND THROAT (local) chlorhexidine gluconate soln 0.12% (Peridex) $0 (1) clotrimazole troche 10 mg $0 (1) 76

83 lidocaine hcl viscous soln 2% $0 (1) nystatin susp unit/ml $0 (1) pilocarpine hcl tab 5 mg (Salagen) $0 (1) 90 pilocarpine hcl tab 7.5 mg (Salagen) $0 (1) 90 sodium fluoride cream 1.1% (Prevident 5000 plus) $0 (1) 90 sodium fluoride gel 1.1% (0.5% f) (Prevident fluoride) $0 (1) 90 sodium fluoride rinse 0.2% $0 (1) 90 triamcinolone acetonide dental paste 0.1% $0 (1) ANORECTAL AGENTS hydrocortisone enema 100 mg/60ml (Cortenema) $0 (1) hydrocortisone rectal cream 1% (Proctocort) $0 (1) hydrocortisone rectal cream 2.5% (Anusol-hc) $0 (1) SKIN CONDITIONS/PRODUCTS Acne benzoyl peroxide liq 10% $0 (1) AL, PA benzoyl peroxide lotion 6% $0 (1) AL, PA clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5% $0 (1) AL, PA (Duac) clindamycin phosphate gel 1% (Cleocin-t) $0 (1) AL, PA clindamycin phosphate lotion 1% (Cleocin-t) $0 (1) AL, PA clindamycin phosphate soln 1% (Cleocin-t) $0 (1) AL, PA clindamycin phosphate swab 1% (Cleocin-t) $0 (1) AL, PA DIFFERIN adapalene gel 0.1% $0 (3) AL, PA erythromycin gel 2% (Erygel) $0 (1) AL, PA erythromycin pads 2% $0 (1) AL, PA erythromycin soln 2% $0 (1) AL, PA isotretinoin cap 10 mg $0 (1) AL, PA isotretinoin cap 20 mg $0 (1) AL, PA metronidazole cream 0.75% (Metrocream) $0 (1) AL, PA metronidazole gel 0.75% $0 (1) AL, PA metronidazole gel 1% (Metrogel) $0 (1) AL, PA sulfacetamide sodium w/ sulfur emulsion 10-1% $0 (1) AL, PA sulfacetamide sodium w/ sulfur emulsion 10-5% $0 (1) AL, PA tazarotene cream 0.1% (Tazorac) $0 (1) AL, PA TAZORAC tazarotene gel 0.05% $0 (2) AL, PA 77

84 TAZORAC tazarotene gel 0.1% $0 (2) AL, PA tretinoin cream 0.025% (Retin-a) $0 (1) AL, PA tretinoin cream 0.05% (Retin-a) $0 (1) AL, PA tretinoin cream 0.1% (Retin-a) $0 (1) AL, PA tretinoin gel 0.01% (Retin-a) $0 (1) AL, PA tretinoin gel 0.025% (Retin-a) $0 (1) AL, PA Anti-infectives bacitracin oint 500 unit/gm $0 (3) bacitracin zinc oint 500 unit/gm $0 (3) bacitracin-polymyxin b oint $0 (3) ciclopirox olamine cream 0.77% (base equiv) (Loprox) $0 (1) clotrimazole cream 1% $0 (1) clotrimazole soln 1% $0 (1) clotrimazole w/ betamethasone cream % (Lotrisone) $0 (1) diclofenac sodium gel 1% (Voltaren) $0 (1) QL (200 grams/30 days) econazole nitrate cream 1% $0 (1) GENTAMICIN SULFATE gentamicin sulfate oint 0.1% $0 (2) gentamicin sulfate cream 0.1% $0 (1) ketoconazole cream 2% $0 (1) ketoconazole shampoo 2% (Nizoral) $0 (1) miconazole nitrate aerosol pow 2% $0 (3) miconazole nitrate cream 2% $0 (3) mupirocin oint 2% $0 (1) neomycin-bacitracin-polymyxin oint $0 (3) nystatin cream unit/gm $0 (1) nystatin oint unit/gm $0 (1) nystatin topical powder unit/gm $0 (1) silver sulfadiazine cream 1% (Silvadene) $0 (1) tolnaftate aerosol 1% $0 (3) Corticosteroids alclometasone dipropionate cream 0.05% $0 (1) alclometasone dipropionate oint 0.05% $0 (1) AUGMENTED BETAMETHASONE D betamethasone dipropionate augmented gel 0.05% $0 (2) 78

85 betamethasone dipropionate augmented cream 0.05% $0 (1) (Diprolene af) betamethasone dipropionate augmented lotion 0.05% (Diprolene) $0 (1) betamethasone dipropionate augmented oint 0.05% (Diprolene) $0 (1) betamethasone dipropionate cream 0.05% $0 (1) betamethasone dipropionate lotion 0.05% $0 (1) betamethasone dipropionate oint 0.05% $0 (1) betamethasone valerate cream 0.1% (base equivalent) $0 (1) betamethasone valerate lotion 0.1% (base equivalent) $0 (1) betamethasone valerate oint 0.1% (base equivalent) $0 (1) clobetasol propionate cream 0.05% (Temovate) $0 (1) clobetasol propionate emollient base cream 0.05% $0 (1) clobetasol propionate gel 0.05% (Temovate) $0 (1) clobetasol propionate oint 0.05% (Temovate) $0 (1) clobetasol propionate soln 0.05% (Temovate) $0 (1) desoximetasone cream 0.25% (Topicort) $0 (1) fluocinolone acetonide cream 0.01% $0 (1) fluocinolone acetonide cream 0.025% (Synalar) $0 (1) fluocinolone acetonide oint 0.025% (Synalar) $0 (1) fluocinolone acetonide soln 0.01% (Synalar) $0 (1) fluocinonide cream 0.05% $0 (1) fluocinonide emulsified base cream 0.05% $0 (1) fluocinonide gel 0.05% $0 (1) fluocinonide oint 0.05% $0 (1) fluocinonide soln 0.05% $0 (1) fluticasone propionate cream 0.05% (Cutivate) $0 (1) fluticasone propionate oint 0.005% $0 (1) halobetasol propionate cream 0.05% (Ultravate) $0 (1) halobetasol propionate oint 0.05% (Ultravate) $0 (1) hydrocortisone butyrate oint 0.1% (Locoid) $0 (1) hydrocortisone cream 0.5% $0 (3) hydrocortisone cream 1% $0 (1) hydrocortisone cream 2.5% $0 (1) hydrocortisone lotion 2.5% $0 (1) hydrocortisone oint 0.5% $0 (3) 79

86 hydrocortisone oint 1% $0 (1) hydrocortisone oint 2.5% $0 (1) hydrocortisone valerate cream 0.2% $0 (1) hydrocortisone valerate oint 0.2% (Westcort) $0 (1) mometasone furoate cream 0.1% (Elocon) $0 (1) mometasone furoate oint 0.1% (Elocon) $0 (1) mometasone furoate solution 0.1% (lotion) $0 (1) PREDNICARBATE prednicarbate cream 0.1% $0 (2) PREDNICARBATE prednicarbate oint 0.1% $0 (2) prednicarbate cream 0.1% (Dermatop) $0 (1) triamcinolone acetonide cream 0.025% $0 (1) triamcinolone acetonide cream 0.1% $0 (1) triamcinolone acetonide cream 0.5% $0 (1) triamcinolone acetonide lotion 0.025% $0 (1) triamcinolone acetonide lotion 0.1% $0 (1) triamcinolone acetonide oint 0.025% $0 (1) triamcinolone acetonide oint 0.1% $0 (1) Other Skin Products calcipotriene cream 0.005% (Dovonex) $0 (1) calcipotriene oint 0.005% $0 (1) calcipotriene soln 0.005% (50 mcg/ml) $0 (1) COSENTYX secukinumab subcutaneous soln prefilled syringe 150 mg/ml COSENTYX SENSOREADY PEN secukinumab subcutaneous soln auto-injector 150 mg/ml $0 (2) PA, QL (2 syringes/28 days), SP, 90 $0 (2) PA, QL (2 pens/28 days), SP, 90 ELIDEL pimecrolimus cream 1% $0 (2) QL (30 grams/1 prescription), ST FLUOROURACIL fluorouracil soln 2% $0 (2) FLUOROURACIL fluorouracil soln 5% $0 (2) fluorouracil cream 5% (Efudex) $0 (1) QL (240 grams/180 days) imiquimod cream 5% (Aldara) $0 (1) QL (48 packs/180 days) lactic acid (ammonium lactate) lotion 12% (Lac-hydrin) $0 (3) lidocaine hcl cream 3% $0 (1) QL (120 grams/30 days) lidocaine hcl gel 2% $0 (1) QL (120 grams/30 days) lidocaine hcl soln 4% (Xylocaine) $0 (1) QL (120 grams/30 days) 80

87 lidocaine oint 5% $0 (1) PA, QL (120 grams/30 days) lidocaine patch 5% (Lidoderm) $0 (1) PA, QL (120 patches/30 days) lidocaine-prilocaine cream kit % $0 (1) lidocaine-prilocaine cream % $0 (1) methoxsalen rapid cap 10 mg (Oxsoralen ultra) $0 (1) permethrin cream 5% (Elimite) $0 (1) permethrin creme rinse 1% $0 (3) podofilox soln 0.5% $0 (1) QC CALAMINE calamine lotion $0 (3) selenium sulfide lotion 2.5% $0 (1) tacrolimus oint 0.03% (Protopic) $0 (1) QL (30 grams/1 prescription), ST tacrolimus oint 0.1% (Protopic) $0 (1) QL (30 grams/1 prescription), ST VALCHLOR mechlorethamine hcl gel 0.016% (base equivalent) $0 (2) SP vitamins a & d oint $0 (3) zinc oxide oint 20% $0 (3) zinc oxide oint 10% $0 (3) ZYCLARA imiquimod cream 3.75% $0 (2) PA, QL (56 packets/180 days) ZYCLARA PUMP imiquimod cream 2.5% $0 (2) PA, QL (15 grams/180 days) ZYCLARA PUMP imiquimod cream 3.75% $0 (2) PA, QL (15 grams/180 days) MISCELLANEOUS CATEGORIES (includes supplies and devices) DIABETIC SUPPLIES GLUCOSE METERS - BAYER ASCENCIA $0 (3) TEST STRIPS - BAYER ASCENCIA $0 (3) QL (204 strips/30 days), ST, 90 ALCOHOL PREP PADS, SWABS - various alcohol swabs $0 (3) QL (200 swabs/30 days), 90 INSULIN PEN NEEDLES - TECHLITE AND TRUEPLUS $0 (3) QL (200 insulin pen needles/30 days), 90 INSULIN SYRINGES - TECHLITE AND TRUEPLUS $0 (3) QL (200 syringes/30 days), 90 LANCETS - BAYER ASCENCIA $0 (3) QL (200 units/30 days), 90 MISCELLANEOUS DRUGS azathioprine tab 50 mg (Imuran) $0 (1) 90 CHEMET succimer cap 100 mg $0 (2) cyclosporine cap 25 mg (Sandimmune) $0 (1) 90 81

88 cyclosporine cap 100 mg (Sandimmune) $0 (1) 90 CYCLOSPORINE MODIFIED cyclosporine modified cap 50 mg $0 (2) 90 cyclosporine modified cap 25 mg (Neoral) $0 (1) 90 cyclosporine modified cap 50 mg (Cyclosporine modifie) $0 (1) 90 cyclosporine modified cap 100 mg (Neoral) $0 (1) 90 cyclosporine modified oral soln 100 mg/ml (Neoral) $0 (1) 90 DEPEN TITRATABS penicillamine tab 250 mg $0 (2) SP irrigation solution, physiological $0 (1) lactated ringer's for irrigation $0 (1) mycophenolate mofetil cap 250 mg (Cellcept) $0 (1) 90 mycophenolate mofetil for oral susp 200 mg/ml (Cellcept) $0 (1) 90 mycophenolate mofetil tab 500 mg (Cellcept) $0 (1) 90 mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv) $0 (1) 90 (Myfortic) mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv) $0 (1) 90 (Myfortic) NALOXONE HCL naloxone hcl soln cartridge 0.4 mg/ml $0 (2) NALOXONE HCL naloxone hcl soln prefilled syringe 2 mg/2ml $0 (2) NARCAN naloxone hcl nasal spray 4 mg/0.1ml $0 (2) REVLIMID lenalidomide caps 2.5 mg $0 (2) PA, QL (30 capsules/30 days), SP REVLIMID lenalidomide cap 5 mg $0 (2) PA, QL (30 capsules/30 days), SP REVLIMID lenalidomide cap 10 mg $0 (2) PA, QL (30 capsules/30 days), SP REVLIMID lenalidomide cap 15 mg $0 (2) PA, QL (21 capsules/28 days), SP REVLIMID lenalidomide cap 20 mg $0 (2) PA, QL (21 capsules/28 days), SP REVLIMID lenalidomide cap 25 mg $0 (2) PA, QL (21 capsules/28 days), SP ringer's solution for irrigation $0 (1) sirolimus tab 0.5 mg (Rapamune) $0 (1) 90 sirolimus tab 1 mg (Rapamune) $0 (1) 90 sirolimus tab 2 mg (Rapamune) $0 (1) 90 sodium polystyrene sulfonate oral susp 15 gm/60ml $0 (1) sodium polystyrene sulfonate powder $0 (1) 82

89 sodium polystyrene sulfonate rectal susp 30 gm/120ml $0 (1) tacrolimus cap 0.5 mg (Prograf) $0 (1) 90 tacrolimus cap 1 mg (Prograf) $0 (1) 90 tacrolimus cap 5 mg (Prograf) $0 (1) 90 THALOMID thalidomide cap 50 mg $0 (2) PA, QL (30 capsules/30 days), SP, 90 THALOMID thalidomide cap 100 mg $0 (2) PA, QL (30 capsules/30 days), SP, 90 THALOMID thalidomide cap 150 mg $0 (2) PA, QL (60 capsules/30 days), SP, 90 water for irrigation, sterile irrigation soln $0 (1) ZORTRESS everolimus tab 0.25 mg $0 (2) 90 ZORTRESS everolimus tab 0.5 mg $0 (2) 90 ZORTRESS everolimus tab 0.75 mg $0 (2) 90 83

90 INDEX A abacavir sulfate-lamivudine tab mg (Epzicom)... 5 abacavir sulfate-lamivudine-zidovudine tab mg (Trizivir)... 5 abacavir sulfate soln 20 mg/ml (base equiv) (Ziagen)... 5 abacavir sulfate tab 300 mg (base equiv) (Ziagen)...5 ABILIFY MAINTENA aripiprazole im for er susp prefilled syringe 300 mg...44 ABILIFY MAINTENA aripiprazole im for er susp prefilled syringe 400 mg...44 ABILIFY MAINTENA aripiprazole im for extended release susp 300 mg...44 ABILIFY MAINTENA aripiprazole im for extended release susp 400 mg...44 acamprosate calcium tab delayed release 333 mg...51 acarbose tab 25 mg (Precose)...17 acarbose tab 50 mg (Precose)...17 acarbose tab 100 mg (Precose)...17 ACCU-CHEK SOFT TOUCH LANC acebutolol hcl cap 200 mg...24 acebutolol hcl cap 400 mg...24 ACETAMINOPHEN/CAFFEINE/DI acetaminophencaffeine-dihydrocodeine cap mg acetaminophen cap 500 mg acetaminophen chew tab 80 mg acetaminophen chew tab 160 mg acetaminophen disintegrating tab 80 mg acetaminophen liquid 160 mg/5ml...52 acetaminophen soln 160 mg/5ml...52 acetaminophen suppos 120 mg acetaminophen susp 80 mg/0.8ml...52 acetaminophen susp 160 mg/5ml...52 acetaminophen tab 325 mg acetaminophen tab 500 mg acetaminophen w/ codeine soln mg/5ml...52 acetaminophen w/ codeine tab mg (Tylenol/ codeine)...52 acetaminophen w/ codeine tab mg (Tylenol/ codeine #3) acetaminophen w/ codeine tab mg (Tylenol/ codeine #4) acetazolamide cap er 12hr 500 mg (Diamox) acetazolamide tab 125 mg acetazolamide tab 250 mg acetic acid otic soln 2% acetylcysteine inhal soln 10%...33 acetylcysteine inhal soln 20%...33 ACTIMMUNE interferon gamma-1b inj 100 mcg/0.5ml ( unit/0.5ml)...9 acyclovir cap 200 mg (Zovirax)... 5 acyclovir susp 200 mg/5ml (Zovirax)...5 acyclovir tab 400 mg (Zovirax)... 5 acyclovir tab 800 mg (Zovirax)... 5 ADCIRCA tadalafil tab 20 mg (pah) ADVATE antihemophilic factor rahf-pfm for inj 250 unit...69 ADVATE antihemophilic factor rahf-pfm for inj 500 unit...69 ADVATE antihemophilic factor rahf-pfm for inj 1000 unit...69 ADVATE antihemophilic factor rahf-pfm for inj 1500 unit...69 ADVATE antihemophilic factor rahf-pfm for inj 2000 unit...69 ADVATE antihemophilic factor rahf-pfm for inj 3000 unit...69 ADVATE antihemophilic factor rahf-pfm for inj 4000 unit...69 ADYNOVATE antihemophilic factor recomb pegylated for inj 250 unit ADYNOVATE antihemophilic factor recomb pegylated for inj 500 unit ADYNOVATE antihemophilic factor recomb pegylated for inj 750 unit ADYNOVATE antihemophilic factor recomb pegylated for inj 1000 unit ADYNOVATE antihemophilic factor recomb pegylated for inj 1500 unit ADYNOVATE antihemophilic factor recomb pegylated for inj 2000 unit ADYNOVATE antihemophilic factor recomb pegylated for inj 3000 unit AFINITOR DISPERZ everolimus tab for oral susp 2 mg...9 AFINITOR DISPERZ everolimus tab for oral susp 3 mg...9 AFINITOR DISPERZ everolimus tab for oral susp 5 mg...9 AFINITOR everolimus tab 2.5 mg... 9 AFINITOR everolimus tab 5 mg... 9 AFINITOR everolimus tab 7.5 mg... 9 AFINITOR everolimus tab 10 mg... 9 ALBENZA albendazole tab 200 mg... 8 albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)...33 albuterol sulfate soln nebu 0.5% (5 mg/ml)...33 albuterol sulfate soln nebu 0.63 mg/3ml (base equiv)...33 albuterol sulfate soln nebu 1.25 mg/3ml (base equiv)...33 albuterol sulfate syrup 2 mg/5ml alclometasone dipropionate cream 0.05% alclometasone dipropionate oint 0.05% ALCOHOL PREP PADS, SWABS - various alcohol swabs ALENDRONATE SODIUM alendronate sodium tab 40 mg...20 alendronate sodium tab 5 mg...20 alendronate sodium tab 10 mg...20 alendronate sodium tab 35 mg...20 alendronate sodium tab 70 mg (Fosamax) alfuzosin hcl tab er 24hr 10 mg (Uroxatral)

