2015 Formulary (List of Covered Drugs)

Transcription

1 HNE Medicare Advantage Plan (HMO and HMO-POS) 2015 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID and version number: 15469v4 This formulary was updated 07/01/2014. For more recent information or other questions, please contact the HNE Medicare Advantage pharmacy benefit manager (PBM), National Pharmaceutical Services (NPS), at or, for TTY users, , 24 hours a day, seven days a week, or visit hne.com/medicare.

2 HNE Medicare Advantage Plan (HMO and HMO- POS) 2015 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID and version number: 15469v4 This formulary was updated on 07/01/2014. For more recent information or other questions, please contact HNE Medicare Advantage pharmacy benefit manager (PBM), National Pharmaceutical Services (NPS) at or, for TTY users, , 24 hours a day, seven days a week, or visit Note to existing members: This formulary 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 Health New England (HNE). When it refers to plan or our plan, it means HNE Medicare Advantage (HMO and HMO-POS). This document includes a list of the drugs (formulary) for our plan which is current as of 06/24/2014. For an updated formulary, 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, 2016, and from time to time during the year. H8578_2015_046R

3 What is the HNE Medicare Advantage (HMO & HMO-POS) Formulary? A formulary is a list of covered drugs selected by HNE Medicare Advantage 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. HNE Medicare Advantage will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a HNE Medicare Advantage 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 Formulary (drug list) change? Generally, if you are taking a drug on our 2015 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2015 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 formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members 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 formulary 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 formulary, or 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 members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of 06/24/2014. To get updated information about the drugs covered by HNE Medicare Advantage, please contact us. Our contact information appears on the front and back cover pages. In the event of nonmaintenance changes to the formulary thoughout the plan year, HNE Medicare Advantage may make changes via errata sheets mailed to you. Additionally you may visit our website for a link to the errata sheet. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 9. The drugs in this formulary 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 2

4 category name in the list that begins 9. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 179. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? HNE Medicare Advantage 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: HNE Medicare Advantage requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from HNE Medicare Advantage before you fill your prescriptions. If you don t get approval, HNE Medicare Advantage may not cover the drug. Quantity Limits: For certain drugs, HNE Medicare Advantage limits the amount of the drug that HNE Medicare Advantage will cover. For example, HNE Medicare Advantage provides 30 tablets per prescription for meloxicam. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, HNE Medicare Advantage 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, HNE Medicare Advantage may not cover Drug B unless you try Drug A first. If Drug A does not work for you, HNE Medicare Advantage will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 9. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line 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 formulary, appears on the front and back cover pages. You can ask HNE Medicare Advantage 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 3

5 section, How do I request an exception to the HNE Medicare Advantage s formulary? on page 4 for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact our pharmacy benefit manager (PBM), National Pharmaceutical Services (NPS)and ask if your drug is covered. If you learn that HNE Medicare Advantage does not cover your drug, you have two options: You can ask our pharmacy benefit manager (PBM), National Pharmaceutical Services (NPS) for a list of similar drugs that are covered by HNE Medicare Advantage. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by HNE Medicare Advantage. You can ask HNE Medicare Advantage to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the HNE Medicare Advantage Plan s Formulary? You can ask HNE Medicare Advantage 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 on our formulary. 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 cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, HNE Medicare Advantage 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. Generally, HNE Medicare Advantage will only approve your request for an exception if the alternative drugs included on the plan s formulary, 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 formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber s supporting statement. You can 4

6 request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 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 member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary 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 formulary 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 ninety (90) days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary thirty (30) day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first thirty (30) day supply, we will not pay for these drugs, even if you have been a member of the plan less than ninety (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 91 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 ninety (90) days if you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first ninety (90) days of membership in our plan, we will cover a 31day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. Exceptions are available for beneficiaries who have experienced a change in the level of care they are receiving which requires them to transition from one facility or treatment center to another. Examples of situations in which beneficiaries would be eligible for the one-time temporary fill exception when they are outside of the three month effective date into the Part D program are as follows: i. For example if a beneficiary was discharged from the hospital and was provided a discharge list of medications based upon the formulary of the hospital. ii. Beneficiaries who end their skilled nursing facility Medicare Part A stay (where payments include all pharmacy charges) and who need to revert back to their Part D plan formulary iii. Beneficiaries who give up Hospice Status to revert back to standard Medicare Part A and B benefits iv. Beneficiaries who are discharged from Chronic Psychiatric Hospitals with medication regimens that are highly individualized. 5

7 All of these situations would warrant a temporary one-time fill exception regardless of if the beneficiary is in their first ninety (90) days of program enrollment. 6

8 For more information For more detailed information about your HNE Medicare Advantage prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about HNE Medicare Advantage, please contact us. Our contact information, along with the date we last updated the formulary, 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 HNE Medicare Advantage (HMO & HMO-POS) Formulary The formulary that begins on page 9 provides coverage information about the drugs covered by HNE Medicare Advantage. If you have trouble finding your drug in the list, turn to the Index that begins on page 179. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., FLECTOR) and generic drugs are listed in lower-case italics (e.g., lisinopril). The second column of the formulary chart that begins on page 9 lists the tier numbers for each drug listed. The cost sharing table below lists the copayment amounts and coinsurance percentages for Tiers 1, 2, 3, or 4. For example, if a number 1 is listed in the Drug Tier column of the formulary chart, Generic copayment amounts apply. If the number 2 is listed in the Drug Tier column of the formulary chart, Brand/Preferred copayment amounts apply. A number 3 means that Brand/Non-Preferred copayment amounts apply. A number 4 means that Specialty coinsurance percentages apply. The information in the Requirements/Limits column tells you if HNE Medicare Advantage has any special requirements for coverage of your drug. 7

9 Cost Sharing for HNE Medicare Premium, Plus, Basic (HMO), and Freedom (HMO- POS) Plans with Prescription Drug Coverage Retail Long-Term Mail-Order Care Drug Tier days 31 days 90 days days 1 Generic $10.00 $30.00 $10.00 $ Brand/ Preferred $45.00 $ $45.00 $ Brand/ Non- Preferred $90.00 $ $90.00 $ Specialty 33% 33% 33% - 1 month Cost Sharing for HNE Medicare Value (HMO) Plan with Prescription Drug Coverage Retail Long-Term Mail-Order Care Drug Tier 30 days 90 days 31 days 90 days 1 Generic $10.00 $30.00 $10.00 $ Brand/ Preferred $45.00 $ $45.00 $ Brand/ Non- Preferred $90.00 $ $90.00 $ Specialty 29% 29% 29% - 1 month Cost Sharing for HNE Premier 1, Premier 2 (HMO) and Premier 3 (HMO-POS) Plan with Prescription Drug Coverage Retail Long-Term Care Mail-Order Drug Tier 30 days 90 days 31 days 90 days 1 Generic $10.00 $30.00 $10.00 $ Brand/ Preferred $45.00 $ $45.00 $ Brand/ Non- Preferred $90.00 $ $90.00 $ Specialty 33% 33% 33% - 1 month These cost sharing amounts are noted for the initial coverage phase of the benefit and are subject to Part D coverage limitations described in your Evidence of Coverage. 8

10 ANALGESICS Analgesics alagesic lq sol 1 Quantity limitation 4500 per 30 days apap/codeinesol120-12/5 1 apap/codeinetab300-15mg 1 Quantity limitation 400 per 30 days apap/codeinetab300-30mg 1 Quantity limitation 400 per 30 days apap/codeinetab300-60mg 1 Quantity limitation 400 per 30 days ascomp/cod cap30mg 1 Quantity limitation 120 per 30 days but/apap/cafcap 1 but/apap/cafcapcodeine 1 Quantity limitation 360 per 30 days but/apap/caftab 1 but/asa/caffcap 1 butal/apap tab50-325mg 1 diclo/misoprtab50-0.2mg 1 diclo/misoprtab75-0.2mg 1 endocet tab10-325mg 1 Quantity limitation 120 per 30 days endocet tab5-325mg 1 Quantity limitation 120 per 30 days endocet tab Quantity limitation 120 per 30 days hycet sol Quantity limitation 3600 per 30 days Quantity limitation 3600 per 30 days hydroco/apapsol hydroco/apaptab10-300mg 1 Quantity limitation 120 per 30 days hydroco/apaptab10-325mg 1 Quantity limitation 120 per 30 days hydroco/apaptab5-300mg 1 Quantity limitation 120 per 30 days hydroco/apaptab5-325mg 1 Quantity limitation 120 per 30 days hydroco/apaptab Quantity limitation 120 per 30 days hydroco/apaptab Quantity limitation 120 per 30 days hydrocod/ibutab Quantity limitation 120 per 30 days oxycod/apap tab10-325mg 1 Quantity limitation 120 per 30 days oxycod/apap tab Quantity limitation 120 per 30 days oxycod/apap tab5-325mg 1 Quantity limitation 120 per 30 days oxycod/apap tab Quantity limitation 120 per 30 days oxycod/asa tab 1 Quantity limitation 120 per 30 days oxycod/ibu tab5-400mg 1 Quantity limitation 120 per 30 days tramadl/apaptab Quantity limitation 240 per 30 days vicodin tab5-300mg 1 Quantity limitation 120 per 30 days vicodin es tab Quantity limitation 120 per 30 days vicodin hp tab10-300mg 1 Quantity limitation 120 per 30 days 9

11 VIMOVO TAB375-20MG 3 Quantity limitation 60 per 30 days VIMOVO TAB500-20MG 3 Quantity limitation 60 per 30 days xodol tab10-300mg 1 Quantity limitation 120 per 30 days xodol tab5-300mg 1 Quantity limitation 120 per 30 days xodol tab Quantity limitation 120 per 30 days Nonsteroidal Anti-Inflammatory Drugs diclofen pottab50mg 1 diclofenac tab100mg er 1 diclofenac tab25mg dr 1 diclofenac tab50mg dr 1 diclofenac tab75mg dr 1 diflunisal tab500mg 1 etodolac cap200mg 1 etodolac cap300mg 1 etodolac tab400mg 1 etodolac tab500mg 1 etodolac er tab400mg 1 etodolac er tab500mg 1 etodolac er tab600mg 1 fenoprofen tab600mg 1 FLECTOR DIS1.3% 3 flurbiprofentab100mg 1 flurbiprofentab50mg 1 ibuprofen sus100/5ml 1 ibuprofen tab400mg 1 ibuprofen tab600mg 1 This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the 10

12 brand name version of selected medications. ibuprofen tab800mg 1 indomethacincap25mg 1 indomethacincap50mg 1 indomethacincap75mg er 1 ketoprofen cap200mg er 1 ketoprofen cap50mg 1 ketoprofen cap75mg 1 meclofen sodcap100mg 1 meclofen sodcap50mg 1 meloxicam tab15mg 1 meloxicam tab7.5mg 1 nabumetone tab500mg 1 nabumetone tab750mg 1 naproxen sus125/5ml 1 naproxen tab250mg 1 naproxen tab375mg 1 naproxen tab500mg 1 naproxen dr tab375mg 1 naproxen dr tab500mg 1 naproxen sodtab275mg 1 naproxen sodtab550mg 1 oxaprozin tab600mg 1 piroxicam cap10mg 1 piroxicam cap20mg 1 sulindac tab150mg 1 This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. Quantity limitation 30 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. Quantity limitation 30 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. 11

13 sulindac tab200mg 1 tolmetin sodcap400mg 1 tolmetin sodtab600mg 1 Opioid Analgesics, Long-Acting fentanyl dis100mcg/h 1 Quantity limitation 30 per 30 days fentanyl dis12mcg/hr 1 Quantity limitation 30 per 30 days fentanyl dis25mcg/hr 1 Quantity limitation 30 per 30 days fentanyl dis50mcg/hr 1 Quantity limitation 30 per 30 days fentanyl dis75mcg/hr 1 Quantity limitation 30 per 30 days levorphanol tab2mg 1 Quantity limitation 120 per 30 days METHADONE INJ10MG/ML 3 Quantity limitation 120 per 30 days; This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of drug to make the methadone sol10mg/5ml 1 Quantity limitation 600 per 30 days Quantity limitation 1200 per 30 methadone sol5mg/5ml 1 days methadone tab10mg 1 Quantity limitation 120 per 30 days methadone tab5mg 1 Quantity limitation 120 per 30 days morphine sulcap100mg er 1 Quantity limitation 60 per 30 days morphine sulcap10mg er 1 Quantity limitation 60 per 30 days morphine sulcap120mg er 1 Quantity limitation 60 per 30 days morphine sulcap20mg er 1 Quantity limitation 60 per 30 days morphine sulcap30mg er 1 Quantity limitation 60 per 30 days morphine sulcap30mg er 1 Quantity limitation 60 per 30 days morphine sulcap45mg er 1 Quantity limitation 60 per 30 days morphine sulcap50mg er 1 Quantity limitation 60 per 30 days morphine sulcap60mg er 1 Quantity limitation 60 per 30 days morphine sulcap60mg er 1 Quantity limitation 60 per 30 days morphine sulcap75mg er 1 Quantity limitation 60 per 30 days morphine sulcap80mg er 1 Quantity limitation 60 per 30 days morphine sulcap90mg er 1 Quantity limitation 60 per 30 days morphine sultab100mg er 1 Quantity limitation 120 per 30 days morphine sultab15mg er 1 Quantity limitation 120 per 30 days morphine sultab200mg er 1 Quantity limitation 120 per 30 days morphine sultab30mg er 1 Quantity limitation 120 per 30 days morphine sultab60mg er 1 Quantity limitation 120 per 30 days oxymorphone tab10mg er 1 Quantity limitation 120 per 30 days oxymorphone tab15mg er 1 Quantity limitation 120 per 30 days 12

14 oxymorphone tab20mg er 1 Quantity limitation 120 per 30 days oxymorphone tab30mg er 1 Quantity limitation 120 per 30 days oxymorphone tab40mg er 1 Quantity limitation 120 per 30 days oxymorphone tab5mg er 1 Quantity limitation 120 per 30 days oxymorphone tab7.5mg er 1 Quantity limitation 120 per 30 days Opioid Analgesics, Short-Acting butorphanol sol10mg/ml 1 Quantity limitation 10 per 30 days duramorph inj0.5mg/ml 1 duramorph inj1mg/ml 1 fentanyl ot loz1200mcg 1 fentanyl ot loz1600mcg 1 fentanyl ot loz200mcg 1 fentanyl ot loz400mcg 1 Quantity limitation 120 per 30 days; This medication requires prior Quantity limitation 120 per 30 days; This medication requires prior Quantity limitation 120 per 30 days; This medication requires prior Quantity limitation 120 per 30 days; This medication requires 13

15 prior Quantity limitation 120 per 30 days; This medication requires prior fentanyl ot loz600mcg 1 Quantity limitation 120 per 30 days; This medication requires prior fentanyl ot loz800mcg 1 hydromorphontab2mg 1 Quantity limitation 120 per 30 days hydromorphontab4mg 1 Quantity limitation 120 per 30 days hydromorphontab8mg 1 Quantity limitation 120 per 30 days morphine sultab15mg 1 Quantity limitation 120 per 30 days morphine sultab30mg 1 Quantity limitation 120 per 30 days nalbuphine inj10mg/ml 3 Quantity limitation 120 per 30 days; This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of drug to make the Quantity limitation 120 per 30 days; This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of drug to make the nalbuphine inj20mg/ml 3 oxycodone tab10mg 1 Quantity limitation 120 per 30 days oxycodone tab15mg 1 Quantity limitation 120 per 30 days oxycodone tab20mg 1 Quantity limitation 120 per 30 days oxycodone tab30mg 1 Quantity limitation 120 per 30 days oxycodone tab5mg 1 Quantity limitation 120 per 30 days 14

16 oxymorphone tabhcl 10mg 1 Quantity limitation 120 per 30 days oxymorphone tabhcl 5mg 1 Quantity limitation 120 per 30 days tramadol hcltab50mg 1 Quantity limitation 240 per 30 days ANESTHETICS Local Anesthetics lido/prilocncre % 1 lidocaine gel2% jelly 1 lidocaine gel2% jelly 1 lidocaine gel2% jelly 1 lidocaine inj0.5% 3 lidocaine inj1% 3 lidocaine oin5% 1 lidocaine pad5% 1 Quantity limitation 90 per 30 days; lidocaine sol2% visc 1 lidocaine sol4% 1 ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS Alcohol Deterrents/Anti-craving acampro cal tab333mg 1 disulfiram tab250mg 1 disulfiram tab500mg 1 Opioid Dependence Treatments bupren/naloxsub2-0.5mg 1 Quantity limitation 120 per 30 days bupren/naloxsub8-2mg 1 Quantity limitation 120 per 30 days buprenorphininj0.3mg/ml 2 15

17 buprenorphinsub2mg 1 Quantity limitation 120 per 30 days buprenorphinsub8mg 1 Quantity limitation 120 per 30 days BUTRANS DIS10MCG/HR 3 Quantity limitation 4 per 28 days BUTRANS DIS15MCG/HR 3 Quantity limitation 4 per 28 days BUTRANS DIS20MCG/HR 3 Quantity limitation 4 per 28 days BUTRANS DIS5MCG/HR 3 Quantity limitation 4 per 28 days SUBOXONE MIS12-3MG 3 Quantity limitation 120 per 30 days SUBOXONE MIS2-0.5MG 3 Quantity limitation 90 per 30 days SUBOXONE MIS4-1MG 3 Quantity limitation 120 per 30 days SUBOXONE MIS8-2MG 3 Quantity limitation 90 per 30 days Opioid Reversal Agents naloxone inj1mg/ml 2 naltrexone tab50mg 1 Smoking Cessation Agents buproban tab150mg 1 Quantity limitation 90 per 30 days bupropion tab100mg 1 Quantity limitation 120 per 30 days bupropion tab100mg sr 1 Quantity limitation 60 per 30 days bupropion tab150mg sr 1 Quantity limitation 90 per 30 days bupropion tab200mg sr 1 Quantity limitation 30 per 30 days bupropion tab75mg 1 Quantity limitation 180 per 30 days bupropn hcl tab150mg xl 1 bupropn hcl tab300mg xl 1 Quantity limitation 60 per 30 days; CHANTIX PAK0.5& 1MG 3 CHANTIX TAB0.5MG 3 Quantity limitation 60 per 30 days; CHANTIX TAB1MG 3 Quantity limitation 60 per 30 days; FORFIVO XL TAB450MG 3 Quantity limitation 30 per 30 days 16

18 NICOTROL NS SPR10MG/ML 2 Quantity limitation 40 per 30 days Aminoglycosides gentak oin0.3% op 1 gentamicin cre0.1% 2 gentamicin inj10mg/ml 3 ANTIBACTERIALS gentamicin inj40mg/ml 3 GENTAMICIN OIN0.1% 2 gentamicin sol0.3% op 1 neomycin tab500mg 1 paromomycin cap250mg 1 streptomycininj1gm 3 TOBI NEB300/5ML TOBRADEX OIN % 3 tobramycin inj10mg/ml 3 17

19 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call tobramycin inj80mg/2ml 3 tobramycin neb300/5ml 4 tobramycin sol0.3% op 1 Antibacterials colistimeth inj150mg 3 neo/poly gu sol40/ml ir 1 SYNERCID INJ500MG ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call

20 Antibacterials, Other acetic acid sol2% otic 1 baciim inj50000unt 3 bacitracin oinop 1 chloramphen inj1gm 3 clindamycin aer1% 1 clindamycin cap150mg 1 clindamycin cap300mg 1 clindamycin cap75mg 1 clindamycin cre2% vag 1 clindamycin gel1% 1 clindamycin inj150mg/ml 3 clindamycin lot1% 1 clindamycin pad1% 1 clindamycin sol1% 1 CUBICIN SOL500MG 3 mafenide acepak5% 1 methenam hiptab1gm 1 METROGEL GEL1% 3 metron/nacl inj500mg 1 metronidazolcre0.75% 1 metronidazolgel0.75% 1 metronidazolgel0.75%vag 1 19

21 metronidazolgel1% 1 metronidazollot0.75% 1 metronidazoltab250mg 1 metronidazoltab500mg 1 MONUROL PAKGRANULES 3 mupirocin cre2% 1 mupirocin oin2% 1 nitrofur maccap50mg 1 nitrofurantncap100mg 1 nitrofurantnsus25mg/5ml 1 SULFAMYLON CRE85MG/GM 3 tinidazole tab250mg 1 tinidazole tab500mg 1 trimethoprimtab100mg 1 TYGACIL INJ50MG 3 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days vancomycin cap125mg 1 vancomycin cap250mg 1 vancomycin inj1000mg 3 ; This prescription drug may be covered 20

22 under our medical benefit. For more information- call hours a day- seven days vancomycin inj10gm 3 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days vancomycin inj500mg 3 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days ZYVOX SOL2MG/ML 4 ZYVOX SUS100MG/5M 4 21

23 ZYVOX TAB600MG 4 Beta-lactam, Cephalosporins cefaclor cap250mg 1 cefaclor cap500mg 1 cefaclor er tab500mg 1 cefadroxil cap500mg 1 cefadroxil sus250/5ml 1 cefadroxil sus500/5ml 1 cefadroxil tab1gm 1 cefazolin inj10gm 3 cefazolin inj1gm 3 cefazolin inj1gm/50ml 3 Quantity limitation 56 per 28 days; ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call

24 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call cefazolin inj500mg 3 cefdinir cap300mg 1 cefdinir sus125/5ml 1 cefdinir sus250/5ml 1 cefepime inj1gm 3 cefepime inj2gm 3 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call

25 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call cefoxitin inj10gm 3 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call cefoxitin inj1gm 3 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call cefoxitin inj2gm 3 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a 24

26 week. TTY/TDD users should call cefpodo proxsus100/5ml 1 cefpodo proxsus50mg/5ml 1 cefpodoxime tab100mg 1 cefpodoxime tab200mg 1 cefprozil sus125/5ml 1 cefprozil sus250/5ml 1 cefprozil tab250mg 1 cefprozil tab500mg 1 ceftriaxone inj10gm 3 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call ceftriaxone inj250mg 3 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call ceftriaxone inj500mg 3 ; This prescription drug may be covered under our medical benefit. For more 25

27 information- call hours a day- seven days a week. TTY/TDD users should call cefuroxime inj1.5gm 3 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call cefuroxime inj7.5gm 3 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call cefuroxime inj750mg 3 cefuroxime tab250mg 1 cefuroxime tab500mg 1 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call

28 cephalexin cap250mg 1 cephalexin cap500mg 1 cephalexin sus125/5ml 1 cephalexin sus250/5ml 1 cephalexin tab250mg 1 cephalexin tab500mg 1 SUPRAX SUS100/5ML 3 SUPRAX SUS200/5ML 3 SUPRAX SUS500/5ML 3 SUPRAX TAB400MG 3 TEFLARO INJ400MG 3 TEFLARO INJ600MG 3 Beta-lactam, Other AZACTAM/DEX INJ1GM 2 AZACTAM/DEX INJ2GM 2 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days ; This prescription drug may be covered under our medical benefit. For 27

29 more information- call hours a day- seven days aztreonam inj1gm 1 imipenem/cilinj250mg 1 imipenem/cilinj500mg 1 INVANZ INJ1GM 3 meropenem inj500mg 1 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should ; This prescription drug may be covered under our 28

30 medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call Beta-lactam, Penicillins amox/k clav chw200mg 1 amox/k clav chw400mg 1 amox/k clav sus200/5ml 1 amox/k clav sus250/5ml 1 amox/k clav sus400/5ml 1 amox/k clav sus600/5ml 1 amox/k clav tab250mg 1 amox/k clav tab500mg 1 amox/k clav tab875mg 1 amoxicillin cap250mg 1 amoxicillin cap500mg 1 amoxicillin chw125mg 1 amoxicillin chw250mg 1 amoxicillin sus125/5ml 1 amoxicillin sus200/5ml 1 amoxicillin sus250/5ml 1 amoxicillin sus400/5ml 1 amoxicillin tab500mg 1 amoxicillin tab875mg 1 amox-pot clataber 1 ampicillin cap250mg 1 ampicillin cap500mg 1 ampicillin inj10gm 3 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call ampicillin inj125mg 3 29

31 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call ampicillin inj1gm 3 ampicillin sus125/5ml 1 ampicillin sus250/5ml 1 amp-sulbactainj15gm 3 amp-sulbactainj3gm 3 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call ; This prescription 30

32 drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call BICILLIN C-RINJ BICILLIN C-RINJ900/300 3 BICILLIN L-AINJ BICILLIN L-AINJ BICILLIN L-AINJ dicloxacill cap250mg 1 dicloxacill cap500mg 1 nafcillin inj10gm 3 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call nafcillin inj1gm 3 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call pen g proc inj

33 pen g sod inj ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call PENICILL GK/INJDEX 2MU 3 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call PENICILL GK/INJDEX 3MU 3 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call penicilln gkinj5mu 3 32

34 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call penicilln vksol125/5ml 1 penicilln vksol250/5ml 1 penicilln vktab250mg 1 penicilln vktab500mg 1 piper/tazobainj g 1 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call piper/tazobainj4-0.5gm 1 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days ZOSYN SOL2-0.25GM 3 ZOSYN SOL G 3 33

35 Macrolides DRUG NAME DRUG TIER REQUIREMENTS/LIMITS ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days azithromycininj500mg 3 azithromycinsus100/5ml 1 Quantity limitation 30 per 5 days azithromycinsus200/5ml 1 Quantity limitation 90 per 5 days azithromycintab250mg 1 Quantity limitation 6 per 5 days azithromycintab500mg 1 Quantity limitation 6 per 5 days azithromycintab600mg 1 Quantity limitation 6 per 5 days clarithromycsus125/5ml 1 clarithromycsus250/5ml 1 clarithromyctab250mg 1 Quantity limitation 28 per 14 days clarithromyctab500mg 1 Quantity limitation 28 per 14 days clarithromyctab500mg er 1 Quantity limitation 28 per 14 days DIFICID TAB200MG 3 ery pad2% 1 ery-tab tab250mg ec 1 ery-tab tab333mg ec 1 ery-tab tab500mg ec 1 ERYTHROCIN INJ500MG 3 34

36 erythrocin tab250mg 1 ERYTHROM ETHTAB400MG 2 erythromycingel2% 1 erythromycinoinop 1 erythromycinsol2% 1 erythromycintab250mg bs 1 erythromycintab500mg bs 1 Quinolones AVELOX INJ 3 CILOXAN OIN0.3% OP 3 ciprofloxacninj200mg 1 ciprofloxacninj400mg 1 ciprofloxacnsol0.3% op 1 ciprofloxacntab1000mg 1 ciprofloxacntab100mg 1 ciprofloxacntab250mg 1 ciprofloxacntab500mg 1 ciprofloxacntab500mg er 1 ciprofloxacntab750mg 1 levofloxacinsol0.5% 1 levofloxacinsol25mg/ml 1 levofloxacintab250mg 1 Quantity limitation 14 per 14 days levofloxacintab500mg 1 Quantity limitation 14 per 14 days levofloxacintab750mg 1 Quantity limitation 14 per 14 days moxifloxacintab400mg 1 35

37 ofloxacin dro0.3% op 1 ofloxacin dro0.3%otic 1 ofloxacin tab200mg 1 ofloxacin tab300mg 1 ofloxacin tab400mg 1 VIGAMOX DRO0.5% 3 Sulfonamides silver sulfacre1% 1 smz/tmp ds tab smz-tmp inj400-80/5 3 smz-tmp sus200-40/5 1 smz-tmp tab400-80mg 1 sod sulfacetsol10% op 1 ssd cre1% 1 sulfacet sodoin10% op 1 sulfacetamidsus10% 1 sulfadiazinetab500mg 1 Tetracyclines demeclocycl tab150mg 1 demeclocycl tab300mg 1 doxycyc monotab150mg 1 doxycyc monotab50mg 1 doxycyc monotab75mg 1 doxycycl hyccap100mg 1 doxycycl hyccap50mg 1 doxycycl hyctab100mg 1 minocycline cap100mg 1 minocycline cap50mg 1 minocycline cap75mg 1 minocycline tab100mg 1 minocycline tab135mg er 1 minocycline tab45mg er 1 minocycline tab50mg 1 minocycline tab75mg 1 minocycline tab90mg er 1 36

38 ANTICONVULSANTS Anticonvulsants, Other APTIOM TAB200MG 3 Quantity limitation 180 per 30 days APTIOM TAB400MG 3 Quantity limitation 90 per 30 days APTIOM TAB600MG 3 Quantity limitation 60 per 30 days APTIOM TAB800MG 3 Quantity limitation 45 per 30 days levetiracetasol100mg/ml 1 levetiracetatab1000mg 1 levetiracetatab250mg 1 levetiracetatab500mg 1 levetiracetatab500mg er 1 levetiracetatab750mg 1 levetiracetatab750mg er 1 levetiracetminj500/5ml 3 POTIGA TAB200MG 3 Quantity limitation 180 per 30 days POTIGA TAB300MG 3 Quantity limitation 120 per 30 days POTIGA TAB400MG 3 Quantity limitation 90 per 30 days POTIGA TAB50MG 3 Quantity limitation 720 per 30 days Calcium Channel Modifying Agents CELONTIN CAP300MG 3 ethosuximidecap250mg 1 ethosuximidesol250/5ml 1 LYRICA CAP100MG 3 LYRICA CAP150MG 3 LYRICA CAP200MG 3 LYRICA CAP225MG 3 LYRICA CAP25MG 3 LYRICA CAP300MG 3 LYRICA CAP50MG 3 LYRICA CAP75MG 3 LYRICA SOL20MG/ML 3 zonisamide cap100mg 1 zonisamide cap25mg 1 zonisamide cap50mg 1 Gamma-aminobutyric Acid (GABA) Augmenting Agents clonazep odttab0.125mg 1 clonazep odttab0.25mg 1 clonazep odttab0.5mg 1 clonazep odttab1mg 1 clonazep odttab2mg 1 clonazepam tab0.5mg 1 clonazepam tab1mg 1 37

39 clonazepam tab2mg 1 cloraz dipottab15mg 1 Quantity limitation 90 per 30 days cloraz dipottab3.75mg 1 Quantity limitation 90 per 30 days cloraz dipottab7.5mg 1 Quantity limitation 90 per 30 days DIASTAT ACDLGEL DIASTAT ACDLGEL5-10MG 3 DIASTAT PED GEL2.5M GEL 3 diazepam con5mg/ml 1 Quantity limitation 240 per 30 days Quantity limitation 1200 per 30 days diazepam sol1mg/ml 1 diazepam tab10mg 1 Quantity limitation 180 per 30 days diazepam tab2mg 1 Quantity limitation 90 per 30 days diazepam tab5mg 1 Quantity limitation 240 per 30 days divalproex cap125mg 1 divalproex tab125mg dr 1 divalproex tab250mg dr 1 divalproex tab250mg er 1 divalproex tab500mg dr 1 divalproex tab500mg er 1 FYCOMPA TAB10MG 3 FYCOMPA TAB12MG 3 FYCOMPA TAB2MG 3 Quantity limitation 120 per 30 days FYCOMPA TAB4MG 3 Quantity limitation 90 per 30 days FYCOMPA TAB6MG 3 Quantity limitation 60 per 30 days FYCOMPA TAB8MG 3 Quantity limitation 30 per 30 days gabapentin cap100mg 1 Quantity limitation 360 per 30 days gabapentin cap300mg 1 Quantity limitation 360 per 30 days gabapentin cap400mg 1 Quantity limitation 270 per 30 days gabapentin sol250/5ml 1 gabapentin tab600mg 1 Quantity limitation 180 per 30 days gabapentin tab800mg 1 Quantity limitation 120 per 30 days GABITRIL TAB12MG 2 GABITRIL TAB16MG 2 lorazepam con2mg/ml 1 lorazepam tab0.5mg 1 lorazepam tab1mg 1 lorazepam tab2mg 1 ONFI SUS2.5MG/ML 3 ONFI TAB10MG 3 Quantity limitation 60 per 30 days ONFI TAB20MG 3 Quantity limitation 60 per 30 days phenobarb elx20mg/5ml 1 PHENOBARB TAB100MG 1 PHENOBARB TAB15MG 1 Quantity limitation 1500 per 30 days 38

