Large Group 2019 Formulary Guide (List of Covered Prescription Medications)

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Transcription:

Large Group 2019 Formulary Guide (List of Covered Prescription Medications)

Pharmacy Benefits Management Table of Contents Overview... iii True Health New Mexico Customer Service... iii Understanding Coverage and Cost Sharing... iii Formulary... iii Tiers... iii Understanding Our Symbols... v Prior Authorization... v Step Therapy... v Quantity Limits... vi About Generic Drugs... vi Short Term Medications... vi Long Term Medications... vii Specialty Medications... vii How to Fill Your Prescription Medications... vii Filling Your Prescription When Traveling... vii Medication Supplies Not Covered by the Health Plan...viii List of Abbreviations... ix ii

Pharmacy Benefits Management Overview This guide provides an overview of your pharmacy benefit. It explains the tiers for drug coverage, the process for getting certain drugs covered, your options for filling prescriptions, important phone numbers, and more. True Health New Mexico Customer Service: 866.341.8561 Hours of operation: 24 hours a day, 7 days a week. Understanding Coverage and Cost Sharing Formulary The Formulary, also known as your Preferred Drug List, is a list of prescription drugs that are covered under your plan. The inclusion of specific medications on the Health Plan formulary is based on the medication s effectiveness, safety, and value. The formulary offers a wide selection of generic and brand-name prescription drugs suggested by the Pharmacy and Therapeutics (P&T) Committee, a group of physicians and pharmacists who research and evaluate medications. The formulary is periodically reviewed and updated throughout the year in order to ensure that our benefits package consistently and adequately meets your needs. When you need a prescription medication, you and your doctor can choose from six different levels of the formulary. These are: Generics Tier 1 and Tier 2, Preferred Brands Tier 3, Non Preferred Brands Tier 4, Preferred Specialty Tier 5, and Non-Preferred Specialty Tier 6. Each level has a different cost share, which could be a copay or coinsurance, depending on your plan. This gives you and your doctor the freedom to choose the medication that is right for you. At the same time, this will help you to better budget your health care dollars. Tiers Generic Medications Tier 1 and Tier 2 have the lowest copayment/coinsurance. Generic drugs offer the same level of safety and quality as their brand name equivalents. They have the same amount of active ingredients as brand name medications. You are required to use a generic version of the drug if one is available. Refer to the generic drugs section of your Summary of Benefits and Coverage for your plan s cost-share amount. Preferred-Brand Medications Tier 3 have the middle level copayment/coinsurance. These drugs are primarily brand medications and preferred because of their value and effectiveness. This tier may also include some generic medications. Refer to the preferred-brand drugs section of your Summary of Benefits and Coverage for your plan s cost-share amount. iii

Pharmacy Benefits Management Non Preferred Brand Medications Tier 4 have a higher copayment/coinsurance level. These medications are primarily brand drugs that are more expensive and have similar effectiveness as Tier 3 medications. This tier may also include higher cost generic medications. Refer to the non-preferred-brand drugs section of your Summary of Benefits and Coverage for your plan s cost-share amount. Preferred Specialty Medications Tier 5 have a higher copayment/coinsurance level. These also include Specialty medications, which usually treat complex and rare conditions. These drugs can be high cost medications and biologicals regardless of how they are administered (injectable, oral, transdermal, or inhalant). Non-Preferred Specialty Medications Tier 6 have the highest copayment/coinsurance level. These also include Specialty medications, which usually treat complex and rare conditions. These drugs can be high cost medications and biologicals regardless of how they are administered (injectable, oral, transdermal, or inhalant) and have similar effectiveness as Tier 5. Affordable Care Act/Zero Cost Share Preventative Drugs ACA Tier have a zero-cost share copay/co-insurance. These medications are brand and generic preventative drugs that may be covered at $0 copay provided that certain clinical conditions are met. These medications are not specifically identified in the drug list but will process at a zero-dollar cost share. ACA Tier drugs are listed in a free-standing document that is posted to the THNM website and is updated quarterly. $0 Generics for Several Chronic Conditions Generic drug coverage is provided at no cost for certain medications used to treat asthma, bipolar disorder, chronic obstructive pulmonary disease, congestive heart failure, coronary artery disease, depression, diabetes, hypercholesterolemia, and hypertension. This benefit does not apply to all plans; please refer to your Summary of Benefits and Coverage for your specific plan benefits. For a listing of these drugs, visit: truehealthnewmexico.com/formulary.aspx Orally Administered Anti-Cancer Medications Coverage of these medications are subject to the same Prior Authorization requirements as intravenously administered injected cancer medications covered by the Health Plan. Orally administered medications cannot cost more than an intravenously injected equivalent. Intravenously injected medications cannot cost more than orally administered medications. iv

Pharmacy Benefits Management Non Formulary Medications may be covered if the formulary medications do not work for you. If you require a Non Formulary medication, your doctor may request coverage for your Tier 4 (Non-Preferred Brand Medications) or your Tier 6 (Non-Preferred Specialty Medications) cost share by making a request for a coverage exception. Understanding Our Symbols Prior Authorization You will see the symbol PA (Prior Authorization). Prior Authorization helps ensure that you re using the best drugs in the safest way. If you are currently taking or have recently been prescribed one of these drugs, please discuss possible alternatives or have your doctor request authorization by calling 866.823.1606. Drugs that require prior authorization are often: Newer drugs for which the Health Plan wants to track usage. Non formulary drugs that require the use of formulary drugs prior to coverage. These drugs are not used as a standard first option in treating a medical condition. Drugs with potential side effects that the Health Plan wants to monitor for patient safety. Drugs categorized as specialty medications. Step Therapy You will see the symbol ST (Step Therapy) next to certain drugs on the formulary tables in this booklet. Step Therapy ensures you are taking the most effective medication at the best cost. This means trying the least expensive medications usually generic medications or drugs that are considered as the standard first line treatment. How Step Therapy Works Step 1: When your prescribed drug is impacted by step therapy, first you will be asked to try generic or first line treatment drugs. The drug recommended will be approved by the Food and Drug Administration (FDA) as providing the same health benefit at a much lower cost. Step 2: If the generic drug in step 1 does not work for you, then you may be able to receive a brand name drug. For more information on Step Therapy, call 866.823.1606. v

Pharmacy Benefits Management Quantity Limits The symbol QL next to the drugs in this formulary booklet stands for Quantity Limits. To ensure you are getting the most cost effective dose for your medication, a quantity limit or dose duration may be placed on certain drugs. These limits are based on FDA guidelines, clinical literature, and manufacturer s instructions. Quantity limits promote appropriate use of the drug, prevent waste, and help control costs. For some drugs, the dosing guidelines may recommend that patients take the drug one time a day in a larger dose instead of several times a day in smaller doses. The quantity limits follow the guidelines and cover one larger dose per day. Prescriptions for specialty medications are limited to a 30 day supply. For more information on quantity limits or dose durations, call 866.823.1606. About Generic Drugs Generic drugs have the same active ingredients as their brand name equivalents but cost significantly less. Not all drugs have a generic equivalent. Generally, new drugs receive patent protection for 20 years. Once the patent expires, other pharmaceutical companies can produce the same drug in a generic formulation. Companies that make generic drugs do not have to invest large amounts of money in research, since the company making the brand name equivalent has already done this. Also, generic companies do not need to advertise their drugs. As a result, generic drug makers can pass these savings on to you. Generic drugs have the same active ingredients as brand name drugs, but their inactive ingredients can vary. This is why the generic drug might look different from the brand name drug. Inactive ingredients can be dyes used to color the drug or powders used to shape the tablets. Inactive ingredients do not affect how the generic drug works. The FDA regulates generic drug manufacturers just as it regulates the makers of brand name medications. The generic drug must pass strict FDA measurements to ensure that it delivers the same amount of the active ingredient in the same time frame as its brand name counterpart. The manufacturer of the generic drug must prove that it produces its product under the same strict guidelines as the brand name drug. Short Term Medications These are drugs you need immediately. This includes medications used to treat short term infections, or to relieve pain temporarily. Locate the nearest retail network pharmacy by calling 866.341.8561. To fill your prescription, present your member ID card and written prescription and pay your copayment/co insurance as described above. vi

Pharmacy Benefits Management Long Term Medications These are drugs you take on a regular basis. These could be drugs to treat asthma, high blood pressure, diabetes, etc. These medications can be mailed to your home for up to a 90 day supply. Please call 866.341.8561 to learn more about your mail-order options. Specialty Medications Specialty medications treat specific medical conditions such as cancer, hemophilia, hepatitis, multiple sclerosis, psoriasis, pulmonary arterial hypertension, respiratory syncytial virus, rheumatoid arthritis, and more. You can fill these prescriptions through CVS Specialty Pharmacy. CVS Specialty Pharmacy is a pharmacy that provides specialty medications. Please call 800.237.2767 between the hours of 6:30 a.m. to 8 p.m. (CT) Monday through Friday to learn more about filling your specialty medication. How to Fill Your Prescription Medications Filling Your Prescription When Traveling When you travel outside of your local area, thousands of pharmacies across the country will honor your Health Plan member ID card. To locate a participating pharmacy, call Customer Service at 866.341.8561. To fill a prescription at a participating out of area pharmacy, present your Health Plan member ID card. Some pharmacies may ask you to pay the full price of the medication. If that happens: Submit a Direct Reimbursement Claim form to the Health Plan at: CVS Caremark RxClaim P.O Box 52136 Phoenix, AZ 85072-2136 Or you may call 866.341.8561 for assistance. If your claim is approved, you will be reimbursed the amount that you paid for the medication, less the appropriate copayment. If you will be away from home for an extended period of time, or if you will be traveling outside of the country, you may want to use our mail order service so that you receive a 90 day supply before you leave home. vii

Pharmacy Benefits Management Medication Supplies Not Covered by the Health Plan Medications received at no charge to the member (workers compensation, medications purchased with a manufacturer s coupon, etc.) will not be covered. Prescriptions that are written more than a year ago will not be covered. Your doctor will need to write a new prescription. viii

Pharmacy Benefits Management List of Abbreviations ACA: Affordable Care Act. LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information, please call Customer Service at 866.341.8561. OTC: Over the Counter. An OTC drug is a non-prescription drug. PA: Prior Authorization. The Health Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don t get approval, we may not cover the drug. QL: Quantity Limit. For certain drugs, the Health Plan limits the amount of the drug that we will cover. ST: Step Therapy. In some cases, the Health 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 Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. ix

Formulary Listing Effective 01/01/2019 Drug Name ANALGESICS COX-II INHIBITORS celecoxib cap 50 2 ST celecoxib cap 100 2 ST; QL celecoxib cap 200 2 ST; QL celecoxib cap 400 2 ST; QL GOUT allopurinol tab 100 1 allopurinol tab 300 2 COLCRYS TAB 0.6MG 3 ULORIC TAB 40MG 3 ST; QL ULORIC TAB 80MG 3 ST MISCELLANEOUS PRIALT INJ 25MCG/ML 5 PRIALT INJ 100MCG 5 PRIALT INJ 500MCG 5 NON-OPIOID ANALGESICS butalbital-acetaminophen tab 50-325 2 butalbital-acetaminophen-caffeine cap 2 50-325-40 butalbital-acetaminophen-caffeine tab 2 50-325-40 butalbital-aspirin-caffeine cap 50-325-40 2 NSAIDS choline & magnesium salicylates liq 500 2 /5ml diclofenac potassium tab 50 2 diclofenac sodium tab delayed release 25 2 diclofenac sodium tab delayed release 50 2 diclofenac sodium tab delayed release 75 2 diclofenac sodium tab er 24hr 100 2 diflunisal tab 500 2 etodolac cap 200 2 etodolac cap 300 2 etodolac tab 400 2 etodolac tab 500 2 etodolac tab er 24hr 400 2 etodolac tab er 24hr 500 2 etodolac tab er 24hr 600 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 1

fenoprofen calcium tab 600 2 flurbiprofen tab 50 2 flurbiprofen tab 100 2 ibuprofen susp 100 /5ml 1 ibuprofen tab 400 1 ibuprofen tab 600 1 ibuprofen tab 800 1 indomethacin cap 25 2 indomethacin cap 50 2 indomethacin cap er 75 2 ketoprofen cap er 24hr 200 2 ketorolac tromethamine tab 10 2 QL meclofenamate sodium cap 50 2 meclofenamate sodium cap 100 2 mefenamic acid cap 250 2 meloxicam tab 7.5 1 meloxicam tab 15 1 nabumetone tab 500 2 nabumetone tab 750 2 naproxen sodium tab 275 2 naproxen sodium tab 550 2 naproxen susp 125 /5ml 2 PA naproxen tab 250 2 naproxen tab 375 1 naproxen tab 500 1 naproxen tab ec 375 2 naproxen tab ec 500 2 oxaprozin tab 600 2 piroxicam cap 10 2 piroxicam cap 20 2 salsalate tab 500 2 salsalate tab 750 2 sulindac tab 150 2 sulindac tab 200 2 tolmetin sodium cap 400 2 tolmetin sodium tab 200 2 tolmetin sodium tab 600 2 NSAIDS, COMBINATIONS diclofenac w/ misoprostol tab delayed 2 release 50-0.2 diclofenac w/ misoprostol tab delayed 2 release 75-0.2 NSAIDS, TOPICAL diclofenac sodium gel 1% 2 QL VOLTAREN GEL 1% 4 QL OPIOID ANALGESICS PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 2

ABSTRAL SUB 100MCG 4 PA; QL ABSTRAL SUB 200MCG 4 PA; QL ABSTRAL SUB 300MCG 4 PA; QL ABSTRAL SUB 400MCG 4 PA; QL ABSTRAL SUB 600MCG 4 PA; QL ABSTRAL SUB 800MCG 4 PA; QL acetaminophen w/ codeine soln 120-12 /5ml 2 PA acetaminophen w/ codeine tab 300-15 2 PA acetaminophen w/ codeine tab 300-30 2 PA acetaminophen w/ codeine tab 300-60 2 PA butalbital-acetaminophen-caff w/ cod cap 2 PA 50-325-40-30 butalbital-aspirin-caff w/ codeine cap 50-325-40-30 2 PA butorphanol tartrate nasal soln 10 /ml 2 PA; QL BUTRANS DIS 5MCG/HR 4 PA, ST BUTRANS DIS 7.5/HR 4 PA, ST BUTRANS DIS 10MCG/HR 4 PA, ST BUTRANS DIS 15MCG/HR 4 PA, ST BUTRANS DIS 20MCG/HR 4 PA, ST codeine sulfate tab 15 2 PA codeine sulfate tab 30 2 PA codeine sulfate tab 60 2 PA endocet tab 5-325 2 PA fentanyl citrate lozenge on a handle 200 2 QL mcg fentanyl citrate lozenge on a handle 600 2 QL mcg fentanyl citrate lozenge on a handle 800 2 QL mcg fentanyl citrate lozenge on a handle 1200 2 QL mcg fentanyl citrate lozenge on a handle 1600 2 QL mcg fentanyl td patch 72hr 12 mcg/hr 2 PA, ST; QL fentanyl td patch 72hr 25 mcg/hr 2 PA, ST; QL fentanyl td patch 72hr 50 mcg/hr 2 PA, ST; QL fentanyl td patch 72hr 75 mcg/hr 2 PA, ST; QL fentanyl td patch 72hr 100 mcg/hr 2 PA, ST; QL FENTORA TAB 100MCG 4 PA; QL FENTORA TAB 200MCG 4 PA; QL FENTORA TAB 400MCG 4 PA; QL FENTORA TAB 600MCG 4 PA; QL FENTORA TAB 800MCG 4 PA; QL hydrocodone-acetaminophen soln 7.5-325 2 PA /15ml PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 3

hydrocodone-acetaminophen soln 10-325 2 PA /15ml hydrocodone-acetaminophen tab 2.5-325 2 PA hydrocodone-acetaminophen tab 5-325 2 PA hydrocodone-acetaminophen tab 7.5-325 2 PA hydrocodone-acetaminophen tab 10-325 2 PA hydrocodone-ibuprofen tab 5-200 2 PA; QL hydrocodone-ibuprofen tab 7.5-200 2 PA; QL hydrocodone-ibuprofen tab 10-200 2 PA; QL HYDROMORPHON SUP 3MG 2 PA hydromorphone hcl tab 2 2 PA hydromorphone hcl tab 4 2 PA hydromorphone hcl tab 8 2 PA LAZANDA SPR 100MCG 4 PA; QL LAZANDA SPR 300MCG 4 PA; QL LAZANDA SPR 400MCG 4 PA; QL meperidine hcl oral soln 50 /5ml 2 PA meperidine hcl tab 50 2 PA meperidine hcl tab 100 2 PA methadone hcl soln 5 /5ml 2 PA, ST methadone hcl soln 10 /5ml 2 PA, ST methadone hcl tab 5 2 PA, ST methadone hcl tab 10 2 PA, ST methadone hcl tab for oral susp 40 2 PA, ST MORPHINE SUL SUP 30MG 2 morphine sulfate oral soln 10 /5ml 2 PA morphine sulfate oral soln 20 /5ml 2 PA morphine sulfate oral soln 100 /5ml (20 2 PA /ml) morphine sulfate suppos 5 2 morphine sulfate suppos 10 2 morphine sulfate suppos 20 2 morphine sulfate tab 15 2 PA; QL morphine sulfate tab 30 2 PA; QL morphine sulfate tab er 15 2 PA, ST; QL morphine sulfate tab er 30 2 PA, ST; QL morphine sulfate tab er 60 2 PA, ST; QL morphine sulfate tab er 100 2 PA, ST; QL morphine sulfate tab er 200 2 PA, ST; QL oxycodone hcl cap 5 2 PA oxycodone hcl conc 100 /5ml (20 2 PA /ml) oxycodone hcl soln 5 /5ml 2 PA oxycodone hcl tab 5 2 PA PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 4

oxycodone hcl tab 10 2 PA oxycodone hcl tab 15 2 PA oxycodone hcl tab 20 2 PA oxycodone hcl tab 30 2 PA oxycodone hcl tab er 12hr deter 10 4 PA, ST; QL oxycodone hcl tab er 12hr deter 15 4 PA, ST; QL oxycodone hcl tab er 12hr deter 20 4 PA, ST; QL oxycodone hcl tab er 12hr deter 30 4 PA, ST; QL oxycodone hcl tab er 12hr deter 40 4 PA, ST; QL oxycodone hcl tab er 12hr deter 60 4 PA, ST; QL oxycodone hcl tab er 12hr deter 80 4 PA, ST; QL oxycodone w/ acetaminophen tab 2.5-325 2 PA oxycodone w/ acetaminophen tab 5-325 2 PA oxycodone w/ acetaminophen tab 7.5-325 2 PA oxycodone w/ acetaminophen tab 10-325 2 PA oxycodone-aspirin tab 4.8355-325 2 PA oxycodone-ibuprofen tab 5-400 2 PA; QL OXYCONTIN TAB 10MG CR 5 PA, ST; QL OXYCONTIN TAB 15MG CR 5 PA, ST; QL OXYCONTIN TAB 20MG CR 5 PA, ST; QL OXYCONTIN TAB 30MG CR 5 PA, ST; QL OXYCONTIN TAB 40MG CR 5 PA, ST; QL OXYCONTIN TAB 60MG CR 5 PA, ST; QL OXYCONTIN TAB 80MG CR 5 PA, ST; QL oxymorphone hcl tab 5 4 PA oxymorphone hcl tab 10 4 PA oxymorphone hcl tab er 12hr 5 4 PA, ST; QL oxymorphone hcl tab er 12hr 7.5 4 PA, ST; QL oxymorphone hcl tab er 12hr 10 4 PA, ST; QL oxymorphone hcl tab er 12hr 15 4 PA, ST; QL oxymorphone hcl tab er 12hr 20 4 PA, ST; QL oxymorphone hcl tab er 12hr 30 4 PA, ST; QL oxymorphone hcl tab er 12hr 40 4 PA, ST; QL pentazocine w/ naloxone tab 50-0.5 2 PA SUBSYS SPR 100MCG 5 PA; QL SUBSYS SPR 200MCG 5 PA; QL SUBSYS SPR 400MCG 5 PA; QL SUBSYS SPR 600MCG 5 PA; QL SUBSYS SPR 800MCG 5 PA; QL SUBSYS SPR 1200MCG 5 PA; QL SUBSYS SPR 1600MCG 5 PA; QL tramadol hcl tab 50 2 PA; QL tramadol hcl tab er 24hr 100 2 PA, ST; QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 5

tramadol hcl tab er 24hr 200 2 PA, ST; QL tramadol hcl tab er 24hr 300 2 PA, ST; QL tramadol-acetaminophen tab 37.5-325 2 PA VISCOSUPPLEMENTS EUFLEXXA INJ 10MG/ML 5 PA; QL ANTI-INFECTIVES AMINOGLYCOSIDES neomycin sulfate tab 500 2 paromomycin sulfate cap 250 2 ANTIBACTERIALS, CEPHALOSPORINS 1ST GEN cefadroxil cap 500 2 cefadroxil for susp 250 /5ml 2 cefadroxil for susp 500 /5ml 2 cefadroxil tab 1 gm 2 cephalexin cap 250 1 cephalexin cap 500 1 cephalexin cap 750 1 cephalexin for susp 125 /5ml 2 cephalexin for susp 250 /5ml 2 cephalexin tab 250 2 cephalexin tab 500 1 ANTIBACTERIALS, CEPHALOSPORINS, 2ND GEN cefaclor cap 250 2 cefaclor cap 500 2 CEFACLOR ER TAB 500MG 2 cefaclor for susp 125 /5ml 2 cefaclor for susp 250 /5ml 2 cefaclor for susp 375 /5ml 2 cefprozil for susp 125 /5ml 2 cefprozil for susp 250 /5ml 2 cefprozil tab 250 2 cefprozil tab 500 2 cefuroxime axetil tab 500 2 ANTIBACTERIALS, CEPHALOSPORINS, 3RD GEN cefdinir cap 300 2 cefdinir for susp 125 /5ml 2 cefdinir for susp 250 /5ml 2 cefixime for susp 100 /5ml 2 cefixime for susp 200 /5ml 2 cefpodoxime proxetil for susp 50 /5ml 2 cefpodoxime proxetil for susp 100 /5ml 2 cefpodoxime proxetil tab 100 2 cefpodoxime proxetil tab 200 2 SUPRAX CAP 400MG 4 SUPRAX CHW 100MG 4 SUPRAX CHW 200MG 4 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 6

SUPRAX SUS 100/5ML 4 SUPRAX SUS 200/5ML 4 SUPRAX SUS 500/5ML 4 ANTIBACTERIALS, ERYTHROMYCINS/MACROLIDES azithromycin for susp 100 /5ml 2 azithromycin for susp 200 /5ml 2 azithromycin tab 250 2 azithromycin tab 500 2 azithromycin tab 600 2 clarithromycin for susp 125 /5ml 2 clarithromycin for susp 250 /5ml 2 clarithromycin tab 250 2 clarithromycin tab 500 2 clarithromycin tab er 24hr 500 2 DIFICID TAB 200MG 5 ST; QL E.E.S. GRAN SUS 200/5ML 4 ERYPED SUS 400/5ML 5 erythromycin ethylsuccinate for susp 200 4 /5ml erythromycin ethylsuccinate tab 400 2 erythromycin stearate tab 250 2 erythromycin tab 250 2 erythromycin tab 500 2 erythromycin tab delayed release 250 3 erythromycin tab delayed release 333 3 erythromycin tab delayed release 500 3 erythromycin w/ delayed release particles 2 cap 250 ANTIBACTERIALS, FLUOROQUINOLONES AVELOX TAB 400MG 4 CIPRO (5%) SUS 250MG/5 4 CIPRO (10%) SUS 500MG/5 4 ciprofloxacin hcl tab 100 (base equiv) 2 ciprofloxacin hcl tab 250 (base equiv) 1 ciprofloxacin hcl tab 500 (base equiv) 1 ciprofloxacin hcl tab 750 (base equiv) 2 ciprofloxacin-ciprofloxacin hcl tab er 24hr 2 QL 500 (base eq) ciprofloxacin-ciprofloxacin hcl tab er 24hr 2 QL 1000 (base eq) levofloxacin oral soln 25 /ml 2 moxifloxacin hcl tab 400 (base equiv) 2 ANTIBACTERIALS, PENICILLINS amoxicillin & k clavulanate chew tab 200-28.5 amoxicillin & k clavulanate chew tab 400-57 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 7 2 2

amoxicillin & k clavulanate for susp 2 200-28.5 /5ml amoxicillin & k clavulanate for susp 2 250-62.5 /5ml amoxicillin & k clavulanate for susp 400-57 2 /5ml amoxicillin & k clavulanate for susp 2 600-42.9 /5ml amoxicillin & k clavulanate tab 250-125 2 amoxicillin & k clavulanate tab 500-125 2 amoxicillin & k clavulanate tab 875-125 2 amoxicillin & k clavulanate tab er 12hr 2 1000-62.5 amoxicillin (trihydrate) cap 250 1 amoxicillin (trihydrate) cap 500 1 amoxicillin (trihydrate) chew tab 125 2 amoxicillin (trihydrate) chew tab 250 2 amoxicillin (trihydrate) for susp 125 1 /5ml amoxicillin (trihydrate) for susp 200 1 /5ml amoxicillin (trihydrate) for susp 250 1 /5ml amoxicillin (trihydrate) for susp 400 1 /5ml amoxicillin (trihydrate) tab 500 1 amoxicillin (trihydrate) tab 875 2 ampicillin cap 500 2 dicloxacillin sodium cap 250 2 dicloxacillin sodium cap 500 2 penicillin v potassium for soln 125 /5ml 1 penicillin v potassium for soln 250 /5ml 1 penicillin v potassium tab 250 1 penicillin v potassium tab 500 2 ANTIBACTERIALS, SULFONAMIDES SULFADIAZINE TAB 500MG 2 sulfamethoxazole-trimethoprim susp 2 200-40 /5ml sulfamethoxazole-trimethoprim tab 400-80 1 sulfamethoxazole-trimethoprim tab 1 800-160 ANTIBACTERIALS, TETRACYCLINES demeclocycline hcl tab 150 2 demeclocycline hcl tab 300 2 doxycycline hyclate tab 20 2 doxycycline hyclate tab 100 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 8

doxycycline hyclate tab delayed release 50 2 ST doxycycline hyclate tab delayed release 75 2 ST doxycycline hyclate tab delayed release 2 ST 100 doxycycline hyclate tab delayed release 2 ST 150 doxycycline hyclate tab delayed release 2 ST 200 doxycycline monohydrate cap 100 2 doxycycline monohydrate cap 150 2 doxycycline monohydrate for susp 25 2 /5ml doxycycline monohydrate tab 50 2 doxycycline monohydrate tab 75 2 doxycycline monohydrate tab 100 2 MINOCIN CAP 50MG 4 minocycline hcl cap 50 2 minocycline hcl cap 75 2 minocycline hcl cap 100 2 minocycline hcl tab 50 2 minocycline hcl tab 75 2 minocycline hcl tab 100 2 tetracycline hcl cap 250 2 tetracycline hcl cap 500 2 VIBRAMYCIN SYP 50MG/5ML 4 ANTIFUNGALS clotrimazole troche 10 2 CRESEMBA CAP 186 MG 4 QL fluconazole for susp 10 /ml 2 fluconazole for susp 40 /ml 2 fluconazole tab 50 2 QL fluconazole tab 100 2 QL fluconazole tab 150 1 QL fluconazole tab 200 2 QL flucytosine cap 250 2 PA flucytosine cap 500 2 PA griseofulvin microsize susp 125 /5ml 2 griseofulvin microsize tab 500 2 itraconazole cap 100 2 PA; QL NOXAFIL SUS 40MG/ML 5 PA NOXAFIL TAB 100MG 5 PA; QL nystatin susp 100000 unit/ml 2 nystatin tab 500000 unit 2 SPORANOX SOL 10MG/ML 4 PA; QL terbinafine hcl tab 250 2 QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 9

voriconazole for susp 40 /ml 2 QL voriconazole tab 50 2 QL voriconazole tab 200 2 QL ANTIMALARIALS COARTEM TAB 20-120MG 3 ANTIRETROVIRALS, ANTIRETROVIRAL ADJUVANTS TYBOST TAB 150MG 3 QL ANTIRETROVIRALS, ANTIRETROVIRAL COMBINATIONS abacavir sulfate-lamivudine tab 600-300 2 abacavir sulfate-lamivudine-zidovudine tab 2 QL 300-150-300 ATRIPLA TAB 3 QL BIKTARVY TAB 3 QL COMPLERA TAB 3 QL DESCOVY TAB 200/25 3 QL EPZICOM TAB 600-300 4 QL EVOTAZ TAB 300-150 3 QL GENVOYA TAB 3 QL lamivudine-zidovudine tab 150-300 2 QL PREZCOBIX TAB 800-150 3 QL STRIBILD TAB 3 QL TRIUMEQ TAB 3 QL TRIZIVIR TAB 3 QL TRUVADA TAB 100-150 3 QL TRUVADA TAB 133-200 3 QL TRUVADA TAB 167-250 3 QL TRUVADA TAB 200-300 3 QL ANTIRETROVIRALS, CHEMOKINE RECEPTOR ANTAGONISTS SELZENTRY SOL 20MG/ML 3 PA; QL SELZENTRY TAB 150MG 3 PA; QL SELZENTRY TAB 300MG 3 PA; QL ANTIRETROVIRALS, FUSION INHIBITORS FUZEON INJ 90MG 3 QL ANTIRETROVIRALS, INTEGRASE INHIBITORS ISENTRESS CHW 25MG 3 QL ISENTRESS CHW 100MG 3 QL ISENTRESS HD TAB 600MG 3 QL ISENTRESS POW 100MG 3 QL ISENTRESS TAB 400MG 3 QL TIVICAY TAB 10MG 3 QL TIVICAY TAB 25MG 3 QL TIVICAY TAB 50MG 3 QL ANTIRETROVIRALS, PROTEASE INHIBITORS APTIVUS CAP 250MG 3 QL APTIVUS SOL 3 QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 10

atazanavir sulfate cap 150 (base equiv) 2 QL atazanavir sulfate cap 200 (base equiv) 2 QL atazanavir sulfate cap 300 (base equiv) 2 QL CRIXIVAN CAP 200MG 3 QL CRIXIVAN CAP 400MG 3 QL fosamprenavir calcium tab 700 (base 2 QL equiv) INVIRASE CAP 200MG 3 QL INVIRASE TAB 500MG 3 QL KALETRA TAB 100-25MG 3 QL KALETRA TAB 200-50MG 3 QL LEXIVA SUS 50MG/ML 3 QL LEXIVA TAB 700MG 4 QL lopinavir-ritonavir soln 400-100 /5ml 2 QL (80-20 /ml) NORVIR CAP 100MG 3 QL NORVIR SOL 80MG/ML 3 QL NORVIR TAB 100MG 3 QL PREZISTA SUS 100MG/ML 3 QL PREZISTA TAB 75MG 3 QL PREZISTA TAB 150MG 3 QL PREZISTA TAB 600MG 3 QL PREZISTA TAB 800MG 3 QL REYATAZ CAP 150MG 4 QL REYATAZ CAP 200MG 4 QL REYATAZ CAP 300MG 4 QL REYATAZ POW 50MG 3 QL ritonavir tab 100 2 QL VIRACEPT TAB 250MG 3 QL VIRACEPT TAB 625MG 3 QL ANTIRETROVIRALS, REVERSE TRANSCRIPTASE INHIBITORS - NON-NUCLEOSIDE EDURANT TAB 25MG 3 QL efavirenz cap 50 2 QL efavirenz cap 200 2 QL efavirenz tab 600 2 QL INTELENCE TAB 25MG 3 PA; QL INTELENCE TAB 100MG 3 PA; QL INTELENCE TAB 200MG 3 PA; QL nevirapine tab 200 2 QL nevirapine tab er 24hr 100 2 QL nevirapine tab er 24hr 400 2 QL RESCRIPTOR TAB 100 MG 3 QL RESCRIPTOR TAB 200MG 3 QL SUSTIVA CAP 50MG 4 QL SUSTIVA CAP 200MG 4 QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 11

SUSTIVA TAB 600MG 4 QL VIRAMUNE SUS 50MG/5ML 3 QL ANTIRETROVIRALS, REVERSE TRANSCRIPTASE INHIBITORS - NUCLEOSIDE abacavir sulfate tab 300 (base equiv) 2 QL didanosine delayed release capsule 200 2 QL didanosine delayed release capsule 250 2 QL didanosine delayed release capsule 400 2 QL EMTRIVA CAP 200MG 3 QL EMTRIVA SOL 10MG/ML 3 QL EPIVIR SOL 10MG/ML 3 lamivudine oral soln 10 /ml 2 lamivudine tab 150 2 lamivudine tab 300 2 RETROVIR INJ 10MG/ML 3 stavudine cap 15 2 QL stavudine cap 20 2 QL stavudine cap 30 2 QL stavudine cap 40 2 QL VIDEX SOL 2GM 3 QL VIDEX SOL 4GM 3 QL zidovudine cap 100 2 QL zidovudine syrup 10 /ml 2 QL zidovudine tab 300 2 QL ANTIRETROVIRALS, REVERSE TRANSCRIPTASE INHIBITORS - NUCLEOTIDE tenofovir disoproxil fumarate tab 300 2 QL VIREAD POW 40MG/GM 3 VIREAD TAB 150MG 3 QL VIREAD TAB 200MG 3 QL VIREAD TAB 250MG 3 QL VIREAD TAB 300MG 4 QL ANTITUBERCULAR AGENTS cycloserine cap 250 3 ethambutol hcl tab 100 2 ethambutol hcl tab 400 2 isoniazid syrup 50 /5ml 2 isoniazid tab 100 2 isoniazid tab 300 1 PASER GRA 4GM 3 PRIFTIN TAB 150MG 3 pyrazinamide tab 500 2 RIFAMATE CAP 4 rifampin cap 150 2 rifampin cap 300 2 RIFATER TAB 3 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 12

SIRTURO TAB 100MG 4 PA TRECATOR TAB 250MG 3 ANTIVIRALS, CMV AGENTS VALCYTE SOL 50MG/ML 5 QL VALCYTE TAB 450MG 5 valganciclovir hcl tab 450 (base equivalent) 4 ANTIVIRALS, HEPATITIS AGENTS - HEPATITIS B BARACLUDE SOL.05MG/ML 5 PA BARACLUDE TAB 0.5MG 5 PA BARACLUDE TAB 1MG 5 PA entecavir tab 0.5 5 PA entecavir tab 1 5 PA EPIVIR HBV SOL 5MG/ML 3 PA EPIVIR HBV TAB 100MG 4 PA lamivudine tab 100 (hbv) 2 PA ANTIVIRALS, HEPATITIS AGENTS - HEPATITIS C EPCLUSA TAB 400-100 5 PA; QL HARVONI TAB 90-400MG 5 PA; QL MAVYRET TAB 100-40MG 5 PA; QL REBETOL SOL 40MG/ML 5 QL ribavirin cap 200 5 QL ribavirin tab 200 5 QL ribavirin tab 400 5 QL ribavirin tab 600 5 QL VOSEVI TAB 5 PA; QL ANTIVIRALS, HERPES AGENTS acyclovir cap 200 1 acyclovir susp 200 /5ml 2 acyclovir tab 400 2 acyclovir tab 800 2 famciclovir tab 125 2 QL famciclovir tab 250 2 QL famciclovir tab 500 2 QL valacyclovir hcl tab 1 gm 2 QL valacyclovir hcl tab 500 2 QL ANTIVIRALS, INFLUENZA AGENTS oseltamivir phosphate cap 30 (base 2 QL equiv) oseltamivir phosphate cap 45 (base 2 QL equiv) oseltamivir phosphate cap 75 (base 2 QL equiv) oseltamivir phosphate for susp 6 /ml 2 QL (base equiv) RELENZA MIS DISKHALE 4 QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 13

rimantadine hydrochloride tab 100 2 TAMIFLU CAP 30MG 4 QL TAMIFLU CAP 45MG 4 QL TAMIFLU CAP 75MG 4 QL TAMIFLU SUS 6MG/ML 4 QL MISCELLANEOUS ALBENZA TAB 200MG 3 ALINIA SUS 100/5ML 3 ALINIA TAB 500MG 3 atovaquone susp 750 /5ml 2 BILTRICIDE TAB 600MG 3 CLEOCIN CAP 75MG 4 CLEOCIN CAP 150MG 4 CLEOCIN CAP 300MG 4 clindamycin hcl cap 75 2 clindamycin hcl cap 150 2 clindamycin hcl cap 300 2 clindamycin palmitate hcl for soln 75 2 /5ml (base equiv) dapsone tab 25 3 dapsone tab 100 3 ivermectin tab 3 2 linezolid for susp 100 /5ml 4 QL linezolid tab 600 2 QL MEPRON SUS 4 metronidazole cap 375 2 metronidazole tab 250 2 metronidazole tab 500 2 NEBUPENT INH 300MG 3 nitrofurantoin macrocrystalline cap 50 2 nitrofurantoin macrocrystalline cap 100 2 nitrofurantoin monohydrate 2 macrocrystalline cap 100 PRIMSOL SOL 50MG/5ML 3 rifabutin cap 150 2 SIVEXTRO INJ 200MG 5 SIVEXTRO TAB 200MG 5 QL STROMECTOL TAB 3MG 4 trimethoprim tab 100 2 vancomycin hcl cap 125 (base 2 equivalent) vancomycin hcl cap 250 (base 2 equivalent) VANCOMYCIN INJ 500MG 4 VANCOMYCIN INJ 750MG 4 XIFAXAN TAB 200MG 4 QL XIFAXAN TAB 550MG 5 PA; QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 14

ANTINEOPLASTIC AGENTS ALKYLATING AGENTS ALKERAN INJ 50MG 5 ALKERAN TAB 2MG 5 BENDEKA INJ 100/4ML 5 BICNU INJ 100MG 5 busulfan inj 6 /ml 5 BUSULFEX INJ 6MG/ML 5 carboplatin iv soln 50 /5ml 5 carboplatin iv soln 150 /15ml 5 carboplatin iv soln 450 /45ml 5 carboplatin iv soln 600 /60ml 5 cisplatin inj 50 /50ml (1 /ml) 5 cisplatin inj 100 /100ml (1 /ml) 5 cisplatin inj 200 /200ml (1 /ml) 5 CYCLOPHOSPH CAP 25MG 5 CYCLOPHOSPH CAP 50MG 5 cyclophosphamide for inj 1 gm 5 cyclophosphamide for inj 2 gm 5 cyclophosphamide for inj 500 5 dacarbazine for inj 100 5 dacarbazine for inj 200 5 EMCYT CAP 140MG 5 PA GLEOSTINE CAP 10MG 5 PA GLEOSTINE CAP 40MG 5 PA GLEOSTINE CAP 100MG 5 PA HEXALEN CAP 50MG 5 IFEX INJ 1GM 5 ifosfamide for inj 1 gm 5 IFOSFAMIDE INJ 3GM 5 ifosfamide iv inj 1 gm/20ml (50 /ml) 5 ifosfamide iv inj 3 gm/60ml (50 /ml) 5 LEUKERAN TAB 2MG 5 melphalan hcl for inj 50 (base equiv) 5 MUSTARGEN INJ 10MG 5 MYLERAN TAB 2MG 5 oxaliplatin for iv inj 50 5 oxaliplatin for iv inj 100 5 oxaliplatin iv soln 50 /10ml 5 oxaliplatin iv soln 100 /20ml 5 TEMODAR CAP 5MG 5 PA TEMODAR CAP 20MG 5 PA TEMODAR CAP 100MG 5 PA TEMODAR CAP 140MG 5 PA TEMODAR CAP 180MG 5 PA TEMODAR CAP 250MG 5 PA PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 15

TEMODAR INJ 100MG 5 PA temozolomide cap 5 5 PA temozolomide cap 20 5 PA temozolomide cap 100 5 PA temozolomide cap 140 5 PA temozolomide cap 180 5 PA temozolomide cap 250 5 PA TREANDA INJ 25MG 5 TREANDA INJ 100MG 5 VALCHLOR GEL 0.016% 5 PA ZANOSAR INJ 1GM 5 ANTIMETABOLITES ALIMTA INJ 100MG 5 ALIMTA INJ 500MG 5 capecitabine tab 150 5 PA capecitabine tab 500 5 PA cladribine iv soln 10 /10ml (1 /ml) 2 cytarabine inj 20 /ml 2 cytarabine inj pf 20 /ml 4 cytarabine inj pf 100 /ml 2 floxuridine for inj 0.5 gm 5 fludarabine phosphate for inj 50 5 fludarabine phosphate inj 25 /ml 5 fluorouracil iv soln 1 gm/20ml (50 /ml) 5 fluorouracil iv soln 2.5 gm/50ml (50 5 /ml) fluorouracil iv soln 5 gm/100ml (50 /ml) 5 fluorouracil iv soln 500 /10ml (50 5 /ml) gemcitabine hcl for inj 2 gm 2 gemcitabine hcl inj 1 gm/26.3ml (38 2 /ml) (base equiv) gemcitabine hcl inj 2 gm/52.6ml (38 2 /ml) (base equiv) gemcitabine hcl inj 200 /5.26ml (38 2 /ml) (base equiv) mercaptopurine tab 50 2 methotrexate sodium for inj 1 gm 2 methotrexate sodium inj 50 /2ml (25 5 /ml) methotrexate sodium inj 250 /10ml (25 5 /ml) methotrexate sodium inj pf 50 /2ml (25 2 /ml) methotrexate sodium inj pf 250 /10ml 2 (25 /ml) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 16

methotrexate sodium inj pf 1000 /40ml 2 (25 /ml) methotrexate sodium tab 2.5 (base 2 equiv) TABLOID TAB 40MG 5 PA XELODA TAB 150MG 5 PA XELODA TAB 500MG 5 PA HORMONAL ANTINEOPLASTICS, ANTIANDROGENS bicalutamide tab 50 2 ERLEADA TAB 60MG 5 PA; QL flutamide cap 125 2 NILANDRON TAB 150MG 5 PA XTANDI CAP 40MG 5 PA; QL ZYTIGA TAB 250MG 5 PA; QL ZYTIGA TAB 500MG 5 PA; QL HORMONAL ANTINEOPLASTICS, ANTIESTROGENS FARESTON TAB 60MG 5 PA FASLODEX INJ 250/5ML 5 HORMONAL ANTINEOPLASTICS, AROMATASE INHIBITORS anastrozole tab 1 2 exemestane tab 25 2 letrozole tab 2.5 2 HORMONAL ANTINEOPLASTICS, GONADOTROPIN RELEASING HORMONE ANTAGONISTS FIRMAGON INJ 80MG 5 PA; QL FIRMAGON INJ 120MG 5 PA; QL HORMONAL ANTINEOPLASTICS, LUTEINIZING HORMONE-RELEASING HORMONE (LHRH) AGONISTS ELIGARD INJ 7.5MG 5 PA; QL ELIGARD INJ 22.5MG 5 PA; QL ELIGARD INJ 30MG 5 PA; QL ELIGARD INJ 45MG 5 PA; QL leuprolide acetate inj kit 5 /ml 5 PA; QL LUPRON DEPOT INJ 3.75MG 5 PA; QL LUPRON DEPOT INJ 7.5MG 5 PA; QL LUPRON DEPOT INJ 11.25MG 5 PA; QL LUPRON DEPOT INJ 22.5MG 5 PA; QL LUPRON DEPOT INJ 30MG 5 PA; QL LUPRON DEPOT INJ 45MG 5 PA; QL TRELSTAR MIX INJ 3.75MG 5 PA; QL TRELSTAR MIX INJ 11.25MG 5 PA; QL TRELSTAR MIX INJ 22.5MG 5 PA; QL VANTAS KIT 50MG 5 PA; QL ZOLADEX IMP 3.6MG 5 PA; QL ZOLADEX IMP 10.8MG 5 PA; QL HORMONAL ANTINEOPLASTICS, PROGESTINS PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 17

DEPO-PROVERA INJ 400/ML 4 QL megestrol acetate susp 40 /ml 2 megestrol acetate tab 20 2 megestrol acetate tab 40 2 IMMUNOMODULATORS POMALYST CAP 1MG 5 PA; QL POMALYST CAP 2MG 5 PA; QL POMALYST CAP 3MG 5 PA; QL POMALYST CAP 4MG 5 PA; QL REVLIMID CAP 2.5MG 5 PA; QL REVLIMID CAP 5MG 5 PA; QL REVLIMID CAP 10MG 5 PA; QL REVLIMID CAP 15MG 5 PA; QL REVLIMID CAP 20MG 5 PA; QL REVLIMID CAP 25MG 5 PA; QL THALOMID CAP 50MG 5 PA; QL THALOMID CAP 100MG 5 PA; QL THALOMID CAP 150MG 5 PA; QL THALOMID CAP 200MG 5 PA; QL KINASE INHIBITORS AFINITOR DIS TAB 2MG 5 PA; QL AFINITOR DIS TAB 3MG 5 PA; QL AFINITOR DIS TAB 5MG 5 PA; QL AFINITOR TAB 2.5MG 5 PA; QL AFINITOR TAB 5MG 5 PA; QL AFINITOR TAB 7.5MG 5 PA; QL AFINITOR TAB 10MG 5 PA; QL ALECENSA CAP 150MG 5 PA; QL ALUNBRIG PAK 5 PA; QL ALUNBRIG TAB 30MG 5 PA; QL ALUNBRIG TAB 90MG 5 PA; QL ALUNBRIG TAB 180MG 5 PA; QL BOSULIF TAB 100MG 5 PA; QL BOSULIF TAB 500MG 5 PA; QL CABOMETYX TAB 20MG 5 PA; QL CABOMETYX TAB 40MG 5 PA; QL CABOMETYX TAB 60MG 5 PA; QL CALQUENCE CAP 100MG 5 PA; QL CAPRELSA TAB 100MG 5 PA; QL CAPRELSA TAB 300MG 5 PA; QL COMETRIQ KIT 60MG 5 PA; QL COMETRIQ KIT 100MG 5 PA; QL COMETRIQ KIT 140MG 5 PA; QL COTELLIC TAB 20MG 5 PA; QL GILOTRIF TAB 20MG 5 PA; QL GILOTRIF TAB 30MG 5 PA; QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 18

GILOTRIF TAB 40MG 5 PA; QL IBRANCE CAP 75MG 5 PA; QL IBRANCE CAP 100MG 5 PA; QL IBRANCE CAP 125MG 5 PA; QL ICLUSIG TAB 15MG 5 PA; QL ICLUSIG TAB 45MG 5 PA; QL imatinib mesylate tab 100 (base 5 PA; QL equivalent) imatinib mesylate tab 400 (base 5 PA; QL equivalent) IMBRUVICA CAP 140MG 5 PA; QL IMBRUVICA TAB 140MG 5 PA; QL IMBRUVICA TAB 280MG 5 PA; QL IMBRUVICA TAB 420MG 5 PA; QL IMBRUVICA TAB 560MG 5 PA; QL INLYTA TAB 1MG 5 PA; QL INLYTA TAB 5MG 5 PA; QL IRESSA TAB 250MG 5 PA; QL JAKAFI TAB 5MG 5 PA; QL JAKAFI TAB 10MG 5 PA; QL JAKAFI TAB 15MG 5 PA; QL JAKAFI TAB 20MG 5 PA; QL JAKAFI TAB 25MG 5 PA; QL KISQALI 200 PAK FEMARA 5 PA; QL KISQALI 400 PAK FEMARA 5 PA; QL KISQALI 600 PAK FEMARA 5 PA; QL KISQALI TAB 200DOSE 5 PA; QL KISQALI TAB 400DOSE 5 PA; QL KISQALI TAB 600DOSE 5 PA; QL LENVIMA CAP 8 MG 5 PA; QL LENVIMA CAP 10 MG 5 PA; QL LENVIMA CAP 14 MG 5 PA; QL LENVIMA CAP 18 MG 5 PA; QL LENVIMA CAP 20 MG 5 PA; QL LENVIMA CAP 24 MG 5 PA; QL MEKINIST TAB 0.5MG 5 PA; QL MEKINIST TAB 2MG 5 PA; QL NERLYNX TAB 40MG 5 PA; QL NEXAVAR TAB 200MG 5 PA; QL RYDAPT CAP 25MG 5 PA; QL SPRYCEL TAB 20MG 5 PA; QL SPRYCEL TAB 50MG 5 PA; QL SPRYCEL TAB 70MG 5 PA; QL SPRYCEL TAB 80MG 5 PA; QL SPRYCEL TAB 100MG 5 PA; QL SPRYCEL TAB 140MG 5 PA; QL STIVARGA TAB 40MG 5 PA; QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 19

SUTENT CAP 12.5MG 5 PA; QL SUTENT CAP 25MG 5 PA; QL SUTENT CAP 37.5MG 5 PA; QL SUTENT CAP 50MG 5 PA; QL TAFINLAR CAP 50MG 5 PA; QL TAFINLAR CAP 75MG 5 PA; QL TAGRISSO TAB 40MG 5 PA; QL TAGRISSO TAB 80MG 5 PA; QL TARCEVA TAB 25MG 5 PA TARCEVA TAB 100MG 5 PA; QL TARCEVA TAB 150MG 5 PA; QL TASIGNA CAP 50MG 5 PA; QL TASIGNA CAP 150MG 5 PA; QL TASIGNA CAP 200MG 5 PA; QL TORISEL SOL 25MG/ML 5 QL TYKERB TAB 250MG 5 PA; QL VERZENIO TAB 50MG 5 PA; QL VERZENIO TAB 100MG 5 PA; QL VERZENIO TAB 150MG 5 PA; QL VERZENIO TAB 200MG 5 PA; QL VOTRIENT TAB 200MG 5 QL XALKORI CAP 200MG 5 PA; QL XALKORI CAP 250MG 5 PA; QL ZELBORAF TAB 240MG 5 PA; QL ZYDELIG TAB 100MG 5 PA; QL ZYDELIG TAB 150MG 5 PA; QL ZYKADIA CAP 150MG 5 PA; QL MISCELLANEOUS ABRAXANE INJ 100MG 5 ADCETRIS INJ 50MG 5 ARRANON INJ 5MG/ML 5 AVASTIN INJ 5 AVASTIN INJ 400/16ML 5 bexarotene cap 75 5 PA bleomycin sulfate for inj 15 unit 5 bleomycin sulfate for inj 30 unit 5 daunorubicin hcl iv soln 20 /4ml (base 5 equiv) doxorubicin hcl for inj 10 5 doxorubicin hcl for inj 50 5 doxorubicin hcl inj 2 /ml 5 ELITEK INJ 1.5MG 5 ELITEK INJ 7.5MG 5 ELLENCE INJ 2MG/ML 5 epirubicin hcl iv soln 200 /100ml (2 5 /ml) ERBITUX INJ 100MG 5 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 20

ERBITUX INJ 200MG 5 ERIVEDGE CAP 150MG 5 PA; QL ETOPOPHOS INJ 100MG 5 etoposide cap 50 5 PA etoposide inj 1 gm/50ml (20 /ml) 2 PA etoposide inj 100 /5ml (20 /ml) 2 PA etoposide inj 500 /25ml (20 /ml) 2 PA FARYDAK CAP 10MG 5 PA; QL FARYDAK CAP 15MG 5 PA; QL FARYDAK CAP 20MG 5 PA; QL HERCEPTIN INJ 150MG 5 HERCEPTIN INJ 440MG 5 hydroxyurea cap 500 2 IDAMYCIN PFS INJ 5MG/5ML 5 IDAMYCIN PFS INJ 20/20ML 5 idarubicin hcl iv inj 5 /5ml (1 /ml) 5 idarubicin hcl iv inj 20 /20ml (1 /ml) 5 IDHIFA TAB 50MG 5 PA; QL IDHIFA TAB 100MG 5 PA; QL IXEMPRA KIT INJ 15MG 5 IXEMPRA KIT INJ 45MG 5 JEVTANA INJ 60/1.5ML 5 KYPROLIS SOL 30MG 5 KYPROLIS SOL 60MG 5 leucovorin calcium for inj 500 5 leucovorin calcium tab 5 5 leucovorin calcium tab 10 2 leucovorin calcium tab 15 5 leucovorin calcium tab 25 5 LONSURF TAB 15-6.14 5 PA LONSURF TAB 20-8.19 5 PA LYNPARZA CAP 50MG 5 PA; QL LYSODREN TAB 500MG 5 PA MATULANE CAP 50MG 5 MESNEX TAB 400MG 5 mitomycin for iv soln 5 5 mitomycin for iv soln 20 5 mitomycin for iv soln 40 5 mitoxantrone hcl inj conc 20 /10ml (2 /ml) 5 mitoxantrone hcl inj conc 25 /12.5ml (2 5 /ml) mitoxantrone hcl inj conc 30 /15ml (2 5 /ml) NINLARO CAP 2.3MG 5 PA; QL NINLARO CAP 3MG 5 PA; QL NINLARO CAP 4MG 5 PA; QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 21

