Providence prescription drug coverage

Transcription

1 Providence prescription drug coverage Providence Health Plan wants to help you to make the most of your prescription drug coverage. That s why we strive to provide you with the information you need to make smart decisions about medications. Know more, save more We encourage you to be knowledgeable about your prescription drug benefits. Information is available on your benefit summary, in your member handbook and on the Providence Health Plan website. When you require a prescription, be sure to let your doctor know cost matters to you. Choosing a generic when possible can help manage your costs. Retail pharmacies You have access to more than 25,000 participating pharmacies nationwide at discounted rates. Search the provider directory to locate participating pharmacies near you. Maintenance drugs Maintenance medications are those typically prescribed to treat long-term or chronic conditions, such as diabetes, high blood pressure and high cholesterol. A 90-day supply of maintenance medication is available through participating mail-order pharmacies, as well as through preferred retail pharmacies. Your 90-day supply copay or coinsurance applies. Not all covered prescription drugs are available in a 90-day supply. Learn more about mail-order pharmacies and preferred retail pharmacies. drugs drugs are prescriptions that require special delivery, handling, administration and monitoring by your pharmacist. These drugs are listed in the Providence formulary with a status of, and are available through Providence Pharmacy Services. Learn more about specialty drugs. drugs Making the switch from brand to generic medication can save you money. drugs, which are available only after the brand-name patent expires: Have the same active ingredient formula as the brand-name drug and Are tested by the Food and Drug Administration (FDA) to be as safe and effective as the brand-name drug. There are two types of generic drugs: equivalent - A generic equivalent is a generic drug that has the same active ingredient, dosage form and strength as its brand-name counterpart. The FDA assures i 1

2 sameness between brand-name and generic equivalent products. equivalents are an important option to brand-name prescription drugs because they cost less. Example: Zocor, a brand-name drug commonly used to treat high cholesterol, is now available in generic form under the name simvastatin. Zocor and simvastatin are identical drugs the only difference is that one costs more than the other. alternative - A generic alternative is a generic drug used to treat the same condition as a brand-name drug. It is not, however, the exact same medication as the brandname drug. According to clinical evidence, a generic alternative can be expected to treat the same condition as well as the brand-name option. Example: Simvastatin, the generic form of Zocor, may be prescribed instead of Crestor in the treatment of high cholesterol. alternatives are an important option for prescription drugs for which there is no generic available. Visit the Consumer Reports Best-Buy Drug website for more information regarding safe and effective drug treatment options. The Providence formulary Your prescription drug plan provides coverage for medications listed on the Providence formulary. Developed in collaboration with Providence Health Plans, physicians and pharmacists, the formulary includes FDA-approved prescription generic, brand-name and specialty medications. The formulary can help you and your physician choose effective, quality medications that minimize your out-ofpocket expense. Search the formulary There are two ways to search the formulary. They include: 1. By medical condition category (e.g., drugs used to treat heart conditions are listed under the category, Cardiovascular Agents); and 2. By index (provides an alphabetical listing of drugs included in the formulary). Formulary updates The formulary is updated every two months. Providence s Oregon Regional Pharmacy and Therapeutics committee (comprised of doctors and pharmacists who practice in the communities we serve) continuously reviews the latest evidence to identify opportunities to promote safe, effective and affordable drug therapy. Generally, the formulary status of a drug covered by your Providence Health Plan prescription drug coverage will not change during the year unless: The medication becomes available in generic form; There are safety or effectiveness concerns raised about the prescription drug; or The Pharmacy and Therapeutics committee determines that changes to the formulary would be in the best overall interest of Providence Health Plan members. ii 2

3 If a change to the formulary results in a reduction of benefits or an increase in member copay, affected individuals are notified in writing. Formulary brand-name drugs The Providence formulary includes prescription drugs that are proven safe, effective and that offer value. Refer to your benefit summary for your brand-name drug copay or coinsurance amount. Remember, even if a generic equivalent is not yet available, safe and effective generic alternatives may be available to treat most common conditions. Using these options can provide cost savings. Non-approved drugs Your prescription drug benefit covers only FDA-approved prescription drugs. It is possible for medications to be on the market without FDA approval. The FDA is taking action to ensure these drugs become approved or are removed from the market. In the meantime, many remain on pharmacy shelves. If the drug you are taking is not FDA approved, know that there are likely approved prescription drugs available to treat your condition. We encourage you to discuss alternative medications with your doctor. Should you and your doctor determine that there is no covered alternative and you choose to continue to take a medication that is not FDA approved, your health plan will not cover that expense. More information regarding medications that are not FDA approved can be found on our website, in the related article and in the FAQ document, which includes links to the FDA website. You may also call the Providence Health Plan pharmacy team for more information and to discuss potential alternatives. Prior authorization Prior authorization is a process to review a prescription drug for coverage before it is dispensed. The prior authorization process is initiated by the prescribing medical provider. Many factors including the potential for serious health risks, FDA-approved indications and costeffectiveness are considered before making the decision to require prior authorization of a prescription medication. A limited number of medications require prior authorization review; any medications requiring prior authorization are indicated as such in the Providence formulary. Keep in mind, the formulary may contain other suitable options. You and your doctor may wish to discuss the possibility of changing your prescription to an effective formulary alternative. Otherwise, your doctor may submit a prior authorization request on your behalf. Formulary exceptions There may be times that you require a medication that is not on the Providence formulary. If you currently take a prescription drug that is not on the formulary, contact customer service to confirm that drug is not covered. If the prescription drug is not covered, your doctor may request a formulary exception. iii 3

4 Step therapy Step therapy is a form of prior authorization. Its purpose is to confirm if drugs generally considered "first-line" therapy based on clinical evidence already have been tried. If they have, the drug requiring prior authorization will automatically be approved. In the event these drugs are not tried first, cannot be tried first or the individual s prescription medication history is not part of Providence Health Plan claims history, prior authorization is required. Quantity limit For certain drugs, Providence Health Plan limits the amount of the drug covered for a specified time frame [e.g., Providence Health Plan provides two inhalers per 30 days for Proair or Proventil HFA (albuterol HFA)]. Quantity limits are in place to ensure safe and appropriate use of a drug. Answers to frequently asked questions Learn more about your prescription drug coverage by reviewing answers to frequently asked questions. iv 4

5 Analgesics butalbital/acetaminophen butalbital/acetaminophen/caffeine ( tablet, tablet, capsule) butalbital/aspirin/caffeine capacet tencon mg tablet Nonsteroidal Anti-inflammatory Drugs CAMBIA celecoxib (50 mg capsule, 100 mg capsule, 200 mg capsule), QL (9 PER 30 DAYS), QL (2 PER DAY) celecoxib 400 mg capsule, QL (1 PER DAY) comfort pac-ibuprofen diclofenac potassium diclofenac sodium (25 mg tablet dr, 50 mg tablet dr, 75 mg tablet dr, 100 mg tab er 24h) diclofenac sodium/misoprostol 75 mg- 200 tab ir dr diflunisal etodolac (200 mg capsule, 300 mg capsule, 400 mg tab er 24h, 400 mg tablet, 500 mg tablet, 500 mg tab er 24h, 600 mg tab er 24h) fenoprofen calcium 600 mg tablet FLECTOR flurbiprofen (50 mg tablet, 100 mg tablet) ibuprofen (400 mg tablet, 600 mg tablet, 800 mg tablet) - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 5 LAST UPDATE 08/2015

6 ibuprofen/oxycodone hcl indomethacin (25 mg capsule, 50 mg capsule, 75 mg capsule er) ketoprofen (50 mg capsule, 75 mg capsule, 200 mg cap24h pel) ketorolac tromethamine 10 mg tablet meclofenamate sodium (50 mg capsule, 100 mg capsule) mefenamic acid 250 mg capsule meloxicam (7.5 mg tablet, 7.5 mg/5ml oral susp, 15 mg tablet) nabumetone (500 mg tablet, 750 mg tablet) naproxen (125 mg/5ml oral susp, 250 mg tablet, 375 mg tablet, 375 mg tablet dr, 500 mg tablet dr, 500 mg tablet) naproxen sodium (275 mg tablet, 550 mg tablet) oxaprozin piroxicam (10 mg capsule, 20 mg capsule) sulindac (150 mg tablet, 200 mg tablet) tolmetin sodium ZORVOLEX 35 MG CAPSULE Opioid Analgesics, Long-acting BUTRANS (5 TCH, 10 TCH, 20 TCH) BUTRANS (7.5 TCH, 15 TCH) fentanyl (12 mcg/hr patch td72, 25mcg/hr patch td72) fentanyl (75mcg/hr patch td72, 100 mcg/hr patch td72), QL (4 PER 28 DAYS), QL (4 PER 28 DAYS) QL (15 PER 30 DAYS) QL (5 PER 30 DAYS) - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 6 LAST UPDATE 08/2015

7 fentanyl 50mcg/hr patch td72 QL (10 PER 30 DAYS) fentanyl citrate (200 mcg lozenge hd, 400 mcg lozenge hd, 600 mcg lozenge hd, 800 mcg lozenge hd, 1200 mcg lozenge hd, 1600 mcg lozenge hd) hydromorphone hcl (8 mg tab er 24h, 12 mg tab er 24h, 16 mg tab er 24h, 32 mg tab er 24h) levorphanol tartrate 2 mg tablet methadone hcl (5 ml solution, 10 ml solution), QL (4 PER DAY), QL (1 PER DAY) QL (20 ML PER DAY) methadone hcl 10 mg tablet QL (120 PER 30 DAYS) methadone hcl 10 mg/ml oral conc QL (4 ML PER DAY) methadone hcl 40 mg tablet sol QL (30 PER 30 DAYS) methadone hcl 5 mg tablet QL (240 PER 30 DAYS) methadone intensol QL (4 ML PER DAY) methadose 40 mg tablet dispr QL (30 PER 30 DAYS) morphine sulfate (20 mg cap er pel, 30 mg cap er pel, 30 mg tablet er) morphine sulfate (50 mg cap er pel, 60 mg cap er pel, 60 mg tablet er) morphine sulfate (80 mg cap er pel, 100 mg cap er pel, 100 mg tablet er, 200 mg tablet er) QL (1 PER DAY) QL (2 PER DAY), QL (1 PER DAY) morphine sulfate 15 mg tablet er QL (3 PER DAY) NUCYNTA ER ONA ER oxycodone hcl (10 mg tab er 12h, 20 mg tab er 12h) oxycodone hcl 40 mg tab er 12h oxycodone hcl 80 mg tab er 12h, QL (60 PER 30 DAYS), QL (2 PER DAY), QL (3 PER DAY), QL (2 PER DAY), QL (1 PER DAY) - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 7 LAST UPDATE 08/2015

8 OXYCONTIN (10 MG TABLET, 15 MG TABLET, 20 MG TABLET) OXYCONTIN 30 MG TABLET OXYCONTIN 40 MG TABLET OXYCONTIN 60 MG TABLET OXYCONTIN 80 MG TABLET oxymorphone hcl (30 mg tab er 12h, 40 mg tab er 12h) oxymorphone hcl (5 mg tab er 12h, 7.5 mg tab er 12h, 10 mg tab er 12h, 15 mg tab er 12h, 20 mg tab er 12h) tramadol hcl (100 mg tbmp 24hr, 100 mg tab er 24h, 200 mg tbmp 24hr, 200 mg tab er 24h, 300 mg tab er 24h, 300 mg tbmp 24hr), QL (3 PER DAY), QL (2 PER DAY), QL (2 PER DAY), QL (1 PER DAY), QL (1 PER DAY), QL (1 PER DAY), QL (2 PER DAY) Opioid Analgesics, Short-acting acetaminophen with codeine phosphate (120-12mg/5 solution, 300mg/12.5 solution, 300mg-30mg tablet, 300mg- 60mg tablet, 300mg-15mg tablet) ( for ages 5 and under) ascomp with codeine ( for ages 5 and under) butalbit/acetamin/caff/codeine capsule ( for ages 5 and under) butorphanol tartrate 10 mg/ml spray QL (2.5 ML PER 30 DAYS) co-gesic codeine phosphate/butalbital/aspirin/caffeine ( for ages 5 and under) codeine phosphate/carisoprodol/aspirin ( for ages 5 and under) codeine sulfate (15 mg tablet, 30 mg tablet, 60 mg tablet) dihydrocodeine bitartrate/acetaminophen/caffeine ( for ages 5 and under) - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 8 LAST UPDATE 08/2015

9 endocet ( mg tablet, mg tablet) endocet ( mg tablet, tablet, mg tablet, mg tablet) endodan hydrocodone bitartrate/acetaminophen ( /5 solution, mg tablet, 5 mg-325mg tablet, 5 mg-500mg tablet, 5-334mg/10 solution, /15 solution, mg tablet, /15 solution, mg tablet, mg tablet, mg tablet, mg tablet, mg tablet, 10mg- 650mg tablet, 10mg-500mg tablet, 10mg-325mg tablet) hydrocodone/ibuprofen QL (8 PER DAY) hydromorphone hcl 1 mg/ml liquid QL (10 ML PER DAY) hydromorphone hcl 2 mg tablet QL (300 PER 30 DAYS) hydromorphone hcl 3 mg supp.rect hydromorphone hcl 4 mg tablet QL (240 PER 30 DAYS) hydromorphone hcl 8 mg tablet QL (120 PER 30 DAYS) ibudone mg tablet lorcet lorcet hd lorcet plus mg tablet lortab (5-325 mg tablet, tablet, mg tablet, mg tablet) meperidine hcl (50 mg tablet, 100 mg tablet) meperitab morphine sulfate (10 ml solution, 20 ml solution) morphine sulfate (5 mg supp.rect, 10 mg supp.rect, 20 mg supp.rect, 30 mg supp.rect) QL (30 ML PER DAY) - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 9 LAST UPDATE 08/2015

10 morphine sulfate 100 mg/5ml solution QL (5 ML PER DAY) morphine sulfate 15 mg tablet QL (8 PER DAY) morphine sulfate 30 mg tablet QL (4 PER DAY) NUCYNTA oxycodone hcl (20 mg/ml oral conc, 20 mg tablet) oxycodone hcl (5 mg capsule, 5 mg tablet) QL (4 PER DAY) QL (10 PER DAY) oxycodone hcl 10 mg tablet QL (8 PER DAY) oxycodone hcl 15 mg tablet QL (5 PER DAY) oxycodone hcl 30 mg tablet oxycodone hcl 5 mg/5 ml solution QL (50 ML PER DAY) oxycodone hcl/acetaminophen (10mg- 650mg tablet, 10mg-325mg tablet) oxycodone hcl/acetaminophen ( mg tablet, 5 mg-500mg capsule, 5 mg-325mg tablet, mg tablet, mg tablet) oxycodone hcl/aspirin QL (8 PER DAY) oxymorphone hcl 10 mg tablet, QL (4 PER DAY) oxymorphone hcl 5 mg tablet, QL (8 PER DAY) reprexain mg tablet ROXICET ORAL SOLUTION roxicet tablet stagesic tramadol hcl 50 mg tablet tramadol hcl/acetaminophen QL (8 PER DAY) VITUZ xylon 10 - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 10 LAST UPDATE 08/2015

11 Anesthetics Local Anesthetics glydo lidocaine 5 % oint. (g) lidocaine 5%(700mg) adh. patch, QL (90 PER 30 DAYS) lidocaine hcl (2 % solution, 2 % jel/pf app, 2 % jel (ml), 4 % solution, 40 mg/ml solution) lidocaine/prilocaine (2.5 %-2.5% cream (g), 2.5 %-2.5% kit) parcaine proparacaine hcl 0.5 % drops relador pak relador pak plus Anti-Addiction/Substance Abuse Treatment Agents Alcohol Deterrents/Anti-craving acamprosate calcium depade disulfiram (250 mg tablet, 500 mg tablet) naltrexone hcl 50 mg tablet revia Opioid Antagonists buprenorphine hcl (2 mg tab subl, 8 mg tab subl) QL (90 PER 30 DAYS) buprenorphine hcl/naloxone hcl QL (90 PER 30 DAYS) SUBOXONE QL (90 PER 30 DAYS) - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 11 LAST UPDATE 08/2015

12 Smoking Cessation Agents buproban CHANTIX Anti-inflammatory Agents Glucocorticoids alclometasone dipropionate amcinonide (0.1 % cream (g), 0.1 % lotion, 0.1 % oint. (g)) anusol-hc 2.5% cream apexicon e betamethasone dipropionate (0.05 % lotion, 0.05 % gel (gram), 0.05 % cream (g), 0.05 % oint. (g)) betamethasone dipropionate/propylene glycol (0.05 % cream (g), 0.05 % oint. (g), 0.05 % lotion) betamethasone valerate (0.1 % cream (g), 0.1 % lotion, 0.1 % oint. (g)) clobetasol propionate (0.05 % solution, 0.05 % lotion, 0.05 % shampoo, 0.05 % cream (g), 0.05 % foam, 0.05 % oint. (g), 0.05 % gel (gram)) clobetasol propionate/emollient base clocortolone pivalate clodan 0.05% shampoo CLODERM CORDRAN (4 CM TAPE LARGE, 4 CM TAPE SMALL) cormax cortisone acetate 25 mg tablet - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 12 LAST UPDATE 08/2015