91 ALKERAN melphalan tab 2 mg...9 allopurinol tab 100 mg (Zyloprim)...57 allopurinol tab 300 mg (Zyloprim)...57 ALOGLIPTIN/METFORMIN HCL alogliptin-metformin hcl tab mg ALOGLIPTIN/METFORMIN HCL alogliptin-metformin hcl tab mg ALOGLIPTIN/PIOGLITAZONE alogliptin-pioglitazone tab mg ALOGLIPTIN/PIOGLITAZONE alogliptin-pioglitazone tab mg ALOGLIPTIN/PIOGLITAZONE alogliptin-pioglitazone tab mg ALOGLIPTIN/PIOGLITAZONE alogliptin-pioglitazone tab mg ALOGLIPTIN/PIOGLITAZONE alogliptin-pioglitazone tab mg ALOGLIPTIN/PIOGLITAZONE alogliptin-pioglitazone tab mg ALOGLIPTIN alogliptin benzoate tab 6.25 mg (base equiv)...17 ALOGLIPTIN alogliptin benzoate tab 12.5 mg (base equiv)...17 ALOGLIPTIN alogliptin benzoate tab 25 mg (base equiv)...17 ALPHAGAN P brimonidine tartrate ophth soln 0.1% ALPHANATE/VON WILLEBRAND antihemophilic factor/ vwf (human) for inj 250 unit ALPHANATE/VON WILLEBRAND antihemophilic factor/ vwf (human) for inj 500 unit ALPHANATE/VON WILLEBRAND antihemophilic factor/ vwf (human) for inj 1000 unit ALPHANATE/VON WILLEBRAND antihemophilic factor/ vwf (human) for inj 1500 unit ALPHANATE/VON WILLEBRAND antihemophilic factor/ vwf (human) for inj 2000 unit ALPHANINE SD coagulation factor ix for inj 500 unit...70 ALPHANINE SD coagulation factor ix for inj 1000 unit...70 ALPHANINE SD coagulation factor ix for inj 1500 unit...70 alprazolam tab 0.25 mg (Xanax) alprazolam tab 0.5 mg (Xanax) alprazolam tab 1 mg (Xanax) alprazolam tab 2 mg (Xanax) alum & mag hydroxide-simethicone susp mg/5ml...36 alum & mag hydroxide-simethicone susp mg/5ml...36 amantadine hcl cap 100 mg amantadine hcl syrup 50 mg/5ml amiloride & hydrochlorothiazide tab 5-50 mg...28 amiloride hcl tab 5 mg amiodarone hcl tab 200 mg...29 amitriptyline hcl tab 10 mg...42 amitriptyline hcl tab 50 mg...42 amitriptyline hcl tab 75 mg...42 amitriptyline hcl tab 100 mg...42 amitriptyline hcl tab 150 mg...42 amitriptyline hcl tab 25 mg (Elavil) amlodipine besylate-benazepril hcl cap mg amlodipine besylate-benazepril hcl cap 5-40 mg amlodipine besylate-benazepril hcl cap 5-10 mg (Lotrel) amlodipine besylate-benazepril hcl cap 5-20 mg (Lotrel) amlodipine besylate-benazepril hcl cap mg (Lotrel) amlodipine besylate-benazepril hcl cap mg (Lotrel) amlodipine besylate tab 2.5 mg (Norvasc)...25 amlodipine besylate tab 5 mg (Norvasc)...25 amlodipine besylate tab 10 mg (Norvasc)...25 amlodipine besylate-valsartan tab mg (Exforge)...25 amlodipine besylate-valsartan tab mg (Exforge)...25 amlodipine besylate-valsartan tab mg (Exforge)...25 amlodipine besylate-valsartan tab mg (Exforge)...25 amoxicillin & k clavulanate for susp mg/5ml... 1 amoxicillin & k clavulanate for susp mg/5ml... 1 amoxicillin & k clavulanate for susp mg/5ml (Augmentin)...1 amoxicillin & k clavulanate for susp mg/5ml (Augmentin es-600)... 1 amoxicillin & k clavulanate tab mg...1 amoxicillin & k clavulanate tab mg (Augmentin)...1 amoxicillin & k clavulanate tab mg (Augmentin)...1 AMOXICILLIN amoxicillin (trihydrate) chew tab 125 mg...1 AMOXICILLIN amoxicillin (trihydrate) chew tab 250 mg...1 amoxicillin (trihydrate) cap 250 mg...1 amoxicillin (trihydrate) cap 500 mg...1 amoxicillin (trihydrate) for susp 125 mg/5ml...1 amoxicillin (trihydrate) for susp 200 mg/5ml...1 amoxicillin (trihydrate) for susp 250 mg/5ml...1 amoxicillin (trihydrate) for susp 400 mg/5ml...1 amoxicillin (trihydrate) tab 875 mg... 1 amphetamine-dextroamphetamine cap er 24hr 5 mg (Adderall xr) amphetamine-dextroamphetamine cap er 24hr 10 mg (Adderall xr) amphetamine-dextroamphetamine cap er 24hr 15 mg (Adderall xr) amphetamine-dextroamphetamine cap er 24hr 20 mg (Adderall xr)

92 amphetamine-dextroamphetamine cap er 24hr 25 mg (Adderall xr) amphetamine-dextroamphetamine cap er 24hr 30 mg (Adderall xr) amphetamine-dextroamphetamine tab 5 mg (Adderall)...48 amphetamine-dextroamphetamine tab 7.5 mg (Adderall)...48 amphetamine-dextroamphetamine tab 10 mg (Adderall)...48 amphetamine-dextroamphetamine tab 12.5 mg (Adderall)...48 amphetamine-dextroamphetamine tab 15 mg (Adderall)...48 amphetamine-dextroamphetamine tab 20 mg (Adderall)...48 amphetamine-dextroamphetamine tab 30 mg (Adderall)...49 AMPICILLIN ampicillin cap 500 mg...1 AMPYRA dalfampridine tab er 12hr 10 mg...50 anagrelide hcl cap 1 mg anagrelide hcl cap 0.5 mg (Agrylin)...70 anastrozole tab 1 mg (Arimidex)... 9 apraclonidine hcl ophth soln 0.5% (base equivalent) (Iopidine) APTIOM eslicarbazepine acetate tab 200 mg...57 APTIOM eslicarbazepine acetate tab 400 mg...57 APTIOM eslicarbazepine acetate tab 600 mg...57 APTIOM eslicarbazepine acetate tab 800 mg...57 APTIVUS tipranavir cap 250 mg... 5 APTIVUS tipranavir oral soln 100 mg/ml... 5 ARANESP ALBUMIN FREE darbepoetin alfa soln inj 25 mcg/ml...70 ARANESP ALBUMIN FREE darbepoetin alfa soln inj 40 mcg/ml...70 ARANESP ALBUMIN FREE darbepoetin alfa soln inj 60 mcg/ml...70 ARANESP ALBUMIN FREE darbepoetin alfa soln inj 100 mcg/ml ARANESP ALBUMIN FREE darbepoetin alfa soln inj 200 mcg/ml ARANESP ALBUMIN FREE darbepoetin alfa soln inj 300 mcg/ml ARANESP ALBUMIN FREE darbepoetin alfa soln prefilled syringe 10 mcg/0.4ml ARANESP ALBUMIN FREE darbepoetin alfa soln prefilled syringe 25 mcg/0.42ml ARANESP ALBUMIN FREE darbepoetin alfa soln prefilled syringe 40 mcg/0.4ml ARANESP ALBUMIN FREE darbepoetin alfa soln prefilled syringe 60 mcg/0.3ml ARANESP ALBUMIN FREE darbepoetin alfa soln prefilled syringe 100 mcg/0.5ml ARANESP ALBUMIN FREE darbepoetin alfa soln prefilled syringe 150 mcg/0.3ml ARANESP ALBUMIN FREE darbepoetin alfa soln prefilled syringe 200 mcg/0.4ml ARANESP ALBUMIN FREE darbepoetin alfa soln prefilled syringe 300 mcg/0.6ml ARANESP ALBUMIN FREE darbepoetin alfa soln prefilled syringe 500 mcg/ml aripiprazole oral solution 1 mg/ml...44 aripiprazole tab 2 mg (Abilify)...44 aripiprazole tab 5 mg (Abilify)...44 aripiprazole tab 10 mg (Abilify)...44 aripiprazole tab 15 mg (Abilify)...44 aripiprazole tab 20 mg (Abilify)...44 aripiprazole tab 30 mg (Abilify)...44 ARISTADA aripiprazole lauroxil im er susp prefilled syr 441 mg/1.6ml ARISTADA aripiprazole lauroxil im er susp prefilled syr 662 mg/2.4ml ARISTADA aripiprazole lauroxil im er susp prefilled syr 882 mg/3.2ml ARISTADA aripiprazole lauroxil im er susp prefilled syr 1064 mg/3.9ml...44 ARNUITY ELLIPTA fluticasone furoate aerosol powder breath activ 100 mcg/act...34 ARNUITY ELLIPTA fluticasone furoate aerosol powder breath activ 200 mcg/act...34 artificial tear ophth solution...76 ASCORBIC ACID ascorbic acid inj 500 mg/ml ascorbic acid tab 500 mg aspirin chew tab 81 mg aspirin-dipyridamole cap er 12hr mg (Aggrenox) aspirin tab delayed release 81 mg aspirin tab delayed release 325 mg aspirin tab 325 mg atazanavir sulfate cap 150 mg (base equiv) (Reyataz)...5 atazanavir sulfate cap 200 mg (base equiv) (Reyataz)...5 atazanavir sulfate cap 300 mg (base equiv) (Reyataz)...5 atenolol & chlorthalidone tab mg (Tenoretic 50)...24 atenolol & chlorthalidone tab mg (Tenoretic 100) atenolol tab 25 mg (Tenormin) atenolol tab 50 mg (Tenormin) atenolol tab 100 mg (Tenormin) atorvastatin calcium tab 10 mg (base equivalent) (Lipitor) atorvastatin calcium tab 20 mg (base equivalent) (Lipitor) atorvastatin calcium tab 40 mg (base equivalent) (Lipitor) atorvastatin calcium tab 80 mg (base equivalent) (Lipitor) atovaquone-proguanil hcl tab mg (Malarone)... 8 atovaquone-proguanil hcl tab mg (Malarone)... 8 atovaquone susp 750 mg/5ml (Mepron)... 8 ATRIPLA efavirenz-emtricitabine-tenofovir df tab mg

93 ATROPINE SULFATE atropine sulfate ophth oint 1% ATROPINE SULFATE atropine sulfate ophth soln 1% ATROVENT HFA ipratropium bromide hfa inhal aerosol 17 mcg/act AUBAGIO teriflunomide tab 7 mg AUBAGIO teriflunomide tab 14 mg AUGMENTED BETAMETHASONE D betamethasone dipropionate augmented gel 0.05%...78 AVONEX interferon beta-1a for im inj kit 30mcg (33mcg(6.6 mu)/vial)...51 AVONEX interferon beta-1a im prefilled syringe kit 30 mcg/0.5ml...51 AVONEX PEN interferon beta-1a im auto-injector kit 30 mcg/0.5ml...51 azathioprine tab 50 mg (Imuran) azelastine hcl nasal spray 0.1% (137 mcg/spray)...33 azelastine hcl ophth soln 0.05%...76 azithromycin for susp 100 mg/5ml (Zithromax)... 2 azithromycin for susp 200 mg/5ml (Zithromax)... 2 azithromycin tab 250 mg (Zithromax)...2 azithromycin tab 500 mg (Zithromax)...2 azithromycin tab 600 mg (Zithromax)...2 B BACITRACIN bacitracin ophth oint 500 unit/gm bacitracin oint 500 unit/gm...78 bacitracin-polymyxin b oint bacitracin-polymyxin b ophth oint bacitracin-polymyxin-neomycin-hc ophth oint 1% bacitracin zinc oint 500 unit/gm...78 baclofen tab 10 mg baclofen tab 20 mg balsalazide disodium cap 750 mg (Colazal)...39 BANZEL rufinamide susp 40 mg/ml BANZEL rufinamide tab 200 mg BANZEL rufinamide tab 400 mg BARACLUDE entecavir oral soln 0.05 mg/ml... 4 BASAGLAR KWIKPEN insulin glargine soln pen-injector 100 unit/ml BAYER CONTOUR BLOOD GLUCO b-complex w/ c & folic acid cap 1 mg (Nephrocaps) b-complex w/ c & folic acid tab...67 b-complex w/ c & folic acid tab 5 mg b-complex w/ c & folic acid tab 1 mg (Nephro-vite rx)...67 BD INSULIN SYRINGE ULTRAF BEBULIN factor ix complex for inj unit...70 benazepril & hydrochlorothiazide tab mg...21 benazepril & hydrochlorothiazide tab mg (Lotensin hct) benazepril & hydrochlorothiazide tab mg (Lotensin hct) benazepril & hydrochlorothiazide tab mg (Lotensin hct)...21 benazepril hcl tab 5 mg benazepril hcl tab 10 mg benazepril hcl tab 20 mg (Lotensin)...21 benazepril hcl tab 40 mg (Lotensin)...21 BENEFIX coagulation factor ix (recombinant) for inj kit 250 unit BENEFIX coagulation factor ix (recombinant) for inj kit 500 unit BENEFIX coagulation factor ix (recombinant) for inj kit 1000 unit BENEFIX coagulation factor ix (recombinant) for inj kit 2000 unit BENEFIX coagulation factor ix (recombinant) for inj kit 3000 unit benzoyl peroxide liq 10%...77 benzoyl peroxide lotion 6%...77 benztropine mesylate tab 0.5 mg benztropine mesylate tab 1 mg benztropine mesylate tab 2 mg betamethasone dipropionate augmented cream 0.05% (Diprolene af) betamethasone dipropionate augmented lotion 0.05% (Diprolene) betamethasone dipropionate augmented oint 0.05% (Diprolene) betamethasone dipropionate cream 0.05%...79 betamethasone dipropionate lotion 0.05% betamethasone dipropionate oint 0.05%...79 betamethasone valerate cream 0.1% (base equivalent)...79 betamethasone valerate lotion 0.1% (base equivalent)...79 betamethasone valerate oint 0.1% (base equivalent) betaxolol hcl ophth soln 0.5%...75 betaxolol hcl tab 10 mg betaxolol hcl tab 20 mg bethanechol chloride tab 5 mg (Urecholine) bethanechol chloride tab 10 mg (Urecholine) bethanechol chloride tab 25 mg (Urecholine) bethanechol chloride tab 50 mg (Urecholine) bexarotene cap 75 mg (Targretin)... 9 bicalutamide tab 50 mg (Casodex)...9 BILTRICIDE praziquantel tab 600 mg... 8 bisacodyl tab delayed release 5 mg...35 bismuth subsalicylate susp 262 mg/15ml...36 bisoprolol & hydrochlorothiazide tab mg (Ziac) bisoprolol & hydrochlorothiazide tab mg (Ziac)...24 bisoprolol & hydrochlorothiazide tab mg (Ziac) bisoprolol fumarate tab 5 mg...24 bisoprolol fumarate tab 10 mg...24 BOTOX onabotulinumtoxina for inj 100 unit...65 BRILINTA ticagrelor tab 60 mg BRILINTA ticagrelor tab 90 mg brimonidine tartrate ophth soln 0.2%...75 BRIVIACT brivaracetam iv soln 50 mg/5ml

94 BRIVIACT brivaracetam oral soln 10 mg/ml BRIVIACT brivaracetam tab 10 mg...57 BRIVIACT brivaracetam tab 25 mg...57 BRIVIACT brivaracetam tab 50 mg...57 BRIVIACT brivaracetam tab 75 mg...57 BRIVIACT brivaracetam tab 100 mg...57 BROHIST D brompheniramine & phenylephrine tab 4-10 mg...33 bromocriptine mesylate tab 2.5 mg (base equivalent) (Parlodel)...64 brompheniramine & phenylephrine elixir mg/5ml...33 budesonide delayed release particles cap 3 mg (Entocort ec)...13 budesonide inhalation susp 0.25 mg/2ml (Pulmicort) budesonide inhalation susp 0.5 mg/2ml (Pulmicort) budesonide inhalation susp 1 mg/2ml (Pulmicort) bumetanide tab 0.5 mg (Bumex)...29 bumetanide tab 1 mg (Bumex)...29 bumetanide tab 2 mg (Bumex)...29 BUNAVAIL buprenorphine-naloxone buccal film mg (base equiv)...53 BUNAVAIL buprenorphine-naloxone buccal film mg (base equiv)...53 BUNAVAIL buprenorphine-naloxone buccal film mg (base equiv)...53 buprenorphine hcl-naloxone hcl sl tab mg (base equiv)...53 buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv)...53 buprenorphine hcl sl tab 2 mg (base equiv)...53 buprenorphine hcl sl tab 8 mg (base equiv)...53 bupropion hcl (smoking deterrent) tab er 12hr 150 mg (Zyban) bupropion hcl tab er 12hr 100 mg (Wellbutrin sr)...42 bupropion hcl tab er 12hr 150 mg (Wellbutrin sr)...42 bupropion hcl tab er 12hr 200 mg (Wellbutrin sr)...42 bupropion hcl tab er 24hr 150 mg (Wellbutrin xl) bupropion hcl tab er 24hr 300 mg (Wellbutrin xl) bupropion hcl tab 75 mg...42 bupropion hcl tab 100 mg...42 buspirone hcl tab 5 mg buspirone hcl tab 10 mg buspirone hcl tab 15 mg buspirone hcl tab 30 mg butalbital-acetaminophen-caffeine cap mg butalbital-acetaminophen-caffeine cap mg (Fioricet) butalbital-acetaminophen-caffeine tab mg (Esgic) butalbital-acetaminophen-caff w/ cod cap mg...53 butalbital-acetaminophen tab mg butalbital-aspirin-caffeine cap mg (Fiorinal)...52 butalbital-aspirin-caff w/ codeine cap mg (Fiorinal/codeine #3)...53 C cabergoline tab 0.5 mg caffeine citrate oral soln 60 mg/3ml (10 mg/ml base equiv)...49 calcipotriene cream 0.005% (Dovonex) calcipotriene oint 0.005%...80 calcipotriene soln 0.005% (50 mcg/ml) calcitonin (salmon) nasal soln 200 unit/act calcitriol cap 0.25 mcg (Rocaltrol) calcitriol cap 0.5 mcg (Rocaltrol) calcitriol oral soln 1 mcg/ml (Rocaltrol) calcium acetate (phosphate binder) cap 667 mg (169 mg ca)...39 calcium acetate (phosphate binder) tab 667 mg (Eliphos) calcium carbonate (antacid) chew tab 500 mg...36 calcium carbonate (antacid) chew tab 750 mg...36 calcium carbonate (antacid) chew tab 1000 mg...37 calcium carbonate-cholecalciferol tab 500 mg-200 unit...67 calcium carbonate-cholecalciferol tab 600 mg-400 unit...67 calcium carbonate tab 1250 mg (500 mg elemental ca)...67 calcium carbonate-vitamin d tab 250 mg-125 unit calcium carbonate-vitamin d tab 500 mg-200 unit calcium carbonate-vitamin d tab 600 mg-400 unit calcium citrate tab 950 mg (200 mg elemental ca) CANASA mesalamine suppos 1000 mg capecitabine tab 150 mg (Xeloda)...9 capecitabine tab 500 mg (Xeloda)...10 CAPTOPRIL/HYDROCHLOROTHIA captopril & hydrochlorothiazide tab mg CAPTOPRIL/HYDROCHLOROTHIA captopril & hydrochlorothiazide tab mg CAPTOPRIL/HYDROCHLOROTHIA captopril & hydrochlorothiazide tab mg CAPTOPRIL/HYDROCHLOROTHIA captopril & hydrochlorothiazide tab mg captopril tab 12.5 mg captopril tab 25 mg captopril tab 50 mg captopril tab 100 mg carbamazepine chew tab 100 mg carbamazepine susp 100 mg/5ml (Tegretol) carbamazepine tab er 12hr 100 mg (Tegretol-xr)...58 carbamazepine tab er 12hr 200 mg (Tegretol-xr)...58 carbamazepine tab er 12hr 400 mg (Tegretol-xr)...58 carbamazepine tab 200 mg (Tegretol) carbamide peroxide 6.5% otic soln CARBATROL carbamazepine cap er 12hr 100 mg...58 CARBATROL carbamazepine cap er 12hr 200 mg...58 CARBATROL carbamazepine cap er 12hr 300 mg...58 carbidopa & levodopa tab er mg (Sinemet cr) carbidopa & levodopa tab er mg (Sinemet cr)

