Methodist Outpatient Generic Purchase Formulary

Transcription

1 Allergy, Cold Analgesic (Anti- Inflammatory, Antimigraine) ANTITUSSIVES Tessalon BENZONATATE 100 MG CAP 30 9 PHENOTHIAZINE DERIVATIVES Phenergan PROMETHAZINE HCL 12.5 MG SUP PHENOTHIAZINE DERIVATIVES Phenergan PROMETHAZINE HCL 12.5 MG TAB 30 3 EXPECTORANT Mucinex GUAIFENESIN 600 mg NONSTEROIDAL ANTI-INFLAMMATORY AGENTS Voltaren DICLOFENAC SODIUM DR 75 MG TAB NONSTEROIDAL ANTI-INFLAMMATORY AGENTS DICLOFENAC TOPICAL GEL 100 G 31 NONSTEROIDAL ANTI-INFLAMMATORY AGENTS Advil IBUPROFEN 600 MG TAB NONSTEROIDAL ANTI-INFLAMMATORY AGENTS Mobic MELOXICAM 15 MG TAB 30 3 NONSTEROIDAL ANTI-INFLAMMATORY AGENTS Mobic MELOXICAM 7.5 MG TAB 30 3 NONSTEROIDAL ANTI-INFLAMMATORY AGENTS Aleve NAPROXEN 500 MG TAB 60 4 ANTIMIGRAINE AGENT Imitrex SUMATRIPTAN 50 MG 9 6 ANTIMIGRAINE AGENT Imitrex SUMATRIPTAN 100 MG 9 7 Anticoagulants, Antiplatelets, Other ANTICOAGULANTS Coumadin WARFARIN SODIUM 1 MG TAB 30 5 ANTICOAGULANTS Coumadin WARFARIN SODIUM 10 MG TAB 30 6 ANTICOAGULANTS Coumadin WARFARIN SODIUM 2 MG TAB 30 4 ANTICOAGULANTS Coumadin WARFARIN SODIUM 2.5 MG TAB 30 5 ANTICOAGULANTS Coumadin WARFARIN SODIUM 3 MG TAB 30 4 ANTICOAGULANTS Coumadin WARFARIN SODIUM 4 MG TAB 30 5 ANTICOAGULANTS Coumadin WARFARIN SODIUM 5 MG TAB 30 5 ANTICOAGULANTS Coumadin WARFARIN SODIUM 6 MG TAB 30 5 ANTICOAGULANTS Coumadin WARFARIN SODIUM 7.5 MG TAB 30 5 ANTIPLATELET Plavix CLOPIDOGREL 75 MG 30 3 As of July 2017; Pricing Updates August

2 Anticonvulsants MISCELLANEOUS Tegretol CARBAMAZEPINE 200 MG TAB MISCELLANEOUS Depakote DIVALPROEX SODIUM DR 500 MG TAB 60 9 MISCELLANEOUS Neurontin GABAPENTIN 300 MG CAP 90 4 MISCELLANEOUS Lamictal LAMOTRIGINE 25 MG TAB 30 3 MISCELLANEOUS Lamictal LAMOTRIGINE 100 MG TAB 30 3 MISCELLANEOUS Lamictal LAMOTRIGINE 150 MG TAB 30 3 Antidepressants MISCELLANEOUS Lamictal LAMOTRIGINE 200 MG TAB 30 3 MISCELLANEOUS Keppra LEVETIRACETAM 500 MG TAB MISCELLANEOUS Topamax TOPIRAMATE 25 MG TAB 30 3 MISCELLANEOUS Topamax TOPIRAMATE 50 MG TAB 30 3 MISCELLANEOUS Topamax TOPIRAMATE 100 MG TAB 30 3 HYDANTOINS Dilantin PHENYTOIN SODIUM EXTENDED 100 MG CAP ANTIDEPRESSANTS Elavil AMITRIPTYLINE HCL 10 MG TAB 30 3 ANTIDEPRESSANTS Elavil AMITRIPTYLINE HCL 25 MG TAB ANTIDEPRESSANTS Wellbutrin XL BUPROPION XL 150 MG TAB ANTIDEPRESSANTS Celexa CITALOPRAM HBR 20 MG TAB 30 3 ANTIDEPRESSANTS Celexa CITALOPRAM HBR 40 MG TAB 30 3 ANTIDEPRESSANTS Lexapro ESCITALOPRAM 10 MG TABLET 30 3 ANTIDEPRESSANTS Lexapro ESCITALOPRAM 20 MG TABLET 30 4 ANTIDEPRESSANTS Prozac FLUOXETINE HCL 10 MG TAB 30 3 ANTIDEPRESSANTS Prozac FLUOXETINE HCL 20 MG CAP 30 3 As of July 2017; Pricing Updates August