13 CORTISPORIN CREAM desonide (0.05 % lotion, 0.05 % cream (g), 0.05 % oint. (g)) desoximetasone diflorasone diacetate fludrocortisone acetate 0.1 mg tablet fluocinolone acetonide (0.01 % cream (g), 0.01 % oil, 0.01 % solution, % oint. (g), % cream (g)) fluocinolone acetonide/shower cap fluocinonide (0.05 % gel (gram), 0.05 % solution, 0.05 % cream (g), 0.05 % oint. (g)) fluocinonide/emollient base fluticasone propionate (0.005 % oint. (g), 0.05 % lotion, 0.05 % cream (g)) halobetasol propionate HALOG 0.1% CREAM hydrocortisone (2.5 % lotion, 2.5 % cream (g), 2.5 % oint. (g)) hydrocortisone butyrate 0.1 % cream (g) methylprednisolone millipred 5 mg tablet millipred dp neomycin sulfate/polymyxin b sulfate/hydrocortisone (drops susp, solution) nystatin/triamcinolone acetonide oralone prednisolone 15 mg/5 ml solution - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 13 LAST UPDATE 08/2015

14 prednisolone sod phosphate (5 mg/5 ml solution, 10 mg tab rapdis, 15 mg tab rapdis, 15 mg/5 ml solution, 30 mg tab rapdis) prednisone (1 mg tablet, 2.5 mg tablet, 5 mg tablet, 5 mg/5 ml solution, 5 mg tab ds pk, 10 mg tablet, 10 mg tab ds pk, 20 mg tablet, 50 mg tablet) prednisone intensol procto-pak proctocream-hc psorcon TEXACORT triamcinolone acetonide (0.025 % cream (g), % oint. (g), % lotion, 0.1 % lotion, 0.1 % oint. (g), 0.1 % cream (g), 0.1 % paste (g), 0.5 % oint. (g), 0.5 % cream (g)) triderm Antibacterials Aminoglycosides garamycin 0.3% eye drops gentak gentamicin sulfate (0.1 % oint. (g), 0.1 % cream (g), 0.3 % oint. (g), 0.3 % drops) neomycin sulfate 500 mg tablet paromomycin sulfate 250 mg capsule TOBI PODHALER TOBRADEX EYE OINTMENT tobramycin 0.3 % drops - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 14 LAST UPDATE 08/2015

15 tobramycin in % sodium chloride LA Antibacterials, Other acetasol hc acetic acid 2 % solution acetic acid/aluminum acetate acetic acid/hydrocortisone ALTABAX bacitracin 500 unit/g oint. (g) chlorhexidine gluconate 0.12 % mouthwash clindacin etz 1% pledget clindacin p clindamycin hcl (75 mg capsule, 150 mg capsule, 300 mg capsule) clindamycin palmitate hcl clindamycin phosphate (1 % foam, 1 % lotion, 1 % gel (gram), 1 % med. swab, 1 % solution, 2 % cream/appl) cycloserine 250 mg capsule erythromycin ethylsuccinate/sulfisoxazole acetyl linezolid 600 mg tablet MACRODANTIN 25 MG CAPSULE methenamine hippurate methenamine mandelate 1 g tablet metronidazole (0.75 % gel (gram), 0.75 % cream (g), 0.75 % gel w/appl, 0.75 % lotion, 250 mg tablet, 375 mg capsule, 500 mg tablet) MONUROL Pref. - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 15 LAST UPDATE 08/2015

16 mupirocin 2 % oint. (g) mupirocin calcium nitrofurantoin 25 mg/5 ml oral susp nitrofurantoin macrocrystal (50 mg capsule, 100 mg capsule) nitrofurantoin monohydrate/macrocrystals paroex periogard PRIMSOL rosadan (0.75% gel, 0.75% cream) SULFAMYLON 8.5% CREAM tinidazole 250 mg tablet tinidazole 500 mg tablet trimethoprim 100 mg tablet vancomycin hcl (125 mg capsule, 250 mg capsule) vandazole vitazol XIFAXAN 200 MG TABLET XIFAXAN 550 MG TABLET ZYVOX (100 MG/5 ML SUSPENSION, 600 MG TABLET), QL (90 PER 30 DAYS), QL (60 PER 30 DAYS) Beta-lactam, Cephalosporins cefaclor (125 mg/5ml susp recon, 250 mg/5ml susp recon, 250 mg capsule, 375 mg/5ml susp recon, 500 mg tab er 12h, 500 mg capsule) - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 16 LAST UPDATE 08/2015

17 cefdinir (125 mg/5ml susp recon, 250 mg/5ml susp recon, 300 mg capsule) cefditoren pivoxil 400 mg tablet cefixime cefpodoxime proxetil (50 mg/5 ml susp recon, 100 mg tablet, 100 mg/5ml susp recon, 200 mg tablet) cefprozil (125 mg/5ml susp recon, 250 mg tablet, 250 mg/5ml susp recon, 500 mg tablet) ceftibuten (180 mg/5ml susp recon, 400 mg capsule) CEFTIN 125 MG/5 ML ORAL SUSP CEFTIN 250 MG/5 ML ORAL SUSP cefuroxime axetil cephalexin (125 mg/5ml susp recon, 250 mg tablet, 250 mg capsule, 250 mg/5ml susp recon, 500 mg tablet, 500 mg capsule, 750 mg capsule) SUPRAX (400 MG TABLET, 400 MG CAPSULE) Beta-lactam, Penicillins amoxicillin (125 mg tab chew, 125 mg/5ml susp recon, 200 mg/5ml susp recon, 250 mg capsule, 250 mg tab chew, 250 mg/5ml susp recon, 400 mg/5ml susp recon, 500 mg tablet, 500 mg capsule, 875 mg tablet) amoxicillin/potassium clavulanate ( mg tab chew, /5 susp recon, mg tablet, /5 susp recon, mg tab chew, mg/5 susp recon, mg tablet, /5 susp recon, mg tablet, tab er 12h) ampicillin trihydrate (125 mg/5ml susp recon, 250 mg capsule, 250 mg/5ml susp recon, 500 mg capsule) Pref. - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 17 LAST UPDATE 08/2015

18 dicloxacillin sodium MOXATAG penicillin g potassium 20mm unit vial penicillin v potassium (125 mg/5ml soln recon, 250 mg tablet, 250 mg/5ml soln recon, 500 mg tablet) pfizerpen 20 million unit vial Macrolides AZASITE azithromycin (1 g packet, 100 mg/5ml susp recon, 200 mg/5ml susp recon, 250 mg tablet, 500 mg tablet, 600 mg tablet) clarithromycin (125 mg/5ml susp recon, 250 mg/5ml susp recon, 250 mg tablet, 500 mg tab er 24h, 500 mg tablet) DIFICID E.E.S. 200 ery ERY-TAB erygel ERYPED 200 ERYTHROCIN STEARATE erythromycin base (5 mg/g oint. (g), 250 mg tablet, 250 mg capsule dr, 500 mg tablet) erythromycin base/ethyl alcohol (2 % med. swab, 2 % solution, 2 % gel (gram)) erythromycin ethylsuccinate 400 mg tablet Pref. Pref. - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 18 LAST UPDATE 08/2015

19 KETEK 300 MG TABLET Pref. Quinolones BESIVANCE ciprofloxacin hcl (0.3 % drops, 100 mg tablet, 250 mg tablet, 500 mg tablet, 750 mg tablet) ciprofloxacin/ciprofloxacin hcl FACTIVE gatifloxacin levofloxacin (0.5 % drops, 250mg/10ml solution, 250 mg tablet, 500 mg tablet, 750 mg tablet) moxifloxacin hcl (100 % powder, 400 mg tablet) NOROXIN ofloxacin (0.3 % drops, 200 mg tablet, 300 mg tablet, 400 mg tablet) VIGAMOX Sulfonamides bleph-10 silver sulfadiazine 1 % cream (g) sulfacetamide sodium (10 % drops, 10 % suspension) sulfadiazine 500 mg tablet sulfamethoxazole/trimethoprim (200-40mg/5 oral susp, 400mg-80mg tablet, /20 oral susp, mg tablet) sulfamide - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 19 LAST UPDATE 08/2015

20 Tetracyclines avidoxy demeclocycline hcl doxycycline hyclate (20 mg tablet, 50 mg capsule, 100 mg capsule, 100 mg tablet) doxycycline monohydrate (50 mg capsule, 50 mg tablet, 75 mg tablet, 100 mg tablet, 100 mg capsule, 150 mg tablet) dynacin (50 mg tablet, 100 mg tablet) minocycline hcl (50 mg tablet, 50 mg capsule, 75 mg capsule, 75 mg tablet, 100 mg capsule, 100 mg tablet) morgidox 100 mg capsule tetracycline hcl (250 mg capsule, 500 mg capsule) Anticonvulsants Anticonvulsants, Other acetazolamide (125 mg tablet, 250 mg tablet) levetiracetam (100 mg/ml solution, 250 mg tablet, 500 mg tab er 24h, 500 mg/5ml solution, 500 mg tablet, 750 mg tab er 24h, 750 mg tablet, 1000 mg tablet) POTIGA primidone (50 mg tablet, 250 mg tablet) Calcium Channel Modifying Agents CELONTIN ethosuximide (250 mg/5ml solution, 250 mg capsule) - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 20 LAST UPDATE 08/2015

21 LYRICA (20 MG/ML ORAL SOLUTION, 25 MG CAPSULE, 50 MG CAPSULE, 75 MG CAPSULE, 100 MG CAPSULE, 150 MG CAPSULE, 200 MG CAPSULE, 225 MG CAPSULE, 300 MG CAPSULE) zonisamide (25 mg capsule, 50 mg capsule, 100 mg capsule) Gamma-aminobutyric Acid (GABA) Augmenting Agents DIASTAT diazepam ( mg kit, kit) diazepam 2.5 mg kit divalproex sodium gabapentin (100 mg capsule, 250 mg/5ml solution, 300 mg capsule, 400 mg capsule, 600 mg tablet, 800 mg tablet) GABITRIL (12 MG TABLET, 16 MG TABLET) ONFI (5 MG TABLET, 10 MG TABLET, 20 MG TABLET) ONFI 2.5 MG/ML SUSPENSION phenobarbital (15 mg tablet, 16.2 mg tablet, 20 mg/5 ml elixir, 30 mg tablet, 32.4 mg tablet, 60 mg tablet, 64.8 mg tablet, 97.2mg tablet, 100 mg tablet) SABRIL STAVZOR tiagabine hcl valproic acid (as sodium salt) (valproate sodium) (250 mg/5ml solution, 500mg/10ml solution), QL (60 PER 30 DAYS) LA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 21 LAST UPDATE 08/2015

22 valproic acid 250 mg capsule Glutamate Reducing Agents felbamate (400 mg tablet, 600 mg tablet, 600 mg/5ml oral susp) lamotrigine (5 mg tb chw dsp, 25 mg tablet, 25mg (35) tab ds pk, 25 mg tb chw dsp, 100 mg tablet, 150 mg tablet, 200 mg tablet) topiragen topiramate (15 mg cap sprink, 25 mg cap sprink, 25 mg tablet, 50 mg tablet, 100 mg tablet, 200 mg tablet) topiramate (25 mg cap spr 24, 50 mg cap spr 24, 100 mg cap spr 24, 150 mg cap spr 24, 200 mg cap spr 24) Sodium Channel Agents APTIOM BANZEL (40 MG/ML SUSPENSION, 200 MG TABLET, 400 MG TABLET) carbamazepine (100 mg cpmp 12hr, 100 mg tab chew, 100 mg/5ml oral susp, 200 mg tablet, 200 mg tab er 12h, 200 mg cpmp 12hr, 300 mg cpmp 12hr, 400 mg tab er 12h) DILANTIN 30 MG CAPSULE epitol oxcarbazepine (150 mg tablet, 300 mg tablet, 300 mg/5ml oral susp, 600 mg tablet) PEGANONE phenytoin (50 mg tab chew, 100 mg/4ml oral susp, 125 mg/5ml oral susp) phenytoin sodium extended Pref. - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 22 LAST UPDATE 08/2015

23 VIMT (10 MG/ML SOLUTION, 50 MG TABLET, 100 MG TABLET, 150 MG TABLET, 200 MG TABLET) ziprasidone hcl 20 mg capsule Antidementia Agents Antidementia Agents, Other ergoloid mesylates 1 mg tablet Cholinesterase Inhibitors donepezil hcl (5 mg tab rapdis, 5 mg tablet, 10 mg tablet, 10 mg tab rapdis) donepezil hcl 23 mg tablet EXELON (4.6 MG/24HR TCH, 9.5 MG/24HR TCH, 13.3 MG/24HR TCH) EXELON 2 MG/ML ORAL SOLUTION galantamine hbr (4 mg tablet, 4 mg/ml solution, 8 mg cap24h pel, 8 mg tablet, 12 mg tablet, 16 mg cap24h pel, 24 mg cap24h pel) rivastigmine tartrate QL (60 PER 30 DAYS) N-methyl-D-aspartate (NMDA) Receptor Antagonist memantine hcl (5 mg tablet, 10 mg tablet) memantine hcl 5 mg-10 mg tab ds pk, QL (2 PER DAY) NAMENDA 10 MG/5 ML SOLUTION Pref., QL (300 ML PER 30 DAYS) Antidepressants Antidepressants, Other ABILIFY 1 MG/ML SOLUTION ABILIFY DISCMELT Pref. Pref. - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 23 LAST UPDATE 08/2015

24 APLENZIN ER 174 MG TABLET aripiprazole budeprion sr bupropion hcl (75 mg tablet, 100 mg tablet er, 100 mg tablet, 150 mg tab er 24h, 150 mg tablet er, 200 mg tablet er, 300 mg tab er 24h) maprotiline hcl mirtazapine (7.5 mg tablet, 15 mg tablet, 15 mg tab rapdis, 30 mg tablet, 30 mg tab rapdis, 45 mg tablet, 45 mg tab rapdis) nefazodone hcl olanzapine/fluoxetine hcl perphenazine/amitriptyline hcl SEROQUEL XR trazodone hcl (50 mg tablet, 100 mg tablet, 150 mg tablet, 300 mg tablet) VIIBRYD Monoamine Oxidase Inhibitors EMSAM MARPLAN phenelzine sulfate 15 mg tablet tranylcypromine sulfate Serotonin/Norepinephrine Reuptake Inhibitors citalopram hydrobromide (10 mg tablet, 10 mg/5 ml solution, 20 mg tablet, 40 mg tablet) duloxetine hcl (20 mg capsule dr, 30 mg capsule dr) QL (60 PER 30 DAYS) - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 24 LAST UPDATE 08/2015

25 duloxetine hcl 60 mg capsule dr QL (30 PER 30 DAYS) escitalopram oxalate (5 mg tablet, 5 mg/5 ml solution, 10 mg tablet, 20 mg tablet) fluoxetine hcl (10 mg tablet, 10 mg capsule, 20 mg tablet, 20 mg/5 ml solution, 20 mg capsule, 40 mg capsule, 60 mg tablet, 90 mg capsule dr) fluvoxamine maleate (25 mg tablet, 50 mg tablet, 100 mg tablet) paroxetine hcl (10 mg tablet, 20 mg tablet, 30 mg tablet, 40 mg tablet) paroxetine hcl (25 mg tab er 24h, 37.5 mg tab er 24h) XIL 10 MG/5 ML SUSPENSION PEXEVA PRISTIQ ER (ER 50 MG TABLET, ER 100 MG TABLET) PRISTIQ ER 25 MG TABLET sertraline hcl (20 mg/ml oral conc, 25 mg tablet, 50 mg tablet, 100 mg tablet) venlafaxine hcl (25 mg tablet, 37.5 mg cap er 24h, 37.5 mg tab er 24, 37.5 mg tablet, 50 mg tablet, 75 mg cap er 24h, 75 mg tab er 24, 75 mg tablet, 100 mg tablet, 150 mg cap er 24h, 150 mg tab er 24) venlafaxine hcl 225 mg tab er 24 Tricyclics amitriptyline hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 75 mg tablet, 100 mg tablet, 150 mg tablet) amoxapine, QL (30 PER 30 DAYS), QL (30 PER 30 DAYS) QL (30 PER 30 DAYS) - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 25 LAST UPDATE 08/2015

26 clomipramine hcl (25 mg capsule, 50 mg capsule, 75 mg capsule) desipramine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 75 mg tablet, 100 mg tablet, 150 mg tablet) doxepin hcl (10 mg/ml oral conc, 10 mg capsule, 25 mg capsule, 50 mg capsule, 75 mg capsule, 100 mg capsule, 150 mg capsule) imipramine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet) imipramine pamoate nortriptyline hcl (10 mg/5 ml solution, 10 mg capsule, 25 mg capsule, 50 mg capsule, 75 mg capsule) protriptyline hcl trimipramine maleate Antiemetics Antiemetics, Other chlorpromazine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 100 mg tablet, 200 mg tablet) compro DICLEGIS hydroxyzine hcl (10 mg tablet, 10 mg/5 ml solution, 25 mg tablet, 50 mg tablet) hydroxyzine pamoate (25 mg capsule, 50 mg capsule, 100 mg capsule) metoclopramide hcl (5 mg tablet, 5 mg/5 ml solution, 10 mg tablet, 10 mg/10ml solution) perphenazine (2 mg tablet, 4 mg tablet, 8 mg tablet, 16 mg tablet) QL (60 PER 30 DAYS) - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 26 LAST UPDATE 08/2015

27 phenadoz prochlorperazine prochlorperazine maleate (5 mg tablet, 10 mg tablet) promethazine hcl (6.25mg/5ml syrup, 12.5 mg supp.rect, 12.5 mg tablet, 25 mg tablet, 25 mg supp.rect, 50 mg supp.rect, 50 mg tablet) promethegan TRANSDERM-SCOP trimethobenzamide hcl 300 mg capsule Emetogenic Therapy Adjuncts ANZEMET (50 MG TABLET, 100 MG TABLET) CESAMET, QL (4 PER 30 DAYS), QL (20 PER 30 DAYS) dronabinol, QL (60 PER 30 DAYS) EMEND 125 MG CAPSULE Pref. QL (2 PER 30 DAYS) EMEND 40 MG CAPSULE Pref. QL (8 PER 30 DAYS) EMEND 80 MG CAPSULE Pref. QL (4 PER 30 DAYS) EMEND TRIFOLD CK Pref. QL (6 PER 30 DAYS) granisetron hcl 1 mg tablet, QL (8 PER 30 DAYS) ondansetron ondansetron hcl (4 mg/5 ml solution, 4 mg tablet, 8 mg tablet, 24 mg tablet) SANCUSO Antifungals, QL (2 PER 30 DAYS) ciclodan 0.77% cream ciclopirox (0.77 % gel (gram), 1 % shampoo) - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 27 LAST UPDATE 08/2015