NIPENT INJ 10MG 5 ODOMZO CAP 200MG 5 PA; QL paclitaxel iv conc 30 /5ml (6 /ml) 2 paclitaxel iv conc 100 /16.7ml (6 /ml) 2 paclitaxel iv conc 150 /25ml (6 /ml) 2 paclitaxel iv conc 300 /50ml (6 /ml) 2 PERJETA INJ 420/14ML 5 PHOTOFRIN INJ 75MG 5 PROLEUKIN INJ 22MU 5 RITUXAN INJ 100MG 5 PA RITUXAN INJ 500MG 5 PA RUBRACA TAB 200MG 5 PA; QL RUBRACA TAB 250MG 5 PA; QL RUBRACA TAB 300MG 5 PA; QL SYNRIBO INJ 3.5MG 5 PA TARGRETIN GEL 1% 5 PA TENIPOSIDE INJ 50MG/5ML 5 THERACYS INJ 5 TICE BCG INJ 5 tretinoin cap 10 5 VECTIBIX INJ 100MG 5 VECTIBIX INJ 400MG 5 VELCADE INJ 3.5MG 5 VENCLEXTA TAB 10MG 5 PA; QL VENCLEXTA TAB 50MG 5 PA; QL VENCLEXTA TAB 100MG 5 PA; QL VENCLEXTA TAB START PK 5 PA; QL vinblastine sulfate inj 1 /ml 2 vincristine sulfate iv soln 1 /ml 2 YERVOY INJ 50MG 5 YERVOY INJ 200MG 5 ZALTRAP INJ 100/4ML 5 ZALTRAP INJ 200/8ML 5 ZEJULA CAP 100MG 5 PA; QL ZEVALIN KIT Y-90 5 ZOLINZA CAP 100MG 5 PA; QL TOPOISOMERASE INHIBITORS CAMPTOSAR INJ 300/15ML 5 HYCAMTIN CAP 0.25MG 5 PA HYCAMTIN CAP 1MG 5 PA irinotecan hcl inj 500 /25ml (20 /ml) 5 TOPOTECAN INJ 4MG/4ML 5 CARDIOVASCULAR ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 22

amlodipine besylate-benazepril hcl cap 2 2.5-10 amlodipine besylate-benazepril hcl cap 2 5-10 amlodipine besylate-benazepril hcl cap 2 5-20 amlodipine besylate-benazepril hcl cap 2 5-40 amlodipine besylate-benazepril hcl cap 2 10-20 amlodipine besylate-benazepril hcl cap 2 10-40 TARKA TAB 2-180 CR 4 TARKA TAB 2-240 CR 4 TARKA TAB 4-240 CR 4 trandolapril-verapamil hcl tab er 1-240 2 trandolapril-verapamil hcl tab er 2-180 2 trandolapril-verapamil hcl tab er 2-240 2 trandolapril-verapamil hcl tab er 4-240 2 ACE INHIBITOR/DIURETIC COMBINATIONS benazepril & hydrochlorothiazide tab 2 5-6.25 benazepril & hydrochlorothiazide tab 2 10-12.5 benazepril & hydrochlorothiazide tab 2 20-12.5 benazepril & hydrochlorothiazide tab 20-25 2 captopril & hydrochlorothiazide tab 25-15 2 captopril & hydrochlorothiazide tab 25-25 2 captopril & hydrochlorothiazide tab 50-15 2 captopril & hydrochlorothiazide tab 50-25 2 enalapril maleate & hydrochlorothiazide tab 2 5-12.5 enalapril maleate & hydrochlorothiazide tab 2 10-25 fosinopril sodium & hydrochlorothiazide tab 2 10-12.5 fosinopril sodium & hydrochlorothiazide tab 2 20-12.5 lisinopril & hydrochlorothiazide tab 10-12.5 1 lisinopril & hydrochlorothiazide tab 20-12.5 1 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 23

lisinopril & hydrochlorothiazide tab 20-25 1 moexipril-hydrochlorothiazide tab 7.5-12.5 2 moexipril-hydrochlorothiazide tab 15-12.5 2 moexipril-hydrochlorothiazide tab 15-25 2 quinapril-hydrochlorothiazide tab 10-12.5 2 quinapril-hydrochlorothiazide tab 20-12.5 2 quinapril-hydrochlorothiazide tab 20-25 2 ACE INHIBITORS benazepril hcl tab 5 1 benazepril hcl tab 10 1 benazepril hcl tab 20 1 benazepril hcl tab 40 1 captopril tab 12.5 2 captopril tab 25 2 captopril tab 50 2 captopril tab 100 2 enalapril maleate tab 2.5 2 enalapril maleate tab 5 1 enalapril maleate tab 10 1 enalapril maleate tab 20 1 enalaprilat iv inj 1.25 /ml 2 fosinopril sodium tab 10 2 fosinopril sodium tab 20 2 fosinopril sodium tab 40 2 lisinopril tab 2.5 1 lisinopril tab 5 1 lisinopril tab 10 1 lisinopril tab 20 1 lisinopril tab 30 1 lisinopril tab 40 1 moexipril hcl tab 7.5 2 moexipril hcl tab 15 2 perindopril erbumine tab 2 2 perindopril erbumine tab 4 2 perindopril erbumine tab 8 2 quinapril hcl tab 5 2 quinapril hcl tab 10 2 quinapril hcl tab 20 2 quinapril hcl tab 40 2 ramipril cap 1.25 2 ramipril cap 2.5 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 24

ramipril cap 5 2 ramipril cap 10 2 trandolapril tab 1 2 trandolapril tab 2 2 trandolapril tab 4 2 ADRENOLYTICS, CENTRAL clonidine hcl tab 0.1 1 clonidine hcl tab 0.2 1 clonidine hcl tab 0.3 1 clonidine td patch weekly 0.1 /24hr 2 clonidine td patch weekly 0.2 /24hr 2 clonidine td patch weekly 0.3 /24hr 2 guanfacine hcl tab 1 1 guanfacine hcl tab 2 1 AGENTS FOR PHEOCHROMOCYTOMA DEMSER CAP 250MG 4 PA DIBENZYLINE CAP 10MG 4 PA phenoxybenzamine hcl cap 10 4 PA ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone tab 25 2 eplerenone tab 50 2 spironolactone tab 25 1 spironolactone tab 50 2 spironolactone tab 100 2 ALPHA BLOCKERS doxazosin mesylate tab 1 2 doxazosin mesylate tab 2 2 doxazosin mesylate tab 4 2 doxazosin mesylate tab 8 2 prazosin hcl cap 1 2 prazosin hcl cap 2 2 prazosin hcl cap 5 2 terazosin hcl cap 1 (base equivalent) 1 terazosin hcl cap 2 (base equivalent) 1 terazosin hcl cap 5 (base equivalent) 1 terazosin hcl cap 10 (base equivalent) 1 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS telmisartan-amlodipine tab 40-5 2 telmisartan-amlodipine tab 40-10 2 telmisartan-amlodipine tab 80-5 2 telmisartan-amlodipine tab 80-10 2 ANGIOTENSIN II RECEPTOR ANTAGONIST/DIURETIC COMBINATIONS PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 25

candesartan cilexetil-hydrochlorothiazide 2 tab 16-12.5 candesartan cilexetil-hydrochlorothiazide 2 tab 32-12.5 candesartan cilexetil-hydrochlorothiazide 2 tab 32-25 irbesartan-hydrochlorothiazide tab 2 150-12.5 irbesartan-hydrochlorothiazide tab 2 300-12.5 losartan potassium & hydrochlorothiazide 2 tab 50-12.5 losartan potassium & hydrochlorothiazide 2 tab 100-12.5 losartan potassium & hydrochlorothiazide 2 tab 100-25 telmisartan-hydrochlorothiazide tab 2 40-12.5 telmisartan-hydrochlorothiazide tab 2 80-12.5 telmisartan-hydrochlorothiazide tab 80-25 2 valsartan-hydrochlorothiazide tab 80-12.5 2 valsartan-hydrochlorothiazide tab 160-12.52 valsartan-hydrochlorothiazide tab 160-25 2 valsartan-hydrochlorothiazide tab 320-12.52 valsartan-hydrochlorothiazide tab 320-25 2 ANGIOTENSIN II RECEPTOR ANTAGONISTS candesartan cilexetil tab 4 2 candesartan cilexetil tab 8 2 candesartan cilexetil tab 16 2 candesartan cilexetil tab 32 2 eprosartan mesylate tab 600 2 irbesartan tab 75 2 irbesartan tab 150 2 irbesartan tab 300 2 losartan potassium tab 25 2 losartan potassium tab 50 2 losartan potassium tab 100 2 telmisartan tab 20 2 telmisartan tab 40 2 telmisartan tab 80 2 valsartan tab 40 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 26

valsartan tab 80 2 valsartan tab 160 2 valsartan tab 320 2 ANTIARRHYTHMICS adenosine iv soln 6 /2ml 2 adenosine iv soln 12 /4ml 2 amiodarone hcl tab 100 4 amiodarone hcl tab 200 2 amiodarone hcl tab 400 2 disopyramide phosphate cap 100 2 disopyramide phosphate cap 150 2 dofetilide cap 125 mcg (0.125 ) 2 QL dofetilide cap 250 mcg (0.25 ) 2 QL dofetilide cap 500 mcg (0.5 ) 2 QL flecainide acetate tab 50 2 flecainide acetate tab 100 2 flecainide acetate tab 150 2 lidocaine hcl iv inj 10 /ml 2 lidocaine hcl iv inj 20 /ml 2 lidocaine iv infusion in d5w inj 4 /ml 2 lidocaine iv infusion in d5w inj 8 /ml 2 mexiletine hcl cap 150 2 mexiletine hcl cap 200 2 mexiletine hcl cap 250 2 MULTAQ TAB 400MG 3 NEXTERONE INJ 4 NORPACE CAP 100MG CR 4 NORPACE CAP 150MG CR 4 PROCAINAMIDE HCL INJ 500 MG/ML 2 propafenone hcl cap er 12hr 225 2 propafenone hcl cap er 12hr 325 2 propafenone hcl cap er 12hr 425 2 propafenone hcl tab 150 2 propafenone hcl tab 225 2 propafenone hcl tab 300 2 quinidine sulfate tab 200 2 quinidine sulfate tab 300 2 sotalol hcl (afib/afl) tab 80 2 sotalol hcl (afib/afl) tab 120 2 sotalol hcl (afib/afl) tab 160 2 sotalol hcl tab 80 1 sotalol hcl tab 120 2 sotalol hcl tab 160 2 sotalol hcl tab 240 2 TIKOSYN CAP 125MCG 3 TIKOSYN CAP 250MCG 3 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 27

TIKOSYN CAP 500MCG 3 ANTILIPEMICS, BILE ACID RESINS cholestyramine light powder 4 gm/dose 2 cholestyramine light powder packets 4 gm 2 cholestyramine powder 4 gm/dose 2 cholestyramine powder packets 4 gm 2 colesevelam hcl tab 625 2 COLESTID GRA 5GM 4 COLESTID POW 5GM 4 COLESTID TAB 1GM 4 colestipol hcl granule packets 5 gm 2 colestipol hcl granules 5 gm 2 colestipol hcl tab 1 gm 2 WELCHOL PAK 3.75GM 3 WELCHOL TAB 625MG 3 ANTILIPEMICS, CHOLESTEROL ABSORPTION INHIBITORS ezetimibe tab 10 2 ANTILIPEMICS, FIBRATES choline fenofibrate cap dr 45 (fenofibric 2 PA, ST acid equiv) choline fenofibrate cap dr 135 2 PA, ST (fenofibric acid equiv) fenofibrate micronized cap 43 2 fenofibrate micronized cap 67 2 fenofibrate micronized cap 134 2 fenofibrate micronized cap 200 2 fenofibrate tab 48 2 fenofibrate tab 54 2 fenofibrate tab 145 2 fenofibrate tab 160 2 fenofibric acid tab 35 2 fenofibric acid tab 105 2 gemfibrozil tab 600 2 LOPID TAB 600MG 4 TRILIPIX CAP 45MG 4 PA, ST TRILIPIX CAP 135MG 4 PA, ST ANTILIPEMICS, HMG-COA REDUCTASE INHIBITORS/COMBINATIONS atorvastatin calcium tab 10 (base 2 equivalent) atorvastatin calcium tab 20 (base 2 equivalent) atorvastatin calcium tab 40 (base 2 equivalent) atorvastatin calcium tab 80 (base 2 equivalent) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 28

ezetimibe-simvastatin tab 10-10 4 QL ezetimibe-simvastatin tab 10-20 4 QL ezetimibe-simvastatin tab 10-40 4 QL ezetimibe-simvastatin tab 10-80 4 QL fluvastatin sodium cap 20 2 fluvastatin sodium cap 40 2 lovastatin tab 10 1 lovastatin tab 20 1 lovastatin tab 40 1 pravastatin sodium tab 10 2 pravastatin sodium tab 20 2 pravastatin sodium tab 40 2 pravastatin sodium tab 80 2 rosuvastatin calcium tab 5 2 rosuvastatin calcium tab 10 2 rosuvastatin calcium tab 20 2 rosuvastatin calcium tab 40 2 simvastatin tab 5 1 simvastatin tab 10 1 simvastatin tab 20 1 simvastatin tab 40 1 simvastatin tab 80 1 VYTORIN TAB 10-10MG 4 ST; QL VYTORIN TAB 10-20MG 4 ST; QL VYTORIN TAB 10-40MG 4 ST; QL VYTORIN TAB 10-80MG 4 ST; QL ANTILIPEMICS, MICROSOMAL TRIGLYCERIDE TRANSFER PROTEIN INHIBITORS JUXTAPID CAP 5MG 5 PA; QL JUXTAPID CAP 10MG 5 PA; QL JUXTAPID CAP 20MG 5 PA; QL JUXTAPID CAP 30MG 5 PA; QL JUXTAPID CAP 40MG 5 PA; QL JUXTAPID CAP 60MG 5 PA; QL ANTILIPEMICS, MISCELLANEOUS KYNAMRO INJ 200MG/ML 5 PA; QL ANTILIPEMICS, NIACINS/COMBINATIONS niacin tab er 500 (antihyperlipidemic) 4 niacin tab er 750 (antihyperlipidemic) 4 niacin tab er 1000 (antihyperlipidemic) 4 ANTILIPEMICS, OMEGA-3 FATTY ACIDS LOVAZA CAP 1GM 4 omega-3-acid ethyl esters cap 1 gm 4 VASCEPA CAP 1GM 3 ANTILIPEMICS, PCSK9 INHIBITORS REPATHA INJ 140MG/ML 5 PA; QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 29

REPATHA PUSH INJ 420/3.5 5 PA; QL REPATHA SURE INJ 140MG/ML 5 PA; QL BETA-BLOCKER/DIURETIC COMBINATIONS atenolol & chlorthalidone tab 50-25 2 atenolol & chlorthalidone tab 100-25 2 bisoprolol & hydrochlorothiazide tab 1 2.5-6.25 bisoprolol & hydrochlorothiazide tab 5-6.25 1 bisoprolol & hydrochlorothiazide tab 1 10-6.25 metoprolol & hydrochlorothiazide tab 2 50-25 metoprolol & hydrochlorothiazide tab 2 100-25 metoprolol & hydrochlorothiazide tab 2 100-50 nadolol & bendroflumethiazide tab 40-5 2 nadolol & bendroflumethiazide tab 80-5 2 propranolol & hydrochlorothiazide tab 2 40-25 propranolol & hydrochlorothiazide tab 2 80-25 BETA-BLOCKERS acebutolol hcl cap 200 2 acebutolol hcl cap 400 2 atenolol tab 25 1 atenolol tab 50 1 atenolol tab 100 1 betaxolol hcl tab 10 2 betaxolol hcl tab 20 2 bisoprolol fumarate tab 5 2 bisoprolol fumarate tab 10 2 BYSTOLIC TAB 2.5MG 4 PA, ST BYSTOLIC TAB 5MG 4 PA, ST BYSTOLIC TAB 10MG 4 PA, ST BYSTOLIC TAB 20MG 4 PA, ST carvedilol tab 3.125 1 carvedilol tab 6.25 1 carvedilol tab 12.5 1 carvedilol tab 25 1 INNOPRAN XL CAP 80MG 4 ST INNOPRAN XL CAP 120MG 4 ST labetalol hcl iv soln 5 /ml 2 labetalol hcl tab 100 2 labetalol hcl tab 200 2 labetalol hcl tab 300 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 30

metoprolol succinate tab er 24hr 25 2 (tartrate equiv) metoprolol succinate tab er 24hr 50 2 (tartrate equiv) metoprolol succinate tab er 24hr 100 2 (tartrate equiv) metoprolol succinate tab er 24hr 200 2 (tartrate equiv) metoprolol tartrate iv soln 5 /5ml 2 metoprolol tartrate tab 25 1 metoprolol tartrate tab 50 1 metoprolol tartrate tab 100 1 nadolol tab 20 2 nadolol tab 40 2 nadolol tab 80 2 pindolol tab 5 2 pindolol tab 10 2 propranolol hcl cap er 24hr 60 2 propranolol hcl cap er 24hr 80 2 propranolol hcl cap er 24hr 120 2 propranolol hcl cap er 24hr 160 2 propranolol hcl inj 1 /ml 2 propranolol hcl oral soln 20 /5ml 2 propranolol hcl oral soln 40 /5ml 2 propranolol hcl tab 10 1 propranolol hcl tab 20 2 propranolol hcl tab 40 2 propranolol hcl tab 60 1 propranolol hcl tab 80 2 timolol maleate tab 5 2 timolol maleate tab 10 2 timolol maleate tab 20 2 CALCIUM CHANNEL BLOCKERS, DIHYDROPYRIDINES amlodipine besylate tab 2.5 (base 1 equivalent) amlodipine besylate tab 5 (base 1 equivalent) amlodipine besylate tab 10 (base 1 equivalent) CLEVIPREX EMU 50/100ML 4 felodipine tab er 24hr 2.5 2 felodipine tab er 24hr 5 2 felodipine tab er 24hr 10 2 isradipine cap 2.5 2 isradipine cap 5 2 nicardipine hcl cap 20 2 nicardipine hcl cap 30 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 31

nicardipine hcl iv soln 2.5 /ml 2 nifedipine cap 20 2 nifedipine tab er 24hr 30 2 nifedipine tab er 24hr 60 2 nifedipine tab er 24hr 90 2 nifedipine tab er 24hr osmotic release 90 2 nimodipine cap 30 2 nisoldipine tab er 24hr 8.5 2 nisoldipine tab er 24hr 17 2 nisoldipine tab er 24hr 20 2 nisoldipine tab er 24hr 25.5 2 nisoldipine tab er 24hr 30 2 nisoldipine tab er 24hr 34 2 nisoldipine tab er 24hr 40 2 NORVASC TAB 2.5MG 4 NORVASC TAB 5MG 4 NORVASC TAB 10MG 4 SULAR TAB 8.5MG 4 SULAR TAB 17MG 4 SULAR TAB 34MG 4 CALCIUM CHANNEL BLOCKERS, NON DIHYDROPYRIDINES CARDIZEM LA TAB 120MG 4 diltiazem hcl cap er 12hr 60 2 diltiazem hcl cap er 12hr 90 2 diltiazem hcl cap er 12hr 120 2 diltiazem hcl cap er 24hr 120 2 diltiazem hcl cap er 24hr 180 2 diltiazem hcl cap er 24hr 240 2 diltiazem hcl coated beads cap er 24hr 120 2 diltiazem hcl coated beads cap er 24hr 180 2 diltiazem hcl coated beads cap er 24hr 240 2 diltiazem hcl coated beads cap er 24hr 300 2 diltiazem hcl coated beads cap er 24hr 360 2 diltiazem hcl coated beads tab er 24hr 180 2 diltiazem hcl coated beads tab er 24hr 240 2 diltiazem hcl coated beads tab er 24hr 300 2 diltiazem hcl coated beads tab er 24hr 360 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 32

diltiazem hcl coated beads tab er 24hr 420 2 diltiazem hcl extended release beads cap 2 er 24hr 120 diltiazem hcl extended release beads cap 2 er 24hr 180 diltiazem hcl extended release beads cap 2 er 24hr 240 diltiazem hcl extended release beads cap 2 er 24hr 300 diltiazem hcl extended release beads cap 2 er 24hr 360 diltiazem hcl extended release beads cap 2 er 24hr 420 diltiazem hcl iv soln 25 /5ml (5 /ml) 2 diltiazem hcl iv soln 50 /10ml (5 2 /ml) diltiazem hcl iv soln 125 /25ml (5 2 /ml) diltiazem hcl tab 30 2 diltiazem hcl tab 60 2 diltiazem hcl tab 90 2 diltiazem hcl tab 120 2 DILTIAZEM INJ 100MG 2 verapamil hcl cap er 24hr 100 2 verapamil hcl cap er 24hr 120 2 verapamil hcl cap er 24hr 180 2 verapamil hcl cap er 24hr 200 2 verapamil hcl cap er 24hr 240 2 verapamil hcl cap er 24hr 300 2 verapamil hcl cap er 24hr 360 2 verapamil hcl iv soln 2.5 /ml 2 verapamil hcl tab 40 1 verapamil hcl tab 80 1 verapamil hcl tab 120 1 verapamil hcl tab er 120 2 verapamil hcl tab er 180 2 verapamil hcl tab er 240 2 DIGITALIS GLYCOSIDES digoxin inj 0.25 /ml 2 digoxin oral soln 0.05 /ml 2 digoxin tab 125 mcg (0.125 ) 2 digoxin tab 250 mcg (0.25 ) 2 LANOXIN INJ 0.25MG/1 4 LANOXIN PED INJ 0.1MG/ML 4 LANOXIN TAB 0.25MG 4 LANOXIN TAB 0.125MG 4 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 33

DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS TEKTURNA HCT TAB 150-12.5 3 ST TEKTURNA HCT TAB 150-25MG 3 ST TEKTURNA HCT TAB 300-12.5 3 ST TEKTURNA HCT TAB 300-25MG 3 ST TEKTURNA TAB 150MG 3 ST TEKTURNA TAB 300MG 3 ST DIURETICS acetazolamide cap er 12hr 500 2 acetazolamide sodium for inj 500 2 acetazolamide tab 125 2 acetazolamide tab 250 2 ALDACTAZIDE TAB 50/50 4 amiloride & hydrochlorothiazide tab 5-50 2 amiloride hcl tab 5 2 bumetanide inj 0.25 /ml 2 bumetanide tab 0.5 2 bumetanide tab 1 2 bumetanide tab 2 2 chlorothiazide sodium for inj 500 2 chlorothiazide tab 250 2 chlorothiazide tab 500 2 chlorthalidone tab 25 2 chlorthalidone tab 50 2 DIURIL SUS 250/5ML 3 DYRENIUM CAP 50MG 4 DYRENIUM CAP 100MG 4 furosemide inj 10 /ml 2 furosemide oral soln 8 /ml 2 furosemide oral soln 10 /ml 2 furosemide tab 20 1 furosemide tab 40 1 furosemide tab 80 1 hydrochlorothiazide cap 12.5 1 hydrochlorothiazide tab 12.5 1 hydrochlorothiazide tab 25 1 hydrochlorothiazide tab 50 1 indapamide tab 1.25 2 indapamide tab 2.5 2 KEVEYIS TAB 50MG 5 PA; QL methazolamide tab 25 2 methazolamide tab 50 2 methyclothiazide tab 5 2 metolazone tab 2.5 2 metolazone tab 5 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 34

metolazone tab 10 2 spironolactone & hydrochlorothiazide tab 2 25-25 torsemide tab 5 2 torsemide tab 10 2 torsemide tab 20 2 torsemide tab 100 2 triamterene & hydrochlorothiazide cap 1 37.5-25 triamterene & hydrochlorothiazide tab 1 37.5-25 triamterene & hydrochlorothiazide tab 1 75-50 HEART FAILURE CORLANOR TAB 5MG 4 PA; QL CORLANOR TAB 7.5MG 4 PA; QL ENTRESTO TAB 24-26MG 3 PA; QL ENTRESTO TAB 49-51MG 3 PA; QL ENTRESTO TAB 97-103MG 3 PA; QL MISCELLANEOUS atropine sulfate inj 0.4 /ml 2 atropine sulfate inj 1 /ml 2 atropine sulfate soln prefill syr 0.5 /5ml 2 (0.1 /ml) atropine sulfate soln prefill syr 0.25 2 /5ml (0.05 /ml) ETHAMOLIN INJ 5% 4 hydralazine hcl inj 20 /ml 2 hydralazine hcl tab 10 2 hydralazine hcl tab 25 2 hydralazine hcl tab 50 1 hydralazine hcl tab 100 1 methyldopa & hydrochlorothiazide tab 2 250-15 methyldopa & hydrochlorothiazide tab 2 250-25 methyldopa tab 250 2 methyldopa tab 500 2 methyldopate hcl inj 250 /5ml 2 midodrine hcl tab 2.5 2 midodrine hcl tab 5 2 midodrine hcl tab 10 2 milrinone lactate in dextrose 5% iv soln 20 2 /100ml milrinone lactate in dextrose 5% iv soln 40 2 /200ml PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 35

milrinone lactate iv soln 10 /10ml (base 2 equivalent) milrinone lactate iv soln 20 /20ml (base 2 equivalent) milrinone lactate iv soln 50 /50ml (base 2 equivalent) minoxidil tab 2.5 2 minoxidil tab 10 2 NATRECOR INJ 1.5MG 4 NORTHERA CAP 200MG 5 PA; QL NORTHERA CAP 300MG 5 PA; QL papaverine hcl inj 30 /ml 2 RANEXA TAB 500MG 3 RANEXA TAB 1000MG 3 NITRATES, INJECTABLE NITROGLYCER INJ 5MG/ML 2 NITRATES, ORAL ISORDIL TAB 40MG 4 isosorbide dinitrate tab 5 2 isosorbide dinitrate tab 10 2 isosorbide dinitrate tab 20 2 isosorbide dinitrate tab 30 2 isosorbide dinitrate tab er 40 2 isosorbide mononitrate tab 10 2 isosorbide mononitrate tab 20 2 isosorbide mononitrate tab er 24hr 30 2 isosorbide mononitrate tab er 24hr 60 2 isosorbide mononitrate tab er 24hr 120 2 nitroglycerin cap er 2.5 2 nitroglycerin cap er 6.5 2 nitroglycerin cap er 9 2 NITRATES, SUBLINGUAL/TRANSLINGUAL nitroglycerin sl tab 0.3 2 nitroglycerin sl tab 0.4 2 nitroglycerin sl tab 0.6 2 nitroglycerin tl soln 0.4 /spray (400 2 mcg/spray) NITROLINGUAL SPR PUMPSPRA 4 NITROSTAT SUB 0.3MG 4 NITROSTAT SUB 0.4MG 4 NITROSTAT SUB 0.6MG 4 NITRATES, TRANSDERMAL NITRO-BID OIN 2% 2 NITRO-DUR DIS 0.1MG/HR 4 NITRO-DUR DIS 0.2MG/HR 4 NITRO-DUR DIS 0.3MG/HR 4 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 36

NITRO-DUR DIS 0.4MG/HR 4 NITRO-DUR DIS 0.6MG/HR 4 NITRO-DUR DIS 0.8MG/HR 4 nitroglycerin td patch 24hr 0.1 /hr 2 nitroglycerin td patch 24hr 0.2 /hr 2 nitroglycerin td patch 24hr 0.4 /hr 2 nitroglycerin td patch 24hr 0.6 /hr 2 PULMONARY ARTERIAL HYPERTENSION, ENDOTHELIN RECEPTOR ANTAGONIST LETAIRIS TAB 5MG 5 PA; QL LETAIRIS TAB 10MG 5 PA; QL TRACLEER TAB 62.5MG 5 PA; QL TRACLEER TAB 125MG 5 PA; QL PULMONARY ARTERIAL HYPERTENSION, PHOSPHODIESTERASE INHIBITOR REVATIO TAB 20MG 5 PA; QL sildenafil citrate tab 20 5 PA; QL PULMONARY ARTERIAL HYPERTENSION, PROSTACYCLIN RECEPTOR AGONISTS UPTRAVI TAB 200/800 4 PA; QL UPTRAVI TAB 200MCG 5 PA; QL UPTRAVI TAB 400MCG 5 PA; QL UPTRAVI TAB 600MCG 5 PA; QL UPTRAVI TAB 800MCG 5 PA; QL UPTRAVI TAB 1000MCG 5 PA; QL UPTRAVI TAB 1200MCG 5 PA; QL UPTRAVI TAB 1400MCG 5 PA; QL UPTRAVI TAB 1600MCG 5 PA; QL PULMONARY ARTERIAL HYPERTENSION, PROSTAGLANDIN VASODILATORS epoprostenol sodium for inj 0.5 5 PA FLOLAN INJ 0.5MG 5 PA FLOLAN INJ 1.5MG 5 PA ORENITRAM TAB 0.25MG 5 PA ORENITRAM TAB 0.125MG 5 PA ORENITRAM TAB 1MG 5 PA ORENITRAM TAB 2.5MG 5 PA ORENITRAM TAB 5MG 5 PA REMODULIN INJ 1MG/ML 5 PA REMODULIN INJ 2.5MG/ML 5 PA REMODULIN INJ 5MG/ML 5 PA REMODULIN INJ 10MG/ML 5 PA TYVASO START SOL 0.6MG/ML 5 PA VELETRI INJ 0.5MG 5 PA VENTAVIS SOL 10MCG/ML 5 PA PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 37

VENTAVIS SOL 20MCG/ML 5 PA PULMONARY ARTERIAL HYPERTENSION, SOLUBLE GUANYLATE CYCLASE STIMULATORS ADEMPAS TAB 0.5MG 5 PA; QL ADEMPAS TAB 1.5MG 5 PA; QL ADEMPAS TAB 1MG 5 PA; QL ADEMPAS TAB 2.5MG 5 PA; QL ADEMPAS TAB 2MG 5 PA; QL VASOPRESSORS dobutamine hcl inj 12.5 /ml 2 dobutamine inj 1 /ml in d5w 2 dobutamine inj 2 /ml in d5w 2 dobutamine inj 4 /ml in d5w 2 dopamine hcl inj 40 /ml 2 dopamine hcl inj 80 /ml 2 dopamine hcl inj 160 /ml 2 ephedrine sulfate inj 50 /ml 2 EPINEPHRINE INJ 1MG/ML 4 phenylephrine hcl inj 10 /ml 2 CENTRAL NERVOUS SYSTEM ANTIANXIETY, BENZODIAZEPINES ALPRAZOLAM CON 1 MG/ML 2 alprazolam orally disintegrating tab 0.5 2 ST alprazolam orally disintegrating tab 0.25 2 ST alprazolam orally disintegrating tab 1 2 ST alprazolam orally disintegrating tab 2 2 ST alprazolam tab 0.5 2 alprazolam tab 0.25 2 alprazolam tab 1 2 alprazolam tab 2 2 alprazolam tab er 24hr 0.5 2 alprazolam tab er 24hr 1 2 alprazolam tab er 24hr 2 2 alprazolam tab er 24hr 3 2 chlordiazepoxide hcl cap 5 2 chlordiazepoxide hcl cap 10 2 chlordiazepoxide hcl cap 25 2 clonazepam orally disintegrating tab 0.5 2 ST clonazepam orally disintegrating tab 0.25 2 ST clonazepam orally disintegrating tab 0.125 2 ST clonazepam orally disintegrating tab 1 2 ST clonazepam orally disintegrating tab 2 2 ST PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 38

clonazepam tab 0.5 2 clonazepam tab 1 2 clonazepam tab 2 2 clorazepate dipotassium tab 3.75 2 clorazepate dipotassium tab 7.5 2 clorazepate dipotassium tab 15 2 diazepam conc 5 /ml 2 diazepam inj 5 /ml 2 DIAZEPAM INJ 10MG/2ML 2 diazepam oral soln 1 /ml 2 diazepam tab 2 2 diazepam tab 5 2 diazepam tab 10 2 lorazepam conc 2 /ml 2 lorazepam inj 2 /ml 2 lorazepam inj 4 /ml 2 lorazepam tab 0.5 2 lorazepam tab 1 2 lorazepam tab 2 2 oxazepam cap 10 2 oxazepam cap 15 2 oxazepam cap 30 2 ANTIANXIETY, MISCELLANEOUS buspirone hcl tab 5 1 buspirone hcl tab 7.5 2 buspirone hcl tab 10 1 buspirone hcl tab 15 1 buspirone hcl tab 30 2 clomipramine hcl cap 25 4 ST clomipramine hcl cap 50 4 ST clomipramine hcl cap 75 4 ST fluvoxamine maleate tab 25 2 fluvoxamine maleate tab 50 2 fluvoxamine maleate tab 100 2 meprobamate tab 200 2 meprobamate tab 400 2 ANTICONVULSANTS APTIOM TAB 200MG 4 PA; QL APTIOM TAB 400MG 4 PA; QL APTIOM TAB 600MG 4 PA; QL APTIOM TAB 800MG 4 PA; QL BANZEL SUS 40MG/ML 4 PA BANZEL TAB 200MG 4 PA BANZEL TAB 400MG 4 PA BRIVIACT INJ 50MG/5ML 4 PA; QL BRIVIACT SOL 10MG/ML 4 PA; QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 39

BRIVIACT TAB 10MG 4 PA; QL BRIVIACT TAB 25MG 4 PA; QL BRIVIACT TAB 50MG 4 PA; QL BRIVIACT TAB 75MG 4 PA; QL BRIVIACT TAB 100MG 4 PA; QL carbamazepine cap er 12hr 100 2 carbamazepine cap er 12hr 200 2 carbamazepine cap er 12hr 300 2 carbamazepine chew tab 100 2 carbamazepine susp 100 /5ml 2 carbamazepine tab 200 1 carbamazepine tab er 12hr 100 2 carbamazepine tab er 12hr 200 2 carbamazepine tab er 12hr 400 2 CARBATROL CAP 100MG 4 CARBATROL CAP 200MG 4 CARBATROL CAP 300MG 4 CELONTIN CAP 300MG 3 DEPAKOTE ER TAB 500MG 4 DIASTAT ACDL GEL 5-10MG 4 DIASTAT ACDL GEL 12.5-20 4 DIASTAT PED GEL 2.5M GEL 4 DILANTIN CAP 30MG 3 DILANTIN CAP 100MG 4 DILANTIN CHW 50MG 4 DILANTIN-125 SUS 125/5ML 4 divalproex sodium cap delayed release sprinkle 125 2 divalproex sodium tab delayed release 125 2 divalproex sodium tab delayed release 250 2 divalproex sodium tab delayed release 500 2 divalproex sodium tab er 24 hr 250 2 divalproex sodium tab er 24 hr 500 2 ethosuximide cap 250 2 ethosuximide soln 250 /5ml 2 felbamate susp 600 /5ml 2 felbamate tab 400 2 felbamate tab 600 2 FYCOMPA SUS 0.5MG/ML 4 QL FYCOMPA TAB 2MG 4 PA; QL FYCOMPA TAB 4MG 4 PA; QL FYCOMPA TAB 6MG 4 PA; QL FYCOMPA TAB 8MG 4 PA; QL FYCOMPA TAB 10MG 4 PA; QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 40

FYCOMPA TAB 12MG 4 PA; QL gabapentin cap 100 1 gabapentin cap 300 2 gabapentin cap 400 2 gabapentin oral soln 250 /5ml 2 gabapentin tab 600 2 gabapentin tab 800 2 GABITRIL TAB 12MG 3 GABITRIL TAB 16MG 3 KEPPRA INJ 500/5ML 4 KEPPRA SOL 100MG/ML 4 KEPPRA TAB 250MG 4 KEPPRA TAB 500MG 4 KEPPRA TAB 750MG 4 KEPPRA TAB 1000MG 4 KEPPRA XR TAB 500MG 4 QL KEPPRA XR TAB 750MG 4 QL lamotrigine tab 25 2 lamotrigine tab 100 2 lamotrigine tab 150 2 lamotrigine tab 200 2 lamotrigine tab chewable dispersible 5 2 lamotrigine tab chewable dispersible 25 2 levetiracetam inj 500 /5ml (100 /ml) 2 levetiracetam oral soln 100 /ml 2 levetiracetam tab 250 2 levetiracetam tab 500 2 levetiracetam tab 750 2 levetiracetam tab 1000 2 levetiracetam tab er 24hr 500 2 QL levetiracetam tab er 24hr 750 2 QL ONFI SUS 2.5MG/ML 5 PA; QL ONFI TAB 10MG 5 PA; QL ONFI TAB 20MG 5 PA; QL oxcarbazepine susp 300 /5ml (60 2 /ml) oxcarbazepine tab 150 2 oxcarbazepine tab 300 2 oxcarbazepine tab 600 2 PHENOBARB INJ 65MG/ML 2 phenobarbital elixir 20 /5ml 2 phenobarbital sodium inj 130 /ml 2 phenobarbital tab 15 2 phenobarbital tab 16.2 2 phenobarbital tab 30 2 phenobarbital tab 32.4 2 phenobarbital tab 60 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 41

phenobarbital tab 64.8 2 phenobarbital tab 97.2 2 phenobarbital tab 100 2 PHENYTEK CAP 200MG 4 PHENYTEK CAP 300MG 4 phenytoin chew tab 50 2 phenytoin sodium extended cap 100 2 phenytoin sodium extended cap 200 2 phenytoin sodium extended cap 300 2 phenytoin sodium inj 50 /ml 2 phenytoin susp 125 /5ml 2 primidone tab 50 2 primidone tab 250 2 SABRIL TAB 500MG 5 PA; QL TEGRETOL SUS 100/5ML 4 TEGRETOL-XR TAB 100MG 4 TEGRETOL-XR TAB 200MG 4 TEGRETOL-XR TAB 400MG 4 tiagabine hcl tab 2 2 tiagabine hcl tab 4 2 tiagabine hcl tab 12 2 tiagabine hcl tab 16 2 topiramate sprinkle cap 15 2 QL topiramate sprinkle cap 25 2 QL topiramate tab 25 2 topiramate tab 50 2 topiramate tab 100 2 topiramate tab 200 2 valproate sodium inj 100 /ml 2 valproate sodium oral soln 250 /5ml 2 (base equiv) valproic acid cap 250 2 vigabatrin powd pack 500 5 PA; QL VIMPAT INJ 200MG/20 4 PA VIMPAT SOL 10MG/ML 4 PA VIMPAT TAB 50MG 4 PA VIMPAT TAB 100MG 4 PA VIMPAT TAB 150MG 4 PA VIMPAT TAB 200MG 4 PA zonisamide cap 25 2 zonisamide cap 50 2 zonisamide cap 100 2 ANTIDEMENTIA donepezil hydrochloride orally 2 disintegrating tab 5 donepezil hydrochloride orally disintegrating tab 10 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 42

donepezil hydrochloride tab 5 2 donepezil hydrochloride tab 10 2 galantamine hydrobromide cap er 24hr 8 2 PA galantamine hydrobromide cap er 24hr 16 2 PA galantamine hydrobromide cap er 24hr 24 2 PA galantamine hydrobromide oral soln 4 2 PA /ml galantamine hydrobromide tab 4 2 PA galantamine hydrobromide tab 8 2 PA galantamine hydrobromide tab 12 2 PA memantine hcl oral solution 2 /ml 2 memantine hcl tab 5 2 memantine hcl tab 5 (28) & 10 2 (21) titration pak memantine hcl tab 10 2 rivastigmine tartrate cap 1.5 (base 2 PA equivalent) rivastigmine tartrate cap 3 (base 2 PA equivalent) rivastigmine tartrate cap 4.5 (base 2 PA equivalent) rivastigmine tartrate cap 6 (base 2 PA equivalent) rivastigmine td patch 24hr 4.6 /24hr 2 PA rivastigmine td patch 24hr 9.5 /24hr 2 PA rivastigmine td patch 24hr 13.3 /24hr 2 PA ANTIDEPRESSANTS, MAOIS MARPLAN TAB 10MG 3 phenelzine sulfate tab 15 2 tranylcypromine sulfate tab 10 2 ANTIDEPRESSANTS, MISCELLANEOUS bupropion hcl tab 75 2 bupropion hcl tab 100 2 bupropion hcl tab er 12hr 100 2 bupropion hcl tab er 12hr 150 2 bupropion hcl tab er 12hr 200 2 bupropion hcl tab er 24hr 150 2 bupropion hcl tab er 24hr 300 2 chlordiazepoxide-amitriptyline tab 5-12.5 2 chlordiazepoxide-amitriptyline tab 10-25 2 maprotiline hcl tab 25 2 maprotiline hcl tab 50 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 43

maprotiline hcl tab 75 2 mirtazapine orally disintegrating tab 15 2 mirtazapine orally disintegrating tab 30 2 mirtazapine orally disintegrating tab 45 2 mirtazapine tab 7.5 2 mirtazapine tab 15 2 mirtazapine tab 30 2 mirtazapine tab 45 2 trazodone hcl tab 50 1 trazodone hcl tab 100 1 trazodone hcl tab 150 1 trazodone hcl tab 300 2 ANTIDEPRESSANTS, SNRIS DESVENLAFAX TAB 50MG ER 4 ST; QL desvenlafaxine succinate tab er 24hr 25 4 ST; QL (base equiv) desvenlafaxine succinate tab er 24hr 50 4 ST; QL (base equiv) desvenlafaxine succinate tab er 24hr 100 4 ST; QL (base equiv) desvenlafaxine tab er 24hr 50 4 ST; QL desvenlafaxine tab er 24hr 100 4 ST; QL duloxetine hcl enteric coated pellets cap 20 2 QL (base eq) duloxetine hcl enteric coated pellets cap 30 2 QL (base eq) duloxetine hcl enteric coated pellets cap 60 2 QL (base eq) FETZIMA CAP 20MG 4 PA; QL FETZIMA CAP 40MG 4 PA; QL FETZIMA CAP 80MG 4 PA; QL FETZIMA CAP 120MG 4 PA; QL FETZIMA CAP TITRATIO 4 PA; QL KHEDEZLA TAB 50MG ER 4 ST; QL KHEDEZLA TAB 100MG ER 4 ST; QL PRISTIQ TAB 25MG 4 ST; QL PRISTIQ TAB 50MG 4 ST; QL PRISTIQ TAB 100MG 4 ST; QL venlafaxine hcl cap er 24hr 37.5 (base 2 equivalent) venlafaxine hcl cap er 24hr 75 (base 2 equivalent) venlafaxine hcl cap er 24hr 150 (base 2 equivalent) venlafaxine hcl tab 25 2 venlafaxine hcl tab 37.5 2 venlafaxine hcl tab 50 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 44

venlafaxine hcl tab 75 2 venlafaxine hcl tab 100 2 venlafaxine hcl tab er 24hr 37.5 (base 2 ST equivalent) venlafaxine hcl tab er 24hr 75 (base 2 ST equivalent) venlafaxine hcl tab er 24hr 150 (base 2 ST equivalent) venlafaxine hcl tab er 24hr 225 (base 2 ST equivalent) ANTIDEPRESSANTS, SSRIS citalopram hydrobromide oral soln 10 /5ml 2 citalopram hydrobromide tab 10 (base 1 QL equiv) citalopram hydrobromide tab 20 (base 1 QL equiv) citalopram hydrobromide tab 40 (base 1 QL equiv) escitalopram oxalate soln 5 /5ml (base 2 QL equiv) escitalopram oxalate tab 5 (base 2 QL equiv) escitalopram oxalate tab 10 (base 2 QL equiv) escitalopram oxalate tab 20 (base 2 QL equiv) fluoxetine hcl (pmdd) cap 10 1 fluoxetine hcl (pmdd) cap 20 1 fluoxetine hcl (pmdd) tab 10 1 fluoxetine hcl (pmdd) tab 20 1 fluoxetine hcl cap 10 1 fluoxetine hcl cap 20 1 fluoxetine hcl cap 40 1 fluoxetine hcl cap delayed release 90 2 QL fluoxetine hcl solution 20 /5ml 2 fluoxetine hcl tab 10 1 ST fluoxetine hcl tab 20 1 ST paroxetine hcl tab 10 1 QL paroxetine hcl tab 20 1 QL paroxetine hcl tab 30 2 QL paroxetine hcl tab 40 2 QL paroxetine hcl tab er 24hr 12.5 2 QL paroxetine hcl tab er 24hr 25 2 QL paroxetine hcl tab er 24hr 37.5 2 QL PAXIL SUS 10MG/5ML 3 QL sertraline hcl oral concentrate for solution 20 /ml 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 45

sertraline hcl tab 25 1 sertraline hcl tab 50 1 sertraline hcl tab 100 1 TRINTELLIX TAB 5MG 4 PA; QL TRINTELLIX TAB 10MG 4 PA; QL TRINTELLIX TAB 20MG 4 PA; QL VIIBRYD KIT STARTER 4 PA; QL VIIBRYD TAB 10MG 4 PA; QL VIIBRYD TAB 20MG 4 PA; QL VIIBRYD TAB 40MG 4 PA; QL ANTIDEPRESSANTS, TCAS amitriptyline hcl tab 10 1 amitriptyline hcl tab 25 1 amitriptyline hcl tab 50 2 amitriptyline hcl tab 75 2 amitriptyline hcl tab 100 2 amitriptyline hcl tab 150 2 amoxapine tab 25 2 amoxapine tab 50 2 amoxapine tab 100 2 amoxapine tab 150 2 desipramine hcl tab 10 2 desipramine hcl tab 25 2 desipramine hcl tab 50 2 desipramine hcl tab 75 2 desipramine hcl tab 100 2 desipramine hcl tab 150 2 doxepin hcl cap 10 2 doxepin hcl cap 25 2 doxepin hcl cap 50 2 doxepin hcl cap 75 2 doxepin hcl cap 100 2 doxepin hcl cap 150 2 doxepin hcl conc 10 /ml 2 imipramine hcl tab 10 2 imipramine hcl tab 25 2 imipramine hcl tab 50 2 imipramine pamoate cap 75 2 imipramine pamoate cap 100 2 imipramine pamoate cap 125 2 imipramine pamoate cap 150 2 nortriptyline hcl cap 10 1 nortriptyline hcl cap 25 1 nortriptyline hcl cap 50 1 nortriptyline hcl cap 75 2 nortriptyline hcl soln 10 /5ml 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 46

protriptyline hcl tab 5 2 protriptyline hcl tab 10 2 SURMONTIL CAP 25MG 4 SURMONTIL CAP 50MG 4 SURMONTIL CAP 100MG 4 ANTIPARKINSONIAN AGENTS amantadine hcl cap 100 2 amantadine hcl syrup 50 /5ml 2 amantadine hcl tab 100 2 APOKYN INJ 10MG/ML 5 PA; QL benztropine mesylate inj 1 /ml 2 benztropine mesylate tab 0.5 1 benztropine mesylate tab 1 1 benztropine mesylate tab 2 1 bromocriptine mesylate cap 5 (base 2 equivalent) bromocriptine mesylate tab 2.5 (base equivalent) 2 carbidopa & levodopa orally disintegrating 2 tab 10-100 carbidopa & levodopa orally disintegrating 2 tab 25-100 carbidopa & levodopa orally disintegrating 2 tab 25-250 carbidopa & levodopa tab 10-100 2 carbidopa & levodopa tab 25-100 2 carbidopa & levodopa tab 25-250 2 carbidopa & levodopa tab er 25-100 2 carbidopa & levodopa tab er 50-200 2 carbidopa tab 25 2 carbidopa-levodopa-entacapone tabs 2 12.5-50-200 carbidopa-levodopa-entacapone tabs 2 18.75-75-200 carbidopa-levodopa-entacapone tabs 2 25-100-200 carbidopa-levodopa-entacapone tabs 2 31.25-125-200 carbidopa-levodopa-entacapone tabs 2 37.5-150-200 carbidopa-levodopa-entacapone tabs 2 50-200-200 DUOPA SUS 4.63-20 4 PA entacapone tab 200 2 pramipexole dihydrochloride tab 0.5 2 pramipexole dihydrochloride tab 0.25 2 pramipexole dihydrochloride tab 0.75 2 pramipexole dihydrochloride tab 0.125 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 47

pramipexole dihydrochloride tab 1 2 pramipexole dihydrochloride tab 1.5 2 pramipexole dihydrochloride tab er 24hr 2 0.75 pramipexole dihydrochloride tab er 24hr 2 0.375 pramipexole dihydrochloride tab er 24hr 2 1.5 pramipexole dihydrochloride tab er 24hr 2 2.25 pramipexole dihydrochloride tab er 24hr 3 2 pramipexole dihydrochloride tab er 24hr 2 3.75 pramipexole dihydrochloride tab er 24hr 2 4.5 rasagiline mesylate tab 0.5 (base 2 equiv) rasagiline mesylate tab 1 (base equiv) 2 ropinirole hydrochloride tab 0.5 2 ropinirole hydrochloride tab 0.25 2 ropinirole hydrochloride tab 1 2 ropinirole hydrochloride tab 2 2 ropinirole hydrochloride tab 3 2 ropinirole hydrochloride tab 4 2 ropinirole hydrochloride tab 5 2 ropinirole hydrochloride tab er 24hr 2 2 ST (base equivalent) ropinirole hydrochloride tab er 24hr 4 2 ST (base equivalent) ropinirole hydrochloride tab er 24hr 6 2 ST (base equivalent) ropinirole hydrochloride tab er 24hr 8 (base equivalent) 2 ST ropinirole hydrochloride tab er 24hr 12 2 ST (base equivalent) selegiline hcl cap 5 2 selegiline hcl tab 5 2 trihexyphenidyl hcl elixir 0.4 /ml 2 trihexyphenidyl hcl tab 2 1 trihexyphenidyl hcl tab 5 2 ANTIPSYCHOTICS, ATYPICALS ABILIFY MAIN INJ 300MG 4 PA; QL ABILIFY MAIN INJ 400MG 4 PA; QL aripiprazole oral solution 1 /ml 4 ST; QL aripiprazole orally disintegrating tab 10 4 ST; QL aripiprazole orally disintegrating tab 15 4 ST; QL aripiprazole tab 2 4 ST; QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 48

aripiprazole tab 5 4 ST; QL aripiprazole tab 10 4 ST; QL aripiprazole tab 15 4 ST; QL aripiprazole tab 20 4 ST; QL aripiprazole tab 30 4 ST; QL ARISTADA INJ 441MG/1. 5 QL ARISTADA INJ 662MG/2 5 QL ARISTADA INJ 882MG/3 5 QL ARISTADA INJ 1064MG 5 PA; QL clozapine orally disintegrating tab 12.5 2 PA; QL clozapine orally disintegrating tab 25 2 PA; QL clozapine orally disintegrating tab 100 2 PA; QL clozapine orally disintegrating tab 150 2 PA; QL clozapine orally disintegrating tab 200 2 PA; QL clozapine tab 25 2 clozapine tab 50 2 clozapine tab 100 2 clozapine tab 200 2 FANAPT PAK 4 PA; QL FANAPT TAB 1MG 4 PA; QL FANAPT TAB 2MG 4 PA; QL FANAPT TAB 4MG 4 PA; QL FANAPT TAB 6MG 4 PA; QL FANAPT TAB 8MG 4 PA; QL FANAPT TAB 10MG 4 PA; QL FANAPT TAB 12MG 4 PA; QL GEODON INJ 20MG 4 INVEGA SUST INJ 39/0.25 5 PA; QL INVEGA SUST INJ 78/0.5ML 5 PA; QL INVEGA SUST INJ 117/0.75 5 PA; QL INVEGA SUST INJ 156MG/ML 5 PA; QL INVEGA SUST INJ 234/1.5 5 PA; QL INVEGA TRINZ INJ 273MG 5 PA; QL INVEGA TRINZ INJ 410MG 5 PA; QL INVEGA TRINZ INJ 546MG 5 PA; QL INVEGA TRINZ INJ 819MG 5 PA; QL LATUDA TAB 20MG 4 ST; QL LATUDA TAB 40MG 4 ST; QL LATUDA TAB 60MG 4 ST; QL LATUDA TAB 80MG 4 ST; QL LATUDA TAB 120MG 4 ST; QL loxapine succinate cap 5 2 loxapine succinate cap 10 2 loxapine succinate cap 25 2 loxapine succinate cap 50 2 NUPLAZID TAB 17MG 5 PA; QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 49

olanzapine for im inj 10 2 olanzapine orally disintegrating tab 5 2 QL olanzapine orally disintegrating tab 10 2 QL olanzapine orally disintegrating tab 15 2 QL olanzapine orally disintegrating tab 20 2 QL olanzapine tab 2.5 2 QL olanzapine tab 5 2 QL olanzapine tab 7.5 2 QL olanzapine tab 10 2 QL olanzapine tab 15 2 QL olanzapine tab 20 2 QL paliperidone tab er 24hr 1.5 4 PA; QL paliperidone tab er 24hr 3 4 PA; QL paliperidone tab er 24hr 6 4 PA; QL paliperidone tab er 24hr 9 4 PA; QL quetiapine fumarate tab 25 2 QL quetiapine fumarate tab 50 2 QL quetiapine fumarate tab 100 2 QL quetiapine fumarate tab 200 2 QL quetiapine fumarate tab 300 2 QL quetiapine fumarate tab 400 2 QL RISPERDAL INJ 12.5MG 4 QL RISPERDAL INJ 25MG 4 QL RISPERDAL INJ 37.5MG 5 QL RISPERDAL INJ 50MG 4 QL risperidone orally disintegrating tab 0.5 2 QL risperidone orally disintegrating tab 0.25 2 QL risperidone orally disintegrating tab 1 2 QL risperidone orally disintegrating tab 2 2 QL risperidone soln 1 /ml 2 QL risperidone tab 0.5 2 QL risperidone tab 0.25 2 QL risperidone tab 1 2 QL risperidone tab 2 2 QL risperidone tab 3 2 QL risperidone tab 4 2 QL SAPHRIS SUB 2.5MG 4 ST; QL SAPHRIS SUB 5MG 4 ST; QL SAPHRIS SUB 10MG 4 ST; QL ziprasidone hcl cap 20 2 QL ziprasidone hcl cap 40 2 QL ziprasidone hcl cap 60 2 QL ziprasidone hcl cap 80 2 QL ZYPREXA RELP INJ 210MG 4 PA; QL ZYPREXA RELP INJ 300MG 4 PA; QL ZYPREXA RELP INJ 405MG 4 PA; QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 50

