HDHP EHB. Effective January 1, 2014

Transcription

1 HDHP EHB Effective January 1, 2014 Listed below in alphabetical order are the commonly prescribed drugs that are covered under the High Deductible Health Plans. This is not a complete list. If there is a prescription drug that is not on this list, go to Humana.com or call the Customer Service phone number on the back of the member ID card to see if it s covered. - plan specific copayments or cost share for high cost/high-technology drugs often requiring special dispensing conditions. drug coverage varies by plan. Visit Humana.com and log in to MyHumana to view specific prescription drug benefits, including copayments or cost share, limitations and exclusions. Note: Generic drugs are CAPITALIZED. All others are Brand name drugs. IR = immediate, SR = sustained, ER = extended, = quantity limited, PA = prior authorization, ST = Step Therapy Drug Name ABACAVIR 300 MG TABLET Abilify 10 mg tablet, PA Abilify 15 mg tablet, PA Abilify 2 mg tablet, PA Abilify 20 mg tablet, PA Abilify 30 mg tablet, PA Abilify 5 mg tablet, PA Abilify Discmelt 10 mg disintegrating tablet, PA Abilify Discmelt 15 mg disintegrating tablet, PA ACARBOSE 100 MG TABLET ACARBOSE 50 MG TABLET ACEBUTOLOL 200 MG CAPSULE ACEBUTOLOL 400 MG CAPSULE ACETAMINOPHEN-COD #2 TABLET ACETAZOLAMIDE 250 MG TABLET Actonel 150 mg tablet Actonel 30 mg tablet Actonel 35 mg tablet Actonel 5 mg tablet Actos 15 mg tablet, ST Actos 30 mg tablet, ST GNHHKJJHH 713 Page 1 of 28

2 Actos 45 mg tablet, ST Acuvail (PF) 0.45 % Eye Dropperette ACCLOVIR 200 MG CAPSULE ACCLOVIR 400 MG TABLET ADAPALENE 0.1% CREAM ADAPALENE 0.1% GEL Advair Diskus 100 mcg-50 mcg/dose for Inhalation Advair Diskus 250 mcg-50 mcg/dose for Inhalation Advair Diskus 500 mcg-50 mcg/dose for Inhalation Advair HFA 115 mcg-21 mcg/actuation Aerosol Inhaler Advair HFA 230 mcg-21 mcg/actuation Aerosol Inhaler Advair HFA 45 mcg-21 mcg/actuation Aerosol Inhaler Aggrenox 200 mg-25 mg capsule, extended ST ALBUTEROL 5 MG/ML SOLUTION ALBUTEROL SUL 1.25 MG/3 ML SOL ALBUTEROL SULF 2 MG/5 ML SRUP ALBUTEROL SULFATE 2 MG TAB ALENDRONATE SODIUM 10 MG TAB ALENDRONATE SODIUM 35 MG TAB ALENDRONATE SODIUM 40 MG TAB ALENDRONATE SODIUM 5 MG TABLET ALENDRONATE SODIUM 70 MG TAB ALLOPURINOL 300 MG TABLET ALPRAZOLAM 0.25 MG ODT ALPRAZOLAM 0.25 MG TABLET ALPRAZOLAM 0.5 MG ODT ALPRAZOLAM 0.5 MG TABLET ALPRAZOLAM 1 MG ODT ALPRAZOLAM 1 MG TABLET ALPRAZOLAM 2 MG ODT ALPRAZOLAM 2 MG TABLET ALPRAZOLAM ER 0.5 MG TABLET ALPRAZOLAM ER 1 MG TABLET ALPRAZOLAM ER 2 MG TABLET ALPRAZOLAM ER 3 MG TABLET ALPRAZOLAM ODT 0.25 MG TAB ALPRAZOLAM ODT 0.5 MG TAB ALPRAZOLAM ODT 1 MG TAB ALPRAZOLAM ODT 2 MG TAB ALPRAZOLAM XR 0.5 MG TABLET ALPRAZOLAM XR 1 MG TABLET GNHHKJJHH 713 Page 2 of 28

3 ALPRAZOLAM XR 2 MG TABLET ALPRAZOLAM XR 3 MG TABLET AMANTADINE 100 MG TABLET AMIKACIN SULFATE 100 MG/2 ML AMIODARONE HCL 200 MG TABLET AMIODARONE HCL 400 MG TABLET AMITRIPTLINE HCL 10 MG TAB AMITRIPTLINE HCL 100 MG TAB AMITRIPTLINE HCL 25 MG TAB AMITRIPTLINE HCL 50 MG TAB AMLODIPINE BESLATE 10 MG TAB AMLODIPINE BESLATE 2.5 MG TAB AMLODIPINE BESLATE 5 MG TAB AMLODIPINE-BENAZEPRIL MG AMLODIPINE-BENAZEPRIL MG AMLODIPINE-BENAZEPRIL AMLODIPINE-BENAZEPRIL 5-10 MG AMLODIPINE-BENAZEPRIL 5-20 MG AMLODIPINE-BENAZEPRIL 5-40 MG AMOXAPINE 100 MG TABLET AMOXAPINE 150 MG TABLET AMOXAPINE 25 MG TABLET AMOXAPINE 50 MG TABLET Ampyra 10 mg tablet, extended, PA Amturnide 150 mg-5 mg-12.5 mg tablet Amturnide 300 mg-10 mg-12.5 mg tablet Amturnide 300 mg-10 mg-25 mg tablet Amturnide 300 mg-5 mg-12.5 mg tablet Amturnide 300 mg-5 mg-25 mg tablet ANASTROZOLE 1 MG TABLET AndroGel 1 % (50 mg/5 gram) Transdermal Packet ASACOL EC 400 MG TABLET, ST Asacol HD 800 mg tablet, delayed, ST Asmanex Twisthaler 110 mcg (30 doses) Breath Activated Asmanex Twisthaler 220 mcg (120 doses) Breath Activated Asmanex Twisthaler 220 mcg (30 doses) Breath Activated Asmanex Twisthaler 220 mcg (60 doses) Breath Activated ATENOLOL 100 MG TABLET ATENOLOL 25 MG TABLET GNHHKJJHH 713 Page 3 of 28