40 phenobarb tab16.2mg 1 Quantity limitation 360 per 30 days PHENOBARB TAB30MG 1 Quantity limitation 195 per 30 days phenobarb tab32.4mg 1 Quantity limitation 180 per 30 days PHENOBARB TAB60MG 1 PHENOBARB TAB64.8MG 2 Quantity limitation 90 per 30 days PHENOBARB TAB97.2MG 2 Quantity limitation 60 per 30 days primidone tab250mg 1 primidone tab50mg 1 Quantity limitation 180 per 30 days; This prescription may be available only at certain pharmacies. For more information please call hours a day- seven days a week. TTY/TDD users should call SABRIL POW500MG 3 SABRIL TAB500MG 3 tiagabine tab2mg 1 tiagabine tab4mg 1 valproate inj100mg/ml 3 valproic acdcap250mg 1 valproic acdsyp250/5ml 1 Glutamate Reducing Agents felbamate sus600/5ml 1 felbamate tab400mg 1 felbamate tab600mg 1 lamotrigine chw25mg 1 lamotrigine chw5mg 1 lamotrigine tab100mg 1 lamotrigine tab100mg er 1 lamotrigine tab150mg 1 lamotrigine tab200mg 1 lamotrigine tab200mg er 1 lamotrigine tab250mg er 1 lamotrigine tab25mg 1 lamotrigine tab25mg er 1 lamotrigine tab300mg er Quantity limitation 180 per 30 days; This prescription may be available only at certain pharmacies. For more information please call hours a day- seven days a week. TTY/TDD users should call

41 lamotrigine tab50mg er 1 topiramate cap15mg 1 topiramate cap25mg 1 topiramate tab100mg 1 topiramate tab200mg 1 topiramate tab25mg 1 topiramate tab50mg 1 TROKENDI XR CAP100MG 3 TROKENDI XR CAP200MG 3 TROKENDI XR CAP25MG 3 TROKENDI XR CAP50MG 3 Sodium Channel Agents Quantity limitation 2400 per 30 days BANZEL SUS40MG/ML 3 BANZEL TAB200MG 3 Quantity limitation 240 per 30 days BANZEL TAB400MG 3 Quantity limitation 240 per 30 days carbamazepincap100mg er 1 carbamazepincap200mg er 1 carbamazepincap300mg er 1 carbamazepinchw100mg 1 carbamazepinsus100/5ml 1 carbamazepintab200mg 1 carbamazepintab200mg er 1 carbamazepintab400mg er 1 DILANTIN CAP30MG 2 epitol tab200mg 1 EQUETRO CAP100MG 3 EQUETRO CAP200MG 3 EQUETRO CAP300MG 3 fosphenytoininj100/2ml 3 oxcarbazepinsus300mg/5m 1 oxcarbazepintab150mg 1 oxcarbazepintab300mg 1 oxcarbazepintab600mg 1 OXTELLAR XR TAB150MG 3 Quantity limitation 480 per 30 days OXTELLAR XR TAB300MG 3 Quantity limitation 240 per 30 days OXTELLAR XR TAB600MG 3 Quantity limitation 120 per 30 days PEGANONE TAB250MG 3 40

42 phenytoin chw50mg 1 phenytoin inj50mg/ml 3 phenytoin sus125/5ml 1 phenytoin excap100mg 1 phenytoin excap200mg 1 phenytoin excap300mg 1 Quantity limitation 1200 per 30 VIMPAT INJ200MG/20 3 VIMPAT SOL10MG/ML 3 days Quantity limitation 1200 per 30 days VIMPAT TAB100MG 3 Quantity limitation 60 per 30 days VIMPAT TAB150MG 3 Quantity limitation 60 per 30 days VIMPAT TAB200MG 3 Quantity limitation 60 per 30 days VIMPAT TAB50MG 3 Quantity limitation 60 per 30 days ANTIDEMENTIA AGENTS Antidementia Agents, Other ergoloid mestab1mg oral 1 Cholinesterase Inhibitors donepezil tab10mg 1 Quantity limitation 30 per 30 days donepezil tab10mg odt 1 Quantity limitation 30 per 30 days donepezil tab5mg 1 Quantity limitation 30 per 30 days donepezil tab5mg odt 1 Quantity limitation 30 per 30 days donepezil tabhcl 23mg 1 Quantity limitation 30 per 30 days EXELON DIS13.3/24 2 EXELON DIS4.6MG/24 2 EXELON DIS9.5MG/24 2 galantamine cap16mg er 1 Quantity limitation 30 per 30 days galantamine cap24mg er 1 Quantity limitation 30 per 30 days galantamine cap8mg er 1 Quantity limitation 30 per 30 days galantamine sol4mg/ml 1 Quantity limitation 180 per 30 days galantamine tab12mg 1 galantamine tab4mg 1 galantamine tab8mg 1 rivastigminecap1.5mg 1 Quantity limitation 60 per 30 days rivastigminecap3mg 1 Quantity limitation 60 per 30 days rivastigminecap4.5mg 1 Quantity limitation 60 per 30 days rivastigminecap6mg 1 Quantity limitation 60 per 30 days N-methyl-D-aspartate (NMDA) Receptor Antagonist 41

43 NAMENDA SOL10MG/5ML 2 Quantity limitation 360 per 30 days NAMENDA XR CAP14MG 2 Quantity limitation 30 per 30 days NAMENDA XR CAP21MG 2 Quantity limitation 30 per 30 days NAMENDA XR CAP28MG 2 Quantity limitation 30 per 30 days NAMENDA XR CAP7MG 2 Quantity limitation 30 per 30 days NAMENDA XR CAPTITRATIO 2 Quantity limitation 30 per 30 days ANTIDEPRESSANTS Antidepressants olanza/fluoxcap12-25mg 1 Quantity limitation 30 per 30 days olanza/fluoxcap12-50mg 1 Quantity limitation 30 per 30 days olanza/fluoxcap3-25mg 1 Quantity limitation 30 per 30 days olanza/fluoxcap6-25mg 1 Quantity limitation 30 per 30 days olanza/fluoxcap6-50mg 1 Quantity limitation 30 per 30 days perphen/amittab2-10mg 1 perphen/amittab2-25mg 1 perphen/amittab4-10mg 1 perphen/amittab4-25mg 1 perphen/amittab4-50mg 1 Antidepressants, Other ABILIFY INJ9.75MG 3 ABILIFY SOL1MG/ML 3 Quantity limitation 900 per 30 days ABILIFY TAB10MG 3 Quantity limitation 90 per 30 days ABILIFY TAB15MG 3 Quantity limitation 60 per 30 days ABILIFY TAB20MG 3 Quantity limitation 60 per 30 days ABILIFY TAB2MG 3 Quantity limitation 450 per 30 days ABILIFY TAB30MG 3 Quantity limitation 30 per 30 days ABILIFY TAB5MG 3 Quantity limitation 180 per 30 days ABILIFY DISCTAB10MG 3 Quantity limitation 90 per 30 days ABILIFY DISCTAB15MG 3 Quantity limitation 60 per 30 days ABILIFY MAININJ300MG 3 mirtazapine tab15mg 1 Quantity limitation 30 per 30 days mirtazapine tab15mg odt 1 Quantity limitation 30 per 30 days mirtazapine tab30mg 1 Quantity limitation 30 per 30 days mirtazapine tab30mg odt 1 Quantity limitation 30 per 30 days mirtazapine tab45mg 1 Quantity limitation 30 per 30 days mirtazapine tab45mg odt 1 Quantity limitation 30 per 30 days mirtazapine tab7.5mg 1 Quantity limitation 30 per 30 days quetiapine tab100mg 1 Quantity limitation 240 per 30 days 42

44 quetiapine tab200mg 1 Quantity limitation 120 per 30 days quetiapine tab25mg 1 Quantity limitation 960 per 30 days quetiapine tab300mg 1 Quantity limitation 90 per 30 days quetiapine tab400mg 1 Quantity limitation 60 per 30 days quetiapine tab50mg 1 Quantity limitation 480 per 30 days SEROQUEL XR TAB150MG 2 Quantity limitation 30 per 30 days SEROQUEL XR TAB200MG 2 Quantity limitation 30 per 30 days SEROQUEL XR TAB300MG 2 Quantity limitation 60 per 30 days SEROQUEL XR TAB400MG 2 Quantity limitation 60 per 30 days SEROQUEL XR TAB50MG 2 Quantity limitation 60 per 30 days Monoamine Oxidase Inhibitors EMSAM DIS12MG/24H 3 Quantity limitation 30 per 30 days EMSAM DIS6MG/24HR 3 Quantity limitation 30 per 30 days EMSAM DIS9MG/24HR 3 Quantity limitation 30 per 30 days MARPLAN TAB10MG 3 phenelzine tab15mg 1 tranylcypromtab10mg 1 SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin Norepinephrine Reuptake Inhibitors) BRINTELLIX TAB10MG 3 Quantity limitation 60 per 30 days BRINTELLIX TAB20MG 3 Quantity limitation 30 per 30 days BRINTELLIX TAB5MG 3 Quantity limitation 120 per 30 days citalopram sol10mg/5ml 1 This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. citalopram tab10mg 1 Quantity limitation 30 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. citalopram tab20mg 1 Quantity limitation 30 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. citalopram tab40mg 1 Quantity limitation 30 per 30 days; This prescription drug is part of the 43

45 free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. DESVENLAFAX TAB100MG ER 3 Quantity limitation 120 per 30 days DESVENLAFAX TAB50MG ER 3 Quantity limitation 240 per 30 days duloxetine cap20mg 1 Quantity limitation 180 per 30 days duloxetine cap30mg 1 Quantity limitation 120 per 30 days duloxetine cap60mg 1 Quantity limitation 60 per 30 days escitalopramsol5mg/5ml 1 Quantity limitation 620 per 30 days escitalopramtab10mg 1 Quantity limitation 60 per 30 days escitalopramtab20mg 1 Quantity limitation 30 per 30 days escitalopramtab5mg 1 Quantity limitation 120 per 30 days FETZIMA CAP120MG 3 Quantity limitation 30 per 30 days FETZIMA CAP20MG 3 Quantity limitation 180 per 30 days FETZIMA CAP40MG 3 Quantity limitation 120 per 30 days FETZIMA CAP80MG 3 Quantity limitation 30 per 30 days FETZIMA CAPTITRATIO 3 Quantity limitation 28 per 28 days fluoxetine cap10mg 1 Quantity limitation 30 per 30 days fluoxetine cap20mg 1 fluoxetine cap40mg 1 Quantity limitation 60 per 30 days fluoxetine cap90mg dr 1 fluoxetine sol20mg/5ml 1 fluoxetine tab10mg 1 Quantity limitation 30 per 30 days fluoxetine tab20mg 1 fluvoxamine cap100mg er 1 Quantity limitation 60 per 30 days fluvoxamine cap150mg er 1 Quantity limitation 60 per 30 days fluvoxamine tab100mg 1 Quantity limitation 90 per 30 days fluvoxamine tab25mg 1 Quantity limitation 360 per 30 days fluvoxamine tab50mg 1 Quantity limitation 180 per 30 days KHEDEZLA TAB100MG ER 3 Quantity limitation 120 per 30 days KHEDEZLA TAB50MG ER 3 Quantity limitation 240 per 30 days maprotiline tab25mg 1 maprotiline tab50mg 1 maprotiline tab75mg 1 nefazodone tab100mg 1 nefazodone tab150mg 1 nefazodone tab200mg 1 nefazodone tab250mg 1 nefazodone tab50mg 1 paroxetin ertab12.5mg 1 Quantity limitation 150 per 30 days; This prescription drug is part of the free first fill program and will 44

46 be provided at zero cost share when you select this medication over the brand name version of selected medications. paroxetin ertab37.5mg 1 Quantity limitation 60 per 30 days paroxetine tab10mg 1 Quantity limitation 90 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. paroxetine tab20mg 1 Quantity limitation 60 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. paroxetine tab25mg er 1 Quantity limitation 90 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. paroxetine tab30mg 1 Quantity limitation 60 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. Quantity limitation 45 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. paroxetine tab40mg 1 PAXIL SUS10MG/5ML 3 PRISTIQ TAB100MG 3 Quantity limitation 30 per 30 days PRISTIQ TAB50MG 3 Quantity limitation 240 per 30 days sertraline con20mg/ml 1 Quantity limitation 300 per 30 days sertraline tab100mg 1 Quantity limitation 60 per 30 days 45

47 sertraline tab25mg 1 Quantity limitation 240 per 30 days sertraline tab50mg 1 Quantity limitation 120 per 30 days trazodone tab100mg 1 trazodone tab150mg 1 trazodone tab300mg 1 trazodone tab50mg 1 venlafaxine cap150mg er 1 Quantity limitation 60 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. venlafaxine cap37.5mg 1 Quantity limitation 180 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. venlafaxine cap75mg er 1 Quantity limitation 90 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. venlafaxine tab100mg 1 Quantity limitation 90 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. venlafaxine tab150mg er 1 Quantity limitation 60 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. VENLAFAXINE TAB225MG ER 3 Quantity limitation 30 per 30 days venlafaxine tab25mg 1 Quantity limitation 270 per 30 days; This prescription drug is part of the free first fill program and will 46

48 be provided at zero cost share when you select this medication over the brand name version of selected medications. venlafaxine tab37.5 er 1 Quantity limitation 180 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. venlafaxine tab37.5mg 1 Quantity limitation 180 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. venlafaxine tab50mg 1 Quantity limitation 150 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. venlafaxine tab75mg 1 Quantity limitation 150 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. Quantity limitation 90 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. venlafaxine tab75mg er 1 VIIBRYD KIT 3 VIIBRYD TAB10MG 3 Quantity limitation 120 per 30 days VIIBRYD TAB20MG 3 Quantity limitation 60 per 30 days VIIBRYD TAB40MG 3 Quantity limitation 30 per 30 days Tricyclics amitriptylintab100mg 1 47

49 amitriptylintab10mg 1 amitriptylintab150mg 1 amitriptylintab25mg 1 amitriptylintab50mg 1 amitriptylintab75mg 1 amoxapine tab100mg 1 amoxapine tab150mg 1 amoxapine tab25mg 1 amoxapine tab50mg 1 clomipraminecap25mg 1 clomipraminecap50mg 1 clomipraminecap75mg 1 desipramine tab100mg 1 desipramine tab10mg 1 desipramine tab150mg 1 desipramine tab25mg 1 desipramine tab50mg 1 desipramine tab75mg 1 doxepin hcl cap100mg 1 doxepin hcl cap10mg 1 doxepin hcl cap150mg 1 doxepin hcl cap25mg 1 doxepin hcl cap50mg 1 doxepin hcl cap75mg 1 doxepin hcl con10mg/ml 1 imipram hcl tab10mg 1 imipram hcl tab25mg 1 imipram hcl tab50mg 1 nortriptylincap10mg 1 nortriptylincap25mg 1 nortriptylincap50mg 1 nortriptylincap75mg 1 nortriptylinsol10mg/5ml 1 protriptylintab10mg 1 protriptylintab5mg 1 SURMONTIL CAP100MG 3 SURMONTIL CAP25MG 3 SURMONTIL CAP50MG 3 ANTIEMETICS Antiemetics, Other chlorpromaz inj25mg/ml 3 chlorpromaz tab100mg 1 chlorpromaz tab10mg 1 48

50 chlorpromaz tab200mg 1 chlorpromaz tab25mg 1 chlorpromaz tab50mg 1 compro sup25mg 1 diphenhydraminj50mg/ml 3 meclizine tab12.5mg 1 meclizine tab25mg 1 metoclopram inj5mg/ml 3 metoclopram sol5mg/5ml 1 metoclopram tab10mg 1 metoclopram tab5mg 1 perphenazinetab16mg 1 perphenazinetab2mg 1 perphenazinetab4mg 1 perphenazinetab8mg 1 phenadoz sup12.5mg 1 prochlorper inj5mg/ml 3 prochlorper sup25mg 1 prochlorper tab10mg 1 prochlorper tab5mg 1 promethazineinj25mg/ml 3 promethazineinj50mg/ml 3 49

51 promethazinesup12.5mg 1 promethazinesup25mg 1 promethegan sup25mg 1 promethegan sup50mg 1 TRANSDERM-SCDIS1.5MG 3 Quantity limitation 24 per 30 days Emetogenic Therapy Adjuncts Quantity limitation 150 per 30 days; This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of drug to ALOXI INJ0.25MG/5 3 make the Quantity limitation 50 per 30 days; ANZEMET INJ20MG/ML 3 Quantity limitation 30 per 30 days; ANZEMET TAB100MG 3 ANZEMET TAB50MG 3 dronabinol cap10mg 1 dronabinol cap2.5mg 1 dronabinol cap5mg 1 EMEND CAP125MG 2 Quantity limitation 30 per 30 days; Quantity limitation 30 per 30 days; 50

52 EMEND CAP40MG 2 Quantity limitation 30 per 30 days; EMEND CAP80MG 2 Quantity limitation 30 per 30 days; EMEND PAK80 & Quantity limitation 30 per 30 days; Quantity limitation 30 per 30 days; granisetron tab1mg 1 Quantity limitation 30 per 3 days; granisol sol2mg/10ml 1 51

53 ondansetron sol4mg/5ml 1 Quantity limitation 450 per 30 days; This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of drug to make the ondansetron tab24mg 1 Quantity limitation 60 per 30 days; ondansetron tab4mg 1 Quantity limitation 60 per 30 days; ondansetron tab4mg odt 1 Quantity limitation 60 per 30 days; ondansetron tab8mg 1 Quantity limitation 60 per 30 days; ondansetron tab8mg odt 1 Quantity limitation 60 per 30 days; 52

54 ZOFRAN INJ40/20ML 3 Antifungals ABELCET INJ5MG/ML 4 AMBISOME INJ50MG 3 amphotericininj50mg 3 CANCIDAS INJ50MG 4 CANCIDAS INJ70MG 4 ANTIFUNGALS 53

55 ciclopirox cre0.77% 1 ciclopirox gel0.77% 1 ciclopirox sha1% 1 ciclopirox sol8% 1 ciclopirox sus0.77% 1 clotrimazolecre1% 1 clotrimazolesol1% 1 clotrimazoletro10mg 1 econazole cre1% 1 ERAXIS INJ100MG 3 EXELDERM CRE1% 3 EXELDERM SOL1% 3 fluconazole sus10mg/ml 1 fluconazole sus40mg/ml 1 fluconazole tab100mg 1 fluconazole tab150mg 1 Quantity limitation 2 per 7 days fluconazole tab200mg 1 fluconazole tab50mg 1 fluconazole/injdex flucytosine cap250mg 1 flucytosine cap500mg 1 griseofulvinsus125/5ml 1 itraconazolecap100mg 1 ketoconazolecre2% 1 ketoconazolesha2% 1 ketoconazoletab200mg 1 miconazole 3sup200mg 1 Quantity limitation 3 per 3 days NAFTIN CRE1% 3 NAFTIN GEL1% 3 NATACYN SUS5% OP 2 NOXAFIL SUS40MG/ML 4 NOXAFIL TAB100MG 4 nystat/triamcre 1 54

56 nystat/triamoin 1 nystatin cre nystatin oin nystatin pow nystatin sus nystatin tab nystop pow OXISTAT CRE1% 3 OXISTAT LOT1% 3 pedi-dri pow terbinafine tab250mg 1 terconazole cre0.4% 1 Quantity limitation 45 per 7 days terconazole cre0.8% 1 terconazole sup80mg 1 Quantity limitation 3 per 3 days voriconazoleinj200mg 3 voriconazolesus40mg/ml 1 voriconazoletab200mg 4 voriconazoletab50mg 4 zazole cre0.4% 2 Antigout Agents allopurinol tab100mg 1 allopurinol tab300mg 1 ANTIGOUT AGENTS 55

57 COLCRYS TAB0.6MG 3 Quantity limitation 120 per 30 days proben/colchtab probenecid tab500mg 1 ANTIMIGRAINE AGENTS Antimigraine Agents migergot sup2/100 1 Ergot Alkaloids dihydroergotinj1mg/ml 2 MIGRANAL SPR4MG/ML 3 Quantity limitation 16 per 30 days OTEZLA TAB10/20/30 3 Quantity limitation 60 per 30 days OTEZLA TAB30MG 3 Quantity limitation 60 per 30 days Prophylactic timolol mal tab10mg 1 timolol mal tab20mg 1 timolol mal tab5mg 1 Serotonin (5-HT) 1b/1d Receptor Agonists naratriptan tab1mg 1 Quantity limitation 9 per 30 days naratriptan tab2.5mg 1 Quantity limitation 9 per 30 days RELPAX TAB20MG 2 Quantity limitation 6 per 30 days RELPAX TAB40MG 2 Quantity limitation 6 per 30 days rizatriptan tab10mg 1 rizatriptan tab10mg odt 1 rizatriptan tab5mg 1 rizatriptan tab5mg odt 1 sumatriptan inj6mg/0.5 3 Quantity limitation 6 per 30 days sumatriptan inj6mg/0.5 3 Quantity limitation 6 per 30 days sumatriptan tab100mg 1 Quantity limitation 12 per 30 days sumatriptan tab25mg 1 Quantity limitation 12 per 30 days sumatriptan tab50mg 1 Quantity limitation 12 per 30 days zolmitriptantab2.5 mg 1 Quantity limitation 6 per 30 days zolmitriptantab2.5mg 1 Quantity limitation 6 per 30 days zolmitriptantab5mg 1 Quantity limitation 6 per 30 days zolmitriptantab5mg 1 Quantity limitation 6 per 30 days ANTIMYASTHENIC AGENTS Parasympathomimetics GUANIDINE TAB125MG 3 MESTINON SYP60MG/5ML 3 MESTINON TABTIMESPAN 3 pyridostigm tab60mg 1 ANTIMYCOBACTERIALS Antimycobacterials, Other dapsone tab100mg 1 56

58 dapsone tab25mg 1 MYCOBUTIN CAP150MG 3 rifabutin cap150mg 1 Antituberculars CAPASTAT SULINJ1GM 3 ethambutol tab100mg 1 ethambutol tab400mg 1 isoniazid syp50mg/5ml 1 isoniazid tab100mg 1 isoniazid tab300mg 1 paser gra4gm 1 PRIFTIN TAB150MG 3 pyrazinamidetab500mg 1 rifampin cap150mg 1 rifampin cap300mg 1 rifampin inj600 mg 3 RIFATER TAB 3 SIRTURO TAB100MG 4 TRECATOR TAB250MG 3 ANTINEOPLASTICS Alkylating Agents CYCLOPHOSPH CAP25MG 3 CYCLOPHOSPH CAP50MG 3 57

59 cyclophosph tab25mg 1 cyclophosph tab50mg 1 HEXALEN CAP50MG 4 LEUKERAN TAB2MG 2 MATULANE CAP50MG 3 Antiandrogens bicalutamidetab50mg 1 Quantity limitation 30 per 30 days flutamide cap125mg 1 NILANDRON TAB150MG 3 XTANDI CAP40MG 4 ZYTIGA TAB250MG 4 Antiangiogenic Agents POMALYST CAP1MG 4 POMALYST CAP2MG 4 POMALYST CAP3MG 4 POMALYST CAP4MG 4 Quantity limitation 120 per 30 days; This prescription may be available only at certain pharmacies. For more information please call hours a day- seven days a week. TTY/TDD users should call Quantity limitation 120 per 30 days; This prescription may be available only at certain pharmacies. For more information please call hours a day- seven days a week. TTY/TDD users should call

60 This prescription may be available only at certain pharmacies. For more information please call hours a dayseven days a week. TTY/TDD REVLIMID CAP10MG 4 users should REVLIMID CAP15MG 4 This prescription may be available only at certain pharmacies. For more information please call hours a dayseven days a week. TTY/TDD users should REVLIMID CAP2.5MG 4 This prescription may be available only at certain pharmacies. For more information please call hours a dayseven days a week. TTY/TDD users should REVLIMID CAP20MG 4 This prescription may be available only at certain pharmacies. For more information please call hours a dayseven days a week. TTY/TDD users should REVLIMID CAP25MG 4 This prescription may be available only at certain pharmacies. For more information please call hours a dayseven days a week. TTY/TDD users should REVLIMID CAP5MG 4 This prescription may be available only at certain pharmacies. For more information please call hours a dayseven days a week. TTY/TDD users should THALOMID CAP100MG 4 THALOMID CAP150MG 4 THALOMID CAP200MG 4 THALOMID CAP50MG 4 Antiestrogens/Modifiers EMCYT CAP140MG 3 FARESTON TAB60MG 3 SOLTAMOX SOL10MG/5ML 3 tamoxifen tab10mg 1 59

61 tamoxifen tab20mg 1 Antimetabolites DROXIA CAP200MG 3 DROXIA CAP300MG 3 DROXIA CAP400MG 3 hydroxyurea cap500mg 1 mercaptopur tab50mg 1 TABLOID TAB40MG 3 Antineoplastics ALIMTA INJ500MG 4 amifostine inj500mg 4 ARRANON INJ5MG/ML 4 AVASTIN INJ 4 azacitidine inj100mg 3 bleomycin inj30unit 3 60

62 DACOGEN INJ50MG 4 decitabine inj50mg 4 DOCEFREZ INJ20MG 4 DOCEFREZ INJ80MG 4 DOCETAXEL INJ80MG/4ML 2 ELITEK INJ1.5MG 4 61

63 FASLODEX INJ250MG 4 FUSILEV INJ50MG 3 gemcitabine inj1gm 3 HALAVEN INJ1MG/2ML 4 HERCEPTIN INJ440MG 4 ISTODAX INJ10MG 4 JEVTANA INJ60/1.5ML 4 62

64 LOMUSTINE CAP100MG 3 LOMUSTINE CAP10MG 3 LOMUSTINE CAP40MG 3 MESNEX TAB400MG 3 oxaliplatin inj100mg 3 PERJETA INJ420/14ML 4 PROLEUKIN INJ22MU 4 SYNRIBO INJ3.5MG 4 TREANDA INJ100MG 4 TRISENOX SOL10MG/10M 3 VELCADE INJ3.5MG 4 YERVOY INJ50MG 4 63

65 ZALTRAP INJ100/4ML 4 ZANOSAR INJ1GM 3 Antineoplastics, Other ERWINAZE INJ10000UNT 4 leucovor ca inj100mg 3 leucovor ca inj350mg 3 leucovor ca tab10mg 1 leucovor ca tab15mg 1 leucovor ca tab25mg 1 leucovor ca tab5mg 1 mitoxantron inj2mg/ml 2 64

66 P Generation DRUG NAME DRUG TIER REQUIREMENTS/LIMITS ONCASPAR INJ750/ML 4 ZOLINZA CAP100MG 4 rd Aromatase Inhibitors, 3P anastrozole tab1mg 1 Quantity limitation 30 per 30 days exemestane tab25mg 1 letrozole tab2.5mg 1 Enzyme Inhibitors ETOPOPHOS INJ100MG 3 etoposide inj20mg/ml 3 toposar inj1gm/50ml 2 topotecan inj4mg 3 65

67 Molecular Target Inhibitors AFINITOR TAB10MG 4 Quantity limitation 60 per 30 days AFINITOR TAB2.5MG 4 Quantity limitation 60 per 30 days AFINITOR TAB5MG 4 Quantity limitation 60 per 30 days AFINITOR TAB7.5MG 4 Quantity limitation 60 per 30 days AFINITOR DISTAB2MG 4 Quantity limitation 150 per 30 days AFINITOR DISTAB3MG 4 Quantity limitation 90 per 30 days AFINITOR DISTAB5MG 4 Quantity limitation 60 per 30 days BOSULIF TAB100MG 4 Quantity limitation 120 per 30 days BOSULIF TAB500MG 4 Quantity limitation 30 per 30 days Quantity limitation 60 per 30 days; This prescription may be available only at certain pharmacies. For more information please call hours a dayseven days a week. TTY/TDD CAPRELSA TAB100MG 4 users should Quantity limitation 30 per 30 days; This prescription may be available only at certain pharmacies. For more information please call hours a dayseven days a week. TTY/TDD users should CAPRELSA TAB300MG 4 COMETRIQ KIT100MG 4 Quantity limitation 56 per 28 days COMETRIQ KIT140MG 4 Quantity limitation 112 per 28 days COMETRIQ KIT60MG 4 Quantity limitation 84 per 28 days ERIVEDGE CAP150MG 3 GILOTRIF TAB20MG 4 Quantity limitation 30 per 30 days GILOTRIF TAB30MG 4 Quantity limitation 30 per 30 days GILOTRIF TAB40MG 4 Quantity limitation 30 per 30 days GLEEVEC TAB100MG 4 Quantity limitation 90 per 30 days GLEEVEC TAB400MG 4 Quantity limitation 60 per 30 days IMBRUVICA CAP140MG 4 Quantity limitation 120 per 30 days INLYTA TAB1MG 3 INLYTA TAB5MG 3 JAKAFI TAB10MG 4 Quantity limitation 60 per 30 days; This prescription may be available only at certain pharmacies. For more information please call hours a dayseven days a week. TTY/TDD 66

68 users should JAKAFI TAB15MG 4 Quantity limitation 60 per 30 days; This prescription may be available only at certain pharmacies. For more information please call hours a dayseven days a week. TTY/TDD users should JAKAFI TAB20MG 4 Quantity limitation 60 per 30 days; This prescription may be available only at certain pharmacies. For more information please call hours a dayseven days a week. TTY/TDD users should JAKAFI TAB25MG 4 Quantity limitation 60 per 30 days; This prescription may be available only at certain pharmacies. For more information please call hours a dayseven days a week. TTY/TDD users should JAKAFI TAB5MG 4 Quantity limitation 60 per 30 days; This prescription may be available only at certain pharmacies. For more information please call hours a dayseven days a week. TTY/TDD users should MEKINIST TAB0.5MG 4 Quantity limitation 120 per 30 days MEKINIST TAB2MG 4 Quantity limitation 30 per 30 days NEXAVAR TAB200MG 4 Quantity limitation 120 per 30 days; This prescription may be available only at certain pharmacies. For more information please call hours a day- seven days a week. TTY/TDD users should call SPRYCEL TAB100MG 4 SPRYCEL TAB140MG 4 SPRYCEL TAB20MG 4 SPRYCEL TAB50MG 4 SPRYCEL TAB70MG 4 SPRYCEL TAB80MG 4 67

69 STIVARGA TAB40MG 4 Quantity limitation 84 per 28 days SUTENT CAP12.5MG 4 SUTENT CAP25MG 4 SUTENT CAP50MG 4 TAFINLAR CAP50MG 4 Quantity limitation 180 per 30 days TAFINLAR CAP75MG 4 Quantity limitation 120 per 30 days TARCEVA TAB100MG 4 TARCEVA TAB150MG 4 TARCEVA TAB25MG 4 TASIGNA CAP150MG 4 TASIGNA CAP200MG 4 TYKERB TAB250MG 4 This prescription may be available only at certain pharmacies. For more information please call hours a dayseven days a week. TTY/TDD users should VOTRIENT TAB200MG 4 XALKORI CAP200MG 4 Quantity limitation 60 per 30 days; This prescription may be available only at certain pharmacies. For more information please call hours a dayseven days a week. TTY/TDD users should XALKORI CAP250MG 4 Quantity limitation 60 per 30 days; This prescription may be available only at certain pharmacies. For more information please call hours a dayseven days a week. TTY/TDD users should ZELBORAF TAB240MG 2 Quantity limitation 240 per 30 days; This prescription may be available only at certain pharmacies. For more information please call hours a day- seven days a week. TTY/TDD users should call ZYKADIA CAP150MG 4 Quantity limitation 150 per 30 days Monoclonal Antibodies ARZERRA CON100/5ML 4 68

70 KADCYLA INJ100MG 4 RITUXAN INJ500MG 4 Retinoids PANRETIN GEL0.1% 4 TARGRETIN CAP75MG 4 TARGRETIN GEL1% 4 Quantity limitation 60 per 30 days tretinoin cap10mg 1 ANTIPARASITICS Anthelminthics ALBENZA TAB200MG 2 BILTRICIDE TAB600MG 3 STROMECTOL TAB3MG 3 Antiprotozoals ALINIA SUS100/5ML 3 ALINIA TAB500MG 3 atovaq/progutab atovaquone sus750/5ml 1 chloroquine tab250mg 1 chloroquine tab500mg 1 COARTEM TAB20-120MG 3 DARAPRIM TAB25MG 3 hydroxychlortab200mg 1 MALARONE TAB mefloquine tab250mg 1 MEPRON SUS 3 NEBUPENT INH300MG 3 69

71 PENTAM 300 INJ300MG 3 PRIMAQUINE TAB26.3MG 3 quinine sulfcap324mg 1 Pediculicides/Scabicides lindane lot1% 1 lindane sha1% 1 permethrin cre5% 1 ANTIPARKINSON AGENTS Anticholinergics benztropine tab0.5mg 1 benztropine tab1mg 1 benztropine tab2mg 1 trihexyphen elx0.4mg/ml 1 trihexyphen tab2mg 1 trihexyphen tab5mg 1 Antiparkinson Agents, Other amantadine cap100mg 1 amantadine syp50mg/5ml 1 amantadine tab100mg 1 entacapone tab200mg 1 Quantity limitation 240 per 30 days TASMAR TAB100MG 3 Dopamine Agonists APOKYN INJ10MG/ML 4 This prescription may be available only at certain pharmacies. For more information please call hours a dayseven days a week. TTY/TDD users should ; bromocriptincap5mg 1 bromocriptintab2.5mg 1 NEUPRO DIS1MG/24HR 3 Quantity limitation 30 per 30 days 70