ANTIPSYCHOTICS, MISCELLANEOUS CHLORPROMAZ INJ 25MG/ML 2 CHLORPROMAZ INJ 50MG/2ML 2 chlorpromazine hcl tab 10 2 chlorpromazine hcl tab 25 2 chlorpromazine hcl tab 50 2 chlorpromazine hcl tab 100 2 chlorpromazine hcl tab 200 2 fluphenazine decanoate inj 25 /ml 2 fluphenazine hcl elixir 2.5 /5ml 2 fluphenazine hcl inj 2.5 /ml 2 fluphenazine hcl oral conc 5 /ml 2 fluphenazine hcl tab 1 2 fluphenazine hcl tab 2.5 2 fluphenazine hcl tab 5 2 fluphenazine hcl tab 10 2 HALDOL DECAN INJ 50MG/ML 4 HALDOL DECAN INJ 100MG/ML 4 HALDOL INJ 5MG/ML 4 haloperidol decanoate im soln 50 /ml 2 haloperidol decanoate im soln 100 /ml 2 haloperidol lactate inj 5 /ml 2 haloperidol lactate oral conc 2 /ml 2 haloperidol tab 0.5 1 haloperidol tab 1 1 haloperidol tab 2 2 haloperidol tab 5 2 haloperidol tab 10 2 haloperidol tab 20 2 perphenazine tab 2 2 perphenazine tab 4 2 perphenazine tab 8 2 perphenazine tab 16 2 perphenazine-amitriptyline tab 2-10 2 perphenazine-amitriptyline tab 2-25 2 perphenazine-amitriptyline tab 4-10 2 perphenazine-amitriptyline tab 4-25 2 perphenazine-amitriptyline tab 4-50 2 pimozide tab 1 2 pimozide tab 2 2 thioridazine hcl tab 10 2 thioridazine hcl tab 25 2 thioridazine hcl tab 50 2 thioridazine hcl tab 100 2 thiothixene cap 1 2 thiothixene cap 2 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 51

thiothixene cap 5 2 thiothixene cap 10 2 trifluoperazine hcl tab 1 (base 2 equivalent) trifluoperazine hcl tab 2 (base 2 equivalent) trifluoperazine hcl tab 5 (base 2 equivalent) trifluoperazine hcl tab 10 (base 2 equivalent) ATTENTION DEFICIT HYPERACTIVITY DISORDER ADDERALL TAB 5MG 4 QL ADDERALL TAB 7.5MG 4 QL ADDERALL TAB 10MG 4 QL ADDERALL TAB 12.5MG 4 QL ADDERALL TAB 15MG 4 QL ADDERALL TAB 20MG 4 QL ADDERALL TAB 30MG 4 QL amphetamine-dextroamphetamine cap er 2 QL 24hr 5 amphetamine-dextroamphetamine cap er 2 QL 24hr 10 amphetamine-dextroamphetamine cap er 2 QL 24hr 15 amphetamine-dextroamphetamine cap er 2 QL 24hr 20 amphetamine-dextroamphetamine cap er 2 QL 24hr 25 amphetamine-dextroamphetamine cap er 2 QL 24hr 30 amphetamine-dextroamphetamine tab 5 2 QL amphetamine-dextroamphetamine tab 7.5 2 QL amphetamine-dextroamphetamine tab 10 2 QL amphetamine-dextroamphetamine tab 2 QL 12.5 amphetamine-dextroamphetamine tab 15 2 QL amphetamine-dextroamphetamine tab 20 2 QL amphetamine-dextroamphetamine tab 30 2 QL atomoxetine hcl cap 10 (base equiv) 2 QL atomoxetine hcl cap 18 (base equiv) 2 QL atomoxetine hcl cap 25 (base equiv) 2 QL atomoxetine hcl cap 40 (base equiv) 2 QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 52

atomoxetine hcl cap 60 (base equiv) 2 QL atomoxetine hcl cap 80 (base equiv) 2 QL atomoxetine hcl cap 100 (base equiv) 2 QL clonidine hcl tab er 12hr 0.1 2 QL DESOXYN TAB 5MG 4 QL DEXEDRINE CAP 5MG CR 4 QL DEXEDRINE CAP 10MG CR 4 QL DEXEDRINE CAP 15MG CR 4 QL dexmethylphenidate hcl cap er 24 hr 5 2 QL dexmethylphenidate hcl cap er 24 hr 10 2 QL dexmethylphenidate hcl cap er 24 hr 15 2 QL dexmethylphenidate hcl cap er 24 hr 20 2 QL dexmethylphenidate hcl cap er 24 hr 25 2 QL dexmethylphenidate hcl cap er 24 hr 30 2 QL dexmethylphenidate hcl cap er 24 hr 35 2 QL dexmethylphenidate hcl cap er 24 hr 40 2 QL dexmethylphenidate hcl tab 2.5 2 QL dexmethylphenidate hcl tab 5 2 QL dexmethylphenidate hcl tab 10 2 QL dextroamphetamine sulfate cap er 24hr 5 2 QL dextroamphetamine sulfate cap er 24hr 10 2 QL dextroamphetamine sulfate cap er 24hr 15 2 QL dextroamphetamine sulfate tab 5 2 QL dextroamphetamine sulfate tab 10 2 QL FOCALIN XR CAP 25MG 4 QL FOCALIN XR CAP 35MG 4 QL guanfacine hcl tab er 24hr 1 (base 2 QL equiv) guanfacine hcl tab er 24hr 2 (base 2 QL equiv) guanfacine hcl tab er 24hr 3 (base 2 QL equiv) guanfacine hcl tab er 24hr 4 (base 2 QL equiv) methamphetamine hcl tab 5 2 QL methylphenidate hcl cap er 10 (cd) 2 QL methylphenidate hcl cap er 20 (cd) 2 QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 53

methylphenidate hcl cap er 24hr 20 2 (la) methylphenidate hcl cap er 24hr 30 2 (la) methylphenidate hcl cap er 24hr 40 2 (la) methylphenidate hcl cap er 30 (cd) 2 QL methylphenidate hcl cap er 40 (cd) 2 QL methylphenidate hcl cap er 50 (cd) 2 QL methylphenidate hcl cap er 60 (cd) 2 QL methylphenidate hcl chew tab 2.5 2 QL methylphenidate hcl chew tab 5 2 QL methylphenidate hcl chew tab 10 2 QL methylphenidate hcl soln 5 /5ml 2 QL methylphenidate hcl soln 10 /5ml 2 QL methylphenidate hcl tab 5 2 QL methylphenidate hcl tab 10 2 QL methylphenidate hcl tab 20 2 QL methylphenidate hcl tab er 10 2 QL methylphenidate hcl tab er 24hr 18 2 QL methylphenidate hcl tab er 24hr 27 2 QL methylphenidate hcl tab er 24hr 36 2 QL methylphenidate hcl tab er 24hr 54 2 QL methylphenidate hcl tab er osmotic release 2 QL (osm) 18 methylphenidate hcl tab er osmotic release 2 QL (osm) 27 methylphenidate hcl tab er osmotic release 2 QL (osm) 36 methylphenidate hcl tab er osmotic release 2 QL (osm) 54 STRATTERA CAP 10MG 4 QL STRATTERA CAP 18MG 4 QL STRATTERA CAP 25MG 4 QL STRATTERA CAP 40MG 4 QL STRATTERA CAP 60MG 4 QL STRATTERA CAP 80MG 4 QL STRATTERA CAP 100MG 4 QL VYVANSE CAP 10MG 4 PA; QL VYVANSE CAP 20MG 4 PA; QL VYVANSE CAP 30MG 4 PA; QL VYVANSE CAP 40MG 4 PA; QL VYVANSE CAP 50MG 4 PA; QL VYVANSE CAP 60MG 4 PA; QL VYVANSE CAP 70MG 4 PA; QL FIBROMYALGIA LYRICA CAP 25MG 4 PA; QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 54

LYRICA CAP 50MG 4 PA; QL LYRICA CAP 75MG 4 PA; QL LYRICA CAP 100MG 4 PA; QL LYRICA CAP 150MG 4 PA; QL LYRICA CAP 200MG 4 PA; QL LYRICA CAP 225MG 4 PA; QL LYRICA CAP 300MG 4 PA; QL LYRICA SOL 20MG/ML 4 PA; QL SAVELLA MIS TITR PAK 4 PA; QL SAVELLA TAB 12.5MG 4 PA; QL SAVELLA TAB 25MG 4 PA; QL SAVELLA TAB 50MG 4 PA; QL SAVELLA TAB 100MG 4 PA; QL HUNTINGTON'S DISEASE AGENTS tetrabenazine tab 12.5 5 PA; QL tetrabenazine tab 25 4 PA; QL XENAZINE TAB 12.5MG 5 PA; QL XENAZINE TAB 25MG 5 PA; QL HYPNOTICS, BENZODIAZEPINES estazolam tab 1 2 estazolam tab 2 2 flurazepam hcl cap 15 2 flurazepam hcl cap 30 2 midazolam hcl inj 2 /2ml (base 2 equivalent) midazolam hcl inj 5 /5ml (base 2 equivalent) midazolam hcl inj 5 /ml (base 2 equivalent) midazolam hcl inj 10 /2ml (base 2 equivalent) midazolam hcl inj 10 /10ml (base 2 equivalent) midazolam hcl inj 25 /5ml (base 2 equivalent) midazolam hcl inj 50 /10ml (base 2 equivalent) midazolam hcl syrup 2 /ml (base 2 equivalent) temazepam cap 7.5 2 temazepam cap 15 2 temazepam cap 22.5 2 temazepam cap 30 2 triazolam tab 0.25 2 triazolam tab 0.125 2 HYPNOTICS, NON-BENZODIAZEPINES AMYTAL SOD INJ 500MG 4 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 55

eszopiclone tab 1 2 QL eszopiclone tab 2 2 QL eszopiclone tab 3 2 QL HETLIOZ CAP 20MG 5 PA; QL zaleplon cap 5 2 QL zaleplon cap 10 2 QL zolpidem tartrate tab 5 2 QL zolpidem tartrate tab 10 2 QL MIGRAINE, ERGOTAMINE DERIVATIVES dihydroergotamine mesylate nasal spray 4 2 /ml MIGRAINE, SELECTIVE SEROTONIN AGONISTS almotriptan malate tab 6.25 2 ST; QL almotriptan malate tab 12.5 2 ST; QL eletriptan hydrobromide tab 20 (base 4 QL equivalent) eletriptan hydrobromide tab 40 (base 4 QL equivalent) frovatriptan succinate tab 2.5 (base 4 ST; QL equivalent) naratriptan hcl tab 1 (base equiv) 2 QL naratriptan hcl tab 2.5 (base equiv) 2 QL rizatriptan benzoate oral disintegrating tab 2 QL 5 (base eq) rizatriptan benzoate oral disintegrating tab 2 QL 10 (base eq) rizatriptan benzoate tab 5 (base 2 QL equivalent) rizatriptan benzoate tab 10 (base 2 QL equivalent) sumatriptan nasal spray 5 /act 4 QL sumatriptan nasal spray 20 /act 4 QL sumatriptan succinate inj 6 /0.5ml 4 QL sumatriptan succinate solution 4 QL auto-injector 4 /0.5ml sumatriptan succinate solution auto-injector 6 /0.5ml 4 QL sumatriptan succinate solution cartridge 4 4 QL /0.5ml sumatriptan succinate solution cartridge 6 4 QL /0.5ml sumatriptan succinate tab 25 2 QL sumatriptan succinate tab 50 2 QL sumatriptan succinate tab 100 2 QL zolmitriptan orally disintegrating tab 2.5 2 QL zolmitriptan orally disintegrating tab 5 2 QL zolmitriptan tab 2.5 2 QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 56

zolmitriptan tab 5 2 QL ZOMIG SPR 2.5MG 4 QL ZOMIG SPR 5MG 4 QL MISCELLANEOUS BOTOX INJ 100UNIT 5 PA; QL BOTOX INJ 200UNIT 5 PA; QL caffeine & sodium benzoate inj 125-125 2 /ml (500 /2ml) DYSPORT INJ 300UNIT 5 PA; QL DYSPORT INJ 500UNIT 5 PA; QL GUANIDINE TAB 125MG 2 REGONOL INJ 5MG/ML 4 riluzole tab 50 5 PA; QL XEOMIN INJ 50 UNIT 5 PA; QL XEOMIN INJ 100UNIT 5 PA; QL XEOMIN INJ 200UNIT 5 PA; QL MOOD STABILIZERS lithium carbonate cap 150 1 lithium carbonate cap 300 1 lithium carbonate cap 600 2 lithium carbonate tab 300 2 lithium carbonate tab er 300 2 lithium carbonate tab er 450 2 LITHIUM SOL 8MEQ/5ML 2 MULTIPLE SCLEROSIS AMPYRA TAB 10MG 5 PA; QL AUBAGIO TAB 7MG 5 PA; QL AUBAGIO TAB 14MG 5 PA; QL AVONEX KIT 30MCG 5 PA; QL AVONEX PEN KIT 30MCG 5 PA; QL AVONEX PREFL KIT 30MCG 5 PA; QL BETASERON INJ 0.3MG 5 PA; QL COPAXONE INJ 20MG/ML 5 PA; QL COPAXONE INJ 40MG/ML 5 PA; QL GILENYA CAP 0.5MG 5 PA; QL glatiramer acetate soln prefilled syringe 20 5 PA; QL /ml glatiramer acetate soln prefilled syringe 40 5 PA; QL /ml glatopa inj 20/ml 5 PA; QL glatopa inj 40/ml 5 PA; QL LEMTRADA INJ 12/1.2ML 5 PA PLEGRIDY INJ 5 PA; QL PLEGRIDY INJ PEN 5 PA; QL PLEGRIDY INJ STARTER 5 PA; QL PLEGRIDY PEN INJ STARTER 5 PA; QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 57

REBIF INJ 22/0.5 5 PA; QL REBIF INJ 44/0.5 5 PA; QL REBIF REBIDO INJ 22/0.5 5 PA; QL REBIF REBIDO INJ 44/0.5 5 PA; QL REBIF REBIDO INJ TITRATN 5 PA; QL REBIF TITRTN INJ PACK 5 PA; QL TECFIDERA CAP 120MG 5 PA; QL TECFIDERA CAP 240MG 5 PA; QL TECFIDERA MIS STARTER 5 PA; QL TYSABRI INJ 300/15ML 5 PA; QL MUSCULOSKELETAL THERAPY AGENTS baclofen tab 10 2 baclofen tab 20 2 carisoprodol tab 250 2 QL carisoprodol tab 350 2 QL carisoprodol w/ aspirin & codeine tab 2 200-325-16 carisoprodol w/ aspirin tab 200-325 2 chlorzoxazone tab 500 2 cyclobenzaprine hcl tab 5 1 cyclobenzaprine hcl tab 10 1 dantrolene sodium cap 25 2 dantrolene sodium cap 50 2 dantrolene sodium cap 100 2 dantrolene sodium for iv soln 20 2 GABLOFEN INJ 10000/20 4 GABLOFEN INJ 20000/20 4 GABLOFEN INJ 40000/20 4 LIORESAL INT INJ 0.05MG/1 4 LIORESAL INT INJ 10MG/5ML 4 LIORESAL INT INJ 10MG/20 4 LIORESAL INT INJ 40MG/20 4 metaxalone tab 800 2 methocarbamol inj 1000 /10ml 2 methocarbamol tab 500 2 methocarbamol tab 750 2 orphenadrine citrate inj 30 /ml 2 orphenadrine citrate tab er 12hr 100 2 tizanidine hcl tab 2 (base equivalent) 2 tizanidine hcl tab 4 (base equivalent) 2 MYASTHENIA GRAVIS ENLON INJ 150/15ML 4 MESTINON SYP 60MG/5ML 3 pyridostigmine bromide tab 60 2 pyridostigmine bromide tab er 180 5 NARCOLEPSY/CATAPLEXY PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 58

armodafinil tab 50 4 PA; QL armodafinil tab 150 4 PA; QL armodafinil tab 200 4 PA; QL armodafinil tab 250 4 PA; QL modafinil tab 100 4 PA; QL modafinil tab 200 4 PA; QL PROVIGIL TAB 100MG 4 PA; QL PROVIGIL TAB 200MG 4 PA; QL XYREM SOL 500MG/ML 5 PA; QL NONDEPOLARIZING MUSCLE RELAXANTS ANECTINE INJ 20MG/ML 2 POSTHERPETIC NEURALGIA GRALISE STAR MIS 300/600 4 PA; QL GRALISE TAB 300MG 4 PA; QL GRALISE TAB 600MG 4 PA; QL PSYCHOTHERAPEUTIC-MISC, ALCOHOL DETERRENTS acamprosate calcium tab delayed release 2 333 disulfiram tab 250 2 disulfiram tab 500 2 VIVITROL INJ 380MG 5 PA PSYCHOTHERAPEUTIC-MISC, OPIOID ANTAGONIST naloxone hcl inj 0.4 /ml 2 naloxone hcl inj 4 /10ml 2 naloxone hcl soln cartridge 0.4 /ml 2 naloxone hcl soln prefilled syringe 2 2 /2ml naltrexone hcl tab 50 2 NARCAN SPR 3 QL PSYCHOTHERAPEUTIC-MISC, OPIOID WITHDRAWAL LUCEMYRA TAB 0.18MG 4 PA; QL PSYCHOTHERAPEUTIC-MISC, PARTIAL OPIOID AGONIST/OPIOID ANTAGONIST COMBINATIONS BUNAVAIL MIS 2.1-0.3 4 QL BUNAVAIL MIS 4.2-0.7 4 QL BUNAVAIL MIS 6.3-1MG 4 QL buprenorphine hcl-naloxone hcl sl tab 2 QL 2-0.5 (base equiv) buprenorphine hcl-naloxone hcl sl tab 8-2 2 QL (base equiv) SUBOXONE MIS 2-0.5MG 3 QL SUBOXONE MIS 4-1MG 3 QL SUBOXONE MIS 8-2MG 3 QL SUBOXONE MIS 12-3MG 3 QL ZUBSOLV SUB 0.7-0.18 3 QL ZUBSOLV SUB 1.4-0.36 3 QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 59

ZUBSOLV SUB 2.9-0.71 3 QL ZUBSOLV SUB 5.7-1.4 3 QL ZUBSOLV SUB 8.6-2.1 3 QL ZUBSOLV SUB 11.4-2.9 3 QL PSYCHOTHERAPEUTIC-MISC, PARTIAL OPIOID AGONISTS buprenorphine hcl sl tab 2 (base equiv) 2 QL buprenorphine hcl sl tab 8 (base equiv) 2 QL PROBUPHINE IMP KIT 74.2 5 PA; QL PSYCHOTHERAPEUTIC-MISC, PSEUDOBULBAR AFFECT NUEDEXTA CAP 20-10MG 5 PA; QL PSYCHOTHERAPEUTIC-MISC, SMOKING DETERRENTS bupropion hcl (smoking deterrent) tab er 2 12hr 150 NICOTROL INH 3 NICOTROL NS SPR 10MG/ML 3 ENDOCRINE AND METABOLIC ANDROGENS ANDRODERM DIS 2MG/24HR 4 PA ANDRODERM DIS 4MG/24HR 4 PA ANDROGEL GEL 1.62% 3 PA AVEED INJ 750/3ML 4 PA FORTESTA GEL 10MG/ACT 4 PA methyltestosterone cap 10 5 PA STRIANT MIS 30MG 4 PA TESTIM GEL 1%(50MG) 4 PA TESTOPEL MIS PELLETS 4 PA testosterone cypionate im inj in oil 100 2 /ml testosterone cypionate im inj in oil 200 2 /ml testosterone enanthate im inj in oil 200 2 PA /ml testosterone td gel 10/act (2%) 4 PA testosterone td gel 12.5 /act (1%) 4 PA testosterone td gel 50 /5gm (1%) 4 PA ANTIDIABETICS, ALPHA-GLUCOSIDASE INHIBITORS acarbose tab 25 2 acarbose tab 50 2 acarbose tab 100 2 miglitol tab 25 2 miglitol tab 50 2 miglitol tab 100 2 ANTIDIABETICS, AMYLIN ANALOGS SYMLINPEN 60 INJ 1000MCG 3 ST; QL SYMLNPEN 120 INJ 1000MCG 3 ST; QL ANTIDIABETICS, BIGUANIDE/SULFONYLUREA COMBINATIONS PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 60

glipizide-metformin hcl tab 2.5-250 2 glipizide-metformin hcl tab 2.5-500 2 glipizide-metformin hcl tab 5-500 2 glyburide-metformin tab 1.25-250 2 glyburide-metformin tab 2.5-500 2 glyburide-metformin tab 5-500 2 ANTIDIABETICS, BIGUANIDES metformin hcl tab 500 1 metformin hcl tab 850 1 metformin hcl tab 1000 1 metformin hcl tab er 24hr 500 2 metformin hcl tab er 24hr 750 2 RIOMET SOL 4 ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITOR/BIGUANIDE COMBINATIONS JANUMET TAB 50-500MG 3 JANUMET TAB 50-1000 3 JANUMET XR TAB 50-500MG 3 JANUMET XR TAB 50-1000 3 JANUMET XR TAB 100-1000 3 JENTADUETO TAB 2.5-500 3 JENTADUETO TAB 2.5-850 3 JENTADUETO TAB 2.5-1000 3 JENTADUETO TAB XR 3 QL ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS JANUVIA TAB 25MG 3 JANUVIA TAB 50MG 3 JANUVIA TAB 100MG 3 TRADJENTA TAB 5MG 3 QL ANTIDIABETICS, INCRETIN MIMETIC AGENTS TRULICITY INJ 0.75/0.5 3 QL TRULICITY INJ 1.5/0.5 3 QL VICTOZA INJ 18MG/3ML 3 ANTIDIABETICS, INSULIN SENSITIZER/BIGUANIDE COMBINATION pioglitazone hcl-metformin hcl tab 15-500 2 pioglitazone hcl-metformin hcl tab 15-850 2 ANTIDIABETICS, INSULIN SENSITIZER/SULFONYLUREA COMBO pioglitazone hcl-glimepiride tab 30-2 2 pioglitazone hcl-glimepiride tab 30-4 2 ANTIDIABETICS, INSULIN SENSITIZERS pioglitazone hcl tab 15 (base equiv) 2 pioglitazone hcl tab 30 (base equiv) 2 pioglitazone hcl tab 45 (base equiv) 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 61

ANTIDIABETICS, INSULINS HUMULIN R INJ U-500 3 QL LANTUS INJ 100/ML 3 LANTUS INJ SOLOSTAR 3 LEVEMIR INJ 3 LEVEMIR INJ FLEXTOUC 3 NOVOLIN INJ 70/30 3 NOVOLIN N INJ U-100 3 NOVOLIN R INJ U-100 3 NOVOLOG INJ 100/ML 3 QL NOVOLOG INJ FLEXPEN 3 QL NOVOLOG INJ PENFILL 3 QL NOVOLOG MIX INJ 70/30 3 QL NOVOLOG MIX INJ FLEXPEN 3 QL TOUJEO SOLO INJ 300IU/ML 3 TRESIBA FLEX INJ 100UNIT 3 QL TRESIBA FLEX INJ 200UNIT 3 QL ANTIDIABETICS, MEGLITINIDE nateglinide tab 60 2 nateglinide tab 120 2 repaglinide tab 0.5 2 repaglinide tab 1 2 repaglinide tab 2 2 ANTIDIABETICS, MEGLITINIDE/BIGUANIDE COMBINATIONS repaglinide-metformin hcl tab 1-500 2 repaglinide-metformin hcl tab 2-500 2 ANTIDIABETICS, MISCELLANEOUS CYCLOSET TAB 0.8MG 4 ANTIDIABETICS, SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITOR/BIGUANIDE COMBINATIONS INVOKAMET TAB 50-500MG 3 QL INVOKAMET TAB 50-1000 3 QL INVOKAMET TAB 150-500 3 QL INVOKAMET TAB 150-1000 3 QL INVOKAMET XR TAB 50-500MG 3 QL INVOKAMET XR TAB 50-1000 3 QL INVOKAMET XR TAB 150-500 3 QL INVOKAMET XR TAB 150-1000 3 QL SYNJARDY TAB 3 QL SYNJARDY TAB 5-500MG 3 QL SYNJARDY TAB 5-1000MG 3 QL SYNJARDY TAB 12.5-500 3 QL SYNJARDY XR TAB 3 QL SYNJARDY XR TAB 5-1000MG 3 QL SYNJARDY XR TAB 10-1000 3 QL SYNJARDY XR TAB 25-1000 3 QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 62

ANTIDIABETICS, SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS INVOKANA TAB 100MG 3 QL INVOKANA TAB 300MG 3 QL JARDIANCE TAB 10MG 3 QL JARDIANCE TAB 25MG 3 QL ANTIDIABETICS, SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR/DPP-4 INHIBITOR COMBINATIONS GLYXAMBI TAB 10-5 MG 3 QL GLYXAMBI TAB 25-5 MG 3 QL ANTIDIABETICS, SULFONYLUREAS chlorpropamide tab 100 2 chlorpropamide tab 250 2 glimepiride tab 1 1 glimepiride tab 2 1 glimepiride tab 4 1 glipizide tab 5 1 glipizide tab 10 1 glipizide tab er 24hr 2.5 2 glipizide tab er 24hr 5 2 glipizide tab er 24hr 10 2 glyburide micronized tab 1.5 2 glyburide micronized tab 3 1 glyburide micronized tab 6 1 glyburide tab 1.25 1 glyburide tab 2.5 1 glyburide tab 5 2 tolbutamide tab 500 2 ANTIDIABETICS, SUPPLIES AUTOPEN MIS 1 UNIT 3 AUTOPEN MIS 1-21UNIT 3 AUTOPEN MIS 2 UNIT 3 AUTOPEN MIS 2-32UNIT 3 AUTOPEN MIS 2-42UNIT 3 AUTOSHIELD MIS 29X3/16" 3 BD PEN MINI MIS 3 BD PEN NEEDL MIS 29GX1/2" 3 BD PEN NEEDL MIS 31GX3/16 3 BD PEN NEEDL MIS 31GX5/16 3 BD PEN NEEDL MIS 32GX4MM 3 BD VEO SYR MIS 0.5/31G 3 CONTROL KIT MONITOR 3 EASY TOUCH MIS 32GX5MM 3 INSULIN PEN MIS 29GX12MM 3 INSULIN SYRG MIS 0.3/29G 3 INSULIN SYRG MIS 0.3/29G 3 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 63

INSULIN SYRG MIS 0.3/30G 3 INSULIN SYRG MIS 0.3/30G 3 INSULIN SYRG MIS 0.3/31G 3 INSULIN SYRG MIS 0.5/27G 3 INSULIN SYRG MIS 0.5/28G 3 INSULIN SYRG MIS 0.5/29G 3 INSULIN SYRG MIS 0.5/29G 3 INSULIN SYRG MIS 0.5/30G 3 INSULIN SYRG MIS 0.5/30G 3 INSULIN SYRG MIS 0.5/31G 3 INSULIN SYRG MIS 1ML 3 INSULIN SYRG MIS 1ML/28G 3 INSULIN SYRG MIS 1ML/29G 3 INSULIN SYRG MIS 1ML/29G 3 INSULIN SYRG MIS 1ML/30G 3 INSULIN SYRG MIS 1ML/31G 3 INSULIN SYRG MIS 28GX1/2" 3 INSUPEN SENS MIS 32GX6MM 3 INSUPEN SENS MIS 32GX8MM 3 LANCET CARRY MIS CASE 3 QL LANCETS MIS 3 QL LANCING DEVI MIS 3 MULTI-LANCET KIT DEVICE 3 NOVOFINE MIS 30GX8MM 3 NOVOTWIST MIS 32GX5MM 3 ONETOUCH KIT ULT MINI 3 ONETOUCH KIT ULTRA 2 3 ONETOUCH KIT ULTRALNK 3 ONETOUCH KIT VERIO 3 ONETOUCH KIT VERIO FL 3 ONETOUCH KIT VERIO IQ 3 ONETOUCH TES ULTRA BL 3 QL ONETOUCH TES VERIO 3 QL PEN NEEDLES MIS 31GX6MM 3 SURESTEP PRO TES HIGH CON 3 SURESTEP PRO TES NORM CON 4 1ST TIER UNI MIS 29GX12MM 3 ULTRAFLEX MIS 24"/10MM 4 V-GO 20 KIT 4 PA V-GO 30 KIT 4 PA V-GO 40 KIT 4 PA ANTIDOTES acetylcysteine inj 200 /ml 2 CETYLEV TAB 2.5GM 4 PA CETYLEV TAB 500MG 4 PA DIGIFAB INJ 40MG 4 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 64

flumazenil iv soln 0.5 /5ml (0.1 /ml) 2 flumazenil iv soln 1 /10ml (0.1 /ml) 2 fomepizole inj 1 gm/ml (for iv infusion) 2 PHYSOS SALIC INJ 1MG/ML 2 PROTOPAM CHL INJ 1GM 4 sodium thiosulfate inj 25% 2 CALCIUM RECEPTOR ANTAGONISTS SENSIPAR TAB 30MG 3 SENSIPAR TAB 60MG 3 SENSIPAR TAB 90MG 3 CALCIUM REGULATORS, BISPHOSPHONATES alendronate sodium oral soln 70 /75ml 2 QL alendronate sodium tab 5 2 alendronate sodium tab 10 2 alendronate sodium tab 35 2 alendronate sodium tab 40 2 alendronate sodium tab 70 1 BONIVA INJ 3MG/3ML 5 ST; QL BONIVA TAB 150MG 4 QL etidronate disodium tab 400 2 ibandronate sodium iv soln 3 /3ml 5 ST; QL (base equivalent) ibandronate sodium tab 150 (base 2 QL equivalent) pamidronate disodium for inj 30 2 pamidronate disodium for inj 90 2 pamidronate disodium iv soln 3 /ml 2 pamidronate disodium iv soln 9 /ml 2 PAMIDRONATE INJ 6MG/ML 2 risedronate sodium tab 5 2 ST; QL risedronate sodium tab 30 2 ST; QL risedronate sodium tab 35 2 ST; QL risedronate sodium tab 150 2 ST; QL risedronate sodium tab delayed release 35 2 ST; QL zoledronic acid inj conc for iv infusion 4 5 QL /5ml zoledronic acid iv soln 5 /100ml 5 ST; QL ZOMETA INJ 4MG/100 5 ST; QL CALCIUM REGULATORS, CALCITONINS calcitonin (salmon) nasal soln 200 unit/act 2 MIACALCIN INJ 200/ML 4 CALCIUM REGULATORS, MISCELLANEOUS PROLIA SOL 60MG/ML 5 PA; QL XGEVA INJ 5 PA; QL CALCIUM REGULATORS, PARATHYROID HORMONES PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 65

FORTEO SOL 600/2.4 5 ST; QL NATPARA INJ 25MCG 5 PA; QL NATPARA INJ 50MCG 5 PA; QL NATPARA INJ 75MCG 5 PA; QL NATPARA INJ 100MCG 5 PA; QL CONTRACEPTIVES, BIPHASIC LO LOESTRIN TAB 1-10-10 3 CONTRACEPTIVES, INJECTABLE DEPO-PROVERA INJ 150MG/ML 4 QL ENDOMETRIOSIS danazol cap 50 2 PA danazol cap 100 2 PA danazol cap 200 2 PA LUPANETA KIT 3.75-5 5 PA; QL LUPANETA KIT 11.25-5 5 PA; QL SYNAREL SOL 2MG/ML 5 PA; QL ESTROGEN/PROGESTIN, ORAL ANGELIQ TAB 0.5-1MG 4 estradiol & norethindrone acetate tab 0.5-0.1 2 estradiol & norethindrone acetate tab 1-0.52 norethindrone acetate-ethinyl estradiol tab 2 0.5-2.5 mcg norethindrone acetate-ethinyl estradiol tab 2 1-5 mcg PREFEST TAB 4 PREMPHASE TAB 3 PREMPRO TAB 0.3-1.5 3 PREMPRO TAB 0.45-1.5 3 PREMPRO TAB 0.625-5 3 PREMPRO TAB.625-2.5 3 ESTROGEN/PROGESTIN, TRANSDERMAL CLIMARA PRO DIS WEEKLY 4 QL COMBIPATCH DIS.05/.14 4 QL COMBIPATCH DIS.05/.25 4 QL ESTROGEN/SELECTIVE ESTROGEN RECEPTOR MODULATOR COMBINATIONS DUAVEE TAB 0.45-20 3 ESTROGENS, INJECTABLE DEPO-ESTRADI INJ 5MG/ML 4 estradiol valerate im in oil 20 /ml 2 estradiol valerate im in oil 40 /ml 2 PREMARIN INJ 25MG 4 ESTROGENS, ORAL estradiol tab 0.5 1 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 66

estradiol tab 1 1 estradiol tab 2 1 MENEST TAB 0.3MG 4 MENEST TAB 0.625MG 4 MENEST TAB 1.25MG 4 PREMARIN TAB 0.3MG 3 PREMARIN TAB 0.9MG 3 PREMARIN TAB 0.45MG 3 PREMARIN TAB 0.625MG 3 PREMARIN TAB 1.25MG 3 ESTROGENS, TRANSDERMAL ALORA DIS 0.1MG 4 QL ALORA DIS 0.05MG 4 QL ALORA DIS 0.025MG 4 QL ALORA DIS 0.075MG 4 QL DIVIGEL GEL 0.5MG 4 DIVIGEL GEL 0.25MG 4 DIVIGEL GEL 1MG/GM 4 estradiol td patch twice weekly 0.1 2 QL /24hr estradiol td patch twice weekly 0.05 2 QL /24hr estradiol td patch twice weekly 0.025 2 QL /24hr estradiol td patch twice weekly 0.075 2 QL /24hr estradiol td patch twice weekly 0.0375 2 QL /24hr estradiol td patch weekly 0.1 /24hr 2 QL estradiol td patch weekly 0.05 /24hr 2 QL estradiol td patch weekly 0.06 /24hr 2 QL estradiol td patch weekly 0.025 /24hr 2 QL estradiol td patch weekly 0.075 /24hr 2 QL estradiol td patch weekly 0.0375 /24hr 2 QL (37.5 mcg/24hr) ESTROGEL GEL 4 QL EVAMIST SPR 1.53MG 4 MENOSTAR DIS 14MCG 4 QL MINIVELLE DIS 0.1MG 4 QL MINIVELLE DIS 0.05MG 4 QL MINIVELLE DIS 0.025MG 4 QL MINIVELLE DIS 0.075MG 4 QL MINIVELLE DIS 0.0375MG 4 QL ESTROGENS, VAGINAL ESTRACE VAG CRE 0.01% 4 estradiol vaginal cream 0.1 /gm 2 estradiol vaginal tab 10 mcg 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 67

ESTRING MIS 2MG 4 FEMRING MIS 0.1MG/24 4 FEMRING MIS 0.05/24H 4 PREMARIN VAG CRE 0.625MG 3 VAGIFEM TAB 10MCG 4 GLUCOCORTICOIDS CORTEF TAB 5MG 4 CORTEF TAB 10MG 4 CORTEF TAB 20MG 4 cortisone acetate tab 25 2 DEPO-MEDROL INJ 20MG/ML 4 DEPO-MEDROL INJ 40MG/ML 4 DEPO-MEDROL INJ 80MG/ML 4 DEXAMETHASON CON 1MG/ML 2 dexamethasone elixir 0.5 /5ml 2 dexamethasone sod phosphate 2 preservative free inj 10 /ml dexamethasone sodium phosphate inj 4 2 /ml dexamethasone sodium phosphate inj 10 2 /ml dexamethasone sodium phosphate inj 20 2 /5ml dexamethasone sodium phosphate inj 100 2 /10ml dexamethasone sodium phosphate inj 120 2 /30ml dexamethasone soln 0.5 /5ml 2 dexamethasone tab 0.5 1 dexamethasone tab 0.75 1 dexamethasone tab 1 1 dexamethasone tab 1.5 1 dexamethasone tab 2 1 dexamethasone tab 4 1 dexamethasone tab 6 1 DEXPAK PAK 6 DAY 3 DEXPAK PAK 10 DAY 3 DEXPAK PAK 13 DAY 3 fludrocortisone acetate tab 0.1 2 hydrocortisone tab 5 2 hydrocortisone tab 10 2 hydrocortisone tab 20 2 KENALOG-10 INJ 10MG/ML 4 KENALOG-40 INJ 40MG/ML 4 METHYLPR ACE INJ 80MG/ML 4 methylprednisolone acetate inj susp 40 2 /ml PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 68

methylprednisolone acetate inj susp 80 2 /ml methylprednisolone sod succ for inj 40 2 (base equiv) methylprednisolone sod succ for inj 125 2 (base equiv) methylprednisolone sod succ for inj 1000 2 (base equiv) methylprednisolone tab 4 2 methylprednisolone tab 8 2 methylprednisolone tab 16 2 methylprednisolone tab 32 2 methylprednisolone tab therapy pack 4 2 (21) MILLIPRED DP PAK 5MG 2 prednisolone sod phosph oral soln 6.7 2 /5ml (5 /5ml base) prednisolone sod phosphate oral soln 10 2 /5ml (base equiv) prednisolone sod phosphate oral soln 15 2 /5ml (base equiv) prednisolone sod phosphate oral soln 20 2 /5ml (base equiv) prednisolone sodium phosphate oral soln 2 25 /5ml (base eq) prednisolone syrup 15 /5ml (usp 2 solution equivalent) prednisone oral soln 5 /5ml 2 prednisone tab 1 2 prednisone tab 2.5 1 prednisone tab 5 1 prednisone tab 10 1 prednisone tab 20 1 prednisone tab 50 2 SOLU-CORTEF INJ 100MG 4 SOLU-CORTEF INJ 250MG 4 SOLU-CORTEF INJ 500MG 4 SOLU-CORTEF INJ 1000MG 4 SOLU-MEDROL INJ 1GM 4 SOLU-MEDROL INJ 2GM 4 SOLU-MEDROL INJ 40MG 4 SOLU-MEDROL INJ 125MG 4 SOLU-MEDROL INJ 500MG 4 GLUCOSE ELEVATING AGENT GLUCAGEN INJ HYPOKIT 3 QL GLUCAGON KIT 1MG 3 QL PROGLYCEM SUS 50MG/ML 3 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 69

HEREDITARY TYROSINEMIA TYPE 1 AGENTS ORFADIN CAP 2MG 5 PA ORFADIN CAP 5MG 5 PA ORFADIN CAP 10MG 5 PA ORFADIN SUS 4MG/ML 5 PA HUMAN GROWTH HORMONES HUMATROPE INJ 5MG 5 PA HUMATROPE INJ 6MG 5 PA HUMATROPE INJ 12MG 5 PA HUMATROPE INJ 24MG 5 PA NORDITROPIN INJ 5/1.5ML 5 PA NORDITROPIN INJ 10/1.5ML 5 PA NORDITROPIN INJ 15/1.5ML 5 PA NORDITROPIN INJ 30/3ML 5 PA SEROSTIM INJ 4MG 5 PA SEROSTIM INJ 5MG 5 PA SEROSTIM INJ 6MG 5 PA HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS calcitriol cap 0.5 mcg 2 calcitriol cap 0.25 mcg 2 calcitriol inj 1 mcg/ml 2 calcitriol oral soln 1 mcg/ml 2 doxercalciferol cap 0.5 mcg 2 doxercalciferol cap 1 mcg 2 doxercalciferol cap 2.5 mcg 2 HECTOROL INJ 2MCG/ML 3 paricalcitol cap 1 mcg 2 paricalcitol cap 2 mcg 2 paricalcitol cap 4 mcg 2 ROCALTROL CAP 0.5MCG 4 ROCALTROL CAP 0.25MCG 4 ROCALTROL SOL 1MCG/ML 4 ZEMPLAR CAP 1MCG 4 ZEMPLAR CAP 2MCG 4 INSULIN-LIKE GROWTH FACTOR INCRELEX INJ 40MG/4ML 5 PA LYSOSOMAL STORAGE DISORDERS ALDURAZYME INJ 2.9MG/5M 5 PA CEREZYME INJ 400UNIT 5 PA ELAPRASE INJ 6MG/3ML 5 PA ELELYSO INJ 200UNIT 5 PA FABRAZYME INJ 5MG 5 PA FABRAZYME INJ 35MG 5 PA NAGLAZYME INJ 1MG/ML 5 PA VIMIZIM INJ 5MG/5ML 5 PA VPRIV INJ 400UNIT 5 PA PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 70

ZAVESCA CAP 100MG 5 PA MISCELLANEOUS ADAGEN INJ 250/ML 5 PA cabergoline tab 0.5 2 CARBAGLU TAB 200MG 5 PA CERVIDIL VAG MIS 10MG INS 3 CYSTADANE POW 5 PA H.P. ACTHAR INJ 80UNIT 5 PA; QL HEMABATE INJ 250MCG 4 KANUMA INJ 20/10ML 5 KORLYM TAB 300MG 5 PA; QL levocarnitine oral soln 1 gm/10ml (10%) 2 levocarnitine tab 330 2 LUPR DEP-PED INJ 3M 30MG 5 PA; QL LUPR DEP-PED INJ 7.5MG 5 PA; QL LUPR DEP-PED INJ 11.25MG 5 PA; QL LUPR DEP-PED INJ 15MG 5 PA; QL methylergonovine maleate inj 0.2 /ml 4 MYALEPT INJ 11.3MG 5 PA; QL octreotide acetate inj 50 mcg/ml (0.05 5 /ml) octreotide acetate inj 100 mcg/ml (0.1 5 /ml) octreotide acetate inj 200 mcg/ml (0.2 5 /ml) octreotide acetate inj 500 mcg/ml (0.5 5 /ml) octreotide acetate inj 1000 mcg/ml (1 5 /ml) PREPIDIL GEL 0.5MG/3G 3 PROSTIN E2 SUP 20MG 3 RAVICTI LIQ 1.1GM/ML 5 PA; QL SANDOSTATIN INJ 50MCG/ML 5 SANDOSTATIN INJ 100MCG 5 SANDOSTATIN INJ 500MCG 5 SANDOSTATIN KIT LAR 10MG 5 PA; QL SANDOSTATIN KIT LAR 20MG 5 PA; QL SANDOSTATIN KIT LAR 30MG 5 PA; QL SIGNIFOR INJ 0.3MG/ML 5 PA; QL SIGNIFOR INJ 0.6MG/ML 5 PA; QL SIGNIFOR INJ 0.9MG/ML 5 PA; QL SIGNIFOR LAR INJ 20MG 5 PA; QL SIGNIFOR LAR INJ 40MG 5 PA; QL SIGNIFOR LAR INJ 60MG 5 PA; QL sodium phenylbutyrate tab 500 4 PA SOMATULINE INJ 60/0.2ML 5 PA; QL SOMATULINE INJ 90/0.3ML 5 PA; QL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 71

SOMATULINE INJ 120/.5ML 5 PA; QL SOMAVERT INJ 10MG 5 PA; QL SOMAVERT INJ 15MG 5 PA; QL SOMAVERT INJ 20MG 5 PA; QL SOMAVERT INJ 25MG 5 PA; QL SOMAVERT INJ 30MG 5 PA; QL STRENSIQ INJ 18/0.45 5 PA STRENSIQ INJ 28/0.7ML 5 PA STRENSIQ INJ 40MG/ML 5 PA STRENSIQ INJ 80/0.8ML 5 PA SUPPRELIN LA KIT 50MG 5 PA; QL SYPRINE CAP 250MG 5 PA THYROGEN INJ 1.1MG 5 trientine hcl cap 250 5 PA PHENYLKETONURIA TREATMENT AGENTS KUVAN POW 100MG 5 PA KUVAN POW 500MG 5 PA KUVAN TAB 100MG 5 PA PALYNZIQ INJ 2.5/0.5 5 PA; QL PALYNZIQ INJ 10/0.5ML 5 PA; QL PALYNZIQ INJ 20MG/ML 5 PA; QL PHOSPHATE BINDER AGENTS AURYXIA TAB 210MG 3 calcium acetate (phosphate binder) cap 2 667 (169 ca) calcium acetate (phosphate binder) tab 2 667 RENAGEL TAB 800MG 5 sevelamer carbonate packet 0.8 gm 2 sevelamer carbonate packet 2.4 gm 2 sevelamer carbonate tab 800 2 POTASSIUM-REMOVING AGENTS LOKELMA PAK 5GM 5 PA; QL LOKELMA PAK 10GM 5 PA; QL sodium polystyrene sulfonate oral susp 15 2 gm/60ml sodium polystyrene sulfonate powder 2 VELTASSA POW 8.4GM 5 PA; QL VELTASSA POW 16.8GM 5 PA; QL VELTASSA POW 25.2GM 5 PA; QL PROGESTINS, INJECTABLE MAKENA INJ 250MG/ML 5 PA PROGESTINS, ORAL medroxyprogesterone acetate tab 2.5 1 medroxyprogesterone acetate tab 5 1 medroxyprogesterone acetate tab 10 1 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 72

norethindrone acetate tab 5 2 progesterone micronized cap 100 2 progesterone micronized cap 200 2 PROGESTINS, VAGINAL CRINONE GEL 4% VAG 3 ENDOMETRIN SUP 100MG 4 THYROID AGENTS, ANTITHYROID AGENTS iodine solution strong 5% (lugol's) 2 methimazole tab 5 2 methimazole tab 10 2 propylthiouracil tab 50 2 SSKI SOL 1GM/ML 2 THYROID SUPPLEMENTS CYTOMEL TAB 5MCG 4 CYTOMEL TAB 25MCG 4 CYTOMEL TAB 50MCG 4 LEVOTHYROXIN INJ 200MCG 2 levothyroxine sodium for iv inj 100 mcg 2 levothyroxine sodium for iv inj 500 mcg 2 levothyroxine sodium tab 25 mcg 2 levothyroxine sodium tab 50 mcg 2 levothyroxine sodium tab 75 mcg 2 levothyroxine sodium tab 88 mcg 2 levothyroxine sodium tab 100 mcg 2 levothyroxine sodium tab 112 mcg 2 levothyroxine sodium tab 125 mcg 2 levothyroxine sodium tab 137 mcg 2 levothyroxine sodium tab 150 mcg 2 levothyroxine sodium tab 175 mcg 2 levothyroxine sodium tab 200 mcg 2 levothyroxine sodium tab 300 mcg 2 liothyronine sodium iv soln 10 mcg/ml 2 liothyronine sodium tab 5 mcg 2 liothyronine sodium tab 25 mcg 2 liothyronine sodium tab 50 mcg 2 NATURE THROI TAB 162.5MG 2 NATURE-THROI TAB 16.25MG 4 NATURE-THROI TAB 32.5MG 2 NATURE-THROI TAB 48.75MG 4 NATURE-THROI TAB 81.25MG 4 NATURE-THROI TAB 97.5MG 2 NATURE-THROI TAB 113.75MG 4 NATURE-THROI TAB 130MG 2 NATURE-THROI TAB 146.25MG 4 NATURE-THROI TAB 195MG 2 NATURE-THROI TAB 260MG 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 73

NATURE-THROI TAB 325MG 2 SYNTHROID TAB 25MCG 4 SYNTHROID TAB 50MCG 4 SYNTHROID TAB 75MCG 4 SYNTHROID TAB 88MCG 4 SYNTHROID TAB 100MCG 4 SYNTHROID TAB 112MCG 4 SYNTHROID TAB 125MCG 4 SYNTHROID TAB 137MCG 4 SYNTHROID TAB 150MCG 4 SYNTHROID TAB 175MCG 4 SYNTHROID TAB 200MCG 4 SYNTHROID TAB 300MCG 4 THYROLAR-1 TAB 60MG 3 THYROLAR-1/2 TAB 30MG 3 THYROLAR-1/4 TAB 15MG 3 THYROLAR-2 TAB 120MG 3 THYROLAR-3 TAB 180MG 3 TIROSINT CAP 13MCG 4 TIROSINT CAP 25MCG 4 TIROSINT CAP 50MCG 4 TIROSINT CAP 75MCG 4 TIROSINT CAP 88MCG 4 TIROSINT CAP 100MCG 4 TIROSINT CAP 112MCG 4 TIROSINT CAP 125MCG 4 TIROSINT CAP 137MCG 4 TIROSINT CAP 150MCG 4 TRIOSTAT INJ 10MCG/ML 4 WESTHROID TAB 32.5MG 2 WESTHROID TAB 97.5MG 2 WESTHROID TAB 130MG 2 VASOPRESSIN RECEPTOR ANTAGONISTS JYNARQUE PAK 45-15MG 5 PA; QL JYNARQUE PAK 60-30MG 5 PA; QL JYNARQUE PAK 90-30MG 5 PA; QL SAMSCA TAB 15MG 5 PA; QL SAMSCA TAB 30MG 5 PA; QL VASOPRESSINS desmopressin acetate inj 4 mcg/ml 5 desmopressin acetate nasal spray soln 5 0.01% desmopressin acetate nasal spray soln 5 0.01% (refrigerated) desmopressin acetate tab 0.1 2 desmopressin acetate tab 0.2 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 74

