2017 Cigna-HealthSpring Rx (PDP) DRUG LIST (Formulary)

Transcription

1 Loudoun County School Board Cigna-HealthSpring Rx (PDP) Cigna-HealthSpring Rx (PDP) DRUG LIST (Formulary) Please read: This document contains information about the drugs we cover in this plan. This drug list was updated September. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary This is not a complete list of drugs covered by our plan. For a complete listing or other questions, please contact Cigna-HealthSpring Rx (PDP) customer service at or, for TTY users, 7, 7 days a week, 8 a.m. 8 p.m. or visit Cigna-HealthSpring is contracted with Medicare for PDP plans, HMO and PPO plans in select states, and with select State Medicaid programs. Enrollment in Cigna-HealthSpring depends on contract renewal. _GF_LCSB INT

2 Note to existing customers: This drug list has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means Cigna-HealthSpring. When it refers to plan or our plan, it means Cigna-HealthSpring Rx (PDP). This document includes a list of the drugs (formulary) for our plans, which is current as of September. If you have any questions, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1,, and from time to time during the year. What is the Cigna-HealthSpring RX PDP Comprehensive Drug List? A drug list is a list of covered drugs selected by Cigna-HealthSpring Rx (PDP) in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Cigna-HealthSpring Rx (PDP) will generally cover the drugs listed in our drug list as long as the drug is medically necessary, the prescription is filled at a Cigna-HealthSpring Rx (PDP) network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Drug List (formulary) change? Generally, if you are taking a drug on our drug list that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of drug list changes, such as removing a drug from our drug list, will not affect customers who are currently taking the drug. It will remain available at the same cost-sharing for those customers taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our drug list, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected customers of the change at least 60 days before the change becomes effective, or at the time the customer requests a refill of the drug, at which time the customer will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our drug list to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our drug list and provide notice to customers who take the drug. The enclosed drug list is current as of September. To get updated information about the drugs covered by Cigna- HealthSpring Rx (PDP), please contact us. Our contact information appears on the front and back cover pages. If there are significant changes made to the printed drug list within the covered year, you may be notified by mail identifying the changes. How do I use the Drug List? There are two ways to find your drug within the drug list: Medical Condition The drug list begins on page 7. The drugs in this drug list are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, CARDIOVASCULAR AGENTS. If you know what your drug is used for, look for the category name in the list that begins on page 7. Then look under the category name for your drug. 2

3 Covered Drug Index If you are not sure what category to look under, you should look for your drug in the Covered Drug Index that begins on page 81. The Covered Drug Index provides a list of all of the drugs included in this document. Both brand name drugs and generic drugs are in the Drug List. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Covered Drug Index and find the name of your drug in the drug name column of the list. What are generic drugs? Cigna-HealthSpring Rx (PDP) covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: The plan requires you or your doctor to get prior authorization for certain drugs. This means that you will need to get approval from the plan before you fill your prescriptions. If you don t get approval, Cigna- HealthSpring Rx (PDP) may not cover the drug. Quantity Limits: For certain drugs, the plan limits the amount of the drug that Cigna-HealthSpring Rx (PDP) will cover. For example, the plan provides 30 (lets) per prescription for VESICARE. This applies to standard one-month supply (for total quantity of 30 per 30 days) or three-month supply (for total quantity of 90 per 90 days). Step Therapy: In some cases, the plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Cigna- HealthSpring Rx (PDP) 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 additional requirements or limits by looking in the drug list that begins on page 7. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the drug list, appears on the front and back cover pages. You can ask Cigna-HealthSpring Rx (PDP) to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the plan drug list? on the next page for information about how to request an exception. Options for Maintenance Medications Taking the medications prescribed by your doctor is important to your health. We are committed to helping you achieve control of chronic conditions by making it easy for you to receive your maintenance medications. As part of our commitment to coordinating your healthcare needs, we have set a goal of helping you take your medications at least 80% of the time. There are several ways we can work together to accomplish this goal: Talk with your doctor about whether a 90 day supply of your ongoing, sle medications may be appropriate. Taking these medications every day as prescribed is important for your overall health, and getting 90 day prescriptions of these medications can ensure that you don t miss a dose. You can receive a 90-day supply at most retail pharmacies or through one of our mail-order pharmacies. Talk to your pharmacist if you are experiencing any new challenges with your maintenance medications. How can I use my prescription drug coverage to save money on my medications? There may be opportunities for you to save money on your medications using your plan coverage. Ask your doctor if there are any lower-cost generic alternatives available for any of your current medications. Explore whether the Medicare Extra Help program may offer additional financial support for your medications. 3

4 If your medication is not covered on the plan drug list, talk with your doctor about alternative medications which are covered in the drug list. What if my drug is not in the Drug List? If your drug is not included in this drug list, you should first contact Customer Service and ask if your drug is covered. If you learn that the plan does not cover your drug, you have two options: You can ask Customer Service for a list of similar drugs that are covered by the plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by the plan. You can ask the plan to make an exception to cover your drug. See below for information about how to request an exception. How do I request an exception to the plan Drug List? You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not in our drug list. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, the plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. You can ask us to provide a tiering exception for a higher cost sharing drug to be covered at a lower cost-sharing tier. If your drug is contained in our Non-Preferred Brand tier or the Non-Preferred Generic tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in the respective Preferred Brand or Preferred Generic tier instead. This would lower the amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not in our drug list, you may not ask us to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in the Specialty tier. Generally, we will only approve your request for an exception if the alternative drug is included on the plan s drug list, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a drug list, tiering or utilization restriction exception. When you request a drug list, tiering or utilization restriction exception, you should submit a statement from your prescriber or doctor supporting your request. Generally, we must make our decision within hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing customer in our plan, you may be taking drugs that are not in our drug list. Or, you may be taking a drug that is on our drug list but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a drug list exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a customer of our plan. For each of your drugs that is not on our drug list or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a customer of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a customer of our plan. If you need a drug that is not on our drug 4

5 list or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a drug list exception. In order to accommodate unexpected transitions of our customers that do not leave time for advanced planning, such as level-ofcare changes due to discharge from a hospital to a nursing facility or to a home, we will allow a one-time 31-day supply (unless the prescription is written for fewer days). Cigna-HealthSpring Rx (PDP) Drug List The comprehensive drug list provides coverage information about all of the drugs covered by Cigna-HealthSpring Rx (PDP). If you have trouble finding your drug in the list, turn to the Covered Drug Index that begins on page 81. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., VESICARE) and generic drugs are listed in lower-case italics (e.g., simvastatin). The information in the Requirements/Limits column tells you if we have any special requirements for coverage of your drug. We provide quantity limits on certain drugs which, are indicated with a QL in the drug list that begins on page 7, along with the amount dispensed per the days supplied. (For example: VESICARE 30/30; this means the drug VESICARE is limited to 30 lets per 30 days. For 90-day supplies, this quantity limit would be expanded to 90 les per 90 days). For more information For more detailed information about your Cigna-HealthSpring Rx (PDP) coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Cigna-HealthSpring Rx (PDP), please contact us. Our contact information, along with the date we last updated the drug list, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call Or, visit 5

6 Drug Tier and Cost Share Table Cigna-HealthSpring Rx (PDP) Cost-Share 30-day supply 30-day supply 90-day supply 90-day supply 30-day supply Tier 1: Preferred Generic Drugs Tier 2: Preferred Brand Drugs Tier 3: Non-Preferred Brand and Generic Drugs Tier 4: Specialty Drugs Specialty drugs are limited to a 30- day supply Retail Mail Order Retail Loudoun County School Board Mail Order Out of Network* $10 copay $10 copay $30 copay $ copay 40% coinsurance $ copay $ copay $60 copay $40 copay 40% coinsurance $40 copay $40 copay $1 copay $80 copay 40% coinsurance $40 copay Specialty drugs are limited to a 30-day supply $40 copay Specialty drugs are limited to a 30-day supply NA NA 40% coinsurance Specialty drugs are limited to a 30-day supply * You may get drugs at an out-of-network pharmacy. You will pay the in-network pharmacy copay or percent of the cost, plus the amount that the out-of-network pharmacy billed charges are higher than our typical standard retail pharmacy billed charges. Note for customers receiving Extra Help: Your LIS copay level will be based on how the Food and Drug Administration (FDA) classifies certain drugs. Due to this, a generic drug may receive a preferred drug copay, or a preferred brand drug may receive a generic drug copay. Please see your LIS Rider for additional information on these copay levels. Or call Customer Service for further clarification regarding a specific drug. You may also refer to your Evidence of Coverage document for additional details.

7 Comprehensive Formulary Cost-Sharing Tier Description Tier 1: Generic Drugs Tier 2: Preferred-Brand Drugs Tier 3: Non-Preferred Brand Drugs Tier 4: Specialty Drugs Symbol Key - Utilization Management Requirements/ Limits B vs. D Coverage determination for Part B or Part D required. Note: Inhalant solutions used in a nebulizer are only covered under Part D when the member is located in a long term care (LTC) setting. PA Prior Authorization is required - your doctor must obtain prior approval for this drug. QL HRM ST * Quantity Limits Apply - You may only obtain coverage for a limited amount of this drug. High Risk Medication. For more information call Customer Service (phone numbers are on the cover of this booklet) 8:00 am to 8:00 pm Monday through Friday. Between October and February, we're also open Saturday and Sunday. Step Therapy is required - You must first use another drug before these drugs can be approved for use. Applies to new starts only + This prescription drug is not normally covered in a Medicare Prescription Drug Plan. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Generally all medications on the formulary are available through mail order except when special circumstances or situations prohibit mailing a particular medication to your home. Comprehensive Formulary Drug Tier Requirements/ Limits Analgesics acetamin-codein mg/ QL 00ML/30 acetaminophen-cod #2 let 1 QL 360/30 acetaminophen-cod #3 let 1 QL 360/30 acetaminophen-cod #4 let 1 QL 0/30 ascomp with codeine capsule 1 PA (HRM),QL 0/30 aspirin-caff-dihydrocodein cap 1 QL 330/30 bupap 50 mg-300 mg let 1 PA (HRM),QL 0/30 buprenorphine 0.3 mg/ml vial 1 QL 0ML/30 butalb-acetamin-caff PA (HRM),QL 0/30 butalb-acetamin-caff PA (HRM),QL 0/30 butalb-acetaminoph-caff-codein 1 PA (HRM),QL 0/30 butalb-caff-acetaminoph-codein 1 PA (HRM),QL 0/30 butalbit-acetaminophen-caff cp 1 PA (HRM),QL 0/30 butalbital comp-codeine #3 cap 1 PA (HRM),QL 0/30 butalbital-acetaminophn PA (HRM),QL 0/30 butalbital-asa-caffeine cap 1 PA (HRM),QL 0/30 butorphanol 1 mg/ml vial 1 QL 0ML/30 butorphanol 10 mg/ml spray 1 QL 5ML/30 +This drug does not count towards your total drug costs. For full description please see key symbol on page 6. 7

8 Comprehensive Formulary butorphanol 2 mg/ml vial 1 QL 240ML/30 BUTRANS 10 MCG/HR PATCH 2 QL 4/ BUTRANS MCG/HR PATCH 2 QL 4/ BUTRANS MCG/HR PATCH 2 QL 4/ BUTRANS 5 MCG/HR PATCH 2 QL 4/ BUTRANS 7.5 MCG/HR PATCH 2 QL 4/ CAMBIA 50 MG POWDER PACKET 3 capacet capsule 1 PA (HRM),QL 0/30 CAPITAL WITH CODEINE SUSP 2 QL 00ML/30 carisoprodol cpd-codeine 1 PA (HRM) celecoxib 100 mg capsule 1 QL 60/30 celecoxib 0 mg capsule 1 QL 60/30 celecoxib 400 mg capsule 1 QL 60/30 celecoxib 50 mg capsule 1 QL 60/30 choline mag trisal liquid 1 codeine sulfate mg let 1 QL 0/30 codeine sulfate 30 mg let 1 QL 360/30 codeine sulfate 60 mg let 1 QL 0/30 DEMEROL 100 MG/ML SYRINGE 3 DEMEROL MG/ML SYRINGE 3 DEMEROL 50 MG/ML VIAL 3 DEMEROL 75 MG/ML SYRINGE 3 diclofenac pot 50 mg let 1 diclofenac sod dr 50 mg 1 diclofenac sod ec mg 1 diclofenac sod ec 75 mg 1 diclofenac sod er 100 mg 1 diclofenac-misoprost tb 1 diclofenac-misoprost tb 1 diflunisal 500 mg let 1 dihydrocodein-acetaminoph-caff 1 QL 300/30 diskets 40 mg let dispr 1 QL 90/30 DURAMORPH 10 MG/10 ML AMPUL 3 QL 0ML/30 DURAMORPH 5 MG/10 ML AMPUL 3 QL 0ML/30 endocet 10-5 mg let 1 QL 360/30 endocet mg let 1 QL 360/30 endocet 5-5 let 1 QL 360/30 endocet mg let 1 QL 360/30 esgic capsule 1 PA (HRM),QL 0/30 etodolac 0 mg capsule 1 etodolac 300 mg capsule 1 etodolac 400 mg let 1 etodolac 500 mg let 1 etodolac er 400 mg let 1 etodolac er 500 mg let 1 etodolac er 600 mg let 1 fenoprofen 400 mg capsule 1 fenoprofen 600 mg let 1 fentanyl 0.05 mg/ml syringe 1 BvsD fentanyl 1,000 mcg/ ml ampul 1 BvsD fentanyl 100 mcg/hr patch 1 QL /30 fentanyl 12 mcg/hr patch 1 QL /30 fentanyl 2,500 mcg/50 ml vial 1 BvsD fentanyl mcg/hr patch 1 QL /30 fentanyl 0 mcg/5 ml vial 1 BvsD fentanyl 37.5 mcg/hr patch 1 QL /30 fentanyl 50 mcg/hr patch 1 QL /30 fentanyl 62.5 mcg/hr patch 1 QL /30 fentanyl 75 mcg/hr patch 1 QL /30 fentanyl 87.5 mcg/hr patch 1 QL /30 fentanyl cit otfc 1,0 mcg 4 PA,QL 1/30 fentanyl cit otfc 1,600 mcg 4 PA,QL 1/30 fentanyl citrate otfc 0 mcg 1 PA,QL 1/30 fentanyl citrate otfc 400 mcg 4 PA,QL 1/30 fentanyl citrate otfc 600 mcg 4 PA,QL 1/30 fentanyl citrate otfc 800 mcg 4 PA,QL 1/30 FIORINAL MG CAPSULE 2 flurbiprofen 100 mg let 1 +This drug does not count towards your total drug costs. For full description please see key symbol on page 6. 8

9 Comprehensive Formulary flurbiprofen 50 mg let 1 hydrocodon-acetamin 7.5-5/ 1 QL 00ML/30 hydrocodon-acetaminoph QL 360/30 hydrocodon-acetaminoph QL 0/30 hydrocodon-acetaminoph QL 0/30 hydrocodon-acetaminophen QL 360/30 hydrocodon-acetaminophen QL 360/30 hydrocodon-acetaminophn QL 0/30 hydrocodon-acetaminophn QL 0/30 hydrocodone-acetamin 10-5/ 1 QL 00ML/30 hydrocodone-ibuprofen QL 0/30 hydrocodone-ibuprofen QL 0/30 hydrocodone-ibuprofen 5-0 mg 1 QL 0/30 hydrocodone-ibuprofen QL 0/30 hydromorphone 1 mg/ml solution 1 QL 10ML/30 hydromorphone 1 mg/ml syringe 1 hydromorphone 10 mg/ml vial 1 hydromorphone 2 mg let 1 QL 0/30 hydromorphone 2 mg/ml syringe 1 hydromorphone 2 mg/ml vial 1 hydromorphone 3 mg suppos 1 hydromorphone 4 mg let 1 QL 0/30 hydromorphone 4 mg/ml syrin 1 hydromorphone 50 mg/5 ml vial 1 hydromorphone 8 mg let 1 QL 240/30 ibudone 5-0 mg let 1 QL 0/30 ibuprofen 100 mg/5 ml susp 1 ibuprofen 400 mg let 1 ibuprofen 600 mg let 1 ibuprofen 800 mg let 1 indomethacin mg capsule 1 indomethacin 50 mg capsule 1 indomethacin er 75 mg capsule 1 INFUMORPH 0 MG/ ML AMPUL 3 QL 0ML/30 INFUMORPH 500 MG/ ML AMPUL 3 QL 0ML/30 ketoprofen 50 mg capsule 1 ketoprofen 75 mg capsule 1 ketoprofen er 0 mg capsule 1 QL 30/30 ketorolac 10 mg let 1 QL /30 ketorolac mg/ml vial 1 ketorolac 30 mg/ml carpuject 1 ketorolac 30 mg/ml vial 1 ketorolac 300 mg/10 ml vial 1 ketorolac 60 mg/2 ml vial 1 levorphanol 2 mg let 1 QL 0/30 lorcet 5-5 mg let 1 QL 360/30 lorcet hd 10-5 mg let 1 QL 0/30 lorcet plus mg let 1 QL 0/30 lor 10-5 mg let 1 QL 0/30 lor 5-5 mg let 1 QL 360/30 lor mg let 1 QL 0/30 margesic capsule 1 PA (HRM),QL 0/30 marten let 1 PA (HRM),QL 0/30 meclofenamate 100 mg capsule 1 meclofenamate 50 mg capsule 1 meloxicam mg let 1 QL 30/30 meloxicam 7.5 mg let 1 QL 30/30 meloxicam 7.5 mg/5 ml susp 1 meperidine 10 mg/ml cartrdge 1 meperidine 100 mg let 1 QL 0/30 meperidine 100 mg/ml vial 1 meperidine mg/ml vial 1 meperidine 50 mg let 1 QL 0/30 meperidine 50 mg/5 ml solution 1 QL 900ML/30 meperidine 50 mg/ml vial 1 methadone 10 mg/5 ml solution 1 QL 900ML/30 methadone 10 mg/ml oral conc 1 QL 500ML/30 methadone 5 mg/5 ml solution 1 QL 00ML/30 methadone hcl 10 mg let 1 QL 0/30 +This drug does not count towards your total drug costs. For full description please see key symbol on page 6. 9

10 Comprehensive Formulary methadone hcl 10 mg/ml vial 1 QL 0ML/30 methadone hcl 5 mg let 1 QL 0/30 methadone intensol 10 mg/ml 1 QL 500ML/30 methadose 10 mg/ml oral conc 1 QL 500ML/30 methadose 40 mg let dispr 1 QL 90/30 morphine 0.5 mg/ml vial 1 QL 0ML/30 morphine 1 mg/ml vial p-f 1 QL 0ML/30 morphine 10 mg/ml isecure syr 1 QL 0ML/30 morphine 10 mg/ml syringe 1 QL 0ML/30 morphine 10 mg/ml vial 1 QL 0ML/30 morphine mg/ml carpuject 1 morphine mg/ml vial 1 morphine 2 mg/ml isecure syr 1 QL 240ML/30 morphine 2 mg/ml syringe 1 morphine 4 mg/ml isecure syr 1 QL 240ML/30 morphine 4 mg/ml syringe 1 morphine 5 mg/ml syringe 1 morphine 5 mg/ml vial 1 morphine 8 mg/ml isecure syr 1 QL 0ML/30 morphine 8 mg/ml syringe 1 QL 0ML/30 morphine sulf 10 mg suppos 1 morphine sulf 10 mg/5 ml soln 1 QL 00ML/30 morphine sulf 100 mg/5 ml soln 1 QL 0ML/30 morphine sulf mg suppos 1 morphine sulf mg/5 ml soln 1 QL 50ML/30 morphine sulf 30 mg suppos 1 morphine sulf 5 mg suppos 1 morphine sulf er 100 mg let 1 QL 1/30 morphine sulf er mg let 1 QL 0/30 morphine sulf er 0 mg let 1 QL 1/30 morphine sulf er 30 mg let 1 QL 0/30 morphine sulf er 60 mg let 1 QL 1/30 morphine sulfate 1 mg/ml vial 1 QL 0/30 morphine sulfate mg/ml vl 1 morphine sulfate 50 mg/ml vial 1 morphine sulfate add-vantage 1 morphine sulfate er 10 mg cap 1 QL 60/30 morphine sulfate er 100 mg cap 1 QL 60/30 morphine sulfate er 1 mg cap 1 QL 60/30 morphine sulfate er mg cap 1 QL 60/30 morphine sulfate er 30 mg cap 1 QL 60/30 morphine sulfate er mg cap 1 QL 60/30 morphine sulfate er 50 mg cap 1 QL 60/30 morphine sulfate er 60 mg cap 1 QL 60/30 morphine sulfate er 75 mg cap 1 QL 60/30 morphine sulfate er 80 mg cap 1 QL 60/30 morphine sulfate er 90 mg cap 1 QL 60/30 morphine sulfate ir mg 1 QL 0/30 morphine sulfate ir 30 mg 1 QL 0/30 nabumetone 500 mg let 1 nabumetone 750 mg let 1 nalbuphine 100 mg/10 ml vial 1 QL 0ML/30 nalbuphine 0 mg/10 ml vial 1 QL 90ML/30 naproxen 1 mg/5 ml suspen 1 naproxen 0 mg let 1 naproxen 375 mg let 1 naproxen 500 mg let 1 naproxen dr 375 mg let 1 naproxen dr 500 mg let 1 naproxen sodium 5 mg 1 naproxen sodium 0 mg 1 OPANA ER 10 MG TABLET 2 QL 60/30 OPANA ER MG TABLET 2 QL 60/30 OPANA ER MG TABLET 2 QL 60/30 OPANA ER 30 MG TABLET 2 QL 60/30 +This drug does not count towards your total drug costs. For full description please see key symbol on page 6. 10

11 Comprehensive Formulary OPANA ER 40 MG TABLET 2 QL 1/30 OPANA ER 5 MG TABLET 2 QL 60/30 OPANA ER 7.5 MG TABLET 2 QL 60/30 opium tincture 10 mg/ml 1 oxaprozin 600 mg let 1 oxycodon-acetaminophen QL 360/30 oxycodon-acetaminophen QL 360/30 oxycodone hcl 10 mg let 1 QL 300/30 oxycodone hcl 100 mg/5 ml soln 1 QL 0ML/30 oxycodone hcl mg let 1 QL 300/30 oxycodone hcl mg let 1 QL 0/30 oxycodone hcl 30 mg let 1 QL 0/30 oxycodone hcl 5 mg capsule 1 QL 300/30 oxycodone hcl 5 mg let 1 QL 300/30 oxycodone hcl 5 mg/5 ml soln 1 QL 10ML/30 oxycodone hcl er 10 mg let 1 QL 90/30 oxycodone hcl er mg let 1 QL 90/30 oxycodone hcl er mg let 1 QL 90/30 oxycodone hcl er 30 mg let 1 QL 90/30 oxycodone hcl er 40 mg let 1 QL 90/30 oxycodone hcl er 60 mg let 1 QL 90/30 oxycodone hcl er 80 mg let 1 QL 1/30 oxycodone-acetaminophen QL 360/30 oxycodone-acetaminophen QL 360/30 oxycodone-acetaminophn 5-5/5 1 QL 00ML/30 oxycodone-aspirin QL 0/30 oxycodone-ibuprofen QL 1/30 OXYCONTIN 10 MG TABLET 2 QL 90/30 OXYCONTIN MG TABLET 2 QL 90/30 OXYCONTIN MG TABLET 2 QL 90/30 OXYCONTIN 30 MG TABLET 2 QL 90/30 OXYCONTIN 40 MG TABLET 2 QL 90/30 OXYCONTIN 60 MG TABLET 2 QL 90/30 OXYCONTIN 80 MG TABLET 2 QL 1/30 oxymorphone hcl 10 mg let 1 QL 0/30 oxymorphone hcl 5 mg let 1 QL 0/30 oxymorphone hcl er 10 mg 1 QL 60/30 oxymorphone hcl er mg 1 QL 60/30 oxymorphone hcl er mg 1 QL 60/30 oxymorphone hcl er 30 mg 1 QL 60/30 oxymorphone hcl er 40 mg 1 QL 1/30 oxymorphone hcl er 5 mg let 1 QL 60/30 oxymorphone hcl er 7.5 mg 1 QL 60/30 pentazocine-naloxone let 1 QL 360/30 piroxicam 10 mg capsule 1 piroxicam mg capsule 1 reprexain 10-0 mg let 1 QL 0/30 reprexain 5-0 mg let 1 QL 0/30 roxicet 5-5 oral solution 1 QL 00ML/30 roxicet 5-5 let 1 QL 360/30 salsalate 500 mg let 1 salsalate 750 mg let 1 sulindac 0 mg let 1 sulindac 0 mg let 1 TALWIN 30 MG/ML VIAL 3 tencon 50-5 mg let 1 PA (HRM),QL 0/30 tolmetin sodium 0 mg 1 tolmetin sodium 400 mg cap 1 tolmetin sodium 600 mg 1 tramadol er 100 mg let 1 QL 30/30 tramadol er 0 mg let 1 QL 30/30 tramadol er 300 mg let 1 QL 30/30 tramadol hcl 50 mg let 1 QL 240/30 tramadol hcl er 100 mg let 1 QL 30/30 tramadol hcl er 0 mg let 1 QL 30/30 tramadol hcl er 300 mg let 1 QL 30/30 tramadol-acetaminophn QL 240/30 trezix mg capsule 1 QL 300/30 vicodin mg let 1 QL 360/30 vicodin es mg let 1 QL 0/30 vicodin hp mg let 1 QL 0/30 VIMOVO DR 375- MG TABLET 3 QL 60/30 VIMOVO DR 500- MG TABLET 3 QL 60/30 XARTEMIS XR MG TABLET 3 QL 1/30 +This drug does not count towards your total drug costs. For full description please see key symbol on page 6.

12 xylon 10-0 mg let 1 QL 0/30 ZAMICET 10-5 MG/ ML SOLN 2 QL 00ML/30 zebutal mg capsule 1 PA (HRM),QL 0/30 Anesthetics glydo 2% jelly syringe 1 lidocaine 2% viscous soln 1 lidocaine 5% ointment 1 QL 1GM/30 lidocaine 5% patch 1 QL 90/30 lidocaine hcl 0.5% vial 1 lidocaine hcl 1% vial 1 lidocaine hcl 1.5% ampul 1 lidocaine hcl 2% 40 mg/2 ml vl 1 lidocaine hcl 2% jelly 1 lidocaine hcl 2% vial 1 lidocaine hcl 4% ampul 1 lidocaine hcl 4% solution 1 lidocaine-prilocaine cream 1 SYNERA PATCH 3 BvsD Anti-Addiction/Substance Abuse Treatment Agents acamprosate calc dr 333 mg 1 buprenorphine 0.3 mg/ml syrn 1 QL 0ML/30 buprenorphine 2 mg let sl 1 QL 90/30 buprenorphine 8 mg let sl 1 QL 90/30 buprenorphin-naloxon 8-2 mg sl 1 PA,QL 90/30 buprenorphn-naloxn mg sl 1 PA,QL 90/30 buproban 0 mg let 1 QL 60/30 bupropion hcl xl 0 mg let 1 QL 90/30 CHANTIX 0.5 MG TABLET 2 QL 336/3 CHANTIX 1 MG CONT MONTH BOX 2 QL 336/3 CHANTIX 1 MG TABLET 2 QL 336/3 CHANTIX STARTING MONTH BOX 2 QL 106/3 Comprehensive Formulary 12 disulfiram 0 mg let 1 disulfiram 500 mg let 1 naloxone 0.4 mg/ml vial 1 naloxone 2 mg/2 ml syringe 1 naltrexone 50 mg let 1 NARCAN 4 MG NASAL SPRAY 2 QL 4/30 NICOTROL CARTRIDGE INHALER 2 QL 1008/90 NICOTROL NS 10 MG/ML SPRAY 2 QL 30ML/30 SUBOXONE 12 MG-3 MG SL FILM 3 PA,QL 90/30 SUBOXONE 2 MG-0.5 MG SL FILM 3 PA,QL 90/30 SUBOXONE 4 MG-1 MG SL FILM 3 PA,QL 90/30 SUBOXONE 8 MG-2 MG SL FILM 3 PA,QL 90/30 VIVITROL 380 MG VIAL + DILUENT 4 PA ZUBSOLV MG TABLET SL 2 PA,QL 90/30 ZUBSOLV MG TABLET SL 2 PA,QL 90/30 ZUBSOLV MG TABLET SL 2 PA,QL 90/30 ZUBSOLV MG TABLET SL 2 PA,QL 90/30 ZUBSOLV MG TABLET SL 2 PA,QL 90/30 Antibacterials ak-poly-bac eye ointment 1 ALCOHOL 70% PREP PADS 2 ALTABAX 1% OINTMENT 3 amikacin sulf 1 gram/4 ml vial 1 amikacin sulf 500 mg/2 ml vial 1 amox-clav 0-.5 mg chew 1 amox-clav 0-.5 mg/5 ml sus 1 amox-clav 0-1 mg let 1 amox-clav mg/5 ml sus 1 amox-clav mg chew 1 amox-clav mg/5 ml susp 1 amox-clav mg let 1 +This drug does not count towards your total drug costs. For full description please see key symbol on page 6.

13 Comprehensive Formulary amox-clav mg/5 ml sus 1 amox-clav mg let 1 amox-clav er 1, mg 1 amoxicillin 1 mg chew 1 amoxicillin 1 mg/5 ml susp 1 amoxicillin 0 mg/5 ml susp 1 amoxicillin 0 mg capsule 1 amoxicillin 0 mg chew 1 amoxicillin 0 mg/5 ml susp 1 amoxicillin 400 mg/5 ml susp 1 amoxicillin 500 mg capsule 1 amoxicillin 500 mg let 1 amoxicillin 875 mg let 1 amoxicillin/potassium clavulanate 1 ampicillin 1 gm a-v vial 1 ampicillin 1 gm vial 1 ampicillin 10 gm vial 1 ampicillin 1 mg vial 1 ampicillin 1 mg/5 ml susp 1 ampicillin 2 gm a-v vial 1 ampicillin 2 gm vial 1 ampicillin 0 mg capsule 1 ampicillin 0 mg vial 1 ampicillin 0 mg/5 ml susp 1 ampicillin 500 mg capsule 1 ampicillin 500 mg vial 1 ampicillin-sulbactam 1.5 gm vl 1 ampicillin-sulbactam gm vl 1 ampicillin-sulbactam 3 gm vial 1 AUGMENTIN MG/5 ML 3 AVC % CREAM 2 AVELOX IV 400 MG/0 ML 2 AZACTAM-ISO-OSMOT 1 GM/50 ML 3 AZACTAM-ISO-OSMOT 2 GM/50 ML 4 AZASITE 1% EYE DROPS 2 azithromycin 1 gm pwd packet 1 azithromycin 100 mg/5 ml susp 1 QL 0ML/30 azithromycin 0 mg/5 ml susp 1 QL 75ML/30 azithromycin 0 mg let 1 QL 12/ azithromycin 500 mg let 1 QL 12/ azithromycin 600 mg let 1 QL 60/30 azithromycin i.v. 500 mg vial 1 aztreonam 1 gm vial 1 aztreonam 2 gm vial 1 baciim 50,000 units vial 1 bacitracin 50,000 units vial 1 bacitracin 500 unit/gm ophth 1 bacitracin-polymyxin eye oint 1 BACTROBAN NASAL 2% OINTMENT 3 BESIVANCE 0.6% SUSP 3 BICILLIN C-R 1.2 MILLION UNIT 3 BICILLIN C-R SYRINGE 3 BICILLIN L-A 1,0,000 UNITS 3 BICILLIN L-A 2,400,000 UNITS 3 BICILLIN L-A 600,000 UNIT/ML 3 BLEPHAMIDE EYE DROPS 3 BLEPHAMIDE EYE OINTMENT 3 cefaclor 1 mg/5 ml susp 1 cefaclor 0 mg capsule 1 cefaclor 0 mg/5 ml susp 1 cefaclor 375 mg/5 ml suspen 1 cefaclor 500 mg capsule 1 cefaclor er 500 mg let 1 cefadroxil 1 gm let 1 cefadroxil 0 mg/5 ml susp 1 cefadroxil 500 mg capsule 1 cefadroxil 500 mg/5 ml susp 1 cefazolin 1 g/50 ml-dextrose 1 cefazolin 1 gm add-van vial 1 cefazolin 1 gm vial 1 cefazolin 10 gm vial 1 cefazolin 2 g/100 ml-dextrose 1 cefazolin 2 g/50 ml-dextrose 1 cefazolin gm bulk vial 1 cefazolin 500 mg vial 1 cefazolin sod 100 gm bulk bag 1 cefazolin sod 300 gm bulk bag 1 cefdinir 1 mg/5 ml susp 1 +This drug does not count towards your total drug costs. For full description please see key symbol on page 6.

14 Comprehensive Formulary Drug Tier cefdinir 0 mg/5 ml susp 1 cefdinir 300 mg capsule 1 cefditoren pivoxil 0 mg 1 cefepime 1 gm injection 1 cefepime 2 gm injection 1 cefepime hcl 1 gm vial 1 cefepime hcl 2 gram vial 1 cefepime-dextrose 1 gm/50 ml 1 cefepime-dextrose 2 gm/50 ml 1 cefixime 100 mg/5 ml susp 1 cefixime 0 mg/5 ml susp 1 cefotaxime sodium 1 gm vial 1 cefotaxime sodium 2 gm vial 1 cefotaxime sodium 500 mg vial 1 cefotetan 1 gm vial 1 cefotetan 10 gm vial 1 cefotetan 2 gm vial 1 cefotetan-dextr 1 g duplex bag 1 cefotetan-dextr 2 g duplex bag 1 cefoxitin 1 gm piggyback bag 1 cefoxitin 1 gm vial 1 cefoxitin 10 gm vial 1 cefoxitin 2 gm piggyback bag 1 cefoxitin 2 gm vial 1 cefpodoxime 100 mg let 1 cefpodoxime 100 mg/5 ml susp 1 cefpodoxime 0 mg let 1 cefpodoxime 50 mg/5 ml susp 1 cefprozil 1 mg/5 ml susp 1 cefprozil 0 mg let 1 cefprozil 0 mg/5 ml susp 1 cefprozil 500 mg let 1 ceftazidime 1 gm piggyback 1 ceftazidime 1 gm vial 1 ceftazidime 2 gm piggyback 1 ceftazidime 2 gm vial 1 ceftazidime 6 gm vial 1 ceftibuten 0 mg/5 ml susp 1 ceftibuten 400 mg capsule 1 CEFTIN 1 MG/5 ML ORAL SUSP 3 Requirements/ Limits CEFTIN 0 MG/5 ML ORAL SUSP 3 ceftriaxone 1 gm piggyback 1 ceftriaxone 1 gm vial 1 ceftriaxone 1 gm-d5w bag 1 ceftriaxone 10 gm vial 1 ceftriaxone 2 gm add vial 1 ceftriaxone 2 gm piggyback 1 ceftriaxone 2 gm vial 1 ceftriaxone 2 gm-d5w bag 1 ceftriaxone 0 mg vial 1 ceftriaxone 500 mg vial 1 cefuroxime 750 mg/50 ml bag 1 cefuroxime axetil 0 mg 1 cefuroxime axetil 500 mg 1 cefuroxime sod 1.5 gm vial 1 cefuroxime sod 7.5 gm vial 1 cefuroxime sod 75 gm bulk bag 1 cefuroxime sod 750 mg vial 1 cephalexin 1 mg/5 ml susp 1 cephalexin 0 mg capsule 1 cephalexin 0 mg let 1 cephalexin 0 mg/5 ml susp 1 cephalexin 500 mg capsule 1 cephalexin 500 mg let 1 cephalexin 750 mg capsule 1 chloramphen na succ 1 gm vl 1 CILOXAN 0.3% OINTMENT 2 CIPRO HC OTIC SUSPENSION 2 CIPRODEX OTIC SUSPENSION 2 ciprofloxacin 0.3% eye drop 1 ciprofloxacin 0 mg/ ml vl 1 ciprofloxacin 0 mg/5 ml susp 1 ciprofloxacin 400 mg/40 ml vl 1 ciprofloxacin 500 mg/5 ml susp 1 ciprofloxacin er 1,000 mg 1 QL / ciprofloxacin er 500 mg let 1 QL 3/3 ciprofloxacin hcl 100 mg 1 ciprofloxacin hcl 0 mg 1 ciprofloxacin hcl 500 mg 1 ciprofloxacin hcl 750 mg 1 +This drug does not count towards your total drug costs. For full description please see key symbol on page 6.

15 Comprehensive Formulary ciprofloxacn-d5w 0 mg/100 ml 1 ciprofloxacn-d5w 400 mg/0 ml 1 CLAFORAN 1 GM ADD-VANTAGE VL 3 CLAFORAN 10 GM VIAL 3 CLAFORAN 2 GM ADD-VANTAGE VL 3 clarithromycin 1 mg/5 ml sus 1 clarithromycin 0 mg let 1 QL 42/ clarithromycin 0 mg/5 ml sus 1 clarithromycin 500 mg let 1 QL 42/ clarithromycin er 500 mg 1 QL 60/30 CLEOCIN 100 MG VAGINAL OVULE 3 clindacin etz 1% pledget 1 clindacin p 1% pledgets 1 clindamax 1% gel 1 clindamycin 0 mg/ml addvan 1 clindamycin 2% vaginal cream 1 clindamycin 300 mg/2 ml addvan 1 clindamycin 600 mg/4 ml addvan 1 clindamycin 900 mg/6 ml addvan 1 clindamycin hcl 0 mg capsule 1 clindamycin hcl 300 mg capsule 1 clindamycin hcl 75 mg capsule 1 clindamycin pediatr 75 mg/5 ml 1 clindamycin ph 1% gel 1 clindamycin ph 1% solution 1 clindamycin ph 300 mg/2 ml vl 1 clindamycin ph 9 g/60 ml vial 1 clindamycin ph 900 mg/6 ml vl 1 clindamycin phos 1% pledget 1 clindamycin phosp 1% lotion 1 clindamycin phosphate 1% foam 1 clindamycin-d5w 300 mg/50 ml 1 clindamycin-d5w 600 mg/50 ml 1 clindamycin-d5w 900 mg/50 ml 1 CLINDESSE 2% VAGINAL CREAM 3 colistimethate 0 mg vial 1 CORTISPORIN CREAM 2 CORTISPORIN OINTMENT 2 CUBICIN 500 MG VIAL 4 BvsD demeclocycline 0 mg let 1 demeclocycline 300 mg let 1 dicloxacillin 0 mg capsule 1 dicloxacillin 500 mg capsule 1 DIFICID 0 MG TABLET 2 PA,QL /30 DORIBAX 0 MG VIAL 3 DORIBAX 500 MG VIAL 3 doxy 100 vial 1 doxycycline mg/5 ml susp 1 doxycycline hyc 100 mg vial 1 doxycycline hyc dr 100 mg 1 doxycycline hyc dr 0 mg 1 doxycycline hyc dr 75 mg 1 doxycycline hyclate 100 mg cap 1 doxycycline hyclate 100 mg 1 doxycycline hyclate mg 1 doxycycline hyclate 50 mg cap 1 doxycycline mono 100 mg cap 1 QL 60/30 doxycycline mono 100 mg let 1 doxycycline mono 0 mg cap 1 doxycycline mono 0 mg let 1 doxycycline mono 50 mg cap 1 QL 60/30 doxycycline mono 50 mg let 1 doxycycline mono 75 mg capsule 1 QL 60/30 doxycycline mono 75 mg let 1 E.E.S. 0 MG/5 ML GRANULES 2 e.e.s. 400 film 1 ery 2% pads 1 ERYPED 0 MG/5 ML SUSPENSION 2 ERYPED 400 MG/5 ML SUSPENSION 2 ERY-TAB EC 0 MG TABLET 2 ERY-TAB EC 333 MG TABLET 2 ERY-TAB EC 500 MG TABLET 2 erythrocin 0 mg film 1 ERYTHROCIN 500 MG ADDVNT VL 2 erythromycin 0.5% eye ointment 1 erythromycin 2% gel 1 erythromycin 2% pledgets 1 erythromycin 2% solution 1 erythromycin 0 mg film 1 +This drug does not count towards your total drug costs. For full description please see key symbol on page 6.

16 Comprehensive Formulary erythromycin 500 mg film 1 erythromycin ec 0 mg cap 1 erythromycin es 400 mg 1 FEM PH VAGINAL JELLY 2 FLAGYL ER 750 MG TABLET 3 FORTAZ 500 MG VIAL 3 FORTAZ-ISO-OSMOT 2 GM/50 ML 3 FORTAZ-ISO-OSMOTIC 1 GM/50 ML 3 garamycin 0.3% eye drops 1 gatifloxacin 0.5% eye drops 1 gentak 0.3 % eye ointment 1 gentamicin 0.1% cream 1 gentamicin 0.1% ointment 1 gentamicin 0.3% eye drops 1 gentamicin 0.3% eye ointment 1 gentamicin 10 mg/ml vial 1 gentamicin mg/2 ml vial 1 gentamicin 70 mg/ns 50 ml pb 1 gentamicin 80 mg/2 ml vial 1 gentamicin 80 mg/ns 100 ml pb 1 gentamicin 90 mg/ns 100 ml pb 1 gentamicin ped mg/2 ml vial 1 ilotycin 0.5% eye ointment 1 imipenem-cilastatin 0 mg vl 1 imipenem-cilastatin 500 mg vl 1 INVANZ 1 GM ADD-VANTAGE VIAL 3 INVANZ 1 GM VIAL 3 iso gentamicin 100 mg/100 ml 1 isoton gentamicin 100 mg/50 ml 1 isoton gentamicin 60 mg/50 ml 1 isoton gentamicin 80 mg/100 ml 1 isoton gentamicin 80 mg/50 ml 1 KETEK 300 MG TABLET 3 QL /30 KETEK 400 MG TABLET 3 QL /30 levofloxacin 0.5% eye drops 1 levofloxacin mg/ml solution 1 levofloxacin 0 mg let 1 QL 30/30 levofloxacin 0 mg/50 ml-d5w 1 levofloxacin 500 mg let 1 QL 30/30 levofloxacin 500 mg/100 ml-d5w 1 levofloxacin 500 mg/ ml vial 1 levofloxacin 750 mg let 1 QL 30/30 levofloxacin 750 mg/0 ml-d5w 1 lincomycin hcl 600 mg/2 ml vl 1 linezolid 100 mg/5 ml susp 4 QL 00ML/30 linezolid 600 mg let 4 QL 60/30 linezolid 600 mg/300 ml iv sol 1 mafenide acetate 50 gm powd pk 1 meropenem iv 1 gm vial 1 meropenem iv 500 mg vial 1 meropenem-0.9% nacl 1 gram/50 1 meropenem-0.9% nacl 500 mg/50 1 methenamine hipp 1 gm let 1 methenamine md 1 gm let 1 methenamine md 500 mg let 1 METRO IV 500 MG/100 ML 3 metronidazole 0.75% cream 1 metronidazole 0.75% lotion 1 metronidazole 0 mg let 1 metronidazole 375 mg capsule 1 metronidazole 500 mg let 1 metronidazole 500 mg/100 ml 1 metronidazole topical 0.75% gl 1 metronidazole topical 1% gel 1 metronidazole vaginal 0.75% gl 1 minocycline 100 mg capsule 1 minocycline 50 mg capsule 1 minocycline 75 mg capsule 1 minocycline hcl 100 mg let 1 minocycline hcl 50 mg let 1 minocycline hcl 75 mg let 1 mondoxyne nl 100 mg capsule 1 QL 60/30 mondoxyne nl 50 mg capsule 1 QL 60/30 mondoxyne nl 75 mg capsule 1 QL 60/30 MONUROL 3 GM SACHET 3 morgidox 100 mg capsule 1 MOXEZA 0.5% EYE DROPS 2 moxifloxacin 400 mg/0 ml bag 1 moxifloxacin hcl 400 mg let 1 QL 30/30 +This drug does not count towards your total drug costs. For full description please see key symbol on page 6.

17 Comprehensive Formulary mupirocin 2% cream 1 mupirocin 2% ointment 1 nafcillin 1 gm add-van vial 1 nafcillin 1 gm vial 1 NAFCILLIN 1 GM/ 50 ML INJ 2 nafcillin 10 gm vial 1 nafcillin 2 gm add-vant vial 1 nafcillin 2 gm vial 1 NAFCILLIN 2 GM/ 100 ML INJ 2 neo-bacit-poly-hc eye ointment 1 neomyc-bacit-polymix eye oint 1 neomycin 500 mg let 1 neomycin-poly-hc eye drops 1 neomyc-polym-gramicid eye drop 1 neomy-polymyxin b 40 mg/ml amp 1 neo-polycin eye ointment 1 neo-polycin hc eye ointment 1 nitrofurantoin mg/5 ml susp 1 QL 00ML/36 5 nitrofurantoin mcr 100 mg cap 1 QL > 90/3 nitrofurantoin mcr mg cap 1 QL > 0/3 nitrofurantoin mcr 50 mg cap 1 QL > 0/3 nitrofurantoin mono-mcr 100 mg 1 QL > 90/3 NORITATE 1% CREAM 4 NOROXIN 3 ofloxacin 0.3% ear drops 1 ofloxacin 0.3% eye drops 1 ofloxacin 400 mg let 1 oxacillin 1 gm add-vantage vl 1 oxacillin 1 gm/ 50 ml inj 1 oxacillin 10 gm vial 1 oxacillin 2 gm add-vantage vl 1 oxacillin 2 gm/ 50 ml inj 1 paromomycin 0 mg capsule 1 PCE 333 MG TABLET 2 PCE 500 MG TABLET 2 Drug Tier pen g 1.2 million unit/2 ml 1 pen g k 1 million unit/50 ml 1 pen g k 2 million unit/50 ml 1 pen g k 3 million unit/50 ml 1 penicillin g k 5 million unit 1 penicillin g na 5 million unit 1 penicillin gk million unit 1 penicillin vk 1 mg/5 ml soln 1 penicillin vk 0 mg let 1 penicillin vk 0 mg/5 ml soln 1 penicillin vk 500 mg let 1 pfizerpen million unit vial 1 pfizerpen 5 million units vial 1 piperacil-tazobact 2. gm vl 1 piperacil-tazobact gm vl 1 piperacil-tazobact 4.5 gm vial 1 piperacil-tazobact 40.5 gram 1 polycin eye ointment 1 polymyxin b sulfate vial 1 polymyxin b-tmp eye drops 1 PRIMSOL 50 MG/5 ML ORAL SOLN 3 rosadan 0.75% cream 1 rosadan 0.75% gel 1 SILVER NITRATE 0.5% SOLN 2 SILVER NITRATE 10% SOLUTION 2 SILVER NITRATE % SOLUTION 2 SILVER NITRATE 50% SOLUTION 2 silver sulfadiazine 1% cream 1 SPECTRACEF 400 MG DOSE PACK TB 3 SSD 1% CREAM 2 streptomycin sulf 1 gm vial 1 sulfacetamide 10% eye drops 1 sulfacetamide 10% eye ointment 1 sulfacetamide sod 10% top susp 1 sulfadiazine 500 mg let 1 sulfamethoxazole-tmp ds let 1 sulfamethoxazole-tmp inj vial 1 sulfamethoxazole-tmp ss let 1 sulfamethoxazole-tmp susp 1 SULFAMYLON 8.5% CREAM 3 Requirements/ Limits +This drug does not count towards your total drug costs. For full description please see key symbol on page 6.

18 sulfatrim pediatric suspension 1 sulf-pred 10-0.% eye drops 1 SUPRAX 100 MG TABLET CHEWABLE 3 SUPRAX 0 MG TABLET CHEWABLE 3 SUPRAX 400 MG CAPSULE 3 SUPRAX 500 MG/5 ML SUSPENSION 3 SYNERCID 500 MG VIAL 4 tazicef 1 gm add-vantage vial 1 tazicef 1 gm/50 ml bag 1 tazicef 1 gram vial 1 tazicef 2 gm add-vantage 1 tazicef 2 gram vial 1 tazicef 6 gram vial 1 TEFLARO 400 MG VIAL 3 TEFLARO 600 MG VIAL 3 tetracycline 0 mg capsule 1 tetracycline 500 mg capsule 1 tobramycin 0.3% eye drops 1 tobramycin 1.2 gm vial 1 tobramycin 1.2 gram/30 ml vial 1 tobramycin 10 mg/ml vial 1 tobramycin 80 mg/100 ml ns 1 tobramycin 80 mg/2 ml vial 1 TOBREX 0.3% EYE OINTMENT 2 trimethoprim 100 mg let 1 TYGACIL 50 MG VIAL 3 UNASYN GM VIAL 2 UNASYN 3 GM VIAL 2 vanco 500 mg/100 ml-0.9% nacl 1 vanco 750 mg/0 ml-0.9% nacl 1 vancomycin 1 g/0ml-0.9% nacl 1 vancomycin 1 gm vial 1 vancomycin 500 mg a-v vial 1 vancomycin 750 mg/0 ml bag 1 vancomycin hcl 10 gm vial 1 vancomycin hcl 1 mg capsule 4 QL 40/10 vancomycin hcl 1g/0 ml bag 1 vancomycin hcl 0 mg capsule 4 QL 80/10 vancomycin hcl 5 gm vial 1 vancomycin hcl 750 mg vial 1 Comprehensive Formulary vancomycin-d5w 500 mg/100 ml 1 VANDAZOLE VAGINAL 0.75% GEL 3 VIGAMOX 0.5% EYE DROPS 2 XIFAXAN 0 MG TABLET 3 PA,QL 9/30 XIFAXAN 0 MG TABLET 4 PA,QL 60/30 ZINACEF 1.5 GRAM/50 ML 2 ZMAX 2 G/60 ML ORAL SUSPENSION 3 QL 60ML/30 ZOSYN 2. GM/50 ML GALAXY BAG 2 ZOSYN GM/50 ML GALAXY 2 ZOSYN 4.5 GM/100 ML GALAXY BAG 2 ZYLET EYE DROPS 3 Anticonvulsants APTIOM 0 MG TABLET 3 QL 30/30 APTIOM 400 MG TABLET 3 QL 30/30 APTIOM 600 MG TABLET 3 QL 60/30 APTIOM 800 MG TABLET 3 QL 30/30 BANZEL 0 MG TABLET 3 QL 60/30 BANZEL 40 MG/ML SUSPENSION 3 QL 2400ML/30 BANZEL 400 MG TABLET 4 QL 240/30 BRIVIACT 10 MG TABLET 4 QL 60/30 BRIVIACT 10 MG/ML ORAL SOLN 4 QL 10ML/30 BRIVIACT 100 MG TABLET 4 QL 1/30 BRIVIACT MG TABLET 4 QL 60/30 BRIVIACT 50 MG TABLET 4 QL 60/30 BRIVIACT 50 MG/5 ML VIAL 4 QL 600ML/30 BRIVIACT 75 MG TABLET 4 QL 60/30 carbamazepine 100 mg chew 1 carbamazepine 100 mg/5 ml susp 1 carbamazepine 0 mg let 1 carbamazepine er 100 mg cap 1 carbamazepine er 100 mg let 1 carbamazepine er 0 mg cap 1 carbamazepine er 0 mg let 1 carbamazepine er 300 mg cap 1 carbamazepine er 400 mg let 1 CELONTIN 300 MG KAPSEAL 3 +This drug does not count towards your total drug costs. For full description please see key symbol on page 6.

19 Comprehensive Formulary clonazepam 0.1 mg dis 1 QL 0/30 clonazepam 0. mg odt 1 QL 0/30 clonazepam 0.5 mg dis let 1 QL 0/30 clonazepam 0.5 mg let 1 QL 0/30 clonazepam 1 mg dis let 1 QL 0/30 clonazepam 1 mg let 1 QL 0/30 clonazepam 2 mg odt 1 QL 300/30 clonazepam 2 mg let 1 QL 300/30 diazepam 10 mg rectal gel syst 1 QL /30 diazepam 2.5 mg rectal gel sys 1 QL 5/30 diazepam mg rectal gel syst 1 QL 40/30 DILANTIN 100 MG CAPSULE 3 DILANTIN 30 MG CAPSULE 3 DILANTIN 50 MG INFATAB 3 divalproex sod dr 1 mg 1 divalproex sod dr 0 mg 1 divalproex sod dr 500 mg 1 divalproex sod er 0 mg 1 divalproex sod er 500 mg 1 divalproex sodium 1 mg cap 1 epitol 0 mg let 1 EQUETRO 100 MG CAPSULE 3 EQUETRO 0 MG CAPSULE 3 EQUETRO 300 MG CAPSULE 3 ethosuximide 0 mg capsule 1 ethosuximide 0 mg/5 ml soln 1 felbamate 400 mg let 1 felbamate 600 mg let 1 felbamate 600 mg/5 ml susp 1 fosphenytoin 100 mg pe/2 ml vl 1 fosphenytoin 500 mg pe/10 ml 1 FYCOMPA 0.5 MG/ML ORAL SUSP 3 QL 0ML/30 FYCOMPA 10 MG TABLET 3 QL 30/30 FYCOMPA 12 MG TABLET 3 QL 30/30 FYCOMPA 2 MG TABLET 3 QL 30/30 FYCOMPA 4 MG TABLET 3 QL 30/30 FYCOMPA 6 MG TABLET 3 QL 30/30 FYCOMPA 8 MG TABLET 3 QL 30/30 gabapentin 100 mg capsule 1 QL 0/30 gabapentin 0 mg/5 ml soln 1 QL ML/30 gabapentin 300 mg capsule 1 QL 0/30 gabapentin 400 mg capsule 1 QL 0/30 gabapentin 600 mg let 1 QL 0/30 gabapentin 800 mg let 1 QL 90/30 GABITRIL 12 MG TABLET 3 QL 1/30 GABITRIL MG TABLET 3 QL 90/30 LAMICTAL TAB START KIT (BLUE) 2 LAMICTAL TAB START KIT (GREEN) 2 LAMICTAL TB START KIT (ORANGE) 2 lamotrigine 100 mg let 1 lamotrigine 0 mg let 1 lamotrigine 0 mg let 1 lamotrigine mg disper 1 lamotrigine mg let 1 lamotrigine 5 mg disper let 1 lamotrigine er 100 mg let 1 lamotrigine er 0 mg let 1 lamotrigine er mg let 1 lamotrigine er 0 mg let 1 lamotrigine er 300 mg let 1 lamotrigine er 50 mg let 1 lamotrigine odt 100 mg let 1 lamotrigine odt 0 mg let 1 lamotrigine odt mg let 1 lamotrigine odt 50 mg let 1 lamotrigine odt kit (blue) 1 lamotrigine odt kit (green) 1 lamotrigine odt kit (orange) 1 levetiracetam 1,000 mg let 1 levetiracetam 100 mg/ml soln 1 levetiracetam 0 mg let 1 levetiracetam 500 mg let 1 levetiracetam 500 mg/5 ml vial 1 levetiracetam 750 mg let 1 levetiracetam er 500 mg let 1 QL 0/30 levetiracetam er 750 mg let 1 QL 1/30 levetiracetam-nacl 1,000mg/100 1 levetiracetam-nacl 1,500mg/ This drug does not count towards your total drug costs. For full description please see key symbol on page 6.

20 Comprehensive Formulary levetiracetam-nacl 500 mg/100 1 LYRICA 100 MG CAPSULE 2 QL 90/30 LYRICA 0 MG CAPSULE 2 QL 90/30 LYRICA MG/ML ORAL SOLUTION 2 QL 900ML/30 LYRICA 0 MG CAPSULE 2 QL 60/30 LYRICA 5 MG CAPSULE 2 QL 60/30 LYRICA MG CAPSULE 2 QL 90/30 LYRICA 300 MG CAPSULE 2 QL 60/30 LYRICA 50 MG CAPSULE 2 QL 90/30 LYRICA 75 MG CAPSULE 2 QL 90/30 magnesium sulf 1 g/100 ml-d5w 1 BvsD magnesium-d5w 1 gm/100 ml soln 1 BvsD ONFI 10 MG TABLET 2 QL 30/30 ONFI 2.5 MG/ML SUSPENSION 2 QL 0ML/30 ONFI MG TABLET 2 QL 60/30 oxcarbazepine 0 mg let 1 oxcarbazepine 300 mg let 1 oxcarbazepine 300 mg/5 ml susp 1 oxcarbazepine 600 mg let 1 OXTELLAR XR 0 MG TABLET 3 OXTELLAR XR 300 MG TABLET 3 OXTELLAR XR 600 MG TABLET 3 PEGANONE 0 MG TABLET 3 phenobarbital 100 mg let 1 QL 90/30 phenobarbital mg let 1 QL 90/30 phenobarbital.2 mg let 1 QL 90/30 phenobarbital mg/5 ml elix 1 QL 00ML/30 phenobarbital 30 mg let 1 QL 90/30 phenobarbital.4 mg let 1 QL 90/30 phenobarbital 60 mg let 1 QL 90/30 phenobarbital 64.8 mg let 1 QL 90/30 phenobarbital 97.2 mg let 1 QL 90/30 PHENYTEK 0 MG CAPSULE 3 PHENYTEK 300 MG CAPSULE 3 phenytoin 1 mg/5 ml susp 1 phenytoin 50 mg infa 1 phenytoin 50 mg let chew 1 phenytoin 50 mg/ml vial 1 phenytoin sod ext 100 mg cap 1 phenytoin sod ext 0 mg cap 1 phenytoin sod ext 300 mg cap 1 POTIGA 0 MG TABLET 3 QL 90/30 POTIGA 300 MG TABLET 3 QL 90/30 POTIGA 400 MG TABLET 3 QL 90/30 POTIGA 50 MG TABLET 3 QL 90/30 primidone 0 mg let 1 primidone 50 mg let 1 roweepra 500 mg let 1 SABRIL 500 MG POWDER PACKET 4 QL 0/30 SABRIL 500 MG TABLET 4 QL 0/30 SPRITAM 1,000 MG TABLET 3 QL 60/30 SPRITAM 0 MG TABLET 3 QL 60/30 SPRITAM 500 MG TABLET 3 QL 60/30 SPRITAM 750 MG TABLET 3 QL 1/30 tiagabine hcl 2 mg let 1 QL 240/30 tiagabine hcl 4 mg let 1 topiramate 100 mg let 1 QL 90/30 topiramate mg sprinkle cap 1 topiramate 0 mg let 1 QL 60/30 topiramate mg sprinkle cap 1 topiramate mg let 1 QL 90/30 topiramate 50 mg let 1 QL 90/30 valproate sod 500 mg/5 ml vl 1 valproic acid 0 mg capsule 1 valproic acid 0 mg/5 ml soln 1 VIMPAT 10 MG/ML SOLUTION 2 QL 10ML/30 VIMPAT 100 MG TABLET 2 QL 60/30 VIMPAT 0 MG TABLET 2 QL 60/30 VIMPAT 0 MG TABLET 2 QL 60/30 VIMPAT 0 MG/ ML VIAL 2 QL 10ML/30 VIMPAT 50 MG TABLET 2 QL 60/30 zonisamide 100 mg capsule 1 zonisamide mg capsule 1 zonisamide 50 mg capsule 1 +This drug does not count towards your total drug costs. For full description please see key symbol on page 6.

21 Comprehensive Formulary Antidementia Agents donepezil hcl 10 mg let 1 QL 60/30 donepezil hcl 23 mg let 1 QL 30/30 donepezil hcl 5 mg let 1 QL 30/30 donepezil hcl odt 10 mg let 1 QL 60/30 donepezil hcl odt 5 mg let 1 QL 30/30 ergoloid mesylates 1 mg 1 PA (HRM) galantamine 4 mg/ml oral soln 1 QL 0ML/30 galantamine er mg capsule 1 QL 30/30 galantamine er 24 mg capsule 1 QL 30/30 galantamine er 8 mg capsule 1 QL 30/30 galantamine hbr 12 mg let 1 QL 60/30 galantamine hbr 4 mg let 1 QL 60/30 galantamine hbr 8 mg let 1 QL 60/30 memantine 5-10 mg titration pk 1 PA if younger than,ql / memantine hcl 10 mg let 1 PA if younger than,ql 60/30 memantine hcl 2 mg/ml solution 1 PA if younger than,ql 300ML/30 memantine hcl 5 mg let 1 PA if younger than,ql 90/30 NAMENDA XR MG CAPSULE 2 PA if younger than,ql 30/30 NAMENDA XR 21 MG CAPSULE 2 PA if younger than,ql 30/30 NAMENDA XR MG CAPSULE 2 PA if younger than,ql 30/30 NAMENDA XR 7 MG CAPSULE 2 PA if younger than,ql 30/30 NAMENDA XR TITRATION PACK 2 PA if younger than,ql /3 NAMZARIC MG-10 MG CAPSULE 2 QL 30/30 NAMZARIC MG-10 MG CAPSULE 2 QL 30/30 rivastigmine 1.5 mg capsule 1 QL 60/30 rivastigmine.3 mg/24hr ptch 1 QL 30/30 rivastigmine 3 mg capsule 1 QL 60/30 rivastigmine 4.5 mg capsule 1 QL 60/30 rivastigmine 4.6 mg/24hr patch 1 QL 30/30 rivastigmine 6 mg capsule 1 QL 60/30 rivastigmine 9.5 mg/24hr patch 1 QL 30/30 Antidepressants amitriptyline hcl 10 mg 1 PA (HRM) amitriptyline hcl 100 mg 1 PA (HRM) amitriptyline hcl 0 mg 1 PA (HRM) amitriptyline hcl mg 1 PA (HRM) amitriptyline hcl 50 mg 1 PA (HRM) amitriptyline hcl 75 mg 1 PA (HRM) amoxapine 100 mg let 1 amoxapine 0 mg let 1 amoxapine mg let 1 amoxapine 50 mg let 1 APLENZIN ER 4 MG TABLET 3 QL 30/30 APLENZIN ER 3 MG TABLET 3 QL 30/30 APLENZIN ER 5 MG TABLET 3 QL 30/30 bupropion hcl 100 mg let 1 QL 1/30 bupropion hcl 75 mg let 1 QL 60/30 bupropion hcl sr 100 mg let 1 QL 60/30 bupropion hcl sr 0 mg 1 QL 60/30 bupropion hcl sr 0 mg let 1 QL 60/30 bupropion hcl sr 0 mg 1 QL 60/30 bupropion hcl xl 300 mg let 1 QL 30/30 chlordiazepo-amitriptyl PA (HRM) chlordiazepox-amitriptyl 10-1 PA (HRM) citalopram hbr 10 mg let 1 QL 30/30 +This drug does not count towards your total drug costs. For full description please see key symbol on page 6. 21

22 Comprehensive Formulary citalopram hbr 10 mg/5 ml soln 1 QL 600ML/30 citalopram hbr mg let 1 QL 30/30 citalopram hbr 40 mg let 1 QL 30/30 clomipramine mg capsule 1 PA (HRM) clomipramine 50 mg capsule 1 PA (HRM) clomipramine 75 mg capsule 1 PA (HRM) desipramine 10 mg let 1 desipramine 100 mg let 1 desipramine 0 mg let 1 desipramine mg let 1 desipramine 50 mg let 1 desipramine 75 mg let 1 doxepin 10 mg capsule 1 PA (HRM) doxepin 10 mg/ml oral conc 1 PA (HRM) doxepin 100 mg capsule 1 PA (HRM) doxepin 0 mg capsule 1 PA (HRM) doxepin mg capsule 1 PA (HRM) doxepin 50 mg capsule 1 PA (HRM) doxepin 75 mg capsule 1 PA (HRM) duloxetine hcl dr mg cap 1 QL 60/30 duloxetine hcl dr 30 mg cap 1 QL 30/30 duloxetine hcl dr 60 mg cap 1 QL 60/30 EMSAM 12 MG/24 HOURS PATCH 4 QL 30/30 EMSAM 6 MG/24 HOURS PATCH 4 QL 30/30 EMSAM 9 MG/24 HOURS PATCH 4 QL 30/30 escitalopram 10 mg let 1 QL 30/30 escitalopram mg let 1 QL 30/30 escitalopram 5 mg let 1 QL 30/30 escitalopram oxalate 5 mg/5 ml 1 QL 600ML/30 FETZIMA -40 MG TITRATION PAK 3 QL /3 FETZIMA ER 1 MG CAPSULE 3 QL 30/30 FETZIMA ER MG CAPSULE 3 QL 30/30 FETZIMA ER 40 MG CAPSULE 3 QL 30/30 FETZIMA ER 80 MG CAPSULE 3 QL 30/30 fluoxetine mg/5 ml solution 1 QL 600ML/30 fluoxetine dr 90 mg capsule 1 QL 4/ fluoxetine hcl 10 mg capsule 1 QL 30/30 fluoxetine hcl 10 mg let 1 QL 30/30 fluoxetine hcl mg capsule 1 QL 1/30 fluoxetine hcl mg let 1 QL 1/30 fluoxetine hcl 40 mg capsule 1 QL 60/30 fluoxetine hcl 60 mg let 1 fluvoxamine er 100 mg capsule 1 QL 90/30 fluvoxamine er 0 mg capsule 1 QL 60/30 fluvoxamine maleate 100 mg 1 QL 90/30 fluvoxamine maleate mg 1 QL 30/30 fluvoxamine maleate 50 mg 1 QL 30/30 imipramine hcl 10 mg let 1 PA (HRM) imipramine hcl mg let 1 PA (HRM) imipramine hcl 50 mg let 1 PA (HRM) imipramine pamoate 100 mg cap 1 PA (HRM) imipramine pamoate 1 mg cap 1 PA (HRM) imipramine pamoate 0 mg cap 1 PA (HRM) imipramine pamoate 75 mg cap 1 PA (HRM) maprotiline mg let 1 QL 90/30 maprotiline 50 mg let 1 QL 90/30 maprotiline 75 mg let 1 QL 90/30 MARPLAN 10 MG TABLET 3 QL 0/30 mirtazapine mg odt 1 QL 30/30 mirtazapine mg let 1 QL 30/30 mirtazapine 30 mg odt 1 QL 30/30 mirtazapine 30 mg let 1 QL 30/30 mirtazapine mg odt 1 QL 30/30 mirtazapine mg let 1 QL 30/30 mirtazapine 7.5 mg let 1 QL 30/30 nefazodone hcl 100 mg let 1 QL 60/30 nefazodone hcl 0 mg let 1 QL 60/30 nefazodone hcl 0 mg let 1 QL 60/30 nefazodone hcl 0 mg let 1 QL 60/30 nefazodone hcl 50 mg let 1 QL 60/30 nortriptyline 10 mg/5 ml sol 1 nortriptyline hcl 10 mg cap 1 nortriptyline hcl mg cap 1 nortriptyline hcl 50 mg cap 1 nortriptyline hcl 75 mg cap 1 olanzapine-fluoxetine 12- mg 1 QL 30/30 olanzapine-fluoxetine mg 1 QL 30/30 +This drug does not count towards your total drug costs. For full description please see key symbol on page 6.

