IEHP Medi-Cal Formulary Maintenance Drug List

IEHP Medi-Cal Formulary Maintenance Drug List The following formulary medications may be approvable up to a three-month supply. FDA-approved generic products must be used if available. Brand name products may be covered through the prior authorization process. BRAND_NAME GENERIC_NAME STRENGTH DOSAGE ACARBOSE ACARBOSE 100 MG TABLET ACARBOSE ACARBOSE 25 MG TABLET ACARBOSE ACARBOSE 50 MG TABLET ACETAZOLAMIDE ACETAZOLAMIDE 125 MG TABLET ACETAZOLAMIDE ACETAZOLAMIDE 250 MG TABLET ACETAZOLAMIDE ACETAZOLAMIDE 500 MG CAPSULE ER ACYCLOVIR ACYCLOVIR 200 MG CAPSULE ACYCLOVIR ACYCLOVIR 200 MG/5ML ORAL SUSP ACYCLOVIR ACYCLOVIR 400 MG TABLET ACYCLOVIR ACYCLOVIR 800 MG TABLET AFINITOR EVEROLIMUS 10 MG TABLET AFINITOR EVEROLIMUS 2.5 MG TABLET AFINITOR EVEROLIMUS 5 MG TABLET AFINITOR EVEROLIMUS 7.5 MG TABLET ALBUTEROL SULFATE ALBUTEROL SULFATE 0.63MG/3ML VIAL NEB ALBUTEROL SULFATE ALBUTEROL SULFATE 1.25MG/3ML VIAL NEB ALBUTEROL SULFATE ALBUTEROL SULFATE 2 MG/5 ML SYRUP ALBUTEROL SULFATE ALBUTEROL SULFATE 2.5 MG/0.5 VIAL NEB ALBUTEROL SULFATE ALBUTEROL SULFATE 2.5 MG/3ML VIAL NEB ALBUTEROL SULFATE ALBUTEROL SULFATE 4 MG TAB ER 12H ALBUTEROL SULFATE ALBUTEROL SULFATE 5 MG/ML SOLUTION ALBUTEROL SULFATE ALBUTEROL SULFATE 8 MG TAB ER 12H ALDACTAZIDE SPIRONOLACTONE/ 50 MG 50MG TABLET ALENDRONATE SODIUM ALENDRONATE SODIUM 10 MG TABLET ALENDRONATE SODIUM ALENDRONATE SODIUM 35 MG TABLET ALENDRONATE SODIUM ALENDRONATE SODIUM 40 MG TABLET ALENDRONATE SODIUM ALENDRONATE SODIUM 70 MG TABLET ALLOPURINOL ALLOPURINOL 100 MG TABLET ALLOPURINOL ALLOPURINOL 300 MG TABLET ALOGLIPTIN ALOGLIPTIN BENZOATE 12.5 MG TABLET ALOGLIPTIN ALOGLIPTIN BENZOATE 25 MG TABLET ALOGLIPTIN ALOGLIPTIN BENZOATE 6.25 MG TABLET 255_FormularyMaintenance_December2018 Page 1 of 35

ALOGLIPTIN METFORMIN ALOGLIPTIN BENZOATE/METFORMIN HCL 12.5 1000 TABLET ALOGLIPTIN METFORMIN ALOGLIPTIN BENZOATE/METFORMIN HCL 12.5 500MG TABLET ALOGLIPTIN ALOGLIPTIN BENZOATE/PIOGLITAZONE HCL 12.5 15 MG TABLET PIOGLITAZONE ALOGLIPTIN ALOGLIPTIN BENZOATE/PIOGLITAZONE HCL 12.5 30 MG TABLET PIOGLITAZONE ALOGLIPTIN ALOGLIPTIN BENZOATE/PIOGLITAZONE HCL 12.5 45 MG TABLET PIOGLITAZONE ALOGLIPTIN ALOGLIPTIN BENZOATE/PIOGLITAZONE HCL 25 MG 15MG TABLET PIOGLITAZONE ALOGLIPTIN ALOGLIPTIN BENZOATE/PIOGLITAZONE HCL 25 MG 30MG TABLET PIOGLITAZONE ALOGLIPTIN ALOGLIPTIN BENZOATE/PIOGLITAZONE HCL 25 MG 45MG TABLET PIOGLITAZONE AMIODARONE HCL AMIODARONE HCL 200 MG TABLET AMITRIPTYLINE HCL AMITRIPTYLINE HCL 10 MG TABLET AMITRIPTYLINE HCL AMITRIPTYLINE HCL 100 MG TABLET AMITRIPTYLINE HCL AMITRIPTYLINE HCL 150 MG TABLET AMITRIPTYLINE HCL AMITRIPTYLINE HCL 25 MG TABLET AMITRIPTYLINE HCL AMITRIPTYLINE HCL 50 MG TABLET AMITRIPTYLINE HCL AMITRIPTYLINE HCL 75 MG TABLET AMLODIPINE BESYLATE AMLODIPINE BESYLATE 10 MG TABLET AMLODIPINE BESYLATE AMLODIPINE BESYLATE 2.5 MG TABLET AMLODIPINE BESYLATE AMLODIPINE BESYLATE 5 MG TABLET AMLODIPINE BESYLATE AMLODIPINE BESYLATE/BENAZEPRIL HCL 10 MG 20MG CAPSULE BENAZEPRIL AMLODIPINE BESYLATE AMLODIPINE BESYLATE/BENAZEPRIL HCL 10 MG 40MG CAPSULE BENAZEPRIL AMLODIPINE BESYLATE AMLODIPINE BESYLATE/BENAZEPRIL HCL 2.5MG 10MG CAPSULE BENAZEPRIL AMLODIPINE BESYLATE AMLODIPINE BESYLATE/BENAZEPRIL HCL 5 MG 10 MG CAPSULE BENAZEPRIL AMLODIPINE BESYLATE AMLODIPINE BESYLATE/BENAZEPRIL HCL 5 MG 20 MG CAPSULE BENAZEPRIL AMLODIPINE BESYLATE AMLODIPINE BESYLATE/BENAZEPRIL HCL 5 MG 40 MG CAPSULE BENAZEPRIL AMPHETAMINE SALT COMBO DEXTROAMPHETAMINE SULF SACCHARATE/AMPHETAMINE SULF ASPARTATE 10 MG TABLET AMPHETAMINE SALT COMBO DEXTROAMPHETAMINE SULF SACCHARATE/AMPHETAMINE SULF ASPARTATE 12.5 MG TABLET 255_FormularyMaintenance_December2018 Page 2 of 35

AMPHETAMINE SALT DEXTROAMPHETAMINE SULF 20 MG TABLET COMBO SACCHARATE/AMPHETAMINE SULF ASPARTATE ANAGRELIDE HCL ANAGRELIDE HCL 0.5 MG CAPSULE ANAGRELIDE HCL ANAGRELIDE HCL 1 MG CAPSULE ANASTROZOLE ANASTROZOLE 1 MG TABLET ANTI DIARRHEAL LOPERAMIDE HCL 1 MG/5 ML LIQUID ARMOUR THYROID THYROID,PORK 120 MG TABLET ARMOUR THYROID THYROID,PORK 15 MG TABLET ARMOUR THYROID THYROID,PORK 180 MG TABLET ARMOUR THYROID THYROID,PORK 240 MG TABLET ARMOUR THYROID THYROID,PORK 30 MG TABLET ARMOUR THYROID THYROID,PORK 300 MG TABLET ARMOUR THYROID THYROID,PORK 60 MG TABLET ARMOUR THYROID THYROID,PORK 90 MG TABLET ASMANEX MOMETASONE FUROATE 110MCG(30) AER POW BA ASMANEX MOMETASONE FUROATE 220MCG 120 AER POW BA ASMANEX MOMETASONE FUROATE 220MCG(30) AER POW BA ASMANEX MOMETASONE FUROATE 220MCG(60) AER POW BA ASPIRIN ASPIRIN 325 MG TABLET ASPIRIN ASPIRIN 81 MG TAB CHEW ASPIRIN EC ASPIRIN 325 MG TABLET DR ASPIRIN EC ASPIRIN 81 MG TABLET DR ATENOLOL ATENOLOL 100 MG TABLET ATENOLOL ATENOLOL 25 MG TABLET ATENOLOL ATENOLOL 50 MG TABLET ATENOLOL ATENOLOL/CHLORTHALIDONE 100MG TABLET CHLORTHALIDONE 25MG ATENOLOL ATENOLOL/CHLORTHALIDONE 50 MG 25MG TABLET CHLORTHALIDONE ATOMOXETINE HCL ATOMOXETINE HCL 10 MG CAPSULE ATOMOXETINE HCL ATOMOXETINE HCL 100 MG CAPSULE ATOMOXETINE HCL ATOMOXETINE HCL 18 MG CAPSULE ATOMOXETINE HCL ATOMOXETINE HCL 25 MG CAPSULE ATOMOXETINE HCL ATOMOXETINE HCL 40 MG CAPSULE ATOMOXETINE HCL ATOMOXETINE HCL 60 MG CAPSULE ATOMOXETINE HCL ATOMOXETINE HCL 80 MG CAPSULE ATORVASTATIN CALCIUM ATORVASTATIN CALCIUM 10 MG TABLET ATORVASTATIN CALCIUM ATORVASTATIN CALCIUM 20 MG TABLET 255_FormularyMaintenance_December2018 Page 3 of 35

ATORVASTATIN CALCIUM ATORVASTATIN CALCIUM 40 MG TABLET ATORVASTATIN CALCIUM ATORVASTATIN CALCIUM 80 MG TABLET ATROPINE SULFATE ATROPINE SULFATE 1 % DROPS ATROPINE SULFATE ATROPINE SULFATE 1 % OINT. (G) ATROVENT HFA IPRATROPIUM BROMIDE 17MCG HFA AER AD AZATHIOPRINE AZATHIOPRINE 50 MG TABLET AZELASTINE HCL AZELASTINE HCL 137 MCG SPRAY/PUMP AZURETTE DESOGESTREL ETHINYL ESTRADIOL/ETHINYL 21 5 TABLET ESTRADIOL BACLOFEN BACLOFEN 10 MG TABLET BACLOFEN BACLOFEN 20 MG TABLET BALZIVA NORETHINDRONE ETHINYL ESTRADIOL 0.4 0.035 TABLET BENAZEPRIL HCL BENAZEPRIL HCL 10 MG TABLET BENAZEPRIL HCL BENAZEPRIL HCL 20 MG TABLET BENAZEPRIL HCL BENAZEPRIL HCL 40 MG TABLET BENAZEPRIL HCL BENAZEPRIL HCL 5 MG TABLET BENAZEPRIL BENAZEPRIL HCL/ 10 12.5MG TABLET BENAZEPRIL BENAZEPRIL HCL/ 20 MG 25MG TABLET BENAZEPRIL BENAZEPRIL HCL/ 20 12.5 MG TABLET BENAZEPRIL BENAZEPRIL HCL/ 5 6.25MG TABLET BEXAROTENE BEXAROTENE 75 MG CAPSULE BRIMONIDINE TARTRATE BRIMONIDINE TARTRATE 0.2 % DROPS BROMOCRIPTINE BROMOCRIPTINE MESYLATE 2.5 MG TABLET MESYLATE BROMOCRIPTINE BROMOCRIPTINE MESYLATE 5 MG CAPSULE MESYLATE BUDESONIDE BUDESONIDE 0.25MG/2ML AMPUL NEB BUDESONIDE BUDESONIDE 0.5 MG/2ML AMPUL NEB BUDESONIDE BUDESONIDE 1 MG/2 ML AMPUL NEB BUMETANIDE BUMETANIDE 0.5 MG TABLET BUMETANIDE BUMETANIDE 1 MG TABLET BUMETANIDE BUMETANIDE 2 MG TABLET BUPROPION HCL BUPROPION HCL 100 MG TABLET BUPROPION HCL BUPROPION HCL 75 MG TABLET BUPROPION HCL ER BUPROPION HCL 200 MG TAB SR 12H 255_FormularyMaintenance_December2018 Page 4 of 35