95 carbidopa & levodopa tab mg (Sinemet)...64 carbidopa & levodopa tab mg (Sinemet)...64 carbidopa & levodopa tab mg (Sinemet)...64 carbidopa tab 25 mg (Lodosyn)...64 carbinoxamine maleate soln 4 mg/5ml...32 carbinoxamine maleate tab 4 mg carteolol hcl ophth soln 1% carvedilol tab mg (Coreg)...24 carvedilol tab 6.25 mg (Coreg)...24 carvedilol tab 12.5 mg (Coreg)...24 carvedilol tab 25 mg (Coreg) cefaclor cap 250 mg... 1 cefaclor cap 500 mg... 1 cefadroxil cap 500 mg...1 cefadroxil for susp 250 mg/5ml... 1 cefadroxil for susp 500 mg/5ml... 1 cefadroxil tab 1 gm... 1 cefdinir cap 300 mg... 2 cefdinir for susp 125 mg/5ml... 2 cefdinir for susp 250 mg/5ml... 2 cefprozil for susp 125 mg/5ml... 2 cefprozil for susp 250 mg/5ml... 2 cefprozil tab 250 mg... 2 cefprozil tab 500 mg... 2 ceftriaxone sodium for inj 1 gm... 2 ceftriaxone sodium for inj 2 gm... 2 ceftriaxone sodium for inj 250 mg... 2 ceftriaxone sodium for inj 500 mg... 2 cefuroxime axetil tab 250 mg... 2 cefuroxime axetil tab 500 mg... 2 celecoxib cap 50 mg (Celebrex)...55 celecoxib cap 100 mg (Celebrex)...55 celecoxib cap 200 mg (Celebrex)...55 celecoxib cap 400 mg (Celebrex)...55 CELONTIN methsuximide cap 300 mg cephalexin cap 250 mg (Keflex)...2 cephalexin cap 500 mg (Keflex)...2 cephalexin for susp 125 mg/5ml...2 cephalexin for susp 250 mg/5ml...2 CEREBYX fosphenytoin sodium inj 100 mg/2ml (phenytoin equiv) CEREBYX fosphenytoin sodium inj 500 mg/10ml (phenytoin equiv) cetirizine hcl oral soln 1 mg/ml (5 mg/5ml)...32 cetirizine hcl tab 5 mg...32 cetirizine hcl tab 10 mg...32 CHANTIX CONTINUING MONTH varenicline tartrate tab 1 mg (base equiv)...51 CHANTIX STARTING MONTH PA varenicline tartrate tab 0.5 mg x 11 & tab 1 mg x 42 pack CHANTIX varenicline tartrate tab 0.5 mg (base equiv)...51 CHANTIX varenicline tartrate tab 1 mg (base equiv) CHEMET succimer cap 100 mg...81 chlordiazepoxide hcl cap 5 mg...41 chlordiazepoxide hcl cap 10 mg...41 chlordiazepoxide hcl cap 25 mg...41 chlorhexidine gluconate soln 0.12% (Peridex) CHLOROQUINE PHOSPHATE chloroquine phosphate tab 250 mg...8 chloroquine phosphate tab 500 mg...8 CHLOROTHIAZIDE chlorothiazide tab 250 mg chlorothiazide tab 500 mg chlorpheniramine maleate tab 4 mg...32 chlorthalidone tab 25 mg chlorthalidone tab 50 mg CHLORZOXAZONE chlorzoxazone tab 500 mg...65 cholecalciferol cap 1000 unit cholecalciferol cap 2000 unit cholecalciferol cap 5000 unit cholecalciferol cap unit cholecalciferol cap unit cholecalciferol oral liquid 400 unit/ml...66 cholecalciferol tab 400 unit cholecalciferol tab 1000 unit cholecalciferol tab 2000 unit cholecalciferol tab unit cholestyramine light powder 4 gm/dose (Questran light)...27 cholestyramine light powder packets 4 gm cholestyramine powder 4 gm/dose (Questran) cholestyramine powder packets 4 gm (Questran)...27 choline fenofibrate cap dr 45 mg (fenofibric acid equiv) (Trilipix)...27 choline fenofibrate cap dr 135 mg (fenofibric acid equiv) (Trilipix)...27 ciclopirox olamine cream 0.77% (base equiv) (Loprox) cilostazol tab 50 mg...71 cilostazol tab 100 mg...71 CIMETIDINE HCL cimetidine hcl soln 300 mg/5ml cimetidine tab 200 mg...37 cimetidine tab 300 mg...37 cimetidine tab 400 mg...37 cimetidine tab 800 mg...37 ciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml) (Cipro)...3 ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml) (Cipro)...3 ciprofloxacin hcl ophth soln 0.3% (Ciloxan) ciprofloxacin hcl tab 750 mg (base equiv)...3 ciprofloxacin hcl tab 250 mg (base equiv) (Cipro)...3 ciprofloxacin hcl tab 500 mg (base equiv) (Cipro)...3 citalopram hydrobromide oral soln 10 mg/5ml citalopram hydrobromide tab 10 mg (base equiv) (Celexa)...42 citalopram hydrobromide tab 20 mg (base equiv) (Celexa)...42 citalopram hydrobromide tab 40 mg (base equiv) (Celexa)...42 CLARITHROMYCIN clarithromycin for susp 125 mg/5ml

96 CLARITHROMYCIN clarithromycin for susp 250 mg/5ml...2 clarithromycin tab 250 mg... 2 clarithromycin tab 500 mg (Biaxin)...2 clemastine fumarate tab 1.34 mg (1 mg base equiv)...32 clindamycin hcl cap 75 mg (Cleocin)...8 clindamycin hcl cap 150 mg (Cleocin)...8 clindamycin hcl cap 300 mg (Cleocin)...8 clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) (Cleocin pediatric gr)... 8 clindamycin phosphate gel 1% (Cleocin-t) clindamycin phosphate lotion 1% (Cleocin-t) clindamycin phosphate soln 1% (Cleocin-t) clindamycin phosphate swab 1% (Cleocin-t) clindamycin phosphate vaginal cream 2% (Cleocin)...40 clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5% (Duac) clobetasol propionate cream 0.05% (Temovate)...79 clobetasol propionate emollient base cream 0.05%...79 clobetasol propionate gel 0.05% (Temovate) clobetasol propionate oint 0.05% (Temovate) clobetasol propionate soln 0.05% (Temovate) clonazepam orally disintegrating tab mg...58 clonazepam orally disintegrating tab 0.25 mg...58 clonazepam orally disintegrating tab 0.5 mg...58 clonazepam orally disintegrating tab 1 mg...58 clonazepam orally disintegrating tab 2 mg...58 clonazepam tab 0.5 mg (Klonopin)...58 clonazepam tab 1 mg (Klonopin)...58 clonazepam tab 2 mg (Klonopin)...58 clonidine hcl tab 0.1 mg (Catapres) clonidine hcl tab 0.2 mg (Catapres) clonidine hcl tab 0.3 mg (Catapres) clonidine hcl td patch weekly 0.1 mg/24hr (Cataprestts-1) clonidine hcl td patch weekly 0.2 mg/24hr (Cataprestts-2) clonidine hcl td patch weekly 0.3 mg/24hr (Cataprestts-3) clopidogrel bisulfate tab 75 mg (base equiv) (Plavix)...71 clopidogrel bisulfate tab 300 mg (base equiv) (Plavix)...71 clorazepate dipotassium tab 3.75 mg...41 clorazepate dipotassium tab 15 mg...41 clorazepate dipotassium tab 7.5 mg (Tranxene t) clotrimazole cream 1%...78 clotrimazole soln 1% clotrimazole troche 10 mg clotrimazole vaginal cream 2%...40 clotrimazole w/ betamethasone cream % (Lotrisone) clozapine orally disintegrating tab 25 mg (Fazaclo)...44 clozapine orally disintegrating tab 100 mg (Fazaclo) clozapine tab 50 mg...44 clozapine tab 200 mg...44 clozapine tab 25 mg (Clozaril)...44 clozapine tab 100 mg (Clozaril)...44 COAGADEX coagulation factor x (human) for inj 250 unit...71 COAGADEX coagulation factor x (human) for inj 500 unit...71 codeine sulfate tab 15 mg (Codeine sulfate) codeine sulfate tab 30 mg (Codeine sulfate) codeine sulfate tab 60 mg (Codeine sulfate) colchicine w/ probenecid tab mg...57 colestipol hcl granule packets 5 gm (Colestid flavored) colestipol hcl granules 5 gm (Colestid) colestipol hcl tab 1 gm (Colestid) COMBIPATCH estradiol-norethindrone ace td pttw mg/day...14 COMBIPATCH estradiol-norethindrone ace td pttw mg/day...14 COMBIVENT RESPIMAT ipratropium-albuterol inhal aerosol soln mcg/act...34 CORTISONE ACETATE cortisone acetate tab 25 mg...13 COSENTYX secukinumab subcutaneous soln prefilled syringe 150 mg/ml...80 COSENTYX SENSOREADY PEN secukinumab subcutaneous soln auto-injector 150 mg/ml...80 COTELLIC cobimetinib fumarate tab 20 mg (base equivalent)...10 CREON pancrelipase (lip-prot-amyl) dr cap unit CREON pancrelipase (lip-prot-amyl) dr cap unit CREON pancrelipase (lip-prot-amyl) dr cap unit CREON pancrelipase (lip-prot-amyl) dr cap unit CREON pancrelipase (lip-prot-amyl) dr cap unit CRIXIVAN indinavir sulfate cap 200 mg...5 CRIXIVAN indinavir sulfate cap 400 mg...5 cromolyn sodium ophth soln 4% cromolyn sodium oral conc 100 mg/5ml (Gastrocrom) cromolyn sodium soln nebu 20 mg/2ml...34 cyanocobalamin inj 1000 mcg/ml cyanocobalamin tab er 1000 mcg cyanocobalamin tab 100 mcg...66 cyanocobalamin tab 250 mcg...66 cyanocobalamin tab 500 mcg...66 cyanocobalamin tab 1000 mcg...66 cyclobenzaprine hcl tab 5 mg...65 cyclobenzaprine hcl tab 10 mg...65 cyclopentolate hcl ophth soln 0.5% (Cyclogyl)...76 cyclopentolate hcl ophth soln 1% (Cyclogyl)...76 cyclopentolate hcl ophth soln 2% (Cyclogyl)...76 CYCLOPHOSPHAMIDE cyclophosphamide cap 25 mg...10 CYCLOPHOSPHAMIDE cyclophosphamide cap 50 mg

97 cyclosporine cap 25 mg (Sandimmune)...81 cyclosporine cap 100 mg (Sandimmune)...82 cyclosporine modified cap 50 mg (Cyclosporine modifie)...82 cyclosporine modified cap 25 mg (Neoral)...82 cyclosporine modified cap 100 mg (Neoral)...82 CYCLOSPORINE MODIFIED cyclosporine modified cap 50 mg cyclosporine modified oral soln 100 mg/ml (Neoral) cyproheptadine hcl syrup 2 mg/5ml...32 cyproheptadine hcl tab 4 mg CYTARABINE cytarabine inj 20 mg/ml D danazol cap 50 mg danazol cap 100 mg danazol cap 200 mg dantrolene sodium cap 100 mg...65 dantrolene sodium cap 25 mg (Dantrium)...65 dantrolene sodium cap 50 mg (Dantrium)...65 dapsone tab 25 mg... 8 dapsone tab 100 mg...8 DARAPRIM pyrimethamine tab 25 mg...8 DECARA cholecalciferol cap unit...66 demeclocycline hcl tab 150 mg... 2 DEPACON valproate sodium inj 100 mg/ml...58 DEPAKENE valproate sodium oral soln 250 mg/5ml (base equiv) DEPAKENE valproic acid cap 250 mg...58 DEPAKOTE divalproex sodium tab delayed release 125 mg...58 DEPAKOTE divalproex sodium tab delayed release 250 mg...58 DEPAKOTE divalproex sodium tab delayed release 500 mg...58 DEPAKOTE ER divalproex sodium tab er 24 hr 250 mg...58 DEPAKOTE ER divalproex sodium tab er 24 hr 500 mg...58 DEPAKOTE SPRINKLES divalproex sodium cap delayed release sprinkle 125 mg...58 DEPEN TITRATABS penicillamine tab 250 mg...82 DESCOVY emtricitabine-tenofovir alafenamide fumarate tab mg... 5 desloratadine tab 5 mg (Clarinex) desmopressin acetate nasal soln 0.01% (refrigerated) (Ddavp)...20 desmopressin acetate nasal spray soln 0.01% (Ddavp)...20 desmopressin acetate nasal spray soln 0.01% (refrigerated) desmopressin acetate tab 0.1 mg (Ddavp) desmopressin acetate tab 0.2 mg (Ddavp) desogest-eth estrad & eth estrad tab /0.01 mg(21/5) (Mircette) desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg (Desogen) desoximetasone cream 0.25% (Topicort)...79 DEXAMETHASONE dexamethasone soln 0.5 mg/5ml...13 dexamethasone elixir 0.5 mg/5ml...13 DEXAMETHASONE SODIUM PHOS dexamethasone sodium phosphate ophth soln 0.1% dexamethasone tab 0.5 mg dexamethasone tab 0.75 mg dexamethasone tab 1.5 mg dexamethasone tab 4 mg dexamethasone tab 6 mg dexmethylphenidate hcl cap er 24 hr 5 mg (Focalin xr) dexmethylphenidate hcl cap er 24 hr 10 mg (Focalin xr) dexmethylphenidate hcl cap er 24 hr 15 mg (Focalin xr) dexmethylphenidate hcl cap er 24 hr 20 mg (Focalin xr) dexmethylphenidate hcl cap er 24 hr 30 mg (Focalin xr) dexmethylphenidate hcl cap er 24 hr 40 mg (Focalin xr) dexmethylphenidate hcl tab 2.5 mg (Focalin) dexmethylphenidate hcl tab 5 mg (Focalin) dexmethylphenidate hcl tab 10 mg (Focalin) dextromethorphan-guaifenesin liquid mg/5ml diazepam conc 5 mg/ml...41 DIAZEPAM RECTAL GEL diazepam rectal gel delivery system 2.5 mg DIAZEPAM RECTAL GEL diazepam rectal gel delivery system 10 mg DIAZEPAM RECTAL GEL diazepam rectal gel delivery system 20 mg diazepam tab 2 mg (Valium)...41 diazepam tab 5 mg (Valium)...41 diazepam tab 10 mg (Valium)...41 diclofenac potassium tab 50 mg...55 diclofenac sodium gel 1% (Voltaren)...55,78 diclofenac sodium ophth soln 0.1%...76 diclofenac sodium tab delayed release 50 mg...55 diclofenac sodium tab delayed release 75 mg...55 diclofenac sodium tab er 24hr 100 mg...55 dicloxacillin sodium cap 250 mg...1 dicloxacillin sodium cap 500 mg...1 dicyclomine hcl cap 10 mg (Bentyl)...37 dicyclomine hcl oral soln 10 mg/5ml dicyclomine hcl tab 20 mg didanosine delayed release capsule 200 mg (Videx ec)...5 didanosine delayed release capsule 250 mg (Videx ec)...5 didanosine delayed release capsule 400 mg (Videx ec)...5 DIFFERIN adapalene gel 0.1%...77 DIGOXIN digoxin oral soln 0.05 mg/ml digoxin tab 125 mcg (0.125 mg) (Lanoxin)

98 digoxin tab 250 mcg (0.25 mg) (Lanoxin) DILANTIN INFATABS phenytoin chew tab 50 mg...59 DILANTIN phenytoin sodium extended cap 30 mg DILANTIN phenytoin sodium extended cap 100 mg DILANTIN-125 phenytoin susp 125 mg/5ml...59 diltiazem hcl cap er 12hr 60 mg...25 diltiazem hcl cap er 24hr 120 mg diltiazem hcl cap er 24hr 180 mg diltiazem hcl cap er 24hr 240 mg diltiazem hcl coated beads cap er 24hr 300 mg diltiazem hcl coated beads cap er 24hr 120 mg (Cardizem cd)...25 diltiazem hcl coated beads cap er 24hr 180 mg (Cardizem cd)...25 diltiazem hcl coated beads cap er 24hr 240 mg (Cardizem cd)...25 diltiazem hcl extended release beads cap er 24hr 120 mg (Tiazac) diltiazem hcl extended release beads cap er 24hr 180 mg (Tiazac) diltiazem hcl extended release beads cap er 24hr 240 mg (Tiazac) diltiazem hcl extended release beads cap er 24hr 300 mg (Tiazac) diltiazem hcl extended release beads cap er 24hr 360 mg (Tiazac) diltiazem hcl extended release beads cap er 24hr 420 mg (Tiazac) diltiazem hcl tab 90 mg...26 diltiazem hcl tab 30 mg (Cardizem)...26 diltiazem hcl tab 60 mg (Cardizem)...26 diltiazem hcl tab 120 mg (Cardizem)...26 diphenhydramine hcl cap 25 mg diphenhydramine hcl cap 50 mg diphenhydramine hcl liquid 12.5 mg/5ml...32 diphenhydramine hcl tab 25 mg diphenhydramine-phenylephrine liq mg/5ml diphenoxylate w/ atropine tab mg (Lomotil) dipyridamole tab 25 mg dipyridamole tab 50 mg dipyridamole tab 75 mg disopyramide phosphate cap 100 mg (Norpace) disopyramide phosphate cap 150 mg (Norpace) disulfiram tab 250 mg (Antab) disulfiram tab 500 mg (Antab) divalproex sodium cap delayed release sprinkle 125 mg (Depakote sprinkles)...59 divalproex sodium tab delayed release 125 mg (Depakote) divalproex sodium tab delayed release 250 mg (Depakote) divalproex sodium tab delayed release 500 mg (Depakote) divalproex sodium tab er 24 hr 250 mg (Depakote er)...59 divalproex sodium tab er 24 hr 500 mg (Depakote er)...59 docusate sodium cap 100 mg docusate sodium cap 250 mg docusate sodium liquid 150 mg/15ml...35 dofetilide cap 125 mcg (0.125 mg) (Tikosyn)...30 dofetilide cap 250 mcg (0.25 mg) (Tikosyn)...30 dofetilide cap 500 mcg (0.5 mg) (Tikosyn)...30 donepezil hydrochloride orally disintegrating tab 5 mg donepezil hydrochloride orally disintegrating tab 10 mg...51 donepezil hydrochloride tab 5 mg (Aricept)...51 donepezil hydrochloride tab 10 mg (Aricept)...51 dorzolamide hcl ophth soln 2% (Trusopt)...75 dorzolamide hcl-timolol maleate ophth soln mg/ ml (Cosopt) doxazosin mesylate tab 1 mg (Cardura) doxazosin mesylate tab 2 mg (Cardura) doxazosin mesylate tab 4 mg (Cardura) doxazosin mesylate tab 8 mg (Cardura) doxepin hcl cap 10 mg doxepin hcl cap 25 mg doxepin hcl cap 50 mg doxepin hcl cap 75 mg doxepin hcl cap 100 mg doxepin hcl cap 150 mg doxepin hcl conc 10 mg/ml...42 doxycycline hyclate cap 50 mg...2 doxycycline hyclate cap 100 mg (Vibramycin)... 2 doxycycline hyclate tab 20 mg... 2 doxycycline hyclate tab 100 mg... 2 doxycycline monohydrate cap 50 mg...2 doxycycline monohydrate cap 100 mg (Monodox)...2 doxycycline monohydrate for susp 25 mg/5ml (Vibramycin)... 3 doxycycline monohydrate tab 50 mg...3 doxycycline monohydrate tab 75 mg...3 doxycycline monohydrate tab 100 mg...3 drospirenone-ethinyl estradiol tab mg (Yasmin 28) duloxetine hcl enteric coated pellets cap 20 mg (base eq) (Cymbalta)...42 duloxetine hcl enteric coated pellets cap 30 mg (base eq) (Cymbalta)...42 duloxetine hcl enteric coated pellets cap 60 mg (base eq) (Cymbalta)...42 DUOPA carbidopa-levodopa enteral susp mg/ ml...64 E econazole nitrate cream 1% EDURANT rilpivirine hcl tab 25 mg (base equivalent)... 5 efavirenz cap 50 mg (Sustiva)...5 efavirenz cap 200 mg (Sustiva)...5 ELIDEL pimecrolimus cream 1%...80 ELIQUIS apixaban tab 2.5 mg ELIQUIS apixaban tab 5 mg ELLA ulipristal acetate tab 30 mg EMTRIVA emtricitabine caps 200 mg