28 ciclopirox olamine (0.77 % cream (g), 0.77 % suspension) ciclopirox/vitamin e mixed/nail lacquer remover, non-acet clotrimazole 10 mg troche econazole nitrate 1 % cream (g) ERTACZO EXELDERM (1% CREAM, 1% SOLUTION) fluconazole (10 mg/ml susp recon, 40 mg/ml susp recon, 50 mg tablet, 100 mg tablet, 150 mg tablet, 200 mg tablet) flucytosine (250 mg capsule, 500 mg capsule) griseofulvin ultramicrosize griseofulvin, microsize (125 mg/5ml oral susp, 500 mg tablet) itraconazole 100 mg capsule ketoconazole (2 % cream (g), 2 % foam, 2 % shampoo) ketodan 2% foam LAMISIL (125 MG GRANULES CKET, MG GRANULES CK) miconazole nitrate 200 mg supp.vag naftifine hcl NAFTIN (1% GEL, 1% CREAM) NATACYN NOXAFIL 40 MG/ML SUSPENSION - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 28 LAST UPDATE 08/2015

29 nyamyc nystatin (50mm unit powder(ea), 150mm unit powder(ea), 500mm unit powder(ea), 500k unit tablet, /ml oral susp, /g powder, /g cream (g), /g oint. (g)) nystop ORAVIG OXISTAT (1% CREAM, 1% LOTION) pedi-dri SPORANOX 10 MG/ML SOLUTION Pref. terbinafine hcl 250 mg tablet terconazole (0.4 % cream/appl, 0.8 % cream/appl, 80 mg supp.vag) voriconazole (50 mg tablet, 200 mg tablet, 200 mg/5ml susp recon) Antigout Agents allopurinol (100 mg tablet, 300 mg tablet) colchicine 0.6 mg tablet Pref. QL (60 PER 30 DAYS) colchicine/probenecid COLCRYS Pref. QL (60 PER 30 DAYS) probenecid ULORIC Antimigraine Agents Ergot Alkaloids cafergot dihydroergotamine mesylate (1 mg/ml ampul, 1 mg/ml vial) - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 29 LAST UPDATE 08/2015

30 dihydroergotamine mesylate 0.5mg/spry spray/pump ERGOMAR ergotamine tartrate/caffeine migergot MIGRANAL Prophylactic timolol maleate (5 mg tablet, 10 mg tablet, 20 mg tablet) QL (3.5 ML PER 30 DAYS) QL (3.5 ML PER 30 DAYS) Serotonin (5-HT) 1b/1d Receptor Agonists almotriptan malate, QL (12 PER 30 DAYS) FROVA, QL (9 PER 30 DAYS) naratriptan hcl QL (9 PER 30 DAYS) RELX, QL (12 PER 30 DAYS) rizatriptan benzoate QL (9 PER 30 DAYS) sumatriptan (5 mg spray, 20 mg spray) QL (6 PER 30 DAYS) sumatriptan succinate (25 mg tablet, 50 mg tablet, 100 mg tablet) sumatriptan succinate (4 cartridge, 6 pen injctr, 6 syringe, 6 cartridge, 6 vial) sumatriptan succinate 4 mg/0.5ml pen injctr zolmitriptan (2.5 mg tab rapdis, 2.5 mg tablet) zolmitriptan (5 mg tab rapdis, 5 mg tablet) ZOMIG 2.5 MG NASAL SPRAY ZOMIG 5 MG NASAL SPRAY QL (9 PER 30 DAYS) QL (2 ML PER 30 DAYS) QL (1 ML PER 30 DAYS) QL (12 PER 30 DAYS) QL (9 PER 30 DAYS) QL (12 PER 30 DAYS), QL (6 PER 30 DAYS) - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 30 LAST UPDATE 08/2015

31 Antimyasthenic Agents Parasympathomimetics guanidine hcl MESTINON 60 MG/5 ML SYRUP pyridostigmine bromide (60 mg tablet, 180 mg tablet er) Antimycobacterials Antimycobacterials, Other dapsone (25 mg tablet, 100 mg tablet) rifabutin Antituberculars ethambutol hcl isoniazid (50 mg/5 ml solution, 100 mg tablet, 300 mg tablet) SER PRIFTIN pyrazinamide RIFAMATE rifampin (150 mg capsule, 300 mg capsule) RIFATER SIRTURO LA TRECATOR Pref. - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 31 LAST UPDATE 08/2015

32 Antineoplastics Alkylating Agents ALKERAN 2 MG TABLET Pref. CEENU CYCLOPHOSPHAMIDE CAPSULES cyclophosphamide tablets GLEOSTINE LEUKERAN lomustine MATULANE Pref. temozolomide VALCHLOR LA Antiangiogenic Agents POMALYST REVLIMID, LA THALOMID Antiestrogens/Modifiers EMCYT FARESTON SOLTAMOX tamoxifen citrate (10 mg tablet, 20 mg tablet) - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 32 LAST UPDATE 08/2015

33 Antimetabolites capecitabine DROXIA hydroxyurea 500 mg capsule mercaptopurine 50 mg tablet methotrexate sodium (2.5 mg tablet, 25 mg/ml vial) methotrexate sodium/pf (1 g vial, 25 mg/ml vial) PURIXAN RHEUMATREX TABLOID Pref. Antineoplastics, Other FARYDAK, QL (6 PER 21 DAYS) flutamide HEXALEN imiquimod 5 % cream pack INTRON A (6 MILLION UNIT/ML VL, 10 MILLION UNIT/ML, 10 MILLION UNITS VIL, 18 MILLION UNITS VIL, 50 MILLION UNITS VIL) leucovorin calcium (5 mg tablet, 10 mg tablet, 15 mg tablet, 25 mg tablet) MESNEX 400 MG TABLET Pref. SYLATRON SYLATRON 4-CK SYNRIBO ZYCLARA (2.5% CREAM PUMP, 3.75% CREAM PUMP, 3.75% CREAM) - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 33 LAST UPDATE 08/2015

34 Aromatase Inhibitors, 3rd Generation anastrozole 1 mg tablet exemestane letrozole 2.5 mg tablet Enzyme Inhibitors BOSULIF GILOTRIF HYCAMTIN (0.25 MG CAPSULE, 1 MG CAPSULE) IMBRUVICA INLYTA, LA JAKAFI, LA LYNRZA, LA MEKINIST TAFINLAR VOTRIENT ZELBORAF ZYTIGA Molecular Target Inhibitors AFINITOR AFINITOR DISPERZ CAPRELSA COMETRIQ, LA ERIVEDGE GLEEVEC IBRANCE ICLUSIG LENVIMA, LA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 34 LAST UPDATE 08/2015

35 NEXAVAR SPRYCEL STIVARGA SUTENT TARCEVA TASIGNA TYKERB vandetanib XALKORI, LA ZOLINZA ZYDELIG, QL (60 PER 30 DAYS) ZYKADIA Retinoids bexarotene NRETIN TARGRETIN 1% GEL tretinoin 10 mg capsule Antiparasitics Anthelmintics ALBENZA BILTRICIDE ivermectin 3 mg tablet SOOLANTRA Antiprotozoals ALINIA 100 MG/5 ML SUSPENSION Pref. ST, QL (30 GM PER 30 DAYS) - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 35 LAST UPDATE 08/2015

36 ALINIA 500 MG TABLET Pref. atovaquone chloroquine phosphate (250 mg tablet, 500 mg tablet) COARTEM DARAPRIM hydroxychloroquine sulfate 200 mg tablet mefloquine hcl primaquine phosphate Pediculicides/Scabicides elimite EURAX 10% CREAM lindane malathion permethrin 5 % cream (g) SKLICE ULESFIA Antiparkinson Agents Anticholinergics benztropine mesylate (0.5 mg tablet, 1 mg tablet, 2 mg tablet) trihexyphenidyl hcl (2 mg/5 ml elixir, 2 mg tablet, 5 mg tablet) - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 36 LAST UPDATE 08/2015

37 Antiparkinson Agents, Other amantadine hcl (50 mg/5 ml solution, 100 mg tablet, 100 mg capsule) carbidopa/levodopa/entacapone entacapone tolcapone Dopamine Agonists APOKYN bromocriptine mesylate (2.5 mg tablet, 5 mg capsule) pramipexole di-hcl (0.125 mg tablet, 0.25 mg tablet, 0.5 mg tablet, 0.75 mg tablet, 1 mg tablet, 1.5 mg tablet) ropinirole hcl (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet, 2 mg tablet, 3 mg tablet, 4 mg tablet, 5 mg tablet) Dopamine Precursors/ L-Amino Acid Decarboxylase Inhibitors carbidopa 25 mg tablet carbidopa/levodopa Monoamine Oxidase B (MAO-B) Inhibitors AZILECT selegiline hcl (5 mg tablet, 5 mg capsule) ZELAR Pref. Antipsychotics 1st Generation/Typical fluphenazine hcl (1 mg tablet, 2.5 mg/5ml elixir, 2.5 mg tablet, 5 mg tablet, 5 mg/ml oral conc, 10 mg tablet) - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 37 LAST UPDATE 08/2015

38 haloperidol lactate 2 mg/ml oral conc loxapine succinate ORAP thioridazine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 100 mg tablet) thiothixene trifluoperazine hcl 2nd Generation/Atypical FANAPT INVEGA LATUDA olanzapine (2.5 mg tablet, 5 mg tablet, 5 mg tab rapdis, 7.5 mg tablet, 10 mg tab rapdis, 10 mg tablet, 15 mg tab rapdis, 15 mg tablet, 20 mg tablet, 20 mg tab rapdis) quetiapine fumarate risperidone (0.25 mg tablet, 0.25 mg tab rapdis, 0.5 mg tab rapdis, 0.5 mg tablet, 1 mg tab rapdis, 1 mg/ml solution, 1 mg tablet, 2 mg tablet, 2 mg tab rapdis, 3 mg tab rapdis, 3 mg tablet, 4 mg tab rapdis, 4 mg tablet) SAPHRIS ziprasidone hcl (40 mg capsule, 60 mg capsule, 80 mg capsule) Treatment-Resistant clozapine (12.5 mg tab rapdis, 25 mg tablet, 25 mg tab rapdis, 50 mg tablet, 100 mg tablet, 100 mg tab rapdis, 200 mg tablet), QL (30 PER 30 DAYS) - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 38 LAST UPDATE 08/2015

39 clozapine (150 mg tab rapdis, 200 mg tab rapdis) VERSACLOZ Antispasticity Agents baclofen (10 mg tablet, 20 mg tablet) dantrolene sodium (25 mg capsule, 50 mg capsule, 100 mg capsule) MYRBETRIQ tizanidine hcl (2 mg tablet, 4 mg tablet) Antivirals Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors EDURANT INTELENCE nevirapine (200 mg tablet, 400 mg tab er 24h) RESCRIPTOR SUSTIVA VIRAMUNE XR 100 MG TABLET Pref. Pref. Pref. Pref. Pref. Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors abacavir sulfate abacavir sulfate/lamivudine/zidovudine COMPLERA didanosine EMTRIVA (10 MG/ML SOLUTION, 200 MG CAPSULE) EPZICOM lamivudine (10 mg/ml solution, 150 mg tablet, 300 mg tablet) Pref. Pref. Pref. - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 39 LAST UPDATE 08/2015

40 lamivudine/zidovudine stavudine (1 mg/ml soln recon, 15 mg capsule, 20 mg capsule, 30 mg capsule, 40 mg capsule) TRUVADA VIDEX VIREAD (150 MG TABLET, 200 MG TABLET, 250 MG TABLET, 300 MG TABLET, POWDER) ZIAGEN 20 MG/ML SOLUTION zidovudine (10 mg/ml syrup, 100 mg capsule, 300 mg tablet) Anti-HIV Agents, Other ATRIPLA FUZEON ISENTRESS (100 MG POWDER CKET, 400 MG TABLET) SELZENTRY STRIBILD TIVICAY TRIUMEQ TYBOST VITEKTA Anti-HIV Agents, Protease Inhibitors APTIVUS (100 MG/ML SOLUTION, 250 MG CAPSULE) CRIXIVAN EVOTAZ Pref. Pref. Pref. Pref. Pref. Pref. Pref. Pref. Pref. Pref. Pref. Pref. - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 40 LAST UPDATE 08/2015

41 INVIRASE KALETRA ( MG TABLET, MG TABLET, /5 ML ORAL SOLU) LEXIVA (50 MG/ML SUSPENSION, 700 MG TABLET) NORVIR (100 MG TABLET, 100 MG SOFTGEL CAP) NORVIR 80 MG/ML SOLUTION PREZCOBIX PREZISTA (75 MG TABLET, 100 MG/ML SUSPENSION, 150 MG TABLET, 400 MG TABLET, 600 MG TABLET, 800 MG TABLET) REYATAZ VIRACEPT Pref. Pref. Pref. Pref. Pref. Pref. Pref. Anti-cytomegalovirus (CMV) Agents VALCYTE 50 MG/ML SOLUTION QL (540 ML PER 30 DAYS) valganciclovir hcl ZIRGAN Pref. Anti-influenza Agents RELENZA rimantadine hcl TAMIFLU (6 MG/ML SUSPENSION, 30 MG CAPSULE, 45 MG CAPSULE, 75 MG CAPSULE) Pref. Pref. Antihepatitis Agents adefovir dipivoxil QL (30 PER 30 DAYS) BARACLUDE 0.05 MG/ML SOLUTION entecavir EPIVIR HBV 25 MG/5 ML SOLN Pref. - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 41 LAST UPDATE 08/2015

42 HARVONI, QL (28 PER 28 DAYS) INCIVEK INFERGEN lamivudine 100 mg tablet MODERIBA OLYSIO, QL (28 PER 28 DAYS) PEGASYS (180 MCG/ML VIAL, 180 MCG/0.5 ML SYRINGE) PEGASYS PROCLICK PEGINTRON PEGINTRON REDIPEN REBETOL 40 MG/ML SOLUTION RIBAK RIBASPHERE RIBASPHERE RIBAK RIBATAB ribavirin (200 mg capsule, 200 mg tablet, 400 mg tablet, 600 mg tablet) SOVALDI, QL (28 PER 28 DAYS) TYZEKA QL (30 PER 30 DAYS) VICTRELIS VIEKIRA K, QL (112 PER 28 DAYS) Antiherpetic Agents acyclovir (200 mg capsule, 200 mg/5ml oral susp, 400 mg tablet, 800 mg tablet) DENAVIR famciclovir trifluridine 1 % drops valacyclovir hcl (500 mg tablet, 1000 mg tablet) - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 42 LAST UPDATE 08/2015

43 Anxiolytics Anxiolytics, Other alprazolam (0.25 mg tablet, 0.5 mg tab er 24h, 0.5 mg tablet, 1 mg tablet, 1 mg tab er 24h, 2 mg tablet, 2 mg tab er 24h, 3 mg tab er 24h) buspirone hcl (5 mg tablet, 7.5 mg tablet, 10 mg tablet, 15 mg tablet, 30 mg tablet) chlordiazepoxide hcl clonazepam (0.125 mg tab rapdis, 0.25 mg tab rapdis, 0.5 mg tablet, 0.5 mg tab rapdis, 1 mg tab rapdis, 1 mg tablet, 2 mg tab rapdis, 2 mg tablet) clorazepate dipotassium diazepam (2 mg tablet, 5 mg/5 ml solution, 5 mg tablet, 5 mg/ml oral conc, 10 mg tablet) lorazepam (0.5 mg tablet, 1 mg tablet, 2 mg tablet, 2 mg/ml oral conc) lorazepam intensol meprobamate 400 mg tablet oxazepam Bipolar Agents Mood Stabilizers lithium carbonate (150 mg capsule, 300 mg tablet er, 300 mg tablet, 300 mg capsule, 450 mg tablet er, 600 mg capsule) lithium citrate - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 43 LAST UPDATE 08/2015

44 Blood Glucose Regulators Antidiabetic Agents acarbose ACTOPLUS MET XR Pref. BYDUREON Pref. ST BYDUREON PEN Pref. ST BYETTA Pref. ST chlorpropamide CYCLOSET FARXIGA glimepiride glipizide (2.5 mg tab er 24, 5 mg tablet, 5 mg tab er 24, 10 mg tab er 24, 10 mg tablet) glipizide/metformin hcl glyburide glyburide,micronized glyburide/metformin hcl GLYSET INVOKAMET INVOKANA JANUMET JANUMET XR JANUVIA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 44 LAST UPDATE 08/2015

45 JARDIANCE JENTADUETO KAZANO KOMBIGLYZE XR metformin hcl (500 mg tablet, 500 mg tab er 24h, 750 mg tab er 24h, 850 mg tablet, 1000 mg tablet) nateglinide NESINA ONGLYZA OSENI pioglitazone hcl pioglitazone hcl/glimepiride pioglitazone hcl/metformin hcl repaglinide (1 mg tablet, 2 mg tablet) RIOMET SYMLINPEN 120 SYMLINPEN 60 tolazamide tolbutamide TRADJENTA VICTOZA 2-K Pref. ST VICTOZA 3-K Pref. ST - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 45 LAST UPDATE 08/2015

