DRUG BENEFIT LIST 2015

Transcription

1 NON-INSURED HEALTH BENEFITS First Nations and Inuit Health Branch DRUG BENEFIT LI The (NIHB) program provides supplementary health benefits, including prescription and non-prescription drugs, for registered First Nations and recognized Inuit throughout Canada. Visit our Web site at:

2

3 INTRODUCTION Drug Benefit List Effective

4 Introduction to NIHB Drug Benefit List Effective Table of Contents 1. Background on NIHB Program... iii 2. Purpose of the NIHB Drug Benefit List... iii 3. Drug Review Process... iii 4. Benefit Criteria... v A. Drug Benefit Listings... v B. Deletion Criteria....vi C. Open Benefits...vii D. Limited Use Benefits... vii E. Exception Criteria... vii F. Exclusions... viii 5. Policies... viii A. Best Price Alternative and Interchangeability... viii B. No Substitution Claims... viii C. Prescription Quantities... ix D. Short Term Dispensing...ix 6. Special Formulary for Chronic Renal Failure Patients... x 7. Palliative Care Formulary... x 8. Drug Utilization Evaluation... x 9. General Information... xi 10. NIHB Privacy Code... xi 11. Pharmacologic-Therapeutic Classification of Drugs... xi Legend... xii Drug Benefit List 04:00 Antihistamine Drugs :00 Anti-Infective Agents :00 Antineoplastic Agents :00 Autonomic Drugs :00 Blood Formation and Coagulation :00 Cardiovascular Drugs :00 Central Nervous System Agents :00 Contraceptives (Non-Oral) :00 Diagnostic Agents :00 Electrolytic, Caloric and Water Balance :00 Respiratory Tract Agents :00 Eye, Ear, Nose and Throat Preparations :00 Gastrointestinal Drugs :00 Gold Compounds :00 Heavy Metal Antagonists :00 Hormones and Synthetic Substitutes :00 Serums, Toxoids and Vaccines :00 Skin and Mucous Membrane Agents :00 Smooth Muscle Relaxants :00 Vitamins :00 Unclassified Therapeutic Agents :00 Devices :00 Pharmaceutical Aids Appendix A (Limited Use Benefits and Criteria)... A-1 Appendix B (Special Formulary for Chronic Renal Failure Patients)... B-1 Appendix C (Palliative Care Formulary)... C-1 Appendix D (List of Drug Manufacturers)... D-1 Appendix E (List of Exclusions)... E-1 Alphabetical Index of drug products... I-1 ii

5 Introduction to NIHB Drug Benefit List Effective 1. BACKGROUND ON NON-INSURED HEALTH BENEFITS (NIHB) PROGRAM The (NIHB) Program of Health Canada provides coverage for approximately 808,686 (decrease attributed to the transfer of clients to the First Nations Health Authority (FNHA) in British Columbia) eligible registered First Nations and recognized Inuit with a limited range of medically necessary health-related goods and services not provided through private or provincial/territorial health insurance plans. These benefits complement provincial and territorial health care programs, such as physician and hospital care, as well as other First Nations and Inuit community-based programs and services. Benefits include drugs, medical transportation, dental care, medical supplies and equipment, crisis intervention counselling and vision care. The authority for the NIHB Program is based on the 1979 Indian Health Policy which describes the responsibility for the health of First Nations as shared amongst various levels of government, the private sector and First Nations communities. As a result of this shared responsibility, when a benefit is covered under another plan, the federal government requires the coordination of benefits to ensure that the other plan meets its obligations. 2. PURPOSE OF THE NIHB DRUG BENEFIT LI (DBL) The Drug Benefit List (DBL) is a listing of the drugs provided as benefits by the NIHB Program. The DBL is updated regularly and published annually. The listed drugs are those primarily used in a home or ambulatory setting. A prescription from a licensed practitioner is required for any listed drug to be processed as a benefit. Practitioners are health professionals authorized to prescribe drugs within the scope of practice in their province or territory. The DBL is a tool for prescribers and pharmacists that encourages the selection of optimal, cost-effective drug therapy. 3. DRUG REVIEW PROCESS The review process for drug products that are considered for inclusion as a benefit under the NIHB Program varies depending on the type of drug submitted. 3.1 New Chemical Entities / New Combination Drug Products/ Existing Chemical Entities with New Indication Submissions for new chemical entities, new combination drug products and existing chemical entities with new indications, must be sent to the Canadian Agency for Drugs and Technologies in Health (CADTH). Clinical and pharmacoeconomic reviews are coordinated by the Common Drug Review (CDR) Directorate and forwarded to the Canadian Drug Expert Committee (CDEC) for recommendations on formulary listing. These recommendations are forwarded to participating drug plans, including the NIHB Program, for consideration. The NIHB Program and other drug plans make listing decisions based on CDEC recommendations and other specific relevant factors, such as mandate, priorities and resources. Please refer to CADTH for a list of requirements for manufacturers submissions and a summary of procedures for the Common Drug Review Process. Inquiries should be directed to: Common Drug Review (CDR) Canadian Agency for Drugs and Technologies in Health 865 Carling Avenue, Suite 600 Ottawa, Ontario K1S 5S8 Telephone: (613) Website: Please ensure a copy of the complete CDR submission is also sent to NIHB either electronically to [email protected] or on CD ROM to the mailing address indicated in section Paper (binder) versions of drug submissions are no longer accepted by the NIHB Program. 3.2 Line Extensions, Generics and All Other Submissions Submissions for line extensions, generics and all other submissions are reviewed internally or by the NIHB Drugs and Therapeutics Advisory Committee (DTAC). Generic drug products are considered for inclusion on the formulary based on provincial interchangeability lists and other relevant factors. iii

6 Introduction to NIHB Drug Benefit List Effective Drugs and Therapeutics Advisory Committee (DTAC) The DTAC provides formulary listing recommendations for drug products to the NIHB Program. The NIHB Program makes listing decisions based on DTAC recommendations and other specific relevant factors, such as mandate, priorities and resources. The DTAC is an advisory body of highly qualified health professionals who bring impartial and practical expert medical and pharmaceutical advice to the NIHB Program to promote improvement in the health outcomes of First Nations and Inuit clients through effective use of pharmaceuticals. The approach is evidence-based and the advice reflects medical and scientific knowledge, current utilization trends, current clinical practice, health care delivery and specific departmental client healthcare needs Submission Requirements All submissions for drug products that are line extensions, generics and all other types of submissions must be submitted to the NIHB Program. Only drug products with a Health Canada Notice of Compliance (NOC) will be considered for provision as a benefit Letter of Authorization The manufacturer will provide a letter authorizing the NIHB Program to gain access to all information with respect to the product in the possession of Health Canada or of the government of any provinces or territory in Canada, Patented Medicine Prices Review Board (PMPRB) or CADTH Justification for Consideration of Listing The manufacturer will provide a statement indicating the rationale and evidence to justify the provision of the new product General Information Additional information should include: Evidence of approval by Health Canada, such as a Notice of Compliance (NOC) and Drug Identification Number (DIN).and Two therapeutic Classifications: - American Hospital Formulary Service (AHFS) Pharmacologic Therapeutic Classification and; - The World Health Organization s Anatomical Therapeutic Chemical (ATC) Classification Pricing and Marketing Information The manufacturer must submit current price information for the drug product. Manufacturers are required to notify the NIHB Program of any significant change to listed drug products. Significant changes include changes in DIN, product name, manufacturer or distributor, indication, product monograph, packaging, formulation, manufacturing specifications or discontinuation of a product. Notification of changes should be provided electronically to the NIHB Program. All submissions for drug products, to be reviewed for inclusion on the NIHB DBL, must be sent to the NIHB Program electronically. Please send all drug submissions to the following address: [email protected]. Submissions will also be accepted on CD ROM when mailed to the following address: C/o Manager of Policy Development - Pharmacy First Nations and Inuit Health Branch, Health Canada 200 Eglantine Driveway, 2nd Floor Postal Locator 1902A Tunney's Pasture Ottawa, Ontario K1A 0K9 Only ONE copy of the submission is required. Receipt of submission will be acknowledged iv

7 Introduction to NIHB Drug Benefit List Effective electronically with a confirmatory message. Paper (binder) versions of drug submissions are no longer accepted by the NIHB Program. 4. BENEFIT CRITERIA The following criteria are the framework for the NIHB Program DBL. The criteria provide the basis for decisions about drugs on the formulary relating to: A. Drug Benefit Listings B. Deletions C. Open Benefit D. Limited Use E. Exceptions F. Exclusions All drugs that are to be either considered for listing or currently listed as Program benefits must, as a minimum: 1. be legally available for sale in Canada with an NOC; 2. be sold in Canada (proof may include a copy of the completed notification form issued under the Food and Drug Regulations or listing on a provincial drug benefit formulary); 3. be administered in a home setting or in other ambulatory care settings; 4. not be provided in a provincially/territorially covered setting (hospital/institution) or provided through provincially/territorial covered programs or clinics according to provincial/territorial legislation; and 5. be in accordance with NIHB Program mandate and policies. A. Drug Benefit Listings The NIHB Program, with assistance from the CDEC and the NIHB DTAC, balances a number of factors in making listing decisions about changes to the Drug Benefit List, such as: The needs of First Nations and Inuit clients; Accumulated scientific and clinical research on currently-listed drugs; Cost-benefit analysis; Availability of alternatives; Current health practices; and Policies and listings in provincial drug formularies. New formulations and new strengths of listed products may be added or may replace previously approved products. Generic products are added according to provincial/territorial interchangeability lists and other relevant factors. Combination products are considered for listing if: 1. each component of the combination makes a contribution to the claimed effect; 2. a pharmacological or pharmaceutical rationale exists for the combination; v

8 Introduction to NIHB Drug Benefit List Effective 3. the dosage of each component (amount, frequency, duration) is safe and effective for a significant proportion of the patient population requiring such concurrent therapy as defined in the labeling of the drug; and 4. the cost is reduced, or scientific evidence indicates that the advantages outweigh any additional cost; or 5. an improvement in compliance, resulting in an increase in clinical effectiveness, is demonstrated. Sustained Release Products may be listed when: 1. clinical studies have demonstrated the safety and efficacy of the active ingredient when administered in the sustained released form; and 2. a therapeutic advantage is demonstrated in the treatment of the disease entity for which the product is indicated (therapeutic advantage is defined as: improved efficacy relative to the conventional dosage with no increase in toxicity; or less toxicity with improved or similar efficacy); or 3. there is demonstrated improvement in compliance resulting in an increase in clinical effectiveness, or 4. there is evidence that the sustained release product is at least as cost-effective as the best price alternative in the conventional form that is currently covered; or 5. there is no suitable conventional dosage form(s) of the drug listed that is readily available. Injectable Drug Products will be considered if they are: 1. self-administered in a home or other ambulatory setting; 2. not part of a physician s standard office supply; 3. not provided in a provincially/territorially covered hospital or institution; or 4. not provided through provincially/territorial covered programs or clinics according to provincial/territorial legislation. B. Deletion Criteria The following deletion criteria guide the removal or delisting of a drug product from the NIHB drug benefit list. Drugs are deleted: 1. when a product is discontinued from the Canadian market; 2. when new products possessing clearly demonstrated therapeutic and safety advantages or improvements have been listed; 3. when new toxicity data shift the risk/benefit ratio to make the continued listing of the product inappropriate; 4. when new information demonstrates that the product does not have the anticipated therapeutic benefit; 5. when the purchase cost is disproportionate to the benefits provided; or 6. when the drug has a high potential for misuse or abuse. vi

9 Introduction to NIHB Drug Benefit List Effective NOTE: Drugs may also be removed at the discretion of the Director General, NIHB Program when there are undesirable financial, supply or administrative implications to the continued listing of a product. C. Open Benefits Open benefits are the drugs listed in the NIHB DBL which do not have established criteria or prior approval requirements. D. Limited Use Benefits Limited use drugs are drug products listed on the NIHB DBL that may be inappropriate for general listing, but have value in specific circumstances. These products will have specific criteria for provision as a benefit under the NIHB Program. A product will be designated for limited use when: 1. it has the potential for widespread use outside the indications for which benefit has been demonstrated; 2. it has proven effectiveness, but is associated with predictable severe adverse effects; 3. it is usually a second or third line choice for treatment and is required because of allergies, intolerance, treatment failure or noncompliance with a first line alternative; or 4. it is very costly and a therapeutically effective alternative is available as a benefit. There are three types of limited use benefits: 1. Limited use benefits which do not require prior approval. These include but are not limited to: Multivitamins (which are benefits for children up to six years of age); and Prenatal and postnatal vitamins (which are benefits for women of childbearing age (12 to 50 years). 2. Benefits which have a quantity and/or frequency limit. A maximum quantity of drug is allowed within a specified period of time. No prior approval is required for the recipient to obtain the allowable quantity of drug within the specified period. An example of a category of drugs with a quantity and frequency limit is smoking cessation products. Recipients are eligible to receive up to three treatment courses of nicotine replacement therapy (NRT) within a 12-month period with quantity limits, which include two courses of NRT patches and one course of NRT products used PRN (i.e. gums, lozenges, inhalers). 3. Limited use benefits which require prior approval (using the Limited Use Drugs Request Form ). Limited use benefits and the criteria for their coverage are identified in the Drug Benefit List and also in Appendix A. The criteria are also listed on the forms faxed to prescribers for completion. E. Exceptions Exception drugs are drug products which are not listed in the DBL. These drug products may be approved in special circumstances upon receipt of a completed Exception Drugs Request Form from the attending licensed practitioner. when the prescription is for a recognized clinical indication and dose which is supported by published evidence or authoritative opinion; and when there is significant evidence that the requested drug is superior to drugs already listed as program benefits; or when a patient has experienced an adverse reaction with a best- price alternative drug, and a higher cost alternative is requested by the prescriber; or vii

10 Introduction to NIHB Drug Benefit List Effective when there is supporting evidence that available alternatives are ineffective, toxic, or contraindicated (personal preference alone does not justify an exception). F. Exclusions Exclusions are items not listed as benefits on the DBL and are not available through the exception or appeal processes. These include certain drug therapies for particular conditions which fall outside of the NIHB mandate and are not provided as benefits under the NIHB Program. Examples of categories of drugs or drug products* that are not considered for coverage under the NIHB Program under any circumstances are listed in Appendix E Anti-obesity drugs; Household products (e.g. regular soaps and shampoos); Cosmetics; Alternative therapies, including glucosamine and evening primrose oil; Megavitamins; Drugs with investigational/experimental status; Vaccines Medications for travel Hair growth stimulants; Fertility agents and impotence drugs; Selected over-the-counter products; Codeine containing cough preparations. *Note: List of excluded drugs or drug products is not exhaustive and may be modified as necessary 5. POLICIES A. Best Price Alternative and Interchangeability The NIHB program will reimburse only the best price (lowest cost) alternative product in a group of interchangeable drug products. Pharmacists must follow their provincial/territorial pharmacy legislation/policies to identify interchangeable products and to select the lowest-priced brand. (NIHB may not necessarily reimburse at the cost listed in the provincial drug plan formulary). B. No Substitution Claims NIHB will consider reimbursement for a higher-cost interchangeable product when a patient has experienced an adverse reaction with a lower-cost alternative. In such circumstances, the prescriber must provide the NIHB Program with: 1. a completed and signed Canada Vigilance Adverse Reaction Reporting Form: Report of suspected adverse reactions to health products in Canada and, 2. the prescription with No Substitution or No Sub written by hand or typed on the prescription. Upon receipt, the pharmacist will forward a copy of the prescription to NIHB for review. The prescriber is responsible for sending a copy of the form to the Canada Vigilance Program. Forms can be obtained by calling the Canada Vigilance Program at or by downloading a copy from Health Canada website at: or by photocopying a copy from the Compendium of Pharmaceuticals and Specialties. NOTE: The Canada Vigilance Adverse Reaction Reporting Form will not need to be resubmitted for renewals or new prescriptions of the same drug for the patient, although No Sub will still have to be written or typed on the prescription. viii

11 Introduction to NIHB Drug Benefit List Effective C. Prescription Quantities The normal quantity dispensed shall be the entire quantity of the drug prescribed. A maximum 100-day supply should be considered for those circumstances where the patient has been stabilized on a medication and the prescriber feels that further adjustment during the prescribed period is unlikely. Prescriptions for opioids have a maximum 30 day supply. The physician may continue to prescribe a smaller quantity with repeats at certain intervals when it is in the patient s best interest. D. Short Term Dispensing Policy It is the Program s expectation that certain medications required for long-term maintenance therapy should be prescribed and dispensed in up to 100 days supplies. For refills for medications requiring shortterm dispensing for a shorter time than 28 days due to compliance concerns, the Program will only reimburse a total of one dispensing fee per 28 days up to the regional maximum of the Program, These medications include (but are not limited to) the following: Antihistamines Anticoagulants Immunosuppressants Antiemetics for cancer chemotherapy Prokinetic agents Synthetic antidiuretic hormone Alpha-adrenoreceptor Antagonists Anti-dementia Drugs Anti-gout Drugs Anti-Parkinsonian Drugs Anti-platelet aggregation Drugs BPH Drugs Cardiovascular Drugs Enzyme Preparations Drugs for Diabetes Drugs for Treatment of Bone Diseases GI Anti-inflammatory Drugs Thyroid Therapy Proton Pump Inhibitors Urinary Anti-Spasmotics NSAIDs H 2 -Receptor Antagonists OTCs (including vitamins) Other Drugs for Peptic Ulcer and Gastro-esophageal Reflux Disease (GERD) Respiratory smooth muscle relaxants Note: This list may be amended as required and changes will be communicated through the quarterly online updates to the DBL. Medications on the Short term Dispensing list are identified in the DBL using the symbol beside the medication strength and dosage form. The following are exceptions to the D policy: Refills for intermittent treatment of a chronic disorder or refills of a medication which is prescribed to be taken on an as needed (PRN) basis. Note: Medications prescribed to be taken on an as needed (PRN) basis and dispensed chronically may be subject to audit and recovery. Prescriptions for dose changes. The following dosage forms: injectable and suppository. Refills or new prescriptions when prescribed/dispensed in accordance with a court order. Others as identified by the NIHB Program Compensation The compensation will be the lesser of the usual and customary fee up to the maximum negotiated NIHB regional dispensing fee for each 28 days supplied. NIHB will continue to audit and recover in instances where quantity reduction occurs. Less than 28 Day Supply For the medications listed below in which short-term dispensing is deemed medically necessary, the Program will compensate up to one full dispensing fee every seven days, up to the regional maximum of the Program. If these medications are dispensed daily, the Program will compensate 1/7th of this fee: Anticonvulsants Contraceptives Antidepressants Needles & Syringes Antipsychotics Drug used in nicotine dependence Benzodiazepines Antimanic agents Stimulants Estrogens Nicotine Replacement Therapy Progestins ix

12 Introduction to NIHB Drug Benefit List Effective Implementation When filling a new prescription for a chronic use drug, the Program will pay a full dispensing fee regardless of the days supply. A new prescription may include a dosage change or an intermittent treatment, based on an assessment by a prescriber. When refilling a prescription for a chronic use drug that is for less than a 28 day supply or when a need for compliance packaging is identified by the prescriber, the Program will pay no more than one full dispensing fee per 28 day period. For the medications listed above the Program will pay no more than full dispensing fee per 7 day period. A refill is defined as the second and all subsequent fills for a given strength and dosage of a drug. 6. FORMULARY FOR CHRONIC RENAL FAILURE PATIENTS Clients with chronic renal failure are eligible to receive a list of supplemental benefits that are not included in the NIHB DBL but which are required on a long-term basis. Some supplemental benefits include: darbepoetin alfa products (except in provinces where NIHB clients are eligible to receive darbepoetin alfa through the provincial programs), calcium products, multivitamins formulated for renal patients and select nutritional supplements formulated for renal patients. New clients requiring drugs on the special formulary will be identified for coverage through the usual prior approval process. Once the client is confirmed as eligible, coverage will automatically be extended to all drugs in the special formulary for as long as needed. 7. PALLIATIVE CARE FORMULARY Clients diagnosed with a terminal illness and are near the end of life will be eligible to receive a list of supplemental benefits that are not included in the NIHB Drug Benefit List. The Palliative Care Formulary includes medications used to provide comfort to those near the end of life. Requests for any of the DINs on the Palliative Care Formulary will generate a Palliative Care Application Form, faxed to the prescriber. Once completed and submitted, the recipient will be eligible for all medications on the Palliative Care Formulary for six months if the following criteria are met: The client: 1. is not receiving care in a provincially covered hospital or provincially covered long-term care facility; and 2. has been diagnosed with a terminal illness or disease which is expected to be the primary cause of death within six months or less If coverage is required beyond the initial six months, an additional six months will be granted upon receipt of another completed Palliative Care Application Form. 8. DRUG UTILIZATION EVALUATION A drug utilization evaluation, which is part of the point-of-service or on-line adjudication system, provides an analysis of both previous claims data and current claims data to identify potential drug-related problems. Messages are returned to pharmacists to alert them of the potential problems. These messages are intended to enhance pharmacy practice with additional information. Currently, the system monitors for: - potential drug/drug interactions - duplicate drugs - duplicate therapy As part of the NIHB Drug Use Evaluation (DUE) Program, DTAC reviews utilization patterns of medications billed to the NIHB program and provides advice to promote effective, efficient and optimal drug therapy to First Nations and Inuit recipients. x

13 Introduction to NIHB Drug Benefit List Effective 9. GENERAL INFORMATION Sources of information about the NIHB Program include: The NIHB section of the Health Canada website which provides background information on the program and a copy of the DBL. This can be found at: NIHB DBL Updates are available to pharmacists and to prescribers via the Health Canada website. These updates can be found at: Information about the NIHB Program can also be obtained by contacting: First Nations and Inuit Health Branch 200 Eglantine Driveway, 2nd Floor Postal Locator 1902A Tunney's Pasture Ottawa, Ontario K1A 0K9 10. NIHB PRIVACY CODE The NIHB Program of Health Canada is committed to protecting an individual s privacy and safeguarding the personal information in its possession. When a benefit request is received, the NIHB Program collects, uses, discloses and retains an individual s personal information according to the applicable federal privacy legislation. The information collected is limited to only that information required for the NIHB Program to administer and verify benefits. As a program of the federal government, the NIHB Program must comply with the Privacy Act, the Canadian Charter of Rights and Freedoms, the Access to Information Act, the Treasury Board of Canada Privacy and Data Protection Policies, the Government Security Policy, and Health Canada s Security Policy. 11. PHARMACOLOGIC-THERAPEUTIC CLASSIFICATION OF DRUGS The drugs in the NIHB DBL are classified according to the AHFS Pharmacologic-Therapeutic classification developed by the American Society of Health-System Pharmacists for the purposes of the AHFS Drug Information. Permission to use this system has been granted by the American Society of Health-System Pharmacists. The Society is not responsible for the accuracy of transpositions from the original context. Drugs are listed alphabetically within each therapeutic classification according to their chemical names. Under each drug, acceptable products are listed. xi

14 Introduction to NIHB Drug Benefit List Effective LEGEND 1. Pharmacologic-Therapeutic classification 2. Pharmacologic-Therapeutic sub-classification 3. Nonproprietary or generic name of the drug 4. Drug strength and dosage form. indicates the drug is identified as a chronic medication under the Short-Term Dispensing Policy. 5. Drug Identification Number (DIN), assigned by the Therapeutic Products Directorate of Health Canada, to uniquely identify the drug product as to its manufacturer, name and strength of active ingredients, route of administration and pharmaceutical dosage form 6. Brand name of the drug 7. List of all active ingredients in a combination product 8. Strengths of active ingredients in a combination product, listed in the same order as the ingredients 9. List of available brands of drugs. Provincial or territorial drug plan formularies should be consulted to determine interchangeable products and to identify best price (lowest cost) alternatives 10. Three letter identification code assigned to manufacturer xii

15 Introduction to NIHB Drug Benefit List Effective 1 04:00 ANTIHIAMINE DRUGS ANTIHIAMINE DRUGS 3 CETIRIZINE HCL 4 10mg Tablet APO-CETIRIZINE APX :08.08 ACETAMINOPHEN, CAFFEINE, CODEINE PHOSPHATE 8 300mg & 15mg & 15mg Tablet PMS-ACET 2 PMS RATIO-LENOLTEC NO.2 RPH TYLENOL WITH CODEINE NO.2 JNO 9 300mg & 15mg & 30mg Tablet RATIO-LENOLTEC NO.3 RPH TYLENOL WITH CODEINE NO.3 JNO 10 xiii

16 DRUG BENEFIT LI

17 04:00 ANTIHIAMINE DRUGS 04:00.00 ANTIHIAMINE DRUGS CETIRIZINE HCL 1mg/mL Syrup REACTINE JNO 10mg Tablet ALLERGY RELIEF ES PED APO-CETIRIZINE APX CETIRIZINE APX REACTINE JNO 20mg Tablet PMS-CETIRIZINE PMS PRIVA-CETIRIZINE PHA REACTINE JNO CHLORPHENIRAMINE MALEATE 12mg Sustained Release Tablet CHLOR-TRIPOLON SCH 4mg Tablet CHLOR-TRIPOLON SCH NOVOPHENIRAM TEV DESLORATADINE 0.5mg/mL Oral Liquid AERIUS KIDS SCH 5mg Tablet AERIUS SCH ALLERNIX MULTI SYMPTOM TEP DESLORATADINE APX DESLORATADINE ALLERGY CONTROL PMS DIPHENHYDRAMINE HCL 25mg Capsule PMS-DIPHENHYDRAMINE PMS 50mg Capsule BENADRYL WLA PMS-DIPHENHYDRAMINE PMS 2.5mg/mL Elixir ALLERNIX RPH BENADRYL WLA DIPHENHYDRAMINE HCL TAN PMS-DIPHENHYDRAMINE PMS 50mg/mL Injection DIPHENHYDRAMINE SDZ PMS-DIPHENHYDRAMINE PMS 1.25mg/mL Liquid BENADRYL CHILD WLA 12.5MG/5ML Liquid JAMP-DIPHENHYDRAMINE JMP 04:00.00 ANTIHIAMINE DRUGS DIPHENHYDRAMINE HCL 25mg Tablet ALLER-AIDE RPH ALLERGY TAN ALLERGY FORMULA SDR ALLERNIX RPH BENADRYL WLA JAMP-DIPHENHYDRAMINE JMP NADRYL RIV 50mg Tablet ALLERNIX PLUS RPH DIPHENHYDRAMINE HCL TAN JAMP-DIPHENHYDRAMINE JMP FEXOFENADINE HCL 60mg Tablet ALLEGRA AVT 120mg Tablet ALLEGRA 24HR SAC KETOTIFEN FUMARATE 0.2mg/mL Syrup APO-KETOTIFEN APX NOVO-KETOTIFEN TEV PMS-KETOTIFEN PMS 1mg Tablet NOVO-KETOTIFEN TEV PMS-KETOTIFEN PMS ZADITEN NVR LORATADINE 1mg/mL Syrup CLARITIN SCH CLARITIN KIDS SCH 10mg Tablet APO-LORATADINE APX CLARITIN SCH LORATADINE VTH Page 1 of 151

18 08:00 ANTI-INFECTIVE AGENTS 08:08.00 ANTHELMINTICS MEBENDAZOLE 100mg Tablet VERMOX JNO PYRANTEL PAMOATE 50mg/mL Suspension COMBANTRIN PFI 125mg Tablet COMBANTRIN PFI 08:12.06 CEPHALOSPORINS CEFACLOR 250mg Capsule APO-CEFACLOR APX CECLOR PHH SCHEIN-CEFACLOR SCN 500mg Capsule APO-CEFACLOR APX CECLOR PHH SCHEIN-CEFACLOR SCN 25mg/mL Suspension CECLOR PHH 50mg/mL Suspension CECLOR PHH 75mg/mL Suspension APO-CEFACLOR APX CECLOR BID PHH CEFADROXIL 500mg Capsule APO-CEFADROXIL APX PRO-CEFADROXIL PDL TEVA-CEFADROXIL TEV CEFIXIME 20mg/mL Suspension SUPRAX SAC 400mg Tablet AURO-CEFIXIME AUR SUPRAX SAC CEFPROZIL 25mg/mL Suspension APO-CEFPROZIL APX AURO-CEFPROZIL AUR CEFZIL BMS RAN-CEFPROZIL RBY SANDOZ CEFPROZIL SDZ 50mg/mL Suspension APO-CEFPROZIL APX AURO-CEFPROZIL AUR CEFZIL BMS RAN-CEFPROZIL RBY SANDOZ CEFPROZIL SDZ 08:12.06 CEPHALOSPORINS CEFPROZIL 250mg Tablet APO-CEFPROZIL APX AURO-CEFPROZIL AUR CEFZIL BMS RAN-CEFPROZIL RBY SANDOZ CEFPROZIL SDZ 500mg Tablet APO-CEFPROZIL APX AURO-CEFPROZIL AUR CEFZIL BMS RAN-CEFPROZIL RBY SANDOZ CEFPROZIL SDZ CEFUROXIME AXETIL 25mg/mL Suspension CEFTIN GSK 250mg Tablet APO-CEFUROXIME APX AURO-CEFUROXIME APL CEFTIN GSK RATIO-CEFUROXIME RPH 500mg Tablet APO-CEFUROXIME APX AURO-CEFUROXIME APL CEFTIN GSK PRO-CEFUROXIME PDL RATIO-CEFUROXIME RPH CEPHALEXIN 250mg Capsule NOVO-LEXIN TEV 500mg Capsule NOVO-LEXIN TEV 25mg/mL Suspension DOM-CEPHALEXIN DPC NOVO-LEXIN TEV 50mg/mL Suspension DOM-CEPHALEXIN DPC NOVO-LEXIN TEV 250mg Tablet APO-CEPHALEX APX CEPHALEXIN PDL DOM-CEPHALEXIN DPC NOVO-LEXIN TEV PMS-CEPHALEXIN PMS 500mg Tablet APO-CEPHALEX APX CEPHALEXIN PDL DOM-CEPHALEXIN DPC NOVO-LEXIN TEV PMS-CEPHALEXIN PMS Page 2 of 151

19 08:12.12 MACROLIDES AZITHROMYCIN 20mg/mL Suspension GD-AZITHROMYCIN PFI PMS-AZITHROMYCIN PMS SANDOZ-AZITHROMYCIN SDZ TEVA-AZITHROMYCIN TEV ZITHROMAX PFI 40mg/mL Suspension PMS-AZITHROMYCIN PMS SANDOZ-AZITHROMYCIN SDZ TEVA-AZITHROMYCIN TEV ZITHROMAX PFI 250mg Tablet APO-AZITHROMYCIN APX APO-AZITHROMYCIN APX AZITHROMYCIN SAN CO AZITHROMYCIN COB DOM-AZITHROMYCIN DOM MYLAN-AZITHROMYCIN MYL PHL-AZITHROMYCIN PMI PMS-AZITHROMYCIN PMS PRO-AZITHROMYCIN PDL RATIO-AZITHROMYCIN RPH RIVA-AZITHROMYCIN RIV SANDOZ-AZITHROMYCIN SDZ TEVA-AZITHROMYCIN TEV ZITHROMAX PFI 600mg Tablet CO AZITHROMYCIN COB PMS-AZITHROMYCIN PMS RIVA-AZITHROMYCIN RIV ZITHROMAX PFI CLARITHROMYCIN 500mg Extended Release Tablet ACT CLARITHROMYCIN XL ATP APO-CLARITHROMYCIN XL APX BIAXIN XL ABB 250mg Film Coated Tablet APO-CLARITHROMYCIN APX BIAXIN ABB MYLAN-CLARITHROMYCIN MYL PMS-CLARITHROMYCIN PMS PRO-CLARITHROMYCIN PDL RAN-CLARITHROMYCIN RBY RATIO-CLARITHROMYCIN RPH SANDOZ-CLARITHROMYCIN SDZ TEVA-CLARITHROMYCIN TEP 08:12.12 MACROLIDES CLARITHROMYCIN 500mg Film Coated Tablet APO-CLARITHROMYCIN APX BIAXIN ABB DOM-CLARITHROMYCIN SEV MYLAN-CLARITHROMYCIN MYL PMS-CLARITHROMYCIN PMS PRO-CLARITHROMYCIN PDL RAN-CLARITHROMYCIN RBY RATIO-CLARITHROMYCIN RPH RIVA-CLARITHROMYCIN RIV SANDOZ-CLARITHROMYCIN SDZ TEVA-CLARITHROMYCIN TEP 25mg/mL Suspension ACCEL-CLARITHROMYCIN ACP BIAXIN ABB CLARITHROMYCIN SAN 50mg/mL Suspension ACCEL-CLARITHROMYCIN ACP BIAXIN ABB CLARITHROMYCIN SAN ERYTHROMYCIN 250mg Enteric Coated Capsule APO-ERYTHRO APX ERYC PFI 333mg Enteric Coated Capsule ERYC PFI 250mg Tablet APO-ERYTHRO BASE APX ERYTHROMYCIN EOLATE 50mg/mL Suspension NOVO-RYTHRO EOLATE TEV ERYTHROMYCIN ETHYLSUCCINATE 600mg Tablet APO-ERYTHRO-S APX EES-600 ABB ERYTHRO-ES PDL ERYTHROMYCIN EARATE 250mg Tablet APO-ERYTHRO-S APX ERYTHROMYCIN PDL 500mg Tablet APO-ERYTHRO S APX ERYTHRO PDL Page 3 of 151

20 08:12.16 PENICILLINS AMOXICILLIN 250mg Capsule AMOXICILLIN SAN AMOXICILLIN SIV APO-AMOXI APX AURO-AMOXICILLIN AUR MYLAN-AMOXICILLIN MYL NOVAMOXIN TEV PMS-AMOXICILLIN PMS 500mg Capsule AMOXICILLIN SAN AMOXICILLIN SIV APO-AMOXI APX AURO-AMOXICILLIN AUR MYLAN-AMOXICILLIN MYL NOVAMOXIN TEV PMS-AMOXICILLIN PMS PRO-AMOX PDL 125mg Chewable Tablet NOVAMOXIN TEV 250mg Chewable Tablet NOVAMOXIN TEV 25mg/mL Oral Solution NOVAMOXIN SUGAR REDUCED 50mg/mL Oral Solution NOVAMOXIN SUGAR REDUCED 25mg/mL Suspension TEV TEV AMOXICILLIN SAN AMOXICILLIN SUGAR SAN REDUCED APO-AMOXI APX NOVAMOXIN TEV PMS-AMOXICILLIN PMS 50mg/mL Suspension AMOXICILLIN SAN AMOXICILLIN SIV AMOXICILLIN SUGAR SAN REDUCED APO-AMOXI APX APO-AMOXI SUGAR FREE APX NOVAMOXIN TEV PMS-AMOXICILLIN PMS PRO-AMOX PDL AMOXICILLIN, CLAVULANIC ACID 25mg & 6.25mg/mL Suspension APO-AMOXI CLAV APX CLAVULIN-F 125 GSK 40mg & 5.7mg/mL Suspension APO-AMOXI CLAV APX CLAVULIN 200 GSK 08:12.16 PENICILLINS AMOXICILLIN, CLAVULANIC ACID 50mg & 12.5mg/mL Suspension APO-AMOXI CLAV APX CLAVULIN-F 250 GSK 80mg & 11.4mg/mL Suspension CLAVULIN 400 GSK 250mg & 125mg Tablet APO-AMOXI CLAV APX 500mg & 125mg Tablet AMOXI-CLAV PDL APO-AMOXI CLAV APX CLAVULIN-F GSK RATIO-ACLAVULANATE RPH 875mg & 125mg Tablet AMOXI-CLAV PDL APO-AMOXI CLAV APX CLAVULIN GSK RATIO-ACLAVULANATE RPH TEVA-CLAVAMOXIN TEV AMPICILLIN 250mg Capsule TEVA-AMPICILLIN TEV 500mg Capsule TEVA-AMPICILLIN TEV 50mg/mL Suspension APO-AMPICILLIN APX CLOXACILLIN 250mg Capsule CLOXACILLINE PRO TEVA-CLOXIN TEV 500mg Capsule CLOXACILLINE PRO TEVA-CLOXIN TEV 25mg/mL Suspension TEVA-CLOXIN TEV PENICILLIN V POTASSIUM 25mg/mL Suspension APO-PEN VK APX 60mg/mL Suspension APO-PEN VK APX NOVO-PEN VK TEV 300mg Tablet APO-PEN VK APX NU-PEN VK NXP PENICILLINE V PDL PIVMECILLINAM HCL 200mg Tablet SELEXID LEO Page 4 of 151

21 08:12.18 QUINOLONES CIPROFLOXACIN HCL 250mg Tablet APO-CIPROFLOX APX AURO-CIPROFLOXACIN AUR CIPRO BAY CIPROFLOXACIN SAN CIPROFLOXACIN SIV CO CIPROFLOXACIN COB JAMP-CIPROFLOXACIN JAP MAR-CIPROFLOXACIN MAR MINT-CIPROFLOX MIN MINT-CIPROFLOXACIN MIN MYLAN-CIPROFLOXACIN MYL PHL-CIPROFLOXACIN PHH PMS-CIPROFLOXACIN PMS PRO-CIPROFLOXACIN PDL RAN-CIPROFLOX RBY RATIO-CIPROFLOXACIN RPH RIVA-CIPROFLOXACIN RIV SANDOZ-CIPROFLOXACIN SDZ SEPTA-CIPROFLOXACIN SPT TARO-CIPROFLOXACIN TAR TEVA-CIPROFLOXACIN TEV 500mg Tablet APO-CIPROFLOX APX AURO-CIPROFLOXACIN AUR CIPRO BAY CIPROFLOXACIN SAN CIPROFLOXACIN SIV CO CIPROFLOXACIN COB DOM-CIPROFLOXACIN PMS JAMP-CIPROFLOXACIN JAP MAR-CIPROFLOXACIN MAR MINT-CIPROFLOX MIN MINT-CIPROFLOXACIN MIN MYLAN-CIPROFLOXACIN MYL PHL-CIPROFLOXACIN PHH PMS-CIPROFLOXACIN PMS PRO-CIPROFLOXACIN PDL RAN-CIPROFLOX RBY RATIO-CIPROFLOXACIN RPH RIVA-CIPROFLOXACIN RIV SANDOZ-CIPROFLOXACIN SDZ SEPTA-CIPROFLOXACIN SPT TARO-CIPROFLOXACIN TAR TEVA-CIPROFLOXACIN TEV 08:12.18 QUINOLONES CIPROFLOXACIN HCL 750mg Tablet APO-CIPROFLOX APX AURO-CIPROFLOXACIN AUR CIPRO BAY CIPROFLOXACIN SAN CO CIPROFLOXACIN COB JAMP-CIPROFLOXACIN JAP MAR-CIPROFLOXACIN MAR MINT-CIPROFLOX MIN MINT-CIPROFLOXACIN MIN MYLAN-CIPROFLOXACIN MYL PHL-CIPROFLOXACIN PHH PMS-CIPROFLOXACIN PMS RAN-CIPROFLOX RBY RATIO-CIPROFLOXACIN RPH RIVA-CIPROFLOXACIN RIV SANDOZ-CIPROFLOXACIN SDZ SEPTA-CIPROFLOXACIN SPT TEVA-CIPROFLOXACIN TEV LEVOFLOXACIN Limited use benefit (prior approval not required). Coverage will be limited to a maximum of 30 days. 250mg Tablet APO-LEVOFLOXACIN APX CO-LEVOFLOXACIN CBT LEVAQUIN JNO MYLAN-LEVOFLOXACIN MYL NOVO-LEVOFLOXACIN TEV PMS-LEVOFLOXACIN PMS SANDOZ LEVOFLOXACIN SDZ 500mg Tablet APO-LEVOFLOXACIN APX CO-LEVOFLOXACIN CBT LEVAQUIN JNO LEVOFLOXACIN PDL MYLAN-LEVOFLOXACIN MYL NOVO-LEVOFLOXACIN TEV PMS-LEVOFLOXACIN PMS SANDOZ LEVOFLOXACIN SDZ 750mg Tablet APO-LEVOFLOXACIN APX CO-LEVOFLOXACIN CBT NOVO-LEVOFLOXACIN TEV PMS-LEVOFLOXACIN PMS SANDOZ LEVOFLOXACIN SDZ NORFLOXACIN 400mg Tablet APO-NORFLOX APX CO NORFLOXACIN COB NOVO-NORFLOXACIN TEV PMS-NORFLOXACIN PMS Page 5 of 151

22 08:12.18 QUINOLONES OFLOXACIN 200mg Tablet OFLOXACIN AAP 300mg Tablet NOVO-OFLOXACIN TEV OFLOXACIN AAP 400mg Tablet OFLOXACIN AAP 08:12.20 SULFONAMIDES SULFAMETHOXAZOLE 500mg Tablet APO-SULFAMETHOXAZOLE APX SULFAMETHOXAZOLE, TRIMETHOPRIM 40mg & 8mg/mL Suspension NOVO-TRIMEL TEV 100mg & 20mg Tablet APO-SULFATRIM PED APX 400mg & 80mg Tablet APO-SULFATRIM APX NOVO-TRIMEL TEV 800mg & 160mg Tablet APO-SULFATRIM DS APX NOVO-TRIMEL DS TEV PROTRIN DF PRO SULFASALAZINE 500mg Enteric Coated Tablet PMS-SULFASALAZINE PMS SALAZOPYRIN PFI 500mg Tablet PMS-SULFASALAZINE PMS SALAZOPYRIN PFI 08:12.24 TETRACYCLINES DOXYCYCLINE 100mg Capsule APO-DOXY APX DOXYCIN RIV DOXYCYCLINE SAN NOVO-DOXYLIN TEV 100mg Tablet APO-DOXY APX DOXYCIN RIV DOXYCYCLINE SAN DOXYTAB PDL NOVO-DOXYLIN TEV 08:12.24 TETRACYCLINES MINOCYCLINE HCL For: a. - patients who cannot tolerate other tetracyclines. b. - patients with severe widespread acne who have failed on tetracycline. 50mg Capsule APO-MINOCYCLINE APX DOM-MINOCYCLINE DPC MINOCYCLINE PDL MINOCYCLINE SAN MYLAN-MINOCYCLINE MYL NOVO-MINOCYCLINE TEV PMS-MINOCYCLINE PMS PMS-MINOCYCLINE PMS RATIO-MINOCYCLINE RPH RIVA-MINOCYCLINE RIV SANDOZ-MINOCYCLINE SDZ 100mg Capsule APO-MINOCYCLINE APX DOM-MINOCYCLINE DPC MINOCYCLINE PDL MINOCYCLINE IVX MINOCYCLINE SAN MYLAN-MINOCYCLINE MYL NOVO-MINOCYCLINE TEV PMS-MINOCYCLINE PMS PMS-MONOCYCLINE PMS RATIO-MINOCYCLINE RPH RIVA-MINOCYCLINE RIV SANDOZ-MINOCYCLINE SDZ TETRACYCLINE HCL 250mg Capsule APO-TETRA APX TETRACYCLINE PRO 08:12.28 MISCELLANEOUS ANTIBIOTICS CLINDAMYCIN HCL 150mg Capsule APO-CLINDAMYCIN APX CLINDAMYCIN SAN CLINDAMYCINE PDL DALACIN C PFI MYLAN-CLINDAMYCIN MYL TEVA-CLINDAMYCIN TEV 300mg Capsule APO-CLINDAMYCIN APX CLINDAMYCIN PDL CLINDAMYCIN SAN DALACIN C PFI MYLAN-CLINDAMYCIN MYL TEVA-CLINDAMYCIN TEV Page 6 of 151

23 08:12.28 MISCELLANEOUS ANTIBIOTICS CLINDAMYCIN PALMITATE HCL 15mg/mL Solution DALACIN C PFI LINEZOLID Tablets: For treatment of proven vancomycin-resistant enterococci (VRE) infections when other antibiotics are not available, and for the treatment of proven Methicillin-Resistant Staphylococcus aureus (MRSA) infections in patients who cannot tolerate or who had an idiosyncratic reaction with Vancomycin. I.V. solution: When linezolid cannot be administered orally in the above mentioned situations. 2mg/mL Injection LINEZOLID TEP ZYVOXAM PFI 600mg Tablet APO-LINEZOLID APX SANDOZ LINEZOLID SDZ ZYVOXAM PFI 08:14.04 ALLYLAMINES TERBINAFINE HCL 250mg Tablet APO-TERBINAFINE APX AURO-TERBINAFINE AUR CO TERBINAFINE COB DOM-TERBINAFINE DOM JAMP-TERBINAFINE JAP LAMISIL NVR MYLAN-TERBINAFINE MYL NOVO-TERBINAFINE TEV PMS-TERBINAFINE PMS PMS-TERBINAFINE PMS RIVA-TERBINAFINE RIV SANDOZ-TERBINAFINE SDZ TERBINAFINE PDL TERBINAFINE SAN TERBINAFINE SIV 08:14.08 AZOLES FLUCONAZOLE 150mg Capsule APO-FLUCONAZOLE APX CANESORAL BAY CO FLUCONAZOLE CBT DIFLUCAN PFI NOVO-FLUCONAZOLE TEV PMS-FLUCONAZOLE PMS PMS-FLUCONAZOLE PMS PRO-FLUCONAZOLE PDL RIVA-FLUCONAZOLE RIV 08:14.08 AZOLES FLUCONAZOLE 10mg/mL Suspension DIFLUCAN PFI 50mg Tablet APO-FLUCONAZOLE APX CO FLUCONAZOLE CBT DIFLUCAN PFI MYLAN-FLUCONAZOLE MYL NOVO-FLUCONAZOLE TEV PMS-FLUCONAZOLE PMS TARO-FLUCONAZOLE TAR 100mg Tablet APO-FLUCONAZOLE APX CO FLUCONAZOLE CBT DOM-FLUCONAZOLE PMS MYLAN-FLUCONAZOLE MYL NOVO-FLUCONAZOLE TEV PMS-FLUCONAZOLE PMS PRO-FLUCONAZOLE PDL RIVA-FLUCONAZOLE RIV TAR0-FLUCONAZOLE TAR ITRACONAZOLE 100mg Capsule SPORANOX JNO 10mg/mL Solution SPORANOX JNO KETOCONAZOLE 200mg Tablet APO-KETOCONAZOLE APX NOVO-KETOCONAZOLE TEV VORICONAZOLE For the treatment of: a. - patients with invasive aspergillosis. b. - culture proven invasive candidiasis with documented resistance to fluconazole. 50mg Tablet APO-VORICONAZOLE APX SANDOZ VORICONAZOLE SDZ TEVA-VORICONAZOLE TEP VFEND PFI 200mg Tablet APO-VORICONAZOLE APX SANDOZ VORICONAZOLE SDZ TEVA-VORICONAZOLE TEP VFEND PFI 08:14.28 POLYENES NYATIN 100,000U/mL Suspension DOM-NYATIN DPC PMS-NYATIN PMS RATIO-NYATIN RPH Page 7 of 151

24 08:14.28 POLYENES NYATIN 500,000U Tablet RATIO-NYATIN RPH 08:16.04 ANTITUBERCULOSIS AGENTS ETHAMBUTOL HCL 100mg Tablet ETIBI VAE 400mg Tablet ETIBI VAE ISONIAZID 10mg/mL Syrup ISOTAMINE VAE PMS-ISONIAZID PMS 300mg Tablet ISOTAMINE VAE PMS-ISONIAZID PMS PYRAZINAMIDE 500mg Tablet PMS-PYRAZINAMIDE PMS TEBRAZID VAE RIFABUTIN 150mg Capsule MYCOBUTIN PFI RIFAMPIN 150mg Capsule RIFADIN SAC ROFACT VAE 300mg Capsule RIFADIN SAC ROFACT VAE 08:18.04 ADAMANTANES AMANTADINE HCL 100mg Capsule DOM-AMANTADINE DPC MYLAN-AMANTADINE MYL PMS-AMANTADINE PMS 10mg/mL Syrup PMS-AMANTADINE PMS 08:18.08 ANTIRETROVIRALS ABACAVIR 20mg/mL Oral Liquid ZIAGEN GSK 300mg Tablet ZIAGEN GSK ABACAVIR, LAMIVUDINE 600mg & 300mg Tablet KIVEXA GSK 08:18.08 ANTIRETROVIRALS ABACAVIR, LAMIVUDINE, ZIDOVUDINE 300mg & 150mg & 300mg Tablet TRIZIVIR GSK ATAZANAVIR SULFATE 150mg Capsule REYATAZ BMS 200mg Capsule REYATAZ BMS 300mg Capsule REYATAZ BMS COBICIAT, EMTRICITABINE, ELVITEGRAVIR, TENOFOVIR 150mg & 200mg & 150mg & 300mg Tablet RIBILD GIL DARUNAVIR 75mg Tablet PREZIA JNO 150mg Tablet PREZIA JNO 400mg Tablet PREZIA JNO 600mg Tablet PREZIA JNO 800mg Tablet PREZIA KEG DIDANOSINE 125mg Capsule VIDEX EC BMS 200mg Capsule VIDEX EC BMS 250mg Capsule VIDEX EC BMS 400mg Capsule VIDEX EC BMS DOLUTEGRAVIR SODIUM 50mg Tablet TIVICAY VII EFAVIRENZ 50mg Capsule SUIVA BMS 200mg Capsule SUIVA BMS 600mg Tablet AURO-EFAVIRENZ AUR MYLAN-EFAVIRENZ MYL SUIVA BMS TEVA-EFAVIRENZ TEP Page 8 of 151

25 08:18.08 ANTIRETROVIRALS EFAVIRENZ, EMTRICITABINE, TENOFOVIR DISOPROXIL FUMARATE 600mg & 200mg & 300mg Tablet ATRIPLA BMS EMTRICITABINE, RILPIVIRINE, TENOFOVIR 200mg & 25mg & 300mg Tablet COMPLERA GIL EMTRICITABINE, TENOFOVIR 200mg & 300mg Tablet TRUVADA GIL ETRAVIRINE For use in combination with other antiretroviral agents for treatment-experienced patients with HIV-1 infection who: a.- have failed prior antiretroviral therapy; and b. - have HIV-1 strains resistant to multiple antiretroviral agents, including NNRTIs 100mg Tablet INTELENCE JNO 200mg Tablet INTELENCE KEG FOSAMPRENAVIR CALCIUM 50mg/mL Oral Suspension TELZIR GSK 700mg Tablet TELZIR GSK INDINAVIR SULFATE 200mg Capsule CRIXIVAN FRS 400mg Capsule CRIXIVAN FRS LAMIVUDINE 10mg/mL Solution TC GSK 100mg Tablet APO-LAMIVUDINE HBV APX HEPTOVIR GSK 150mg Tablet TC GSK APO-LAMIVUDINE APX 300mg Tablet TC GSK APO-LAMIVUDINE APX LAMIVUDINE, ZIDOVUDINE 150mg & 300mg Tablet APO-LAMIVUDINE- APX ZIDOVUDINE COMBIVIR GSK TEVA- LAMIVUDINE/ZIDOVUDINE TEP 08:18.08 ANTIRETROVIRALS LOPINAVIR, RITONAVIR 80mg & 20mg/mL Oral Solution KALETRA ABB 100mg & 25mg Tablet KALETRA ABB 200mg & 50mg Tablet KALETRA ABB MARAVIROC For the treatment of HIV-1 infection, given in combination with other antiretroviral agents, in patients who have: a. - CR5 tropic viruses; and b. - documented resistance to at least one agent from each of the three major classes of antiretroviral agents (nucleoside reverse transcriptase inhibitors, non-nucleoside reverse transcriptase inhibitors, and protease inhibitors) 150mg Tablet CELSENTRI VII 300mg Tablet CELSENTRI VII NELFINAVIR MESYLATE 50mg/g Powder for Suspension VIRACEPT PFI 250mg Tablet VIRACEPT PFI 625mg Tablet VIRACEPT PFI NEVIRAPINE 400MG Extended Release Tablet VIRAMUNE XR BOE 200mg Tablet AURO-NEVIRAPINE AUR MYLAN-NEVIRAPINE MYL PMS-NEVIRAPINE PMS TEVA-NEVIRAPINE TEV VIRAMUNE BOE RALTEGRAVIR For the treatment of HIV infection in patients who are antiretroviral experienced and have virologic failure due to resistance to at least one agent from each of the three major classes of antiretroviral agents, nucleoside/tide reverse transcriptase inhibitors, non-nucleoside reverse transcriptase inhibitors and protease inhibitors. 400mg Tablet ISENTRESS FRS RILPIVIRINE HCL 25mg Tablet EDURANT KEG Page 9 of 151

26 08:18.08 ANTIRETROVIRALS RITONAVIR 80mg/mL Liquid NORVIR ABB 100mg Tablet NORVIR ABB SAQUINAVIR MESYLATE 200mg Capsule INVIRASE HLR 500mg Tablet INVIRASE HLR AVUDINE 15mg Capsule ZERIT BMS 20mg Capsule ZERIT BMS 30mg Capsule ZERIT BMS 40mg Capsule ZERIT BMS TENOFOVIR DISOPROXIL FUMARATE For the management of HIV disease in patients who have failed or have experienced adverse events to an alternative nucleoside reverse transcriptase inhibitor. 245mg Tablet VIREAD GIL TIPRANAVIR For the management of HIV disease in patients a. - who have failed all currently listed protease inhibitors b. - intolerant to all currently listed protease inhibitors 250mg Capsule APTIVUS BOE ZIDOVUDINE 100mg Capsule APO-ZIDOVUDINE APX RETROVIR GSK 10mg/mL Syrup RETROVIR GSK 08:18.20 INTERFERONS PEGINTERFERON ALFA-2A For the treatment of chronic hepatitis C in patients who are treatment naïve, upon the written request of a hepatologist or other specialist in this area. a. - For genotypes 1, 4, 5 and 6, an initial 24 week supply will be approved. A further 24 week supply may be approved if patient has a viral reduction of at least 2 logs or HCV is undetectable at 12 weeks (48 weeks total). b. - For genotypes 2 or 3, initial coverage for a maximum of 24 weeks will be approved. Renewals will not be covered 180mcg/0.5mL Injection PEGASYS HLR 180mcg/1mL Injection PEGASYS HLR PEGINTERFERON ALFA-2A, RIBAVIRIN For the treatment of chronic hepatitis C in patients who are treatment naïve, upon the written request of a hepatologist or other specialist in this area. a. - For genotypes 1, 4, 5 and 6, an initial 24 week supply will be approved. A further 24 week supply may be approved if patient has a viral reduction of at least 2 logs or HCV is undetectable at 12 weeks (48 weeks total). b. - For genotypes 2 or 3, initial coverage for a maximum of 24 weeks will be approved. Renewals will not be covered 180mcg/0.5mL & 200mg Injection & Tablet PEGASYS RBV HLR 180mcg/1mL & 200mg Injection & Tablet PEGASYS RBV HLR PEGINTERFERON ALFA-2B, RIBAVIRIN For the treatment of chronic hepatitis C in patients who are treatment naïve, upon the written request of a hepatologist or other specialist in this area. a. - For genotypes 1, 4, 5 and 6, an initial 24 week supply will be approved. A further 24 week supply may be approved if patient has a viral reduction of at least 2 logs or HCV is undetectable at 12 weeks (48 weeks total). b. - For genotypes 2 or 3, initial coverage for a maximum of 24 weeks will be approved. Renewals will not be covered 50mcg/0.5mL & 200mg Injection & Capsule PEGETRON SCH PEGETRON REDIPEN SCH 80mcg/0.5mL & 200mg Injection & Capsule PEGETRON REDIPEN SCH 100mcg/0.5mL & 200mg Injection & Capsule PEGETRON REDIPEN SCH 120mcg/0.5mL & 200mg Injection & Capsule PEGETRON REDIPEN SCH Page 10 of 151

27 08:18.20 INTERFERONS PEGINTERFERON ALFA-2B, RIBAVIRIN For the treatment of chronic hepatitis C in patients who are treatment naïve, upon the written request of a hepatologist or other specialist in this area. a. - For genotypes 1, 4, 5 and 6, an initial 24 week supply will be approved. A further 24 week supply may be approved if patient has a viral reduction of at least 2 logs or HCV is undetectable at 12 weeks (48 weeks total). b. - For genotypes 2 or 3, initial coverage for a maximum of 24 weeks will be approved. Renewals will not be covered 150mcg/0.5mL & 200mg Injection & Capsule PEGETRON SCH PEGETRON REDIPEN SCH 08:18.32 NUCLEOSIDES AND NUCLEOTIDES ACYCLOVIR 40mg/mL Suspension ZOVIRAX GSK 200mg Tablet ACYCLOVIR SAN APO-ACYCLOVIR APX MYLAN-ACYCLOVIR MYL RATIO-ACYCLOVIR RPH TEVA-ACYCLOVIR TEV ZOVIRAX GSK 400mg Tablet ACYCLOVIR SAN APO-ACYCLOVIR APX MYLAN-ACYCLOVIR MYL RATIO-ACYCLOVIR RPH TEVA-ACYCLOVIR TEV ZOVIRAX GSK 800mg Tablet ACYCLOVIR SAN APO-ACYCLOVIR APX MYLAN-ACYCLOVIR MYL RATIO-ACYCLOVIR RPH TEVA-ACYCLOVIR TEV ADEFOVIR DIPIVOXIL 08:18.32 NUCLEOSIDES AND NUCLEOTIDES ENTECAVIR For the treatment of chronic hepatitis B infection in patients with cirrhosis documented on radiologic or histologic grounds and a HBV DNA concentration above 2000IU/mL. 0.5mg Tablet APO-ENTECAVIR APX BARACLUDE BMS PMS-ENTECAVIR PMS FAMCICLOVIR 125mg Tablet APO-FAMCICLOVIR APX CO FAMCICLOVIR COB FAMCICLOVIR PDL FAMVIR NVR PMS-FAMCICLOVIR PMS SANDOZ-FAMCICLOVIR SDZ 250mg Tablet APO-FAMCICLOVIR APX CO FAMCICLOVIR COB FAMCICLOVIR PDL FAMVIR NVR PMS-FAMCICLOVIR PMS SANDOZ-FAMCICLOVIR SDZ 500mg Tablet APO-FAMCICLOVIR APX CO FAMCICLOVIR COB FAMCICLOVIR PDL FAMVIR NVR PMS-FAMCICLOVIR PMS SANDOZ-FAMCICLOVIR SDZ GANCICLOVIR SODIUM 500mg Injection CYTOVENE HLR For the treatment of chronic hepatitis B infection when used in combination with lamivudine in patients who have developed failure to lamivudine, as defined by an increase in HBV DNA of 1 log10 IU/mL above the nadir, measured on two separate occasions within an interval of at least one month, after the first three months of lamivudine therapy, and when failure to lamivudine is not due to poor adherence to therapy. 10MG Tablet APO-ADEFOVIR APX HEPSERA GIL Page 11 of 151

28 08:18.32 NUCLEOSIDES AND NUCLEOTIDES SOFOSBUVIR For the treatment of chronic Hepatitis C in adult patients with compensated liver disease, including cirrhosis, if the following clinincal criteria and conditions are met: Patients with Genotype 1 CHC infection, in combination with pegylated-interferon and ribavirin (PEG IFN/RBV): - Fibrosis stage F2 or greater - Treatment naïve If approved, treatment should not exceed a duration of 12 weeks. Patients with Genotype 2 CHC infection, in combination with RBV: - Fibrosis stage F2 or greater - Previous treatment experience with Peg-IFN/RBV ; OR - A medical contraindication to Peg-IFN/RBV If approved, treatment should not exceed a duration of 12 weeks. Patients with Genotype 3 CHC infection, in combination with RBV: - Fibrosis stage F2 or greater - Previous treatment experience with Peg-IFN/RBV ; OR - A medical contraindication to Peg-IFN/RBV If approved, treatment should not exceed a duration of 24 weeks. Not eligible for coverage: Patients currently being treated with another HCV antiviral agent Patients who have previously received a treatment course of Sovaldi (Re-treatment requests will not be considered). 400mg Tablet SOVALDI GIL 08:18.32 NUCLEOSIDES AND NUCLEOTIDES SOFOSBUVIR, LEDIPASVIR For the treatment of chronic hepatitis C virus (HCV) genotype 1 infection in adults with a liver fibrosis stage F2 (Metavir score or equivalent). Criteria & Duration Treatment-naïve patients with no cirrhosis, viral load < 6 million IU/mL - 8 weeks* Treatment-naïve patients with no cirrhosis, viral load 6 million IU/mL -12 weeks Treatment-naïve patients with compensated cirrhosis -12 weeks Treatment-experienced patients with no cirrhosis - 12 weeks Treatment-experienced patients with compensated cirrhosis - 24 weeks *For this population cohort (treatment naïve, non-cirrhotic, viral load < 6 million IU/mL), evidence has shown that the SVR rates with the 8-week and 12-week treatment regimens are similar. Treatment regimens of up to 12 weeks are recognized as a Health Canada approved treatment option. Patients may be considered for 12 weeks of coverage if they have severe fibrosis/borderline cirrhosis (F3-4) or if they are co-infected with HIV. Not eligible for coverage: Patients currently being treated with another HCV antiviral agent Patients who have previously received a treatment course of Harvoni (Re-treatment requests will not be considered). 400mg & 90mg Tablet HARVONI GIL VALACYCLOVIR HCL 500mg Tablet APO-VALACYCLOVIR APX CO VALACYCLOVIR CBT DOM-VALACYCLOVIR DOM MYLAN-VALACYCLOVIR MYL PMS-VALACYCLOVIR PMS PRO-VALACYCLOVIR PDL RIVA-VALACYCLOVIR RIV TEVA-VALACYCLOVIR TEP VALTREX GSK VALGANCICLOVIR HCL 450mg Tablet APO-VALGANCICLOVIR APX TEVA-VALGANCICLOVIR TEP VALCYTE HLR Page 12 of 151

29 08:18.40 BOCEPREVIR For the treatment of chronic hepatitis C (CHC) genotype 1 infection in adult patients with compensated liver disease, in combination with peginterferon alpha (a or b) + ribavirin), and the following criteria: -detectable levels of hepatitis C virus RNA in the last six months; - fibrosis stage of F2, F3 or F4; -one course of treatment only (maximum of 44 weeks, based on response). 200mg Capsule VICTRELIS FRS BOCEPREVIR, PEGINTERFERON, RIBAVIRIN For the treatment of chronic hepatitis C (CHC) genotype 1 infection in adult patients with compensated liver disease, in combination with peginterferon alpha (a or b) + ribavirin), and the following criteria: -detectable levels of hepatitis C virus RNA in the last six months; - fibrosis stage of F2, F3 or F4; -one course of treatment only (maximum of 44 weeks, based on response). 200mg & 100mcg & 200mg Kit VICTRELIS TRIPLE FRS 200mg & 120mcg & 200mg Kit VICTRELIS TRIPLE FRS 200mg & 150mcg & 200mg Kit VICTRELIS TRIPLE FRS 200mg & 80mcg & 200mg Kit VICTRELIS TRIPLE FRS SIMEPREVIR For the treatment of chronic Hepatitis C in treatment-naïve and treatment-experienced patients who meet all of the following criteria: - Chronic hepatitis C virus (HCV) genotype 1 infection - Detectable levels of HCV RNA in the last six months - Fibrosis stage F2 or greater (Metavir scale or equivalent) - Patient has not received a prior full therapeutic course of boceprevir or telaprevir. Not eligible for coverage: Patients currently being treated with another HCV antiviral agent Patients who have previously received a treatment course of Galexos (Re-treatment requests will not be considered). 150mg Capsule GALEXOS KEG 08:30.04 AMEBICIDES DIIODOHYDROXYQUIN 210mg Tablet DIODOQUIN GLE 08:30.04 AMEBICIDES DIIODOHYDROXYQUIN 650mg Tablet DIODOQUIN GLE PAROMOMYCIN SULFATE 250mg Capsule HUMATIN ERF 08:30.08 ANTIMALARIALS CHLOROQUINE PHOSPHATE 250mg Tablet TEVA-CHLOROQUINE TEV HYDROXYCHLOROQUINE SULFATE 200mg Tablet APO-HYDROXYQUINE APX MINT- MIN HYDROXYCHLOROQUINE MYLAN- MYL HYDROXYCHLOROQUINE PLAQUENIL SAC PRO-HYDROXYQUINE PDL PRIMAQUINE PHOSPHATE 26.3mg Tablet PRIMAQUINE SAC PYRIMETHAMINE 25mg Tablet DARAPRIM GSK 08:30.92 MISCELLANEOUS ANTIPROTOZOALS ATOVAQUONE 150mg/mL Suspension MEPRON GSK METRONIDAZOLE 500mg Capsule METRONIDAZOLE AAP 250mg Tablet METRONIDAZOLE PDL METRONIDAZOLE AAP 08:36.00 URINARY ANTI-INFECTIVES FOSFOMYCIN TROMETHAMINE For the treatment of women (>12 years old) with: Urinary tract infections with organisms resistant to first line therapy OR Urinary tract infections in pregnancy when first line agents are contraindicated 3gm/pk Powder MONUROL PAL Page 13 of 151

30 08:36.00 URINARY ANTI-INFECTIVES NITROFURANTOIN 50mg Capsule NOVO-FURANTOIN TEV 100mg Capsule MACROBID PGP NOVO-FURANTOIN TEV 50mg Tablet NITROFURANTOIN AAP 100mg Tablet NITROFURANTOIN AAP TRIMETHOPRIM 100mg Tablet TRIMETHOPRIM AAP 200mg Tablet TRIMETHOPRIM AAP Page 14 of 151

31 10:00 ANTINEOPLAIC AGENTS 10:00.00 ANTINEOPLAIC AGENTS ALTRETAMINE 50mg Capsule HEXALEN LIL ANAROZOLE 1mg Tablet ACH-ANAROZOLE ACC ANAROZOLE PDL APO-ANAROZOLE APX ARIMIDEX AZC AURO-ANAROZOLE AUR CO ANAROZOLE CBT JAMP-ANAROZOLE JAP MAR-ANAROZOLE MAR MED-ANAROZOLE GMP MINT-ANAROZOLE MIN MYLAN-ANAROZOLE MYL PMS-ANAROZOLE PMS RAN-ANAROZOLE RBY RIVA-ANAROZOLE RIV SANDOZ ANAROZOLE SDZ TARO-ANAROZOLE TAR TEVA-ANAROZOLE TEP BICALUTAMIDE 50MG Tablet ACH-BICALUTAMIDE ACC APO-BICALUTAMIDE APX BICALUTAMIDE SIV CASODEX AZC CO BICALUTAMIDE COB JAMP-BICALUTAMIDE JAP MYLAN-BICALUTAMIDE MYL PMS-BICALUTAMIDE PMS PRO-BICALUTAMIDE PDL RAN-BICALUTAMIDE RBY SANDOZ-BICALUTAMIDE SDZ TEVA-BICALUTAMIDE TEV BUSERELIN ACETATE 1mg/mL Injection SUPREFACT SAC 1mg/mL Nasal Solution SUPREFACT SAC 6.3mg/Implant Subcutaneous Injection SUPREFACT DEPOT 2 MONTHS 9.45mg/Implant Subcutaneous Injection SUPREFACT DEPOT 3 MONTHS BUSULFAN 2mg Tablet SAC SAC MYLERAN GSK 10:00.00 ANTINEOPLAIC AGENTS CAPECITABINE 150mg Tablet SANDOZ CAPECITABINE SDZ TEVA-CAPECITABINE TEP XELODA HLR 500mg Tablet ACH-CAPECITABINE ACC 500mg Tablet SANDOZ CAPECITABINE SDZ TEVA-CAPECITABINE TEP XELODA HLR CHLORAMBUCIL 2mg Tablet LEUKERAN GSK CYCLOPHOSPHAMIDE 25mg Tablet PROCYTOX BAT 50mg Tablet PROCYTOX BAT CYPROTERONE ACETATE 50mg Tablet ANDROCUR BEX APO-CYPROTERONE APX MED-CYPROTERONE GMP RIVA-CYPROTERONE RIV DEGARELIX ACETATE 80mg Injection FIRMAGON FEI 120mg Injection FIRMAGON FEI ERLOTINIB HYDROCLORIDE Treatment of non-small cell lung cancer (NSCLC) after failure of at least one prior chemotherapy regimen, and whose EGFR expression status is positive or unknown. 100mg Tablet TARCEVA HLR 150mg Tablet TARCEVA HLR ETOPOSIDE 50mg Capsule VEPESID BMS EXEMEANE 25mg Tablet APO-EXEMEANE APX AROMASIN PFI CO EXEMEANE CBT MED-EXEMEANE GMP TEVA-EXEMEANE TEP Page 15 of 151

32 10:00.00 ANTINEOPLAIC AGENTS FLUDARABINE PHOSPHATE 10mg Tablet FLUDARA BEX FLUTAMIDE 250mg Tablet APO-FLUTAMIDE APX EUFLEX SCH PMS-FLUTAMIDE PMS TEVA-FLUTAMIDE TEV GOSERELIN ACETATE 3.6mg/Depot Injection ZOLADEX AZC 10.8mg/Depot Injection ZOLADEX LA AZC HYDROXYUREA 500mg Capsule APO-HYDROXYUREA APX HYDREA BMS HYDROXYUREA SAN MYLAN-HYDROXYUREA MYL IMATINIB MESYLATE a.- For the treatment of patients with chronic myeloid leukemia (CML) in blast crisis, accelerated phase, or in chronic phase. b.- For the treatment of patients with gastrointestinal stromal tumour. c.- For newly diagnosed adult patients with Philadelphia chromosome-positive (CML). 100mg Tablet APO-IMATINIB APX CO IMATINIB ATP GLEEVEC NVR TEVA-IMATINIB TEP 400mg Tablet APO-IMATINIB APX CO IMATINIB CBT GLEEVEC TEV TEVA-IMATINIB TEP INTERFERON ALFA-2B 6,000,000IU/mL Injection INTRON A SCH 10,000,000IU/mL Injection INTRON A SCH 10,000,000IU/Vial Injection INTRON A SCH 15,000,000IU/mL Injection INTRON A SCH 25,000,000IU/mL Injection INTRON A SCH 50,000,000IU/mL Injection INTRON A SCH 10:00.00 ANTINEOPLAIC AGENTS LETROZOLE 2.5mg Tablet ACH-LETROZOLE ACC APO-LETROZOLE APX AURO-LETROZOLE AUR FEMARA NVR JAMP-LETROZOLE JAP LETROZOLE TEV LETROZOLE CBT LETROZOLE PDL MAR-LETROZOLE MAR MED-LETROZOLE GMP PMS-LETROZOLE PMS RAN-LETROZOLE RBY RIVA-LETROZOLE RIV SANDOZ LETROZOLE SDZ TEVA-LETROZOLE TEP LEUPROLIDE ACETATE 3.75mg/Vial Injection LUPRON DEPOT ABB 7.5mg/Vial Injection LUPRON DEPOT ABB 11.25mg/Vial Injection LUPRON DEPOT ABB 22.5mg/Vial Injection ELIGARD SAC LUPRON DEPOT ABB 30mg/Vial Injection ELIGARD SAC LUPRON DEPOT ABB 45mg/Vial Injection ELIGARD SAC LOMUINE 10mg Capsule CEENU BMS 40mg Capsule CEENU BMS 100mg Capsule CEENU BMS MEGEROL ACETATE 40mg/mL Suspension MEGACE BMS 40mg Tablet MEGEROL AAP 160mg Tablet MEGEROL AAP MELPHALAN 2mg Tablet ALKERAN GSK Page 16 of 151

33 10:00.00 ANTINEOPLAIC AGENTS MERCAPTOPURINE 50mg Tablet MERCAPTOPURINE E PURINETHOL TEV METHOTREXATE 25mg/mL Injection METHOTREXATE SDZ METHOTREXATE SODIUM 10mg/mL Injection METHOTREXATE MAY 25mg/mL Injection JAMP-METHOTREXATE JAP METHOTREXATE MAY METHOTREXATE MAY METHOTREXATE MYL NOVO-METHOTREXATE TEV 2.5mg Tablet APO-METHOTREXATE APX METHOTREXATE WAY RATIO-METHOTREXATE RPH 10mg Tablet METHOTREXATE MAY MITOTANE 500mg Tablet LYSODREN BMS NILUTAMIDE 50mg Tablet ANANDRON SAC PROCARBAZINE HCL 50mg Capsule MATULAN SIG RITUXIMAB Prescribed by a rheumatologist for treatment of adult patients with severely active rheumatoid arthritis who have failed to respond to a trial of an anti-tnf agent. Treatment should be combined with methotrexate. Rituximab should not be used in combination with anti-tnf agents. Treatment beyond six months will only be considered for patients who have achieved a response. (Please refer to Appendix A). 10mg/mL Injection RITUXAN HLR 10:00.00 ANTINEOPLAIC AGENTS SUNITINIB MALATE Limited use benefit (Prior approval required) Criteria for initial six month coverage of Sutent: For patients with histologically proven unresectable or recurrent/metastatic GI who have failed or are unable to tolerate imatinib therapy. Sunitinib will not be funded concomitantly with imatinib. Criteria for assessment at every six months: There is no objective evidence of disease progression. 12.5mg Capsule SUTENT PFI 25mg Capsule SUTENT PFI 50mg Capsule SUTENT PFI TAMOXIFEN CITRATE 10mg Tablet APO-TAMOX APX MYLAN-TAMOXIFEN MYL PMS-TAMOXIFEN PMS TEVA-TAMOXIFEN TEV 20mg Tablet APO-TAMOX APX NOLVADEX D AZC PMS-TAMOXIFEN PMS TEVA-TAMOXIFEN TEV TEMOZOLOMIDE For: a. - treatment of adult patients with glioblastoma multiforme or anaplastic astrocytoma, and documented evidence of recurrence or progression after standard therapy (resection, radiotherapy, and chemotherapy). b. - treatment of adult patients with newly diagnosed glioblastoma multiforme concomitantly with radiotherapy and then as maintenance treatment. 5mg Capsule TEMODAL SCH 20mg Capsule CO TEMOZOLOMIDE CBT TEMODAL SCH 100mg Capsule CO TEMOZOLOMIDE CBT TEMODAL SCH 140mg Capsule APO-TEMOZOLOMIDE APX CO TEMOZOLOMIDE CBT TEMODAL FRS 250mg Capsule CO TEMOZOLOMIDE CBT TEMODAL SCH Page 17 of 151

34 10:00.00 ANTINEOPLAIC AGENTS THIOGUANINE 40mg Tablet LANVIS GSK TRETINOIN 10mg Capsule VESANOID HLR TRIPTORELIN PAMOATE 3.75mg/Vial Injection TRELAR WAT 11.25mg/Vial Injection TRELAR LA WAT 22.5mg Injection TRELAR ACY VINCRIINE SULFATE 1mg/mL Injection VINCRIINE SULFATE TEV VINCRIINE SULFATE MAY Page 18 of 151

35 12:00 AUTONOMIC DRUGS 12:04.00 PARASYMPATHOMIMETIC AGENTS BETHANECHOL CHLORIDE 10mg Tablet DUVOID SHI 25mg Tablet DUVOID SHI 50mg Tablet DUVOID SHI DONEPEZIL HCL Initial six month coverage for cholinesterase inhibitors: Diagnosis of mild to moderate Alzheimer s disease; AND Mini Mental State Exam (MMSE) score of 10-26, established within the last 60 days; AND Global Deterioration Scale (GDS) score between 4 to 6, established within the last 60 days Continued coverage beyond 6 months will be based on improvement or stabilization of cognition, function or behaviour. Criteria for coverage at every six month interval: Diagnosis is still mild to moderate Alzheimer s disease; AND MMSE score > 10; OR GDS score between 4 to 6; AND Improvement or stabilization in at least one of the following domains (please indicate improved, worsened, or no change) 1.Memory, reasoning and perception (e.g., names, tasks, MMSE) 2.Instrumental activities of daily living (IADLs: e.g., telephone, shopping, meal preparation) 3.Basic activities of daily living (e.g., bathing, dressing, hygiene, toileting) 4.Neuropsychiatric symptoms (e.g., agitation, delusions, hallucination, apathy) 5mg Tablet ACCEL-DONEPEZIL ACP ACT DONEPEZIL ATP APO-DONEPEZIL APX ARICEPT PFI AURO-DONEPEZIL AUR DONEPEZIL ACC DONEPEZIL PDL DONEPEZIL SIV JAMP-DONEPEZIL JAP JAMP-DONEPEZIL JAP MAR-DONEPEZIL MAR MYLAN-DONEPEZIL MYL PMS-DONEPEZIL PMS RAN-DONEPEZIL RBY RIVA-DONEPEZIL RIV SANDOZ DONEPEZIL SDZ SEPTA-DONEPEZIL SPT TEVA-DONEPEZIL TEP 12:04.00 PARASYMPATHOMIMETIC AGENTS DONEPEZIL HCL Initial six month coverage for cholinesterase inhibitors: Diagnosis of mild to moderate Alzheimer s disease; AND Mini Mental State Exam (MMSE) score of 10-26, established within the last 60 days; AND Global Deterioration Scale (GDS) score between 4 to 6, established within the last 60 days Continued coverage beyond 6 months will be based on improvement or stabilization of cognition, function or behaviour. Criteria for coverage at every six month interval: Diagnosis is still mild to moderate Alzheimer s disease; AND MMSE score > 10; OR GDS score between 4 to 6; AND Improvement or stabilization in at least one of the following domains (please indicate improved, worsened, or no change) 1.Memory, reasoning and perception (e.g., names, tasks, MMSE) 2.Instrumental activities of daily living (IADLs: e.g., telephone, shopping, meal preparation) 3.Basic activities of daily living (e.g., bathing, dressing, hygiene, toileting) 4.Neuropsychiatric symptoms (e.g., agitation, delusions, hallucination, apathy) 10mg Tablet ACCEL-DONEPEZIL ACP ACT DONEPEZIL ATP APO-DONEPEZIL APX ARICEPT PFI AURO-DONEPEZIL AUR DONEPEZIL ACC DONEPEZIL PDL DONEPEZIL SIV JAMP-DONEPEZIL JAP JAMP-DONEPEZIL JAP MAR-DONEPEZIL MAR MYLAN-DONEPEZIL MYL PMS-DONEPEZIL PMS RAN-DONEPEZIL RBY RIVA-DONEPEZIL RIV SANDOZ DONEPEZIL SDZ SEPTA-DONEPEZIL SPT TEVA-DONEPEZIL TEP Page 19 of 151

36 12:04.00 PARASYMPATHOMIMETIC AGENTS GALANTAMINE Initial six month coverage for cholinesterase inhibitors: Diagnosis of mild to moderate Alzheimer s disease; AND Mini Mental State Exam (MMSE) score of 10-26, established within the last 60 days; AND Global Deterioration Scale (GDS) score between 4 to 6, established within the last 60 days Continued coverage beyond 6 months will be based on improvement or stabilization of cognition, function or behaviour. Criteria for coverage at every six month interval: Diagnosis is still mild to moderate Alzheimer s disease; AND MMSE score > 10; OR GDS score between 4 to 6; AND Improvement or stabilization in at least one of the following domains (please indicate improved, worsened, or no change) 1.Memory, reasoning and perception (e.g., names, tasks, MMSE) 2.Instrumental activities of daily living (IADLs: e.g., telephone, shopping, meal preparation) 3.Basic activities of daily living (e.g., bathing, dressing, hygiene, toileting) 4.Neuropsychiatric symptoms (e.g., agitation, delusions, hallucination, apathy) 8mg Extended Release Capsule GALANTAMINE ER PDL MAR-GALANTAMINE ER MAR MYLAN-GALANTAMINE ER MYL PAT-GALANTAMINE ER JNO PMS-GALANTAMINE ER PMS REMINYL ER JNO TEVA-GALANTAMINE ER TEP 16mg Extended Release Capsule GALANTAMINE ER PDL MAR-GALANTAMINE ER MAR MYLAN-GALANTAMINE ER MYL PAT-GALANTAMINE ER JNO PMS-GALANTAMINE ER PMS REMINYL ER JNO TEVA-GALANTAMINE ER TEP 24mg Extended Release Capsule GALANTAMINE ER PDL MAR-GALANTAMINE ER MAR MYLAN-GALANTAMINE ER MYL PAT-GALANTAMINE ER JNO PMS-GALANTAMINE ER PMS REMINYL ER JNO TEVA-GALANTAMINE ER TEP NEOIGMINE BROMIDE 15mg Tablet PROIGMIN VAE 12:04.00 PARASYMPATHOMIMETIC AGENTS PILOCARPINE HCL 5mg Tablet PILOCARPINE E SALAGEN PFI PYRIDOIGMINE BROMIDE 180mg Sustained Release Tablet MEINON-SR VAE 60mg Tablet MEINON VAE RIVAIGMINE Initial six month coverage for cholinesterase inhibitors: Diagnosis of mild to moderate Alzheimer s disease; AND Mini Mental State Exam (MMSE) score of 10-26, established within the last 60 days; AND Global Deterioration Scale (GDS) score between 4 to 6, established within the last 60 days Continued coverage beyond 6 months will be based on improvement or stabilization of cognition, function or behaviour. Criteria for coverage at every six month interval: Diagnosis is still mild to moderate Alzheimer s disease; AND MMSE score > 10; OU GDS score between 4 to 6; AND Improvement or stabilization in at least one of the following domains (please indicate improved, worsened, or no change) 1.Memory, reasoning and perception (e.g., names, tasks, MMSE) 2.Instrumental activities of daily living (IADLs: e.g., telephone, shopping, meal preparation) 3.Basic activities of daily living (e.g., bathing, dressing, hygiene, toileting) 4.Neuropsychiatric symptoms (e.g., agitation, delusions, hallucination, apathy) 1.5mg Capsule APO-RIVAIGMINE APX EXELON NOV MED-RIVAIGMINE GMP MINT-RIVAIGMINE MIN MYLAN-RIVAIGMINE MYL NOVO-RIVAIGMINE TEV PMS-RIVAIGMINE PMS RATIO-RIVAIGMINE RPH RIVAIGMINE PDL SANDOZ RIVAIGMINE SDZ Page 20 of 151

37 12:04.00 PARASYMPATHOMIMETIC AGENTS RIVAIGMINE Initial six month coverage for cholinesterase inhibitors: Diagnosis of mild to moderate Alzheimer s disease; AND Mini Mental State Exam (MMSE) score of 10-26, established within the last 60 days; AND Global Deterioration Scale (GDS) score between 4 to 6, established within the last 60 days Continued coverage beyond 6 months will be based on improvement or stabilization of cognition, function or behaviour. Criteria for coverage at every six month interval: Diagnosis is still mild to moderate Alzheimer s disease; AND MMSE score > 10; OU GDS score between 4 to 6; AND Improvement or stabilization in at least one of the following domains (please indicate improved, worsened, or no change) 1.Memory, reasoning and perception (e.g., names, tasks, MMSE) 2.Instrumental activities of daily living (IADLs: e.g., telephone, shopping, meal preparation) 3.Basic activities of daily living (e.g., bathing, dressing, hygiene, toileting) 4.Neuropsychiatric symptoms (e.g., agitation, delusions, hallucination, apathy) 3mg Capsule APO-RIVAIGMINE APX EXELON NOV MED-RIVAIGMINE GMP MINT-RIVAIGMINE MIN MYLAN-RIVAIGMINE MYL NOVO-RIVAIGMINE TEV PMS-RIVAIGMINE PMS RATIO-RIVAIGMINE RPH RIVAIGMINE PDL SANDOZ RIVAIGMINE SDZ 4.5mg Capsule APO-RIVAIGMINE APX EXELON NOV MED-RIVAIGMINE GMP MINT-RIVAIGMINE MIN MYLAN-RIVAIGMINE MYL NOVO-RIVAIGMINE TEV PMS-RIVAIGMINE PMS RATIO-RIVAIGMINE RPH RIVAIGMINE PDL SANDOZ RIVAIGMINE SDZ 12:04.00 PARASYMPATHOMIMETIC AGENTS RIVAIGMINE Initial six month coverage for cholinesterase inhibitors: Diagnosis of mild to moderate Alzheimer s disease; AND Mini Mental State Exam (MMSE) score of 10-26, established within the last 60 days; AND Global Deterioration Scale (GDS) score between 4 to 6, established within the last 60 days Continued coverage beyond 6 months will be based on improvement or stabilization of cognition, function or behaviour. Criteria for coverage at every six month interval: Diagnosis is still mild to moderate Alzheimer s disease; AND MMSE score > 10; OU GDS score between 4 to 6; AND Improvement or stabilization in at least one of the following domains (please indicate improved, worsened, or no change) 1.Memory, reasoning and perception (e.g., names, tasks, MMSE) 2.Instrumental activities of daily living (IADLs: e.g., telephone, shopping, meal preparation) 3.Basic activities of daily living (e.g., bathing, dressing, hygiene, toileting) 4.Neuropsychiatric symptoms (e.g., agitation, delusions, hallucination, apathy) 6mg Capsule APO-RIVAIGMINE APX EXELON NOV MED-RIVAIGMINE GMP MINT-RIVAIGMINE MIN MYLAN-RIVAIGMINE MYL NOVO-RIVAIGMINE TEV PMS-RIVAIGMINE PMS RATIO-RIVAIGMINE RPH RIVAIGMINE PDL SANDOZ RIVAIGMINE SDZ 2mg/mL Oral Liquid EXELON NOV 12:08.08 ANTIMUSCARINICS / ANTISPASMODICS ACLIDINIUM BROMIDE For patients with chronic obstructive pulmonary disease (COPD) and who: did not respond to a trial of ipratropium (Atrovent); OR did not have a previous trial of ipratropium, but who have moderate to severe COPD, defined as <60% FEV1, FEV1/FVC<0.7 and MRC 3 to mcg Inhaler TUDORZA GENUAIR AZE Page 21 of 151

38 12:08.08 ANTIMUSCARINICS / ANTISPASMODICS GLYCOPYRRONIUM For patients with chronic obstructive pulmonary disease (COPD) and who: did not respond to a trial of ipratropium (Atrovent); OR did not have a previous trial of ipratropium, but who have moderate to severe COPD, defined as <60% FEV1, FEV1/FVC<0.7 and MRC 3 to 5. 50mcg Powder for Inhalation (Capsule) SEEBRI BREEZHALER TEV IPRATROPIUM BROMIDE 250mcg/mL Inhalation Solution (Multi-Dose) APO-IPRAVENT APX MYLAN-IPRATROPIUM MYL NOVO-IPRAMIDE TEV PMS-IPRATROPIUM PMS 125mcg/mL Inhalation Solution (Unit Dose) PMS-IPRATROPIUM UDV PMS RATIO-IPRATROPIUM UDV RPH 250mcg/mL Inhalation Solution (Unit Dose) MYLAN-IPRATROPIUM UDV MYL PMS-IPRATROPIUM UDV PMS PMS-IPRATROPIUM UDV PMS RATIO-IPRATROPIUM UDV RPH RATIO-IPRATROPIUM UDV RPH 20mcg/Inhalation Inhaler ATROVENT HFA BOE 0.03% Nasal Spray APO-IPRAVENT APX ATROVENT BOE DOM-IPRATROPIUM DPC PMS-IPRATROPIUM PMS 0.06% Nasal Spray APO-IPRAVENT APX ATROVENT BOE IPRATROPIUM BROMIDE, SALBUTAMOL 0.2mg & 1mg/mL Inhalation Solution (Unit Dose) COMBIVENT BOE RATIO-IPRA SAL RPH TEVA-COMBO ERINEBS TEV SALBUTAMOL, IPRATROPIUM 100mcg & 20mcg Inhaler COMBIVENT RESPIMAT BOE SCOPOLAMINE BUTYLBROMIDE 10mg Tablet BUSCOPAN BOE 12:08.08 ANTIMUSCARINICS / ANTISPASMODICS TIOTROPIUM BROMIDE MONOHYDRATE For patients with chronic obstructive pulmonary disease (COPD) and who: -did not respond to a trial of ipratropium (Atrovent); OR -did not have a previous trial of ipratropium, but who have moderate to severe COPD, defined as <60% FEV1, FEV1/FVC<0.7 and MRC 3 to 5. 18mcg Powder for Inhalation (Capsule) SPIRIVA BOE 12:12.08 BETA ADRENERGIC AGONIS FORMOTEROL FUMARATE For the treatment of asthma in patients who are using optimal corticosteroid therapy and experiencing breakthrough symptoms requiring regular use of a rapid-onset, shortduration bronchodilator. OR For the treatment of Chronic Obstructive Pulmonary Disease (COPD) in patients not adequately controlled with either ipratropium, tiotropium or a short acting beta-agonist. 12mcg/Capsule Powder for Inhalation FORADIL NVR FORMOTEROL FUMARATE DIHYDRATE For the treatment of asthma in patients who are using optimal corticosteroid therapy and experiencing breakthrough symptoms requiring regular use of rapid onset, short duration bronchodilator 6mcg/Dose Dry Powder Inhaler OXEZE TURBUHALER AZC 12mcg/Dose Dry Powder Inhaler OXEZE TURBUHALER AZC Page 22 of 151

39 12:12.08 BETA ADRENERGIC AGONIS FORMOTEROL FUMARATE DIHYDRATE, BUDESONIDE For the treatment of reversible obstructive airway disease in patients who are not adequately controlled on medium doses of inhaled corticosteroids (e.g. fluticasone mcg daily, or the equivalent) as the sole agent and require addition of a long-acting beta agonist. Patients using this combination product must also have access to a short-acting bronchodilator for symptomatic relief. OR ONE OF THE FOLLOWING For the treatment of moderate* COPD, if a patient continues to be symptomatic after an adequate trial of a long acting anticholinergic AND a long acting beta-agonist. For the treatment of severe** COPD, if a patient continues to be symptomatic after an adequate trial of a long acting anticholinergic OR a long acting beta-agonist. 6mcg & 100mcg/Inhalation Inhaler SYMBICORT 100 TURBUHALER AZC 6mcg & 200mcg/Inhalation Inhaler SYMBICORT 200 TURBUHALER AZC FORMOTEROL FUMARATE DIHYDRATE, MOMETASONE FUROATE For the treatment of reversible obstructive airway disease in patients who are not adequately controlled on medium doses of inhaled corticosteroids (e.g. fluticasone mcg daily, or the equivalent) as the sole agent and require addition of a long-acting beta agonist. Patients using this combination product must also have access to a short-acting bronchodilator for symptomatic relief. 5mcg & 100mcg/Inhalation Inhaler ZENHALE FRS 5mcg & 200mcg/Inhalation Inhaler ZENHALE FRS 5mcg & 50mcg/Inhalation Inhaler ZENHALE FRS INDACATEROL MALEATE 12:12.08 BETA ADRENERGIC AGONIS SALBUTAMOL 0.5mg/mL Inhalation Solution (Unit Dose) PMS-SALBUTAMOL PMS RATIO-SALBUTAMOL RPH 1mg/mL Inhalation Solution (Unit Dose) DOM-SALBUTAMOL DPC PMS-SALBUTAMOL PMS RATIO-SALBUTAMOL RPH VENTOLIN PF GSK 2mg/mL Inhalation Solution (Unit Dose) PMS-SALBUTAMOL PMS VENTOLIN PF GSK 100mcg/Inhalation Inhaler SALBUTAMOL HFA SAN 100mcg/Inhalation Inhaler AIROMIR MMH APO-SALVENT CFC FREE APX NOVO-SALBUTAMOL HFA TEV VENTOLIN HFA GSK 2mg Tablet APO-SALVENT APX 4mg Tablet APO-SALVENT APX SALMETEROL XINAFOATE a. - For the treatment of asthma in patients who are using optimal corticosteroid therapy and experiencing breakthrough symptoms requiring regular use of a rapid onset, short duration bronchodilator. Serevent is not intended for the relief of acute asthma symptoms: patients must have access to an inhaled fast-acting bronchodilator (beta-2 agonist) for symptomatic relief. b. - For the treatment of Chronic Obstructive Pulmonary Disease (COPD) in patients not adequately controlled with ipratropium, tiotropium or a short acting beta-agonist. 50mcg/inhalation Powder Diskus SEREVENT DISKUS GSK 50mcg/Inhalation Powder for Inhalation SEREVENT DISKHALER GSK For the treatment of Chronic Obstructive Pulmonary Disease (COPD) in patients not adequately controlled with either ipratropium, tiotropium or a short acting beta-agonist. 75mcg Powder for Inhalation (Capsule) ONBREZ BREEZHALER TEV ORCIPRENALINE SULFATE 2mg/mL Syrup APO-ORCIPRENALINE APX SALBUTAMOL 5mg/mL Inhalation Solution (Multi-Dose) RATIO-SALBUTAMOL RPH SANDOZ-SALBUTAMOL SDZ VENTOLIN GSK Page 23 of 151

40 12:12.08 BETA ADRENERGIC AGONIS SALMETEROL XINAFOATE, FLUTICASONE PROPIONATE For the treatment of reversible obstructive airway disease in patients who are not adequately controlled on medium doses of inhaled corticosteroids (e.g. fluticasone mcg daily, or the equivalent) as the sole agent and require addition of a long-acting beta agonist. Patients using this combination product must also have access to a short-acting bronchodilator for symptomatic relief. OR ONE OF THE FOLLOWING For the treatment of moderate* COPD, if a patient continues to be symptomatic after an adequate trial of a long acting anticholinergic AND a long acting beta-agonist. For the treatment of severe** COPD, if a patient continues to be symptomatic after an adequate trial of a long acting anticholinergic OR a long acting beta-agonist. 25mcg & 125mcg Inhaler ADVAIR GSK 25mcg & 250mcg Inhaler ADVAIR GSK 50mcg & 100mcg Inhaler ADVAIR DISKUS 100 GSK 50mcg & 250mcg Inhaler ADVAIR DISKUS 250 GSK 50mcg & 500mcg Inhaler ADVAIR DISKUS 500 GSK TERBUTALINE SULFATE 500mcg/Inhalation Powder for Inhalation BRICANYL TURBUHALER AZC 12:12.12 ALPHA AND BETA ADRENERGIC AGONIS EPINEPHRINE 0.15mg injection ALLERJECT SAC 0.15mg/0.15mL Injection TWINJECT PAL 0.3mg injection ALLERJECT SAC 0.5mg/mL Injection EPIPEN JR AXL 1mg/mL Injection ADRENALIN ERF EPINEPHRINE ABB EPIPEN AXL TWINJECT PAL 1mg/mL Topical Solution ADRENALIN ERF 12:16.00 SYMPATHOLYTIC AGENTS DIHYDROERGOTAMINE MESYLATE 1mg/mL Injection DIHYDROERGOTAMINE E DIHYDROERGOTAMINE SDZ 4mg/mL Nasal Spray MIGRANAL E 12:16.04 ALPHA-ADRENERGIC BLOCKING AGENTS ALFUZOSIN HYDROCHLORIDE 10mg Sustained Release Tablet ALFUZOSIN PDL APO-ALFUZOSIN ER APX SANDOZ ALFUZOSIN SDZ TEVA-ALFUZOSIN PR TEV XATRAL SAC TAMSULOSIN HCL 0.4mg Long Acting Capsule RATIO-TAMSULOSIN RPH RATIO-TAMSULOSIN RAT SANDOZ TAMSULOSIN SDZ SANDOZ TAMSULOSIN SDZ TEVA-TAMSULOSIN TEV 0.4mg Long Acting Tablet APO-TAMSULOSIN CR APX FLOMAX CR BOE SANDOZ TAMSULOSIN SDZ TAMSULOSIN CR PDL TAMSULOSIN CR SAN TAMSULOSIN CR SIV TEVA-TAMSULOSIN CR TEP 12:20.04 CENTRALL ACTING SKELETAL MUSCLE RELAXANTS CYCLOBENZAPRINE HCL Limited use benefit (prior approval is not required). For relief of muscle spasm associated with acute, painful musculoskeletal conditions. Coverage is limited to 60mg per day for three (3) weeks renewable every two (2) months. 10mg Tablet APO-CYCLOBENZAPRINE APX AURO-CYCLOBENZAPRINE AUR CYCLOBENZAPRINE PDL CYCLOBENZAPRINE SAN CYCLOBENZAPRINE SIV DOM-CYCLOBENZAPRINE DPC JAMP-CYCLOBENZAPRINE JAP MYLAN-CYCLOPRINE MYL PHL-CYCLOBENZAPRINE PHH PMS-CYCLOBENZAPRINE PMS RATIO-CYCLOBENZAPRINE RPH RIVA-CYCLOBENZAPRINE RIV TEVA-CYCLOPRINE TEV Page 24 of 151

41 12:20.04 CENTRALL ACTING SKELETAL MUSCLE RELAXANTS TIZANIDINE HCL For treatment of spasticity in patients with multiple sclerosis, who have failed therapy with or are intolerant to baclofen. 4mg Tablet APO-TIZANIDINE APX ZANAFLEX ELN 12:20.08 DIRECT-ACTING SKELETAL MUSCLE RELAXANTS DANTROLENE SODIUM 25mg Capsule DANTRIUM PGP 100mg Capsule DANTRIUM PGP 12:20.12 GABA-DERIVATIVE SKELETAL MUSCLE RELAXANTS BACLOFEN 10mg Tablet APO-BACLOFEN APX BACLOFEN PDL BACLOFEN SAN DOM-BACLOFEN DPC LIORESAL NVR MYLAN-BACLOFEN MYL PHL-BACLOFEN PHH PMS-BACLOFEN PMS RATIO-BACLOFEN RPH RIVA-BACLOFEN RIV 20mg Tablet APO-BACLOFEN APX BACLOFEN PDL BACLOFEN SAN DOM-BACLOFEN DPC LIORESAL DS NVR MYLAN-BACLOFEN MYL PHL-BACLOFEN PHH PMS-BACLOFEN PMS RATIO-BACLOFEN RPH RIVA-BACLOFEN RIV 12:92.00 MISCELLANEOUS AUTONOMIC DRUGS NICOTINE (GUM) Limited use benefit with quantity and frequency limits (prior approval is not required). For smoking cessation: Coverage is limited to 945 pieces during a one-year period. The year starts on the date the first prescription is filled. Once this quantity has been reached, the client is eligible again for coverage for nicotine gum or lozenges when one year has elapsed from the day the initial prescription was filled. 2mg Gum NICORETTE JNO THRIVE TEV 4mg Gum NICORETTE PLUS PMJ NICOTINE GUM PER THRIVE TEV THRIVE TEV NICOTINE (INHALER) Limited use benefit with quantity and frequency limits (prior approval is not required). For smoking cessation: Coverage is limited to 945 during a one-year period. The year starts on the date the first prescription is filled. Once this quantity has been reached, the client is eligible again for coverage for nicotine gum or lozenges when one year has elapsed from the day the initial prescription was filled. 10mg Inhaler NICORETTE JNO NICOTINE (LOZENGE) Limited use benefit with quantity and frequency limits (prior approval is not required). For smoking cessation: Coverage is limited to 945 pieces during a one-year period. The year starts on the date the first prescription is filled. Once this quantity has been reached, the client is eligible again for coverage for nicotine gum or lozenges when one year has elapsed from the day the initial prescription was filled. 1mg Lozenge THRIVE TEV THRIVE TEV 2mg Lozenge NICORETTE LOZENGE JNO THRIVE TEV THRIVE TEV 4mg Lozenge NICORETTE LOZENGE JNO Page 25 of 151

42 12:92.00 MISCELLANEOUS AUTONOMIC DRUGS NICOTINE (PATCH) Limited use benefit with quantity and frequency limits (prior approval is not required). For smoking cessation: Coverage will be provided for up to the allowable number of patches for one of the following products, during a one-year period. The year starts on the date the first prescription is filled. The number of patches covered in the one-year period is: Habitrol 168 patches or Nicoderm 140 patches or Nicotrol 140 patches Once this quantity has been reached, the client is eligible again for coverage for nicotine patches when one year has elapsed from the day the initial prescription was filled. 5mg Patch NICOTROL TRANSDERMAL WAR 7mg Patch HABITROL NVC 8.3mg/10cm2 Patch NICOTROL TRANSDERMAL JNO 10mg Patch NICOTROL TRANSDERMAL WAR 14mg Patch HABITROL NVC 15mg Patch NICOTROL TRANSDERMAL WAR 16.6mg/20cm2 Patch NICOTROL TRANSDERMAL JNO 17.5mg Patch TRANSDERMAL NICOTINE NVC 21mg Patch HABITROL NVC 24.9mg/30cm2 Patch NICOTROL TRANSDERMAL JNO 35mg Patch TRANSDERMAL NICOTINE NVC 36mg Patch NICODERM PMJ 52.5mg Patch TRANSDERMAL NICOTINE NVC 78mg Patch NICODERM PMJ 114mg Patch NICODERM PMJ 12:92.00 MISCELLANEOUS AUTONOMIC DRUGS VARENICLINE Limited use benefit with quantity and frequency limits (prior approval is not required). Coverage will be limited to 165 tablets during a one-year period. The year starts on the date the first prescription is filled. Once this quantity has been reached, the client is eligible again for coverage for varenicline (Champix ) when one year has elapsed from the day the initial prescription was filled. 0.5mg Tablet CHAMPIX PFI 0.5mg & 1mg Tablet CHAMPIX ARTER PACK PFI 1mg Tablet CHAMPIX PFI Page 26 of 151

43 20:00 BLOOD FORMATION COAGULATION AND THROMBOSIS 20:04.04 IRON PREPARATIONS FERROUS FUMARATE 300mg Capsule EURO-FER EUR NEO FER NEO PALAFER GSK 300mg/5mL Oral Liquid FERRATE O/L EUR 20mg Suspension JAMP FERROUS FUMARATE JAP 60mg/mL Suspension PALAFER GSK 300mg Tablet FERROUS FUMARATE JMP FERROUS GLUCONATE 35mg Tablet FERROUS GLUCONATE WNP 300mg Tablet APO-FERROUS GLUCONATE APX FERROUS GLUCONATE JMP FERROUS GLUCONATE ADA FERROUS GLUCONATE PMT FERROUS GLUCONATE GFP FERROUS GLUCONATE WAM NOVO-FERROGLUC NUR 324mg Tablet FERROUS GLUCONATE VTH FERROUS SULFATE 15mg/mL Drop FERODAN ODN PEDIAFER EUR PMS-FERROUS SULFATE PMS 75mg/mL Drop FER-IN-SOL MJO JAMP SULFATE FERREUX JMP 6mg/mL Syrup FER-IN-SOL MJO PEDIAFER EUR 30mg/mL Syrup FERODAN ODN JAMP SULFATE FERREUX JMP PMS-FERROUS SULFATE PMS 300mg Tablet EURO-FERROUS SULFATE EUR FERODAN ODN FERROUS SULFATE JMP FERROUS SULFATE PMT FERROUS SULFATE VTH PMS-FERROUS SULFATE PMS 20:04.04 IRON PREPARATIONS IRON 100mg Capsule JAMP-FER JAP 12.5mg/mL Injection FERRLECIT SAC 60mg Tablet IRON WNP IRON DEXTRAN 50mg/mL Injection DEXIRON MYL INFUFER SDZ IRON SUCROSE 20mg/mL Injection VENOFER LUI 20:12.04 ANTICOAGULANTS APIXABAN Limited use benefit (prior approval required) For at risk patients* with non-valvular atrial fibrillation who require apixaban for the prevention of stroke and systemic embolism AND in whom: trial of warfarin (please provide a copy of INR records for the last two months of warfarin therapy); OR inability to regularly monitor via INR testing (i.e., no access to INR testing services at a laboratory, clinic, pharmacy and at home). * At risk patients with atrial fibrillation are defined as those with a CHADS2 score of 1. # Inadequate anticoagulation is defined as INR testing results that are outside the desired INR range for at least 35% of the tests during the monitoring period, i.e., adequate anticoagulation is defined as INR test results that are within the desired INR range for at least 65% of the tests during the monitoring period. 2.5mg Tablet ELIQUIS BMS 5mg Tablet ELIQUIS BMS Page 27 of 151