3 Antihistamines ANTIDEPRESSANTS Remeron MIRTAZAPINE 15 MG TAB 30 3 ANTIDEPRESSANTS Remeron MIRTAZAPINE 30 MG TAB 30 4 ANTIDEPRESSANTS Pamelor NORTRIPTYLINE HCL 25 MG CAP 60 7 ANTIDEPRESSANTS Paxil PAROXETINE HCL 40 MG TAB 30 4 ANTIDEPRESSANTS Paxil PAROXETINE HCL 20 MG TAB 30 3 ANTIDEPRESSANTS Zoloft SERTRALINE 100 MG TAB 30 3 ANTIDEPRESSANTS Zoloft SERTRALINE 50 MG TAB 30 3 ANTIDEPRESSANTS Desyrel TRAZODONE HCL 50 MG TAB 90 5 ANTIDEPRESSANTS Effexor VENLAFAXINE HCL 37.5 MG TAB ANTIDEPRESSANTS Effexor VENLAFAXINE HCL 75 MG TAB ANTIDEPRESSANTS Cymbalta DULOXETINE 30 MG CAPSULE ANTIDEPRESSANTS Cymbalta DULOXETINE 60 MG CAPSULE ANTIDEPRESSANTS Pristiq DESVENLAFAXINE 50 MG TAB 30 3 MTP; 122 CHC ANTIDEPRESSANTS Pristiq DESVENLAFAXINE 100 MG TAB 30 3 MTP; 127 CHC LEUKOTRIENTE RECEPTOR ANTAGONIST Singulair MONTELUKAST 5 MG TABLETS 30 7 LEUKOTRIENTE RECEPTOR ANTAGONIST Singulair MONTELUKAST 10 MG TABLETS 30 4 SECOND GENERATION ANTIHISTAMINES Zyrtec CETIRIZINE 10 MG TABLETS 30 3 SECOND GENERATION ANTIHISTAMINES Zyrtec CETIRIZINE HCL 1 MG/ML SOL 120 ml 4 SECOND GENERATION ANTIHISTAMINES Claritin LORATADINE 10 MG TAB 30 3 Antigout, uricosuric agent Antihypertensive ANTIGOUT AGENTS Aloprim ALLOPURINOL 100 MG TAB 60 6 ANTIGOUT AGENTS Aloprim ALLOPURINOL 300 MG TAB 30 6 ALPHA-1 BLOCKER Flomax TAMSULOSIN 0.4 MG CAP 30 5 As of July 2017; Pricing Updates August

4 ALPHA-ADRENERGIC BLOCKING AGENTS Hytrin TERAZOSIN HCL 1 MG CAP 30 3 ALPHA-ADRENERGIC BLOCKING AGENTS Hytrin TERAZOSIN HCL 2 MG CAP 30 3 ALPHA-ADRENERGIC BLOCKING AGENTS Hytrin TERAZOSIN HCL 5 MG CAP 30 3 INHIBITORS Lotensin BENAZEPRIL 5 MG 30 3 INHIBITORS Lotensin BENAZEPRIL 10 MG 30 3 INHIBITORS Lotensin BENAZEPRIL 20 MG 30 3 INHIBITORS Lotensin BENAZEPRIL 40 MG 30 3 INHIBITORS Zestril LISINOPRIL 2.5 MG TAB 30 3 INHIBITORS Zestril LISINOPRIL 5 MG TAB 30 3 INHIBITORS Zestril LISINOPRIL 10 MG TAB 30 3 INHIBITORS Zestril LISINOPRIL 20 MG TAB 30 3 INHIBITORS Zestril LISINOPRIL 40 MG TAB 30 3 INHIBITORS-DIURETIC Zestoretic LISINOP/HCTZ 10/12.5MG TAB 30 3 INHIBITORS-DIURETIC Zestoretic LISINOP/HCTZ 20/12.5MG TAB 30 3 INHIBITORS-DIURETIC Zestoretic LISINOP/HCTZ 20/ 25MG TAB 30 3 As of July 2017; Pricing Updates August