46 WELCHOL XIGDUO XR Glycemic Agents GLUCAGEN 1MG HYPOKIT GLUCAGON EMERGENCY KIT PROGLYCEM Insulins APIDRA APIDRA SOLOSTAR HUMALOG HUMALOG KWIKPEN HUMALOG MIX HUMALOG MIX KWIKPEN HUMALOG MIX HUMALOG MIX KWIKPEN HUMULIN (PEN, VIAL) HUMULIN 70/30 KWIKPEN HUMULIN N (N 100 PEN, N 100 VIAL) HUMULIN N KWIKPEN HUMULIN R 100 UNITS/ML VIAL LANTUS LANTUS SOLOSTAR LEVEMIR LEVEMIR FLEXPEN LEVEMIR FLEXTOUCH NOVOLIN UNIT/ML VIAL Pref. Pref. Pref. Pref. Pref. Pref. Pref. Pref. Pref. Pref. Pref. Pref. Pref. Pref. Pref. Pref. Pref. Pref. Pref. Pref. Pref. - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 46 LAST UPDATE 08/2015

47 NOVOLIN N 100 UNITS/ML VIAL NOVOLIN R 100 UNITS/ML VIAL NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX NOVOLOG MIX FLEXPEN TOUJEO SOLOSTAR Pref. Pref. Pref. Pref. Pref. Pref. Pref. Blood Products/Modifiers/ Volume Expanders Anticoagulants ELIQUIS enoxaparin sodium fondaparinux sodium FRAGMIN (2,500 UNITS/0.2 ML SYR, 5,000 UNITS/0.2 ML SYR, 7,500 UNITS/0.3 ML SYR, 10,000 UNITS/ML SYRING, 12,500 UNITS/0.5 ML, 15,000 UNITS/0.6 ML, 18,000 UNITS/0.72 ML, 25,000 UNITS/ML VIAL, 95,000 UNITS/3.8 ML VL) jantoven PRADAXA SAVAYSA warfarin sodium (1 mg tablet, 2 mg tablet, 2.5 mg tablet, 3 mg tablet, 4 mg tablet, 5 mg tablet, 6 mg tablet, 7.5 mg tablet, 10 mg tablet) XARELTO Pref. Pref. Pref. Blood Formation Modifiers anagrelide hcl ARANESP - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 47 LAST UPDATE 08/2015

48 EPOGEN GRANIX LEUKINE (250 MCG VIAL, 500 MCG/ML VIAL) NEULASTA NEUMEGA NEUPOGEN PROCRIT PROMACTA Coagulants tranexamic acid 650 mg tablet Platelet Modifying Agents AGGRENOX aspirin/dipyridamole BRILINTA cilostazol clopidogrel bisulfate 75 mg tablet dipyridamole (25 mg tablet, 50 mg tablet, 75 mg tablet) EFFIENT ticlopidine hcl Pref. Pref. Pref. Pref. Cardiovascular Agents Alpha-adrenergic Agonists clonidine clonidine hcl (0.1 mg tablet, 0.2 mg tablet, 0.3 mg tablet) guanfacine hcl (1 mg tablet, 2 mg tablet) methyldopa - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 48 LAST UPDATE 08/2015

49 midodrine hcl Alpha-adrenergic Blocking Agents DIBENZYLINE doxazosin mesylate (1 mg tablet, 2 mg tablet, 4 mg tablet, 8 mg tablet) prazosin hcl (1 mg capsule, 2 mg capsule, 5 mg capsule) terazosin hcl Angiotensin II Receptor Antagonists BENICAR candesartan cilexetil EDARBI irbesartan losartan potassium telmisartan valsartan Angiotensin-converting Enzyme (ACE) Inhibitors benazepril hcl (5 mg tablet, 10 mg tablet, 20 mg tablet, 40 mg tablet) captopril (12.5 mg tablet, 25 mg tablet, 50 mg tablet, 100 mg tablet) enalapril maleate (2.5 mg tablet, 5 mg tablet, 10 mg tablet, 20 mg tablet) ENED fosinopril sodium lisinopril (2.5 mg tablet, 5 mg tablet, 10 mg tablet, 20 mg tablet, 30 mg tablet, 40 mg tablet) - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 49 LAST UPDATE 08/2015

50 moexipril hcl perindopril erbumine quinapril hcl ramipril trandolapril Antiarrhythmics amiodarone hcl (100 mg tablet, 200 mg tablet, 400 mg tablet) disopyramide phosphate flecainide acetate mexiletine hcl (150 mg capsule, 200 mg capsule, 250 mg capsule) MULTAQ NORCE CR pacerone 200 mg tablet propafenone hcl quinidine gluconate 324 mg tablet er quinidine sulfate (200 mg tablet, 300 mg tablet er, 300 mg tablet) sorine sotalol hcl (80 mg tablet, 120 mg tablet, 160 mg tablet, 240 mg tablet) TIKOSYN verapamil hcl (40 mg tablet, 80 mg tablet, 120 mg tablet) Beta-adrenergic Blocking Agents acebutolol hcl (200 mg capsule, 400 mg capsule) atenolol (25 mg tablet, 50 mg tablet, 100 mg tablet) betaxolol hcl (10 mg tablet, 20 mg tablet) Pref. Pref. Pref. - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 50 LAST UPDATE 08/2015

51 bisoprolol fumarate BYSTOLIC carvedilol COREG CR labetalol hcl (100 mg tablet, 200 mg tablet, 300 mg tablet) LEVATOL metoprolol succinate metoprolol tartrate (25 mg tablet, 50 mg tablet, 100 mg tablet) nadolol (20 mg tablet, 40 mg tablet, 80 mg tablet) pindolol propranolol hcl (10 mg tablet, 20 mg/5 ml solution, 20 mg tablet, 40 mg tablet, 40mg/5ml solution, 60 mg cap sa 24h, 60 mg tablet, 80 mg tablet, 80 mg cap sa 24h, 120 mg cap sa 24h, 160 mg cap sa 24h) Calcium Channel Blocking Agents afeditab cr amlodipine besylate (2.5 mg tablet, 5 mg tablet, 10 mg tablet) cartia xt dilt-cd dilt-xr diltia xt - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 51 LAST UPDATE 08/2015

52 diltiazem hcl (30 mg tablet, 60 mg cap er 12h, 60 mg tablet, 90 mg cap er 12h, 90 mg tablet, 120 mg cap er 12h, 120 mg cap er 24h, 120 mg cap er deg, 120 mg capsule er, 120 mg tablet, 180 mg cap er 24h, 180 mg tab er 24h, 180 mg capsule er, 180 mg cap er deg, 240 mg tab er 24h, 240 mg cap er deg, 240 mg cap er 24h, 240 mg capsule er, 300 mg capsule er, 300 mg tab er 24h, 300 mg cap er 24h, 360 mg cap er 24h, 360 mg capsule er, 360 mg tab er 24h, 420mg tab er 24h, 420mg capsule er) diltzac er felodipine isradipine matzim la nicardipine hcl (20 mg capsule, 30 mg capsule) nifediac cc nifedical xl nifedipine (30 mg tab er 24, 30 mg tablet er, 60 mg tablet er, 60 mg tab er 24, 90 mg tab er 24, 90 mg tablet er) nimodipine 30 mg capsule nisoldipine taztia xt verapamil hcl (100 mg cap24h pct, 120 mg tablet er, 120 mg cap24h pel, 180 mg tablet er, 180 mg cap24h pel, 200 mg cap24h pct, 240 mg cap24h pel, 240 mg tablet er, 300 mg cap24h pct, 360 mg cap24h pel) Cardiovascular Agents, Other amiloride hcl/hydrochlorothiazide amlodipine besylate/atorvastatin calcium - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 52 LAST UPDATE 08/2015

53 amlodipine besylate/benazepril hcl atenolol/chlorthalidone benazepril hcl/hydrochlorothiazide bisoprolol fumarate/hydrochlorothiazide captopril/hydrochlorothiazide digitek digox digoxin (50 mcg/ml solution, 125 mcg tablet, 250 mcg tablet) EDARBYCLOR enalapril maleate/hydrochlorothiazide fosinopril sodium/hydrochlorothiazide irbesartan/hydrochlorothiazide lisinopril/hydrochlorothiazide losartan potassium/hydrochlorothiazide methyldopa/hydrochlorothiazide metoprolol tartrate/hydrochlorothiazide moexipril hcl/hydrochlorothiazide nadolol/bendroflumethiazide pentoxifylline 400 mg tablet er propranolol hcl/hydrochlorothiazide quinapril hcl/hydrochlorothiazide RANEXA spironolactone/hydrochlorothiazide TEKTURNA telmisartan/hydrochlorothiazide Pref. - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 53 LAST UPDATE 08/2015

54 triamterene/hydrochlorothiazide ( mg capsule, mg tablet, 75 mg-50mg tablet) valsartan/hydrochlorothiazide Diuretics, Carbonic Anhydrase Inhibitors acetazolamide 500 mg capsule er methazolamide (25 mg tablet, 50 mg tablet) Diuretics, Loop bumetanide (0.5 mg tablet, 1 mg tablet, 2 mg tablet) EDECRIN furosemide (10 mg/ml solution, 20 mg tablet, 40 mg tablet, 40mg/5ml solution, 80 mg tablet) torsemide (5 mg tablet, 10 mg tablet, 20 mg tablet, 100 mg tablet) Diuretics, Potassium-sparing amiloride hcl DYRENIUM eplerenone spironolactone (25 mg tablet, 50 mg tablet, 100 mg tablet) Diuretics, Thiazide chlorothiazide chlorthalidone hydrochlorothiazide (12.5 mg capsule, 12.5 mg tablet, 25 mg tablet, 50 mg tablet) indapamide methyclothiazide Pref. - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 54 LAST UPDATE 08/2015

55 metolazone Dyslipidemics, Fibric Acid Derivatives fenofibrate (54 mg tablet, 160 mg tablet) fenofibrate nanocrystallized fenofibrate,micronized (67 mg capsule, 134mg capsule, 200 mg capsule) fenofibric acid fenofibric acid (choline) gemfibrozil 600 mg tablet lofibra Dyslipidemics, HMG CoA Reductase Inhibitors atorvastatin calcium CRESTOR fluvastatin sodium LIVALO lovastatin pravastatin sodium simvastatin (5 mg tablet, 10 mg tablet, 20 mg tablet) Pref. simvastatin 40 mg tablet QL (30 PER 30 DAYS) Dyslipidemics, Other cholestyramine (with sugar) (4 g powder, 4 g powd pack) cholestyramine/aspartame (4 g powd pack, 4 g powder) COLESTID FLAVORED GRANULES colestid granules colestipol hcl (1 g tablet, 5 g packet, 5 g granules) - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 55 LAST UPDATE 08/2015

56 JUXTAPID, LA KYNAMRO, LA niacin (500 mg tab er 24h, 750 mg tab er 24h, 1000 mg tab er 24h) niacor omega-3 acid ethyl esters prevalite (packet, powder) ZETIA Vasodilators, Direct-acting Arterial hydralazine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 100 mg tablet) minoxidil (2.5 mg tablet, 10 mg tablet) RECTIV Pref. Vasodilators, Direct-acting Arterial/Venous DILATRATE-SR isochron isosorbide dinitrate isosorbide mononitrate minitran NITRO-BID NITRO-DUR (0.3 TCH, 0.8 TCH) nitro-time nitroglycerin (0.1mg/hr patch td24, 0.2mg/hr patch td24, 0.4mg/hr patch td24, 0.6mg/hr patch td24, 2.5 mg capsule er, 6.5 mg capsule er, 9 mg capsule er, 400mcg/spr spray) NITROSTAT (0.3 MG TABLET, 0.6 MG TABLET) NITROSTAT 0.4 MG TABLET SL Pref. Pref. Pref. - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 56 LAST UPDATE 08/2015

57 Central Nervous System Agents Attention Deficit Hyperactivity Disorder Agents, Amphetamines dextroamphetamine sulfsaccharate/amphetamine sulfaspartate (5 mg cap er 24h, 10 mg cap er 24h, 15 mg cap er 24h, 25 mg cap er 24h, 30 mg cap er 24h) dextroamphetamine sulfsaccharate/amphetamine sulfaspartate (5 mg tablet, 7.5 mg tablet, 10 mg tablet, 12.5 mg tablet, 15 mg tablet, 20 mg tablet, 20 mg cap er 24h, 30 mg tablet) dextroamphetamine sulfate (5 mg tablet, 5 mg capsule er, 10 mg tablet, 10 mg capsule er, 15 mg capsule er) methamphetamine hcl VYVANSE zenzedi (5 mg tablet, 10 mg tablet) QL (30 PER 30 DAYS) QL (60 PER 30 DAYS), QL (30 PER 30 DAYS) Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines clonidine hcl 0.1 mg tab er 12h DAYTRANA dexmethylphenidate hcl (2.5 mg tablet, 5 mg tablet, 10 mg tablet) guanfacine hcl (1 mg tab er 24h, 2 mg tab er 24h, 3 mg tab er 24h, 4 mg tab er 24h) metadate er methylphenidate hcl (18 mg tab er 24, 27 mg tab er 24), QL (30 PER 30 DAYS), QL (30 PER 30 DAYS) QL (30 PER 30 DAYS) - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 57 LAST UPDATE 08/2015

58 methylphenidate hcl (5 mg tablet, 5 mg/5 ml solution, 10 mg tablet, 10 mg tablet er, 10 mg/5 ml solution, 10 mg cpbp 30-70, 20 mg cpbp 30-70, 20 mg tablet, 20 mg cpbp 50-50, 20 mg tablet er, 30 mg cpbp 50-50, 30 mg cpbp 30-70, 36 mg tab er 24, 40 mg cpbp 50-50, 40 mg cpbp 30-70, 50 mg cpbp 30-70, 54 mg tab er 24, 60 mg cpbp 30-70) RITALIN LA 10 MG CAPSULE RITALIN LA 60 MG CAPSULE STRATTERA, QL (30 PER 30 DAYS), QL (30 PER 30 DAYS) Central Nervous System Agents, Other cevimeline hcl NUEDEXTA riluzole XENAZINE Fibromyalgia Agents SAVELLA (12.5 MG TABLET, 25 MG TABLET, 50 MG TABLET, 100 MG TABLET) SAVELLA TITRATION CK, QL (60 PER 30 DAYS), QL (55 PER 28 DAYS) Multiple Sclerosis Agents AMPYRA, LA, QL (60 PER 30 DAYS) AUBAGIO, LA, QL (30 PER 30 DAYS) AVONEX (SYR 30 MCG, SYR 30 MCG KT) AVONEX ADMINISTRATION CK AVONEX PEN BETASERON 0.3 MG KIT, QL (14 PER 30 DAYS) - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 58 LAST UPDATE 08/2015

59 BETASERON 0.3 MG VIAL, QL (15 PER 30 DAYS) COXONE 20 MG/ML SYRINGE QL (30 ML PER 30 DAYS) COXONE 40 MG/ML SYRINGE QL (12 ML PER 28 DAYS) EXTAVIA 0.3 MG KIT, QL (14 PER 30 DAYS) EXTAVIA 0.3 MG VIAL, QL (15 PER 30 DAYS) GILENYA, QL (30 PER 30 DAYS) GLATO QL (30 ML PER 30 DAYS) PLEGRIDY QL (1 ML PER 28 DAYS) PLEGRIDY PEN QL (1 ML PER 28 DAYS) REBIF QL (6 ML PER 30 DAYS) REBIF REBIDOSE QL (6 ML PER 30 DAYS) TECFIDERA QL (60 PER 30 DAYS) Dental and Oral Agents pilocarpine hcl (5 mg tablet, 7.5 mg tablet) Dermatological Agents ONEXTON 8-MOP ABSORICA (25 MG CAPSULE, 35 MG CAPSULE) ACANYA acitretin adapalene (0.1 % gel (gram), 0.1 % cream (g)) adapalene (0.3 % gel (gram), 0.3 % gel w/pump) amnesteem - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 59 LAST UPDATE 08/2015

60 avita 0.025% cream AZELEX BENZACLIN (GEL 35G PUMP, GEL 50G PUMP) BENZAMYCINK calcipotriene (0.005 % cream (g), % oint. (g), % solution) calcipotriene/betamethasone dipropionate calcitrene, QL (120 GM PER 30 DAYS) calcitriol 3 mcg/g oint. (g), QL (100 GM PER 30 DAYS) CARAC claravis clindamycin phosphate/benzoyl peroxide clotrimazole/betamethasone dipropionate (1 %-0.05 % lotion, 1 % % cream (g)) CONDYLOX 0.5% GEL CORTISPORIN OINTMENT cyclosporine, modified (25 mg capsule, 50 mg capsule, 100 mg/ml solution) diclofenac sodium 3 % gel (gram) DIFFERIN 0.3% GEL ELIDEL EPIDUO - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 60 LAST UPDATE 08/2015

61 EPIDUO FORTE erythromycin base/benzoyl peroxide FINACEA Pref. FLUOROPLEX fluorouracil (2 % solution, 5 % solution, 5 % cream (g)) fluorouracil 0.5 % cream (g) gengraf (25 mg capsule, 100 mg/ml solution, 100 mg capsule) hypercare methoxsalen, rapid mometasone furoate (0.1 % cream (g), 0.1 % oint. (g), 0.1 % solution) myorisan neuac gel OXSORALEN PHISOHEX PICATO podofilox 0.5 % solution prednicarbate PRUDOXIN refissa Pref. REGRANEX SANTYL Pref. QL (30 GM PER 30 DAYS) selenium sulfide 2.5 % suspension spinosad - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 61 LAST UPDATE 08/2015