4 ATENOLOL 50 MG TABLET ATORVASTATIN 10 MG TABLET ATORVASTATIN 20 MG TABLET ATORVASTATIN 40 MG TABLET ATORVASTATIN 80 MG TABLET Avandia 2 mg tablet Avandia 4 mg tablet Avandia 8 mg tablet Avinza 120 mg capsule, extended Avinza 30 mg capsule, extended Avinza 45 mg capsule, extended Avinza 60 mg capsule, extended Avinza 75 mg capsule, extended Avinza 90 mg capsule, extended Avodart 0.5 mg capsule, ST, ST, ST, ST, ST, ST Avonex 30 mcg IM Kit, PA Avonex Administration Pack 30 mcg/0.5 ml IM Kit, PA AZATHIOPRINE 50 MG TABLET Azopt 1 % Eye Drops ST Azor 10 mg-20 mg tablet, ST Azor 10 mg-40 mg tablet, ST Azor 5 mg-20 mg tablet, ST Azor 5 mg-40 mg tablet, ST BENAZEPRIL HCL 10 MG TABLET BENAZEPRIL HCL 40 MG TABLET BENAZEPRIL HCL 5 MG TABLET BENAZEPRIL-HCTZ MG TAB BENAZEPRIL-HCTZ MG TAB BENAZEPRIL-HCTZ MG TAB BENAZEPRIL-HCTZ MG TAB Benicar 20 mg tablet, ST Benicar 40 mg tablet, ST Benicar 5 mg tablet, ST Benicar HCT 20 mg-12.5 mg tablet, ST Benicar HCT 40 mg-12.5 mg tablet, ST Benicar HCT 40 mg-25 mg tablet, ST BETAMETHASONE DP AUG 0.05% GEL BETAMETHASONE VALER 0.12% FOAM Betaseron 0.3 mg Sub-Q Kit, PA BETAXOLOL 10 MG TABLET BICALUTAMIDE 50 MG TABLET Budeprion SR 100 mg tablet, extended GNHHKJJHH 713 Page 4 of 28

5 Budeprion SR 150 mg tablet, extended BUDESONIDE 0.25 MG/2 ML SUSP BUDESONIDE 0.5 MG/2 ML SUSP BUPROPION HCL SR 200 MG TAB BUPROPION HCL XL 150 MG TABLET BUPROPION HCL XL 300 MG TABLET BUPROPION SR 150 MG TABLET BUPROPION SR 150 MG TABLET BUSPIRONE HCL 15 MG TABLET BUSPIRONE HCL 7.5 MG TABLET Butisol 30 mg tablet Butisol 50 mg tablet Bydureon 2 mg SubQ suspension, extended, PA Byetta 10 mcg/0.04 ml per dose Sub-Q Pen Injector, PA Byetta 5 mcg/0.02 ml per dose Sub-Q Pen Injector, PA Bystolic 10 mg tablet, ST Bystolic 2.5 mg tablet, ST Bystolic 20 mg tablet, ST Bystolic 5 mg tablet, ST CALCIPOTRIENE 0.005% CREAM CALCITONIN-SALMON 200 UNITS SP CALCITRIOL 0.5 MCG CAPSULE CANDESARTAN-HCTZ MG TB CANDESARTAN-HCTZ MG TB CANDESARTAN-HCTZ MG TAB CAPTOPRIL 100 MG TABLET CAPTOPRIL 12.5 MG TABLET CAPTOPRIL 25 MG TABLET CAPTOPRIL 50 MG TABLET CAPTOPRIL-HCTZ MG TABLET CAPTOPRIL-HCTZ MG TABLET CAPTOPRIL-HCTZ MG TABLET CAPTOPRIL-HCTZ MG TABLET CARBAMAZEPINE 100 MG TAB CHEW CARBAMAZEPINE 200 MG TABLET CARBAMAZEPINE ER 200 MG TABLET CARBAMAZEPINE ER 400 MG TABLET CARBAMAZEPINE XR 200 MG TABLET CARBAMAZEPINE XR 400 MG TABLET CARBIDOPA-LEVO MG ODT CARBIDOPA-LEVO MG ODT CARBIDOPA-LEVO MG ODT GNHHKJJHH 713 Page 5 of 28

6 CARBIDOPA-LEVO ER TAB CARBIDOPA-LEVO ER TAB CARBIDOPA-LEVODOPA TAB CARBIDOPA-LEVODOPA TAB CARBIDOPA-LEVODOPA TAB Cartia XT 120 mg capsule, extended Cartia XT 240 mg capsule, extended Cartia XT 300 mg capsule, extended CARVEDILOL 12.5 MG TABLET CARVEDILOL 25 MG TABLET CARVEDILOL MG TABLET CARVEDILOL 6.25 MG TABLET Celebrex 100 mg capsule Celebrex 200 mg capsule Celebrex 400 mg capsule Celebrex 50 mg capsule CHLORDIAZEPO-AMITRIPTL CHLORDIAZEPOX-AMITRIPTL CHLORDIAZEPOXIDE 10 MG CAPSULE CHLORDIAZEPOXIDE 25 MG CAPSULE CHLORDIAZEPOXIDE 5 MG CAPSULE CHLOROTHIAZIDE 250 MG TABLET CHLOROTHIAZIDE 500 MG TABLET CILOSTAZOL 100 MG TABLET CILOSTAZOL 50 MG TABLET CIMETIDINE 300 MG TABLET CIMETIDINE 400 MG TABLET CIMETIDINE 800 MG TABLET Cimzia 400 mg/2 ml (200 mg/ml x 2) SubQ Syringe Kit Cimzia Powder for Reconstitution 400 mg (200 mg x 2 vials) Sub-Q Kit CIPROFLOXACIN HCL 250 MG TAB CIPROFLOXACIN HCL 500 MG TAB CIPROFLOXACIN HCL 750 MG TAB CITALOPRAM HBR 10 MG TABLET CITALOPRAM HBR 20 MG TABLET CITALOPRAM HBR 40 MG TABLET CLARITHROMCIN 250 MG TABLET CLARITHROMCIN 500 MG TABLET CLINDAMCIN HCL 75 MG CAPSULE CLONAZEPAM MG DIS TAB CLONAZEPAM 0.25 MG ODT, PA GNHHKJJHH 713 Page 6 of 28

7 CLONAZEPAM 0.5 MG DIS TABLET CLONAZEPAM 0.5 MG TABLET CLONAZEPAM 1 MG DIS TABLET CLONAZEPAM 1 MG TABLET CLONAZEPAM 2 MG ODT CLONAZEPAM 2 MG TABLET CLOPIDOGREL 300 MG TABLET CLOPIDOGREL 75 MG TABLET CLORAZEPATE 15 MG TABLET CLORAZEPATE 3.75 MG TABLET CLORAZEPATE 7.5 MG TABLET CLOZAPINE 100 MG TABLET CLOZAPINE 200 MG TABLET CLOZAPINE 25 MG TABLET CLOZAPINE 50 MG TABLET Combivent 18 mcg-103 mcg/actuation Aerosol Inhaler Comtan 200 mg tablet Coreg CR 10 mg capsule, extended Coreg CR 20 mg capsule, extended Coreg CR 40 mg capsule, extended Coreg CR 80 mg capsule, extended Creon 3,000-9,500-15,000 unit capsule, delayed Crestor 10 mg tablet Crestor 20 mg tablet Crestor 40 mg tablet Crestor 5 mg tablet Crixivan 200 mg capsule Crixivan 400 mg capsule CROMOLN 20 MG/2 ML NEB SOLN CCLOSPORINE MODIFIED 25 MG Cymbalta 20 mg capsule, delayed, PA Cymbalta 30 mg capsule, delayed, PA Cymbalta 60 mg capsule, delayed, PA DANAZOL 100 MG CAPSULE DANAZOL 50 MG CAPSULE DESIPRAMINE 10 MG TABLET DESIPRAMINE 100 MG TABLET DESIPRAMINE 25 MG TABLET DESIPRAMINE 50 MG TABLET DESIPRAMINE 75 MG TABLET DESLORATADINE 2.5 MG ODT, ST GNHHKJJHH 713 Page 7 of 28