99 EMTRIVA emtricitabine soln 10 mg/ml...5 enalapril maleate & hydrochlorothiazide tab mg...22 enalapril maleate & hydrochlorothiazide tab mg (Vaseretic) enalapril maleate tab 2.5 mg (Vasotec)...22 enalapril maleate tab 5 mg (Vasotec) enalapril maleate tab 10 mg (Vasotec) enalapril maleate tab 20 mg (Vasotec) ENBREL etanercept for subcutaneous inj 25 mg...55 ENBREL etanercept subcutaneous soln prefilled syringe 25 mg/0.5ml ENBREL etanercept subcutaneous soln prefilled syringe 50 mg/ml ENBREL SURECLICK etanercept subcutaneous solution auto-injector 50 mg/ml...55 enoxaparin sodium inj 30 mg/0.3ml (Lovenox) enoxaparin sodium inj 40 mg/0.4ml (Lovenox) enoxaparin sodium inj 60 mg/0.6ml (Lovenox) enoxaparin sodium inj 80 mg/0.8ml (Lovenox) enoxaparin sodium inj 100 mg/ml (Lovenox) enoxaparin sodium inj 120 mg/0.8ml (Lovenox) enoxaparin sodium inj 150 mg/ml (Lovenox) enoxaparin sodium inj 300 mg/3ml (Lovenox) entacapone tab 200 mg (Comtan)...64 entecavir tab 0.5 mg (Baraclude)... 4 entecavir tab 1 mg (Baraclude)... 4 ENTRESTO sacubitril-valsartan tab mg ENTRESTO sacubitril-valsartan tab mg ENTRESTO sacubitril-valsartan tab mg EPCLUSA sofosbuvir-velpatasvir tab mg... 4 EPINEPHRINE epinephrine solution auto-injector 0.15 mg/0.3ml (1:2000) EPINEPHRINE epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000) EPINEPHRINE HCL epinephrine inj 30 mg/30ml EQ MULTIVITAMINS ADULT GU multiple vitamins w/ minerals chew tab ergocalciferol cap unit...66 erythromycin gel 2% (Erygel) erythromycin ophth oint 5 mg/gm...75 erythromycin pads 2% erythromycin soln 2%...77 escitalopram oxalate soln 5 mg/5ml (base equiv)...42 escitalopram oxalate tab 5 mg (base equiv) (Lexapro) escitalopram oxalate tab 10 mg (base equiv) (Lexapro)...42 escitalopram oxalate tab 20 mg (base equiv) (Lexapro)...42 estazolam tab 1 mg estazolam tab 2 mg estradiol & norethindrone acetate tab mg (Activella)...14 estradiol & norethindrone acetate tab mg (Activella)...14 estradiol tab 0.5 mg (Estrace) estradiol tab 1 mg (Estrace) estradiol tab 2 mg (Estrace) estradiol td patch twice weekly mg/24hr (Vivelledot) estradiol td patch twice weekly mg/24hr (Vivelledot) estradiol td patch twice weekly 0.05 mg/24hr (Vivelledot) estradiol td patch twice weekly mg/24hr (Vivelledot) estradiol td patch twice weekly 0.1 mg/24hr (Vivelledot) estradiol td patch weekly mg/24hr (Climara)...15 estradiol td patch weekly 0.05 mg/24hr (Climara)...15 estradiol td patch weekly 0.06 mg/24hr (Climara)...15 estradiol td patch weekly mg/24hr (Climara)...15 estradiol td patch weekly 0.1 mg/24hr (Climara)...15 estradiol td patch weekly mg/24hr (37.5 mcg/24hr) (Climara)...15 estradiol vaginal tab 10 mcg (Vagifem)...40 ESTROPIPATE estropipate tab 0.75 mg...15 ESTROPIPATE estropipate tab 1.5 mg...15 ESTROPIPATE estropipate tab 3 mg...15 eszopiclone tab 1 mg (Lunesta) eszopiclone tab 2 mg (Lunesta) eszopiclone tab 3 mg (Lunesta) ethambutol hcl tab 100 mg (Myambutol)...3 ethambutol hcl tab 400 mg (Myambutol)...3 ethosuximide cap 250 mg (Zarontin)...59 ethosuximide soln 250 mg/5ml (Zarontin) ethynodiol diacetate & ethinyl estradiol tab 1 mg-50 mcg...16 exemestane tab 25 mg (Aromasin) EXTAVIA interferon beta-1b for inj kit 0.3 mg...51 F famotidine for susp 40 mg/5ml (Pepcid)...37 famotidine tab 10 mg famotidine tab 20 mg (Pepcid) famotidine tab 40 mg (Pepcid) fe fumarate-vit c-vit b12-fa cap 460 (151 fe) mg...67 fe fumarate w/ b12-vit c-fa-ifc cap mg...67 fe fum-iron polysacch complex-fa-b cmplx-c-zn-mn-cu cap (Tandem plus)...67 felbamate susp 600 mg/5ml (Felbatol)...59 felbamate tab 400 mg (Felbatol) felbamate tab 600 mg (Felbatol) FELBATOL felbamate susp 600 mg/5ml...59 FELBATOL felbamate tab 400 mg FELBATOL felbamate tab 600 mg felodipine tab er 24hr 2.5 mg felodipine tab er 24hr 5 mg felodipine tab er 24hr 10 mg fenofibrate micronized cap 43 mg

100 fenofibrate micronized cap 67 mg (Lofibra)...28 fenofibrate micronized cap 134 mg (Lofibra)...28 fenofibrate micronized cap 200 mg (Lofibra)...28 fenofibrate tab 160 mg...28 fenofibrate tab 54 mg (Lofibra) fenofibrate tab 48 mg (Tricor) fenofibrate tab 145 mg (Tricor) fentanyl td patch 72hr 12 mcg/hr (Duragesic)...53 fentanyl td patch 72hr 25 mcg/hr (Duragesic)...53 fentanyl td patch 72hr 50 mcg/hr (Duragesic)...53 fentanyl td patch 72hr 75 mcg/hr (Duragesic)...53 fentanyl td patch 72hr 100 mcg/hr (Duragesic)...53 ferrous fumarate-fa-b complex-c-zn-mg-mn-cu tab mg...67 ferrous fumarate-folic acid tab mg ferrous sulfate tab ec 325 mg (65 mg fe equivalent)...68 ferrous sulfate tab 325 mg (65 mg elemental fe) fexofenadine hcl susp 30 mg/5ml (6 mg/ml) fexofenadine hcl tab 60 mg fexofenadine hcl tab 180 mg finasteride tab 5 mg (Proscar) FIRAZYR icatibant acetate inj 30 mg/3ml (base equivalent)...71 FISH OIL ULTRA omega-3 fatty acids cap 1400 mg flecainide acetate tab 50 mg flecainide acetate tab 100 mg flecainide acetate tab 150 mg FLEET LIQUID GLYCERIN SUP glycerin enema adult 5.4 gm/average delivered dose FLOVENT DISKUS fluticasone propionate aer pow ba 50 mcg/blister FLOVENT DISKUS fluticasone propionate aer pow ba 100 mcg/blister FLOVENT DISKUS fluticasone propionate aer pow ba 250 mcg/blister FLOVENT HFA fluticasone propionate hfa inhal aer 110 mcg/act (125/valve) FLOVENT HFA fluticasone propionate hfa inhal aer 220 mcg/act (250/valve) FLOVENT HFA fluticasone propionate hfa inhal aero 44 mcg/act (50/valve) fluconazole for susp 10 mg/ml (Diflucan)... 4 fluconazole for susp 40 mg/ml (Diflucan)... 4 fluconazole tab 50 mg (Diflucan)...4 fluconazole tab 100 mg (Diflucan)...4 fluconazole tab 150 mg (Diflucan)...4 fluconazole tab 200 mg (Diflucan)...4 flucytosine cap 250 mg (Ancobon)...4 flucytosine cap 500 mg (Ancobon)...4 fludrocortisone acetate tab 0.1 mg...13 FLUNISOLIDE flunisolide nasal soln 25 mcg/act (0.025%)...33 fluocinolone acetonide cream 0.01% fluocinolone acetonide cream 0.025% (Synalar)...79 fluocinolone acetonide oint 0.025% (Synalar)...79 fluocinolone acetonide soln 0.01% (Synalar) fluocinonide cream 0.05% fluocinonide emulsified base cream 0.05%...79 fluocinonide gel 0.05%...79 fluocinonide oint 0.05%...79 fluocinonide soln 0.05%...79 fluorometholone ophth susp 0.1% (Fml liquifilm) fluorouracil cream 5% (Efudex) FLUOROURACIL fluorouracil soln 2%...80 FLUOROURACIL fluorouracil soln 5%...80 fluoxetine hcl cap 10 mg (Prozac)...43 fluoxetine hcl cap 20 mg (Prozac)...43 fluoxetine hcl solution 20 mg/5ml fluphenazine decanoate inj 25 mg/ml...44 FLUPHENAZINE HCL fluphenazine hcl elixir 2.5 mg/5ml...44 FLUPHENAZINE HCL fluphenazine hcl oral conc 5 mg/ ml...45 fluphenazine hcl tab 1 mg fluphenazine hcl tab 2.5 mg fluphenazine hcl tab 5 mg fluphenazine hcl tab 10 mg FLURBIPROFEN SODIUM flurbiprofen sodium ophth soln 0.03% flurbiprofen tab 50 mg...55 flurbiprofen tab 100 mg...55 flutamide cap 125 mg FLUTICASONE PROPIONATE/SA fluticasonesalmeterol aer powder ba mcg/act FLUTICASONE PROPIONATE/SA fluticasonesalmeterol aer powder ba mcg/act FLUTICASONE PROPIONATE/SA fluticasonesalmeterol aer powder ba mcg/act fluticasone propionate cream 0.05% (Cutivate) fluticasone propionate nasal susp 50 mcg/act fluticasone propionate oint 0.005% fluvoxamine maleate tab 25 mg fluvoxamine maleate tab 50 mg fluvoxamine maleate tab 100 mg FOLBEE PLUS CZ b-complex w/ c-biotin-minerals & folic acid tab 5 mg...67 folic acid tab 400 mcg...66 folic acid tab 800 mcg...66 folic acid tab 1 mg folic acid-vitamin b6-vitamin b12 tab mg...66 folic acid-vitamin b6-vitamin b12 tab mg...66 folic acid-vitamin b6-vitamin b12 tab mg (Folgard rx) fosamprenavir calcium tab 700 mg (base equiv) (Lexiva)...6 fosinopril sodium & hydrochlorothiazide tab mg...22 fosinopril sodium & hydrochlorothiazide tab mg...22 fosinopril sodium tab 10 mg fosinopril sodium tab 20 mg fosinopril sodium tab 40 mg

101 fructose-dextrose-phosphoric acid oral soln...38 furosemide oral soln 10 mg/ml furosemide tab 20 mg (Lasix)...29 furosemide tab 40 mg (Lasix)...29 furosemide tab 80 mg (Lasix)...29 FYCOMPA perampanel susp 0.5 mg/ml FYCOMPA perampanel tab 2 mg...59 FYCOMPA perampanel tab 4 mg...59 FYCOMPA perampanel tab 6 mg...59 FYCOMPA perampanel tab 8 mg...59 FYCOMPA perampanel tab 10 mg...59 FYCOMPA perampanel tab 12 mg...59 G gabapentin cap 100 mg (Neurontin)...59 gabapentin cap 300 mg (Neurontin)...59 gabapentin cap 400 mg (Neurontin)...59 gabapentin oral soln 250 mg/5ml (Neurontin) gabapentin tab 600 mg (Neurontin)...60 gabapentin tab 800 mg (Neurontin)...60 GABITRIL tiagabine hcl tab 2 mg GABITRIL tiagabine hcl tab 4 mg GABITRIL tiagabine hcl tab 12 mg GABITRIL tiagabine hcl tab 16 mg gemfibrozil tab 600 mg (Lopid)...28 GENTAK gentamicin sulfate ophth oint 0.3%...75 gentamicin sulfate cream 0.1% GENTAMICIN SULFATE gentamicin sulfate oint 0.1% gentamicin sulfate ophth soln 0.3%...75 GENVOYA elvitegrav-cobic-emtricitab-tenofov af tab mg... 6 glatiramer acetate soln prefilled syringe 20 mg/ml (Copaxone) glatiramer acetate soln prefilled syringe 40 mg/ml (Copaxone) glimepiride tab 1 mg (Amaryl) glimepiride tab 2 mg (Amaryl) glimepiride tab 4 mg (Amaryl) glipizide tab er 24hr 2.5 mg (Glucotrol xl) glipizide tab er 24hr 5 mg (Glucotrol xl) glipizide tab er 24hr 10 mg (Glucotrol xl) glipizide tab 5 mg (Glucotrol)...17 glipizide tab 10 mg (Glucotrol)...17 GLUCAGON EMERGENCY KIT glucagon (rdna) for inj kit 1 mg glyburide-metformin tab mg glyburide-metformin tab mg (Glucovance)...18 glyburide-metformin tab mg (Glucovance)...18 glyburide micronized tab 1.5 mg (Glynase)...17 glyburide micronized tab 3 mg (Glynase)...17 glyburide micronized tab 6 mg (Glynase)...17 glyburide tab 1.25 mg glyburide tab 2.5 mg glyburide tab 5 mg glycerin suppos 1 gm...36 glycerin suppos 2 gm...36 glycopyrrolate tab 1 mg (Robinul) glycopyrrolate tab 2 mg (Robinul forte) griseofulvin microsize susp 125 mg/5ml...4 griseofulvin microsize tab 500 mg...4 griseofulvin ultramicrosize tab 125 mg (Gris-peg)...4 griseofulvin ultramicrosize tab 250 mg (Gris-peg)...4 guaifenesin-codeine soln mg/5ml...33 guaifenesin liquid 100 mg/5ml guanfacine hcl tab er 24hr 1 mg (base equiv) (Intuniv)...49 guanfacine hcl tab er 24hr 2 mg (base equiv) (Intuniv)...49 guanfacine hcl tab er 24hr 3 mg (base equiv) (Intuniv)...49 guanfacine hcl tab er 24hr 4 mg (base equiv) (Intuniv)...49 guanfacine hcl tab 1 mg guanfacine hcl tab 2 mg H halobetasol propionate cream 0.05% (Ultravate)...79 halobetasol propionate oint 0.05% (Ultravate) haloperidol decanoate im soln 50 mg/ml (Haldol decanoate 50)...45 haloperidol decanoate im soln 100 mg/ml (Haldol decanoate 100)...45 haloperidol lactate oral conc 2 mg/ml...45 haloperidol tab 0.5 mg haloperidol tab 1 mg haloperidol tab 2 mg haloperidol tab 5 mg haloperidol tab 10 mg haloperidol tab 20 mg HELIXATE FS antihemophilic factor (recombinant) for inj kit 250 unit HELIXATE FS antihemophilic factor (recombinant) for inj kit 500 unit HELIXATE FS antihemophilic factor (recombinant) for inj kit 1000 unit HELIXATE FS antihemophilic factor (recombinant) for inj kit 2000 unit HELIXATE FS antihemophilic factor (recombinant) for inj kit 3000 unit HEMOFIL M antihemophilic factor (human) for inj 250 unit...72 HEMOFIL M antihemophilic factor (human) for inj 500 unit...72 HEMOFIL M antihemophilic factor (human) for inj 1000 unit...72 HEMOFIL M antihemophilic factor (human) for inj 1700 unit...72 HUMALOG insulin lispro inj 100 unit/ml...18 HUMALOG insulin lispro soln cartridge 100 unit/ml HUMALOG JUNIOR KWIKPEN insulin lispro soln peninjector 100 unit/ml HUMALOG KWIKPEN insulin lispro soln pen-injector 100 unit/ml HUMALOG KWIKPEN insulin lispro soln pen-injector 200 unit/ml

102 HUMALOG MIX 75/25 insulin lispro prot & lispro inj 100 unit/ml (75-25)...19 HUMALOG MIX 50/50 insulin lispro protamine & lispro inj 100 unit/ml (50-50) HUMALOG MIX 50/50 KWIKPEN insulin lispro prot & lispro sus pen-inj 100 unit/ml (50-50) HUMALOG MIX 75/25 KWIKPEN insulin lispro prot & lispro sus pen-inj 100 unit/ml (75-25) HUMATE-P antihemophilic factor/vwf (human) for inj unit...72 HUMATE-P antihemophilic factor/vwf (human) for inj unit...72 HUMATE-P antihemophilic factor/vwf (human) for inj unit...72 HUMIRA adalimumab prefilled syringe kit 10 mg/0.2ml...55 HUMIRA adalimumab prefilled syringe kit 20 mg/0.4ml...55 HUMIRA adalimumab prefilled syringe kit 40 mg/0.8ml...55 HUMIRA PEDIATRIC CROHNS D adalimumab prefilled syringe kit 40 mg/0.8ml...56 HUMIRA PEN adalimumab pen-injector kit 40 mg/0.8ml...56 HUMIRA PEN-CROHNS DISEASE adalimumab peninjector kit 40 mg/0.8ml...56 HUMIRA PEN-PSORIASIS STAR adalimumab peninjector kit 40 mg/0.8ml...56 HUMULIN 70/30 insulin nph isophane & regular human inj 100 unit/ml (70-30) HUMULIN 70/30 KWIKPEN insulin nph & regular susp pen-inj 100 unit/ml (70-30)...19 HUMULIN N insulin nph (human) (isophane) inj 100 unit/ml...19 HUMULIN N KWIKPEN insulin nph (human) (isophane) susp pen-injector 100 unit/ml...19 HUMULIN R insulin regular (human) inj 100 unit/ml hydralazine hcl tab 10 mg hydralazine hcl tab 25 mg hydralazine hcl tab 50 mg hydralazine hcl tab 100 mg hydrochlorothiazide cap 12.5 mg (Microzide) hydrochlorothiazide tab 12.5 mg hydrochlorothiazide tab 25 mg hydrochlorothiazide tab 50 mg hydrocodone-acetaminophen soln mg/15ml (Hycet)...53 hydrocodone-acetaminophen tab mg...53 hydrocodone-acetaminophen tab mg (Norco) hydrocodone-acetaminophen tab mg (Norco) hydrocodone-acetaminophen tab mg (Norco) hydrocortisone butyrate oint 0.1% (Locoid)...79 hydrocortisone cream 0.5% hydrocortisone cream 1% hydrocortisone cream 2.5% hydrocortisone enema 100 mg/60ml (Cortenema)...77 hydrocortisone lotion 2.5% hydrocortisone oint 0.5% hydrocortisone oint 1% hydrocortisone oint 2.5% hydrocortisone rectal cream 2.5% (Anusol-hc) hydrocortisone rectal cream 1% (Proctocort)...77 hydrocortisone tab 5 mg (Cortef)...13 hydrocortisone tab 10 mg (Cortef)...14 hydrocortisone tab 20 mg (Cortef)...14 hydrocortisone valerate cream 0.2%...80 hydrocortisone valerate oint 0.2% (Westcort) hydrocortisone w/ acetic acid otic soln 1-2% hydromorphone hcl liqd 1 mg/ml (Dilaudid)...53 hydromorphone hcl tab 2 mg (Dilaudid)...53 hydromorphone hcl tab 4 mg (Dilaudid)...53 hydromorphone hcl tab 8 mg (Dilaudid)...53 hydroxychloroquine sulfate tab 200 mg (Plaquenil)... 8 hydroxyurea cap 500 mg (Hydrea)...10 HYDROXYZINE HCL hydroxyzine hcl im soln 25 mg/ ml...41 hydroxyzine hcl syrup 10 mg/5ml...41 hydroxyzine hcl tab 10 mg...41 hydroxyzine hcl tab 25 mg...41 hydroxyzine hcl tab 50 mg...41 hydroxyzine pamoate cap 25 mg (Vistaril) hydroxyzine pamoate cap 50 mg (Vistaril) hyoscyamine sulfate elixir mg/5ml hyoscyamine sulfate soln mg/ml hyoscyamine sulfate tab disint mg (Anaspaz)...37 hyoscyamine sulfate tab er 12hr mg (Levbid) hyoscyamine sulfate tab mg (Levsin)...37 hyoscyamine sulfate tab sl mg (Levsin/sl)...37 I IBRANCE palbociclib cap 75 mg...10 IBRANCE palbociclib cap 100 mg...10 IBRANCE palbociclib cap 125 mg...10 ibuprofen cap 200 mg...56 ibuprofen susp 100 mg/5ml ibuprofen tab 200 mg...56 ibuprofen tab 400 mg...56 ibuprofen tab 600 mg...56 ibuprofen tab 800 mg...56 imatinib mesylate tab 100 mg (base equivalent) (Gleevec)...10 imatinib mesylate tab 400 mg (base equivalent) (Gleevec)...10 imipramine hcl tab 10 mg (Tofranil)...43 imipramine hcl tab 25 mg (Tofranil)...43 imipramine hcl tab 50 mg (Tofranil)...43 imiquimod cream 5% (Aldara) indapamide tab 1.25 mg indapamide tab 2.5 mg indomethacin cap er 75 mg indomethacin cap 25 mg indomethacin cap 50 mg