STIMATE SOL 1.5MG/ML 5 GASTROINTESTINAL ANTIDIARRHEALS diphenoxylate w/ atropine liq 2.5-0.025 2 /5ml diphenoxylate w/ atropine tab 2.5-0.025 2 loperamide hcl cap 2 2 ANTIEMETICS AKYNZEO CAP 300-0.5 4 QL ALOXI INJ 0.25MG/5 4 ST aprepitant capsule 40 3 QL aprepitant capsule 80 3 QL aprepitant capsule 125 3 QL aprepitant capsule therapy pack 80 & 125 3 QL CESAMET CAP 1MG 3 DIMENHYDRIN INJ 50MG/ML 2 dronabinol cap 2.5 2 dronabinol cap 5 2 dronabinol cap 10 2 droperidol inj 2.5 /ml 2 EMEND SOL 150MG 4 QL granisetron hcl inj 0.1 /ml 2 ST; QL granisetron hcl inj 1 /ml 2 ST; QL granisetron hcl inj 4 /4ml (1 /ml) 2 ST; QL granisetron hcl tab 1 2 ST; QL meclizine hcl tab 12.5 2 meclizine hcl tab 25 2 metoclopramide hcl inj 5 /ml (base 2 equivalent) metoclopramide hcl soln 5 /5ml (10 1 /10ml) (base equiv) metoclopramide hcl tab 5 (base 1 equivalent) metoclopramide hcl tab 10 (base 1 equivalent) ondansetron hcl inj 4 /2ml (2 /ml) 2 ondansetron hcl inj 40 /20ml (2 /ml) 2 ondansetron hcl oral soln 4 /5ml 2 ondansetron hcl tab 4 2 QL ondansetron hcl tab 8 2 QL ondansetron hcl tab 24 2 QL ondansetron orally disintegrating tab 4 2 QL ondansetron orally disintegrating tab 8 2 QL prochlorperazine edisylate inj 5 /ml 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 75

prochlorperazine maleate tab 5 (base 1 equivalent) prochlorperazine maleate tab 10 (base 1 equivalent) prochlorperazine suppos 25 2 promethazine hcl inj 25 /ml 2 promethazine hcl inj 50 /ml 2 promethazine hcl suppos 12.5 2 promethazine hcl suppos 25 2 promethazine hcl suppos 50 2 promethazine hcl syrup 6.25 /5ml 1 promethazine hcl tab 12.5 2 promethazine hcl tab 25 1 promethazine hcl tab 50 2 SANCUSO DIS 3.1MG 4 ST; QL scopolamine td patch 72hr 1 /3days 2 TIGAN INJ 100MG/ML 4 TRANSDERM-SC DIS 1.5MG 4 trimethobenzamide hcl cap 300 2 ANTISPASMODICS BELLA/OPIUM SUP 16.2-30 2 chlordiazepoxide hcl-clidinium bromide cap 2 5-2.5 CUVPOSA SOL 1MG/5ML 4 PA dicyclomine hcl cap 10 1 dicyclomine hcl oral soln 10 /5ml 2 dicyclomine hcl tab 20 1 GLYCOPYRROLA INJ 1MG/5ML 2 glycopyrrolate inj 0.2 /ml 2 glycopyrrolate inj 0.4 /2ml (0.2 /ml) 2 glycopyrrolate inj 1 /5ml (0.2 /ml) 2 glycopyrrolate inj 4 /20ml (0.2 /ml) 2 glycopyrrolate tab 1 2 glycopyrrolate tab 2 2 hyoscyamine sulfate elixir 0.125 /5ml 2 hyoscyamine sulfate sl tab 0.125 2 hyoscyamine sulfate soln 0.125 /ml 2 hyoscyamine sulfate tab 0.125 2 hyoscyamine sulfate tab disint 0.125 2 hyoscyamine sulfate tab er 12hr 0.375 2 LEVSIN INJ 0.5MG/ML 4 methscopolamine bromide tab 2.5 2 methscopolamine bromide tab 5 2 propantheline bromide tab 15 2 SYMAX DUOTAB TAB 4 CHOLELITHOLYTICS PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 76

ursodiol cap 300 2 ursodiol tab 250 2 ursodiol tab 500 2 INFLAMMATORY BOWEL DISEASE, ORAL AGENTS APRISO CAP 0.375GM 3 ASACOL HD TAB 800MG 3 balsalazide disodium cap 750 2 budesonide delayed release particles cap 3 2 DELZICOL CAP 400MG 3 DIPENTUM CAP 250MG 4 ST mesalamine tab delayed release 1.2 gm 2 PENTASA CAP 250MG CR 4 PENTASA CAP 500MG CR 4 sulfasalazine tab 500 2 sulfasalazine tab delayed release 500 2 UCERIS TAB 9MG 5 PA INFLAMMATORY BOWEL DISEASE, RECTAL AGENTS CANASA SUP 1000MG 5 CORTIFOAM AER 90MG 4 hydrocortisone enema 100 /60ml 2 mesalamine enema 4 gm 2 UCERIS AER 2MG/ACT 5 IRRITABLE BOWEL SYNDROME WITH CONSTIPATION AMITIZA CAP 8MCG 4 ST; QL AMITIZA CAP 24MCG 4 ST; QL LINZESS CAP 72MCG 3 QL LINZESS CAP 145MCG 3 QL LINZESS CAP 290MCG 3 QL IRRITABLE BOWEL SYNDROME WITH DIARRHEA alosetron hcl tab 0.5 (base equiv) 4 PA; QL alosetron hcl tab 1 (base equiv) 4 PA; QL LOTRONEX TAB 0.5MG 4 PA; QL LOTRONEX TAB 1MG 4 PA; QL VIBERZI TAB 75MG 5 PA; QL VIBERZI TAB 100MG 5 PA; QL LAXATIVES/STOOL SOFTENERS GOLYTELY SOL 3 lactulose solution 10 gm/15ml 2 OSMOPREP TAB 1.5GM 4 peg 3350-kcl-na bicarb-nacl-na sulfate for 2 soln 236 gm peg 3350-kcl-na bicarb-nacl-na sulfate for 2 soln 240 gm peg 3350-kcl-sod bicarb-nacl for soln 420 2 gm PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 77

polyethylene glycol 3350 oral powder 2 polyethylene glycol 3350 oral powder 2 MISCELLANEOUS BUPHENYL POW 4 PA BUPHENYL TAB 500MG 4 PA CARAFATE SUS 1GM/10ML 3 cromolyn sodium oral conc 100 /5ml 2 GATTEX KIT 5MG 5 PA; QL KEPIVANCE INJ 6.25MG 5 lactulose (encephalopathy) solution 10 2 gm/15ml OCALIVA TAB 5MG 5 PA OCALIVA TAB 10MG 5 PA RECTIV OIN 0.4% 4 PA sodium phenylbutyrate oral powder 3 4 PA gm/teaspoonful SUCRAID SOL 8500/ML 5 PA sucralfate tab 1 gm 2 OPIOID-INDUCED CONSTIPATION MOVANTIK TAB 12.5MG 3 QL MOVANTIK TAB 25MG 3 QL PANCREATIC ENZYMES CREON CAP 3000UNIT 3 CREON CAP 6000UNIT 3 CREON CAP 12000UNT 3 CREON CAP 24000UNT 3 CREON CAP 36000UNT 3 PANCREAZE CAP 4200UNIT 4 ST PANCREAZE CAP 10500UNT 4 ST PANCREAZE CAP 16800UNT 4 ST PANCREAZE CAP 21000UNT 4 ST PERTZYE CAP 8000UNIT 4 ST PERTZYE CAP 16000U 4 ST VIOKACE TAB 10440 4 ST VIOKACE TAB 20880 4 ST PROSTAGLANDINS misoprostol tab 100 mcg 2 misoprostol tab 200 mcg 2 SALIVA STIMULANTS cevimeline hcl cap 30 2 pilocarpine hcl tab 5 2 pilocarpine hcl tab 7.5 2 STEROIDS, RECTAL EPIFOAM AER 1% 4 hydrocortisone acetate suppos 25 2 hydrocortisone acetate suppos 30 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 78

hydrocortisone acetate w/ pramoxine rectal 2 cream 1-1% hydrocortisone acetate w/ pramoxine rectal 2 cream 2.5-1% hydrocortisone rectal cream 1% 2 hydrocortisone rectal cream 2.5% 2 lidocaine-hydrocortisone acetate rectal 2 cream 3-0.5% lidocaine-hydrocortisone acetate rectal 2 cream kit 2-2% lidocaine-hydrocortisone acetate rectal 2 cream kit 3-0.5% lidocaine-hydrocortisone acetate rectal 2 cream kit 3-1% lidocaine-hydrocortisone acetate rectal gel 2 kit 3-2.5% PROCTOFOAM AER HC 1% 4 ULCER THERAPY COMBINATION amoxicillin cap-clarithro tab-lansopraz cap 2 dr therapy pack OMECLAMOX- MIS PAK 4 GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl tab er 24hr 10 2 CARDURA XL TAB 4MG 4 QL CARDURA XL TAB 8MG 4 QL dutasteride cap 0.5 2 dutasteride-tamsulosin hcl cap 0.5-0.4 2 finasteride tab 5 2 RAPAFLO CAP 4MG 4 ST RAPAFLO CAP 8MG 4 ST tamsulosin hcl cap 0.4 2 UROXATRAL TAB 10MG 4 GENITOURINARY IRRIGANTS acetic acid irrigation soln 0.25% 2 glycine irrigation soln 1.5% 2 neomycin-polymyxin b gu irrigation soln 2 RESECTISOL SOL 5% 3 sodium chloride irrigation soln 0.9% 2 MISCELLANEOUS acetic acid-oxyquinoline vaginal gel 4 0.9-0.025% bethanechol chloride tab 5 2 bethanechol chloride tab 10 2 bethanechol chloride tab 25 2 bethanechol chloride tab 50 2 CYSTAGON CAP 50MG 5 PA PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 79

CYSTAGON CAP 150MG 5 PA ELMIRON CAP 100MG 3 FEM PH GEL 2 mannitol iv soln 25% 2 methenamine hippurate tab 1 gm 2 methenamine-hyosc-meth blue-benz 2 acid-phenyl sal tab 81.6 ORACIT SOL 3 phenazopyridine hcl tab 100 2 phenazopyridine hcl tab 200 2 pot & sod citrates w/ cit ac soln 550-500-334 /5ml 2 potassium citrate & citric acid powder pack 2 3300-1002 potassium citrate & citric acid soln 2 1100-334 /5ml potassium citrate tab er 5 meq (540 ) 2 potassium citrate tab er 10 meq (1080 ) 2 potassium citrate tab er 15 meq (1620 ) 2 PROCYSBI CAP 25MG 5 PA; QL PROCYSBI CAP 75MG 5 PA; QL RIMSO-50 SOL 50% 3 sodium citrate & citric acid soln 500-334 2 /5ml THIOLA TAB 100MG 5 PERITONEAL DIALYSIS SOLUTION DELFLEX-LC/ SOL 2.5% DEX 4 URINARY ANTISPASMODICS MYRBETRIQ TAB 25MG 3 QL MYRBETRIQ TAB 50MG 3 QL oxybutynin chloride syrup 5 /5ml 2 oxybutynin chloride tab 5 2 oxybutynin chloride tab er 24hr 5 2 oxybutynin chloride tab er 24hr 10 2 oxybutynin chloride tab er 24hr 15 2 tolterodine tartrate cap er 24hr 2 2 tolterodine tartrate cap er 24hr 4 2 tolterodine tartrate tab 1 2 tolterodine tartrate tab 2 2 trospium chloride cap er 24hr 60 2 trospium chloride tab 20 2 VESICARE TAB 5MG 3 VESICARE TAB 10MG 3 VAGINAL ANTI-INFECTIVES CLEOCIN SUP 100MG 3 clindamycin phosphate vaginal cream 2% 2 GYNAZOLE-1 CRE 2% 4 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 80

metronidazole vaginal gel 0.75% 2 terconazole vaginal suppos 80 2 HEMATOLOGIC ANTICOAGULANTS, INJECTABLE ARGATROBAN INJ 50MG/50M 4 argatroban inj 250 /2.5ml (concentrate 4 for iv infusion) ARGATROBAN INJ 250/250 4 enoxaparin sodium inj 30 /0.3ml 2 enoxaparin sodium inj 40 /0.4ml 2 enoxaparin sodium inj 60 /0.6ml 2 enoxaparin sodium inj 80 /0.8ml 2 enoxaparin sodium inj 100 /ml 2 enoxaparin sodium inj 120 /0.8ml 2 enoxaparin sodium inj 150 /ml 2 enoxaparin sodium inj 300 /3ml 2 fondaparinux sodium subcutaneous inj 2.5 5 QL /0.5ml fondaparinux sodium subcutaneous inj 5 /0.4ml 5 QL fondaparinux sodium subcutaneous inj 7.5 5 QL /0.6ml fondaparinux sodium subcutaneous inj 10 5 QL /0.8ml FRAGMIN INJ 2500/0.2 5 QL FRAGMIN INJ 5000/0.2 5 QL FRAGMIN INJ 7500/0.3 5 QL FRAGMIN INJ 10000/ML 5 QL FRAGMIN INJ 12500UNT 5 QL FRAGMIN INJ 15000UNT 5 QL FRAGMIN INJ 18000UNT 5 QL FRAGMIN INJ 95000UNT 5 QL heparin sodium (porcine) inj 1000 unit/ml 2 heparin sodium (porcine) inj 5000 unit/ml 2 heparin sodium (porcine) inj 10000 unit/ml 2 heparin sodium (porcine) inj 20000 unit/ml 2 heparin sodium (porcine) pf inj 5000 2 unit/0.5ml ANTICOAGULANTS, ORAL ELIQUIS TAB 2.5MG 3 QL ELIQUIS TAB 5MG 3 QL warfarin sodium tab 1 1 warfarin sodium tab 2 1 warfarin sodium tab 2.5 1 warfarin sodium tab 3 1 warfarin sodium tab 4 1 warfarin sodium tab 5 1 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 81

warfarin sodium tab 6 1 warfarin sodium tab 7.5 1 warfarin sodium tab 10 1 XARELTO STAR TAB 15/20MG 3 QL XARELTO TAB 10MG 3 QL XARELTO TAB 15MG 3 QL XARELTO TAB 20MG 3 QL ANTIHEMOPHILIC AGENTS OBIZUR INJ 500 UNIT 4 HEMATOPOIETIC GROWTH FACTORS ARANESP INJ 10MCG 5 PA ARANESP INJ 25MCG 5 PA ARANESP INJ 40MCG 5 PA ARANESP INJ 60MCG 5 PA ARANESP INJ 100MCG 5 PA ARANESP INJ 150MCG 5 PA ARANESP INJ 200MCG 5 PA ARANESP INJ 300MCG 5 PA ARANESP INJ 500MCG 5 PA EPOGEN INJ 2000/ML 5 PA EPOGEN INJ 3000/ML 5 PA EPOGEN INJ 4000/ML 5 PA EPOGEN INJ 10000/ML 5 PA EPOGEN INJ 20000/ML 5 PA GRANIX INJ 300/0.5 5 PA GRANIX INJ 480/0.8 5 PA LEUKINE INJ 250MCG 5 PA NEULASTA INJ 6MG/0.6M 5 PA NEUPOGEN INJ 300/0.5 5 PA NEUPOGEN INJ 300MCG 5 PA NEUPOGEN INJ 480/0.8 5 PA NEUPOGEN INJ 480MCG 5 PA PROCRIT INJ 40000/ML 5 PA ZARXIO INJ 300/0.5 5 PA ZARXIO INJ 480/0.8 5 PA HEMOSTATICS, SYSTEMIC aminocaproic acid inj 250 /ml 2 tranexamic acid iv soln 1000 /10ml 2 (100 /ml) tranexamic acid tab 650 2 QL HEMOSTATICS, TOPICAL AVITENE PAD 35X35MM 4 AVITENE POW FLOUR 4 AVITENE SYRG MIS 1GM 4 ENDO AVITENE MIS 5MM DIA 4 ENDO AVITENE MIS 10MM DIA 4 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 82

GELFOAM MIS DENTAL 4 4 GELFOAM MIS SPON COM 4 GELFOAM POW 4 MONSELS FERR SOL SUBSULF 4 THROMBIN-JMI KIT 20000UNT 4 HEREDITARY ANGIOEDEMA AGENTS BERINERT INJ 500UNIT 5 PA; QL CINRYZE SOL 500 UNIT 5 PA; QL FIRAZYR INJ 30MG/3ML 5 PA; QL KALBITOR INJ 10MG/ML 5 PA RUCONEST INJ 2100UNIT 5 PA IDIOPATHIC THROMBOCYTOPENIC PURPURA DOPTELET TAB 20MG 5 PA; QL NPLATE INJ 250MCG 5 PA NPLATE INJ 500MCG 5 PA PROMACTA TAB 12.5MG 5 PA; QL PROMACTA TAB 25MG 5 PA; QL PROMACTA TAB 50MG 5 PA; QL PROMACTA TAB 75MG 5 PA; QL MISCELLANEOUS ACD FORMULA SOL A 4 ACTIVASE INJ 50MG 4 ACTIVASE INJ 100MG 4 ANTICOAG CIT SOL DEX SOL 4 ANTICOAG CPD SOL 3 CATHFLO ACTI INJ VASE 4 CEPROTIN INJ 1000UNIT 4 CHEMET CAP 100MG 4 PA cilostazol tab 50 2 cilostazol tab 100 2 deferoxamine mesylate for inj 2 gm 2 EXJADE TAB 125MG 5 PA EXJADE TAB 250MG 5 PA EXJADE TAB 500MG 5 PA FERRIPROX SOL 100MG/ML 4 PA FERRIPROX TAB 500MG 5 PA JADENU TAB 90MG 5 PA JADENU TAB 180MG 5 PA JADENU TAB 360MG 5 PA NOCLOT-50 SOL ACD-A 4 pentoxifylline tab er 400 2 protamine sulfate inj 10 /ml 2 THROMBAT III INJ 500UNIT 4 TRICITRASOL CON 4 PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS SOLIRIS INJ 10MG/ML 5 PA PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 83

PLATELET AGGREGATION INHIBITORS AGGRENOX CAP 25-200MG 4 aspirin-dipyridamole cap er 12hr 25-200 2 BRILINTA TAB 60MG 3 QL BRILINTA TAB 90MG 3 QL clopidogrel bisulfate tab 75 (base 1 equiv) clopidogrel bisulfate tab 300 (base 2 equiv) dipyridamole tab 25 2 dipyridamole tab 50 2 dipyridamole tab 75 2 prasugrel hcl tab 5 (base equiv) 2 prasugrel hcl tab 10 (base equiv) 2 REOPRO INJ 2MG/ML 4 ZONTIVITY TAB 2.08MG 4 PA; QL PLATELET SYNTHESIS INHIBITOR anagrelide hcl cap 0.5 2 anagrelide hcl cap 1 2 STEM CELL MOBILIZERS MOZOBIL INJ 5 PA; QL IMMUNOLOGIC AGENTS AUTOIMMUNE AGENTS COSENTYX INJ 150MG/ML 5 PA; QL COSENTYX PEN INJ 300DOSE 5 PA; QL ENBREL INJ 25/0.5ML 5 PA; QL ENBREL INJ 25MG 5 PA; QL ENBREL INJ 50MG/ML 5 PA; QL ENBREL MINI INJ 50MG/ML 5 PA; QL ENBREL SRCLK INJ 50MG/ML 5 PA; QL HUMIRA INJ 10/0.1ML 5 PA; QL HUMIRA INJ 10MG/0.2 5 PA; QL HUMIRA INJ 20/0.2ML 5 PA; QL HUMIRA INJ 40/0.4ML 5 PA; QL HUMIRA KIT 20MG/0.4 5 PA; QL HUMIRA KIT 40MG/0.8 5 PA; QL HUMIRA PEDIA INJ CROHNS 5 PA; QL HUMIRA PEN INJ 40/0.4ML 5 PA; QL HUMIRA PEN INJ 40MG/0.8 5 PA; QL HUMIRA PEN KIT CD/UC/HS 5 PA; QL HUMIRA PEN KIT PS/UV 5 PA; QL STELARA INJ 5MG/ML 5 PA; QL STELARA INJ 45MG/0.5 5 PA; QL STELARA INJ 90MG/ML 5 PA; QL DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDS) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 84

DEPEN TITRA TAB 250MG 5 PA hydroxychloroquine sulfate tab 200 2 leflunomide tab 10 2 leflunomide tab 20 2 OTREXUP INJ 10MG 5 PA; QL OTREXUP INJ 12.5/0.4 5 QL OTREXUP INJ 15MG 5 PA; QL OTREXUP INJ 17.5/0.4 5 QL OTREXUP INJ 20MG 5 PA; QL OTREXUP INJ 22.5/0.4 5 QL OTREXUP INJ 25MG 5 PA; QL RASUVO INJ 7.5MG 5 PA; QL RASUVO INJ 10MG 5 PA; QL RASUVO INJ 12.5MG 5 PA; QL RASUVO INJ 15MG 5 PA; QL RASUVO INJ 17.5MG 5 PA; QL RASUVO INJ 20MG 5 PA; QL RASUVO INJ 22.5MG 5 PA; QL RASUVO INJ 25MG 5 PA; QL RASUVO INJ 30MG 5 PA; QL IMMUNE GLOBULINS ATGAM INJ 250MG 5 CARIMUNE NF INJ 6GM 5 PA CARIMUNE NF INJ 12GM 5 PA FLEBOGAMMA INJ 20/400ML 5 PA FLEBOGAMMA INJ DIF 5% 5 PA GAMASTAN S/D INJ 5 PA GAMMAGARD INJ 1GM/10ML 5 PA GAMMAGARD INJ 2.5GM/25 5 PA GAMMAGARD INJ 5GM/50ML 5 PA GAMMAGARD INJ 10GM/100 5 PA GAMMAGARD INJ 20GM/200 5 PA GAMMAGARD INJ 30GM/300 5 PA GAMMAGARD SD INJ 5GM HU 5 PA GAMMAGARD SD INJ 10GM HU 5 PA GAMUNEX-C INJ 40/400ML 5 PA HIZENTRA INJ 1GM/5ML 5 PA HIZENTRA INJ 2GM/10ML 5 PA HIZENTRA INJ 4GM/20ML 5 PA HIZENTRA INJ 10/50ML 5 PA HYQVIA INJ 2.5-200 5 PA HYQVIA INJ 5-400 5 PA HYQVIA INJ 10-800 5 PA HYQVIA INJ 20-1600 5 PA HYQVIA INJ 30-2400 5 PA OCTAGAM INJ 1GM 5 PA PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 85

OCTAGAM INJ 2.5GM 5 PA OCTAGAM INJ 2GM/20ML 5 PA OCTAGAM INJ 5GM 5 PA OCTAGAM INJ 10GM 5 PA OCTAGAM INJ 25GM 5 PA PRIVIGEN INJ 5 GRAMS 5 PA PRIVIGEN INJ 10GRAMS 5 PA PRIVIGEN INJ 20GRAMS 5 PA PRIVIGEN INJ 40GRAMS 5 PA THYMOGLOBULN INJ 25MG 5 IMMUNOMODULATORS, INTERFERONS ACTIMMUNE INJ 2MU/0.5 5 PA ALFERON N INJ 5MU/ML 5 PA INTRON A INJ 18MU 5 PA INTRON A INJ 25MU 5 PA PEG-INTRON KIT 50MCG 5 PA; QL PEGASYS INJ 180MCG/M 5 PA; QL PEGASYS INJ PROCLICK 5 PA; QL SYLATRON KIT 200MCG 5 PA SYLATRON KIT 300MCG 5 PA SYLATRON KIT 600MCG 5 PA IMMUNOMODULATORS, MISCELLANEOUS ARCALYST INJ 220MG 5 PA; QL ILARIS INJ 150MG/ML 5 PA; QL OTEZLA TAB 10/20/30 5 PA; QL OTEZLA TAB 30MG 5 PA; QL IMMUNOSUPPRESSANTS, ANTIMETABOLITES azathioprine tab 50 2 CELLCEPT CAP 250MG 4 CELLCEPT SUS 200MG/ML 4 CELLCEPT TAB 500MG 4 mycophenolate mofetil cap 250 2 mycophenolate mofetil for oral susp 200 2 /ml mycophenolate mofetil tab 500 2 mycophenolate sodium tab dr 180 2 (mycophenolic acid equiv) mycophenolate sodium tab dr 360 2 (mycophenolic acid equiv) IMMUNOSUPPRESSANTS, CALCINEURIN INHIBITORS cyclosporine cap 25 2 cyclosporine cap 100 2 cyclosporine iv soln 50 /ml 2 cyclosporine modified cap 50 2 cyclosporine modified oral soln 100 /ml 2 NEORAL CAP 25MG 4 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 86

NEORAL CAP 100MG 4 NEORAL SOL 100MG/ML 4 PROGRAF CAP 0.5MG 4 PROGRAF CAP 1MG 4 PROGRAF CAP 5MG 4 PROGRAF INJ 5MG/ML 5 SANDIMMUNE CAP 25MG 4 SANDIMMUNE CAP 100MG 4 SANDIMMUNE INJ 50MG/ML 5 SANDIMMUNE SOL 100MG/ML 3 tacrolimus cap 0.5 2 tacrolimus cap 1 2 tacrolimus cap 5 2 IMMUNOSUPPRESSANTS, MISCELLANEOUS BENLYSTA INJ 120MG 5 PA BENLYSTA INJ 400MG 5 PA NULOJIX INJ 250MG 5 PA SIMULECT INJ 10MG 5 SIMULECT INJ 20MG 5 IMMUNOSUPPRESSANTS, RAPAMYCIN DERIVATIVE RAPAMUNE SOL 1MG/ML 3 PA RAPAMUNE TAB 0.5MG 5 PA RAPAMUNE TAB 1MG 5 PA RAPAMUNE TAB 2MG 5 PA sirolimus tab 0.5 2 PA sirolimus tab 1 2 PA sirolimus tab 2 2 PA ZORTRESS TAB 0.5MG 4 PA ZORTRESS TAB 0.25MG 4 PA ZORTRESS TAB 0.75MG 4 PA MONOCLONAL ANTIBODIES SYNAGIS INJ 50MG 5 PA; QL SYNAGIS INJ 100MG/ML 5 PA; QL VACCINES BCG VACCINE INJ 5 NUTRITIONAL / SUPPLEMENTS DIETARY MANAGEMENT PRODUCTS CARDIOTEK-RX TAB 4 FOLTANX TAB 2 METAFOLBIC TAB PLUS 2 PHENYLADE POW GMP 4 ELECTROLYTES, MISCELLANEOUS K-PHOS TAB 4 K-PHOS TAB NEUTRAL 2 K-PHOS TAB NO 2 4 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 87

pot phos monobasic w/sod phos di & 2 monobas tab 155-852-130 ELECTROLYTES, POTASSIUM EFFER-K TAB 10MEQ 3 EFFER-K TAB 20MEQ 3 KLOR-CON M15 TAB 15MEQ ER 2 pot bicarbonate & chloride effer tab 25 2 meq potassium bicarbonate effer tab 25 meq 2 potassium chloride cap er 8 meq 2 potassium chloride cap er 10 meq 2 potassium chloride microencapsulated crys 2 er tab 10 meq potassium chloride microencapsulated crys 2 er tab 20 meq potassium chloride oral soln 10% (20 2 meq/15ml) potassium chloride oral soln 20% (40 2 meq/15ml) potassium chloride powder packet 20 meq 2 potassium chloride tab er 8 meq (600 ) 2 potassium chloride tab er 10 meq 2 potassium chloride tab er 20 meq (1500 2 ) VITAMINS AND MINERALS, FOLIC ACID / COMBINATIONS ANIMI-3 CAP 4 ANIMI-3 CAP VIT D 4 BP VIT 3 CAP 4 FOLGARD RX TAB 4 folic acid tab 1 1 folic acid-vitamin b6-vitamin b12 tab 2 2.2-25-0.5 folic acid-vitamin b6-vitamin b12 tab 2 2.2-25-1 folic acid-vitamin b6-vitamin b12 tab 2 2.5-25-1 FOLTRATE TAB 3 VITAMINS AND MINERALS, MISCELLANEOUS ACTIVE FE TAB 75-1.25 4 AQUASOL A INJ 50000/ML 4 b-complex w/ c & folic acid cap 1 2 b-complex w/ c & folic acid tab 1 2 BIFERARX TAB 4 CALCIUM-FA WAF PLUS D 2 CORVITE 150 TAB 4 CORVITE FE TAB 4 ergocalciferol cap 50000 unit 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 88

ESCAVITE CHW 4 ESCAVITE D CHW 4 fe asp gly-fe polysacch-succ ac-c-threon 2 ac-b12-fa cap fe asparto gly-fe fum-b12-fa-c-succinic ac 2 tab ther pack fe fumarate w/ b12-vit c-fa-ifc cap 2 110-0.015-75-0.5-240 FERAHEME INJ 510/17ML 4 FERRALET 90 TAB 4 FERRAPLUS 90 TAB 2 ferrex 150 cap 150 2 FLORIVA CHW 0.5MG 4 FLORIVA CHW 0.25MG 4 FLORIVA CHW 1MG 4 FLORIVA DRO 0.25MG 4 FUSION PAK SPRINKLE 4 FUSION PLUS CAP 4 GALZIN CAP 25MG 3 PA GALZIN CAP 50MG 3 PA HEMATOGEN FA CAP 2 HEMATRON-AF TAB 4 HEMETAB TAB 2 hydroxocobalamin acetate inj 1000 mcg/ml 2 (base equivalent) INFED INJ 50MG/ML 2 INTEGRA F CAP 4 INTEGRA PLUS CAP 4 iron combination cap 2 iron polysacch complex-vit b12-fa cap 2 150-0.025-1 iron polysacch complex-vit b12-fa cap 2 150-0.025-1 iron-folic acid-vit c-vit b6-vit b12-zinc tab 2 150-1.25 IROSPAN 24/6 MIS 4 MAGNEBIND TAB 400 3 MEPHYTON TAB 5MG 4 NEPHPLEX RX TAB 2 NEPHRON FA TAB 4 NEURIN-SL SUB 4 NICADAN TAB 4 pediatric multiple vitamin w/ minerals & c 4 drops 45 /ml pediatric multiple vitamins w/ fl-fe drops 4 0.25-6 /ml pediatric multiple vitamins w/ fl-fe drops 2 0.25-10 /ml PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 89

pediatric multiple vitamins w/ fluoride 2 chew tab 0.5 POLY-VI-FLOR CHW 0.5MG 4 POLY-VI-FLOR CHW 0.25MG 4 POLY-VI-FLOR CHW 1MG 4 POLY-VI-FLOR SUS 0.25/ML 4 POLY-VI-FLOR SUS /IRON 4 PROFERRIN- TAB FORTE 4 PUREFE CAP PLUS 4 pyridoxine hcl inj 100 /ml 2 QUFLORA PED CHW 0.5MG 4 QUFLORA PED CHW 0.25MG 4 QUFLORA PED CHW 1MG 4 sodium fluoride chew tab 1 f (from 2.2 2 naf) sodium fluoride tab 1 f (from 2.2 2 naf) TANDEM PLUS CAP 4 TARON FORTE CAP 2 TEXAVITE LQ LIQ 4 thiamine hcl inj 100 /ml 2 TRI-VI-FLOR SUS 0.5MG/ML 4 TRI-VI-FLOR SUS 0.25/ML 4 VENOFER INJ 20MG/ML 4 VITAMINS AND MINERALS, PRENATAL VITAMINS ATABEX EC TAB 29-1MG 4 C-NATE DHA CAP 28-1-200 2 CITRANATAL CAP HARMONY 4 CITRANATAL MIS 90 DHA 4 CITRANATAL MIS B-CALM 4 CITRANATAL PAK ASSURE 4 CITRANATAL PAK DHA 4 CITRANATAL TAB RX 4 COMPLETE NAT PAK DHA 2 COMPLETENATE CHW 2 CONCEPT DHA CAP 4 CONCEPT OB CAP 4 DOTHELLE DHA CAP 2 DUET DHA 400 MIS 25-1-400 4 DUET DHA MIS BALANCED 4 ENBRACE HR CAP 4 FOLET DHA PAK 4 FOLET ONE CAP 38-1-225 4 FOLIVANE-OB CAP 2 HEMENATAL OB TAB 28-6-1MG 2 M-VIT TAB 27-1MG 3 MARNATAL-F CAP 4 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 90

MYNATAL CAP 2 MYNATAL TAB 2 MYNATAL TAB ADVANCE 2 MYNATAL-Z TAB 2 MYNATE 90 TAB PLUS 2 NATACHEW CHW 4 NATELLE ONE CAP 4 NEEVO DHA CAP 27-1.13 4 NESTABS ABC MIS 4 NESTABS DHA PAK 4 NEWGEN TAB 32-1MG 2 NIVA-PLUS TAB 4 O-CAL FA TAB 3 O-CAL TAB PRENATAL 3 OB COMPLETE CAP ONE 4 OB COMPLETE CAP PETITE 4 OB COMPLETE TAB 3 OB COMPLETE TAB PREMIER 4 OBSTETRIX EC TAB 3 OBSTETRIX PAK DHA 4 PNV OB+DHA PAK 2 PNV PRENATAL TAB PLUS 2 PNV PRENATAL TAB PLUS 2 PNV TABS TAB 29-1MG 2 PNV-DHA CAP DOCUSATE 2 PR NATAL 400 PAK 2 PR NATAL 430 PAK 2 PR NATAL 430 PAK EC 2 PREFERAOB MIS +DHA 4 PRENAISSANCE CAP PLUS 2 PRENAT PLUS TAB 27-1MG 2 prenat w/o a w/fefum-methfol-fa-dha cap 2 27-0.6-0.4-300 PRENATA CHW 29-1MG 4 PRENATAL TAB 27-1MG 2 PRENATAL TAB PLUS 2 PRENATAL VIT TAB LOW IRON 2 prenatal vit w/ dss-fe fumarate-fa tab 29-1 2 prenatal vit w/ fe fum-methylfolate-fa tab 2 27-0.6-0.4 prenatal vit w/ fe fumarate-fa chew tab 2 29-1 prenatal vit w/ fe fumarate-fa tab 27-1 2 prenatal vit w/ fe fumarate-fa tab 28-1 2 PRENATAL+FE TAB 29-1MG 2 PRENATAL-U CAP 106.5-1 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 91

PRENATE AM TAB 1MG 4 PRENATE CAP ENHANCE 4 PRENATE CAP PIXIE 4 PRENATE CAP RESTORE 4 PRENATE CHW 0.6-0.4 4 PRENATE DHA CAP 4 PRENATE MINI CAP 4 PRENATE TAB ELITE 4 PREPLUS TAB 27-1MG 2 PRETAB TAB 29-1MG 2 PROVIDA DHA CAP 4 PROVIDA OB CAP 4 PUREFE OB CAP PLUS 4 REDICHEW RX CHW 4 RELNATE DHA CAP 2 SE-NATAL 19 TAB 2 SELECT-OB CHW 4 SELECT-OB+ PAK DHA 4 TARON-C DHA CAP 2 TARON-PREX CAP 2 TL-SELECT CAP 2 TRI-TABS DHA MIS 2 TRICARE PRE CAP 27-1-500 4 TRICARE TAB PRENATAL 4 TRISTART DHA CAP 4 VENA-BAL MIS DHA 2 VINATE II TAB 2 VINATE M TAB 2 VINATE ONE TAB 2 VIRT-C DHA CAP 2 VIRT-NATE CAP DHA 2 VIRT-PN PLUS CAP 2 VIRT-PN TAB 2 VITAFOL CAP ULTRA 4 VITAFOL FE+ CAP 4 VITAFOL-NANO TAB 4 VITAFOL-OB PAK +DHA 4 VITAFOL-ONE CAP 4 VITAMEDMD CAP ONE RX 4 VITAPEARL CAP 4 VITATRUE MIS 4 VIVA DHA CAP 4 VOL-PLUS TAB 2 VOL-TAB RX TAB 4 VP-PNV-DHA CAP 4 ZATEAN-PN CAP DHA 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 92

ZATEAN-PN CAP PLUS 2 RESPIRATORY ANAPHYLAXIS TREATMENT AGENTS ADRENALIN INJ 1MG/ML 4 ADRENALIN INJ 30/30ML 4 epinephrine pf inj 1 /ml 2 epinephrine pf soln prefilled syringe 1 2 /10ml (0.1 /ml) epinephrine solution auto-injector 0.3 2 /0.3ml (1:1000) epinephrine solution auto-injector 0.15 2 /0.15ml (1:1000) EPIPEN 2-PAK INJ 0.3MG 4 EPIPEN-JR INJ 2-PAK 3 ANTICHOLINERGIC/BETA AGONIST COMBINATIONS, LONG ACTING ANORO ELLIPT AER 62.5-25 3 STIOLTO AER 2.5-2.5 3 UTIBRON CAP NEOHALER 4 ANTICHOLINERGIC/BETA AGONIST COMBINATIONS, SHORT ACTING COMBIVENT AER 20-100 3 ipratropium-albuterol nebu soln 0.5-2.5(3) 2 /3ml ANTICHOLINERGICS ATROVENT HFA AER 17MCG 4 ipratropium bromide inhal soln 0.02% 2 SEEBRI NEOHA CAP 15.6MCG 4 SPIRIVA AER 1.25MCG 3 SPIRIVA CAP HANDIHLR 3 SPIRIVA SPR 2.5MCG 3 ANTIHISTAMINE/DECONGESTANT COMBINATIONS promethazine & phenylephrine syrup 2 6.25-5 /5ml ANTIHISTAMINES, LOW-SEDATING levocetirizine dihydrochloride soln 2.5 2 PA /5ml (0.5 /ml) levocetirizine dihydrochloride tab 5 2 ANTIHISTAMINES, SEDATING carbinoxamine maleate soln 4 /5ml 2 carbinoxamine maleate tab 4 2 clemastine fumarate tab 2.68 2 cyproheptadine hcl syrup 2 /5ml 2 cyproheptadine hcl tab 4 2 diphenhydramine hcl cap 50 5 diphenhydramine hcl elixir 12.5 /5ml 5 diphenhydramine hcl inj 50 /ml 5 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 93

hydroxyzine hcl im soln 25 /ml 2 hydroxyzine hcl im soln 50 /ml 2 hydroxyzine hcl syrup 10 /5ml 2 hydroxyzine hcl tab 10 2 hydroxyzine hcl tab 25 2 hydroxyzine hcl tab 50 2 hydroxyzine pamoate cap 25 2 hydroxyzine pamoate cap 50 2 hydroxyzine pamoate cap 100 2 ANTITUSSIVE COMBINATIONS, NON-OPIOID promethazine-dm syrup 6.25-15 /5ml 1 pseudoephed-bromphen-dm syrup 30-2-104 /5ml ANTITUSSIVE COMBINATIONS, OPIOID CAPCOF SYP 5-2-10MG 4 guaifenesin-codeine soln 100-10 /5ml 2 hydrocod polst-chlorphen polst er susp 2 10-8 /5ml hydrocodone w/ homatropine syrup 5-1.5 2 /5ml m-clear wc liq 100-6.3 2 M-END PE LIQ 4 promethazine w/ codeine syrup 6.25-10 2 /5ml TUSSICAPS CAP 5-4MG 4 TUSSICAPS CAP 10-8MG 4 Z-TUSS AC LIQ 2-9/5ML 4 ANTITUSSIVES benzonatate cap 100 1 benzonatate cap 200 2 BETA AGONISTS, INHALANTS, LONG ACTING, Hand-held Active Inhalation ARCAPTA CAP 75MCG 4 ST SEREVENT DIS AER 50MCG 3 STRIVERDI AER 2.5MCG 4 BETA AGONISTS, INHALANTS, LONG ACTING, Nebulized Passive Inhalation BROVANA NEB 15MCG 4 PERFOROMIST NEB 20MCG 4 BETA AGONISTS, INHALANTS, SHORT ACTING albuterol sulfate soln nebu 0.5% (5 /ml) 2 albuterol sulfate soln nebu 0.63 /3ml 2 (base equiv) albuterol sulfate soln nebu 0.083% (2.5 1 /3ml) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 94

albuterol sulfate soln nebu 1.25 /3ml 2 (base equiv) levalbuterol hcl soln nebu 0.31 /3ml 2 (base equiv) levalbuterol hcl soln nebu 0.63 /3ml 2 (base equiv) levalbuterol hcl soln nebu 1.25 /3ml 2 (base equiv) levalbuterol hcl soln nebu conc 1.25 2 /0.5ml (base equiv) levalbuterol tartrate inhal aerosol 45 4 QL mcg/act (base equiv) metaproterenol sulfate syrup 10 /5ml 2 metaproterenol sulfate tab 10 2 metaproterenol sulfate tab 20 2 PROVENTIL AER HFA 4 PA; QL VENTOLIN HFA AER 3 QL XOPENEX HFA AER 4 QL BETA AGONISTS, INJECTABLE ISUPREL INJ 0.2MG/ML 4 terbutaline sulfate inj 1 /ml 2 BETA AGONISTS, ORAL AGENTS albuterol sulfate syrup 2 /5ml 1 albuterol sulfate tab 2 1 albuterol sulfate tab 4 2 albuterol sulfate tab er 12hr 4 2 albuterol sulfate tab er 12hr 8 2 terbutaline sulfate tab 2.5 2 terbutaline sulfate tab 5 2 CYSTIC FIBROSIS BETHKIS NEB 300/4ML 5 QL CAYSTON INH 75MG 5 QL KALYDECO PAK 50MG 5 PA; QL KALYDECO PAK 75MG 5 PA; QL KALYDECO TAB 150MG 5 PA; QL ORKAMBI TAB 200-125 5 PA; QL PULMOZYME SOL 1MG/ML 5 PA; QL SYMDEKO TAB 100-150 5 PA; QL TOBI PODHALR CAP 28MG 5 QL tobramycin nebu soln 300 /5ml 5 QL LEUKOTRIENE MODIFIERS montelukast sodium chew tab 4 (base 2 QL equiv) montelukast sodium chew tab 5 (base 2 QL equiv) montelukast sodium oral granules packet 4 2 QL (base equiv) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 95

montelukast sodium tab 10 (base 2 QL equiv) zafirlukast tab 10 2 zafirlukast tab 20 2 MAST CELL STABILIZERS cromolyn sodium soln nebu 20 /2ml 2 MEDICAL SUPPLIES AEROCHAMBER MIS PLUS 4 MISCELLANEOUS acetylcysteine inhal soln 10% 2 acetylcysteine inhal soln 20% 2 ARALAST NP INJ 500MG 5 PA CINQAIR INJ 5 PA GLASSIA INJ 5 PA HYPER-SAL NEB 7% 4 HYPERSAL NEB 3.5% 4 ipratropium bromide nasal soln 0.03% (21 2 mcg/spray) ipratropium bromide nasal soln 0.06% (42 2 mcg/spray) NEBUSAL NEB 6% 4 NUCALA INJ 100MG 5 PA; QL PROLASTIN-C INJ 1000MG 5 PA sodium chloride soln nebu 0.9% 2 sodium chloride soln nebu 3% 2 sodium chloride soln nebu 7% 2 sodium chloride soln nebu 10% 2 XOLAIR SOL 150MG 5 PA; QL ZEMAIRA INJ 1000MG 5 PA NASAL ANTIHISTAMINES azelastine hcl nasal spray 0.1% (137 2 mcg/spray) azelastine hcl nasal spray 0.15% (205.5 2 mcg/spray) olopatadine hcl nasal soln 0.6% 2 PATANASE SPR 0.6% 4 PHOSPHODIESTERASE-4 INHIBITORS DALIRESP TAB 500MCG 4 PA PULMONARY FIBROSIS AGENTS ESBRIET CAP 267MG 5 PA ESBRIET TAB 267MG 5 PA ESBRIET TAB 801MG 5 PA OFEV CAP 100MG 5 PA OFEV CAP 150MG 5 PA STEROID INHALANTS ARNUITY ELPT INH 100MCG 3 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 96

ARNUITY ELPT INH 200MCG 3 ASMANEX 30 AER 110MCG 3 ASMANEX 120 AER 220MCG 3 ASMANEX HFA AER 100 MCG 3 ASMANEX HFA AER 200 MCG 3 budesonide inhalation susp 0.5 /2ml 2 budesonide inhalation susp 0.25 /2ml 2 budesonide inhalation susp 1 /2ml 2 FLOVENT DISK AER 50MCG 3 FLOVENT DISK AER 100MCG 3 FLOVENT DISK AER 250MCG 3 FLOVENT HFA AER 44MCG 3 FLOVENT HFA AER 110MCG 3 FLOVENT HFA AER 220MCG 3 PULMICORT INH 90MCG 3 PULMICORT INH 180MCG 3 QVAR REDIHA AER 80MCG 3 QVAR REDIHAL AER 40MCG 3 STEROID/BETA AGONIST COMBINATIONS ADVAIR DISKU AER 100/50 3 ADVAIR DISKU AER 250/50 3 ADVAIR DISKU AER 500/50 3 ADVAIR HFA AER 45/21 3 ADVAIR HFA AER 115/21 3 ADVAIR HFA AER 230/21 3 BREO ELLIPTA INH 100-25 3 BREO ELLIPTA INH 200-25 3 SYMBICORT AER 80-4.5 3 SYMBICORT AER 160-4.5 3 TOPICAL DECONGESTANTS ADRENALIN SOL 1:1000 3 XANTHINES ELIXOPHYLLIN ELX 80/15ML 4 THEO-24 CAP 100MG CR 4 THEO-24 CAP 200MG CR 4 THEO-24 CAP 300MG CR 4 THEO-24 CAP 400MG ER 4 theophylline soln 80 /15ml 2 theophylline tab er 12hr 100 2 theophylline tab er 12hr 200 2 theophylline tab er 12hr 300 2 theophylline tab er 12hr 450 2 theophylline tab er 24hr 400 2 theophylline tab er 24hr 600 2 TOPICAL DERMATOLOGY, ACNE: ORAL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 97

isotretinoin cap 10 2 isotretinoin cap 20 2 isotretinoin cap 30 2 isotretinoin cap 40 2 DERMATOLOGY, ACNE: TOPICAL ACZONE GEL 5% 4 PA ACZONE GEL 7.5% 4 PA adapalene cream 0.1% 2 PA adapalene gel 0.3% 2 PA AZELEX CRE 20% 4 PA benzoyl peroxide-erythromycin gel 5-3% 2 clindamycin phosphate foam 1% 2 clindamycin phosphate gel 1% 2 clindamycin phosphate lotion 1% 2 clindamycin phosphate soln 1% 2 clindamycin phosphate swab 1% 2 creamy face liq wash 4% 2 dapsone gel 5% 2 PA erythromycin gel 2% 2 erythromycin pads 2% 2 erythromycin soln 2% 2 sulfacetamide sodium w/ sulfur emulsion 2 10-1% sulfacetamide sodium w/ sulfur wash 2 9-4.5% tazarotene cream 0.1% 2 TAZORAC CRE 0.1% 4 PA TAZORAC CRE 0.05% 4 PA TAZORAC GEL 0.1% 4 PA TAZORAC GEL 0.05% 4 PA tretinoin cream 0.1% 2 tretinoin cream 0.05% 2 tretinoin cream 0.025% 2 tretinoin gel 0.01% 2 tretinoin gel 0.025% 2 DERMATOLOGY, ACTINIC KERATOSIS fluorouracil cream 5% 4 fluorouracil soln 2% 4 fluorouracil soln 5% 5 DERMATOLOGY, ANTI-INFECTIVE/ANTI-INFLAMMATORY COMBINATIONS CORTISPORIN CRE 0.5% 4 CORTISPORIN OIN 1% 4 DERMATOLOGY, ANTIBIOTICS ALTABAX OIN 1% 4 BACTROBAN OIN NASAL 2% 4 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 98

gentamicin sulfate cream 0.1% 2 gentamicin sulfate oint 0.1% 2 mupirocin calcium cream 2% 2 ST mupirocin oint 2% 2 silver sulfadiazine cream 1% 2 DERMATOLOGY, ANTIFUNGALS ciclopirox gel 0.77% 2 ciclopirox olamine cream 0.77% (base 2 equiv) ciclopirox olamine susp 0.77% (base 2 equiv) ciclopirox solution 8% 2 clotrimazole cream 1% 2 clotrimazole w/ betamethasone lotion 2 1-0.05% econazole nitrate cream 1% 2 EXELDERM CRE 1% 4 EXELDERM SOL 1% 4 EXODERM LOT 25-1% 4 ketoconazole cream 2% 2 ketoconazole shampoo 2% 2 nystatin cream 100000 unit/gm 2 nystatin oint 100000 unit/gm 2 nystatin topical powder 100000 unit/gm 2 nystatin-triamcinolone cream 100000-0.1 2 unit/gm-% nystatin-triamcinolone oint 100000-0.1 2 unit/gm-% oxiconazole nitrate cream 1% 2 PA; QL PENLAC SOL 8% 4 DERMATOLOGY, ANTIPSORIATICS, ORAL acitretin cap 10 4 acitretin cap 17.5 4 methoxsalen rapid cap 10 5 PA OXSORALEN-UL CAP 10MG 5 PA DERMATOLOGY, ANTIPSORIATICS, TOPICAL calcipotriene cream 0.005% 2 QL calcipotriene oint 0.005% 2 QL calcipotriene soln 0.005% (50 mcg/ml) 2 QL calcitriol oint 3 mcg/gm 2 DRITHO-CREME CRE HP 1% 3 DERMATOLOGY, ANTISEBORRHEICS selenium sulfide shampoo 2.25% 2 DERMATOLOGY, ANTISEPTICS/DISINFECTANTS formaldehyde solution 20% 4 PHENOL LIQ 89% 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 99