BUPROPION HCL SR BUPROPION HCL 100 MG TAB SR 12H BUPROPION XL BUPROPION HCL 150 MG TAB ER 24H BUPROPION XL BUPROPION HCL 300 MG TAB ER 24H BUSPIRONE HCL BUSPIRONE HCL 10 MG TABLET BUSPIRONE HCL BUSPIRONE HCL 15 MG TABLET BUSPIRONE HCL BUSPIRONE HCL 30 MG TABLET BUSPIRONE HCL BUSPIRONE HCL 5 MG TABLET BUSPIRONE HCL BUSPIRONE HCL 7.5 MG TABLET CALCITONIN SALMON CALCITONIN,SALMON,SYNTHETIC 200/SPRAY SPRAY/PUMP CALCITRIOL CALCITRIOL 0.25 MCG CAPSULE CALCITRIOL CALCITRIOL 0.5 MCG CAPSULE CALCIUM ACETATE CALCIUM ACETATE 667 MG CAPSULE CALCIUM ACETATE CALCIUM ACETATE 667 MG TABLET CAMRESE LEVONORGESTREL/ETHINYL ESTRADIOL AND 150 30(84) TBDSPK 3MO ETHINYL ESTRADIOL CAPTOPRIL CAPTOPRIL 100 MG TABLET CAPTOPRIL CAPTOPRIL 12.5 MG TABLET CAPTOPRIL CAPTOPRIL 25 MG TABLET CAPTOPRIL CAPTOPRIL 50 MG TABLET CARAFATE SUCRALFATE 1 G/10 ML ORAL SUSP CARBAMAZEPINE CARBAMAZEPINE 100 MG TAB CHEW CARBAMAZEPINE CARBAMAZEPINE 100 MG/5ML ORAL SUSP CARBAMAZEPINE CARBAMAZEPINE 200 MG TABLET CARBAMAZEPINE ER CARBAMAZEPINE 100 MG CPMP 12HR CARBAMAZEPINE ER CARBAMAZEPINE 100 MG TAB ER 12H CARBAMAZEPINE ER CARBAMAZEPINE 200 MG CPMP 12HR CARBAMAZEPINE ER CARBAMAZEPINE 200 MG TAB ER 12H CARBAMAZEPINE ER CARBAMAZEPINE 300 MG CPMP 12HR CARBAMAZEPINE ER CARBAMAZEPINE 400 MG TAB ER 12H CARBATROL CARBAMAZEPINE 100 MG CPMP 12HR CARBATROL CARBAMAZEPINE 200 MG CPMP 12HR CARBATROL CARBAMAZEPINE 300 MG CPMP 12HR CARBIDOPA LEVODOPA CARBIDOPA/LEVODOPA 10MG TABLET 100MG CARBIDOPA LEVODOPA CARBIDOPA/LEVODOPA 25MG TABLET 100MG CARBIDOPA LEVODOPA CARBIDOPA/LEVODOPA 25MG 250MG TABLET 255_FormularyMaintenance_December2018 Page 5 of 35

CARBIDOPA LEVODOPA CARBIDOPA/LEVODOPA 50MG TABLET ER 200MG CARBIDOPA LEVODOPA CARBIDOPA/LEVODOPA 25MG TABLET ER ER 100MG CARBIDOPA LEVODOPA CARBIDOPA/LEVODOPA/ENTACAPONE 12.5 50 MG TABLET ENTACAPONE CARBIDOPA LEVODOPA CARBIDOPA/LEVODOPA/ENTACAPONE 18.75 75MG TABLET ENTACAPONE CARBIDOPA LEVODOPA CARBIDOPA/LEVODOPA/ENTACAPONE 25 100 200 TABLET ENTACAPONE CARBIDOPA LEVODOPA CARBIDOPA/LEVODOPA/ENTACAPONE 31.25 125 TABLET ENTACAPONE CARBIDOPA LEVODOPA CARBIDOPA/LEVODOPA/ENTACAPONE 37.5 150MG TABLET ENTACAPONE CARBIDOPA LEVODOPA CARBIDOPA/LEVODOPA/ENTACAPONE 50 200 200 TABLET ENTACAPONE CARNITOR SF LEVOCARNITINE 100 MG/ML SOLUTION CARVEDILOL CARVEDILOL 12.5 MG TABLET CARVEDILOL CARVEDILOL 25 MG TABLET CARVEDILOL CARVEDILOL 3.125 MG TABLET CARVEDILOL CARVEDILOL 6.25 MG TABLET CAZIANT DESOGESTREL ETHINYL ESTRADIOL 7 DAYS X 3 TABLET CELECOXIB CELECOXIB 100 MG CAPSULE CELECOXIB CELECOXIB 200 MG CAPSULE CELECOXIB CELECOXIB 50 MG CAPSULE CHILDREN'S IBUPROFEN IBUPROFEN 100 MG/5ML ORAL SUSP CHLOROTHIAZIDE CHLOROTHIAZIDE 250 MG TABLET CHLOROTHIAZIDE CHLOROTHIAZIDE 500 MG TABLET CHLORTHALIDONE CHLORTHALIDONE 25 MG TABLET CHLORTHALIDONE CHLORTHALIDONE 50 MG TABLET CHOLESTYRAMINE CHOLESTYRAMINE (WITH SUGAR) 4 G POWD PACK CHOLESTYRAMINE CHOLESTYRAMINE (WITH SUGAR) 4 G POWDER CHOLESTYRAMINE LIGHT CHOLESTYRAMINE/ASPARTAME 4 G POWD PACK CHOLESTYRAMINE LIGHT CHOLESTYRAMINE/ASPARTAME 4 G POWDER CILOSTAZOL CILOSTAZOL 100 MG TABLET CILOSTAZOL CILOSTAZOL 50 MG TABLET CIMETIDINE CIMETIDINE 200 MG TABLET CIMETIDINE CIMETIDINE 300 MG TABLET CIMETIDINE CIMETIDINE 400 MG TABLET 255_FormularyMaintenance_December2018 Page 6 of 35

CIMETIDINE CIMETIDINE 800 MG TABLET CIMETIDINE CIMETIDINE HCL 300 MG/5ML SOLUTION CITALOPRAM CITALOPRAM HYDROBROMIDE 10 MG/5 ML SOLUTION CITALOPRAM HBR CITALOPRAM HYDROBROMIDE 10 MG TABLET CITALOPRAM HBR CITALOPRAM HYDROBROMIDE 20 MG TABLET CITALOPRAM HBR CITALOPRAM HYDROBROMIDE 40 MG TABLET CLONAZEPAM CLONAZEPAM 0.5 MG TABLET CLONAZEPAM CLONAZEPAM 1 MG TABLET CLONAZEPAM CLONAZEPAM 2 MG TABLET CLONIDINE CLONIDINE 0.1MG/24HR PATCH TDWK CLONIDINE CLONIDINE 0.2MG/24HR PATCH TDWK CLONIDINE CLONIDINE 0.3MG/24HR PATCH TDWK CLONIDINE HCL CLONIDINE HCL 0.1 MG TABLET CLONIDINE HCL CLONIDINE HCL 0.2 MG TABLET CLONIDINE HCL CLONIDINE HCL 0.3 MG TABLET CLONIDINE HCL ER CLONIDINE HCL 0.1 MG TAB ER 12H CLOPIDOGREL CLOPIDOGREL BISULFATE 75 MG TABLET COLCHICINE COLCHICINE 0.6 MG CAPSULE COLCHICINE COLCHICINE 0.6 MG TABLET COMBIVENT RESPIMAT IPRATROPIUM BROMIDE/ALBUTEROL SULFATE 20 100 MCG MIST INHAL COTELLIC COBIMETINIB FUMARATE 20 MG TABLET COUMADIN WARFARIN SODIUM 1 MG TABLET COUMADIN WARFARIN SODIUM 10 MG TABLET COUMADIN WARFARIN SODIUM 2 MG TABLET COUMADIN WARFARIN SODIUM 2.5 MG TABLET COUMADIN WARFARIN SODIUM 3 MG TABLET COUMADIN WARFARIN SODIUM 4 MG TABLET COUMADIN WARFARIN SODIUM 5 MG TABLET COUMADIN WARFARIN SODIUM 6 MG TABLET COUMADIN WARFARIN SODIUM 7.5 MG TABLET CREON LIPASE/PROTEASE/AMYLASE 12K 38K 60 CAPSULE DR CREON LIPASE/PROTEASE/AMYLASE 24 76 120K CAPSULE DR CREON LIPASE/PROTEASE/AMYLASE 3 9.5 15K CAPSULE DR CREON LIPASE/PROTEASE/AMYLASE 36K 114K CAPSULE DR CREON LIPASE/PROTEASE/AMYLASE 6K 19K 30K CAPSULE DR CYANOCOBALAMIN INJECTION CYANOCOBALAMIN (VITAMIN B 12) 1000MCG/ML VIAL 255_FormularyMaintenance_December2018 Page 7 of 35

CYCLOSPORINE CYCLOSPORINE, MODIFIED 100 MG CAPSULE CYCLOSPORINE CYCLOSPORINE, MODIFIED 25 MG CAPSULE CYCLOSPORINE MODIFIED CYCLOSPORINE, MODIFIED 50 MG CAPSULE CYRAMZA RAMUCIRUMAB 100MG/10ML VIAL CYTOMEL LIOTHYRONINE SODIUM 25 MCG TABLET CYTOMEL LIOTHYRONINE SODIUM 5 MCG TABLET CYTOMEL LIOTHYRONINE SODIUM 50 MCG TABLET DAPSONE DAPSONE 100 MG TABLET DAPSONE DAPSONE 25 MG TABLET DEPAKENE VALPROIC ACID 250 MG CAPSULE DEPAKENE VALPROIC ACID (AS SODIUM SALT) (VALPROATE 250 MG/5ML SOLUTION SODIUM) DEPAKOTE DIVALPROEX SODIUM 125 MG TABLET DR DEPAKOTE DIVALPROEX SODIUM 250 MG TABLET DR DEPAKOTE DIVALPROEX SODIUM 500 MG TABLET DR DEPAKOTE ER DIVALPROEX SODIUM 250 MG TAB ER 24H DEPAKOTE ER DIVALPROEX SODIUM 500 MG TAB ER 24H DEPAKOTE SPRINKLE DIVALPROEX SODIUM 125 MG CAP DR SPR DEPO PROVERA MEDROXYPROGESTERONE ACETATE 400 MG/ML VIAL DESIPRAMINE HCL DESIPRAMINE HCL 10 MG TABLET DESIPRAMINE HCL DESIPRAMINE HCL 100 MG TABLET DESIPRAMINE HCL DESIPRAMINE HCL 150 MG TABLET DESIPRAMINE HCL DESIPRAMINE HCL 25 MG TABLET DESIPRAMINE HCL DESIPRAMINE HCL 50 MG TABLET DESIPRAMINE HCL DESIPRAMINE HCL 75 MG TABLET DESMOPRESSIN ACETATE DESMOPRESSIN ACETATE 0.1 MG TABLET DESMOPRESSIN ACETATE DESMOPRESSIN ACETATE 0.2 MG TABLET DEXMETHYLPHENIDATE DEXMETHYLPHENIDATE HCL 10 MG TABLET HCL DEXMETHYLPHENIDATE DEXMETHYLPHENIDATE HCL 2.5 MG TABLET HCL DEXMETHYLPHENIDATE DEXMETHYLPHENIDATE HCL 5 MG TABLET HCL DEXMETHYLPHENIDATE DEXMETHYLPHENIDATE HCL 10 MG CPBP 50 50 HCL ER DEXMETHYLPHENIDATE DEXMETHYLPHENIDATE HCL 15 MG CPBP 50 50 HCL ER DEXMETHYLPHENIDATE HCL ER DEXMETHYLPHENIDATE HCL 20 MG CPBP 50 50 255_FormularyMaintenance_December2018 Page 8 of 35

