Formulary ID: 15074, Version 34 H3653_S5588_2015_CompForm_REV

Transcription

1 This formulary was updated on 11/01/2015. For more recent information or other questions, please contact Paramount Elite/Paramount Prescription Plan Member Services at or, for TTY users, , 8:00 a.m. to 8:00 p.m., Monday through Friday. From October 1 through February 14, we are available 8:00 a.m. to 8:00 p.m. seven days per week, or visit Formulary ID: 15074, Version 34 H3653_S5588_2015_CompForm_REV

2 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 Paramount Care, Inc. / Paramount Insurance Co. When it refers to plan or our plan, it means Paramount Elite (HMO) / Paramount Prescription (Employer PDP) Plan. This document includes a list of the drugs (formulary) for our plan which is current as of November 1, 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. What is the Paramount Elite / Paramount Prescription Plan Formulary? A formulary is a list of covered drugs selected by our plan 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. Our plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a plan 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 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 November 1, To get updated information about the drugs covered by our plan, please contact us. Our contact information appears on the front and back cover pages. If our plan makes any Medicare approved nonmaintenance formulary drug changes to this printed formulary during 2015, our plan will mail members notification of the formulary change via the Medicare Part D Explanation of Benefits or via errata sheets. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 6. 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. If you know what your drug is used for, look for the category name in the list that begins on page number 6. Then look under the category name for your drug. 1

3 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 99. 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? Our plan 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: Our plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from our plan before you fill your prescriptions. If you don t get approval, our plan may not cover the drug. Quantity Limits: For certain drugs, our plan limits the amount of the drug that our plan will cover. For example, our plan provides nine 25mg tablets per prescription (30 day supply) for sumatriptan. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, our plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, our plan may not cover B unless you try A first. If A does not work for you, our plan will then cover B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 6. 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 our plan to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the Paramount Elite / Paramount Prescription Plan s formulary? on page 3 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 Member Services and ask if your drug is covered. If you learn that our plan does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by our plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by our plan. You can ask our plan to make an exception and cover your drug. See below for information about how to request an exception. 2

4 How do I request an exception to the Paramount Elite / Paramount Prescription Plan s Formulary? You can ask our plan 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 costsharing 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, our plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, our plan 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 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 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 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 93-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a 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 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. As part of our transition of care policy, we may approve an early refill or, if necessary, up to a 30- or 31-day (31 days for long-term care) temporary emergency supply. 3

5 For more information For more detailed information about your plan s prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Paramount Elite / Paramount Prescription Plan, 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 Paramount Elite / Paramount Prescription Plan s Formulary The formulary below provides coverage information about the drugs covered by our plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 98. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., CRESTOR) and generic drugs are listed in lower-case italics (e.g., citalopram). The information in the Requirements/Limits column tells you if our plan has any special requirements for coverage of your drug. o Prior Authorization (PA): Our plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from our plan before you fill your prescriptions. If you don t get approval, our plan may not cover the drug. o Step Therapy (ST): In some cases, our plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, our plan may not cover B unless you try A first. If A does not work for you, our plan will then cover B. o Quantity Limits (QL): For certain drugs, our plan limits the amount of the drug that our plan will cover. For example, our plan provides nine 25 mg tablets per prescription (30 day supply) for sumatriptan. o B/D: This prescription drug has a Part B versus D administrative prior authorization requirement. 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 the drug to make the determination. o Limited Availability (LA): This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at ; 8:00 a.m. to 8:00 p.m., Monday through Friday. From October 1 to February 14 we are available 8:00 a.m. to 8:00 p.m. seven days per week. TTY users should call o Maintenance /Mail-Order Eligible (MO): We provide an extended day supply (90-day) of drugs that you take on a regular basis for a chronic or long-term medical condition. Medications must be noted with MO under Requirements/Limits to be eligible for an extended days supply. 4

6 Cost-Sharing Tier Tier Name Paramount Elite Enhanced Medical & Formulary Tier Reference Table 30/90 Day Standard Retail Network Pharmacy 90-Day Standard Mail-Order Pharmacy 1 Preferred Generic $2 / $6 $4 2 Non-Preferred Generic $8 / $24 $16 3 Preferred Brand $40 / $120 $80 4 Injectable s 33% (30-day supply only) Not offered 5 Specialty Tier 33% (30-day supply only) Not offered Cost Sharing Tier Tier Name Paramount Standard Medical & Formulary Tier Reference Table 30/90 Day Standard Retail Network Pharmacy 90-Day Standard Mail-Order Pharmacy 1 Preferred Generic $5 / $15 $10 2 Non-Preferred Generic $15 / $45 $30 3 Preferred Brand** $40 / $120 $80 4 Injectable s 33% (30-day supply only) Not offered 5 Specialty Tier 33% (30-day supply only) Not offered ** Note: Cost-sharing (copay) for Tier 3 Preferred Brand drugs begins after you have paid $100 deductible. 5

7 Name ANALGESICS ANALGESICS nalbuphine hcl injection 10mg/ml 4 nalbuphine hcl injection 20mg/ml 4 tramadol hcl er capsule extended release 24 hour 100mg 2 tramadol hcl er capsule extended release 24 hour 200mg 2 tramadol hcl er capsule extended release 24 hour 300mg 2 tramadol hcl er tablet extended release 24 hour 100mg 2 QL (30 EA per 30 days) tramadol hcl er tablet extended release 24 hour 200mg 2 QL (30 EA per 30 days) tramadol hcl er tablet extended release 24 hour 300mg 2 QL (30 EA per 30 days) tramadol hcl tablet 50mg 2 QL (240 EA per 30 days) tramadol hydrochloride/acetaminophen tablet 325mg; 37.5mg 2 QL (240 EA per 30 days) CLASS II NARCOTICS codeine sulfate tablet 15mg 2 codeine sulfate tablet 30mg 2 codeine sulfate tablet 60mg 2 duramorph injection 0.5mg/ml 4 B/D duramorph injection 1mg/ml 4 B/D endocet tablet 325mg; 10mg 2 QL (360 EA per 30 days) endocet tablet 325mg; 5mg 2 QL (360 EA per 30 days) endocet tablet 325mg; 7.5mg 2 QL (360 EA per 30 days) endodan tablet 325mg; 4.835mg 2 fentanyl citrate oral transmucosal lozenge on a handle 5 QL (120 EA per 30 days) PA 1200mcg fentanyl citrate oral transmucosal lozenge on a handle 1600mcg 5 QL (120 EA per 30 days) PA fentanyl citrate oral transmucosal lozenge on a handle 200mcg5 QL (120 EA per 30 days) PA fentanyl citrate oral transmucosal lozenge on a handle 400mcg5 QL (120 EA per 30 days) PA fentanyl citrate oral transmucosal lozenge on a handle 600mcg5 QL (120 EA per 30 days) PA fentanyl citrate oral transmucosal lozenge on a handle 800mcg5 QL (120 EA per 30 days) PA fentanyl patch 72 hour 100mcg/hr 2 QL (10 EA per 30 days) fentanyl patch 72 hour 12mcg/hr 2 QL (10 EA per 30 days) fentanyl patch 72 hour 25mcg/hr 2 QL (10 EA per 30 days) fentanyl patch 72 hour 37.5mcg/hr 2 QL (10 EA per 30 days) fentanyl patch 72 hour 50mcg/hr 2 QL (10 EA per 30 days) fentanyl patch 72 hour 62.5mcg/hr 2 QL (10 EA per 30 days) fentanyl patch 72 hour 75mcg/hr 2 QL (10 EA per 30 days) fentanyl patch 72 hour 87.5mcg/hr 2 QL (10 EA per 30 days) FENTORA TABLET 100MCG 5 QL (120 EA per 30 days) PA FENTORA TABLET 200MCG 5 QL (120 EA per 30 days) PA FENTORA TABLET 400MCG 5 QL (120 EA per 30 days) PA FENTORA TABLET 600MCG 5 QL (86 EA per 30 days) PA FENTORA TABLET 800MCG 5 QL (64 EA per 30 days) PA hydrocodone bitartrate/acetaminophen solution 325mg/15ml; 2 7.5mg/15ml hydrocodone bitartrate/acetaminophen tablet 325mg; 2.5mg 2 hydromorphone hcl er tablet er 24 hour abuse-deterrent 12mg 2 hydromorphone hcl er tablet er 24 hour abuse-deterrent 16mg 2 hydromorphone hcl er tablet er 24 hour abuse-deterrent 32mg 2 6

8 Name hydromorphone hcl er tablet er 24 hour abuse-deterrent 8mg 2 hydromorphone hcl injection 500mg/50ml 4 B/D hydromorphone hcl liquid 1mg/ml 2 hydromorphone hcl tablet 2mg 2 QL (270 EA per 30 days) hydromorphone hcl tablet 4mg 2 QL (270 EA per 30 days) hydromorphone hcl tablet 8mg 2 QL (270 EA per 30 days) LAZANDA SOLUTION 100MCG/ACT 3 PA LAZANDA SOLUTION 400MCG/ACT 3 PA levorphanol tartrate tablet 2mg 2 METHADONE HCL INJECTION 10MG/ML 4 methadone hcl solution 10mg/5ml 2 QL (600 ML per 30 days) methadone hcl solution 5mg/5ml 2 QL (600 ML per 30 days) methadone hcl tablet 10mg 2 QL (240 EA per 30 days) methadone hcl tablet 5mg 2 QL (240 EA per 30 days) morphine sulfate er capsule extended release 24 hour 100mg 2 QL (60 EA per 30 days) morphine sulfate er capsule extended release 24 hour 10mg 2 QL (60 EA per 30 days) morphine sulfate er capsule extended release 24 hour 120mg 2 QL (60 EA per 30 days) morphine sulfate er capsule extended release 24 hour 20mg 2 QL (60 EA per 30 days) morphine sulfate er capsule extended release 24 hour 30mg 2 QL (60 EA per 30 days) morphine sulfate er capsule extended release 24 hour 30mg 2 QL (60 EA per 30 days) morphine sulfate er capsule extended release 24 hour 45mg 2 QL (60 EA per 30 days) morphine sulfate er capsule extended release 24 hour 50mg 2 QL (60 EA per 30 days) morphine sulfate er capsule extended release 24 hour 60mg 2 QL (60 EA per 30 days) morphine sulfate er capsule extended release 24 hour 60mg 2 QL (60 EA per 30 days) morphine sulfate er capsule extended release 24 hour 75mg 2 QL (60 EA per 30 days) morphine sulfate er capsule extended release 24 hour 80mg 2 QL (60 EA per 30 days) morphine sulfate er capsule extended release 24 hour 90mg 2 QL (60 EA per 30 days) morphine sulfate er tablet extended release 100mg 2 QL (90 EA per 30 days) morphine sulfate er tablet extended release 15mg 2 QL (90 EA per 30 days) morphine sulfate er tablet extended release 200mg 2 QL (60 EA per 30 days) morphine sulfate er tablet extended release 30mg 2 QL (90 EA per 30 days) morphine sulfate er tablet extended release 60mg 2 QL (90 EA per 30 days) morphine sulfate injection 10mg/ml 4 morphine sulfate injection 2mg/ml 4 morphine sulfate injection 4mg/ml 4 morphine sulfate injection 8mg/ml 4 morphine sulfate solution 100mg/5ml 2 morphine sulfate solution 10mg/5ml 2 morphine sulfate solution 20mg/5ml 2 morphine sulfate tablet 15mg 2 QL (180 EA per 30 days) morphine sulfate tablet 30mg 2 QL (180 EA per 30 days) NUCYNTA TABLET 100MG 3 QL (181 EA per 30 days) NUCYNTA TABLET 50MG 3 QL (181 EA per 30 days) NUCYNTA TABLET 75MG 3 QL (181 EA per 30 days) OPANA ER (CRUSH RESISTANT) TABLET ER 12 HOUR 3 QL (90 EA per 30 days) ST ABUSE-DETERRENT 10MG OPANA ER (CRUSH RESISTANT) TABLET ER 12 HOUR 3 QL (90 EA per 30 days) ST ABUSE-DETERRENT 15MG 7

9 Name OPANA ER (CRUSH RESISTANT) TABLET ER 12 HOUR 3 QL (90 EA per 30 days) ST ABUSE-DETERRENT 20MG OPANA ER (CRUSH RESISTANT) TABLET ER 12 HOUR 3 QL (90 EA per 30 days) ST ABUSE-DETERRENT 30MG OPANA ER (CRUSH RESISTANT) TABLET ER 12 HOUR 3 QL (90 EA per 30 days) ST ABUSE-DETERRENT 40MG OPANA ER (CRUSH RESISTANT) TABLET ER 12 HOUR 3 QL (90 EA per 30 days) ST ABUSE-DETERRENT 5MG OPANA ER (CRUSH RESISTANT) TABLET ER 12 HOUR 3 QL (90 EA per 30 days) ST ABUSE-DETERRENT 7.5MG oxycodone hcl er tablet er 12 hour abuse-deterrent 10mg 2 oxycodone hcl er tablet er 12 hour abuse-deterrent 20mg 2 oxycodone hcl er tablet er 12 hour abuse-deterrent 40mg 2 oxycodone hcl er tablet er 12 hour abuse-deterrent 80mg 2 oxycodone hcl capsule 5mg 2 QL (180 EA per 30 days) oxycodone hcl concentrate 100mg/5ml 2 oxycodone hcl solution 5mg/5ml 2 QL (1200 ML per 30 days) oxycodone hcl tablet 10mg 2 QL (180 EA per 30 days) oxycodone hcl tablet 15mg 2 QL (180 EA per 30 days) oxycodone hcl tablet 20mg 2 QL (180 EA per 30 days) oxycodone hcl tablet 30mg 2 QL (180 EA per 30 days) oxycodone hcl tablet 5mg 2 QL (180 EA per 30 days) oxycodone/acetaminophen tablet 325mg; 10mg 2 QL (360 EA per 30 days) oxycodone/acetaminophen tablet 325mg; 2.5mg 2 QL (360 EA per 30 days) oxycodone/acetaminophen tablet 325mg; 5mg 2 QL (360 EA per 30 days) oxycodone/acetaminophen tablet 325mg; 7.5mg 2 QL (360 EA per 30 days) oxycodone/ibuprofen tablet 400mg; 5mg 2 OXYCONTIN TABLET ER 12 HOUR 3 QL (90 EA per 30 days) ST ABUSE-DETERRENT 10MG OXYCONTIN TABLET ER 12 HOUR 3 QL (90 EA per 30 days) ST ABUSE-DETERRENT 15MG OXYCONTIN TABLET ER 12 HOUR 3 QL (90 EA per 30 days) ST ABUSE-DETERRENT 20MG OXYCONTIN TABLET ER 12 HOUR 3 QL (90 EA per 30 days) ST ABUSE-DETERRENT 30MG OXYCONTIN TABLET ER 12 HOUR 3 QL (90 EA per 30 days) ST ABUSE-DETERRENT 40MG OXYCONTIN TABLET ER 12 HOUR 3 QL (90 EA per 30 days) ST ABUSE-DETERRENT 60MG OXYCONTIN TABLET ER 12 HOUR ABUSE-DETERRENT 80MG 3 QL (90 EA per 30 days) ST oxymorphone hydrochloride er tablet extended release 12 hour 2 QL (90 EA per 30 days) 10mg oxymorphone hydrochloride er tablet extended release 12 hour 2 QL (90 EA per 30 days) 15mg oxymorphone hydrochloride er tablet extended release 12 hour 2 QL (90 EA per 30 days) 20mg oxymorphone hydrochloride er tablet extended release 12 hour 2 QL (90 EA per 30 days) 30mg 8

10 Name oxymorphone hydrochloride er tablet extended release 12 hour 2 QL (90 EA per 30 days) 40mg oxymorphone hydrochloride er tablet extended release 12 hour 2 QL (90 EA per 30 days) 5mg oxymorphone hydrochloride er tablet extended release 12 hour 2 QL (90 EA per 30 days) 7.5mg oxymorphone hydrochloride tablet 10mg 2 oxymorphone hydrochloride tablet 5mg 2 CLASS III NARCOTICS acetaminophen/codeine #3 tablet 300mg; 30mg 2 acetaminophen/codeine solution 120mg/5ml; 12mg/5ml 2 QL (5000 ML per 30 days) acetaminophen/codeine tablet 300mg; 15mg 2 QL (400 EA per 30 days) acetaminophen/codeine tablet 300mg; 60mg 2 QL (400 EA per 30 days) buprenorphine hcl/naloxone hcl tablet sublingual 2mg; 0.5mg 2 QL (120 EA per 30 days) PA buprenorphine hcl/naloxone hcl tablet sublingual 8mg; 2mg 2 QL (120 EA per 30 days) PA buprenorphine hcl injection 0.3mg/ml 4 buprenorphine hcl tablet sublingual 2mg 2 PA buprenorphine hcl tablet sublingual 8mg 2 PA CAPITAL/CODEINE SUSPENSION 120MG/5ML; 3 12MG/5ML hydrocodone bitartrate/acetaminophen tablet 300mg; 10mg 2 hydrocodone bitartrate/acetaminophen tablet 300mg; 5mg 2 hydrocodone bitartrate/acetaminophen tablet 300mg; 7.5mg 2 hydrocodone/acetaminophen tablet 325mg; 10mg 2 QL (360 EA per 30 days) hydrocodone/acetaminophen tablet 325mg; 5mg 2 QL (360 EA per 30 days) hydrocodone/acetaminophen tablet 325mg; 7.5mg 2 QL (360 EA per 30 days) hydrocodone/ibuprofen tablet 7.5mg; 200mg 2 QL (150 EA per 30 days) SYNALGOS-DC CAPSULE 356.4MG; 30MG; 16MG 3 CLASS IV NARCOTICS butorphanol tartrate injection 1mg/ml 4 butorphanol tartrate injection 2mg/ml 4 butorphanol tartrate solution 10mg/ml 2 QL (5 ML per 3 days) pentazocine/naloxone hcl tablet 0.5mg; 50mg 2 TALWIN INJECTION 30MG/ML 4 NON-STEROIDAL ANTIINFLAMMATORY DRUGS CELEBREX CAPSULE 100MG 3 QL (60 EA per 30 days) MO CELEBREX CAPSULE 200MG 3 QL (60 EA per 30 days) MO CELEBREX CAPSULE 400MG 3 QL (60 EA per 30 days) MO CELEBREX CAPSULE 50MG 3 QL (60 EA per 30 days) MO celecoxib capsule 100mg 2 celecoxib capsule 200mg 2 celecoxib capsule 400mg 2 celecoxib capsule 50mg 2 diclofenac potassium tablet 50mg 2 MO diclofenac sodium dr tablet delayed release 25mg 2 MO diclofenac sodium dr tablet delayed release 50mg 2 MO diclofenac sodium dr tablet delayed release 75mg 2 MO diclofenac sodium er tablet extended release 24 hour 100mg 2 MO 9

11 Name diclofenac sodium/misoprostol tablet delayed release 50mg; 2 ST MO 200mcg diclofenac sodium/misoprostol tablet delayed release 75mg; 2 ST MO 200mcg diflunisal tablet 500mg 2 MO etodolac er tablet extended release 24 hour 400mg 2 MO etodolac er tablet extended release 24 hour 500mg 2 MO etodolac er tablet extended release 24 hour 600mg 2 MO etodolac capsule 200mg 2 MO etodolac capsule 300mg 2 MO etodolac tablet 400mg 2 MO etodolac tablet 500mg 2 MO fenoprofen calcium tablet 600mg 2 MO FLECTOR PATCH 1.3% 3 QL (60 EA per 30 days) PA MO flurbiprofen tablet 100mg 2 MO flurbiprofen tablet 50mg 2 MO ibuprofen suspension 100mg/5ml 2 MO ibuprofen tablet 400mg 1 MO ibuprofen tablet 600mg 1 MO ibuprofen tablet 800mg 1 MO INDOCIN SUSPENSION 25MG/5ML 3 MO indomethacin er capsule extended release 75mg 2 MO indomethacin capsule 25mg 2 MO indomethacin capsule 50mg 2 MO ketoprofen capsule 50mg 2 MO ketoprofen capsule 75mg 2 MO ketorolac tromethamine injection 15mg/ml 4 ketorolac tromethamine injection 30mg/ml 4 ketorolac tromethamine tablet 10mg 2 QL (20 EA per 5 days) MO meclofenamate sodium capsule 100mg 2 MO meclofenamate sodium capsule 50mg 2 MO mefenamic acid capsule 250mg 2 MO meloxicam suspension 7.5mg/5ml 2 MO meloxicam tablet 15mg 1 MO meloxicam tablet 7.5mg 1 MO nabumetone tablet 500mg 2 MO nabumetone tablet 750mg 2 MO naproxen dr tablet delayed release 375mg 1 MO naproxen dr tablet delayed release 500mg 1 MO naproxen sodium er tablet extended release 24 hour 500mg 2 naproxen sodium tablet 275mg 2 MO naproxen sodium tablet 550mg 2 MO naproxen suspension 125mg/5ml 2 MO naproxen tablet 250mg 1 MO naproxen tablet 375mg 1 MO naproxen tablet 500mg 1 MO oxaprozin tablet 600mg 2 MO piroxicam capsule 10mg 2 MO piroxicam capsule 20mg 2 MO 10

12 Name sulindac tablet 150mg 2 MO sulindac tablet 200mg 2 MO tolmetin sodium capsule 400mg 2 MO tolmetin sodium tablet 200mg 2 MO tolmetin sodium tablet 600mg 2 MO VOLTAREN GEL 1% 3 ST MO ANESTHETICS TOPICAL ANESTHETICS lidocaine hcl jelly gel 2% 2 lidocaine hcl jelly gel 2% 2 lidocaine hcl injection 0.5% 4 B/D lidocaine hcl injection 2% 2 lidocaine hcl solution 4% 2 lidocaine viscous solution 2% 2 lidocaine/prilocaine cream 2.5%; 2.5% 2 B/D lidocaine ointment 5% 2 lidocaine patch 5% 2 QL (3 EA per 1 days) PA SYNERA PATCH 70MG; 70MG 3 ANTI-INFECTIVES AMEBICIDES metronidazole in nacl 0.79% injection 500mg/100ml; 0.79% 4 metronidazole capsule 375mg 2 metronidazole tablet 250mg 2 metronidazole tablet 500mg 2 paromomycin sulfate capsule 250mg 2 tinidazole tablet 250mg 2 tinidazole tablet 500mg 2 AMINOGLYCOSIDES amikacin sulfate injection 500mg/2ml 4 GENTAMICIN SULFATE/0.9% SODIUM CHLORIDE 4 INJECTION 0.9MG/ML; 0.9% GENTAMICIN SULFATE/0.9% SODIUM CHLORIDE 4 INJECTION 1.4MG/ML; 0.9% gentamicin sulfate/0.9% sodium chloride injection 1.6mg/ml; 4 0.9% gentamicin sulfate/0.9% sodium chloride injection 1mg/ml; 4 0.9% gentamicin sulfate injection 10mg/ml 4 gentamicin sulfate injection 40mg/ml 4 gentamicin sulfate ointment 0.1% 2 isotonic gentamicin injection 0.8mg/ml; 0.9% 4 isotonic gentamicin injection 1.2mg/ml; 0.9% 4 TOBI PODHALER CAPSULE 28MG 5 TOBRAMYCIN SULFATE/SODIUM CHLORIDE 4 INJECTION 0.9%; 0.8MG/ML tobramycin sulfate injection 10mg/ml 4 tobramycin sulfate injection 80mg/2ml 4 tobramycin nebulization solution 300mg/5ml 2 B/D ANTHELMINTICS 11

13 Name ALBENZA TABLET 200MG 3 BILTRICIDE TABLET 600MG 3 ivermectin tablet 3mg 2 SOOLANTRA CREAM 1% 3 STROMECTOL TABLET 3MG 3 ANTIRETROVIRALS AND PROTEASE INHIBITORS abacavir sulfate/lamivudine/zidovudine tablet 300mg; 150mg; 300mg abacavir tablet 300mg 2 APTIVUS CAPSULE 250MG 5 APTIVUS SOLUTION 100MG/ML 5 ATRIPLA TABLET 600MG; 200MG; 300MG 5 COMPLERA TABLET 200MG; 25MG; 300MG 3 CRIXIVAN CAPSULE 200MG 3 CRIXIVAN CAPSULE 400MG 3 didanosine capsule delayed release 125mg 2 didanosine capsule delayed release 200mg 2 didanosine capsule delayed release 250mg 2 didanosine capsule delayed release 400mg 2 EDURANT TABLET 25MG 5 EMTRIVA CAPSULE 200MG 3 EMTRIVA SOLUTION 10MG/ML 3 EPIVIR SOLUTION 10MG/ML 3 EPZICOM TABLET 600MG; 300MG 5 EVOTAZ TABLET 300MG; 150MG 3 FUZEON INJECTION 90MG 5 INTELENCE TABLET 100MG 5 INTELENCE TABLET 200MG 5 INTELENCE TABLET 25MG 3 INVIRASE CAPSULE 200MG 3 INVIRASE TABLET 500MG 3 ISENTRESS PACKET 100MG 3 ISENTRESS TABLET CHEWABLE 100MG 3 ISENTRESS TABLET CHEWABLE 25MG 3 ISENTRESS TABLET 400MG 3 KALETRA SOLUTION 400MG/5ML; 100MG/5ML 3 KALETRA TABLET 100MG; 25MG 3 KALETRA TABLET 200MG; 50MG 3 lamivudine/zidovudine tablet 150mg; 300mg 2 lamivudine solution 10mg/ml 2 lamivudine tablet 100mg 2 lamivudine tablet 150mg 2 lamivudine tablet 300mg 2 LEXIVA SUSPENSION 50MG/ML 3 LEXIVA TABLET 700MG 3 nevirapine er tablet extended release 24 hour 400mg 2 nevirapine suspension 50mg/5ml 2 nevirapine tablet 200mg 2 NORVIR CAPSULE 100MG 3 Tier 2 Requirements/Limits 12

14 Name NORVIR SOLUTION 80MG/ML 3 NORVIR TABLET 100MG 3 PREZCOBIX TABLET 150MG; 800MG 3 PREZISTA SUSPENSION 100MG/ML 3 PREZISTA TABLET 150MG 3 PREZISTA TABLET 600MG 3 PREZISTA TABLET 75MG 3 PREZISTA TABLET 800MG 3 RESCRIPTOR TABLET 100MG 3 RESCRIPTOR TABLET 200MG 3 RETROVIR IV INFUSION INJECTION 10MG/ML 4 REYATAZ CAPSULE 150MG 3 REYATAZ CAPSULE 200MG 3 REYATAZ CAPSULE 300MG 3 REYATAZ PACKET 50MG 3 SELZENTRY TABLET 150MG 5 SELZENTRY TABLET 300MG 5 stavudine capsule 15mg 2 stavudine capsule 20mg 2 stavudine capsule 30mg 2 stavudine capsule 40mg 2 stavudine solution reconstituted 1mg/ml 2 STRIBILD TABLET 150MG; 150MG; 200MG; 300MG 3 SUSTIVA CAPSULE 200MG 3 SUSTIVA CAPSULE 50MG 3 SUSTIVA TABLET 600MG 3 TIVICAY TABLET 50MG 3 TRIUMEQ TABLET 600MG; 50MG; 300MG 3 TRUVADA TABLET 200MG; 300MG 5 QL (30 EA per 30 days) TYBOST TABLET 150MG 3 VIDEX PEDIATRIC SOLUTION RECONSTITUTED 2GM 3 VIRACEPT TABLET 250MG 3 VIRACEPT TABLET 625MG 3 VIRAMUNE XR TABLET EXTENDED RELEASE 24 3 HOUR 100MG VIRAMUNE XR TABLET EXTENDED RELEASE 24 3 HOUR 400MG VIRAMUNE SUSPENSION 50MG/5ML 3 VIREAD POWDER 40MG/GM 3 VIREAD TABLET 150MG 3 VIREAD TABLET 200MG 3 VIREAD TABLET 250MG 3 VIREAD TABLET 300MG 3 VITEKTA TABLET 150MG 3 VITEKTA TABLET 85MG 3 ZIAGEN SOLUTION 20MG/ML 3 zidovudine capsule 100mg 2 zidovudine syrup 50mg/5ml 2 zidovudine tablet 300mg 2 13

15 Name ANTITUBERCULARS CAPASTAT SULFATE INJECTION 1GM 4 ethambutol hcl tablet 100mg 2 ethambutol hcl tablet 400mg 2 ISONIAZID INJECTION 100MG/ML 4 isoniazid syrup 50mg/5ml 2 isoniazid tablet 100mg 2 isoniazid tablet 300mg 2 MYCOBUTIN CAPSULE 150MG 3 PASER PACKET 4GM 3 PRIFTIN TABLET 150MG 3 pyrazinamide tablet 500mg 2 rifabutin capsule 150mg 2 rifampin capsule 150mg 2 rifampin capsule 300mg 2 rifampin injection 600mg 4 RIFATER TABLET 50MG; 300MG; 120MG 3 SIRTURO TABLET 100MG 3 LA STREPTOMYCIN SULFATE INJECTION 1GM 4 TRECATOR TABLET 250MG 3 CEPHALOSPORINS CEDAX CAPSULE 400MG 3 cefaclor er tablet extended release 12 hour 500mg 2 cefaclor capsule 250mg 2 cefaclor capsule 500mg 2 cefadroxil capsule 500mg 2 cefadroxil suspension reconstituted 250mg/5ml 2 cefadroxil suspension reconstituted 500mg/5ml 2 cefadroxil tablet 1gm 2 cefazolin sodium injection 10gm 4 cefazolin sodium injection 1gm 4 CEFAZOLIN SODIUM INJECTION 1GM; 5% 4 cefazolin sodium injection 500mg 4 cefdinir capsule 300mg 2 cefdinir suspension reconstituted 125mg/5ml 2 cefdinir suspension reconstituted 250mg/5ml 2 cefepime injection 1gm/50ml; 5% 4 cefepime injection 1gm 4 cefepime injection 2gm/50ml; 5% 4 cefepime injection 2gm 4 cefixime suspension reconstituted 100mg/5ml 2 cefixime suspension reconstituted 200mg/5ml 2 cefotaxime sodium injection 1gm 4 cefotaxime sodium injection 2gm 4 cefotaxime sodium injection 500mg 4 CEFOTETAN INJECTION 10GM 4 CEFOTETAN INJECTION 1GM 4 CEFOTETAN INJECTION 2GM 4 cefoxitin sodium injection 10gm 4 14

16 Name Tier cefoxitin sodium injection 1gm 4 CEFOXITIN SODIUM INJECTION 1GM; 4% 4 cefoxitin sodium injection 2gm 4 CEFOXITIN SODIUM INJECTION 2GM; 2.2% 4 cefpodoxime proxetil suspension reconstituted 100mg/5ml 2 cefpodoxime proxetil suspension reconstituted 50mg/5ml 2 cefpodoxime proxetil tablet 100mg 2 cefpodoxime proxetil tablet 200mg 2 cefprozil suspension reconstituted 125mg/5ml 2 cefprozil suspension reconstituted 250mg/5ml 2 cefprozil tablet 250mg 2 cefprozil tablet 500mg 2 CEFTAZIDIME/DEXTROSE INJECTION 1GM/50ML; 5% 4 CEFTAZIDIME/DEXTROSE INJECTION 2GM/50ML; 5% 4 ceftazidime injection 1gm 4 ceftazidime injection 2gm 4 ceftazidime injection 6gm 4 ceftriaxone sodium injection 10gm 4 ceftriaxone sodium injection 1gm 4 ceftriaxone sodium injection 250mg 4 ceftriaxone sodium injection 2gm 4 ceftriaxone sodium injection 500mg 4 cefuroxime axetil tablet 250mg 2 cefuroxime axetil tablet 500mg 2 cefuroxime sodium injection 1.5gm 4 cefuroxime sodium injection 7.5gm 4 cefuroxime sodium injection 750mg 4 cephalexin capsule 250mg 2 cephalexin capsule 500mg 2 cephalexin suspension reconstituted 125mg/5ml 2 cephalexin suspension reconstituted 250mg/5ml 2 cephalexin tablet 250mg 2 cephalexin tablet 500mg 2 FORTAZ INJECTION 1GM 4 FORTAZ INJECTION 2GM 4 MAXIPIME INJECTION 1GM 4 MAXIPIME INJECTION 2GM 4 SUPRAX CAPSULE 400MG 3 SUPRAX SUSPENSION RECONSTITUTED 100MG/5ML 3 SUPRAX SUSPENSION RECONSTITUTED 200MG/5ML 3 SUPRAX SUSPENSION RECONSTITUTED 500MG/5ML 3 SUPRAX TABLET CHEWABLE 100MG 3 SUPRAX TABLET CHEWABLE 200MG 3 tazicef injection 1gm 4 TEFLARO INJECTION 400MG 4 TEFLARO INJECTION 600MG 4 ZERBAXA INJECTION 1GM; 0.5GM 4 CLINDAMYCINS CLEOCIN IN D5W INJECTION 900MG/50ML; 5% 4 Requirements/Limits 15

17 Name CLEOCIN CAPSULE 75MG 3 clindamycin hcl capsule 150mg 2 clindamycin hcl capsule 300mg 2 clindamycin hcl capsule 75mg 2 clindamycin palmitate hcl solution reconstituted 75mg/5ml 2 clindamycin phosphate add-vantage injection 150mg/ml 4 clindamycin phosphate in d5w injection 300mg/50ml; 5% 4 clindamycin phosphate in d5w injection 600mg/50ml; 5% 4 clindamycin phosphate in d5w injection 900mg/50ml; 5% 4 MACROLIDES azithromycin injection 500mg 4 azithromycin packet 1gm 2 GC azithromycin suspension reconstituted 100mg/5ml 2 azithromycin suspension reconstituted 200mg/5ml 2 azithromycin tablet 250mg 2 azithromycin tablet 250mg 2 azithromycin tablet 500mg 2 azithromycin tablet 600mg 2 clarithromycin er tablet extended release 24 hour 500mg 2 clarithromycin suspension reconstituted 125mg/5ml 2 clarithromycin suspension reconstituted 250mg/5ml 2 clarithromycin tablet 250mg 2 clarithromycin tablet 500mg 2 DIFICID TABLET 200MG 3 ERY-TAB TABLET DELAYED RELEASE 500MG 3 ery pad 2% 2 ERYTHROCIN LACTOBIONATE INJECTION 500MG 4 erythromycin base tablet 500mg 2 erythromycin ethylsuccinate tablet 400mg 2 erythromycin gel 2% 2 PCE TABLET DELAYED RELEASE 333MG 3 PCE TABLET DELAYED RELEASE 500MG 3 ZMAX SUSPENSION RECONSTITUTED 2GM 3 ORAL ANTIFUNGALS clotrimazole troche 10mg 2 fluconazole suspension reconstituted 10mg/ml 2 fluconazole suspension reconstituted 40mg/ml 2 fluconazole tablet 100mg 2 fluconazole tablet 150mg 2 fluconazole tablet 200mg 2 fluconazole tablet 50mg 2 flucytosine capsule 250mg 2 flucytosine capsule 500mg 2 griseofulvin microsize suspension 125mg/5ml 2 griseofulvin microsize tablet 500mg 2 griseofulvin ultramicrosize tablet 125mg 2 griseofulvin ultramicrosize tablet 250mg 2 itraconazole capsule 100mg 2 QL (120 EA per 30 days) ketoconazole tablet 200mg 2 16

18 Name NOXAFIL SUSPENSION 40MG/ML 3 NOXAFIL TABLET DELAYED RELEASE 100MG 3 nystatin suspension unit/ml 2 nystatin tablet unit 2 SPORANOX SOLUTION 10MG/ML 3 voriconazole suspension reconstituted 40mg/ml 2 PA voriconazole tablet 200mg 2 PA voriconazole tablet 50mg 2 PA OTHER ANTI-INFECTIVE DRUGS ALINIA SUSPENSION RECONSTITUTED 100MG/5ML 3 ALINIA TABLET 500MG 3 AZACTAM IN ISO-OSMOTIC DEXTROSE INJECTION 4 1GM; 0 AZACTAM IN ISO-OSMOTIC DEXTROSE INJECTION 4 2GM; 0 aztreonam injection 1gm 4 baciim injection 50000unit 4 BACITRACIN INJECTION 50000UNIT 4 CAYSTON SOLUTION RECONSTITUTED 75MG 3 QL (84 ML per 28 days) LA CHLORAMPHENICOL SODIUM SUCCINATE 4 INJECTION 1GM colistimethate sodium injection 150mg 4 CUBICIN INJECTION 500MG 4 B/D DAPSONE TABLET 100MG 3 DAPSONE TABLET 25MG 3 DORIBAX INJECTION 500MG 4 imipenem/cilastatin injection 250mg; 250mg 4 imipenem/cilastatin injection 500mg; 500mg 4 INVANZ INJECTION 1GM 4 KETEK TABLET 300MG 3 KETEK TABLET 400MG 3 LINCOCIN INJECTION 300MG/ML 4 linezolid injection 2mg/ml 4 PA linezolid tablet 600mg 2 PA MEPRON SUSPENSION 750MG/5ML 5 meropenem injection 500mg 4 NEBUPENT SOLUTION RECONSTITUTED 300MG 3 B/D PENTAM 300 INJECTION 300MG 4 B/D polymyxin b sulfate injection unit 4 SIVEXTRO INJECTION 200MG 4 SIVEXTRO TABLET 200MG 4 SYNERCID INJECTION 350MG; 150MG 4 vancomycin hcl capsule 125mg 2 vancomycin hcl capsule 250mg 2 vancomycin hcl injection 1000mg 4 B/D vancomycin hcl injection 10gm 4 B/D vancomycin hcl injection 500mg 4 B/D XIFAXAN TABLET 200MG 3 PA XIFAXAN TABLET 550MG 3 PA 17

19 Name ZYVOX INJECTION 2MG/ML 5 PA ZYVOX SUSPENSION RECONSTITUTED 100MG/5ML 5 PA ZYVOX TABLET 600MG 5 PA OTHER ANTIVIRAL DRUGS acyclovir sodium injection 50mg/ml 4 B/D acyclovir capsule 200mg 2 acyclovir ointment 5% 2 acyclovir suspension 200mg/5ml 2 acyclovir tablet 400mg 2 acyclovir tablet 800mg 2 adefovir dipivoxil tablet 10mg 2 amantadine hcl capsule 100mg 2 MO amantadine hcl syrup 50mg/5ml 2 amantadine hcl tablet 100mg 2 MO cidofovir injection 75mg/ml 4 DENAVIR CREAM 1% 3 EPIVIR HBV SOLUTION 5MG/ML 3 famciclovir tablet 125mg 2 QL (21 EA per 10 days) famciclovir tablet 250mg 2 QL (68 EA per 34 days) famciclovir tablet 500mg 2 QL (21 EA per 7 days) ganciclovir injection 500mg 4 B/D RELENZA DISKHALER AEROSOL POWDER BREATH 3 QL (60 EA per 180 days) ACTIVATED 5MG/BLISTER rimantadine hcl tablet 100mg 2 TAMIFLU CAPSULE 30MG 3 QL (84 EA per 180 days) TAMIFLU CAPSULE 45MG 3 QL (42 EA per 180 days) TAMIFLU CAPSULE 75MG 3 QL (42 EA per 180 days) TAMIFLU SUSPENSION RECONSTITUTED 6MG/ML 3 QL (600 ML per 180 days) TYZEKA TABLET 600MG 3 valacyclovir hcl tablet 1000mg 2 valacyclovir hcl tablet 500mg 2 VALCYTE SOLUTION RECONSTITUTED 50MG/ML 5 VALCYTE TABLET 450MG 5 valganciclovir tablet 450mg 2 XERESE CREAM 5%; 1% 3 ZOVIRAX CREAM 5% 3 PARENTERAL ANTIFUNGALS ABELCET INJECTION 5MG/ML 4 B/D AMBISOME INJECTION 50MG 4 B/D AMPHOTERICIN B INJECTION 50MG 4 B/D CANCIDAS INJECTION 50MG 4 CANCIDAS INJECTION 70MG 4 ERAXIS INJECTION 100MG 4 fluconazole in dextrose injection 56mg/ml; 400mg/200ml 4 MYCAMINE INJECTION 100MG 4 MYCAMINE INJECTION 50MG 4 voriconazole injection 200mg 4 PA PENICILLINS 18