103 INTELENCE etravirine tab 25 mg... 6 INTELENCE etravirine tab 100 mg... 6 INTELENCE etravirine tab 200 mg... 6 INVEGA SUSTENNA paliperidone palmitate im extended-release susp 39 mg/0.25ml INVEGA SUSTENNA paliperidone palmitate im extended-release susp 78 mg/0.5ml INVEGA SUSTENNA paliperidone palmitate im extended-release susp 156 mg/ml...45 INVEGA SUSTENNA paliperidone palmitate im extended-release susp 234 mg/1.5ml INVEGA SUSTENNA paliperidone palmitate im extendrelease susp 117 mg/0.75ml...45 INVIRASE saquinavir mesylate cap 200 mg...6 INVIRASE saquinavir mesylate tab 500 mg...6 ipratropium-albuterol nebu soln (3) mg/3ml ipratropium bromide inhal soln 0.02%...34 irbesartan-hydrochlorothiazide tab mg (Avalide) irbesartan-hydrochlorothiazide tab mg (Avalide) irbesartan tab 75 mg (Avapro)...23 irbesartan tab 150 mg (Avapro)...23 irbesartan tab 300 mg (Avapro)...23 iron combination cap...66 iron-docusate-b12-folic acid-c-e-cu-biotin tab mg (Hematron-af)...66 iron-folic acid-vit c-vit b6-vit b12-zinc tab mg (Corvite 150) iron polysacch complex-vit b12-fa cap mg...66 irrigation solution, physiological ISENTRESS HD raltegravir potassium tab 600 mg (base equiv)... 6 ISENTRESS raltegravir potassium chew tab 25 mg (base equiv)... 6 ISENTRESS raltegravir potassium chew tab 100 mg (base equiv)... 6 ISENTRESS raltegravir potassium packet for susp 100 mg (base equiv)...6 ISENTRESS raltegravir potassium tab 400 mg (base equiv)...6 isoniazid tab 100 mg...3 isoniazid tab 300 mg...3 ISOSORBIDE DINITRATE ER isosorbide dinitrate tab er 40 mg isosorbide dinitrate tab 10 mg isosorbide dinitrate tab 20 mg isosorbide dinitrate tab 30 mg isosorbide dinitrate tab 5 mg (Isordil titradose) isosorbide mononitrate tab er 24hr 30 mg isosorbide mononitrate tab er 24hr 60 mg isosorbide mononitrate tab er 24hr 120 mg isosorbide mononitrate tab 10 mg...27 isosorbide mononitrate tab 20 mg...27 isotretinoin cap 10 mg...77 isotretinoin cap 20 mg...77 itraconazole cap 100 mg (Sporanox)... 4 ivermectin tab 3 mg (Stromectol)... 8 IXINITY coagulation factor ix (recombinant) for inj 500 unit...72 IXINITY coagulation factor ix (recombinant) for inj 1000 unit...72 IXINITY coagulation factor ix (recombinant) for inj 1500 unit...72 J K KALETRA lopinavir-ritonavir tab mg... 6 KALETRA lopinavir-ritonavir tab mg... 6 KALYDECO ivacaftor packet 50 mg...35 KALYDECO ivacaftor packet 75 mg...35 KALYDECO ivacaftor tab 150 mg KEPPRA levetiracetam inj 500 mg/5ml (100 mg/ml)...60 KEPPRA levetiracetam oral soln 100 mg/ml...60 KEPPRA levetiracetam tab 250 mg KEPPRA levetiracetam tab 500 mg KEPPRA levetiracetam tab 750 mg KEPPRA levetiracetam tab 1000 mg KEPPRA XR levetiracetam tab er 24hr 500 mg...60 KEPPRA XR levetiracetam tab er 24hr 750 mg...60 ketoconazole cream 2%...78 ketoconazole shampoo 2% (Nizoral)...78 ketoconazole tab 200 mg... 4 ketoprofen cap 50 mg...56 ketoprofen cap 75 mg...56 ketorolac tromethamine ophth soln 0.5% (Acular) ketorolac tromethamine ophth soln 0.4% (Acular ls)...76 ketorolac tromethamine tab 10 mg...56 ketotifen fumarate ophth soln 0.025% (base equiv)...76 KINEVAC sincalide for inj 5 mcg...39 KISQALI FEMARA 200 DOSE ribociclib tab 200 mg & letrozole tab 2.5 mg therapy pack KISQALI FEMARA 400 DOSE ribociclib tab 200 mg & letrozole tab 2.5 mg therapy pack KISQALI FEMARA 600 DOSE ribociclib tab 200 mg & letrozole tab 2.5 mg therapy pack KISQALI ribociclib succinate tab 200 mg (base equiv)...10 KOATE antihemophilic factor (human) for inj 250 unit...72 KOATE antihemophilic factor (human) for inj 500 unit...72 KOATE antihemophilic factor (human) for inj 1000 unit...72 KOATE-DVI antihemophilic factor (human) for inj 250 unit...72 KOATE-DVI antihemophilic factor (human) for inj 500 unit...72 KOATE-DVI antihemophilic factor (human) for inj 1000 unit

104 KOGENATE FS antihemophilic factor (recombinant) for inj kit 250 unit KOGENATE FS antihemophilic factor (recombinant) for inj kit 500 unit KOGENATE FS antihemophilic factor (recombinant) for inj kit 1000 unit KOGENATE FS antihemophilic factor (recombinant) for inj kit 2000 unit KOGENATE FS antihemophilic factor (recombinant) for inj kit 3000 unit KOGENATE FS BIO-SET antihemophilic factor (recombinant) for inj kit 250 unit KOGENATE FS BIO-SET antihemophilic factor (recombinant) for inj kit 500 unit KOGENATE FS BIO-SET antihemophilic factor (recombinant) for inj kit 1000 unit KOGENATE FS BIO-SET antihemophilic factor (recombinant) for inj kit 2000 unit KOGENATE FS BIO-SET antihemophilic factor (recombinant) for inj kit 3000 unit KONSYL-D psyllium powder 52.3%...36 KONSYL psyllium powder 60.3%...36 KONSYL psyllium powder 71.67%...36 K-PHOS potassium phosphate monobasic tab 500 mg...68 KYLEENA levonorgestrel releasing iud 17.5 mcg/day (19.5 mg total) L labetalol hcl tab 100 mg labetalol hcl tab 200 mg labetalol hcl tab 300 mg lactated ringer's for irrigation lactic acid (ammonium lactate) lotion 12% (Lachydrin) lactulose (encephalopathy) solution 10 gm/15ml lactulose solution 10 gm/15ml LAMICTAL CHEWABLE DISPERS lamotrigine tab chewable dispersible 5 mg LAMICTAL CHEWABLE DISPERS lamotrigine tab chewable dispersible 25 mg LAMICTAL lamotrigine tab 25 mg LAMICTAL lamotrigine tab 100 mg LAMICTAL lamotrigine tab 150 mg LAMICTAL lamotrigine tab 200 mg LAMICTAL ODT lamotrigine orally disintegrating tab 25 mg...60 LAMICTAL ODT lamotrigine orally disintegrating tab 50 mg...60 LAMICTAL ODT lamotrigine orally disintegrating tab 100 mg...60 LAMICTAL ODT lamotrigine orally disintegrating tab 200 mg...60 LAMICTAL ODT lamotrigine tab disint 25 (14) & 50 mg (14) & 100 mg (7) kit...60 LAMICTAL ODT lamotrigine tab disint 25 mg (21) & 50 mg (7) titration kit LAMICTAL ODT lamotrigine tab disint 50 mg (42)- 100 mg(14) titration kit...60 LAMICTAL STARTER/NOT TAKI lamotrigine tab 25 mg (42) & 100 mg (7) starter kit LAMICTAL STARTER/TAKING C lamotrigine tab 25 mg (84) & 100 mg (14) starter kit LAMICTAL STARTER/TAKING V lamotrigine tab 25 mg (35) starter kit LAMICTAL XR lamotrigine tab er 24hr 25 (14) & 50 mg (14) & 100 mg(7) kit...61 LAMICTAL XR lamotrigine tab er 24hr 50 (14) & 100 mg(14) & 200 mg(7) kit...61 LAMICTAL XR lamotrigine tab er 24hr 25 mg...61 LAMICTAL XR lamotrigine tab er 24hr 50 mg...61 LAMICTAL XR lamotrigine tab er 24hr 100 mg...61 LAMICTAL XR lamotrigine tab er 24hr 200 mg...61 LAMICTAL XR lamotrigine tab er 24hr 250 mg...61 LAMICTAL XR lamotrigine tab er 24hr 300 mg...61 LAMICTAL XR lamotrigine tab er 24hr 25 mg (21) & 50 mg (7) titration kit lamivudine oral soln 10 mg/ml (Epivir)... 6 lamivudine tab 150 mg (Epivir)...6 lamivudine tab 300 mg (Epivir)...6 lamivudine tab 100 mg (hbv) (Epivir hbv)... 4 lamivudine-zidovudine tab mg (Combivir)...6 lamotrigine tab chewable dispersible 5 mg (Lamictal chewable di)...61 lamotrigine tab chewable dispersible 25 mg (Lamictal chewable di)...61 lamotrigine tab 25 mg (Lamictal)...61 lamotrigine tab 100 mg (Lamictal)...61 lamotrigine tab 150 mg (Lamictal)...61 lamotrigine tab 200 mg (Lamictal)...61 lansoprazole cap delayed release 15 mg (Prevacid) lansoprazole cap delayed release 30 mg (Prevacid) latanoprost ophth soln 0.005% (Xalatan) LATUDA lurasidone hcl tab 20 mg...45 LATUDA lurasidone hcl tab 40 mg...45 LATUDA lurasidone hcl tab 60 mg...45 LATUDA lurasidone hcl tab 80 mg...45 LATUDA lurasidone hcl tab 120 mg...45 leflunomide tab 10 mg (Arava) leflunomide tab 20 mg (Arava) LENVIMA 14 MG DAILY DOSE lenvatinib cap therapy pack 10 & 4 mg (14 mg daily dose) LENVIMA 18 MG DAILY DOSE lenvatinib cap therapy pack 10 & 4 (2) mg (18 mg daily dose)...10 LENVIMA 24 MG DAILY DOSE lenvatinib cap therapy pack 10 (2) & 4 mg (24 mg daily dose)...10 LENVIMA 10 MG DAILY DOSE lenvatinib cap therapy pack 10 mg (10 mg daily dose) LENVIMA 20 MG DAILY DOSE lenvatinib cap therapy pack 10 (2) mg (20 mg daily dose)

105 LENVIMA 8 MG DAILY DOSE lenvatinib cap therapy pack 4 (2) mg (8 mg daily dose) letrozole tab 2.5 mg (Femara) LEUCOVORIN CALCIUM leucovorin calcium tab 10 mg...11 LEUCOVORIN CALCIUM leucovorin calcium tab 15 mg...11 leucovorin calcium tab 5 mg...11 leucovorin calcium tab 25 mg...11 LEUKERAN chlorambucil tab 2 mg...11 LEVETIRACETAM levetiracetam in sodium chloride iv soln 500 mg/100ml...61 LEVETIRACETAM levetiracetam in sodium chloride iv soln 1000 mg/100ml...61 LEVETIRACETAM levetiracetam in sodium chloride iv soln 1500 mg/100ml...61 levetiracetam oral soln 100 mg/ml (Keppra) levetiracetam tab er 24hr 500 mg (Keppra xr) levetiracetam tab er 24hr 750 mg (Keppra xr) levetiracetam tab 250 mg (Keppra)...61 levetiracetam tab 500 mg (Keppra)...61 levetiracetam tab 750 mg (Keppra)...61 levetiracetam tab 1000 mg (Keppra)...61 levobunolol hcl ophth soln 0.5% (Betagan)...76 levocarnitine oral soln 1 gm/10ml (10%) (Carnitor)...20 levocarnitine tab 330 mg (Carnitor)...20 levocetirizine dihydrochloride tab 5 mg LEVOFLOXACIN levofloxacin oral soln 25 mg/ml... 3 levofloxacin ophth soln 0.5% levofloxacin tab 250 mg (Levaquin)...3 levofloxacin tab 500 mg (Levaquin)...3 levofloxacin tab 750 mg (Levaquin)...3 levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg levonorgestrel-eth estra tab / / mg-mcg...16 levonorgestrel tab 1.5 mg levothyroxine sodium tab 25 mcg (Synthroid) levothyroxine sodium tab 50 mcg (Synthroid) levothyroxine sodium tab 75 mcg (Synthroid) levothyroxine sodium tab 88 mcg (Synthroid) levothyroxine sodium tab 100 mcg (Synthroid) levothyroxine sodium tab 112 mcg (Synthroid) levothyroxine sodium tab 125 mcg (Synthroid) levothyroxine sodium tab 137 mcg (Synthroid) levothyroxine sodium tab 150 mcg (Synthroid) levothyroxine sodium tab 175 mcg (Synthroid) levothyroxine sodium tab 200 mcg (Synthroid) levothyroxine sodium tab 300 mcg (Synthroid) LEXIVA fosamprenavir calcium susp 50 mg/ml (base equiv)...6 lidocaine hcl cream 3%...80 lidocaine hcl gel 2%...80 lidocaine hcl soln 4% (Xylocaine)...80 lidocaine hcl viscous soln 2%...77 lidocaine oint 5%...81 lidocaine patch 5% (Lidoderm)...81 lidocaine-prilocaine cream % lidocaine-prilocaine cream kit %...81 linezolid for susp 100 mg/5ml (Zyvox)...8 linezolid tab 600 mg (Zyvox)... 8 liothyronine sodium tab 5 mcg (Cytomel)...20 liothyronine sodium tab 25 mcg (Cytomel)...20 liothyronine sodium tab 50 mcg (Cytomel)...20 lisinopril & hydrochlorothiazide tab mg (Zestoretic) lisinopril & hydrochlorothiazide tab mg (Zestoretic) lisinopril & hydrochlorothiazide tab mg (Zestoretic) lisinopril tab 5 mg (Prinivil) lisinopril tab 10 mg (Prinivil) lisinopril tab 20 mg (Prinivil) lisinopril tab 2.5 mg (Zestril) lisinopril tab 30 mg (Zestril) lisinopril tab 40 mg (Zestril) lithium carbonate cap 300 mg lithium carbonate cap 150 mg (Lithium carbonate)...45 lithium carbonate cap 600 mg (Lithium carbonate)...45 lithium carbonate tab er 450 mg...46 lithium carbonate tab er 300 mg (Lithobid) lithium carbonate tab 300 mg LITHIUM lithium oral solution 8 meq/5ml LMD 10% DEXTROSE 5% dextran 40 inj 10% in d5w loperamide hcl cap 2 mg loperamide hcl liq 1 mg/5ml (0.2 mg/ml) loperamide hcl tab 2 mg lopinavir-ritonavir soln mg/5ml (80-20 mg/ml) (Kaletra)...6 loratadine syrup 5 mg/5ml loratadine tab 10 mg...32 lorazepam conc 2 mg/ml lorazepam tab 0.5 mg (Ativan) lorazepam tab 1 mg (Ativan) lorazepam tab 2 mg (Ativan) losartan potassium & hydrochlorothiazide tab mg (Hyzaar)...23 losartan potassium & hydrochlorothiazide tab mg (Hyzaar) losartan potassium & hydrochlorothiazide tab mg (Hyzaar)...23 losartan potassium tab 25 mg (Cozaar) losartan potassium tab 50 mg (Cozaar) losartan potassium tab 100 mg (Cozaar) lovastatin tab 10 mg...28 lovastatin tab 20 mg...28 lovastatin tab 40 mg...28 loxapine succinate cap 5 mg loxapine succinate cap 10 mg...46 loxapine succinate cap 25 mg...46 loxapine succinate cap 50 mg

106 LUPRON DEPOT (1-MONTH) leuprolide acetate for inj kit 3.75 mg...11 LUPRON DEPOT (1-MONTH) leuprolide acetate for inj kit 7.5 mg...11 LUPRON DEPOT (3-MONTH) leuprolide acetate (3 month) for inj kit mg LUPRON DEPOT (3-MONTH) leuprolide acetate (3 month) for inj kit 22.5 mg...11 LUPRON DEPOT (4-MONTH) leuprolide acetate (4 month) for inj kit 30 mg...11 LUPRON DEPOT (6-MONTH) leuprolide acetate (6 month) for inj kit 45 mg...11 LUPRON DEPOT-PED (1-MONTH leuprolide acetate for inj pediatric kit 7.5 mg... 16,20 LUPRON DEPOT-PED (1-MONTH leuprolide acetate for inj pediatric kit mg...16,21 LUPRON DEPOT-PED (1-MONTH leuprolide acetate for inj pediatric kit 15 mg... 16,21 LUPRON DEPOT-PED (3-MONTH leuprolide acetate (3 month) for inj pediatric kit mg LUPRON DEPOT-PED (3-MONTH leuprolide acetate (3 month) for inj pediatric kit 30 mg LYNPARZA olaparib cap 50 mg LYNPARZA olaparib tab 100 mg...11 LYNPARZA olaparib tab 150 mg...11 M MAGNESIUM CHLORIDE magnesium chloride inj 200 mg/ml...68 magnesium citrate soln magnesium oxide tab 400 mg magnesium oxide tab 400 mg (241.3 mg elemental mg) MAVYRET glecaprevir-pibrentasvir tab mg... 4 meclizine hcl tab 12.5 mg...38 meclizine hcl tab 25 mg...38 medroxyprogesterone acetate im susp 150 mg/ml (Depoprovera contrac) medroxyprogesterone acetate tab 2.5 mg (Provera) medroxyprogesterone acetate tab 5 mg (Provera) medroxyprogesterone acetate tab 10 mg (Provera) MEFLOQUINE HCL mefloquine hcl tab 250 mg...8 megestrol acetate susp 40 mg/ml megestrol acetate susp 625 mg/5ml (Megace es) megestrol acetate tab 20 mg...11 megestrol acetate tab 40 mg...11 MEKINIST trametinib dimethyl sulfoxide tab 0.5 mg (base equivalent) MEKINIST trametinib dimethyl sulfoxide tab 2 mg (base equivalent)...11 meloxicam tab 7.5 mg (Mobic) meloxicam tab 15 mg (Mobic) melphalan tab 2 mg (Alkeran) meperidine hcl tab 50 mg meperidine hcl tab 100 mg (Demerol)...53 MEPHYTON phytonadione tab 5 mg mercaptopurine tab 50 mg...11 MESALAMINE DR mesalamine tab delayed release 800 mg...39 mesalamine enema 4 gm METAMUCIL MULTIHEALTH FIB psyllium powder 55.46% METAMUCIL MULTIHEALTH FIB psyllium powder 63% METAMUCIL SMOOTH TEXTURE psyllium powder 63% metformin hcl tab er 24hr 500 mg (Glucophage xr) metformin hcl tab er 24hr 750 mg (Glucophage xr) metformin hcl tab 500 mg (Glucophage)...18 metformin hcl tab 850 mg (Glucophage)...18 metformin hcl tab 1000 mg (Glucophage)...18 METHERGINE methylergonovine maleate tab 0.2 mg...21 methimazole tab 5 mg (Tapazole) methimazole tab 10 mg (Tapazole) methocarbamol tab 750 mg (Robaxin-750)...65 methocarbamol tab 500 mg (Robaxin)...65 METHOTREXATE SODIUM methotrexate sodium inj 250 mg/10ml (25 mg/ml)...11 methotrexate sodium tab 2.5 mg (base equiv)...11 methoxsalen rapid cap 10 mg (Oxsoralen ultra) methyldopa tab 250 mg methyldopa tab 500 mg METHYLDOPATE HCL methyldopate hcl inj 250 mg/5ml...31 methylphenidate hcl cap er 24hr 20 mg (la) (Ritalin la)...50 methylphenidate hcl cap er 24hr 30 mg (la) (Ritalin la)...50 methylphenidate hcl cap er 24hr 40 mg (la) (Ritalin la)...50 methylphenidate hcl cap er 10 mg (cd)...49 methylphenidate hcl cap er 20 mg (cd)...49 methylphenidate hcl cap er 30 mg (cd)...49 methylphenidate hcl cap er 40 mg (cd)...49 methylphenidate hcl cap er 50 mg (cd)...49 methylphenidate hcl cap er 60 mg (cd)...49 METHYLPHENIDATE HCL ER methylphenidate hcl tab er 24hr 18 mg...50 METHYLPHENIDATE HCL ER methylphenidate hcl tab er 24hr 27 mg...50 METHYLPHENIDATE HCL ER methylphenidate hcl tab er 24hr 36 mg...50 METHYLPHENIDATE HCL ER methylphenidate hcl tab er 24hr 54 mg...50 methylphenidate hcl tab er 10 mg...50 methylphenidate hcl tab er osmotic release (osm) 18 mg (Concerta) methylphenidate hcl tab er osmotic release (osm) 27 mg (Concerta) methylphenidate hcl tab er osmotic release (osm) 36 mg (Concerta)