DEXMETHYLPHENIDATE DEXMETHYLPHENIDATE HCL 25 MG CPBP 50 50 HCL ER DEXMETHYLPHENIDATE DEXMETHYLPHENIDATE HCL 30 MG CPBP 50 50 HCL ER DEXMETHYLPHENIDATE DEXMETHYLPHENIDATE HCL 35 MG CPBP 50 50 HCL ER DEXMETHYLPHENIDATE DEXMETHYLPHENIDATE HCL 40 MG CPBP 50 50 HCL ER DEXMETHYLPHENIDATE DEXMETHYLPHENIDATE HCL 5 MG CPBP 50 50 HCL ER DEXTROAMPHETAMINE DEXTROAMPHETAMINE SULFATE 10 MG CAPSULE ER SULFATE DEXTROAMPHETAMINE DEXTROAMPHETAMINE SULFATE 10 MG TABLET SULFATE DEXTROAMPHETAMINE DEXTROAMPHETAMINE SULFATE 5 MG CAPSULE ER SULFATE DEXTROAMPHETAMINE DEXTROAMPHETAMINE SULFATE 5 MG TABLET SULFATE DEXTROAMPHETAMINE DEXTROAMPHETAMINE SULFATE 15 MG CAPSULE ER SULFATE ER DEXTROAMPHETAMINE DEXTROAMPHETAMINE SULF 10 MG CAP ER 24H AMPHET ER SACCHARATE/AMPHETAMINE SULF ASPARTATE DEXTROAMPHETAMINE DEXTROAMPHETAMINE SULF 15 MG CAP ER 24H AMPHET ER SACCHARATE/AMPHETAMINE SULF ASPARTATE DEXTROAMPHETAMINE DEXTROAMPHETAMINE SULF 20 MG CAP ER 24H AMPHET ER SACCHARATE/AMPHETAMINE SULF ASPARTATE DEXTROAMPHETAMINE DEXTROAMPHETAMINE SULF 25 MG CAP ER 24H AMPHET ER SACCHARATE/AMPHETAMINE SULF ASPARTATE DEXTROAMPHETAMINE DEXTROAMPHETAMINE SULF 30 MG CAP ER 24H AMPHET ER SACCHARATE/AMPHETAMINE SULF ASPARTATE DEXTROAMPHETAMINE DEXTROAMPHETAMINE SULF 5 MG CAP ER 24H AMPHET ER SACCHARATE/AMPHETAMINE SULF ASPARTATE DEXTROAMPHETAMINE DEXTROAMPHETAMINE SULF 15 MG TABLET AMPHETAMINE SACCHARATE/AMPHETAMINE SULF ASPARTATE DEXTROAMPHETAMINE DEXTROAMPHETAMINE SULF 30 MG TABLET AMPHETAMINE SACCHARATE/AMPHETAMINE SULF ASPARTATE DEXTROAMPHETAMINE DEXTROAMPHETAMINE SULF 5 MG TABLET AMPHETAMINE SACCHARATE/AMPHETAMINE SULF ASPARTATE DEXTROAMPHETAMINE DEXTROAMPHETAMINE SULF 7.5 MG TABLET AMPHETAMINE SACCHARATE/AMPHETAMINE SULF ASPARTATE DIASTIX REAGENT URINE GLUCOSE TEST STRIP STRIP DICLOFENAC SODIUM DICLOFENAC SODIUM 1 % GEL (GRAM) 255_FormularyMaintenance_December2018 Page 9 of 35

DICYCLOMINE HCL DICYCLOMINE HCL 10 MG CAPSULE DICYCLOMINE HCL DICYCLOMINE HCL 10 MG/5 ML SOLUTION DICYCLOMINE HCL DICYCLOMINE HCL 20 MG TABLET DIGOXIN DIGOXIN 125 MCG TABLET DIGOXIN DIGOXIN 250 MCG TABLET DIGOXIN DIGOXIN 50 MCG/ML SOLUTION DILANTIN PHENYTOIN 50 MG TAB CHEW DILANTIN PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE DILANTIN PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE DILANTIN 125 PHENYTOIN 125 MG/5ML ORAL SUSP DILATRATE SR ISOSORBIDE DINITRATE 40 MG CAPSULE ER DILT XR DILTIAZEM HCL 120 MG CAP ER DEG DILT XR DILTIAZEM HCL 180 MG CAP ER DEG DILT XR DILTIAZEM HCL 240 MG CAP ER DEG DILTIAZEM 12HR ER DILTIAZEM HCL 120 MG CAP ER 12H DILTIAZEM 12HR ER DILTIAZEM HCL 60 MG CAP ER 12H DILTIAZEM 12HR ER DILTIAZEM HCL 90 MG CAP ER 12H DILTIAZEM 24HR CD DILTIAZEM HCL 120 MG CAP ER 24H DILTIAZEM 24HR CD DILTIAZEM HCL 180 MG CAP ER 24H DILTIAZEM 24HR CD DILTIAZEM HCL 240 MG CAP ER 24H DILTIAZEM 24HR CD DILTIAZEM HCL 300 MG CAP ER 24H DILTIAZEM 24HR CD DILTIAZEM HCL 360 MG CAP ER 24H DILTIAZEM 24HR ER DILTIAZEM HCL 360 MG CAP SA 24H DILTIAZEM 24HR ER DILTIAZEM HCL 420 MG CAP SA 24H DILTIAZEM HCL DILTIAZEM HCL 120 MG TABLET DILTIAZEM HCL DILTIAZEM HCL 30 MG TABLET DILTIAZEM HCL DILTIAZEM HCL 60 MG TABLET DILTIAZEM HCL DILTIAZEM HCL 90 MG TABLET DISULFIRAM DISULFIRAM 250 MG TABLET DISULFIRAM DISULFIRAM 500 MG TABLET DIURIL CHLOROTHIAZIDE 250 MG/5ML ORAL SUSP DIVALPROEX SODIUM DIVALPROEX SODIUM 125 MG CAP DR SPR DIVALPROEX SODIUM DIVALPROEX SODIUM 125 MG TABLET DR DIVALPROEX SODIUM DIVALPROEX SODIUM 250 MG TABLET DR DIVALPROEX SODIUM DIVALPROEX SODIUM 500 MG TABLET DR DIVALPROEX SODIUM ER DIVALPROEX SODIUM 250 MG TAB ER 24H DIVALPROEX SODIUM ER DIVALPROEX SODIUM 500 MG TAB ER 24H 255_FormularyMaintenance_December2018 Page 10 of 35

DONEPEZIL HCL DONEPEZIL HCL 10 MG TABLET DONEPEZIL HCL DONEPEZIL HCL 5 MG TABLET DONEPEZIL HCL ODT DONEPEZIL HCL 10 MG TAB RAPDIS DONEPEZIL HCL ODT DONEPEZIL HCL 5 MG TAB RAPDIS DORZOLAMIDE HCL DORZOLAMIDE HCL 2 % DROPS DORZOLAMIDE TIMOLOL DORZOLAMIDE HCL/TIMOLOL MALEATE 22.3 6.8/1 DROPS DOXAZOSIN MESYLATE DOXAZOSIN MESYLATE 1 MG TABLET DOXAZOSIN MESYLATE DOXAZOSIN MESYLATE 2 MG TABLET DOXAZOSIN MESYLATE DOXAZOSIN MESYLATE 4 MG TABLET DOXAZOSIN MESYLATE DOXAZOSIN MESYLATE 8 MG TABLET DOXEPIN HCL DOXEPIN HCL 10 MG CAPSULE DOXEPIN HCL DOXEPIN HCL 100 MG CAPSULE DOXEPIN HCL DOXEPIN HCL 150 MG CAPSULE DOXEPIN HCL DOXEPIN HCL 25 MG CAPSULE DOXEPIN HCL DOXEPIN HCL 50 MG CAPSULE DOXEPIN HCL DOXEPIN HCL 75 MG CAPSULE DROSPIRENONE ETH DROSPIRENONE/ETHINYL 3 0.02(24) TABLET ESTRA LEVOMEF ESTRADIOL/LEVOMEFOLATE CALCIUM DULOXETINE HCL DULOXETINE HCL 20 MG CAPSULE DR DULOXETINE HCL DULOXETINE HCL 30 MG CAPSULE DR DULOXETINE HCL DULOXETINE HCL 60 MG CAPSULE DR DYRENIUM TRIAMTERENE 50 MG CAPSULE EFFER K POTASSIUM BICARBONATE/CITRIC ACID 10 MEQ TABLET EFF EFFER K POTASSIUM BICARBONATE/CITRIC ACID 20 MEQ TABLET EFF EFFER K POTASSIUM BICARBONATE/CITRIC ACID 25 MEQ TABLET EFF ELIGARD LEUPROLIDE ACETATE 22.5 MG SYRINGE ELIGARD LEUPROLIDE ACETATE 30 MG SYRINGE ELIGARD LEUPROLIDE ACETATE 45 MG SYRINGE ELIGARD LEUPROLIDE ACETATE 7.5 MG SYRINGE ELIQUIS APIXABAN 2.5 MG TABLET ELIQUIS APIXABAN 5 MG TABLET EMOQUETTE DESOGESTREL ETHINYL ESTRADIOL 0.15 0.03 TABLET ENALAPRIL MALEATE ENALAPRIL MALEATE 10 MG TABLET ENALAPRIL MALEATE ENALAPRIL MALEATE 2.5 MG TABLET ENALAPRIL MALEATE ENALAPRIL MALEATE 20 MG TABLET ENALAPRIL MALEATE ENALAPRIL MALEATE 5 MG TABLET ENTACAPONE ENTACAPONE 200 MG TABLET 255_FormularyMaintenance_December2018 Page 11 of 35