72 NEUPRO DIS2MG/24HR 3 Quantity limitation 30 per 30 days NEUPRO DIS3MG/24HR 3 Quantity limitation 30 per 30 days NEUPRO DIS4MG/24HR 3 Quantity limitation 30 per 30 days NEUPRO DIS6MG/24HR 3 Quantity limitation 30 per 30 days NEUPRO DIS8MG/24HR 3 Quantity limitation 30 per 30 days pramipexole tab0.125mg 1 Quantity limitation 90 per 30 days pramipexole tab0.25mg 1 Quantity limitation 90 per 30 days pramipexole tab0.5mg 1 Quantity limitation 90 per 30 days pramipexole tab0.75mg 1 Quantity limitation 90 per 30 days pramipexole tab1.5mg 1 Quantity limitation 90 per 30 days pramipexole tab1mg 1 Quantity limitation 90 per 30 days ropinirole tab0.25mg 1 ropinirole tab0.5mg 1 ropinirole tab1mg 1 ropinirole tab2mg 1 ropinirole tab3mg 1 ropinirole tab4mg 1 ropinirole tab5mg 1 Dopamine Precursors/L-Amino Acid Decarboxylase Inhibitors carb/levo tab10-100mg 1 carb/levo tab25-100mg 1 carb/levo tab25-250mg 1 carb/levo ertab25-100mg 1 carb/levo ertab50-200mg 1 carbidopa tab25mg 1 LODOSYN TAB25MG 3 Monoamine Oxidase B (MAO-B) Inhibitors AZILECT TAB0.5MG 3 AZILECT TAB1MG 3 selegiline cap5mg 1 selegiline tab5mg 1 ANTIPSYCHOTICS 1st Generation/Typical fluphenaz deinj25mg/ml 3 fluphenazinecon5mg/ml 1 fluphenazineelx2.5/5ml 1 fluphenazineinj2.5mg/ml 3 fluphenazinetab10mg 1 fluphenazinetab1mg 1 fluphenazinetab2.5mg 1 fluphenazinetab5mg 1 haloper dec inj100mg/ml 3 71

73 haloper dec inj50mg/ml 3 haloper lac inj5mg/ml 3 haloperidol con2mg/ml 1 haloperidol tab0.5mg 1 haloperidol tab10mg 1 haloperidol tab1mg 1 haloperidol tab20mg 1 haloperidol tab2mg 1 haloperidol tab5mg 1 loxapine cap10mg 1 loxapine cap25mg 1 loxapine cap50mg 1 loxapine cap5mg 1 ORAP TAB1MG 3 ORAP TAB2MG 3 thioridazinetab100mg 1 thioridazinetab10mg 1 thioridazinetab25mg 1 thioridazinetab50mg 1 thiothixene cap10mg 1 thiothixene cap1mg 1 thiothixene cap2mg 1 thiothixene cap5mg 1 trifluoperaztab10mg 1 trifluoperaztab1mg 1 trifluoperaztab2mg 1 trifluoperaztab5mg 1 2nd Generation/Atypical FANAPT PAK 3 Quantity limitation 60 per 30 days FANAPT TAB10MG 3 Quantity limitation 90 per 30 days FANAPT TAB12MG 3 Quantity limitation 60 per 30 days FANAPT TAB1MG 3 Quantity limitation 720 per 30 days 72

74 FANAPT TAB2MG 3 Quantity limitation 360 per 30 days FANAPT TAB4MG 3 Quantity limitation 180 per 30 days FANAPT TAB6MG 3 Quantity limitation 120 per 30 days FANAPT TAB8MG 3 Quantity limitation 90 per 30 days GEODON INJ20MG 3 INVEGA TAB1.5MG 3 Quantity limitation 240 per 30 days INVEGA TAB3MG 3 Quantity limitation 120 per 30 days INVEGA TAB6MG 3 Quantity limitation 60 per 30 days INVEGA TAB9MG 3 Quantity limitation 60 per 30 days INVEGA SUST INJ117/ INVEGA SUST INJ156MG/ML 4 INVEGA SUST INJ234/1.5 4 INVEGA SUST INJ39/ INVEGA SUST INJ78/0.5ML 3 LATUDA TAB120MG 3 Quantity limitation 30 per 30 days LATUDA TAB20MG 3 Quantity limitation 120 per 30 days LATUDA TAB40MG 3 Quantity limitation 60 per 30 days LATUDA TAB60MG 3 Quantity limitation 60 per 30 days LATUDA TAB80MG 3 Quantity limitation 30 per 30 days Quantity limitation 30 per 30 days; olanzapine inj10mg 3 olanzapine tab10mg 1 Quantity limitation 60 per 30 days olanzapine tab10mg odt 1 Quantity limitation 60 per 30 days olanzapine tab15mg 1 Quantity limitation 60 per 30 days olanzapine tab15mg odt 1 Quantity limitation 60 per 30 days olanzapine tab2.5mg 1 Quantity limitation 240 per 30 days olanzapine tab20mg 1 Quantity limitation 30 per 30 days olanzapine tab20mg odt 1 Quantity limitation 30 per 30 days olanzapine tab5mg 1 Quantity limitation 120 per 30 days olanzapine tab5mg odt 1 Quantity limitation 120 per 30 days olanzapine tab7.5mg 1 Quantity limitation 90 per 30 days RISPERDAL INJ12.5MG 3 RISPERDAL INJ25MG 3 RISPERDAL INJ37.5MG 3 RISPERDAL INJ50MG 3 risperidone sol1mg/ml 1 Quantity limitation 480 per 30 days; This prescription drug is part of the free first fill program and will 73

75 be provided at zero cost share when you select this medication over the brand name version of selected medications. risperidone tab0.25 odt 1 Quantity limitation 1920 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. risperidone tab0.25mg 1 Quantity limitation 1920 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. risperidone tab0.5mg 1 Quantity limitation 960 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. risperidone tab0.5mg od 1 Quantity limitation 960 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. risperidone tab1mg 1 Quantity limitation 480 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. risperidone tab1mg odt 1 Quantity limitation 480 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of 74

76 selected medications. risperidone tab2mg 1 Quantity limitation 240 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. risperidone tab2mg odt 1 Quantity limitation 240 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. risperidone tab3mg 1 Quantity limitation 180 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. risperidone tab3mg odt 1 Quantity limitation 180 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. risperidone tab4mg 1 Quantity limitation 120 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. risperidone tab4mg odt 1 Quantity limitation 120 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. SAPHRIS SUB10MG 3 Quantity limitation 60 per 30 days SAPHRIS SUB5MG 3 Quantity limitation 120 per 30 days 75

77 ziprasidone cap20mg 1 Quantity limitation 240 per 30 days ziprasidone cap40mg 1 Quantity limitation 120 per 30 days ziprasidone cap60mg 1 Quantity limitation 90 per 30 days ziprasidone cap80mg 1 Quantity limitation 60 per 30 days Treatment Resistent clozapine tab100mg 1 Quantity limitation 120 per 30 days clozapine tab200mg 1 Quantity limitation 120 per 30 days clozapine tab25mg 1 Quantity limitation 120 per 30 days clozapine tab50mg 1 Quantity limitation 120 per 30 days FAZACLO TAB100/ODT 3 Quantity limitation 270 per 30 days FAZACLO TAB12.5/ODT 3 Quantity limitation 90 per 30 days FAZACLO TAB150MG 3 Quantity limitation 180 per 30 days FAZACLO TAB200MG 3 Quantity limitation 120 per 30 days FAZACLO TAB25MG ODT 3 Quantity limitation 270 per 30 days VERSACLOZ SUS50MG/ML 3 Quantity limitation 540 per 30 days ANTISPASTICITY AGENTS Antispasticity Agents baclofen tab10mg 1 baclofen tab20mg 1 dantrolene cap100mg 1 dantrolene cap25mg 1 dantrolene cap50mg 1 tizanidine tab2mg 1 tizanidine tab4mg 1 ANTIVIRALS Anti-cytomegalovirus (CMV) Agents adefov dipivtab10mg 1 cidofovir inj75mg/ml 3 foscarnet inj24mg/ml 3 ganciclovir inj500mg 2 VALCYTE SOL50MG/ML 4 VALCYTE TAB450MG 4 Anti-hepatitis B (HBV) Agents BARACLUDE SOL.05MG/ML 3 Quantity limitation 600 per 30 days; This medication requires prior 76

78 Quantity limitation 30 per 30 days; BARACLUDE TAB0.5MG 4 BARACLUDE TAB1MG 4 EPIVIR HBV SOL5MG/ML 2 EPIVIR HBV TAB100MG 2 INTRON-A INJ10MU 3 INTRON-A INJ18MU 3 lamivudine tab100mg 1 PEGASYS INJ 4 PEGASYS INJ180MCG/M 4 PEGASYS INJPROCLICK 4 PEG-INTRON KIT120 RP 4 Quantity limitation 30 per 30 days; Quantity limitation 2 per 28 days; Quantity limitation 4 per 28 days; Quantity limitation 4 per 28 days; 77

79 PEG-INTRON KIT120MCG 4 Quantity limitation 4 per 28 days; PEG-INTRON KIT150 RP 4 Quantity limitation 4 per 28 days; PEG-INTRON KIT150MCG 4 Quantity limitation 4 per 28 days; PEG-INTRON KIT50MCG 4 Quantity limitation 5 per 28 days; PEG-INTRON KIT50MCG RP 4 Quantity limitation 4 per 28 days; PEG-INTRON KIT80MCG 4 Quantity limitation 4 per 28 days; 78

80 PEG-INTRON KIT80MCG RP 4 Quantity limitation 4 per 28 days; ribasphere cap200mg 1 ribasphere tab200mg 1 ribasphere tab400mg 1 ribasphere tab600mg 1 ribavirin cap200mg 1 ribavirin tab200mg 1 SYLATRON KIT296MCG 4 Quantity limitation 5 per 28 days SYLATRON KIT444MCG 4 Quantity limitation 5 per 28 days SYLATRON KIT888MCG 4 Quantity limitation 5 per 28 days TYZEKA TAB600MG 3 Anti-hepatitis C (HCV) Agents INCIVEK TAB375MG 4 Quantity limitation 180 per 30 days OLYSIO CAP150MG 4 Quantity limitation 30 per 30 days; SOVALDI TAB400MG 4 Antiherpetic Agents acyclovir cap200mg 1 acyclovir oin5% 1 acyclovir sus200/5ml 1 acyclovir tab400mg 1 acyclovir tab800mg 1 acyclovir nainj500mg 3 Quantity limitation 30 per 30 days; 79

81 DENAVIR CRE1% 3 Quantity limitation 5 per 28 days famciclovir tab125mg 1 Quantity limitation 21 per 10 days famciclovir tab250mg 1 Quantity limitation 60 per 30 days famciclovir tab500mg 1 Quantity limitation 21 per 7 days trifluridinesol1% op 1 valacyclovirtab1gm 1 Quantity limitation 30 per 30 days valacyclovirtab500mg 1 Quantity limitation 30 per 30 days ZOVIRAX CRE5% 3 Quantity limitation 10 per 30 days Anti-HIV Agents, Integrase Inhibitors (INSTI) ISENTRESS CHW100MG 4 ISENTRESS CHW25MG 3 ISENTRESS POW100MG 3 ISENTRESS TAB400MG 4 STRIBILD TAB 2 Quantity limitation 30 per 30 days Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI) COMPLERA TAB 2 Quantity limitation 30 per 30 days EDURANT TAB25MG 4 Quantity limitation 30 per 30 days INTELENCE TAB100MG 3 Quantity limitation 120 per 30 days INTELENCE TAB200MG 4 INTELENCE TAB25MG 3 NEVIRAPINE SUS50MG/5ML 1 nevirapine tab200mg 1 nevirapine tab400mg er 1 RESCRIPTOR TAB100 MG 3 RESCRIPTOR TAB200MG 3 SUSTIVA CAP200MG 2 SUSTIVA CAP50MG 2 SUSTIVA TAB600MG 2 VIRAMUNE SUS50MG/5ML 2 VIRAMUNE XR TAB100MG 2 VIRAMUNE XR TAB400MG 2 Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI) abacav/lamivtab/zidovud 1 abacavir tab300mg 1 didanosine cap125mg 1 didanosine cap200mg 1 didanosine cap250mg 1 didanosine cap400mg 1 EMTRIVA CAP200MG 3 EMTRIVA SOL10MG/ML 3 EPIVIR SOL10MG/ML 2 80

82 EPZICOM TAB lamivud/zidotab lamivudine tab150mg 1 lamivudine tab300mg 1 RETROVIR INJ10MG/ML 3 stavudine cap15mg 1 stavudine cap20mg 1 stavudine cap30mg 1 stavudine cap40mg 1 stavudine sol1mg/ml 1 TRIZIVIR TAB 2 TRUVADA TAB VIDEX SOL2GM 3 VIREAD POW40MG/GM 3 VIREAD TAB150MG 3 VIREAD TAB200MG 3 VIREAD TAB250MG 3 VIREAD TAB300MG 3 ZIAGEN SOL20MG/ML 2 zidovudine cap100mg 1 zidovudine syp50mg/5ml 1 zidovudine tab300mg 1 Anti-HIV Agents, Other FUZEON INJ90MG 2 SELZENTRY TAB150MG 4 SELZENTRY TAB300MG 4 TIVICAY TAB50MG 4 Quantity limitation 60 per 30 days Anti-HIV Agents, Protease Inhibitors APTIVUS CAP250MG 3 APTIVUS SOL 3 Quantity limitation 300 per 30 days CRIXIVAN CAP200MG 3 CRIXIVAN CAP400MG 3 INVIRASE CAP200MG 3 INVIRASE TAB500MG 3 KALETRA SOL 2 KALETRA TAB100-25MG 2 KALETRA TAB200-50MG 2 LEXIVA SUS50MG/ML 2 LEXIVA TAB700MG 2 NORVIR CAP100MG 3 NORVIR SOL80MG/ML 3 NORVIR TAB100MG 3 PREZISTA SUS100MG/ML 3 PREZISTA TAB150MG 3 81

83 PREZISTA TAB600MG 3 PREZISTA TAB75MG 3 PREZISTA TAB800MG 3 REYATAZ CAP150MG 2 REYATAZ CAP200MG 2 REYATAZ CAP300MG 2 VIRACEPT TAB250MG 3 VIRACEPT TAB625MG 3 Anti-influenza Agents RELENZA MISDISKHALE 3 rimantadine tab100mg 1 TAMIFLU CAP30MG 2 TAMIFLU CAP45MG 2 TAMIFLU CAP75MG 2 TAMIFLU SUS6MG/ML 2 Antivirals ATRIPLA TAB 3 VIRAZOLE INH6GM 4 ANXIOLYTICS Anxiolytics, Other buspirone tab10mg 1 buspirone tab15mg 1 buspirone tab30mg 1 buspirone tab5mg 1 buspirone tab7.5mg 1 hydroxyz hclinj25mg/ml 3 hydroxyz hclinj50mg/ml 3 meprobamate tab200mg 1 meprobamate tab400mg 1 Benzodiazepines alprazolam con1 mg/ml 1 alprazolam tab0.25 odt 1 alprazolam tab0.25mg 1 alprazolam tab0.5mg 1 alprazolam tab0.5mg er 1 alprazolam tab0.5mg od 1 alprazolam tab1mg 1 alprazolam tab1mg er 1 82

84 alprazolam tab1mg odt 1 alprazolam tab2mg 1 alprazolam tab2mg er 1 alprazolam tab2mg odt 1 alprazolam tab3mg er 1 chlordiazep cap10mg 1 chlordiazep cap25mg 1 chlordiazep cap5mg 1 BIPOLAR AGENTS Mood Stabilizers lithium carbcap150mg 1 lithium carbcap300mg 1 lithium carbcap600mg 1 lithium carbtab300mg 1 lithium carbtab300mg er 1 lithium carbtab450mg er 1 LITHIUM CITRSOL8MEQ/5ML 2 BLOOD GLUCOSE REGULATORS Antidiabetic Agents BYETTA INJ10MCG 3 Quantity limitation 2.4 per 30 days BYETTA INJ5MCG 3 Quantity limitation 2.4 per 30 days chlorpropam tab100mg 1 chlorpropam tab250mg 1 CYCLOSET TAB0.8MG 3 Quantity limitation 180 per 30 days; This medication requires prior glimepiride tab1mg 1 Quantity limitation 60 per 30 days glimepiride tab2mg 1 Quantity limitation 60 per 30 days glimepiride tab4mg 1 Quantity limitation 60 per 30 days glipizide tab10mg 1 Quantity limitation 120 per 30 days glipizide tab5mg 1 Quantity limitation 240 per 30 days glipizide ertab10mg 1 Quantity limitation 60 per 30 days glipizide ertab2.5mg 1 Quantity limitation 240 per 30 days glipizide ertab5mg 1 Quantity limitation 120 per 30 days Quantity limitation 90 per 30 days; GLYSET TAB100MG 3 Step therapy protocols apply GLYSET TAB25MG 3 Quantity limitation 90 per 30 days; Step therapy protocols apply GLYSET TAB50MG 3 Quantity limitation 90 per 30 days; 83

85 Step therapy protocols apply JANUVIA TAB100MG 3 Quantity limitation 30 per 30 days JANUVIA TAB25MG 3 Quantity limitation 30 per 30 days JANUVIA TAB50MG 3 Quantity limitation 30 per 30 days metformin tab1000mg 1 Quantity limitation 90 per 30 days metformin tab500mg 1 Quantity limitation 150 per 30 days metformin tab500mg er 1 Quantity limitation 120 per 30 days metformin tab750mg er 1 Quantity limitation 90 per 30 days metformin tab850mg 1 Quantity limitation 90 per 30 days metformin ertab1000mg 1 nateglinide tab120mg 1 Quantity limitation 90 per 30 days; Step therapy protocols apply nateglinide tab60mg 1 Quantity limitation 90 per 30 days; Step therapy protocols apply Quantity limitation 30 per 30 days; ONGLYZA TAB2.5MG 3 Step therapy protocols apply Quantity limitation 30 per 30 days; Step therapy protocols apply ONGLYZA TAB5MG 3 pioglitazonetab15mg 1 Quantity limitation 30 per 30 days pioglitazonetab30mg 1 Quantity limitation 30 per 30 days pioglitazonetab45mg 1 Quantity limitation 30 per 30 days repaglinide tab0.5mg 1 repaglinide tab1mg 1 repaglinide tab2mg 1 SYMLINPEN 60INJ1000MCG 3 Quantity limitation 10.8 per 30 days Quantity limitation 10.8 per 30 days SYMLNPEN 120INJ1000MCG 3 tolazamide tab250mg 1 tolazamide tab500mg 1 tolbutamide tab500mg 1 VICTOZA INJ18MG/3ML 3 Quantity limitation 9 per 30 days WELCHOL TAB625MG 3 Blood Glucose Regulators glip/metformtab m 1 Quantity limitation 240 per 30 days glip/metformtab m 1 Quantity limitation 120 per 30 days glip/metformtab5-500mg 1 Quantity limitation 120 per 30 days glyb/metformtab Quantity limitation 240 per 30 days glyb/metformtab Quantity limitation 120 per 30 days glyb/metformtab5-500mg 1 Quantity limitation 120 per 30 days JANUMET TAB JANUMET TAB50-500MG 3 Quantity limitation 60 per 30 days; Step therapy protocols apply Quantity limitation 60 per 30 days; Step therapy protocols apply 84

86 JANUMET XR TAB Quantity limitation 60 per 30 days JANUMET XR TAB Quantity limitation 60 per 30 days JANUMET XR TAB50-500MG 3 Quantity limitation 60 per 30 days KOMBIGLYZE TAB Quantity limitation 60 per 30 days; Step therapy protocols apply Quantity limitation 60 per 30 days; KOMBIGLYZE TAB5-1000MG 3 Step therapy protocols apply Quantity limitation 60 per 30 days; Step therapy protocols apply KOMBIGLYZE TAB5-500MG 3 pioglit/glimtab30-2mg 1 pioglit/glimtab30-4mg 1 pioglita/mettab15-500mg 1 Quantity limitation 90 per 30 days pioglita/mettab15-850mg 1 Quantity limitation 90 per 30 days Glycemic Agents GLUCAGEN INJHYPOKIT 2 Quantity limitation 30 per 30 days GLUCAGON KIT1MG 2 Quantity limitation 2 per 30 days PROGLYCEM SUS50MG/ML 3 Insulins APIDRA INJSOLOSTAR 2 Quantity limitation 30 per 30 days APIDRA INJU Quantity limitation 30 per 30 days HUMALOG INJ100/ML 2 Quantity limitation 30 per 30 days HUMALOG INJ100/ML 2 Quantity limitation 30 per 30 days HUMALOG MIX INJ50/50 2 Quantity limitation 30 per 30 days HUMALOG MIX INJ50/50KWP 2 Quantity limitation 30 per 30 days HUMALOG MIX INJ75/25KWP 2 Quantity limitation 30 per 30 days HUMALOG MIX SUS75/25 2 Quantity limitation 30 per 30 days HUMULIN INJ70/30 2 Quantity limitation 30 per 30 days HUMULIN N INJU Quantity limitation 30 per 30 days HUMULIN N PNINJU Quantity limitation 30 per 30 days HUMULIN PEN INJ70/30 2 Quantity limitation 30 per 30 days HUMULIN R INJU Quantity limitation 30 per 30 days HUMULIN R INJU Quantity limitation 30 per 30 days LANTUS INJ100/ML 2 Quantity limitation 30 per 30 days LANTUS INJSOLOSTAR 2 Quantity limitation 30 per 30 days LEVEMIR INJ 2 Quantity limitation 30 per 30 days LEVEMIR INJFLEXPEN 2 Quantity limitation 30 per 30 days NOVOLIN INJ70/30 2 Quantity limitation 30 per 30 days NOVOLIN N INJU Quantity limitation 30 per 30 days NOVOLIN R INJU Quantity limitation 30 per 30 days NOVOLOG INJ100/ML 2 Quantity limitation 30 per 30 days NOVOLOG INJPENFILL 2 Quantity limitation 30 per 30 days NOVOLOG MIX INJ70/30 2 Quantity limitation 30 per 30 days NOVOLOG MIX INJFLEXPEN 2 Quantity limitation 30 per 30 days 85

87 Anticoagulants DRUG NAME DRUG TIER REQUIREMENTS/LIMITS BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS COUMADIN INJ5 MG 2 COUMADIN TAB10MG 2 COUMADIN TAB1MG 2 COUMADIN TAB2.5MG 2 COUMADIN TAB2MG 2 COUMADIN TAB3MG 2 COUMADIN TAB4MG 2 COUMADIN TAB5MG 2 COUMADIN TAB6MG 2 COUMADIN TAB7.5MG 2 enoxaparin inj100mg/ml 3 Quantity limitation 28 per 30 days Quantity limitation 22.4 per 30 days enoxaparin inj120/0.8 3 enoxaparin inj150mg/ml 3 Quantity limitation 28 per 30 days enoxaparin inj30/0.3ml 3 Quantity limitation 8.4 per 30 days enoxaparin inj300/3ml 3 Quantity limitation 84 per 30 days enoxaparin inj40/0.4ml 3 enoxaparin inj60/0.6ml 3 enoxaparin inj80/0.8ml 3 fondaparinuxsol10/0.8 3 fondaparinuxsol2.5/0.5 3 Quantity limitation 11.2 per 30 days Quantity limitation 16.8 per 30 days Quantity limitation 22.4 per 30 days Quantity limitation 24 per 30 days; Quantity limitation 15 per 30 days; 86

88 fondaparinuxsol5.0/0.4 3 Quantity limitation 12 per 30 days; fondaparinuxsol7.5/0.6 3 Quantity limitation 18 per 30 days; Quantity limitation 20 per 30 days; FRAGMIN INJ10000/ML 4 FRAGMIN INJ12500UNT 4 Quantity limitation 20 per 30 days; FRAGMIN INJ15000UNT 4 Quantity limitation 20 per 30 days; FRAGMIN INJ18000UNT 4 Quantity limitation 20 per 30 days; 87

89 Quantity limitation 20 per 30 days; FRAGMIN INJ2500/0.2 3 FRAGMIN INJ25000/ML 3 Quantity limitation 20 per 30 days; FRAGMIN INJ5000/0.2 3 Quantity limitation 20 per 30 days; FRAGMIN INJ7500/0.3 4 Quantity limitation 20 per 30 days; hep sod/d5w inj25000unt 3 hep sod/d5w inj25000unt 3 hep sod/naclinj1000unit 3 88

90 heparin sod inj1000/ml 3 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call heparin sod inj10000/ml 3 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call heparin sod inj20000/ml 3 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call heparin sod inj5000/ml 3 89

91 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call jantoven tab10mg 1 jantoven tab1mg 1 jantoven tab2.5mg 1 jantoven tab2mg 1 jantoven tab3mg 1 jantoven tab4mg 1 jantoven tab5mg 1 jantoven tab6mg 1 jantoven tab7.5mg 1 PRADAXA CAP150MG 3 Quantity limitation 60 per 30 days PRADAXA CAP75MG 3 Quantity limitation 60 per 30 days warfarin tab10mg 1 warfarin tab1mg 1 warfarin tab2.5mg 1 warfarin tab2mg 1 warfarin tab3mg 1 warfarin tab4mg 1 warfarin tab5mg 1 warfarin tab6mg 1 warfarin tab7.5mg 1 XARELTO TAB10MG 3 Quantity limitation 30 per 30 days XARELTO TAB15MG 3 Quantity limitation 30 per 30 days XARELTO TAB20MG 3 Quantity limitation 30 per 30 days Blood Formation Modifiers anagrelide cap0.5mg 1 anagrelide cap1mg 1 ARANESP INJ100MCG 3 Quantity limitation 2 per 28 days; 90

92 Quantity limitation 4 per 28 days; ARANESP INJ100MCG 3 ARANESP INJ150MCG 4 Quantity limitation 1.2 per 28 days; ARANESP INJ200MCG 4 Quantity limitation 4 per 28 days; ARANESP INJ200MCG 4 Quantity limitation 1.6 per 28 days; ARANESP INJ25MCG 3 Quantity limitation 4 per 28 days; ARANESP INJ25MCG 3 Quantity limitation 1.68 per 28 days; This medication requires prior ARANESP INJ300MCG 4 Quantity limitation 2.4 per 28 days; 91

93 Quantity limitation 4 per 28 days; ARANESP INJ300MCG 4 ARANESP INJ40MCG 3 Quantity limitation 4 per 28 days; ARANESP INJ40MCG 3 Quantity limitation 1.6 per 28 days; ARANESP INJ500MCG 4 Quantity limitation 4 per 28 days; ARANESP INJ60MCG 3 Quantity limitation 4 per 28 days; ARANESP INJ60MCG 3 Quantity limitation 1.2 per 28 days; 92

94 EPOGEN INJ10000/ML 3 EPOGEN INJ2000/ML 3 Quantity limitation 12 per 28 days; EPOGEN INJ20000/ML 3 EPOGEN INJ3000/ML 2 Quantity limitation 12 per 28 days; EPOGEN INJ4000/ML 3 Quantity limitation 12 per 28 days; LEUKINE INJ250MCG 3 methylergon tab0.2mg 1 MOZOBIL INJ 4 93

95 Quantity limitation 2 per 30 days; NEULASTA INJ6MG/0.6M 4 NEUPOGEN INJ300/0.5 4 NEUPOGEN INJ480/0.8 4 NEUPOGEN INJ480MCG 4 PROCRIT INJ10000/ML 3 PROCRIT INJ2000/ML 3 Quantity limitation 12 per 28 days; PROCRIT INJ20000/ML 4 94

96 Quantity limitation 12 per 28 days; PROCRIT INJ3000/ML 3 PROCRIT INJ4000/ML 3 Quantity limitation 12 per 28 days; PROCRIT INJ40000/ML 4 Quantity limitation 90 per 30 days; This prescription may be available only at certain pharmacies. For more information please call hours a dayseven days a week. TTY/TDD users should ; PROMACTA TAB12.5MG 4 PROMACTA TAB25MG 4 Quantity limitation 90 per 30 days; This prescription may be available only at certain pharmacies. For more information please call hours a dayseven days a week. TTY/TDD users should ; 95

97 Quantity limitation 90 per 30 days; This prescription may be available only at certain pharmacies. For more information please call hours a dayseven days a week. TTY/TDD users should ; PROMACTA TAB50MG 4 PROMACTA TAB75MG 4 Blood Products/Modifiers/Volume Expanders Quantity limitation 90 per 30 days; This prescription may be available only at certain pharmacies. For more information please call hours a dayseven days a week. TTY/TDD users should ; Quantity limitation 21 per 21 days; NEUMEGA INJ5MG 4 Coagulants CYKLOKAPRON INJ100MG/ML 2 tranex acid tab650mg 1 Platelet Modifying Agents AGGRENOX CAP25-200MG 3 BRILINTA TAB90MG 2 Quantity limitation 60 per 30 days cilostazol tab100mg 1 cilostazol tab50mg 1 96

98 clopidogrel tab300mg 1 Quantity limitation 30 per 30 days clopidogrel tab75mg 1 Quantity limitation 30 per 30 days EFFIENT TAB10MG 2 Quantity limitation 30 per 30 days EFFIENT TAB5MG 2 Quantity limitation 30 per 30 days ticlopidine tab250mg 1 CARDIOVASCULAR AGENTS Alpha-adrenergic Agonists clonidine dis0.1/24hr 1 Quantity limitation 4 per 28 days clonidine dis0.2/24hr 1 Quantity limitation 4 per 28 days clonidine dis0.3/24hr 1 Quantity limitation 4 per 28 days clonidine tab0.1mg 1 clonidine tab0.2mg 1 clonidine tab0.3mg 1 guanfacine tab1mg 1 guanfacine tab2mg 1 methyldopa tab250mg 1 methyldopa tab500mg 1 methyldopateinj250/5ml 3 midodrine tab10mg 1 midodrine tab2.5mg 1 midodrine tab5mg 1 Alpha-adrenergic Blocking Agents doxazosin tab1mg 1 Quantity limitation 30 per 30 days doxazosin tab2mg 1 Quantity limitation 30 per 30 days doxazosin tab4mg 1 Quantity limitation 30 per 30 days doxazosin tab8mg 1 Quantity limitation 60 per 30 days prazosin hclcap1mg 1 prazosin hclcap2mg 1 prazosin hclcap5mg 1 terazosin cap10mg 1 Quantity limitation 60 per 30 days terazosin cap1mg 1 Quantity limitation 30 per 30 days terazosin cap2mg 1 Quantity limitation 30 per 30 days terazosin cap5mg 1 Quantity limitation 30 per 30 days Angiotensin II Receptor Antagonists Quantity limitation 30 per 30 days; BENICAR TAB20MG 3 Step therapy protocols apply BENICAR TAB40MG 3 Quantity limitation 30 per 30 days; Step therapy protocols apply 97

99 Quantity limitation 30 per 30 days; BENICAR TAB5MG 3 Step therapy protocols apply candesartan tab16mg 1 candesartan tab32mg 1 candesartan tab4mg 1 candesartan tab8mg 1 DIOVAN TAB160MG 2 Quantity limitation 30 per 30 days; Step therapy protocols apply DIOVAN TAB320MG 2 Quantity limitation 30 per 30 days; Step therapy protocols apply Quantity limitation 30 per 30 days; DIOVAN TAB40MG 2 Step therapy protocols apply Quantity limitation 30 per 30 days; Step therapy protocols apply DIOVAN TAB80MG 2 eprosart mestab600mg 1 irbesartan tab150mg 1 Quantity limitation 30 per 30 days irbesartan tab300mg 1 Quantity limitation 30 per 30 days irbesartan tab75mg 1 Quantity limitation 30 per 30 days losartan pottab100mg 1 losartan pottab25mg 1 Quantity limitation 30 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. Quantity limitation 30 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. Quantity limitation 30 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. losartan pottab50mg 1 telmisartan tab20mg 1 Quantity limitation 30 per 30 days telmisartan tab40mg 1 Quantity limitation 30 per 30 days telmisartan tab80mg 1 Quantity limitation 30 per 30 days Angiotensin-converting Enzyme (ACE) Inhibitors benazepril tab10mg 1 benazepril tab20mg 1 98