23 Comprehensive Formulary olanzapine-fluoxetine 3- mg 1 QL 30/30 olanzapine-fluoxetine 6- mg 1 QL 30/30 olanzapine-fluoxetine 6-50 mg 1 QL 30/30 paroxetine cr 12.5 mg let 1 QL 30/30 paroxetine cr mg let 1 QL 90/30 paroxetine er 37.5 mg let 1 QL 60/30 paroxetine hcl 10 mg let 1 QL 30/30 paroxetine hcl mg let 1 QL 30/30 paroxetine hcl 30 mg let 1 QL 60/30 paroxetine hcl 40 mg let 1 QL 30/30 PAXIL 10 MG/5 ML SUSPENSION 3 QL 900ML/30 perphen-amitrip 2 mg-10 mg 1 PA (HRM) perphen-amitrip 2 mg- mg 1 PA (HRM) perphen-amitrip 4 mg-10 mg 1 PA (HRM) perphen-amitrip 4 mg- mg 1 PA (HRM) perphen-amitrip 4 mg-50 mg 1 PA (HRM) phenelzine sulfate mg 1 PRISTIQ ER 100 MG TABLET 2 QL 30/30 PRISTIQ ER MG TABLET 2 QL 30/30 PRISTIQ ER 50 MG TABLET 2 QL 30/30 protriptyline hcl 10 mg let 1 protriptyline hcl 5 mg let 1 sertraline mg/ml oral conc 1 QL 300ML/30 sertraline hcl 100 mg let 1 QL 60/30 sertraline hcl mg let 1 QL 30/30 sertraline hcl 50 mg let 1 QL 30/30 tranylcypromine sulf 10 mg 1 trazodone 100 mg let 1 trazodone 0 mg let 1 trazodone 300 mg let 1 trazodone 50 mg let 1 trimipramine maleate 100 mg cp 1 PA (HRM) trimipramine maleate mg cap 1 PA (HRM) trimipramine maleate 50 mg cap 1 PA (HRM) TRINTELLIX 10 MG TABLET 3 QL 30/30 TRINTELLIX MG TABLET 3 QL 30/30 TRINTELLIX 5 MG TABLET 3 QL 30/30 venlafaxine hcl 100 mg let 1 QL 90/30 venlafaxine hcl mg let 1 QL 90/30 venlafaxine hcl 37.5 mg let 1 QL 90/30 venlafaxine hcl 50 mg let 1 QL 90/30 venlafaxine hcl 75 mg let 1 QL 90/30 venlafaxine hcl er 0 mg cap 1 QL 30/30 venlafaxine hcl er 0 mg 1 QL 30/30 venlafaxine hcl er 5 mg 1 QL 30/30 venlafaxine hcl er 37.5 mg cap 1 QL 30/30 venlafaxine hcl er 37.5 mg 1 QL 30/30 venlafaxine hcl er 75 mg cap 1 QL 30/30 venlafaxine hcl er 75 mg 1 QL 30/30 VIIBRYD 10 MG TABLET 2 QL 30/30 VIIBRYD 10- MG STARTER PACK 3 QL 30/30 VIIBRYD MG STARTER PK 2 QL 30/30 VIIBRYD MG TABLET 2 QL 30/30 VIIBRYD 40 MG TABLET 2 QL 30/30 Antiemetics ALOXI 0. MG/5 ML VIAL 3 BvsD ANZEMET 100 MG TABLET 3 QL 5/30,BvsD ANZEMET MG/ML VIAL 3 PA ANZEMET 50 MG TABLET 3 QL 5/30,BvsD CESAMET 1 MG CAPSULE 3 BvsD dimenhydrinate 50 mg/ml vial 1 dronabinol 10 mg capsule 1 QL 60/30,BvsD dronabinol 2.5 mg capsule 1 QL 60/30,BvsD dronabinol 5 mg capsule 1 QL 60/30,BvsD droperidol 2.5 mg/ml ampul 1 EMEND 1 MG CAPSULE 2 QL 2/,BvsD EMEND 0 MG VIAL 2 BvsD EMEND 40 MG CAPSULE 2 QL 1/30,BvsD EMEND 80 MG CAPSULE 2 QL 4/,BvsD EMEND TRIPACK 2 QL 6/,BvsD +This drug does not count towards your total drug costs. For full description please see key symbol on page 6. 23

24 Comprehensive Formulary granisetron hcl 0.1 mg/ml vial 1 QL 60ML/30,B vsd granisetron hcl 1 mg let 1 QL 60/30,BvsD granisetron hcl 1 mg/ml vial 1 QL 60ML/30,B vsd granisetron hcl 4 mg/4 ml vial 1 QL 60ML/30,B vsd hydroxyzine 10 mg/5 ml soln 1 hydroxyzine hcl 10 mg let 1 hydroxyzine hcl mg let 1 meclizine 12.5 mg let 1 meclizine mg let 1 ondansetron 4 mg/2 ml isecure 1 ondansetron 4 mg/5 ml solution 1 QL 0ML/30, BvsD ondansetron 40 mg/ ml vial 1 ondansetron hcl 24 mg let 1 QL /30,BvsD ondansetron hcl 4 mg let 1 QL 90/30,BvsD ondansetron hcl 4 mg/2 ml vial 1 ondansetron hcl 8 mg let 1 QL 90/30,BvsD ondansetron odt 4 mg let 1 QL 90/30,BvsD ondansetron odt 8 mg let 1 QL 90/30,BvsD phenadoz 12.5 mg suppository 1 PA (HRM) phenadoz mg suppository 1 PA (HRM) phenergan 12.5 mg suppository 1 PA (HRM) phenergan mg suppository 1 PA (HRM) phenergan 50 mg suppository 1 PA (HRM) promethazine 12.5 mg suppos 1 PA (HRM) promethazine mg suppository 1 PA (HRM) promethazine 50 mg suppository 1 PA (HRM) promethegan 12.5 mg suppos 1 PA (HRM) promethegan mg suppository 1 PA (HRM) promethegan 50 mg suppository 1 PA (HRM) SANCUSO 3.1 MG/24 HR PATCH 3 PA,QL 4/30 TIGAN 100 MG/ML VIAL 2 TRANSDERM-SCOP 1.5 MG/3 DAY 3 QL 10/30 trimethobenzamide 300 mg cap 1 Antifungals ABELCET 100 MG/ ML VIAL 4 BvsD AMBISOME 50 MG VIAL 4 BvsD amphotericin b 50 mg vial 1 BvsD BENSAL HP 3% OINTMENT 2 CANCIDAS IV 50 MG VIAL 4 PA CANCIDAS IV 70 MG VIAL 4 PA ciclodan 0.77% cream 1 ciclodan 8% solution 1 ciclopirox 0.77% cream 1 ciclopirox 0.77% gel 1 ciclopirox 0.77% topical susp 1 ciclopirox 1% shampoo 1 ciclopirox 8% solution 1 clotrimazole 1% cream 1 clotrimazole 1% solution 1 clotrimazole 10 mg troche 1 clotrimazole-betamethasone crm 1 clotrimazole-betamethasone lot 1 econazole nitrate 1% cream 1 ERAXIS(WATER DIL) 100 MG VIAL 2 ERAXIS(WATER DIL) 50 MG VIAL 2 ERTACZO 2% CREAM 3 fluconazole 10 mg/ml susp 1 fluconazole 100 mg let 1 fluconazole 0 mg let 1 fluconazole 0 mg let 1 fluconazole 40 mg/ml susp 1 fluconazole 50 mg let 1 fluconazole-dext 0 mg/100 ml 1 fluconazole-dext 400 mg/0 ml 1 fluconazole-nacl 100 mg/50 ml 1 fluconazole-nacl 0 mg/100 ml 1 fluconazole-nacl 400 mg/0 ml 1 flucytosine 0 mg capsule 4 +This drug does not count towards your total drug costs. For full description please see key symbol on page 6. 24

25 Comprehensive Formulary flucytosine 500 mg capsule 4 GRIFULVIN V 500 MG TABLET 2 griseofulvin 1 mg/5 ml susp 1 griseofulvin micro 500 mg 1 griseofulvin ultra 1 mg 1 griseofulvin ultra 0 mg 1 GYNAZOLE 1 2% CREAM 3 itraconazole 100 mg capsule 1 QL 1/30 ketoconazole 2% cream 1 ketoconazole 2% shampoo 1 ketoconazole 0 mg let 1 miconazole 3 0 mg vag supp 1 MYCAMINE 100 MG VIAL 4 MYCAMINE 50 MG VIAL 4 naftifine hcl 1% cream 1 naftifine hcl 2% cream 1 NAFTIN 1% GEL 3 NAFTIN 2% CREAM 3 NAFTIN 2% GEL 3 NATACYN EYE DROPS 3 NOXAFIL 40 MG/ML SUSPENSION 4 QL 600ML/30 NOXAFIL DR 100 MG TABLET 4 QL 93/30 nyamyc 100,000 units/gm powder 1 nystatin 100,000 unit/gm cream 1 nystatin 100,000 unit/gm powd 1 nystatin 100,000 units/gm oint 1 nystatin 100,000 units/ml susp 1 nystatin 500,000 unit oral 1 nystatin-triamcinolone cream 1 nystatin-triamcinolone ointm 1 nystop 100,000 units/gm powder 1 oxiconazole nitrate 1% cream 1 OXISTAT 1% LOTION 2 SPORANOX 10 MG/ML SOLUTION 3 terbinafine hcl 0 mg let 1 QL 90/3 terconazole 0.4% cream 1 terconazole 0.8% cream 1 terconazole 80 mg suppository 1 voriconazole 0 mg let 4 QL 90/30 voriconazole 0 mg vial 1 voriconazole 40 mg/ml susp 4 QL 300ML/30 voriconazole 50 mg let 4 QL 90/30 zazole 0.8% vaginal cream 1 zazole vaginal 0.4% cream 1 Antigout Agents allopurinol 100 mg let 1 allopurinol 300 mg let 1 ALOPRIM 500 MG VIAL 3 colchicine 0.6 mg capsule 1 QL 60/30 colchicine 0.6 mg let 1 QL 1/30 probenecid 500 mg let 1 probenecid-colchicine s 1 ULORIC 40 MG TABLET 2 QL 30/30,ST ULORIC 80 MG TABLET 2 QL 30/30,ST Antimigraine Agents almotriptan malate 12.5 mg 1 QL 12/30,ST almotriptan malate 6. mg 1 QL /30,ST CAFERGOT TABLET 3 QL 40/ dihydroergotamine 1 mg/ml am 1 QL 30/ dihydroergotamine 4 mg/ml spry 1 QL 8ML/30 ERGOMAR 2 MG TABLET SL 3 frovatriptan succ 2.5 mg 1 QL /30,ST isometh/apap cap dichlor 1 + isometh/caff /apap 1 + migergot suppository 1 QL / migragesic cap ida 1 + naratriptan hcl 1 mg let 1 QL 9/30 naratriptan hcl 2.5 mg let 1 QL 9/30 nodolor cap 1 + PRODRIN TAB 2 + RELPAX MG TABLET 3 QL 12/30,ST RELPAX 40 MG TABLET 3 QL 6/30,ST rizatriptan 10 mg odt 1 QL 12/30 +This drug does not count towards your total drug costs. For full description please see key symbol on page 6.

26 Comprehensive Formulary rizatriptan 10 mg let 1 QL 12/30 rizatriptan 5 mg odt 1 QL 12/30 rizatriptan 5 mg let 1 QL 12/30 sumatriptan mg nasal spray 1 QL 12/30 sumatriptan 4 mg/0.5 ml cart 1 QL 4ML/30 sumatriptan 4 mg/0.5 ml inject 1 QL 4ML/30 sumatriptan 5 mg nasal spray 1 QL 12/30 sumatriptan 6 mg/0.5 ml inject 1 QL 4ML/30 sumatriptan 6 mg/0.5 ml refill 1 QL 4ML/30 sumatriptan 6 mg/0.5 ml syrng 1 QL 4ML/30 sumatriptan 6 mg/0.5 ml vial 1 QL 4ML/30 sumatriptan succ 100 mg let 1 QL 9/30 sumatriptan succ mg let 1 QL 9/30 sumatriptan succ 50 mg let 1 QL 9/30 zolmitriptan 2.5 mg odt 1 QL 12/30 zolmitriptan 2.5 mg let 1 QL 12/30 zolmitriptan 5 mg odt 1 QL 6/30 zolmitriptan 5 mg let 1 QL 6/30 Antimyasthenic Agents GUANIDINE HCL 1 MG TABLET 2 MESTINON 60 MG/5 ML SYRUP 2 PROSTIGMIN MG TABLET 3 pyridostigmine br 60 mg let 1 pyridostigmine er 0 mg 1 REGONOL 10 MG/2 ML AMPUL 3 Antimycobacterials CAPASTAT SULFATE 1 GM VIAL 2 cycloserine 0 mg capsule 1 dapsone 100 mg let 1 dapsone mg let 1 ethambutol hcl 100 mg let 1 ethambutol hcl 400 mg let 1 isoniazid 100 mg let 1 isoniazid 100 mg/ml vial 1 isoniazid 300 mg let 1 isoniazid 50 mg/5 ml solution 1 MYCOBUTIN 0 MG CAPSULE 2 PASER GRANULES 4 GM PACKET 3 PRIFTIN 0 MG TABLET 3 pyrazinamide 500 mg let 1 rifabutin 0 mg capsule 1 RIFADIN IV 600 MG VIAL 2 RIFAMATE CAPSULE 3 rifampin 0 mg capsule 1 rifampin 300 mg capsule 1 rifampin iv 600 mg vial 1 RIFATER TABLET 3 SIRTURO 100 MG TABLET 3 QL 8/3 TRECATOR 0 MG TABLET 2 Antineoplastics ABRAXANE 100 MG VIAL 4 BvsD adrucil 2,500 mg/50 ml vial 1 BvsD adrucil 5 gram/100 ml vial 1 BvsD adrucil 500 mg/10 ml vial 1 BvsD AFINITOR 10 MG TABLET 4 QL 60/30 AFINITOR 2.5 MG TABLET 4 QL 30/30 AFINITOR 5 MG TABLET 4 QL 30/30 AFINITOR 7.5 MG TABLET 4 QL 30/30 AFINITOR DISPERZ 2 MG TABLET 4 QL 60/30 AFINITOR DISPERZ 3 MG TABLET 4 QL 60/30 AFINITOR DISPERZ 5 MG TABLET 4 QL 1/30 ALECENSA 0 MG CAPSULE 4 QL 240/30 ALIMTA 100 MG VIAL 4 BvsD ALIMTA 500 MG VIAL 4 BvsD amifostine 500 mg vial 4 BvsD anastrozole 1 mg let 1 QL 30/30 ARRANON 0 MG VIAL 3 BvsD ARZERRA 1,000 MG/50 ML VIAL 4 BvsD ARZERRA 100 MG/5 ML VIAL 4 BvsD AVASTIN 100 MG/4 ML VIAL 4 BvsD AVASTIN 400 MG/ ML VIAL 4 BvsD azacitidine 100 mg vial 1 BvsD BCG (TICE STRAIN) VIAL 2 BvsD BELEODAQ 500 MG VIAL 4 BvsD BENDEKA 100 MG/4 ML VIAL 4 QL 6ML/21,Bvs D bexarotene 75 mg capsule 4 bicalutamide 50 mg let 1 QL 30/30 +This drug does not count towards your total drug costs. For full description please see key symbol on page 6.

27 Comprehensive Formulary BICNU 100 MG VIAL 2 BvsD bleomycin sulfate unit vial 1 BvsD bleomycin sulfate 30 unit vial 1 BvsD BOSULIF 100 MG TABLET 4 QL 1/30 BOSULIF 500 MG TABLET 4 QL 30/30 BUSULFEX 60 MG/10 ML VIAL 2 BvsD CABOMETYX MG TABLET 4 QL 30/30 CABOMETYX 40 MG TABLET 4 QL 60/30 CABOMETYX 60 MG TABLET 4 QL 30/30 CAMPTOSAR 300 MG/ ML VIAL 3 BvsD CAPRELSA 100 MG TABLET 4 QL 60/30 CAPRELSA 300 MG TABLET 4 QL 30/30 carboplatin 0 mg/ ml vial 1 BvsD carboplatin 0 mg/ ml vial 1 BvsD carboplatin 50 mg/5 ml vial 1 BvsD carboplatin 600 mg/60 ml vial 1 BvsD cisplatin 100 mg/100 ml vial 1 BvsD cisplatin 0 mg/0 ml vial 1 BvsD cisplatin 50 mg/50 ml vial 1 BvsD cladribine 10 mg/10 ml vial 3 BvsD CLOLAR MG/ ML VIAL 3 BvsD COMETRIQ 100 MG DAILY-DOSE PK 4 QL / COMETRIQ 0 MG DAILY-DOSE PK 4 QL 2/ COMETRIQ 60 MG DAILY-DOSE PACK 4 QL 84/ COSMEGEN 0.5 MG VIAL 4 BvsD COTELLIC MG TABLET 4 QL 63/ cyclophosphamide 1 gm vial 1 BvsD cyclophosphamide 2 gm vial 1 BvsD cyclophosphamide mg capsule 1 BvsD cyclophosphamide 50 mg capsule 1 BvsD cyclophosphamide 500 mg vial 1 BvsD CYRAMZA 100 MG/10 ML VIAL 4 BvsD CYRAMZA 500 MG/50 ML VIAL 4 BvsD cytarabine 100 mg/5 ml vial 1 BvsD cytarabine 1000 mg/50 ml vial 1 BvsD cytarabine 2 g/ ml vial 1 BvsD cytarabine mg/ml vial 1 BvsD cytarabine 500 mg/ ml vial 1 BvsD dacarbazine 100 mg vial 1 BvsD dacarbazine 0 mg vial 1 BvsD DARZALEX 100 MG/5 ML VIAL 4 BvsD DARZALEX 400 MG/ ML VIAL 4 BvsD daunorubicin mg/4 ml vial 1 BvsD DAUNOXOME 50 MG (2 MG/ML) VIAL 4 BvsD deciine 50 mg vial 4 BvsD dexrazoxane 0 mg vial 1 BvsD dexrazoxane 500 mg vial 1 BvsD DOCEFREZ MG VIAL 4 BvsD DOCEFREZ 80 MG VIAL 4 BvsD docetaxel 0 mg/7 ml vial 4 BvsD docetaxel 0 mg/ ml vial 4 BvsD docetaxel 0 mg/8 ml vial 4 BvsD docetaxel mg/0.5 ml vial 4 BvsD docetaxel mg/2 ml vial 4 BvsD docetaxel mg/ml vial 4 BvsD docetaxel 0 mg/ ml vial 4 BvsD docetaxel 80 mg/2 ml vial 4 BvsD docetaxel 80 mg/4 ml vial 4 BvsD docetaxel 80 mg/8 ml vial 4 BvsD doxorubicin 10 mg vial 1 BvsD doxorubicin 50 mg vial 1 BvsD doxorubicin 50 mg/ ml vial 1 BvsD doxorubicin liposome mg/10ml 4 BvsD DROXIA 0 MG CAPSULE 2 DROXIA 300 MG CAPSULE 2 DROXIA 400 MG CAPSULE 2 ELITEK 1.5 MG VIAL 4 ELITEK 7.5 MG VIAL 4 EMCYT 0 MG CAPSULE 2 EMPLICITI 300 MG VIAL 4 BvsD EMPLICITI 400 MG VIAL 4 BvsD epirubicin 0 mg/100 ml vial 1 BvsD epirubicin 50 mg/ ml vial 1 BvsD epirubicin hcl 1 BvsD ERBITUX 100 MG/50 ML VIAL 4 BvsD ERBITUX 0 MG/100 ML VIAL 4 BvsD ERIVEDGE 0 MG CAPSULE 4 QL 30/30 ERWINAZE 10,000 UNITS VIAL 4 QL 60/,BvsD ETOPOPHOS 100 MG VIAL 3 BvsD +This drug does not count towards your total drug costs. For full description please see key symbol on page 6.

28 Comprehensive Formulary etoposide 1,000 mg/50 ml vial 1 BvsD etoposide 100 mg/5 ml vial 1 BvsD etoposide 500 mg/ ml vial 1 BvsD EVOMELA 50 MG VIAL 4 BvsD exemestane mg let 1 QL 60/30 FARESTON 60 MG TABLET 4 QL 30/30 FARYDAK 10 MG CAPSULE 4 QL 6/21 FARYDAK MG CAPSULE 4 QL 6/21 FARYDAK MG CAPSULE 4 QL 6/21 FASLODEX 0 MG/5 ML SYRINGE 4 QL 30ML/30,B vsd floxuridine 500 mg vial 1 BvsD fludarabine 50 mg vial 1 BvsD fludarabine 50 mg/2 ml vial 1 BvsD fluorouracil 1,000 mg/ ml vl 1 BvsD fluorouracil 2,500 mg/50 ml vl 1 BvsD fluorouracil 5,000 mg/100 ml 1 BvsD fluorouracil 500 mg/10 ml vial 1 BvsD flutamide 1 mg capsule 1 FOLOTYN MG/ML VIAL 4 BvsD FOLOTYN 40 MG/2 ML VIAL 4 BvsD FUSILEV I.V. 50 MG VIAL 4 GAZYVA 1,000 MG/40 ML VIAL 4 BvsD gemciine 1 gram/.3 ml vl 1 BvsD gemciine 2 gram/.6 ml vl 1 BvsD gemciine 0 mg/5. ml vl 1 BvsD gemciine hcl 1 gram vial 1 BvsD gemciine hcl 2 gram vial 1 BvsD gemciine hcl 0 mg vial 1 BvsD GILOTRIF MG TABLET 4 QL 30/30 GILOTRIF 30 MG TABLET 4 QL 30/30 GILOTRIF 40 MG TABLET 4 QL 30/30 GLEOSTINE 10 MG CAPSULE 2 GLEOSTINE 100 MG CAPSULE 2 GLEOSTINE 40 MG CAPSULE 2 GLEOSTINE 5 MG CAPSULE 2 HALAVEN 1 MG/2 ML VIAL 4 HERCEPTIN 440 MG VIAL 4 BvsD HEXALEN 50 MG CAPSULE 4 hydroxyurea 500 mg capsule 1 IBRANCE 100 MG CAPSULE 4 QL 21/ IBRANCE 1 MG CAPSULE 4 QL 21/ IBRANCE 75 MG CAPSULE 4 QL 21/ ICLUSIG MG TABLET 4 QL 60/30 ICLUSIG MG TABLET 4 QL 30/30 idarubicin hcl 10 mg/10 ml vl 4 BvsD idarubicin hcl mg/ ml vl 4 BvsD idarubicin hcl 5 mg/5 ml vial 4 BvsD ifosfamide 1 gm vial 1 BvsD ifosfamide 1 gm/ ml vial 1 BvsD ifosfamide 3 gm vial 1 BvsD ifosfamide 3 gm/ 60 ml vial 1 BvsD imatinib mesylate 100 mg 4 QL 60/30 imatinib mesylate 400 mg 4 QL 60/30 IMBRUVICA 0 MG CAPSULE 4 QL 1/30 INLYTA 1 MG TABLET 4 QL 1/30 INLYTA 5 MG TABLET 4 QL 1/30 IRESSA 0 MG TABLET 4 QL 30/30 irinotecan hcl 100 mg/5 ml vl 1 BvsD irinotecan hcl 40 mg/2 ml vial 1 BvsD irinotecan hcl 500 mg/ ml vl 1 BvsD ISTODAX 10 MG VIAL 4 BvsD IXEMPRA MG KIT 4 BvsD IXEMPRA MG KIT 4 BvsD JAKAFI 10 MG TABLET 4 QL 60/30 JAKAFI MG TABLET 4 QL 60/30 JAKAFI MG TABLET 4 QL 60/30 JAKAFI MG TABLET 4 QL 60/30 JAKAFI 5 MG TABLET 4 QL 60/30 JEVTANA 60 MG/1.5 ML KIT 4 BvsD KADCYLA 100 MG VIAL 4 BvsD KADCYLA 0 MG VIAL 4 BvsD KEYTRUDA 100 MG/4 ML VIAL 4 BvsD KEYTRUDA 50 MG VIAL 4 BvsD LENVIMA 10 MG DAILY DOSE 4 QL 30/30 LENVIMA MG DAILY DOSE 4 QL 60/30 LENVIMA MG DAILY DOSE 4 QL 90/30 LENVIMA MG DAILY DOSE 4 QL 60/30 LENVIMA 24 MG DAILY DOSE 4 QL 90/30 +This drug does not count towards your total drug costs. For full description please see key symbol on page 6.

29 Comprehensive Formulary LENVIMA 8 MG DAILY DOSE 4 QL 60/30 letrozole 2.5 mg let 1 QL 30/30 leucovorin calcium 10 mg 1 leucovorin calcium 100 mg vial 1 leucovorin calcium mg 1 leucovorin calcium 0 mg vial 1 leucovorin calcium mg 1 leucovorin calcium 350 mg vial 1 leucovorin calcium 5 mg 1 leucovorin calcium 50 mg vial 1 leucovorin calcium 500 mg vl 1 LEUKERAN 2 MG TABLET 2 LEVOLEUCOVORIN 4 levoleucovorin 5 mg/.5 ml 4 levoleucovorin 0 mg/ ml vl 4 LONSURF MG-6. MG TABLET 4 QL 100/ LONSURF MG-8. MG TABLET 4 QL 80/ LYNPARZA 50 MG CAPSULE 4 QL 0ML/30 MARQIBO KIT 4 BvsD MATULANE 50 MG CAPSULE 4 MEKINIST 0.5 MG TABLET 4 QL 90/30 MEKINIST 2 MG TABLET 4 QL 30/30 melphalan hcl 50 mg vial 1 BvsD mercaptopurine 50 mg let 1 mesna 100 mg/ml vial 1 BvsD MESNEX 400 MG TABLET 4 mitomycin mg vial 4 BvsD mitomycin 40 mg vial 4 BvsD mitomycin 5 mg vial 3 BvsD mitoxantrone mg/10 ml vial 1 BvsD mitoxantrone mg/12.5 ml vl 1 BvsD mitoxantrone 30 mg/ ml vial 1 BvsD MUSTARGEN 10 MG VIAL 2 BvsD NEXAVAR 0 MG TABLET 4 QL 1/30 NILANDRON 0 MG TABLET 4 QL 60/30 nilutamide 0 mg let 4 QL 60/30 NINLARO 2.3 MG CAPSULE 4 QL 3/ NINLARO 3 MG CAPSULE 4 QL 3/ NINLARO 4 MG CAPSULE 4 QL 3/ NIPENT 10 MG VIAL 4 BvsD ODOMZO 0 MG CAPSULE 4 QL 30/30 ONCASPAR 750 UNIT/ML VIAL 4 BvsD ONIVYDE MG/10 ML VIAL 4 BvsD OPDIVO 100 MG/10 ML VIAL 4 QL 80ML/,B vsd OPDIVO 40 MG/4 ML VIAL 4 QL 80ML/,B vsd oxaliplatin 100 mg powder vial 4 BvsD oxaliplatin 100 mg/ ml vial 4 BvsD oxaliplatin 50 mg powder vial 4 BvsD oxaliplatin 50 mg/10 ml vial 4 BvsD paclitaxel 100 mg/.7 ml vial 1 BvsD paclitaxel 0 mg/ ml vial 1 BvsD paclitaxel 30 mg/5 ml vial 1 BvsD paclitaxel 300 mg/50 ml vial 1 BvsD PANRETIN 0.1% GEL 4 PERJETA 4 MG/ ML VIAL 4 BvsD PHOTOFRIN 75 MG VIAL 4 BvsD POMALYST 1 MG CAPSULE 4 QL 21/ POMALYST 2 MG CAPSULE 4 QL 21/ POMALYST 3 MG CAPSULE 4 QL 21/ POMALYST 4 MG CAPSULE 4 QL 21/,BvsD PORTRAZZA 800 MG/50 ML VIAL 4 QL 100ML/21, BvsD PROLEUKIN MILLION UNIT VIAL 4 PURIXAN MG/ML ORAL SUSP 3 QL 300ML/30 REVLIMID 10 MG CAPSULE 4 QL / REVLIMID MG CAPSULE 4 QL 21/ REVLIMID 2.5 MG CAPSULE 4 QL / REVLIMID MG CAPSULE 4 QL 21/ REVLIMID MG CAPSULE 4 QL 21/ REVLIMID 5 MG CAPSULE 4 QL / RITUXAN 10 MG/ML VIAL 4 PA SOLTAMOX 10 MG/5 ML SOLN 3 SPRYCEL 100 MG TABLET 4 QL 30/30 +This drug does not count towards your total drug costs. For full description please see key symbol on page 6. 29

30 SPRYCEL 0 MG TABLET 4 QL 30/30 SPRYCEL MG TABLET 4 QL 30/30 SPRYCEL 50 MG TABLET 4 QL 30/30 SPRYCEL 70 MG TABLET 4 QL 30/30 SPRYCEL 80 MG TABLET 4 QL 30/30 STIVARGA 40 MG TABLET 4 QL 84/ SUTENT 12.5 MG CAPSULE 4 QL / SUTENT MG CAPSULE 4 QL / SUTENT 37.5 MG CAPSULE 4 QL / SUTENT 50 MG CAPSULE 4 QL / SYLATRON 0 MCG KIT 4 PA,QL 4/ SYLATRON 300 MCG KIT 4 PA,QL 4/ SYLATRON 600 MCG KIT 4 PA,QL 4/ SYNRIBO 3.5 MG/ML VIAL 4 QL /,BvsD TABLOID 40 MG TABLET 3 TAFINLAR 50 MG CAPSULE 4 QL 1/30 TAFINLAR 75 MG CAPSULE 4 QL 1/30 TAGRISSO 40 MG TABLET 4 QL 30/30 TAGRISSO 80 MG TABLET 4 QL 30/30 tamoxifen 10 mg let 1 tamoxifen mg let 1 TARCEVA 100 MG TABLET 4 QL 30/30 TARCEVA 0 MG TABLET 4 QL 30/30 TARCEVA MG TABLET 4 QL 60/30 TARGRETIN 1% GEL 4 QL 60GM/30 TASIGNA 0 MG CAPSULE 4 QL 1/30 TASIGNA 0 MG CAPSULE 4 QL 1/30 TECENTRIQ 1,0 MG/ ML VIAL 4 QL ML/21,B vsd teniposide 50 mg/5 ml ampule 1 BvsD THALOMID 100 MG CAPSULE 4 QL 30/30 THALOMID 0 MG CAPSULE 4 QL 30/30 THALOMID 0 MG CAPSULE 4 QL 60/30 THALOMID 50 MG CAPSULE 4 QL 30/30 thiotepa mg vial 1 BvsD toposar 1,000 mg/50 ml vial 1 BvsD toposar 100 mg/5 ml vial 1 BvsD toposar 500 mg/ ml vial 1 BvsD Comprehensive Formulary 30 topotecan hcl 4 mg vial 4 topotecan hcl 4 mg/4 ml vial 4 TREANDA 100 MG VIAL 4 QL 8/21,BvsD TREANDA 0 MG/2 ML VIAL 4 QL 4ML/21,Bvs D TREANDA MG VIAL 4 QL 8/21,BvsD TREANDA MG/0.5 ML VIAL 4 QL 6ML/21,Bvs D tretinoin 10 mg capsule 4 TRISENOX 10 MG/10 ML AMPULE 3 BvsD TYKERB 0 MG TABLET 4 QL 0/30 UNITUXIN.5 MG/ 5 ML VIAL 4 BvsD VALCHLOR 0.0% GEL 4 QL 60GM/30 VECTIBIX 100 MG/5 ML VIAL 4 BvsD VECTIBIX 400 MG/ ML VIAL 4 BvsD VELCADE 3.5 MG VIAL 4 QL /21,BvsD VENCLEXTA 10 MG TABLET 3 QL 60/30 VENCLEXTA 100 MG TABLET 4 QL 1/30 VENCLEXTA 50 MG TABLET 3 QL 30/30 VENCLEXTA STARTING PACK 4 QL 84/3 VIDAZA 100 MG VIAL 2 BvsD vinblastine 1 mg/ml vial 1 BvsD vincasar pfs 1 mg/ml vial 1 BvsD vincristine 1 mg/ml vial 1 BvsD vinorelbine 10 mg/ml vial 1 BvsD vinorelbine 50 mg/5 ml vial 1 BvsD VOTRIENT 0 MG TABLET 4 QL 1/30 XALKORI 0 MG CAPSULE 4 QL 60/30 XALKORI 0 MG CAPSULE 4 QL 60/30 XTANDI 40 MG CAPSULE 4 QL 1/30 YERVOY 0 MG/40 ML VIAL 4 QL 70ML/21,B vsd YERVOY 50 MG/10 ML VIAL 4 QL 300ML/21, BvsD +This drug does not count towards your total drug costs. For full description please see key symbol on page 6.

31 Comprehensive Formulary YONDELIS 1 MG VIAL 4 BvsD ZALTRAP 100 MG/4 ML VIAL 4 QL 40ML/,B vsd ZALTRAP 0 MG/8 ML VIAL 4 QL 40ML/,B vsd ZANOSAR 1 GM POWDER VIAL 3 BvsD ZELBORAF 240 MG TABLET 4 QL 240/30 ZOLINZA 100 MG CAPSULE 4 QL 1/30 ZYDELIG 100 MG TABLET 4 QL 60/30 ZYDELIG 0 MG TABLET 4 QL 60/30 ZYKADIA 0 MG CAPSULE 4 QL 0/30 ZYTIGA 0 MG TABLET 4 QL 1/30 Antiparasitics ALBENZA 0 MG TABLET 3 ALINIA 100 MG/5 ML SUSPENSION 3 QL 0ML/30 ALINIA 500 MG TABLET 3 QL /30 atovaquone 750 mg/5 ml susp 4 atovaquone-proguanil atovaquone-proguanil BILTRICIDE 600 MG TABLET 3 chloroquine ph 0 mg let 1 chloroquine ph 500 mg let 1 COARTEM TABLETS 3 QL 24/30 DARAPRIM MG TABLET 3 QL 90/30 EURAX 10% CREAM 3 EURAX 10% LOTION 3 hydroxychloroquine 0 mg 1 ivermectin 3 mg let 1 lindane 1% lotion 1 lindane 1% shampoo 1 malathion 0.5% lotion 1 mefloquine hcl 0 mg let 1 NEBUPENT 300 MG INHAL POWDER 3 QL 6/,BvsD PENTAM 300 VIAL 3 permethrin 5% cream 1 primaquine.3 mg let 3 QL 90/30 quinine sulfate 4 mg capsule 1 QL 42/7 SKLICE 0.5% LOTION 3 tinidazole 0 mg let 1 tinidazole 500 mg let 1 Antiparkinson Agents APOKYN 30 MG/3 ML CARTRIDGE 4 QL 60/30 AZILECT 0.5 MG TABLET 2 QL 30/30 AZILECT 1 MG TABLET 2 QL 30/30 benztropine 2 mg/2 ml ampule 1 benztropine mes 0.5 mg 1 PA (HRM) benztropine mes 1 mg let 1 PA (HRM) benztropine mes 2 mg let 1 PA (HRM) bromocriptine 2.5 mg let 1 bromocriptine 5 mg capsule 1 carbidopa mg let 1 carbidopa-levo mg odt 1 carbidopa-levo -100 mg odt 1 carbidopa-levo -0 mg odt 1 carbidopa-levo er carbidopa-levo er carbidopa-levodopa carbidopa-levodopa carbidopa-levodopa -0 1 carbidopa-levodopa-enta 100 mg 1 carbidopa-levodopa-enta 1 mg 1 carbidopa-levodopa-enta 0 mg 1 carbidopa-levodopa-enta 0 mg 1 carbidopa-levodopa-enta 50 mg 1 carbidopa-levodopa-enta 75 mg 1 entacapone 0 mg let 1 QL 240/30 NEUPRO 1 MG/24 HR PATCH 3 QL 30/30 NEUPRO 2 MG/24 HR PATCH 3 QL 30/30 NEUPRO 3 MG/24 HR PATCH 3 QL 30/30 NEUPRO 4 MG/24 HR PATCH 3 QL 30/30 NEUPRO 6 MG/24 HR PATCH 3 QL 30/30 NEUPRO 8 MG/24 HR PATCH 3 QL 30/30 pramipexole 0.1 mg let 1 QL 90/30 pramipexole 0. mg let 1 QL 90/30 pramipexole 0.5 mg let 1 QL 90/30 pramipexole 0.75 mg let 1 QL 90/30 pramipexole 1 mg let 1 QL 90/30 +This drug does not count towards your total drug costs. For full description please see key symbol on page 6. 31

32 Comprehensive Formulary pramipexole 1.5 mg let 1 QL 90/30 pramipexole er mg let 1 QL 90/30 pramipexole er 0.75 mg let 1 QL 90/30 pramipexole er 1.5 mg let 1 QL 90/30 pramipexole er 2. mg let 1 QL 30/30 pramipexole er 3 mg let 1 QL 30/30 pramipexole er 3.75 mg let 1 QL 30/30 pramipexole er 4.5 mg let 1 QL 30/30 ropinirole hcl 0. mg let 1 ropinirole hcl 0.5 mg let 1 ropinirole hcl 1 mg let 1 ropinirole hcl 2 mg let 1 ropinirole hcl 3 mg let 1 ropinirole hcl 4 mg let 1 ropinirole hcl 5 mg let 1 ropinirole hcl er 12 mg let 1 ropinirole hcl er 2 mg let 1 ropinirole hcl er 4 mg let 1 ropinirole hcl er 6 mg let 1 ropinirole hcl er 8 mg let 1 selegiline hcl 5 mg capsule 1 selegiline hcl 5 mg let 1 tolcapone 100 mg let 4 trihexyphenidyl 2 mg let 1 PA (HRM) trihexyphenidyl 2 mg/5 ml elx 1 PA (HRM) trihexyphenidyl 5 mg let 1 PA (HRM) ZELAPAR 1. MG ODT TABLET 3 Antipsychotics ABILIFY MAINTENA ER 300 MG SYR 4 QL 1/30 ABILIFY MAINTENA ER 300 MG VL 4 QL 1/30 ABILIFY MAINTENA ER 400 MG SYR 4 QL 1/30 aripiprazole 1 mg/ml solution 1 QL 900ML/30 aripiprazole 10 mg let 1 QL 30/30 aripiprazole mg let 1 QL 30/30 aripiprazole 2 mg let 1 QL 30/30 aripiprazole mg let 1 QL 30/30 aripiprazole 30 mg let 1 QL 30/30 aripiprazole 5 mg let 1 QL 30/30 aripiprazole odt 10 mg let 1 QL 60/30 aripiprazole odt mg let 1 QL 60/30 ARISTADA ER 441 MG/1.6 ML SYRN 4 QL 1.6ML/30 ARISTADA ER 662 MG/2.4 ML SYRN 4 QL 2.4ML/30 ARISTADA ER 882 MG/3.2 ML SYRN 4 QL 3.2ML/30 chlorpromazine 10 mg let 1 chlorpromazine 100 mg let 1 chlorpromazine 0 mg let 1 chlorpromazine mg let 1 chlorpromazine mg/ml amp 1 chlorpromazine 50 mg let 1 clozapine 100 mg let 1 QL 0/30 clozapine 0 mg let 1 QL 1/30 clozapine mg let 1 QL 90/30 clozapine 50 mg let 1 QL 90/30 clozapine odt 100 mg let 1 QL 0/30 clozapine odt 12.5 mg let 1 QL 60/30 clozapine odt 0 mg let 1 QL 0/30 clozapine odt 0 mg let 1 QL 1/30 clozapine odt mg let 1 QL 90/30 compro mg suppository 1 FANAPT 1 MG TABLET 3 QL 60/30 FANAPT 10 MG TABLET 3 QL 60/30 FANAPT 12 MG TABLET 3 QL 60/30 FANAPT 2 MG TABLET 3 QL 60/30 FANAPT 4 MG TABLET 3 QL 60/30 FANAPT 6 MG TABLET 3 QL 60/30 FANAPT 8 MG TABLET 3 QL 60/30 FANAPT TITRATION PACK 3 QL /30 fluphenazine 1 mg let 1 fluphenazine 10 mg let 1 fluphenazine 2.5 mg let 1 fluphenazine 2.5 mg/5 ml elix 1 fluphenazine 2.5 mg/ml vial 1 fluphenazine 5 mg let 1 fluphenazine 5 mg/ml conc 1 fluphenazine dec mg/ml vial 1 GEODON MG/ML VIAL 3 QL 6/30 +This drug does not count towards your total drug costs. For full description please see key symbol on page 6.

33 haloperidol 0.5 mg let 1 haloperidol 1 mg let 1 haloperidol 10 mg let 1 haloperidol 2 mg let 1 haloperidol mg let 1 haloperidol 5 mg let 1 haloperidol dec 100 mg/ml vial 1 haloperidol dec 50 mg/ml vial 1 haloperidol lac 2 mg/ml conc 1 haloperidol lac 5 mg/ml vial 1 INVEGA SUSTENNA 1 MG/0.75 ML 4 QL 0.75ML/ INVEGA SUSTENNA 6 MG/ML 4 QL 1/ SYRG INVEGA SUSTENNA 2 MG/1.5 ML 4 QL 1.5ML/ INVEGA SUSTENNA 39 MG/0. ML 3 QL 0.ML/ INVEGA SUSTENNA MG/0.5 ML 3 QL 0.5ML/ INVEGA TRINZA 3 MG/0.875 ML 4 QL 0.88ML/90 INVEGA TRINZA 410 MG/1.3 ML 4 QL 1.ML/90 INVEGA TRINZA 5 MG/1.75 ML 4 QL 1.75ML/90 INVEGA TRINZA 8 MG/2.6 ML 4 QL 2.63ML/90 LATUDA 1 MG TABLET 4 QL 30/30 LATUDA MG TABLET 4 QL 30/30 LATUDA 40 MG TABLET 4 QL 30/30 LATUDA 60 MG TABLET 4 QL 30/30 LATUDA 80 MG TABLET 4 QL 60/30 loxapine 10 mg capsule 1 QL 1/30 loxapine mg capsule 1 loxapine 5 mg capsule 1 QL 1/30 loxapine 50 mg capsule 1 molindone hcl 10 mg let 1 molindone hcl mg let 1 molindone hcl 5 mg let 1 NUPLAZID MG TABLET 4 PA,QL 60/30 Comprehensive Formulary 33 olanzapine 10 mg let 1 QL 30/30 olanzapine 10 mg vial 1 QL 30/30 olanzapine mg let 1 QL 30/30 olanzapine 2.5 mg let 1 QL 30/30 olanzapine mg let 1 QL 30/30 olanzapine 5 mg let 1 QL 30/30 olanzapine 7.5 mg let 1 QL 30/30 olanzapine odt 10 mg let 1 QL 30/30 olanzapine odt mg let 1 QL 30/30 olanzapine odt mg let 1 QL 30/30 olanzapine odt 5 mg let 1 QL 30/30 paliperidone er 1.5 mg let 1 QL 30/30 paliperidone er 3 mg let 1 QL 30/30 paliperidone er 6 mg let 1 QL 60/30 paliperidone er 9 mg let 4 QL 30/30 perphenazine mg let 1 perphenazine 2 mg let 1 perphenazine 4 mg let 1 perphenazine 8 mg let 1 pimozide 1 mg let 1 pimozide 2 mg let 1 prochlorperazine 10 mg 1 prochlorperazine 10 mg/2 ml vl 1 prochlorperazine mg supp 1 prochlorperazine 5 mg let 1 quetiapine fumarate 100 mg 1 QL 60/30 quetiapine fumarate 0 mg 1 QL 60/30 quetiapine fumarate mg 1 QL 60/30 quetiapine fumarate 300 mg 1 QL 60/30 quetiapine fumarate 400 mg 1 QL 60/30 quetiapine fumarate 50 mg 1 QL 60/30 REXULTI 0. MG TABLET 4 QL 30/30 REXULTI 0.5 MG TABLET 4 QL 30/30 REXULTI 1 MG TABLET 4 QL 30/30 REXULTI 2 MG TABLET 4 QL 30/30 REXULTI 3 MG TABLET 4 QL 30/30 REXULTI 4 MG TABLET 4 QL 30/30 RISPERDAL CONSTA 12.5 MG SYR 3 QL 2/ RISPERDAL CONSTA MG SYR 3 QL 2/ RISPERDAL CONSTA 37.5 MG SYR 4 QL 2/ +This drug does not count towards your total drug costs. For full description please see key symbol on page 6.

34 Comprehensive Formulary RISPERDAL CONSTA 50 MG SYR 4 QL 2/ risperidone 0. mg odt 1 QL 60/30 risperidone 0. mg let 1 QL 60/30 risperidone 0.5 mg odt 1 QL 60/30 risperidone 0.5 mg let 1 QL 60/30 risperidone 1 mg odt 1 QL 60/30 risperidone 1 mg let 1 QL 60/30 risperidone 1 mg/ml solution 1 QL 360ML/30 risperidone 2 mg odt 1 QL 60/30 risperidone 2 mg let 1 QL 60/30 risperidone 3 mg odt 1 QL 60/30 risperidone 3 mg let 1 QL 60/30 risperidone 4 mg odt 1 QL 1/30 risperidone 4 mg let 1 QL 1/30 SAPHRIS 10 MG TAB SL BLK CHERY 2 QL 60/30 SAPHRIS 2.5 MG TAB SL BLK CHRY 2 QL 60/30 SAPHRIS 5 MG TAB SL BLK CHERRY 2 QL 60/30 SEROQUEL XR 0 MG TABLET 3 QL 30/30 SEROQUEL XR 0 MG TABLET 3 QL 30/30 SEROQUEL XR 300 MG TABLET 3 QL 60/30 SEROQUEL XR 400 MG TABLET 3 QL 60/30 SEROQUEL XR 50 MG TABLET 3 QL 60/30 thioridazine 10 mg let 1 PA (HRM) thioridazine 100 mg let 1 PA (HRM) thioridazine mg let 1 PA (HRM) thioridazine 50 mg let 1 PA (HRM) thiothixene 1 mg capsule 1 thiothixene 10 mg capsule 1 thiothixene 2 mg capsule 1 thiothixene 5 mg capsule 1 trifluoperazine 1 mg let 1 trifluoperazine 10 mg let 1 trifluoperazine 2 mg let 1 trifluoperazine 5 mg let 1 VERSACLOZ 50 MG/ML SUSPENSION 3 QL 540ML/30 VRAYLAR 1.5 MG CAPSULE 4 QL 30/30 VRAYLAR 1.5 MG-3 MG PACK 3 QL /3 VRAYLAR 3 MG CAPSULE 4 QL 30/30 VRAYLAR 4.5 MG CAPSULE 4 QL 30/30 VRAYLAR 6 MG CAPSULE 4 QL 30/30 ziprasidone hcl mg capsule 1 QL 60/30 ziprasidone hcl 40 mg capsule 1 QL 60/30 ziprasidone hcl 60 mg capsule 1 QL 60/30 ziprasidone hcl 80 mg capsule 1 QL 60/30 ZYPREXA RELPREVV 210 MG VL KIT 3 QL 2/ ZYPREXA RELPREVV 300 MG VL KIT 4 QL 2/ ZYPREXA RELPREVV 405 MG VL KIT 4 QL 1/ Antispasticity Agents baclofen 10 mg let 1 baclofen mg let 1 chlordiazepo/clidi cap 5-2.5mg 1 + dantrolene sodium 100 mg cap 1 dantrolene sodium mg cap 1 dantrolene sodium 50 mg cap 1 DONNATAL ELX 2 + DONNATAL TAB 2 + DONNATAL TAB.2MG 2 + LIBRAX CAP 5-2.5MG 2 + PAMINE FQ KIT 2 + tizanidine hcl 2 mg capsule 1 tizanidine hcl 2 mg let 1 tizanidine hcl 4 mg capsule 1 tizanidine hcl 4 mg let 1 tizanidine hcl 6 mg capsule 1 Antivirals abacavir 300 mg let 1 QL 60/30 abacavir-lamivudine-zidov 4 QL 60/30 acyclovir 0 mg capsule 1 acyclovir 0 mg/5 ml susp 1 acyclovir 400 mg let 1 acyclovir 5% ointment 1 QL 30GM/30 acyclovir 500 mg/10 ml vial 1 acyclovir 800 mg let 1 acyclovir sodium 500 mg vial 1 BvsD adefovir dipivoxil 10 mg 4 QL 30/30 amantadine 100 mg capsule 1 amantadine 100 mg let 1 +This drug does not count towards your total drug costs. For full description please see key symbol on page 6.

35 amantadine 50 mg/5 ml solution 1 APTIVUS 100 MG/ML SOLUTION 4 QL 5ML/ APTIVUS 0 MG CAPSULE 4 QL 1/30 ATRIPLA TABLET 4 QL 30/30 BARACLUDE 0.05 MG/ML SOLUTION 2 QL 630ML/30 cidofovir 375 mg/5 ml vial 4 COMPLERA TABLET 4 QL 30/30 CRIXIVAN 0 MG CAPSULE 2 QL 0/30 CRIXIVAN 400 MG CAPSULE 2 QL 0/30 DENAVIR 1% CREAM 2 DESCOVY 0- MG TABLET 4 QL 30/30 didanosine dr 1 mg capsule 1 QL 30/30 didanosine dr 0 mg capsule 1 QL 30/30 didanosine dr 0 mg capsule 1 QL 30/30 didanosine dr 400 mg capsule 1 QL 30/30 EDURANT MG TABLET 4 QL 30/30 EMTRIVA 10 MG/ML SOLUTION 3 QL 680ML/ EMTRIVA 0 MG CAPSULE 3 QL 30/30 entecavir 0.5 mg let 1 QL 30/30 entecavir 1 mg let 1 QL 30/30 EPIVIR HBV MG/5 ML SOLN 3 EPZICOM TABLET 4 QL 30/30 EVOTAZ 300 MG-0 MG TABLET 4 QL 30/30 famciclovir 1 mg let 1 QL 60/30 famciclovir 0 mg let 1 QL 60/30 famciclovir 500 mg let 1 QL 60/30 FOSCAVIR 6,000 MG/0 ML BTTL 3 FUZEON 90 MG VIAL 4 QL 60/30 ganciclovir 500 mg vial 1 BvsD GENVOYA TABLET 4 QL 30/30 HARVONI MG TABLET 4 PA,QL / INTELENCE 100 MG TABLET 4 QL 60/30 INTELENCE 0 MG TABLET 4 QL 60/30 INTELENCE MG TABLET 3 QL 1/30 INTRON A 10 MILLION UNITS VIAL 3 INTRON A MILLION UNIT/3 ML 3 INTRON A MILLION UNITS VIAL 3 Comprehensive Formulary 35 INTRON A MILLION UNIT/2.5ML 3 INTRON A 50 MILLION UNITS VIAL 3 INVIRASE 0 MG CAPSULE 3 QL 300/30 INVIRASE 500 MG TABLET 4 QL 1/30 ISENTRESS 100 MG POWDER 2 QL 0/30 PACKET ISENTRESS 100 MG TABLET CHEW 2 QL 0/30 ISENTRESS MG TABLET CHEW 2 QL 0/30 ISENTRESS 400 MG TABLET 4 QL 60/30 KALETRA 100- MG TABLET 3 QL 300/30 KALETRA 0-50 MG TABLET 4 QL 1/30 KALETRA /5 ML ORAL SOLU 4 QL 0ML/30 lamivudine 10 mg/ml oral soln 1 QL 900ML/30 lamivudine 0 mg let 1 QL 60/30 lamivudine 300 mg let 1 QL 30/30 lamivudine hbv 100 mg let 1 lamivudine-zidovudine let 1 QL 60/30 LEXIVA 50 MG/ML SUSPENSION 3 QL 75ML/ LEXIVA 700 MG TABLET 4 QL 1/30 nevirapine 0 mg let 1 QL 60/30 nevirapine 50 mg/5 ml susp 1 QL 10ML/30 nevirapine er 100 mg let 1 QL 90/30 nevirapine er 400 mg let 1 QL 30/30 NORVIR 100 MG SOFTGEL CAP 3 QL 360/30 NORVIR 100 MG TABLET 3 QL 360/30 NORVIR 80 MG/ML SOLUTION 3 QL 0ML/30 ODEFSEY TABLET 4 QL 30/30 PEGASYS 0 MCG/0.5 ML SYRINGE 4 PA,QL 2ML/ PEGASYS 0 MCG/0.5 ML SYRINGE 4 PA,QL 2/ PEGASYS 0 MCG/ML VIAL 4 PA,QL 4/ PEGASYS PROCLICK 5 MCG/0.5 4 PA,QL 2ML/ PEGASYS PROCLICK 0 MCG/0.5 4 PA,QL 2ML/ PEGINTRON 1 MCG KIT 4 PA,QL 4/ +This drug does not count towards your total drug costs. For full description please see key symbol on page 6.

36 PEGINTRON 0 MCG KIT 4 PA,QL 4/ PEGINTRON 50 MCG KIT 4 PA,QL 4/ PEGINTRON 80 MCG KIT 4 PA,QL 4/ PEGINTRON REDIPEN 1 MCG 4 PA,QL 4/ PEGINTRON REDIPEN 1 MCG 4PK 4 PA,QL 4/ PEGINTRON REDIPEN 0 MCG 4 PA,QL 4/ PEGINTRON REDIPEN 0 MCG 4PK 4 PA,QL 4/ PEGINTRON REDIPEN 50 MCG 4 PA,QL 4/ PEGINTRON REDIPEN 50 MCG 4PK 4 PA,QL 4/ PEGINTRON REDIPEN 80 MCG 4 PA,QL 4/ PEGINTRON REDIPEN 80 MCG 4PK 4 PA,QL 4/ PREZCOBIX 800 MG-0 MG TABLET 4 QL 30/30 PREZISTA 100 MG/ML SUSPENSION 3 QL 400ML/30 PREZISTA 0 MG TABLET 3 QL 0/30 PREZISTA 600 MG TABLET 4 QL 60/30 PREZISTA 75 MG TABLET 3 QL 210/30 PREZISTA 800 MG TABLET 4 QL 30/30 RELENZA 5 MG DISKHALER 3 QL 1/3 RESCRIPTOR 100 MG TABLET 3 QL 0/30 RESCRIPTOR 0 MG TABLET 3 QL 0/30 RETROVIR 0 MG/ ML VIAL 3 REYATAZ 0 MG CAPSULE 2 QL 30/30 REYATAZ 0 MG CAPSULE 2 QL 60/30 REYATAZ 300 MG CAPSULE 2 QL 30/30 REYATAZ 50 MG POWDER PACKET 2 QL 0/30 ribavirin 0 mg capsule 1 QL 8/ ribavirin 0 mg let 1 QL 8/ rimantadine hcl 100 mg let 1 SELZENTRY 0 MG TABLET 4 QL 60/30 SELZENTRY 300 MG TABLET 4 QL 1/30 SOVALDI 400 MG TABLET 4 PA,QL / stavudine 1 mg/ml solution 1 QL 2400ML/30 stavudine mg capsule 1 QL 60/30 stavudine mg capsule 1 QL 60/30 stavudine 30 mg capsule 1 QL 60/30 stavudine 40 mg capsule 1 QL 60/30 STRIBILD TABLET 4 QL 30/30 Comprehensive Formulary 36 SUSTIVA 0 MG CAPSULE 2 QL 60/30 SUSTIVA 50 MG CAPSULE 2 QL 90/30 SUSTIVA 600 MG TABLET 2 QL 30/30 TAMIFLU 30 MG CAPSULE 2 QL 2/3 TAMIFLU MG CAPSULE 2 QL /3 TAMIFLU 6 MG/ML SUSPENSION 2 QL 700ML/3 TAMIFLU 75 MG CAPSULE 2 QL /3 TIVICAY 10 MG TABLET 3 QL 60/30 TIVICAY MG TABLET 3 QL 60/30 TIVICAY 50 MG TABLET 4 QL 60/30 trifluridine 1% eye drops 1 TRIUMEQ TABLET 4 QL 30/30 TRUVADA 100 MG-0 MG TABLET 4 QL 30/30 TRUVADA 3 MG-0 MG TABLET 4 QL 30/30 TRUVADA 7 MG-0 MG TABLET 4 QL 30/30 TRUVADA 0 MG-300 MG TABLET 4 QL 30/30 TYBOST 0 MG TABLET 2 QL 30/30 TYZEKA 600 MG TABLET 4 QL 30/30 valacyclovir hcl 1 gram let 1 QL 30/30 valacyclovir hcl 500 mg let 1 QL 30/30 VALCYTE 50 MG/ML SOLUTION 4 valganciclovir 0 mg let 4 VICTRELIS 0 MG CAPSULE 4 PA VIDEX 2 GM PEDIATRIC SOLN 2 QL 900ML/30 VIDEX 4 GM PEDIATRIC SOLN 2 QL 10ML/30 VIRACEPT 0 MG TABLET 4 QL 0/30 VIRACEPT 6 MG TABLET 4 QL 1/30 VIREAD 0 MG TABLET 4 QL 30/30 VIREAD 0 MG TABLET 4 QL 30/30 VIREAD 0 MG TABLET 4 QL 30/30 VIREAD 300 MG TABLET 4 QL 30/30 VIREAD POWDER 4 QL 240GM/30 VITEKTA 0 MG TABLET 4 QL 30/30 VITEKTA 85 MG TABLET 4 QL 30/30 ZIAGEN MG/ML SOLUTION 3 QL 960ML/30 +This drug does not count towards your total drug costs. For full description please see key symbol on page 6.