62 STELARA 45 MG/0.5 ML SYRINGE QL (0.5 ML PER 90 DAYS) STELARA 90 MG/ML SYRINGE QL (1 ML PER 90 DAYS) TACLONEX 0.005%-0.064% SUSPENS tacrolimus (0.03 % oint. (g), 0.1 % oint. (g)) TAZORAC tretinoin (0.01 % gel (gram), % gel (gram), % cream (g), 0.05 % cream (g), 0.1 % cream (g)) tretinoin/emollient base trianex VELTIN VEREGEN VOLTAREN zenatane ZIANA ZONALON Enzyme Replacement/ Modifiers ADAGEN BUPHENYL 500 MG TABLET CARBAGLU CERDELGA CREON CYSTADANE Pref. Pref. Pref. KUVAN, LA, QL (60 GM PER 30 DAYS) - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 62 LAST UPDATE 08/2015

63 ORFADIN (2 MG CAPSULE, 5 MG CAPSULE) ORFADIN 10 MG CAPSULE pancrelipase 5,000 RAVICTI LA sodium phenylbutyrate 0.94 g/g powder SUCRAID ZAVESCA ZENPEP (DR 3,000 CAPSULE, DR 10,000 CAPSULE, DR 15,000 CAPSULE, DR 20,000 CAPSULE, DR 25,000 CAPSULE, DR 40,000 CAPSULE) Gastrointestinal Agents Pref. Antispasmodics, Gastrointestinal CANTIL CUVPOSA dicyclomine hcl (10 mg capsule, 10 mg/5 ml solution, 20 mg tablet) glycopyrrolate (1 mg tablet, 2 mg tablet) methscopolamine bromide (2.5 mg tablet, 5 mg tablet) Gastrointestinal Agents, Other APRISO ASACOL HD CANASA Pref. Pref. Pref. CHENODAL, LA DELZICOL diphenoxylate hcl/atropine sulfate ( mg tablet, /5 liquid) Pref. - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 63 LAST UPDATE 08/2015

64 FULYZAQ GATTEX lansoprazole/amoxicillin trihydrate/clarithromycin LIALDA mesalamine 4 g/60 ml enema mesalamine with cleansing wipes MOTOFEN PENTASA PROCTOFOAM-HC propantheline bromide 15 mg tablet PYLERA RELISTOR (8 MG/0.4 ML SYRINGE, 12 MG/0.6 ML KIT, 12 MG/0.6 ML VIAL, 12 MG/0.6 ML SYRINGE) sulfasalazine (500 mg tablet, 500 mg tablet dr) sulfazine sulfazine ec ursodiol (250 mg tablet, 300 mg capsule, 500 mg tablet) Histamine2 (H2) Receptor Antagonists cimetidine (300 mg tablet, 400 mg tablet, 800 mg tablet) cimetidine hcl famotidine (40mg/5ml oral susp, 40 mg tablet) nizatidine (150mg/10ml solution, 150 mg capsule, 300 mg capsule) ranitidine hcl (15 mg/ml syrup, 300 mg tablet, 300 mg capsule) Pref. Pref. Pref. - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 64 LAST UPDATE 08/2015

65 Irritable Bowel Syndrome Agents alosetron hcl AMITIZA Laxatives constulose enulose gavilyte-c gavilyte-g gavilyte-n generlac GOLYTELY CKET lactulose MOVIPREP NULYTELY WITH FLAVOR CKS peg 3350/sod sulf/sod bicarbonate/sod chloride/potassium chl sodium chloride/sodium bicarbonate/potassium chloride/peg SUPREP trilyte with flavor packets Protectants CARAFATE 1 GM/10 ML SUSP misoprostol (100 mcg tablet, 200 mcg tablet) sucralfate 1 g tablet Pref. - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 65 LAST UPDATE 08/2015

66 Proton Pump Inhibitors DEXILANT, QL (30 PER 30 DAYS) esomeprazole magnesium, QL (30 PER 30 DAYS) lansoprazole 30 mg capsule dr NEXIUM (DR 20 MG CKET, DR 40 MG CKET) omeprazole (10 mg capsule dr, 20 mg capsule dr, 40 mg capsule dr) pantoprazole sodium (20 mg tablet dr, 40 mg tablet dr) PROTONIX 40 MG SUSPENSION rabeprazole sodium Genitourinary Agents Antispasmodics, Urinary ENABLEX flavoxate hcl oxybutynin chloride (5 mg/5 ml syrup, 5 mg tablet, 5 mg tab er 24, 10 mg tab er 24, 15 mg tab er 24) OXYTROL tolterodine tartrate TOVIAZ trospium chloride 20 mg tablet Pref. trospium chloride 60 mg cap er 24h VESICARE, QL (30 PER 30 DAYS) - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 66 LAST UPDATE 08/2015

67 Benign Prostatic Hypertrophy Agents alfuzosin hcl AVODART CIALIS 5 MG TABLET finasteride 5 mg tablet RAFLO tamsulosin hcl, QL (30 PER 30 DAYS) Genitourinary Agents, Other bethanechol chloride (5 mg tablet, 10 mg tablet, 25 mg tablet, 50 mg tablet) CUPRIMINE CYSTAGON DEPEN ELMIRON methylergonovine maleate 0.2 mg tablet Pref. PROCYSBI, LA THIOLA Phosphate Binders AURYXIA calcium acetate 667 mg capsule FOSRENOL PHOSLYRA Pref. RENAGEL Pref. QL (90 PER 30 DAYS) - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 67 LAST UPDATE 08/2015

68 RENVELA Pref. sevelamer carbonate Pref. Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal) Glucocorticoids/Mineralocorticoids betamethasone acetate/betamethasone sodium phosphate budesonide 3 mg capdr - er dexamethasone (0.5 mg tablet, 0.5 mg/5ml elixir, 0.5 mg/5ml solution, 0.75 mg tablet, 1 mg tablet, 1.5 mg tablet, 2 mg tablet, 4 mg tablet, 6 mg tablet) dexamethasone sod phosphate 0.1 % drops diclofenac sodium 0.1 % drops DUREZOL EPIFOAM FLAREX FLOVENT DISKUS FLOVENT HFA fluocinolone acetonide oil fluorometholone fluticasone propionate 50 mcg spray susp FML FORTE FML S.O.P. hydrocortisone (5 mg tablet, 10 mg tablet, 20 mg tablet) hydrocortisone butyrate (0.1 % oint. (g), 0.1 % solution) Pref. Pref. Pref. Pref. - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 68 LAST UPDATE 08/2015

69 hydrocortisone valerate hydrocortisone/mineral oil/petrolatum,white MAXIDEX prednisolone acetate triamcinolone acetonide 55 mcg spray VERAMYST Hormonal Agents, Stimulant/Replacement/Modifying (Other) MYALEPT Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) desmopressin acetate (0.1 mg tablet, 0.1 mg/ml solution, 0.2 mg tablet, 10/spray spray/pump) desmopressin acetate (nonrefrigerated) EGRIFTA GENOTROPIN 5 MG CARTRIDGE H.P. ACTHAR HUMATROPE INCRELEX, LA NORDITROPIN 5 MG/1.5 ML CRTG NUTROPIN 10 MG VIAL NUTROPIN AQ (20 MG/2ML PEN CART, PEN CARTRIDGE) NUTROPIN AQ NUSPIN OMNITROPE (5 MG/1.5 ML CRTG, 5.8 MG VIAL, 10 MG/1.5 ML CRTG) SAIZEN 8.8 MG CLICK.EASY CARTG - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 69 LAST UPDATE 08/2015

70 SEROSTIM 4 MG VIAL STIMATE Pref. ZOMACTON 10 MG VIAL Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) Anabolic Steroids ANADROL-50 oxandrolone (2.5 mg tablet, 10 mg tablet) Androgens ANDRODERM ANDROGEL (1.62%(1.25G) GEL PCKT, 1.62% GEL PUMP, 1.62%(2.5G) GEL PCKT) ANDROID androxy danazol (50 mg capsule, 100 mg capsule, 200 mg capsule) METHITEST testosterone (1.25g (1%) gel md pmp, 25mg(1%) gel packet, 50 mg (1%) gel (gram), 50 mg (1%) gel packet) testosterone cypionate (100 mg/ml vial, 200 mg/ml vial) testosterone enanthate 200 mg/ml vial TESTRED Estrogens ALTAVERA ALYACEN Pref. Pref. - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 70 LAST UPDATE 08/2015

71 AMETHIA AMETHIA LO AMETHYST APRI ARANELLE ashlyna AUBRA AVIANE AZURETTE BALZIVA BRIELLYN CAMRESE CAMRESE LO CAZIANT CENESTIN (0.625 MG TABLET, 1.25 MG TABLET) CHATEAL COMBITCH CRYSELLE CYCLAFEM DASETTA DAYSEE DELYLA desogestrel-ethinyl estradiol desogestrel-ethinyl estradiol/ethinyl estradiol DUAVEE ELINEST EMOQUETTE - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 71 LAST UPDATE 08/2015

72 ENJUVIA (0.3 MG TABLET, 0.45 MG TABLET, MG TABLET) ENPRESSE ENSKYCE ESTARYLLA ESTRACE 0.01% CREAM estradiol (.025mg/24h patch tdsw,.025mg/24h patch tdwk,.0375mg/24 patch tdwk,.0375mg/24 patch tdsw, 0.05mg/24h patch tdsw, 0.05mg/24h patch tdwk, 0.06mg/24h patch tdwk,.075mg/24h patch tdwk,.075mg/24h patch tdsw, 0.1mg/24hr patch tdwk, 0.1mg/24hr patch tdsw, 0.5 mg tablet, 1 mg tablet, 2 mg tablet) estradiol/norethindrone acetate ESTRING estropipate ethinyl estradiol/drospirenone FALMINA GIANVI GILDAGIA GILDESS GILDESS 24 FE GILDESS FE INTROVALE JINTELI JOLESSA JUNEL JUNEL FE junel fe 24 KARIVA Pref. Pref. - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 72 LAST UPDATE 08/2015

73 KELNOR 1-35 kimidess KURVELO l-norgest/e.estradion-e.estrad (84) tbdspk 3mo l-norgest/e.estradion-e.estrad (84) tbdspk 3mo LARIN larin 24 fe LARIN FE LEENA LESSINA LEVONEST levonorgestrel-ethin estradiol 90-20mcg tablet levonorgestrel-ethinyl estradiol ( tablet, tbdspk 3mo, tablet) LEVORA-28 LOPREEZA LORYNA LOW-OGESTREL LUTERA MARLISSA MENEST MICROGESTIN MICROGESTIN FE mimvey mimvey lo - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 73 LAST UPDATE 08/2015

74 MONO-LINYAH MONONESSA MYZILRA NECON NIKKI norethindrone ac-eth estradiol 1mg- 20mcg tablet norethindrone ac-eth estradiol 1mg- 5mcg tablet norethindrone-e.estradiol-iron 1mg- 20(21) tablet norethindrone-e.estradiol-iron 1mg- 20(24) tablet norgestimate-ethinyl estradiol NORTREL NUVARING OCELLA OGESTREL ORSYTHIA ORTHO TRI-CYCLEN LO PHILITH PIMTREA PIRMELLA PORTIA PREMARIN (0.3 MG TABLET, 0.45 MG TABLET, MG TABLET, 0.9 MG TABLET, 1.25 MG TABLET) PREMARIN VAGINAL CREAM-APPL PREMPHASE PREMPRO Pref. - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 74 LAST UPDATE 08/2015

75 PREVIFEM QUASENSE RECLIPSEN SPRINTEC SRONYX SYEDA tarina fe TILIA FE TRI-ESTARYLLA TRI-LEGEST FE TRI-LINYAH TRI-PREVIFEM TRI-SPRINTEC TRINESSA TRIVORA-28 VAGIFEM VELIVET VESTURA VIORELE VYFEMLA WERA WYMZYA FE XULANE ZARAH ZENCHENT ZENCHENT FE ZEOSA ZOVIA 1-35E Pref. - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 75 LAST UPDATE 08/2015

76 ZOVIA 1-50E Progestins CAMILA CRINONE 4% GEL deblitane DEPO-SUBQ PROVERA 104 ELLA ENDOMETRIN ERRIN HEATHER JENCYCLA JOLIVETTE levonorgestrel 0.75 mg tablet LYZA medroxyprogesterone acetate (150 mg/ml vial, 150 mg/ml syringe) medroxyprogesterone acetate (2.5 mg tablet, 5 mg tablet, 10 mg tablet) megestrol acetate (20 mg tablet, 40 mg tablet, 400mg/10ml oral susp) NORA-BE norethindrone 0.35 mg tablet norethindrone acetate 5 mg tablet NORLYROC progesterone,micronized (100 mg capsule, 200 mg capsule) sharobel - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 76 LAST UPDATE 08/2015

77 Selective Estrogen Receptor Modifying Agents raloxifene hcl Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) levothyroxine sodium (25 mcg tablet, 50 mcg tablet, 75 mcg tablet, 88 mcg tablet, 100 mcg tablet, 112 mcg tablet, 125 mcg tablet, 137 mcg tablet, 150 mcg tablet, 175mcg tablet, 200 mcg tablet, 300 mcg tablet) levoxyl liothyronine sodium (5 mcg tablet, 25 mcg tablet, 50 mcg tablet) THYROLAR-1 THYROLAR-1/2 THYROLAR-1/4 THYROLAR-2 THYROLAR-3 unithroid (25 mcg tablet, 50 mcg tablet, 75 mcg tablet, 88 mcg tablet, 100 mcg tablet, 112 mcg tablet, 125 mcg tablet, 150 mcg tablet, 175 mcg tablet, 200 mcg tablet, 300 mcg tablet) Hormonal Agents, Suppressant (Adrenal) LYSODREN Pref. SIGNIFOR, LA Hormonal Agents, Suppressant (Parathyroid) calcitriol (0.25 mcg capsule, 0.5 mcg capsule, 1 mcg/ml solution) - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 77 LAST UPDATE 08/2015

78 paricalcitol (1 mcg capsule, 2 mcg capsule, 4mcg capsule) SENSIR (30 MG TABLET, 60 MG TABLET) ST QL (60 PER 30 DAYS) SENSIR 90 MG TABLET QL (120 PER 30 DAYS) Hormonal Agents, Suppressant (Pituitary) cabergoline ELIGARD leuprolide acetate 1 mg/0.2ml kit octreotide acetate SOMAVERT, LA SYNAREL Hormonal Agents, Suppressant (Sex Hormones/Modifiers) Antiandrogens bicalutamide NILANDRON Pref. XTANDI Hormonal Agents, Suppressant (Thyroid) Antithyroid Agents methimazole (5 mg tablet, 10 mg tablet) propylthiouracil 50 mg tablet Immunological Agents Angioedema (HAE) Agents BERINERT, QL (3 PER 30 DAYS) - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 78 LAST UPDATE 08/2015

79 Immune Suppressants ASTAGRAF XL azathioprine 50 mg tablet CIMZIA (200 MG/ML STARTER KIT, 200 MG/ML SYRINGE KIT) cyclosporine (25 mg capsule, 100 mg capsule) cyclosporine, modified 100 mg capsule ENBREL (50 MG/ML SYRINGE, 50 MG/ML SURECLICK SYR), QL (1 PER 28 DAYS) QL (3.92 ML PER 28 DAYS) ENBREL 25 MG KIT QL (8 PER 28 DAYS) ENBREL 25 MG/0.5 ML SYRINGE QL (4.08 ML PER 28 DAYS) hecoria HUMIRA QL (2 PER 28 DAYS) HUMIRA CROHN'S QL (6 PER 28 DAYS) HUMIRA PEDIATRIC CROHN'S QL (6 PER 28 DAYS) HUMIRA PSORIASIS QL (4 PER 28 DAYS) KINERET, QL (0.67 ML PER DAY) mycophenolate mofetil (200 mg/ml susp recon, 250 mg capsule, 500 mg tablet) mycophenolate sodium RAMUNE 1 MG/ML ORAL SOLN RESTASIS Pref. QL (60 PER 30 DAYS) SANDIMMUNE 100 MG/ML SOLN SIMPONI (100 MG/ML PEN INJECTOR, 100 MG/ML SYRINGE) SIMPONI (50 ML SYRINGE, 50 ML PEN INJEC) QL (1 ML PER 30 DAYS) QL (0.5 ML PER 30 DAYS) - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 79 LAST UPDATE 08/2015

80 sirolimus (0.5 mg tablet, 1 mg tablet, 2 mg tablet) tacrolimus (0.5 mg capsule, 1 mg capsule, 5 mg capsule) ZORTRESS Immunizing Agents, Passive GAMMAKED GAMUNEX GAMUNEX-C HIZENTRA HYQVIA Immunomodulators ACTIMMUNE FIRAZYR, QL (9 ML PER 30 DAYS) leflunomide OTEZLA (28 DAY CK, CK) OTEZLA 30 MG TABLET, QL (2 PER DAY) RIDAURA Inflammatory Bowel Disease Agents Aminosalicylates balsalazide disodium DIPENTUM Glucocorticoids colocort hydrocortisone 100mg/60ml enema proctosol-hc proctozone-hc UCERIS 9 MG ER TABLET Pref. - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 80 LAST UPDATE 08/2015

81 MISCELLANEOUS THERAPEUTIC AGENTS hydroxyprogesterone caproate testosterone cypionate 100 % powder Metabolic Bone Disease Agents alendronate sodium (5 mg tablet, 10 mg tablet, 35 mg tablet, 40 mg tablet, 70 mg/75ml solution, 70 mg tablet) calcitonin,salmon,synthetic doxercalciferol (0.5 mcg capsule, 1 mcg capsule, 2.5 mcg capsule) etidronate disodium FORTEO fortical FOSAMAX PLUS D ibandronate sodium 150 mg tablet MIACALCIN 200 UNIT/ML VIAL OMONTYS risedronate sodium Miscellaneous Glucose Testing ACCU-CHECK (METERS & TEST STRIPS) DME Benefit QL LIFESCAN (METERS & TEST STRIPS) DME Benefit QL ST - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 81 LAST UPDATE 08/2015