44 20:12.04 ANTICOAGULANTS DABIGATRAN ETEXILATE MESILATE For at risk patients* with non-valvular atrial fibrillation who require dabigatran for the prevention of stroke and systemic embolism AND in whom: of warfarin (please provide a copy of INR records for the last two months of warfarin therapy); OR inability to regularly monitor via INR testing (i.e., no access to INR testing services at a laboratory, clinic, pharmacy and at home). 110mg Capsule PRADAXA BOE 150mg Capsule PRADAXA BOE DALTEPARIN SODIUM 10,000IU/mL Injection (Multi-Dose) FRAGMIN PMJ 25,000IU/mL Injection (Multi-Dose) FRAGMIN PMJ 2,500IU/0.2mL Injection (Pre-filled Syringe) FRAGMIN PMJ 5,000IU/0.2mL Injection (Pre-filled Syringe) FRAGMIN PMJ 7,500IU/0.3mL Injection (Pre-filled Syringe) FRAGMIN PFI 10,000IU/0.4mL Injection (Pre-filled Syringe) FRAGMIN PFI 12,500IU/0.5mL Injection (Pre-filled Syringe) FRAGMIN PFI 15,000IU/0.6mL Injection (Pre-filled Syringe) FRAGMIN PFI 18,000IU/0.72mL Injection (Pre-filled Syringe) FRAGMIN PFI ENOXAPARIN SODIUM 20:12.04 ANTICOAGULANTS ENOXAPARIN SODIUM 300mg/3mL Injection LOVENOX SAC HEPARIN SODIUM 1,000 U/Ml Injection HEPARIN LEO INJ LEO 1000UNIT/ML HEPARIN SODIUM 1000U/ML SDZ 5,000U/mL Injection HEPARIN SODIUM 5000U/ML PFI 10,000 U/mL Injection HEPARIN LEO INJ LEO 10000UNIT/ML HEPARIN SODIUM 10000U/ML SDZ HEPARIN SODIUM 10000U/ML SDZ 25,000 U/mL Injection HEPARIN LEO INJ 25000UNIT/ML 10 U/mL Lock Flush LEO HEPARIN LOCK FLUSH ABB 100 U/mL Lock Flush HEPARIN LEO LEO HEPARIN LOCK FLUSH HOS NADROPARIN CALCIUM 9,500IU/mL Injection FRAXIPARINE GSK 19,000IU/mL Injection FRAXIPARINE FORTE GSK NICOUMALONE 1mg Tablet SINTROM PED 4mg Tablet SINTROM PED 30mg/0.3mL Injection LOVENOX SAC 40mg/0.4mL Injection LOVENOX SAC 60mg/0.6mL Injection LOVENOX SAC 80mg/0.8mL Injection LOVENOX SAC 100mg/1mL Injection LOVENOX SAC 150mg/1.0mL Injection LOVENEX HP SAC 150mg/mL Injection LOVENEX HP SAC Page 28 of 151

45 20:12.04 ANTICOAGULANTS RIVAROXABAN Criteria for Rivaroxaban 15 mg, 20mg tablets (Xarelto) for Stroke Prevention in Atrial Fibrillation (SPAF) For the prevention of stroke and systemic embolism in at-risk patients* who have non-valvular atrial fibrillation (AF) AND in whom: Anticoagulation is inadequate# following a two-month trial on warfarin (please provide copy of INR records for the last two months of warfarin therapy); OR Anticoagulation with warfarin is contraindicated; ;OR Anticoagulation is not possible due to inability to regularly monitor via International Normalized Ratio (INR) testing (i.e., no access to INR testing service at a laboratory, clinic, pharmacy, and at home) Criteria for Rivaroxaban 15 mg, 20mg tablets (Xarelto) for Deep Vein Thrombosis (DVT) For the treatment of deep vein thrombosis (DVT) in patients without symptomatic pulmonary embolism (PE) for a duration of up to six months. 15mg Tablet XARELTO BAY 20mg Tablet XARELTO B A RIVAROXABAN (10) Limited use benefit (prior approval not required). For the prevention of venous thromboembolism following total knee replacement or total hip replacement surgery, for up to 35 days. 10mg Tablet XARELTO BAY TINZAPARIN SODIUM 10,000IU/mL Injection INNOHEP LEO 20,000IU/mL Injection INNOHEP LEO 10,000IU/0.5mL Injection (Graduated Syringe) INNOHEP LEO 14,000IU/0.7mL Injection (Graduated Syringe) INNOHEP LEO 18,000IU/0.9mL Injection (Graduated Syringe) INNOHEP LEO 2,500IU/0.25mL Injection (Pre-filled Syringe) INNOHEP LEO 3,500IU/0.35mL Injection (Pre-filled Syringe) INNOHEP LEO 4,500IU/0.45mL Injection (Pre-filled Syringe) INNOHEP LEO 20:12.04 ANTICOAGULANTS WARFARIN SODIUM 1mg Tablet APO-WARFARIN APX COUMADIN BMS MYLAN-WARFARIN MYL NOVO-WARFARIN TEV TARO-WARFARIN TAR WARFARIN SAN 2mg Tablet APO-WARFARIN APX COUMADIN BMS MYLAN-WARFARIN MYL NOVO-WARFARIN TEV TARO-WARFARIN TAR WARFARIN SAN 2.5mg Tablet APO-WARFARIN APX COUMADIN BMS MYLAN-WARFARIN MYL NOVO-WARFARIN TEV TARO-WARFARIN TAR WARFARIN SAN 3mg Tablet APO-WARFARIN APX COUMADIN BMS MYLAN-WARFARIN MYL NOVO-WARFARIN TEV TARO-WARFARIN TAR WARFARIN SAN 4mg Tablet APO-WARFARIN APX COUMADIN BMS MYLAN-WARFARIN MYL NOVO-WARFARIN TEV TARO-WARFARIN TAR WARFARIN SAN 5mg Tablet APO-WARFARIN APX COUMADIN BMS MYLAN-WARFARIN MYL NOVO-WARFARIN TEV TARO-WARFARIN TAR WARFARIN SAN 6mg Tablet MYLAN-WARFARIN MYL TARO-WARFARIN TAR WARFARIN SAN 7.5mg Tablet MYLAN-WARFARIN MYL TARO-WARFARIN TAR WARFARIN SAN Page 29 of 151

46 20:12.04 ANTICOAGULANTS WARFARIN SODIUM 10mg Tablet APO-WARFARIN APX COUMADIN BMS MYLAN-WARFARIN MYL TARO-WARFARIN TAR WARFARIN SAN 20:12.18 PLATELET AGGREGATION INHIBITORS ANAGRELIDE HCL 0.5mg Capsule AGRYLIN SHI PMS-ANAGRELIDE PMS SANDOZ-ANAGRELIDE SDZ CLOPIDOGREL BISULFATE Limited use benefit (prior approval not required). Limit of 12 months following a client s initial cardiovascular event (stroke, acute coronary syndrome (ACS) or stent). Continued coverage beyond one year will be provided for patients with a previous stroke or transient ischemic attack (TIA) and be considered for patients with ACS or stent placement with appropriate rationale from the client`s cardiologist or treating physician. 75mg Tablet ABBOTT-CLOPIDOGREL ABB ACCEL-CLOPIDOGREL ACP APO-CLOPIDOGREL APX AURO-CLOPIDOGREL AUR CLOPIDOGREL SIV CLOPIDOGREL PDL CLOPIDOGREL SAN CO CLOPIDOGREL CBT DOM-CLOPIDOGREL DOM JAMP-CLOPIDOGREL JAP MAR-CLOPIDOGREL MAR MINT-CLOPIDOGREL MIN MYLAN-CLOPIDOGREL MYL PLAVIX SAC PMS CLOPIDOGREL PMS RAN-CLOPIDOGREL RBY RIVA CLOPIDOGREL RIV SANDOZ CLOPIDOGREL SDZ TEVA-CLOPIDOGREL TEP TICAGRELOR Limited use benefit (prior approval not required). 20:12.18 PLATELET AGGREGATION INHIBITORS TICLOPIDINE HCL 250mg Tablet APO-TICLOPIDINE APX MYLAN-TICLOPIDINE MYL TEVA-TICLOPIDINE TEV TICLOPIDINE SAN 20:16.00 HEMATOPOIETIC AGENTS FILGRAIM 300mcg/mL Injection NEUPOGEN AMG 20:24.00 HEMORRHEOLOGIC AGENTS PENTOXIFYLLINE 400mg Sustained Release Tablet APO-PENTOXIFYL APX 20:28.16 HEMOATICS TRANEXAMIC ACID 500mg Tablet CYKLOKAPRON PFI TRANEXAMIC ACID E For the treatment of Acute Coronary Syndrome, defined as unstable angina or myocardial infarction, when initiated in hospital in consultation with a Specialist in Cardiology, Cardiac Surgery, Cardiovascular & Thoracic Surgery, Internal Medicine or General Surgery. Treatment must be in combination with low dose ASA. Special authorization may be granted for 12 months. 90mg Tablet BRILINTA AZE Page 30 of 151

47 24:00 CARDIOVASCULAR DRUGS 24:04.04 ANTIARRHYTHMIC AGENTS AMIODARONE HCL 100mg Tablet PMS-AMIODARONE PMS 200mg Tablet AMIODARONE SAN AMIODARONE SIV APO-AMIODARONE APX CORDARONE WAY DOM-AMIODARONE PMS MYLAN-AMIODARONE MYL PHL-AMIODARONE PHH PMS-AMIODARONE PMS PRO-AMIODARONE PDL RIVA-AMIODARONE RIV SANDOZ-AMIODARONE SDZ TEVA-AMIODARONE TEV DISOPYRAMIDE 100mg Capsule RYTHMODAN SAC FLECAINIDE ACETATE 50mg Tablet APO-FLECAINIDE APX TAMBOCOR MMH 100mg Tablet APO-FLECAINIDE APX TAMBOCOR MMH MEXILETINE HCL 100mg Capsule NOVO-MEXILETINE TEV 200mg Capsule NOVO-MEXILETINE TEV PROCAINAMIDE HCL 250mg Capsule APO-PROCAINAMIDE APX 375mg Capsule APO-PROCAINAMIDE APX 500mg Capsule APO-PROCAINAMIDE APX 250mg Sustained Release Tablet PROCAN SR PFI 500mg Sustained Release Tablet PROCAN SR PFI 750mg Sustained Release Tablet PROCAN SR PFI 24:04.04 ANTIARRHYTHMIC AGENTS PROPAFENONE HYDROCHLORIDE 150mg Tablet APO-PROPAFENONE APX MYLAN-PROPAFENONE MYL PMS-PROPAFENONE PMS PMS-PROPAFENONE PMS PROPAFENONE PDL PROPAFENONE SAN RYTHMOL ABB 300mg Tablet APO-PROPAFENONE APX MYLAN-PROPAFENONE MYL PMS-PROPAFENONE PMS PMS-PROPAFENONE PMS PROPAFENONE PDL PROPAFENONE SAN RYTHMOL ABB 24:04.08 CARDIOTONIC AGENTS DIGOXIN 0.05mg/mL Elixir TOLOXIN MTH mg Tablet TOLOXIN MTH 0.125mg Tablet TOLOXIN MTH 0.250mg Tablet TOLOXIN MTH 24:06.04 BILE ACID SEQUERANTS CHOLEYRAMINE RESIN 4g Powder OLEYR LIGHT MTH OLEYR REGULAR MTH COLESEVELAM 625mg Tablet LODALIS VAE COLEIPOL HCL 5g Granules COLEID PFI COLEID ORANGE PFI 1g Tablet COLEID PFI Page 31 of 151

48 24:06.05 CHOLEEROL ABSORPTION INHIBITORS EZETIMIBE a.- For use in combination with a HMG-CoA reductase inhibitor ( statin ) in patients with hypercholesterolemia who have not reached target LDL levels despite the use of maximally tolerated statin doses. b.- For use as monotherapy in the management of hypercholesterolemia in patients intolerant to HMG-CoA reductase inhibitors. 10mg Tablet ACT EZETIMIBE ATP APO-EZETIMIBE APX EZETIMIBE PDL EZETIMIBE SIV EZETROL MSP JAMP-EZETIMIBE JAP MAR-EZETIMIBE MAR MINT-EZETIMIBE MIN MYLAN-EZETIMIBE MYL PMS-EZETIMIBE PMS PRIVA-EZETIMIBE PHA RAN-EZETIMIBE RBY RIVA-EZETIMIBE RIV SANDOZ EZETIMIBE SDZ TEVA-EZETIMIBE TEP 24:06.06 FIBRIC ACID DERIVATIVES BEZAFIBRATE 400mg Sustained Release Tablet BEZALIP SR ACG 200mg Tablet PMS-BEZAFIBRATE PMS FENOFIBRATE 67mg Capsule APO-FENO-MICRO APX NOVO-FENOFIBRATE TEV 100mg Capsule APO-FENOFIBRATE APX 160mg Capsule FENOMAX CIP 200mg Capsule APO-FENO-MICRO APX FENOFIBRATE MICRO SAN FENO-MICRO PDL LIPIDIL MICRO FOU MYLAN-FENOFIBRATE MYL NOVO-FENOFIBRATE TEV RATIO-FENOFIBRATE RPH RIVA-FENOFIBRATE MICRO RIV 48mg Tablet LIPIDIL EZ FOU SANDOZ FENOFIBRATE E SDZ 24:06.06 FIBRIC ACID DERIVATIVES FENOFIBRATE 100mg Tablet APO-FENO-SUPER APX FENOFIBRATE-S SAN LIPIDIL SUPRA FOU NOVO-FENOFIBRATE-S TEV PRO-FENO-SUPER PDL SANDOZ FENOFIBRATE S SDZ 145mg Tablet LIPIDIL EZ FOU SANDOZ FENOFIBRATE E SDZ 160mg Tablet APO-FENO-SUPER APX FENOFIBRATE-S SAN LIPIDIL SUPRA FOU NOVO-FENOFIBRATE-S TEV PRO-FENO-SUPER PDL SANDOZ FENOFIBRATE S SDZ GEMFIBROZIL 300mg Capsule APO-GEMFIBROZIL APX DOM-GEMFIBROZIL DPC MYLAN-FIBRO MYL NOVO-GEMFIBROZIL TEV PMS-GEMFIBROZIL PMS 600mg Tablet APO-GEMFIBROZIL APX DOM-GEMFIBROZIL DPC GEMFIBROZIL PDL MYLAN-GEMFIBROZIL MYL NOVO-GEMFIBROZIL TEV RIVA-GEMFIBROZIL RIV Page 32 of 151

49 24:06.08 HMG-COA REDUCTASE INHIBITORS ATORVAATIN CALCIUM 10mg Tablet APO-ATORVAATIN APX APO-ATORVAATIN APX ATORVAATIN PDL ATORVAATIN RPH ATORVAATIN SAN ATORVAATIN-10 SIV AURO-ATORVAATIN AUR CO ATORVAATIN CBT DOM-ATORVAATIN DOM DOM-ATORVAATIN DOM GD-ATORVAATIN PFI JAMP-ATORVAATIN JAP LIPITOR PFI MYLAN-ATORVAATIN MYL MYLAN-ATORVAATIN MYL PMS-ATORVAATIN PMS PMS-ATORVAATIN PMS RAN-ATORVAATIN RBY RATIO-ATORVAATIN TEV RIVA-ATORVAATIN RIV SANDOZ ATORVAATIN SDZ SIV-ATORVAATIN SIV TEVA-ATORVAATIN TEV 20mg Tablet APO-ATORVAATIN APX APO-ATORVAATIN APX ATORVAATIN PDL ATORVAATIN RPH ATORVAATIN SAN ATORVAATIN-20 SIV CO ATORVAATIN CBT DOM-ATORVAATIN DOM DOM-ATORVAATIN DOM GD-ATORVAATIN PFI JAMP-ATORVAATIN JAP LIPITOR PFI MYLAN-ATORVAATIN MYL MYLAN-ATORVAATIN MYL PMS-ATORVAATIN PMS PMS-ATORVAATIN PMS RAN-ATORVAATIN RBY RATIO-ATORVAATIN TEV RIVA-ATORVAATIN RIV SANDOZ ATORVAATIN SDZ SIV-ATORVAATIN SIV TEVA-ATORVAATIN TEV 24:06.08 HMG-COA REDUCTASE INHIBITORS ATORVAATIN CALCIUM 40mg Tablet APO-ATORVAATIN APX APO-ATORVAATIN APX ATORVAATIN PDL ATORVAATIN RPH ATORVAATIN SAN ATORVAATIN-40 SIV CO ATORVAATIN CBT DOM-ATORVAATIN DOM DOM-ATORVAATIN DOM GD-ATORVAATIN PFI JAMP-ATORVAATIN JAP LIPITOR PFI MYLAN-ATORVAATIN MYL MYLAN-ATORVAATIN MYL PMS-ATORVAATIN PMS PMS-ATORVAATIN PMS RAN-ATORVAATIN RBY RATIO-ATORVAATIN TEV RIVA-ATORVAATIN RIV SANDOZ ATORVAATIN SDZ SIV-ATORVAATIN SIV TEVA-ATORVAATIN TEV 80mg Tablet APO-ATORVAATIN APX APO-ATORVAATIN APX ATORVAATIN PDL ATORVAATIN RPH ATORVAATIN SAN ATORVAATIN-80 SIV CO ATORVAATIN CBT GD-ATORVAATIN PFI JAMP-ATORVAATIN JAP LIPITOR PFI MYLAN-ATORVAATIN MYL MYLAN-ATORVAATIN MYL PMS-ATORVAATIN PMS PMS-ATORVAATIN PMS RAN-ATORVAATIN RBY RATIO-ATORVAATIN TEV RIVA-ATORVAATIN RIV SANDOZ ATORVAATIN SDZ SIV-ATORVAATIN SIV TEVA-ATORVAATIN TEV FLUVAATIN SODIUM 20mg Capsule LESCOL NVR SANDOZ FLUVAATIN SDZ TEVA-FLUVAATIN TEP 40mg Capsule LESCOL NVR SANDOZ FLUVAATIN SDZ TEVA-FLUVAATIN TEP Page 33 of 151

50 24:06.08 HMG-COA REDUCTASE INHIBITORS FLUVAATIN SODIUM 80mg Extended Release Tablet LESCOL XL NVR LOVAATIN 20mg Tablet APO-LOVAATIN APX CO LOVAATIN COB LOVAATIN SAN MEVACOR FRS MYLAN-LOVAATIN MYL NOVO-LOVAATIN TEV PMS-LOVAATIN PMS PRO-LOVAATIN PDL RIVA-LOVAATIN RIV SANDOZ-LOVAATIN SDZ 40mg Tablet APO-LOVAATIN APX CO LOVAATIN COB LOVAATIN SAN MEVACOR FRS MYLAN-LOVAATIN MYL NOVO-LOVAATIN TEV PMS-LOVAATIN PMS PRO-LOVAATIN PDL RIVA-LOVAATIN RIV SANDOZ-LOVAATIN SDZ PRAVAATIN SODIUM 10mg Tablet APO-PRAVAATIN APX CO PRAVAATIN COB DOM-PRAVAATIN DPC JAMP-PRAVAATIN JMP MINT-PRAVAATIN MIN MYLAN-PRAVAATIN MYL NOVO-PRAVAATIN TEV PMS-PRAVAATIN PMS PRAVACHOL BMS PRAVAATIN MEL PRAVAATIN SOR PRAVAATIN SAN PRAVAATIN SIV PRAVAATIN-10 PDL RAN-PRAVAATIN RBY RATIO-PRAVAATIN RPH RIVA-PRAVAATIN RIV SANDOZ-PRAVAATIN SDZ 24:06.08 HMG-COA REDUCTASE INHIBITORS PRAVAATIN SODIUM 20mg Tablet APO-PRAVAATIN APX CO PRAVAATIN COB DOM-PRAVAATIN DPC JAMP-PRAVAATIN JMP MINT-PRAVAATIN MIN MYLAN-PRAVAATIN MYL NOVO-PRAVAATIN TEV PMS-PRAVAATIN PMS PRAVACHOL BMS PRAVAATIN MEL PRAVAATIN SOR PRAVAATIN SAN PRAVAATIN SIV PRAVAATIN-20 PDL RAN-PRAVAATIN RBY RATIO-PRAVAATIN RPH RIVA-PRAVAATIN RIV SANDOZ-PRAVAATIN SDZ 40mg Tablet APO-PRAVAATIN APX CO PRAVAATIN COB DOM-PRAVAATIN DPC JAMP-PRAVAATIN JMP MINT-PRAVAATIN MIN MYLAN-PRAVAATIN MYL NOVO-PRAVAATIN TEV PMS-PRAVAATIN PMS PRAVACHOL BMS PRAVAATIN MEL PRAVAATIN SOR PRAVAATIN SAN PRAVAATIN SIV PRAVAATIN-40 PDL RAN-PRAVAATIN RBY RATIO-PRAVAATIN RPH RIVA-PRAVAATIN RIV Page 34 of 151

51 24:06.08 HMG-COA REDUCTASE INHIBITORS ROSUVAATIN CALCIUM 5mg Tablet APO-ROSUVAATIN APX CO ROSUVAATIN CBT CREOR AZC DOM-ROSUVAATIN DOM JAMP-ROSUVAATIN JAP MAR-ROSUVAATIN MAR MED-ROSUVAATIN GMP MINT-ROSUVAATIN MIN MYLAN-ROSUVAATIN MYL PMS-ROSUVAATIN PMS RAN-ROSUVAATIN RBY RIVA-ROSUVAATIN RIV ROSUVAATIN PDL ROSUVAATIN SIV ROSUVAATIN SAN ROSUVAATIN-5 SIV SANDOZ ROSUVAATIN SDZ TEVA-ROSUVAATIN TEP 10mg Tablet APO-ROSUVAATIN APX CO ROSUVAATIN CBT CREOR AZC DOM-ROSUVAATIN DOM JAMP-ROSUVAATIN JAP MAR-ROSUVAATIN MAR MED-ROSUVAATIN GMP MINT-ROSUVAATIN MIN MYLAN-ROSUVAATIN MYL PMS-ROSUVAATIN PMS RAN-ROSUVAATIN RBY RIVA-ROSUVAATIN RIV ROSUVAATIN PDL ROSUVAATIN SIV ROSUVAATIN SAN ROSUVAATIN-10 SIV SANDOZ ROSUVAATIN SDZ TEVA-ROSUVAATIN TEP 24:06.08 HMG-COA REDUCTASE INHIBITORS ROSUVAATIN CALCIUM 20mg Tablet APO-ROSUVAATIN APX CO ROSUVAATIN CBT CREOR AZC DOM-ROSUVAATIN DOM JAMP-ROSUVAATIN JAP MAR-ROSUVAATIN MAR MED-ROSUVAATIN GMP MINT-ROSUVAATIN MIN MYLAN-ROSUVAATIN MYL PMS-ROSUVAATIN PMS RAN-ROSUVAATIN RBY RIVA-ROSUVAATIN RIV ROSUVAATIN PDL ROSUVAATIN SIV ROSUVAATIN SAN ROSUVAATIN-20 SIV SANDOZ ROSUVAATIN SDZ TEVA-ROSUVAATIN TEP 40mg Tablet APO-ROSUVAATIN APX CO ROSUVAATIN CBT CREOR AZC JAMP-ROSUVAATIN JAP MAR-ROSUVAATIN MAR MED-ROSUVAATIN GMP MINT-ROSUVAATIN MIN MYLAN-ROSUVAATIN MYL PMS-ROSUVAATIN PMS RAN-ROSUVAATIN RBY RIVA-ROSUVAATIN RIV ROSUVAATIN PDL ROSUVAATIN SIV ROSUVAATIN SAN ROSUVAATIN-40 SIV SANDOZ ROSUVAATIN SDZ TEVA-ROSUVAATIN TEP Page 35 of 151

52 24:06.08 HMG-COA REDUCTASE INHIBITORS SIMVAATIN 5mg Tablet APO-SIMVAATIN APX AURO-SIMVAATIN AUR CO SIMVAATIN COB DOM-SIMVAATIN DPC DOM-SIMVAATIN DPC JAMP-SIMVAATIN JMP JAMP-SIMVAATIN JAP MAR-SIMVAATIN MAR MINT-SIMVAATIN MIN MYLAN-SIMVAATIN MYL PHL-SIMVAATIN PMI PMS-SIMVAATIN PMS PMS-SIMVAATIN PMS RAN-SIMVAATIN RBY RATIO-SIMVAATIN RPH RIVA-SIMVAATIN RIV SANDOZ-SIMVAATIN SDZ SIMVAATIN SAN SIMVAATIN SIV TEVA-SIMVAATIN TEV ZOCOR FRS ZYM-SIMVAATIN ZYM 10mg Tablet APO-SIMVAATIN APX AURO-SIMVAATIN AUR CO SIMVAATIN COB DOM-SIMVAATIN DPC DOM-SIMVAATIN DPC JAMP-SIMVAATIN JMP JAMP-SIMVAATIN JAP MAR-SIMVAATIN MAR MINT-SIMVAATIN MIN MYLAN-SIMVAATIN MYL NOVO-SIMVAATIN TEV PHL-SIMVAATIN PMI PMS-SIMVAATIN PMS PMS-SIMVAATIN PMS RAN-SIMVAATIN RBY RATIO-SIMVAATIN RPH RIVA-SIMVAATIN RIV SANDOZ-SIMVAATIN SDZ SIMVAATIN SAN SIMVAATIN SIV SIMVAATIN-10 PDL TARO-SIMVAATIN TAR ZOCOR FRS ZYM-SIMVAATIN ZYM 24:06.08 HMG-COA REDUCTASE INHIBITORS SIMVAATIN 20mg Tablet APO-SIMVAATIN APX AURO-SIMVAATIN AUR CO SIMVAATIN COB DOM-SIMVAATIN DPC DOM-SIMVAATIN DPC JAMP-SIMVAATIN JMP JAMP-SIMVAATIN JAP MAR-SIMVAATIN MAR MINT-SIMVAATIN MIN MYLAN-SIMVAATIN MYL NOVO-SIMVAATIN TEV PHL-SIMVAATIN PMI PMS-SIMVAATIN PMS PMS-SIMVAATIN PMS RAN-SIMVAATIN RBY RIVA-SIMVAATIN RIV SANDOZ-SIMVAATIN SDZ SIMVAATIN SAN SIMVAATIN SIV SIMVAATIN-20 PDL TARO-SIMVAATIN TAR ZOCOR FRS ZYM-SIMVAATIN ZYM 40mg Tablet APO-SIMVAATIN APX AURO-SIMVAATIN AUR CO SIMVAATIN COB DOM-SIMVAATIN DPC DOM-SIMVAATIN DPC JAMP-SIMVAATIN JMP JAMP-SIMVAATIN JAP MAR-SIMVAATIN MAR MINT-SIMVAATIN MIN MYLAN-SIMVAATIN MYL NOVO-SIMVAATIN TEV PHL-SIMVAATIN PMI PMS-SIMVAATIN PMS PMS-SIMVAATIN PMS RAN-SIMVAATIN RBY RIVA-SIMVAATIN RIV SANDOZ-SIMVAATIN SDZ SIMVAATIN SAN SIMVAATIN SIV SIMVAATIN-40 PDL TARO-SIMVAATIN TAR ZOCOR FRS ZYM-SIMVAATIN ZYM Page 36 of 151

53 24:06.08 HMG-COA REDUCTASE INHIBITORS SIMVAATIN 80mg Tablet APO-SIMVAATIN APX AURO-SIMVAATIN AUR CO SIMVAATIN COB DOM-SIMVAATIN DPC DOM-SIMVAATIN DPC JAMP-SIMVAATIN JMP JAMP-SIMVAATIN JAP MAR-SIMVAATIN MAR MINT-SIMVAATIN MIN MYLAN-SIMVAATIN MYL NOVO-SIMVAATIN TEV PHL-SIMVAATIN PMI PMS-SIMVAATIN PMS PMS-SIMVAATIN PMS RAN-SIMVAATIN RBY RATIO-SIMVAATIN RPH RIVA-SIMVAATIN RIV SANDOZ-SIMVAATIN SDZ SIMVAATIN SAN SIMVAATIN SIV SIMVAATIN-80 PDL ZOCOR FRS ZYM-SIMVAATIN ZYM 24:08.16 CENTRAL ALPHA-AGONIS CLONIDINE HCL 0.025mg Tablet DIXARIT BOE TEVA-CLONIDINE TEV 0.1mg Tablet CATAPRES BOE CLONIDINE PRO TEVA-CLONIDINE TEV 0.2mg Tablet APO-CLONIDINE APX CATAPRES BOE CLONIDINE PRO TEVA-CLONIDINE TEV METHYLDOPA 125mg Tablet METHYLDOPA AAP 250mg Tablet METHYLDOPA AAP 500mg Tablet METHYLDOPA AAP METHYLDOPA, HYDROCHLOROTHIAZIDE 250mg & 15mg Tablet APO-METHAZIDE-15 APX 250mg & 25mg Tablet APO-METHAZIDE-25 APX 24:08.20 DIRECT VASODILATORS DIAZOXIDE 100mg Capsule PROGLYCEM SCH HYDRALAZINE HCL 10mg Tablet APO-HYDRALAZINE APX HYDRALAZINE PDL 25mg Tablet APO-HYDRALAZINE APX 50mg Tablet APO-HYDRALAZINE APX NOVO-HYLAZIN TEV MINOXIDIL 2.5mg Tablet LONITEN PFI 10mg Tablet LONITEN PFI 24:12.08 NITRATES AND NITRITES ISOSORBIDE DINITRATE 5mg Sublingual Tablet ISDN AAP 10mg Tablet ISDN AAP PMS-ISOSORBIDE PMS 30mg Tablet ISDN AAP ISOSORBIDE-5-MONONITRATE 60mg Tablet APO-ISMN APX IMDUR AZE PMS-ISMN PMS PRO-ISMN PDL NITROGLYCERIN 2% Ointment NITROL SQU 0.2mg Patch MINITRAN MMH MYLAN-NITRO MYL NITRO-DUR KEY TRANSDERM-NITRO NVR TRINIPATCH TRT 0.4mg Patch MINITRAN MMH MYLAN-NITRO MYL NITRO-DUR KEY TRANSDERM-NITRO NVR TRINIPATCH TRT Page 37 of 151

54 24:12.08 NITRATES AND NITRITES NITROGLYCERIN 0.6mg Patch MINITRAN MMH MYLAN-NITRO MYL NITRO-DUR KEY TRANSDERM-NITRO NVR TRINIPATCH TRT 0.8mg Patch MYLAN-NITRO MYL NITRO-DUR KEY 0.4mg Spray APO-NITROGLYCERIN APX MYLAN-NITRO MYL NITROLINGUAL PUMPSPRAY SAC RHO-NITRO PUMPSPRAY SAC 0.3mg Sublingual Tablet NITROAT PFI 0.6mg Sublingual Tablet NITROAT PFI 24:12.12 PHOSPHODIEERASE INHIBITORS SILDENAFIL CITRATE Patients with World Health Organization (WHO) class III pulmonary artery hypertension (PAH), either idiopathic (i.e. primary) or associated with a congenital or systemic condition (e.g. connective tissue disease) and confirmed by right heart catheterization; AND who have failed to respond to conventional therapy; OR who have contraindications to conventional agents. 20mg Tablet PMS-SILDENAFIL R PMS RATIO-SILDENAFIL R TEP REVATIO PFI 20mg Tablet APO-SILDENAFIL R APX TADALAFIL Maximum dose covered is 40 mg daily Patients with World Health Organization (WHO) class III pulmonary artery hypertension (PAH), either idiopathic (i.e. primary) or associated with a congenital or systemic condition (e.g. connective tissue disease) and confirmed by right heart catheterization; AND who have failed to respond to conventional therapy; OR who have contraindications to conventional agents 20mg Tablet ADCIRCA LIL 24:12.92 MISCELLANEOUS VASODILATING AGENTS AMBRISENTAN Maximum dose covered is 10 mg once daily. Patients with World Health Organization (WHO) class III pulmonary artery hypertension (PAH), either idiopathic (i.e. primary) or associated with a congenital or systemic condition (e.g. connective tissue disease) and confirmed by right heart catheterization; AND -who have failed to respond to sildenafil OR tadalafil; OR -who have contraindications to sildenafil OR tadalafil. 5mg Tablet VOLIBRIS GSK 10mg Tablet VOLIBRIS GSK BOSENTAN MONOHYDRATE Maximum dose covered is 125 mg twice daily -Patients with World Health Organization (WHO) class III pulmonary artery hypertension (PAH), either idiopathic (i.e. primary) or associated with a congenital or systemic condition (e.g. connective tissue disease) and confirmed by right heart catheterization; AND -who have failed to respond to sildenafil OR tadalafil; OR -who have contraindications to sildenafil OR tadalafil. 62.5mg Tablet APO-BOSENTAN APX CO BOSENTAN ATP MYLAN-BOSENTAN MYL PMS-BOSENTAN PMS SANDOZ BOSENTAN SDZ TEVA-BOSENTAN TEP TRACLEER ACN 125mg Tablet CO BOSENTAN ATP MYLAN-BOSENTAN MYL PMS-BOSENTAN PMS SANDOZ BOSENTAN SDZ TEVA-BOSENTAN TEP TRACLEER ACN DIPYRIDAMOLE 25mg Tablet APO-DIPYRIDAMOLE APX 50mg Tablet APO-DIPYRIDAMOLE APX APO-DIPYRIDAMOLE APX 75mg Tablet APO-DIPYRIDAMOLE APX APO-DIPYRIDAMOLE APX DIPYRIDAMOLE, ACETYLSALICYLIC ACID 200mg & 25mg Capsule AGGRENOX BOE Page 38 of 151

55 24:20.00 ALPHA ADRENERGIC BLOCKING AGENTS DOXAZOSIN MESYLATE 1mg Tablet APO-DOXAZOSIN APX CARDURA 1 PFI DOXAZOSIN PDL MYLAN-DOXAZOSIN MYL NOVO-DOXAZOSIN TEV PMS-DOXAZOSIN PMS 2mg Tablet APO-DOXAZOSIN APX CARDURA 2 PFI DOXAZOSIN PDL MYLAN-DOXAZOSIN MYL NOVO-DOXAZOSIN TEV PMS-DOXAZOSIN PMS 4mg Tablet APO-DOXAZOSIN APX CARDURA 4 PFI DOXAZOSIN PDL MYLAN-DOXAZOSIN MYL NOVO-DOXAZOSIN TEV PMS-DOXAZOSIN PMS PRAZOSIN HCL 1mg Tablet APO-PRAZO APX MINIPRESS ERF NOVO-PRAZIN TEV 2mg Tablet APO-PRAZO APX MINIPRESS ERF NOVO-PRAZIN TEV 5mg Tablet APO-PRAZO APX MINIPRESS ERF NOVO-PRAZIN TEV TERAZOSIN HCL 1mg Tablet APO-TERAZOSIN APX DOM-TERAZOSIN DPC HYTRIN ABB MYLAN-TERAZOSIN MYL PMS-TERAZOSIN PMS RATIO-TERAZOSIN RPH TERAZOSIN PDL TERAZOSIN SAN TEVA-TERAZOSIN TEV 24:20.00 ALPHA ADRENERGIC BLOCKING AGENTS TERAZOSIN HCL 2mg Tablet APO-TERAZOSIN APX DOM-TERAZOSIN DPC HYTRIN ABB MYLAN-TERAZOSIN MYL PMS-TERAZOSIN PMS RATIO-TERAZOSIN RPH TERAZOSIN PDL TERAZOSIN SAN TEVA-TERAZOSIN TEV 5mg Tablet APO-TERAZOSIN APX DOM-TERAZOSIN DPC HYTRIN ABB MYLAN-TERAZOSIN MYL PMS-TERAZOSIN PMS RATIO-TERAZOSIN RPH TERAZOSIN PDL TERAZOSIN SAN TEVA-TERAZOSIN TEV 10mg Tablet APO-TERAZOSIN APX DOM-TERAZOSIN DPC HYTRIN ABB MYLAN-TERAZOSIN MYL PMS-TERAZOSIN PMS RATIO-TERAZOSIN RPH TERAZOSIN PDL TERAZOSIN SAN TEVA-TERAZOSIN TEV 24:24.00 BETA ADRENERGIC BLOCKING AGENTS ACEBUTOLOL HCL 100mg Tablet ACEBUTOLOL PDL ACEBUTOLOL SAN APO-ACEBUTOLOL APX MYLAN-ACEBUTOLOL MYL MYLAN-ACEBUTOLOL (TYPE MYL S) SANDOZ-ACEBUTOLOL SDZ SECTRAL SAC TEVA-ACEBUTOLOL TEV 200mg Tablet ACEBUTOLOL SAN APO-ACEBUTOLOL APX MYLAN-ACEBUTOLOL MYL MYLAN-ACEBUTOLOL (TYPE MYL S) PDL-ACEBUTOLOL PDL SANDOZ-ACEBUTOLOL SDZ SECTRAL SAC TEVA-ACEBUTOLOL TEV Page 39 of 151

56 24:24.00 BETA ADRENERGIC BLOCKING AGENTS ACEBUTOLOL HCL 400mg Tablet ACEBUTOLOL SAN APO-ACEBUTOLOL APX MYLAN-ACEBUTOLOL MYL MYLAN-ACEBUTOLOL (TYPE MYL S) PDL-ACEBUTOLOL PDL SANDOZ-ACEBUTOLOL SDZ SECTRAL SAC TEVA-ACEBUTOLOL TEV ATENOLOL 25mg Tablet ATENOLOL PDL JAMP-ATENOLOL JAP MAR-ATENOLOL MAR MINT-ATENOLOL MIN MYLAN-ATENOLOL MYL PHL-ATENOLOL PMI PMS-ATENOLOL PMS RAN-ATENOLOL RBY RIVA-ATENOLOL RIV SEPTA-ATENOLOL SPT TEVA-ATENOL TEV 50mg Tablet APO-ATENOL APX ATENOLOL PDL CO ATENOLOL COB DOM-ATENOLOL DPC JAMP-ATENOLOL JAP MAR-ATENOLOL MAR MINT-ATENOLOL MIN MYLAN-ATENOLOL MYL PHL-ATENOLOL PHH PMS-ATENOLOL PMS RAN-ATENOLOL RBY RATIO-ATENOLOL RPH RIVA-ATENOLOL RIV SANDOZ-ATENOLOL SDZ SEPTA-ATENOLOL SPT TENORMIN AZC TEVA-ATENOL TEV 24:24.00 BETA ADRENERGIC BLOCKING AGENTS ATENOLOL 100mg Tablet APO-ATENOL APX ATENOLOL PDL CO ATENOLOL COB DOM-ATENOLOL DPC JAMP-ATENOLOL JAP MAR-ATENOLOL MAR MINT-ATENOLOL MIN MYLAN-ATENOLOL MYL PHL-ATENOLOL PHH PMS-ATENOLOL PMS RAN-ATENOLOL RBY RATIO-ATENOLOL RPH RIVA-ATENOLOL RIV SEPTA-ATENOLOL SPT TENORMIN AZC TEVA-ATENOL TEV ATENOLOL, CHLORTHALIDONE 50mg & 25mg Tablet APO-ATENIDONE APX TENORETIC AZC TEVA-ATENOLTHALIDONE TEV 100mg & 25mg Tablet APO-ATENIDONE APX TENORETIC AZC TEVA-ATENOLTHALIDONE TEV BISOPROLOL FUMARATE 5mg Tablet APO-BISOPROLOL APX BISOPROLOL SOR BISOPROLOL SIV BISOPROLOL SAN MYLAN-BISOPROLOL MYL PMS-BISOPROLOL PMS PRO-BISOPROLOL PDL SANDOZ-BISOPROLOL SDZ TEVA-BIPOPROLOL TEV 10mg Tablet APO-BISOPROLOL APX BISOPROLOL SOR BISOPROLOL SIV BISOPROLOL SAN MYLAN-BISOPROLOL MYL PMS-BISOPROLOL PMS PRO-BISOPROLOL PDL SANDOZ-BISOPROLOL SDZ TEVA-BIPOPROLOL TEV Page 40 of 151

57 24:24.00 BETA ADRENERGIC BLOCKING AGENTS CARVEDILOL 3.125mg Tablet APO-CARVEDILOL APX AURO-CARVEDILOL AUR CARVEDILOL SAN DOM-CARVEDILOL DPC JAMP-CARVEDILOL JAP MYLAN-CARVEDILOL MYL PHL-CARVEDILOL PMI PMS-CARVEDILOL PMS PRO-CARVEDILOL PDL RAN-CARVEDILOL RBY RATIO-CARVEDILOL RPH ZYM-CARVEDILOL ZYM 6.25mg Tablet APO-CARVEDILOL APX AURO-CARVEDILOL AUR CARVEDILOL SAN DOM-CARVEDILOL DPC JAMP-CARVEDILOL JAP MYLAN-CARVEDILOL MYL PHL-CARVEDILOL PMI PMS-CARVEDILOL PMS PRO-CARVEDILOL PDL RAN-CARVEDILOL RBY RATIO-CARVEDILOL RPH ZYM-CARVEDILOL ZYM 12.5mg Tablet APO-CARVEDILOL APX AURO-CARVEDILOL AUR CARVEDILOL SAN DOM-CARVEDILOL DPC JAMP-CARVEDILOL JAP MYLAN-CARVEDILOL MYL PHL-CARVEDILOL PMI PMS-CARVEDILOL PMS PRO-CARVEDILOL PDL RAN-CARVEDILOL RBY RATIO-CARVEDILOL RPH ZYM-CARVEDILOL ZYM 25mg Tablet APO-CARVEDILOL APX AURO-CARVEDILOL AUR CARVEDILOL SAN DOM-CARVEDILOL DPC JAMP-CARVEDILOL JAP MYLAN-CARVEDILOL MYL PHL-CARVEDILOL PMI PMS-CARVEDILOL PMS PRO-CARVEDILOL PDL RAN-CARVEDILOL RBY RATIO-CARVEDILOL RPH ZYM-CARVEDILOL ZYM 24:24.00 BETA ADRENERGIC BLOCKING AGENTS LABETALOL HCL 100mg Tablet TRANDATE SHI 200mg Tablet TRANDATE SHI METOPROLOL TARTRATE 100mg Sustained Release Tablet APO-METOPROLOL SR APX LOPRESOR SR NVR SANDOZ-METOPROLOL SR SDZ 200mg Sustained Release Tablet APO-METOPROLOL SR APX LOPRESOR SR NVR METOPROLOL SR PDL SANDOZ-METOPROLOL SR SDZ 25mg Tablet APO-METOPROLOL APX DOM-METOPROLOL-L DPC JAMP-METOPROLOL-L JAP METOPROLOL PDL METOPROLOL-L SOR MYLAN-METOPROLOL (TYPE MYL L) PMS-METOPROLOL-L PMS RIVA-METOPROLOL L RIV TEVA-METOPROL TEP 50mg Tablet APO-METOPROLOL APX APO-METOPROLOL-L APX DOM-METOPROLOL-B DPC DOM-METOPROLOL-L DPC JAMP-METOPROLOL-L JAP LOPRESOR NVR METOPROLOL PDL METOPROLOL SAN METOPROLOL-L SOR MYLAN-METOPROLOL (TYPE MYL L) PMS-METOPROLOL-B PMS PMS-METOPROLOL-L PMS RIVA-METOPROLOL L RIV SANDOZ METOPROLOL (L) SDZ TEVA-METOPROL TEV TEVA-METOPROL TEV Page 41 of 151

58 24:24.00 BETA ADRENERGIC BLOCKING AGENTS METOPROLOL TARTRATE 100mg Tablet APO-METOPROLOL APX APO-METOPROLOL-L APX DOM-METOPROLOL-B DPC DOM-METOPROLOL-L DPC JAMP-METOPROLOL-L JAP LOPRESOR NVR METOPROLOL PDL METOPROLOL SAN METOPROLOL SR PDL METOPROLOL-L SOR MYLAN-METOPROLOL (TYPE MYL L) PMS-METOPROLOL-B PMS PMS-METOPROLOL-L PMS RIVA-METOPROLOL L RIV SANDOZ METOPROLOL (L) SDZ TEVA-METOPROL TEV TEVA-METOPROL-B TEV NADOLOL 40mg Tablet APO-NADOL APX NADOLOL PDL 80mg Tablet APO-NADOL APX NADOLOL PDL 160mg Tablet APO-NADOL APX PINDOLOL 5mg Tablet APO-PINDOL APX DOM-PINDOLOL DPC NOVO-PINDOL TEV PINDOLOL PDL PMS-PINDOLOL PMS SANDOZ-PINDOLOL SDZ VISKEN NVR 10mg Tablet APO-PINDOL APX DOM-PINDOLOL DPC NOVO-PINDOL TEV PINDOLOL PDL PMS-PINDOLOL PMS SANDOZ-PINDOLOL SDZ VISKEN NVR 24:24.00 BETA ADRENERGIC BLOCKING AGENTS PINDOLOL 15mg Tablet APO-PINDOL APX DOM-PINDOLOL DPC NOVO-PINDOL TEV PINDOLOL PDL PMS-PINDOLOL PMS SANDOZ-PINDOLOL SDZ VISKEN NVR PINDOLOL, HYDROCHLOROTHIAZIDE 10mg & 25mg Tablet VISKAZIDE NVR 10mg & 50mg Tablet VISKAZIDE NVR PROPRANOLOL HCL 60mg Long Acting Capsule INDERAL LA WAY 80mg Long Acting Capsule INDERAL LA WAY 120mg Long Acting Capsule INDERAL LA WAY 160mg Long Acting Capsule INDERAL LA WAY 10mg Tablet DOM-PROPRANOLOL DPC NOVO-PRANOL TEV 20mg Tablet NOVO-PRANOL TEV 40mg Tablet DOM-PROPRANOLOL DPC NOVO-PRANOL TEV 80mg Tablet DOM-PROPRANOLOL DPC NOVO-PRANOL TEV PMS-PROPRANOLOL PMS 120mg Tablet APO-PROPRANOLOL APX PMS-PROPRANOLOL PMS SOTALOL HCL 80mg Tablet APO-SOTALOL APX CO SOTALOL COB DOM-SOTALOL DPC JAMP-SOTALOL JAP NOVO-SOTALOL TEV PHL-SOTALOL PHH PMS-SOTALOL PMS PRO-SOTALOL PDL RATIO-SOTALOL RPH SANDOZ-SOTALOL SDZ SOTALOL SIV Page 42 of 151

59 24:24.00 BETA ADRENERGIC BLOCKING AGENTS SOTALOL HCL 160mg Tablet APO-SOTALOL APX CO SOTALOL COB DOM-SOTALOL DPC JAMP-SOTALOL JAP MYLAN-SOTALOL MYL NOVO-SOTALOL TEV PHL-SOTALOL PHH PMS-SOTALOL PMS PRO-SOTALOL PDL RATIO-SOTALOL RPH RIVA-SOTALOL RIV SANDOZ-SOTALOL SDZ SOTALOL SIV TIMOLOL MALEATE 5mg Tablet APO-TIMOL APX TEVA-TIMOL TEV TIMOLOL PDL 10mg Tablet APO-TIMOL APX TEVA-TIMOL TEV TIMOLOL PDL 20mg Tablet APO-TIMOL APX TEVA-TIMOL TEV 24:28.08 DIHYDROPYRIDINES AMLODIPINE 2.5mg Tablet ACT AMLODIPINE ATP AMLODIPINE PDL AMLODIPINE SIV AMLODIPINE-ODAN ODN DOM-AMLODIPINE DOM GD-AMLODIPINE PFI JAMP-AMLODIPINE JAP MAR-AMLODIPINE MAR PHL-AMLODIPINE PMI PMS-AMLODIPINE PMS RAN-AMLODIPINE RBY RIVA-AMLODIPINE RIV SANDOZ-AMLODIPINE SDZ SEPTA-AMLODIPINE SPT 24:28.08 DIHYDROPYRIDINES AMLODIPINE 5mg Tablet ACCEL-AMLODIPINE ACP AMLODIPINE PDL AMLODIPINE SAN AMLODIPINE SIV AMLODIPINE JAP AMLODIPINE-ODAN ODN APO-AMLODIPINE APX AURO-AMLODIPINE AUR CO AMLODIPINE CBT DOM-AMLODIPINE DOM GD-AMLODIPINE PFI JAMP-AMLODIPINE JAP MAR-AMLODIPINE MAR MINT-AMLODIPINE MIN MYLAN-AMLODIPINE MYL NORVASC PFI PHL-AMLODIPINE PMI PMS-AMLODIPINE PMS RAN-AMLODIPINE RBY RATIO-AMLODIPINE RPH RIVA-AMLODIPINE RIV SANDOZ-AMLODIPINE SDZ SEPTA-AMLODIPINE SPT TEVA-AMLODIPINE TEV ZYM-AMLODIPINE ZYM 10mg Tablet ACCEL-AMLODIPINE ACP AMLODIPINE PDL AMLODIPINE SAN AMLODIPINE SIV AMLODIPINE JAP AMLODIPINE-ODAN ODN APO-AMLODIPINE APX AURO-AMLODIPINE AUR CO AMLODIPINE CBT DOM-AMLODIPINE DOM GD-AMLODIPINE PFI JAMP-AMLODIPINE JAP MAR-AMLODIPINE MAR MINT-AMLODIPINE MIN MYLAN-AMLODIPINE MYL NORVASC PFI PHL-AMLODIPINE PMI PMS-AMLODIPINE PMS RAN-AMLODIPINE RBY RATIO-AMLODIPINE RPH RIVA-AMLODIPINE RIV SANDOZ-AMLODIPINE SDZ SEPTA-AMLODIPINE SPT TEVA-AMLODIPINE TEV ZYM-AMLODIPINE ZYM Page 43 of 151

60 24:28.08 DIHYDROPYRIDINES AMLODIPINE, ATORVAATIN 5mg & 10mg Tablet APO-AMLODIPINE- APX ATORVAATIN CADUET PFI GD-AMLODIPINE- PFI ATORVAATIN PMS-AMLODIPINE- ATORVAATIN PMS 5mg & 20mg Tablet APO-AMLODIPINE- APX ATORVAATIN CADUET PFI GD-AMLODIPINE- PFI ATORVAATIN PMS-AMLODIPINE- ATORVAATIN PMS 5mg & 40mg Tablet APO-AMLODIPINE- APX ATORVAATIN CADUET PFI GD-AMLODIPINE- ATORVAATIN PFI 5mg & 80mg Tablet APO-AMLODIPINE- APX ATORVAATIN CADUET PFI GD-AMLODIPINE- ATORVAATIN PFI 10mg & 10mg Tablet APO-AMLODIPINE- APX ATORVAATIN CADUET PFI GD-AMLODIPINE- PFI ATORVAATIN PMS-AMLODIPINE- ATORVAATIN PMS 10mg & 20mg Tablet APO-AMLODIPINE- APX ATORVAATIN CADUET PFI GD-AMLODIPINE- PFI ATORVAATIN PMS-AMLODIPINE- ATORVAATIN PMS 10mg & 40mg Tablet APO-AMLODIPINE- APX ATORVAATIN CADUET PFI GD-AMLODIPINE- ATORVAATIN PFI 10mg & 80mg Tablet APO-AMLODIPINE- APX ATORVAATIN CADUET PFI GD-AMLODIPINE- ATORVAATIN PFI 24:28.08 DIHYDROPYRIDINES AMLODIPINE, TELMISARTAN 5mg & 40mg Tablet TWYNA BOE 5mg & 80mg Tablet TWYNA BOE 10mg & 40mg Tablet TWYNA BOE 10mg & 80mg Tablet TWYNA BOE FELODIPINE 2.5mg Extended Release Tablet PLENDIL AZC 5mg Extended Release Tablet PLENDIL AZC SANDOZ-FELODIPINE SDZ SANDOZ-FELODIPINE SDZ 10mg Extended Release Tablet PLENDIL AZC SANDOZ-FELODIPINE SDZ SANDOZ-FELODIPINE SDZ NIFEDIPINE 5mg Capsule NIFEDIPINE AAP PMS-NIFEDIPINE PMS 10mg Capsule NIFEDIPINE AAP PMS-NIFEDIPINE PMS 20mg Extended Release Tablet ADALAT XL BAY 30mg Extended Release Tablet ADALAT XL BAY MYLAN-NIFEDIPINE ER MYL 60mg Extended Release Tablet ADALAT XL BAY MYLAN-NIFEDIPINE ER MYL 10mg Sustained Release Tablet APO-NIFED PA APX 20mg Sustained Release Tablet APO-NIFED PA APX NIMODIPINE 30mg Tablet NIMOTOP BAY Page 44 of 151

61 24:28.92 MISCELLANEOUS CALCIUM- CHANNEL BLOCKING AGENTS DILTIAZEM HCL 120mg Controlled Delivery Capsule APO-DILTIAZ CD APX CARDIZEM CD BPC DILTIAZEM CD PDL DILTIAZEM CD SAN PMS-DILTIAZEM CD PMS RATIO-DILTIAZEM CD RPH SANDOZ-DILTIAZEM CD SDZ TEVA-DILTAZEM CD TEV 180mg Controlled Delivery Capsule APO-DILTIAZ CD APX CARDIZEM CD BPC DILTIAZEM CD PDL DILTIAZEM CD SAN PMS-DILTIAZEM CD PMS RATIO-DILTIAZEM CD RPH SANDOZ-DILTIAZEM CD SDZ TEVA-DILTAZEM CD TEV 240mg Controlled Delivery Capsule APO-DILTIAZ CD APX CARDIZEM CD BPC DILTIAZEM CD PDL DILTIAZEM CD SAN PMS-DILTIAZEM CD PMS RATIO-DILTIAZEM CD RPH SANDOZ-DILTIAZEM CD SDZ TEVA-DILTAZEM CD TEV 300mg Controlled Delivery Capsule APO-DILTIAZ CD APX CARDIZEM CD BPC DILTIAZEM CD PDL DILTIAZEM CD SAN PMS-DILTIAZEM CD PMS RATIO-DILTIAZEM CD RPH SANDOZ-DILTIAZEM CD SDZ TEVA-DILTAZEM CD TEV 120mg Extended Release Capsule ACT DILTIAZEM CD ATP ACT DILTIAZEM T ATP DILTIAZEM TZ PDL TEVA-DILTIAZEM ER TEV TIAZAC BPC 180mg Extended Release Capsule ACT DILTIAZEM CD ATP ACT DILTIAZEM T ATP DILTIAZEM TZ PDL TEVA-DILTIAZEM ER TEV TIAZAC BPC 24:28.92 MISCELLANEOUS CALCIUM- CHANNEL BLOCKING AGENTS DILTIAZEM HCL 240mg Extended Release Capsule ACT DILTIAZEM CD ATP ACT DILTIAZEM T ATP DILTIAZEM TZ PDL TEVA-DILTIAZEM ER TEV TIAZAC BPC 300mg Extended Release Capsule ACT DILTIAZEM CD ATP ACT DILTIAZEM T ATP DILTIAZEM TZ PDL TEVA-DILTIAZEM ER TEV TIAZAC BPC 360mg Extended Release Capsule ACT DILTIAZEM T ATP DILTIAZEM TZ PDL TEVA-DILTIAZEM ER TEV TIAZAC BPC 120mg Extended Release Tablet TIAZAC XC BPC 180mg Extended Release Tablet TIAZAC XC BPC 240mg Extended Release Tablet TIAZAC XC BPC 300mg Extended Release Tablet TIAZAC XC BPC 360mg Extended Release Tablet TIAZAC XC BPC 60mg Sustained Release Capsule APO-DILTIAZ SR APX 90mg Sustained Release Capsule APO-DILTIAZ SR APX 120mg Sustained Release Capsule APO-DILTIAZ SR APX SANDOZ-DILTIAZEM T SDZ 180mg Sustained Release Capsule SANDOZ-DILTIAZEM T SDZ 240mg Sustained Release Capsule SANDOZ-DILTIAZEM T SDZ 300mg Sustained Release Capsule SANDOZ-DILTIAZEM T SDZ 360mg Sustained Release Capsule SANDOZ-DILTIAZEM T SDZ 30mg Tablet APO-DILTIAZ APX DILTIAZEM PDL TEVA-DILTIAZEM TEV 60mg Tablet APO-DILTIAZ APX DILTIAZEM PDL TEVA-DILTIAZEM TEV Page 45 of 151

62 24:28.92 MISCELLANEOUS CALCIUM- CHANNEL BLOCKING AGENTS VERAPAMIL HCL 180mg Extended Release Tablet COVERA-HS PFI 240mg Extended Release Tablet COVERA-HS PFI 120mg Sustained Release Tablet APO-VERAP SR APX ISOPTIN SR ABB MYLAN-VERAPAMIL SR MYL PRO-VERAPAMIL SR PDL 180mg Sustained Release Tablet APO-VERAP SR APX ISOPTIN SR ABB MYLAN-VERAPAMIL SR MYL PRO-VERAPAMIL SR PDL 240mg Sustained Release Tablet APO-VERAP SR APX DOM-VERAPAMIL SR DPC ISOPTIN SR ABB MYLAN-VERAPAMIL SR MYL NOVO-VERAMIL SR TEV PHL-VERAPAMIL SR PHH PMS-VERAPAMIL SR PMS PRO-VERAPAMIL SR PDL RIVA-VERAPAMIL SR RIV 80mg Tablet APO-VERAP APX MYLAN-VERAPAMIL MYL NOVO-VERAMIL TEV VERAPAMIL PDL 120mg Tablet APO-VERAP APX MYLAN-VERAPAMIL MYL NOVO-VERAMIL TEV 24:32.04 ANGIOTENSIN-CONVERTING ENZYME INHIBITORS BENAZEPRIL HCL 5mg Tablet BENAZEPRIL AAP LOTENSIN NVR 10mg Tablet BENAZEPRIL AAP 20mg Tablet BENAZEPRIL AAP LOTENSIN NVR CAPTOPRIL 6.25mg Tablet APO-CAPTO APX 24:32.04 ANGIOTENSIN-CONVERTING ENZYME INHIBITORS CAPTOPRIL 12.5mg Tablet APO-CAPTO APX CAPTOPRIL SOR DOM-CAPTOPRIL DPC MYLAN-CAPTOPRIL MYL TEVA-CAPTORIL TEV 25mg Tablet APO-CAPTO APX CAPTOPRIL PDL CAPTOPRIL SOR DOM-CAPTOPRIL DPC MYLAN-CAPTOPRIL MYL TEVA-CAPTORIL TEV 50mg Tablet APO-CAPTO APX CAPTOPRIL SPR DOM-CAPTOPRIL DPC MYLAN-CAPTOPRIL MYL TEVA-CAPTORIL TEV 100mg Tablet APO-CAPTO APX CAPTOPRIL SOR DOM-CAPTOPRIL DPC MYLAN-CAPTOPRIL MYL PMS-CAPTOPRIL PMS TEVA-CAPTORIL TEV CILAZAPRIL 1mg Tablet APO-CILAZAPRIL APX CILAZAPRIL SAN MYLAN-CILAZAPRIL MYL PMS-CILAZAPRIL PMS TEVA-CILAZAPRIL TEV 2.5mg Tablet APO-CILAZAPRIL APX CILAZAPRIL SAN CO CILAZAPRIL COB INHIBACE HLR MYLAN-CILAZAPRIL MYL PMS-CILAZAPRIL PMS TEVA-CILAZAPRIL TEV 5mg Tablet APO-CILAZAPRIL APX CILAZAPRIL SAN CO CILAZAPRIL COB INHIBACE HLR MYLAN-CILAZAPRIL MYL PMS-CILAZAPRIL PMS TEVA-CILAZAPRIL TEV Page 46 of 151

63 24:32.04 ANGIOTENSIN-CONVERTING ENZYME INHIBITORS CILAZAPRIL, HYDROCHLOROTHIAZIDE 5mg & 12.5mg Tablet APO-CILAZAPRIL HCTZ APX INHIBACE PLUS HLR TEVA-CILAZAPRIL/HCTZ TEV ENALAPRIL MALEATE 2.5mg Tablet APO ENALAPRIL APX CO ENALAPRIL COB ENALAPRIL SAN MYLAN-ENALAPRIL MYL NOVO-ENALAPRIL TEV PMS-ENALAPRIL PMS PRO-ENALAPRIL PDL RAN-ENALAPRIL RBY RATIO-ENALAPRIL RPH RIVA-ENALAPRIL RIV SANDOZ ENALAPRIL SDZ SIG-ENALAPRIL SIG TARO-ENALAPRIL TAR VASOTEC FRS 5mg Tablet APO ENALAPRIL APX CO ENALAPRIL COB ENALAPRIL SAN MYLAN-ENALAPRIL MYL NOVO-ENALAPRIL TEV PMS-ENALAPRIL PMS PRO-ENALAPRIL PDL RAN-ENALAPRIL RBY RATIO-ENALAPRIL RPH RIVA-ENALAPRIL RIV SANDOZ ENALAPRIL SDZ SIG-ENALAPRIL SIG TARO-ENALAPRIL TAR VASOTEC FRS 10mg Tablet APO ENALAPRIL APX CO ENALAPRIL COB ENALAPRIL SAN MYLAN-ENALAPRIL MYL NOVO-ENALAPRIL TEV PMS-ENALAPRIL PMS PRO-ENALAPRIL PDL RAN-ENALAPRIL RBY RATIO-ENALAPRIL RPH RIVA-ENALAPRIL RIV SANDOZ ENALAPRIL SDZ SIG-ENALAPRIL SIG TARO-ENALAPRIL TAR VASOTEC FRS 24:32.04 ANGIOTENSIN-CONVERTING ENZYME INHIBITORS ENALAPRIL MALEATE 20mg Tablet APO ENALAPRIL APX CO ENALAPRIL COB ENALAPRIL SAN MYLAN-ENALAPRIL MYL NOVO-ENALAPRIL TEV PMS-ENALAPRIL PMS PRO-ENALAPRIL PDL RAN-ENALAPRIL RBY RATIO-ENALAPRIL RPH RIVA-ENALAPRIL RIV SANDOZ ENALAPRIL SDZ SIG-ENALAPRIL SIG TARO-ENALAPRIL TAR VASOTEC FRS ENALAPRIL MALEATE, HYDROCHLOROTHIAZIDE 5mg & 12.5mg Tablet APO-ENALAPRIL APX MALEATE/HCTZ NOVO-ENALAPRIL/HCTZ TEV 10mg & 25mg Tablet APO-ENALAPRIL APX MALEATE/HCTZ NOVO-ENALAPRIL/HCTZ TEV VASERETIC FRS FOSINOPRIL SODIUM 10mg Tablet APO-FOSINOPRIL APX FOSINOPRIL PDL FOSINOPRIL RBY JAMP-FOSINOPRIL JMP MYLAN-FOSINOPRIL MYL NOVO-FOSINOPRIL TEV PMS-FOSINOPRIL PMS RAN-FOSINOPRIL RBY RIVA-FOSINOPRIL RIV 20mg Tablet APO-FOSINOPRIL APX FOSINOPRIL PDL FOSINOPRIL RBY JAMP-FOSINOPRIL JMP MYLAN-FOSINOPRIL MYL NOVO-FOSINOPRIL TEV PMS-FOSINOPRIL PMS RAN-FOSINOPRIL RBY RIVA-FOSINOPRIL RIV Page 47 of 151

64 24:32.04 ANGIOTENSIN-CONVERTING ENZYME INHIBITORS LISINOPRIL 5mg Tablet APO-LISINOPRIL APX APO-LISINOPRIL (TYPE Z) APX AURO-LISINOPRIL AUR CO LISINOPRIL COB JAMP-LISINOPRIL JAP LISINOPRIL SIV MYLAN-LISINOPRIL MYL NOVO-LISINOPRIL (TYPE P) TEV NOVO-LISINOPRIL (TYPE Z) TEV PMS-LISINOPRIL PMS PRINIVIL FRS PRO-LISINOPRIL PDL RAN-LISINOPRIL RBY RIVA-LISINOPRIL RIV SANDOZ LISINOPRIL SDZ ZERIL AZC 10mg Tablet APO-LISINOPRIL APX APO-LISINOPRIL (TYPE Z) APX AURO-LISINOPRIL AUR CO LISINOPRIL COB JAMP-LISINOPRIL JAP LISINOPRIL SIV MYLAN-LISINOPRIL MYL NOVO-LISINOPRIL (TYPE P) TEV NOVO-LISINOPRIL (TYPE Z) TEV PMS-LISINOPRIL PMS PRINIVIL FRS PRO-LISINOPRIL PDL RAN-LISINOPRIL RBY RIVA-LISINOPRIL RIV SANDOZ-LISINOPRIL SDZ ZERIL AZC 20mg Tablet APO-LISINOPRIL APX APO-LISINOPRIL (TYPE Z) APX AURO-LISINOPRIL AUR CO LISINOPRIL COB JAMP-LISINOPRIL JAP LISINOPRIL SIV MYLAN-LISINOPRIL MYL NOVO-LISINOPRIL (TYPE P) TEV NOVO-LISINOPRIL (TYPE Z) TEV PMS-LISINOPRIL PMS PRINIVIL FRS PRO-LISINOPRIL PDL RAN-LISINOPRIL RBY RIVA-LISINOPRIL RIV SANDOZ LISINOPRIL SDZ ZERIL AZC 24:32.04 ANGIOTENSIN-CONVERTING ENZYME INHIBITORS LISINOPRIL, HYDROCHLOROTHIAZIDE 10mg & 12.5mg Tablet LISINOPRIL/HCTZ (Z) SAN MYLAN-LISINOPRIL HCTZ MYL NOVO-LISINOPRIL/HCTZ TEV (TYPE P) NOVO-LISINOPRIL/HCTZ TEV (TYPE Z) SANDOZ LISINOPRIL HCT SDZ ZEORETIC AZC 20mg & 12.5mg Tablet LISINOPRIL/HCTZ (Z) SAN MYLAN-LISINOPRIL HCTZ MYL NOVO-LISINOPRIL (TYPE P) TEV NOVO-LISINOPRIL/HCTZ TEV (TYPE Z) PRINZIDE FRS SANDOZ LISINOPRIL HCT SDZ ZEORETIC AZC 20mg & 25mg Tablet LISINOPRIL/HCTZ (Z) SAN MYLAN-LISINOPRIL HCTZ MYL NOVO-LISINOPRIL/HCTZ TEV (TYPE P) NOVO-LISINOPRIL/HCTZ TEV (TYPE Z) SANDOZ LISINOPRIL HCT SDZ ZEORETIC AZC PERINDOPRIL ERBUMINE 2mg Tablet COVERSYL SEV 4mg Tablet COVERSYL SEV 8mg Tablet COVERSYL SEV PERINDOPRIL ERBUMINE, INDAPAMIDE 4mg & 1.25mg Tablet COVERSYL PLUS SEV PERINDOPRIL ERBUMINE,INDAPAMIDE 8mg & 2.5mg Tablet COVERSYL PLUS HD SEV QUINAPRIL HCL 5mg Tablet ACCUPRIL PFI APO-QUINAPRIL APX GD-QUINAPRIL PFI PMS-QUINAPRIL PMS QUINAPRIL PDL Page 48 of 151

65 24:32.04 ANGIOTENSIN-CONVERTING ENZYME INHIBITORS QUINAPRIL HCL 10mg Tablet ACCUPRIL PFI APO-QUINAPRIL APX GD-QUINAPRIL PFI PMS-QUINAPRIL PMS QUINAPRIL PDL 20mg Tablet ACCUPRIL PFI APO-QUINAPRIL APX GD-QUINAPRIL PFI PMS-QUINAPRIL PMS QUINAPRIL PDL 40mg Tablet ACCUPRIL PFI APO-QUINAPRIL APX GD-QUINAPRIL PFI PMS-QUINAPRIL PMS QUINAPRIL PDL QUINAPRIL HCL, HYDROCHLOROTHIAZIDE 10mg & 12.5mg Tablet ACCURETIC PFI APO-QUINAPRIL/HCTZ APX 20mg & 12.5mg Tablet ACCURETIC PFI APO-QUINAPRIL/HCTZ APX 20mg & 25mg Tablet ACCURETIC PFI APO-QUINAPRIL/HCTZ APX RAMIPRIL 1.25mg Capsule ALTACE SAC APO-RAMIPRIL APX AURO-RAMIPRIL AUR CO RAMIPRIL COB JAMP-RAMIPRIL JMP MAR-RAMIPRIL MAR MYLAN-RAMIPRIL MYL PMS-RAMIPRIL PMS PRO-RAMIPRIL PDL RAMIPRIL RIV RAMIPRIL SIV RAN RAMIPRIL RBY RATIO-RAMIPRIL RPH 24:32.04 ANGIOTENSIN-CONVERTING ENZYME INHIBITORS RAMIPRIL 2.5mg Capsule ALTACE SAC APO-RAMIPRIL APX AURO-RAMIPRIL AUR CO RAMIPRIL COB DOM-RAMIPRIL DOM JAMP-RAMIPRIL JMP MAR-RAMIPRIL MAR MINT-RAMIPRIL MIN MYLAN-RAMIPRIL MYL NOVO-RAMIPRIL TEV PMS-RAMIPRIL PMS PRO-RAMIPRIL PDL RAMIPRIL RIV RAMIPRIL SIV RAMIPRIL SAN RAMIPRIL-2.5 SIV RAN RAMIPRIL RBY RATIO-RAMIPRIL RPH 5mg Capsule ALTACE SAC APO-RAMIPRIL APX AURO-RAMIPRIL AUR CO RAMIPRIL COB DOM-RAMIPRIL DOM JAMP-RAMIPRIL JMP MAR-RAMIPRIL MAR MINT-RAMIPRIL MIN MYLAN-RAMIPRIL MYL NOVO-RAMIPRIL TEV PMS-RAMIPRIL PMS PRO-RAMIPRIL PDL RAMIPRIL PMS RAMIPRIL SIV RAMIPRIL SAN RAMIPRIL-5 SIV RAN RAMIPRIL RBY Page 49 of 151

66 24:32.04 ANGIOTENSIN-CONVERTING ENZYME INHIBITORS RAMIPRIL 10mg Capsule ALTACE SAC APO-RAMIPRIL APX AURO-RAMIPRIL AUR CO RAMIPRIL COB DOM-RAMIPRIL DOM JAMP-RAMIPRIL JMP MAR-RAMIPRIL MAR MINT-RAMIPRIL MIN MYLAN-RAMIPRIL MYL NOVO-RAMIPRIL TEV PMS-RAMIPRIL PMS PRO-RAMIPRIL PDL RAMIPRIL PMS RAMIPRIL SIV RAMIPRIL SAN RAMIPRIL-10 SIV RAN RAMIPRIL RBY 15mg Capsule APO-RAMIPRIL APX MAR-RAMIPRIL MAR MINT-RAMIPRIL MIN PMS-RAMIPRIL PMS 1.25mg Tablet SANDOZ RAMIPRIL SDZ 2.5mg Tablet SANDOZ RAMIPRIL SDZ 5mg Tablet SANDOZ RAMIPRIL SDZ 10mg Tablet SANDOZ RAMIPRIL SDZ RAMIPRIL, HYDROCHLOROTHIAZIDE 2.5mg & 12.5mg Tablet ALTACE HCT SAC APO-RAMIPRIL/HCTZ APX PMS-RAMIPRIL-HCTZ PMS 5mg & 12.5mg Tablet ALTACE HCT SAC APO-RAMIPRIL/HCTZ APX PMS-RAMIPRIL-HCTZ PMS RAMIPRIL-HCTZ SAN RAMIPRIL-HCTZ PDL 5mg & 25mg Tablet ALTACE HCT SAC APO-RAMIPRIL/HCTZ APX PMS-RAMIPRIL-HCTZ PMS RAMIPRIL-HCTZ SAN 10mg & 12.5mg Tablet ALTACE HCT SAC PMS-RAMIPRIL-HCTZ PMS RAMIPRIL-HCTZ SAN RAMIPRIL-HCTZ PDL 24:32.04 ANGIOTENSIN-CONVERTING ENZYME INHIBITORS RAMIPRIL, HYDROCHLOROTHIAZIDE 10mg & 25mg Tablet ALTACE HCT SAC APO-RAMIPRIL/HCTZ APX PMS-RAMIPRIL-HCTZ PMS RAMIPRIL-HCTZ SAN RAMIPRIL-HCTZ PDL TRANDOLAPRIL 0.5mg Capsule MAVIK ABB 1mg Capsule MAVIK ABB 2mg Capsule MAVIK ABB 4mg Capsule MAVIK ABB 24:32.08 ANGIOTENSIN II RECEPTOR ANTAGONIS CANDESARTAN CILEXETIL 4mg Tablet ACH-CANDESARTAN ACC APO-CANDESARTAN APX ATACAND AZE CANDESARTAN SIV CANDESARTAN SAN CO-CANDESARTAN ATP JAMP-CANDESARTAN JAP MYLAN-CANDESARTAN MYL PMS-CANDESARTAN PMS RAN-CANDESARTAN RBY RIVA-CANDESARTAN RIV SANDOZ CANDESARTAN SDZ 8mg Tablet ACH-CANDESARTAN ACC APO-CANDESARTAN APX ATACAND AZC CANDESARTAN PDL CANDESARTAN SIV CANDESARTAN SAN CO-CANDESARTAN ATP DOM-CANDESARTAN DOM JAMP-CANDESARTAN JAP MYLAN-CANDESARTAN MYL PMS-CANDESARTAN PMS RAN-CANDESARTAN RBY RIVA-CANDESARTAN RIV SANDOZ CANDESARTAN SDZ TEVA-CANDESARTAN TEP Page 50 of 151

67 24:32.08 ANGIOTENSIN II RECEPTOR ANTAGONIS CANDESARTAN CILEXETIL 16mg Tablet ACH-CANDESARTAN ACC APO-CANDESARTAN APX ATACAND AZC CANDESARTAN PDL CANDESARTAN SIV CANDESARTAN SAN CO-CANDESARTAN ATP JAMP-CANDESARTAN JAP MYLAN-CANDESARTAN MYL PMS-CANDESARTAN PMS RAN-CANDESARTAN RBY RIVA-CANDESARTAN RIV SANDOZ CANDESARTAN SDZ TEVA-CANDESARTAN TEP 32mg Tablet ACH-CANDESARTAN ACC APO-CANDESARTAN APX ATACAND AZC CANDESARTAN PDL CANDESARTAN SAN CO-CANDESARTAN ATP JAMP-CANDESARTAN JAP MYLAN-CANDESARTAN MYL PMS-CANDESARTAN PMS RAN-CANDESARTAN RBY RIVA-CANDESARTAN RIV SANDOZ CANDESARTAN SDZ SANDOZ CANDESARTAN SDZ TEVA-CANDESARTAN TEP CANDESARTAN CILEXETIL, HYDROCHLOROTHIAZIDE 16mg & 12.5mg Tablet ACT CANDESARTAN/HCT ATP APO-CANDESARTAN/HCTZ APX CANDESARTAN-HCTZ PDL CANDESARTAN-HCTZ SAN CANDESARTAN-HCTZ SIV MYLAN-CANDESART HCTZ MYL PMS-CANDESARTAN HCTZ CBT SANDOZ CANDESARTAN PLUS SDZ TEVA-CANDESARTAN/HCTZ TEP 32mg & 12.5mg Tablet APO-CANDESARTAN/HCTZ APX SANDOZ CANDESARTAN PLUS SDZ TEVA-CANDESARTAN/HCTZ TEP 32mg & 25mg Tablet APO-CANDESARTAN/HCTZ APX SANDOZ CANDESARTAN PLUS SDZ 16mg & 12.5mg Tablet ATACAND PLUS AZC 24:32.08 ANGIOTENSIN II RECEPTOR ANTAGONIS CANDESARTAN CILEXETIL, HYDROCHLOROTHIAZIDE 32mg & 12.5mg Tablet ATACAND PLUS AZE 32mg & 25mg Tablet ATACAND PLUS AZE EPOSARTAN MESYLATE 400mg Tablet TEVETEN SPH 600mg Tablet TEVETEN SPH EPOSARTAN MESYLATE, HYDROCHLOROTHIAZIDE 600mg & 12.5mg Tablet TEVETEN PLUS SPH IRBESARTAN 75mg Tablet APO-IRBESARTAN APX AURO-IRBESARTAN AUR AVAPRO SAC CO IRBESARTAN CBT IRBESARTAN PDL IRBESARTAN SAN IRBESARTAN SIV JAMP-IRBESARTAN JAP MYLAN-IRBESARTAN MYL PMS-IRBESARTAN PMS RAN-IRBESARTAN RBY RATIO-IRBESARTAN RTP RIVA-IRBESARTAN RIV SANDOZ IRBESARTAN SDZ TEVA-IRBESARTAN TEP 150mg Tablet APO-IRBESARTAN APX AURO-IRBESARTAN AUR AVAPRO SAC CO IRBESARTAN CBT DOM-IRBESARTAN DOM IRBESARTAN PDL IRBESARTAN SAN IRBESARTAN SIV JAMP-IRBESARTAN JAP MYLAN-IRBESARTAN MYL PMS-IRBESARTAN PMS RAN-IRBESARTAN RBY RATIO-IRBESARTAN RTP RIVA-IRBESARTAN RIV SANDOZ IRBESARTAN SDZ TEVA-IRBESARTAN TEP Page 51 of 151

68 24:32.08 ANGIOTENSIN II RECEPTOR ANTAGONIS IRBESARTAN 300mg Tablet APO-IRBESARTAN APX AURO-IRBESARTAN AUR AVAPRO SAC CO IRBESARTAN CBT IRBESARTAN PDL IRBESARTAN SAN IRBESARTAN SIV JAMP-IRBESARTAN JAP MYLAN-IRBESARTAN MYL PMS-IRBESARTAN PMS RAN-IRBESARTAN RBY RATIO-IRBESARTAN RTP RIVA-IRBESARTAN RIV SANDOZ IRBESARTAN SDZ TEVA-IRBESARTAN TEP IRBESARTAN, HYDROCHLOROTHIAZIDE 150mg & 12.5mg Tablet APO-IRBESARTAN/HCTZ APX AVALIDE SAC CO IRBESARTAN/HCT CBT IRBESARTAN HCT SIV IRBESARTAN/HCTZ SAN IRBESARTAN-HCTZ PDL JAMP-IRBESARTAN/HCT JAP MINT-IRBESARTAN/HCTZ MIN PMS-IRBESARTAN/HCT PMS RAN-IRBESARTAN HCTZ RBY RATIO-IRBESART/HCT RTP SANDOZ IRBESART/HCT SDZ TEVA-IRBESARTAN/HCT TEP 300mg & 12.5mg Tablet APO-IRBESARTAN/HCTZ APX AVALIDE SAC CO IRBESARTAN/HCT CBT IRBESARTAN HCT SIV IRBESARTAN/HCTZ SAN IRBESARTAN-HCTZ PDL JAMP-IRBESARTAN/HCT JAP MINT-IRBESARTAN/HCTZ MIN PMS-IRBESARTAN/HCT PMS RAN-IRBESARTAN HCTZ RBY RATIO-IRBESART/HCT RTP SANDOZ IRBESART/HCT SDZ TEVA-IRBESARTAN/HCT TEP 24:32.08 ANGIOTENSIN II RECEPTOR ANTAGONIS IRBESARTAN, HYDROCHLOROTHIAZIDE 300mg & 25mg Tablet APO-IRBESARTAN/HCTZ APX AVALIDE SAC CO IRBESARTAN/HCT CBT IRBESARTAN HCT SIV IRBESARTAN/HCTZ SAN IRBESARTAN-HCTZ PDL JAMP-IRBESARTAN/HCT JAP MINT-IRBESARTAN/HCTZ MIN PMS-IRBESARTAN/HCT PMS RAN-IRBESARTAN HCTZ RBY RATIO-IRBESART/HCT RTP SANDOZ IRBESART/HCT SDZ TEVA-IRBESARTAN/HCT TEP LOSARTAN POTASSIUM 25mg Tablet ACT-LOSARTAN ATP APO-LOSARTAN APX AURO-LOSARTAN AUR COZAAR FRS JAMP-LOSARTAN JAP LOSARTAN SIV LOSARTAN SAN LOSARTAN PDL MINT-LOSARTAN MIN MYLAN-LOSARTAN MYL PMS-LOSARTAN PMS SANDOZ LOSARTAN SDZ SEPTA-LOSARTAN SPT TEVA-LOSARTAN TEP 50mg Tablet ACT-LOSARTAN ATP APO-LOSARTAN APX AURO-LOSARTAN AUR COZAAR FRS JAMP-LOSARTAN JAP LOSARTAN SIV LOSARTAN SAN LOSARTAN PDL MINT-LOSARTAN MIN MYLAN-LOSARTAN MYL PMS-LOSARTAN PMS RAN-LOSARTAN RBY SANDOZ LOSARTAN SDZ SEPTA-LOSARTAN SPT TEVA-LOSARTAN TEP Page 52 of 151

69 24:32.08 ANGIOTENSIN II RECEPTOR ANTAGONIS LOSARTAN POTASSIUM 100mg Tablet ACT-LOSARTAN ATP APO-LOSARTAN APX AURO-LOSARTAN AUR COZAAR FRS JAMP-LOSARTAN JAP LOSARTAN SIV LOSARTAN SAN LOSARTAN PDL MINT-LOSARTAN MIN MYLAN-LOSARTAN MYL PMS-LOSARTAN PMS RAN-LOSARTAN RBY SANDOZ LOSARTAN SDZ SEPTA-LOSARTAN SPT TEVA-LOSARTAN TEP LOSARTAN POTASSIUM, HYDROCHLOROTHIAZIDE 50mg & 12.5mg Tablet ACT LOSARTAN/HCT ATP APO-LOSARTAN/HCTZ APX HYZAAR FRS JAMP-LOSARTAN HCTZ JAP LOSARTAN/HCT SIV LOSARTAN/HCTZ SAN LOSARTAN-HCTZ PDL MINT-LOSARTAN/HCTZ MIN MYLAN-LOSARTAN/HCTZ MYL PMS-LOSARTAN-HCTZ PMS SANDOZ LOSARTAN HCT SDZ SEPTA-LOSARTAN HCTZ SPT TEVA-LOSARTAN HCTZ TEP 100mg & 12.5mg Tablet ACT LOSARTAN/HCT ATP APO-LOSARTAN/HCTZ APX HYZAAR FRS LOSARTAN/HCT SIV LOSARTAN/HCTZ SAN LOSARTAN-HCTZ PDL MINT-LOSARTAN/HCTZ MIN MYLAN-LOSARTAN/HCTZ MYL PMS-LOSARTAN-HCTZ PMS SANDOZ LOSARTAN HCT SDZ TEVA-LOSARTAN HCTZ TEP 24:32.08 ANGIOTENSIN II RECEPTOR ANTAGONIS LOSARTAN POTASSIUM, HYDROCHLOROTHIAZIDE 100mg & 25mg Tablet ACT LOSARTAN/HCT ATP APO-LOSARTAN/HCTZ APX HYZAAR DS FRS JAMP-LOSARTAN HCTZ JAP LOSARTAN/HCT SIV LOSARTAN/HCTZ SAN LOSARTAN-HCTZ PDL MINT-LOSARTAN/HCTZ MIN MYLAN-LOSARTAN/HCTZ MYL PMS-LOSARTAN-HCTZ PMS SANDOZ LOSARTAN HCT SDZ SEPTA-LOSARTAN HCTZ SPT TEVA-LOSARTAN HCTZ TEP OLMESARTAN MEDOXOMIL 20mg Tablet OLMETEC SCH 40mg Tablet OLMETEC SCH OLMESARTAN MEDOXOMIL, HYDROCHLORTHIAZIDE 20mg/12.5mg Tablet OLMETEC PLUS SCH 40mg/12.5mg Tablet OLMETEC PLUS SCH 40mg/25mg Tablet OLMETEC PLUS SCH TELMISARTAN 40mg Tablet ACT TELMISARTAN ATP APO-TELMISARTAN APX MICARDIS BOE MYLAN-TELMISARTAN MYL PMS-TELMISARTAN PMS SANDOZ TELMISARTAN SDZ TELMISARTAN SAN TELMISARTAN SIV TELMISARTAN PDL TEVA-TELMISARTAN TEP 80mg Tablet ACT TELMISARTAN ATP APO-TELMISARTAN APX MICARDIS BOE MYLAN-TELMISARTAN MYL PMS-TELMISARTAN PMS SANDOZ TELMISARTAN SDZ TELMISARTAN SAN TELMISARTAN SIV TELMISARTAN PDL TEVA-TELMISARTAN TEP Page 53 of 151

70 24:32.08 ANGIOTENSIN II RECEPTOR ANTAGONIS TELMISARTAN, HYDROCHLOROTHIAZIDE 80mg & 12.5mg Tablet APO-TELMISARTAN/HCTZ APX CO TELMISARTAN/HCT ATP MICARDIS PLUS BOE MYLAN-TELMISARTAN HCTZ MYL PMS-TELMISARTAN-HCTZ PMS SANDOZ TELMISARTAN HCT SDZ TELMISARTAN HCTZ SIV TELMISARTAN HCTZ SAN TELMISARTAN/HCTZ PDL TEVA-TELMISARTAN HCTZ TEP 80mg & 25mg Tablet APO-TELMISARTAN/HCTZ APX CO TELMISARTAN/HCT ATP MICARDIS PLUS BOE MYLAN-TELMISARTAN HCTZ MYL SANDOZ TELMISARTAN HCT SDZ TELMISARTAN HCTZ SIV TELMISARTAN HCTZ SAN TELMISARTAN/HCTZ PDL TEVA-TELMISARTAN HCTZ TEP VALSARTAN 80mg Capsule DIOVAN NOV 40mg Tablet APO-VALSARTAN APX AURO-VALSARTAN AUR CO VALSARTAN CBT DIOVAN NVR MYLAN-VALSARTAN MYL PMS-VALSARTAN PMS RAN-VALSARTAN RBY RIVA-VALSARTAN RIV SANDOZ VALSARTAN SDZ TEVA-VALSARTAN TEV VALSARTAN SAN VALSARTAN PDL VALSARTAN SIV 80mg Tablet APO-VALSARTAN APX AURO-VALSARTAN AUR CO VALSARTAN CBT DIOVAN NVR DOM-VALSARTAN DOM MYLAN-VALSARTAN MYL PMS-VALSARTAN PMS RAN-VALSARTAN RBY RIVA-VALSARTAN RIV SANDOZ VALSARTAN SDZ TEVA-VALSARTAN TEV VALSARTAN SAN VALSARTAN PDL VALSARTAN SIV 24:32.08 ANGIOTENSIN II RECEPTOR ANTAGONIS VALSARTAN 160mg Tablet APO-VALSARTAN APX AURO-VALSARTAN AUR CO VALSARTAN CBT DIOVAN NVR MYLAN-VALSARTAN MYL PMS-VALSARTAN PMS RAN-VALSARTAN RBY RIVA-VALSARTAN RIV SANDOZ VALSARTAN SDZ TEVA-VALSARTAN TEV VALSARTAN SAN VALSARTAN PDL VALSARTAN SIV 320mg Tablet APO-VALSARTAN APX AURO-VALSARTAN AUR CO VALSARTAN CBT DIOVAN NVR MYLAN-VALSARTAN MYL PMS-VALSARTAN PMS RIVA-VALSARTAN RIV SANDOZ VALSARTAN SDZ TEVA-VALSARTAN TEV VALSARTAN SAN VALSARTAN PDL VALSARTAN SIV VALSARTAN, HYDROCHLOROTHIAZIDE 80mg & 12.5mg Tablet APO-VALSARTAN/HCTZ APX AURO-VALSARTAN HCT AUR DIOVAN-HCT NVR MYLAN-VALSARTAN HCTZ MYL SANDOZ VALSARTAN HCT SDZ TEVA-VALSARTAN/HCTZ TEV VALSARTAN HCT SAN VALSARTAN HCT SIV VALSARTAN-HCTZ PDL 160mg & 12.5mg Tablet APO-VALSARTAN/HCTZ APX AURO-VALSARTAN HCT AUR DIOVAN-HCT NVR MYLAN-VALSARTAN HCTZ MYL SANDOZ VALSARTAN HCT SDZ TEVA-VALSARTAN/HCTZ TEV VALSARTAN HCT SAN VALSARTAN HCT SIV VALSARTAN-HCTZ PDL Page 54 of 151

71 24:32.08 ANGIOTENSIN II RECEPTOR ANTAGONIS VALSARTAN, HYDROCHLOROTHIAZIDE 160mg & 25mg Tablet APO-VALSARTAN/HCTZ APX AURO-VALSARTAN HCT AUR DIOVAN-HCT NVR MYLAN-VALSARTAN HCTZ MYL SANDOZ VALSARTAN HCT SDZ TEVA-VALSARTAN/HCTZ TEV VALSARTAN HCT SAN VALSARTAN HCT SIV VALSARTAN-HCTZ PDL 320mg & 12.5mg Tablet APO-VALSARTAN/HCTZ APX AURO-VALSARTAN HCT AUR DIOVAN-HCT NOV MYLAN-VALSARTAN HCTZ MYL SANDOZ VALSARTAN HCT SDZ TEVA-VALSARTAN/HCTZ TEV VALSARTAN HCT SAN VALSARTAN HCT SIV 320mg & 25mg Tablet APO-VALSARTAN/HCTZ APX AURO-VALSARTAN HCT AUR DIOVAN-HCT NOV MYLAN-VALSARTAN HCTZ MYL SANDOZ VALSARTAN HCT SDZ TEVA-VALSARTAN/HCTZ TEV VALSARTAN HCT SAN VALSARTAN HCT SIV 24:32.20 MINERALOCORTICOIDE (ALDOERONE) RECEPTOR ANTAGONIS SPIRONOLACTONE 25mg Tablet ALDACTONE PFI NOVO-SPIROTON TEV 100mg Tablet ALDACTONE PFI NOVO-SPIROTON TEV SPIRONOLACTONE, HYDROCHLOROTHIAZIDE 25mg & 25mg Tablet ALDACTAZIDE-25 PFI NOVO-SPIROZINE-25 TEV 50mg & 50mg Tablet ALDACTAZIDE-50 PFI NOVO-SPIROZINE-50 TEV Page 55 of 151

72 28:00 CENTRAL NERVOUS SYEM AGENTS 28:08.04 NONEROIDAL ANTI- INFLAMMATORY AGENTS ACETYLSALICYLIC ACID Limited use benefit (prior approval is not required). ASA 80 mg tablets are a benefit to clients age 21 years and under to allow access for use in pediatric conditions (e.g. Kawasaki Syndrome). 80mg Chewable Tablet ASA SOR ASAPHEN PMS ASATAB ODN EURO-ASA EUR JAMP-ASA JMP LOWPRIN EUR RIVASA RIV 81mg Chewable Tablet ENTROPHEN CHEWABLE PED 80mg Delayed Release Tablet ACETYLSALICYLIC ACID JMP ASA EC SOR ASA EC SAN ASAPHEN EC PMS PRO-ASA 80MG EC TAB PRO PRO-ASA 80MG TAB PRO 81mg Delayed Release Tablet ASA VTH ASA EC SAN ENTROPHEN EC PED PRAXIS ASA EC PMS RIVASA EC RIV 162mg Delayed Release Tablet ASAPHEN EC PMS 325mg Delayed Release Tablet ASA VTH ASATAB EC ODN ASPIRIN BCD ENTROPHEN WAM ENTROPHEN-5 WAM PMS-ASA EC PMS PMS-ASA EC PMS 650mg Delayed Release Tablet ASA WSB ASATAB EC ODN PMS-ASA EC PMS 81mg Enteric Coated Tablet ASA PMS ASA PMS ASPIRIN BCD EQUATE DAILY LOW-DOSE PMS EXACT ASA EC PMS 28:08.04 NONEROIDAL ANTI- INFLAMMATORY AGENTS ACETYLSALICYLIC ACID Limited use benefit (prior approval is not required). ASA 80 mg tablets are a benefit to clients age 21 years and under to allow access for use in pediatric conditions (e.g. Kawasaki Syndrome). 325mg Enteric Coated Tablet APO-ASEN ECT APX NOVASEN TEV 650mg Enteric Coated Tablet ASA APX ENTROPHEN 10 FRS ENTROPHEN-10 FRS NOVASEN TEV 150mg Suppository PMS-ASA PMS 650mg Suppository ASA JNO 80mg Tablet LOWPRIN EUR RIVASA RIV 325mg Tablet APO-ASA APX ASA TEV ASA VTH ASPIRIN BCD Page 56 of 151

73 28:08.04 NONEROIDAL ANTI- INFLAMMATORY AGENTS CELECOXIB For patients who have: A history of serious gastrointestinal complications (e.g. ulcer, bleeding, perforation); OR Multiple (at least two) risk factors for serious gastrointestinal complications (e.g. age >60, concurrent use of ASA, SSRIs, corticosteroids, anticoagulants or antiplatelet agents). 100mg Capsule APO-CELECOXIB APX BIO-CELECOXIB BMI CELEBREX PFI CELECOXIB PDL CELECOXIB SIV 0245 CO CELECOXIB ATP CO CELECOXIB JAP GD-CELECOXIB PFI MAR-CELECOXIB MAR MINT-CELECOXIB MIN MYLAN-CELECOXIB MYL PMS-CELECOXIB PMS PRIVA-CELECOXIB PHA RAN-CELECOXIB RBY RIVA-CELECOX RIV SANDOZ CELECOXIB SDZ TEVA-CELECOXIB TEP 200mg Capsule APO-CELECOXIB APX BIO-CELECOXIB BMI CELEBREX PFI CELECOXIB PDL CELECOXIB SIV CO CELECOXIB ATP CO CELECOXIB JAP GD-CELECOXIB PFI MAR-CELECOXIB MAR MINT-CELECOXIB MIN MYLAN-CELECOXIB MYL PMS-CELECOXIB PMS PRIVA-CELECOXIB PHA RAN-CELECOXIB RBY RIVA-CELECOX RIV SANDOZ CELECOXIB SDZ TEVA-CELECOXIB TEP DICLOFENAC SODIUM 25mg Delayed Release Tablet PMS-DICLOFENAC PMS 50mg Delayed Release Tablet PMS-DICLOFENAC PMS 28:08.04 NONEROIDAL ANTI- INFLAMMATORY AGENTS DICLOFENAC SODIUM 25mg Enteric Coated Tablet APO-DICLO APX DOM-DICLOFENAC DPC PMS-DICLOFENAC PMS SANDOZ-DICLOFENAC SDZ TEVA-DICLOFENAC TEV 50mg Enteric Coated Tablet APO-DICLO APX DICLOFENAC EC SAN DICLOFENAC-50 PDL DOM-DICLOFENAC DPC PMS-DICLOFENAC PMS SANDOZ-DICLOFENAC SDZ TEVA-DICLOFENAC TEV VOLTAREN NVR 50mg Suppository PMS-DICLOFENAC PMS SANDOZ-DICLOFENAC SDZ VOLTAREN NVR 100mg Suppository PMS-DICLOFENAC PMS SANDOZ-DICLOFENAC SDZ VOLTAREN NVR 75mg Sustained Release Tablet DICLOFENAC SR SAN DICLOFENAC-SR PDL DOM-DICLOFENAC SR DPC PMS-DICLOFENAC SR PMS SANDOZ-DICLOFENAC SR SDZ TEVA-DICLOFENAC SR TEV VOLTAREN SR NVR 100mg Sustained Release Tablet APO-DICLO SR APX DICLOFENAC-SR PDL PMS-DICLOFENAC SR PMS SANDOZ-DICLOFENAC SR SDZ TEVA-DICLOFENAC SR TEV VOLTAREN SR NVR DICLOFENAC SODIUM (TOPICAL) For the treatment of osteoarthritis when: pain is inadequately controlled with acetaminophen AND a non-steroidal anti-inflammatory (NSAID); OR there is contraindication to acetaminophen and NSAID; OR there is intolerance to acetaminophen and NSAID 1.5% Topical Solution PMS-DICLOFENAC PMS TARO-DICLOFENAC TAR Page 57 of 151

74 28:08.04 NONEROIDAL ANTI- INFLAMMATORY AGENTS DICLOFENAC SODIUM, MISOPROOL 50mg & 200mcg Tablet ARTHROTEC PFI CO DICLO-MISO CBT SANDOZ DICLO/MISOPROS SDZ 75mg & 200mcg Tablet ARTHROTEC PFI CO DICLO-MISO CBT SANDOZ DICLO/MISOPROS SDZ DIFLUNISAL 250mg Tablet APO-DIFLUNISAL APX TEVA-DIFLUNISAL TEV 500mg Tablet APO-DIFLUNISAL APX FLURBIPROFEN 50mg Tablet APO-FLURBIPROFEN APX NOVO-FLURPROFEN TEV 100mg Tablet APO-FLURBIPROFEN APX NOVO-FLURPROFEN TEV IBUPROFEN 100mg Chewable Tablet ADVIL JUNIOR RENGTH WRI 40mg/mL Drop ADVIL PEDIATRIC WRI CHILDREN'S MOTRIN MCL 20mg/mL Oral Liquid CHILDREN'S ADVIL WRI CHILDREN'S MOTRIN JNO 100mg Tablet MOTRIN JUNIOR RENGTH MCL 200mg Tablet ADVIL WRI APO-IBUPROFEN APX IBUPROFEN PMT IBUPROFEN VTH IBUPROFEN PMS IBUPROFEN PMS MOTRIN MCL 300mg Tablet APO-IBUPROFEN APX 400mg Tablet APO-IBUPROFEN APX IBUPROFEN PDL IBUPROFEN PMS JAMP IBUPROFEN JMP JAMP-IBUPROFEN JAP PMS-IBUPROFEN PMS 28:08.04 NONEROIDAL ANTI- INFLAMMATORY AGENTS IBUPROFEN 600mg Tablet APO-IBUPROFEN APX NOVO-PROFEN TEV INDOMETHACIN 25mg Capsule APO-INDOMETHACIN APX NOVO-METHACIN TEV PRO-INDO PDL 50mg Capsule APO-INDOMETHACIN APX NOVO-METHACIN TEV PRO-INDO PDL 50mg Suppository SANDOZ INDOMETHACIN SDZ 100mg Suppository RATIO-INDOMETHACIN RPH SANDOZ INDOMETHACIN SDZ KETOPROFEN 50mg Capsule KETOPROFEN AAP PMS-KETOPROFEN PMS 50mg Enteric Coated Tablet KETOPROFEN-E AAP PMS-KETOPROFEN PMS 100mg Enteric Coated Tablet KETOPROFEN-E AAP PMS-KETOPROFEN PMS 100mg Suppository 0951 PMS-KETOPROFEN PMS 200mg Sustained Release Tablet KETOPROFEN SR AAP MEFENAMIC ACID 250mg Capsule DOM-MEFENAMIC ACID DPC MEFENAMIC AAP MELOXICAM 7.5mg Tablet APO-MELOXICAM APX AURO-MELOXICAM AUR CO MELOXICAM COB DOM-MELOXICAM DPC MELOXICAM PDL MELOXICAM SAN MOBICOX BOE MYLAN-MELOXICAM MYL NOVO-MELOXICAM TEV PHL-MELOXICAM PHH PMS-MELOXICAM PMS RATIO-MELOXICAM RPH Page 58 of 151

75 28:08.04 NONEROIDAL ANTI- INFLAMMATORY AGENTS MELOXICAM 15mg Tablet APO-MELOXICAM APX AURO-MELOXICAM AUR CO MELOXICAM COB DOM-MELOXICAM DPC MELOXICAM PDL MELOXICAM SAN MOBICOX BOE MYLAN-MELOXICAM MYL NOVO-MELOXICAM TEV PHL-MELOXICAM PHH PMS-MELOXICAM PMS RATIO-MELOXICAM RPH NAPROXEN 250mg Enteric Coated Tablet APO-NAPROXEN EC APX NAPROXEN EC SAN NOVO-NAPROX TEV 375mg Enteric Coated Tablet APO-NAPROXEN EC APX NAPROSYN E HLR NAPROXEN EC SAN NOVO-NAPROX TEV PMS-NAPROXEN EC PMS PRO-NAPROXEN EC PDL 500mg Enteric Coated Tablet APO-NAPROXEN EC APX MYLAN-NAPROXEN EC MYL NAPROSYN E HLR NAPROXEN EC SAN NOVO-NAPROX TEV PMS-NAPROXEN EC PMS PRO-NAPROXEN EC PDL 25mg/mL Suspension NAPROSYN HLR 750mg Sustained Release Tablet NAPROSYN SR HLR 550MG Tablet NAPROXEN SODIUM DS SAN 125mg Tablet APO-NAPROXEN APX 220mg Tablet NAPROXEN PMS 250mg Tablet APO-NAPROXEN APX NAPROXEN PDL NAPROXEN SAN NOVO-NAPROX TEV 28:08.04 NONEROIDAL ANTI- INFLAMMATORY AGENTS NAPROXEN 375mg Tablet APO-NAPROXEN APX MYLAN-NAPROXEN MYL NAPROXEN PDL NAPROXEN SAN NOVO-NAPROX TEV 500mg Tablet APO-NAPROXEN APX NAPROXEN PDL NAPROXEN SAN NOVO-NAPROX TEV NAPROXEN SODIUM 275mg Tablet ANAPROX HLR APO-NAPRO NA APX NAPROXEN NA PDL NAPROXEN SODIUM SAN NOVO-NAPROX SODIUM TEV 550mg Tablet ANAPROX DS HLR APO-NAPRO NA DS APX NAPROXEN-NA DF PDL NOVO-NAPROX SODIUM DS TEV PIROXICAM 10mg Capsule APO-PIROXICAM APX PMS-PIROXICAM PMS 20mg Capsule APO-PIROXICAM APX DOM-PIROXICAM DPC PMS-PIROXICAM PMS 10mg Suppository PMS-PIROXICAM PMS 10mg Tablet NOVO-PIROCAM TEV 20mg Tablet NOVO-PIROCAM TEV SULINDAC 150mg Tablet NOVO-SUNDAC TEV 200mg Tablet NOVO-SUNDAC TEV TIAPROFENIC ACID 200mg Tablet NOVO-TIAPROFENIC TEV PMS-TIAPROFENIC PMS 300mg Tablet DOM-TIAPROFENIC DPC NOVO-TIAPROFENIC TEV Page 59 of 151

76 28:08.08 OPIATE AGONIS ACETAMINOPHEN, CAFFEINE CITRATE, CODEINE PHOSPHATE Limited use benefit (prior approval is not required). For safety reasons NIHB has implemented a dose limit on acetaminophen. The limit accumulates against the amount of acetaminophen claimed to the program from plain acetaminophen and/or acetaminophen in combination with opioids such as codeine (i.e. Tylenol #3) or oxycodone (i.e. Percocet ). A total of 360 grams of acetaminophen is permitted in a 100-day period, for a total daily dose of 3600mg/day. 300mg & 15mg & 15mg Tablet RATIO-LENOLTEC NO.2 RPH TYLENOL WITH CODEINE NO.2 JNO 300mg & 15mg & 30mg Tablet RATIO-LENOLTEC NO.3 RPH TYLENOL WITH CODEINE NO.3 JNO 300mg & 30mg & 15mg Tablet EXDOL-15 PED 300mg & 30mg & 30mg Tablet EXDOL-30 PED 325mg & 30mg & 15mg Tablet ATASOL-15 HOR 325mg & 30mg & 30mg Tablet ATASOL-30 HOR ACETAMINOPHEN, CODEINE PHOSPHATE Limited use benefit (prior approval is not required). For safety reasons NIHB has implemented a dose limit on acetaminophen. The limit accumulates against the amount of acetaminophen claimed to the program from plain acetaminophen and/or acetaminophen in combination with opioids such as codeine (i.e. Tylenol #3) or oxycodone (i.e. Percocet ). A total of 360 grams of acetaminophen is permitted in a 100-day period, for a total daily dose of 3600mg/day. 32mg & 1.6mg/mL Elixir PMS-ACETAMINOPHEN WITH CODEINE 300mg & 30mg Tablet PMS ACET CODEINE 30 PMS PROCET-30 PDL RATIO-EMTEC-30 RPH TRIATEC-30 TRI ACETAMINOPHEN, OXYCODONE HCL Limited use benefit (prior approval is not required). For safety reasons NIHB has implemented a dose limit on acetaminophen. The limit accumulates against the amount of acetaminophen claimed to the program from plain acetaminophen and/or acetaminophen in combination with opioids such as codeine (i.e. Tylenol #3) or oxycodone (i.e. Percocet ). A total of 360 grams of acetaminophen is permitted in a 100-day period, for a total daily dose of 3600mg/day. 325mg & 2.5mg Tablet PERCOCET DEMI BMS 28:08.08 OPIATE AGONIS ACETAMINOPHEN, OXYCODONE HCL Limited use benefit (prior approval is not required). For safety reasons NIHB has implemented a dose limit on acetaminophen. The limit accumulates against the amount of acetaminophen claimed to the program from plain acetaminophen and/or acetaminophen in combination with opioids such as codeine (i.e. Tylenol #3) or oxycodone (i.e. Percocet ). A total of 360 grams of acetaminophen is permitted in a 100-day period, for a total daily dose of 3600mg/day. 325mg & 5mg Tablet APO-OXYCODONE/ACET APX ENDOCET EDM OXYCODONE/ACET SAN PERCOCET BMS PRO-OXYCOD ACET PDL RATIO-OXYCOCET RPH RIVACOCET RIV SANDOZ OXYCODONE ACET SDZ ACETYLSALICYLIC ACID, OXYCODONE HCL Limited use benefit (prior approval is not required). To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented an opioid dose limit of 450 mg morphine equivalents per day for non-cancer, nonpalliative pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 30- day period (i.e morphine equivalents over 30 days). 325mg & 5mg Tablet RATIO-OXYCODAN RPH CODEINE MONOHYDRATE, CODEINE SULFATE TRIHYDRATE For treatment of: a. - chronic pain and palliative care patients as an alternative to products containing codeine in combination with acetaminophen or ASA with or without caffeine, or b. - chronic pain and palliative care patients as an alternative to regular release codeine tablets when large doses are required. To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented an opioid dose limit of 450 mg morphine equivalents per day for non-cancer, nonpalliative pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 30- day period (i.e morphine equivalents over 30 days). 50mg Long Acting Tablet CODEINE CONTIN CR PFR 100mg Long Acting Tablet CODEINE CONTIN CR PFR 150mg Long Acting Tablet CODEINE CONTIN CR PFR 200mg Long Acting Tablet CODEINE CONTIN CR PFR Page 60 of 151