8 DESLORATADINE 5 MG ODT, ST DESLORATADINE 5 MG TABLET, ST DESOXIMETASONE 0.05% OINTMENT Detrol 1 mg tablet, ST Detrol 2 mg tablet, ST Detrol LA 2 mg capsule, extended Detrol LA 4 mg capsule, extended DEXAMETHASONE 1 MG TABLET DEXAMETHASONE 1.5 MG TABLET DEXAMETHASONE 2 MG TABLET DEXAMETHASONE 4 MG TABLET DEXAMETHASONE 6 MG TABLET Dexilant 30 mg capsule, delayed, ST Dexilant 60 mg capsule, delayed, ST DEXTROAMP-AMPHET ER 10 MG CAP DEXTROAMP-AMPHET ER 15 MG CAP DEXTROAMP-AMPHET ER 20 MG CAP DEXTROAMP-AMPHET ER 25 MG CAP DEXTROAMP-AMPHET ER 30 MG CAP DEXTROAMP-AMPHET ER 5 MG CAP DIAZEPAM 10 MG TABLET DIAZEPAM 2 MG TABLET DIAZEPAM 5 MG TABLET DICLOFENAC-MISOPROST TB ST DICLOFENAC-MISOPROST TB ST DICLOFENAC-MISOPROST TB ST DICLOFENAC-MISOPROST TB ST DIGOXIN 125 MCG TABLET DIGOXIN 250 MCG TABLET DILTIAZEM 120 MG TABLET DILT-XR 180 mg capsule, extended Diovan 160 mg tablet, ST Diovan 320 mg tablet, ST Diovan 40 mg tablet, ST Diovan 80 mg tablet, ST Diovan HCT 160 mg-12.5 mg tablet, ST Diovan HCT 160 mg-25 mg tablet, ST Diovan HCT 320 mg-12.5 mg tablet, ST Diovan HCT 320 mg-25 mg tablet, ST Diovan HCT 80 mg-12.5 mg tablet, ST DIPRIDAMOLE 25 MG TABLET DIPRIDAMOLE 50 MG TABLET GNHHKJJHH 713 Page 8 of 28

9 DIPRIDAMOLE 75 MG TABLET DONEPEZIL HCL 10 MG TABLET DONEPEZIL HCL 5 MG TABLET DONEPEZIL HCL ODT 10 MG TABLET DONEPEZIL HCL ODT 5 MG TABLET DORZOLAMIDE HCL 2% EE DROPS DORZOLAMIDE-TIMOLOL EE DROPS DOXAZOSIN MESLATE 1 MG TAB DOXAZOSIN MESLATE 2 MG TAB DOXAZOSIN MESLATE 4 MG TAB DOXAZOSIN MESLATE 8 MG TAB DOXCCLINE HC DR 100 MG TAB DOXCCLINE HC DR 75 MG TAB DUETACT 30 mg-2 mg tablet, ST DUETACT 30 mg-4 mg tablet, ST Dulera 100 mcg-5 mcg/actuation HFA Aerosol Inhaler Dulera 200 mcg-5 mcg/actuation HFA Aerosol Inhaler Effient 10 mg tablet Effient 5 mg tablet Eliquis 2.5 mg tablet Eliquis 5 mg tablet Enablex 15 mg tablet, extended Enablex 7.5 mg tablet, extended ENALAPRIL MALEATE 10 MG TAB ENALAPRIL-HCTZ MG TABLET Enbrel 25 mg (1 ml) Sub-Q Kit, PA Enbrel 25 mg/0.5 ml (0.51 ml) Sub-Q Syringe, PA Enbrel 50 mg/ml (0.98 ml) Sub-Q Syringe, PA Endocet 10 mg-325 mg tablet Endocet 10 mg-650 mg tablet Endocet 5 mg-325 mg tablet Endocet 7.5 mg-325 mg tablet Endocet 7.5 mg-500 mg tablet ENOXAPARIN 100 MG/ML SR ENOXAPARIN 100 MG/ML SRINGE ENOXAPARIN 120 MG/0.8 ML SR ENOXAPARIN 150 MG/ML SR ENOXAPARIN 150 MG/ML SRINGE ENOXAPARIN 30 MG/0.3 ML SR ENOXAPARIN 300 MG/3 ML VIAL ENOXAPARIN 40 MG/0.4 ML SR ENOXAPARIN 60 MG/0.6 ML SR GNHHKJJHH 713 Page 9 of 28

10 ENOXAPARIN 80 MG/0.8 ML SR ENTACAPONE 200 MG TABLET Epivir 300 mg tablet Epivir HBV 100 mg tablet ESCITALOPRAM 10 MG TABLET ESCITALOPRAM 20 MG TABLET ESCITALOPRAM 5 MG TABLET ESCITALOPRAM OXALATE 5 MG/5 ML ESTAZOLAM 1 MG TABLET ESTAZOLAM 2 MG TABLET ESTROPIPATE 0.625(0.75 MG) TAB ESTROPIPATE 1.25(1.5 MG) TAB ESTROPIPATE 2.5(3 MG) TAB Evista 60 mg tablet Exelon 4.6 mg/24 hour Transderm 24 hr Patch Exelon 9.5 mg/24 hour Transderm 24 hr Patch Exforge 10 mg-160 mg tablet, ST Exforge 10 mg-320 mg tablet, ST Exforge 5 mg-160 mg tablet, ST Exforge 5 mg-320 mg tablet, ST Exforge HCT 10 mg-160 mg-12.5 mg tablet, ST Exforge HCT 10 mg-160 mg-25 mg tablet, ST Exforge HCT 10 mg-320 mg-25 mg tablet, ST Exforge HCT 5 mg-160 mg-12.5 mg tablet, ST Exforge HCT 5 mg-160 mg-25 mg tablet, ST FAMCICLOVIR 125 MG TABLET FAMCICLOVIR 250 MG TABLET FAMCICLOVIR 500 MG TABLET FAMOTIDINE 20 MG TABLET FAMOTIDINE 40 MG TABLET FELODIPINE ER 10 MG TABLET FELODIPINE ER 2.5 MG TABLET FELODIPINE ER 5 MG TABLET FENOFIBRATE 134 MG CAPSULE FENOFIBRATE 145 MG TABLET FENOFIBRATE 200 MG CAPSULE FENOFIBRATE 48 MG TABLET FENOFIBRATE 54 MG TABLET FENOFIBRATE 67 MG CAPSULE FENTANL 100 MCG/HR PATCH FINASTERIDE 5 MG TABLET Flovent Diskus 100 mcg/actuation for Inhalation GNHHKJJHH 713 Page 10 of 28