DERMATOLOGY, ATOPIC DERMATITIS ELIDEL CRE 1% 4 PA tacrolimus oint 0.1% 2 PA; QL tacrolimus oint 0.03% 2 PA; QL DERMATOLOGY, CORTICOSTEROID COMBINATIONS pramoxine-hc cream 1-2.5% 2 DERMATOLOGY, CORTICOSTEROIDS: HIGH POTENCY amcinonide cream 0.1% 2 amcinonide lotion 0.1% 2 AMCINONIDE OIN 0.1% 2 betamethasone dipropionate augmented 2 cream 0.05% betamethasone dipropionate augmented 2 lotion 0.05% betamethasone dipropionate cream 0.05% 2 betamethasone dipropionate lotion 0.05% 2 desoximetasone cream 0.25% 2 desoximetasone gel 0.05% 2 desoximetasone oint 0.25% 2 fluocinonide cream 0.05% 2 QL fluocinonide emulsified base cream 0.05% 2 fluocinonide gel 0.05% 2 fluocinonide oint 0.05% 2 fluocinonide soln 0.05% 2 triamcinolone acetonide cream 0.5% 1 triamcinolone acetonide oint 0.5% 2 DERMATOLOGY, CORTICOSTEROIDS: LOW POTENCY alclometasone dipropionate cream 0.05% 2 alclometasone dipropionate oint 0.05% 2 desonide cream 0.05% 2 desonide lotion 0.05% 2 desonide oint 0.05% 2 fluocinolone acetonide cream 0.01% 2 fluocinolone acetonide oil 0.01% (body oil) 2 fluocinolone acetonide oil 0.01% (scalp oil) 2 fluocinolone acetonide soln 0.01% 2 hydrocortisone cream 2.5% 2 hydrocortisone lotion 2.5% 2 hydrocortisone oint 1% 2 DERMATOLOGY, CORTICOSTEROIDS: MEDIUM POTENCY betamethasone valerate cream 0.1% (base 2 equivalent) betamethasone valerate lotion 0.1% (base 2 equivalent) betamethasone valerate oint 0.1% (base 2 equivalent) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 100

desoximetasone cream 0.05% 2 desoximetasone oint 0.05% 2 fluocinolone acetonide cream 0.025% 2 fluocinolone acetonide oint 0.025% 2 fluticasone propionate cream 0.05% 2 fluticasone propionate oint 0.005% 2 hydrocortisone butyrate cream 0.1% 2 hydrocortisone butyrate oint 0.1% 2 hydrocortisone butyrate soln 0.1% 2 hydrocortisone valerate cream 0.2% 2 hydrocortisone valerate oint 0.2% 2 mometasone furoate cream 0.1% 2 mometasone furoate oint 0.1% 2 mometasone furoate solution 0.1% (lotion) 2 prednicarbate cream 0.1% 2 prednicarbate oint 0.1% 2 triamcinolone acetonide cream 0.1% 1 triamcinolone acetonide cream 0.025% 2 triamcinolone acetonide lotion 0.1% 2 triamcinolone acetonide lotion 0.025% 2 triamcinolone acetonide oint 0.1% 1 triamcinolone acetonide oint 0.025% 1 DERMATOLOGY, CORTICOSTEROIDS: VERY HIGH POTENCY betamethasone dipropionate augmented 2 gel 0.05% betamethasone dipropionate augmented 2 oint 0.05% clobetasol propionate cream 0.05% 2 QL clobetasol propionate emollient base cream 2 QL 0.05% clobetasol propionate gel 0.05% 2 QL clobetasol propionate oint 0.05% 2 QL clobetasol propionate soln 0.05% 2 QL halobetasol propionate cream 0.05% 2 QL halobetasol propionate oint 0.05% 2 QL DERMATOLOGY, EMOLLIENTS lactic acid (ammonium lactate) cream 12% 2 lactic acid (ammonium lactate) lotion 10% 2 DERMATOLOGY, LOCAL ANALGESIC lidocaine patch 5% 4 PA; QL LIDODERM DIS 5% 4 PA; QL DERMATOLOGY, LOCAL ANESTHETICS ANACAINE OIN 3 CETACAINE AER 4 cocaine hcl soln 4% 2 lidocaine hcl cream 3% 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 101

lidocaine hcl gel 2% 2 LIDOCAINE HCL LOTION 3% 2 lidocaine hcl soln 4% 2 PA; QL lidocaine oint 5% 2 PA; QL lidocaine-prilocaine cream 2.5-2.5% 2 PA; QL lidocaine-prilocaine cream kit 2.5-2.5% 2 QUTENZA KIT 8% 1-PCH 5 PA; QL DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE acyclovir oint 5% 4 ARZOL SILVER MIS NITR APP 3 BUCALSEP SOL 3 BUCALSEP SPR 3 CONDYLOX GEL 0.5% 4 DENAVIR CRE 1% 4 DRYSOL SOL 20% 4 GEBAUERS SPR AER /STRETCH 4 GORDOFILM SOL 3 imiquimod cream 5% 2 PANRETIN GEL 0.1% 5 PA PODOCON SOL 25% 3 podofilox soln 0.5% 2 PR CREAM KIT 2 salicylic acid cream 6% 2 salicylic acid film forming liquid 27.5% 2 salicylic acid lotion 6% 2 salicylic acid shampoo 6% 2 SALICYLIC ACID SOLN 26% 2 salisol fort sol 26% 2 SANTYL OIN 250/GM 3 PA SILVER NITRA OIN 10% 2 SILVER NITRA SOL 0.5% 2 SILVER NITRA SOL 10% 2 SILVER NITRA SOL 25% 2 SILVER NITRA SOL 50% 2 SULFAMYLON CRE 85MG/GM 3 TRI-CHLOR LIQ 80% 3 DERMATOLOGY, ROSACEA FINACEA GEL 15% 4 metronidazole cream 0.75% 2 metronidazole gel 0.75% 2 metronidazole lotion 0.75% 2 MIRVASO GEL 0.33% 4 PA DERMATOLOGY, SCABICIDES AND PEDICULICIDES EURAX CRE 10% 3 EURAX LOT 10% 3 lindane shampoo 1% 3 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 102

malathion lotion 0.5% 2 permethrin cream 5% 2 ULESFIA LOT 5% 4 DERMATOLOGY, WOUND CARE PRODUCTS AVO CREAM EMU 2 BIAFINE EMU 4 PRUTECT EMU 2 REGENECARE GEL 3 SILVRSTAT GEL DRESSING 4 SONAFINE EMU 4 IRRIGATION SOLUTIONS irrigation solution, physiological 4 lactated ringer's for irrigation 2 ringer's solution for irrigation 2 water for irrigation, sterile irrigation soln 2 MOUTH/THROAT/DENTAL AGENTS, MISCELLANEOUS AQUORAL SPR 4 BIOTENE DRY SPR MOIST 3 BIOTENE SPR MOUTH 3 CAPHOSOL SOL 3 chlorhexidine gluconate soln 0.12% 1 DEBACTEROL SOL 30-50% 3 fluorid sens pst 1.1-5% 4 GELCLAIR GEL 4 lidocaine hcl laryngotracheal soln 4% 2 lidocaine hcl viscous soln 2% 1 MOI-STIR SOL 3 MOUTHKOTE SOL 3 NUMOISYN LOZ 4 PREVDNT 5000 PST 1.1% 4 PREVDNT 5000 PST 1.1-5% 4 PREVIDENT GEL 1.1% 4 PREVIDENT GEL 1.1% BER 4 PREVIDENT GEL 1.1% CHR 4 PREVIDENT GEL 1.1% MIN 4 PREVIDENT PST 5000 BST 4 sodium fluoride cream 1.1% 2 sodium fluoride gel 1.1% (0.5% f) 2 sodium fluoride paste 1.1% 4 sodium fluoride rinse 0.2% 2 sodium fluoride rinse 0.2% 2 triamcinolone acetonide dental paste 0.1% 2 MOUTH/THROAT/DENTAL AGENTS, PROTECTANTS ORAMAGICRX SUS 4 OPHTHALMIC, ANTI-INFECTIVE/ANTI-INFLAMMATORY COMBINATIONS PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 103

bacitracin-polymyxin-neomycin-hc ophth 2 oint 1% BLEPHAMIDE OIN S.O.P. 3 BLEPHAMIDE SUS OP 3 neomycin-polymyxin-dexamethasone 2 ophth oint 0.1% neomycin-polymyxin-dexamethasone 2 ophth susp 0.1% neomycin-polymyxin-hc ophth susp 2 PRED-G S.O.P OIN OP 3 PRED-G SUS OP 3 sulfacetamide sodium-prednisolone ophth 2 soln 10-0.23(0.25)% TOBRADEX OIN 0.3-0.1% 4 TOBRADEX ST SUS 0.3-0.05 4 tobramycin-dexamethasone ophth susp 2 0.3-0.1% ZYLET SUS 0.5-0.3% 4 OPHTHALMIC, ANTI-INFECTIVES AZASITE SOL 1% 4 bacitracin ophth oint 500 unit/gm 2 bacitracin-polymyxin b ophth oint 2 BESIVANCE SUS 0.6% 4 BETADINE SOL 5% OP 3 CILOXAN OIN 0.3% OP 4 ciprofloxacin hcl ophth soln 0.3% 2 erythromycin ophth oint 5 /gm 1 gatifloxacin ophth soln 0.5% 2 gentamicin sulfate ophth oint 0.3% 1 gentamicin sulfate ophth soln 0.3% 1 levofloxacin ophth soln 0.5% 2 MOXEZA SOL 0.5% 3 moxifloxacin hcl ophth soln 0.5% (base 2 equiv) neomycin-bacitrac zn-polymyx 2 5(3.5)-400unt-10000unt op oin neomycin-polymy-gramicid op sol 2 1.75-10000-0.025-unt-/ml ofloxacin ophth soln 0.3% 2 polymyxin b-trimethoprim ophth soln 2 10000 unit/ml-0.1% sulfacetamide sodium ophth oint 10% 2 sulfacetamide sodium ophth soln 10% 2 tobramycin ophth soln 0.3% 1 TOBREX OIN 0.3% OP 4 ZYMAXID SOL 0.5% 3 OPHTHALMIC, ANTI-INFLAMMATORY: NONSTEROIDAL PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 104

ACUVAIL SOL 0.45% 4 QL bromfenac sodium ophth soln 0.09% (base 2 equiv) (once-daily) diclofenac sodium ophth soln 0.1% 1 flurbiprofen sodium ophth soln 0.03% 2 ketorolac tromethamine ophth soln 0.4% 2 QL ketorolac tromethamine ophth soln 0.5% 2 QL NEVANAC SUS 0.1% 4 PROLENSA SOL 0.07% 4 OPHTHALMIC, ANTI-INFLAMMATORY: STEROIDAL ALREX SUS 0.2% 4 dexamethasone sodium phosphate ophth 2 soln 0.1% DUREZOL EMU 0.05% 3 FLAREX SUS 0.1% OP 4 fluorometholone ophth susp 0.1% 2 FML FORTE SUS 0.25% OP 4 FML LIQUIFLM SUS 0.1% OP 4 FML OIN 0.1% OP 3 ILUVIEN IMP 0.19MG 5 PA; QL LOTEMAX GEL 0.5% 4 LOTEMAX OIN 0.5% 4 LOTEMAX SUS 0.5% 4 MAXIDEX SUS 0.1% OP 4 OMNIPRED SUS 1% OP 4 PRED MILD SUS 0.12% OP 4 prednisolone acetate ophth susp 1% 2 TRIESENCE INJ 40MG/ML 4 OPHTHALMIC, ANTIALLERGICS ALOCRIL SOL 2% 4 ALOMIDE SOL 0.1% OP 4 azelastine hcl ophth soln 0.05% 2 BEPREVE DRO 1.5% 4 cromolyn sodium ophth soln 4% 2 EMADINE SOL 0.05% OP 4 epinastine hcl ophth soln 0.05% 2 olopatadine hcl ophth soln 0.1% (base 2 equivalent) olopatadine hcl ophth soln 0.2% (base 2 equivalent) PAZEO DRO 0.7% 3 OPHTHALMIC, ANTIFUNGALS NATACYN SUS 5% OP 3 OPHTHALMIC, ANTIVIRAL trifluridine ophth soln 1% 2 ZIRGAN GEL 0.15% 3 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 105

OPHTHALMIC, BETA-BLOCKERS: NONSELECTIVE BETIMOL SOL 0.5% 4 BETIMOL SOL 0.25% 4 carteolol hcl ophth soln 1% 2 ISTALOL SOL 0.5% OP 4 levobunolol hcl ophth soln 0.5% 2 metipranolol ophth soln 0.3% 2 timolol maleate ophth gel forming soln 2 0.5% timolol maleate ophth gel forming soln 2 0.25% timolol maleate ophth soln 0.5% 2 timolol maleate ophth soln 0.5% 2 (once-daily) timolol maleate ophth soln 0.25% 2 TIMOPTIC OCU SOL 0.5% OP 4 TIMOPTIC OCU SOL 0.25% OP 4 OPHTHALMIC, BETA-BLOCKERS: SELECTIVE betaxolol hcl ophth soln 0.5% 2 BETOPTIC-S SUS 0.25% OP 3 OPHTHALMIC, CARBONIC ANHYDRASE INHIBITOR/BETA-BLOCKER COMBINATIONS COSOPT PF SOL 4 dorzolamide hcl-timolol maleate ophth soln 2 22.3-6.8 /ml OPHTHALMIC, CARBONIC ANHYDRASE INHIBITOR/SYMPATHOMIMETIC COMBINATIONS SIMBRINZA SUS 1-0.2% 3 OPHTHALMIC, CARBONIC ANHYDRASE INHIBITORS: TOPICAL AZOPT SUS 1% OP 3 dorzolamide hcl ophth soln 2% 2 OPHTHALMIC, DIAGNOSTIC PRODUCTS fluorescein sodium ophth strips 1 4 fluorescein w/ benoxinate ophth soln 2 0.25-0.4% OPHTHALMIC, DRY EYE DISEASE RESTASIS EMU 0.05% 3 QL OPHTHALMIC, MISCELLANEOUS AMVISC INJ 12MG/ML 4 AMVISC PLUS INJ 16MG/ML 4 CYSTARAN SOL 0.44% 5 PA; QL EYLEA INJ 2/0.05ML 5 PA LACRISERT MIS 5MG OP 4 LUCENTIS SOL 0.3MG 5 PA LUCENTIS SOL 0.5MG 5 PA MACUGEN INJ 5 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 106

MEMBRANEBLUE SOL 0.15% 4 phenylephrine hcl ophth soln 2.5% 2 phenylephrine hcl ophth soln 10% 2 PROVISC INJ 1% 4 RHOPRESSA SOL 0.02% 4 ST tetracaine hcl ophth soln 0.5% 2 tetracaine hcl ophth soln 0.5% 4 VISUDYNE INJ 15MG 5 OPHTHALMIC, MYDRIATICS ATROPINE SUL OIN 1% OP 2 atropine sulfate ophth soln 1% 2 CYCLOMYDRIL SOL OP 3 cyclopentolate hcl ophth soln 0.5% 2 cyclopentolate hcl ophth soln 1% 2 cyclopentolate hcl ophth soln 2% 2 homatropine hbr ophth soln 5% 2 tropicamide ophth soln 0.5% 2 tropicamide ophth soln 1% 2 OPHTHALMIC, PARASYMPATHOMIMETICS MIOSTAT INJ 0.01% OP 4 pilocarpine hcl ophth soln 1% 2 pilocarpine hcl ophth soln 4% 2 OPHTHALMIC, PROSTAGLANDINS bimatoprost ophth soln 0.03% 2 ST latanoprost ophth soln 0.005% 2 LUMIGAN SOL 0.01% 3 TRAVATAN Z DRO 0.004% 4 ST ZIOPTAN DRO 0.0015% 4 ST OPHTHALMIC, SYMPATHOMIMETIC/BETA-BLOCKER COMBINATIONS COMBIGAN SOL 0.2/0.5% 3 OPHTHALMIC, SYMPATHOMIMETICS ALPHAGAN P SOL 0.1% 3 brimonidine tartrate ophth soln 0.2% 2 brimonidine tartrate ophth soln 0.15% 2 PHOSPHOLINE SOL 0.125%OP 4 OTIC, ANTI-INFECTIVE/ANTI-INFLAMMATORY COMBINATIONS CIPRO HC SUS OTIC 3 CIPRODEX SUS 0.3-0.1% 3 neomycin-polymyxin-hc otic soln 1% 2 neomycin-polymyxin-hc otic susp 3.5 2 /ml-10000 unit/ml-1% OTIC, ANTI-INFECTIVES acetic acid otic soln 2% 2 CETRAXAL SOL 0.2% 4 ciprofloxacin hcl otic soln 0.2% (base 2 equivalent) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 107

ofloxacin otic soln 0.3% 2 OTIC, MISCELLANEOUS DERMOTIC OIL 0.01% 4 fluocinolone acetonide (otic) oil 0.01% 2 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy 108

Index 1 1ST TIER UNI MIS 29GX12MM... 64 A abacavir sulfate tab 300 (base equiv)... 12 abacavir sulfate-lamivudine tab 600-300... 10 abacavir sulfate-lamivudine-zidovudine tab 300-150-300... 10 ABILIFY MAIN INJ 300MG... 48 ABILIFY MAIN INJ 400MG... 48 ABRAXANE INJ 100MG... 20 ABSTRAL SUB 100MCG... 3 ABSTRAL SUB 200MCG... 3 ABSTRAL SUB 300MCG... 3 ABSTRAL SUB 400MCG... 3 ABSTRAL SUB 600MCG... 3 ABSTRAL SUB 800MCG... 3 acamprosate calcium tab delayed release 333... 59 acarbose tab 100... 60 acarbose tab 25... 60 acarbose tab 50... 60 ACD FORMULA SOL A... 83 acebutolol hcl cap 200... 30 acebutolol hcl cap 400... 30 acetaminophen w/ codeine soln 120-12 /5ml... 3 acetaminophen w/ codeine tab 300-15... 3 acetaminophen w/ codeine tab 300-30... 3 acetaminophen w/ codeine tab 300-60... 3 acetazolamide cap er 12hr 500... 34 acetazolamide sodium for inj 500.. 34 acetazolamide tab 125... 34 acetazolamide tab 250... 34 acetic acid irrigation soln 0.25%... 79 acetic acid otic soln 2%... 107 acetic acid-oxyquinoline vaginal gel 0.9-0.025%... 79 acetylcysteine inhal soln 10%... 96 acetylcysteine inhal soln 20%... 96 acetylcysteine inj 200 /ml... 64 acitretin cap 10... 99 acitretin cap 17.5... 99 ACTIMMUNE INJ 2MU/0.5... 86 ACTIVASE INJ 100MG... 83 ACTIVASE INJ 50MG... 83 ACTIVE FE TAB 75-1.25... 88 ACUVAIL SOL 0.45%... 105 acyclovir cap 200... 13 acyclovir oint 5%... 102 acyclovir susp 200 /5ml... 13 acyclovir tab 400... 13 acyclovir tab 800... 13 ACZONE GEL 5%... 98 ACZONE GEL 7.5%... 98 ADAGEN INJ 250/ML... 71 adapalene cream 0.1%... 98 adapalene gel 0.3%... 98 ADCETRIS INJ 50MG... 20 ADDERALL TAB 10MG... 52 ADDERALL TAB 12.5MG... 52 ADDERALL TAB 15MG... 52 ADDERALL TAB 20MG... 52 ADDERALL TAB 30MG... 52 ADDERALL TAB 5MG... 52 ADDERALL TAB 7.5MG... 52 ADEMPAS TAB 0.5MG... 38 ADEMPAS TAB 1.5MG... 38 ADEMPAS TAB 1MG... 38 ADEMPAS TAB 2.5MG... 38 ADEMPAS TAB 2MG... 38 adenosine iv soln 12 /4ml... 27 adenosine iv soln 6 /2ml... 27 ADRENALIN INJ 1MG/ML... 93 ADRENALIN INJ 30/30ML... 93 ADRENALIN SOL 1:1000... 97 ADVAIR DISKU AER 100/50... 97 ADVAIR DISKU AER 250/50... 97 ADVAIR DISKU AER 500/50... 97 ADVAIR HFA AER 115/21... 97 ADVAIR HFA AER 230/21... 97 ADVAIR HFA AER 45/21... 97 AEROCHAMBER MIS PLUS... 96 AFINITOR DIS TAB 2MG... 18 AFINITOR DIS TAB 3MG... 18 AFINITOR DIS TAB 5MG... 18 AFINITOR TAB 10MG... 18 AFINITOR TAB 2.5MG... 18 AFINITOR TAB 5MG... 18 AFINITOR TAB 7.5MG... 18 109

AGGRENOX CAP 25-200MG... 84 AKYNZEO CAP 300-0.5... 75 ALBENZA TAB 200MG... 14 albuterol sulfate soln nebu 0.083% (2.5 /3ml)... 94 albuterol sulfate soln nebu 0.5% (5 /ml)... 94 albuterol sulfate soln nebu 0.63 /3ml (base equiv)... 94 albuterol sulfate soln nebu 1.25 /3ml (base equiv)... 95 albuterol sulfate syrup 2 /5ml... 95 albuterol sulfate tab 2... 95 albuterol sulfate tab 4... 95 albuterol sulfate tab er 12hr 4... 95 albuterol sulfate tab er 12hr 8... 95 alclometasone dipropionate cream 0.05%... 100 alclometasone dipropionate oint 0.05%... 100 ALDACTAZIDE TAB 50/50... 34 ALDURAZYME INJ 2.9MG/5M... 70 ALECENSA CAP 150MG... 18 alendronate sodium oral soln 70 /75ml... 65 alendronate sodium tab 10... 65 alendronate sodium tab 35... 65 alendronate sodium tab 40... 65 alendronate sodium tab 5... 65 alendronate sodium tab 70... 65 ALFERON N INJ 5MU/ML... 86 alfuzosin hcl tab er 24hr 10... 79 ALIMTA INJ 100MG... 16 ALIMTA INJ 500MG... 16 ALINIA SUS 100/5ML... 14 ALINIA TAB 500MG... 14 ALKERAN INJ 50MG... 15 ALKERAN TAB 2MG... 15 allopurinol tab 100... 1 allopurinol tab 300... 1 almotriptan malate tab 12.5... 56 almotriptan malate tab 6.25... 56 ALOCRIL SOL 2%... 105 ALOMIDE SOL 0.1% OP... 105 ALORA DIS 0.025MG... 67 ALORA DIS 0.05MG... 67 ALORA DIS 0.075MG... 67 ALORA DIS 0.1MG... 67 alosetron hcl tab 0.5 (base equiv). 77 alosetron hcl tab 1 (base equiv)... 77 ALOXI INJ 0.25MG/5... 75 ALPHAGAN P SOL 0.1%... 107 ALPRAZOLAM CON 1 MG/ML... 38 alprazolam orally disintegrating tab 0.25... 38 alprazolam orally disintegrating tab 0.5... 38 alprazolam orally disintegrating tab 1... 38 alprazolam orally disintegrating tab 2... 38 alprazolam tab 0.25... 38 alprazolam tab 0.5... 38 alprazolam tab 1... 38 alprazolam tab 2... 38 alprazolam tab er 24hr 0.5... 38 alprazolam tab er 24hr 1... 38 alprazolam tab er 24hr 2... 38 alprazolam tab er 24hr 3... 38 ALREX SUS 0.2%... 105 ALTABAX OIN 1%... 98 ALUNBRIG PAK... 18 ALUNBRIG TAB 180MG... 18 ALUNBRIG TAB 30MG... 18 ALUNBRIG TAB 90MG... 18 amantadine hcl cap 100... 47 amantadine hcl syrup 50 /5ml... 47 amantadine hcl tab 100... 47 amcinonide cream 0.1%... 100 amcinonide lotion 0.1%... 100 AMCINONIDE OIN 0.1%... 100 amiloride & hydrochlorothiazide tab 5-50... 34 amiloride hcl tab 5... 34 aminocaproic acid inj 250 /ml... 82 amiodarone hcl tab 100... 27 amiodarone hcl tab 200... 27 amiodarone hcl tab 400... 27 AMITIZA CAP 24MCG... 77 AMITIZA CAP 8MCG... 77 amitriptyline hcl tab 10... 46 amitriptyline hcl tab 100... 46 amitriptyline hcl tab 150... 46 amitriptyline hcl tab 25... 46 amitriptyline hcl tab 50... 46 amitriptyline hcl tab 75... 46 110

amlodipine besylate tab 10 (base equivalent)... 31 amlodipine besylate tab 2.5 (base equivalent)... 31 amlodipine besylate tab 5 (base equivalent)... 31 amlodipine besylate-benazepril hcl cap 10-20... 23 amlodipine besylate-benazepril hcl cap 10-40... 23 amlodipine besylate-benazepril hcl cap 2.5-10... 23 amlodipine besylate-benazepril hcl cap 5-10... 23 amlodipine besylate-benazepril hcl cap 5-20... 23 amlodipine besylate-benazepril hcl cap 5-40... 23 amoxapine tab 100... 46 amoxapine tab 150... 46 amoxapine tab 25... 46 amoxapine tab 50... 46 amoxicillin & k clavulanate chew tab 200-28.5... 7 amoxicillin & k clavulanate chew tab 400-57... 7 amoxicillin & k clavulanate for susp 200-28.5 /5ml... 8 amoxicillin & k clavulanate for susp 250-62.5 /5ml... 8 amoxicillin & k clavulanate for susp 400-57 /5ml... 8 amoxicillin & k clavulanate for susp 600-42.9 /5ml... 8 amoxicillin & k clavulanate tab 250-125... 8 amoxicillin & k clavulanate tab 500-125... 8 amoxicillin & k clavulanate tab 875-125... 8 amoxicillin & k clavulanate tab er 12hr 1000-62.5... 8 amoxicillin (trihydrate) cap 250... 8 amoxicillin (trihydrate) cap 500... 8 amoxicillin (trihydrate) chew tab 125... 8 amoxicillin (trihydrate) chew tab 250... 8 amoxicillin (trihydrate) for susp 125 /5ml... 8 amoxicillin (trihydrate) for susp 200 /5ml... 8 amoxicillin (trihydrate) for susp 250 /5ml... 8 amoxicillin (trihydrate) for susp 400 /5ml... 8 amoxicillin (trihydrate) tab 500... 8 amoxicillin (trihydrate) tab 875... 8 amoxicillin cap-clarithro tab-lansopraz cap dr therapy pack... 79 amphetamine-dextroamphetamine cap er 24hr 10... 52 amphetamine-dextroamphetamine cap er 24hr 15... 52 amphetamine-dextroamphetamine cap er 24hr 20... 52 amphetamine-dextroamphetamine cap er 24hr 25... 52 amphetamine-dextroamphetamine cap er 24hr 30... 52 amphetamine-dextroamphetamine cap er 24hr 5... 52 amphetamine-dextroamphetamine tab 10... 52 amphetamine-dextroamphetamine tab 12.5... 52 amphetamine-dextroamphetamine tab 15... 52 amphetamine-dextroamphetamine tab 20... 52 amphetamine-dextroamphetamine tab 30... 52 amphetamine-dextroamphetamine tab 5... 52 amphetamine-dextroamphetamine tab 7.5... 52 ampicillin cap 500... 8 AMPYRA TAB 10MG... 57 AMVISC INJ 12MG/ML... 106 AMVISC PLUS INJ 16MG/ML... 106 AMYTAL SOD INJ 500MG... 55 ANACAINE OIN... 101 anagrelide hcl cap 0.5... 84 anagrelide hcl cap 1... 84 anastrozole tab 1... 17 ANDRODERM DIS 2MG/24HR... 60 111

ANDRODERM DIS 4MG/24HR... 60 ANDROGEL GEL 1.62%... 60 ANECTINE INJ 20MG/ML... 59 ANGELIQ TAB 0.5-1MG... 66 ANIMI-3 CAP... 88 ANIMI-3 CAP VIT D... 88 ANORO ELLIPT AER 62.5-25... 93 ANTICOAG CIT SOL DEX SOL... 83 ANTICOAG CPD SOL... 83 APOKYN INJ 10MG/ML... 47 aprepitant capsule 125... 75 aprepitant capsule 40... 75 aprepitant capsule 80... 75 aprepitant capsule therapy pack 80 & 125... 75 APRISO CAP 0.375GM... 77 APTIOM TAB 200MG... 39 APTIOM TAB 400MG... 39 APTIOM TAB 600MG... 39 APTIOM TAB 800MG... 39 APTIVUS CAP 250MG... 10 APTIVUS SOL... 10 AQUASOL A INJ 50000/ML... 88 AQUORAL SPR... 103 ARALAST NP INJ 500MG... 96 ARANESP INJ 100MCG... 82 ARANESP INJ 10MCG... 82 ARANESP INJ 150MCG... 82 ARANESP INJ 200MCG... 82 ARANESP INJ 25MCG... 82 ARANESP INJ 300MCG... 82 ARANESP INJ 40MCG... 82 ARANESP INJ 500MCG... 82 ARANESP INJ 60MCG... 82 ARCALYST INJ 220MG... 86 ARCAPTA CAP 75MCG... 94 argatroban inj 250 /2.5ml (concentrate for iv infusion)... 81 ARGATROBAN INJ 250/250... 81 ARGATROBAN INJ 50MG/50M... 81 aripiprazole oral solution 1 /ml... 48 aripiprazole orally disintegrating tab 10... 48 aripiprazole orally disintegrating tab 15... 48 aripiprazole tab 10... 49 aripiprazole tab 15... 49 aripiprazole tab 2... 48 aripiprazole tab 20... 49 aripiprazole tab 30... 49 aripiprazole tab 5... 49 ARISTADA INJ 1064MG... 49 ARISTADA INJ 441MG/1.... 49 ARISTADA INJ 662MG/2... 49 ARISTADA INJ 882MG/3... 49 armodafinil tab 150... 59 armodafinil tab 200... 59 armodafinil tab 250... 59 armodafinil tab 50... 59 ARNUITY ELPT INH 100MCG... 96 ARNUITY ELPT INH 200MCG... 97 ARRANON INJ 5MG/ML... 20 ARZOL SILVER MIS NITR APP... 102 ASACOL HD TAB 800MG... 77 ASMANEX 120 AER 220MCG... 97 ASMANEX 30 AER 110MCG... 97 ASMANEX HFA AER 100 MCG... 97 ASMANEX HFA AER 200 MCG... 97 aspirin-dipyridamole cap er 12hr 25-200... 84 ATABEX EC TAB 29-1MG... 90 atazanavir sulfate cap 150 (base equiv)... 11 atazanavir sulfate cap 200 (base equiv)... 11 atazanavir sulfate cap 300 (base equiv)... 11 atenolol & chlorthalidone tab 100-25... 30 atenolol & chlorthalidone tab 50-25... 30 atenolol tab 100... 30 atenolol tab 25... 30 atenolol tab 50... 30 ATGAM INJ 250MG... 85 atomoxetine hcl cap 10 (base equiv)... 52 atomoxetine hcl cap 100 (base equiv)... 53 atomoxetine hcl cap 18 (base equiv)... 52 atomoxetine hcl cap 25 (base equiv)... 52 atomoxetine hcl cap 40 (base equiv)... 52 atomoxetine hcl cap 60 (base equiv) 112

... 53 atomoxetine hcl cap 80 (base equiv)... 53 atorvastatin calcium tab 10 (base equivalent)... 28 atorvastatin calcium tab 20 (base equivalent)... 28 atorvastatin calcium tab 40 (base equivalent)... 28 atorvastatin calcium tab 80 (base equivalent)... 28 atovaquone susp 750 /5ml... 14 ATRIPLA TAB... 10 ATROPINE SUL OIN 1% OP... 107 atropine sulfate inj 0.4 /ml... 35 atropine sulfate inj 1 /ml... 35 atropine sulfate ophth soln 1%... 107 atropine sulfate soln prefill syr 0.25 /5ml (0.05 /ml)... 35 atropine sulfate soln prefill syr 0.5 /5ml (0.1 /ml)... 35 ATROVENT HFA AER 17MCG... 93 AUBAGIO TAB 14MG... 57 AUBAGIO TAB 7MG... 57 AURYXIA TAB 210MG... 72 AUTOPEN MIS 1 UNIT... 63 AUTOPEN MIS 1-21UNIT... 63 AUTOPEN MIS 2 UNIT... 63 AUTOPEN MIS 2-32UNIT... 63 AUTOPEN MIS 2-42UNIT... 63 AUTOSHIELD MIS 29X3/16"... 63 AVASTIN INJ... 20 AVASTIN INJ 400/16ML... 20 AVEED INJ 750/3ML... 60 AVELOX TAB 400MG... 7 AVITENE PAD 35X35MM... 82 AVITENE POW FLOUR... 82 AVITENE SYRG MIS 1GM... 82 AVO CREAM EMU... 103 AVONEX KIT 30MCG... 57 AVONEX PEN KIT 30MCG... 57 AVONEX PREFL KIT 30MCG... 57 AZASITE SOL 1%... 104 azathioprine tab 50... 86 azelastine hcl nasal spray 0.1% (137 mcg/spray)... 96 azelastine hcl nasal spray 0.15% (205.5 mcg/spray)... 96 azelastine hcl ophth soln 0.05%... 105 AZELEX CRE 20%... 98 azithromycin for susp 100 /5ml... 7 azithromycin for susp 200 /5ml... 7 azithromycin tab 250... 7 azithromycin tab 500... 7 azithromycin tab 600... 7 AZOPT SUS 1% OP... 106 B bacitracin ophth oint 500 unit/gm... 104 bacitracin-polymyxin b ophth oint... 104 bacitracin-polymyxin-neomycin-hc ophth oint 1%... 104 baclofen tab 10... 58 baclofen tab 20... 58 BACTROBAN OIN NASAL 2%... 98 balsalazide disodium cap 750... 77 BANZEL SUS 40MG/ML... 39 BANZEL TAB 200MG... 39 BANZEL TAB 400MG... 39 BARACLUDE SOL.05MG/ML... 13 BARACLUDE TAB 0.5MG... 13 BARACLUDE TAB 1MG... 13 BCG VACCINE INJ... 87 b-complex w/ c & folic acid cap 1.. 88 b-complex w/ c & folic acid tab 1.. 88 BD PEN MINI MIS... 63 BD PEN NEEDL MIS 29GX1/2"... 63 BD PEN NEEDL MIS 31GX3/16... 63 BD PEN NEEDL MIS 31GX5/16... 63 BD PEN NEEDL MIS 32GX4MM... 63 BD VEO SYR MIS 0.5/31G... 63 BELLA/OPIUM SUP 16.2-30... 76 benazepril & hydrochlorothiazide tab 10-12.5... 23 benazepril & hydrochlorothiazide tab 20-12.5... 23 benazepril & hydrochlorothiazide tab 20-25... 23 benazepril & hydrochlorothiazide tab 5-6.25... 23 benazepril hcl tab 10... 24 benazepril hcl tab 20... 24 benazepril hcl tab 40... 24 benazepril hcl tab 5... 24 BENDEKA INJ 100/4ML... 15 BENLYSTA INJ 120MG... 87 BENLYSTA INJ 400MG... 87 113

benzonatate cap 100... 94 benzonatate cap 200... 94 benzoyl peroxide-erythromycin gel 5-3%... 98 benztropine mesylate inj 1 /ml... 47 benztropine mesylate tab 0.5... 47 benztropine mesylate tab 1... 47 benztropine mesylate tab 2... 47 BEPREVE DRO 1.5%... 105 BERINERT INJ 500UNIT... 83 BESIVANCE SUS 0.6%... 104 BETADINE SOL 5% OP... 104 betamethasone dipropionate augmented cream 0.05%... 100 betamethasone dipropionate augmented gel 0.05%... 101 betamethasone dipropionate augmented lotion 0.05%... 100 betamethasone dipropionate augmented oint 0.05%... 101 betamethasone dipropionate cream 0.05%... 100 betamethasone dipropionate lotion 0.05%... 100 betamethasone valerate cream 0.1% (base equivalent)... 100 betamethasone valerate lotion 0.1% (base equivalent)... 100 betamethasone valerate oint 0.1% (base equivalent)... 100 BETASERON INJ 0.3MG... 57 betaxolol hcl ophth soln 0.5%... 106 betaxolol hcl tab 10... 30 betaxolol hcl tab 20... 30 bethanechol chloride tab 10... 79 bethanechol chloride tab 25... 79 bethanechol chloride tab 5... 79 bethanechol chloride tab 50... 79 BETHKIS NEB 300/4ML... 95 BETIMOL SOL 0.25%... 106 BETIMOL SOL 0.5%... 106 BETOPTIC-S SUS 0.25% OP... 106 bexarotene cap 75... 20 BIAFINE EMU... 103 bicalutamide tab 50... 17 BICNU INJ 100MG... 15 BIFERARX TAB... 88 BIKTARVY TAB... 10 BILTRICIDE TAB 600MG... 14 bimatoprost ophth soln 0.03%... 107 BIOTENE DRY SPR MOIST... 103 BIOTENE SPR MOUTH... 103 bisoprolol & hydrochlorothiazide tab 10-6.25... 30 bisoprolol & hydrochlorothiazide tab 2.5-6.25... 30 bisoprolol & hydrochlorothiazide tab 5-6.25... 30 bisoprolol fumarate tab 10... 30 bisoprolol fumarate tab 5... 30 bleomycin sulfate for inj 15 unit... 20 bleomycin sulfate for inj 30 unit... 20 BLEPHAMIDE OIN S.O.P.... 104 BLEPHAMIDE SUS OP... 104 BONIVA INJ 3MG/3ML... 65 BONIVA TAB 150MG... 65 BOSULIF TAB 100MG... 18 BOSULIF TAB 500MG... 18 BOTOX INJ 100UNIT... 57 BOTOX INJ 200UNIT... 57 BP VIT 3 CAP... 88 BREO ELLIPTA INH 100-25... 97 BREO ELLIPTA INH 200-25... 97 BRILINTA TAB 60MG... 84 BRILINTA TAB 90MG... 84 brimonidine tartrate ophth soln 0.15%... 107 brimonidine tartrate ophth soln 0.2% 107 BRIVIACT INJ 50MG/5ML... 39 BRIVIACT SOL 10MG/ML... 39 BRIVIACT TAB 100MG... 40 BRIVIACT TAB 10MG... 40 BRIVIACT TAB 25MG... 40 BRIVIACT TAB 50MG... 40 BRIVIACT TAB 75MG... 40 bromfenac sodium ophth soln 0.09% (base equiv) (once-daily)... 105 bromocriptine mesylate cap 5 (base equivalent)... 47 bromocriptine mesylate tab 2.5 (base equivalent)... 47 BROVANA NEB 15MCG... 94 BUCALSEP SOL... 102 BUCALSEP SPR... 102 budesonide delayed release particles cap 3... 77 114

budesonide inhalation susp 0.25 /2ml... 97 budesonide inhalation susp 0.5 /2ml... 97 budesonide inhalation susp 1 /2ml.. 97 bumetanide inj 0.25 /ml... 34 bumetanide tab 0.5... 34 bumetanide tab 1... 34 bumetanide tab 2... 34 BUNAVAIL MIS 2.1-0.3... 59 BUNAVAIL MIS 4.2-0.7... 59 BUNAVAIL MIS 6.3-1MG... 59 BUPHENYL POW... 78 BUPHENYL TAB 500MG... 78 buprenorphine hcl sl tab 2 (base equiv)... 60 buprenorphine hcl sl tab 8 (base equiv)... 60 buprenorphine hcl-naloxone hcl sl tab 2-0.5 (base equiv)... 59 buprenorphine hcl-naloxone hcl sl tab 8-2 (base equiv)... 59 bupropion hcl (smoking deterrent) tab er 12hr 150... 60 bupropion hcl tab 100... 43 bupropion hcl tab 75... 43 bupropion hcl tab er 12hr 100... 43 bupropion hcl tab er 12hr 150... 43 bupropion hcl tab er 12hr 200... 43 bupropion hcl tab er 24hr 150... 43 bupropion hcl tab er 24hr 300... 43 buspirone hcl tab 10... 39 buspirone hcl tab 15... 39 buspirone hcl tab 30... 39 buspirone hcl tab 5... 39 buspirone hcl tab 7.5... 39 busulfan inj 6 /ml... 15 BUSULFEX INJ 6MG/ML... 15 butalbital-acetaminophen tab 50-325... 1 butalbital-acetaminophen-caff w/ cod cap 50-325-40-30... 3 butalbital-acetaminophen-caffeine cap 50-325-40... 1 butalbital-acetaminophen-caffeine tab 50-325-40... 1 butalbital-aspirin-caff w/ codeine cap 50-325-40-30... 3 butalbital-aspirin-caffeine cap 50-325-40... 1 butorphanol tartrate nasal soln 10 /ml... 3 BUTRANS DIS 10MCG/HR... 3 BUTRANS DIS 15MCG/HR... 3 BUTRANS DIS 20MCG/HR... 3 BUTRANS DIS 5MCG/HR... 3 BUTRANS DIS 7.5/HR... 3 BYSTOLIC TAB 10MG... 30 BYSTOLIC TAB 2.5MG... 30 BYSTOLIC TAB 20MG... 30 BYSTOLIC TAB 5MG... 30 C cabergoline tab 0.5... 71 CABOMETYX TAB 20MG... 18 CABOMETYX TAB 40MG... 18 CABOMETYX TAB 60MG... 18 caffeine & sodium benzoate inj 125-125 /ml (500 /2ml)... 57 calcipotriene cream 0.005%... 99 calcipotriene oint 0.005%... 99 calcipotriene soln 0.005% (50 mcg/ml)... 99 calcitonin (salmon) nasal soln 200 unit/act... 65 calcitriol cap 0.25 mcg... 70 calcitriol cap 0.5 mcg... 70 calcitriol inj 1 mcg/ml... 70 calcitriol oint 3 mcg/gm... 99 calcitriol oral soln 1 mcg/ml... 70 calcium acetate (phosphate binder) cap 667 (169 ca)... 72 calcium acetate (phosphate binder) tab 667... 72 CALCIUM-FA WAF PLUS D... 88 CALQUENCE CAP 100MG... 18 CAMPTOSAR INJ 300/15ML... 22 CANASA SUP 1000MG... 77 candesartan cilexetil tab 16... 26 candesartan cilexetil tab 32... 26 candesartan cilexetil tab 4... 26 candesartan cilexetil tab 8... 26 candesartan cilexetil-hydrochlorothiazide tab 16-12.5... 26 candesartan cilexetil-hydrochlorothiazide tab 32-12.5... 26 candesartan cilexetil-hydrochlorothiazide 115

tab 32-25... 26 CAPCOF SYP 5-2-10MG... 94 capecitabine tab 150... 16 capecitabine tab 500... 16 CAPHOSOL SOL... 103 CAPRELSA TAB 100MG... 18 CAPRELSA TAB 300MG... 18 captopril & hydrochlorothiazide tab 25-15... 23 captopril & hydrochlorothiazide tab 25-25... 23 captopril & hydrochlorothiazide tab 50-15... 23 captopril & hydrochlorothiazide tab 50-25... 23 captopril tab 100... 24 captopril tab 12.5... 24 captopril tab 25... 24 captopril tab 50... 24 CARAFATE SUS 1GM/10ML... 78 CARBAGLU TAB 200MG... 71 carbamazepine cap er 12hr 100... 40 carbamazepine cap er 12hr 200... 40 carbamazepine cap er 12hr 300... 40 carbamazepine chew tab 100... 40 carbamazepine susp 100 /5ml... 40 carbamazepine tab 200... 40 carbamazepine tab er 12hr 100... 40 carbamazepine tab er 12hr 200... 40 carbamazepine tab er 12hr 400... 40 CARBATROL CAP 100MG... 40 CARBATROL CAP 200MG... 40 CARBATROL CAP 300MG... 40 carbidopa & levodopa orally disintegrating tab 10-100... 47 carbidopa & levodopa orally disintegrating tab 25-100... 47 carbidopa & levodopa orally disintegrating tab 25-250... 47 carbidopa & levodopa tab 10-100.. 47 carbidopa & levodopa tab 25-100.. 47 carbidopa & levodopa tab 25-250.. 47 carbidopa & levodopa tab er 25-100... 47 carbidopa & levodopa tab er 50-200... 47 carbidopa tab 25... 47 carbidopa-levodopa-entacapone tabs 12.5-50-200... 47 carbidopa-levodopa-entacapone tabs 18.75-75-200... 47 carbidopa-levodopa-entacapone tabs 25-100-200... 47 carbidopa-levodopa-entacapone tabs 31.25-125-200... 47 carbidopa-levodopa-entacapone tabs 37.5-150-200... 47 carbidopa-levodopa-entacapone tabs 50-200-200... 47 carbinoxamine maleate soln 4 /5ml 93 carbinoxamine maleate tab 4... 93 carboplatin iv soln 150 /15ml... 15 carboplatin iv soln 450 /45ml... 15 carboplatin iv soln 50 /5ml... 15 carboplatin iv soln 600 /60ml... 15 CARDIOTEK-RX TAB... 87 CARDIZEM LA TAB 120MG... 32 CARDURA XL TAB 4MG... 79 CARDURA XL TAB 8MG... 79 CARIMUNE NF INJ 12GM... 85 CARIMUNE NF INJ 6GM... 85 carisoprodol tab 250... 58 carisoprodol tab 350... 58 carisoprodol w/ aspirin & codeine tab 200-325-16... 58 carisoprodol w/ aspirin tab 200-325... 58 carteolol hcl ophth soln 1%... 106 carvedilol tab 12.5... 30 carvedilol tab 25... 30 carvedilol tab 3.125... 30 carvedilol tab 6.25... 30 CATHFLO ACTI INJ VASE... 83 CAYSTON INH 75MG... 95 cefaclor cap 250... 6 cefaclor cap 500... 6 CEFACLOR ER TAB 500MG... 6 cefaclor for susp 125 /5ml... 6 cefaclor for susp 250 /5ml... 6 cefaclor for susp 375 /5ml... 6 cefadroxil cap 500... 6 cefadroxil for susp 250 /5ml... 6 cefadroxil for susp 500 /5ml... 6 cefadroxil tab 1 gm... 6 cefdinir cap 300... 6 cefdinir for susp 125 /5ml... 6 116

cefdinir for susp 250 /5ml... 6 cefixime for susp 100 /5ml... 6 cefixime for susp 200 /5ml... 6 cefpodoxime proxetil for susp 100 /5ml... 6 cefpodoxime proxetil for susp 50 /5ml... 6 cefpodoxime proxetil tab 100... 6 cefpodoxime proxetil tab 200... 6 cefprozil for susp 125 /5ml... 6 cefprozil for susp 250 /5ml... 6 cefprozil tab 250... 6 cefprozil tab 500... 6 cefuroxime axetil tab 500... 6 celecoxib cap 100... 1 celecoxib cap 200... 1 celecoxib cap 400... 1 celecoxib cap 50... 1 CELLCEPT CAP 250MG... 86 CELLCEPT SUS 200MG/ML... 86 CELLCEPT TAB 500MG... 86 CELONTIN CAP 300MG... 40 cephalexin cap 250... 6 cephalexin cap 500... 6 cephalexin cap 750... 6 cephalexin for susp 125 /5ml... 6 cephalexin for susp 250 /5ml... 6 cephalexin tab 250... 6 cephalexin tab 500... 6 CEPROTIN INJ 1000UNIT... 83 CEREZYME INJ 400UNIT... 70 CERVIDIL VAG MIS 10MG INS... 71 CESAMET CAP 1MG... 75 CETACAINE AER... 101 CETRAXAL SOL 0.2%... 107 CETYLEV TAB 2.5GM... 64 CETYLEV TAB 500MG... 64 cevimeline hcl cap 30... 78 CHEMET CAP 100MG... 83 chlordiazepoxide hcl cap 10... 38 chlordiazepoxide hcl cap 25... 38 chlordiazepoxide hcl cap 5... 38 chlordiazepoxide hcl-clidinium bromide cap 5-2.5... 76 chlordiazepoxide-amitriptyline tab 10-25... 43 chlordiazepoxide-amitriptyline tab 5-12.5... 43 chlorhexidine gluconate soln 0.12%.. 103 chlorothiazide sodium for inj 500.. 34 chlorothiazide tab 250... 34 chlorothiazide tab 500... 34 CHLORPROMAZ INJ 25MG/ML... 51 CHLORPROMAZ INJ 50MG/2ML... 51 chlorpromazine hcl tab 10... 51 chlorpromazine hcl tab 100... 51 chlorpromazine hcl tab 200... 51 chlorpromazine hcl tab 25... 51 chlorpromazine hcl tab 50... 51 chlorpropamide tab 100... 63 chlorpropamide tab 250... 63 chlorthalidone tab 25... 34 chlorthalidone tab 50... 34 chlorzoxazone tab 500... 58 cholestyramine light powder 4 gm/dose... 28 cholestyramine light powder packets 4 gm... 28 cholestyramine powder 4 gm/dose... 28 cholestyramine powder packets 4 gm. 28 choline & magnesium salicylates liq 500 /5ml... 1 choline fenofibrate cap dr 135 (fenofibric acid equiv)... 28 choline fenofibrate cap dr 45 (fenofibric acid equiv)... 28 ciclopirox gel 0.77%... 99 ciclopirox olamine cream 0.77% (base equiv)... 99 ciclopirox olamine susp 0.77% (base equiv)... 99 ciclopirox solution 8%... 99 cilostazol tab 100... 83 cilostazol tab 50... 83 CILOXAN OIN 0.3% OP... 104 CINQAIR INJ... 96 CINRYZE SOL 500 UNIT... 83 CIPRO (10%) SUS 500MG/5... 7 CIPRO (5%) SUS 250MG/5... 7 CIPRO HC SUS OTIC... 107 CIPRODEX SUS 0.3-0.1%... 107 ciprofloxacin hcl ophth soln 0.3%... 104 ciprofloxacin hcl otic soln 0.2% (base equivalent)... 107 ciprofloxacin hcl tab 100 (base equiv)... 7 117

ciprofloxacin hcl tab 250 (base equiv)... 7 ciprofloxacin hcl tab 500 (base equiv)... 7 ciprofloxacin hcl tab 750 (base equiv)... 7 ciprofloxacin-ciprofloxacin hcl tab er 24hr 1000 (base eq)... 7 ciprofloxacin-ciprofloxacin hcl tab er 24hr 500 (base eq)... 7 cisplatin inj 100 /100ml (1 /ml). 15 cisplatin inj 200 /200ml (1 /ml). 15 cisplatin inj 50 /50ml (1 /ml)... 15 citalopram hydrobromide oral soln 10 /5ml... 45 citalopram hydrobromide tab 10 (base equiv)... 45 citalopram hydrobromide tab 20 (base equiv)... 45 citalopram hydrobromide tab 40 (base equiv)... 45 CITRANATAL CAP HARMONY... 90 CITRANATAL MIS 90 DHA... 90 CITRANATAL MIS B-CALM... 90 CITRANATAL PAK ASSURE... 90 CITRANATAL PAK DHA... 90 CITRANATAL TAB RX... 90 cladribine iv soln 10 /10ml (1 /ml)... 16 clarithromycin for susp 125 /5ml... 7 clarithromycin for susp 250 /5ml... 7 clarithromycin tab 250... 7 clarithromycin tab 500... 7 clarithromycin tab er 24hr 500... 7 clemastine fumarate tab 2.68... 93 CLEOCIN CAP 150MG... 14 CLEOCIN CAP 300MG... 14 CLEOCIN CAP 75MG... 14 CLEOCIN SUP 100MG... 80 CLEVIPREX EMU 50/100ML... 31 CLIMARA PRO DIS WEEKLY... 66 clindamycin hcl cap 150... 14 clindamycin hcl cap 300... 14 clindamycin hcl cap 75... 14 clindamycin palmitate hcl for soln 75 /5ml (base equiv)... 14 clindamycin phosphate foam 1%... 98 clindamycin phosphate gel 1%... 98 clindamycin phosphate lotion 1%... 98 clindamycin phosphate soln 1%... 98 clindamycin phosphate swab 1%... 98 clindamycin phosphate vaginal cream 2%... 80 clobetasol propionate cream 0.05%.. 101 clobetasol propionate emollient base cream 0.05%... 101 clobetasol propionate gel 0.05%... 101 clobetasol propionate oint 0.05%... 101 clobetasol propionate soln 0.05%... 101 clomipramine hcl cap 25... 39 clomipramine hcl cap 50... 39 clomipramine hcl cap 75... 39 clonazepam orally disintegrating tab 0.125... 38 clonazepam orally disintegrating tab 0.25... 38 clonazepam orally disintegrating tab 0.5... 38 clonazepam orally disintegrating tab 1... 38 clonazepam orally disintegrating tab 2... 38 clonazepam tab 0.5... 39 clonazepam tab 1... 39 clonazepam tab 2... 39 clonidine hcl tab 0.1... 25 clonidine hcl tab 0.2... 25 clonidine hcl tab 0.3... 25 clonidine hcl tab er 12hr 0.1... 53 clonidine td patch weekly 0.1 /24hr 25 clonidine td patch weekly 0.2 /24hr 25 clonidine td patch weekly 0.3 /24hr 25 clopidogrel bisulfate tab 300 (base equiv)... 84 clopidogrel bisulfate tab 75 (base equiv)... 84 clorazepate dipotassium tab 15... 39 clorazepate dipotassium tab 3.75.. 39 clorazepate dipotassium tab 7.5... 39 clotrimazole cream 1%... 99 clotrimazole troche 10... 9 clotrimazole w/ betamethasone lotion 1-0.05%... 99 clozapine orally disintegrating tab 100... 49 clozapine orally disintegrating tab 12.5 118

... 49 clozapine orally disintegrating tab 150... 49 clozapine orally disintegrating tab 200... 49 clozapine orally disintegrating tab 25... 49 clozapine tab 100... 49 clozapine tab 200... 49 clozapine tab 25... 49 clozapine tab 50... 49 C-NATE DHA CAP 28-1-200... 90 COARTEM TAB 20-120MG... 10 cocaine hcl soln 4%... 101 codeine sulfate tab 15... 3 codeine sulfate tab 30... 3 codeine sulfate tab 60... 3 COLCRYS TAB 0.6MG... 1 colesevelam hcl tab 625... 28 COLESTID GRA 5GM... 28 COLESTID POW 5GM... 28 COLESTID TAB 1GM... 28 colestipol hcl granule packets 5 gm... 28 colestipol hcl granules 5 gm... 28 colestipol hcl tab 1 gm... 28 COMBIGAN SOL 0.2/0.5%... 107 COMBIPATCH DIS.05/.14... 66 COMBIPATCH DIS.05/.25... 66 COMBIVENT AER 20-100... 93 COMETRIQ KIT 100MG... 18 COMETRIQ KIT 140MG... 18 COMETRIQ KIT 60MG... 18 COMPLERA TAB... 10 COMPLETE NAT PAK DHA... 90 COMPLETENATE CHW... 90 CONCEPT DHA CAP... 90 CONCEPT OB CAP... 90 CONDYLOX GEL 0.5%... 102 CONTROL KIT MONITOR... 63 COPAXONE INJ 20MG/ML... 57 COPAXONE INJ 40MG/ML... 57 CORLANOR TAB 5MG... 35 CORLANOR TAB 7.5MG... 35 CORTEF TAB 10MG... 68 CORTEF TAB 20MG... 68 CORTEF TAB 5MG... 68 CORTIFOAM AER 90MG... 77 cortisone acetate tab 25... 68 CORTISPORIN CRE 0.5%... 98 CORTISPORIN OIN 1%... 98 CORVITE 150 TAB... 88 CORVITE FE TAB... 88 COSENTYX INJ 150MG/ML... 84 COSENTYX PEN INJ 300DOSE... 84 COSOPT PF SOL... 106 COTELLIC TAB 20MG... 18 creamy face liq wash 4%... 98 CREON CAP 12000UNT... 78 CREON CAP 24000UNT... 78 CREON CAP 3000UNIT... 78 CREON CAP 36000UNT... 78 CREON CAP 6000UNIT... 78 CRESEMBA CAP 186 MG... 9 CRINONE GEL 4% VAG... 73 CRIXIVAN CAP 200MG... 11 CRIXIVAN CAP 400MG... 11 cromolyn sodium ophth soln 4%... 105 cromolyn sodium oral conc 100 /5ml... 78 cromolyn sodium soln nebu 20 /2ml... 96 CUVPOSA SOL 1MG/5ML... 76 cyclobenzaprine hcl tab 10... 58 cyclobenzaprine hcl tab 5... 58 CYCLOMYDRIL SOL OP... 107 cyclopentolate hcl ophth soln 0.5%.. 107 cyclopentolate hcl ophth soln 1%... 107 cyclopentolate hcl ophth soln 2%... 107 CYCLOPHOSPH CAP 25MG... 15 CYCLOPHOSPH CAP 50MG... 15 cyclophosphamide for inj 1 gm... 15 cyclophosphamide for inj 2 gm... 15 cyclophosphamide for inj 500... 15 cycloserine cap 250... 12 CYCLOSET TAB 0.8MG... 62 cyclosporine cap 100... 86 cyclosporine cap 25... 86 cyclosporine iv soln 50 /ml... 86 cyclosporine modified cap 50... 86 cyclosporine modified oral soln 100 /ml... 86 cyproheptadine hcl syrup 2 /5ml... 93 cyproheptadine hcl tab 4... 93 CYSTADANE POW... 71 CYSTAGON CAP 150MG... 80 CYSTAGON CAP 50MG... 79 119