77 28:08.08 OPIATE AGONIS CODEINE PHOSPHATE Limited use benefit (prior approval is not required). To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented an opioid dose limit of 450 mg morphine equivalents per day for non-cancer, nonpalliative pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 30- day period (i.e morphine equivalents over 30 days). 2mg/mL Liquid LINCTUS CODEINE ATL 5mg/mL Syrup CODEINE PHOSPHATE ATL RATIO-CODEINE RPH 15mg Tablet CODEINE RPH CODEINE RIV RATIO-CODEINE RPH 30mg Tablet CODEINE RIV CODEINE PHOSPHATE RPH PMS-CODEINE PMS FENTANYL For the management of chronic pain in patients who are unresponsive or intolerant to at least one long-acting oral sustained released product, such as morphine, hydromorphone and oxycodone, despite appropriate dose titration and adjunctive therapy including laxatives and antiemetics. To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented an opioid dose limit of 450 mg morphine equivalents per day for non-cancer, nonpalliative pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 30- day period (i.e morphine equivalents over 30 days). 12mcg/HR Transdermal Patch CO FENTANYL CBT FENTANYL PDL MYLAN-FENTANYL MATRIX MYL PMS-FENTANYL MTX PMS RAN-FENTANYL MATRIX RBY SANDOZ FENTANYL SDZ TEVA-FENTANYL TEV 25mcg/HR Transdermal Patch APO-FENTANYL MATRIX APX CO FENTANYL CBT DURAGESIC MAT JNO FENTANYL PDL MYLAN-FENTANYL MATRIX MYL PMS-FENTANYL MTX PMS RAN-FENTANYL MATRIX RBY SANDOZ FENTANYL SDZ TEVA-FENTANYL TEV 28:08.08 OPIATE AGONIS FENTANYL For the management of chronic pain in patients who are unresponsive or intolerant to at least one long-acting oral sustained released product, such as morphine, hydromorphone and oxycodone, despite appropriate dose titration and adjunctive therapy including laxatives and antiemetics. To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented an opioid dose limit of 450 mg morphine equivalents per day for non-cancer, nonpalliative pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 30- day period (i.e morphine equivalents over 30 days). 50mcg/HR Transdermal Patch APO-FENTANYL MATRIX APX CO FENTANYL CBT DURAGESIC MAT JNO FENTANYL PDL MYLAN-FENTANYL MATRIX MYL PMS-FENTANYL MTX PMS RAN-FENTANYL MATRIX RBY SANDOZ FENTANYL SDZ TEVA-FENTANYL TEV 75mcg/HR Transdermal Patch APO-FENTANYL MATRIX APX CO FENTANYL CBT DURAGESIC MAT JNO FENTANYL PDL MYLAN-FENTANYL MATRIX MYL PMS-FENTANYL MTX PMS RAN-FENTANYL MATRIX RBY SANDOZ FENTANYL SDZ TEVA-FENTANYL TEV 100mcg/HR Transdermal Patch APO-FENTANYL MATRIX APX CO FENTANYL CBT DURAGESIC MAT JNO FENTANYL PDL MYLAN-FENTANYL MATRIX MYL PMS-FENTANYL MTX PMS RAN-FENTANYL MATRIX RBY SANDOZ FENTANYL SDZ TEVA-FENTANYL TEV Page 61 of 151

78 28:08.08 OPIATE AGONIS HYDROMORPHONE HCL Limited use benefit. Prior approval required for controlled release capsules only. Regular release dosage forms are full benefits and do not require prior approval. For treatment of moderate to severe chronic pain when other opioids such as morphine have been ineffective in controlling pain or in patients experiencing intolerable side effects. To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented an opioid dose limit of 450 mg morphine equivalents per day for non-cancer, nonpalliative pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 30- day period (i.e morphine equivalents over 30 days). 3mg Controlled Release Capsule HYDROMORPH CONTIN PFR 4.5mg Controlled Release Capsule HYDROMORPH CONTIN PFR 6mg Controlled Release Capsule HYDROMORPH CONTIN PFR 9mg Controlled Release Capsule HYDROMORPH CONTIN PFR 12mg Controlled Release Capsule HYDROMORPH CONTIN PFR 18mg Controlled Release Capsule HYDROMORPH CONTIN PFR 24mg Controlled Release Capsule HYDROMORPH CONTIN PFR 30mg Controlled Release Capsule HYDROMORPH CONTIN PFR 1mg/mL Oral Liquid DILAUDID PFR PMS-HYDROMORPHONE PMS 3mg Suppository PMS-HYDROMORPHONE PMS 1mg Tablet APO-HYDROMORPHONE APX DILAUDID PFR HYDROMORPHONE SOR PMS-HYDROMORPHONE PMS TEVA-HYDROMORPHONE TEP 2mg Tablet APO-HYDROMORPHONE APX DILAUDID PFR HYDROMORPHONE SOR PMS-HYDROMORPHONE PMS TEVA-HYDROMORPHONE TEP 4mg Tablet APO-HYDROMORPHONE APX DILAUDID PFR HYDROMORPHONE SOR PMS-HYDROMORPHONE PMS TEVA-HYDROMORPHONE TEP 28:08.08 OPIATE AGONIS HYDROMORPHONE HCL Limited use benefit. Prior approval required for controlled release capsules only. Regular release dosage forms are full benefits and do not require prior approval. For treatment of moderate to severe chronic pain when other opioids such as morphine have been ineffective in controlling pain or in patients experiencing intolerable side effects. To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented an opioid dose limit of 450 mg morphine equivalents per day for non-cancer, nonpalliative pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 30- day period (i.e morphine equivalents over 30 days). 8mg Tablet APO-HYDROMORPHONE APX DILAUDID PFR HYDROMORPHONE SOR PMS-HYDROMORPHONE PMS TEVA-HYDROMORPHONE TEP METHADONE HCL 10mg/mL Oral Liquid METHADOSE MAT METHADOSE SUGARFREE MAT METHADONE HCL (BC ONLY) 10mg/mL Oral Liquid METHADOSE DELIV. W DIRECT INT METHADOSE DELIV. W/OUT DIRECT METHADOSE W/OUT DIRECT INTERA METHADOSE DIRECT INTERACTION METHADONE HCL (PA) UNK UNK UNK UNK limited use benefit (prior approval required) with the following criteria: Prescriber is registered with Health Canada and is eligible to prescribe methadone for the management of pain. AND For the management of moderate to severe cancer pain or chronic non-cancer pain, as an alternative to other opioids. OR, For the management of pain for palliative care patients. Pharmacists may only dispense a maximum supply of 30 days at one time. 1mg/mL Oral Liquid METADOL PAL 10mg/mL Oral Liquid METADOL PAL 1mg Tablet METADOL PAL 5mg Tablet METADOL PAL 10mg Tablet METADOL PAL Page 62 of 151

79 28:08.08 OPIATE AGONIS METHADONE HCL (PA) limited use benefit (prior approval required) with the following criteria: Prescriber is registered with Health Canada and is eligible to prescribe methadone for the management of pain. AND For the management of moderate to severe cancer pain or chronic non-cancer pain, as an alternative to other opioids. OR, For the management of pain for palliative care patients. Pharmacists may only dispense a maximum supply of 30 days at one time. 25mg Tablet METADOL PAL MORPHINE HCL Limited use benefit (prior approval is not required). To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented an opioid dose limit of 450 mg morphine equivalents per day for non-cancer, nonpalliative pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 30- day period (i.e morphine equivalents over 30 days). 5mg/mL Oral liquid M.O.S. ICN 30mg Sustained Release Tablet M.O.S. SR VAE 60mg Sustained Release Tablet M.O.S. SR VAE 1mg/mL Syrup DOLORAL 1 ATL RATIO-MORPHINE RPH 5mg/mL Syrup DOLORAL 5 ATL RATIO-MORPHINE RPH 10mg/mL Syrup M.O.S. 10 VAE RATIO-MORPHINE RPH 20mg/mL Syrup RATIO-MORPHINE RPH 50mg/mL Syrup M.O.S. 50 VAE 10mg Tablet M.O.S. 10 VAE 20mg Tablet M.O.S. 20 VAE 40mg Tablet M.O.S. 40 VAE 60mg Tablet M.O.S. 60 VAE 28:08.08 OPIATE AGONIS MORPHINE SULFATE Limited use benefit (prior approval is not required). To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented an opioid dose limit of 450 mg morphine equivalents per day for non-cancer, nonpalliative pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 30- day period (i.e morphine equivalents over 30 days). 50mg/mL Drop ATEX PMS 5mg Suppository ATEX PMS 10mg Suppository ATEX PMS 20mg Suppository ATEX PMS 10mg Sustained Release Capsule M-ESLON SAC 15mg Sustained Release Capsule M-ESLON SAC 30mg Sustained Release Capsule M-ESLON SAC 60mg Sustained Release Capsule M-ESLON SAC 100mg Sustained Release Capsule M-ESLON SAC 200mg Sustained Release Capsule M-ESLON SAC 15mg Sustained Release Tablet MORPHINE SR SAN 0439 MS CONTIN SR PFR NOVO-MORPHINE SR TEV SANDOZ MORPHINE SR SDZ 30mg Sustained Release Tablet MORPHINE SR SAN MS CONTIN SR PFR NOVO-MORPHINE SR TEV SANDOZ MORPHINE SR SDZ 60mg Sustained Release Tablet MORPHINE SR SAN MS CONTIN SR PFR NOVO-MORPHINE SR TEV SANDOZ MORPHINE SR SDZ 100mg Sustained Release Tablet MORPHINE SR SAN MS CONTIN SR PFR NOVO-MORPHINE SR TEV 200mg Sustained Release Tablet MORPHINE SR SAN MS CONTIN SR PFR NOVO-MORPHINE SR TEV 1mg/mL Syrup ATEX PMS Page 63 of 151

80 28:08.08 OPIATE AGONIS MORPHINE SULFATE Limited use benefit (prior approval is not required). To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented an opioid dose limit of 450 mg morphine equivalents per day for non-cancer, nonpalliative pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 30- day period (i.e morphine equivalents over 30 days). 5mg/mL Syrup ATEX PMS 10mg/mL Syrup ATEX PMS 5mg Tablet M.O.S. SULFATE VAE MS IR PFR ATEX PMS 10mg Tablet M.O.S. SULFATE VAE MS IR PFR ATEX PMS 20mg Tablet MS IR PFR 25mg Tablet M.O.S. SULFATE VAE ATEX PMS 30mg Tablet MS IR PFR 50mg Tablet M.O.S. SULFATE VAE ATEX PMS MORPHINE SULFATE (K) For the treatment of opioid dependence where methadone and Suboxone are not available or not appropriate OR For the treatment of chronic pain. To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented an opioid dose limit of 450 mg morphine equivalents per day for non-cancer, nonpalliative pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 30- day period (i.e morphine equivalents over 30 days). 10mg Sustained Release Capsule KADIAN MAY 20mg Sustained Release Capsule KADIAN MAY 50mg Sustained Release Capsule KADIAN MAY 100mg Sustained Release Capsule KADIAN MAY 28:08.08 OPIATE AGONIS OXYCODONE HCL Limited use benefit (prior approval is not required). To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented an opioid dose limit of 450 mg morphine equivalents per day for non-cancer, nonpalliative pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 30- day period (i.e morphine equivalents over 30 days). 10mg Suppository SUPEUDOL SDZ 20mg Suppository SUPEUDOL SDZ 5mg Tablet OXYCODONE PDL OXY-IR PFR PMS-OXYCODONE PMS SUPEUDOL SDZ 10mg Tablet OXYCODONE PDL OXY-IR PFR PMS-OXYCODONE PMS SUPEUDOL SDZ 20mg Tablet OXYCODONE PDL OXY-IR PFR PMS-OXYCODONE PMS SUPEUDOL SDZ 28:08.12 OPIATE PARTIAL AGONIS BUPRENORPHINE, NALOXONE For the treatment of opioid dependence when: A rationale for using Suboxone instead of the alternative (i.e. methadone); and In cases where the client lives in a remote or isolated location, confirmation is required that the cmmunity has the ability to support Suboxone administration. These supports include the safe daily witnessing, storage and handling of the Suboxone doses. After this confirmation, NIHB will approve the Suboxone for the client. The client must be 16 years or older. 2mg & 0.5mg Sublingual Tablet SUBOXONE RBP 8mg & 2mg Sublingual Tablet SUBOXONE RBP Page 64 of 151

81 28:08.92 MISCELLANEOUS ANALGESICS AND ANTIPYRETICS ACETAMINOPHEN Limited use benefit (prior approval is not required). For safety reasons NIHB has implemented a dose limit on acetaminophen. The limit accumulates against the amount of acetaminophen claimed to the program from plain acetaminophen and/or acetaminophen in combination with opioids such as codeine (i.e. Tylenol #3) or oxycodone (i.e. Percocet ). A total of 360 grams of acetaminophen is permitted in a 100-day period, for a total daily dose of 3600mg/day. 80mg Chewable Tablet ACETAMINOPHEN TRI 0676 ACETAMINOPHEN TAN ACETAMINOPHEN RIV ACETAMINOPHEN VTH PEDIAPHEN CHEWABLE EUR 160mg Chewable Tablet ACETAMINOPHEN RIV ACETAMINOPHEN TAN FEVERHALT PED PEDIAPHEN CHEWABLE EUR 80mg/mL Drop ACETAMINOPHEN TAN ACETAMINOPHEN TRI ATASOL HOR FEVERHALT PED PEDIAPHEN EUR PEDIATRIX RPH PMS-ACETAMINOPHEN PMS TEMPRA MJO TYLENOL MCL 16mg/mL Liquid ACETAMINOPHEN TRI PEDIAPHEN EUR PMS-ACETAMINOPHEN PMS TEMPRA MJO 32mg/mL Liquid ACETAMINOPHEN JMP ACETAMINOPHEN TRI PEDIAPHEN EUR PEDIATRIX RPH PMS-ACETAMINOPHEN PMS TEMPRA DOUBLE RENGTH MJO TYLENOL MCL 80mg/mL Oral Liquid ACETAMINOPHEN PER 120mg Suppository ABENOL PED ACET 120 PMS PMS-ACETAMINOPHEN PMS 160mg Suppository ACET PMS 28:08.92 MISCELLANEOUS ANALGESICS AND ANTIPYRETICS ACETAMINOPHEN Limited use benefit (prior approval is not required). For safety reasons NIHB has implemented a dose limit on acetaminophen. The limit accumulates against the amount of acetaminophen claimed to the program from plain acetaminophen and/or acetaminophen in combination with opioids such as codeine (i.e. Tylenol #3) or oxycodone (i.e. Percocet ). A total of 360 grams of acetaminophen is permitted in a 100-day period, for a total daily dose of 3600mg/day. 325mg Suppository ABENOL PED ACET 325 PMS PMS-ACETAMINOPHEN PMS 650mg Suppository ABENOL PED ACET 650 PMS PMS-ACETAMINOPHEN PMS 80mg Tablet TYLENOL JR RENGTH FAMELTS 160mg Tablet JNO ACETAMINOPHEN WTR TYLENOL JR RENGTH JNO FAMELTS TYLENOL JUNIOR RENGTH JNO 325mg Tablet ACETAMINOPHEN WAM ACETAMINOPHEN PRO ACETAMINOPHEN PMS ACETAMINOPHEN VTH ACETAMINOPHEN PMT ACETAMINOPHEN TRI ACETAMINOPHEN JMP ACETAMINOPHEN RIV APO-ACETAMINOPHEN APX APO-ACETAMINOPHEN APX ATASOL HOR NOVO-GESIC TEV TYLENOL MCL TYLENOL MCL Page 65 of 151

82 28:08.92 MISCELLANEOUS ANALGESICS AND ANTIPYRETICS ACETAMINOPHEN Limited use benefit (prior approval is not required). For safety reasons NIHB has implemented a dose limit on acetaminophen. The limit accumulates against the amount of acetaminophen claimed to the program from plain acetaminophen and/or acetaminophen in combination with opioids such as codeine (i.e. Tylenol #3) or oxycodone (i.e. Percocet ). A total of 360 grams of acetaminophen is permitted in a 100-day period, for a total daily dose of 3600mg/day. 500mg Tablet ACETAMINOPHEN PDL ACETAMINOPHEN PMT ACETAMINOPHEN PED ACETAMINOPHEN PMS ACETAMINOPHEN VTH ACETAMINOPHEN TRI ACETAMINOPHEN JMP ACETAMINOPHEN RIV ACETAMINOPHEN PMT ACETAMINOPHEN PMT APO-ACETAMINOPHEN APX APO-ACETAMINOPHEN APX ATASOL FORTE HOR JAMP-ACETAMINOPHEN JAP NOVO-GESIC TEV PMS-ACETAMINOPHEN PMS TANTAPHEN TAN TYLENOL EXTRA RENGTH MCL TYLENOL EXTRA RENGTH MCL FLOCTAFENINE 200mg Tablet FLOCTAFENINE AAP 400mg Tablet FLOCTAFENINE AAP 28:12.04 ANTICONVULSANTS - BARBITURATES PHENOBARBITAL 5mg/mL Liquid PHENOBARB PMS 15mg Tablet PHENOBARB PMS 30mg Tablet PHENOBARB PMS 60mg Tablet PHENOBARB PMS 100mg Tablet PHENOBARB PMS PRIMIDONE 125mg Tablet PRIMIDONE AAP 28:12.04 ANTICONVULSANTS - BARBITURATES PRIMIDONE 250mg Tablet PRIMIDONE AAP 28:12.08 ANTICONVULSANTS - BENZODIAZEPINES CLONAZEPAM Limited use benefit (prior approval is not required). To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 40 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e diazepam equivalents over 100 days). According to the product monograph for diazepam, the recommended usual adult dosage is up to 40 mg per day. 0.25mg Tablet PMS-CLONAZEPAM PMS 0.5mg Tablet APO-CLONAZEPAM APX CLONAPAM VAE CO CLONAZEPAM COB DOM-CLONAZEPAM DPC DOM-CLONAZEPAM-R DPC MYLAN-CLONAZEPAM MYL PHL-CLONAZEPAM PHH PHL-CLONAZEPAM-R 0.5MG PMI PMS-CLONAZEPAM PMS PMS-CLONAZEPAM R PMS PRO-CLONAZEPAM PDL RIVA-CLONAZEPAM RIV RIVOTRIL HLR SANDOZ-CLONAZEPAM SDZ TEVA-CLONAZEPAM TEV ZYM-CLONAZEPAM ZYM 1mg Tablet CLONAPAM VAE CO CLONAZEPAM COB PHL-CLONAZEPAM PHH PMS-CLONAZEPAM PMS PRO-CLONAZEPAM PDL SANDOZ-CLONAZEPAM SDZ ZYM-CLONAZEPAM ZYM Page 66 of 151

83 28:12.08 ANTICONVULSANTS - BENZODIAZEPINES CLONAZEPAM Limited use benefit (prior approval is not required). To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 40 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e diazepam equivalents over 100 days). According to the product monograph for diazepam, the recommended usual adult dosage is up to 40 mg per day. 2mg Tablet APO-CLONAZEPAM APX CLONAPAM VAE CO CLONAZEPAM COB DOM-CLONAZEPAM DPC GEN-CLONAZEPAM MYL PHL-CLONAZEPAM PHH PMS-CLONAZEPAM PMS PRO-CLONAZEPAM PDL RIVA-CLONAZEPAM RIV RIVOTRIL HLR SANDOZ-CLONAZEPAM SDZ TEVA-CLONAZEPAM TEV ZYM-CLONAZEPAM ZYM 28:12.12 ANTICONVULSANTS - HYDANTOINS PHENYTOIN 30mg Capsule DILANTIN PFI 100mg Capsule DILANTIN PFI 50mg Chewable Tablet DILANTIN INFATABS PFI 6mg/mL Suspension DILANTIN 30 PFI 25mg/mL Suspension DILANTIN 125 PFI TARO-PHENYTOIN TAR 28:12.20 ANTICONVULSANTS- SUCCINIMIDES ETHOSUXIMIDE 250mg Capsule ZARONTIN ERF 50mg/mL Syrup ZARONTIN ERF METHSUXIMIDE 300mg Capsule CELONTIN ERF 28:12.92 MISCELLANEOUS ANTICONVULSANTS CARBAMAZEPINE 100mg Chewable Tablet PMS-CARBAMAZEPINE PMS SANDOZ-CARBAMAZEPINE SDZ TARO-CARBAMAZEPINE TAR TEGRETOL NVR 200mg Chewable Tablet PMS-CARBAMAZEPINE PMS SANDOZ-CARBAMAZEPINE SDZ TARO-CARBAMAZEPINE TAR TEGRETOL NVR 200mg Extended Release Tablet SANDOZ-CARBAMAZEPINE SDZ 400mg Extended Release Tablet SANDOZ-CARBAMAZEPINE SDZ 20mg/mL Suspension TARO-CARBAMAZEPINE TAR TEGRETOL NVR 200mg Sustained Release Tablet CARBAMAZEPINE CR PDL DOM-CARBAMAZEPINE CR DPC MYLAN-CARBAMAZEPINE CR MYL PMS-CARBAMAZEPINE CR PMS TARO-CARBAMAZEPINE CR TAR TEGRETOL CR NVR 400mg Sustained Release Tablet CARBAMAZEPINE CR PDL DOM-CARBAMAZEPINE CR DPC PMS-CARBAMAZEPINE CR PMS TARO-CARBAMAZEPINE CR TAR TEGRETOL CR NVR 200mg Tablet APO-CARBAMAZEPINE APX TARO-CARBAMAZEPINE TAR TEGRETOL NVR TEVA-CARBAMAZ TEV DIVALPROEX SODIUM 125mg Enteric Coated Tablet APO-DIVALPROEX APX DIVALPROEX PDL DIVALPROEX SAN EPIVAL ABB PMS-DIVALPROEX PMS TEVA-DIVALPROEX TEV 250mg Enteric Coated Tablet APO-DIVALPROEX APX DIVALPROEX PDL DIVALPROEX SAN EPIVAL ABB PMS-DIVALPROEX PMS TEVA-DIVALPROEX TEV Page 67 of 151

84 28:12.92 MISCELLANEOUS ANTICONVULSANTS DIVALPROEX SODIUM 500mg Enteric Coated Tablet APO-DIVALPROEX APX DIVALPROEX PDL DIVALPROEX SAN EPIVAL ABB PMS-DIVALPROEX PMS TEVA-DIVALPROEX TEV GABAPENTIN Limited use benefit (prior approval is not required). For safety reasons NIHB has implemented a dose limit on gabapentin. The limit accumulates against the amount of gabapentin claimed to the program. A total of 400 grams of gabapentin is permitted in a 100-day period, for a total daily dose of 4000mg/day. 100mg Capsule APO-GABAPENTIN APX AURO-GABAPENTIN AUR CO GABAPENTIN COB DOM-GABAPENTIN DPC GABAPENTIN MEL GABAPENTIN SOR GABAPENTIN SAN GABAPENTIN ACC GD-GABAPENTIN PFI JAMP-GABAPENTIN JAP MAR-GABAPENTIN MAR MYLAN-GABAPENTIN MYL NEURONTIN PFI NOVO-GABAPENTIN TEV PMS-GABAPENTIN PMS PRO-GABAPENTIN PDL RAN-GABAPENTIN RBY RIVA-GABAPENTIN RIV 300mg Capsule APO-GABAPENTIN APX AURO-GABAPENTIN AUR CO GABAPENTIN COB DOM-GABAPENTIN DPC GABAPENTIN MEL GABAPENTIN SOR GABAPENTIN SAN GABAPENTIN ACC GD-GABAPENTIN PFI JAMP-GABAPENTIN JAP MAR-GABAPENTIN MAR MYLAN-GABAPENTIN MYL NEURONTIN PFI NOVO-GABAPENTIN TEV PMS-GABAPENTIN PMS PRO-GABAPENTIN PDL RAN-GABAPENTIN RBY RIVA-GABAPENTIN RIV 28:12.92 MISCELLANEOUS ANTICONVULSANTS GABAPENTIN Limited use benefit (prior approval is not required). For safety reasons NIHB has implemented a dose limit on gabapentin. The limit accumulates against the amount of gabapentin claimed to the program. A total of 400 grams of gabapentin is permitted in a 100-day period, for a total daily dose of 4000mg/day. 400mg Capsule APO-GABAPENTIN APX AURO-GABAPENTIN AUR CO GABAPENTIN COB DOM-GABAPENTIN DPC GABAPENTIN MEL GABAPENTIN SOR GABAPENTIN SAN GABAPENTIN ACC GD-GABAPENTIN PFI JAMP-GABAPENTIN JAP MAR-GABAPENTIN MAR MYLAN-GABAPENTIN MYL NEURONTIN PFI NOVO-GABAPENTIN TEV PMS-GABAPENTIN PMS PRO-GABAPENTIN PDL RAN-GABAPENTIN RBY RATIO-GABAPENTIN RPH RIVA-GABAPENTIN RIV 600mg Tablet APO-GABAPENTIN APX GABAPENTIN SIV GABAPENTIN ACC GD-GABAPENTIN PFI JAMP-GABAPENTIN JAP MYLAN-GABAPENTIN MYL NEURONTIN PFI NOVO-GABAPENTIN TEV PMS-GABAPENTIN PMS PRO-GABAPENTIN PDL RATIO-GABAPENTIN RPH RIVA-GABAPENTIN RIV 800mg Tablet APO-GABAPENTIN APX GABAPENTIN SIV GABAPENTIN ACC GD-GABAPENTIN PFI JAMP-GABAPENTIN JAP MYLAN-GABAPENTIN MYL NEURONTIN PFI NOVO-GABAPENTIN TEV PMS-GABAPENTIN PMS PRO-GABAPENTIN PDL RATIO-GABAPENTIN RPH RIVA-GABAPENTIN RIV Page 68 of 151

85 28:12.92 MISCELLANEOUS ANTICONVULSANTS LACOSAMIDE For adjunctive therapy in patients with refractory partial-onset seizures who meet all of the following criteria: a- Are under the care of a physician experienced in the treatment of epilepsy, AND b- Are currently receiving two or more antiepileptic medications, AND c- Have failed or demonstrated intolerance to at least two other antiepileptic medications. 50mg Tablet VIMPAT UCB 100mg Tablet VIMPAT UCB 150mg Tablet VIMPAT UCB 200mg Tablet VIMPAT UCB LAMOTRIGINE 2mg Chewable Tablet LAMICTAL GSK 5mg Chewable Tablet LAMICTAL GSK 25mg Tablet APO-LAMOTRIGINE APX AURO-LAMOTRIGINE AUR LAMICTAL GSK LAMOTRIGINE PDL LAMOTRIGINE SAN LAMOTRIGINE SIV MYLAN-LAMOTRIGINE MYL NOVO-LAMOTRIGINE TEV PMS-LAMOTRIGINE PMS 100mg Tablet APO-LAMOTRIGINE APX AURO-LAMOTRIGINE AUR LAMICTAL GSK LAMOTRIGINE PDL LAMOTRIGINE SAN LAMOTRIGINE SIV MYLAN-LAMOTRIGINE MYL NOVO-LAMOTRIGINE TEV PMS-LAMOTRIGINE PMS 150mg Tablet APO-LAMOTRIGINE APX AURO-LAMOTRIGINE AUR LAMICTAL GSK LAMOTRIGINE PDL LAMOTRIGINE SAN LAMOTRIGINE SIV MYLAN-LAMOTRIGINE MYL NOVO-LAMOTRIGINE TEV PMS-LAMOTRIGINE PMS 28:12.92 MISCELLANEOUS ANTICONVULSANTS LEVETIRACETAM For the use in combination with other anti-epileptic medication(s) in the treatment of partial seizures in patients who are refractory to adequate trials of two anti-epileptic medications used either as monotherapy or in combination. 250mg Tablet ABBOTT-LEVETIRACETAM ABB APO-LEVETIRACETAM APX AURO-LEVETIRACETAM AUR CO LEVETIRACETAM COB JAMP-LEVETIRACETAM JAP KEPPRA UCB LEVETIRACETAM SAN LEVETIRACETAM ACC PMS-LEVETIRACETAM PMS RAN-LEVETIRACETAM RBY 500mg Tablet ABBOTT-LEVETIRACETAM ABB APO-LEVETIRACETAM APX AURO-LEVETIRACETAM AUR CO LEVETIRACETAM COB DOM-LEVETIRACETAM DOM JAMP-LEVETIRACETAM JAP KEPPRA UCB LEVETIRACETAM SAN LEVETIRACETAM ACC PMS-LEVETIRACETAM PMS PRO-LEVETIRACETAM PDL RAN-LEVETIRACETAM RBY 750mg Tablet ABBOTT-LEVETIRACETAM ABB APO-LEVETIRACETAM APX AURO-LEVETIRACETAM AUR CO LEVETIRACETAM COB JAMP-LEVETIRACETAM JAP KEPPRA UCB LEVETIRACETAM SAN LEVETIRACETAM ACC PMS-LEVETIRACETAM PMS PRO-LEVETIRACETAM PDL RAN-LEVETIRACETAM RBY Page 69 of 151

86 28:12.92 MISCELLANEOUS ANTICONVULSANTS PREGABALIN For the treatment of neuropathic pain in patients who have failed to effectively treat their pain with a tricyclic antidepressant (TCA) OR For the treatment of neuropathic pain in patients who have a contraindication or intolerance with a TCA. The dose of pregabalin is limited to a maximum of 600 mg per day 25mg Capsule ACT-PREGABALIN ATP APO-PREGABALIN APX DOM-PREGABALIN DOM GD-PREGABALIN PFI LYRICA PFI MAR-PREGABALIN MAR MINT-PREGABALIN MIN MYL-PREGABALIN MYL PMS-PREGABALIN PMS PREGABALIN PDL PREGABALIN SIV PREGABALIN SAN PREGABALIN-25 SIV RAN-PREGABALIN RBY RIVA-PREGABALIN RIV SANDOZ PREGABALIN SDZ TEVA-PREGABALIN TEP 50mg Capsule ACT-PREGABALIN ATP APO-PREGABALIN APX DOM-PREGABALIN DOM GD-PREGABALIN PFI LYRICA PFI MAR-PREGABALIN MAR MINT-PREGABALIN MIN MYL-PREGABALIN MYL PMS-PREGABALIN PMS PREGABALIN PDL PREGABALIN SIV PREGABALIN SAN PREGABALIN-50 SIV RAN-PREGABALIN RBY RIVA-PREGABALIN RIV SANDOZ PREGABALIN SDZ TEVA-PREGABALIN TEP 28:12.92 MISCELLANEOUS ANTICONVULSANTS PREGABALIN For the treatment of neuropathic pain in patients who have failed to effectively treat their pain with a tricyclic antidepressant (TCA) OR For the treatment of neuropathic pain in patients who have a contraindication or intolerance with a TCA. The dose of pregabalin is limited to a maximum of 600 mg per day 75mg Capsule ACT-PREGABALIN ATP APO-PREGABALIN APX DOM-PREGABALIN DOM GD-PREGABALIN PFI LYRICA PFI MAR-PREGABALIN MAR MINT-PREGABALIN MIN MYL-PREGABALIN MYL PMS-PREGABALIN PMS PREGABALIN PDL PREGABALIN SIV PREGABALIN SAN PREGABALIN-75 SIV RAN-PREGABALIN RBY RIVA-PREGABALIN RIV SANDOZ PREGABALIN SDZ TEVA-PREGABALIN TEP 150mg Capsule ACT-PREGABALIN ATP APO-PREGABALIN APX DOM-PREGABALIN DOM GD-PREGABALIN PFI LYRICA PFI MAR-PREGABALIN MAR MINT-PREGABALIN MIN MYL-PREGABALIN MYL PMS-PREGABALIN PMS PREGABALIN PDL PREGABALIN SIV PREGABALIN SAN PREGABALIN-150 SIV RAN-PREGABALIN RBY RIVA-PREGABALIN RIV SANDOZ PREGABALIN SDZ TEVA-PREGABALIN TEP Page 70 of 151

87 28:12.92 MISCELLANEOUS ANTICONVULSANTS PREGABALIN For the treatment of neuropathic pain in patients who have failed to effectively treat their pain with a tricyclic antidepressant (TCA) OR For the treatment of neuropathic pain in patients who have a contraindication or intolerance with a TCA. The dose of pregabalin is limited to a maximum of 600 mg per day 300mg Capsule ACT-PREGABALIN ATP APO-PREGABALIN APX GD-PREGABALIN PFI LYRICA PFI MYL-PREGABALIN MYL PMS-PREGABALIN PMS PREGABALIN PDL PREGABALIN SIV PREGABALIN SAN RAN-PREGABALIN RBY RIVA-PREGABALIN RIV SANDOZ PREGABALIN SDZ TEVA-PREGABALIN TEP RUFINAMIDE -For the adjunctive treatment of seizures associated with Lennox-Gastaux syndrome in adults and children 4 years and older when prescribed by a neurologist or experienced specialist -Patient has failed or is intolerant to or has contraindications to at least two adjunctive antiepileptic drugs 100mg Tablet BANZEL EIS 200mg Tablet BANZEL EIS 400mg Tablet BANZEL EIS TOPIRAMATE 15mg Sprinkle Capsule TOPAMAX SPRINKLE JNO 25mg Sprinkle Capsule TOPAMAX SPRINKLE JNO 28:12.92 MISCELLANEOUS ANTICONVULSANTS TOPIRAMATE 25mg Tablet ABBOTT-TOPIRAMATE BGP ACCEL-TOPIRAMATE ACP APO-TOPIRAMATE APX AURO-TOPIRAMATE APL CO TOPIRAMATE COB DOM-TOPIRAMATE DPC MINT-TOPIRAMATE MIN MYLAN-TOPIRAMATE MYL NOVO-TOPIRAMATE TEV PHL-TOPIRAMATE PMI PMS-TOPIRAMATE PMS PRO-TOPIRAMATE PDL RAN-TOPIRAMATE RBY SANDOZ-TOPIRAMATE SDZ TOPAMAX JNO TOPIRAMATE SAN TOPIRAMATE SIV ZYM-TOPIRAMATE ZYM 50mg Tablet PMS-TOPIRAMATE PMS 100mg Tablet ABBOTT-TOPIRAMATE BGP ACCEL-TOPIRAMATE ACP APO-TOPIRAMATE APX AURO-TOPIRAMATE APL CO TOPIRAMATE COB DOM-TOPIRAMATE DPC MINT-TOPIRAMATE MIN MYLAN-TOPIRAMATE MYL NOVO-TOPIRAMATE TEV PHL-TOPIRAMATE PMI PMS-TOPIRAMATE PMS PRO-TOPIRAMATE PDL RAN-TOPIRAMATE RBY SANDOZ-TOPIRAMATE SDZ TOPAMAX JNO TOPIRAMATE SAN TOPIRAMATE SIV ZYM-TOPIRAMATE ZYM Page 71 of 151

88 28:12.92 MISCELLANEOUS ANTICONVULSANTS TOPIRAMATE 200mg Tablet ABBOTT-TOPIRAMATE BGP ACCEL-TOPIRAMATE ACP APO-TOPIRAMATE APX AURO-TOPIRAMATE APL CO TOPIRAMATE COB DOM-TOPIRAMATE DPC MINT-TOPIRAMATE MIN MYLAN-TOPIRAMATE MYL NOVO-TOPIRAMATE TEV PHL-TOPIRAMATE PMI PMS-TOPIRAMATE PMS PRO-TOPIRAMATE PDL RAN-TOPIRAMATE RBY SANDOZ-TOPIRAMATE SDZ TOPAMAX JNO TOPIRAMATE SAN ZYM-TOPIRAMATE ZYM VALPROATE, SODIUM 50mg/mL Syrup APO-VALPROIC APX DEPAKENE ABB DOM-VALPROIC ACID DPC PMS-VALPROIC ACID PMS VALPROIC ACID 250mg Capsule APO-VALPROIC APX DEPAKENE ABB DOM-VALPROIC ACID DPC MYLAN-VALPROIC MYL NOVO-VALPROIC TEV PMS-VALPROIC ACID PMS SANDOZ-VALPROIC SDZ 500mg Enteric Coated Capsule DOM-VALPROIC ACID DPC NOVO-VALPROIC TEV PHL-VALPROIC ACID PHH PMS-VALPROIC ACID PMS VIGABATRIN 500mg Powder SABRIL OVA 500mg Tablet SABRIL OVA 28:16.04 ANTIDEPRESSANTS AMITRIPTYLINE HCL 10mg Tablet AMITRIPTYLINE PRO APO-AMITRIPTYLINE APX ELAVIL AAP MAR-AMITRIPTYLINE MAR PMS-AMITRIPTYLINE PMS TEVA-AMITRIPTYLINE TEP 25mg Tablet AMITRIPTYLINE PRO APO-AMITRIPTYLINE APX ELAVIL AAP MAR-AMITRIPTYLINE MAR PMS-AMITRIPTYLINE PMS TEVA-AMITRIPTYLINE TEP 50mg Tablet AMITRIPTYLINE PDL APO-AMITRIPTYLINE APX ELAVIL AAP LEVATE VAE MAR-AMITRIPTYLINE MAR TEVA-AMITRIPTYLINE TEP 75mg Tablet APO-AMITRIPTYLINE APX ELAVIL AAP LEVATE VAE MAR-AMITRIPTYLINE MAR BUPROPION HCL (WELLBUTRIN) Limited use benefit with quantity and frequency limits (prior approval is not required). Coverage of Wellbutrin XL and Bupropion SR is limited to 300 mg per day. (Note: this product will not be approved for coverage for smoking cessation). 150mg Extended Release Tablet MYLAN-BUPROPION XL MYL WELLBUTRIN XL VAE 300mg Extended Release Tablet MYLAN-BUPROPION XL MYL WELLBUTRIN XL VAE 100mg Sustained Release Tablet BUPROPION SR PDL BUPROPION SR SAN PMS-BUPROPION SR PMS RATIO-BUPROPION RPH SANDOZ-BUPROPION SR SDZ 150mg Sustained Release Tablet BUPROPION SR PDL BUPROPION SR SAN PMS-BUPROPION SR PMS RATIO-BUPROPION RPH SANDOZ-BUPROPION SR SDZ WELLBUTRIN SR VAE Page 72 of 151

89 28:16.04 ANTIDEPRESSANTS BUPROPION HCL (ZYBAN) Limited use benefit with quantity and frequency limits (prior approval is not required). For smoking cessation: Coverage is limited to 180 tablets during a one-year period. The year starts on the date the first prescription is filled. Once this quantity has been reached the client is eligible again for coverage for bupropion HCl when one year has elapsed from the day the initial prescription was filled. 150mg Sustained Release Tablet ZYBAN VAE CITALOPRAM 10mg Tablet ABBOTT-CITALOPRAM ABB ACCEL-CITALOPRAM ACP CITALOPRAM MEL CITALOPRAM PDL CITALOPRAM SIV CITALOPRAM JAP DOM-CITALOPRAM PMS ECL-CITALOPRAM ECL JAMP-CITALOPRAM JAP MAR-CITALOPRAM MAR MINT-CITALOPRAM MIN NAT-CITALOPRAM NPH PHL-CITALOPRAM PHH PMS-CITALOPRAM PMS RIVA-CITALOPRAM RIV TEVA-CITALOPRAM TEV 20mg Tablet ABBOTT-CITALOPRAM ABB ACCEL-CITALOPRAM ACP APO-CITALOPRAM APX AURO-CITALOPRAM AUR CELEXA LUD CITALOPRAM PDL CITALOPRAM MEL CITALOPRAM ODN CITALOPRAM SAN CITALOPRAM SIV CITALOPRAM JAP CO CITALOPRAM COB DOM-CITALOPRAM DPC JAMP-CITALOPRAM JMP MAR-CITALOPRAM MAR MINT-CITALOPRAM MIN MYLAN-CITALOPRAM MYL NAT-CITALOPRAM NPH PHL-CITALOPRAM PHH PMS-CITALOPRAM PMS RAN-CITALO RBY RIVA-CITALOPRAM RIV SANDOZ-CITALOPRAM SDZ SEPTA-CITALOPRAM SPT TEVA-CITALOPRAM TEV 28:16.04 ANTIDEPRESSANTS CITALOPRAM 30mg Tablet CTP 30 ORY 40mg Tablet ABBOTT-CITALOPRAM ABB ACCEL-CITALOPRAM ACP APO-CITALOPRAM APX AURO-CITALOPRAM AUR CELEXA LUD CITALOPRAM PDL CITALOPRAM MEL CITALOPRAM ODN CITALOPRAM SAN CITALOPRAM SIV CITALOPRAM JAP CO CITALOPRAM COB DOM-CITALOPRAM DPC JAMP-CITALOPRAM JMP MAR-CITALOPRAM MAR MINT-CITALOPRAM MIN MYLAN-CITALOPRAM MYL NAT-CITALOPRAM NPH PHL-CITALOPRAM PHH PMS-CITALOPRAM PMS RAN-CITALO RBY RIVA-CITALOPRAM RIV RIVA-CITALOPRAM RIV SANDOZ-CITALOPRAM SDZ SEPTA-CITALOPRAM SPT TEVA-CITALOPRAM TEV CLOMIPRAMINE HCL 10mg Tablet ANAFRANIL ORY APO-CLOMIPRAMINE APX CO CLOMIPRAMINE COB TEVA-CLOPAMINE TEV 25mg Tablet ANAFRANIL ORY APO-CLOMIPRAMINE APX CO CLOMIPRAMINE COB TEVA-CLOPAMINE TEV 50mg Tablet ANAFRANIL ORY APO-CLOMIPRAMINE APX CO CLOMIPRAMINE COB TEVA-CLOPAMINE TEV DESIPRAMINE HCL 10mg Tablet APO-DESIPRAMINE APX TEVA-DESIPRAMINE TEV 25mg Tablet APO-DESIPRAMINE APX DOM-DESIPRAMINE DPC TEVA-DESIPRAMINE TEV Page 73 of 151

90 28:16.04 ANTIDEPRESSANTS DESIPRAMINE HCL 50mg Tablet APO-DESIPRAMINE APX DOM-DESIPRAMINE DPC PMS-DESIPRAMINE PMS TEVA-DESIPRAMINE TEV 75mg Tablet APO-DESIPRAMINE APX PMS-DESIPRAMINE PMS TEVA-DESIPRAMINE TEV 100mg Tablet APO-DESIPRAMINE APX DOXEPIN HCL 10mg Capsule APO-DOXEPIN APX SINEQUAN ERF 25mg Capsule APO-DOXEPIN APX SINEQUAN ERF 50mg Capsule APO-DOXEPIN APX SINEQUAN ERF 75mg Capsule APO-DOXEPIN APX SINEQUAN ERF 100mg Capsule APO-DOXEPIN APX SINEQUAN ERF DULOXETINE HCL 30mg Sustained Release Capsule CYMBALTA LIL 60mg Sustained Release Capsule CYMBALTA LIL ESCITALOPRAM 10mg Orally Disintegrating Tablet CIPRALEX MELTZ LUK 20mg Orally Disintegrating Tablet CIPRALEX MELTZ LUK 28:16.04 ANTIDEPRESSANTS ESCITALOPRAM 10mg Tablet APO-ESCITALOPRAM APX AURO-ESCITALOPRAM AUR CIPRALEX 10MG TAB LUK CO ESCITALOPRAM CBT ESCITALOPRAM PDL ESCITALOPRAM SAN JAMP-ESCITALOPRAM JAP MAR-ESCITALOPRAM MAR MYLAN-ESCITALOPRAM MYL PMS-ESCITALOPRAM PMS PRIVA-ESCITALOPRAM PHA RAN-ESCITALOPRAM RBY RIVA-ESCITALOPRAM RIV SANDOZ ESCITALOPRAM SDZ TEVA-ESCITALOPRAM TEP 20mg Tablet APO-ESCITALOPRAM APX AURO-ESCITALOPRAM AUR CIPRALEX 20MG TAB LUK CO ESCITALOPRAM CBT ESCITALOPRAM PDL ESCITALOPRAM SAN JAMP-ESCITALOPRAM JAP MAR-ESCITALOPRAM MAR MYLAN-ESCITALOPRAM MYL PMS-ESCITALOPRAM PMS PRIVA-ESCITALOPRAM PHA RAN-ESCITALOPRAM RBY RIVA-ESCITALOPRAM RIV SANDOZ ESCITALOPRAM SDZ TEVA-ESCITALOPRAM TEP FLUOXETINE HCL 10mg Capsule APO-FLUOXETINE APX CO-FLUOXETINE SCN DOM-FLUOXETINE DPC FLUOXETINE SAN FLUOXETINE SIV FLUOXETINE ACC JAMP-FLUOXETINE JAP MAR-FLUOXETINE MAR MINT-FLUOXETINE MIN MYLAN-FLUOXETINE MYL NOVO-FLUOXETINE TEV PHL-FLUOXETINE PHH PMS-FLUOXETINE PMS PRO-FLUOXETINE PDL PROZAC LIL RAN-FLUOXETINE RBY RIVA-FLUOXETINE RIV ZYM-FLUOXETINE ZYM Page 74 of 151

91 28:16.04 ANTIDEPRESSANTS FLUOXETINE HCL 20mg Capsule APO-FLUOXETINE APX CO-FLUOXETINE SCN DOM-FLUOXETINE DPC FLUOXETINE SAN FLUOXETINE SIV FLUOXETINE ACC JAMP-FLUOXETINE JAP MAR-FLUOXETINE MAR MINT-FLUOXETINE MIN MYLAN-FLUOXETINE MYL NOVO-FLUOXETINE TEV PHL-FLUOXETINE PHH PMS-FLUOXETINE PMS PRO-FLUOXETINE PDL PROZAC LIL RAN-FLUOXETINE RBY RIVA-FLUOXETINE RIV ZYM-FLUOXETINE ZYM 4mg/mL Liquid APO-FLUOXETINE APX FLUVOXAMINE MALEATE 50mg Tablet APO-FLUVOXAMINE APX CO FLUVOXAMINE COB DOM-FLUVOXAMINE DPC FLUVOXAMINE PDL LUVOX ABB NOVO-FLUVOXAMINE TEV RATIO-FLUVOXAMINE RPH RIVA-FLUVOX RIV SANDOZ-FLUVOXAMINE SDZ 100mg Tablet APO-FLUVOXAMINE APX CO FLUVOXAMINE COB DOM-FLUVOXAMINE DPC FLUVOXAMINE PDL LUVOX ABB NOVO-FLUVOXAMINE TEV RATIO-FLUVOXAMINE RPH RIVA-FLUVOX RIV SANDOZ-FLUVOXAMINE SDZ IMIPRAMINE HCL 10mg Tablet IMIPRAMINE AAP NOVO-PRAMINE TEV 25mg Tablet IMIPRAMINE AAP 50mg Tablet IMIPRAMINE AAP NOVO-PRAMINE TEV 75mg Tablet IMIPRAMINE AAP 28:16.04 ANTIDEPRESSANTS MAPROTILINE HCL 25mg Tablet NOVO-MAPROTILINE TEV 50mg Tablet NOVO-MAPROTILINE TEV 75mg Tablet NOVO-MAPROTILINE TEV MIRTAZAPINE 15mg Orally Disintegrating Tablet AURO-MIRTAZAPINE OD AUR NOVO-MIRTAZAPINE OD TEV REMERON RD FRS 30mg Orally Disintegrating Tablet AURO-MIRTAZAPINE OD AUR NOVO-MIRTAZAPINE OD TEV REMERON RD FRS 45mg Orally Disintegrating Tablet AURO-MIRTAZAPINE OD AUR NOVO-MIRTAZAPINE OD TEV REMERON RD FRS 15mg Tablet APO-MIRTAZAPINE APX AURO-MIRTAZAPINE AUR MIRTAZAPINE MEL MYLAN-MIRTAZAPINE MYL PMS-MIRTAZAPINE PMS PRO-MIRTAZAPINE PDL SANDOZ-MIRTAZAPINE SDZ ZYM-MIRTAZAPINE ZYM 30mg Tablet APO-MIRTAZAPINE APX AURO-MIRTAZAPINE AUR CO MIRTAZAPINE COB DOM-MIRTAZAPINE DPC MIRTAZAPINE MEL MIRTAZAPINE SAN MYLAN-MIRTAZAPINE MYL NOVO-MIRTAZAPINE TEV PMS-MIRTAZAPINE PMS PRO-MIRTAZAPINE PDL RATIO-MIRTAZAPINE RPH REMERON FRS RIVA-MIRTAZAPINE RIV SANDOZ-MIRTAZAPINE SDZ ZYM-MIRTAZAPINE ZYM 45mg Tablet APO-MIRTAZAPINE APX AURO-MIRTAZAPINE AUR MYLAN-MIRTAZAPINE MYL MOCLOBEMIDE 100mg Tablet APO-MOCLOBEMIDE APX NOVO-MOCLOBEMIDE TEV Page 75 of 151

92 28:16.04 ANTIDEPRESSANTS MOCLOBEMIDE 150mg Tablet APO-MOCLOBEMIDE APX MANERIX MAB NOVO-MOCLOBEMIDE TEV PMS-MOCLOBEMIDE PMS 300mg Tablet APO-MOCLOBEMIDE APX MANERIX MAB NOVO-MOCLOBEMIDE TEV PMS-MOCLOBEMIDE PMS NORTRIPTYLINE HCL 10mg Capsule APO-NORTRIPTYLINE APX AVENTYL PHH DOM-NORTRIPTYLINE DPC PDL-NORTRIPTYLINE PDL 25mg Capsule APO-NORTRIPTYLINE APX AVENTYL PHH DOM-NORTRIPTYLINE DPC PDL-NORTRIPTYLINE PDL PAROXETINE HCL 10mg Tablet APO-PAROXETINE APX AURO-PAROXETINE AUR CO PAROXETINE COB DOM-PAROXETINE DPC JAMP-PAROXETINE JAP MAR-PAROXETINE MAR MINT-PAROXETINE MIN MYLAN-PAROXETINE MYL NOVO-PAROXETINE TEV PAROXETINE MEL PAROXETINE PDL PAROXETINE SAN PAROXETINE SOR PAROXETINE SIV PAXIL GSK PMS-PAROXETINE PMS RIVA-PAROXETINE RIV SANDOZ-PAROXETINE SDZ 28:16.04 ANTIDEPRESSANTS PAROXETINE HCL 20mg Tablet APO-PAROXETINE APX AURO-PAROXETINE AUR CO PAROXETINE COB DOM-PAROXETINE DPC JAMP-PAROXETINE JAP MAR-PAROXETINE MAR MINT-PAROXETINE MIN MYLAN-PAROXETINE MYL NOVO-PAROXETINE TEV PAROXETINE MEL PAROXETINE PDL PAROXETINE SAN PAROXETINE SOR PAROXETINE SIV PAXIL GSK PMS-PAROXETINE PMS RIVA-PAROXETINE RIV SANDOZ-PAROXETINE SDZ SANDOZ-PAROXETINE SDZ 30mg Tablet APO-PAROXETINE APX AURO-PAROXETINE AUR CO PAROXETINE COB DOM-PAROXETINE DPC JAMP-PAROXETINE JAP MAR-PAROXETINE MAR MINT-PAROXETINE MIN MYLAN-PAROXETINE MYL NOVO-PAROXETINE TEV PAROXETINE MEL PAROXETINE PDL PAROXETINE SAN PAROXETINE SOR PAROXETINE SIV PAXIL GSK PMS-PAROXETINE PMS RIVA-PAROXETINE RIV SANDOZ-PAROXETINE SDZ SANDOZ-PAROXETINE SDZ 40mg Tablet PMS-PAROXETINE PMS PHENELZINE SULFATE 15mg Tablet NARDIL PFI Page 76 of 151

93 28:16.04 ANTIDEPRESSANTS SERTRALINE 25mg Capsule APO-SERTRALINE APX AURO-SERTRALINE AUR CO SERTRALINE COB DOM-SERTRALINE DPC GD-SERTRALINE PFI JAMP-SERTRALINE JAP MAR-SERTRALINE MAR MINT-SERTRALINE MIN MYLAN-SERTRALINE MYL NOVO-SERTRALINE TEV PHL-SERTRALINE PHH PMS-SERTRALINE PMS RAN-SERTRALINE RBY RIVA-SERTRALINE RIV SANDOZ-SERTRALINE SDZ SERTRALINE MEL SERTRALINE SAN SERTRALINE SIV SERTRALINE-25 PDL ZOLOFT PFI 50mg Capsule APO-SERTRALINE APX AURO-SERTRALINE AUR CO SERTRALINE COB DOM-SERTRALINE DPC GD-SERTRALINE PFI JAMP-SERTRALINE JAP MAR-SERTRALINE MAR MINT-SERTRALINE MIN MYLAN-SERTRALINE MYL NOVO-SERTRALINE TEV PHL-SERTRALINE PHH PMS-SERTRALINE PMS RAN-SERTRALINE RBY RIVA-SERTRALINE RIV SANDOZ-SERTRALINE SDZ SERTRALINE MEL SERTRALINE SAN SERTRALINE SIV SERTRALINE-50 PDL ZOLOFT PFI 28:16.04 ANTIDEPRESSANTS SERTRALINE 100mg Capsule APO-SERTRALINE APX AURO-SERTRALINE AUR CO SERTRALINE COB DOM-SERTRALINE DPC GD-SERTRALINE PFI JAMP-SERTRALINE JAP MAR-SERTRALINE MAR MINT-SERTRALINE MIN MYLAN-SERTRALINE MYL NOVO-SERTRALINE TEV PHL-SERTRALINE PHH PMS-SERTRALINE PMS RAN-SERTRALINE RBY RIVA-SERTRALINE RIV SANDOZ-SERTRALINE SDZ SERTRALINE MEL SERTRALINE SAN SERTRALINE SIV SERTRALINE-100 PDL ZOLOFT PFI TRANYLCYPROMINE SULFATE 10mg Tablet PARNATE GSK TRAZODONE HCL 50mg Tablet APO-TRAZODONE APX DOM-TRAZODONE DPC MYLAN-TRAZODONE MYL NOVO-TRAZODONE TEV PHL-TRAZODONE PHH PMS-TRAZODONE PMS TRAZODONE PDL TRAZODONE SAN TRAZOREL VAE 75mg Tablet PMS-TRAZODONE PMS 100mg Tablet APO-TRAZODONE APX DOM-TRAZODONE DPC MYLAN-TRAZODONE MYL NOVO-TRAZODONE TEV PHL-TRAZODONE PHH PMS-TRAZODONE PMS TRAZODONE PDL TRAZODONE SAN TRAZOREL VAE 150mg Tablet APO-TRAZODONE D APX NOVO-TRAZODONE TEV NU-TRAZODONE D NXP TRAZODONE PDL TRAZODONE SAN Page 77 of 151

94 28:16.04 ANTIDEPRESSANTS TRIMIPRAMINE MALEATE 75mg Capsule TRIMIPRAMINE AAP 12.5mg Tablet TRIMIPRAMINE AAP 25mg Tablet NOVO-TRIPRAMINE TEV TRIMIPRAMINE AAP 50mg Tablet NOVO-TRIPRAMINE TEV TRIMIPRAMINE AAP 100mg Tablet NOVO-TRIPRAMINE TEV TRIMIPRAMINE AAP VENLAFAXINE HCL 37.5mg Sustained Release Capsule APO-VENLAFAXINE XR APX CO VENLAFAXINE XR COB EFFEXOR XR WAY GD-VENLAFAXINE XR PFI MYLAN-VENLAFAXINE XR MYL NOVO-VENLAFAXINE XR TEV PMS-VENLAFAXINE XR PMS RAN-VENLAFAXINE XR RBY RIVA-VENLAFAXINE XR RIV SANDOZ VENLAFAXINE XR SDZ VENLAFAXINE XR PDL VENLAFAXINE XR SAN VENLAFAXINE XR SIV 75mg Sustained Release Capsule APO-VENLAFAXINE XR APX CO VENLAFAXINE XR COB DOM-VENLAFAXINE XR DOM EFFEXOR XR WAY GD-VENLAFAXINE XR PFI MYLAN-VENLAFAXINE XR MYL NOVO-VENLAFAXINE XR TEV PMS-VENLAFAXINE XR PMS RAN-VENLAFAXINE XR RBY RIVA-VENLAFAXINE XR RIV SANDOZ VENLAFAXINE XR SDZ VENLAFAXINE XR PDL VENLAFAXINE XR SAN VENLAFAXINE XR SIV 28:16.04 ANTIDEPRESSANTS VENLAFAXINE HCL 150mg Sustained Release Capsule APO-VENLAFAXINE XR APX CO VENLAFAXINE XR COB EFFEXOR XR WAY GD-VENLAFAXINE XR PFI MYLAN-VENLAFAXINE XR MYL NOVO-VENLAFAXINE XR TEV PMS-VENLAFAXINE XR PMS RAN-VENLAFAXINE XR RBY RIVA-VENLAFAXINE XR RIV SANDOZ VENLAFAXINE XR SDZ VENLAFAXINE XR PDL VENLAFAXINE XR SAN VENLAFAXINE XR SIV 28:16.08 ANTIPSYCHOTIC AGENTS ARIPIPRAZOLE For the treatment of schizophrenia and schizoaffective disorders in patients who have a. Intolerance or lack of response to an adequate trial of another antipsychotic agent; OR b. A contraindication to another antipsychotic agent 2mg Tablet ABILIFY BMS 5mg Tablet ABILIFY BMS 10mg Tablet ABILIFY 15mg Tablet ABILIFY BMS 20mg Tablet ABILIFY BMS 30mg Tablet ABILIFY BMS ASENAPINE For the acute treatment of manic or mixed episodes associated with bipolar I disorder as either: - Monotherapy, after a trial of lithium or divalproex sodium has failed or is contraindicated, and trials of two atypical antipsychotic agents have failed due to intolerance or lack of response OR - Co-therapy with lithium or divalproex sodium, after trials of two atypical antipsychotic agents have failed due to intolerance or lack of response. 5mg Tablet SAPHRIS FRS 10mg Tablet SAPHRIS FRS Page 78 of 151

95 28:16.08 ANTIPSYCHOTIC AGENTS CHLORPROMAZINE 25mg/mL Injection CHLORPROMAZINE HCL SDZ 25mg Tablet TEVA-CHLORPROMAZINE TEV 50mg Tablet TEVA-CHLORPROMAZINE TEV 100mg Tablet TEVA-CHLORPROMAZINE TEV CLOZAPINE 25mg Tablet APO-CLOZAPINE APX CLOZARIL NVR GEN-CLOZAPINE MYL 50mg Tablet GEN-CLOZAPINE MYL 100mg Tablet APO-CLOZAPINE APX CLOZARIL NVR GEN-CLOZAPINE MYL 200mg Tablet GEN-CLOZAPINE MYL FLUPENTHIXOL DECANOATE 20mg/mL Injection FLUANXOL DEPOT LUD 100mg/mL Injection FLUANXOL DEPOT LUD FLUPENTHIXOL DIHYDROCHLORIDE 0.5mg Tablet FLUANXOL LUD 3mg Tablet FLUANXOL LUD FLUPHENAZINE DECANOATE 25mg/mL Injection PMS-FLUPHENAZINE PMS 100mg/mL Injection MODECATE BMS PMS-FLUPHENAZINE PMS FLUPHENAZINE HCL 1mg Tablet APO-FLUPHENAZINE APX 2mg Tablet APO-FLUPHENAZINE APX 5mg Tablet APO-FLUPHENAZINE APX HALOPERIDOL 5mg/mL Injection HALOPERIDOL SDZ HALOPERIDOL OMG 28:16.08 ANTIPSYCHOTIC AGENTS HALOPERIDOL 2mg/mL Solution PMS-HALOPERIDOL PMS 0.5mg Tablet APO-HALOPERIDOL APX NOVO-PERIDOL TEV 1mg Tablet APO-HALOPERIDOL APX NOVO-PERIDOL TEV 2mg Tablet NOVO-PERIDOL TEV 5mg Tablet NOVO-PERIDOL TEV 10mg Tablet APO-HALOPERIDOL APX NOVO-PERIDOL TEV 20mg Tablet NOVO-PERIDOL TEV HALOPERIDOL DECANOATE 50mg/mL Injection HALOPERIDOL LA SDZ PMS-HALOPERIDOL LA PMS 100mg/mL Injection HALOPERIDOL LA SDZ HALOPERIDOL LA OMG PMS-HALOPERIDOL LA PMS LOXAPINE HCL 25mg/mL Oral Liquid XYLAC MMT LOXAPINE SUCCINATE 2.5mg Tablet XYLAC MMT 5mg Tablet DOM-LOXAPINE DPC PHL-LOXAPINE PHH XYLAC MMT 10mg Tablet DOM-LOXAPINE DPC PHL-LOXAPINE PHH XYLAC MMT 25mg Tablet DOM-LOXAPINE DPC PHL-LOXAPINE PHH XYLAC MMT 50mg Tablet DOM-LOXAPINE DPC PHL-LOXAPINE PHH XYLAC MMT METHOTRIMEPRAZINE 2mg Tablet APO-METHOPRAZINE APX Page 79 of 151

96 28:16.08 ANTIPSYCHOTIC AGENTS METHOTRIMEPRAZINE 5mg Tablet APO-METHOPRAZINE APX PMS-METHOTRIMEPRAZINE PMS 25mg Tablet APO-METHOPRAZINE APX NOVO-MEPRAZINE TEV 50mg Tablet APO-METHOPRAZINE APX OLANZAPINE 5mg Orally Disintegrating Tablet APO-OLANZAPINE ODT APX CO OLANZAPINE ODT CBT JAMP-OLANZAPINE ODT JAP MAR-OLANZAPINE ODT MAR MYLAN-OLANZAPINE ODT MYL NOVO-OLANZAPINE ODT TEV OLANZAPINE ODT PDL OLANZAPINE ODT SIV OLANZAPINE ODT SAN PMS-OLANZAPINE ODT PMS RAN-OLANZAPINE ODT RBY SANDOZ OLANZAPINE ODT SDZ ZYPREXA ZYDIS LIL 10mg Orally Disintegrating Tablet APO-OLANZAPINE ODT APX CO OLANZAPINE ODT CBT JAMP-OLANZAPINE ODT JAP MAR-OLANZAPINE ODT MAR MYLAN-OLANZAPINE ODT MYL NOVO-OLANZAPINE ODT TEV OLANZAPINE ODT PDL OLANZAPINE ODT SIV OLANZAPINE ODT SAN PMS-OLANZAPINE ODT PMS RAN-OLANZAPINE ODT RBY SANDOZ OLANZAPINE ODT SDZ ZYPREXA ZYDIS LIL 15mg Orally Disintegrating Tablet APO-OLANZAPINE APX APO-OLANZAPINE ODT APX CO OLANZAPINE ODT CBT JAMP-OLANZAPINE ODT JAP MAR-OLANZAPINE ODT MAR MYLAN-OLANZAPINE ODT MYL NOVO-OLANZAPINE ODT TEV OLANZAPINE ODT PDL OLANZAPINE ODT SIV OLANZAPINE ODT SAN PMS-OLANZAPINE ODT PMS RAN-OLANZAPINE ODT RBY SANDOZ OLANZAPINE ODT SDZ ZYPREXA ZYDIS LIL 28:16.08 ANTIPSYCHOTIC AGENTS OLANZAPINE 2.5mg Tablet ACCEL-OLANZAPINE ACP APO-OLANZAPINE APX CO OLANZAPINE CBT MAR-OLANZAPINE MAR MYLAN-OLANZAPINE MYL NOVO-OLANZAPINE TEV OLANZAPINE PDL OLANZAPINE SAN OLANZAPINE SIV PMS-OLANZAPINE PMS RAN-OLANZAPINE RBY RIVA-OLANZAPINE RIV SANDOZ-OLANZAPINE SDZ ZYPREXA LIL 5mg Tablet APO-OLANZAPINE APX CO OLANZAPINE CBT MAR-OLANZAPINE MAR MYLAN-OLANZAPINE MYL NOVO-OLANZAPINE TEV OLANZAPINE PDL OLANZAPINE SAN OLANZAPINE SIV PMS-OLANZAPINE PMS RAN-OLANZAPINE RBY RIVA-OLANZAPINE RIV SANDOZ-OLANZAPINE SDZ ZYPREXA LIL 7.5mg Tablet APO-OLANZAPINE APX CO OLANZAPINE CBT MAR-OLANZAPINE MAR MYLAN-OLANZAPINE MYL NOVO-OLANZAPINE TEV OLANZAPINE PDL OLANZAPINE SAN OLANZAPINE SIV PMS-OLANZAPINE PMS RAN-OLANZAPINE RBY RIVA-OLANZAPINE RIV SANDOZ-OLANZAPINE SDZ ZYPREXA LIL Page 80 of 151

97 28:16.08 ANTIPSYCHOTIC AGENTS OLANZAPINE 10mg Tablet APO-OLANZAPINE APX CO OLANZAPINE CBT MAR-OLANZAPINE MAR MYLAN-OLANZAPINE MYL NOVO-OLANZAPINE TEV OLANZAPINE PDL OLANZAPINE SAN OLANZAPINE SIV PMS-OLANZAPINE PMS RAN-OLANZAPINE RBY RIVA-OLANZAPINE RIV SANDOZ-OLANZAPINE SDZ ZYPREXA LIL 15mg Tablet CO OLANZAPINE CBT MAR-OLANZAPINE MAR MYLAN-OLANZAPINE MYL NOVO-OLANZAPINE TEV OLANZAPINE PDL OLANZAPINE SAN OLANZAPINE SIV PMS-OLANZAPINE PMS RAN-OLANZAPINE RBY RIVA-OLANZAPINE RIV SANDOZ-OLANZAPINE SDZ ZYPREXA LIL PALIPERIDONE PALMITATE For the management of manifestations of schizophrenia and related psychotic disorders in patients who have: tried oral risperidone or paliperidone and at least one other antipsychotic agent and continue to be inadequately controlled at maximally tolerated doses; OR who are currently receiving a conventional depot antipsychotic and are experiencing significant side effects such as extrapyramidal symptoms or tardive dyskinesia; OR who have a history of non-adherence to antipsychotic medications resulting in important negative outcomes such as repeated hospitalizations 50mg/0.5mL Injection INVEGA SUENNA JNO 75mg/0.75mL Injection INVEGA SUENNA JNO 100mg/mL Injection INVEGA SUENNA JNO 150mg/1.5mL Injection INVEGA SUENNA JNO PERICYAZINE 5mg Capsule NEULEPTIL ERF 28:16.08 ANTIPSYCHOTIC AGENTS PERICYAZINE 10mg Capsule NEULEPTIL ERF 20mg Capsule NEULEPTIL ERF 10mg/mL Drop NEULEPTIL ERF PERPHENAZINE 3.2mg/mL Liquid PMS-PERPHENAZINE PMS 2mg Tablet APO-PERPHENAZINE APX 4mg Tablet APO-PERPHENAZINE APX 8mg Tablet APO-PERPHENAZINE APX 16mg Tablet APO-PERPHENAZINE APX PIMOZIDE 2mg Tablet APO-PIMOZIDE APX ORAP PHH 4mg Tablet APO-PIMOZIDE APX ORAP PHH PROCHLORPERAZINE 5mg/mL Injection PROCHLORPERAZINE SDZ 10mg Suppository PMS-PROCHLORPERAZINE PMS PROCHLORPERAZINE SDZ 5mg Tablet APO-PROCHLORAZINE APX PMS-PROCHLORPERAZINE PMS 10mg Tablet APO-PROCHLORAZINE APX PMS-PROCHLORPERAZINE PMS QUETIAPINE FUMARATE 50mg Extended Release Tablet QUETIAPINE XR SIV QUETIAPINE XR PDL SANDOZ QUETIAPINE XRT SDZ SEROQUEL XR AZE TEVA-QUETIAPINE XR TEP 150mg Extended Release Tablet QUETIAPINE XR SIV QUETIAPINE XR PDL SANDOZ QUETIAPINE XRT SDZ SEROQUEL XR AZE TEVA-QUETIAPINE XR TEP Page 81 of 151

98 28:16.08 ANTIPSYCHOTIC AGENTS QUETIAPINE FUMARATE 200mg Extended Release Tablet QUETIAPINE XR SIV QUETIAPINE XR PDL SANDOZ QUETIAPINE XRT SDZ SEROQUEL XR AZE TEVA-QUETIAPINE XR TEP 300mg Extended Release Tablet QUETIAPINE XR SIV QUETIAPINE XR PDL SANDOZ QUETIAPINE XRT SDZ SEROQUEL XR AZE TEVA-QUETIAPINE XR TEP 400mg Extended Release Tablet QUETIAPINE XR SIV QUETIAPINE XR PDL SANDOZ QUETIAPINE XRT SDZ SEROQUEL XR AZE TEVA-QUETIAPINE XR TEP 25mg Tablet ABBOTT-QUETIAPINE BGP APO-QUETIAPINE APX AURO-QUETIAPINE AUR CO QUETIAPINE COB DOM-QUETIAPINE DOM JAMP-QUETIAPINE JMP MAR-QUETIAPINE MAR MYLAN-QUETIAPINE MYL NOVO-QUETIAPINE TEV PHL-QUETIAPINE PMI PMS-QUETIAPINE PMS PRO-QUETIAPINE PDL QUETIAPINE MEL QUETIAPINE SAN RAN-QUETIAPINE RBY RATIO-QUETIAPINE RPH RIVA-QUETIAPINE RIV SANDOZ-QUETIAPINE SDZ SEROQUEL AZC 50mg Tablet PMS-QUETIAPINE VTH 28:16.08 ANTIPSYCHOTIC AGENTS QUETIAPINE FUMARATE 100mg Tablet ABBOTT-QUETIAPINE BGP APO-QUETIAPINE APX AURO-QUETIAPINE AUR CO QUETIAPINE COB DOM-QUETIAPINE DOM JAMP-QUETIAPINE JMP MAR-QUETIAPINE MAR MYLAN-QUETIAPINE MYL NOVO-QUETIAPINE TEV PHL-QUETIAPINE PMI PMS-QUETIAPINE PMS PRO-QUETIAPINE PDL QUETIAPINE MEL QUETIAPINE SAN RAN-QUETIAPINE RBY RATIO-QUETIAPINE RPH RIVA-QUETIAPINE RIV SANDOZ-QUETIAPINE SDZ SEROQUEL AZC 150mg Tablet NOVO-QUETIAPINE TEV 200mg Tablet ABBOTT-QUETIAPINE BGP APO-QUETIAPINE APX AURO-QUETIAPINE AUR CO QUETIAPINE COB DOM-QUETIAPINE DOM JAMP-QUETIAPINE JMP MAR-QUETIAPINE MAR MYLAN-QUETIAPINE MYL NOVO-QUETIAPINE TEV PHL-QUETIAPINE PMI PMS-QUETIAPINE PMS PRO-QUETIAPINE PDL QUETIAPINE MEL QUETIAPINE SAN RAN-QUETIAPINE RBY RATIO-QUETIAPINE RPH RIVA-QUETIAPINE RIV SANDOZ-QUETIAPINE SDZ SEROQUEL AZC Page 82 of 151

99 28:16.08 ANTIPSYCHOTIC AGENTS QUETIAPINE FUMARATE 300mg Tablet ABBOTT-QUETIAPINE BGP APO-QUETIAPINE APX AURO-QUETIAPINE AUR CO QUETIAPINE COB DOM-QUETIAPINE DOM JAMP-QUETIAPINE JMP MAR-QUETIAPINE MAR MYLAN-QUETIAPINE MYL NOVO-QUETIAPINE TEV PHL-QUETIAPINE PMI PMS-QUETIAPINE PMS PRO-QUETIAPINE PDL QUETIAPINE MEL QUETIAPINE SAN RAN-QUETIAPINE RBY RIVA-QUETIAPINE RIV SANDOZ-QUETIAPINE SDZ SEROQUEL AZC RISPERIDONE 0.5mg Orally Disintegrating Tablet MYLAN-RISPERIDONE ODT MYL RISPERDAL-M JNO 1mg Orally Disintegrating Tablet MYLAN-RISPERIDONE ODT MYL PMS-RISPERIDONE ODT PMS RISPERDAL-M JNO 2mg Orally Disintegrating Tablet MYLAN-RISPERIDONE ODT MYL PMS-RISPERIDONE ODT PMS RISPERDAL-M JNO 3mg Orally Disintegrating Tablet MYLAN-RISPERIDONE ODT MYL PMS-RISPERIDONE ODT PMS RISPERDAL-M JNO 4mg Orally Disintegrating Tablet MYLAN-RISPERIDONE ODT MYL PMS-RISPERIDONE ODT PMS RISPERDAL-M JNO 1mg/mL Solution APO-RISPERIDONE APX PMS-RISPERIDONE PMS RISPERDAL JNO 28:16.08 ANTIPSYCHOTIC AGENTS RISPERIDONE 0.25mg Tablet APO-RISPERIDONE APX CO RISPERIDONE COB JAMP-RISPERIDONE JAP MAR-RISPERIDONE MAR MINT-RISPERIDONE MIN MYLAN-RISPERIDONE MYL NOVO-RISPERIDONE TEV PHL-RISPERIDONE PMI PMS-RISPERIDONE PMS PRO-RISPERIDONE PDL RATIO-RISPERIDONE RPH RBX-RISPERIDONE RBY RISPERDAL JNO RISPERIDONE MEL RISPERIDONE SAN RIVA-RISPERIDONE RIV SANDOZ RISPERIDONE SDZ 0.5mg Tablet APO-RISPERIDONE APX CO RISPERIDONE COB JAMP-RISPERIDONE JAP MAR-RISPERIDONE MAR MINT-RISPERIDONE MIN MYLAN-RISPERIDONE MYL NOVO-RISPERIDONE TEV PHL-RISPERIDONE PMI 0225 PMS-RISPERIDONE PMS PRO-RISPERIDONE PDL RATIO-RISPERIDONE RPH RBX-RISPERIDONE RBY RISPERDAL JNO RISPERIDONE MEL RISPERIDONE SAN RIVA-RISPERIDONE RIV SANDOZ RISPERIDONE SDZ 1mg Tablet APO-RISPERIDONE APX CO RISPERIDONE COB JAMP-RISPERIDONE JAP MAR-RISPERIDONE MAR MINT-RISPERIDONE MIN MYLAN-RISPERIDONE MYL NOVO-RISPERIDONE TEV PHL-RISPERIDONE PMI PMS-RISPERIDONE PMS PRO-RISPERIDONE PDL RATIO-RISPERIDONE RPH RBX-RISPERIDONE RBY RISPERDAL JNO RISPERIDONE MEL RISPERIDONE SAN RIVA-RISPERIDONE RIV SANDOZ-RISPERIDONE SDZ Page 83 of 151

100 28:16.08 ANTIPSYCHOTIC AGENTS RISPERIDONE 2mg Tablet APO-RISPERIDONE APX CO RISPERIDONE COB JAMP-RISPERIDONE JAP MAR-RISPERIDONE MAR MINT-RISPERIDONE MIN MYLAN-RISPERIDONE MYL NOVO-RISPERIDONE TEV PHL-RISPERIDONE PMI PMS-RISPERIDONE PMS PRO-RISPERIDONE PDL RATIO-RISPERIDONE RPH RBX-RISPERIDONE RBY RISPERDAL JNO RISPERIDONE MEL RISPERIDONE SAN RIVA-RISPERIDONE RIV SANDOZ-RISPERIDONE SDZ 3mg Tablet APO-RISPERIDONE APX CO RISPERIDONE COB JAMP-RISPERIDONE JAP MAR-RISPERIDONE MAR MINT-RISPERIDONE MIN MYLAN-RISPERIDONE MYL NOVO-RISPERIDONE TEV PHL-RISPERIDONE PMI PMS-RISPERIDONE PMS PRO-RISPERIDONE PDL RATIO-RISPERIDONE RPH RBX-RISPERIDONE RBY RISPERDAL JNO RISPERIDONE MEL RISPERIDONE SAN RIVA-RISPERIDONE RIV SANDOZ-RISPERIDONE SDZ 4mg Tablet APO-RISPERIDONE APX CO RISPERIDONE COB JAMP-RISPERIDONE JAP MAR-RISPERIDONE MAR MINT-RISPERIDONE MIN MYLAN-RISPERIDONE MYL NOVO-RISPERIDONE TEV PHL-RISPERIDONE PMI PMS-RISPERIDONE PMS PRO-RISPERIDONE PDL RATIO-RISPERIDONE RPH RBX-RISPERIDONE RBY RISPERDAL JNO RISPERIDONE MEL RISPERIDONE SAN RIVA-RISPERIDONE RIV SANDOZ-RISPERIDONE SDZ 28:16.08 ANTIPSYCHOTIC AGENTS RISPERIDONE (CONA) For the management of manifestations of schizophrenia and related psychotic disorders in patients who have: tried oral risperidone or paliperidone and at least one other antipsychotic agent and continue to be inadequately controlled at maximally tolerated doses; OR who are currently receiving a conventional depot antipsychotic and are experiencing significant side effects such as extrapyramidal symptoms or tardive dyskinesia; OR who have a history of non-adherence to antipsychotic medications resulting in important negative outcomes such as repeated hospitalizations 12.5mg Injection RISPERDAL CONA JNO 25mg Injection RISPERDAL CONA JNO 37.5mg Injection RISPERDAL CONA JNO 50mg Injection RISPERDAL CONA JNO THIOPROPERAZINE MESYLATE 10mg Tablet MAJEPTIL ERF THIOTHIXENE 2mg Capsule NAVANE ERF 5mg Capsule NAVANE ERF 10mg Capsule NAVANE ERF TRIFLUOPERAZINE HCL 10mg/mL Liquid PMS-TRIFLUOPERAZINE PMS 1mg Tablet TRIFLUOPERAZINE AAP 2mg Tablet TRIFLUOPERAZINE AAP 5mg Tablet TRIFLUOPERAZINE AAP 10mg Tablet TRIFLUOPERAZINE AAP 20mg Tablet TRIFLUOPERAZINE AAP ZIPRASIDONE HCL MONOHYDRATE 20MG Capsule ZELDOX PFI 40MG Capsule ZELDOX PFI Page 84 of 151

101 28:16.08 ANTIPSYCHOTIC AGENTS ZIPRASIDONE HCL MONOHYDRATE 60mg Capsule ZELDOX PFI 80mg Capsule ZELDOX PFI ZUCLOPENTHIXOL DIHYDROCHLORIDE 50mg/mL Injection CLOPIXOL ACUPHASE LUK 200mg/mL Injection CLOPIXOL DEPOT LUK 10mg Tablet CLOPIXOL LUK 25mg Tablet CLOPIXOL LUK 28:20.04 AMPHETAMINES DEXTROAMPHETAMINE SULFATE Limited use benefit (prior approval is not required). The NIHB Program introduced a dose coverage limit for stimulants on February 25, as part of a strategy to deal with the potential misuse and abuse of these medications. The stimulant dose coverage limit is set at 150 mg of methylphenidate equivalents* per day for adults and children. This limit is calculated based on the total dose of all stimulants that patients are receiving from NIHB. The Program will continue to monitor the utilization of stimulants and adjust the eligible dose limit as required. To convert to methylphenidate equivalents, 1 mg of METHYLPHENIDATE, or LISDEXAMFETAMINE is equal to 0.5 mg DEXTROAMPHETAMINE 10mg Sustained Release Capsule DEXEDRINE SPANSULE GSK 15mg Sustained Release Capsule DEXEDRINE SPANSULE GSK 5mg Tablet DEXEDRINE GSK LISDEXAMFETAMINE DIMESYLATE Limited use benefit (prior approval is not required). The NIHB Program introduced a dose coverage limit for stimulants on February 25, as part of a strategy to deal with the potential misuse and abuse of these medications. The stimulant dose coverage limit is set at 150 mg of methylphenidate equivalents* per day for adults and children. This limit is calculated based on the total dose of all stimulants that patients are receiving from NIHB. The Program will continue to monitor the utilization of stimulants and adjust the eligible dose limit as required. To convert to methylphenidate equivalents, 1 mg of METHYLPHENIDATE, or LISDEXAMFETAMINE is equal to 0.5 mg DEXTROAMPHETAMINE 20mg Capsule VYVANSE SHI 30mg Capsule VYVANSE SHI 28:20.04 AMPHETAMINES LISDEXAMFETAMINE DIMESYLATE Limited use benefit (prior approval is not required). The NIHB Program introduced a dose coverage limit for stimulants on February 25, as part of a strategy to deal with the potential misuse and abuse of these medications. The stimulant dose coverage limit is set at 150 mg of methylphenidate equivalents* per day for adults and children. This limit is calculated based on the total dose of all stimulants that patients are receiving from NIHB. The Program will continue to monitor the utilization of stimulants and adjust the eligible dose limit as required. To convert to methylphenidate equivalents, 1 mg of METHYLPHENIDATE, or LISDEXAMFETAMINE is equal to 0.5 mg DEXTROAMPHETAMINE 40mg Capsule VYVANSE SHI 50mg Capsule VYVANSE SHI 60mg Capsule VYVANSE SHI 28:20.32 METHYLPHENIDATE HCL Limited use benefit (prior approval is not required). The NIHB Program introduced a dose coverage limit for stimulants on February 25, as part of a strategy to deal with the potential misuse and abuse of these medications. The stimulant dose coverage limit is set at 150 mg of methylphenidate equivalents* per day for adults and children. This limit is calculated based on the total dose of all stimulants that patients are receiving from NIHB. The Program will continue to monitor the utilization of stimulants and adjust the eligible dose limit as required. To convert to methylphenidate equivalents, 1 mg of METHYLPHENIDATE, or LISDEXAMFETAMINE is equal to 0.5 mg DEXTROAMPHETAMINE 18mg Sustained Release Tablet PMS-METHYLPHENIDATE ER PMS 27mg Sustained Release Tablet PMS-METHYLPHENIDATE ER PMS 36mg Sustained Release Tablet PMS-METHYLPHENIDATE ER PMS 54mg Sustained Release Tablet PMS-METHYLPHENIDATE ER PMS 28:20.80 MODAFINIL 100mg Tablet ALERTEC DPY MAR-MODAFINIL MAR MODAFINIL AAP TEVA-MODAFINIL TEP Page 85 of 151

102 28:20.92 MISC ANOREXIGENIC AGENTS & RESPIRATORY & CEREBRAL IMULANT METHYLPHENIDATE HCL Limited use benefit (prior approval is not required). The NIHB Program introduced a dose coverage limit for stimulants on February 25, as part of a strategy to deal with the potential misuse and abuse of these medications. The stimulant dose coverage limit is set at 150 mg of methylphenidate equivalents* per day for adults and children. This limit is calculated based on the total dose of all stimulants that patients are receiving from NIHB. The Program will continue to monitor the utilization of stimulants and adjust the eligible dose limit as required. To convert to methylphenidate equivalents, 1 mg of METHYLPHENIDATE, or LISDEXAMFETAMINE is equal to 0.5 mg DEXTROAMPHETAMINE 18mg Extended Release Tablet CONCERTA JNO NOVO-METHYLPHENIDATE ER TEV 27mg Extended Release Tablet CONCERTA JNO NOVO-METHYLPHENIDATE ER TEV 36mg Extended Release Tablet CONCERTA JNO NOVO-METHYLPHENIDATE ER TEV 54mg Extended Release Tablet APO-METHYLPHENIDATE ER APX CONCERTA JNO NOVO-METHYLPHENIDATE ER TEV 20mg Sustained Release Tablet APO-METHYLPHENIDATE SR APX SANDOZ-METHYLPHENIDATE SDZ SR 5mg Tablet APO-METHYLPHENIDATE APX METHYLPHENIDATE PDL PMS-METHYLPHENIDATE PMS 10mg Tablet APO-METHYLPHENIDATE APX METHYLPHENIDATE PDL PMS-METHYLPHENIDATE PMS 20mg Tablet APO-METHYLPHENIDATE APX METHYLPHENIDATE PDL PMS-METHYLPHENIDATE PMS 28:24.08 ANXIOLYTICS, SEDATIVES AND HYPNOTICS - BENZODIAZEPINES ALPRAZOLAM Limited use benefit (prior approval is not required). To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 40 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e diazepam equivalents over 100 days). According to the product monograph for diazepam, the recommended usual adult dosage is up to 40 mg per day. 0.25mg Tablet ALPRAZOLAM PDL ALPRAZOLAM SAN APO-ALPRAZ APX JAMP-ALPRAZOLAM JAP MYLAN-ALPRAZOLAM MYL RIVA-ALPRAZOLAM RIV TEVA-ALPRAZOL TEV XANAX PFI 0.5mg Tablet ALPRAZOLAM PDL ALPRAZOLAM SAN APO-ALPRAZ APX JAMP-ALPRAZOLAM JAP MYLAN-ALPRAZOLAM MYL RIVA-ALPRAZOLAM RIV TEVA-ALPRAZOL TEV XANAX PFI 1mg Tablet ALPRAZOLAM PDL APO-ALPRAZ APX JAMP-ALPRAZOLAM JAP MYLAN-ALPRAZOLAM MYL RIVA-ALPRAZOLAM RIV XANAX PFI 2mg Tablet APO-ALPRAZ APX JAMP-ALPRAZOLAM JAP MYLAN-ALPRAZOLAM MYL XANAX TS PFI BROMAZEPAM Limited use benefit (prior approval is not required). To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 40 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e diazepam equivalents over 100 days). According to the product monograph for diazepam, the recommended usual adult dosage is up to 40 mg per day. 1.5mg Tablet APO-BROMAZEPAM APX Page 86 of 151

103 28:24.08 ANXIOLYTICS, SEDATIVES AND HYPNOTICS - BENZODIAZEPINES BROMAZEPAM Limited use benefit (prior approval is not required). To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 40 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e diazepam equivalents over 100 days). According to the product monograph for diazepam, the recommended usual adult dosage is up to 40 mg per day. 3mg Tablet APO-BROMAZEPAM APX BROMAZEPAM PDL LECTOPAM HLR TEVA-BROMAZEPAM TEV 6mg Tablet APO-BROMAZEPAM APX BROMAZEPAM PDL LECTOPAM HLR TEVA-BROMAZEPAM TEV CLOBAZAM 10mg Tablet APO-CLOBAZAM APX CLOBAZAM PDL DOM-CLOBAZAM DPC FRISIUM PED PMS-CLOBAZAM PMS TEVA-CLOBAZAM TEV DIAZEPAM Limited use benefit (prior approval is not required). To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 40 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e diazepam equivalents over 100 days). According to the product monograph for diazepam, the recommended usual adult dosage is up to 40 mg per day. 1mg/mL Oral Solution PMS-DIAZEPAM PMS 2mg Tablet APO-DIAZEPAM APX DIAZEPAM PDL PMS-DIAZEPAM PMS 5mg Tablet APO-DIAZEPAM APX DIAZEPAM PRO PMS-DIAZEPAM PMS VALIUM HLR 10mg Tablet APO-DIAZEPAM APX DIAZEPAM PDL PMS-DIAZEPAM PMS 28:24.08 ANXIOLYTICS, SEDATIVES AND HYPNOTICS - BENZODIAZEPINES LORAZEPAM Limited use benefit (prior approval is not required). To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 40 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e diazepam equivalents over 100 days). According to the product monograph for diazepam, the recommended usual adult dosage is up to 40 mg per day. 0.5mg Tablet APO-LORAZEPAM APX APO-LORAZEPAM SL APX ATIVAN WAY ATIVAN SUBLINGUAL WAY DOM-LORAZEPAM DPC LORAZEPAM SAN NOVO-LORAZEM TEV PMS-LORAZEPAM PMS PRO-LORAZEPAM PDL 1mg Tablet APO-LORAZEPAM APX APO-LORAZEPAM SL APX ATIVAN WAY ATIVAN SUBLINGUAL WAY DOM-LORAZEPAM DPC LORAZEPAM SAN NOVO-LORAZEM TEV PMS-LORAZEPAM PMS PRO-LORAZEPAM PDL 2mg Tablet APO-LORAZEPAM APX APO-LORAZEPAM SL APX ATIVAN WAY ATIVAN SUBLINGUAL WAY DOM-LORAZEPAM DPC LORAZEPAM SAN NOVO-LORAZEM TEV PMS-LORAZEPAM PMS PRO-LORAZEPAM PDL NITRAZEPAM Limited use benefit (prior approval is not required). To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 40 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e diazepam equivalents over 100 days). According to the product monograph for diazepam, the recommended usual adult dosage is up to 40 mg per day. 5mg Tablet MOGADON ICN 10mg Tablet MOGADON VAE Page 87 of 151

104 28:24.08 ANXIOLYTICS, SEDATIVES AND HYPNOTICS - BENZODIAZEPINES OXAZEPAM Limited use benefit (prior approval is not required). To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 40 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e diazepam equivalents over 100 days). According to the product monograph for diazepam, the recommended usual adult dosage is up to 40 mg per day. 10mg Tablet APO-OXAZEPAM APX OXAZEPAM PDL OXPAM BMI RIVA OXAZEPAM RIV 15mg Tablet APO-OXAZEPAM APX OXAZEPAM PDL RIVA OXAZEPAM RIV 30mg Tablet APO-OXAZEPAM APX OXAZEPAM PDL OXPAM BMI RIVA OXAZEPAM RIV TEMAZEPAM Limited use benefit (prior approval is not required). To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 40 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e diazepam equivalents over 100 days). According to the product monograph for diazepam, the recommended usual adult dosage is up to 40 mg per day. 15mg Capsule APO-TEMAZEPAM APX CO TEMAZEPAM COB DOM-TEMAZEPAM DPC NOVO-TEMAZEPAM TEV RATIO-TEMAZEPAM RPH REORIL ORY TEMAZEPAM PDL 30mg Capsule APO-TEMAZEPAM APX CO TEMAZEPAM COB DOM-TEMAZEPAM DPC NOVO-TEMAZEPAM TEV RATIO-TEMAZEPAM RPH REORIL ORY TEMAZEPAM PDL 28:24.08 ANXIOLYTICS, SEDATIVES AND HYPNOTICS - BENZODIAZEPINES TRIAZOLAM Limited use benefit (prior approval is not required). To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 40 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e diazepam equivalents over 100 days). According to the product monograph for diazepam, the recommended usual adult dosage is up to 40 mg per day mg Tablet APO-TRIAZO APX 0.25mg Tablet APO-TRIAZO APX 28:24.92 MISCELLANEOUS ANXIOLYTICS, SEDATIVES, AND HYPNOTICS HYDROXYZINE HCL 10mg Capsule APO-HYDROXYZINE APX HYDROXYZINE PDL NOVO-HYDROXYZIN TEV RIVA-HYDROXYZIN RIV 25mg Capsule APO-HYDROXYZINE APX HYDROXYZINE PDL NOVO-HYDROXYZIN TEV RIVA-HYDROXYZIN RIV 50mg Capsule APO-HYDROXYZINE APX HYDROXYZINE PDL NOVO-HYDROXYZIN TEV RIVA-HYDROXYZIN RIV 2mg/mL Syrup ATARAX ERF PMS-HYDROXYZINE PMS 28:28.00 ANTIMANIC AGENTS LITHIUM CARBONATE 150mg Capsule APO-LITHIUM CARB APX APO-LITHIUM CARBONATE APX LITHANE ERF PMS-LITHIUM CARBONATE PMS 300mg Capsule APO-LITHIUM CARB APX APO-LITHIUM CARBONATE APX CARBOLITH VAE LITHANE ERF PMS-LITHIUM CARBONATE PMS 600mg Capsule CARBOLITH VAE PMS-LITHIUM CARBONATE PMS Page 88 of 151

105 28:28.00 ANTIMANIC AGENTS LITHIUM CITRATE 60mg/mL Syrup PMS-LITHIUM CITRATE PMS 28:32.28 SELECTIVE SEROTONIN AGONIS ALMOTRIPTAN MALATE Limited use benefit (prior approval is not required). A total of 12 tablets (or injections) are permitted in a 30-day period. 6.25MG Tablet APO-ALMOTRIPTAN APX AXERT MCL MYLAN-ALMOTRIPTAN MYL 12.5MG Tablet ALMOTRIPTAN PDL APO-ALMOTRIPTAN APX AXERT MCL MYLAN-ALMOTRIPTAN MYL SANDOZ ALMOTRIPTAN SDZ NARATRIPTAN HCL Limited use benefit (prior approval is not required). A total of 12 tablets (or injections) are permitted in a 30-day period. 1mg Tablet AMERGE GSK NOVO-NARATRIPTAN TEV 2.5mg Tablet AMERGE GSK NOVO-NARATRIPTAN TEV SANDOZ NARATRIPTAN SDZ RIZATRIPTAN Limited use benefit (prior approval is not required). A total of 12 tablets (or injections) are permitted in a 30-day period. 5mg Orally Disintegrating Tablet APO-RIZATRIPTAN RPD APX CO-RIZATRIPTAN ODT ATP MYLAN-RIZATRIPTAN ODT MYL PMS-RIZATRIPTAN RDT PMS RIVA-RIZATRIPTAN ODT RIV RIZATRIPTAN RDT PDL SANDOZ RIZATRIPTAN ODT SDZ TEVA-RIZATRIPTAN RDT TEP 28:32.28 SELECTIVE SEROTONIN AGONIS RIZATRIPTAN Limited use benefit (prior approval is not required). A total of 12 tablets (or injections) are permitted in a 30-day period. 10mg Orally Disintegrating Tablet APO-RIZATRIPTAN RPD APX CO-RIZATRIPTAN ODT ATP DOM-RIZATRIPTAN RDT DOM MYLAN-RIZATRIPTAN ODT MYL PMS-RIZATRIPTAN RDT PMS RIVA-RIZATRIPTAN ODT RIV RIZATRIPTAN RDT PDL SANDOZ RIZATRIPTAN ODT SDZ TEVA-RIZATRIPTAN RDT TEP 5mg Tablet APO-RIZATRIPTAN APX JAMP-RIZATRIPTAN JAP JAMP-RIZATRIPTAN IR JAP MAR-RIZATRIPTAN MAR 10mg Tablet APO-RIZATRIPTAN APX CO RIZATRIPTAN ATP JAMP-RIZATRIPTAN JAP JAMP-RIZATRIPTAN IR JAP MAR-RIZATRIPTAN MAR MAXALT FRS 5mg Wafer MAXALT RPD FRS 10mg Wafer MAXALT RPD FRS SUMATRIPTAN HEMISULFATE 5mg Nasal Spray IMITREX GSK 20mg Nasal Spray IMITREX GSK SUMATRIPTAN SUCCINATE Limited use benefit (prior approval is not required). A total of 12 tablets (or injections) are permitted in a 30-day period. 12mg/mL Injection IMITREX GSK TARO-SUMATRIPTAN TAR 25mg Tablet CO SUMATRIPTAN COB DOM-SUMATRIPTAN DPC MYLAN-SUMATRIPTAN MYL NOVO-SUMATRIPTAN DF TEV PMS-SUMATRIPTAN PMS SUMATRIPTAN SAN Page 89 of 151

106 28:32.28 SELECTIVE SEROTONIN AGONIS SUMATRIPTAN SUCCINATE Limited use benefit (prior approval is not required). A total of 12 tablets (or injections) are permitted in a 30-day period. 50mg Tablet APO-SUMATRIPTAN APX CO SUMATRIPTAN COB DOM-SUMATRIPTAN DPC IMITREX DF GSK MYLAN-SUMATRIPTAN MYL NOVO-SUMATRIPTAN DF TEV PMS-SUMATRIPTAN PMS SANDOZ-SUMATRIPTAN SDZ SUMATRIPTAN SAN SUMATRIPTAN PDL SUMATRIPTAN DF SIV 100mg Tablet APO-SUMATRIPTAN APX CO SUMATRIPTAN COB DOM-SUMATRIPTAN DPC IMITREX DF GSK MYLAN-SUMATRIPTAN MYL NOVO-SUMATRIPTAN TEV NOVO-SUMATRIPTAN DF TEV PMS-SUMATRIPTAN PMS SANDOZ-SUMATRIPTAN SDZ SUMATRIPTAN SAN SUMATRIPTAN PDL SUMATRIPTAN DF SIV ZOLMITRIPTAN Limited use benefit (prior approval is not required). A total of 12 tablets (or injections) are permitted in a 30-day period. 2.5mg Orally Disintegrating Tablet APO-ZOLMITRIPTAN RAPID APX JAMP-ZOLMITRIPTAN ODT JAP MINT-ZOLMITRIPTAN ODT MIN MYLAN-ZOLMITRIPTAN ODT MYL PMS-ZOLMITRIPTAN ODT PMS SANDOZ ZOLMITRIPTAN ODT SDZ SEPTA-ZOLMITRIPTAN-ODT SPT TEVA-ZOLMITRIPTAN OD TEP ZOLMITRIPTAN ODT PDL ZOMIG RAPIMELT AZC 28:32.28 SELECTIVE SEROTONIN AGONIS ZOLMITRIPTAN Limited use benefit (prior approval is not required). A total of 12 tablets (or injections) are permitted in a 30-day period. 2.5mg Tablet APO-ZOLMITRIPTAN APX DOM-ZOLMITRIPTAN DOM JAMP-ZOLMITRIPTAN JAP MAR-ZOLMITRIPTAN MAR MINT-ZOLMITRIPTAN MIN MYLAN ZOLMITRIPTAN MYL PMS-ZOLMITRIPTAN PMS RIVA-ZOLMITRIPTAN RIV SANDOZ ZOLMITRIPTAN SDZ TEVA-ZOLMITRIPTAN TEP ZOLMITRIPTAN PDL ZOMIG AZC 28:32.92 MISCELLANEOUS ANTIMIGRANE AGENTS FLUNARIZINE HCL 5mg Capsule FLUNARIZINE AAP PIZOTYLINE HYDROGEN MALATE 0.5mg Tablet SANDOMIGRAN PED 1mg Tablet SANDOMIGRAN DS PED 28:36.08 ANTIPARKINSONIAN AGENTS - ANTICHOLINERGIC AGENTS BENZTROPINE MESYLATE 1mg/mL Injection BENZTROPINE OMEGA OMG 1mg Tablet PMS-BENZTROPINE PMS 2mg Tablet APO-BENZTROPINE APX PMS-BENZTROPINE PMS ETHOPROPAZINE HCL 50mg Tablet PARSITAN ERF PROCYCLIDINE HCL 0.5mg/mL Elixir PMS-PROCYCLIDINE PMS 2.5mg Tablet PMS-PROCYCLIDINE PMS 5mg Tablet PMS-PROCYCLIDINE PMS Page 90 of 151

107 28:36.08 ANTIPARKINSONIAN AGENTS - ANTICHOLINERGIC AGENTS TRIHEXYPHENIDYL HCL 0.4mg/mL Liquid PMS-TRIHEXYPHENIDYL PMS 2mg Tablet TRIHEXYPHENIDYL AAP 5mg Tablet TRIHEXYPHENIDYL AAP 28:36.12 ANTIPARKINSONIAN AGENTS - CATECHOL-O- METHYLTRANSFERASE (COMT) INHIBITORS ENTACAPONE 200mg Tablet COMTAN NVR MYLAN-ENTACAPONE MYL SANDOZ ENTACAPONE SDZ TEVA-ENTACAPONE TEP 28:36.16 ANTIPARKINSONIAN AGENTS - DOPAMINE PRECURSORS LEVODOPA, BENZERAZIDE 50mg & 12.5mg Capsule PROLOPA HLR 100mg & 25mg Capsule PROLOPA HLR 200mg & 50mg Capsule PROLOPA HLR LEVODOPA, CARBIDOPA 100/25MG Controlled Release Tablet PMS-LEVOCARB CR PMS 200/50MG Controlled Release Tablet PMS-LEVOCARB CR PMS 200MG/50MG Controlled Release Tablet APO-LEVOCARB CR APX 100mg & 25mg Controlled Release Tablet LEVOCARB CR AAP SINEMET CR BMS 200mg & 50mg Controlled Release Tablet SINEMET CR BMS 100mg & 10mg Tablet APO-LEVOCARB APX NOVO-LEVOCARBIDOPA TEV SINEMET BMS 100mg & 25mg Tablet APO-LEVOCARB APX NOVO-LEVOCARBIDOPA TEV PRO-LEVOCARB PDL SINEMET BMS 28:36.16 ANTIPARKINSONIAN AGENTS - DOPAMINE PRECURSORS LEVODOPA, CARBIDOPA 250mg & 25mg Tablet APO-LEVOCARB APX NOVO-LEVOCARBIDOPA TEV SINEMET BMS LEVODOPA, CARBIDOPA,ENTACAPONE 50mg & 12.5mg & 200mg Tablet ALEVO TEV 75mg & 18.75mg & 200mg Tablet ALEVO TEV 100mg & 25mg & 200mg Tablet ALEVO TEV 125mg & 31.25mg & 200mg Tablet ALEVO TEV 150mg & 37.5mg & 200mg Tablet ALEVO TEV 28:36.20 ANTIPARKINSONIAN AGENTS - DOPAMINE RECEPTOR AGONIS BROMOCRIPTINE MESYLATE 5mg Capsule APO-BROMOCRIPTINE APX DOM-BROMOCRIPTINE DPC PMS-BROMOCRIPTINE PMS 2.5mg Tablet APO-BROMOCRIPTINE APX DOM-BROMOCRIPTINE DPC PMS-BROMOCRIPTINE PMS CABERGOLINE For treatment of hyperprolactinemia in patients who have failed therapy with or are intolerant to bromocriptine. 0.5mg Tablet CO CABERGOLINE COB DOINEX PFI PRAMIPEXOLE DIHYDROCHLORIDE 0.25mg Tablet APO-PRAMIPEXOLE APX CO PRAMIPEXOLE CBT DOM-PRAMIPEXOLE DOM MIRAPEX BOE MIRAPEX (ONT) BOE MYLAN-PRAMIPEXOLE MYL NOVO-PRAMIPEXOLE TEV PMS-PRAMIPREXOLE PMS PRAMIPEXOLE SIV PRAMIPEXOLE PDL PRAMIPEXOLE SAN SANDOZ-PRAMIPEXOLE SDZ Page 91 of 151

108 28:36.20 ANTIPARKINSONIAN AGENTS - DOPAMINE RECEPTOR AGONIS PRAMIPEXOLE DIHYDROCHLORIDE 0.5mg Tablet APO-PRAMIPEXOLE APX CO PRAMIPEXOLE CBT MIRAPEX BOE MYLAN-PRAMIPEXOLE MYL NOVO-PRAMIPEXOLE TEV PMS-PRAMIPREXOLE PMS PRAMIPEXOLE SIV PRAMIPEXOLE PDL PRAMIPEXOLE SAN SANDOZ-PRAMIPEXOLE SDZ 1mg Tablet APO-PRAMIPEXOLE APX CO PRAMIPEXOLE CBT MIRAPEX BOE MIRAPEX (ONT) BOE MYLAN-PRAMIPEXOLE MYL NOVO-PRAMIPEXOLE TEV PMS-PRAMIPREXOLE PMS PRAMIPEXOLE SIV PRAMIPEXOLE PDL PRAMIPEXOLE SAN SANDOZ-PRAMIPEXOLE SDZ 1.5mg Tablet APO-PRAMIPEXOLE APX CO PRAMIPEXOLE CBT MIRAPEX BOE MIRAPEX (ONT) BOE MYLAN-PRAMIPEXOLE MYL NOVO-PRAMIPEXOLE TEV PMS-PRAMIPREXOLE PMS PRAMIPEXOLE SIV PRAMIPEXOLE PDL SANDOZ-PRAMIPEXOLE SDZ ROPINIROLE HCL 0.25mg Tablet APO-ROPINIROLE APX CO-ROPINIROLE CBT JAMP-ROPINIROLE JAP PMS-ROPINIROLE PMS RAN-ROPINIROLE RBY REQUIP GSK ROPINIROLE SAN 1mg Tablet APO-ROPINIROLE APX CO-ROPINIROLE CBT JAMP-ROPINIROLE JAP PMS-ROPINIROLE PMS RAN-ROPINIROLE RBY REQUIP GSK ROPINIROLE SAN 28:36.20 ANTIPARKINSONIAN AGENTS - DOPAMINE RECEPTOR AGONIS ROPINIROLE HCL 2mg Tablet APO-ROPINIROLE APX CO-ROPINIROLE CBT JAMP-ROPINIROLE JAP PMS-ROPINIROLE PMS RAN-ROPINIROLE RBY REQUIP GSK ROPINIROLE SAN 5mg Tablet APO-ROPINIROLE APX CO-ROPINIROLE CBT JAMP-ROPINIROLE JAP PMS-ROPINIROLE PMS RAN-ROPINIROLE RBY REQUIP GSK ROPINIROLE SAN 28:36.32 ANTIPARKINSONIAN AGENTS - MONOAMINE OXIDASE B INHIBITORS SELEGILINE HCL 5mg Tablet APO-SELEGILINE APX DOM-SELEGILINE DPC MYLAN-SELEGILINE MYL NOVO-SELEGILINE TEV 28:92.00 MISCELLANEOUS CENTRAL NERVOUS SYEM AGENTS ACAMPROSATE CALCIUM For patients who have been abstinent from alcohol for at least four days and where available, are currently enrolled in an alcohol addiction treatment program 333mg Sustained Release Tablet CAMPRAL MYL TETRABENAZINE 25mg Tablet APO-TETRABENAZINE APX NITOMAN VAE PMS-TETRABENAZINE PMS TETRABENAZINE E Page 92 of 151