11 Flovent Diskus 250 mcg/actuation for Inhalation Flovent Diskus 50 mcg/actuation for Inhalation Flovent HFA 110 mcg/actuation Aerosol Inhaler Flovent HFA 220 mcg/actuation Aerosol Inhaler Flovent HFA 44 mcg/actuation Aerosol Inhaler FLUOROURACIL 2% TOPICAL SOLN FLUOROURACIL 5% TOP SOLUTION FLUOXETINE HCL 10 MG CAPSULE FLUOXETINE HCL 20 MG CAPSULE FLUOXETINE HCL 40 MG CAPSULE FLUOXETINE HCL 60 MG TABLET FLURAZEPAM 15 MG CAPSULE FLURAZEPAM 30 MG CAPSULE FLUVASTATIN SODIUM 20 MG CAP FLUVASTATIN SODIUM 40 MG CAP FONDAPARINUX 2.5 MG/0.5 ML SR FONDAPARINUX 5 MG/0.4 ML SR FONDAPARINUX 7.5 MG/0.6 ML SR Forteo 20 mcg/dose (600 mcg/2.4 ml) Sub-Q Pen Injector FORTICAL 200 unit/actuation Nasal Spray FOSINOPRIL SODIUM 10 MG TAB FUROSEMIDE 20 MG TABLET FUROSEMIDE 80 MG TABLET GABAPENTIN 300 MG CAPSULE GABAPENTIN 400 MG CAPSULE GABAPENTIN 600 MG TABLET GABAPENTIN 800 MG TABLET GALANTAMINE ER 16 MG CAPSULE GALANTAMINE ER 24 MG CAPSULE GALANTAMINE ER 8 MG CAPSULE GALANTAMINE HBR 12 MG TABLET GALANTAMINE HBR 4 MG TABLET GALANTAMINE HBR 8 MG TABLET, PA Gilenya 0.5 mg capsule, PA GLIMEPIRIDE 1 MG TABLET GLIMEPIRIDE 2 MG TABLET GLIMEPIRIDE 4 MG TABLET GLIPIZIDE 10 MG TABLET GLIPIZIDE ER 2.5 MG TABLET GLIPIZIDE XL 2.5 MG TABLET GLIPIZIDE-METFORMIN MG GLIPIZIDE-METFORMIN MG GNHHKJJHH 713 Page 11 of 28

12 GLIPIZIDE-METFORMIN MG Glumetza 500 mg tablet, extended, ST GLBURIDE 2.5 MG TABLET GLBURIDE MICRO 1.5 MG TAB GLBURIDE MICRO 3 MG TABLET GLBURIDE MICRO 6 MG TABLET GLBURIDE-METFORMIN MG GLBURIDE-METFORMIN MG GLBURID-METFORMIN MG Golytely g-21.5 g-6.36 g-5.53 g Packet Golytely 236 g g-6.74 g-5.86 g Oral Solution HALOPERIDOL 1 MG TABLET HALOPERIDOL 2 MG TABLET Hectorol 0.5 mcg capsule Hectorol 1 mcg capsule Hectorol 2.5 mcg capsule Humalog Mix unit/ml (50-50) Susp, Sub-Q Inj Humalog Mix unit/ml (75-25) Susp, Sub-Q Inj Humira 20 mg/0.4 ml Sub-Q Kit, PA Humira 40 mg/0.8 ml Sub-Q Kit, PA Humira Crohn s Disease Starter Pack 40 mg/0.8 ml SubQ Pen Kit Humulin 70/ unit/ml (70-30) Susp, Sub-Q Inj Humulin 70/30 Pen 100 unit/ml (70-30) SubQ Humulin N 100 unit/ml Susp, Sub-Q Inj Humulin N Pen 100 unit/ml (3 ml) SubQ Humulin R 100 unit/ml Injection Humulin R U-500 Concentrated Insulin 500 unit/ml Sub-Q HDRALAZINE 10 MG TABLET HDRALAZINE 100 MG TABLET HDRALAZINE 25 MG TABLET HDRALAZINE 50 MG TABLET HDROCHLOROTHIAZIDE 25 MG TAB HDROCORTISONE 0.1% SOLN HDROCORTISONE BUT 0.1% CREAM HDROCORTISONE BUTR 0.1% OINT HDROXZINE HCL 10 MG TABLET HDROXZINE HCL 25 MG TABLET IBANDRONATE SODIUM 150 MG TAB IBUPROFEN 600 MG TABLET GNHHKJJHH 713 Page 12 of 28, PA

13 IBUPROFEN 800 MG TABLET Ilevro 0.3 % Eye Drops Invega Sustenna 117 mg/0.75 ml IM Syringe, PA Invega Sustenna 156 mg/ml (1 ml) IM Syringe, PA Invega Sustenna 234 mg/1.5 ml IM Syringe, PA Invega Sustenna 39 mg/0.25 ml IM Syringe, PA Invega Sustenna 78 mg/0.5 ml IM Syringe, PA IRBESARTAN 150 MG TABLET IRBESARTAN 300 MG TABLET IRBESARTAN 75 MG TABLET IRBESARTAN-HCTZ MG TB IRBESARTAN-HCTZ MG TB Jalyn 0.5 mg-0.4 mg capsule, extended Janumet 50 mg-1,000 mg tablet, ST Janumet 50 mg-500 mg tablet, ST Janumet XR 100 mg-1,000 mg tablet, extended Janumet XR 50 mg-1,000 mg tablet, extended GNHHKJJHH 713 Page 13 of 28, ST, ST Janumet XR 50 mg-500 mg tablet, extended, ST Januvia 100 mg tablet, ST Januvia 25 mg tablet, ST Januvia 50 mg tablet, ST Juvisync 100 mg-10 mg tablet, ST Juvisync 100 mg-20 mg tablet, ST Juvisync 100 mg-40 mg tablet, ST Kombiglyze XR 2.5 mg-1,000 mg tablet, extended Kombiglyze XR 5 mg-1,000 mg tablet, extended Kombiglyze XR 5 mg-500 mg tablet, extended LABETALOL HCL 100 MG TABLET LABETALOL HCL 200 MG TABLET LABETALOL HCL 300 MG TABLET Lamictal XR 250 mg tablet, extended LAMOTRIGINE 100 MG TABLET LAMOTRIGINE 150 MG TABLET LAMOTRIGINE 200 MG TABLET LAMOTRIGINE 25 MG DISPER TAB LAMOTRIGINE 25 MG TABLET LAMOTRIGINE 5 MG DISPER TABLET LAMOTRIGINE ER 100 MG TABLET LAMOTRIGINE ER 200 MG TABLET, ST, ST, ST