20 Name Tier amoxicillin/clavulanate potassium er tablet extended release 2 12 hour 1000mg; 62.5mg amoxicillin/clavulanate potassium suspension reconstituted 2 200mg/5ml; 28.5mg/5ml amoxicillin/clavulanate potassium suspension reconstituted 2 250mg/5ml; 62.5mg/5ml amoxicillin/clavulanate potassium suspension reconstituted 2 400mg/5ml; 57mg/5ml amoxicillin/clavulanate potassium suspension reconstituted 2 600mg/5ml; 42.9mg/5ml amoxicillin/clavulanate potassium tablet chewable 200mg; mg amoxicillin/clavulanate potassium tablet chewable 400mg; 2 57mg amoxicillin/clavulanate potassium tablet 250mg; 125mg 2 amoxicillin/clavulanate potassium tablet 500mg; 125mg 2 amoxicillin/clavulanate potassium tablet 875mg; 125mg 2 amoxicillin capsule 250mg 2 amoxicillin capsule 500mg 2 amoxicillin suspension reconstituted 125mg/5ml 2 amoxicillin suspension reconstituted 200mg/5ml 2 amoxicillin suspension reconstituted 250mg/5ml 2 amoxicillin suspension reconstituted 400mg/5ml 2 amoxicillin tablet chewable 125mg 2 amoxicillin tablet chewable 250mg 2 amoxicillin tablet 500mg 2 amoxicillin tablet 875mg 2 ampicillin sodium injection 10gm 4 AMPICILLIN SODIUM INJECTION 125MG 4 ampicillin sodium injection 1gm 4 ampicillin-sulbactam injection 10gm; 5gm 4 ampicillin-sulbactam injection 1gm; 0.5gm 4 ampicillin-sulbactam injection 2gm; 1gm 4 ampicillin capsule 250mg 2 ampicillin capsule 500mg 2 ampicillin suspension reconstituted 125mg/5ml 2 ampicillin suspension reconstituted 250mg/5ml 2 BACTOCILL IN DEXTROSE INJECTION 0; 1GM/50ML 4 BACTOCILL IN DEXTROSE INJECTION 0; 2GM/50ML 4 BICILLIN C-R INJECTION UNIT/ML; UNIT/ML BICILLIN C-R INJECTION UNIT/2ML; UNIT/2ML BICILLIN L-A INJECTION UNIT/2ML 4 BICILLIN L-A INJECTION UNIT/4ML 4 BICILLIN L-A INJECTION UNIT/ML 4 dicloxacillin sodium capsule 250mg 2 dicloxacillin sodium capsule 500mg 2 NAFCILLIN SODIUM INJECTION 10GM 4 Requirements/Limits 19

21 Name Tier NAFCILLIN SODIUM INJECTION 1GM 4 NALLPEN/DEXTROSE INJECTION 0; 1GM/50ML 4 OXACILLIN SODIUM INJECTION 10GM 4 OXACILLIN SODIUM INJECTION 2GM 4 PENICILLIN G POTASSIUM IN ISO-OSMOTIC 4 DEXTROSE INJECTION 0; 40000UNIT/ML PENICILLIN G POTASSIUM IN ISO-OSMOTIC 4 DEXTROSE INJECTION 0; 60000UNIT/ML penicillin g potassium injection unit 4 PENICILLIN G PROCAINE INJECTION UNIT/ML 4 PENICILLIN G SODIUM INJECTION UNIT 4 penicillin v potassium solution reconstituted 125mg/5ml 2 penicillin v potassium solution reconstituted 250mg/5ml 2 penicillin v potassium tablet 250mg 2 penicillin v potassium tablet 500mg 2 piperacillin sodium/tazobactam sodium injection 3gm; gm piperacillin sodium/tazobactam sodium injection 4gm; 0.5gm 4 ZOSYN INJECTION 5%; 2GM/50ML; 0.25GM/50ML 4 ZOSYN INJECTION 5%; 3GM/50ML; 0.375GM/50ML 4 PLASMODICIDES atovaquone/proguanil hcl tablet 250mg; 100mg 2 atovaquone/proguanil hcl tablet 62.5mg; 25mg 2 atovaquone suspension 750mg/5ml 2 chloroquine phosphate tablet 250mg 2 chloroquine phosphate tablet 500mg 2 COARTEM TABLET 20MG; 120MG 3 DARAPRIM TABLET 25MG 3 hydroxychloroquine sulfate tablet 200mg 2 MALARONE TABLET 62.5MG; 25MG 3 mefloquine hcl tablet 250mg 2 PRIMAQUINE PHOSPHATE TABLET 26.3MG 3 quinine sulfate capsule 324mg 2 QUINOLONES AVELOX ABC PACK TABLET 400MG 3 AVELOX INJECTION 400MG/250ML; 0.8% 4 ciprofloxacin er tablet extended release 24 hour 1000mg; 0 2 ciprofloxacin er tablet extended release 24 hour 500mg; 0 2 ciprofloxacin hcl tablet 100mg 2 ciprofloxacin hcl tablet 250mg 2 ciprofloxacin hcl tablet 500mg 2 ciprofloxacin hcl tablet 750mg 2 ciprofloxacin i.v.-in d5w injection 200mg/100ml; 5% 4 ciprofloxacin injection 400mg/40ml 4 ciprofloxacin suspension reconstituted 250mg/5ml 2 ciprofloxacin suspension reconstituted 500mg/5ml 2 CIPRO SUSPENSION RECONSTITUTED 500MG/5ML 3 CIPRO SUSPENSION RECONSTITUTED 5GM/100ML 3 levofloxacin in d5w injection 5%; 500mg/100ml 4 Requirements/Limits 20

22 Name Tier levofloxacin injection 25mg/ml 4 levofloxacin solution 25mg/ml 2 levofloxacin tablet 250mg 2 levofloxacin tablet 500mg 2 levofloxacin tablet 750mg 2 moxifloxacin hcl injection 400mg/250ml 4 moxifloxacin hcl tablet 400mg 2 ofloxacin tablet 400mg 2 SULFONAMIDES sulfadiazine tablet 500mg 2 sulfamethoxazole/trimethoprim ds tablet 800mg; 160mg 2 SULFAMETHOXAZOLE/TRIMETHOPRIM INJECTION 4 400MG/5ML; 80MG/5ML sulfamethoxazole/trimethoprim suspension 200mg/5ml; 2 40mg/5ml sulfamethoxazole/trimethoprim tablet 400mg; 80mg 2 TETRACYCLINES demeclocycline hcl tablet 150mg 2 demeclocycline hcl tablet 300mg 2 doxy 100 injection 100mg 4 doxycycline hyclate dr tablet delayed release 100mg 2 doxycycline hyclate dr tablet delayed release 150mg 2 doxycycline hyclate dr tablet delayed release 75mg 2 doxycycline hyclate capsule 100mg 2 doxycycline hyclate capsule 50mg 2 doxycycline hyclate injection 100mg 4 doxycycline hyclate tablet 100mg 2 doxycycline monohydrate capsule 100mg 2 doxycycline monohydrate capsule 50mg 2 doxycycline monohydrate tablet 100mg 2 doxycycline monohydrate tablet 150mg 2 doxycycline monohydrate tablet 50mg 2 doxycycline monohydrate tablet 50mg 2 doxycycline monohydrate tablet 75mg 2 doxycycline capsule 150mg 2 doxycycline capsule 75mg 2 doxycycline suspension reconstituted 25mg/5ml 2 minocycline hcl er tablet extended release 24 hour 135mg 2 minocycline hcl er tablet extended release 24 hour 45mg 2 minocycline hcl er tablet extended release 24 hour 90mg 2 minocycline hcl capsule 100mg 2 minocycline hcl capsule 50mg 2 minocycline hcl capsule 75mg 2 minocycline hcl tablet 100mg 2 minocycline hcl tablet 50mg 2 minocycline hcl tablet 75mg 2 TYGACIL INJECTION 50MG 4 TOPICAL ANTIFUNGAL-CORTICOSTEROID COMB clotrimazole/betamethasone dipropionate cream 0.05%; 1% 2 Requirements/Limits 21

23 Name clotrimazole/betamethasone dipropionate lotion 0.05%; 1% 2 nystatin/triamcinolone cream unit/gm; 0.1% 2 nystatin/triamcinolone ointment unit/gm; 0.1% 2 TOPICAL ANTIFUNGALS ciclopirox olamine cream 0.77% 2 ciclopirox gel 0.77% 2 clotrimazole solution 1% 2 EXELDERM SOLUTION 1% 3 ketoconazole shampoo 2% 2 NAFTIN GEL 1% 3 nyamyc powder unit/gm 2 nystatin powder unit/gm 2 OXISTAT LOTION 1% 3 VAGINAL ANTIFUNGALS AVC CREAM 15% 3 GYNAZOLE-1 CREAM 2% 3 miconazole 3 suppository 200mg 2 QL (3 EA per 3 days) terconazole cream 0.4% 2 QL (45 GM per 7 days) terconazole cream 0.8% 2 terconazole suppository 80mg 2 QL (3 EA per 3 days) zazole cream 0.4% 2 zazole cream 0.8% 2 ANTINEOPLASTIC ANTINEOPLASTIC/IMMUNOSUPPRESSANT ABRAXANE INJECTION 900MG; 100MG 4 B/D ADRUCIL INJECTION 500MG/10ML 4 AFINITOR TABLET 10MG 5 PA AFINITOR TABLET 2.5MG 5 PA AFINITOR TABLET 5MG 5 PA AFINITOR TABLET 7.5MG 5 PA ALIMTA INJECTION 500MG 5 B/D amifostine injection 500mg 5 B/D anagrelide hydrochloride capsule 0.5mg 2 MO anagrelide hydrochloride capsule 1mg 2 MO anastrozole tablet 1mg 2 MO ARRANON INJECTION 5MG/ML 5 B/D ARZERRA INJECTION 100MG/5ML 5 B/D AVASTIN INJECTION 100MG/4ML 5 B/D AVASTIN INJECTION 400MG/16ML 5 B/D azacitidine injection 100mg 5 B/D AZASAN TABLET 100MG 3 B/D AZASAN TABLET 75MG 3 B/D azathioprine tablet 50mg 2 B/D BELEODAQ INJECTION 500MG 5 B/D BEXAROTENE CAPSULE 75MG 5 PA bicalutamide tablet 50mg 2 MO BICNU INJECTION 100MG 4 B/D bleomycin sulfate injection 30unit 4 B/D BOSULIF TABLET 100MG 5 PA 22

24 Name BOSULIF TABLET 500MG 5 PA BUSULFEX INJECTION 6MG/ML 4 B/D CAPRELSA TABLET 100MG 5 PA LA CAPRELSA TABLET 300MG 5 PA LA carboplatin injection 150mg/15ml 4 B/D CIMZIA INJECTION 200MG 5 QL (6 EA per 28 days) PA cisplatin injection 100mg/100ml 4 B/D cladribine injection 1mg/ml 4 B/D CLOLAR INJECTION 1MG/ML 4 B/D COMETRIQ KIT 0 5 PA COMETRIQ KIT 0 5 PA COMETRIQ KIT 20MG 5 PA COSMEGEN INJECTION 0.5MG 4 cyclophosphamide capsule 25mg 2 B/D cyclophosphamide capsule 50mg 2 B/D cyclosporine modified capsule 50mg 2 B/D cyclosporine capsule 100mg 2 B/D cyclosporine capsule 25mg 2 B/D CYRAMZA INJECTION 100MG/10ML 5 B/D CYRAMZA INJECTION 500MG/50ML 5 B/D CYTARABINE AQUEOUS INJECTION 100MG/ML 4 B/D CYTARABINE AQUEOUS INJECTION 20MG/ML 4 B/D dacarbazine injection 200mg 4 B/D DACOGEN INJECTION 50MG 5 daunorubicin hcl injection 5mg/ml 4 B/D DAUNOXOME INJECTION 2MG/ML 4 decitabine injection 50mg 5 DEPO-PROVERA INJECTION 400MG/ML 4 B/D dexrazoxane injection 250mg 4 B/D DOCEFREZ INJECTION 20MG 4 B/D docetaxel injection 80mg/4ml 4 B/D docetaxel injection 80mg/8ml 4 B/D DOXIL INJECTION 2MG/ML 4 B/D doxorubicin hcl injection 2mg/ml 4 B/D DROXIA CAPSULE 200MG 3 DROXIA CAPSULE 300MG 3 DROXIA CAPSULE 400MG 3 ELIGARD INJECTION 22.5MG 4 ELIGARD INJECTION 30MG 4 ELIGARD INJECTION 45MG 4 ELIGARD INJECTION 7.5MG 4 ELITEK INJECTION 1.5MG 5 B/D ELLENCE INJECTION 200MG/100ML 4 B/D EMCYT CAPSULE 140MG 3 epirubicin hcl injection 50mg/25ml 4 B/D ERIVEDGE CAPSULE 150MG 5 PA LA ERWINAZE INJECTION 10000UNIT 4 ETOPOPHOS INJECTION 100MG 4 B/D etoposide injection 500mg/25ml 4 B/D 23

25 Name exemestane tablet 25mg 2 MO FARESTON TABLET 60MG 3 MO FARYDAK CAPSULE 10MG 5 PA FARYDAK CAPSULE 15MG 5 PA FARYDAK CAPSULE 20MG 5 PA FASLODEX INJECTION 250MG/5ML 4 B/D FIRMAGON INJECTION 120MG 4 B/D FIRMAGON INJECTION 80MG 4 B/D fludarabine phosphate injection 50mg 4 B/D fluorouracil injection 2.5gm/50ml 4 B/D flutamide capsule 125mg 2 FOLOTYN INJECTION 40MG/2ML 5 FUSILEV INJECTION 50MG 4 B/D gemcitabine hcl injection 1gm 4 B/D gengraf capsule 100mg 2 B/D gengraf capsule 25mg 2 B/D gengraf solution 100mg/ml 2 B/D GILOTRIF TABLET 20MG 5 QL (60 EA per 30 days) PA GILOTRIF TABLET 30MG 5 QL (40 EA per 30 days) PA GILOTRIF TABLET 40MG 5 QL (30 EA per 30 days) PA GLEEVEC TABLET 100MG 5 PA GLEEVEC TABLET 400MG 5 PA GLEOSTINE CAPSULE 100MG 3 GLEOSTINE CAPSULE 10MG 3 GLEOSTINE CAPSULE 40MG 3 HALAVEN INJECTION 1MG/2ML 5 B/D HERCEPTIN INJECTION 440MG 5 B/D HEXALEN CAPSULE 50MG 3 hydroxyurea capsule 500mg 2 IBRANCE CAPSULE 100MG 5 PA IBRANCE CAPSULE 125MG 5 PA IBRANCE CAPSULE 75MG 5 PA ICLUSIG TABLET 15MG 5 PA ICLUSIG TABLET 45MG 5 PA IDAMYCIN PFS INJECTION 20MG/20ML 4 B/D idarubicin hcl injection 10mg/10ml 4 B/D ifosfamide injection 1gm 4 B/D IMBRUVICA CAPSULE 140MG 5 PA INLYTA TABLET 1MG 5 PA LA INLYTA TABLET 5MG 5 PA LA irinotecan injection 100mg/5ml 4 B/D ISTODAX INJECTION 10MG 5 B/D IXEMPRA KIT INJECTION 45MG 5 B/D JAKAFI TABLET 10MG 5 PA LA JAKAFI TABLET 15MG 5 PA LA JAKAFI TABLET 20MG 5 PA LA JAKAFI TABLET 25MG 5 PA LA JAKAFI TABLET 5MG 5 PA LA JEVTANA INJECTION 60MG/1.5ML 5 B/D 24

26 Name KEPIVANCE INJECTION 6.25MG 4 LA KEYTRUDA INJECTION 100MG/4ML 5 B/D KEYTRUDA INJECTION 50MG 5 B/D leflunomide tablet 10mg 2 QL (30 EA per 30 days) LENVIMA 10MG DAILY DOSE CAPSULE THERAPY 5 PACK 10MG LENVIMA 14MG DAILY DOSE CAPSULE THERAPY 5 PACK 0 LENVIMA 20MG DAILY DOSE CAPSULE THERAPY 5 PACK 10MG LENVIMA 24MG DAILY DOSE CAPSULE THERAPY 5 PACK 0 letrozole tablet 2.5mg 2 MO leucovorin calcium injection 100mg 4 B/D leucovorin calcium injection 350mg 4 B/D leucovorin calcium tablet 10mg 2 leucovorin calcium tablet 15mg 2 leucovorin calcium tablet 25mg 2 leucovorin calcium tablet 5mg 2 LEUKERAN TABLET 2MG 3 leuprolide acetate injection 1mg/0.2ml 4 PA levoleucovorin calcium injection 175mg/17.5ml 4 lomustine capsule 100mg 2 lomustine capsule 10mg 2 lomustine capsule 40mg 2 LUPRON DEPOT-PED INJECTION 11.25MG 4 PA LUPRON DEPOT-PED INJECTION 15MG 4 PA LUPRON DEPOT INJECTION 11.25MG 4 PA LUPRON DEPOT INJECTION 22.5MG 4 PA LUPRON DEPOT INJECTION 3.75MG 4 PA LUPRON DEPOT INJECTION 30MG 4 PA LUPRON DEPOT INJECTION 45MG 4 PA LUPRON DEPOT INJECTION 7.5MG 4 PA LYNPARZA CAPSULE 50MG 5 PA LYSODREN TABLET 500MG 3 MATULANE CAPSULE 50MG 5 MEGACE ES SUSPENSION 625MG/5ML 3 PA megestrol acetate suspension 40mg/ml 2 PA megestrol acetate suspension 625mg/5ml 2 PA megestrol acetate tablet 20mg 2 PA megestrol acetate tablet 40mg 2 PA MEKINIST TABLET 0.5MG 3 QL (120 EA per 30 days) PA MEKINIST TABLET 2MG 3 QL (30 EA per 30 days) PA melphalan hydrochloride injection 50mg 5 B/D mercaptopurine tablet 50mg 2 mesna injection 100mg/ml 4 B/D MESNEX TABLET 400MG 3 methotrexate sodium injection 1gm/40ml 4 B/D METHOTREXATE SODIUM INJECTION 1GM 4 B/D 25

27 Name methotrexate tablet 2.5mg 2 B/D mitomycin injection 20mg 4 B/D mitoxantrone hcl injection 2mg/ml 4 B/D MUSTARGEN INJECTION 10MG 4 mycophenolate mofetil capsule 250mg 2 B/D MO mycophenolate mofetil tablet 500mg 2 B/D MO NEXAVAR TABLET 200MG 5 PA LA NILANDRON TABLET 150MG 3 octreotide acetate injection 1000mcg/ml 4 PA octreotide acetate injection 100mcg/ml 4 PA octreotide acetate injection 200mcg/ml 4 PA octreotide acetate injection 500mcg/ml 4 PA octreotide acetate injection 50mcg/ml 4 PA ONCASPAR INJECTION 750UNIT/ML 4 OPDIVO INJECTION 40MG/4ML 4 B/D oxaliplatin injection 100mg/20ml 4 B/D paclitaxel injection 300mg/50ml 4 B/D PERJETA INJECTION 420MG/14ML 5 B/D POMALYST CAPSULE 1MG 5 PA LA POMALYST CAPSULE 2MG 5 PA LA POMALYST CAPSULE 3MG 5 PA LA POMALYST CAPSULE 4MG 5 PA LA PURIXAN SUSPENSION 2000MG/100ML 3 REVLIMID CAPSULE 10MG 5 PA LA REVLIMID CAPSULE 15MG 5 PA LA REVLIMID CAPSULE 2.5MG 5 PA LA REVLIMID CAPSULE 20MG 5 PA LA REVLIMID CAPSULE 25MG 5 PA LA REVLIMID CAPSULE 5MG 5 PA LA RHEUMATREX TABLET 2.5MG 3 RHEUMATREX TABLET 2.5MG 3 RHEUMATREX TABLET 2.5MG 3 RHEUMATREX TABLET 2.5MG 3 RHEUMATREX TABLET 2.5MG 3 RITUXAN INJECTION 500MG/50ML 5 PA SANDOSTATIN LAR DEPOT INJECTION 10MG 5 PA SANDOSTATIN LAR DEPOT INJECTION 20MG 5 PA SANDOSTATIN LAR DEPOT INJECTION 30MG 5 PA SIGNIFOR INJECTION 0.3MG/ML 5 PA SIGNIFOR INJECTION 0.6MG/ML 5 PA SIGNIFOR INJECTION 0.9MG/ML 5 PA SIMULECT INJECTION 20MG 4 SOLTAMOX SOLUTION 10MG/5ML 3 SOMATULINE DEPOT INJECTION 120MG/0.5ML 5 PA SOMATULINE DEPOT INJECTION 60MG/0.2ML 5 PA SOMATULINE DEPOT INJECTION 90MG/0.3ML 5 PA SPRYCEL TABLET 100MG 5 PA SPRYCEL TABLET 140MG 5 PA SPRYCEL TABLET 20MG 5 PA 26

28 Name SPRYCEL TABLET 50MG 5 PA SPRYCEL TABLET 70MG 5 PA SPRYCEL TABLET 80MG 5 PA STIVARGA TABLET 40MG 5 PA LA SUTENT CAPSULE 12.5MG 5 PA SUTENT CAPSULE 25MG 5 PA SUTENT CAPSULE 37.5MG 5 PA SUTENT CAPSULE 50MG 5 PA SYLVANT INJECTION 100MG 5 SYNRIBO INJECTION 3.5MG 5 PA TABLOID TABLET 40MG 3 TAFINLAR CAPSULE 50MG 5 QL (180 EA per 30 days) PA TAFINLAR CAPSULE 75MG 5 QL (120 EA per 30 days) PA tamoxifen citrate tablet 10mg 2 MO tamoxifen citrate tablet 20mg 2 MO TARCEVA TABLET 100MG 5 PA TARCEVA TABLET 150MG 5 PA TARCEVA TABLET 25MG 5 PA TARGRETIN CAPSULE 75MG 5 PA TASIGNA CAPSULE 150MG 5 PA TASIGNA CAPSULE 200MG 5 PA THALOMID CAPSULE 100MG 5 PA THALOMID CAPSULE 150MG 5 PA THALOMID CAPSULE 200MG 5 PA THALOMID CAPSULE 50MG 5 PA thiotepa injection 15mg 4 toposar injection 1gm/50ml 4 B/D topotecan hcl injection 4mg 5 B/D TORISEL INJECTION 25MG/ML 5 B/D TREANDA INJECTION 100MG 5 B/D TREANDA INJECTION 45MG/0.5ML 4 B/D TRELSTAR MIXJECT INJECTION 11.25MG 5 PA TRELSTAR MIXJECT INJECTION 22.5MG 5 PA TRELSTAR MIXJECT INJECTION 3.75MG 5 PA TRETINOIN CAPSULE 10MG 5 TREXALL TABLET 10MG 3 B/D TREXALL TABLET 15MG 3 B/D TREXALL TABLET 5MG 3 B/D TREXALL TABLET 7.5MG 3 B/D TRISENOX INJECTION 10MG/10ML 4 B/D TYKERB TABLET 250MG 5 PA LA UVADEX INJECTION 20MCG/ML 4 B/D VALCHLOR GEL 0.016% 3 PA VELCADE INJECTION 3.5MG 5 B/D VINBLASTINE SULFATE INJECTION 1MG/ML 4 B/D vincasar pfs injection 1mg/ml 4 B/D vincristine sulfate injection 1mg/ml 4 B/D vinorelbine tartrate injection 50mg/5ml 4 B/D VOTRIENT TABLET 200MG 5 PA 27

29 Name XALKORI CAPSULE 200MG 5 PA LA XALKORI CAPSULE 250MG 5 PA LA XTANDI CAPSULE 40MG 5 PA LA ZALTRAP INJECTION 100MG/4ML 5 B/D ZANOSAR INJECTION 1GM 4 B/D ZELBORAF TABLET 240MG 5 PA LA ZOLINZA CAPSULE 100MG 5 PA ZYDELIG TABLET 100MG 5 PA ZYDELIG TABLET 150MG 5 PA ZYKADIA CAPSULE 150MG 5 ZYTIGA TABLET 250MG 5 PA CARDIOVASCULAR ANGIOTENSIN CONVERTING ENZYME INHIBITORS benazepril hcl tablet 10mg 1 MO benazepril hcl tablet 20mg 1 MO benazepril hcl tablet 40mg 1 MO benazepril hcl tablet 5mg 1 MO captopril tablet 100mg 1 MO captopril tablet 12.5mg 1 MO captopril tablet 25mg 1 MO captopril tablet 50mg 1 MO enalapril maleate tablet 10mg 1 MO enalapril maleate tablet 2.5mg 1 MO enalapril maleate tablet 20mg 1 MO enalapril maleate tablet 5mg 1 MO EPANED SOLUTION RECONSTITUTED 1MG/ML 3 fosinopril sodium tablet 10mg 2 MO fosinopril sodium tablet 20mg 2 MO fosinopril sodium tablet 40mg 2 MO lisinopril tablet 10mg 1 MO lisinopril tablet 2.5mg 1 MO lisinopril tablet 20mg 1 MO lisinopril tablet 30mg 1 MO lisinopril tablet 40mg 1 MO lisinopril tablet 5mg 1 MO moexipril hcl tablet 15mg 2 MO moexipril hcl tablet 7.5mg 2 MO perindopril erbumine tablet 2mg 2 MO perindopril erbumine tablet 4mg 2 MO perindopril erbumine tablet 8mg 2 MO quinapril hcl tablet 10mg 1 MO quinapril hcl tablet 20mg 1 MO quinapril hcl tablet 40mg 1 MO quinapril hcl tablet 5mg 1 MO ramipril capsule 1.25mg 1 MO ramipril capsule 10mg 1 MO ramipril capsule 2.5mg 1 MO ramipril capsule 5mg 1 MO trandolapril tablet 1mg 2 MO 28

30 Name trandolapril tablet 2mg 2 MO trandolapril tablet 4mg 2 MO ANGIOTENSIN II RECEPTOR ANTAGONISTS candesartan cilexetil tablet 16mg 2 MO candesartan cilexetil tablet 32mg 2 MO candesartan cilexetil tablet 4mg 2 MO candesartan cilexetil tablet 8mg 2 MO DIOVAN TABLET 160MG 3 MO DIOVAN TABLET 320MG 3 MO DIOVAN TABLET 40MG 3 MO DIOVAN TABLET 80MG 3 MO eprosartan mesylate tablet 600mg 2 MO irbesartan tablet 150mg 2 MO irbesartan tablet 300mg 2 MO irbesartan tablet 75mg 2 MO losartan potassium tablet 100mg 1 MO losartan potassium tablet 25mg 1 MO losartan potassium tablet 50mg 1 MO telmisartan tablet 20mg 2 MO telmisartan tablet 40mg 2 MO telmisartan tablet 80mg 2 MO valsartan tablet 160mg 2 valsartan tablet 320mg 2 valsartan tablet 40mg 2 valsartan tablet 80mg 2 ANTIARRHYTHMICS amiodarone hcl injection 50mg/ml 4 amiodarone hcl tablet 200mg 2 MO amiodarone hcl tablet 400mg 2 MO disopyramide phosphate capsule 100mg 2 MO disopyramide phosphate capsule 150mg 2 MO flecainide acetate tablet 100mg 2 MO flecainide acetate tablet 150mg 2 MO flecainide acetate tablet 50mg 2 MO mexiletine hcl capsule 150mg 2 MO mexiletine hcl capsule 200mg 2 MO mexiletine hcl capsule 250mg 2 MO MULTAQ TABLET 400MG 3 MO NORPACE CR CAPSULE EXTENDED RELEASE 12 3 MO HOUR 100MG pacerone tablet 100mg 2 MO pacerone tablet 200mg 2 MO pacerone tablet 400mg 2 MO procainamide hcl injection 100mg/ml 4 PROCAINAMIDE HCL INJECTION 500MG/ML 4 propafenone hcl er capsule extended release 12 hour 225mg 2 MO propafenone hcl er capsule extended release 12 hour 325mg 2 MO propafenone hcl er capsule extended release 12 hour 425mg 2 MO propafenone hcl tablet 150mg 2 MO 29

31 Name propafenone hcl tablet 225mg 2 MO propafenone hcl tablet 300mg 2 MO QUINIDINE GLUCONATE INJECTION 80MG/ML 4 MO quinidine sulfate tablet 200mg 2 MO quinidine sulfate tablet 300mg 2 MO sorine tablet 120mg 2 MO sorine tablet 160mg 2 MO sorine tablet 240mg 2 MO sorine tablet 80mg 2 MO sotalol hcl (af) tablet 120mg 2 MO sotalol hcl tablet 160mg 2 MO sotalol hcl tablet 240mg 2 MO sotalol hcl tablet 80mg 2 MO SOTYLIZE SOLUTION 5MG/ML 3 TIKOSYN CAPSULE 125MCG 3 MO TIKOSYN CAPSULE 250MCG 3 MO TIKOSYN CAPSULE 500MCG 3 MO ANTIPLATELETS AGGRENOX CAPSULE EXTENDED RELEASE 12 HOUR 3 MO 25MG; 200MG aspirin/dipyridamole capsule extended release 12 hour 25mg; 2 MO 200mg BRILINTA TABLET 90MG 3 cilostazol tablet 100mg 2 MO cilostazol tablet 50mg 2 MO clopidogrel tablet 300mg 2 MO clopidogrel tablet 75mg 2 QL (30 EA per 30 days) MO dipyridamole tablet 25mg 2 MO dipyridamole tablet 50mg 2 MO dipyridamole tablet 75mg 2 MO EFFIENT TABLET 10MG 3 MO EFFIENT TABLET 5MG 3 MO ticlopidine hcl tablet 250mg 2 MO ZONTIVITY TABLET 2.08MG 3 BETA-ADRENERGIC ANTAGONISTS acebutolol hcl capsule 200mg 2 MO acebutolol hcl capsule 400mg 2 MO atenolol tablet 100mg 1 MO atenolol tablet 25mg 1 MO atenolol tablet 50mg 1 MO betaxolol hcl tablet 10mg 2 MO betaxolol hcl tablet 20mg 2 MO bisoprolol fumarate tablet 10mg 2 MO bisoprolol fumarate tablet 5mg 2 MO carvedilol tablet 12.5mg 1 MO carvedilol tablet 25mg 1 MO carvedilol tablet 3.125mg 1 MO carvedilol tablet 6.25mg 1 MO 30

32 Name INNOPRAN XL CAPSULE EXTENDED RELEASE 24 3 MO HOUR 120MG INNOPRAN XL CAPSULE EXTENDED RELEASE 24 3 MO HOUR 80MG labetalol hcl injection 5mg/ml 4 labetalol hcl tablet 100mg 2 MO labetalol hcl tablet 200mg 2 MO labetalol hcl tablet 300mg 2 MO metoprolol succinate er tablet extended release 24 hour 100mg2 MO metoprolol succinate er tablet extended release 24 hour 200mg2 MO metoprolol succinate er tablet extended release 24 hour 25mg 2 MO metoprolol succinate er tablet extended release 24 hour 50mg 2 MO metoprolol tartrate injection 1mg/ml 4 metoprolol tartrate tablet 100mg 1 MO metoprolol tartrate tablet 25mg 1 MO metoprolol tartrate tablet 50mg 1 MO nadolol tablet 20mg 2 MO nadolol tablet 40mg 2 MO nadolol tablet 80mg 2 MO pindolol tablet 10mg 2 MO pindolol tablet 5mg 2 MO propranolol hcl er capsule extended release 24 hour 120mg 1 MO propranolol hcl er capsule extended release 24 hour 160mg 1 MO propranolol hcl er capsule extended release 24 hour 60mg 1 MO propranolol hcl er capsule extended release 24 hour 80mg 1 MO propranolol hcl injection 1mg/ml 4 propranolol hcl solution 20mg/5ml 2 MO propranolol hcl solution 40mg/5ml 2 MO propranolol hcl tablet 10mg 1 MO propranolol hcl tablet 20mg 1 MO propranolol hcl tablet 40mg 1 MO propranolol hcl tablet 60mg 1 MO propranolol hcl tablet 80mg 1 MO timolol maleate tablet 10mg 2 MO timolol maleate tablet 20mg 2 MO timolol maleate tablet 5mg 2 MO CALCIUM CHANNEL BLOCKERS afeditab cr tablet extended release 24 hour 30mg 2 MO afeditab cr tablet extended release 24 hour 60mg 2 MO amlodipine besylate/benazepril hcl capsule 5mg; 40mg 2 MO amlodipine besylate/benazepril hydrochloride capsule 10mg; 2 MO 20mg amlodipine besylate/benazepril hydrochloride capsule 10mg; 2 MO 40mg amlodipine besylate/benazepril hydrochloride capsule 2.5mg; 2 MO 10mg amlodipine besylate/benazepril hydrochloride capsule 5mg; 10mg 2 MO 31

33 Name amlodipine besylate/benazepril hydrochloride capsule 5mg; 2 MO 20mg amlodipine besylate tablet 10mg 1 MO amlodipine besylate tablet 2.5mg 1 MO amlodipine besylate tablet 5mg 1 MO CARDENE IV INJECTION 20MG/200ML; 0.86% 4 cartia xt capsule extended release 24 hour 120mg 2 MO cartia xt capsule extended release 24 hour 180mg 2 MO cartia xt capsule extended release 24 hour 240mg 2 MO cartia xt capsule extended release 24 hour 300mg 2 MO dilt-xr capsule extended release 24 hour 120mg 2 MO dilt-xr capsule extended release 24 hour 180mg 2 MO dilt-xr capsule extended release 24 hour 240mg 2 MO diltiazem cd capsule extended release 24 hour 240mg 2 MO diltiazem hcl er capsule extended release 12 hour 120mg 2 MO diltiazem hcl er capsule extended release 12 hour 60mg 2 MO diltiazem hcl er capsule extended release 12 hour 90mg 2 MO diltiazem hcl er capsule extended release 24 hour 120mg 2 MO diltiazem hcl er capsule extended release 24 hour 180mg 2 diltiazem hcl er capsule extended release 24 hour 300mg 2 MO diltiazem hcl er capsule extended release 24 hour 360mg 2 MO diltiazem hcl er capsule extended release 24 hour 420mg 2 MO DILTIAZEM HCL INJECTION 100MG 4 diltiazem hcl injection 50mg/10ml 4 diltiazem hcl tablet 120mg 1 MO diltiazem hcl tablet 30mg 1 MO diltiazem hcl tablet 60mg 1 MO diltiazem hcl tablet 90mg 1 MO felodipine er tablet extended release 24 hour 10mg 2 MO felodipine er tablet extended release 24 hour 2.5mg 2 MO felodipine er tablet extended release 24 hour 5mg 2 MO isradipine capsule 2.5mg 2 MO isradipine capsule 5mg 2 MO matzim la tablet extended release 24 hour 180mg 2 MO matzim la tablet extended release 24 hour 240mg 2 MO matzim la tablet extended release 24 hour 300mg 2 MO matzim la tablet extended release 24 hour 360mg 2 MO matzim la tablet extended release 24 hour 420mg 2 MO nicardipine hcl capsule 20mg 2 MO nicardipine hcl capsule 30mg 2 MO nicardipine hcl injection 2.5mg/ml 4 MO nifedical xl tablet extended release 24 hour 30mg 2 MO nifedical xl tablet extended release 24 hour 60mg 2 MO nifedipine er tablet extended release 24 hour 30mg 2 MO nifedipine er tablet extended release 24 hour 60mg 2 MO nifedipine er tablet extended release 24 hour 90mg 2 MO nisoldipine er tablet extended release 24 hour 25.5mg 2 MO nisoldipine tablet extended release 24 hour 17mg 2 MO nisoldipine tablet extended release 24 hour 20mg 2 MO 32

34 Name nisoldipine tablet extended release 24 hour 30mg 2 MO nisoldipine tablet extended release 24 hour 34mg 2 MO nisoldipine tablet extended release 24 hour 40mg 2 MO nisoldipine tablet extended release 24 hour 8.5mg 2 MO taztia xt capsule extended release 24 hour 120mg 2 MO taztia xt capsule extended release 24 hour 180mg 2 MO taztia xt capsule extended release 24 hour 240mg 2 MO taztia xt capsule extended release 24 hour 300mg 2 MO taztia xt capsule extended release 24 hour 360mg 2 MO verapamil hcl er capsule extended release 24 hour 100mg 2 MO verapamil hcl er capsule extended release 24 hour 120mg 1 MO verapamil hcl er capsule extended release 24 hour 180mg 1 MO verapamil hcl er capsule extended release 24 hour 200mg 2 MO verapamil hcl er capsule extended release 24 hour 240mg 1 MO verapamil hcl er capsule extended release 24 hour 300mg 2 MO verapamil hcl er tablet extended release 120mg 1 MO verapamil hcl er tablet extended release 180mg 1 MO verapamil hcl er tablet extended release 240mg 1 MO verapamil hcl sr capsule extended release 24 hour 360mg 1 MO verapamil hcl injection 2.5mg/ml 4 verapamil hcl tablet 120mg 1 MO verapamil hcl tablet 40mg 1 MO verapamil hcl tablet 80mg 1 MO CARDIAC GLYCOSIDES digoxin injection 0.25mg/ml 4 digoxin solution 0.05mg/ml 2 MO digoxin tablet 125mcg 1 QL (30 EA per 30 days) MO digoxin tablet 250mcg 1 PA MO LANOXIN INJECTION 0.25MG/ML 3 MO LANOXIN TABLET 125MCG 3 QL (30 EA per 30 days) MO LANOXIN TABLET 187.5MCG 3 MO LANOXIN TABLET 250MCG 3 MO LANOXIN TABLET 62.5MCG 3 MO CENTRALLY ACTING ANTIHYPERTENSIVES clonidine hcl patch weekly 0.1mg/24hr 2 QL (4 EA per 28 days) MO clonidine hcl patch weekly 0.2mg/24hr 2 QL (4 EA per 28 days) MO clonidine hcl patch weekly 0.3mg/24hr 2 QL (4 EA per 28 days) MO clonidine hcl tablet 0.1mg 2 MO clonidine hcl tablet 0.2mg 2 MO clonidine hcl tablet 0.3mg 2 MO guanfacine hcl tablet 1mg 2 MO guanfacine hcl tablet 2mg 2 MO methyldopa tablet 250mg 2 MO methyldopa tablet 500mg 2 MO METHYLDOPATE HCL INJECTION 250MG/5ML 4 reserpine tablet 0.1mg 2 MO reserpine tablet 0.25mg 2 MO HMG-COA COMBINATIONS 33