37 Comprehensive Formulary zidovudine 100 mg capsule 1 QL 0/30 zidovudine 300 mg let 1 QL 60/30 zidovudine 50 mg/5 ml syrup 1 QL 80ML/ ZIRGAN 0.% OPHTHALMIC GEL 3 QL 5GM/30 ZOVIRAX 5% CREAM 3 Anxiolytics alprazolam 0. mg let 1 QL 1/30 alprazolam 0.5 mg let 1 QL 1/30 alprazolam 1 mg let 1 QL 1/30 alprazolam 1 mg/ml oral conc 1 QL 300ML/30 alprazolam 2 mg let 1 QL 0/30 alprazolam er 1 mg let 1 QL 90/30 alprazolam er 2 mg let 1 QL 90/30 alprazolam er 3 mg let 1 QL 90/30 alprazolam odt 0. mg 1 QL 1/30 alprazolam odt 0.5 mg 1 QL 1/30 alprazolam odt 1 mg 1 QL 1/30 alprazolam odt 2 mg 1 QL 0/30 alprazolam xr 0.5 mg let 1 QL 90/30 alprazolam xr 1 mg let 1 QL 90/30 alprazolam xr 2 mg let 1 QL 90/30 alprazolam xr 3 mg let 1 QL 90/30 buspirone hcl 10 mg let 1 buspirone hcl mg let 1 buspirone hcl 30 mg let 1 buspirone hcl 5 mg let 1 buspirone hcl 7.5 mg let 1 chlordiazepoxide 10 mg capsule 1 QL 1/30 chlordiazepoxide mg capsule 1 QL 360/30 chlordiazepoxide 5 mg capsule 1 QL 1/30 clorazepate mg let 1 QL 0/30 clorazepate 3.75 mg let 1 QL 90/30 clorazepate 7.5 mg let 1 QL 90/30 diazepam 10 mg let 1 QL 1/30 diazepam 10 mg/2 ml carpuject 1 diazepam 10 mg/2 ml syringe 1 diazepam 2 mg let 1 QL 1/30 diazepam 5 mg let 1 QL 1/30 diazepam 5 mg/5 ml solution 1 QL 10ML/30 diazepam 5 mg/ml oral conc 1 QL 240ML/30 diazepam 5 mg/ml vial 1 estazolam 1 mg let 1 QL 30/30 estazolam 2 mg let 1 QL 30/30 flurazepam mg capsule 1 QL > 90/3 flurazepam 30 mg capsule 1 QL > 90/3 lorazepam 0.5 mg let 1 QL 90/30 lorazepam 1 mg let 1 QL 1/30 lorazepam 2 mg let 1 QL 0/30 lorazepam 2 mg/ml carpuject 1 lorazepam 2 mg/ml oral concent 1 QL 0ML/30 lorazepam 2 mg/ml vial 1 lorazepam 4 mg/ml carpuject 1 lorazepam 4 mg/ml vial 1 lorazepam intensol 2 mg/ml 1 QL 0ML/30 meprobamate 0 mg let 1 meprobamate 400 mg let 1 midazolam hcl 2 mg/ml syrup 1 oxazepam 10 mg capsule 1 QL 1/30 oxazepam mg capsule 1 QL 1/30 oxazepam 30 mg capsule 1 QL 1/30 triazolam 0.1 mg let 1 QL > 90/3 triazolam 0. mg let 1 QL > 90/3 Bipolar Agents lithium 8 meq/5 ml solution 1 lithium carbonate 0 mg cap 1 lithium carbonate 300 mg cap 1 lithium carbonate 300 mg 1 lithium carbonate 600 mg cap 1 lithium carbonate er 300 mg tb 1 lithium carbonate er 0 mg tb 1 +This drug does not count towards your total drug costs. For full description please see key symbol on page 6. 37

38 Comprehensive Formulary Blood Glucose Regulators acarbose 100 mg let 1 QL 90/30 acarbose mg let 1 QL 90/30 acarbose 50 mg let 1 QL 90/30 APIDRA 100 UNITS/ML VIAL 3 QL 40ML/30,S T APIDRA SOLOSTAR 100 UNITS/ML 3 QL 40ML/30,S T AVANDIA 2 MG TABLET 3 QL 60/30 AVANDIA 4 MG TABLET 3 QL 60/30 AVANDIA 8 MG TABLET 3 QL 30/30 BYDUREON 2 MG PEN INJECT 2 QL 4/ BYDUREON 2 MG VIAL 2 QL 4/ BYETTA 10 MCG DOSE PEN INJ 2 QL 2.4ML/30 BYETTA 5 MCG DOSE PEN INJ 2 QL 1.2ML/30 chlorpropamide 100 mg let 1 chlorpropamide 0 mg let 1 FARXIGA 10 MG TABLET 2 QL 30/30 FARXIGA 5 MG TABLET 2 QL 30/30 glimepiride 1 mg let 1 QL 30/30 glimepiride 2 mg let 1 QL 30/30 glimepiride 4 mg let 1 QL 60/30 glipizide 10 mg let 1 QL 1/30 glipizide 5 mg let 1 QL 60/30 glipizide er 10 mg let 1 QL 60/30 glipizide er 2.5 mg let 1 QL 30/30 glipizide er 5 mg let 1 QL 30/30 glipizide xl 10 mg let 1 QL 60/30 glipizide xl 2.5 mg let 1 QL 30/30 glipizide xl 5 mg let 1 QL 30/30 glipizide-metformin mg 1 QL 240/30 glipizide-metformin mg 1 QL 1/30 glipizide-metformin mg 1 QL 1/30 GLUCAGEN 1 MG HYPOKIT 2 QL 4/30 GLUCAGON 1 MG EMERGENCY KIT 2 QL 4/30 glyburide 1. mg let 1 PA (HRM) glyburide 2.5 mg let 1 PA (HRM) glyburide 5 mg let 1 PA (HRM) glyburide micro 1.5 mg 1 PA (HRM) glyburide micro 3 mg let 1 PA (HRM) glyburide micro 6 mg let 1 PA (HRM) glyburide-metformin mg 1 PA (HRM) glyburide-metformin mg 1 PA (HRM) glyburid-metformin 1.-0 mg 1 PA (HRM) HUMALOG 100 UNITS/ML CARTRIDGE 2 QL 40ML/30 HUMALOG 100 UNITS/ML KWIKPEN 2 QL 40ML/30 HUMALOG 100 UNITS/ML VIAL 2 QL 40ML/30 HUMALOG 0 UNITS/ML KWIKPEN 2 QL 30ML/30 HUMALOG MIX KWIKPEN 2 QL 40ML/30 HUMALOG MIX VIAL 2 QL 40ML/30 HUMALOG MIX 75- KWIKPEN 2 QL 40ML/30 HUMALOG MIX 75- VIAL 2 QL 40ML/30 HUMULIN 70/30 KWIKPEN 2 QL 40ML/30 HUMULIN VIAL 2 QL 40ML/30 HUMULIN N 100 UNITS/ML KWIKPEN 2 QL 40ML/30 HUMULIN N 100 UNITS/ML VIAL 2 QL 40ML/30 HUMULIN R 100 UNITS/ML VIAL 2 QL 40ML/30 HUMULIN R 500 UNITS/ML KWIKPEN 2 QL ML/30 HUMULIN R 500 UNITS/ML VIAL 2 QL ML/30 INVOKAMET 0-1,000 MG TABLET 2 QL 60/30 INVOKAMET MG TABLET 2 QL 60/30 INVOKAMET 50-1,000 MG TABLET 2 QL 60/30 INVOKAMET MG TABLET 2 QL 60/30 INVOKANA 100 MG TABLET 2 QL 30/30 +This drug does not count towards your total drug costs. For full description please see key symbol on page 6. 38

39 Comprehensive Formulary INVOKANA 300 MG TABLET 2 QL 30/30 JANUMET 50-1,000 MG TABLET 2 QL 60/30 JANUMET MG TABLET 2 QL 60/30 JANUMET XR 100-1,000 MG TABLET 2 QL 30/30 JANUMET XR 50-1,000 MG TABLET 2 QL 60/30 JANUMET XR MG TABLET 2 QL 30/30 JANUVIA 100 MG TABLET 2 QL 30/30 JANUVIA MG TABLET 2 QL 30/30 JANUVIA 50 MG TABLET 2 QL 30/30 JENTADUETO 2.5 MG-1000 MG TAB 2 QL 60/30 JENTADUETO 2.5 MG-500 MG TAB 2 QL 60/30 JENTADUETO 2.5 MG-850 MG TAB 2 QL 60/30 JENTADUETO XR 2.5 MG-1,000 MG 2 QL 60/30 JENTADUETO XR 5 MG-1,000 MG TB 2 QL 30/30 KOMBIGLYZE XR 2.5-1,000 MG TAB 3 QL 60/30,ST KOMBIGLYZE XR 5-1,000 MG TAB 3 QL 30/30,ST KOMBIGLYZE XR MG TABLET 3 QL 30/30,ST LANTUS 100 UNITS/ML VIAL 2 QL 30ML/30 LANTUS SOLOSTAR 100 UNITS/ML 2 QL 30ML/30 LEVEMIR 100 UNITS/ML VIAL 2 QL 40ML/30 LEVEMIR FLEXTOUCH 100 UNITS/ML 2 QL 40ML/30 metformin er 1,000 mg osm- 1 QL 60/30 metformin hcl 1,000 mg let 1 QL 60/30 metformin hcl 500 mg let 1 QL 0/30 metformin hcl 850 mg let 1 QL 90/30 metformin hcl er 500 mg osm-tb 1 QL 0/30 metformin hcl er 500 mg let 1 QL 1/30 metformin hcl er 750 mg let 1 QL 60/30 miglitol 100 mg let 1 QL 90/30 miglitol mg let 1 QL 90/30 miglitol 50 mg let 1 QL 90/30 nateglinide 1 mg let 1 QL 90/30 nateglinide 60 mg let 1 QL 90/30 NOVOLIN UNIT/ML VIAL 3 QL 40ML/30,S T NOVOLIN N 100 UNITS/ML VIAL 3 QL 40ML/30,S T NOVOLIN R 100 UNITS/ML VIAL 3 QL 40ML/30,S T NOVOLOG 100 UNIT/ML CARTRIDGE 3 QL 40ML/30,S T NOVOLOG 100 UNIT/ML VIAL 3 QL 40ML/30,S T NOVOLOG 100 UNITS/ML FLEXPEN 3 QL 40ML/30,S T NOVOLOG MIX FLEXPEN SYRN 3 QL 40ML/30,S T NOVOLOG MIX VIAL 3 QL 40ML/30,S T ONGLYZA 2.5 MG TABLET 3 QL 30/30,ST ONGLYZA 5 MG TABLET 3 QL 30/30,ST pioglitazone hcl mg let 1 QL 30/30 pioglitazone hcl 30 mg let 1 QL 30/30 pioglitazone hcl mg let 1 QL 30/30 pioglitazone-glimepiride QL 30/30 pioglitazone-glimepiride QL 30/30 pioglitazone-metformin QL 90/30 pioglitazone-metformin QL 90/30 PROGLYCEM 50 MG/ML ORAL SUSP 3 RELION NOVOLIN VIAL 3 QL 40ML/30,S T RELION NOVOLIN N 100 UNIT/ML 3 QL 40ML/30,S T +This drug does not count towards your total drug costs. For full description please see key symbol on page 6. 39

40 RELION NOVOLIN R 100 UNIT/ML 3 QL 40ML/30,S T repaglinide 0.5 mg let 1 QL 1/30 repaglinide 1 mg let 1 QL 1/30 repaglinide 2 mg let 1 QL 240/30 RIOMET 500 MG/5 ML SOLUTION 2 QL 750ML/30 SYMLINPEN 1 PEN INJECTOR 3 QL ML/30 SYMLINPEN 60 PEN INJECTOR 3 QL 6ML/30 tolazamide 0 mg let 1 tolazamide 500 mg let 1 tolbutamide 500 mg let 1 TOUJEO SOLOSTAR 300 UNITS/ML 2 QL 9ML/30 TRADJENTA 5 MG TABLET 2 QL 30/30 TRESIBA FLEXTOUCH 100 UNITS/ML 2 QL 30ML/30 TRESIBA FLEXTOUCH 0 UNITS/ML 2 QL ML/30 TRULICITY 0.75 MG/0.5 ML PEN 2 QL 2ML/ TRULICITY 1.5 MG/0.5 ML PEN 2 QL 2ML/ VICTOZA 3-PAK MG/3 ML PEN 2 QL 9ML/30 XIGDUO XR 10 MG-1,000 MG TAB 2 QL 30/30 XIGDUO XR 10 MG-500 MG TABLET 2 QL 30/30 XIGDUO XR 5 MG-1,000 MG TABLET 2 QL 60/30 XIGDUO XR 5 MG-500 MG TABLET 2 QL 30/30 Blood Products/Modifiers/Volume Expanders AGGRENOX MG-0 MG CAPSULE 3 QL 60/30,ST aminocaproic acid 1,000 mg 1 aminocaproic acid % solution 1 aminocaproic acid 5 g/ ml vl 1 aminocaproic acid 500 mg 1 anagrelide hcl 0.5 mg capsule 1 anagrelide hcl 1 mg capsule 1 ARANESP 10 MCG/0.4 ML SYRINGE 2 PA,QL 1.6ML/ ARANESP 100 MCG/0.5 ML SYRINGE 4 PA,QL 2ML/ ARANESP 100 MCG/ML VIAL 4 PA,QL 4ML/ Comprehensive Formulary 40 ARANESP 0 MCG/0.3 ML SYRINGE 4 PA,QL 1.2ML/ ARANESP 0 MCG/0.4 ML SYRINGE 4 PA,QL 1.6ML/ ARANESP 0 MCG/ML VIAL 4 PA,QL 4ML/ ARANESP MCG/0.42 ML SYRING 2 PA,QL 1.68ML/ ARANESP MCG/ML VIAL 2 PA,QL 4ML/ ARANESP 300 MCG/0.6 ML SYRINGE 4 PA,QL 2.4ML/ ARANESP 300 MCG/ML VIAL 4 PA,QL 4ML/ ARANESP 40 MCG/0.4 ML SYRINGE 2 PA,QL 1.6ML/ ARANESP 40 MCG/ML VIAL 2 PA,QL 4ML/ ARANESP 500 MCG/1 ML SYRINGE 4 PA,QL 1ML/21 ARANESP 60 MCG/0.3 ML SYRINGE 2 PA,QL 1.2ML/ ARANESP 60 MCG/ML VIAL 2 PA,QL 4ML/ aspirin-dipyridam er -0 mg 1 QL 60/30 BRILINTA 60 MG TABLET 2 QL 60/30 BRILINTA 90 MG TABLET 2 QL 60/30 cilostazol 100 mg let 1 cilostazol 50 mg let 1 clopidogrel 300 mg let 1 QL 2/3 clopidogrel 75 mg let 1 QL 30/30 COUMADIN 1 MG TABLET 3 COUMADIN 10 MG TABLET 3 COUMADIN 2 MG TABLET 3 COUMADIN 2.5 MG TABLET 3 COUMADIN 3 MG TABLET 3 COUMADIN 4 MG TABLET 3 COUMADIN 5 MG TABLET 3 COUMADIN 6 MG TABLET 3 COUMADIN 7.5 MG TABLET 3 dipyridamole mg let 1 dipyridamole 50 mg let 1 +This drug does not count towards your total drug costs. For full description please see key symbol on page 6.

41 Comprehensive Formulary dipyridamole 75 mg let 1 EFFIENT 10 MG TABLET 2 QL 30/30 EFFIENT 5 MG TABLET 2 QL 30/30 ELIQUIS 2.5 MG TABLET 3 QL 60/30 ELIQUIS 5 MG TABLET 3 QL 74/30 enoxaparin 100 mg/ml syringe 1 QL 30ML/90 enoxaparin 1 mg/0.8 ml syr 1 QL 24ML/90 enoxaparin 0 mg/ml syringe 4 QL 30ML/90 enoxaparin 30 mg/0.3 ml syr 1 QL 9/90 enoxaparin 300 mg/3 ml vial 1 QL 30ML/90 enoxaparin 40 mg/0.4 ml syr 1 QL 12ML/90 enoxaparin 60 mg/0.6 ml syr 1 QL ML/90 enoxaparin 80 mg/0.8 ml syr 1 QL 24ML/90 EPOGEN 2,000 UNITS/ML VIAL 3 PA EPOGEN,000 UNITS/2 ML VIAL 3 PA EPOGEN,000 UNITS/ML VIAL 3 PA EPOGEN 3,000 UNITS/ML VIAL 3 PA EPOGEN 4,000 UNITS/ML VIAL 3 PA fondaparinux 10 mg/0.8 ml syr 4 QL 24/30 fondaparinux 2.5 mg/0.5 ml syr 1 QL ML/30 fondaparinux 5 mg/0.4 ml syr 4 QL 12ML/30 fondaparinux 7.5 mg/0.6 ml syr 4 QL ML/30 FRAGMIN 10,000 UNITS/ML SYRING 4 QL 30ML/30,S T FRAGMIN 12,500 UNITS/0.5 ML 4 QL ML/30,S T FRAGMIN,000 UNITS/0.6 ML 4 QL ML/30,S T FRAGMIN,000 UNITS/0. ML 4 QL 21.6ML/30, ST FRAGMIN 2,500 UNITS/0.2 ML SYR 3 QL 6ML/30,ST FRAGMIN 5,000 UNITS/0.2 ML SYR 3 QL 6ML/30,ST FRAGMIN 7,500 UNITS/0.3 ML SYR 4 QL 9/30,ST FRAGMIN 95,000 UNITS/3.8 ML VL 4 QL.8ML/30, ST GRANIX 300 MCG/0.5 ML SAFE SYR 4 GRANIX 0 MCG/0.8 ML SAFE SYR 4 heparin 10,000 unit/10 ml vial 1 heparin,000 unit/500 ml-d5w 1 heparin 50,000 units/10 ml vl 1 heparin sod 10,000 unit/ml vl 1 heparin sod,000 unit/ml vl 1 heparin sod 5,000 unit/0.5 ml 1 heparin sodium 1 heparin-1/2ns,000 units/0 1 heparin-1/2ns,000 units/500 1 heparin-d5w,000 unit/0 ml 1 heparin-d5w,000 unit/500 ml 1 heparin-ns 1,000 units/500 ml 1 heparin-ns 2,000 unit/1,000 ml 1 IPRIVASK MG VIAL 4 QL 30/30 JANTOVEN 1 MG TABLET 1 JANTOVEN 10 MG TABLET 1 JANTOVEN 2 MG TABLET 1 JANTOVEN 2.5 MG TABLET 1 JANTOVEN 3 MG TABLET 1 JANTOVEN 4 MG TABLET 1 JANTOVEN 5 MG TABLET 1 JANTOVEN 6 MG TABLET 1 JANTOVEN 7.5 MG TABLET 1 LEUKINE 0 MCG VIAL 4 NEULASTA 6 MG/0.6 ML SYRINGE 4 QL 1.2ML/ NEUMEGA 5 MG VIAL 4 PA NEUPOGEN 300 MCG/0.5 ML SYR 4 QL 7/ +This drug does not count towards your total drug costs. For full description please see key symbol on page 6. 41

42 Comprehensive Formulary NEUPOGEN 300 MCG/ML VIAL 4 QL ML/ NEUPOGEN 0 MCG/0.8 ML SYR 4 QL.2ML/ NEUPOGEN 0 MCG/1.6 ML VIAL 4 QL.4ML/30 PRADAXA 0 MG CAPSULE 2 QL 60/30 PRADAXA 0 MG CAPSULE 2 QL 60/30 PRADAXA 75 MG CAPSULE 2 QL 60/30 PROCRIT 10,000 UNITS/ML VIAL 2 PA,QL 12ML/ PROCRIT 2,000 UNITS/ML VIAL 2 PA,QL 12ML/ PROCRIT,000 UNITS/ML VIAL 4 PA,QL 12ML/ PROCRIT 3,000 UNITS/ML VIAL 2 PA,QL 12ML/ PROCRIT 4,000 UNITS/ML VIAL 2 PA,QL 12ML/ PROCRIT 40,000 UNITS/ML VIAL 4 PA,QL 6ML/ PROMACTA 12.5 MG TABLET 4 QL 30/30 PROMACTA MG TABLET 4 QL 30/30 PROMACTA 50 MG TABLET 4 QL 30/30 PROMACTA 75 MG TABLET 4 QL 30/30 SAVAYSA MG TABLET 3 QL 30/30 SAVAYSA 30 MG TABLET 3 QL 30/30 SAVAYSA 60 MG TABLET 3 QL 30/30 tranexamic acid 1,000 mg/10 ml 1 tranexamic acid 0 mg let 1 QL 30/ warfarin sodium 1 mg let 1 warfarin sodium 10 mg let 1 warfarin sodium 2 mg let 1 warfarin sodium 2.5 mg let 1 warfarin sodium 3 mg let 1 warfarin sodium 4 mg let 1 warfarin sodium 5 mg let 1 warfarin sodium 6 mg let 1 warfarin sodium 7.5 mg let 1 XARELTO 10 MG TABLET 2 QL 30/30 XARELTO MG TABLET 2 QL 60/30 XARELTO MG TABLET 2 QL 30/30 XARELTO STARTER PACK 2 QL 102/3 ZARXIO 300 MCG/0.5 ML SYRINGE 4 ZARXIO 0 MCG/0.8 ML SYRINGE 4 Cardiovascular Agents acebutolol 0 mg capsule 1 acebutolol 400 mg capsule 1 acetazolamide 1 mg let 1 acetazolamide 0 mg let 1 acetazolamide sod 500 mg vial 1 ADVICOR 1,000 MG- MG TABLET 3 QL 30/30 ADVICOR 1,000 MG-40 MG TABLET 3 QL 30/30 ADVICOR 500 MG- MG TABLET 3 QL 30/30 ADVICOR 750 MG- MG TABLET 3 QL 30/30 AFEDITAB CR 30 MG TABLET 1 QL 30/30 AFEDITAB CR 60 MG TABLET 1 QL 60/30 amiloride hcl 5 mg let 1 amiloride hcl-hctz 5-50 mg 1 amiodarone 0 mg/3 ml amp 1 amiodarone 0 mg/9 ml vial 1 amiodarone 900 mg/ ml vial 1 amiodarone hcl 100 mg let 1 amiodarone hcl 0 mg let 1 amiodarone hcl 400 mg let 1 amlodipine besylate 10 mg 1 QL 30/30 amlodipine besylate 2.5 mg 1 QL 30/30 amlodipine besylate 5 mg 1 QL /30 amlodipine-atorvast mg 1 QL 30/30 amlodipine-atorvast 10- mg 1 QL 30/30 amlodipine-atorvast mg 1 QL 30/30 amlodipine-atorvast mg 1 QL 30/30 amlodipine-atorvast mg 1 QL 30/30 amlodipine-atorvast 2.5- mg 1 QL 30/30 amlodipine-atorvast mg 1 QL 30/30 amlodipine-atorvast 5-10 mg 1 QL 30/30 amlodipine-atorvast 5- mg 1 QL 30/30 amlodipine-atorvast 5-40 mg 1 QL 30/30 amlodipine-atorvast 5-80 mg 1 QL 30/30 amlodipine-benazepril 10- mg 1 QL 30/30 +This drug does not count towards your total drug costs. For full description please see key symbol on page 6. 42

43 Comprehensive Formulary amlodipine-benazepril mg 1 QL 30/30 amlodipine-benazepril QL 30/30 amlodipine-benazepril 5-10 mg 1 QL 30/30 amlodipine-benazepril 5- mg 1 QL 30/30 amlodipine-benazepril 5-40 mg 1 QL 30/30 amlodipine-valsartan 10-0 mg 1 QL 30/30 amlodipine-valsartan 10-0 mg 1 QL 30/30 amlodipine-valsartan 5-0 mg 1 QL 30/30 amlodipine-valsartan 5-0 mg 1 QL 30/30 amlod-valsa-hctz mg 1 QL 30/30 amlod-valsa-hctz mg 1 QL 30/30 amlod-valsa-hctz mg 1 QL 30/30 amlod-valsa-hctz mg 1 QL 30/30 amlod-valsa-hctz 5-0- mg 1 QL 30/30 atenolol 100 mg let 1 atenolol mg let 1 atenolol 50 mg let 1 atenolol-chlorthalidone atenolol-chlorthalidone 50-1 atorvastatin 10 mg let 1 QL 30/30 atorvastatin mg let 1 QL 30/30 atorvastatin 40 mg let 1 QL 30/30 atorvastatin 80 mg let 1 QL 30/30 benazepril hcl 10 mg let 1 QL 30/30 benazepril hcl mg let 1 QL 30/30 benazepril hcl 40 mg let 1 QL 60/30 benazepril hcl 5 mg let 1 QL 30/30 benazepril-hctz mg 1 QL 30/30 benazepril-hctz mg 1 QL 30/30 benazepril-hctz - mg 1 QL 30/30 benazepril-hctz 5-6. mg 1 QL 30/30 BENICAR MG TABLET 3 QL 30/30,ST BENICAR 40 MG TABLET 3 QL 30/30,ST BENICAR 5 MG TABLET 3 QL 30/30,ST BENICAR HCT MG TABLET 3 QL 30/30,ST BENICAR HCT MG TABLET 3 QL 30/30,ST BENICAR HCT 40- MG TABLET 3 QL 30/30,ST betaxolol 10 mg let 1 betaxolol mg let 1 BIDIL TABLET 3 QL 0/30 bisoprolol fumarate 10 mg 1 bisoprolol fumarate 5 mg 1 bisoprolol-hctz mg 1 bisoprolol-hctz mg tb 1 bisoprolol-hctz 5-6. mg 1 bumetanide 0. mg/ml vial 1 bumetanide 0.5 mg let 1 bumetanide 1 mg let 1 bumetanide 2 mg let 1 BYSTOLIC 10 MG TABLET 2 QL 30/30 BYSTOLIC 2.5 MG TABLET 2 QL 30/30 BYSTOLIC MG TABLET 2 QL 60/30 BYSTOLIC 5 MG TABLET 2 QL 30/30 candesartan cilexetil mg tb 1 QL 30/30 candesartan cilexetil mg tb 1 QL 30/30 candesartan cilexetil 4 mg 1 QL 30/30 candesartan cilexetil 8 mg 1 QL 30/30 candesartan-hctz mg tb 1 QL 30/30 candesartan-hctz mg tb 1 QL 30/30 candesartan-hctz - mg 1 QL 30/30 captopril 100 mg let 1 QL 1/30 captopril 12.5 mg let 1 QL 90/30 captopril mg let 1 QL 90/30 captopril 50 mg let 1 QL 0/30 captopril-hctz - mg let 1 QL 90/30 captopril-hctz - mg let 1 QL 60/30 captopril-hctz 50- mg let 1 QL 90/30 captopril-hctz 50- mg let 1 QL 60/30 CARDENE-DEX MG/0 ML SOLN 3 CARDENE-DEX 40 MG/0 ML IV 3 CARDENE-NACL MG/0 ML 3 SOLN CARDENE-NACL 40 MG/0 ML IV 3 CARTIA XT 1 MG CAPSULE 1 QL 30/30 CARTIA XT 0 MG CAPSULE 1 QL 30/30 +This drug does not count towards your total drug costs. For full description please see key symbol on page 6.

44 CARTIA XT 240 MG CAPSULE 1 QL 60/30 CARTIA XT 300 MG CAPSULE 1 QL 30/30 carvedilol 12.5 mg let 1 carvedilol mg let 1 carvedilol 3.1 mg let 1 carvedilol 6. mg let 1 chlorothiazide 0 mg let 1 chlorothiazide 500 mg let 1 chlorothiazide sod 500 mg vial 1 chlorthalidone mg let 1 chlorthalidone 50 mg let 1 cholestyramine light packet 1 cholestyramine light powder 1 cholestyramine packet 1 cholestyramine powder 1 clonidine 0.1 mg/day patch 1 QL 4/ clonidine 0.2 mg/day patch 1 QL 4/ clonidine 0.3 mg/day patch 1 QL 8/ clonidine hcl 0.1 mg let 1 clonidine hcl 0.2 mg let 1 clonidine hcl 0.3 mg let 1 clorpres 0.1- let 1 clorpres 0.2- let 1 clorpres 0.3- let 1 colestipol hcl 1 gm let 1 colestipol hcl granules 1 colestipol hcl granules packet 1 COREG CR 10 MG CAPSULE 2 COREG CR MG CAPSULE 2 COREG CR 40 MG CAPSULE 2 COREG CR 80 MG CAPSULE 2 CRESTOR 10 MG TABLET 3 QL 30/30,ST CRESTOR MG TABLET 3 QL 30/30,ST CRESTOR 40 MG TABLET 3 QL 30/30,ST CRESTOR 5 MG TABLET 3 QL 30/30,ST DEMSER 0 MG CAPSULE 2 digitek 1 mcg let 1 QL 30/30 Comprehensive Formulary 44 digitek 0 mcg let 1 PA (HRM),QL 30/30 digox 1 mcg let 1 QL 30/30 digox 0 mcg let 1 PA (HRM),QL 30/30 digoxin 0.05 mg/ml solution 1 digoxin 1 mcg let 1 QL 30/30 digoxin 0 mcg let 1 PA (HRM),QL 30/30 digoxin 500 mcg/2 ml ampule 1 PA (HRM) DILT XR 1 MG CAPSULE 1 QL 30/30 DILT XR 0 MG CAPSULE 1 QL 30/30 DILT XR 240 MG CAPSULE 1 QL 60/30 DILT-CD 0 MG CAPSULE 1 DILT-CD 240 MG CAPSULE 1 diltiazem 1 mg let 1 diltiazem 1 mg/ ml vial 1 diltiazem 12hr er 1 mg cap 1 diltiazem 12hr er 60 mg cap 1 diltiazem 12hr er 90 mg cap 1 diltiazem 24hr cd 1 mg cap 1 QL 30/30 diltiazem 24hr cd 0 mg cap 1 QL 30/30 diltiazem 24hr cd 240 mg cap 1 QL 60/30 diltiazem 24hr cd 300 mg cap 1 QL 30/30 diltiazem 24hr cd 360 mg cap 1 QL 30/30 diltiazem 24hr er 1 mg cap 1 QL 30/30 diltiazem 24hr er 0 mg cap 1 QL 30/30 diltiazem 24hr er 240 mg cap 1 QL 60/30 diltiazem 24hr er 300 mg cap 1 QL 30/30 diltiazem 24hr er 360 mg cap 1 QL 30/30 diltiazem mg/5 ml vial 1 diltiazem 30 mg let 1 diltiazem 50 mg/10 ml vial 1 diltiazem 60 mg let 1 diltiazem 90 mg let 1 diltiazem er 1 mg capsule 1 QL 30/30 diltiazem er 0 mg capsule 1 QL 30/30 diltiazem er 0 mg let 1 QL 30/30 +This drug does not count towards your total drug costs. For full description please see key symbol on page 6.

45 Comprehensive Formulary diltiazem er 240 mg capsule 1 QL 60/30 diltiazem er 240 mg let 1 QL 60/30 diltiazem er 300 mg let 1 QL 30/30 diltiazem er 360 mg let 1 QL 30/30 diltiazem er 4 mg let 1 QL 30/30 diltiazem hcl 100 mg vial 1 diltiazem hcl er 240 mg cap 1 QL 60/30 diltiazem hcl er 300 mg cap 1 QL 30/30 diltiazem hcl er 360 mg cap 1 QL 30/30 diltiazem hcl er 4 mg cap 1 QL 30/30 disopyramide 100 mg capsule 1 disopyramide 0 mg capsule 1 DIURIL 0 MG/5 ML ORAL SUSP 2 dofetilide 1 mcg capsule 1 QL 60/30 dofetilide 0 mcg capsule 1 QL 60/30 dofetilide 500 mcg capsule 1 QL 60/30 DUTOPROL MG TABLET 3 QL 60/30 DUTOPROL MG TABLET 3 QL 60/30 DUTOPROL MG TABLET 3 QL 60/30 DYRENIUM 100 MG CAPSULE 3 DYRENIUM 50 MG CAPSULE 3 EDECRIN MG TABLET 2 enalapril maleate 10 mg 1 QL 60/30 enalapril maleate 2.5 mg 1 QL 60/30 enalapril maleate mg 1 QL 60/30 enalapril maleate 5 mg let 1 QL 60/30 enalaprilat 2.5 mg/2 ml vial 1 enalapril-hctz 10- mg let 1 QL 60/30 enalapril-hctz mg 1 QL 30/30 ENTRESTO 24 MG- MG TABLET 2 PA,QL 60/30 ENTRESTO MG-51 MG TABLET 2 PA,QL 60/30 ENTRESTO 97 MG-103 MG TABLET 2 PA,QL 60/30 eplerenone mg let 1 eplerenone 50 mg let 1 eprosartan mesylate 600 mg 1 QL 30/30 esmolol hcl 100 mg/10 ml vial 1 ethacrynate sodium 50 mg vial 1 ethacrynic acid mg let 1 felodipine er 10 mg let 1 QL 30/30 felodipine er 2.5 mg let 1 QL 30/30 felodipine er 5 mg let 1 QL 30/30 fenofibrate 1 mg let 1 QL 30/30 fenofibrate 0 mg capsule 1 QL 30/30 fenofibrate 4 mg capsule 1 QL 30/30 fenofibrate 5 mg let 1 QL 30/30 fenofibrate 0 mg capsule 1 QL 30/30 fenofibrate 0 mg let 1 QL 30/30 fenofibrate 0 mg capsule 1 QL 30/30 fenofibrate 40 mg let 1 QL 60/30 fenofibrate mg capsule 1 QL 60/30 fenofibrate mg let 1 QL 60/30 fenofibrate 50 mg capsule 1 QL 60/30 fenofibrate 54 mg let 1 QL 60/30 fenofibrate 67 mg capsule 1 QL 60/30 fenofibric acid 105 mg let 1 QL 30/30 fenofibric acid 35 mg let 1 QL 60/30 fenofibric acid dr 5 mg cap 1 QL 30/30 fenofibric acid dr mg cap 1 QL 60/30 flecainide acetate 100 mg 1 flecainide acetate 0 mg 1 flecainide acetate 50 mg 1 fluvastatin er 80 mg let 1 QL 30/30 fluvastatin sodium mg cap 1 QL 30/30 fluvastatin sodium 40 mg cap 1 QL 60/30 fosinopril sodium 10 mg 1 QL 60/30 fosinopril sodium mg 1 QL 60/30 fosinopril sodium 40 mg 1 QL 60/30 fosinopril-hctz mg 1 QL 1/30 fosinopril-hctz mg 1 QL 1/30 furosemide 10 mg/ml solution 1 furosemide 10 mg/ml syringe 1 furosemide 100 mg/10 ml vial 1 furosemide mg let 1 furosemide 40 mg let 1 furosemide 40 mg/5 ml soln 1 furosemide 80 mg let 1 gemfibrozil 600 mg let 1 QL 60/30 +This drug does not count towards your total drug costs. For full description please see key symbol on page 6.

46 Comprehensive Formulary guanfacine 1 mg let 1 guanfacine 2 mg let 1 hydralazine 10 mg let 1 hydralazine 100 mg let 1 hydralazine mg/ml vial 1 hydralazine mg let 1 hydralazine 50 mg let 1 hydrochlorothiazide 12.5 mg cp 1 hydrochlorothiazide 12.5 mg tb 1 hydrochlorothiazide mg 1 hydrochlorothiazide 50 mg 1 indapamide 1. mg let 1 indapamide 2.5 mg let 1 INNOPRAN XL 1 MG CAPSULE 3 INNOPRAN XL 80 MG CAPSULE 3 irbesartan 0 mg let 1 QL 30/30 irbesartan 300 mg let 1 QL 30/30 irbesartan 75 mg let 1 QL 30/30 irbesartan-hctz mg tb 1 QL 30/30 irbesartan-hctz mg tb 1 QL 30/30 isosorbide dn 10 mg let 1 isosorbide dn mg let 1 isosorbide dn 30 mg let 1 isosorbide dn 5 mg let 1 isosorbide dn er 40 mg let 1 isosorbide mn 10 mg let 1 isosorbide mn mg let 1 isosorbide mn er 1 mg 1 isosorbide mn er 30 mg let 1 isosorbide mn er 60 mg let 1 isoxsuprine 10mg 1 + ISOXSUPRINE TAB HCL MG 2 + isradipine 2.5 mg capsule 1 isradipine 5 mg capsule 1 JUXTAPID 10 MG CAPSULE 4 PA JUXTAPID MG CAPSULE 4 PA JUXTAPID 30 MG CAPSULE 4 PA JUXTAPID 40 MG CAPSULE 4 PA JUXTAPID 5 MG CAPSULE 4 PA JUXTAPID 60 MG CAPSULE 4 PA KYNAMRO 0 MG/ML SYRINGE 4 PA,QL 4/ labetalol hcl 100 mg let 1 labetalol hcl 100 mg/ ml vl 1 labetalol hcl 0 mg let 1 labetalol hcl 300 mg let 1 LANOXIN 1 MCG TABLET 2 QL 30/30 LANOXIN 7.5 MCG TABLET 3 PA (HRM) LANOXIN 0 MCG TABLET 2 PA (HRM),QL 30/30 LANOXIN 62.5 MCG TABLET 3 LANOXIN PED 100 MCG/ML AMPUL 2 PA (HRM) lidocaine hcl 1% abboject 1 lidocaine hcl 2% luer-jet 1 lisinopril 10 mg let 1 QL 60/30 lisinopril 2.5 mg let 1 QL 60/30 lisinopril mg let 1 QL 60/30 lisinopril 30 mg let 1 QL 60/30 lisinopril 40 mg let 1 QL 60/30 lisinopril 5 mg let 1 QL 60/30 lisinopril-hctz mg 1 QL 30/30 lisinopril-hctz mg 1 QL 1/30 lisinopril-hctz - mg 1 QL 60/30 losartan potassium 100 mg 1 QL 30/30 losartan potassium mg 1 QL 30/30 losartan potassium 50 mg 1 QL 30/30 losartan-hctz mg 1 QL 30/30 losartan-hctz 100- mg 1 QL 30/30 losartan-hctz mg 1 QL 30/30 lovastatin 10 mg let 1 QL 30/30 lovastatin mg let 1 QL 30/30 lovastatin 40 mg let 1 QL 60/30 MATZIM LA 0 MG TABLET 1 QL 30/30 MATZIM LA 240 MG TABLET 1 QL 60/30 MATZIM LA 300 MG TABLET 1 QL 30/30 MATZIM LA 360 MG TABLET 1 QL 30/30 MATZIM LA 4 MG TABLET 1 QL 30/30 methyclothiazide 5 mg let 1 methyldopa 0 mg let 1 PA (HRM) methyldopa 500 mg let 1 PA (HRM) +This drug does not count towards your total drug costs. For full description please see key symbol on page 6.

47 Comprehensive Formulary methyldopa-hctz 0- mg 1 PA (HRM) methyldopa-hctz 0- mg 1 PA (HRM) methyldopate 0 mg/5 ml vial 1 PA (HRM) metolazone 10 mg let 1 metolazone 2.5 mg let 1 metolazone 5 mg let 1 metoprolol 1 mg/ml carpuject 1 metoprolol succ er 100 mg 1 QL /30 metoprolol succ er 0 mg 1 QL 60/30 metoprolol succ er mg 1 QL 60/30 metoprolol succ er 50 mg 1 QL 60/30 metoprolol tart 5 mg/5 ml amp 1 metoprolol tartrate 100 mg 1 metoprolol tartrate mg 1 metoprolol tartrate 37.5 mg tb 1 metoprolol tartrate 50 mg 1 metoprolol tartrate 75 mg 1 metoprolol-hctz 100- mg 1 metoprolol-hctz mg 1 metoprolol-hctz 50- mg 1 mexiletine 0 mg capsule 1 mexiletine 0 mg capsule 1 mexiletine 0 mg capsule 1 midodrine hcl 10 mg let 1 midodrine hcl 2.5 mg let 1 midodrine hcl 5 mg let 1 minitran 0.1 mg/hr patch 1 QL 30/30 minitran 0.2 mg/hr patch 1 QL 30/30 minitran 0.4 mg/hr patch 1 QL 30/30 minitran 0.6 mg/hr patch 1 QL 30/30 minoxidil 10 mg let 1 minoxidil 2.5 mg let 1 moexipril hcl mg let 1 moexipril hcl 7.5 mg let 1 moexipril-hctz mg 1 QL 60/30 moexipril-hctz - mg let 1 QL 60/30 moexipril-hctz mg 1 QL 30/30 MULTAQ 400 MG TABLET 2 QL 60/30 nadolol mg let 1 nadolol 40 mg let 1 nadolol 80 mg let 1 nadolol-bendroflu 40-5 mg 1 QL 30/30 nadolol-bendroflu 80-5 mg 1 niacin er 1,000 mg let 1 QL 60/30 niacin er 500 mg let 1 QL 30/30 niacin er 750 mg let 1 QL 60/30 niacor 500 mg let 1 nicardipine mg capsule 1 nicardipine mg/10 ml vial 1 nicardipine 30 mg capsule 1 nifedical xl 30 mg let 1 QL 30/30 nifedical xl 60 mg let 1 QL 60/30 nifedipine 10 mg capsule 1 nifedipine mg capsule 1 nifedipine er 30 mg let 1 QL 30/30 nifedipine er 60 mg let 1 QL 60/30 nifedipine er 90 mg let 1 QL 30/30 nimodipine 30 mg capsule 1 nisoldipine er mg let 1 nisoldipine er mg let 1 nisoldipine er.5 mg let 1 nisoldipine er 30 mg let 1 nisoldipine er mg let 1 nisoldipine er 40 mg let 1 nisoldipine er 8.5 mg let 1 NITRO-BID 2% OINTMENT 3 NITRO-DUR 0.3 MG/HR PATCH 3 NITRO-DUR 0.8 MG/HR PATCH 3 nitroglycer cap 2.5mg er 1 + nitroglycer cap 6.5mg er 1 + nitroglycer cap 9mg er 1 + nitroglycerin 0.1 mg/hr patch 1 QL 30/30 nitroglycerin 0.2 mg/hr patch 1 QL 30/30 nitroglycerin 0.4 mg/hr patch 1 QL 30/30 nitroglycerin 0.6 mg/hr patch 1 QL 30/30 nitroglycerin 5 mg/ml vial 1 nitroglycerin lingual 0.4 mg 1 NITROSTAT 0.3 MG TABLET SL 2 NITROSTAT 0.4 MG TABLET SL 2 NITROSTAT 0.6 MG TABLET SL 2 +This drug does not count towards your total drug costs. For full description please see key symbol on page 6.

48 Comprehensive Formulary NORPACE CR 100 MG CAPSULE 3 NORPACE CR 0 MG CAPSULE 3 NORTHERA 100 MG CAPSULE 4 PA,QL 90/30 NORTHERA 0 MG CAPSULE 4 PA,QL 0/30 NORTHERA 300 MG CAPSULE 4 PA,QL 0/30 NYMALIZE 60 MG/ ML SOLUTION 4 omega-3 ethyl esters 1 gm cap 1 QL 1/30 pacerone 100 mg let 1 pacerone 0 mg let 1 pacerone 400 mg let 1 pentoxifylline er 400 mg 1 perindopril erbumine 2 mg 1 QL 30/30 perindopril erbumine 4 mg 1 QL 30/30 perindopril erbumine 8 mg 1 QL 60/30 phenoxybenzamine hcl 10 mg cap 4 pindolol 10 mg let 1 pindolol 5 mg let 1 pravastatin sodium 10 mg 1 QL 30/30 pravastatin sodium mg 1 QL 30/30 pravastatin sodium 40 mg 1 QL 30/30 pravastatin sodium 80 mg 1 QL 30/30 prazosin 1 mg capsule 1 prazosin 2 mg capsule 1 prazosin 5 mg capsule 1 prevalite packet 1 prevalite powder 1 procainamide 100 mg/ml vial 1 procainamide 500 mg/ml vial 1 propafenone hcl 0 mg let 1 propafenone hcl 5 mg 1 propafenone hcl 300 mg 1 propafenone hcl er 5 mg cap 1 propafenone hcl er 5 mg cap 1 propafenone hcl er 4 mg cap 1 propranolol 1 mg/ml vial 1 propranolol 10 mg let 1 propranolol mg let 1 propranolol mg/5 ml soln 1 propranolol 40 mg let 1 propranolol 40 mg/5 ml soln 1 propranolol 60 mg let 1 propranolol 80 mg let 1 propranolol er 1 mg capsule 1 propranolol er 0 mg capsule 1 propranolol er 60 mg capsule 1 propranolol er 80 mg capsule 1 propranolol-hctz 40- mg 1 propranolol-hctz 80- mg 1 quinapril 10 mg let 1 QL 60/30 quinapril mg let 1 QL 60/30 quinapril 40 mg let 1 QL 60/30 quinapril 5 mg let 1 QL 60/30 quinapril-hctz mg 1 QL 30/30 quinapril-hctz mg 1 QL 60/30 quinapril-hctz - mg 1 QL 60/30 quinidine gluc 80 mg/ml vial 1 quinidine gluc er 4 mg 1 quinidine sulf er 300 mg 1 quinidine sulfate 0 mg 1 quinidine sulfate 300 mg 1 ramipril 1. mg capsule 1 QL 60/30 ramipril 10 mg capsule 1 QL 60/30 ramipril 2.5 mg capsule 1 QL 60/30 ramipril 5 mg capsule 1 QL 60/30 RANEXA ER 1,000 MG TABLET 2 QL 60/30 RANEXA ER 500 MG TABLET 2 QL 60/30 RECTIV 0.4% OINTMENT 3 REPATHA 0 MG/ML SURECLICK 4 PA,QL 3ML/30 REPATHA 0 MG/ML SYRINGE 4 PA,QL 3ML/30 reserpine 0.1 mg let 1 reserpine 0. mg let 1 rosuvastatin calcium 10 mg 1 QL 30/30 rosuvastatin calcium mg 1 QL 30/30 rosuvastatin calcium 40 mg 1 QL 30/30 rosuvastatin calcium 5 mg 1 QL 30/30 +This drug does not count towards your total drug costs. For full description please see key symbol on page 6.

49 Comprehensive Formulary simvastatin 10 mg let 1 QL 30/30 simvastatin mg let 1 QL 30/30 simvastatin 40 mg let 1 QL 30/30 simvastatin 5 mg let 1 QL 30/30 simvastatin 80 mg let 1 QL 30/30 sorine 1 mg let 1 sorine 0 mg let 1 sorine 240 mg let 1 sorine 80 mg let 1 sotalol 1 mg let 1 sotalol 0 mg let 1 sotalol 240 mg let 1 sotalol 80 mg let 1 sotalol af 1 mg let 1 sotalol af 0 mg let 1 sotalol af 80 mg let 1 spironolactone 100 mg let 1 spironolactone mg let 1 spironolactone 50 mg let 1 spironolactone-hctz - 1 TAZTIA XT 1 MG CAPSULE 1 QL 30/30 TAZTIA XT 0 MG CAPSULE 1 QL 30/30 TAZTIA XT 240 MG CAPSULE 1 QL 60/30 TAZTIA XT 300 MG CAPSULE 1 QL 30/30 TAZTIA XT 360 MG CAPSULE 1 QL 30/30 TEKTURNA 0 MG TABLET 3 QL 30/30 TEKTURNA 300 MG TABLET 3 QL 30/30 TEKTURNA HCT MG TAB 3 QL 30/30 TEKTURNA HCT 0- MG TABLET 3 QL 30/30 TEKTURNA HCT MG TAB 3 QL 30/30 TEKTURNA HCT 300- MG TABLET 3 QL 30/30 telmisartan mg let 1 QL 30/30 telmisartan 40 mg let 1 QL 30/30 telmisartan 80 mg let 1 QL 30/30 telmisartan-amlodipine QL 30/30 telmisartan-amlodipine 40-5 mg 1 QL 30/30 telmisartan-amlodipine QL 30/30 telmisartan-amlodipine 80-5 mg 1 QL 30/30 telmisartan-hctz mg tb 1 QL 30/30 telmisartan-hctz mg tb 1 QL 30/30 telmisartan-hctz 80- mg 1 QL 30/30 TIKOSYN 1 MCG CAPSULE 3 QL 60/30 TIKOSYN 0 MCG CAPSULE 3 QL 60/30 TIKOSYN 500 MCG CAPSULE 3 QL 60/30 timolol maleate 10 mg let 1 timolol maleate mg let 1 timolol maleate 5 mg let 1 torsemide 10 mg let 1 torsemide 100 mg let 1 torsemide mg let 1 torsemide mg/2 ml vial 1 torsemide 5 mg let 1 torsemide 50 mg/5 ml vial 1 trandolapril 1 mg let 1 QL 30/30 trandolapril 2 mg let 1 QL 30/30 trandolapril 4 mg let 1 QL 60/30 trandolapr-verapam er mg 1 QL 30/30 trandolapr-verapam er 2-0 mg 1 QL 30/30 trandolapr-verapam er mg 1 QL 30/30 trandolapr-verapam er mg 1 QL 60/30 triamterene-hctz mg cp 1 triamterene-hctz mg tb 1 triamterene-hctz 50- mg cap 1 triamterene-hctz mg 1 valsartan 0 mg let 1 QL 30/30 valsartan 0 mg let 1 QL 30/30 valsartan 40 mg let 1 QL 30/30 valsartan 80 mg let 1 QL 30/30 valsartan-hctz mg 1 QL 30/30 valsartan-hctz 0- mg 1 QL 30/30 valsartan-hctz mg 1 QL 30/30 valsartan-hctz 0- mg 1 QL 30/30 valsartan-hctz mg 1 QL 30/30 VASCEPA 1 GM CAPSULE 3 QL 1/30 verapamil 1 mg let 1 verapamil 2.5 mg/ml ampul 1 verapamil 360 mg cap pellet 1 QL 30/30 verapamil 40 mg let 1 verapamil 80 mg let 1 verapamil er 1 mg capsule 1 QL 30/30 +This drug does not count towards your total drug costs. For full description please see key symbol on page 6.

50 Comprehensive Formulary verapamil er 1 mg let 1 verapamil er 0 mg capsule 1 QL 30/30 verapamil er 0 mg let 1 verapamil er 240 mg capsule 1 QL 30/30 verapamil er 240 mg let 1 verapamil er pm 100 mg capsule 1 QL 30/30 verapamil er pm 0 mg capsule 1 QL 60/30 verapamil er pm 300 mg capsule 1 QL 30/30 verapamil sr 1 mg capsule 1 verapamil sr 0 mg capsule 1 verapamil sr 240 mg capsule 1 VYTORIN MG TABLET 3 QL 30/30 VYTORIN 10- MG TABLET 3 QL 30/30 VYTORIN MG TABLET 3 QL 30/30 VYTORIN MG TABLET 3 QL 30/30 WELCHOL 3.75G PACKET 2 WELCHOL 6 MG TABLET 2 ZETIA 10 MG TABLET 2 QL 30/30 Central Nervous System Agents AMPYRA ER 10 MG TABLET 4 PA,QL 60/30 AUBAGIO MG TABLET 4 PA,QL 30/30 AUBAGIO 7 MG TABLET 4 PA,QL 30/30 AVONEX ADMIN PACK 30 MCG VL 4 PA,QL 4/ AVONEX PEN 30 MCG/0.5 ML KIT 4 PA,QL 4/ AVONEX PREFILLED SYR 30 MCG KT 4 PA,QL 4/ BETASERON 0.3 MG KIT 4 PA,QL / clonidine hcl er 0.1 mg let 1 QL 1/30 COPAXONE MG/ML SYRINGE 4 QL 30ML/ COPAXONE 40 MG/ML SYRINGE 4 QL 12ML/ d-amphetamine er 10 mg capsule 1 QL 90/30 d-amphetamine er mg capsule 1 QL 1/30 d-amphetamine er 5 mg capsule 1 QL 60/30 DAYTRANA 10 MG/9 HR PATCH 3 QL 30/30 DAYTRANA MG/9 HR PATCH 3 QL 30/30 DAYTRANA MG/9 HOUR PATCH 3 QL 30/30 DAYTRANA 30 MG/9 HOUR PATCH 3 QL 30/30 dexmethylphenidate 10 mg 1 QL 60/30 dexmethylphenidate 2.5 mg 1 QL 60/30 dexmethylphenidate 5 mg 1 QL 60/30 dextroamp-amphet er 10 mg cap 1 QL 30/30 dextroamp-amphet er mg cap 1 QL 30/30 dextroamp-amphet er mg cap 1 QL 30/30 dextroamp-amphet er mg cap 1 QL 30/30 dextroamp-amphet er 30 mg cap 1 QL 30/30 dextroamp-amphet er 5 mg cap 1 QL 30/30 dextroamp-amphetam 12.5 mg 1 QL 60/30 dextroamp-amphetam 7.5 mg 1 QL 60/30 dextroamp-amphetamin 10 mg 1 QL 60/30 dextroamp-amphetamin mg 1 QL 60/30 dextroamp-amphetamin mg 1 QL 60/30 dextroamp-amphetamin 30 mg 1 QL 60/30 dextroamp-amphetamine 5 mg 1 QL 60/30 dextroamphetamine 10 mg 1 QL 0/30 dextroamphetamine 5 mg 1 QL 60/30 dextroamphetamine 5 mg/5 ml 1 QL 00ML/30 EXTAVIA 0.3 MG KIT 4 PA GILENYA 0.5 MG CAPSULE 4 PA,QL 30/30 GLATOPA MG/ML SYRINGE 4 guanfacine hcl er 1 mg let 1 QL 30/30 guanfacine hcl er 2 mg let 1 QL 30/30 guanfacine hcl er 3 mg let 1 QL 30/30 guanfacine hcl er 4 mg let 1 QL 30/30 HETLIOZ MG CAPSULE 4 PA,QL 30/30 HORIZANT ER 300 MG TABLET 3 HORIZANT ER 600 MG TABLET 3 metadate er mg let 1 QL 90/30 methamphetamine 5 mg let 1 PA methylphenidate 10 mg chew 1 methylphenidate 10 mg let 1 QL 60/30 methylphenidate 10 mg/5 ml sol 1 methylphenidate 2.5 mg chew tb 1 methylphenidate mg let 1 QL 90/30 +This drug does not count towards your total drug costs. For full description please see key symbol on page 6. 50

51 Comprehensive Formulary methylphenidate 5 mg chew 1 methylphenidate 5 mg let 1 QL 60/30 methylphenidate 5 mg/5 ml soln 1 methylphenidate cd 10 mg cap 1 QL 30/30 methylphenidate cd mg cap 1 QL 30/30 methylphenidate cd 30 mg cap 1 QL 30/30 methylphenidate cd 40 mg cap 1 QL 30/30 methylphenidate cd 50 mg cap 1 QL 30/30 methylphenidate cd 60 mg cap 1 QL 30/30 methylphenidate er 10 mg 1 QL 30/30 methylphenidate er mg 1 QL 30/30 methylphenidate er mg 1 QL 90/30 methylphenidate er mg 1 QL 30/30 methylphenidate er 30 mg cap 1 QL 30/30 methylphenidate er 36 mg 1 QL 30/30 methylphenidate er 40 mg cap 1 QL 30/30 methylphenidate er 54 mg 1 QL 30/30 methylphenidate la mg cap 1 QL 30/30 methylphenidate sr mg 1 QL 90/30 NUEDEXTA -10 MG CAPSULE 2 QL 60/30 procentra 5 mg/5 ml solution 1 REBIF MCG/0.5 ML SYRINGE 4 PA,QL 6ML/ REBIF 44 MCG/0.5 ML SYRINGE 4 PA,QL 6ML/ REBIF REBIDOSE MCG/0.5 ML 4 PA,QL 6ML/ REBIF REBIDOSE 44 MCG/0.5 ML 4 PA,QL 6ML/ REBIF REBIDOSE TITRATION PACK 4 PA,QL 4.2ML/ REBIF TITRATION PACK 4 PA,QL 4.2ML/ riluzole 50 mg let 1 SAVELLA 100 MG TABLET 2 QL 60/30 SAVELLA 12.5 MG TABLET 2 QL 60/30 SAVELLA MG TABLET 2 QL 60/30 SAVELLA 50 MG TABLET 2 QL 60/30 SAVELLA TITRATION PACK 2 QL /30 STRATTERA 10 MG CAPSULE 2 QL 60/30 STRATTERA 100 MG CAPSULE 2 QL 30/30 STRATTERA MG CAPSULE 2 QL 60/30 STRATTERA MG CAPSULE 2 QL 60/30 STRATTERA 40 MG CAPSULE 2 QL 60/30 STRATTERA 60 MG CAPSULE 2 QL 30/30 STRATTERA 80 MG CAPSULE 2 QL 30/30 tetrabenazine 12.5 mg let 4 QL 90/30 tetrabenazine mg let 4 QL 1/30 TYSABRI 300 MG/ ML VIAL 4 PA,QL ML/ Dental and Oral Agents ARESTIN 1 MG MICROSPHERE 3 BUCALSEP SOL 2 + BUCALSEP SPR 2 + CAPHOSOL SOL 2 + cevimeline hcl 30 mg capsule 1 chlorhexidine 0.12% rinse 1 FIRST-MOUTHW SUS BLM 2 + KEPIVANCE 6. MG VIAL 4 oralone 0.1% paste 1 paroex 0.12% oral rinse 1 periogard 0.12% oral rinse 1 pilocarpine hcl 5 mg let 1 pilocarpine hcl 7.5 mg let 1 stannous fluor 0.63% rinse 1 triamcinolone 0.1% paste 1 Dermatological Agents 8-MOP 10 MG CAPSULE 2 acitretin 10 mg capsule 4 acitretin.5 mg capsule 4 acitretin mg capsule 4 adapalene 0.1% cream 1 adapalene 0.1% gel 1 adapalene 0.1% lotion 1 adapalene 0.3% gel 1 ALA QUIN CREAM 3-0.5% 2 + ALCORTIN A GEL 2 + ALOQUIN GEL 1.-1% 2 + ALUVEA CREAM 39% 2 + ammonium lactate 12% cream 1 ammonium lactate 12% lotion 1 +This drug does not count towards your total drug costs. For full description please see key symbol on page 6. 51

52 Comprehensive Formulary amnesteem 10 mg capsule 1 amnesteem mg capsule 1 amnesteem 40 mg capsule 1 ANALPRAM E KIT 2 + ANALPRAM HC CREAM 2.5-1% 2 + ANALPRAM KIT ADVANCED 2 + ANALPRAM-HC LOT 2.5% 2 + ANALPRAM-HC CREAM 1-1% 2 + ANALPRAM-HC CREAM SINGLES 2 + ANALPRM SNGL CREAM HC anucort-hc sup mg 1 + ANUSOL-HC SUP MG 2 + ARZOL SILVER MIS NITR APP 2 + AURSTAT ANTI GEL -ITCH 2 + AZELEX % CREAM 2 BENZEFOAM AER 5.3% 2 + BENZEFOAM AER 9.8% 2 + benzepro aer 5.3% 1 + benzepro liq creamy 1 + benzepro sc aer 9.8% 1 + benzoyl per aer 5.3% 1 + benzoyl per aer 9.8% 1 + benzoyl pero aer 9.8% 1 + BIONECT GEL 0.2% 2 + bp cleansing wash 1 bp foam aer 5.3% 1 + bp foam aer 9.8% 1 + bp wash liq 7% 1 + calcipotriene 0.005% cream 1 QL 1GM/30 calcipotriene 0.005% ointment 1 QL 1GM/30 calcipotriene 0.005% solution 1 QL 60ML/30 calcitrene 0.005% ointment 1 QL 1GM/30 calcitriol 3 mcg/g ointment 1 QL 800GM/30 CARAC 0.5% CREAM 3 CEM-UREA SOL % 2 + ciclodan cream kit 0.77% 2 + claravis 10 mg capsule 1 claravis mg capsule 1 claravis 30 mg capsule 1 claravis 40 mg capsule 1 clind ph-benzoyl perox 1.2-5% 1 clindamycin-benzoyl perox 1-5% 1 CONDYLOX 0.5% GEL 3 CORTANE-B LOT 2 + CURITY GAUZE PADS 2"X2" 2 cyotic dro 1 + DERMACINRX KIT SILAPAK 2 + DERMASORB HC KIT 2% 2 + DERMASORB TA KIT 0.1% 2 + dermazene cream 1% 1 + diclofenac 1.5% topical soln 1 QL 1050ML/30 diclofenac sodium 3% gel 1 doxepin 5% cream 1 doxycycline ir-dr 40 mg cap 1 ELIDEL 1% CREAM 3 QL 100GM/90 EPIFOAM AER 1% 2 + erythromycin-benzoyl gel 1 ETHYL CHLOR AER FINE PIN 2 + ETHYL CHLOR AER FN STRM 2 + ETHYL CHLOR AER MED JET 2 + ETHYL CHLOR AER MED STRM 2 + ETHYL CHLOR AER MIST 2 + ethyl chlor aer spray 1 + FINACEA % FOAM 2 FINACEA % GEL 2 fluorouracil 0.5% cream 1 fluorouracil 2% topical soln 1 fluorouracil 5% cream 1 fluorouracil 5% top solution 1 grafco silvr mis nit appl 1 + GRANULEX AER 2 + hc pramoxine cream 1-1% 1 + hc pramoxine cream 2.5-1% 1 + HPR AER 2 + +This drug does not count towards your total drug costs. For full description please see key symbol on page 6.

53 Comprehensive Formulary HPR PLUS AER 2 + HYDRO 35 AER 2 + hydrocort cre iodoquin 1 + hydrocort ac sup mg 1 + hydrocort ac sup 30mg 1 + hydrocort/ cre iodoquin 1 + hydrocort/kit pramoxin 1 + HYLATOPIC AER 2 + HYLATOPIC AER PLUS 2 + hypercare % solution 1 imiquimod 5% cream packet 1 QL 12/30 ISO CARBACHO SOL 1.5% OP 2 + ISO CARBACHO SOL 3% OP 2 + KETODAN KIT 2% 2 + lactic acid cream /vit e 1 + lactic acid cream e 1 + LATRIX XM EMU % 2 + LEVULAN KERASTICK 2 lidocaine cre 3% 1 + lidocaine/hc kit 3-2.5% 1 + lidopin cream 3% 1 + LIDOVEX CREAM 3.75% 2 + LIDOVIR OIN 4-4% 2 + methoxsalen 10 mg capsule 4 myorisan 10 mg capsule 1 myorisan mg capsule 1 myorisan 30 mg capsule 1 myorisan 40 mg capsule 1 NEOSALUS AER 2 + NEO-SYNALAR KIT 2 + neuac gel 1 NOVACORT GEL 2 + NUMOISYN LIQ 2 + OXSORALEN 1% LOTION 3 PAIN RELIEF PAD PATCH (RX) 2 + PEDIADERM AF KIT COMPLETE 2 + PEDIADERM HC KIT 2 + PEDIADERM TA KIT 2 + PICATO 0.0% GEL 3 QL 3/ PICATO 0.05% GEL 3 QL 2GM/ podocon- liquid 1 podofilox 0.5% topical soln 1 pr benzoyl liq 7% wash 1 + pramcort cre 1-1% 1 + PRAMOSONE CREAM 1% 2 + PRAMOSONE CREAM 1-2.5% 2 + PRAMOSONE LOT 1% 2 + PRAMOSONE LOT 2.5% 2 + PRAMOSONE OIN 1% 2 + PRAMOSONE OIN 2.5% 2 + prascion ra cream 1 PRESERA AER 2 + PROCORT CREAM 2 + PROCTOCORT SUP 30MG 2 + PROCTOFOAM AER HC 1% 2 + rea lo 39 cre 39% 1 + REGRANEX 0.01% GEL 4 PA,QL GM/30 RETIN-A MICRO PUMP 0.08% GEL 3 PA RIAX AER 5.5% 2 + RIAX AER 9.5% 2 + ROSADAN KIT 0.75% 2 + ROSULA LIQ % 2 + salacyn 6% cream 1 salicylic acid 6% cream 1 salicylic acid 6% gel 1 salicylic acid 6% shampoo 1 SANTYL OINTMENT 2 QL 30G/30 SCALACORT DK KIT 2 + SCAR PATCH PAD (RX) 2 + selenium sulfide 2.5% lotion 1 sod sul/sulf kit 1 + sodium sulf-sulfur cleanser 1 sulf/sunscrn kit 9-4.5% 1 + SUMADAN KIT 2 + SUMADAN XLT KIT 9-4.5% 2 + SUMAXIN CP KIT 2 + tacrolimus 0.03% ointment 1 QL 100GM/90 +This drug does not count towards your total drug costs. For full description please see key symbol on page 6.

54 Comprehensive Formulary tacrolimus 0.1% ointment 1 QL 100GM/90 TAZORAC 0.05% CREAM 3 QL 1GM/30 TAZORAC 0.05% GEL 3 QL 100GM/30 TAZORAC 0.1% CREAM 3 QL 1GM/30 TAZORAC 0.1% GEL 3 QL 100GM/30 tretinoin 0.01% gel 1 PA,QL GM/30 tretinoin 0.0% cream 1 PA,QL GM/30 tretinoin 0.0% gel 1 PA,QL GM/30 tretinoin 0.05% cream 1 PA,QL GM/30 tretinoin 0.05% gel 1 PA,QL GM/30 tretinoin 0.1% cream 1 PA,QL GM/30 tretinoin gel micro 0.04% pump 1 PA tretinoin gel micro 0.1% pump 1 PA ULTRAVATE X KIT % 2 + URAMAXIN CREAM % 2 + URAMAXIN GEL % 2 + URAMAXIN LOT % 2 + URAMAXIN % FOAM 2 URAMAXIN GT GEL % 2 + urea cream % 1 + urea lot % 1 + urea 40% gel 1 urea cream 39% 1 + urea emu 50% 1 + urea hydrati aer 35% 1 + urea nail gel % 1 + UREA NAIL KIT 2 + UREVAZ CRE 44% 2 + UVADEX MCG/ML VIAL 2 BvsD VELTIN 1.2 %-0.0 % GEL 3 VEREGEN % OINTMENT 2 VOLTAREN 1% GEL 2 QL 1000GM/30 VYTONE CREAM 1-1.9% 2 + XENADERM OINTMENT 2 + XERAC AC 6.% SOLUTION 2 zenatane 10 mg capsule 1 zenatane mg capsule 1 zenatane 30 mg capsule 1 zenatane 40 mg capsule 1 ZIANA GEL 3 ZYCLARA 2.5% CREAM PUMP 2 QL GM/30 ZYCLARA 3.75% CREAM 2 QL GM/30 ZYCLARA 3.75% CREAM PUMP 2 ZYPRAM CREAM 2 + Enzyme Replacement/Modifiers ADAGEN 0 UNITS/ML VIAL 4 ALDURAZYME 2.9 MG/5 ML VIAL 4 BUPHENYL 500 MG TABLET 4 CEREZYME 400 UNITS VIAL 4 CREON DR 12,000 UNITS CAPSULE 2 CREON DR 24,000 UNITS CAPSULE 2 CREON DR 3,000 UNITS CAPSULE 2 CREON DR 36,000 UNITS CAPSULE 2 CREON DR 6,000 UNITS CAPSULE 2 CYSTADANE POWDER 4 CYSTAGON 0 MG CAPSULE 2 CYSTAGON 50 MG CAPSULE 2 ELAPRASE 6 MG/3 ML VIAL 4 ELELYSO 0 UNITS VIAL 4 FABRAZYME 35 MG VIAL 4 FABRAZYME 5 MG VIAL 4 KUVAN 100 MG POWDER PACKET 4 QL 750/30 KUVAN 100 MG TABLET 4 QL 750/30 KUVAN 500 MG POWDER PACKET 4 QL 0/30 LUMIZYME 50 MG VIAL 4 MYOZYME 50 MG VIAL 4 NAGLAZYME 5 MG/5 ML VIAL 4 ORFADIN 10 MG CAPSULE 4 +This drug does not count towards your total drug costs. For full description please see key symbol on page 6. 54

55 Comprehensive Formulary ORFADIN 2 MG CAPSULE 4 ORFADIN 4 MG/ML SUSPENSION 4 ORFADIN 5 MG CAPSULE 4 RAVICTI 1.1 GRAM/ML LIQUID 4 sodium phenylbutyrate powder 1 SUCRAID 8,500 UNITS/ML SOLN 4 VPRIV 400 UNITS VIAL 4 BvsD XIAFLEX 0.9 MG VIAL 4 PA ZAVESCA 100 MG CAPSULE 4 QL 90/30 ZENPEP DR 10,000 UNITS CAPSULE 2 ZENPEP DR,000 UNITS CAPSULE 2 ZENPEP DR,000 UNITS CAPSULE 2 ZENPEP DR,000 UNITS CAPSULE 2 ZENPEP DR 3,000 UNITS CAPSULE 2 ZENPEP DR 40,000 UNITS CAPSULE 2 ZENPEP DR 5,000 UNITS CAPSULE 2 Gastrointestinal Agents alosetron hcl 0.5 mg let 4 PA,QL 60/30 alosetron hcl 1 mg let 4 PA,QL 60/30 AMITIZA 24 MCG CAPSULES 2 QL 60/30 AMITIZA 8 MCG CAPSULE 2 QL 60/30 anaspaz 0.1 mg let odt 1 atropine 0.05 mg/ml syringe 1 atropine 0.1 mg/ml syringe 1 atropine 1 mg/ml vial 1 atropine 8 mg/ ml vial 1 atropine sulfate 1 belladonna-opium.2-30 supp 1 belladonna-opium.2-60 supp 1 CANTIL MG TABLET 2 CARAFATE 1 GM/10 ML SUSP 3 CHENODAL 0 MG TABLET 4 cimetidine 0 mg let 1 cimetidine 300 mg let 1 cimetidine 300 mg/5 ml soln 1 cimetidine 400 mg let 1 cimetidine 800 mg let 1 constulose 10 gm/ ml soln 1 cromolyn 100 mg/5 ml oral conc 1 CUVPOSA 1 MG/5 ML SOLUTION 3 DEXILANT DR 30 MG CAPSULE 3 QL 60/30 DEXILANT DR 60 MG CAPSULE 3 QL 60/30 dicyclomine 10 mg capsule 1 dicyclomine 10 mg/5 ml soln 1 dicyclomine mg let 1 diphenoxylat-atrop /5 1 diphenoxylate-atrop ed-spaz 0.1 mg odt 1 enulose 10 gm/ ml solution 1 esomeprazole mag dr mg cap 1 QL 60/30 esomeprazole mag dr 40 mg cap 1 QL 60/30 esomeprazole sodium mg vial 1 esomeprazole sodium 40 mg vial 1 famotidine mg piggyback 1 famotidine mg let 1 famotidine mg/2 ml vial 1 famotidine 0 mg/ ml vial 1 famotidine 40 mg let 1 famotidine 40 mg/4 ml vial 1 famotidine 40 mg/5 ml susp 1 famotidine 500 mg/50 ml vial 1 FIRST-OMEPRA SUS 2MG/ML 2 + gastrinex nf capsule 1 GATTEX 5 MG ONE-VIAL KIT 4 PA,QL 30/30 gavilyte-c solution 1 gavilyte-g solution 1 gavilyte-n solution 1 generlac 10 gm/ ml solution 1 glycopyrrolate 0.2 mg/ml vial 1 glycopyrrolate 1 mg let 1 glycopyrrolate 2 mg let 1 GOLYTELY PACKET 2 hyoscyamine 0.1 mg odt 1 hyoscyamine 0.1 mg sl 1 hyoscyamine 0.1 mg/5 ml elix 1 hyoscyamine 0.1 mg/ml drop 1 hyoscyamine er mg 1 +This drug does not count towards your total drug costs. For full description please see key symbol on page 6.