14 LAMOTRIGINE ER 25 MG TABLET LAMOTRIGINE ER 250 MG TABLET LAMOTRIGINE ER 300 MG TABLET LAMOTRIGINE ER 50 MG TABLET LANSOPRAZOLE DR 30 MG CAPSULE Lantus 100 unit/ml Sub-Q Latuda 20 mg tablet, PA Latuda 40 mg tablet, PA Latuda 80 mg tablet, PA LEFLUNOMIDE 10 MG TABLET Lescol XL 80 mg tablet, extended, ST Letairis 10 mg tablet, PA Letairis 5 mg tablet, PA LETROZOLE 2.5 MG TABLET Levemir 100 unit/ml Sub-Q Levemir Flexpen 100 unit/ml (3 ml) Sub-Q Insulin Pen LEVETIRACETAM 1,000 MG TABLET LEVETIRACETAM 250 MG TABLET LEVETIRACETAM 500 MG TABLET LEVETIRACETAM 750 MG TABLET LEVOCETIRIZINE 5 MG TABLET LEVOFLOXACIN 250 MG TABLET LEVOFLOXACIN 500 MG TABLET LEVOTHROXINE 112 MCG TABLET LEVOTHROXINE 88 MCG TABLET Levoxyl 100 mcg tablet Levoxyl 112 mcg tablet Levoxyl 125 mcg tablet Levoxyl 137 mcg tablet Levoxyl 150 mcg tablet Levoxyl 175 mcg tablet Levoxyl 200 mcg tablet Levoxyl 25 mcg tablet Levoxyl 50 mcg tablet Levoxyl 75 mcg tablet Levoxyl 88 mcg tablet Linzess 145 mcg capsule Linzess 290 mcg capsule LISINOPRIL 10 MG TABLET LISINOPRIL 20 MG TABLET LISINOPRIL 30 MG TABLET LISINOPRIL 40 MG TABLET GNHHKJJHH 713 Page 14 of 28

15 LISINOPRIL-HCTZ MG TAB LISINOPRIL-HCTZ MG TAB LISINOPRIL-HCTZ MG TAB LITHIUM CARBONATE 150 MG CAP LITHIUM CARBONATE ER 300 MG TB Livalo 1 mg tablet, ST Livalo 2 mg tablet, ST Livalo 4 mg tablet, ST LORAZEPAM 0.5 MG TABLET LORAZEPAM 1 MG TABLET LORAZEPAM 2 MG TABLET LOSARTAN POTASSIUM 100 MG TAB LOSARTAN POTASSIUM 25 MG TAB LOSARTAN POTASSIUM 50 MG TAB LOSARTAN-HCTZ MG TAB LOSARTAN-HCTZ MG TAB LOSARTAN-HCTZ MG TAB LOVASTATIN 10 MG TABLET LOVASTATIN 20 MG TABLET LOVASTATIN 40 MG TABLET Lovaza 1 gram capsule Lumigan 0.01 % Eye Drops Lyrica 100 mg capsule, PA Lyrica 150 mg capsule, PA Lyrica 20 mg/ml Oral Soln, PA Lyrica 200 mg capsule, PA Lyrica 225 mg capsule, PA Lyrica 25 mg capsule, PA Lyrica 300 mg capsule, PA Lyrica 50 mg capsule, PA Lyrica 75 mg capsule, PA MELOXICAM 15 MG TABLET MELOXICAM 7.5 MG TABLET Mepron 750 mg/5 ml Oral Susp METFORMIN HCL 1,000 MG TABLET METFORMIN HCL 500 MG TABLET METFORMIN HCL 850 MG TABLET METFORMIN HCL ER 500 MG TABLET METFORMIN HCL ER 750 MG TABLET METHOTREXATE 2.5 MG TABLET METHLDOPA 250 MG TABLET METHLDOPA 500 MG TABLET GNHHKJJHH 713 Page 15 of 28

16 METHLPHENIDATE CD 10 MG CAP METHLPHENIDATE CD 50 MG CAP METHLPHENIDATE CD 60 MG CAP METHLPHENIDATE ER 27 MG TAB METOCLOPRAMIDE 10 MG TABLET METOCLOPRAMIDE 5 MG TABLET METOPROLOL SUCC ER 200 MG TAB METOPROLOL SUCC ER 25 MG TAB METOPROLOL TARTRATE 100 MG TAB METOPROLOL TARTRATE 25 MG TAB METOPROLOL TARTRATE 50 MG TAB METOPROLOL-HCTZ MG TAB METOPROLOL-HCTZ MG TAB METOPROLOL-HCTZ MG TAB MINOXIDIL 10 MG TABLET MINOXIDIL 2.5 MG TABLET MIRTAZAPINE 15 MG ODT MIRTAZAPINE 15 MG TABLET MIRTAZAPINE 30 MG ODT MIRTAZAPINE 30 MG TABLET MIRTAZAPINE 45 MG ODT MIRTAZAPINE 45 MG TABLET MIRTAZAPINE 7.5 MG TABLET MISOPROSTOL 100 MCG TABLET MODAFINIL 100 MG TABLET, PA MODAFINIL 200 MG TABLET, PA MONTELUKAST SOD 10 MG TABLET MONTELUKAST SOD 4 MG GRANULES MONTELUKAST SOD 4 MG TAB CHEW MONTELUKAST SOD 5 MG TAB CHEW MORPHINE SULF ER 100 MG TABLET MORPHINE SULF ER 30 MG TABLET MUPIROCIN 2% CREAM MCOPHENOLATE 250 MG CAPSULE MCOPHENOLATE 500 MG TABLET Namenda 10 mg tablet Namenda 10 mg/5 ml Oral Soln Namenda 5 mg tablet Namenda Titration Pak 5 mg-10 mg tablets in a dose pack NAPROXEN 250 MG TABLET NAPROXEN 375 MG TABLET NAPROXEN 500 MG TABLET GNHHKJJHH 713 Page 16 of 28