82 Ophthalmic Agents Ophthalmic Prostaglandin and Prostamide Analogs bimatoprost ST, QL (2.5 ML PER 30 DAYS) latanoprost % drops LUMIGAN Pref. ST, QL (2.5 ML PER 30 DAYS) TRAVATAN Z travoprost (benzalkonium) Ophthalmic Agents, Other ak-poly-bac bacitracin/polymyxin b sulfate k/g oint. (g) BLEPHAMIDE BLEPHAMIDE S.O.P. Pref. Pref. CYSTARAN, LA, QL (60 ML PER 30 DAYS) LACRISERT naphazoline hcl neo-polycin neo-polycin hc neomycin sulfate/bacitracin zinc/polymyxin b/hydrocortisone neomycin sulfate/bacitracin/polymyxin b neomycin sulfate/polymyxin b sulfate/gramicidin d neomycin/polymyxin b sulf/hc k- 10 drops susp neomycin/polymyxin b sulfate/dexamethasone (0.1 % drops susp, k-.1 oint. (g)) - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 82 LAST UPDATE 08/2015

83 neosporin eye drops polycin polymyxin b sulfate/trimethoprim sulfacetamide sodium 10 % oint. (g) sulfacetamide sodium/prednisolone sodium phosphate tobramycin/dexamethasone tropicamide (0.5 % drops, 1 % drops) ZYLET Ophthalmic Anti-allergy Agents ALOCRIL ALOMIDE azelastine hcl 0.05 % drops BEPREVE cromolyn sodium 4 % drops EMADINE epinastine hcl LASTACAFT TADAY TANOL Ophthalmic Anti-inflammatories ALREX bromfenac sodium - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 83 LAST UPDATE 08/2015

84 flurbiprofen sodium ketorolac tromethamine (0.4 % drops, 0.5 % drops) LOTEMAX (0.5% EYE DROPS, 0.5% OPHTHALMIC GEL, 0.5% EYE OINTMENT) NEVANAC prednisolone sod phosphate 1 % drops VEXOL Ophthalmic Antiglaucoma Agents ALPHAGAN P 0.1% DROPS apraclonidine hcl AZOPT betaxolol hcl 0.5 % drops BETIMOL BETOPTIC S brimonidine tartrate (0.15 % drops, 0.2 % drops) carteolol hcl COMBIGAN dorzolamide hcl dorzolamide hcl/timolol maleate ISTALOL levobunolol hcl metipranolol PHOSPHOLINE IODIDE Pref. Pref. Pref. - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 84 LAST UPDATE 08/2015

85 pilocarpine hcl (1 % drops, 2 % drops, 4 % drops) PILOPINE HS timolol maleate (0.25 % drops, 0.25 % sol-gel, 0.5 % drops, 0.5 % sol-gel) ZIOPTAN Otic Agents CIPRO HC CIPRODEX ciprofloxacin hcl 0.2 % droperette COLY-MYCIN S CORTISPORIN-TC Pref. Pref. Respiratory Tract Agents Anti-inflammatories, Inhaled Corticosteroids AEROSN ALVESCO ARNUITY ELLIPTA ASMANEX ASMANEX HFA BREO ELLIPTA MCG INH budesonide (0.25mg/2ml ampul-neb, 0.5 mg/2ml ampul-neb, 1 mg/2 ml ampul-neb, 32mcg spray/pump) flunisolide (25 mcg spray, 29mcg spray) NASONEX Pref. Pref. Pref. Pref. Pref. QL (17 GM PER 30 DAYS) - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 85 LAST UPDATE 08/2015

86 OMNARIS PULMICORT FLEXHALER QVAR ZETONNA Pref. Pref. Antihistamines arbinoxa (4 mg tablet, 4 mg/5 ml liquid) azelastine hcl 137 mcg spray/pump carbinoxamine maleate (4 mg tablet, 4 mg/5 ml liquid) clemastine fumarate (0.67mg/5ml syrup, 2.68 mg tablet) cyproheptadine hcl (2 mg/5 ml syrup, 4 mg tablet) desloratadine 5 mg tablet levocetirizine dihydrochloride (2.5 mg/5ml solution, 5 mg tablet) olopatadine hcl palgic (4 mg/5 ml liquid, 4 mg tablet) Antileukotrienes montelukast sodium (4 mg gran pack, 4 mg tab chew, 5 mg tab chew, 10 mg tablet) zafirlukast ZYFLO CR Bronchodilators, Anticholinergic ATROVENT HFA INCRUSE ELLIPTA ipratropium bromide (0.2 mg/ml solution, 21 mcg spray, 42mcg spray) Pref. Pref. - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 86 LAST UPDATE 08/2015

87 SPIRIVA Pref. QL (30 PER 30 DAYS) SPIRIVA RESPIMAT Pref. Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) LUFYLLIN theochron theophylline anhydrous (100 mg tab er 12h, 200 mg tab er 12h, 300 mg tab er 12h, 400 mg tablet er, 450 mg tab er 12h, 600 mg tablet er) Bronchodilators, Sympathomimetic ADVAIR DISKUS ADVAIR HFA albuterol sulfate (0.63mg/3ml vial-neb, 1.25mg/3ml vial-neb, 2 mg/5 ml syrup, 2 mg tablet, 2.5 mg/3ml vial-neb, 2.5 mg/0.5 vial-neb, 4 mg tab er 12h, 4 mg tablet, 5 mg/ml solution, 8 mg tab er 12h) ANORO ELLIPTA ARCAPTA NEOHALER BREO ELLIPTA MCG INH Pref. Pref. Pref. Pref. QL (30 PER 30 DAYS) BROVANA QL (120 ML PER 30 DAYS) COMBIVENT Pref. COMBIVENT RESPIMAT Pref. QL (4 GM PER 30 DAYS) EPIPEN 2-K EPIPEN JR 2-K FORADIL ipratropium bromide/albuterol sulfate levalbuterol hcl (0.31mg/3ml vial-neb, 0.63mg/3ml vial-neb, 1.25mg/0.5 vialneb, 1.25mg/3ml vial-neb) Pref. Pref. Pref. - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 87 LAST UPDATE 08/2015

88 MAXAIR AUTOHALER metaproterenol sulfate (10 mg tablet, 10 mg/5 ml syrup, 20 mg tablet) PERFOROMIST Pref. proair hfa QL (17 GM PER 30 DAYS) proair respiclick QL (2 PER 30 DAYS) SEREVENT DISKUS SYMBICORT terbutaline sulfate (2.5 mg tablet, 5 mg tablet) Pref. Pref. ventolin hfa QL (36 GM PER 30 DAYS) XOPENEX HFA Mast Cell Stabilizers cromolyn sodium (20 mg/ml oral conc, 20 mg/2 ml ampul-neb) Pulmonary Antihypertensives ADCIRCA, QL (60 PER 30 DAYS) ADEMS LETAIRIS OPSUMIT, LA ORENITRAM ER, LA REVATIO 10 MG/ML ORAL SUSP sildenafil citrate 20 mg tablet, QL (90 PER 30 DAYS) TRACLEER, LA VENTAVIS Respiratory Tract Agents, Other acetylcysteine (100 mg/ml vial, 200 mg/ml vial) - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 88 LAST UPDATE 08/2015

89 ambitussin ac ( for ages 5 and under) benzonatate cheratussin ac ( for ages 5 and under) cheratussin dac ( for ages 5 and under) DALIRESP ESBRIET, LA GRASTEK guaiatussin ac ( for ages 5 and under) guaifenesin ac ( for ages 5 and under) guaifenesin dac ( for ages 5 and under) guaifenesin/codeine phosphate mg/5 liquid hydrocodone bit/homatrop me-br mg/5 syrup hydromet HYPER-SAL 3.5% VIAL ( for ages 5 and under) iophen-c nr ( for ages 5 and under) KALYDECO (50 MG GRANULES CKET, 75 MG GRANULES CKET), LA, QL (60 PER 30 DAYS) KALYDECO 150 MG TABLET, LA, QL (60 PER 30 DAYS) lortuss ex ( for ages 5 and under) OFEV ORALAIR phenylephrine hcl/promethazine hcl, LA promethazine hcl/codeine ( for ages 5 and under) promethazine hcl/dextromethorphan hbr promethazine/phenylephrine hcl/codeine ( for ages 5 and under) - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 89 LAST UPDATE 08/2015

90 pulmosal PULMOZYME RAGWITEK sodium chloride for inhalation 7 % vialneb tusnel c ( for ages 5 and under) TYZINE virtussin ac ( for ages 5 and under) virtussin dac ( for ages 5 and under) Skeletal Muscle Relaxants carisoprodol (250 mg tablet, 350 mg tablet) carisoprodol/aspirin chlorzoxazone cyclobenzaprine hcl (5 mg tablet, 7.5 mg tablet, 10 mg tablet) metaxalone 800 mg tablet methocarbamol (500 mg tablet, 750 mg tablet) orphenadrine citrate 100 mg tablet er orphenadrine/aspirin/caffeine tablet Sleep Disorder Agents GABA Receptor Modulators estazolam eszopiclone QL (30 PER 30 DAYS) flurazepam hcl - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 90 LAST UPDATE 08/2015

91 temazepam triazolam zaleplon QL (30 PER 30 DAYS) zolpidem tartrate (5 mg tablet, 10 mg tablet) Sleep Disorders, Other QL (30 PER 30 DAYS) modafinil, QL (30 PER 30 DAYS) NUVIGIL (150 MG TABLET, 250 MG TABLET) NUVIGIL 200 MG TABLET NUVIGIL 50 MG TABLET ROZEREM, QL (30 PER 30 DAYS), QL (30 PER 30 DAYS), QL (60 PER 30 DAYS), QL (30 PER 30 DAYS) XYREM, LA, QL (540 ML PER 30 DAYS) Therapeutic Nutrients/ Minerals/ Electrolytes Electrolyte/Mineral Modifiers CHEMET EXJADE FERRIPROX kionex (15 gm/60 ml suspension, powder) levocarnitine (with sugar) levocarnitine 330 mg tablet marlexate SAMSCA sodium polystyrene sulfonate (15 g/60 ml oral susp, 30g/120ml enema, 50g/200ml enema, powder) - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 91 LAST UPDATE 08/2015

92 sps 15 gm/60 ml suspension SYPRINE Electrolyte/Mineral Replacement cyanocobalamin (vitamin b-12) 1000mcg/ml vial ergocalciferol (vitamin d2) unit capsule fluoride/iron/vitamins a,c,and d klor-con 10 KLOR-CON 8 klor-con m10 klor-con m15 klor-con m20 NIVA-PLUS OSMOPREP pediatric multivitamin combination no.2/sodium fluoride pediatric multivitamins no.82 with sodium fluoride pnv-vp-u potassium chloride (8 capsule er, 8 tablet er, 10 tab er prt, 10 tablet er, 10 capsule er, 20 tablet er, 20 tab er prt) potassium citrate (5 tablet er, 10 tablet er) prenatal vits with calcium #72/ferrous fumarate/folic acid prenatal vits with calcium #74/ferrous fumarate/folic acid prenatal vits without calc no5/ferrous fumarate/folic acid - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 92 LAST UPDATE 08/2015

93 preplus QUFLORA (0.25 MG/ML DROP, 0.5 MG/ML DROP) TL FOLATE triveen-u - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 93 LAST UPDATE 08/2015

94 Alphabetical Listing 8 8-MOP 59 A abacavir sulfate 39 abacavir sulfate/lamivudine/zidovudine 39 ABILIFY 23 ABILIFY DISCMELT 23 ABSORICA 59 acamprosate calcium 11 ACANYA 59 acarbose 44 acebutolol hcl 50 acetaminophen with codeine phosphate 8 acetasol hc 15 acetazolamide 20,54 acetic acid 15 acetic acid/aluminum acetate 15 acetic acid/hydrocortisone 15 acetylcysteine 88 acitretin 59 ACTIMMUNE 80 ACTOPLUS MET XR 44 acyclovir 42 ADAGEN 62 adapalene 59 ADCIRCA 88 adefovir dipivoxil 41 ADEMS 88 ADVAIR DISKUS 87 ADVAIR HFA 87 AEROSN 85 afeditab cr 51 AFINITOR 34 AFINITOR DISPERZ 34 AGGRENOX 48 ak-poly-bac 82 ALBENZA 35 albuterol sulfate 87 alclometasone dipropionate 12 alendronate sodium 81 alfuzosin hcl 67 ALINIA 35,36 ALKERAN 32 allopurinol 29 almotriptan malate 30 ALOCRIL 83 ALOMIDE 83 alosetron hcl 65 ALPHAGAN P 84 alprazolam 43 ALREX 83 ALTABAX 15 ALTAVERA 70 ALVESCO 85 ALYACEN 70 amantadine hcl 37 ambitussin ac 89 amcinonide 12 AMETHIA 71 AMETHIA LO 71 AMETHYST 71 amiloride hcl 54 amiloride hcl/hydrochlorothiazide 52 amiodarone hcl 50 AMITIZA 65 amitriptyline hcl 25 amlodipine besylate 51 amlodipine besylate/atorvastatin calcium 52 amlodipine besylate/benazepril hcl 53 amnesteem 59 amoxapine 25 amoxicillin 17 amoxicillin/potassium clavulanate 17 ampicillin trihydrate 17 AMPYRA 58 ANADROL anagrelide hcl 47 anastrozole 34 ANDRODERM 70 ANDROGEL 70 94

95 ANDROID 70 androxy 70 ANORO ELLIPTA 87 anusol-hc 12 ANZEMET 27 apexicon e 12 APIDRA 46 APIDRA SOLOSTAR 46 APLENZIN 24 APOKYN 37 apraclonidine hcl 84 APRI 71 APRISO 63 APTIOM 22 APTIVUS 40 ARANELLE 71 ARANESP 47 arbinoxa 86 ARCAPTA NEOHALER 87 aripiprazole 24 ARNUITY ELLIPTA 85 ASACOL HD 63 ascomp with codeine 8 ashlyna 71 ASMANEX 85 ASMANEX HFA 85 aspirin/dipyridamole 48 ASTAGRAF XL 79 atenolol 50 atenolol/chlorthalidone 53 atorvastatin calcium 55 atovaquone 36 ATRIPLA 40 ATROVENT HFA 86 AUBAGIO 58 AUBRA 71 AURYXIA 67 AVIANE 71 avidoxy 20 avita 60 AVODART 67 AVONEX 58 AVONEX ADMINISTRATION CK 58 AVONEX PEN 58 AZASITE 18 azathioprine 79 azelastine hcl 83,86 AZELEX 60 AZILECT 37 azithromycin 18 AZOPT 84 AZURETTE 71 B bacitracin 15 bacitracin/polymyxin b sulfate 82 baclofen 39 balsalazide disodium 80 BALZIVA 71 BANZEL 22 BARACLUDE 41 benazepril hcl 49 benazepril hcl/hydrochlorothiazide 53 BENICAR 49 BENZACLIN 60 BENZAMYCINK 60 benzonatate 89 benztropine mesylate 36 BEPREVE 83 BERINERT 78 BESIVANCE 19 betamethasone acetate/betamethasone sodium phosphate 68 betamethasone dipropionate 12 betamethasone dipropionate/propylene glycol 12 betamethasone valerate 12 BETASERON 58,59 betaxolol hcl 50,84 bethanechol chloride 67 BETIMOL 84 BETOPTIC S 84 bexarotene 35 95

96 bicalutamide 78 BILTRICIDE 35 bimatoprost 82 bisoprolol fumarate 51 bisoprolol fumarate/hydrochlorothiazide 53 bleph BLEPHAMIDE 82 BLEPHAMIDE S.O.P. 82 blood sugar diagnostic 81 BOSULIF 34 BREO ELLIPTA 85,87 BRIELLYN 71 BRILINTA 48 brimonidine tartrate 84 bromfenac sodium 83 bromocriptine mesylate 37 BROVANA 87 budeprion sr 24 budesonide 68,85 bumetanide 54 BUPHENYL 62 buprenorphine hcl 11 buprenorphine hcl/naloxone hcl 11 buproban 12 bupropion hcl 24 buspirone hcl 43 butalbital/acetaminophen 5 butalbital/acetaminophen/caffeine 5 butalbital/acetaminophen/caffeine/codeine phosphate 8 butalbital/aspirin/caffeine 5 butorphanol tartrate 8 BUTRANS 6 BYDUREON 44 BYDUREON PEN 44 BYETTA 44 BYSTOLIC 51 C cabergoline 78 cafergot 29 calcipotriene 60 calcipotriene/betamethasone dipropionate 60 calcitonin,salmon,synthetic 81 calcitrene 60 calcitriol 60,77 calcium acetate 67 CAMBIA 5 CAMILA 76 CAMRESE 71 CAMRESE LO 71 CANASA 63 candesartan cilexetil 49 CANTIL 63 capacet 5 capecitabine 33 CAPRELSA 34 captopril 49 captopril/hydrochlorothiazide 53 CARAC 60 CARAFATE 65 CARBAGLU 62 carbamazepine 22 carbidopa 37 carbidopa/levodopa 37 carbidopa/levodopa/entacapone 37 carbinoxamine maleate 86 carisoprodol 90 carisoprodol/aspirin 90 carteolol hcl 84 cartia xt 51 carvedilol 51 CAZIANT 71 CEENU 32 cefaclor 16 cefadroxil 17 cefdinir 17 cefditoren pivoxil 17 cefixime 17 cefpodoxime proxetil 17 cefprozil 17 ceftibuten 17 CEFTIN 17 96