5 BLOCKERS Cozaar LOSARTAN 25 MG 30 3 BLOCKERS Cozaar LOSARTAN 50 MG 30 3 BLOCKERS Cozaar LOSARTAN 100 MG 30 3 BLOCKERS Diovan VALSARTAN 80 MG 30 6 BLOCKERS Diovan VALSARTAN 160 MG 30 7 BLOCKERS Benicar OLMESARTAN 5 MG 30 3 BLOCKERS Benicar OLMESARTAN 20 MG 30 7 BLOCKERS Benicar OLMESARTAN 40 MG BLOCKERS-DIURETIC Benicar HCT OLMESARTAN/HCTZ 20/12.5 MG 30 4 BLOCKERS-DIURETIC Benicar HCT OLMESARTAN/HCTZ 40/12.5 MG 30 5 BLOCKERS-DIURETIC Benicar HCT OLMESARTAN/HCTZ 40/25 MG 30 5 BLOCKERS-DIURETIC Hyzaar LOSARTAN/HCTZ 50 MG/12.5 MG 30 3 BLOCKERS-DIURETIC Hyzaar LOSARTAN/HCTZ 100 MG/12.5 MG 30 3 As of July 2017; Pricing Updates August

6 BLOCKERS-DIURETIC Hyzaar LOSARTAN/HCTZ 100 MG/25 MG 30 4 BLOCKERS-DIURETIC Avalide IRBESARTAN/HCTZ 150 MG/12.5 MG 30 5 BLOCKERS-DIURETIC Avalide IRBESARTAN/HCTZ 300 MG/12.5 MG 30 5 AGENTS Tenormin ATENOLOL 100 MG TAB 30 4 AGENTS Tenormin ATENOLOL 50 MG TAB 30 3 AGENTS-DIURETIC Tenoretic ATENOLOL/CHLORTHALIDONE 50/25MG TAB AGENTS Coreg CARVEDILOL 12.5 MG TAB 60 3 AGENTS Coreg CARVEDILOL 25 MG TAB 60 3 AGENTS Coreg CARVEDILOL 6.25 MG TAB 60 3 AGENTS Lopressor METOPROLOL TARTRATE 100 MG TAB 60 3 AGENTS Lopressor METOPROLOL TARTRATE 25 MG TAB 60 3 AGENTS Lopressor METOPROLOL TARTRATE 50 MG TAB 60 3 AGENTS Toprol XL METOPROLOL SUCCINATE 25 MG TABLET AGENTS Toprol XL METOPROLOL SUCCINATE 50 MG TABLET AGENTS Toprol XL METOPROLOL SUCCINATE 100 MG TABLET AGENTS Corgard NADOLOL 20 MG 30 4 MTP As of July 2017; Pricing Updates August

7 AGENTS Corgard NADOLOL 40 MG 30 8 MTP AGENTS Corgard NADOLOL 80 MG 30 9 MTP AGENTS Inderal PROPRANOLOL HCL 20 MG TAB AGENTS Inderal PROPRANOLOL HCL 40 MG TAB AGENTS Inderal PROPRANOLOL HCL ER 80 MG CAP AGENTS, DIHYDROPYRIDINES Norvasc AMLODIPINE BESYLATE 10 MG TAB 30 3 AGENTS, DIHYDROPYRIDINES Norvasc AMLODIPINE BESYLATE 2.5 MG TAB 30 3 AGENTS, DIHYDROPYRIDINES Norvasc AMLODIPINE BESYLATE 5 MG TAB 30 3 AGENTS/ACE INHIBITOR COMBINATION Lotrel AMLODIPINE 5 MG/BENAZEPRIL 10 MG AGENTS/ACE INHIBITOR COMBINATION Lotrel AMLODIPINE 5 MG/BENAZEPRIL 20 MG AGENTS/ACE INHIBITOR COMBINATION Lotrel AMLODIPINE 10 MG/BENAZEPRIL 20 MG AGENTS/ACE INHIBITOR COMBINATION Lotrel AMLODIPINE 10 MG/BENAZEPRIL 40 MG As of July 2017; Pricing Updates August