ENULOSE LACTULOSE 10 G/15 ML SOLUTION EPOGEN EPOETIN ALFA 10000/ML VIAL EPOGEN EPOETIN ALFA 2000/ML VIAL EPOGEN EPOETIN ALFA 20000/2ML VIAL EPOGEN EPOETIN ALFA 20000/ML VIAL EPOGEN EPOETIN ALFA 3000/ML VIAL EPOGEN EPOETIN ALFA 4000/ML VIAL ERGOCALCIFEROL ERGOCALCIFEROL (VITAMIN D2) 50000 UNIT CAPSULE (VITAMIN D2) ESCITALOPRAM OXALATE ESCITALOPRAM OXALATE 10 MG TABLET ESCITALOPRAM OXALATE ESCITALOPRAM OXALATE 20 MG TABLET ESCITALOPRAM OXALATE ESCITALOPRAM OXALATE 5 MG TABLET ESOMEPRAZOLE ESOMEPRAZOLE MAGNESIUM 20 MG CAPSULE DR MAGNESIUM ESOMEPRAZOLE ESOMEPRAZOLE MAGNESIUM 40 MG CAPSULE DR MAGNESIUM ESTRADIOL ESTRADIOL.025MG/24H PATCH TDSW ESTRADIOL ESTRADIOL.025MG/24H PATCH TDWK ESTRADIOL ESTRADIOL.0375MG/24 PATCH TDSW ESTRADIOL ESTRADIOL.0375MG/24 PATCH TDWK ESTRADIOL ESTRADIOL.075MG/24H PATCH TDSW ESTRADIOL ESTRADIOL.075MG/24H PATCH TDWK ESTRADIOL ESTRADIOL 0.01 % CREAM/APPL ESTRADIOL ESTRADIOL 0.05MG/24H PATCH TDSW ESTRADIOL ESTRADIOL 0.05MG/24H PATCH TDWK ESTRADIOL ESTRADIOL 0.06MG/24H PATCH TDWK ESTRADIOL ESTRADIOL 0.1MG/24HR PATCH TDSW ESTRADIOL ESTRADIOL 0.1MG/24HR PATCH TDWK ESTRADIOL ESTRADIOL 0.5 MG TABLET ESTRADIOL ESTRADIOL 1 MG TABLET ESTRADIOL ESTRADIOL 2 MG TABLET ESTROGEN ESTROGENS,ESTERIFIED/METHYLTESTOSTERONE 0.625 1.25 TABLET METHYLTESTOSTERONE ESTROGEN ESTROGENS,ESTERIFIED/METHYLTESTOSTERONE 1.25 2.5MG TABLET METHYLTESTOSTERONE ETHACRYNIC ACID ETHACRYNIC ACID 25 MG TABLET ETHOSUXIMIDE ETHOSUXIMIDE 250 MG CAPSULE ETHOSUXIMIDE ETHOSUXIMIDE 250 MG/5ML SOLUTION 255_FormularyMaintenance_December2018 Page 12 of 35

ETHYNODIOL ETHINYL ETHYNODIOL DIACETATE ETHINYL ESTRADIOL 1 MG 50MCG TABLET ESTRADIOL ETODOLAC ETODOLAC 200 MG CAPSULE ETODOLAC ETODOLAC 300 MG CAPSULE ETODOLAC ETODOLAC 400 MG TABLET ETODOLAC ETODOLAC 500 MG TABLET EZETIMIBE EZETIMIBE 10 MG TABLET FAMCICLOVIR FAMCICLOVIR 125 MG TABLET FAMCICLOVIR FAMCICLOVIR 250 MG TABLET FAMCICLOVIR FAMCICLOVIR 500 MG TABLET FAMOTIDINE FAMOTIDINE 10 MG TABLET FAMOTIDINE FAMOTIDINE 20 MG TABLET FAMOTIDINE FAMOTIDINE 40 MG TABLET FAMOTIDINE FAMOTIDINE 40MG/5ML ORAL SUSP FELODIPINE ER FELODIPINE 10 MG TAB ER 24H FELODIPINE ER FELODIPINE 2.5 MG TAB ER 24H FELODIPINE ER FELODIPINE 5 MG TAB ER 24H FENOFIBRATE FENOFIBRATE 160 MG TABLET FENOFIBRATE FENOFIBRATE 54 MG TABLET FENOFIBRATE FENOFIBRATE NANOCRYSTALLIZED 145MG TABLET FENOFIBRATE FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET FENOFIBRATE FENOFIBRATE,MICRONIZED 134 MG CAPSULE FENOFIBRATE FENOFIBRATE,MICRONIZED 200 MG CAPSULE FENOFIBRATE FENOFIBRATE,MICRONIZED 67 MG CAPSULE FENOFIBRIC ACID FENOFIBRIC ACID (CHOLINE) 135 MG CAPSULE DR FENOFIBRIC ACID FENOFIBRIC ACID (CHOLINE) 45 MG CAPSULE DR FINASTERIDE FINASTERIDE 5 MG TABLET FLECAINIDE ACETATE FLECAINIDE ACETATE 100 MG TABLET FLECAINIDE ACETATE FLECAINIDE ACETATE 150 MG TABLET FLECAINIDE ACETATE FLECAINIDE ACETATE 50 MG TABLET FLOVENT DISKUS FLUTICASONE PROPIONATE 100 MCG BLST W/DEV FLOVENT DISKUS FLUTICASONE PROPIONATE 250 MCG BLST W/DEV FLOVENT DISKUS FLUTICASONE PROPIONATE 50 MCG BLST W/DEV FLOVENT HFA FLUTICASONE PROPIONATE 110 MCG AER W/ADAP FLOVENT HFA FLUTICASONE PROPIONATE 220 MCG AER W/ADAP FLOVENT HFA FLUTICASONE PROPIONATE 44 MCG AER W/ADAP 255_FormularyMaintenance_December2018 Page 13 of 35

FLUDROCORTISONE FLUDROCORTISONE ACETATE 0.1 MG TABLET ACETATE FLUORIDE FLUORIDE (SODIUM) 0.25(0.55) TAB CHEW FLUORIDE FLUORIDE (SODIUM) 0.5(1.1)MG TAB CHEW FLUORITAB FLUORIDE (SODIUM) 1MG(2.2MG) TAB CHEW FLUOXETINE HCL FLUOXETINE HCL 10 MG CAPSULE FLUOXETINE HCL FLUOXETINE HCL 20 MG CAPSULE FLUOXETINE HCL FLUOXETINE HCL 20 MG/5 ML SOLUTION FLUOXETINE HCL FLUOXETINE HCL 40 MG CAPSULE FLUTAMIDE FLUTAMIDE 125 MG CAPSULE FLUTICASONE FLUTICASONE PROPIONATE/SALMETEROL 113 14 MCG AER POW BA SALMETEROL XINAFOATE FLUTICASONE FLUTICASONE PROPIONATE/SALMETEROL 232 14 MCG AER POW BA SALMETEROL XINAFOATE FLUTICASONE FLUTICASONE PROPIONATE/SALMETEROL 55 14 MCG AER POW BA SALMETEROL XINAFOATE FLUVOXAMINE MALEATE FLUVOXAMINE MALEATE 100 MG TABLET FLUVOXAMINE MALEATE FLUVOXAMINE MALEATE 25 MG TABLET FLUVOXAMINE MALEATE FLUVOXAMINE MALEATE 50 MG TABLET FOLIC ACID FOLIC ACID 0.4 MG TABLET FOLIC ACID FOLIC ACID 1 MG TABLET FUROSEMIDE FUROSEMIDE 10 MG/ML SOLUTION FUROSEMIDE FUROSEMIDE 20 MG TABLET FUROSEMIDE FUROSEMIDE 40 MG TABLET FUROSEMIDE FUROSEMIDE 40MG/5ML SOLUTION FUROSEMIDE FUROSEMIDE 80 MG TABLET GABAPENTIN GABAPENTIN 100 MG CAPSULE GABAPENTIN GABAPENTIN 300 MG CAPSULE GABAPENTIN GABAPENTIN 400 MG CAPSULE GABAPENTIN GABAPENTIN 600 MG TABLET GABAPENTIN GABAPENTIN 800 MG TABLET GALANTAMINE HBR GALANTAMINE HBR 12 MG TABLET GALANTAMINE HBR GALANTAMINE HBR 4 MG TABLET GALANTAMINE HBR GALANTAMINE HBR 8 MG TABLET GEMFIBROZIL GEMFIBROZIL 600 MG TABLET GIANVI ETHINYL ESTRADIOL/DROSPIRENONE 0.02 3(24) TABLET GLIMEPIRIDE GLIMEPIRIDE 1 MG TABLET GLIMEPIRIDE GLIMEPIRIDE 2 MG TABLET 255_FormularyMaintenance_December2018 Page 14 of 35

GLIMEPIRIDE GLIMEPIRIDE 4 MG TABLET GLIPIZIDE GLIPIZIDE 10 MG TABLET GLIPIZIDE GLIPIZIDE 5 MG TABLET GLIPIZIDE ER GLIPIZIDE 10 MG TAB ER 24 GLIPIZIDE ER GLIPIZIDE 2.5 MG TAB ER 24 GLIPIZIDE ER GLIPIZIDE 5 MG TAB ER 24 GLIPIZIDE METFORMIN GLIPIZIDE/METFORMIN HCL 2.5 250 MG TABLET GLIPIZIDE METFORMIN GLIPIZIDE/METFORMIN HCL 2.5 500 MG TABLET GLIPIZIDE METFORMIN GLIPIZIDE/METFORMIN HCL 5 MG 500MG TABLET GLYBURIDE GLYBURIDE 1.25 MG TABLET GLYBURIDE GLYBURIDE 2.5 MG TABLET GLYBURIDE GLYBURIDE 5 MG TABLET GLYBURIDE METFORMIN GLYBURIDE/METFORMIN HCL 1.25 250MG TABLET HCL GLYBURIDE METFORMIN GLYBURIDE/METFORMIN HCL 2.5 500 MG TABLET HCL GLYBURIDE METFORMIN GLYBURIDE/METFORMIN HCL 5 MG 500MG TABLET HCL GUANFACINE HCL GUANFACINE HCL 1 MG TABLET GUANFACINE HCL GUANFACINE HCL 2 MG TABLET GUANFACINE HCL ER GUANFACINE HCL 1 MG TAB ER 24H GUANFACINE HCL ER GUANFACINE HCL 2 MG TAB ER 24H GUANFACINE HCL ER GUANFACINE HCL 3 MG TAB ER 24H GUANFACINE HCL ER GUANFACINE HCL 4 MG TAB ER 24H HERCEPTIN TRASTUZUMAB 440 MG VIAL HOMATROPAIRE HOMATROPINE HBR 5 % DROPS HYDRALAZINE HCL HYDRALAZINE HCL 10 MG TABLET HYDRALAZINE HCL HYDRALAZINE HCL 100 MG TABLET HYDRALAZINE HCL HYDRALAZINE HCL 25 MG TABLET HYDRALAZINE HCL HYDRALAZINE HCL 50 MG TABLET 12.5 MG CAPSULE 12.5 MG TABLET 25 MG TABLET 50 MG TABLET HYDROCORTISONE HYDROCORTISONE 10 MG TABLET HYDROCORTISONE HYDROCORTISONE 20 MG TABLET HYDROCORTISONE HYDROCORTISONE 5 MG TABLET 255_FormularyMaintenance_December2018 Page 15 of 35