56 hyoscyamine sr mg 1 hyoscyamine sulf 0.1 mg 1 ISOPTO HYOSCINE 0.% DROPS 2 KRISTALOSE 10 GM PACKET 3 KRISTALOSE GM PACKET 3 lactulose 10 gm/ ml solution 1 lansoprazol-amoxicil-clarithro 1 lansoprazole dr mg capsule 1 QL 60/30 lansoprazole dr 30 mg capsule 1 QL 60/30 LANSOPRAZOLE SUS 3MG/ML 2 + LINZESS 5 MCG CAPSULE 3 QL 30/30 LINZESS 290 MCG CAPSULE 3 QL 30/30 loperamide 2 mg capsule 1 methscopolamine brom 2.5 mg tb 1 methscopolamine brom 5 mg 1 metoclopramide 10 mg let 1 metoclopramide 10 mg/2 ml vial 1 metoclopramide 5 mg let 1 metoclopramide 5 mg/5 ml soln 1 misoprostol 100 mcg let 1 misoprostol 0 mcg let 1 MOTOFEN TABLET 2 MOVIPREP POWDER PACKET 3 NEXIUM DR 10 MG PACKET 2 QL 60/30 NEXIUM DR 2.5 MG PACKET 2 QL 60/30 NEXIUM DR MG PACKET 2 QL 60/30 NEXIUM DR 40 MG PACKET 2 QL 60/30 NEXIUM DR 5 MG PACKET 2 QL 60/30 nizatidine 0 mg capsule 1 nizatidine 300 mg capsule 1 nulev 0.1 mg chewable melt 1 OMEPRAZOLE + SUS SYRSPEND 2 + omeprazole dr 10 mg capsule 1 QL 60/30 omeprazole dr mg capsule 1 QL 60/30 omeprazole dr 40 mg capsule 1 QL 60/30 omeprazole-bicarb -1,100 cap 1 QL 60/30 omeprazole-bicarb 40-1,100 cap 1 QL 60/30 oscimin 0.1 mg odt 1 oscimin 0.1 mg let 1 oscimin sl 0.1 mg let 1 Comprehensive Formulary oscimin sr mg let 1 OSMOPREP TABLET 3 pantoprazole sod dr mg 1 QL 60/30 pantoprazole sod dr 40 mg 1 QL 60/30 PAREGORIC LIQUID 2 peg 3350 electrolyte soln 1 peg 3350-electrolyte solution 1 peg-3350 and electrolytes soln 1 polyethylene glycol 3350 powd 1 propantheline mg let 1 rabeprazole sod dr mg 1 QL 60/30 ranitidine mg/ml syrup 1 ranitidine 0 mg capsule 1 ranitidine 0 mg let 1 ranitidine 300 mg capsule 1 ranitidine 300 mg let 1 ranitidine hcl 0 mg/6 ml vl 1 ranitidine hcl 50 mg/2 ml vial 1 RELISTOR 12 MG/0.6 ML SYRINGE 2 QL ML/30 RELISTOR 12 MG/0.6 ML VIAL 2 QL ML/30 RELISTOR 8 MG/0.4 ML SYRINGE 2 QL 12ML/30 sucralfate 1 gm let 1 SUPREP BOWEL PREP KIT 3 symax-sr mg let 1 trilyte with flavor packets 1 ursodiol 0 mg let 1 ursodiol 300 mg capsule 1 ursodiol 500 mg let 1 VIBERZI 100 MG TABLET 3 PA,QL 60/30 VIBERZI 75 MG TABLET 3 PA,QL 60/30 ZEGERID MG PACKET 3 QL 60/30 ZEGERID 40 MG PACKET 3 QL 60/30 Genitourinary Agents acetic acid 0.% irrig soln 1 alfuzosin hcl er 10 mg let 1 QL 30/30 AURYXIA 210 MG TABLET 3 QL 360/30 +This drug does not count towards your total drug costs. For full description please see key symbol on page 6.

57 Comprehensive Formulary azuphen mb capsule 1 bethanechol 10 mg let 1 bethanechol mg let 1 bethanechol 5 mg let 1 bethanechol 50 mg let 1 calcium acetate 667 mg capsule 1 calcium acetate 667 mg let 1 CIALIS 2.5 MG TABLET 2 PA,QL 30/30 CIALIS 5 MG TABLET 2 PA,QL 30/30 darifenacin er mg let 1 QL 30/30 darifenacin er 7.5 mg let 1 QL 30/30 doxazosin mesylate 1 mg 1 QL 30/30 doxazosin mesylate 2 mg 1 QL 30/30 doxazosin mesylate 4 mg 1 QL 30/30 doxazosin mesylate 8 mg 1 QL 60/30 dutasteride 0.5 mg capsule 1 QL 30/30 dutasteride-tamsulosin QL 30/30 eliphos 667 mg let 1 ELMIRON 100 MG CAPSULE 3 ENABLEX MG TABLET 3 QL 30/30,ST ENABLEX 7.5 MG TABLET 3 QL 30/30,ST finasteride 5 mg let 1 QL 30/30 flavoxate hcl 100 mg let 1 FOSRENOL 1,000 MG POWDER PACK 4 FOSRENOL 1,000 MG TABLET CHEW 4 FOSRENOL 500 MG TABLET CHEW 4 FOSRENOL 750 MG POWDER PACKET 4 FOSRENOL 750 MG TABLET CHEW 4 GELNIQUE 10% GEL SACHETS 2 QL 30GM/30 GELNIQUE 3% GEL 2 QL 92GM/30 HYOLEV MB TABLET 3 LITHOSTAT 0 MG TABLET 2 MAGNEBIND 400 RX TABLET 3 MYRBETRIQ ER MG TABLET 3 QL 30/30 MYRBETRIQ ER 50 MG TABLET 3 QL 30/30 oxybutynin 5 mg let 1 QL 1/30 oxybutynin 5 mg/5 ml syrup 1 QL 600ML/30 oxybutynin cl er 10 mg let 1 QL 30/30 oxybutynin cl er mg let 1 QL 60/30 oxybutynin cl er 5 mg let 1 QL 30/30 phenazopyridine 100 mg 1 phenazopyridine 0 mg 1 PHOSLYRA 667 MG/5 ML SOLUTION 3 QL 00ML/30 phosphasal let 1 RAPAFLO 4 MG CAPSULE 2 QL 30/30 RAPAFLO 8 MG CAPSULE 2 QL 30/30 RENVELA 0.8 GM POWDER PACKET 2 QL 0/30 RENVELA 2.4 GM POWDER PACKET 2 QL 90/30 RENVELA 800 MG TABLET 2 QL 0/30 tamsulosin hcl 0.4 mg capsule 1 QL 60/30 terazosin 1 mg capsule 1 QL 30/30 terazosin 10 mg capsule 1 QL 60/30 terazosin 2 mg capsule 1 QL 30/30 terazosin 5 mg capsule 1 QL 30/30 tolterodine tart er 2 mg cap 1 QL 30/30 tolterodine tart er 4 mg cap 1 QL 30/30 tolterodine tartrate 1 mg 1 QL 60/30 tolterodine tartrate 2 mg 1 QL 60/30 TOVIAZ ER 4 MG TABLET 3 QL 30/30,ST TOVIAZ ER 8 MG TABLET 3 QL 30/30,ST trospium chloride mg let 1 QL 60/30 trospium chloride er 60 mg cap 1 QL 30/30 ur n-c let 1 URELLE TABLET 3 urin d.s. let 1 URO-L TABLET 3 ustell capsule 1 VELPHORO 500 MG CHEWABLE TAB 3 QL 0/30 VESICARE 10 MG TABLET 2 QL 30/30 VESICARE 5 MG TABLET 2 QL 30/30 +This drug does not count towards your total drug costs. For full description please see key symbol on page 6. 57

58 Comprehensive Formulary Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) a-hydrocort 100 mg vial 1 ala-cort 1% cream 1 ALA-SCALP 2% LOTION 2 alclometasone dipr 0.05% oint 1 alclometasone dipro 0.05% crm 1 amcinonide 0.1% cream 1 amcinonide 0.1% lotion 1 amcinonide 0.1% ointment 1 a-methapred 1 ana-lex 2-2% kit 1 apexicon e 0.05% cream 1 ARISTOSPAN INTRA-ARTICULAR 3 betamethasone ac-sp 6 mg/ml vl 1 betamethasone dp 0.05% crm 1 betamethasone dp 0.05% lot 1 betamethasone dp 0.05% oint 1 betamethasone dp aug 0.05% crm 1 betamethasone dp aug 0.05% gel 1 betamethasone dp aug 0.05% lot 1 betamethasone dp aug 0.05% oin 1 betamethasone va 0.1% cream 1 betamethasone va 0.1% lotion 1 betamethasone valer 0.1% ointm 1 betamethasone valer 0.12% foam 1 clobetasol 0.05% cream 1 clobetasol 0.05% gel 1 clobetasol 0.05% ointment 1 clobetasol 0.05% shampoo 1 clobetasol 0.05% solution 1 clobetasol 0.05% topical lotn 1 clobetasol emollient 0.05% crm 1 clobetasol emollnt 0.05% foam 1 clobetasol emulsion 0.05% foam 1 clobetasol prop 0.05% foam 1 clobetasol prop 0.05% spray 1 clocortolone 0.1% cream pump 1 clocortolone pivalate 0.1% crm 1 clodan 0.05% shampoo 1 Drug Tier CORDRAN 0.05% CREAM 2 CORDRAN 0.05% LOTION 2 CORDRAN 0.05% OINTMENT 2 CORDRAN 4 MCG/SQ CM TAPE LARGE 2 cormax 0.05% solution 1 CORTIFOAM 10% AEROSOL 3 cortisone mg let 1 CUTIVATE 0.05% LOTION 3 DEPO-MEDROL MG/ML VIAL 3 DESONATE 0.05% GEL 3 desonide 0.05% cream 1 desonide 0.05% lotion 1 desonide 0.05% ointment 1 desoximetasone 0.05% cream 1 desoximetasone 0.05% gel 1 desoximetasone 0.05% ointment 1 desoximetasone 0.% cream 1 desoximetasone 0.% ointment 1 dexamethasone 0.5 mg let 1 dexamethasone 0.5 mg/5 ml elx 1 dexamethasone 0.5 mg/5 ml liq 1 dexamethasone 0.75 mg let 1 dexamethasone 1 mg let 1 dexamethasone 1.5 mg let 1 dexamethasone 10 mg/ml vial 1 dexamethasone 100 mg/10 ml vl 1 dexamethasone 1 mg/30 ml vl 1 dexamethasone 2 mg let 1 dexamethasone mg/5 ml vial 1 dexamethasone 4 mg let 1 dexamethasone 4 mg/ml vial 1 dexamethasone 6 mg let 1 dexamethasone intensol 1mg/1ml 1 diflorasone 0.05% cream 1 diflorasone 0.05% ointment 1 fludrocortisone 0.1 mg let 1 fluocinolone 0.01% body oil 1 fluocinolone 0.01% cream 1 fluocinolone 0.01% solution 1 fluocinolone 0.0% cream 1 Requirements/ Limits +This drug does not count towards your total drug costs. For full description please see key symbol on page 6.

59 Comprehensive Formulary Drug Tier fluocinolone 0.0% ointment 1 fluocinolone acetonide scalp 1 fluocinonide 0.05% cream 1 fluocinonide 0.05% gel 1 fluocinonide 0.05% ointment 1 fluocinonide 0.05% solution 1 fluocinonide 0.1% cream 1 fluocinonide-e 0.05% cream 1 fluticasone prop 0.005% oint 1 fluticasone prop 0.05% cream 1 fluticasone prop 0.05% lotion 1 halobetasol prop 0.05% cream 1 halobetasol prop 0.05% ointmnt 1 hydrocort buty 0.1% lipid crm 1 hydrocort buty 0.1% lipo cream 1 hydrocortisone 0.1% soln 1 hydrocortisone 1% absorbase 1 hydrocortisone 1% cream 1 hydrocortisone 1% ointment 1 hydrocortisone 10 mg let 1 hydrocortisone 2.5% cream 1 hydrocortisone 2.5% lotion 1 hydrocortisone 2.5% ointment 1 hydrocortisone mg let 1 hydrocortisone 5 mg let 1 hydrocortisone buty 0.1% cream 1 hydrocortisone butyr 0.1% oint 1 hydrocortisone val 0.2% cream 1 hydrocortisone val 0.2% ointmt 1 KENALOG MG/ML VIAL 3 KENALOG MG/ML VIAL 3 lidocaine-hc 2-2% cream kit 1 lidocaine-hc 3-0.5% cream kit 1 lidocaine-hc 3-1% cream kit 1 lokara 0.05% lotion 1 MEDROL 2 MG TABLET 3 methylprednisolone 1 mg vial 1 methylprednisolone mg 1 methylprednisolone mg 1 methylprednisolone 4 mg dosepk 1 Requirements/ Limits Drug Tier methylprednisolone 4 mg let 1 methylprednisolone 40 mg vial 1 methylprednisolone 40 mg/ml vl 1 methylprednisolone 8 mg 1 methylprednisolone 80 mg/ml vl 1 methylprednisolone ss 1 gm vl 1 mometasone furoate 0.1% cream 1 mometasone furoate 0.1% oint 1 mometasone furoate 0.1% soln 1 NUCORT LOTION 2 PANDEL 0.1% CREAM 2 prednicarbate 0.1% cream 1 prednicarbate 0.1% ointment 1 prednisolone mg/5 ml soln 1 prednisolone 5 mg/5 ml soln 1 prednisolone odt 10 mg let 1 prednisolone odt mg let 1 prednisolone odt 30 mg let 1 prednisolone sod ph mg/5 ml 1 prednisone 1 mg let 1 prednisone 10 mg dose pack 1 prednisone 10 mg let 1 prednisone 2.5 mg let 1 prednisone mg let 1 prednisone 5 mg dose pack 1 prednisone 5 mg let 1 prednisone 5 mg/5 ml solution 1 prednisone 5 mg/ml solution 1 prednisone 50 mg let 1 procto-med hc 2.5% cream 1 procto-pak 1% cream 1 proctosol-hc 2.5% cream 1 proctozone-hc 2.5% cream 1 SOLU-CORTEF 1,000 MG VIAL 2 SOLU-CORTEF 100 MG VIAL 2 SOLU-CORTEF 0 MG VIAL 2 SOLU-CORTEF 500 MG VIAL 2 SOLU-MEDROL 2,000 MG VIAL 2 SOLU-MEDROL 500 MG VIAL 2 TEXACORT 2.5% SOLUTION 2 Requirements/ Limits +This drug does not count towards your total drug costs. For full description please see key symbol on page 6.

60 triamcinolone 0.0% cream 1 triamcinolone 0.0% lotion 1 triamcinolone 0.0% oint 1 triamcinolone 0.1% cream 1 triamcinolone 0.1% lotion 1 triamcinolone 0.1% ointment 1 triamcinolone 0.1 mg/g spray 1 triamcinolone 0.5% cream 1 triamcinolone 0.5% ointment 1 trianex 0.05% ointment 1 triderm 0.1% cream 1 Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) chorionic gonad 10,000 unit vl 1 PA desmopressin 0.01% solution 1 QL ML/30 desmopressin 0.1 mg/ml sol 1 QL ML/30 desmopressin 10 mcg/0.1 ml spr 1 QL ML/30 desmopressin ac 4 mcg/ml vial 1 desmopressin acetate 0.1 mg tb 1 desmopressin acetate 0.2 mg tb 1 EGRIFTA 1 MG VIAL 4 PA,QL 60/30 GENOTROPIN 12 MG CARTRIDGE 4 PA GENOTROPIN 5 MG CARTRIDGE 4 PA GENOTROPIN MINIQUICK 0.2 MG 3 PA GENOTROPIN MINIQUICK 0.4 MG 4 PA GENOTROPIN MINIQUICK 0.6 MG 4 PA GENOTROPIN MINIQUICK 0.8 MG 4 PA GENOTROPIN MINIQUICK 1 MG 4 PA GENOTROPIN MINIQUICK 1.2 MG 4 PA GENOTROPIN MINIQUICK 1.4 MG 4 PA GENOTROPIN MINIQUICK 1.6 MG 4 PA GENOTROPIN MINIQUICK 1.8 MG 4 PA GENOTROPIN MINIQUICK 2 MG 4 PA HP ACTHAR GEL 80 UNIT/ML VIAL 4 PA HUMATROPE 12 MG CARTRIDGE 4 PA HUMATROPE 24 MG CARTRIDGE 4 PA HUMATROPE 5 MG VIAL 4 PA Comprehensive Formulary 60 HUMATROPE 6 MG CARTRIDGE 4 PA INCRELEX 40 MG/4 ML VIAL 3 PA NORDITROPIN FLEXPRO 10 MG/1.5 4 PA NORDITROPIN FLEXPRO MG/1.5 4 PA NORDITROPIN FLEXPRO 30 MG/3 ML 4 PA NORDITROPIN FLEXPRO 5 MG/1.5 4 PA NOVAREL 10,000 UNITS VIAL 3 PA NUTROPIN AQ MG/2ML PEN CART 4 PA NUTROPIN AQ NUSPIN 10 INJECTOR 4 PA NUTROPIN AQ NUSPIN INJECTOR 4 PA NUTROPIN AQ NUSPIN 5 INJECTOR 4 PA NUTROPIN AQ PEN CARTRIDGE 4 PA OMNITROPE 10 MG/1.5 ML CRTG 3 PA OMNITROPE 5 MG/1.5 ML CRTG 3 PA OMNITROPE 5.8 MG VIAL 4 PA PREGNYL 10,000 UNITS VIAL 3 PA SAIZEN 5 MG VIAL 4 PA SAIZEN 8.8 MG CLICK.EASY CARTG 4 PA SAIZEN 8.8 MG VIAL 4 PA SEROSTIM 4 MG VIAL 4 PA SEROSTIM 5 MG VIAL 4 PA SEROSTIM 6 MG VIAL 4 PA STIMATE 1.5 MG/ML NASAL SPRAY 2 TEV-TROPIN 5 MG VIAL 3 PA ZORBTIVE 8.8 MG VIAL 4 PA Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) ALORA 0.0 MG PATCH 3 PA (HRM),QL 8/ ALORA 0.05 MG PATCH 3 PA (HRM),QL 8/ ALORA MG PATCH 3 PA (HRM),QL 8/ ALORA 0.1 MG PATCH 3 PA (HRM),QL 8/ altavera- let 1 +This drug does not count towards your total drug costs. For full description please see key symbol on page 6.

61 Comprehensive Formulary alyacen let 1 alyacen let 1 amethia mg 1 amethia lo let 1 QL 91/91 amethyst 90- mcg let 1 ANADROL-50 TABLET 4 ANDRODERM 2 MG/24HR PATCH 2 QL 90/30 ANDRODERM 4 MG/24HR PATCH 2 QL 30/30 ANDROGEL 1.62% GEL PUMP 2 QL 0GM/30 ANDROGEL 1.62%(1.G) GEL PCKT 2 QL 2.5GM/3 0 ANDROGEL 1.62%(2.5G) GEL PCKT 2 QL 0GM/30 ANDROXY 10 MG TABLET 3 ANGELIQ 0. MG-0.5 MG TABLET 3 ANGELIQ 0.5 MG-1 MG TABLET 3 apri day let 1 aranelle let 1 ashlyna mg 1 aubra- let 1 aviane- let 1 azurette day let 1 balziva let 1 bekyree day let 1 blisovi fe 1- let 1 briellyn let 1 camila let 1 camrese mg 1 camrese lo let 1 QL 91/91 caziant day let 1 chateal- let 1 CLIMARA PRO PATCH 3 PA (HRM),QL 4/ COMBIPATCH MG PTCH 3 PA (HRM) COMBIPATCH MG PTCH 3 PA (HRM) covaryx 1 + covaryx hs 1 + cryselle- let 1 cyclafem let 1 cyclafem let 1 cyred day let 1 danazol 100 mg capsule 1 danazol 0 mg capsule 1 danazol 50 mg capsule 1 dasetta let 1 dasetta 7/7/7- let 1 daysee mg 1 deblitane 0.35 mg let 1 DELESTROGEN 10 MG/ML VIAL 3 delyla- let 1 DEPO-ESTRADIOL 5 MG/ML VIAL 2 DEPO-PROVERA 400 MG/ML VIAL 2 QL 10ML/ DEPO-SUBQ PROVERA 104 SYRINGE 2 desogestrel-ethinyl estrad 1 desogestr-eth estrad eth estra 1 DIVIGEL 0.5 MG GEL PACKET 3 drospirenone-ee mg 1 drospirenone-ee mg 1 eemt hs 1 + eemt 1 + elinest- let 1 ELLA 30 MG TABLET 2 emoquette day let 1 ENJUVIA 0.3 MG TABLET 2 ENJUVIA 0. MG TABLET 2 ENJUVIA 0.6 MG TABLET 2 ENJUVIA 0.9 MG TABLET 2 ENJUVIA 1. MG TABLET 2 enpresse- let 1 enskyce let 1 errin 0.35 mg let 1 est estrogen mtest 1 + est estrogen mtest ds 1 + est estrogen mtest hs 1 + estarylla mg let 1 ESTRACE 0.01% CREAM 3 +This drug does not count towards your total drug costs. For full description please see key symbol on page 6. 61

62 estradiol 0.0 mg patch 1 PA (HRM),QL 8/ estradiol mg patch 1 PA (HRM),QL 8/ estradiol 0.05 mg patch 1 PA (HRM),QL 8/ estradiol mg patch 1 PA (HRM),QL 8/ estradiol 0.1 mg patch 1 PA (HRM),QL 8/ estradiol 0.5 mg let 1 PA (HRM) estradiol 1 mg let 1 PA (HRM) estradiol 2 mg let 1 PA (HRM) estradiol tds 0.0 mg/day 1 PA (HRM),QL 4/ estradiol tds mg/day 1 PA (HRM),QL 4/ estradiol tds 0.05 mg/day 1 PA (HRM),QL 4/ estradiol tds 0.06 mg/day 1 PA (HRM),QL 4/ estradiol tds mg/day 1 PA (HRM),QL 4/ estradiol tds 0.1 mg/day 1 PA (HRM),QL 4/ estradiol valerate 10 mg/ml vl 1 estradiol valerate mg/ml vl 1 estradiol valerate 40 mg/ml vl 1 estradiol-noreth mg tb 1 PA (HRM) estradiol-noreth mg 1 PA (HRM) ESTRING 2 MG VAGINAL RING 3 QL 1/90 ESTROGEL 0.06% GEL 3 estropipate 0.6(0.75 mg) 1 Comprehensive Formulary 62 estropipate 1.(1.5 mg) 1 estropipate 2.5(3 mg) 1 falmina- let 1 FEMRING 0.05 MG VAGINAL RING 3 QL 1/90 FEMRING 0.10 MG VAGINAL RING 3 QL 1/90 FIRST-TESTOS CREAM MC 2% 2 + FIRST-TESTOS OIN 2% 2 + fyavolv 0.5 mg-2.5 mcg let 1 PA (HRM) gianvi 3 mg-0.02 mg let 1 gildagia 0.4 mg mg 1 gildess 1 mg- mcg let 1 gildess 1.5 mg-30 mcg let 1 gildess 24 fe mg let 1 gildess fe let 1 gildess fe 1- let 1 heather let 1 hydroxyprogesterone 1. g/5ml 4 introvale mg let 1 QL 91/91 jencycla 0.35 mg let 1 jevantique lo 0.5 mg-2.5 mcg 1 PA (HRM) jinteli 1 mg-5 mcg let 1 PA (HRM) jolessa 0. mg-0.03 mg let 1 QL 91/91 jolivette let 1 juleber day let 1 junel 1 mg- mcg let 1 junel 1.5 mg-30 mcg let 1 junel fe 1 mg- mcg let 1 junel fe 1.5 mg-30 mcg let 1 junel fe 24 let 1 kaitlib fe chewable let 1 kariva day let 1 kelnor 1-35 let 1 kimidess day let 1 kurvelo let 1 larin 1.5 mg-30 mcg let 1 larin let 1 larin fe let 1 larin fe 1- let 1 layolis fe chewable let 1 leena let 1 +This drug does not count towards your total drug costs. For full description please see key symbol on page 6.

63 lessina- let 1 levonest- let 1 levono-e estrad QL 91/91 levono-e estrad levonor-eth estra mg 1 levonor-eth estrad mg 1 levonor-eth estrad levonor-eth estrad QL 91/91 levonor-eth estrad triphasic 1 levora- let 1 lomedia 24 fe 1 mg- mcg 1 lopreeza 0.5 mg-0.1 mg let 1 PA (HRM) lopreeza 1 mg-0.5 mg let 1 PA (HRM) loryna 3 mg-0.02 mg let 1 low-ogestrel- let 1 lutera- let 1 lyza 0.35 mg let 1 MAKENA 0 MG/ML VIAL 4 marlissa- let 1 medroxyprogesterone 10 mg 1 medroxyprogesterone 0 mg/ml 1 QL 1ML/90 medroxyprogesterone 2.5 mg 1 medroxyprogesterone 5 mg 1 megestrol mg let 1 PA (HRM) megestrol 40 mg let 1 PA (HRM) megestrol 6 mg/5 ml susp 1 PA (HRM) megestrol acet 40 mg/ml susp 1 PA (HRM) MENEST 0.3 MG TABLET 3 PA (HRM) MENEST 0.6 MG TABLET 3 PA (HRM) MENEST 1. MG TABLET 3 PA (HRM) MENEST 2.5 MG TABLET 3 PA (HRM) MENOSTAR MCG/DAY PATCH 3 PA (HRM),QL 4/ methitest 10 mg let 1 microgestin microgestin let 1 microgestin fe microgestin fe 1- let 1 mimvey mg let 1 PA (HRM) Comprehensive Formulary 63 mimvey lo mg let 1 PA (HRM) MINIVELLE 0.0 MG PATCH 3 PA (HRM),QL 8/ MINIVELLE MG PATCH 3 PA (HRM),QL 8/ MINIVELLE 0.05 MG PATCH 3 PA (HRM),QL 8/ MINIVELLE MG PATCH 3 PA (HRM),QL 8/ MINIVELLE 0.1 MG PATCH 3 PA (HRM),QL 8/ mono-linyah let 1 mononessa let 1 myzilra- let 1 necon let 1 necon 10-- let 1 necon let 1 necon let 1 necon let 1 nikki 3 mg-0.02 mg let 1 nora-be let 1 noreth-estrad-fe (21)-75 1 noreth-estrad-fe (24)-75 1 norethind-eth estrad PA (HRM) norethind-eth estrad mg 1 norethindrone 0.35 mg let 1 norethindrone 5 mg let 1 norethin-estra-fe mg 1 norethin-eth estrad 1 mg-5 mcg 1 PA (HRM) norg-ee /0.0 1 norg-ee / norg-ethin estra mg 1 norlyroc 0.35 mg let 1 nortrel let 1 nortrel 1-35 let 1 nortrel let 1 NUVARING VAGINAL RING 3 +This drug does not count towards your total drug costs. For full description please see key symbol on page 6.

64 ocella 3 mg-0.03 mg let 1 ogestrel let 1 orsythia- let 1 oxandrolone 10 mg let 4 QL 60/30 oxandrolone 2.5 mg let 1 QL 1/30 philith mg let 1 pimtrea day let 1 pirmella let 1 pirmella let 1 portia- let 1 PREFEST TABLET 3 PA (HRM) PREMARIN 0.3 MG TABLET 3 PA (HRM),QL 30/30 PREMARIN 0. MG TABLET 3 PA (HRM),QL 30/30 PREMARIN 0.6 MG TABLET 3 PA (HRM),QL 30/30 PREMARIN 0.9 MG TABLET 3 PA (HRM),QL 30/30 PREMARIN 1. MG TABLET 3 PA (HRM),QL 30/30 PREMARIN MG VIAL 3 PREMARIN VAGINAL CREAM-APPL 2 PREMPHASE MG TABLET 3 PREMPRO 0.3 MG-1.5 MG TABLET 3 PA (HRM) PREMPRO MG TABLET 3 PA (HRM) PREMPRO MG TABLET 3 PA (HRM) PREMPRO MG TABLET 3 PA (HRM) previfem let 1 progesterone 100 mg capsule 1 progesterone 0 mg capsule 1 progesterone oil 50 mg/ml vl 1 quasense mg let 1 QL 91/91 raloxifene hcl 60 mg let 1 QL 30/30 reclipsen day let 1 setlakin 0. mg-0.03 mg 1 QL 91/91 sharobel 0.35 mg let 1 Comprehensive Formulary 64 solia 1 sprintec day let 1 sronyx mg let 1 STRIANT 30 MG MUCOADHESIVE 3 QL 60/30 tarina fe 1- let 1 testosteron cyp 1,000 mg/10 ml 1 testosteron cyp 2,000 mg/10 ml 1 testosterone 12.5 mg/1. gram 1 QL 300GM/30 testosterone mg/2.5 gm pkt 1 QL 300GM/30 testosterone 50 mg/5 gram pkt 1 QL 300GM/30 testosterone enan 0 mg/ml 1 QL 5ML/30 tilia fe let 1 tri-estarylla let 1 tri-legest fe- day let 1 tri-linyah let 1 tri-lo-estarylla let 1 tri-lo-marzia let 1 trinessa lo let 1 trinessa let 1 tri-previfem let 1 tri-sprintec let 1 trivora- let 1 VAGIFEM 10 MCG VAGINAL TAB 3 QL / velivet day let 1 vestura 3 mg-0.02 mg let 1 viorele day let 1 vyfemla let 1 wera 0.5/0.035 mg let 1 wymzya fe chewable let 1 xulane patch 1 zenchent 0.4 mg-35 mcg let 1 zenchent fe let chewable 1 zeosa chewable let 1 zovia 1-35e let 1 zovia 1-50e let 1 +This drug does not count towards your total drug costs. For full description please see key symbol on page 6.

65 Comprehensive Formulary Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) ARMOUR THYROID 1 MG TABLET 2 ARMOUR THYROID MG TABLET 2 ARMOUR THYROID 0 MG TABLET 2 ARMOUR THYROID 240 MG TABLET 2 ARMOUR THYROID 30 MG TABLET 2 ARMOUR THYROID 300 MG TABLET 2 ARMOUR THYROID 60 MG TABLET 2 ARMOUR THYROID 90 MG TABLET 2 levothyroxine 100 mcg let 1 levothyroxine 100 mcg vial 1 levothyroxine 2 mcg let 1 levothyroxine 1 mcg let 1 levothyroxine 7 mcg let 1 levothyroxine 0 mcg let 1 levothyroxine 5 mcg let 1 levothyroxine 0 mcg let 1 levothyroxine 0 mcg vial 1 levothyroxine mcg let 1 levothyroxine 300 mcg let 1 levothyroxine 50 mcg let 1 levothyroxine 500 mcg vial 1 levothyroxine 75 mcg let 1 levothyroxine 88 mcg let 1 LEVOXYL 100 MCG TABLET 2 LEVOXYL 2 MCG TABLET 2 LEVOXYL 1 MCG TABLET 2 LEVOXYL 7 MCG TABLET 2 LEVOXYL 0 MCG TABLET 2 LEVOXYL 5 MCG TABLET 2 LEVOXYL 0 MCG TABLET 2 LEVOXYL MCG TABLET 2 LEVOXYL 50 MCG TABLET 2 LEVOXYL 75 MCG TABLET 2 LEVOXYL 88 MCG TABLET 2 liothyronine sod 10 mcg/ml vl 1 liothyronine sod mcg 1 liothyronine sod 5 mcg 1 liothyronine sod 50 mcg 1 Drug Tier nature-throid 1.75 mg let 1 nature-throid 0 mg let 1 nature-throid 6. mg let 1 nature-throid. mg let 1 nature-throid 2.5 mg let 1 nature-throid 5 mg let 1 nature-throid 0 mg let 1 nature-throid.5 mg let 1 nature-throid 5 mg let 1 nature-throid.75 mg let 1 nature-throid mg let 1 nature-throid 81. mg let 1 nature-throid 97.5 mg let 1 np thyroid 30 mg let 1 np thyroid 60 mg let 1 np thyroid 90 mg let 1 SYNTHROID 100 MCG TABLET 3 SYNTHROID 2 MCG TABLET 3 SYNTHROID 1 MCG TABLET 3 SYNTHROID 7 MCG TABLET 3 SYNTHROID 0 MCG TABLET 3 SYNTHROID 5 MCG TABLET 3 SYNTHROID 0 MCG TABLET 3 SYNTHROID MCG TABLET 3 SYNTHROID 300 MCG TABLET 3 SYNTHROID 50 MCG TABLET 3 SYNTHROID 75 MCG TABLET 3 SYNTHROID 88 MCG TABLET 3 THYROLAR-1 STRENGTH TABLET 3 THYROLAR-1/2 STRENGTH TAB 3 THYROLAR-1/4 STRENGTH TAB 3 THYROLAR-2 STRENGTH TABLET 3 THYROLAR-3 STRENGTH TABLET 3 UNITHROID 100 MCG TABLET 2 UNITHROID 2 MCG TABLET 2 UNITHROID 1 MCG TABLET 2 UNITHROID 7 MCG TABLET 2 UNITHROID 0 MCG TABLET 2 UNITHROID 5 MCG TABLET 2 UNITHROID 0 MCG TABLET 2 Requirements/ Limits +This drug does not count towards your total drug costs. For full description please see key symbol on page 6.

66 Comprehensive Formulary UNITHROID MCG TABLET 2 UNITHROID 300 MCG TABLET 2 UNITHROID 50 MCG TABLET 2 UNITHROID 75 MCG TABLET 2 UNITHROID 88 MCG TABLET 2 westhroid 1.75 mg let 1 westhroid 0 mg let 1 westhroid 6. mg let 1 westhroid. mg let 1 westhroid 2.5 mg let 1 westhroid 5 mg let 1 westhroid 0 mg let 1 westhroid.5 mg let 1 westhroid 5 mg let 1 westhroid.75 mg let 1 westhroid mg let 1 westhroid 81. mg let 1 westhroid 97.5 mg let 1 Hormonal Agents, Suppressant (Adrenal) LYSODREN 500 MG TABLET 4 Hormonal Agents, Suppressant (Parathyroid) SENSIPAR 30 MG TABLET 2 QL 60/30 SENSIPAR 60 MG TABLET 4 QL 60/30 SENSIPAR 90 MG TABLET 4 QL 1/30 Hormonal Agents, Suppressant (Pituitary) cabergoline 0.5 mg let 1 QL /30 ELIGARD.5 MG SYRINGE KIT 3 PA,QL 1/90 ELIGARD 30 MG SYRINGE KIT 3 PA,QL 1/1 ELIGARD MG SYRINGE KIT 3 PA,QL 1/0 ELIGARD 7.5 MG SYRINGE KIT 3 PA,QL 1/30 FIRMAGON 2 X 1 MG KIT 3 QL 4/3,BvsD FIRMAGON 80 MG KIT 3 QL 1/,BvsD leuprolide 2wk 1 mg/0.2 ml kit 1 PA LUPRON DEPOT. MG 3MO KIT 4 PA,QL 1/90 LUPRON DEPOT.5 MG 3MO KIT 4 PA,QL 1/84 LUPRON DEPOT 3.75 MG KIT 4 PA,QL 1/30 LUPRON DEPOT MG 6MO KIT 4 PA,QL 1/8 LUPRON DEPOT 7.5 MG KIT 4 PA,QL 1/30 LUPRON DEPOT-4 MONTH KIT 4 PA,QL 1/2 LUPRON DEPOT-PED. MG 3MO 4 PA,QL 1/30 LUPRON DEPOT-PED. MG KIT 4 PA,QL 1/30 LUPRON DEPOT-PED MG KIT 4 PA,QL 1/30 LUPRON DEPOT-PED 30 MG 3MO KIT 4 PA,QL 1/30 LUPRON DEPOT-PED 7.5 MG KIT 4 PA,QL 1/30 octreotide 1,000 mcg/ml vial 4 octreotide acet 100 mcg/ml amp 1 octreotide acet 0 mcg/ml vl 1 octreotide acet 50 mcg/ml amp 1 octreotide acet 500 mcg/ml amp 4 SANDOSTATIN LAR DEPOT 10 MG KT 4 SANDOSTATIN LAR DEPOT MG KT 4 SANDOSTATIN LAR DEPOT 30 MG KT 4 SIGNIFOR 0.3 MG/ML AMPULE 4 QL 60ML/30 SIGNIFOR 0.6 MG/ML AMPULE 4 QL 60ML/30 SIGNIFOR 0.9 MG/ML AMPULE 4 QL 60ML/30 SOMATULINE DEPOT 1 MG/0.5 ML 4 QL 0.5ML/ SOMATULINE DEPOT 60 MG/0.2 ML 4 QL 0.2ML/ SOMATULINE DEPOT 90 MG/0.3 ML 4 QL 0.3ML/ SOMAVERT 10 MG VIAL 4 QL 30/30 SOMAVERT MG VIAL 4 QL 30/30 SOMAVERT MG VIAL 4 QL 30/30 SOMAVERT MG VIAL 4 QL 30/30 SOMAVERT 30 MG VIAL 4 QL 30/30 SYNAREL 2 MG/ML NASAL SPRAY 4 PA TRELSTAR. MG SYRINGE 2 PA,QL 1/84 TRELSTAR.5 MG VIAL 2 PA,QL 1/8 TRELSTAR 3.75 MG SYRINGE 2 PA,QL 1/ TRELSTAR DEPOT 3.75 MG VIAL 2 PA,QL 1/ +This drug does not count towards your total drug costs. For full description please see key symbol on page 6. 66

67 TRELSTAR LA. MG VIAL 2 PA,QL 1/84 ZOLADEX 10.8 MG IMPLANT SYRN 3 PA ZOLADEX 3.6 MG IMPLANT SYRN 3 PA Hormonal Agents, Suppressant (Thyroid) methimazole 10 mg let 1 methimazole 5 mg let 1 propylthiouracil 50 mg let 1 Immunological Agents ACTEMRA 2 MG/0.9 ML SYRINGE 4 PA,QL 3.6ML/ ACTEMRA 0 MG/10 ML VIAL 4 PA,QL 40ML/ ACTEMRA 400 MG/ ML VIAL 4 PA,QL 40ML/ ACTEMRA 80 MG/4 ML VIAL 4 PA,QL 40ML/ ACTHIB VACCINE WITH DILUENT 2 ACTIMMUNE 100 MCG/0.5 ML VIAL 4 ADACEL TDAP VIAL 2 QL 0.5ML/3 ARCALYST 0 MG INJECTION 4 PA ASTAGRAF XL 0.5 MG CAPSULE 3 PA ASTAGRAF XL 1 MG CAPSULE 3 PA ASTAGRAF XL 5 MG CAPSULE 3 PA ATGAM 50 MG/ML AMPUL 3 PA AZASAN 100 MG TABLET 3 PA AZASAN 75 MG TABLET 3 PA azathioprine 50 mg let 1 PA azathioprine sod 100 mg vial 3 PA BCG VACCINE (TICE STRAIN) VIAL 2 BENLYSTA 1 MG VIAL 4 PA,QL 30/ BENLYSTA 400 MG VIAL 4 PA,QL 9/ BERINERT 500 UNIT KIT 4 PA BEXSERO PREFILLED SYRINGE 2 BIVIGAM LIQUID 10% VIAL 4 BvsD BOOSTRIX TDAP VACCINE SYRINGE 2 QL 0.5ML/3 BOOSTRIX TDAP VACCINE VIAL 2 QL 0.5ML/3 CARIMUNE NF 12 GM VIAL 4 BvsD Comprehensive Formulary 67 CARIMUNE NF 6 GM VIAL 4 BvsD CELLCEPT 0 MG/ML ORAL SUSP 4 PA CELLCEPT 0 MG CAPSULE 3 PA CELLCEPT 500 MG TABLET 4 PA CELLCEPT 500 MG VIAL 3 PA CERVARIX VACCINE SYRINGE 2 CINRYZE 500 UNIT VIAL 4 PA,QL 100/30 COMVAX VACCINE VIAL 2 cyclosporine 100 mg capsule 1 PA cyclosporine 100 mg/ml soln 1 PA cyclosporine mg capsule 1 PA cyclosporine 50 mg/ml ampul 1 PA cyclosporine modified 100 mg 1 PA cyclosporine modified mg 1 PA cyclosporine modified 50 mg 1 PA DAPTACEL DTAP VACCINE 2 DIPHTHERIA-TETANUS TOXOIDS-PED 2 ENBREL MG KIT 4 PA,QL 8/ ENBREL MG/0.5 ML SYRINGE 4 PA,QL 4ML/ ENBREL 50 MG/ML SURECLICK SYR 4 PA,QL 8ML/ ENBREL 50 MG/ML SYRINGE 4 PA,QL 8ML/ ENGERIX-B 10 MCG/0.5 ML PED VL 2 QL 3ML/3,B vsd ENGERIX-B MCG/ML SYRINGE 2 QL 8ML/3,B vsd ENGERIX-B PEDI 10 MCG/0.5 SYRN 2,BvsD ENVARSUS XR 0.75 MG TABLET 3 PA ENVARSUS XR 1 MG TABLET 3 PA ENVARSUS XR 4 MG TABLET 3 PA FIRAZYR 30 MG/3 ML SYRINGE 4 PA,QL ML/30 FLEBOGAMMA DIF 10% VIAL 4 BvsD FLEBOGAMMA DIF 5% VIAL 4 BvsD GAMASTAN S-D VIAL 2 BvsD GAMMAGARD LIQUID 10% VIAL 4 BvsD +This drug does not count towards your total drug costs. For full description please see key symbol on page 6.

68 Comprehensive Formulary GAMMAKED 1 GRAM/10 ML VIAL 4 BvsD GAMMAKED 10 GRAM/100 ML VIAL 4 BvsD GAMMAKED 2.5 GRAM/ ML VIAL 4 BvsD GAMMAKED GRAM/0 ML VIAL 4 BvsD GAMMAKED 5 GRAM/50 ML VIAL 4 BvsD GAMMAPLEX 5% VIAL 4 BvsD GAMUNEX-C 1 GRAM/10 ML VIAL 4 BvsD GAMUNEX-C 10 GRAM/100 ML VIAL 4 BvsD GAMUNEX-C 2.5 GRAM/ ML VIAL 4 BvsD GAMUNEX-C GRAM/0 ML VIAL 4 BvsD GAMUNEX-C 40 GRAM/400 ML VIAL 4 BvsD GAMUNEX-C 5 GRAM/50 ML VIAL 4 BvsD GARDASIL 9 SYRINGE 2 QL 1.5ML/3 GARDASIL 9 VIAL 2 QL 1.5ML/3 GARDASIL SYRINGE 2 QL 1.5ML/3 GARDASIL VIAL 2 QL 1.5ML/3 gengraf 100 mg capsule 1 PA gengraf 100 mg/ml solution 1 PA gengraf mg capsule 1 PA gengraf 50 mg capsule 1 PA HAVRIX 1,440 UNITS/ML VIAL 2 HAVRIX 0 UNIT/0.5 ML SYRINGE 2 hecoria 0.5 mg capsule 1 PA hecoria 1 mg capsule 1 PA hecoria 5 mg capsule 1 PA HIBERIX VACCINE WITH DILUENT 2 HIZENTRA 1 GRAM/5 ML VIAL 4 BvsD HIZENTRA 10 GRAM/50 ML VIAL 4 BvsD HIZENTRA 2 GRAM/10 ML VIAL 4 BvsD HIZENTRA 4 GRAM/ ML VIAL 4 BvsD HUMIRA 10 MG/0.2 ML SYRINGE 4 PA,QL 2/ HUMIRA MG/0.4 ML SYRINGE 4 PA,QL 2/ HUMIRA 40 MG/0.8 ML PEN 4 PA,QL 4/ HUMIRA 40 MG/0.8 ML SYRINGE 4 PA,QL 4/ HUMIRA PEDIATRIC CROHN'S START 4 PA,QL 6/3 HUMIRA PEN CROHN'S-UC-HS START 4 PA,QL 12/3 HUMIRA PEN PSORIASIS START PK 4 PA,QL 8/3 ILARIS 0 MG VIAL 4 PA,QL 2/ IMOVAX RABIES VACCINE+DILUENT 2 INFANRIX DTAP VIAL 2 IPOL VIAL 2 IXIARO 6 MCG/0.5 ML SYRINGE 2 KALBITOR 10 MG/ML VIAL 4 PA KINERET 100 MG/0.67 ML SYRINGE 4 PA,QL.1/30 KINRIX VIAL 2 leflunomide 10 mg let 1 QL 30/30 leflunomide mg let 1 QL 30/30 MENACTRA VIAL 2 MENHIBRIX VACCINE VIAL 2 MENOMUNE-A-C-Y-W-5 W- 2 DILUENT MENVEO A-C-Y-W-5-DIP VIAL KT 2 methotrexate 1 gm vial 1 methotrexate 1 gram/40 ml vial 1 methotrexate 100 mg/4 ml vial 1 methotrexate 2.5 mg let 1 methotrexate 0 mg/8 ml vial 1 methotrexate 0 mg/10 ml vial 1 methotrexate 50 mg/2 ml vial 1 M-M-R II VACCINE WITH DILUENT 2 QL 2/3 mycophenolate 0 mg/ml susp 1 PA mycophenolate 0 mg capsule 1 PA mycophenolate 500 mg let 1 PA mycophenolic acid dr 0 mg tb 1 PA mycophenolic acid dr 360 mg tb 1 PA MYFORTIC 0 MG TABLET 2 PA MYFORTIC 360 MG TABLET 2 PA NEORAL 100 MG GELATIN CAPSULE 3 PA NEORAL 100 MG/ML SOLUTION 3 PA NEORAL MG GELATIN CAPSULE 3 PA NULOJIX 0 MG VIAL 4 PA,QL 0/30 OCTAGAM 10% VIAL 4 BvsD +This drug does not count towards your total drug costs. For full description please see key symbol on page 6. 68

69 Comprehensive Formulary OCTAGAM 5% VIAL 4 BvsD ORENCIA 0 MG VIAL 4 PA PEDIARIX 0.5 ML SYRINGE 2 PEDVAXHIB VACCINE VIAL 2 PENTACEL VIAL KIT 2 PRIVIGEN 10% VIAL 4 BvsD PROGRAF 0.5 MG CAPSULE 3 PA PROGRAF 1 MG CAPSULE 3 PA PROGRAF 5 MG CAPSULE 3 PA PROGRAF 5 MG/ML AMPULE 3 PA PROQUAD VIAL 2 QL 2/3 QUADRACEL DTAP-IPV VIAL 2 RABAVERT RABIES VACCINE VIAL 2 RAPAMUNE 0.5 MG TABLET 3 PA RAPAMUNE 1 MG TABLET 4 PA RAPAMUNE 1 MG/ML ORAL SOLN 4 PA RAPAMUNE 2 MG TABLET 4 PA RECOMBIVAX HB 10 MCG/ML SYR 2 QL 3ML/3,B vsd RECOMBIVAX HB 10 MCG/ML VIAL 2 QL 3ML/3,B vsd RECOMBIVAX HB 40 MCG/ML VIAL 2 QL 3ML/3,B vsd RECOMBIVAX HB 5 MCG/0.5 ML SYR 2 QL 3ML/3,B vsd REMICADE 100 MG VIAL 4 PA RHEUMATREX 2.5 MG TABLET 3 RIDAURA 3 MG CAPSULE 4 ROTARIX VACCINE SUSPENSION 2 ROTATEQ VACCINE 2 SANDIMMUNE 100 MG/ML SOLN 2 PA SIMULECT 10 MG VIAL 4 BvsD SIMULECT MG VIAL 4 BvsD sirolimus 0.5 mg let 1 PA sirolimus 1 mg let 1 PA sirolimus 2 mg let 1 PA SYNAGIS 100 MG/1 ML VIAL 4 PA SYNAGIS 50 MG/0.5 ML VIAL 4 PA tacrolimus 0.5 mg capsule 1 PA tacrolimus 1 mg capsule 1 PA tacrolimus 5 mg capsule 1 PA TENIVAC SYRINGE 2 QL 0.5ML/ TETANUS DIPHTHERIA TOXOIDS 2 THERACYS 81 MG VIAL 2 BvsD THYMOGLOBULIN MG VIAL 3 BvsD TORISEL MG KIT 4 QL 4ML/,Bvs D TREXALL 10 MG TABLET 3 TREXALL MG TABLET 3 TREXALL 5 MG TABLET 3 TREXALL 7.5 MG TABLET 3 TRUMENBA 1 MCG/0.5 ML VACCIN 2 TWINRIX VACCINE VIAL 2 TYPHIM VI MCG/0.5 ML SYRNG 2 TYPHIM VI MCG/0.5 ML VIAL 2 VAQTA UNITS/0.5 ML SYRINGE 2 VAQTA 50 UNITS/ML SYRINGE 2 VARIVAX VACCINE WITH DILUENT 2 QL 1/3 VARIZIG 1 UNIT/1.2 ML VIAL 3 QL 12ML/30 YF-VAX 1 DOSE VIAL 2 ZORTRESS 0. MG TABLET 4 PA,QL 60/30 ZORTRESS 0.5 MG TABLET 4 PA,QL 1/30 ZORTRESS 0.75 MG TABLET 4 PA,QL 60/30 ZOSTAVAX VIAL 2 QL 1/999 Inflammatory Bowel Disease Agents APRISO ER GRAM CAPSULE 2 QL 1/30 ASACOL HD DR 800 MG TABLET 3 ST balsalazide disodium 750 mg cp 1 budesonide ec 3 mg capsule 1 CANASA 1,000 MG SUPPOSITORY 2 colocort 100 mg enema 1 DELZICOL DR 400 MG CAPSULE 3 +This drug does not count towards your total drug costs. For full description please see key symbol on page 6. 69

70 Comprehensive Formulary DIPENTUM 0 MG CAPSULE 2 hydrocortisone 100 mg/60 ml 1 LIALDA DR 1.2 GM TABLET 2 mesalamine 4 gm/60 ml enema 1 mesalamine 4 gm/60 ml kit 1 PENTASA 0 MG CAPSULE 2 PENTASA 500 MG CAPSULE 2 sulfasalazine 500 mg let 1 sulfasalazine dr 500 mg 1 Meolic Bone Disease Agents alendronate sod 70 mg/75 ml 1 alendronate sodium 10 mg 1 QL 30/30 alendronate sodium 35 mg 1 QL 4/ alendronate sodium 40 mg 1 QL 30/30 alendronate sodium 5 mg let 1 QL 30/30 alendronate sodium 70 mg 1 QL 4/ calcitonin-salmon 0 units sp 1 QL 3.7/30 calcitriol 0. mcg capsule 1 calcitriol 0.5 mcg capsule 1 calcitriol 1 mcg/ml ampul 1 calcitriol 1 mcg/ml solution 1 doxercalciferol 0.5 mcg cap 1 QL 90/30 doxercalciferol 1 mcg capsule 1 QL 240/30 doxercalciferol 2.5 mcg cap 1 QL 1/30 doxercalciferol 4 mcg/2 ml amp 1 etidronate disodium 0 mg 1 etidronate disodium 400 mg 1 FORTEO 600 MCG/2.4 ML PEN INJ 4 QL 2.4ML/ FOSAMAX PLUS D 70 MG-2,800 IU 3 QL 4/,ST FOSAMAX PLUS D 70 MG-5,600 IU 3 QL 4/,ST ibandronate 3 mg/3 ml vial 1 ibandronate sodium 0 mg 1 QL 1/ MIACALCIN 400 UNIT/2 ML VIAL 3 pamidronate 30 mg/10 ml vial 1 BvsD pamidronate 60 mg/10 ml vial 1 BvsD pamidronate 90 mg/10 ml vial 1 BvsD pamidronate disod 30 mg vial 1 BvsD pamidronate disod 90 mg vial 1 BvsD paricalcitol 1 mcg capsule 1 QL 90/30 paricalcitol 2 mcg capsule 1 QL 90/30 paricalcitol 2 mcg/ml vial 1 BvsD paricalcitol 4 mcg capsule 1 QL 60/30 paricalcitol 5 mcg/ml vial 1 BvsD PROLIA 60 MG/ML SYRINGE 3 QL 1ML/0 risedronate sod dr 35 mg 1 risedronate sodium 0 mg 1 QL 1/30 risedronate sodium 30 mg 1 QL 30/30 risedronate sodium 35 mg 1 QL 4/ risedronate sodium 5 mg let 1 QL 30/30 XGEVA 1 MG/1.7 ML VIAL 4 PA,QL 1.7ML/ zoledronic acid 4 mg vial 1 QL 3/21,BvsD zoledronic acid 4 mg/100 ml 1 BvsD zoledronic acid 4 mg/5 ml vial 1 QL ML/21,B vsd zoledronic acid 5 mg/100 ml 1 QL 100ML/3,BvsD Miscellaneous Therapeutic Agents BD ECLIPSE 30GX1/2" SYRINGE 2 QL 0/30 BD INSULIN SYR 0.3 ML 8MMX31G 2 QL 0/30 BD INSULIN SYR 0.5 ML 30GX1/2" 2 QL 0/30 BD INSULIN SYR 1 ML 29GX1/2" 2 QL 0/30 BD INSULIN SYR 1 ML 31GX5/" 2 QL 0/30 BD SAFETYGLIDE SYRINGE GX5/8 2 QL 0/30 BD ULTRA-FINE NDL 12.7MMX29G 2 QL 0/30 BD ULTRA-FINE PEN NDL 4MMXG 2 QL 0/30 BD ULTRA-FINE PEN NDL 5MMX31G 2 QL 0/30 BOTOX 100 UNITS VIAL 3 PA BOTOX 0 UNITS VIAL 3 PA DYSPORT 300 UNIT VIAL 3 PA DYSPORT 500 UNITS VIAL 3 PA E-Z-DISK TAB 700MG 2 + E-Z-PAQUE SUS 60% 2 + FERRIPROX 100 MG/ML SOLUTION 4 FERRIPROX 500 MG TABLET 4 fomepizole 1.5 gm/1.5 ml vial 4 +This drug does not count towards your total drug costs. For full description please see key symbol on page 6. 70

71 Comprehensive Formulary KORLYM 300 MG TABLET 4 PA,QL 1/30 LACTATED RINGERS IRRIGATION 2 levocarnitine 100 mg/ml soln 1 levocarnitine 0 mg/ml vial 1 levocarnitine 330 mg let 1 methylergonovine 0.2 mg let 1 methylergonovine 0.2 mg/ml vl 1 NATPARA 100 MCG DOSE CARTRIDGE 4 PA,QL 2/ NATPARA MCG DOSE CARTRIDGE 4 PA,QL 2/ NATPARA 50 MCG DOSE CARTRIDGE 4 PA,QL 2/ NATPARA 75 MCG DOSE CARTRIDGE 4 PA,QL 2/ NOVOFINE 30G X 1/3" NEEDLES 2 QL 0/30 NOVOFINE 31 2 QL 0/30 NOVOFINE G NEEDLES 2 QL 0/30 NOVOFINE AUTOCOVER 30G NEEDLE 2 QL 0/30 NOVOTWIST NEEDLE 30G 8MM 2 QL 0/30 NOVOTWIST NEEDLE G 5MM 2 QL 0/30 PHYSIOLYTE IRRIGATION SOLN 2 PHYSIOSOL IRRIGATION SOLN 2 POLIBAR SUS 100% 2 + POLIBAR ACB KIT 96% 2 + READI-CAT 2 SUS 2.1% 2 + READI-CAT 2 SUS APPLE 2 + READI-CAT 2 SUS MOCHACCI 2 + RINGERS IRRIGATION SOLUTION 2 sodium chloride 0.9% irrig. 1 sterile water for irrigation 1 TAGITOL V SUS 40% 2 + VARIBAR PST PUDDING 2 + VARIBAR HONE SUS 40% 2 + VARIBAR NECT SUS 40% 2 + VARIBAR THIN SUS HONEY 2 + VARIBAR THIN SUS LIQUID 2 + VGO DISPOSABLE DEVICE 3 VGO 30 DISPOSABLE DEVICE 3 VGO 40 DISPOSABLE DEVICE 3 XEOMIN 100 UNITS VIAL 3 PA XEOMIN 50 UNITS VIAL 3 PA Ophthalmic Agents acetazolamide er 500 mg cap 1 alcaine 0.5% eye drops 1 ALOCRIL 2% EYE DROPS 3 ALOMIDE 0.1% EYE DROPS 3 ALPHAGAN P 0.1% DROPS 2 altacaine 1 apraclonidine hcl 0.5% drops 1 atropine 1% eye drops 1 atropine 1% eye ointment 1 azelastine hcl 0.05% drops 1 AZOPT 1% EYE DROPS 2 betaxolol hcl 0.5% eye drop 1 BETIMOL 0.% EYE DROPS 3 BETIMOL 0.5% EYE DROPS 3 BETOPTIC S 0.% EYE DROPS 2 bimatoprost 0.03% eye drops 1 QL 5ML/30 brimonidine 0.2% eye drop 1 brimonidine tartrate 0.% drp 1 bromfenac sodium 0.09% eye drp 1 carteolol hcl 1% eye drops 1 COMBIGAN 0.2%-0.5% EYE DROPS 2 COSOPT PF EYE DROPS 3 QL 60/30 cromolyn 4% eye drops 1 CYCLOMYDRIL EYE DROPS 2 cyclopentolate 0.5% eye drops 1 cyclopentolate 1% eye drops 1 cyclopentolate hcl 2% drops 1 CYSTARAN 0.44% EYE DROPS 4 QL 60ML/30 dexamethasone 0.1% eye drop 1 diclofenac 0.1% eye drops 1 dorzolamide hcl 2% eye drops 1 QL 10ML/30 dorzolamide-timolol eye drops 1 QL 10ML/30 DUREZOL 0.05% EYE DROPS 2 EMADINE 0.05% EYE DROPS 3 epinastine hcl 0.05% eye drops 1 FLAREX 0.1% EYE DROPS 3 +This drug does not count towards your total drug costs. For full description please see key symbol on page 6.

72 Comprehensive Formulary fluorometholone 0.1% drops 1 flurbiprofen 0.03% eye drop 1 FML FORTE 0.% EYE DROPS 3 FML S.O.P. 0.1% OINTMENT 3 ILEVRO 0.3% OPHTH DROPS 2 IOPIDINE 1% EYE DROPS 3 isopto atropine 1% eye drops 1 isopto carpine 1% eye drops 1 isopto carpine 2% eye drops 1 isopto carpine 4% eye drops 1 isopto homatropine 2% drops 1 isopto homatropine 5% drops 1 ISTALOL 0.5% EYE DROPS 3 ketorolac 0.4% ophth solution 1 ketorolac 0.5% ophth solution 1 LACRISERT 5 MG EYE INSERT 3 latanoprost 0.005% eye drops 1 QL 5ML/30 levobunolol 0.5% eye drops 1 LOTEMAX 0.5% EYE DROPS 3 LOTEMAX 0.5% EYE OINTMENT 3 LOTEMAX 0.5% OPHTHALMIC GEL 3 LUMIGAN 0.01% EYE DROPS 2 QL 5ML/30 MAXIDEX 0.1% EYE DROPS 3 methazolamide mg let 1 methazolamide 50 mg let 1 metipranolol 0.3% eye drops 1 mydral 1 naphazoline 0.1% eye drops 1 neomyc-polym-dexamet eye ointm 1 neomyc-polym-dexameth eye drop 1 NEVANAC 0.1% DROPTAINER 2 olopatadine hcl 0.1% eye drops 1 QL 5ML/30 PATADAY 0.2% EYE DROPS 2 QL 2.5ML/30 PAZEO 0.7% EYE DROPS 2 QL 2.5ML/30 phenylephrine 10% eye drops 1 phenylephrine 2.5% eye drop 1 PHOSPHOLINE IODIDE 0.1% 3 pilocarpine 1% eye drops 1 pilocarpine 2% eye drops 1 pilocarpine 4% eye drops 1 PRED MILD 0.12% EYE DROPS 3 PRED-G 1% EYE DROPS 2 PRED-G S.O.P. EYE OINTMENT 2 prednisolone ac 1% eye drop 1 prednisolone sod 1% eye drop 1 PROCYSBI DR MG CAPSULE 4 PROCYSBI DR 75 MG CAPSULE 4 PROLENSA 0.07% EYE DROPS 3 proparacaine 0.5% eye drops 1 RESTASIS 0.05% EYE EMULSION 2 QL 60ML/30 SIMBRINZA 1%-0.2% EYE DROPS 3 tetracaine 0.5% eye drops 1 tetravisc 0.5% eye drops 1 tetravisc forte 0.5% eye drops 1 timolol 0.% eye drops 1 timolol 0.% gel-solution 1 timolol 0.5% eye drops 1 timolol 0.5% gel-solution 1 TOBRADEX EYE OINTMENT 3 TOBRADEX ST EYE DROPS 3 tobramycin-dexameth ophth susp 1 TRAVATAN Z 0.004% EYE DROP 2 QL 5ML/30 travoprost 0.004% eye drop 1 QL 5ML/30 tropicamide 0.5% eye drops 1 tropicamide 1% eye drops 1 VEXOL 1% EYE DROPS 3 ZIOPTAN 0.00% EYE DROPS 3 QL 30/30 Otic Agents acetasol hc ear drops 1 acetic acid 2% ear solution 1 acetic acid-aluminum drops 1 antipyrine-benzocaine ear drop 1 COLY-MYCIN S OTIC SUSP DROP 3 CORTANE-B DRO AQ OTIC 2 + CORTANE-B DRO OTIC 2 + cortic-nd dro 1 + CORTISPORIN-TC EAR SUSPENSION 3 +This drug does not count towards your total drug costs. For full description please see key symbol on page 6.