CYSTARAN SOL 0.44%... 106 cytarabine inj 20 /ml... 16 cytarabine inj pf 100 /ml... 16 cytarabine inj pf 20 /ml... 16 CYTOMEL TAB 25MCG... 73 CYTOMEL TAB 50MCG... 73 CYTOMEL TAB 5MCG... 73 D dacarbazine for inj 100... 15 dacarbazine for inj 200... 15 DALIRESP TAB 500MCG... 96 danazol cap 100... 66 danazol cap 200... 66 danazol cap 50... 66 dantrolene sodium cap 100... 58 dantrolene sodium cap 25... 58 dantrolene sodium cap 50... 58 dantrolene sodium for iv soln 20... 58 dapsone gel 5%... 98 dapsone tab 100... 14 dapsone tab 25... 14 daunorubicin hcl iv soln 20 /4ml (base equiv)... 20 DEBACTEROL SOL 30-50%... 103 deferoxamine mesylate for inj 2 gm... 83 DELFLEX-LC/ SOL 2.5% DEX... 80 DELZICOL CAP 400MG... 77 demeclocycline hcl tab 150... 8 demeclocycline hcl tab 300... 8 DEMSER CAP 250MG... 25 DENAVIR CRE 1%... 102 DEPAKOTE ER TAB 500MG... 40 DEPEN TITRA TAB 250MG... 85 DEPO-ESTRADI INJ 5MG/ML... 66 DEPO-MEDROL INJ 20MG/ML... 68 DEPO-MEDROL INJ 40MG/ML... 68 DEPO-MEDROL INJ 80MG/ML... 68 DEPO-PROVERA INJ 150MG/ML... 66 DEPO-PROVERA INJ 400/ML... 18 DERMOTIC OIL 0.01%... 108 DESCOVY TAB 200/25... 10 desipramine hcl tab 10... 46 desipramine hcl tab 100... 46 desipramine hcl tab 150... 46 desipramine hcl tab 25... 46 desipramine hcl tab 50... 46 desipramine hcl tab 75... 46 desmopressin acetate inj 4 mcg/ml... 74 desmopressin acetate nasal spray soln 0.01%... 74 desmopressin acetate nasal spray soln 0.01% (refrigerated)... 74 desmopressin acetate tab 0.1... 74 desmopressin acetate tab 0.2... 74 desonide cream 0.05%... 100 desonide lotion 0.05%... 100 desonide oint 0.05%... 100 desoximetasone cream 0.05%... 101 desoximetasone cream 0.25%... 100 desoximetasone gel 0.05%... 100 desoximetasone oint 0.05%... 101 desoximetasone oint 0.25%... 100 DESOXYN TAB 5MG... 53 DESVENLAFAX TAB 50MG ER... 44 desvenlafaxine succinate tab er 24hr 100 (base equiv)... 44 desvenlafaxine succinate tab er 24hr 25 (base equiv)... 44 desvenlafaxine succinate tab er 24hr 50 (base equiv)... 44 desvenlafaxine tab er 24hr 100... 44 desvenlafaxine tab er 24hr 50... 44 DEXAMETHASON CON 1MG/ML... 68 dexamethasone elixir 0.5 /5ml... 68 dexamethasone sod phosphate preservative free inj 10 /ml... 68 dexamethasone sodium phosphate inj 10 /ml... 68 dexamethasone sodium phosphate inj 100 /10ml... 68 dexamethasone sodium phosphate inj 120 /30ml... 68 dexamethasone sodium phosphate inj 20 /5ml... 68 dexamethasone sodium phosphate inj 4 /ml... 68 dexamethasone sodium phosphate ophth soln 0.1%... 105 dexamethasone soln 0.5 /5ml... 68 dexamethasone tab 0.5... 68 dexamethasone tab 0.75... 68 dexamethasone tab 1... 68 dexamethasone tab 1.5... 68 dexamethasone tab 2... 68 dexamethasone tab 4... 68 dexamethasone tab 6... 68 120

DEXEDRINE CAP 10MG CR... 53 DEXEDRINE CAP 15MG CR... 53 DEXEDRINE CAP 5MG CR... 53 dexmethylphenidate hcl cap er 24 hr 10... 53 dexmethylphenidate hcl cap er 24 hr 15... 53 dexmethylphenidate hcl cap er 24 hr 20... 53 dexmethylphenidate hcl cap er 24 hr 25... 53 dexmethylphenidate hcl cap er 24 hr 30... 53 dexmethylphenidate hcl cap er 24 hr 35... 53 dexmethylphenidate hcl cap er 24 hr 40... 53 dexmethylphenidate hcl cap er 24 hr 5... 53 dexmethylphenidate hcl tab 10... 53 dexmethylphenidate hcl tab 2.5... 53 dexmethylphenidate hcl tab 5... 53 DEXPAK PAK 10 DAY... 68 DEXPAK PAK 13 DAY... 68 DEXPAK PAK 6 DAY... 68 dextroamphetamine sulfate cap er 24hr 10... 53 dextroamphetamine sulfate cap er 24hr 15... 53 dextroamphetamine sulfate cap er 24hr 5... 53 dextroamphetamine sulfate tab 10 53 dextroamphetamine sulfate tab 5.. 53 DIASTAT ACDL GEL 12.5-20... 40 DIASTAT ACDL GEL 5-10MG... 40 DIASTAT PED GEL 2.5M GEL... 40 diazepam conc 5 /ml... 39 DIAZEPAM INJ 10MG/2ML... 39 diazepam inj 5 /ml... 39 diazepam oral soln 1 /ml... 39 diazepam tab 10... 39 diazepam tab 2... 39 diazepam tab 5... 39 DIBENZYLINE CAP 10MG... 25 diclofenac potassium tab 50... 1 diclofenac sodium gel 1%... 2 diclofenac sodium ophth soln 0.1%... 105 diclofenac sodium tab delayed release 25... 1 diclofenac sodium tab delayed release 50... 1 diclofenac sodium tab delayed release 75... 1 diclofenac sodium tab er 24hr 100.. 1 diclofenac w/ misoprostol tab delayed release 50-0.2... 2 diclofenac w/ misoprostol tab delayed release 75-0.2... 2 dicloxacillin sodium cap 250... 8 dicloxacillin sodium cap 500... 8 dicyclomine hcl cap 10... 76 dicyclomine hcl oral soln 10 /5ml... 76 dicyclomine hcl tab 20... 76 didanosine delayed release capsule 200... 12 didanosine delayed release capsule 250... 12 didanosine delayed release capsule 400... 12 DIFICID TAB 200MG... 7 diflunisal tab 500... 1 DIGIFAB INJ 40MG... 64 digoxin inj 0.25 /ml... 33 digoxin oral soln 0.05 /ml... 33 digoxin tab 125 mcg (0.125 )... 33 digoxin tab 250 mcg (0.25 )... 33 dihydroergotamine mesylate nasal spray 4 /ml... 56 DILANTIN CAP 100MG... 40 DILANTIN CAP 30MG... 40 DILANTIN CHW 50MG... 40 DILANTIN-125 SUS 125/5ML... 40 diltiazem hcl cap er 12hr 120... 32 diltiazem hcl cap er 12hr 60... 32 diltiazem hcl cap er 12hr 90... 32 diltiazem hcl cap er 24hr 120... 32 diltiazem hcl cap er 24hr 180... 32 diltiazem hcl cap er 24hr 240... 32 diltiazem hcl coated beads cap er 24hr 120... 32 diltiazem hcl coated beads cap er 24hr 180... 32 diltiazem hcl coated beads cap er 24hr 240... 32 diltiazem hcl coated beads cap er 24hr 300... 32 121

diltiazem hcl coated beads cap er 24hr 360... 32 diltiazem hcl coated beads tab er 24hr 180... 32 diltiazem hcl coated beads tab er 24hr 240... 32 diltiazem hcl coated beads tab er 24hr 300... 32 diltiazem hcl coated beads tab er 24hr 360... 32 diltiazem hcl coated beads tab er 24hr 420... 33 diltiazem hcl extended release beads cap er 24hr 120... 33 diltiazem hcl extended release beads cap er 24hr 180... 33 diltiazem hcl extended release beads cap er 24hr 240... 33 diltiazem hcl extended release beads cap er 24hr 300... 33 diltiazem hcl extended release beads cap er 24hr 360... 33 diltiazem hcl extended release beads cap er 24hr 420... 33 diltiazem hcl iv soln 125 /25ml (5 /ml)... 33 diltiazem hcl iv soln 25 /5ml (5 /ml)... 33 diltiazem hcl iv soln 50 /10ml (5 /ml)... 33 diltiazem hcl tab 120... 33 diltiazem hcl tab 30... 33 diltiazem hcl tab 60... 33 diltiazem hcl tab 90... 33 DILTIAZEM INJ 100MG... 33 DIMENHYDRIN INJ 50MG/ML... 75 DIPENTUM CAP 250MG... 77 diphenhydramine hcl cap 50... 93 diphenhydramine hcl elixir 12.5 /5ml... 93 diphenhydramine hcl inj 50 /ml... 93 diphenoxylate w/ atropine liq 2.5-0.025 /5ml... 75 diphenoxylate w/ atropine tab 2.5-0.025... 75 dipyridamole tab 25... 84 dipyridamole tab 50... 84 dipyridamole tab 75... 84 disopyramide phosphate cap 100.. 27 disopyramide phosphate cap 150.. 27 disulfiram tab 250... 59 disulfiram tab 500... 59 DIURIL SUS 250/5ML... 34 divalproex sodium cap delayed release sprinkle 125... 40 divalproex sodium tab delayed release 125... 40 divalproex sodium tab delayed release 250... 40 divalproex sodium tab delayed release 500... 40 divalproex sodium tab er 24 hr 250... 40 divalproex sodium tab er 24 hr 500... 40 DIVIGEL GEL 0.25MG... 67 DIVIGEL GEL 0.5MG... 67 DIVIGEL GEL 1MG/GM... 67 dobutamine hcl inj 12.5 /ml... 38 dobutamine inj 1 /ml in d5w... 38 dobutamine inj 2 /ml in d5w... 38 dobutamine inj 4 /ml in d5w... 38 dofetilide cap 125 mcg (0.125 )... 27 dofetilide cap 250 mcg (0.25 )... 27 dofetilide cap 500 mcg (0.5 )... 27 donepezil hydrochloride orally disintegrating tab 10... 42 donepezil hydrochloride orally disintegrating tab 5... 42 donepezil hydrochloride tab 10... 43 donepezil hydrochloride tab 5... 43 dopamine hcl inj 160 /ml... 38 dopamine hcl inj 40 /ml... 38 dopamine hcl inj 80 /ml... 38 DOPTELET TAB 20MG... 83 dorzolamide hcl ophth soln 2%... 106 dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 /ml... 106 DOTHELLE DHA CAP... 90 doxazosin mesylate tab 1... 25 doxazosin mesylate tab 2... 25 doxazosin mesylate tab 4... 25 doxazosin mesylate tab 8... 25 doxepin hcl cap 10... 46 doxepin hcl cap 100... 46 doxepin hcl cap 150... 46 122

doxepin hcl cap 25... 46 doxepin hcl cap 50... 46 doxepin hcl cap 75... 46 doxepin hcl conc 10 /ml... 46 doxercalciferol cap 0.5 mcg... 70 doxercalciferol cap 1 mcg... 70 doxercalciferol cap 2.5 mcg... 70 doxorubicin hcl for inj 10... 20 doxorubicin hcl for inj 50... 20 doxorubicin hcl inj 2 /ml... 20 doxycycline hyclate tab 100... 8 doxycycline hyclate tab 20... 8 doxycycline hyclate tab delayed release 100... 9 doxycycline hyclate tab delayed release 150... 9 doxycycline hyclate tab delayed release 200... 9 doxycycline hyclate tab delayed release 50... 9 doxycycline hyclate tab delayed release 75... 9 doxycycline monohydrate cap 100.. 9 doxycycline monohydrate cap 150.. 9 doxycycline monohydrate for susp 25 /5ml... 9 doxycycline monohydrate tab 100.. 9 doxycycline monohydrate tab 50... 9 doxycycline monohydrate tab 75... 9 DRITHO-CREME CRE HP 1%... 99 dronabinol cap 10... 75 dronabinol cap 2.5... 75 dronabinol cap 5... 75 droperidol inj 2.5 /ml... 75 DRYSOL SOL 20%... 102 DUAVEE TAB 0.45-20... 66 DUET DHA 400 MIS 25-1-400... 90 DUET DHA MIS BALANCED... 90 duloxetine hcl enteric coated pellets cap 20 (base eq)... 44 duloxetine hcl enteric coated pellets cap 30 (base eq)... 44 duloxetine hcl enteric coated pellets cap 60 (base eq)... 44 DUOPA SUS 4.63-20... 47 DUREZOL EMU 0.05%... 105 dutasteride cap 0.5... 79 dutasteride-tamsulosin hcl cap 0.5-0.4... 79 DYRENIUM CAP 100MG... 34 DYRENIUM CAP 50MG... 34 DYSPORT INJ 300UNIT... 57 DYSPORT INJ 500UNIT... 57 E E.E.S. GRAN SUS 200/5ML... 7 EASY TOUCH MIS 32GX5MM... 63 econazole nitrate cream 1%... 99 EDURANT TAB 25MG... 11 efavirenz cap 200... 11 efavirenz cap 50... 11 efavirenz tab 600... 11 EFFER-K TAB 10MEQ... 88 EFFER-K TAB 20MEQ... 88 ELAPRASE INJ 6MG/3ML... 70 ELELYSO INJ 200UNIT... 70 eletriptan hydrobromide tab 20 (base equivalent)... 56 eletriptan hydrobromide tab 40 (base equivalent)... 56 ELIDEL CRE 1%... 100 ELIGARD INJ 22.5MG... 17 ELIGARD INJ 30MG... 17 ELIGARD INJ 45MG... 17 ELIGARD INJ 7.5MG... 17 ELIQUIS TAB 2.5MG... 81 ELIQUIS TAB 5MG... 81 ELITEK INJ 1.5MG... 20 ELITEK INJ 7.5MG... 20 ELIXOPHYLLIN ELX 80/15ML... 97 ELLENCE INJ 2MG/ML... 20 ELMIRON CAP 100MG... 80 EMADINE SOL 0.05% OP... 105 EMCYT CAP 140MG... 15 EMEND SOL 150MG... 75 EMTRIVA CAP 200MG... 12 EMTRIVA SOL 10MG/ML... 12 enalapril maleate & hydrochlorothiazide tab 10-25... 23 enalapril maleate & hydrochlorothiazide tab 5-12.5... 23 enalapril maleate tab 10... 24 enalapril maleate tab 2.5... 24 enalapril maleate tab 20... 24 enalapril maleate tab 5... 24 enalaprilat iv inj 1.25 /ml... 24 ENBRACE HR CAP... 90 123

ENBREL INJ 25/0.5ML... 84 ENBREL INJ 25MG... 84 ENBREL INJ 50MG/ML... 84 ENBREL MINI INJ 50MG/ML... 84 ENBREL SRCLK INJ 50MG/ML... 84 ENDO AVITENE MIS 10MM DIA... 82 ENDO AVITENE MIS 5MM DIA... 82 endocet tab 5-325... 3 ENDOMETRIN SUP 100MG... 73 ENLON INJ 150/15ML... 58 enoxaparin sodium inj 100 /ml... 81 enoxaparin sodium inj 120 /0.8ml.. 81 enoxaparin sodium inj 150 /ml... 81 enoxaparin sodium inj 30 /0.3ml... 81 enoxaparin sodium inj 300 /3ml... 81 enoxaparin sodium inj 40 /0.4ml... 81 enoxaparin sodium inj 60 /0.6ml... 81 enoxaparin sodium inj 80 /0.8ml... 81 entacapone tab 200... 47 entecavir tab 0.5... 13 entecavir tab 1... 13 ENTRESTO TAB 24-26MG... 35 ENTRESTO TAB 49-51MG... 35 ENTRESTO TAB 97-103MG... 35 EPCLUSA TAB 400-100... 13 ephedrine sulfate inj 50 /ml... 38 EPIFOAM AER 1%... 78 epinastine hcl ophth soln 0.05%... 105 EPINEPHRINE INJ 1MG/ML... 38 epinephrine pf inj 1 /ml... 93 epinephrine pf soln prefilled syringe 1 /10ml (0.1 /ml)... 93 epinephrine solution auto-injector 0.15 /0.15ml (1:1000)... 93 epinephrine solution auto-injector 0.3 /0.3ml (1:1000)... 93 EPIPEN 2-PAK INJ 0.3MG... 93 EPIPEN-JR INJ 2-PAK... 93 epirubicin hcl iv soln 200 /100ml (2 /ml)... 20 EPIVIR HBV SOL 5MG/ML... 13 EPIVIR HBV TAB 100MG... 13 EPIVIR SOL 10MG/ML... 12 eplerenone tab 25... 25 eplerenone tab 50... 25 EPOGEN INJ 10000/ML... 82 EPOGEN INJ 2000/ML... 82 EPOGEN INJ 20000/ML... 82 EPOGEN INJ 3000/ML... 82 EPOGEN INJ 4000/ML... 82 epoprostenol sodium for inj 0.5... 37 eprosartan mesylate tab 600... 26 EPZICOM TAB 600-300... 10 ERBITUX INJ 100MG... 20 ERBITUX INJ 200MG... 21 ergocalciferol cap 50000 unit... 88 ERIVEDGE CAP 150MG... 21 ERLEADA TAB 60MG... 17 ERYPED SUS 400/5ML... 7 erythromycin ethylsuccinate for susp 200 /5ml... 7 erythromycin ethylsuccinate tab 400... 7 erythromycin gel 2%... 98 erythromycin ophth oint 5 /gm... 104 erythromycin pads 2%... 98 erythromycin soln 2%... 98 erythromycin stearate tab 250... 7 erythromycin tab 250... 7 erythromycin tab 500... 7 erythromycin tab delayed release 250... 7 erythromycin tab delayed release 333... 7 erythromycin tab delayed release 500... 7 erythromycin w/ delayed release particles cap 250... 7 ESBRIET CAP 267MG... 96 ESBRIET TAB 267MG... 96 ESBRIET TAB 801MG... 96 ESCAVITE CHW... 89 ESCAVITE D CHW... 89 escitalopram oxalate soln 5 /5ml (base equiv)... 45 escitalopram oxalate tab 10 (base equiv)... 45 escitalopram oxalate tab 20 (base equiv)... 45 escitalopram oxalate tab 5 (base equiv)... 45 estazolam tab 1... 55 estazolam tab 2... 55 ESTRACE VAG CRE 0.01%... 67 estradiol & norethindrone acetate tab 0.5-0.1... 66 124

estradiol & norethindrone acetate tab 1-0.5... 66 estradiol tab 0.5... 66 estradiol tab 1... 67 estradiol tab 2... 67 estradiol td patch twice weekly 0.025 /24hr... 67 estradiol td patch twice weekly 0.0375 /24hr... 67 estradiol td patch twice weekly 0.05 /24hr... 67 estradiol td patch twice weekly 0.075 /24hr... 67 estradiol td patch twice weekly 0.1 /24hr... 67 estradiol td patch weekly 0.025 /24hr... 67 estradiol td patch weekly 0.0375 /24hr (37.5 mcg/24hr)... 67 estradiol td patch weekly 0.05 /24hr... 67 estradiol td patch weekly 0.06 /24hr... 67 estradiol td patch weekly 0.075 /24hr... 67 estradiol td patch weekly 0.1 /24hr 67 estradiol vaginal cream 0.1 /gm... 67 estradiol vaginal tab 10 mcg... 67 estradiol valerate im in oil 20 /ml... 66 estradiol valerate im in oil 40 /ml... 66 ESTRING MIS 2MG... 68 ESTROGEL GEL... 67 eszopiclone tab 1... 56 eszopiclone tab 2... 56 eszopiclone tab 3... 56 ethambutol hcl tab 100... 12 ethambutol hcl tab 400... 12 ETHAMOLIN INJ 5%... 35 ethosuximide cap 250... 40 ethosuximide soln 250 /5ml... 40 etidronate disodium tab 400... 65 etodolac cap 200... 1 etodolac cap 300... 1 etodolac tab 400... 1 etodolac tab 500... 1 etodolac tab er 24hr 400... 1 etodolac tab er 24hr 500... 1 etodolac tab er 24hr 600... 1 ETOPOPHOS INJ 100MG... 21 etoposide cap 50... 21 etoposide inj 1 gm/50ml (20 /ml).. 21 etoposide inj 100 /5ml (20 /ml) 21 etoposide inj 500 /25ml (20 /ml)... 21 EUFLEXXA INJ 10MG/ML... 6 EURAX CRE 10%... 102 EURAX LOT 10%... 102 EVAMIST SPR 1.53MG... 67 EVOTAZ TAB 300-150... 10 EXELDERM CRE 1%... 99 EXELDERM SOL 1%... 99 exemestane tab 25... 17 EXJADE TAB 125MG... 83 EXJADE TAB 250MG... 83 EXJADE TAB 500MG... 83 EXODERM LOT 25-1%... 99 EYLEA INJ 2/0.05ML... 106 ezetimibe tab 10... 28 ezetimibe-simvastatin tab 10-10... 29 ezetimibe-simvastatin tab 10-20... 29 ezetimibe-simvastatin tab 10-40... 29 ezetimibe-simvastatin tab 10-80... 29 F FABRAZYME INJ 35MG... 70 FABRAZYME INJ 5MG... 70 famciclovir tab 125... 13 famciclovir tab 250... 13 famciclovir tab 500... 13 FANAPT PAK... 49 FANAPT TAB 10MG... 49 FANAPT TAB 12MG... 49 FANAPT TAB 1MG... 49 FANAPT TAB 2MG... 49 FANAPT TAB 4MG... 49 FANAPT TAB 6MG... 49 FANAPT TAB 8MG... 49 FARESTON TAB 60MG... 17 FARYDAK CAP 10MG... 21 FARYDAK CAP 15MG... 21 FARYDAK CAP 20MG... 21 FASLODEX INJ 250/5ML... 17 fe asp gly-fe polysacch-succ ac-c-threon ac-b12-fa cap... 89 fe asparto gly-fe fum-b12-fa-c-succinic ac tab ther pack... 89 fe fumarate w/ b12-vit c-fa-ifc cap 125

110-0.015-75-0.5-240... 89 felbamate susp 600 /5ml... 40 felbamate tab 400... 40 felbamate tab 600... 40 felodipine tab er 24hr 10... 31 felodipine tab er 24hr 2.5... 31 felodipine tab er 24hr 5... 31 FEM PH GEL... 80 FEMRING MIS 0.05/24H... 68 FEMRING MIS 0.1MG/24... 68 fenofibrate micronized cap 134... 28 fenofibrate micronized cap 200... 28 fenofibrate micronized cap 43... 28 fenofibrate micronized cap 67... 28 fenofibrate tab 145... 28 fenofibrate tab 160... 28 fenofibrate tab 48... 28 fenofibrate tab 54... 28 fenofibric acid tab 105... 28 fenofibric acid tab 35... 28 fenoprofen calcium tab 600... 2 fentanyl citrate lozenge on a handle 1200 mcg... 3 fentanyl citrate lozenge on a handle 1600 mcg... 3 fentanyl citrate lozenge on a handle 200 mcg... 3 fentanyl citrate lozenge on a handle 600 mcg... 3 fentanyl citrate lozenge on a handle 800 mcg... 3 fentanyl td patch 72hr 100 mcg/hr... 3 fentanyl td patch 72hr 12 mcg/hr... 3 fentanyl td patch 72hr 25 mcg/hr... 3 fentanyl td patch 72hr 50 mcg/hr... 3 fentanyl td patch 72hr 75 mcg/hr... 3 FENTORA TAB 100MCG... 3 FENTORA TAB 200MCG... 3 FENTORA TAB 400MCG... 3 FENTORA TAB 600MCG... 3 FENTORA TAB 800MCG... 3 FERAHEME INJ 510/17ML... 89 FERRALET 90 TAB... 89 FERRAPLUS 90 TAB... 89 ferrex 150 cap 150... 89 FERRIPROX SOL 100MG/ML... 83 FERRIPROX TAB 500MG... 83 FETZIMA CAP 120MG... 44 FETZIMA CAP 20MG... 44 FETZIMA CAP 40MG... 44 FETZIMA CAP 80MG... 44 FETZIMA CAP TITRATIO... 44 FINACEA GEL 15%... 102 finasteride tab 5... 79 FIRAZYR INJ 30MG/3ML... 83 FIRMAGON INJ 120MG... 17 FIRMAGON INJ 80MG... 17 FLAREX SUS 0.1% OP... 105 FLEBOGAMMA INJ 20/400ML... 85 FLEBOGAMMA INJ DIF 5%... 85 flecainide acetate tab 100... 27 flecainide acetate tab 150... 27 flecainide acetate tab 50... 27 FLOLAN INJ 0.5MG... 37 FLOLAN INJ 1.5MG... 37 FLORIVA CHW 0.25MG... 89 FLORIVA CHW 0.5MG... 89 FLORIVA CHW 1MG... 89 FLORIVA DRO 0.25MG... 89 FLOVENT DISK AER 100MCG... 97 FLOVENT DISK AER 250MCG... 97 FLOVENT DISK AER 50MCG... 97 FLOVENT HFA AER 110MCG... 97 FLOVENT HFA AER 220MCG... 97 FLOVENT HFA AER 44MCG... 97 floxuridine for inj 0.5 gm... 16 fluconazole for susp 10 /ml... 9 fluconazole for susp 40 /ml... 9 fluconazole tab 100... 9 fluconazole tab 150... 9 fluconazole tab 200... 9 fluconazole tab 50... 9 flucytosine cap 250... 9 flucytosine cap 500... 9 fludarabine phosphate for inj 50... 16 fludarabine phosphate inj 25 /ml... 16 fludrocortisone acetate tab 0.1... 68 flumazenil iv soln 0.5 /5ml (0.1 /ml)... 65 flumazenil iv soln 1 /10ml (0.1 /ml)... 65 fluocinolone acetonide (otic) oil 0.01%... 108 fluocinolone acetonide cream 0.01% 100 fluocinolone acetonide cream 0.025% 101 fluocinolone acetonide oil 0.01% (body 126

oil)... 100 fluocinolone acetonide oil 0.01% (scalp oil)... 100 fluocinolone acetonide oint 0.025%... 101 fluocinolone acetonide soln 0.01%... 100 fluocinonide cream 0.05%... 100 fluocinonide emulsified base cream 0.05%... 100 fluocinonide gel 0.05%... 100 fluocinonide oint 0.05%... 100 fluocinonide soln 0.05%... 100 fluorescein sodium ophth strips 1 106 fluorescein w/ benoxinate ophth soln 0.25-0.4%... 106 fluorid sens pst 1.1-5%... 103 fluorometholone ophth susp 0.1%... 105 fluorouracil cream 5%... 98 fluorouracil iv soln 1 gm/20ml (50 /ml)... 16 fluorouracil iv soln 2.5 gm/50ml (50 /ml)... 16 fluorouracil iv soln 5 gm/100ml (50 /ml)... 16 fluorouracil iv soln 500 /10ml (50 /ml)... 16 fluorouracil soln 2%... 98 fluorouracil soln 5%... 98 fluoxetine hcl (pmdd) cap 10... 45 fluoxetine hcl (pmdd) cap 20... 45 fluoxetine hcl (pmdd) tab 10... 45 fluoxetine hcl (pmdd) tab 20... 45 fluoxetine hcl cap 10... 45 fluoxetine hcl cap 20... 45 fluoxetine hcl cap 40... 45 fluoxetine hcl cap delayed release 90... 45 fluoxetine hcl solution 20 /5ml... 45 fluoxetine hcl tab 10... 45 fluoxetine hcl tab 20... 45 fluphenazine decanoate inj 25 /ml.. 51 fluphenazine hcl elixir 2.5 /5ml... 51 fluphenazine hcl inj 2.5 /ml... 51 fluphenazine hcl oral conc 5 /ml... 51 fluphenazine hcl tab 1... 51 fluphenazine hcl tab 10... 51 fluphenazine hcl tab 2.5... 51 fluphenazine hcl tab 5... 51 flurazepam hcl cap 15... 55 flurazepam hcl cap 30... 55 flurbiprofen sodium ophth soln 0.03%... 105 flurbiprofen tab 100... 2 flurbiprofen tab 50... 2 flutamide cap 125... 17 fluticasone propionate cream 0.05%. 101 fluticasone propionate oint 0.005%.. 101 fluvastatin sodium cap 20... 29 fluvastatin sodium cap 40... 29 fluvoxamine maleate tab 100... 39 fluvoxamine maleate tab 25... 39 fluvoxamine maleate tab 50... 39 FML FORTE SUS 0.25% OP... 105 FML LIQUIFLM SUS 0.1% OP... 105 FML OIN 0.1% OP... 105 FOCALIN XR CAP 25MG... 53 FOCALIN XR CAP 35MG... 53 FOLET DHA PAK... 90 FOLET ONE CAP 38-1-225... 90 FOLGARD RX TAB... 88 folic acid tab 1... 88 folic acid-vitamin b6-vitamin b12 tab 2.2-25-0.5... 88 folic acid-vitamin b6-vitamin b12 tab 2.2-25-1... 88 folic acid-vitamin b6-vitamin b12 tab 2.5-25-1... 88 FOLIVANE-OB CAP... 90 FOLTANX TAB... 87 FOLTRATE TAB... 88 fomepizole inj 1 gm/ml (for iv infusion)... 65 fondaparinux sodium subcutaneous inj 10 /0.8ml... 81 fondaparinux sodium subcutaneous inj 2.5 /0.5ml... 81 fondaparinux sodium subcutaneous inj 5 /0.4ml... 81 fondaparinux sodium subcutaneous inj 7.5 /0.6ml... 81 formaldehyde solution 20%... 99 FORTEO SOL 600/2.4... 66 FORTESTA GEL 10MG/ACT... 60 fosamprenavir calcium tab 700 (base equiv)... 11 fosinopril sodium & hydrochlorothiazide tab 10-12.5... 23 127

fosinopril sodium & hydrochlorothiazide tab 20-12.5... 23 fosinopril sodium tab 10... 24 fosinopril sodium tab 20... 24 fosinopril sodium tab 40... 24 FRAGMIN INJ 10000/ML... 81 FRAGMIN INJ 12500UNT... 81 FRAGMIN INJ 15000UNT... 81 FRAGMIN INJ 18000UNT... 81 FRAGMIN INJ 2500/0.2... 81 FRAGMIN INJ 5000/0.2... 81 FRAGMIN INJ 7500/0.3... 81 FRAGMIN INJ 95000UNT... 81 frovatriptan succinate tab 2.5 (base equivalent)... 56 furosemide inj 10 /ml... 34 furosemide oral soln 10 /ml... 34 furosemide oral soln 8 /ml... 34 furosemide tab 20... 34 furosemide tab 40... 34 furosemide tab 80... 34 FUSION PAK SPRINKLE... 89 FUSION PLUS CAP... 89 FUZEON INJ 90MG... 10 FYCOMPA SUS 0.5MG/ML... 40 FYCOMPA TAB 10MG... 40 FYCOMPA TAB 12MG... 41 FYCOMPA TAB 2MG... 40 FYCOMPA TAB 4MG... 40 FYCOMPA TAB 6MG... 40 FYCOMPA TAB 8MG... 40 G gabapentin cap 100... 41 gabapentin cap 300... 41 gabapentin cap 400... 41 gabapentin oral soln 250 /5ml... 41 gabapentin tab 600... 41 gabapentin tab 800... 41 GABITRIL TAB 12MG... 41 GABITRIL TAB 16MG... 41 GABLOFEN INJ 10000/20... 58 GABLOFEN INJ 20000/20... 58 GABLOFEN INJ 40000/20... 58 galantamine hydrobromide cap er 24hr 16... 43 galantamine hydrobromide cap er 24hr 24... 43 galantamine hydrobromide cap er 24hr 8... 43 galantamine hydrobromide oral soln 4 /ml... 43 galantamine hydrobromide tab 12 43 galantamine hydrobromide tab 4.. 43 galantamine hydrobromide tab 8.. 43 GALZIN CAP 25MG... 89 GALZIN CAP 50MG... 89 GAMASTAN S/D INJ... 85 GAMMAGARD INJ 10GM/100... 85 GAMMAGARD INJ 1GM/10ML... 85 GAMMAGARD INJ 2.5GM/25... 85 GAMMAGARD INJ 20GM/200... 85 GAMMAGARD INJ 30GM/300... 85 GAMMAGARD INJ 5GM/50ML... 85 GAMMAGARD SD INJ 10GM HU... 85 GAMMAGARD SD INJ 5GM HU... 85 GAMUNEX-C INJ 40/400ML... 85 gatifloxacin ophth soln 0.5%... 104 GATTEX KIT 5MG... 78 GEBAUERS SPR AER /STRETCH... 102 GELCLAIR GEL... 103 GELFOAM MIS DENTAL 4... 83 GELFOAM MIS SPON COM... 83 GELFOAM POW... 83 gemcitabine hcl for inj 2 gm... 16 gemcitabine hcl inj 1 gm/26.3ml (38 /ml) (base equiv)... 16 gemcitabine hcl inj 2 gm/52.6ml (38 /ml) (base equiv)... 16 gemcitabine hcl inj 200 /5.26ml (38 /ml) (base equiv)... 16 gemfibrozil tab 600... 28 gentamicin sulfate cream 0.1%... 99 gentamicin sulfate oint 0.1%... 99 gentamicin sulfate ophth oint 0.3%.. 104 gentamicin sulfate ophth soln 0.3%.. 104 GENVOYA TAB... 10 GEODON INJ 20MG... 49 GILENYA CAP 0.5MG... 57 GILOTRIF TAB 20MG... 18 GILOTRIF TAB 30MG... 18 GILOTRIF TAB 40MG... 19 GLASSIA INJ... 96 glatiramer acetate soln prefilled syringe 20 /ml... 57 glatiramer acetate soln prefilled syringe 40 /ml... 57 128

glatopa inj 20/ml... 57 glatopa inj 40/ml... 57 GLEOSTINE CAP 100MG... 15 GLEOSTINE CAP 10MG... 15 GLEOSTINE CAP 40MG... 15 glimepiride tab 1... 63 glimepiride tab 2... 63 glimepiride tab 4... 63 glipizide tab 10... 63 glipizide tab 5... 63 glipizide tab er 24hr 10... 63 glipizide tab er 24hr 2.5... 63 glipizide tab er 24hr 5... 63 glipizide-metformin hcl tab 2.5-250... 61 glipizide-metformin hcl tab 2.5-500... 61 glipizide-metformin hcl tab 5-500.. 61 GLUCAGEN INJ HYPOKIT... 69 GLUCAGON KIT 1MG... 69 glyburide micronized tab 1.5... 63 glyburide micronized tab 3... 63 glyburide micronized tab 6... 63 glyburide tab 1.25... 63 glyburide tab 2.5... 63 glyburide tab 5... 63 glyburide-metformin tab 1.25-250. 61 glyburide-metformin tab 2.5-500.. 61 glyburide-metformin tab 5-500... 61 glycine irrigation soln 1.5%... 79 GLYCOPYRROLA INJ 1MG/5ML... 76 glycopyrrolate inj 0.2 /ml... 76 glycopyrrolate inj 0.4 /2ml (0.2 /ml)... 76 glycopyrrolate inj 1 /5ml (0.2 /ml)... 76 glycopyrrolate inj 4 /20ml (0.2 /ml)... 76 glycopyrrolate tab 1... 76 glycopyrrolate tab 2... 76 GLYXAMBI TAB 10-5 MG... 63 GLYXAMBI TAB 25-5 MG... 63 GOLYTELY SOL... 77 GORDOFILM SOL... 102 GRALISE STAR MIS 300/600... 59 GRALISE TAB 300MG... 59 GRALISE TAB 600MG... 59 granisetron hcl inj 0.1 /ml... 75 granisetron hcl inj 1 /ml... 75 granisetron hcl inj 4 /4ml (1 /ml)... 75 granisetron hcl tab 1... 75 GRANIX INJ 300/0.5... 82 GRANIX INJ 480/0.8... 82 griseofulvin microsize susp 125 /5ml 9 griseofulvin microsize tab 500... 9 guaifenesin-codeine soln 100-10 /5ml... 94 guanfacine hcl tab 1... 25 guanfacine hcl tab 2... 25 guanfacine hcl tab er 24hr 1 (base equiv)... 53 guanfacine hcl tab er 24hr 2 (base equiv)... 53 guanfacine hcl tab er 24hr 3 (base equiv)... 53 guanfacine hcl tab er 24hr 4 (base equiv)... 53 GUANIDINE TAB 125MG... 57 GYNAZOLE-1 CRE 2%... 80 H H.P. ACTHAR INJ 80UNIT... 71 HALDOL DECAN INJ 100MG/ML... 51 HALDOL DECAN INJ 50MG/ML... 51 HALDOL INJ 5MG/ML... 51 halobetasol propionate cream 0.05% 101 halobetasol propionate oint 0.05%... 101 haloperidol decanoate im soln 100 /ml... 51 haloperidol decanoate im soln 50 /ml... 51 haloperidol lactate inj 5 /ml... 51 haloperidol lactate oral conc 2 /ml. 51 haloperidol tab 0.5... 51 haloperidol tab 1... 51 haloperidol tab 10... 51 haloperidol tab 2... 51 haloperidol tab 20... 51 haloperidol tab 5... 51 HARVONI TAB 90-400MG... 13 HECTOROL INJ 2MCG/ML... 70 HEMABATE INJ 250MCG... 71 HEMATOGEN FA CAP... 89 HEMATRON-AF TAB... 89 HEMENATAL OB TAB 28-6-1MG... 90 HEMETAB TAB... 89 129

heparin sodium (porcine) inj 1000 unit/ml... 81 heparin sodium (porcine) inj 10000 unit/ml... 81 heparin sodium (porcine) inj 20000 unit/ml... 81 heparin sodium (porcine) inj 5000 unit/ml... 81 heparin sodium (porcine) pf inj 5000 unit/0.5ml... 81 HERCEPTIN INJ 150MG... 21 HERCEPTIN INJ 440MG... 21 HETLIOZ CAP 20MG... 56 HEXALEN CAP 50MG... 15 HIZENTRA INJ 10/50ML... 85 HIZENTRA INJ 1GM/5ML... 85 HIZENTRA INJ 2GM/10ML... 85 HIZENTRA INJ 4GM/20ML... 85 homatropine hbr ophth soln 5%... 107 HUMATROPE INJ 12MG... 70 HUMATROPE INJ 24MG... 70 HUMATROPE INJ 5MG... 70 HUMATROPE INJ 6MG... 70 HUMIRA INJ 10/0.1ML... 84 HUMIRA INJ 10MG/0.2... 84 HUMIRA INJ 20/0.2ML... 84 HUMIRA INJ 40/0.4ML... 84 HUMIRA KIT 20MG/0.4... 84 HUMIRA KIT 40MG/0.8... 84 HUMIRA PEDIA INJ CROHNS... 84 HUMIRA PEN INJ 40/0.4ML... 84 HUMIRA PEN INJ 40MG/0.8... 84 HUMIRA PEN KIT CD/UC/HS... 84 HUMIRA PEN KIT PS/UV... 84 HUMULIN R INJ U-500... 62 HYCAMTIN CAP 0.25MG... 22 HYCAMTIN CAP 1MG... 22 hydralazine hcl inj 20 /ml... 35 hydralazine hcl tab 10... 35 hydralazine hcl tab 100... 35 hydralazine hcl tab 25... 35 hydralazine hcl tab 50... 35 hydrochlorothiazide cap 12.5... 34 hydrochlorothiazide tab 12.5... 34 hydrochlorothiazide tab 25... 34 hydrochlorothiazide tab 50... 34 hydrocod polst-chlorphen polst er susp 10-8 /5ml... 94 hydrocodone w/ homatropine syrup 5-1.5 /5ml... 94 hydrocodone-acetaminophen soln 10-325 /15ml... 4 hydrocodone-acetaminophen soln 7.5-325 /15ml... 3 hydrocodone-acetaminophen tab 10-325... 4 hydrocodone-acetaminophen tab 2.5-325... 4 hydrocodone-acetaminophen tab 5-325... 4 hydrocodone-acetaminophen tab 7.5-325... 4 hydrocodone-ibuprofen tab 10-200. 4 hydrocodone-ibuprofen tab 5-200... 4 hydrocodone-ibuprofen tab 7.5-200 4 hydrocortisone acetate suppos 25. 78 hydrocortisone acetate suppos 30. 78 hydrocortisone acetate w/ pramoxine rectal cream 1-1%... 79 hydrocortisone acetate w/ pramoxine rectal cream 2.5-1%... 79 hydrocortisone butyrate cream 0.1% 101 hydrocortisone butyrate oint 0.1%... 101 hydrocortisone butyrate soln 0.1%... 101 hydrocortisone cream 2.5%... 100 hydrocortisone enema 100 /60ml.. 77 hydrocortisone lotion 2.5%... 100 hydrocortisone oint 1%... 100 hydrocortisone rectal cream 1%... 79 hydrocortisone rectal cream 2.5%... 79 hydrocortisone tab 10... 68 hydrocortisone tab 20... 68 hydrocortisone tab 5... 68 hydrocortisone valerate cream 0.2% 101 hydrocortisone valerate oint 0.2%... 101 HYDROMORPHON SUP 3MG... 4 hydromorphone hcl tab 2... 4 hydromorphone hcl tab 4... 4 hydromorphone hcl tab 8... 4 hydroxocobalamin acetate inj 1000 mcg/ml (base equivalent)... 89 hydroxychloroquine sulfate tab 200... 85 hydroxyurea cap 500... 21 hydroxyzine hcl im soln 25 /ml... 94 hydroxyzine hcl im soln 50 /ml... 94 130

hydroxyzine hcl syrup 10 /5ml... 94 hydroxyzine hcl tab 10... 94 hydroxyzine hcl tab 25... 94 hydroxyzine hcl tab 50... 94 hydroxyzine pamoate cap 100... 94 hydroxyzine pamoate cap 25... 94 hydroxyzine pamoate cap 50... 94 hyoscyamine sulfate elixir 0.125 /5ml... 76 hyoscyamine sulfate sl tab 0.125... 76 hyoscyamine sulfate soln 0.125 /ml 76 hyoscyamine sulfate tab 0.125... 76 hyoscyamine sulfate tab disint 0.125... 76 hyoscyamine sulfate tab er 12hr 0.375... 76 HYPERSAL NEB 3.5%... 96 HYPER-SAL NEB 7%... 96 HYQVIA INJ 10-800... 85 HYQVIA INJ 2.5-200... 85 HYQVIA INJ 20-1600... 85 HYQVIA INJ 30-2400... 85 HYQVIA INJ 5-400... 85 I ibandronate sodium iv soln 3 /3ml (base equivalent)... 65 ibandronate sodium tab 150 (base equivalent)... 65 IBRANCE CAP 100MG... 19 IBRANCE CAP 125MG... 19 IBRANCE CAP 75MG... 19 ibuprofen susp 100 /5ml... 2 ibuprofen tab 400... 2 ibuprofen tab 600... 2 ibuprofen tab 800... 2 ICLUSIG TAB 15MG... 19 ICLUSIG TAB 45MG... 19 IDAMYCIN PFS INJ 20/20ML... 21 IDAMYCIN PFS INJ 5MG/5ML... 21 idarubicin hcl iv inj 20 /20ml (1 /ml)... 21 idarubicin hcl iv inj 5 /5ml (1 /ml)... 21 IDHIFA TAB 100MG... 21 IDHIFA TAB 50MG... 21 IFEX INJ 1GM... 15 ifosfamide for inj 1 gm... 15 IFOSFAMIDE INJ 3GM... 15 ifosfamide iv inj 1 gm/20ml (50 /ml)... 15 ifosfamide iv inj 3 gm/60ml (50 /ml)... 15 ILARIS INJ 150MG/ML... 86 ILUVIEN IMP 0.19MG... 105 imatinib mesylate tab 100 (base equivalent)... 19 imatinib mesylate tab 400 (base equivalent)... 19 IMBRUVICA CAP 140MG... 19 IMBRUVICA TAB 140MG... 19 IMBRUVICA TAB 280MG... 19 IMBRUVICA TAB 420MG... 19 IMBRUVICA TAB 560MG... 19 imipramine hcl tab 10... 46 imipramine hcl tab 25... 46 imipramine hcl tab 50... 46 imipramine pamoate cap 100... 46 imipramine pamoate cap 125... 46 imipramine pamoate cap 150... 46 imipramine pamoate cap 75... 46 imiquimod cream 5%... 102 INCRELEX INJ 40MG/4ML... 70 indapamide tab 1.25... 34 indapamide tab 2.5... 34 indomethacin cap 25... 2 indomethacin cap 50... 2 indomethacin cap er 75... 2 INFED INJ 50MG/ML... 89 INLYTA TAB 1MG... 19 INLYTA TAB 5MG... 19 INNOPRAN XL CAP 120MG... 30 INNOPRAN XL CAP 80MG... 30 INSULIN PEN MIS 29GX12MM... 63 INSULIN SYRG MIS 0.3/29G... 63 INSULIN SYRG MIS 0.3/30G... 64 INSULIN SYRG MIS 0.3/31G... 64 INSULIN SYRG MIS 0.5/27G... 64 INSULIN SYRG MIS 0.5/28G... 64 INSULIN SYRG MIS 0.5/29G... 64 INSULIN SYRG MIS 0.5/30G... 64 INSULIN SYRG MIS 0.5/31G... 64 INSULIN SYRG MIS 1ML... 64 INSULIN SYRG MIS 1ML/28G... 64 INSULIN SYRG MIS 1ML/29G... 64 INSULIN SYRG MIS 1ML/30G... 64 INSULIN SYRG MIS 1ML/31G... 64 131

INSULIN SYRG MIS 28GX1/2"... 64 INSUPEN SENS MIS 32GX6MM... 64 INSUPEN SENS MIS 32GX8MM... 64 INTEGRA F CAP... 89 INTEGRA PLUS CAP... 89 INTELENCE TAB 100MG... 11 INTELENCE TAB 200MG... 11 INTELENCE TAB 25MG... 11 INTRON A INJ 18MU... 86 INTRON A INJ 25MU... 86 INVEGA SUST INJ 117/0.75... 49 INVEGA SUST INJ 156MG/ML... 49 INVEGA SUST INJ 234/1.5... 49 INVEGA SUST INJ 39/0.25... 49 INVEGA SUST INJ 78/0.5ML... 49 INVEGA TRINZ INJ 273MG... 49 INVEGA TRINZ INJ 410MG... 49 INVEGA TRINZ INJ 546MG... 49 INVEGA TRINZ INJ 819MG... 49 INVIRASE CAP 200MG... 11 INVIRASE TAB 500MG... 11 INVOKAMET TAB 150-1000... 62 INVOKAMET TAB 150-500... 62 INVOKAMET TAB 50-1000... 62 INVOKAMET TAB 50-500MG... 62 INVOKAMET XR TAB 150-1000... 62 INVOKAMET XR TAB 150-500... 62 INVOKAMET XR TAB 50-1000... 62 INVOKAMET XR TAB 50-500MG... 62 INVOKANA TAB 100MG... 63 INVOKANA TAB 300MG... 63 iodine solution strong 5% (lugol's)... 73 ipratropium bromide inhal soln 0.02%. 93 ipratropium bromide nasal soln 0.03% (21 mcg/spray)... 96 ipratropium bromide nasal soln 0.06% (42 mcg/spray)... 96 ipratropium-albuterol nebu soln 0.5-2.5(3) /3ml... 93 irbesartan tab 150... 26 irbesartan tab 300... 26 irbesartan tab 75... 26 irbesartan-hydrochlorothiazide tab 150-12.5... 26 irbesartan-hydrochlorothiazide tab 300-12.5... 26 IRESSA TAB 250MG... 19 irinotecan hcl inj 500 /25ml (20 /ml)... 22 iron combination cap... 89 iron polysacch complex-vit b12-fa cap 150-0.025-1... 89 iron-folic acid-vit c-vit b6-vit b12-zinc tab 150-1.25... 89 IROSPAN 24/6 MIS... 89 irrigation solution, physiological... 103 ISENTRESS CHW 100MG... 10 ISENTRESS CHW 25MG... 10 ISENTRESS HD TAB 600MG... 10 ISENTRESS POW 100MG... 10 ISENTRESS TAB 400MG... 10 isoniazid syrup 50 /5ml... 12 isoniazid tab 100... 12 isoniazid tab 300... 12 ISORDIL TAB 40MG... 36 isosorbide dinitrate tab 10... 36 isosorbide dinitrate tab 20... 36 isosorbide dinitrate tab 30... 36 isosorbide dinitrate tab 5... 36 isosorbide dinitrate tab er 40... 36 isosorbide mononitrate tab 10... 36 isosorbide mononitrate tab 20... 36 isosorbide mononitrate tab er 24hr 120... 36 isosorbide mononitrate tab er 24hr 30... 36 isosorbide mononitrate tab er 24hr 60... 36 isotretinoin cap 10... 98 isotretinoin cap 20... 98 isotretinoin cap 30... 98 isotretinoin cap 40... 98 isradipine cap 2.5... 31 isradipine cap 5... 31 ISTALOL SOL 0.5% OP... 106 ISUPREL INJ 0.2MG/ML... 95 itraconazole cap 100... 9 ivermectin tab 3... 14 IXEMPRA KIT INJ 15MG... 21 IXEMPRA KIT INJ 45MG... 21 J JADENU TAB 180MG... 83 JADENU TAB 360MG... 83 JADENU TAB 90MG... 83 JAKAFI TAB 10MG... 19 JAKAFI TAB 15MG... 19 132