HYDROXYCHLOROQUINE HYDROXYCHLOROQUINE SULFATE 200 MG TABLET SULFATE HYDROXYUREA HYDROXYUREA 500 MG CAPSULE IBANDRONATE SODIUM IBANDRONATE SODIUM 150 MG TABLET IBUPROFEN IBUPROFEN 200 MG CAPSULE IBUPROFEN IBUPROFEN 200 MG TABLET IBUPROFEN IBUPROFEN 400 MG TABLET IBUPROFEN IBUPROFEN 600 MG TABLET IBUPROFEN IBUPROFEN 800 MG TABLET IMIPRAMINE HCL IMIPRAMINE HCL 10 MG TABLET IMIPRAMINE HCL IMIPRAMINE HCL 25 MG TABLET IMIPRAMINE HCL IMIPRAMINE HCL 50 MG TABLET INCRUSE ELLIPTA UMECLIDINIUM BROMIDE 62.5 MCG BLST W/DEV INDAPAMIDE INDAPAMIDE 1.25 MG TABLET INDAPAMIDE INDAPAMIDE 2.5 MG TABLET INVOKAMET CANAGLIFLOZIN/METFORMIN HCL 150 1000MG TABLET INVOKAMET CANAGLIFLOZIN/METFORMIN HCL 150 500 MG TABLET INVOKAMET CANAGLIFLOZIN/METFORMIN HCL 50 1000 MG TABLET INVOKAMET CANAGLIFLOZIN/METFORMIN HCL 50MG TABLET 500MG INVOKAMET XR CANAGLIFLOZIN/METFORMIN HCL 150 1000MG TAB BP 24H INVOKAMET XR CANAGLIFLOZIN/METFORMIN HCL 150 500 MG TAB BP 24H INVOKAMET XR CANAGLIFLOZIN/METFORMIN HCL 50 1000 MG TAB BP 24H INVOKAMET XR CANAGLIFLOZIN/METFORMIN HCL 50MG TAB BP 24H 500MG INVOKANA CANAGLIFLOZIN 100 MG TABLET INVOKANA CANAGLIFLOZIN 300 MG TABLET IPRATROPIUM BROMIDE IPRATROPIUM BROMIDE 0.2 MG/ML SOLUTION IPRATROPIUM IPRATROPIUM BROMIDE/ALBUTEROL SULFATE 0.5 3MG/3 AMPUL NEB ALBUTEROL IRBESARTAN IRBESARTAN 150 MG TABLET IRBESARTAN IRBESARTAN 300 MG TABLET IRBESARTAN IRBESARTAN 75 MG TABLET IRBESARTAN IRBESARTAN/ 150 12.5MG TABLET IRBESARTAN IRBESARTAN/ 300 12.5MG TABLET ISORDIL ISOSORBIDE DINITRATE 40 MG TABLET 255_FormularyMaintenance_December2018 Page 16 of 35

ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE 10 MG TABLET ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE 20 MG TABLET ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE 30 MG TABLET ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE 5 MG TABLET ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE 40 MG TABLET ER ER ISOSORBIDE ISOSORBIDE MONONITRATE 10 MG TABLET MONONITRATE ISOSORBIDE ISOSORBIDE MONONITRATE 120 MG TAB ER 24H MONONITRATE ISOSORBIDE ISOSORBIDE MONONITRATE 20 MG TABLET MONONITRATE ISOSORBIDE ISOSORBIDE MONONITRATE 30 MG TAB ER 24H MONONITRATE ISOSORBIDE ISOSORBIDE MONONITRATE 60 MG TAB ER 24H MONONITRATE JANTOVEN WARFARIN SODIUM 1 MG TABLET JANTOVEN WARFARIN SODIUM 10 MG TABLET JANTOVEN WARFARIN SODIUM 2 MG TABLET JANTOVEN WARFARIN SODIUM 2.5 MG TABLET JANTOVEN WARFARIN SODIUM 3 MG TABLET JANTOVEN WARFARIN SODIUM 4 MG TABLET JANTOVEN WARFARIN SODIUM 5 MG TABLET JANTOVEN WARFARIN SODIUM 6 MG TABLET JANTOVEN WARFARIN SODIUM 7.5 MG TABLET JINTELI NORETHINDRONE ACETATE ETHINYL ESTRADIOL 1MG 5MCG TABLET JUNEL FE NORETHINDRONE ACETATE ETHINYL 1.5 30(21) TABLET ESTRADIOL/FERROUS FUMARATE JUNEL FE NORETHINDRONE ACETATE ETHINYL 1MG 20(21) TABLET ESTRADIOL/FERROUS FUMARATE KETO DIASTIX REAGENT URINE GLUCOSE ACET TEST STRIP STRIP KETONE TEST STRIP URINE ACETONE TEST,STRIPS STRIP LABETALOL HCL LABETALOL HCL 100 MG TABLET LABETALOL HCL LABETALOL HCL 200 MG TABLET LABETALOL HCL LABETALOL HCL 300 MG TABLET LACTULOSE LACTULOSE 10 G/15 ML SOLUTION LAMOTRIGINE LAMOTRIGINE 100 MG TABLET LAMOTRIGINE LAMOTRIGINE 150 MG TABLET LAMOTRIGINE LAMOTRIGINE 200 MG TABLET 255_FormularyMaintenance_December2018 Page 17 of 35

LAMOTRIGINE LAMOTRIGINE 25 MG TABLET LAMOTRIGINE LAMOTRIGINE 25 MG TB CHW DSP LAMOTRIGINE LAMOTRIGINE 5 MG TB CHW DSP LANOXIN DIGOXIN 125 MCG TABLET LANOXIN DIGOXIN 250 MCG TABLET LANSOPRAZOLE LANSOPRAZOLE 15 MG CAPSULE DR LANSOPRAZOLE LANSOPRAZOLE 30 MG CAPSULE DR LARTRUVO OLARATUMAB 190MG/19ML VIAL LATANOPROST LATANOPROST 0.005 % DROPS LEENA NORETHINDRONE ETHINYL ESTRADIOL 7 9 5 TABLET LEFLUNOMIDE LEFLUNOMIDE 10 MG TABLET LEFLUNOMIDE LEFLUNOMIDE 20 MG TABLET LEVALBUTEROL LEVALBUTEROL HCL 1.25MG/0.5 VIAL NEB CONCENTRATE LEVALBUTEROL HCL LEVALBUTEROL HCL 0.31MG/3ML VIAL NEB LEVALBUTEROL HCL LEVALBUTEROL HCL 0.63MG/3ML VIAL NEB LEVALBUTEROL HCL LEVALBUTEROL HCL 1.25MG/3ML VIAL NEB LEVETIRACETAM LEVETIRACETAM 100 MG/ML SOLUTION LEVETIRACETAM LEVETIRACETAM 1000 MG TABLET LEVETIRACETAM LEVETIRACETAM 250 MG TABLET LEVETIRACETAM LEVETIRACETAM 500 MG TABLET LEVETIRACETAM LEVETIRACETAM 750 MG TABLET LEVETIRACETAM ER LEVETIRACETAM 500 MG TAB ER 24H LEVETIRACETAM ER LEVETIRACETAM 750 MG TAB ER 24H LEVO T LEVOTHYROXINE SODIUM 100 MCG TABLET LEVO T LEVOTHYROXINE SODIUM 112 MCG TABLET LEVO T LEVOTHYROXINE SODIUM 125 MCG TABLET LEVO T LEVOTHYROXINE SODIUM 137 MCG TABLET LEVO T LEVOTHYROXINE SODIUM 150 MCG TABLET LEVO T LEVOTHYROXINE SODIUM 175MCG TABLET LEVO T LEVOTHYROXINE SODIUM 200 MCG TABLET LEVO T LEVOTHYROXINE SODIUM 25 MCG TABLET LEVO T LEVOTHYROXINE SODIUM 300 MCG TABLET LEVO T LEVOTHYROXINE SODIUM 50 MCG TABLET LEVO T LEVOTHYROXINE SODIUM 75 MCG TABLET LEVO T LEVOTHYROXINE SODIUM 88 MCG TABLET LEVOBUNOLOL HCL LEVOBUNOLOL HCL 0.5 % DROPS 255_FormularyMaintenance_December2018 Page 18 of 35

LEVONORG ETH ESTRAD LEVONORGESTREL/ETHINYL ESTRADIOL AND 100 20(84) TBDSPK 3MO ETH ESTRAD ETHINYL ESTRADIOL LEVONORGESTREL ETH LEVONORGESTREL ETHINYL ESTRADIOL 90 20 MCG TABLET ESTRADIOL LEVORA 28 LEVONORGESTREL ETHINYL ESTRADIOL 0.15 0.03 TABLET LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 100 MCG TABLET LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 112 MCG TABLET LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 125 MCG TABLET LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 137 MCG TABLET LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 150 MCG TABLET LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 175MCG TABLET LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 200 MCG TABLET LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 25 MCG TABLET LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 300 MCG TABLET LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 50 MCG TABLET LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 75 MCG TABLET LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 88 MCG TABLET LEVOXYL LEVOTHYROXINE SODIUM 100 MCG TABLET LEVOXYL LEVOTHYROXINE SODIUM 112 MCG TABLET LEVOXYL LEVOTHYROXINE SODIUM 125 MCG TABLET LEVOXYL LEVOTHYROXINE SODIUM 137 MCG TABLET LEVOXYL LEVOTHYROXINE SODIUM 150 MCG TABLET LEVOXYL LEVOTHYROXINE SODIUM 175MCG TABLET LEVOXYL LEVOTHYROXINE SODIUM 200 MCG TABLET LEVOXYL LEVOTHYROXINE SODIUM 25 MCG TABLET LEVOXYL LEVOTHYROXINE SODIUM 50 MCG TABLET LEVOXYL LEVOTHYROXINE SODIUM 75 MCG TABLET LEVOXYL LEVOTHYROXINE SODIUM 88 MCG TABLET LIOTHYRONINE SODIUM LIOTHYRONINE SODIUM 25 MCG TABLET LIOTHYRONINE SODIUM LIOTHYRONINE SODIUM 5 MCG TABLET LIOTHYRONINE SODIUM LIOTHYRONINE SODIUM 50 MCG TABLET LISINOPRIL LISINOPRIL 10 MG TABLET LISINOPRIL LISINOPRIL 2.5 MG TABLET LISINOPRIL LISINOPRIL 20 MG TABLET LISINOPRIL LISINOPRIL 30 MG TABLET LISINOPRIL LISINOPRIL 40 MG TABLET LISINOPRIL LISINOPRIL 5 MG TABLET 255_FormularyMaintenance_December2018 Page 19 of 35

LISINOPRIL LISINOPRIL/ 10 12.5MG TABLET LISINOPRIL LISINOPRIL/ 20 MG 25MG TABLET LISINOPRIL LISINOPRIL/ 20 12.5 MG TABLET LOPERAMIDE LOPERAMIDE HCL 2 MG CAPSULE LOPERAMIDE LOPERAMIDE HCL 2 MG TABLET LOSARTAN POTASSIUM LOSARTAN POTASSIUM 100 MG TABLET LOSARTAN POTASSIUM LOSARTAN POTASSIUM 25 MG TABLET LOSARTAN POTASSIUM LOSARTAN POTASSIUM 50 MG TABLET LOSARTAN LOSARTAN POTASSIUM/ 100 12.5MG TABLET LOSARTAN LOSARTAN POTASSIUM/ 100MG TABLET 25MG LOSARTAN LOSARTAN POTASSIUM/ 50 12.5 MG TABLET LOVASTATIN LOVASTATIN 10 MG TABLET LOVASTATIN LOVASTATIN 20 MG TABLET LOVASTATIN LOVASTATIN 40 MG TABLET LOW OGESTREL NORGESTREL ETHINYL ESTRADIOL 0.3 0.03MG TABLET LYSODREN MITOTANE 500 MG TABLET MEDROXYPROGESTERONE MEDROXYPROGESTERONE ACETATE 10 MG TABLET ACETATE MEDROXYPROGESTERONE MEDROXYPROGESTERONE ACETATE 150 MG/ML SYRINGE ACETATE MEDROXYPROGESTERONE MEDROXYPROGESTERONE ACETATE 150 MG/ML VIAL ACETATE MEDROXYPROGESTERONE MEDROXYPROGESTERONE ACETATE 2.5 MG TABLET ACETATE MEDROXYPROGESTERONE MEDROXYPROGESTERONE ACETATE 5 MG TABLET ACETATE MEGESTROL ACETATE MEGESTROL ACETATE 400MG/10ML ORAL SUSP MELOXICAM MELOXICAM 15 MG TABLET MELOXICAM MELOXICAM 7.5 MG TABLET MEMANTINE HCL MEMANTINE HCL 10 MG TABLET MEMANTINE HCL MEMANTINE HCL 5 MG TABLET MENEST ESTROGENS,ESTERIFIED 0.3 MG TABLET MENEST ESTROGENS,ESTERIFIED 0.625 MG TABLET MENEST ESTROGENS,ESTERIFIED 1.25 MG TABLET 255_FormularyMaintenance_December2018 Page 20 of 35