73 Comprehensive Formulary exotic-hc dro otic 1 + fluocinolone acetonide ear drops 1 fluocinolone oil 0.01% ear drp 1 hydrocortison-acetic acid soln 1 neomycin-polymyxin-hc ear soln 1 neomycin-polymyxin-hc ear susp 1 OTIC CARE OTIC SOLUTION 2 OTICIN HC DRO 2 + oto-end 10 sol 1 + otomax-hc dro 1 + Respiratory Tract Agents HYPERSAL NEB 7% 2 + HYPER-SAL NEB 7% 2 + nebusal neb 3% 1 + NEBUSAL NEB 6% 2 + pulmosal neb 7% 1 + pyril d sus -5mg/5 1 + pyril/phenyl sus -5mg/5 1 + sodium chlor neb 10% 1 + sodium chlor neb 3% 1 + sodium chlor neb 7% 1 + Respiratory Tract/Pulmonary Agents acetylcysteine 10% vial 1 BvsD acetylcysteine % vial 1 BvsD ADCIRCA MG TABLET 4 PA,QL 60/30 ADEMPAS 0.5 MG TABLET 4 PA,QL 90/30 ADEMPAS 1 MG TABLET 4 PA,QL 90/30 ADEMPAS 1.5 MG TABLET 4 PA,QL 90/30 ADEMPAS 2 MG TABLET 4 PA,QL 90/30 ADEMPAS 2.5 MG TABLET 4 PA,QL 90/30 ADRENALIN 1 MG/ML VIAL 2 ADVAIR DISKUS 2 QL 60/30 ADVAIR 0-50 DISKUS 2 QL 60/30 ADVAIR DISKUS 2 QL 60/30 ADVAIR HFA 1-21 MCG INHALER 2 QL 12GM/30 ADVAIR HFA MCG INHALER 2 QL 12GM/30 ADVAIR HFA -21 MCG INHALER 2 QL 12GM/30 albuterol 5 mg/ml solution 1 QL 0ML/30, BvsD albuterol sul 0.63 mg/3 ml sol 1 QL 360ML/30, BvsD albuterol sul 1. mg/3 ml sol 1 QL 360ML/30, BvsD albuterol sul 2.5 mg/3 ml soln 1 QL 360ML/30, BvsD albuterol sulf 2 mg/5 ml syrup 1 albuterol sulfate 2 mg 1 albuterol sulfate 4 mg 1 albuterol sulfate er 4 mg 1 albuterol sulfate er 8 mg 1 ALVESCO 0 MCG INHALER 3 ST ALVESCO 80 MCG INHALER 3 ST aminophylline 0 mg/10 ml vl 1 ANORO ELLIPTA MCG INH 2 QL 60/30 ARALAST NP 1,000 MG VIAL 4 BvsD ARALAST NP 500 MG VIAL 4 BvsD arbinoxa 4 mg let 1 arbinoxa 4 mg/5 ml liquid 1 ARCAPTA NEOHALER 75 MCG CAP 3 ARNUITY ELLIPTA 100 MCG INH 2 QL 30/30 ARNUITY ELLIPTA 0 MCG INH 2 QL 30/30 ASMANEX HFA 100 MCG INHALER 3 ST ASMANEX HFA 0 MCG INHALER 3 ST ASMANEX TWISTHALER 0 MCG 3 ST #30 ASMANEX TWISTHALER 0 MCG #7 3 ST ASMANEX TWISTHALER 0 MCG 3 ST # +This drug does not count towards your total drug costs. For full description please see key symbol on page 6. 73

74 Comprehensive Formulary ASMANEX TWISTHALER 0 MCG 3 ST #30 ASMANEX TWISTHALER 0 MCG 3 ST #60 ASMANEX TWISTHALR 0 MCG 3 ST #1 ATROVENT HFA INHALER 3 QL.8GM/30 AUVI-Q 0. MG AUTO-INJECTOR 3 QL 2/30 AUVI-Q 0.3 MG AUTO-INJECTOR 3 QL 2/30 azelastine 0.1% (7 mcg) spry 1 QL 30/ azelastine 0.% nasal spray 1 QL 30/ BETHKIS 300 MG/4 ML AMPULE 4 BvsD BREO ELLIPTA 100- MCG INH 2 QL 60/30 BREO ELLIPTA 0- MCG INH 2 QL 60/30 BROVANA MCG/2 ML SOLUTION 3 BvsD budesonide 0. mg/2 ml susp 1 QL 1ML/30, BvsD budesonide 0.5 mg/2 ml susp 1 QL 1ML/30, BvsD budesonide 1 mg/2 ml inh susp 1 QL 1ML/30, BvsD budesonide mcg nasal spray 1 QL.2GM/30 carbinoxamine 4 mg/5 ml liquid 1 carbinoxamine maleate 4 mg 1 CAYSTON 75 MG INHAL SOLUTION 4 QL 84ML/ CLARINEX-D 12 HOUR TABLET 3 QL 60/30 clemastine 0.5 mg/5 ml syrup 1 clemastine fum 2.68 mg 1 COMBIVENT RESPIMAT INHAL SPRAY 2 QL 4GM/30 cromolyn mg/2 ml neb soln 1 QL 240ML/30, BvsD cyproheptadine 2 mg/5 ml syrup 1 cyproheptadine 4 mg let 1 DALIRESP 500 MCG TABLET 3 QL 30/30 desloratadine 2.5 mg odt 1 QL 30/30 desloratadine 5 mg odt 1 QL 30/30 desloratadine 5 mg let 1 QL 30/30 dexchlorphen 2 mg/5 ml syrup 1 diphenhydramine 50 mg/ml vial 1 DULERA 100 MCG/5 MCG INHALER 3 DULERA 0 MCG/5 MCG INHALER 3 DYMISTA NASAL SPRAY 2 ELIXOPHYLLIN 80 MG/ ML ELIX 3 epinephrine 0.1 mg/ml syringe 1 epinephrine 0. mg auto-injct 1 QL 2/30 epinephrine 0.3 mg auto-inject 1 QL 2/30 epinephrine 1 mg/ml ampul 1 EPIPEN 2-PAK 0.3 MG AUTO-INJCT 2 QL 2/30 EPIPEN JR 2-PAK 0. MG INJCTR 2 QL 2/30 ESBRIET 7 MG CAPSULE 4 PA,QL 0/30 FLOVENT 100 MCG DISKUS 2 QL 60/30 FLOVENT 0 MCG DISKUS 2 QL 60/30 FLOVENT 50 MCG DISKUS 2 QL 60/30 FLOVENT HFA 0 MCG INHALER 2 QL 12GM/30 FLOVENT HFA 0 MCG INHALER 2 QL 24/30 FLOVENT HFA 44 MCG INHALER 2 QL 10.6GM/30 flunisolide 0.0% spray 1 QL 50ML/30 fluticasone prop 50 mcg spray 1 QL GM/30 GLASSIA 1 GM/50 ML VIAL 4 BvsD hydroxyzine mg/ml vial 1 hydroxyzine 50 mg/ml vial 1 hydroxyzine hcl 50 mg let 1 hydroxyzine pam 100 mg cap 1 hydroxyzine pam mg cap 1 hydroxyzine pam 50 mg cap 1 INCRUSE ELLIPTA 62.5 MCG INH 2 QL 30/30 iprat-albut 0.5-3(2.5) mg/3 ml 1 QL 540ML/30, BvsD ipratropium 0.03% spray 1 QL 30ML/30 +This drug does not count towards your total drug costs. For full description please see key symbol on page 6. 74

75 ipratropium 0.06% spray 1 QL 30ML/30 ipratropium br 0.02% soln 1 QL 300ML/30, BvsD ISUPREL 0.2 MG/ML AMPUL 2 KALYDECO 0 MG TABLET 4 PA,QL 60/30 KALYDECO 50 MG GRANULES PACKET 4 PA,QL 60/30 KALYDECO 75 MG GRANULES PACKET 4 PA,QL 60/30 LETAIRIS 10 MG TABLET 4 PA,QL 30/30 LETAIRIS 5 MG TABLET 4 PA,QL 30/30 levalbuterol 0.31 mg/3 ml sol 1 BvsD levalbuterol 0.63 mg/3 ml sol 1 BvsD levalbuterol 1. mg/3 ml sol 1 BvsD levalbuterol conc 1. mg/0.5 1 BvsD levocetirizine 2.5 mg/5 ml sol 1 QL 300ML/30 levocetirizine 5 mg let 1 QL 30/30 LUFYLLIN 0 MG TABLET 3 metaproterenol 10 mg let 1 metaproterenol 10 mg/5 ml syr 1 metaproterenol mg let 1 mometasone furoate 50 mcg spry 1 QL GM/30 montelukast sod 10 mg let 1 QL 30/30 montelukast sod 4 mg granules 1 QL 30/30 montelukast sod 4 mg chew 1 QL 30/30 montelukast sod 5 mg chew 1 QL 30/30 NASONEX 50 MCG NASAL SPRAY 3 QL GM/30,S T OFEV 100 MG CAPSULE 4 PA,QL 60/30 OFEV 0 MG CAPSULE 4 PA,QL 60/30 OMNARIS 50 MCG NASAL SPRAY 3 QL 12.5GM/30, ST Comprehensive Formulary 75 OPSUMIT 10 MG TABLET 4 PA,QL 30/30 ORKAMBI 0 MG-1 MG TABLET 4 PA,QL 1/30 PERFOROMIST MCG/2 ML SOLN 3 QL 1ML/30, BvsD PROAIR HFA 90 MCG INHALER 2 QL GM/30 PROAIR RESPICLICK INHAL POWDER 2 QL 2/30 PROLASTIN C 1,000 MG VIAL 4 BvsD promethazine 12.5 mg let 1 PA (HRM) promethazine mg let 1 PA (HRM) promethazine mg/ml vial 1 PA (HRM) promethazine 50 mg let 1 PA (HRM) promethazine 50 mg/ml vial 1 PA (HRM) promethazine 6. mg/5 ml syrp 1 PA (HRM) promethazine vc syrup 1 PA (HRM) promethazine-phenylephrine syr 1 PA (HRM) PROVENTIL HFA 90 MCG INHALER 3 PULMICORT 0. MG/2 ML RESPUL 3 BvsD PULMICORT 0.5 MG/2 ML RESPULE 3 BvsD PULMICORT 1 MG/2 ML RESPULE 3 BvsD PULMICORT 0 MCG FLEXHALER 3 QL 2/30,ST PULMICORT 90 MCG FLEXHALER 3 QL 1/30,ST PULMOZYME 1 MG/ML AMPUL 4 QL 0ML/30, BvsD QVAR 40 MCG ORAL INHALER 3 ST QVAR 80 MCG ORAL INHALER 3 ST REMODULIN 1 MG/ML VIAL 4 BvsD REMODULIN 10 MG/ML VIAL 4 BvsD REMODULIN 2.5 MG/ML VIAL 4 BvsD REMODULIN 5 MG/ML VIAL 4 BvsD SEMPREX-D 8 MG-60 MG CAPSULE 3 SEREVENT DISKUS 50 MCG 2 QL 60/30 sildenafil mg let 1 PA,QL 90/30 SPIRIVA MCG CP-HANDIHALER 3 SPIRIVA RESPIMAT 1. MCG INH 3 SPIRIVA RESPIMAT 2.5 MCG INH 3 +This drug does not count towards your total drug costs. For full description please see key symbol on page 6.

76 Comprehensive Formulary STIOLTO RESPIMAT INHAL SPRAY 3 STRIVERDI RESPIMAT INHAL SPRAY 3 SYMBICORT MCG INHALER 3 SYMBICORT MCG INHALER 3 terbutaline sulf 1 mg/ml vial 1 terbutaline sulfate 2.5 mg 1 terbutaline sulfate 5 mg 1 THEO-24 ER 100 MG CAPSULE 2 THEO-24 ER 0 MG CAPSULE 2 THEO-24 ER 300 MG CAPSULE 2 THEO-24 ER 400 MG CAPSULE 2 theochron er 100 mg let 1 theochron er 0 mg let 1 theochron er 300 mg let 1 theophylline 400 mg/500 ml d5w 1 theophylline 80 mg/ ml soln 1 theophylline er 100 mg let 1 theophylline er 0 mg let 1 theophylline er 300 mg 1 theophylline er 400 mg let 1 theophylline er 0 mg 1 theophylline er 600 mg let 1 TOBI PODHALER MG INHALE CAP 4 QL 68/3 tobramycin 300 mg/5 ml ampule 4 QL 0ML/, BvsD TRACLEER 1 MG TABLET 4 PA,QL 60/30 TRACLEER 62.5 MG TABLET 4 PA,QL 60/30 triamcinolone mcg nasal spr 1 TUDORZA PRESSAIR 400 MCG INH 3 QL 1/30 TYVASO 1.74 MG/2.9 ML SOLUTION 4 BvsD TYZINE PEDIATRIC 0.05% DROP 3 VENTAVIS 10 MCG/1 ML SOLUTION 4 PA,QL 0ML/30 VENTAVIS MCG/1 ML SOLUTION 4 PA,QL 0ML/30 VENTOLIN HFA 90 MCG INHALER 3 QL 36/30 VERAMYST.5 MCG NASAL SPRAY 3 QL 10GM/30,S T VIRAZOLE 6 GM VIAL 4 BvsD XOLAIR 0 MG VIAL 4 PA,QL 6/ XOPENEX HFA MCG INHALER 3 zafirlukast 10 mg let 1 QL 60/30 zafirlukast mg let 1 QL 60/30 ZEMAIRA 1,000 MG VIAL 4 BvsD ZETONNA 37 MCG NASAL SPRAY 3 QL 6.1GM/30,S T ZYFLO CR 600 MG TABLET 3 Skeletal Muscle Relaxants carisoprodol 350 mg let 1 PA (HRM) carisoprodol compound 1 PA (HRM) chlorzoxazone 500 mg let 1 PA (HRM) cyclobenzaprine 10 mg let 1 PA (HRM),QL 90/30 cyclobenzaprine 5 mg let 1 PA (HRM),QL 90/30 metaxalone 400 mg let 1 PA (HRM) metaxalone 800 mg let 1 PA (HRM) methocarbamol 500 mg let 1 PA (HRM) methocarbamol 750 mg let 1 PA (HRM) orphenadrine 30 mg/ml vial 1 PA (HRM) orphenadrine er 100 mg let 1 PA (HRM),QL 60/30 Sleep Disorder Agents armodafinil 0 mg let 1 PA,QL 30/30 armodafinil 0 mg let 1 PA,QL 30/30 armodafinil 0 mg let 1 PA,QL 30/30 armodafinil 50 mg let 1 PA,QL 30/30 BUTISOL SODIUM 30 MG TABLET 2 BUTISOL SODIUM 50 MG TABLET 2 +This drug does not count towards your total drug costs. For full description please see key symbol on page 6. 76

77 eszopiclone 1 mg let 1 PA (HRM),QL 90/3 eszopiclone 2 mg let 1 PA (HRM),QL 90/3 eszopiclone 3 mg let 1 PA (HRM),QL 90/3 modafinil 100 mg let 1 PA,QL 30/30 modafinil 0 mg let 1 PA,QL 60/30 NUVIGIL 0 MG TABLET 3 PA,QL 30/30 NUVIGIL 0 MG TABLET 3 PA,QL 30/30 NUVIGIL 0 MG TABLET 3 PA,QL 30/30 NUVIGIL 50 MG TABLET 3 PA,QL 30/30 ROZEREM 8 MG TABLET 3 QL 30/30 SILENOR 3 MG TABLET 3 QL 30/30 SILENOR 6 MG TABLET 3 QL 30/30 temazepam mg capsule 1 QL > 90/3 temazepam.5 mg capsule 1 QL > 90/3 temazepam 30 mg capsule 1 QL > 90/3 temazepam 7.5 mg capsule 1 QL > 90/3 XYREM 500 MG/ML ORAL SOLUTION 4 QL 540ML/30 zaleplon 10 mg capsule 1 QL > 90/3 zaleplon 5 mg capsule 1 QL > 90/3 zolpidem tart er 12.5 mg 1 QL > 90/3 zolpidem tart er 6. mg 1 QL > 90/3 zolpidem tartrate 10 mg let 1 QL > 90/3 Comprehensive Formulary 77 zolpidem tartrate 5 mg let 1 QL > 90/3 Therapeutic Nutrients/Minerals/Electrolytes AMINO ACIDS % SOLUTION 2 BvsD AMINOSYN 2 BvsD AMINOSYN 10% IV SOLUTION 2 BvsD AMINOSYN 7%-ELECTROLYTE SOL 2 BvsD AMINOSYN 8.5% IV SOLUTION 2 BvsD AMINOSYN 8.5%-ELECTROLYTES 2 BvsD SOL AMINOSYN II 10% IV SOLUTION 2 BvsD AMINOSYN II % IV SOLUTION 2 BvsD AMINOSYN II 7% IV SOLUTION 2 BvsD AMINOSYN II 8.5% IV SOLUTION 2 BvsD AMINOSYN II 8.5%-ELECTROLYTES 2 BvsD AMINOSYN M 3.5% IV SOLUTION 2 BvsD AMINOSYN-HBC 7% IV SOLUTION 2 BvsD AMINOSYN-PF 10% IV SOLUTION 2 BvsD AMINOSYN-PF 7% IV SOLUTION 2 BvsD AMINOSYN-RF 5.2% IV SOLUTION 2 BvsD ammonium chloride 5 meq/ml 1 av-phos 0 neutral 1 bacteriostatic saline vial 1 CARBAGLU 0 MG DISPER TABLET 4 CHEMET 100 MG CAPSULE 3 CLINIMIX 2.75%-5% SOLUTION 2 BvsD CLINIMIX 4.%-10% SOLUTION 2 BvsD CLINIMIX 4.%-% SOLUTION 2 BvsD CLINIMIX 4.%-% SOLUTION 2 BvsD CLINIMIX 4.%-5% SOLUTION 2 BvsD CLINIMIX 5%-% SOLUTION 2 BvsD CLINIMIX 5%-% SOLUTION 2 BvsD CLINIMIX 5%-% SOLUTION 2 BvsD CLINIMIX E 2.75%-10% SOLUTION 2 BvsD CLINIMIX E 2.75%-5% SOLUTION 2 BvsD CLINIMIX E 4.%-10% SOLUTION 2 BvsD CLINIMIX E 4.%-% SOLUTION 2 BvsD CLINIMIX E 4.%-5% SOLUTION 2 BvsD CLINIMIX E 5%-% SOLUTION 2 BvsD CLINIMIX E 5%-% SOLUTION 2 BvsD +This drug does not count towards your total drug costs. For full description please see key symbol on page 6.

78 Comprehensive Formulary CLINIMIX E 5%-% SOLUTION 2 BvsD CLINISOL % SOLUTION 2 BvsD CUPRIMINE 0 MG CAPSULE 2 cytra-2 oral solution 1 cytra-3 syrup 1 cytra-k crystals packet 1 cytra-k oral solution 1 D5%-1/2NS-KCL 10 MEQ/L IV SOL 2 BvsD D5%-1/2NS-KCL 30 MEQ/L IV SOL 2 BvsD D5%-1/2NS-KCL 40 MEQ/L IV SOL 2 BvsD denta 5000 plus cream 1 dentagel 1.1% gel 1 DEPEN 0 MG TITRATAB 2 DEXTROSE 10%-0.2% NACL IV 2 BvsD SOLN DEXTROSE 10%-0.% NACL IV SOL 2 BvsD dextrose 10%-water iv solution 1 BvsD DEXTROSE 2.5%-0.% NACL IV 2 BvsD dextrose %-water iv soln 1 BvsD dextrose %-water syringe 1 BvsD dextrose 30%-water iv soln 1 BvsD dextrose 40%-water iv soln 1 BvsD DEXTROSE 5%-0.2% NACL IV SOLN 2 BvsD DEXTROSE 5%-0.5% NACL IV SOL 2 BvsD DEXTROSE 5%-0.3% NACL IV SOLN 2 BvsD DEXTROSE 5%-0.33% NACL IV 2 BvsD SOLN DEXTROSE 5%-0.% NACL IV 2 BvsD SOLN DEXTROSE 5%-0.9% NACL IV SOLN 2 BvsD DEXTROSE 5%-ELECTROLYTE 2 BvsD DEXTROSE 5%-LR IV SOLUTION 2 dextrose 5%-water iv soln 1 BvsD dextrose 50%-water iv soln 1 BvsD dextrose 70%-water iv soln 1 BvsD effer-k meq let eff 1 EXJADE 1 MG TABLET 4 EXJADE 0 MG TABLET 4 EXJADE 500 MG TABLET 4 fluor-a-day 0. mg chew 1 fluor-a-day 0.5 mg chew 1 fluor-a-day 1 mg let chew 1 fluor-a-day 2.5 mg/ml drops 1 fluoride 0. mg let chew 1 fluoride 0.5 mg let chew 1 fluoride 1 mg let chewable 1 fluoridex defense 1.1% gel 1 fluori 0.5 mg let chew 1 fluori 1 mg let chew 1 FREAMINE HBC 6.9% IV SOLN 2 BvsD FREAMINE III 10% IV SOLN. 2 BvsD HEPATAMINE 8% IV SOLUTION 2 BvsD hyperlyte cr vial 1 BvsD INTRALIPID % IV FAT EMUL 2 BvsD INTRALIPID 30% IV FAT EMUL 2 BvsD IONOSOL B-D5W IV SOLUTION 2 BvsD IONOSOL MB-D5W IV SOLUTION 2 BvsD ISOLYTE P-DEXTROSE 5% SOLN 2 BvsD ISOLYTE S IV SOLN PH7.4 2 BvsD ISOLYTE S IV SOLUTION-EXCEL 2 BvsD JADENU 0 MG TABLET 4 JADENU 360 MG TABLET 4 JADENU 90 MG TABLET 4 k effervescent meq let 1 KABIVEN IV EMULSION 3 BvsD KCL MEQ IN D5W SOLUTION 2 BvsD KCL MEQ IN D5W-0.5% NACL 2 BvsD KCL MEQ IN D5W-0.3% NACL 2 BvsD KCL MEQ IN D5W-0.33% NACL 2 BvsD KCL MEQ IN D5W-0.% NACL 2 BvsD KCL MEQ IN D5W-LACT RINGER 2 BvsD KCL MEQ IN D5W-NS 2 BvsD KCL MEQ-NS 1,000 ML IV SOLN 2 BvsD KCL 40 MEQ IN D5W SOLUTION 2 BvsD KCL 40 MEQ IN D5W-LACT RINGER 2 BvsD KCL 40 MEQ IN D5W-NACL 0.9% 2 BvsD KCL 40 MEQ-NS 1,000 ML IV SOLN 2 BvsD KCL 5 MEQ IN D5W-0.2% NACL 2 BvsD kionex gm/60 ml suspension 1 kionex powder 1 +This drug does not count towards your total drug costs. For full description please see key symbol on page 6.

79 Comprehensive Formulary klor-con 10 meq let 1 klor-con meq packet 1 klor-con meq packet 1 klor-con 8 meq let 1 klor-con m10 let 1 klor-con m let 1 klor-con m let 1 klor-con sprinkle er 10 meq cp 1 klor-con sprinkle er 8 meq cap 1 klor-con-ef meq eff 1 K-PHOS #2 TABLET 2 K-PHOS NEUTRAL TABLET 2 K-PHOS ORIGINAL TABLET 2 k-sol 10% ( meq/ ml) liq 1 k-sol % (40 meq/ ml) liq 1 LACTATED RINGERS INJECTION 2 LIPOSYN III 10% IV FAT EMULSN 2 BvsD LIPOSYN III % IV FAT EMULSN 2 BvsD LIPOSYN III 30% IV FAT EMULSN 2 BvsD ludent fluoride 0. mg tb chw 1 ludent fluoride 0.5 mg tb chew 1 ludent fluoride 1 mg chew 1 magnesium sulf 2 g/50 ml bag 1 BvsD magnesium sulf g/500 ml bag 1 BvsD magnesium sulf 4 g/100 ml bag 1 BvsD magnesium sulf 4 g/50 ml bag 1 BvsD magnesium sulf 4% iv soln 1 BvsD magnesium sulf 40 g/1,000 ml 1 BvsD magnesium sulf 8% iv soln 1 BvsD magnesium sulfate 50% syringe 1 BvsD magnesium sulfate 50% vial 1 BvsD MOZOBIL 24 MG/1.2 ML VIAL 4 QL 9.6ML/30 multivit & fluor 0.5 mg/ml drp 1 multi-vit w-fluor 0. mg/ml 1 multi-vit w-fluor 0.5 mg/ml 1 multivitamins/fluoride 1 multivit-fluor 0. mg chw 1 multivit-fluor 0. mg/ml drop 1 multivit-fluor 0.5 mg chew 1 multivit-fluor 0.5 mg/ml drop 1 multivit-fluoride 1 mg chw 1 multivit-fluor-iron 0. mg/ml 1 multivit-iron-fl 0. mg/ml 1 mvc-fluoride 0. mg chew 1 mvc-fluoride 0.5 mg chew 1 mvc-fluoride 1 mg chew 1 NEPHRAMINE 5.4% IV SOLUTION 2 BvsD neutral sodium fluoride 1 NORMOSOL-M AND DEXTROSE 5% 2 BvsD NORMOSOL-R IV SOLUTION 2 BvsD NORMOSOL-R PH 7.4 IV SOLUTION 2 BvsD NORMOSOL-R-DEXTROSE 5% IV 2 BvsD SOLN NUTRILIPID % IV FAT EMULSION 2 BvsD NUTRILYTE II VIAL 2 BvsD NUTRILYTE VIAL 2 BvsD PERIKABIVEN IV EMULSION 3 BvsD phospha 0 neutral let 1 PLASMA-LYTE 8 IV SOLUTION 2 BvsD PLASMA-LYTE -DEXTROSE 5% 2 BvsD PLASMA-LYTE A PH 7.4 SOLN. 2 BvsD pot citrate-citric acid packet 1 potassium meq let eff 1 potassium cit-citric acid soln 1 potassium citrate er 10 meq tb 1 potassium citrate er meq tb 1 potassium citrate er 5 meq 1 potassium cl 10 meq/100 ml sol 1 BvsD potassium cl 10% ( meq/ ml 1 potassium cl 2 meq/ml vial 1 BvsD potassium cl meq packet 1 potassium cl meq/100 ml sol 1 BvsD POTASSIUM CL MEQ-0.% NACL 2 BvsD potassium cl % (40 meq/ ml 1 potassium cl meq eff 1 potassium cl 40 meq/100 ml sol 1 BvsD potassium cl er 10 meq capsule 1 potassium cl er 10 meq let 1 potassium cl er meq let 1 +This drug does not count towards your total drug costs. For full description please see key symbol on page 6.

80 Comprehensive Formulary potassium cl er 8 meq capsule 1 potassium cl er 8 meq let 1 PREMASOL 10% IV SOLUTION 2 BvsD PREMASOL 6% IV SOLUTION 2 BvsD PREVIDENT 1.1% GEL 2 PREVIDENT % DRY MOUTH 2 PREVIDENT 5000 PLUS CREAM 2 PREVIDENT DENTAL RINSE 2 PROCALAMINE IV SOLUTION 2 BvsD PROSOL % INJECTION 3 BvsD RINGER'S IV SOLUTION 2 SAMSCA MG TABLET 4 QL 30/30 SAMSCA 30 MG TABLET 4 QL 60/30 sf 1.1% gel 1 sf 5000 plus cream 1 sod citrate-citric acid soln 1 sod polystyren sulf g/60 ml 1 sodium bicarb 4.2% abbjct 1 sodium bicarb 4.2% vial 1 sodium bicarb 7.5% abboject 1 sodium bicarb 8.4% abboject 1 sodium chloride 0.% soln 1 sodium chloride 0.9% solution 1 sodium chloride 0.9% vial 1 sodium chloride 3% iv soln 1 sodium chloride 4 meq/ml vl 1 sodium chloride 5% iv soln 1 sodium cl 2.5 meq/ml vial 1 sodium fluoride 0.5 mg(1.1 mg) 1 sodium fluoride 0.5 mg/ml drop 1 sodium fluoride 1 mg (2.2 mg) 1 SODIUM LACTATE 5 MEQ/ML VIAL 2 BvsD sodium polystyrene sulf powder 1 sps gm/60 ml suspension 1 sps 30 gm/1 ml enema 1 SYPRINE 0 MG CAPSULE 2 tl-fluorivite chewable let 1 TPN ELECTROLYTES VIAL 2 BvsD TRAVASOL 10% SOLN VIAFLEX 3 BvsD triple-vit w-fluor 0. mg/ml 1 tri-vit-fluor 0. mg/ml drop 1 tri-vit-fluor 0.5 mg/ml drop 1 tri-vit-fluor-iron 0. mg/ml 1 TROPHAMINE 10% IV SOLUTION 2 BvsD TROPHAMINE 6% IV SOLUTION 2 BvsD virt-phos 0 neutral let 1 virtrate-2 solution 1 virtrate-k solution 1 vitamins a,c,d & fluoride drop 1 VP-PNV-DHA CAPSULE 2 +This drug does not count towards your total drug costs. For full description please see key symbol on page 6. 80

81 Index of Medications 8-MOP 10 MG CAPSULE 51 acitretin mg capsule 51 ADVAIR 0-50 DISKUS 73 abacavir 300 mg let abacavir-lamivudine-zidov ABELCET 100 MG/ ML VIAL ABILIFY MAINTENA ER 300 MG SYR ABILIFY MAINTENA ER 300 MG VL ABILIFY MAINTENA ER 400 MG SYR ABRAXANE 100 MG VIAL acamprosate calc dr 333 mg acarbose 100 mg let acarbose mg let acarbose 50 mg let acebutolol 0 mg capsule acebutolol 400 mg capsule acetamin-codein mg/12.5 acetaminophen-cod #2 let acetaminophen-cod #3 let acetaminophen-cod #4 let acetasol hc ear drops acetazolamide 1 mg let acetazolamide 0 mg let acetazolamide er 500 mg cap acetazolamide sod 500 mg vial acetic acid 0.% irrig soln acetic acid 2% ear solution acetic acid-aluminum drops acetylcysteine 10% vial acetylcysteine % vial acitretin 10 mg capsule acitretin.5 mg capsule ACTEMRA 2 MG/0.9 ML SYRINGE ACTEMRA 0 MG/10 ML VIAL ACTEMRA 400 MG/ ML VIAL ACTEMRA 80 MG/4 ML VIAL ACTHIB VACCINE WITH DILUENT ACTIMMUNE 100 MCG/0.5 ML VIAL acyclovir 0 mg capsule acyclovir 0 mg/5 ml susp acyclovir 400 mg let acyclovir 5% ointment acyclovir 500 mg/10 ml vial acyclovir 800 mg let acyclovir sodium 500 mg vial ADACEL TDAP VIAL ADAGEN 0 UNITS/ML VIAL adapalene 0.1% cream adapalene 0.1% gel adapalene 0.1% lotion adapalene 0.3% gel ADCIRCA MG TABLET adefovir dipivoxil 10 mg ADEMPAS 0.5 MG TABLET ADEMPAS 1 MG TABLET ADEMPAS 1.5 MG TABLET ADEMPAS 2 MG TABLET ADEMPAS 2.5 MG TABLET ADRENALIN 1 MG/ML VIAL adrucil 2,500 mg/50 ml vial adrucil 5 gram/100 ml vial adrucil 500 mg/10 ml vial ADVAIR DISKUS ADVAIR DISKUS ADVAIR HFA 1-21 MCG INHALER ADVAIR HFA MCG INHALER ADVAIR HFA -21 MCG INHALER ADVICOR 1,000 MG- MG TABLET ADVICOR 1,000 MG-40 MG TABLET ADVICOR 500 MG- MG TABLET ADVICOR 750 MG- MG TABLET AFEDITAB CR 30 MG TABLET AFEDITAB CR 60 MG TABLET AFINITOR 10 MG TABLET AFINITOR 2.5 MG TABLET AFINITOR 5 MG TABLET AFINITOR 7.5 MG TABLET AFINITOR DISPERZ 2 MG TABLET AFINITOR DISPERZ 3 MG TABLET AFINITOR DISPERZ 5 MG TABLET AGGRENOX MG-0 MG CAPSULE a-hydrocort 100 mg vial ak-poly-bac eye ointment ALA QUIN CREAM 3-0.5% ala-cort 1% cream ALA-SCALP 2% LOTION ALBENZA 0 MG TABLET albuterol 5 mg/ml solution albuterol sul 0.63 mg/3 ml sol Comprehensive Formulary 81

82 albuterol sul 1. mg/3 ml sol 73 ALOCRIL 2% EYE DROPS amantadine 100 mg capsule albuterol sul 2.5 mg/3 ml soln 73 ALOMIDE 0.1% EYE DROPS amantadine 100 mg let albuterol sulf 2 mg/5 ml syrup albuterol sulfate 2 mg albuterol sulfate 4 mg albuterol sulfate er 4 mg albuterol sulfate er 8 mg alcaine 0.5% eye drops alclometasone dipr 0.05% oint alclometasone dipro 0.05% crm ALCOHOL 70% PREP PADS ALCORTIN A GEL ALDURAZYME 2.9 MG/5 ML VIAL ALECENSA 0 MG CAPSULE alendronate sod 70 mg/75 ml alendronate sodium 10 mg alendronate sodium 35 mg alendronate sodium 40 mg alendronate sodium 5 mg let alendronate sodium 70 mg alfuzosin hcl er 10 mg let ALIMTA 100 MG VIAL ALIMTA 500 MG VIAL ALINIA 100 MG/5 ML SUSPENSION ALINIA 500 MG TABLET allopurinol 100 mg let allopurinol 300 mg let almotriptan malate 12.5 mg almotriptan malate 6. mg ALOPRIM 500 MG VIAL ALOQUIN GEL 1.-1% ALORA 0.0 MG PATCH ALORA 0.05 MG PATCH ALORA MG PATCH ALORA 0.1 MG PATCH alosetron hcl 0.5 mg let alosetron hcl 1 mg let ALOXI 0. MG/5 ML VIAL ALPHAGAN P 0.1% DROPS alprazolam 0. mg let alprazolam 0.5 mg let alprazolam 1 mg let alprazolam 1 mg/ml oral conc alprazolam 2 mg let alprazolam er 1 mg let alprazolam er 2 mg let alprazolam er 3 mg let alprazolam odt 0. mg alprazolam odt 0.5 mg alprazolam odt 1 mg alprazolam odt 2 mg alprazolam xr 0.5 mg let alprazolam xr 1 mg let alprazolam xr 2 mg let alprazolam xr 3 mg let ALTABAX 1% OINTMENT altacaine altavera- let ALUVEA CREAM 39% ALVESCO 0 MCG INHALER ALVESCO 80 MCG INHALER alyacen let alyacen let amantadine 50 mg/5 ml solution AMBISOME 50 MG VIAL amcinonide 0.1% cream amcinonide 0.1% lotion amcinonide 0.1% ointment a-methapred amethia mg amethia lo let amethyst 90- mcg let amifostine 500 mg vial amikacin sulf 1 gram/4 ml vial amikacin sulf 500 mg/2 ml vial amiloride hcl 5 mg let amiloride hcl-hctz 5-50 mg AMINO ACIDS % SOLUTION aminocaproic acid 1,000 mg aminocaproic acid % solution aminocaproic acid 5 g/ ml vl aminocaproic acid 500 mg aminophylline 0 mg/10 ml vl AMINOSYN AMINOSYN 10% IV SOLUTION AMINOSYN 7%-ELECTROLYTE SOL AMINOSYN 8.5% IV SOLUTION AMINOSYN 8.5%- ELECTROLYTES SOL AMINOSYN II 10% IV SOLUTION AMINOSYN II % IV SOLUTION AMINOSYN II 7% IV SOLUTION Comprehensive Formulary 82

83 AMINOSYN II 8.5% IV SOLUTION AMINOSYN II 8.5%- ELECTROLYTES AMINOSYN M 3.5% IV SOLUTION AMINOSYN-HBC 7% IV SOLUTION AMINOSYN-PF 10% IV SOLUTION AMINOSYN-PF 7% IV SOLUTION AMINOSYN-RF 5.2% IV SOLUTION amiodarone 0 mg/3 ml amp amiodarone 0 mg/9 ml vial amiodarone 900 mg/ ml vial amiodarone hcl 100 mg let amiodarone hcl 0 mg let amiodarone hcl 400 mg let AMITIZA 24 MCG CAPSULES AMITIZA 8 MCG CAPSULE amitriptyline hcl 10 mg amitriptyline hcl 100 mg amitriptyline hcl 0 mg amitriptyline hcl mg amitriptyline hcl 50 mg amitriptyline hcl 75 mg amlodipine besylate 10 mg amlodipine besylate 2.5 mg amlodipine besylate 5 mg amlodipine-atorvast mg amlodipine-atorvast 10- mg amlodipine-atorvast mg amlodipine-atorvast mg amlodipine-atorvast mg amlodipine-atorvast 2.5- mg amlodipine-atorvast mg amlodipine-atorvast 5-10 mg amlodipine-atorvast 5- mg amlodipine-atorvast 5-40 mg amlodipine-atorvast 5-80 mg amlodipine-benazepril 10- mg amlodipine-benazepril mg amlodipine-benazepril amlodipine-benazepril 5-10 mg amlodipine-benazepril 5- mg amlodipine-benazepril 5-40 mg amlodipine-valsartan 10-0 mg amlodipine-valsartan 10-0 mg amlodipine-valsartan 5-0 mg amlodipine-valsartan 5-0 mg amlod-valsa-hctz mg amlod-valsa-hctz mg amlod-valsa-hctz mg amlod-valsa-hctz mg amlod-valsa-hctz 5-0- mg ammonium chloride 5 meq/ml ammonium lactate 12% cream ammonium lactate 12% lotion amnesteem 10 mg capsule amnesteem mg capsule amnesteem 40 mg capsule amoxapine 100 mg let amoxapine 0 mg let amoxapine mg let amoxapine 50 mg let amox-clav 0-.5 mg chew amox-clav 0-.5 mg/5 ml sus amox-clav 0-1 mg let amox-clav mg/5 ml sus amox-clav mg chew amox-clav mg/5 ml susp amox-clav mg let amox-clav mg/5 ml sus amox-clav mg let amox-clav er 1, mg amoxicillin 1 mg chew amoxicillin 1 mg/5 ml susp amoxicillin 0 mg/5 ml susp amoxicillin 0 mg capsule amoxicillin 0 mg chew amoxicillin 0 mg/5 ml susp amoxicillin 400 mg/5 ml susp amoxicillin 500 mg capsule amoxicillin 500 mg let amoxicillin 875 mg let amoxicillin/potassium clavulanate amphotericin b 50 mg vial ampicillin 1 gm a-v vial ampicillin 1 gm vial Comprehensive Formulary 83

84 ampicillin 10 gm vial ampicillin 1 mg vial ampicillin 1 mg/5 ml susp ampicillin 2 gm a-v vial ampicillin 2 gm vial ampicillin 0 mg capsule ampicillin 0 mg vial ANDROXY 10 MG TABLET ANGELIQ 0. MG-0.5 MG TABLET ANGELIQ 0.5 MG-1 MG TABLET ANORO ELLIPTA MCG INH antipyrine-benzocaine ear drop ARANESP 100 MCG/0.5 ML SYRINGE ARANESP 100 MCG/ML VIAL ARANESP 0 MCG/0.3 ML SYRINGE ARANESP 0 MCG/0.4 ML SYRINGE ARANESP 0 MCG/ML VIAL ampicillin 0 mg/5 ml susp ampicillin 500 mg capsule ampicillin 500 mg vial ampicillin-sulbactam 1.5 gm vl ampicillin-sulbactam gm vl ampicillin-sulbactam 3 gm vial AMPYRA ER 10 MG TABLET 50 anucort-hc sup mg ANUSOL-HC SUP MG ANZEMET 100 MG TABLET ANZEMET MG/ML VIAL ANZEMET 50 MG TABLET apexicon e 0.05% cream APIDRA 100 UNITS/ML VIAL ARANESP MCG/0.42 ML SYRING ARANESP MCG/ML VIAL ARANESP 300 MCG/0.6 ML SYRINGE ARANESP 300 MCG/ML VIAL ARANESP 40 MCG/0.4 ML SYRINGE ANADROL-50 TABLET anagrelide hcl 0.5 mg capsule anagrelide hcl 1 mg capsule ana-lex 2-2% kit ANALPRAM E KIT ANALPRAM HC CREAM 2.5-1% ANALPRAM KIT ADVANCED ANALPRAM-HC LOT 2.5% ANALPRAM-HC CREAM 1-1% ANALPRAM-HC CREAM SINGLES ANALPRM SNGL CREAM HC anaspaz 0.1 mg let odt anastrozole 1 mg let ANDRODERM 2 MG/24HR PATCH ANDRODERM 4 MG/24HR PATCH ANDROGEL 1.62% GEL PUMP ANDROGEL 1.62%(1.G) GEL PCKT ANDROGEL 1.62%(2.5G) GEL PCKT APIDRA SOLOSTAR 100 UNITS/ML APLENZIN ER 4 MG TABLET APLENZIN ER 3 MG TABLET APLENZIN ER 5 MG TABLET APOKYN 30 MG/3 ML CARTRIDGE apraclonidine hcl 0.5% drops apri day let APRISO ER GRAM CAPSULE APTIOM 0 MG TABLET APTIOM 400 MG TABLET APTIOM 600 MG TABLET APTIOM 800 MG TABLET APTIVUS 100 MG/ML SOLUTION APTIVUS 0 MG CAPSULE ARALAST NP 1,000 MG VIAL ARALAST NP 500 MG VIAL aranelle let ARANESP 10 MCG/0.4 ML SYRINGE ARANESP 40 MCG/ML VIAL ARANESP 500 MCG/1 ML SYRINGE ARANESP 60 MCG/0.3 ML SYRINGE ARANESP 60 MCG/ML VIAL arbinoxa 4 mg let arbinoxa 4 mg/5 ml liquid ARCALYST 0 MG INJECTION ARCAPTA NEOHALER 75 MCG CAP ARESTIN 1 MG MICROSPHERE aripiprazole 1 mg/ml solution aripiprazole 10 mg let aripiprazole mg let aripiprazole 2 mg let aripiprazole mg let aripiprazole 30 mg let aripiprazole 5 mg let aripiprazole odt 10 mg let aripiprazole odt mg let ARISTADA ER 441 MG/1.6 ML SYRN Comprehensive Formulary 84

85 ARISTADA ER 662 MG/2.4 ML SYRN ARISTADA ER 882 MG/3.2 ML SYRN ARISTOSPAN INTRA-ARTICULAR armodafinil 0 mg let armodafinil 0 mg let armodafinil 0 mg let armodafinil 50 mg let ARMOUR THYROID 1 MG TABLET ARMOUR THYROID MG TABLET ASMANEX HFA 0 MCG INHALER ASMANEX TWISTHALER 0 MCG #30 ASMANEX TWISTHALER 0 MCG #7 ASMANEX TWISTHALER 0 MCG # ASMANEX TWISTHALER 0 MCG #30 ASMANEX TWISTHALER 0 MCG #60 ASMANEX TWISTHALR 0 MCG # atropine 1% eye drops atropine 1% eye ointment atropine 8 mg/ ml vial atropine sulfate ATROVENT HFA INHALER AUBAGIO MG TABLET AUBAGIO 7 MG TABLET aubra- let AUGMENTIN MG/5 ML AURSTAT ANTI GEL -ITCH AURYXIA 210 MG TABLET ARMOUR THYROID 0 MG TABLET ARMOUR THYROID 240 MG TABLET ARMOUR THYROID 30 MG TABLET ARMOUR THYROID 300 MG TABLET aspirin-caff-dihydrocodein cap aspirin-dipyridam er -0 mg ASTAGRAF XL 0.5 MG CAPSULE ASTAGRAF XL 1 MG CAPSULE ASTAGRAF XL 5 MG CAPSULE atenolol 100 mg let AUVI-Q 0. MG AUTO- INJECTOR AUVI-Q 0.3 MG AUTO-INJECTOR AVANDIA 2 MG TABLET AVANDIA 4 MG TABLET AVANDIA 8 MG TABLET AVASTIN 100 MG/4 ML VIAL ARMOUR THYROID 60 MG TABLET ARMOUR THYROID 90 MG TABLET ARNUITY ELLIPTA 100 MCG INH ARNUITY ELLIPTA 0 MCG INH ARRANON 0 MG VIAL ARZERRA 1,000 MG/50 ML VIAL ARZERRA 100 MG/5 ML VIAL ARZOL SILVER MIS NITR APP ASACOL HD DR 800 MG TABLET ascomp with codeine capsule ashlyna mg ASMANEX HFA 100 MCG INHALER atenolol mg let atenolol 50 mg let atenolol-chlorthalidone 100- atenolol-chlorthalidone 50- ATGAM 50 MG/ML AMPUL atorvastatin 10 mg let atorvastatin mg let atorvastatin 40 mg let atorvastatin 80 mg let atovaquone 750 mg/5 ml atovaquone-proguanil atovaquone-proguanil ATRIPLA TABLET atropine 0.05 mg/ml syringe atropine 0.1 mg/ml syringe atropine 1 mg/ml vial AVASTIN 400 MG/ ML VIAL AVC % CREAM AVELOX IV 400 MG/0 ML aviane- let AVONEX ADMIN PACK 30 MCG VL AVONEX PEN 30 MCG/0.5 ML KIT AVONEX PREFILLED SYR 30 MCG KT av-phos 0 neutral azacitidine 100 mg vial AZACTAM-ISO-OSMOT 1 GM/50 ML AZACTAM-ISO-OSMOT 2 GM/50 ML AZASAN 100 MG TABLET AZASAN 75 MG TABLET AZASITE 1% EYE DROPS Comprehensive Formulary 85

86 azathioprine 50 mg let 67 BANZEL 400 MG TABLET BENICAR MG TABLET azathioprine sod 100 mg vial azelastine 0.1% (7 mcg) spry azelastine 0.% nasal spray azelastine hcl 0.05% drops AZELEX % CREAM AZILECT 0.5 MG TABLET AZILECT 1 MG TABLET azithromycin 1 gm pwd packet azithromycin 100 mg/5 ml susp azithromycin 0 mg/5 ml susp azithromycin 0 mg let azithromycin 500 mg let azithromycin 600 mg let azithromycin i.v. 500 mg vial BARACLUDE 0.05 MG/ML SOLUTION BCG (TICE STRAIN) VIAL BCG VACCINE (TICE STRAIN) VIAL BD ECLIPSE 30GX1/2" SYRINGE BD INSULIN SYR 0.3 ML 8MMX31G BD INSULIN SYR 0.5 ML 30GX1/2" BD INSULIN SYR 1 ML 29GX1/2" BD INSULIN SYR 1 ML 31GX5/" BD SAFETYGLIDE SYRINGE GX5/8 BD ULTRA-FINE NDL 12.7MMX29G BENICAR 40 MG TABLET BENICAR 5 MG TABLET BENICAR HCT MG TABLET BENICAR HCT MG TABLET BENICAR HCT 40- MG TABLET BENLYSTA 1 MG VIAL BENLYSTA 400 MG VIAL BENSAL HP 3% OINTMENT BENZEFOAM AER 5.3% BENZEFOAM AER 9.8% benzepro aer 5.3% benzepro liq creamy benzepro sc aer 9.8% benzoyl per aer 5.3% AZOPT 1% EYE DROPS aztreonam 1 gm vial aztreonam 2 gm vial azuphen mb capsule azurette day let baciim 50,000 units vial bacitracin 50,000 units vial bacitracin 500 unit/gm ophth bacitracin-polymyxin eye oint baclofen 10 mg let baclofen mg let bacteriostatic saline vial BACTROBAN NASAL 2% OINTMENT balsalazide disodium 750 mg cp balziva let BANZEL 0 MG TABLET BANZEL 40 MG/ML SUSPENSION BD ULTRA-FINE PEN NDL 4MMXG BD ULTRA-FINE PEN NDL 5MMX31G bekyree day let BELEODAQ 500 MG VIAL belladonna-opium.2-30 supp belladonna-opium.2-60 supp benazepril hcl 10 mg let benazepril hcl mg let benazepril hcl 40 mg let benazepril hcl 5 mg let benazepril-hctz mg benazepril-hctz mg benazepril-hctz - mg benazepril-hctz 5-6. mg BENDEKA 100 MG/4 ML VIAL benzoyl per aer 9.8% benzoyl pero aer 9.8% benztropine 2 mg/2 ml ampule benztropine mes 0.5 mg benztropine mes 1 mg let benztropine mes 2 mg let BERINERT 500 UNIT KIT BESIVANCE 0.6% SUSP betamethasone ac-sp 6 mg/ml vl betamethasone dp 0.05% crm betamethasone dp 0.05% lot betamethasone dp 0.05% oint betamethasone dp aug 0.05% crm betamethasone dp aug 0.05% gel betamethasone dp aug 0.05% lot Comprehensive Formulary 86

87 betamethasone dp aug 0.05% oin betamethasone va 0.1% cream betamethasone va 0.1% betamethasone valer 0.1% ointm betamethasone valer 0.12% foam BETASERON 0.3 MG KIT betaxolol 10 mg let betaxolol mg let betaxolol hcl 0.5% eye drop bethanechol 10 mg let bethanechol mg let bethanechol 5 mg let bethanechol 50 mg let BETHKIS 300 MG/4 ML AMPULE BETIMOL 0.% EYE DROPS BETIMOL 0.5% EYE DROPS BETOPTIC S 0.% EYE DROPS bexarotene 75 mg capsule BEXSERO PREFILLED SYRINGE bicalutamide 50 mg let BICILLIN C-R 1.2 MILLION UNIT bisoprolol-hctz mg bisoprolol-hctz mg tb bisoprolol-hctz 5-6. mg BIVIGAM LIQUID 10% VIAL bleomycin sulfate unit vial bleomycin sulfate 30 unit vial BLEPHAMIDE EYE DROPS BLEPHAMIDE EYE OINTMENT blisovi fe 1- let BOOSTRIX TDAP VACCINE SYRINGE BOOSTRIX TDAP VACCINE VIAL BOSULIF 100 MG TABLET BOSULIF 500 MG TABLET BOTOX 100 UNITS VIAL BOTOX 0 UNITS VIAL bp cleansing wash bp foam aer 5.3% bp foam aer 9.8% bp wash liq 7% BREO ELLIPTA 100- MCG INH BREO ELLIPTA 0- MCG INH BRIVIACT 50 MG/5 ML VIAL BRIVIACT 75 MG TABLET bromfenac sodium 0.09% eye drp bromocriptine 2.5 mg let bromocriptine 5 mg capsule BROVANA MCG/2 ML SOLUTION BUCALSEP SOL BUCALSEP SPR budesonide 0. mg/2 ml susp budesonide 0.5 mg/2 ml susp budesonide 1 mg/2 ml inh susp budesonide mcg nasal spray budesonide ec 3 mg capsule bumetanide 0. mg/ml vial bumetanide 0.5 mg let bumetanide 1 mg let bumetanide 2 mg let bupap 50 mg-300 mg let BUPHENYL 500 MG TABLET buprenorphine 0.3 mg/ml syrn buprenorphine 0.3 mg/ml vial BICILLIN C-R SYRINGE briellyn let 61 buprenorphine 2 mg let sl 12 BICILLIN L-A 1,0,000 UNITS BRILINTA 60 MG TABLET 40 buprenorphine 8 mg let sl 12 BICILLIN L-A 2,400,000 UNITS BICILLIN L-A 600,000 UNIT/ML BICNU 100 MG VIAL BIDIL TABLET BILTRICIDE 600 MG TABLET bimatoprost 0.03% eye drops BIONECT GEL 0.2% bisoprolol fumarate 10 mg bisoprolol fumarate 5 mg 31 BRILINTA 90 MG TABLET brimonidine 0.2% eye drop brimonidine tartrate 0.% drp BRIVIACT 10 MG TABLET BRIVIACT 10 MG/ML ORAL SOLN BRIVIACT 100 MG TABLET BRIVIACT MG TABLET BRIVIACT 50 MG TABLET 40 buprenorphin-naloxon 8-2 mg sl buprenorphn-naloxn mg sl buproban 0 mg let bupropion hcl 100 mg let bupropion hcl 75 mg let bupropion hcl sr 100 mg let bupropion hcl sr 0 mg Comprehensive Formulary 87

88 bupropion hcl sr 0 mg let bupropion hcl sr 0 mg bupropion hcl xl 0 mg let bupropion hcl xl 300 mg let buspirone hcl 10 mg let buspirone hcl mg let buspirone hcl 30 mg let buspirone hcl 5 mg let BYDUREON 2 MG PEN INJECT BYDUREON 2 MG VIAL BYETTA 10 MCG DOSE PEN INJ BYETTA 5 MCG DOSE PEN INJ BYSTOLIC 10 MG TABLET BYSTOLIC 2.5 MG TABLET BYSTOLIC MG TABLET BYSTOLIC 5 MG TABLET cabergoline 0.5 mg let CABOMETYX MG TABLET CANCIDAS IV 70 MG VIAL candesartan cilexetil mg tb candesartan cilexetil mg tb candesartan cilexetil 4 mg candesartan cilexetil 8 mg candesartan-hctz mg tb candesartan-hctz mg tb candesartan-hctz - mg 24 buspirone hcl 7.5 mg let 37 CABOMETYX 40 MG TABLET CANTIL MG TABLET BUSULFEX 60 MG/10 ML VIAL CABOMETYX 60 MG TABLET capacet capsule 8 butalb-acetamin-caff butalb-acetamin-caff butalb-acetaminoph-caffcodein butalb-caff-acetaminophcodein butalbit-acetaminophen-caff cp butalbital comp-codeine #3 cap butalbital-acetaminophn 50-5 butalbital-asa-caffeine cap BUTISOL SODIUM 30 MG TABLET BUTISOL SODIUM 50 MG TABLET butorphanol 1 mg/ml vial butorphanol 10 mg/ml spray butorphanol 2 mg/ml vial BUTRANS 10 MCG/HR PATCH BUTRANS MCG/HR PATCH BUTRANS MCG/HR PATCH BUTRANS 5 MCG/HR PATCH BUTRANS 7.5 MCG/HR PATCH CAFERGOT TABLET calcipotriene 0.005% cream calcipotriene 0.005% ointment calcipotriene 0.005% solution calcitonin-salmon 0 units sp calcitrene 0.005% ointment calcitriol 0. mcg capsule calcitriol 0.5 mcg capsule calcitriol 1 mcg/ml ampul calcitriol 1 mcg/ml solution calcitriol 3 mcg/g ointment calcium acetate 667 mg capsule calcium acetate 667 mg let CAMBIA 50 MG POWDER PACKET camila let CAMPTOSAR 300 MG/ ML VIAL camrese mg camrese lo let CANASA 1,000 MG SUPPOSITORY CANCIDAS IV 50 MG VIAL CAPASTAT SULFATE 1 GM VIAL CAPHOSOL SOL CAPITAL WITH CODEINE SUSP CAPRELSA 100 MG TABLET CAPRELSA 300 MG TABLET captopril 100 mg let captopril 12.5 mg let captopril mg let captopril 50 mg let captopril-hctz - mg let captopril-hctz - mg let captopril-hctz 50- mg let captopril-hctz 50- mg let CARAC 0.5% CREAM CARAFATE 1 GM/10 ML SUSP CARBAGLU 0 MG DISPER TABLET carbamazepine 100 mg chew carbamazepine 100 mg/5 ml susp carbamazepine 0 mg let carbamazepine er 100 mg cap carbamazepine er 100 mg let Comprehensive Formulary 88

89 carbamazepine er 0 mg cap carbamazepine er 0 mg let carbamazepine er 300 mg cap carbamazepine er 400 mg let carbidopa mg let carbidopa-levo mg odt carbidopa-levo -100 mg odt carbidopa-levo -0 mg odt carbidopa-levo er -100 carbidopa-levo er 50-0 carbidopa-levodopa carbidopa-levodopa -100 carbidopa-levodopa -0 carbidopa-levodopa-enta 100 mg carbidopa-levodopa-enta 1 mg carbidopa-levodopa-enta 0 mg carbidopa-levodopa-enta 0 mg carbidopa-levodopa-enta 50 mg carbidopa-levodopa-enta 75 mg carbinoxamine 4 mg/5 ml liquid carbinoxamine maleate 4 mg carboplatin 0 mg/ ml vial carboplatin 0 mg/ ml vial carboplatin 50 mg/5 ml vial carboplatin 600 mg/60 ml vial CARDENE-DEX MG/0 ML SOLN CARDENE-DEX 40 MG/0 ML IV CARDENE-NACL MG/0 ML SOLN CARDENE-NACL 40 MG/0 ML IV CARIMUNE NF 12 GM VIAL CARIMUNE NF 6 GM VIAL carisoprodol 350 mg let carisoprodol compound carisoprodol cpd-codeine carteolol hcl 1% eye drops CARTIA XT 1 MG CAPSULE CARTIA XT 0 MG CAPSULE CARTIA XT 240 MG CAPSULE CARTIA XT 300 MG CAPSULE carvedilol 12.5 mg let carvedilol mg let carvedilol 3.1 mg let carvedilol 6. mg let CAYSTON 75 MG INHAL SOLUTION caziant day let cefaclor 1 mg/5 ml susp cefaclor 0 mg capsule cefaclor 0 mg/5 ml susp cefaclor 375 mg/5 ml suspen cefaclor 500 mg capsule cefaclor er 500 mg let cefadroxil 1 gm let cefadroxil 0 mg/5 ml susp cefadroxil 500 mg capsule cefadroxil 500 mg/5 ml susp cefazolin 1 g/50 ml-dextrose cefazolin 1 gm add-van vial cefazolin 1 gm vial cefazolin 10 gm vial cefazolin 2 g/100 ml-dextrose cefazolin 2 g/50 ml-dextrose cefazolin gm bulk vial cefazolin 500 mg vial cefazolin sod 100 gm bulk bag cefazolin sod 300 gm bulk bag cefdinir 1 mg/5 ml susp cefdinir 0 mg/5 ml susp cefdinir 300 mg capsule cefditoren pivoxil 0 mg cefepime 1 gm injection cefepime 2 gm injection cefepime hcl 1 gm vial cefepime hcl 2 gram vial cefepime-dextrose 1 gm/50 ml cefepime-dextrose 2 gm/50 ml cefixime 100 mg/5 ml susp cefixime 0 mg/5 ml susp cefotaxime sodium 1 gm vial cefotaxime sodium 2 gm vial cefotaxime sodium 500 mg vial cefotetan 1 gm vial cefotetan 10 gm vial cefotetan 2 gm vial cefotetan-dextr 1 g duplex bag cefotetan-dextr 2 g duplex bag cefoxitin 1 gm piggyback bag cefoxitin 1 gm vial cefoxitin 10 gm vial cefoxitin 2 gm piggyback bag cefoxitin 2 gm vial Comprehensive Formulary 89

90 cefpodoxime 100 mg let cefpodoxime 100 mg/5 ml susp cefpodoxime 0 mg let cefpodoxime 50 mg/5 ml susp cefprozil 1 mg/5 ml susp cefprozil 0 mg let cefuroxime sod 750 mg vial celecoxib 100 mg capsule celecoxib 0 mg capsule celecoxib 400 mg capsule celecoxib 50 mg capsule CELLCEPT 0 MG/ML ORAL SUSP chlordiazepox-amitriptyl 10- chlordiazepoxide 10 mg capsule chlordiazepoxide mg capsule chlordiazepoxide 5 mg capsule cefprozil 0 mg/5 ml susp CELLCEPT 0 MG CAPSULE 67 chlorhexidine 0.12% rinse 51 cefprozil 500 mg let CELLCEPT 500 MG TABLET 67 chloroquine ph 0 mg let 31 ceftazidime 1 gm piggyback CELLCEPT 500 MG VIAL 67 chloroquine ph 500 mg let 31 ceftazidime 1 gm vial CELONTIN 300 MG KAPSEAL chlorothiazide 0 mg let 44 ceftazidime 2 gm piggyback CEM-UREA SOL % chlorothiazide 500 mg let 44 ceftazidime 2 gm vial ceftazidime 6 gm vial ceftibuten 0 mg/5 ml susp ceftibuten 400 mg capsule CEFTIN 1 MG/5 ML ORAL SUSP CEFTIN 0 MG/5 ML ORAL SUSP ceftriaxone 1 gm piggyback ceftriaxone 1 gm vial ceftriaxone 1 gm-d5w bag ceftriaxone 10 gm vial ceftriaxone 2 gm add vial ceftriaxone 2 gm piggyback ceftriaxone 2 gm vial ceftriaxone 2 gm-d5w bag ceftriaxone 0 mg vial ceftriaxone 500 mg vial cefuroxime 750 mg/50 ml bag cefuroxime axetil 0 mg cefuroxime axetil 500 mg cefuroxime sod 1.5 gm vial cefuroxime sod 7.5 gm vial cefuroxime sod 75 gm bulk bag cephalexin 1 mg/5 ml susp cephalexin 0 mg capsule cephalexin 0 mg let cephalexin 0 mg/5 ml susp cephalexin 500 mg capsule cephalexin 500 mg let cephalexin 750 mg capsule CEREZYME 400 UNITS VIAL CERVARIX VACCINE SYRINGE CESAMET 1 MG CAPSULE cevimeline hcl 30 mg capsule CHANTIX 0.5 MG TABLET CHANTIX 1 MG CONT MONTH BOX CHANTIX 1 MG TABLET CHANTIX STARTING MONTH BOX chateal- let CHEMET 100 MG CAPSULE CHENODAL 0 MG TABLET chloramphen na succ 1 gm vl chlordiazepo/clidi cap 5-2.5mg chlordiazepo-amitriptyl chlorothiazide sod 500 mg vial chlorpromazine 10 mg let chlorpromazine 100 mg let chlorpromazine 0 mg let chlorpromazine mg let chlorpromazine mg/ml amp chlorpromazine 50 mg let chlorpropamide 100 mg let chlorpropamide 0 mg let chlorthalidone mg let chlorthalidone 50 mg let chlorzoxazone 500 mg let cholestyramine light packet cholestyramine light powder cholestyramine packet cholestyramine powder choline mag trisal liquid chorionic gonad 10,000 unit vl CIALIS 2.5 MG TABLET CIALIS 5 MG TABLET ciclodan 0.77% cream ciclodan 8% solution ciclodan cream kit 0.77% Comprehensive Formulary 90

91 ciclopirox 0.77% cream ciclopirox 0.77% gel ciclopirox 0.77% topical susp ciclopirox 1% shampoo ciclopirox 8% solution cidofovir 375 mg/5 ml vial cilostazol 100 mg let cilostazol 50 mg let CILOXAN 0.3% OINTMENT cimetidine 0 mg let cimetidine 300 mg let cimetidine 300 mg/5 ml soln cimetidine 400 mg let citalopram hbr 10 mg let citalopram hbr 10 mg/5 ml soln citalopram hbr mg let citalopram hbr 40 mg let cladribine 10 mg/10 ml vial CLAFORAN 1 GM ADD- VANTAGE VL CLAFORAN 10 GM VIAL CLAFORAN 2 GM ADD- VANTAGE VL claravis 10 mg capsule claravis mg capsule claravis 30 mg capsule 21 clindamycin 600 mg/4 ml addvan clindamycin 900 mg/6 ml addvan clindamycin hcl 0 mg capsule clindamycin hcl 300 mg capsule clindamycin hcl 75 mg capsule clindamycin pediatr 75 mg/5 ml clindamycin ph 1% gel clindamycin ph 1% solution clindamycin ph 300 mg/2 ml vl cimetidine 800 mg let claravis 40 mg capsule clindamycin ph 9 g/60 ml vial CINRYZE 500 UNIT VIAL CIPRO HC OTIC SUSPENSION CIPRODEX OTIC SUSPENSION ciprofloxacin 0.3% eye drop ciprofloxacin 0 mg/ ml vl ciprofloxacin 0 mg/5 ml susp ciprofloxacin 400 mg/40 ml vl ciprofloxacin 500 mg/5 ml susp ciprofloxacin er 1,000 mg ciprofloxacin er 500 mg let ciprofloxacin hcl 100 mg ciprofloxacin hcl 0 mg ciprofloxacin hcl 500 mg ciprofloxacin hcl 750 mg ciprofloxacn-d5w 0 mg/100 ml ciprofloxacn-d5w 400 mg/0 ml cisplatin 100 mg/100 ml vial cisplatin 0 mg/0 ml vial cisplatin 50 mg/50 ml vial 67 CLARINEX-D 12 HOUR TABLET clarithromycin 1 mg/5 ml sus clarithromycin 0 mg let clarithromycin 0 mg/5 ml sus clarithromycin 500 mg let clarithromycin er 500 mg clemastine 0.5 mg/5 ml syrup clemastine fum 2.68 mg CLEOCIN 100 MG VAGINAL OVULE CLIMARA PRO PATCH clind ph-benzoyl perox 1.2-5% clindacin etz 1% pledget clindacin p 1% pledgets clindamax 1% gel clindamycin 0 mg/ml addvan clindamycin 2% vaginal cream clindamycin 300 mg/2 ml addvan clindamycin ph 900 mg/6 ml vl clindamycin phos 1% pledget clindamycin phosp 1% lotion clindamycin phosphate 1% foam clindamycin-benzoyl perox 1-5% clindamycin-d5w 300 mg/50 ml clindamycin-d5w 600 mg/50 ml clindamycin-d5w 900 mg/50 ml CLINDESSE 2% VAGINAL CREAM CLINIMIX 2.75%-5% SOLUTION CLINIMIX 4.%-10% SOLUTION CLINIMIX 4.%-% SOLUTION CLINIMIX 4.%-% SOLUTION CLINIMIX 4.%-5% SOLUTION Comprehensive Formulary 91

92 CLINIMIX 5%-% SOLUTION 77 clomipramine mg capsule clozapine 50 mg let CLINIMIX 5%-% SOLUTION 77 clomipramine 50 mg capsule clozapine odt 100 mg let CLINIMIX 5%-% SOLUTION 77 clomipramine 75 mg capsule clozapine odt 12.5 mg let CLINIMIX E 2.75%-10% SOLUTION CLINIMIX E 2.75%-5% SOLUTION CLINIMIX E 4.%-10% SOLUTION clonazepam 0.1 mg dis clonazepam 0. mg odt clonazepam 0.5 mg dis let clonazepam 0.5 mg let clonazepam 1 mg dis let clozapine odt 0 mg let clozapine odt 0 mg let clozapine odt mg let COARTEM TABLETS codeine sulfate mg let 31 8 CLINIMIX E 4.%-% SOLUTION CLINIMIX E 4.%-5% SOLUTION CLINIMIX E 5%-% SOLUTION clonazepam 1 mg let clonazepam 2 mg odt clonazepam 2 mg let clonidine 0.1 mg/day patch clonidine 0.2 mg/day patch codeine sulfate 30 mg let codeine sulfate 60 mg let colchicine 0.6 mg capsule colchicine 0.6 mg let colestipol hcl 1 gm let CLINIMIX E 5%-% SOLUTION CLINIMIX E 5%-% SOLUTION CLINISOL % SOLUTION 77 clonidine 0.3 mg/day patch clonidine hcl 0.1 mg let clonidine hcl 0.2 mg let clonidine hcl 0.3 mg let colestipol hcl granules colestipol hcl granules packet colistimethate 0 mg vial colocort 100 mg enema clobetasol 0.05% cream clobetasol 0.05% gel clobetasol 0.05% ointment clobetasol 0.05% shampoo clobetasol 0.05% solution clobetasol 0.05% topical lotn clobetasol emollient 0.05% crm clobetasol emollnt 0.05% foam clobetasol emulsion 0.05% foam clobetasol prop 0.05% foam clobetasol prop 0.05% spray clocortolone 0.1% cream pump clocortolone pivalate 0.1% crm clodan 0.05% shampoo CLOLAR MG/ ML VIAL clonidine hcl er 0.1 mg let clopidogrel 300 mg let clopidogrel 75 mg let clorazepate mg let clorazepate 3.75 mg let clorazepate 7.5 mg let clorpres 0.1- let clorpres 0.2- let clorpres 0.3- let clotrimazole 1% cream clotrimazole 1% solution clotrimazole 10 mg troche clotrimazole-betamethasone crm clotrimazole-betamethasone lot clozapine 100 mg let clozapine 0 mg let clozapine mg let COLY-MYCIN S OTIC SUSP DROP COMBIGAN 0.2%-0.5% EYE DROPS COMBIPATCH MG PTCH COMBIPATCH MG PTCH COMBIVENT RESPIMAT INHAL SPRAY COMETRIQ 100 MG DAILY- DOSE PK COMETRIQ 0 MG DAILY- DOSE PK COMETRIQ 60 MG DAILY-DOSE PACK COMPLERA TABLET compro mg suppository COMVAX VACCINE VIAL CONDYLOX 0.5% GEL constulose 10 gm/ ml soln Comprehensive Formulary 92