100 benazepril tab40mg 1 benazepril tab5mg 1 captopril tab100mg 1 captopril tab12.5mg 1 captopril tab25mg 1 captopril tab50mg 1 enalapril tab10mg 1 enalapril tab2.5mg 1 enalapril tab20mg 1 enalapril tab5mg 1 fosinopril tab10mg 1 fosinopril tab20mg 1 fosinopril tab40mg 1 lisinopril tab10mg 1 lisinopril tab2.5mg 1 lisinopril tab20mg 1 lisinopril tab30mg 1 lisinopril tab40mg 1 lisinopril tab5mg 1 moexipril tab15mg 1 moexipril tab7.5mg 1 perindopril tab2mg 1 perindopril tab4mg 1 perindopril tab8mg 1 quinapril tab10mg 1 quinapril tab20mg 1 quinapril tab40mg 1 quinapril tab5mg 1 ramipril cap1.25mg 1 Quantity limitation 30 per 30 days ramipril cap10mg 1 Quantity limitation 60 per 30 days ramipril cap2.5mg 1 Quantity limitation 30 per 30 days ramipril cap5mg 1 Quantity limitation 30 per 30 days trandolapriltab1mg 1 trandolapriltab2mg 1 trandolapriltab4mg 1 Antiarrhythmics amiodarone tab200mg 1 amiodarone tab400mg 1 disopyramidecap100mg 1 disopyramidecap150mg 1 flecainide tab100mg 1 flecainide tab150mg 1 flecainide tab50mg 1 mexiletine cap150mg 1 99

101 mexiletine cap200mg 1 mexiletine cap250mg 1 MULTAQ TAB400MG 3 pacerone tab100mg 1 pacerone tab200mg 1 pacerone tab400mg 1 procainamideinj100mg/ml 3 propafenone tab150mg 1 propafenone tab225mg 1 propafenone tab300mg 1 quinidine gltab324mg cr 1 quinidine sutab200mg 1 quinidine sutab300mg 1 quinidine sutab300mg er 1 sorine tab120mg 1 sorine tab160mg 1 sorine tab240mg 1 sorine tab80mg 1 sotalol af tab120mg 1 sotalol hcl tab160mg 1 sotalol hcl tab240mg 1 sotalol hcl tab80mg 1 TIKOSYN CAP125MCG 3 TIKOSYN CAP250MCG 3 TIKOSYN CAP500MCG 3 Beta-adrenergic Blocking Agents acebutolol cap200mg 1 acebutolol cap400mg 1 atenolol tab100mg 1 atenolol tab25mg 1 atenolol tab50mg 1 betaxolol tab10mg 1 Quantity limitation 60 per 30 days; 100

102 betaxolol tab20mg 1 bisoprol fumtab10mg 1 bisoprol fumtab5mg 1 carvedilol tab12.5mg 1 Quantity limitation 60 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. carvedilol tab25mg 1 Quantity limitation 60 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. Quantity limitation 60 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected carvedilol tab3.125mg 1 carvedilol tab6.25mg 1 INNOPRAN XL CAP120MG 2 INNOPRAN XL CAP80MG 2 labetalol tab100mg 1 labetalol tab200mg 1 labetalol tab300mg 1 metoprol tartab100mg 1 metoprol tartab25mg 1 metoprol tartab50mg 1 metoprolol inj1mg/ml 3 medications. Quantity limitation 60 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. 101

103 metoprolol tab100mg er 1 Quantity limitation 30 per 30 days metoprolol tab200mg er 1 Quantity limitation 60 per 30 days metoprolol tab25mg er 1 Quantity limitation 30 per 30 days metoprolol tab50mg er 1 Quantity limitation 30 per 30 days nadolol tab20mg 1 nadolol tab40mg 1 nadolol tab80mg 1 pindolol tab10mg 1 pindolol tab5mg 1 propranolol cap120mg er 1 propranolol cap160mg er 1 propranolol cap60mg er 1 propranolol cap80mg er 1 propranolol inj1mg/ml 3 propranolol sol20mg/5ml 1 propranolol sol40mg/5ml 1 propranolol tab10mg 1 propranolol tab20mg 1 propranolol tab40mg 1 propranolol tab60mg 1 propranolol tab80mg 1 Calcium Channel Blocking Agents afeditab tab30mg cr 1 afeditab tab60mg cr 1 amlodipine tab10mg 1 Quantity limitation 30 per 30 days amlodipine tab2.5mg 1 Quantity limitation 30 per 30 days amlodipine tab5mg 1 Quantity limitation 30 per 30 days cartia xt cap120/24hr 1 cartia xt cap180/24hr 1 cartia xt cap240/24hr 1 cartia xt cap300/24hr 1 diltiazem cap120mg cd 1 diltiazem cap120mg er 1 diltiazem cap180mg/24 1 diltiazem cap240mg cd 1 diltiazem cap300mg er 1 diltiazem cap360mg/

104 diltiazem cap420mg/24 1 diltiazem cap60mg er 1 diltiazem cap90mg er 1 diltiazem tab120mg 1 diltiazem tab30mg 1 diltiazem tab60mg 1 diltiazem tab90mg 1 dilt-xr cap120mg 1 dilt-xr cap180mg 1 dilt-xr cap240mg 1 felodipine tab10mg er 1 felodipine tab2.5mg er 1 felodipine tab5mg er 1 isradipine cap2.5mg 1 isradipine cap5mg 1 matzim la tab180mg/24 1 matzim la tab240mg/24 1 matzim la tab300mg/24 1 matzim la tab360mg/24 1 matzim la tab420mg/24 1 nicardipine cap20mg 1 nicardipine cap30mg 1 nifedical xltab30mg 1 nifedical xltab60mg 1 nifedipine tab30mg er 1 nifedipine tab60mg er 1 nifedipine tab90mg er 1 nimodipine cap30mg 1 nisoldipine tab17mg er 1 nisoldipine tab20mg 1 nisoldipine tab25.5mg 1 nisoldipine tab30mg 1 nisoldipine tab34mg er 1 nisoldipine tab40mg 1 nisoldipine tab8.5mg er 1 taztia xt cap120mg/24 1 taztia xt cap180mg/24 1 taztia xt cap240mg/24 1 taztia xt cap300mg/24 1 taztia xt cap360mg/24 1 verapamil cap100mg er 1 verapamil cap120mg er 1 verapamil cap180mg er 1 verapamil cap200mg er 1 103

105 verapamil cap240mg er 1 verapamil cap300mg er 1 verapamil cap360mg sr 1 verapamil inj2.5mg/ml 3 verapamil tab120mg 1 verapamil tab120mg er 1 verapamil tab180mg er 1 verapamil tab240mg er 1 verapamil tab40mg 1 verapamil tab80mg 1 Cardiovascular Agents amilor/hctz tab amlod/atorvatab10-10mg 1 Quantity limitation 30 per 30 days amlod/atorvatab10-20mg 1 Quantity limitation 30 per 30 days amlod/atorvatab10-40mg 1 Quantity limitation 30 per 30 days amlod/atorvatab10-80mg 1 Quantity limitation 30 per 30 days amlod/atorvatab2.5-10mg 1 Quantity limitation 30 per 30 days amlod/atorvatab2.5-20mg 1 Quantity limitation 30 per 30 days amlod/atorvatab2.5-40mg 1 Quantity limitation 30 per 30 days amlod/atorvatab5-10mg 1 Quantity limitation 30 per 30 days amlod/atorvatab5-20mg 1 Quantity limitation 30 per 30 days amlod/atorvatab5-40mg 1 Quantity limitation 30 per 30 days amlod/atorvatab5-80mg 1 Quantity limitation 30 per 30 days amlod/benazpcap10-20mg 1 Quantity limitation 30 per 30 days amlod/benazpcap10-40mg 1 Quantity limitation 30 per 30 days amlod/benazpcap2.5-10mg 1 Quantity limitation 30 per 30 days amlod/benazpcap5-10mg 1 Quantity limitation 30 per 30 days amlod/benazpcap5-20mg 1 Quantity limitation 30 per 30 days amlod/benazpcap5-40mg 1 Quantity limitation 30 per 30 days AMTURNIDE150TAB Quantity limitation 30 per 30 days AMTURNIDE300TAB Quantity limitation 30 per 30 days AMTURNIDE300TAB-10-25MG 3 Quantity limitation 30 per 30 days AMTURNIDE300TAB Quantity limitation 30 per 30 days AMTURNIDE300TAB-5-25MG 3 Quantity limitation 30 per 30 days atenol/chlortab100-25mg 1 atenol/chlortab50-25mg 1 benazep/hctztab benazep/hctztab

106 benazep/hctztab20-25mg 1 benazep/hctztab BENICAR HCT TAB Quantity limitation 30 per 30 days; Step therapy protocols apply Quantity limitation 30 per 30 days; BENICAR HCT TAB Step therapy protocols apply Quantity limitation 30 per 30 days; Step therapy protocols apply BENICAR HCT TAB40-25MG 3 bisoprl/hctztab10/ bisoprl/hctztab2.5/ bisoprl/hctztab5-6.25mg 1 candesa/hctztab candesa/hctztab candesa/hctztab32-25mg 1 captopr/hctztab25-15mg 1 captopr/hctztab25-25mg 1 captopr/hctztab50-15mg 1 captopr/hctztab50-25mg 1 clorpres tab0.1-15mg 1 clorpres tab0.2-15mg 1 clorpres tab0.3-15mg 1 DEMSER CAP250MG 4 Quantity limitation 480 per 30 days enalapr/hctztab10-25mg 1 enalapr/hctztab5-12.5mg 1 EXFORGE TAB10-160MG 2 Quantity limitation 30 per 30 days EXFORGE TAB10-320MG 2 Quantity limitation 30 per 30 days EXFORGE TAB5-160MG 2 Quantity limitation 30 per 30 days EXFORGE TAB5-320MG 2 Quantity limitation 30 per 30 days EXFORGEH/10-TAB Quantity limitation 30 per 30 days EXFORGEH/10-TAB Quantity limitation 30 per 30 days EXFORGEH/10-TAB Quantity limitation 30 per 30 days EXFORGEH/5- TAB Quantity limitation 30 per 30 days EXFORGEH/5- TAB Quantity limitation 30 per 30 days fosinop/hctztab10/ fosinop/hctztab20/ irbesar/hctztab Quantity limitation 30 per 30 days irbesar/hctztab Quantity limitation 30 per 30 days lisinop/hctztab lisinop/hctztab lisinop/hctztab20-25mg 1 losartan/hcttab Quantity limitation 30 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when 105

107 you select this medication over the brand name version of selected medications. Quantity limitation 30 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected losartan/hcttab medications. Quantity limitation 30 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. losartan/hcttab methyld/hctztab250/15 1 methyld/hctztab250/25 1 metoprl/hctztab100-25mg 1 metoprl/hctztab100-50mg 1 metoprl/hctztab50-25mg 1 moexipr/hctztab moexipr/hctztab15-25mg 1 moexipr/hctztab nadolol/bendtab40-5mg 1 nadolol/bendtab80-5mg 1 propran/hctztab40/25 1 propran/hctztab80/25 1 qnapril/hctztab qnapril/hctztab qnapril/hctztab20-25mg 1 RESERPINE TAB0.1MG 2 RESERPINE TAB0.25MG 2 SIMCOR TAB Quantity limitation 60 per 30 days SIMCOR TAB Quantity limitation 60 per 30 days SIMCOR TAB500-20MG 2 Quantity limitation 60 per 30 days SIMCOR TAB500-40MG 2 Quantity limitation 60 per 30 days SIMCOR TAB750-20MG 2 Quantity limitation 60 per 30 days spirono/hctztab25/25 1 TEKAMLO TAB150-10MG 2 Quantity limitation 30 per 30 days TEKAMLO TAB150-5MG 2 Quantity limitation 30 per 30 days TEKAMLO TAB300-10MG 2 Quantity limitation 30 per 30 days TEKAMLO TAB300-5MG 2 Quantity limitation 30 per 30 days 106

108 TEKTURNA HCTTAB Quantity limitation 30 per 30 days; Step therapy protocols apply TEKTURNA HCTTAB150-25MG 2 Quantity limitation 30 per 30 days; Step therapy protocols apply TEKTURNA HCTTAB Quantity limitation 30 per 30 days; Step therapy protocols apply TEKTURNA HCTTAB300-25MG 2 Quantity limitation 30 per 30 days; Step therapy protocols apply telmis/amlodtab40-10mg 1 telmis/amlodtab40-5mg 1 telmis/amlodtab80-10mg 1 telmis/amlodtab80-5mg 1 triamt/hctz cap triamt/hctz tab triamt/hctz tab75-50mg 1 valsart/hctztab valsart/hctztab160-25mg 1 valsart/hctztab valsart/hctztab320-25mg 1 valsart/hctztab Quantity limitation 30 per 30 days; VYTORIN TAB10-10MG 3 Step therapy protocols apply VYTORIN TAB10-20MG 3 Quantity limitation 30 per 30 days; Step therapy protocols apply Quantity limitation 30 per 30 days; VYTORIN TAB10-40MG 3 Step therapy protocols apply Quantity limitation 30 per 30 days; Step therapy protocols apply VYTORIN TAB10-80MG 3 Cardiovascular Agents, Other DIGOXIN SOL50MCG/ML 2 digoxin tab0.125mg 1 digoxin tab0.25mg 1 pentoxifyllitab400mg er 1 RANEXA TAB1000MG 2 Quantity limitation 120 per 30 days RANEXA TAB500MG 2 Quantity limitation 120 per 30 days TEKTURNA TAB150MG 2 TEKTURNA TAB300MG 2 Diuretics, Carbonic Anhydrase Inhibitors acetazolamidcap500mg er 1 acetazolamidtab125mg 1 acetazolamidtab250mg 1 methazolamidtab25mg 1 Quantity limitation 30 per 30 days; Step therapy protocols apply Quantity limitation 30 per 30 days; Step therapy protocols apply 107

109 methazolamidtab50mg 1 Diuretics, Loop bumetanide tab0.5mg 1 bumetanide tab1mg 1 bumetanide tab2mg 1 furosemide inj10mg/ml 3 furosemide sol10mg/ml 1 furosemide sol8mg/ml 1 furosemide tab20mg 1 furosemide tab40mg 1 furosemide tab80mg 1 torsemide tab100mg 1 torsemide tab10mg 1 torsemide tab20mg 1 torsemide tab5mg 1 Diuretics, Potassium-sparing amiloride tab5mg 1 eplerenone tab25mg 1 eplerenone tab50mg 1 spironolact tab100mg 1 spironolact tab25mg 1 spironolact tab50mg 1 Diuretics, Thiazide chlorothiaz tab250mg 1 chlorothiaz tab500mg 1 chlorthalid tab25mg 1 chlorthalid tab50mg 1 hydrochlorotcap12.5mg 1 hydrochlorottab12.5mg 1 hydrochlorottab25mg 1 hydrochlorottab50mg 1 indapamide tab1.25mg 1 indapamide tab2.5mg 1 methyclothiatab5mg 1 metolazone tab10mg 1 metolazone tab2.5mg 1 metolazone tab5mg 1 108

110 Dyslipidemics, Fibric Acid Derivatives fenofibrate cap134mg 1 Quantity limitation 30 per 30 days fenofibrate cap200mg 1 Quantity limitation 30 per 30 days fenofibrate cap67mg 1 Quantity limitation 30 per 30 days fenofibrate tab145mg 1 Quantity limitation 30 per 30 days fenofibrate tab160mg 1 Quantity limitation 30 per 30 days fenofibrate tab48mg 1 Quantity limitation 30 per 30 days fenofibrate tab54mg 1 Quantity limitation 30 per 30 days fenofibric cap135mg dr 1 Quantity limitation 30 per 30 days fenofibric cap45mg dr 1 Quantity limitation 30 per 30 days gemfibrozil tab600mg 1 Dyslipidemics, HMG CoA Reductase Inhibitors atorvastatintab10mg 1 Quantity limitation 30 per 30 days atorvastatintab20mg 1 Quantity limitation 30 per 30 days atorvastatintab40mg 1 Quantity limitation 30 per 30 days atorvastatintab80mg 1 Quantity limitation 30 per 30 days fluvastatin cap20mg 1 Quantity limitation 60 per 30 days fluvastatin cap40mg 1 Quantity limitation 60 per 30 days Quantity limitation 30 per 30 days; Step therapy protocols apply LESCOL XL TAB80MG 3 lovastatin tab10mg 1 Quantity limitation 30 per 30 days lovastatin tab20mg 1 Quantity limitation 30 per 30 days lovastatin tab40mg 1 Quantity limitation 60 per 30 days pravastatin tab10mg 1 Quantity limitation 30 per 30 days pravastatin tab20mg 1 Quantity limitation 30 per 30 days pravastatin tab40mg 1 Quantity limitation 60 per 30 days pravastatin tab80mg 1 Quantity limitation 30 per 30 days simvastatin tab10mg 1 simvastatin tab20mg 1 simvastatin tab40mg 1 Quantity limitation 30 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. Quantity limitation 30 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. Quantity limitation 30 per 30 days; This prescription drug is part of the free first fill program and will be 109

111 provided at zero cost share when you select this medication over the brand name version of selected medications. Quantity limitation 30 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected simvastatin tab5mg 1 medications. Quantity limitation 30 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. simvastatin tab80mg 1 Dyslipidemics, Other cholestyram pow4gm lite 1 colestipol gra5gm 1 colestipol tab1gm 1 LOVAZA CAP1GM 3 niacin er tab1000mg 1 Quantity limitation 60 per 30 days niacin er tab500mg 1 Quantity limitation 60 per 30 days niacin er tab750mg 1 Quantity limitation 60 per 30 days niacor tab500mg 1 omega-3-acidcap1gm 1 prevalite pow4gm 1 ZETIA TAB10MG 3 Quantity limitation 30 per 30 days Vasodilators, Direct-acting Arterial hydralazine inj20mg/ml 3 hydralazine tab100mg 1 hydralazine tab10mg 1 hydralazine tab25mg 1 hydralazine tab50mg 1 minoxidil tab10mg 1 minoxidil tab2.5mg 1 Vasodilators, Direct-acting Arterial/Venous 110

112 isosorb din tab10mg 1 isosorb din tab20mg 1 isosorb din tab30mg 1 isosorb din tab40mg er 1 isosorb din tab5mg 1 isosorb monotab10mg 1 isosorb monotab120mg er 1 isosorb monotab20mg 1 isosorb monotab30mg er 1 isosorb monotab60mg er 1 NITRO-DUR DIS0.3MG/HR 3 NITRO-DUR DIS0.8MG/HR 3 nitroglycer dis0.1mg/hr 1 nitroglycer dis0.2mg/hr 1 nitroglycer dis0.4mg/hr 1 nitroglycer inj5mg/ml 3 nitroglyceridis0.6mg/hr 1 nitroglycrn spr0.4mg 1 NITROLINGUALSPRPUMPSPR 3 NITROSTAT SUB0.3MG 2 NITROSTAT SUB0.4MG 2 NITROSTAT SUB0.6MG 2 CENTRAL NERVOUS SYSTEM AGENTS Attention Deficit Hyperactivity Disorder Agents, Amphetamines amphetamine tab10mg 1 amphetamine tab12.5mg 1 amphetamine tab15mg 1 amphetamine tab20mg 1 amphetamine tab30mg 1 amphetamine tab5mg 1 amphetamine tab7.5mg 1 dextroamphettab10mg 1 dextroamphettab5mg 1 zenzedi tab10mg 1 zenzedi tab5mg 1 Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines dexmethylph tab10mg 1 Quantity limitation 90 per 30 days dexmethylph tab2.5mg 1 Quantity limitation 90 per 30 days 111

113 dexmethylph tab5mg 1 Quantity limitation 90 per 30 days INTUNIV TAB1MG 3 INTUNIV TAB2MG 3 INTUNIV TAB3MG 3 INTUNIV TAB4MG 3 metadate tab20mg er 1 methylphenidcap20mg er 1 methylphenidcap30mg er 1 methylphenidcap40mg er 1 methylphenidtab10mg 1 methylphenidtab20mg 1 methylphenidtab20mg er 1 methylphenidtab5mg 1 STRATTERA CAP100MG 2 Quantity limitation 60 per 30 days STRATTERA CAP10MG 2 Quantity limitation 60 per 30 days STRATTERA CAP18MG 2 Quantity limitation 60 per 30 days STRATTERA CAP25MG 2 Quantity limitation 60 per 30 days STRATTERA CAP40MG 2 Quantity limitation 60 per 30 days STRATTERA CAP60MG 2 Quantity limitation 60 per 30 days STRATTERA CAP80MG 2 Quantity limitation 60 per 30 days Central Nervous System, Other Quantity limitation 60 per 30 days; NUEDEXTA CAP20-10MG 2 riluzole tab50mg 1 XENAZINE TAB12.5MG 4 XENAZINE TAB25MG 4 This prescription may be available only at certain pharmacies. For more information please call hours a dayseven days a week. TTY/TDD users should ; This prescription may be available only at certain pharmacies. For more information please call 1-112

114 hours a dayseven days a week. TTY/TDD users should ; Fibromyalgia Agents SAVELLA MISTITR PAK 2 SAVELLA TAB100MG 2 SAVELLA TAB12.5MG 2 SAVELLA TAB25MG 2 SAVELLA TAB50MG 2 Multiple Sclerosis Agents Quantity limitation 4 per 28 days; AVONEX KIT30MCG 4 Quantity limitation 4 per 28 days; AVONEX PREFLKIT30MCG 4 BETASERON INJ0.3MG 4 Quantity limitation 15 per 30 days COPAXONE KIT20MG/ML 4 GILENYA CAP0.5MG 4 REBIF INJ22/0.5 4 Quantity limitation 12 per 30 days; 113

115 REBIF INJ44/0.5 4 Quantity limitation 12 per 30 days; Quantity limitation 6 per 30 days; REBIF TITRTNSOLPACK 4 TYSABRI INJ300/15ML 4 DENTAL AND ORAL AGENTS Dental and Oral Agents chlorhex glusol0.12% 1 doxycycline tab20mg 1 periogard sol0.12% 1 pilocarpine tab5mg 1 pilocarpine tab7.5mg 1 triamcin/orapst0.1% 1 DERMATOLOGICAL AGENTS Dermatological Agents 8-MOP CAP10MG 2 This prescription may be available only at certain pharmacies. For more information please call hours a dayseven days a week. TTY/TDD users should ; 114

116 acitretin cap10mg 1 acitretin cap17.5mg 1 acitretin cap25mg 1 adapalene cre0.1% 1 adapalene gel0.1% 1 ammonium laccre12% 1 ammonium laclot12% 1 amnesteem cap10mg 1 amnesteem cap20mg 1 amnesteem cap40mg 1 calcipotriencre0.005% 1 Quantity limitation 120 per 30 days calcipotrienoin0.005% 1 calcipotriensol0.005% 1 claravis cap10mg 1 claravis cap20mg 1 claravis cap30mg 1 claravis cap40mg 1 clindamy/bengel1-5% 1 clotrim/betacrediprop 1 clotrim/betalotdiprop 1 diclofenac gel3% 1 ELIDEL CRE1% 2 Quantity limitation 100 per 30 days; This medication requires prior Quantity limitation 30 per 30 days; 115

117 erythromycingel/benzoyl 1 fluorouracilcre5% 1 fluorouracilsol2% 1 fluorouracilsol5% 1 imiquimod cre5% 1 myorisan cap10mg 1 myorisan cap20mg 1 myorisan cap40mg 1 ORACEA CAP40MG 3 OXSORALEN-ULCAP10MG 3 authorization for new starts only. To obtain an exception please call hours a dayseven days a week. TTY/TDD users should podofilox sol0.5% 1 PROTOPIC OIN0.03% 3 Quantity limitation 30 per 30 days; authorization for new starts only. To obtain an exception please call hours a dayseven days a week. TTY/TDD users should Quantity limitation 30 per 30 days; authorization for new starts only. To obtain an exception please call hours a dayseven days a week. TTY/TDD users should PROTOPIC OIN0.1% 3 RETIN-A MICRGEL0.04% 3 RETIN-A MICRGEL0.1% 3 SANTYL OIN250/GM 2 Quantity limitation 30 per 30 days selenium sullot2.5% 1 TAZORAC CRE0.05% 3 TAZORAC CRE0.1% 3 TAZORAC GEL0.05% 3 TAZORAC GEL0.1% 3 tretinoin cre0.025% 1 tretinoin cre0.05% 1 tretinoin cre0.1% 1 tretinoin gel0.01% 1 116

118 tretinoin gel0.025% 1 zenatane cap10mg 1 zenatane cap20mg 1 zenatane cap40mg 1 DIABETES SUPPLIES Diabetes Supplies ALCOHOL PAD 2 GAUZE PAD2"X2" 2 INSULIN SYRGMIS0.3/31G 1 INSULIN SYRGMIS0.5/29G 1 INSULIN SYRGMIS0.5/31G 1 INSULIN SYRGMIS1ML/29G 1 PEN NEEDLES MIS31GX8MM 2 ENZYME REPLACEMENTS/MODIFIERS Enzyme Replacements/Modifiers ADAGEN INJ250/ML 4 ALDURAZYME INJ2.9MG/5M 4 This prescription may be available only at certain pharmacies. For more information please call hours a dayseven days a week. TTY/TDD users should ; CEREZYME INJ400UNIT 4 CREON CAP12000UNT 2 CREON CAP24000UNT 2 CREON CAP6000UNIT 2 CYSTADANE POW 3 CYSTAGON CAP150MG 3 This prescription may be available 117

119 only at certain pharmacies. For more information please call hours a dayseven days a week. TTY/TDD users should This prescription may be available only at certain pharmacies. For more information please call hours a dayseven days a week. TTY/TDD CYSTAGON CAP50MG 3 users should ELAPRASE INJ6MG/3ML 4 FABRAZYME INJ35MG 4 This prescription may be available only at certain pharmacies. For more information please call hours a dayseven days a week. TTY/TDD users should ; KUVAN TAB100MG 4 MYOZYME INJ50MG 4 This prescription may be available only at certain pharmacies. For more information please call 1- NAGLAZYME INJ1MG/ML hours a day- 118

120 seven days a week. TTY/TDD users should ; PANCREAZE CAP10500UNT 3 PANCREAZE CAP16800UNT 3 PANCREAZE CAP21000UNT 3 PANCREAZE CAP4200UNIT 3 ZAVESCA CAP100MG 3 This prescription may be available only at certain pharmacies. For more information please call hours a dayseven days a week. TTY/TDD users should ZENPEP CAP10000UNT 3 ZENPEP CAP15000UNT 3 ZENPEP CAP20000UNT 3 ZENPEP CAP5000UNIT 3 GASTROINTESTINAL AGENTS Antispasmodics, Gastrointestinal atropine sulinj0.1mg/ml 3 CANTIL TAB25MG 3 dicyclomine cap10mg 1 dicyclomine sol10mg/5ml 1 dicyclomine tab20mg 1 glycopyrrol tab1mg 1 glycopyrrol tab2mg 1 methscopolamtab2.5mg 1 methscopolamtab5mg 1 Gastrointestinal Agents CREON CAP3000UNIT 2 CREON CAP36000UNT 2 gavilyte-c sol 1 gavilyte-g sol 1 119

121 gavilyte-n solflav pk 1 trilyte sol 1 ZENPEP CAP25000UNT 3 ZENPEP CAP3000UNIT 3 Gastrointestinal Agents, Other GENOTROPIN INJ12MG 4 loperamide cap2mg 1 RELISTOR KIT12/0.6ML 3 SEROSTIM INJ4MG 4 SEROSTIM INJ5MG 4 SEROSTIM INJ6MG 4 ursodiol cap300mg 1 ursodiol tab250mg 1 ursodiol tab500mg 1 ZORBTIVE INJ8.8MG 4 120

122 Histamine2 (H2) Receptor Antagonists cimetidine sol300/5ml 1 cimetidine tab200mg 1 cimetidine tab300mg 1 cimetidine tab400mg 1 cimetidine tab800mg 1 famotidine inj10mg/ml 3 famotidine inj20mg/50m 3 famotidine sus40mg/5ml 1 famotidine tab20mg 1 famotidine tab40mg 1 nizatidine cap150mg 1 nizatidine cap300mg 1 nizatidine sol15mg/ml 1 ranitidine cap150mg 1 ranitidine cap300mg 1 ranitidine inj150/6ml 3 ranitidine syp15mg/ml 1 ranitidine tab150mg 1 ranitidine tab300mg 1 Irritable Bowel Syndrome Agents AMITIZA CAP24MCG 3 Quantity limitation 60 per 30 days AMITIZA CAP8MCG 3 Quantity limitation 60 per 30 days LOTRONEX TAB0.5MG 2 Quantity limitation 60 per 30 days LOTRONEX TAB1MG 2 Quantity limitation 60 per 30 days Laxatives 121

123 constulose sol10gm/15 1 enulose sol10gm/15 1 generlac sol10gm/15 1 lactulose sol10gm/15 1 polyeth glycpow3350 nf 1 Protectants misoprostol tab100mcg 1 misoprostol tab200mcg 1 sucralfate tab1gm 1 Proton Pump Inhibitors esomeprazoleinj20mg 3 esomeprazoleinj40mg 3 lansoprazolecap15mg dr 1 Quantity limitation 30 per 30 days lansoprazolecap30mg dr 1 Quantity limitation 30 per 30 days NEXIUM I.V. INJ20MG 3 NEXIUM I.V. INJ40MG 3 omeprazole cap10mg 1 Quantity limitation 120 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication 122

124 over the brand name version of selected medications. Quantity limitation 120 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of omeprazole cap20mg 1 omeprazole cap40mg 1 selected medications. Quantity limitation 120 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. pantoprazoletab20mg 1 Quantity limitation 30 per 30 days pantoprazoletab40mg 1 Quantity limitation 30 per 30 days rabeprazole tab20mg 1 Quantity limitation 30 per 30 days GENITOURINARY AGENTS Antispasmodics, Urinary ENABLEX TAB15MG 2 ENABLEX TAB7.5MG 2 flavoxate tab100mg 1 MYRBETRIQ TAB25MG 3 Quantity limitation 30 per 30 days; Step therapy protocols apply Quantity limitation 30 per 30 days; Step therapy protocols apply Quantity limitation 30 per 30 days; Step therapy protocols apply Quantity limitation 30 per 30 days; Step therapy protocols apply MYRBETRIQ TAB50MG 3 oxybutynin syp5mg/5ml 1 oxybutynin tab10mg er 1 Quantity limitation 90 per 30 days oxybutynin tab15mg er 1 Quantity limitation 60 per 30 days oxybutynin tab5mg 1 oxybutynin tab5mg er 1 Quantity limitation 180 per 30 days OXYTROL DIS3.9MG/24 3 Quantity limitation 8 per 28 days tolterodine tab1mg 1 Quantity limitation 60 per 30 days; Step therapy protocols apply tolterodine tab2mg 1 Quantity limitation 60 per 30 days; Step therapy protocols apply trospium chlcap60mg er 1 Quantity limitation 30 per 30 days Quantity limitation 30 per 30 days; VESICARE TAB10MG 2 Step therapy protocols apply VESICARE TAB5MG 2 Quantity limitation 30 per 30 days; 123

125 Step therapy protocols apply Benign Prostatic Hypertrophy Agents alfuzosin tab10mg 1 AVODART CAP0.5MG 2 Quantity limitation 30 per 30 days finasteride tab5mg 1 Quantity limitation 30 per 30 days tamsulosin cap0.4mg 1 Quantity limitation 60 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. Genitourinary Agents, Other bethanechol tab10mg 1 bethanechol tab25mg 1 bethanechol tab50mg 1 bethanechol tab5mg 1 DEPEN TITRA TAB250MG 3 Phosphate Binders calc acetatecap667mg 1 eliphos tab667mg 1 FOSRENOL CHW1000MG 3 FOSRENOL CHW500MG 3 FOSRENOL CHW750MG 3 PHOSLYRA SOL 3 HORMONAL AGENTS, STIMULANT/REPLACEMENT/ MODIFYING (Adrenal) Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) ala cort cre1% 1 alclometasoncre0.05% 1 alclometasonoin0.05% 1 amcinonide cre0.1% 1 amcinonide lot0.1% 1 amcinonide oin0.1% 1 aug betamet cre0.05% 1 aug betamet gel0.05% 1 aug betamet lot0.05% 1 aug betamet oin0.05% 1 betameth dipcre0.05% 1 betameth diplot0.05% 1 betameth dipoin0.05% 1 betameth valaer0.12% 1 124