8 AGENTS, MISC. Cardizem DILTIAZEM HCL ER 240 MG CAP AGENTS, MISC. Cardizem DILTIAZEM HCL ER 24H 180 MG CAP AGENTS, MISC. Calan VERAPAMIL HCL SA 240 MG ER TAB 30 6 CENTRAL ALPHA-AGONISTS Catapres CLONIDINE HCL 0.1 MG TAB 60 3 CENTRAL ALPHA-AGONISTS Catapres CLONIDINE HCL 0.2 MG TAB 60 3 CENTRAL ALPHA-AGONISTS Catapres CLONIDINE HCL 0.3 MG TAB 60 3 DIRECT VASODILATORS Apresoline HYDRALAZINE HCL 25 MG TAB 60 3 DIRECT VASODILATORS Apresoline HYDRALAZINE HCL 50 MG TAB 60 3 DIRECT VASODILATORS Apresoline HYDRALAZINE HCL 100 MG TAB 60 5 DIURETIC LOOP Lasix FUROSEMIDE 20 MG TAB 60 3 DIURETIC LOOP Lasix FUROSEMIDE 40 MG TAB 60 3 DIURETIC LOOP Lasix FUROSEMIDE 80 MG TAB 60 3 DIURETIC LOOP Demadex TORSEMIDE 10 MG TAB 30 3 DIURETIC LOOP Demadex TORSEMIDE 20 MG TAB 30 3 DIURETIC LOOP Demadex TORSEMIDE 100 MG TAB 30 7 DIURETIC, POTASSIUM-SPARING Dyazide TRIAMTERENE/HCTZ 37.5 /25MG TAB 30 4 DIURETIC, THIAZIDE Microzide HCTZ(HYDROCHLOROTHIAZIDE) 12.5 MG CAP 30 3 DIURETIC, THIAZIDE Microzide HCTZ(HYDROCHLOROTHIAZIDE) 25 MG TAB 30 3 DIURETIC, THIAZIDE Zaroxolyn METOLAZONE 2.5 MG TABLET DIURETIC, THIAZIDE Zaroxolyn METOLAZONE 5 MG TABLET MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS Aldactone SPIRONOLACTONE 25 MG TAB 30 3 NITRATES AND NITRITES Imdur ISOSORBIDE MONONIT SR 24H 60 MG TAB 30 5 NITRATES AND NITRITES Imdur ISOSORBIDE MONONIT SR 24H 30 MG TAB 30 5 DIURETIC, THIAZIDE Thalitone CHLORTHALIDONE 25 mg Anti-Infectives ALLYLAMINES Lamisil TERBINAFINE HCL 250 MG TAB 30 4 As of July 2017; Pricing Updates August

9 ANTIBACTERIALS, MISCELLANEOUS Cleocin CLINDAMYCIN HCL 150 MG CAP 40 5 ANTIMALARIALS Plaquenil HYDROXYCHLOROQUINE SULF 200 MG TAB ANTIPROTOZOALS, MISCELLANEOUS Flagyl METRONIDAZOLE 500 MG TABLET AZOLES Diflucan FLUCONAZOLE 100 MG TAB AZOLES Diflucan FLUCONAZOLE 150 MG TAB 1 3 AZOLES Diflucan FLUCONAZOLE 200 MG TAB CEPHALOSPORINS Keflex CEPHALEXIN MONOHYDRATE 250 MG CAP 40 4 CEPHALOSPORINS Keflex CEPHALEXIN MONOHYDRATE 500 MG CAP 40 4 MACROLIDES Zithromax AZITHROMYCIN 250 MG TAB 6 3 MACROLIDES Biaxin CLARITHROMYCIN 500 MG TAB ANTIVIRAL AGENT Zovirax ACYCLOVIR 400 MG TAB 50 6 ANTIVIRAL AGENT Zovirax ACYCLOVIR 800 MG TAB 50 4 ANTIVIRAL AGENT Valtrex VALACYCLOVIR 500 MG TAB ANTIVIRAL AGENT Valtrex VALACYCLOVIR 1000 MG TAB PENICILLINS AMOX TR/POT CLAVULANATE 400/ 57 MG SUS 100 ML 9 PENICILLINS Augmentin AMOX TR/POT CLAVULANATE 500/125MG TAB PENICILLINS Augmentin AMOX TR/POT CLAVULANATE 875/125MG TAB PENICILLINS Amoxil AMOXICILLIN TRIHYDRATE 250 MG/5ML SUS 100 ML 3 PENICILLINS Amoxil AMOXICILLIN TRIHYDRATE 500 MG CAP 30 3 PENICILLINS Amoxil AMOXICILLIN TRIHYDRATE 875 MG TAB 20 4 PENICILLINS PENICILLIN V POTASSIUM 125 MG/5ML SUS 100 ML 4 PENICILLINS PENICILLIN V POTASSIUM 250 MG TAB 40 6 PENICILLINS PENICILLIN V POTASSIUM 250 MG/5ML SUS 200 ML 9 PENICILLINS PENICILLIN V POTASSIUM 500 MG TAB POLYENES Mycostatin NYSTATIN 100M UN/ML SUS 200 ML 22 QUINOLONES Cipro CIPROFLOXACIN HCL 250 MG TAB 20 3 QUINOLONES Cipro CIPROFLOXACIN HCL 500 MG TAB 20 3 QUINOLONES Levaquin LEVOFLOXACIN 250 MG TAB 10 3 QUINOLONES Levaquin LEVOFLOXACIN 500 MG TAB 10 3 QUINOLONES Levaquin LEVOFLOXACIN 750 MG TAB 10 4 As of July 2017; Pricing Updates August