97 cefuroxime axetil 17 celecoxib 5 CELONTIN 20 CENESTIN 71 cephalexin 17 CERDELGA 62 CESAMET 27 cevimeline hcl 58 CHANTIX 12 CHATEAL 71 CHEMET 91 CHENODAL 63 cheratussin ac 89 cheratussin dac 89 chlordiazepoxide hcl 43 chlorhexidine gluconate 15 chloroquine phosphate 36 chlorothiazide 54 chlorpromazine hcl 26 chlorpropamide 44 chlorthalidone 54 chlorzoxazone 90 cholestyramine (with sugar) 55 cholestyramine/aspartame 55 CIALIS 67 ciclodan 27 ciclopirox 27 ciclopirox olamine 28 ciclopirox/vitamin e mixed/nail lacquer remover, nonacet 28 cilostazol 48 cimetidine 64 cimetidine hcl 64 CIMZIA 79 CIPRO HC 85 CIPRODEX 85 ciprofloxacin hcl 19,85 ciprofloxacin/ciprofloxacin hcl 19 citalopram hydrobromide 24 claravis 60 clarithromycin 18 clemastine fumarate 86 clindacin etz 15 clindacin p 15 clindamycin hcl 15 clindamycin palmitate hcl 15 clindamycin phosphate 15 clindamycin phosphate/benzoyl peroxide 60 clobetasol propionate 12 clobetasol propionate/emollient base 12 clocortolone pivalate 12 clodan 12 CLODERM 12 clomipramine hcl 26 clonazepam 43 clonidine 48 clonidine hcl 48,57 clopidogrel bisulfate 48 clorazepate dipotassium 43 clotrimazole 28 clotrimazole/betamethasone dipropionate 60 clozapine 38,39 co-gesic 8 COARTEM 36 codeine phosphate/butalbital/aspirin/caffeine 8 codeine phosphate/carisoprodol/aspirin 8 codeine sulfate 8 colchicine 29 colchicine/probenecid 29 COLCRYS 29 COLESTID 55 colestid 55 colestipol hcl 55 colocort 80 COLY-MYCIN S 85 COMBIGAN 84 COMBITCH 71 COMBIVENT 87 COMBIVENT RESPIMAT 87 COMETRIQ 34 comfort pac-ibuprofen 5 COMPLERA 39 97

98 compro 26 CONDYLOX 60 constulose 65 COXONE 59 CORDRAN 12 COREG CR 51 cormax 12 cortisone acetate 12 CORTISPORIN 13,60 CORTISPORIN-TC 85 CREON 62 CRESTOR 55 CRINONE 76 CRIXIVAN 40 cromolyn sodium 83,88 CRYSELLE 71 CUPRIMINE 67 CUVPOSA 63 cyanocobalamin (vitamin b-12) 92 CYCLAFEM 71 cyclobenzaprine hcl 90 CYCLOPHOSPHAMIDE CAPSULES 32 cyclophosphamide tablets 32 cycloserine 15 CYCLOSET 44 cyclosporine 79 cyclosporine, modified 60,79 cyproheptadine hcl 86 CYSTADANE 62 CYSTAGON 67 CYSTARAN 82 D DALIRESP 89 danazol 70 dantrolene sodium 39 dapsone 31 DARAPRIM 36 DASETTA 71 DAYSEE 71 DAYTRANA 57 deblitane 76 DELYLA 71 DELZICOL 63 demeclocycline hcl 20 DENAVIR 42 depade 11 DEPEN 67 DEPO-SUBQ PROVERA desipramine hcl 26 desloratadine 86 desmopressin acetate 69 desmopressin acetate (non-refrigerated) 69 desogestrel-ethinyl estradiol 71 desogestrel-ethinyl estradiol/ethinyl estradiol 71 desonide 13 desoximetasone 13 dexamethasone 68 dexamethasone sod phosphate 68 DEXILANT 66 dexmethylphenidate hcl 57 dextroamphetamine sulf-saccharate/amphetamine sulfaspartate 57 dextroamphetamine sulfate 57 DIASTAT 21 diazepam 21,43 DIBENZYLINE 49 DICLEGIS 26 diclofenac potassium 5 diclofenac sodium 5,60,68 diclofenac sodium/misoprostol 5 dicloxacillin sodium 18 dicyclomine hcl 63 didanosine 39 DIFFERIN 60 DIFICID 18 diflorasone diacetate 13 diflunisal 5 digitek 53 digox 53 digoxin 53 dihydrocodeine bitartrate/acetaminophen/caffeine 8 98

99 dihydroergotamine mesylate 29,30 DILANTIN 22 DILATRATE-SR 56 dilt-cd 51 dilt-xr 51 diltia xt 51 diltiazem hcl 52 diltzac er 52 DIPENTUM 80 diphenoxylate hcl/atropine sulfate 63 dipyridamole 48 disopyramide phosphate 50 disulfiram 11 divalproex sodium 21 donepezil hcl 23 dorzolamide hcl 84 dorzolamide hcl/timolol maleate 84 doxazosin mesylate 49 doxepin hcl 26 doxercalciferol 81 doxycycline hyclate 20 doxycycline monohydrate 20 dronabinol 27 DROXIA 33 DUAVEE 71 duloxetine hcl 24,25 DUREZOL 68 dynacin 20 DYRENIUM 54 E E.E.S econazole nitrate 28 EDARBI 49 EDARBYCLOR 53 EDECRIN 54 EDURANT 39 EFFIENT 48 EGRIFTA 69 ELIDEL 60 ELIGARD 78 elimite 36 ELINEST 71 ELIQUIS 47 ELLA 76 ELMIRON 67 EMADINE 83 EMCYT 32 EMEND 27 EMOQUETTE 71 EMSAM 24 EMTRIVA 39 ENABLEX 66 enalapril maleate 49 enalapril maleate/hydrochlorothiazide 53 ENBREL 79 endocet 9 endodan 9 ENDOMETRIN 76 ENJUVIA 72 enoxaparin sodium 47 ENPRESSE 72 ENSKYCE 72 entacapone 37 entecavir 41 enulose 65 ENED 49 EPIDUO 60 EPIDUO FORTE 61 EPIFOAM 68 epinastine hcl 83 EPIPEN 2-K 87 EPIPEN JR 2-K 87 epitol 22 EPIVIR HBV 41 eplerenone 54 EPOGEN 48 EPZICOM 39 ergocalciferol (vitamin d2) 92 ergoloid mesylates 23 ERGOMAR 30 ergotamine tartrate/caffeine 30 99

100 ERIVEDGE 34 ERRIN 76 ERTACZO 28 ery 18 ERY-TAB 18 erygel 18 ERYPED ERYTHROCIN STEARATE 18 erythromycin base 18 erythromycin base/benzoyl peroxide 61 erythromycin base/ethyl alcohol 18 erythromycin ethylsuccinate 18 erythromycin ethylsuccinate/sulfisoxazole acetyl 15 ESBRIET 89 escitalopram oxalate 25 esomeprazole magnesium 66 ESTARYLLA 72 estazolam 90 ESTRACE 72 estradiol 72 estradiol/norethindrone acetate 72 ESTRING 72 estropipate 72 eszopiclone 90 ethambutol hcl 31 ethinyl estradiol/drospirenone 72 ethosuximide 20 etidronate disodium 81 etodolac 5 EURAX 36 EVOTAZ 40 EXELDERM 28 EXELON 23 exemestane 34 EXJADE 91 EXTAVIA 59 F FACTIVE 19 FALMINA 72 famciclovir 42 famotidine 64 FANAPT 38 FARESTON 32 FARXIGA 44 FARYDAK 33 felbamate 22 felodipine 52 fenofibrate 55 fenofibrate nanocrystallized 55 fenofibrate,micronized 55 fenofibric acid 55 fenofibric acid (choline) 55 fenoprofen calcium 5 fentanyl 6,7 fentanyl citrate 7 FERRIPROX 91 FINACEA 61 finasteride 67 FIRAZYR 80 FLAREX 68 flavoxate hcl 66 flecainide acetate 50 FLECTOR 5 FLOVENT DISKUS 68 FLOVENT HFA 68 fluconazole 28 flucytosine 28 fludrocortisone acetate 13 flunisolide 85 fluocinolone acetonide 13 fluocinolone acetonide oil 68 fluocinolone acetonide/shower cap 13 fluocinonide 13 fluocinonide/emollient base 13 fluoride/iron/vitamins a,c,and d 92 fluorometholone 68 FLUOROPLEX 61 fluorouracil 61 fluoxetine hcl 25 fluphenazine hcl 37 flurazepam hcl

101 flurbiprofen 5 flurbiprofen sodium 84 flutamide 33 fluticasone propionate 13,68 fluvastatin sodium 55 fluvoxamine maleate 25 FML FORTE 68 FML S.O.P. 68 fondaparinux sodium 47 FORADIL 87 FORTEO 81 fortical 81 FOSAMAX PLUS D 81 fosinopril sodium 49 fosinopril sodium/hydrochlorothiazide 53 FOSRENOL 67 FRAGMIN 47 FROVA 30 FULYZAQ 64 furosemide 54 FUZEON 40 G gabapentin 21 GABITRIL 21 galantamine hbr 23 GAMMAKED 80 GAMUNEX 80 GAMUNEX-C 80 garamycin 14 gatifloxacin 19 GATTEX 64 gavilyte-c 65 gavilyte-g 65 gavilyte-n 65 gemfibrozil 55 generlac 65 gengraf 61 GENOTROPIN 69 gentak 14 gentamicin sulfate 14 GIANVI 72 GILDAGIA 72 GILDESS 72 GILDESS 24 FE 72 GILDESS FE 72 GILENYA 59 GILOTRIF 34 GLATO 59 GLEEVEC 34 GLEOSTINE 32 glimepiride 44 glipizide 44 glipizide/metformin hcl 44 GLUCAGEN 1MG HYPOKIT 46 GLUCAGON EMERGENCY KIT 46 glyburide 44 glyburide,micronized 44 glyburide/metformin hcl 44 glycopyrrolate 63 glydo 11 GLYSET 44 GOLYTELY 65 granisetron hcl 27 GRANIX 48 GRASTEK 89 griseofulvin ultramicrosize 28 griseofulvin, microsize 28 guaiatussin ac 89 guaifenesin ac 89 guaifenesin dac 89 guaifenesin/codeine phosphate 89 guanfacine hcl 48,57 guanidine hcl 31 H H.P. ACTHAR 69 halobetasol propionate 13 HALOG 13 haloperidol 38 haloperidol lactate 38 HARVONI

102 HEATHER 76 hecoria 79 HEXALEN 33 HIZENTRA 80 HUMALOG 46 HUMALOG KWIKPEN 46 HUMALOG MIX HUMALOG MIX KWIKPEN 46 HUMALOG MIX HUMALOG MIX KWIKPEN 46 HUMATROPE 69 HUMIRA 79 HUMIRA CROHN'S 79 HUMIRA PEDIATRIC CROHN'S 79 HUMIRA PSORIASIS 79 HUMULIN HUMULIN 70/30 KWIKPEN 46 HUMULIN N 46 HUMULIN N KWIKPEN 46 HUMULIN R 46 HYCAMTIN 34 hydralazine hcl 56 hydrochlorothiazide 54 hydrocodone bitartrate/acetaminophen 9 hydrocodone bitartrate/homatropine methylbromide 89 hydrocodone/ibuprofen 9 hydrocortisone 13,68,80 hydrocortisone butyrate 13,68 hydrocortisone valerate 69 hydrocortisone/mineral oil/petrolatum,white 69 hydromet 89 hydromorphone hcl 7,9 hydroxychloroquine sulfate 36 hydroxyprogesterone caproate 81 hydroxyurea 33 hydroxyzine hcl 26 hydroxyzine pamoate 26 HYPER-SAL 89 hypercare 61 HYQVIA 80 I ibandronate sodium 81 IBRANCE 34 ibudone 9 ibuprofen 5 ibuprofen/oxycodone hcl 6 ICLUSIG 34 IMBRUVICA 34 imipramine hcl 26 imipramine pamoate 26 imiquimod 33 INCIVEK 42 INCRELEX 69 INCRUSE ELLIPTA 86 indapamide 54 indomethacin 6 INFERGEN 42 INLYTA 34 INTELENCE 39 INTRON A 33 INTROVALE 72 INVEGA 38 INVIRASE 41 INVOKAMET 44 INVOKANA 44 iophen-c nr 89 ipratropium bromide 86 ipratropium bromide/albuterol sulfate 87 irbesartan 49 irbesartan/hydrochlorothiazide 53 ISENTRESS 40 isochron 56 isoniazid 31 isosorbide dinitrate 56 isosorbide mononitrate 56 isradipine 52 ISTALOL 84 itraconazole 28 ivermectin

103 J JAKAFI 34 jantoven 47 JANUMET 44 JANUMET XR 44 JANUVIA 44 JARDIANCE 45 JENCYCLA 76 JENTADUETO 45 JINTELI 72 JOLESSA 72 JOLIVETTE 76 JUNEL 72 JUNEL FE 72 junel fe JUXTAPID 56 K KALETRA 41 KALYDECO 89 KARIVA 72 KAZANO 45 KELNOR KETEK 19 ketoconazole 28 ketodan 28 ketoprofen 6 ketorolac tromethamine 6,84 kimidess 73 KINERET 79 kionex 91 klor-con KLOR-CON 8 92 klor-con m10 92 klor-con m15 92 klor-con m20 92 KOMBIGLYZE XR 45 KURVELO 73 KUVAN 62 KYNAMRO 56 L labetalol hcl 51 LACRISERT 82 lactulose 65 LAMISIL 28 lamivudine 39,42 lamivudine/zidovudine 40 lamotrigine 22 lansoprazole 66 lansoprazole/amoxicillin trihydrate/clarithromycin 64 LANTUS 46 LANTUS SOLOSTAR 46 LARIN 73 larin 24 fe 73 LARIN FE 73 LASTACAFT 83 latanoprost 82 LATUDA 38 LEENA 73 leflunomide 80 LENVIMA 34 LESSINA 73 LETAIRIS 88 letrozole 34 leucovorin calcium 33 LEUKERAN 32 LEUKINE 48 leuprolide acetate 78 levalbuterol hcl 87 LEVATOL 51 LEVEMIR 46 LEVEMIR FLEXPEN 46 LEVEMIR FLEXTOUCH 46 levetiracetam 20 levobunolol hcl 84 levocarnitine 91 levocarnitine (with sugar) 91 levocetirizine dihydrochloride 86 levofloxacin 19 LEVONEST

104 levonorgestrel 76 levonorgestrel-ethinyl estradiol 73 levonorgestrel/ethinyl estradiol and ethinyl estradiol 73 LEVORA levorphanol tartrate 7 levothyroxine sodium 77 levoxyl 77 LEXIVA 41 LIALDA 64 lidocaine 11 lidocaine hcl 11 lidocaine/prilocaine 11 lindane 36 linezolid 15 liothyronine sodium 77 lisinopril 49 lisinopril/hydrochlorothiazide 53 lithium carbonate 43 lithium citrate 43 LIVALO 55 lofibra 55 lomustine 32 LOPREEZA 73 lorazepam 43 lorazepam intensol 43 lorcet 9 lorcet hd 9 lorcet plus 9 lortab 9 lortuss ex 89 LORYNA 73 losartan potassium 49 losartan potassium/hydrochlorothiazide 53 LOTEMAX 84 lovastatin 55 LOW-OGESTREL 73 loxapine succinate 38 LUFYLLIN 87 LUMIGAN 82 LUTERA 73 LYNRZA 34 LYRICA 21 LYSODREN 77 LYZA 76 M MACRODANTIN 15 malathion 36 maprotiline hcl 24 marlexate 91 MARLISSA 73 MARPLAN 24 MATULANE 32 matzim la 52 MAXAIR AUTOHALER 88 MAXIDEX 69 meclofenamate sodium 6 medroxyprogesterone acetate 76 mefenamic acid 6 mefloquine hcl 36 megestrol acetate 76 MEKINIST 34 meloxicam 6 memantine hcl 23 MENEST 73 meperidine hcl 9 meperitab 9 meprobamate 43 mercaptopurine 33 mesalamine 64 mesalamine with cleansing wipes 64 MESNEX 33 MESTINON 31 metadate er 57 metaproterenol sulfate 88 metaxalone 90 metformin hcl 45 methadone hcl 7 methadone intensol 7 methadose 7 methamphetamine hcl 57 methazolamide

105 methenamine hippurate 15 methenamine mandelate 15 methimazole 78 METHITEST 70 methocarbamol 90 methotrexate sodium 33 methotrexate sodium/pf 33 methoxsalen, rapid 61 methscopolamine bromide 63 methyclothiazide 54 methyldopa 48 methyldopa/hydrochlorothiazide 53 methylergonovine maleate 67 methylphenidate hcl 57,58 methylprednisolone 13 metipranolol 84 metoclopramide hcl 26 metolazone 55 metoprolol succinate 51 metoprolol tartrate 51 metoprolol tartrate/hydrochlorothiazide 53 metronidazole 15 mexiletine hcl 50 MIACALCIN 81 miconazole nitrate 28 MICROGESTIN 73 MICROGESTIN FE 73 midodrine hcl 49 migergot 30 MIGRANAL 30 millipred 13 millipred dp 13 mimvey 73 mimvey lo 73 minitran 56 minocycline hcl 20 minoxidil 56 mirtazapine 24 misoprostol 65 modafinil 91 MODERIBA 42 moexipril hcl 50 moexipril hcl/hydrochlorothiazide 53 mometasone furoate 61 MONO-LINYAH 74 MONONESSA 74 montelukast sodium 86 MONUROL 15 morgidox 20 morphine sulfate 7,9,10 MOTOFEN 64 MOVIPREP 65 MOXATAG 18 moxifloxacin hcl 19 MULTAQ 50 mupirocin 16 mupirocin calcium 16 MYALEPT 69 mycophenolate mofetil 79 mycophenolate sodium 79 myorisan 61 MYRBETRIQ 39 MYZILRA 74 N nabumetone 6 nadolol 51 nadolol/bendroflumethiazide 53 naftifine hcl 28 NAFTIN 28 naltrexone hcl 11 NAMENDA 23 naphazoline hcl 82 naproxen 6 naproxen sodium 6 naratriptan hcl 30 NASONEX 85 NATACYN 28 nateglinide 45 NECON 74 nefazodone hcl 24 neo-polycin