35 Name ADVICOR TABLET EXTENDED RELEASE 24 HOUR 3 QL (60 EA per 30 days) MO 20MG; 1000MG ADVICOR TABLET EXTENDED RELEASE 24 HOUR 3 QL (30 EA per 30 days) MO 20MG; 500MG ADVICOR TABLET EXTENDED RELEASE 24 HOUR 3 QL (60 EA per 30 days) MO 20MG; 750MG ADVICOR TABLET EXTENDED RELEASE 24 HOUR 40MG; 1000MG 3 QL (30 EA per 30 days) MO amlodipine besylate/atorvastatin calcium tablet 10mg; 10mg 2 amlodipine besylate/atorvastatin calcium tablet 10mg; 20mg 2 amlodipine besylate/atorvastatin calcium tablet 10mg; 40mg 2 amlodipine besylate/atorvastatin calcium tablet 10mg; 80mg 2 amlodipine besylate/atorvastatin calcium tablet 2.5mg; 10mg 2 amlodipine besylate/atorvastatin calcium tablet 2.5mg; 20mg 2 amlodipine besylate/atorvastatin calcium tablet 2.5mg; 40mg 2 amlodipine besylate/atorvastatin calcium tablet 5mg; 10mg 2 amlodipine besylate/atorvastatin calcium tablet 5mg; 20mg 2 amlodipine besylate/atorvastatin calcium tablet 5mg; 40mg 2 amlodipine besylate/atorvastatin calcium tablet 5mg; 80mg 2 SIMCOR TABLET EXTENDED RELEASE 24 HOUR 3 QL (30 EA per 30 days) MO 1000MG; 40MG SIMCOR TABLET EXTENDED RELEASE 24 HOUR 3 QL (30 EA per 30 days) MO 500MG; 20MG SIMCOR TABLET EXTENDED RELEASE 24 HOUR 3 QL (30 EA per 30 days) MO 500MG; 40MG SIMCOR TABLET EXTENDED RELEASE 24 HOUR 3 QL (60 EA per 30 days) MO 750MG; 20MG VYTORIN TABLET 10MG; 10MG 3 QL (30 EA per 30 days) MO VYTORIN TABLET 10MG; 20MG 3 QL (30 EA per 30 days) MO VYTORIN TABLET 10MG; 40MG 3 QL (30 EA per 30 days) MO VYTORIN TABLET 10MG; 80MG 3 QL (30 EA per 30 days) MO HMG-COA REDUCTASE INHIBITORS atorvastatin calcium tablet 10mg 1 QL (30 EA per 30 days) MO atorvastatin calcium tablet 20mg 1 QL (30 EA per 30 days) MO atorvastatin calcium tablet 40mg 1 QL (30 EA per 30 days) MO atorvastatin calcium tablet 80mg 1 QL (30 EA per 30 days) MO CRESTOR TABLET 10MG 3 QL (30 EA per 30 days) MO CRESTOR TABLET 20MG 3 QL (30 EA per 30 days) MO CRESTOR TABLET 40MG 3 QL (30 EA per 30 days) MO CRESTOR TABLET 5MG 3 QL (30 EA per 30 days) MO fluvastatin capsule 20mg 2 QL (30 EA per 30 days) MO fluvastatin capsule 40mg 2 QL (60 EA per 30 days) MO lovastatin tablet 10mg 1 QL (30 EA per 30 days) MO lovastatin tablet 20mg 1 QL (120 EA per 30 days) MO lovastatin tablet 40mg 1 QL (60 EA per 30 days) MO pravastatin sodium tablet 10mg 1 MO pravastatin sodium tablet 20mg 1 MO pravastatin sodium tablet 40mg 1 MO pravastatin sodium tablet 80mg 1 MO 34

36 Name simvastatin tablet 10mg 1 QL (30 EA per 30 days) MO simvastatin tablet 20mg 1 QL (30 EA per 30 days) MO simvastatin tablet 40mg 1 QL (30 EA per 30 days) MO simvastatin tablet 5mg 1 QL (30 EA per 30 days) MO simvastatin tablet 80mg 1 QL (30 EA per 30 days) MO LOOP DIURETICS bumetanide injection 0.25mg/ml 4 bumetanide tablet 0.5mg 2 MO bumetanide tablet 1mg 2 MO bumetanide tablet 2mg 2 MO EDECRIN TABLET 25MG 3 MO ethacrynate sodium injection 50mg 4 furosemide injection 10mg/ml 4 furosemide injection 10mg/ml 4 furosemide solution 10mg/ml 2 MO furosemide solution 8mg/ml 2 MO furosemide tablet 20mg 1 MO furosemide tablet 40mg 1 MO furosemide tablet 80mg 1 MO torsemide tablet 100mg 2 MO torsemide tablet 10mg 2 MO torsemide tablet 20mg 2 MO torsemide tablet 5mg 2 MO NITRATES ISORDIL TITRADOSE TABLET 40MG 3 MO ISORDIL TITRADOSE TABLET 5MG 3 isosorbide dinitrate er tablet extended release 40mg 2 MO isosorbide dinitrate tablet 10mg 2 MO isosorbide dinitrate tablet 20mg 2 MO isosorbide dinitrate tablet 30mg 2 MO isosorbide dinitrate tablet 5mg 2 MO isosorbide mononitrate er tablet extended release 24 hour 1 MO 120mg isosorbide mononitrate er tablet extended release 24 hour 1 MO 30mg isosorbide mononitrate er tablet extended release 24 hour 1 MO 60mg isosorbide mononitrate tablet 10mg 1 MO isosorbide mononitrate tablet 20mg 1 MO NITRO-BID OINTMENT 2% 3 MO nitroglycerin lingual solution 0.4mg/spray 2 nitroglycerin transdermal patch 24 hour 0.1mg/hr 2 MO nitroglycerin transdermal patch 24 hour 0.2mg/hr 2 MO nitroglycerin transdermal patch 24 hour 0.4mg/hr 2 MO nitroglycerin transdermal patch 24 hour 0.6mg/hr 2 MO NITROGLYCERIN INJECTION 5MG/ML 4 NITROLINGUAL PUMPSPRAY SOLUTION 3 MO 0.4MG/SPRAY NITROMIST AEROSOL SOLUTION 400MCG/SPRAY 3 MO 35

37 Name NITROSTAT TABLET SUBLINGUAL 0.3MG 3 MO NITROSTAT TABLET SUBLINGUAL 0.4MG 3 MO NITROSTAT TABLET SUBLINGUAL 0.6MG 3 MO RECTIV OINTMENT 0.4% 3 ORAL ANTICOAGULANTS COUMADIN TABLET 10MG 3 COUMADIN TABLET 1MG 3 COUMADIN TABLET 2.5MG 3 COUMADIN TABLET 2MG 3 COUMADIN TABLET 3MG 3 COUMADIN TABLET 4MG 3 COUMADIN TABLET 5MG 3 COUMADIN TABLET 6MG 3 COUMADIN TABLET 7.5MG 3 ELIQUIS TABLET 2.5MG 3 MO ELIQUIS TABLET 5MG 3 MO jantoven tablet 10mg 1 jantoven tablet 1mg 1 jantoven tablet 2.5mg 1 jantoven tablet 2mg 1 jantoven tablet 3mg 1 jantoven tablet 4mg 1 jantoven tablet 5mg 1 jantoven tablet 6mg 1 jantoven tablet 7.5mg 1 PRADAXA CAPSULE 150MG 3 MO PRADAXA CAPSULE 75MG 3 MO SAVAYSA TABLET 15MG 3 MO SAVAYSA TABLET 30MG 3 MO SAVAYSA TABLET 60MG 3 MO warfarin sodium tablet 10mg 1 warfarin sodium tablet 1mg 1 warfarin sodium tablet 2.5mg 1 warfarin sodium tablet 2mg 1 warfarin sodium tablet 3mg 1 warfarin sodium tablet 4mg 1 warfarin sodium tablet 5mg 1 warfarin sodium tablet 6mg 1 warfarin sodium tablet 7.5mg 1 XARELTO STARTER PACK TABLET THERAPY PACK 0 3 MO XARELTO TABLET 10MG 3 MO XARELTO TABLET 15MG 3 MO XARELTO TABLET 20MG 3 MO OTHER ANTIHYPERTENSIVES amlodipine besylate/valsartan tablet 10mg; 160mg 2 MO amlodipine besylate/valsartan tablet 10mg; 320mg 2 MO amlodipine besylate/valsartan tablet 5mg; 160mg 2 MO amlodipine besylate/valsartan tablet 5mg; 320mg 2 MO amlodipine/valsartan/hctz tablet 10mg; 12.5mg; 160mg 2 MO 36

38 Name amlodipine/valsartan/hctz tablet 10mg; 25mg; 160mg 2 MO amlodipine/valsartan/hctz tablet 10mg; 25mg; 320mg 2 MO amlodipine/valsartan/hctz tablet 5mg; 12.5mg; 160mg 2 MO amlodipine/valsartan/hctz tablet 5mg; 25mg; 160mg 2 MO atenolol/chlorthalidone tablet 100mg; 25mg 1 MO atenolol/chlorthalidone tablet 50mg; 25mg 1 MO benazepril hcl/hydrochlorothiazide tablet 10mg; 12.5mg 1 MO benazepril hcl/hydrochlorothiazide tablet 20mg; 12.5mg 1 MO benazepril hcl/hydrochlorothiazide tablet 20mg; 25mg 1 MO benazepril hcl/hydrochlorothiazide tablet 5mg; 6.25mg 1 MO bisoprolol fumarate/hydrochlorothiazide tablet 10mg; 6.25mg 1 MO bisoprolol fumarate/hydrochlorothiazide tablet 2.5mg; 6.25mg1 MO bisoprolol fumarate/hydrochlorothiazide tablet 5mg; 6.25mg 1 MO candesartan cilexetil/hydrochlorothiazide tablet 16mg; 12.5mg2 MO candesartan cilexetil/hydrochlorothiazide tablet 32mg; 12.5mg2 MO candesartan cilexetil/hydrochlorothiazide tablet 32mg; 25mg 2 MO captopril/hydrochlorothiazide tablet 25mg; 15mg 1 MO captopril/hydrochlorothiazide tablet 25mg; 25mg 1 MO captopril/hydrochlorothiazide tablet 50mg; 15mg 1 MO captopril/hydrochlorothiazide tablet 50mg; 25mg 1 MO CLORPRES TABLET 15MG; 0.1MG 3 MO CLORPRES TABLET 15MG; 0.2MG 3 MO CLORPRES TABLET 15MG; 0.3MG 3 MO enalapril maleate/hydrochlorothiazide tablet 10mg; 25mg 1 MO enalapril maleate/hydrochlorothiazide tablet 5mg; 12.5mg 1 MO fosinopril sodium/hydrochlorothiazide tablet 10mg; 12.5mg 2 MO fosinopril sodium/hydrochlorothiazide tablet 20mg; 12.5mg 2 MO irbesartan/hydrochlorothiazide tablet 12.5mg; 150mg 2 MO irbesartan/hydrochlorothiazide tablet 12.5mg; 300mg 2 MO lisinopril/hydrochlorothiazide tablet 12.5mg; 10mg 1 MO lisinopril/hydrochlorothiazide tablet 12.5mg; 20mg 1 MO lisinopril/hydrochlorothiazide tablet 25mg; 20mg 1 MO losartan potassium/hydrochlorothiazide tablet 12.5mg; 100mg 1 MO losartan potassium/hydrochlorothiazide tablet 12.5mg; 50mg 1 MO losartan potassium/hydrochlorothiazide tablet 25mg; 100mg 1 MO methyldopa/hydrochlorothiazide tablet 15mg; 250mg 2 MO methyldopa/hydrochlorothiazide tablet 25mg; 250mg 2 MO metoprolol/hydrochlorothiazide tablet 25mg; 100mg 2 MO metoprolol/hydrochlorothiazide tablet 25mg; 50mg 2 MO metoprolol/hydrochlorothiazide tablet 50mg; 100mg 2 MO moexipril/hydrochlorothiazide tablet 12.5mg; 15mg 2 MO moexipril/hydrochlorothiazide tablet 12.5mg; 7.5mg 2 MO moexipril/hydrochlorothiazide tablet 25mg; 15mg 2 MO nadolol/bendroflumethiazide tablet 5mg; 40mg 2 MO nadolol/bendroflumethiazide tablet 5mg; 80mg 2 MO propranolol/hydrochlorothiazide tablet 25mg; 40mg 1 MO propranolol/hydrochlorothiazide tablet 25mg; 80mg 1 MO quinapril/hydrochlorothiazide tablet 12.5mg; 10mg 2 MO quinapril/hydrochlorothiazide tablet 12.5mg; 20mg 2 MO 37

39 Name quinapril/hydrochlorothiazide tablet 25mg; 20mg 2 MO telmisartan/amlodipine tablet 10mg; 40mg 2 MO telmisartan/amlodipine tablet 10mg; 80mg 2 MO telmisartan/amlodipine tablet 5mg; 40mg 2 MO telmisartan/amlodipine tablet 5mg; 80mg 2 MO telmisartan/hydrochlorothiazide tablet 12.5mg; 40mg 2 telmisartan/hydrochlorothiazide tablet 12.5mg; 80mg 2 telmisartan/hydrochlorothiazide tablet 25mg; 80mg 2 valsartan/hydrochlorothiazide tablet 12.5mg; 160mg 2 MO valsartan/hydrochlorothiazide tablet 12.5mg; 320mg 2 MO valsartan/hydrochlorothiazide tablet 12.5mg; 80mg 2 MO valsartan/hydrochlorothiazide tablet 25mg; 160mg 2 MO valsartan/hydrochlorothiazide tablet 25mg; 320mg 2 MO OTHER CARDIOVASCULAR DRUGS ADRENALIN INJECTION 1MG/ML 3 DEMSER CAPSULE 250MG 3 MO DIBENZYLINE CAPSULE 10MG 3 MO midodrine hcl tablet 10mg 2 MO midodrine hcl tablet 2.5mg 2 MO midodrine hcl tablet 5mg 2 MO NORTHERA CAPSULE 100MG 3 NORTHERA CAPSULE 200MG 3 NORTHERA CAPSULE 300MG 3 pentoxifylline er tablet extended release 400mg 2 MO phenoxybenzamine hydrochloride capsule 10mg 2 RANEXA TABLET EXTENDED RELEASE 12 HOUR 3 MO 1000MG RANEXA TABLET EXTENDED RELEASE 12 HOUR 500MG 3 MO trandolapril/verapamil hcl tablet extended release 1mg; 240mg2 trandolapril/verapamil hcl tablet extended release 2mg; 180mg2 trandolapril/verapamil hcl tablet extended release 2mg; 240mg2 trandolapril/verapamil hcl tablet extended release 4mg; 240mg2 VECAMYL TABLET 2.5MG 3 OTHER LIPID-LOWERING DRUGS cholestyramine light packet 4gm 2 MO colestipol hcl granules 5gm 2 MO colestipol hcl tablet 1gm 2 MO fenofibrate micronized capsule 134mg 2 MO fenofibrate micronized capsule 200mg 2 MO fenofibrate micronized capsule 67mg 2 MO fenofibrate capsule 130mg 2 fenofibrate capsule 150mg 2 fenofibrate capsule 43mg 2 fenofibrate capsule 50mg 2 fenofibrate tablet 120mg 2 MO fenofibrate tablet 145mg 2 MO fenofibrate tablet 160mg 2 MO fenofibrate tablet 48mg 2 MO 38

40 Name fenofibrate tablet 54mg 2 MO fenofibric acid dr capsule delayed release 135mg 2 fenofibric acid dr capsule delayed release 45mg 2 gemfibrozil tablet 600mg 2 MO KYNAMRO INJECTION 200MG/ML 5 PA LOVAZA CAPSULE 375MG; 465MG; 1GM 3 MO niacin er tablet extended release 1000mg 2 niacin er tablet extended release 500mg 2 niacin er tablet extended release 750mg 2 NIACOR TABLET 500MG 3 MO omega-3-acid ethyl esters capsule 375mg; 465mg; 1gm 2 prevalite powder 4gm/dose 2 MO WELCHOL PACKET 3.75GM 3 MO WELCHOL TABLET 625MG 3 MO ZETIA TABLET 10MG 3 MO OTHER VASODILATING DRUGS hydralazine hcl injection 20mg/ml 4 hydralazine hcl tablet 100mg 2 MO hydralazine hcl tablet 10mg 2 MO hydralazine hcl tablet 25mg 2 MO hydralazine hcl tablet 50mg 2 MO minoxidil tablet 10mg 2 MO minoxidil tablet 2.5mg 2 MO ORENITRAM TABLET EXTENDED RELEASE 0.125MG 3 PA ORENITRAM TABLET EXTENDED RELEASE 0.25MG 5 PA ORENITRAM TABLET EXTENDED RELEASE 1MG 5 PA ORENITRAM TABLET EXTENDED RELEASE 2.5MG 5 PA REMODULIN INJECTION 10MG/ML 5 PA LA REMODULIN INJECTION 1MG/ML 5 PA LA REMODULIN INJECTION 2.5MG/ML 5 PA LA REMODULIN INJECTION 5MG/ML 5 PA LA TYVASO SOLUTION 0.6MG/ML 5 B/D VENTAVIS SOLUTION 10MCG/ML 3 B/D VENTAVIS SOLUTION 20MCG/ML 3 B/D POTASSIUM SPARING DIURETICS amiloride hcl tablet 5mg 2 MO amiloride/hydrochlorothiazide tablet 5mg; 50mg 1 MO DYRENIUM CAPSULE 0; 100MG 3 MO DYRENIUM CAPSULE 50MG 3 MO eplerenone tablet 25mg 2 MO eplerenone tablet 50mg 2 MO spironolactone/hydrochlorothiazide tablet 25mg; 25mg 1 MO spironolactone tablet 100mg 1 MO spironolactone tablet 25mg 1 MO spironolactone tablet 50mg 1 MO triamterene/hydrochlorothiazide capsule 25mg; 37.5mg 1 MO triamterene/hydrochlorothiazide capsule 25mg; 50mg 1 MO triamterene/hydrochlorothiazide tablet 25mg; 37.5mg 1 MO triamterene/hydrochlorothiazide tablet 50mg; 75mg 1 MO 39

41 Name THIAZIDE AND RELATED DRUGS chlorothiazide sodium injection 500mg 4 chlorothiazide tablet 250mg 2 MO chlorothiazide tablet 500mg 2 MO chlorthalidone tablet 25mg 1 MO chlorthalidone tablet 50mg 1 MO DIURIL SUSPENSION 250MG/5ML 3 MO hydrochlorothiazide capsule 12.5mg 1 MO hydrochlorothiazide tablet 12.5mg 1 MO hydrochlorothiazide tablet 25mg 1 MO hydrochlorothiazide tablet 50mg 1 MO indapamide tablet 1.25mg 1 MO indapamide tablet 2.5mg 1 MO methyclothiazide tablet 5mg 2 MO metolazone tablet 10mg 2 MO metolazone tablet 2.5mg 2 MO metolazone tablet 5mg 2 MO VASODILATOR ANTIHYPERTENSIVES doxazosin mesylate tablet 1mg 2 QL (30 EA per 30 days) MO doxazosin mesylate tablet 2mg 2 MO doxazosin mesylate tablet 4mg 2 QL (30 EA per 30 days) MO doxazosin mesylate tablet 8mg 2 QL (60 EA per 30 days) MO prazosin hcl capsule 1mg 2 MO prazosin hcl capsule 2mg 2 MO prazosin hcl capsule 5mg 2 MO terazosin hcl capsule 10mg 2 QL (60 EA per 30 days) MO terazosin hcl capsule 1mg 2 QL (30 EA per 30 days) MO terazosin hcl capsule 2mg 2 MO terazosin hcl capsule 5mg 2 QL (30 EA per 30 days) MO CENTRAL NERVOUS SYSTEM ANTICONVULSANTS APTIOM TABLET 200MG 3 APTIOM TABLET 400MG 3 APTIOM TABLET 600MG 3 APTIOM TABLET 800MG 3 BANZEL SUSPENSION 40MG/ML 3 MO BANZEL TABLET 200MG 3 MO BANZEL TABLET 400MG 3 MO CELONTIN CAPSULE 300MG 3 MO CEREBYX INJECTION 500MG PE/10ML 4 clonazepam odt tablet dispersible 0.125mg 2 QL (4800 EA per 30 days) clonazepam odt tablet dispersible 0.25mg 2 QL (2400 EA per 30 days) clonazepam odt tablet dispersible 0.5mg 2 QL (1200 EA per 30 days) clonazepam odt tablet dispersible 1mg 2 QL (600 EA per 30 days) clonazepam odt tablet dispersible 2mg 2 QL (300 EA per 30 days) clonazepam tablet 0.5mg 2 QL (1200 EA per 30 days) clonazepam tablet 1mg 2 QL (600 EA per 30 days) clonazepam tablet 2mg 2 QL (300 EA per 30 days) DIASTAT ACUDIAL GEL 10MG 3 40

42 Name DIASTAT ACUDIAL GEL 20MG 3 DIASTAT PEDIATRIC GEL 2.5MG 3 diazepam intensol concentrate 5mg/ml 2 QL (240 ML per 30 days) diazepam gel 10mg 2 diazepam gel 2.5mg 2 diazepam gel 20mg 2 diazepam solution 1mg/ml 2 QL (1200 ML per 30 days) diazepam tablet 10mg 2 QL (120 EA per 30 days) diazepam tablet 2mg 2 QL (120 EA per 30 days) diazepam tablet 5mg 2 QL (120 EA per 30 days) divalproex sodium dr tablet delayed release 125mg 2 MO divalproex sodium dr tablet delayed release 250mg 2 MO divalproex sodium dr tablet delayed release 500mg 2 MO divalproex sodium er tablet extended release 24 hour 250mg 2 MO divalproex sodium er tablet extended release 24 hour 500mg 2 MO divalproex sodium capsule sprinkle 125mg 2 MO ethosuximide capsule 250mg 2 MO ethosuximide solution 250mg/5ml 2 MO felbamate suspension 600mg/5ml 2 felbamate tablet 400mg 2 felbamate tablet 600mg 2 fosphenytoin sodium injection 100mg pe/2ml 4 FYCOMPA TABLET 10MG 3 QL (30 EA per 30 days) FYCOMPA TABLET 12MG 3 QL (30 EA per 30 days) FYCOMPA TABLET 2MG 3 QL (180 EA per 30 days) FYCOMPA TABLET 4MG 3 QL (90 EA per 30 days) FYCOMPA TABLET 6MG 3 QL (60 EA per 30 days) FYCOMPA TABLET 8MG 3 QL (30 EA per 30 days) gabapentin capsule 100mg 1 QL (1080 EA per 30 days) MO gabapentin capsule 300mg 1 QL (360 EA per 30 days) MO gabapentin capsule 400mg 1 QL (270 EA per 30 days) MO gabapentin solution 250mg/5ml 2 QL (2160 ML per 30 days) MO gabapentin tablet 600mg 1 QL (180 EA per 30 days) MO gabapentin tablet 800mg 1 QL (120 EA per 30 days) MO GABITRIL TABLET 12MG 3 MO GABITRIL TABLET 16MG 3 MO GRALISE STARTER MISCELLANEOUS 0 3 GRALISE TABLET 300MG 3 GRALISE TABLET 600MG 3 HORIZANT TABLET EXTENDED RELEASE 300MG 3 HORIZANT TABLET EXTENDED RELEASE 600MG 3 LAMICTAL ODT TABLET DISPERSIBLE 100MG 3 MO LAMICTAL ODT TABLET DISPERSIBLE 200MG 3 MO LAMICTAL ODT TABLET DISPERSIBLE 25MG 3 MO LAMICTAL ODT TABLET DISPERSIBLE 50MG 3 MO LAMICTAL XR KIT 0 3 MO LAMICTAL XR KIT 0 3 MO LAMICTAL XR KIT 0 3 MO lamotrigine er tablet extended release 24 hour 100mg 2 MO 41

43 Name lamotrigine er tablet extended release 24 hour 200mg 2 MO lamotrigine er tablet extended release 24 hour 250mg 2 MO lamotrigine er tablet extended release 24 hour 25mg 2 MO lamotrigine er tablet extended release 24 hour 300mg 2 MO lamotrigine er tablet extended release 24 hour 50mg 2 MO lamotrigine odt tablet dispersible 100mg 2 MO lamotrigine odt tablet dispersible 200mg 2 MO lamotrigine odt tablet dispersible 25mg 2 MO lamotrigine odt tablet dispersible 50mg 2 MO lamotrigine tablet chewable 25mg 2 MO lamotrigine tablet chewable 5mg 2 MO lamotrigine tablet 100mg 2 MO lamotrigine tablet 150mg 2 MO lamotrigine tablet 200mg 2 MO lamotrigine tablet 25mg 2 MO levetiracetam er tablet extended release 24 hour 500mg 2 levetiracetam er tablet extended release 24 hour 750mg 2 levetiracetam injection 1000mg/100ml; 750mg/100ml 4 levetiracetam injection 1500mg/100ml; 540mg/100ml 4 levetiracetam injection 500mg/100ml; 820mg/100ml 4 levetiracetam injection 500mg/5ml 4 levetiracetam solution 100mg/ml 2 MO levetiracetam tablet 1000mg 2 MO levetiracetam tablet 250mg 2 MO levetiracetam tablet 500mg 2 MO levetiracetam tablet 750mg 2 MO LYRICA CAPSULE 100MG 3 QL (120 EA per 30 days) MO LYRICA CAPSULE 150MG 3 QL (120 EA per 30 days) MO LYRICA CAPSULE 200MG 3 QL (90 EA per 30 days) MO LYRICA CAPSULE 225MG 3 QL (60 EA per 30 days) MO LYRICA CAPSULE 25MG 3 QL (120 EA per 30 days) MO LYRICA CAPSULE 300MG 3 QL (60 EA per 30 days) MO LYRICA CAPSULE 50MG 3 QL (120 EA per 30 days) MO LYRICA CAPSULE 75MG 3 QL (120 EA per 30 days) MO LYRICA SOLUTION 20MG/ML 3 QL (946 ML per 30 days) MO ONFI SUSPENSION 2.5MG/ML 3 ONFI TABLET 10MG 3 ONFI TABLET 20MG 3 phenobarbital elixir 20mg/5ml 2 PA phenobarbital tablet 100mg 2 PA phenobarbital tablet 15mg 2 PA phenobarbital tablet 16.2mg 2 PA phenobarbital tablet 30mg 2 PA phenobarbital tablet 32.4mg 2 PA phenobarbital tablet 60mg 2 PA phenobarbital tablet 64.8mg 2 PA phenobarbital tablet 97.2mg 2 PA POTIGA TABLET 200MG 3 QL (180 EA per 30 days) POTIGA TABLET 300MG 3 QL (90 EA per 30 days) 42

44 Name POTIGA TABLET 400MG 3 QL (90 EA per 30 days) POTIGA TABLET 50MG 3 primidone tablet 250mg 2 MO primidone tablet 50mg 2 MO QUDEXY XR CAPSULE ER 24 HOUR SPRINKLE 100MG 3 QUDEXY XR CAPSULE ER 24 HOUR SPRINKLE 150MG 3 QUDEXY XR CAPSULE ER 24 HOUR SPRINKLE 200MG 3 QUDEXY XR CAPSULE ER 24 HOUR SPRINKLE 25MG 3 QUDEXY XR CAPSULE ER 24 HOUR SPRINKLE 50MG 3 SABRIL PACKET 500MG 5 QL (180 EA per 30 days) LA SABRIL TABLET 500MG 5 QL (180 EA per 30 days) LA tiagabine hydrochloride tablet 2mg 2 MO tiagabine hydrochloride tablet 4mg 2 MO TOPIRAMATE ER CAPSULE ER 24 HOUR SPRINKLE 3 PA 100MG TOPIRAMATE ER CAPSULE ER 24 HOUR SPRINKLE 3 PA 150MG TOPIRAMATE ER CAPSULE ER 24 HOUR SPRINKLE 3 PA 200MG TOPIRAMATE ER CAPSULE ER 24 HOUR SPRINKLE 3 PA 25MG TOPIRAMATE ER CAPSULE ER 24 HOUR SPRINKLE 3 PA 50MG topiramate capsule sprinkle 15mg 2 PA MO topiramate capsule sprinkle 25mg 2 PA MO topiramate tablet 100mg 2 PA MO topiramate tablet 200mg 2 PA MO topiramate tablet 25mg 2 PA MO topiramate tablet 50mg 2 PA MO TROKENDI XR CAPSULE EXTENDED RELEASE 24 3 PA HOUR 100MG TROKENDI XR CAPSULE EXTENDED RELEASE 24 3 PA HOUR 200MG TROKENDI XR CAPSULE EXTENDED RELEASE 24 3 PA HOUR 25MG TROKENDI XR CAPSULE EXTENDED RELEASE 24 3 PA HOUR 50MG valproate sodium injection 500mg/5ml 4 valproic acid capsule 250mg 2 MO valproic acid syrup 250mg/5ml 2 MO VIMPAT INJECTION 200MG/20ML 4 VIMPAT SOLUTION 10MG/ML 3 QL (1200 ML per 30 days) MO VIMPAT TABLET 100MG 3 QL (60 EA per 30 days) MO VIMPAT TABLET 150MG 3 QL (60 EA per 30 days) MO VIMPAT TABLET 200MG 3 QL (60 EA per 30 days) MO VIMPAT TABLET 50MG 3 QL (180 EA per 30 days) MO zonisamide capsule 100mg 2 PA MO zonisamide capsule 25mg 2 PA MO zonisamide capsule 50mg 2 PA MO 43

45 Name ANTIDEMENTIA donepezil hcl tablet dispersible 10mg 2 MO donepezil hcl tablet dispersible 5mg 2 QL (30 EA per 30 days) MO donepezil hcl tablet 10mg 2 MO donepezil hcl tablet 23mg 2 donepezil hcl tablet 5mg 2 QL (30 EA per 30 days) MO EXELON PATCH 24 HOUR 13.3MG/24HR 3 QL (30 EA per 30 days) ST MO EXELON PATCH 24 HOUR 4.6MG/24HR 3 QL (30 EA per 30 days) ST MO EXELON PATCH 24 HOUR 9.5MG/24HR 3 QL (30 EA per 30 days) ST MO galantamine hydrobromide capsule extended release 24 hour 2 QL (30 EA per 30 days) MO 16mg galantamine hydrobromide capsule extended release 24 hour 2 MO 24mg galantamine hydrobromide capsule extended release 24 hour 2 QL (30 EA per 30 days) MO 8mg galantamine hydrobromide solution 4mg/ml 2 MO galantamine hydrobromide tablet 12mg 2 MO galantamine hydrobromide tablet 4mg 2 QL (180 EA per 30 days) MO galantamine hydrobromide tablet 8mg 2 QL (90 EA per 30 days) MO memantine hcl titration pak tablet 0 2 MO memantine hcl tablet 10mg 2 MO memantine hcl tablet 5mg 2 MO NAMENDA TITRATION PAK TABLET 0 3 MO NAMENDA XR TITRATION PACK CAPSULE 3 MO EXTENDED RELEASE 24 HOUR 0 NAMENDA XR CAPSULE EXTENDED RELEASE 24 3 QL (30 EA per 30 days) MO HOUR 14MG NAMENDA XR CAPSULE EXTENDED RELEASE 24 3 MO HOUR 21MG NAMENDA XR CAPSULE EXTENDED RELEASE 24 3 MO HOUR 28MG NAMENDA XR CAPSULE EXTENDED RELEASE 24 3 QL (30 EA per 30 days) MO HOUR 7MG NAMENDA SOLUTION 10MG/5ML 3 MO NAMENDA TABLET 10MG 3 MO NAMENDA TABLET 5MG 3 MO rivastigmine tartrate capsule 1.5mg 2 MO rivastigmine tartrate capsule 3mg 2 MO rivastigmine tartrate capsule 4.5mg 2 MO rivastigmine tartrate capsule 6mg 2 MO ANTIPARKINSON ANTICHOLINERGIC benztropine mesylate injection 1mg/ml 4 PA benztropine mesylate tablet 0.5mg 1 PA MO benztropine mesylate tablet 1mg 1 PA MO benztropine mesylate tablet 2mg 1 PA MO trihexyphenidyl hcl elixir 0.4mg/ml 2 PA MO trihexyphenidyl hcl tablet 2mg 1 PA MO trihexyphenidyl hcl tablet 5mg 1 PA MO ANTIPSYCHOTICS 44

46 Name ABILIFY MAINTENA INJECTION 300MG 4 QL (1 EA per 28 days) PA ABILIFY MAINTENA INJECTION 300MG 4 PA ABILIFY MAINTENA INJECTION 400MG 4 PA ABILIFY TABLET 10MG 3 QL (30 EA per 30 days) ABILIFY TABLET 15MG 3 QL (30 EA per 30 days) ABILIFY TABLET 20MG 3 QL (30 EA per 30 days) ABILIFY TABLET 2MG 3 QL (30 EA per 30 days) ABILIFY TABLET 30MG 3 QL (30 EA per 30 days) ABILIFY TABLET 5MG 3 QL (30 EA per 30 days) aripiprazole tablet 10mg 2 QL (30 EA per 30 days) aripiprazole tablet 15mg 2 QL (30 EA per 30 days) aripiprazole tablet 20mg 2 QL (30 EA per 30 days) aripiprazole tablet 2mg 2 QL (30 EA per 30 days) aripiprazole tablet 30mg 2 QL (30 EA per 30 days) aripiprazole tablet 5mg 2 QL (30 EA per 30 days) CHLORPROMAZINE HCL INJECTION 50MG/2ML 4 chlorpromazine hcl tablet 100mg 2 chlorpromazine hcl tablet 10mg 2 chlorpromazine hcl tablet 200mg 2 chlorpromazine hcl tablet 25mg 2 chlorpromazine hcl tablet 50mg 2 clozapine odt tablet dispersible 100mg 2 clozapine odt tablet dispersible 12.5mg 2 clozapine odt tablet dispersible 150mg 2 clozapine odt tablet dispersible 200mg 2 clozapine odt tablet dispersible 25mg 2 clozapine tablet 100mg 2 QL (270 EA per 30 days) clozapine tablet 200mg 2 QL (135 EA per 30 days) clozapine tablet 25mg 2 clozapine tablet 50mg 2 FANAPT TITRATION PACK TABLET 0 3 FANAPT TABLET 10MG 3 QL (60 EA per 30 days) FANAPT TABLET 12MG 3 QL (60 EA per 30 days) FANAPT TABLET 1MG 3 QL (60 EA per 30 days) FANAPT TABLET 2MG 3 QL (60 EA per 30 days) FANAPT TABLET 4MG 3 QL (60 EA per 30 days) FANAPT TABLET 6MG 3 QL (60 EA per 30 days) FANAPT TABLET 8MG 3 QL (60 EA per 30 days) FAZACLO TABLET DISPERSIBLE 100MG 3 FAZACLO TABLET DISPERSIBLE 12.5MG 3 FAZACLO TABLET DISPERSIBLE 150MG 3 FAZACLO TABLET DISPERSIBLE 200MG 3 FAZACLO TABLET DISPERSIBLE 25MG 3 fluphenazine decanoate injection 25mg/ml 4 fluphenazine hcl concentrate 5mg/ml 2 fluphenazine hcl elixir 2.5mg/5ml 2 FLUPHENAZINE HCL INJECTION 2.5MG/ML 4 fluphenazine hcl tablet 10mg 2 fluphenazine hcl tablet 1mg 2 45

47 Name fluphenazine hcl tablet 2.5mg 2 fluphenazine hcl tablet 5mg 2 GEODON INJECTION 20MG 4 QL (6 EA per 3 days) haloperidol decanoate injection 100mg/ml 4 haloperidol decanoate injection 50mg/ml 4 haloperidol lactate injection 5mg/ml 4 haloperidol concentrate 2mg/ml 2 haloperidol tablet 0.5mg 2 haloperidol tablet 10mg 2 haloperidol tablet 1mg 2 haloperidol tablet 20mg 2 haloperidol tablet 2mg 2 haloperidol tablet 5mg 2 INVEGA SUSTENNA INJECTION 117MG/0.75ML 4 QL (0.75 ML per 28 days) PA INVEGA SUSTENNA INJECTION 156MG/ML 4 QL (1 ML per 28 days) PA INVEGA SUSTENNA INJECTION 234MG/1.5ML 4 QL (1.5 ML per 28 days) PA INVEGA SUSTENNA INJECTION 39MG/0.25ML 4 QL (0.25 ML per 28 days) PA INVEGA SUSTENNA INJECTION 78MG/0.5ML 4 QL (0.5 ML per 28 days) PA INVEGA TABLET EXTENDED RELEASE 24 HOUR 1.5MG 3 QL (30 EA per 30 days) MO INVEGA TABLET EXTENDED RELEASE 24 HOUR 3MG 3 QL (30 EA per 30 days) MO INVEGA TABLET EXTENDED RELEASE 24 HOUR 6MG 3 QL (60 EA per 30 days) MO INVEGA TABLET EXTENDED RELEASE 24 HOUR 9MG 3 QL (30 EA per 30 days) MO LATUDA TABLET 120MG 3 QL (30 EA per 30 days) LATUDA TABLET 20MG 3 QL (240 EA per 30 days) MO LATUDA TABLET 40MG 3 QL (30 EA per 30 days) MO LATUDA TABLET 60MG 3 QL (60 EA per 30 days) MO LATUDA TABLET 80MG 3 QL (60 EA per 30 days) MO loxapine succinate capsule 10mg 2 loxapine succinate capsule 25mg 2 loxapine succinate capsule 50mg 2 loxapine succinate capsule 5mg 2 olanzapine odt tablet dispersible 10mg 2 QL (60 EA per 30 days) olanzapine odt tablet dispersible 15mg 2 QL (60 EA per 30 days) olanzapine odt tablet dispersible 20mg 2 QL (60 EA per 30 days) olanzapine odt tablet dispersible 5mg 2 QL (30 EA per 30 days) olanzapine/fluoxetine capsule 25mg; 12mg 2 olanzapine/fluoxetine capsule 25mg; 3mg 2 olanzapine/fluoxetine capsule 25mg; 6mg 2 olanzapine/fluoxetine capsule 50mg; 12mg 2 olanzapine/fluoxetine capsule 50mg; 6mg 2 olanzapine injection 10mg 4 QL (3 EA per 1 days) olanzapine tablet 10mg 2 QL (60 EA per 30 days) olanzapine tablet 15mg 2 QL (60 EA per 30 days) olanzapine tablet 2.5mg 2 QL (30 EA per 30 days) olanzapine tablet 20mg 2 QL (60 EA per 30 days) olanzapine tablet 5mg 2 QL (30 EA per 30 days) olanzapine tablet 7.5mg 2 QL (30 EA per 30 days) ORAP TABLET 1MG 3 46

48 Name ORAP TABLET 2MG 3 perphenazine tablet 16mg 2 perphenazine tablet 2mg 2 perphenazine tablet 4mg 2 perphenazine tablet 8mg 2 quetiapine fumarate tablet 100mg 2 QL (90 EA per 30 days) quetiapine fumarate tablet 200mg 2 QL (90 EA per 30 days) quetiapine fumarate tablet 25mg 2 QL (90 EA per 30 days) quetiapine fumarate tablet 300mg 2 QL (90 EA per 30 days) quetiapine fumarate tablet 400mg 2 QL (90 EA per 30 days) quetiapine fumarate tablet 50mg 2 QL (90 EA per 30 days) REXULTI TABLET 0.25MG 3 REXULTI TABLET 0.5MG 3 REXULTI TABLET 1MG 3 REXULTI TABLET 2MG 3 REXULTI TABLET 3MG 3 REXULTI TABLET 4MG 3 RISPERDAL CONSTA INJECTION 12.5MG 4 PA RISPERDAL CONSTA INJECTION 25MG 4 PA RISPERDAL CONSTA INJECTION 37.5MG 4 PA RISPERDAL CONSTA INJECTION 50MG 4 PA risperidone odt tablet dispersible 0.25mg 2 QL (90 EA per 30 days) risperidone odt tablet dispersible 0.5mg 2 QL (90 EA per 30 days) risperidone odt tablet dispersible 1mg 2 QL (60 EA per 30 days) risperidone odt tablet dispersible 2mg 2 QL (60 EA per 30 days) risperidone odt tablet dispersible 3mg 2 QL (60 EA per 30 days) risperidone odt tablet dispersible 4mg 2 QL (120 EA per 30 days) risperidone solution 1mg/ml 2 QL (240 ML per 30 days) risperidone tablet 0.25mg 2 QL (90 EA per 30 days) risperidone tablet 0.5mg 2 QL (90 EA per 30 days) risperidone tablet 1mg 2 QL (60 EA per 30 days) risperidone tablet 2mg 2 QL (60 EA per 30 days) risperidone tablet 3mg 2 QL (60 EA per 30 days) risperidone tablet 4mg 2 QL (120 EA per 30 days) SAPHRIS TABLET SUBLINGUAL 10MG 3 QL (60 EA per 30 days) SAPHRIS TABLET SUBLINGUAL 2.5MG 3 SAPHRIS TABLET SUBLINGUAL 5MG 3 QL (120 EA per 30 days) SEROQUEL XR TABLET EXTENDED RELEASE 24 3 QL (30 EA per 30 days) HOUR 150MG SEROQUEL XR TABLET EXTENDED RELEASE 24 3 QL (30 EA per 30 days) HOUR 200MG SEROQUEL XR TABLET EXTENDED RELEASE 24 3 QL (60 EA per 30 days) HOUR 300MG SEROQUEL XR TABLET EXTENDED RELEASE 24 3 QL (60 EA per 30 days) HOUR 400MG SEROQUEL XR TABLET EXTENDED RELEASE 24 3 QL (120 EA per 30 days) HOUR 50MG thioridazine hcl tablet 100mg 2 PA thioridazine hcl tablet 10mg 2 PA 47