10 Antilipid SULFAMETHOXAZOLE/TRIMETHO 800/ 160MG SULFONAMIDES (SYSTEMIC) Bactrim TAB 20 3 TETRACYCLINES DOXYCYCLINE 100 MG TETRACYCLINES MINOCYCLINE 100 MG URINARY ANTI-INFECTIVES Macrobid NITROFURANTOIN/NITRO MAC 100 MG CAP FIBRIC ACID DERIVATIVES Lopid GEMFIBROZIL 600 MG TAB 60 7 HMG-COA REDUCTASE INHIBITORS Zocor SIMVASTATIN 20 MG TAB 30 3 HMG-COA REDUCTASE INHIBITORS Zocor SIMVASTATIN 40 MG TAB 30 3 HMG-COA REDUCTASE INHIBITORS Pravachol PRAVASTATIN 10 MG 30 6 HMG-COA REDUCTASE INHIBITORS Pravachol PRAVASTATIN 20 MG 30 5 HMG-COA REDUCTASE INHIBITORS Pravachol PRAVASTATIN 40 MG 30 6 HMG-COA REDUCTASE INHIBITORS Pravachol PRAVASTATIN 80 MG HMG-COA REDUCTASE INHIBITORS Lipitor ATORVASTATIN 10 MG 30 3 HMG-COA REDUCTASE INHIBITORS Lipitor ATORVASTATIN 20 MG 30 3 HMG-COA REDUCTASE INHIBITORS Lipitor ATORVASTATIN 40 MG 30 3 HMG-COA REDUCTASE INHIBITORS Lipitor ATORVASTATIN 80 MG 30 4 HMG-COA REDUCTASE INHIBITORS Crestor ROSUVASTATIN 5 MG 30 6 HMG-COA REDUCTASE INHIBITORS Crestor ROSUVASTATIN 10 MG 30 6 HMG-COA REDUCTASE INHIBITORS Crestor ROSUVASTATIN 20 MG 30 6 As of July 2017; Pricing Updates August

11 HMG-COA REDUCTASE INHIBITORS Crestor ROSUVASTATIN 40 MG 30 6 FIBRIC ACID DERIVATIVES FENOFIBRATE 48 MG TAB FIBRIC ACID DERIVATIVES FENOFIBRATE 145 MG TAB MTP; 89 CHC ANTILIPEMIC AGENTS, MISCELLANEOUS Omacor FISH OIL (OMEGA 3 ACID ETHYL ETHERS) 1000 MG CAPSULES Anti-neoplastic ANTIPSYCHOTIC ANXIOLYTIC, SEDATIVE/HYP ANTINEOPLASTIC AGENTS Trexall METHOTREXATE SODIUM 2.5 MG TAB ANTINEOPLASTIC AGENTS Hydrea HYDROXYUREA 500 MG ORAL CAP ANTINEOPLASTIC AGENTS TAMOXIFEN 10 MG 30 8 ANTINEOPLASTIC AGENTS TAMOXIFEN 20 MG ANTIMANIC AGENTS Lithobid LITHIUM CARBONATE 300 MG CAP ANTIPSYCHOTIC AGENTS Abilify ARIPIPRAZOLE 2 MG TAB 30 6 MTP, 107 CHC ANTIPSYCHOTIC AGENTS Abilify ARIPIPRAZOLE 5 MG TAB 30 8 MTP, 107 CHC ANTIPSYCHOTIC AGENTS Abilify ARIPIPRAZOLE 10 MG TAB 30 3 MTP; 93 CHC ANTIPSYCHOTIC AGENTS Abilify ARIPIPRAZOLE 15 MG TAB 30 9 MTP; 75 CHC ANTIPSYCHOTIC AGENTS Abilify ARIPIPRAZOLE 20 MG TAB MTP; 151 CHC ANTIPSYCHOTIC AGENTS Abilify ARIPIPRAZOLE 30 MG TAB MTP; 107 CHC ANTIPSYCHOTIC AGENTS Risperdal RISPERIDONE 1 MG TAB 60 4 ANTIPSYCHOTIC AGENTS Seroquel QUETIAPINE 25 MG TAB 30 3 ANTIPSYCHOTIC AGENTS Seroquel QUETIAPINE 50 MG TAB 30 4 ANTIPSYCHOTIC AGENTS Seroquel QUETIAPINE 100 MG TAB 30 4 ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC. BuSpar BUSPIRONE HCL 15 MG TAB 60 7 As of July 2017; Pricing Updates August