109 32:00 CONTRACEPTIVES (NON-ORAL) 32:00.00 CONTRACEPTIVES (NON-ORAL) CONDOM, MALE Device CONDOM, LATEX, LUBRICATED CONDOM, LATEX, LUBRICATED, NONOXYNOL CONDOM, LATEX, NON- LUBRICATED CONDOM, NON-LATEX, LUBRICATED INTRAUTERINE DEVICE Limited use benefit with quantity and frequency limits (prior approval is not required). Coverage is granted for 1 device every 12 months. Device FLEXI-T IUD PRN LIBERTE UT380 SHORT MSC LIBERTE UT380 ANDARD MSC MONA LISA 10 PAE MONA LISA 5 PAE MONA LISA N PAE NOVA-T IUD BEX Page 93 of 151

110 36:00 DIAGNOIC AGENTS (DX) 36:00.00 DIAGNOIC AGENTS (DX) THYROTROPIN ALFA 0.9mg/mL Powder for Solution THYROGEN GEE 36:26.00 DX - DIABETES MELLITUS GLUCOSE OXIDASE, PEROXIDASE Limited use benefit (prior approval not required). The number of test strips that will be covered by the NIHB Program will depend on the client's medical treatment: Clients managing diabetes with insulin will be allowed 500 test strips per 100 days. A client can test up to five times per day. Clients managing diabetes with diabetes medication with a high risk of causing low blood sugar will be allowed 400 test strips per 365 days. A client can test once daily. Clients managing diabetes with diabetes medication with a low risk of causing low blood sugar will be allowed 200 test strips per 365 days. A client can test three to four times per week. Clients managing diabetes with diet/lifestyle therapy only (no insulin or diabetes medications) will be allowed 200 test strips per 365 days. A client can test three to four times per week. Accu-Chek Advantage Strip ACCU-CHEK ADVANTAGE ROC ACCU-CHEK ADVANTAGE (ON) ROC Accu-Chek Aviva Strip ACCU-CHEK AVIVA ROD ACCU-CHEK AVIVA (ON) ROC Accu-Chek Compact Strip ACCU-CHEK COMPACT ROD ACCU-CHEK COMPACT (ON) ROD Accu-Chek Mobile Strip ACCU-CHEK MOBILE ROC ACCU-CHEK MOBILE (ON) ROC Accutrend Strip ACCUTREND ROC ACCUTREND (ON) ROD Ascensia Breeze 2 Strip ASCENSIA BREEZE 2 BAY ASCENSIA BREEZE 2 (ON) BAY Ascensia Contour Strip ASCENSIA CONTOUR BAY ASCENSIA CONTOUR (ON) BAY BG Star Strip BG AR SAC BG AR (ON) SAC Contour Next Strip CONTOUR NEXT BAY CONTOUR NEXT (ON) BAY 36:26.00 DX - DIABETES MELLITUS GLUCOSE OXIDASE, PEROXIDASE Limited use benefit (prior approval not required). The number of test strips that will be covered by the NIHB Program will depend on the client's medical treatment: Clients managing diabetes with insulin will be allowed 500 test strips per 100 days. A client can test up to five times per day. Clients managing diabetes with diabetes medication with a high risk of causing low blood sugar will be allowed 400 test strips per 365 days. A client can test once daily. Clients managing diabetes with diabetes medication with a low risk of causing low blood sugar will be allowed 200 test strips per 365 days. A client can test three to four times per week. Clients managing diabetes with diet/lifestyle therapy only (no insulin or diabetes medications) will be allowed 200 test strips per 365 days. A client can test three to four times per week. EZ Health Strip EZ HEALTH ORACLE TRE EZ HEALTH ORACLE (ON) TRE Freestyle Strip FREEYLE ABB FREEYLE (ON) ABB Freestyle Lite Strip FREEYLE LITE ABB FREEYLE LITE (ON) ABB Freestyle Precision Strip FREEYLE PRECISION ABB FREEYLE PRECISION (ON) ABB Itest Strip ITE AUC ITE (ON) AUC Medi+Sure Strip MEDI+SURE MSD MEDI+SURE (ON) MSD One Touch Ultra Strip ONE TOUCH ULTRA JAJ ONE TOUCH ULTRA (ON) JAJ One Touch Verio Strip ONE TOUCH VERIO JAJ ONE TOUCH VERIO (ON) JAJ Precision Xtra Strip PRECISION XTRA ABB PRECISION XTRA (ON) ABB Sidekick Strip SIDEKICK HOD TrueTest Strip TRUETE HOD Truetrack Strip TRUETRACK HOD TRUETRACK (ON) AUC Page 94 of 151

111 36:88.00 DX - URINE AND FECES CONTENTS GLUCOSE OXIDASE, PEROXIDASE. Strip DIAIX BAY SODIUM NITROPRUSSIDE Strip KETOIX BAY Page 95 of 151

112 40:00 ELECTROLYTIC, CALORIC, AND WATER BALANCE 40:08.00 ALKALINIZING AGENTS CITRIC ACID, SODIUM CITRATE 66.8mg & 100mg/mL Solution DICITRATE PMS SODIUM BICARBONATE 325mg Tablet SODIUM BICARBONATE XEN 40:10.00 AMMONIA DETOXICANTS LACTULOSE 667mg/mL Oral Liquid LACTULOSE SAN TEVA-LACTULOSE TEV 40:12.00 REPLACEMENT PREPARATIONS CALCIUM 500mg Chewable Tablet CALCIUM WAM Oral Liquid CARBOCAL EUR 100mg Oral Liquid NU-CAL ODN SOLUCAL GREEN APPLE JAP SOLUCAL RASPBERRY JAP CALCIUM CARBONATE 500mg Capsule OYER SHELL CALCIUM NUR 500mg Tablet APO-CAL 500 APX CALCIUM PMT CALCIUM WNP CALCIUM TRI CALCIUM PRO CALCIUM CARBONATE JMP EURO-CAL EUR JAMP-CALCIUM JAP NU-CAL ODN O-CALCIUM 500 VTH PMS-CALCIUM PMS CALCIUM LACTOGLUCONATE 20mg/mL Oral Liquid SOLUCAL JMP WAMPOLE MINERAL CALCIUM JMP CALCIUM, VITAMIN D 500mg & 400IU Chewable Tablet CALODAN D ODN CARBOCAL D EUR 500mg Oral Liquid SOLUCAL D CITRUS JAP SOLUCAL D RASPBERRY JAP 40:12.00 REPLACEMENT PREPARATIONS CALCIUM, VITAMIN D 500mg & 1000IU Oral Liquid SOLUCAL D FORT JAP 500mg & 400IU Oral Liquid SOLUCAL D JAP 500mg& 800IU Oral Liquid CALCIUM LACTOGLUCONATE + VIT D Tablet JAP CAL-D PDL 500mg & 1000IU Tablet M-CAL D MAN 500mg & 400IU Tablet CALCITE D 400 RIV CALCIUM + VIT D WAM CALCIUM D 400 TRI CALCIUM 500MG WITH VIT D JMP CARBOCAL D EUR JAMP-CALCIUM + VIT D JAP JAMP-CALCIUM+VITAM D JMP M-CAL D MAN NU-CAL D ODN 500mg & 800IU Tablet M-CAL D MAN 600mg & 400IU Tablet CALCIUM + VIT D WAM ELECTROLYTE & DEXTROSE 3.56g & 300mg & 470mg & 530mg Powder GAROLYTE REG SAC 25mg & 2.2mg & 2.2mg & 0.9mg/mL Solution PEDIALYTE ABB PEDIATRIC ELECTROLYTE PMS ELECTROLYTES, DEXTROSE Miscellaneous HYDRALYTE ELECTROLYTE POPS Powder HPP HYDRALYTE ELECTROLYTE HPP JAMP REHYDRALYTE JAP Solution HYDRALYTE ELECTROLYTE HPP MAGNESIUM 25mg Oral Liquid JAMP-MAGNESIUM JMP 28mg Tablet JAMP-MAGNESIUM JMP 100mg Tablet MAGNESIUM JAM MAGNESIUM CITRATE 5.40% Oral Liquid CITRO MAG 15GM/300ML TCH Page 96 of 151

113 40:12.00 REPLACEMENT PREPARATIONS MAGNESIUM GLUCONATE 100mg/mL Oral Liquid RATIO-MAGNESIUM RPH POTASSIUM CHLORIDE 25MEQ Effervescent Tablet K LYTE WPC 8mmol Long Acting Capsule RIVA-K RIV 600mg Long Acting Capsule MICRO K EXTENCAPS SRC WAY 8mmol Long Acting Tablet APO-K APX EURO-K 600 EUR MK 8 MAN ODAN K-8 ODN PRO-600K PDL 20mmol Long Acting Tablet BIO K-20 BMI EURO-K 20 EUR ODAN K-20 ODN RIVA-K 20 RIV Oral Liquid JAMP-POTASSIUM CHLORIDE JAP K-10 GSK 1.33MEQ/mL Oral Liquid PMS-POTASSIUM PMS Tablet MK 20 MAN 8mmol Tablet JAMP-K 600 JAP 20mmol Tablet JAMP-K 1500 JAP 600mg Tablet SLOW-K TEV POTASSIUM CITRATE 10mmol Long Acting Tablet MK 10 MAN SODIUM CHLORIDE 0.9% Inhalation Diluent BACTERIOATIC NACL BIO SODIUM CHLORIDE SODIUM CHLORIDE BDH 0.9% Injection BACTERIOATIC SODIUM ABB CHLORIDE SODIUM CHLORIDE BAT SODIUM CHLORIDE ABB SODIUM CHLORIDE OMG 40:17.00 CALCIUM-REMOVING RESINS CALCIUM POLYYRENE SULFONATE 1g binds with approx 1.6mmol K Powder RESONIUM CALCIUM SAC 40:18.00 ION-REMOVING AGENTS SODIUM POLYYRENE SULFONATE 1g binds with approx 1mmol K Powder KAYEXALATE SAC K-EXIT OMG PMS-SOD POLYYRENE SULFONA PMS 250mg/mL Oral Suspension PMS-SOD POLYYRENE SULF 250mg/mL Retention Enema PMS-SOD POLYYRENE SULF 40:20.00 CALORIC AGENTS LEVOCARNITINE For treatment of carnitine deficiency 100mg/mL Oral Liquid PMS PMS CARNITOR SIG 200mg/mL Solution CARNITOR IV SIG 330mg Tablet CARNITOR SIG 40:28.08 LOOP DIURETICS ETHACRYNIC ACID 25mg Tablet EDECRIN FRS FUROSEMIDE 10mg/mL Solution LASIX SAC 20mg Tablet APO-FUROSEMIDE APX BIO-FUROSEMIDE BMI FUROSEMIDE PDL FUROSEMIDE SAN LASIX SAC NOVO-SEMIDE TEV PMS-FUROSEMIDE PMS 40mg Tablet APO-FUROSEMIDE APX BIO-FUROSEMIDE BMI FUROSEMIDE PDL FUROSEMIDE SAN LASIX SAC NOVO-SEMIDE TEV PMS-FUROSEMIDE PMS Page 97 of 151

114 40:28.08 LOOP DIURETICS FUROSEMIDE 80mg Tablet APO-FUROSEMIDE APX FUROSEMIDE PDL FUROSEMIDE SAN NOVO-SEMIDE TEV 500mg Tablet LASIX SPECIAL SAC 40:28.16 POTASSIUM SPARING DIURETICS AMILORIDE HCL 5mg Tablet MIDAMOR AAP AMILORIDE HCL, HYDROCHLOROTHIAZIDE 5mg & 50mg Tablet AMI-HYDRO PDL APO-AMILZIDE APX NOVAMILOR TEV TRIAMTERENE, HYDROCHLOROTHIAZIDE 50mg & 25mg Tablet APO-TRIAZIDE APX NOVO-TRIAMZIDE TEV PRO-TRIAZIDE PRO 40:28.20 TIAZIDE DIURETICS HYDROCHLOROTHIAZIDE 12.5mg Tablet APO-HYDRO APX MINT- MIN HYDROCHLOROTHIAZIDE PMS-HYDROCHLOROTHIAZIDE BMI 25mg Tablet APO-HYDROCLOROTHIAZIDE APX BIO-HYDROCHLOROTHIAZIDE BMI HYDROCHLOROTHIAZIDE PDL HYDROCHLOROTHIAZIDE SAN MINT- MIN HYDROCHLOROTHIAZIDE NOVO-HYDRAZIDE TEV PMS-HYDROCHLOROTHIAZIDE PMS 50mg Tablet APO-HYDRO APX BIO-HYDROCHLOROTHIAZIDE BMI HYDROCHLOROTHIAZIDE SAN MINT- MIN HYDROCHLOROTHIAZIDE NOVO-HYDRAZIDE TEV PMS-HYDROCHLOROTHIAZIDE PMS 100mg Tablet APO-HYDRO APX 40:28.24 THIAZIDE LIKE DIURETICS CHLORTHALIDONE 50mg Tablet CHLORTHALIDONE AAP 100mg Tablet APO-CHLORTHALIDONE APX INDAPAMIDE 1.25mg Tablet APO-INDAPAMIDE APX DOM-INDAPAMIDE DPC JAMP-INDAPAMIDE JAP LOZIDE SEV MYLAN-INDAPAMIDE MYL PHL-INDAPAMIDE PHH PMS-INDAPAMIDE PMS PRO-INDAPAMIDE PDL RIVA-INDAPAMIDE RIV 2.5mg Tablet APO-INDAPAMIDE APX DOM-INDAPAMIDE DPC JAMP-INDAPAMIDE JAP LOZIDE SEV MYLAN-INDAPAMIDE MYL NOVO-INDAPAMIDE TEV PMS-INDAPAMIDE PMS PRO-INDAPAMIDE PDL RIVA-INDAPAMIDE RIV METOLAZONE 2.5mg Tablet ZAROXOLYN AVT 40:36.00 IRRIGATING SOLUTIONS WATER Injection ERILE WATER ABB ERILE WATER (QC) ERILE WATER FOR INJ OMG ERILE WATER FOR INJ HOS WATER FOR INJECTION (QC) 40:40.00 URICOSURIC AGENTS SULFINPYRAZONE 200mg Tablet SULFINPYRAZONE AAP Page 98 of 151

115 48:00 RESPIRATORY TRACT AGENTS 48:10.24 LEUKOTRIENE MODIFIERS MONTELUKA For treatment of: a. - asthma when used in patients on concurrent steroid therapy. b. - asthma patients not well controlled with or intolerant to inhaled corticosteroids. 4mg Chewable Tablet ACH-MONTELUKA ACC APO-MONTELUKA APX MONTELUKA SIV MYLAN-MONTELUKA MYL PMS-MONTELUKA PMS SANDOZ MONTELUKA TEP SINGULAIR FRS TEVA- MONTELUKA TEP 5mg Chewable Tablet ACH-MONTELUKA ACC APO-MONTELUKA APX MONTELUKA SAN MONTELUKA SIV MYLAN-MONTELUKA MYL PMS-MONTELUKA PMS SANDOZ MONTELUKA TEP SINGULAIR FRS TEVA- MONTELUKA TEP 4mg Granules SANDOZ MONTELUKA SDZ SINGULAIR FRS 4mg Tablet MAR-MONTELUKA MAR MINT-MONTELUKA MIN MONTELUKA SAN MONTELUKA PDL RAN-MONTELUKA RBY 5mg Tablet MAR-MONTELUKA MAR MINT-MONTELUKA MIN MONTELUKA PDL RAN-MONTELUKA RBY 48:10.24 LEUKOTRIENE MODIFIERS MONTELUKA For treatment of: a. - asthma when used in patients on concurrent steroid therapy. b. - asthma patients not well controlled with or intolerant to inhaled corticosteroids. 10mg Tablet APO-MONTELUKA APX AURO-MONTELUKA AUR DOM-MONTELUKA DOM JAMP-MONTELUKA JAP MAR-MONTELUKA MAR MINT-MONTELUKA MIN MONTELUKA ACC MONTELUKA SAN MONTELUKA PDL MONTELUKA SIV MYLAN-MONTELUKA MYL PMS-MONTELUKA PMS RAN-MONTELUKA RBY RIVA-MOTELUKA RIV SANDOZ MONTELUKA SDZ SINGULAIR FRS TEVA- MONTELUKA TEP ZAFIRLUKA For treatment of: a. - asthma when used in patients on concurrent steroid therapy. b. - asthma patients not well controlled with or intolerant to inhaled corticosteroids. 20mg Tablet ACCOLATE AZC 48:10.32 MA CELL ABILIZERS SODIUM CROMOGLYCATE 100mg Capsule NALCROM AVT 10mg/mL Inhalation Solution (Unit Dose) PMS-SOD CROMOGLYCATE PMS 2% Nasal Solution APO-CROMOLYN APX RHINARIS-CS PMS 2% Ophth Solution CROMOLYN PMS OPTICROM ALL Page 99 of 151

116 52:00 EYE, EAR, NOSE AND THROAT (EENT) PREPARATIONS 52:02.00 EENT - ANTIALLERGIC AGENTS LEVOCABAINE HCL 0.05% Nasal Spray LIVOIN JNO OLOPATADINE HCL 0.1% Ophth Solution ACT OLOPATADINE ATP APO-OLOPATADINE APX PATANOL ALC SANDOZ OLOPATADINE SDZ 0.2% Ophth Solution ACT OLOPATADINE ATP APO-OLOPATADINE APX SANDOZ OLOPATADINE SDZ 52:04.04 EENT - ANTIBACTERIALS BACITRACIN ZINC, POLYMYXIN B SULFATE 500IU & 10,000IU/g Ophth Ointment OPTIMYXIN SDZ POLYSPORIN PFI CHLORAMPHENICOL 1% Ophth Ointment DIOCHLORAM DKT 0.5% Ophth Solution DIOCHLORAM DKT CIPROFLOXACIN HCL 0.3% Ophth Ointment CILOXAN 0.3% ALC 0.3% Ophth Solution APO-CIPROFLOX APX CILOXAN ALC SANDOZ CIPROFLOXACIN SDZ CIPROFLOXACIN HCL, DEXAMETHASONE 0.3%/0.1% Otic Solution CIPRODEX ALC ERYTHROMYCIN 5mg/g Ophth Ointment ERYTHROMYCIN G PMS-ERYTHROMYCIN PMS FRAMYCETIN SULFATE 0.5% Ophth Ointment SOFRAMYCIN ERILE EYE ERF 0.5% Ophth Solution SOFRAMYCIN ERF GATIFLOXACIN 0.3% Ophth Solution ZYMAR ALL 52:04.04 EENT - ANTIBACTERIALS GENTAMICIN SULFATE 0.3% Ophth Ointment DIOGENT DKT 0.3% Solution DIOGENT DKT GENTAMICIN SPH PMS-GENTAMICIN PMS GRAMICIDIN, POLYMYXIN B SULFATE 0.025mg & 10,000U/mL Solution OPTIMYXIN EYE/EAR SDZ POLYSPORIN EYE/EAR WLA MOXIFLOXACIN HCL 0.5% Ophth Solution VIGAMOX ALC OFLOXACIN 0.3% Ophth Solution APO-OFLOXACIN APX OCUFLOX ALL SANDOZ OFLOXACIN SDZ POLYMYXIN B SULFATE, TRIMETHOPRIM SULFATE 10,000U & 1mg/mL Ophth Solution PMS-POLYTRIMETHOPRIM PMS POLYTRIM ALL SANDOZ POLYTRIMETHOPRIM SDZ SULFACETAMIDE SODIUM 10% Ophth Solution DIOSULF DKT TOBRAMYCIN 0.3% Ophth Ointment TOBREX ALC 0.3% Ophth Solution SANDOZ-TOBRAMYCIN SDZ TOBREX ALC 52:04.20 EENT - ANTIVIRALS TRIFLURIDINE 1% Ophth Solution VIROPTIC GSK 52:08.08 EENT - CORTICOEROIDS BECLOMETHASONE DIPROPIONATE 50mcg/Dose Nasal Spray APO-BECLOMETHASONE APX MYLAN-BECLO AQ MYL RIVANASE AQ RIV BETAMETHASONE SODIUM PHOSPHATE, GENTAMICIN SULFATE 0.1% & 0.3% Ophth Ointment GARASONE SCH Page 100 of 151

117 52:08.08 EENT - CORTICOEROIDS BUDESONIDE 64mcg/Dose Nasal Spray MYLAN-BUDESONIDE AQ MYL RHINOCORT AQ AZC 100mcg/Dose Nasal Spray MYLAN-BUDESONIDE AQ MYL 100mcg/Dose Powder RHINOCORT TURBUHALER AZC DEXAMETHASONE 0.1% Ophth Ointment MAXIDEX ALC 0.1% Ophth Solution DIODEX DKT PMS-DEXAMETHASONE PMS SANDOZ-DEXAMETHASONE SDZ 0.1% Ophth Suspension MAXIDEX ALC DEXAMETHASONE, TOBRAMYCIN 0.1% & 0.3% Ophth Ointment TOBRADEX ALC 0.1% & 0.3% Ophth Suspension TOBRADEX ALC FLUMETHASONE PIVALATE, CLIOQUINOL 0.02% & 1% Otic Solution LOCACORTEN VIOFORM PAL FLUNISOLIDE 0.25mg/mL Nasal Spray APO-FLUNISOLIDE APX FLUOROMETHOLONE 0.1% Ophth Solution PMS-FLUOROMETHOLONE PMS SANDOZ FLUOROMETHOLONE SDZ 0.1% Ophth Suspension FML ALL 0.25% Ophth Suspension FML FORTE ALL FLUOROMETHOLONE ACETATE 0.1% Ophth Solution FLAREX ALC FLUTICASONE PROPIONATE 50mcg/Dose Nasal Spray APO-FLUTICASONE APX FLONASE GSK RATIO-FLUTICASONE RPH FRAMYCETIN SULFATE, GRAMICIDIN, DEXAMETHASONE 5mg & 0.05mg/mL & 0.5mg Ophth/Otic Solution SOFRACORT EYE/EAR SAC 52:08.08 EENT - CORTICOEROIDS MOMETASONE FUROATE 50mcg Nasal Spray APO-MOMETASONE APX NASONEX SCH PREDNISOLONE ACETATE 0.12% Ophth Suspension PRED MILD ALL 1% Ophth Suspension PRED FORTE ALL RATIO-PREDNISOLONE RPH SANDOZ-PREDNISOLONE SDZ PREDNISOLONE ACETATE, SULFACETAMIDE SODIUM 0.2% & 10% Ophth Ointment BLEPHAMIDE ALL 0.2% & 10% Ophth Suspension BLEPHAMIDE ALL 0.5% & 10% Ophth Suspension DIOPTIMYD DKT PREDNISOLONE SODIUM PHOSPHATE 0.5% Ophth Solution PREDNISOLONE CUV TRIAMCINOLONE ACETONIDE 55mcg/Dose Nasal Spray NASACORT AQ SAC 52:08.20 EENT - NONEROIDAL ANTI- INFLAMMATORY AGENTS DICLOFENAC SODIUM 0.1% Ophth Solution VOLTAREN NVR KETOROLAC TROMETHAMINE 0.45% Ophth Solution ACUVAIL ALL 0.5% Ophth Solution ACULAR ALL APO-KETOROLAC APX NEPAFENAC 0.1% Ophth Solution NEVANAC 0.1% OP SOL ALC 0.3% Ophth Solution ILEVRO 0.3% OP SUSP ALC 52:12.00 EENT - CONTACT LENS SOLUTION HYPROMELLOSE 3mg Ophth Solution GENTEAL NVC Page 101 of 151

118 52:20.00 EENT - MIOTICS CARBACHOL 1.5% Ophth Solution ISOPTO CARBACHOL ALC 52:24.00 EENT - MYDRIATICS ATROPINE SULFATE 1% Ophth Solution ATROPINE DKT ATROPINE SULPHATE MINIMS NVR ISOPTO ATROPINE ALC CYCLOPENTOLATE HCL 0.5% Ophth Solution CYCLOPENTOLATE NVR 1% Ophth Solution CYCLOGYL ALC CYCLOPENTOLATE MINIMS NVR DIOPENTOLATE DKT DIPIVEFRIN HCL 0.1% Ophth Solution APO-DIPIVEFRIN APX PMS-DIPIVEFRIN PMS HOMATROPINE HBR 2% Ophth Solution ISOPTO HOMATROPINE ALC 5% Ophth Solution ISOPTO HOMATROPINE ALC TROPICAMIDE 0.5% Ophth Solution MYDRIACYL ALC 1% Ophth Solution MYDRIACYL ALC 52:28.00 EENT - MOUTHWASHES AND GARGLES BENZYDAMINE HCL For: a. - treatment of radiation mucositis and oral ulcerative complications of chemotherapy. b. - use in immunocompromised patients who are at risk of mucosal breakdown. 0.15% Rinse APO-BENZYDAMINE APX DOM-BENZYDAMINE DPC PMS-BENZYDAMINE PMS TEVA-BENZYDAMINE TEV CHLORHEXIDINE GLUCONATE 0.12% Rinse G.U.M. PAROEX SUS PERICHLOR PMS PERIDEX MMH PERIOGARD COP 52:32.00 EENT - VASOCONRICTORS ANTAZOLINE PHOSPHATE, NAPHAZOLINE HCL 0.5% & 0.05% Ophth Solution ALBALON A ALL NAPHAZOLINE HCL 0.1% Ophth Solution ALBALON ALL NAPHCON FORTE ALC PHENYLEPHRINE HCL 0.12% Ophth Solution PREFRIN LIQUIFILM ALL 2.5% Ophth Solution DIONEPHRINE DKT MYDFRIN ALC PHENYLEPHRINE MINIMS NVR 10% Ophth Solution PHENYLEPHRINE NVR 52:40.04 EENT - ALPHA-ADRENERGIC AGONIS BRIMONIDINE TARTRATE 0.2% Ophth Solution ALPHAGAN ALL APO-BRIMONIDINE APX PMS-BRIMONIDINE PMS RATIO-BRIMONIDINE RPH SANDOZ BRIMONIDINE SDZ BRIMONIDINE TARTRATE (ALPHAGAN P) For patients who are intolerant to brimonidine tartrate 0.2% or benzalkonium chloride. 0.15% Ophth Solution ALPHAGAN P ALL APO-BRIMONIDINE P APX BRIMONIDINE TARTRATE, TIMOLOL MALEATE 0.2% & 0.5% Ophth Solution COMBIGAN ALL 52:40.08 EENT - BETA-ADRENERGIC BLOCKING AGENTS BETAXOLOL HCL 0.5% Ophth Solution SANDOZ-BETAXOLOL SDZ 0.25% Ophth Suspension BETOPTIC S ALC LEVOBUNOLOL HCL 0.25% Ophth Solution APO-LEVOBUNOLOL APX BETAGAN ALL RATIO-LEVOBUNOLOL RPH Page 102 of 151

119 52:40.08 EENT - BETA-ADRENERGIC BLOCKING AGENTS LEVOBUNOLOL HCL 0.5% Ophth Solution BETAGAN ALL PMS-LEVOBUNOLOL PMS RATIO-LEVOBUNOLOL RPH SANDOZ-LEVOBUNOLOL SDZ TIMOLOL MALEATE 0.25% Long Acting Ophth Solution TIMOPTIC-XE FRS 0.5% Long Acting Ophth Solution TIMOPTIC-XE FRS 0.25% Ophth Gel Solution TIMOLOL MALEATE-EX PMS 0.5% Ophth Gel Solution APO-TIMOP APX TIMOLOL MALEATE-EX PMS 0.25% Ophth Solution APO-TIMOP APX DOM-TIMOLOL DPC NOVO-TIMOL TEV PMS-TIMOLOL PMS 0.5% Ophth Solution APO-TIMOP APX DOM-TIMOLOL DPC PMS-TIMOLOL PMS SANDOZ-TIMOLOL SDZ TIMOPTIC FRS 52:40.12 EENT - CARBONIC ANHYDRASE INHIBITORS ACETAZOLAMIDE 250mg Tablet ACETAZOLAMIDE AAP BRINZOLAMIDE 1% Ophth Suspension AZOPT ALC BRINZOLAMIDE/TIMOLOL MALEATE 1%/0.5% Ophth Solution AZARGA ALC DORZOLAMIDE HCL 2% Ophth Solution TRUSOPT FRS 20mg/mL Ophth Solution SANDOZ DORZOLAMIDE SDZ 52:40.12 EENT - CARBONIC ANHYDRASE INHIBITORS DORZOLAMIDE HCL, TIMOLOL MALEATE 20mg & 5mg/mL Ophth Solution ACT DORZOTIMOLOL ATP APO-DORZO-TIMOP APX COSOPT FRS SANDOZ SDZ DORZOLAMIDE/TIMOLOL TEVA-DORZOTIMOL TEP METHAZOLAMIDE 50mg Tablet METHAZOLAMIDE AAP 52:40.20 EENT - MIOTICS CARBACHOL 0.01% Ophth Solution MIOAT ALC 3% Ophth Solution ISOPTO CARBACHOL ALC PILOCARPINE HCL 4% Ophth Gel PILOPINE HS ALC 1% Ophth Solution ISOPTO CARPINE ALC PILOCARPINE SCN 2% Ophth Solution ISOPTO CARPINE ALC 4% Ophth Solution DIOCARPINE DKT ISOPTO CARPINE ALC PILOCARPINE NITRATE 2% Ophth Solution PILOCARPINE NITRATE MINIMS 52:40.28 EENT - PROAGLANDIN AGENTS BIMATOPRO 0.01% Ophth Solution NVR LUMIGAN ALL LATANOPRO 0.005% Ophth Solution APO-LATANOPRO APX CO LATANOPRO CBT GD-LATANOPRO PFI LATANOPRO RIV MED-LATANOPRO GMP PMS-LATANOPRO PMS SANDOZ LATANOPRO SDZ XALATAN PFI Page 103 of 151

120 52:40.28 EENT - PROAGLANDIN AGENTS LATANOPRO/TIMOLOL MALEATE 0.005% & 0.5% Ophth Solution APO-LATANOPRO-TIMOP APX GD-LATANOPRO/TIMOLOL PFI PMS-LATANOPRO-TIMOLOL PMS SANDOZ SDZ LATANOPRO/TIMOLOL TEVA- TEP LATANOPRO/TIMOLOL XALACOM PFI TIMOLOL MALEATE, TRAVOPRO 0.5% & 0.004% Ophth Solution DUO TRAV ALC TRAVOPRO 0.004% Ophth Solution APO-TRAVOPRO Z APX SANDOZ TRAVOPRO SDZ TEVA-TRAVOPRO Z TEP TRAVATAN Z ALC 52:92.00 MISCELLANEOUS EENT DRUGS APRACLONIDINE HCL 0.5% Ophth Solution IOPIDINE ALC DEXTRAN 70, HYDROXYPROPYLMETHYLCELLULOSE 0.1% & 0.3% Ophth Solution TEARS NATURALE ALC TEARS NATURALE FREE ALC TEARS NATURALE II ALC DIPIVEFRIN HCL, LEVOBUNOLOL HCL 0.1% & 0.5% Ophth Solution PROBETA ALL HYDROXYPROPYL CELLULOSE 5mg Ophth Solution LACRISERT FRS HYDROXYPROPYLMETHYLCELLULOSE 0.5% Ophth Solution ISOPTO TEARS ALC 1% Ophth Solution ISOPTO TEARS ALC LODOXAMIDE TROMETHAMINE 0.1% Ophth Solution ALOMIDE ALC MACROGOL, PROPYLENE GLYCOL 15% & 20% Nasal Gel LUBRICATING NASAL GEL PMS SECARIS PMS 52:92.00 MISCELLANEOUS EENT DRUGS MACROGOL, PROPYLENE GLYCOL 15% & 20% Nasal Spray LUBRICATING NASAL MI PMS MINERAL OIL, PETROLATUM 80% & 20% Ophth Ointment DUOLUBE BSH MINERAL OIL, WHITE PETROLATUM 55.5% & 42.5% Ophth Ointment LACRI LUBE ALL PETROLATUM, LANOLIN, MINERAL OIL 94% & 3% & 3% Ophth Ointment TEARS NATURALE P.M. ALC PETROLATUM, PETROLATUM LIQUID 85% & 15% Ophth Ointment HYPOTEARS NVR POLYVINYL ALCOHOL 1% Ophth Solution HYPOTEARS NVR 1.4% Ophth Solution ARTIFICIAL TEARS PMS TEARS PLUS ALL POLYVINYL ALCOHOL, POVIDONE 1.4% & 0.6% Ophth Solution ARTIFICIAL TEARS EXTRA PMS Page 104 of 151

121 52:92.00 MISCELLANEOUS EENT DRUGS RANIBIZUMAB For the treatment of: a. Diabetic Macular Edema (DME) b. Wet Age-Related Macular Degeneration (w-amd) Criteria for coverage of ranibizumab (Lucentis) for DME and w- AMD: Administered by a qualified ophthalmologist experienced in intravitreal injections Interval between doses not shorter than 1 month Note: Coverage will be limited to a maximum of 1 vial of Lucentis per eye treated every 30 days For the treatment of diabetic macular edema (DME) for patients who meet the following: Clinically significant diabetic macular edema for whom laser photocoagulation is also indicated; AND Have a hemoglobin A1c of less than 11% Initial Coverage for the treatment of neovascular wet agerelated macular degeneration (wamd) where all of the following apply to the eye to be treated: Best Corrected Visual Acuity (BCVA) is between 6/12 and 6/96 The lesion size is less than or equal to 12 disc areas in greatest linear dimension There is evidence of recent (< 3 months) presumed disease progression (blood vessel growth, as indicated by fluorescein angiography, or optical coherence tomography (OCT)) Note: Coverage will not be approved for patients: With permanent retinal damage as defined by the Royal College of Ophthalmology guidelines. Receiving concurrent treatment with verteporfin Continued Coverage: Treatment with Lucentis for wamd should be continued only in people who maintain adequate response to therapy Treatment with Lucentis should be permanently discontinued if any one of the following occurs: Reduction in BCVA in the treated eye to less than 15 letters (a bsolute) on two (2) consecutive visits in the treated eye, attributed to AMD in the absence of other pathology Reductions in BCVA of 30 letters or more compared to either baseline and/or best recorded level since baseline as this may indicate either poor treatment effect, adverse events or both. There is evidence of deterioration of the lesion morphology despite optimum treatment over three (3) consecutive visits. 10MG/ML INJ LUCENTIS PFS 10MG/ML INJ TEV SODIUM CARBOXYMETHYL CELLULOSE 0.5% Ophth Solution REFRESH PLUS ALL 1% Ophth Solution CELLUVISC ALL 10mg/mL Ophth Solution REFRESH LIQUIGEL ALL 0.5% Ophth Solution (Multi-Dose) REFRESH TEARS ALL SODIUM CHLORIDE 0.7% Nasal Solution OTRIVIN SALINE NVC 52:92.00 MISCELLANEOUS EENT DRUGS SODIUM CHLORIDE 9mg/mL Nasal Solution SALINEX SDZ SALINEX DROPS SDZ 0.7% Nasal Spray OTRIVIN SALINE NVC 5% Ophth Ointment MURO-128 BSH 5% Ophth Solution MURO-128 BSH VERTEPORFIN For treatment of age related macular degeneration for patients with this diagnosis who are being treated by a certified ophthalmologist. 15mg/Vial Injection VISUDYNE QLT Page 105 of 151

122 56:00 GAROINTEINAL DRUGS 56:04.00 ANTACIDS AND ADSORBENTS BISMUTH SUBSALICYLATE 17.6mg/mL Liquid PEPTO BISMOL PGI 262mg Tablet PEPTO BISMOL PGI MAG OXIDE 420mg Tablet MAGNESIUM OXIDE SWS 56:08.00 ANTIDIARRHEA AGENTS LOPERAMIDE HCL 0.2mg/mL Liquid DIARR-EZE PMS PMS-LOPERAMIDE PMS 2mg/15mL Liquid IMODIUM CALMING LIQUID JNO 2mg Tablet ANTI-DIARRHEAL 2MG TAB A APO-LOPERAMIDE APX DIARR-EZE PMS DIARRHEA RELIEF VTH DIARRHEA RELIEF 2MG TAB PMS DOM-LOPERAMIDE DPC IMODIUM MCL LOPERAMIDE PDL NOVO-LOPERAMIDE TEV PMS-LOPERAMIDE PMS RIVA-LOPERAMIDE RIV SANDOZ-LOPERAMIDE SDZ 56:12.00 CATHARTICS AND LAXATIVES BISACODYL 5mg Delayed Release Tablet BISACODYL-ODAN ODN 5mg Enteric Coated Tablet APO-BISACODYL APX BISACOLAX ICN DULCOLAX BOE JAMP-BISACODYL JMP PMS-BISACODYL PMS 5mg Suppository BISACODYL JAP DULCOLAX BOE 10mg Suppository BISACOLAX ICN DULCOLAX BOE JAMP-BISACODYL JAP PMS-BISACODYL PMS RATIO-BISACODYL RPH SOFLAX EX PMS 56:12.00 CATHARTICS AND LAXATIVES BISACODYL (POLYETHYLENE GLYCOL BASE) 10mg Suppository MAGIC BULLET DCM CITRIC ACID, MAGNESIUM OXIDE, SODIUM PICOSULFATE Oral Liquid PURG-ODAN ODN Powder PICO-SALAX FEI DOCUSATE CALCIUM 240mg Capsule APO-DOCUSATE CALCIUM APX DOCUSATE CALCIUM TAR JAMP-DOCUSATE CALCIUM JMP NOVO-DOCUSATE CALCIUM TEV PMS-DOCUSATE CALCIUM PMS RATIO-DOCUSATE CALCIUM RPH DOCUSATE SODIUM 100mg Capsule APO-DOCUSATE SODIUM APX COLACE WPC DOCUSATE SODIUM SDR DOCUSATE SODIUM TRI DOCUSATE SODIUM JMP DOCUSATE SODIUM RPH DOCUSATE SODIUM PDL DOCUSATE SODIUM SAN DOM-DOCUSATE SODIUM DPC EURO-DOCUSATE EUR EURO-DOCUSATE EUR NOVO-DOCUSATE TEV PMS-DOCUSATE SODIUM PMS RATIO-DOCUSATE SODIUM RPH SELAX ODN SOFLAX PMS OOL SOFTENER PMS OOL SOFTENER VTH TARO-DOCUSATE TAR 200mg Capsule SOFLAX PMS 250mg Capsule SELAX ODN 10mg/mL Drop COLACE WPC DOCUSATE SODIUM RPH PMS-SODIUM DOCUSATE PMS SOFLAX PMS Page 106 of 151

123 56:12.00 CATHARTICS AND LAXATIVES DOCUSATE SODIUM 4mg/mL Syrup COLACE WPC DOCUSATE SODIUM ATL PMS-DOCUSATE SODIUM PMS RATIO-DOCUSATE SODIUM RPH SELAX ODN SOFLAX SYRUP PMS 20mg/mL Syrup DOCUSATE SODIUM JMP 50mg/mL Syrup DOCUSATE SODIUM JMP PMS-DOCUSATE SODIUM PMS DOCUSATE SODIUM, SENNA 50mg & 187mg Tablet SENOKOT S PFR 50mg & 8.6mg Tablet EURO-SENNA S EUR GLYCERINE Adult Suppository GLYCERIN RPH GLYCERIN WLA GLYCERIN TCH JAMP GLYCERIN JAP Pediatric Suppository GLYCERIN INFANT RPH GLYCERIN INFANT & CHILD PFI LACTULOSE 667mg/mL Oral Liquid APO-LACTULOSE APX EURO-LAC EUR LACTULOSE JMP PMS-LACTULOSE PMS RATIO-LACTULOSE RPH MACROGOL, POTASSIUM CHLORIDE, SODIUM BICARBONATE, SODIUM CHLORIDE, SODIUM SULFATE 60g & 750mg & 1.68g & 1.46g & 5.68g/L Powder COLYTE ZYM GOLYTELY BAX PEGLYTE PMS MAGNESIUM HYDROXIDE 80mg/mL Liquid MILK OF MAGNESIA PMS MILK OF MAGNESIA BCD PLAIN/SUGARFREE 311mg Tablet MILK OF MAGNESIA BCD 56:12.00 CATHARTICS AND LAXATIVES MINERAL OIL 78% Jelly LANSOYL GEL AXC LANSOYL GEL SUGARFREE AXC Liquid MINERAL OIL (HEAVY) RWP PLANTAGO SEED 50% Powder MUCILLIUM PMS POLYETHYLENE GLYCOL 3350 Kit BI-PEGLYTE KIT PEI Powder POLYETHYLENE GLYCOL WIL POLYETHYLENE GLYCOL 3350 WIL 1g/g Powder RELAXA RLI 1g/g Powder LAX-A-DAY PED PEG 3350 MDS POLYETHYLENE GLYCOL, POTASSIUM CHLORIDE, SODIUM BICARBONATE, SODIUM CHLORIDE, SODIUM SULFATE Oral Liquid KLEAN-PREP RVX PSYLLIUM HYDROPHILIC MUCILLOID 680mg/g Powder METAMUCIL ORIGINAL PGI TEXTURE METAMUCIL SM TEXT PGI ORANGE METAMUCIL SM TEXT PGI ORANGE S/F METAMUCIL SM TEXT UNFLAV PGI SENNOSIDES 1.7mg/Ml Liquid JAMP-SENNA JAP SENNALAX PMS SENNAPREP PMS SENOKOT PFR 8.6mg Tablet EURO-SENNA EUR JAMP-SENNA JAP JAMP-SENNOSIDES JMP M-SENNOSIDES MAN PMS-SENNOSIDES PMS RIVA-SENNA RIV SENNA LAXATIVE SDR SENNATAB PMS SENOKOT PFR Page 107 of 151

124 56:12.00 CATHARTICS AND LAXATIVES SENNOSIDES 12MG Tablet JAMP-SENNOSIDES JMP PMS-SENNOSIDES PMS SODIUM BIPHOSPHATE 2.4gm Oral Liquid JAMP-SODIUM PHOSPHATE JAP SODIUM CITRATE, SODIUM LAURYL SULFOACETATE, SORBITOL 90mg & 9mg & 625mg Enema MICROLAX PMS SODIUM PHOSPHATE Oral Liquid PHOSLAX ODN SODIUM PHOSPHATE DIBASIC, SODIUM PHOSPHATE MONOBASIC 180mg & 480mg/mL Oral Liquid PMS-PHOSPHATES SOLUTION PMS 60mg & 160mg/mL Rectal Liquid ENEMOL DPC FLEET ENEMA FRS 60mg & 160mg/mL PED Rectal Liquid FLEET ENEMA PEDIATRIC JAJ 56:14.00 CHOLELITHOLYTIC AGENTS URSODIOL 250mg Tablet PHL-URSODIOL C PHH PMS-URSODIOL PMS URSO AXC 500mg Tablet PHL-URSODIOL C PHH PMS-URSODIOL PMS URSO DS AXC 56:16.00 DIGEANTS ANETHOLE TRITHIONE 25mg Tablet SIALOR PAL LACTASE Tablet LACTAID ULTRA JNO 3,000U Tablet DAIRY DIGEIVE PER DAIRY DIGEIVE SDR DAIRYAID TAN LACTAID JNO LACTOMAX KIN 56:16.00 DIGEANTS LACTASE 4,500U Tablet DAIRY DIGEIVE EXTRA SDR RENGTH LACTAID EXTRA RENGTH JNO LACTOMAX EXTRA KIN LIPASE, AMYLASE, PROTEASE 6,000U & 30,000U & 19,000U Capsule CREON MINIMICROSPHERES 6 ABB 8,000U & 30,000U & 30,000U Capsule COTAZYM ORG 4,000U & 12,000U & 12,000U Capsule (Enteric Coated Particles) PANCREASE MT 4 JNO 4,500U & 20,000U & 25,000U Capsule (Enteric Coated Particles) ULTRASE MS 4 AXC 8,000U & 30,000U & 30,000U Capsule (Enteric Coated Particles) COTAZYM ECS 8 ORG 10,000U & 30,000U & 30,000U Capsule (Enteric Coated Particles) PANCREASE MT 10 JNO 10,000U & 33,200U & 37,500U Capsule (Enteric Coated Particles) CREON 10 MINIMICROSPHERES SPH 12,000U & 39,000U & 39,000U Capsule (Enteric Coated Particles) ULTRASE MT 12 AXC 16,000U & 48,000U & 48,000U Capsule (Enteric Coated Particles) PANCREASE MT 16 JNO 20,000U & 55,000U & 55,000U Capsule (Enteric Coated Particles) COTAZYM ECS 20 ORG 20,000U & 65,000 & 65,000U Capsule (Enteric Coated Particles) ULTRASE MT 20 AXC 25,000U & 74,000U & 62,500U Capsule (Enteric Coated Particles) CREON 25 MINIMICROSPHERES 8,000U & 30,000U & 30,000U Tablet SPH VIOKASE AXC 16,000U & 60,000U & 60,000U Tablet VIOKASE AXC 56:20.00 EMETICS IPECAC 14mg/mL Syrup IPECAC XEN Page 108 of 151

125 56:22.00 ANTIEMETICS DIMENHYDRINATE 50mg Tablet MOTION SICKNESS ATM 56:22.08 ANTIHIAMINES DIMENHYDRINATE 50mg/mL Injection DIMENHYDRINATE SDZ GRAVOL HOR 3mg/mL Liquid GRAVOL HOR 25mg Suppository GRAVOL HOR 50mg Suppository DIMENHYDRINATE SDZ 100mg Suppository GRAVOL ADULT HOR 15mg Tablet GRAVOL HOR 50mg Tablet APO-DIMENHYDRINATE APX GRAVOL HOR NAUSEATOL SDZ PMS-DIMENHYDRINATE PMS TEVA-DIMENATE TEV TRAVEL AID VTH TRAVEL TABLET JMP DOXYLAMINE SUCCINATE, PYRIDOXINE HCL 10mg & 10mg Tablet DICLECTIN DUI 56: HT3 RECEPTOR ANTAGONIS DOLASETRON MESYLATE 100mg Tablet ANZEMET SAC GRANISETRON 1mg Tablet GRANISETRON AAP KYTRIL HLR ONDANSETRON HCL DIHYDRATE 0.8mg/mL Liquid ONDANSETRON AAP ZOFRAN GSK 4mg Orally Disintegrating Tablet ZOFRAN ODT GSK 8mg Orally Disintegrating Tablet ZOFRAN ODT GSK 56: HT3 RECEPTOR ANTAGONIS ONDANSETRON HCL DIHYDRATE 4mg Tablet APO-ONDANSETRON APX CO-ONDANSETRON CBT JAMP ONDANSETRON JMP MAR-ONDANSETRON MAR MINT-ONDANSETRON MIN MYLAN-ONDANSETRON MYL NOVO-ONDANSETRON TEV ONDANSETRON SAN ONDANSETRON-ODAN ODN ONDISSOLVE ODF TAK PHL-ONDANSETRON PHH PMS-ONDANSETRON PMS RAN-ONDANSETRON RBY RATIO-ONDANSETRON RPH SANDOZ-ONDANSETRON SDZ SEPTA-ONDANSETRON SPT ZOFRAN GSK ZYM-ONDANSETRON ZYM 8mg Tablet APO-ONDANSETRON APX CO-ONDANSETRON CBT JAMP ONDANSETRON JMP MAR-ONDANSETRON MAR MINT-ONDANSETRON MIN MYLAN-ONDANSETRON MYL NOVO-ONDANSETRON TEV ONDANSETRON PDL ONDANSETRON SAN ONDANSETRON-ODAN ODN ONDISSOLVE ODF TAK PHL-ONDANSETRON PHH PMS-ONDANSETRON PMS RAN-ONDANSETRON RBY RATIO-ONDANSETRON RPH SANDOZ-ONDANSETRON SDZ SEPTA-ONDANSETRON SPT ZOFRAN GSK ZYM-ONDANSETRON ZYM 56:22.92 MISCELLANEOUS ANTIEMETICS APREPITANT When used in combination with a 5-HT3 antagonist and dexamethasone for the prevention of acute and delayed nausea and vomiting due to highly emetogenic cancer chemotherapy (eg. Cisplatin > 70mg/m2) in patients who have experienced emesis despite treatment with a combination of a 5-HT3 antagonist and dexamethasone in a previous cycle of highly emetogenic chemotherapy. 80mg Capsule EMEND FRS 125mg Capsule EMEND FRS Page 109 of 151

126 56:22.92 MISCELLANEOUS ANTIEMETICS APREPITANT When used in combination with a 5-HT3 antagonist and dexamethasone for the prevention of acute and delayed nausea and vomiting due to highly emetogenic cancer chemotherapy (eg. Cisplatin > 70mg/m2) in patients who have experienced emesis despite treatment with a combination of a 5-HT3 antagonist and dexamethasone in a previous cycle of highly emetogenic chemotherapy. 125mg & 80mg Capsule EMEND TRI PACK FRS NABILONE For patients who are experiencing nausea and vomiting due to cancer chemotherapy or radiation; OR patient is palliative (diagnosed with a terminal illness or disease which is expected to be the primary cause of death within six months or less 0.25mg Capsule CESAMET VAE RAN-NABILONE RBY TEVA-NABILONE TEP 0.5mg Capsule ACT-NABILONE ATP CESAMET VAE PMS-NABILONE PMS RAN-NABILONE RBY TEVA-NABILONE TEP 1mg Capsule ACT-NABILONE ATP CESAMET VAE PMS-NABILONE PMS RAN-NABILONE RBY TEVA-NABILONE TEP 56:28.12 HIAMINE H2-ANTAGONIS CIMETIDINE 200mg Tablet APO-CIMETIDINE APX PMS-CIMETIDINE PMS TEVA-CIMETINE TEV 300mg Tablet APO-CIMETIDINE APX DOM-CIMETIDINE DPC MYLAN-CIMETIDINE MYL PMS-CIMETIDINE PMS TEVA-CIMETINE TEV 400mg Tablet APO-CIMETIDINE APX DOM-CIMETIDINE DPC MYLAN-CIMETIDINE MYL PMS-CIMETIDINE PMS TEVA-CIMETINE TEV 56:28.12 HIAMINE H2-ANTAGONIS CIMETIDINE 600mg Tablet APO-CIMETIDINE APX CIMETIDINE PDL DOM-CIMETIDINE DPC MYLAN-CIMETIDINE MYL PMS-CIMETIDINE PMS TEVA-CIMETINE TEV 800mg Tablet APO-CIMETIDINE APX MYLAN-CIMETIDINE MYL PMS-CIMETIDINE PMS TEVA-CIMETINE TEV FAMOTIDINE 20mg Tablet APO-FAMOTIDINE APX FAMOTIDINE SAN MYLAN-FAMOTIDINE MYL NOVO-FAMOTIDINE TEV ULCIDINE VAE 40mg Tablet APO-FAMOTIDINE APX FAMOTIDINE SAN MYLAN-FAMOTIDINE MYL NOVO-FAMOTIDINE TEV ULCIDINE VAE NIZATIDINE 150mg Capsule AXID PHH DOM-NIZATIDINE DPC NOVO-NIZATIDINE TEV PMS-NIZATIDINE PMS 300mg Capsule AXID PHH NIZATIDINE PHH NOVO-NIZATIDINE TEV PMS-NIZATIDINE PMS RANITIDINE HCL 15mg/mL Oral Solution APO-RANITIDINE APX NOVO-RANITIDINE TEV Page 110 of 151

127 56:28.12 HIAMINE H2-ANTAGONIS RANITIDINE HCL 150mg Tablet APO-RANITIDINE APX CO RANITIDINE COB MAXIMUM RENGTH ACID PMS REDUCER MYLAN-RANITIDINE MYL MYL-RANITIDINE MYL NOVO-RANIDINE TEV PHL-RANITIDINE PHH PMS-RANITIDINE PMS RANITIDINE PDL RANITIDINE SAN RANITIDINE SIV RAN-RANITIDINE RBY RIVA-RANTIDINE RIV SANDOZ-RANITIDINE SDZ ZANTAC GSK 300mg Tablet APO-RANITIDINE APX CO RANITIDINE COB MYLAN-RANITIDINE MYL MYL-RANITIDINE MYL PHL-RANITIDINE PHH PMS-RANITIDINE PMS RANITIDINE PDL RANITIDINE SAN RANITIDINE SIV RAN-RANITIDINE RBY RATIO-RANITIDINE RPH RIVA-RANITIDINE RIV SANDOZ-RANITIDINE SDZ ZANTAC GSK 56:28.28 PROAGLANDINS MISOPROOL 100mcg Tablet MISOPROOL AAP 200mcg Tablet MISOPROOL AAP PMS-MISOPROOL PMS 56:28.32 PROTECTANTS SUCRALFATE 200mg/mL Suspension SULCRATE PLUS AXC 1g Tablet APO-SUCRALFATE APX NOVO-SUCRALATE TEV SUCRALFATE-1 PDL SULCRATE AXC 56:28.36 PROTON-PUMP INHIBITORS AMOXICILLIN, CLARITHROMYCIN, LANSOPRAZOLE 500mg & 500mg & 30mg Kit HP-PAC ABB LANSOPRAZOLE (Please refer to Appendix A). Limited use benefit (prior approval not required). Coverage will be limited to 400 tablets/capsules every 180 days. 15mg Sustained Release Capsule LANSOPRAZOLE SIV LANSOPRAZOLE PMS LANSOPRAZOLE-15 SIV PMS-LANSOPRAZOLE PMS RAN-LANSOPRAZOLE RBY RIVA-LANSOPRAZOLE RIV SANDOZ LANSOPRAZOLE SDZ 30mg Sustained Release Capsule DOM-LANSOPRAZOLE DOM LANSOPRAZOLE PDL LANSOPRAZOLE SIV LANSOPRAZOLE-30 SIV PMS-LANSOPRAZOLE PMS RAN-LANSOPRAZOLE RBY RIVA-LANSOPRAZOLE RIV SANDOZ LANSOPRAZOLE SDZ 15mg Sustained Release Capsule APO-LANSOPRAZOLE APX LANSOPRAZOLE SAN MYLAN-LANSOPRAZOLE MYL NOVO-LANSOPRAZOLE TEV PREVACID ABB 30mg Sustained Release Capsule APO-LANSOPRAZOLE APX LANSOPRAZOLE SAN MYLAN-LANSOPRAZOLE MYL NOVO-LANSOPRAZOLE TEV PREVACID ABB LANSOPRAZOLE ODT (Please refer to Appendix A). Coverage will be limited to 400 tablets/capsules every 180 days. For children 12 years of age or under who are unable to swallow the capsule formulation For patients with dysphagia or a feeding tube when the use of the capsule formulation is not possible. 15MG Orally Disintegrating Tablet PREVACID FAAB TAK 30MG Orally Disintegrating Tablet PREVACID FAAB TAK Page 111 of 151

128 56:28.36 PROTON-PUMP INHIBITORS OMEPRAZOLE (Please refer to Appendix A). Limited use benefit (prior approval not required). Coverage will be limited to 400 tablets/capsules every 180 days. 20mg Capsule APO-OMEPRAZOLE APX LOSEC AZC MYLAN-OMEPRAZOLE MYL OMEPRAZOLE PDL OMEPRAZOLE SAN OMEPRAZOLE SIV OMEPRAZOLE-20 SIV PMS-OMEPRAZOLE PMS RAN-OMEPRAZOLE RBY SANDOZ OMEPRAZOLE SDZ 20mg Delayed Release Tablet LOSEC AZC OMEPRAZOLE MAGNESIUM ACC DR PMS-OMEPRAZOLE PMS RAN-OMEPRAZOLE RBY RATIO-OMEPRAZOLE RPH TEVA-OMEPRAZOLE TEP 20mg Tablet DOM-OMEPRAZOLE DR DOM JAMP-OMEPRAZOLE DR JAP RIVA-OMEPRAZOLE DR RIV PANTOPRAZOLE MAGNESIUM 40mg Enteric Coated Tablet TECTA NCC 56:28.36 PROTON-PUMP INHIBITORS PANTOPRAZOLE SODIUM (Please refer to Appendix A). Limited use benefit (prior approval not required). Coverage will be limited to 400 tablets/capsules every 180 days. 40mg Delayed Release Tablet ABBOTT-PANTOPRAZOLE ABB APO-PANTOPRAZOLE APX CO PANTOPRAZOLE COB DOM-PANTOPRAZOLE DOM JAMP-PANTOPRAZOLE JAP MAR-PANTOPRAZOLE MAR MINT-PANTOPRAZOLE MIN MYLAN-PANTOPRAZOLE MYL NOVO-PANTOPRAZOLE TEV PANTOLOC NYC PANTOPRAZOLE MEL PANTOPRAZOLE SOR PANTOPRAZOLE PDL PANTOPRAZOLE SAN PANTOPRAZOLE SIV PANTOPRAZOLE RIV PANTOPRAZOLE-40 SIV PMS-PANTOPRAZOLE PMS PRIVA-PANTOPRAZOLE PHA RAN-PANTOPRAZOLE RBY RIVA-PANTOPRAZOLE RIV SANDOZ-PANTOPRAZOLE SDZ RABEPRAZOLE SODIUM (Please refer to Appendix A). Limited use benefit (prior approval not required). Coverage will be limited to 400 tablets/capsules every 180 days. 10mg Enteric Coated Tablet ABBOTT-RABEPRAZOLE BGP APO-RABEPRAZOLE APX MYLAN-RABEPRAZOLE MYL NOVO-RABEPRAZOLE TEV PARIET EC JNO PMS-RABEPRAZOLE PMS PRO-RABEPRAZOLE PDL RABEPRAZOLE SIV RABEPRAZOLE EC SAN RAN-RABEPRAZOLE RBY RIVA-RABEPRAZOLE EC RIV SANDOZ-RABEPRAZOLE SDZ Page 112 of 151

129 56:28.36 PROTON-PUMP INHIBITORS RABEPRAZOLE SODIUM (Please refer to Appendix A). Limited use benefit (prior approval not required). Coverage will be limited to 400 tablets/capsules every 180 days. 20mg Enteric Coated Tablet ABBOTT-RABEPRAZOLE BGP APO-RABEPRAZOLE APX DOM-RABEPRAZOLE EC DOM MYLAN-RABEPRAZOLE MYL NOVO-RABEPRAZOLE TEV PARIET EC JNO PMS-RABEPRAZOLE PMS PRO-RABEPRAZOLE PDL RABEPRAZOLE SIV RABEPRAZOLE EC SAN RAN-RABEPRAZOLE RBY RIVA-RABEPRAZOLE RIV SANDOZ-RABEPRAZOLE SDZ 56:32.00 PROKINETIC AGENTS DOMPERIDONE MALEATE 10mg Tablet APO-DOMPERIDONE APX DOM-DOMPERIDONE DPC DOMPERIDONE PDL DOMPERIDONE SIV DOMPERIDONE SAN JAMP-DOMPERIDONE JAP MAR-DOMPERIDONE MAR MYLAN-DOMPERIDONE MYL NOVO-DOMPERIDONE TEV PMS-DOMPERIDONE PMS RAN-DOMPERIDONE RBY RATIO-DOMPERIDONE RPH METOCLOPRAMIDE HCL 1mg/mL Oral Liquid PMS-METOCLOPRAMIDE PMS 5mg Tablet APO-METOCLOP APX PMS-METOCLOPRAMIDE PMS 10mg Tablet APO-METOCLOP APX PMS-METOCLOPRAMIDE PMS 56:36.00 ANTI-INFLAMMATORY AGENTS 5-AMINOSALICYLIC ACID 500mg Delayed Release Tablet PENTASA FEI 2g/60g Enema SALOFALK AXC 4g/60g Enema SALOFALK AXC 56:36.00 ANTI-INFLAMMATORY AGENTS 5-AMINOSALICYLIC ACID 400mg Enteric Coated Tablet ASACOL PGP 500mg Enteric Coated Tablet SALOFALK AXC 800mg Enteric Coated Tablet ASACOL WAC 500mg Suppository SALOFALK AXC MESALAZINE 1g/100mL Enema PENTASA FEI 4g/100mL Enema PENTASA FEI 400mg Enteric Coated Tablet NOVO 5-ASA TEV 500mg Enteric Coated Tablet MESASAL GSK 1.2G Extended Release Tablet MEZAVANT SHI 1g Suppository PENTASA FEI 1000mg Suppository SALOFALK AXC OLSALAZINE SODIUM 250mg Capsule DIPENTUM LUD Page 113 of 151

130 60:00 GOLD COMPOUNDS 60:00.00 GOLD COMPOUNDS AURANOFIN 3mg Capsule RIDAURA SQU SODIUM AUROTHIOMALATE 10mg/mL Injection MYOCHRYSINE SAC SODIUM AUROTHIOMALATE SDZ 25mg/mL Injection MYOCHRYSINE SAC 50mg/mL Injection SODIUM AUROTHIOMALATE SDZ Page 114 of 151

131 64:00 HEAVY METAL ANTAGONIS 64:00.00 HEAVY METAL ANTAGONIS PENICILLAMINE 250mg Capsule CUPRIMINE FRS Page 115 of 151

132 68:00 HORMONES AND SYNTHETIC SUBITUTES 68:04.00 ADRENALS BECLOMETHASONE DIPROPIONATE 50mcg Inhaler QVAR MMH 100mcg Inhaler QVAR MMH BUDESONIDE 0.125mg/mL Inhalation Solution PULMICORT NEBUAMP AZC 0.25mg/mL Inhalation Solution PULMICORT NEBUAMP AZC 0.5mg/mL Inhalation Solution PULMICORT NEBUAMP AZC 100mcg Powder for Inhalation PULMICORT TURBUHALER AZC 200mcg Powder for Inhalation PULMICORT TURBUHALER AZC 400mcg Powder for Inhalation PULMICORT TURBUHALER AZC CICLESONIDE 100mg/Inhalation Inhaler ALVESCO NYC 200mg/Inhalation Inhaler ALVESCO NYC CORTISONE ACETATE 25mg Tablet CORTISONE VAE DEXAMETHASONE 0.1mg/mL Elixir PMS-DEXAMETHASONE PMS 0.5mg Tablet APO-DEXAMETHASONE APX PHL-DEXAMETHASONE PHH PMS-DEXAMETHASONE PMS RATIO-DEXAMETHASONE RPH 0.75mg Tablet DEXASONE VAE PMS-DEXAMETHASONE PMS 2mg Tablet PMS-DEXAMETHASONE PMS 4mg Tablet APO-DEXAMETHASONE APX DEXASONE VAE PHL-DEXAMETHASONE PHH PMS-DEXAMETHASONE PMS PRO-DEXAMETHASONE PRO RATIO-DEXAMETHASONE RPH 68:04.00 ADRENALS DEXAMETHASONE PHOSPHATE 4mg/mL Injection DEXAMETHASONE SDZ DEXAMETHASONE CYX DEXAMETHASONE-OMEGA OMG 10mg/mL Injection DEXAMETHASONE SDZ DEXAMETHASONE-OMEGA OMG PMS-DEXAMETHASONE PMS FLUDROCORTISONE ACETATE 0.1mg Tablet FLORINEF SHI FLUTICASONE PROPIONATE 50mcg/Inhalation Inhaler FLOVENT HFA 50 GSK 125mcg/Inhalation Inhaler FLOVENT HFA 125 GSK 250mcg/Inhalation Inhaler FLOVENT HFA 250 GSK 50mcg/Dose Powder Diskus FLOVENT DISKUS GSK 100mcg/Dose Powder Diskus FLOVENT DISKUS GSK 250mcg/Dose Powder Diskus FLOVENT DISKUS GSK 500mcg/Dose Powder Diskus FLOVENT DISKUS GSK HYDROCORTISONE 10mg Tablet CORTEF PFI 20mg Tablet CORTEF PFI METHYLPREDNISOLONE 4mg Tablet MEDROL PFI 16mg Tablet MEDROL PFI METHYLPREDNISOLONE ACETATE 40mg/mL Suspension for Injection DEPO-MEDROL PMJ METHYLPREDNISOLONE SDZ METHYLPREDNISOLONE SDZ 80mg/mL Suspension for Injection DEPO-MEDROL PMJ METHYLPREDNISOLONE SDZ METHYLPREDNISOLONE SDZ 20mg/mL Suspension for Injection (Multi-Dose) DEPO-MEDROL PMJ 40mg/mL Suspension for Injection (Multi-Dose) DEPO-MEDROL PMJ Page 116 of 151

133 68:04.00 ADRENALS METHYLPREDNISOLONE ACETATE 80mg/mL Suspension for Injection (Multi-Dose) DEPO-MEDROL PMJ MOMETASONE FUROATE 200mcg Inhaler ASMANEX TWIHALER FRS 400mcg Inhaler ASMANEX TWIHALER FRS PREDNISOLONE SODIUM PHOSPHATE 1mg/mL Oral Liquid PEDIAPRED AVT PMS-PREDNISOLONE PMS PREDNISONE 1mg Tablet APO-PREDNISONE APX WINPRED VAE 5mg Tablet APO-PREDNISONE APX PREDNISONE PRO 50mg Tablet APO-PREDNISONE APX NOVO-PREDNISONE TEV PREDNISONE PRO TRIAMCINOLONE ACETONIDE 10mg/mL Suspension for Injection KENALOG-10 WSB TRIAMCINOLONE SDZ 40mg/mL Suspension for Injection KENALOG-40 WSB TRIAMCINOLONE SDZ TRIAMCINOLONE ACETONIDE (5ML) SDZ TRIAMCINOLONE DIACETATE 40mg/mL Suspension for Injection ERILE TRIAMCINOLONE CYX 68:08.00 ANDROGENS DANAZOL 50mg Capsule CYCLOMEN SAC 100mg Capsule CYCLOMEN SAC 200mg Capsule CYCLOMEN SAC TEOERONE CYPIONATE 100mg/mL Injection DEPO-TEOERONE PFI TEOERONE CYPIONATE SDZ 68:08.00 ANDROGENS TEOERONE ENANTHATE 200mg/mL Injection DELATERYL BMS TEOERONE UNDECANOATE 40mg Capsule ANDRIOL ORG PMS-TEOERONE PMS TARO-TEOERONE TAR 68:12.00 CONTRACEPTIVES ETHINYL ERADIOL, DESOGEREL 25mcg & 150mcg, 125mcg, 100mcg Tablet LINESSA 21 ORG LINESSA 28 ORG 30mcg & 150mcg Tablet APRI 21 BAR APRI 28 BAR FREYA 21 FAM FREYA 28 FAM MARVELON 21 ORG MARVELON 28 ORG MIRVALA 21 APX MIRVALA 28 APX ORTHO CEPT 28 JNO RECLIPSEN 21 ATP RECLIPSEN 28 ATP ETHINYL ERADIOL, DROSPIRENONE 0.02mg & 3mg Tablet MYA 28 APX YAZ BAY 0.03mg & 3mg Tablet YASMIN 21 BAY YASMIN 28 BAY ZAMINE 21 APX ZAMINE 28 APX ZARAH 21 CBT ZARAH 28 CBT ETHINYL ERADIOL, ETHYNODIOL DIACETATE 30mcg & 2mg Tablet DEMULEN PFI DEMULEN PFI ETHINYL ERADIOL, ETONOGEREL 2.6mg & 11.4mg Device NUVARING ORG ETHINYL ERADIOL, LEVONORGEREL 0.15mg & 0.03mg Tablet SEASONALE ACG 0.15mg & 0.03mg & 0.01mg Tablet SEASONIQUE ACG Page 117 of 151

134 68:12.00 CONTRACEPTIVES ETHINYL ERADIOL, LEVONORGEREL 20mcg & 100mcg Tablet ALESSE 21 WAY ALESSE 28 WAY ALYSENA 21 APX ALYSENA 28 APX AVIANE 21 BAR AVIANE 28 BAR ESME 21 FAM ESME 28 FAM LUTERA 21 CBT LUTERA 28 CBT 30mcg & 0.05mg, 40mcg & 0.075mg, 30mcg & 0.125mg Tablet TRIQUILAR 21 BEX TRIQUILAR 28 BEX 30mcg & 150mcg Tablet MIN-OVRAL 21 WAY MIN-OVRAL 28 WAY OVIMA 21 APX OVIMA 28 APX PORTIA 21 BAR PORTIA 28 BAR ETHINYL ERADIOL, NORELGEROMIM 6mg & 0.6mg Patch EVRA JNO ETHINYL ERADIOL, NORETHINDRONE 20mcg & 1mg Tablet MINERIN 1/20 21 GCL MINERIN 1/20 28 GCL 30mcg & 1.5mg Tablet LOERIN 1.5/30 21 GCL LOERIN 1.5/30 28 GCL 35mcg & 0.5mg Tablet BREVICON 0.5/35 21 PFI BREVICON 0.5/35 28 PFI ORTHO 0.5/35 28 JNO ORTHO 0.5/35 21 JNO 35mcg & 0.5mg, 35mcg & 1mg Tablet SYNPHASIC 21 PFI SYNPHASIC 28 PFI 35mcg & 1mg Tablet BREVICON 1/35 21 PFI BREVICON 1/35 28 PFI ORTHO 1/35 28 JNO ORTHO 1/35 21 JNO SELECT 1/35 21 DSP SELECT 1/35 28 DSP 35mcg & 500mcg, 35mcg & 750mcg, 35mcg & 1mg Tablet ORTHO 7/7/7 21 JNO ORTHO 7/7/7 28 JNO 68:12.00 CONTRACEPTIVES ETHINYL ERADIOL, NORGEIMATE 25mcg & 0.180mg, 25mcg & 0.215mg, 25mcg & 0.25mg Tablet TRICIRA LO 21 APX TRICIRA LO 28 APX TRI-CYCLEN LO 21 JNO TRI-CYCLEN LO 28 JNO 35mcg & 0.180mg, 35mcg & 0.215mg, 35mcg & 0.25mg Tablet TRI-CYCLEN 21 JNO TRI-CYCLEN 28 JNO 35mcg & 0.25mg Tablet CYCLEN 21 JNO CYCLEN 28 JNO LEVONORGEREL 0.75mg Tablet NEXT CHOICE CBT NORLEVO LAP OPTION 2 PER PLAN B BAR LEVONORGEREL INTRAUTERINE INSERT Limited use benefit with quantity and frequency limits (prior approval is not required). Coverage is granted for 1 device every 2 years. 13.5mg Intrauterine Insert JAYDESS BAY 52mg Intrauterine Insert MIRENA BAY NORETHINDRONE 0.35mg Tablet MICRONOR 28 JNO 68:16.04 EROGENS CONJUGATED EROGENS 0.3mg Extended Release Tablet PREMARIN PFI 0.625mg Extended Release Tablet PREMARIN PFI 1.25mg Extended Release Tablet PREMARIN PFI 0.625mg/g Vaginal Cream PREMARIN WAY CONJUGATED EROGENS, MEDROXYPROGEERONE ACETATE 0.625mg & 2.5mg Kit PREMPLUS WAY 0.625mg & 5mg Kit PREMPLUS WAY ERADIOL 0.06% Gel EROGEL SCH Page 118 of 151

135 68:16.04 EROGENS ERADIOL 0.25mg Gel DIVIGEL TEP 0.5mg Gel DIVIGEL TEP 1mg Gel DIVIGEL TEP 0.39mg Patch ERADOT 25 NVR 0.585mg Patch ERADOT 37.5 NVR 0.78mg Patch ERADOT 50 NVR 1.17mg Patch ERADOT 75 NVR 1.56mg Patch ERADOT 100 NVR 4mg Patch SANDOZ-ERADIOL DERM 50 SDZ 5mg Patch OESCLIM PAL 6mg Patch SANDOZ-ERADIOL DERM 75 SDZ 8mg Patch ERADERM 100 NVR SANDOZ-ERADIOL DERM SDZ mg Patch OESCLIM PAL 0.5mg Tablet ERACE SHI 1mg Tablet ERACE SHI 2mg Tablet ERACE SHI 2mg Vaginal Ring ERING PMJ ERADIOL (ERADIOL HEMIHYDRATE) 2mg Patch CLIMARA 25 BEX 3.8mg Patch CLIMARA 50 BEX 5.7mg Patch CLIMARA 75 BEX 7.6mg Patch CLIMARA 100 BEX 10mcg Vaginal Tablet VAGIFEM 10 NOO 68:16.04 EROGENS ERADIOL, NORETHINDRONE ACETATE 0.62mg & 2.7mg Patch EALIS 140/50 NVR ERONE 1mg/g Vaginal Cream ERAGYN TRT EROPIPATE 0.75mg Tablet OGEN.625 PFI 68:16.12 EROGEN AGONIS- ANTAGONIS RALOXIFENE HCL For: a.- secondary prevention of osteoporosis in women who experience failure on bisphosphonates. b. - secondary prevention of osteoporosis in women who have a personal history or a first degree relative with a history of breast cancer. 60mg Tablet ACT RALOXIFENE ATP APO-RALOXIFENE APX EVIA LIL NOVO-RALOXIFENE TEV PMS-RALOXIFENE PMS RALOXIFENE PDL 68:18.00 GONADOTROPINS NAFARELIN ACETATE 2mg/mL Nasal Solution SYNAREL PFI 68:20.02 ALPHA-GLUCOSIDASE INHIBITORS ACARBOSE 50mg Tablet GLUCOBAY BAY 100mg Tablet GLUCOBAY BAY ERADIOL, NORETHINDRONE ACETATE 0.51mg & 4.8mg Patch EALIS 250/50 NVR Page 119 of 151

136 68:20.04 BIGUANIDES METFORMIN HCL 500mg Tablet APO-METFORMIN APX CO METFORMIN COB DOM-METFORMIN DPC ECL-METFORMIN ECL GLUCOPHAGE SAC GLYCON VAE JAMP-METFORMIN JAP JAMP-METFORMIN JAP BLACKBERRY MAR-METFORMIN MAR METFORMIN MEL METFORMIN SAN METFORMIN MAR METFORMIN FC SIV MINT-METFORMIN MIN MYLAN-METFORMIN MYL NOVO-METFORMIN TEV PMS-METFORMIN PMS PRO-METFORMIN PDL RAN-METFORMIN RBY RATIO-METFORMIN RPH RIVA-METFORMIN RIV SANDOZ-METFORMIN FC SDZ SEPTA-METFORMIN SPT 850mg Tablet APO-METFORMIN APX CO METFORMIN COB DOM-METFORMIN DPC ECL-METFORMIN ECL GLUCOPHAGE SAC GLYCON VAE JAMP-METFORMIN JAP JAMP-METFORMIN JAP BLACKBERRY MAR-METFORMIN MAR METFORMIN SOR METFORMIN SAN METFORMIN MAR METFORMIN FC SIV MINT-METFORMIN MIN MYLAN-METFORMIN MYL NOVO-METFORMIN TEV PMS-METFORMIN PMS PRO-METFORMIN PDL RAN-METFORMIN RBY RATIO-METFORMIN RPH RIVA-METFORMIN RIV SANDOZ-METFORMIN SDZ SEPTA-METFORMIN SPT 68:20.04 BIGUANIDES SITAGLIPTIN, METFORMIN For the treatment of patients with type 2 diabetes mellitus who: did not achieve glycemic control or who demonstrated intolerance to an adequate trial of metformin AND a sulfonylurea. 50mg & 1000mg Tablet JANUMET FRS 50mg & 500mg Tablet JANUMET FRS 50mg & 850mg Tablet JANUMET FRS 68:20.05 LINAGLIPTIN For the treatment of patients with type 2 diabetes mellitus who: did not achieve glycemic control or who demonstrated intolerance to an adequate trial of metformin AND a sulfonylurea. 5mg Tablet TRAJENTA BOE LINAGLIPTIN, METFORMIN For the treatment of patients with type 2 diabetes mellitus who: did not achieve glycemic control or who demonstrated intolerance to an adequate trial of metformin AND a sulfonylurea. 2.5mg & 1000mg Tablet JENTADUETO BOE 2.5mg & 500mg Tablet JENTADUETO BOE 2.5mg & 850mg Tablet JENTADUETO BOE SAXAGLIPTIN HCL For the treatment of patients with type 2 diabetes mellitus who: did not achieve glycemic control or who demonstrated intolerance to an adequate trial of metformin AND a sulfonylurea. 2.5mg Tablet ONGLYZA AZE 5mg Tablet ONGLYZA AZE SAXAGLIPTIN, METFORMIN - For the treatment of patients with type 2 diabetes mellitus who: did not achieve glycemic control or who demonstrated intolerance to an adequate trial of metformin AND a sulfonylurea. 2.5mg & 1000mg Tablet KOMBOGLYZE AZE Page 120 of 151

137 68:20.05 SAXAGLIPTIN, METFORMIN - For the treatment of patients with type 2 diabetes mellitus who: did not achieve glycemic control or who demonstrated intolerance to an adequate trial of metformin AND a sulfonylurea. 2.5mg & 500mg Tablet KOMBOGLYZE AZE 2.5mg & 850mg Tablet KOMBOGLYZE AZE SITAGLIPTIN For the treatment of patients with type 2 diabetes mellitus who: did not achieve glycemic control or who demonstrated intolerance to an adequate trial of metformin AND a sulfonylurea. 25mg Tablet JANUVIA MSP 50mg Tablet JANUVIA MSP 100mg Tablet JANUVIA FRS SITAGLIPTIN, METFORMIN For the treatment of patients with type 2 diabetes mellitus who: did not achieve glycemic control or who demonstrated intolerance to an adequate trial of metformin AND a sulfonylurea. 50mg & 1000mg Extended Release Tablet JANUMET XR FRS 68:20.08 INSULINS INSULIN (30% NEUTRAL & 70% ISOPHANE) HUMAN BIOSYNTHETIC 100U/mL Injection NOVOLIN GE 30/70 PENFILL NOO NOVOLIN GE 30/70 PENFILL NOO (ON) NOVOLIN GE 30/70 VIAL NOO INSULIN (40% NEUTRAL & 60% ISOPHANE) HUMAN BIOSYNTHETIC 100U/mL Injection NOVOLIN GE 40/60 PENFILL NOO INSULIN (50% NEUTRAL & 50% ISOPHANE) HUMAN BIOSYNTHETIC 100U/mL Injection NOVOLIN GE 50/50 PENFILL NOO 68:20.08 INSULINS INSULIN (ISOPHANE) HUMAN BIOSYNTHETIC 100U/mL Injection HUMULIN N CARTRIDGE LIL HUMULIN N LIL CARTRIDGE/KWIKPEN (ON) HUMULIN N KWIKPEN LIL HUMULIN N VIAL LIL NOVOLIN GE NPH PENFILL NOO NOVOLIN GE NPH PENFILL NOO (ON) NOVOLIN GE NPH VIAL NOO INSULIN (ZINC CRYALLINE) HUMAN BIOSYNTHETIC (RDNA ORIGIN) 100U/mL Injection HUMULIN R CARTRIDGE LIL HUMULIN R CARTRIDGE (ON) LIL HUMULIN R VIAL LIL INSULIN ASPART 100U/mL Injection NOVORAPID NOO NOVORAPID FLEXTOUCH NOO NOVORAPID VIAL NOO INSULIN DETEMIR 100U/mL Injection LEVEMIR 100UNIT/ML SC PENFILL LEVEMIR FLEXTOUCH 100U/ML INJ INSULIN GLARGINE 100U/mL Injection NOO NOO LANTUS CARTRIDGE SAC LANTUS SOLOAR SAC LANTUS VIAL SAC INSULIN GLULISINE 100U/mL Injection APIDRA CARTRIDGE SAC APIDRA SOLOAR SAC APIDRA VIAL SAC INSULIN HUMAN BIOSYNTHETIC 100U/mL Injection NOVOLIN GE TORONTO NOO PENFILL NOVOLIN GE TORONTO NOO PENFILL (ON) NOVOLIN GE TORONTO VIAL NOO INSULIN HUMAN BIOSYNTHETIC 30% & ISOPHANE 70% 100U/mL Injection HUMULIN 30/70 CARTRIDGE LIL HUMULIN 30/70 CARTRIDGE LIL (ON) HUMULIN 30/70 VIAL LIL Page 121 of 151

138 68:20.08 INSULINS INSULIN LISPRO 100U/mL Injection HUMALOG LIL CARTRIDGE/KWIKPEN HUMALOG LIL CARTRIDGE/KWIKPEN (ON) HUMALOG KWIKPEN LIL HUMALOG VIAL LIL INSULIN LISPRO, INSULIN LISPRO PROTAMINE 100U/ML Injection HUMALOG MIX 25 KWIKPEN LIL HUMALOG MIX 25 KWIKPEN LIL HUMALOG MIX 50 KWIKPEN LIL HUMALOG MIX 50 KWIKPEN INJ LIL 68:20.16 MEGLITINIDES NATEGLINIDE 60mg Tablet ARLIX NVR 120mg Tablet ARLIX NVR REPAGLINIDE 0.5mg Tablet APO-REPAGLINIDE APX CO-REPAGLINIDE CBT GLUCONORM NOO PMS-REPAGLINIDE PMS REPAGLINIDE PDL SANDOZ REPAGLINIDE SDZ 1mg Tablet APO-REPAGLINIDE APX CO-REPAGLINIDE CBT GLUCONORM NOO PMS-REPAGLINIDE PMS REPAGLINIDE PDL SANDOZ REPAGLINIDE SDZ 2mg Tablet APO-REPAGLINIDE APX CO-REPAGLINIDE CBT GLUCONORM NOO PMS-REPAGLINIDE PMS REPAGLINIDE PDL SANDOZ REPAGLINIDE PFI 68:20.20 ANTIDIABETIC AGENTS - SULFONYLUREAS GLICLAZIDE 30mg Tablet APO-GLICLAZIDE APX DIAMICRON MR SEV MINT-GLICLAZIDE MR MIN 60mg Tablet DIAMICRON MR SEV 68:20.20 ANTIDIABETIC AGENTS - SULFONYLUREAS GLICLAZIDE 80mg Tablet APO-GLICLAZIDE APX DIAMICRON SEV GLICLAZIDE PDL GLICLAZIDE SAN MYLAN-GLICLAZIDE MYL NOVO-GLICLAZIDE TEV GLYBURIDE 2.5mg Tablet APO-GLYBURIDE APX DIABETA SAC GLYBURIDE PDL GLYBURIDE SAN NOVO-GLYBURIDE TEV RATIO-GLYBURIDE RPH SANDOZ-GLYBURIDE SDZ 5mg Tablet APO-GLYBURIDE APX DIABETA SAC DOM-GLYBURIDE DPC EUGLUCON PMS GLYBURIDE SAN MYLAN-GLYBE MYL NOVO-GLYBURIDE TEV PMS-GLYBURIDE PMS PRO-GLYBURIDE PDL RATIO-GLYBURIDE RPH RIVA-GLYBURIDE PHH SANDOZ-GLYBURIDE SDZ TOLBUTAMIDE 500mg Tablet TOLBUTAMIDE AAP Page 122 of 151

139 68:20.28 THIAZOLIDINEDIONES PIOGLITAZONE HCL For treatment of type 2 diabetic patients who are not adequately controlled by or are intolerant to metformin and sulfonylureas or for whom these products are contraindicated. 15mg Tablet ACCEL PIOGLITAZONE ACP ACH-PIOGLITAZONE ACC ACTOS LIL APO-PIOGLITAZONE APX CO PIOGLITAZONE COB DOM-PIOGLITAZONE DOM JAMP-PIOGLITAZONE JAP MINT-PIOGLITAZONE MIN MYLAN-PIOGLITAZONE MYL NOVO-PIOGLITAZONE TEV PHL-PIOGLITAZONE PMI PIOGLITAZONE SIV PMS-PIOGLITAZONE PMS PRO-PIOGLITAZONE PDL RAN-PIOGLITAZONE RBY RATIO-PIOGLITAZONE RPH SANDOZ PIOGLITAZONE SDZ ZYM-PIOGLITAZONE ZYM 30mg Tablet ACCEL PIOGLITAZONE ACP ACH-PIOGLITAZONE ACC ACTOS LIL APO-PIOGLITAZONE APX CO PIOGLITAZONE COB DOM-PIOGLITAZONE DOM JAMP-PIOGLITAZONE JAP MINT-PIOGLITAZONE MIN MYLAN-PIOGLITAZONE MYL NOVO-PIOGLITAZONE TEV PHL-PIOGLITAZONE PMI PIOGLITAZONE SIV PMS-PIOGLITAZONE PMS PRO-PIOGLITAZONE PDL RAN-PIOGLITAZONE RBY RATIO-PIOGLITAZONE RPH SANDOZ PIOGLITAZONE SDZ ZYM-PIOGLITAZONE ZYM 68:20.28 THIAZOLIDINEDIONES PIOGLITAZONE HCL For treatment of type 2 diabetic patients who are not adequately controlled by or are intolerant to metformin and sulfonylureas or for whom these products are contraindicated. 45mg Tablet ACCEL PIOGLITAZONE ACP ACTOS LIL APO-PIOGLITAZONE APX CO PIOGLITAZONE COB DOM-PIOGLITAZONE DOM JAMP-PIOGLITAZONE JAP MINT-PIOGLITAZONE MIN MYLAN-PIOGLITAZONE MYL NOVO-PIOGLITAZONE TEV PHL-PIOGLITAZONE PMI PIOGLITAZONE ACC PIOGLITAZONE SIV PMS-PIOGLITAZONE PMS PRO-PIOGLITAZONE PDL RAN-PIOGLITAZONE RBY RATIO-PIOGLITAZONE RPH SANDOZ PIOGLITAZONE SDZ ZYM-PIOGLITAZONE ZYM ROSIGLITAZONE MALEATE For treatment of type 2 diabetic patients who are not adequately controlled by or are intolerant to metformin and sulfonylureas or for whom these products are contraindicated. 2mg Tablet AVANDIA GSK 4mg Tablet AVANDIA GSK 8mg Tablet AVANDIA GSK 68:22.12 GLYCOGENOLYTIC AGENTS GLUCAGON RECOMBINANT DNA ORGIN 1mg/mL Injection GLUCAGEN NOO GLUCAGEN HYPOKIT NOO GLUCAGON LIL 68:24.00 PARATHYROID CALCITONIN SALMON (SYNTHETIC) 200IU/mL Injection CALCIMAR SAC 68:28.00 PITUITARY DESMOPRESSIN ACETATE 4mcg/mL Injection DDAVP FEI 0.1mg/mL Nasal Solution DDAVP FEI Page 123 of 151

140 68:28.00 PITUITARY DESMOPRESSIN ACETATE 0.1mg/mL Nasal Spray DDAVP FEI DESMOPRESSIN AAP 0.1mg Tablet APO-DESMOPRESSIN APX DDAVP FEI PMS-DESMOPRESSIN PMS TEVA-DESMOPRESSIN TEV 0.2mg Tablet APO-DESMOPRESSIN APX DDAVP FEI PMS-DESMOPRESSIN PMS TEVA-DESMOPRESSIN TEV 60mcg Tablet DDAVP MELT FEI 120mcg Tablet DDAVP MELT FEI 240mcg Tablet DDAVP MELT FEI 68:29.04 SOMATOATIN AGONIS OCTREOTIDE 50mcg/mL Injection OCPHYL PED 100mcg/mL Injection OCPHYL PED 500mcg/mL Injection OCPHYL PED 68:32.00 PROGEINS DIENOGE a.- For the management of pelvic pain associated with endometriosis 2mg Tablet VISANNE BAY MEDROXYPROGEERONE ACETATE 50mg/mL Injection DEPO-PROVERA PFI 150mg/mL Injection DEPO-PROVERA PFI MEDROXYPROGEERONE SDZ 2.5mg Tablet APO-MEDROXY APX DOM- DPC MEDROXYPROGEERONE MEDROXY PDL NOVO-MEDRONE TEV PROVERA PFI 68:32.00 PROGEINS MEDROXYPROGEERONE ACETATE 5mg Tablet APO-MEDROXY APX DOM- DPC MEDROXYPROGEERONE MEDROXY PDL NOVO-MEDRONE TEV PROVERA PFI PROVERA PAK PFI 10mg Tablet APO-MEDROXY APX DOM- DPC MEDROXYPROGEERONE NOVO-MEDRONE TEV PROVERA PFI PROVERA PFI 100mg Tablet APO-MEDROXY APX PROGEERONE For the treatment of women: With postmenopausal symptoms who are intolerant to medroxyprogesterone acetate (MPA); OR Who are at risk of preterm birth; OR Who are using the medication to prevent miscarriage. 100mg Capsule PROMETRIUM FRS 68:36.04 THYROID AGENTS LEVOTHYROXINE SODIUM 0.025mg Tablet EUTHYROX MYL SYNTHROID ABB 0.05mg Tablet ELTROXIN GSK EUTHYROX MYL SYNTHROID ABB 0.075mg Tablet EUTHYROX MYL SYNTHROID ABB 0.088mg Tablet SYNTHROID ABB 0.1mg Tablet ELTROXIN GSK EUTHYROX MYL SYNTHROID ABB 0.112mg Tablet EUTHYROX MYL SYNTHROID ABB 0.125mg Tablet EUTHYROX MYL SYNTHROID ABB Page 124 of 151

141 68:36.04 THYROID AGENTS LEVOTHYROXINE SODIUM 0.137mg Tablet EUTHYROX MYL SYNTHROID ABB 0.15mg Tablet ELTROXIN GSK EUTHYROX MYL SYNTHROID ABB 0.175mg Tablet EUTHYROX MYL SYNTHROID ABB 0.2mg Tablet ELTROXIN GSK EUTHYROX MYL SYNTHROID ABB 0.3mg Tablet ELTROXIN ASI EUTHYROX MYL SYNTHROID ABB THYROID 30mg Tablet THYROID ERF 60mg Tablet THYROID ERF 125mg Tablet THYROID ERF 68:36.08 ANTITHYROID AGENTS PROPYLTHIOURACIL 50mg Tablet PROPYL THYRACIL SQU 100mg Tablet PROPYL THYRACIL SQU THIAMAZOLE 5mg Tablet TAPAZOLE PAL 10mg Tablet TAPAZOLE PAL Page 125 of 151

142 80:00 SERUMS, TOXOIDS, AND VACCINES 80:04.00 SERUMS DOLICHOVESPULA ARENARIA VENOM PROTEIN 120mcg Injection YELLOW HORNET VENOM PROTEIN DOLICHOVESPULA MACULATA VENOM PROTEIN EXTRACT 120mcg Injection WHITE FACED HORNET VENOM HONEY BEE VENOM PROTEIN EXTRACT 1.1mg Injection ALK ALK HONEY BEE VENOM ALK 120mcg Injection HONEY BEE VENOM ALK VENOMIL HONEY BEE VENOM HOL 550mcg Injection HONEY BEE VENOM HOL NON POLLEN Injection ALLERGENIC EXTRACT NON ALK POLLENS ALLERGENIC EXTRACTS MSL POLIES SPP VENOM PROTEIN EXTRACT 1.1mg Injection WASP VENOM PROTEIN ALK POLLEN Injection ALLERGENIC EXTRACT ALK POLLENS POLLINEX R BEN POLLEN AND NON POLLEN Injection CENTER-AL ALK VESPULA SPP VENOM PROTEIN EXTRACT 1.1mg Injection YELLOW JACKET VENOM PROTEIN 120mcg Injection YELLOW JACKET VENOM PROTEIN WASP VENOM PROTEIN 120mcg Injection VENOMIL WASP VENOM PROTEIN 550mcg Injection ALG ALK HOL WASP VENOM PROTEIN HOL 80:04.00 SERUMS WHITE FACED HORNET VENOM PROTEIN 120mcg Injection VENOMIL WHITE FACED HORNET VENOM PROTEIN HOL WHITE FACED HORNET VENOM PROTEIN, YELLOW HORNET VENOM PROTEIN, YELLOW JACKET VENOM PROTEIN 120mcg Injection MIXED VESPID VENOM PROTEIN VENOMIL MIXED VESPID VENOM PROTEIN 550mcg Injection MIXED VESPID VENOM PROTEIN YELLOW HORNET VENOM PROTEIN 120mcg/mL Injection YELLOW JACKET HORNET VENOM PROTEIN 550mcg Injection YELLOW HORNET VENOM PROTEIN YELLOW JACKET VENOM PROTEIN 120mcg Injection VENOMIL YELLOW JACKET VENOM PROTEIN 550mcg Injection YELLOW JACKET VENOM PROTEIN ALK HOL HOL BAY HOL HOL BAY Page 126 of 151

143 84:00 SKIN AND MUCOUS MEMBRANE AGENTS (SMMA) 84:04.04 SMMA - ANTIBIOTICS BACITRACIN 500IU Ointment BACITIN PMS BACITRACIN JAP BACITRACIN ZINC, POLYMYXIN B SULFATE 500IU & 10,000IU Ointment POLYSPORIN ANTIBIOTIC PFI CLINDAMYCIN PHOSPHATE 1% Solution CLINDA-T VAE DALACIN T PFI TARO-CLINDAMYCIN TAR 2% Vaginal Cream DALACIN PMJ CLINDAMYCIN, BENZOYL PEROXIDE 1% & 3% Gel CLINDOXYL ADV GSK 1% & 5% Gel BENZACLIN TOPICAL GEL VAE CLINDOXYL GSK ERYTHROMYCIN, BENZOYL PEROXIDE 3% & 5% Gel BENZAMYCIN VAE ERYTHROMYCIN, TRETINOIN 4% & 0.01% Gel 0994 IEVAMYCIN MILD I 4% & 0.025% Gel IEVAMYCIN I 4% & 0.05% Gel IEVAMYCIN FORTE I FUSIDATE SODIUM 2% Ointment FUCIDIN LEO FUSIDIC ACID 2% Cream FUCIDIN LEO GRAMICIDIN, POLYMYXIN B SULFATE 0.25mg & 10,000IU Cream POLYSPORIN ANTIBIOTIC PFI MUPIROCIN 2% Cream BACTROBAN GSK 2% Ointment BACTROBAN GSK TARO-MUPIROCIN TAR 84:04.04 SMMA - ANTIBIOTICS POLYMYXIN B SULFATE, BACITRACIN 10,000IU & 500IU Ointment ANTIBIOTIC OINT PED BACIMYXIN PMS BIODERM ODN JAMPOLYCIN JAP POLYTOPIC SDZ POLYMYXIN B SULFATE, BACITRACIN, GRAMICIDIN Ointment POLYSPORIN TRIPLE PFI 84:04.06 SMMA - ANTIVIRALS ACYCLOVIR 5% Cream ZOVIRAX GSK 5% Ointment ZOVIRAX GSK 84:04.08 SMMA - ANTIFUNGALS CLOTRIMAZOLE 1% Cream CANEEN BCD CLOTRIMADERM TAR 1% & 200mg Cream & Vaginal Suppository CANEEN 3 COMFORT COMBI PAK 1% & 500mg Cream & Vaginal Suppository CANEEN 1 COMFORT COMBI PAK 1% Vaginal Cream BCD BCD CANEEN BCD CLOTRIMADERM TAR 2% Vaginal Cream CANEEN BCD CLOTRIMADERM TAR KETOCONAZOLE 2% Cream KETODERM TAR 2% Shampoo NIZORAL MCL MICONAZOLE NITRATE 2% Cream MICATIN MCL MONIAT-DERM MCL 2% & 100mg Cream & Vaginal Suppository MONIAT 7 DUAL PAK MCL 2% & 400mg Cream & Vaginal Suppository MONIAT 3 DUAL PAK MCL 2% Vaginal Cream MICOZOLE TAR MONIAT 7 MCL Page 127 of 151

144 84:04.08 SMMA - ANTIFUNGALS MICONAZOLE NITRATE 400mg Vaginal Suppository MICONAZOLE VTH MONIAT 3 MCL NYATIN 100,000IU Cream NYADERM TAR RATIO-NYATIN RPH 100,000IU Ointment RATIO-NYATIN RPH 25,000IU Vaginal Cream NYADERM TAR 100,000IU Vaginal Cream RATIO-NYATIN RPH TERBINAFINE HCL 1% Cream LAMISIL NVR TERCONAZOLE 0.4% Vaginal Cream TARO-TERCONAZOLE TAR TERAZOL 7 JNO TOLNAFTATE 1% Cream TINACTIN SCH 1% Powder ATHLETES FOOT SPRAY SCH TINACTIN SCH ZEASORB AF I 1% Spray TINACTIN AEROSOL SCH 84:04.12 SMMA - SCABICIDES AND PEDICULICIDES CROTAMITON 10% Cream EURAX NVC DIMETHICONE 50% Solution NYDA GPB ISOPROPYL MYRIATE 50% Solution RESULTZ NYC PERMETHRIN 5% Cream NIX DERMAL GSK 5% Lotion KWELLADA-P GSK 1% Rinse KWELLADA-P GSK NIX WLA 84:04.12 SMMA - SCABICIDES AND PEDICULICIDES PIPERONYL BUTOXIDE, PYRETHRINS 3% & 0.3% Shampoo R & C GSK 84:04.92 SMMA - MISCELLANEOUS LOCAL ANTI-INFECTIVES BENZOYL PEROXIDE 5% Gel (Alcohol Base) BENZAGEL NVC 5% Gel (Water Base) BENZAC AC GAC BENZAC W5 GAC 2.5% Lotion OXY 5 GSK 5% Lotion BENZAGEL 5 NVC 5% Soap PANOXYL-5 I 5% Wash BENZAC W GAC BENZAGEL NVC PANOXYL I CHLORHEXIDINE ACETATE 0.5% Dressing BACTIGRAS SNE METRONIDAZOLE 0.75% Cream METROCREAM GAC 1% Cream NORITATE SAC 0.75% Gel METROGEL GAC 1% Gel METROGEL GAC 0.75% Lotion METROLOTION GAC 10% Vaginal Cream FLAGYL SAC 0.75% Vaginal Gel NIDAGEL MMH METRONIDAZOLE, AVOBENZONE, OCTINOXATE 1% & 2% & 7.5% Cream ROSASOL I METRONIDAZOLE, NYATIN 100mg & 20,000U/g Vaginal Cream FLAGYATIN AVT 500mg & 100,000IU Vaginal Suppository FLAGYATIN AVT Page 128 of 151

145 84:04.92 SMMA - MISCELLANEOUS LOCAL ANTI-INFECTIVES POVIDONE-IODINE 10% Liquid BETADINE PFR SELENIUM SULFIDE 2.5% Lotion SELSUN ABB VERSEL VAO SILVER SULFADIAZINE 1% Cream DERMAZIN PMS FLAMAZINE SNE FLAMAZINE 50G SNE 84:06.00 SMMA - ANTI-INFLAMMATORY AGENTS AMCINONIDE 0.1% Cream CYCLOCORT I RATIO-AMCINONIDE RPH TARO-AMCINONIDE TAR 0.1% Lotion CYCLOCORT I RATIO-AMCINONIDE RPH 0.1% Ointment CYCLOCORT I RATIO-AMCINONIDE RPH BECLOMETHASONE DIPROPIONATE 0.025% Cream PROPADERM SHI BETAMETHASONE DIPROPIONATE 0.05% Cream DIPROSONE SCH RATIO-TOPISONE RPH ROSONE RIV TARO-SONE TAR 0.05% Lotion DIPROSONE SCH RATIO-TOPISONE RPH ROSONE RIV 0.05% Ointment DIPROSONE SCH RATIO-TOPISONE RPH ROSONE RIV BETAMETHASONE DIPROPIONATE IN PROPYLENE GLYCOL 0.05% Cream DIPROLENE SCH RATIO-TOPILENE GLYCOL RPH ROLENE RIV 84:06.00 SMMA - ANTI-INFLAMMATORY AGENTS BETAMETHASONE DIPROPIONATE IN PROPYLENE GLYCOL 0.05% Lotion DIPROLENE SCH RATIO-TOPILENE GLYCOL RPH ROLENE RIV 0.05% Ointment DIPROLENE SCH RATIO-TOPILENE GLYCOL RPH ROLENE RIV BETAMETHASONE DIPROPIONATE, CLOTRIMAZOLE 0.05% & 1% Cream LOTRIDERM SCH BETAMETHASONE DIPROPIONATE, SALICYLIC ACID 0.05% & 2% Lotion DIPROSALIC SCH RATIO-TOPISALIC RPH 0.05% & 3% Ointment DIPROSALIC SCH BETAMETHASONE DISODIUM PHOSPHATE 0.05mg/mL Enema BETNESOL SHI BETAMETHASONE VALERATE 0.05% Cream RATIO-ECTOSONE RPH 0.1% Cream BETADERM TAR CELEODERM V VAO PREVEX B I RATIO-ECTOSONE RPH 0.05% Lotion RATIO-ECTOSONE RPH 0.1% Lotion RATIO-ECTOSONE RPH 0.05% Ointment BETADERM TAR 0.1% Ointment BETADERM TAR CELEODERM V VAO 0.1% Scalp Lotion BETADERM TAR RIVASONE RIV VALISONE SCH BUDESONIDE 0.02mg/mL Enema ENTOCORT AZC Page 129 of 151

146 84:06.00 SMMA - ANTI-INFLAMMATORY AGENTS CALCIPOTRIOL, BETAMETHASONE 0.5mg & 50mcg Gel DOVOBET LEO CLOBETASOL PROPIONATE 0.05% Cream DERMOVATE TAR MYLAN-CLOBETASOL MYL PMS-CLOBETASOL PMS PMS-CLOBETASOL PMS RATIO-CLOBETASOL RPH TARO-CLOBETASOL TAR TEVA-CLOBETASOL TEV 0.05% Ointment DERMOVATE TAR MYLAN-CLOBETASOL MYL PMS-CLOBETASOL PMS RATIO-CLOBETASOL RPH TARO-CLOBETASOL TAR TEVA-CLOBETASOL TEV 0.05% Scalp Lotion DERMOVATE TAR MYLAN-CLOBETASOL MYL PMS-CLOBETASOL PMS RATIO-CLOBETASOL RPH 0.05% Solution TARO-CLOBETASOL TAR CLOBETASONE BUTYRATE 0.05% Cream EUMOVATE GSK DESONIDE 0.05% Cream PMS-DESONIDE PMS TRIDESILON SCN 0.05% Ointment PMS-DESONIDE PMS TRIDESILON SCN DESOXIMETASONE 0.05% Cream TOPICORT SAC 0.25% Cream TOPICORT SAC 0.05% Gel TOPICORT SAC 0.25% Ointment TOPICORT SAC DIFLUCORTOLONE VALERATE 0.1% Cream NERISONE I NERISONE OILY I 84:06.00 SMMA - ANTI-INFLAMMATORY AGENTS DIFLUCORTOLONE VALERATE 0.1% Ointment NERISONE I FLUOCINOLONE ACETONIDE 0.025% Ointment SYNALAR MDC 0.01% Scalp Lotion DERMA-SMOOTHE HIL FLUOCINONIDE 0.05% Cream LIDEX VAL LYDERM OPT 0.05% Emollient Cream LIDEMOL MDC TIAMOL TAR 0.05% Gel LIDEX VAL LYDERM OPT 0.05% Ointment LIDEX VAL LYDERM OPT FLUTICASONE PROPIONATE 0.05% Cream CUTIVATE GSK HALOBETASOL PROPIONATE 0.05% Cream ULTRAVATE WSB 0.05% Ointment ULTRAVATE WSB HYDROCORTISONE 0.5% Cream CORTATE SPL 1% Cream BARRIERE HC SHI EMO CORT I EURO-HYDROCORTISONE EUR HYDROSONE TCH PREVEX HC I 2.5% Cream EMO CORT I 100mg/60mL Enema CORTENEMA AXC 0.5% Lotion CORTATE SPL 1% Lotion EMO CORT I SARNA HC I Page 130 of 151

147 84:06.00 SMMA - ANTI-INFLAMMATORY AGENTS HYDROCORTISONE 2.5% Lotion EMO CORT I EMO CORT SCALP I SARNA HC I 0.5% Ointment CORTATE SPL CORTODERM TAR 1% Ointment CORTODERM TAR HYDROCORTISONE ACETATE 10% Aerosol Foam CORTIFOAM SQU 0.5% Cream HYDERM TAR 1% Cream HYDERM TAR 2% Cream NEO-HC NEO 1% Lotion DERMAFLEX HC NEO HYDROCORTISONE ACETATE, ZINC SULFATE 0.5% & 0.5% Ointment ANODAN-HC ODN ANUSOL HC PFI EGOZINC-HC PMS JAMPZINC-HC OINT JAP RATIO-HEMCORT HC RPH RIVASOL HC RIV SANDOZ-ANUZINC HC SDZ 10mg & 10mg Suppository ANODAN-HC ODN ANUSOL HC PFI EGOZINC HC PMS RATIO-HEMCORT HC RPH RIVASOL-HC RIV SANDOZ ANUZINC HC SDZ HYDROCORTISONE ACETATE, ZINC SULFATE, PRAMOXINE HCL 0.5% & 0.5% & 1% Ointment ANUGESIC HC PFI PROCTODAN HC ODN 10mg & 10mg & 20mg Suppository ANUGESIC HC PFI PROCTODAN HC ODN SANDOZ ANUZINC HC PLUS SDZ HYDROCORTISONE VALERATE 0.2% Cream HYDROVAL TAR 84:06.00 SMMA - ANTI-INFLAMMATORY AGENTS HYDROCORTISONE VALERATE 0.2% Ointment HYDROVAL TAR HYDROCORTISONE, DIBUCAINE HCL, ESCULIN, FRAMYCETIN SULFATE 5mg & 5mg & 10mg & 10mg Ointment PROCTOL ODN PROCTOSEDYL AXC RATIO-PROCTOSONE RPH SANDOZ-PROCTOMYXIN HC SDZ 5mg & 5mg & 10mg & 10mg Suppository PROCTOL ODN PROCTOSEDYL AXC RATIO-PROCTOSONE RPH SANDOZ PROCTOMYXIN HC SDZ HYDROCORTISONE, UREA 1% & 10% Cream DERMAFLEX HC NEB UREMOL HC I 1% & 10% Lotion UREMOL HC I MOMETASONE FUROATE 0.1% Cream ELOCOM SCH TARO-MOMETASONE TAR 0.1% Lotion ELOCOM SCH TARO-MOMETASONE TAR 0.1% Ointment ELOCOM SCH PMS-MOMETASONE PMS PMS-MOMETASONE PMS RATIO-MOMETASONE RPH TARO-MOMETASONE TAR TRIAMCINOLONE ACETONIDE 0.1% Cream ARIOCORT R VAO 0.5% Cream ARIOCORT C VAO 0.1% Ointment ARIOCORT R VAO 0.1% Paste ORACORT TAR 84:08.00 SMMA - ANTIPRURITICS AND LOCAL ANEHETICS LIDOCAINE HCL 2% Liquid LIDODAN VISCOUS ODN PMS-LIDOCAINE VISCOUS PMS XYLOCAINE VISCOUS AZC Page 131 of 151