49 Name thioridazine hcl tablet 25mg 2 PA thioridazine hcl tablet 50mg 2 PA thiothixene capsule 10mg 2 thiothixene capsule 1mg 2 thiothixene capsule 2mg 2 thiothixene capsule 5mg 2 trifluoperazine hcl tablet 10mg 2 trifluoperazine hcl tablet 1mg 2 trifluoperazine hcl tablet 2mg 2 trifluoperazine hcl tablet 5mg 2 VERSACLOZ SUSPENSION 50MG/ML 3 LA ziprasidone hcl capsule 20mg 2 QL (60 EA per 30 days) ziprasidone hcl capsule 40mg 2 QL (60 EA per 30 days) ziprasidone hcl capsule 60mg 2 QL (90 EA per 30 days) ziprasidone hcl capsule 80mg 2 QL (90 EA per 30 days) ZYPREXA RELPREVV INJECTION 210MG 4 ANXIOLYTICS alprazolam tablet 0.25mg 2 alprazolam tablet 0.5mg 2 alprazolam tablet 1mg 2 alprazolam tablet 2mg 2 buspirone hcl tablet 10mg 2 buspirone hcl tablet 15mg 2 buspirone hcl tablet 30mg 2 buspirone hcl tablet 5mg 2 buspirone hcl tablet 7.5mg 2 clorazepate dipotassium tablet 15mg 2 QL (180 EA per 30 days) clorazepate dipotassium tablet 3.75mg 2 QL (120 EA per 30 days) clorazepate dipotassium tablet 7.5mg 2 QL (120 EA per 30 days) lorazepam intensol concentrate 2mg/ml 2 QL (150 ML per 30 days) lorazepam tablet 0.5mg 2 QL (150 EA per 30 days) lorazepam tablet 1mg 2 QL (150 EA per 30 days) lorazepam tablet 2mg 2 QL (150 EA per 30 days) CARBAMAZEPINES carbamazepine er capsule extended release 12 hour 100mg 2 carbamazepine er capsule extended release 12 hour 200mg 2 carbamazepine er capsule extended release 12 hour 300mg 2 carbamazepine er tablet extended release 12 hour 200mg 2 MO carbamazepine er tablet extended release 12 hour 400mg 2 MO carbamazepine suspension 100mg/5ml 2 MO carbamazepine tablet chewable 100mg 1 MO carbamazepine tablet 200mg 1 MO epitol tablet 200mg 2 MO EQUETRO CAPSULE EXTENDED RELEASE 12 HOUR 3 MO 100MG EQUETRO CAPSULE EXTENDED RELEASE 12 HOUR 3 MO 200MG EQUETRO CAPSULE EXTENDED RELEASE 12 HOUR 300MG 3 MO 48

50 Name oxcarbazepine suspension 300mg/5ml 2 oxcarbazepine tablet 150mg 2 MO oxcarbazepine tablet 300mg 2 MO oxcarbazepine tablet 600mg 2 MO OXTELLAR XR TABLET EXTENDED RELEASE 24 3 HOUR 150MG OXTELLAR XR TABLET EXTENDED RELEASE 24 3 HOUR 300MG OXTELLAR XR TABLET EXTENDED RELEASE 24 3 HOUR 600MG TEGRETOL-XR TABLET EXTENDED RELEASE 12 3 MO HOUR 100MG CNS STIMULANTS amphetamine/dextroamphetamine capsule extended release 242 QL (90 EA per 30 days) hour 1.25mg; 1.25mg; 1.25mg; 1.25mg amphetamine/dextroamphetamine capsule extended release 242 QL (90 EA per 30 days) hour 2.5mg; 2.5mg; 2.5mg; 2.5mg amphetamine/dextroamphetamine capsule extended release 242 QL (30 EA per 30 days) hour 3.75mg; 3.75mg; 3.75mg; 3.75mg amphetamine/dextroamphetamine capsule extended release 242 QL (30 EA per 30 days) hour 5mg; 5mg; 5mg; 5mg amphetamine/dextroamphetamine capsule extended release 242 QL (30 EA per 30 days) hour 6.25mg; 6.25mg; 6.25mg; 6.25mg amphetamine/dextroamphetamine capsule extended release 242 QL (30 EA per 30 days) hour 7.5mg; 7.5mg; 7.5mg; 7.5mg amphetamine/dextroamphetamine tablet 1.25mg; 1.25mg; 2 QL (360 EA per 30 days) 1.25mg; 1.25mg amphetamine/dextroamphetamine tablet 1.875mg; 1.875mg; 1.875mg; 1.875mg 2 QL (240 EA per 30 days) amphetamine/dextroamphetamine tablet 2.5mg; 2.5mg; 2.5mg; 2 QL (180 EA per 30 days) 2.5mg amphetamine/dextroamphetamine tablet 3.125mg; 3.125mg; 2 QL (144 EA per 30 days) 3.125mg; 3.125mg amphetamine/dextroamphetamine tablet 3.75mg; 3.75mg; 3.75mg; 3.75mg 2 QL (120 EA per 30 days) amphetamine/dextroamphetamine tablet 5mg; 5mg; 5mg; 5mg 2 QL (90 EA per 30 days) amphetamine/dextroamphetamine tablet 7.5mg; 7.5mg; 7.5mg; 2 QL (60 EA per 30 days) 7.5mg dexmethylphenidate hcl er capsule extended release 24 hour 2 10mg dexmethylphenidate hcl er capsule extended release 24 hour 2 15mg dexmethylphenidate hcl er capsule extended release 24 hour 2 20mg dexmethylphenidate hcl er capsule extended release 24 hour 2 30mg dexmethylphenidate hcl er capsule extended release 24 hour 2 40mg 49

51 Name dexmethylphenidate hcl er capsule extended release 24 hour 2 5mg dexmethylphenidate hcl tablet 10mg 2 dexmethylphenidate hcl tablet 2.5mg 2 dexmethylphenidate hcl tablet 5mg 2 dextroamphetamine sulfate er capsule extended release 24 2 hour 10mg dextroamphetamine sulfate er capsule extended release 24 2 hour 15mg dextroamphetamine sulfate er capsule extended release 24 2 hour 5mg dextroamphetamine sulfate tablet 10mg 2 dextroamphetamine sulfate tablet 5mg 2 metadate er tablet extended release 20mg 2 QL (90 EA per 30 days) methamphetamine hcl tablet 5mg 2 METHYLIN TABLET CHEWABLE 10MG 3 METHYLIN TABLET CHEWABLE 2.5MG 3 METHYLIN TABLET CHEWABLE 5MG 3 methylphenidate hcl cd capsule extended release 10mg 2 methylphenidate hcl cd capsule extended release 50mg 2 methylphenidate hcl cd capsule extended release 60mg 2 methylphenidate hcl er capsule extended release 24 hour 20mg2 methylphenidate hcl er capsule extended release 24 hour 30mg2 methylphenidate hcl er capsule extended release 24 hour 40mg2 methylphenidate hcl er tablet extended release 24 hour 18mg 2 methylphenidate hcl er tablet extended release 24 hour 27mg 2 methylphenidate hcl er tablet extended release 24 hour 36mg 2 methylphenidate hcl er tablet extended release 24 hour 54mg 2 methylphenidate hcl er tablet extended release 10mg 2 QL (90 EA per 30 days) methylphenidate hcl er tablet extended release 20mg 2 QL (90 EA per 30 days) methylphenidate hcl tablet chewable 10mg 2 methylphenidate hcl tablet chewable 2.5mg 2 methylphenidate hcl tablet chewable 5mg 2 methylphenidate hcl tablet 10mg 2 QL (180 EA per 30 days) methylphenidate hcl tablet 20mg 2 QL (90 EA per 30 days) methylphenidate hcl tablet 5mg 2 QL (180 EA per 30 days) methylphenidate hydrochloride solution 10mg/5ml 2 QL (900 ML per 30 days) methylphenidate hydrochloride solution 5mg/5ml 2 QL (1800 ML per 30 days) modafinil tablet 200mg 2 PA STRATTERA CAPSULE 100MG 3 QL (30 EA per 30 days) STRATTERA CAPSULE 10MG 3 QL (120 EA per 30 days) STRATTERA CAPSULE 18MG 3 QL (120 EA per 30 days) STRATTERA CAPSULE 25MG 3 QL (120 EA per 30 days) STRATTERA CAPSULE 40MG 3 QL (60 EA per 30 days) STRATTERA CAPSULE 60MG 3 QL (30 EA per 30 days) STRATTERA CAPSULE 80MG 3 QL (30 EA per 30 days) DRUGS FOR HEADACHES ascomp/codeine capsule 325mg; 50mg; 40mg; 30mg 2 PA 50

52 Name butalbital/acetaminophen/caffeine/codeine capsule 300mg; 2 50mg; 40mg; 30mg butalbital/acetaminophen/caffeine/codeine capsule 325mg; 2 PA 50mg; 40mg; 30mg butalbital/acetaminophen/caffeine capsule 300mg; 50mg; 2 40mg butalbital/acetaminophen/caffeine capsule 325mg; 50mg; 40mg 2 butalbital/acetaminophen/caffeine tablet 325mg; 50mg; 40mg 2 butalbital/acetaminophen tablet 325mg; 50mg 2 butalbital/aspirin/caffeine capsule 325mg; 50mg; 40mg 2 ergoloid mesylates tablet 1mg 2 MIGERGOT SUPPOSITORY 100MG; 2MG 3 HYDANTOINS DILANTIN INFATABS TABLET CHEWABLE 50MG 3 MO DILANTIN-125 SUSPENSION 125MG/5ML 3 MO DILANTIN CAPSULE 100MG 3 MO DILANTIN CAPSULE 30MG 3 MO PEGANONE TABLET 250MG 3 MO phenytoin sodium extended capsule 100mg 2 MO phenytoin sodium extended capsule 200mg 2 MO phenytoin sodium extended capsule 300mg 2 MO phenytoin sodium injection 50mg/ml 4 phenytoin suspension 125mg/5ml 2 MO phenytoin tablet chewable 50mg 2 MO MAO INHIBITORS AZILECT TABLET 0.5MG 3 MO AZILECT TABLET 1MG 3 MO EMSAM PATCH 24 HOUR 12MG/24HR 3 QL (30 EA per 30 days) MO EMSAM PATCH 24 HOUR 6MG/24HR 3 QL (30 EA per 30 days) MO EMSAM PATCH 24 HOUR 9MG/24HR 3 QL (30 EA per 30 days) MO MARPLAN TABLET 10MG 3 MO phenelzine sulfate tablet 15mg 2 MO selegiline hcl capsule 5mg 2 MO selegiline hcl tablet 5mg 2 MO tranylcypromine sulfate tablet 10mg 2 MO MIGRAINE almotriptan malate tablet 12.5mg 2 almotriptan malate tablet 6.25mg 2 AXERT TABLET 12.5MG 3 AXERT TABLET 6.25MG 3 dihydroergotamine mesylate injection 1mg/ml 4 dihydroergotamine mesylate solution 4mg/ml 2 FIORICET CAPSULE 300MG; 50MG; 40MG 3 FIORINAL CAPSULE 325MG; 50MG; 40MG 3 FROVA TABLET 2.5MG 3 MIGRANAL SOLUTION 4MG/ML 3 QL (8 ML per 28 days) naratriptan hcl tablet 1mg 2 naratriptan hcl tablet 2.5mg 2 51

53 Name RELPAX TABLET 20MG 3 RELPAX TABLET 40MG 3 rizatriptan benzoate odt tablet dispersible 10mg 2 rizatriptan benzoate odt tablet dispersible 5mg 2 rizatriptan benzoate tablet 10mg 2 rizatriptan benzoate tablet 5mg 2 sumatriptan succinate refill injection 4mg/0.5ml 2 QL (6 ML per 30 days) sumatriptan succinate refill injection 6mg/0.5ml 2 QL (6 ML per 30 days) sumatriptan succinate injection 6mg/0.5ml 4 sumatriptan succinate injection 6mg/0.5ml 2 sumatriptan succinate injection 6mg/0.5ml 2 QL (6 ML per 30 days) sumatriptan succinate tablet 100mg 2 sumatriptan succinate tablet 25mg 2 sumatriptan succinate tablet 50mg 2 sumatriptan solution 20mg/act 2 sumatriptan solution 5mg/act 2 zolmitriptan odt tablet dispersible 2.5mg 2 zolmitriptan odt tablet dispersible 5mg 2 zolmitriptan tablet 2.5mg 2 zolmitriptan tablet 5mg 2 ZOMIG NASAL SPRAY SOLUTION 5MG 3 ZOMIG SOLUTION 2.5MG 3 OTHER ANTIDEPRESSANTS APLENZIN TABLET EXTENDED RELEASE 24 HOUR 3 QL (90 EA per 30 days) ST MO 174MG APLENZIN TABLET EXTENDED RELEASE 24 HOUR 3 QL (60 EA per 30 days) ST MO 348MG APLENZIN TABLET EXTENDED RELEASE 24 HOUR 3 QL (30 EA per 30 days) ST MO 522MG bupropion hcl sr tablet extended release 12 hour 100mg 2 QL (120 EA per 30 days) MO bupropion hcl sr tablet extended release 12 hour 200mg 2 QL (60 EA per 30 days) MO bupropion hcl xl tablet extended release 24 hour 150mg 2 QL (90 EA per 30 days) MO bupropion hcl xl tablet extended release 24 hour 300mg 2 QL (30 EA per 30 days) MO bupropion hcl tablet 100mg 2 MO bupropion hcl tablet 75mg 2 MO chlordiazepoxide/amitriptyline tablet 12.5mg; 5mg 2 MO chlordiazepoxide/amitriptyline tablet 25mg; 10mg 2 MO FORFIVO XL TABLET EXTENDED RELEASE 24 HOUR 3 QL (30 EA per 30 days) MO 450MG lithium carbonate er tablet extended release 300mg 1 MO lithium carbonate er tablet extended release 450mg 1 MO lithium carbonate capsule 150mg 1 lithium carbonate capsule 300mg 1 MO lithium carbonate capsule 600mg 1 MO lithium carbonate tablet 300mg 1 MO lithium solution 8meq/5ml 2 MO maprotiline hcl tablet 25mg 2 MO maprotiline hcl tablet 50mg 2 MO maprotiline hcl tablet 75mg 2 MO 52

54 Name mirtazapine odt tablet dispersible 15mg 2 QL (30 EA per 30 days) MO mirtazapine odt tablet dispersible 30mg 2 MO mirtazapine odt tablet dispersible 45mg 2 MO mirtazapine tablet 15mg 2 QL (45 EA per 30 days) MO mirtazapine tablet 30mg 2 MO mirtazapine tablet 45mg 2 MO mirtazapine tablet 7.5mg 2 QL (45 EA per 30 days) MO nefazodone hcl tablet 100mg 2 MO nefazodone hcl tablet 150mg 2 MO nefazodone hcl tablet 200mg 2 MO nefazodone hcl tablet 250mg 2 MO nefazodone hcl tablet 50mg 2 MO perphenazine/amitriptyline tablet 10mg; 2mg 2 MO perphenazine/amitriptyline tablet 10mg; 4mg 2 MO perphenazine/amitriptyline tablet 25mg; 2mg 2 MO perphenazine/amitriptyline tablet 25mg; 4mg 2 MO perphenazine/amitriptyline tablet 50mg; 4mg 2 MO trazodone hcl tablet 100mg 1 MO trazodone hcl tablet 150mg 1 MO trazodone hcl tablet 300mg 1 MO trazodone hcl tablet 50mg 1 MO venlafaxine hcl tablet 37.5mg 2 QL (180 EA per 30 days) MO OTHER ANTIPARKINSON DRUGS APOKYN INJECTION 10MG/ML 5 PA LA bromocriptine mesylate capsule 5mg 2 MO bromocriptine mesylate tablet 2.5mg 2 MO carbidopa/levodopa er tablet extended release 25mg; 100mg 2 MO carbidopa/levodopa er tablet extended release 50mg; 200mg 2 MO carbidopa/levodopa odt tablet dispersible 10mg; 100mg 2 MO carbidopa/levodopa odt tablet dispersible 25mg; 100mg 2 MO carbidopa/levodopa odt tablet dispersible 25mg; 250mg 2 MO carbidopa/levodopa/entacapone tablet 12.5mg; 200mg; 50mg 2 carbidopa/levodopa/entacapone tablet 18.75mg; 200mg; 75mg2 carbidopa/levodopa/entacapone tablet 25mg; 200mg; 100mg 2 carbidopa/levodopa/entacapone tablet 31.25mg; 200mg; 2 125mg carbidopa/levodopa/entacapone tablet 37.5mg; 200mg; 150mg2 carbidopa/levodopa/entacapone tablet 50mg; 200mg; 200mg 2 carbidopa/levodopa tablet 10mg; 100mg 2 MO carbidopa/levodopa tablet 25mg; 100mg 2 MO carbidopa/levodopa tablet 25mg; 250mg 2 MO carbidopa tablet 25mg 2 DUOPA SUSPENSION 4.63MG/ML; 20MG/ML 3 entacapone tablet 200mg 2 MO MIRAPEX ER TABLET EXTENDED RELEASE 24 HOUR 3 MO 0.375MG MIRAPEX ER TABLET EXTENDED RELEASE 24 HOUR 3 MO 0.75MG 53

55 Name MIRAPEX ER TABLET EXTENDED RELEASE 24 HOUR 3 MO 1.5MG MIRAPEX ER TABLET EXTENDED RELEASE 24 HOUR 3 MO 2.25MG MIRAPEX ER TABLET EXTENDED RELEASE 24 HOUR 3 MO 3.75MG MIRAPEX ER TABLET EXTENDED RELEASE 24 HOUR 3 MO 3MG MIRAPEX ER TABLET EXTENDED RELEASE 24 HOUR 3 MO 4.5MG NEUPRO PATCH 24 HOUR 1MG/24HR 3 MO NEUPRO PATCH 24 HOUR 2MG/24HR 3 MO NEUPRO PATCH 24 HOUR 3MG/24HR 3 MO NEUPRO PATCH 24 HOUR 4MG/24HR 3 MO NEUPRO PATCH 24 HOUR 6MG/24HR 3 MO NEUPRO PATCH 24 HOUR 8MG/24HR 3 MO pramipexole dihydrochloride er tablet extended release 24 2 MO hour 0.375mg pramipexole dihydrochloride er tablet extended release 24 2 MO hour 0.75mg pramipexole dihydrochloride er tablet extended release 24 2 MO hour 1.5mg pramipexole dihydrochloride er tablet extended release 24 2 hour 3mg pramipexole dihydrochloride er tablet extended release 24 2 hour 4.5mg pramipexole dihydrochloride tablet 0.125mg 2 MO pramipexole dihydrochloride tablet 0.25mg 2 MO pramipexole dihydrochloride tablet 0.5mg 2 MO pramipexole dihydrochloride tablet 0.75mg 2 MO pramipexole dihydrochloride tablet 1.5mg 2 MO pramipexole dihydrochloride tablet 1mg 2 MO ropinirole er tablet extended release 24 hour 12mg 2 MO ropinirole er tablet extended release 24 hour 2mg 2 MO ropinirole er tablet extended release 24 hour 4mg 2 MO ropinirole er tablet extended release 24 hour 6mg 2 MO ropinirole er tablet extended release 24 hour 8mg 2 MO ropinirole hcl tablet 0.25mg 2 MO ropinirole hcl tablet 0.5mg 2 MO ropinirole hcl tablet 1mg 2 MO ropinirole hcl tablet 2mg 2 MO ropinirole hcl tablet 3mg 2 MO ropinirole hcl tablet 4mg 2 MO ropinirole hcl tablet 5mg 2 MO RYTARY CAPSULE EXTENDED RELEASE 23.75MG; 3 95MG RYTARY CAPSULE EXTENDED RELEASE 36.25MG; 145MG 3 54

56 Name RYTARY CAPSULE EXTENDED RELEASE 48.75MG; 3 195MG RYTARY CAPSULE EXTENDED RELEASE 61.25MG; 3 245MG STALEVO 100 TABLET 25MG; 200MG; 100MG 3 MO STALEVO 125 TABLET 31.25MG; 200MG; 125MG 3 MO STALEVO 150 TABLET 37.5MG; 200MG; 150MG 3 MO STALEVO 200 TABLET 50MG; 200MG; 200MG 3 MO STALEVO 50 TABLET 12.5MG; 200MG; 50MG 3 MO STALEVO 75 TABLET 18.75MG; 200MG; 75MG 3 MO TASMAR TABLET 100MG 3 MO tolcapone tablet 100mg 2 ZELAPAR TABLET DISPERSIBLE 1.25MG 3 MO OTHER CNS/AUTONOMIC DRUGS ATROPINE SULFATE INJECTION 0.05MG/ML 4 atropine sulfate injection 0.1mg/ml 4 clonidine hcl er tablet extended release 12 hour 0.1mg 2 guanfacine er tablet extended release 24 hour 1mg 2 guanfacine er tablet extended release 24 hour 2mg 2 guanfacine er tablet extended release 24 hour 3mg 2 guanfacine er tablet extended release 24 hour 4mg 2 guanidine hcl tablet 125mg 2 INTUNIV TABLET EXTENDED RELEASE 24 HOUR 1MG3 MO INTUNIV TABLET EXTENDED RELEASE 24 HOUR 2MG3 MO INTUNIV TABLET EXTENDED RELEASE 24 HOUR 3MG3 MO INTUNIV TABLET EXTENDED RELEASE 24 HOUR 4MG3 MO MESTINON TIMESPAN TABLET EXTENDED RELEASE 3 MO 180MG MESTINON SYRUP 60MG/5ML 3 MO NUEDEXTA CAPSULE 20MG; 10MG 3 PA pyridostigmine bromide tablet extended release 180mg 2 MO pyridostigmine bromide tablet 60mg 2 MO tetrabenazine tablet 12.5mg 2 QL (240 EA per 30 days) PA tetrabenazine tablet 25mg 2 QL (120 EA per 30 days) PA XENAZINE TABLET 12.5MG 5 QL (240 EA per 30 days) PA LA XENAZINE TABLET 25MG 5 QL (120 EA per 30 days) PA LA XYREM SOLUTION 500MG/ML 5 QL (540 ML per 30 days) PA LA SECONDARY AMINES amoxapine tablet 100mg 2 MO amoxapine tablet 150mg 2 MO amoxapine tablet 25mg 2 MO amoxapine tablet 50mg 2 MO desipramine hcl tablet 100mg 2 MO desipramine hcl tablet 10mg 2 MO desipramine hcl tablet 150mg 2 MO desipramine hcl tablet 25mg 2 MO desipramine hcl tablet 50mg 2 MO desipramine hcl tablet 75mg 2 MO nortriptyline hcl capsule 10mg 2 MO 55

57 Name nortriptyline hcl capsule 25mg 2 MO nortriptyline hcl capsule 50mg 2 MO nortriptyline hcl capsule 75mg 2 MO nortriptyline hcl solution 10mg/5ml 2 protriptyline hcl tablet 10mg 2 MO protriptyline hcl tablet 5mg 2 MO SEDATIVE/HYPNOTIC DRUGS HETLIOZ CAPSULE 20MG 5 LUNESTA TABLET 1MG 3 PA LUNESTA TABLET 2MG 3 PA LUNESTA TABLET 3MG 3 PA ROZEREM TABLET 8MG 3 QL (30 EA per 30 days) zaleplon capsule 10mg 2 QL (60 EA per 30 days) PA zaleplon capsule 5mg 2 QL (30 EA per 30 days) PA zolpidem tartrate er tablet extended release 12.5mg 2 QL (30 EA per 30 days) PA zolpidem tartrate er tablet extended release 6.25mg 2 QL (30 EA per 30 days) PA zolpidem tartrate tablet 10mg 2 QL (30 EA per 30 days) PA zolpidem tartrate tablet 5mg 2 QL (30 EA per 30 days) PA SELECTIVE SEROTONIN REUPTAKE INHIBITORS BRINTELLIX TABLET 10MG 3 QL (60 EA per 30 days) ST BRINTELLIX TABLET 20MG 3 QL (30 EA per 30 days) ST BRINTELLIX TABLET 5MG 3 QL (120 EA per 30 days) ST BRISDELLE CAPSULE 7.5MG 3 QL (30 EA per 30 days) citalopram hydrobromide solution 10mg/5ml 2 MO citalopram hydrobromide tablet 10mg 1 QL (45 EA per 30 days) MO citalopram hydrobromide tablet 20mg 1 QL (45 EA per 30 days) MO citalopram hydrobromide tablet 40mg 1 QL (30 EA per 30 days) MO escitalopram oxalate solution 5mg/5ml 2 QL (600 ML per 30 days) ST MO escitalopram oxalate tablet 10mg 2 QL (45 EA per 30 days) ST MO escitalopram oxalate tablet 20mg 2 QL (60 EA per 30 days) ST MO escitalopram oxalate tablet 5mg 2 QL (45 EA per 30 days) ST MO fluoxetine dr capsule delayed release 90mg 2 QL (4 EA per 28 days) MO fluoxetine hcl capsule 10mg 2 QL (30 EA per 30 days) MO fluoxetine hcl capsule 20mg 2 QL (120 EA per 30 days) MO fluoxetine hcl capsule 40mg 2 QL (60 EA per 30 days) MO fluoxetine hcl solution 20mg/5ml 2 MO fluoxetine hcl tablet 10mg 2 QL (45 EA per 30 days) MO fluoxetine hcl tablet 20mg 2 MO FLUOXETINE HCL TABLET 60MG 3 fluvoxamine maleate er capsule extended release 24 hour 2 QL (90 EA per 30 days) ST MO 100mg fluvoxamine maleate er capsule extended release 24 hour 2 QL (60 EA per 30 days) ST MO 150mg fluvoxamine maleate tablet 100mg 2 QL (90 EA per 30 days) MO fluvoxamine maleate tablet 25mg 2 QL (45 EA per 30 days) MO fluvoxamine maleate tablet 50mg 2 QL (45 EA per 30 days) MO paroxetine hcl er tablet extended release 24 hour 12.5mg 2 QL (180 EA per 30 days) MO paroxetine hcl er tablet extended release 24 hour 25mg 2 QL (90 EA per 30 days) MO paroxetine hcl er tablet extended release 24 hour 37.5mg 2 QL (60 EA per 30 days) MO 56

58 Name paroxetine hcl tablet 10mg 1 QL (45 EA per 30 days) MO paroxetine hcl tablet 20mg 1 QL (45 EA per 30 days) MO paroxetine hcl tablet 30mg 1 QL (60 EA per 30 days) MO paroxetine hcl tablet 40mg 1 QL (45 EA per 30 days) MO PAXIL SUSPENSION 10MG/5ML 3 QL (900 ML per 30 days) SARAFEM TABLET 10MG 3 QL (272 EA per 14 days) MO SARAFEM TABLET 20MG 3 QL (140 EA per 14 days) MO sertraline hcl concentrate 20mg/ml 2 MO sertraline hcl tablet 100mg 1 QL (60 EA per 30 days) MO sertraline hcl tablet 25mg 1 QL (45 EA per 30 days) MO sertraline hcl tablet 50mg 1 QL (45 EA per 30 days) MO VIIBRYD KIT 0 3 QL (30 EA per 30 days) ST MO VIIBRYD TABLET 10MG 3 QL (30 EA per 30 days) ST MO VIIBRYD TABLET 20MG 3 QL (30 EA per 30 days) ST MO VIIBRYD TABLET 40MG 3 QL (30 EA per 30 days) ST MO SEROTONIN NOREPINEPHRINE REUPTAKE INHIBITORS CYMBALTA CAPSULE DELAYED RELEASE 3 QL (180 EA per 30 days) MO PARTICLES 20MG CYMBALTA CAPSULE DELAYED RELEASE 3 QL (120 EA per 30 days) MO PARTICLES 30MG CYMBALTA CAPSULE DELAYED RELEASE 3 QL (60 EA per 30 days) MO PARTICLES 60MG desvenlafaxine er tablet extended release 24 hour 100mg 2 ST MO desvenlafaxine er tablet extended release 24 hour 50mg 2 ST MO duloxetine hcl capsule delayed release particles 20mg 2 QL (60 EA per 30 days) MO duloxetine hcl capsule delayed release particles 30mg 2 QL (60 EA per 30 days) MO duloxetine hcl capsule delayed release particles 40mg 2 MO duloxetine hcl capsule delayed release particles 60mg 2 QL (60 EA per 30 days) MO FETZIMA TITRATION PACK CAPSULE ER 24 HOUR 3 ST THERAPY PACK 0 FETZIMA CAPSULE EXTENDED RELEASE 24 HOUR 3 QL (30 EA per 30 days) ST 120MG FETZIMA CAPSULE EXTENDED RELEASE 24 HOUR 3 QL (180 EA per 30 days) ST 20MG FETZIMA CAPSULE EXTENDED RELEASE 24 HOUR 3 QL (90 EA per 30 days) ST 40MG FETZIMA CAPSULE EXTENDED RELEASE 24 HOUR 3 QL (30 EA per 30 days) ST 80MG KHEDEZLA TABLET EXTENDED RELEASE 24 HOUR 3 ST 100MG KHEDEZLA TABLET EXTENDED RELEASE 24 HOUR 3 ST 50MG PRISTIQ TABLET EXTENDED RELEASE 24 HOUR 100MG 3 MO PRISTIQ TABLET EXTENDED RELEASE 24 HOUR 25MG3 PRISTIQ TABLET EXTENDED RELEASE 24 HOUR 50MG3 MO SAVELLA TITRATION PACK MISCELLANEOUS 0 3 QL (1 EA per 30 days) MO SAVELLA TABLET 100MG 3 QL (60 EA per 30 days) MO SAVELLA TABLET 12.5MG 3 QL (480 EA per 30 days) MO 57

59 Name SAVELLA TABLET 25MG 3 QL (240 EA per 30 days) MO SAVELLA TABLET 50MG 3 QL (120 EA per 30 days) MO venlafaxine hcl er capsule extended release 24 hour 150mg 2 QL (60 EA per 30 days) MO venlafaxine hcl er capsule extended release 24 hour 37.5mg 2 QL (30 EA per 30 days) MO venlafaxine hcl er capsule extended release 24 hour 75mg 2 QL (30 EA per 30 days) MO VENLAFAXINE HCL ER TABLET EXTENDED RELEASE 3 QL (60 EA per 30 days) MO 24 HOUR 150MG VENLAFAXINE HCL ER TABLET EXTENDED RELEASE 3 QL (30 EA per 30 days) MO 24 HOUR 225MG VENLAFAXINE HCL ER TABLET EXTENDED RELEASE 3 QL (180 EA per 30 days) MO 24 HOUR 37.5MG VENLAFAXINE HCL ER TABLET EXTENDED RELEASE 3 QL (90 EA per 30 days) MO 24 HOUR 75MG venlafaxine hcl tablet 100mg 2 QL (90 EA per 30 days) MO venlafaxine hcl tablet 25mg 2 QL (270 EA per 30 days) MO venlafaxine hcl tablet 50mg 2 QL (150 EA per 30 days) MO venlafaxine hcl tablet 75mg 2 QL (90 EA per 30 days) MO SMOKING CESSATION PRODUCTS buproban tablet extended release 12 hour 150mg 2 bupropion hcl sr tablet extended release 12 hour 150mg 2 QL (90 EA per 30 days) CHANTIX CONTINUING MONTH PAK TABLET 1MG 3 CHANTIX STARTING MONTH PAK TABLET 0 3 CHANTIX TABLET 0.5MG 3 CHANTIX TABLET 1MG 3 NICOTROL INHALER INHALER 10MG 3 NICOTROL NS SOLUTION 10MG/ML 3 TERTIARY AMINES amitriptyline hcl tablet 100mg 2 PA MO amitriptyline hcl tablet 10mg 2 PA MO amitriptyline hcl tablet 150mg 2 PA MO amitriptyline hcl tablet 25mg 2 PA MO amitriptyline hcl tablet 50mg 2 PA MO amitriptyline hcl tablet 75mg 2 PA MO clomipramine hcl capsule 25mg 2 PA MO clomipramine hcl capsule 50mg 2 PA MO clomipramine hcl capsule 75mg 2 PA MO doxepin hcl capsule 100mg 2 PA MO doxepin hcl capsule 10mg 2 PA MO doxepin hcl capsule 150mg 2 PA MO doxepin hcl capsule 25mg 2 PA MO doxepin hcl capsule 50mg 2 PA MO doxepin hcl capsule 75mg 2 PA MO doxepin hcl concentrate 10mg/ml 2 PA MO imipramine hcl tablet 10mg 2 PA MO imipramine hcl tablet 25mg 2 PA MO imipramine hcl tablet 50mg 2 PA MO imipramine pamoate capsule 100mg 2 PA MO imipramine pamoate capsule 125mg 2 PA MO imipramine pamoate capsule 150mg 2 PA MO 58

60 Name imipramine pamoate capsule 75mg 2 PA MO SURMONTIL CAPSULE 100MG 3 PA SURMONTIL CAPSULE 25MG 3 PA SURMONTIL CAPSULE 50MG 3 PA DERMATOLOGICAL ANTIACNE DRUGS adapalene cream 0.1% 2 PA adapalene gel 0.1% 2 PA adapalene gel 0.3% 2 PA amnesteem capsule 10mg 2 amnesteem capsule 20mg 2 amnesteem capsule 40mg 2 avita cream 0.025% 2 PA avita gel 0.025% 2 PA AZELEX CREAM 20% 3 claravis capsule 10mg 2 claravis capsule 20mg 2 claravis capsule 30mg 2 claravis capsule 40mg 2 clindamycin phosphate foam 1% 2 clindamycin phosphate gel 1% 2 clindamycin phosphate lotion 1% 2 clindamycin phosphate solution 1% 2 clindamycin phosphate swab 1% 2 clindamycin/benzoyl peroxide gel 5%; 1% 2 DIFFERIN GEL 0.3% 3 PA DIFFERIN LOTION 0.1% 3 PA erythromycin/benzoyl peroxide gel 5%; 3% 2 erythromycin solution 2% 2 metronidazole cream 0.75% 2 metronidazole gel 0.75% 2 metronidazole gel 1% 2 metronidazole lotion 0.75% 2 tretinoin microsphere gel 0.04% 2 PA tretinoin microsphere gel 0.1% 2 PA tretinoin cream 0.025% 2 PA tretinoin cream 0.05% 2 PA tretinoin cream 0.1% 2 PA tretinoin gel 0.01% 2 PA tretinoin gel 0.025% 2 PA ANTIPRURITIC DRUGS hydroxyzine hcl solution 10mg/5ml 2 PA procto-pak cream 1% 2 proctosol hc cream 2.5% 2 proctozone-hc cream 2.5% 2 ZONALON CREAM 5% 3 ANTIPSORIASIS AND ANTIECZEMA DRUGS 8-MOP CAPSULE 10MG 3 acitretin capsule 10mg 2 59

61 Name acitretin capsule 17.5mg 2 acitretin capsule 25mg 2 calcipotriene/betamethasone dipropionate ointment 0.064%; % calcipotriene cream 0.005% 2 calcipotriene ointment 0.005% 2 calcipotriene solution 0.005% 2 calcitriol ointment 3mcg/gm 2 COSENTYX SENSOREADY PEN INJECTION 150MG/ML 5 COSENTYX INJECTION 150MG/ML 5 methoxsalen capsule 10mg 2 OXSORALEN ULTRA CAPSULE 10MG 3 selenium sulfide lotion 2.5% 2 VECTICAL OINTMENT 3MCG/GM 3 KERATOLYTICS ammonium lactate lotion 12% 2 CONDYLOX GEL 0.5% 3 podofilox solution 0.5% 2 TAZORAC CREAM 0.05% 3 PA TAZORAC CREAM 0.1% 3 PA TAZORAC GEL 0.05% 3 PA TAZORAC GEL 0.1% 3 PA SCABICIDES EURAX CREAM 10% 3 EURAX LOTION 10% 3 lindane lotion 1% 2 lindane shampoo 1% 2 malathion lotion 0.5% 2 permethrin cream 5% 2 TOPICAL ANTIBACTERIAL DRUGS BACTROBAN NASAL OINTMENT 2% 3 CORTISPORIN CREAM 0.5%; 0.5%; 10000UNIT/GM 3 CORTISPORIN OINTMENT 400UNIT/GM; 1%; 0.5%; UNIT/GM DALVANCE INJECTION 500MG 3 gentamicin sulfate cream 0.1% 2 mupirocin cream 2% 2 mupirocin ointment 2% 2 silver sulfadiazine cream 1% 2 ssd cream 1% 2 SULFAMYLON CREAM 85MG/GM 3 TOPICAL ANTIFUNGALS ciclopirox nail lacquer solution 8% 2 ciclopirox shampoo 1% 2 ciclopirox suspension 0.77% 2 clotrimazole cream 1% 2 econazole nitrate cream 1% 2 EXELDERM CREAM 1% 3 ketoconazole cream 2% 2 60

62 Name ketoconazole foam 2% 2 naftifine hcl cream 1% 2 NAFTIN CREAM 1% 3 nystatin cream unit/gm 2 nystatin ointment unit/gm 2 nystop powder unit/gm 2 OXISTAT CREAM 1% 3 terbinafine hcl tablet 250mg 2 QL (90 EA per 365 days) TOPICAL CORTICOSTEROID DRUGS a-hydrocort injection 100mg 4 ala cort cream 1% 2 alclometasone dipropionate cream 0.05% 2 alclometasone dipropionate ointment 0.05% 2 amcinonide cream 0.1% 2 amcinonide lotion 0.1% 2 amcinonide ointment 0.1% 2 augmented betamethasone dipropionate cream 0.05% 2 augmented betamethasone dipropionate gel 0.05% 2 augmented betamethasone dipropionate lotion 0.05% 2 augmented betamethasone dipropionate ointment 0.05% 2 betamethasone dipropionate cream 0.05% 2 betamethasone dipropionate lotion 0.05% 2 betamethasone dipropionate ointment 0.05% 2 betamethasone valerate cream 0.1% 2 betamethasone valerate foam 0.12% 2 betamethasone valerate lotion 0.1% 2 betamethasone valerate ointment 0.1% 2 clobetasol propionate e cream 0.05% 2 clobetasol propionate foam 0.05% 2 clobetasol propionate gel 0.05% 2 clobetasol propionate liquid 0.05% 2 clobetasol propionate lotion 0.05% 2 clobetasol propionate ointment 0.05% 2 clobetasol propionate shampoo 0.05% 2 clobetasol propionate solution 0.05% 2 clodan shampoo 0.05% 2 CORDRAN TAPE TAPE 4MCG/SQCM 3 desonide cream 0.05% 2 desonide lotion 0.05% 2 desonide ointment 0.05% 2 desoximetasone cream 0.05% 2 desoximetasone cream 0.25% 2 desoximetasone gel 0.05% 2 desoximetasone ointment 0.05% 2 desoximetasone ointment 0.25% 2 diflorasone diacetate cream 0.05% 2 diflorasone diacetate ointment 0.05% 2 fluocinolone acetonide body oil 0.01% 2 fluocinolone acetonide cream 0.01% 2 61