12 Cardiac (Antiarrhythmics, Angina, Nitrates) ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC. Vistaril HYDROXYZINE PAMOATE 25 MG CAP 90 5 ANTIARRHYTHMIC AGENTS Cordarone AMIODARONE HCL 200 MG TAB 60 8 ANTIARRHYTHMIC AGENTS Rythmol PROPAFENONE HCL 150 MG TAB ANTIARRHYTHMIC AGENTS Rythmol PROPAFENONE HCL 225 MG TAB 90 9 MTP; 21 CHC ANTIARRHYTHMIC AGENTS Betapace SOTALOL 80 MG CAPLET 60 6 ANTIARRHYTHMIC AGENTS Betapace SOTALOL 120 MG CAPLET 60 7 CARDIOTONIC AGENTS Lanoxin DIGOXIN MG TAB CARDIOTONIC AGENTS Lanoxin DIGOXIN 0.25 MG TAB NITRATES AND NITRITES Nitrostat NITROGLYCERIN SUBL 0.4 MG TAB 25 6 Diabetes Medication BIGUANIDES Glucophage METFORMIN HCL 1000 MG TAB 60 3 BIGUANIDES Glucophage METFORMIN HCL 500 MG TAB BIGUANIDES Glucophage METFORMIN HCL 850 MG TAB 90 3 BIGUANIDES Glucophage XR METFORMIN ER 500 MG 30 3 BIGUANIDES Glucophage XR METFORMIN ER 750 MG 30 3 SULFONYLUREAS Amaryl GLIMEPIRIDE 1 MG TAB 30 3 SULFONYLUREAS Amaryl GLIMEPIRIDE 2 MG TAB 30 3 SULFONYLUREAS Amaryl GLIMEPIRIDE 4 MG TAB 30 6 SULFONYLUREAS Glucotrol GLIPIZIDE 10 MG TAB 60 3 SULFONYLUREAS Glucotrol GLIPIZIDE 5 MG TAB 60 3 SULFONYLUREAS Glucotrol XL GLIPIZIDE ER 24H 2.5 MG TAB 30 5 SULFONYLUREAS Glucotrol XL GLIPIZIDE ER 24H 5 MG TAB 30 5 SULFONYLUREAS Glucotrol XL GLIPIZIDE ER 24H 10 MG TAB 30 7 INSULIN Novolin R INSULIN REGULAR 1 vial 12.5 MTP; 75 CHC INSULIN Novolin N INSULIN NPH 1 vial 12.5 MTP; 75 CHC INSULIN Novolin 70/30 INSULIN 70/30 1 vial 12.5 MTP; 75 CHC As of July 2017; Pricing Updates August

13 Diabetes Supplies BLOOD GLUCOSE METER ON CALL PLUS METER 1 meter 12 BLOOD GLUCOSE TEST STRIPS ON CALL PLUS TEST STRIPS 1 Box-50 Count 6 EENT Anti-Infective Misc AntiInfe, ANTIBACTERIALS (EENT) Ciloxan CIPROFLOXACIN HCL 0.3 % DRP 2.5 ML 4 AntiInfe, ANTIBACTERIALS (EENT) GENTAMICIN: OINTMENT, TOPICAL: 0.1% 15 GM 35 AntiInfe, ANTIBACTERIALS (EENT) Gentasol GENTAMICIN SOLUTION OPHTHALMIC 0.3% 5 ML 5 AntiInfe, ANTIBACTERIALS (EENT) NEOMYCIN/POLYMYX/DEXAMETH SUS 5 ML 10 AntiInfe, ANTIBACTERIALS (EENT) NEOMYCIN/POLYMYXIN/BACITR 3.5 MG/400 ONT 30 GM 3 AntiInfe, ANTIBACTERIALS (EENT) NEOMYCIN/POLYMYXIN/HC SUS 10 ML 42 Antiglaucoma, Prostaglandin, Ophthalmic Agent Xalatan Latanoprost 0.005% 2.5 ML 6 Antiglaucoma, Ophthalmic Agent (Beta Blocker and Carbonic Anhydrase Inhibitor) Cosopt Dorzolamide 2% and Timolol 0.5% 10 ML 10 Other CORTICOSTEROID Entocort BUDESONIDE 3 MG ORAL CAPSULE MTP CORTICOSTEROIDS (EENT) Flonase FLUTICASONE PROPIONATE 50 MCG SPY 16 GM 5 Atrovent 29 MISCELLANEOUS Nasal IPRATROPIUM BROMIDE 42 MCG SPY 15 ML Gastrointestinal Health Anti-emetic 5-HT3 RECEPTOR ANTAGONISTS Zofran ONDANSETRON HCL 4 MG TABLET HT3 RECEPTOR ANTAGONISTS Zofran ONDANSETRON HCL 8 MG TABLET HT3 RECEPTOR ANTAGONISTS Zofran ODT ONDANSETRON ODT 4 MG TABLET Antihistamines ANTIHISTAMINES Antivert MECLIZINE HCL 12.5 MG TAB 30 4 As of July 2017; Pricing Updates August