93 COPAXONE MG/ML SYRINGE COPAXONE 40 MG/ML SYRINGE CORDRAN 0.05% CREAM CORDRAN 0.05% LOTION CORDRAN 0.05% OINTMENT CREON DR 12,000 UNITS CAPSULE CREON DR 24,000 UNITS CAPSULE CREON DR 3,000 UNITS CAPSULE cyclophosphamide mg capsule cyclophosphamide 50 mg capsule cyclophosphamide 500 mg vial CORDRAN 4 MCG/SQ CM TAPE LARGE COREG CR 10 MG CAPSULE COREG CR MG CAPSULE COREG CR 40 MG CAPSULE COREG CR 80 MG CAPSULE cormax 0.05% solution CORTANE-B CORTANE-B CORTANE-B cortic-nd dro DRO AQ OTIC DRO OTIC LOT CORTIFOAM 10% AEROSOL cortisone mg let CREON DR 36,000 UNITS CAPSULE CREON DR 6,000 UNITS CAPSULE CRESTOR 10 MG TABLET CRESTOR MG TABLET CRESTOR 40 MG TABLET CRESTOR 5 MG TABLET CRIXIVAN 0 MG CAPSULE CRIXIVAN 400 MG CAPSULE cromolyn 100 mg/5 ml oral conc cromolyn mg/2 ml neb soln cycloserine 0 mg capsule cyclosporine 100 mg capsule cyclosporine 100 mg/ml soln cyclosporine mg capsule cyclosporine 50 mg/ml ampul cyclosporine modified 100 mg cyclosporine modified mg cyclosporine modified 50 mg cyotic dro cyproheptadine 2 mg/5 ml syrup cyproheptadine 4 mg let CYRAMZA 100 MG/10 ML VIAL CORTISPORIN CREAM cromolyn 4% eye drops CYRAMZA 500 MG/50 ML VIAL CORTISPORIN OINTMENT cryselle- let 61 cyred day let 61 CORTISPORIN-TC EAR SUSPENSION COSMEGEN 0.5 MG VIAL COSOPT PF EYE DROPS COTELLIC MG TABLET COUMADIN 1 MG TABLET COUMADIN 10 MG TABLET CUBICIN 500 MG VIAL CUPRIMINE 0 MG CAPSULE CURITY GAUZE PADS 2"X2" CUTIVATE 0.05% LOTION CUVPOSA 1 MG/5 ML SOLUTION cyclafem let 61 CYSTADANE POWDER CYSTAGON 0 MG CAPSULE CYSTAGON 50 MG CAPSULE CYSTARAN 0.44% EYE DROPS cytarabine 100 mg/5 ml vial cytarabine 1000 mg/50 ml vial COUMADIN 2 MG TABLET 40 cyclafem let 61 cytarabine 2 g/ ml vial COUMADIN 2.5 MG TABLET 40 cyclobenzaprine 10 mg let 76 cytarabine mg/ml vial COUMADIN 3 MG TABLET 40 cyclobenzaprine 5 mg let 76 cytarabine 500 mg/ ml vial COUMADIN 4 MG TABLET 40 CYCLOMYDRIL EYE DROPS cytra-2 oral solution COUMADIN 5 MG TABLET COUMADIN 6 MG TABLET COUMADIN 7.5 MG TABLET covaryx covaryx hs cyclopentolate 0.5% eye drops cyclopentolate 1% eye drops cyclopentolate hcl 2% drops cyclophosphamide 1 gm vial cyclophosphamide 2 gm vial cytra-3 syrup cytra-k crystals packet cytra-k oral solution D5%-1/2NS-KCL 10 MEQ/L IV SOL Comprehensive Formulary 93

94 D5%-1/2NS-KCL 30 MEQ/L IV SOL D5%-1/2NS-KCL 40 MEQ/L IV SOL dacarbazine 100 mg vial dacarbazine 0 mg vial DALIRESP 500 MCG TABLET d-amphetamine er 10 mg capsule d-amphetamine er mg capsule d-amphetamine er 5 mg capsule danazol 100 mg capsule danazol 0 mg capsule danazol 50 mg capsule dantrolene sodium 100 mg cap dantrolene sodium mg cap dantrolene sodium 50 mg cap dapsone 100 mg let dapsone mg let DAPTACEL DTAP VACCINE DARAPRIM MG TABLET darifenacin er mg let darifenacin er 7.5 mg let DARZALEX 100 MG/5 ML VIAL DARZALEX 400 MG/ ML VIAL dasetta let dasetta 7/7/7- let daunorubicin mg/4 ml vial DAUNOXOME 50 MG (2 MG/ML) VIAL daysee mg DAYTRANA 10 MG/9 HR PATCH DAYTRANA MG/9 HR PATCH DAYTRANA MG/9 HOUR PATCH DAYTRANA 30 MG/9 HOUR PATCH deblitane 0.35 mg let deciine 50 mg vial DELESTROGEN 10 MG/ML VIAL delyla- let DELZICOL DR 400 MG CAPSULE demeclocycline 0 mg let demeclocycline 300 mg let DEMEROL 100 MG/ML SYRINGE DEMEROL MG/ML SYRINGE DEMEROL 50 MG/ML VIAL DEMEROL 75 MG/ML SYRINGE DEMSER 0 MG CAPSULE DENAVIR 1% CREAM denta 5000 plus cream dentagel 1.1% gel DEPEN 0 MG TITRATAB DEPO-ESTRADIOL 5 MG/ML VIAL DEPO-MEDROL MG/ML VIAL DEPO-PROVERA 400 MG/ML VIAL DEPO-SUBQ PROVERA 104 SYRINGE DERMACINRX KIT SILAPAK DERMASORB HC KIT 2% DERMASORB TA KIT 0.1% dermazene cream 1% DESCOVY 0- MG TABLET desipramine 10 mg let desipramine 100 mg let desipramine 0 mg let desipramine mg let desipramine 50 mg let desipramine 75 mg let desloratadine 2.5 mg odt desloratadine 5 mg odt desloratadine 5 mg let desmopressin 0.01% solution desmopressin 0.1 mg/ml sol desmopressin 10 mcg/0.1 ml spr desmopressin ac 4 mcg/ml vial desmopressin acetate 0.1 mg tb desmopressin acetate 0.2 mg tb desogestrel-ethinyl estrad desogestr-eth estrad eth estra DESONATE 0.05% GEL desonide 0.05% cream desonide 0.05% lotion desonide 0.05% ointment desoximetasone 0.05% cream desoximetasone 0.05% gel desoximetasone 0.05% ointment desoximetasone 0.% cream desoximetasone 0.% ointment dexamethasone 0.1% eye drop dexamethasone 0.5 mg let dexamethasone 0.5 mg/5 ml elx dexamethasone 0.5 mg/5 ml liq dexamethasone 0.75 mg let dexamethasone 1 mg let dexamethasone 1.5 mg let dexamethasone 10 mg/ml vial Comprehensive Formulary 94

95 dexamethasone 100 mg/10 ml vl dexamethasone 1 mg/30 ml vl dexamethasone 2 mg let dexamethasone mg/5 ml vial dexamethasone 4 mg let dexamethasone 4 mg/ml vial dexamethasone 6 mg let dexamethasone intensol 1mg/1ml dexchlorphen 2 mg/5 ml syrup DEXILANT DR 30 MG CAPSULE DEXILANT DR 60 MG CAPSULE dexmethylphenidate 10 mg dexmethylphenidate 2.5 mg dexmethylphenidate 5 mg dexrazoxane 0 mg vial dexrazoxane 500 mg vial dextroamp-amphet er 10 mg cap dextroamp-amphet er mg cap dextroamp-amphet er mg cap dextroamp-amphet er mg cap dextroamp-amphet er 30 mg cap dextroamp-amphet er 5 mg cap dextroamp-amphetam 12.5 mg dextroamp-amphetam 7.5 mg dextroamp-amphetamin 10 mg dextroamp-amphetamin mg dextroamp-amphetamin mg dextroamp-amphetamin 30 mg dextroamp-amphetamine 5 mg dextroamphetamine 10 mg dextroamphetamine 5 mg dextroamphetamine 5 mg/5 DEXTROSE 10%-0.2% NACL IV SOLN DEXTROSE 10%-0.% NACL IV SOL dextrose 10%-water iv solution DEXTROSE 2.5%-0.% NACL IV dextrose %-water iv soln dextrose %-water syringe dextrose 30%-water iv soln dextrose 40%-water iv soln DEXTROSE 5%-0.2% NACL IV SOLN DEXTROSE 5%-0.5% NACL IV SOL DEXTROSE 5%-0.3% NACL IV SOLN DEXTROSE 5%-0.33% NACL IV SOLN DEXTROSE 5%-0.% NACL IV SOLN DEXTROSE 5%-0.9% NACL IV SOLN DEXTROSE 5%-ELECTROLYTE DEXTROSE 5%-LR IV SOLUTION dextrose 5%-water iv soln dextrose 50%-water iv soln dextrose 70%-water iv soln diazepam 10 mg rectal gel syst diazepam 10 mg let diazepam 10 mg/2 ml carpuject diazepam 10 mg/2 ml syringe diazepam 2 mg let diazepam 2.5 mg rectal gel sys diazepam mg rectal gel syst diazepam 5 mg let diazepam 5 mg/5 ml solution diazepam 5 mg/ml oral conc diazepam 5 mg/ml vial diclofenac 0.1% eye drops diclofenac 1.5% topical soln diclofenac pot 50 mg let diclofenac sod dr 50 mg diclofenac sod ec mg diclofenac sod ec 75 mg diclofenac sod er 100 mg diclofenac sodium 3% gel diclofenac-misoprost tb diclofenac-misoprost tb dicloxacillin 0 mg capsule dicloxacillin 500 mg capsule dicyclomine 10 mg capsule dicyclomine 10 mg/5 ml soln dicyclomine mg let didanosine dr 1 mg capsule didanosine dr 0 mg capsule didanosine dr 0 mg capsule didanosine dr 400 mg capsule DIFICID 0 MG TABLET Comprehensive Formulary 95

96 diflorasone 0.05% cream diltiazem 24hr er 240 mg cap 44 disulfiram 0 mg let 12 diflorasone 0.05% ointment diltiazem 24hr er 300 mg cap 44 disulfiram 500 mg let 12 diflunisal 500 mg let digitek 1 mcg let digitek 0 mcg let digox 1 mcg let digox 0 mcg let digoxin 0.05 mg/ml solution digoxin 1 mcg let digoxin 0 mcg let digoxin 500 mcg/2 ml ampule dihydrocodein-acetaminophcaff dihydroergotamine 1 mg/ml am dihydroergotamine 4 mg/ml spry DILANTIN 100 MG CAPSULE DILANTIN 30 MG CAPSULE DILANTIN 50 MG INFATAB DILT XR 1 MG CAPSULE DILT XR 0 MG CAPSULE DILT XR 240 MG CAPSULE DILT-CD 0 MG CAPSULE DILT-CD 240 MG CAPSULE diltiazem 1 mg let diltiazem 1 mg/ ml vial diltiazem 12hr er 1 mg cap diltiazem 12hr er 60 mg cap diltiazem 12hr er 90 mg cap diltiazem 24hr cd 1 mg cap diltiazem 24hr cd 0 mg cap diltiazem 24hr cd 240 mg cap diltiazem 24hr cd 300 mg cap diltiazem 24hr cd 360 mg cap diltiazem 24hr er 1 mg cap diltiazem 24hr er 0 mg cap diltiazem 24hr er 360 mg cap diltiazem mg/5 ml vial diltiazem 30 mg let diltiazem 50 mg/10 ml vial diltiazem 60 mg let diltiazem 90 mg let diltiazem er 1 mg capsule diltiazem er 0 mg capsule diltiazem er 0 mg let diltiazem er 240 mg capsule diltiazem er 240 mg let diltiazem er 300 mg let diltiazem er 360 mg let diltiazem er 4 mg let diltiazem hcl 100 mg vial diltiazem hcl er 240 mg cap diltiazem hcl er 300 mg cap diltiazem hcl er 360 mg cap diltiazem hcl er 4 mg cap dimenhydrinate 50 mg/ml vial DIPENTUM 0 MG CAPSULE diphenhydramine 50 mg/ml vial diphenoxylat-atrop /5 diphenoxylate-atrop DIPHTHERIA-TETANUS TOXOIDS-PED dipyridamole mg let dipyridamole 50 mg let dipyridamole 75 mg let diskets 40 mg let dispr disopyramide 100 mg capsule disopyramide 0 mg capsule DIURIL 0 MG/5 ML ORAL SUSP divalproex sod dr 1 mg divalproex sod dr 0 mg divalproex sod dr 500 mg divalproex sod er 0 mg divalproex sod er 500 mg divalproex sodium 1 mg cap DIVIGEL 0.5 MG GEL PACKET DOCEFREZ MG VIAL DOCEFREZ 80 MG VIAL docetaxel 0 mg/7 ml vial docetaxel 0 mg/ ml vial docetaxel 0 mg/8 ml vial docetaxel mg/0.5 ml vial docetaxel mg/2 ml vial docetaxel mg/ml vial docetaxel 0 mg/ ml vial docetaxel 80 mg/2 ml vial docetaxel 80 mg/4 ml vial docetaxel 80 mg/8 ml vial dofetilide 1 mcg capsule dofetilide 0 mcg capsule dofetilide 500 mcg capsule donepezil hcl 10 mg let donepezil hcl 23 mg let donepezil hcl 5 mg let donepezil hcl odt 10 mg let donepezil hcl odt 5 mg let DONNATAL ELX DONNATAL TAB DONNATAL TAB.2MG DORIBAX 0 MG VIAL DORIBAX 500 MG VIAL Comprehensive Formulary 96

97 dorzolamide hcl 2% eye drops dorzolamide-timolol eye drops doxazosin mesylate 1 mg doxazosin mesylate 2 mg doxazosin mesylate 4 mg doxazosin mesylate 8 mg doxepin 10 mg capsule doxepin 10 mg/ml oral conc doxycycline mono 100 mg cap doxycycline mono 100 mg let doxycycline mono 0 mg cap doxycycline mono 0 mg let doxycycline mono 50 mg cap doxycycline mono 50 mg let DUTOPROL MG TABLET DUTOPROL MG TABLET DUTOPROL MG TABLET DYMISTA NASAL SPRAY DYRENIUM 100 MG CAPSULE DYRENIUM 50 MG CAPSULE 74 doxepin 100 mg capsule doxepin 0 mg capsule doxepin mg capsule doxepin 5% cream doxepin 50 mg capsule doxepin 75 mg capsule doxercalciferol 0.5 mcg cap doxercalciferol 1 mcg capsule doxercalciferol 2.5 mcg cap doxercalciferol 4 mcg/2 ml amp doxorubicin 10 mg vial doxycycline mono 75 mg capsule doxycycline mono 75 mg let dronabinol 10 mg capsule dronabinol 2.5 mg capsule dronabinol 5 mg capsule droperidol 2.5 mg/ml ampul drospirenone-ee mg drospirenone-ee mg DROXIA 0 MG CAPSULE DYSPORT 300 UNIT VIAL DYSPORT 500 UNITS VIAL E.E.S. 0 MG/5 ML GRANULES e.e.s. 400 film econazole nitrate 1% cream EDECRIN MG TABLET ed-spaz 0.1 mg odt EDURANT MG TABLET eemt hs eemt effer-k meq let eff doxorubicin 50 mg vial DROXIA 300 MG CAPSULE EFFIENT 10 MG TABLET 41 doxorubicin 50 mg/ ml vial DROXIA 400 MG CAPSULE EFFIENT 5 MG TABLET 41 doxorubicin liposome mg/10ml doxy 100 vial doxycycline mg/5 ml susp doxycycline hyc 100 mg vial doxycycline hyc dr 100 mg doxycycline hyc dr 0 mg doxycycline hyc dr 75 mg doxycycline hyclate 100 mg cap doxycycline hyclate 100 mg doxycycline hyclate mg doxycycline hyclate 50 mg cap doxycycline ir-dr 40 mg cap DULERA 100 MCG/5 MCG INHALER DULERA 0 MCG/5 MCG INHALER duloxetine hcl dr mg cap duloxetine hcl dr 30 mg cap duloxetine hcl dr 60 mg cap DURAMORPH 10 MG/10 ML AMPUL DURAMORPH 5 MG/10 ML AMPUL DUREZOL 0.05% EYE DROPS dutasteride 0.5 mg capsule dutasteride-tamsulosin EGRIFTA 1 MG VIAL ELAPRASE 6 MG/3 ML VIAL ELELYSO 0 UNITS VIAL ELIDEL 1% CREAM ELIGARD.5 MG SYRINGE KIT ELIGARD 30 MG SYRINGE KIT ELIGARD MG SYRINGE KIT ELIGARD 7.5 MG SYRINGE KIT elinest- let eliphos 667 mg let ELIQUIS 2.5 MG TABLET ELIQUIS 5 MG TABLET ELITEK 1.5 MG VIAL ELITEK 7.5 MG VIAL Comprehensive Formulary 97

98 ELIXOPHYLLIN 80 MG/ ML ELIX ELLA 30 MG TABLET ELMIRON 100 MG CAPSULE EMADINE 0.05% EYE DROPS EMCYT 0 MG CAPSULE EMEND 1 MG CAPSULE EMEND 0 MG VIAL EMEND 40 MG CAPSULE EMEND 80 MG CAPSULE EMEND TRIPACK emoquette day let EMPLICITI 300 MG VIAL EMPLICITI 400 MG VIAL EMSAM 12 MG/24 HOURS PATCH EMSAM 6 MG/24 HOURS PATCH endocet mg let endocet 5-5 let endocet mg let ENGERIX-B 10 MCG/0.5 ML PED VL ENGERIX-B MCG/ML SYRINGE ENGERIX-B PEDI 10 MCG/0.5 SYRN ENJUVIA 0.3 MG TABLET ENJUVIA 0. MG TABLET ENJUVIA 0.6 MG TABLET ENJUVIA 0.9 MG TABLET ENJUVIA 1. MG TABLET enoxaparin 100 mg/ml syringe enoxaparin 1 mg/0.8 ml syr enoxaparin 0 mg/ml syringe enoxaparin 30 mg/0.3 ml syr EPIFOAM AER 1% epinastine hcl 0.05% eye drops epinephrine 0.1 mg/ml syringe epinephrine 0. mg autoinjct epinephrine 0.3 mg autoinject epinephrine 1 mg/ml ampul EPIPEN 2-PAK 0.3 MG AUTO- INJCT EPIPEN JR 2-PAK 0. MG INJCTR epirubicin 0 mg/100 ml vial epirubicin 50 mg/ ml vial epirubicin hcl epitol 0 mg let EPIVIR HBV MG/5 ML SOLN EMSAM 9 MG/24 HOURS PATCH EMTRIVA 10 MG/ML SOLUTION EMTRIVA 0 MG CAPSULE ENABLEX MG TABLET ENABLEX 7.5 MG TABLET enalapril maleate 10 mg enalapril maleate 2.5 mg enalapril maleate mg enalapril maleate 5 mg let enalaprilat 2.5 mg/2 ml vial enalapril-hctz 10- mg let enalapril-hctz mg ENBREL MG KIT ENBREL MG/0.5 ML SYRINGE ENBREL 50 MG/ML SURECLICK SYR ENBREL 50 MG/ML SYRINGE endocet 10-5 mg let enoxaparin 300 mg/3 ml vial enoxaparin 40 mg/0.4 ml syr enoxaparin 60 mg/0.6 ml syr enoxaparin 80 mg/0.8 ml syr enpresse- let enskyce let entacapone 0 mg let entecavir 0.5 mg let entecavir 1 mg let ENTRESTO 24 MG- MG TABLET ENTRESTO MG-51 MG TABLET ENTRESTO 97 MG-103 MG TABLET enulose 10 gm/ ml solution ENVARSUS XR 0.75 MG TABLET ENVARSUS XR 1 MG TABLET ENVARSUS XR 4 MG TABLET eplerenone mg let eplerenone 50 mg let EPOGEN 2,000 UNITS/ML VIAL EPOGEN,000 UNITS/2 ML VIAL EPOGEN,000 UNITS/ML VIAL EPOGEN 3,000 UNITS/ML VIAL EPOGEN 4,000 UNITS/ML VIAL eprosartan mesylate 600 mg EPZICOM TABLET EQUETRO 100 MG CAPSULE EQUETRO 0 MG CAPSULE EQUETRO 300 MG CAPSULE ERAXIS(WATER DIL) 100 MG VIAL ERAXIS(WATER DIL) 50 MG VIAL ERBITUX 100 MG/50 ML VIAL ERBITUX 0 MG/100 ML VIAL Comprehensive Formulary 98

99 ergoloid mesylates 1 mg ERGOMAR 2 MG TABLET SL ERIVEDGE 0 MG CAPSULE errin 0.35 mg let ERTACZO 2% CREAM esomeprazole mag dr 40 mg cap esomeprazole sodium mg vial esomeprazole sodium 40 mg vial estropipate 1.(1.5 mg) estropipate 2.5(3 mg) eszopiclone 1 mg let eszopiclone 2 mg let eszopiclone 3 mg let ERWINAZE 10,000 UNITS VIAL est estrogen mtest 61 ethacrynate sodium 50 mg ery 2% pads est estrogen mtest ds 61 ethacrynic acid mg let ERYPED 0 MG/5 ML SUSPENSION ERYPED 400 MG/5 ML SUSPENSION ERY-TAB EC 0 MG TABLET ERY-TAB EC 333 MG TABLET ERY-TAB EC 500 MG TABLET erythrocin 0 mg film ERYTHROCIN 500 MG ADDVNT VL erythromycin 0.5% eye ointment est estrogen mtest hs estarylla mg let estazolam 1 mg let estazolam 2 mg let ESTRACE 0.01% CREAM estradiol 0.0 mg patch estradiol mg patch estradiol 0.05 mg patch estradiol mg patch estradiol 0.1 mg patch ethambutol hcl 100 mg let ethambutol hcl 400 mg let ethosuximide 0 mg capsule ethosuximide 0 mg/5 ml soln ETHYL CHLOR AER FINE PIN ETHYL CHLOR AER FN STRM ETHYL CHLOR AER MED JET ETHYL CHLOR AER MED STRM ETHYL CHLOR AER MIST ethyl chlor aer spray erythromycin 2% gel erythromycin 2% pledgets erythromycin 2% solution erythromycin 0 mg film erythromycin 500 mg film erythromycin ec 0 mg cap erythromycin es 400 mg erythromycin-benzoyl gel ESBRIET 7 MG CAPSULE escitalopram 10 mg let escitalopram mg let escitalopram 5 mg let escitalopram oxalate 5 mg/5 ml esgic capsule esmolol hcl 100 mg/10 ml vial esomeprazole mag dr mg cap 74 8 estradiol 0.5 mg let estradiol 1 mg let estradiol 2 mg let estradiol tds 0.0 mg/day estradiol tds mg/day estradiol tds 0.05 mg/day estradiol tds 0.06 mg/day estradiol tds mg/day estradiol tds 0.1 mg/day estradiol valerate 10 mg/ml vl estradiol valerate mg/ml vl estradiol valerate 40 mg/ml vl estradiol-noreth mg tb estradiol-noreth mg ESTRING 2 MG VAGINAL RING ESTROGEL 0.06% GEL estropipate 0.6(0.75 mg) etidronate disodium 0 mg etidronate disodium 400 mg etodolac 0 mg capsule etodolac 300 mg capsule etodolac 400 mg let etodolac 500 mg let etodolac er 400 mg let etodolac er 500 mg let etodolac er 600 mg let ETOPOPHOS 100 MG VIAL etoposide 1,000 mg/50 ml vial etoposide 100 mg/5 ml vial etoposide 500 mg/ ml vial EURAX 10% CREAM EURAX 10% LOTION EVOMELA 50 MG VIAL Comprehensive Formulary 99

100 EVOTAZ 300 MG-0 MG TABLET exemestane mg let EXJADE 1 MG TABLET EXJADE 0 MG TABLET EXJADE 500 MG TABLET exotic-hc dro otic EXTAVIA 0.3 MG KIT E-Z-DISK TAB 700MG E-Z-PAQUE SUS 60% FABRAZYME 35 MG VIAL FABRAZYME 5 MG VIAL falmina- let famciclovir 1 mg let famciclovir 0 mg let famciclovir 500 mg let famotidine mg piggyback famotidine mg let famotidine mg/2 ml vial famotidine 0 mg/ ml vial famotidine 40 mg let famotidine 40 mg/4 ml vial famotidine 40 mg/5 ml susp famotidine 500 mg/50 ml vial FANAPT 1 MG TABLET FANAPT 10 MG TABLET FANAPT 12 MG TABLET FANAPT 2 MG TABLET FANAPT 4 MG TABLET FANAPT 6 MG TABLET FANAPT 8 MG TABLET FANAPT TITRATION PACK FARESTON 60 MG TABLET FARXIGA 10 MG TABLET FARXIGA 5 MG TABLET FARYDAK 10 MG CAPSULE FARYDAK MG CAPSULE FARYDAK MG CAPSULE FASLODEX 0 MG/5 ML SYRINGE felbamate 400 mg let felbamate 600 mg let felbamate 600 mg/5 ml susp felodipine er 10 mg let felodipine er 2.5 mg let felodipine er 5 mg let FEM PH VAGINAL JELLY FEMRING 0.05 MG VAGINAL RING FEMRING 0.10 MG VAGINAL RING fenofibrate 1 mg let fenofibrate 0 mg capsule fenofibrate 4 mg capsule fenofibrate 5 mg let fenofibrate 0 mg capsule fenofibrate 0 mg let fenofibrate 0 mg capsule fenofibrate 40 mg let fenofibrate mg capsule fenofibrate mg let fenofibrate 50 mg capsule fenofibrate 54 mg let fenofibrate 67 mg capsule fenofibric acid 105 mg let fenofibric acid 35 mg let fenofibric acid dr 5 mg cap fenofibric acid dr mg cap fenoprofen 400 mg capsule fenoprofen 600 mg let fentanyl 0.05 mg/ml syringe fentanyl 1,000 mcg/ ml ampul fentanyl 100 mcg/hr patch fentanyl 12 mcg/hr patch fentanyl 2,500 mcg/50 ml vial fentanyl mcg/hr patch fentanyl 0 mcg/5 ml vial fentanyl 37.5 mcg/hr patch fentanyl 50 mcg/hr patch fentanyl 62.5 mcg/hr patch fentanyl 75 mcg/hr patch fentanyl 87.5 mcg/hr patch fentanyl cit otfc 1,0 mcg fentanyl cit otfc 1,600 mcg fentanyl citrate otfc 0 mcg fentanyl citrate otfc 400 mcg fentanyl citrate otfc 600 mcg fentanyl citrate otfc 800 mcg FERRIPROX 100 MG/ML SOLUTION FERRIPROX 500 MG TABLET FETZIMA -40 MG TITRATION PAK FETZIMA ER 1 MG CAPSULE FETZIMA ER MG CAPSULE FETZIMA ER 40 MG CAPSULE FETZIMA ER 80 MG CAPSULE FINACEA % FOAM FINACEA % GEL finasteride 5 mg let FIORINAL MG CAPSULE FIRAZYR 30 MG/3 ML SYRINGE FIRMAGON 2 X 1 MG KIT FIRMAGON 80 MG KIT FIRST-MOUTHW SUS BLM FIRST-OMEPRA SUS 2MG/ML FIRST-TESTOS CREAM MC 2% FIRST-TESTOS OIN 2% Comprehensive Formulary 100

101 FLAGYL ER 750 MG TABLET FLAREX 0.1% EYE DROPS flavoxate hcl 100 mg let FLEBOGAMMA DIF 10% VIAL FLEBOGAMMA DIF 5% VIAL flecainide acetate 100 mg flecainide acetate 0 mg flecainide acetate 50 mg FLOVENT 100 MCG DISKUS FLOVENT 0 MCG DISKUS FLOVENT 50 MCG DISKUS FLOVENT HFA 0 MCG INHALER fludrocortisone 0.1 mg let flunisolide 0.0% spray fluocinolone 0.01% body oil fluocinolone 0.01% cream fluocinolone 0.01% solution fluocinolone 0.0% cream fluocinolone 0.0% ointment fluocinolone acetonide ear drops fluocinolone acetonide scalp fluocinolone oil 0.01% ear drp fluocinonide 0.05% cream fluocinonide 0.05% gel fluoxetine mg/5 ml solution fluoxetine dr 90 mg capsule fluoxetine hcl 10 mg capsule fluoxetine hcl 10 mg let fluoxetine hcl mg capsule fluoxetine hcl mg let fluoxetine hcl 40 mg capsule fluoxetine hcl 60 mg let fluphenazine 1 mg let fluphenazine 10 mg let fluphenazine 2.5 mg let fluphenazine 2.5 mg/5 ml elix FLOVENT HFA 0 MCG INHALER FLOVENT HFA 44 MCG INHALER floxuridine 500 mg vial fluconazole 10 mg/ml susp fluconazole 100 mg let fluconazole 0 mg let fluconazole 0 mg let fluconazole 40 mg/ml susp fluconazole 50 mg let fluconazole-dext 0 mg/100 ml fluconazole-dext 400 mg/0 ml fluconazole-nacl 100 mg/50 ml fluconazole-nacl 0 mg/100 ml fluconazole-nacl 400 mg/0 ml flucytosine 0 mg capsule flucytosine 500 mg capsule fludarabine 50 mg vial fludarabine 50 mg/2 ml vial fluocinonide 0.05% ointment fluocinonide 0.05% solution fluocinonide 0.1% cream fluocinonide-e 0.05% cream fluor-a-day 0. mg chew fluor-a-day 0.5 mg chew fluor-a-day 1 mg let chew fluor-a-day 2.5 mg/ml drops fluoride 0. mg let chew fluoride 0.5 mg let chew fluoride 1 mg let chewable fluoridex defense 1.1% gel fluori 0.5 mg let chew fluori 1 mg let chew fluorometholone 0.1% drops fluorouracil 0.5% cream fluorouracil 1,000 mg/ ml vl fluorouracil 2% topical soln fluorouracil 2,500 mg/50 ml vl fluorouracil 5% cream fluorouracil 5% top solution fluorouracil 5,000 mg/100 ml fluorouracil 500 mg/10 ml vial fluphenazine 2.5 mg/ml vial fluphenazine 5 mg let fluphenazine 5 mg/ml conc fluphenazine dec mg/ml vial flurazepam mg capsule flurazepam 30 mg capsule flurbiprofen 0.03% eye drop flurbiprofen 100 mg let flurbiprofen 50 mg let flutamide 1 mg capsule fluticasone prop 0.005% oint fluticasone prop 0.05% cream fluticasone prop 0.05% lotion fluticasone prop 50 mcg spray fluvastatin er 80 mg let fluvastatin sodium mg cap fluvastatin sodium 40 mg cap fluvoxamine er 100 mg capsule fluvoxamine er 0 mg capsule fluvoxamine maleate 100 mg Comprehensive Formulary 101

102 fluvoxamine maleate mg fluvoxamine maleate 50 mg FML FORTE 0.% EYE DROPS FML S.O.P. 0.1% OINTMENT FOLOTYN MG/ML VIAL FOLOTYN 40 MG/2 ML VIAL fomepizole 1.5 gm/1.5 ml vial fondaparinux 10 mg/0.8 ml syr FOSRENOL 1,000 MG TABLET CHEW FOSRENOL 500 MG TABLET CHEW FOSRENOL 750 MG POWDER PACKET FOSRENOL 750 MG TABLET CHEW FRAGMIN 10,000 UNITS/ML SYRING FRAGMIN 12,500 UNITS/0.5 ML FYCOMPA 12 MG TABLET FYCOMPA 2 MG TABLET FYCOMPA 4 MG TABLET FYCOMPA 6 MG TABLET FYCOMPA 8 MG TABLET gabapentin 100 mg capsule gabapentin 0 mg/5 ml soln gabapentin 300 mg capsule gabapentin 400 mg capsule gabapentin 600 mg let fondaparinux 2.5 mg/0.5 ml syr fondaparinux 5 mg/0.4 ml syr fondaparinux 7.5 mg/0.6 ml syr FORTAZ 500 MG VIAL FORTAZ-ISO-OSMOT 2 GM/50 ML FORTAZ-ISO-OSMOTIC 1 GM/50 ML FORTEO 600 MCG/2.4 ML PEN INJ FOSAMAX PLUS D 70 MG- 2,800 IU FOSAMAX PLUS D 70 MG- 5,600 IU FOSCAVIR 6,000 MG/0 ML BTTL fosinopril sodium 10 mg fosinopril sodium mg fosinopril sodium 40 mg fosinopril-hctz mg fosinopril-hctz mg fosphenytoin 100 mg pe/2 ml vl fosphenytoin 500 mg pe/10 ml FOSRENOL 1,000 MG POWDER PACK FRAGMIN,000 UNITS/0.6 ML FRAGMIN,000 UNITS/0. ML FRAGMIN 2,500 UNITS/0.2 ML SYR FRAGMIN 5,000 UNITS/0.2 ML SYR FRAGMIN 7,500 UNITS/0.3 ML SYR FRAGMIN 95,000 UNITS/3.8 ML VL FREAMINE HBC 6.9% IV SOLN FREAMINE III 10% IV SOLN. frovatriptan succ 2.5 mg furosemide 10 mg/ml solution furosemide 10 mg/ml syringe furosemide 100 mg/10 ml vial furosemide mg let furosemide 40 mg let furosemide 40 mg/5 ml soln furosemide 80 mg let FUSILEV I.V. 50 MG VIAL FUZEON 90 MG VIAL fyavolv 0.5 mg-2.5 mcg let FYCOMPA 0.5 MG/ML ORAL SUSP FYCOMPA 10 MG TABLET gabapentin 800 mg let GABITRIL 12 MG TABLET GABITRIL MG TABLET galantamine 4 mg/ml oral soln galantamine er mg capsule galantamine er 24 mg capsule galantamine er 8 mg capsule galantamine hbr 12 mg let galantamine hbr 4 mg let galantamine hbr 8 mg let GAMASTAN S-D VIAL GAMMAGARD LIQUID 10% VIAL GAMMAKED 1 GRAM/10 ML VIAL GAMMAKED 10 GRAM/100 ML VIAL GAMMAKED 2.5 GRAM/ ML VIAL GAMMAKED GRAM/0 ML VIAL GAMMAKED 5 GRAM/50 ML VIAL GAMMAPLEX 5% VIAL GAMUNEX-C 1 GRAM/10 ML VIAL GAMUNEX-C 10 GRAM/100 ML VIAL Comprehensive Formulary 102

103 GAMUNEX-C 2.5 GRAM/ ML VIAL GAMUNEX-C GRAM/0 ML VIAL GAMUNEX-C 40 GRAM/400 ML VIAL GAMUNEX-C 5 GRAM/50 ML VIAL ganciclovir 500 mg vial garamycin 0.3% eye drops GARDASIL 9 SYRINGE GARDASIL 9 VIAL GARDASIL SYRINGE GARDASIL VIAL gastrinex nf capsule gatifloxacin 0.5% eye drops GATTEX 5 MG ONE-VIAL KIT gavilyte-c solution gavilyte-g solution gavilyte-n solution GAZYVA 1,000 MG/40 ML VIAL GELNIQUE 10% GEL SACHETS GELNIQUE 3% GEL gemciine 1 gram/.3 ml vl gemciine 2 gram/.6 ml vl gemciine 0 mg/5. ml vl gemciine hcl 1 gram vial gemciine hcl 2 gram vial gemciine hcl 0 mg vial gemfibrozil 600 mg let generlac 10 gm/ ml solution gengraf 100 mg capsule gengraf 100 mg/ml solution gengraf mg capsule gengraf 50 mg capsule GENOTROPIN 12 MG CARTRIDGE GENOTROPIN 5 MG CARTRIDGE GENOTROPIN MINIQUICK 0.2 MG GENOTROPIN MINIQUICK 0.4 MG GENOTROPIN MINIQUICK 0.6 MG GENOTROPIN MINIQUICK 0.8 MG GENOTROPIN MINIQUICK 1 MG GENOTROPIN MINIQUICK 1.2 MG GENOTROPIN MINIQUICK 1.4 MG GENOTROPIN MINIQUICK 1.6 MG GENOTROPIN MINIQUICK 1.8 MG GENOTROPIN MINIQUICK 2 MG gentak 0.3 % eye ointment gentamicin 0.1% cream gentamicin 0.1% ointment gentamicin 0.3% eye drops gentamicin 0.3% eye ointment gentamicin 10 mg/ml vial gentamicin mg/2 ml vial gentamicin 70 mg/ns 50 ml pb gentamicin 80 mg/2 ml vial gentamicin 80 mg/ns 100 ml pb gentamicin 90 mg/ns 100 ml pb gentamicin ped mg/2 ml vial GENVOYA TABLET GEODON MG/ML VIAL gianvi 3 mg-0.02 mg let gildagia 0.4 mg mg gildess 1 mg- mcg let gildess 1.5 mg-30 mcg let gildess 24 fe mg let gildess fe let gildess fe 1- let GILENYA 0.5 MG CAPSULE GILOTRIF MG TABLET GILOTRIF 30 MG TABLET GILOTRIF 40 MG TABLET GLASSIA 1 GM/50 ML VIAL GLATOPA MG/ML SYRINGE GLEOSTINE 10 MG CAPSULE GLEOSTINE 100 MG CAPSULE GLEOSTINE 40 MG CAPSULE GLEOSTINE 5 MG CAPSULE glimepiride 1 mg let glimepiride 2 mg let glimepiride 4 mg let glipizide 10 mg let glipizide 5 mg let glipizide er 10 mg let glipizide er 2.5 mg let glipizide er 5 mg let glipizide xl 10 mg let glipizide xl 2.5 mg let glipizide xl 5 mg let glipizide-metformin mg glipizide-metformin mg glipizide-metformin mg GLUCAGEN 1 MG HYPOKIT GLUCAGON 1 MG EMERGENCY KIT glyburide 1. mg let glyburide 2.5 mg let Comprehensive Formulary 103

104 glyburide 5 mg let glyburide micro 1.5 mg glyburide micro 3 mg let glyburide micro 6 mg let glyburide-metformin mg glyburide-metformin mg glyburid-metformin 1.-0 mg glycopyrrolate 0.2 mg/ml vial glycopyrrolate 1 mg let glycopyrrolate 2 mg let glydo 2% jelly syringe GOLYTELY PACKET GYNAZOLE 1 2% CREAM HALAVEN 1 MG/2 ML VIAL halobetasol prop 0.05% cream halobetasol prop 0.05% ointmnt haloperidol 0.5 mg let haloperidol 1 mg let haloperidol 10 mg let haloperidol 2 mg let haloperidol mg let haloperidol 5 mg let haloperidol dec 100 mg/ml vial haloperidol dec 50 mg/ml vial heparin-1/2ns,000 units/500 heparin-d5w,000 unit/0 ml heparin-d5w,000 unit/500 ml heparin-ns 1,000 units/500 ml heparin-ns 2,000 unit/1,000 ml HEPATAMINE 8% IV SOLUTION HERCEPTIN 440 MG VIAL HETLIOZ MG CAPSULE HEXALEN 50 MG CAPSULE HIBERIX VACCINE WITH DILUENT grafco silvr mis nit appl haloperidol lac 2 mg/ml conc 33 HIZENTRA 1 GRAM/5 ML VIAL 68 granisetron hcl 0.1 mg/ml vial granisetron hcl 1 mg let granisetron hcl 1 mg/ml vial granisetron hcl 4 mg/4 ml vial GRANIX 300 MCG/0.5 ML SAFE SYR haloperidol lac 5 mg/ml vial HARVONI MG TABLET HAVRIX 1,440 UNITS/ML VIAL HAVRIX 0 UNIT/0.5 ML SYRINGE hc pramoxine cream 1-1% HIZENTRA 10 GRAM/50 ML VIAL HIZENTRA 2 GRAM/10 ML VIAL HIZENTRA 4 GRAM/ ML VIAL HORIZANT ER 300 MG TABLET HORIZANT ER 600 MG TABLET GRANIX 0 MCG/0.8 ML SAFE SYR GRANULEX AER GRIFULVIN V 500 MG TABLET griseofulvin 1 mg/5 ml griseofulvin micro 500 mg griseofulvin ultra 1 mg griseofulvin ultra 0 mg guanfacine 1 mg let guanfacine 2 mg let 41 hc pramoxine cream 2.5-1% heather let hecoria 0.5 mg capsule hecoria 1 mg capsule hecoria 5 mg capsule heparin 10,000 unit/10 ml vial heparin,000 unit/500 mld5w heparin 50,000 units/10 ml vl heparin sod 10,000 unit/ml vl HP ACTHAR GEL 80 UNIT/ML VIAL HPR AER HPR PLUS AER HUMALOG 100 UNITS/ML CARTRIDGE HUMALOG 100 UNITS/ML KWIKPEN HUMALOG 100 UNITS/ML VIAL HUMALOG 0 UNITS/ML KWIKPEN guanfacine hcl er 1 mg let 50 heparin sod,000 unit/ml vl 41 HUMALOG MIX KWIKPEN 38 guanfacine hcl er 2 mg let 50 heparin sod 5,000 unit/0.5 ml 41 HUMALOG MIX VIAL 38 guanfacine hcl er 3 mg let 50 heparin sodium 41 HUMALOG MIX 75- KWIKPEN 38 guanfacine hcl er 4 mg let GUANIDINE HCL 1 MG TABLET 50 heparin-1/2ns,000 units/0 41 HUMALOG MIX 75- VIAL HUMATROPE 12 MG CARTRIDGE Comprehensive Formulary 104

105 HUMATROPE 24 MG CARTRIDGE HUMATROPE 5 MG VIAL HUMATROPE 6 MG CARTRIDGE HUMIRA 10 MG/0.2 ML SYRINGE HUMIRA MG/0.4 ML SYRINGE HUMIRA 40 MG/0.8 ML PEN HUMIRA 40 MG/0.8 ML SYRINGE HUMIRA PEDIATRIC CROHN'S START HUMIRA PEN CROHN'S-UC-HS START HUMIRA PEN PSORIASIS START PK HUMULIN 70/30 KWIKPEN HUMULIN VIAL HUMULIN N 100 UNITS/ML KWIKPEN HUMULIN N 100 UNITS/ML VIAL HUMULIN R 100 UNITS/ML VIAL hydrocodon-acetamin 7.5-5/ hydrocodon-acetaminoph hydrocodon-acetaminoph hydrocodon-acetaminoph hydrocodon-acetaminophen hydrocodon-acetaminophen 5-5 hydrocodon-acetaminophn hydrocodon-acetaminophn 10-5 hydrocodone-acetamin 10-5/ hydrocodone-ibuprofen 10-0 hydrocodone-ibuprofen hydrocodone-ibuprofen 5-0 mg hydrocodone-ibuprofen hydrocortisone 2.5% cream hydrocortisone 2.5% lotion hydrocortisone 2.5% ointment hydrocortisone mg let hydrocortisone 5 mg let hydrocortisone buty 0.1% cream hydrocortisone butyr 0.1% oint hydrocortisone val 0.2% cream hydrocortisone val 0.2% ointmt hydromorphone 1 mg/ml solution hydromorphone 1 mg/ml syringe hydromorphone 10 mg/ml vial hydromorphone 2 mg let hydromorphone 2 mg/ml syringe hydromorphone 2 mg/ml vial hydromorphone 3 mg suppos hydromorphone 4 mg let HUMULIN R 500 UNITS/ML KWIKPEN HUMULIN R 500 UNITS/ML VIAL hydralazine 10 mg let hydralazine 100 mg let hydralazine mg/ml vial hydralazine mg let hydralazine 50 mg let HYDRO 35 AER hydrochlorothiazide 12.5 mg cp hydrochlorothiazide 12.5 mg tb hydrochlorothiazide mg hydrochlorothiazide 50 mg hydrocort cre iodoquin hydrocort ac sup mg hydrocort ac sup 30mg hydrocort buty 0.1% lipid crm hydrocort buty 0.1% lipo cream hydrocort/ cre iodoquin hydrocort/kit pramoxin hydrocortison-acetic acid soln hydrocortisone 0.1% soln hydrocortisone 1% absorbase hydrocortisone 1% cream hydrocortisone 1% ointment hydrocortisone 10 mg let hydrocortisone 100 mg/60 ml hydromorphone 4 mg/ml syrin hydromorphone 50 mg/5 ml vial hydromorphone 8 mg let hydroxychloroquine 0 mg hydroxyprogesterone 1. g/5ml hydroxyurea 500 mg capsule hydroxyzine 10 mg/5 ml soln hydroxyzine mg/ml vial hydroxyzine 50 mg/ml vial hydroxyzine hcl 10 mg let hydroxyzine hcl mg let hydroxyzine hcl 50 mg let Comprehensive Formulary 105

106 hydroxyzine pam 100 mg cap 74 ifosfamide 1 gm/ ml vial INLYTA 1 MG TABLET hydroxyzine pam mg cap 74 ifosfamide 3 gm vial INLYTA 5 MG TABLET hydroxyzine pam 50 mg cap HYLATOPIC HYLATOPIC AER AER PLUS HYOLEV MB TABLET hyoscyamine 0.1 mg odt hyoscyamine 0.1 mg sl hyoscyamine 0.1 mg/5 ml elix hyoscyamine 0.1 mg/ml drop hyoscyamine er mg hyoscyamine sr mg hyoscyamine sulf 0.1 mg hypercare % solution hyperlyte cr vial HYPERSAL NEB 7% HYPER-SAL NEB 7% ifosfamide 3 gm/ 60 ml vial ILARIS 0 MG VIAL ILEVRO 0.3% OPHTH DROPS ilotycin 0.5% eye ointment imatinib mesylate 100 mg imatinib mesylate 400 mg IMBRUVICA 0 MG CAPSULE imipenem-cilastatin 0 mg vl imipenem-cilastatin 500 mg vl imipramine hcl 10 mg let imipramine hcl mg let imipramine hcl 50 mg let imipramine pamoate 100 mg cap imipramine pamoate 1 mg cap imipramine pamoate 0 mg cap 68 INNOPRAN XL 1 MG CAPSULE INNOPRAN XL 80 MG CAPSULE INTELENCE 100 MG TABLET INTELENCE 0 MG TABLET INTELENCE MG TABLET INTRALIPID % IV FAT EMUL INTRALIPID 30% IV FAT EMUL INTRON A 10 MILLION UNITS VIAL INTRON A MILLION UNIT/3 ML INTRON A MILLION UNITS VIAL INTRON A MILLION UNIT/2.5ML INTRON A 50 MILLION UNITS VIAL introvale mg let ibandronate 3 mg/3 ml vial ibandronate sodium 0 mg imipramine pamoate 75 mg cap imiquimod 5% cream packet INVANZ 1 GM ADD-VANTAGE VIAL INVANZ 1 GM VIAL IBRANCE 100 MG CAPSULE IBRANCE 1 MG CAPSULE IBRANCE 75 MG CAPSULE ibudone 5-0 mg let ibuprofen 100 mg/5 ml susp ibuprofen 400 mg let ibuprofen 600 mg let ibuprofen 800 mg let ICLUSIG MG TABLET ICLUSIG MG TABLET idarubicin hcl 10 mg/10 ml vl idarubicin hcl mg/ ml vl idarubicin hcl 5 mg/5 ml vial ifosfamide 1 gm vial IMOVAX RABIES VACCINE+DILUENT INCRELEX 40 MG/4 ML VIAL INCRUSE ELLIPTA 62.5 MCG INH indapamide 1. mg let indapamide 2.5 mg let indomethacin mg capsule indomethacin 50 mg capsule indomethacin er 75 mg capsule INFANRIX DTAP VIAL INFUMORPH 0 MG/ ML AMPUL INFUMORPH 500 MG/ ML AMPUL INVEGA SUSTENNA 1 MG/0.75 ML INVEGA SUSTENNA 6 MG/ML SYRG INVEGA SUSTENNA 2 MG/1.5 ML INVEGA SUSTENNA 39 MG/0. ML INVEGA SUSTENNA MG/0.5 ML INVEGA TRINZA 3 MG/0.875 ML INVEGA TRINZA 410 MG/1.3 ML INVEGA TRINZA 5 MG/1.75 ML Comprehensive Formulary 106

107 INVEGA TRINZA 8 MG/2.6 ML 33 ISENTRESS MG TABLET CHEW 35 isoton gentamicin 60 mg/50 ml INVIRASE 0 MG CAPSULE INVIRASE 500 MG TABLET INVOKAMET 0-1,000 MG TABLET INVOKAMET MG TABLET INVOKAMET 50-1,000 MG TABLET INVOKAMET MG TABLET INVOKANA 100 MG TABLET INVOKANA 300 MG TABLET IONOSOL B-D5W IV SOLUTION IONOSOL MB-D5W IV SOLUTION ISENTRESS 400 MG TABLET ISO CARBACHO SOL 1.5% OP ISO CARBACHO SOL 3% OP iso gentamicin 100 mg/100 ml ISOLYTE P-DEXTROSE 5% SOLN ISOLYTE S IV SOLN PH7.4 ISOLYTE S IV SOLUTION-EXCEL isometh/apap cap dichlor isometh/caff /apap isoniazid 100 mg let isoniazid 100 mg/ml vial isoniazid 300 mg let 35 isoton gentamicin 80 mg/100 ml isoton gentamicin 80 mg/50 ml isoxsuprine 10mg ISOXSUPRINE TAB HCL MG isradipine 2.5 mg capsule isradipine 5 mg capsule ISTALOL 0.5% EYE DROPS ISTODAX 10 MG VIAL ISUPREL 0.2 MG/ML AMPUL itraconazole 100 mg capsule ivermectin 3 mg let IXEMPRA MG KIT IOPIDINE 1% EYE DROPS isoniazid 50 mg/5 ml solution IXEMPRA MG KIT IPOL VIAL 68 isopto atropine 1% eye drops IXIARO 6 MCG/0.5 ML SYRINGE 68 iprat-albut 0.5-3(2.5) mg/3 ml ipratropium 0.03% spray ipratropium 0.06% spray ipratropium br 0.02% soln IPRIVASK MG VIAL irbesartan 0 mg let irbesartan 300 mg let irbesartan 75 mg let irbesartan-hctz mg tb irbesartan-hctz mg tb IRESSA 0 MG TABLET irinotecan hcl 100 mg/5 ml vl irinotecan hcl 40 mg/2 ml vial irinotecan hcl 500 mg/ ml vl ISENTRESS 100 MG POWDER PACKET ISENTRESS 100 MG TABLET CHEW isopto carpine 1% eye drops isopto carpine 2% eye drops isopto carpine 4% eye drops isopto homatropine 2% drops isopto homatropine 5% drops ISOPTO HYOSCINE 0.% DROPS isosorbide dn 10 mg let isosorbide dn mg let isosorbide dn 30 mg let isosorbide dn 5 mg let isosorbide dn er 40 mg let isosorbide mn 10 mg let isosorbide mn mg let isosorbide mn er 1 mg isosorbide mn er 30 mg let isosorbide mn er 60 mg let isoton gentamicin 100 mg/50 ml JADENU 0 MG TABLET JADENU 360 MG TABLET JADENU 90 MG TABLET JAKAFI 10 MG TABLET JAKAFI MG TABLET JAKAFI MG TABLET JAKAFI MG TABLET JAKAFI 5 MG TABLET JANTOVEN 1 MG TABLET JANTOVEN 10 MG TABLET JANTOVEN 2 MG TABLET JANTOVEN 2.5 MG TABLET JANTOVEN 3 MG TABLET JANTOVEN 4 MG TABLET JANTOVEN 5 MG TABLET JANTOVEN 6 MG TABLET JANTOVEN 7.5 MG TABLET JANUMET 50-1,000 MG TABLET Comprehensive Formulary 107

108 JANUMET MG TABLET 39 k effervescent meq let KENALOG MG/ML VIAL JANUMET XR 100-1,000 MG TABLET JANUMET XR 50-1,000 MG TABLET JANUMET XR MG TABLET KABIVEN IV EMULSION KADCYLA 100 MG VIAL KADCYLA 0 MG VIAL kaitlib fe chewable let KALBITOR 10 MG/ML VIAL KEPIVANCE 6. MG VIAL KETEK 300 MG TABLET KETEK 400 MG TABLET ketoconazole 2% cream ketoconazole 2% shampoo 51 JANUVIA 100 MG TABLET 39 KALETRA 100- MG TABLET 35 ketoconazole 0 mg let JANUVIA MG TABLET 39 KALETRA 0-50 MG TABLET 35 KETODAN KIT 2% JANUVIA 50 MG TABLET jencycla 0.35 mg let JENTADUETO 2.5 MG-1000 MG TAB JENTADUETO 2.5 MG-500 MG TAB JENTADUETO 2.5 MG-850 MG TAB KALETRA /5 ML ORAL SOLU KALYDECO 0 MG TABLET KALYDECO 50 MG GRANULES PACKET KALYDECO 75 MG GRANULES PACKET kariva day let ketoprofen 50 mg capsule ketoprofen 75 mg capsule ketoprofen er 0 mg capsule ketorolac 0.4% ophth solution ketorolac 0.5% ophth solution ketorolac 10 mg let ketorolac mg/ml vial JENTADUETO XR 2.5 MG- 1,000 MG JENTADUETO XR 5 MG-1,000 MG TB jevantique lo 0.5 mg-2.5 mcg JEVTANA 60 MG/1.5 ML KIT jinteli 1 mg-5 mcg let jolessa 0. mg-0.03 mg let jolivette let juleber day let junel 1 mg- mcg let junel 1.5 mg-30 mcg let junel fe 1 mg- mcg let junel fe 1.5 mg-30 mcg let junel fe 24 let JUXTAPID 10 MG CAPSULE JUXTAPID MG CAPSULE JUXTAPID 30 MG CAPSULE JUXTAPID 40 MG CAPSULE JUXTAPID 5 MG CAPSULE JUXTAPID 60 MG CAPSULE KCL MEQ IN D5W SOLUTION KCL MEQ IN D5W-0.5% NACL KCL MEQ IN D5W-0.3% NACL KCL MEQ IN D5W-0.33% NACL KCL MEQ IN D5W-0.% NACL KCL MEQ IN D5W-LACT RINGER KCL MEQ IN D5W-NS KCL MEQ-NS 1,000 ML IV SOLN KCL 40 MEQ IN D5W SOLUTION KCL 40 MEQ IN D5W-LACT RINGER KCL 40 MEQ IN D5W-NACL 0.9% KCL 40 MEQ-NS 1,000 ML IV SOLN KCL 5 MEQ IN D5W-0.2% NACL kelnor 1-35 let KENALOG MG/ML VIAL 62 ketorolac 30 mg/ml carpuject ketorolac 30 mg/ml vial ketorolac 300 mg/10 ml vial ketorolac 60 mg/2 ml vial KEYTRUDA 100 MG/4 ML VIAL KEYTRUDA 50 MG VIAL kimidess day let KINERET 100 MG/0.67 ML SYRINGE KINRIX VIAL kionex gm/60 ml suspension kionex powder klor-con 10 meq let klor-con meq packet klor-con meq packet klor-con 8 meq let klor-con m10 let klor-con m let klor-con m let klor-con sprinkle er 10 meq cp Comprehensive Formulary 108

109 klor-con sprinkle er 8 meq cap klor-con-ef meq eff KOMBIGLYZE XR 2.5-1,000 MG TAB KOMBIGLYZE XR 5-1,000 MG TAB LAMICTAL TAB START KIT (GREEN) LAMICTAL TB START KIT (ORANGE) lamivudine 10 mg/ml oral soln lamivudine 0 mg let lansoprazole dr 30 mg capsule LANSOPRAZOLE SUS 3MG/ML LANTUS 100 UNITS/ML VIAL LANTUS SOLOSTAR 100 UNITS/ML KOMBIGLYZE XR MG TABLET KORLYM 300 MG TABLET K-PHOS #2 TABLET K-PHOS NEUTRAL TABLET K-PHOS ORIGINAL TABLET KRISTALOSE 10 GM PACKET KRISTALOSE GM PACKET k-sol 10% ( meq/ ml) liq k-sol % (40 meq/ ml) liq kurvelo let KUVAN 100 MG POWDER PACKET KUVAN 100 MG TABLET KUVAN 500 MG POWDER PACKET lamivudine 300 mg let lamivudine hbv 100 mg let lamivudine-zidovudine let lamotrigine 100 mg let lamotrigine 0 mg let lamotrigine 0 mg let lamotrigine mg disper lamotrigine mg let lamotrigine 5 mg disper let lamotrigine er 100 mg let lamotrigine er 0 mg let lamotrigine er mg let lamotrigine er 0 mg let lamotrigine er 300 mg let lamotrigine er 50 mg let larin 1.5 mg-30 mcg let larin let larin fe let larin fe 1- let latanoprost 0.005% eye LATRIX XM EMU % LATUDA 1 MG TABLET LATUDA MG TABLET LATUDA 40 MG TABLET LATUDA 60 MG TABLET LATUDA 80 MG TABLET layolis fe chewable let leena let leflunomide 10 mg let leflunomide mg let KYNAMRO 0 MG/ML SYRINGE labetalol hcl 100 mg let labetalol hcl 100 mg/ ml vl labetalol hcl 0 mg let labetalol hcl 300 mg let LACRISERT 5 MG EYE INSERT LACTATED RINGERS INJECTION LACTATED RINGERS IRRIGATION lactic acid cream /vit e lactic acid cream e lactulose 10 gm/ ml solution LAMICTAL TAB START KIT (BLUE) lamotrigine odt 100 mg let lamotrigine odt 0 mg let lamotrigine odt mg let lamotrigine odt 50 mg let lamotrigine odt kit (blue) lamotrigine odt kit (green) lamotrigine odt kit (orange) LANOXIN 1 MCG TABLET LANOXIN 7.5 MCG TABLET LANOXIN 0 MCG TABLET LANOXIN 62.5 MCG TABLET LANOXIN PED 100 MCG/ML AMPUL lansoprazol-amoxicil-clarithro lansoprazole dr mg capsule LENVIMA 10 MG DAILY DOSE LENVIMA MG DAILY DOSE LENVIMA MG DAILY DOSE LENVIMA MG DAILY DOSE LENVIMA 24 MG DAILY DOSE LENVIMA 8 MG DAILY DOSE lessina- let LETAIRIS 10 MG TABLET LETAIRIS 5 MG TABLET letrozole 2.5 mg let leucovorin calcium 10 mg leucovorin calcium 100 mg vial leucovorin calcium mg leucovorin calcium 0 mg vial Comprehensive Formulary 109

110 leucovorin calcium mg leucovorin calcium 350 mg vial leucovorin calcium 5 mg leucovorin calcium 50 mg vial leucovorin calcium 500 mg vl LEUKERAN 2 MG TABLET LEUKINE 0 MCG VIAL leuprolide 2wk 1 mg/0.2 ml levalbuterol 0.31 mg/3 ml sol levalbuterol 0.63 mg/3 ml sol levalbuterol 1. mg/3 ml sol levalbuterol conc 1. mg/0.5 LEVEMIR 100 UNITS/ML VIAL LEVEMIR FLEXTOUCH 100 UNITS/ML levetiracetam 1,000 mg let levetiracetam 100 mg/ml soln levetiracetam 0 mg let levetiracetam 500 mg let levetiracetam 500 mg/5 ml vial levetiracetam 750 mg let levetiracetam er 500 mg let levetiracetam er 750 mg let levetiracetam-nacl 1,000mg/100 levetiracetam-nacl 1,500mg/100 levetiracetam-nacl 500 mg/100 levobunolol 0.5% eye drops levocarnitine 100 mg/ml soln levocarnitine 0 mg/ml vial levocarnitine 330 mg let levocetirizine 2.5 mg/5 ml sol levocetirizine 5 mg let levofloxacin 0.5% eye drops levofloxacin mg/ml solution levofloxacin 0 mg let levofloxacin 0 mg/50 mld5w levofloxacin 500 mg let levofloxacin 500 mg/100 mld5w levofloxacin 500 mg/ ml vial levofloxacin 750 mg let levofloxacin 750 mg/0 mld5w LEVOLEUCOVORIN levoleucovorin 5 mg/.5 ml levoleucovorin 0 mg/ ml vl levonest- let levono-e estrad levono-e estrad levonor-eth estra mg levonor-eth estrad mg levonor-eth estrad levonor-eth estrad levonor-eth estrad triphasic levora- let levorphanol 2 mg let levothyroxine 100 mcg let levothyroxine 100 mcg vial levothyroxine 2 mcg let levothyroxine 1 mcg let levothyroxine 7 mcg let levothyroxine 0 mcg let levothyroxine 5 mcg let levothyroxine 0 mcg let levothyroxine 0 mcg vial levothyroxine mcg let levothyroxine 300 mcg let levothyroxine 50 mcg let levothyroxine 500 mcg vial levothyroxine 75 mcg let levothyroxine 88 mcg let LEVOXYL 100 MCG TABLET LEVOXYL 2 MCG TABLET LEVOXYL 1 MCG TABLET LEVOXYL 7 MCG TABLET LEVOXYL 0 MCG TABLET LEVOXYL 5 MCG TABLET LEVOXYL 0 MCG TABLET LEVOXYL MCG TABLET LEVOXYL 50 MCG TABLET LEVOXYL 75 MCG TABLET LEVOXYL 88 MCG TABLET LEVULAN KERASTICK LEXIVA 50 MG/ML SUSPENSION LEXIVA 700 MG TABLET LIALDA DR 1.2 GM TABLET LIBRAX CAP 5-2.5MG lidocaine 2% viscous soln lidocaine 5% ointment lidocaine 5% patch lidocaine cre 3% lidocaine hcl 0.5% vial lidocaine hcl 1% abboject lidocaine hcl 1% vial lidocaine hcl 1.5% ampul lidocaine hcl 2% 40 mg/2 ml vl lidocaine hcl 2% jelly lidocaine hcl 2% luer-jet Comprehensive Formulary 0

111 lidocaine hcl 2% vial lidocaine hcl 4% ampul lidocaine hcl 4% solution lidocaine/hc kit 3-2.5% lidocaine-hc 2-2% cream kit lidocaine-hc 3-0.5% cream kit lidocaine-hc 3-1% cream kit lidocaine-prilocaine cream lidopin cream 3% LIDOVEX CREAM 3.75% LIDOVIR OIN 4-4% lincomycin hcl 600 mg/2 ml vl lindane 1% lotion lisinopril-hctz - mg lithium 8 meq/5 ml solution lithium carbonate 0 mg cap lithium carbonate 300 mg cap lithium carbonate 300 mg lithium carbonate 600 mg cap lithium carbonate er 300 mg tb lithium carbonate er 0 mg tb LITHOSTAT 0 MG TABLET lokara 0.05% lotion lomedia 24 fe 1 mg- mcg losartan potassium 100 mg losartan potassium mg losartan potassium 50 mg losartan-hctz mg losartan-hctz 100- mg losartan-hctz mg LOTEMAX 0.5% EYE DROPS LOTEMAX 0.5% EYE OINTMENT LOTEMAX 0.5% OPHTHALMIC GEL lovastatin 10 mg let lovastatin mg let lindane 1% shampoo linezolid 100 mg/5 ml susp linezolid 600 mg let linezolid 600 mg/300 ml iv LINZESS 5 MCG CAPSULE LINZESS 290 MCG CAPSULE liothyronine sod 10 mcg/ml vl liothyronine sod mcg liothyronine sod 5 mcg liothyronine sod 50 mcg LIPOSYN III 10% IV FAT EMULSN LIPOSYN III % IV FAT EMULSN LIPOSYN III 30% IV FAT EMULSN lisinopril 10 mg let 31 LONSURF MG-6. MG TABLET LONSURF MG-8. MG TABLET loperamide 2 mg capsule lopreeza 0.5 mg-0.1 mg let lopreeza 1 mg-0.5 mg let lorazepam 0.5 mg let lorazepam 1 mg let lorazepam 2 mg let lorazepam 2 mg/ml carpuject lorazepam 2 mg/ml oral concent lorazepam 2 mg/ml vial lorazepam 4 mg/ml carpuject lorazepam 4 mg/ml vial lorazepam intensol 2 mg/ml lovastatin 40 mg let low-ogestrel- let loxapine 10 mg capsule loxapine mg capsule loxapine 5 mg capsule loxapine 50 mg capsule ludent fluoride 0. mg tb chw ludent fluoride 0.5 mg tb chew ludent fluoride 1 mg chew LUFYLLIN 0 MG TABLET LUMIGAN 0.01% EYE DROPS LUMIZYME 50 MG VIAL LUPRON DEPOT. MG 3MO KIT LUPRON DEPOT.5 MG 3MO KIT lisinopril 2.5 mg let lorcet 5-5 mg let 9 LUPRON DEPOT 3.75 MG KIT 66 lisinopril mg let lisinopril 30 mg let lisinopril 40 mg let lisinopril 5 mg let lisinopril-hctz mg lisinopril-hctz mg lorcet hd 10-5 mg let lorcet plus mg let lor 10-5 mg let lor 5-5 mg let lor mg let loryna 3 mg-0.02 mg let LUPRON DEPOT MG 6MO KIT LUPRON DEPOT 7.5 MG KIT LUPRON DEPOT-4 MONTH KIT LUPRON DEPOT-PED. MG 3MO Comprehensive Formulary 1