17 NARATRIPTAN 1 MG TABLET NARATRIPTAN 2.5 MG TABLET NARATRIPTAN HCL 1 MG TABLET NARATRIPTAN HCL 2.5 MG TABLET Nasonex 50 mcg/actuation Spray NATEGLINIDE 120 MG TABLET NATEGLINIDE 60 MG TABLET Nevanac 0.1 % Eye Drops Nexium 20 mg capsule, delayed Nexium 40 mg capsule, delayed Niaspan Extended-Release 1,000 mg tablet, extended Niaspan Extended-Release 500 mg tablet, extended Niaspan Extended-Release 750 mg tablet, extended NIFEDIPINE ER 30 MG TABLET NIFEDIPINE ER 60 MG TABLET NIFEDIPINE ER 90 MG TABLET NISOLDIPINE ER 17 MG TABLET NISOLDIPINE ER 20 MG TABLET NISOLDIPINE ER 25.5 MG TABLET NISOLDIPINE ER 30 MG TABLET NISOLDIPINE ER 34 MG TABLET NISOLDIPINE ER 40 MG TABLET NISOLDIPINE ER 8.5 MG TABLET NITROGLCERIN 0.2 MG/HR PATCH NITROGLCERIN 0.4 MG/HR PATCH NITROGLCERIN 0.6 MG/HR PATCH NORTRIPTLINE HCL 75 MG CAP Norvir 100 mg tablet Novolin 70/ unit/ml (70-30) Susp, Sub-Q Inj Novolin N 100 unit/ml Susp, Sub-Q Inj Novolin R 100 unit/ml Injection Novolog 100 unit/ml Sub-Q Novolog Flexpen 100 unit/ml Sub-Q Novolog Mix unit/ml (70-30) Sub-Q Novolog Mix FlexPen 100 unit/ml (70-30) Sub-Q NuLTEL with Flavor Packs 420 gram Oral Solution OLANZAPINE 10 MG TABLET OLANZAPINE 15 MG TABLET OLANZAPINE 2.5 MG TABLET ST PA PA PA GNHHKJJHH 713 Page 17 of 28

18 OLANZAPINE 20 MG TABLET OLANZAPINE 5 MG TABLET OLANZAPINE 7.5 MG TABLET OLANZAPINE ODT 10 MG TABLET OLANZAPINE ODT 15 MG TABLET OLANZAPINE ODT 20 MG TABLET OLANZAPINE ODT 5 MG TABLET OMEPRAZOLE DR 20 MG CAPSULE OMEPRAZOLE DR 40 MG CAPSULE Onfi 10 mg tablet, PA Onfi 20 mg tablet, PA Onfi 5 mg tablet, PA Onglyza 2.5 mg tablet, ST Onglyza 5 mg tablet, ST OXAZEPAM 10 MG CAPSULE OXAZEPAM 15 MG CAPSULE OXAZEPAM 30 MG CAPSULE OXBUTNIN 5 MG TABLET OXBUTNIN CL ER 10 MG TABLET OXBUTNIN CL ER 15 MG TABLET OXBUTNIN CL ER 5 MG TABLET OXCODONE HCL 10 MG TABLET OXCODONE HCL 20 MG TABLET OXMORPHONE HCL ER 10 MG TAB OXMORPHONE HCL ER 20 MG TAB OXMORPHONE HCL ER 30 MG TAB OXMORPHONE HCL ER 40 MG TAB OXMORPHONE HCL ER 5 MG TABLET Pancreaze 10,500-25,000-43,750 unit capsule, delayed Pancreaze 16,800-40,000-70,000 unit capsule, delayed Pancreaze 21,000-37,000-61,000 unit capsule, delayed Pancreaze 4,200-10,000-17,500 unit capsule, delayed PANTOPRAZOLE SOD DR 20 MG TAB PANTOPRAZOLE SOD DR 40 MG TAB Pataday 0.2 % Eye Drops Patanase 0.6 % Nasal Spray, ST Pegasys 180 mcg/ml Sub-Q, PA PegIntron 50 mcg/0.5 ml Sub-Q Kit, PA PegIntron Redipen 120 mcg/0.5 ml SubQ Kit, PA GNHHKJJHH 713 Page 18 of 28

19 PegIntron Redipen 150 mcg/0.5 ml SubQ Kit, PA PegIntron Redipen 50 mcg/0.5 ml SubQ Kit, PA PegIntron Redipen 80 mcg/0.5 ml SubQ Kit, PA Pennsaid 1.5 % Topical Drops PHENOBARBITAL 100 MG TABLET PHENOBARBITAL 15 MG TABLET PHENOBARBITAL 16.2 MG TABLET PHENOBARBITAL 20 MG/5 ML ELIX PHENOBARBITAL 20 MG/5 ML SOLN PHENOBARBITAL 30 MG TABLET PHENOBARBITAL 32.4 MG TABLET PHENOBARBITAL 60 MG TABLET PHENOBARBITAL 64.8 MG TABLET PHENOBARBITAL 97.2 MG TABLET Phenytek 200 mg capsule Phenytek 300 mg capsule PHENTOIN 50 MG INFATAB PHENTOIN 50 MG TABLET CHEW PhosLo 667 mg capsule PIOGLITAZ-GLIMEPIR 30-2 MG TAB, ST PIOGLITAZ-GLIMEPIR 30-4 MG TAB, ST PIOGLITAZONE HCL 15 MG TABLET PIOGLITAZONE HCL 30 MG TABLET PIOGLITAZONE HCL 45 MG TABLET PIOGLITAZONE-METFORMIN PIOGLITAZONE-METFORMIN POTASSIUM CITRATE ER 10 MEQ TB POTASSIUM CITRATE ER 5 MEQ TAB Potiga 200 mg tablet PA Potiga 300 mg tablet PA Potiga 400 mg tablet PA Potiga 50 mg tablet PA Pradaxa 150 mg capsule Pradaxa 75 mg capsule PRAMIPEXOLE MG TABLET PRAMIPEXOLE 0.25 MG TABLET PRAMIPEXOLE 0.5 MG TABLET PRAMIPEXOLE 0.75 MG TABLET PRAMIPEXOLE 1 MG TABLET PRAMIPEXOLE 1.5 MG TABLET PRAVASTATIN SODIUM 10 MG TAB PRAVASTATIN SODIUM 20 MG TAB GNHHKJJHH 713 Page 19 of 28

20 PRAVASTATIN SODIUM 40 MG TAB PRAVASTATIN SODIUM 80 MG TAB PREDNISONE 1 MG TABLET PREDNISONE 10 MG TABLET PREDNISONE 2.5 MG TABLET Premarin mg/gram Vaginal Cream PRIMAQUINE 26.3 MG TABLET Pristiq 100 mg tablet, extended Pristiq 50 mg tablet, extended ProAir HFA 90 mcg/actuation Aerosol Inhaler PROCHLORPERAZINE 25 MG SUPP Procrit 10,000 unit/ml Injection, PA Procrit 2,000 unit/ml Injection, PA Procrit 20,000 unit/ml Injection, PA Procrit 3,000 unit/ml Injection, PA Procrit 4,000 unit/ml Injection, PA Procrit 40,000 unit/ml Injection, PA Prolia 60 mg/ml Sub-Q Syringe PROMETHAZINE 12.5 MG SUPPOS PROMETHAZINE 25 MG SUPPOSITOR PROPAFENONE HCL ER 225 MG CAP PROPAFENONE HCL SR 325 MG CAP PROPAFENONE HCL SR 425 MG CAP PROPRANOLOL 40 MG TABLET PROPRANOLOL 60 MG TABLET PROPRANOLOL 80 MG TABLET Proventil HFA 90 mcg/actuation Aerosol Inhaler QUETIAPINE FUMARATE 100 MG TAB QUETIAPINE FUMARATE 200 MG TAB QUETIAPINE FUMARATE 25 MG TAB QUETIAPINE FUMARATE 300 MG TAB QUETIAPINE FUMARATE 400 MG TAB QUETIAPINE FUMARATE 50 MG TAB QUININE SULFATE 324 MG CAPSULE Qvar 40 mcg/actuation Metered Aerosol Oral Inhaler Qvar 80 mcg/actuation Metered Aerosol Oral Inhaler RAMIPRIL 1.25 MG CAPSULE RAMIPRIL 10 MG CAPSULE RAMIPRIL 2.5 MG CAPSULE RAMIPRIL 5 MG CAPSULE RANITIDINE 150 MG CAPSULE RANITIDINE 150 MG TABLET, PA, PA GNHHKJJHH 713 Page 20 of 28