148 84:08.00 SMMA - ANTIPRURITICS AND LOCAL ANEHETICS LIDOCAINE, PRILOCAINE 2.5% & 2.5% Cream EMLA AZC 2.5% & 2.5% Patch EMLA AZC 84:16.00 SMMA - CELL IMULANTS AND PROLIFERANTS TRETINOIN 0.01% Cream RETIN A JAJ IEVA-A I 0.025% Cream RETIN A JAJ IEVA-A I 0.05% Cream RETIN A JAJ IEVA-A I 0.1% Cream RETIN A JAJ IEVA-A FORTE I 0.01% Gel VITAMIN A ACID SAC 0.025% Gel IEVA-A I VITAMIN A ACID SAC 0.05% Gel VITAMIN A ACID SAC 0.025% Solution IEVA-A I 84:24.12 BASIC OINTMENTS AND PROTECTANTS DIMETHICONE 20% Cream BARRIERE WPC PETROLATUM 67% Cream PREVEX I ZINC OXIDE 15% Cream ZINC OXIDE CREAM 15% HJS 25% Ointment IHLES PAE RPH IHLES PAE ATL 40% Ointment ZINCOFAX EXTRA RENGTH GSK 84:28.00 KERATOLYTIC AGENTS ADAPALENE 0.1% Cream DIFFERIN GAC 0.1% Gel DIFFERIN GAC BENZOYL PEROXIDE 2.50% Solution PURIFYING CLEANSER VAE 3.50% Solution OIL-FREE ACNE WASH CLEANSER 4% Wash JOM SPECTRO ACNECARE WASH GSK 2.50% Wipes EMERGENCY ACNE VANISHING WIPES CANTHARIDIN, PODOPHYLLIN, SALICYLIC ACID 1% & 2% & 30% Liquid MEM CANTHARONE PLUS DOR 1% & 5% & 30% Liquid CANTHACUR PS PMS DITHRANOL 0.1% Cream ANTHRANOL MTI 0.2% Cream ANTHRANOL MTI 0.4% Lotion ANTHRASCALP MTI 1% Ointment ANTHRAFORTE 1 MTI 2% Ointment ANTHRAFORTE 2 MTI FORMALDEHYDE, LACTIC ACID, SALICYLIC ACID 5% & 10% & 25% Ointment DUOPLANT I LACTIC ACID, SALICYLIC ACID 17% & 17% Liquid DUOFILM I PODOFILOX 0.5% Solution CONDYLINE CDX PODOPHYLLIN 25% Liquid PODOFILM PMS SALICYLIC ACID 27% Gel DUOFORTE 27 I Page 132 of 151

149 84:28.00 KERATOLYTIC AGENTS SALICYLIC ACID 170mg/mL Gel COMPOUND W GEL WHR 20% Liquid SOLUVER DER 26% Liquid OCCLUSAL HP MYL 27% Liquid SOLUVER PLUS DER 40% Plaster CLEAR AWAY SCH 4% Shampoo SEBCUR DER 84:32.00 KERATOPLAIC AGENTS COAL TAR 10% Gel TARGEL ODN 20% Liquid ODANS LIQUOR CARBONIS DETERGENT 1% Shampoo ODN NEUTROGENA T/GEL JAJ TERSA-TAR MILD I 3% Shampoo TERSA-TAR I 4.3% Shampoo PENTRAX MYL COAL TAR, JUNIPER TAR, PINE TAR 1% Shampoo POLYTAR I COAL TAR, JUNIPER TAR, PINE TAR, ZINC PYRITHIONE 0.166% & 0.166% & 0.166% & 1% Shampoo MULTI-TAR PLUS MILD VAE 0.33% & 0.33% & 0.33% & 1% Shampoo MULTITAR PLUS VAE COAL TAR, SALICYLIC ACID 8% & 2% Gel P&S PLUS BAK 10% & 3% Liquid TARGEL SA ODN 10% & 4% Shampoo SEBCUR-T DER COAL TAR, SALICYLIC ACID, SULFUR 2% & 2% & 2% Shampoo EREX IDE 84:50.06 PIGMENTING AGENTS METHOXSALEN 10mg Capsule OXSORALEN VAE OXSORALEN VAE 1% Lotion OXSORALEN VAE 84:92.00 MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS ACITRETIN Open benefit (prior approval not required). Soriatane should be used with caution in women of childbearing potential due to its teratogenicity. Pregnancy must be excluded. Effective contraception must be used. Manufacturer's literature regarding contraindications and warnings, should be consulted prior to prescribing or dispensing this drug. 10mg Capsule SORIATANE ACG 25mg Capsule SORIATANE ACG AZELAIC ACID 15% Gel FINACEA BAY CALCIPOTRIOL 50mcg/g Cream DOVONEX LEO 50mcg/g Ointment DOVONEX LEO 50mcg/mL Solution DOVONEX LEO CALCIPOTRIOL, BETAMETHASONE 0.5mg & 50mcg Ointment DOVOBET LEO CAPSAICIN 0.025% Cream CAPSAICIN VAO ZODERM EUR ZORIX MYL 0.075% Cream CAPSAICIN HP VAO COLLAGENASE 250U Ointment SANTYL HPC FLUOROURACIL 5% Cream EFUDEX VAE Page 133 of 151

150 84:92.00 MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS IMIQUIMOD -For the treatment of condylomata acuminate (genital warts) in patients who have failed: -self-applied podophyllotoxin (podofilox 0.5% solution); OR -provider-applied podophyllum resin (10%-25%) 5% Cream ALDARA P VAE APO-IMIQUIMOD APX ISOTRETINOIN Open benefit (prior approval not required). Accutane should be used with caution in women of childbearing potential due to its teratogenicity. Pregnancy must be excluded. Effective contraception must be used. Manufacturer's literature regarding contraindications and warnings should be consulted prior to prescribing or dispensing this drug. 10mg Capsule ACCUTANE HLR CLARUS MYL 40mg Capsule ACCUTANE HLR CLARUS MYL PIMECROLIMUS For patients who have failed topical corticosteroid therapy or have experienced side effects from such treatment. Note: Contraindicated in children less than 2 years of age. 1% Cream ELIDEL NVC TACROLIMUS (PROTOPIC) For patients who have failed topical corticosteroid therapy or have experienced side effects from such treatment. Note: Contraindicated in children less than 2 years of age. 0.03% Ointment PROTOPIC A 0.1% Ointment PROTOPIC A TAZAROTENE 0.05% Cream TAZORAC ALL 0.1% Cream TAZORAC ALL 0.05% Gel TAZORAC ALL 0.1% Gel TAZORAC ALL Page 134 of 151

151 86:00 SMOOTH MUSCLE RELAXANTS 86:12.00 GENITOURINARY SMOOTH MUSCLE RELAXANTS DARIFENACIN HYDROBROMIDE For the symptomatic relief of overactive bladder in patients: with symptoms of urinary frequency, urgency or urge incontinence; AND who have failed on or are intolerant to therapy with immediate-release oxybutynin 7.5mg Long Acting Tablet ENABLEX TEV 15mg Long Acting Tablet ENABLEX TEV FLAVOXATE HCL 200mg Tablet URISPAS PAL OXYBUTYNIN CHLORIDE 1mg/mL Syrup APO-OXYBUTYNIN APX PMS-OXYBUTYNIN PMS 2.5mg Tablet PMS-OXYBUTYNIN PMS 5mg Tablet APO-OXYBUTYNIN APX DOM-OXYBUTYNIN DPC NOVO-OXYBUTYNIN TEV OXYBUTYN VAE OXYBUTYNIN SAN OXYBUTYNINE PDL PMS-OXYBUTYNIN PMS RIVA-OXYBUTYNIN RIV SOLIFENACIN SUCCINATE For symptomatic relief in patients with an overactive bladder with symptoms of urinary frequency urgency or urge incontinence in patients who have failed on or are intolerant of therapy with oxybutynin. 5mg Tablet VESICARE A 10mg Tablet VESICARE A TOLTERODINE For the symptomatic relief of patients with an overactive bladder with symptoms of urinary frequency urgency or urge incontinence or any combination of these in patients who have failed on or are intolerant of therapy with oxybutynin. 2mg Extended Release Capsule DETROL LA PFI 4mg Extended Release Capsule DETROL LA PFI 86:12.00 GENITOURINARY SMOOTH MUSCLE RELAXANTS TOLTERODINE For the symptomatic relief of patients with an overactive bladder with symptoms of urinary frequency urgency or urge incontinence or any combination of these in patients who have failed on or are intolerant of therapy with oxybutynin. 1mg Tablet DETROL PFI 2mg Tablet DETROL PFI TROSPIUM CHLORIDE For the symptomatic relief of patients with an overactive bladder with symptoms of urinary frequency, urgency or urge incontinence or any combination of these in patients who have failed on or are intolerant of therapy with oxybutynin. 20mg Tablet TROSEC ORY 86:16.00 RESPIRATORY SMOOTH MUSCLE RELAXANTS OXTRIPHYLLINE 20mg/mL Elixir CHOLEDYL PFI THEOPHYLLINE 5.33mg/mL Elixir PMS-THEOPHYLLINE PMS PULMOPHYLLIN RIV THEOPHYLLINE ATL 5.33mg/mL Solution THEOLAIR MMH 100mg Sustained Release Tablet APO-THEO APX NOVO-THEOPHYL SR TEV 200mg Sustained Release Tablet APO-THEO LA APX NOVO-THEOPHYL SR TEV 300mg Sustained Release Tablet APO-THEO LA APX NOVO-THEOPHYL SR TEV 400mg Sustained Release Tablet THEO ER AAP UNIPHYL PFR 600mg Sustained Release Tablet THEO ER AAP UNIPHYL PFR Page 135 of 151

152 88:00 VITAMINS 88:04.00 VITAMIN A VITAMIN A 10,000IU Capsule VIT A VTH VITAMIN A JAM 25,000IU Capsule VITAMIN A TEV 50,000IU Capsule VITAMIN A TEV 88:08.00 VITAMIN B COMPLEX CYANOCOBALAMIN 100mcg/mL Injection VITAMIN B12 ABB VITAMIN B12 SDZ 1,000mcg/mL Injection CYANOCOBALAMIN CYX CYANOCOBALAMIN TAR CYANOCOBALAMIN MYL JAMP-CYANOCOBALAMIN JAP VIT B12 SDZ VITAMIN B12 ABB VITAMIN B12 OMA 200mcg/mL Oral liquid BEDUZIL ORM JAMP-VITAMIN B12 JAP 250mcg Tablet JAMP-VITAMIN B12 JAP VITAMIN B12 JAM VITAMIN B12 PMT VITAMIN B12 WNP 1000mcg Tablet JAMP-VITAMIN B12 JAP JAMP-VITAMIN B12 JAP LB VITAMIN B12 WNP VITAMIN B12 SWS VITAMIN B12 PMT FOLIC ACID 1mg Tablet FOLIC ACID JAM FOLIC ACID VTH FOLIC ACID PMT FOLIC ACID PED FOLIC ACID WNP 5mg Tablet APO-FOLIC ACID APX EURO-FOLIC EUR JAMP-FOLIC ACID JAP NIACIN 50mg Tablet NIACIN PMS 100mg Tablet NIACIN VAE 88:08.00 VITAMIN B COMPLEX NIACIN 500mg Tablet NIACIN VAE NIACIN ODN NIACIN PMT NIACIN YEA FREE VTH VITAMIN B3 JAM PYRIDOXINE HCL 25mg Tablet VITAMIN B6 JAM VITAMIN B6 PMS VITAMIN B6 ODN VITAMIN B6 JMP 50mg Tablet VITAMIN B6 VAE VITAMIN B6 JAM VITAMIN B6 PMS 100mg Tablet VITAMIN B6 ICN VITAMIN B6 JAM VITAMIN B6 VTH VITAMIN B6 PMT THIAMINE 100mg Tablet VITAMIN B1 ICN THIAMINE HCL 100mg/mL Injection BETAXIN ABB THIAMIJECT OMG THIAMINE CYX VITAMIN B1 SDZ 50mg Tablet EURO-B1 EUR JAMP-VITAMIN B1 JMP VITAMIN B1 VAE 100mg Tablet VITAMIN B1 PMS VITAMIN B1 JAM VITAMIN B1 PMT 88:12.00 VITAMIN C ASCORBIC ACID 250mg Chewable Tablet VITAMIN C PMT 500mg Chewable Tablet VIT C LAL VITAMIN C PED VITAMIN C VTH VITAMIN C PMT VITAMIN C WNP VITAMIN C PMT 1000mg Sustained Release Tablet VITAMIN C PMT Page 136 of 151

153 88:12.00 VITAMIN C ASCORBIC ACID 250mg Tablet VIT C ADA VIT C VTH VITAMIN C PMT 500mg Tablet ASCORBIC ACID PMT VIT C ADA VITAMIN C PED VITAMIN C VTH VITAMIN C SWS VITAMIN C PMT 1000mg Tablet VITAMIN C PMT 88:16.00 VITAMIN D ALFACALCIDOL 0.25mcg Capsule ONE-ALPHA LEO 1mcg Capsule ONE-ALPHA LEO 2mcg/mL Oral Liquid ONE-ALPHA LEO CALCITRIOL 0.25mcg Capsule CALCITRIOL-ODAN ODN ROCALTROL HLR 0.5mcg Capsule ROCALTROL HLR CHOLECALCIFEROL 400IU Capsule EURO D EUR JAMP-VITAMIN D JMP RIVA-D 400 UNIT CAP RIV 800IU Capsule JAMP-VITAMIN D JMP 10,000IU Capsule EURO D EUR VITAMIN D PDL 50,000IU Capsule OOFORTE TRT 400IU Drop BABY DDROPS DDP DDROPS VITAMIN D DDP 400IU/mL Drop D VI SOL MJO JAMP-VITAMIN D JMP PEDIAVIT D EUR 1000IU Drop DDROPS VITAMIN D DDP 88:16.00 VITAMIN D CHOLECALCIFEROL 400IU Tablet VITAMIN D LAL VITAMIN D VTH VITAMIN D WAM VITAMIN D PMT 1,000IU Tablet VITAMIN D PMT 10,000IU Tablet D-TABS RIV ERGOCALCIFEROL 50,000IU Capsule D-FORTE EUR 8,288IU/mL Solution DRISDOL SAC VITAMIN D 400IU Capsule PHARMA D PED VITAMIN D BMI 800IU Capsule EURO D EUR 1,000IU Capsule D-GEL JAP PHARMA D PMS 10,000IU Capsule PHARMA D PMS 1,000IU Chewable Tablet VITAMIN D WAM 8.288U/ML Liquid D2-DOL JAP 400IU Liquid D3-DOL JAP DECAXIL ORM DECAXIL ORM 800IU Liquid PEDIAVIT D EUR 1,000IU Liquid VITAMIN D JAP VITAMIN D JAP VITAMIN D JAP 400IU Tablet VITAMIN D SWS 1,000IU Tablet VITAMIN D JAM VITAMIN D WNP 10,000IU Tablet JAMP-VITAMINE D JAP VIDEXTRA ORM Page 137 of 151

154 88:20.00 VITAMIN E VITAMIN E For use in malabsorption 200IU Capsule VITAMIN E JAM 400IU Capsule VITAMIN E NATUAL SOURCE JAM 50IU Liquid AQUASOL E NVC 50IU/mL Liquid AQUASOL E NVC 88:28.00 MULTIVITAMIN PREPARATIONS CALCIUM, VITAMIN D 500mg & 400IU Tablet BIOCAL-D FORTE BMI MULTIVITAMINS (PEDIATRIC) Limited use benefit (prior approval is not required). Pediatric multivitamins are benefits for children up to 6 years of age. Drop POLY-VI-SOL MJO 2,500IU & IU & 50mg/mL Drop PEDIAVIT EUR TR- VI-SOL MJO Liquid INFANTOL HOR Oral Liquid JAMP-MULTIVITAMIN A/D/C DROPS Tablet JMP CENTRUM JUNIOR COMPLETE WYE CENTRUM JUNIOR COMPLETE PFI FLINTONES EXTRA C BCD MULTIVITAMINS (PRENATAL) Limited use benefit (prior approval is not required.). Prenatal and postnatal vitamins are benefits only for women of childbearing age (12 to 50 years). Tablet CENTRUM MATERNA NES MULTI-PRE AND PO NATAL PED PRENATAL & POPARTUM PMT PRENATAL AND POPARTUM SDR Page 138 of 151

155 92:00 UNCLASSIFIED THERAPEUTIC AGENTS 92:00.00 UNCLASSIFIED THERAPEUTIC AGENTS BETAHIINE HCL 8mg Tablet NOVO-BETAHIINE TEV 16mg Tablet CO BETAHIINE ATP PMS-BETAHIINE PMS SERC SPH TEVA-BETAHIINE TEV 24mg Tablet CO BETAHIINE ATP PMS-BETAHIINE PMS SERC SPH TEVA-BETAHIINE TEV ERGOCALCIFEROL 8288IU/mL Oral Liquid ERDOL ODN EXTEMPORANEOUS MIXTURE Miscellaneous EXTEMPORANEOUS MIXTURE (BC) (SK) (YT) EXTEMPORANEOUS MIXTURE (NB) (NS) (PE) (NL) EXTEMPORANEOUS MIXTURE (NU) (AB) (MB) (QC) (NT) EXTEMPORANEOUS MIXTURE (ON) ERILE EXTEMPORANEOUS MIXTURE (QC) INCOBOTULINUMTOXINA For the treatment of: strabismus and blepharospasm associated with dystonia, including benign essential blepharospasm or VII nerve disorder in patients 12 years of age or older; OR cervical dystonia (spasmodic torticollis); OR urinary incontinence due to neurogenic detrusor overactivity resulting from neurogenic bladder associated with MS or subcervical spinal cord injury. 50Unit/Vial Injection XEOMIN MEZ LANREOTIDE 120mg/0.5mL Injection SOMATULINE AUTOGEL IPS NEDOCROMIL SODIUM 2% Ophth Solution ALOCRIL ALL OCTREOTIDE 92:00.00 UNCLASSIFIED THERAPEUTIC AGENTS OCTREOTIDE 20mg/Vial Injection SANDOATIN LAR NVR 30mg/Vial Injection SANDOATIN LAR NVR 50mcg/mL Injection OCTREOTIDE ACETATE OMG OMEGA SANDOATIN NVR 100mcg/mL Injection OCTREOTIDE ACETATE OMG OMEGA SANDOATIN NVR 200mcg/mL Injection OCTREOTIDE ACETATE OMG OMEGA SANDOATIN TEV 500mcg/mL Injection OCTREOTIDE ACETATE OMG OMEGA SANDOATIN NVR PENTOSAN POLYSULFATE SODIUM 100mg Capsule ELMIRON JNO UEKINUMAB For the treatment of moderate to severe psoriasis according to established criteria. (Please refer to Appendix A). 45mg/0.5mL Injection ELARA JNO 90mg/mL Injection ELARA JNO 92:01.88 ASCORBIC ACID 500mg Tablet VITAMIN C JAM CALCIUM, VITAMIN D 500mg & 400IU Chewable Tablet M-CAL D MAN FOLIC ACID 1mg Tablet JAMP-FOLIC ACID JAP MAGNESIUM 100mg/mL Oral Liquid MAGNESIUM-ODAN ODN 10mg/Vial Injection SANDOATIN LAR NVR Page 139 of 151

156 92:01.88 MAGNESIUM CITRATE 50mg/mL Solution CITRODAN ODN THIAMINE HCL 100mg Tablet JAMP-VITAMIN JAP VITAMIN D 400IU Tablet VITAMIN D WNP 1,000IU Tablet VITAMIN D PMS VITAMIN D SWS 92:08.00 DUTAERIDE a. - For treatment of Benign Prostatic Hyperplasia (BPH) in patients who do not tolerate or have not responded to an adrenergic blocker. or b. - For use in combination therapy when monotherapy with an alpha-blocker is not sufficient. 0.5MG Capsule ACT DUTAERIDE ATP APO-DUTAERIDE APX AVODART GSK DUTAERIDE PDL DUTAERIDE SIV MED-DUTAERIDE GMP MINT-DUTAERIDE MIN PMS-DUTAERIDE PMS RIVA-DUTAERIDE RIV SANDOZ DUTAERIDE SDZ TEVA-DUTAERIDE TEP 92:08.00 FINAERIDE a. - For treatment of Benign Prostatic Hyperplasia (BPH) in patients who do not tolerate or have not responded to an alpha-adrenergic blocker. or b. - For use in combination therapy when monotherapy with an alpha-blocker is not sufficient. 5mg Tablet APO-FINAERIDE APX AURO-FINAERIDE AUR CO FINAERIDE CBT DOM-FINAERIDE DOM FINAERIDE PDL FINAERIDE ACC JAMP-FINAERIDE JAP MINT-FINAERIDE MIN MYLAN-FINAERIDE MYL NOVO-FINAERIDE TEV PMS-FINAERIDE PMS PROSCAR FRS RAN-FINAERIDE RBY RATIO-FINAERIDE RPH SANDOZ FINAERIDE SDZ 92:12.00 LEUCOVORIN CALCIUM 5mg Tablet LEUCOVORIN CALCIUM WAY 92:16.00 ALLOPURINOL 100mg Tablet ALLOPRIN VAE ALLOPURINOL PDL APO-ALLOPURINOL APX JAMP-ALLOPURINOL JAP MAR-ALLOPURINOL MAR ZYLOPRIM AAP 200mg Tablet ALLOPRIN VAE ALLOPURINOL PDL APO-ALLOPURINOL APX JAMP-ALLOPURINOL JAP MAR-ALLOPURINOL MAR ZYLOPRIM AAP 300mg Tablet ALLOPRIN VAE ALLOPURINOL APX ALLOPURINOL PDL APO-ALLOPURINOL APX JAMP-ALLOPURINOL JAP MAR-ALLOPURINOL MAR ZYLOPRIM AAP Page 140 of 151

157 92:16.00 COLCHICINE 0.6mg Tablet COLCHICINE ODN JAMP-COLCHICINE JAP PMS-COLCHICINE PMS 1mg Tablet COLCHICINE ODN FEBUXOAT For patients with symptomatic gout who have documented hypersensitivity to allopurinol 80mg Tablet ULORIC TAK 92:24.00 ALENDRONATE SODIUM For the treatment of: a. - Paget's Disease OR b. - Osteoporosis in patients who are 60 years of age or over OR c. - Osteoporosis in patients under 60 who have documented hip, vertebral or other fractures OR d. - Osteoporosis in patients under 60 with no evidence of fracture but who have a high (>20%) 10-year fracture risk OR e. - Osteoporosis or risk of osteoporosis in patients under 60 who have been, or who will be, on systemic corticosteroid therapy equivalent to a dose of prednisone 7.5mg per day for 3 months. 5mg Tablet ALENDRONATE ACC APO-ALENDRONATE APX RAN-ALENDRONATE RBY SANDOZ ALENDRONATE SDZ TEVA-ALENDRONATE TEV 10mg Tablet ALENDRONATE ACC APO-ALENDRONATE APX AURO-ALENDRONATE AUR MINT-ALENDRONATE MIN MYLAN-ALENDRONATE MYL SANDOZ ALENDRONATE SDZ TEVA-ALENDRONATE TEV 40mg Tablet CO ALENDRONATE COB 92:24.00 ALENDRONATE SODIUM For the treatment of: a. - Paget's Disease OR b. - Osteoporosis in patients who are 60 years of age or over OR c. - Osteoporosis in patients under 60 who have documented hip, vertebral or other fractures OR d. - Osteoporosis in patients under 60 with no evidence of fracture but who have a high (>20%) 10-year fracture risk OR e. - Osteoporosis or risk of osteoporosis in patients under 60 who have been, or who will be, on systemic corticosteroid therapy equivalent to a dose of prednisone 7.5mg per day for 3 months. 70mg Tablet ALENDRONATE MEL ALENDRONATE SOR ALENDRONATE SAN ALENDRONATE ACC ALENDRONATE-70 PDL APO-ALENDRONATE APX AURO-ALENDRONATE AUR CO ALENDRONATE COB DOM-ALENDRONATE DOM FOSAMAX FRS JAMP-ALENDRONATE JAP MINT-ALENDRONATE MIN MYLAN-ALENDRONATE MYL PMS-ALENDRONATE PMS PMS-ALENDRONATE FC PMS RAN-ALENDRONATE RBY RIVA-ALENDRONATE RIV SANDOZ ALENDRONATE SDZ TEVA-ALENDRONATE TEV ALENDRONATE SODIUM, VITAMIN D3 For the treatment of: a. - Paget's Disease OR b. - Osteoporosis in patients who are 60 years of age or over OR c. - Osteoporosis in patients under 60 who have documented hip, vertebral or other fractures OR d. - Osteoporosis in patients under 60 with no evidence of fracture but who have a high (>20%) 10-year fracture risk OR e. - Osteoporosis or risk of osteoporosis in patients under 60 who have been, or who will be, on systemic corticosteroid therapy equivalent to a dose of prednisone 7.5mg per day for 3 months. 70mg/2800U Tablet FOSAVANCE FRS TEVA- ALENDRONATE/CHOLECALCIF EROL TEP Page 141 of 151

158 92:24.00 ALENDRONATE SODIUM, VITAMIN D3 For the treatment of: a. - Paget's Disease OR b. - Osteoporosis in patients who are 60 years of age or over OR c. - Osteoporosis in patients under 60 who have documented hip, vertebral or other fractures OR d. - Osteoporosis in patients under 60 with no evidence of fracture but who have a high (>20%) 10-year fracture risk OR e. - Osteoporosis or risk of osteoporosis in patients under 60 who have been, or who will be, on systemic corticosteroid therapy equivalent to a dose of prednisone 7.5mg per day for 3 months. 70mg/5600U Tablet FOSAVANCE MSP SANDOZ SDZ ALENDRONATE/CHOLECALCIF EROL TEVA- ALENDRONATE/CHOLECALCIF EROL TEP DENOSUMAB (P) For women with postmenopausal osteoporosis who would otherwise be eligible for coverage of oral bisphosphonates, but for whom: - bisphosphonates are contraindicated due to hypersensitivity or abnormalities of the esophagus (e.g., esophageal stricture or achalasia); AND Have at least two of the following: - age >70 years - a prior fragility fracture - a bone mineral density (BMD) T-score mg/mL Injection PROLIA AMG DENOSUMAB (X) For the prevention of skeletal-related events (SREs) in patients with castrate-resistant prostate cancer (CRPC) with: One or more documented bone metastases; AND Good performance status (ECOG performance status score of 0, 1, or 2). 120mg/1.7mL Injection XGEVA AMG ETIDRONATE DISODIUM 92:24.00 ETIDRONATE DISODIUM, CALCIUM CARBONATE 400mg & 500mg Tablet CO-ETIDROCAL COB DIDROCAL PGP ETIDROCAL SAN MYLAN-ETI-CAL CP MYL NOVO-ETIDRONATECAL KIT TEV PAMIDRONATE DISODIUM 6mg/mL Injection PAMIDRONATE DISODIUM OMG 30mg Injection AREDIA IV NVR PAMIDRONATE DISODIUM MAY SANDOZ-PAMIDRONATE SDZ 60mg Injection PAMIDRONATE DISODIUM HOS SANDOZ-PAMIDRONATE SDZ 90mg Injection AREDIA IV NVR PAMIDRONATE DISODIUM MAY PMS-PAMIDRONATE PMS SANDOZ-PAMIDRONATE SDZ RISEDRONATE SODIUM For the treatment of: a. - Osteoporosis in patients who are 60 years of age and over or b. - Osteoporosis in patients who have documented hip, vertebral or other fractures or c. - Paget's Disease or d. - Osteoporosis in patients with no evidence of fracture but who have a high (>20%) 10-year fracture risk or e. - Osteoporosis in patients with moderate 10-year fracture risk (10-20%) and use of systemic glucocorticoid therapy > 3 months 5mg Tablet ACTONEL PGP NOVO-RISEDRONATE TEV 30mg Tablet ACTONEL PGP NOVO-RISEDRONATE TEV 200mg Tablet CO ETIDRONATE COB MYLAN-ETIDRONATE MYL Page 142 of 151

159 92:24.00 RISEDRONATE SODIUM For the treatment of: a. - Osteoporosis in patients who are 60 years of age and over or b. - Osteoporosis in patients who have documented hip, vertebral or other fractures or c. - Paget's Disease or d. - Osteoporosis in patients with no evidence of fracture but who have a high (>20%) 10-year fracture risk or e. - Osteoporosis in patients with moderate 10-year fracture risk (10-20%) and use of systemic glucocorticoid therapy > 3 months 35mg Tablet ACTONEL PGP APO-RISEDRONATE APO AURO-RISEDRONATE AUR DOM-RISEDRONATE DOM JAMP-RISEDRONATE JAP MYLAN-RISEDRONATE MYL NOVO-RISEDRONATE TEV PMS-RISEDRONATE PMS RISEDRONATE PDL RISEDRONATE SIV RISEDRONATE SAN RISEDRONATE-35 SIV RIVA-RISEDRONATE RIV SANDOZ RISEDRONATE SDZ ZOLEDRONIC ACID For the treatment of Paget s disease. Coverage will be granted for one dose per 12 month period. OR. For women with postmenopausal osteoporosis who would otherwise be eligible for coverage of oral bisphosphonates*, but who have a contraindication to bisphosphonates due to hypersensitivity or abnormalities of the esophagus (e.g, esophageal stricture or achalasia); ANDwho have at least two of the following: age >70 years a prior fragility fracture a bone mineral density (BMD) T-score a bone mineral density (BMD) T-score mg/100mL Injection ACLAA NOV TARO-ZOLEDRONIC ACID TAR ZOLEDRONIC ACID TEP ZOLEDRONIC ACID REC 92:36.00 DISEASE-MODIFYING ANTIRHEUMATIC AGENTS ABATACEPT For the treatment of: Rheumatoid Arthritis according to established criteria. Juvenile Idiopathic Arthritis (Please refer to Appendix A). 125mg Injection ORENCIA BMS 250mg Injection ORENCIA BMS ADALIMUMAB For the treatment of: Rheumatoid Arthritis according to established criteria. Psoriatic Arthritis according to established criteria. Ankylosing Spondylitis according to established criteria. Psoriasis according to established criteria. Crohn's disease according to established criteria. Juvenile idiopathic arthritis according to established criteria. (Please refer to Appendix A). 40mg/Vial Injection HUMIRA ABB CERTOLIZUMAB PEGOL For the treatment of: Rheumatoid Arthritis according to established criteria. (Please refer to Appendix A). 200mg/mL Injection CIMZIA UCB ETANERCEPT For the treatment of: Rheumatoid Arthritis according to established criteria. Psoriatic Arthritis according to established criteria. Ankylosing Spondylitis according to established criteria. Juvenile Idiopathic Arthritis (Please refer to Appendix A). 25mg/Vial Injection ENBREL IMX 50mg/mL Injection ENBREL IMX ENBREL SURECLICK (QC) AMG Page 143 of 151

160 92:36.00 DISEASE-MODIFYING ANTIRHEUMATIC AGENTS GOLIMUMAB For the treatment of: Rheumatoid Arthritis according to established criteria. Psoriatic Arthritis according to established criteria. Ankylosing Spondylitis according to established criteria. (Please refer to Appendix A). 50mg/0.5mL Injection SIMPONI AUTO INJECTOR CER SIMPONI PRE-FILLED CER SYRINGE INFLIXIMAB For treatment of: Fistulizing Crohn s disease according to established criteria. For adult patients with moderately to severely active Crohn s Disease who have had an inadequate response to conventional therapy. (Please refer to Appendix A). or Rheumatoid Arthritis according to established criteria (Please refer to Appendix A). 100mg/Vial Injection REMICADE CEN LEFLUNOMIDE 10mg Tablet APO-LEFLUNOMIDE APX ARAVA SAC LEFLUNOMIDE SAN LEFLUNOMIDE PDL MYLAN-LEFLUNOMIDE MYL NOVO-LEFLUNOMIDE TEV PMS-LEFLUNOMIDE PMS SANDOZ LEFLUNOMIDE SDZ 20mg Tablet APO-LEFLUNOMIDE APX ARAVA SAC LEFLUNOMIDE SAN LEFLUNOMIDE PDL MYLAN-LEFLUNOMIDE MYL NOVO-LEFLUNOMIDE TEV PMS-LEFLUNOMIDE PMS SANDOZ LEFLUNOMIDE SDZ TOCILIZUMAB For the treatment of adult patients with moderate to severely active rheumatoid arthritis who have failed to respond to an adequate trial of an anti-tnf agent. (Please refer to Appendix A). 80mg/4ml Injection ACTEMRA HLR 200mg/10ml Injection ACTEMRA HLR 92:36.00 DISEASE-MODIFYING ANTIRHEUMATIC AGENTS TOCILIZUMAB For the treatment of adult patients with moderate to severely active rheumatoid arthritis who have failed to respond to an adequate trial of an anti-tnf agent. (Please refer to Appendix A). 400mg/20ml Injection ACTEMRA HLR 92:44.00 AZATHIOPRINE 50mg Tablet APO-AZATHIOPRINE APX AZATHIOPRINE SAN AZATHIOPRINE-50 PDL IMURAN GSK MYLAN-AZATHIOPRINE MYL CYCLOSPORINE For transplant therapy. 10mg Capsule NEORAL NVR 25mg Capsule NEORAL NVR SANDOZ-CYCLOSPORINE SDZ 50mg Capsule NEORAL NVR SANDOZ-CYCLOSPORINE SDZ 100mg Capsule NEORAL NVR SANDOZ-CYCLOSPORINE SDZ 100mg/mL Solution NEORAL NVR MYCOPHENOLATE MOFETIL For transplant therapy. 250mg Capsule ACH-MYCOPHENOLATE ACC APO-MYCOPHENOLATE APX CELLCEPT HLR JAMP-MYCOPHENOLATE JAP MYLAN-MYCOPHENOLATE MYL SANDOZ MYCOPHENOLATE SDZ TEVA-MYCOPHENOLATE TEP 500mg Tablet APO-MYCOPHENOLATE APX CELLCEPT HLR JAMP-MYCOPHENOLATE JAP MYCOPHENOLATE ACC MYLAN-MYCOPHENOLATE MYL SANDOZ-MYCOPHENOLATE SDZ TEVA-MYCOPHENOLATE TEP Page 144 of 151

161 92:44.00 MYCOPHENOLATE SODIUM For transplant therapy. 180mg Enteric Coated Tablet APO-MYCOPHENOLIC ACID APX MYFORTIC NVR 360mg Enteric Coated Tablet APO-MYCOPHENOLIC ACID APX MYFORTIC NVR SIROLIMUS Coverage will be provided as a second line therapy for patients failing mycophenolate mofetil. 1mg/mL Oral Liquid RAPAMUNE WAY 1mg Tablet RAPAMUNE WAY TACROLIMUS For transplant therapy. 3MG CAP LA ADVAGRAF 3MG ER CAP A 0.5mg Capsule PROGRAF A SANDOZ TACROLIMUS SDZ 1mg Capsule PROGRAF A SANDOZ TACROLIMUS SDZ 5mg Capsule PROGRAF A SANDOZ TACROLIMUS SDZ 5mg/mL Injection PROGRAF A 0.5mg Long Acting Capsule ADVAGRAF A 1mg Long Acting Capsule ADVAGRAF A 5mg Long Acting Capsule ADVAGRAF A 92:92.00 BOTULINUM TOXIN TYPE A For the treatment of: a. - strabismus and blepharospasm associated with dystonia, including benign essential blepharospasm or VII nerve disorder in patients 12 years of age or older b. - cervical dystonia (spasmodic torticollis); OR urinary incontinence due to neurogenic detrusor overactivity resulting from neurogenic bladder associated with MS or subcervical spinal cord injury. 50IU Injection BOTOX ALL 100IU Injection BOTOX ALL 200IU Injection BOTOX ALL CYPROTERONE ACETATE, ETHINYL ERADIOL 2mg & 35mcg Tablet CYERA-35 PMS DIANE-35 BAY TEVA- CYPROTERONE/ETHINYL ERADIOL TEV INCOBOTULINUMTOXINA For the treatment of: strabismus and blepharospasm associated with dystonia, including benign essential blepharospasm or VII nerve disorder in patients 12 years of age or older; OR cervical dystonia (spasmodic torticollis); OR urinary incontinence due to neurogenic detrusor overactivity resulting from neurogenic bladder associated with MS or subcervical spinal cord injury. 100U/vial Injection XEOMIN MEZ LANREOTIDE 60mg/0.3mL Injection SOMATULINE AUTOGEL IPS 90mg/0.3mL Injection SOMATULINE AUTOGEL IPS Page 145 of 151

162 94:00 DEVICES 94:00.00 DEVICES SPACER DEVICE Limited use benefit with quantity and frequency limits (prior approval is not required). Coverage is granted for 1 spacer device every 12 months. Device AEROCHAMBER AC BOYZ TRU AEROCHAMBER AC GIRLZ TRU AEROCHAMBER PLUS FLOW- TRU VU LG AEROCHAMBER PLUS FLOW- TRU VU MED AEROCHAMBER PLUS FLOW- TRU VU MOUTH AEROCHAMBER PLUS FLOW- TRU VU SM AEROTRACH PLUS TMI E-Z SPACER WEP E-Z SPACER (MASK ONLY) WEP E-Z SPACER WITH SMALL WEP MASK OPTICHAMBER AUC OPTICHAMBER DIAMOND AUC (CHAMBER) OPTICHAMBER DIAMOND AUC (LARGE M) OPTICHAMBER DIAMOND AUC (MEDIUM M) OPTICHAMBER DIAMOND AUC (MEDIUM M) OPTICHAMBER LARGE MASK AUC OPTICHAMBER MEDIUM MASK AUC OPTICHAMBER SMALL MASK AUC OPTIHALER AUC POCKET CHAMBER MCA POCKET CHAMBER WITH MCA ADULT MASK POCKET CHAMBER WITH MCA INFANT MASK POCKET CHAMBER WITH MCA MEDIUM MASK POCKET CHAMBER WITH SMALL MASK MCA 94:01.00 DEVICES (DIABETIC) INSULIN PUMP SUPPLIES -Insulin pump supplies are approved for NIHB clients following the approval of an insulin pump by NIHB. OR -Insulin pump supplies are approved for NIHB clients with Type 1 diabetes if an insulin pump was partially or totally covered by another insurance. Rapid-D Accu-Chek - Infusion Set RAPID-D 10MM/110CM DIS RAPID-D 10MM/60CM DIS RAPID-D 10MM/80CM DIS RAPID-D 6MM/110CM DIS RAPID-D 6MM/60CM DIS RAPID-D 6MM/80CM DIS RAPID-D 8MM/110CM DIS RAPID-D 8MM/60CM DIS RAPID-D 8MM/80CM DIS Tender Accu-Chek - Infusion Set TENDER-1 17MM/110CM DIS TENDER-1 17MM/60CM DIS TENDER-1 17MM/80CM DIS TENDER-2 17MM/110CM DIS TENDER-2 17MM/60CM DIS TENDER-2 17MM/80CM DIS Tender "Mini" Accu-Chek - Infusion Set TENDER-1 "MINI" 13MM/110CM DIS TENDER-1 "MINI" 13MM/60CM DIS TENDER-1 "MINI" 13MM/80CM DIS TENDER-2 "MINI" 13MM/110CM DIS TENDER-2 "MINI" 13MM/60CM DIS TENDER-2 "MINI" 13MM/80CM DIS UltraFlex Accu-Chek - Infusion Set ULTRAFLEX MM/110CM DIS ULTRAFLEX MM/60CM DIS ULTRAFLEX MM/80CM DIS ULTRAFLEX - 1 8MM/110CM DIS ULTRAFLEX - 1 8MM/60CM DIS ULTRAFLEX - 1 8MM/80CM DIS Accu-Chek - Resevoirs SPIRIT CARTRIDGE 3.15ML Comfort Angled Animas - Infusion Set COMFORT ANGLED 17MMX110CM (10 TUBING/BOX) COMFORT ANGLED 17MMX60CM (10 TUBING/BOX) Comfort Short Angled Animas - Infusion Set COMFORT SHORT ANGLED 13MMX110CM (10 TUBING/BOX) COMFORT SHORT ANGLED 13MMX60CM (10 TUBING/BOX) DIS AMS AMS AMS AMS Page 146 of 151

163 94:01.00 DEVICES (DIABETIC) INSULIN PUMP SUPPLIES -Insulin pump supplies are approved for NIHB clients following the approval of an insulin pump by NIHB. OR -Insulin pump supplies are approved for NIHB clients with Type 1 diabetes if an insulin pump was partially or totally covered by another insurance. Contact Detach Animas - Infusion Set CONTACT DETACH 90 DEGREE 6MMX60CM CONTACT DETACH 90 DEGREE 8MMX60CM Inset II Animas - Infusion Set INSET II 90 DEGREE 6MMX110CM INSET II 90 DEGREE 6MMX60CM INSET II 90 DEGREE 9MMX110CM INSET II 90 DEGREE 9MMX60CM Animas - Resevoirs AMS AMS AMS AMS AMS AMS CARTRIDGE FOR IR200 2ML AMS Mio Medtronic - Infusion Set MIO BLUE 6MMX18" MDT MIO BLUE 6MMX23" MDT MIO CLEAR 6MMX32" MDT MIO CLEAR 9MMX32" MDT MIO PINK 6MMX18" MDT MIO PINK 6MMX23" MDT Paradigm Silhouette Medtronic - Infusion Set PARADIGM SILHOUETTE 13MMX18" PARADIGM SILHOUETTE 13MMX23" PARADIGM SILHOUETTE 13MMX32" PARADIGM SILHOUETTE 13MMX43" PARADIGM SILHOUETTE 17MMX23" PARADIGM SILHOUETTE 17MMX32" PARADIGM SILHOUETTE 17MMX43" PARADIGM SILHOUETTE CANNULA 13MM PARADIGM SILHOUETTE CANNULA 17MM Quick-Set Medtronic - Infusion Set MDT MDT MDT MDT MDT MDT MDT MDT MDT QUICK-SET 6MMX18" MDT QUICK-SET 6MMX23" MDT QUICK-SET 6MMX32" MDT QUICK-SET 6MMX43" MDT QUICK-SET 9MMX23" MDT QUICK-SET 9MMX32" MDT QUICK-SET 9MMX43" MDT 94:01.00 DEVICES (DIABETIC) INSULIN PUMP SUPPLIES -Insulin pump supplies are approved for NIHB clients following the approval of an insulin pump by NIHB. OR -Insulin pump supplies are approved for NIHB clients with Type 1 diabetes if an insulin pump was partially or totally covered by another insurance. Sure-T Medtronic - Infusion Set PARADIGM SURE-T 29G 6MMX18" PARADIGM SURE-T 29G 6MMX23" PARADIGM SURE-T 29G 8MMX23" Medtronic - Resevoirs RESERVOIR 5XX 1.8ML SYRINGE RESERVOIR PARADIGM 7XX3.0ML OmniPod Omnipod - POD MDT MDT MDT MDT MDT PODS OMD ISOPROPYL ALCOHOL 70% Swab ALCOHOL PREP SWAB PFD ALCOHOL SWAB TIP ALCOHOL SWABS BD BTD B-D ALCOHOL SWAB BTD MONOJECT ALCOHOL WIPES SHM WEBCOL ALCOHOL PREP JAJ Page 147 of 151

164 94:01.00 DEVICES (DIABETIC) LANCET Lancet ACCU-CHEK FACLIK ROC LANCET ACCU-CHEK FACLIK ROC LANCET ACCU-CHEK MULTICLIX ROD ACCU-CHEK SOFTCLIX ROC LANCETS ACCU-CHEK SOFTCLIX ROC LANCETS BD ULTRAFINE 33G LANCETS BTD BG AR LANCETS SAC EZ HEALTH ORACLE LANCETS TRE FINGERIX LANCETS BAY FREEYLE LANCETS BAY ITE LANCETS 28G AUC ITE LANCETS 33G AUC MEDI+SURE SOFT 30G TWI MEC LANC MEDI+SURE SOFT 33G TWI MEC LANC MICROLET LANCETS BAY MONOLET (MONOJECT) 21G TYC MONOLET THIN (MONOJECT) TYC 28G MPD THIN (100) MPD MPD THIN (200) MPD MPD ULTRA THIN (100) MPD MPD ULTRA THIN (200) MPD ONE TOUCH DELICA LANCET JAJ 30G ONETOUCH DELICA LANCET JAJ 33G ONETOUCH ULTRASOFT JAJ LANCETS ULTILET CLASSIC LANCETS SKY MAGNIFIER Magnifier SYRINGE SCALE MAGNIFIER NEEDLE 18G Needle BD PRECISIONGLIDE 18GX1 1/2 INCH BD PRECISIONGLIDE 18GX1 INCH 25G Needle BD PRECISIONGLIDE 25GX5/8 INCH BD PRECISIONGLIDE 25GX7/8 INCH 26G Needle BD PRECISIONGLIDE 26GX1/2 INCH BD PRECISIONGLIDE 26GX3/8 INCH BTD BTD BTD BTD BTD BTD 94:01.00 DEVICES (DIABETIC) NEEDLE 27G Needle BD PRECISIONGLIDE 27GX1 1/4 INCH 27GX1/2 Needle BD PRECISIONGLIDE 27GX1/2 INCH PEN NEEDLE 29G Needle BTD BTD BD ULTRA-FINE PEN NEEDLE BTD 29GX12.7MM Needle SUPER-FINE PEN NEEDLES ANDARD 29GX12MM Needle PMS INSUPEN PEN NEEDLES DPI ULTICARE PEN NEEDLES UMI WITH SHARP CONTAINER UNIFINE PENTIPS (OWEN MUMFORD) AUC 29GX8MM Needle BD AUTOSHIELD PEN NEEDLES 30G Needle BTD NOVOTWI TIP NEEDLES NOO 30GX8MM Needle INSUPEN PEN NEEDLES DPI 31GX4.5MM Needle CLICKFINE PEN NEEDLES AUC 31GX5MM Needle SUPER-FINE PEN NEEDLES MICRO UNIFINE PENTIPS (OWEN MUMFORD) 31GX6MM Needle PMS AUC CLICKFINE PEN NEEDLES AUC INSULIN PEN NEEDLE MTD INSUPEN PEN NEEDLES DPI ULTICARE PEN NEEDLES UMI WITH SHARP CONTAINER UNIFINE PENTIPS (OWEN MUMFORD) AUC 31GX8MM Needle CLICKFINE PEN NEEDLES AUC INSULIN PEN NEEDLE MTD INSUPEN PEN NEEDLES DPI LIFE BRAND PEN NEEDLES HOD SUPER-FINE PEN NEEDLES PMS XTRA ULTICARE PEN NEEDLES UMI WITH SHARP CONTAINER UNIFINE PENTIPS (OWEN MUMFORD) AUC 32G Needle NOVOFINE PEN NEEDLES NOO NOVOTWI TIP NEEDLES NOO Page 148 of 151

165 94:01.00 DEVICES (DIABETIC) PEN NEEDLE 32GX4MM Needle BD ULTRA-FINE NANO PEN BTD NEEDLES INSULIN PEN NEEDLE MTD NOVOFINE PLUS NOO ULTICARE PEN NEEDLES DPI 32GX6MM Needle INSULIN PEN NEEDLE MTD INSUPEN PEN NEEDLES DPI 32GX8MM Needle INSULIN PEN NEEDLE MTD INSUPEN PEN NEEDLES DPI SHARPS CONTAINER Device B-D SHARPS CONTAINER 1.4L BTD B-D SHARPS CONTAINER 3.1L BTD SYRINGE Syringe ULTICARE LOW DEAD SPACE SYRINGE 1ML Syringe BD LUER-LOK SYRINGE ONLY (1ML) BD SLIP TIP SYRINGE ONLY (1ML) 3ML Syringe BD LUER-LOK SYRINGE ONLY (3ML) BD SLIP TIP SYRINGE ONLY (3ML) 5ML Syringe BD LUER-LOK SYRINGE ONLY (5ML) BD SLIP TIP SYRINGE ONLY (5ML) 10ML Syringe BD LUER-LOK SYRINGE ONLY (10ML) BD SLIP TIP SYRINGE ONLY (10ML) 20ML Syringe BD LUER-LOK SYRINGE ONLY (20ML) BD SLIP TIP SYRINGE ONLY (20ML) 30ML Syringe BD LUER-LOK SYRINGE ONLY (30ML) BD SLIP TIP SYRINGE ONLY (30ML) SYRINGE & NEEDLE 31GX0.3CC Syringe UMI BTD BTD BTD BTD BTD BTD BTD BTD BTD BTD BTD BTD INSULIN SYRINGES MTD 94:01.00 DEVICES (DIABETIC) SYRINGE & NEEDLE 31GX0.5CC Syringe INSULIN SYRINGES MTD 31GX1CC Syringe INSULIN SYRINGES MTD 29GX0.3CC Syringe and Needle ULTICARE INSULIN SYRINGE UMI 18GX1 1/2 Syringe and Needle BD LUER-LOK SYRINGE/NEEDLE COMBO (3ML) 21GX1 Syringe and Needle BD TUBERCULIN SYR/DETACHABLE NEEDLE SLIP TIP 25GX1 Syringe and Needle BD LUER-LOK SYRINGE/NEEDLE COMBO (3ML) 25GX1 1/2 Syringe and Needle BD LUER-LOK SYRINGE/NEEDLE COMBO (3ML) 25GX5/8 Syringe and Needle BD LUER-LOK SYRINGE/NEEDLE COMBO (3ML) BD TUBERCULIN SYR/DETACHABLE NEEDLE SLIP TIP 26GX3/8 Syringe and Needle BD TUBERCULIN SYR/DETACHABLE NEEDLE SLIP TIP 26GX5/8 Syringe and Needle BTD BTD BTD BTD BTD BTD BTD BD SLIP TIP SUB Q (1ML) BTD 27GX1/2 Syringe and Needle BD TUBERCULIN SYR/DETACHABLE NEEDLE SLIP TIP BD TUBERCULIN SYR/PERMANENT NEEDLE 28GX0.5CC Syringe and Needle BTD BTD ULTICARE SYRINGE UMI 28GX1CC Syringe and Needle ULTICARE SYRINGE UMI 29GX0.3CC Syringe and Needle BD ULTRA-FINE BTD ULTICARE SYGINGES WITH UMI ULTIGUARD 29GX0.5CC Syringe and Needle BD ULTRA-FINE BTD ULTICARE INSULIN SYRINGE UMI ULTICARE SYGINGES WITH ULTIGUARD UMI Page 149 of 151

166 94:01.00 DEVICES (DIABETIC) SYRINGE & NEEDLE 29GX1CC Syringe and Needle BD ULTRA-FINE BTD ULTICARE INSULIN SYRINGE UMI ULTICARE SYGINGES WITH ULTIGUARD UMI 30GX0.3CC Syringe and Needle BD ULTRA-FINE II SHORT BTD ULTICARE INSULIN SYRINGE UMI ULTICARE SYGINGES WITH UMI ULTIGUARD ULTICARE SYRINGES WITH ULTIGUARD UMI 30GX0.5CC Syringe and Needle BD ULTRA-FINE II SHORT BTD ULTICARE INSULIN SYRINGE UMI ULTICARE SYGINGES WITH UMI ULTIGUARD ULTICARE SYRINGES WITH ULTIGUARD UMI 30GX1CC Syringe and Needle BD ULTRA-FINE II SHORT BTD ULTICARE INSULIN SYRINGE UMI ULTICARE SYGINGES WITH UMI ULTIGUARD ULTICARE SYRINGES WITH ULTIGUARD UMI 31GX0.3CC Syringe and Needle ULTICARE SYRINGE UMI ULTICARE SYRINGES WITH UMI ULTIGUARD 31GX0.5CC Syringe and Needle ULTICARE SYRINGE UMI ULTICARE SYRINGES WITH UMI ULTIGUARD 31GX1CC Syringe and Needle ULTICARE SYRINGE UMI ULTICARE SYRINGES WITH UMI ULTIGUARD 31GX6MMX0.3CC Syringe and Needle BD SYRINGE WITH ULTRA- FINE NEEDLE 31X6MMX0.5CC Syringe and Needle BTD BD SYRINGE + NEEDLE BTD 31X6MMX1CC Syringe and Needle BD SYRINGE + NEEDLE BTD SYRINGE CASE Syringe Case MYHEALTH SYRINGE CASE-7 AUC MYHEALTH SYRINGE CASE- AUC SINGLE Page 150 of 151

167 96:00 PHARMACEUTICAL AIDS 96:00.00 PHARMACEUTICAL AIDS CAFFEINE CITRATE Limited use benefit (prior approval not required). For children up to 1 year of age Powder CAFFEINE CITRATE WIL METHADONE HCL Powder METHADONE WIL Page 151 of 151

168 APPENDIX A LIMITED USE BENEFITS AND CRITERIA

169 Appendix A - Limited Use Benefits and Criteria 08:00 ANTI-INFECTIVE AGENTS 08:12.24 TETRACYCLINES MINOCYCLINE HCL For: a. - patients who cannot tolerate other tetracyclines. b. - patients with severe widespread acne who have failed on tetracycline. 50mg Capsule APO-MINOCYCLINE APX DOM-MINOCYCLINE DPC MINOCYCLINE PDL MINOCYCLINE SAN MYLAN-MINOCYCLINE MYL NOVO-MINOCYCLINE TEV PMS-MINOCYCLINE PMS PMS-MINOCYCLINE PMS RATIO-MINOCYCLINE RPH RIVA-MINOCYCLINE RIV SANDOZ-MINOCYCLINE SDZ 100mg Capsule APO-MINOCYCLINE APX DOM-MINOCYCLINE DPC MINOCYCLINE PDL MINOCYCLINE IVX MINOCYCLINE SAN MYLAN-MINOCYCLINE MYL NOVO-MINOCYCLINE TEV PMS-MINOCYCLINE PMS PMS-MONOCYCLINE PMS RATIO-MINOCYCLINE RPH RIVA-MINOCYCLINE RIV SANDOZ-MINOCYCLINE SDZ 08:12.28 MISCELLANEOUS ANTIBIOTICS LINEZOLID Tablets: For treatment of proven vancomycin-resistant enterococci (VRE) infections when other antibiotics are not available, and for the treatment of proven Methicillin- Resistant Staphylococcus aureus (MRSA) infections in patients who cannot tolerate or who had an idiosyncratic reaction with Vancomycin. I.V. solution: When linezolid cannot be administered orally in the above mentioned situations. 2mg/mL Injection LINEZOLID TEP ZYVOXAM PFI 600mg Tablet APO-LINEZOLID APX SANDOZ LINEZOLID SDZ ZYVOXAM PFI Page A-1 de 81

170 Appendix A - Limited Use Benefits and Criteria 08:14.08 AZOLES VORICONAZOLE For the treatment of: a. - patients with invasive aspergillosis. b. - culture proven invasive candidiasis with documented resistance to fluconazole. 50mg Tablet APO-VORICONAZOLE APX SANDOZ VORICONAZOLE SDZ TEVA-VORICONAZOLE TEP VFEND PFI 200mg Tablet APO-VORICONAZOLE APX SANDOZ VORICONAZOLE SDZ TEVA-VORICONAZOLE TEP VFEND PFI 08:18.08 ANTIRETROVIRALS ETRAVIRINE For use in combination with other antiretroviral agents for treatment-experienced patients with HIV-1 infection who: a.- have failed prior antiretroviral therapy; and b. - have HIV-1 strains resistant to multiple antiretroviral agents, including NNRTIs 100mg Tablet INTELENCE JNO 200mg Tablet INTELENCE KEG MARAVIROC For the treatment of HIV-1 infection, given in combination with other antiretroviral agents, in patients who have: a. - CR5 tropic viruses; and b. - documented resistance to at least one agent from each of the three major classes of antiretroviral agents (nucleoside reverse transcriptase inhibitors, nonnucleoside reverse transcriptase inhibitors, and protease inhibitors) 150mg Tablet CELSENTRI VII 300mg Tablet CELSENTRI VII RALTEGRAVIR For the treatment of HIV infection in patients who are antiretroviral experienced and have virologic failure due to resistance to at least one agent from each of the three major classes of antiretroviral agents, nucleoside/tide reverse transcriptase inhibitors, non-nucleoside reverse transcriptase inhibitors and protease inhibitors. 400mg Tablet ISENTRESS FRS TENOFOVIR DISOPROXIL FUMARATE For the management of HIV disease in patients who have failed or have experienced adverse events to an alternative nucleoside reverse transcriptase inhibitor. 245mg Tablet VIREAD GIL TIPRANAVIR For the management of HIV disease in patients a. - who have failed all currently listed protease inhibitors b. - intolerant to all currently listed protease inhibitors 250mg Capsule APTIVUS BOE Page A-2 de 81

171 Appendix A - Limited Use Benefits and Criteria 08:18.20 INTERFERONS PEGINTERFERON ALFA-2A For the treatment of chronic hepatitis C in patients who are treatment naïve, upon the written request of a hepatologist or other specialist in this area. a. - For genotypes 1, 4, 5 and 6, an initial 24 week supply will be approved. A further 24 week supply may be approved if patient has a viral reduction of at least 2 logs or HCV is undetectable at 12 weeks (48 weeks total). b. - For genotypes 2 or 3, initial coverage for a maximum of 24 weeks will be approved. Renewals will not be covered 180mcg/0.5mL Injection PEGASYS HLR 180mcg/1mL Injection PEGASYS HLR PEGINTERFERON ALFA-2A, RIBAVIRIN For the treatment of chronic hepatitis C in patients who are treatment naïve, upon the written request of a hepatologist or other specialist in this area. a. - For genotypes 1, 4, 5 and 6, an initial 24 week supply will be approved. A further 24 week supply may be approved if patient has a viral reduction of at least 2 logs or HCV is undetectable at 12 weeks (48 weeks total). b. - For genotypes 2 or 3, initial coverage for a maximum of 24 weeks will be approved. Renewals will not be covered 180mcg/0.5mL & 200mg Injection & Tablet PEGASYS RBV HLR 180mcg/1mL & 200mg Injection & Tablet PEGASYS RBV HLR PEGINTERFERON ALFA-2B, RIBAVIRIN For the treatment of chronic hepatitis C in patients who are treatment naïve, upon the written request of a hepatologist or other specialist in this area. a. - For genotypes 1, 4, 5 and 6, an initial 24 week supply will be approved. A further 24 week supply may be approved if patient has a viral reduction of at least 2 logs or HCV is undetectable at 12 weeks (48 weeks total). b. - For genotypes 2 or 3, initial coverage for a maximum of 24 weeks will be approved. Renewals will not be covered 50mcg/0.5mL & 200mg Injection & Capsule PEGETRON SCH PEGETRON REDIPEN SCH 80mcg/0.5mL & 200mg Injection & Capsule PEGETRON REDIPEN SCH 100mcg/0.5mL & 200mg Injection & Capsule PEGETRON REDIPEN SCH 120mcg/0.5mL & 200mg Injection & Capsule PEGETRON REDIPEN SCH 150mcg/0.5mL & 200mg Injection & Capsule PEGETRON SCH PEGETRON REDIPEN SCH 08:18.32 NUCLEOSIDES AND NUCLEOTIDES ADEFOVIR DIPIVOXIL For the treatment of chronic hepatitis B infection when used in combination with lamivudine in patients who have developed failure to lamivudine, as defined by an increase in HBV DNA of 1 log10 IU/mL above the nadir, measured on two separate occasions within an interval of at least one month, after the first three months of lamivudine therapy, and when failure to lamivudine is not due to poor adherence to therapy. 10MG Tablet APO-ADEFOVIR APX HEPSERA GIL Page A-3 de 81

172 Appendix A - Limited Use Benefits and Criteria 08:18.32 NUCLEOSIDES AND NUCLEOTIDES ENTECAVIR For the treatment of chronic hepatitis B infection in patients with cirrhosis documented on radiologic or histologic grounds and a HBV DNA concentration above 2000IU/mL. 0.5mg Tablet APO-ENTECAVIR APX BARACLUDE BMS PMS-ENTECAVIR PMS SOFOSBUVIR For the treatment of chronic Hepatitis C in adult patients with compensated liver disease, including cirrhosis, if the following clinincal criteria and conditions are met: Patients with Genotype 1 CHC infection, in combination with pegylated-interferon and ribavirin (PEG IFN/RBV): - Fibrosis stage F2 or greater - Treatment naïve If approved, treatment should not exceed a duration of 12 weeks. Patients with Genotype 2 CHC infection, in combination with RBV: - Fibrosis stage F2 or greater - Previous treatment experience with Peg-IFN/RBV ; OR - A medical contraindication to Peg-IFN/RBV If approved, treatment should not exceed a duration of 12 weeks. Patients with Genotype 3 CHC infection, in combination with RBV: - Fibrosis stage F2 or greater - Previous treatment experience with Peg-IFN/RBV ; OR - A medical contraindication to Peg-IFN/RBV If approved, treatment should not exceed a duration of 24 weeks. Not eligible for coverage: Patients currently being treated with another HCV antiviral agent Patients who have previously received a treatment course of Sovaldi (Re-treatment requests will not be considered). 400mg Tablet SOVALDI GIL SOFOSBUVIR, LEDIPASVIR For the treatment of chronic hepatitis C virus (HCV) genotype 1 infection in adults with a liver fibrosis stage F2 (Metavir score or equivalent). Criteria & Duration Treatment-naïve patients with no cirrhosis, viral load < 6 million IU/mL - 8 weeks* Treatment-naïve patients with no cirrhosis, viral load 6 million IU/mL -12 weeks Treatment-naïve patients with compensated cirrhosis -12 weeks Treatment-experienced patients with no cirrhosis - 12 weeks Treatment-experienced patients with compensated cirrhosis - 24 weeks *For this population cohort (treatment naïve, non-cirrhotic, viral load < 6 million IU/mL), evidence has shown that the SVR rates with the 8-week and 12-week treatment regimens are similar. Treatment regimens of up to 12 weeks are recognized as a Health Canada approved treatment option. Patients may be considered for 12 weeks of coverage if they have severe fibrosis/borderline cirrhosis (F3-4) or if they are co-infected with HIV. Not eligible for coverage: Patients currently being treated with another HCV antiviral agent Patients who have previously received a treatment course of Harvoni (Re-treatment requests will not be considered). 400mg & 90mg Tablet HARVONI GIL Page A-4 de 81

173 Appendix A - Limited Use Benefits and Criteria 08:18.40 BOCEPREVIR For the treatment of chronic hepatitis C (CHC) genotype 1 infection in adult patients with compensated liver disease, in combination with peginterferon alpha (a or b) + ribavirin), and the following criteria: -detectable levels of hepatitis C virus RNA in the last six months; - fibrosis stage of F2, F3 or F4; -one course of treatment only (maximum of 44 weeks, based on response). 200mg Capsule VICTRELIS FRS BOCEPREVIR, PEGINTERFERON, RIBAVIRIN For the treatment of chronic hepatitis C (CHC) genotype 1 infection in adult patients with compensated liver disease, in combination with peginterferon alpha (a or b) + ribavirin), and the following criteria: -detectable levels of hepatitis C virus RNA in the last six months; - fibrosis stage of F2, F3 or F4; -one course of treatment only (maximum of 44 weeks, based on response). 200mg & 100mcg & 200mg Kit VICTRELIS TRIPLE FRS 200mg & 120mcg & 200mg Kit VICTRELIS TRIPLE FRS 200mg & 150mcg & 200mg Kit VICTRELIS TRIPLE FRS 200mg & 80mcg & 200mg Kit VICTRELIS TRIPLE FRS SIMEPREVIR For the treatment of chronic Hepatitis C in treatment-naïve and treatment-experienced patients who meet all of the following criteria: - Chronic hepatitis C virus (HCV) genotype 1 infection - Detectable levels of HCV RNA in the last six months - Fibrosis stage F2 or greater (Metavir scale or equivalent) - Patient has not received a prior full therapeutic course of boceprevir or telaprevir. Not eligible for coverage: Patients currently being treated with another HCV antiviral agent Patients who have previously received a treatment course of Galexos (Re-treatment requests will not be considered). 150mg Capsule GALEXOS KEG 08:36.00 URINARY ANTI-INFECTIVES FOSFOMYCIN TROMETHAMINE For the treatment of women (>12 years old) with: Urinary tract infections with organisms resistant to first line therapy OR Urinary tract infections in pregnancy when first line agents are contraindicated 3gm/pk Powder MONUROL PAL 10:00 ANTINEOPLAIC AGENTS 10:00.00 ANTINEOPLAIC AGENTS ERLOTINIB HYDROCLORIDE Treatment of non-small cell lung cancer (NSCLC) after failure of at least one prior chemotherapy regimen, and whose EGFR expression status is positive or unknown. 100mg Tablet TARCEVA HLR Page A-5 de 81

174 Appendix A - Limited Use Benefits and Criteria 10:00.00 ANTINEOPLAIC AGENTS ERLOTINIB HYDROCLORIDE Treatment of non-small cell lung cancer (NSCLC) after failure of at least one prior chemotherapy regimen, and whose EGFR expression status is positive or unknown. 150mg Tablet TARCEVA HLR IMATINIB MESYLATE a.- For the treatment of patients with chronic myeloid leukemia (CML) in blast crisis, accelerated phase, or in chronic phase. b.- For the treatment of patients with gastrointestinal stromal tumour. c.- For newly diagnosed adult patients with Philadelphia chromosome-positive (CML). 100mg Tablet APO-IMATINIB APX CO IMATINIB ATP GLEEVEC NVR TEVA-IMATINIB TEP 400mg Tablet APO-IMATINIB APX CO IMATINIB CBT GLEEVEC TEV TEVA-IMATINIB TEP RITUXIMAB Prescribed by a rheumatologist for treatment of adult patients with severely active rheumatoid arthritis who have failed to respond to a trial of an anti-tnf agent. Treatment should be combined with methotrexate. Rituximab should not be used in combination with anti-tnf agents. For continued coverage for rituximab beyond twenty-four weeks, patient must meet all the following criteria: a. - Initially prescribed by a rheumatologist b. - Patient has been assessed after the twentieth to twenty-fourth week of rituximab therapy and meets the response criteria of: c. - a >20% reduction in number of tender and swollen joints d. - a >20% improvement in physician global assessment scale. e. - either a >20% improvement in the patient global assessment scale or a >20% reduction in the acute phase as measured by ESR or CRP. 10mg/mL Injection RITUXAN HLR SUNITINIB MALATE Limited use benefit (Prior approval required). Criteria for initial six month coverage of Sutent: For patients with histologically proven unresectable or recurrent/metastatic GI who have failed or are unable to tolerate imatinib therapy. Sunitinib will not be funded concomitantly with imatinib. Criteria for assessment at every six months: There is no objective evidence of disease progression. 12.5mg Capsule SUTENT PFI 25mg Capsule SUTENT PFI 50mg Capsule SUTENT PFI TEMOZOLOMIDE For: a. - treatment of adult patients with glioblastoma multiforme or anaplastic astrocytoma, and documented evidence of recurrence or progression after standard therapy (resection, radiotherapy, and chemotherapy). b. - treatment of adult patients with newly diagnosed glioblastoma multiforme concomitantly with radiotherapy and then as maintenance treatment. 5mg Capsule TEMODAL SCH Page A-6 de 81

175 Appendix A - Limited Use Benefits and Criteria 10:00.00 ANTINEOPLAIC AGENTS TEMOZOLOMIDE For: a. - treatment of adult patients with glioblastoma multiforme or anaplastic astrocytoma, and documented evidence of recurrence or progression after standard therapy (resection, radiotherapy, and chemotherapy). b. - treatment of adult patients with newly diagnosed glioblastoma multiforme concomitantly with radiotherapy and then as maintenance treatment. 20mg Capsule CO TEMOZOLOMIDE CBT TEMODAL SCH 100mg Capsule CO TEMOZOLOMIDE CBT TEMODAL SCH 140mg Capsule APO-TEMOZOLOMIDE APX CO TEMOZOLOMIDE CBT TEMODAL FRS 250mg Capsule CO TEMOZOLOMIDE CBT TEMODAL SCH 12:00 AUTONOMIC DRUGS 12:04.00 PARASYMPATHOMIMETIC AGENTS DONEPEZIL HCL Initial six month coverage for cholinesterase inhibitors: Diagnosis of mild to moderate Alzheimer s disease; AND Mini Mental State Exam (MMSE) score of 10-26, established within the last 60 days; AND Global Deterioration Scale (GDS) score between 4 to 6, established within the last 60 days Continued coverage beyond 6 months will be based on improvement or stabilization of cognition, function or behaviour. Criteria for coverage at every six month interval: Diagnosis is still mild to moderate Alzheimer s disease; AND MMSE score > 10; OR GDS score between 4 to 6; AND Improvement or stabilization in at least one of the following domains (please indicate improved, worsened, or no change) 1.Memory, reasoning and perception (e.g., names, tasks, MMSE) 2.Instrumental activities of daily living (IADLs: e.g., telephone, shopping, meal preparation) 3.Basic activities of daily living (e.g., bathing, dressing, hygiene, toileting) 4.Neuropsychiatric symptoms (e.g., agitation, delusions, hallucination, apathy) 5mg Tablet ACCEL-DONEPEZIL ACP ACT DONEPEZIL ATP APO-DONEPEZIL APX ARICEPT PFI AURO-DONEPEZIL AUR DONEPEZIL ACC DONEPEZIL PDL DONEPEZIL SIV JAMP-DONEPEZIL JAP JAMP-DONEPEZIL JAP MAR-DONEPEZIL MAR MYLAN-DONEPEZIL MYL PMS-DONEPEZIL PMS RAN-DONEPEZIL RBY RIVA-DONEPEZIL RIV SANDOZ DONEPEZIL SDZ SEPTA-DONEPEZIL SPT TEVA-DONEPEZIL TEP Page A-7 de 81

176 Appendix A - Limited Use Benefits and Criteria 12:04.00 PARASYMPATHOMIMETIC AGENTS DONEPEZIL HCL Initial six month coverage for cholinesterase inhibitors: Diagnosis of mild to moderate Alzheimer s disease; AND Mini Mental State Exam (MMSE) score of 10-26, established within the last 60 days; AND Global Deterioration Scale (GDS) score between 4 to 6, established within the last 60 days Continued coverage beyond 6 months will be based on improvement or stabilization of cognition, function or behaviour. Criteria for coverage at every six month interval: Diagnosis is still mild to moderate Alzheimer s disease; AND MMSE score > 10; OR GDS score between 4 to 6; AND Improvement or stabilization in at least one of the following domains (please indicate improved, worsened, or no change) 1.Memory, reasoning and perception (e.g., names, tasks, MMSE) 2.Instrumental activities of daily living (IADLs: e.g., telephone, shopping, meal preparation) 3.Basic activities of daily living (e.g., bathing, dressing, hygiene, toileting) 4.Neuropsychiatric symptoms (e.g., agitation, delusions, hallucination, apathy) 10mg Tablet ACCEL-DONEPEZIL ACP ACT DONEPEZIL ATP APO-DONEPEZIL APX ARICEPT PFI AURO-DONEPEZIL AUR DONEPEZIL ACC DONEPEZIL PDL DONEPEZIL SIV JAMP-DONEPEZIL JAP JAMP-DONEPEZIL JAP MAR-DONEPEZIL MAR MYLAN-DONEPEZIL MYL PMS-DONEPEZIL PMS RAN-DONEPEZIL RBY RIVA-DONEPEZIL RIV SANDOZ DONEPEZIL SDZ SEPTA-DONEPEZIL SPT TEVA-DONEPEZIL TEP GALANTAMINE Initial six month coverage for cholinesterase inhibitors: Diagnosis of mild to moderate Alzheimer s disease; AND Mini Mental State Exam (MMSE) score of 10-26, established within the last 60 days; AND Global Deterioration Scale (GDS) score between 4 to 6, established within the last 60 days Continued coverage beyond 6 months will be based on improvement or stabilization of cognition, function or behaviour. Criteria for coverage at every six month interval: Diagnosis is still mild to moderate Alzheimer s disease; AND MMSE score > 10; OR GDS score between 4 to 6; AND Improvement or stabilization in at least one of the following domains (please indicate improved, worsened, or no change) 1.Memory, reasoning and perception (e.g., names, tasks, MMSE) 2.Instrumental activities of daily living (IADLs: e.g., telephone, shopping, meal preparation) 3.Basic activities of daily living (e.g., bathing, dressing, hygiene, toileting) 4.Neuropsychiatric symptoms (e.g., agitation, delusions, hallucination, apathy) 8mg Extended Release Capsule GALANTAMINE ER PDL MAR-GALANTAMINE ER MAR MYLAN-GALANTAMINE ER MYL PAT-GALANTAMINE ER JNO PMS-GALANTAMINE ER PMS REMINYL ER JNO TEVA-GALANTAMINE ER TEP Page A-8 de 81

177 Appendix A - Limited Use Benefits and Criteria 12:04.00 PARASYMPATHOMIMETIC AGENTS GALANTAMINE Initial six month coverage for cholinesterase inhibitors: Diagnosis of mild to moderate Alzheimer s disease; AND Mini Mental State Exam (MMSE) score of 10-26, established within the last 60 days; AND Global Deterioration Scale (GDS) score between 4 to 6, established within the last 60 days Continued coverage beyond 6 months will be based on improvement or stabilization of cognition, function or behaviour. Criteria for coverage at every six month interval: Diagnosis is still mild to moderate Alzheimer s disease; AND MMSE score > 10; OR GDS score between 4 to 6; AND Improvement or stabilization in at least one of the following domains (please indicate improved, worsened, or no change) 1.Memory, reasoning and perception (e.g., names, tasks, MMSE) 2.Instrumental activities of daily living (IADLs: e.g., telephone, shopping, meal preparation) 3.Basic activities of daily living (e.g., bathing, dressing, hygiene, toileting) 4.Neuropsychiatric symptoms (e.g., agitation, delusions, hallucination, apathy) 16mg Extended Release Capsule GALANTAMINE ER PDL MAR-GALANTAMINE ER MAR MYLAN-GALANTAMINE ER MYL PAT-GALANTAMINE ER JNO PMS-GALANTAMINE ER PMS REMINYL ER JNO TEVA-GALANTAMINE ER TEP 24mg Extended Release Capsule GALANTAMINE ER PDL MAR-GALANTAMINE ER MAR MYLAN-GALANTAMINE ER MYL PAT-GALANTAMINE ER JNO PMS-GALANTAMINE ER PMS REMINYL ER JNO TEVA-GALANTAMINE ER TEP RIVAIGMINE Initial six month coverage for cholinesterase inhibitors: Diagnosis of mild to moderate Alzheimer s disease; AND Mini Mental State Exam (MMSE) score of 10-26, established within the last 60 days; AND Global Deterioration Scale (GDS) score between 4 to 6, established within the last 60 days Continued coverage beyond 6 months will be based on improvement or stabilization of cognition, function or behaviour. Criteria for coverage at every six month interval: Diagnosis is still mild to moderate Alzheimer s disease; AND MMSE score > 10; OR GDS score between 4 to 6; AND Improvement or stabilization in at least one of the following domains (please indicate improved, worsened, or no change) 1.Memory, reasoning and perception (e.g., names, tasks, MMSE) 2.Instrumental activities of daily living (IADLs: e.g., telephone, shopping, meal preparation) 3.Basic activities of daily living (e.g., bathing, dressing, hygiene, toileting) 4.Neuropsychiatric symptoms (e.g., agitation, delusions, hallucination, apathy) 1.5mg Capsule APO-RIVAIGMINE APX EXELON NOV MED-RIVAIGMINE GMP MINT-RIVAIGMINE MIN MYLAN-RIVAIGMINE MYL NOVO-RIVAIGMINE TEV PMS-RIVAIGMINE PMS RATIO-RIVAIGMINE RPH RIVAIGMINE PDL SANDOZ RIVAIGMINE SDZ Page A-9 de 81

178 Appendix A - Limited Use Benefits and Criteria 12:04.00 PARASYMPATHOMIMETIC AGENTS RIVAIGMINE Initial six month coverage for cholinesterase inhibitors: Diagnosis of mild to moderate Alzheimer s disease; AND Mini Mental State Exam (MMSE) score of 10-26, established within the last 60 days; AND Global Deterioration Scale (GDS) score between 4 to 6, established within the last 60 days Continued coverage beyond 6 months will be based on improvement or stabilization of cognition, function or behaviour. Criteria for coverage at every six month interval: Diagnosis is still mild to moderate Alzheimer s disease; AND MMSE score > 10; OR GDS score between 4 to 6; AND Improvement or stabilization in at least one of the following domains (please indicate improved, worsened, or no change) 1.Memory, reasoning and perception (e.g., names, tasks, MMSE) 2.Instrumental activities of daily living (IADLs: e.g., telephone, shopping, meal preparation) 3.Basic activities of daily living (e.g., bathing, dressing, hygiene, toileting) 4.Neuropsychiatric symptoms (e.g., agitation, delusions, hallucination, apathy) 3mg Capsule APO-RIVAIGMINE APX EXELON NOV MED-RIVAIGMINE GMP MINT-RIVAIGMINE MIN MYLAN-RIVAIGMINE MYL NOVO-RIVAIGMINE TEV PMS-RIVAIGMINE PMS RATIO-RIVAIGMINE RPH RIVAIGMINE PDL SANDOZ RIVAIGMINE SDZ 4.5mg Capsule APO-RIVAIGMINE APX EXELON NOV MED-RIVAIGMINE GMP MINT-RIVAIGMINE MIN MYLAN-RIVAIGMINE MYL NOVO-RIVAIGMINE TEV PMS-RIVAIGMINE PMS RATIO-RIVAIGMINE RPH RIVAIGMINE PDL SANDOZ RIVAIGMINE SDZ 6mg Capsule APO-RIVAIGMINE APX EXELON NOV MED-RIVAIGMINE GMP MINT-RIVAIGMINE MIN MYLAN-RIVAIGMINE MYL NOVO-RIVAIGMINE TEV PMS-RIVAIGMINE PMS RATIO-RIVAIGMINE RPH RIVAIGMINE PDL SANDOZ RIVAIGMINE SDZ 2mg/mL Oral Liquid EXELON NOV Page A-10 de 81

179 Appendix A - Limited Use Benefits and Criteria 12:08.08 ANTIMUSCARINICS / ANTISPASMODICS ACLIDINIUM BROMIDE For patients with chronic obstructive pulmonary disease (COPD) and who: did not respond to a trial of ipratropium (Atrovent); OR did not have a previous trial of ipratropium, but who have moderate to severe COPD, defined as <60% FEV1, FEV1/FVC<0.7 and MRC 3 to mcg Inhaler TUDORZA GENUAIR AZE GLYCOPYRRONIUM For patients with chronic obstructive pulmonary disease (COPD) and who: did not respond to a trial of ipratropium (Atrovent); OR did not have a previous trial of ipratropium, but who have moderate to severe COPD, defined as <60% FEV1, FEV1/FVC<0.7 and MRC 3 to 5. 50mcg Powder for Inhalation (Capsule) SEEBRI BREEZHALER TEV TIOTROPIUM BROMIDE MONOHYDRATE For patients with chronic obstructive pulmonary disease (COPD) and who: -did not respond to a trial of ipratropium (Atrovent); OR -did not have a previous trial of ipratropium, but who have moderate to severe COPD, defined as <60% FEV1, FEV1/FVC<0.7 and MRC 3 to 5. 18mcg Powder for Inhalation (Capsule) SPIRIVA BOE 12:12.08 BETA ADRENERGIC AGONIS FORMOTEROL FUMARATE For the treatment of asthma in patients who are using optimal corticosteroid therapy and experiencing breakthrough symptoms requiring regular use of a rapidonset, short-duration bronchodilator. OR For the treatment of Chronic Obstructive Pulmonary Disease (COPD) in patients not adequately controlled with either ipratropium, tiotropium or a short acting betaagonist. 12mcg/Capsule Powder for Inhalation FORADIL NVR FORMOTEROL FUMARATE DIHYDRATE For the treatment of asthma in patients who are using optimal corticosteroid therapy and experiencing breakthrough symptoms requiring regular use of rapid onset, short duration bronchodilator 6mcg/Dose Dry Powder Inhaler OXEZE TURBUHALER AZC 12mcg/Dose Dry Powder Inhaler OXEZE TURBUHALER AZC Page A-11 de 81

180 Appendix A - Limited Use Benefits and Criteria 12:12.08 BETA ADRENERGIC AGONIS FORMOTEROL FUMARATE DIHYDRATE, BUDESONIDE For the treatment of reversible obstructive airway disease in patients who are not adequately controlled on medium doses of inhaled corticosteroids (e.g. fluticasone mcg daily, or the equivalent) as the sole agent and require addition of a long-acting beta agonist. Patients using this combination product must also have access to a short-acting bronchodilator for symptomatic relief. OR ONE OF THE FOLLOWING For the treatment of moderate* COPD, if a patient continues to be symptomatic after an adequate trial of a long acting anticholinergic AND a long acting betaagonist. For the treatment of severe** COPD, if a patient continues to be symptomatic after an adequate trial of a long acting anticholinergic OR a long acting beta-agonist. 6mcg & 100mcg/Inhalation Inhaler SYMBICORT 100 TURBUHALER AZC 6mcg & 200mcg/Inhalation Inhaler SYMBICORT 200 TURBUHALER AZC FORMOTEROL FUMARATE DIHYDRATE, MOMETASONE FUROATE For the treatment of reversible obstructive airway disease in patients who are not adequately controlled on medium doses of inhaled corticosteroids (e.g. fluticasone mcg daily, or the equivalent) as the sole agent and require addition of a long-acting beta agonist. Patients using this combination product must also have access to a short-acting bronchodilator for symptomatic relief. 5mcg & 100mcg/Inhalation Inhaler ZENHALE FRS 5mcg & 200mcg/Inhalation Inhaler ZENHALE FRS 5mcg & 50mcg/Inhalation Inhaler ZENHALE FRS INDACATEROL MALEATE For the treatment of Chronic Obstructive Pulmonary Disease (COPD) in patients not adequately controlled with either ipratropium, tiotropium or a short acting betaagonist. 75mcg Powder for Inhalation (Capsule) ONBREZ BREEZHALER TEV SALMETEROL XINAFOATE a. - For the treatment of asthma in patients who are using optimal corticosteroid therapy and experiencing breakthrough symptoms requiring regular use of a rapid onset, short duration bronchodilator. Serevent is not intended for the relief of acute asthma symptoms: patients must have access to an inhaled fast-acting bronchodilator (beta-2 agonist) for symptomatic relief. b. - For the treatment of Chronic Obstructive Pulmonary Disease (COPD) in patients not adequately controlled with ipratropium, tiotropium or a short acting betaagonist. 50mcg/inhalation Powder Diskus SEREVENT DISKUS GSK 50mcg/Inhalation Powder for Inhalation SEREVENT DISKHALER GSK SALMETEROL XINAFOATE, FLUTICASONE PROPIONATE For the treatment of reversible obstructive airway disease in patients who are not adequately controlled on medium doses of inhaled corticosteroids (e.g. fluticasone mcg daily, or the equivalent) as the sole agent and require addition of a long-acting beta agonist. Patients using this combination product must also have access to a short-acting bronchodilator for symptomatic relief. OR ONE OF THE FOLLOWING For the treatment of moderate* COPD, if a patient continues to be symptomatic after an adequate trial of a long acting anticholinergic AND a long acting betaagonist. For the treatment of severe** COPD, if a patient continues to be symptomatic after an adequate trial of a long acting anticholinergic OR a long acting beta-agonist. 25mcg & 125mcg Inhaler ADVAIR GSK Page A-12 de 81

181 Appendix A - Limited Use Benefits and Criteria 12:12.08 BETA ADRENERGIC AGONIS SALMETEROL XINAFOATE, FLUTICASONE PROPIONATE For the treatment of reversible obstructive airway disease in patients who are not adequately controlled on medium doses of inhaled corticosteroids (e.g. fluticasone mcg daily, or the equivalent) as the sole agent and require addition of a long-acting beta agonist. Patients using this combination product must also have access to a short-acting bronchodilator for symptomatic relief. OR ONE OF THE FOLLOWING For the treatment of moderate* COPD, if a patient continues to be symptomatic after an adequate trial of a long acting anticholinergic AND a long acting betaagonist. For the treatment of severe** COPD, if a patient continues to be symptomatic after an adequate trial of a long acting anticholinergic OR a long acting beta-agonist. 25mcg & 250mcg Inhaler ADVAIR GSK 50mcg & 100mcg Inhaler ADVAIR DISKUS 100 GSK 50mcg & 250mcg Inhaler ADVAIR DISKUS 250 GSK 50mcg & 500mcg Inhaler ADVAIR DISKUS 500 GSK 12:20.04 CENTRALL ACTING SKELETAL MUSCLE RELAXANTS CYCLOBENZAPRINE HCL Limited use benefit (prior approval is not required). For relief of muscle spasm associated with acute, painful musculoskeletal conditions. Coverage is limited to 60mg per day for three (3) weeks renewable every two (2) months. 10mg Tablet APO-CYCLOBENZAPRINE APX AURO-CYCLOBENZAPRINE AUR CYCLOBENZAPRINE PDL CYCLOBENZAPRINE SAN CYCLOBENZAPRINE SIV DOM-CYCLOBENZAPRINE DPC JAMP-CYCLOBENZAPRINE JAP MYLAN-CYCLOPRINE MYL PHL-CYCLOBENZAPRINE PHH PMS-CYCLOBENZAPRINE PMS RATIO-CYCLOBENZAPRINE RPH RIVA-CYCLOBENZAPRINE RIV TEVA-CYCLOPRINE TEV TIZANIDINE HCL For treatment of spasticity in patients with multiple sclerosis, who have failed therapy with or are intolerant to baclofen. 4mg Tablet APO-TIZANIDINE APX ZANAFLEX ELN 12:92.00 MISCELLANEOUS AUTONOMIC DRUGS NICOTINE (GUM) Limited use benefit with quantity and frequency limits (prior approval is not required). For smoking cessation: Coverage is limited to 945 pieces during a one-year period. The year starts on the date the first prescription is filled. Once this quantity has been reached, the client is eligible again for coverage for nicotine gum or lozenges when one year has elapsed from the day the initial prescription was filled. 2mg Gum NICORETTE JNO THRIVE TEV Page A-13 de 81

182 Appendix A - Limited Use Benefits and Criteria 12:92.00 MISCELLANEOUS AUTONOMIC DRUGS NICOTINE (GUM) Limited use benefit with quantity and frequency limits (prior approval is not required). For smoking cessation: Coverage is limited to 945 pieces during a one-year period. The year starts on the date the first prescription is filled. Once this quantity has been reached, the client is eligible again for coverage for nicotine gum or lozenges when one year has elapsed from the day the initial prescription was filled. 4mg Gum NICORETTE PLUS PMJ NICOTINE GUM PER THRIVE TEV THRIVE TEV NICOTINE (INHALER) Limited use benefit with quantity and frequency limits (prior approval is not required). For smoking cessation: Coverage is limited to 945 during a one-year period. The year starts on the date the first prescription is filled. Once this quantity has been reached, the client is eligible again for coverage for nicotine gum or lozenges when one year has elapsed from the day the initial prescription was filled. 10mg Inhaler NICORETTE JNO NICOTINE (LOZENGE) Limited use benefit with quantity and frequency limits (prior approval is not required). For smoking cessation: Coverage is limited to 945 pieces during a one-year period. The year starts on the date the first prescription is filled. Once this quantity has been reached, the client is eligible again for coverage for nicotine gum or lozenges when one year has elapsed from the day the initial prescription was filled. 1mg Lozenge THRIVE TEV THRIVE TEV 2mg Lozenge NICORETTE LOZENGE JNO THRIVE TEV THRIVE TEV 4mg Lozenge NICORETTE LOZENGE JNO NICOTINE (PATCH) Limited use benefit with quantity and frequency limits (prior approval is not required). For smoking cessation: Coverage will be provided for up to the allowable number of patches for one of the following products, during a one-year period. The year starts on the date the first prescription is filled. The number of patches covered in the one-year period is: Habitrol 168 patches or Nicoderm 140 patches or Nicotrol 140 patches Once this quantity has been reached, the client is eligible again for coverage for nicotine patches when one year has elapsed from the day the initial prescription was filled. 5mg Patch NICOTROL TRANSDERMAL WAR 7mg Patch HABITROL NVC 8.3mg/10cm2 Patch NICOTROL TRANSDERMAL JNO 10mg Patch NICOTROL TRANSDERMAL WAR 14mg Patch HABITROL NVC 15mg Patch NICOTROL TRANSDERMAL WAR Page A-14 de 81

183 Appendix A - Limited Use Benefits and Criteria 12:92.00 MISCELLANEOUS AUTONOMIC DRUGS NICOTINE (PATCH) Limited use benefit with quantity and frequency limits (prior approval is not required). For smoking cessation: Coverage will be provided for up to the allowable number of patches for one of the following products, during a one-year period. The year starts on the date the first prescription is filled. The number of patches covered in the one-year period is: Habitrol 168 patches or Nicoderm 140 patches or Nicotrol 140 patches Once this quantity has been reached, the client is eligible again for coverage for nicotine patches when one year has elapsed from the day the initial prescription was filled. 16.6mg/20cm2 Patch NICOTROL TRANSDERMAL JNO 17.5mg Patch TRANSDERMAL NICOTINE NVC 21mg Patch HABITROL NVC 24.9mg/30cm2 Patch NICOTROL TRANSDERMAL JNO 35mg Patch TRANSDERMAL NICOTINE NVC 36mg Patch NICODERM PMJ 52.5mg Patch TRANSDERMAL NICOTINE NVC 78mg Patch NICODERM PMJ 114mg Patch NICODERM PMJ VARENICLINE Limited use benefit with quantity and frequency limits (prior approval is not required). Coverage will be limited to 165 tablets during a one-year period. The year starts on the date the first prescription is filled. Once this quantity has been reached, the client is eligible again for coverage for varenicline (Champix ) when one year has elapsed from the day the initial prescription was filled. 0.5mg Tablet CHAMPIX PFI 0.5mg & 1mg Tablet CHAMPIX ARTER PACK PFI 1mg Tablet CHAMPIX PFI 20:00 BLOOD FORMATION COAGULATION AND THROMBOSIS 20:12.04 ANTICOAGULANTS APIXABAN Limited use benefit (prior approval required) For at risk patients* with non-valvular atrial fibrillation who require apixaban for the prevention of stroke and systemic embolism AND in whom: records for the last two months of warfarin therapy); OR (i.e., no access to INR testing services at a laboratory, clinic, pharmacy and at home). * At risk patients with atrial fibrillation are defined as those with a CHADS2 score of 1. # Inadequate anticoagulation is defined as INR testing results that are outside the desired INR range for at least 35% of the tests during the monitoring period, i.e., adequate anticoagulation is defined as INR test results that are within the desired INR range for at least 65% of the tests during the monitoring period. 2.5mg Tablet ELIQUIS BMS Page A-15 de 81

184 Appendix A - Limited Use Benefits and Criteria 20:12.04 ANTICOAGULANTS APIXABAN Limited use benefit (prior approval required) For at risk patients* with non-valvular atrial fibrillation who require apixaban for the prevention of stroke and systemic embolism AND in whom: records for the last two months of warfarin therapy); OR (i.e., no access to INR testing services at a laboratory, clinic, pharmacy and at home). * At risk patients with atrial fibrillation are defined as those with a CHADS2 score of 1. # Inadequate anticoagulation is defined as INR testing results that are outside the desired INR range for at least 35% of the tests during the monitoring period, i.e., adequate anticoagulation is defined as INR test results that are within the desired INR range for at least 65% of the tests during the monitoring period. 5mg Tablet ELIQUIS BMS RIVAROXABAN Criteria for Rivaroxaban 15 mg, 20mg tablets (Xarelto) for Stroke Prevention in Atrial Fibrillation (SPAF) For the prevention of stroke and systemic embolism in at-risk patients* who have non-valvular atrial fibrillation (AF) AND in whom: Anticoagulation is inadequate# following a two-month trial on warfarin (please provide copy of INR records for the last two months of warfarin therapy); OR Anticoagulation with warfarin is contraindicated; ;OR Anticoagulation is not possible due to inability to regularly monitor via International Normalized Ratio (INR) testing (i.e., no access to INR testing service at a laboratory, clinic, pharmacy, and at home) Criteria for Rivaroxaban 15 mg, 20mg tablets (Xarelto) for Deep Vein Thrombosis (DVT) For the treatment of deep vein thrombosis (DVT) in patients without symptomatic pulmonary embolism (PE) for a duration of up to six months. Note: The recommended dose of rivaroxaban for patients initiating DVT treatment is 15 mg twice daily for 3 weeks, followed by 20 mg once daily. NIHB Program coverage for rivaroxaban is an alternative to heparin/warfarin for up to 6 months. When used for greater than 6 months, rivaroxaban is more costly than heparin/warfarin. IF THE INTENDED DURATION OF THERAPY IS GREATER THAN 6 MONTHS, INITIATION OF HEPARIN/WARFARIN SHOULD BE CONSIDERED. 15mg Tablet XARELTO BAY 20mg Tablet XARELTO B A RIVAROXABAN (10) Limited use benefit (prior approval not required). For the prevention of venous thromboembolism following total knee replacement or total hip replacement surgery, for up to 35 days. 10mg Tablet XARELTO BAY Page A-16 de 81

185 Appendix A - Limited Use Benefits and Criteria 20:12.18 PLATELET AGGREGATION INHIBITORS CLOPIDOGREL BISULFATE Limited use benefit (prior approval not required). Limit of 12 months following a client s initial cardiovascular event (stroke, acute coronary syndrome (ACS) or stent). Continued coverage beyond one year will be provided for patients with a previous stroke or transient ischemic attack (TIA) and be considered for patients with ACS or stent placement with appropriate rationale from the client`s cardiologist or treating physician. 75mg Tablet ABBOTT-CLOPIDOGREL ABB ACCEL-CLOPIDOGREL ACP APO-CLOPIDOGREL APX AURO-CLOPIDOGREL AUR CLOPIDOGREL SIV CLOPIDOGREL PDL CLOPIDOGREL SAN CO CLOPIDOGREL CBT DOM-CLOPIDOGREL DOM JAMP-CLOPIDOGREL JAP MAR-CLOPIDOGREL MAR MINT-CLOPIDOGREL MIN MYLAN-CLOPIDOGREL MYL PLAVIX SAC PMS CLOPIDOGREL PMS RAN-CLOPIDOGREL RBY RIVA CLOPIDOGREL RIV SANDOZ CLOPIDOGREL SDZ TEVA-CLOPIDOGREL TEP TICAGRELOR Limited use benefit (prior approval not required). For the treatment of Acute Coronary Syndrome, defined as unstable angina or myocardial infarction, when initiated in hospital in consultation with a Specialist in Cardiology, Cardiac Surgery, Cardiovascular & Thoracic Surgery, Internal Medicine or General Surgery. Treatment must be in combination with low dose ASA. Special authorization may be granted for 12 months. 90mg Tablet BRILINTA AZE Page A-17 de 81

186 Appendix A - Limited Use Benefits and Criteria 24:00 CARDIOVASCULAR DRUGS 24:06.05 CHOLEEROL ABSORPTION INHIBITORS EZETIMIBE a.- For use in combination with a HMG-CoA reductase inhibitor ( statin ) in patients with hypercholesterolemia who have not reached target LDL levels despite the use of maximally tolerated statin doses. b.- For use as monotherapy in the management of hypercholesterolemia in patients intolerant to HMG-CoA reductase inhibitors. 10mg Tablet ACT EZETIMIBE ATP APO-EZETIMIBE APX EZETIMIBE PDL EZETIMIBE SIV EZETROL MSP JAMP-EZETIMIBE JAP MAR-EZETIMIBE MAR MINT-EZETIMIBE MIN MYLAN-EZETIMIBE MYL PMS-EZETIMIBE PMS PRIVA-EZETIMIBE PHA RAN-EZETIMIBE RBY RIVA-EZETIMIBE RIV SANDOZ EZETIMIBE SDZ TEVA-EZETIMIBE TEP 24:12.12 PHOSPHODIEERASE INHIBITORS SILDENAFIL CITRATE Patients with World Health Organization (WHO) class III pulmonary artery hypertension (PAH), either idiopathic (i.e. primary) or associated with a congenital or systemic condition (e.g. connective tissue disease) and confirmed by right heart catheterization; AND who have failed to respond to conventional therapy; OR who have contraindications to conventional agents. 20mg Tablet PMS-SILDENAFIL R PMS RATIO-SILDENAFIL R TEP REVATIO PFI 20mg Tablet APO-SILDENAFIL R APX TADALAFIL Maximum dose covered is 40 mg daily Patients with World Health Organization (WHO) class III pulmonary artery hypertension (PAH), either idiopathic (i.e. primary) or associated with a congenital or systemic condition (e.g. connective tissue disease) and confirmed by right heart catheterization; AND who have failed to respond to conventional therapy; OR who have contraindications to conventional agents 20mg Tablet ADCIRCA LIL Page A-18 de 81

187 Appendix A - Limited Use Benefits and Criteria 24:12.92 MISCELLANEOUS VASODILATING AGENTS AMBRISENTAN Maximum dose covered is 10 mg once daily. Patients with World Health Organization (WHO) class III pulmonary artery hypertension (PAH), either idiopathic (i.e. primary) or associated with a congenital or systemic condition (e.g. connective tissue disease) and confirmed by right heart catheterization; AND -who have failed to respond to sildenafil OR tadalafil; OR -who have contraindications to sildenafil OR tadalafil. 5mg Tablet VOLIBRIS GSK 10mg Tablet VOLIBRIS GSK BOSENTAN MONOHYDRATE Maximum dose covered is 125 mg twice daily -Patients with World Health Organization (WHO) class III pulmonary artery hypertension (PAH), either idiopathic (i.e. primary) or associated with a congenital or systemic condition (e.g. connective tissue disease) and confirmed by right heart catheterization; AND -who have failed to respond to sildenafil OR tadalafil; OR -who have contraindications to sildenafil OR tadalafil. 62.5mg Tablet APO-BOSENTAN APX CO BOSENTAN ATP MYLAN-BOSENTAN MYL PMS-BOSENTAN PMS SANDOZ BOSENTAN SDZ TEVA-BOSENTAN TEP TRACLEER ACN 125mg Tablet CO BOSENTAN ATP MYLAN-BOSENTAN MYL PMS-BOSENTAN PMS SANDOZ BOSENTAN SDZ TEVA-BOSENTAN TEP TRACLEER ACN 28:00 CENTRAL NERVOUS SYEM AGENTS 28:08.04 NONEROIDAL ANTI-INFLAMMATORY AGENTS ACETYLSALICYLIC ACID Limited use benefit (prior approval is not required). ASA 80 mg tablets are a benefit to clients age 21 years and under to allow access for use in pediatric conditions (e.g. Kawasaki Syndrome). 80mg Chewable Tablet ASA SOR ASAPHEN PMS ASATAB ODN EURO-ASA EUR JAMP-ASA JMP LOWPRIN EUR RIVASA RIV 80mg Delayed Release Tablet ACETYLSALICYLIC ACID JMP ASA EC SOR ASA EC SAN ASAPHEN EC PMS PRO-ASA 80MG EC TAB PRO PRO-ASA 80MG TAB PRO Page A-19 de 81

188 Appendix A - Limited Use Benefits and Criteria 28:08.04 NONEROIDAL ANTI-INFLAMMATORY AGENTS ACETYLSALICYLIC ACID Limited use benefit (prior approval is not required). ASA 80 mg tablets are a benefit to clients age 21 years and under to allow access for use in pediatric conditions (e.g. Kawasaki Syndrome). 80mg Tablet LOWPRIN EUR RIVASA RIV CELECOXIB For patients who have: A history of serious gastrointestinal complications (e.g. ulcer, bleeding, perforation); OR Multiple (at least two) risk factors for serious gastrointestinal complications (e.g. age >60, concurrent use of ASA, SSRIs, corticosteroids, anticoagulants or antiplatelet agents). 100mg Capsule APO-CELECOXIB APX BIO-CELECOXIB BMI CELEBREX PFI CELECOXIB PDL CELECOXIB SIV 0245 CO CELECOXIB ATP CO CELECOXIB JAP GD-CELECOXIB PFI MAR-CELECOXIB MAR MINT-CELECOXIB MIN MYLAN-CELECOXIB MYL PMS-CELECOXIB PMS PRIVA-CELECOXIB PHA RAN-CELECOXIB RBY RIVA-CELECOX RIV SANDOZ CELECOXIB SDZ TEVA-CELECOXIB TEP 200mg Capsule APO-CELECOXIB APX BIO-CELECOXIB BMI CELEBREX PFI CELECOXIB PDL CELECOXIB SIV CO CELECOXIB ATP CO CELECOXIB JAP GD-CELECOXIB PFI MAR-CELECOXIB MAR MINT-CELECOXIB MIN MYLAN-CELECOXIB MYL PMS-CELECOXIB PMS PRIVA-CELECOXIB PHA RAN-CELECOXIB RBY RIVA-CELECOX RIV SANDOZ CELECOXIB SDZ TEVA-CELECOXIB TEP Page A-20 de 81

189 Appendix A - Limited Use Benefits and Criteria 28:08.04 NONEROIDAL ANTI-INFLAMMATORY AGENTS DICLOFENAC SODIUM (TOPICAL) For the treatment of osteoarthritis when: pain is inadequately controlled with acetaminophen AND a non-steroidal anti-inflammatory (NSAID); OR there is contraindication to acetaminophen and NSAID; OR there is intolerance to acetaminophen and NSAID 1.5% Topical Solution PMS-DICLOFENAC PMS TARO-DICLOFENAC TAR 28:08.08 OPIATE AGONIS ACETAMINOPHEN, CAFFEINE CITRATE, CODEINE PHOSPHATE Limited use benefit (prior approval is not required). For safety reasons NIHB has implemented a dose limit on acetaminophen. The limit accumulates against the amount of acetaminophen claimed to the program from plain acetaminophen and/or acetaminophen in combination with opioids such as codeine (i.e. Tylenol #3) or oxycodone (i.e. Percocet ). A total of 360 grams of acetaminophen is permitted in a 100-day period, for a total daily dose of 3600mg/day. 300mg & 15mg & 15mg Tablet RATIO-LENOLTEC NO.2 RPH TYLENOL WITH CODEINE NO.2 JNO 300mg & 15mg & 30mg Tablet RATIO-LENOLTEC NO.3 RPH TYLENOL WITH CODEINE NO.3 JNO 300mg & 30mg & 15mg Tablet EXDOL-15 PED 300mg & 30mg & 30mg Tablet EXDOL-30 PED 325mg & 30mg & 15mg Tablet ATASOL-15 HOR 325mg & 30mg & 30mg Tablet ATASOL-30 HOR ACETAMINOPHEN, CODEINE PHOSPHATE Limited use benefit (prior approval is not required). For safety reasons NIHB has implemented a dose limit on acetaminophen. The limit accumulates against the amount of acetaminophen claimed to the program from plain acetaminophen and/or acetaminophen in combination with opioids such as codeine (i.e. Tylenol #3) or oxycodone (i.e. Percocet ). A total of 360 grams of acetaminophen is permitted in a 100-day period, for a total daily dose of 3600mg/day. 32mg & 1.6mg/mL Elixir PMS-ACETAMINOPHEN WITH CODEINE PMS 300mg & 30mg Tablet ACET CODEINE 30 PMS PROCET-30 PDL RATIO-EMTEC-30 RPH TRIATEC-30 TRI ACETAMINOPHEN, OXYCODONE HCL Limited use benefit (prior approval is not required). For safety reasons NIHB has implemented a dose limit on acetaminophen. The limit accumulates against the amount of acetaminophen claimed to the program from plain acetaminophen and/or acetaminophen in combination with opioids such as codeine (i.e. Tylenol #3) or oxycodone (i.e. Percocet ). A total of 360 grams of acetaminophen is permitted in a 100-day period, for a total daily dose of 3600mg/day. 325mg & 2.5mg Tablet PERCOCET DEMI BMS Page A-21 de 81