63 Name fluocinolone acetonide cream 0.025% 2 fluocinolone acetonide ointment 0.025% 2 fluocinolone acetonide solution 0.01% 2 fluocinonide-e cream 0.05% 2 fluocinonide cream 0.1% 2 fluocinonide gel 0.05% 2 fluocinonide ointment 0.05% 2 fluocinonide solution 0.05% 2 fluticasone propionate cream 0.05% 2 fluticasone propionate lotion 0.05% 2 fluticasone propionate ointment 0.005% 2 halobetasol propionate cream 0.05% 2 MO halobetasol propionate ointment 0.05% 2 hydrocortisone butyrate (lipophilic) cream 0.1% 2 hydrocortisone butyrate ointment 0.1% 2 hydrocortisone butyrate solution 0.1% 2 hydrocortisone valerate cream 0.2% 2 hydrocortisone valerate ointment 0.2% 2 hydrocortisone cream 1% 2 hydrocortisone lotion 2.5% 2 hydrocortisone ointment 1% 2 hydrocortisone ointment 2.5% 2 LOCOID CREAM 0.1% 3 LOCOID LOTION 0.1% 3 LOCOID OINTMENT 0.1% 3 LOCOID SOLUTION 0.1% 3 lokara lotion 0.05% 2 mometasone furoate cream 0.1% 2 mometasone furoate ointment 0.1% 2 prednicarbate cream 0.1% 2 prednicarbate ointment 0.1% 2 triamcinolone acetonide aerosol solution 0.147mg/gm 2 triamcinolone acetonide cream 0.025% 2 triamcinolone acetonide cream 0.1% 2 triamcinolone acetonide cream 0.5% 2 triamcinolone acetonide lotion 0.025% 2 triamcinolone acetonide lotion 0.1% 2 triamcinolone acetonide ointment 0.025% 2 triamcinolone acetonide ointment 0.1% 2 triamcinolone acetonide ointment 0.5% 2 triderm cream 0.1% 2 TOPICAL DERMATOLOGICAL DRUGS ammonium lactate cream 12% 2 CARAC CREAM 0.5% 3 diclofenac sodium gel 3% 2 diclofenac sodium solution 1.5% 2 ST ELIDEL CREAM 1% 3 PA fluorouracil cream 0.5% 2 fluorouracil cream 5% 2 62

64 Name fluorouracil solution 2% 2 fluorouracil solution 5% 2 imiquimod cream 5% 2 OXSORALEN LOTION 1% 3 PANRETIN GEL 0.1% 3 REGRANEX GEL 0.01% 3 QL (15 GM per 30 days) PA SANTYL OINTMENT 250UNIT/GM 3 VEREGEN OINTMENT 15% 3 ZYCLARA PUMP CREAM 2.5% 3 ZYCLARA CREAM 3.75% 3 EAR, NOSE, AND THROAT DRUGS AFFECTING THE EAR ACETASOL HC SOLUTION 2%; 1% 3 acetic acid solution 2% 2 CIPRO HC SUSPENSION 0.2%; 1% 3 CIPRODEX SUSPENSION 0.3%; 0.1% 3 COLY-MYCIN S SUSPENSION 3MG/ML; 10MG/ML; 3 3.3MG/ML; 0.5MG/ML CORTISPORIN-TC SUSPENSION 3MG/ML; 10MG/ML; 3 3.3MG/ML; 0.5MG/ML fluocinolone acetonide oil 0.01% 2 hydrocortisone/acetic acid solution 2%; 1% 2 neomycin/polymyxin/hc solution 1%; 3.5mg/ml; 10000unit/ml 2 neomycin/polymyxin/hydrocortisone suspension 1%; 2 3.5mg/ml; 10000unit/ml DRUGS AFFECTING THE NOSE ASTEPRO SOLUTION 0.15% 3 QL (60 ML per 34 days) MO azelastine hcl solution 0.1% 2 QL (60 ML per 30 days) MO azelastine hcl solution 0.15% 2 budesonide suspension 32mcg/act 2 fluticasone propionate suspension 50mcg/act 2 QL (16 GM per 30 days) MO ipratropium bromide solution 0.03% 2 QL (30 ML per 30 days) MO ipratropium bromide solution 0.06% 2 QL (30 ML per 30 days) MO NASONEX SUSPENSION 50MCG/ACT 3 MO olopatadine hcl solution 0.6% 2 triamcinolone acetonide aerosol 55mcg/act 2 QL (16.5 GM per 30 days) TYZINE PEDIATRIC NASAL DROPS SOLUTION 0.05% 3 DRUGS AFFECTING THE THROAT AND MOUTH cevimeline hcl capsule 30mg 2 chlorhexidine gluconate oral rinse solution 0.12% 2 doxycycline hyclate tablet 20mg 2 periogard solution 0.12% 2 pilocarpine hcl tablet 7.5mg 2 pilocarpine hydrochloride tablet 5mg 2 triamcinolone in orabase paste 0.1% 2 ENDOCRINE AND METABOLIC ANDROGEN DRUGS ANADROL-50 TABLET 50MG 3 MO ANDROGEL PUMP GEL 1% 3 MO 63

65 Name ANDROGEL PUMP GEL 1.62% 3 PA MO ANDROGEL GEL 50MG/5GM 3 PA MO AXIRON SOLUTION 30MG/ACT 3 PA danazol capsule 100mg 2 MO danazol capsule 200mg 2 MO danazol capsule 50mg 2 MO FORTESTA GEL 10MG/ACT 3 PA MO METHITEST TABLET 10MG 3 MO oxandrolone tablet 10mg 2 PA MO oxandrolone tablet 2.5mg 2 PA MO TESTIM GEL 1% 3 QL (300 GM per 30 days) PA MO testosterone cypionate injection 200mg/ml 4 testosterone enanthate injection 200mg/ml 4 testosterone pump gel 1% 2 PA testosterone gel 1% 2 PA testosterone gel 1% 2 PA testosterone gel 10mg/act 2 PA testosterone gel 25mg/2.5gm 2 PA TESTRED CAPSULE 10MG 3 MO ANTITHYROID methimazole tablet 10mg 2 MO methimazole tablet 5mg 2 MO propylthiouracil tablet 50mg 2 MO CORTICOSTEROIDS hydrocortisone tablet 10mg 2 hydrocortisone tablet 5mg 2 methylprednisolone dose pack tablet 4mg 1 methylprednisolone tablet 16mg 1 methylprednisolone tablet 32mg 1 methylprednisolone tablet 4mg 1 methylprednisolone tablet 8mg 1 prednisolone sodium phosphate odt tablet dispersible 10mg 2 prednisolone sodium phosphate odt tablet dispersible 15mg 2 prednisolone sodium phosphate odt tablet dispersible 30mg 2 prednisolone sodium phosphate solution 15mg/5ml 2 prednisolone sodium phosphate solution 25mg/5ml 2 prednisolone sodium phosphate solution 5mg/5ml 2 prednisone intensol concentrate 5mg/ml 2 prednisone solution 5mg/5ml 2 prednisone tablet 10mg 1 prednisone tablet 1mg 1 prednisone tablet 2.5mg 1 prednisone tablet 20mg 1 prednisone tablet 50mg 1 prednisone tablet 5mg 1 triamcinolone acetonide injection 10mg/ml 4 triamcinolone acetonide injection 40mg/ml 4 DIPEPTIDYL PEPTIDASE-4 INHIBITORS 64

66 Name JANUMET XR TABLET EXTENDED RELEASE 24 HOUR 3 QL (30 EA per 30 days) MO 1000MG; 100MG JANUMET XR TABLET EXTENDED RELEASE 24 HOUR 3 QL (60 EA per 30 days) MO 1000MG; 50MG JANUMET XR TABLET EXTENDED RELEASE 24 HOUR 3 QL (60 EA per 30 days) MO 500MG; 50MG JANUMET TABLET 1000MG; 50MG 3 QL (60 EA per 30 days) MO JANUMET TABLET 500MG; 50MG 3 QL (60 EA per 30 days) MO JANUVIA TABLET 100MG 3 QL (30 EA per 30 days) MO JANUVIA TABLET 25MG 3 QL (30 EA per 30 days) MO JANUVIA TABLET 50MG 3 QL (30 EA per 30 days) MO JENTADUETO TABLET 2.5MG; 1000MG 3 QL (60 EA per 30 days) MO JENTADUETO TABLET 2.5MG; 500MG 3 QL (60 EA per 30 days) MO JENTADUETO TABLET 2.5MG; 850MG 3 QL (60 EA per 30 days) MO KOMBIGLYZE XR TABLET EXTENDED RELEASE 24 3 QL (60 EA per 30 days) MO HOUR 1000MG; 2.5MG KOMBIGLYZE XR TABLET EXTENDED RELEASE 24 3 QL (30 EA per 30 days) MO HOUR 1000MG; 5MG KOMBIGLYZE XR TABLET EXTENDED RELEASE 24 3 QL (30 EA per 30 days) MO HOUR 500MG; 5MG ONGLYZA TABLET 2.5MG 3 QL (30 EA per 30 days) MO ONGLYZA TABLET 5MG 3 QL (30 EA per 30 days) MO TRADJENTA TABLET 5MG 3 QL (30 EA per 30 days) MO GLUCOCORTICOID DRUGS CORTIFOAM FOAM 10% 3 cortisone acetate tablet 25mg 2 dexamethasone intensol concentrate 1mg/ml 2 dexamethasone sodium phosphate injection 10mg/ml 4 dexamethasone sodium phosphate injection 120mg/30ml 4 dexamethasone elixir 0.5mg/5ml 2 dexamethasone tablet 0.5mg 1 dexamethasone tablet 0.75mg 1 dexamethasone tablet 1.5mg 1 dexamethasone tablet 1mg 1 dexamethasone tablet 2mg 1 dexamethasone tablet 4mg 1 dexamethasone tablet 6mg 1 DEXPAK 13 DAY TABLET 1.5MG 3 fludrocortisone acetate tablet 0.1mg 2 hydrocortisone tablet 20mg 2 KENALOG-10 INJECTION 10MG/ML 4 KENALOG-40 INJECTION 40MG/ML 4 methylprednisolone acetate injection 40mg/ml 4 methylprednisolone acetate injection 80mg/ml 4 ORAPRED ODT TABLET DISPERSIBLE 10MG 3 ORAPRED ODT TABLET DISPERSIBLE 15MG 3 ORAPRED ODT TABLET DISPERSIBLE 30MG 3 SOLU-CORTEF INJECTION 100MG 4 SOLU-CORTEF INJECTION 250MG 4 65

67 Name SOLU-MEDROL INJECTION 125MG 4 SOLU-MEDROL INJECTION 2GM 4 SOLU-MEDROL INJECTION 40MG 4 SOLU-MEDROL INJECTION 500MG 4 VERIPRED 20 SOLUTION 20MG/5ML 3 GLUCOSE ELEVATING DRUGS GLUCAGEN HYPOKIT INJECTION 1MG 3 GLUCAGON EMERGENCY KIT INJECTION 1MG 3 PROGLYCEM SUSPENSION 50MG/ML 3 GROWTH HORMONES AND RELATED DRUGS EGRIFTA INJECTION 2MG 5 PA GENOTROPIN MINIQUICK INJECTION 0.2MG 4 PA GENOTROPIN MINIQUICK INJECTION 0.4MG 4 PA GENOTROPIN MINIQUICK INJECTION 0.6MG 4 PA GENOTROPIN MINIQUICK INJECTION 0.8MG 4 PA GENOTROPIN MINIQUICK INJECTION 1.2MG 4 PA GENOTROPIN MINIQUICK INJECTION 1.4MG 4 PA GENOTROPIN MINIQUICK INJECTION 1.6MG 4 PA GENOTROPIN MINIQUICK INJECTION 1.8MG 4 PA GENOTROPIN MINIQUICK INJECTION 1MG 4 PA GENOTROPIN MINIQUICK INJECTION 2MG 4 PA GENOTROPIN INJECTION 12MG 5 PA GENOTROPIN INJECTION 5MG 5 PA HUMATROPE COMBO PACK INJECTION 5MG 5 PA HUMATROPE INJECTION 12MG 5 PA HUMATROPE INJECTION 24MG 5 PA HUMATROPE INJECTION 6MG 5 PA INCRELEX INJECTION 40MG/4ML 4 PA LA NORDITROPIN FLEXPRO INJECTION 10MG/1.5ML 5 PA NORDITROPIN FLEXPRO INJECTION 15MG/1.5ML 5 PA NORDITROPIN FLEXPRO INJECTION 30MG/3ML 5 PA NORDITROPIN FLEXPRO INJECTION 5MG/1.5ML 5 PA NUTROPIN AQ NUSPIN 5 INJECTION 5MG/2ML 5 PA NUTROPIN AQ PEN INJECTION 20MG/2ML 5 PA OMNITROPE INJECTION 10MG/1.5ML 4 PA OMNITROPE INJECTION 5.8MG 5 PA OMNITROPE INJECTION 5MG/1.5ML 4 PA SAIZEN CLICK.EASY INJECTION 8.8MG 5 PA SAIZEN INJECTION 5MG 5 PA SAIZEN INJECTION 8.8MG 5 PA SEROSTIM INJECTION 4MG 5 PA LA SEROSTIM INJECTION 5MG 5 PA LA SEROSTIM INJECTION 6MG 5 PA LA ZORBTIVE INJECTION 8.8MG 5 PA LA INSULIN SENSITIZERS AND COMBOS ACTOPLUS MET XR TABLET EXTENDED RELEASE 24 3 QL (60 EA per 30 days) MO HOUR 1000MG; 15MG ACTOPLUS MET XR TABLET EXTENDED RELEASE 24 3 QL (30 EA per 30 days) MO HOUR 1000MG; 30MG 66

68 Name pioglitazone hcl/metformin hcl tablet 500mg; 15mg 2 QL (90 EA per 30 days) MO pioglitazone hcl/metformin hcl tablet 850mg; 15mg 2 QL (90 EA per 30 days) MO pioglitazone hcl tablet 15mg 2 QL (30 EA per 30 days) MO pioglitazone hcl tablet 30mg 2 QL (30 EA per 30 days) MO pioglitazone hcl tablet 45mg 2 QL (30 EA per 30 days) MO INSULIN HUMALOG MIX 50/50 KWIKPEN INJECTION 3 MO 50UNIT/ML; 50UNIT/ML HUMALOG MIX 50/50 INJECTION 50UNIT/ML; 3 MO 50UNIT/ML HUMULIN R U-500 (CONCENTRATED) INJECTION 3 B/D MO 500UNIT/ML LANTUS SOLOSTAR INJECTION 100UNIT/ML 3 MO LANTUS INJECTION 100UNIT/ML 3 MO LEVEMIR FLEXTOUCH INJECTION 100UNIT/ML 3 MO LEVEMIR INJECTION 100UNIT/ML 3 MO NOVOLIN 70/30 INJECTION 30UNIT/ML; 70UNIT/ML 3 MO NOVOLIN N INJECTION 100UNIT/ML 3 MO NOVOLIN R INJECTION 100UNIT/ML 3 MO NOVOLOG FLEXPEN INJECTION 100UNIT/ML 3 MO NOVOLOG MIX 70/30 PREFILLED FLEXPEN INJECTION3 MO 30UNIT/ML; 70UNIT/ML NOVOLOG MIX 70/30 INJECTION 30UNIT/ML; 3 MO 70UNIT/ML NOVOLOG PENFILL INJECTION 100UNIT/ML 3 MO NOVOLOG INJECTION 100UNIT/ML 3 MO ORAL HYPOGLYCEMICS AND COMBOS acarbose tablet 100mg 2 MO acarbose tablet 25mg 2 MO acarbose tablet 50mg 2 MO CYCLOSET TABLET 0.8MG 3 QL (180 EA per 30 days) MO glimepiride tablet 1mg 1 QL (240 EA per 30 days) MO glimepiride tablet 2mg 1 QL (120 EA per 30 days) MO glimepiride tablet 4mg 1 QL (60 EA per 30 days) MO glipizide er tablet extended release 24 hour 10mg 1 QL (60 EA per 30 days) MO glipizide er tablet extended release 24 hour 2.5mg 1 QL (240 EA per 30 days) MO glipizide er tablet extended release 24 hour 5mg 1 QL (120 EA per 30 days) MO glipizide/metformin hcl tablet 2.5mg; 250mg 2 QL (240 EA per 30 days) MO glipizide/metformin hcl tablet 2.5mg; 500mg 2 QL (120 EA per 30 days) MO glipizide/metformin hcl tablet 5mg; 500mg 2 QL (120 EA per 30 days) MO glipizide tablet 10mg 1 QL (120 EA per 30 days) MO glipizide tablet 5mg 1 QL (240 EA per 30 days) MO GLYSET TABLET 100MG 3 MO GLYSET TABLET 25MG 3 MO GLYSET TABLET 50MG 3 MO GLYXAMBI TABLET 10MG; 5MG 3 GLYXAMBI TABLET 25MG; 5MG 3 metformin hcl er tablet extended release 24 hour 1000mg 1 QL (75 EA per 30 days) MO metformin hcl er tablet extended release 24 hour 500mg 1 QL (120 EA per 30 days) MO 67

69 Name metformin hcl er tablet extended release 24 hour 750mg 1 QL (60 EA per 30 days) MO metformin hcl tablet 1000mg 1 QL (75 EA per 30 days) MO metformin hcl tablet 500mg 1 QL (150 EA per 30 days) MO metformin hcl tablet 850mg 1 QL (90 EA per 30 days) MO nateglinide tablet 120mg 2 QL (90 EA per 30 days) MO nateglinide tablet 60mg 2 QL (90 EA per 30 days) MO pioglitazone hcl-glimepiride tablet 2mg; 30mg 2 QL (30 EA per 30 days) MO pioglitazone hcl-glimepiride tablet 4mg; 30mg 2 QL (30 EA per 30 days) MO PRANDIMET TABLET 500MG; 1MG 3 QL (150 EA per 30 days) MO PRANDIMET TABLET 500MG; 2MG 3 QL (150 EA per 30 days) MO repaglinide tablet 0.5mg 2 QL (120 EA per 30 days) MO repaglinide tablet 1mg 2 QL (120 EA per 30 days) MO repaglinide tablet 2mg 2 QL (240 EA per 30 days) MO RIOMET SOLUTION 500MG/5ML 3 QL (946 ML per 30 days) MO tolazamide tablet 250mg 2 MO tolazamide tablet 500mg 2 MO tolbutamide tablet 500mg 2 MO OTHER ENDOCRINE DRUGS ACTONEL TABLET 150MG 3 QL (1 EA per 30 days) ST MO ACTONEL TABLET 30MG 3 QL (90 EA per 90 days) ST MO ACTONEL TABLET 35MG 3 QL (4 EA per 28 days) ST MO ACTONEL TABLET 5MG 3 QL (30 EA per 30 days) ST MO ALDURAZYME INJECTION 2.9MG/5ML 5 PA LA alendronate sodium tablet 10mg 1 QL (30 EA per 30 days) MO alendronate sodium tablet 35mg 1 QL (4 EA per 28 days) MO alendronate sodium tablet 40mg 1 QL (30 EA per 30 days) MO alendronate sodium tablet 5mg 1 QL (30 EA per 30 days) MO alendronate sodium tablet 70mg 1 QL (4 EA per 28 days) MO BYDUREON INJECTION 2MG 3 PA MO BYDUREON INJECTION 2MG 3 QL (4 EA per 28 days) PA MO BYETTA INJECTION 10MCG/0.04ML 3 QL (2.4 ML per 30 days) PA MO BYETTA INJECTION 5MCG/0.02ML 3 QL (1.2 ML per 30 days) PA MO cabergoline tablet 0.5mg 2 QL (16 EA per 28 days) MO calcitonin-salmon solution 200unit/act 2 MO CERDELGA CAPSULE 84MG 5 PA CEREZYME INJECTION 400UNIT 5 PA desmopressin acetate injection 4mcg/ml 4 desmopressin acetate solution 0.01% 2 desmopressin acetate solution 0.01% 2 desmopressin acetate tablet 0.1mg 2 desmopressin acetate tablet 0.2mg 2 ELAPRASE INJECTION 6MG/3ML 5 LA ELELYSO INJECTION 200UNIT 5 PA etidronate disodium tablet 200mg 2 MO etidronate disodium tablet 400mg 2 MO FABRAZYME INJECTION 35MG 5 PA LA FORTEO INJECTION 600MCG/2.4ML 4 QL (2.4 ML per 28 days) PA FORTICAL SOLUTION 200UNIT/ACT 3 MO H.P. ACTHAR INJECTION 80UNIT/ML 5 PA 68

70 Name ibandronate sodium injection 3mg/3ml 4 PA ibandronate sodium injection 3mg/3ml 4 ibandronate sodium tablet 150mg 2 QL (1 EA per 30 days) ST B/D MO KORLYM TABLET 300MG 5 PA KUVAN PACKET 500MG 5 PA KUVAN TABLET SOLUBLE 100MG 5 PA LA LUMIZYME INJECTION 50MG 5 PA LA MIACALCIN INJECTION 200UNIT/ML 4 B/D MYALEPT INJECTION 11.3MG 4 MYOZYME INJECTION 50MG 5 PA LA NAGLAZYME INJECTION 1MG/ML 5 PA LA NATPARA INJECTION 100MCG 5 NATPARA INJECTION 25MCG 5 NATPARA INJECTION 50MCG 5 NATPARA INJECTION 75MCG 5 pamidronate disodium injection 30mg/10ml 4 B/D PAMIDRONATE DISODIUM INJECTION 6MG/ML 4 B/D pamidronate disodium injection 90mg/10ml 4 B/D PROLIA INJECTION 60MG/ML 4 QL (1 ML per 180 days) PA raloxifene hydrochloride tablet 60mg 2 risedronate sodium dr tablet delayed release 35mg 2 risedronate sodium tablet 150mg 2 risedronate sodium tablet 30mg 2 MO risedronate sodium tablet 35mg 2 MO risedronate sodium tablet 35mg 2 MO risedronate sodium tablet 5mg 2 MO SAMSCA TABLET 15MG 5 QL (60 EA per 30 days) PA SAMSCA TABLET 30MG 5 QL (60 EA per 30 days) PA SENSIPAR TABLET 30MG 3 QL (120 EA per 30 days) MO SENSIPAR TABLET 60MG 3 QL (60 EA per 30 days) MO SENSIPAR TABLET 90MG 3 QL (120 EA per 30 days) MO SIGNIFOR LAR INJECTION 20MG 5 PA SIGNIFOR LAR INJECTION 40MG 5 PA SIGNIFOR LAR INJECTION 60MG 5 PA SOMAVERT INJECTION 10MG 5 PA LA SOMAVERT INJECTION 15MG 5 PA LA SOMAVERT INJECTION 20MG 5 PA LA SOMAVERT INJECTION 25MG 5 PA SOMAVERT INJECTION 30MG 5 PA STIMATE SOLUTION 1.5MG/ML 3 SYMLINPEN 120 INJECTION 2700MCG/2.7ML 3 QL (10.8 ML per 30 days) PA MO SYMLINPEN 60 INJECTION 1500MCG/1.5ML 3 QL (12 ML per 30 days) PA MO TRULICITY INJECTION 0.75MG/0.5ML 3 PA MO TRULICITY INJECTION 1.5MG/0.5ML 3 PA MO VICTOZA INJECTION 18MG/3ML 3 QL (9 ML per 30 days) PA MO XGEVA INJECTION 120MG/1.7ML 4 PA ZAVESCA CAPSULE 100MG 5 PA LA zoledronic acid injection 4mg/5ml 4 B/D zoledronic acid injection 5mg/100ml 4 69

71 Name SODIUM-GLUCOSE COTRANSPORTER 2 (SGLT2) INHIBITORS FARXIGA TABLET 10MG 3 MO FARXIGA TABLET 5MG 3 MO INVOKAMET TABLET 150MG; 1000MG 3 MO INVOKAMET TABLET 150MG; 500MG 3 MO INVOKAMET TABLET 50MG; 1000MG 3 MO INVOKAMET TABLET 50MG; 500MG 3 MO INVOKANA TABLET 100MG 3 MO INVOKANA TABLET 300MG 3 MO JARDIANCE TABLET 10MG 3 QL (60 EA per 30 days) MO JARDIANCE TABLET 25MG 3 QL (30 EA per 30 days) MO XIGDUO XR TABLET EXTENDED RELEASE 24 HOUR 3 10MG; 1000MG XIGDUO XR TABLET EXTENDED RELEASE 24 HOUR 3 10MG; 500MG XIGDUO XR TABLET EXTENDED RELEASE 24 HOUR 3 5MG; 1000MG XIGDUO XR TABLET EXTENDED RELEASE 24 HOUR 3 5MG; 500MG THYROID SUPPLEMENTS levothyroxine sodium injection 100mcg 4 levothyroxine sodium tablet 100mcg 1 MO levothyroxine sodium tablet 112mcg 1 MO levothyroxine sodium tablet 125mcg 1 MO levothyroxine sodium tablet 137mcg 1 MO levothyroxine sodium tablet 150mcg 1 MO levothyroxine sodium tablet 175mcg 1 MO levothyroxine sodium tablet 200mcg 1 MO levothyroxine sodium tablet 25mcg 1 MO levothyroxine sodium tablet 300mcg 1 MO levothyroxine sodium tablet 50mcg 1 MO levothyroxine sodium tablet 75mcg 1 MO levothyroxine sodium tablet 88mcg 1 MO levoxyl tablet 100mcg 1 MO levoxyl tablet 112mcg 1 MO levoxyl tablet 125mcg 1 MO levoxyl tablet 137mcg 1 MO levoxyl tablet 150mcg 1 MO levoxyl tablet 175mcg 1 MO levoxyl tablet 200mcg 1 MO levoxyl tablet 25mcg 1 MO levoxyl tablet 50mcg 1 MO levoxyl tablet 75mcg 1 MO levoxyl tablet 88mcg 1 MO liothyronine sodium injection 10mcg/ml 4 liothyronine sodium tablet 25mcg 1 MO liothyronine sodium tablet 50mcg 1 MO liothyronine sodium tablet 5mcg 1 MO 70

72 Name SYNTHROID TABLET 100MCG 3 MO SYNTHROID TABLET 112MCG 3 MO SYNTHROID TABLET 125MCG 3 MO SYNTHROID TABLET 137MCG 3 MO SYNTHROID TABLET 150MCG 3 MO SYNTHROID TABLET 175MCG 3 MO SYNTHROID TABLET 200MCG 3 MO SYNTHROID TABLET 25MCG 3 MO SYNTHROID TABLET 300MCG 3 MO SYNTHROID TABLET 50MCG 3 MO SYNTHROID TABLET 75MCG 3 MO SYNTHROID TABLET 88MCG 3 MO THYROLAR-1/2 TABLET 30MG 3 MO THYROLAR-1/4 TABLET 15MG 3 MO THYROLAR-1 TABLET 60MG 3 MO THYROLAR-2 TABLET 120MG 3 MO THYROLAR-3 TABLET 180MG 3 MO TRIOSTAT INJECTION 10MCG/ML 4 unithroid tablet 100mcg 1 MO unithroid tablet 112mcg 1 MO unithroid tablet 125mcg 1 MO unithroid tablet 150mcg 1 MO unithroid tablet 175mcg 1 MO unithroid tablet 200mcg 1 MO unithroid tablet 25mcg 1 MO unithroid tablet 300mcg 1 MO unithroid tablet 50mcg 1 MO unithroid tablet 75mcg 1 MO unithroid tablet 88mcg 1 MO GASTROINTESTINAL ANTIDIARRHEAL DRUGS diphenoxylate/atropine liquid 0.025mg/5ml; 2.5mg/5ml 2 diphenoxylate/atropine tablet 0.025mg; 2.5mg 2 FULYZAQ TABLET DELAYED RELEASE 125MG 3 loperamide hcl capsule 2mg 2 ANTISPASMODICS/GI MOTILITY CANTIL TABLET 25MG 3 dicyclomine hcl capsule 10mg 2 dicyclomine hcl solution 10mg/5ml 2 dicyclomine hcl tablet 20mg 2 glycopyrrolate injection 4mg/20ml 4 glycopyrrolate tablet 1mg 2 glycopyrrolate tablet 2mg 2 methscopolamine bromide tablet 5mg 2 metoclopramide hcl injection 5mg/ml 4 metoclopramide hcl solution 5mg/5ml 2 metoclopramide hcl tablet 10mg 2 metoclopramide hcl tablet 5mg 2 metoclopramide odt tablet dispersible 5mg 2 71

73 Name propantheline bromide tablet 15mg 2 ANTIVERTIGO AND ANTIEMETICS AKYNZEO CAPSULE 300MG; 0.5MG 3 B/D ALOXI INJECTION 0.25MG/5ML 4 QL (10 ML per 30 days) B/D CESAMET CAPSULE 1MG 5 QL (30 EA per 5 days) B/D compro suppository 25mg 2 dronabinol capsule 10mg 2 QL (60 EA per 30 days) B/D GC dronabinol capsule 2.5mg 2 QL (60 EA per 30 days) B/D dronabinol capsule 5mg 2 QL (60 EA per 30 days) B/D EMEND CAPSULE 0 3 B/D EMEND CAPSULE 125MG 3 B/D EMEND CAPSULE 40MG 3 QL (6 EA per 3 days) B/D EMEND CAPSULE 80MG 3 QL (2 EA per 2 days) B/D granisetron hcl injection 0.1mg/ml 4 B/D granisetron hcl tablet 1mg 2 QL (2 EA per 1 days) B/D meclizine hcl tablet 12.5mg 2 meclizine hcl tablet 25mg 2 methscopolamine bromide tablet 2.5mg 2 ondansetron hcl injection 4mg/2ml 4 ondansetron hcl injection 4mg/2ml 4 B/D ondansetron hcl solution 4mg/5ml 2 B/D ondansetron hcl tablet 24mg 2 B/D ondansetron hcl tablet 4mg 2 B/D ondansetron hcl tablet 8mg 2 B/D ondansetron odt tablet dispersible 4mg 2 B/D ondansetron odt tablet dispersible 8mg 2 B/D prochlorperazine edisylate injection 5mg/ml 4 prochlorperazine maleate tablet 10mg 2 prochlorperazine maleate tablet 5mg 2 prochlorperazine suppository 25mg 2 promethazine hcl suppository 50mg 2 promethegan suppository 25mg 2 promethegan suppository 50mg 2 TRANSDERM-SCOP PATCH 72 HOUR 1MG/3DAYS 3 trimethobenzamide hcl capsule 300mg 2 H2 BLOCKERS cimetidine hcl solution 300mg/5ml 2 MO cimetidine tablet 200mg 2 MO cimetidine tablet 300mg 2 MO cimetidine tablet 400mg 2 MO cimetidine tablet 800mg 2 MO FAMOTIDINE PREMIXED INJECTION 0.4MG/ML; 0.9% 4 famotidine injection 20mg/2ml 4 famotidine suspension reconstituted 40mg/5ml 2 MO famotidine tablet 20mg 1 MO famotidine tablet 40mg 1 MO nizatidine capsule 150mg 2 MO nizatidine capsule 300mg 2 MO nizatidine solution 15mg/ml 2 MO 72

74 Name ranitidine hcl capsule 150mg 1 MO ranitidine hcl capsule 300mg 1 MO ranitidine hcl injection 150mg/6ml 4 ranitidine hcl syrup 15mg/ml 2 MO ranitidine hcl tablet 150mg 1 MO ranitidine hcl tablet 300mg 1 MO HEPATITIS C DRUGS HARVONI TABLET 90MG; 400MG 5 PA MODERIBA 1200 DOSE PACK TABLET 600MG 3 PA MODERIBA 800 DOSE PACK TABLET 400MG 3 PA MODERIBA TABLET 200MG 3 PA OLYSIO CAPSULE 150MG 5 PA REBETOL SOLUTION 40MG/ML 3 PA RIBASPHERE RIBAPAK TABLET 0 5 PA ribasphere ribapak tablet 400mg 5 PA ribasphere ribapak tablet 600mg 5 PA ribasphere capsule 200mg 2 PA ribasphere tablet 200mg 2 PA ribasphere tablet 400mg 2 PA RIBASPHERE TABLET 600MG 5 PA ribavirin capsule 200mg 2 PA ribavirin tablet 200mg 2 PA SOVALDI TABLET 400MG 5 PA VIRAZOLE SOLUTION RECONSTITUTED 6GM 5 PA LAXATIVES AND CATHARTICS gavilyte-g solution reconstituted 236gm; 2.97gm; 6.74gm; gm; 22.74gm GOLYTELY SOLUTION RECONSTITUTED 227.1GM; GM; 6.36GM; 5.53GM; 21.5GM MOVIPREP SOLUTION RECONSTITUTED 4.7GM; 3 100GM; 1.015GM; 5.9GM; 2.691GM; 7.5GM OSMOPREP TABLET 0.398GM; 1.102GM 3 peg-3350/electrolytes solution reconstituted 236gm; 2.97gm; gm; 5.86gm; 22.74gm polyethylene glycol 3350 powder 0 2 SUPREP BOWEL PREP SOLUTION 1.6GM/180ML; GM/180ML; 17.5GM/180ML trilyte solution reconstituted 420gm; 1.48gm; 5.72gm; 11.2gm 2 OTHER ANTIULCER DRUGS CARAFATE SUSPENSION 1GM/10ML 3 MO lansoprazole/amoxicillin/clarithromycin miscellaneous 0; 0; 0 2 QL (112 EA per 30 days) misoprostol tablet 100mcg 2 MO misoprostol tablet 200mcg 2 MO PYLERA CAPSULE 140MG; 125MG; 125MG 3 sucralfate tablet 1gm 2 MO OTHER GI DRUGS alosetron hydrochloride tablet 0.5mg 2 alosetron hydrochloride tablet 1mg 2 AMITIZA CAPSULE 24MCG 3 QL (60 EA per 30 days) MO 73

75 Name AMITIZA CAPSULE 8MCG 3 QL (60 EA per 30 days) MO APRISO CAPSULE EXTENDED RELEASE 24 HOUR 3 MO 0.375GM ASACOL HD TABLET DELAYED RELEASE 800MG 3 MO balsalazide disodium capsule 750mg 2 MO budesonide capsule extended release 24 hour 3mg 2 CANASA SUPPOSITORY 1000MG 3 MO CHENODAL TABLET 250MG 3 PA colocort enema 100mg/60ml 2 CREON CAPSULE DELAYED RELEASE PARTICLES 3 MO UNIT; 24000UNIT; 76000UNIT CREON CAPSULE DELAYED RELEASE PARTICLES UNIT; 3000UNIT; 9500UNIT CREON CAPSULE DELAYED RELEASE PARTICLES 3 MO UNIT; 36000UNIT; UNIT CREON CAPSULE DELAYED RELEASE PARTICLES 3 MO 30000UNIT; 6000UNIT; 19000UNIT CREON CAPSULE DELAYED RELEASE PARTICLES 3 MO 60000UNIT; 12000UNIT; 38000UNIT DELZICOL CAPSULE DELAYED RELEASE 400MG 3 DIPENTUM CAPSULE 250MG 3 MO ENTOCORT EC CAPSULE EXTENDED RELEASE 24 3 HOUR 3MG GASTROCROM CONCENTRATE 100MG/5ML 3 gavilyte-c solution reconstituted 240gm; 2.98gm; 6.72gm; 5.84gm; 22.72gm 2 gavilyte-n/flavor pack solution reconstituted 420gm; 1.48gm; gm; 11.2gm hydrocortisone cream 2.5% 2 hydrocortisone enema 100mg/60ml 2 LIALDA TABLET DELAYED RELEASE 1.2GM 3 MO LINZESS CAPSULE 145MCG 3 MO LINZESS CAPSULE 290MCG 3 MO LOTRONEX TABLET 0.5MG 3 MO LOTRONEX TABLET 1MG 3 MO mesalamine kit 4gm 2 MO PENTASA CAPSULE EXTENDED RELEASE 250MG 3 MO PENTASA CAPSULE EXTENDED RELEASE 500MG 3 MO RELISTOR INJECTION 12MG/0.6ML 3 PA RELISTOR INJECTION 12MG/0.6ML 3 PA RELISTOR INJECTION 8MG/0.4ML 3 PA SUCRAID SOLUTION 8500UNIT/ML 5 sulfasalazine tablet 500mg 2 MO sulfazine ec tablet delayed release 500mg 2 MO UCERIS FOAM 2MG/ACT 3 UCERIS TABLET EXTENDED RELEASE 24 HOUR 9MG 5 ursodiol capsule 300mg 2 MO ursodiol tablet 250mg 2 MO ursodiol tablet 500mg 2 MO 74

76 Name PROTON PUMP INHIBITORS DEXILANT CAPSULE DELAYED RELEASE 30MG 3 QL (30 EA per 30 days) ST MO DEXILANT CAPSULE DELAYED RELEASE 60MG 3 QL (30 EA per 30 days) ST MO lansoprazole capsule delayed release 15mg 2 ST MO lansoprazole capsule delayed release 30mg 2 ST MO omeprazole capsule delayed release 10mg 2 MO omeprazole capsule delayed release 20mg 2 MO omeprazole capsule delayed release 40mg 2 MO pantoprazole sodium tablet delayed release 20mg 2 MO pantoprazole sodium tablet delayed release 40mg 2 MO HEMATOLOGICAL ERYTHROID STIMULANTS ARANESP ALBUMIN FREE INJECTION 100MCG/0.5ML 4 PA ARANESP ALBUMIN FREE INJECTION 100MCG/ML 4 PA ARANESP ALBUMIN FREE INJECTION 10MCG/0.4ML 4 ARANESP ALBUMIN FREE INJECTION 150MCG/0.3ML 5 PA ARANESP ALBUMIN FREE INJECTION 200MCG/0.4ML 5 PA ARANESP ALBUMIN FREE INJECTION 200MCG/ML 5 PA ARANESP ALBUMIN FREE INJECTION 25MCG/0.42ML 4 PA ARANESP ALBUMIN FREE INJECTION 25MCG/ML 4 PA ARANESP ALBUMIN FREE INJECTION 300MCG/0.6ML 5 PA ARANESP ALBUMIN FREE INJECTION 300MCG/ML 5 PA ARANESP ALBUMIN FREE INJECTION 40MCG/0.4ML 4 PA ARANESP ALBUMIN FREE INJECTION 40MCG/ML 4 PA ARANESP ALBUMIN FREE INJECTION 500MCG/ML 5 PA ARANESP ALBUMIN FREE INJECTION 60MCG/0.3ML 4 PA ARANESP ALBUMIN FREE INJECTION 60MCG/ML 4 PA EPOGEN INJECTION 10000UNIT/ML 4 PA EPOGEN INJECTION 20000UNIT/ML 4 PA EPOGEN INJECTION 2000UNIT/ML 4 PA EPOGEN INJECTION 3000UNIT/ML 4 PA EPOGEN INJECTION 4000UNIT/ML 4 PA PROCRIT INJECTION 10000UNIT/ML 3 PA PROCRIT INJECTION 20000UNIT/ML 3 PA PROCRIT INJECTION 2000UNIT/ML 3 PA PROCRIT INJECTION 3000UNIT/ML 3 PA PROCRIT INJECTION 40000UNIT/ML 3 PA PROCRIT INJECTION 4000UNIT/ML 3 PA HEMOSTATICS PROMACTA TABLET 12.5MG 5 QL (240 EA per 30 days) PA LA PROMACTA TABLET 25MG 5 QL (120 EA per 30 days) PA LA PROMACTA TABLET 50MG 5 QL (60 EA per 30 days) PA LA PROMACTA TABLET 75MG 5 QL (30 EA per 30 days) PA LA tranexamic acid injection 100mg/ml 4 tranexamic acid tablet 650mg 2 INJECTABLE ANTICOAGULANTS enoxaparin sodium injection 100mg/ml 2 enoxaparin sodium injection 120mg/0.8ml 2 enoxaparin sodium injection 150mg/ml 2 75