14 Antispasmodics ANTIMUSCARINICS/ANTISPASMODICS Bentyl DICYCLOMINE 10 MG CAPSULES 60 5 HISTAMINE H2-ANTAGONISTS Zantac RANITIDINE HCL 150 MG TAB 60 3 PROTON-PUMP INHIBITORS Prilosec OMEPRAZOLE EC 20 MG CAP 30 3 PROTON-PUMP INHIBITORS Protonix PANTOPRAZOLE 40 MG TAB 30 3 Other PROKINETIC AGENTS Reglan METOCLOPRAMIDE HCL 10 MG TAB PROKINETIC AGENTS Azulfidine SULFASALAZINE 500 MG TAB Health & Nutrition Women's Health Oral Contraceptives Parkinson's Disease/Dopamine Agonist LAXATIVE, OSMOTIC LACTULOSE 16 OZ 5 LAXATIVE, OSMOTIC Gavilyte POLYETHYLENE GLYCOL-ELECTROLYTE SOLN 4000 ML 4 BONE RESORPTION INHIBITORS Fosamax ALENDRONATE SODIUM 70 MG TAB 4 4 VITAMIN, WATER SOLUBLE FOLIC ACID 1 MG TAB 30 3 REPLACEMENT PREPARATIONS Klor-Con POTASSIUM CHLORIDE SA 10 MEQ TAB 30 8 VITAMIN D D3-50 Vitamin D 50,000 international unit capsules 4 3 VITAMIN D ANALOG Rocaltrol CALCITRIOL 0.25 MCG VITAMIN D ANALOG Rocaltrol CALCITRIOL 0.5 MCG ELECTROLYTE SUPPLEMENT Phospha 250 Neutral Potassium phosphate and Sodum phosphate CONTRACEPTIVES Sprintec NORGESTIMATE/ETHINYL EST TAB 1 12 CONTRACEPTIVES Tri-Sprintec NORGESTIMATE/ETHINYL EST TAB 1 23 ESTROGENS ESTRADIOL 0.5 MG TAB 30 4 ESTROGENS ESTRADIOL 1 MG TAB 30 5 PROGESTINS Provera MEDROXYPROGESTERONE ACET 10 MG TAB 30 4 PROGESTINS Depo-Provera MEDROXYPROGESTERONE INJECTION 150 mg/ml 1 75 DOPAMINE AGONIST Mirapex PRAMIPEXOLE MG TABLET 90 5 DOPAMINE AGONIST Mirapex PRAMIPEXOLE 0.25 MG TABLET 90 5 As of July 2017; Pricing Updates August

15 DOPAMINE AGONIST Mirapex PRAMIPEXOLE 0.5 MG TABLET 90 6 DOPAMINE AGONIST Mirapex PRAMIPEXOLE 1 MG TABLET 90 6 DOPAMINE AGONIST Mirapex PRAMIPEXOLE 1.5 MG TABLET 90 6 Immunosuppressive Agents IMMUNOSUPPRESSIVE AGENTS Cellcept MYCOPHENOLATE MOFETIL 500 MG TABLET 30 7 IMMUNOSUPPRESSIVE AGENTS Imuran AZATHIOPRINE 50 MG TAB Alzheimer's dementia ACETYLCHOLINESTERASE INHIBITOR (CENTRAL) Aricept DONEPEZIL 5 MG 30 3 ACETYLCHOLINESTERASE INHIBITOR (CENTRAL) Aricept DONEPEZIL 10 MG 30 3 Respiratory and MISC ADRENALS Florinef FLUDROCORTISONE 0.1 MG TAB ADRENALS Cortef HYDROCORTISONE 5 MG TAB 50 8 ADRENALS Medrol METHYLPREDNISOLONE 4 MG DPK ADRENALS PREDNISONE 10 MG TAB 30 4 ADRENALS PREDNISONE 20 MG TAB 30 4 ADRENALS PREDNISONE 5 MG TAB 30 3 BETA-ADRENERGIC AGONISTS Ventolin ALBUTEROL 90 MCG/INHALATION 8 GRAM 8 GRAM 20 BETA-ADRENERGIC AGONISTS AccuNeb ALBUTEROL SULFATE INH 0.83 MG/ML SOL 60X3 ML 20 ANTIMUSCARINICS/ANTISPASMODICS Atrovent IPRATROPIUM BROMIDE 0.2 MG/ML SOL 60X2.5 ML 8 SKELETAL MUSCLE RELAXNT TOPICAL Agents Antiinfectives CENTRALLY ACTING SKELETAL MUSCLE RELAXNT Flexeril CYCLOBENZAPRINE HCL 10 MG TAB 30 3 GABA-DERIVATIVE SKELETAL MUSCLE RELAXANT Lioresal BACLOFEN 10 MG TAB ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE) BACITRACIN 500 Unit/GM PKT 30 GM 3 As of July 2017; Pricing Updates August