MERCAPTOPURINE MERCAPTOPURINE 50 MG TABLET MESTINON PYRIDOSTIGMINE BROMIDE 60 MG/5 ML SYRUP METAPROTERENOL METAPROTERENOL SULFATE 10 MG TABLET SULFATE METAPROTERENOL METAPROTERENOL SULFATE 10 MG/5 ML SYRUP SULFATE METAPROTERENOL METAPROTERENOL SULFATE 20 MG TABLET SULFATE METFORMIN HCL METFORMIN HCL 1000 MG TABLET METFORMIN HCL METFORMIN HCL 500 MG TABLET METFORMIN HCL METFORMIN HCL 850 MG TABLET METFORMIN HCL ER METFORMIN HCL 500 MG TAB ER 24H METFORMIN HCL ER METFORMIN HCL 750 MG TAB ER 24H METHIMAZOLE METHIMAZOLE 10 MG TABLET METHIMAZOLE METHIMAZOLE 5 MG TABLET METHOTREXATE METHOTREXATE SODIUM 2.5 MG TABLET METHYLDOPA METHYLDOPA 250 MG TABLET METHYLDOPA METHYLDOPA 500 MG TABLET METHYLDOPA METHYLDOPA/ 250MG TABLET 15MG METHYLDOPA METHYLDOPA/ 250MG TABLET 25MG METHYLPHENIDATE ER METHYLPHENIDATE HCL 10 MG TABLET ER METHYLPHENIDATE ER METHYLPHENIDATE HCL 18 MG TAB ER 24 METHYLPHENIDATE ER METHYLPHENIDATE HCL 20 MG TABLET ER METHYLPHENIDATE ER METHYLPHENIDATE HCL 27 MG TAB ER 24 METHYLPHENIDATE ER METHYLPHENIDATE HCL 36 MG TAB ER 24 METHYLPHENIDATE ER METHYLPHENIDATE HCL 54 MG TAB ER 24 METHYLPHENIDATE ER METHYLPHENIDATE HCL 10 MG CPBP 50 50 (LA) METHYLPHENIDATE ER METHYLPHENIDATE HCL 40 MG CPBP 50 50 (LA) METHYLPHENIDATE HCL METHYLPHENIDATE HCL 10 MG TABLET METHYLPHENIDATE HCL METHYLPHENIDATE HCL 20 MG TABLET METHYLPHENIDATE HCL METHYLPHENIDATE HCL 5 MG TABLET METHYLPHENIDATE HCL METHYLPHENIDATE HCL 10 MG CPBP 30 70 CD METHYLPHENIDATE HCL CD METHYLPHENIDATE HCL 20 MG CPBP 30 70 255_FormularyMaintenance_December2018 Page 21 of 35

METHYLPHENIDATE HCL METHYLPHENIDATE HCL 30 MG CPBP 30 70 CD METHYLPHENIDATE HCL METHYLPHENIDATE HCL 40 MG CPBP 30 70 CD METHYLPHENIDATE HCL METHYLPHENIDATE HCL 50 MG CPBP 30 70 CD METHYLPHENIDATE HCL METHYLPHENIDATE HCL 60 MG CPBP 30 70 CD METHYLPHENIDATE LA METHYLPHENIDATE HCL 20 MG CPBP 50 50 METHYLPHENIDATE LA METHYLPHENIDATE HCL 30 MG CPBP 50 50 METHYLPHENIDATE LA METHYLPHENIDATE HCL 60 MG CPBP 50 50 METIPRANOLOL METIPRANOLOL 0.3 % DROPS METOPROLOL SUCCINATE METOPROLOL SUCCINATE 100 MG TAB ER 24H METOPROLOL SUCCINATE METOPROLOL SUCCINATE 200 MG TAB ER 24H METOPROLOL SUCCINATE METOPROLOL SUCCINATE 25 MG TAB ER 24H METOPROLOL SUCCINATE METOPROLOL SUCCINATE 50 MG TAB ER 24H METOPROLOL TARTRATE METOPROLOL TARTRATE 100 MG TABLET METOPROLOL TARTRATE METOPROLOL TARTRATE 25 MG TABLET METOPROLOL TARTRATE METOPROLOL TARTRATE 50 MG TABLET MEXILETINE HCL MEXILETINE HCL 150 MG CAPSULE MEXILETINE HCL MEXILETINE HCL 200 MG CAPSULE MEXILETINE HCL MEXILETINE HCL 250 MG CAPSULE MICROGESTIN NORETHINDRONE ACETATE ETHINYL ESTRADIOL 1.5 0.03MG TABLET MICROGESTIN NORETHINDRONE ACETATE ETHINYL ESTRADIOL 1MG 20MCG TABLET MINOXIDIL MINOXIDIL 10 MG TABLET MINOXIDIL MINOXIDIL 2.5 MG TABLET MIRTAZAPINE MIRTAZAPINE 15 MG TAB RAPDIS MIRTAZAPINE MIRTAZAPINE 15 MG TABLET MIRTAZAPINE MIRTAZAPINE 30 MG TAB RAPDIS MIRTAZAPINE MIRTAZAPINE 30 MG TABLET MIRTAZAPINE MIRTAZAPINE 45 MG TAB RAPDIS MIRTAZAPINE MIRTAZAPINE 45 MG TABLET MIRTAZAPINE MIRTAZAPINE 7.5 MG TABLET MISOPROSTOL MISOPROSTOL 100 MCG TABLET MISOPROSTOL MISOPROSTOL 200 MCG TABLET MONONESSA NORGESTIMATE ETHINYL ESTRADIOL 0.25 0.035 TABLET MONTELUKAST SODIUM MONTELUKAST SODIUM 10 MG TABLET MONTELUKAST SODIUM MONTELUKAST SODIUM 4 MG TAB CHEW 255_FormularyMaintenance_December2018 Page 22 of 35

MONTELUKAST SODIUM MONTELUKAST SODIUM 5 MG TAB CHEW MYCOPHENOLATE MYCOPHENOLATE MOFETIL 250 MG CAPSULE MOFETIL MYCOPHENOLATE MYCOPHENOLATE MOFETIL 500 MG TABLET MOFETIL NAPROXEN NAPROXEN 125 MG/5ML ORAL SUSP NAPROXEN NAPROXEN 250 MG TABLET NAPROXEN NAPROXEN 375 MG TABLET NAPROXEN NAPROXEN 500 MG TABLET NAPROXEN SODIUM NAPROXEN SODIUM 220 MG TABLET NAPROXEN SODIUM NAPROXEN SODIUM 275 MG TABLET NAPROXEN SODIUM NAPROXEN SODIUM 550 MG TABLET NEBUPENT PENTAMIDINE ISETHIONATE 300 MG VIAL NEB NECON NORETHINDRONE ETHINYL ESTRADIOL 0.5 0.035 TABLET NEFAZODONE HCL NEFAZODONE HCL 100 MG TABLET NEFAZODONE HCL NEFAZODONE HCL 150 MG TABLET NEFAZODONE HCL NEFAZODONE HCL 200 MG TABLET NEFAZODONE HCL NEFAZODONE HCL 250 MG TABLET NEFAZODONE HCL NEFAZODONE HCL 50 MG TABLET NIACIN NIACIN 250 MG CAPSULE ER NIACIN NIACIN 500 MG CAPSULE ER NIACIN ER NIACIN 1000 MG TAB ER 24H NIACIN ER NIACIN 750 MG TAB ER 24H NIACOR NIACIN 500 MG TABLET NIFEDIPINE NIFEDIPINE 10 MG CAPSULE NIFEDIPINE NIFEDIPINE 20 MG CAPSULE NIFEDIPINE ER NIFEDIPINE 30 MG TAB ER 24 NIFEDIPINE ER NIFEDIPINE 30 MG TABLET ER NIFEDIPINE ER NIFEDIPINE 60 MG TAB ER 24 NIFEDIPINE ER NIFEDIPINE 60 MG TABLET ER NIFEDIPINE ER NIFEDIPINE 90 MG TAB ER 24 NIFEDIPINE ER NIFEDIPINE 90 MG TABLET ER NITRO BID NITROGLYCERIN 2 % OINT. (G) NITROGLYCERIN NITROGLYCERIN 0.3 MG TAB SUBL NITROGLYCERIN NITROGLYCERIN 0.4 MG TAB SUBL NITROGLYCERIN NITROGLYCERIN 0.6 MG TAB SUBL NORETHIN ETH ESTRA FERROUS FUM NORETHINDRONE ACETATE ETHINYL ESTRADIOL/FERROUS FUMARATE 1MG 20(24) TAB CHEW 255_FormularyMaintenance_December2018 Page 23 of 35

NORETHIN ETH ESTRA NORETHINDRONE ACETATE ETHINYL 1MG 20(24) TABLET FERROUS FUM ESTRADIOL/FERROUS FUMARATE NORETHIN ETH ESTRA NORETHINDRONE ETHINYL ESTRADIOL/FERROUS 0.4 35(21) TAB CHEW FERROUS FUM FUMARATE NORETHIN ETH ESTRA NORETHINDRONE ETHINYL ESTRADIOL/FERROUS 0.8 25(24) TAB CHEW FERROUS FUM FUMARATE NORETHINDRONE NORETHINDRONE 0.35 MG TABLET NORGESTIMATE ETHINYL NORGESTIMATE ETHINYL ESTRADIOL 7DAYSX3 LO TABLET ESTRADIOL NORTREL NORETHINDRONE ETHINYL ESTRADIOL 1 MG 35MCG TABLET NORTREL NORETHINDRONE ETHINYL ESTRADIOL 7 DAYS X 3 TABLET NORTRIPTYLINE HCL NORTRIPTYLINE HCL 10 MG CAPSULE NORTRIPTYLINE HCL NORTRIPTYLINE HCL 10 MG/5 ML SOLUTION NORTRIPTYLINE HCL NORTRIPTYLINE HCL 25 MG CAPSULE NORTRIPTYLINE HCL NORTRIPTYLINE HCL 50 MG CAPSULE NORTRIPTYLINE HCL NORTRIPTYLINE HCL 75 MG CAPSULE NP THYROID THYROID,PORK 15 MG TABLET NP THYROID THYROID,PORK 30 MG TABLET NP THYROID THYROID,PORK 60 MG TABLET NP THYROID THYROID,PORK 90 MG TABLET NUVARING ETONOGESTREL/ETHINYL ESTRADIOL.12.015MG VAG RING OCELLA ETHINYL ESTRADIOL/DROSPIRENONE 0.03MG 3MG TABLET ODOMZO SONIDEGIB PHOSPHATE 200 MG CAPSULE OGESTREL NORGESTREL ETHINYL ESTRADIOL 0.5 MG 50 TABLET OMEPRAZOLE OMEPRAZOLE 10 MG CAPSULE DR OMEPRAZOLE OMEPRAZOLE 20 MG CAPSULE DR OMEPRAZOLE OMEPRAZOLE 20 MG TABLET DR OMEPRAZOLE OMEPRAZOLE 40 MG CAPSULE DR ONE TOUCH VERIO BLOOD GLUCOSE CALIBRATION CONTROL EACH SOLUTION, NORMAL ONE TOUCH VERIO BLOOD SUGAR DIAGNOSTIC STRIP OPDIVO NIVOLUMAB 100MG/10ML VIAL OPDIVO NIVOLUMAB 40 MG/4 ML VIAL OXCARBAZEPINE OXCARBAZEPINE 150 MG TABLET OXCARBAZEPINE OXCARBAZEPINE 300 MG TABLET OXCARBAZEPINE OXCARBAZEPINE 300 MG/5ML ORAL SUSP OXCARBAZEPINE OXCARBAZEPINE 600 MG TABLET OXYBUTYNIN CHLORIDE OXYBUTYNIN CHLORIDE 5 MG TABLET 255_FormularyMaintenance_December2018 Page 24 of 35