126 betameth valcre0.1% 1 betameth vallot0.1% 1 betameth valoin0.1% 1 budesonide cap3mg/24hr 1 CAPEX SHA0.01% 3 clobetasol aer0.05% 1 clobetasol gel0.05% 1 clobetasol lot0.05% 1 clobetasol oin0.05% 1 clobetasol sha0.05% 1 clobetasol sol0.05% 1 clobetasol ecre0.05% 1 colocort ene100mg 1 cortisone actab25mg 1 desonide cre0.05% 1 desonide lot0.05% 1 desonide oin0.05% 1 desoximetas cre0.05% 1 desoximetas cre0.25% 1 desoximetas gel0.05% 1 desoximetas oin0.25% 1 dexameth phoinj120mg/30 3 dexamethasoncon1mg/ml 1 dexamethasonelx0.5/5ml 1 dexamethasontab0.5mg 1 dexamethasontab0.75mg 1 dexamethasontab1.5mg 1 dexamethasontab1mg 1 dexamethasontab2mg 1 dexamethasontab4mg 1 dexamethasontab6mg 1 diflorasone cre0.05% 1 diflorasone oin0.05% 1 fludrocort tab0.1mg 1 fluocin acetcre0.01% 1 fluocin acetcre0.025% 1 fluocin acetoin0.025% 1 fluocin acetsol0.01% 1 fluocinonidecre-e 0.05% 1 fluocinonidegel0.05% 1 fluocinonideoin0.05% 1 fluocinonidesol0.05% 1 fluticasone cre0.05% 1 fluticasone lot0.05% 1 125

127 fluticasone oin0.005% 1 halobetasol cre0.05% 1 halobetasol oin0.05% 1 HALOG CRE0.1% 3 HALOG OIN0.1% 3 hc valerate cre0.2% 1 hc valerate oin0.2% 1 hydrocort cre1% 1 hydrocort cre2.5% 1 hydrocort ene100mg 1 hydrocort lot2.5% 1 hydrocort oin1% 1 hydrocort oin2.5% 1 hydrocort tab10mg 1 hydrocort tab20mg 1 hydrocort tab5mg 1 lokara lot0.05% 1 methylpr aceinj40mg/ml 3 methylpr aceinj80mg/ml 3 methylpr ss inj125mg 3 methylpr ss inj40mg 3 126

128 methylpred pak4mg 1 methylpred tab16mg 1 methylpred tab32mg 1 methylpred tab4mg 1 methylpred tab8mg 1 mometasone cre0.1% 1 mometasone oin0.1% 1 mometasone sol0.1% 1 pred sod phosol5mg/5ml 1 prednicarbatoin0.1% 1 prednisolonesol15mg/5ml 1 prednisone con5mg/ml 1 prednisone sol5mg/5ml 1 prednisone tab10mg 1 prednisone tab1mg 1 prednisone tab2.5mg 1 prednisone tab20mg 1 prednisone tab50mg 1 prednisone tab5mg 1 procto-pak cre1% 1 proctozone cre-hc 2.5% 1 topicort cre0.05% 1 triamcinoloncre0.025% 1 triamcinoloncre0.1% 1 triamcinoloncre0.5% 1 triamcinolonlot0.025% 1 triamcinolonlot0.1% 1 triamcinolonoin0.025% 1 triamcinolonoin0.1% 1 triamcinolonoin0.5% 1 triamcinolonspr55mcg/ac 1 Quantity limitation 33 per 30 days triderm cre0.1% 1 u-cort cre1% 1 HORMONAL AGENTS, STIMULANT/REPLACEMENT/ MODIFYING (PITUITARY) Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) desmopressininj4mcg/ml 3 127

129 desmopressinspr0.01% 1 desmopressintab0.1mg 1 desmopressintab0.2mg 1 GENOTROPIN INJ0.2MG 3 GENOTROPIN INJ0.4MG 3 GENOTROPIN INJ0.6MG 3 GENOTROPIN INJ0.8MG 3 GENOTROPIN INJ1.2MG 3 GENOTROPIN INJ1.4MG 3 GENOTROPIN INJ1.6MG 3 128

130 GENOTROPIN INJ1.8MG 3 GENOTROPIN INJ1MG 3 GENOTROPIN INJ2MG 3 GENOTROPIN INJ5MG 4 HUMATROPE INJ12MG 4 HUMATROPE INJ24MG 4 This prescription may be available only at certain pharmacies. For more information please call hours a dayseven days a week. TTY/TDD users should ; INCRELEX INJ40MG/4ML 4 129

131 NORDITROPIN INJ15/1.5ML 4 NORDITROPIN INJ5/1.5ML 4 NUTROPIN AQ INJ10MG/2ML 4 SAIZEN INJ5MG 4 SAIZEN INJ8.8MG 4 STIMATE SOL1.5MG/ML 3 HORMONAL AGENTS, STIMULANT/REPLACEMENT/ MODIFYING (SEX HORMONES/MODIFIERS) Androgens ANDROGEL GEL1%(50MG) 3 Quantity limitation 300 per 30 days ANDROGEL GEL1.62% 3 ANDROXY TAB10MG 3 AXIRON SOL30MG/ACT 3 Quantity limitation 180 per 30 days danazol cap100mg 1 130

132 danazol cap200mg 1 danazol cap50mg 1 TESTIM GEL1%(50MG) 3 testost enaninj200mg/ml 3 Estrogens ALORA DIS0.025MG 2 Quantity limitation 8 per 28 days ALORA DIS0.05MG 2 Quantity limitation 8 per 28 days ALORA DIS0.075MG 2 Quantity limitation 8 per 28 days ALORA DIS0.1MG 2 Quantity limitation 8 per 28 days estrace vag cre0.1mg/gm 3 estradiol tab0.5mg 1 estradiol tab1mg 1 estradiol tab2mg 1 ESTRING MIS2MG 3 Quantity limitation 1 per 90 days estropipate tab0.75mg 1 estropipate tab1.5mg 1 estropipate tab3mg 1 menest tab0.3mg 1 menest tab0.625mg 1 menest tab1.25mg 1 menest tab2.5mg 1 PREMARIN TAB0.3MG 2 PREMARIN TAB0.45MG 2 PREMARIN TAB0.625MG 2 PREMARIN TAB0.9MG 2 PREMARIN TAB1.25MG 2 PREMARIN VAGCRE0.625MG 2 VAGIFEM TAB10MCG 3 ALORA DIS0.025MG 2 Quantity limitation 8 per 28 days ALORA DIS0.05MG 2 Quantity limitation 8 per 28 days ALORA DIS0.075MG 2 Quantity limitation 8 per 28 days ALORA DIS0.1MG 2 Quantity limitation 8 per 28 days estrace vag cre0.1mg/gm 3 estradiol tab0.5mg 1 estradiol tab1mg 1 estradiol tab2mg 1 ESTRING MIS2MG 3 Quantity limitation 1 per 90 days estropipate tab0.75mg 1 131

133 estropipate tab1.5mg 1 estropipate tab3mg 1 menest tab0.3mg 1 menest tab0.625mg 1 menest tab1.25mg 1 menest tab2.5mg 1 PREMARIN TAB0.3MG 2 PREMARIN TAB0.45MG 2 PREMARIN TAB0.625MG 2 PREMARIN TAB0.9MG 2 PREMARIN TAB1.25MG 2 PREMARIN VAGCRE0.625MG 2 VAGIFEM TAB10MCG 3 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) amethyst tab90-20mcg 1 apri tab 1 aranelle tab 1 aviane tab 1 balziva tab 1 briellyn tab 1 cryselle-28 tab28 tabs 1 cyclafem tab7/7/7 1 drospir/ethitab3-0.03mg 1 DUAVEE TAB Quantity limitation 30 per 30 days enpresse-28 tab 1 estra/norethtab estra/norethtab1-0.5mg 1 gildagia tab jinteli tab1mg-5mcg 1 junel 1.5/30tab 1 junel 1/20 tab 1 junel fe tab1.5/30 1 junel fe tab1/20 1 kariva tab28 day 1 kelnor tab1/35 1 lessina tab 1 levora-28 tab0.15/30 1 loryna tab3-0.02mg 1 low-ogestreltab 1 lutera tab 1 microgestin tab1.5/30 1 microgestin tab1/20 1 microgestin tabfe 1/20 1 microgestin tabfe1.5/

134 necon tab0.5/35 1 necon tab1/35 1 necon tab10/ nortrel tab0.5/35 1 nortrel tab1/35 1 nortrel tab1/35 1 nortrel tab7/7/7 1 NUVARING MIS 3 ogestrel tab 1 ORTHO EVRA DISWEEK 3 oxandrolone tab10mg 1 oxandrolone tab2.5mg 1 portia-28 tab 1 PREFEST TAB 2 PREMPHASE TAB 2 PREMPRO TAB PREMPRO TAB PREMPRO TAB PREMPRO TAB previfem tab 1 quasense tab 1 reclipsen tab 1 sprintec 28 tab28 day 1 sronyx tab 1 tri-legest tabfe 1 tri-previfemtab 1 tri-sprintectab 1 trivora-28 tab 1 velivet pak 1 vestura tab3-0.02mg 1 xulane dis zovia 1/35e tab 1 zovia 1/50e tab 1 Progesterone Agonists/Antagonists ELLA TAB30MG 2 Progestins camila tab0.35mg 1 CRINONE GEL4% VAG 3 CRINONE GEL8% VAG 3 DEPO-PROVERAINJ150MG/ML 3 Quantity limitation 1 per 90 days DEPO-PROVERAINJ400/ML 3 errin tab0.35mg 1 medroxypr acinj150mg/ml 3 Quantity limitation 1 per 90 days medroxypr actab10mg 1 133

135 medroxypr actab2.5mg 1 medroxypr actab5mg 1 MEGACE ES SUS625/5ML 3 megestrol acsus40mg/ml 1 megestrol actab20mg 1 megestrol actab40mg 1 norethin acetab5mg 1 progesteronecap100mg 1 progesteronecap200mg 1 Selective Estrogen Receptor Modifying Agents raloxifene tab60mg 1 HORMONAL AGENTS, STIMULANT/REPLACEMENT/ MODIFYING (THYROID) Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) levothyroxintab100mcg 1 levothyroxintab112mcg 1 levothyroxintab125mcg 1 levothyroxintab137mcg 1 levothyroxintab150mcg 1 levothyroxintab175mcg 1 levothyroxintab200mcg 1 levothyroxintab25mcg 1 levothyroxintab300mcg 1 levothyroxintab50mcg 1 levothyroxintab75mcg 1 levothyroxintab88mcg 1 liothyroninetab25mcg 1 liothyroninetab50mcg 1 liothyroninetab5mcg 1 SYNTHROID TAB100MCG 2 SYNTHROID TAB112MCG 2 SYNTHROID TAB125MCG 2 SYNTHROID TAB137MCG 2 SYNTHROID TAB150MCG 2 SYNTHROID TAB175MCG 2 SYNTHROID TAB200MCG 2 SYNTHROID TAB25MCG 2 SYNTHROID TAB300MCG 2 SYNTHROID TAB50MCG 2 SYNTHROID TAB75MCG 2 SYNTHROID TAB88MCG 2 UNITHROID TAB100MCG 2 134

136 UNITHROID TAB112MCG 2 UNITHROID TAB125MCG 2 UNITHROID TAB150MCG 2 UNITHROID TAB175MCG 2 UNITHROID TAB200MCG 2 UNITHROID TAB25MCG 2 UNITHROID TAB300MCG 2 UNITHROID TAB50MCG 2 UNITHROID TAB75MCG 2 UNITHROID TAB88MCG 2 HORMONAL AGENTS, SUPPRESSANT (ADRENAL) Hormonal Agents, Suppressant (Adrenal) LYSODREN TAB500MG 2 HORMONAL AGENTS, SUPPRESSANT (PARATHYROID) Hormonal Agents, Suppressant (Parathyroid) SENSIPAR TAB30MG 2 SENSIPAR TAB60MG 2 SENSIPAR TAB90MG 2 HORMONAL AGENTS, SUPPRESSANT (PITUITARY) Hormonal Agents, Suppressant (Pituitary) cabergoline tab0.5mg 1 leuprolide inj1mg/0.2 3 LUPR DEP-PEDINJ11.25MG 3 LUPR DEP-PEDINJ15MG 3 LUPRON DEPOTINJ11.25MG 3 LUPRON DEPOTINJ22.5MG 3 LUPRON DEPOTINJ3.75MG 3 LUPRON DEPOTINJ30MG 3 LUPRON DEPOTINJ45MG 3 LUPRON DEPOTINJ7.5MG 3 octreotide inj1000mcg 4 octreotide inj100mcg 3 135

137 octreotide inj200mcg 3 octreotide inj500mcg 4 octreotide inj50mcg/ml 3 SANDOSTATIN KITLAR 10MG 4 SANDOSTATIN KITLAR 20MG 4 SANDOSTATIN KITLAR 30MG 4 SOMATULINE INJ120/.5ML 4 SOMATULINE INJ60/0.2ML 4 136

138 SOMATULINE INJ90/0.3ML 4 This prescription may be available only at certain pharmacies. For more information please call hours a dayseven days a week. TTY/TDD users should ; SOMAVERT INJ10MG 4 SOMAVERT INJ15MG 4 This prescription may be available only at certain pharmacies. For more information please call hours a dayseven days a week. TTY/TDD users should ; SOMAVERT INJ20MG 4 This prescription may be available only at certain pharmacies. For more information please call hours a dayseven days a week. TTY/TDD users should ; 137

139 SYNAREL SOL2MG/ML 4 TRELSTAR DEPINJ3.75MG 4 TRELSTAR LA INJ11.25MG 4 HORMONAL AGENTS, SUPPRESSANT (THYROID) Antithyroid Agents methimazole tab10mg 1 methimazole tab5mg 1 propylthiourtab50mg 1 IMMUNOLOGICAL AGENTS Angioedema (HAE) Agents CINRYZE SOL500 UNIT 4 FIRAZYR INJ30MG/3ML 4 Immune Suppressants ASTAGRAF XL CAP0.5MG 3 This prescription may be available only at certain pharmacies. For more information please call hours a dayseven days a week. TTY/TDD users should ; Quantity limitation 9 per 30 days; 138

140 ASTAGRAF XL CAP1MG 3 ASTAGRAF XL CAP5MG 4 azasan tab100mg 1 azasan tab75 mg 1 azathioprinetab50mg 1 CELLCEPT SUS200MG/ML 3 CELLCEPT IV INJ500MG 3 139

141 cyclosporinecap100mg 1 cyclosporinecap100mg md 1 cyclosporinecap25mg 1 cyclosporinecap25mg mod 1 cyclosporinecap50mg mod 1 cyclosporineinj50mg/ml 3 140

142 cyclosporinesolmodified 1 Quantity limitation 8 per 28 days; ENBREL INJ25/0.5ML 4 ENBREL INJ25MG 4 Quantity limitation 16 per 28 days; ENBREL INJ50MG/ML 4 Quantity limitation 8 per 28 days; gengraf cap100mg 1 gengraf cap25mg 1 gengraf sol100mg/ml 1 141

143 Quantity limitation 8 per 28 days; HUMIRA KIT20MG/0.4 4 HUMIRA KIT40MG/0.8 4 Quantity limitation 8 per 28 days; Quantity limitation 8 per 28 days; HUMIRA PEN KITCROHNS 4 KINERET INJ 4 methotrexateinj1gm 3 methotrexateinj25mg/ml 3 142

144 methotrexatetab2.5mg 1 mycophenolatcap250mg 1 mycophenolattab500mg 1 mycophenolictab180mg dr 1 mycophenolictab360mg dr 1 MYFORTIC TAB180MG 3 MYFORTIC TAB360MG 3 ORENCIA INJ250MG 4 143

145 PROGRAF INJ5MG/ML 3 RAPAMUNE SOL1MG/ML 3 RAPAMUNE TAB0.5MG RAPAMUNE TAB1MG 3 RAPAMUNE TAB2MG 3 REMICADE INJ100MG 4 144

146 SANDIMMUNE SOL100MG/ML 3 sirolimus tab0.5mg 1 tacrolimus cap0.5mg 1 tacrolimus cap1mg 1 tacrolimus cap5mg 1 Quantity limitation 60 per 30 days; ZORTRESS TAB0.25MG 3 ZORTRESS TAB0.5MG 4 Quantity limitation 60 per 30 days; 145

147 Quantity limitation 60 per 30 days; ZORTRESS TAB0.75MG 4 Immunizing Agents, Passive CARIMUNE NF INJ3GM 4 GAMASTAN S/DINJ 2 GAMMAGARD INJ2.5GM/25 4 THYMOGLOBULNINJ25MG 4 Immunological Agents NULOJIX INJ250MG 4 146

148 SIMULECT INJ20MG 4 SYNAGIS INJ50MG 4 Immunomodulators ACTIMMUNE INJ2MU/0.5 4 This prescription may be available only at certain pharmacies. For more information please call hours a dayseven days a week. TTY/TDD users should ; ARCALYST INJ220MG 4 BENLYSTA INJ120MG 4 ILARIS INJ180MG 4 This prescription may be available 147

149 only at certain pharmacies. For more information please call hours a dayseven days a week. TTY/TDD users should ; leflunomide tab10mg 1 Quantity limitation 30 per 30 days leflunomide tab20mg 1 Quantity limitation 30 per 30 days RIDAURA CAP3MG 3 Vaccines ACTHIB INJ 3 ADACEL INJ 3 BOOSTRIX INJ 3 BOOSTRIX INJ 3 CERVARIX INJ 3 COMVAX INJ 3 DAPTACEL INJ 3 DIP/TET PED INJ25-5LFU 3 ENGERIX-B INJ10/0.5ML 3 ENGERIX-B INJ10/0.5ML 3 ENGERIX-B INJ20MCG/ML 3 148

150 GARDASIL INJ 3 HAVRIX INJ1440UNIT 3 HAVRIX INJ720UNIT 3 IMOVAX RABIEINJ2.5/ML 3 INFANRIX INJ 3 IPOL INJINACTIVE 3 IXIARO INJ 3 MENACTRA INJ 3 MENOMUNE INJA/C/Y/W 3 MENVEO INJ 3 M-M-R II INJLIVE 3 PEDVAX HIB INJ 3 PROQUAD INJ 3 RABAVERT INJ 3 RECOMBIVA HBINJ10MCG/ML 3 RECOMBIVA-HBINJ40MCG/ML 3 ROTARIX SUS 3 ROTATEQ SOL 3 TET/DIP TOX INJ2-2 LF 3 TETANUS TOX INJ5LF ADS 2 TWINRIX INJ 3 TYPHIM VI INJ 3 VAQTA INJ25/0.5ML 3 VARIVAX INJ 3 YF-VAX INJ 3 ZOSTAVAX INJ 3 INFLAMMATORY BOWEL DISEASE AGENTS 149

151 Aminosalicylates balsalazide cap750mg 1 CANASA SUP1000MG 3 DELZICOL CAP400MG 2 DIPENTUM CAP250MG 3 mesalamine kit4gm 1 PENTASA CAP250MG CR 3 PENTASA CAP500MG CR 3 Sulfonamides sulfasalazintab500mg 1 sulfazine ectab500mg 1 METABOLIC BONE DISEASE AGENTS Metabolic Bone Disease Agents alendronate sol70/75ml 1 alendronate tab10mg 1 alendronate tab35mg 1 alendronate tab40mg 1 alendronate tab5mg 1 alendronate tab70mg 1 Quantity limitation 120 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. Quantity limitation 5 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. Quantity limitation 30 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. Quantity limitation 240 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. Quantity limitation 5 per 30 days; This prescription drug is part of the 150

152 free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. calcitonin spr200/act 1 calcitriol cap0.25mcg 1 calcitriol cap0.5mcg 1 calcitriol inj1mcg/ml 2 calcitriol sol1mcg/ml 1 doxercalcif cap0.5mcg 1 doxercalcif cap1mcg 1 doxercalcif cap2.5mcg 1 doxercalcif inj4mcg/2ml 1 etidron disdtab200mg 1 etidron disdtab400mg 1 FORTEO SOL600/2.4 4 FORTICAL SPR200/ACT 2 HECTOROL CAP0.5MCG 3 HECTOROL CAP1MCG 3 HECTOROL CAP2.5MCG 3 ibandronate inj3mg/3ml 1 Quantity limitation 1 per 30 days; ibandronate tab150mg 1 Quantity limitation 1 per 30 days MIACALCIN INJ200/ML 3 151

153 pamidronate inj30/10ml 3 pamidronate inj6mg/ml 3 pamidronate inj90/10ml 3 paricalcitolcap1 mcg 1 paricalcitolcap2 mcg 1 paricalcitolcap4 mcg 1 PROLIA SOL60MG/ML 3 152

154 XGEVA INJ 4 ZEMPLAR INJ2MCG/ML 3 ZEMPLAR INJ5MCG/ML 3 zoledronic inj4mg/5ml 3 zoledronic inj5/100ml 3 Ophthalmic Agents bacit/polymyoinop 1 blephamide oins.o.p. 1 BLEPHAMIDE SUSOP 3 dorzol/timolsol2-0.5%op 1 neo/bac/polyoinop 1 neo/poly/bacoin/hc 1%op 1 neo/poly/dexoin0.1% op 1 neo/poly/dexsus0.1% op 1 neo/poly/grasolop 1 neo/poly/hc susop 1 polymyxin b/soltrimethp 1 PRED-G SUSOP 3 PRED-G S.O.POINOP 3 OPHTHALMIC AGENTS 153

155 proparacainesol0.5% op 1 sulf/pred nasolop 1 tobra/dexamesus % 1 Ophthalmic Agents, Other naphazoline sol0.1% op 1 RESTASIS EMU0.05% 3 Quantity limitation 60 per 30 days Ophthalmic Anti-allergy Agents ALOCRIL SOL2% 3 ALOMIDE SOL0.1% OP 3 azelastine dro0.05% 1 cromolyn sodsol4% op 1 epinastine dro0.05% 1 PATANOL SOL0.1% OP 3 Ophthalmic Antiglaucoma Agents ALPHAGAN P SOL0.1% 3 apraclonidinsol0.5% op 1 AZOPT SUS1% OP 3 betaxolol sol0.5% op 1 BETOPTIC-S SUS0.25% OP 3 brimonidine sol0.15% 1 brimonidine sol0.2% op 1 carteolol sol1% op 1 dorzolamide sol2% op 1 IOPIDINE SOL1% OP 3 levobunolol sol0.5% op 1 metipranololsol0.3% oph 1 PHOSPHOLINE SOL0.125%OP 3 timolol gel sol0.25% op 1 timolol gel sol0.5% op 1 timolol mal sol0.25% op 1 timolol mal sol0.5% op 1 Ophthalmic Anti-inflammatories ALREX SUS0.2% 3 bromfenac sol0.09% 1 dexameth phosol0.1% op 1 diclofenac sol0.1% op 1 FLAREX SUS0.1% OP 3 flurbiprofensol0.03% op 1 FML OIN0.1% OP 3 FML FORTE SUS0.25% OP 3 ketorolac sol0.4% 1 ketorolac sol0.5% 1 LOTEMAX GEL0.5% 3 LOTEMAX OIN0.5% 3 154

156 LOTEMAX SUS0.5% 3 MAXIDEX SUS0.1% OP 3 NEVANAC SUS0.1% 3 PRED MILD SUS0.12% OP 3 pred sod phosol1% op 1 VEXOL SUS1% OP 3 Ophthalmic Prostaglandin and Prostamide Analogs latanoprost sol0.005% 1 Quantity limitation 5 per 30 days LUMIGAN SOL0.01% 3 Quantity limitation 7.5 per 30 days TRAVATAN Z DRO0.004% 2 Quantity limitation 5 per 30 days travoprost dro0.004% 1 Quantity limitation 5 per 30 days OTIC AGENTS Otic Agents acetasol hc solotic 1 CIPRO HC SUSOTIC 2 CIPRODEX SUS % 3 COLY-MYCIN SSUSOTIC 3 hc/acet acidsolotic 1 neo/poly/hc sol1% otic 1 neo/poly/hc sus1% otic 1 RESPIRATORY TRACT/PULMONARY AGENTS Antihistamines azelastine spr0.1% 1 Quantity limitation 30 per 30 days carbinoxaminsol4mg/5ml 1 clemastine tab2.68mg 1 cyproheptad syp2mg/5ml 1 cyproheptad tab4mg 1 levocetirizisol2.5/5ml 1 levocetirizitab5mg 1 palgic sol4mg/5ml 1 Anti-inflammatories, Inhaled Corticosteroids ASMANEX 120 AER220MCG 3 Quantity limitation 2 per 30 days ASMANEX 30 AER110MCG 3 Quantity limitation 2 per 30 days ASMANEX 30 AER220MCG 3 Quantity limitation 2 per 30 days ASMANEX 60 AER220MCG 3 Quantity limitation 2 per 30 days BECONASE AQ SUS0.042% 3 Quantity limitation 50 per 30 days Quantity limitation per 30 budesonide sus32mcg 1 days FLOVENT DISKAER100MCG 2 Quantity limitation 120 per 30 days FLOVENT DISKAER250MCG 2 Quantity limitation 300 per 30 days FLOVENT DISKAER50MCG 2 Quantity limitation 120 per 30 days FLOVENT HFA AER110MCG 2 Quantity limitation 24 per 30 days FLOVENT HFA AER220MCG 2 Quantity limitation 24 per 30 days 155

157 FLOVENT HFA AER44MCG 2 Quantity limitation 21.2 per 30 days flunisolide spr0.025% 1 Quantity limitation 50 per 30 days fluticasone spr50mcg 1 Quantity limitation 16 per 30 days; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. PULMICORT INH180MCG 2 Quantity limitation 2 per 30 days PULMICORT INH90MCG 2 Quantity limitation 2 per 30 days Quantity limitation 21.9 per 30 QVAR AER40MCG 3 days QVAR AER80MCG 3 Quantity limitation 21.9 per 30 days Quantity limitation 17.2 per 30 RHINOCORT SUSAQUA 2 days VERAMYST SPR27.5MCG 2 Quantity limitation 20 per 30 days Antileukotrienes montelukast chw4mg 1 Quantity limitation 30 per 30 days montelukast chw5mg 1 Quantity limitation 30 per 30 days montelukast gra4mg 1 montelukast tab10mg 1 Quantity limitation 30 per 30 days zafirlukast tab10mg 1 Quantity limitation 60 per 30 days zafirlukast tab20mg 1 Quantity limitation 60 per 30 days ZYFLO CR TAB600MG 2 Quantity limitation 120 per 30 days Bronchodilators, Anticholinergic ATROVENT HFAAER17MCG 3 Quantity limitation 25.8 per 30 days ipratropium spr0.03% 1 Quantity limitation 30 per 30 days ipratropium spr0.06% 1 Quantity limitation 30 per 30 days SPIRIVA CAPHANDIHLR 2 Quantity limitation 90 per 30 days Bronchodilators, Sympathomimetic albuterol neb0.083% 1 albuterol neb0.5% 1 156

158 albuterol neb0.63mg/3 1 albuterol neb1.25mg/3 1 albuterol syp2mg/5ml 1 albuterol tab2mg 1 albuterol tab4mg 1 albuterol tab4mg er 1 albuterol tab8mg er 1 ARCAPTA CAP75MCG 2 Quantity limitation 30 per 30 days EPIPEN 2-PAKINJ0.3MG 3 Quantity limitation 1 per 30 days EPIPEN-JR INJ2-PAK 3 Quantity limitation 1 per 30 days FORADIL CAPAEROLIZE 3 Quantity limitation 60 per 30 days metaproterensyp10mg/5ml 1 metaproterentab10mg 1 metaproterentab20mg 1 PROAIR HFA AER 2 Quantity limitation 17 per 30 days Quantity limitation 13.4 per 30 PROVENTIL AERHFA 3 days SEREVENT DISAER50MCG 2 Quantity limitation 60 per 30 days terbutaline inj1mg/ml 3 terbutaline tab2.5mg 1 terbutaline tab5mg 1 VENTOLIN HFAAER 3 Quantity limitation 36 per 30 days vospire er tab4mg 1 157

159 vospire er tab8mg 1 XOPENEX HFA AER 3 Quantity limitation 30 per 30 days Cystic Fibrosis Agents CAYSTON INH75MG 3 TOBI PODHALRCAP28MG 2 Mast Cell Stabilizers cromolyn sodcon100/5ml 1 This prescription may be available only at certain pharmacies. For more information please call hours a dayseven days a week. TTY/TDD users should cromolyn sodneb20mg/2ml 1 Phosphodiesterase Inhibitors, Airways Disease DALIRESP TAB500MCG 3 Quantity limitation 30 per 30 days lufyllin tab200mg 1 lufyllin tab400mg 1 theophyllinetab100mg cr 1 theophyllinetab200mg cr 1 theophyllinetab300mg er 1 theophyllinetab400mg er 1 theophyllinetab450mg er 1 theophyllinetab600mg er 1 Pulmonary Antihypertensives ADCIRCA TAB20MG 4 LETAIRIS TAB10MG 4 Quantity limitation 60 per 30 days; This prescription may be available only at certain pharmacies. For more information please call hours a dayseven days a week. TTY/TDD users should ; 158

160 This prescription may be available only at certain pharmacies. For more information please call hours a dayseven days a week. TTY/TDD users should ; LETAIRIS TAB5MG 4 This prescription may be available only at certain pharmacies. For more information please call hours a dayseven days a week. TTY/TDD users should ; REMODULIN INJ10MG/ML 4 REMODULIN INJ1MG/ML 4 This prescription may be available only at certain pharmacies. For more information please call hours a dayseven days a week. TTY/TDD users should ; REMODULIN INJ2.5MG/ML 4 This prescription may be available only at certain pharmacies. For more information please call hours a dayseven days a week. TTY/TDD 159

161 users should ; REMODULIN INJ5MG/ML 4 This prescription may be available only at certain pharmacies. For more information please call hours a dayseven days a week. TTY/TDD users should ; sildenafil tab20mg 1 Quantity limitation 90 per 30 days; This prescription may be available only at certain pharmacies. For more information please call hours a dayseven days a week. TTY/TDD users should ; TRACLEER TAB125MG 4 TRACLEER TAB62.5MG 4 This prescription may be available only at certain pharmacies. For more information please call hours a dayseven days a week. TTY/TDD users should ; 160

162 Respiratory Tract Agents, Other acetylcyst sol10% 1 acetylcyst sol20% 1 ADVAIR DISKUAER100/50 2 Quantity limitation 60 per 30 days ADVAIR DISKUAER250/50 2 Quantity limitation 60 per 30 days ADVAIR DISKUAER500/50 2 Quantity limitation 60 per 30 days ADVAIR HFA AER115/21 2 Quantity limitation 12 per 30 days ADVAIR HFA AER230/21 2 Quantity limitation 12 per 30 days ADVAIR HFA AER45/21 2 Quantity limitation 12 per 30 days ANORO ELLIPTAER Quantity limitation 60 per 30 days ARALAST NP INJ400MG 4 This prescription may be available only at certain pharmacies. For more information please call hours a dayseven days a week. TTY/TDD users should ; authorization for new starts only. To obtain an exception please call hours a dayseven days a week. TTY/TDD users should DULERA AER100-5MCG 3 Quantity limitation 13 per 30 days DULERA AER200-5MCG 3 Quantity limitation 13 per 30 days Quantity limitation 10.2 per 30 SYMBICORT AER days SYMBICORT AER Quantity limitation 10.2 per 30 days 161

163 tyzine ped dro0.05% 1 This prescription may be available only at certain pharmacies. For more information please call hours a dayseven days a week. TTY/TDD users should ; ZEMAIRA INJ1000MG 4 Respiratory Tract/Pulmonary Agents COMBIVENT AERRESPIMAT 3 Quantity limitation 4 per 20 days PULMOZYME SOL1MG/ML 4 This prescription may be available only at certain pharmacies. For more information please call hours a dayseven days a week. TTY/TDD users should ; XOLAIR SOL150MG 4 Skeletal Muscle Relaxants SKELETAL MUSCLE RELAXANTS cyclobenzaprtab10mg 1 cyclobenzaprtab5mg 1 162

164 orphenadrineinj30mg/ml 3 SLEEP DISORDER AGENTS GABA Receptor Modulators zaleplon cap10mg 1 Quantity limitation 60 per 30 days zaleplon cap5mg 1 Quantity limitation 30 per 30 days zolpidem tab10mg 1 Quantity limitation 30 per 30 days; Step therapy protocols apply; This medication requires prior ; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. zolpidem tab5mg 1 Sleep Disorders, Other modafinil tab100mg 1 Quantity limitation 30 per 30 days; Step therapy protocols apply; This medication requires prior ; This prescription drug is part of the free first fill program and will be provided at zero cost share when you select this medication over the brand name version of selected medications. Quantity limitation 60 per 30 days; 163

165 modafinil tab200mg 1 Quantity limitation 60 per 30 days; Quantity limitation 30 per 30 days; ROZEREM TAB8MG 3 XYREM SOL500MG/ML 3 Step therapy protocols apply This prescription may be available only at certain pharmacies. For more information please call hours a dayseven days a week. TTY/TDD users should ; THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES Therapeutic Nutrients/Minerals/Electrolytes AMINOSYN INJ8.5/LYTE 3 AMINOSYN II INJ10% 3 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call