21 RANITIDINE 300 MG CAPSULE RANITIDINE 300 MG TABLET Rebif 22 mcg/0.5 ml Sub-Q Syringe, PA Rebif 44 mcg/0.5 ml Sub-Q Syringe, PA Rebif Titration Pack 8.8 mcg/0.2 ml-22 mcg/0.5 ml Sub-Q Syringe Remicade 100 mg IV Solution Renvela 0.8 gram Oral Powder Packet Renvela 2.4 gram Oral Powder Packet Renvela 800 mg tablet Restasis 0.05 % Eye Dropperette RISPERIDONE 0.25 MG ODT RISPERIDONE 0.25 MG TABLET RISPERIDONE 0.5 MG ODT RISPERIDONE 0.5 MG TABLET RISPERIDONE 1 MG TABLET RISPERIDONE 2 MG ODT RISPERIDONE 2 MG TABLET RISPERIDONE 3 MG ODT RISPERIDONE 3 MG TABLET RISPERIDONE 4 MG ODT RISPERIDONE 4 MG TABLET RIVASTIGMINE 1.5 MG CAPSULE RIVASTIGMINE 3 MG CAPSULE RIVASTIGMINE 4.5 MG CAPSULE RIVASTIGMINE 6 MG CAPSULE RIZATRIPTAN 10 MG ODT RIZATRIPTAN 10 MG TABLET RIZATRIPTAN 5 MG ODT RIZATRIPTAN 5 MG TABLET ROPINIROLE HCL 0.25 MG TABLET ROPINIROLE HCL 0.5 MG TABLET ROPINIROLE HCL 1 MG TABLET ROPINIROLE HCL 2 MG TABLET ROPINIROLE HCL 3 MG TABLET ROPINIROLE HCL 4 MG TABLET ROPINIROLE HCL 5 MG TABLET Sensipar 30 mg tablet Sensipar 60 mg tablet Sensipar 90 mg tablet Serevent Diskus 50 mcg/dose for Inhalation Seroquel XR 150 mg tablet, extended Seroquel XR 200 mg tablet, extended, PA PA GNHHKJJHH 713 Page 21 of 28

22 Seroquel XR 300 mg tablet, extended Seroquel XR 400 mg tablet, extended Seroquel XR 50 mg tablet, extended SERTRALINE HCL 100 MG TABLET SERTRALINE HCL 25 MG TABLET SERTRALINE HCL 50 MG TABLET SILDENAFIL 20 MG TABLET, PA Simcor 1,000 mg-40 mg tablet, extended, ST Simcor 500 mg-20 mg tablet, extended, ST Simcor 500 mg-40 mg tablet, extended, ST Simcor 750 mg-20 mg tablet, extended, ST SIMVASTATIN 10 MG TABLET SIMVASTATIN 20 MG TABLET SIMVASTATIN 40 MG TABLET SIMVASTATIN 5 MG TABLET SIMVASTATIN 80 MG TABLET SODIUM LACTATE 1/6MOLAR INJ Soriatane 17.5 mg capsule SOTALOL 160 MG TABLET SOTALOL 240 MG TABLET SOTALOL 80 MG TABLET Spiriva with HandiHaler 18 mcg & inhalation capsules SPIRONOLACTONE 100 MG TABLET SPIRONOLACTONE 25 MG TABLET SPIRONOLACTONE 50 MG TABLET Stelara 45 mg/0.5 ml Sub-Q Syringe Stelara 90 mg/ml Sub-Q Syringe PA, PA, PA Suboxone 2 mg-0.5 mg sublingual film, PA Suboxone 8 mg-2 mg sublingual film, PA SULFAMETHOXAZOLE-TMP DS TABLET SULFAMETHOXAZOLE-TMP SS TABLET SUMATRIPTAN 6 MG/0.5 ML VIAL SUMATRIPTAN SUCC 100 MG TABLET SUMATRIPTAN SUCC 25 MG TABLET SUMATRIPTAN SUCC 50 MG TABLET Suprep 17.5 gram-3.13 gram-1.6 gram Oral Solution Sustiva 200 mg capsule Sustiva 50 mg capsule Sustiva 600 mg tablet Symbicort 160 mcg-4.5 mcg/actuation HFA Aerosol Inhaler Symbicort 80 mcg-4.5 mcg/actuation HFA Aerosol Inhaler GNHHKJJHH 713 Page 22 of 28

23 TAMOXIFEN 10 MG TABLET TAMOXIFEN 20 MG TABLET TAMSULOSIN HCL 0.4 MG CAPSULE Tekamlo 150 mg-10 mg tablet Tekamlo 150 mg-5 mg tablet Tekamlo 300 mg-10 mg tablet Tekamlo 300 mg-5 mg tablet Tekturna 150 mg tablet Tekturna 300 mg tablet Tekturna HCT 150 mg-12.5 mg tablet Tekturna HCT 150 mg-25 mg tablet Tekturna HCT 300 mg-12.5 mg tablet Tekturna HCT 300 mg-25 mg tablet TEMAZEPAM 15 MG CAPSULE TEMAZEPAM 22.5 MG CAPSULE TEMAZEPAM 30 MG CAPSULE TEMAZEPAM 7.5 MG CAPSULE TIAGABINE HCL 2 MG TABLET TIAGABINE HCL 4 MG TABLET TIMOLOL 0.25% EE DROPS TIMOLOL 0.25% GEL-SOLUTION TIMOLOL 0.25% GFS GEL-SOLUTION TIMOLOL 0.5% EE DROPS TIMOLOL 0.5% GEL-SOLUTION TIMOLOL 0.5% GFS GEL-SOLUTION TIMOLOL MALEATE 10 MG TABLET TIMOLOL MALEATE 20 MG TABLET TIMOLOL MALEATE 5 MG TABLET TINIDAZOLE 250 MG TABLET TINIDAZOLE 500 MG TABLET TOLTERODINE TARTRATE 1 MG TAB TOLTERODINE TARTRATE 2 MG TAB TOPIRAMATE 100 MG TABLET TOPIRAMATE 15 MG SPRINKLE CAP TOPIRAMATE 200 MG TABLET TOPIRAMATE 25 MG SPRINKLE CAP TOPIRAMATE 25 MG TABLET TOPIRAMATE 50 MG TABLET TORSEMIDE 10 MG TABLET TORSEMIDE 100 MG TABLET TORSEMIDE 20 MG TABLET TORSEMIDE 5 MG TABLET GNHHKJJHH 713 Page 23 of 28