107 methylphenidate hcl tab er osmotic release (osm) 54 mg (Concerta) methylphenidate hcl tab 5 mg (Ritalin)...50 methylphenidate hcl tab 10 mg (Ritalin)...50 methylphenidate hcl tab 20 mg (Ritalin)...50 methylprednisolone tab 4 mg (Medrol)...14 methylprednisolone tab 8 mg (Medrol)...14 methylprednisolone tab 16 mg (Medrol)...14 methylprednisolone tab 32 mg (Medrol)...14 methylprednisolone tab therapy pack 4 mg (21) (Medrol dosepak)...14 metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) metoclopramide hcl tab 5 mg (Reglan) metoclopramide hcl tab 10 mg (Reglan) metolazone tab 2.5 mg metolazone tab 5 mg metolazone tab 10 mg METOPROLOL/HYDROCHLOROTHI metoprolol & hydrochlorothiazide tab mg metoprolol & hydrochlorothiazide tab mg...24 metoprolol & hydrochlorothiazide tab mg (Lopressor hct)...24 metoprolol succinate tab er 24hr 25 mg (tartrate equiv) (Toprol xl) metoprolol succinate tab er 24hr 50 mg (tartrate equiv) (Toprol xl) metoprolol succinate tab er 24hr 100 mg (tartrate equiv) (Toprol xl) metoprolol succinate tab er 24hr 200 mg (tartrate equiv) (Toprol xl) metoprolol tartrate tab 25 mg metoprolol tartrate tab 50 mg (Lopressor)...24 metoprolol tartrate tab 100 mg (Lopressor)...24 metronidazole cap 375 mg (Flagyl)...8 metronidazole cream 0.75% (Metrocream) metronidazole gel 0.75% metronidazole gel 1% (Metrogel)...77 metronidazole tab 250 mg (Flagyl)...9 metronidazole tab 500 mg (Flagyl)...9 metronidazole vaginal gel 0.75% (Metrogel-vaginal) mexiletine hcl cap 150 mg...30 mexiletine hcl cap 200 mg...30 mexiletine hcl cap 250 mg...30 miconazole nitrate aerosol pow 2%...78 miconazole nitrate cream 2% miconazole nitrate vaginal cream 2%...40 midodrine hcl tab 2.5 mg midodrine hcl tab 5 mg midodrine hcl tab 10 mg minocycline hcl cap 75 mg... 3 minocycline hcl cap 50 mg (Minocin)... 3 minocycline hcl cap 100 mg (Minocin)... 3 minocycline hcl tab 50 mg... 3 minocycline hcl tab 75 mg... 3 minocycline hcl tab 100 mg... 3 minoxidil tab 2.5 mg...31 minoxidil tab 10 mg...31 MIRENA levonorgestrel releasing iud 20 mcg/day (52 mg total) mirtazapine orally disintegrating tab 15 mg (Remeron soltab)...43 mirtazapine orally disintegrating tab 30 mg (Remeron soltab)...43 mirtazapine orally disintegrating tab 45 mg (Remeron soltab)...43 mirtazapine tab 15 mg (Remeron)...43 mirtazapine tab 30 mg (Remeron)...43 mirtazapine tab 45 mg (Remeron)...43 misoprostol tab 100 mcg (Cytotec)...37 misoprostol tab 200 mcg (Cytotec)...37 modafinil tab 100 mg (Provigil)...50 modafinil tab 200 mg (Provigil)...50 moexipril hcl tab 7.5 mg moexipril hcl tab 15 mg moexipril-hydrochlorothiazide tab mg moexipril-hydrochlorothiazide tab mg moexipril-hydrochlorothiazide tab mg mometasone furoate cream 0.1% (Elocon)...80 mometasone furoate oint 0.1% (Elocon)...80 mometasone furoate solution 0.1% (lotion)...80 MONOCLATE-P antihemophilic factor (human) for inj kit 1000 unit MONOCLATE-P antihemophilic factor (human) for inj kit 1500 unit MONONINE coagulation factor ix for inj 1000 unit...73 montelukast sodium chew tab 4 mg (base equiv) (Singulair)...34 montelukast sodium chew tab 5 mg (base equiv) (Singulair)...34 montelukast sodium oral granules packet 4 mg (base equiv) (Singulair) montelukast sodium tab 10 mg (base equiv) (Singulair)...34 MORPHINE SULFATE morphine sulfate inj 8 mg/ml MORPHINE SULFATE morphine sulfate suppos 5 mg...54 MORPHINE SULFATE morphine sulfate suppos 10 mg...54 MORPHINE SULFATE morphine sulfate suppos 20 mg...54 MORPHINE SULFATE morphine sulfate suppos 30 mg...54 MORPHINE SULFATE morphine sulfate tab 15 mg MORPHINE SULFATE morphine sulfate tab 30 mg morphine sulfate oral soln 10 mg/5ml morphine sulfate oral soln 20 mg/5ml morphine sulfate oral soln 100 mg/5ml (20 mg/ml)...54 morphine sulfate tab er 15 mg (Ms contin) morphine sulfate tab er 30 mg (Ms contin) morphine sulfate tab er 60 mg (Ms contin) morphine sulfate tab er 100 mg (Ms contin) morphine sulfate tab er 200 mg (Ms contin)

108 multiple vitamins w/ iron tab multiple vitamins w/ minerals & fa tab 1.25 mg (Corvite)...67 multiple vitamins w/ minerals cap...67 multiple vitamins w/ minerals tab (Strovite forte)...67 multiple vitamin tab mupirocin oint 2%...78 mycophenolate mofetil cap 250 mg (Cellcept) mycophenolate mofetil for oral susp 200 mg/ml (Cellcept)...82 mycophenolate mofetil tab 500 mg (Cellcept)...82 mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv) (Myfortic)...82 mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv) (Myfortic)...82 MYLERAN busulfan tab 2 mg MYSOLINE primidone tab 50 mg...61 MYSOLINE primidone tab 250 mg...61 N nabumetone tab 500 mg...56 nabumetone tab 750 mg...56 nadolol tab 20 mg (Corgard) nadolol tab 40 mg (Corgard) nadolol tab 80 mg (Corgard) NALOXONE HCL naloxone hcl soln cartridge 0.4 mg/ ml...82 NALOXONE HCL naloxone hcl soln prefilled syringe 2 mg/2ml...82 naltrexone hcl tab 50 mg naproxen sodium tab 220 mg...56 naproxen sodium tab 275 mg...56 naproxen sodium tab 550 mg (Anaprox ds)...56 naproxen tab ec 375 mg (Ec-naprosyn)...56 naproxen tab ec 500 mg (Ec-naprosyn)...56 naproxen tab 250 mg...56 naproxen tab 375 mg...56 naproxen tab 500 mg (Naprosyn)...56 NARCAN naloxone hcl nasal spray 4 mg/0.1ml...82 NATACYN natamycin ophth susp 5% nateglinide tab 60 mg (Starlix)...18 nateglinide tab 120 mg (Starlix)...18 neomycin-bacitracin-polymyxin oint...78 neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin neomycin-polymy-gramicid op sol mgunt-mg/ml (Neosporin)...75 neomycin-polymyxin-dexamethasone ophth oint 0.1% (Maxitrol) neomycin-polymyxin-dexamethasone ophth susp 0.1% (Maxitrol) neomycin-polymyxin-hc otic soln 1% neomycin-polymyxin-hc otic susp 3.5 mg/ml unit/ ml-1% neomycin sulfate tab 500 mg... 3 NEUPOGEN filgrastim inj 300 mcg/ml NEUPOGEN filgrastim inj 480 mcg/1.6ml (300 mcg/ ml)...73 NEUPOGEN filgrastim soln prefilled syringe 300 mcg/0.5ml...73 NEUPOGEN filgrastim soln prefilled syringe 480 mcg/0.8ml (600 mcg/ml)...73 NEURONTIN gabapentin cap 100 mg NEURONTIN gabapentin cap 300 mg NEURONTIN gabapentin cap 400 mg NEURONTIN gabapentin oral soln 250 mg/5ml...61 NEURONTIN gabapentin tab 600 mg NEURONTIN gabapentin tab 800 mg nevirapine tab er 24hr 100 mg (Viramune xr)... 6 nevirapine tab er 24hr 400 mg (Viramune xr)... 6 nevirapine tab 200 mg (Viramune)... 6 NEXAVAR sorafenib tosylate tab 200 mg (base equivalent)...11 NEXPLANON etonogestrel subdermal implant 68 mg...16 niacin cap er 250 mg niacin cap er 500 mg niacin tab er 250 mg...66 niacin tab er 500 mg...66 niacin tab er 750 mg...66 niacin tab 100 mg niacin tab 500 mg NIACIN TR niacin tab er 1000 mg nicotine polacrilex gum 2 mg...51 nicotine polacrilex gum 4 mg...51 nicotine td patch 24hr 7 mg/24hr...51 nicotine td patch 24hr 14 mg/24hr...51 nicotine td patch 24hr 21 mg/24hr...51 nifedipine cap 10 mg (Procardia) nifedipine tab er 24hr 30 mg (Adalat cc)...26 nifedipine tab er 24hr 60 mg (Adalat cc)...26 nifedipine tab er 24hr 90 mg (Adalat cc)...26 nifedipine tab er 24hr osmotic release 30 mg (Procardia xl)...26 nifedipine tab er 24hr osmotic release 60 mg (Procardia xl)...26 nifedipine tab er 24hr osmotic release 90 mg (Procardia xl)...26 nitrofurantoin macrocrystalline cap 25 mg (Macrodantin)...39 nitrofurantoin macrocrystalline cap 50 mg (Macrodantin)...40 nitrofurantoin macrocrystalline cap 100 mg (Macrodantin)...40 nitrofurantoin monohydrate macrocrystalline cap 100 mg (Macrobid) nitrofurantoin susp 25 mg/5ml (Furadantin) nitroglycerin cap er 2.5 mg nitroglycerin cap er 6.5 mg nitroglycerin cap er 9 mg nitroglycerin sl tab 0.3 mg (Nitrostat) nitroglycerin sl tab 0.4 mg (Nitrostat)

109 nitroglycerin sl tab 0.6 mg (Nitrostat) nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur) nitroglycerin td patch 24hr 0.2 mg/hr (Nitro-dur) nitroglycerin td patch 24hr 0.4 mg/hr (Nitro-dur) nitroglycerin td patch 24hr 0.6 mg/hr (Nitro-dur) NITYR nitisinone tab 2 mg NITYR nitisinone tab 5 mg NITYR nitisinone tab 10 mg nizatidine cap 150 mg...37 nizatidine cap 300 mg...37 NIZATIDINE nizatidine oral soln 15 mg/ml...37 norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg (Loestrin fe 1/20) norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg (Loestrin 1/20-21) norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg (Loestrin 1.5/30-21) norethindrone acetate-ethinyl estradiol tab 1 mg-5 mcg...15 norethindrone acetate tab 5 mg (Aygestin) norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg (Ortho-cyclen) norgestimate-eth estrad tab / / mg-mcg (Ortho tri-cyclen) norgestimate-eth estrad tab / / mg-mcg (Ortho tri-cyclen lo) nortriptyline hcl cap 10 mg (Pamelor) nortriptyline hcl cap 25 mg (Pamelor) nortriptyline hcl cap 50 mg (Pamelor) nortriptyline hcl cap 75 mg (Pamelor) NORVIR ritonavir cap 100 mg...6 NORVIR ritonavir oral soln 80 mg/ml...6 NORVIR ritonavir tab 100 mg... 6 NOVOLIN 70/30 insulin nph isophane & regular human inj 100 unit/ml (70-30) NOVOLIN 70/30 RELION insulin nph isophane & regular human inj 100 unit/ml (70-30) NOVOLIN N insulin nph (human) (isophane) inj 100 unit/ ml...19 NOVOLIN N RELION insulin nph (human) (isophane) inj 100 unit/ml NOVOLIN R insulin regular (human) inj 100 unit/ml NOVOLIN R RELION insulin regular (human) inj 100 unit/ml...18 NOVOLOG FLEXPEN insulin aspart soln pen-injector 100 unit/ml NOVOLOG insulin aspart inj 100 unit/ml NOVOLOG MIX 70/30 insulin aspart prot & aspart (human) inj 100 unit/ml (70-30) NOVOLOG MIX 70/30 PREFILL insulin aspart prot & aspart sus pen-inj 100 unit/ml (70-30)...19 NOVOLOG PENFILL insulin aspart soln cartridge 100 unit/ml...18 NOXAFIL posaconazole susp 40 mg/ml... 4 NOXAFIL posaconazole tab delayed release 100 mg... 4 NUVARING etonogestrel-ethinyl estradiol va ring mg/24hr nystatin cream unit/gm nystatin oint unit/gm...78 nystatin susp unit/ml nystatin tab unit... 4 nystatin topical powder unit/gm...78 O OCEAN BLUE MINICAPS OMEGA omega-3 fatty acids cap 350 mg...68 octreotide acetate inj 50 mcg/ml (0.05 mg/ml) (Sandostatin)...21 octreotide acetate inj 100 mcg/ml (0.1 mg/ml) (Sandostatin)...21 octreotide acetate inj 200 mcg/ml (0.2 mg/ml) (Sandostatin)...21 octreotide acetate inj 500 mcg/ml (0.5 mg/ml) (Sandostatin)...21 octreotide acetate inj 1000 mcg/ml (1 mg/ml) (Sandostatin)...21 ofloxacin ophth soln 0.3% (Ocuflox)...75 ofloxacin otic soln 0.3% (Floxin otic) olanzapine for im inj 10 mg (Zyprexa)...46 olanzapine orally disintegrating tab 5 mg (Zyprexa zydis) olanzapine orally disintegrating tab 10 mg (Zyprexa zydis) olanzapine orally disintegrating tab 15 mg (Zyprexa zydis) olanzapine orally disintegrating tab 20 mg (Zyprexa zydis) olanzapine tab 2.5 mg (Zyprexa)...46 olanzapine tab 5 mg (Zyprexa)...46 olanzapine tab 7.5 mg (Zyprexa)...46 olanzapine tab 10 mg (Zyprexa)...46 olanzapine tab 15 mg (Zyprexa)...46 olanzapine tab 20 mg (Zyprexa)...46 omega-3 fatty acids cap delayed release 1000 mg...69 omega-3 fatty acids cap delayed release 1200 mg...69 omega-3 fatty acids cap 500 mg...69 omega-3 fatty acids cap 435 mg...69 omega-3 fatty acids cap 1000 mg...69 omega-3 fatty acids cap 1200 mg...69 OMEGA-3 IQ omega-3 fatty acids chew tab 240 mg OMEGA-3 omega-3 fatty acids cap 1400 mg OMEGA omega-3 fatty acids cap 1050 mg OMEGA POWER omega-3 fatty acids cap 1050 mg omeprazole cap delayed release 20 mg omeprazole cap delayed release 40 mg OMNITROPE somatropin for inj 5.8 mg...20 ondansetron hcl oral soln 4 mg/5ml (Zofran) ondansetron hcl tab 24 mg...38 ondansetron hcl tab 4 mg (Zofran)...38 ondansetron hcl tab 8 mg (Zofran)

110 ondansetron orally disintegrating tab 4 mg (Zofran odt) ondansetron orally disintegrating tab 8 mg (Zofran odt) ONFI clobazam suspension 2.5 mg/ml ONFI clobazam tab 10 mg ONFI clobazam tab 20 mg oral electrolyte solution orphenadrine citrate tab er 12hr 100 mg...65 oseltamivir phosphate cap 30 mg (base equiv) (Tamiflu)...8 oseltamivir phosphate cap 45 mg (base equiv) (Tamiflu)...8 oseltamivir phosphate cap 75 mg (base equiv) (Tamiflu)...8 oseltamivir phosphate for susp 6 mg/ml (base equiv) (Tamiflu)...8 oxcarbazepine susp 300 mg/5ml (60 mg/ml) (Trileptal) oxcarbazepine tab 150 mg (Trileptal) oxcarbazepine tab 300 mg (Trileptal) oxcarbazepine tab 600 mg (Trileptal) OXTELLAR XR oxcarbazepine tab er 24hr 150 mg...62 OXTELLAR XR oxcarbazepine tab er 24hr 300 mg...62 OXTELLAR XR oxcarbazepine tab er 24hr 600 mg...62 oxybutynin chloride syrup 5 mg/5ml...40 oxybutynin chloride tab er 24hr 5 mg (Ditropan xl) oxybutynin chloride tab er 24hr 10 mg (Ditropan xl) oxybutynin chloride tab er 24hr 15 mg (Ditropan xl) oxybutynin chloride tab 5 mg...40 OXYCODONE/ACETAMINOPHEN oxycodone w/ acetaminophen soln mg/5ml...54 oxycodone-aspirin tab mg oxycodone hcl conc 100 mg/5ml (20 mg/ml) oxycodone hcl soln 5 mg/5ml oxycodone hcl tab 10 mg oxycodone hcl tab 20 mg oxycodone hcl tab 5 mg (Roxicodone)...54 oxycodone hcl tab 15 mg (Roxicodone)...54 oxycodone hcl tab 30 mg (Roxicodone)...54 oxycodone w/ acetaminophen tab mg (Percocet)...54 oxycodone w/ acetaminophen tab mg (Percocet)...54 oxycodone w/ acetaminophen tab mg (Percocet)...54 P pantoprazole sodium ec tab 20 mg (base equiv) (Protonix)...38 pantoprazole sodium ec tab 40 mg (base equiv) (Protonix)...38 PAPAVERINE HCL papaverine hcl inj 30 mg/ml...31 PARAGARD INTRAUTERINE COP copper iud paromomycin sulfate cap 250 mg... 3 paroxetine hcl tab 10 mg (Paxil)...43 paroxetine hcl tab 20 mg (Paxil)...43 paroxetine hcl tab 30 mg (Paxil)...43 paroxetine hcl tab 40 mg (Paxil)...43 PEDIA-LAX glycerin liquid suppos 2.8 gm (2.7 ml)...36 pediatric multiple vitamin w/ c & fa chew tab pediatric multiple vitamin w/ minerals & c drops 45 mg/ ml...67 PEGANONE ethotoin tab 250 mg peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm (Colyte-flavor packs)...36 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm (Golytely)...36 peg 3350-kcl-sod bicarb-nacl for soln 420 gm (Nulytely/ flavor pack) PENICILLIN V POTASSIUM penicillin v potassium for soln 125 mg/5ml... 1 PENICILLIN V POTASSIUM penicillin v potassium for soln 250 mg/5ml... 1 penicillin v potassium tab 250 mg... 1 penicillin v potassium tab 500 mg... 1 pentoxifylline tab er 400 mg perindopril erbumine tab 2 mg...22 perindopril erbumine tab 4 mg (Aceon)...22 perindopril erbumine tab 8 mg (Aceon)...22 permethrin cream 5% (Elimite) permethrin creme rinse 1% perphenazine tab 2 mg...46 perphenazine tab 4 mg...46 perphenazine tab 8 mg...46 perphenazine tab 16 mg...46 phenazopyridine hcl tab 100 mg (Pyridium)...40 phenazopyridine hcl tab 200 mg (Pyridium)...40 phenobarbital elixir 20 mg/5ml...47 PHENOBARBITAL phenobarbital tab 15 mg PHENOBARBITAL phenobarbital tab 30 mg PHENOBARBITAL phenobarbital tab 60 mg PHENOBARBITAL phenobarbital tab 100 mg PHENOBARBITAL SODIUM phenobarbital sodium inj 65 mg/ml PHENOBARBITAL SODIUM phenobarbital sodium inj 130 mg/ml phenobarbital tab 16.2 mg...48 phenobarbital tab 32.4 mg...48 phenobarbital tab 64.8 mg...48 phenobarbital tab 97.2 mg...48 phenoxybenzamine hcl cap 10 mg (Dibenzyline)...31 PHENYLEPHRINE/GUAIFENESIN phenylephrineguaifenesin liqd mg/5ml ( mg/ml) phenylephrine-guaifenesin tab mg phenylephrine hcl tab 10 mg phenylephrine w/ dm-gg liqd mg/5ml PHENYTEK phenytoin sodium extended cap 200 mg...62 PHENYTEK phenytoin sodium extended cap 300 mg...62 phenytoin chew tab 50 mg (Dilantin infatabs)