77 Name enoxaparin sodium injection 300mg/3ml 2 enoxaparin sodium injection 30mg/0.3ml 2 enoxaparin sodium injection 40mg/0.4ml 2 enoxaparin sodium injection 60mg/0.6ml 2 enoxaparin sodium injection 80mg/0.8ml 2 fondaparinux sodium injection 10mg/0.8ml 4 fondaparinux sodium injection 2.5mg/0.5ml 4 fondaparinux sodium injection 5mg/0.4ml 4 fondaparinux sodium injection 7.5mg/0.6ml 4 FRAGMIN INJECTION 10000UNIT/ML 4 FRAGMIN INJECTION 12500UNIT/0.5ML 4 FRAGMIN INJECTION 15000UNIT/0.6ML 4 FRAGMIN INJECTION 18000UNT/0.72ML 4 FRAGMIN INJECTION 2500UNIT/0.2ML 4 FRAGMIN INJECTION 5000UNIT/0.2ML 4 FRAGMIN INJECTION 7500UNIT/0.3ML 4 FRAGMIN INJECTION 95000UNIT/3.8ML 4 HEPARIN SODIUM/D5W INJECTION 5%; 100UNIT/ML 4 B/D heparin sodium/d5w injection 5%; 40unit/ml 4 B/D HEPARIN SODIUM/D5W INJECTION 5%; 50UNIT/ML 4 B/D heparin sodium injection 10000unit/ml 4 B/D heparin sodium injection 1000unit/ml 4 B/D heparin sodium injection 20000unit/ml 4 B/D heparin sodium injection 5000unit/ml 4 B/D IRON OVERLOAD AGENTS EXJADE TABLET SOLUBLE 125MG 5 LA EXJADE TABLET SOLUBLE 250MG 5 LA EXJADE TABLET SOLUBLE 500MG 5 LA FERRIPROX TABLET 500MG 5 MYELOID STIMULANTS GRANIX INJECTION 300MCG/0.5ML 5 GRANIX INJECTION 480MCG/0.8ML 5 LEUKINE INJECTION 250MCG 5 PA NEULASTA INJECTION 6MG/0.6ML 5 QL (2 ML per 30 days) NEUPOGEN INJECTION 300MCG/0.5ML 5 NEUPOGEN INJECTION 300MCG/ML 4 NEUPOGEN INJECTION 480MCG/0.8ML 5 NEUPOGEN INJECTION 480MCG/1.6ML 5 IMMUNOLOGICALS AND VACCINES IMMUNE GLOBULIN BIVIGAM INJECTION 10GM/100ML 4 PA CARIMUNE NANOFILTERED INJECTION 6GM 5 PA GAMASTAN S/D INJECTION 0 4 B/D GAMMAGARD LIQUID INJECTION 2.5GM/25ML 5 PA GAMMAPLEX INJECTION 10GM/200ML 5 PA GAMUNEX-C INJECTION 1GM/10ML 4 PA HYPERRAB S/D INJECTION 150UNIT/ML 3 HYPERRAB S/D INJECTION 150UNIT/ML 3 PRIVIGEN INJECTION 20GM/200ML 3 PA 76

78 Name VARIZIG INJECTION 125UNIT/1.2ML 3 IMMUNOLOGICALS AND VACCINES ACTHIB INJECTION 0 3 ADACEL INJECTION 15.5MCG/0.5ML; 2LF/0.5ML; 3 5LF/0.5ML ATGAM INJECTION 50MG/ML 5 BARACLUDE SOLUTION 0.05MG/ML 3 BARACLUDE TABLET 0.5MG 5 BARACLUDE TABLET 1MG 5 BCG VACCINE INJECTION 0 3 BEXSERO INJECTION 0 3 BOOSTRIX INJECTION 18.5MCG/0.5ML; 2.5LF/0.5ML; 3 5LF/0.5ML BOOSTRIX INJECTION 18.5MCG/0.5ML; 2.5LF/0.5ML; 3 5LF/0.5ML CERVARIX INJECTION 0 3 CINRYZE INJECTION 500UNIT 5 PA COMVAX INJECTION 7.5MCG/0.5ML; 5MCG/0.5ML 3 DAPTACEL INJECTION 10MCG/0.5ML; 15LF/0.5ML; 3 5LF/0.5ML DIPHTHERIA/TETANUS TOXOIDS ADSORBED 3 PEDIATRIC INJECTION 25LFU/0.5ML; 5LFU/0.5ML ENGERIX-B INJECTION 10MCG/0.5ML 3 B/D ENGERIX-B INJECTION 10MCG/0.5ML 3 B/D ENGERIX-B INJECTION 20MCG/ML 3 B/D ENTECAVIR TABLET 0.5MG 3 ENTECAVIR TABLET 1MG 3 FIRAZYR INJECTION 30MG/3ML 5 PA GARDASIL 9 INJECTION 0 3 GARDASIL 9 INJECTION 0 3 GARDASIL INJECTION 0 3 GARDASIL INJECTION 0 3 HAVRIX INJECTION 1440ELU/ML 3 HAVRIX INJECTION 720ELU/0.5ML 3 IMOVAX RABIES (H.D.C.V.) INJECTION 2.5UNIT/ML 3 INFANRIX INJECTION 58MCG/0.5ML; 25LFU/0.5ML; 3 10LFU/0.5ML IPOL INACTIVATED IPV INJECTION 0 3 IPOL INACTIVATED IPV INJECTION 0 3 IXIARO INJECTION 0 3 M-M-R II INJECTION 0; 0; 0 3 MENACTRA INJECTION 0 3 MENOMUNE-A/C/Y/W-135 INJECTION 0 3 MENVEO INJECTION 0 3 PEDVAX HIB INJECTION 7.5MCG/0.5ML 3 PROQUAD INJECTION 0; 0; 0; 0 3 QUADRACEL INJECTION 48MCG/0.5ML; 15LFU/0.5ML; 3 0; 5LFU/0.5ML RABAVERT INJECTION

79 Name RECOMBIVAX HB INJECTION 10MCG/ML 3 B/D RECOMBIVAX HB INJECTION 10MCG/ML 3 RECOMBIVAX HB INJECTION 40MCG/ML 3 B/D RECOMBIVAX HB INJECTION 5MCG/0.5ML 3 ROTARIX SUSPENSION RECONSTITUTED 0 3 ROTATEQ SOLUTION 0 3 sirolimus tablet 0.5mg 2 B/D SYNAGIS INJECTION 50MG/0.5ML 5 LA TENIVAC INJECTION 2LFU; 5LFU 3 TETANUS/DIPHTHERIA TOXOIDS-ADSORBED ADULT 3 B/D INJECTION 2LF/0.5ML; 2LF/0.5ML THYMOGLOBULIN INJECTION 25MG 5 TRUMENBA INJECTION 0 3 TWINRIX INJECTION 720ELU/ML; 20MCG/ML 3 B/D TYPHIM VI INJECTION 25MCG/0.5ML 3 TYPHIM VI INJECTION 25MCG/0.5ML 3 VAQTA INJECTION 25UNIT/0.5ML 3 VAQTA INJECTION 25UNIT/0.5ML 3 VAQTA INJECTION 50UNIT/ML 3 VARIVAX INJECTION 1350PFU/0.5ML 3 YF-VAX INJECTION 0 3 ZOSTAVAX INJECTION 19400UNT/0.65ML 3 QL (1 EA per 999 days) IMMUNOSUPPRESSANTS AFINITOR DISPERZ TABLET SOLUBLE 2MG 5 PA AFINITOR DISPERZ TABLET SOLUBLE 3MG 5 PA AFINITOR DISPERZ TABLET SOLUBLE 5MG 5 PA ASTAGRAF XL CAPSULE EXTENDED RELEASE 24 3 B/D HOUR 0.5MG ASTAGRAF XL CAPSULE EXTENDED RELEASE 24 3 B/D HOUR 1MG ASTAGRAF XL CAPSULE EXTENDED RELEASE 24 3 B/D HOUR 5MG BENLYSTA INJECTION 120MG 5 CELLCEPT INTRAVENOUS INJECTION 500MG 4 B/D CELLCEPT SUSPENSION RECONSTITUTED 200MG/ML 5 B/D cyclosporine modified capsule 100mg 2 B/D cyclosporine modified capsule 25mg 2 B/D cyclosporine modified solution 100mg/ml 2 B/D cyclosporine injection 50mg/ml 4 B/D mycophenolate mofetil suspension reconstituted 200mg/ml 2 B/D mycophenolic acid dr tablet delayed release 180mg 2 B/D mycophenolic acid dr tablet delayed release 360mg 2 B/D NEORAL SOLUTION 100MG/ML 3 B/D NULOJIX INJECTION 250MG 5 B/D OTREXUP INJECTION 10MG/0.4ML 4 OTREXUP INJECTION 15MG/0.4ML 4 OTREXUP INJECTION 20MG/0.4ML 4 OTREXUP INJECTION 25MG/0.4ML 4 OTREXUP INJECTION 7.5MG/0.4ML 4 78

80 Name PROGRAF INJECTION 5MG/ML 4 B/D RAPAMUNE SOLUTION 1MG/ML 3 B/D RAPAMUNE TABLET 1MG 3 B/D RAPAMUNE TABLET 2MG 3 B/D SANDIMMUNE INJECTION 50MG/ML 4 B/D SANDIMMUNE SOLUTION 100MG/ML 3 B/D sirolimus tablet 1mg 2 B/D sirolimus tablet 2mg 2 B/D STELARA INJECTION 45MG/0.5ML 5 PA STELARA INJECTION 90MG/ML 5 PA tacrolimus capsule 0.5mg 2 B/D tacrolimus capsule 1mg 2 B/D tacrolimus capsule 5mg 2 B/D tacrolimus ointment 0.03% 2 tacrolimus ointment 0.1% 2 ZORTRESS TABLET 0.25MG 3 B/D ZORTRESS TABLET 0.5MG 3 B/D ZORTRESS TABLET 0.75MG 3 B/D INTERFERONS ACTIMMUNE INJECTION UNIT/0.5ML 5 PA LA INTRON A W/DILUENT INJECTION 10MU 4 B/D INTRON A INJECTION 18MU 4 INTRON A INJECTION 50MU 4 INTRON A INJECTION UNIT/ML 4 B/D PEG-INTRON REDIPEN INJECTION 120MCG/0.5ML 5 QL (4 EA per 28 days) PA PEG-INTRON REDIPEN INJECTION 150MCG/0.5ML 5 QL (4 EA per 28 days) PA PEG-INTRON REDIPEN INJECTION 50MCG/0.5ML 5 QL (4 EA per 28 days) PA PEG-INTRON REDIPEN INJECTION 80MCG/0.5ML 5 QL (4 EA per 28 days) PA PEG-INTRON INJECTION 50MCG/0.5ML 5 QL (4 EA per 28 days) PA PEGASYS PROCLICK INJECTION 135MCG/0.5ML 5 QL (4 ML per 28 days) PA PEGASYS PROCLICK INJECTION 180MCG/0.5ML 5 PA PEGASYS INJECTION 180MCG/0.5ML 5 QL (4 ML per 28 days) PA PEGASYS INJECTION 180MCG/ML 5 QL (4 ML per 28 days) PA PEGINTRON INJECTION 120MCG/0.5ML 5 QL (5 EA per 34 days) PA PEGINTRON INJECTION 150MCG/0.5ML 5 QL (5 EA per 34 days) PA PEGINTRON INJECTION 80MCG/0.5ML 5 QL (5 EA per 34 days) PA SYLATRON INJECTION 200MCG 5 PA SYLATRON INJECTION 300MCG 5 PA SYLATRON INJECTION 600MCG 5 PA INTERLEUKIN RECEPTOR ANTAGONIST ACTEMRA INJECTION 162MG/0.9ML 5 PA ACTEMRA INJECTION 200MG/10ML 5 PA ACTEMRA INJECTION 400MG/20ML 5 PA ACTEMRA INJECTION 80MG/4ML 4 PA ARCALYST INJECTION 220MG 5 PA LA ILARIS INJECTION 180MG 5 PA LA INTERLEUKINS NEUMEGA INJECTION 5MG 5 QL (21 EA per 21 days) PROLEUKIN INJECTION UNIT 5 B/D 79

81 Name MS DRUGS AMPYRA TABLET EXTENDED RELEASE 12 HOUR 5 PA LA 10MG AUBAGIO TABLET 14MG 5 PA AUBAGIO TABLET 7MG 5 PA AVONEX PEN INJECTION 30MCG/0.5ML 3 AVONEX INJECTION 30MCG/0.5ML 3 QL (4 EA per 28 days) AVONEX INJECTION 30MCG/VIAL 3 QL (4 EA per 28 days) BETASERON INJECTION 0.3MG 5 QL (14 EA per 28 days) PA COPAXONE INJECTION 20MG/ML 5 QL (30 ML per 30 days) PA COPAXONE INJECTION 40MG/ML 5 PA EXTAVIA INJECTION 0.3MG 5 QL (15 EA per 28 days) PA GILENYA CAPSULE 0.5MG 5 QL (30 EA per 30 days) PA PLEGRIDY STARTER PACK INJECTION 0 5 QL (1 ML per 28 days) PA PLEGRIDY INJECTION 125MCG/0.5ML 5 QL (1 ML per 28 days) PA PLEGRIDY INJECTION 125MCG/0.5ML 5 PA REBIF REBIDOSE TITRATION PACK INJECTION 0 5 PA REBIF REBIDOSE INJECTION 22MCG/0.5ML 5 PA REBIF REBIDOSE INJECTION 44MCG/0.5ML 5 PA REBIF TITRATION PACK INJECTION 0 5 QL (12 ML per 28 days) PA REBIF INJECTION 22MCG/0.5ML 5 QL (6 ML per 28 days) PA REBIF INJECTION 44MCG/0.5ML 5 QL (6 ML per 28 days) PA TECFIDERA STARTER PACK MISCELLANEOUS 0 5 PA TECFIDERA CAPSULE DELAYED RELEASE 120MG 5 PA TECFIDERA CAPSULE DELAYED RELEASE 240MG 5 PA TYSABRI INJECTION 300MG/15ML 5 PA LA MEDICAL (MISCELLANEOUS) SUPPLIES DIABETIC SUPPLIES alcohol prep pads pad 70% 2 MO bd insulin syringe safetyglide/1ml/29g x 1/2" miscellaneous 2 MO bd insulin syringe ultrafine/0.3ml/31g x 5/16" miscellaneous 2 MO bd insulin syringe ultrafine/0.5ml/30g x 1/2" miscellaneous 2 MO bd insulin syringe ultrafine/1ml/31g x 5/16" miscellaneous 2 MO bd pen needle/ultrafine/29g x 12.7mm miscellaneous 2 MO curity gauze pads 2"x2" pad 2 MO MISCELLANEOUS DRUGS MISCELLANEOUS DRUGS ADAGEN INJECTION 250UNIT/ML 4 LA CARBAGLU TABLET 200MG 5 PA LA MOZOBIL INJECTION 24MG/1.2ML 5 PA ORFADIN CAPSULE 10MG 5 PA LA ORFADIN CAPSULE 2MG 5 PA LA ORFADIN CAPSULE 5MG 5 PA LA RAVICTI LIQUID 1.1GM/ML 5 sodium phenylbutyrate powder 3gm/tsp 2 NUTRITIONAL/SUPPLEMENTS BLOOD DETOXICANTS enulose solution 10gm/15ml 2 lactulose solution 10gm/15ml 2 80

82 Name neomycin sulfate tablet 500mg 2 ELECTROLYTES, IRRIGATING SOLUTIONS, ETC AMINOSYN 7%/ELECTROLYTES INJECTION 124MEQ/L; 900MG/100ML; 690MG/100ML; 96MEQ/L; 900MG/100ML; 210MG/100ML; 510MG/100ML; 4 660MG/100ML; 510MG/100ML; 10MEQ/L; 280MG/100ML; 310MG/100ML; 30MMOLE/L; 65MEQ/L; 610MG/100ML; 300MG/100ML; 65MEQ/L; 370MG/100ML; 120MG/100ML; 44MG/100ML; 560MG/100ML aminosyn 8.5%/electrolytes injection 142meq/l; 4 B/D 1100mg/100ml; 850mg/100ml; 98meq/l; 1100mg/100ml; 260mg/100ml; 620mg/100ml; 810mg/100ml; 624mg/100ml; 10meq/l; 340mg/100ml; 380mg/100ml; 30meq/l; 65meq/l; 750mg/100ml; 370mg/100ml; 65meq/l; 460mg/100ml; 150mg/100ml; 44mg/100ml; 680mg/100ml aminosyn ii 8.5%/electrolytes injection 61meq/l; 844mg/100ml; 865mg/100ml; 595mg/100ml; 86meq/l; 627mg/100ml; 425mg/100ml; 255mg/100ml; 561mg/100ml; 850mg/100ml; 893mg/100ml; 10meq/l; 146mg/100ml; 253mg/100ml; 30mmole/l; 66meq/l; 614mg/100ml; 450mg/100ml; 80meq/l; 340mg/100ml; 170mg/100ml; 230mg/100ml; 425mg/100ml 4 B/D AMINOSYN II INJECTION 107.6MEQ/L; 1490MG/100ML; 4 B/D 1527MG/100ML; 1050MG/100ML; 1107MG/100ML; 750MG/100ML; 450MG/100ML; 990MG/100ML; 1500MG/100ML; 1575MG/100ML; 258MG/100ML; 447MG/100ML; 1083MG/100ML; 795MG/100ML; 50MEQ/L; 600MG/100ML; 300MG/100ML; 405MG/100ML; 750MG/100ML AMINOSYN II INJECTION 50.3MEQ/L; 695MG/100ML; 4 B/D 713MG/100ML; 490MG/100ML; 517MG/100ML; 350MG/100ML; 210MG/100ML; 462MG/100ML; 700MG/100ML; 735MG/100ML; 120MG/100ML; 209MG/100ML; 505MG/100ML; 371MG/100ML; 31.3MEQ/L; 280MG/100ML; 140MG/100ML; 189MG/100ML; 350MG/100ML AMINOSYN II INJECTION 61.1MEQ/L; 844MG/100ML; 865MG/100ML; 595MG/100ML; 627MG/100ML; 425MG/100ML; 255MG/100ML; 561MG/100ML; 850MG/100ML; 893MG/100ML; 146MG/100ML; 253MG/100ML; 614MG/100ML; 450MG/100ML; 33.3MEQ/L; 340MG/100ML; 170MG/100ML; 230MG/100ML; 425MG/100ML 4 B/D 81

83 Name AMINOSYN II INJECTION 71.8MEQ/L; 993MG/100ML; 4 B/D 1018MG/100ML; 700MG/100ML; 738MG/100ML; 500MG/100ML; 300MG/100ML; 660MG/100ML; 1000MG/100ML; 1050MG/100ML; 172MG/100ML; 298MG/100ML; 722MG/100ML; 530MG/100ML; 45.3MEQ/L; 400MG/100ML; 200MG/100ML; 270MG/100ML; 500MG/100ML AMINOSYN M INJECTION 65MEQ/L; 448MG/100ML; 4 B/D 343MG/100ML; 40MEQ/L; 448MG/100ML; 105MG/100ML; 252MG/100ML; 329MG/100ML; 252MG/100ML; 3MEQ/L; 140MG/100ML; 154MG/100ML; 3.5MMOLE/L; 13MEQ/L; 300MG/100ML; 147MG/100ML; 40MEQ/L; 182MG/100ML; 56MG/100ML; 31MG/100ML; 280MG/100ML AMINOSYN-HBC INJECTION 7.1MEQ/100ML; 4 B/D 660MG/100ML; 507MG/100ML; 4MEQ/100ML; 660MG/100ML; 154MG/100ML; 789MG/100ML; 1576MG/100ML; 265MG/100ML; 206MG/100ML; 1.12GM/100ML; 228MG/100ML; 448MG/100ML; 221MG/100ML; 272MG/100ML; 88MG/100ML; 33MG/100ML; 789MG/100ML AMINOSYN-PF 7% INJECTION 32.5MEQ/L; 4 B/D 490MG/100ML; 861MG/100ML; 370MG/100ML; 576MG/100ML; 270MG/100ML; 220MG/100ML; 534MG/100ML; 831MG/100ML; 475MG/100ML; 125MG/100ML; 10.69GM/L; 300MG/100ML; 570MG/100ML; 70GM/L; 347MG/100ML; 50MG/100ML; 360MG/100ML; 125MG/100ML; 44MG/100ML; 452MG/100ML AMINOSYN-PF INJECTION 46MEQ/L; 698MG/100ML; 4 B/D 1227MG/100ML; 527MG/100ML; 820MG/100ML; 385MG/100ML; 312MG/100ML; 760MG/100ML; 1200MG/100ML; 677MG/100ML; 180MG/100ML; 427MG/100ML; 812MG/100ML; 495MG/100ML; 3.4MEQ/L; 70MG/100ML; 512MG/100ML; 180MG/100ML; 44MG/100ML; 673MG/100ML AMINOSYN-RF INJECTION 113MEQ/L; 600MG/100ML; 4 429MG/100ML; 462MG/100ML; 726MG/100ML; 535MG/100ML; 726MG/100ML; 726MG/100ML; 330MG/100ML; 165MG/100ML; 528MG/100ML AMMONIUM CHLORIDE INJECTION 5MEQ/ML 4 CYSTAGON CAPSULE 150MG 3 PA LA CYSTAGON CAPSULE 50MG 3 PA LA DEXTROSE 10%/NACL 0.45% INJECTION 10%; 0.45% 4 dextrose 10% flex container injection 10% 4 dextrose 10%/nacl 0.2% injection 10%; 0.2% 4 dextrose 2.5%/sodium chloride 0.45% injection 2.5%; 0.45% 4 dextrose 5%/nacl 0.2% injection 5%; 0.2% 4 DEXTROSE 5%/NACL 0.225% INJECTION 5%; 0.225% 4 dextrose 5%/nacl 0.33% injection 5%; 0.33% 4 82

84 Name dextrose 5%/nacl 0.45% injection 5%; 0.45% 4 dextrose 5%/nacl 0.9% injection 5%; 0.9% 4 dextrose 5%/potassium chloride 0.15% injection 5%; 20meq/l 4 dextrose 5% injection 5% 4 FREAMINE HBC 6.9% INJECTION 59.3MEQ/L; 4 400MG/100ML; 580MG/100ML; 3MEQ/L; 14MG/100ML; 330MG/100ML; 160MG/100ML; 760MG/100ML; 1370MG/100ML; 410MG/100ML; 250MG/100ML; 320MG/100ML; 630MG/100ML; 330MG/100ML; 10MEQ/L; 200MG/100ML; 90MG/100ML; 880MG/100ML hepatamine injection 62meq/l; 770mg/100ml; 600mg/100ml; 4 B/D 3meq/l; 20mg/100ml; 900mg/100ml; 240mg/100ml; 900mg/100ml; 1100mg/100ml; 610mg/100ml; 100mg/100ml; 100mg/100ml; 115mg/100ml; 800mg/100ml; 500mg/100ml; 100mg/100ml; 450mg/100ml; 66mg/100ml; 840mg/100ml intralipid injection 20gm/100ml 4 B/D INTRALIPID INJECTION 30GM/100ML 4 B/D IONOSOL-B/DEXTROSE 5% INJECTION 49MEQ/L; 5%; 25MEQ/L; 5MEQ/L; 13MEQ/L; 25MEQ/L; 57MEQ/L 4 IONOSOL-MB/DEXTROSE 5% INJECTION 22MEQ/L; 5%; 4 23MEQ/L; 3MEQ/L; 3MEQ/L; 20MEQ/L; 25MEQ/L ISOLYTE-P/DEXTROSE 5% INJECTION 23MEQ/L; 4 23MEQ/L; 5%; 3MEQ/L; 3MEQ/L; 20MEQ/L; 25MEQ/L ISOLYTE-S INJECTION 27MEQ/L; 98MEQ/L; 23MEQ/L; 4 3MEQ/L; 5MEQ/L; 140MEQ/L kcl 0.075%/d5w/nacl 0.45% injection 5%; 10meq/l; 0.45% 4 kcl 0.15%/d5w/nacl 0.2% injection 5%; 20meq/l; 0.2% 4 KCL 0.15%/D5W/NACL 0.225% INJECTION 5%; 4 20MEQ/L; 0.225% kcl 0.15%/d5w/nacl 0.9% injection 5%; 20meq/l; 0.9% 4 kcl 0.3%/d5w/nacl 0.45% injection 5%; 40meq/l; 0.45% 4 KCL 0.3%/D5W/NACL 0.9% INJECTION 5%; 40MEQ/L; 4 0.9% lactated ringers irrigation solution 3meq/l; 109meq/l; 28meq/l; 2 4meq/l; 130meq/l lactated ringers viaflex injection 3meq/l; 109meq/l; 28meq/l; 4 4meq/l; 130meq/l LIPOSYN III INJECTION 1.2GM/100ML; 2.5GM/100ML; 4 B/D 10GM/100ML LIPOSYN III INJECTION 1.2GM/100ML; 2.5GM/100ML; 4 B/D 20GM/100ML magnesium sulfate injection 50% 4 magnesium sulfate injection 50% 4 NEPHRAMINE INJECTION 44MEQ/L; 20MG/100ML; 4 B/D 250MG/100ML; 560MG/100ML; 880MG/100ML; 640MG/100ML; 880MG/100ML; 880MG/100ML; 6MEQ/L; 400MG/100ML; 200MG/100ML; 640MG/100ML normosol-m in d5w injection 16meq/l; 40meq/l; 5%; 3meq/l; 13meq/l; 40meq/l 4 83

85 Name normosol-r in d5w injection 27meq/l; 98meq/l; 5%; 23meq/l; 4 3meq/l; 5meq/l; 140meq/l NORMOSOL-R INJECTION 27MEQ/L; 98MEQ/L; 4 23MEQ/L; 3MEQ/L; 5MEQ/L; 140MEQ/L nutrilipid injection 20gm/100ml 4 physiolyte solution 27meq/1000ml; 98meq/1000ml; 2 23meq/1000ml; 3meq/1000ml; 5meq/1000ml; 140meq/1000ml PHYSIOSOL IRRIGATION SOLUTION 30MG/100ML; 3 37MG/100ML; 222MG/100ML; 526MG/100ML; 502MG/100ML PLASMA-LYTE A INJECTION 27MEQ/L; 98MEQ/L; 4 23MEQ/L; 3MEQ/L; 5MEQ/L; 140MEQ/L PLASMA-LYTE-148 INJECTION 27MEQ/L; 98MEQ/L; 4 23MEQ/L; 3MEQ/L; 5MEQ/L; 140MEQ/L PLASMA-LYTE-56/D5W INJECTION 16MEQ/L; 4 40MEQ/L; 5%; 3MEQ/L; 13MEQ/L; 40MEQ/L potassium chloride 0.15% /nacl 0.45% viaflex injection 4 20meq/l; 0.45% potassium chloride 0.15% d5w/nacl 0.33% injection 5%; 4 20meq/l; 0.33% potassium chloride 0.15% d5w/nacl 0.45% injection 5%; 4 20meq/l; 0.45% potassium chloride 0.15%/nacl 0.9% injection 20meq/l; 0.9% 4 potassium chloride 0.22% d5w/nacl 0.45% injection 5%; 4 30meq/l; 0.45% POTASSIUM CHLORIDE 0.3%/ NACL 0.9% INJECTION 4 40MEQ/L; 0.9% potassium chloride 0.3%/d5w injection 5%; 40meq/l 4 PREMASOL INJECTION 52MEQ/L; 1760MG/100ML; 4 B/D 880MG/100ML; 34MEQ/L; 1760MG/100ML; 372MG/100ML; 406MG/100ML; 526MG/100ML; 492MG/100ML; 492MG/100ML; 526MG/100ML; 356MG/100ML; 356MG/100ML; 390MG/100ML; 34MG/100ML; 152MG/100ML premasol injection 56meq/l; 320mg/100ml; 730mg/100ml; 4 B/D 190mg/100ml; 3meq/l; 20mg/100ml; 300mg/100ml; 220mg/100ml; 290mg/100ml; 490mg/100ml; 840mg/100ml; 490mg/100ml; 200mg/100ml; 290mg/100ml; 410mg/100ml; 230mg/100ml; 5meq/l; 15mg/100ml; 250mg/100ml; 120mg/100ml; 140mg/100ml; 470mg/100ml PROCALAMINE INJECTION 47MEQ/L; 210MG/100ML; 290MG/100ML; 3MEQ/L; 41MEQ/L; 20MG/100ML; 420MG/100ML; 85MG/100ML; 210MG/100ML; 270MG/100ML; 220MG/100ML; 5MEQ/L; 160MG/100ML; 170MG/100ML; 7MMOLE/L; 24MEQ/L; 340MG/100ML; 180MG/100ML; 35MEQ/L; 120MG/100ML; 46MG/100ML; 200MG/100ML 4 B/D 84

86 Name PROSOL INJECTION 2.76GM/100ML; 1.96GM/100ML; 4 B/D 600MG/100ML; 1.02GM/100ML; 2.06GM/100ML; 1.18GM/100ML; 1.08GM/100ML; 1.08GM/100ML; 1.35GM/100ML; 760MG/100ML; 1GM/100ML; 1.34GM/100ML; 1.02GM/100ML; 980MG/100ML; 320MG/100ML; 50MG/100ML; 1.44GM/100ML ringers injection injection 4.5meq/l; 156meq/l; 4meq/l; 4 147meq/l ringers irrigation solution 4.5meq/l; 156meq/l; 4meq/l; 2 147meq/l sodium chloride 0.45% viaflex injection 0.45% 4 sodium chloride 0.9% solution 0.9% 2 sodium chloride injection 0.9% 4 sodium chloride injection 2.5meq/ml 4 sodium chloride injection 3% 4 sodium chloride injection 5% 4 SODIUM LACTATE INJECTION 5MEQ/ML 4 sterile water irrigation solution 0 2 tpn electrolytes injection 29.5meq/20ml; 4.5meq/20ml; 4 B/D 35meq/20ml; 5meq/20ml; 20meq/20ml; 35meq/20ml TRAVASOL INJECTION 52MEQ/L; 1760MG/100ML; 4 B/D 880MG/100ML; 34MEQ/L; 1760MG/100ML; 372MG/100ML; 406MG/100ML; 526MG/100ML; 492MG/100ML; 492MG/100ML; 526MG/100ML; 356MG/100ML; 356MG/100ML; 390MG/100ML; 34MG/100ML; 152MG/100ML TROPHAMINE INJECTION 0; 0.32GM/100ML; 4 B/D 0.73GM/100ML; 0.19GM/100ML; 0.014GM/100ML; 0.22GM/100ML; 0.29GM/100ML; 0.49GM/100ML; 0.3GM/100ML; 0.84GM/100ML; 0.49GM/100ML; 0.2GM/100ML; 0.29GM/100ML; 0.41GM/100ML; 0.23GM/100ML; 0.05GM/100ML; 0.015GM/100ML; 0.25GM/100ML; 0.12GM/100ML; 0.14GM/100ML; 0.47GM/100ML TROPHAMINE INJECTION 97MEQ/L; 0.54GM/100ML; 4 B/D 1.2GM/100ML; 0.32GM/100ML; 0; 0; 0.5GM/100ML; 0.36GM/100ML; 0.48GM/100ML; 0.82GM/100ML; 1.4GM/100ML; 1.2GM/100ML; 0.34GM/100ML; 0.48GM/100ML; 0.68GM/100ML; 0.38GM/100ML; 5MEQ/L; 0.025GM/100ML; 0.42GM/100ML; 0.2GM/100ML; 0.24GM/100ML; 0.78GM/100ML POTASSIUM SUPPLEMENTS KCL 0.15%/D5W/LR INJECTION 3MEQ/L; 149MEQ/L; 5%; 4 28MEQ/L; 24MEQ/L; 130MEQ/L klor-con 10 tablet extended release 10meq 2 MO klor-con 8 tablet extended release 8meq 2 MO klor-con m15 tablet extended release 15meq 2 MO klor-con m20 tablet extended release 20meq 2 MO 85

87 Name LACTATED RINGERS DEXTROSE 5% VIAFLEX 4 INJECTION 2.7MEQ/L; 109MEQ/L; 5%; 28MEQ/L; 4MEQ/L; 130MEQ/L potassium chloride er capsule extended release 10meq 2 MO potassium chloride er capsule extended release 8meq 2 MO potassium chloride er tablet extended release 10meq 2 MO potassium chloride er tablet extended release 20meq 2 MO potassium chloride er tablet extended release 8meq 2 potassium chloride injection 10meq/100ml 4 POTASSIUM CHLORIDE INJECTION 20MEQ/100ML 4 potassium chloride injection 2meq/ml 4 potassium chloride injection 40meq/100ml 4 potassium chloride solution 10% 2 potassium chloride solution 20% 2 potassium citrate er tablet extended release 15meq 2 THERAPEUTIC VITAMINS AND MINERALS AURYXIA TABLET 210MG 3 calcitriol capsule 0.25mcg 2 B/D MO calcitriol capsule 0.5mcg 2 B/D MO calcitriol injection 1mcg/ml 4 B/D calcitriol solution 1mcg/ml 2 B/D calcium acetate capsule 667mg 2 MO doxercalciferol capsule 0.5mcg 2 MO doxercalciferol capsule 1mcg 2 MO doxercalciferol capsule 2.5mcg 2 MO doxercalciferol injection 4mcg/2ml 4 ELIPHOS TABLET 667MG 3 MO FOSRENOL PACKET 1000MG 3 MO FOSRENOL PACKET 750MG 3 MO FOSRENOL TABLET CHEWABLE 1000MG 3 MO FOSRENOL TABLET CHEWABLE 500MG 3 MO FOSRENOL TABLET CHEWABLE 750MG 3 MO HECTOROL CAPSULE 0.5MCG 3 B/D MO HECTOROL CAPSULE 1MCG 3 B/D MO HECTOROL CAPSULE 2.5MCG 3 B/D MO HECTOROL INJECTION 4MCG/2ML 4 B/D levocarnitine injection 200mg/ml 4 B/D levocarnitine solution 1gm/10ml 2 B/D MO levocarnitine tablet 330mg 2 B/D MO paricalcitol capsule 1mcg 2 B/D paricalcitol capsule 2mcg 2 B/D paricalcitol capsule 4mcg 2 B/D paricalcitol injection 2mcg/ml 4 paricalcitol injection 5mcg/ml 4 RENVELA PACKET 0.8GM 3 MO RENVELA PACKET 2.4GM 3 MO RENVELA TABLET 800MG 3 MO sodium fluoride tablet 1mg 2 MO 86

88 Name vp-pnv-dha capsule 80mg; 50mg; 400unit; 1mg; 12mcg; 2 MO 200mg; 15.8mg; 28mg; 1mg; 30mg; 20mg; 16mg; 2.2mg; 6mg; 30unit; 2500unit; 20mg ZEMPLAR INJECTION 2MCG/ML 4 B/D ZEMPLAR INJECTION 5MCG/ML 4 B/D OBSTETRICS AND GYNECOLOGY CONTRACEPTIVES apri tablet 0.15mg; 30mcg 2 MO aranelle tablet 0; 0 2 MO aviane tablet 20mcg; 0.1mg 2 MO balziva tablet 35mcg; 0.4mg 2 MO cryselle-28 tablet 30mcg; 0.3mg 2 MO cyclafem 1/35 tablet 35mcg; 1mg 2 MO cyclafem 7/7/7 tablet 0; 0 2 MO desogestrel/ethinyl estradiol tablet 0; 0 2 ELLA TABLET 30MG 3 QL (1 EA per 1 days) MO enpresse-28 tablet 0; 0 2 MO gianvi tablet 3mg; 0.02mg 2 MO junel 1.5/30 tablet 30mcg; 1.5mg 2 MO junel 1/20 tablet 20mcg; 1mg 2 MO junel fe 1.5/30 tablet 30mcg; 75mg; 1.5mg 2 MO junel fe 1/20 tablet 20mcg; 75mg; 1mg 2 MO kariva tablet 0; 0 2 MO kelnor 1/35 tablet 35mcg; 1mg 2 MO leena tablet 0; 0 2 MO lessina tablet 20mcg; 0.1mg 2 MO levonorgestrel and ethinyl estradiol tablet 20mcg; 90mcg 2 levonorgestrel/ethinyl estradiol tablet 0.03mg; 0.15mg 2 levonorgestrel/ethinyl estradiol tablet 0; 0 2 MO levonorgestrel/ethinyl estradiol tablet 20mcg; 0.1mg 2 levora 0.15/30-28 tablet 30mcg; 0.15mg 2 MO low-ogestrel tablet 30mcg; 0.3mg 2 MO lutera tablet 20mcg; 0.1mg 2 MO microgestin 1.5/30 tablet 30mcg; 1.5mg 2 MO microgestin 1/20 tablet 20mcg; 1mg 2 MO microgestin fe 1.5/30 tablet 30mcg; 75mg; 1.5mg 2 MO microgestin fe tablet 20mcg; 75mg; 1mg 2 MO mononessa tablet 35mcg; 0.25mg 2 MO necon 0.5/35-28 tablet 35mcg; 0.5mg 2 MO necon 1/35 tablet 35mcg; 1mg 2 MO necon 1/50-28 tablet 50mcg; 1mg 2 MO necon 10/11-28 tablet 35mcg; 0 2 MO necon 7/7/7 tablet 0; 0 2 MO norethindrone & ethinyl estradiol ferrous fumarate tablet chewable 25mcg; 75mg; 0.8mg 2 norethindrone acetate/ethinyl estradiol/ferrous fumarate tablet 2 20mcg; 75mg; 1mg norethindrone acetate/ethinyl estradiol tablet 2.5mcg; 0.5mg 2 norethindrone acetate/ethinyl estradiol tablet 5mcg; 1mg 2 87

89 Name nortrel 0.5/35 (28) tablet 35mcg; 0.5mg 2 MO nortrel 1/35 tablet 35mcg; 1mg 2 MO nortrel 1/35 tablet 35mcg; 1mg 2 MO nortrel 7/7/7 tablet 0; 0 2 MO NUVARING RING 0.015MG/24HR; 0.12MG/24HR 3 MO ocella tablet 3mg; 0.03mg 2 MO ogestrel tablet 50mcg; 0.5mg 2 MO ORTHO TRI-CYCLEN LO TABLET 0; 0 3 MO portia-28 tablet 0.03mg; 0.15mg 2 MO previfem tablet 35mcg; 0.25mg 2 MO QUASENSE TABLET 0.03MG; 0.15MG 3 MO reclipsen tablet 0.15mg; 30mcg 2 MO sprintec 28 tablet 35mcg; 0.25mg 2 MO sronyx tablet 20mcg; 0.1mg 2 MO tri-legest fe tablet 0; 75mg; 1mg 2 MO tri-previfem tablet 0; 0 2 MO tri-sprintec tablet 0; 0 2 MO trinessa tablet 0; 0 2 MO trivora-28 tablet 0; 0 2 MO velivet tablet 0; 0 2 MO zovia 1/35e tablet 35mcg; 1mg 2 MO zovia 1/50e tablet 50mcg; 1mg 2 MO ESTROGEN DRUGS DELESTROGEN INJECTION 10MG/ML 4 DELESTROGEN INJECTION 20MG/ML 4 DELESTROGEN INJECTION 40MG/ML 4 DEPO-ESTRADIOL INJECTION 5MG/ML 4 DIVIGEL GEL 0.5MG/0.5GM 3 QL (30 EA per 30 days) MO ESTRACE CREAM 0.1MG/GM 3 MO estradiol valerate injection 20mg/ml 4 estradiol valerate injection 40mg/ml 4 estradiol patch twice weekly 0.025mg/24hr 2 MO estradiol patch twice weekly mg/24hr 2 MO estradiol patch twice weekly 0.05mg/24hr 2 MO estradiol patch twice weekly 0.075mg/24hr 2 MO estradiol patch twice weekly 0.1mg/24hr 2 MO estradiol patch weekly 0.025mg/24hr 2 QL (4 EA per 28 days) PA MO estradiol patch weekly 0.05mg/24hr 2 QL (4 EA per 28 days) PA MO estradiol patch weekly 0.06mg/24hr 2 QL (4 EA per 28 days) PA MO estradiol patch weekly 0.075mg/24hr 2 QL (4 EA per 28 days) PA MO estradiol patch weekly 0.1mg/24hr 2 QL (4 EA per 28 days) PA MO estradiol patch weekly 37.5mcg/24hr 2 QL (4 EA per 28 days) PA MO estradiol tablet 0.5mg 2 PA MO estradiol tablet 1mg 2 PA MO estradiol tablet 2mg 2 PA MO ESTRING RING 2MG 3 MO estropipate tablet 0.75mg 2 PA MO estropipate tablet 1.5mg 2 PA MO estropipate tablet 3mg 2 PA MO 88