166 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call AMINOSYN II INJ7% 3 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call AMINOSYN II INJ8.5% 3 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call AMINOSYN II INJ8.5/LYTE 3 ; This prescription drug may be covered under our medical benefit. For more 165

167 information- call hours a day- seven days a week. TTY/TDD users should call AMINOSYN M INJ3.5% 3 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call AMINOSYN-HBCINJ7% 3 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call AMINOSYN-PF INJ10% 3 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call AMINOSYN-PF INJ7% 3 166

168 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call D10W/NACL INJ0.2% 3 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call D10W/NACL INJ0.45% 3 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call d2.5w/nacl inj0.45% 3 ; This prescription drug may be covered under our 167

169 medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call d5w/lr inj 3 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call d5w/nacl inj0.2% ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call D5W/NACL INJ0.225% d5w/nacl inj0.33% 3 168

170 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call d5w/nacl inj0.45% d5w/nacl inj0.9% 3 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call dextrose inj10% 3 ; This prescription 169

171 drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call dextrose inj5% 3 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call intralipid inj20% ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call kcl/d5w inj0.15%

172 kcl/d5w inj0.3% 3 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call kcl/d5w/lr inj0.15% kcl/d5w/naclinj.075/.45 3 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call kcl/d5w/naclinj.15/.33% 3 171

173 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call kcl/d5w/naclinj.15/.45% 3 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call kcl/d5w/naclinj.22/.45 3 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call kcl/d5w/naclinj0.15/0.2 3 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call 172

174 KCL/D5W/NACLINJ0.15/0.2 3 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call kcl/d5w/naclinj0.3/ ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call kcl/d5w/naclinj0.3/0.9% 3 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call lactated rininj 3 173

175 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call levocarnitinsol1gm/10ml 1 levocarnitintab330mg 1 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call TPN ELECTROLINJ 3 TROPHAMINE INJ10% 3 Electrolyte/Mineral Modifiers EXJADE TAB125MG ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call This prescription may be available only at certain pharmacies. For more information please call hours a dayseven days a week. TTY/TDD users should ; 174

176 This prescription may be available only at certain pharmacies. For more information please call hours a dayseven days a week. TTY/TDD users should ; EXJADE TAB250MG 4 EXJADE TAB500MG 4 sod poly sulsus15gm/60 1 SYPRINE CAP250MG 3 Electrolyte/Mineral Replacement This prescription may be available only at certain pharmacies. For more information please call hours a dayseven days a week. TTY/TDD users should ; kcl in nacl inj 3 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call KCL/NACL INJ

177 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call klor-con 10 tab10meq er 1 klor-con 8 tab8meq er 1 klor-con m15tab 1 klor-con m20tab20meq er 1 magnesium suinj50% 3 pot chloridecap10meq er 1 pot chloridecap8meq er 1 pot chlorideinj2meq/ml 3 pot citrate tab1080mg 1 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call

178 pot citrate tab540mg 1 pot cl microtab10meq er 1 pot cl microtab20meq er 1 sod chlorideinj0.45% 3 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call sod chlorideinj0.9% 3 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call sod chlorideinj2.5/ml 3 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call sod chlorideinj3% 3 177

179 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call sod chlorideinj5% 3 sodium chlorsol0.9% irr 1 klor-con 10 tab10meq er 1 klor-con 8 tab8meq er 1 klor-con m15tab 1 klor-con m20tab20meq er 1 ; This prescription drug may be covered under our medical benefit. For more information- call hours a day- seven days a week. TTY/TDD users should call ENHANCED COVERAGE DRUGS folic acid tab 1 mg 2 VIAGRA TAB 100MG 4 Quantity limitation 4 per 30 days; 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. 178

180 VIAGRA TAB 25MG 4 Quantity limitation 4 per 30 days; 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. VIAGRA TAB 50MG 4 Quantity limitation 4 per 30 days; 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. 179

181 Index of Drugs UTherapeutic Classes and Categories Therapeutic Categories are listed in Bold Therapeutic Classes are also listed in Bold 1st Generation/Typical nd Generation/Atypical MOP CAP10MG abacav/lamivtab/zidovud abacavir tab300mg ABELCET INJ5MG/ML ABILIFY INJ9.75MG ABILIFY SOL1MG/ML ABILIFY TAB10MG ABILIFY TAB15MG ABILIFY TAB20MG ABILIFY TAB2MG ABILIFY TAB30MG ABILIFY TAB5MG ABILIFY DISCTAB10MG ABILIFY DISCTAB15MG ABILIFY MAININJ300MG acampro cal tab333mg acebutolol cap200mg acebutolol cap400mg acetasol hc solotic acetazolamidcap500mg er acetazolamidtab125mg acetazolamidtab250mg acetic acid sol2% otic acetylcyst sol10% acetylcyst sol20% acitretin cap10mg acitretin cap17.5mg acitretin cap25mg ACTHIB INJ ACTIMMUNE INJ2MU/ acyclovir cap200mg acyclovir oin5% acyclovir sus200/5ml acyclovir tab400mg acyclovir tab800mg acyclovir nainj500mg ADACEL INJ ADAGEN INJ250/ML adapalene cre0.1% adapalene gel0.1% ADCIRCA TAB20MG adefov dipivtab10mg ADVAIR DISKUAER100/ ADVAIR DISKUAER250/ ADVAIR DISKUAER500/ ADVAIR HFA AER115/ ADVAIR HFA AER230/ ADVAIR HFA AER45/ afeditab tab30mg cr afeditab tab60mg cr AFINITOR TAB10MG AFINITOR TAB2.5MG AFINITOR TAB5MG AFINITOR TAB7.5MG AFINITOR DISTAB2MG AFINITOR DISTAB3MG AFINITOR DISTAB5MG AGGRENOX CAP25-200MG ala cort cre1% alagesic lq sol... 9 ALBENZA TAB200MG albuterol neb0.083% albuterol neb0.5% albuterol neb0.63mg/ albuterol neb1.25mg/ albuterol syp2mg/5ml albuterol tab2mg albuterol tab4mg albuterol tab4mg er albuterol tab8mg er alclometasoncre0.05% alclometasonoin0.05% ALCOHOL PAD Alcohol Deterrents/Anti-craving ALDURAZYME INJ2.9MG/5M alendronate sol70/75ml alendronate tab10mg alendronate tab35mg

182 alendronate tab40mg alendronate tab5mg alendronate tab70mg alfuzosin tab10mg ALIMTA INJ500MG ALINIA SUS100/5ML ALINIA TAB500MG Alkylating Agents allopurinol tab100mg allopurinol tab300mg ALOCRIL SOL2% ALOMIDE SOL0.1% OP ALORA DIS0.025MG ALORA DIS0.05MG ALORA DIS0.075MG ALORA DIS0.1MG ALOXI INJ0.25MG/ Alpha-adrenergic Agonists Alpha-adrenergic Blocking Agents. 97 ALPHAGAN P SOL0.1% alprazolam con1 mg/ml alprazolam tab0.25 odt alprazolam tab0.25mg alprazolam tab0.5mg alprazolam tab0.5mg er alprazolam tab0.5mg od alprazolam tab1mg... 82, 83 alprazolam tab1mg er alprazolam tab1mg odt alprazolam tab2mg alprazolam tab2mg er alprazolam tab2mg odt alprazolam tab3mg er ALREX SUS0.2% amantadine cap100mg amantadine syp50mg/5ml amantadine tab100mg AMBISOME INJ50MG amcinonide cre0.1% amcinonide lot0.1% amcinonide oin0.1% amethyst tab90-20mcg amifostine inj500mg amilor/hctz tab amiloride tab5mg Aminoglycosides Aminosalicylates AMINOSYN INJ8.5/LYTE AMINOSYN II INJ10% AMINOSYN II INJ7% AMINOSYN II INJ8.5% AMINOSYN II INJ8.5/LYTE AMINOSYN M INJ3.5% AMINOSYN-HBCINJ7% AMINOSYN-PF INJ10% AMINOSYN-PF INJ7% amiodarone tab200mg amiodarone tab400mg AMITIZA CAP24MCG AMITIZA CAP8MCG amitriptylintab100mg amitriptylintab10mg amitriptylintab150mg amitriptylintab25mg amitriptylintab50mg amitriptylintab75mg amlod/atorvatab10-10mg amlod/atorvatab10-20mg amlod/atorvatab10-40mg amlod/atorvatab10-80mg amlod/atorvatab2.5-10mg amlod/atorvatab2.5-20mg amlod/atorvatab2.5-40mg amlod/atorvatab5-10mg amlod/atorvatab5-20mg amlod/atorvatab5-40mg amlod/atorvatab5-80mg amlod/benazpcap10-20mg amlod/benazpcap10-40mg amlod/benazpcap2.5-10mg amlod/benazpcap5-10mg amlod/benazpcap5-20mg amlod/benazpcap5-40mg amlodipine tab10mg amlodipine tab2.5mg amlodipine tab5mg ammonium laccre12% ammonium laclot12% amnesteem cap10mg amnesteem cap20mg amnesteem cap40mg amox/k clav chw200mg

183 amox/k clav chw400mg amox/k clav sus200/5ml amox/k clav sus250/5ml amox/k clav sus400/5ml amox/k clav sus600/5ml amox/k clav tab250mg amox/k clav tab500mg amox/k clav tab875mg amoxapine tab100mg amoxapine tab150mg amoxapine tab25mg amoxapine tab50mg amoxicillin cap250mg amoxicillin cap500mg amoxicillin chw125mg amoxicillin chw250mg amoxicillin sus125/5ml amoxicillin sus200/5ml amoxicillin sus250/5ml amoxicillin sus400/5ml amoxicillin tab500mg amoxicillin tab875mg amox-pot clataber amphetamine tab10mg amphetamine tab12.5mg amphetamine tab15mg amphetamine tab20mg amphetamine tab30mg amphetamine tab5mg amphetamine tab7.5mg amphotericininj50mg ampicillin cap250mg ampicillin cap500mg ampicillin inj10gm ampicillin inj125mg ampicillin inj1gm ampicillin sus125/5ml ampicillin sus250/5ml amp-sulbactainj15gm amp-sulbactainj3gm AMTURNIDE150TAB AMTURNIDE300TAB AMTURNIDE300TAB-10-25MG AMTURNIDE300TAB AMTURNIDE300TAB-5-25MG anagrelide cap0.5mg anagrelide cap1mg Analgesics... 9 ANALGESICS... 9 anastrozole tab1mg ANDROGEL GEL1%(50MG) ANDROGEL GEL1.62% Androgens ANDROXY TAB10MG ANESTHETICS Angioedema (HAE) Agents Angiotensin II Receptor Antagonists Angiotensin-converting Enzyme (ACE) Inhibitors ANORO ELLIPTAER Anthelminthics ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS Antiandrogens Antiangiogenic Agents Antiarrhythmics Antibacterials ANTIBACTERIALS Antibacterials, Other Anticholinergics Anticoagulants ANTICONVULSANTS Anticonvulsants, Other Anti-cytomegalovirus (CMV) Agents ANTIDEMENTIA AGENTS Antidementia Agents, Other Antidepressants ANTIDEPRESSANTS Antidepressants, Other Antidiabetic Agents ANTIEMETICS Antiemetics, Other Antiestrogens/Modifiers Antifungals ANTIFUNGALS Antigout Agents ANTIGOUT AGENTS Anti-hepatitis B (HBV) Agents Anti-hepatitis C (HCV) Agents Antiherpetic Agents

184 Antihistamines Anti-HIV Agents, Integrase Inhibitors (INSTI) Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI) Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI) Anti-HIV Agents, Other Anti-HIV Agents, Protease Inhibitors Anti-inflammatories, Inhaled Corticosteroids Anti-influenza Agents Antileukotrienes Antimetabolites Antimigraine Agents ANTI-MIGRAINE AGENTS ANTIMYASTHENIC AGENTS ANTIMYCOBACTERIALS Antimycobacterials, Other Antineoplastics ANTINEOPLASTICS Antineoplastics, Other ANTIPARASITICS ANTIPARKINSON AGENTS Antiparkinson Agents, Other Antiprotozoals ANTIPSYCHOTICS Antispasmodics, Gastrointestinal 119 Antispasmodics, Urinary Antispasticity Agents ANTISPASTICITY AGENTS Antithyroid Agents Antituberculars Antivirals ANTIVIRALS ANXIOLYTICS Anxiolytics, Other ANZEMET INJ20MG/ML ANZEMET TAB100MG ANZEMET TAB50MG apap/codeinesol120-12/ apap/codeinetab300-15mg... 9 apap/codeinetab300-30mg... 9 apap/codeinetab300-60mg... 9 APIDRA INJSOLOSTAR APIDRA INJU APOKYN INJ10MG/ML apraclonidinsol0.5% op apri tab APTIOM TAB200MG APTIOM TAB400MG APTIOM TAB600MG APTIOM TAB800MG APTIVUS CAP250MG APTIVUS SOL ARALAST NP INJ400MG aranelle tab ARANESP INJ100MCG... 90, 91 ARANESP INJ150MCG ARANESP INJ200MCG ARANESP INJ25MCG ARANESP INJ300MCG... 91, 92 ARANESP INJ40MCG ARANESP INJ500MCG ARANESP INJ60MCG ARCALYST INJ220MG ARCAPTA CAP75MCG Aromatase Inhibitors, 3rd Generation ARRANON INJ5MG/ML ARZERRA CON100/5ML ascomp/cod cap30mg... 9 ASMANEX 120 AER220MCG ASMANEX 30 AER110MCG ASMANEX 30 AER220MCG ASMANEX 60 AER220MCG ASTAGRAF XL CAP0.5MG ASTAGRAF XL CAP1MG ASTAGRAF XL CAP5MG atenol/chlortab100-25mg atenol/chlortab50-25mg atenolol tab100mg atenolol tab25mg atenolol tab50mg atorvastatintab10mg atorvastatintab20mg atorvastatintab40mg atorvastatintab80mg atovaq/progutab

185 atovaquone sus750/5ml ATRIPLA TAB atropine sulinj0.1mg/ml ATROVENT HFAAER17MCG Attention Deficit Hyperactivity Disorder Agents, Amphetamines Attention Deficit Hyperactivity Disorder Agents, Nonamphetamines aug betamet cre0.05% aug betamet gel0.05% aug betamet lot0.05% aug betamet oin0.05% AVASTIN INJ AVELOX INJ aviane tab AVODART CAP0.5MG AVONEX KIT30MCG AVONEX PREFLKIT30MCG AXIRON SOL30MG/ACT azacitidine inj100mg AZACTAM/DEX INJ1GM AZACTAM/DEX INJ2GM azasan tab100mg azasan tab75 mg azathioprinetab50mg azelastine dro0.05% azelastine spr0.1% AZILECT TAB0.5MG AZILECT TAB1MG azithromycininj500mg azithromycinsus100/5ml azithromycinsus200/5ml azithromycintab250mg azithromycintab500mg azithromycintab600mg AZOPT SUS1% OP aztreonam inj1gm baciim inj50000unt bacit/polymyoinop bacitracin oinop baclofen tab10mg baclofen tab20mg balsalazide cap750mg balziva tab BANZEL SUS40MG/ML BANZEL TAB200MG BANZEL TAB400MG BARACLUDE SOL.05MG/ML BARACLUDE TAB0.5MG BARACLUDE TAB1MG BECONASE AQ SUS0.042% benazep/hctztab benazep/hctztab benazep/hctztab20-25mg benazep/hctztab benazepril tab10mg benazepril tab20mg benazepril tab40mg benazepril tab5mg BENICAR TAB20MG BENICAR TAB40MG BENICAR TAB5MG BENICAR HCT TAB BENICAR HCT TAB BENICAR HCT TAB40-25MG Benign Prostatic Hypertrophy Agents BENLYSTA INJ120MG Benzodiazepines benztropine tab0.5mg benztropine tab1mg benztropine tab2mg Beta-adrenergic Blocking Agents. 100 Beta-lactam, Cephalosporins Beta-lactam, Other Beta-lactam, Penicillins betameth dipcre0.05% betameth diplot0.05% betameth dipoin0.05% betameth valaer0.12% betameth valcre0.1% betameth vallot0.1% betameth valoin0.1% BETASERON INJ0.3MG betaxolol sol0.5% op betaxolol tab10mg betaxolol tab20mg bethanechol tab10mg bethanechol tab25mg bethanechol tab50mg

186 bethanechol tab5mg BETOPTIC-S SUS0.25% OP bicalutamidetab50mg BICILLIN C-RINJ BICILLIN C-RINJ900/ BICILLIN L-AINJ BICILLIN L-AINJ BICILLIN L-AINJ BILTRICIDE TAB600MG BIPOLAR AGENTS bisoprl/hctztab10/ bisoprl/hctztab2.5/ bisoprl/hctztab5-6.25mg bisoprol fumtab10mg bisoprol fumtab5mg bleomycin inj30unit blephamide oins.o.p BLEPHAMIDE SUSOP Blood Formation Modifiers Blood Glucose Regulators BLOOD GLUCOSE REGULATORS.. 83 BLOOD PRODUCTS/MODIFIERS/ VOLUME EXPANDERS Blood Products/Modifiers/Volume Expanders BOOSTRIX INJ BOSULIF TAB100MG BOSULIF TAB500MG briellyn tab BRILINTA TAB90MG brimonidine sol0.15% brimonidine sol0.2% op BRINTELLIX TAB10MG BRINTELLIX TAB20MG BRINTELLIX TAB5MG bromfenac sol0.09% bromocriptincap5mg bromocriptintab2.5mg Bronchodilators, Anticholinergic Bronchodilators, Sympathomimetic budesonide cap3mg/24hr budesonide sus32mcg bumetanide tab0.5mg bumetanide tab1mg bumetanide tab2mg bupren/naloxsub2-0.5mg bupren/naloxsub8-2mg buprenorphininj0.3mg/ml buprenorphinsub2mg buprenorphinsub8mg buproban tab150mg bupropion tab100mg bupropion tab100mg sr bupropion tab150mg sr bupropion tab200mg sr bupropion tab75mg bupropn hcl tab150mg xl bupropn hcl tab300mg xl buspirone tab10mg buspirone tab15mg buspirone tab30mg buspirone tab5mg buspirone tab7.5mg but/apap/cafcap... 9 but/apap/cafcapcodeine... 9 but/apap/caftab... 9 but/asa/caffcap... 9 butal/apap tab50-325mg... 9 butorphanol sol10mg/ml BUTRANS DIS10MCG/HR BUTRANS DIS15MCG/HR BUTRANS DIS20MCG/HR BUTRANS DIS5MCG/HR BYETTA INJ10MCG BYETTA INJ5MCG cabergoline tab0.5mg calc acetatecap667mg calcipotriencre0.005% calcipotrienoin0.005% calcipotriensol0.005% calcitonin spr200/act calcitriol cap0.25mcg calcitriol cap0.5mcg calcitriol inj1mcg/ml calcitriol sol1mcg/ml Calcium Channel Blocking Agents 102 Calcium Channel Modifying Agents 37 camila tab0.35mg CANASA SUP1000MG CANCIDAS INJ50MG CANCIDAS INJ70MG

187 candesa/hctztab candesa/hctztab candesa/hctztab32-25mg candesartan tab16mg candesartan tab32mg candesartan tab4mg candesartan tab8mg CANTIL TAB25MG CAPASTAT SULINJ1GM CAPEX SHA0.01% CAPRELSA TAB100MG CAPRELSA TAB300MG captopr/hctztab25-15mg captopr/hctztab25-25mg captopr/hctztab50-15mg captopr/hctztab50-25mg captopril tab100mg captopril tab12.5mg captopril tab25mg captopril tab50mg carb/levo tab10-100mg carb/levo tab25-100mg carb/levo tab25-250mg carb/levo ertab25-100mg carb/levo ertab50-200mg carbamazepincap100mg er carbamazepincap200mg er carbamazepincap300mg er carbamazepinchw100mg carbamazepinsus100/5ml carbamazepintab200mg carbamazepintab200mg er carbamazepintab400mg er carbidopa tab25mg carbinoxaminsol4mg/5ml Cardiovascular Agents CARDIOVASCULAR AGENTS Cardiovascular Agents, Other CARIMUNE NF INJ3GM carteolol sol1% op cartia xt cap120/24hr cartia xt cap180/24hr cartia xt cap240/24hr cartia xt cap300/24hr carvedilol tab12.5mg carvedilol tab25mg carvedilol tab3.125mg carvedilol tab6.25mg CAYSTON INH75MG cefaclor cap250mg cefaclor cap500mg cefaclor er tab500mg cefadroxil cap500mg cefadroxil sus250/5ml cefadroxil sus500/5ml cefadroxil tab1gm cefazolin inj10gm cefazolin inj1gm cefazolin inj1gm/50ml cefazolin inj500mg cefdinir cap300mg cefdinir sus125/5ml cefdinir sus250/5ml cefepime inj1gm cefepime inj2gm cefoxitin inj10gm cefoxitin inj1gm cefoxitin inj2gm cefpodo proxsus100/5ml cefpodo proxsus50mg/5ml cefpodoxime tab100mg cefpodoxime tab200mg cefprozil sus125/5ml cefprozil sus250/5ml cefprozil tab250mg cefprozil tab500mg ceftriaxone inj10gm ceftriaxone inj250mg ceftriaxone inj500mg cefuroxime inj1.5gm cefuroxime inj7.5gm cefuroxime inj750mg cefuroxime tab250mg cefuroxime tab500mg CELLCEPT SUS200MG/ML CELLCEPT IV INJ500MG CELONTIN CAP300MG CENTRAL NERVOUS SYSTEM AGENTS Central Nervous System, Other cephalexin cap250mg cephalexin cap500mg

188 cephalexin sus125/5ml cephalexin sus250/5ml cephalexin tab250mg cephalexin tab500mg CEREZYME INJ400UNIT CERVARIX INJ CHANTIX PAK0.5& 1MG CHANTIX TAB0.5MG CHANTIX TAB1MG chloramphen inj1gm chlordiazep cap10mg chlordiazep cap25mg chlordiazep cap5mg chlorhex glusol0.12% chloroquine tab250mg chloroquine tab500mg chlorothiaz tab250mg chlorothiaz tab500mg chlorpromaz inj25mg/ml chlorpromaz tab100mg chlorpromaz tab10mg chlorpromaz tab200mg chlorpromaz tab25mg chlorpromaz tab50mg chlorpropam tab100mg chlorpropam tab250mg chlorthalid tab25mg chlorthalid tab50mg cholestyram pow4gm lite Cholinesterase Inhibitors ciclopirox cre0.77% ciclopirox gel0.77% ciclopirox sha1% ciclopirox sol8% ciclopirox sus0.77% cidofovir inj75mg/ml cilostazol tab100mg cilostazol tab50mg CILOXAN OIN0.3% OP cimetidine sol300/5ml cimetidine tab200mg cimetidine tab300mg cimetidine tab400mg cimetidine tab800mg CINRYZE SOL500 UNIT CIPRO HC SUSOTIC CIPRODEX SUS % ciprofloxacninj200mg ciprofloxacninj400mg ciprofloxacnsol0.3% op ciprofloxacntab1000mg ciprofloxacntab100mg ciprofloxacntab250mg ciprofloxacntab500mg ciprofloxacntab500mg er ciprofloxacntab750mg citalopram sol10mg/5ml citalopram tab10mg citalopram tab20mg citalopram tab40mg claravis cap10mg claravis cap20mg claravis cap30mg claravis cap40mg clarithromycsus125/5ml clarithromycsus250/5ml clarithromyctab250mg clarithromyctab500mg clarithromyctab500mg er clemastine tab2.68mg clindamy/bengel1-5% clindamycin aer1% clindamycin cap150mg clindamycin cap300mg clindamycin cap75mg clindamycin cre2% vag clindamycin gel1% clindamycin inj150mg/ml clindamycin lot1% clindamycin pad1% clindamycin sol1% clobetasol aer0.05% clobetasol gel0.05% clobetasol lot0.05% clobetasol oin0.05% clobetasol sha0.05% clobetasol sol0.05% clobetasol ecre0.05% clomipraminecap25mg clomipraminecap50mg clomipraminecap75mg clonazep odttab0.125mg

189 clonazep odttab0.25mg clonazep odttab0.5mg clonazep odttab1mg clonazep odttab2mg clonazepam tab0.5mg clonazepam tab1mg clonazepam tab2mg clonidine dis0.1/24hr clonidine dis0.2/24hr clonidine dis0.3/24hr clonidine tab0.1mg clonidine tab0.2mg clonidine tab0.3mg clopidogrel tab300mg clopidogrel tab75mg cloraz dipottab15mg cloraz dipottab3.75mg cloraz dipottab7.5mg clorpres tab0.1-15mg clorpres tab0.2-15mg clorpres tab0.3-15mg clotrim/betacrediprop clotrim/betalotdiprop clotrimazolecre1% clotrimazolesol1% clotrimazoletro10mg clozapine tab100mg clozapine tab200mg clozapine tab25mg clozapine tab50mg Coagulants COARTEM TAB20-120MG COLCRYS TAB0.6MG colestipol gra5gm colestipol tab1gm colistimeth inj150mg colocort ene100mg COLY-MYCIN SSUSOTIC COMBIVENT AERRESPIMAT COMETRIQ KIT100MG COMETRIQ KIT140MG COMETRIQ KIT60MG COMPLERA TAB compro sup25mg COMVAX INJ constulose sol10gm/ COPAXONE KIT20MG/ML cortisone actab25mg COUMADIN INJ5 MG COUMADIN TAB10MG COUMADIN TAB1MG COUMADIN TAB2.5MG COUMADIN TAB2MG COUMADIN TAB3MG COUMADIN TAB4MG COUMADIN TAB5MG COUMADIN TAB6MG COUMADIN TAB7.5MG CREON CAP12000UNT CREON CAP24000UNT CREON CAP3000UNIT CREON CAP36000UNT CREON CAP6000UNIT CRINONE GEL4% VAG CRINONE GEL8% VAG CRIXIVAN CAP200MG CRIXIVAN CAP400MG cromolyn sodcon100/5ml cromolyn sodneb20mg/2ml cromolyn sodsol4% op cryselle-28 tab28 tabs CUBICIN SOL500MG cyclafem tab7/7/ cyclobenzaprtab10mg cyclobenzaprtab5mg CYCLOPHOSPH CAP25MG CYCLOPHOSPH CAP50MG cyclophosph tab25mg cyclophosph tab50mg CYCLOSET TAB0.8MG cyclosporinecap100mg cyclosporinecap100mg md cyclosporinecap25mg cyclosporinecap25mg mod cyclosporinecap50mg mod cyclosporineinj50mg/ml cyclosporinesolmodified CYKLOKAPRON INJ100MG/ML cyproheptad syp2mg/5ml cyproheptad tab4mg CYSTADANE POW CYSTAGON CAP150MG

190 CYSTAGON CAP50MG Cystic Fibrosis Agents D10W/NACL INJ0.2% D10W/NACL INJ0.45% d2.5w/nacl inj0.45% d5w/lr inj d5w/nacl inj0.2% D5W/NACL INJ0.225% d5w/nacl inj0.33% d5w/nacl inj0.45% d5w/nacl inj0.9% DACOGEN INJ50MG DALIRESP TAB500MCG danazol cap100mg danazol cap200mg danazol cap50mg dantrolene cap100mg dantrolene cap25mg dantrolene cap50mg dapsone tab100mg dapsone tab25mg DAPTACEL INJ DARAPRIM TAB25MG decitabine inj50mg DELZICOL CAP400MG demeclocycl tab150mg demeclocycl tab300mg DEMSER CAP250MG DENAVIR CRE1% Dental and Oral Agents DENTAL AND ORAL AGENTS DEPEN TITRA TAB250MG DEPO-PROVERAINJ150MG/ML DEPO-PROVERAINJ400/ML Dermatological Agents DERMATOLOGICAL AGENTS desipramine tab100mg desipramine tab10mg desipramine tab150mg desipramine tab25mg desipramine tab50mg desipramine tab75mg desmopressininj4mcg/ml desmopressinspr0.01% desmopressintab0.1mg desmopressintab0.2mg desonide cre0.05% desonide lot0.05% desonide oin0.05% desoximetas cre0.05% desoximetas cre0.25% desoximetas gel0.05% desoximetas oin0.25% DESVENLAFAX TAB100MG ER DESVENLAFAX TAB50MG ER dexameth phoinj120mg/ dexameth phosol0.1% op dexamethasoncon1mg/ml dexamethasonelx0.5/5ml dexamethasontab0.5mg dexamethasontab0.75mg dexamethasontab1.5mg dexamethasontab1mg dexamethasontab2mg dexamethasontab4mg dexamethasontab6mg dexmethylph tab10mg dexmethylph tab2.5mg dexmethylph tab5mg dextroamphettab10mg dextroamphettab5mg dextrose inj10% dextrose inj5% Diabetes Supplies DIABETES SUPPLIES DIASTAT ACDLGEL DIASTAT ACDLGEL5-10MG DIASTAT PED GEL2.5M GEL diazepam con5mg/ml diazepam sol1mg/ml diazepam tab10mg diazepam tab2mg diazepam tab5mg diclo/misoprtab50-0.2mg... 9 diclo/misoprtab75-0.2mg... 9 diclofen pottab50mg diclofenac gel3% diclofenac sol0.1% op diclofenac tab100mg er diclofenac tab25mg dr diclofenac tab50mg dr diclofenac tab75mg dr

191 dicloxacill cap250mg dicloxacill cap500mg dicyclomine cap10mg dicyclomine sol10mg/5ml dicyclomine tab20mg didanosine cap125mg didanosine cap200mg didanosine cap250mg didanosine cap400mg DIFICID TAB200MG diflorasone cre0.05% diflorasone oin0.05% diflunisal tab500mg DIGOXIN SOL50MCG/ML digoxin tab0.125mg digoxin tab0.25mg dihydroergotinj1mg/ml DILANTIN CAP30MG diltiazem cap120mg cd diltiazem cap120mg er diltiazem cap180mg/ diltiazem cap240mg cd diltiazem cap300mg er diltiazem cap360mg/ diltiazem cap420mg/ diltiazem cap60mg er diltiazem cap90mg er diltiazem tab120mg diltiazem tab30mg diltiazem tab60mg diltiazem tab90mg dilt-xr cap120mg dilt-xr cap180mg dilt-xr cap240mg DIOVAN TAB160MG DIOVAN TAB320MG DIOVAN TAB40MG DIOVAN TAB80MG DIP/TET PED INJ25-5LFU DIPENTUM CAP250MG diphenhydraminj50mg/ml disopyramidecap100mg disopyramidecap150mg disulfiram tab250mg disulfiram tab500mg Diuretics, Carbonic Anhydrase Inhibitors Diuretics, Loop Diuretics, Potassium-sparing Diuretics, Thiazide divalproex cap125mg divalproex tab125mg dr divalproex tab250mg dr divalproex tab250mg er divalproex tab500mg dr divalproex tab500mg er DOCEFREZ INJ20MG DOCEFREZ INJ80MG DOCETAXEL INJ80MG/4ML donepezil tab10mg donepezil tab10mg odt donepezil tab5mg donepezil tab5mg odt donepezil tabhcl 23mg Dopamine Agonists Dopamine Precursors/L-Amino Acid Decarboxylase Inhibitors dorzol/timolsol2-0.5%op dorzolamide sol2% op doxazosin tab1mg doxazosin tab2mg doxazosin tab4mg doxazosin tab8mg doxepin hcl cap100mg doxepin hcl cap10mg doxepin hcl cap150mg doxepin hcl cap25mg doxepin hcl cap50mg doxepin hcl cap75mg doxepin hcl con10mg/ml doxercalcif cap0.5mcg doxercalcif cap1mcg doxercalcif cap2.5mcg doxercalcif inj4mcg/2ml doxycyc monotab150mg doxycyc monotab50mg doxycyc monotab75mg doxycycl hyccap100mg doxycycl hyccap50mg doxycycl hyctab100mg doxycycline tab20mg