JAKAFI TAB 20MG... 19 JAKAFI TAB 25MG... 19 JAKAFI TAB 5MG... 19 JANUMET TAB 50-1000... 61 JANUMET TAB 50-500MG... 61 JANUMET XR TAB 100-1000... 61 JANUMET XR TAB 50-1000... 61 JANUMET XR TAB 50-500MG... 61 JANUVIA TAB 100MG... 61 JANUVIA TAB 25MG... 61 JANUVIA TAB 50MG... 61 JARDIANCE TAB 10MG... 63 JARDIANCE TAB 25MG... 63 JENTADUETO TAB 2.5-1000... 61 JENTADUETO TAB 2.5-500... 61 JENTADUETO TAB 2.5-850... 61 JENTADUETO TAB XR... 61 JEVTANA INJ 60/1.5ML... 21 JUXTAPID CAP 10MG... 29 JUXTAPID CAP 20MG... 29 JUXTAPID CAP 30MG... 29 JUXTAPID CAP 40MG... 29 JUXTAPID CAP 5MG... 29 JUXTAPID CAP 60MG... 29 JYNARQUE PAK 45-15MG... 74 JYNARQUE PAK 60-30MG... 74 JYNARQUE PAK 90-30MG... 74 K KALBITOR INJ 10MG/ML... 83 KALETRA TAB 100-25MG... 11 KALETRA TAB 200-50MG... 11 KALYDECO PAK 50MG... 95 KALYDECO PAK 75MG... 95 KALYDECO TAB 150MG... 95 KANUMA INJ 20/10ML... 71 KENALOG-10 INJ 10MG/ML... 68 KENALOG-40 INJ 40MG/ML... 68 KEPIVANCE INJ 6.25MG... 78 KEPPRA INJ 500/5ML... 41 KEPPRA SOL 100MG/ML... 41 KEPPRA TAB 1000MG... 41 KEPPRA TAB 250MG... 41 KEPPRA TAB 500MG... 41 KEPPRA TAB 750MG... 41 KEPPRA XR TAB 500MG... 41 KEPPRA XR TAB 750MG... 41 ketoconazole cream 2%... 99 ketoconazole shampoo 2%... 99 ketoprofen cap er 24hr 200... 2 ketorolac tromethamine ophth soln 0.4%... 105 ketorolac tromethamine ophth soln 0.5%... 105 ketorolac tromethamine tab 10... 2 KEVEYIS TAB 50MG... 34 KHEDEZLA TAB 100MG ER... 44 KHEDEZLA TAB 50MG ER... 44 KISQALI 200 PAK FEMARA... 19 KISQALI 400 PAK FEMARA... 19 KISQALI 600 PAK FEMARA... 19 KISQALI TAB 200DOSE... 19 KISQALI TAB 400DOSE... 19 KISQALI TAB 600DOSE... 19 KLOR-CON M15 TAB 15MEQ ER... 88 KORLYM TAB 300MG... 71 K-PHOS TAB... 87 K-PHOS TAB NEUTRAL... 87 K-PHOS TAB NO 2... 87 KUVAN POW 100MG... 72 KUVAN POW 500MG... 72 KUVAN TAB 100MG... 72 KYNAMRO INJ 200MG/ML... 29 KYPROLIS SOL 30MG... 21 KYPROLIS SOL 60MG... 21 L labetalol hcl iv soln 5 /ml... 30 labetalol hcl tab 100... 30 labetalol hcl tab 200... 30 labetalol hcl tab 300... 30 LACRISERT MIS 5MG OP... 106 lactated ringer's for irrigation... 103 lactic acid (ammonium lactate) cream 12%... 101 lactic acid (ammonium lactate) lotion 10%... 101 lactulose (encephalopathy) solution 10 gm/15ml... 78 lactulose solution 10 gm/15ml... 77 lamivudine oral soln 10 /ml... 12 lamivudine tab 100 (hbv)... 13 lamivudine tab 150... 12 lamivudine tab 300... 12 lamivudine-zidovudine tab 150-300... 10 lamotrigine tab 100... 41 lamotrigine tab 150... 41 133

lamotrigine tab 200... 41 lamotrigine tab 25... 41 lamotrigine tab chewable dispersible 25... 41 lamotrigine tab chewable dispersible 5... 41 LANCET CARRY MIS CASE... 64 LANCETS MIS... 64 LANCING DEVI MIS... 64 LANOXIN INJ 0.25MG/1... 33 LANOXIN PED INJ 0.1MG/ML... 33 LANOXIN TAB 0.125MG... 33 LANOXIN TAB 0.25MG... 33 LANTUS INJ 100/ML... 62 LANTUS INJ SOLOSTAR... 62 latanoprost ophth soln 0.005%... 107 LATUDA TAB 120MG... 49 LATUDA TAB 20MG... 49 LATUDA TAB 40MG... 49 LATUDA TAB 60MG... 49 LATUDA TAB 80MG... 49 LAZANDA SPR 100MCG... 4 LAZANDA SPR 300MCG... 4 LAZANDA SPR 400MCG... 4 leflunomide tab 10... 85 leflunomide tab 20... 85 LEMTRADA INJ 12/1.2ML... 57 LENVIMA CAP 10 MG... 19 LENVIMA CAP 14 MG... 19 LENVIMA CAP 18 MG... 19 LENVIMA CAP 20 MG... 19 LENVIMA CAP 24 MG... 19 LENVIMA CAP 8 MG... 19 LETAIRIS TAB 10MG... 37 LETAIRIS TAB 5MG... 37 letrozole tab 2.5... 17 leucovorin calcium for inj 500... 21 leucovorin calcium tab 10... 21 leucovorin calcium tab 15... 21 leucovorin calcium tab 25... 21 leucovorin calcium tab 5... 21 LEUKERAN TAB 2MG... 15 LEUKINE INJ 250MCG... 82 leuprolide acetate inj kit 5 /ml... 17 levalbuterol hcl soln nebu 0.31 /3ml (base equiv)... 95 levalbuterol hcl soln nebu 0.63 /3ml (base equiv)... 95 levalbuterol hcl soln nebu 1.25 /3ml (base equiv)... 95 levalbuterol hcl soln nebu conc 1.25 /0.5ml (base equiv)... 95 levalbuterol tartrate inhal aerosol 45 mcg/act (base equiv)... 95 LEVEMIR INJ... 62 LEVEMIR INJ FLEXTOUC... 62 levetiracetam inj 500 /5ml (100 /ml)... 41 levetiracetam oral soln 100 /ml... 41 levetiracetam tab 1000... 41 levetiracetam tab 250... 41 levetiracetam tab 500... 41 levetiracetam tab 750... 41 levetiracetam tab er 24hr 500... 41 levetiracetam tab er 24hr 750... 41 levobunolol hcl ophth soln 0.5%... 106 levocarnitine oral soln 1 gm/10ml (10%)... 71 levocarnitine tab 330... 71 levocetirizine dihydrochloride soln 2.5 /5ml (0.5 /ml)... 93 levocetirizine dihydrochloride tab 5 93 levofloxacin ophth soln 0.5%... 104 levofloxacin oral soln 25 /ml... 7 LEVOTHYROXIN INJ 200MCG... 73 levothyroxine sodium for iv inj 100 mcg... 73 levothyroxine sodium for iv inj 500 mcg... 73 levothyroxine sodium tab 100 mcg... 73 levothyroxine sodium tab 112 mcg... 73 levothyroxine sodium tab 125 mcg... 73 levothyroxine sodium tab 137 mcg... 73 levothyroxine sodium tab 150 mcg... 73 levothyroxine sodium tab 175 mcg... 73 levothyroxine sodium tab 200 mcg... 73 levothyroxine sodium tab 25 mcg... 73 levothyroxine sodium tab 300 mcg... 73 levothyroxine sodium tab 50 mcg... 73 levothyroxine sodium tab 75 mcg... 73 levothyroxine sodium tab 88 mcg... 73 LEVSIN INJ 0.5MG/ML... 76 LEXIVA SUS 50MG/ML... 11 LEXIVA TAB 700MG... 11 lidocaine hcl cream 3%... 101 lidocaine hcl gel 2%... 102 134

lidocaine hcl iv inj 10 /ml... 27 lidocaine hcl iv inj 20 /ml... 27 lidocaine hcl laryngotracheal soln 4% 103 LIDOCAINE HCL LOTION 3%... 102 lidocaine hcl soln 4%... 102 lidocaine hcl viscous soln 2%... 103 lidocaine iv infusion in d5w inj 4 /ml... 27 lidocaine iv infusion in d5w inj 8 /ml... 27 lidocaine oint 5%... 102 lidocaine patch 5%... 101 lidocaine-hydrocortisone acetate rectal cream 3-0.5%... 79 lidocaine-hydrocortisone acetate rectal cream kit 2-2%... 79 lidocaine-hydrocortisone acetate rectal cream kit 3-0.5%... 79 lidocaine-hydrocortisone acetate rectal cream kit 3-1%... 79 lidocaine-hydrocortisone acetate rectal gel kit 3-2.5%... 79 lidocaine-prilocaine cream 2.5-2.5%. 102 lidocaine-prilocaine cream kit 2.5-2.5%... 102 LIDODERM DIS 5%... 101 lindane shampoo 1%... 102 linezolid for susp 100 /5ml... 14 linezolid tab 600... 14 LINZESS CAP 145MCG... 77 LINZESS CAP 290MCG... 77 LINZESS CAP 72MCG... 77 LIORESAL INT INJ 0.05MG/1... 58 LIORESAL INT INJ 10MG/20... 58 LIORESAL INT INJ 10MG/5ML... 58 LIORESAL INT INJ 40MG/20... 58 liothyronine sodium iv soln 10 mcg/ml 73 liothyronine sodium tab 25 mcg... 73 liothyronine sodium tab 5 mcg... 73 liothyronine sodium tab 50 mcg... 73 lisinopril & hydrochlorothiazide tab 10-12.5... 23 lisinopril & hydrochlorothiazide tab 20-12.5... 23 lisinopril & hydrochlorothiazide tab 20-25... 24 lisinopril tab 10... 24 lisinopril tab 2.5... 24 lisinopril tab 20... 24 lisinopril tab 30... 24 lisinopril tab 40... 24 lisinopril tab 5... 24 lithium carbonate cap 150... 57 lithium carbonate cap 300... 57 lithium carbonate cap 600... 57 lithium carbonate tab 300... 57 lithium carbonate tab er 300... 57 lithium carbonate tab er 450... 57 LITHIUM SOL 8MEQ/5ML... 57 LO LOESTRIN TAB 1-10-10... 66 LOKELMA PAK 10GM... 72 LOKELMA PAK 5GM... 72 LONSURF TAB 15-6.14... 21 LONSURF TAB 20-8.19... 21 loperamide hcl cap 2... 75 LOPID TAB 600MG... 28 lopinavir-ritonavir soln 400-100 /5ml (80-20 /ml)... 11 lorazepam conc 2 /ml... 39 lorazepam inj 2 /ml... 39 lorazepam inj 4 /ml... 39 lorazepam tab 0.5... 39 lorazepam tab 1... 39 lorazepam tab 2... 39 losartan potassium & hydrochlorothiazide tab 100-12.5... 26 losartan potassium & hydrochlorothiazide tab 100-25... 26 losartan potassium & hydrochlorothiazide tab 50-12.5... 26 losartan potassium tab 100... 26 losartan potassium tab 25... 26 losartan potassium tab 50... 26 LOTEMAX GEL 0.5%... 105 LOTEMAX OIN 0.5%... 105 LOTEMAX SUS 0.5%... 105 LOTRONEX TAB 0.5MG... 77 LOTRONEX TAB 1MG... 77 lovastatin tab 10... 29 lovastatin tab 20... 29 lovastatin tab 40... 29 LOVAZA CAP 1GM... 29 loxapine succinate cap 10... 49 loxapine succinate cap 25... 49 loxapine succinate cap 5... 49 loxapine succinate cap 50... 49 135

LUCEMYRA TAB 0.18MG... 59 LUCENTIS SOL 0.3MG... 106 LUCENTIS SOL 0.5MG... 106 LUMIGAN SOL 0.01%... 107 LUPANETA KIT 11.25-5... 66 LUPANETA KIT 3.75-5... 66 LUPR DEP-PED INJ 11.25MG... 71 LUPR DEP-PED INJ 15MG... 71 LUPR DEP-PED INJ 3M 30MG... 71 LUPR DEP-PED INJ 7.5MG... 71 LUPRON DEPOT INJ 11.25MG... 17 LUPRON DEPOT INJ 22.5MG... 17 LUPRON DEPOT INJ 3.75MG... 17 LUPRON DEPOT INJ 30MG... 17 LUPRON DEPOT INJ 45MG... 17 LUPRON DEPOT INJ 7.5MG... 17 LYNPARZA CAP 50MG... 21 LYRICA CAP 100MG... 55 LYRICA CAP 150MG... 55 LYRICA CAP 200MG... 55 LYRICA CAP 225MG... 55 LYRICA CAP 25MG... 54 LYRICA CAP 300MG... 55 LYRICA CAP 50MG... 55 LYRICA CAP 75MG... 55 LYRICA SOL 20MG/ML... 55 LYSODREN TAB 500MG... 21 M MACUGEN INJ... 106 MAGNEBIND TAB 400... 89 MAKENA INJ 250MG/ML... 72 malathion lotion 0.5%... 103 mannitol iv soln 25%... 80 maprotiline hcl tab 25... 43 maprotiline hcl tab 50... 43 maprotiline hcl tab 75... 44 MARNATAL-F CAP... 90 MARPLAN TAB 10MG... 43 MATULANE CAP 50MG... 21 MAVYRET TAB 100-40MG... 13 MAXIDEX SUS 0.1% OP... 105 m-clear wc liq 100-6.3... 94 meclizine hcl tab 12.5... 75 meclizine hcl tab 25... 75 meclofenamate sodium cap 100... 2 meclofenamate sodium cap 50... 2 medroxyprogesterone acetate tab 10... 72 medroxyprogesterone acetate tab 2.5... 72 medroxyprogesterone acetate tab 5... 72 mefenamic acid cap 250... 2 megestrol acetate susp 40 /ml... 18 megestrol acetate tab 20... 18 megestrol acetate tab 40... 18 MEKINIST TAB 0.5MG... 19 MEKINIST TAB 2MG... 19 meloxicam tab 15... 2 meloxicam tab 7.5... 2 melphalan hcl for inj 50 (base equiv)... 15 memantine hcl oral solution 2 /ml.. 43 memantine hcl tab 10... 43 memantine hcl tab 5... 43 memantine hcl tab 5 (28) & 10 (21) titration pak... 43 MEMBRANEBLUE SOL 0.15%... 107 M-END PE LIQ... 94 MENEST TAB 0.3MG... 67 MENEST TAB 0.625MG... 67 MENEST TAB 1.25MG... 67 MENOSTAR DIS 14MCG... 67 meperidine hcl oral soln 50 /5ml... 4 meperidine hcl tab 100... 4 meperidine hcl tab 50... 4 MEPHYTON TAB 5MG... 89 meprobamate tab 200... 39 meprobamate tab 400... 39 MEPRON SUS... 14 mercaptopurine tab 50... 16 mesalamine enema 4 gm... 77 mesalamine tab delayed release 1.2 gm... 77 MESNEX TAB 400MG... 21 MESTINON SYP 60MG/5ML... 58 METAFOLBIC TAB PLUS... 87 metaproterenol sulfate syrup 10 /5ml... 95 metaproterenol sulfate tab 10... 95 metaproterenol sulfate tab 20... 95 metaxalone tab 800... 58 metformin hcl tab 1000... 61 metformin hcl tab 500... 61 metformin hcl tab 850... 61 metformin hcl tab er 24hr 500... 61 136

metformin hcl tab er 24hr 750... 61 methadone hcl soln 10 /5ml... 4 methadone hcl soln 5 /5ml... 4 methadone hcl tab 10... 4 methadone hcl tab 5... 4 methadone hcl tab for oral susp 40. 4 methamphetamine hcl tab 5... 53 methazolamide tab 25... 34 methazolamide tab 50... 34 methenamine hippurate tab 1 gm... 80 methenamine-hyosc-meth blue-benz acid-phenyl sal tab 81.6... 80 methimazole tab 10... 73 methimazole tab 5... 73 methocarbamol inj 1000 /10ml... 58 methocarbamol tab 500... 58 methocarbamol tab 750... 58 methotrexate sodium for inj 1 gm... 16 methotrexate sodium inj 250 /10ml (25 /ml)... 16 methotrexate sodium inj 50 /2ml (25 /ml)... 16 methotrexate sodium inj pf 1000 /40ml (25 /ml)... 17 methotrexate sodium inj pf 250 /10ml (25 /ml)... 16 methotrexate sodium inj pf 50 /2ml (25 /ml)... 16 methotrexate sodium tab 2.5 (base equiv)... 17 methoxsalen rapid cap 10... 99 methscopolamine bromide tab 2.5. 76 methscopolamine bromide tab 5... 76 methyclothiazide tab 5... 34 methyldopa & hydrochlorothiazide tab 250-15... 35 methyldopa & hydrochlorothiazide tab 250-25... 35 methyldopa tab 250... 35 methyldopa tab 500... 35 methyldopate hcl inj 250 /5ml... 35 methylergonovine maleate inj 0.2 /ml... 71 methylphenidate hcl cap er 10 (cd) 53 methylphenidate hcl cap er 20 (cd) 53 methylphenidate hcl cap er 24hr 20 (la)... 54 methylphenidate hcl cap er 24hr 30 (la)... 54 methylphenidate hcl cap er 24hr 40 (la)... 54 methylphenidate hcl cap er 30 (cd) 54 methylphenidate hcl cap er 40 (cd) 54 methylphenidate hcl cap er 50 (cd) 54 methylphenidate hcl cap er 60 (cd) 54 methylphenidate hcl chew tab 10.. 54 methylphenidate hcl chew tab 2.5. 54 methylphenidate hcl chew tab 5... 54 methylphenidate hcl soln 10 /5ml.. 54 methylphenidate hcl soln 5 /5ml... 54 methylphenidate hcl tab 10... 54 methylphenidate hcl tab 20... 54 methylphenidate hcl tab 5... 54 methylphenidate hcl tab er 10... 54 methylphenidate hcl tab er 24hr 18... 54 methylphenidate hcl tab er 24hr 27... 54 methylphenidate hcl tab er 24hr 36... 54 methylphenidate hcl tab er 24hr 54... 54 methylphenidate hcl tab er osmotic release (osm) 18... 54 methylphenidate hcl tab er osmotic release (osm) 27... 54 methylphenidate hcl tab er osmotic release (osm) 36... 54 methylphenidate hcl tab er osmotic release (osm) 54... 54 METHYLPR ACE INJ 80MG/ML... 68 methylprednisolone acetate inj susp 40 /ml... 68 methylprednisolone acetate inj susp 80 /ml... 69 methylprednisolone sod succ for inj 1000 (base equiv)... 69 methylprednisolone sod succ for inj 125 (base equiv)... 69 methylprednisolone sod succ for inj 40 (base equiv)... 69 methylprednisolone tab 16... 69 methylprednisolone tab 32... 69 methylprednisolone tab 4... 69 methylprednisolone tab 8... 69 methylprednisolone tab therapy pack 4 137

(21)... 69 methyltestosterone cap 10... 60 metipranolol ophth soln 0.3%... 106 metoclopramide hcl inj 5 /ml (base equivalent)... 75 metoclopramide hcl soln 5 /5ml (10 /10ml) (base equiv)... 75 metoclopramide hcl tab 10 (base equivalent)... 75 metoclopramide hcl tab 5 (base equivalent)... 75 metolazone tab 10... 35 metolazone tab 2.5... 34 metolazone tab 5... 34 metoprolol & hydrochlorothiazide tab 100-25... 30 metoprolol & hydrochlorothiazide tab 100-50... 30 metoprolol & hydrochlorothiazide tab 50-25... 30 metoprolol succinate tab er 24hr 100 (tartrate equiv)... 31 metoprolol succinate tab er 24hr 200 (tartrate equiv)... 31 metoprolol succinate tab er 24hr 25 (tartrate equiv)... 31 metoprolol succinate tab er 24hr 50 (tartrate equiv)... 31 metoprolol tartrate iv soln 5 /5ml... 31 metoprolol tartrate tab 100... 31 metoprolol tartrate tab 25... 31 metoprolol tartrate tab 50... 31 metronidazole cap 375... 14 metronidazole cream 0.75%... 102 metronidazole gel 0.75%... 102 metronidazole lotion 0.75%... 102 metronidazole tab 250... 14 metronidazole tab 500... 14 metronidazole vaginal gel 0.75%... 81 mexiletine hcl cap 150... 27 mexiletine hcl cap 200... 27 mexiletine hcl cap 250... 27 MIACALCIN INJ 200/ML... 65 midazolam hcl inj 10 /10ml (base equivalent)... 55 midazolam hcl inj 10 /2ml (base equivalent)... 55 midazolam hcl inj 2 /2ml (base equivalent)... 55 midazolam hcl inj 25 /5ml (base equivalent)... 55 midazolam hcl inj 5 /5ml (base equivalent)... 55 midazolam hcl inj 5 /ml (base equivalent)... 55 midazolam hcl inj 50 /10ml (base equivalent)... 55 midazolam hcl syrup 2 /ml (base equivalent)... 55 midodrine hcl tab 10... 35 midodrine hcl tab 2.5... 35 midodrine hcl tab 5... 35 miglitol tab 100... 60 miglitol tab 25... 60 miglitol tab 50... 60 MILLIPRED DP PAK 5MG... 69 milrinone lactate in dextrose 5% iv soln 20 /100ml... 35 milrinone lactate in dextrose 5% iv soln 40 /200ml... 35 milrinone lactate iv soln 10 /10ml (base equivalent)... 36 milrinone lactate iv soln 20 /20ml (base equivalent)... 36 milrinone lactate iv soln 50 /50ml (base equivalent)... 36 MINIVELLE DIS 0.025MG... 67 MINIVELLE DIS 0.0375MG... 67 MINIVELLE DIS 0.05MG... 67 MINIVELLE DIS 0.075MG... 67 MINIVELLE DIS 0.1MG... 67 MINOCIN CAP 50MG... 9 minocycline hcl cap 100... 9 minocycline hcl cap 50... 9 minocycline hcl cap 75... 9 minocycline hcl tab 100... 9 minocycline hcl tab 50... 9 minocycline hcl tab 75... 9 minoxidil tab 10... 36 minoxidil tab 2.5... 36 MIOSTAT INJ 0.01% OP... 107 mirtazapine orally disintegrating tab 15... 44 mirtazapine orally disintegrating tab 30... 44 mirtazapine orally disintegrating tab 45 138

... 44 mirtazapine tab 15... 44 mirtazapine tab 30... 44 mirtazapine tab 45... 44 mirtazapine tab 7.5... 44 MIRVASO GEL 0.33%... 102 misoprostol tab 100 mcg... 78 misoprostol tab 200 mcg... 78 mitomycin for iv soln 20... 21 mitomycin for iv soln 40... 21 mitomycin for iv soln 5... 21 mitoxantrone hcl inj conc 20 /10ml (2 /ml)... 21 mitoxantrone hcl inj conc 25 /12.5ml (2 /ml)... 21 mitoxantrone hcl inj conc 30 /15ml (2 /ml)... 21 modafinil tab 100... 59 modafinil tab 200... 59 moexipril hcl tab 15... 24 moexipril hcl tab 7.5... 24 moexipril-hydrochlorothiazide tab 15-12.5... 24 moexipril-hydrochlorothiazide tab 15-25... 24 moexipril-hydrochlorothiazide tab 7.5-12.5... 24 MOI-STIR SOL... 103 mometasone furoate cream 0.1%... 101 mometasone furoate oint 0.1%... 101 mometasone furoate solution 0.1% (lotion)... 101 MONSELS FERR SOL SUBSULF... 83 montelukast sodium chew tab 4 (base equiv)... 95 montelukast sodium chew tab 5 (base equiv)... 95 montelukast sodium oral granules packet 4 (base equiv)... 95 montelukast sodium tab 10 (base equiv)... 96 MORPHINE SUL SUP 30MG... 4 morphine sulfate oral soln 10 /5ml.. 4 morphine sulfate oral soln 100 /5ml (20 /ml)... 4 morphine sulfate oral soln 20 /5ml.. 4 morphine sulfate suppos 10... 4 morphine sulfate suppos 20... 4 morphine sulfate suppos 5... 4 morphine sulfate tab 15... 4 morphine sulfate tab 30... 4 morphine sulfate tab er 100... 4 morphine sulfate tab er 15... 4 morphine sulfate tab er 200... 4 morphine sulfate tab er 30... 4 morphine sulfate tab er 60... 4 MOUTHKOTE SOL... 103 MOVANTIK TAB 12.5MG... 78 MOVANTIK TAB 25MG... 78 MOXEZA SOL 0.5%... 104 moxifloxacin hcl ophth soln 0.5% (base equiv)... 104 moxifloxacin hcl tab 400 (base equiv)... 7 MOZOBIL INJ... 84 MULTAQ TAB 400MG... 27 MULTI-LANCET KIT DEVICE... 64 mupirocin calcium cream 2%... 99 mupirocin oint 2%... 99 MUSTARGEN INJ 10MG... 15 M-VIT TAB 27-1MG... 90 MYALEPT INJ 11.3MG... 71 mycophenolate mofetil cap 250... 86 mycophenolate mofetil for oral susp 200 /ml... 86 mycophenolate mofetil tab 500... 86 mycophenolate sodium tab dr 180 (mycophenolic acid equiv)... 86 mycophenolate sodium tab dr 360 (mycophenolic acid equiv)... 86 MYLERAN TAB 2MG... 15 MYNATAL CAP... 91 MYNATAL TAB... 91 MYNATAL TAB ADVANCE... 91 MYNATAL-Z TAB... 91 MYNATE 90 TAB PLUS... 91 MYRBETRIQ TAB 25MG... 80 MYRBETRIQ TAB 50MG... 80 N nabumetone tab 500... 2 nabumetone tab 750... 2 nadolol & bendroflumethiazide tab 40-5... 30 nadolol & bendroflumethiazide tab 80-5... 30 nadolol tab 20... 31 139

nadolol tab 40... 31 nadolol tab 80... 31 NAGLAZYME INJ 1MG/ML... 70 naloxone hcl inj 0.4 /ml... 59 naloxone hcl inj 4 /10ml... 59 naloxone hcl soln cartridge 0.4 /ml. 59 naloxone hcl soln prefilled syringe 2 /2ml... 59 naltrexone hcl tab 50... 59 naproxen sodium tab 275... 2 naproxen sodium tab 550... 2 naproxen susp 125 /5ml... 2 naproxen tab 250... 2 naproxen tab 375... 2 naproxen tab 500... 2 naproxen tab ec 375... 2 naproxen tab ec 500... 2 naratriptan hcl tab 1 (base equiv).. 56 naratriptan hcl tab 2.5 (base equiv)... 56 NARCAN SPR... 59 NATACHEW CHW... 91 NATACYN SUS 5% OP... 105 nateglinide tab 120... 62 nateglinide tab 60... 62 NATELLE ONE CAP... 91 NATPARA INJ 100MCG... 66 NATPARA INJ 25MCG... 66 NATPARA INJ 50MCG... 66 NATPARA INJ 75MCG... 66 NATRECOR INJ 1.5MG... 36 NATURE THROI TAB 162.5MG... 73 NATURE-THROI TAB 113.75MG... 73 NATURE-THROI TAB 130MG... 73 NATURE-THROI TAB 146.25MG... 73 NATURE-THROI TAB 16.25MG... 73 NATURE-THROI TAB 195MG... 73 NATURE-THROI TAB 260MG... 73 NATURE-THROI TAB 32.5MG... 73 NATURE-THROI TAB 325MG... 74 NATURE-THROI TAB 48.75MG... 73 NATURE-THROI TAB 81.25MG... 73 NATURE-THROI TAB 97.5MG... 73 NEBUPENT INH 300MG... 14 NEBUSAL NEB 6%... 96 NEEVO DHA CAP 27-1.13... 91 neomycin sulfate tab 500... 6 neomycin-bacitrac zn-polymyx 5(3.5)-400unt-10000unt op oin... 104 neomycin-polymy-gramicid op sol 1.75-10000-0.025-unt-/ml... 104 neomycin-polymyxin b gu irrigation soln... 79 neomycin-polymyxin-dexamethasone ophth oint 0.1%... 104 neomycin-polymyxin-dexamethasone ophth susp 0.1%... 104 neomycin-polymyxin-hc ophth susp.. 104 neomycin-polymyxin-hc otic soln 1% 107 neomycin-polymyxin-hc otic susp 3.5 /ml-10000 unit/ml-1%... 107 NEORAL CAP 100MG... 87 NEORAL CAP 25MG... 86 NEORAL SOL 100MG/ML... 87 NEPHPLEX RX TAB... 89 NEPHRON FA TAB... 89 NERLYNX TAB 40MG... 19 NESTABS ABC MIS... 91 NESTABS DHA PAK... 91 NEULASTA INJ 6MG/0.6M... 82 NEUPOGEN INJ 300/0.5... 82 NEUPOGEN INJ 300MCG... 82 NEUPOGEN INJ 480/0.8... 82 NEUPOGEN INJ 480MCG... 82 NEURIN-SL SUB... 89 NEVANAC SUS 0.1%... 105 nevirapine tab 200... 11 nevirapine tab er 24hr 100... 11 nevirapine tab er 24hr 400... 11 NEWGEN TAB 32-1MG... 91 NEXAVAR TAB 200MG... 19 NEXTERONE INJ... 27 niacin tab er 1000 (antihyperlipidemic)... 29 niacin tab er 500 (antihyperlipidemic)... 29 niacin tab er 750 (antihyperlipidemic)... 29 NICADAN TAB... 89 nicardipine hcl cap 20... 31 nicardipine hcl cap 30... 31 nicardipine hcl iv soln 2.5 /ml... 32 NICOTROL INH... 60 NICOTROL NS SPR 10MG/ML... 60 nifedipine cap 20... 32 nifedipine tab er 24hr 30... 32 140

nifedipine tab er 24hr 60... 32 nifedipine tab er 24hr 90... 32 nifedipine tab er 24hr osmotic release 90... 32 NILANDRON TAB 150MG... 17 nimodipine cap 30... 32 NINLARO CAP 2.3MG... 21 NINLARO CAP 3MG... 21 NINLARO CAP 4MG... 21 NIPENT INJ 10MG... 22 nisoldipine tab er 24hr 17... 32 nisoldipine tab er 24hr 20... 32 nisoldipine tab er 24hr 25.5... 32 nisoldipine tab er 24hr 30... 32 nisoldipine tab er 24hr 34... 32 nisoldipine tab er 24hr 40... 32 nisoldipine tab er 24hr 8.5... 32 NITRO-BID OIN 2%... 36 NITRO-DUR DIS 0.1MG/HR... 36 NITRO-DUR DIS 0.2MG/HR... 36 NITRO-DUR DIS 0.3MG/HR... 36 NITRO-DUR DIS 0.4MG/HR... 37 NITRO-DUR DIS 0.6MG/HR... 37 NITRO-DUR DIS 0.8MG/HR... 37 nitrofurantoin macrocrystalline cap 100... 14 nitrofurantoin macrocrystalline cap 50... 14 nitrofurantoin monohydrate macrocrystalline cap 100... 14 NITROGLYCER INJ 5MG/ML... 36 nitroglycerin cap er 2.5... 36 nitroglycerin cap er 6.5... 36 nitroglycerin cap er 9... 36 nitroglycerin sl tab 0.3... 36 nitroglycerin sl tab 0.4... 36 nitroglycerin sl tab 0.6... 36 nitroglycerin td patch 24hr 0.1 /hr.. 37 nitroglycerin td patch 24hr 0.2 /hr.. 37 nitroglycerin td patch 24hr 0.4 /hr.. 37 nitroglycerin td patch 24hr 0.6 /hr.. 37 nitroglycerin tl soln 0.4 /spray (400 mcg/spray)... 36 NITROLINGUAL SPR PUMPSPRA... 36 NITROSTAT SUB 0.3MG... 36 NITROSTAT SUB 0.4MG... 36 NITROSTAT SUB 0.6MG... 36 NIVA-PLUS TAB... 91 NOCLOT-50 SOL ACD-A... 83 NORDITROPIN INJ 10/1.5ML... 70 NORDITROPIN INJ 15/1.5ML... 70 NORDITROPIN INJ 30/3ML... 70 NORDITROPIN INJ 5/1.5ML... 70 norethindrone acetate tab 5... 73 norethindrone acetate-ethinyl estradiol tab 0.5-2.5 mcg... 66 norethindrone acetate-ethinyl estradiol tab 1-5 mcg... 66 NORPACE CAP 100MG CR... 27 NORPACE CAP 150MG CR... 27 NORTHERA CAP 200MG... 36 NORTHERA CAP 300MG... 36 nortriptyline hcl cap 10... 46 nortriptyline hcl cap 25... 46 nortriptyline hcl cap 50... 46 nortriptyline hcl cap 75... 46 nortriptyline hcl soln 10 /5ml... 46 NORVASC TAB 10MG... 32 NORVASC TAB 2.5MG... 32 NORVASC TAB 5MG... 32 NORVIR CAP 100MG... 11 NORVIR SOL 80MG/ML... 11 NORVIR TAB 100MG... 11 NOVOFINE MIS 30GX8MM... 64 NOVOLIN INJ 70/30... 62 NOVOLIN N INJ U-100... 62 NOVOLIN R INJ U-100... 62 NOVOLOG INJ 100/ML... 62 NOVOLOG INJ FLEXPEN... 62 NOVOLOG INJ PENFILL... 62 NOVOLOG MIX INJ 70/30... 62 NOVOLOG MIX INJ FLEXPEN... 62 NOVOTWIST MIS 32GX5MM... 64 NOXAFIL SUS 40MG/ML... 9 NOXAFIL TAB 100MG... 9 NPLATE INJ 250MCG... 83 NPLATE INJ 500MCG... 83 NUCALA INJ 100MG... 96 NUEDEXTA CAP 20-10MG... 60 NULOJIX INJ 250MG... 87 NUMOISYN LOZ... 103 NUPLAZID TAB 17MG... 49 nystatin cream 100000 unit/gm... 99 nystatin oint 100000 unit/gm... 99 nystatin susp 100000 unit/ml... 9 nystatin tab 500000 unit... 9 141

nystatin topical powder 100000 unit/gm... 99 nystatin-triamcinolone cream 100000-0.1 unit/gm-%... 99 nystatin-triamcinolone oint 100000-0.1 unit/gm-%... 99 O OB COMPLETE CAP ONE... 91 OB COMPLETE CAP PETITE... 91 OB COMPLETE TAB... 91 OB COMPLETE TAB PREMIER... 91 OBIZUR INJ 500 UNIT... 82 OBSTETRIX EC TAB... 91 OBSTETRIX PAK DHA... 91 O-CAL FA TAB... 91 O-CAL TAB PRENATAL... 91 OCALIVA TAB 10MG... 78 OCALIVA TAB 5MG... 78 OCTAGAM INJ 10GM... 86 OCTAGAM INJ 1GM... 85 OCTAGAM INJ 2.5GM... 86 OCTAGAM INJ 25GM... 86 OCTAGAM INJ 2GM/20ML... 86 OCTAGAM INJ 5GM... 86 octreotide acetate inj 100 mcg/ml (0.1 /ml)... 71 octreotide acetate inj 1000 mcg/ml (1 /ml)... 71 octreotide acetate inj 200 mcg/ml (0.2 /ml)... 71 octreotide acetate inj 50 mcg/ml (0.05 /ml)... 71 octreotide acetate inj 500 mcg/ml (0.5 /ml)... 71 ODOMZO CAP 200MG... 22 OFEV CAP 100MG... 96 OFEV CAP 150MG... 96 ofloxacin ophth soln 0.3%... 104 ofloxacin otic soln 0.3%... 108 olanzapine for im inj 10... 50 olanzapine orally disintegrating tab 10... 50 olanzapine orally disintegrating tab 15... 50 olanzapine orally disintegrating tab 20... 50 olanzapine orally disintegrating tab 5... 50 olanzapine tab 10... 50 olanzapine tab 15... 50 olanzapine tab 2.5... 50 olanzapine tab 20... 50 olanzapine tab 5... 50 olanzapine tab 7.5... 50 olopatadine hcl nasal soln 0.6%... 96 olopatadine hcl ophth soln 0.1% (base equivalent)... 105 olopatadine hcl ophth soln 0.2% (base equivalent)... 105 OMECLAMOX- MIS PAK... 79 omega-3-acid ethyl esters cap 1 gm... 29 OMNIPRED SUS 1% OP... 105 ondansetron hcl inj 4 /2ml (2 /ml)... 75 ondansetron hcl inj 40 /20ml (2 /ml)... 75 ondansetron hcl oral soln 4 /5ml... 75 ondansetron hcl tab 24... 75 ondansetron hcl tab 4... 75 ondansetron hcl tab 8... 75 ondansetron orally disintegrating tab 4... 75 ondansetron orally disintegrating tab 8... 75 ONETOUCH KIT ULT MINI... 64 ONETOUCH KIT ULTRA 2... 64 ONETOUCH KIT ULTRALNK... 64 ONETOUCH KIT VERIO... 64 ONETOUCH KIT VERIO FL... 64 ONETOUCH KIT VERIO IQ... 64 ONETOUCH TES ULTRA BL... 64 ONETOUCH TES VERIO... 64 ONFI SUS 2.5MG/ML... 41 ONFI TAB 10MG... 41 ONFI TAB 20MG... 41 ORACIT SOL... 80 ORAMAGICRX SUS... 103 ORENITRAM TAB 0.125MG... 37 ORENITRAM TAB 0.25MG... 37 ORENITRAM TAB 1MG... 37 ORENITRAM TAB 2.5MG... 37 ORENITRAM TAB 5MG... 37 ORFADIN CAP 10MG... 70 ORFADIN CAP 2MG... 70 ORFADIN CAP 5MG... 70 ORFADIN SUS 4MG/ML... 70 142

ORKAMBI TAB 200-125... 95 orphenadrine citrate inj 30 /ml... 58 orphenadrine citrate tab er 12hr 100... 58 oseltamivir phosphate cap 30 (base equiv)... 13 oseltamivir phosphate cap 45 (base equiv)... 13 oseltamivir phosphate cap 75 (base equiv)... 13 oseltamivir phosphate for susp 6 /ml (base equiv)... 13 OSMOPREP TAB 1.5GM... 77 OTEZLA TAB 10/20/30... 86 OTEZLA TAB 30MG... 86 OTREXUP INJ 10MG... 85 OTREXUP INJ 12.5/0.4... 85 OTREXUP INJ 15MG... 85 OTREXUP INJ 17.5/0.4... 85 OTREXUP INJ 20MG... 85 OTREXUP INJ 22.5/0.4... 85 OTREXUP INJ 25MG... 85 oxaliplatin for iv inj 100... 15 oxaliplatin for iv inj 50... 15 oxaliplatin iv soln 100 /20ml... 15 oxaliplatin iv soln 50 /10ml... 15 oxaprozin tab 600... 2 oxazepam cap 10... 39 oxazepam cap 15... 39 oxazepam cap 30... 39 oxcarbazepine susp 300 /5ml (60 /ml)... 41 oxcarbazepine tab 150... 41 oxcarbazepine tab 300... 41 oxcarbazepine tab 600... 41 oxiconazole nitrate cream 1%... 99 OXSORALEN-UL CAP 10MG... 99 oxybutynin chloride syrup 5 /5ml... 80 oxybutynin chloride tab 5... 80 oxybutynin chloride tab er 24hr 10 80 oxybutynin chloride tab er 24hr 15 80 oxybutynin chloride tab er 24hr 5.. 80 oxycodone hcl cap 5... 4 oxycodone hcl conc 100 /5ml (20 /ml)... 4 oxycodone hcl soln 5 /5ml... 4 oxycodone hcl tab 10... 5 oxycodone hcl tab 15... 5 oxycodone hcl tab 20... 5 oxycodone hcl tab 30... 5 oxycodone hcl tab 5... 4 oxycodone hcl tab er 12hr deter 10. 5 oxycodone hcl tab er 12hr deter 15. 5 oxycodone hcl tab er 12hr deter 20. 5 oxycodone hcl tab er 12hr deter 30. 5 oxycodone hcl tab er 12hr deter 40. 5 oxycodone hcl tab er 12hr deter 60. 5 oxycodone hcl tab er 12hr deter 80. 5 oxycodone w/ acetaminophen tab 10-325... 5 oxycodone w/ acetaminophen tab 2.5-325... 5 oxycodone w/ acetaminophen tab 5-325... 5 oxycodone w/ acetaminophen tab 7.5-325... 5 oxycodone-aspirin tab 4.8355-325.. 5 oxycodone-ibuprofen tab 5-400... 5 OXYCONTIN TAB 10MG CR... 5 OXYCONTIN TAB 15MG CR... 5 OXYCONTIN TAB 20MG CR... 5 OXYCONTIN TAB 30MG CR... 5 OXYCONTIN TAB 40MG CR... 5 OXYCONTIN TAB 60MG CR... 5 OXYCONTIN TAB 80MG CR... 5 oxymorphone hcl tab 10... 5 oxymorphone hcl tab 5... 5 oxymorphone hcl tab er 12hr 10... 5 oxymorphone hcl tab er 12hr 15... 5 oxymorphone hcl tab er 12hr 20... 5 oxymorphone hcl tab er 12hr 30... 5 oxymorphone hcl tab er 12hr 40... 5 oxymorphone hcl tab er 12hr 5... 5 oxymorphone hcl tab er 12hr 7.5... 5 P paclitaxel iv conc 100 /16.7ml (6 /ml)... 22 paclitaxel iv conc 150 /25ml (6 /ml)... 22 paclitaxel iv conc 30 /5ml (6 /ml)... 22 paclitaxel iv conc 300 /50ml (6 /ml)... 22 paliperidone tab er 24hr 1.5... 50 paliperidone tab er 24hr 3... 50 paliperidone tab er 24hr 6... 50 143

paliperidone tab er 24hr 9... 50 PALYNZIQ INJ 10/0.5ML... 72 PALYNZIQ INJ 2.5/0.5... 72 PALYNZIQ INJ 20MG/ML... 72 pamidronate disodium for inj 30... 65 pamidronate disodium for inj 90... 65 pamidronate disodium iv soln 3 /ml 65 pamidronate disodium iv soln 9 /ml 65 PAMIDRONATE INJ 6MG/ML... 65 PANCREAZE CAP 10500UNT... 78 PANCREAZE CAP 16800UNT... 78 PANCREAZE CAP 21000UNT... 78 PANCREAZE CAP 4200UNIT... 78 PANRETIN GEL 0.1%... 102 papaverine hcl inj 30 /ml... 36 paricalcitol cap 1 mcg... 70 paricalcitol cap 2 mcg... 70 paricalcitol cap 4 mcg... 70 paromomycin sulfate cap 250... 6 paroxetine hcl tab 10... 45 paroxetine hcl tab 20... 45 paroxetine hcl tab 30... 45 paroxetine hcl tab 40... 45 paroxetine hcl tab er 24hr 12.5... 45 paroxetine hcl tab er 24hr 25... 45 paroxetine hcl tab er 24hr 37.5... 45 PASER GRA 4GM... 12 PATANASE SPR 0.6%... 96 PAXIL SUS 10MG/5ML... 45 PAZEO DRO 0.7%... 105 pediatric multiple vitamin w/ minerals & c drops 45 /ml... 89 pediatric multiple vitamins w/ fl-fe drops 0.25-10 /ml... 89 pediatric multiple vitamins w/ fl-fe drops 0.25-6 /ml... 89 pediatric multiple vitamins w/ fluoride chew tab 0.5... 90 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm... 77 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm... 77 peg 3350-kcl-sod bicarb-nacl for soln 420 gm... 77 PEGASYS INJ 180MCG/M... 86 PEGASYS INJ PROCLICK... 86 PEG-INTRON KIT 50MCG... 86 PEN NEEDLES MIS 31GX6MM... 64 penicillin v potassium for soln 125 /5ml... 8 penicillin v potassium for soln 250 /5ml... 8 penicillin v potassium tab 250... 8 penicillin v potassium tab 500... 8 PENLAC SOL 8%... 99 PENTASA CAP 250MG CR... 77 PENTASA CAP 500MG CR... 77 pentazocine w/ naloxone tab 50-0.5 5 pentoxifylline tab er 400... 83 PERFOROMIST NEB 20MCG... 94 perindopril erbumine tab 2... 24 perindopril erbumine tab 4... 24 perindopril erbumine tab 8... 24 PERJETA INJ 420/14ML... 22 permethrin cream 5%... 103 perphenazine tab 16... 51 perphenazine tab 2... 51 perphenazine tab 4... 51 perphenazine tab 8... 51 perphenazine-amitriptyline tab 2-10... 51 perphenazine-amitriptyline tab 2-25... 51 perphenazine-amitriptyline tab 4-10... 51 perphenazine-amitriptyline tab 4-25... 51 perphenazine-amitriptyline tab 4-50... 51 PERTZYE CAP 16000U... 78 PERTZYE CAP 8000UNIT... 78 phenazopyridine hcl tab 100... 80 phenazopyridine hcl tab 200... 80 phenelzine sulfate tab 15... 43 PHENOBARB INJ 65MG/ML... 41 phenobarbital elixir 20 /5ml... 41 phenobarbital sodium inj 130 /ml.. 41 phenobarbital tab 100... 42 phenobarbital tab 15... 41 phenobarbital tab 16.2... 41 phenobarbital tab 30... 41 phenobarbital tab 32.4... 41 phenobarbital tab 60... 41 phenobarbital tab 64.8... 42 phenobarbital tab 97.2... 42 PHENOL LIQ 89%... 99 144

phenoxybenzamine hcl cap 10... 25 PHENYLADE POW GMP... 87 phenylephrine hcl inj 10 /ml... 38 phenylephrine hcl ophth soln 10%... 107 phenylephrine hcl ophth soln 2.5%... 107 PHENYTEK CAP 200MG... 42 PHENYTEK CAP 300MG... 42 phenytoin chew tab 50... 42 phenytoin sodium extended cap 100... 42 phenytoin sodium extended cap 200... 42 phenytoin sodium extended cap 300... 42 phenytoin sodium inj 50 /ml... 42 phenytoin susp 125 /5ml... 42 PHOSPHOLINE SOL 0.125%OP... 107 PHOTOFRIN INJ 75MG... 22 PHYSOS SALIC INJ 1MG/ML... 65 pilocarpine hcl ophth soln 1%... 107 pilocarpine hcl ophth soln 4%... 107 pilocarpine hcl tab 5... 78 pilocarpine hcl tab 7.5... 78 pimozide tab 1... 51 pimozide tab 2... 51 pindolol tab 10... 31 pindolol tab 5... 31 pioglitazone hcl tab 15 (base equiv)... 61 pioglitazone hcl tab 30 (base equiv)... 61 pioglitazone hcl tab 45 (base equiv)... 61 pioglitazone hcl-glimepiride tab 30-2... 61 pioglitazone hcl-glimepiride tab 30-4... 61 pioglitazone hcl-metformin hcl tab 15-500... 61 pioglitazone hcl-metformin hcl tab 15-850... 61 piroxicam cap 10... 2 piroxicam cap 20... 2 PLEGRIDY INJ... 57 PLEGRIDY INJ PEN... 57 PLEGRIDY INJ STARTER... 57 PLEGRIDY PEN INJ STARTER... 57 PNV OB+DHA PAK... 91 PNV PRENATAL TAB PLUS... 91 PNV TABS TAB 29-1MG... 91 PNV-DHA CAP DOCUSATE... 91 PODOCON SOL 25%... 102 podofilox soln 0.5%... 102 polyethylene glycol 3350 oral powder. 78 polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1%... 104 POLY-VI-FLOR CHW 0.25MG... 90 POLY-VI-FLOR CHW 0.5MG... 90 POLY-VI-FLOR CHW 1MG... 90 POLY-VI-FLOR SUS /IRON... 90 POLY-VI-FLOR SUS 0.25/ML... 90 POMALYST CAP 1MG... 18 POMALYST CAP 2MG... 18 POMALYST CAP 3MG... 18 POMALYST CAP 4MG... 18 pot & sod citrates w/ cit ac soln 550-500-334 /5ml... 80 pot bicarbonate & chloride effer tab 25 meq... 88 pot phos monobasic w/sod phos di & monobas tab 155-852-130... 88 potassium bicarbonate effer tab 25 meq... 88 potassium chloride cap er 10 meq... 88 potassium chloride cap er 8 meq... 88 potassium chloride microencapsulated crys er tab 10 meq... 88 potassium chloride microencapsulated crys er tab 20 meq... 88 potassium chloride oral soln 10% (20 meq/15ml)... 88 potassium chloride oral soln 20% (40 meq/15ml)... 88 potassium chloride powder packet 20 meq... 88 potassium chloride tab er 10 meq... 88 potassium chloride tab er 20 meq (1500 )... 88 potassium chloride tab er 8 meq (600 )... 88 potassium citrate & citric acid powder pack 3300-1002... 80 potassium citrate & citric acid soln 1100-334 /5ml... 80 potassium citrate tab er 10 meq (1080 )... 80 145

potassium citrate tab er 15 meq (1620 )... 80 potassium citrate tab er 5 meq (540 )... 80 PR CREAM KIT... 102 PR NATAL 400 PAK... 91 PR NATAL 430 PAK... 91 PR NATAL 430 PAK EC... 91 pramipexole dihydrochloride tab 0.125... 47 pramipexole dihydrochloride tab 0.25... 47 pramipexole dihydrochloride tab 0.5... 47 pramipexole dihydrochloride tab 0.75... 47 pramipexole dihydrochloride tab 1. 48 pramipexole dihydrochloride tab 1.5... 48 pramipexole dihydrochloride tab er 24hr 0.375... 48 pramipexole dihydrochloride tab er 24hr 0.75... 48 pramipexole dihydrochloride tab er 24hr 1.5... 48 pramipexole dihydrochloride tab er 24hr 2.25... 48 pramipexole dihydrochloride tab er 24hr 3... 48 pramipexole dihydrochloride tab er 24hr 3.75... 48 pramipexole dihydrochloride tab er 24hr 4.5... 48 pramoxine-hc cream 1-2.5%... 100 prasugrel hcl tab 10 (base equiv).. 84 prasugrel hcl tab 5 (base equiv)... 84 pravastatin sodium tab 10... 29 pravastatin sodium tab 20... 29 pravastatin sodium tab 40... 29 pravastatin sodium tab 80... 29 prazosin hcl cap 1... 25 prazosin hcl cap 2... 25 prazosin hcl cap 5... 25 PRED MILD SUS 0.12% OP... 105 PRED-G S.O.P OIN OP... 104 PRED-G SUS OP... 104 prednicarbate cream 0.1%... 101 prednicarbate oint 0.1%... 101 prednisolone acetate ophth susp 1% 105 prednisolone sod phosph oral soln 6.7 /5ml (5 /5ml base)... 69 prednisolone sod phosphate oral soln 10 /5ml (base equiv)... 69 prednisolone sod phosphate oral soln 15 /5ml (base equiv)... 69 prednisolone sod phosphate oral soln 20 /5ml (base equiv)... 69 prednisolone sodium phosphate oral soln 25 /5ml (base eq)... 69 prednisolone syrup 15 /5ml (usp solution equivalent)... 69 prednisone oral soln 5 /5ml... 69 prednisone tab 1... 69 prednisone tab 10... 69 prednisone tab 2.5... 69 prednisone tab 20... 69 prednisone tab 5... 69 prednisone tab 50... 69 PREFERAOB MIS +DHA... 91 PREFEST TAB... 66 PREMARIN INJ 25MG... 66 PREMARIN TAB 0.3MG... 67 PREMARIN TAB 0.45MG... 67 PREMARIN TAB 0.625MG... 67 PREMARIN TAB 0.9MG... 67 PREMARIN TAB 1.25MG... 67 PREMARIN VAG CRE 0.625MG... 68 PREMPHASE TAB... 66 PREMPRO TAB.625-2.5... 66 PREMPRO TAB 0.3-1.5... 66 PREMPRO TAB 0.45-1.5... 66 PREMPRO TAB 0.625-5... 66 PRENAISSANCE CAP PLUS... 91 PRENAT PLUS TAB 27-1MG... 91 prenat w/o a w/fefum-methfol-fa-dha cap 27-0.6-0.4-300... 91 PRENATA CHW 29-1MG... 91 PRENATAL TAB 27-1MG... 91 PRENATAL TAB PLUS... 91 PRENATAL VIT TAB LOW IRON... 91 prenatal vit w/ dss-fe fumarate-fa tab 29-1... 91 prenatal vit w/ fe fumarate-fa chew tab 29-1... 91 prenatal vit w/ fe fumarate-fa tab 27-1... 91 146

prenatal vit w/ fe fumarate-fa tab 28-1... 91 prenatal vit w/ fe fum-methylfolate-fa tab 27-0.6-0.4... 91 PRENATAL+FE TAB 29-1MG... 91 PRENATAL-U CAP 106.5-1... 91 PRENATE AM TAB 1MG... 92 PRENATE CAP ENHANCE... 92 PRENATE CAP PIXIE... 92 PRENATE CAP RESTORE... 92 PRENATE CHW 0.6-0.4... 92 PRENATE DHA CAP... 92 PRENATE MINI CAP... 92 PRENATE TAB ELITE... 92 PREPIDIL GEL 0.5MG/3G... 71 PREPLUS TAB 27-1MG... 92 PRETAB TAB 29-1MG... 92 PREVDNT 5000 PST 1.1%... 103 PREVDNT 5000 PST 1.1-5%... 103 PREVIDENT GEL 1.1%... 103 PREVIDENT GEL 1.1% BER... 103 PREVIDENT GEL 1.1% CHR... 103 PREVIDENT GEL 1.1% MIN... 103 PREVIDENT PST 5000 BST... 103 PREZCOBIX TAB 800-150... 10 PREZISTA SUS 100MG/ML... 11 PREZISTA TAB 150MG... 11 PREZISTA TAB 600MG... 11 PREZISTA TAB 75MG... 11 PREZISTA TAB 800MG... 11 PRIALT INJ 100MCG... 1 PRIALT INJ 25MCG/ML... 1 PRIALT INJ 500MCG... 1 PRIFTIN TAB 150MG... 12 primidone tab 250... 42 primidone tab 50... 42 PRIMSOL SOL 50MG/5ML... 14 PRISTIQ TAB 100MG... 44 PRISTIQ TAB 25MG... 44 PRISTIQ TAB 50MG... 44 PRIVIGEN INJ 10GRAMS... 86 PRIVIGEN INJ 20GRAMS... 86 PRIVIGEN INJ 40GRAMS... 86 PRIVIGEN INJ 5 GRAMS... 86 PROBUPHINE IMP KIT 74.2... 60 PROCAINAMIDE HCL INJ 500 MG/ML... 27 prochlorperazine edisylate inj 5 /ml 75 prochlorperazine maleate tab 10 (base equivalent)... 76 prochlorperazine maleate tab 5 (base equivalent)... 76 prochlorperazine suppos 25... 76 PROCRIT INJ 40000/ML... 82 PROCTOFOAM AER HC 1%... 79 PROCYSBI CAP 25MG... 80 PROCYSBI CAP 75MG... 80 PROFERRIN- TAB FORTE... 90 progesterone micronized cap 100. 73 progesterone micronized cap 200. 73 PROGLYCEM SUS 50MG/ML... 69 PROGRAF CAP 0.5MG... 87 PROGRAF CAP 1MG... 87 PROGRAF CAP 5MG... 87 PROGRAF INJ 5MG/ML... 87 PROLASTIN-C INJ 1000MG... 96 PROLENSA SOL 0.07%... 105 PROLEUKIN INJ 22MU... 22 PROLIA SOL 60MG/ML... 65 PROMACTA TAB 12.5MG... 83 PROMACTA TAB 25MG... 83 PROMACTA TAB 50MG... 83 PROMACTA TAB 75MG... 83 promethazine & phenylephrine syrup 6.25-5 /5ml... 93 promethazine hcl inj 25 /ml... 76 promethazine hcl inj 50 /ml... 76 promethazine hcl suppos 12.5... 76 promethazine hcl suppos 25... 76 promethazine hcl suppos 50... 76 promethazine hcl syrup 6.25 /5ml.. 76 promethazine hcl tab 12.5... 76 promethazine hcl tab 25... 76 promethazine hcl tab 50... 76 promethazine w/ codeine syrup 6.25-10 /5ml... 94 promethazine-dm syrup 6.25-15 /5ml... 94 propafenone hcl cap er 12hr 225.. 27 propafenone hcl cap er 12hr 325.. 27 propafenone hcl cap er 12hr 425.. 27 propafenone hcl tab 150... 27 propafenone hcl tab 225... 27 propafenone hcl tab 300... 27 propantheline bromide tab 15... 76 propranolol & hydrochlorothiazide tab 40-25... 30 147

propranolol & hydrochlorothiazide tab 80-25... 30 propranolol hcl cap er 24hr 120... 31 propranolol hcl cap er 24hr 160... 31 propranolol hcl cap er 24hr 60... 31 propranolol hcl cap er 24hr 80... 31 propranolol hcl inj 1 /ml... 31 propranolol hcl oral soln 20 /5ml... 31 propranolol hcl oral soln 40 /5ml... 31 propranolol hcl tab 10... 31 propranolol hcl tab 20... 31 propranolol hcl tab 40... 31 propranolol hcl tab 60... 31 propranolol hcl tab 80... 31 propylthiouracil tab 50... 73 PROSTIN E2 SUP 20MG... 71 protamine sulfate inj 10 /ml... 83 PROTOPAM CHL INJ 1GM... 65 protriptyline hcl tab 10... 47 protriptyline hcl tab 5... 47 PROVENTIL AER HFA... 95 PROVIDA DHA CAP... 92 PROVIDA OB CAP... 92 PROVIGIL TAB 100MG... 59 PROVIGIL TAB 200MG... 59 PROVISC INJ 1%... 107 PRUTECT EMU... 103 pseudoephed-bromphen-dm syrup 30-2-10 /5ml... 94 PULMICORT INH 180MCG... 97 PULMICORT INH 90MCG... 97 PULMOZYME SOL 1MG/ML... 95 PUREFE CAP PLUS... 90 PUREFE OB CAP PLUS... 92 pyrazinamide tab 500... 12 pyridostigmine bromide tab 60... 58 pyridostigmine bromide tab er 180 58 pyridoxine hcl inj 100 /ml... 90 Q quetiapine fumarate tab 100... 50 quetiapine fumarate tab 200... 50 quetiapine fumarate tab 25... 50 quetiapine fumarate tab 300... 50 quetiapine fumarate tab 400... 50 quetiapine fumarate tab 50... 50 QUFLORA PED CHW 0.25MG... 90 QUFLORA PED CHW 0.5MG... 90 QUFLORA PED CHW 1MG... 90 quinapril hcl tab 10... 24 quinapril hcl tab 20... 24 quinapril hcl tab 40... 24 quinapril hcl tab 5... 24 quinapril-hydrochlorothiazide tab 10-12.5... 24 quinapril-hydrochlorothiazide tab 20-12.5... 24 quinapril-hydrochlorothiazide tab 20-25... 24 quinidine sulfate tab 200... 27 quinidine sulfate tab 300... 27 QUTENZA KIT 8% 1-PCH... 102 QVAR REDIHA AER 80MCG... 97 QVAR REDIHAL AER 40MCG... 97 R ramipril cap 1.25... 24 ramipril cap 10... 25 ramipril cap 2.5... 24 ramipril cap 5... 25 RANEXA TAB 1000MG... 36 RANEXA TAB 500MG... 36 RAPAFLO CAP 4MG... 79 RAPAFLO CAP 8MG... 79 RAPAMUNE SOL 1MG/ML... 87 RAPAMUNE TAB 0.5MG... 87 RAPAMUNE TAB 1MG... 87 RAPAMUNE TAB 2MG... 87 rasagiline mesylate tab 0.5 (base equiv)... 48 rasagiline mesylate tab 1 (base equiv)... 48 RASUVO INJ 10MG... 85 RASUVO INJ 12.5MG... 85 RASUVO INJ 15MG... 85 RASUVO INJ 17.5MG... 85 RASUVO INJ 20MG... 85 RASUVO INJ 22.5MG... 85 RASUVO INJ 25MG... 85 RASUVO INJ 30MG... 85 RASUVO INJ 7.5MG... 85 RAVICTI LIQ 1.1GM/ML... 71 REBETOL SOL 40MG/ML... 13 REBIF INJ 22/0.5... 58 REBIF INJ 44/0.5... 58 REBIF REBIDO INJ 22/0.5... 58 REBIF REBIDO INJ 44/0.5... 58 REBIF REBIDO INJ TITRATN... 58 148