90 Name FEMRING RING 0.05MG/24HR 3 MO FEMRING RING 0.1MG/24HR 3 MO MENEST TABLET 0.3MG 3 PA MO MENEST TABLET 0.625MG 3 PA MO MENEST TABLET 1.25MG 3 PA MO MENEST TABLET 2.5MG 3 PA MO PREMARIN CREAM 0.625MG/GM 3 MO PREMARIN INJECTION 25MG 4 PREMARIN TABLET 0.3MG 3 PA MO PREMARIN TABLET 0.45MG 3 PA MO PREMARIN TABLET 0.625MG 3 PA MO PREMARIN TABLET 0.9MG 3 PA MO PREMARIN TABLET 1.25MG 3 PA MO VAGIFEM TABLET 10MCG 3 MO VIVELLE-DOT PATCH TWICE WEEKLY 0.025MG/24HR 3 QL (8 EA per 28 days) PA MO VIVELLE-DOT PATCH TWICE WEEKLY MG/24HR3 QL (8 EA per 28 days) PA MO VIVELLE-DOT PATCH TWICE WEEKLY 0.05MG/24HR 3 QL (8 EA per 28 days) PA MO VIVELLE-DOT PATCH TWICE WEEKLY 0.075MG/24HR 3 QL (8 EA per 28 days) PA MO VIVELLE-DOT PATCH TWICE WEEKLY 0.1MG/24HR 3 QL (8 EA per 28 days) PA MO ESTROGEN/PROGESTIN COMBINATIONS ANGELIQ TABLET 0.5MG; 1MG 3 PA MO CLIMARA PRO PATCH WEEKLY 0.045MG/DAY; 3 QL (4 EA per 28 days) PA MO 0.015MG/DAY COMBIPATCH PATCH TWICE WEEKLY 0.05MG/DAY; 3 PA MO 0.14MG/DAY COMBIPATCH PATCH TWICE WEEKLY 0.05MG/DAY; 3 PA MO 0.25MG/DAY drospirenone/ethinyl estradiol tablet 3mg; 0.03mg 2 estradiol/norethindrone acetate tablet 0.5mg; 0.1mg 2 PA MO estradiol/norethindrone acetate tablet 1mg; 0.5mg 2 PA MO PREFEST TABLET 0; 0 3 PA MO PREMPRO TABLET 0.3MG; 1.5MG 3 PA MO PREMPRO TABLET 0.45MG; 1.5MG 3 PA MO PREMPRO TABLET 0.625MG; 2.5MG 3 PA MO PREMPRO TABLET 0.625MG; 5MG 3 PA MO xulane patch weekly 35mcg/24hr; 150mcg/24hr 2 OB/GYN TOPICAL ANTIINFECTIVES CLEOCIN SUPPOSITORY 100MG 3 clindamycin phosphate cream 2% 2 metronidazole vaginal gel 0.75% 2 vandazole gel 0.75% 2 PROGESTIN DRUGS camila tablet 0.35mg 2 MO CRINONE GEL 4% 3 MO CRINONE GEL 8% 3 MO DEPO-SUBQ PROVERA 104 INJECTION 104MG/0.65ML 4 QL (1 ML per 90 days) errin tablet 0.35mg 2 MO jolivette tablet 0.35mg 2 MO medroxyprogesterone acetate injection 150mg/ml 4 QL (1 ML per 90 days) 89

91 Name medroxyprogesterone acetate tablet 10mg 2 MO medroxyprogesterone acetate tablet 2.5mg 2 MO medroxyprogesterone acetate tablet 5mg 2 MO nora-be tablet 0.35mg 2 MO norethindrone acetate tablet 5mg 2 MO norethindrone tablet 0.35mg 2 progesterone capsule 100mg 2 MO progesterone capsule 200mg 2 MO SPECIALIZED OB/GYN DRUGS chorionic gonadotropin injection 10000unit 4 PA methylergonovine maleate tablet 0.2mg 2 pregnyl w/diluent benzyl alcohol/nacl injection 10000unit 4 PA SYNAREL SOLUTION 2MG/ML 3 OPHTHALMIC ANTIGLAUCOMA DRUGS acetazolamide er capsule extended release 12 hour 500mg 2 MO acetazolamide sodium injection 500mg 4 acetazolamide tablet 125mg 2 MO acetazolamide tablet 250mg 2 MO ALPHAGAN P SOLUTION 0.1% 3 apraclonidine solution 0.5% 2 MO AZOPT SUSPENSION 1% 3 MO betaxolol hcl solution 0.5% 2 MO BETOPTIC-S SUSPENSION 0.25% 3 MO brimonidine tartrate solution 0.15% 2 MO brimonidine tartrate solution 0.2% 2 MO carteolol hcl solution 1% 2 MO COMBIGAN SOLUTION 0.2%; 0.5% 3 MO dorzolamide hcl/timolol maleate solution 22.3mg/ml; 6.8mg/ml2 MO dorzolamide hcl solution 2% 2 MO IOPIDINE SOLUTION 1% 3 MO ISOPTO CARPINE SOLUTION 1% 3 ISOPTO CARPINE SOLUTION 2% 3 ISOPTO CARPINE SOLUTION 4% 3 latanoprost solution 0.005% 2 MO levobunolol hcl solution 0.5% 1 MO LUMIGAN SOLUTION 0.01% 3 ST MO methazolamide tablet 25mg 2 MO methazolamide tablet 50mg 2 MO metipranolol solution 0.3% 2 MO PHOSPHOLINE IODIDE SOLUTION RECONSTITUTED 3 MO 0.125% pilocarpine hcl solution 1% 2 pilocarpine hcl solution 2% 2 pilocarpine hcl solution 4% 2 RESCULA SOLUTION 0.15% 3 SIMBRINZA SUSPENSION 0.2%; 1% 3 MO timolol maleate ophthalmic gel forming gel forming solution 0.25% 1 MO 90

92 Name timolol maleate ophthalmic gel forming gel forming solution 1 MO 0.5% timolol maleate solution 0.25% 1 MO timolol maleate solution 0.5% 1 MO TIMOPTIC OCUDOSE SOLUTION 0.25% 3 MO TIMOPTIC OCUDOSE SOLUTION 0.5% 3 MO travoprost solution 0.004% 2 OPHTHALMIC ANTIINFECTIVE/CORTICOSTEROIDS BLEPHAMIDE S.O.P. OINTMENT 0.2%; 10% 3 BLEPHAMIDE SUSPENSION 0.2%; 10% 3 neomycin/polymyxin/bacitracin/hydrocortisone ointment 2 400unit/gm; 1%; 0.5%; 10000unit/gm neomycin/polymyxin/dexamethasone ointment 0.1%; 1 3.5mg/gm; 10000unit/gm neomycin/polymyxin/dexamethasone suspension 0.1%; 1 3.5mg/ml; 10000unit/ml neomycin/polymyxin/hydrocortisone suspension 1%; 2 3.5mg/ml; 10000unit/ml PRED-G S.O.P. OINTMENT 0.3%; 0.6% 3 PRED-G SUSPENSION 0.3%; 1% 3 sulfacetamide sodium/prednisolone sodium phosphate solution2 0.23%; 10% TOBRADEX OINTMENT 0.1%; 0.3% 3 tobramycin/dexamethasone suspension 0.1%; 0.3% 2 ZYLET SUSPENSION 0.5%; 0.3% 3 OPHTHALMIC CORTICOSTEROIDS ALREX SUSPENSION 0.2% 3 dexamethasone sodium phosphate solution 0.1% 2 DUREZOL EMULSION 0.05% 3 FLAREX SUSPENSION 0.1% 3 fluorometholone suspension 0.1% 2 FML FORTE SUSPENSION 0.25% 3 FML OINTMENT 0.1% 3 LOTEMAX GEL 0.5% 3 LOTEMAX OINTMENT 0.5% 3 LOTEMAX SUSPENSION 0.5% 3 MAXIDEX SUSPENSION 0.1% 3 PRED MILD SUSPENSION 0.12% 3 prednisolone acetate suspension 1% 2 prednisolone sodium phosphate solution 1% 2 VEXOL SUSPENSION 1% 3 OPHTHALMIC TOPICAL ANTI-INFECTIVE AZASITE SOLUTION 1% 3 bacitracin/polymyxin b ointment 500unit/gm; 10000unit/gm 2 bacitracin ointment 500unit/gm 2 BESIVANCE SUSPENSION 0.6% 3 CILOXAN OINTMENT 0.3% 3 ciprofloxacin hcl solution 0.3% 2 erythromycin ointment 5mg/gm 2 91

93 Name gatifloxacin solution 0.5% 2 gentak ointment 0.3% 1 gentamicin sulfate ointment 0.3% 2 gentamicin sulfate solution 0.3% 1 levofloxacin solution 0.5% 2 neomycin/bacitracin/polymyxin ointment 400unit/gm; 5mg/gm; unit/gm neomycin/polymyxin/gramicidin solution 0.025mg/ml; mg/ml; 10000unit/ml ofloxacin solution 0.3% 2 ofloxacin solution 0.3% 2 polymyxin b sulfate/trimethoprim sulfate solution unit/ml; 0.1% sodium sulfacetamide solution 10% 2 sulfacetamide sodium ointment 10% 2 sulfacetamide sodium suspension 10% 2 tobramycin sulfate solution 0.3% 2 TOBREX OINTMENT 0.3% 3 VIGAMOX SOLUTION 0.5% 3 ZYMAXID SOLUTION 0.5% 3 OPHTHALMIC TOPICAL ANTIVIRAL DRUGS trifluridine solution 1% 2 ZIRGAN GEL 0.15% 3 OTHER OPHTHALMIC DRUGS ACUVAIL SOLUTION 0.45% 3 ALOCRIL SOLUTION 2% 3 ALOMIDE SOLUTION 0.1% 3 atropine sulfate solution 1% 2 azelastine hcl solution 0.05% 2 BEPREVE SOLUTION 1.5% 3 cromolyn sodium solution 4% 2 CYSTARAN SOLUTION 0.44% 5 diclofenac sodium solution 0.1% 2 EMADINE SOLUTION 0.05% 3 epinastine hcl solution 0.05% 2 flurbiprofen sodium solution 0.03% 2 ILEVRO SUSPENSION 0.3% 3 ketorolac tromethamine solution 0.4% 2 ketorolac tromethamine solution 0.5% 2 LACRISERT INSERT 5MG 3 LASTACAFT SOLUTION 0.25% 3 naphazoline hcl solution 0.1% 2 NATACYN SUSPENSION 5% 3 NEVANAC SUSPENSION 0.1% 3 PATADAY SOLUTION 0.2% 3 PATANASE SOLUTION 0.6% 3 QL (30.5 GM per 30 days) PATANOL SOLUTION 0.1% 3 proparacaine hcl solution 0.5% 2 RESTASIS EMULSION 0.05% 3 QL (64 EA per 30 days) 92

94 Name RESPIRATORY ANTIHISTAMINES carbinoxamine maleate solution 4mg/5ml 2 carbinoxamine maleate tablet 4mg 2 clemastine fumarate tablet 2.68mg 2 cyproheptadine hcl syrup 2mg/5ml 2 PA cyproheptadine hcl tablet 4mg 2 PA diphenhydramine hcl injection 50mg/ml 4 levocetirizine dihydrochloride solution 2.5mg/5ml 2 levocetirizine dihydrochloride tablet 5mg 2 QL (30 EA per 30 days) MO promethazine hcl injection 25mg/ml 4 promethazine hcl injection 50mg/ml 4 promethazine hcl suppository 12.5mg 2 promethazine hcl suppository 25mg 2 promethazine hcl syrup 6.25mg/5ml 2 PA promethazine hcl tablet 12.5mg 2 PA promethazine hcl tablet 25mg 2 PA promethazine hcl tablet 50mg 2 PA promethazine vc plain syrup 5mg/5ml; 6.25mg/5ml 2 PA BETA-2 ADRENERGICS albuterol sulfate er tablet extended release 12 hour 4mg 2 MO albuterol sulfate er tablet extended release 12 hour 8mg 2 MO albuterol sulfate nebulization solution 0.083% 2 B/D MO albuterol sulfate nebulization solution 0.5% 2 B/D MO albuterol sulfate nebulization solution 0.63mg/3ml 2 B/D MO albuterol sulfate nebulization solution 1.25mg/3ml 2 B/D MO albuterol sulfate syrup 2mg/5ml 2 MO albuterol sulfate tablet 2mg 2 MO albuterol sulfate tablet 4mg 2 MO BROVANA NEBULIZATION SOLUTION 15MCG/2ML 3 B/D MO FORADIL AEROLIZER CAPSULE 12MCG 3 QL (60 EA per 30 days) MO ipratropium bromide/albuterol sulfate solution 2.5mg/3ml; 2 B/D MO 0.5mg/3ml levalbuterol hcl nebulization solution 0.31mg/3ml 2 B/D levalbuterol hcl nebulization solution 0.63mg/3ml 2 B/D metaproterenol sulfate syrup 10mg/5ml 2 metaproterenol sulfate tablet 10mg 2 MO metaproterenol sulfate tablet 20mg 2 MO PERFOROMIST NEBULIZATION SOLUTION 3 B/D 20MCG/2ML PROAIR HFA AEROSOL SOLUTION 108MCG/ACT 3 QL (17 GM per 30 days) MO PROAIR RESPICLICK AEROSOL POWDER BREATH ACTIVATED 108MCG/ACT 3 PROVENTIL HFA AEROSOL SOLUTION 108MCG/ACT 3 QL (13.4 GM per 30 days) MO SEREVENT DISKUS AEROSOL POWDER BREATH 3 QL (60 EA per 30 days) MO ACTIVATED 50MCG/DOSE STRIVERDI RESPIMAT AEROSOL SOLUTION 3 QL (4 GM per 30 days) MO 2.5MCG/ACT terbutaline sulfate injection 1mg/ml 4 B/D 93

95 Name terbutaline sulfate tablet 2.5mg 2 MO terbutaline sulfate tablet 5mg 2 MO VENTOLIN HFA AEROSOL SOLUTION 108MCG/ACT 3 MO XOPENEX HFA AEROSOL 45MCG/ACT 3 QL (30 GM per 30 days) MO LEUKOTRIENE MODIFIERS montelukast sodium packet 4mg 2 MO montelukast sodium tablet chewable 4mg 2 MO montelukast sodium tablet chewable 5mg 2 MO montelukast sodium tablet 10mg 2 MO zafirlukast tablet 10mg 2 MO zafirlukast tablet 20mg 2 MO ZYFLO CR TABLET EXTENDED RELEASE 12 HOUR 3 MO 600MG ZYFLO TABLET 600MG 3 MO METHYLXANTHINES aminophylline injection 25mg/ml 4 ELIXOPHYLLIN ELIXIR 80MG/15ML 3 MO THEO-24 CAPSULE EXTENDED RELEASE 24 HOUR 0; 3 MO 100MG THEO-24 CAPSULE EXTENDED RELEASE 24 HOUR 3 MO 300MG THEO-24 CAPSULE EXTENDED RELEASE 24 HOUR 3 MO 400MG theophylline cr tablet extended release 12 hour 100mg 2 MO theophylline cr tablet extended release 12 hour 200mg 2 MO theophylline er tablet extended release 12 hour 300mg 2 MO theophylline er tablet extended release 12 hour 450mg 2 MO theophylline er tablet extended release 24 hour 400mg 2 MO theophylline er tablet extended release 24 hour 600mg 2 MO OTHER DRUGS FOR ASTHMA acetylcysteine solution 10% 2 B/D MO acetylcysteine solution 20% 2 B/D MO budesonide suspension 0.25mg/2ml 2 B/D budesonide suspension 0.5mg/2ml 2 B/D budesonide suspension 1mg/2ml 2 B/D COMBIVENT RESPIMAT AEROSOL SOLUTION 3 QL (8 GM per 30 days) MO 100MCG/ACT; 20MCG/ACT cromolyn sodium concentrate 100mg/5ml 2 cromolyn sodium nebulization solution 20mg/2ml 2 B/D MO DULERA AEROSOL 5MCG/ACT; 100MCG/ACT 3 QL (13 GM per 30 days) DULERA AEROSOL 5MCG/ACT; 200MCG/ACT 3 QL (13 GM per 30 days) epinephrine injection 0.15mg/0.15ml 2 epinephrine injection 0.3mg/0.3ml 2 EPIPEN-JR 2-PAK INJECTION 0.15MG/0.3ML 3 QL (4 EA per 30 days) MO FLOVENT DISKUS AEROSOL POWDER BREATH 3 QL (120 EA per 30 days) MO ACTIVATED 100MCG/BLIST FLOVENT DISKUS AEROSOL POWDER BREATH ACTIVATED 250MCG/BLIST 3 QL (240 EA per 30 days) MO 94

96 Name FLOVENT DISKUS AEROSOL POWDER BREATH 3 QL (120 EA per 30 days) MO ACTIVATED 50MCG/BLIST FLOVENT HFA AEROSOL 110MCG/ACT 3 QL (24 GM per 30 days) MO FLOVENT HFA AEROSOL 220MCG/ACT 3 QL (24 GM per 30 days) MO FLOVENT HFA AEROSOL 44MCG/ACT 3 QL (21.2 GM per 30 days) MO ipratropium bromide solution 0.02% 2 B/D MO levalbuterol nebulization solution 1.25mg/0.5ml 2 B/D PULMICORT FLEXHALER AEROSOL POWDER 3 QL (2 EA per 30 days) MO BREATH ACTIVATED 180MCG/ACT PULMICORT FLEXHALER AEROSOL POWDER 3 QL (1 EA per 30 days) MO BREATH ACTIVATED 90MCG/ACT QVAR AEROSOL SOLUTION 40MCG/ACT 3 QVAR AEROSOL SOLUTION 80MCG/ACT 3 QL (17.4 GM per 30 days) SPIRIVA HANDIHALER CAPSULE 18MCG 3 QL (30 EA per 30 days) MO SYMBICORT AEROSOL 160MCG/ACT; 4.5MCG/ACT 3 QL (10.2 GM per 30 days) MO SYMBICORT AEROSOL 80MCG/ACT; 4.5MCG/ACT 3 QL (10.2 GM per 30 days) XOLAIR INJECTION 150MG 5 PA LA OTHER RESPIRATORY DRUGS ADCIRCA TABLET 20MG 5 QL (60 EA per 30 days) PA ADEMPAS TABLET 0.5MG 5 QL (90 EA per 30 days) PA LA ADEMPAS TABLET 1.5MG 5 QL (90 EA per 30 days) PA LA ADEMPAS TABLET 1MG 5 QL (90 EA per 30 days) PA LA ADEMPAS TABLET 2.5MG 5 QL (90 EA per 30 days) PA LA ADEMPAS TABLET 2MG 5 QL (90 EA per 30 days) PA LA ANORO ELLIPTA AEROSOL POWDER BREATH 3 ACTIVATED 62.5MCG/INH; 25MCG/INH ARALAST NP INJECTION 400MG 4 PA LA ATROVENT HFA AEROSOL SOLUTION 17MCG/ACT 3 QL (25.8 GM per 30 days) MO AUVI-Q INJECTION 0.15MG/0.15ML 3 QL (2 EA per 30 days) AUVI-Q INJECTION 0.3MG/0.3ML 3 QL (2 EA per 30 days) DALIRESP TABLET 500MCG 3 PA MO EPIPEN 2-PAK INJECTION 0.3MG/0.3ML 3 QL (4 EA per 30 days) GLASSIA INJECTION 1000MG/50ML 4 PA LA INCRUSE ELLIPTA AEROSOL POWDER BREATH 3 ACTIVATED 62.5MCG/INH KALYDECO PACKET 50MG 5 KALYDECO PACKET 75MG 5 KALYDECO TABLET 150MG 5 LETAIRIS TABLET 10MG 5 QL (30 EA per 30 days) PA LA LETAIRIS TABLET 5MG 5 QL (30 EA per 30 days) PA LA OPSUMIT TABLET 10MG 5 PA LA ORKAMBI TABLET 125MG; 200MG 5 PA PROLASTIN-C INJECTION 1000MG 4 PA LA PULMOZYME SOLUTION 1MG/ML 5 B/D REVATIO INJECTION 10MG/12.5ML 5 PA REVATIO SUSPENSION RECONSTITUTED 10MG/ML 3 PA sildenafil injection 10mg/12.5ml 4 PA sildenafil tablet 20mg 2 QL (90 EA per 30 days) PA SPIRIVA RESPIMAT AEROSOL SOLUTION 2.5MCG/ACT3 QL (4 GM per 30 days) MO 95

97 Name TRACLEER TABLET 125MG 5 QL (60 EA per 30 days) PA LA TRACLEER TABLET 62.5MG 5 QL (120 EA per 30 days) PA LA TUDORZA PRESSAIR AEROSOL POWDER BREATH 3 MO ACTIVATED 400MCG/ACT TUDORZA PRESSAIR AEROSOL POWDER BREATH 3 MO ACTIVATED 400MCG/ACT ZEMAIRA INJECTION 1000MG 4 PA LA RHEUMATIC AND MUSCULOSKELETAL DIRECT MUSCLE RELAXANTS baclofen tablet 10mg 2 baclofen tablet 20mg 2 cyclobenzaprine hcl tablet 10mg 2 PA cyclobenzaprine hcl tablet 5mg 2 PA cyclobenzaprine hcl tablet 7.5mg 2 PA dantrolene sodium capsule 100mg 2 dantrolene sodium capsule 25mg 2 dantrolene sodium capsule 50mg 2 tizanidine hcl capsule 2mg 2 tizanidine hcl capsule 4mg 2 tizanidine hcl capsule 6mg 2 tizanidine hcl tablet 2mg 2 tizanidine hcl tablet 4mg 2 XEOMIN INJECTION 50UNIT 4 PA DRUGS TO PREVENT AND TREAT GOUT allopurinol tablet 100mg 1 MO allopurinol tablet 300mg 1 MO colchicine capsule 0.6mg 2 MO colchicine tablet 0.6mg 2 MO COLCRYS TABLET 0.6MG 3 QL (120 EA per 30 days) MO probenecid/colchicine tablet 0.5mg; 500mg 2 MO probenecid tablet 500mg 2 MO ULORIC TABLET 40MG 3 ST MO ULORIC TABLET 80MG 3 ST MO OTHER DRUGS FOR ARTHRITIS RASUVO INJECTION 10MG/0.2ML 4 RASUVO INJECTION 12.5MG/0.25ML 4 RASUVO INJECTION 15MG/0.3ML 4 RASUVO INJECTION 17.5MG/0.35ML 4 RASUVO INJECTION 20MG/0.4ML 4 RASUVO INJECTION 22.5MG/0.45ML 4 RASUVO INJECTION 25MG/0.5ML 4 RASUVO INJECTION 27.5MG/0.55ML 4 RASUVO INJECTION 30MG/0.6ML 4 RASUVO INJECTION 7.5MG/0.15ML 4 RIDAURA CAPSULE 3MG 3 MO XELJANZ TABLET 5MG 5 PA RHEUMATIC AND MUSCULOSKELETAL CIMZIA INJECTION 200MG/ML 5 QL (6 EA per 28 days) PA ENBREL SURECLICK INJECTION 50MG/ML 5 PA 96

98 Name ENBREL INJECTION 25MG/0.5ML 5 PA ENBREL INJECTION 25MG 5 QL (16 EA per 28 days) PA ENBREL INJECTION 50MG/ML 5 PA HUMIRA PEN-CROHNS DISEASESTARTER INJECTION 5 PA 40MG/0.8ML HUMIRA INJECTION 10MG/0.2ML 5 PA HUMIRA INJECTION 20MG/0.4ML 5 QL (2 EA per 28 days) PA HUMIRA INJECTION 40MG/0.8ML 5 PA leflunomide tablet 20mg 2 QL (30 EA per 30 days) ORENCIA INJECTION 125MG/ML 5 PA ORENCIA INJECTION 250MG 5 PA REMICADE INJECTION 100MG 5 PA riluzole tablet 50mg 2 SIMPONI ARIA INJECTION 50MG/4ML 5 PA SIMPONI INJECTION 100MG/ML 5 PA SIMPONI INJECTION 100MG/ML 5 PA SIMPONI INJECTION 50MG/0.5ML 5 PA SIMPONI INJECTION 50MG/0.5ML 5 PA TOXICOLOGIC ALCOHOL AND OPIOID ANTAGONISTS acamprosate calcium dr tablet delayed release 333mg 2 disulfiram tablet 250mg 2 disulfiram tablet 500mg 2 naloxone hcl injection 1mg/ml 2 naltrexone hcl tablet 50mg 2 VIVITROL INJECTION 380MG 4 CHELATORS AND OTHER ANTIDOTES CHEMET CAPSULE 100MG 3 CUPRIMINE CAPSULE 250MG 3 MO DEPEN TITRATABS TABLET 250MG 3 MO fomepizole injection 1gm/ml 4 sodium polystyrene sulfonate suspension 15gm/60ml 2 SYPRINE CAPSULE 250MG 5 UROLOGICAL ANTICHOLINERGIC ANTISPASMODICS flavoxate hcl tablet 100mg 2 MO oxybutynin chloride er tablet extended release 24 hour 10mg 2 QL (60 EA per 30 days) MO oxybutynin chloride er tablet extended release 24 hour 15mg 2 QL (60 EA per 30 days) MO oxybutynin chloride er tablet extended release 24 hour 5mg 2 QL (30 EA per 30 days) MO oxybutynin chloride syrup 5mg/5ml 2 MO oxybutynin chloride tablet 5mg 2 MO tolterodine tartrate er capsule extended release 24 hour 2mg 2 QL (30 EA per 30 days) tolterodine tartrate er capsule extended release 24 hour 4mg 2 QL (30 EA per 30 days) tolterodine tartrate tablet 1mg 2 MO tolterodine tartrate tablet 2mg 2 MO TOVIAZ TABLET EXTENDED RELEASE 24 HOUR 4MG 3 QL (30 EA per 30 days) MO TOVIAZ TABLET EXTENDED RELEASE 24 HOUR 8MG 3 QL (30 EA per 30 days) MO VESICARE TABLET 10MG 3 MO VESICARE TABLET 5MG 3 MO 97

99 Name OTHER GENITOURINARY PRODUCTS alfuzosin hcl er tablet extended release 24 hour 10mg 2 QL (30 EA per 30 days) MO AVODART CAPSULE 0.5MG 3 QL (30 EA per 30 days) MO bethanechol chloride tablet 10mg 2 MO bethanechol chloride tablet 25mg 2 MO bethanechol chloride tablet 50mg 2 MO bethanechol chloride tablet 5mg 2 MO CIALIS TABLET 2.5MG 3 PA CIALIS TABLET 5MG 3 PA CYSTADANE POWDER 0 3 ELMIRON CAPSULE 100MG 3 finasteride tablet 5mg 2 MO JALYN CAPSULE 0.5MG; 0.4MG 3 QL (30 EA per 30 days) MO MYRBETRIQ TABLET EXTENDED RELEASE 24 HOUR 3 MO 25MG MYRBETRIQ TABLET EXTENDED RELEASE 24 HOUR 3 MO 50MG neomycin/polymyxin b sulfates solution 40mg/ml; unit/ml potassium citrate er tablet extended release 1080mg 2 MO potassium citrate er tablet extended release 540mg 2 MO PROCYSBI CAPSULE DELAYED RELEASE 25MG 5 PROCYSBI CAPSULE DELAYED RELEASE 75MG 5 tamsulosin hcl capsule 0.4mg 2 QL (60 EA per 30 days) MO trospium chloride er capsule extended release 24 hour 60mg 2 MO trospium chloride tablet 20mg 2 QL (60 EA per 30 days) MO URINARY ANTIINFECTIVES MACRODANTIN CAPSULE 25MG 3 PA methenamine hippurate tablet 1gm 2 MONUROL PACKET 5.631GM 3 nitrofurantoin macrocrystals capsule 100mg 2 PA nitrofurantoin macrocrystals capsule 50mg 2 PA nitrofurantoin monohydrate capsule 100mg 2 PA nitrofurantoin suspension 25mg/5ml 2 PA PRIMSOL SOLUTION 50MG/5ML 3 trimethoprim tablet 100mg 2 98

100 Index Name Page # 8-MOP 59 abacavir 12 abacavir sulfate/lamivudine/zidovudine 12 ABELCET 18 ABILIFY 45 ABILIFY MAINTENA 45 ABRAXANE 22 acamprosate calcium dr 97 acarbose 67 acebutolol hcl 30 acetaminophen/codeine 9 acetaminophen/codeine #3 9 ACETASOL HC 63 acetazolamide 90 acetazolamide er 90 acetazolamide sodium 90 acetic acid 63 acetylcysteine 94 acitretin 59 ACTEMRA 79 ACTHIB 77 ACTIMMUNE 79 ACTONEL 68 ACTOPLUS MET XR 66 ACUVAIL 92 acyclovir 18 acyclovir sodium 18 ADACEL 77 ADAGEN 80 adapalene 59 ADCIRCA 95 adefovir dipivoxil 18 ADEMPAS 95 ADRENALIN 38 ADRUCIL 22 ADVICOR 34 afeditab cr 31 AFINITOR 22 AFINITOR DISPERZ 78 AGGRENOX 30 a-hydrocort 61 AKYNZEO 72 ala cort 61 ALBENZA 12 albuterol sulfate 93 albuterol sulfate er 93 alclometasone dipropionate 61 Name Page # alcohol prep pads 80 ALDURAZYME 68 alendronate sodium 68 alfuzosin hcl er 98 ALIMTA 22 ALINIA 17 allopurinol 96 almotriptan malate 51 ALOCRIL 92 ALOMIDE 92 alosetron hydrochloride 73 ALOXI 72 ALPHAGAN P 90 alprazolam 48 ALREX 91 amantadine hcl 18 AMBISOME 18 amcinonide 61 amifostine 22 amikacin sulfate 11 amiloride hcl 39 amiloride/hydrochlorothiazide 39 aminophylline 94 AMINOSYN 7%/ELECTROLYTES 81 aminosyn 8.5%/electrolytes 81 AMINOSYN II 81 aminosyn ii 8.5%/electrolytes 81 AMINOSYN M 82 AMINOSYN-HBC 82 AMINOSYN-PF 82 AMINOSYN-PF 7% 82 AMINOSYN-RF 82 amiodarone hcl 29 AMITIZA 73 amitriptyline hcl 58 amlodipine besylate 32 amlodipine besylate/atorvastatin calcium 34 amlodipine besylate/benazepril hcl 31 amlodipine besylate/benazepril 31 hydrochloride amlodipine besylate/valsartan 36 amlodipine/valsartan/hctz 36 AMMONIUM CHLORIDE 82 ammonium lactate 60 ammonium lactate 62 amnesteem 59 amoxapine 55 amoxicillin 19 amoxicillin/clavulanate potassium 19 amoxicillin/clavulanate potassium er 19 99

101 Name Page # amphetamine/dextroamphetamine 49 AMPHOTERICIN B 18 ampicillin 19 ampicillin sodium 19 ampicillin-sulbactam 19 AMPYRA 80 ANADROL anagrelide hydrochloride 22 anastrozole 22 ANDROGEL 64 ANDROGEL PUMP 63 ANGELIQ 89 ANORO ELLIPTA 95 APLENZIN 52 APOKYN 53 apraclonidine 90 apri 87 APRISO 74 APTIOM 40 APTIVUS 12 ARALAST NP 95 aranelle 87 ARANESP ALBUMIN FREE 75 ARCALYST 79 aripiprazole 45 ARRANON 22 ARZERRA 22 ASACOL HD 74 ascomp/codeine 50 aspirin/dipyridamole 30 ASTAGRAF XL 78 ASTEPRO 63 atenolol 30 atenolol/chlorthalidone 37 ATGAM 77 atorvastatin calcium 34 atovaquone 20 atovaquone/proguanil hcl 20 ATRIPLA 12 ATROPINE SULFATE 55 atropine sulfate 92 ATROVENT HFA 95 AUBAGIO 80 augmented betamethasone dipropionate 61 AURYXIA 86 AUVI-Q 95 AVASTIN 22 AVC 22 AVELOX 20 AVELOX ABC PACK 20 Name Page # aviane 87 avita 59 AVODART 98 AVONEX 80 AVONEX PEN 80 AXERT 51 AXIRON 64 azacitidine 22 AZACTAM IN ISO-OSMOTIC 17 DEXTROSE AZASAN 22 AZASITE 91 azathioprine 22 azelastine hcl 63 azelastine hcl 92 AZELEX 59 AZILECT 51 azithromycin 16 AZOPT 90 aztreonam 17 baciim 17 BACITRACIN 17 bacitracin 91 bacitracin/polymyxin b 91 baclofen 96 BACTOCILL IN DEXTROSE 19 BACTROBAN NASAL 60 balsalazide disodium 74 balziva 87 BANZEL 40 BARACLUDE 77 BCG VACCINE 77 bd insulin syringe safetyglide/1ml/29g x 1/2" 80 bd insulin syringe ultrafine/0.3ml/31g x 80 5/16" bd insulin syringe ultrafine/0.5ml/30g x 1/2" 80 bd insulin syringe ultrafine/1ml/31g x 5/16" 80 bd pen needle/ultrafine/29g x 12.7mm 80 BELEODAQ 22 benazepril hcl 28 benazepril hcl/hydrochlorothiazide 37 BENLYSTA 78 benztropine mesylate 44 BEPREVE 92 BESIVANCE 91 betamethasone dipropionate 61 betamethasone valerate 61 BETASERON 80 betaxolol hcl 30 betaxolol hcl

102 Name Page # bethanechol chloride 98 BETOPTIC-S 90 BEXAROTENE 22 BEXSERO 77 bicalutamide 22 BICILLIN C-R 19 BICILLIN L-A 19 BICNU 22 BILTRICIDE 12 bisoprolol fumarate 30 bisoprolol fumarate/hydrochlorothiazide 37 BIVIGAM 76 bleomycin sulfate 22 BLEPHAMIDE 91 BLEPHAMIDE S.O.P. 91 BOOSTRIX 77 BOSULIF 22 BRILINTA 30 brimonidine tartrate 90 BRINTELLIX 56 BRISDELLE 56 bromocriptine mesylate 53 BROVANA 93 budesonide 63 budesonide 74 budesonide 94 bumetanide 35 buprenorphine hcl 9 buprenorphine hcl/naloxone hcl 9 buproban 58 bupropion hcl 52 bupropion hcl sr 52 bupropion hcl sr 58 bupropion hcl xl 52 buspirone hcl 48 BUSULFEX 23 butalbital/acetaminophen 51 butalbital/acetaminophen/caffeine 51 butalbital/acetaminophen/caffeine/codeine 51 butalbital/aspirin/caffeine 51 butorphanol tartrate 9 BYDUREON 68 BYETTA 68 cabergoline 68 calcipotriene 60 calcipotriene/betamethasone dipropionate 60 calcitonin-salmon 68 calcitriol 60 calcitriol 86 calcium acetate 86 Name Page # camila 89 CANASA 74 CANCIDAS 18 candesartan cilexetil 29 candesartan cilexetil/hydrochlorothiazide 37 CANTIL 71 CAPASTAT SULFATE 14 CAPITAL/CODEINE 9 CAPRELSA 23 captopril 28 captopril/hydrochlorothiazide 37 CARAC 62 CARAFATE 73 CARBAGLU 80 carbamazepine 48 carbamazepine er 48 carbidopa 53 carbidopa/levodopa 53 carbidopa/levodopa er 53 carbidopa/levodopa odt 53 carbidopa/levodopa/entacapone 53 carbinoxamine maleate 93 carboplatin 23 CARDENE IV 32 CARIMUNE NANOFILTERED 76 carteolol hcl 90 cartia xt 32 carvedilol 30 CAYSTON 17 CEDAX 14 cefaclor 14 cefaclor er 14 cefadroxil 14 cefazolin sodium 14 cefdinir 14 cefepime 14 cefixime 14 cefotaxime sodium 14 CEFOTETAN 14 cefoxitin sodium 14 cefpodoxime proxetil 15 cefprozil 15 ceftazidime 15 CEFTAZIDIME/DEXTROSE 15 ceftriaxone sodium 15 cefuroxime axetil 15 cefuroxime sodium 15 CELEBREX 9 celecoxib 9 CELLCEPT

103 Name Page # CELLCEPT INTRAVENOUS 78 CELONTIN 40 cephalexin 15 CERDELGA 68 CEREBYX 40 CEREZYME 68 CERVARIX 77 CESAMET 72 cevimeline hcl 63 CHANTIX 58 CHANTIX CONTINUING MONTH PAK 58 CHANTIX STARTING MONTH PAK 58 CHEMET 97 CHENODAL 74 CHLORAMPHENICOL SODIUM 17 SUCCINATE chlordiazepoxide/amitriptyline 52 chlorhexidine gluconate oral rinse 63 chloroquine phosphate 20 chlorothiazide 40 chlorothiazide sodium 40 CHLORPROMAZINE HCL 45 chlorthalidone 40 cholestyramine light 38 chorionic gonadotropin 90 CIALIS 98 ciclopirox 22 ciclopirox 60 ciclopirox nail lacquer 60 ciclopirox olamine 22 cidofovir 18 cilostazol 30 CILOXAN 91 cimetidine 72 cimetidine hcl 72 CIMZIA 23 CIMZIA 96 CINRYZE 77 CIPRO 20 CIPRO HC 63 CIPRODEX 63 ciprofloxacin 20 ciprofloxacin er 20 ciprofloxacin hcl 20 ciprofloxacin hcl 91 ciprofloxacin i.v.-in d5w 20 cisplatin 23 citalopram hydrobromide 56 cladribine 23 claravis 59 Name Page # clarithromycin 16 clarithromycin er 16 clemastine fumarate 93 CLEOCIN 16 CLEOCIN 89 CLEOCIN IN D5W 15 CLIMARA PRO 89 clindamycin hcl 16 clindamycin palmitate hcl 16 clindamycin phosphate 59 clindamycin phosphate 89 clindamycin phosphate add-vantage 16 clindamycin phosphate in d5w 16 clindamycin/benzoyl peroxide 59 clobetasol propionate 61 clobetasol propionate e 61 clodan 61 CLOLAR 23 clomipramine hcl 58 clonazepam 40 clonazepam odt 40 clonidine hcl 33 clonidine hcl er 55 clopidogrel 30 clorazepate dipotassium 48 CLORPRES 37 clotrimazole 16 clotrimazole 22 clotrimazole 60 clotrimazole/betamethasone dipropionate 21 clozapine 45 clozapine odt 45 COARTEM 20 codeine sulfate 6 colchicine 96 COLCRYS 96 colestipol hcl 38 colistimethate sodium 17 colocort 74 COLY-MYCIN S 63 COMBIGAN 90 COMBIPATCH 89 COMBIVENT RESPIMAT 94 COMETRIQ 23 COMPLERA 12 compro 72 COMVAX 77 CONDYLOX 60 COPAXONE 80 CORDRAN TAPE