192 dronabinol cap10mg dronabinol cap2.5mg dronabinol cap5mg drospir/ethitab3-0.03mg DROXIA CAP200MG DROXIA CAP300MG DROXIA CAP400MG DUAVEE TAB DULERA AER100-5MCG DULERA AER200-5MCG duloxetine cap20mg duloxetine cap30mg duloxetine cap60mg duramorph inj0.5mg/ml duramorph inj1mg/ml Dyslipidemics Dyslipidemics, Fibric Acid Derivatives Dyslipidemics, HMG CoA Reductase Inhibitors Dyslipidemics, Other econazole cre1% EDURANT TAB25MG EFFIENT TAB10MG EFFIENT TAB5MG ELAPRASE INJ6MG/3ML Electrolyte/Mineral Modifiers Electrolyte/Mineral Replacement ELIDEL CRE1% eliphos tab667mg ELITEK INJ1.5MG ELLA TAB30MG EMCYT CAP140MG EMEND CAP125MG EMEND CAP40MG EMEND CAP80MG EMEND PAK80 & Emetogenic Therapy Adjuncts EMSAM DIS12MG/24H EMSAM DIS6MG/24HR EMSAM DIS9MG/24HR EMTRIVA CAP200MG EMTRIVA SOL10MG/ML ENABLEX TAB15MG ENABLEX TAB7.5MG enalapr/hctztab10-25mg enalapr/hctztab5-12.5mg enalapril tab10mg enalapril tab2.5mg enalapril tab20mg enalapril tab5mg ENBREL INJ25/0.5ML ENBREL INJ25MG ENBREL INJ50MG/ML endocet tab10-325mg... 9 endocet tab5-325mg... 9 endocet tab ENGERIX-B INJ10/0.5ML ENGERIX-B INJ20MCG/ML ENHANCED COVERAGE DRUGS enoxaparin inj100mg/ml enoxaparin inj120/ enoxaparin inj150mg/ml enoxaparin inj30/0.3ml enoxaparin inj300/3ml enoxaparin inj40/0.4ml enoxaparin inj60/0.6ml enoxaparin inj80/0.8ml enpresse-28 tab entacapone tab200mg enulose sol10gm/ Enzyme Inhibitors Enzyme Replacements/ Modifiers. 117 ENZYME REPLACEMENTS/ MODIFIERS epinastine dro0.05% EPIPEN 2-PAKINJ0.3MG EPIPEN-JR INJ2-PAK epitol tab200mg EPIVIR SOL10MG/ML EPIVIR HBV SOL5MG/ML EPIVIR HBV TAB100MG eplerenone tab25mg eplerenone tab50mg EPOGEN INJ10000/ML EPOGEN INJ2000/ML EPOGEN INJ20000/ML EPOGEN INJ3000/ML EPOGEN INJ4000/ML eprosart mestab600mg EPZICOM TAB EQUETRO CAP100MG

193 EQUETRO CAP200MG EQUETRO CAP300MG ERAXIS INJ100MG ergoloid mestab1mg oral Ergot Alkaloids ERIVEDGE CAP150MG errin tab0.35mg ERWINAZE INJ10000UNT ery pad2% ery-tab tab250mg ec ery-tab tab333mg ec ery-tab tab500mg ec ERYTHROCIN INJ500MG erythrocin tab250mg ERYTHROM ETHTAB400MG erythromycingel/benzoyl erythromycingel2% erythromycinoinop erythromycinsol2% erythromycintab250mg bs erythromycintab500mg bs escitalopramsol5mg/5ml escitalopramtab10mg escitalopramtab20mg escitalopramtab5mg esomeprazoleinj20mg esomeprazoleinj40mg estra/norethtab estra/norethtab1-0.5mg estrace vag cre0.1mg/gm estradiol tab0.5mg estradiol tab1mg estradiol tab2mg ESTRING MIS2MG Estrogens estropipate tab0.75mg estropipate tab1.5mg , 132 estropipate tab3mg , 132 ethambutol tab100mg ethambutol tab400mg ethosuximidecap250mg ethosuximidesol250/5ml etidron disdtab200mg etidron disdtab400mg etodolac cap200mg etodolac cap300mg etodolac tab400mg etodolac tab500mg etodolac er tab400mg etodolac er tab500mg etodolac er tab600mg ETOPOPHOS INJ100MG etoposide inj20mg/ml EXELDERM CRE1% EXELDERM SOL1% EXELON DIS13.3/ EXELON DIS4.6MG/ EXELON DIS9.5MG/ exemestane tab25mg EXFORGE TAB10-160MG EXFORGE TAB10-320MG EXFORGE TAB5-160MG EXFORGE TAB5-320MG EXFORGEH/10-TAB EXFORGEH/10-TAB EXFORGEH/10-TAB EXFORGEH/5- TAB EXFORGEH/5- TAB EXJADE TAB125MG EXJADE TAB250MG EXJADE TAB500MG FABRAZYME INJ35MG famciclovir tab125mg famciclovir tab250mg famciclovir tab500mg famotidine inj10mg/ml famotidine inj20mg/50m famotidine sus40mg/5ml famotidine tab20mg famotidine tab40mg FANAPT PAK FANAPT TAB10MG FANAPT TAB12MG FANAPT TAB1MG FANAPT TAB2MG FANAPT TAB4MG FANAPT TAB6MG FANAPT TAB8MG FARESTON TAB60MG FASLODEX INJ250MG FAZACLO TAB100/ODT FAZACLO TAB12.5/ODT

194 FAZACLO TAB150MG FAZACLO TAB200MG FAZACLO TAB25MG ODT felbamate sus600/5ml felbamate tab400mg felbamate tab600mg felodipine tab10mg er felodipine tab2.5mg er felodipine tab5mg er fenofibrate cap134mg fenofibrate cap200mg fenofibrate cap67mg fenofibrate tab145mg fenofibrate tab160mg fenofibrate tab48mg fenofibrate tab54mg fenofibric cap135mg dr fenofibric cap45mg dr fenoprofen tab600mg fentanyl dis100mcg/h fentanyl dis12mcg/hr fentanyl dis25mcg/hr fentanyl dis50mcg/hr fentanyl dis75mcg/hr fentanyl ot loz1200mcg fentanyl ot loz1600mcg fentanyl ot loz200mcg fentanyl ot loz400mcg fentanyl ot loz600mcg fentanyl ot loz800mcg FETZIMA CAP120MG FETZIMA CAP20MG FETZIMA CAP40MG FETZIMA CAP80MG FETZIMA CAPTITRATIO Fibromyalgia Agents finasteride tab5mg FIRAZYR INJ30MG/3ML FLAREX SUS0.1% OP flavoxate tab100mg flecainide tab100mg flecainide tab150mg flecainide tab50mg FLECTOR DIS1.3% FLOVENT DISKAER100MCG FLOVENT DISKAER250MCG FLOVENT DISKAER50MCG FLOVENT HFA AER110MCG FLOVENT HFA AER220MCG FLOVENT HFA AER44MCG fluconazole sus10mg/ml fluconazole sus40mg/ml fluconazole tab100mg fluconazole tab150mg fluconazole tab200mg fluconazole tab50mg fluconazole/injdex flucytosine cap250mg flucytosine cap500mg fludrocort tab0.1mg flunisolide spr0.025% fluocin acetcre0.01% fluocin acetcre0.025% fluocin acetoin0.025% fluocin acetsol0.01% fluocinonidecre-e 0.05% fluocinonidegel0.05% fluocinonideoin0.05% fluocinonidesol0.05% fluorouracilcre5% fluorouracilsol2% fluorouracilsol5% fluoxetine cap10mg fluoxetine cap20mg fluoxetine cap40mg fluoxetine cap90mg dr fluoxetine sol20mg/5ml fluoxetine tab10mg fluoxetine tab20mg fluphenaz deinj25mg/ml fluphenazinecon5mg/ml fluphenazineelx2.5/5ml fluphenazineinj2.5mg/ml fluphenazinetab10mg fluphenazinetab1mg fluphenazinetab2.5mg fluphenazinetab5mg flurbiprofensol0.03% op flurbiprofentab100mg flurbiprofentab50mg flutamide cap125mg fluticasone cre0.05%

195 fluticasone lot0.05% fluticasone oin0.005% fluticasone spr50mcg fluvastatin cap20mg fluvastatin cap40mg fluvoxamine cap100mg er fluvoxamine cap150mg er fluvoxamine tab100mg fluvoxamine tab25mg fluvoxamine tab50mg FML OIN0.1% OP FML FORTE SUS0.25% OP folic acid tab 1mg fondaparinuxsol10/ fondaparinuxsol2.5/ fondaparinuxsol5.0/ fondaparinuxsol7.5/ FORADIL CAPAEROLIZE FORFIVO XL TAB450MG FORTEO SOL600/ FORTICAL SPR200/ACT foscarnet inj24mg/ml fosinop/hctztab10/ fosinop/hctztab20/ fosinopril tab10mg fosinopril tab20mg fosinopril tab40mg fosphenytoininj100/2ml FOSRENOL CHW1000MG FOSRENOL CHW500MG FOSRENOL CHW750MG FRAGMIN INJ10000/ML FRAGMIN INJ12500UNT FRAGMIN INJ15000UNT FRAGMIN INJ18000UNT FRAGMIN INJ2500/ FRAGMIN INJ25000/ML FRAGMIN INJ5000/ FRAGMIN INJ7500/ furosemide inj10mg/ml furosemide sol10mg/ml furosemide sol8mg/ml furosemide tab20mg furosemide tab40mg furosemide tab80mg FUSILEV INJ50MG FUZEON INJ90MG FYCOMPA TAB10MG FYCOMPA TAB12MG FYCOMPA TAB2MG FYCOMPA TAB4MG FYCOMPA TAB6MG FYCOMPA TAB8MG GABA Receptor Modulators gabapentin cap100mg gabapentin cap300mg gabapentin cap400mg gabapentin sol250/5ml gabapentin tab600mg gabapentin tab800mg GABITRIL TAB12MG GABITRIL TAB16MG galantamine cap16mg er galantamine cap24mg er galantamine cap8mg er galantamine sol4mg/ml galantamine tab12mg galantamine tab4mg galantamine tab8mg GAMASTAN S/DINJ Gamma-aminobutyric Acid (GABA) Augmenting Agents GAMMAGARD INJ2.5GM/ ganciclovir inj500mg GARDASIL INJ Gastrointestinal Agents GASTROINTESTINAL AGENTS Gastrointestinal Agents, Other GAUZE PAD gavilyte-c sol gavilyte-g sol gavilyte-n solflav pk gemcitabine inj1gm gemfibrozil tab600mg generlac sol10gm/ gengraf cap100mg gengraf cap25mg gengraf sol100mg/ml GENITOURINARY AGENTS Genitourinary Agents, Other GENOTROPIN INJ0.2MG GENOTROPIN INJ0.4MG

196 GENOTROPIN INJ0.6MG GENOTROPIN INJ0.8MG GENOTROPIN INJ1.2MG GENOTROPIN INJ1.4MG GENOTROPIN INJ1.6MG GENOTROPIN INJ1.8MG GENOTROPIN INJ12MG GENOTROPIN INJ1MG GENOTROPIN INJ2MG GENOTROPIN INJ5MG gentak oin0.3% op gentamicin cre0.1% gentamicin inj10mg/ml gentamicin inj40mg/ml GENTAMICIN OIN0.1% gentamicin sol0.3% op GEODON INJ20MG gildagia tab GILENYA CAP0.5MG GILOTRIF TAB20MG GILOTRIF TAB30MG GILOTRIF TAB40MG GLEEVEC TAB100MG GLEEVEC TAB400MG glimepiride tab1mg glimepiride tab2mg glimepiride tab4mg glip/metformtab m glip/metformtab m glip/metformtab5-500mg glipizide tab10mg glipizide tab5mg glipizide ertab10mg glipizide ertab2.5mg glipizide ertab5mg GLUCAGEN INJHYPOKIT GLUCAGON KIT1MG Glutamate Reducing Agents glyb/metformtab glyb/metformtab glyb/metformtab5-500mg Glycemic Agents glycopyrrol tab1mg glycopyrrol tab2mg GLYSET TAB100MG GLYSET TAB25MG GLYSET TAB50MG granisetron tab1mg granisol sol2mg/10ml griseofulvinsus125/5ml guanfacine tab1mg guanfacine tab2mg GUANIDINE TAB125MG HALAVEN INJ1MG/2ML halobetasol cre0.05% halobetasol oin0.05% HALOG CRE0.1% HALOG OIN0.1% haloper dec inj100mg/ml haloper dec inj50mg/ml haloper lac inj5mg/ml haloperidol con2mg/ml haloperidol tab0.5mg haloperidol tab10mg haloperidol tab1mg haloperidol tab20mg haloperidol tab2mg haloperidol tab5mg HAVRIX INJ1440UNIT HAVRIX INJ720UNIT hc valerate cre0.2% hc valerate oin0.2% hc/acet acidsolotic HECTOROL CAP0.5MCG HECTOROL CAP1MCG HECTOROL CAP2.5MCG hep sod/d5w inj25000unt hep sod/naclinj1000unit heparin sod inj1000/ml heparin sod inj10000/ml heparin sod inj20000/ml heparin sod inj5000/ml HERCEPTIN INJ440MG HEXALEN CAP50MG Histamine2 (H2) Receptor Antagonists HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (Adrenal) HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (PITUITARY)

197 HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (SEX HORMONES/MODIFIERS) HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (THYROID) Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Hormonal Agents, Suppressant (Adrenal) HORMONAL AGENTS, SUPPRESSANT (ADRENAL) Hormonal Agents, Suppressant (Parathyroid) HORMONAL AGENTS, SUPPRESSANT (PARATHYROID) Hormonal Agents, Suppressant (Pituitary) HORMONAL AGENTS, SUPPRESSANT (PITUITARY) HORMONAL AGENTS, SUPPRESSANTS (THYROID) HUMALOG INJ100/ML HUMALOG MIX INJ50/ HUMALOG MIX INJ50/50KWP HUMALOG MIX INJ75/25KWP HUMALOG MIX SUS75/ HUMATROPE INJ12MG HUMATROPE INJ24MG HUMIRA KIT20MG/ HUMIRA KIT40MG/ HUMIRA PEN KITCROHNS HUMULIN INJ70/ HUMULIN N INJU HUMULIN N PNINJU HUMULIN PEN INJ70/ HUMULIN R INJU HUMULIN R INJU hycet sol hydralazine inj20mg/ml hydralazine tab100mg hydralazine tab10mg hydralazine tab25mg hydralazine tab50mg hydrochlorotcap12.5mg hydrochlorottab12.5mg hydrochlorottab25mg hydrochlorottab50mg hydroco/apapsol hydroco/apaptab10-300mg... 9 hydroco/apaptab10-325mg... 9 hydroco/apaptab5-300mg... 9 hydroco/apaptab5-325mg... 9 hydroco/apaptab hydroco/apaptab hydrocod/ibutab hydrocort cre1% hydrocort cre2.5% hydrocort ene100mg hydrocort lot2.5% hydrocort oin1% hydrocort oin2.5% hydrocort tab10mg hydrocort tab20mg hydrocort tab5mg hydromorphontab2mg hydromorphontab4mg hydromorphontab8mg hydroxychlortab200mg hydroxyurea cap500mg hydroxyz hclinj25mg/ml hydroxyz hclinj50mg/ml ibandronate inj3mg/3ml ibandronate tab150mg ibuprofen sus100/5ml ibuprofen tab400mg ibuprofen tab600mg ibuprofen tab800mg ILARIS INJ180MG IMBRUVICA CAP140MG imipenem/cilinj250mg

198 imipenem/cilinj500mg imipram hcl tab10mg imipram hcl tab25mg imipram hcl tab50mg imiquimod cre5% Immune Suppressants Immunizing Agents, Passive Immunological Agents IMMUNOLOGICAL AGENTS Immunomodulators IMOVAX RABIEINJ2.5/ML INCIVEK TAB375MG INCRELEX INJ40MG/4ML indapamide tab1.25mg indapamide tab2.5mg indomethacincap25mg indomethacincap50mg indomethacincap75mg er INFANRIX INJ INFLAMMATORY BOWEL DISEASE AGENTS INLYTA TAB1MG INLYTA TAB5MG INNOPRAN XL CAP120MG INNOPRAN XL CAP80MG INSULIN SYRGMIS0.3/31G INSULIN SYRGMIS0.5/29G INSULIN SYRGMIS0.5/31G INSULIN SYRGMIS1ML/29G Insulins INTELENCE TAB100MG INTELENCE TAB200MG INTELENCE TAB25MG intralipid inj20% INTRON-A INJ10MU INTRON-A INJ18MU INTUNIV TAB1MG INTUNIV TAB2MG INTUNIV TAB3MG INTUNIV TAB4MG INVANZ INJ1GM INVEGA TAB1.5MG INVEGA TAB3MG INVEGA TAB6MG INVEGA TAB9MG INVEGA SUST INJ117/ INVEGA SUST INJ156MG/ML INVEGA SUST INJ234/ INVEGA SUST INJ39/ INVEGA SUST INJ78/0.5ML INVIRASE CAP200MG INVIRASE TAB500MG IOPIDINE SOL1% OP IPOL INJINACTIVE ipratropium spr0.03% ipratropium spr0.06% irbesar/hctztab irbesar/hctztab irbesartan tab150mg irbesartan tab300mg irbesartan tab75mg Irritable Bowel Syndrome Agents. 121 ISENTRESS CHW100MG ISENTRESS CHW25MG ISENTRESS POW100MG ISENTRESS TAB400MG isoniazid syp50mg/5ml isoniazid tab100mg isoniazid tab300mg isosorb din tab10mg isosorb din tab20mg isosorb din tab30mg isosorb din tab40mg er isosorb din tab5mg isosorb monotab10mg isosorb monotab120mg er isosorb monotab20mg isosorb monotab30mg er isosorb monotab60mg er isradipine cap2.5mg isradipine cap5mg ISTODAX INJ10MG itraconazolecap100mg IXIARO INJ JAKAFI TAB10MG JAKAFI TAB15MG JAKAFI TAB20MG JAKAFI TAB25MG JAKAFI TAB5MG jantoven tab10mg jantoven tab1mg jantoven tab2.5mg

199 jantoven tab2mg jantoven tab3mg jantoven tab4mg jantoven tab5mg jantoven tab6mg jantoven tab7.5mg JANUMET TAB JANUMET TAB50-500MG JANUMET XR TAB JANUMET XR TAB JANUMET XR TAB50-500MG JANUVIA TAB100MG JANUVIA TAB25MG JANUVIA TAB50MG JEVTANA INJ60/1.5ML jinteli tab1mg-5mcg junel 1.5/30tab junel 1/20 tab junel fe tab1.5/ junel fe tab1/ KADCYLA INJ100MG KALETRA SOL KALETRA TAB100-25MG KALETRA TAB200-50MG kariva tab28 day kcl in nacl inj kcl/d5w inj0.15% kcl/d5w inj0.3% kcl/d5w/lr inj0.15% kcl/d5w/naclinj.075/ kcl/d5w/naclinj.15/.33% kcl/d5w/naclinj.15/.45% kcl/d5w/naclinj.22/ kcl/d5w/naclinj0.15/ KCL/D5W/NACLINJ0.15/ kcl/d5w/naclinj0.3/ kcl/d5w/naclinj0.3/0.9% KCL/NACL INJ kelnor tab1/ ketoconazolecre2% ketoconazolesha2% ketoconazoletab200mg ketoprofen cap200mg er ketoprofen cap50mg ketoprofen cap75mg ketorolac sol0.4% ketorolac sol0.5% KHEDEZLA TAB100MG ER KHEDEZLA TAB50MG ER KINERET INJ klor-con 10 tab10meq er , 178 klor-con 8 tab8meq er , 178 klor-con m15tab , 178 klor-con m20tab20meq er , 178 KOMBIGLYZE TAB KOMBIGLYZE TAB5-1000MG KOMBIGLYZE TAB5-500MG KUVAN TAB100MG labetalol tab100mg labetalol tab200mg labetalol tab300mg lactated rininj lactulose sol10gm/ lamivud/zidotab lamivudine tab100mg lamivudine tab150mg lamivudine tab300mg lamotrigine chw25mg lamotrigine chw5mg lamotrigine tab100mg lamotrigine tab100mg er lamotrigine tab150mg lamotrigine tab200mg lamotrigine tab200mg er lamotrigine tab250mg er lamotrigine tab25mg lamotrigine tab25mg er lamotrigine tab300mg er lamotrigine tab50mg er lansoprazolecap15mg dr lansoprazolecap30mg dr LANTUS INJ100/ML LANTUS INJSOLOSTAR latanoprost sol0.005% LATUDA TAB120MG LATUDA TAB20MG LATUDA TAB40MG LATUDA TAB60MG LATUDA TAB80MG Laxatives leflunomide tab10mg leflunomide tab20mg

200 LESCOL XL TAB80MG lessina tab LETAIRIS TAB10MG LETAIRIS TAB5MG letrozole tab2.5mg leucovor ca inj100mg leucovor ca inj350mg leucovor ca tab10mg leucovor ca tab15mg leucovor ca tab25mg leucovor ca tab5mg LEUKERAN TAB2MG LEUKINE INJ250MCG leuprolide inj1mg/ LEVEMIR INJ LEVEMIR INJFLEXPEN levetiracetasol100mg/ml levetiracetatab1000mg levetiracetatab250mg levetiracetatab500mg levetiracetatab500mg er levetiracetatab750mg levetiracetatab750mg er levetiracetminj500/5ml levobunolol sol0.5% op levocarnitinsol1gm/10ml levocarnitintab330mg levocetirizisol2.5/5ml levocetirizitab5mg levofloxacinsol0.5% levofloxacinsol25mg/ml levofloxacintab250mg levofloxacintab500mg levofloxacintab750mg levora-28 tab0.15/ levorphanol tab2mg levothyroxintab100mcg levothyroxintab112mcg levothyroxintab125mcg levothyroxintab137mcg levothyroxintab150mcg levothyroxintab175mcg levothyroxintab200mcg levothyroxintab25mcg levothyroxintab300mcg levothyroxintab50mcg levothyroxintab75mcg levothyroxintab88mcg LEXIVA SUS50MG/ML LEXIVA TAB700MG lido/prilocncre % lidocaine gel2% jelly lidocaine inj0.5% lidocaine inj1% lidocaine oin5% lidocaine pad5% lidocaine sol2% visc lidocaine sol4% lindane lot1% lindane sha1% liothyroninetab25mcg liothyroninetab50mcg liothyroninetab5mcg lisinop/hctztab lisinop/hctztab lisinop/hctztab20-25mg lisinopril tab10mg lisinopril tab2.5mg lisinopril tab20mg lisinopril tab30mg lisinopril tab40mg lisinopril tab5mg lithium carbcap150mg lithium carbcap300mg lithium carbcap600mg lithium carbtab300mg lithium carbtab300mg er lithium carbtab450mg er LITHIUM CITRSOL8MEQ/5ML Local Anesthetics LODOSYN TAB25MG lokara lot0.05% LOMUSTINE CAP100MG LOMUSTINE CAP10MG LOMUSTINE CAP40MG loperamide cap2mg lorazepam con2mg/ml lorazepam tab0.5mg lorazepam tab1mg lorazepam tab2mg loryna tab3-0.02mg losartan pottab100mg

201 losartan pottab25mg losartan pottab50mg losartan/hcttab losartan/hcttab losartan/hcttab LOTEMAX GEL0.5% LOTEMAX OIN0.5% LOTEMAX SUS0.5% LOTRONEX TAB0.5MG LOTRONEX TAB1MG lovastatin tab10mg lovastatin tab20mg lovastatin tab40mg LOVAZA CAP1GM low-ogestreltab loxapine cap10mg loxapine cap25mg loxapine cap50mg loxapine cap5mg lufyllin tab200mg lufyllin tab400mg LUMIGAN SOL0.01% LUPR DEP-PEDINJ11.25MG LUPR DEP-PEDINJ15MG LUPRON DEPOTINJ11.25MG LUPRON DEPOTINJ22.5MG LUPRON DEPOTINJ3.75MG LUPRON DEPOTINJ30MG LUPRON DEPOTINJ45MG LUPRON DEPOTINJ7.5MG lutera tab LYRICA CAP100MG LYRICA CAP150MG LYRICA CAP200MG LYRICA CAP225MG LYRICA CAP25MG LYRICA CAP300MG LYRICA CAP50MG LYRICA CAP75MG LYRICA SOL20MG/ML LYSODREN TAB500MG Macrolides mafenide acepak5% magnesium suinj50% MALARONE TAB maprotiline tab25mg maprotiline tab50mg maprotiline tab75mg MARPLAN TAB10MG Mast Cell Stabilizers MATULANE CAP50MG matzim la tab180mg/ matzim la tab240mg/ matzim la tab300mg/ matzim la tab360mg/ matzim la tab420mg/ MAXIDEX SUS0.1% OP meclizine tab12.5mg meclizine tab25mg meclofen sodcap100mg meclofen sodcap50mg medroxypr acinj150mg/ml medroxypr actab10mg medroxypr actab2.5mg medroxypr actab5mg mefloquine tab250mg MEGACE ES SUS625/5ML megestrol acsus40mg/ml megestrol actab20mg megestrol actab40mg MEKINIST TAB0.5MG MEKINIST TAB2MG meloxicam tab15mg meloxicam tab7.5mg MENACTRA INJ menest tab0.3mg , 132 menest tab0.625mg , 132 menest tab1.25mg , 132 menest tab2.5mg , 132 MENOMUNE INJA/C/Y/W MENVEO INJ meprobamate tab200mg meprobamate tab400mg MEPRON SUS mercaptopur tab50mg meropenem inj500mg mesalamine kit4gm MESNEX TAB400MG MESTINON SYP60MG/5ML MESTINON TABTIMESPAN Metabolic Bone Disease Agents

202 METABOLIC BONE DISEASE AGENTS metadate tab20mg er metaproterensyp10mg/5ml metaproterentab10mg metaproterentab20mg metformin tab1000mg metformin tab500mg metformin tab500mg er metformin tab750mg er metformin tab850mg metformin ertab1000mg METHADONE INJ10MG/ML methadone sol10mg/5ml methadone sol5mg/5ml methadone tab10mg methadone tab5mg methazolamidtab25mg methazolamidtab50mg methenam hiptab1gm methimazole tab10mg methimazole tab5mg methotrexateinj1gm methotrexateinj25mg/ml methotrexatetab2.5mg methscopolamtab2.5mg methscopolamtab5mg methyclothiatab5mg methyld/hctztab250/ methyld/hctztab250/ methyldopa tab250mg methyldopa tab500mg methyldopateinj250/5ml methylergon tab0.2mg methylphenidcap20mg er methylphenidcap30mg er methylphenidcap40mg er methylphenidtab10mg methylphenidtab20mg methylphenidtab20mg er methylphenidtab5mg methylpr aceinj40mg/ml methylpr aceinj80mg/ml methylpr ss inj125mg methylpr ss inj40mg methylpred pak4mg methylpred tab16mg methylpred tab32mg methylpred tab4mg methylpred tab8mg metipranololsol0.3% oph metoclopram inj5mg/ml metoclopram sol5mg/5ml metoclopram tab10mg metoclopram tab5mg metolazone tab10mg metolazone tab2.5mg metolazone tab5mg metoprl/hctztab100-25mg metoprl/hctztab100-50mg metoprl/hctztab50-25mg metoprol tartab100mg metoprol tartab25mg metoprol tartab50mg metoprolol inj1mg/ml metoprolol tab100mg er metoprolol tab200mg er metoprolol tab25mg er metoprolol tab50mg er METROGEL GEL1% metron/nacl inj500mg metronidazolcre0.75% metronidazolgel0.75% metronidazolgel0.75%vag metronidazolgel1% metronidazollot0.75% metronidazoltab250mg metronidazoltab500mg mexiletine cap150mg mexiletine cap200mg mexiletine cap250mg MIACALCIN INJ200/ML miconazole 3sup200mg microgestin tab1.5/ microgestin tab1/ microgestin tabfe 1/ microgestin tabfe1.5/ midodrine tab10mg midodrine tab2.5mg midodrine tab5mg migergot sup2/ MIGRANAL SPR4MG/ML

203 minocycline cap100mg minocycline cap50mg minocycline cap75mg minocycline tab100mg minocycline tab135mg er minocycline tab45mg er minocycline tab50mg minocycline tab75mg minocycline tab90mg er minoxidil tab10mg minoxidil tab2.5mg mirtazapine tab15mg mirtazapine tab15mg odt mirtazapine tab30mg mirtazapine tab30mg odt mirtazapine tab45mg mirtazapine tab45mg odt mirtazapine tab7.5mg misoprostol tab100mcg misoprostol tab200mcg mitoxantron inj2mg/ml M-M-R II INJLIVE modafinil tab100mg modafinil tab200mg moexipr/hctztab moexipr/hctztab15-25mg moexipr/hctztab moexipril tab15mg moexipril tab7.5mg Molecular Target Inhibitors mometasone cre0.1% mometasone oin0.1% mometasone sol0.1% Monoamine Oxidase B (MAO-B) Inhibitors Monoamine Oxidase Inhibitors Monoclonal Antibodies montelukast chw4mg montelukast chw5mg montelukast gra4mg montelukast tab10mg MONUROL PAKGRANULES Mood Stabilizers morphine sulcap100mg er morphine sulcap10mg er morphine sulcap120mg er morphine sulcap20mg er morphine sulcap30mg er morphine sulcap45mg er morphine sulcap50mg er morphine sulcap60mg er morphine sulcap75mg er morphine sulcap80mg er morphine sulcap90mg er morphine sultab100mg er morphine sultab15mg... 12, 14 morphine sultab15mg er morphine sultab200mg er morphine sultab30mg... 12, 14 morphine sultab30mg er morphine sultab60mg er moxifloxacintab400mg MOZOBIL INJ MULTAQ TAB400MG Multiple Sclerosis Agents mupirocin cre2% mupirocin oin2% MYCOBUTIN CAP150MG mycophenolatcap250mg mycophenolattab500mg mycophenolictab180mg dr mycophenolictab360mg dr MYFORTIC TAB180MG MYFORTIC TAB360MG myorisan cap10mg myorisan cap20mg myorisan cap40mg MYOZYME INJ50MG MYRBETRIQ TAB25MG MYRBETRIQ TAB50MG nabumetone tab500mg nabumetone tab750mg nadolol tab20mg nadolol tab40mg nadolol tab80mg nadolol/bendtab40-5mg nadolol/bendtab80-5mg nafcillin inj10gm nafcillin inj1gm NAFTIN CRE1% NAFTIN GEL1% NAGLAZYME INJ1MG/ML

204 nalbuphine inj10mg/ml nalbuphine inj20mg/ml naloxone inj1mg/ml naltrexone tab50mg NAMENDA SOL10MG/5ML NAMENDA XR CAP14MG NAMENDA XR CAP21MG NAMENDA XR CAP28MG NAMENDA XR CAP7MG NAMENDA XR CAPTITRATIO naphazoline sol0.1% op naproxen sus125/5ml naproxen tab250mg naproxen tab375mg naproxen tab500mg naproxen dr tab375mg naproxen dr tab500mg naproxen sodtab275mg naproxen sodtab550mg naratriptan tab1mg naratriptan tab2.5mg NATACYN SUS5% OP nateglinide tab120mg nateglinide tab60mg NEBUPENT INH300MG necon tab0.5/ necon tab1/ necon tab10/ nefazodone tab100mg nefazodone tab150mg nefazodone tab200mg nefazodone tab250mg nefazodone tab50mg neo/bac/polyoinop neo/poly gu sol40/ml ir neo/poly/bacoin/hc 1%op neo/poly/dexoin0.1% op neo/poly/dexsus0.1% op neo/poly/grasolop neo/poly/hc sol1% otic neo/poly/hc sus1% otic neo/poly/hc susop neomycin tab500mg NEULASTA INJ6MG/0.6M NEUMEGA INJ5MG NEUPOGEN INJ300/ NEUPOGEN INJ480/ NEUPOGEN INJ480MCG NEUPRO DIS1MG/24HR NEUPRO DIS2MG/24HR NEUPRO DIS3MG/24HR NEUPRO DIS4MG/24HR NEUPRO DIS6MG/24HR NEUPRO DIS8MG/24HR NEVANAC SUS0.1% NEVIRAPINE SUS50MG/5ML nevirapine tab200mg nevirapine tab400mg er NEXAVAR TAB200MG NEXIUM I.V. INJ20MG NEXIUM I.V. INJ40MG niacin er tab1000mg niacin er tab500mg niacin er tab750mg niacor tab500mg nicardipine cap20mg nicardipine cap30mg NICOTROL NS SPR10MG/ML nifedical xltab30mg nifedical xltab60mg nifedipine tab30mg er nifedipine tab60mg er nifedipine tab90mg er NILANDRON TAB150MG nimodipine cap30mg nisoldipine tab17mg er nisoldipine tab20mg nisoldipine tab25.5mg nisoldipine tab30mg nisoldipine tab34mg er nisoldipine tab40mg nisoldipine tab8.5mg er NITRO-DUR DIS0.3MG/HR NITRO-DUR DIS0.8MG/HR nitrofur maccap50mg nitrofurantncap100mg nitrofurantnsus25mg/5ml nitroglycer dis0.1mg/hr nitroglycer dis0.2mg/hr nitroglycer dis0.4mg/hr nitroglycer inj5mg/ml nitroglyceridis0.6mg/hr