REBIF TITRTN INJ PACK... 58 RECTIV OIN 0.4%... 78 REDICHEW RX CHW... 92 REGENECARE GEL... 103 REGONOL INJ 5MG/ML... 57 RELENZA MIS DISKHALE... 13 RELNATE DHA CAP... 92 REMODULIN INJ 10MG/ML... 37 REMODULIN INJ 1MG/ML... 37 REMODULIN INJ 2.5MG/ML... 37 REMODULIN INJ 5MG/ML... 37 RENAGEL TAB 800MG... 72 REOPRO INJ 2MG/ML... 84 repaglinide tab 0.5... 62 repaglinide tab 1... 62 repaglinide tab 2... 62 repaglinide-metformin hcl tab 1-500... 62 repaglinide-metformin hcl tab 2-500... 62 REPATHA INJ 140MG/ML... 29 REPATHA PUSH INJ 420/3.5... 30 REPATHA SURE INJ 140MG/ML... 30 RESCRIPTOR TAB 100 MG... 11 RESCRIPTOR TAB 200MG... 11 RESECTISOL SOL 5%... 79 RESTASIS EMU 0.05%... 106 RETROVIR INJ 10MG/ML... 12 REVATIO TAB 20MG... 37 REVLIMID CAP 10MG... 18 REVLIMID CAP 15MG... 18 REVLIMID CAP 2.5MG... 18 REVLIMID CAP 20MG... 18 REVLIMID CAP 25MG... 18 REVLIMID CAP 5MG... 18 REYATAZ CAP 150MG... 11 REYATAZ CAP 200MG... 11 REYATAZ CAP 300MG... 11 REYATAZ POW 50MG... 11 RHOPRESSA SOL 0.02%... 107 ribavirin cap 200... 13 ribavirin tab 200... 13 ribavirin tab 400... 13 ribavirin tab 600... 13 rifabutin cap 150... 14 RIFAMATE CAP... 12 rifampin cap 150... 12 rifampin cap 300... 12 RIFATER TAB... 12 riluzole tab 50... 57 rimantadine hydrochloride tab 100 14 RIMSO-50 SOL 50%... 80 ringer's solution for irrigation... 103 RIOMET SOL... 61 risedronate sodium tab 150... 65 risedronate sodium tab 30... 65 risedronate sodium tab 35... 65 risedronate sodium tab 5... 65 risedronate sodium tab delayed release 35... 65 RISPERDAL INJ 12.5MG... 50 RISPERDAL INJ 25MG... 50 RISPERDAL INJ 37.5MG... 50 RISPERDAL INJ 50MG... 50 risperidone orally disintegrating tab 0.25... 50 risperidone orally disintegrating tab 0.5... 50 risperidone orally disintegrating tab 1... 50 risperidone orally disintegrating tab 2... 50 risperidone soln 1 /ml... 50 risperidone tab 0.25... 50 risperidone tab 0.5... 50 risperidone tab 1... 50 risperidone tab 2... 50 risperidone tab 3... 50 risperidone tab 4... 50 ritonavir tab 100... 11 RITUXAN INJ 100MG... 22 RITUXAN INJ 500MG... 22 rivastigmine tartrate cap 1.5 (base equivalent)... 43 rivastigmine tartrate cap 3 (base equivalent)... 43 rivastigmine tartrate cap 4.5 (base equivalent)... 43 rivastigmine tartrate cap 6 (base equivalent)... 43 rivastigmine td patch 24hr 13.3 /24hr... 43 rivastigmine td patch 24hr 4.6 /24hr... 43 rivastigmine td patch 24hr 9.5 /24hr... 43 149

rizatriptan benzoate oral disintegrating tab 10 (base eq)... 56 rizatriptan benzoate oral disintegrating tab 5 (base eq)... 56 rizatriptan benzoate tab 10 (base equivalent)... 56 rizatriptan benzoate tab 5 (base equivalent)... 56 ROCALTROL CAP 0.25MCG... 70 ROCALTROL CAP 0.5MCG... 70 ROCALTROL SOL 1MCG/ML... 70 ropinirole hydrochloride tab 0.25... 48 ropinirole hydrochloride tab 0.5... 48 ropinirole hydrochloride tab 1... 48 ropinirole hydrochloride tab 2... 48 ropinirole hydrochloride tab 3... 48 ropinirole hydrochloride tab 4... 48 ropinirole hydrochloride tab 5... 48 ropinirole hydrochloride tab er 24hr 12 (base equivalent)... 48 ropinirole hydrochloride tab er 24hr 2 (base equivalent)... 48 ropinirole hydrochloride tab er 24hr 4 (base equivalent)... 48 ropinirole hydrochloride tab er 24hr 6 (base equivalent)... 48 ropinirole hydrochloride tab er 24hr 8 (base equivalent)... 48 rosuvastatin calcium tab 10... 29 rosuvastatin calcium tab 20... 29 rosuvastatin calcium tab 40... 29 rosuvastatin calcium tab 5... 29 RUBRACA TAB 200MG... 22 RUBRACA TAB 250MG... 22 RUBRACA TAB 300MG... 22 RUCONEST INJ 2100UNIT... 83 RYDAPT CAP 25MG... 19 S SABRIL TAB 500MG... 42 salicylic acid cream 6%... 102 salicylic acid film forming liquid 27.5%... 102 salicylic acid lotion 6%... 102 salicylic acid shampoo 6%... 102 SALICYLIC ACID SOLN 26%... 102 salisol fort sol 26%... 102 salsalate tab 500... 2 salsalate tab 750... 2 SAMSCA TAB 15MG... 74 SAMSCA TAB 30MG... 74 SANCUSO DIS 3.1MG... 76 SANDIMMUNE CAP 100MG... 87 SANDIMMUNE CAP 25MG... 87 SANDIMMUNE INJ 50MG/ML... 87 SANDIMMUNE SOL 100MG/ML... 87 SANDOSTATIN INJ 100MCG... 71 SANDOSTATIN INJ 500MCG... 71 SANDOSTATIN INJ 50MCG/ML... 71 SANDOSTATIN KIT LAR 10MG... 71 SANDOSTATIN KIT LAR 20MG... 71 SANDOSTATIN KIT LAR 30MG... 71 SANTYL OIN 250/GM... 102 SAPHRIS SUB 10MG... 50 SAPHRIS SUB 2.5MG... 50 SAPHRIS SUB 5MG... 50 SAVELLA MIS TITR PAK... 55 SAVELLA TAB 100MG... 55 SAVELLA TAB 12.5MG... 55 SAVELLA TAB 25MG... 55 SAVELLA TAB 50MG... 55 scopolamine td patch 72hr 1 /3days... 76 SEEBRI NEOHA CAP 15.6MCG... 93 SELECT-OB CHW... 92 SELECT-OB+ PAK DHA... 92 selegiline hcl cap 5... 48 selegiline hcl tab 5... 48 selenium sulfide shampoo 2.25%... 99 SELZENTRY SOL 20MG/ML... 10 SELZENTRY TAB 150MG... 10 SELZENTRY TAB 300MG... 10 SE-NATAL 19 TAB... 92 SENSIPAR TAB 30MG... 65 SENSIPAR TAB 60MG... 65 SENSIPAR TAB 90MG... 65 SEREVENT DIS AER 50MCG... 94 SEROSTIM INJ 4MG... 70 SEROSTIM INJ 5MG... 70 SEROSTIM INJ 6MG... 70 sertraline hcl oral concentrate for solution 20 /ml... 45 sertraline hcl tab 100... 46 sertraline hcl tab 25... 46 sertraline hcl tab 50... 46 sevelamer carbonate packet 0.8 gm... 72 sevelamer carbonate packet 2.4 gm... 72 150

sevelamer carbonate tab 800... 72 SIGNIFOR INJ 0.3MG/ML... 71 SIGNIFOR INJ 0.6MG/ML... 71 SIGNIFOR INJ 0.9MG/ML... 71 SIGNIFOR LAR INJ 20MG... 71 SIGNIFOR LAR INJ 40MG... 71 SIGNIFOR LAR INJ 60MG... 71 sildenafil citrate tab 20... 37 SILVER NITRA OIN 10%... 102 SILVER NITRA SOL 0.5%... 102 SILVER NITRA SOL 10%... 102 SILVER NITRA SOL 25%... 102 SILVER NITRA SOL 50%... 102 silver sulfadiazine cream 1%... 99 SILVRSTAT GEL DRESSING... 103 SIMBRINZA SUS 1-0.2%... 106 SIMULECT INJ 10MG... 87 SIMULECT INJ 20MG... 87 simvastatin tab 10... 29 simvastatin tab 20... 29 simvastatin tab 40... 29 simvastatin tab 5... 29 simvastatin tab 80... 29 sirolimus tab 0.5... 87 sirolimus tab 1... 87 sirolimus tab 2... 87 SIRTURO TAB 100MG... 13 SIVEXTRO INJ 200MG... 14 SIVEXTRO TAB 200MG... 14 sodium chloride irrigation soln 0.9%... 79 sodium chloride soln nebu 0.9%... 96 sodium chloride soln nebu 10%... 96 sodium chloride soln nebu 3%... 96 sodium chloride soln nebu 7%... 96 sodium citrate & citric acid soln 500-334 /5ml... 80 sodium fluoride chew tab 1 f (from 2.2 naf)... 90 sodium fluoride cream 1.1%... 103 sodium fluoride gel 1.1% (0.5% f)... 103 sodium fluoride paste 1.1%... 103 sodium fluoride rinse 0.2%... 103 sodium fluoride tab 1 f (from 2.2 naf)... 90 sodium phenylbutyrate oral powder 3 gm/teaspoonful... 78 sodium phenylbutyrate tab 500... 71 sodium polystyrene sulfonate oral susp 15 gm/60ml... 72 sodium polystyrene sulfonate powder. 72 sodium thiosulfate inj 25%... 65 SOLIRIS INJ 10MG/ML... 83 SOLU-CORTEF INJ 1000MG... 69 SOLU-CORTEF INJ 100MG... 69 SOLU-CORTEF INJ 250MG... 69 SOLU-CORTEF INJ 500MG... 69 SOLU-MEDROL INJ 125MG... 69 SOLU-MEDROL INJ 1GM... 69 SOLU-MEDROL INJ 2GM... 69 SOLU-MEDROL INJ 40MG... 69 SOLU-MEDROL INJ 500MG... 69 SOMATULINE INJ 120/.5ML... 72 SOMATULINE INJ 60/0.2ML... 71 SOMATULINE INJ 90/0.3ML... 71 SOMAVERT INJ 10MG... 72 SOMAVERT INJ 15MG... 72 SOMAVERT INJ 20MG... 72 SOMAVERT INJ 25MG... 72 SOMAVERT INJ 30MG... 72 SONAFINE EMU... 103 sotalol hcl (afib/afl) tab 120... 27 sotalol hcl (afib/afl) tab 160... 27 sotalol hcl (afib/afl) tab 80... 27 sotalol hcl tab 120... 27 sotalol hcl tab 160... 27 sotalol hcl tab 240... 27 sotalol hcl tab 80... 27 SPIRIVA AER 1.25MCG... 93 SPIRIVA CAP HANDIHLR... 93 SPIRIVA SPR 2.5MCG... 93 spironolactone & hydrochlorothiazide tab 25-25... 35 spironolactone tab 100... 25 spironolactone tab 25... 25 spironolactone tab 50... 25 SPORANOX SOL 10MG/ML... 9 SPRYCEL TAB 100MG... 19 SPRYCEL TAB 140MG... 19 SPRYCEL TAB 20MG... 19 SPRYCEL TAB 50MG... 19 SPRYCEL TAB 70MG... 19 SPRYCEL TAB 80MG... 19 SSKI SOL 1GM/ML... 73 stavudine cap 15... 12 stavudine cap 20... 12 stavudine cap 30... 12 151

stavudine cap 40... 12 STELARA INJ 45MG/0.5... 84 STELARA INJ 5MG/ML... 84 STELARA INJ 90MG/ML... 84 STIMATE SOL 1.5MG/ML... 75 STIOLTO AER 2.5-2.5... 93 STIVARGA TAB 40MG... 19 STRATTERA CAP 100MG... 54 STRATTERA CAP 10MG... 54 STRATTERA CAP 18MG... 54 STRATTERA CAP 25MG... 54 STRATTERA CAP 40MG... 54 STRATTERA CAP 60MG... 54 STRATTERA CAP 80MG... 54 STRENSIQ INJ 18/0.45... 72 STRENSIQ INJ 28/0.7ML... 72 STRENSIQ INJ 40MG/ML... 72 STRENSIQ INJ 80/0.8ML... 72 STRIANT MIS 30MG... 60 STRIBILD TAB... 10 STRIVERDI AER 2.5MCG... 94 STROMECTOL TAB 3MG... 14 SUBOXONE MIS 12-3MG... 59 SUBOXONE MIS 2-0.5MG... 59 SUBOXONE MIS 4-1MG... 59 SUBOXONE MIS 8-2MG... 59 SUBSYS SPR 100MCG... 5 SUBSYS SPR 1200MCG... 5 SUBSYS SPR 1600MCG... 5 SUBSYS SPR 200MCG... 5 SUBSYS SPR 400MCG... 5 SUBSYS SPR 600MCG... 5 SUBSYS SPR 800MCG... 5 SUCRAID SOL 8500/ML... 78 sucralfate tab 1 gm... 78 SULAR TAB 17MG... 32 SULAR TAB 34MG... 32 SULAR TAB 8.5MG... 32 sulfacetamide sodium ophth oint 10%... 104 sulfacetamide sodium ophth soln 10%... 104 sulfacetamide sodium w/ sulfur emulsion 10-1%... 98 sulfacetamide sodium w/ sulfur wash 9-4.5%... 98 sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)%... 104 SULFADIAZINE TAB 500MG... 8 sulfamethoxazole-trimethoprim susp 200-40 /5ml... 8 sulfamethoxazole-trimethoprim tab 400-80... 8 sulfamethoxazole-trimethoprim tab 800-160... 8 SULFAMYLON CRE 85MG/GM... 102 sulfasalazine tab 500... 77 sulfasalazine tab delayed release 500... 77 sulindac tab 150... 2 sulindac tab 200... 2 sumatriptan nasal spray 20 /act... 56 sumatriptan nasal spray 5 /act... 56 sumatriptan succinate inj 6 /0.5ml. 56 sumatriptan succinate solution auto-injector 4 /0.5ml... 56 sumatriptan succinate solution auto-injector 6 /0.5ml... 56 sumatriptan succinate solution cartridge 4 /0.5ml... 56 sumatriptan succinate solution cartridge 6 /0.5ml... 56 sumatriptan succinate tab 100... 56 sumatriptan succinate tab 25... 56 sumatriptan succinate tab 50... 56 SUPPRELIN LA KIT 50MG... 72 SUPRAX CAP 400MG... 6 SUPRAX CHW 100MG... 6 SUPRAX CHW 200MG... 6 SUPRAX SUS 100/5ML... 7 SUPRAX SUS 200/5ML... 7 SUPRAX SUS 500/5ML... 7 SURESTEP PRO TES HIGH CON... 64 SURESTEP PRO TES NORM CON... 64 SURMONTIL CAP 100MG... 47 SURMONTIL CAP 25MG... 47 SURMONTIL CAP 50MG... 47 SUSTIVA CAP 200MG... 11 SUSTIVA CAP 50MG... 11 SUSTIVA TAB 600MG... 12 SUTENT CAP 12.5MG... 20 SUTENT CAP 25MG... 20 SUTENT CAP 37.5MG... 20 SUTENT CAP 50MG... 20 SYLATRON KIT 200MCG... 86 SYLATRON KIT 300MCG... 86 152

SYLATRON KIT 600MCG... 86 SYMAX DUOTAB TAB... 76 SYMBICORT AER 160-4.5... 97 SYMBICORT AER 80-4.5... 97 SYMDEKO TAB 100-150... 95 SYMLINPEN 60 INJ 1000MCG... 60 SYMLNPEN 120 INJ 1000MCG... 60 SYNAGIS INJ 100MG/ML... 87 SYNAGIS INJ 50MG... 87 SYNAREL SOL 2MG/ML... 66 SYNJARDY TAB... 62 SYNJARDY TAB 12.5-500... 62 SYNJARDY TAB 5-1000MG... 62 SYNJARDY TAB 5-500MG... 62 SYNJARDY XR TAB... 62 SYNJARDY XR TAB 10-1000... 62 SYNJARDY XR TAB 25-1000... 62 SYNJARDY XR TAB 5-1000MG... 62 SYNRIBO INJ 3.5MG... 22 SYNTHROID TAB 100MCG... 74 SYNTHROID TAB 112MCG... 74 SYNTHROID TAB 125MCG... 74 SYNTHROID TAB 137MCG... 74 SYNTHROID TAB 150MCG... 74 SYNTHROID TAB 175MCG... 74 SYNTHROID TAB 200MCG... 74 SYNTHROID TAB 25MCG... 74 SYNTHROID TAB 300MCG... 74 SYNTHROID TAB 50MCG... 74 SYNTHROID TAB 75MCG... 74 SYNTHROID TAB 88MCG... 74 SYPRINE CAP 250MG... 72 T TABLOID TAB 40MG... 17 tacrolimus cap 0.5... 87 tacrolimus cap 1... 87 tacrolimus cap 5... 87 tacrolimus oint 0.03%... 100 tacrolimus oint 0.1%... 100 TAFINLAR CAP 50MG... 20 TAFINLAR CAP 75MG... 20 TAGRISSO TAB 40MG... 20 TAGRISSO TAB 80MG... 20 TAMIFLU CAP 30MG... 14 TAMIFLU CAP 45MG... 14 TAMIFLU CAP 75MG... 14 TAMIFLU SUS 6MG/ML... 14 tamsulosin hcl cap 0.4... 79 TANDEM PLUS CAP... 90 TARCEVA TAB 100MG... 20 TARCEVA TAB 150MG... 20 TARCEVA TAB 25MG... 20 TARGRETIN GEL 1%... 22 TARKA TAB 2-180 CR... 23 TARKA TAB 2-240 CR... 23 TARKA TAB 4-240 CR... 23 TARON FORTE CAP... 90 TARON-C DHA CAP... 92 TARON-PREX CAP... 92 TASIGNA CAP 150MG... 20 TASIGNA CAP 200MG... 20 TASIGNA CAP 50MG... 20 tazarotene cream 0.1%... 98 TAZORAC CRE 0.05%... 98 TAZORAC CRE 0.1%... 98 TAZORAC GEL 0.05%... 98 TAZORAC GEL 0.1%... 98 TECFIDERA CAP 120MG... 58 TECFIDERA CAP 240MG... 58 TECFIDERA MIS STARTER... 58 TEGRETOL SUS 100/5ML... 42 TEGRETOL-XR TAB 100MG... 42 TEGRETOL-XR TAB 200MG... 42 TEGRETOL-XR TAB 400MG... 42 TEKTURNA HCT TAB 150-12.5... 34 TEKTURNA HCT TAB 150-25MG... 34 TEKTURNA HCT TAB 300-12.5... 34 TEKTURNA HCT TAB 300-25MG... 34 TEKTURNA TAB 150MG... 34 TEKTURNA TAB 300MG... 34 telmisartan tab 20... 26 telmisartan tab 40... 26 telmisartan tab 80... 26 telmisartan-amlodipine tab 40-10. 25 telmisartan-amlodipine tab 40-5... 25 telmisartan-amlodipine tab 80-10. 25 telmisartan-amlodipine tab 80-5... 25 telmisartan-hydrochlorothiazide tab 40-12.5... 26 telmisartan-hydrochlorothiazide tab 80-12.5... 26 telmisartan-hydrochlorothiazide tab 80-25... 26 temazepam cap 15... 55 temazepam cap 22.5... 55 temazepam cap 30... 55 153

temazepam cap 7.5... 55 TEMODAR CAP 100MG... 15 TEMODAR CAP 140MG... 15 TEMODAR CAP 180MG... 15 TEMODAR CAP 20MG... 15 TEMODAR CAP 250MG... 15 TEMODAR CAP 5MG... 15 TEMODAR INJ 100MG... 16 temozolomide cap 100... 16 temozolomide cap 140... 16 temozolomide cap 180... 16 temozolomide cap 20... 16 temozolomide cap 250... 16 temozolomide cap 5... 16 TENIPOSIDE INJ 50MG/5ML... 22 tenofovir disoproxil fumarate tab 300... 12 terazosin hcl cap 1 (base equivalent)... 25 terazosin hcl cap 10 (base equivalent)... 25 terazosin hcl cap 2 (base equivalent)... 25 terazosin hcl cap 5 (base equivalent)... 25 terbinafine hcl tab 250... 9 terbutaline sulfate inj 1 /ml... 95 terbutaline sulfate tab 2.5... 95 terbutaline sulfate tab 5... 95 terconazole vaginal suppos 80... 81 TESTIM GEL 1%(50MG)... 60 TESTOPEL MIS PELLETS... 60 testosterone cypionate im inj in oil 100 /ml... 60 testosterone cypionate im inj in oil 200 /ml... 60 testosterone enanthate im inj in oil 200 /ml... 60 testosterone td gel 10/act (2%)... 60 testosterone td gel 12.5 /act (1%). 60 testosterone td gel 50 /5gm (1%).. 60 tetrabenazine tab 12.5... 55 tetrabenazine tab 25... 55 tetracaine hcl ophth soln 0.5%... 107 tetracycline hcl cap 250... 9 tetracycline hcl cap 500... 9 TEXAVITE LQ LIQ... 90 THALOMID CAP 100MG... 18 THALOMID CAP 150MG... 18 THALOMID CAP 200MG... 18 THALOMID CAP 50MG... 18 THEO-24 CAP 100MG CR... 97 THEO-24 CAP 200MG CR... 97 THEO-24 CAP 300MG CR... 97 THEO-24 CAP 400MG ER... 97 theophylline soln 80 /15ml... 97 theophylline tab er 12hr 100... 97 theophylline tab er 12hr 200... 97 theophylline tab er 12hr 300... 97 theophylline tab er 12hr 450... 97 theophylline tab er 24hr 400... 97 theophylline tab er 24hr 600... 97 THERACYS INJ... 22 thiamine hcl inj 100 /ml... 90 THIOLA TAB 100MG... 80 thioridazine hcl tab 10... 51 thioridazine hcl tab 100... 51 thioridazine hcl tab 25... 51 thioridazine hcl tab 50... 51 thiothixene cap 1... 51 thiothixene cap 10... 52 thiothixene cap 2... 51 thiothixene cap 5... 52 THROMBAT III INJ 500UNIT... 83 THROMBIN-JMI KIT 20000UNT... 83 THYMOGLOBULN INJ 25MG... 86 THYROGEN INJ 1.1MG... 72 THYROLAR-1 TAB 60MG... 74 THYROLAR-1/2 TAB 30MG... 74 THYROLAR-1/4 TAB 15MG... 74 THYROLAR-2 TAB 120MG... 74 THYROLAR-3 TAB 180MG... 74 tiagabine hcl tab 12... 42 tiagabine hcl tab 16... 42 tiagabine hcl tab 2... 42 tiagabine hcl tab 4... 42 TICE BCG INJ... 22 TIGAN INJ 100MG/ML... 76 TIKOSYN CAP 125MCG... 27 TIKOSYN CAP 250MCG... 27 TIKOSYN CAP 500MCG... 28 timolol maleate ophth gel forming soln 0.25%... 106 timolol maleate ophth gel forming soln 0.5%... 106 timolol maleate ophth soln 0.25%... 106 154

timolol maleate ophth soln 0.5%... 106 timolol maleate ophth soln 0.5% (once-daily)... 106 timolol maleate tab 10... 31 timolol maleate tab 20... 31 timolol maleate tab 5... 31 TIMOPTIC OCU SOL 0.25% OP... 106 TIMOPTIC OCU SOL 0.5% OP... 106 TIROSINT CAP 100MCG... 74 TIROSINT CAP 112MCG... 74 TIROSINT CAP 125MCG... 74 TIROSINT CAP 137MCG... 74 TIROSINT CAP 13MCG... 74 TIROSINT CAP 150MCG... 74 TIROSINT CAP 25MCG... 74 TIROSINT CAP 50MCG... 74 TIROSINT CAP 75MCG... 74 TIROSINT CAP 88MCG... 74 TIVICAY TAB 10MG... 10 TIVICAY TAB 25MG... 10 TIVICAY TAB 50MG... 10 tizanidine hcl tab 2 (base equivalent)... 58 tizanidine hcl tab 4 (base equivalent)... 58 TL-SELECT CAP... 92 TOBI PODHALR CAP 28MG... 95 TOBRADEX OIN 0.3-0.1%... 104 TOBRADEX ST SUS 0.3-0.05... 104 tobramycin nebu soln 300 /5ml... 95 tobramycin ophth soln 0.3%... 104 tobramycin-dexamethasone ophth susp 0.3-0.1%... 104 TOBREX OIN 0.3% OP... 104 tolbutamide tab 500... 63 tolmetin sodium cap 400... 2 tolmetin sodium tab 200... 2 tolmetin sodium tab 600... 2 tolterodine tartrate cap er 24hr 2.. 80 tolterodine tartrate cap er 24hr 4.. 80 tolterodine tartrate tab 1... 80 tolterodine tartrate tab 2... 80 topiramate sprinkle cap 15... 42 topiramate sprinkle cap 25... 42 topiramate tab 100... 42 topiramate tab 200... 42 topiramate tab 25... 42 topiramate tab 50... 42 TOPOTECAN INJ 4MG/4ML... 22 TORISEL SOL 25MG/ML... 20 torsemide tab 10... 35 torsemide tab 100... 35 torsemide tab 20... 35 torsemide tab 5... 35 TOUJEO SOLO INJ 300IU/ML... 62 TRACLEER TAB 125MG... 37 TRACLEER TAB 62.5MG... 37 TRADJENTA TAB 5MG... 61 tramadol hcl tab 50... 5 tramadol hcl tab er 24hr 100... 5 tramadol hcl tab er 24hr 200... 6 tramadol hcl tab er 24hr 300... 6 tramadol-acetaminophen tab 37.5-325... 6 trandolapril tab 1... 25 trandolapril tab 2... 25 trandolapril tab 4... 25 trandolapril-verapamil hcl tab er 1-240... 23 trandolapril-verapamil hcl tab er 2-180... 23 trandolapril-verapamil hcl tab er 2-240... 23 trandolapril-verapamil hcl tab er 4-240... 23 tranexamic acid iv soln 1000 /10ml (100 /ml)... 82 tranexamic acid tab 650... 82 TRANSDERM-SC DIS 1.5MG... 76 tranylcypromine sulfate tab 10... 43 TRAVATAN Z DRO 0.004%... 107 trazodone hcl tab 100... 44 trazodone hcl tab 150... 44 trazodone hcl tab 300... 44 trazodone hcl tab 50... 44 TREANDA INJ 100MG... 16 TREANDA INJ 25MG... 16 TRECATOR TAB 250MG... 13 TRELSTAR MIX INJ 11.25MG... 17 TRELSTAR MIX INJ 22.5MG... 17 TRELSTAR MIX INJ 3.75MG... 17 TRESIBA FLEX INJ 100UNIT... 62 TRESIBA FLEX INJ 200UNIT... 62 tretinoin cap 10... 22 tretinoin cream 0.025%... 98 tretinoin cream 0.05%... 98 155

tretinoin cream 0.1%... 98 tretinoin gel 0.01%... 98 tretinoin gel 0.025%... 98 triamcinolone acetonide cream 0.025%... 101 triamcinolone acetonide cream 0.1%. 101 triamcinolone acetonide cream 0.5%. 100 triamcinolone acetonide dental paste 0.1%... 103 triamcinolone acetonide lotion 0.025%... 101 triamcinolone acetonide lotion 0.1%.. 101 triamcinolone acetonide oint 0.025%. 101 triamcinolone acetonide oint 0.1%... 101 triamcinolone acetonide oint 0.5%... 100 triamterene & hydrochlorothiazide cap 37.5-25... 35 triamterene & hydrochlorothiazide tab 37.5-25... 35 triamterene & hydrochlorothiazide tab 75-50... 35 triazolam tab 0.125... 55 triazolam tab 0.25... 55 TRICARE PRE CAP 27-1-500... 92 TRICARE TAB PRENATAL... 92 TRI-CHLOR LIQ 80%... 102 TRICITRASOL CON... 83 trientine hcl cap 250... 72 TRIESENCE INJ 40MG/ML... 105 trifluoperazine hcl tab 1 (base equivalent)... 52 trifluoperazine hcl tab 10 (base equivalent)... 52 trifluoperazine hcl tab 2 (base equivalent)... 52 trifluoperazine hcl tab 5 (base equivalent)... 52 trifluridine ophth soln 1%... 105 trihexyphenidyl hcl elixir 0.4 /ml... 48 trihexyphenidyl hcl tab 2... 48 trihexyphenidyl hcl tab 5... 48 TRILIPIX CAP 135MG... 28 TRILIPIX CAP 45MG... 28 trimethobenzamide hcl cap 300... 76 trimethoprim tab 100... 14 TRINTELLIX TAB 10MG... 46 TRINTELLIX TAB 20MG... 46 TRINTELLIX TAB 5MG... 46 TRIOSTAT INJ 10MCG/ML... 74 TRISTART DHA CAP... 92 TRI-TABS DHA MIS... 92 TRIUMEQ TAB... 10 TRI-VI-FLOR SUS 0.25/ML... 90 TRI-VI-FLOR SUS 0.5MG/ML... 90 TRIZIVIR TAB... 10 tropicamide ophth soln 0.5%... 107 tropicamide ophth soln 1%... 107 trospium chloride cap er 24hr 60.. 80 trospium chloride tab 20... 80 TRULICITY INJ 0.75/0.5... 61 TRULICITY INJ 1.5/0.5... 61 TRUVADA TAB 100-150... 10 TRUVADA TAB 133-200... 10 TRUVADA TAB 167-250... 10 TRUVADA TAB 200-300... 10 TUSSICAPS CAP 10-8MG... 94 TUSSICAPS CAP 5-4MG... 94 TYBOST TAB 150MG... 10 TYKERB TAB 250MG... 20 TYSABRI INJ 300/15ML... 58 TYVASO START SOL 0.6MG/ML... 37 U UCERIS AER 2MG/ACT... 77 UCERIS TAB 9MG... 77 ULESFIA LOT 5%... 103 ULORIC TAB 40MG... 1 ULORIC TAB 80MG... 1 ULTRAFLEX MIS 24"/10MM... 64 UPTRAVI TAB 1000MCG... 37 UPTRAVI TAB 1200MCG... 37 UPTRAVI TAB 1400MCG... 37 UPTRAVI TAB 1600MCG... 37 UPTRAVI TAB 200/800... 37 UPTRAVI TAB 200MCG... 37 UPTRAVI TAB 400MCG... 37 UPTRAVI TAB 600MCG... 37 UPTRAVI TAB 800MCG... 37 UROXATRAL TAB 10MG... 79 ursodiol cap 300... 77 ursodiol tab 250... 77 ursodiol tab 500... 77 UTIBRON CAP NEOHALER... 93 V VAGIFEM TAB 10MCG... 68 valacyclovir hcl tab 1 gm... 13 valacyclovir hcl tab 500... 13 156

VALCHLOR GEL 0.016%... 16 VALCYTE SOL 50MG/ML... 13 VALCYTE TAB 450MG... 13 valganciclovir hcl tab 450 (base equivalent)... 13 valproate sodium inj 100 /ml... 42 valproate sodium oral soln 250 /5ml (base equiv)... 42 valproic acid cap 250... 42 valsartan tab 160... 27 valsartan tab 320... 27 valsartan tab 40... 26 valsartan tab 80... 27 valsartan-hydrochlorothiazide tab 160-12.5... 26 valsartan-hydrochlorothiazide tab 160-25... 26 valsartan-hydrochlorothiazide tab 320-12.5... 26 valsartan-hydrochlorothiazide tab 320-25... 26 valsartan-hydrochlorothiazide tab 80-12.5... 26 vancomycin hcl cap 125 (base equivalent)... 14 vancomycin hcl cap 250 (base equivalent)... 14 VANCOMYCIN INJ 500MG... 14 VANCOMYCIN INJ 750MG... 14 VANTAS KIT 50MG... 17 VASCEPA CAP 1GM... 29 VECTIBIX INJ 100MG... 22 VECTIBIX INJ 400MG... 22 VELCADE INJ 3.5MG... 22 VELETRI INJ 0.5MG... 37 VELTASSA POW 16.8GM... 72 VELTASSA POW 25.2GM... 72 VELTASSA POW 8.4GM... 72 VENA-BAL MIS DHA... 92 VENCLEXTA TAB 100MG... 22 VENCLEXTA TAB 10MG... 22 VENCLEXTA TAB 50MG... 22 VENCLEXTA TAB START PK... 22 venlafaxine hcl cap er 24hr 150 (base equivalent)... 44 venlafaxine hcl cap er 24hr 37.5 (base equivalent)... 44 venlafaxine hcl cap er 24hr 75 (base equivalent)... 44 venlafaxine hcl tab 100... 45 venlafaxine hcl tab 25... 44 venlafaxine hcl tab 37.5... 44 venlafaxine hcl tab 50... 44 venlafaxine hcl tab 75... 45 venlafaxine hcl tab er 24hr 150 (base equivalent)... 45 venlafaxine hcl tab er 24hr 225 (base equivalent)... 45 venlafaxine hcl tab er 24hr 37.5 (base equivalent)... 45 venlafaxine hcl tab er 24hr 75 (base equivalent)... 45 VENOFER INJ 20MG/ML... 90 VENTAVIS SOL 10MCG/ML... 37 VENTAVIS SOL 20MCG/ML... 38 VENTOLIN HFA AER... 95 verapamil hcl cap er 24hr 100... 33 verapamil hcl cap er 24hr 120... 33 verapamil hcl cap er 24hr 180... 33 verapamil hcl cap er 24hr 200... 33 verapamil hcl cap er 24hr 240... 33 verapamil hcl cap er 24hr 300... 33 verapamil hcl cap er 24hr 360... 33 verapamil hcl iv soln 2.5 /ml... 33 verapamil hcl tab 120... 33 verapamil hcl tab 40... 33 verapamil hcl tab 80... 33 verapamil hcl tab er 120... 33 verapamil hcl tab er 180... 33 verapamil hcl tab er 240... 33 VERZENIO TAB 100MG... 20 VERZENIO TAB 150MG... 20 VERZENIO TAB 200MG... 20 VERZENIO TAB 50MG... 20 VESICARE TAB 10MG... 80 VESICARE TAB 5MG... 80 V-GO 20 KIT... 64 V-GO 30 KIT... 64 V-GO 40 KIT... 64 VIBERZI TAB 100MG... 77 VIBERZI TAB 75MG... 77 VIBRAMYCIN SYP 50MG/5ML... 9 VICTOZA INJ 18MG/3ML... 61 VIDEX SOL 2GM... 12 VIDEX SOL 4GM... 12 vigabatrin powd pack 500... 42 157

VIIBRYD KIT STARTER... 46 VIIBRYD TAB 10MG... 46 VIIBRYD TAB 20MG... 46 VIIBRYD TAB 40MG... 46 VIMIZIM INJ 5MG/5ML... 70 VIMPAT INJ 200MG/20... 42 VIMPAT SOL 10MG/ML... 42 VIMPAT TAB 100MG... 42 VIMPAT TAB 150MG... 42 VIMPAT TAB 200MG... 42 VIMPAT TAB 50MG... 42 VINATE II TAB... 92 VINATE M TAB... 92 VINATE ONE TAB... 92 vinblastine sulfate inj 1 /ml... 22 vincristine sulfate iv soln 1 /ml... 22 VIOKACE TAB 10440... 78 VIOKACE TAB 20880... 78 VIRACEPT TAB 250MG... 11 VIRACEPT TAB 625MG... 11 VIRAMUNE SUS 50MG/5ML... 12 VIREAD POW 40MG/GM... 12 VIREAD TAB 150MG... 12 VIREAD TAB 200MG... 12 VIREAD TAB 250MG... 12 VIREAD TAB 300MG... 12 VIRT-C DHA CAP... 92 VIRT-NATE CAP DHA... 92 VIRT-PN PLUS CAP... 92 VIRT-PN TAB... 92 VISUDYNE INJ 15MG... 107 VITAFOL CAP ULTRA... 92 VITAFOL FE+ CAP... 92 VITAFOL-NANO TAB... 92 VITAFOL-OB PAK +DHA... 92 VITAFOL-ONE CAP... 92 VITAMEDMD CAP ONE RX... 92 VITAPEARL CAP... 92 VITATRUE MIS... 92 VIVA DHA CAP... 92 VIVITROL INJ 380MG... 59 VOL-PLUS TAB... 92 VOL-TAB RX TAB... 92 VOLTAREN GEL 1%... 2 voriconazole for susp 40 /ml... 10 voriconazole tab 200... 10 voriconazole tab 50... 10 VOSEVI TAB... 13 VOTRIENT TAB 200MG... 20 VP-PNV-DHA CAP... 92 VPRIV INJ 400UNIT... 70 VYTORIN TAB 10-10MG... 29 VYTORIN TAB 10-20MG... 29 VYTORIN TAB 10-40MG... 29 VYTORIN TAB 10-80MG... 29 VYVANSE CAP 10MG... 54 VYVANSE CAP 20MG... 54 VYVANSE CAP 30MG... 54 VYVANSE CAP 40MG... 54 VYVANSE CAP 50MG... 54 VYVANSE CAP 60MG... 54 VYVANSE CAP 70MG... 54 W warfarin sodium tab 1... 81 warfarin sodium tab 10... 82 warfarin sodium tab 2... 81 warfarin sodium tab 2.5... 81 warfarin sodium tab 3... 81 warfarin sodium tab 4... 81 warfarin sodium tab 5... 81 warfarin sodium tab 6... 82 warfarin sodium tab 7.5... 82 water for irrigation, sterile irrigation soln... 103 WELCHOL PAK 3.75GM... 28 WELCHOL TAB 625MG... 28 WESTHROID TAB 130MG... 74 WESTHROID TAB 32.5MG... 74 WESTHROID TAB 97.5MG... 74 X XALKORI CAP 200MG... 20 XALKORI CAP 250MG... 20 XARELTO STAR TAB 15/20MG... 82 XARELTO TAB 10MG... 82 XARELTO TAB 15MG... 82 XARELTO TAB 20MG... 82 XELODA TAB 150MG... 17 XELODA TAB 500MG... 17 XENAZINE TAB 12.5MG... 55 XENAZINE TAB 25MG... 55 XEOMIN INJ 100UNIT... 57 XEOMIN INJ 200UNIT... 57 XEOMIN INJ 50 UNIT... 57 XGEVA INJ... 65 XIFAXAN TAB 200MG... 14 XIFAXAN TAB 550MG... 14 158

XOLAIR SOL 150MG... 96 XOPENEX HFA AER... 95 XTANDI CAP 40MG... 17 XYREM SOL 500MG/ML... 59 Y YERVOY INJ 200MG... 22 YERVOY INJ 50MG... 22 Z zafirlukast tab 10... 96 zafirlukast tab 20... 96 zaleplon cap 10... 56 zaleplon cap 5... 56 ZALTRAP INJ 100/4ML... 22 ZALTRAP INJ 200/8ML... 22 ZANOSAR INJ 1GM... 16 ZARXIO INJ 300/0.5... 82 ZARXIO INJ 480/0.8... 82 ZATEAN-PN CAP DHA... 92 ZATEAN-PN CAP PLUS... 93 ZAVESCA CAP 100MG... 71 ZEJULA CAP 100MG... 22 ZELBORAF TAB 240MG... 20 ZEMAIRA INJ 1000MG... 96 ZEMPLAR CAP 1MCG... 70 ZEMPLAR CAP 2MCG... 70 ZEVALIN KIT Y-90... 22 zidovudine cap 100... 12 zidovudine syrup 10 /ml... 12 zidovudine tab 300... 12 ZIOPTAN DRO 0.0015%... 107 ziprasidone hcl cap 20... 50 ziprasidone hcl cap 40... 50 ziprasidone hcl cap 60... 50 ziprasidone hcl cap 80... 50 ZIRGAN GEL 0.15%... 105 ZOLADEX IMP 10.8MG... 17 ZOLADEX IMP 3.6MG... 17 zoledronic acid inj conc for iv infusion 4 /5ml... 65 zoledronic acid iv soln 5 /100ml... 65 ZOLINZA CAP 100MG... 22 zolmitriptan orally disintegrating tab 2.5... 56 zolmitriptan orally disintegrating tab 5... 56 zolmitriptan tab 2.5... 56 zolmitriptan tab 5... 57 zolpidem tartrate tab 10... 56 zolpidem tartrate tab 5... 56 ZOMETA INJ 4MG/100... 65 ZOMIG SPR 2.5MG... 57 ZOMIG SPR 5MG... 57 zonisamide cap 100... 42 zonisamide cap 25... 42 zonisamide cap 50... 42 ZONTIVITY TAB 2.08MG... 84 ZORTRESS TAB 0.25MG... 87 ZORTRESS TAB 0.5MG... 87 ZORTRESS TAB 0.75MG... 87 Z-TUSS AC LIQ 2-9/5ML... 94 ZUBSOLV SUB 0.7-0.18... 59 ZUBSOLV SUB 1.4-0.36... 59 ZUBSOLV SUB 11.4-2.9... 60 ZUBSOLV SUB 2.9-0.71... 60 ZUBSOLV SUB 5.7-1.4... 60 ZUBSOLV SUB 8.6-2.1... 60 ZYDELIG TAB 100MG... 20 ZYDELIG TAB 150MG... 20 ZYKADIA CAP 150MG... 20 ZYLET SUS 0.5-0.3%... 104 ZYMAXID SOL 0.5%... 104 ZYPREXA RELP INJ 210MG... 50 ZYPREXA RELP INJ 300MG... 50 ZYPREXA RELP INJ 405MG... 50 ZYTIGA TAB 250MG... 17 ZYTIGA TAB 500MG... 17 159

Language Assistance Services Servicios de acceso al idioma English Spanish Navajo Vietnamese German Chinese Arabic Korean TagalogFilipino Japanese French Italian Russian Hindi Farsi Thai THNM-ID0049-1017 ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-855-769-6642 (TTY: 711). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-855-769-6642 (TTY: 711). é 1-855-769-6642 (TTY: 711.) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-855-769-6642 (TTY: 711). ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-855-769-6642 (TTY: 711). 注意 如果您使用繁體中文 您可以免費獲得語言援助服務 請致電 1-855-769-6642 TTY 711.)711: (رقم هاتف الصم والبكم 6642-769-855-1 اتصل برقم. فإن خدمات المساعدة اللغوية تتوافر لك بالمجان إذا كنت تتحدث اذكر اللغة : ملحوظة 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-855-769-6642 (TTY: 711) 번으로 전화해 주십시오. PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng a serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-855-769-6642 (TTY: 711). 注意事項 日本語を話される場合 無料の言語支援をご利用いただけます 1-855-769-6642 TTY: 711 まで お 電話にてご連絡ください ATTENTION: Si vous parlez français, des services d aide linguistique vous sont proposés gratuitement. Appelez le 1-855-7696642 (ATS : 711). ATTENZIONE: In caso la lingua parlata sia l italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-855-769-6642 (TTY: 711). ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-855-7696642 (телетайп: 711). ध य न द : यदद आप ह द ब लत ह त आपक ललए म फ त म भ ष सह यत स व ए उपलब ध ह 1-855-769-6642 (TTY: 711) पर क ल कर. تماس بگیرید 1-855-769-6642 (TTY: 711) با. تسهیالت زبانی بصورت رایگان برای شما فراهم می باشد اگر به زبان فارسی گفتگو می کنید : توجه เร ยน: ถ าค ณพ ดภาษาไทยค ณสามารถใช บร การช วยเหล อทางภาษาได ฟร โทร 1-855-769-6642 (TTY: 711).

Notice of Non-Discrimination and Accessibility Aviso de no discriminación y accesibilidad The following is a statement describing nondiscrimination for True Health New Mexico and the services it provides to its clients and members. We do not discriminate on the basis of race, color, national origin, age, disability, or gender in our health programs or activities. We provide help free of charge to people with disabilities or whose primary language is not English. To ask for a document in another format such as large print, or to get language help such as a qualified interpreter, please call True Health New Mexico Customer Service at 1-855-769-6642, Monday through Friday, 8:00 a.m. to 5:00 p.m. TTY: 1-800-659-8331. If you believe that we have failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or gender, you can send a complaint to: True Health New Mexico Compliance Hotline, 2440 Louisiana Blvd. NE, Suite 601, Albuquerque, NM 87110. Phone: 1-855-882-3904. Fax: 1-866-231-1344. You also have the right to file a complaint directly with the U.S. Dept. of Health and Human Services online, by phone, or by mail: Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf. Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. Phone: Toll-free: 1-800-368-1019, TDD: 1-800-537-7697 Mail: U.S. Dept. of Health & Human Services, 200 Independence Ave. SW, Room 509F, HHH Bldg., Washington, DC 20201 Aviso de no discriminación y accesibilidad A continuación presentamos una declaración que resume la norma de no discriminación de True Health New Mexico y los servicios que prestamos a nuestros clientes y asegurados. No discriminamos por la raza, el color, el origen nacional, la edad, las discapacidades o el sexo en nuestras actividades o programas de salud. Ayudamos gratuitamente a las personas que tienen discapacidades o cuyo idioma nativo no es el inglés. Para pedir un documento en otro formato, como en letra grande, o para recibir la ayuda de un intérprete calificado, favor de llamar al Centro de Atención al Cliente de True Health New Mexico al 1-855-769-6642, para los servicios TTY llame al 1-800-659-8331, de lunes a viernes, de las 8:00 de la mañana a las 5:00 de la tarde. Si usted cree que no hemos prestado estos servicios o que le hemos discriminado de alguna otra manera por su raza, color, origen nacional, edad, discapacidad o sexo, puede enviar una queja a: True Health New Mexico Compliance Hotline, 2440 Louisiana Blvd. NE, Suite 601, Albuquerque, NM 87110. Teléfono: 1-855-882-3904. Fax: 1-866-231-1344. Además tiene derecho a presentar una queja directamente al Departamento de Salud y Servicios Humanos de los EE. UU. [U.S. Dept. of Health and Human Services] ya sea en línea, por teléfono o por correo: En línea: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf. Los formularios de queja están a su disposición en: http://www.hhs.gov/ocr/office/file/index.html. Por teléfono: Línea telefónica gratis: 1-800-368-1019, TDD: 1-800-537-7697 Por correo: U.S. Dept. of Health & Human Services, 200 Independence Ave. SW, Room 509F, HHH Bldg., Washington, DC 20201 THNM-ID0050-1017

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