104 Name Page # CORTIFOAM 65 cortisone acetate 65 CORTISPORIN 60 CORTISPORIN-TC 63 COSENTYX 60 COSENTYX SENSOREADY PEN 60 COSMEGEN 23 COUMADIN 36 CREON 74 CRESTOR 34 CRINONE 89 CRIXIVAN 12 cromolyn sodium 92 cromolyn sodium 94 cryselle CUBICIN 17 CUPRIMINE 97 curity gauze pads 2"x2" 80 cyclafem 1/35 87 cyclafem 7/7/7 87 cyclobenzaprine hcl 96 cyclophosphamide 23 CYCLOSET 67 cyclosporine 23 cyclosporine 78 cyclosporine modified 23 cyclosporine modified 78 CYMBALTA 57 cyproheptadine hcl 93 CYRAMZA 23 CYSTADANE 98 CYSTAGON 82 CYSTARAN 92 CYTARABINE AQUEOUS 23 dacarbazine 23 DACOGEN 23 DALIRESP 95 DALVANCE 60 danazol 64 dantrolene sodium 96 DAPSONE 17 DAPTACEL 77 DARAPRIM 20 daunorubicin hcl 23 DAUNOXOME 23 decitabine 23 DELESTROGEN 88 DELZICOL 74 demeclocycline hcl 21 DEMSER 38 Name Page # DENAVIR 18 DEPEN TITRATABS 97 DEPO-ESTRADIOL 88 DEPO-PROVERA 23 DEPO-SUBQ PROVERA desipramine hcl 55 desmopressin acetate 68 desogestrel/ethinyl estradiol 87 desonide 61 desoximetasone 61 desvenlafaxine er 57 dexamethasone 65 dexamethasone intensol 65 dexamethasone sodium phosphate 65 dexamethasone sodium phosphate 91 DEXILANT 75 dexmethylphenidate hcl 50 dexmethylphenidate hcl er 49 DEXPAK 13 DAY 65 dexrazoxane 23 dextroamphetamine sulfate 50 dextroamphetamine sulfate er 50 DEXTROSE 10%/NACL 0.45% 82 dextrose 10% flex container 82 dextrose 10%/nacl 0.2% 82 dextrose 2.5%/sodium chloride 0.45% 82 dextrose 5% 83 dextrose 5%/nacl 0.2% 82 DEXTROSE 5%/NACL 0.225% 82 dextrose 5%/nacl 0.33% 82 dextrose 5%/nacl 0.45% 83 dextrose 5%/nacl 0.9% 83 dextrose 5%/potassium chloride 0.15% 83 DIASTAT ACUDIAL 40 DIASTAT PEDIATRIC 41 diazepam 41 diazepam intensol 41 DIBENZYLINE 38 diclofenac potassium 9 diclofenac sodium 62 diclofenac sodium 92 diclofenac sodium dr 9 diclofenac sodium er 9 diclofenac sodium/misoprostol 10 dicloxacillin sodium 19 dicyclomine hcl 71 didanosine 12 DIFFERIN 59 DIFICID 16 diflorasone diacetate

105 Name Page # diflunisal 10 digoxin 33 dihydroergotamine mesylate 51 DILANTIN 51 DILANTIN INFATABS 51 DILANTIN diltiazem cd 32 DILTIAZEM HCL 32 diltiazem hcl er 32 dilt-xr 32 DIOVAN 29 DIPENTUM 74 diphenhydramine hcl 93 diphenoxylate/atropine 71 DIPHTHERIA/TETANUS TOXOIDS 77 ADSORBED PEDIATRIC dipyridamole 30 disopyramide phosphate 29 disulfiram 97 DIURIL 40 divalproex sodium 41 divalproex sodium dr 41 divalproex sodium er 41 DIVIGEL 88 DOCEFREZ 23 docetaxel 23 donepezil hcl 44 DORIBAX 17 dorzolamide hcl 90 dorzolamide hcl/timolol maleate 90 doxazosin mesylate 40 doxepin hcl 58 doxercalciferol 86 DOXIL 23 doxorubicin hcl 23 doxy doxycycline 21 doxycycline hyclate 21 doxycycline hyclate 63 doxycycline hyclate dr 21 doxycycline monohydrate 21 dronabinol 72 drospirenone/ethinyl estradiol 89 DROXIA 23 DULERA 94 duloxetine hcl 57 DUOPA 53 duramorph 6 DUREZOL 91 DYRENIUM 39 Name Page # econazole nitrate 60 EDECRIN 35 EDURANT 12 EFFIENT 30 EGRIFTA 66 ELAPRASE 68 ELELYSO 68 ELIDEL 62 ELIGARD 23 ELIPHOS 86 ELIQUIS 36 ELITEK 23 ELIXOPHYLLIN 94 ELLA 87 ELLENCE 23 ELMIRON 98 EMADINE 92 EMCYT 23 EMEND 72 EMSAM 51 EMTRIVA 12 enalapril maleate 28 enalapril maleate/hydrochlorothiazide 37 ENBREL 97 ENBREL SURECLICK 96 endocet 6 endodan 6 ENGERIX-B 77 enoxaparin sodium 75 enpresse entacapone 53 ENTECAVIR 77 ENTOCORT EC 74 enulose 80 EPANED 28 epinastine hcl 92 epinephrine 94 EPIPEN 2-PAK 95 EPIPEN-JR 2-PAK 94 epirubicin hcl 23 epitol 48 EPIVIR 12 EPIVIR HBV 18 eplerenone 39 EPOGEN 75 eprosartan mesylate 29 EPZICOM 12 EQUETRO 48 ERAXIS 18 ergoloid mesylates

106 Name Page # ERIVEDGE 23 errin 89 ERWINAZE 23 ery 16 ERY-TAB 16 ERYTHROCIN LACTOBIONATE 16 erythromycin 16 erythromycin 59 erythromycin 91 erythromycin base 16 erythromycin ethylsuccinate 16 erythromycin/benzoyl peroxide 59 escitalopram oxalate 56 ESTRACE 88 estradiol 88 estradiol valerate 88 estradiol/norethindrone acetate 89 ESTRING 88 estropipate 88 ethacrynate sodium 35 ethambutol hcl 14 ethosuximide 41 etidronate disodium 68 etodolac 10 etodolac er 10 ETOPOPHOS 23 etoposide 23 EURAX 60 EVOTAZ 12 EXELDERM 22 EXELDERM 60 EXELON 44 exemestane 24 EXJADE 76 EXTAVIA 80 FABRAZYME 68 famciclovir 18 famotidine 72 FAMOTIDINE PREMIXED 72 FANAPT 45 FANAPT TITRATION PACK 45 FARESTON 24 FARXIGA 70 FARYDAK 24 FASLODEX 24 FAZACLO 45 felbamate 41 felodipine er 32 FEMRING 89 fenofibrate 38 Name Page # fenofibrate micronized 38 fenofibric acid dr 39 fenoprofen calcium 10 fentanyl 6 fentanyl citrate oral transmucosal 6 FENTORA 6 FERRIPROX 76 FETZIMA 57 FETZIMA TITRATION PACK 57 finasteride 98 FIORICET 51 FIORINAL 51 FIRAZYR 77 FIRMAGON 24 FLAREX 91 flavoxate hcl 97 flecainide acetate 29 FLECTOR 10 FLOVENT DISKUS 94 FLOVENT HFA 95 fluconazole 16 fluconazole in dextrose 18 flucytosine 16 fludarabine phosphate 24 fludrocortisone acetate 65 fluocinolone acetonide 61 fluocinolone acetonide 63 fluocinolone acetonide body 61 fluocinonide 62 fluocinonide-e 62 fluorometholone 91 fluorouracil 24 fluorouracil 62 fluoxetine dr 56 fluoxetine hcl 56 fluphenazine decanoate 45 fluphenazine hcl 45 flurbiprofen 10 flurbiprofen sodium 92 flutamide 24 fluticasone propionate 62 fluticasone propionate 63 fluvastatin 34 fluvoxamine maleate 56 fluvoxamine maleate er 56 FML 91 FML FORTE 91 FOLOTYN 24 fomepizole 97 fondaparinux sodium

107 Name Page # FORADIL AEROLIZER 93 FORFIVO XL 52 FORTAZ 15 FORTEO 68 FORTESTA 64 FORTICAL 68 fosinopril sodium 28 fosinopril sodium/hydrochlorothiazide 37 fosphenytoin sodium 41 FOSRENOL 86 FRAGMIN 76 FREAMINE HBC 6.9% 83 FROVA 51 FULYZAQ 71 furosemide 35 FUSILEV 24 FUZEON 12 FYCOMPA 41 gabapentin 41 GABITRIL 41 galantamine hydrobromide 44 GAMASTAN S/D 76 GAMMAGARD LIQUID 76 GAMMAPLEX 76 GAMUNEX-C 76 ganciclovir 18 GARDASIL 77 GARDASIL 9 77 GASTROCROM 74 gatifloxacin 92 gavilyte-c 74 gavilyte-g 73 gavilyte-n/flavor pack 74 gemcitabine hcl 24 gemfibrozil 39 gengraf 24 GENOTROPIN 66 GENOTROPIN MINIQUICK 66 gentak 92 gentamicin sulfate 11 gentamicin sulfate 60 gentamicin sulfate 92 GENTAMICIN SULFATE/0.9% SODIUM 11 CHLORIDE GEODON 46 gianvi 87 GILENYA 80 GILOTRIF 24 GLASSIA 95 GLEEVEC 24 Name Page # GLEOSTINE 24 glimepiride 67 glipizide 67 glipizide er 67 glipizide/metformin hcl 67 GLUCAGEN HYPOKIT 66 GLUCAGON EMERGENCY KIT 66 glycopyrrolate 71 GLYSET 67 GLYXAMBI 67 GOLYTELY 73 GRALISE 41 GRALISE STARTER 41 granisetron hcl 72 GRANIX 76 griseofulvin microsize 16 griseofulvin ultramicrosize 16 guanfacine er 55 guanfacine hcl 33 guanidine hcl 55 GYNAZOLE-1 22 H.P. ACTHAR 68 HALAVEN 24 halobetasol propionate 62 haloperidol 46 haloperidol decanoate 46 haloperidol lactate 46 HARVONI 73 HAVRIX 77 HECTOROL 86 heparin sodium 76 HEPARIN SODIUM/D5W 76 hepatamine 83 HERCEPTIN 24 HETLIOZ 56 HEXALEN 24 HORIZANT 41 HUMALOG MIX 50/50 67 HUMALOG MIX 50/50 KWIKPEN 67 HUMATROPE 66 HUMATROPE COMBO PACK 66 HUMIRA 97 HUMIRA PEN-CROHNS 97 DISEASESTARTER HUMULIN R U-500 (CONCENTRATED) 67 hydralazine hcl 39 hydrochlorothiazide 40 hydrocodone bitartrate/acetaminophen 6 hydrocodone bitartrate/acetaminophen 9 hydrocodone/acetaminophen 9 106

108 Name Page # hydrocodone/ibuprofen 9 hydrocortisone 62 hydrocortisone 64 hydrocortisone 65 hydrocortisone 74 hydrocortisone butyrate 62 hydrocortisone butyrate (lipophilic) 62 hydrocortisone valerate 62 hydrocortisone/acetic acid 63 hydromorphone hcl 7 hydromorphone hcl er 6 hydroxychloroquine sulfate 20 hydroxyurea 24 hydroxyzine hcl 59 HYPERRAB S/D 76 ibandronate sodium 69 IBRANCE 24 ibuprofen 10 ICLUSIG 24 IDAMYCIN PFS 24 idarubicin hcl 24 ifosfamide 24 ILARIS 79 ILEVRO 92 IMBRUVICA 24 imipenem/cilastatin 17 imipramine hcl 58 imipramine pamoate 58 imiquimod 63 IMOVAX RABIES (H.D.C.V.) 77 INCRELEX 66 INCRUSE ELLIPTA 95 indapamide 40 INDOCIN 10 indomethacin 10 indomethacin er 10 INFANRIX 77 INLYTA 24 INNOPRAN XL 31 INTELENCE 12 intralipid 83 INTRON A 79 INTRON A W/DILUENT 79 INTUNIV 55 INVANZ 17 INVEGA 46 INVEGA SUSTENNA 46 INVIRASE 12 INVOKAMET 70 INVOKANA 70 Name Page # IONOSOL-B/DEXTROSE 5% 83 IONOSOL-MB/DEXTROSE 5% 83 IOPIDINE 90 IPOL INACTIVATED IPV 77 ipratropium bromide 63 ipratropium bromide 95 ipratropium bromide/albuterol sulfate 93 irbesartan 29 irbesartan/hydrochlorothiazide 37 irinotecan 24 ISENTRESS 12 ISOLYTE-P/DEXTROSE 5% 83 ISOLYTE-S 83 ISONIAZID 14 ISOPTO CARPINE 90 ISORDIL TITRADOSE 35 isosorbide dinitrate 35 isosorbide dinitrate er 35 isosorbide mononitrate 35 isosorbide mononitrate er 35 isotonic gentamicin 11 isradipine 32 ISTODAX 24 itraconazole 16 ivermectin 12 IXEMPRA KIT 24 IXIARO 77 JAKAFI 24 JALYN 98 jantoven 36 JANUMET 65 JANUMET XR 65 JANUVIA 65 JARDIANCE 70 JENTADUETO 65 JEVTANA 24 jolivette 89 junel 1.5/30 87 junel 1/20 87 junel fe 1.5/30 87 junel fe 1/20 87 KALETRA 12 KALYDECO 95 kariva 87 kcl 0.075%/d5w/nacl 0.45% 83 KCL 0.15%/D5W/LR 85 kcl 0.15%/d5w/nacl 0.2% 83 KCL 0.15%/D5W/NACL 0.225% 83 kcl 0.15%/d5w/nacl 0.9% 83 kcl 0.3%/d5w/nacl 0.45%

109 Name Page # KCL 0.3%/D5W/NACL 0.9% 83 kelnor 1/35 87 KENALOG KENALOG KEPIVANCE 25 KETEK 17 ketoconazole 16 ketoconazole 22 ketoconazole 60 ketoprofen 10 ketorolac tromethamine 10 ketorolac tromethamine 92 KEYTRUDA 25 KHEDEZLA 57 klor-con klor-con 8 85 klor-con m15 85 klor-con m20 85 KOMBIGLYZE XR 65 KORLYM 69 KUVAN 69 KYNAMRO 39 labetalol hcl 31 LACRISERT 92 LACTATED RINGERS DEXTROSE 5% 86 VIAFLEX lactated ringers irrigation 83 lactated ringers viaflex 83 lactulose 80 LAMICTAL ODT 41 LAMICTAL XR 41 lamivudine 12 lamivudine/zidovudine 12 lamotrigine 42 lamotrigine er 41 lamotrigine odt 42 LANOXIN 33 lansoprazole 75 lansoprazole/amoxicillin/clarithromycin 73 LANTUS 67 LANTUS SOLOSTAR 67 LASTACAFT 92 latanoprost 90 LATUDA 46 LAZANDA 7 leena 87 leflunomide 25 leflunomide 97 LENVIMA 10MG DAILY DOSE 25 LENVIMA 14MG DAILY DOSE 25 Name Page # LENVIMA 20MG DAILY DOSE 25 LENVIMA 24MG DAILY DOSE 25 lessina 87 LETAIRIS 95 letrozole 25 leucovorin calcium 25 LEUKERAN 25 LEUKINE 76 leuprolide acetate 25 levalbuterol 95 levalbuterol hcl 93 LEVEMIR 67 LEVEMIR FLEXTOUCH 67 levetiracetam 42 levetiracetam er 42 levobunolol hcl 90 levocarnitine 86 levocetirizine dihydrochloride 93 levofloxacin 21 levofloxacin 92 levofloxacin in d5w 20 levoleucovorin calcium 25 levonorgestrel and ethinyl estradiol 87 levonorgestrel/ethinyl estradiol 87 levora 0.15/ levorphanol tartrate 7 levothyroxine sodium 70 levoxyl 70 LEXIVA 12 LIALDA 74 lidocaine 11 lidocaine hcl 11 lidocaine hcl jelly 11 lidocaine viscous 11 lidocaine/prilocaine 11 LINCOCIN 17 lindane 60 linezolid 17 LINZESS 74 liothyronine sodium 70 LIPOSYN III 83 lisinopril 28 lisinopril/hydrochlorothiazide 37 lithium 52 lithium carbonate 52 lithium carbonate er 52 LOCOID 62 lokara 62 lomustine 25 loperamide hcl

110 Name Page # lorazepam 48 lorazepam intensol 48 losartan potassium 29 losartan potassium/hydrochlorothiazide 37 LOTEMAX 91 LOTRONEX 74 lovastatin 34 LOVAZA 39 low-ogestrel 87 loxapine succinate 46 LUMIGAN 90 LUMIZYME 69 LUNESTA 56 LUPRON DEPOT 25 LUPRON DEPOT-PED 25 lutera 87 LYNPARZA 25 LYRICA 42 LYSODREN 25 MACRODANTIN 98 magnesium sulfate 83 MALARONE 20 malathion 60 maprotiline hcl 52 MARPLAN 51 MATULANE 25 matzim la 32 MAXIDEX 91 MAXIPIME 15 meclizine hcl 72 meclofenamate sodium 10 medroxyprogesterone acetate 89 mefenamic acid 10 mefloquine hcl 20 MEGACE ES 25 megestrol acetate 25 MEKINIST 25 meloxicam 10 melphalan hydrochloride 25 memantine hcl 44 memantine hcl titration pak 44 MENACTRA 77 MENEST 89 MENOMUNE-A/C/Y/W MENVEO 77 MEPRON 17 mercaptopurine 25 meropenem 17 mesalamine 74 mesna 25 Name Page # MESNEX 25 MESTINON 55 MESTINON TIMESPAN 55 metadate er 50 metaproterenol sulfate 93 metformin hcl 68 metformin hcl er 67 METHADONE HCL 7 methamphetamine hcl 50 methazolamide 90 methenamine hippurate 98 methimazole 64 METHITEST 64 methotrexate 26 methotrexate sodium 25 methoxsalen 60 methscopolamine bromide 71 methscopolamine bromide 72 methyclothiazide 40 methyldopa 33 methyldopa/hydrochlorothiazide 37 METHYLDOPATE HCL 33 methylergonovine maleate 90 METHYLIN 50 methylphenidate hcl 50 methylphenidate hcl cd 50 methylphenidate hcl er 50 methylphenidate hydrochloride 50 methylprednisolone 64 methylprednisolone acetate 65 methylprednisolone dose pack 64 metipranolol 90 metoclopramide hcl 71 metoclopramide odt 71 metolazone 40 metoprolol succinate er 31 metoprolol tartrate 31 metoprolol/hydrochlorothiazide 37 metronidazole 11 metronidazole 59 metronidazole in nacl 0.79% 11 metronidazole vaginal 89 mexiletine hcl 29 MIACALCIN 69 miconazole 3 22 microgestin 1.5/30 87 microgestin 1/20 87 microgestin fe 87 microgestin fe 1.5/30 87 midodrine hcl

111 Name Page # MIGERGOT 51 MIGRANAL 51 minocycline hcl 21 minocycline hcl er 21 minoxidil 39 MIRAPEX ER 53 mirtazapine 53 mirtazapine odt 53 misoprostol 73 mitomycin 26 mitoxantrone hcl 26 M-M-R II 77 modafinil 50 MODERIBA 73 MODERIBA 1200 DOSE PACK 73 MODERIBA 800 DOSE PACK 73 moexipril hcl 28 moexipril/hydrochlorothiazide 37 mometasone furoate 62 mononessa 87 montelukast sodium 94 MONUROL 98 morphine sulfate 7 morphine sulfate er 7 MOVIPREP 73 moxifloxacin hcl 21 MOZOBIL 80 MULTAQ 29 mupirocin 60 MUSTARGEN 26 MYALEPT 69 MYCAMINE 18 MYCOBUTIN 14 mycophenolate mofetil 26 mycophenolate mofetil 78 mycophenolic acid dr 78 MYOZYME 69 MYRBETRIQ 98 nabumetone 10 nadolol 31 nadolol/bendroflumethiazide 37 NAFCILLIN SODIUM 19 naftifine hcl 61 NAFTIN 22 NAFTIN 61 NAGLAZYME 69 nalbuphine hcl 6 NALLPEN/DEXTROSE 20 naloxone hcl 97 naltrexone hcl 97 Name Page # NAMENDA 44 NAMENDA TITRATION PAK 44 NAMENDA XR 44 NAMENDA XR TITRATION PACK 44 naphazoline hcl 92 naproxen 10 naproxen dr 10 naproxen sodium 10 naproxen sodium er 10 naratriptan hcl 51 NASONEX 63 NATACYN 92 nateglinide 68 NATPARA 69 NEBUPENT 17 necon 0.5/ necon 1/35 87 necon 1/ necon 10/ necon 7/7/7 87 nefazodone hcl 53 neomycin sulfate 81 neomycin/bacitracin/polymyxin 92 neomycin/polymyxin b sulfates 98 neomycin/polymyxin/bacitracin/hydrocortis 91 one neomycin/polymyxin/dexamethasone 91 neomycin/polymyxin/gramicidin 92 neomycin/polymyxin/hc 63 neomycin/polymyxin/hydrocortisone 63 neomycin/polymyxin/hydrocortisone 91 NEORAL 78 NEPHRAMINE 83 NEULASTA 76 NEUMEGA 79 NEUPOGEN 76 NEUPRO 54 NEVANAC 92 nevirapine 12 nevirapine er 12 NEXAVAR 26 niacin er 39 NIACOR 39 nicardipine hcl 32 NICOTROL INHALER 58 NICOTROL NS 58 nifedical xl 32 nifedipine er 32 NILANDRON 26 nisoldipine

112 Name Page # nisoldipine er 32 NITRO-BID 35 nitrofurantoin 98 nitrofurantoin macrocrystals 98 nitrofurantoin monohydrate 98 NITROGLYCERIN 35 nitroglycerin lingual 35 nitroglycerin transdermal 35 NITROLINGUAL PUMPSPRAY 35 NITROMIST 35 NITROSTAT 36 nizatidine 72 nora-be 90 NORDITROPIN FLEXPRO 66 norethindrone 90 norethindrone & ethinyl estradiol ferrous 87 fumarate norethindrone acetate 90 norethindrone acetate/ethinyl estradiol 87 norethindrone acetate/ethinyl 87 estradiol/ferrous fumarate normosol-m in d5w 83 NORMOSOL-R 84 normosol-r in d5w 84 NORPACE CR 29 NORTHERA 38 nortrel 0.5/35 (28) 88 nortrel 1/35 88 nortrel 7/7/7 88 nortriptyline hcl 55 NORVIR 12 NOVOLIN 70/30 67 NOVOLIN N 67 NOVOLIN R 67 NOVOLOG 67 NOVOLOG FLEXPEN 67 NOVOLOG MIX 70/30 67 NOVOLOG MIX 70/30 PREFILLED 67 FLEXPEN NOVOLOG PENFILL 67 NOXAFIL 17 NUCYNTA 7 NUEDEXTA 55 NULOJIX 78 nutrilipid 84 NUTROPIN AQ NUSPIN 5 66 NUTROPIN AQ PEN 66 NUVARING 88 nyamyc 22 nystatin 17 Name Page # nystatin 22 nystatin 61 nystatin/triamcinolone 22 nystop 61 ocella 88 octreotide acetate 26 ofloxacin 21 ofloxacin 92 ogestrel 88 olanzapine 46 olanzapine odt 46 olanzapine/fluoxetine 46 olopatadine hcl 63 OLYSIO 73 omega-3-acid ethyl esters 39 omeprazole 75 OMNITROPE 66 ONCASPAR 26 ondansetron hcl 72 ondansetron odt 72 ONFI 42 ONGLYZA 65 OPANA ER (CRUSH RESISTANT) 7 OPDIVO 26 OPSUMIT 95 ORAP 46 ORAPRED ODT 65 ORENCIA 97 ORENITRAM 39 ORFADIN 80 ORKAMBI 95 ORTHO TRI-CYCLEN LO 88 OSMOPREP 73 OTREXUP 78 OXACILLIN SODIUM 20 oxaliplatin 26 oxandrolone 64 oxaprozin 10 oxcarbazepine 49 OXISTAT 22 OXISTAT 61 OXSORALEN 63 OXSORALEN ULTRA 60 OXTELLAR XR 49 oxybutynin chloride 97 oxybutynin chloride er 97 oxycodone hcl 8 oxycodone hcl er 8 oxycodone/acetaminophen 8 oxycodone/ibuprofen 8 111

113 Name Page # OXYCONTIN 8 oxymorphone hydrochloride 9 oxymorphone hydrochloride er 8 pacerone 29 paclitaxel 26 pamidronate disodium 69 PANRETIN 63 pantoprazole sodium 75 paricalcitol 86 paromomycin sulfate 11 paroxetine hcl 57 paroxetine hcl er 56 PASER 14 PATADAY 92 PATANASE 92 PATANOL 92 PAXIL 57 PCE 16 PEDVAX HIB 77 peg-3350/electrolytes 73 PEGANONE 51 PEGASYS 79 PEGASYS PROCLICK 79 PEGINTRON 79 PEG-INTRON 79 PEG-INTRON REDIPEN 79 penicillin g potassium 20 PENICILLIN G POTASSIUM IN 20 ISO-OSMOTIC DEXTROSE PENICILLIN G PROCAINE 20 PENICILLIN G SODIUM 20 penicillin v potassium 20 PENTAM PENTASA 74 pentazocine/naloxone hcl 9 pentoxifylline er 38 PERFOROMIST 93 perindopril erbumine 28 periogard 63 PERJETA 26 permethrin 60 perphenazine 47 perphenazine/amitriptyline 53 phenelzine sulfate 51 phenobarbital 42 phenoxybenzamine hydrochloride 38 phenytoin 51 phenytoin sodium 51 phenytoin sodium extended 51 PHOSPHOLINE IODIDE 90 Name Page # physiolyte 84 PHYSIOSOL IRRIGATION 84 pilocarpine hcl 63 pilocarpine hcl 90 pilocarpine hydrochloride 63 pindolol 31 pioglitazone hcl 67 pioglitazone hcl/metformin hcl 67 pioglitazone hcl-glimepiride 68 piperacillin sodium/tazobactam sodium 20 piroxicam 10 PLASMA-LYTE A 84 PLASMA-LYTE PLASMA-LYTE-56/D5W 84 PLEGRIDY 80 PLEGRIDY STARTER PACK 80 podofilox 60 polyethylene glycol polymyxin b sulfate 17 polymyxin b sulfate/trimethoprim sulfate 92 POMALYST 26 portia potassium chloride 86 potassium chloride 0.15% /nacl 0.45% 84 viaflex potassium chloride 0.15% d5w/nacl 0.33% 84 potassium chloride 0.15% d5w/nacl 0.45% 84 potassium chloride 0.15%/nacl 0.9% 84 potassium chloride 0.22% d5w/nacl 0.45% 84 POTASSIUM CHLORIDE 0.3%/ NACL % potassium chloride 0.3%/d5w 84 potassium chloride er 86 potassium citrate er 86 potassium citrate er 98 POTIGA 42 PRADAXA 36 pramipexole dihydrochloride 54 pramipexole dihydrochloride er 54 PRANDIMET 68 pravastatin sodium 34 prazosin hcl 40 PRED MILD 91 PRED-G 91 PRED-G S.O.P. 91 prednicarbate 62 prednisolone acetate 91 prednisolone sodium phosphate 64 prednisolone sodium phosphate 91 prednisolone sodium phosphate odt

114 Name Page # prednisone 64 prednisone intensol 64 PREFEST 89 pregnyl w/diluent benzyl alcohol/nacl 90 PREMARIN 89 PREMASOL 84 PREMPRO 89 prevalite 39 previfem 88 PREZCOBIX 13 PREZISTA 13 PRIFTIN 14 PRIMAQUINE PHOSPHATE 20 primidone 43 PRIMSOL 98 PRISTIQ 57 PRIVIGEN 76 PROAIR HFA 93 PROAIR RESPICLICK 93 probenecid 96 probenecid/colchicine 96 procainamide hcl 29 PROCALAMINE 84 prochlorperazine 72 prochlorperazine edisylate 72 prochlorperazine maleate 72 PROCRIT 75 procto-pak 59 proctosol hc 59 proctozone-hc 59 PROCYSBI 98 progesterone 90 PROGLYCEM 66 PROGRAF 79 PROLASTIN-C 95 PROLEUKIN 79 PROLIA 69 PROMACTA 75 promethazine hcl 72 promethazine hcl 93 promethazine vc plain 93 promethegan 72 propafenone hcl 29 propafenone hcl er 29 propantheline bromide 72 proparacaine hcl 92 propranolol hcl 31 propranolol hcl er 31 propranolol/hydrochlorothiazide 37 propylthiouracil 64 Name Page # PROQUAD 77 PROSOL 85 protriptyline hcl 56 PROVENTIL HFA 93 PULMICORT FLEXHALER 95 PULMOZYME 95 PURIXAN 26 PYLERA 73 pyrazinamide 14 pyridostigmine bromide 55 QUADRACEL 77 QUASENSE 88 QUDEXY XR 43 quetiapine fumarate 47 quinapril hcl 28 quinapril/hydrochlorothiazide 37 QUINIDINE GLUCONATE 30 quinidine sulfate 30 quinine sulfate 20 QVAR 95 RABAVERT 77 raloxifene hydrochloride 69 ramipril 28 RANEXA 38 ranitidine hcl 73 RAPAMUNE 79 RASUVO 96 RAVICTI 80 REBETOL 73 REBIF 80 REBIF REBIDOSE 80 REBIF REBIDOSE TITRATION PACK 80 REBIF TITRATION PACK 80 reclipsen 88 RECOMBIVAX HB 78 RECTIV 36 REGRANEX 63 RELENZA DISKHALER 18 RELISTOR 74 RELPAX 52 REMICADE 97 REMODULIN 39 RENVELA 86 repaglinide 68 RESCRIPTOR 13 RESCULA 90 reserpine 33 RESTASIS 92 RETROVIR IV INFUSION 13 REVATIO

115 Name Page # REVLIMID 26 REXULTI 47 REYATAZ 13 RHEUMATREX 26 ribasphere 73 RIBASPHERE RIBAPAK 73 ribavirin 73 RIDAURA 96 rifabutin 14 rifampin 14 RIFATER 14 riluzole 97 rimantadine hcl 18 ringers injection 85 ringers irrigation 85 RIOMET 68 risedronate sodium 69 risedronate sodium dr 69 RISPERDAL CONSTA 47 risperidone 47 risperidone odt 47 RITUXAN 26 rivastigmine tartrate 44 rizatriptan benzoate 52 rizatriptan benzoate odt 52 ropinirole er 54 ropinirole hcl 54 ROTARIX 78 ROTATEQ 78 ROZEREM 56 RYTARY 54 SABRIL 43 SAIZEN 66 SAIZEN CLICK.EASY 66 SAMSCA 69 SANDIMMUNE 79 SANDOSTATIN LAR DEPOT 26 SANTYL 63 SAPHRIS 47 SARAFEM 57 SAVAYSA 36 SAVELLA 57 SAVELLA TITRATION PACK 57 selegiline hcl 51 selenium sulfide 60 SELZENTRY 13 SENSIPAR 69 SEREVENT DISKUS 93 SEROQUEL XR 47 SEROSTIM 66 Name Page # sertraline hcl 57 SIGNIFOR 26 SIGNIFOR LAR 69 sildenafil 95 silver sulfadiazine 60 SIMBRINZA 90 SIMCOR 34 SIMPONI 97 SIMPONI ARIA 97 SIMULECT 26 simvastatin 35 sirolimus 78 sirolimus 79 SIRTURO 14 SIVEXTRO 17 sodium chloride 85 sodium chloride 0.45% viaflex 85 sodium chloride 0.9% 85 sodium fluoride 86 SODIUM LACTATE 85 sodium phenylbutyrate 80 sodium polystyrene sulfonate 97 sodium sulfacetamide 92 SOLTAMOX 26 SOLU-CORTEF 65 SOLU-MEDROL 66 SOMATULINE DEPOT 26 SOMAVERT 69 SOOLANTRA 12 sorine 30 sotalol hcl 30 sotalol hcl (af) 30 SOTYLIZE 30 SOVALDI 73 SPIRIVA HANDIHALER 95 SPIRIVA RESPIMAT 95 spironolactone 39 spironolactone/hydrochlorothiazide 39 SPORANOX 17 sprintec SPRYCEL 26 sronyx 88 ssd 60 STALEVO STALEVO STALEVO STALEVO STALEVO STALEVO stavudine

116 Name Page # STELARA 79 sterile water irrigation 85 STIMATE 69 STIVARGA 27 STRATTERA 50 STREPTOMYCIN SULFATE 14 STRIBILD 13 STRIVERDI RESPIMAT 93 STROMECTOL 12 SUCRAID 74 sucralfate 73 sulfacetamide sodium 92 sulfacetamide sodium/prednisolone sodium 91 phosphate sulfadiazine 21 SULFAMETHOXAZOLE/TRIMETHOPRI 21 M sulfamethoxazole/trimethoprim ds 21 SULFAMYLON 60 sulfasalazine 74 sulfazine ec 74 sulindac 11 sumatriptan 52 sumatriptan succinate 52 sumatriptan succinate refill 52 SUPRAX 15 SUPREP BOWEL PREP 73 SURMONTIL 59 SUSTIVA 13 SUTENT 27 SYLATRON 79 SYLVANT 27 SYMBICORT 95 SYMLINPEN SYMLINPEN SYNAGIS 78 SYNALGOS-DC 9 SYNAREL 90 SYNERA 11 SYNERCID 17 SYNRIBO 27 SYNTHROID 71 SYPRINE 97 TABLOID 27 tacrolimus 79 TAFINLAR 27 TALWIN 9 TAMIFLU 18 tamoxifen citrate 27 tamsulosin hcl 98 Name Page # TARCEVA 27 TARGRETIN 27 TASIGNA 27 TASMAR 55 tazicef 15 TAZORAC 60 taztia xt 33 TECFIDERA 80 TECFIDERA STARTER PACK 80 TEFLARO 15 TEGRETOL-XR 49 telmisartan 29 telmisartan/amlodipine 38 telmisartan/hydrochlorothiazide 38 TENIVAC 78 terazosin hcl 40 terbinafine hcl 61 terbutaline sulfate 93 terconazole 22 TESTIM 64 testosterone 64 testosterone cypionate 64 testosterone enanthate 64 testosterone pump 64 TESTRED 64 TETANUS/DIPHTHERIA 78 TOXOIDS-ADSORBED ADULT tetrabenazine 55 THALOMID 27 THEO theophylline cr 94 theophylline er 94 thioridazine hcl 47 thiotepa 27 thiothixene 48 THYMOGLOBULIN 78 THYROLAR-1 71 THYROLAR-1/2 71 THYROLAR-1/4 71 THYROLAR-2 71 THYROLAR-3 71 tiagabine hydrochloride 43 ticlopidine hcl 30 TIKOSYN 30 timolol maleate 31 timolol maleate 91 timolol maleate ophthalmic gel forming 90 TIMOPTIC OCUDOSE 91 tinidazole 11 TIVICAY

117 Name Page # tizanidine hcl 96 TOBI PODHALER 11 TOBRADEX 91 tobramycin 11 tobramycin sulfate 11 tobramycin sulfate 92 TOBRAMYCIN SULFATE/SODIUM 11 CHLORIDE tobramycin/dexamethasone 91 TOBREX 92 tolazamide 68 tolbutamide 68 tolcapone 55 tolmetin sodium 11 tolterodine tartrate 97 tolterodine tartrate er 97 topiramate 43 TOPIRAMATE ER 43 toposar 27 topotecan hcl 27 TORISEL 27 torsemide 35 TOVIAZ 97 tpn electrolytes 85 TRACLEER 96 TRADJENTA 65 tramadol hcl 6 tramadol hcl er 6 tramadol hydrochloride/acetaminophen 6 trandolapril 28 trandolapril/verapamil hcl 38 tranexamic acid 75 TRANSDERM-SCOP 72 tranylcypromine sulfate 51 TRAVASOL 85 travoprost 91 trazodone hcl 53 TREANDA 27 TRECATOR 14 TRELSTAR MIXJECT 27 TRETINOIN 27 tretinoin 59 tretinoin microsphere 59 TREXALL 27 triamcinolone acetonide 62 triamcinolone acetonide 63 triamcinolone acetonide 64 triamcinolone in orabase 63 triamterene/hydrochlorothiazide 39 triderm 62 Name Page # trifluoperazine hcl 48 trifluridine 92 trihexyphenidyl hcl 44 tri-legest fe 88 trilyte 73 trimethobenzamide hcl 72 trimethoprim 98 trinessa 88 TRIOSTAT 71 tri-previfem 88 TRISENOX 27 tri-sprintec 88 TRIUMEQ 13 trivora TROKENDI XR 43 TROPHAMINE 85 trospium chloride 98 trospium chloride er 98 TRULICITY 69 TRUMENBA 78 TRUVADA 13 TUDORZA PRESSAIR 96 TWINRIX 78 TYBOST 13 TYGACIL 21 TYKERB 27 TYPHIM VI 78 TYSABRI 80 TYVASO 39 TYZEKA 18 TYZINE PEDIATRIC NASAL DROPS 63 UCERIS 74 ULORIC 96 unithroid 71 ursodiol 74 UVADEX 27 VAGIFEM 89 valacyclovir hcl 18 VALCHLOR 27 VALCYTE 18 valganciclovir 18 valproate sodium 43 valproic acid 43 valsartan 29 valsartan/hydrochlorothiazide 38 vancomycin hcl 17 vandazole 89 VAQTA 78 VARIVAX 78 VARIZIG

118 Name Page # VECAMYL 38 VECTICAL 60 VELCADE 27 velivet 88 venlafaxine hcl 53 venlafaxine hcl 58 venlafaxine hcl er 58 VENTAVIS 39 VENTOLIN HFA 94 verapamil hcl 33 verapamil hcl er 33 verapamil hcl sr 33 VEREGEN 63 VERIPRED VERSACLOZ 48 VESICARE 97 VEXOL 91 VICTOZA 69 VIDEX PEDIATRIC 13 VIGAMOX 92 VIIBRYD 57 VIMPAT 43 VINBLASTINE SULFATE 27 vincasar pfs 27 vincristine sulfate 27 vinorelbine tartrate 27 VIRACEPT 13 VIRAMUNE 13 VIRAMUNE XR 13 VIRAZOLE 73 VIREAD 13 VITEKTA 13 VIVELLE-DOT 89 VIVITROL 97 VOLTAREN 11 voriconazole 17 voriconazole 18 VOTRIENT 27 vp-pnv-dha 87 VYTORIN 34 warfarin sodium 36 WELCHOL 39 XALKORI 28 XARELTO 36 XARELTO STARTER PACK 36 XELJANZ 96 XENAZINE 55 XEOMIN 96 XERESE 18 XGEVA 69 Name Page # XIFAXAN 17 XIGDUO XR 70 XOLAIR 95 XOPENEX HFA 94 XTANDI 28 xulane 89 XYREM 55 YF-VAX 78 zafirlukast 94 zaleplon 56 ZALTRAP 28 ZANOSAR 28 ZAVESCA 69 zazole 22 ZELAPAR 55 ZELBORAF 28 ZEMAIRA 96 ZEMPLAR 87 ZERBAXA 15 ZETIA 39 ZIAGEN 13 zidovudine 13 ziprasidone hcl 48 ZIRGAN 92 ZMAX 16 zoledronic acid 69 ZOLINZA 28 zolmitriptan 52 zolmitriptan odt 52 zolpidem tartrate 56 zolpidem tartrate er 56 ZOMIG 52 ZOMIG NASAL SPRAY 52 ZONALON 59 zonisamide 43 ZONTIVITY 30 ZORBTIVE 66 ZORTRESS 79 ZOSTAVAX 78 ZOSYN 20 zovia 1/35e 88 zovia 1/50e 88 ZOVIRAX 18 ZYCLARA 63 ZYCLARA PUMP 63 ZYDELIG 28 ZYFLO 94 ZYFLO CR 94 ZYKADIA 28 ZYLET

119 Name Page # ZYMAXID 92 ZYPREXA RELPREVV 48 ZYTIGA 28 ZYVOX

120 This formulary was updated on 11/01/2015. For more recent information or other questions, please contact Paramount Elite/Paramount Prescription Plan Member Services at , or for TTY users, , 8:00 a.m. to 8:00 p.m., Monday through Friday. From October 1 through February 14, we are available 8:00 a.m. to 8:00 p.m. seven days per week, or visit