205 nitroglycrn spr0.4mg NITROSTAT SUB0.3MG NITROSTAT SUB0.4MG NITROSTAT SUB0.6MG nizatidine cap150mg nizatidine cap300mg nizatidine sol15mg/ml N-methyl-D-aspartate (NMDA) Receptor Antagonist Nonsteroidal Anti-Inflammatory Drugs NORDITROPIN INJ15/1.5ML NORDITROPIN INJ5/1.5ML norethin acetab5mg nortrel tab0.5/ nortrel tab1/ nortrel tab7/7/ nortriptylincap10mg nortriptylincap25mg nortriptylincap50mg nortriptylincap75mg nortriptylinsol10mg/5ml NORVIR CAP100MG NORVIR SOL80MG/ML NORVIR TAB100MG NOVOLIN INJ70/ NOVOLIN N INJU NOVOLIN R INJU NOVOLOG INJ100/ML NOVOLOG INJPENFILL NOVOLOG MIX INJ70/ NOVOLOG MIX INJFLEXPEN NOXAFIL SUS40MG/ML NOXAFIL TAB100MG NUEDEXTA CAP20-10MG NULOJIX INJ250MG NUTROPIN AQ INJ10MG/2ML NUVARING MIS nystat/triamcre nystat/triamoin nystatin cre nystatin oin nystatin pow nystatin sus nystatin tab nystop pow octreotide inj1000mcg octreotide inj100mcg octreotide inj200mcg octreotide inj500mcg octreotide inj50mcg/ml ofloxacin dro0.3% op ofloxacin dro0.3%otic ofloxacin tab200mg ofloxacin tab300mg ofloxacin tab400mg ogestrel tab olanza/fluoxcap12-25mg olanza/fluoxcap12-50mg olanza/fluoxcap3-25mg olanza/fluoxcap6-25mg olanza/fluoxcap6-50mg olanzapine inj10mg olanzapine tab10mg olanzapine tab10mg odt olanzapine tab15mg olanzapine tab15mg odt olanzapine tab2.5mg olanzapine tab20mg olanzapine tab20mg odt olanzapine tab5mg olanzapine tab5mg odt olanzapine tab7.5mg OLYSIO CAP150MG omega-3-acidcap1gm omeprazole cap10mg omeprazole cap20mg omeprazole cap40mg ONCASPAR INJ750/ML ondansetron sol4mg/5ml ondansetron tab24mg ondansetron tab4mg ondansetron tab4mg odt ondansetron tab8mg ondansetron tab8mg odt ONFI SUS2.5MG/ML ONFI TAB10MG ONFI TAB20MG ONGLYZA TAB2.5MG ONGLYZA TAB5MG Ophthalmic Agents OPHTHALMIC AGENTS

206 Ophthalmic Agents, Other Ophthalmic Anti-allergy Agents Ophthalmic Antiglaucoma Agents 154 Ophthalmic Anti-inflammatories Ophthalmic Prostaglandins and Prostamide Analogs Opioid Analgesics, Long-Acting Opioid Analgesics, Short-Acting Opioid Dependence Treatments Opioid Reversal Agents ORACEA CAP40MG ORAP TAB1MG ORAP TAB2MG ORENCIA INJ250MG orphenadrineinj30mg/ml ORTHO EVRA DISWEEK OTEZLA TAB10/20/ OTEZLA TAB30MG Otic Agents OTIC AGENTS oxaliplatin inj100mg oxandrolone tab10mg oxandrolone tab2.5mg oxaprozin tab600mg oxcarbazepinsus300mg/5m oxcarbazepintab150mg oxcarbazepintab300mg oxcarbazepintab600mg OXISTAT CRE1% OXISTAT LOT1% OXSORALEN-ULCAP10MG OXTELLAR XR TAB150MG OXTELLAR XR TAB300MG OXTELLAR XR TAB600MG oxybutynin syp5mg/5ml oxybutynin tab10mg er oxybutynin tab15mg er oxybutynin tab5mg oxybutynin tab5mg er oxycod/apap tab10-325mg... 9 oxycod/apap tab oxycod/apap tab5-325mg... 9 oxycod/apap tab oxycod/asa tab... 9 oxycod/ibu tab5-400mg... 9 oxycodone tab10mg oxycodone tab15mg oxycodone tab20mg oxycodone tab30mg oxycodone tab5mg oxymorphone tab10mg er oxymorphone tab15mg er oxymorphone tab20mg er oxymorphone tab30mg er oxymorphone tab40mg er oxymorphone tab5mg er oxymorphone tab7.5mg er oxymorphone tabhcl 10mg oxymorphone tabhcl 5mg OXYTROL DIS3.9MG/ pacerone tab100mg pacerone tab200mg pacerone tab400mg palgic sol4mg/5ml pamidronate inj30/10ml pamidronate inj6mg/ml pamidronate inj90/10ml PANCREAZE CAP10500UNT PANCREAZE CAP16800UNT PANCREAZE CAP21000UNT PANCREAZE CAP4200UNIT PANRETIN GEL0.1% pantoprazoletab20mg pantoprazoletab40mg Parasympathomimetics paricalcitolcap1 mcg paricalcitolcap2 mcg paricalcitolcap4 mcg paromomycin cap250mg paroxetin ertab12.5mg paroxetin ertab37.5mg paroxetine tab10mg paroxetine tab20mg paroxetine tab25mg er paroxetine tab30mg paroxetine tab40mg paser gra4gm PATANOL SOL0.1% OP PAXIL SUS10MG/5ML Pediculicides/Scabicides pedi-dri pow PEDVAX HIB INJ

207 PEGANONE TAB250MG PEGASYS INJ PEGASYS INJ180MCG/M PEGASYS INJPROCLICK PEG-INTRON KIT120 RP PEG-INTRON KIT120MCG PEG-INTRON KIT150 RP PEG-INTRON KIT150MCG PEG-INTRON KIT50MCG PEG-INTRON KIT50MCG RP PEG-INTRON KIT80MCG... 78, 79 PEG-INTRON KIT80MCG RP pen g proc inj pen g sod inj PEN NEEDLES MIS31GX8MM PENICILL GK/INJDEX 2MU PENICILL GK/INJDEX 3MU penicilln gkinj5mu penicilln vksol125/5ml penicilln vksol250/5ml penicilln vktab250mg penicilln vktab500mg PENTAM 300 INJ300MG PENTASA CAP250MG CR PENTASA CAP500MG CR pentoxifyllitab400mg er perindopril tab2mg perindopril tab4mg perindopril tab8mg periogard sol0.12% PERJETA INJ420/14ML permethrin cre5% perphen/amittab2-10mg perphen/amittab2-25mg perphen/amittab4-10mg perphen/amittab4-25mg perphen/amittab4-50mg perphenazinetab16mg perphenazinetab2mg perphenazinetab4mg perphenazinetab8mg phenadoz sup12.5mg phenelzine tab15mg phenobarb elx20mg/5ml PHENOBARB TAB100MG PHENOBARB TAB15MG phenobarb tab16.2mg PHENOBARB TAB30MG phenobarb tab32.4mg PHENOBARB TAB60MG PHENOBARB TAB64.8MG PHENOBARB TAB97.2MG phenytoin chw50mg phenytoin inj50mg/ml phenytoin sus125/5ml phenytoin excap100mg phenytoin excap200mg phenytoin excap300mg PHOSLYRA SOL Phosphate Binders Phosphodiesterase Inhibitors, Airways Disease PHOSPHOLINE SOL0.125%OP pilocarpine tab5mg pilocarpine tab7.5mg pindolol tab10mg pindolol tab5mg pioglit/glimtab30-2mg pioglit/glimtab30-4mg pioglita/mettab15-500mg pioglita/mettab15-850mg pioglitazonetab15mg pioglitazonetab30mg pioglitazonetab45mg piper/tazobainj g piper/tazobainj4-0.5gm piroxicam cap10mg piroxicam cap20mg Platelet Modifying Agents podofilox sol0.5% polyeth glycpow3350 nf polymyxin b/soltrimethp POMALYST CAP1MG POMALYST CAP2MG POMALYST CAP3MG POMALYST CAP4MG portia-28 tab pot chloridecap10meq er pot chloridecap8meq er pot chlorideinj2meq/ml pot citrate tab1080mg pot citrate tab540mg

208 pot cl microtab10meq er pot cl microtab20meq er POTIGA TAB200MG POTIGA TAB300MG POTIGA TAB400MG POTIGA TAB50MG PRADAXA CAP150MG PRADAXA CAP75MG pramipexole tab0.125mg pramipexole tab0.25mg pramipexole tab0.5mg pramipexole tab0.75mg pramipexole tab1.5mg pramipexole tab1mg pravastatin tab10mg pravastatin tab20mg pravastatin tab40mg pravastatin tab80mg prazosin hclcap1mg prazosin hclcap2mg prazosin hclcap5mg PRED MILD SUS0.12% OP pred sod phosol1% op pred sod phosol5mg/5ml PRED-G SUSOP PRED-G S.O.POINOP prednicarbatoin0.1% prednisolonesol15mg/5ml prednisone con5mg/ml prednisone sol5mg/5ml prednisone tab10mg prednisone tab1mg prednisone tab2.5mg prednisone tab20mg prednisone tab50mg prednisone tab5mg PREFEST TAB PREMARIN TAB0.3MG , 132 PREMARIN TAB0.45MG , 132 PREMARIN TAB0.625MG , 132 PREMARIN TAB0.9MG , 132 PREMARIN TAB1.25MG , 132 PREMARIN VAGCRE0.625MG 131, 132 PREMPHASE TAB PREMPRO TAB PREMPRO TAB PREMPRO TAB PREMPRO TAB prevalite pow4gm previfem tab PREZISTA SUS100MG/ML PREZISTA TAB150MG PREZISTA TAB600MG PREZISTA TAB75MG PREZISTA TAB800MG PRIFTIN TAB150MG PRIMAQUINE TAB26.3MG primidone tab250mg primidone tab50mg PRISTIQ TAB100MG PRISTIQ TAB50MG PROAIR HFA AER proben/colchtab probenecid tab500mg procainamideinj100mg/ml prochlorper inj5mg/ml prochlorper sup25mg prochlorper tab10mg prochlorper tab5mg PROCRIT INJ10000/ML PROCRIT INJ2000/ML PROCRIT INJ20000/ML PROCRIT INJ3000/ML PROCRIT INJ4000/ML PROCRIT INJ40000/ML procto-pak cre1% proctozone cre-hc 2.5% Progesterone Agonists/Antagonists progesteronecap100mg progesteronecap200mg Progestins PROGLYCEM SUS50MG/ML PROGRAF INJ5MG/ML PROLEUKIN INJ22MU PROLIA SOL60MG/ML PROMACTA TAB12.5MG PROMACTA TAB25MG PROMACTA TAB50MG PROMACTA TAB75MG promethazineinj25mg/ml promethazineinj50mg/ml

209 promethazinesup12.5mg promethazinesup25mg promethegan sup25mg promethegan sup50mg propafenone tab150mg propafenone tab225mg propafenone tab300mg proparacainesol0.5% op Prophylactic propran/hctztab40/ propran/hctztab80/ propranolol cap120mg er propranolol cap160mg er propranolol cap60mg er propranolol cap80mg er propranolol inj1mg/ml propranolol sol20mg/5ml propranolol sol40mg/5ml propranolol tab10mg propranolol tab20mg propranolol tab40mg propranolol tab60mg propranolol tab80mg propylthiourtab50mg PROQUAD INJ Protectants Proton Pump Inhibitors PROTOPIC OIN0.03% PROTOPIC OIN0.1% protriptylintab10mg protriptylintab5mg PROVENTIL AERHFA PULMICORT INH180MCG PULMICORT INH90MCG Pulmonary Antihypertensives PULMOZYME SOL1MG/ML pyrazinamidetab500mg pyridostigm tab60mg qnapril/hctztab qnapril/hctztab qnapril/hctztab20-25mg quasense tab quetiapine tab100mg quetiapine tab200mg quetiapine tab25mg quetiapine tab300mg quetiapine tab400mg quetiapine tab50mg quinapril tab10mg quinapril tab20mg quinapril tab40mg quinapril tab5mg quinidine gltab324mg cr quinidine sutab200mg quinidine sutab300mg quinidine sutab300mg er quinine sulfcap324mg Quinolones QVAR AER40MCG QVAR AER80MCG RABAVERT INJ rabeprazole tab20mg raloxifene tab60mg ramipril cap1.25mg ramipril cap10mg ramipril cap2.5mg ramipril cap5mg RANEXA TAB1000MG RANEXA TAB500MG ranitidine cap150mg ranitidine cap300mg ranitidine inj150/6ml ranitidine syp15mg/ml ranitidine tab150mg ranitidine tab300mg RAPAMUNE SOL1MG/ML RAPAMUNE TAB0.5MG RAPAMUNE TAB1MG RAPAMUNE TAB2MG REBIF INJ22/ REBIF INJ44/ REBIF TITRTNSOLPACK reclipsen tab RECOMBIVA HBINJ10MCG/ML RECOMBIVA-HBINJ40MCG/ML RELENZA MISDISKHALE RELISTOR KIT12/0.6ML RELPAX TAB20MG RELPAX TAB40MG REMICADE INJ100MG REMODULIN INJ10MG/ML REMODULIN INJ1MG/ML

210 REMODULIN INJ2.5MG/ML REMODULIN INJ5MG/ML repaglinide tab0.5mg repaglinide tab1mg repaglinide tab2mg RESCRIPTOR TAB100 MG RESCRIPTOR TAB200MG RESERPINE TAB0.1MG RESERPINE TAB0.25MG RESPIRATORY TRACT AGENTS Respiratory Tract Agents, Other.. 161, 162 RESTASIS EMU0.05% RETIN-A MICRGEL0.04% RETIN-A MICRGEL0.1% Retinoids RETROVIR INJ10MG/ML REVLIMID CAP10MG REVLIMID CAP15MG REVLIMID CAP2.5MG REVLIMID CAP20MG REVLIMID CAP25MG REVLIMID CAP5MG REYATAZ CAP150MG REYATAZ CAP200MG REYATAZ CAP300MG RHINOCORT SUSAQUA ribasphere cap200mg ribasphere tab200mg ribasphere tab400mg ribasphere tab600mg ribavirin cap200mg ribavirin tab200mg RIDAURA CAP3MG rifabutin cap150mg rifampin cap150mg rifampin cap300mg rifampin inj600 mg RIFATER TAB riluzole tab50mg rimantadine tab100mg RISPERDAL INJ12.5MG RISPERDAL INJ25MG RISPERDAL INJ37.5MG RISPERDAL INJ50MG risperidone sol1mg/ml risperidone tab0.25 odt risperidone tab0.25mg risperidone tab0.5mg risperidone tab0.5mg od risperidone tab1mg risperidone tab1mg odt risperidone tab2mg risperidone tab2mg odt risperidone tab3mg risperidone tab3mg odt risperidone tab4mg risperidone tab4mg odt RITUXAN INJ500MG rivastigminecap1.5mg rivastigminecap3mg rivastigminecap4.5mg rivastigminecap6mg rizatriptan tab10mg rizatriptan tab10mg odt rizatriptan tab5mg rizatriptan tab5mg odt ropinirole tab0.25mg ropinirole tab0.5mg ropinirole tab1mg ropinirole tab2mg ropinirole tab3mg ropinirole tab4mg ropinirole tab5mg ROTARIX SUS ROTATEQ SOL ROZEREM TAB8MG SABRIL POW500MG SABRIL TAB500MG SAIZEN INJ5MG SAIZEN INJ8.8MG SANDIMMUNE SOL100MG/ML SANDOSTATIN KITLAR 10MG SANDOSTATIN KITLAR 20MG SANDOSTATIN KITLAR 30MG SANTYL OIN250/GM SAPHRIS SUB10MG SAPHRIS SUB5MG SAVELLA MISTITR PAK SAVELLA TAB100MG SAVELLA TAB12.5MG SAVELLA TAB25MG

211 SAVELLA TAB50MG Selective Estrogen Receptor Modifying Agents selegiline cap5mg selegiline tab5mg selenium sullot2.5% SELZENTRY TAB150MG SELZENTRY TAB300MG SENSIPAR TAB30MG SENSIPAR TAB60MG SENSIPAR TAB90MG SEREVENT DISAER50MCG SEROQUEL XR TAB150MG SEROQUEL XR TAB200MG SEROQUEL XR TAB300MG SEROQUEL XR TAB400MG SEROQUEL XR TAB50MG SEROSTIM INJ4MG SEROSTIM INJ5MG SEROSTIM INJ6MG Serotonin (5-HT) 1b/1d Receptor Agonists sertraline con20mg/ml sertraline tab100mg sertraline tab25mg sertraline tab50mg sildenafil tab20mg silver sulfacre1% SIMCOR TAB SIMCOR TAB SIMCOR TAB500-20MG SIMCOR TAB500-40MG SIMCOR TAB750-20MG SIMULECT INJ20MG simvastatin tab10mg simvastatin tab20mg simvastatin tab40mg simvastatin tab5mg simvastatin tab80mg sirolimus tab0.5mg SIRTURO TAB100MG Skeletal Muscle Relaxants SKELETAL MUSCLE RELAXANTS 162 SLEEP DISORDER AGENTS Sleep Disorders, Other Smoking Cessation Agents smz/tmp ds tab smz-tmp inj400-80/ smz-tmp sus200-40/ smz-tmp tab400-80mg sod chlorideinj0.45% sod chlorideinj0.9% sod chlorideinj2.5/ml sod chlorideinj3% sod chlorideinj5% sod poly sulsus15gm/ sod sulfacetsol10% op Sodium Channel Inhibitors sodium chlorsol0.9% irr SOLTAMOX SOL10MG/5ML SOMATULINE INJ120/.5ML SOMATULINE INJ60/0.2ML SOMATULINE INJ90/0.3ML SOMAVERT INJ10MG SOMAVERT INJ15MG SOMAVERT INJ20MG sorine tab120mg sorine tab160mg sorine tab240mg sorine tab80mg sotalol af tab120mg sotalol hcl tab160mg sotalol hcl tab240mg sotalol hcl tab80mg SOVALDI TAB400MG SPIRIVA CAPHANDIHLR spirono/hctztab25/ spironolact tab100mg spironolact tab25mg spironolact tab50mg sprintec 28 tab28 day SPRYCEL TAB100MG SPRYCEL TAB140MG SPRYCEL TAB20MG SPRYCEL TAB50MG SPRYCEL TAB70MG SPRYCEL TAB80MG sronyx tab ssd cre1% SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin 210

212 Norepinephrine Reuptake Inhibitors) stavudine cap15mg stavudine cap20mg stavudine cap30mg stavudine cap40mg stavudine sol1mg/ml STIMATE SOL1.5MG/ML STIVARGA TAB40MG STRATTERA CAP100MG STRATTERA CAP10MG STRATTERA CAP18MG STRATTERA CAP25MG STRATTERA CAP40MG STRATTERA CAP60MG STRATTERA CAP80MG streptomycininj1gm STRIBILD TAB STROMECTOL TAB3MG SUBOXONE MIS12-3MG SUBOXONE MIS2-0.5MG SUBOXONE MIS4-1MG SUBOXONE MIS8-2MG sucralfate tab1gm sulf/pred nasolop sulfacet sodoin10% op sulfacetamidsus10% sulfadiazinetab500mg SULFAMYLON CRE85MG/GM sulfasalazintab500mg sulfazine ectab500mg Sulfonamides... 36, 150 sulindac tab150mg sulindac tab200mg sumatriptan inj6mg/ sumatriptan tab100mg sumatriptan tab25mg sumatriptan tab50mg SUPRAX SUS100/5ML SUPRAX SUS200/5ML SUPRAX SUS500/5ML SUPRAX TAB400MG SURMONTIL CAP100MG SURMONTIL CAP25MG SURMONTIL CAP50MG SUSTIVA CAP200MG SUSTIVA CAP50MG SUSTIVA TAB600MG SUTENT CAP12.5MG SUTENT CAP25MG SUTENT CAP50MG SYLATRON KIT296MCG SYLATRON KIT444MCG SYLATRON KIT888MCG SYMBICORT AER SYMBICORT AER SYMLINPEN 60INJ1000MCG SYMLNPEN 120INJ1000MCG SYNAGIS INJ50MG SYNAREL SOL2MG/ML SYNERCID INJ500MG SYNRIBO INJ3.5MG SYNTHROID TAB100MCG SYNTHROID TAB112MCG SYNTHROID TAB125MCG SYNTHROID TAB137MCG SYNTHROID TAB150MCG SYNTHROID TAB175MCG SYNTHROID TAB200MCG SYNTHROID TAB25MCG SYNTHROID TAB300MCG SYNTHROID TAB50MCG SYNTHROID TAB75MCG SYNTHROID TAB88MCG SYPRINE CAP250MG TABLOID TAB40MG tacrolimus cap0.5mg tacrolimus cap1mg tacrolimus cap5mg TAFINLAR CAP50MG TAFINLAR CAP75MG TAMIFLU CAP30MG TAMIFLU CAP45MG TAMIFLU CAP75MG TAMIFLU SUS6MG/ML tamoxifen tab10mg tamoxifen tab20mg tamsulosin cap0.4mg TARCEVA TAB100MG TARCEVA TAB150MG TARCEVA TAB25MG TARGRETIN CAP75MG

213 TARGRETIN GEL1% TASIGNA CAP150MG TASIGNA CAP200MG TASMAR TAB100MG TAZORAC CRE0.05% TAZORAC CRE0.1% TAZORAC GEL0.05% TAZORAC GEL0.1% taztia xt cap120mg/ taztia xt cap180mg/ taztia xt cap240mg/ taztia xt cap300mg/ taztia xt cap360mg/ TEFLARO INJ400MG TEFLARO INJ600MG TEKAMLO TAB150-10MG TEKAMLO TAB150-5MG TEKAMLO TAB300-10MG TEKAMLO TAB300-5MG TEKTURNA TAB150MG TEKTURNA TAB300MG TEKTURNA HCTTAB TEKTURNA HCTTAB150-25MG TEKTURNA HCTTAB TEKTURNA HCTTAB300-25MG telmis/amlodtab40-10mg telmis/amlodtab40-5mg telmis/amlodtab80-10mg telmis/amlodtab80-5mg telmisartan tab20mg telmisartan tab40mg telmisartan tab80mg terazosin cap10mg terazosin cap1mg terazosin cap2mg terazosin cap5mg terbinafine tab250mg terbutaline inj1mg/ml terbutaline tab2.5mg terbutaline tab5mg terconazole cre0.4% terconazole cre0.8% terconazole sup80mg TESTIM GEL1%(50MG) testost enaninj200mg/ml TET/DIP TOX INJ2-2 LF TETANUS TOX INJ5LF ADS Tetracyclines THALOMID CAP100MG THALOMID CAP150MG THALOMID CAP200MG THALOMID CAP50MG theophyllinetab100mg cr theophyllinetab200mg cr theophyllinetab300mg er theophyllinetab400mg er theophyllinetab450mg er theophyllinetab600mg er Therapeutic Nutrients/ Minerals/ Electrolytes THERAPEUTIC NUTRIENTS/MINERALS/ELECTROL YTES thioridazinetab100mg thioridazinetab10mg thioridazinetab25mg thioridazinetab50mg thiothixene cap10mg thiothixene cap1mg thiothixene cap2mg thiothixene cap5mg THYMOGLOBULNINJ25MG tiagabine tab2mg tiagabine tab4mg ticlopidine tab250mg TIKOSYN CAP125MCG TIKOSYN CAP250MCG TIKOSYN CAP500MCG timolol gel sol0.25% op timolol gel sol0.5% op timolol mal sol0.25% op timolol mal sol0.5% op timolol mal tab10mg timolol mal tab20mg timolol mal tab5mg tinidazole tab250mg tinidazole tab500mg TIVICAY TAB50MG tizanidine tab2mg tizanidine tab4mg TOBI NEB300/5ML TOBI PODHALRCAP28MG

214 tobra/dexamesus % TOBRADEX OIN % tobramycin inj10mg/ml tobramycin inj80mg/2ml tobramycin neb300/5ml tobramycin sol0.3% op tolazamide tab250mg tolazamide tab500mg tolbutamide tab500mg tolmetin sodcap400mg tolmetin sodtab600mg tolterodine tab1mg tolterodine tab2mg topicort cre0.05% topiramate cap15mg topiramate cap25mg topiramate tab100mg topiramate tab200mg topiramate tab25mg topiramate tab50mg toposar inj1gm/50ml topotecan inj4mg torsemide tab100mg torsemide tab10mg torsemide tab20mg torsemide tab5mg TPN ELECTROLINJ TRACLEER TAB125MG TRACLEER TAB62.5MG tramadl/apaptab tramadol hcltab50mg trandolapriltab1mg trandolapriltab2mg trandolapriltab4mg tranex acid tab650mg TRANSDERM-SCDIS1.5MG TRAVATAN Z DRO0.004% travoprost dro0.004% trazodone tab100mg trazodone tab150mg trazodone tab300mg trazodone tab50mg TREANDA INJ100MG Treatment Resistent TRECATOR TAB250MG TRELSTAR DEPINJ3.75MG TRELSTAR LA INJ11.25MG tretinoin cap10mg tretinoin cre0.025% tretinoin cre0.05% tretinoin cre0.1% tretinoin gel0.01% tretinoin gel0.025% triamcin/orapst0.1% triamcinoloncre0.025% triamcinoloncre0.1% triamcinoloncre0.5% triamcinolonlot0.025% triamcinolonlot0.1% triamcinolonoin0.025% triamcinolonoin0.1% triamcinolonoin0.5% triamcinolonspr55mcg/ac triamt/hctz cap triamt/hctz tab triamt/hctz tab75-50mg Tricyclics triderm cre0.1% trifluoperaztab10mg trifluoperaztab1mg trifluoperaztab2mg trifluoperaztab5mg trifluridinesol1% op trihexyphen elx0.4mg/ml trihexyphen tab2mg trihexyphen tab5mg tri-legest tabfe trilyte sol trimethoprimtab100mg tri-previfemtab TRISENOX SOL10MG/10M tri-sprintectab trivora-28 tab TRIZIVIR TAB TROKENDI XR CAP100MG TROKENDI XR CAP200MG TROKENDI XR CAP25MG TROKENDI XR CAP50MG TROPHAMINE INJ10% trospium chlcap60mg er TRUVADA TAB TWINRIX INJ

215 TYGACIL INJ50MG TYKERB TAB250MG TYPHIM VI INJ TYSABRI INJ300/15ML TYZEKA TAB600MG tyzine ped dro0.05% u-cort cre1% UNITHROID TAB100MCG UNITHROID TAB112MCG UNITHROID TAB125MCG UNITHROID TAB150MCG UNITHROID TAB175MCG UNITHROID TAB200MCG UNITHROID TAB25MCG UNITHROID TAB300MCG UNITHROID TAB50MCG UNITHROID TAB75MCG UNITHROID TAB88MCG ursodiol cap300mg ursodiol tab250mg ursodiol tab500mg Vaccines VAGIFEM TAB10MCG , 132 valacyclovirtab1gm valacyclovirtab500mg VALCYTE SOL50MG/ML VALCYTE TAB450MG valproate inj100mg/ml valproic acdcap250mg valproic acdsyp250/5ml valsart/hctztab valsart/hctztab160-25mg valsart/hctztab valsart/hctztab320-25mg valsart/hctztab vancomycin cap125mg vancomycin cap250mg vancomycin inj1000mg vancomycin inj10gm vancomycin inj500mg VAQTA INJ25/0.5ML VARIVAX INJ Vasodilators, Direct-acting Arterial Vasodilators, Direct-acting Arterial/Venous VELCADE INJ3.5MG velivet pak venlafaxine cap150mg er venlafaxine cap37.5mg venlafaxine cap75mg er venlafaxine tab100mg venlafaxine tab150mg er VENLAFAXINE TAB225MG ER venlafaxine tab25mg venlafaxine tab37.5 er venlafaxine tab37.5mg venlafaxine tab50mg venlafaxine tab75mg venlafaxine tab75mg er VENTOLIN HFAAER VERAMYST SPR27.5MCG verapamil cap100mg er verapamil cap120mg er verapamil cap180mg er verapamil cap200mg er verapamil cap240mg er verapamil cap300mg er verapamil cap360mg sr verapamil inj2.5mg/ml verapamil tab120mg verapamil tab120mg er verapamil tab180mg er verapamil tab240mg er verapamil tab40mg verapamil tab80mg VERSACLOZ SUS50MG/ML VESICARE TAB10MG VESICARE TAB5MG vestura tab3-0.02mg VEXOL SUS1% OP VIAGRA TAB 100MG VIAGRA TAB 25MG VIAGRA TAB 50MG vicodin tab5-300mg... 9 vicodin es tab vicodin hp tab10-300mg... 9 VICTOZA INJ18MG/3ML VIDEX SOL2GM VIGAMOX DRO0.5% VIIBRYD KIT VIIBRYD TAB10MG

216 VIIBRYD TAB20MG VIIBRYD TAB40MG VIMOVO TAB375-20MG VIMOVO TAB500-20MG VIMPAT INJ200MG/ VIMPAT SOL10MG/ML VIMPAT TAB100MG VIMPAT TAB150MG VIMPAT TAB200MG VIMPAT TAB50MG VIRACEPT TAB250MG VIRACEPT TAB625MG VIRAMUNE SUS50MG/5ML VIRAMUNE XR TAB100MG VIRAMUNE XR TAB400MG VIRAZOLE INH6GM VIREAD POW40MG/GM VIREAD TAB150MG VIREAD TAB200MG VIREAD TAB250MG VIREAD TAB300MG voriconazoleinj200mg voriconazolesus40mg/ml voriconazoletab200mg voriconazoletab50mg vospire er tab4mg vospire er tab8mg VOTRIENT TAB200MG VYTORIN TAB10-10MG VYTORIN TAB10-20MG VYTORIN TAB10-40MG VYTORIN TAB10-80MG warfarin tab10mg warfarin tab1mg warfarin tab2.5mg warfarin tab2mg warfarin tab3mg warfarin tab4mg warfarin tab5mg warfarin tab6mg warfarin tab7.5mg WELCHOL TAB625MG XALKORI CAP200MG XALKORI CAP250MG XARELTO TAB10MG XARELTO TAB15MG XARELTO TAB20MG XENAZINE TAB12.5MG XENAZINE TAB25MG XGEVA INJ xodol tab10-300mg xodol tab5-300mg xodol tab XOLAIR SOL150MG XOPENEX HFA AER XTANDI CAP40MG xulane dis XYREM SOL500MG/ML YERVOY INJ50MG YF-VAX INJ zafirlukast tab10mg zafirlukast tab20mg zaleplon cap10mg zaleplon cap5mg ZALTRAP INJ100/4ML ZANOSAR INJ1GM ZAVESCA CAP100MG zazole cre0.4% ZELBORAF TAB240MG ZEMAIRA INJ1000MG ZEMPLAR INJ2MCG/ML ZEMPLAR INJ5MCG/ML zenatane cap10mg zenatane cap20mg zenatane cap40mg ZENPEP CAP10000UNT ZENPEP CAP15000UNT ZENPEP CAP20000UNT ZENPEP CAP25000UNT ZENPEP CAP3000UNIT ZENPEP CAP5000UNIT zenzedi tab10mg zenzedi tab5mg ZETIA TAB10MG ZIAGEN SOL20MG/ML zidovudine cap100mg zidovudine syp50mg/5ml zidovudine tab300mg ziprasidone cap20mg ziprasidone cap40mg ziprasidone cap60mg ziprasidone cap80mg

217 ZOFRAN INJ40/20ML zoledronic inj4mg/5ml zoledronic inj5/100ml ZOLINZA CAP100MG zolmitriptantab2.5 mg zolmitriptantab2.5mg zolmitriptantab5mg zolpidem tab10mg zolpidem tab5mg zonisamide cap100mg zonisamide cap25mg zonisamide cap50mg ZORBTIVE INJ8.8MG ZORTRESS TAB0.25MG ZORTRESS TAB0.5MG ZORTRESS TAB0.75MG ZOSTAVAX INJ ZOSYN SOL2-0.25GM ZOSYN SOL G zovia 1/35e tab zovia 1/50e tab ZOVIRAX CRE5% ZYFLO CR TAB600MG ZYKADIA CAP150MG ZYTIGA TAB250MG ZYVOX SOL2MG/ML ZYVOX SUS100MG/5M ZYVOX TAB600MG This formulary was updated on 07/01/2014. For more recent information or other questions, please contact HNE Medicare Advantage pharmacy benefit manager (PBM), National Pharmaceutical Services (NPS) at or, for TTY users, , 24 hours a day, seven days a week, or visit 216

218 This formulary was updated 07/01/2014. For more recent information or other questions, please contact the HNE Medicare Advantage pharmacy benefit manager (PBM), National Pharmaceutical Services (NPS), at or, for TTY users, , 24 hours a day, seven days a week, or visit hne.com/medicare. One Monarch Place Suite 1500 Springfield, MA TTY/TDD hne.com/medicare H8578_2015_046R Accepted