112 LUPRON DEPOT-PED. MG KIT LUPRON DEPOT-PED MG KIT LUPRON DEPOT-PED 30 MG 3MO KIT LUPRON DEPOT-PED 7.5 MG KIT lutera- let magnesium-d5w 1 gm/100 ml soln MAKENA 0 MG/ML VIAL malathion 0.5% lotion maprotiline mg let maprotiline 50 mg let maprotiline 75 mg let margesic capsule MEKINIST 0.5 MG TABLET MEKINIST 2 MG TABLET meloxicam mg let meloxicam 7.5 mg let meloxicam 7.5 mg/5 ml susp melphalan hcl 50 mg vial memantine 5-10 mg titration pk LYNPARZA 50 MG CAPSULE 29 marlissa- let 63 memantine hcl 10 mg let 21 LYRICA 100 MG CAPSULE LYRICA 0 MG CAPSULE LYRICA MG/ML ORAL SOLUTION LYRICA 0 MG CAPSULE LYRICA 5 MG CAPSULE LYRICA MG CAPSULE LYRICA 300 MG CAPSULE LYRICA 50 MG CAPSULE LYRICA 75 MG CAPSULE LYSODREN 500 MG TABLET lyza 0.35 mg let mafenide acetate 50 gm powd pk MAGNEBIND 400 RX TABLET magnesium sulf 1 g/100 mld5w magnesium sulf 2 g/50 ml bag magnesium sulf g/500 ml bag magnesium sulf 4 g/100 ml bag magnesium sulf 4 g/50 ml bag magnesium sulf 4% iv soln MARPLAN 10 MG TABLET MARQIBO KIT marten let MATULANE 50 MG CAPSULE MATZIM LA 0 MG TABLET MATZIM LA 240 MG TABLET MATZIM LA 300 MG TABLET MATZIM LA 360 MG TABLET MATZIM LA 4 MG TABLET MAXIDEX 0.1% EYE DROPS meclizine 12.5 mg let meclizine mg let meclofenamate 100 mg capsule meclofenamate 50 mg capsule MEDROL 2 MG TABLET medroxyprogesterone 10 mg medroxyprogesterone 0 mg/ml medroxyprogesterone 2.5 mg medroxyprogesterone 5 mg memantine hcl 2 mg/ml solution memantine hcl 5 mg let MENACTRA VIAL MENEST 0.3 MG TABLET MENEST 0.6 MG TABLET MENEST 1. MG TABLET MENEST 2.5 MG TABLET MENHIBRIX VACCINE VIAL MENOMUNE-A-C-Y-W-5 W- DILUENT MENOSTAR MCG/DAY PATCH MENVEO A-C-Y-W-5-DIP VIAL KT meperidine 10 mg/ml cartrdge meperidine 100 mg let meperidine 100 mg/ml vial meperidine mg/ml vial meperidine 50 mg let meperidine 50 mg/5 ml solution meperidine 50 mg/ml vial meprobamate 0 mg let magnesium sulf 40 g/1,000 ml magnesium sulf 8% iv soln magnesium sulfate 50% syringe magnesium sulfate 50% vial mefloquine hcl 0 mg let megestrol mg let megestrol 40 mg let megestrol 6 mg/5 ml susp megestrol acet 40 mg/ml susp meprobamate 400 mg let mercaptopurine 50 mg let meropenem iv 1 gm vial meropenem iv 500 mg vial Comprehensive Formulary 2

113 meropenem-0.9% nacl 1 gram/50 meropenem-0.9% nacl 500 mg/50 mesalamine 4 gm/60 ml enema mesalamine 4 gm/60 ml kit methadose 40 mg let dispr methamphetamine 5 mg let methazolamide mg let methazolamide 50 mg let methenamine hipp 1 gm let methenamine md 1 gm let methylergonovine 0.2 mg/ml vl methylphenidate 10 mg chew methylphenidate 10 mg let methylphenidate 10 mg/5 ml sol mesna 100 mg/ml vial MESNEX 400 MG TABLET MESTINON 60 MG/5 ML SYRUP metadate er mg let metaproterenol 10 mg let metaproterenol 10 mg/5 ml syr metaproterenol mg let metaxalone 400 mg let metaxalone 800 mg let metformin er 1,000 mg osm metformin hcl 1,000 mg let metformin hcl 500 mg let metformin hcl 850 mg let metformin hcl er 500 mg osmtb metformin hcl er 500 mg let metformin hcl er 750 mg let methadone 10 mg/5 ml solution methadone 10 mg/ml oral conc methadone 5 mg/5 ml solution methadone hcl 10 mg let methadone hcl 10 mg/ml vial methadone hcl 5 mg let methadone intensol 10 mg/ml methadose 10 mg/ml oral conc methenamine md 500 mg let methimazole 10 mg let methimazole 5 mg let methitest 10 mg let methocarbamol 500 mg let methocarbamol 750 mg let methotrexate 1 gm vial methotrexate 1 gram/40 ml vial methotrexate 100 mg/4 ml vial methotrexate 2.5 mg let methotrexate 0 mg/8 ml vial methotrexate 0 mg/10 ml vial methotrexate 50 mg/2 ml vial methoxsalen 10 mg capsule methscopolamine brom 2.5 mg tb methscopolamine brom 5 mg methyclothiazide 5 mg let methyldopa 0 mg let methyldopa 500 mg let methyldopa-hctz 0- mg methyldopa-hctz 0- mg methyldopate 0 mg/5 ml vial methylergonovine 0.2 mg let methylphenidate 2.5 mg chew tb methylphenidate mg let methylphenidate 5 mg chew methylphenidate 5 mg let methylphenidate 5 mg/5 ml soln methylphenidate cd 10 mg cap methylphenidate cd mg cap methylphenidate cd 30 mg cap methylphenidate cd 40 mg cap methylphenidate cd 50 mg cap methylphenidate cd 60 mg cap methylphenidate er 10 mg methylphenidate er mg methylphenidate er mg methylphenidate er mg methylphenidate er 30 mg cap methylphenidate er 36 mg methylphenidate er 40 mg cap methylphenidate er 54 mg methylphenidate la mg cap methylphenidate sr mg methylprednisolone 1 mg vial methylprednisolone mg Comprehensive Formulary 1

114 methylprednisolone mg metoprolol-hctz 50- mg minitran 0.2 mg/hr patch methylprednisolone 4 mg dosepk methylprednisolone 4 mg let methylprednisolone 40 mg vial methylprednisolone 40 mg/ml vl methylprednisolone 8 mg methylprednisolone 80 mg/ml vl methylprednisolone ss 1 gm vl metipranolol 0.3% eye drops metoclopramide 10 mg let metoclopramide 10 mg/2 ml vial METRO IV 500 MG/100 ML metronidazole 0.75% cream metronidazole 0.75% lotion metronidazole 0 mg let metronidazole 375 mg capsule metronidazole 500 mg let metronidazole 500 mg/100 ml metronidazole topical 0.75% gl metronidazole topical 1% gel metronidazole vaginal 0.75% gl mexiletine 0 mg capsule mexiletine 0 mg capsule minitran 0.4 mg/hr patch minitran 0.6 mg/hr patch MINIVELLE 0.0 MG PATCH MINIVELLE MG PATCH MINIVELLE 0.05 MG PATCH MINIVELLE MG PATCH MINIVELLE 0.1 MG PATCH minocycline 100 mg capsule minocycline 50 mg capsule minocycline 75 mg capsule minocycline hcl 100 mg let minocycline hcl 50 mg let minocycline hcl 75 mg let minoxidil 10 mg let metoclopramide 5 mg let mexiletine 0 mg capsule minoxidil 2.5 mg let metoclopramide 5 mg/5 ml soln metolazone 10 mg let metolazone 2.5 mg let metolazone 5 mg let metoprolol 1 mg/ml carpuject metoprolol succ er 100 mg metoprolol succ er 0 mg metoprolol succ er mg metoprolol succ er 50 mg metoprolol tart 5 mg/5 ml amp metoprolol tartrate 100 mg metoprolol tartrate mg metoprolol tartrate 37.5 mg tb metoprolol tartrate 50 mg metoprolol tartrate 75 mg metoprolol-hctz 100- mg metoprolol-hctz mg MIACALCIN 400 UNIT/2 ML VIAL miconazole 3 0 mg vag supp microgestin microgestin let microgestin fe microgestin fe 1- let midazolam hcl 2 mg/ml syrup midodrine hcl 10 mg let midodrine hcl 2.5 mg let midodrine hcl 5 mg let migergot suppository miglitol 100 mg let miglitol mg let miglitol 50 mg let migragesic cap ida mimvey mg let mimvey lo mg let minitran 0.1 mg/hr patch mirtazapine mg odt mirtazapine mg let mirtazapine 30 mg odt mirtazapine 30 mg let mirtazapine mg odt mirtazapine mg let mirtazapine 7.5 mg let misoprostol 100 mcg let misoprostol 0 mcg let mitomycin mg vial mitomycin 40 mg vial mitomycin 5 mg vial mitoxantrone mg/10 ml vial mitoxantrone mg/12.5 ml vl mitoxantrone 30 mg/ ml vial M-M-R II VACCINE WITH DILUENT modafinil 100 mg let Comprehensive Formulary 1

115 modafinil 0 mg let 77 morphine mg/ml carpuject 10 morphine sulfate er 30 mg cap 10 moexipril hcl mg let morphine mg/ml vial 10 morphine sulfate er mg cap 10 moexipril hcl 7.5 mg let morphine 2 mg/ml isecure syr 10 morphine sulfate er 50 mg cap 10 moexipril-hctz mg morphine 2 mg/ml syringe 10 morphine sulfate er 60 mg cap 10 moexipril-hctz - mg let moexipril-hctz mg molindone hcl 10 mg let molindone hcl mg let molindone hcl 5 mg let mometasone furoate 0.1% cream mometasone furoate 0.1% oint mometasone furoate 0.1% soln mometasone furoate 50 mcg spry mondoxyne nl 100 mg capsule mondoxyne nl 50 mg capsule mondoxyne nl 75 mg capsule mono-linyah let mononessa let montelukast sod 10 mg let montelukast sod 4 mg granules montelukast sod 4 mg chew montelukast sod 5 mg chew MONUROL 3 GM SACHET morgidox 100 mg capsule morphine 0.5 mg/ml vial morphine 1 mg/ml vial p-f morphine 10 mg/ml isecure syr morphine 10 mg/ml syringe morphine 10 mg/ml vial morphine 4 mg/ml isecure syr morphine 4 mg/ml syringe morphine 5 mg/ml syringe morphine 5 mg/ml vial morphine 8 mg/ml isecure syr morphine 8 mg/ml syringe morphine sulf 10 mg suppos morphine sulf 10 mg/5 ml soln morphine sulf 100 mg/5 ml soln morphine sulf mg suppos morphine sulf mg/5 ml soln morphine sulf 30 mg suppos morphine sulf 5 mg suppos morphine sulf er 100 mg let morphine sulf er mg let morphine sulf er 0 mg let morphine sulf er 30 mg let morphine sulf er 60 mg let morphine sulfate 1 mg/ml vial morphine sulfate mg/ml vl morphine sulfate 50 mg/ml vial morphine sulfate add-vantage morphine sulfate er 10 mg cap morphine sulfate er 100 mg cap morphine sulfate er 1 mg cap morphine sulfate er mg cap morphine sulfate er 75 mg cap morphine sulfate er 80 mg cap morphine sulfate er 90 mg cap morphine sulfate ir mg morphine sulfate ir 30 mg MOTOFEN TABLET MOVIPREP POWDER PACKET MOXEZA 0.5% EYE DROPS moxifloxacin 400 mg/0 ml bag moxifloxacin hcl 400 mg let MOZOBIL 24 MG/1.2 ML VIAL MULTAQ 400 MG TABLET multivit & fluor 0.5 mg/ml drp multi-vit w-fluor 0. mg/ml multi-vit w-fluor 0.5 mg/ml multivitamins/fluoride multivit-fluor 0. mg chw multivit-fluor 0. mg/ml drop multivit-fluor 0.5 mg chew multivit-fluor 0.5 mg/ml drop multivit-fluoride 1 mg chw multivit-fluor-iron 0. mg/ml multivit-iron-fl 0. mg/ml mupirocin 2% cream mupirocin 2% ointment MUSTARGEN 10 MG VIAL mvc-fluoride 0. mg chew mvc-fluoride 0.5 mg chew mvc-fluoride 1 mg chew MYCAMINE 100 MG VIAL Comprehensive Formulary 1

116 MYCAMINE 50 MG VIAL naftifine hcl 1% cream nateglinide 60 mg let 39 MYCOBUTIN 0 MG CAPSULE mycophenolate 0 mg/ml susp mycophenolate 0 mg capsule mycophenolate 500 mg let mycophenolic acid dr 0 mg tb mycophenolic acid dr 360 mg tb mydral MYFORTIC 0 MG TABLET MYFORTIC 360 MG TABLET myorisan 10 mg capsule myorisan mg capsule myorisan 30 mg capsule myorisan 40 mg capsule MYOZYME 50 MG VIAL MYRBETRIQ ER MG TABLET MYRBETRIQ ER 50 MG TABLET myzilra- let nabumetone 500 mg let nabumetone 750 mg let nadolol mg let nadolol 40 mg let nadolol 80 mg let nadolol-bendroflu 40-5 mg nadolol-bendroflu 80-5 mg nafcillin 1 gm add-van vial nafcillin 1 gm vial NAFCILLIN 1 GM/ 50 ML INJ nafcillin 10 gm vial nafcillin 2 gm add-vant vial nafcillin 2 gm vial NAFCILLIN 2 GM/ 100 ML INJ naftifine hcl 2% cream NAFTIN 1% GEL NAFTIN 2% CREAM NAFTIN 2% GEL NAGLAZYME 5 MG/5 ML VIAL nalbuphine 100 mg/10 ml vial nalbuphine 0 mg/10 ml vial naloxone 0.4 mg/ml vial naloxone 2 mg/2 ml syringe naltrexone 50 mg let NAMENDA XR MG CAPSULE NAMENDA XR 21 MG CAPSULE NAMENDA XR MG CAPSULE NAMENDA XR 7 MG CAPSULE NAMENDA XR TITRATION PACK NAMZARIC MG-10 MG CAPSULE NAMZARIC MG-10 MG CAPSULE naphazoline 0.1% eye drops naproxen 1 mg/5 ml suspen naproxen 0 mg let naproxen 375 mg let naproxen 500 mg let naproxen dr 375 mg let naproxen dr 500 mg let naproxen sodium 5 mg naproxen sodium 0 mg naratriptan hcl 1 mg let naratriptan hcl 2.5 mg let NARCAN 4 MG NASAL SPRAY NASONEX 50 MCG NASAL SPRAY NATACYN EYE DROPS nateglinide 1 mg let NATPARA 100 MCG DOSE CARTRIDGE NATPARA MCG DOSE CARTRIDGE NATPARA 50 MCG DOSE CARTRIDGE NATPARA 75 MCG DOSE CARTRIDGE nature-throid 1.75 mg let nature-throid 0 mg let nature-throid 6. mg let nature-throid. mg let nature-throid 2.5 mg let nature-throid 5 mg let nature-throid 0 mg let nature-throid.5 mg let nature-throid 5 mg let nature-throid.75 mg let nature-throid mg let nature-throid 81. mg let nature-throid 97.5 mg let NEBUPENT 300 MG INHAL POWDER nebusal neb 3% NEBUSAL NEB 6% necon let necon 10-- let necon let necon let necon let nefazodone hcl 100 mg let nefazodone hcl 0 mg let nefazodone hcl 0 mg let nefazodone hcl 0 mg let nefazodone hcl 50 mg let Comprehensive Formulary 1

117 neo-bacit-poly-hc eye ointment neomyc-bacit-polymix eye oint neomycin 500 mg let neomycin-poly-hc eye drops neomycin-polymyxin-hc ear soln neomycin-polymyxin-hc ear susp NEUPRO 3 MG/24 HR PATCH NEUPRO 4 MG/24 HR PATCH NEUPRO 6 MG/24 HR PATCH NEUPRO 8 MG/24 HR PATCH neutral sodium fluoride NEVANAC 0.1% DROPTAINER nevirapine 0 mg let nevirapine 50 mg/5 ml susp nimodipine 30 mg capsule NINLARO 2.3 MG CAPSULE NINLARO 3 MG CAPSULE NINLARO 4 MG CAPSULE NIPENT 10 MG VIAL nisoldipine er mg let nisoldipine er mg let nisoldipine er.5 mg let neomyc-polym-dexamet eye ointm neomyc-polym-dexameth eye drop neomyc-polym-gramicid eye drop nevirapine er 100 mg let nevirapine er 400 mg let NEXAVAR 0 MG TABLET NEXIUM DR 10 MG PACKET NEXIUM DR 2.5 MG PACKET nisoldipine er 30 mg let nisoldipine er mg let nisoldipine er 40 mg let nisoldipine er 8.5 mg let NITRO-BID 2% OINTMENT neomy-polymyxin b 40 mg/ml amp neo-polycin eye ointment neo-polycin hc eye ointment NEORAL 100 MG GELATIN CAPSULE NEORAL 100 MG/ML SOLUTION NEORAL MG GELATIN CAPSULE NEOSALUS AER NEO-SYNALAR KIT NEPHRAMINE 5.4% IV SOLUTION neuac gel NEULASTA 6 MG/0.6 ML SYRINGE NEUMEGA 5 MG VIAL NEUPOGEN 300 MCG/0.5 ML SYR NEUPOGEN 300 MCG/ML VIAL NEUPOGEN 0 MCG/0.8 ML SYR NEUPOGEN 0 MCG/1.6 ML VIAL NEUPRO 1 MG/24 HR PATCH NEUPRO 2 MG/24 HR PATCH NEXIUM DR MG PACKET NEXIUM DR 40 MG PACKET NEXIUM DR 5 MG PACKET niacin er 1,000 mg let niacin er 500 mg let niacin er 750 mg let niacor 500 mg let nicardipine mg capsule nicardipine mg/10 ml vial nicardipine 30 mg capsule NICOTROL CARTRIDGE INHALER NICOTROL NS 10 MG/ML SPRAY nifedical xl 30 mg let nifedical xl 60 mg let nifedipine 10 mg capsule nifedipine mg capsule nifedipine er 30 mg let nifedipine er 60 mg let nifedipine er 90 mg let nikki 3 mg-0.02 mg let NILANDRON 0 MG TABLET nilutamide 0 mg let NITRO-DUR 0.3 MG/HR PATCH NITRO-DUR 0.8 MG/HR PATCH nitrofurantoin mg/5 ml susp nitrofurantoin mcr 100 mg cap nitrofurantoin mcr mg cap nitrofurantoin mcr 50 mg cap nitrofurantoin mono-mcr 100 mg nitroglycer cap 2.5mg er nitroglycer cap 6.5mg er nitroglycer cap 9mg er nitroglycerin 0.1 mg/hr patch nitroglycerin 0.2 mg/hr patch nitroglycerin 0.4 mg/hr patch nitroglycerin 0.6 mg/hr patch nitroglycerin 5 mg/ml vial nitroglycerin lingual 0.4 mg NITROSTAT 0.3 MG TABLET SL NITROSTAT 0.4 MG TABLET SL NITROSTAT 0.6 MG TABLET SL nizatidine 0 mg capsule nizatidine 300 mg capsule Comprehensive Formulary 1

118 nodolor cap nora-be let NORDITROPIN FLEXPRO 10 MG/1.5 NORDITROPIN FLEXPRO MG/1.5 NORDITROPIN FLEXPRO 30 MG/3 ML NORDITROPIN FLEXPRO 5 MG/1.5 noreth-estrad-fe (21)- 75 noreth-estrad-fe (24)- 75 norethind-eth estrad norethind-eth estrad mg norethindrone 0.35 mg let norethindrone 5 mg let norethin-estra-fe mg norethin-eth estrad 1 mg-5 mcg norg-ee /0.0 norg-ee /0.035 norg-ethin estra mg NORITATE 1% CREAM norlyroc 0.35 mg let NORMOSOL-M AND DEXTROSE 5% NORMOSOL-R IV SOLUTION NORMOSOL-R PH 7.4 IV SOLUTION NORMOSOL-R-DEXTROSE 5% IV SOLN NOROXIN NORPACE CR 100 MG CAPSULE NORPACE CR 0 MG CAPSULE NORTHERA 100 MG CAPSULE NORTHERA 0 MG CAPSULE NORTHERA 300 MG CAPSULE nortrel let nortrel 1-35 let nortrel let nortriptyline 10 mg/5 ml sol nortriptyline hcl 10 mg cap nortriptyline hcl mg cap nortriptyline hcl 50 mg cap nortriptyline hcl 75 mg cap NORVIR 100 MG SOFTGEL CAP NORVIR 100 MG TABLET NORVIR 80 MG/ML SOLUTION NOVACORT GEL NOVAREL 10,000 UNITS VIAL NOVOFINE 30G X 1/3" NEEDLES NOVOFINE 31 NOVOFINE G NEEDLES NOVOFINE AUTOCOVER 30G NEEDLE NOVOLIN UNIT/ML VIAL NOVOLIN N 100 UNITS/ML VIAL NOVOLIN R 100 UNITS/ML VIAL NOVOLOG 100 UNIT/ML CARTRIDGE NOVOLOG 100 UNIT/ML VIAL NOVOLOG 100 UNITS/ML FLEXPEN NOVOLOG MIX FLEXPEN SYRN NOVOLOG MIX VIAL NOVOTWIST NEEDLE 30G 8MM NOVOTWIST NEEDLE G 5MM NOXAFIL 40 MG/ML SUSPENSION NOXAFIL DR 100 MG TABLET np thyroid 30 mg let np thyroid 60 mg let np thyroid 90 mg let NUCORT LOTION NUEDEXTA -10 MG CAPSULE nulev 0.1 mg chewable melt NULOJIX 0 MG VIAL NUMOISYN LIQ NUPLAZID MG TABLET NUTRILIPID % IV FAT EMULSION NUTRILYTE II VIAL NUTRILYTE VIAL NUTROPIN AQ MG/2ML PEN CART NUTROPIN AQ NUSPIN 10 INJECTOR NUTROPIN AQ NUSPIN INJECTOR NUTROPIN AQ NUSPIN 5 INJECTOR NUTROPIN AQ PEN CARTRIDGE NUVARING VAGINAL RING NUVIGIL 0 MG TABLET NUVIGIL 0 MG TABLET NUVIGIL 0 MG TABLET NUVIGIL 50 MG TABLET nyamyc 100,000 units/gm powder NYMALIZE 60 MG/ ML SOLUTION nystatin 100,000 unit/gm cream nystatin 100,000 unit/gm powd nystatin 100,000 units/gm oint Comprehensive Formulary 1

119 nystatin 100,000 units/ml susp nystatin 500,000 unit oral nystatin-triamcinolone cream nystatin-triamcinolone ointm nystop 100,000 units/gm powder ocella 3 mg-0.03 mg let OCTAGAM 10% VIAL OCTAGAM 5% VIAL octreotide 1,000 mcg/ml vial octreotide acet 100 mcg/ml amp octreotide acet 0 mcg/ml vl octreotide acet 50 mcg/ml amp octreotide acet 500 mcg/ml amp ODEFSEY TABLET ODOMZO 0 MG CAPSULE OFEV 100 MG CAPSULE OFEV 0 MG CAPSULE ofloxacin 0.3% ear drops ofloxacin 0.3% eye drops ofloxacin 400 mg let ogestrel let olanzapine 10 mg let olanzapine 10 mg vial olanzapine mg let olanzapine 2.5 mg let olanzapine mg let olanzapine 5 mg let olanzapine 7.5 mg let olanzapine odt 10 mg let olanzapine odt mg let olanzapine odt mg let olanzapine odt 5 mg let olanzapine-fluoxetine 12- mg olanzapine-fluoxetine mg olanzapine-fluoxetine 3- mg olanzapine-fluoxetine 6- mg olanzapine-fluoxetine 6-50 mg olopatadine hcl 0.1% eye drops omega-3 ethyl esters 1 gm cap OMEPRAZOLE + SUS SYRSPEND omeprazole dr 10 mg capsule omeprazole dr mg capsule omeprazole dr 40 mg capsule omeprazole-bicarb -1,100 cap omeprazole-bicarb 40-1,100 cap OMNARIS 50 MCG NASAL SPRAY OMNITROPE 10 MG/1.5 ML CRTG OMNITROPE 5 MG/1.5 ML CRTG OMNITROPE 5.8 MG VIAL ONCASPAR 750 UNIT/ML VIAL ondansetron 4 mg/2 ml isecure ondansetron 4 mg/5 ml solution ondansetron 40 mg/ ml vial ondansetron hcl 24 mg let ondansetron hcl 4 mg let ondansetron hcl 4 mg/2 ml vial ondansetron hcl 8 mg let ondansetron odt 4 mg let ondansetron odt 8 mg let ONFI 10 MG TABLET ONFI 2.5 MG/ML SUSPENSION ONFI MG TABLET ONGLYZA 2.5 MG TABLET ONGLYZA 5 MG TABLET ONIVYDE MG/10 ML VIAL OPANA ER 10 MG TABLET OPANA ER MG TABLET OPANA ER MG TABLET OPANA ER 30 MG TABLET OPANA ER 40 MG TABLET OPANA ER 5 MG TABLET OPANA ER 7.5 MG TABLET OPDIVO 100 MG/10 ML VIAL OPDIVO 40 MG/4 ML VIAL opium tincture 10 mg/ml OPSUMIT 10 MG TABLET oralone 0.1% paste ORENCIA 0 MG VIAL ORFADIN 10 MG CAPSULE ORFADIN 2 MG CAPSULE ORFADIN 4 MG/ML SUSPENSION ORFADIN 5 MG CAPSULE ORKAMBI 0 MG-1 MG TABLET orphenadrine 30 mg/ml vial orphenadrine er 100 mg let orsythia- let oscimin 0.1 mg odt oscimin 0.1 mg let oscimin sl 0.1 mg let oscimin sr mg let OSMOPREP TABLET Comprehensive Formulary 1

120 OTIC CARE OTIC SOLUTION OTICIN HC DRO oto-end 10 sol otomax-hc dro oxacillin 1 gm add-vantage vl oxacillin 1 gm/ 50 ml inj oxycodon-acetaminophen oxycodon-acetaminophen oxycodone hcl 10 mg let oxycodone hcl 100 mg/5 ml soln oxymorphone hcl 5 mg let oxymorphone hcl er 10 mg oxymorphone hcl er mg oxymorphone hcl er mg oxymorphone hcl er 30 mg oxymorphone hcl er 40 mg oxacillin 10 gm vial oxacillin 2 gm add-vantage vl oxacillin 2 gm/ 50 ml inj oxaliplatin 100 mg powder vial oxaliplatin 100 mg/ ml vial oxaliplatin 50 mg powder vial oxaliplatin 50 mg/10 ml vial oxandrolone 10 mg let oxandrolone 2.5 mg let oxaprozin 600 mg let oxazepam 10 mg capsule oxazepam mg capsule oxazepam 30 mg capsule oxcarbazepine 0 mg let oxcarbazepine 300 mg let oxcarbazepine 300 mg/5 ml susp oxcarbazepine 600 mg let oxiconazole nitrate 1% cream OXISTAT 1% LOTION OXSORALEN 1% LOTION OXTELLAR XR 0 MG TABLET OXTELLAR XR 300 MG TABLET OXTELLAR XR 600 MG TABLET oxybutynin 5 mg let oxybutynin 5 mg/5 ml syrup oxybutynin cl er 10 mg let oxybutynin cl er mg let oxybutynin cl er 5 mg let oxycodone hcl mg let oxycodone hcl mg let oxycodone hcl 30 mg let oxycodone hcl 5 mg capsule oxycodone hcl 5 mg let oxycodone hcl 5 mg/5 ml soln oxycodone hcl er 10 mg let oxycodone hcl er mg let oxycodone hcl er mg let oxycodone hcl er 30 mg let oxycodone hcl er 40 mg let oxycodone hcl er 60 mg let oxycodone hcl er 80 mg let oxycodone-acetaminophen 10-5 oxycodone-acetaminophen 5-5 oxycodone-acetaminophn 5-5/5 oxycodone-aspirin oxycodone-ibuprofen OXYCONTIN 10 MG TABLET OXYCONTIN MG TABLET OXYCONTIN MG TABLET OXYCONTIN 30 MG TABLET OXYCONTIN 40 MG TABLET OXYCONTIN 60 MG TABLET OXYCONTIN 80 MG TABLET oxymorphone hcl 10 mg let oxymorphone hcl er 5 mg let oxymorphone hcl er 7.5 mg pacerone 100 mg let pacerone 0 mg let pacerone 400 mg let paclitaxel 100 mg/.7 ml vial paclitaxel 0 mg/ ml vial paclitaxel 30 mg/5 ml vial paclitaxel 300 mg/50 ml vial PAIN RELIEF PAD PATCH (RX) paliperidone er 1.5 mg let paliperidone er 3 mg let paliperidone er 6 mg let paliperidone er 9 mg let pamidronate 30 mg/10 ml vial pamidronate 60 mg/10 ml vial pamidronate 90 mg/10 ml vial pamidronate disod 30 mg vial pamidronate disod 90 mg vial PAMINE FQ KIT PANDEL 0.1% CREAM PANRETIN 0.1% GEL pantoprazole sod dr mg pantoprazole sod dr 40 mg PAREGORIC LIQUID paricalcitol 1 mcg capsule paricalcitol 2 mcg capsule Comprehensive Formulary 1

121 paricalcitol 2 mcg/ml vial paricalcitol 4 mcg capsule paricalcitol 5 mcg/ml vial paroex 0.12% oral rinse paromomycin 0 mg capsule paroxetine cr 12.5 mg let paroxetine cr mg let paroxetine er 37.5 mg let paroxetine hcl 10 mg let paroxetine hcl mg let paroxetine hcl 30 mg let PEGASYS PROCLICK 0 MCG/0.5 PEGINTRON 1 MCG KIT PEGINTRON 0 MCG KIT PEGINTRON 50 MCG KIT PEGINTRON 80 MCG KIT PEGINTRON REDIPEN 1 MCG PEGINTRON REDIPEN 1 MCG 4PK PEGINTRON REDIPEN 0 MCG PEGINTRON REDIPEN 0 MCG 4PK perindopril erbumine 2 mg perindopril erbumine 4 mg perindopril erbumine 8 mg periogard 0.12% oral rinse PERJETA 4 MG/ ML VIAL permethrin 5% cream perphen-amitrip 2 mg-10 mg perphen-amitrip 2 mg- mg perphen-amitrip 4 mg-10 mg paroxetine hcl 40 mg let PASER GRANULES 4 GM PACKET PATADAY 0.2% EYE DROPS PAXIL 10 MG/5 ML SUSPENSION PEGINTRON REDIPEN 50 MCG PEGINTRON REDIPEN 50 MCG 4PK PEGINTRON REDIPEN 80 MCG PEGINTRON REDIPEN 80 MCG 4PK perphen-amitrip 4 mg- mg perphen-amitrip 4 mg-50 mg perphenazine mg let perphenazine 2 mg let PAZEO 0.7% EYE DROPS pen g 1.2 million unit/2 ml perphenazine 4 mg let 33 PCE 333 MG TABLET pen g k 1 million unit/50 ml perphenazine 8 mg let 33 PCE 500 MG TABLET pen g k 2 million unit/50 ml pfizerpen million unit vial PEDIADERM AF KIT COMPLETE pen g k 3 million unit/50 ml pfizerpen 5 million units vial PEDIADERM HC KIT PEDIADERM TA KIT PEDIARIX 0.5 ML SYRINGE PEDVAXHIB VACCINE VIAL peg 3350 electrolyte soln peg 3350-electrolyte solution peg-3350 and electrolytes soln PEGANONE 0 MG TABLET PEGASYS 0 MCG/0.5 ML SYRINGE PEGASYS 0 MCG/0.5 ML SYRINGE PEGASYS 0 MCG/ML VIAL PEGASYS PROCLICK 5 MCG/ penicillin g k 5 million unit penicillin g na 5 million unit penicillin gk million unit penicillin vk 1 mg/5 ml soln penicillin vk 0 mg let penicillin vk 0 mg/5 ml soln penicillin vk 500 mg let PENTACEL VIAL KIT PENTAM 300 VIAL PENTASA 0 MG CAPSULE PENTASA 500 MG CAPSULE pentazocine-naloxone let pentoxifylline er 400 mg PERFOROMIST MCG/2 ML SOLN PERIKABIVEN IV EMULSION phenadoz 12.5 mg suppository phenadoz mg suppository phenazopyridine 100 mg phenazopyridine 0 mg phenelzine sulfate mg phenergan 12.5 mg suppository phenergan mg suppository phenergan 50 mg suppository phenobarbital 100 mg let phenobarbital mg let phenobarbital.2 mg let phenobarbital mg/5 ml elix phenobarbital 30 mg let phenobarbital.4 mg let Comprehensive Formulary 121

122 phenobarbital 60 mg let phenobarbital 64.8 mg let phenobarbital 97.2 mg let phenoxybenzamine hcl 10 mg cap phenylephrine 10% eye drops phenylephrine 2.5% eye drop PHENYTEK 0 MG CAPSULE pindolol 5 mg let pioglitazone hcl mg let pioglitazone hcl 30 mg let pioglitazone hcl mg let pioglitazone-glimepiride 30-2 pioglitazone-glimepiride 30-4 pioglitazone-metformin PORTRAZZA 800 MG/50 ML VIAL pot citrate-citric acid packet potassium meq let eff potassium cit-citric acid soln potassium citrate er 10 meq potassium citrate er meq potassium citrate er 5 meq 29 PHENYTEK 300 MG CAPSULE phenytoin 1 mg/5 ml susp phenytoin 50 mg infa phenytoin 50 mg let chew phenytoin 50 mg/ml vial phenytoin sod ext 100 mg cap phenytoin sod ext 0 mg cap phenytoin sod ext 300 mg cap philith mg let PHOSLYRA 667 MG/5 ML SOLUTION phospha 0 neutral let phosphasal let PHOSPHOLINE IODIDE 0.1% PHOTOFRIN 75 MG VIAL PHYSIOLYTE IRRIGATION SOLN PHYSIOSOL IRRIGATION SOLN PICATO 0.0% GEL PICATO 0.05% GEL pilocarpine 1% eye drops pilocarpine 2% eye drops pioglitazone-metformin piperacil-tazobact 2. gm vl piperacil-tazobact gm vl piperacil-tazobact 4.5 gm vial piperacil-tazobact 40.5 gram pirmella let pirmella let piroxicam 10 mg capsule piroxicam mg capsule PLASMA-LYTE 8 IV SOLUTION PLASMA-LYTE -DEXTROSE 5% PLASMA-LYTE A PH 7.4 SOLN. podocon- liquid podofilox 0.5% topical soln POLIBAR SUS 100% POLIBAR ACB KIT 96% polycin eye ointment polyethylene glycol 3350 powd potassium cl 10 meq/100 ml sol potassium cl 10% ( meq/ ml potassium cl 2 meq/ml vial potassium cl meq packet potassium cl meq/100 ml sol POTASSIUM CL MEQ- 0.% NACL potassium cl % (40 meq/ ml potassium cl meq eff potassium cl 40 meq/100 ml sol potassium cl er 10 meq capsule potassium cl er 10 meq let potassium cl er meq let potassium cl er 8 meq capsule potassium cl er 8 meq let POTIGA 0 MG TABLET POTIGA 300 MG TABLET pilocarpine 4% eye drops polymyxin b sulfate vial POTIGA 400 MG TABLET pilocarpine hcl 5 mg let 51 polymyxin b-tmp eye drops POTIGA 50 MG TABLET pilocarpine hcl 7.5 mg let 51 POMALYST 1 MG CAPSULE 29 pr benzoyl liq 7% wash pimozide 1 mg let 33 POMALYST 2 MG CAPSULE 29 PRADAXA 0 MG CAPSULE 42 pimozide 2 mg let 33 POMALYST 3 MG CAPSULE 29 PRADAXA 0 MG CAPSULE 42 pimtrea day let 64 POMALYST 4 MG CAPSULE 29 PRADAXA 75 MG CAPSULE 42 pindolol 10 mg let portia- let 64 pramcort cre 1-1% Comprehensive Formulary 1

123 pramipexole 0.1 mg let pramipexole 0. mg let pramipexole 0.5 mg let pramipexole 0.75 mg let pramipexole 1 mg let pramipexole 1.5 mg let pramipexole er mg let pramipexole er 0.75 mg let pramipexole er 1.5 mg let pramipexole er 2. mg let pramipexole er 3 mg let pramipexole er 3.75 mg let pramipexole er 4.5 mg let PRAMOSONE CREAM 1% prednisolone odt 10 mg let prednisolone odt mg let prednisolone odt 30 mg let prednisolone sod 1% eye drop prednisolone sod ph mg/5 ml prednisone 1 mg let prednisone 10 mg dose pack prednisone 10 mg let prednisone 2.5 mg let prednisone mg let prednisone 5 mg dose pack prednisone 5 mg let PREMPRO MG TABLET PREMPRO MG TABLET PRESERA AER prevalite packet prevalite powder PREVIDENT 1.1% GEL PREVIDENT % DRY MOUTH PREVIDENT 5000 PLUS CREAM PREVIDENT DENTAL RINSE previfem let PREZCOBIX 800 MG-0 MG TABLET PREZISTA 100 MG/ML SUSPENSION PRAMOSONE CREAM 1-2.5% PRAMOSONE LOT 1% PRAMOSONE LOT 2.5% PRAMOSONE OIN 1% PRAMOSONE OIN 2.5% prascion ra cream pravastatin sodium 10 mg pravastatin sodium mg pravastatin sodium 40 mg pravastatin sodium 80 mg prazosin 1 mg capsule prazosin 2 mg capsule prazosin 5 mg capsule PRED MILD 0.12% EYE DROPS PRED-G 1% EYE DROPS PRED-G S.O.P. EYE OINTMENT prednicarbate 0.1% cream prednicarbate 0.1% ointment prednisolone mg/5 ml soln prednisolone 5 mg/5 ml soln prednisolone ac 1% eye drop prednisone 5 mg/5 ml solution prednisone 5 mg/ml solution prednisone 50 mg let PREFEST TABLET PREGNYL 10,000 UNITS VIAL PREMARIN 0.3 MG TABLET PREMARIN 0. MG TABLET PREMARIN 0.6 MG TABLET PREMARIN 0.9 MG TABLET PREMARIN 1. MG TABLET PREMARIN MG VIAL PREMARIN VAGINAL CREAM- APPL PREMASOL 10% IV SOLUTION PREMASOL 6% IV SOLUTION PREMPHASE MG TABLET PREMPRO 0.3 MG-1.5 MG TABLET PREMPRO MG TABLET PREZISTA 0 MG TABLET PREZISTA 600 MG TABLET PREZISTA 75 MG TABLET PREZISTA 800 MG TABLET PRIFTIN 0 MG TABLET primaquine.3 mg let primidone 0 mg let primidone 50 mg let PRIMSOL 50 MG/5 ML ORAL SOLN PRISTIQ ER 100 MG TABLET PRISTIQ ER MG TABLET PRISTIQ ER 50 MG TABLET PRIVIGEN 10% VIAL PROAIR HFA 90 MCG INHALER PROAIR RESPICLICK INHAL POWDER probenecid 500 mg let probenecid-colchicine s procainamide 100 mg/ml vial procainamide 500 mg/ml vial PROCALAMINE IV SOLUTION Comprehensive Formulary 123

124 procentra 5 mg/5 ml solution 51 PROLIA 60 MG/ML SYRINGE 70 propranolol mg let prochlorperazine 10 mg 33 PROMACTA 12.5 MG TABLET 42 propranolol mg/5 ml soln prochlorperazine 10 mg/2 ml vl prochlorperazine mg supp prochlorperazine 5 mg let PROCORT CREAM PROCRIT 10,000 UNITS/ML VIAL PROCRIT 2,000 UNITS/ML VIAL PROCRIT,000 UNITS/ML VIAL PROCRIT 3,000 UNITS/ML VIAL PROCRIT 4,000 UNITS/ML VIAL PROCRIT 40,000 UNITS/ML VIAL PROCTOCORT SUP 30MG PROCTOFOAM AER HC 1% procto-med hc 2.5% cream procto-pak 1% cream PROMACTA MG TABLET PROMACTA 50 MG TABLET PROMACTA 75 MG TABLET promethazine 12.5 mg suppos promethazine 12.5 mg let promethazine mg suppository promethazine mg let promethazine mg/ml vial promethazine 50 mg suppository promethazine 50 mg let promethazine 50 mg/ml vial promethazine 6. mg/5 ml syrp promethazine vc syrup promethazine-phenylephrine syr propranolol 40 mg let propranolol 40 mg/5 ml soln propranolol 60 mg let propranolol 80 mg let propranolol er 1 mg capsule propranolol er 0 mg capsule propranolol er 60 mg capsule propranolol er 80 mg capsule propranolol-hctz 40- mg propranolol-hctz 80- mg propylthiouracil 50 mg let PROQUAD VIAL PROSOL % INJECTION PROSTIGMIN MG TABLET proctosol-hc 2.5% cream promethegan 12.5 mg suppos 24 protriptyline hcl 10 mg let 23 proctozone-hc 2.5% cream PROCYSBI DR MG CAPSULE PROCYSBI DR 75 MG CAPSULE PRODRIN TAB progesterone 100 mg capsule progesterone 0 mg capsule promethegan mg suppository promethegan 50 mg suppository propafenone hcl 0 mg let propafenone hcl 5 mg protriptyline hcl 5 mg let PROVENTIL HFA 90 MCG INHALER PULMICORT 0. MG/2 ML RESPUL PULMICORT 0.5 MG/2 ML RESPULE progesterone oil 50 mg/ml vl PROGLYCEM 50 MG/ML ORAL SUSP PROGRAF 0.5 MG CAPSULE PROGRAF 1 MG CAPSULE PROGRAF 5 MG CAPSULE PROGRAF 5 MG/ML AMPULE PROLASTIN C 1,000 MG VIAL PROLENSA 0.07% EYE DROPS PROLEUKIN MILLION UNIT VIAL propafenone hcl 300 mg propafenone hcl er 5 mg cap propafenone hcl er 5 mg cap propafenone hcl er 4 mg cap propantheline mg let proparacaine 0.5% eye drops propranolol 1 mg/ml vial propranolol 10 mg let PULMICORT 1 MG/2 ML RESPULE PULMICORT 0 MCG FLEXHALER PULMICORT 90 MCG FLEXHALER pulmosal neb 7% PULMOZYME 1 MG/ML AMPUL PURIXAN MG/ML ORAL SUSP pyrazinamide 500 mg let Comprehensive Formulary 124

125 pyridostigmine br 60 mg let pyridostigmine er 0 mg pyril d sus -5mg/5 pyril/phenyl sus -5mg/5 QUADRACEL DTAP-IPV VIAL quasense mg let quetiapine fumarate 100 mg quetiapine fumarate 0 mg ramipril 1. mg capsule ramipril 10 mg capsule ramipril 2.5 mg capsule ramipril 5 mg capsule RANEXA ER 1,000 MG TABLET RANEXA ER 500 MG TABLET ranitidine mg/ml syrup ranitidine 0 mg capsule ranitidine 0 mg let ranitidine 300 mg capsule RECOMBIVAX HB 10 MCG/ML VIAL RECOMBIVAX HB 40 MCG/ML VIAL RECOMBIVAX HB 5 MCG/0.5 ML SYR RECTIV 0.4% OINTMENT REGONOL 10 MG/2 ML AMPUL REGRANEX 0.01% GEL RELENZA 5 MG DISKHALER RELION NOVOLIN VIAL quetiapine fumarate mg quetiapine fumarate 300 mg quetiapine fumarate 400 mg ranitidine 300 mg let ranitidine hcl 0 mg/6 ml vl ranitidine hcl 50 mg/2 ml vial RAPAFLO 4 MG CAPSULE RAPAFLO 8 MG CAPSULE RELION NOVOLIN N 100 UNIT/ML RELION NOVOLIN R 100 UNIT/ML RELISTOR 12 MG/0.6 ML SYRINGE quetiapine fumarate 50 mg quinapril 10 mg let quinapril mg let quinapril 40 mg let 33 RAPAMUNE 0.5 MG TABLET RAPAMUNE 1 MG TABLET RAPAMUNE 1 MG/ML ORAL SOLN RAPAMUNE 2 MG TABLET RELISTOR 12 MG/0.6 ML VIAL RELISTOR 8 MG/0.4 ML SYRINGE RELPAX MG TABLET RELPAX 40 MG TABLET quinapril 5 mg let RAVICTI 1.1 GRAM/ML LIQUID REMICADE 100 MG VIAL 69 quinapril-hctz mg rea lo 39 cre 39% REMODULIN 1 MG/ML VIAL 75 quinapril-hctz mg READI-CAT 2 SUS 2.1% REMODULIN 10 MG/ML VIAL 75 quinapril-hctz - mg READI-CAT 2 SUS APPLE REMODULIN 2.5 MG/ML VIAL 75 quinidine gluc 80 mg/ml vial READI-CAT 2 SUS MOCHACCI REMODULIN 5 MG/ML VIAL 75 quinidine gluc er 4 mg quinidine sulf er 300 mg quinidine sulfate 0 mg quinidine sulfate 300 mg quinine sulfate 4 mg capsule QVAR 40 MCG ORAL INHALER QVAR 80 MCG ORAL INHALER RABAVERT RABIES VACCINE VIAL rabeprazole sod dr mg raloxifene hcl 60 mg let REBIF MCG/0.5 ML REBIF 44 MCG/0.5 ML REBIF REBIDOSE MCG/0.5 ML REBIF REBIDOSE 44 MCG/0.5 ML REBIF REBIDOSE TITRATION PACK REBIF TITRATION PACK reclipsen day let RECOMBIVAX HB 10 MCG/ML SYR RENVELA 0.8 GM POWDER PACKET RENVELA 2.4 GM POWDER PACKET RENVELA 800 MG TABLET repaglinide 0.5 mg let repaglinide 1 mg let repaglinide 2 mg let REPATHA 0 MG/ML SURECLICK REPATHA 0 MG/ML SYRINGE reprexain 10-0 mg let Comprehensive Formulary 1

126 reprexain 5-0 mg let rifampin 300 mg capsule RITUXAN 10 MG/ML VIAL 29 RESCRIPTOR 100 MG TABLET 36 rifampin iv 600 mg vial rivastigmine 1.5 mg capsule 21 RESCRIPTOR 0 MG TABLET reserpine 0.1 mg let reserpine 0. mg let RESTASIS 0.05% EYE EMULSION RETIN-A MICRO PUMP 0.08% GEL RETROVIR 0 MG/ ML VIAL REVLIMID 10 MG CAPSULE REVLIMID MG CAPSULE REVLIMID 2.5 MG CAPSULE REVLIMID MG CAPSULE REVLIMID MG CAPSULE REVLIMID 5 MG CAPSULE REXULTI 0. MG TABLET REXULTI 0.5 MG TABLET REXULTI 1 MG TABLET REXULTI 2 MG TABLET REXULTI 3 MG TABLET REXULTI 4 MG TABLET REYATAZ 0 MG CAPSULE REYATAZ 0 MG CAPSULE REYATAZ 300 MG CAPSULE REYATAZ 50 MG POWDER PACKET RHEUMATREX 2.5 MG TABLET RIAX AER 5.5% RIAX AER 9.5% ribavirin 0 mg capsule ribavirin 0 mg let RIDAURA 3 MG CAPSULE rifabutin 0 mg capsule RIFADIN IV 600 MG VIAL RIFAMATE CAPSULE rifampin 0 mg capsule RIFATER TABLET riluzole 50 mg let rimantadine hcl 100 mg let RINGERS IRRIGATION SOLUTION RINGER'S IV SOLUTION RIOMET 500 MG/5 ML SOLUTION risedronate sod dr 35 mg risedronate sodium 0 mg risedronate sodium 30 mg risedronate sodium 35 mg risedronate sodium 5 mg let RISPERDAL CONSTA 12.5 MG SYR RISPERDAL CONSTA MG SYR RISPERDAL CONSTA 37.5 MG SYR RISPERDAL CONSTA 50 MG SYR risperidone 0. mg odt risperidone 0. mg let risperidone 0.5 mg odt risperidone 0.5 mg let risperidone 1 mg odt risperidone 1 mg let risperidone 1 mg/ml solution risperidone 2 mg odt risperidone 2 mg let risperidone 3 mg odt risperidone 3 mg let risperidone 4 mg odt risperidone 4 mg let rivastigmine.3 mg/24hr ptch rivastigmine 3 mg capsule rivastigmine 4.5 mg capsule rivastigmine 4.6 mg/24hr patch rivastigmine 6 mg capsule rivastigmine 9.5 mg/24hr patch rizatriptan 10 mg odt rizatriptan 10 mg let rizatriptan 5 mg odt rizatriptan 5 mg let ropinirole hcl 0. mg let ropinirole hcl 0.5 mg let ropinirole hcl 1 mg let ropinirole hcl 2 mg let ropinirole hcl 3 mg let ropinirole hcl 4 mg let ropinirole hcl 5 mg let ropinirole hcl er 12 mg let ropinirole hcl er 2 mg let ropinirole hcl er 4 mg let ropinirole hcl er 6 mg let ropinirole hcl er 8 mg let ROSADAN KIT 0.75% rosadan 0.75% cream rosadan 0.75% gel ROSULA LIQ % rosuvastatin calcium 10 mg rosuvastatin calcium mg rosuvastatin calcium 40 mg rosuvastatin calcium 5 mg Comprehensive Formulary 1

127 ROTARIX VACCINE SUSPENSION ROTATEQ VACCINE roweepra 500 mg let roxicet 5-5 oral solution roxicet 5-5 let ROZEREM 8 MG TABLET SABRIL 500 MG POWDER PACKET SABRIL 500 MG TABLET SAIZEN 5 MG VIAL SAIZEN 8.8 MG CLICK.EASY CARTG SAVAYSA 30 MG TABLET SAVAYSA 60 MG TABLET SAVELLA 100 MG TABLET SAVELLA 12.5 MG TABLET SAVELLA MG TABLET SAVELLA 50 MG TABLET SAVELLA TITRATION PACK SCALACORT DK KIT SCAR PATCH PAD (RX) selegiline hcl 5 mg capsule selegiline hcl 5 mg let selenium sulfide 2.5% lotion SIGNIFOR 0.3 MG/ML AMPULE SIGNIFOR 0.6 MG/ML AMPULE SIGNIFOR 0.9 MG/ML AMPULE sildenafil mg let SILENOR 3 MG TABLET SILENOR 6 MG TABLET SILVER NITRATE 0.5% SOLN SILVER NITRATE 10% SOLUTION SILVER NITRATE % SOLUTION SILVER NITRATE 50% SOLUTION SAIZEN 8.8 MG VIAL 60 SELZENTRY 0 MG TABLET 36 silver sulfadiazine 1% cream salacyn 6% cream salicylic acid 6% cream salicylic acid 6% gel salicylic acid 6% shampoo salsalate 500 mg let salsalate 750 mg let SAMSCA MG TABLET SAMSCA 30 MG TABLET SANCUSO 3.1 MG/24 HR PATCH SELZENTRY 300 MG TABLET SEMPREX-D 8 MG-60 MG CAPSULE SENSIPAR 30 MG TABLET SENSIPAR 60 MG TABLET SENSIPAR 90 MG TABLET SEREVENT DISKUS 50 MCG SEROQUEL XR 0 MG TABLET SEROQUEL XR 0 MG TABLET SEROQUEL XR 300 MG TABLET SIMBRINZA 1%-0.2% EYE DROPS SIMULECT 10 MG VIAL SIMULECT MG VIAL simvastatin 10 mg let simvastatin mg let simvastatin 40 mg let simvastatin 5 mg let simvastatin 80 mg let sirolimus 0.5 mg let SANDIMMUNE 100 MG/ML SOLN SANDOSTATIN LAR DEPOT 10 MG KT SANDOSTATIN LAR DEPOT MG KT SEROQUEL XR 400 MG TABLET SEROQUEL XR 50 MG TABLET SEROSTIM 4 MG VIAL SEROSTIM 5 MG VIAL SEROSTIM 6 MG VIAL sirolimus 1 mg let sirolimus 2 mg let SIRTURO 100 MG TABLET SKLICE 0.5% LOTION sod citrate-citric acid soln SANDOSTATIN LAR DEPOT 30 MG KT SANTYL OINTMENT SAPHRIS 10 MG TAB SL BLK CHERY SAPHRIS 2.5 MG TAB SL BLK CHRY SAPHRIS 5 MG TAB SL BLK CHERRY SAVAYSA MG TABLET sertraline mg/ml oral conc sertraline hcl 100 mg let sertraline hcl mg let sertraline hcl 50 mg let setlakin 0. mg-0.03 mg sf 1.1% gel sf 5000 plus cream sharobel 0.35 mg let sod polystyren sulf g/60 ml sod sul/sulf kit sodium bicarb 4.2% abbjct sodium bicarb 4.2% vial sodium bicarb 7.5% abboject sodium bicarb 8.4% abboject sodium chlor neb 10% Comprehensive Formulary 1

128 sodium chlor neb 3% 73 SOMAVERT MG VIAL 66 SPRYCEL 50 MG TABLET 30 sodium chlor neb 7% 73 SOMAVERT MG VIAL 66 SPRYCEL 70 MG TABLET 30 sodium chloride 0.% soln 80 SOMAVERT 30 MG VIAL 66 SPRYCEL 80 MG TABLET 30 sodium chloride 0.9% irrig. sorine 1 mg let sps gm/60 ml suspension 80 sodium chloride 0.9% solution 80 sorine 0 mg let sps 30 gm/1 ml enema 80 sodium chloride 0.9% vial 80 sorine 240 mg let sronyx mg let 64 sodium chloride 3% iv soln 80 sorine 80 mg let SSD 1% CREAM sodium chloride 4 meq/ml vl 80 sotalol 1 mg let stannous fluor 0.63% rinse 51 sodium chloride 5% iv soln 80 sotalol 0 mg let stavudine 1 mg/ml solution 36 sodium cl 2.5 meq/ml vial 80 sotalol 240 mg let stavudine mg capsule 36 sodium fluoride 0.5 mg(1.1 mg) sodium fluoride 0.5 mg/ml drop sodium fluoride 1 mg (2.2 mg) SODIUM LACTATE 5 MEQ/ML VIAL sodium phenylbutyrate powder sotalol 80 mg let sotalol af 1 mg let sotalol af 0 mg let sotalol af 80 mg let SOVALDI 400 MG TABLET SPECTRACEF 400 MG DOSE PACK TB SPIRIVA MCG CP- HANDIHALER stavudine mg capsule stavudine 30 mg capsule stavudine 40 mg capsule sterile water for irrigation STIMATE 1.5 MG/ML NASAL SPRAY STIOLTO RESPIMAT INHAL SPRAY STIVARGA 40 MG TABLET sodium polystyrene sulf powder sodium sulf-sulfur cleanser solia SOLTAMOX 10 MG/5 ML SOLN SOLU-CORTEF 1,000 MG VIAL SOLU-CORTEF 100 MG VIAL SOLU-CORTEF 0 MG VIAL SOLU-CORTEF 500 MG VIAL SOLU-MEDROL 2,000 MG VIAL SOLU-MEDROL 500 MG VIAL SOMATULINE DEPOT 1 MG/0.5 ML SOMATULINE DEPOT 60 MG/0.2 ML SPIRIVA RESPIMAT 1. MCG INH SPIRIVA RESPIMAT 2.5 MCG INH spironolactone 100 mg let spironolactone mg let spironolactone 50 mg let spironolactone-hctz - SPORANOX 10 MG/ML SOLUTION sprintec day let SPRITAM 1,000 MG TABLET SPRITAM 0 MG TABLET SPRITAM 500 MG TABLET SPRITAM 750 MG TABLET STRATTERA 10 MG CAPSULE STRATTERA 100 MG CAPSULE STRATTERA MG CAPSULE STRATTERA MG CAPSULE STRATTERA 40 MG CAPSULE STRATTERA 60 MG CAPSULE STRATTERA 80 MG CAPSULE streptomycin sulf 1 gm vial STRIANT 30 MG MUCOADHESIVE STRIBILD TABLET STRIVERDI RESPIMAT INHAL SPRAY SUBOXONE 12 MG-3 MG SL FILM SOMATULINE DEPOT 90 MG/0.3 ML SOMAVERT 10 MG VIAL SOMAVERT MG VIAL SPRYCEL 100 MG TABLET SPRYCEL 0 MG TABLET SPRYCEL MG TABLET SUBOXONE 2 MG-0.5 MG SL FILM SUBOXONE 4 MG-1 MG SL FILM SUBOXONE 8 MG-2 MG SL FILM Comprehensive Formulary 1

129 SUCRAID 8,500 UNITS/ML SOLN sucralfate 1 gm let sulf/sunscrn kit 9-4.5% sulfacetamide 10% eye drops sulfacetamide 10% eye ointment sulfacetamide sod 10% top susp sulfadiazine 500 mg let sumatriptan succ mg let sumatriptan succ 50 mg let SUMAXIN CP KIT SUPRAX 100 MG TABLET CHEWABLE SUPRAX 0 MG TABLET CHEWABLE SUPRAX 400 MG CAPSULE SUPRAX 500 MG/5 ML SUSPENSION SYNTHROID 7 MCG TABLET SYNTHROID 0 MCG TABLET SYNTHROID 5 MCG TABLET SYNTHROID 0 MCG TABLET SYNTHROID MCG TABLET SYNTHROID 300 MCG TABLET SYNTHROID 50 MCG TABLET SYNTHROID 75 MCG TABLET SYNTHROID 88 MCG TABLET sulfamethoxazole-tmp ds let sulfamethoxazole-tmp inj vial sulfamethoxazole-tmp ss let sulfamethoxazole-tmp susp SULFAMYLON 8.5% CREAM sulfasalazine 500 mg let sulfasalazine dr 500 mg sulfatrim pediatric suspension sulf-pred 10-0.% eye drops sulindac 0 mg let sulindac 0 mg let SUMADAN KIT SUMADAN XLT KIT 9-4.5% sumatriptan mg nasal spray sumatriptan 4 mg/0.5 ml cart sumatriptan 4 mg/0.5 ml inject sumatriptan 5 mg nasal spray sumatriptan 6 mg/0.5 ml inject sumatriptan 6 mg/0.5 ml refill sumatriptan 6 mg/0.5 ml syrng sumatriptan 6 mg/0.5 ml vial sumatriptan succ 100 mg let SUPREP BOWEL PREP KIT SUSTIVA 0 MG CAPSULE SUSTIVA 50 MG CAPSULE SUSTIVA 600 MG TABLET SUTENT 12.5 MG CAPSULE SUTENT MG CAPSULE SUTENT 37.5 MG CAPSULE SUTENT 50 MG CAPSULE SYLATRON 0 MCG KIT SYLATRON 300 MCG KIT SYLATRON 600 MCG KIT symax-sr mg let SYMBICORT MCG INHALER SYMBICORT MCG INHALER SYMLINPEN 1 PEN INJECTOR SYMLINPEN 60 PEN INJECTOR SYNAGIS 100 MG/1 ML VIAL SYNAGIS 50 MG/0.5 ML VIAL SYNAREL 2 MG/ML NASAL SPRAY SYNERA PATCH SYNERCID 500 MG VIAL SYNRIBO 3.5 MG/ML VIAL SYNTHROID 100 MCG TABLET SYNTHROID 2 MCG TABLET SYNTHROID 1 MCG TABLET SYPRINE 0 MG CAPSULE TABLOID 40 MG TABLET tacrolimus 0.03% ointment tacrolimus 0.1% ointment tacrolimus 0.5 mg capsule tacrolimus 1 mg capsule tacrolimus 5 mg capsule TAFINLAR 50 MG CAPSULE TAFINLAR 75 MG CAPSULE TAGITOL V SUS 40% TAGRISSO 40 MG TABLET TAGRISSO 80 MG TABLET TALWIN 30 MG/ML VIAL TAMIFLU 30 MG CAPSULE TAMIFLU MG CAPSULE TAMIFLU 6 MG/ML SUSPENSION TAMIFLU 75 MG CAPSULE tamoxifen 10 mg let tamoxifen mg let tamsulosin hcl 0.4 mg capsule TARCEVA 100 MG TABLET TARCEVA 0 MG TABLET TARCEVA MG TABLET TARGRETIN 1% GEL tarina fe 1- let TASIGNA 0 MG CAPSULE Comprehensive Formulary 129

130 TASIGNA 0 MG CAPSULE tazicef 1 gm add-vantage vial tazicef 1 gm/50 ml bag tazicef 1 gram vial tazicef 2 gm add-vantage 30 telmisartan-amlodipine 80-5 mg telmisartan-hctz mg tb telmisartan-hctz mg tb tetrabenazine 12.5 mg let tetrabenazine mg let tetracaine 0.5% eye drops tetracycline 0 mg capsule tetracycline 500 mg capsule tazicef 2 gram vial telmisartan-hctz 80- mg tetravisc 0.5% eye drops tazicef 6 gram vial temazepam mg capsule 77 tetravisc forte 0.5% eye drops TAZORAC 0.05% CREAM 54 temazepam.5 mg capsule 77 TEV-TROPIN 5 MG VIAL 60 TAZORAC 0.05% GEL 54 temazepam 30 mg capsule 77 TEXACORT 2.5% SOLUTION TAZORAC 0.1% CREAM 54 temazepam 7.5 mg capsule 77 THALOMID 100 MG CAPSULE 30 TAZORAC 0.1% GEL 54 tencon 50-5 mg let THALOMID 0 MG CAPSULE 30 TAZTIA XT 1 MG CAPSULE TAZTIA XT 0 MG CAPSULE TAZTIA XT 240 MG CAPSULE TAZTIA XT 300 MG CAPSULE TAZTIA XT 360 MG CAPSULE TECENTRIQ 1,0 MG/ ML VIAL TEFLARO 400 MG VIAL TEFLARO 600 MG VIAL TEKTURNA 0 MG TABLET TEKTURNA 300 MG TABLET 30 teniposide 50 mg/5 ml ampule TENIVAC SYRINGE terazosin 1 mg capsule terazosin 10 mg capsule terazosin 2 mg capsule terazosin 5 mg capsule terbinafine hcl 0 mg let terbutaline sulf 1 mg/ml vial terbutaline sulfate 2.5 mg terbutaline sulfate 5 mg THALOMID 0 MG CAPSULE THALOMID 50 MG CAPSULE THEO-24 ER 100 MG CAPSULE THEO-24 ER 0 MG CAPSULE THEO-24 ER 300 MG CAPSULE THEO-24 ER 400 MG CAPSULE theochron er 100 mg let theochron er 0 mg let theochron er 300 mg let theophylline 400 mg/500 ml d5w TEKTURNA HCT MG TAB TEKTURNA HCT 0- MG TABLET TEKTURNA HCT MG TAB TEKTURNA HCT 300- MG TABLET telmisartan mg let telmisartan 40 mg let terconazole 0.4% cream terconazole 0.8% cream terconazole 80 mg suppository testosteron cyp 1,000 mg/10 ml testosteron cyp 2,000 mg/10 ml testosterone 12.5 mg/1. gram theophylline 80 mg/ ml soln theophylline er 100 mg let theophylline er 0 mg let theophylline er 300 mg theophylline er 400 mg let theophylline er 0 mg theophylline er 600 mg let THERACYS 81 MG VIAL telmisartan 80 mg let telmisartan-amlodipine telmisartan-amlodipine 40-5 mg telmisartan-amlodipine testosterone mg/2.5 gm pkt testosterone 50 mg/5 gram pkt testosterone enan 0 mg/ml TETANUS DIPHTHERIA TOXOIDS thioridazine 10 mg let thioridazine 100 mg let thioridazine mg let thioridazine 50 mg let thiotepa mg vial 30 Comprehensive Formulary 0