190 Appendix A - Limited Use Benefits and Criteria 28:08.08 OPIATE AGONIS ACETAMINOPHEN, OXYCODONE HCL Limited use benefit (prior approval is not required). For safety reasons NIHB has implemented a dose limit on acetaminophen. The limit accumulates against the amount of acetaminophen claimed to the program from plain acetaminophen and/or acetaminophen in combination with opioids such as codeine (i.e. Tylenol #3) or oxycodone (i.e. Percocet ). A total of 360 grams of acetaminophen is permitted in a 100-day period, for a total daily dose of 3600mg/day. 325mg & 5mg Tablet APO-OXYCODONE/ACET APX ENDOCET EDM OXYCODONE/ACET SAN PERCOCET BMS PRO-OXYCOD ACET PDL RATIO-OXYCOCET RPH RIVACOCET RIV SANDOZ OXYCODONE ACET SDZ ACETYLSALICYLIC ACID, OXYCODONE HCL Limited use benefit (prior approval is not required). To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented an opioid dose limit of 450 mg morphine equivalents per day for non-cancer, non-palliative pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 30-day period (i.e morphine equivalents over 30 days). 325mg & 5mg Tablet RATIO-OXYCODAN RPH CODEINE MONOHYDRATE, CODEINE SULFATE TRIHYDRATE For treatment of: a. - chronic pain and palliative care patients as an alternative to products containing codeine in combination with acetaminophen or ASA with or without caffeine, or b. - chronic pain and palliative care patients as an alternative to regular release codeine tablets when large doses are required. To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented an opioid dose limit of 450 mg morphine equivalents per day for non-cancer, non-palliative pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 30-day period (i.e morphine equivalents over 30 days). 50mg Long Acting Tablet CODEINE CONTIN CR PFR 100mg Long Acting Tablet CODEINE CONTIN CR PFR 150mg Long Acting Tablet CODEINE CONTIN CR PFR 200mg Long Acting Tablet CODEINE CONTIN CR PFR CODEINE PHOSPHATE Limited use benefit (prior approval is not required). To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented an opioid dose limit of 450 mg morphine equivalents per day for non-cancer, non-palliative pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 30-day period (i.e morphine equivalents over 30 days). 2mg/mL Liquid LINCTUS CODEINE ATL 5mg/mL Syrup CODEINE PHOSPHATE ATL RATIO-CODEINE RPH 15mg Tablet CODEINE RPH CODEINE RIV RATIO-CODEINE RPH 30mg Tablet CODEINE RIV CODEINE PHOSPHATE RPH PMS-CODEINE PMS Page A-22 de 81

191 Appendix A - Limited Use Benefits and Criteria 28:08.08 OPIATE AGONIS FENTANYL For the management of chronic pain in patients who are unresponsive or intolerant to at least one long-acting oral sustained released product, such as morphine, hydromorphone and oxycodone, despite appropriate dose titration and adjunctive therapy including laxatives and antiemetics. To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented an opioid dose limit of 450 mg morphine equivalents per day for non-cancer, non-palliative pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 30-day period (i.e morphine equivalents over 30 days). 12mcg/HR Transdermal Patch CO FENTANYL CBT FENTANYL PDL MYLAN-FENTANYL MATRIX MYL PMS-FENTANYL MTX PMS RAN-FENTANYL MATRIX RBY SANDOZ FENTANYL SDZ TEVA-FENTANYL TEV 25mcg/HR Transdermal Patch APO-FENTANYL MATRIX APX CO FENTANYL CBT DURAGESIC MAT JNO FENTANYL PDL MYLAN-FENTANYL MATRIX MYL PMS-FENTANYL MTX PMS RAN-FENTANYL MATRIX RBY SANDOZ FENTANYL SDZ TEVA-FENTANYL TEV 50mcg/HR Transdermal Patch APO-FENTANYL MATRIX APX CO FENTANYL CBT DURAGESIC MAT JNO FENTANYL PDL MYLAN-FENTANYL MATRIX MYL PMS-FENTANYL MTX PMS RAN-FENTANYL MATRIX RBY SANDOZ FENTANYL SDZ TEVA-FENTANYL TEV 75mcg/HR Transdermal Patch APO-FENTANYL MATRIX APX CO FENTANYL CBT DURAGESIC MAT JNO FENTANYL PDL MYLAN-FENTANYL MATRIX MYL PMS-FENTANYL MTX PMS RAN-FENTANYL MATRIX RBY SANDOZ FENTANYL SDZ TEVA-FENTANYL TEV 100mcg/HR Transdermal Patch APO-FENTANYL MATRIX APX CO FENTANYL CBT DURAGESIC MAT JNO FENTANYL PDL MYLAN-FENTANYL MATRIX MYL PMS-FENTANYL MTX PMS RAN-FENTANYL MATRIX RBY SANDOZ FENTANYL SDZ TEVA-FENTANYL TEV Page A-23 de 81

192 Appendix A - Limited Use Benefits and Criteria 28:08.08 OPIATE AGONIS HYDROMORPHONE HCL Limited use benefit. Prior approval required for controlled release capsules only. Regular release dosage forms are full benefits and do not require prior approval. For treatment of moderate to severe chronic pain when other opioids such as morphine have been ineffective in controlling pain or in patients experiencing intolerable side effects. To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented an opioid dose limit of 450 mg morphine equivalents per day for non-cancer, non-palliative pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 30-day period (i.e morphine equivalents over 30 days). 3mg Controlled Release Capsule HYDROMORPH CONTIN PFR 4.5mg Controlled Release Capsule HYDROMORPH CONTIN PFR 6mg Controlled Release Capsule HYDROMORPH CONTIN PFR 9mg Controlled Release Capsule HYDROMORPH CONTIN PFR 12mg Controlled Release Capsule HYDROMORPH CONTIN PFR 18mg Controlled Release Capsule HYDROMORPH CONTIN PFR 24mg Controlled Release Capsule HYDROMORPH CONTIN PFR 30mg Controlled Release Capsule HYDROMORPH CONTIN PFR 1mg/mL Oral Liquid DILAUDID PFR PMS-HYDROMORPHONE PMS 3mg Suppository PMS-HYDROMORPHONE PMS 1mg Tablet APO-HYDROMORPHONE APX DILAUDID PFR HYDROMORPHONE SOR PMS-HYDROMORPHONE PMS TEVA-HYDROMORPHONE TEP 2mg Tablet APO-HYDROMORPHONE APX DILAUDID PFR HYDROMORPHONE SOR PMS-HYDROMORPHONE PMS TEVA-HYDROMORPHONE TEP 4mg Tablet APO-HYDROMORPHONE APX DILAUDID PFR HYDROMORPHONE SOR PMS-HYDROMORPHONE PMS TEVA-HYDROMORPHONE TEP 8mg Tablet APO-HYDROMORPHONE APX DILAUDID PFR HYDROMORPHONE SOR PMS-HYDROMORPHONE PMS TEVA-HYDROMORPHONE TEP Page A-24 de 81

193 Appendix A - Limited Use Benefits and Criteria 28:08.08 OPIATE AGONIS METHADONE HCL 10mg/mL Oral Liquid METHADOSE MAT * METHADOSE SUGARFREE MAT METHADONE HCL (BC ONLY) 10mg/mL Oral Liquid METHADOSE DELIV. W DIRECT INT UNK * METHADOSE DELIV. W/OUT DIRECT UNK * METHADOSE W/OUT DIRECT INTERA UNK * METHADOSE DIRECT INTERACTION UNK * METHADONE HCL (PA) limited use benefit (prior approval required) with the following criteria: Prescriber is registered with Health Canada and is eligible to prescribe methadone for the management of pain. AND For the management of moderate to severe cancer pain or chronic non-cancer pain, as an alternative to other opioids. OR, For the management of pain for palliative care patients. Pharmacists may only dispense a maximum supply of 30 days at one time. 1mg/mL Oral Liquid METADOL PAL 10mg/mL Oral Liquid METADOL PAL 1mg Tablet METADOL PAL 5mg Tablet METADOL PAL 10mg Tablet METADOL PAL 25mg Tablet METADOL PAL MORPHINE HCL Limited use benefit (prior approval is not required). To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented an opioid dose limit of 450 mg morphine equivalents per day for non-cancer, non-palliative pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 30-day period (i.e morphine equivalents over 30 days). 5mg/mL Oral liquid M.O.S. ICN 30mg Sustained Release Tablet M.O.S. SR VAE 60mg Sustained Release Tablet M.O.S. SR VAE 1mg/mL Syrup DOLORAL 1 ATL RATIO-MORPHINE RPH 5mg/mL Syrup DOLORAL 5 ATL RATIO-MORPHINE RPH 10mg/mL Syrup M.O.S. 10 VAE RATIO-MORPHINE RPH 20mg/mL Syrup RATIO-MORPHINE RPH 50mg/mL Syrup M.O.S. 50 VAE Page A-25 de 81

194 Appendix A - Limited Use Benefits and Criteria 28:08.08 OPIATE AGONIS MORPHINE HCL Limited use benefit (prior approval is not required). To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented an opioid dose limit of 450 mg morphine equivalents per day for non-cancer, non-palliative pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 30-day period (i.e morphine equivalents over 30 days). 10mg Tablet M.O.S. 10 VAE 20mg Tablet M.O.S. 20 VAE 40mg Tablet M.O.S. 40 VAE 60mg Tablet M.O.S. 60 VAE MORPHINE SULFATE Limited use benefit (prior approval is not required). To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented an opioid dose limit of 450 mg morphine equivalents per day for non-cancer, non-palliative pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 30-day period (i.e morphine equivalents over 30 days). 50mg/mL Drop ATEX PMS 5mg Suppository ATEX PMS 10mg Suppository ATEX PMS 20mg Suppository ATEX PMS 10mg Sustained Release Capsule M-ESLON SAC 15mg Sustained Release Capsule M-ESLON SAC 30mg Sustained Release Capsule M-ESLON SAC 60mg Sustained Release Capsule M-ESLON SAC 100mg Sustained Release Capsule M-ESLON SAC 200mg Sustained Release Capsule M-ESLON SAC 15mg Sustained Release Tablet MORPHINE SR SAN 0439 MS CONTIN SR PFR NOVO-MORPHINE SR TEV SANDOZ MORPHINE SR SDZ 30mg Sustained Release Tablet MORPHINE SR SAN MS CONTIN SR PFR NOVO-MORPHINE SR TEV SANDOZ MORPHINE SR SDZ 60mg Sustained Release Tablet MORPHINE SR SAN MS CONTIN SR PFR NOVO-MORPHINE SR TEV SANDOZ MORPHINE SR SDZ Page A-26 de 81

195 Appendix A - Limited Use Benefits and Criteria 28:08.08 OPIATE AGONIS MORPHINE SULFATE Limited use benefit (prior approval is not required). To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented an opioid dose limit of 450 mg morphine equivalents per day for non-cancer, non-palliative pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 30-day period (i.e morphine equivalents over 30 days). 100mg Sustained Release Tablet MORPHINE SR SAN MS CONTIN SR PFR NOVO-MORPHINE SR TEV 200mg Sustained Release Tablet MORPHINE SR SAN MS CONTIN SR PFR NOVO-MORPHINE SR TEV 1mg/mL Syrup ATEX PMS 5mg/mL Syrup ATEX PMS 10mg/mL Syrup ATEX PMS 5mg Tablet M.O.S. SULFATE VAE MS IR PFR ATEX PMS 10mg Tablet M.O.S. SULFATE VAE MS IR PFR ATEX PMS 20mg Tablet MS IR PFR 25mg Tablet M.O.S. SULFATE VAE ATEX PMS 30mg Tablet MS IR PFR 50mg Tablet M.O.S. SULFATE VAE ATEX PMS MORPHINE SULFATE (K) For the treatment of opioid dependence where methadone and Suboxone are not available or not appropriate OR For the treatment of chronic pain. To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented an opioid dose limit of 450 mg morphine equivalents per day for non-cancer, non-palliative pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 30-day period (i.e morphine equivalents over 30 days). 10mg Sustained Release Capsule KADIAN MAY 20mg Sustained Release Capsule KADIAN MAY 50mg Sustained Release Capsule KADIAN MAY 100mg Sustained Release Capsule KADIAN MAY Page A-27 de 81

196 Appendix A - Limited Use Benefits and Criteria 28:08.08 OPIATE AGONIS OXYCODONE HCL Limited use benefit (prior approval is not required). To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented an opioid dose limit of 450 mg morphine equivalents per day for non-cancer, non-palliative pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 30-day period (i.e morphine equivalents over 30 days). 10mg Suppository SUPEUDOL SDZ 20mg Suppository SUPEUDOL SDZ 5mg Tablet OXYCODONE PDL OXY-IR PFR PMS-OXYCODONE PMS SUPEUDOL SDZ 10mg Tablet OXYCODONE PDL OXY-IR PFR PMS-OXYCODONE PMS SUPEUDOL SDZ 20mg Tablet OXYCODONE PDL OXY-IR PFR PMS-OXYCODONE PMS SUPEUDOL SDZ 28:08.12 OPIATE PARTIAL AGONIS BUPRENORPHINE, NALOXONE For the treatment of opioid dependence when: A rationale for using Suboxone instead of the alternative (i.e. methadone); and In cases where the client lives in a remote or isolated location, confirmation is required that the cmmunity has the ability to support Suboxone administration. These supports include the safe daily witnessing, storage and handling of the Suboxone doses. After this confirmation, NIHB will approve the Suboxone for the client. The client must be 16 years or older. 2mg & 0.5mg Sublingual Tablet SUBOXONE RBP 8mg & 2mg Sublingual Tablet SUBOXONE RBP 28:08.92 MISCELLANEOUS ANALGESICS AND ANTIPYRETICS ACETAMINOPHEN Limited use benefit (prior approval is not required). For safety reasons NIHB has implemented a dose limit on acetaminophen. The limit accumulates against the amount of acetaminophen claimed to the program from plain acetaminophen and/or acetaminophen in combination with opioids such as codeine (i.e. Tylenol #3) or oxycodone (i.e. Percocet ). A total of 360 grams of acetaminophen is permitted in a 100-day period, for a total daily dose of 3600mg/day. 80mg Chewable Tablet ACETAMINOPHEN TRI 0676 ACETAMINOPHEN TAN ACETAMINOPHEN RIV ACETAMINOPHEN VTH PEDIAPHEN CHEWABLE EUR 160mg Chewable Tablet ACETAMINOPHEN RIV ACETAMINOPHEN TAN FEVERHALT PED PEDIAPHEN CHEWABLE EUR Page A-28 de 81

197 Appendix A - Limited Use Benefits and Criteria 28:08.92 MISCELLANEOUS ANALGESICS AND ANTIPYRETICS ACETAMINOPHEN Limited use benefit (prior approval is not required). For safety reasons NIHB has implemented a dose limit on acetaminophen. The limit accumulates against the amount of acetaminophen claimed to the program from plain acetaminophen and/or acetaminophen in combination with opioids such as codeine (i.e. Tylenol #3) or oxycodone (i.e. Percocet ). A total of 360 grams of acetaminophen is permitted in a 100-day period, for a total daily dose of 3600mg/day. 80mg/mL Drop ACETAMINOPHEN TAN ACETAMINOPHEN TRI ATASOL HOR FEVERHALT PED PEDIAPHEN EUR PEDIATRIX RPH PMS-ACETAMINOPHEN PMS TEMPRA MJO TYLENOL MCL 16mg/mL Liquid ACETAMINOPHEN TRI PEDIAPHEN EUR PMS-ACETAMINOPHEN PMS TEMPRA MJO 32mg/mL Liquid ACETAMINOPHEN JMP ACETAMINOPHEN TRI PEDIAPHEN EUR PEDIATRIX RPH PMS-ACETAMINOPHEN PMS TEMPRA DOUBLE RENGTH MJO TYLENOL MCL 80mg/mL Oral Liquid ACETAMINOPHEN PER 120mg Suppository ABENOL PED ACET 120 PMS PMS-ACETAMINOPHEN PMS 160mg Suppository ACET PMS 325mg Suppository ABENOL PED ACET 325 PMS PMS-ACETAMINOPHEN PMS 650mg Suppository ABENOL PED ACET 650 PMS PMS-ACETAMINOPHEN PMS 80mg Tablet TYLENOL JR RENGTH FAMELTS JNO 160mg Tablet ACETAMINOPHEN WTR TYLENOL JR RENGTH FAMELTS JNO TYLENOL JUNIOR RENGTH JNO Page A-29 de 81

198 Appendix A - Limited Use Benefits and Criteria 28:08.92 MISCELLANEOUS ANALGESICS AND ANTIPYRETICS ACETAMINOPHEN Limited use benefit (prior approval is not required). For safety reasons NIHB has implemented a dose limit on acetaminophen. The limit accumulates against the amount of acetaminophen claimed to the program from plain acetaminophen and/or acetaminophen in combination with opioids such as codeine (i.e. Tylenol #3) or oxycodone (i.e. Percocet ). A total of 360 grams of acetaminophen is permitted in a 100-day period, for a total daily dose of 3600mg/day. 325mg Tablet ACETAMINOPHEN WAM ACETAMINOPHEN PRO ACETAMINOPHEN PMS ACETAMINOPHEN VTH * ACETAMINOPHEN PMT ACETAMINOPHEN TRI ACETAMINOPHEN JMP ACETAMINOPHEN RIV APO-ACETAMINOPHEN APX APO-ACETAMINOPHEN APX ATASOL HOR NOVO-GESIC TEV TYLENOL MCL TYLENOL MCL 500mg Tablet ACETAMINOPHEN PDL ACETAMINOPHEN PMT ACETAMINOPHEN PED ACETAMINOPHEN PMS ACETAMINOPHEN VTH ACETAMINOPHEN TRI ACETAMINOPHEN JMP ACETAMINOPHEN RIV ACETAMINOPHEN PMT ACETAMINOPHEN PMT APO-ACETAMINOPHEN APX APO-ACETAMINOPHEN APX ATASOL FORTE HOR JAMP-ACETAMINOPHEN JAP NOVO-GESIC TEV PMS-ACETAMINOPHEN PMS TANTAPHEN TAN TYLENOL EXTRA RENGTH MCL TYLENOL EXTRA RENGTH MCL 28:12.08 ANTICONVULSANTS - BENZODIAZEPINES CLONAZEPAM Limited use benefit (prior approval is not required). To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 40 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e diazepam equivalents over 100 days). According to the product monograph for diazepam, the recommended usual adult dosage is up to 40 mg per day. 0.25mg Tablet PMS-CLONAZEPAM PMS Page A-30 de 81

199 Appendix A - Limited Use Benefits and Criteria 28:12.08 ANTICONVULSANTS - BENZODIAZEPINES CLONAZEPAM Limited use benefit (prior approval is not required). To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 40 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e diazepam equivalents over 100 days). According to the product monograph for diazepam, the recommended usual adult dosage is up to 40 mg per day. 0.5mg Tablet APO-CLONAZEPAM APX CLONAPAM VAE CO CLONAZEPAM COB DOM-CLONAZEPAM DPC DOM-CLONAZEPAM-R DPC MYLAN-CLONAZEPAM MYL PHL-CLONAZEPAM PHH PHL-CLONAZEPAM-R 0.5MG PMI PMS-CLONAZEPAM PMS PMS-CLONAZEPAM R PMS PRO-CLONAZEPAM PDL RIVA-CLONAZEPAM RIV RIVOTRIL HLR SANDOZ-CLONAZEPAM SDZ TEVA-CLONAZEPAM TEV ZYM-CLONAZEPAM ZYM 1mg Tablet CLONAPAM VAE CO CLONAZEPAM COB PHL-CLONAZEPAM PHH PMS-CLONAZEPAM PMS PRO-CLONAZEPAM PDL SANDOZ-CLONAZEPAM SDZ ZYM-CLONAZEPAM ZYM 2mg Tablet APO-CLONAZEPAM APX CLONAPAM VAE CO CLONAZEPAM COB DOM-CLONAZEPAM DPC GEN-CLONAZEPAM MYL PHL-CLONAZEPAM PHH PMS-CLONAZEPAM PMS PRO-CLONAZEPAM PDL RIVA-CLONAZEPAM RIV RIVOTRIL HLR SANDOZ-CLONAZEPAM SDZ TEVA-CLONAZEPAM TEV ZYM-CLONAZEPAM ZYM Page A-31 de 81

200 Appendix A - Limited Use Benefits and Criteria 28:12.92 MISCELLANEOUS ANTICONVULSANTS GABAPENTIN Limited use benefit (prior approval is not required). For safety reasons NIHB has implemented a dose limit on gabapentin. The limit accumulates against the amount of gabapentin claimed to the program. A total of 400 grams of gabapentin is permitted in a 100-day period, for a total daily dose of 4000mg/day. 100mg Capsule APO-GABAPENTIN APX AURO-GABAPENTIN AUR CO GABAPENTIN COB DOM-GABAPENTIN DPC GABAPENTIN MEL GABAPENTIN SOR GABAPENTIN SAN GABAPENTIN ACC GD-GABAPENTIN PFI JAMP-GABAPENTIN JAP MAR-GABAPENTIN MAR MYLAN-GABAPENTIN MYL NEURONTIN PFI NOVO-GABAPENTIN TEV PMS-GABAPENTIN PMS PRO-GABAPENTIN PDL RAN-GABAPENTIN RBY RIVA-GABAPENTIN RIV 300mg Capsule APO-GABAPENTIN APX AURO-GABAPENTIN AUR CO GABAPENTIN COB DOM-GABAPENTIN DPC GABAPENTIN MEL GABAPENTIN SOR GABAPENTIN SAN GABAPENTIN ACC GD-GABAPENTIN PFI JAMP-GABAPENTIN JAP MAR-GABAPENTIN MAR MYLAN-GABAPENTIN MYL NEURONTIN PFI NOVO-GABAPENTIN TEV PMS-GABAPENTIN PMS PRO-GABAPENTIN PDL RAN-GABAPENTIN RBY RIVA-GABAPENTIN RIV Page A-32 de 81

201 Appendix A - Limited Use Benefits and Criteria 28:12.92 MISCELLANEOUS ANTICONVULSANTS GABAPENTIN Limited use benefit (prior approval is not required). For safety reasons NIHB has implemented a dose limit on gabapentin. The limit accumulates against the amount of gabapentin claimed to the program. A total of 400 grams of gabapentin is permitted in a 100-day period, for a total daily dose of 4000mg/day. 400mg Capsule APO-GABAPENTIN APX AURO-GABAPENTIN AUR CO GABAPENTIN COB DOM-GABAPENTIN DPC GABAPENTIN MEL GABAPENTIN SOR GABAPENTIN SAN GABAPENTIN ACC GD-GABAPENTIN PFI JAMP-GABAPENTIN JAP MAR-GABAPENTIN MAR MYLAN-GABAPENTIN MYL NEURONTIN PFI NOVO-GABAPENTIN TEV PMS-GABAPENTIN PMS PRO-GABAPENTIN PDL RAN-GABAPENTIN RBY RATIO-GABAPENTIN RPH RIVA-GABAPENTIN RIV 600mg Tablet APO-GABAPENTIN APX GABAPENTIN SIV GABAPENTIN ACC GD-GABAPENTIN PFI JAMP-GABAPENTIN JAP MYLAN-GABAPENTIN MYL NEURONTIN PFI NOVO-GABAPENTIN TEV PMS-GABAPENTIN PMS PRO-GABAPENTIN PDL RATIO-GABAPENTIN RPH RIVA-GABAPENTIN RIV 800mg Tablet APO-GABAPENTIN APX GABAPENTIN SIV GABAPENTIN ACC GD-GABAPENTIN PFI JAMP-GABAPENTIN JAP MYLAN-GABAPENTIN MYL NEURONTIN PFI NOVO-GABAPENTIN TEV PMS-GABAPENTIN PMS PRO-GABAPENTIN PDL RATIO-GABAPENTIN RPH RIVA-GABAPENTIN RIV Page A-33 de 81

202 Appendix A - Limited Use Benefits and Criteria 28:12.92 MISCELLANEOUS ANTICONVULSANTS LACOSAMIDE For adjunctive therapy in patients with refractory partial-onset seizures who meet all of the following criteria: a- Are under the care of a physician experienced in the treatment of epilepsy, AND b- Are currently receiving two or more antiepileptic medications, AND c- Have failed or demonstrated intolerance to at least two other antiepileptic medications. 50mg Tablet VIMPAT UCB 100mg Tablet VIMPAT UCB 150mg Tablet VIMPAT UCB 200mg Tablet VIMPAT UCB LEVETIRACETAM For the use in combination with other anti-epileptic medication(s) in the treatment of partial seizures in patients who are refractory to adequate trials of two antiepileptic medications used either as monotherapy or in combination. 250mg Tablet ABBOTT-LEVETIRACETAM ABB APO-LEVETIRACETAM APX AURO-LEVETIRACETAM AUR CO LEVETIRACETAM COB JAMP-LEVETIRACETAM JAP KEPPRA UCB LEVETIRACETAM SAN LEVETIRACETAM ACC PMS-LEVETIRACETAM PMS RAN-LEVETIRACETAM RBY 500mg Tablet ABBOTT-LEVETIRACETAM ABB APO-LEVETIRACETAM APX AURO-LEVETIRACETAM AUR CO LEVETIRACETAM COB DOM-LEVETIRACETAM DOM JAMP-LEVETIRACETAM JAP KEPPRA UCB LEVETIRACETAM SAN LEVETIRACETAM ACC PMS-LEVETIRACETAM PMS PRO-LEVETIRACETAM PDL RAN-LEVETIRACETAM RBY 750mg Tablet ABBOTT-LEVETIRACETAM ABB APO-LEVETIRACETAM APX AURO-LEVETIRACETAM AUR CO LEVETIRACETAM COB JAMP-LEVETIRACETAM JAP KEPPRA UCB LEVETIRACETAM SAN LEVETIRACETAM ACC PMS-LEVETIRACETAM PMS PRO-LEVETIRACETAM PDL RAN-LEVETIRACETAM RBY Page A-34 de 81

203 Appendix A - Limited Use Benefits and Criteria 28:12.92 MISCELLANEOUS ANTICONVULSANTS PREGABALIN For the treatment of neuropathic pain in patients who have failed to effectively treat their pain with a tricyclic antidepressant (TCA) OR For the treatment of neuropathic pain in patients who have a contraindication or intolerance with a TCA. The dose of pregabalin is limited to a maximum of 600 mg per day 25mg Capsule ACT-PREGABALIN ATP APO-PREGABALIN APX DOM-PREGABALIN DOM GD-PREGABALIN PFI LYRICA PFI MAR-PREGABALIN MAR MINT-PREGABALIN MIN MYL-PREGABALIN MYL PMS-PREGABALIN PMS PREGABALIN PDL PREGABALIN SIV PREGABALIN SAN PREGABALIN-25 SIV RAN-PREGABALIN RBY RIVA-PREGABALIN RIV SANDOZ PREGABALIN SDZ TEVA-PREGABALIN TEP 50mg Capsule ACT-PREGABALIN ATP APO-PREGABALIN APX DOM-PREGABALIN DOM GD-PREGABALIN PFI LYRICA PFI MAR-PREGABALIN MAR MINT-PREGABALIN MIN MYL-PREGABALIN MYL PMS-PREGABALIN PMS PREGABALIN PDL PREGABALIN SIV PREGABALIN SAN PREGABALIN-50 SIV RAN-PREGABALIN RBY RIVA-PREGABALIN RIV SANDOZ PREGABALIN SDZ TEVA-PREGABALIN TEP Page A-35 de 81

204 Appendix A - Limited Use Benefits and Criteria 28:12.92 MISCELLANEOUS ANTICONVULSANTS PREGABALIN For the treatment of neuropathic pain in patients who have failed to effectively treat their pain with a tricyclic antidepressant (TCA) OR For the treatment of neuropathic pain in patients who have a contraindication or intolerance with a TCA. The dose of pregabalin is limited to a maximum of 600 mg per day 75mg Capsule ACT-PREGABALIN ATP APO-PREGABALIN APX DOM-PREGABALIN DOM GD-PREGABALIN PFI LYRICA PFI MAR-PREGABALIN MAR MINT-PREGABALIN MIN MYL-PREGABALIN MYL PMS-PREGABALIN PMS PREGABALIN PDL PREGABALIN SIV PREGABALIN SAN PREGABALIN-75 SIV RAN-PREGABALIN RBY RIVA-PREGABALIN RIV SANDOZ PREGABALIN SDZ TEVA-PREGABALIN TEP 150mg Capsule ACT-PREGABALIN ATP APO-PREGABALIN APX DOM-PREGABALIN DOM GD-PREGABALIN PFI LYRICA PFI MAR-PREGABALIN MAR MINT-PREGABALIN MIN MYL-PREGABALIN MYL PMS-PREGABALIN PMS PREGABALIN PDL PREGABALIN SIV PREGABALIN SAN PREGABALIN-150 SIV RAN-PREGABALIN RBY RIVA-PREGABALIN RIV SANDOZ PREGABALIN SDZ TEVA-PREGABALIN TEP Page A-36 de 81

205 Appendix A - Limited Use Benefits and Criteria 28:12.92 MISCELLANEOUS ANTICONVULSANTS PREGABALIN For the treatment of neuropathic pain in patients who have failed to effectively treat their pain with a tricyclic antidepressant (TCA) OR For the treatment of neuropathic pain in patients who have a contraindication or intolerance with a TCA. The dose of pregabalin is limited to a maximum of 600 mg per day 300mg Capsule ACT-PREGABALIN ATP APO-PREGABALIN APX GD-PREGABALIN PFI LYRICA PFI MYL-PREGABALIN MYL PMS-PREGABALIN PMS PREGABALIN PDL PREGABALIN SIV PREGABALIN SAN RAN-PREGABALIN RBY RIVA-PREGABALIN RIV SANDOZ PREGABALIN SDZ TEVA-PREGABALIN TEP RUFINAMIDE -For the adjunctive treatment of seizures associated with Lennox-Gastaux syndrome in adults and children 4 years and older when prescribed by a neurologist or experienced specialist -Patient has failed or is intolerant to or has contraindications to at least two adjunctive antiepileptic drugs 100mg Tablet BANZEL EIS 200mg Tablet BANZEL EIS 400mg Tablet BANZEL EIS 28:16.04 ANTIDEPRESSANTS BUPROPION HCL (WELLBUTRIN) Limited use benefit with quantity and frequency limits (prior approval is not required). Coverage of Wellbutrin XL and Bupropion SR is limited to 300 mg per day. (Note: this product will not be approved for coverage for smoking cessation). 150mg Extended Release Tablet MYLAN-BUPROPION XL MYL WELLBUTRIN XL VAE 300mg Extended Release Tablet MYLAN-BUPROPION XL MYL WELLBUTRIN XL VAE 100mg Sustained Release Tablet BUPROPION SR PDL BUPROPION SR SAN PMS-BUPROPION SR PMS RATIO-BUPROPION RPH SANDOZ-BUPROPION SR SDZ Page A-37 de 81

206 Appendix A - Limited Use Benefits and Criteria 28:16.04 ANTIDEPRESSANTS BUPROPION HCL (WELLBUTRIN) Limited use benefit with quantity and frequency limits (prior approval is not required). Coverage of Wellbutrin XL and Bupropion SR is limited to 300 mg per day. (Note: this product will not be approved for coverage for smoking cessation). 150mg Sustained Release Tablet BUPROPION SR PDL BUPROPION SR SAN PMS-BUPROPION SR PMS RATIO-BUPROPION RPH SANDOZ-BUPROPION SR SDZ WELLBUTRIN SR VAE BUPROPION HCL (ZYBAN) Limited use benefit with quantity and frequency limits (prior approval is not required). For smoking cessation: Coverage is limited to 180 tablets during a one-year period. The year starts on the date the first prescription is filled. Once this quantity has been reached the client is eligible again for coverage for bupropion HCl when one year has elapsed from the day the initial prescription was filled. 150mg Sustained Release Tablet ZYBAN VAE DULOXETINE HCL 30mg Sustained Release Capsule CYMBALTA LIL 60mg Sustained Release Capsule CYMBALTA LIL 28:16.08 ANTIPSYCHOTIC AGENTS ARIPIPRAZOLE For the treatment of schizophrenia and schizoaffective disorders in patients who have a. Intolerance or lack of response to an adequate trial of another antipsychotic agent; OR b. A contraindication to another antipsychotic agent 2mg Tablet ABILIFY BMS 5mg Tablet ABILIFY BMS 10mg Tablet ABILIFY 15mg Tablet ABILIFY BMS 20mg Tablet ABILIFY BMS 30mg Tablet ABILIFY BMS ASENAPINE For the acute treatment of manic or mixed episodes associated with bipolar I disorder as either: - Monotherapy, after a trial of lithium or divalproex sodium has failed or is contraindicated, and trials of two atypical antipsychotic agents have failed due to intolerance or lack of response OR - Co-therapy with lithium or divalproex sodium, after trials of two atypical antipsychotic agents have failed due to intolerance or lack of response. 5mg Tablet SAPHRIS FRS Page A-38 de 81

207 Appendix A - Limited Use Benefits and Criteria 28:16.08 ANTIPSYCHOTIC AGENTS ASENAPINE For the acute treatment of manic or mixed episodes associated with bipolar I disorder as either: - Monotherapy, after a trial of lithium or divalproex sodium has failed or is contraindicated, and trials of two atypical antipsychotic agents have failed due to intolerance or lack of response OR - Co-therapy with lithium or divalproex sodium, after trials of two atypical antipsychotic agents have failed due to intolerance or lack of response. 10mg Tablet SAPHRIS FRS PALIPERIDONE PALMITATE For the management of manifestations of schizophrenia and related psychotic disorders in patients who have: tried oral risperidone or paliperidone and at least one other antipsychotic agent and continue to be inadequately controlled at maximally tolerated doses; OR who are currently receiving a conventional depot antipsychotic and are experiencing significant side effects such as extrapyramidal symptoms or tardive dyskinesia; OR who have a history of non-adherence to antipsychotic medications resulting in important negative outcomes such as repeated hospitalizations 50mg/0.5mL Injection INVEGA SUENNA JNO 75mg/0.75mL Injection INVEGA SUENNA JNO 100mg/mL Injection INVEGA SUENNA JNO 150mg/1.5mL Injection INVEGA SUENNA JNO RISPERIDONE (CONA) For the management of manifestations of schizophrenia and related psychotic disorders in patients who have: tried oral risperidone or paliperidone and at least one other antipsychotic agent and continue to be inadequately controlled at maximally tolerated doses; OR who are currently receiving a conventional depot antipsychotic and are experiencing significant side effects such as extrapyramidal symptoms or tardive dyskinesia; OR who have a history of non-adherence to antipsychotic medications resulting in important negative outcomes such as repeated hospitalizations 12.5mg Injection RISPERDAL CONA JNO 25mg Injection RISPERDAL CONA JNO 37.5mg Injection RISPERDAL CONA JNO 50mg Injection RISPERDAL CONA JNO ZIPRASIDONE HCL MONOHYDRATE 20MG Capsule ZELDOX PFI 40MG Capsule ZELDOX PFI 60mg Capsule ZELDOX PFI 80mg Capsule ZELDOX PFI Page A-39 de 81

208 Appendix A - Limited Use Benefits and Criteria 28:20.04 AMPHETAMINES DEXTROAMPHETAMINE SULFATE Limited use benefit (prior approval is not required). The NIHB Program introduced a dose coverage limit for stimulants on February 25, as part of a strategy to deal with the potential misuse and abuse of these medications. The stimulant dose coverage limit is set at 150 mg of methylphenidate equivalents* per day for adults and children. This limit is calculated based on the total dose of all stimulants that patients are receiving from NIHB. The Program will continue to monitor the utilization of stimulants and adjust the eligible dose limit as required. To convert to methylphenidate equivalents, 1 mg of METHYLPHENIDATE, or LISDEXAMFETAMINE is equal to 0.5 mg DEXTROAMPHETAMINE 10mg Sustained Release Capsule DEXEDRINE SPANSULE GSK 15mg Sustained Release Capsule DEXEDRINE SPANSULE GSK 5mg Tablet DEXEDRINE GSK LISDEXAMFETAMINE DIMESYLATE Limited use benefit (prior approval is not required). The NIHB Program introduced a dose coverage limit for stimulants on February 25, as part of a strategy to deal with the potential misuse and abuse of these medications. The stimulant dose coverage limit is set at 150 mg of methylphenidate equivalents* per day for adults and children. This limit is calculated based on the total dose of all stimulants that patients are receiving from NIHB. The Program will continue to monitor the utilization of stimulants and adjust the eligible dose limit as required. To convert to methylphenidate equivalents, 1 mg of METHYLPHENIDATE, or LISDEXAMFETAMINE is equal to 0.5 mg DEXTROAMPHETAMINE 20mg Capsule VYVANSE SHI 30mg Capsule VYVANSE SHI 40mg Capsule VYVANSE SHI 50mg Capsule VYVANSE SHI 60mg Capsule VYVANSE SHI 28:20.32 METHYLPHENIDATE HCL Limited use benefit (prior approval is not required). The NIHB Program introduced a dose coverage limit for stimulants on February 25, as part of a strategy to deal with the potential misuse and abuse of these medications. The stimulant dose coverage limit is set at 150 mg of methylphenidate equivalents* per day for adults and children. This limit is calculated based on the total dose of all stimulants that patients are receiving from NIHB. The Program will continue to monitor the utilization of stimulants and adjust the eligible dose limit as required. To convert to methylphenidate equivalents, 1 mg of METHYLPHENIDATE, or LISDEXAMFETAMINE is equal to 0.5 mg DEXTROAMPHETAMINE 18mg Sustained Release Tablet PMS-METHYLPHENIDATE ER PMS 27mg Sustained Release Tablet PMS-METHYLPHENIDATE ER PMS 36mg Sustained Release Tablet PMS-METHYLPHENIDATE ER PMS 54mg Sustained Release Tablet PMS-METHYLPHENIDATE ER PMS Page A-40 de 81

209 Appendix A - Limited Use Benefits and Criteria 28:20.92 MISC ANOREXIGENIC AGENTS & RESPIRATORY & CEREBRAL IMULANT METHYLPHENIDATE HCL Limited use benefit (prior approval is not required). The NIHB Program introduced a dose coverage limit for stimulants on February 25, as part of a strategy to deal with the potential misuse and abuse of these medications. The stimulant dose coverage limit is set at 150 mg of methylphenidate equivalents* per day for adults and children. This limit is calculated based on the total dose of all stimulants that patients are receiving from NIHB. The Program will continue to monitor the utilization of stimulants and adjust the eligible dose limit as required. To convert to methylphenidate equivalents, 1 mg of METHYLPHENIDATE, or LISDEXAMFETAMINE is equal to 0.5 mg DEXTROAMPHETAMINE 18mg Extended Release Tablet CONCERTA JNO NOVO-METHYLPHENIDATE ER TEV 27mg Extended Release Tablet CONCERTA JNO NOVO-METHYLPHENIDATE ER TEV 36mg Extended Release Tablet CONCERTA JNO NOVO-METHYLPHENIDATE ER TEV 54mg Extended Release Tablet APO-METHYLPHENIDATE ER APX CONCERTA JNO NOVO-METHYLPHENIDATE ER TEV 20mg Sustained Release Tablet APO-METHYLPHENIDATE SR APX SANDOZ-METHYLPHENIDATE SR SDZ 5mg Tablet APO-METHYLPHENIDATE APX METHYLPHENIDATE PDL PMS-METHYLPHENIDATE PMS 10mg Tablet APO-METHYLPHENIDATE APX METHYLPHENIDATE PDL PMS-METHYLPHENIDATE PMS 20mg Tablet APO-METHYLPHENIDATE APX METHYLPHENIDATE PDL PMS-METHYLPHENIDATE PMS 28:24.08 ANXIOLYTICS, SEDATIVES AND HYPNOTICS - BENZODIAZEPINES ALPRAZOLAM Limited use benefit (prior approval is not required). To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 40 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e diazepam equivalents over 100 days). According to the product monograph for diazepam, the recommended usual adult dosage is up to 40 mg per day. 0.25mg Tablet ALPRAZOLAM PDL ALPRAZOLAM SAN APO-ALPRAZ APX JAMP-ALPRAZOLAM JAP MYLAN-ALPRAZOLAM MYL RIVA-ALPRAZOLAM RIV TEVA-ALPRAZOL TEV XANAX PFI Page A-41 de 81

210 Appendix A - Limited Use Benefits and Criteria 28:24.08 ANXIOLYTICS, SEDATIVES AND HYPNOTICS - BENZODIAZEPINES ALPRAZOLAM Limited use benefit (prior approval is not required). To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 40 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e diazepam equivalents over 100 days). According to the product monograph for diazepam, the recommended usual adult dosage is up to 40 mg per day. 0.5mg Tablet ALPRAZOLAM PDL ALPRAZOLAM SAN APO-ALPRAZ APX JAMP-ALPRAZOLAM JAP MYLAN-ALPRAZOLAM MYL RIVA-ALPRAZOLAM RIV TEVA-ALPRAZOL TEV XANAX PFI 1mg Tablet ALPRAZOLAM PDL APO-ALPRAZ APX JAMP-ALPRAZOLAM JAP MYLAN-ALPRAZOLAM MYL RIVA-ALPRAZOLAM RIV XANAX PFI 2mg Tablet APO-ALPRAZ APX JAMP-ALPRAZOLAM JAP MYLAN-ALPRAZOLAM MYL XANAX TS PFI BROMAZEPAM Limited use benefit (prior approval is not required). To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 40 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e diazepam equivalents over 100 days). According to the product monograph for diazepam, the recommended usual adult dosage is up to 40 mg per day. 1.5mg Tablet APO-BROMAZEPAM APX 3mg Tablet APO-BROMAZEPAM APX BROMAZEPAM PDL LECTOPAM HLR TEVA-BROMAZEPAM TEV 6mg Tablet APO-BROMAZEPAM APX BROMAZEPAM PDL LECTOPAM HLR TEVA-BROMAZEPAM TEV DIAZEPAM Limited use benefit (prior approval is not required). To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 40 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e diazepam equivalents over 100 days). According to the product monograph for diazepam, the recommended usual adult dosage is up to 40 mg per day. 1mg/mL Oral Solution PMS-DIAZEPAM PMS 2mg Tablet APO-DIAZEPAM APX DIAZEPAM PDL PMS-DIAZEPAM PMS Page A-42 de 81

211 Appendix A - Limited Use Benefits and Criteria 28:24.08 ANXIOLYTICS, SEDATIVES AND HYPNOTICS - BENZODIAZEPINES DIAZEPAM Limited use benefit (prior approval is not required). To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 40 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e diazepam equivalents over 100 days). According to the product monograph for diazepam, the recommended usual adult dosage is up to 40 mg per day. 5mg Tablet APO-DIAZEPAM APX DIAZEPAM PRO PMS-DIAZEPAM PMS VALIUM HLR 10mg Tablet APO-DIAZEPAM APX DIAZEPAM PDL PMS-DIAZEPAM PMS LORAZEPAM Limited use benefit (prior approval is not required). To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 40 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e diazepam equivalents over 100 days). According to the product monograph for diazepam, the recommended usual adult dosage is up to 40 mg per day. 0.5mg Tablet APO-LORAZEPAM APX APO-LORAZEPAM SL APX ATIVAN WAY ATIVAN SUBLINGUAL WAY DOM-LORAZEPAM DPC LORAZEPAM SAN NOVO-LORAZEM TEV PMS-LORAZEPAM PMS PRO-LORAZEPAM PDL 1mg Tablet APO-LORAZEPAM APX APO-LORAZEPAM SL APX ATIVAN WAY ATIVAN SUBLINGUAL WAY DOM-LORAZEPAM DPC LORAZEPAM SAN NOVO-LORAZEM TEV PMS-LORAZEPAM PMS PRO-LORAZEPAM PDL 2mg Tablet APO-LORAZEPAM APX APO-LORAZEPAM SL APX ATIVAN WAY ATIVAN SUBLINGUAL WAY DOM-LORAZEPAM DPC LORAZEPAM SAN NOVO-LORAZEM TEV PMS-LORAZEPAM PMS PRO-LORAZEPAM PDL Page A-43 de 81

212 Appendix A - Limited Use Benefits and Criteria 28:24.08 ANXIOLYTICS, SEDATIVES AND HYPNOTICS - BENZODIAZEPINES NITRAZEPAM Limited use benefit (prior approval is not required). To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 40 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e diazepam equivalents over 100 days). According to the product monograph for diazepam, the recommended usual adult dosage is up to 40 mg per day. 5mg Tablet MOGADON ICN 10mg Tablet MOGADON VAE OXAZEPAM Limited use benefit (prior approval is not required). To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 40 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e diazepam equivalents over 100 days). According to the product monograph for diazepam, the recommended usual adult dosage is up to 40 mg per day. 10mg Tablet APO-OXAZEPAM APX OXAZEPAM PDL OXPAM BMI RIVA OXAZEPAM RIV 15mg Tablet APO-OXAZEPAM APX OXAZEPAM PDL RIVA OXAZEPAM RIV 30mg Tablet APO-OXAZEPAM APX OXAZEPAM PDL OXPAM BMI RIVA OXAZEPAM RIV TEMAZEPAM Limited use benefit (prior approval is not required). To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 40 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e diazepam equivalents over 100 days). According to the product monograph for diazepam, the recommended usual adult dosage is up to 40 mg per day. 15mg Capsule APO-TEMAZEPAM APX CO TEMAZEPAM COB DOM-TEMAZEPAM DPC NOVO-TEMAZEPAM TEV RATIO-TEMAZEPAM RPH REORIL ORY TEMAZEPAM PDL 30mg Capsule APO-TEMAZEPAM APX CO TEMAZEPAM COB DOM-TEMAZEPAM DPC NOVO-TEMAZEPAM TEV RATIO-TEMAZEPAM RPH REORIL ORY TEMAZEPAM PDL Page A-44 de 81

213 Appendix A - Limited Use Benefits and Criteria 28:24.08 ANXIOLYTICS, SEDATIVES AND HYPNOTICS - BENZODIAZEPINES TRIAZOLAM Limited use benefit (prior approval is not required). To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 40 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e diazepam equivalents over 100 days). According to the product monograph for diazepam, the recommended usual adult dosage is up to 40 mg per day mg Tablet APO-TRIAZO APX 0.25mg Tablet APO-TRIAZO APX 28:32.28 SELECTIVE SEROTONIN AGONIS ALMOTRIPTAN MALATE Limited use benefit (prior approval is not required). A total of 12 tablets (or injections) are permitted in a 30-day period. 6.25MG Tablet APO-ALMOTRIPTAN APX AXERT MCL MYLAN-ALMOTRIPTAN MYL 12.5MG Tablet ALMOTRIPTAN PDL APO-ALMOTRIPTAN APX AXERT MCL MYLAN-ALMOTRIPTAN MYL SANDOZ ALMOTRIPTAN SDZ NARATRIPTAN HCL Limited use benefit (prior approval is not required). A total of 12 tablets (or injections) are permitted in a 30-day period. 1mg Tablet AMERGE GSK NOVO-NARATRIPTAN TEV 2.5mg Tablet AMERGE GSK NOVO-NARATRIPTAN TEV SANDOZ NARATRIPTAN SDZ RIZATRIPTAN Limited use benefit (prior approval is not required). A total of 12 tablets (or injections) are permitted in a 30-day period. 5mg Orally Disintegrating Tablet APO-RIZATRIPTAN RPD APX CO-RIZATRIPTAN ODT ATP MYLAN-RIZATRIPTAN ODT MYL PMS-RIZATRIPTAN RDT PMS RIVA-RIZATRIPTAN ODT RIV RIZATRIPTAN RDT PDL SANDOZ RIZATRIPTAN ODT SDZ TEVA-RIZATRIPTAN RDT TEP Page A-45 de 81

214 Appendix A - Limited Use Benefits and Criteria 28:32.28 SELECTIVE SEROTONIN AGONIS RIZATRIPTAN Limited use benefit (prior approval is not required). A total of 12 tablets (or injections) are permitted in a 30-day period. 10mg Orally Disintegrating Tablet APO-RIZATRIPTAN RPD APX CO-RIZATRIPTAN ODT ATP DOM-RIZATRIPTAN RDT DOM MYLAN-RIZATRIPTAN ODT MYL PMS-RIZATRIPTAN RDT PMS RIVA-RIZATRIPTAN ODT RIV RIZATRIPTAN RDT PDL SANDOZ RIZATRIPTAN ODT SDZ TEVA-RIZATRIPTAN RDT TEP 5mg Tablet APO-RIZATRIPTAN APX JAMP-RIZATRIPTAN JAP JAMP-RIZATRIPTAN IR JAP MAR-RIZATRIPTAN MAR 10mg Tablet APO-RIZATRIPTAN APX CO RIZATRIPTAN ATP JAMP-RIZATRIPTAN JAP JAMP-RIZATRIPTAN IR JAP MAR-RIZATRIPTAN MAR MAXALT FRS 5mg Wafer MAXALT RPD FRS 10mg Wafer MAXALT RPD FRS SUMATRIPTAN HEMISULFATE 5mg Nasal Spray IMITREX GSK 20mg Nasal Spray IMITREX GSK SUMATRIPTAN SUCCINATE Limited use benefit (prior approval is not required). A total of 12 tablets (or injections) are permitted in a 30-day period. 12mg/mL Injection IMITREX GSK TARO-SUMATRIPTAN TAR 25mg Tablet CO SUMATRIPTAN COB DOM-SUMATRIPTAN DPC MYLAN-SUMATRIPTAN MYL NOVO-SUMATRIPTAN DF TEV PMS-SUMATRIPTAN PMS SUMATRIPTAN SAN Page A-46 de 81

215 Appendix A - Limited Use Benefits and Criteria 28:32.28 SELECTIVE SEROTONIN AGONIS SUMATRIPTAN SUCCINATE Limited use benefit (prior approval is not required). A total of 12 tablets (or injections) are permitted in a 30-day period. 50mg Tablet APO-SUMATRIPTAN APX CO SUMATRIPTAN COB DOM-SUMATRIPTAN DPC IMITREX DF GSK MYLAN-SUMATRIPTAN MYL NOVO-SUMATRIPTAN DF TEV PMS-SUMATRIPTAN PMS SANDOZ-SUMATRIPTAN SDZ SUMATRIPTAN SAN SUMATRIPTAN PDL SUMATRIPTAN DF SIV 100mg Tablet APO-SUMATRIPTAN APX CO SUMATRIPTAN COB DOM-SUMATRIPTAN DPC IMITREX DF GSK MYLAN-SUMATRIPTAN MYL NOVO-SUMATRIPTAN TEV NOVO-SUMATRIPTAN DF TEV PMS-SUMATRIPTAN PMS SANDOZ-SUMATRIPTAN SDZ SUMATRIPTAN SAN SUMATRIPTAN PDL SUMATRIPTAN DF SIV ZOLMITRIPTAN Limited use benefit (prior approval is not required). A total of 12 tablets (or injections) are permitted in a 30-day period. 2.5mg Orally Disintegrating Tablet APO-ZOLMITRIPTAN RAPID APX JAMP-ZOLMITRIPTAN ODT JAP MINT-ZOLMITRIPTAN ODT MIN MYLAN-ZOLMITRIPTAN ODT MYL PMS-ZOLMITRIPTAN ODT PMS SANDOZ ZOLMITRIPTAN ODT SDZ SEPTA-ZOLMITRIPTAN-ODT SPT TEVA-ZOLMITRIPTAN OD TEP ZOLMITRIPTAN ODT PDL ZOMIG RAPIMELT AZC 2.5mg Tablet APO-ZOLMITRIPTAN APX DOM-ZOLMITRIPTAN DOM JAMP-ZOLMITRIPTAN JAP MAR-ZOLMITRIPTAN MAR MINT-ZOLMITRIPTAN MIN MYLAN ZOLMITRIPTAN MYL PMS-ZOLMITRIPTAN PMS RIVA-ZOLMITRIPTAN RIV SANDOZ ZOLMITRIPTAN SDZ TEVA-ZOLMITRIPTAN TEP ZOLMITRIPTAN PDL ZOMIG AZC Page A-47 de 81

216 Appendix A - Limited Use Benefits and Criteria 28:36.20 ANTIPARKINSONIAN AGENTS - DOPAMINE RECEPTOR AGONIS CABERGOLINE For treatment of hyperprolactinemia in patients who have failed therapy with or are intolerant to bromocriptine. 0.5mg Tablet CO CABERGOLINE COB DOINEX PFI 28:92.00 MISCELLANEOUS CENTRAL NERVOUS SYEM AGENTS ACAMPROSATE CALCIUM For patients who have been abstinent from alcohol for at least four days and where available, are currently enrolled in an alcohol addiction treatment program 333mg Sustained Release Tablet CAMPRAL MYL 32:00 CONTRACEPTIVES (NON-ORAL) 32:00.00 CONTRACEPTIVES (NON-ORAL) INTRAUTERINE DEVICE Limited use benefit with quantity and frequency limits (prior approval is not required). Coverage is granted for 1 device every 12 months. Device FLEXI-T IUD PRN LIBERTE UT380 SHORT MSC LIBERTE UT380 ANDARD MSC MONA LISA 10 PAE MONA LISA 5 PAE MONA LISA N PAE NOVA-T IUD BEX 36:00 DIAGNOIC AGENTS (DX) 36:26.00 DX - DIABETES MELLITUS GLUCOSE OXIDASE, PEROXIDASE Limited use benefit (prior approval not required). The number of test strips that will be covered by the NIHB Program will depend on the client's medical treatment: Clients managing diabetes with insulin will be allowed 500 test strips per 100 days. A client can test up to five times per day. Clients managing diabetes with diabetes medication with a high risk of causing low blood sugar will be allowed 400 test strips per 365 days. A client can test once daily. Clients managing diabetes with diabetes medication with a low risk of causing low blood sugar will be allowed 200 test strips per 365 days. A client can test three to four times per week. Clients managing diabetes with diet/lifestyle therapy only (no insulin or diabetes medications) will be allowed 200 test strips per 365 days. A client can test three to four times per week. Accu-Chek Advantage Strip ACCU-CHEK ADVANTAGE ROC * ACCU-CHEK ADVANTAGE (ON) ROC * Accu-Chek Aviva Strip ACCU-CHEK AVIVA ROD * ACCU-CHEK AVIVA (ON) ROC * Accu-Chek Compact Strip ACCU-CHEK COMPACT ROD * ACCU-CHEK COMPACT (ON) ROD * Accu-Chek Mobile Strip ACCU-CHEK MOBILE ROC * ACCU-CHEK MOBILE (ON) ROC * Page A-48 de 81

217 Appendix A - Limited Use Benefits and Criteria 36:26.00 DX - DIABETES MELLITUS GLUCOSE OXIDASE, PEROXIDASE Limited use benefit (prior approval not required). The number of test strips that will be covered by the NIHB Program will depend on the client's medical treatment: Clients managing diabetes with insulin will be allowed 500 test strips per 100 days. A client can test up to five times per day. Clients managing diabetes with diabetes medication with a high risk of causing low blood sugar will be allowed 400 test strips per 365 days. A client can test once daily. Clients managing diabetes with diabetes medication with a low risk of causing low blood sugar will be allowed 200 test strips per 365 days. A client can test three to four times per week. Clients managing diabetes with diet/lifestyle therapy only (no insulin or diabetes medications) will be allowed 200 test strips per 365 days. A client can test three to four times per week. Accutrend Strip ACCUTREND ROC ACCUTREND (ON) ROD Ascensia Breeze 2 Strip ASCENSIA BREEZE 2 BAY ASCENSIA BREEZE 2 (ON) BAY Ascensia Contour Strip ASCENSIA CONTOUR BAY ASCENSIA CONTOUR (ON) BAY * BG Star Strip BG AR SAC BG AR (ON) SAC * Contour Next Strip CONTOUR NEXT BAY CONTOUR NEXT (ON) BAY EZ Health Strip EZ HEALTH ORACLE TRE EZ HEALTH ORACLE (ON) TRE Freestyle Strip FREEYLE ABB FREEYLE (ON) ABB Freestyle Lite Strip FREEYLE LITE ABB FREEYLE LITE (ON) ABB Freestyle Precision Strip FREEYLE PRECISION ABB FREEYLE PRECISION (ON) ABB Itest Strip ITE AUC ITE (ON) AUC Medi+Sure Strip MEDI+SURE MSD MEDI+SURE (ON) MSD One Touch Ultra Strip ONE TOUCH ULTRA JAJ ONE TOUCH ULTRA (ON) JAJ * One Touch Verio Strip ONE TOUCH VERIO JAJ ONE TOUCH VERIO (ON) JAJ Precision Xtra Strip PRECISION XTRA ABB PRECISION XTRA (ON) ABB Page A-49 de 81

218 Appendix A - Limited Use Benefits and Criteria 36:26.00 DX - DIABETES MELLITUS GLUCOSE OXIDASE, PEROXIDASE Limited use benefit (prior approval not required). The number of test strips that will be covered by the NIHB Program will depend on the client's medical treatment: Clients managing diabetes with insulin will be allowed 500 test strips per 100 days. A client can test up to five times per day. Clients managing diabetes with diabetes medication with a high risk of causing low blood sugar will be allowed 400 test strips per 365 days. A client can test once daily. Clients managing diabetes with diabetes medication with a low risk of causing low blood sugar will be allowed 200 test strips per 365 days. A client can test three to four times per week. Clients managing diabetes with diet/lifestyle therapy only (no insulin or diabetes medications) will be allowed 200 test strips per 365 days. A client can test three to four times per week. Sidekick Strip SIDEKICK HOD TrueTest Strip TRUETE HOD Truetrack Strip TRUETRACK HOD TRUETRACK (ON) AUC 40:00 ELECTROLYTIC, CALORIC, AND WATER BALANCE 40:20.00 CALORIC AGENTS LEVOCARNITINE For treatment of carnitine deficiency 100mg/mL Oral Liquid CARNITOR SIG 200mg/mL Solution CARNITOR IV SIG 330mg Tablet CARNITOR SIG 48:00 RESPIRATORY TRACT AGENTS 48:10.24 LEUKOTRIENE MODIFIERS MONTELUKA For treatment of: a. - asthma when used in patients on concurrent steroid therapy. b. - asthma patients not well controlled with or intolerant to inhaled corticosteroids. 4mg Chewable Tablet ACH-MONTELUKA ACC APO-MONTELUKA APX MONTELUKA SIV MYLAN-MONTELUKA MYL PMS-MONTELUKA PMS SANDOZ MONTELUKA TEP SINGULAIR FRS TEVA- MONTELUKA TEP Page A-50 de 81

219 Appendix A - Limited Use Benefits and Criteria 48:10.24 LEUKOTRIENE MODIFIERS MONTELUKA For treatment of: a. - asthma when used in patients on concurrent steroid therapy. b. - asthma patients not well controlled with or intolerant to inhaled corticosteroids. 5mg Chewable Tablet ACH-MONTELUKA ACC APO-MONTELUKA APX MONTELUKA SAN MONTELUKA SIV MYLAN-MONTELUKA MYL PMS-MONTELUKA PMS SANDOZ MONTELUKA TEP SINGULAIR FRS TEVA- MONTELUKA TEP 4mg Granules SANDOZ MONTELUKA SDZ SINGULAIR FRS 4mg Tablet MAR-MONTELUKA MAR MINT-MONTELUKA MIN MONTELUKA SAN MONTELUKA PDL RAN-MONTELUKA RBY 5mg Tablet MAR-MONTELUKA MAR MINT-MONTELUKA MIN MONTELUKA PDL RAN-MONTELUKA RBY 10mg Tablet APO-MONTELUKA APX AURO-MONTELUKA AUR DOM-MONTELUKA DOM JAMP-MONTELUKA JAP MAR-MONTELUKA MAR MINT-MONTELUKA MIN MONTELUKA ACC MONTELUKA SAN MONTELUKA PDL MONTELUKA SIV MYLAN-MONTELUKA MYL PMS-MONTELUKA PMS RAN-MONTELUKA RBY RIVA-MOTELUKA RIV SANDOZ MONTELUKA SDZ SINGULAIR FRS TEVA- MONTELUKA TEP ZAFIRLUKA For treatment of: a. - asthma when used in patients on concurrent steroid therapy. b. - asthma patients not well controlled with or intolerant to inhaled corticosteroids. 20mg Tablet ACCOLATE AZC Page A-51 de 81

220 Appendix A - Limited Use Benefits and Criteria 52:00 EYE, EAR, NOSE AND THROAT (EENT) PREPARATIONS 52:28.00 EENT - MOUTHWASHES AND GARGLES BENZYDAMINE HCL For: a. - treatment of radiation mucositis and oral ulcerative complications of chemotherapy. b. - use in immunocompromised patients who are at risk of mucosal breakdown. 0.15% Rinse APO-BENZYDAMINE APX DOM-BENZYDAMINE DPC PMS-BENZYDAMINE PMS TEVA-BENZYDAMINE TEV 52:40.04 EENT - ALPHA-ADRENERGIC AGONIS BRIMONIDINE TARTRATE (ALPHAGAN P) For patients who are intolerant to brimonidine tartrate 0.2% or benzalkonium chloride. 0.15% Ophth Solution ALPHAGAN P ALL APO-BRIMONIDINE P APX 52:92.00 MISCELLANEOUS EENT DRUGS VERTEPORFIN For treatment of age related macular degeneration for patients with this diagnosis who are being treated by a certified ophthalmologist. 15mg/Vial Injection VISUDYNE QLT 56:00 GAROINTEINAL DRUGS 56:22.92 MISCELLANEOUS ANTIEMETICS APREPITANT When used in combination with a 5-HT3 antagonist and dexamethasone for the prevention of acute and delayed nausea and vomiting due to highly emetogenic cancer chemotherapy (eg. Cisplatin > 70mg/m2) in patients who have experienced emesis despite treatment with a combination of a 5-HT3 antagonist and dexamethasone in a previous cycle of highly emetogenic chemotherapy. 80mg Capsule EMEND FRS 125mg Capsule EMEND FRS 125mg & 80mg Capsule EMEND TRI PACK FRS NABILONE For patients who are experiencing nausea and vomiting due to cancer chemotherapy or radiation; OR patient is palliative (diagnosed with a terminal illness or disease which is expected to be the primary cause of death within six months or less 0.25mg Capsule CESAMET VAE RAN-NABILONE RBY TEVA-NABILONE TEP Page A-52 de 81

221 Appendix A - Limited Use Benefits and Criteria 56:22.92 MISCELLANEOUS ANTIEMETICS NABILONE For patients who are experiencing nausea and vomiting due to cancer chemotherapy or radiation; OR patient is palliative (diagnosed with a terminal illness or disease which is expected to be the primary cause of death within six months or less 0.5mg Capsule ACT-NABILONE ATP CESAMET VAE PMS-NABILONE PMS RAN-NABILONE RBY TEVA-NABILONE TEP 1mg Capsule ACT-NABILONE ATP CESAMET VAE PMS-NABILONE PMS RAN-NABILONE RBY TEVA-NABILONE TEP 56:28.36 PROTON-PUMP INHIBITORS LANSOPRAZOLE Limited use benefit (prior approval not required). The following PPI status change is primarily based on the Canadian Optimal Medication Prescribing and Utilization Service (COMPUS) report on optimal PPI therapy. The report concluded that; All PPIs are equally efficacious Double dose PPI is not necessary for initial therapy Double dose PPI is effective in H. Pylori eradication; however, treatment is not needed beyond 14 days. PPI use has been associated with increased risk of hip fracture, community-acquired pneumonia and Clostridium difficile associated diarrhea. Although further study is needed to establish clinical significance, it is prudent to use the lowest dose and shortest duration of therapy required to control symptoms. All proton pump inhibitors (open benefit and limited use (LU) PPIs) have a maximum quantity limit of 400 tablets/capsules per 180 day period. This quantity limit will be in effect for the entire class of PPIs. For example, if a patient fills 30 tablets of rabeprazole, then switch to 30 tablets of omeprazole, then switch to 30 capsules of lansoprazole, this will count as 90 PPI tablets/capsules towards the quantity limit. Patients taking two rabeprazole 10mg tablets a day can be switched to one rabeprazole 20mg tablet a day to avoid reaching the quantity limit Patients taking two omeprazole 10mg tablets/capsules a day can be switched to one omeprazole 20mg tablet/capsule a day to avoid reaching the quantity limit Patients with Zollinger Ellison Syndrome, Barrett s esophagus, erosive esophagitis and those who remain symptomatic on a single dose PPI will be eligible for additional doses above 400 tablets/capsules per 180 days through the prior approval process. Coverage will be limited to 400 tablets/capsules every 180 days. 15mg Sustained Release Capsule LANSOPRAZOLE SIV LANSOPRAZOLE PMS LANSOPRAZOLE-15 SIV PMS-LANSOPRAZOLE PMS RAN-LANSOPRAZOLE RBY RIVA-LANSOPRAZOLE RIV SANDOZ LANSOPRAZOLE SDZ 30mg Sustained Release Capsule DOM-LANSOPRAZOLE DOM LANSOPRAZOLE PDL LANSOPRAZOLE SIV LANSOPRAZOLE-30 SIV PMS-LANSOPRAZOLE PMS RAN-LANSOPRAZOLE RBY RIVA-LANSOPRAZOLE RIV SANDOZ LANSOPRAZOLE SDZ Page A-53 de 81

222 Appendix A - Limited Use Benefits and Criteria 56:28.36 PROTON-PUMP INHIBITORS LANSOPRAZOLE Limited use benefit (prior approval not required). The following PPI status change is primarily based on the Canadian Optimal Medication Prescribing and Utilization Service (COMPUS) report on optimal PPI therapy. The report concluded that; All PPIs are equally efficacious Double dose PPI is not necessary for initial therapy Double dose PPI is effective in H. Pylori eradication; however, treatment is not needed beyond 14 days. PPI use has been associated with increased risk of hip fracture, community-acquired pneumonia and Clostridium difficile associated diarrhea. Although further study is needed to establish clinical significance, it is prudent to use the lowest dose and shortest duration of therapy required to control symptoms. All proton pump inhibitors (open benefit and limited use (LU) PPIs) have a maximum quantity limit of 400 tablets/capsules per 180 day period. This quantity limit will be in effect for the entire class of PPIs. For example, if a patient fills 30 tablets of rabeprazole, then switch to 30 tablets of omeprazole, then switch to 30 capsules of lansoprazole, this will count as 90 PPI tablets/capsules towards the quantity limit. Patients taking two rabeprazole 10mg tablets a day can be switched to one rabeprazole 20mg tablet a day to avoid reaching the quantity limit Patients taking two omeprazole 10mg tablets/capsules a day can be switched to one omeprazole 20mg tablet/capsule a day to avoid reaching the quantity limit Patients with Zollinger Ellison Syndrome, Barrett s esophagus, erosive esophagitis and those who remain symptomatic on a single dose PPI will be eligible for additional doses above 400 tablets/capsules per 180 days through the prior approval process. Coverage will be limited to 400 tablets/capsules every 180 days. 15mg Sustained Release Capsule APO-LANSOPRAZOLE APX LANSOPRAZOLE SAN MYLAN-LANSOPRAZOLE MYL NOVO-LANSOPRAZOLE TEV PREVACID ABB 30mg Sustained Release Capsule APO-LANSOPRAZOLE APX LANSOPRAZOLE SAN MYLAN-LANSOPRAZOLE MYL NOVO-LANSOPRAZOLE TEV PREVACID ABB LANSOPRAZOLE ODT The following PPI status change is primarily based on the Canadian Optimal Medication Prescribing and Utilization Service (COMPUS) report on optimal PPI therapy. The report concluded that; All PPIs are equally efficacious Double dose PPI is not necessary for initial therapy Double dose PPI is effective in H. Pylori eradication; however, treatment is not needed beyond 14 days. PPI use has been associated with increased risk of hip fracture, community-acquired pneumonia and Clostridium difficile associated diarrhea. Although further study is needed to establish clinical significance, it is prudent to use the lowest dose and shortest duration of therapy required to control symptoms. All proton pump inhibitors (open benefit and limited use (LU) PPIs) have a maximum quantity limit of 400 tablets/capsules per 180 day period. This quantity limit will be in effect for the entire class of PPIs. For example, if a patient fills 30 tablets of rabeprazole, then switch to 30 tablets of omeprazole, then switch to 30 capsules of lansoprazole, this will count as 90 PPI tablets/capsules towards the quantity limit. Patients taking two rabeprazole 10mg tablets a day can be switched to one rabeprazole 20mg tablet a day to avoid reaching the quantity limit Patients taking two omeprazole 10mg tablets/capsules a day can be switched to one omeprazole 20mg tablet/capsule a day to avoid reaching the quantity limit Patients with Zollinger Ellison Syndrome, Barrett s esophagus, erosive esophagitis and those who remain symptomatic on a single dose PPI will be eligible for additional doses above 400 tablets/capsules per 180 days through the prior approval process. Limited use benefit (prior approval not required). Coverage will be limited to 400 tablets/capsules every 180 days. 15MG Orally Disintegrating Tablet PREVACID FAAB TAK 30MG Orally Disintegrating Tablet PREVACID FAAB TAK Page A-54 de 81

223 Appendix A - Limited Use Benefits and Criteria 56:28.36 PROTON-PUMP INHIBITORS OMEPRAZOLE The following PPI status change is primarily based on the Canadian Optimal Medication Prescribing and Utilization Service (COMPUS) report on optimal PPI therapy. The report concluded that; All PPIs are equally efficacious Double dose PPI is not necessary for initial therapy Double dose PPI is effective in H. Pylori eradication; however, treatment is not needed beyond 14 days. PPI use has been associated with increased risk of hip fracture, community-acquired pneumonia and Clostridium difficile associated diarrhea. Although further study is needed to establish clinical significance, it is prudent to use the lowest dose and shortest duration of therapy required to control symptoms. All proton pump inhibitors (open benefit and limited use (LU) PPIs) have a maximum quantity limit of 400 tablets/capsules per 180 day period. This quantity limit will be in effect for the entire class of PPIs. For example, if a patient fills 30 tablets of rabeprazole, then switch to 30 tablets of omeprazole, then switch to 30 capsules of lansoprazole, this will count as 90 PPI tablets/capsules towards the quantity limit. Patients taking two rabeprazole 10mg tablets a day can be switched to one rabeprazole 20mg tablet a day to avoid reaching the quantity limit Patients taking two omeprazole 10mg tablets/capsules a day can be switched to one omeprazole 20mg tablet/capsule a day to avoid reaching the quantity limit Patients with Zollinger Ellison Syndrome, Barrett s esophagus, erosive esophagitis and those who remain symptomatic on a single dose PPI will be eligible for additional doses above 400 tablets/capsules per 180 days through the prior approval process. Limited use benefit (prior approval not required). Coverage will be limited to 400 tablets/capsules every 180 days. 20mg Capsule APO-OMEPRAZOLE APX LOSEC AZC MYLAN-OMEPRAZOLE MYL OMEPRAZOLE PDL OMEPRAZOLE SAN OMEPRAZOLE SIV OMEPRAZOLE-20 SIV PMS-OMEPRAZOLE PMS RAN-OMEPRAZOLE RBY SANDOZ OMEPRAZOLE SDZ 20mg Delayed Release Tablet LOSEC AZC OMEPRAZOLE MAGNESIUM DR ACC PMS-OMEPRAZOLE PMS RAN-OMEPRAZOLE RBY RATIO-OMEPRAZOLE RPH TEVA-OMEPRAZOLE TEP 20mg Tablet DOM-OMEPRAZOLE DR DOM JAMP-OMEPRAZOLE DR JAP RIVA-OMEPRAZOLE DR RIV PANTOPRAZOLE MAGNESIUM 40mg Enteric Coated Tablet TECTA NCC Page A-55 de 81

224 Appendix A - Limited Use Benefits and Criteria 56:28.36 PROTON-PUMP INHIBITORS PANTOPRAZOLE SODIUM The following PPI status change is primarily based on the Canadian Optimal Medication Prescribing and Utilization Service (COMPUS) report on optimal PPI therapy. The report concluded that; All PPIs are equally efficacious Double dose PPI is not necessary for initial therapy Double dose PPI is effective in H. Pylori eradication; however, treatment is not needed beyond 14 days. PPI use has been associated with increased risk of hip fracture, community-acquired pneumonia and Clostridium difficile associated diarrhea. Although further study is needed to establish clinical significance, it is prudent to use the lowest dose and shortest duration of therapy required to control symptoms. All proton pump inhibitors (open benefit and limited use (LU) PPIs) have a maximum quantity limit of 400 tablets/capsules per 180 day period. This quantity limit will be in effect for the entire class of PPIs. For example, if a patient fills 30 tablets of rabeprazole, then switch to 30 tablets of omeprazole, then switch to 30 capsules of lansoprazole, this will count as 90 PPI tablets/capsules towards the quantity limit. Patients taking two rabeprazole 10mg tablets a day can be switched to one rabeprazole 20mg tablet a day to avoid reaching the quantity limit Patients taking two omeprazole 10mg tablets/capsules a day can be switched to one omeprazole 20mg tablet/capsule a day to avoid reaching the quantity limit Patients with Zollinger Ellison Syndrome, Barrett s esophagus, erosive esophagitis and those who remain symptomatic on a single dose PPI will be eligible for additional doses above 400 tablets/capsules per 180 days through the prior approval process. Limited use benefit (prior approval not required). Coverage will be limited to 400 tablets/capsules every 180 days. 40mg Delayed Release Tablet ABBOTT-PANTOPRAZOLE ABB APO-PANTOPRAZOLE APX CO PANTOPRAZOLE COB DOM-PANTOPRAZOLE DOM JAMP-PANTOPRAZOLE JAP MAR-PANTOPRAZOLE MAR MINT-PANTOPRAZOLE MIN MYLAN-PANTOPRAZOLE MYL NOVO-PANTOPRAZOLE TEV PANTOLOC NYC PANTOPRAZOLE MEL PANTOPRAZOLE SOR PANTOPRAZOLE PDL PANTOPRAZOLE SAN PANTOPRAZOLE SIV PANTOPRAZOLE RIV PANTOPRAZOLE-40 SIV PMS-PANTOPRAZOLE PMS PRIVA-PANTOPRAZOLE PHA RAN-PANTOPRAZOLE RBY RIVA-PANTOPRAZOLE RIV SANDOZ-PANTOPRAZOLE SDZ Page A-56 de 81

225 Appendix A - Limited Use Benefits and Criteria 56:28.36 PROTON-PUMP INHIBITORS RABEPRAZOLE SODIUM The following PPI status change is primarily based on the Canadian Optimal Medication Prescribing and Utilization Service (COMPUS) report on optimal PPI therapy. The report concluded that; All PPIs are equally efficacious Double dose PPI is not necessary for initial therapy Double dose PPI is effective in H. Pylori eradication; however, treatment is not needed beyond 14 days. PPI use has been associated with increased risk of hip fracture, community-acquired pneumonia and Clostridium difficile associated diarrhea. Although further study is needed to establish clinical significance, it is prudent to use the lowest dose and shortest duration of therapy required to control symptoms. All proton pump inhibitors (open benefit and limited use (LU) PPIs) have a maximum quantity limit of 400 tablets/capsules per 180 day period. This quantity limit will be in effect for the entire class of PPIs. For example, if a patient fills 30 tablets of rabeprazole, then switch to 30 tablets of omeprazole, then switch to 30 capsules of lansoprazole, this will count as 90 PPI tablets/capsules towards the quantity limit. Patients taking two rabeprazole 10mg tablets a day can be switched to one rabeprazole 20mg tablet a day to avoid reaching the quantity limit Patients taking two omeprazole 10mg tablets/capsules a day can be switched to one omeprazole 20mg tablet/capsule a day to avoid reaching the quantity limit Patients with Zollinger Ellison Syndrome, Barrett s esophagus, erosive esophagitis and those who remain symptomatic on a single dose PPI will be eligible for additional doses above 400 tablets/capsules per 180 days through the prior approval process. Limited use benefit (prior approval not required). Coverage will be limited to 400 tablets/capsules every 180 days. 10mg Enteric Coated Tablet ABBOTT-RABEPRAZOLE BGP APO-RABEPRAZOLE APX MYLAN-RABEPRAZOLE MYL NOVO-RABEPRAZOLE TEV PARIET EC JNO PMS-RABEPRAZOLE PMS PRO-RABEPRAZOLE PDL RABEPRAZOLE SIV RABEPRAZOLE EC SAN RAN-RABEPRAZOLE RBY RIVA-RABEPRAZOLE EC RIV SANDOZ-RABEPRAZOLE SDZ 20mg Enteric Coated Tablet ABBOTT-RABEPRAZOLE BGP APO-RABEPRAZOLE APX DOM-RABEPRAZOLE EC DOM MYLAN-RABEPRAZOLE MYL NOVO-RABEPRAZOLE TEV PARIET EC JNO PMS-RABEPRAZOLE PMS PRO-RABEPRAZOLE PDL RABEPRAZOLE SIV RABEPRAZOLE EC SAN RAN-RABEPRAZOLE RBY RIVA-RABEPRAZOLE RIV SANDOZ-RABEPRAZOLE SDZ 68:00 HORMONES AND SYNTHETIC SUBITUTES 68:12.00 CONTRACEPTIVES LEVONORGEREL INTRAUTERINE INSERT Limited use benefit with quantity and frequency limits (prior approval is not required). Coverage is granted for 1 device every 2 years. 13.5mg Intrauterine Insert JAYDESS BAY 52mg Intrauterine Insert MIRENA BAY Page A-57 de 81

226 Appendix A - Limited Use Benefits and Criteria 68:16.12 EROGEN AGONIS-ANTAGONIS RALOXIFENE HCL For: a.- secondary prevention of osteoporosis in women who experience failure on bisphosphonates. b. - secondary prevention of osteoporosis in women who have a personal history or a first degree relative with a history of breast cancer. 60mg Tablet ACT RALOXIFENE ATP APO-RALOXIFENE APX EVIA LIL NOVO-RALOXIFENE TEV PMS-RALOXIFENE PMS RALOXIFENE PDL 68:20.04 BIGUANIDES SITAGLIPTIN, METFORMIN For the treatment of patients with type 2 diabetes mellitus who: did not achieve glycemic control or who demonstrated intolerance to an adequate trial of metformin AND a sulfonylurea. 50mg & 1000mg Tablet JANUMET FRS 50mg & 500mg Tablet JANUMET FRS 50mg & 850mg Tablet JANUMET FRS 68:20.05 LINAGLIPTIN For the treatment of patients with type 2 diabetes mellitus who: did not achieve glycemic control or who demonstrated intolerance to an adequate trial of metformin AND a sulfonylurea. 5mg Tablet TRAJENTA BOE LINAGLIPTIN, METFORMIN For the treatment of patients with type 2 diabetes mellitus who: did not achieve glycemic control or who demonstrated intolerance to an adequate trial of metformin AND a sulfonylurea. 2.5mg & 1000mg Tablet JENTADUETO BOE 2.5mg & 500mg Tablet JENTADUETO BOE 2.5mg & 850mg Tablet JENTADUETO BOE SAXAGLIPTIN HCL For the treatment of patients with type 2 diabetes mellitus who: did not achieve glycemic control or who demonstrated intolerance to an adequate trial of metformin AND a sulfonylurea. 2.5mg Tablet ONGLYZA AZE 5mg Tablet ONGLYZA AZE Page A-58 de 81

227 Appendix A - Limited Use Benefits and Criteria 68:20.05 SAXAGLIPTIN, METFORMIN - For the treatment of patients with type 2 diabetes mellitus who: did not achieve glycemic control or who demonstrated intolerance to an adequate trial of metformin AND a sulfonylurea. 2.5mg & 1000mg Tablet KOMBOGLYZE AZE 2.5mg & 500mg Tablet KOMBOGLYZE AZE 2.5mg & 850mg Tablet KOMBOGLYZE AZE SITAGLIPTIN For the treatment of patients with type 2 diabetes mellitus who: did not achieve glycemic control or who demonstrated intolerance to an adequate trial of metformin AND a sulfonylurea. 25mg Tablet JANUVIA MSP 50mg Tablet JANUVIA MSP 100mg Tablet JANUVIA FRS SITAGLIPTIN, METFORMIN For the treatment of patients with type 2 diabetes mellitus who: did not achieve glycemic control or who demonstrated intolerance to an adequate trial of metformin AND a sulfonylurea. 50mg & 1000mg Extended Release Tablet JANUMET XR FRS 68:20.28 THIAZOLIDINEDIONES PIOGLITAZONE HCL For treatment of type 2 diabetic patients who are not adequately controlled by or are intolerant to metformin and sulfonylureas or for whom these products are contraindicated. 15mg Tablet ACCEL PIOGLITAZONE ACP ACH-PIOGLITAZONE ACC ACTOS LIL APO-PIOGLITAZONE APX CO PIOGLITAZONE COB DOM-PIOGLITAZONE DOM JAMP-PIOGLITAZONE JAP MINT-PIOGLITAZONE MIN MYLAN-PIOGLITAZONE MYL NOVO-PIOGLITAZONE TEV PHL-PIOGLITAZONE PMI PIOGLITAZONE SIV PMS-PIOGLITAZONE PMS PRO-PIOGLITAZONE PDL RAN-PIOGLITAZONE RBY RATIO-PIOGLITAZONE RPH SANDOZ PIOGLITAZONE SDZ ZYM-PIOGLITAZONE ZYM Page A-59 de 81

228 Appendix A - Limited Use Benefits and Criteria 68:20.28 THIAZOLIDINEDIONES PIOGLITAZONE HCL For treatment of type 2 diabetic patients who are not adequately controlled by or are intolerant to metformin and sulfonylureas or for whom these products are contraindicated. 30mg Tablet ACCEL PIOGLITAZONE ACP ACH-PIOGLITAZONE ACC ACTOS LIL APO-PIOGLITAZONE APX CO PIOGLITAZONE COB DOM-PIOGLITAZONE DOM JAMP-PIOGLITAZONE JAP MINT-PIOGLITAZONE MIN MYLAN-PIOGLITAZONE MYL NOVO-PIOGLITAZONE TEV PHL-PIOGLITAZONE PMI PIOGLITAZONE SIV PMS-PIOGLITAZONE PMS PRO-PIOGLITAZONE PDL RAN-PIOGLITAZONE RBY RATIO-PIOGLITAZONE RPH SANDOZ PIOGLITAZONE SDZ ZYM-PIOGLITAZONE ZYM 45mg Tablet ACCEL PIOGLITAZONE ACP ACTOS LIL APO-PIOGLITAZONE APX CO PIOGLITAZONE COB DOM-PIOGLITAZONE DOM JAMP-PIOGLITAZONE JAP MINT-PIOGLITAZONE MIN MYLAN-PIOGLITAZONE MYL NOVO-PIOGLITAZONE TEV PHL-PIOGLITAZONE PMI PIOGLITAZONE ACC PIOGLITAZONE SIV PMS-PIOGLITAZONE PMS PRO-PIOGLITAZONE PDL RAN-PIOGLITAZONE RBY RATIO-PIOGLITAZONE RPH SANDOZ PIOGLITAZONE SDZ ZYM-PIOGLITAZONE ZYM ROSIGLITAZONE MALEATE For treatment of type 2 diabetic patients who are not adequately controlled by or are intolerant to metformin and sulfonylureas or for whom these products are contraindicated. 2mg Tablet AVANDIA GSK 4mg Tablet AVANDIA GSK 8mg Tablet AVANDIA GSK Page A-60 de 81

229 Appendix A - Limited Use Benefits and Criteria 68:32.00 PROGEINS DIENOGE a.- For the management of pelvic pain associated with endometriosis 2mg Tablet VISANNE BAY PROGEERONE For the treatment of women: With postmenopausal symptoms who are intolerant to medroxyprogesterone acetate (MPA); OR Who are at risk of preterm birth; OR Who are using the medication to prevent miscarriage. 100mg Capsule PROMETRIUM FRS 84:00 SKIN AND MUCOUS MEMBRANE AGENTS (SMMA) 84:92.00 MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS ACITRETIN Open benefit (prior approval not required). Soriatane should be used with caution in women of childbearing potential due to its teratogenicity. Pregnancy must be excluded. Effective contraception must be used. Manufacturer's literature regarding contraindications and warnings, should be consulted prior to prescribing or dispensing this drug. 10mg Capsule SORIATANE ACG 25mg Capsule SORIATANE ACG IMIQUIMOD -For the treatment of condylomata acuminate (genital warts) in patients who have failed: -self-applied podophyllotoxin (podofilox 0.5% solution); OR -provider-applied podophyllum resin (10%-25%) 5% Cream ALDARA P VAE APO-IMIQUIMOD APX ISOTRETINOIN Open benefit (prior approval not required). Accutane should be used with caution in women of childbearing potential due to its teratogenicity. Pregnancy must be excluded. Effective contraception must be used. Manufacturer's literature regarding contraindications and warnings should be consulted prior to prescribing or dispensing this drug. 10mg Capsule ACCUTANE HLR CLARUS MYL 40mg Capsule ACCUTANE HLR CLARUS MYL PIMECROLIMUS For patients who have failed topical corticosteroid therapy or have experienced side effects from such treatment. Note: Contraindicated in children less than 2 years of age. 1% Cream ELIDEL NVC Page A-61 de 81

230 Appendix A - Limited Use Benefits and Criteria 84:92.00 MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS TACROLIMUS (PROTOPIC) For patients who have failed topical corticosteroid therapy or have experienced side effects from such treatment. Note: Contraindicated in children less than 2 years of age. 0.03% Ointment PROTOPIC A 0.1% Ointment PROTOPIC A 86:00 SMOOTH MUSCLE RELAXANTS 86:12.00 GENITOURINARY SMOOTH MUSCLE RELAXANTS DARIFENACIN HYDROBROMIDE For the symptomatic relief of overactive bladder in patients: with symptoms of urinary frequency, urgency or urge incontinence; AND who have failed on or are intolerant to therapy with immediate-release oxybutynin 7.5mg Long Acting Tablet ENABLEX TEV 15mg Long Acting Tablet ENABLEX TEV SOLIFENACIN SUCCINATE For symptomatic relief in patients with an overactive bladder with symptoms of urinary frequency urgency or urge incontinence in patients who have failed on or are intolerant of therapy with oxybutynin. 5mg Tablet VESICARE A 10mg Tablet VESICARE A TOLTERODINE For the symptomatic relief of patients with an overactive bladder with symptoms of urinary frequency urgency or urge incontinence or any combination of these in patients who have failed on or are intolerant of therapy with oxybutynin. 2mg Extended Release Capsule DETROL LA PFI 4mg Extended Release Capsule DETROL LA PFI 1mg Tablet DETROL PFI 2mg Tablet DETROL PFI TROSPIUM CHLORIDE For the symptomatic relief of patients with an overactive bladder with symptoms of urinary frequency, urgency or urge incontinence or any combination of these in patients who have failed on or are intolerant of therapy with oxybutynin. 20mg Tablet TROSEC ORY Page A-62 de 81

231 Appendix A - Limited Use Benefits and Criteria 88:00 VITAMINS 88:20.00 VITAMIN E VITAMIN E For use in malabsorption 200IU Capsule VITAMIN E JAM 400IU Capsule VITAMIN E NATUAL SOURCE JAM 50IU Liquid AQUASOL E NVC 50IU/mL Liquid AQUASOL E NVC 88:28.00 MULTIVITAMIN PREPARATIONS MULTIVITAMINS (PEDIATRIC) Limited use benefit (prior approval is not required). Pediatric multivitamins are benefits for children up to 6 years of age. Drop POLY-VI-SOL MJO 2,500IU & IU & 50mg/mL Drop PEDIAVIT EUR TR- VI-SOL MJO Liquid INFANTOL HOR Oral Liquid JAMP-MULTIVITAMIN A/D/C DROPS JMP Tablet CENTRUM JUNIOR COMPLETE WYE CENTRUM JUNIOR COMPLETE PFI FLINTONES EXTRA C BCD MULTIVITAMINS (PRENATAL) Limited use benefit (prior approval is not required.). Prenatal and postnatal vitamins are benefits only for women of childbearing age (12 to 50 years). Tablet CENTRUM MATERNA NES MULTI-PRE AND PO NATAL PED PRENATAL & POPARTUM PMT PRENATAL AND POPARTUM SDR 92:00 UNCLASSIFIED THERAPEUTIC AGENTS 92:00.00 UNCLASSIFIED THERAPEUTIC AGENTS INCOBOTULINUMTOXINA For the treatment of: strabismus and blepharospasm associated with dystonia, including benign essential blepharospasm or VII nerve disorder in patients 12 years of age or older; OR cervical dystonia (spasmodic torticollis); OR urinary incontinence due to neurogenic detrusor overactivity resulting from neurogenic bladder associated with MS or subcervical spinal cord injury. 50Unit/Vial Injection XEOMIN MEZ Page A-63 de 81

232 Appendix A - Limited Use Benefits and Criteria 92:00.00 UNCLASSIFIED THERAPEUTIC AGENTS UEKINUMAB For the treatment of moderate to severe psoriasis in patients who meet the following criteria: a. - Body surface area involvement greater than 10% and/or significant involvement of the face, hands, feet or genital region and b. - Intolerance or lack of response to methotrexate and cyclosporine or c. - A contraindication to methotrexate and/or cyclosporine and d. - Intolerance or lack of response to phototherapy or e. - Inability to access phototherapy Coverage beyond 16 weeks will be based on a significant reduction in the Body Surface Area (BSA) involved and improvements in the Psoriasis Area Severity Index (PASI) score and the Dermatology Life Quality Index (DLQI). 45mg/0.5mL Injection ELARA JNO 90mg/mL Injection ELARA JNO 92:08.00 DUTAERIDE a. - For treatment of Benign Prostatic Hyperplasia (BPH) in patients who do not tolerate or have not responded to an adrenergic blocker. or b. - For use in combination therapy when monotherapy with an alpha-blocker is not sufficient. 0.5MG Capsule ACT DUTAERIDE ATP APO-DUTAERIDE APX AVODART GSK DUTAERIDE PDL DUTAERIDE SIV MED-DUTAERIDE GMP MINT-DUTAERIDE MIN PMS-DUTAERIDE PMS RIVA-DUTAERIDE RIV SANDOZ DUTAERIDE SDZ TEVA-DUTAERIDE TEP FINAERIDE a. - For treatment of Benign Prostatic Hyperplasia (BPH) in patients who do not tolerate or have not responded to an alpha-adrenergic blocker. or b. - For use in combination therapy when monotherapy with an alpha-blocker is not sufficient. 5mg Tablet APO-FINAERIDE APX AURO-FINAERIDE AUR CO FINAERIDE CBT DOM-FINAERIDE DOM FINAERIDE PDL FINAERIDE ACC JAMP-FINAERIDE JAP MINT-FINAERIDE MIN MYLAN-FINAERIDE MYL NOVO-FINAERIDE TEV PMS-FINAERIDE PMS PROSCAR FRS RAN-FINAERIDE RBY RATIO-FINAERIDE RPH SANDOZ FINAERIDE SDZ Page A-64 de 81

233 Appendix A - Limited Use Benefits and Criteria 92:24.00 ALENDRONATE SODIUM For the treatment of: a. - Paget's Disease OR b. - Osteoporosis in patients who are 60 years of age or over OR c. - Osteoporosis in patients under 60 who have documented hip, vertebral or other fractures OR d. - Osteoporosis in patients under 60 with no evidence of fracture but who have a high (>20%) 10-year fracture risk OR e. - Osteoporosis or risk of osteoporosis in patients under 60 who have been, or who will be, on systemic corticosteroid therapy equivalent to a dose of prednisone 7.5mg per day for 3 months. 5mg Tablet ALENDRONATE ACC APO-ALENDRONATE APX RAN-ALENDRONATE RBY SANDOZ ALENDRONATE SDZ TEVA-ALENDRONATE TEV 10mg Tablet ALENDRONATE ACC APO-ALENDRONATE APX AURO-ALENDRONATE AUR MINT-ALENDRONATE MIN MYLAN-ALENDRONATE MYL SANDOZ ALENDRONATE SDZ TEVA-ALENDRONATE TEV 40mg Tablet CO ALENDRONATE COB 70mg Tablet ALENDRONATE MEL ALENDRONATE SOR ALENDRONATE SAN ALENDRONATE ACC ALENDRONATE-70 PDL APO-ALENDRONATE APX AURO-ALENDRONATE AUR CO ALENDRONATE COB DOM-ALENDRONATE DOM FOSAMAX FRS JAMP-ALENDRONATE JAP MINT-ALENDRONATE MIN MYLAN-ALENDRONATE MYL PMS-ALENDRONATE PMS PMS-ALENDRONATE FC PMS RAN-ALENDRONATE RBY RIVA-ALENDRONATE RIV SANDOZ ALENDRONATE SDZ TEVA-ALENDRONATE TEV Page A-65 de 81

234 Appendix A - Limited Use Benefits and Criteria 92:24.00 ALENDRONATE SODIUM, VITAMIN D3 For the treatment of: a. - Paget's Disease OR b. - Osteoporosis in patients who are 60 years of age or over OR c. - Osteoporosis in patients under 60 who have documented hip, vertebral or other fractures OR d. - Osteoporosis in patients under 60 with no evidence of fracture but who have a high (>20%) 10-year fracture risk OR e. - Osteoporosis or risk of osteoporosis in patients under 60 who have been, or who will be, on systemic corticosteroid therapy equivalent to a dose of prednisone 7.5mg per day for 3 months. 70mg/2800U Tablet FOSAVANCE FRS TEVA-ALENDRONATE/CHOLECALCIFEROL TEP 70mg/5600U Tablet FOSAVANCE MSP SANDOZ ALENDRONATE/CHOLECALCIFEROL SDZ TEVA-ALENDRONATE/CHOLECALCIFEROL TEP DENOSUMAB (P) For women with postmenopausal osteoporosis who would otherwise be eligible for coverage of oral bisphosphonates, but for whom: - bisphosphonates are contraindicated due to hypersensitivity or abnormalities of the esophagus (e.g., esophageal stricture or achalasia); AND Have at least two of the following: - age >70 years - a prior fragility fracture - a bone mineral density (BMD) T-score mg/mL Injection PROLIA AMG DENOSUMAB (X) For the prevention of skeletal-related events (SREs) in patients with castrate-resistant prostate cancer (CRPC) with: One or more documented bone metastases; AND Good performance status (ECOG performance status score of 0, 1, or 2). 120mg/1.7mL Injection XGEVA AMG RISEDRONATE SODIUM For the treatment of: a. - Osteoporosis in patients who are 60 years of age and over or b. - Osteoporosis in patients who have documented hip, vertebral or other fractures or c. - Paget's Disease or d. - Osteoporosis in patients with no evidence of fracture but who have a high (>20%) 10-year fracture risk or e. - Osteoporosis in patients with moderate 10-year fracture risk (10-20%) and use of systemic glucocorticoid therapy > 3 months 5mg Tablet ACTONEL PGP NOVO-RISEDRONATE TEV 30mg Tablet ACTONEL PGP NOVO-RISEDRONATE TEV Page A-66 de 81

235 Appendix A - Limited Use Benefits and Criteria 92:24.00 RISEDRONATE SODIUM For the treatment of: a. - Osteoporosis in patients who are 60 years of age and over or b. - Osteoporosis in patients who have documented hip, vertebral or other fractures or c. - Paget's Disease or d. - Osteoporosis in patients with no evidence of fracture but who have a high (>20%) 10-year fracture risk or e. - Osteoporosis in patients with moderate 10-year fracture risk (10-20%) and use of systemic glucocorticoid therapy > 3 months 35mg Tablet ACTONEL PGP APO-RISEDRONATE APO AURO-RISEDRONATE AUR DOM-RISEDRONATE DOM JAMP-RISEDRONATE JAP MYLAN-RISEDRONATE MYL NOVO-RISEDRONATE TEV PMS-RISEDRONATE PMS RISEDRONATE PDL RISEDRONATE SIV RISEDRONATE SAN RISEDRONATE-35 SIV RIVA-RISEDRONATE RIV SANDOZ RISEDRONATE SDZ ZOLEDRONIC ACID For the treatment of Paget s disease. Coverage will be granted for one dose per 12 month period. OR. For women with postmenopausal osteoporosis who would otherwise be eligible for coverage of oral bisphosphonates*, but who have a contraindication to bisphosphonates due to hypersensitivity or abnormalities of the esophagus (e.g, esophageal stricture or achalasia); ANDwho have at least two of the following: age >70 years a prior fragility fracture a bone mineral density (BMD) T-score a bone mineral density (BMD) T-score mg/100mL Injection ACLAA NOV TARO-ZOLEDRONIC ACID TAR ZOLEDRONIC ACID TEP ZOLEDRONIC ACID REC Page A-67 de 81

236 Appendix A - Limited Use Benefits and Criteria 92:36.00 DISEASE-MODIFYING ANTIRHEUMATIC AGENTS ABATACEPT Coverage is provided for the 2 indications. 1. For the treatment of severely active RHEUMATOID ARTHRITIS: Criteria for initial for one year coverage: Prescribed by a rheumatologist Coverage is provided for in adult patients 18 years for use, in combination with methotrexate (MTX) or other disease modifying anti-rheumatic drugs (DMARDs), for the reduction in signs and symptoms of severely active RA who has failed: MTX (oral or parenteral) at a dose 20 mg weekly ( 15 mg weekly if patient is 65 years) for a minimum of 12 weeks of continuous treatment. Note: Patients who do not exhibit a clinical response to oral MTX or who experience gastrointestinal intolerance may consider a trial of parenteral MTX. AND MTX in combination with at least two other DMARDS, such as sulfasalazine and hydroxychloroquine, for a minimum of 12 weeks of continuous treatment. AND Etanercept OR adalimumab OR golimumab OR certolizumab OR abatacept (SC): minimum of 12 weeks trial OR, if the patient has a contraindication or intolerance to MTX and has failed: Combination of at least two DMARDS, such as sulfasalazine, hydroxychloroquine, azathioprine, leflunomide, cyclosporine or gold, for a minimum of 12 weeks of continuous treatment. Note: Initial one-year coverage for rheumatoid arthritis is provided at a dose of 500 mg for patients weighing < 60 kg; 750 mg for patients weighing 60 to 100 kg; and 1000 mg for patients weighing > 100 kg. Doses are given at 0, 2 and 4 weeks, then every 4 weeks. Coverage beyond one year will be based on improvement in number of swollen joints, number of tender joints, ESR or CRP, duration of morning stiffness, Physician Global Assessment scale and Patient Global Assessment scale. 2. For the treatment of JUVENILE IDIOPATHIC ARTHRITIS in children 6 to 17 years who meet all of the following: Criteria for initial for one year coverage: Prescribed by a rheumatologist 5 swollen joints; AND 3 joints with limited range of motion and/or pain/tenderness; AND Condition is refractory to an adequate trial of a therapeutic dose of MTX. An adequate trial is defined as at least 3 months of oral or parenteral MTX at 10mg/m2 weekly (unless significant toxicity limits the dose tolerated) Note: Initial 16-week coverage for juvenile idiopathic arthritis is provided at a dose of 10 mg/kg for children weighing < 75 kg; 750 mg for children weighing 75 to 100 kg; and 1000 mg for patients weighing > 100 kg. Doses are given at 0, 2, and 4 weeks, then every 4 weeks. Coverage beyond 16 weeks will be based on improvement in number of active joints, number of joints with loss of range of motion, ESR, Physician Global Assessment scale, Patient or Parent Global Assessment scale and Child Health Assessment Questionnaire. Note: Initial 16-week coverage for juvenile idiopathic arthritis is provided at a dose of 10 mg/kg for children weighing < 75 kg; 750 mg for children weighing 75 to 100 kg; and 1000 mg for patients weighing > 100 kg. Doses are given at 0, 2, and 4 weeks, then every 4 weeks. Coverage beyond 16 weeks will be based on improvement in number of active joints, number of joints with loss of range of motion, ESR, Physician Global Assessment scale, Patient or Parent Global Assessment scale and Child Health Assessment Questionnaire. 125mg Injection ORENCIA BMS 250mg Injection ORENCIA BMS Page A-68 de 81

237 Appendix A - Limited Use Benefits and Criteria 92:36.00 DISEASE-MODIFYING ANTIRHEUMATIC AGENTS ADALIMUMAB Coverage is provided in adult patients 18 years for coverage for a MAXIMUM dose of 40mg every 2 weeks the 2 indications. 1. For the treatment of severely active RHEUMATOID ARTHRITIS Criteria for initial for one year: Prescribed by a rheumatologist Coverage is provided for use, in combination with methotrexate (MTX) or other disease modifying anti-rheumatic drugs (DMARDs), for the reduction in signs and symptoms of severely active RA in adult patients 18 years who has failed: MTX (oral or parenteral) at a dose 20 mg weekly ( 15 mg weekly if patient is 65 years) for a minimum of 12 weeks of continuous treatment. Note: Patients who do not exhibit a clinical response to oral MTX or who experience gastrointestinal intolerance may consider a trial of parenteral MTX. AND MTX in combination with at least two other DMARDS, such as sulfasalazine and hydroxychloroquine, for a minimum of 12 weeks of continuous treatment. OR, if the patient has a contraindication or intolerance to MTX and has failed: Combination of at least two DMARDS, such as sulfasalazine, hydroxychloroquine, azathioprine, leflunomide, cyclosporine or gold, for a minimum of 12 weeks of continuous treatment. 2. For the treatment of moderate to severe PSORIATIC ARTHRITIS Criteria for initial for one year: Prescribed by a rheumatologist Client must have at least two of the following: 5 or more swollen joints if less than 5 swollen joints, at least one joint proximal to, or including wrist or ankle more than one joint with erosion on imaging study dactylitis of two or more digits tenosynovitis refractory to oral NSAIDs and steroid injections enthesitis refractory to oral NSAIDs and steroid injections (not required for Achilles tendon) inflammatory spinal symptoms refractory to two NSAIDs (minimum four weeks trial each) and has a BASDAI greater than 4. daily use of corticosteroids use of opioids > 12 hours per day for pain resulting from inflammation Patient is refractory to: NSAIDs and methotrexate weekly parenteral (SC or IM) at 20mg or greater (15mg or greater if patient is >65 years of age) for more than 8 weeks PLUS a minimum of one of the following: leflunomide: 20mg daily for 10 weeks OR gold: weekly injections for 20 weeks OR cyclosporine: 2-5 mg/kg/day for 12 weeks OR sulfasalazine at least 2g daily for 3 months 3. For the treatment of ANKYLOSING SPONDYLITIS Criteria for initial for one year: Prescribed by a rheumatologist Client who meet the following criteria: BASDAI > 4 AND patient is refractory to a 4 week trial of at least 3 NSAIDs at maximum tolerated dose AND for peripheral joint involvement, patient is refractory to weekly parenteral (SC or IM) at 20mg or greater (15mg or greater if patient is >65 years of age) for more than 8 weeks AND sulfasalazine 2g/day for four months. NOTE: For axial involvement, patient does not need to be tried on methotrexate or sulfasalazine. 4. For the treatment of patients with moderate to severe PSORIASIS Criteria for initial for one year: Prescribed by a dermatologist Client who meet all of the following criteria: Body surface area involvement greater than 10% and/or significant involvement of the face, hands, feet or genital region AND Intolerance or lack of response to methotrexate AND cyclosporine OR A contraindication to methotrexate and/or cyclosporine AND Intolerance or lack of response to phototherapy OR Inability to access phototherapy Coverage beyond 16 weeks will be based on a significant reduction in the Body Surface Area (BSA) involved and improvements in the Psoriasis Area Severity Index (PASI) score and the Dermatology Life Quality Index (DLQI). Page A-69 de 81

238 Appendix A - Limited Use Benefits and Criteria 92:36.00 DISEASE-MODIFYING ANTIRHEUMATIC AGENTS 5. For the treatment of moderately to severely active CROHN'S DISEASE. Criteria for initial for one year: Prescribed by a gastroenterology specialist Initial treatment will allow for an induction dose of adalimumab 160mg followed by 80mg 2 weeks later. Maintenance therapy will only be provided at a dose not exceeding 40mg every two weeks. Criteria for initial four week coverage are: Patient is an adult with moderate to severely active Crohn's disease refractory to: therapy with 5-ASA products (at least 3g/day for a minimum of 6 weeks); PLUS glucorticoids equivalent to prednisone 40mg/day for a minimum of 2 weeks; PLUS azathioprine 2 to 2.5 mg/kg/day for a minimum of 3 months; OR 6-mercaptopurine 50 to 70 mg/day for a minimum of 3 months; OR MTX (oral or parenteral) 15 to 25 mg, per week for a minimum of 3 months. 6. For the treatment of severely active polyarticular JUVENILE IDIOPATHIC ARTHRITIS in children 4 to 17 years Criteria for initial for one year: Prescribed by a rheumatologist Client who meet ALL of the following criteria: 5 swollen joints; AND 3 joints with limited range of motion and/or pain/tenderness; AND Condition is refractory an adequate trial of a therapeutic dose of MTX. An adequate trial is defined as at least 3 months of oral or parenteral MTX at 10mg/m2 weekly (unless significant toxicity limits the dose tolerated) 40mg/Vial Injection HUMIRA ABB CERTOLIZUMAB PEGOL Coverage is provided in adult patients 18 years. 1. For the treatment of severely active RHEUMATOID ARTHRITIS Criteria for initial for one year: Prescribed by a rheumatologist Coverage is provided at a dose of 400mg at weeks 0, 2, and 4, followed by 200mg every other week or 400mg every 4 weeks. Coverage is provided for use, in combination with methotrexate (MTX) or other disease modifying anti-rheumatic drugs (DMARDs), for the reduction in signs and symptoms of severely active RA in adult patients 18 years who has failed: MTX (oral or parenteral) at a dose 20 mg weekly ( 15 mg weekly if patient is 65 years) for a minimum of 12 weeks of continuous treatment. Note: Patients who do not exhibit a clinical response to oral MTX or who experience gastrointestinal intolerance may consider a trial of parenteral MTX. AND MTX in combination with at least two other DMARDS, such as sulfasalazine and hydroxychloroquine, for a minimum of 12 weeks of continuous treatment. OR, if the patient has a contraindication or intolerance to MTX and has failed: Combination of at least two DMARDS, such as sulfasalazine, hydroxychloroquine, azathioprine, leflunomide, cyclosporine or gold, for a minimum of 12 weeks of continuous treatment Note: Criteria will be confirmed against patient s medication history. Coverage beyond one year will be based on improvement in number of swollen joints, number of tender joints, ESR, CRP, duration of morning stiffness, Physician Global Assessment scale and Patient Global Assessment scale. 200mg/mL Injection CIMZIA UCB Page A-70 de 81