111 phenytoin sodium extended cap 100 mg (Dilantin)...62 phenytoin sodium extended cap 200 mg (Phenytek)...62 phenytoin sodium extended cap 300 mg (Phenytek)...62 phenytoin susp 125 mg/5ml (Dilantin-125)...62 pilocarpine hcl ophth soln 1% (Isopto carpine) pilocarpine hcl ophth soln 2% (Isopto carpine) pilocarpine hcl ophth soln 4% (Isopto carpine) pilocarpine hcl tab 5 mg (Salagen)...77 pilocarpine hcl tab 7.5 mg (Salagen)...77 pimozide tab 1 mg (Orap)...51 pimozide tab 2 mg (Orap)...51 pioglitazone hcl tab 15 mg (base equiv) (Actos) pioglitazone hcl tab 30 mg (base equiv) (Actos) pioglitazone hcl tab 45 mg (base equiv) (Actos) piroxicam cap 10 mg (Feldene)...57 piroxicam cap 20 mg (Feldene)...57 PLAN B ONE-STEP levonorgestrel tab 1.5 mg podofilox soln 0.5%...81 polyethylene glycol 3350 oral powder polymyxin b-trimethoprim ophth soln unit/ml-0.1% (Polytrim)...75 pot & sod citrates w/ cit ac soln mg/5ml...40 potassium bicarbonate effer tab 25 meq...68 potassium chloride cap er 8 meq (Micro-k)...68 potassium chloride cap er 10 meq (Micro-k)...68 POTASSIUM CHLORIDE ER potassium chloride tab er 8 meq (600 mg)...68 potassium chloride microencapsulated crys er tab 10 meq...68 potassium chloride microencapsulated crys er tab 20 meq...68 potassium chloride oral soln 10% (20 meq/15ml) POTASSIUM CHLORIDE potassium chloride oral soln 20% (40 meq/15ml)...68 potassium chloride powder packet 20 meq...68 potassium chloride tab er 10 meq (K-tab)...68 potassium chloride tab er 8 meq (600 mg) potassium citrate & citric acid powder pack mg...40 potassium citrate & citric acid soln mg/5ml potassium citrate tab er 5 meq (540 mg) (Urocit-k 5)...40 potassium citrate tab er 10 meq (1080 mg) (Urocit-k 10) potassium citrate tab er 15 meq (1620 mg) (Urocit-k 15) pot bicarbonate & chloride effer tab 25 meq pot phos monobasic w/sod phos di & monobas tab mg (K-phos neutral)...68 PRALUENT alirocumab subcutaneous soln pen-injector 75 mg/ml PRALUENT alirocumab subcutaneous soln pen-injector 150 mg/ml pramipexole dihydrochloride tab mg (Mirapex) pramipexole dihydrochloride tab 0.25 mg (Mirapex) pramipexole dihydrochloride tab 0.5 mg (Mirapex) pramipexole dihydrochloride tab 0.75 mg (Mirapex) pramipexole dihydrochloride tab 1 mg (Mirapex) pramipexole dihydrochloride tab 1.5 mg (Mirapex) pravastatin sodium tab 10 mg pravastatin sodium tab 20 mg (Pravachol)...28 pravastatin sodium tab 40 mg (Pravachol)...28 pravastatin sodium tab 80 mg (Pravachol)...28 prazosin hcl cap 1 mg (Minipress) prazosin hcl cap 2 mg (Minipress) prazosin hcl cap 5 mg (Minipress) prednicarbate cream 0.1% (Dermatop) PREDNICARBATE prednicarbate cream 0.1%...80 PREDNICARBATE prednicarbate oint 0.1%...80 prednisolone acetate ophth susp 1% (Pred forte)...75 PREDNISOLONE SODIUM PHOSP prednisolone sodium phosphate ophth soln 1% prednisolone sod phosphate oral soln 15 mg/5ml (base equiv)...14 prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base) (Pediapred)...14 prednisolone syrup 15 mg/5ml (usp solution equivalent)...14 PREDNISONE prednisone oral soln 5 mg/5ml PREDNISONE prednisone tab 50 mg...14 prednisone tab 1 mg...14 prednisone tab 2.5 mg...14 prednisone tab 5 mg...14 prednisone tab 10 mg...14 prednisone tab 20 mg...14 PREMPRO conjugated estrogen-medroxyprogest acetate tab mg...15 PREMPRO conjugated estrogen-medroxyprogest acetate tab mg...15 PREMPRO conjugated estrogen-medroxyprogest acetate tab mg...15 PRESERVISION AREDS 2 + MU multiple vitamins w/ minerals cap PREZISTA darunavir ethanolate susp 100 mg/ml (base equiv)...6 PREZISTA darunavir ethanolate tab 75 mg (base equiv)...6 PREZISTA darunavir ethanolate tab 150 mg (base equiv)...6 PREZISTA darunavir ethanolate tab 600 mg (base equiv)...6 PREZISTA darunavir ethanolate tab 800 mg (base equiv)...6 PRIFTIN rifapentine tab 150 mg... 3 PRIMAQUINE PHOSPHATE primaquine phosphate tab 26.3 mg (15 mg base)... 8 primidone tab 50 mg (Mysoline)...62 primidone tab 250 mg (Mysoline)...62 probenecid tab 500 mg...57 PROBUPHINE IMPLANT KIT buprenorphine hcl subdermal implant 74.2 mg (base equiv) prochlorperazine maleate tab 5 mg (base equivalent)

112 prochlorperazine maleate tab 10 mg (base equivalent)...38 prochlorperazine suppos 25 mg PROFILNINE factor ix complex for inj 500 unit...73 PROFILNINE factor ix complex for inj 1000 unit...73 PROFILNINE factor ix complex for inj 1500 unit...73 PROFILNINE SD factor ix complex for inj 500 unit PROFILNINE SD factor ix complex for inj 1000 unit PROFILNINE SD factor ix complex for inj 1500 unit progesterone im in oil 50 mg/ml...15 progesterone micronized cap 100 mg (Prometrium)...15 progesterone micronized cap 200 mg (Prometrium)...15 promethazine hcl suppos 12.5 mg promethazine hcl suppos 25 mg promethazine hcl syrup 6.25 mg/5ml promethazine hcl tab 12.5 mg promethazine hcl tab 25 mg promethazine hcl tab 50 mg promethazine w/ codeine syrup mg/5ml PRO NUTRIENTS OMEGA 3 omega-3 fatty acids cap delayed release mg propafenone hcl tab 150 mg...30 propafenone hcl tab 225 mg...30 propafenone hcl tab 300 mg...30 proparacaine hcl ophth soln 0.5%...76 PROPRANOLOL/HYDROCHLOROTH propranolol & hydrochlorothiazide tab mg propranolol hcl tab 10 mg...25 propranolol hcl tab 20 mg...25 propranolol hcl tab 40 mg...25 propranolol hcl tab 60 mg...25 propranolol hcl tab 80 mg...25 propylthiouracil tab 50 mg psyllium powder 28.3% psyllium powder 30% psyllium powder 30.9% psyllium powder 48.57%...36 psyllium powder 58.6% psyllium powder 95% PULMOZYME dornase alfa inhal soln 1 mg/ml...35 pyrazinamide tab 500 mg... 3 pyridostigmine bromide tab 60 mg (Mestinon) Q QC CALAMINE calamine lotion...81 QUDEXY XR topiramate cap er 24hr sprinkle 25 mg...62 QUDEXY XR topiramate cap er 24hr sprinkle 50 mg...62 QUDEXY XR topiramate cap er 24hr sprinkle 100 mg...62 QUDEXY XR topiramate cap er 24hr sprinkle 150 mg...62 QUDEXY XR topiramate cap er 24hr sprinkle 200 mg...62 quetiapine fumarate tab 25 mg (Seroquel)...46 quetiapine fumarate tab 50 mg (Seroquel)...46 quetiapine fumarate tab 100 mg (Seroquel)...46 quetiapine fumarate tab 200 mg (Seroquel)...46 quetiapine fumarate tab 300 mg (Seroquel)...46 quetiapine fumarate tab 400 mg (Seroquel)...46 quinapril hcl tab 5 mg (Accupril)...22 quinapril hcl tab 10 mg (Accupril)...22 quinapril hcl tab 20 mg (Accupril)...23 quinapril hcl tab 40 mg (Accupril)...23 quinapril-hydrochlorothiazide tab mg (Accuretic) quinapril-hydrochlorothiazide tab mg (Accuretic) quinapril-hydrochlorothiazide tab mg (Accuretic) quinidine gluconate tab er 324 mg...30 QUINIDINE SULFATE quinidine sulfate tab 200 mg QUINIDINE SULFATE quinidine sulfate tab 300 mg QVAR beclomethasone diprop inhal aero soln 40 mcg/ act (50/valve) QVAR beclomethasone diprop inhal aero soln 80 mcg/ act (100/valve) R raloxifene hcl tab 60 mg (Evista)...21 ramipril cap 1.25 mg (Altace) ramipril cap 2.5 mg (Altace) ramipril cap 5 mg (Altace) ramipril cap 10 mg (Altace) ranitidine hcl syrup 15 mg/ml (75 mg/5ml) ranitidine hcl tab 75 mg ranitidine hcl tab 150 mg (Zantac)...38 ranitidine hcl tab 300 mg (Zantac)...38 RECOMBINATE antihemophilic factor (recombinant) for inj unit...73 RECOMBINATE antihemophilic factor (recombinant) for inj unit...73 RECOMBINATE antihemophilic factor (recombinant) for inj unit...73 RECOMBINATE antihemophilic factor (recombinant) for inj unit...73 RECOMBINATE antihemophilic factor (recombinant) for inj unit...73 RELENZA DISKHALER zanamivir aero powder breath activated 5 mg/blister... 8 RELHIST BP brompheniramine & phenylephrine tab 4-10 mg...33 REPATHA evolocumab subcutaneous soln prefilled syringe 140 mg/ml...28 REPATHA SURECLICK evolocumab subcutaneous soln auto-injector 140 mg/ml...28 RESCRIPTOR delavirdine mesylate tab 100 mg...7 RESCRIPTOR delavirdine mesylate tab 200 mg...7 REVLIMID lenalidomide cap 5 mg REVLIMID lenalidomide cap 10 mg REVLIMID lenalidomide cap 15 mg

113 REVLIMID lenalidomide cap 20 mg REVLIMID lenalidomide cap 25 mg REVLIMID lenalidomide caps 2.5 mg REYATAZ atazanavir sulfate oral powder packet 50 mg (base equiv)... 7 ribavirin cap 200 mg (Rebetol)... 4 rifabutin cap 150 mg (Mycobutin)...3 rifampin cap 300 mg... 4 rifampin cap 150 mg (Rifadin)... 3 riluzole tab 50 mg (Rilutek)...65 ringer's solution for irrigation...82 RISPERIDONE ODT risperidone orally disintegrating tab 0.25 mg risperidone orally disintegrating tab 0.5 mg (Risperdal m- tab) risperidone orally disintegrating tab 1 mg (Risperdal m- tab) risperidone orally disintegrating tab 2 mg (Risperdal m- tab) risperidone orally disintegrating tab 3 mg (Risperdal m- tab) risperidone orally disintegrating tab 4 mg (Risperdal m- tab) risperidone soln 1 mg/ml (Risperdal)...47 risperidone tab 0.25 mg (Risperdal)...47 risperidone tab 0.5 mg (Risperdal)...47 risperidone tab 1 mg (Risperdal)...47 risperidone tab 2 mg (Risperdal)...47 risperidone tab 3 mg (Risperdal)...47 risperidone tab 4 mg (Risperdal)...47 RIXUBIS coagulation factor ix (recombinant) for inj 250 unit...73 RIXUBIS coagulation factor ix (recombinant) for inj 500 unit...73 RIXUBIS coagulation factor ix (recombinant) for inj 1000 unit...73 RIXUBIS coagulation factor ix (recombinant) for inj 2000 unit...73 RIXUBIS coagulation factor ix (recombinant) for inj 3000 unit...73 rizatriptan benzoate oral disintegrating tab 5 mg (base eq) (Maxalt-mlt) rizatriptan benzoate oral disintegrating tab 10 mg (base eq) (Maxalt-mlt)...57 rizatriptan benzoate tab 5 mg (base equivalent) (Maxalt) rizatriptan benzoate tab 10 mg (base equivalent) (Maxalt) ropinirole hydrochloride tab 0.25 mg (Requip) ropinirole hydrochloride tab 0.5 mg (Requip) ropinirole hydrochloride tab 1 mg (Requip) ropinirole hydrochloride tab 2 mg (Requip) ropinirole hydrochloride tab 3 mg (Requip) ropinirole hydrochloride tab 4 mg (Requip) ropinirole hydrochloride tab 5 mg (Requip) rosuvastatin calcium tab 5 mg (Crestor) rosuvastatin calcium tab 10 mg (Crestor) rosuvastatin calcium tab 20 mg (Crestor) rosuvastatin calcium tab 40 mg (Crestor) RUBRACA rucaparib camsylate tab 200 mg (base equivalent)...11 RUBRACA rucaparib camsylate tab 250 mg (base equivalent)...12 RUBRACA rucaparib camsylate tab 300 mg (base equivalent)...12 RU-HIST D brompheniramine & phenylephrine tab 4-10 mg...33 RYDAPT midostaurin cap 25 mg S SABRIL vigabatrin powd pack 500 mg SABRIL vigabatrin tab 500 mg...62 saline nasal spray 0.65%...33 salsalate tab 500 mg...52 salsalate tab 750 mg...52 selegiline hcl cap 5 mg (Eldepryl) selegiline hcl tab 5 mg...65 selenium sulfide lotion 2.5% SELZENTRY maraviroc tab 25 mg... 7 SELZENTRY maraviroc tab 75 mg... 7 SELZENTRY maraviroc tab 300 mg... 7 sennosides tab 8.6 mg SEREVENT DISKUS salmeterol xinafoate aer pow ba 50 mcg/dose (base equiv) sertraline hcl oral conc 20 mg/ml (Zoloft)...43 sertraline hcl tab 25 mg (Zoloft) sertraline hcl tab 50 mg (Zoloft) sertraline hcl tab 100 mg (Zoloft) sildenafil citrate tab 20 mg (Revatio)...31 silver sulfadiazine cream 1% (Silvadene) simethicone chew tab 80 mg...39 simethicone susp 40 mg/0.6ml simvastatin tab 5 mg (Zocor)...28 simvastatin tab 10 mg (Zocor)...28 simvastatin tab 20 mg (Zocor)...28 simvastatin tab 40 mg (Zocor)...28 sirolimus tab 0.5 mg (Rapamune) sirolimus tab 1 mg (Rapamune) sirolimus tab 2 mg (Rapamune) SKYLA levonorgestrel releasing iud 14 mcg/day (13.5 mg total) sodium chloride irrigation soln 0.9%...41 sodium chloride soln nebu 0.9% sodium chloride soln nebu 3% sodium chloride soln nebu 10% sodium chloride soln nebu 7% (Hyper-sal) sodium citrate & citric acid soln mg/5ml (Shohls solution modi) sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf) sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf)...68 sodium fluoride chew tab 1 mg f (from 2.2 mg naf)

114 sodium fluoride cream 1.1% (Prevident 5000 plus) sodium fluoride gel 1.1% (0.5% f) (Prevident fluoride)...77 sodium fluoride rinse 0.2% SODIUM FLUORIDE sodium fluoride tab 1 mg f (from 2.2 mg naf) sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf) sodium polystyrene sulfonate oral susp 15 gm/60ml sodium polystyrene sulfonate powder sodium polystyrene sulfonate rectal susp 30 gm/120ml...83 sotalol hcl tab 240 mg sotalol hcl tab 80 mg (Betapace)...30 sotalol hcl tab 120 mg (Betapace)...30 sotalol hcl tab 160 mg (Betapace)...30 SOVALDI sofosbuvir tab 400 mg... 4 SPIRIVA HANDIHALER tiotropium bromide monohydrate inhal cap 18 mcg (base equiv) spironolactone & hydrochlorothiazide tab mg (Aldactazide) spironolactone tab 25 mg (Aldactone)...29 spironolactone tab 50 mg (Aldactone)...29 spironolactone tab 100 mg (Aldactone) SPRITAM levetiracetam tab disintegrating soluble 250 mg...62 SPRITAM levetiracetam tab disintegrating soluble 500 mg...62 SPRITAM levetiracetam tab disintegrating soluble 750 mg...63 SPRITAM levetiracetam tab disintegrating soluble 1000 mg...63 SPRYCEL dasatinib tab 20 mg SPRYCEL dasatinib tab 50 mg SPRYCEL dasatinib tab 70 mg SPRYCEL dasatinib tab 80 mg SPRYCEL dasatinib tab 100 mg SPRYCEL dasatinib tab 140 mg stavudine cap 15 mg (Zerit)...7 stavudine cap 20 mg (Zerit)...7 stavudine cap 30 mg (Zerit)...7 stavudine cap 40 mg (Zerit)...7 STIMATE desmopressin acetate nasal soln 1.5 mg/ ml...21 STIVARGA regorafenib tab 40 mg SUBOXONE buprenorphine hcl-naloxone hcl sl film mg (base equiv)...54 SUBOXONE buprenorphine hcl-naloxone hcl sl film 4-1 mg (base equiv)...54 SUBOXONE buprenorphine hcl-naloxone hcl sl film 8-2 mg (base equiv)...54 SUBOXONE buprenorphine hcl-naloxone hcl sl film 12-3 mg (base equiv)...54 sucralfate tab 1 gm (Carafate)...38 sulfacetamide sodium ophth soln 10% (Bleph-10)...75 sulfacetamide sodium-prednisolone ophth soln (0.25)% sulfacetamide sodium w/ sulfur emulsion 10-1% sulfacetamide sodium w/ sulfur emulsion 10-5% SULFADIAZINE sulfadiazine tab 500 mg...3 sulfamethoxazole-trimethoprim susp mg/5ml... 9 sulfamethoxazole-trimethoprim tab mg (Bactrim)...9 sulfamethoxazole-trimethoprim tab mg (Bactrim ds)...9 sulfasalazine tab delayed release 500 mg (Azulfidine entabs)...39 sulfasalazine tab 500 mg (Azulfidine)...39 sulindac tab 150 mg...57 sulindac tab 200 mg...57 sumatriptan succinate inj 6 mg/0.5ml (Imitrex)...57 sumatriptan succinate solution cartridge 6 mg/0.5ml (Imitrex statdose ref) sumatriptan succinate tab 25 mg (Imitrex) sumatriptan succinate tab 50 mg (Imitrex) sumatriptan succinate tab 100 mg (Imitrex) SUSTIVA efavirenz cap 50 mg...7 SUSTIVA efavirenz cap 200 mg...7 SUSTIVA efavirenz tab 600 mg... 7 SUTENT sunitinib malate cap 12.5 mg (base equivalent)...12 SUTENT sunitinib malate cap 25 mg (base equivalent)...12 SUTENT sunitinib malate cap 37.5 mg (base equivalent)...12 SUTENT sunitinib malate cap 50 mg (base equivalent)...12 SYMBICORT budesonide-formoterol fumarate dihyd aerosol mcg/act...35 SYMBICORT budesonide-formoterol fumarate dihyd aerosol mcg/act...35 SYNAGIS palivizumab im soln 50 mg/0.5ml...9 SYNAGIS palivizumab im soln 100 mg/ml...9 T tacrolimus cap 0.5 mg (Prograf)...83 tacrolimus cap 1 mg (Prograf) tacrolimus cap 5 mg (Prograf) tacrolimus oint 0.03% (Protopic)...81 tacrolimus oint 0.1% (Protopic)...81 tamoxifen citrate tab 10 mg (base equivalent) tamoxifen citrate tab 20 mg (base equivalent) tamsulosin hcl cap 0.4 mg (Flomax) TARCEVA erlotinib hcl tab 25 mg (base equivalent) TARCEVA erlotinib hcl tab 100 mg (base equivalent)...12 TARCEVA erlotinib hcl tab 150 mg (base equivalent)...12 TASIGNA nilotinib hcl cap 150 mg (base equivalent)...12 TASIGNA nilotinib hcl cap 200 mg (base equivalent)...13 tazarotene cream 0.1% (Tazorac) TAZORAC tazarotene gel 0.05%