131 thiothixene 1 mg capsule tl-fluorivite chewable let 80 topotecan hcl 4 mg vial 30 thiothixene 10 mg capsule thiothixene 2 mg capsule thiothixene 5 mg capsule THYMOGLOBULIN MG VIAL THYROLAR-1 STRENGTH TABLET THYROLAR-1/2 STRENGTH TAB THYROLAR-1/4 STRENGTH TAB THYROLAR-2 STRENGTH TABLET THYROLAR-3 STRENGTH TABLET tiagabine hcl 2 mg let tiagabine hcl 4 mg let TIGAN 100 MG/ML VIAL TIKOSYN 1 MCG CAPSULE TIKOSYN 0 MCG CAPSULE TIKOSYN 500 MCG CAPSULE tilia fe let timolol 0.% eye drops timolol 0.% gel-solution timolol 0.5% eye drops timolol 0.5% gel-solution timolol maleate 10 mg let timolol maleate mg let timolol maleate 5 mg let tinidazole 0 mg let tinidazole 500 mg let TIVICAY 10 MG TABLET TIVICAY MG TABLET TIVICAY 50 MG TABLET tizanidine hcl 2 mg capsule tizanidine hcl 2 mg let tizanidine hcl 4 mg capsule tizanidine hcl 4 mg let tizanidine hcl 6 mg capsule TOBI PODHALER MG INHALE CAP TOBRADEX EYE OINTMENT TOBRADEX ST EYE DROPS tobramycin 0.3% eye drops tobramycin 1.2 gm vial tobramycin 1.2 gram/30 ml vial tobramycin 10 mg/ml vial tobramycin 300 mg/5 ml ampule tobramycin 80 mg/100 ml ns tobramycin 80 mg/2 ml vial tobramycin-dexameth ophth susp TOBREX 0.3% EYE OINTMENT tolazamide 0 mg let tolazamide 500 mg let tolbutamide 500 mg let tolcapone 100 mg let tolmetin sodium 0 mg tolmetin sodium 400 mg cap tolmetin sodium 600 mg tolterodine tart er 2 mg cap tolterodine tart er 4 mg cap tolterodine tartrate 1 mg tolterodine tartrate 2 mg topiramate 100 mg let topiramate mg sprinkle cap topiramate 0 mg let topiramate mg sprinkle cap topiramate mg let topiramate 50 mg let toposar 1,000 mg/50 ml vial toposar 100 mg/5 ml vial toposar 500 mg/ ml vial topotecan hcl 4 mg/4 ml vial TORISEL MG KIT torsemide 10 mg let torsemide 100 mg let torsemide mg let torsemide mg/2 ml vial torsemide 5 mg let torsemide 50 mg/5 ml vial TOUJEO SOLOSTAR 300 UNITS/ML TOVIAZ ER 4 MG TABLET TOVIAZ ER 8 MG TABLET TPN ELECTROLYTES VIAL TRACLEER 1 MG TABLET TRACLEER 62.5 MG TABLET TRADJENTA 5 MG TABLET tramadol er 100 mg let tramadol er 0 mg let tramadol er 300 mg let tramadol hcl 50 mg let tramadol hcl er 100 mg let tramadol hcl er 0 mg let tramadol hcl er 300 mg let tramadol-acetaminophn trandolapril 1 mg let trandolapril 2 mg let trandolapril 4 mg let trandolapr-verapam er mg trandolapr-verapam er 2-0 mg trandolapr-verapam er mg trandolapr-verapam er mg Comprehensive Formulary 1

132 tranexamic acid 1,000 mg/10 ml tranexamic acid 0 mg let TRANSDERM-SCOP 1.5 MG/3 DAY tranylcypromine sulf 10 mg TRAVASOL 10% SOLN VIAFLEX TRAVATAN Z 0.004% EYE DROP travoprost 0.004% eye drop trazodone 100 mg let trazodone 0 mg let trazodone 300 mg let trazodone 50 mg let TREANDA 100 MG VIAL TREANDA 0 MG/2 ML VIAL TREANDA MG VIAL TREANDA MG/0.5 ML VIAL TRECATOR 0 MG TABLET TRELSTAR. MG SYRINGE TRELSTAR.5 MG VIAL tretinoin gel micro 0.04% pump tretinoin gel micro 0.1% pump TREXALL 10 MG TABLET TREXALL MG TABLET TREXALL 5 MG TABLET TREXALL 7.5 MG TABLET trezix mg capsule triamcinolone 0.0% cream triamcinolone 0.0% lotion triamcinolone 0.0% oint triamcinolone 0.1% cream triamcinolone 0.1% lotion triamcinolone 0.1% ointment triamcinolone 0.1% paste triamcinolone 0.1 mg/g spray triamcinolone 0.5% cream triamcinolone 0.5% ointment triamcinolone mcg nasal spr trifluoperazine 5 mg let trifluridine 1% eye drops trihexyphenidyl 2 mg let trihexyphenidyl 2 mg/5 ml elx trihexyphenidyl 5 mg let tri-legest fe- day let tri-linyah let tri-lo-estarylla let tri-lo-marzia let trilyte with flavor packets trimethobenzamide 300 mg cap trimethoprim 100 mg let trimipramine maleate 100 mg cp trimipramine maleate mg cap trimipramine maleate 50 mg cap trinessa lo let trinessa let TRINTELLIX 10 MG TABLET TRELSTAR 3.75 MG SYRINGE TRELSTAR DEPOT 3.75 MG VIAL TRELSTAR LA. MG VIAL TRESIBA FLEXTOUCH 100 UNITS/ML TRESIBA FLEXTOUCH 0 UNITS/ML tretinoin 0.01% gel tretinoin 0.0% cream tretinoin 0.0% gel tretinoin 0.05% cream tretinoin 0.05% gel tretinoin 0.1% cream tretinoin 10 mg capsule triamterene-hctz mg cp triamterene-hctz mg tb triamterene-hctz 50- mg cap triamterene-hctz mg trianex 0.05% ointment triazolam 0.1 mg let triazolam 0. mg let triderm 0.1% cream tri-estarylla let trifluoperazine 1 mg let trifluoperazine 10 mg let trifluoperazine 2 mg let TRINTELLIX MG TABLET TRINTELLIX 5 MG TABLET triple-vit w-fluor 0. mg/ml tri-previfem let TRISENOX 10 MG/10 ML AMPULE tri-sprintec let TRIUMEQ TABLET tri-vit-fluor 0. mg/ml drop tri-vit-fluor 0.5 mg/ml drop tri-vit-fluor-iron 0. mg/ml trivora- let TROPHAMINE 10% IV SOLUTION TROPHAMINE 6% IV SOLUTION tropicamide 0.5% eye drops Comprehensive Formulary 2

133 tropicamide 1% eye drops UNITHROID 2 MCG TABLET valacyclovir hcl 1 gram let 36 trospium chloride mg let trospium chloride er 60 mg cap TRULICITY 0.75 MG/0.5 ML PEN UNITHROID 1 MCG TABLET UNITHROID 7 MCG TABLET UNITHROID 0 MCG TABLET UNITHROID 5 MCG TABLET UNITHROID 0 MCG TABLET valacyclovir hcl 500 mg let VALCHLOR 0.0% GEL VALCYTE 50 MG/ML SOLUTION valganciclovir 0 mg let valproate sod 500 mg/5 ml vl TRULICITY 1.5 MG/0.5 ML PEN 40 UNITHROID MCG TABLET 66 valproic acid 0 mg capsule TRUMENBA 1 MCG/0.5 ML VACCIN TRUVADA 100 MG-0 MG TABLET TRUVADA 3 MG-0 MG TABLET TRUVADA 7 MG-0 MG TABLET TRUVADA 0 MG-300 MG TABLET TUDORZA PRESSAIR 400 MCG INH TWINRIX VACCINE VIAL TYBOST 0 MG TABLET TYGACIL 50 MG VIAL TYKERB 0 MG TABLET TYPHIM VI MCG/0.5 ML SYRNG TYPHIM VI MCG/0.5 ML VIAL TYSABRI 300 MG/ ML VIAL TYVASO 1.74 MG/2.9 ML SOLUTION TYZEKA 600 MG TABLET TYZINE PEDIATRIC 0.05% DROP ULORIC 40 MG TABLET ULORIC 80 MG TABLET ULTRAVATE X KIT % UNASYN GM VIAL UNASYN 3 GM VIAL UNITHROID 100 MCG TABLET UNITHROID 300 MCG TABLET UNITHROID 50 MCG TABLET UNITHROID 75 MCG TABLET UNITHROID 88 MCG TABLET UNITUXIN.5 MG/ 5 ML VIAL ur n-c let URAMAXIN CREAM % URAMAXIN GEL % URAMAXIN LOT % URAMAXIN % FOAM URAMAXIN GT GEL % urea cream % urea lot % urea 40% gel urea cream 39% urea emu 50% urea hydrati aer 35% urea nail gel % UREA NAIL KIT URELLE TABLET UREVAZ CRE 44% urin d.s. let URO-L TABLET ursodiol 0 mg let ursodiol 300 mg capsule ursodiol 500 mg let ustell capsule UVADEX MCG/ML VIAL VAGIFEM 10 MCG VAGINAL TAB valproic acid 0 mg/5 ml soln valsartan 0 mg let valsartan 0 mg let valsartan 40 mg let valsartan 80 mg let valsartan-hctz mg valsartan-hctz 0- mg valsartan-hctz mg valsartan-hctz 0- mg valsartan-hctz mg vanco 500 mg/100 ml-0.9% nacl vanco 750 mg/0 ml-0.9% nacl vancomycin 1 g/0ml-0.9% nacl vancomycin 1 gm vial vancomycin 500 mg a-v vial vancomycin 750 mg/0 ml bag vancomycin hcl 10 gm vial vancomycin hcl 1 mg capsule vancomycin hcl 1g/0 ml bag vancomycin hcl 0 mg capsule vancomycin hcl 5 gm vial vancomycin hcl 750 mg vial Comprehensive Formulary 3

134 vancomycin-d5w 500 mg/100 ml VANDAZOLE VAGINAL 0.75% GEL VAQTA UNITS/0.5 ML SYRINGE VAQTA 50 UNITS/ML SYRINGE VARIBAR PST PUDDING venlafaxine hcl er 75 mg cap venlafaxine hcl er 75 mg VENTAVIS 10 MCG/1 ML SOLUTION VENTAVIS MCG/1 ML SOLUTION VENTOLIN HFA 90 MCG INHALER VGO 30 DISPOSABLE DEVICE VGO 40 DISPOSABLE DEVICE VIBERZI 100 MG TABLET VIBERZI 75 MG TABLET vicodin mg let vicodin es mg let vicodin hp mg let VARIBAR HONE SUS 40% VARIBAR NECT SUS 40% VARIBAR THIN SUS HONEY VARIBAR THIN SUS LIQUID VARIVAX VACCINE WITH DILUENT 69 VERAMYST.5 MCG NASAL SPRAY verapamil 1 mg let verapamil 2.5 mg/ml ampul verapamil 360 mg cap pellet verapamil 40 mg let 76 VICTOZA 3-PAK MG/3 ML PEN VICTRELIS 0 MG CAPSULE VIDAZA 100 MG VIAL VIDEX 2 GM PEDIATRIC SOLN VIDEX 4 GM PEDIATRIC SOLN VARIZIG 1 UNIT/1.2 ML VIAL 69 verapamil 80 mg let VIGAMOX 0.5% EYE DROPS VASCEPA 1 GM CAPSULE verapamil er 1 mg capsule VIIBRYD 10 MG TABLET 23 VECTIBIX 100 MG/5 ML VIAL VECTIBIX 400 MG/ ML VIAL VELCADE 3.5 MG VIAL velivet day let VELPHORO 500 MG CHEWABLE TAB VELTIN 1.2 %-0.0 % GEL VENCLEXTA 10 MG TABLET VENCLEXTA 100 MG TABLET VENCLEXTA 50 MG TABLET VENCLEXTA STARTING PACK venlafaxine hcl 100 mg let venlafaxine hcl mg let venlafaxine hcl 37.5 mg let venlafaxine hcl 50 mg let venlafaxine hcl 75 mg let verapamil er 1 mg let verapamil er 0 mg capsule verapamil er 0 mg let verapamil er 240 mg capsule verapamil er 240 mg let verapamil er pm 100 mg capsule verapamil er pm 0 mg capsule verapamil er pm 300 mg capsule verapamil sr 1 mg capsule verapamil sr 0 mg capsule verapamil sr 240 mg capsule VEREGEN % OINTMENT VERSACLOZ 50 MG/ML SUSPENSION VIIBRYD 10- MG STARTER PACK VIIBRYD MG STARTER PK VIIBRYD MG TABLET VIIBRYD 40 MG TABLET VIMOVO DR 375- MG TABLET VIMOVO DR 500- MG TABLET VIMPAT 10 MG/ML SOLUTION VIMPAT 100 MG TABLET VIMPAT 0 MG TABLET VIMPAT 0 MG TABLET VIMPAT 0 MG/ ML VIAL VIMPAT 50 MG TABLET vinblastine 1 mg/ml vial venlafaxine hcl er 0 mg cap 23 VESICARE 10 MG TABLET 57 vincasar pfs 1 mg/ml vial 30 venlafaxine hcl er 0 mg 23 VESICARE 5 MG TABLET 57 vincristine 1 mg/ml vial 30 venlafaxine hcl er 5 mg 23 vestura 3 mg-0.02 mg let 64 vinorelbine 10 mg/ml vial 30 venlafaxine hcl er 37.5 mg cap 23 VEXOL 1% EYE DROPS vinorelbine 50 mg/5 ml vial 30 venlafaxine hcl er 37.5 mg 23 VGO DISPOSABLE DEVICE viorele day let 64 Comprehensive Formulary 4

135 VIRACEPT 0 MG TABLET 36 warfarin sodium 10 mg let 42 XERAC AC 6.% SOLUTION 54 VIRACEPT 6 MG TABLET 36 warfarin sodium 2 mg let 42 XGEVA 1 MG/1.7 ML VIAL 70 VIRAZOLE 6 GM VIAL 76 warfarin sodium 2.5 mg let 42 XIAFLEX 0.9 MG VIAL VIREAD 0 MG TABLET 36 warfarin sodium 3 mg let 42 XIFAXAN 0 MG TABLET VIREAD 0 MG TABLET 36 warfarin sodium 4 mg let 42 XIFAXAN 0 MG TABLET VIREAD 0 MG TABLET VIREAD 300 MG TABLET VIREAD POWDER virt-phos 0 neutral let virtrate-2 solution warfarin sodium 5 mg let warfarin sodium 6 mg let warfarin sodium 7.5 mg let WELCHOL 3.75G PACKET WELCHOL 6 MG TABLET XIGDUO XR 10 MG-1,000 MG TAB XIGDUO XR 10 MG-500 MG TABLET XIGDUO XR 5 MG-1,000 MG TABLET virtrate-k solution vitamins a,c,d & fluoride drop VITEKTA 0 MG TABLET VITEKTA 85 MG TABLET VIVITROL 380 MG VIAL + DILUENT VOLTAREN 1% GEL voriconazole 0 mg let voriconazole 0 mg vial voriconazole 40 mg/ml susp voriconazole 50 mg let VOTRIENT 0 MG TABLET VP-PNV-DHA CAPSULE VPRIV 400 UNITS VIAL VRAYLAR 1.5 MG CAPSULE VRAYLAR 1.5 MG-3 MG PACK VRAYLAR 3 MG CAPSULE VRAYLAR 4.5 MG CAPSULE VRAYLAR 6 MG CAPSULE vyfemla let VYTONE CREAM 1-1.9% VYTORIN MG TABLET VYTORIN 10- MG TABLET VYTORIN MG TABLET VYTORIN MG TABLET warfarin sodium 1 mg let wera 0.5/0.035 mg let westhroid 1.75 mg let westhroid 0 mg let westhroid 6. mg let westhroid. mg let westhroid 2.5 mg let westhroid 5 mg let westhroid 0 mg let westhroid.5 mg let westhroid 5 mg let westhroid.75 mg let westhroid mg let westhroid 81. mg let westhroid 97.5 mg let wymzya fe chewable let XALKORI 0 MG CAPSULE XALKORI 0 MG CAPSULE XARELTO 10 MG TABLET XARELTO MG TABLET XARELTO MG TABLET XARELTO STARTER PACK XARTEMIS XR MG TABLET XENADERM OINTMENT XEOMIN 100 UNITS VIAL XEOMIN 50 UNITS VIAL XIGDUO XR 5 MG-500 MG TABLET XOLAIR 0 MG VIAL XOPENEX HFA MCG INHALER XTANDI 40 MG CAPSULE xulane patch xylon 10-0 mg let XYREM 500 MG/ML ORAL SOLUTION YERVOY 0 MG/40 ML VIAL YERVOY 50 MG/10 ML VIAL YF-VAX 1 DOSE VIAL YONDELIS 1 MG VIAL zafirlukast 10 mg let zafirlukast mg let zaleplon 10 mg capsule zaleplon 5 mg capsule ZALTRAP 100 MG/4 ML VIAL ZALTRAP 0 MG/8 ML VIAL ZAMICET 10-5 MG/ ML SOLN ZANOSAR 1 GM POWDER VIAL ZARXIO 300 MCG/0.5 ML SYRINGE ZARXIO 0 MCG/0.8 ML SYRINGE ZAVESCA 100 MG CAPSULE Comprehensive Formulary 5

136 zazole 0.8% vaginal cream zazole vaginal 0.4% cream zebutal mg capsule ZEGERID MG PACKET ZEGERID 40 MG PACKET ZELAPAR 1. MG ODT TABLET ZELBORAF 240 MG TABLET ZEMAIRA 1,000 MG VIAL zenatane 10 mg capsule zenatane mg capsule zenatane 30 mg capsule zenatane 40 mg capsule zenchent 0.4 mg-35 mcg let zenchent fe let chewable ZENPEP DR 10,000 UNITS CAPSULE ZINACEF 1.5 GRAM/50 ML ZIOPTAN 0.00% EYE DROPS ziprasidone hcl mg capsule ziprasidone hcl 40 mg capsule ziprasidone hcl 60 mg capsule ziprasidone hcl 80 mg capsule ZIRGAN 0.% OPHTHALMIC GEL ZMAX 2 G/60 ML ORAL SUSPENSION ZOLADEX 10.8 MG IMPLANT SYRN ZOLADEX 3.6 MG IMPLANT SYRN zoledronic acid 4 mg vial zoledronic acid 4 mg/100 ml zoledronic acid 4 mg/5 ml vial zoledronic acid 5 mg/100 ml ZOLINZA 100 MG CAPSULE ZOSYN GM/50 ML GALAXY ZOSYN 4.5 GM/100 ML GALAXY BAG zovia 1-35e let zovia 1-50e let ZOVIRAX 5% CREAM ZUBSOLV MG TABLET SL ZUBSOLV MG TABLET SL ZUBSOLV MG TABLET SL ZUBSOLV MG TABLET SL ZUBSOLV MG TABLET SL ZYCLARA 2.5% CREAM PUMP ZYCLARA 3.75% CREAM ZYCLARA 3.75% CREAM PUMP ZENPEP DR,000 UNITS CAPSULE ZENPEP DR,000 UNITS CAPSULE ZENPEP DR,000 UNITS CAPSULE zolmitriptan 2.5 mg odt zolmitriptan 2.5 mg let zolmitriptan 5 mg odt zolmitriptan 5 mg let zolpidem tart er 12.5 mg 77 ZYDELIG 100 MG TABLET ZYDELIG 0 MG TABLET ZYFLO CR 600 MG TABLET ZYKADIA 0 MG CAPSULE ZYLET EYE DROPS ZENPEP DR 3,000 UNITS CAPSULE ZENPEP DR 40,000 UNITS CAPSULE ZENPEP DR 5,000 UNITS CAPSULE zeosa chewable let 64 zolpidem tart er 6. mg zolpidem tartrate 10 mg let zolpidem tartrate 5 mg let zonisamide 100 mg capsule zonisamide mg capsule zonisamide 50 mg capsule ZYPRAM CREAM ZYPREXA RELPREVV 210 MG VL KIT ZYPREXA RELPREVV 300 MG VL KIT ZYPREXA RELPREVV 405 MG VL KIT 54 ZETIA 10 MG TABLET 50 ZORBTIVE 8.8 MG VIAL 60 ZYTIGA 0 MG TABLET 31 ZETONNA 37 MCG NASAL SPRAY ZIAGEN MG/ML SOLUTION ZIANA GEL zidovudine 100 mg capsule zidovudine 300 mg let zidovudine 50 mg/5 ml syrup ZORTRESS 0. MG TABLET ZORTRESS 0.5 MG TABLET ZORTRESS 0.75 MG TABLET ZOSTAVAX VIAL ZOSYN 2. GM/50 ML GALAXY BAG Comprehensive Formulary 6

137 Customer Notice High Risk Medications List for Cigna- HealthSpring Customers Years of Age and Older Effective date: January 1, This following list was made because of the Medicare Part D defined needs for customers who are years of age and older. If you have any questions, you may call Cigna-HealthSpring at Contact your doctor to review safer formulary drugs. Your doctor may call Cigna-HealthSpring for a review if the formulary drugs are not right for you. s and Groups Antibacterials nitrofurantoin 100 mg caps 1 nitrofurantoin mg, 50 mg caps 2 Antiemetics PHENADOZ SUPPOSITORY promethegan suppositories PHENERGAN SUPPOSITORY promethazine hcl suppositories Diabetes GLUCOVANCE glyburide micronized s glyburide s glyburide/metformin hcl s Heart Health and High Blood Pressure DIGITEK, DIGOX, LANOXIN s 3 methyldopa s digoxin s 3 methyldopa/hydrochlorothiazide s digoxin oral solution methyldopate injecle solution LANOXIN ORAL SOLUTION Hormone Replacement ALORA PATCHES 4 MENEST TABS CLIMARA, CLIMARA PRO PATCHES 4 MENOSTAR PATCHES 4 COMBIPATCH 4 MIMVEY, MIMVEY LO TABS estradiol s, patches 4 MINIVELLE PATCHES 4 estradiol/norethindrone acetate s norethindrone/estradiol mcg s FEMHRT norethindrone/estradiol 1-5 mcg s FYAVOLV PREFEST TABS JEVANTIQUE LO PREMARIN TABS 4 JINTELI PREMPRO megestrol acetate s, oral suspension VIVELLE-DOT 4 Customer HRM Notice with Brand Package Page 1 of 2 INT 883

138 Mental Health amitriptyline hcl s 5 ergoloid mesylates s ANAFRANIL 5 imipramine caps, s 5 chlordiazepoxide/amitriptyline s 5 perphenazine/amitriptyline s 5 clomipramine hcl caps 5 thioridazine hcl s 5 doxepin hcl caps, oral concentrate 5 trimipramine maleate caps 5 Pain Relievers butalbital/acetaminophen s 4 butalbital/aspirin/caffeine s, caps 4 butalbital/acetaminophen/caffeine, caps 4 butalbital/aspirin/caffeine/codeine caps 4 Respiratory Medications promethazine oral solution, syrup, s, inj promethazine vc plain syrup Sleep Medications Ambien, Ambien CR 1 triazolam 1 eszopiclone 1 zaleplon capules 1 flurazepam 1 zolpidem tartrate s, er s 1 temazepam 1 Muscle Relaxants carisoprodol s cyclobenzaprine s 4 carisoprodol/aspirin s metaxalone s carisoprodol/aspirin/codeine s methocarbamol s chlorzoxazone s orphenadrine citrate er s 4, oral solution Parkinsons benztropine s trihexyphenidyl hcl s, elixer 1 PA if > 90 caps or s per year 4 QL limits apply. See the formulary drug list 2 PA if > 0 caps or s per year 5 PA for new starts only 3 PA for doses > 0 mg per day Need Help? If you have any questions about the pharmacy plan, Cigna-HealthSpring Rx (PDP), its benefits and features, simply call Cigna-HealthSpring Rx (PDP) Customer Service Team Monday through Friday at , 8 a.m. 8 p.m., local time. (Between October 1 and February, you can reach us seven days a week.) TTY/TDD users, please call 7. This information is available for free in other languages. Please call our customer service number at (TTY 7), Monday through Friday at , 8 a.m. 8 p.m., local time. Esta información está disponible de forma gratuita en otros idiomas. Por favor, llame a nuestro servicio al cliente al , servicio al Cliente siete días de la semana, de 8am a 8pm. Los usuarios de TTY deben llamar al 7.All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Cigna HealthCare of South Carolina, Inc., Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of Arizona, Inc., Cigna HealthCare of St. Louis, Inc., HealthSpring Life & Health Insurance Company, Inc., HealthSpring of Tennessee, Inc., HealthSpring of Alabama, Inc., HealthSpring of Florida, Inc., Bravo Health Mid-Atlantic, Inc., and Bravo Health Pennsylvania, Inc. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. Cigna-HealthSpring Rx (PDP) is a Medicare Prescription Drug plan (PDP) with a Medicare contract. Enrollment in Cigna-HealthSpring depends on contract renewal. Customer HRM Notice with Brand Package Page 2 of 2

139 Brand Package with all Clinical Edits Type Class Name Tier PA QL Sleep Disorder Agents BRAND AMBIEN TAB 10MG 3 QL if or older (90 per 3 days) Sleep Disorder Agents BRAND AMBIEN TAB 5MG 3 QL if or older (90 per 3 days) Sleep Disorder Agents BRAND AMBIEN CR TAB 12.5MG 3 QL if or older (90 per 3 days) Sleep Disorder Agents BRAND AMBIEN CR TAB 6.MG 3 QL if or older (90 per 3 days) Antipsychotics BRAND ABILIFY TAB 10MG 3 QL (30 per 30 days) Antipsychotics BRAND ABILIFY TAB MG 3 QL (30 per 30 days) Antipsychotics BRAND ABILIFY TAB MG 3 QL (30 per 30 days) Antipsychotics BRAND ABILIFY TAB 2MG 3 QL (30 per 30 days) Antipsychotics BRAND ABILIFY TAB 30MG 3 QL (30 per 30 days) Antipsychotics BRAND ABILIFY TAB 5MG 3 QL (30 per 30 days) Antipsychotics BRAND ABILIFY DISC TAB 10MG 3 QL (60 per 30 days) Antipsychotics BRAND ABILIFY DISC TAB MG 3 QL (60 per 30 days) Gastrointestinal Agents BRAND ACIPHEX TAB MG 3 QL (60 per 30 days) Meolic Bone Disease Agents BRAND ACTONEL TAB 0MG 3 QL (1 per 30 days) Meolic Bone Disease Agents BRAND ACTONEL TAB 30MG 3 QL (30 per 30 days) Meolic Bone Disease Agents BRAND ACTONEL TAB 35MG 3 QL (4 per days) Meolic Bone Disease Agents BRAND ACTONEL TAB 5MG 3 QL (30 per 30 days) Blood Glucose Regulators BRAND ACTOPLUS MET TAB -500MG 3 QL (90 per 30 days) Blood Glucose Regulators BRAND ACTOPLUS MET TAB -850MG 3 QL (90 per 30 days) Blood Glucose Regulators BRAND ACTOS TAB MG 3 QL (30 per 30 days) Blood Glucose Regulators BRAND ACTOS TAB 30MG 3 QL (30 per 30 days) Blood Glucose Regulators BRAND ACTOS TAB MG 3 QL (30 per 30 days) Central Nervous System Agents BRAND ADDERALL XR CAP 10MG 3 QL (30 per 30 days) Central Nervous System Agents BRAND ADDERALL XR CAP MG 3 QL (30 per 30 days) Central Nervous System Agents BRAND ADDERALL XR CAP MG 3 QL (30 per 30 days) Central Nervous System Agents BRAND ADDERALL XR CAP MG 3 QL (30 per 30 days) Central Nervous System Agents BRAND ADDERALL XR CAP 30MG 3 QL (30 per 30 days) Central Nervous System Agents BRAND ADDERALL XR CAP 5MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND ALTOPREV TAB MG ER 3 QL (30 per 30 days) Cardiovascular Agents BRAND ALTOPREV TAB 40MG ER 3 QL (30 per 30 days) Cardiovascular Agents BRAND ALTOPREV TAB 60MG ER 3 QL (30 per 30 days) Blood Glucose Regulators BRAND AMARYL TAB 1MG 3 QL (30 per 30 days) Blood Glucose Regulators BRAND AMARYL TAB 2MG 3 QL (30 per 30 days) Blood Glucose Regulators BRAND AMARYL TAB 4MG 3 QL (60 per 30 days) Skeletal Muscle Relaxants BRAND AMRIX CAP MG 3 QL (30 per 30 days) Skeletal Muscle Relaxants BRAND AMRIX CAP 30MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND ANTARA CAP 0MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND ANTARA CAP 30MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND ANTARA CAP MG 3 QL (60 per 30 days) Cardiovascular Agents BRAND ANTARA CAP 90MG 3 QL (60 per 30 days) Antineoplastics BRAND ARIMIDEX TAB 1MG 3 QL (30 per 30 days) Antineoplastics BRAND AROMASIN TAB MG 3 QL (60 per 30 days) Respiratory Tract/Pulmonary Agents BRAND ASTELIN NASA SPR 7MCG 3 QL (30 ML per days) Respiratory Tract/Pulmonary Agents BRAND ASTEPRO SPR 0.% 3 QL (30 ML per days) Cardiovascular Agents BRAND ATACAND TAB MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND ATACAND TAB MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND ATACAND TAB 4MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND ATACAND TAB 8MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND ATACAND HCT TAB QL (30 per 30 days) Cardiovascular Agents BRAND ATACAND HCT TAB QL (30 per 30 days) Cardiovascular Agents BRAND ATACAND HCT TAB -MG 3 QL (30 per 30 days) Genitourinary Agents BRAND AVODART CAP 0.5MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND AZOR TAB 10-MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND AZOR TAB 10-40MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND AZOR TAB 5-MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND AZOR TAB 5-40MG 3 QL (30 per 30 days) Meolic Bone Disease Agents BRAND BONIVA TAB 0MG 3 QL (1 per days) 1 of 9

140 Brand Package with all Clinical Edits Cardiovascular Agents BRAND CADUET TAB 10-10MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND CADUET TAB 10-MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND CADUET TAB 10-40MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND CADUET TAB 10-80MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND CADUET TAB MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND CADUET TAB 2.5-MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND CADUET TAB MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND CADUET TAB 5-10MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND CADUET TAB 5-MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND CADUET TAB 5-40MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND CADUET TAB 5-80MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND CARDIZEM LA TAB 1MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND CATAPRES-TTS DIS 0.1/24HR 3 QL (4 per days) Cardiovascular Agents BRAND CATAPRES-TTS DIS 0.2/24HR 3 QL (4 per days) Cardiovascular Agents BRAND CATAPRES-TTS DIS 0.3/24HR 3 QL (8 per days) Analgesics BRAND CELEBREX CAP 100MG 3 QL (60 per 30 days) Analgesics BRAND CELEBREX CAP 0MG 3 QL (60 per 30 days) Analgesics BRAND CELEBREX CAP 400MG 3 QL (60 per 30 days) Analgesics BRAND CELEBREX CAP 50MG 3 QL (60 per 30 days) Antidepressants BRAND CELEXA TAB 10MG 3 QL (30 per 30 days) Antidepressants BRAND CELEXA TAB MG 3 QL (30 per 30 days) Antidepressants BRAND CELEXA TAB 40MG 3 QL (30 per 30 days) Respiratory Tract/Pulmonary Agents BRAND CLARINEX TAB 5MG 3 QL (30 per 30 days) Hormonal Agents, Stimulant/Replacement/Modifying (Sex BRAND CLIMARA DIS 0.0MG 3 PA (HRM) QL (4 per days) Hormones/Modifiers) Hormonal Agents, Stimulant/Replacement/Modifying (Sex BRAND CLIMARA DIS MG 3 PA (HRM) QL (4 per days) Hormones/Modifiers) Hormonal Agents, Stimulant/Replacement/Modifying (Sex BRAND CLIMARA DIS 0.05MG 3 PA (HRM) QL (4 per days) Hormones/Modifiers) Hormonal Agents, Stimulant/Replacement/Modifying (Sex BRAND CLIMARA DIS 0.06MG 3 PA (HRM) QL (4 per days) Hormones/Modifiers) Hormonal Agents, Stimulant/Replacement/Modifying (Sex BRAND CLIMARA DIS 0.075MG 3 PA (HRM) QL (4 per days) Hormones/Modifiers) Hormonal Agents, Stimulant/Replacement/Modifying (Sex BRAND CLIMARA DIS 0.1MG 3 PA (HRM) QL (4 per days) Hormones/Modifiers) Antigout Agents BRAND COLCRYS TAB 0.6MG 3 QL (1 per 30 days) Central Nervous System Agents BRAND CONCERTA TAB MG 3 QL (30 per 30 days) Central Nervous System Agents BRAND CONCERTA TAB MG 3 QL (30 per 30 days) Central Nervous System Agents BRAND CONCERTA TAB 36MG 3 QL (30 per 30 days) Central Nervous System Agents BRAND CONCERTA TAB 54MG 3 QL (30 per 30 days) Ophthalmic Agents BRAND COSOPT SOL QL (10 ML per 30 days) Cardiovascular Agents BRAND COZAAR TAB 100MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND COZAAR TAB MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND COZAAR TAB 50MG 3 QL (30 per 30 days) Antidepressants BRAND CYMBALTA CAP MG 3 QL (60 per 30 days) Antidepressants BRAND CYMBALTA CAP 30MG 3 QL (30 per 30 days) Antidepressants BRAND CYMBALTA CAP 60MG 3 QL (60 per 30 days) Cardiovascular Agents BRAND DIOVAN TAB 0MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND DIOVAN TAB 0MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND DIOVAN TAB 40MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND DIOVAN TAB 80MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND DIOVAN HCT TAB QL (30 per 30 days) Cardiovascular Agents BRAND DIOVAN HCT TAB 0-MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND DIOVAN HCT TAB QL (30 per 30 days) Cardiovascular Agents BRAND DIOVAN HCT TAB 0-MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND DIOVAN HCT TAB 80/ QL (30 per 30 days) 2 of 9

141 Brand Package with all Clinical Edits Central Nervous System Agents BRAND DUEXIS TAB QL (90 per 30 days) Cardiovascular Agents BRAND EDARBI TAB 40MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND EDARBI TAB 80MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND EDARBYCLOR TAB QL (30 per 30 days) Cardiovascular Agents BRAND EDARBYCLOR TAB 40-MG 3 QL (30 per 30 days) Antidepressants BRAND EFFEXOR XR CAP 0MG 3 QL (30 per 30 days) Antidepressants BRAND EFFEXOR XR CAP 37.5MG 3 QL (30 per 30 days) Antidepressants BRAND EFFEXOR XR CAP 75MG 3 QL (30 per 30 days) Hormonal Agents, Stimulant/Replacement/Modifying (Sex BRAND EVISTA TAB 60MG 3 QL (30 per 30 days) Hormones/Modifiers) Antidementia Agents BRAND EXELON DIS.3/24 3 QL (30 per 30 days) Antidementia Agents BRAND EXELON DIS 4.6MG/24 3 QL (30 per 30 days) Antidementia Agents BRAND EXELON DIS 9.5MG/24 3 QL (30 per 30 days) Cardiovascular Agents BRAND EXFORGE TAB 10-0MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND EXFORGE TAB 10-0MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND EXFORGE TAB 5-0MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND EXFORGE TAB 5-0MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND EXFORGEH/10- TAB QL (30 per 30 days) Cardiovascular Agents BRAND EXFORGEH/10- TAB 0-3 QL (30 per 30 days) Cardiovascular Agents BRAND EXFORGEH/10- TAB 0-3 QL (30 per 30 days) Cardiovascular Agents BRAND EXFORGEH/5- TAB QL (30 per 30 days) Cardiovascular Agents BRAND EXFORGEH/5- TAB 0-3 QL (30 per 30 days) Antineoplastics BRAND FEMARA TAB 2.5MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND FENOGLIDE TAB 1MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND FENOGLIDE TAB 40MG 3 QL (60 per 30 days) Genitourinary Agents BRAND FLOMAX CAP 0.4MG 3 QL (60 per 30 days) Central Nervous System Agents BRAND FOCALIN TAB 10MG 3 QL (60 per 30 days) Central Nervous System Agents BRAND FOCALIN TAB 2.5MG 3 QL (60 per 30 days) Central Nervous System Agents BRAND FOCALIN TAB 5MG 3 QL (60 per 30 days) Central Nervous System Agents BRAND FOCALIN XR CAP 10MG 3 QL (30 per 30 days) Central Nervous System Agents BRAND FOCALIN XR CAP MG 3 QL (30 per 30 days) Central Nervous System Agents BRAND FOCALIN XR CAP MG 3 QL (30 per 30 days) Central Nervous System Agents BRAND FOCALIN XR CAP MG 3 QL (30 per 30 days) Central Nervous System Agents BRAND FOCALIN XR CAP 30MG 3 QL (30 per 30 days) Central Nervous System Agents BRAND FOCALIN XR CAP 35MG 3 QL (30 per 30 days) Central Nervous System Agents BRAND FOCALIN XR CAP 40MG 3 QL (30 per 30 days) Central Nervous System Agents BRAND FOCALIN XR CAP 5MG 3 QL (30 per 30 days) Blood Glucose Regulators BRAND FORTAMET TAB 1000MG 3 QL (60 per 30 days) Blood Glucose Regulators BRAND FORTAMET TAB 500MG 3 QL (90 per 30 days) Meolic Bone Disease Agents BRAND FORTICAL SPR 0/ACT 3 QL (3.7 ML per 30 days) Meolic Bone Disease Agents BRAND FOSAMAX TAB 70MG 3 QL (4 per days) Antimigraine Agents BRAND FROVA TAB 2.5MG 3 QL ( per 30 days) Anticonvulsants BRAND GABITRIL TAB 2MG 3 QL (240 per 30 days) Antipsychotics BRAND GEODON CAP MG 3 QL (60 per 30 days) Antipsychotics BRAND GEODON CAP 40MG 3 QL (60 per 30 days) Antipsychotics BRAND GEODON CAP 60MG 3 QL (60 per 30 days) Antipsychotics BRAND GEODON CAP 80MG 3 QL (60 per 30 days) Antineoplastics BRAND GLEEVEC TAB 100MG 3 QL (60 per 30 days) Antineoplastics BRAND GLEEVEC TAB 400MG 3 QL (60 per 30 days) Blood Glucose Regulators BRAND GLUCOPHAGE TAB 1000MG 3 QL (60 per 30 days) Blood Glucose Regulators BRAND GLUCOPHAGE TAB 500MG 3 QL (0 per 30 days) Blood Glucose Regulators BRAND GLUCOPHAGE TAB 500MG XR 3 QL (1 per 30 days) Blood Glucose Regulators BRAND GLUCOPHAGE TAB 750MG XR 3 QL (60 per 30 days) Blood Glucose Regulators BRAND GLUCOPHAGE TAB 850MG 3 QL (90 per 30 days) Blood Glucose Regulators BRAND GLUMETZA TAB 1000MG 3 QL (60 per 30 days) Blood Glucose Regulators BRAND GLUMETZA TAB 500MG 3 QL (60 per 30 days) Cardiovascular Agents BRAND HYZAAR TAB QL (30 per 30 days) Cardiovascular Agents BRAND HYZAAR TAB QL (30 per 30 days) Cardiovascular Agents BRAND HYZAAR TAB QL (30 per 30 days) Genitourinary Agents BRAND JALYN CAP 3 QL (30 per 30 days) Anticonvulsants BRAND KEPPRA XR TAB 500MG 3 QL (0 per 30 days) 3 of 9

142 Brand Package with all Clinical Edits Anticonvulsants BRAND KEPPRA XR TAB 750MG 3 QL (1 per 30 days) Cardiovascular Agents BRAND LESCOL XL TAB 80MG 3 QL (30 per 30 days) Antidepressants BRAND LEXAPRO TAB 10MG 3 QL (30 per 30 days) Antidepressants BRAND LEXAPRO TAB MG 3 QL (30 per 30 days) Antidepressants BRAND LEXAPRO TAB 5MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND LIPITOR TAB 10MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND LIPITOR TAB MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND LIPITOR TAB 40MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND LIPITOR TAB 80MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND LIVALO TAB 1MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND LIVALO TAB 2MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND LIVALO TAB 4MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND LOTREL CAP 10-MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND LOTREL CAP 10-40MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND LOTREL CAP MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND LOTREL CAP 5-10MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND LOTREL CAP 5-MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND LOTREL CAP 5-40MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND LOVAZA CAP 1GM 3 QL (1 per 30 days) Antidepressants BRAND LUVOX CR CAP 100MG 3 QL (90 per 30 days) Antidepressants BRAND LUVOX CR CAP 0MG 3 QL (60 per 30 days) Central Nervous System Agents BRAND METADATE CD CAP 10MG 3 QL (30 per 30 days) Central Nervous System Agents BRAND METADATE CD CAP MG 3 QL (30 per 30 days) Central Nervous System Agents BRAND METADATE CD CAP 30MG 3 QL (30 per 30 days) Central Nervous System Agents BRAND METADATE CD CAP 40MG 3 QL (30 per 30 days) Central Nervous System Agents BRAND METADATE CD CAP 50MG 3 QL (30 per 30 days) Central Nervous System Agents BRAND METADATE CD CAP 60MG 3 QL (30 per 30 days) Meolic Bone Disease Agents BRAND MIACALCIN SPR 0/ACT 3 QL (3.7 ML per 30 days) Cardiovascular Agents BRAND MICARDIS TAB MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND MICARDIS TAB 40MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND MICARDIS TAB 80MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND MICARDIS HCT TAB 40/ QL (30 per 30 days) Cardiovascular Agents BRAND MICARDIS HCT TAB 80/ QL (30 per 30 days) Cardiovascular Agents BRAND MICARDIS HCT TAB 80-MG 3 QL (30 per 30 days) Antiparkinson Agents BRAND MIRAPEX ER TAB 0.375MG 3 QL (90 per 30 days) Antiparkinson Agents BRAND MIRAPEX ER TAB 0.75MG 3 QL (90 per 30 days) Antiparkinson Agents BRAND MIRAPEX ER TAB 1.5MG 3 QL (90 per 30 days) Antiparkinson Agents BRAND MIRAPEX ER TAB 2.MG 3 QL (30 per 30 days) Antiparkinson Agents BRAND MIRAPEX ER TAB 3.75MG 3 QL (30 per 30 days) Antiparkinson Agents BRAND MIRAPEX ER TAB 3MG 3 QL (30 per 30 days) Antiparkinson Agents BRAND MIRAPEX ER TAB 4.5MG 3 QL (30 per 30 days) Analgesics BRAND MOBIC TAB MG 3 QL (30 per 30 days) Analgesics BRAND MOBIC TAB 7.5MG 3 QL (30 per 30 days) Antidementia Agents BRAND NAMENDA SOL 10MG/5ML 3 PA if younger than QL (300 ML per 30 days) Antidementia Agents BRAND NAMENDA TAB 10MG 3 PA if younger than QL (60 per 30 days) Antidementia Agents BRAND NAMENDA TAB 5-10MG 3 PA if younger than QL ( per days) Antidementia Agents BRAND NAMENDA TAB 5MG 3 PA if younger than QL (90 per 30 days) Anticonvulsants BRAND NEURONTIN CAP 100MG 3 QL (0 per 30 days) Anticonvulsants BRAND NEURONTIN CAP 300MG 3 QL (0 per 30 days) Anticonvulsants BRAND NEURONTIN CAP 400MG 3 QL (0 per 30 days) Anticonvulsants BRAND NEURONTIN TAB 600MG 3 QL (0 per 30 days) Anticonvulsants BRAND NEURONTIN TAB 800MG 3 QL (90 per 30 days) Gastrointestinal Agents BRAND NEXIUM CAP MG 3 QL (60 per 30 days) Gastrointestinal Agents BRAND NEXIUM CAP 40MG 3 QL (60 per 30 days) Cardiovascular Agents BRAND NORVASC TAB 10MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND NORVASC TAB 2.5MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND NORVASC TAB 5MG 3 QL ( per 30 days) Immunological Agents BRAND ORENCIA INJ 1MG/ML 3 QL (4 ML per day) Antidepressants BRAND PAXIL TAB 10MG 3 QL (30 per 30 days) Antidepressants BRAND PAXIL TAB MG 3 QL (30 per 30 days) Antidepressants BRAND PAXIL TAB 30MG 3 QL (60 per 30 days) 4 of 9

143 Brand Package with all Clinical Edits Antidepressants BRAND PAXIL TAB 40MG 3 QL (30 per 30 days) Antidepressants BRAND PAXIL CR TAB 12.5MG 3 QL (30 per 30 days) Antidepressants BRAND PAXIL CR TAB MG 3 QL (90 per 30 days) Antidepressants BRAND PAXIL CR TAB 37.5MG 3 QL (60 per 30 days) Dermatological Agents BRAND PENNSAID SOL 1.5% 3 QL (1050 ML per 30 days) Blood Products/Modifiers/Volume Expanders BRAND PLAVIX TAB 300MG 3 QL (2 per 3 days) Blood Products/Modifiers/Volume Expanders BRAND PLAVIX TAB 75MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND PRAVACHOL TAB MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND PRAVACHOL TAB 40MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND PRAVACHOL TAB 80MG 3 QL (30 per 30 days) Gastrointestinal Agents BRAND PREVACID CAP 30MG DR 3 QL (60 per 30 days) Gastrointestinal Agents BRAND PREVACID TAB MG STB 3 QL (60 per 30 days) Gastrointestinal Agents BRAND PREVACID TAB 30MG STB 3 QL (60 per 30 days) Gastrointestinal Agents BRAND PRILOSEC CAP 10MG 3 QL (60 per 30 days) Gastrointestinal Agents BRAND PRILOSEC CAP MG 3 QL (60 per 30 days) Gastrointestinal Agents BRAND PRILOSEC CAP 40MG 3 QL (60 per 30 days) Genitourinary Agents BRAND PROSCAR TAB 5MG 3 QL (30 per 30 days) Gastrointestinal Agents BRAND PROTONIX PAK 3 QL (60 per 30 days) Gastrointestinal Agents BRAND PROTONIX TAB MG 3 QL (60 per 30 days) Gastrointestinal Agents BRAND PROTONIX TAB 40MG 3 QL (60 per 30 days) Sleep Disorder Agents BRAND PROVIGIL TAB 100MG 3 PA QL (30 per 30 days) Sleep Disorder Agents BRAND PROVIGIL TAB 0MG 3 PA QL (60 per 30 days) Antidepressants BRAND PROZAC CAP 10MG 3 QL (30 per 30 days) Antidepressants BRAND PROZAC CAP MG 3 QL (1 per 30 days) Antidepressants BRAND PROZAC CAP 40MG 3 QL (60 per 30 days) Antidepressants BRAND PROZAC WEEKL CAP 90MG 3 QL (4 per days) Antidepressants BRAND REMERON TAB MG 3 QL (30 per 30 days) Antidepressants BRAND REMERON TAB 30MG 3 QL (30 per 30 days) Antidepressants BRAND REMERON TAB MG 3 QL (30 per 30 days) Respiratory Tract/Pulmonary Agents BRAND RHINOCORT SUS AQUA 3 QL (.2 GM per 30 days) Respiratory Tract/Pulmonary Agents BRAND RHINOCORT SUS AQUA 3 QL (.2 GM per 30 days) Antipsychotics BRAND RISPERDAL SOL 1MG/ML 3 QL (360 ML per 30 days) Antipsychotics BRAND RISPERDAL TAB 0.MG 3 QL (60 per 30 days) Antipsychotics BRAND RISPERDAL TAB 0.5MG 3 QL (60 per 30 days) Antipsychotics BRAND RISPERDAL TAB 1MG 3 QL (60 per 30 days) Antipsychotics BRAND RISPERDAL TAB 2MG 3 QL (60 per 30 days) Antipsychotics BRAND RISPERDAL TAB 3MG 3 QL (60 per 30 days) Antipsychotics BRAND RISPERDAL TAB 4MG 3 QL (1 per 30 days) Central Nervous System Agents BRAND RITALIN TAB 10MG 3 QL (60 per 30 days) Central Nervous System Agents BRAND RITALIN TAB MG 3 QL (90 per 30 days) Central Nervous System Agents BRAND RITALIN TAB MG SR 3 QL (90 per 30 days) Central Nervous System Agents BRAND RITALIN TAB 5MG 3 QL (60 per 30 days) Central Nervous System Agents BRAND RITALIN LA CAP 10MG 3 QL (30 per 30 days) Central Nervous System Agents BRAND RITALIN LA CAP MG 3 QL (30 per 30 days) Central Nervous System Agents BRAND RITALIN LA CAP 30MG 3 QL (30 per 30 days) Central Nervous System Agents BRAND RITALIN LA CAP 40MG 3 QL (30 per 30 days) Central Nervous System Agents BRAND RITALIN LA CAP 60MG 3 QL (30 per 30 days) Antipsychotics BRAND SEROQUEL TAB 100MG 3 QL (60 per 30 days) Antipsychotics BRAND SEROQUEL TAB 0MG 3 QL (60 per 30 days) Antipsychotics BRAND SEROQUEL TAB MG 3 QL (60 per 30 days) Antipsychotics BRAND SEROQUEL TAB 300MG 3 QL (60 per 30 days) Antipsychotics BRAND SEROQUEL TAB 400MG 3 QL (60 per 30 days) Antipsychotics BRAND SEROQUEL TAB 50MG 3 QL (60 per 30 days) Immunological Agents BRAND SIMPONI INJ 100MG/ML 3 QL (3 ML per 30 days) Immunological Agents BRAND SIMPONI INJ 100MG/ML 3 QL (3 ML per 30 days) Immunological Agents BRAND SIMPONI INJ 50/0.5ML 3 QL (0.5 ML per 30 days) Immunological Agents BRAND SIMPONI INJ 50/0.5ML 3 QL (0.5 ML per 30 days) Respiratory Tract/Pulmonary Agents BRAND SINGULAIR TAB 10MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND TARKA TAB CR 3 QL (30 per 30 days) Cardiovascular Agents BRAND TARKA TAB 2-0 CR 3 QL (30 per 30 days) 5 of 9

144 Brand Package with all Clinical Edits Cardiovascular Agents BRAND TARKA TAB CR 3 QL (30 per 30 days) Cardiovascular Agents BRAND TARKA TAB CR 3 QL (60 per 30 days) Miscellaneous Therapeutic Agents BRAND TECFIDERA CAP 1MG 3 QL (60 per 30 days) Miscellaneous Therapeutic Agents BRAND TECFIDERA CAP 240MG 3 QL (60 per 30 days) Hormonal Agents, Stimulant/Replacement/Modifying (Sex BRAND TESTIM GEL 1%(50MG) 3 QL (300 GM per 30 days) Hormones/Modifiers) Anticonvulsants BRAND TOPAMAX TAB 100MG 3 QL (90 per 30 days) Anticonvulsants BRAND TOPAMAX TAB 0MG 3 QL (60 per 30 days) Anticonvulsants BRAND TOPAMAX TAB MG 3 QL (90 per 30 days) Anticonvulsants BRAND TOPAMAX TAB 50MG 3 QL (90 per 30 days) Anticonvulsants BRAND TOPAMAX SPR CAP MG 3 QL (30 per 30 days) Anticonvulsants BRAND TOPAMAX SPR CAP MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND TOPROL XL TAB 100MG 3 QL ( per 30 days) Cardiovascular Agents BRAND TOPROL XL TAB 0MG 3 QL (60 per 30 days) Cardiovascular Agents BRAND TOPROL XL TAB MG 3 QL (60 per 30 days) Cardiovascular Agents BRAND TOPROL XL TAB 50MG 3 QL (60 per 30 days) Cardiovascular Agents BRAND TRIBENZOR- TAB MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND TRIBENZOR40- TAB QL (30 per 30 days) Cardiovascular Agents BRAND TRIBENZOR40- TAB 10-MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND TRIBENZOR40- TAB MG 3 QL (30 per 30 days) Cardiovascular Agents BRAND TRIBENZOR40- TAB 5-MG 3 QL (30 per 30 days) Genitourinary Agents BRAND UROXATRAL TAB 10MG 3 QL (30 per 30 days) Antivirals BRAND VALTREX TAB 1GM 3 QL (30 per 30 days) Antivirals BRAND VALTREX TAB 500MG 3 QL (30 per 30 days) Hormonal Agents, Stimulant/Replacement/Modifying (Sex BRAND VIVELLE-DOT DIS 0.0MG 3 PA (HRM) QL (8 EA per days) Hormones/Modifiers) Hormonal Agents, Stimulant/Replacement/Modifying (Sex BRAND VIVELLE-DOT DIS MG 3 PA (HRM) QL (8 EA per days) Hormones/Modifiers) Hormonal Agents, Stimulant/Replacement/Modifying (Sex BRAND VIVELLE-DOT DIS 0.05MG 3 PA (HRM) QL (8 EA per days) Hormones/Modifiers) Hormonal Agents, Stimulant/Replacement/Modifying (Sex BRAND VIVELLE-DOT DIS 0.075MG 3 PA (HRM) QL (8 EA per days) Hormones/Modifiers) Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) BRAND VIVELLE-DOT DIS 0.1MG 3 PA (HRM) QL (8 EA per days) Central Nervous System Agents BRAND VYVANSE CAP MG 3 QL (30 per 30 days) Central Nervous System Agents BRAND VYVANSE CAP 30MG 3 QL (30 per 30 days) Central Nervous System Agents BRAND VYVANSE CAP 40MG 3 QL (30 per 30 days) Central Nervous System Agents BRAND VYVANSE CAP 50MG 3 QL (30 per 30 days) Central Nervous System Agents BRAND VYVANSE CAP 60MG 3 QL (30 per 30 days) Central Nervous System Agents BRAND VYVANSE CAP 70MG 3 QL (30 per 30 days) Antidepressants BRAND WELLBUTRIN TAB 100MG 3 QL (1 per 30 days) Antidepressants BRAND WELLBUTRIN TAB 100MG SR 3 QL (60 per 30 days) Antidepressants BRAND WELLBUTRIN TAB 0MG SR 3 QL (60 per 30 days) Antidepressants BRAND WELLBUTRIN TAB 0MG SR 3 QL (60 per 30 days) Antidepressants BRAND WELLBUTRIN TAB 75MG 3 QL (60 per 30 days) Antidepressants BRAND WELLBUTRIN TAB XL 0MG 3 QL (90 per 30 days) Antidepressants BRAND WELLBUTRIN TAB XL 300MG 3 QL (30 per 30 days) Ophthalmic Agents BRAND XALATAN SOL 0.005% 3 QL (5ML per 30 days) Antidepressants BRAND ZOLOFT TAB 100MG 3 QL (60 per 30 days) Antidepressants BRAND ZOLOFT TAB MG 3 QL (30 per 30 days) Antidepressants BRAND ZOLOFT TAB 50MG 3 QL (30 per 30 days) Antipsychotics BRAND ZYPREXA TAB 10MG 3 QL (30 per 30 days) Antipsychotics BRAND ZYPREXA TAB MG 3 QL (30 per 30 days) Antipsychotics BRAND ZYPREXA TAB 2.5MG 3 QL (30 per 30 days) Antipsychotics BRAND ZYPREXA TAB MG 3 QL (30 per 30 days) Antipsychotics BRAND ZYPREXA TAB 5MG 3 QL (30 per 30 days) 6 of 9

145 Brand Package with all Clinical Edits Antipsychotics BRAND ZYPREXA TAB 7.5MG 3 QL (30 per 30 days) Gastrointestinal Agents BRAND ACTIGALL CAP 300MG 3 Blood Glucose Regulators BRAND ACTOPLUS MET TAB XR 3 Blood Glucose Regulators BRAND ACTOPLUS MET TAB XR 3 Ophthalmic Agents BRAND ACUVAIL SOL 0.% 3 Cardiovascular Agents BRAND ALDACTAZIDE TAB / 3 Cardiovascular Agents BRAND ALDACTAZIDE TAB 50/50 3 Ophthalmic Agents BRAND ALPHAGAN P SOL 0.% 3 Antidepressants BRAND ANAFRANIL CAP MG 3 PA New Starts (HRM) Antidepressants BRAND ANAFRANIL CAP 50MG 3 PA New Starts (HRM) Antidepressants BRAND ANAFRANIL CAP 75MG 3 PA New Starts (HRM) Hormonal Agents, Stimulant/Replacement/Modifying (Sex BRAND ANDROID CAP 10MG 3 Hormones/Modifiers) Anti-Addiction/Substance Abuse Treatment Agents BRAND ANTABUSE TAB 0MG 3 Anti-Addiction/Substance Abuse Treatment Agents BRAND ANTABUSE TAB 500MG 3 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) BRAND AXIRON SOL 30MG/ACT 3 Respiratory Tract/Pulmonary Agents BRAND BECONASE AQ SUS 0.042% 3 Cardiovascular Agents BRAND CALAN SR TAB 1MG 3 Cardiovascular Agents BRAND CALAN SR TAB 0MG 3 Cardiovascular Agents BRAND CALAN SR TAB 240MG 3 Genitourinary Agents BRAND CARDURA XL TAB 4MG 3 Genitourinary Agents BRAND CARDURA XL TAB 8MG 3 Gastrointestinal Agents BRAND CIMZIA KIT 3 Gastrointestinal Agents BRAND CIMZIA KIT STARTER 3 Gastrointestinal Agents BRAND CIMZIA PREFL KIT 0MG/ML 3 Respiratory Tract/Pulmonary Agents BRAND CLARINEX SYP 0.5MG/ML 3 Cardiovascular Agents BRAND COREG TAB 12.5MG 3 Cardiovascular Agents BRAND COREG TAB MG 3 Cardiovascular Agents BRAND COREG TAB 3.1MG 3 Cardiovascular Agents BRAND COREG TAB 6.MG 3 Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) BRAND CORTEF TAB 10MG 3 Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) BRAND CORTEF TAB MG 3 BRAND CORTEF TAB 5MG 3 Blood Glucose Regulators BRAND CYCLOSET TAB 0.8MG 3 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) BRAND CYTOMEL TAB MCG 3 BRAND CYTOMEL TAB 50MCG 3 BRAND CYTOMEL TAB 5MCG 3 Anticonvulsants BRAND DEPAKOTE TAB 1MG DR 3 Anticonvulsants BRAND DEPAKOTE TAB 1MG DR 3 Anticonvulsants BRAND DEPAKOTE TAB 0MG DR 3 Anticonvulsants BRAND DEPAKOTE TAB 500MG DR 3 Anticonvulsants BRAND DEPAKOTE ER TAB 0MG 3 7 of 9

146 Brand Package with all Clinical Edits Anticonvulsants BRAND DEPAKOTE ER TAB 500MG 3 Anticonvulsants BRAND DEPAKOTE SPR CAP 1MG 3 Hormonal Agents, Stimulant/Replacement/Modifying (Sex BRAND DEPO-TESTOST INJ 100MG/ML 3 Hormones/Modifiers) Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) BRAND DEPO-TESTOST INJ 0MG/ML 3 Cardiovascular Agents BRAND DYAZIDE CAP Hormonal Agents, Stimulant/Replacement/Modifying (Sex BRAND ELESTRIN GEL 0.06% 3 Hormones/Modifiers) Hormonal Agents, Stimulant/Replacement/Modifying (Sex BRAND FEMHRT TAB PA (HRM) Hormones/Modifiers) Anticonvulsants BRAND GABITRIL TAB 4MG 3 Blood Glucose Regulators BRAND GLUCOVANCE TAB PA (HRM) Blood Glucose Regulators BRAND GLUCOVANCE TAB 5-500MG 3 PA (HRM) Antineoplastics BRAND HYDREA CAP 500MG 3 Cardiovascular Agents BRAND INDERAL LA CAP 1MG 3 Cardiovascular Agents BRAND INDERAL LA CAP 0MG 3 Cardiovascular Agents BRAND INDERAL LA CAP 60MG 3 Cardiovascular Agents BRAND INDERAL LA CAP 80MG 3 Anticonvulsants BRAND KEPPRA SOL 100MG/ML 3 Anticonvulsants BRAND KEPPRA TAB 1000MG 3 Anticonvulsants BRAND KEPPRA TAB 0MG 3 Anticonvulsants BRAND KEPPRA TAB 500MG 3 Anticonvulsants BRAND KEPPRA TAB 750MG 3 Anticonvulsants BRAND LAMICTAL CHW MG 3 Anticonvulsants BRAND LAMICTAL CHW 5MG 3 Anticonvulsants BRAND LAMICTAL TAB 100MG 3 Anticonvulsants BRAND LAMICTAL TAB 0MG 3 Anticonvulsants BRAND LAMICTAL TAB 0MG 3 Anticonvulsants BRAND LAMICTAL TAB MG 3 Anticonvulsants BRAND LAMICTAL XR TAB 100MG 3 Anticonvulsants BRAND LAMICTAL XR TAB 0MG 3 Anticonvulsants BRAND LAMICTAL XR TAB 0MG 3 Anticonvulsants BRAND LAMICTAL XR TAB MG 3 Anticonvulsants BRAND LAMICTAL XR TAB 300MG 3 Anticonvulsants BRAND LAMICTAL XR TAB 50MG 3 Cardiovascular Agents BRAND LASIX TAB MG 3 Cardiovascular Agents BRAND LASIX TAB 40MG 3 Cardiovascular Agents BRAND LASIX TAB 80MG 3 Analgesics BRAND NAPRELAN TAB 375MG CR 3 Analgesics BRAND NAPRELAN TAB 500MG CR 3 Analgesics BRAND NAPRELAN TAB 750MG CR 3 Gastrointestinal Agents BRAND NEXIUM I.V. MG 3 Gastrointestinal Agents BRAND NEXIUM I.V. 40 MG 3 Dermatological Agents BRAND ORACEA CAP 40MG 3 Enzyme Replacement/Modifiers BRAND PANCREAZE CAP 10500UNT 3 Enzyme Replacement/Modifiers BRAND PANCREAZE CAP 800UNT 3 Enzyme Replacement/Modifiers BRAND PANCREAZE CAP 21000UNT 3 Enzyme Replacement/Modifiers BRAND PANCREAZE CAP 40UNIT 3 Dermatological Agents BRAND PENNSAID SOL 2% 3 Enzyme Replacement/Modifiers BRAND PERTZYE CAP 3 Enzyme Replacement/Modifiers BRAND PERTZYE CAP 3 Antiparasitics BRAND PLAQUENIL TAB 0MG 3 Central Nervous System Agents BRAND QUILLIVANT SUS MG/5ML 3 Gastrointestinal Agents BRAND RENAGEL TAB 400MG 3 Gastrointestinal Agents BRAND RENAGEL TAB 800MG 3 Ophthalmic Agents BRAND RESCULA SOL 0.% 3 Immunological Agents BRAND SIMPONI ARIA SOL 50MG/4ML 3 8 of 9

147 Brand Package with all Clinical Edits Dermatological Agents BRAND STELARA INJ MG/0.5 3 Dermatological Agents BRAND STELARA INJ 90MG/ML 3 Cardiovascular Agents BRAND TENORMIN TAB 100MG 3 Cardiovascular Agents BRAND TENORMIN TAB MG 3 Cardiovascular Agents BRAND TENORMIN TAB 50MG 3 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) BRAND TESTRED CAP 10MG 3 Ophthalmic Agents BRAND TIMOPTIC OCU SOL 0.% OP 3 Ophthalmic Agents BRAND TIMOPTIC OCU SOL 0.5% OP 3 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) BRAND TIROSINT CAP 100MCG 3 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) BRAND TIROSINT CAP 2MCG 3 BRAND TIROSINT CAP 1MCG 3 BRAND TIROSINT CAP 7MCG 3 BRAND TIROSINT CAP MCG 3 BRAND TIROSINT CAP 0MCG 3 BRAND TIROSINT CAP MCG 3 BRAND TIROSINT CAP 50MCG 3 BRAND TIROSINT CAP 75MCG 3 BRAND TIROSINT CAP 88MCG 3 Enzyme Replacement/Modifiers BRAND ULTRESA CAP 800UNT 3 Enzyme Replacement/Modifiers BRAND ULTRESA CAP 700UNT 3 Enzyme Replacement/Modifiers BRAND ULTRESA CAP 23000UNT 3 Anticonvulsants BRAND LAMICTAL XR START KIT (BLUE) 3 Anticonvulsants BRAND LAMICTAL XR START KIT (BLUE) 3 Anticonvulsants BRAND LAMICTAL XR START KIT (BLUE) 3 Anticonvulsants BRAND LAMICTAL XR START KIT (GREEN) 3 Anticonvulsants BRAND LAMICTAL XR START KIT (GREEN) 3 Anticonvulsants BRAND LAMICTAL XR START KIT (GREEN) 3 Anticonvulsants BRAND LAMICTAL XR START KIT (ORANGE) 3 Anticonvulsants BRAND LAMICTAL XR START KIT (ORANGE) 3 Anticonvulsants BRAND LAMICTAL XR START KIT (ORANGE) 3 Anticonvulsants BRAND TRILEPTAL SUS 300MG/5M 3 Anticonvulsants BRAND TRILEPTAL TAB 0MG 3 Anticonvulsants BRAND TRILEPTAL TAB 300MG 3 Anticonvulsants BRAND TRILEPTAL TAB 600MG 3 9 of 9

148 (TTY7) 8AM-8PM, local time, Monday through Friday This drug list was updated on September 21,. For more recent information or other questions, please contact Cigna- HealthSpring Rx (PDP) Customer Service, at or, for TTY users, 7, 8AM-8PM, local time, Monday through Friday. Between October 1 and February, we are also open Saturday and Sunday, or visit This information is available for free in other languages. Please call our customer service number at (TTY 7), Monday through Friday, 8am to 8pm). Esta información está disponible de forma gratuita en otros idiomas. Por favor, llame a nuestro servicio al cliente al (TTY 7), de lunes a Viernes, 8 am a 8 pm.all Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Cigna HealthCare of South Carolina, Inc., Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of Arizona, Inc., Cigna HealthCare of St. Louis, Inc., HealthSpring Life & Health Insurance Company, Inc., HealthSpring of Tennessee, Inc., HealthSpring of Alabama, Inc., HealthSpring of Florida, Inc., Bravo Health Mid-Atlantic, Inc., and Bravo Health Pennsylvania, Inc. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. Cigna