106 neo-polycin hc 82 neomycin sulfate 14 neomycin sulfate/bacitracin zinc/polymyxin b/hydrocortisone 82 neomycin sulfate/bacitracin/polymyxin b 82 neomycin sulfate/polymyxin b sulfate/gramicidin d 82 neomycin sulfate/polymyxin b sulfate/hydrocortisone 13,82 neomycin/polymyxin b sulfate/dexamethasone 82 neosporin 83 NESINA 45 neuac 61 NEULASTA 48 NEUMEGA 48 NEUPOGEN 48 NEVANAC 84 nevirapine 39 NEXAVAR 35 NEXIUM 66 niacin 56 niacor 56 nicardipine hcl 52 nifediac cc 52 nifedical xl 52 nifedipine 52 NIKKI 74 NILANDRON 78 nimodipine 52 nisoldipine 52 NITRO-BID 56 NITRO-DUR 56 nitro-time 56 nitrofurantoin 16 nitrofurantoin macrocrystal 16 nitrofurantoin monohydrate/macrocrystals 16 nitroglycerin 56 NITROSTAT 56 NIVA-PLUS 92 nizatidine 64 NORA-BE 76 NORDITROPIN 69 norethindrone 76 norethindrone acetate 76 norethindrone acetate-ethinyl estradiol 74 norethindrone acetate-ethinyl estradiol/ferrous fumarate 74 norgestimate-ethinyl estradiol 74 NORLYROC 76 NOROXIN 19 NORCE CR 50 NORTREL 74 nortriptyline hcl 26 NORVIR 41 NOVOLIN NOVOLIN N 47 NOVOLIN R 47 NOVOLOG 47 NOVOLOG FLEXPEN 47 NOVOLOG MIX NOVOLOG MIX FLEXPEN 47 NOXAFIL 28 NUCYNTA 10 NUCYNTA ER 7 NUEDEXTA 58 NULYTELY WITH FLAVOR CKS 65 NUTROPIN 69 NUTROPIN AQ 69 NUTROPIN AQ NUSPIN 69 NUVARING 74 NUVIGIL 91 nyamyc 29 nystatin 29 nystatin/triamcinolone acetonide 13 nystop 29 O OCELLA 74 octreotide acetate 78 OFEV 89 ofloxacin 19 OGESTREL 74 olanzapine

107 olanzapine/fluoxetine hcl 24 olopatadine hcl 86 OLYSIO 42 omega-3 acid ethyl esters 56 omeprazole 66 OMNARIS 86 OMNITROPE 69 OMONTYS 81 ondansetron 27 ondansetron hcl 27 ONEXTON 59 ONFI 21 ONGLYZA 45 ONA ER 7 OPSUMIT 88 ORALAIR 89 oralone 13 ORAP 38 ORAVIG 29 ORENITRAM ER 88 ORFADIN 63 orphenadrine citrate 90 orphenadrine citrate/aspirin/caffeine 90 ORSYTHIA 74 ORTHO TRI-CYCLEN LO 74 OSENI 45 OSMOPREP 92 OTEZLA 80 oxandrolone 70 oxaprozin 6 oxazepam 43 oxcarbazepine 22 OXISTAT 29 OXSORALEN 61 oxybutynin chloride 66 oxycodone hcl 7,10 oxycodone hcl/acetaminophen 10 oxycodone hcl/aspirin 10 OXYCONTIN 8 oxymorphone hcl 8,10 OXYTROL 66 P pacerone 50 palgic 86 pancrelipase 5, NRETIN 35 pantoprazole sodium 66 parcaine 11 paricalcitol 78 paroex 16 paromomycin sulfate 14 paroxetine hcl 25 SER 31 TADAY 83 TANOL 83 XIL 25 pedi-dri 29 pediatric multivitamin combination no.2/sodium fluoride 92 pediatric multivitamins no.82 with sodium fluoride 92 peg 3350/sod sulf/sod bicarbonate/sod chloride/potassium chl 65 PEGANONE 22 PEGASYS 42 PEGASYS PROCLICK 42 PEGINTRON 42 PEGINTRON REDIPEN 42 penicillin g potassium 18 penicillin v potassium 18 PENTASA 64 pentoxifylline 53 PERFOROMIST 88 perindopril erbumine 50 periogard 16 permethrin 36 perphenazine 26 perphenazine/amitriptyline hcl 24 PEXEVA 25 pfizerpen 18 phenadoz 27 phenelzine sulfate

108 phenobarbital 21 phenylephrine hcl/promethazine hcl 89 phenytoin 22 phenytoin sodium extended 22 PHILITH 74 PHISOHEX 61 PHOSLYRA 67 PHOSPHOLINE IODIDE 84 PICATO 61 pilocarpine hcl 59,85 PILOPINE HS 85 PIMTREA 74 pindolol 51 pioglitazone hcl 45 pioglitazone hcl/glimepiride 45 pioglitazone hcl/metformin hcl 45 PIRMELLA 74 piroxicam 6 PLEGRIDY 59 PLEGRIDY PEN 59 pnv-vp-u 92 podofilox 61 polycin 83 polymyxin b sulfate/trimethoprim 83 POMALYST 32 PORTIA 74 potassium chloride 92 potassium citrate 92 POTIGA 20 PRADAXA 47 pramipexole di-hcl 37 pravastatin sodium 55 prazosin hcl 49 prednicarbate 61 prednisolone 13 prednisolone acetate 69 prednisolone sod phosphate 14,84 prednisone 14 prednisone intensol 14 PREMARIN 74 PREMPHASE 74 PREMPRO 74 prenatal vits with calcium #72/ferrous fumarate/folic acid 92 prenatal vits with calcium #74/ferrous fumarate/folic acid 92 prenatal vits without calc no5/ferrous fumarate/folic acid 92 preplus 93 prevalite 56 PREVIFEM 75 PREZCOBIX 41 PREZISTA 41 PRIFTIN 31 primaquine phosphate 36 primidone 20 PRIMSOL 16 PRISTIQ ER 25 proair hfa 88 proair respiclick 88 probenecid 29 prochlorperazine 27 prochlorperazine maleate 27 PROCRIT 48 procto-pak 14 proctocream-hc 14 PROCTOFOAM-HC 64 proctosol-hc 80 proctozone-hc 80 PROCYSBI 67 progesterone,micronized 76 PROGLYCEM 46 PROMACTA 48 promethazine hcl 27 promethazine hcl/codeine 89 promethazine hcl/dextromethorphan hbr 89 promethazine/phenylephrine hcl/codeine 89 promethegan 27 propafenone hcl 50 propantheline bromide 64 proparacaine hcl 11 propranolol hcl

109 propranolol hcl/hydrochlorothiazide 53 propylthiouracil 78 PROTONIX 66 protriptyline hcl 26 PRUDOXIN 61 psorcon 14 PULMICORT FLEXHALER 86 pulmosal 90 PULMOZYME 90 PURIXAN 33 PYLERA 64 pyrazinamide 31 pyridostigmine bromide 31 Q QUASENSE 75 quetiapine fumarate 38 QUFLORA 93 quinapril hcl 50 quinapril hcl/hydrochlorothiazide 53 quinidine gluconate 50 quinidine sulfate 50 QVAR 86 R rabeprazole sodium 66 RAGWITEK 90 raloxifene hcl 77 ramipril 50 RANEXA 53 ranitidine hcl 64 RAFLO 67 RAMUNE 79 RAVICTI 63 REBETOL 42 REBIF 59 REBIF REBIDOSE 59 RECLIPSEN 75 RECTIV 56 refissa 61 REGRANEX 61 relador pak 11 relador pak plus 11 RELENZA 41 RELISTOR 64 RELX 30 RENAGEL 67 RENVELA 68 repaglinide 45 reprexain 10 RESCRIPTOR 39 RESTASIS 79 REVATIO 88 revia 11 REVLIMID 32 REYATAZ 41 RHEUMATREX 33 RIBAK 42 RIBASPHERE 42 RIBASPHERE RIBAK 42 RIBATAB 42 ribavirin 42 RIDAURA 80 rifabutin 31 RIFAMATE 31 rifampin 31 RIFATER 31 riluzole 58 rimantadine hcl 41 RIOMET 45 risedronate sodium 81 risperidone 38 RITALIN LA 58 rivastigmine tartrate 23 rizatriptan benzoate 30 ropinirole hcl 37 rosadan 16 ROXICET 10 roxicet 10 ROZEREM

110 S SABRIL 21 SAIZEN 69 SAMSCA 91 SANCUSO 27 SANDIMMUNE 79 SANTYL 61 SAPHRIS 38 SAVAYSA 47 SAVELLA 58 selegiline hcl 37 selenium sulfide 61 SELZENTRY 40 SENSIR 78 SEREVENT DISKUS 88 SEROQUEL XR 24 SEROSTIM 70 sertraline hcl 25 sevelamer carbonate 68 sharobel 76 SIGNIFOR 77 sildenafil citrate 88 silver sulfadiazine 19 SIMPONI 79 simvastatin 55 sirolimus 80 SIRTURO 31 SKLICE 36 sodium chloride for inhalation 90 sodium chloride/sodium bicarbonate/potassium chloride/peg 65 sodium phenylbutyrate 63 sodium polystyrene sulfonate 91 SOLTAMOX 32 SOMAVERT 78 SOOLANTRA 35 sorine 50 sotalol hcl 50 SOVALDI 42 spinosad 61 SPIRIVA 87 SPIRIVA RESPIMAT 87 spironolactone 54 spironolactone/hydrochlorothiazide 53 SPORANOX 29 SPRINTEC 75 SPRYCEL 35 sps 92 SRONYX 75 stagesic 10 stavudine 40 STAVZOR 21 STELARA 62 STIMATE 70 STIVARGA 35 STRATTERA 58 STRIBILD 40 SUBOXONE 11 SUCRAID 63 sucralfate 65 sulfacetamide sodium 19,83 sulfacetamide sodium/prednisolone sodium phosphate 83 sulfadiazine 19 sulfamethoxazole/trimethoprim 19 sulfamide 19 SULFAMYLON 16 sulfasalazine 64 sulfazine 64 sulfazine ec 64 sulindac 6 sumatriptan 30 sumatriptan succinate 30 SUPRAX 17 SUPREP 65 SUSTIVA 39 SUTENT 35 SYEDA 75 SYLATRON 33 SYLATRON 4-CK 33 SYMBICORT

111 SYMLINPEN SYMLINPEN SYNAREL 78 SYNRIBO 33 SYPRINE 92 T TABLOID 33 TACLONEX 62 tacrolimus 62,80 TAFINLAR 34 TAMIFLU 41 tamoxifen citrate 32 tamsulosin hcl 67 TARCEVA 35 TARGRETIN 35 tarina fe 75 TASIGNA 35 TAZORAC 62 taztia xt 52 TECFIDERA 59 TEKTURNA 53 telmisartan 49 telmisartan/hydrochlorothiazide 53 temazepam 91 temozolomide 32 tencon 5 terazosin hcl 49 terbinafine hcl 29 terbutaline sulfate 88 terconazole 29 testosterone 70 testosterone cypionate 70,81 testosterone enanthate 70 TESTRED 70 tetracycline hcl 20 TEXACORT 14 THALOMID 32 theochron 87 theophylline anhydrous 87 THIOLA 67 thioridazine hcl 38 thiothixene 38 THYROLAR-1 77 THYROLAR-1/2 77 THYROLAR-1/4 77 THYROLAR-2 77 THYROLAR-3 77 tiagabine hcl 21 ticlopidine hcl 48 TIKOSYN 50 TILIA FE 75 timolol maleate 30,85 tinidazole 16 TIVICAY 40 tizanidine hcl 39 TL FOLATE 93 TOBI PODHALER 14 TOBRADEX 14 tobramycin 14 tobramycin in % sodium chloride 15 tobramycin/dexamethasone 83 tolazamide 45 tolbutamide 45 tolcapone 37 tolmetin sodium 6 tolterodine tartrate 66 topiragen 22 topiramate 22 torsemide 54 TOUJEO SOLOSTAR 47 TOVIAZ 66 TRACLEER 88 TRADJENTA 45 tramadol hcl 8,10 tramadol hcl/acetaminophen 10 trandolapril 50 tranexamic acid 48 TRANSDERM-SCOP 27 tranylcypromine sulfate 24 TRAVATAN Z 82 travoprost (benzalkonium)

112 trazodone hcl 24 TRECATOR 31 tretinoin 35,62 tretinoin/emollient base 62 TRI-ESTARYLLA 75 TRI-LEGEST FE 75 TRI-LINYAH 75 TRI-PREVIFEM 75 TRI-SPRINTEC 75 triamcinolone acetonide 14,69 triamterene/hydrochlorothiazide 54 trianex 62 triazolam 91 triderm 14 trifluoperazine hcl 38 trifluridine 42 trihexyphenidyl hcl 36 trilyte with flavor packets 65 trimethobenzamide hcl 27 trimethoprim 16 trimipramine maleate 26 TRINESSA 75 TRIUMEQ 40 triveen-u 93 TRIVORA tropicamide 83 trospium chloride 66 TRUVADA 40 tusnel c 90 TYBOST 40 TYKERB 35 TYZEKA 42 TYZINE 90 U UCERIS 80 ULESFIA 36 ULORIC 29 unithroid 77 ursodiol 64 V VAGIFEM 75 valacyclovir hcl 42 VALCHLOR 32 VALCYTE 41 valganciclovir hcl 41 valproic acid 22 valproic acid (as sodium salt) (valproate sodium) 21 valsartan 49 valsartan/hydrochlorothiazide 54 vancomycin hcl 16 vandazole 16 vandetanib 35 VELIVET 75 VELTIN 62 venlafaxine hcl 25 VENTAVIS 88 ventolin hfa 88 VERAMYST 69 verapamil hcl 50,52 VEREGEN 62 VERSACLOZ 39 VESICARE 66 VESTURA 75 VEXOL 84 VICTOZA 2-K 45 VICTOZA 3-K 45 VICTRELIS 42 VIDEX 40 VIEKIRA K 42 VIGAMOX 19 VIIBRYD 24 VIMT 23 VIORELE 75 VIRACEPT 41 VIRAMUNE XR 39 VIREAD 40 virtussin ac 90 virtussin dac 90 vitazol

113 VITEKTA 40 VITUZ 10 VOLTAREN 62 voriconazole 29 VOTRIENT 34 VYFEMLA 75 VYVANSE 57 W warfarin sodium 47 WELCHOL 46 WERA 75 WYMZYA FE 75 X XALKORI 35 XARELTO 47 XENAZINE 58 XIFAXAN 16 XIGDUO XR 46 XOPENEX HFA 88 XTANDI 78 XULANE 75 xylon XYREM 91 ZIAGEN 40 ZIANA 62 zidovudine 40 ZIOPTAN 85 ziprasidone hcl 23,38 ZIRGAN 41 ZOLINZA 35 zolmitriptan 30 zolpidem tartrate 91 ZOMACTON 70 ZOMIG 30 ZONALON 62 zonisamide 21 ZORTRESS 80 ZORVOLEX 6 ZOVIA 1-35E 75 ZOVIA 1-50E 76 ZYCLARA 33 ZYDELIG 35 ZYFLO CR 86 ZYKADIA 35 ZYLET 83 ZYTIGA 34 ZYVOX 16 Z zafirlukast 86 zaleplon 91 ZARAH 75 ZAVESCA 63 ZELAR 37 ZELBORAF 34 zenatane 62 ZENCHENT 75 ZENCHENT FE 75 ZENPEP 63 zenzedi 57 ZEOSA 75 ZETIA 56 ZETONNA

114 Category Listing Analgesics 5 Anesthetics 11 Anti-Addiction/Substance Abuse Treatment Agents 11 Anti-inflammatory Agents 12 Antibacterials 14 Anticonvulsants 20 Antidementia Agents 23 Antidepressants 23 Antiemetics 26 Antifungals 27 Antigout Agents 29 Antimigraine Agents 29 Antimyasthenic Agents 31 Antimycobacterials 31 Antineoplastics 32 Antiparasitics 35 Antiparkinson Agents 36 Antipsychotics 37 Antispasticity Agents 39 Antivirals 39 Anxiolytics 43 Bipolar Agents 43 Blood Glucose Regulators 44 Blood Products/Modifiers/ Volume Expanders 47 Cardiovascular Agents 48 Central Nervous System Agents 57 Dental and Oral Agents 59 Dermatological Agents 59 Enzyme Replacement/ Modifiers 62 Gastrointestinal Agents 63 Genitourinary Agents 66 Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal) 68 Hormonal Agents, Stimulant/Replacement/Modifying (Other) 69 Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) 69 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) 70 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) 77 Hormonal Agents, Suppressant (Adrenal) 77 Hormonal Agents, Suppressant (Parathyroid) 77 Hormonal Agents, Suppressant (Pituitary) 78 Hormonal Agents, Suppressant (Sex Hormones/Modifiers) 78 Hormonal Agents, Suppressant (Thyroid) 78 Immunological Agents 78 Inflammatory Bowel Disease Agents 80 Metabolic Bone Disease Agents 81 Miscellaneous

115 MISCELLANEOUS THERAPEUTIC AGENTS 81 Ophthalmic Agents 82 Otic Agents 85 Respiratory Tract Agents 85 Skeletal Muscle Relaxants 90 Sleep Disorder Agents 90 Therapeutic Nutrients/ Minerals/ Electrolytes