115 TAZORAC tazarotene gel 0.1% TECHLITE PEN NEEDLES 29G TEGRETOL carbamazepine susp 100 mg/5ml...63 TEGRETOL carbamazepine tab 200 mg TEGRETOL-XR carbamazepine tab er 12hr 100 mg...63 TEGRETOL-XR carbamazepine tab er 12hr 200 mg...63 TEGRETOL-XR carbamazepine tab er 12hr 400 mg...63 temazepam cap 15 mg (Restoril) temazepam cap 30 mg (Restoril) temozolomide cap 5 mg (Temodar)...13 temozolomide cap 20 mg (Temodar)...13 temozolomide cap 100 mg (Temodar)...13 temozolomide cap 140 mg (Temodar)...13 temozolomide cap 180 mg (Temodar)...13 temozolomide cap 250 mg (Temodar)...13 tenofovir disoproxil fumarate tab 300 mg (Viread)... 7 terazosin hcl cap 1 mg terazosin hcl cap 2 mg terazosin hcl cap 5 mg terazosin hcl cap 10 mg terbinafine hcl tab 250 mg (Lamisil)... 4 terbutaline sulfate tab 2.5 mg terbutaline sulfate tab 5 mg terconazole vaginal cream 0.8% terconazole vaginal cream 0.4% (Terazol 7)...40 terconazole vaginal suppos 80 mg...40 testosterone cypionate im inj in oil 100 mg/ml (Depotestosterone) testosterone cypionate im inj in oil 200 mg/ml (Depotestosterone) testosterone enanthate im inj in oil 200 mg/ml...14 tetracaine hcl ophth soln 0.5% tetrahydroz-dextran-peg-povidone ophth soln % THALOMID thalidomide cap 50 mg THALOMID thalidomide cap 100 mg THALOMID thalidomide cap 150 mg theophylline soln 80 mg/15ml theophylline tab er 12hr 100 mg...35 theophylline tab er 12hr 200 mg...35 theophylline tab er 12hr 300 mg...35 theophylline tab er 12hr 450 mg...35 theophylline tab er 24hr 400 mg...35 theophylline tab er 24hr 600 mg...35 thiamine hcl tab 50 mg thiamine hcl tab 100 mg thioridazine hcl tab 10 mg thioridazine hcl tab 25 mg thioridazine hcl tab 50 mg thioridazine hcl tab 100 mg thiothixene cap 1 mg...47 thiothixene cap 2 mg...47 thiothixene cap 5 mg...47 thiothixene cap 10 mg...47 thyroid tab 30 mg (1/2 grain) (Armour thyroid)...20 thyroid tab 90 mg (1 1/2 grain) (Armour thyroid)...20 thyroid tab 60 mg (1 grain) (Armour thyroid)...20 timolol maleate ophth soln 0.25% (Timoptic) timolol maleate ophth soln 0.5% (Timoptic) tioconazole vaginal oint 6.5% TIVICAY dolutegravir sodium tab 10 mg (base equiv)... 7 TIVICAY dolutegravir sodium tab 25 mg (base equiv)... 7 TIVICAY dolutegravir sodium tab 50 mg (base equiv)... 7 tizanidine hcl tab 2 mg (base equivalent)...65 tizanidine hcl tab 4 mg (base equivalent) (Zanaflex)...65 tobramycin-dexamethasone ophth susp % (Tobradex) tobramycin nebu soln 300 mg/5ml (Tobi)... 3 tobramycin ophth soln 0.3% (Tobrex)...75 TOLAZAMIDE tolazamide tab 250 mg...18 tolnaftate aerosol 1% TOPAMAX SPRINKLE topiramate sprinkle cap 15 mg...63 TOPAMAX SPRINKLE topiramate sprinkle cap 25 mg...63 TOPAMAX topiramate tab 25 mg...63 TOPAMAX topiramate tab 50 mg...63 TOPAMAX topiramate tab 100 mg...63 TOPAMAX topiramate tab 200 mg...63 TOPIRAMATE ER topiramate cap er 24hr sprinkle 25 mg...63 TOPIRAMATE ER topiramate cap er 24hr sprinkle 50 mg...63 TOPIRAMATE ER topiramate cap er 24hr sprinkle 100 mg...63 TOPIRAMATE ER topiramate cap er 24hr sprinkle 150 mg...63 TOPIRAMATE ER topiramate cap er 24hr sprinkle 200 mg...63 topiramate sprinkle cap 15 mg (Topamax sprinkle) topiramate sprinkle cap 25 mg (Topamax sprinkle) topiramate tab 25 mg (Topamax) topiramate tab 50 mg (Topamax) topiramate tab 100 mg (Topamax) topiramate tab 200 mg (Topamax) torsemide tab 5 mg...29 torsemide tab 100 mg...29 torsemide tab 10 mg (Demadex)...29 torsemide tab 20 mg (Demadex)...29 TRACLEER bosentan tab 62.5 mg TRACLEER bosentan tab 125 mg tramadol hcl tab 50 mg (Ultram)...54 trandolapril tab 1 mg...23 trandolapril tab 4 mg...23 trandolapril tab 2 mg (Mavik)...23 tranexamic acid tab 650 mg (Lysteda) trazodone hcl tab 50 mg...43 trazodone hcl tab 100 mg...43 trazodone hcl tab 150 mg...43 tretinoin cap 10 mg tretinoin cream 0.025% (Retin-a)...78 tretinoin cream 0.05% (Retin-a)

116 tretinoin cream 0.1% (Retin-a)...78 tretinoin gel 0.01% (Retin-a)...78 tretinoin gel 0.025% (Retin-a)...78 triamcinolone acetonide cream 0.025% triamcinolone acetonide cream 0.1% triamcinolone acetonide cream 0.5% triamcinolone acetonide dental paste 0.1% triamcinolone acetonide lotion 0.025%...80 triamcinolone acetonide lotion 0.1%...80 triamcinolone acetonide oint 0.025% triamcinolone acetonide oint 0.1%...80 TRIAMINIC NIGHT TIME COLD diphenhydraminephenylephrine syrup mg/5ml triamterene & hydrochlorothiazide cap mg (Dyazide)...29 triamterene & hydrochlorothiazide tab mg (Maxzide-25) triamterene & hydrochlorothiazide tab mg (Maxzide)...29 trifluoperazine hcl tab 1 mg (base equivalent) trifluoperazine hcl tab 2 mg (base equivalent) trifluoperazine hcl tab 5 mg (base equivalent) trifluoperazine hcl tab 10 mg (base equivalent) trifluridine ophth soln 1% (Viroptic)...75 trihexyphenidyl hcl elixir 0.4 mg/ml...65 trihexyphenidyl hcl tab 2 mg...65 trihexyphenidyl hcl tab 5 mg...65 TRILEPTAL oxcarbazepine susp 300 mg/5ml (60 mg/ ml)...63 TRILEPTAL oxcarbazepine tab 150 mg...63 TRILEPTAL oxcarbazepine tab 300 mg...63 TRILEPTAL oxcarbazepine tab 600 mg...63 trimethoprim tab 100 mg...9 TRI-VI-SOL pediatric vitamins adc drops 750 unit-400 unit-35 mg/ml TROKENDI XR topiramate cap er 24hr 25 mg TROKENDI XR topiramate cap er 24hr 50 mg TROKENDI XR topiramate cap er 24hr 100 mg TROKENDI XR topiramate cap er 24hr 200 mg TRUVADA emtricitabine-tenofovir disoproxil fumarate tab mg... 7 TRUVADA emtricitabine-tenofovir disoproxil fumarate tab mg... 7 TRUVADA emtricitabine-tenofovir disoproxil fumarate tab mg... 7 TRUVADA emtricitabine-tenofovir disoproxil fumarate tab mg... 7 TYMLOS abaloparatide subcutaneous soln pen-injector 3120 mcg/1.56ml U ursodiol cap 300 mg (Actigall) ursodiol tab 250 mg (Urso 250)...39 ursodiol tab 500 mg (Urso forte) V valacyclovir hcl tab 1 gm (Valtrex)...5 valacyclovir hcl tab 500 mg (Valtrex)...5 VALCHLOR mechlorethamine hcl gel 0.016% (base equivalent)...81 valganciclovir hcl tab 450 mg (base equivalent) (Valcyte)... 4 valproate sodium oral soln 250 mg/5ml (base equiv) (Depakene) valproic acid cap 250 mg (Depakene)...63 valsartan-hydrochlorothiazide tab mg (Diovan hct)...23 valsartan-hydrochlorothiazide tab mg (Diovan hct)...23 valsartan-hydrochlorothiazide tab mg (Diovan hct)...23 valsartan-hydrochlorothiazide tab mg (Diovan hct)...23 valsartan-hydrochlorothiazide tab mg (Diovan hct)...23 valsartan tab 40 mg (Diovan) valsartan tab 80 mg (Diovan) valsartan tab 160 mg (Diovan) valsartan tab 320 mg (Diovan) vancomycin hcl cap 125 mg (Vancocin hcl)... 9 vancomycin hcl cap 250 mg (Vancocin hcl)... 9 venlafaxine hcl cap er 24hr 37.5 mg (base equivalent) (Effexor xr) venlafaxine hcl cap er 24hr 75 mg (base equivalent) (Effexor xr) venlafaxine hcl cap er 24hr 150 mg (base equivalent) (Effexor xr) venlafaxine hcl tab 25 mg...44 venlafaxine hcl tab 37.5 mg...44 venlafaxine hcl tab 50 mg...44 venlafaxine hcl tab 75 mg...44 venlafaxine hcl tab 100 mg...44 VENTOLIN HFA albuterol sulfate inhal aero 108 mcg/act (90mcg base equiv)...35 verapamil hcl cap er 24hr 120 mg (Verelan)...26 verapamil hcl cap er 24hr 180 mg (Verelan)...26 verapamil hcl cap er 24hr 240 mg (Verelan)...26 verapamil hcl cap er 24hr 360 mg (Verelan)...26 verapamil hcl cap er 24hr 100 mg (Verelan pm)...26 verapamil hcl cap er 24hr 200 mg (Verelan pm)...26 verapamil hcl cap er 24hr 300 mg (Verelan pm)...26 verapamil hcl tab er 120 mg (Calan sr)...26 verapamil hcl tab er 180 mg (Calan sr)...26 verapamil hcl tab er 240 mg (Calan sr)...26 verapamil hcl tab 40 mg verapamil hcl tab 80 mg (Calan) verapamil hcl tab 120 mg (Calan) VICTOZA liraglutide soln pen-injector 18 mg/3ml (6 mg/ ml)...18 VIDEX didanosine for soln 2 gm

117 VIDEX didanosine for soln 4 gm... 7 vigabatrin powd pack 500 mg (Sabril)...63 VIMPAT lacosamide iv inj 200 mg/20ml (10 mg/ml) VIMPAT lacosamide oral solution 10 mg/ml...64 VIMPAT lacosamide tab 50 mg VIMPAT lacosamide tab 100 mg VIMPAT lacosamide tab 150 mg VIMPAT lacosamide tab 200 mg VIRACEPT nelfinavir mesylate tab 250 mg... 7 VIRACEPT nelfinavir mesylate tab 625 mg... 7 VIRAMUNE nevirapine susp 50 mg/5ml... 7 VIREAD tenofovir disoproxil fumarate oral powder 40 mg/gm...7 VIREAD tenofovir disoproxil fumarate tab 150 mg...7 VIREAD tenofovir disoproxil fumarate tab 200 mg...7 VIREAD tenofovir disoproxil fumarate tab 250 mg...7 VIREAD tenofovir disoproxil fumarate tab 300 mg...7 VITAMIN B-COMPLEX 100 b-complex vitamin inj vitamins a & d oint VIVITROL naltrexone for im extended release susp 380 mg...52 voriconazole for susp 40 mg/ml (Vfend)...4 voriconazole tab 50 mg (Vfend)... 4 voriconazole tab 200 mg (Vfend)... 4 VOTRIENT pazopanib hcl tab 200 mg (base equiv) W warfarin sodium tab 1 mg (Coumadin) warfarin sodium tab 2 mg (Coumadin) warfarin sodium tab 2.5 mg (Coumadin) warfarin sodium tab 3 mg (Coumadin) warfarin sodium tab 4 mg (Coumadin) warfarin sodium tab 5 mg (Coumadin) warfarin sodium tab 6 mg (Coumadin) warfarin sodium tab 7.5 mg (Coumadin) warfarin sodium tab 10 mg (Coumadin) water for irrigation, sterile irrigation soln X XALKORI crizotinib cap 200 mg...13 XALKORI crizotinib cap 250 mg...13 XARELTO rivaroxaban tab 10 mg...74 XARELTO rivaroxaban tab 15 mg...74 XARELTO rivaroxaban tab 20 mg...74 XARELTO STARTER PACK rivaroxaban tab starter therapy pack 15 mg & 20 mg XIFAXAN rifaximin tab 200 mg...9 XIFAXAN rifaximin tab 550 mg...9 XTANDI enzalutamide cap 40 mg XULANE norelgestromin-ethinyl estradiol td ptwk mcg/24hr XYNTHA antihemophilic factor recombinant paf for inj kit 250 unit XYNTHA antihemophilic factor recombinant paf for inj kit 500 unit XYNTHA antihemophilic factor recombinant paf for inj kit 1000 unit XYNTHA antihemophilic factor recombinant paf for inj kit 2000 unit XYNTHA SOLOFUSE antihemophilic factor recombinant paf for inj kit 250 unit XYNTHA SOLOFUSE antihemophilic factor recombinant paf for inj kit 500 unit XYNTHA SOLOFUSE antihemophilic factor recombinant paf for inj kit 1000 unit XYNTHA SOLOFUSE antihemophilic factor recombinant paf for inj kit 2000 unit XYNTHA SOLOFUSE antihemophilic factor recombinant paf for inj kit 3000 unit XYREM sodium oxybate oral solution 500 mg/ml...52 Y Z zaleplon cap 5 mg (Sonata) zaleplon cap 10 mg (Sonata) ZARONTIN ethosuximide cap 250 mg...64 ZARONTIN ethosuximide soln 250 mg/5ml ZARXIO filgrastim-sndz soln prefilled syringe 300 mcg/0.5ml...74 ZARXIO filgrastim-sndz soln prefilled syringe 480 mcg/0.8ml...74 ZELBORAF vemurafenib tab 240 mg ZENPEP pancrelipase (lip-prot-amyl) dr cap unit ZENPEP pancrelipase (lip-prot-amyl) dr cap unit ZENPEP pancrelipase (lip-prot-amyl) dr cap unit ZENPEP pancrelipase (lip-prot-amyl) dr cap unit ZENPEP pancrelipase (lip-prot-amyl) dr cap unit ZENPEP pancrelipase (lip-prot-amyl) dr cap unit ZEPATIER elbasvir-grazoprevir tab mg... 5 zidovudine cap 100 mg (Retrovir)... 7 zidovudine syrup 10 mg/ml (Retrovir)...8 zidovudine tab 300 mg...8 zinc oxide oint 10%...81 zinc oxide oint 20%...81 ziprasidone hcl cap 20 mg (Geodon) ziprasidone hcl cap 40 mg (Geodon) ziprasidone hcl cap 60 mg (Geodon) ziprasidone hcl cap 80 mg (Geodon) zolpidem tartrate tab 5 mg (Ambien)...48 zolpidem tartrate tab 10 mg (Ambien)...48 ZONEGRAN zonisamide cap 25 mg...64 ZONEGRAN zonisamide cap 100 mg...64 zonisamide cap 50 mg...64 zonisamide cap 25 mg (Zonegran)

118 zonisamide cap 100 mg (Zonegran)...64 ZORTRESS everolimus tab 0.25 mg ZORTRESS everolimus tab 0.5 mg ZORTRESS everolimus tab 0.75 mg ZUBSOLV buprenorphine hcl-naloxone hcl sl tab mg (base eq)...54 ZUBSOLV buprenorphine hcl-naloxone hcl sl tab mg (base eq)...55 ZUBSOLV buprenorphine hcl-naloxone hcl sl tab mg (base eq) ZUBSOLV buprenorphine hcl-naloxone hcl sl tab mg (base eq) ZUBSOLV buprenorphine hcl-naloxone hcl sl tab mg (base eq)...55 ZYCLARA imiquimod cream 3.75% ZYCLARA PUMP imiquimod cream 2.5%...81 ZYCLARA PUMP imiquimod cream 3.75%...81 ZYTIGA abiraterone acetate tab 250 mg ZYTIGA abiraterone acetate tab 500 mg ZYVOX linezolid for susp 100 mg/5ml

119 Important Phone Numbers 24/7 Nurseline 24-hour-a-day help line , TTY/TDD: 711 Emergency Care 911 Blue Cross Community Health Plans Member Services We are available 24 hours a day, seven (7) days a week. The call is free. Website: Service Area: The plan covers members who live in the state of Illinois. Blue Cross Community Health Plans Special Investigation Department (SID) , TTY/TDD: National Poison Control Center Calls are routed to the office closest to you Non-Emergency Medical Transportation , TTY/TDD: 711 Behavioral Health Services , TTY/TDD: 711 Children s Mobile Crisis , TTY/TDD: 711 Grievances and Appeals , TTY/TDD: 711 Fraud and Ab , TTY/TDD: 711 Care Coordination , TTY/TDD: 711 Adult Protective Services TTY: Nursing Home Hotline , TTY: DentaQuest Davis Vision Illinois Department of Health

120 To ask for supportive aids and services, or materials in other formats and languages for free, please call, TTY/TDD:711. Blue Cross and Blue Shield of Illinois complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Blue Cross and Blue Shield of Illinois does not exclude people or treat them differently beca of race, color, national origin, age, disability, or sex. Blue Cross and Blue Shield of Illinois: Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, contact Civil Rights Coordinator. If you believe that Blue Cross and Blue Shield of Illinois has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, Office of Civil Rights Coordinator, 300 E. Randolph St., 35 th floor, Chicago, Illinois 60601, , TTY/TDD: , Fax: , Civilrightscoordinator@hcsc.net. You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD) Complaint forms are available at

121 English: ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call (TTY/TDD: 711). Español (Spanish): ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY/TDD: 711). 繁體中文 (Chinese): 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY/TDD: 711). Tagalog (Tagalog Filipino): PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY/TDD: 711). Français (French): ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS : 711). Tiếng Việt (Vietnamese): CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY/TDD: 711). Deutsch (German): ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY/TDD: 711). 한국어 (Korean): 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY/TDD: 711) 번으로전화해주십시오. Русский (Russian): ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 711). (Arabic): العربية ( :.)117 : ह द (Hindi): ध य न द : यदद आप द द ब लत त आपक ललए म फ त म भ ष स यत स व ए उपलब ध (TTY/TDD: 711) पर क ल कर Italiano (Italian): ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (TTY/TDD: 711). ગ જર ત (Gujarati): સ ચન : જ તમ ગ જર ત બ લત હ, ત નન:શ લ ક ભ ષ સહ ય સ વ ઓ તમ ર મ ટ ઉપલબ ધ છ. ફ ન કર (TTY/TDD: 711). کریںکال ہیں دستیاب میں مفت خدماتکی مددکی زبانکو آپتو ہیںبولتے اردو آپ اگر :خبردار (Urdu): ا رد و (TTY/TDD: 711). Polski (Polish): UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer (TTY/TDD: 711). λληνικά (Greek): ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθε σή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε (TTY/TDD: 711).

122 Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association