24 Toviaz 4 mg tablet, extended Toviaz 8 mg tablet, extended Travatan Z % Eye Drops TRAZODONE 150 MG TABLET TRAZODONE 300 MG TABLET Trelstar 22.5 mg IM Susp Treximet 85 mg-500 mg tablet TRIAMTERENE-HCTZ MG CP TRIAMTERENE-HCTZ MG TB TRIAMTERENE-HCTZ MG TAB TRIAZOLAM MG TABLET TRIAZOLAM 0.25 MG TABLET, PA Tribenzor 20 mg-5 mg-12.5 mg tablet, ST Tribenzor 40 mg-10 mg-12.5 mg tablet, ST Tribenzor 40 mg-10 mg-25 mg tablet, ST Tribenzor 40 mg-5 mg-12.5 mg tablet, ST Tribenzor 40 mg-5 mg-25 mg tablet, ST Tricor 145 mg tablet, ST Tricor 48 mg tablet, ST Trizivir 300 mg-150 mg-300 mg tablet TROSPIUM CHLORIDE 20 MG TABLET TROSPIUM CHLORIDE ER 60 MG CAP Tudorza Pressair 400 mcg/actuation Breath Activated, PA VALSARTAN-HCTZ MG TAB VALSARTAN-HCTZ MG TAB VALSARTAN-HCTZ MG TAB VALSARTAN-HCTZ MG TAB VALSARTAN-HCTZ MG TAB VENLAFAXINE HCL 100 MG TABLET VENLAFAXINE HCL 25 MG TABLET VENLAFAXINE HCL 37.5 MG TABLET VENLAFAXINE HCL 50 MG TABLET VENLAFAXINE HCL 75 MG TABLET VENLAFAXINE HCL ER 150 MG CAP VENLAFAXINE HCL ER 150 MG TAB VENLAFAXINE HCL ER 225 MG TAB VENLAFAXINE HCL ER 37.5 MG CAP VENLAFAXINE HCL ER 75 MG CAP VENLAFAXINE HCL ER 75 MG TAB Ventolin HFA 90 mcg/actuation Aerosol Inhaler Veramyst 27.5 mcg/actuation Nasal Spray VERAPAMIL 120 MG TABLET GNHHKJJHH 713 Page 24 of 28

25 VERAPAMIL 80 MG TABLET Vesicare 10 mg tablet Vesicare 5 mg tablet Victoza 3-Pak 0.6 mg/0.1 ml (18 mg/3 ml) Sub-Q Pen Injector Viibryd 10 mg (7)-20 mg (7)-40 mg(16) tablets in a dose pack Vimovo 375 mg-20 mg tablet,immediate & delayed Vimovo 500 mg-20 mg tablet,immediate & delayed Vimpat 10 mg/ml Oral Soln Viread 150 mg tablet Viread 200 mg tablet Viread 250 mg tablet Viread 300 mg tablet Viread 40 mg/scoop (40 mg/gram) Oral Powder Voltaren 1 % Topical Gel, ST, ST, ST, ST Vytorin mg-10 mg tablet, ST Vytorin mg-20 mg tablet, ST Vytorin mg-40 mg tablet, ST Vytorin mg-80 mg tablet, ST WARFARIN SODIUM 1 MG TABLET WARFARIN SODIUM 2 MG TABLET WARFARIN SODIUM 2.5 MG TABLET WARFARIN SODIUM 3 MG TABLET WARFARIN SODIUM 4 MG TABLET WARFARIN SODIUM 5 MG TABLET WARFARIN SODIUM 6 MG TABLET WARFARIN SODIUM 7.5 MG TABLET WelChol 625 mg tablet Xarelto 10 mg tablet Xarelto 15 mg tablet Xarelto 20 mg tablet ZAFIRLUKAST 10 MG TABLET ZAFIRLUKAST 20 MG TABLET Zemplar 1 mcg capsule Zemplar 2 mcg capsule Zemplar 4 mcg capsule Zenpep 10,000-34,000-55,000 unit capsule, delayed Zenpep 15,000-51,000-82,000 unit capsule, delayed GNHHKJJHH 713 Page 25 of 28

26 Zenpep 20,000-68, ,000 unit capsule, delayed Zenpep 5,000-17,000-27,000 unit capsule, delayed Zetia 10 mg tablet ZIPRASIDONE HCL 20 MG CAPSULE ZIPRASIDONE HCL 40 MG CAPSULE ZIPRASIDONE HCL 60 MG CAPSULE ZIPRASIDONE HCL 80 MG CAPSULE ZOLPIDEM TART ER 12.5 MG TAB ZOLPIDEM TART ER 6.25 MG TAB ZOLPIDEM TARTRATE 10 MG TABLET ZOLPIDEM TARTRATE 5 MG TABLET ZONISAMIDE 100 MG CAPSULE ZONISAMIDE 25 MG CAPSULE ZONISAMIDE 50 MG CAPSULE ZOSTAVAX (PF) 19,400 unit Sub-Q Susp Zyclara 3.75 % Topical Cream Packet Zymaxid 0.5 % Eye Drops, ST, ST Zytiga 250 mg tablet, PA ST GNHHKJJHH 713 Page 26 of 28

27 GNHHKJJHH 713 Page 27 of 28

28 Humana Plans are offered by the Family of Insurance and Health Plan Companies including Humana Medical Plan, Inc., Humana Employers Health Plan of Georgia, Inc., Humana Health Plan, Inc., Humana Health Benefit Plan of Louisiana, Inc., Humana Health Plans of Michigan, Inc., Humana Health Plan of Ohio, Inc., Humana Health Plans of Puerto Rico, Inc. License # , Humana Wisconsin Health Organization Insurance Corporation, or Humana Health Plan of Texas, Inc. A Health Organization or insured by Humana Health Insurance Company of Florida, Inc., Humana Health Plan, Inc., Humana Health Benefit Plan of Louisiana, Inc., Humana Insurance Company, Humana Insurance Company of Kentucky, Emphesys Insurance Company, or Humana Insurance of Puerto Rico, Inc. License # or administered by Humana Insurance Company or Humana Health Plan, Inc. For Arizona Residents: Offered by Humana Health Plan, Inc. or insured by Emphesys Insurance Company or insured or administered by Humana Insurance Company or Humana Health Plan, Inc. Please refer to your Benefit Plan Document (Certificate of Coverage/Insurance or Summary Plan Description) for more information on the company providing your benefits. Our health benefit plans have limitations and exclusions. Humana.com GNHHKJJHH 713 Page 28 of 28