239 Appendix A - Limited Use Benefits and Criteria 92:36.00 DISEASE-MODIFYING ANTIRHEUMATIC AGENTS ETANERCEPT Limited use benefit (prior approval required) The coverage of etanercept in adult patients 18 years is set at a MAXIMUM dose of 50mg weekly for the four indications.1. For the treatment of severely active RHEUMATOID ARTHRITIS Criteria for initial one year: - Prescribed by a rheumatologist Coverage is provided for use, in combination with methotrexate (MTX) or other disease modifying anti-rheumatic drugs (DMARDs), for the reduction in signs and symptoms of severely active RA in adult patients 18 years who have failed: - MTX (oral or parenteral a dose 20mg weekly ( 15 mg weekly if patient is 65 years) for a minimum of 12 weeks of continuous treatment. Note: Patients who do not exhibit a clinical response to oral MTX or who experience gastrointestinal intolerance may consider a trial of parenteral MTX. AND - MTX in combination with at least two other DMARDs, such as sulfasalazine and hydroxycholorquine, for a minimum of 12 weeks of continuous treatment. OR, if the patient has a contraindication or intolerance to MTX and has failed: - Combination of at least two DMARDs, such as sulfasalazine, hydroxychloroquine, azathioprine, leflunomide, cyclosporine or gold, for a minimum of 12 weeks of contiuous treament, or are refractory to a combination of at least 2 DMARDs 2. For the treatment of moderate to severe PSORIATIC ARTHRITIS Criteria for initial for one year: - Prescribed by a rheumatologist Client must have at least two of the following: - 5 or more swollen joints - if less than 5 swollen joints, at least one joint proximal to, or including wrist or ankle - more than one joint with erosion on imaging study - dactylitis of two or more digits - tenosynovitis refractory to oral NSAIDs and steroid injections - enthesitis refractory to oral NSAIDs and steroid injections (not required for Achilles tendon) - inflammatory spinal symptoms refractory to two NSAIDs (minimum four weeks trial each) and has a BASDAI greater than 4 - daily use of corticosteroids - use of opioids > 12 hours per day for pain resulting from imflammation Patient is refractory to: - NSAIDs AND - methotrexate weekly parenteral (SC or IM) at 20mg or greater (15mg or greater if patient is > 65 years of age) for more than 8 weeks PLUS a minimum of one of the following: - leflunomide: 20mg daily for 10 weeks OR - gold: weekly injections for 20 weeks OR - cyclosporine: 2-5 mg/kg/day for 12 weeks OR - sulfasalazine at least 2g daily for 3 months 3. For the treatment of ANKYLOSING SPONDYLITIS Criteria for initial one year: - Prescribed by rheumatologist Client who meet all of the following criteria: - BASDAI > 4 AND - patient is refractory to a three month trial of at least 3 NSAIDs at maximum tolerated dose AND - for peripheral joint involvement, patient is refractory to weekly parenteral (SC or IM) at 20mg or greater (15mg or greater if patient is > 65 years of age) for more than 8 weeks AND sulfasalazine 2g/day for four months Note: For axial involvement, patient does not need to be tried on MTX or sulfasalazine. 4. For the treatment of severely active polyarticular JUVENILE IDIOPATHIC ARTHRITIS in children 4 to 17 years Criteria who meet all the following criteria: - 5 swollen joints; AND - 3 joints with limited range of motion and/or pain/tenderness; AND - Condition is refractory to an adequate trial of a therapeutic dose of methotrexate. 25mg/Vial Injection ENBREL IMX Page A-71 de 81

240 Appendix A - Limited Use Benefits and Criteria 92:36.00 DISEASE-MODIFYING ANTIRHEUMATIC AGENTS ETANERCEPT Limited use benefit (prior approval required) The coverage of etanercept in adult patients 18 years is set at a MAXIMUM dose of 50mg weekly for the four indications.1. For the treatment of severely active RHEUMATOID ARTHRITIS Criteria for initial one year: - Prescribed by a rheumatologist Coverage is provided for use, in combination with methotrexate (MTX) or other disease modifying anti-rheumatic drugs (DMARDs), for the reduction in signs and symptoms of severely active RA in adult patients 18 years who have failed: - MTX (oral or parenteral a dose 20mg weekly ( 15 mg weekly if patient is 65 years) for a minimum of 12 weeks of continuous treatment. Note: Patients who do not exhibit a clinical response to oral MTX or who experience gastrointestinal intolerance may consider a trial of parenteral MTX. AND - MTX in combination with at least two other DMARDs, such as sulfasalazine and hydroxycholorquine, for a minimum of 12 weeks of continuous treatment. OR, if the patient has a contraindication or intolerance to MTX and has failed: - Combination of at least two DMARDs, such as sulfasalazine, hydroxychloroquine, azathioprine, leflunomide, cyclosporine or gold, for a minimum of 12 weeks of contiuous treament, or are refractory to a combination of at least 2 DMARDs 2. For the treatment of moderate to severe PSORIATIC ARTHRITIS Criteria for initial for one year: - Prescribed by a rheumatologist Client must have at least two of the following: - 5 or more swollen joints - if less than 5 swollen joints, at least one joint proximal to, or including wrist or ankle - more than one joint with erosion on imaging study - dactylitis of two or more digits - tenosynovitis refractory to oral NSAIDs and steroid injections - enthesitis refractory to oral NSAIDs and steroid injections (not required for Achilles tendon) - inflammatory spinal symptoms refractory to two NSAIDs (minimum four weeks trial each) and has a BASDAI greater than 4 - daily use of corticosteroids - use of opioids > 12 hours per day for pain resulting from imflammation Patient is refractory to: - NSAIDs AND - methotrexate weekly parenteral (SC or IM) at 20mg or greater (15mg or greater if patient is > 65 years of age) for more than 8 weeks PLUS a minimum of one of the following: - leflunomide: 20mg daily for 10 weeks OR - gold: weekly injections for 20 weeks OR - cyclosporine: 2-5 mg/kg/day for 12 weeks OR - sulfasalazine at least 2g daily for 3 months 3. For the treatment of ANKYLOSING SPONDYLITIS Criteria for initial one year: - Prescribed by rheumatologist Client who meet all of the following criteria: - BASDAI > 4 AND - patient is refractory to a three month trial of at least 3 NSAIDs at maximum tolerated dose AND - for peripheral joint involvement, patient is refractory to weekly parenteral (SC or IM) at 20mg or greater (15mg or greater if patient is > 65 years of age) for more than 8 weeks AND sulfasalazine 2g/day for four months Note: For axial involvement, patient does not need to be tried on MTX or sulfasalazine. 4. For the treatment of severely active polyarticular JUVENILE IDIOPATHIC ARTHRITIS in children 4 to 17 years Criteria who meet all the following criteria: - 5 swollen joints; AND - 3 joints with limited range of motion and/or pain/tenderness; AND - Condition is refractory to an adequate trial of a therapeutic dose of methotrexate. 50mg/mL Injection ENBREL IMX Page A-72 de 81

241 Appendix A - Limited Use Benefits and Criteria 92:36.00 DISEASE-MODIFYING ANTIRHEUMATIC AGENTS ETANERCEPT Limited use benefit (prior approval required) The coverage of etanercept in adult patients 18 years is set at a MAXIMUM dose of 50mg weekly for the four indications.1. For the treatment of severely active RHEUMATOID ARTHRITIS Criteria for initial one year: - Prescribed by a rheumatologist Coverage is provided for use, in combination with methotrexate (MTX) or other disease modifying anti-rheumatic drugs (DMARDs), for the reduction in signs and symptoms of severely active RA in adult patients 18 years who have failed: - MTX (oral or parenteral a dose 20mg weekly ( 15 mg weekly if patient is 65 years) for a minimum of 12 weeks of continuous treatment. Note: Patients who do not exhibit a clinical response to oral MTX or who experience gastrointestinal intolerance may consider a trial of parenteral MTX. AND - MTX in combination with at least two other DMARDs, such as sulfasalazine and hydroxycholorquine, for a minimum of 12 weeks of continuous treatment. OR, if the patient has a contraindication or intolerance to MTX and has failed: - Combination of at least two DMARDs, such as sulfasalazine, hydroxychloroquine, azathioprine, leflunomide, cyclosporine or gold, for a minimum of 12 weeks of contiuous treament, or are refractory to a combination of at least 2 DMARDs 2. For the treatment of moderate to severe PSORIATIC ARTHRITIS Criteria for initial for one year: - Prescribed by a rheumatologist Client must have at least two of the following: - 5 or more swollen joints - if less than 5 swollen joints, at least one joint proximal to, or including wrist or ankle - more than one joint with erosion on imaging study - dactylitis of two or more digits - tenosynovitis refractory to oral NSAIDs and steroid injections - enthesitis refractory to oral NSAIDs and steroid injections (not required for Achilles tendon) - inflammatory spinal symptoms refractory to two NSAIDs (minimum four weeks trial each) and has a BASDAI greater than 4 - daily use of corticosteroids - use of opioids > 12 hours per day for pain resulting from imflammation Patient is refractory to: - NSAIDs AND - methotrexate weekly parenteral (SC or IM) at 20mg or greater (15mg or greater if patient is > 65 years of age) for more than 8 weeks PLUS a minimum of one of the following: - leflunomide: 20mg daily for 10 weeks OR - gold: weekly injections for 20 weeks OR - cyclosporine: 2-5 mg/kg/day for 12 weeks OR - sulfasalazine at least 2g daily for 3 months 3. For the treatment of ANKYLOSING SPONDYLITIS Criteria for initial one year: - Prescribed by rheumatologist Client who meet all of the following criteria: - BASDAI > 4 AND - patient is refractory to a three month trial of at least 3 NSAIDs at maximum tolerated dose AND - for peripheral joint involvement, patient is refractory to weekly parenteral (SC or IM) at 20mg or greater (15mg or greater if patient is > 65 years of age) for more than 8 weeks AND sulfasalazine 2g/day for four months Note: For axial involvement, patient does not need to be tried on MTX or sulfasalazine. 4. For the treatment of severely active polyarticular JUVENILE IDIOPATHIC ARTHRITIS in children 4 to 17 years Criteria who meet all the following criteria: - 5 swollen joints; AND - 3 joints with limited range of motion and/or pain/tenderness; AND - Condition is refractory to an adequate trial of a therapeutic dose of methotrexate. 50mg/mL Injection ENBREL SURECLICK (QC) AMG Page A-73 de 81

242 Appendix A - Limited Use Benefits and Criteria 92:36.00 DISEASE-MODIFYING ANTIRHEUMATIC AGENTS GOLIMUMAB The coverage of golimumab in adult patients 18 years is set at a MAXIMUM dose of 50mg every month for the 3 indications. 1. For the treatment of severely active RHEUMATOID ARTHRITIS.: Criteria for initial for one year: Prescribed by a rheumatologist Client who meet all of the following criteria: Coverage is provided for use, in combination with methotrexate (MTX) or other disease modifying anti-rheumatic drugs (DMARDs), for the reduction in signs and symptoms of severely active RA in adult patients 18 years who has failed: MTX (oral or parenteral) at a dose 20 mg weekly ( 15 mg weekly if patient is 65 years) for a minimum of 12 weeks of continuous treatment. Note: Patients who do not exhibit a clinical response to oral MTX or who experience gastrointestinal intolerance may consider a trial of parenteral MTX. AND MTX in combination with at least two other DMARDS, such as sulfasalazine and hydroxychloroquine, for a minimum of 12 weeks of continuous treatment. OR, if the patient has a contraindication or intolerance to MTX and has failed: Combination of at least two DMARDS, such as sulfasalazine, hydroxychloroquine, azathioprine, leflunomide, cyclosporine or gold, for a minimum of 12 weeks of continuous treatment. 2. For the treatment of moderate to severe PSORIATIC ARTHRITIS Criteria for initial for one year: Prescribed by a rheumatologist Client who meet all least 2 of the following criteria: - 5 or more swollen joints - if less than 5 swollen joints, at least one joint proximal to, or including wrist or ankle - more than one joint with erosion on imaging study - dactylitis of two or more digits - tenosynovitis refractory to oral NSAIDs and steroid injections - enthesitis refractory to oral NSAIDs and steroid injections (not required for Achilles tendon) - inflammatory spinal symptoms refractory to two NSAIDs (minimum four weeks trial each) and has a BASDAI greater than 4 - daily use of corticosteroids - use of opioids > 12 hours per day for pain resulting from inflammation Patient is refractory to: - NSAIDs AND - methotrexate weekly parenteral (SC or IM) at 20mg or greater (15mg or greater if patient is >65 years of age) for more than 8 weeks PLUS a minimum of one of the following: - leflunomide: 20mg daily for 10 weeks OR - gold: weekly injections for 20 weeks OR - cyclosporine: 2-5 mg/kg/day for 12 weeks OR - sulfasalazine at least 2g daily for 3 months. 3. For the treatment of ANKYLOSING SPONDYLITIS when the following criteria are met: - BASDAI > 4 AND - patient is refractory to a three month trial of at least 3 NSAIDs at maximum tolerated dose AND for peripheral joint involvement, patient is refractory to weekly parenteral (SC or IM) at 20mg or greater (15mg or greater if patient is >65 years of age) for more than 8 weeks AND sulfasalazine 2g/day for four months. NOTE: For axial involvement, patient does not need to be tried on methotrexate or sulfasalazine. 50mg/0.5mL Injection SIMPONI AUTO INJECTOR CER SIMPONI PRE-FILLED SYRINGE CER Page A-74 de 81

243 Appendix A - Limited Use Benefits and Criteria 92:36.00 DISEASE-MODIFYING ANTIRHEUMATIC AGENTS INFLIXIMAB The coverage of etanercept in adult patients 18 years for 12 weeks for the 4 indications. 1. For the treatment of severely active RHEUMATOID ARTHRITIS Criteria for initial for one year: Prescribed by a rheumatologist Coverage is provided for use, in combination with methotrexate (MTX) or other disease modifying anti-rheumatic drugs (DMARDs), for the reduction in signs and symptoms of severely active RA in adult patients 18 years who has failed: MTX (oral or parenteral) at a dose 20 mg weekly ( 15 mg weekly if patient is 65 years) for a minimum of 12 weeks of continuous treatment. Note: Patients who do not exhibit a clinical response to oral MTX or who experience gastrointestinal intolerance may consider a trial of parenteral MTX. AND MTX in combination with at least two other DMARDS, such as sulfasalazine and hydroxychloroquine, for a minimum of 12 weeks of continuous treatment. AND Etanercept OR adalimumab OR golimumab OR certolizumab OR abatacept (SC): minimum of 12 weeks trial OR, if the patient has a contraindication or intolerance to MTX and has failed: Combination of at least two DMARDS, such as sulfasalazine, hydroxychloroquine, azathioprine, leflunomide, cyclosporine or gold, for a minimum of 12 weeks of continuous treatment. CRITERIA FOR CONTINUED COVERAGE FOR INFLIXIMAB BEYOND TWELVE WEEKS Patient meets all the following criteria: Initially prescribed by a rheumatologist Previous failure to etanercept or adalimumab Patient has been assessed after the eighth to twelfth week of infliximab therapy and meets the following response criteria: >20% reduction in number of tender and swollen joints PLUS >20% improvement in physician global assessment scale PLUS EITHER >20% improvement in the patient global assessment scale, OR >20% reduction in the acute phase as measured by ESR or CRP 2. For the treatment of FIULIZING CROHN S DISEASE Criteria for initial for one year: Prescribed by a gastroenterology specialist The initial coverage will allow for 3 doses of 5mg/kg/dose, administered at 0, 2 and 6 weeks. For continued coverage, patient must be reassessed after the initial doses. Patient meets all the following criteria: Patient is an adult with actively draining perianal or entercutaneous fistula(e) that have recurred or persisted despite: -a course of appropriate antibiotic therapy (e.g. ciprofloxacin with or without metronidazole for a minimum of 3 weeks) PLUS -immunosuppressive therapy: azathioprine 2 to 2.5mg/kg/day for a minimum of 6 weeks or treatment discontinued before 6 weeks due to severe adverse reactions. OR 6-mercaptopurine, 50-70mg/day for a minimum of 6 weeks or treatment discontinued before 6 weeks due to severe adverse reactions. OR OR Other. 3. For the treatment for SEVERE ACTIVE CROHN`S DISEASE Criteria for initial for one year: Prescribed by a gastroenterology specialist The initial coverage will allow for 3 doses of 5mg/kg/dose, administered at 0, 2 and 6 weeks. For continued coverage, patient must be reassessed after the initial doses. Patient meets the following criteria: Patient is an adult with severe active Crohn s disease that has recurred or persisted despite: Therapy with 5-ASA products (at least 3g/day for a minimum of 6 weeks). PLUS Glucocorticoids equivalent to prednisone 40mg/day for a minimum of 2 weeks. OR Treatment discontinued due to serious adverse reactions OR OR Page A-75 de 81

244 Appendix A - Limited Use Benefits and Criteria 92:36.00 DISEASE-MODIFYING ANTIRHEUMATIC AGENTS Contraindication to glucocorticoid therapy. PLUS Azathioprine 2 to 2.5mg/kg/day for a minimum of 3 months. OR 6-mercaptopurine 50 to 70mg/day for a minimum of 3 months. OR Methotrexate 15 to 25mg/week for a minimum of 3 months. 100mg/Vial Injection REMICADE CEN TOCILIZUMAB The coverage of tocilizumab is for 16 weeks. Patient must had a tuberculin skin test performed. Tocilizumab should not be used in combination with anti-tnf agents. 1. For the treatment of moderate to severely active RHEUMATOID ARTHRITIS Criteria for initial for one year: Prescribed by a rheumatologist For patients who have failed to respond to an adequate trial of an anti-tnf agent Note: Treatment should be combined with methotrexate or other DMARD. Coverage is initially provided for 16 weeks at an initial dose of 4 mg/kg/dose every 4 weeks. 2. For the treatment of active SYEMIC JUVENILE IDIOPATHIC ARTHRITIS Criteria for initial for one year: Prescribed by a rheumatologist Coverage is for patients two years of age and older who have responded inadequately to non-steroidal anti-inflammatory drugs (NSAIDs) and systemic corticosteroids (with or without methotrexate), due to intolerance or lack of efficacy. Coverage is initially provided for 16-week at a dose of 12 mg/kg once every two weeks for children weighing < 30 kg and 8 mg/kg for children weighing > 30 kg. 3. For the treatment of severely active POLYARTICULAR JUVENILE IDIOPATHIC ARTHRITIS in children 2 to 17 years where the following criteria are met: 5 swollen joints; AND 3 joints with limited range of motion and/or pain/tenderness; AND Condition is refractory to an adequate trial of a therapeutic dose of methotrexate. 80mg/4ml Injection ACTEMRA HLR 200mg/10ml Injection ACTEMRA HLR 400mg/20ml Injection ACTEMRA HLR 92:44.00 CYCLOSPORINE For transplant therapy. 10mg Capsule NEORAL NVR 25mg Capsule NEORAL NVR SANDOZ-CYCLOSPORINE SDZ 50mg Capsule NEORAL NVR SANDOZ-CYCLOSPORINE SDZ 100mg Capsule NEORAL NVR SANDOZ-CYCLOSPORINE SDZ 100mg/mL Solution NEORAL NVR Page A-76 de 81

245 Appendix A - Limited Use Benefits and Criteria 92:44.00 MYCOPHENOLATE MOFETIL For transplant therapy. 250mg Capsule ACH-MYCOPHENOLATE ACC APO-MYCOPHENOLATE APX CELLCEPT HLR JAMP-MYCOPHENOLATE JAP MYLAN-MYCOPHENOLATE MYL SANDOZ MYCOPHENOLATE SDZ TEVA-MYCOPHENOLATE TEP 500mg Tablet APO-MYCOPHENOLATE APX CELLCEPT HLR JAMP-MYCOPHENOLATE JAP MYCOPHENOLATE ACC MYLAN-MYCOPHENOLATE MYL SANDOZ-MYCOPHENOLATE SDZ TEVA-MYCOPHENOLATE TEP MYCOPHENOLATE SODIUM For transplant therapy. 180mg Enteric Coated Tablet APO-MYCOPHENOLIC ACID APX MYFORTIC NVR 360mg Enteric Coated Tablet APO-MYCOPHENOLIC ACID APX MYFORTIC NVR SIROLIMUS Coverage will be provided as a second line therapy for patients failing mycophenolate mofetil. 1mg/mL Oral Liquid RAPAMUNE WAY 1mg Tablet RAPAMUNE WAY TACROLIMUS For transplant therapy. 3MG CAP LA ADVAGRAF 3MG ER CAP A 0.5mg Capsule PROGRAF A SANDOZ TACROLIMUS SDZ 1mg Capsule PROGRAF A SANDOZ TACROLIMUS SDZ 5mg Capsule PROGRAF A SANDOZ TACROLIMUS SDZ 5mg/mL Injection PROGRAF A Page A-77 de 81

246 Appendix A - Limited Use Benefits and Criteria 92:44.00 TACROLIMUS For transplant therapy. 0.5mg Long Acting Capsule ADVAGRAF A 1mg Long Acting Capsule ADVAGRAF A 5mg Long Acting Capsule ADVAGRAF A 92:92.00 BOTULINUM TOXIN TYPE A For the treatment of: a. - strabismus and blepharospasm associated with dystonia, including benign essential blepharospasm or VII nerve disorder in patients 12 years of age or older b. - cervical dystonia (spasmodic torticollis); OR urinary incontinence due to neurogenic detrusor overactivity resulting from neurogenic bladder associated with MS or subcervical spinal cord injury. 50IU Injection BOTOX ALL 100IU Injection BOTOX ALL 200IU Injection BOTOX ALL INCOBOTULINUMTOXINA For the treatment of: strabismus and blepharospasm associated with dystonia, including benign essential blepharospasm or VII nerve disorder in patients 12 years of age or older; OR cervical dystonia (spasmodic torticollis); OR urinary incontinence due to neurogenic detrusor overactivity resulting from neurogenic bladder associated with MS or subcervical spinal cord injury. 100U/vial Injection XEOMIN MEZ Page A-78 de 81

247 Appendix A - Limited Use Benefits and Criteria 94:00 DEVICES 94:00.00 DEVICES SPACER DEVICE Limited use benefit with quantity and frequency limits (prior approval is not required). Coverage is granted for 1 spacer device every 12 months. Device AEROCHAMBER AC BOYZ TRU AEROCHAMBER AC GIRLZ TRU AEROCHAMBER PLUS FLOW-VU LG TRU AEROCHAMBER PLUS FLOW-VU MED TRU AEROCHAMBER PLUS FLOW-VU MOUTH TRU AEROCHAMBER PLUS FLOW-VU SM TRU AEROTRACH PLUS TMI E-Z SPACER WEP E-Z SPACER (MASK ONLY) WEP E-Z SPACER WITH SMALL MASK WEP OPTICHAMBER AUC OPTICHAMBER DIAMOND (CHAMBER) AUC OPTICHAMBER DIAMOND (LARGE M) AUC OPTICHAMBER DIAMOND (MEDIUM M) AUC OPTICHAMBER DIAMOND (MEDIUM M) AUC OPTICHAMBER LARGE MASK AUC OPTICHAMBER MEDIUM MASK AUC OPTICHAMBER SMALL MASK AUC OPTIHALER AUC POCKET CHAMBER MCA POCKET CHAMBER WITH ADULT MASK MCA POCKET CHAMBER WITH INFANT MASK MCA POCKET CHAMBER WITH MEDIUM MASK MCA POCKET CHAMBER WITH SMALL MASK MCA 94:01.00 DEVICES (DIABETIC) INSULIN PUMP SUPPLIES -Insulin pump supplies are approved for NIHB clients following the approval of an insulin pump by NIHB. OR -Insulin pump supplies are approved for NIHB clients with Type 1 diabetes if an insulin pump was partially or totally covered by another insurance. Rapid-D Accu-Chek - Infusion Set RAPID-D 10MM/110CM DIS RAPID-D 10MM/60CM DIS RAPID-D 10MM/80CM DIS RAPID-D 6MM/110CM DIS RAPID-D 6MM/60CM DIS RAPID-D 6MM/80CM DIS RAPID-D 8MM/110CM DIS RAPID-D 8MM/60CM DIS RAPID-D 8MM/80CM DIS Tender Accu-Chek - Infusion Set TENDER-1 17MM/110CM DIS TENDER-1 17MM/60CM DIS TENDER-1 17MM/80CM DIS TENDER-2 17MM/110CM DIS TENDER-2 17MM/60CM DIS TENDER-2 17MM/80CM DIS Page A-79 de 81

248 Appendix A - Limited Use Benefits and Criteria 94:01.00 DEVICES (DIABETIC) INSULIN PUMP SUPPLIES -Insulin pump supplies are approved for NIHB clients following the approval of an insulin pump by NIHB. OR -Insulin pump supplies are approved for NIHB clients with Type 1 diabetes if an insulin pump was partially or totally covered by another insurance. Tender "Mini" Accu-Chek - Infusion Set TENDER-1 "MINI" 13MM/110CM DIS TENDER-1 "MINI" 13MM/60CM DIS TENDER-1 "MINI" 13MM/80CM DIS TENDER-2 "MINI" 13MM/110CM DIS TENDER-2 "MINI" 13MM/60CM DIS TENDER-2 "MINI" 13MM/80CM DIS UltraFlex Accu-Chek - Infusion Set ULTRAFLEX MM/110CM DIS ULTRAFLEX MM/60CM DIS ULTRAFLEX MM/80CM DIS ULTRAFLEX - 1 8MM/110CM DIS ULTRAFLEX - 1 8MM/60CM DIS ULTRAFLEX - 1 8MM/80CM DIS Accu-Chek - Resevoirs SPIRIT CARTRIDGE 3.15ML Comfort Angled Animas - Infusion Set COMFORT ANGLED 17MMX110CM (10 AMS TUBING/BOX) COMFORT ANGLED 17MMX60CM (10 TUBING/BOX) AMS Comfort Short Angled Animas - Infusion Set COMFORT SHORT ANGLED 13MMX110CM (10 TUBING/BOX) COMFORT SHORT ANGLED 13MMX60CM (10 TUBING/BOX) Contact Detach Animas - Infusion Set CONTACT DETACH 90 DEGREE 6MMX60CM AMS CONTACT DETACH 90 DEGREE 8MMX60CM AMS Inset II Animas - Infusion Set INSET II 90 DEGREE 6MMX110CM AMS INSET II 90 DEGREE 6MMX60CM AMS INSET II 90 DEGREE 9MMX110CM AMS INSET II 90 DEGREE 9MMX60CM AMS Animas - Resevoirs CARTRIDGE FOR IR200 2ML AMS Mio Medtronic - Infusion Set MIO BLUE 6MMX18" MDT MIO BLUE 6MMX23" MDT MIO CLEAR 6MMX32" MDT MIO CLEAR 9MMX32" MDT MIO PINK 6MMX18" MDT MIO PINK 6MMX23" MDT DIS AMS AMS Page A-80 de 81

249 Appendix A - Limited Use Benefits and Criteria 94:01.00 DEVICES (DIABETIC) INSULIN PUMP SUPPLIES -Insulin pump supplies are approved for NIHB clients following the approval of an insulin pump by NIHB. OR -Insulin pump supplies are approved for NIHB clients with Type 1 diabetes if an insulin pump was partially or totally covered by another insurance. Paradigm Silhouette Medtronic - Infusion Set PARADIGM SILHOUETTE 13MMX18" MDT PARADIGM SILHOUETTE 13MMX23" MDT PARADIGM SILHOUETTE 13MMX32" MDT PARADIGM SILHOUETTE 13MMX43" MDT PARADIGM SILHOUETTE 17MMX23" MDT PARADIGM SILHOUETTE 17MMX32" MDT PARADIGM SILHOUETTE 17MMX43" MDT PARADIGM SILHOUETTE CANNULA 13MM MDT PARADIGM SILHOUETTE CANNULA 17MM MDT Quick-Set Medtronic - Infusion Set QUICK-SET 6MMX18" MDT QUICK-SET 6MMX23" MDT QUICK-SET 6MMX32" MDT QUICK-SET 6MMX43" MDT QUICK-SET 9MMX23" MDT QUICK-SET 9MMX32" MDT QUICK-SET 9MMX43" MDT Sure-T Medtronic - Infusion Set PARADIGM SURE-T 29G 6MMX18" MDT PARADIGM SURE-T 29G 6MMX23" MDT PARADIGM SURE-T 29G 8MMX23" MDT Medtronic - Resevoirs RESERVOIR 5XX 1.8ML SYRINGE MDT RESERVOIR PARADIGM 7XX3.0ML MDT OmniPod Omnipod - POD PODS OMD 96:00 PHARMACEUTICAL AIDS 96:00.00 PHARMACEUTICAL AIDS CAFFEINE CITRATE Limited use benefit (prior approval not required). For children up to 1 year of age Powder CAFFEINE CITRATE WIL METHADONE HCL Powder METHADONE WIL Page A-81 de 81

250 Appendix A Limited Use Benefits and Criteria Page Page Page ABBOTT-CLOPIDOGREL 1 17 ALMOTRIPTAN ALPHAGAN P AQUASOL E ARICEPT 63 7 ABBOTT-LEVETIRACETAM 34 ALPRAZOLAM 41 ASA 19 ABBOTT-PANTOPRAZOLE 56 AMERGE 45 ASA EC 19 ABBOTT-RABEPRAZOLE 57 APO-ACETAMINOPHEN 30 ASAPHEN 19 ABENOL 29 APO-ADEFOVIR 3 ASAPHEN EC 19 ABILIFY 38 APO-ALENDRONATE 65 ASATAB 19 ACCEL PIOGLITAZONE 59 APO-ALMOTRIPTAN 45 ASCENSIA BREEZE 2 49 ACCEL-CLOPIDOGREL 17 APO-ALPRAZ 41 ASCENSIA BREEZE 2 (ON) 49 ACCEL-DONEPEZIL 7 APO-BENZYDAMINE 52 ASCENSIA CONTOUR 49 ACCOLATE 51 APO-BOSENTAN 19 ASCENSIA CONTOUR (ON) 49 ACCU-CHEK ADVANTAGE 48 APO-BRIMONIDINE P 52 ATASOL 29 ACCU-CHEK ADVANTAGE (ON) 48 APO-BROMAZEPAM 42 ATASOL FORTE 30 ACCU-CHEK AVIVA 48 APO-CELECOXIB 20 ATASOL ACCU-CHEK AVIVA (ON) 48 APO-CLONAZEPAM 31 ATASOL ACCU-CHEK COMPACT 48 APO-CLOPIDOGREL 17 ATIVAN 43 ACCU-CHEK COMPACT (ON) 48 APO-CYCLOBENZAPRINE 13 ATIVAN SUBLINGUAL 43 ACCU-CHEK MOBILE 48 APO-DIAZEPAM 42 AURO-ALENDRONATE 65 ACCU-CHEK MOBILE (ON) 48 APO-DONEPEZIL 7 AURO-CLOPIDOGREL 17 ACCUTANE 61 APO-DUTAERIDE 64 AURO-CYCLOBENZAPRINE 13 ACCUTREND 49 APO-ENTECAVIR 4 AURO-DONEPEZIL 7 ACCUTREND (ON) 49 APO-EZETIMIBE 18 AURO-FINAERIDE 64 ACET 29 APO-FENTANYL MATRIX 23 AURO-GABAPENTIN 32 ACET APO-FINAERIDE 64 AURO-LEVETIRACETAM 34 ACET APO-GABAPENTIN 32 AURO-MONTELUKA 51 ACET APO-HYDROMORPHONE 24 AURO-RISEDRONATE 67 ACET CODEINE APO-IMATINIB 6 AVANDIA 60 ACETAMINOPHEN 28 APO-IMIQUIMOD 61 AVODART 64 ACETYLSALICYLIC ACID 19 APO-LANSOPRAZOLE 54 AXERT 45 ACH-MONTELUKA 50 APO-LEVETIRACETAM 34 BANZEL 37 ACH-MYCOPHENOLATE 77 APO-LINEZOLID 1 BARACLUDE 4 ACH-PIOGLITAZONE 59 APO-LORAZEPAM 43 BG AR 49 ACLAA 67 APO-LORAZEPAM SL 43 BG AR (ON) 49 ACT DONEPEZIL 7 APO-METHYLPHENIDATE 41 BIO-CELECOXIB 20 ACT DUTAERIDE 64 APO-METHYLPHENIDATE ER 41 BOTOX 78 ACT EZETIMIBE 18 APO-METHYLPHENIDATE SR 41 BRILINTA 17 ACT RALOXIFENE 58 APO-MINOCYCLINE 1 BROMAZEPAM 42 ACTEMRA 76 APO-MONTELUKA 50 BUPROPION SR 37 ACT-NABILONE 53 APO-MYCOPHENOLATE 77 CAFFEINE CITRATE 81 ACTONEL 66 APO-MYCOPHENOLIC ACID 77 CAMPRAL 48 ACTOS 59 APO-OMEPRAZOLE 55 CARNITOR 50 ACT-PREGABALIN 35 APO-OXAZEPAM 44 CARNITOR IV 50 ADCIRCA 18 APO-OXYCODONE/ACET 22 CARTRIDGE FOR IR200 2ML 80 ADVAGRAF 78 APO-PANTOPRAZOLE 56 CELEBREX 20 ADVAGRAF 3MG ER CAP 77 APO-PIOGLITAZONE 59 CELECOXIB 20 ADVAIR 12 APO-PREGABALIN 35 CELLCEPT 77 ADVAIR DISKUS APO-RABEPRAZOLE 57 CELSENTRI 2 ADVAIR DISKUS APO-RALOXIFENE 58 CENTRUM JUNIOR COMPLETE 63 ADVAIR DISKUS APO-RISEDRONATE 67 CENTRUM MATERNA 63 AEROCHAMBER AC BOYZ 79 APO-RIVAIGMINE 9 CESAMET 52 AEROCHAMBER AC GIRLZ 79 APO-RIZATRIPTAN 46 CHAMPIX 15 AEROCHAMBER PLUS FLOW-VU LG AEROCHAMBER PLUS FLOW-VU MED AEROCHAMBER PLUS FLOW-VU MOUTH AEROCHAMBER PLUS FLOW-VU SM AEROTRACH PLUS ALDARA P ALENDRONATE ALENDRONATE APO-RIZATRIPTAN RPD APO-SILDENAFIL R APO-SUMATRIPTAN APO-TEMAZEPAM APO-TEMOZOLOMIDE APO-TIZANIDINE APO-TRIAZO APO-VORICONAZOLE APO-ZOLMITRIPTAN APO-ZOLMITRIPTAN RAPID APTIVUS CHAMPIX ARTER PACK CIMZIA CLARUS CLONAPAM CLOPIDOGREL CO ALENDRONATE CO BOSENTAN CO CABERGOLINE CO CELECOXIB CO CLONAZEPAM CO CLOPIDOGREL Page A-1 of 5

251 Appendix A Limited Use Benefits and Criteria Page Page Page CO FENTANYL 23 DONEPEZIL 7 ITE 49 CO FINAERIDE 64 DOINEX 48 ITE (ON) 49 CO GABAPENTIN 32 DURAGESIC MAT 23 JAMP-ACETAMINOPHEN 30 CO IMATINIB 6 DUTAERIDE 64 JAMP-ALENDRONATE 65 CO LEVETIRACETAM 34 ELIDEL 61 JAMP-ALPRAZOLAM 41 CO PANTOPRAZOLE 56 ELIQUIS 15 JAMP-ASA 19 CO PIOGLITAZONE 59 EMEND 52 JAMP-CLOPIDOGREL 17 CO RIZATRIPTAN 46 EMEND TRI PACK 52 JAMP-CYCLOBENZAPRINE 13 CO SUMATRIPTAN 46 ENABLEX 62 JAMP-DONEPEZIL 7 CO TEMAZEPAM 44 ENBREL 71 JAMP-EZETIMIBE 18 CO TEMOZOLOMIDE 7 ENBREL SURECLICK (QC) 73 JAMP-FINAERIDE 64 CODEINE 22 ENDOCET 22 JAMP-GABAPENTIN 32 CODEINE CONTIN CR 22 EURO-ASA 19 JAMP-LEVETIRACETAM 34 CODEINE PHOSPHATE 22 EVIA 58 JAMP-MONTELUKA 51 COMFORT ANGLED 17MMX110CM (10 TUBING/BOX) COMFORT ANGLED 17MMX60CM (10 TUBING/BOX) COMFORT SHORT ANGLED 13MMX110CM (10 TUBING/BOX) COMFORT SHORT ANGLED 13MMX60CM (10 TUBING/BOX) CONCERTA CONTACT DETACH 90 DEGREE 6MMX60CM CONTACT DETACH 90 DEGREE 8MMX60CM CONTOUR NEXT CONTOUR NEXT (ON) CO-RIZATRIPTAN ODT CYCLOBENZAPRINE CYMBALTA DETROL DETROL LA DEXEDRINE DEXEDRINE SPANSULE DIAZEPAM DILAUDID DOLORAL 1 DOLORAL 5 DOM-ALENDRONATE DOM-BENZYDAMINE DOM-CLONAZEPAM DOM-CLONAZEPAM-R DOM-CLOPIDOGREL DOM-CYCLOBENZAPRINE DOM-FINAERIDE DOM-GABAPENTIN DOM-LANSOPRAZOLE DOM-LEVETIRACETAM DOM-LORAZEPAM DOM-MINOCYCLINE DOM-MONTELUKA DOM-OMEPRAZOLE DR DOM-PANTOPRAZOLE DOM-PIOGLITAZONE DOM-PREGABALIN DOM-RABEPRAZOLE EC DOM-RISEDRONATE DOM-RIZATRIPTAN RDT DOM-SUMATRIPTAN DOM-TEMAZEPAM DOM-ZOLMITRIPTAN EXDOL-15 EXDOL-30 EXELON EZ HEALTH ORACLE EZ HEALTH ORACLE (ON) E-Z SPACER E-Z SPACER (MASK ONLY) E-Z SPACER WITH SMALL MASK EZETIMIBE EZETROL FENTANYL FEVERHALT FINAERIDE FLEXI-T IUD FLINTONES EXTRA C FORADIL FOSAMAX FOSAVANCE FREEYLE FREEYLE (ON) FREEYLE LITE FREEYLE LITE (ON) FREEYLE PRECISION FREEYLE PRECISION (ON) GABAPENTIN GALANTAMINE ER GALEXOS GD-CELECOXIB GD-GABAPENTIN GD-PREGABALIN GEN-CLONAZEPAM GLEEVEC HABITROL HARVONI HEPSERA HUMIRA HYDROMORPH CONTIN HYDROMORPHONE IMITREX IMITREX DF INFANTOL INSET II 90 DEGREE 6MMX110CM INSET II 90 DEGREE 6MMX60CM INSET II 90 DEGREE 9MMX110CM INSET II 90 DEGREE 9MMX60CM INTELENCE INVEGA SUENNA ISENTRESS JAMP-MULTIVITAMIN A/D/C DROPS JAMP-MYCOPHENOLATE JAMP-OMEPRAZOLE DR JAMP-PANTOPRAZOLE JAMP-PIOGLITAZONE JAMP-RISEDRONATE JAMP-RIZATRIPTAN JAMP-RIZATRIPTAN IR JAMP-ZOLMITRIPTAN JAMP-ZOLMITRIPTAN ODT JANUMET JANUMET XR JANUVIA JAYDESS JENTADUETO KADIAN KEPPRA KOMBOGLYZE LANSOPRAZOLE LANSOPRAZOLE-15 LANSOPRAZOLE-30 LECTOPAM LEVETIRACETAM LIBERTE UT380 SHORT LIBERTE UT380 ANDARD LINCTUS CODEINE LINEZOLID LORAZEPAM LOSEC LOWPRIN LYRICA M.O.S. M.O.S. 10 M.O.S. 20 M.O.S. 40 M.O.S. 50 M.O.S. 60 M.O.S. SR M.O.S. SULFATE MAR-CELECOXIB MAR-CLOPIDOGREL MAR-DONEPEZIL MAR-EZETIMIBE MAR-GABAPENTIN MAR-GALANTAMINE ER MAR-MONTELUKA MAR-PANTOPRAZOLE Page A-2 of 5

252 Appendix A Limited Use Benefits and Criteria Page Page Page MAR-PREGABALIN MAR-RIZATRIPTAN MAR-ZOLMITRIPTAN MAXALT MAXALT RPD MED-DUTAERIDE MEDI+SURE MEDI+SURE (ON) MED-RIVAIGMINE M-ESLON METADOL METHADONE METHADOSE METHADOSE DELIV. W DIRECT INT METHADOSE DELIV. W/OUT DIRECT METHADOSE W/OUT DIRECT INTERA METHADOSE DIRECT INTERACTION METHADOSE SUGARFREE METHYLPHENIDATE MINOCYCLINE MINT-ALENDRONATE MINT-CELECOXIB MINT-CLOPIDOGREL MINT-DUTAERIDE MINT-EZETIMIBE MINT-FINAERIDE MINT-MONTELUKA MINT-PANTOPRAZOLE MINT-PIOGLITAZONE MINT-PREGABALIN MINT-RIVAIGMINE MINT-ZOLMITRIPTAN MINT-ZOLMITRIPTAN ODT MIO BLUE 6MMX18" MIO BLUE 6MMX23" MIO CLEAR 6MMX32" MIO CLEAR 9MMX32" MIO PINK 6MMX18" MIO PINK 6MMX23" MIRENA MOGADON MONA LISA 10 MONA LISA 5 MONA LISA N MONTELUKA MONUROL MORPHINE SR MS CONTIN SR MS IR MULTI-PRE AND PO NATAL MYCOPHENOLATE MYFORTIC MYLAN ZOLMITRIPTAN MYLAN-ALENDRONATE MYLAN-ALMOTRIPTAN MYLAN-ALPRAZOLAM MYLAN-BOSENTAN MYLAN-BUPROPION XL MYLAN-CELECOXIB MYLAN-CLONAZEPAM MYLAN-CLOPIDOGREL MYLAN-CYCLOPRINE MYLAN-DONEPEZIL MYLAN-EZETIMIBE MYLAN-FENTANYL MATRIX MYLAN-FINAERIDE MYLAN-GABAPENTIN MYLAN-GALANTAMINE ER MYLAN-LANSOPRAZOLE MYLAN-MINOCYCLINE MYLAN-MONTELUKA MYLAN-MYCOPHENOLATE MYLAN-OMEPRAZOLE MYLAN-PANTOPRAZOLE MYLAN-PIOGLITAZONE MYLAN-RABEPRAZOLE MYLAN-RISEDRONATE MYLAN-RIVAIGMINE MYLAN-RIZATRIPTAN ODT MYLAN-SUMATRIPTAN MYLAN-ZOLMITRIPTAN ODT MYL-PREGABALIN NEORAL NEURONTIN NICODERM NICORETTE NICORETTE LOZENGE NICORETTE PLUS NICOTINE GUM NICOTROL TRANSDERMAL NOVA-T IUD NOVO-FINAERIDE NOVO-GABAPENTIN NOVO-GESIC NOVO-LANSOPRAZOLE NOVO-LORAZEM NOVO-METHYLPHENIDATE ER NOVO-MINOCYCLINE NOVO-MORPHINE SR NOVO-NARATRIPTAN NOVO-PANTOPRAZOLE NOVO-PIOGLITAZONE NOVO-RABEPRAZOLE NOVO-RALOXIFENE NOVO-RISEDRONATE NOVO-RIVAIGMINE NOVO-SUMATRIPTAN NOVO-SUMATRIPTAN DF NOVO-TEMAZEPAM OMEPRAZOLE OMEPRAZOLE MAGNESIUM DR OMEPRAZOLE-20 ONBREZ BREEZHALER ONE TOUCH ULTRA ONE TOUCH ULTRA (ON) ONE TOUCH VERIO ONE TOUCH VERIO (ON) ONGLYZA OPTICHAMBER OPTICHAMBER DIAMOND (CHAMBER) OPTICHAMBER DIAMOND (LARGE M) OPTICHAMBER DIAMOND (MEDIUM M) OPTICHAMBER LARGE MASK OPTICHAMBER MEDIUM MASK OPTICHAMBER SMALL MASK OPTIHALER ORENCIA OXAZEPAM OXEZE TURBUHALER OXPAM OXYCODONE OXYCODONE/ACET OXY-IR PANTOLOC PANTOPRAZOLE PANTOPRAZOLE-40 PARADIGM SILHOUETTE 13MMX18" PARADIGM SILHOUETTE 13MMX23" PARADIGM SILHOUETTE 13MMX32" PARADIGM SILHOUETTE 13MMX43" PARADIGM SILHOUETTE 17MMX23" PARADIGM SILHOUETTE 17MMX32" PARADIGM SILHOUETTE 17MMX43" PARADIGM SILHOUETTE CANNULA 13MM PARADIGM SILHOUETTE CANNULA 17MM PARADIGM SURE-T 29G 6MMX18" PARADIGM SURE-T 29G 6MMX23" PARADIGM SURE-T 29G 8MMX23" PARIET EC PAT-GALANTAMINE ER PEDIAPHEN PEDIAPHEN CHEWABLE PEDIATRIX PEDIAVIT PEGASYS PEGASYS RBV PEGETRON PEGETRON REDIPEN PERCOCET PERCOCET DEMI PHL-CLONAZEPAM PHL-CLONAZEPAM-R 0.5MG PHL-CYCLOBENZAPRINE PHL-PIOGLITAZONE PIOGLITAZONE PLAVIX PMS CLOPIDOGREL PMS-ACETAMINOPHEN PMS-ACETAMINOPHEN WITH CODEINE PMS-ALENDRONATE PMS-ALENDRONATE FC PMS-BENZYDAMINE Page A-3 of 5

253 Appendix A Limited Use Benefits and Criteria Page Page Page PMS-BOSENTAN 19 PRIVA-CELECOXIB 20 RATIO-LENOLTEC NO.3 21 PMS-BUPROPION SR 37 PRIVA-EZETIMIBE 18 RATIO-MINOCYCLINE 1 PMS-CELECOXIB 20 PRIVA-PANTOPRAZOLE 56 RATIO-MORPHINE 25 PMS-CLONAZEPAM 30 PRO-ASA 80MG EC TAB 19 RATIO-OMEPRAZOLE 55 PMS-CLONAZEPAM R 31 PRO-ASA 80MG TAB 19 RATIO-OXYCOCET 22 PMS-CODEINE 22 PROCET RATIO-OXYCODAN 22 PMS-CYCLOBENZAPRINE 13 PRO-CLONAZEPAM 31 RATIO-PIOGLITAZONE 59 PMS-DIAZEPAM 42 PRO-GABAPENTIN 32 RATIO-RIVAIGMINE 9 PMS-DICLOFENAC 21 PROGRAF 77 RATIO-SILDENAFIL R 18 PMS-DONEPEZIL 7 PRO-LEVETIRACETAM 34 RATIO-TEMAZEPAM 44 PMS-DUTAERIDE 64 PROLIA 66 REMICADE 76 PMS-ENTECAVIR 4 PRO-LORAZEPAM 43 REMINYL ER 8 PMS-EZETIMIBE 18 PROMETRIUM 61 RESERVOIR 5XX 1.8ML SYRINGE 81 PMS-FENTANYL MTX 23 PRO-OXYCOD ACET 22 RESERVOIR PARADIGM 7XX3.0ML 81 PMS-FINAERIDE 64 PRO-PIOGLITAZONE 59 REORIL 44 PMS-GABAPENTIN 32 PRO-RABEPRAZOLE 57 REVATIO 18 PMS-GALANTAMINE ER 8 PROSCAR 64 RISEDRONATE 67 PMS-HYDROMORPHONE 24 PROTOPIC 62 RISEDRONATE PMS-LANSOPRAZOLE 53 QUICK-SET 6MMX18" 81 RISPERDAL CONA 39 PMS-LEVETIRACETAM 34 QUICK-SET 6MMX23" 81 RITUXAN 6 PMS-LORAZEPAM 43 QUICK-SET 6MMX32" 81 RIVA CLOPIDOGREL 17 PMS-METHYLPHENIDATE 41 QUICK-SET 6MMX43" 81 RIVA OXAZEPAM 44 PMS-METHYLPHENIDATE ER 40 QUICK-SET 9MMX23" 81 RIVA-ALENDRONATE 65 PMS-MINOCYCLINE 1 QUICK-SET 9MMX32" 81 RIVA-ALPRAZOLAM 41 PMS-MONOCYCLINE 1 QUICK-SET 9MMX43" 81 RIVA-CELECOX 20 PMS-MONTELUKA 50 RABEPRAZOLE 57 RIVA-CLONAZEPAM 31 PMS-NABILONE 53 RABEPRAZOLE EC 57 RIVACOCET 22 PMS-OMEPRAZOLE 55 RALOXIFENE 58 RIVA-CYCLOBENZAPRINE 13 PMS-OXYCODONE 28 RAN-ALENDRONATE 65 RIVA-DONEPEZIL 7 PMS-PANTOPRAZOLE 56 RAN-CELECOXIB 20 RIVA-DUTAERIDE 64 PMS-PIOGLITAZONE 59 RAN-CLOPIDOGREL 17 RIVA-EZETIMIBE 18 PMS-PREGABALIN 35 RAN-DONEPEZIL 7 RIVA-GABAPENTIN 32 PMS-RABEPRAZOLE 57 RAN-EZETIMIBE 18 RIVA-LANSOPRAZOLE 53 PMS-RALOXIFENE 58 RAN-FENTANYL MATRIX 23 RIVA-MINOCYCLINE 1 PMS-RISEDRONATE 67 RAN-FINAERIDE 64 RIVA-MOTELUKA 51 PMS-RIVAIGMINE 9 RAN-GABAPENTIN 32 RIVA-OMEPRAZOLE DR 55 PMS-RIZATRIPTAN RDT 45 RAN-LANSOPRAZOLE 53 RIVA-PANTOPRAZOLE 56 PMS-SILDENAFIL R 18 RAN-LEVETIRACETAM 34 RIVA-PREGABALIN 35 PMS-SUMATRIPTAN 46 RAN-MONTELUKA 51 RIVA-RABEPRAZOLE 57 PMS-ZOLMITRIPTAN 47 RAN-NABILONE 52 RIVA-RABEPRAZOLE EC 57 PMS-ZOLMITRIPTAN ODT 47 RAN-OMEPRAZOLE 55 RIVA-RISEDRONATE 67 POCKET CHAMBER 79 RAN-PANTOPRAZOLE 56 RIVA-RIZATRIPTAN ODT 45 POCKET CHAMBER WITH ADULT MASK POCKET CHAMBER WITH INFANT MASK POCKET CHAMBER WITH MEDIUM MASK POCKET CHAMBER WITH SMALL MASK PODS POLY-VI-SOL PRECISION XTRA PRECISION XTRA (ON) PREGABALIN PREGABALIN-150 PREGABALIN-25 PREGABALIN-50 PREGABALIN-75 PRENATAL & POPARTUM PRENATAL AND POPARTUM PREVACID PREVACID FAAB RAN-PIOGLITAZONE RAN-PREGABALIN RAN-RABEPRAZOLE RAPAMUNE RAPID-D 10MM/110CM RAPID-D 10MM/60CM RAPID-D 10MM/80CM RAPID-D 6MM/110CM RAPID-D 6MM/60CM RAPID-D 6MM/80CM RAPID-D 8MM/110CM RAPID-D 8MM/60CM RAPID-D 8MM/80CM RATIO-BUPROPION RATIO-CODEINE RATIO-CYCLOBENZAPRINE RATIO-EMTEC-30 RATIO-FINAERIDE RATIO-GABAPENTIN RATIO-LENOLTEC NO RIVASA RIVAIGMINE RIVA-ZOLMITRIPTAN RIVOTRIL RIZATRIPTAN RDT SANDOZ ALENDRONATE SANDOZ ALENDRONATE/CHOLECALCIFER OL SANDOZ ALMOTRIPTAN SANDOZ BOSENTAN SANDOZ CELECOXIB SANDOZ CLOPIDOGREL SANDOZ DONEPEZIL SANDOZ DUTAERIDE SANDOZ EZETIMIBE SANDOZ FENTANYL SANDOZ FINAERIDE SANDOZ LANSOPRAZOLE SANDOZ LINEZOLID Page A-4 of 5

254 Appendix A Limited Use Benefits and Criteria Page Page Page SANDOZ MONTELUKA 50 TENDER-1 17MM/80CM 79 VICTRELIS 5 SANDOZ MORPHINE SR 26 TENDER-2 "MINI" 13MM/110CM 80 VICTRELIS TRIPLE 5 SANDOZ MYCOPHENOLATE 77 TENDER-2 "MINI" 13MM/60CM 80 VIMPAT 34 SANDOZ NARATRIPTAN 45 TENDER-2 "MINI" 13MM/80CM 80 VIREAD 2 SANDOZ OMEPRAZOLE 55 TENDER-2 17MM/110CM 79 VISANNE 61 SANDOZ OXYCODONE ACET 22 TENDER-2 17MM/60CM 79 VISUDYNE 52 SANDOZ PIOGLITAZONE 59 TENDER-2 17MM/80CM 79 VITAMIN E 63 SANDOZ PREGABALIN 35 TEVA- MONTELUKA 50 VITAMIN E NATUAL SOURCE 63 SANDOZ RISEDRONATE 67 TEVA-ALENDRONATE 65 VOLIBRIS 19 SANDOZ RIVAIGMINE SANDOZ RIZATRIPTAN ODT SANDOZ TACROLIMUS SANDOZ VORICONAZOLE SANDOZ ZOLMITRIPTAN SANDOZ ZOLMITRIPTAN ODT SANDOZ-BUPROPION SR SANDOZ-CLONAZEPAM SANDOZ-CYCLOSPORINE SANDOZ-METHYLPHENIDATE SR SANDOZ-MINOCYCLINE SANDOZ-MYCOPHENOLATE SANDOZ-PANTOPRAZOLE SANDOZ-RABEPRAZOLE SANDOZ-SUMATRIPTAN SAPHRIS SEEBRI BREEZHALER SEPTA-DONEPEZIL SEPTA-ZOLMITRIPTAN-ODT SEREVENT DISKHALER SEREVENT DISKUS SIDEKICK SIMPONI AUTO INJECTOR SIMPONI PRE-FILLED SYRINGE SINGULAIR SORIATANE SOVALDI SPIRIT CARTRIDGE 3.15ML SPIRIVA ATEX ELARA SUBOXONE SUMATRIPTAN SUMATRIPTAN DF SUPEUDOL SUTENT SYMBICORT 100 TURBUHALER SYMBICORT 200 TURBUHALER TANTAPHEN TARCEVA TARO-DICLOFENAC TARO-SUMATRIPTAN TARO-ZOLEDRONIC ACID TECTA TEMAZEPAM TEMODAL TEMPRA TEMPRA DOUBLE RENGTH TENDER-1 "MINI" 13MM/110CM TENDER-1 "MINI" 13MM/60CM TENDER-1 "MINI" 13MM/80CM TENDER-1 17MM/110CM TENDER-1 17MM/60CM TEVA- ALENDRONATE/CHOLECALCIFER OL TEVA-ALPRAZOL TEVA-BENZYDAMINE TEVA-BOSENTAN TEVA-BROMAZEPAM TEVA-CELECOXIB TEVA-CLONAZEPAM TEVA-CLOPIDOGREL TEVA-CYCLOPRINE TEVA-DONEPEZIL TEVA-DUTAERIDE TEVA-EZETIMIBE TEVA-FENTANYL TEVA-GALANTAMINE ER TEVA-HYDROMORPHONE TEVA-IMATINIB TEVA-MYCOPHENOLATE TEVA-NABILONE TEVA-OMEPRAZOLE TEVA-PREGABALIN TEVA-RIZATRIPTAN RDT TEVA-VORICONAZOLE TEVA-ZOLMITRIPTAN TEVA-ZOLMITRIPTAN OD THRIVE TR- VI-SOL TRACLEER TRAJENTA TRANSDERMAL NICOTINE TRIATEC-30 TROSEC TRUETE TRUETRACK TRUETRACK (ON) TUDORZA GENUAIR TYLENOL TYLENOL EXTRA RENGTH TYLENOL JR RENGTH FAMELTS TYLENOL JUNIOR RENGTH TYLENOL WITH CODEINE NO.2 TYLENOL WITH CODEINE NO.3 ULTRAFLEX MM/110CM ULTRAFLEX MM/60CM ULTRAFLEX MM/80CM ULTRAFLEX - 1 8MM/110CM ULTRAFLEX - 1 8MM/60CM ULTRAFLEX - 1 8MM/80CM VALIUM VESICARE VFEND VYVANSE WELLBUTRIN SR WELLBUTRIN XL XANAX XANAX TS XARELTO XEOMIN XGEVA ZANAFLEX ZELDOX ZENHALE ZOLEDRONIC ACID ZOLMITRIPTAN ZOLMITRIPTAN ODT ZOMIG ZOMIG RAPIMELT ZYBAN ZYM-CLONAZEPAM ZYM-PIOGLITAZONE ZYVOXAM Page A-5 of 5

255 APPENDIX B SPECIAL FORMULARY FOR CHRONIC RENAL FAILURE PATIENTS

256 Appendix B Special Formulary for Chronic Renal Failure Patients The Special Formulary for Chronic Renal Failure Patients defines selected drugs (for example: darbepoetin alfa, calcium products, water-soluble multivitamin products and selected nutritional products formulated for renal patients) that are covered for identified eligible NIHB clients in chronic renal failure. These drugs are covered in addition to the drugs and products listed in the NIHB Drug Benefit List. 20:00 BLOOD FORMATION COAGULATION AND THROMBOSIS 20:16.00 HEMATOPOIETIC AGENTS DARBEPOETIN ALFA 25mcg/mL Injection ARANESP AMG 40mcg/mL Injection ARANESP AMG 100mcg/mL Injection ARANESP AMG 200mcg/mL Injection ARANESP AMG 500mcg/mL Injection ARANESP AMG EPOETIN ALFA 20,000IU/mL Injection EPREX JNO 20000IU/0.5mL injection EPREX JNO 5,000IU/mL Injection EPREX JNO 30000IU/0.75mL Injection EPREX JNO 1,000IU/0.5mL Prefilled Syringe EPREX JNO 2,000IU/0.5mL Prefilled Syringe EPREX JNO 3,000IU/0.3mL Prefilled Syringe EPREX JNO 4,000IU/0.4mL Prefilled Syringe EPREX JNO 6,000IU/0.6mL Prefilled Syringe EPREX JNO 8,000IU/0.8mL Prefilled Syringe EPREX JNO 10,000IU/mL Prefilled Syringe EPREX JNO 40,000IU/mL Prefilled Syringe EPREX JNO 40:00 ELECTROLYTIC, CALORIC, AND WATER BALANCE 40:12.00 REPLACEMENT PREPARATIONS CALCIUM (CALCIUM GLUCONOLACTATE, CALCIUM CARBONATE) 300mg & 2940mg Effervescent Tablet CALCIUM SANDOZ NVC 1750mg & 2327mg Effervescent Tablet GRAMCAL NVC CALCIUM CARBONATE 500mg Capsule CALSAN NVC 500mg Chewable Tablet CALCIUM WAM CALSAN NVC 250mg Tablet APO-CAL 250 APX CALCIUM TEV PHOSPHORUS 500mg Effervescent Tablet PHOSPHATE-NOVARTIS NVR ZINC GLUCONATE 50mg Tablet ZINC VTH ZINC JAM 56:00 GAROINTEINAL DRUGS 56:04.00 ANTACIDS AND ADSORBENTS ALUMINUM HYDROXIDE 500mg Capsule BASALJEL AXC 60mg/mL Liquid ALUGEL ATL 64mg/mL Liquid AMPHOJEL AXC 600mg Tablet AMPHOJEL AXC CALCIUM CARBONATE 500mg Tablet TUMS GSK 750mg Tablet TUMS EXTRA RENGTH GSK 1000mg Tablet TUMS ULTRA RENGTH GSK Page B-1 of 2

257 Appendix B Special Formulary for Chronic Renal Failure Patients The Special Formulary for Chronic Renal Failure Patients defines selected drugs (for example: darbepoetin alfa, calcium products, water-soluble multivitamin products and selected nutritional products formulated for renal patients) that are covered for identified eligible NIHB clients in chronic renal failure. These drugs are covered in addition to the drugs and products listed in the NIHB Drug Benefit List. 88:00 VITAMINS 88:12.00 VITAMIN C VITAMIN B COMPLEX Tablet B COMPLEX PLUS C JAM VITAMIN B COMPLEX WITH VITAMIN C Tablet DIAMINE EUR 88:28.00 MULTIVITAMIN PREPARATIONS MULTIVITAMINS Tablet REPLAVITE WNP RESS PLEX C JAM 96:00 PHARMACEUTICAL AIDS 96:00.00 PHARMACEUTICAL AIDS NUTRITIONAL SUPPLEMENT Liquid NOVASOURCE RENAL NES Liquid NEPRO ABB NOVASOURCE NVR SUPLENA ABB 235mL Liquid NEPRO ABB SUPLENA ABB Powder RESOURCE BENEPROTEIN NVR Page B-2 of 2

258 Appendix B Special Formulary for Chronic Renal Failure Patients ALUGEL ALUMINUM HYDROXIDE AMPHOJEL APO-CAL 250 ARANESP B COMPLEX PLUS C BASALJEL CALCIUM CALCIUM (CALCIUM GLUCONOLACTATE, CALCIUM CARBONATE) CALCIUM CARBONATE CALCIUM SANDOZ CALSAN DARBEPOETIN ALFA DIAMINE EPOETIN ALFA EPREX GRAMCAL MULTIVITAMINS NEPRO NOVASOURCE NUTRITIONAL SUPPLEMENT PHOSPHATE-NOVARTIS PHOSPHORUS REPLAVITE RESOURCE BENEPROTEIN RESS PLEX C SUPLENA TUMS TUMS EXTRA RENGTH TUMS ULTRA RENGTH VITAMIN B COMPLEX VITAMIN B COMPLEX WITH VITAMIN C ZINC ZINC GLUCONATE Page Page B-1 of 1

259 APPENDIX C PALLIATIVE CARE FORMULARY

260 Appendix C Palliative Care Formulary Effective April 1, 2009, recipients diagnosed with a terminal illness and are near the end of life will be eligible to receive a list of supplemental benefits that are not included in the NIHB Drug Benefit List. The Palliative Care Formulary includes medications used to provide comfort to those near the end of life. Requests for any of the DINs below will generate a Palliative Care Application Form, faxed to the prescribing physician. Once completed and submitted, the recipient will be eligible for all medications on the Palliative Care Formulary if the following criteria are met: The recipient: 1. is not receiving care in a provincially funded hospital or provincially funded long-term care facility and 2. has been diagnosed with a terminal illness or disease which is expected to be the primary cause of death within six months or less Once approved, the recipient will be eligible for all medications on the Palliative Care Formulary for six months without the need for further prior approval. If coverage is required beyond the initial six months, an additional six months may be granted upon receipt of another Palliative Care Application Form completed. Please note: During the six month coverage period, a maximum 30 day supply will be reimbursed at any one time. 12:00 AUTONOMIC DRUGS 12:08.08 ANTIMUSCARINICS / ANTISPASMODICS ATROPINE SULFATE 0.4mg/mL Injection ATROPINE SULFATE SDZ 12:08.08 ANTIMUSCARINICS / ANTISPASMODICS SCOPOLAMINE HYDROBROMIDE 0.6mg/mL Injection SCOPOLAMINE ABB ATROPINE SULFATE SDZ 0.6mg/mL Injection ATROPINE SULFATE GSK ATROPINE SULFATE SDZ GLYCOPYRROLATE 0.2mg/mL Injection GLYCOPYRROLATE SDZ HYOSCINE BUTYLBROMIDE 20mg/mL Injection BUSCOPAN BOE HYOSCINE SDZ SCOPOLAMINE HYDROBROMIDE 0.4mg/mL Injection SCOPOLAMINE ABB Page C-1 of 5

261 Appendix C Palliative Care Formulary Effective April 1, 2009, recipients diagnosed with a terminal illness and are near the end of life will be eligible to receive a list of supplemental benefits that are not included in the NIHB Drug Benefit List. The Palliative Care Formulary includes medications used to provide comfort to those near the end of life. Requests for any of the DINs below will generate a Palliative Care Application Form, faxed to the prescribing physician. Once completed and submitted, the recipient will be eligible for all medications on the Palliative Care Formulary if the following criteria are met: The recipient: 1. is not receiving care in a provincially funded hospital or provincially funded long-term care facility and 2. has been diagnosed with a terminal illness or disease which is expected to be the primary cause of death within six months or less Once approved, the recipient will be eligible for all medications on the Palliative Care Formulary for six months without the need for further prior approval. If coverage is required beyond the initial six months, an additional six months may be granted upon receipt of another Palliative Care Application Form completed. Please note: During the six month coverage period, a maximum 30 day supply will be reimbursed at any one time. 28:00 CENTRAL NERVOUS SYEM AGENTS 28:08.08 OPIATE AGONIS FENTANYL 12mcg/HR Transdermal Patch CO FENTANYL CBT 28:08.08 OPIATE AGONIS FENTANYL 25mcg/HR Transdermal Patch APO-FENTANYL MATRIX APX CO FENTANYL CBT FENTANYL PDL DURAGESIC MAT JNO MYLAN-FENTANYL MATRIX MYL FENTANYL PDL PMS-FENTANYL MTX PMS MYLAN-FENTANYL MATRIX MYL RAN-FENTANYL MATRIX RBY PMS-FENTANYL MTX PMS SANDOZ FENTANYL SDZ RAN-FENTANYL MATRIX RBY TEVA-FENTANYL TEV SANDOZ FENTANYL SDZ TEVA-FENTANYL TEV Page C-2 of 5

262 Appendix C Palliative Care Formulary Effective April 1, 2009, recipients diagnosed with a terminal illness and are near the end of life will be eligible to receive a list of supplemental benefits that are not included in the NIHB Drug Benefit List. The Palliative Care Formulary includes medications used to provide comfort to those near the end of life. Requests for any of the DINs below will generate a Palliative Care Application Form, faxed to the prescribing physician. Once completed and submitted, the recipient will be eligible for all medications on the Palliative Care Formulary if the following criteria are met: The recipient: 1. is not receiving care in a provincially funded hospital or provincially funded long-term care facility and 2. has been diagnosed with a terminal illness or disease which is expected to be the primary cause of death within six months or less Once approved, the recipient will be eligible for all medications on the Palliative Care Formulary for six months without the need for further prior approval. If coverage is required beyond the initial six months, an additional six months may be granted upon receipt of another Palliative Care Application Form completed. Please note: During the six month coverage period, a maximum 30 day supply will be reimbursed at any one time. 28:08.08 OPIATE AGONIS FENTANYL 50mcg/HR Transdermal Patch APO-FENTANYL MATRIX APX 28:08.08 OPIATE AGONIS FENTANYL 75mcg/HR Transdermal Patch APO-FENTANYL MATRIX APX CO FENTANYL CBT CO FENTANYL CBT DURAGESIC MAT JNO DURAGESIC MAT JNO FENTANYL PDL FENTANYL PDL MYLAN-FENTANYL MATRIX MYL MYLAN-FENTANYL MATRIX MYL PMS-FENTANYL MTX PMS PMS-FENTANYL MTX PMS RAN-FENTANYL MATRIX RBY RAN-FENTANYL MATRIX RBY SANDOZ FENTANYL SDZ SANDOZ FENTANYL SDZ TEVA-FENTANYL TEV TEVA-FENTANYL TEV Page C-3 of 5

263 Appendix C Palliative Care Formulary Effective April 1, 2009, recipients diagnosed with a terminal illness and are near the end of life will be eligible to receive a list of supplemental benefits that are not included in the NIHB Drug Benefit List. The Palliative Care Formulary includes medications used to provide comfort to those near the end of life. Requests for any of the DINs below will generate a Palliative Care Application Form, faxed to the prescribing physician. Once completed and submitted, the recipient will be eligible for all medications on the Palliative Care Formulary if the following criteria are met: The recipient: 1. is not receiving care in a provincially funded hospital or provincially funded long-term care facility and 2. has been diagnosed with a terminal illness or disease which is expected to be the primary cause of death within six months or less Once approved, the recipient will be eligible for all medications on the Palliative Care Formulary for six months without the need for further prior approval. If coverage is required beyond the initial six months, an additional six months may be granted upon receipt of another Palliative Care Application Form completed. Please note: During the six month coverage period, a maximum 30 day supply will be reimbursed at any one time. 28:08.08 OPIATE AGONIS FENTANYL 100mcg/HR Transdermal Patch APO-FENTANYL MATRIX APX 28:16.08 ANTIPSYCHOTIC AGENTS METHOTRIMEPRAZINE 25mg/mL Injection NOZINAN SAC CO FENTANYL CBT DURAGESIC MAT JNO FENTANYL PDL 28:24.08 ANXIOLYTICS, SEDATIVES AND HYPNOTICS - BENZODIAZEPINES DIAZEPAM 5mg/mL Injection DIAZEMULS VL ACG MYLAN-FENTANYL MATRIX MYL DIAZEPAM SDZ PMS-FENTANYL MTX PMS RAN-FENTANYL MATRIX RBY LORAZEPAM 4mg/mL Injection LORAZEPAM SDZ SANDOZ FENTANYL SDZ TEVA-FENTANYL TEV MIDAZOLAM 1mg/mL Injection MIDAZOLAM SDZ FENTANYL CITRATE 50mcg/mL Injection FENTANYL CITRATE HOS MIDAZOLAM PPC MIDAZOLAM TEV FENTANYL CITRATE SDZ Page C-4 of 5

264 Appendix C Palliative Care Formulary Effective April 1, 2009, recipients diagnosed with a terminal illness and are near the end of life will be eligible to receive a list of supplemental benefits that are not included in the NIHB Drug Benefit List. The Palliative Care Formulary includes medications used to provide comfort to those near the end of life. Requests for any of the DINs below will generate a Palliative Care Application Form, faxed to the prescribing physician. Once completed and submitted, the recipient will be eligible for all medications on the Palliative Care Formulary if the following criteria are met: The recipient: 1. is not receiving care in a provincially funded hospital or provincially funded long-term care facility and 2. has been diagnosed with a terminal illness or disease which is expected to be the primary cause of death within six months or less Once approved, the recipient will be eligible for all medications on the Palliative Care Formulary for six months without the need for further prior approval. If coverage is required beyond the initial six months, an additional six months may be granted upon receipt of another Palliative Care Application Form completed. Please note: During the six month coverage period, a maximum 30 day supply will be reimbursed at any one time. 28:24.08 ANXIOLYTICS, SEDATIVES AND HYPNOTICS - BENZODIAZEPINES MIDAZOLAM 5mg/mL Injection MIDAZOLAM SDZ MIDAZOLAM PPC MIDAZOLAM TEV 56:00 GAROINTEINAL DRUGS 56:32.00 PROKINETIC AGENTS METOCLOPRAMIDE 5mg/mL Injection METOCLOPRAMIDE SDZ METOCLOPRAMIDE OMEGA OMG 56:92.00 MISCELLANEOUS GI DRUGS METHYLNALTREXONE BROMIDE 20mg/mL Injection RELIOR WYE Page C-5 of 5

265 APPENDIX D LI OF DRUG MANUFACTURERS

266 Appendix D List of Drug Manufacturers MFR Manufacturer Name MFR Manufacturer Name AAP AA PHARMA INC. BMI BIOMED 2002 INCORPORATED ABB ABBOTT LABORATORIES LIMITED BMS BRIOL-MYERS SQUIBB CANADA ACG ACN ACP ADA ALC ALG ALK ALL AMG APX A ATL AUC AUR AXC AXL AXX AZC BAK ACTAVIS GROUP PTC EHF ACTELION PHARMACEUTICALS LTD ACCEL PHARMA INC ADAMS LABS LIMITED ALCON CANADA INCORPORATED ALLERGOLOGISK LAB A/S ALK ABELLO A/S ALLERGAN INCORPORATED AMGEN CANADA INCORPORATED APOTEX INCORPORATED AELLAS PHARMA CANADA INCORPORATED LABORATORIE ATLAS INCORPORATED AUTO CONTROL AURO PHARMA INC AXCAN PHARMA INCORPORATED ALLEREX LABORATORY LIMITED AXXESS PHARMA INCORPORATED ARAZENECA CANADA INCORPORATED BAKER CUMMINS INCORPORATED. BOE BPC BSH CDX CEN CIP COB COP CUV CYX DCM DDP DER DKT BOEHRINGER INGELHEIM (CANADA) LIMITED BIOVAIL PHARMACEUTICALS CANADA BAUSCH & LOMB CANADA INCORPORATED CANDERM PHARMA CENTOCOR INCORPORATED CIPHER PHARMACEUTICALS INCORPORATED COBALT PHARMACEUTICALS INCORPORATED COLGATE ORAL PHRAMACEUTICALS INCORPORATED CHAUVIN PHARMACEUTICALS LIMITED CYTEX PHARMACEUTICALS INCORPORATED D & C MOBILITY THE D DROPS COMPANY INCORPORATED DERMIK LABORATORIES CANADA INCORPORATED DIOPTIC LABORATORIES INCORPORATED BAR BARR PHARMACEUTICALS INCORPORATED DOR DORMER LABORATORIES INCORPORATED BAT BAXTER CORPORATION DPC DOMINION PHARMACAL BAX BRAINTREE LAB INCORPORATED DPI DOMREX PHARMA INC BAY BCD BDH BEN BEX BIO BAYER INCORPORATED, HEALTHCARE/DIAGNOICS BAYER INCORPORATED, CONSUMER CARE DIVISION BDH INCORPORATED BENCARD ALLERGY LABORATORIES BERLEX CANADA INCORPORATED BIONICHE PHARMA (CANADA) LIMITED DPY DSP DUI EDM ELN ERF EUR DRAXIS HEALTH INCORPORATED DISPENSA PHARM CANADA LIMITED DUCHESNAY INCORPORATED ENDO CANADA INCORPORATED ELAN PHARMACEUTICALS INCORPORATED ERFA CANADA INCORPORATED EURO-PHARM INTERNATIONAL CANADA INCORPORATED Page D-1 of 4

267 Appendix D List of Drug Manufacturers MFR Manufacturer Name MFR Manufacturer Name FEI FOU FRS GAC GCL GEE GIL GLE GMP GSC GSK HIL HJS HLR HOL HOR HOS HPC HRA ICN IDE IMX IPS IVX JAJ JAM JLF JMP JNO KEY FERRING INCORPORATED FOURNIER PHARMA INCORPORATED MERCK FROS CANADA LIMITED GALDERMA CANADA INCORPORATED GALEN CHEMICALS LIMITED GENZYME CANADA INCORPORATED GILEAD SCIENCES INCORPORATED GLENWOOD LABORATORIES CANADA LIMITED GENERIC MEDICAL PARTNERS INC GELDA SCIENTIFIC & INDURIAL DEVELOPMENT CORP GLAXOSMITHKLINE INCORPORATED HILL DERMACEUTICALS INCORPORATED H.J. SUTTON INDURIES LIMITED HOFFMAN-LAROCHE LIMITED HOLLIER LIMITED CARTER-HORNER CORPORATION HOSPIRA HEALTHCARE CORPORATION HEALTHPOINT CANADA ULC HRA PHARMA ICN CANADA LIMITED INTERNATIONAL DERMATOLOGICALS INCORPORATED IMMUNEX CORPORATION IPSEN LIMITED IVAX PHARMACEUTICALS INCORPORATED. JOHNSON & JOHNSON C.E. JAMIESON COMPANY LIMITED J.L.FREEMAN JAMP PHARMA CORPORATION JANSSEN-ORTHO INCORPORATED KEY PHARMACEUTICALS INCORPORATED LAL LEO LIL LUD MAB MAN MAR MAY MCA MCL MDC MDS MDT MEL MET MEZ MIN MJO MMH MMT MPD MSL MSP MTH MTI MYL NCA NEO LABORATOIRE LALCO INCORPORATED LEO PHARMA INCORPORATED ELI LILLY CANADA INCORPORATED LUNDBECK CANADA INCORPORATED MEDA AB MANTRA PHARMA INC MARCAN PHARMACEUTICALS INC MAYNE PHARMA (CANADA) INCORPORATED MCARTHUR MEDICAL SALES INCORPORATED MCNEIL CONSUMER PRODUCTS COMPANY MEDICIS CANADA CORPORATION MEDISCA PHARMACEUTIQUE INC MEDTRONIC OF CANADA LIMITED MELIAPHARM INC MEDICAL TEXTILES MARKETING INCORPORATED MERZ PHARMACEUTICALS GMBH MINT PHARMACEUTICALS INCORPORATED MEAD JOHNSON CANADA INCORPORATED 3M PHARMACEUTICALS MM THERAPEUTICS INC. MEDICAL PLAIC DEVICES INCORPORATED MEDIC SAVOURE LIMITED MERCK FROS / SCHERING PHARMA GP MM THERAPEUTICS INC MEDICAN TECHNOLOGIES INCORPORATED MYLAN PHARMACEUTICALS ULC NOVA DIABETES CARE NEOLAB INCORPORATED Page D-2 of 4

268 Appendix D List of Drug Manufacturers MFR Manufacturer Name MFR Manufacturer Name NOO NUR NVC NVR NXP ODN OMG OPT ORG ORY OVA PAL PDL PED PER PFD PFI PFR PGI PGP PHH PMJ PMS PMT PPC PRO QLT RBP RIV NOVO NORDISK CANADA INCORPORATED NUTRICORP INTERNATIONAL NOVARTIS CONSUMER HEALTH CANADA INCORPORATED NOVARTIS PHARMACEUTICALS CANADA INCORPORATED NU-PHARM INCORPORATED ODAN LABORATORIES LIMITED OMEGA LABORATORIES LIMITED OPTREX LABS LIMITED ORGANON CANADA LIMITED ORYX PHARMACEUTICALS INCORPORATED OVATION PHARMACEUTICALS INCORPORATED PALADIN LABS INCORPORATED PRO DOC LIMITED PENDOPHARM INCORPORATED PERRIGO INTERNATIONAL PROFESSIONAL DISPOSABLES PFIZER CANADA INCORPORATED PURDUE PHARMA PROCTOR & GAMBLE INCORPORATED PROCTOR & GAMBLE PHARMACEUTICALS INCORPORATED PHARMEL INCORPORATED PHARMACIA CANADA INCORPORATED PHARMASCIENCE INCORPORATED PHARMETICS INCORPORATED PHARMACEUTICAL PARTNERS OF CANADA,INC PROVAL PHARMA INCORPORATED QLT INCORPORATED RB PHARMACEUTICALS LIMITED LABORATORIE RIVA INCORPORATED ROD RPH RVX RWP SAC SAN SCH SCN SDR SDZ SEV SHI SHM SIG SNE SOR SPH SQU E G I SUN SWS TAK TAN TAR TEV TIP TRE ROCHE DIAGNOICS RATIOPHARM INCORPORATED RIVEX PHARMA INCORPORATED RW PACKAGING LIMITED SANOFI-AVENTIS CANADA SANIS HEALTH INC SCHERING CANADA INCORPORATED SCHEIN PHARMACEUTICAL CANADA INCORPORATED ANLEY PHARMACEUTICALS LIMITED SANDOZ CANADA INCORPORATED SERVIER CANADA INCORPORATED SHIRE CANADA INCORPORATED SHERWOOD INCORPORATED SIGMA-TAU PHARMACEUTICALS INCORPORATED SMITH & NEPHEW INCORPORATED SORRES PHARMA INC SOLVAY PHARMA INCORPORATED SQUIRE PHARMACEUTICALS INCORPORATED ERIMAX INCORPORATED LABORATOIRES ERIGEN INC IEFEL CANADA INCORPORATED SUN PHARMA GLOBAL FZE SWISS HERBAL REMEDIES LIMITED TAKEDA PHARMACEUTICALS AMERICA INC TANTA PHARMACEUTICALS INCORPORATED TARO PHARMACEUTICALS INCORPORATED TEVA CANADA LIMITED H & P INDURIES / THE TRIAD- GROUP TREMBLAY HARRISON INC Page D-3 of 4

269 Appendix D List of Drug Manufacturers MFR Manufacturer Name MFR Manufacturer Name TRI TRT TRU TSN UCB UMI VAE VAO VTH WAM WAT WAY WCC WCI WEP WLA WNP WPC WRI WSB WTR XEN ZYM TRIANON LABORATORIES INCORPORATED TRITON PHARMA INCORPORATED TRUDELL MEDICAL INTERNATIONAL TRIMEDIC SUPPLY NETWORK LTD UBC PHARMA INCORPORATED ULTIMED, INCORPORATED VALEANT CANADA LIMITED VALEO PHARMA INCORPORATED VITA HEALTH PRODUCTS INCORPORATED WAMPOLE INCORPORATED WATSON LABORATORIES INCORPORATED WYETH CANADA WOMEN'S CAPITAL CORPORATION WARNER CHILCOTT COMPANY INCORPORATED WE PHARMACEUTICALS WARNER-LAMBERT CONSUMER HEALTHCARE INCORPORATED WN PHARMACEUTICALS LIMITED WELLSPRING PHARMACEUTICAL CANADA CORPORATION WHITEHALL-ROBINS INCORPORATED WEWOOD SQUIBB INCORPORATED WECAN PHARMACEUTICALS LIMITED XENEX LABS INCORPORATED ZYMCAN PHARMACEUTICALS Page D-4 of 4

270 APPENDIX E LI OF EXCLUSIONS

271 Appendix E EXCLUSIONS Certain drug products are not within the scope of the program. These products will not be reimbursed as benefits under the NIHB Program: Anti-obesity drugs; Household products (regular soaps and shampoos); Cosmetics; Alternative therapies, including glucosamine and evening primrose oil; Megavitamins; Drugs with investigational/experimental status; Vaccinations for travel indications; Hair growth stimulants; Fertility agents and impotence drugs; Selected over-the-counter products; Codeine containing cough preparations; Dalmane, Somnol and generics (flurazepam); Darvon and 642 (propoxyphene); Fiorinal, Fiorinal C ¼, Fiorinal C ½ and generics (Butalbital containing analgesics with and without codeine); Librium, Solium, Medilium and generics (chlordiazepoxide); Stadol TM NS and generics (butorphanol tartrate nasal spray); Tranxene and generics (clorazepate); and Imovane and generics (zopiclone). The following drugs are excluded from the NIHB Program as recommended by the Common Drug Review (CDR) and the NIHB Drugs and Therapeutics Advisory Committee (DTAC) because published evidence does not support the clinical value or cost of the drug relative to existing therapies, or there is insufficient clinical evidence to support coverage. Of Note: The Appeal Process and the Emergency Supply Policy will not apply for the following drug products. DIN MFR BRAND NAME ALL ACULAR LS 0.4% OPHTHALMIC SOLUTION A AMEVIVE 15MG/0.5ML POWDER FOR SOLUTION BAY CIPRO XL 500MG TABLET BAY CIPRO XL 1000MG TABLET FEI GYNAZOLE-1 VAG CREAM 2% SAC IMOVANE 5MG TABLET SAC IMOVANE 7.5MG TABLET AZC NEXIUM 20MG SR TABLET AZC NEXIUM 40MG SR TABLET SPH PANTOLOC 20MG EC TABLET GSK PAXIL CR 12.5MG EXTENDED RELEASE TABLET GSK PAXIL CR 25MG EXTENDED RELEASE TABLET NAB PHOSLO 667MG TABLET PFI RELPAX 20MG TABLET PFI RELPAX 40MG TABLET Page E-1 of 1

272 ALPHABETICAL INDEX OF DRUG PRODUCTS

273 3TC 5-AMINOSALICYLIC ACID ABACAVIR ABACAVIR, LAMIVUDINE ABACAVIR, LAMIVUDINE, ZIDOVUDINE ABATACEPT ABBOTT-CITALOPRAM ABBOTT-CLOPIDOGREL ABBOTT-LEVETIRACETAM ABBOTT-PANTOPRAZOLE ABBOTT-QUETIAPINE ABBOTT-RABEPRAZOLE ABBOTT-TOPIRAMATE ABENOL ABILIFY ACAMPROSATE CALCIUM ACARBOSE ACCEL PIOGLITAZONE ACCEL-AMLODIPINE ACCEL-CITALOPRAM ACCEL-CLARITHROMYCIN ACCEL-CLOPIDOGREL ACCEL-DONEPEZIL ACCEL-OLANZAPINE ACCEL-TOPIRAMATE ACCOLATE ACCU-CHEK ADVANTAGE ACCU-CHEK ADVANTAGE (ON) ACCU-CHEK AVIVA ACCU-CHEK AVIVA (ON) ACCU-CHEK COMPACT ACCU-CHEK COMPACT (ON) ACCU-CHEK FACLIK LANCET 102 ACCU-CHEK FACLIK LANCET 204 ACCU-CHEK MOBILE ACCU-CHEK MOBILE (ON) ACCU-CHEK MULTICLIX ACCU-CHEK SOFTCLIX LANCETS ACCUPRIL ACCURETIC ACCUTANE ACCUTREND ACCUTREND (ON) ACEBUTOLOL ACEBUTOLOL HCL ACET ACET 120 ACET 325 ACET 650 ACET CODEINE 30 ACETAMINOPHEN ACETAMINOPHEN ACETAMINOPHEN, CAFFEINE CITRATE, CODEINE PHOSPHATE ACETAMINOPHEN, CODEINE PHOSPHATE ACETAMINOPHEN, OXYCODONE HCL ACETAZOLAMIDE ACETAZOLAMIDE ACETYLSALICYLIC ACID Page ACETYLSALICYLIC ACID ACETYLSALICYLIC ACID, OXYCODONE HCL ACH-ANAROZOLE ACH-BICALUTAMIDE ACH-CANDESARTAN ACH-CAPECITABINE ACH-LETROZOLE ACH-MONTELUKA ACH-MYCOPHENOLATE ACH-PIOGLITAZONE ACITRETIN ACLAA ACLIDINIUM BROMIDE ACT AMLODIPINE ACT CANDESARTAN/HCT ACT CLARITHROMYCIN XL ACT DILTIAZEM CD ACT DILTIAZEM T ACT DONEPEZIL ACT DORZOTIMOLOL ACT DUTAERIDE ACT EZETIMIBE ACT LOSARTAN/HCT ACT OLOPATADINE ACT RALOXIFENE ACT TELMISARTAN ACTEMRA ACT-LOSARTAN ACT-NABILONE ACTONEL ACTOS ACT-PREGABALIN ACULAR ACUVAIL ACYCLOVIR ACYCLOVIR ADALAT XL ADALIMUMAB ADAPALENE ADCIRCA ADEFOVIR DIPIVOXIL ADRENALIN ADVAGRAF ADVAGRAF 3MG ER CAP ADVAIR ADVAIR DISKUS 100 ADVAIR DISKUS 250 ADVAIR DISKUS 500 ADVIL ADVIL JUNIOR RENGTH ADVIL PEDIATRIC AERIUS AERIUS KIDS AEROCHAMBER AC BOYZ AEROCHAMBER AC GIRLZ AEROCHAMBER PLUS FLOW-VU LG AEROCHAMBER PLUS FLOW-VU MED AEROCHAMBER PLUS FLOW-VU MOUTH AEROCHAMBER PLUS FLOW-VU SM Page AEROTRACH PLUS AGGRENOX AGRYLIN AIROMIR ALBALON ALBALON A ALCOHOL PREP SWAB ALCOHOL SWAB ALCOHOL SWABS BD ALDACTAZIDE-25 ALDACTAZIDE-50 ALDACTONE ALDARA P ALENDRONATE ALENDRONATE SODIUM ALENDRONATE SODIUM, VITAMIN D3 ALENDRONATE-70 ALERTEC ALESSE 21 ALESSE 28 ALFACALCIDOL ALFUZOSIN ALFUZOSIN HYDROCHLORIDE ALKERAN ALLEGRA ALLEGRA 24HR ALLER-AIDE ALLERGENIC EXTRACT NON POLLENS ALLERGENIC EXTRACT POLLENS ALLERGENIC EXTRACTS ALLERGY ALLERGY FORMULA ALLERGY RELIEF ES ALLERJECT ALLERNIX ALLERNIX MULTI SYMPTOM ALLERNIX PLUS ALLOPRIN ALLOPURINOL ALLOPURINOL ALMOTRIPTAN ALMOTRIPTAN MALATE ALOCRIL ALOMIDE ALPHAGAN ALPHAGAN P ALPRAZOLAM ALPRAZOLAM ALTACE ALTACE HCT ALTRETAMINE ALVESCO ALYSENA 21 ALYSENA 28 AMANTADINE HCL AMBRISENTAN AMCINONIDE AMERGE AMI-HYDRO AMILORIDE HCL AMILORIDE HCL, HYDROCHLOROTHIAZIDE Page Page I-1 of 26

274 Page Page Page AMIODARONE 31 APO-ANAROZOLE 15 APO-DIVALPROEX 67 AMIODARONE HCL 31 APO-ASA 56 APO-DOCUSATE CALCIUM 106 AMITRIPTYLINE 72 APO-ASEN ECT 56 APO-DOCUSATE SODIUM 106 AMITRIPTYLINE HCL 72 APO-ATENIDONE 40 APO-DOMPERIDONE 113 AMLODIPINE 43 APO-ATENOL 40 APO-DONEPEZIL 19 AMLODIPINE 43 APO-ATORVAATIN 33 APO-DORZO-TIMOP 103 AMLODIPINE, ATORVAATIN AMLODIPINE, TELMISARTAN AMLODIPINE-ODAN AMOXICILLIN AMOXICILLIN AMOXICILLIN SUGAR REDUCED AMOXICILLIN, CLARITHROMYCIN, LANSOPRAZOLE AMOXICILLIN, CLAVULANIC ACID AMOXI-CLAV AMPICILLIN ANAFRANIL ANAGRELIDE HCL ANANDRON ANAPROX ANAPROX DS ANAROZOLE ANAROZOLE ANDRIOL ANDROCUR ANETHOLE TRITHIONE ANODAN-HC ANTAZOLINE PHOSPHATE, NAPHAZOLINE HCL ANTHRAFORTE 1 ANTHRAFORTE 2 ANTHRANOL ANTHRASCALP ANTIBIOTIC OINT ANTI-DIARRHEAL 2MG TAB ANUGESIC HC ANUSOL HC ANZEMET APIDRA CARTRIDGE APIDRA SOLOAR APIDRA VIAL APIXABAN APO ENALAPRIL APO-ACEBUTOLOL APO-ACETAMINOPHEN APO-ACYCLOVIR APO-ADEFOVIR APO-ALENDRONATE APO-ALFUZOSIN ER APO-ALLOPURINOL APO-ALMOTRIPTAN APO-ALPRAZ APO-AMILZIDE APO-AMIODARONE APO-AMITRIPTYLINE APO-AMLODIPINE APO-AMLODIPINE- ATORVAATIN APO-AMOXI APO-AMOXI CLAV APO-AMOXI SUGAR FREE APO-AMPICILLIN APO-AZATHIOPRINE APO-AZITHROMYCIN APO-BACLOFEN APO-BECLOMETHASONE APO-BENZTROPINE APO-BENZYDAMINE APO-BICALUTAMIDE APO-BISACODYL APO-BISOPROLOL APO-BOSENTAN APO-BRIMONIDINE APO-BRIMONIDINE P APO-BROMAZEPAM APO-BROMOCRIPTINE APO-CAL 500 APO-CANDESARTAN APO-CANDESARTAN/HCTZ APO-CAPTO APO-CARBAMAZEPINE APO-CARVEDILOL APO-CEFACLOR APO-CEFADROXIL APO-CEFPROZIL APO-CEFUROXIME APO-CELECOXIB APO-CEPHALEX APO-CETIRIZINE APO-CHLORTHALIDONE APO-CILAZAPRIL APO-CILAZAPRIL HCTZ APO-CIMETIDINE APO-CIPROFLOX APO-CITALOPRAM APO-CLARITHROMYCIN APO-CLARITHROMYCIN XL APO-CLINDAMYCIN APO-CLOBAZAM APO-CLOMIPRAMINE APO-CLONAZEPAM APO-CLONIDINE APO-CLOPIDOGREL APO-CLOZAPINE APO-CROMOLYN APO-CYCLOBENZAPRINE APO-CYPROTERONE APO-DESIPRAMINE APO-DESMOPRESSIN APO-DEXAMETHASONE APO-DIAZEPAM APO-DICLO APO-DICLO SR APO-DIFLUNISAL APO-DILTIAZ APO-DILTIAZ CD APO-DILTIAZ SR APO-DIMENHYDRINATE APO-DIPIVEFRIN APO-DIPYRIDAMOLE APO-DOXAZOSIN APO-DOXEPIN APO-DOXY APO-DUTAERIDE APO-ENALAPRIL MALEATE/HCTZ APO-ENTECAVIR APO-ERYTHRO APO-ERYTHRO BASE APO-ERYTHRO S APO-ERYTHRO-S APO-ESCITALOPRAM APO-EXEMEANE APO-EZETIMIBE APO-FAMCICLOVIR APO-FAMOTIDINE APO-FENOFIBRATE APO-FENO-MICRO APO-FENO-SUPER APO-FENTANYL MATRIX APO-FERROUS GLUCONATE APO-FINAERIDE APO-FLECAINIDE APO-FLUCONAZOLE APO-FLUNISOLIDE APO-FLUOXETINE APO-FLUPHENAZINE APO-FLURBIPROFEN APO-FLUTAMIDE APO-FLUTICASONE APO-FLUVOXAMINE APO-FOLIC ACID APO-FOSINOPRIL APO-FUROSEMIDE APO-GABAPENTIN APO-GEMFIBROZIL APO-GLICLAZIDE APO-GLYBURIDE APO-HALOPERIDOL APO-HYDRALAZINE APO-HYDRO APO-HYDROCLOROTHIAZIDE APO-HYDROMORPHONE APO-HYDROXYQUINE APO-HYDROXYUREA APO-HYDROXYZINE APO-IBUPROFEN APO-IMATINIB APO-IMIQUIMOD APO-INDAPAMIDE APO-INDOMETHACIN APO-IPRAVENT APO-IRBESARTAN APO-IRBESARTAN/HCTZ APO-ISMN APO-K APO-KETOCONAZOLE APO-KETOROLAC APO-KETOTIFEN Page I-2 of 26

275 Page Page Page APO-LACTULOSE 107 APO-OXAZEPAM 88 APO-TIMOP 103 APO-LAMIVUDINE 9 APO-OXYBUTYNIN 135 APO-TIZANIDINE 25 APO-LAMIVUDINE HBV 9 APO-OXYCODONE/ACET 60 APO-TOPIRAMATE 71 APO-LAMIVUDINE-ZIDOVUDINE 9 APO-PANTOPRAZOLE 112 APO-TRAVOPRO Z 104 APO-LAMOTRIGINE 69 APO-PAROXETINE 76 APO-TRAZODONE 77 APO-LANSOPRAZOLE 111 APO-PEN VK 4 APO-TRAZODONE D 77 APO-LATANOPRO 103 APO-PENTOXIFYL 30 APO-TRIAZIDE 98 APO-LATANOPRO-TIMOP 104 APO-PERPHENAZINE 81 APO-TRIAZO 88 APO-LEFLUNOMIDE 144 APO-PIMOZIDE 81 APO-VALACYCLOVIR 12 APO-LETROZOLE 16 APO-PINDOL 42 APO-VALGANCICLOVIR 12 APO-LEVETIRACETAM 69 APO-PIOGLITAZONE 123 APO-VALPROIC 72 APO-LEVOBUNOLOL 102 APO-PIROXICAM 59 APO-VALSARTAN 54 APO-LEVOCARB 91 APO-PRAMIPEXOLE 91 APO-VALSARTAN/HCTZ 54 APO-LEVOCARB CR 91 APO-PRAVAATIN 34 APO-VENLAFAXINE XR 78 APO-LEVOFLOXACIN 5 APO-PRAZO 39 APO-VERAP 46 APO-LINEZOLID 7 APO-PREDNISONE 117 APO-VERAP SR 46 APO-LISINOPRIL 48 APO-PREGABALIN 70 APO-VORICONAZOLE 7 APO-LISINOPRIL (TYPE Z) 48 APO-PROCAINAMIDE 31 APO-WARFARIN 29 APO-LITHIUM CARB 88 APO-PROCHLORAZINE 81 APO-ZIDOVUDINE 10 APO-LITHIUM CARBONATE 88 APO-PROPAFENONE 31 APO-ZOLMITRIPTAN 90 APO-LOPERAMIDE 106 APO-PROPRANOLOL 42 APO-ZOLMITRIPTAN RAPID 90 APO-LORATADINE 1 APO-QUETIAPINE 82 APRACLONIDINE HCL 104 APO-LORAZEPAM 87 APO-QUINAPRIL 48 APREPITANT 109 APO-LORAZEPAM SL 87 APO-QUINAPRIL/HCTZ 49 APRI APO-LOSARTAN 52 APO-RABEPRAZOLE 112 APRI APO-LOSARTAN/HCTZ 53 APO-RALOXIFENE 119 APTIVUS 10 APO-LOVAATIN 34 APO-RAMIPRIL 49 AQUASOL E 138 APO-MEDROXY 124 APO-RAMIPRIL/HCTZ 50 ARAVA 144 APO-MELOXICAM 58 APO-RANITIDINE 110 AREDIA IV 142 APO-METFORMIN 120 APO-REPAGLINIDE 122 ARICEPT 19 APO-METHAZIDE APO-RISEDRONATE 143 ARIMIDEX 15 APO-METHAZIDE APO-RISPERIDONE 83 ARIPIPRAZOLE 78 APO-METHOPRAZINE 79 APO-RIVAIGMINE 20 ARIOCORT C 131 APO-METHOTREXATE 17 APO-RIZATRIPTAN 89 ARIOCORT R 131 APO-METHYLPHENIDATE 86 APO-RIZATRIPTAN RPD 89 AROMASIN 15 APO-METHYLPHENIDATE ER 86 APO-ROPINIROLE 92 ARTHROTEC 58 APO-METHYLPHENIDATE SR 86 APO-ROSUVAATIN 35 ARTIFICIAL TEARS 104 APO-METOCLOP 113 APO-SALVENT 23 ARTIFICIAL TEARS EXTRA 104 APO-METOPROLOL 41 APO-SALVENT CFC FREE 23 ASA 56 APO-METOPROLOL SR 41 APO-SELEGILINE 92 ASA EC 56 APO-METOPROLOL-L 41 APO-SERTRALINE 77 ASACOL 113 APO-MINOCYCLINE 6 APO-SILDENAFIL R 38 ASAPHEN 56 APO-MIRTAZAPINE 75 APO-SIMVAATIN 36 ASAPHEN EC 56 APO-MOCLOBEMIDE 75 APO-SOTALOL 42 ASATAB 56 APO-MOMETASONE 101 APO-SUCRALFATE 111 ASATAB EC 56 APO-MONTELUKA 99 APO-SULFAMETHOXAZOLE 6 ASCENSIA BREEZE 2 94 APO-MYCOPHENOLATE 144 APO-SULFATRIM 6 ASCENSIA BREEZE 2 (ON) 94 APO-MYCOPHENOLIC ACID 145 APO-SULFATRIM DS 6 ASCENSIA CONTOUR 94 APO-NADOL 42 APO-SULFATRIM PED 6 ASCENSIA CONTOUR (ON) 94 APO-NAPRO NA APO-NAPRO NA DS APO-SUMATRIPTAN APO-TAMOX ASCORBIC ACID ASCORBIC ACID APO-NAPROXEN APO-NAPROXEN EC APO-NIFED PA APO-NITROGLYCERIN APO-NORFLOX APO-NORTRIPTYLINE APO-OFLOXACIN APO-OLANZAPINE APO-TAMSULOSIN CR APO-TELMISARTAN APO-TELMISARTAN/HCTZ APO-TEMAZEPAM APO-TEMOZOLOMIDE APO-TERAZOSIN APO-TERBINAFINE APO-TETRA ASENAPINE ASMANEX TWIHALER ASPIRIN ATACAND ATACAND PLUS ATARAX ATASOL ATASOL FORTE APO-OLANZAPINE ODT APO-OLOPATADINE APO-OMEPRAZOLE APO-ONDANSETRON APO-ORCIPRENALINE APO-TETRABENAZINE APO-THEO APO-THEO LA APO-TICLOPIDINE APO-TIMOL ATASOL-15 ATASOL-30 ATAZANAVIR SULFATE ATENOLOL Page I-3 of 26

276 Page ATENOLOL 40 ATENOLOL, CHLORTHALIDONE 40 ATHLETES FOOT SPRAY 128 ATIVAN 87 ATIVAN SUBLINGUAL 87 ATORVAATIN 33 ATORVAATIN CALCIUM 33 ATORVAATIN ATORVAATIN ATORVAATIN ATORVAATIN ATOVAQUONE 13 ATRIPLA 9 ATROPINE 102 ATROPINE SULFATE 102 ATROPINE SULPHATE MINIMS 102 ATROVENT 22 ATROVENT HFA 22 AURANOFIN 114 AURO-ALENDRONATE 141 AURO-AMLODIPINE 43 AURO-AMOXICILLIN 4 AURO-ANAROZOLE 15 AURO-ATORVAATIN 33 AURO-CARVEDILOL 41 AURO-CEFIXIME 2 AURO-CEFPROZIL 2 AURO-CEFUROXIME 2 AURO-CIPROFLOXACIN 5 AURO-CITALOPRAM 73 AURO-CLOPIDOGREL 30 AURO-CYCLOBENZAPRINE 24 AURO-DONEPEZIL 19 AURO-EFAVIRENZ 8 AURO-ESCITALOPRAM 74 AURO-FINAERIDE 140 AURO-GABAPENTIN 68 AURO-IRBESARTAN 51 AURO-LAMOTRIGINE 69 AURO-LETROZOLE 16 AURO-LEVETIRACETAM 69 AURO-LISINOPRIL 48 AURO-LOSARTAN 52 AURO-MELOXICAM 58 AURO-MIRTAZAPINE 75 AURO-MIRTAZAPINE OD 75 AURO-MONTELUKA 99 AURO-NEVIRAPINE 9 AURO-PAROXETINE 76 AURO-QUETIAPINE 82 AURO-RAMIPRIL 49 AURO-RISEDRONATE 143 AURO-SERTRALINE 77 AURO-SIMVAATIN 36 AURO-TERBINAFINE 7 AURO-TOPIRAMATE 71 AURO-VALSARTAN 54 AURO-VALSARTAN HCT 54 AVALIDE 52 AVANDIA 123 AVAPRO 51 AVENTYL 76 AVIANE AVIANE 28 AVODART AXERT AXID AZARGA AZATHIOPRINE AZATHIOPRINE AZATHIOPRINE-50 AZELAIC ACID AZITHROMYCIN AZITHROMYCIN AZOPT BABY DDROPS BACIMYXIN BACITIN BACITRACIN BACITRACIN BACITRACIN ZINC, POLYMYXIN B SULFATE Page BACLOFEN 25 BACLOFEN 25 BACTERIOATIC NACL 97 BACTERIOATIC SODIUM 97 CHLORIDE BACTIGRAS 128 BACTROBAN 127 BANZEL 71 BARACLUDE 11 BARRIERE 132 BARRIERE HC 130 B-D ALCOHOL SWAB 147 BD AUTOSHIELD PEN NEEDLES 148 BD LUER-LOK SYRINGE ONLY 149 (10ML) BD LUER-LOK SYRINGE ONLY 149 (1ML) BD LUER-LOK SYRINGE ONLY 149 (20ML) BD LUER-LOK SYRINGE ONLY 149 (30ML) BD LUER-LOK SYRINGE ONLY 149 (3ML) BD LUER-LOK SYRINGE ONLY 149 (5ML) BD LUER-LOK SYRINGE/NEEDLE 149 COMBO (3ML) BD PRECISIONGLIDE 18GX1 1/2 148 INCH BD PRECISIONGLIDE 18GX1 INCH 148 BD PRECISIONGLIDE 25GX5/8 148 INCH BD PRECISIONGLIDE 25GX7/8 148 INCH BD PRECISIONGLIDE 26GX1/2 148 INCH BD PRECISIONGLIDE 26GX3/8 148 INCH BD PRECISIONGLIDE 27GX1 1/4 148 INCH BD PRECISIONGLIDE 27GX1/2 148 INCH B-D SHARPS CONTAINER 1.4L 149 B-D SHARPS CONTAINER 3.1L 149 BD SLIP TIP SUB Q (1ML) 149 BD SLIP TIP SYRINGE ONLY 149 (10ML) BD SLIP TIP SYRINGE ONLY (1ML) 149 BD SLIP TIP SYRINGE ONLY (20ML) BD SLIP TIP SYRINGE ONLY (30ML) BD SLIP TIP SYRINGE ONLY (3ML) BD SLIP TIP SYRINGE ONLY (5ML) BD SYRINGE + NEEDLE BD SYRINGE WITH ULTRA-FINE NEEDLE BD TUBERCULIN SYR/DETACHABLE NEEDLE SLIP TIP BD TUBERCULIN SYR/PERMANENT NEEDLE BD ULTRA-FINE BD ULTRAFINE 33G LANCETS BD ULTRA-FINE II SHORT BD ULTRA-FINE NANO PEN NEEDLES BD ULTRA-FINE PEN NEEDLE BECLOMETHASONE DIPROPIONATE BEDUZIL BENADRYL BENADRYL CHILD BENAZEPRIL BENAZEPRIL HCL BENZAC AC BENZAC W BENZAC W5 BENZACLIN TOPICAL GEL BENZAGEL BENZAGEL 5 BENZAMYCIN BENZOYL PEROXIDE BENZTROPINE MESYLATE BENZTROPINE OMEGA BENZYDAMINE HCL BETADERM BETADINE BETAGAN BETAHIINE HCL BETAMETHASONE DIPROPIONATE BETAMETHASONE DIPROPIONATE IN PROPYLENE GLYCOL BETAMETHASONE DIPROPIONATE, CLOTRIMAZOLE BETAMETHASONE DIPROPIONATE, SALICYLIC ACID BETAMETHASONE DISODIUM PHOSPHATE BETAMETHASONE SODIUM PHOSPHATE, GENTAMICIN SULFATE BETAMETHASONE VALERATE BETAXIN BETAXOLOL HCL BETHANECHOL CHLORIDE BETNESOL BETOPTIC S BEZAFIBRATE BEZALIP SR BG AR BG AR (ON) Page Page I-4 of 26