OXYBUTYNIN CHLORIDE OXYBUTYNIN CHLORIDE 10 MG TAB ER 24 ER OXYBUTYNIN CHLORIDE OXYBUTYNIN CHLORIDE 15 MG TAB ER 24 ER OXYBUTYNIN CHLORIDE OXYBUTYNIN CHLORIDE 5 MG TAB ER 24 ER OZEMPIC SEMAGLUTIDE 0.25 OR.5 PEN INJCTR OZEMPIC SEMAGLUTIDE 1MG/0.75ML PEN INJCTR P D NATAL PLUS WITH PRENATAL VITAMIN CALCIUM,IRON,FOLIC ACID TABLET FOLIC ACID (LESS THAN 1 MG) PANTOPRAZOLE SODIUM PANTOPRAZOLE SODIUM 20 MG TABLET DR PANTOPRAZOLE SODIUM PANTOPRAZOLE SODIUM 40 MG TABLET DR PAROXETINE HCL PAROXETINE HCL 10 MG TABLET PAROXETINE HCL PAROXETINE HCL 20 MG TABLET PAROXETINE HCL PAROXETINE HCL 30 MG TABLET PAROXETINE HCL PAROXETINE HCL 40 MG TABLET PENTOXIFYLLINE PENTOXIFYLLINE 400 MG TABLET ER PHENOBARBITAL PHENOBARBITAL 100 MG TABLET PHENOBARBITAL PHENOBARBITAL 15 MG TABLET PHENOBARBITAL PHENOBARBITAL 16.2 MG TABLET PHENOBARBITAL PHENOBARBITAL 20 MG/5 ML ELIXIR PHENOBARBITAL PHENOBARBITAL 30 MG TABLET PHENOBARBITAL PHENOBARBITAL 32.4 MG TABLET PHENOBARBITAL PHENOBARBITAL 60 MG TABLET PHENOBARBITAL PHENOBARBITAL 64.8 MG TABLET PHENOBARBITAL PHENOBARBITAL 97.2MG TABLET PHENYTOIN PHENYTOIN 125 MG/5ML ORAL SUSP PHENYTOIN PHENYTOIN 50 MG TAB CHEW PHENYTOIN SODIUM PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE EXTENDED PILOCARPINE HCL PILOCARPINE HCL 1 % DROPS PILOCARPINE HCL PILOCARPINE HCL 2 % DROPS PILOCARPINE HCL PILOCARPINE HCL 4 % DROPS PIOGLITAZONE HCL PIOGLITAZONE HCL 15 MG TABLET PIOGLITAZONE HCL PIOGLITAZONE HCL 30 MG TABLET PIOGLITAZONE HCL PIOGLITAZONE HCL 45 MG TABLET PNV 29 1 PRENATAL VITAMIN WITH CALCIUM NO.76/IRON,CARBONYL/FOLIC ACID 29 MG 1 MG TABLET 255_FormularyMaintenance_December2018 Page 25 of 35

POTASSIUM CHLORIDE POTASSIUM CHLORIDE 10 MEQ CAPSULE ER POTASSIUM CHLORIDE POTASSIUM CHLORIDE 10 MEQ TAB ER PRT POTASSIUM CHLORIDE POTASSIUM CHLORIDE 10 MEQ TABLET ER POTASSIUM CHLORIDE POTASSIUM CHLORIDE 20 MEQ TAB ER PRT POTASSIUM CHLORIDE POTASSIUM CHLORIDE 20MEQ/15ML LIQUID POTASSIUM CHLORIDE POTASSIUM CHLORIDE 40MEQ/15ML LIQUID POTASSIUM CHLORIDE POTASSIUM CHLORIDE 8 MEQ CAPSULE ER POTASSIUM CHLORIDE POTASSIUM CHLORIDE 8 MEQ TABLET ER PRAMIPEXOLE PRAMIPEXOLE DI HCL 0.125 MG TABLET DIHYDROCHLORIDE PRAMIPEXOLE PRAMIPEXOLE DI HCL 0.25 MG TABLET DIHYDROCHLORIDE PRAMIPEXOLE PRAMIPEXOLE DI HCL 0.5 MG TABLET DIHYDROCHLORIDE PRAMIPEXOLE PRAMIPEXOLE DI HCL 0.75 MG TABLET DIHYDROCHLORIDE PRAMIPEXOLE PRAMIPEXOLE DI HCL 1 MG TABLET DIHYDROCHLORIDE PRAMIPEXOLE PRAMIPEXOLE DI HCL 1.5 MG TABLET DIHYDROCHLORIDE PRAVASTATIN SODIUM PRAVASTATIN SODIUM 10 MG TABLET PRAVASTATIN SODIUM PRAVASTATIN SODIUM 20 MG TABLET PRAVASTATIN SODIUM PRAVASTATIN SODIUM 40 MG TABLET PRAVASTATIN SODIUM PRAVASTATIN SODIUM 80 MG TABLET PRAZOSIN HCL PRAZOSIN HCL 1 MG CAPSULE PRAZOSIN HCL PRAZOSIN HCL 2 MG CAPSULE PRAZOSIN HCL PRAZOSIN HCL 5 MG CAPSULE PREMARIN ESTROGENS, CONJUGATED 0.3 MG TABLET PREMARIN ESTROGENS, CONJUGATED 0.45MG TABLET PREMARIN ESTROGENS, CONJUGATED 0.625 MG TABLET PREMARIN ESTROGENS, CONJUGATED 0.625 MG/G CREAM (G) PREMARIN ESTROGENS, CONJUGATED 0.9 MG TABLET PREMARIN ESTROGENS, CONJUGATED 1.25 MG TABLET PREMPHASE ESTROGENS, 0.625 (14) TABLET CONJUGATED/MEDROXYPROGESTERONE ACETATE PREMPRO ESTROGENS, 0.3 1.5MG TABLET CONJUGATED/MEDROXYPROGESTERONE ACETATE PREMPRO ESTROGENS, CONJUGATED/MEDROXYPROGESTERONE ACETATE 0.45 1.5MG TABLET 255_FormularyMaintenance_December2018 Page 26 of 35

PREMPRO ESTROGENS, 0.625 2.5 TABLET CONJUGATED/MEDROXYPROGESTERONE ACETATE PREMPRO ESTROGENS, 0.625 5 MG TABLET CONJUGATED/MEDROXYPROGESTERONE ACETATE PRENATAL PRENATAL VITS WITH CALCIUM 95/FERROUS 28MG 0.8MG TABLET FUMARATE/FOLIC ACID PRENATAL PRENATAL VITS WITH CALCIUM NO.96/FERROUS 27MG 0.8MG TABLET FUMARATE/FOLIC ACID PRENATAL COMPLETE PRENATAL VITS WITH CALCIUM NO.21/FERROUS 14 MG 400 TABLET FUMARATE/FOLIC ACID PRENATAL LOW IRON PRENATAL VITS WITH CALCIUM NO.74/FERROUS 27 MG 1 MG TABLET FUMARATE/FOLIC ACID PRENATAL PLUS PRENATAL VITS WITH CALCIUM NO.72/FERROUS 27 MG 1 MG TABLET FUMARATE/FOLIC ACID PRENATAL PLUS PRENATAL VITS WITH CALCIUM 29 MG 1 MG TABLET NO.72/IRON,CARBONYL/FOLIC ACID PRENATAL VITAMINS PRENATAL VITAMINS WITH CALCIUM/FERROUS 27MG 0.8MG TABLET FUMARATE/FOLIC ACID PRENATAL VITAMINS PRENATAL VITAMINS WITH CALCIUM/FERROUS 28MG 0.8MG TABLET FUMARATE/FOLIC ACID PRETAB PRENATAL VITS WITH CALCIUM NO.78/FERROUS 29 MG 1 MG TABLET FUMARATE/FOLIC ACID PREVACID 24HR LANSOPRAZOLE 15 MG CAPSULE DR PRILOSEC OTC OMEPRAZOLE MAGNESIUM 20 MG TABLET DR PRIMIDONE PRIMIDONE 250 MG TABLET PRIMIDONE PRIMIDONE 50 MG TABLET PROBENECID PROBENECID 500 MG TABLET PROBENECID COLCHICINE PROBENECID/COLCHICINE 500 0.5 MG TABLET PROPAFENONE HCL PROPAFENONE HCL 150 MG TABLET PROPAFENONE HCL PROPAFENONE HCL 225 MG TABLET PROPAFENONE HCL PROPAFENONE HCL 300 MG TABLET PROPAFENONE HCL ER PROPAFENONE HCL 225 MG CAP ER 12H PROPAFENONE HCL ER PROPAFENONE HCL 325 MG CAP ER 12H PROPAFENONE HCL ER PROPAFENONE HCL 425 MG CAP ER 12H PROPRANOLOL HCL PROPRANOLOL HCL 10 MG TABLET PROPRANOLOL HCL PROPRANOLOL HCL 20 MG TABLET PROPRANOLOL HCL PROPRANOLOL HCL 20 MG/5 ML SOLUTION PROPRANOLOL HCL PROPRANOLOL HCL 40 MG TABLET PROPRANOLOL HCL PROPRANOLOL HCL 40MG/5ML SOLUTION PROPRANOLOL HCL PROPRANOLOL HCL 60 MG TABLET 255_FormularyMaintenance_December2018 Page 27 of 35