16 Anti-inflammatory Anti-Pruritic ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE) Bactroban MUPIROCIN 2 % ONT 22 GM 6 ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE) Neosporin NEOMYCIN/POLYMYXIN/ BACITR ONT 1 OZ 3 ANTIFUNGALS (SKIN & MUCOUS MEMBRANE) Lotrimin AF CLOTRIMAZOLE 1 % CRM 30 GM 3 ANTIFUNGALS (SKIN & MUCOUS MEMBRANE) Lotrisone CLOTRIMAZOLE/BETAMETH DIP 1/.05% CRM 45 GM 17 ANTIFUNGALS (SKIN & MUCOUS MEMBRANE) Nizoral KETOCONAZOLE 2 % SHM 120 ML 10 ANTIFUNGALS (SKIN & MUCOUS MEMBRANE) NYSTATIN 100K U/GM PWD 60 GM 18 LOCAL ANTI-INFECTIVES, MISCELLANEOUS Hibiclens CHLORHEXIDINE GLUCONATE 4 % LIQ 4 OZ 3 LOCAL ANTI-INFECTIVES, MISCELLANEOUS MetroGel METRONIDAZOLE TOPICAL 0.75 % GEL 45 GM 77 LOCAL ANTI-INFECTIVES, MISCELLANEOUS POVIDONE-IODINE 10 % SOL 8 OZ 3 LOCAL ANTI-INFECTIVES, MISCELLANEOUS SELENIUM SULFIDE 2.5 % SHM LOT 4 OZ 8 LOCAL ANTI-INFECTIVES, MISCELLANEOUS Silvadene SILVER SULFADIAZINE 1 % CRM 25 GM 5 SCABICIDES AND PEDICULICIDES Elimite PERMETHRIN 5 % CRM 60 GM 50 SCABICIDES AND PEDICULICIDES Nix PERMETHRIN 1% TOPICAL RINSE 60 ML 6 ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) Diprolene AF BETAMETHASONE DIPRO 0.05 % CRM 15 GM 25 ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) Temovate E CLOBETASOL PROPIONATE 0.05 % CRM 30 GM 101 ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) HYDROCORTISONE 2.5 % CRM 1 OZ 3 ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) TRIAMCINOLONE ACETONIDE 0.1 % CRM 15 GM 6 ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) TRIAMCINOLONE ACETONIDE 0.1 % CRM 80 GM 10 As of July 2017; Pricing Updates August

17 Other Thyroid/Pituitary ANTITHYROID AGENTS Tapazole METHIMAZOLE 10 MG TAB 60 8 ANTITHYROID AGENTS Thyracil PROPYLTHIOURACIL 50 MG TAB THYROID AGENTS LEVOTHYROXINE SODIUM 100 MCG TAB THYROID AGENTS LEVOTHYROXINE SODIUM 125 MCG TAB THYROID AGENTS LEVOTHYROXINE SODIUM 150 MCG TAB THYROID AGENTS LEVOTHYROXINE SODIUM 50 MCG TAB THYROID AGENTS LEVOTHYROXINE SODIUM 75 MCG TAB Men's Health 5-ALPHA-REDUCTASE INHIBITOR Proscar FINASTERIDE 5 MG TAB ALPHA-REDUCTASE INHIBITOR Avodart DUTASTERIDE 0.5 MG CAP 30 9 Urinary GENITOURINARY SMOOTH MUSCLE RELAXANTS Ditropan OXYBUTYNIN CHL 5 MG TAB ANTICHOLINERGIC AGENT Detrol TOLTERODINE 2 MG TAB Antidote Antidote Kayexalate SODIUM POLYSTYRENE SULFONATE 16 0Z 16 0Z 48 As of July 2017; Pricing Updates August