PROPRANOLOL HCL PROPRANOLOL HCL 80 MG TABLET PROPRANOLOL HCL ER PROPRANOLOL HCL 120 MG CAP SA 24H PROPRANOLOL HCL ER PROPRANOLOL HCL 160 MG CAP SA 24H PROPRANOLOL HCL ER PROPRANOLOL HCL 60 MG CAP SA 24H PROPRANOLOL HCL ER PROPRANOLOL HCL 80 MG CAP SA 24H PROPYLTHIOURACIL PROPYLTHIOURACIL 50 MG TABLET PULMICORT FLEXHALER BUDESONIDE 180 MCG AER POW BA PULMICORT FLEXHALER BUDESONIDE 90 MCG AER POW BA PYRIDOSTIGMINE PYRIDOSTIGMINE BROMIDE 60 MG TABLET BROMIDE PYRIDOSTIGMINE PYRIDOSTIGMINE BROMIDE 180 MG TABLET ER BROMIDE ER QUASENSE LEVONORGESTREL ETHINYL ESTRADIOL 0.15 0.03 TBDSPK 3MO QUINIDINE GLUCONATE QUINIDINE GLUCONATE 324 MG TABLET ER QVAR REDIHALER BECLOMETHASONE DIPROPIONATE 40 MCG HFA AEROBA QVAR REDIHALER BECLOMETHASONE DIPROPIONATE 80 MCG HFA AEROBA RABEPRAZOLE SODIUM RABEPRAZOLE SODIUM 20 MG TABLET DR RANITIDINE HCL RANITIDINE HCL 15 MG/ML SYRUP RANITIDINE HCL RANITIDINE HCL 150 MG TABLET RANITIDINE HCL RANITIDINE HCL 300 MG TABLET RANITIDINE HCL RANITIDINE HCL 75 MG TABLET RENA VITE RX VITAMIN B COMPLEX NO.3/FOLIC ACID/ASCORBIC 1MG 60MG TABLET ACID(VITC)/BIOTIN RENAGEL SEVELAMER HCL 800 MG TABLET REPAGLINIDE REPAGLINIDE 0.5 MG TABLET REPAGLINIDE REPAGLINIDE 1 MG TABLET REPAGLINIDE REPAGLINIDE 2 MG TABLET RESTASIS CYCLOSPORINE 0.05 % DROPERETTE RESTASIS MULTIDOSE CYCLOSPORINE 0.05 % DROPS RIDAURA AURANOFIN 3 MG CAPSULE RILUZOLE RILUZOLE 50 MG TABLET RIVASTIGMINE RIVASTIGMINE TARTRATE 1.5 MG CAPSULE RIVASTIGMINE RIVASTIGMINE TARTRATE 3 MG CAPSULE RIVASTIGMINE RIVASTIGMINE TARTRATE 4.5 MG CAPSULE RIVASTIGMINE RIVASTIGMINE TARTRATE 6 MG CAPSULE RIVELSA LEVONORGESTREL/ETHINYL ESTRADIOL AND 0.15MG(84) TBDSPK 3MO ETHINYL ESTRADIOL ROPINIROLE HCL ROPINIROLE HCL 0.25 MG TABLET 255_FormularyMaintenance_December2018 Page 28 of 35

ROPINIROLE HCL ROPINIROLE HCL 0.5 MG TABLET ROPINIROLE HCL ROPINIROLE HCL 1 MG TABLET ROPINIROLE HCL ROPINIROLE HCL 2 MG TABLET ROPINIROLE HCL ROPINIROLE HCL 3 MG TABLET ROPINIROLE HCL ROPINIROLE HCL 4 MG TABLET ROPINIROLE HCL ROPINIROLE HCL 5 MG TABLET ROSUVASTATIN CALCIUM ROSUVASTATIN CALCIUM 10 MG TABLET ROSUVASTATIN CALCIUM ROSUVASTATIN CALCIUM 20 MG TABLET ROSUVASTATIN CALCIUM ROSUVASTATIN CALCIUM 40 MG TABLET ROSUVASTATIN CALCIUM ROSUVASTATIN CALCIUM 5 MG TABLET SAVELLA MILNACIPRAN HCL 100 MG TABLET SAVELLA MILNACIPRAN HCL 12.5 MG TABLET SAVELLA MILNACIPRAN HCL 25 MG TABLET SAVELLA MILNACIPRAN HCL 50 MG TABLET SEGLUROMET ERTUGLIFLOZIN PIDOLATE/METFORMIN HCL 2.5 1000MG TABLET SEGLUROMET ERTUGLIFLOZIN PIDOLATE/METFORMIN HCL 2.5 500 MG TABLET SEGLUROMET ERTUGLIFLOZIN PIDOLATE/METFORMIN HCL 7.5 1000MG TABLET SEGLUROMET ERTUGLIFLOZIN PIDOLATE/METFORMIN HCL 7.5 500 MG TABLET SELEGILINE HCL SELEGILINE HCL 5 MG CAPSULE SELEGILINE HCL SELEGILINE HCL 5 MG TABLET SENSIPAR CINACALCET HCL 30 MG TABLET SENSIPAR CINACALCET HCL 60 MG TABLET SENSIPAR CINACALCET HCL 90 MG TABLET SEREVENT DISKUS SALMETEROL XINAFOATE 50 MCG BLST W/DEV SERTRALINE HCL SERTRALINE HCL 100 MG TABLET SERTRALINE HCL SERTRALINE HCL 20 MG/ML ORAL CONC SERTRALINE HCL SERTRALINE HCL 25 MG TABLET SERTRALINE HCL SERTRALINE HCL 50 MG TABLET SEVELAMER CARBONATE SEVELAMER CARBONATE 800 MG TABLET SF 5000 PLUS FLUORIDE (SODIUM) 1.1 % CREAM (G) SIMVASTATIN SIMVASTATIN 10 MG TABLET SIMVASTATIN SIMVASTATIN 20 MG TABLET SIMVASTATIN SIMVASTATIN 40 MG TABLET SIMVASTATIN SIMVASTATIN 5 MG TABLET SIMVASTATIN SIMVASTATIN 80 MG TABLET SODIUM CHLORIDE SODIUM CHLORIDE 5 % DROPS SODIUM CHLORIDE SODIUM CHLORIDE 5 % OINT. (G) 255_FormularyMaintenance_December2018 Page 29 of 35

SODIUM FLUORIDE FLUORIDE (SODIUM) 0.5 MG/ML DROPS SOTALOL SOTALOL HCL 120 MG TABLET SOTALOL SOTALOL HCL 160 MG TABLET SOTALOL SOTALOL HCL 240 MG TABLET SOTALOL SOTALOL HCL 80 MG TABLET SPIRONOLACTONE SPIRONOLACTONE 100 MG TABLET SPIRONOLACTONE SPIRONOLACTONE 25 MG TABLET SPIRONOLACTONE SPIRONOLACTONE 50 MG TABLET SPIRONOLACTONE HCTZ SPIRONOLACTONE/ 25 MG 25MG TABLET SRONYX LEVONORGESTREL ETHINYL ESTRADIOL 0.1 0.02MG TABLET STEGLATRO ERTUGLIFLOZIN PIDOLATE 15 MG TABLET STEGLATRO ERTUGLIFLOZIN PIDOLATE 5 MG TABLET STEGLUJAN ERTUGLIFLOZIN PIDOLATE/SITAGLIPTIN 15MG TABLET PHOSPHATE 100MG STEGLUJAN ERTUGLIFLOZIN PIDOLATE/SITAGLIPTIN 5 MG 100MG TABLET PHOSPHATE STIOLTO RESPIMAT TIOTROPIUM BROMIDE/OLODATEROL HCL 2.5 2.5MCG MIST INHAL SUCRALFATE SUCRALFATE 1 G TABLET SULFASALAZINE SULFASALAZINE 500 MG TABLET SULFASALAZINE DR SULFASALAZINE 500 MG TABLET DR SYLATRON PEGINTERFERON ALFA 2B 200 MCG KIT SYLATRON PEGINTERFERON ALFA 2B 300 MCG KIT SYLATRON PEGINTERFERON ALFA 2B 600 MCG KIT SYNTHROID LEVOTHYROXINE SODIUM 100 MCG TABLET SYNTHROID LEVOTHYROXINE SODIUM 112 MCG TABLET SYNTHROID LEVOTHYROXINE SODIUM 125 MCG TABLET SYNTHROID LEVOTHYROXINE SODIUM 137 MCG TABLET SYNTHROID LEVOTHYROXINE SODIUM 150 MCG TABLET SYNTHROID LEVOTHYROXINE SODIUM 175MCG TABLET SYNTHROID LEVOTHYROXINE SODIUM 200 MCG TABLET SYNTHROID LEVOTHYROXINE SODIUM 25 MCG TABLET SYNTHROID LEVOTHYROXINE SODIUM 300 MCG TABLET SYNTHROID LEVOTHYROXINE SODIUM 50 MCG TABLET SYNTHROID LEVOTHYROXINE SODIUM 75 MCG TABLET SYNTHROID LEVOTHYROXINE SODIUM 88 MCG TABLET TACROLIMUS TACROLIMUS 0.5 MG CAPSULE TACROLIMUS TACROLIMUS 1 MG CAPSULE 255_FormularyMaintenance_December2018 Page 30 of 35

TACROLIMUS TACROLIMUS 5 MG CAPSULE TAMOXIFEN CITRATE TAMOXIFEN CITRATE 10 MG TABLET TAMOXIFEN CITRATE TAMOXIFEN CITRATE 20 MG TABLET TAMSULOSIN HCL TAMSULOSIN HCL 0.4 MG CAPSULE TAZTIA XT DILTIAZEM HCL 120 MG CAP SA 24H TAZTIA XT DILTIAZEM HCL 180 MG CAP SA 24H TAZTIA XT DILTIAZEM HCL 240 MG CAP SA 24H TAZTIA XT DILTIAZEM HCL 300 MG CAP SA 24H TEGRETOL CARBAMAZEPINE 100 MG/5ML ORAL SUSP TEGRETOL CARBAMAZEPINE 200 MG TABLET TEGRETOL XR CARBAMAZEPINE 100 MG TAB ER 12H TEGRETOL XR CARBAMAZEPINE 200 MG TAB ER 12H TEGRETOL XR CARBAMAZEPINE 400 MG TAB ER 12H TERAZOSIN HCL TERAZOSIN HCL 1 MG CAPSULE TERAZOSIN HCL TERAZOSIN HCL 10 MG CAPSULE TERAZOSIN HCL TERAZOSIN HCL 2 MG CAPSULE TERAZOSIN HCL TERAZOSIN HCL 5 MG CAPSULE TERBUTALINE SULFATE TERBUTALINE SULFATE 2.5 MG TABLET TERBUTALINE SULFATE TERBUTALINE SULFATE 5 MG TABLET TESTOSTERONE TESTOSTERONE CYPIONATE 100 MG/ML VIAL CYPIONATE TESTOSTERONE TESTOSTERONE CYPIONATE 200 MG/ML VIAL CYPIONATE THEOPHYLLINE THEOPHYLLINE ANHYDROUS 400 MG TAB ER 24H THEOPHYLLINE THEOPHYLLINE ANHYDROUS 600 MG TAB ER 24H THEOPHYLLINE THEOPHYLLINE ANHYDROUS 80 MG/15ML SOLUTION THEOPHYLLINE THEOPHYLLINE ANHYDROUS 100 MG TAB ER 12H ANHYDROUS THEOPHYLLINE THEOPHYLLINE ANHYDROUS 200 MG TAB ER 12H ANHYDROUS THEOPHYLLINE THEOPHYLLINE ANHYDROUS 300 MG TAB ER 12H ANHYDROUS THEOPHYLLINE THEOPHYLLINE ANHYDROUS 450 MG TAB ER 12H ANHYDROUS TILIA FE NORETHINDRONE ACETATE ETHINYL 5 7 9 7 TABLET ESTRADIOL/FERROUS FUMARATE TIMOLOL MALEATE TIMOLOL MALEATE 0.25 % DROPS TIMOLOL MALEATE TIMOLOL MALEATE 0.25 % SOL GEL TIMOLOL MALEATE TIMOLOL MALEATE 0.5 % DROPS 255_FormularyMaintenance_December2018 Page 31 of 35