277 BG AR LANCETS BIAXIN BIAXIN XL BICALUTAMIDE BICALUTAMIDE BIMATOPRO BIO K-20 BIOCAL-D FORTE BIO-CELECOXIB BIODERM BIO-FUROSEMIDE BIO-HYDROCHLOROTHIAZIDE BI-PEGLYTE KIT BISACODYL BISACODYL BISACODYL (POLYETHYLENE GLYCOL BASE) BISACODYL-ODAN BISACOLAX BISMUTH SUBSALICYLATE BISOPROLOL BISOPROLOL FUMARATE BLEPHAMIDE BOCEPREVIR BOCEPREVIR, PEGINTERFERON, RIBAVIRIN BOSENTAN MONOHYDRATE BOTOX BOTULINUM TOXIN TYPE A BREVICON 0.5/35 21 BREVICON 0.5/35 28 BREVICON 1/35 21 BREVICON 1/35 28 BRICANYL TURBUHALER BRILINTA BRIMONIDINE TARTRATE BRIMONIDINE TARTRATE (ALPHAGAN P) BRIMONIDINE TARTRATE, TIMOLOL MALEATE BRINZOLAMIDE BRINZOLAMIDE/TIMOLOL MALEATE BROMAZEPAM BROMAZEPAM BROMOCRIPTINE MESYLATE BUDESONIDE BUPRENORPHINE, NALOXONE BUPROPION HCL (WELLBUTRIN) BUPROPION HCL (ZYBAN) BUPROPION SR BUSCOPAN BUSERELIN ACETATE BUSULFAN CABERGOLINE CADUET CAFFEINE CITRATE CAFFEINE CITRATE CALCIMAR CALCIPOTRIOL CALCIPOTRIOL, BETAMETHASONE CALCITE D 400 Page CALCITONIN SALMON (SYNTHETIC) CALCITRIOL CALCITRIOL-ODAN CALCIUM CALCIUM CALCIUM + VIT D CALCIUM D 400 CALCIUM 500MG WITH VIT D CALCIUM CARBONATE CALCIUM CARBONATE CALCIUM LACTOGLUCONATE CALCIUM LACTOGLUCONATE + VIT D CALCIUM POLYYRENE SULFONATE CALCIUM, VITAMIN D CAL-D CALODAN D CAMPRAL CANDESARTAN CANDESARTAN CILEXETIL CANDESARTAN CILEXETIL, HYDROCHLOROTHIAZIDE CANDESARTAN-HCTZ CANESORAL CANEEN CANEEN 1 COMFORT COMBI PAK CANEEN 3 COMFORT COMBI PAK CANTHACUR PS CANTHARIDIN, PODOPHYLLIN, SALICYLIC ACID CANTHARONE PLUS CAPECITABINE CAPSAICIN CAPSAICIN CAPSAICIN HP CAPTOPRIL CAPTOPRIL CARBACHOL CARBAMAZEPINE CARBAMAZEPINE CR CARBOCAL CARBOCAL D CARBOLITH CARDIZEM CD CARDURA 1 CARDURA 2 CARDURA 4 CARNITOR CARNITOR IV CARTRIDGE FOR IR200 2ML CARVEDILOL CARVEDILOL CASODEX CATAPRES CECLOR CECLOR BID CEENU CEFACLOR CEFADROXIL CEFIXIME CEFPROZIL Page CEFTIN CEFUROXIME AXETIL CEFZIL CELEBREX CELECOXIB CELECOXIB CELEODERM V CELEXA CELLCEPT CELLUVISC CELONTIN CELSENTRI CENTER-AL CENTRUM JUNIOR COMPLETE CENTRUM MATERNA CEPHALEXIN CEPHALEXIN CERTOLIZUMAB PEGOL CESAMET CETIRIZINE CETIRIZINE HCL CHAMPIX CHAMPIX ARTER PACK CHILDREN'S ADVIL CHILDREN'S MOTRIN CHLORAMBUCIL CHLORAMPHENICOL CHLORHEXIDINE ACETATE CHLORHEXIDINE GLUCONATE CHLOROQUINE PHOSPHATE CHLORPHENIRAMINE MALEATE CHLORPROMAZINE CHLORPROMAZINE HCL CHLORTHALIDONE CHLORTHALIDONE CHLOR-TRIPOLON CHOLECALCIFEROL CHOLEDYL CHOLEYRAMINE RESIN CICLESONIDE CILAZAPRIL CILAZAPRIL CILAZAPRIL, HYDROCHLOROTHIAZIDE CILOXAN CILOXAN 0.3% CIMETIDINE CIMETIDINE CIMZIA CIPRALEX 10MG TAB CIPRALEX 20MG TAB CIPRALEX MELTZ CIPRO CIPRODEX CIPROFLOXACIN CIPROFLOXACIN HCL CIPROFLOXACIN HCL, DEXAMETHASONE CITALOPRAM CITALOPRAM CITRIC ACID, MAGNESIUM OXIDE, SODIUM PICOSULFATE CITRIC ACID, SODIUM CITRATE CITRO MAG 15GM/300ML Page Page I-5 of 26

278 CITRODAN CLARITHROMYCIN CLARITHROMYCIN CLARITIN CLARITIN KIDS CLARUS CLAVULIN CLAVULIN 200 CLAVULIN 400 CLAVULIN-F CLAVULIN-F 125 CLAVULIN-F 250 CLEAR AWAY CLICKFINE PEN NEEDLES CLIMARA 100 CLIMARA 25 CLIMARA 50 CLIMARA 75 CLINDAMYCIN CLINDAMYCIN HCL CLINDAMYCIN PALMITATE HCL CLINDAMYCIN PHOSPHATE CLINDAMYCIN, BENZOYL PEROXIDE CLINDAMYCINE CLINDA-T CLINDOXYL CLINDOXYL ADV CLOBAZAM CLOBAZAM CLOBETASOL PROPIONATE CLOBETASONE BUTYRATE CLOMIPRAMINE HCL CLONAPAM CLONAZEPAM CLONIDINE CLONIDINE HCL CLOPIDOGREL CLOPIDOGREL BISULFATE CLOPIXOL CLOPIXOL ACUPHASE CLOPIXOL DEPOT CLOTRIMADERM CLOTRIMAZOLE CLOXACILLIN CLOXACILLINE CLOZAPINE CLOZARIL CO ALENDRONATE CO AMLODIPINE CO ANAROZOLE CO ATENOLOL CO ATORVAATIN CO AZITHROMYCIN CO BETAHIINE CO BICALUTAMIDE CO BOSENTAN CO CABERGOLINE CO CELECOXIB CO CILAZAPRIL CO CIPROFLOXACIN CO CITALOPRAM CO CLOMIPRAMINE Page CO CLONAZEPAM CO CLOPIDOGREL CO DICLO-MISO CO ENALAPRIL CO ESCITALOPRAM CO ETIDRONATE CO EXEMEANE CO FAMCICLOVIR CO FENTANYL CO FINAERIDE CO FLUCONAZOLE CO FLUVOXAMINE CO GABAPENTIN CO IMATINIB CO IRBESARTAN CO IRBESARTAN/HCT CO LATANOPRO CO LEVETIRACETAM CO LISINOPRIL CO LOVAATIN CO MELOXICAM CO METFORMIN CO MIRTAZAPINE CO NORFLOXACIN CO OLANZAPINE CO OLANZAPINE ODT CO PANTOPRAZOLE CO PAROXETINE CO PIOGLITAZONE CO PRAMIPEXOLE CO PRAVAATIN CO QUETIAPINE CO RAMIPRIL CO RANITIDINE CO RISPERIDONE CO RIZATRIPTAN CO ROSUVAATIN CO SERTRALINE CO SIMVAATIN CO SOTALOL CO SUMATRIPTAN CO TELMISARTAN/HCT CO TEMAZEPAM CO TEMOZOLOMIDE CO TERBINAFINE CO TOPIRAMATE CO VALACYCLOVIR CO VALSARTAN CO VENLAFAXINE XR COAL TAR COAL TAR, JUNIPER TAR, PINE TAR COAL TAR, JUNIPER TAR, PINE TAR, ZINC PYRITHIONE COAL TAR, SALICYLIC ACID COAL TAR, SALICYLIC ACID, SULFUR COBICIAT, EMTRICITABINE, ELVITEGRAVIR, TENOFOVIR CO-CANDESARTAN CODEINE CODEINE CONTIN CR CODEINE MONOHYDRATE, CODEINE SULFATE TRIHYDRATE Page CODEINE PHOSPHATE CODEINE PHOSPHATE CO-ETIDROCAL CO-FLUOXETINE COLACE COLCHICINE COLCHICINE COLESEVELAM COLEID COLEID ORANGE COLEIPOL HCL CO-LEVOFLOXACIN COLLAGENASE COLYTE COMBANTRIN COMBIGAN COMBIVENT COMBIVENT RESPIMAT COMBIVIR COMFORT ANGLED 17MMX110CM (10 TUBING/BOX) COMFORT ANGLED 17MMX60CM (10 TUBING/BOX) COMFORT SHORT ANGLED 13MMX110CM (10 TUBING/BOX) COMFORT SHORT ANGLED 13MMX60CM (10 TUBING/BOX) COMPLERA COMPOUND W GEL COMTAN CONCERTA CONDOM, LATEX, LUBRICATED CONDOM, LATEX, LUBRICATED, NONOXYNOL CONDOM, LATEX, NON- LUBRICATED CONDOM, MALE CONDOM, NON-LATEX, LUBRICATED CONDYLINE CONJUGATED EROGENS CONJUGATED EROGENS, MEDROXYPROGEERONE ACETATE CONTACT DETACH 90 DEGREE 6MMX60CM CONTACT DETACH 90 DEGREE 8MMX60CM CONTOUR NEXT CONTOUR NEXT (ON) CO-ONDANSETRON CORDARONE CO-REPAGLINIDE CO-RIZATRIPTAN ODT CO-ROPINIROLE CORTATE CORTEF CORTENEMA CORTIFOAM CORTISONE CORTISONE ACETATE CORTODERM COSOPT COTAZYM COTAZYM ECS 8 COTAZYM ECS 20 Page Page I-6 of 26

279 Page Page Page COUMADIN 29 DENOSUMAB (P) 142 DIFLUCORTOLONE VALERATE 130 COVERA-HS 46 DENOSUMAB (X) 142 DIFLUNISAL 58 COVERSYL 48 DEPAKENE 72 DIGOXIN 31 COVERSYL PLUS 48 DEPO-MEDROL 116 DIHYDROERGOTAMINE 24 COVERSYL PLUS HD COZAAR CREON 10 MINIMICROSPHERES CREON 25 MINIMICROSPHERES CREON MINIMICROSPHERES 6 CREOR CRIXIVAN CROMOLYN CROTAMITON CTP 30 CUPRIMINE CUTIVATE CYANOCOBALAMIN CYANOCOBALAMIN CYCLEN 21 CYCLEN 28 CYCLOBENZAPRINE CYCLOBENZAPRINE HCL CYCLOCORT CYCLOGYL CYCLOMEN CYCLOPENTOLATE CYCLOPENTOLATE HCL CYCLOPENTOLATE MINIMS CYCLOPHOSPHAMIDE CYCLOSPORINE CYERA-35 CYKLOKAPRON CYMBALTA CYPROTERONE ACETATE CYPROTERONE ACETATE, ETHINYL ERADIOL CYTOVENE D VI SOL D2-DOL D3-DOL DABIGATRAN ETEXILATE MESILATE DAIRY DIGEIVE DAIRY DIGEIVE EXTRA RENGTH DAIRYAID DALACIN DALACIN C DALACIN T DALTEPARIN SODIUM DANAZOL DANTRIUM DANTROLENE SODIUM DARAPRIM DARIFENACIN HYDROBROMIDE DARUNAVIR DDAVP DDAVP MELT DDROPS VITAMIN D DECAXIL DEGARELIX ACETATE DELATERYL DEMULEN DEMULEN DEPO-PROVERA DEPO-TEOERONE DERMAFLEX HC DERMA-SMOOTHE DERMAZIN DERMOVATE DESIPRAMINE HCL DESLORATADINE DESLORATADINE DESLORATADINE ALLERGY CONTROL DESMOPRESSIN DESMOPRESSIN ACETATE DESONIDE DESOXIMETASONE DETROL DETROL LA DEXAMETHASONE DEXAMETHASONE DEXAMETHASONE PHOSPHATE DEXAMETHASONE, TOBRAMYCIN DEXAMETHASONE-OMEGA DEXASONE DEXEDRINE DEXEDRINE SPANSULE DEXIRON DEXTRAN 70, HYDROXYPROPYLMETHYLCELL ULOSE DEXTROAMPHETAMINE SULFATE D-FORTE D-GEL DIABETA DIAMICRON DIAMICRON MR DIANE-35 DIARR-EZE DIARRHEA RELIEF DIARRHEA RELIEF 2MG TAB DIAIX DIAZEPAM DIAZEPAM DIAZOXIDE DICITRATE DICLECTIN DICLOFENAC EC DICLOFENAC SODIUM DICLOFENAC SODIUM (TOPICAL) DICLOFENAC SODIUM, MISOPROOL DICLOFENAC SR DICLOFENAC-50 DICLOFENAC-SR DIDANOSINE DIDROCAL DIENOGE DIFFERIN DIFLUCAN DIHYDROERGOTAMINE MESYLATE DIIODOHYDROXYQUIN DILANTIN DILANTIN 30 DILANTIN 125 DILANTIN INFATABS DILAUDID DILTIAZEM DILTIAZEM CD DILTIAZEM HCL DILTIAZEM TZ DIMENHYDRINATE DIMENHYDRINATE DIMETHICONE DIOCARPINE DIOCHLORAM DIODEX DIODOQUIN DIOGENT DIONEPHRINE DIOPENTOLATE DIOPTIMYD DIOSULF DIOVAN DIOVAN-HCT DIPENTUM DIPHENHYDRAMINE DIPHENHYDRAMINE HCL DIPHENHYDRAMINE HCL DIPIVEFRIN HCL DIPIVEFRIN HCL, LEVOBUNOLOL HCL DIPROLENE DIPROSALIC DIPROSONE DIPYRIDAMOLE DIPYRIDAMOLE, ACETYLSALICYLIC ACID DISOPYRAMIDE DITHRANOL DIVALPROEX DIVALPROEX SODIUM DIVIGEL DIXARIT DOCUSATE CALCIUM DOCUSATE CALCIUM DOCUSATE SODIUM DOCUSATE SODIUM DOCUSATE SODIUM, SENNA DOLASETRON MESYLATE DOLICHOVESPULA ARENARIA VENOM PROTEIN DOLICHOVESPULA MACULATA VENOM PROTEIN EXTRACT DOLORAL 1 DOLORAL 5 DOLUTEGRAVIR SODIUM DOM-ALENDRONATE DOM-AMANTADINE Page I-7 of 26

280 Page Page Page DOM-AMIODARONE DOM-AMLODIPINE DOM-ATENOLOL DOM-ATORVAATIN DOM-AZITHROMYCIN DOM-BACLOFEN DOM-BENZYDAMINE DOM-BROMOCRIPTINE DOM-CANDESARTAN DOM-CAPTOPRIL DOM-CARBAMAZEPINE CR DOM-CARVEDILOL DOM-CEPHALEXIN DOM-CIMETIDINE DOM-CIPROFLOXACIN DOM-CITALOPRAM DOM-CLARITHROMYCIN DOM-CLOBAZAM DOM-CLONAZEPAM DOM-CLONAZEPAM-R DOM-CLOPIDOGREL DOM-CYCLOBENZAPRINE DOM-DESIPRAMINE DOM-DICLOFENAC DOM-DICLOFENAC SR DOM-DOCUSATE SODIUM DOM-DOMPERIDONE DOM-FINAERIDE DOM-FLUCONAZOLE DOM-FLUOXETINE DOM-FLUVOXAMINE DOM-GABAPENTIN DOM-GEMFIBROZIL DOM-GLYBURIDE DOM-INDAPAMIDE DOM-IPRATROPIUM DOM-IRBESARTAN DOM-LANSOPRAZOLE DOM-LEVETIRACETAM DOM-LOPERAMIDE DOM-LORAZEPAM DOM-LOXAPINE DOM-MEDROXYPROGEERONE DOM-MEFENAMIC ACID DOM-MELOXICAM DOM-METFORMIN DOM-METOPROLOL-B DOM-METOPROLOL-L DOM-MINOCYCLINE DOM-MIRTAZAPINE DOM-MONTELUKA DOM-NIZATIDINE DOM-NORTRIPTYLINE DOM-NYATIN DOM-OMEPRAZOLE DR DOM-OXYBUTYNIN DOM-PANTOPRAZOLE DOM-PAROXETINE DOMPERIDONE DOMPERIDONE MALEATE DOM-PINDOLOL DOM-PIOGLITAZONE DOM-PIROXICAM DOM-PRAMIPEXOLE DOM-PRAVAATIN DOM-PREGABALIN DOM-PROPRANOLOL DOM-QUETIAPINE DOM-RABEPRAZOLE EC DOM-RAMIPRIL DOM-RISEDRONATE DOM-RIZATRIPTAN RDT DOM-ROSUVAATIN DOM-SALBUTAMOL DOM-SELEGILINE DOM-SERTRALINE DOM-SIMVAATIN DOM-SOTALOL DOM-SUMATRIPTAN DOM-TEMAZEPAM DOM-TERAZOSIN DOM-TERBINAFINE DOM-TIAPROFENIC DOM-TIMOLOL DOM-TOPIRAMATE DOM-TRAZODONE DOM-VALACYCLOVIR DOM-VALPROIC ACID DOM-VALSARTAN DOM-VENLAFAXINE XR DOM-VERAPAMIL SR DOM-ZOLMITRIPTAN DONEPEZIL DONEPEZIL HCL DORZOLAMIDE HCL DORZOLAMIDE HCL, TIMOLOL MALEATE DOINEX DOVOBET DOVONEX DOXAZOSIN DOXAZOSIN MESYLATE DOXEPIN HCL DOXYCIN DOXYCYCLINE DOXYCYCLINE DOXYLAMINE SUCCINATE, PYRIDOXINE HCL DOXYTAB DRISDOL D-TABS DULCOLAX DULOXETINE HCL DUO TRAV DUOFILM DUOFORTE 27 DUOLUBE DUOPLANT DURAGESIC MAT DUTAERIDE DUTAERIDE DUVOID ECL-CITALOPRAM ECL-METFORMIN EDECRIN EDURANT EES-600 EFAVIRENZ EFAVIRENZ, EMTRICITABINE, TENOFOVIR DISOPROXIL FUMARATE EFFEXOR XR EFUDEX EGOZINC HC EGOZINC-HC ELAVIL ELECTROLYTE & DEXTROSE ELECTROLYTES, DEXTROSE ELIDEL ELIGARD ELIQUIS ELMIRON ELOCOM ELTROXIN EMEND EMEND TRI PACK EMERGENCY ACNE VANISHING WIPES EMLA EMO CORT EMO CORT SCALP EMTRICITABINE, RILPIVIRINE, TENOFOVIR EMTRICITABINE, TENOFOVIR ENABLEX ENALAPRIL ENALAPRIL MALEATE ENALAPRIL MALEATE, HYDROCHLOROTHIAZIDE ENBREL ENBREL SURECLICK (QC) ENDOCET ENEMOL ENOXAPARIN SODIUM ENTACAPONE ENTECAVIR ENTOCORT ENTROPHEN ENTROPHEN 10 ENTROPHEN CHEWABLE ENTROPHEN EC ENTROPHEN-10 ENTROPHEN-5 EPINEPHRINE EPINEPHRINE EPIPEN EPIPEN JR EPIVAL EPOSARTAN MESYLATE EPOSARTAN MESYLATE, HYDROCHLOROTHIAZIDE EQUATE DAILY LOW-DOSE ERDOL ERGOCALCIFEROL ERLOTINIB HYDROCLORIDE ERYC ERYTHRO ERYTHRO-ES ERYTHROMYCIN ERYTHROMYCIN ERYTHROMYCIN EOLATE ERYTHROMYCIN ETHYLSUCCINATE Page I-8 of 26

281 ERYTHROMYCIN EARATE ERYTHROMYCIN, BENZOYL PEROXIDE ERYTHROMYCIN, TRETINOIN ESCITALOPRAM ESCITALOPRAM ESME 21 ESME 28 EALIS 140/50 EALIS 250/50 ERACE ERADERM 100 ERADIOL ERADIOL (ERADIOL HEMIHYDRATE) ERADIOL, NORETHINDRONE ACETATE ERADOT 100 ERADOT 25 ERADOT 37.5 ERADOT 50 ERADOT 75 ERAGYN ERING EROGEL ERONE EROPIPATE ETANERCEPT ETHACRYNIC ACID ETHAMBUTOL HCL ETHINYL ERADIOL, DESOGEREL ETHINYL ERADIOL, DROSPIRENONE ETHINYL ERADIOL, ETHYNODIOL DIACETATE ETHINYL ERADIOL, ETONOGEREL ETHINYL ERADIOL, LEVONORGEREL ETHINYL ERADIOL, NORELGEROMIM ETHINYL ERADIOL, NORETHINDRONE ETHINYL ERADIOL, NORGEIMATE ETHOPROPAZINE HCL ETHOSUXIMIDE ETIBI ETIDROCAL ETIDRONATE DISODIUM ETIDRONATE DISODIUM, CALCIUM CARBONATE ETOPOSIDE ETRAVIRINE EUFLEX EUGLUCON EUMOVATE EURAX EURO D EURO-ASA EURO-B1 EURO-CAL EURO-DOCUSATE EURO-FER Page EURO-FERROUS SULFATE EURO-FOLIC EURO-HYDROCORTISONE EURO-K 20 EURO-K 600 EURO-LAC EURO-SENNA EURO-SENNA S EUTHYROX EVIA EVRA EXACT ASA EC EXDOL-15 EXDOL-30 EXELON EXEMEANE EXTEMPORANEOUS MIXTURE EXTEMPORANEOUS MIXTURE (BC) (SK) (YT) EXTEMPORANEOUS MIXTURE (NB) (NS) (PE) (NL) EXTEMPORANEOUS MIXTURE (NU) (AB) (MB) (QC) (NT) EXTEMPORANEOUS MIXTURE (ON) EZ HEALTH ORACLE EZ HEALTH ORACLE (ON) EZ HEALTH ORACLE LANCETS E-Z SPACER E-Z SPACER (MASK ONLY) E-Z SPACER WITH SMALL MASK EZETIMIBE EZETIMIBE EZETROL FAMCICLOVIR FAMCICLOVIR FAMOTIDINE FAMOTIDINE FAMVIR FEBUXOAT FELODIPINE FEMARA FENOFIBRATE FENOFIBRATE MICRO FENOFIBRATE-S FENOMAX FENO-MICRO FENTANYL FENTANYL FER-IN-SOL FERODAN FERRATE O/L FERRLECIT FERROUS FUMARATE FERROUS FUMARATE FERROUS GLUCONATE FERROUS GLUCONATE FERROUS SULFATE FERROUS SULFATE FEVERHALT FEXOFENADINE HCL FILGRAIM FINACEA FINAERIDE Page FINAERIDE FINGERIX LANCETS FIRMAGON FLAGYL FLAGYATIN FLAMAZINE FLAMAZINE 50G FLAREX FLAVOXATE HCL FLECAINIDE ACETATE FLEET ENEMA FLEET ENEMA PEDIATRIC FLEXI-T IUD FLINTONES EXTRA C FLOCTAFENINE FLOCTAFENINE FLOMAX CR FLONASE FLORINEF FLOVENT DISKUS FLOVENT HFA 125 FLOVENT HFA 250 FLOVENT HFA 50 FLUANXOL FLUANXOL DEPOT FLUCONAZOLE FLUDARA FLUDARABINE PHOSPHATE FLUDROCORTISONE ACETATE FLUMETHASONE PIVALATE, CLIOQUINOL FLUNARIZINE FLUNARIZINE HCL FLUNISOLIDE FLUOCINOLONE ACETONIDE FLUOCINONIDE FLUOROMETHOLONE FLUOROMETHOLONE ACETATE FLUOROURACIL FLUOXETINE FLUOXETINE HCL FLUPENTHIXOL DECANOATE FLUPENTHIXOL DIHYDROCHLORIDE FLUPHENAZINE DECANOATE FLUPHENAZINE HCL FLURBIPROFEN FLUTAMIDE FLUTICASONE PROPIONATE FLUVAATIN SODIUM FLUVOXAMINE FLUVOXAMINE MALEATE FML FML FORTE FOLIC ACID FOLIC ACID FORADIL FORMALDEHYDE, LACTIC ACID, SALICYLIC ACID FORMOTEROL FUMARATE FORMOTEROL FUMARATE DIHYDRATE FORMOTEROL FUMARATE DIHYDRATE, BUDESONIDE Page Page I-9 of 26

282 FORMOTEROL FUMARATE DIHYDRATE, MOMETASONE FUROATE FOSAMAX FOSAMPRENAVIR CALCIUM FOSAVANCE FOSFOMYCIN TROMETHAMINE FOSINOPRIL FOSINOPRIL SODIUM FRAGMIN FRAMYCETIN SULFATE FRAMYCETIN SULFATE, GRAMICIDIN, DEXAMETHASONE FRAXIPARINE FRAXIPARINE FORTE FREEYLE FREEYLE (ON) FREEYLE LANCETS FREEYLE LITE FREEYLE LITE (ON) FREEYLE PRECISION FREEYLE PRECISION (ON) FREYA 21 FREYA 28 FRISIUM FUCIDIN FUROSEMIDE FUROSEMIDE FUSIDATE SODIUM FUSIDIC ACID G.U.M. PAROEX GABAPENTIN GABAPENTIN GALANTAMINE GALANTAMINE ER GALEXOS GANCICLOVIR SODIUM GARASONE GAROLYTE REG GATIFLOXACIN GD-AMLODIPINE GD-AMLODIPINE-ATORVAATIN GD-ATORVAATIN GD-AZITHROMYCIN GD-CELECOXIB GD-GABAPENTIN GD-LATANOPRO GD-LATANOPRO/TIMOLOL GD-PREGABALIN GD-QUINAPRIL GD-SERTRALINE GD-VENLAFAXINE XR GEMFIBROZIL GEMFIBROZIL GEN-CLONAZEPAM GEN-CLOZAPINE GENTAMICIN GENTAMICIN SULFATE GENTEAL GLEEVEC GLICLAZIDE GLICLAZIDE GLUCAGEN GLUCAGEN HYPOKIT Page GLUCAGON GLUCAGON RECOMBINANT DNA ORGIN GLUCOBAY GLUCONORM GLUCOPHAGE GLUCOSE OXIDASE, PEROXIDASE GLUCOSE OXIDASE, PEROXIDASE. GLYBURIDE GLYBURIDE GLYCERIN GLYCERIN INFANT GLYCERIN INFANT & CHILD GLYCERINE GLYCON GLYCOPYRRONIUM GOLIMUMAB GOLYTELY GOSERELIN ACETATE GRAMICIDIN, POLYMYXIN B SULFATE GRANISETRON GRANISETRON GRAVOL GRAVOL ADULT HABITROL HALOBETASOL PROPIONATE HALOPERIDOL HALOPERIDOL HALOPERIDOL DECANOATE HALOPERIDOL LA HARVONI HEPARIN LEO HEPARIN LEO INJ 10000UNIT/ML HEPARIN LEO INJ 1000UNIT/ML HEPARIN LEO INJ 25000UNIT/ML HEPARIN LOCK FLUSH HEPARIN SODIUM HEPARIN SODIUM 10000U/ML HEPARIN SODIUM 1000U/ML HEPARIN SODIUM 5000U/ML HEPSERA HEPTOVIR HEXALEN HOMATROPINE HBR HONEY BEE VENOM HONEY BEE VENOM PROTEIN EXTRACT HP-PAC HUMALOG CARTRIDGE/KWIKPEN HUMALOG CARTRIDGE/KWIKPEN (ON) HUMALOG KWIKPEN HUMALOG MIX 25 KWIKPEN HUMALOG MIX 50 KWIKPEN HUMALOG MIX 50 KWIKPEN INJ HUMALOG VIAL HUMATIN HUMIRA HUMULIN 30/70 CARTRIDGE HUMULIN 30/70 CARTRIDGE (ON) HUMULIN 30/70 VIAL Page HUMULIN N CARTRIDGE HUMULIN N CARTRIDGE/KWIKPEN (ON) HUMULIN N KWIKPEN HUMULIN N VIAL HUMULIN R CARTRIDGE HUMULIN R CARTRIDGE (ON) HUMULIN R VIAL HYDERM HYDRALAZINE HYDRALAZINE HCL HYDRALYTE ELECTROLYTE HYDRALYTE ELECTROLYTE POPS HYDREA HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE HYDROCORTISONE HYDROCORTISONE ACETATE HYDROCORTISONE ACETATE, ZINC SULFATE HYDROCORTISONE ACETATE, ZINC SULFATE, PRAMOXINE HCL HYDROCORTISONE VALERATE HYDROCORTISONE, DIBUCAINE HCL, ESCULIN, FRAMYCETIN SULFATE HYDROCORTISONE, UREA HYDROMORPH CONTIN HYDROMORPHONE HYDROMORPHONE HCL HYDROSONE HYDROVAL HYDROXYCHLOROQUINE SULFATE HYDROXYPROPYL CELLULOSE HYDROXYPROPYLMETHYLCELL ULOSE HYDROXYUREA HYDROXYUREA HYDROXYZINE HYDROXYZINE HCL HYPOTEARS HYPROMELLOSE HYTRIN HYZAAR HYZAAR DS IBUPROFEN IBUPROFEN IHLES PAE ILEVRO 0.3% OP SUSP IMATINIB MESYLATE IMDUR IMIPRAMINE IMIPRAMINE HCL IMIQUIMOD IMITREX IMITREX DF IMODIUM IMODIUM CALMING LIQUID IMURAN INCOBOTULINUMTOXINA INDACATEROL MALEATE INDAPAMIDE INDERAL LA Page Page I-10 of 26

283 Page Page Page INDINAVIR SULFATE 9 ISONIAZID 8 JAMP-K INDOMETHACIN 58 ISOPROPYL ALCOHOL 147 JAMP-LETROZOLE 16 INFANTOL 138 ISOPROPYL MYRIATE 128 JAMP-LEVETIRACETAM 69 INFLIXIMAB 144 ISOPTIN SR 46 JAMP-LISINOPRIL 48 INFUFER 27 ISOPTO ATROPINE 102 JAMP-LOSARTAN 52 INHIBACE 46 ISOPTO CARBACHOL 102 JAMP-LOSARTAN HCTZ 53 INHIBACE PLUS 47 ISOPTO CARPINE 103 JAMP-MAGNESIUM 96 INNOHEP 29 ISOPTO HOMATROPINE 102 JAMP-METFORMIN 120 INSET II 90 DEGREE 6MMX110CM 147 ISOPTO TEARS 104 JAMP-METFORMIN BLACKBERRY 120 INSET II 90 DEGREE 6MMX60CM 147 ISOSORBIDE DINITRATE 37 JAMP-METHOTREXATE 17 INSET II 90 DEGREE 9MMX110CM INSET II 90 DEGREE 9MMX60CM INSULIN (30% NEUTRAL & 70% ISOPHANE) HUMAN BIOSYNTHETIC INSULIN (40% NEUTRAL & 60% ISOPHANE) HUMAN BIOSYNTHETIC INSULIN (50% NEUTRAL & 50% ISOPHANE) HUMAN BIOSYNTHETIC INSULIN (ISOPHANE) HUMAN BIOSYNTHETIC INSULIN (ZINC CRYALLINE) HUMAN BIOSYNTHETIC (RDNA ORIGIN) INSULIN ASPART INSULIN DETEMIR INSULIN GLARGINE INSULIN GLULISINE INSULIN HUMAN BIOSYNTHETIC INSULIN HUMAN BIOSYNTHETIC 30% & ISOPHANE 70% INSULIN LISPRO INSULIN LISPRO, INSULIN LISPRO PROTAMINE INSULIN PEN NEEDLE INSULIN PUMP SUPPLIES INSULIN SYRINGES INSUPEN PEN NEEDLES INTELENCE INTERFERON ALFA-2B INTRAUTERINE DEVICE INTRON A INVEGA SUENNA INVIRASE IOPIDINE IPECAC IPECAC IPRATROPIUM BROMIDE IPRATROPIUM BROMIDE, SALBUTAMOL IRBESARTAN IRBESARTAN IRBESARTAN HCT IRBESARTAN, HYDROCHLOROTHIAZIDE IRBESARTAN/HCTZ IRBESARTAN-HCTZ IRON IRON IRON DEXTRAN IRON SUCROSE ISDN ISENTRESS ISOSORBIDE-5-MONONITRATE ISOTAMINE ISOTRETINOIN ITE ITE (ON) ITE LANCETS 28G ITE LANCETS 33G ITRACONAZOLE JAMP FERROUS FUMARATE JAMP GLYCERIN JAMP IBUPROFEN JAMP ONDANSETRON JAMP REHYDRALYTE JAMP SULFATE FERREUX JAMP-ACETAMINOPHEN JAMP-ALENDRONATE JAMP-ALLOPURINOL JAMP-ALPRAZOLAM JAMP-AMLODIPINE JAMP-ANAROZOLE JAMP-ASA JAMP-ATENOLOL JAMP-ATORVAATIN JAMP-BICALUTAMIDE JAMP-BISACODYL JAMP-CALCIUM JAMP-CALCIUM + VIT D JAMP-CALCIUM+VITAM D JAMP-CANDESARTAN JAMP-CARVEDILOL JAMP-CIPROFLOXACIN JAMP-CITALOPRAM JAMP-CLOPIDOGREL JAMP-COLCHICINE JAMP-CYANOCOBALAMIN JAMP-CYCLOBENZAPRINE JAMP-DIPHENHYDRAMINE JAMP-DOCUSATE CALCIUM JAMP-DOMPERIDONE JAMP-DONEPEZIL JAMP-ESCITALOPRAM JAMP-EZETIMIBE JAMP-FER JAMP-FINAERIDE JAMP-FLUOXETINE JAMP-FOLIC ACID JAMP-FOSINOPRIL JAMP-GABAPENTIN JAMP-IBUPROFEN JAMP-INDAPAMIDE JAMP-IRBESARTAN JAMP-IRBESARTAN/HCT JAMP-K JAMP-METOPROLOL-L JAMP-MONTELUKA JAMP-MULTIVITAMIN A/D/C DROPS JAMP-MYCOPHENOLATE JAMP-OLANZAPINE ODT JAMPOLYCIN JAMP-OMEPRAZOLE DR JAMP-PANTOPRAZOLE JAMP-PAROXETINE JAMP-PIOGLITAZONE JAMP-POTASSIUM CHLORIDE JAMP-PRAVAATIN JAMP-QUETIAPINE JAMP-RAMIPRIL JAMP-RISEDRONATE JAMP-RISPERIDONE JAMP-RIZATRIPTAN JAMP-RIZATRIPTAN IR JAMP-ROPINIROLE JAMP-ROSUVAATIN JAMP-SENNA JAMP-SENNOSIDES JAMP-SERTRALINE JAMP-SIMVAATIN JAMP-SODIUM PHOSPHATE JAMP-SOTALOL JAMP-TERBINAFINE JAMP-VITAMIN JAMP-VITAMIN B1 JAMP-VITAMIN B12 JAMP-VITAMIN D JAMP-VITAMINE D JAMPZINC-HC OINT JAMP-ZOLMITRIPTAN JAMP-ZOLMITRIPTAN ODT JANUMET JANUMET XR JANUVIA JAYDESS JENTADUETO K LYTE K-10 KADIAN KALETRA KAYEXALATE KENALOG-10 KENALOG-40 KEPPRA KETOCONAZOLE KETODERM KETOPROFEN KETOPROFEN KETOPROFEN SR Page I-11 of 26

284 Page Page Page KETOPROFEN-E 58 LEVEMIR 100UNIT/ML SC PENFILL 121 LORATADINE 1 KETOROLAC TROMETHAMINE KETOIX KETOTIFEN FUMARATE K-EXIT KIVEXA KLEAN-PREP KOMBOGLYZE KWELLADA-P KYTRIL LABETALOL HCL LACOSAMIDE LACRI LUBE LACRISERT LACTAID LACTAID EXTRA RENGTH LACTAID ULTRA LACTASE LACTIC ACID, SALICYLIC ACID LACTOMAX LACTOMAX EXTRA LACTULOSE LACTULOSE LAMICTAL LAMISIL LAMIVUDINE LAMIVUDINE, ZIDOVUDINE LAMOTRIGINE LAMOTRIGINE LANCET LANREOTIDE LANSOPRAZOLE LANSOPRAZOLE LANSOPRAZOLE ODT LANSOPRAZOLE-15 LANSOPRAZOLE-30 LANSOYL GEL LANSOYL GEL SUGARFREE LANTUS CARTRIDGE LANTUS SOLOAR LANTUS VIAL LANVIS LASIX LASIX SPECIAL LATANOPRO LATANOPRO LATANOPRO/TIMOLOL MALEATE LAX-A-DAY LB VITAMIN B12 LECTOPAM LEFLUNOMIDE LEFLUNOMIDE LESCOL LESCOL XL LETROZOLE LETROZOLE LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM LEUKERAN LEUPROLIDE ACETATE LEVAQUIN LEVATE LEVEMIR FLEXTOUCH 100U/ML INJ LEVETIRACETAM LEVETIRACETAM LEVOBUNOLOL HCL LEVOCABAINE HCL LEVOCARB CR LEVOCARNITINE LEVODOPA, BENZERAZIDE LEVODOPA, CARBIDOPA LEVODOPA, CARBIDOPA,ENTACAPONE LEVOFLOXACIN LEVOFLOXACIN LEVONORGEREL LEVONORGEREL INTRAUTERINE INSERT LEVOTHYROXINE SODIUM LIBERTE UT380 SHORT LIBERTE UT380 ANDARD LIDEMOL LIDEX LIDOCAINE HCL LIDOCAINE, PRILOCAINE LIDODAN VISCOUS LIFE BRAND PEN NEEDLES LINAGLIPTIN LINAGLIPTIN, METFORMIN LINCTUS CODEINE LINESSA 21 LINESSA 28 LINEZOLID LINEZOLID LIORESAL LIORESAL DS LIPASE, AMYLASE, PROTEASE LIPIDIL EZ LIPIDIL MICRO LIPIDIL SUPRA LIPITOR LISDEXAMFETAMINE DIMESYLATE LISINOPRIL LISINOPRIL LISINOPRIL, HYDROCHLOROTHIAZIDE LISINOPRIL/HCTZ (Z) LITHANE LITHIUM CARBONATE LITHIUM CITRATE LIVOIN LOCACORTEN VIOFORM LODALIS LODOXAMIDE TROMETHAMINE LOERIN 1.5/30 21 LOERIN 1.5/30 28 LOMUINE LONITEN LOPERAMIDE LOPERAMIDE HCL LOPINAVIR, RITONAVIR LOPRESOR LOPRESOR SR LORATADINE LORAZEPAM LORAZEPAM LOSARTAN LOSARTAN POTASSIUM LOSARTAN POTASSIUM, HYDROCHLOROTHIAZIDE LOSARTAN/HCT LOSARTAN/HCTZ LOSARTAN-HCTZ LOSEC LOTENSIN LOTRIDERM LOVAATIN LOVAATIN LOVENEX HP LOVENOX LOWPRIN LOXAPINE HCL LOXAPINE SUCCINATE LOZIDE LUBRICATING NASAL GEL LUBRICATING NASAL MI LUCENTIS PFS 10MG/ML INJ LUMIGAN LUPRON DEPOT LUTERA 21 LUTERA 28 LUVOX LYDERM LYRICA LYSODREN M.O.S. M.O.S. 10 M.O.S. 20 M.O.S. 40 M.O.S. 50 M.O.S. 60 M.O.S. SR M.O.S. SULFATE MACROBID MACROGOL, POTASSIUM CHLORIDE, SODIUM BICARBONATE, SODIUM CHLORIDE, SODIUM SULFATE MACROGOL, PROPYLENE GLYCOL MAG OXIDE MAGIC BULLET MAGNESIUM MAGNESIUM MAGNESIUM CITRATE MAGNESIUM GLUCONATE MAGNESIUM HYDROXIDE MAGNESIUM OXIDE MAGNESIUM-ODAN MAGNIFIER MAJEPTIL MANERIX MAPROTILINE HCL MAR-ALLOPURINOL MAR-AMITRIPTYLINE MAR-AMLODIPINE Page I-12 of 26

285 Page Page Page MAR-ANAROZOLE 15 MEFENAMIC ACID 58 METRONIDAZOLE 13 MAR-ATENOLOL 40 MEGACE 16 METRONIDAZOLE 13 MARAVIROC MAR-CELECOXIB MAR-CIPROFLOXACIN MAR-CITALOPRAM MAR-CLOPIDOGREL MAR-DOMPERIDONE MAR-DONEPEZIL MAR-ESCITALOPRAM MAR-EZETIMIBE MAR-FLUOXETINE MAR-GABAPENTIN MAR-GALANTAMINE ER MAR-LETROZOLE MAR-METFORMIN MAR-MODAFINIL MAR-MONTELUKA MAR-OLANZAPINE MAR-OLANZAPINE ODT MAR-ONDANSETRON MAR-PANTOPRAZOLE MAR-PAROXETINE MAR-PREGABALIN MAR-QUETIAPINE MAR-RAMIPRIL MAR-RISPERIDONE MAR-RIZATRIPTAN MAR-ROSUVAATIN MAR-SERTRALINE MAR-SIMVAATIN MARVELON 21 MARVELON 28 MAR-ZOLMITRIPTAN MATERNA MATULAN MAVIK MAXALT MAXALT RPD MAXIDEX MAXIMUM RENGTH ACID REDUCER M-CAL D MEBENDAZOLE MED-ANAROZOLE MED-CYPROTERONE MED-DUTAERIDE MED-EXEMEANE MEDI+SURE MEDI+SURE (ON) MEDI+SURE SOFT 30G TWI LANC. MEDI+SURE SOFT 33G TWI LANC. MED-LATANOPRO MED-LETROZOLE MED-RIVAIGMINE MEDROL MED-ROSUVAATIN MEDROXY MEDROXYPROGEERONE MEDROXYPROGEERONE ACETATE MEFENAMIC MEGEROL MEGEROL ACETATE MELOXICAM MELOXICAM MELPHALAN MEPRON MERCAPTOPURINE MERCAPTOPURINE MESALAZINE MESASAL M-ESLON MEINON MEINON-SR METADOL METAMUCIL ORIGINAL TEXTURE METAMUCIL SM TEXT ORANGE METAMUCIL SM TEXT ORANGE S/F METAMUCIL SM TEXT UNFLAV METFORMIN METFORMIN FC METFORMIN HCL METHADONE METHADONE HCL METHADONE HCL (BC ONLY) METHADONE HCL (PA) METHADOSE METHADOSE DELIV. W DIRECT INT METHADOSE DELIV. W/OUT DIRECT METHADOSE W/OUT DIRECT INTERA METHADOSE DIRECT INTERACTION METHADOSE SUGARFREE METHAZOLAMIDE METHAZOLAMIDE METHOTREXATE METHOTREXATE METHOTREXATE SODIUM METHOTRIMEPRAZINE METHOXSALEN METHSUXIMIDE METHYLDOPA METHYLDOPA METHYLDOPA, HYDROCHLOROTHIAZIDE METHYLPHENIDATE METHYLPHENIDATE HCL METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE ACETATE METOCLOPRAMIDE HCL METOLAZONE METOPROLOL METOPROLOL SR METOPROLOL TARTRATE METOPROLOL-L METROCREAM METROGEL METROLOTION METRONIDAZOLE, AVOBENZONE, OCTINOXATE METRONIDAZOLE, NYATIN MEVACOR MEXILETINE HCL MEZAVANT MICARDIS MICARDIS PLUS MICATIN MICONAZOLE MICONAZOLE NITRATE MICOZOLE MICRO K EXTENCAPS SRC MICROLAX MICROLET LANCETS MICRONOR 28 MIDAMOR MIGRANAL MILK OF MAGNESIA MILK OF MAGNESIA PLAIN/SUGARFREE MINERAL OIL MINERAL OIL (HEAVY) MINERAL OIL, PETROLATUM MINERAL OIL, WHITE PETROLATUM MINERIN 1/20 21 MINERIN 1/20 28 MINIPRESS MINITRAN MINOCYCLINE MINOCYCLINE HCL MIN-OVRAL 21 MIN-OVRAL 28 MINOXIDIL MINT-ALENDRONATE MINT-AMLODIPINE MINT-ANAROZOLE MINT-ATENOLOL MINT-CELECOXIB MINT-CIPROFLOX MINT-CIPROFLOXACIN MINT-CITALOPRAM MINT-CLOPIDOGREL MINT-DUTAERIDE MINT-EZETIMIBE MINT-FINAERIDE MINT-FLUOXETINE MINT-GLICLAZIDE MR MINT-HYDROCHLOROTHIAZIDE MINT-HYDROXYCHLOROQUINE MINT-IRBESARTAN/HCTZ MINT-LOSARTAN MINT-LOSARTAN/HCTZ MINT-METFORMIN MINT-MONTELUKA MINT-ONDANSETRON MINT-PANTOPRAZOLE MINT-PAROXETINE MINT-PIOGLITAZONE MINT-PRAVAATIN MINT-PREGABALIN Page I-13 of 26

286 Page Page Page MINT-RAMIPRIL 49 MS CONTIN SR 63 MYLAN-EFAVIRENZ 8 MINT-RISPERIDONE 83 MS IR 64 MYLAN-ENALAPRIL 47 MINT-RIVAIGMINE 20 M-SENNOSIDES 107 MYLAN-ENTACAPONE 91 MINT-ROSUVAATIN 35 MUCILLIUM 107 MYLAN-ESCITALOPRAM 74 MINT-SERTRALINE 77 MULTI-PRE AND PO NATAL 138 MYLAN-ETI-CAL CP 142 MINT-SIMVAATIN 36 MULTITAR PLUS 133 MYLAN-ETIDRONATE 142 MINT-TOPIRAMATE 71 MULTI-TAR PLUS MILD 133 MYLAN-EZETIMIBE 32 MINT-ZOLMITRIPTAN 90 MULTIVITAMINS (PEDIATRIC) 138 MYLAN-FAMOTIDINE 110 MINT-ZOLMITRIPTAN ODT 90 MULTIVITAMINS (PRENATAL) 138 MYLAN-FENOFIBRATE 32 MIO BLUE 6MMX18" 147 MUPIROCIN 127 MYLAN-FENTANYL MATRIX 61 MIO BLUE 6MMX23" 147 MURO MYLAN-FIBRO 32 MIO CLEAR 6MMX32" 147 MYA MYLAN-FINAERIDE 140 MIO CLEAR 9MMX32" 147 MYCOBUTIN 8 MYLAN-FLUCONAZOLE 7 MIO PINK 6MMX18" 147 MYCOPHENOLATE 144 MYLAN-FLUOXETINE 74 MIO PINK 6MMX23" MIOAT MIRAPEX MIRAPEX (ONT) MIRENA MIRTAZAPINE MIRTAZAPINE MIRVALA 21 MIRVALA 28 MISOPROOL MISOPROOL MITOTANE MIXED VESPID VENOM PROTEIN MK 10 MK 20 MK 8 MOBICOX MOCLOBEMIDE MODAFINIL MODAFINIL MODECATE MOGADON MOMETASONE FUROATE MONA LISA 10 MONA LISA 5 MONA LISA N MONIAT 3 MONIAT 3 DUAL PAK MONIAT 7 MONIAT 7 DUAL PAK MONIAT-DERM MONOJECT ALCOHOL WIPES MONOLET (MONOJECT) 21G MONOLET THIN (MONOJECT) 28G MONTELUKA MONTELUKA MONUROL MORPHINE HCL MORPHINE SR MORPHINE SULFATE MORPHINE SULFATE (K) MOTION SICKNESS MOTRIN MOTRIN JUNIOR RENGTH MOXIFLOXACIN HCL MPD THIN (100) MPD THIN (200) MPD ULTRA THIN (100) MPD ULTRA THIN (200) MYCOPHENOLATE MOFETIL MYCOPHENOLATE SODIUM MYDFRIN MYDRIACYL MYFORTIC MYHEALTH SYRINGE CASE-7 MYHEALTH SYRINGE CASE- SINGLE MYLAN ZOLMITRIPTAN MYLAN-ACEBUTOLOL MYLAN-ACEBUTOLOL (TYPE S) MYLAN-ACYCLOVIR MYLAN-ALENDRONATE MYLAN-ALMOTRIPTAN MYLAN-ALPRAZOLAM MYLAN-AMANTADINE MYLAN-AMIODARONE MYLAN-AMLODIPINE MYLAN-AMOXICILLIN MYLAN-ANAROZOLE MYLAN-ATENOLOL MYLAN-ATORVAATIN MYLAN-AZATHIOPRINE MYLAN-AZITHROMYCIN MYLAN-BACLOFEN MYLAN-BECLO AQ MYLAN-BICALUTAMIDE MYLAN-BISOPROLOL MYLAN-BOSENTAN MYLAN-BUDESONIDE AQ MYLAN-BUPROPION XL MYLAN-CANDESART HCTZ MYLAN-CANDESARTAN MYLAN-CAPTOPRIL MYLAN-CARBAMAZEPINE CR MYLAN-CARVEDILOL MYLAN-CELECOXIB MYLAN-CILAZAPRIL MYLAN-CIMETIDINE MYLAN-CIPROFLOXACIN MYLAN-CITALOPRAM MYLAN-CLARITHROMYCIN MYLAN-CLINDAMYCIN MYLAN-CLOBETASOL MYLAN-CLONAZEPAM MYLAN-CLOPIDOGREL MYLAN-CYCLOPRINE MYLAN-DOMPERIDONE MYLAN-DONEPEZIL MYLAN-DOXAZOSIN MYLAN-FOSINOPRIL MYLAN-GABAPENTIN MYLAN-GALANTAMINE ER MYLAN-GEMFIBROZIL MYLAN-GLICLAZIDE MYLAN-GLYBE MYLAN-HYDROXYCHLOROQUINE MYLAN-HYDROXYUREA MYLAN-INDAPAMIDE MYLAN-IPRATROPIUM MYLAN-IPRATROPIUM UDV MYLAN-IRBESARTAN MYLAN-LAMOTRIGINE MYLAN-LANSOPRAZOLE MYLAN-LEFLUNOMIDE MYLAN-LEVOFLOXACIN MYLAN-LISINOPRIL MYLAN-LISINOPRIL HCTZ MYLAN-LOSARTAN MYLAN-LOSARTAN/HCTZ MYLAN-LOVAATIN MYLAN-MELOXICAM MYLAN-METFORMIN MYLAN-METOPROLOL (TYPE L) MYLAN-MINOCYCLINE MYLAN-MIRTAZAPINE MYLAN-MONTELUKA MYLAN-MYCOPHENOLATE MYLAN-NAPROXEN MYLAN-NAPROXEN EC MYLAN-NEVIRAPINE MYLAN-NIFEDIPINE ER MYLAN-NITRO MYLAN-OLANZAPINE MYLAN-OLANZAPINE ODT MYLAN-OMEPRAZOLE MYLAN-ONDANSETRON MYLAN-PANTOPRAZOLE MYLAN-PAROXETINE MYLAN-PIOGLITAZONE MYLAN-PRAMIPEXOLE MYLAN-PRAVAATIN MYLAN-PROPAFENONE MYLAN-QUETIAPINE MYLAN-RABEPRAZOLE MYLAN-RAMIPRIL MYLAN-RANITIDINE MYLAN-RISEDRONATE MYLAN-RISPERIDONE MYLAN-RISPERIDONE ODT Page I-14 of 26

287 Page Page Page MYLAN-RIVAIGMINE 20 NEOIGMINE BROMIDE 20 NOVO-DOMPERIDONE 113 MYLAN-RIZATRIPTAN ODT 89 NEPAFENAC 101 NOVO-DOXAZOSIN 39 MYLAN-ROSUVAATIN 35 NERISONE 130 NOVO-DOXYLIN 6 MYLAN-SELEGILINE 92 NERISONE OILY 130 NOVO-ENALAPRIL 47 MYLAN-SERTRALINE 77 NEULEPTIL 81 NOVO-ENALAPRIL/HCTZ 47 MYLAN-SIMVAATIN 36 NEUPOGEN 30 NOVO-ETIDRONATECAL KIT 142 MYLAN-SOTALOL 43 NEURONTIN 68 NOVO-FAMOTIDINE 110 MYLAN-SUMATRIPTAN 89 NEUTROGENA T/GEL 133 NOVO-FENOFIBRATE 32 MYLAN-TAMOXIFEN 17 NEVANAC 0.1% OP SOL 101 NOVO-FENOFIBRATE-S 32 MYLAN-TELMISARTAN 53 NEVIRAPINE 9 NOVO-FERROGLUC 27 MYLAN-TELMISARTAN HCTZ 54 NEXT CHOICE 118 NOVO-FINAERIDE 140 MYLAN-TERAZOSIN 39 NIACIN 136 NOVOFINE PEN NEEDLES 148 MYLAN-TERBINAFINE 7 NIACIN 136 NOVOFINE PLUS 149 MYLAN-TICLOPIDINE 30 NIACIN YEA FREE 136 NOVO-FLUCONAZOLE 7 MYLAN-TOPIRAMATE 71 NICODERM 26 NOVO-FLUOXETINE 74 MYLAN-TRAZODONE 77 NICORETTE 25 NOVO-FLURPROFEN 58 MYLAN-VALACYCLOVIR 12 NICORETTE LOZENGE 25 NOVO-FLUVOXAMINE 75 MYLAN-VALPROIC 72 NICORETTE PLUS 25 NOVO-FOSINOPRIL 47 MYLAN-VALSARTAN MYLAN-VALSARTAN HCTZ MYLAN-VENLAFAXINE XR MYLAN-VERAPAMIL MYLAN-VERAPAMIL SR MYLAN-WARFARIN MYLAN-ZOLMITRIPTAN ODT MYLERAN MYL-PREGABALIN MYL-RANITIDINE MYOCHRYSINE NABILONE NADOLOL NADOLOL NADROPARIN CALCIUM NADRYL NAFARELIN ACETATE NALCROM NAPHAZOLINE HCL NAPHCON FORTE NAPROSYN NAPROSYN E NAPROSYN SR NAPROXEN NAPROXEN NAPROXEN EC NAPROXEN NA NAPROXEN SODIUM NAPROXEN SODIUM NAPROXEN SODIUM DS NAPROXEN-NA DF NARATRIPTAN HCL NARDIL NASACORT AQ NASONEX NAT-CITALOPRAM NATEGLINIDE NAUSEATOL NAVANE NEDOCROMIL SODIUM NEEDLE NELFINAVIR MESYLATE NEO FER NEO-HC NEORAL NICOTINE (GUM) NICOTINE (INHALER) NICOTINE (LOZENGE) NICOTINE (PATCH) NICOTINE GUM NICOTROL TRANSDERMAL NICOUMALONE NIDAGEL NIFEDIPINE NIFEDIPINE NILUTAMIDE NIMODIPINE NIMOTOP NITOMAN NITRAZEPAM NITRO-DUR NITROFURANTOIN NITROFURANTOIN NITROGLYCERIN NITROL NITROLINGUAL PUMPSPRAY NITROAT NIX NIX DERMAL NIZATIDINE NIZATIDINE NIZORAL NOLVADEX D NON POLLEN NORETHINDRONE NORFLOXACIN NORITATE NORLEVO NORTRIPTYLINE HCL NORVASC NORVIR NOVAMILOR NOVAMOXIN NOVAMOXIN SUGAR REDUCED NOVASEN NOVA-T IUD NOVO 5-ASA NOVO-BETAHIINE NOVO-DOCUSATE NOVO-DOCUSATE CALCIUM NOVO-FURANTOIN NOVO-GABAPENTIN NOVO-GEMFIBROZIL NOVO-GESIC NOVO-GLICLAZIDE NOVO-GLYBURIDE NOVO-HYDRAZIDE NOVO-HYDROXYZIN NOVO-HYLAZIN NOVO-INDAPAMIDE NOVO-IPRAMIDE NOVO-KETOCONAZOLE NOVO-KETOTIFEN NOVO-LAMOTRIGINE NOVO-LANSOPRAZOLE NOVO-LEFLUNOMIDE NOVO-LEVOCARBIDOPA NOVO-LEVOFLOXACIN NOVO-LEXIN NOVOLIN GE 30/70 PENFILL NOVOLIN GE 30/70 PENFILL (ON) NOVOLIN GE 30/70 VIAL NOVOLIN GE 40/60 PENFILL NOVOLIN GE 50/50 PENFILL NOVOLIN GE NPH PENFILL NOVOLIN GE NPH PENFILL (ON) NOVOLIN GE NPH VIAL NOVOLIN GE TORONTO PENFILL NOVOLIN GE TORONTO PENFILL (ON) NOVOLIN GE TORONTO VIAL NOVO-LISINOPRIL (TYPE P) NOVO-LISINOPRIL (TYPE Z) NOVO-LISINOPRIL/HCTZ (TYPE P) NOVO-LISINOPRIL/HCTZ (TYPE Z) NOVO-LOPERAMIDE NOVO-LORAZEM NOVO-LOVAATIN NOVO-MAPROTILINE NOVO-MEDRONE NOVO-MELOXICAM NOVO-MEPRAZINE NOVO-METFORMIN NOVO-METHACIN NOVO-METHOTREXATE NOVO-METHYLPHENIDATE ER Page I-15 of 26

288 Page Page Page NOVO-MEXILETINE NOVO-MINOCYCLINE NOVO-MIRTAZAPINE NOVO-MIRTAZAPINE OD NOVO-MOCLOBEMIDE NOVO-MORPHINE SR NOVO-NAPROX NOVO-NAPROX SODIUM NOVO-NAPROX SODIUM DS NOVO-NARATRIPTAN NOVO-NIZATIDINE NOVO-NORFLOXACIN NOVO-OFLOXACIN NOVO-OLANZAPINE NOVO-OLANZAPINE ODT NOVO-ONDANSETRON NOVO-OXYBUTYNIN NOVO-PANTOPRAZOLE NOVO-PAROXETINE NOVO-PEN VK NOVO-PERIDOL NOVOPHENIRAM NOVO-PINDOL NOVO-PIOGLITAZONE NOVO-PIROCAM NOVO-PRAMINE NOVO-PRAMIPEXOLE NOVO-PRANOL NOVO-PRAVAATIN NOVO-PRAZIN NOVO-PREDNISONE NOVO-PROFEN NOVO-QUETIAPINE NOVO-RABEPRAZOLE NOVO-RALOXIFENE NOVO-RAMIPRIL NOVO-RANIDINE NOVO-RANITIDINE NOVORAPID NOVORAPID FLEXTOUCH NOVORAPID VIAL NOVO-RISEDRONATE NOVO-RISPERIDONE NOVO-RIVAIGMINE NOVO-RYTHRO EOLATE NOVO-SALBUTAMOL HFA NOVO-SELEGILINE NOVO-SEMIDE NOVO-SERTRALINE NOVO-SIMVAATIN NOVO-SOTALOL NOVO-SPIROTON NOVO-SPIROZINE-25 NOVO-SPIROZINE-50 NOVO-SUCRALATE NOVO-SUMATRIPTAN NOVO-SUMATRIPTAN DF NOVO-SUNDAC NOVO-TEMAZEPAM NOVO-TERBINAFINE NOVO-THEOPHYL SR NOVO-TIAPROFENIC NOVO-TIMOL NOVO-TOPIRAMATE NOVO-TRAZODONE NOVO-TRIAMZIDE NOVO-TRIMEL NOVO-TRIMEL DS NOVO-TRIPRAMINE NOVOTWI TIP NEEDLES NOVO-VALPROIC NOVO-VENLAFAXINE XR NOVO-VERAMIL NOVO-VERAMIL SR NOVO-WARFARIN NU-CAL NU-CAL D NU-PEN VK NU-TRAZODONE D NUVARING NYADERM NYDA NYATIN O-CALCIUM 500 OCCLUSAL HP OCPHYL OCTREOTIDE OCTREOTIDE ACETATE OMEGA OCUFLOX ODAN K-20 ODAN K-8 ODANS LIQUOR CARBONIS DETERGENT OESCLIM OFLOXACIN OFLOXACIN OGEN.625 OIL-FREE ACNE WASH CLEANSER OLANZAPINE OLANZAPINE OLANZAPINE ODT OLEYR LIGHT OLEYR REGULAR OLMESARTAN MEDOXOMIL OLMESARTAN MEDOXOMIL, HYDROCHLORTHIAZIDE OLMETEC OLMETEC PLUS OLOPATADINE HCL OLSALAZINE SODIUM OMEPRAZOLE OMEPRAZOLE OMEPRAZOLE MAGNESIUM DR OMEPRAZOLE-20 ONBREZ BREEZHALER ONDANSETRON ONDANSETRON HCL DIHYDRATE ONDANSETRON-ODAN ONDISSOLVE ODF ONE TOUCH DELICA LANCET 30G ONE TOUCH ULTRA ONE TOUCH ULTRA (ON) ONE TOUCH VERIO ONE TOUCH VERIO (ON) ONE-ALPHA ONETOUCH DELICA LANCET 33G ONETOUCH ULTRASOFT LANCETS ONGLYZA OPTICHAMBER OPTICHAMBER DIAMOND (CHAMBER) OPTICHAMBER DIAMOND (LARGE M) OPTICHAMBER DIAMOND (MEDIUM M) OPTICHAMBER LARGE MASK OPTICHAMBER MEDIUM MASK OPTICHAMBER SMALL MASK OPTICROM OPTIHALER OPTIMYXIN OPTIMYXIN EYE/EAR OPTION 2 ORACORT ORAP ORCIPRENALINE SULFATE ORENCIA ORTHO 0.5/35 28 ORTHO 7/7/7 21 ORTHO 7/7/7 28 ORTHO 0.5/35 21 ORTHO 1/35 28 ORTHO 1/35 21 ORTHO CEPT 28 OOFORTE OTRIVIN SALINE OVIMA 21 OVIMA 28 OXAZEPAM OXAZEPAM OXEZE TURBUHALER OXPAM OXSORALEN OXTRIPHYLLINE OXY 5 OXYBUTYN OXYBUTYNIN OXYBUTYNIN CHLORIDE OXYBUTYNINE OXYCODONE OXYCODONE HCL OXYCODONE/ACET OXY-IR OYER SHELL CALCIUM P&S PLUS PALAFER PALIPERIDONE PALMITATE PAMIDRONATE DISODIUM PAMIDRONATE DISODIUM PANCREASE MT 10 PANCREASE MT 16 PANCREASE MT 4 PANOXYL PANOXYL-5 PANTOLOC PANTOPRAZOLE PANTOPRAZOLE MAGNESIUM PANTOPRAZOLE SODIUM PANTOPRAZOLE Page I-16 of 26

289 Page Page Page PARADIGM SILHOUETTE 13MMX18" PARADIGM SILHOUETTE 13MMX23" PARADIGM SILHOUETTE 13MMX32" PARADIGM SILHOUETTE 13MMX43" PARADIGM SILHOUETTE 17MMX23" PARADIGM SILHOUETTE 17MMX32" PARADIGM SILHOUETTE 17MMX43" PARADIGM SILHOUETTE CANNULA 13MM PARADIGM SILHOUETTE CANNULA 17MM PARADIGM SURE-T 29G 6MMX18" PARADIGM SURE-T 29G 6MMX23" PARADIGM SURE-T 29G 8MMX23" PARIET EC PARNATE PAROMOMYCIN SULFATE PAROXETINE PAROXETINE HCL PARSITAN PATANOL PAT-GALANTAMINE ER PAXIL PDL-ACEBUTOLOL PDL-NORTRIPTYLINE PEDIAFER PEDIALYTE PEDIAPHEN PEDIAPHEN CHEWABLE PEDIAPRED PEDIATRIC ELECTROLYTE PEDIATRIX PEDIAVIT PEDIAVIT D PEG 3350 PEGASYS PEGASYS RBV PEGETRON PEGETRON REDIPEN PEGINTERFERON ALFA-2A PEGINTERFERON ALFA-2A, RIBAVIRIN PEGINTERFERON ALFA-2B, RIBAVIRIN PEGLYTE PEN NEEDLE PENICILLAMINE PENICILLIN V POTASSIUM PENICILLINE V PENTASA PENTOSAN POLYSULFATE SODIUM PENTOXIFYLLINE PENTRAX PEPTO BISMOL PERCOCET PERCOCET DEMI PERICHLOR PERICYAZINE PERIDEX PERINDOPRIL ERBUMINE PERINDOPRIL ERBUMINE, INDAPAMIDE PERINDOPRIL ERBUMINE,INDAPAMIDE PERIOGARD PERMETHRIN PERPHENAZINE PETROLATUM PETROLATUM, LANOLIN, MINERAL OIL PETROLATUM, PETROLATUM LIQUID PHARMA D PHENELZINE SULFATE PHENOBARB PHENOBARBITAL PHENYLEPHRINE PHENYLEPHRINE HCL PHENYLEPHRINE MINIMS PHENYTOIN PHL-AMIODARONE PHL-AMLODIPINE PHL-ATENOLOL PHL-AZITHROMYCIN PHL-BACLOFEN PHL-CARVEDILOL PHL-CIPROFLOXACIN PHL-CITALOPRAM PHL-CLONAZEPAM PHL-CLONAZEPAM-R 0.5MG PHL-CYCLOBENZAPRINE PHL-DEXAMETHASONE PHL-FLUOXETINE PHL-INDAPAMIDE PHL-LOXAPINE PHL-MELOXICAM PHL-ONDANSETRON PHL-PIOGLITAZONE PHL-QUETIAPINE PHL-RANITIDINE PHL-RISPERIDONE PHL-SERTRALINE PHL-SIMVAATIN PHL-SOTALOL PHL-TOPIRAMATE PHL-TRAZODONE PHL-URSODIOL C PHL-VALPROIC ACID PHL-VERAPAMIL SR PHOSLAX PICO-SALAX PILOCARPINE PILOCARPINE HCL PILOCARPINE NITRATE PILOCARPINE NITRATE MINIMS PILOPINE HS PIMECROLIMUS PIMOZIDE PINDOLOL PINDOLOL PINDOLOL, HYDROCHLOROTHIAZIDE PIOGLITAZONE PIOGLITAZONE HCL PIPERONYL BUTOXIDE, PYRETHRINS PIROXICAM PIVMECILLINAM HCL PIZOTYLINE HYDROGEN MALATE PLAN B PLANTAGO SEED PLAQUENIL PLAVIX PLENDIL PMS CLOPIDOGREL PMS-ACETAMINOPHEN PMS-ACETAMINOPHEN WITH CODEINE PMS-ALENDRONATE PMS-ALENDRONATE FC PMS-AMANTADINE PMS-AMIODARONE PMS-AMITRIPTYLINE PMS-AMLODIPINE PMS-AMLODIPINE- ATORVAATIN PMS-AMOXICILLIN PMS-ANAGRELIDE PMS-ANAROZOLE PMS-ASA PMS-ASA EC PMS-ATENOLOL PMS-ATORVAATIN PMS-AZITHROMYCIN PMS-BACLOFEN PMS-BENZTROPINE PMS-BENZYDAMINE PMS-BETAHIINE PMS-BEZAFIBRATE PMS-BICALUTAMIDE PMS-BISACODYL PMS-BISOPROLOL PMS-BOSENTAN PMS-BRIMONIDINE PMS-BROMOCRIPTINE PMS-BUPROPION SR PMS-CALCIUM PMS-CANDESARTAN PMS-CANDESARTAN HCTZ PMS-CAPTOPRIL PMS-CARBAMAZEPINE PMS-CARBAMAZEPINE CR PMS-CARVEDILOL PMS-CELECOXIB PMS-CEPHALEXIN PMS-CETIRIZINE PMS-CILAZAPRIL PMS-CIMETIDINE PMS-CIPROFLOXACIN PMS-CITALOPRAM PMS-CLARITHROMYCIN PMS-CLOBAZAM PMS-CLOBETASOL PMS-CLONAZEPAM PMS-CLONAZEPAM R PMS-CODEINE Page I-17 of 26

290 Page Page Page PMS-COLCHICINE 141 PMS-LEVETIRACETAM 69 PMS-RAMIPRIL 49 PMS-CYCLOBENZAPRINE 24 PMS-LEVOBUNOLOL 103 PMS-RAMIPRIL-HCTZ 50 PMS-DESIPRAMINE 74 PMS-LEVOCARB CR 91 PMS-RANITIDINE 111 PMS-DESMOPRESSIN 124 PMS-LEVOFLOXACIN 5 PMS-REPAGLINIDE 122 PMS-DESONIDE 130 PMS-LIDOCAINE VISCOUS 131 PMS-RISEDRONATE 143 PMS-DEXAMETHASONE 101 PMS-LISINOPRIL 48 PMS-RISPERIDONE 83 PMS-DIAZEPAM 87 PMS-LITHIUM CARBONATE 88 PMS-RISPERIDONE ODT 83 PMS-DICLOFENAC 57 PMS-LITHIUM CITRATE 89 PMS-RIVAIGMINE 20 PMS-DICLOFENAC SR 57 PMS-LOPERAMIDE 106 PMS-RIZATRIPTAN RDT 89 PMS-DILTIAZEM CD 45 PMS-LORAZEPAM 87 PMS-ROPINIROLE 92 PMS-DIMENHYDRINATE 109 PMS-LOSARTAN 52 PMS-ROSUVAATIN 35 PMS-DIPHENHYDRAMINE 1 PMS-LOSARTAN-HCTZ 53 PMS-SALBUTAMOL 23 PMS-DIPIVEFRIN 102 PMS-LOVAATIN 34 PMS-SENNOSIDES 107 PMS-DIVALPROEX 67 PMS-MELOXICAM 58 PMS-SERTRALINE 77 PMS-DOCUSATE CALCIUM 106 PMS-METFORMIN 120 PMS-SILDENAFIL R 38 PMS-DOCUSATE SODIUM 106 PMS-METHOTRIMEPRAZINE 80 PMS-SIMVAATIN 36 PMS-DOMPERIDONE 113 PMS-METHYLPHENIDATE 86 PMS-SOD CROMOGLYCATE 99 PMS-DONEPEZIL 19 PMS-METHYLPHENIDATE ER 85 PMS-SOD POLYYRENE SULF 97 PMS-DOXAZOSIN PMS-DUTAERIDE PMS-ENALAPRIL PMS-ENTECAVIR PMS-ERYTHROMYCIN PMS-ESCITALOPRAM PMS-EZETIMIBE PMS-FAMCICLOVIR PMS-FENTANYL MTX PMS-FERROUS SULFATE PMS-FINAERIDE PMS-FLUCONAZOLE PMS-FLUOROMETHOLONE PMS-FLUOXETINE PMS-FLUPHENAZINE PMS-FLUTAMIDE PMS-FOSINOPRIL PMS-FUROSEMIDE PMS-GABAPENTIN PMS-GALANTAMINE ER PMS-GEMFIBROZIL PMS-GENTAMICIN PMS-GLYBURIDE PMS-HALOPERIDOL PMS-HALOPERIDOL LA PMS-HYDROCHLOROTHIAZIDE PMS-HYDROMORPHONE PMS-HYDROXYZINE PMS-IBUPROFEN PMS-INDAPAMIDE PMS-IPRATROPIUM PMS-IPRATROPIUM UDV PMS-IRBESARTAN PMS-IRBESARTAN/HCT PMS-ISMN PMS-ISONIAZID PMS-METOCLOPRAMIDE PMS-METOPROLOL-B PMS-METOPROLOL-L PMS-MINOCYCLINE PMS-MIRTAZAPINE PMS-MISOPROOL PMS-MOCLOBEMIDE PMS-MOMETASONE PMS-MONOCYCLINE PMS-MONTELUKA PMS-NABILONE PMS-NAPROXEN EC PMS-NEVIRAPINE PMS-NIFEDIPINE PMS-NIZATIDINE PMS-NORFLOXACIN PMS-NYATIN PMS-OLANZAPINE PMS-OLANZAPINE ODT PMS-OMEPRAZOLE PMS-ONDANSETRON PMS-OXYBUTYNIN PMS-OXYCODONE PMS-PAMIDRONATE PMS-PANTOPRAZOLE PMS-PAROXETINE PMS-PERPHENAZINE PMS-PHOSPHATES SOLUTION PMS-PINDOLOL PMS-PIOGLITAZONE PMS-PIROXICAM PMS-POLYTRIMETHOPRIM PMS-POTASSIUM PMS-PRAMIPREXOLE PMS-PRAVAATIN PMS-PREDNISOLONE PMS-SOD POLYYRENE SULFONA PMS-SODIUM DOCUSATE PMS-SOTALOL PMS-SULFASALAZINE PMS-SUMATRIPTAN PMS-TAMOXIFEN PMS-TELMISARTAN PMS-TELMISARTAN-HCTZ PMS-TERAZOSIN PMS-TERBINAFINE PMS-TEOERONE PMS-TETRABENAZINE PMS-THEOPHYLLINE PMS-TIAPROFENIC PMS-TIMOLOL PMS-TOPIRAMATE PMS-TRAZODONE PMS-TRIFLUOPERAZINE PMS-TRIHEXYPHENIDYL PMS-URSODIOL PMS-VALACYCLOVIR PMS-VALPROIC ACID PMS-VALSARTAN PMS-VENLAFAXINE XR PMS-VERAPAMIL SR PMS-ZOLMITRIPTAN PMS-ZOLMITRIPTAN ODT POCKET CHAMBER POCKET CHAMBER WITH ADULT MASK POCKET CHAMBER WITH INFANT MASK POCKET CHAMBER WITH MEDIUM MASK POCKET CHAMBER WITH SMALL MASK PMS-ISOSORBIDE 37 PMS-PREGABALIN 70 PODOFILM 132 PMS-KETOPROFEN 58 PMS-PROCHLORPERAZINE 81 PODOFILOX 132 PMS-KETOTIFEN 1 PMS-PROCYCLIDINE 90 PODOPHYLLIN 132 PMS-LACTULOSE 107 PMS-PROPAFENONE 31 PODS 147 PMS-LAMOTRIGINE PMS-LANSOPRAZOLE PMS-LATANOPRO PMS-LATANOPRO-TIMOLOL PMS-LEFLUNOMIDE PMS-LETROZOLE PMS-PROPRANOLOL PMS-PYRAZINAMIDE PMS-QUETIAPINE PMS-QUINAPRIL PMS-RABEPRAZOLE PMS-RALOXIFENE POLIES SPP VENOM PROTEIN EXTRACT POLLEN POLLEN AND NON POLLEN POLLINEX R POLYETHYLENE GLYCOL Page I-18 of 26

291 Page Page Page POLYETHYLENE GLYCOL PREVEX 132 PROMETRIUM 124 POLYETHYLENE GLYCOL PREVEX B 129 PRO-MIRTAZAPINE 75 POLYETHYLENE GLYCOL, POTASSIUM CHLORIDE, SODIUM BICARBONATE, SODIUM CHLORIDE, SODIUM SULFATE POLYMYXIN B SULFATE, BACITRACIN POLYMYXIN B SULFATE, BACITRACIN, GRAMICIDIN POLYMYXIN B SULFATE, TRIMETHOPRIM SULFATE POLYSPORIN POLYSPORIN ANTIBIOTIC POLYSPORIN EYE/EAR POLYSPORIN TRIPLE POLYTAR POLYTOPIC POLYTRIM POLYVINYL ALCOHOL POLYVINYL ALCOHOL, POVIDONE POLY-VI-SOL PORTIA 21 PORTIA 28 POTASSIUM CHLORIDE POTASSIUM CITRATE POVIDONE-IODINE PRADAXA PRAMIPEXOLE PRAMIPEXOLE DIHYDROCHLORIDE PRAVACHOL PRAVAATIN PRAVAATIN SODIUM PRAVAATIN-10 PRAVAATIN-20 PRAVAATIN-40 PRAXIS ASA EC PRAZOSIN HCL PRECISION XTRA PRECISION XTRA (ON) PRED FORTE PRED MILD PREDNISOLONE PREDNISOLONE ACETATE PREDNISOLONE ACETATE, SULFACETAMIDE SODIUM PREDNISOLONE SODIUM PHOSPHATE PREDNISONE PREDNISONE PREFRIN LIQUIFILM PREGABALIN PREGABALIN PREGABALIN-150 PREGABALIN-25 PREGABALIN-50 PREGABALIN-75 PREMARIN PREMPLUS PRENATAL & POPARTUM PRENATAL AND POPARTUM PREVACID PREVACID FAAB PREVEX HC PREZIA PRIMAQUINE PRIMAQUINE PHOSPHATE PRIMIDONE PRIMIDONE PRINIVIL PRINZIDE PRIVA-CELECOXIB PRIVA-CETIRIZINE PRIVA-ESCITALOPRAM PRIVA-EZETIMIBE PRIVA-PANTOPRAZOLE PRO-600K PRO-AMIODARONE PRO-AMOX PRO-ASA 80MG EC TAB PRO-ASA 80MG TAB PRO-AZITHROMYCIN PROBETA PRO-BICALUTAMIDE PRO-BISOPROLOL PROCAINAMIDE HCL PROCAN SR PROCARBAZINE HCL PRO-CARVEDILOL PRO-CEFADROXIL PRO-CEFUROXIME PROCET-30 PROCHLORPERAZINE PROCHLORPERAZINE PRO-CIPROFLOXACIN PRO-CLARITHROMYCIN PRO-CLONAZEPAM PROCTODAN HC PROCTOL PROCTOSEDYL PROCYCLIDINE HCL PROCYTOX PRO-DEXAMETHASONE PRO-ENALAPRIL PRO-FENO-SUPER PRO-FLUCONAZOLE PRO-FLUOXETINE PRO-GABAPENTIN PROGEERONE PRO-GLYBURIDE PROGLYCEM PROGRAF PRO-HYDROXYQUINE PRO-INDAPAMIDE PRO-INDO PRO-ISMN PRO-LEVETIRACETAM PRO-LEVOCARB PROLIA PRO-LISINOPRIL PROLOPA PRO-LORAZEPAM PRO-LOVAATIN PRO-METFORMIN PRO-NAPROXEN EC PRO-OXYCOD ACET PROPADERM PROPAFENONE PROPAFENONE HYDROCHLORIDE PRO-PIOGLITAZONE PROPRANOLOL HCL PROPYL THYRACIL PROPYLTHIOURACIL PRO-QUETIAPINE PRO-RABEPRAZOLE PRO-RAMIPRIL PRO-RISPERIDONE PROSCAR PRO-SOTALOL PROIGMIN PROTOPIC PRO-TOPIRAMATE PRO-TRIAZIDE PROTRIN DF PRO-VALACYCLOVIR PROVERA PROVERA PAK PRO-VERAPAMIL SR PROZAC PSYLLIUM HYDROPHILIC MUCILLOID PULMICORT NEBUAMP PULMICORT TURBUHALER PULMOPHYLLIN PURG-ODAN PURIFYING CLEANSER PURINETHOL PYRANTEL PAMOATE PYRAZINAMIDE PYRIDOIGMINE BROMIDE PYRIDOXINE HCL PYRIMETHAMINE QUETIAPINE QUETIAPINE FUMARATE QUETIAPINE XR QUICK-SET 6MMX18" QUICK-SET 6MMX23" QUICK-SET 6MMX32" QUICK-SET 6MMX43" QUICK-SET 9MMX23" QUICK-SET 9MMX32" QUICK-SET 9MMX43" QUINAPRIL QUINAPRIL HCL QUINAPRIL HCL, HYDROCHLOROTHIAZIDE QVAR R & C RABEPRAZOLE RABEPRAZOLE EC RABEPRAZOLE SODIUM RALOXIFENE RALOXIFENE HCL RALTEGRAVIR RAMIPRIL Page I-19 of 26

292 Page Page Page RAMIPRIL 49 RAPID-D 10MM/110CM 146 RATIO-PIOGLITAZONE 123 RAMIPRIL, HYDROCHLOROTHIAZIDE RAMIPRIL-10 RAMIPRIL-2.5 RAMIPRIL-5 RAMIPRIL-HCTZ RAN RAMIPRIL RAN-ALENDRONATE RAN-AMLODIPINE RAN-ANAROZOLE RAN-ATENOLOL RAN-ATORVAATIN RAN-BICALUTAMIDE RAN-CANDESARTAN RAN-CARVEDILOL RAN-CEFPROZIL RAN-CELECOXIB RAN-CIPROFLOX RAN-CITALO RAN-CLARITHROMYCIN RAN-CLOPIDOGREL RAN-DOMPERIDONE RAN-DONEPEZIL RAN-ENALAPRIL RAN-ESCITALOPRAM RAN-EZETIMIBE RAN-FENTANYL MATRIX RAN-FINAERIDE RAN-FLUOXETINE RAN-FOSINOPRIL RAN-GABAPENTIN RANIBIZUMAB RAN-IRBESARTAN RAN-IRBESARTAN HCTZ RANITIDINE RANITIDINE HCL RAN-LANSOPRAZOLE RAN-LETROZOLE RAN-LEVETIRACETAM RAN-LISINOPRIL RAN-LOSARTAN RAN-METFORMIN RAN-MONTELUKA RAN-NABILONE RAN-OLANZAPINE RAN-OLANZAPINE ODT RAN-OMEPRAZOLE RAN-ONDANSETRON RAN-PANTOPRAZOLE RAN-PIOGLITAZONE RAN-PRAVAATIN RAN-PREGABALIN RAN-QUETIAPINE RAN-RABEPRAZOLE RAN-RANITIDINE RAN-ROPINIROLE RAN-ROSUVAATIN RAN-SERTRALINE RAN-SIMVAATIN RAN-TOPIRAMATE RAN-VALSARTAN RAN-VENLAFAXINE XR RAPAMUNE RAPID-D 10MM/60CM RAPID-D 10MM/80CM RAPID-D 6MM/110CM RAPID-D 6MM/60CM RAPID-D 6MM/80CM RAPID-D 8MM/110CM RAPID-D 8MM/60CM RAPID-D 8MM/80CM RATIO-ACLAVULANATE RATIO-ACYCLOVIR RATIO-AMCINONIDE RATIO-AMLODIPINE RATIO-ATENOLOL RATIO-ATORVAATIN RATIO-AZITHROMYCIN RATIO-BACLOFEN RATIO-BISACODYL RATIO-BRIMONIDINE RATIO-BUPROPION RATIO-CARVEDILOL RATIO-CEFUROXIME RATIO-CIPROFLOXACIN RATIO-CLARITHROMYCIN RATIO-CLOBETASOL RATIO-CODEINE RATIO-CYCLOBENZAPRINE RATIO-DEXAMETHASONE RATIO-DILTIAZEM CD RATIO-DOCUSATE CALCIUM RATIO-DOCUSATE SODIUM RATIO-DOMPERIDONE RATIO-ECTOSONE RATIO-EMTEC-30 RATIO-ENALAPRIL RATIO-FENOFIBRATE RATIO-FINAERIDE RATIO-FLUTICASONE RATIO-FLUVOXAMINE RATIO-GABAPENTIN RATIO-GLYBURIDE RATIO-HEMCORT HC RATIO-INDOMETHACIN RATIO-IPRA SAL RATIO-IPRATROPIUM UDV RATIO-IRBESART/HCT RATIO-IRBESARTAN RATIO-LACTULOSE RATIO-LENOLTEC NO.2 RATIO-LENOLTEC NO.3 RATIO-LEVOBUNOLOL RATIO-MAGNESIUM RATIO-MELOXICAM RATIO-METFORMIN RATIO-METHOTREXATE RATIO-MINOCYCLINE RATIO-MIRTAZAPINE RATIO-MOMETASONE RATIO-MORPHINE RATIO-NYATIN RATIO-OMEPRAZOLE RATIO-ONDANSETRON RATIO-OXYCOCET RATIO-OXYCODAN RATIO-PRAVAATIN RATIO-PREDNISOLONE RATIO-PROCTOSONE RATIO-QUETIAPINE RATIO-RAMIPRIL RATIO-RANITIDINE RATIO-RISPERIDONE RATIO-RIVAIGMINE RATIO-SALBUTAMOL RATIO-SILDENAFIL R RATIO-SIMVAATIN RATIO-SOTALOL RATIO-TAMSULOSIN RATIO-TEMAZEPAM RATIO-TERAZOSIN RATIO-TOPILENE GLYCOL RATIO-TOPISALIC RATIO-TOPISONE RBX-RISPERIDONE REACTINE RECLIPSEN 21 RECLIPSEN 28 REFRESH LIQUIGEL REFRESH PLUS REFRESH TEARS RELAXA REMERON REMERON RD REMICADE REMINYL ER REPAGLINIDE REPAGLINIDE REQUIP RESERVOIR 5XX 1.8ML SYRINGE RESERVOIR PARADIGM 7XX3.0ML RESONIUM CALCIUM REORIL RESULTZ RETIN A RETROVIR REVATIO REYATAZ RHINARIS-CS RHINOCORT AQ RHINOCORT TURBUHALER RHO-NITRO PUMPSPRAY RIDAURA RIFABUTIN RIFADIN RIFAMPIN RILPIVIRINE HCL RISEDRONATE RISEDRONATE SODIUM RISEDRONATE-35 RISPERDAL RISPERDAL CONA RISPERDAL-M RISPERIDONE RISPERIDONE RISPERIDONE (CONA) RITONAVIR RITUXAN Page I-20 of 26

293 Page Page Page RITUXIMAB 17 RIVA-RISPERIDONE 83 SANDOZ ALMOTRIPTAN 89 RIVA CLOPIDOGREL 30 RIVA-RIZATRIPTAN ODT 89 SANDOZ ANAROZOLE 15 RIVA OXAZEPAM 88 RIVA-ROSUVAATIN 35 SANDOZ ANUZINC HC 131 RIVA-ALENDRONATE 141 RIVAROXABAN 29 SANDOZ ANUZINC HC PLUS 131 RIVA-ALPRAZOLAM 86 RIVAROXABAN (10) 29 SANDOZ ATORVAATIN 33 RIVA-AMIODARONE 31 RIVASA 56 SANDOZ BOSENTAN 38 RIVA-AMLODIPINE 43 RIVASA EC 56 SANDOZ BRIMONIDINE 102 RIVA-ANAROZOLE 15 RIVA-SENNA 107 SANDOZ CANDESARTAN 50 RIVA-ATENOLOL 40 RIVA-SERTRALINE 77 SANDOZ CANDESARTAN PLUS 51 RIVA-ATORVAATIN 33 RIVA-SIMVAATIN 36 SANDOZ CAPECITABINE 15 RIVA-AZITHROMYCIN 3 RIVASOL HC 131 SANDOZ CEFPROZIL 2 RIVA-BACLOFEN 25 RIVASOL-HC 131 SANDOZ CELECOXIB 57 RIVA-CANDESARTAN 50 RIVASONE 129 SANDOZ CIPROFLOXACIN 100 RIVA-CELECOX 57 RIVA-SOTALOL 43 SANDOZ CLOPIDOGREL 30 RIVA-CIPROFLOXACIN 5 RIVAIGMINE 20 SANDOZ DICLO/MISOPROS 58 RIVA-CITALOPRAM 73 RIVAIGMINE 20 SANDOZ DONEPEZIL 19 RIVA-CLARITHROMYCIN 3 RIVA-TERBINAFINE 7 SANDOZ DORZOLAMIDE 103 RIVA-CLONAZEPAM 66 RIVA-VALACYCLOVIR 12 SANDOZ DORZOLAMIDE/TIMOLOL 103 RIVACOCET 60 RIVA-VALSARTAN 54 SANDOZ DUTAERIDE 140 RIVA-CYCLOBENZAPRINE 24 RIVA-VENLAFAXINE XR 78 SANDOZ ENALAPRIL 47 RIVA-CYPROTERONE 15 RIVA-VERAPAMIL SR 46 SANDOZ ENTACAPONE 91 RIVA-D 400 UNIT CAP 137 RIVA-ZOLMITRIPTAN 90 SANDOZ ESCITALOPRAM 74 RIVA-DONEPEZIL 19 RIVOTRIL 66 SANDOZ EZETIMIBE 32 RIVA-DUTAERIDE 140 RIZATRIPTAN 89 SANDOZ FENOFIBRATE E 32 RIVA-ENALAPRIL 47 RIZATRIPTAN RDT 89 SANDOZ FENOFIBRATE S 32 RIVA-ESCITALOPRAM 74 ROCALTROL 137 SANDOZ FENTANYL 61 RIVA-EZETIMIBE 32 ROFACT 8 SANDOZ FINAERIDE 140 RIVA-FENOFIBRATE MICRO 32 ROLENE 129 SANDOZ FLUOROMETHOLONE 101 RIVA-FLUCONAZOLE 7 ROPINIROLE 92 SANDOZ FLUVAATIN 33 RIVA-FLUOXETINE RIVA-FLUVOX RIVA-FOSINOPRIL RIVA-GABAPENTIN RIVA-GEMFIBROZIL RIVA-GLYBURIDE RIVA-HYDROXYZIN RIVA-INDAPAMIDE RIVA-IRBESARTAN RIVA-K RIVA-K 20 RIVA-LANSOPRAZOLE RIVA-LETROZOLE RIVA-LISINOPRIL RIVA-LOPERAMIDE RIVA-LOVAATIN RIVA-METFORMIN RIVA-METOPROLOL L RIVA-MINOCYCLINE RIVA-MIRTAZAPINE RIVA-MOTELUKA RIVANASE AQ RIVA-OLANZAPINE RIVA-OMEPRAZOLE DR RIVA-OXYBUTYNIN RIVA-PANTOPRAZOLE RIVA-PAROXETINE RIVA-PRAVAATIN RIVA-PREGABALIN RIVA-QUETIAPINE RIVA-RABEPRAZOLE RIVA-RABEPRAZOLE EC RIVA-RANITIDINE RIVA-RANTIDINE RIVA-RISEDRONATE ROPINIROLE HCL ROSASOL ROSIGLITAZONE MALEATE ROSONE ROSUVAATIN ROSUVAATIN CALCIUM ROSUVAATIN-10 ROSUVAATIN-20 ROSUVAATIN-40 ROSUVAATIN-5 RUFINAMIDE RYTHMODAN RYTHMOL SABRIL SALAGEN SALAZOPYRIN SALBUTAMOL SALBUTAMOL HFA SALBUTAMOL, IPRATROPIUM SALICYLIC ACID SALINEX SALINEX DROPS SALMETEROL XINAFOATE SALMETEROL XINAFOATE, FLUTICASONE PROPIONATE SALOFALK SANDOMIGRAN SANDOMIGRAN DS SANDOATIN SANDOATIN LAR SANDOZ ALENDRONATE SANDOZ ALENDRONATE/CHOLECALCIFER OL SANDOZ ALFUZOSIN SANDOZ INDOMETHACIN SANDOZ IRBESART/HCT SANDOZ IRBESARTAN SANDOZ LANSOPRAZOLE SANDOZ LATANOPRO SANDOZ LATANOPRO/TIMOLOL SANDOZ LEFLUNOMIDE SANDOZ LETROZOLE SANDOZ LEVOFLOXACIN SANDOZ LINEZOLID SANDOZ LISINOPRIL SANDOZ LISINOPRIL HCT SANDOZ LOSARTAN SANDOZ LOSARTAN HCT SANDOZ METOPROLOL (L) SANDOZ MONTELUKA SANDOZ MORPHINE SR SANDOZ MYCOPHENOLATE SANDOZ NARATRIPTAN SANDOZ OFLOXACIN SANDOZ OLANZAPINE ODT SANDOZ OLOPATADINE SANDOZ OMEPRAZOLE SANDOZ OXYCODONE ACET SANDOZ PIOGLITAZONE SANDOZ POLYTRIMETHOPRIM SANDOZ PREGABALIN SANDOZ PROCTOMYXIN HC SANDOZ QUETIAPINE XRT SANDOZ RAMIPRIL SANDOZ REPAGLINIDE SANDOZ RISEDRONATE SANDOZ RISPERIDONE SANDOZ RIVAIGMINE Page I-21 of 26

294 Page Page Page SANDOZ RIZATRIPTAN ODT 89 SANDOZ-RABEPRAZOLE 112 SIALOR 108 SANDOZ ROSUVAATIN 35 SANDOZ-RANITIDINE 111 SIDEKICK 94 SANDOZ TACROLIMUS 145 SANDOZ-RISPERIDONE 83 SIG-ENALAPRIL 47 SANDOZ TAMSULOSIN 24 SANDOZ-SALBUTAMOL 23 SILDENAFIL CITRATE 38 SANDOZ TELMISARTAN 53 SANDOZ-SERTRALINE 77 SILVER SULFADIAZINE 129 SANDOZ TELMISARTAN HCT 54 SANDOZ-SIMVAATIN 36 SIMEPREVIR 13 SANDOZ TRAVOPRO 104 SANDOZ-SOTALOL 42 SIMPONI AUTO INJECTOR 144 SANDOZ VALSARTAN 54 SANDOZ-SUMATRIPTAN 90 SIMPONI PRE-FILLED SYRINGE 144 SANDOZ VALSARTAN HCT 54 SANDOZ-TERBINAFINE 7 SIMVAATIN 36 SANDOZ VENLAFAXINE XR 78 SANDOZ-TIMOLOL 103 SIMVAATIN 36 SANDOZ VORICONAZOLE 7 SANDOZ-TOBRAMYCIN 100 SIMVAATIN SANDOZ ZOLMITRIPTAN 90 SANDOZ-TOPIRAMATE 71 SIMVAATIN SANDOZ ZOLMITRIPTAN ODT 90 SANDOZ-VALPROIC 72 SIMVAATIN SANDOZ-ACEBUTOLOL 39 SANTYL 133 SIMVAATIN SANDOZ-AMIODARONE 31 SAPHRIS 78 SINEMET 91 SANDOZ-AMLODIPINE 43 SAQUINAVIR MESYLATE 10 SINEMET CR 91 SANDOZ-ANAGRELIDE 30 SARNA HC 130 SINEQUAN 74 SANDOZ-ANUZINC HC 131 SAXAGLIPTIN HCL 120 SINGULAIR 99 SANDOZ-ATENOLOL 40 SAXAGLIPTIN, METFORMIN 120 SINTROM 28 SANDOZ-AZITHROMYCIN SANDOZ-BETAXOLOL SANDOZ-BICALUTAMIDE SANDOZ-BISOPROLOL SANDOZ-BUPROPION SR SANDOZ-CARBAMAZEPINE SANDOZ-CIPROFLOXACIN SANDOZ-CITALOPRAM SANDOZ-CLARITHROMYCIN SANDOZ-CLONAZEPAM SANDOZ-CYCLOSPORINE SANDOZ-DEXAMETHASONE SCHEIN-CEFACLOR SCOPOLAMINE BUTYLBROMIDE SEASONALE SEASONIQUE SEBCUR SEBCUR-T SECARIS SECTRAL SEEBRI BREEZHALER SELAX SELECT 1/35 21 SELECT 1/ SIROLIMUS SITAGLIPTIN SITAGLIPTIN, METFORMIN SIV-ATORVAATIN SLOW-K SODIUM AUROTHIOMALATE SODIUM AUROTHIOMALATE SODIUM BICARBONATE SODIUM BICARBONATE SODIUM BIPHOSPHATE SODIUM CARBOXYMETHYL CELLULOSE SANDOZ-DICLOFENAC SANDOZ-DICLOFENAC SR SANDOZ-DILTIAZEM CD SANDOZ-DILTIAZEM T SANDOZ-ERADIOL DERM 100 SANDOZ-ERADIOL DERM 50 SANDOZ-ERADIOL DERM 75 SANDOZ-FAMCICLOVIR SANDOZ-FELODIPINE SANDOZ-FLUVOXAMINE SANDOZ-GLYBURIDE SANDOZ-LEVOBUNOLOL SANDOZ-LISINOPRIL SANDOZ-LOPERAMIDE SANDOZ-LOVAATIN SANDOZ-METFORMIN SANDOZ-METFORMIN FC SANDOZ-METHYLPHENIDATE SR SANDOZ-METOPROLOL SR SANDOZ-MINOCYCLINE SANDOZ-MIRTAZAPINE SANDOZ-MYCOPHENOLATE SANDOZ-OLANZAPINE SANDOZ-ONDANSETRON SANDOZ-PAMIDRONATE SANDOZ-PANTOPRAZOLE SANDOZ-PAROXETINE SANDOZ-PINDOLOL SANDOZ-PRAMIPEXOLE SANDOZ-PRAVAATIN SANDOZ-PREDNISOLONE SANDOZ-PROCTOMYXIN HC SANDOZ-QUETIAPINE SELEGILINE HCL SELENIUM SULFIDE SELEXID SELSUN SENNA LAXATIVE SENNALAX SENNAPREP SENNATAB SENNOSIDES SENOKOT SENOKOT S SEPTA-AMLODIPINE SEPTA-ATENOLOL SEPTA-CIPROFLOXACIN SEPTA-CITALOPRAM SEPTA-DONEPEZIL SEPTA-LOSARTAN SEPTA-LOSARTAN HCTZ SEPTA-METFORMIN SEPTA-ONDANSETRON SEPTA-ZOLMITRIPTAN-ODT SERC SEREVENT DISKHALER SEREVENT DISKUS SEROQUEL SEROQUEL XR SERTRALINE SERTRALINE SERTRALINE-100 SERTRALINE-25 SERTRALINE-50 SHARPS CONTAINER SODIUM CHLORIDE SODIUM CHLORIDE SODIUM CITRATE, SODIUM LAURYL SULFOACETATE, SORBITOL SODIUM CROMOGLYCATE SODIUM NITROPRUSSIDE SODIUM PHOSPHATE SODIUM PHOSPHATE DIBASIC, SODIUM PHOSPHATE MONOBASIC SODIUM POLYYRENE SULFONATE SOFLAX SOFLAX EX SOFLAX SYRUP SOFOSBUVIR SOFOSBUVIR, LEDIPASVIR SOFRACORT EYE/EAR SOFRAMYCIN SOFRAMYCIN ERILE EYE SOLIFENACIN SUCCINATE SOLUCAL SOLUCAL D SOLUCAL D CITRUS SOLUCAL D FORT SOLUCAL D RASPBERRY SOLUCAL GREEN APPLE SOLUCAL RASPBERRY SOLUVER SOLUVER PLUS SOMATULINE AUTOGEL SORIATANE Page I-22 of 26

295 Page Page Page SOTALOL 42 SYNPHASIC TEMPRA DOUBLE RENGTH 65 SOTALOL HCL 42 SYNPHASIC TENDER-1 "MINI" 13MM/110CM 146 SOVALDI 12 SYNTHROID 124 TENDER-1 "MINI" 13MM/60CM 146 SPACER DEVICE 146 SYRINGE 149 TENDER-1 "MINI" 13MM/80CM 146 SPECTRO ACNECARE WASH 132 SYRINGE & NEEDLE 149 TENDER-1 17MM/110CM 146 SPIRIT CARTRIDGE 3.15ML 146 SYRINGE CASE 150 TENDER-1 17MM/60CM 146 SPIRIVA 22 SYRINGE SCALE MAGNIFIER 148 TENDER-1 17MM/80CM 146 SPIRONOLACTONE 55 TACROLIMUS 145 TENDER-2 "MINI" 13MM/110CM 146 SPIRONOLACTONE, HYDROCHLOROTHIAZIDE SPORANOX ALEVO ARLIX ATEX AVUDINE ELARA EREX ERILE EXTEMPORANEOUS MIXTURE (QC) ERILE TRIAMCINOLONE ERILE WATER ERILE WATER (QC) ERILE WATER FOR INJ IEVA-A IEVA-A FORTE IEVAMYCIN IEVAMYCIN FORTE IEVAMYCIN MILD OOL SOFTENER RIBILD SUBOXONE SUCRALFATE SUCRALFATE-1 SULCRATE SULCRATE PLUS SULFACETAMIDE SODIUM SULFAMETHOXAZOLE SULFAMETHOXAZOLE, TRIMETHOPRIM SULFASALAZINE SULFINPYRAZONE SULFINPYRAZONE SULINDAC SUMATRIPTAN SUMATRIPTAN DF SUMATRIPTAN HEMISULFATE SUMATRIPTAN SUCCINATE SUNITINIB MALATE SUPER-FINE PEN NEEDLES MICRO SUPER-FINE PEN NEEDLES ANDARD SUPER-FINE PEN NEEDLES XTRA SUPEUDOL SUPRAX SUPREFACT SUPREFACT DEPOT 2 MONTHS SUPREFACT DEPOT 3 MONTHS SUIVA SUTENT SYMBICORT 100 TURBUHALER SYMBICORT 200 TURBUHALER SYNALAR SYNAREL TACROLIMUS (PROTOPIC) TADALAFIL TAMBOCOR TAMOXIFEN CITRATE TAMSULOSIN CR TAMSULOSIN HCL TANTAPHEN TAPAZOLE TAR0-FLUCONAZOLE TARCEVA TARGEL TARGEL SA TARO-AMCINONIDE TARO-ANAROZOLE TARO-CARBAMAZEPINE TARO-CARBAMAZEPINE CR TARO-CIPROFLOXACIN TARO-CLINDAMYCIN TARO-CLOBETASOL TARO-DICLOFENAC TARO-DOCUSATE TARO-ENALAPRIL TARO-FLUCONAZOLE TARO-MOMETASONE TARO-MUPIROCIN TARO-PHENYTOIN TARO-SIMVAATIN TARO-SONE TARO-SUMATRIPTAN TARO-TERCONAZOLE TARO-TEOERONE TARO-WARFARIN TARO-ZOLEDRONIC ACID TAZAROTENE TAZORAC TEARS NATURALE TEARS NATURALE FREE TEARS NATURALE II TEARS NATURALE P.M. TEARS PLUS TEBRAZID TECTA TEGRETOL TEGRETOL CR TELMISARTAN TELMISARTAN TELMISARTAN HCTZ TELMISARTAN, HYDROCHLOROTHIAZIDE TELMISARTAN/HCTZ TELZIR TEMAZEPAM TEMAZEPAM TEMODAL TEMOZOLOMIDE TEMPRA TENDER-2 "MINI" 13MM/60CM TENDER-2 "MINI" 13MM/80CM TENDER-2 17MM/110CM TENDER-2 17MM/60CM TENDER-2 17MM/80CM TENOFOVIR DISOPROXIL FUMARATE TENORETIC TENORMIN TERAZOL 7 TERAZOSIN TERAZOSIN HCL TERBINAFINE TERBINAFINE HCL TERBUTALINE SULFATE TERCONAZOLE TERSA-TAR TERSA-TAR MILD TEOERONE CYPIONATE TEOERONE CYPIONATE TEOERONE ENANTHATE TEOERONE UNDECANOATE TETRABENAZINE TETRABENAZINE TETRACYCLINE TETRACYCLINE HCL TEVA- MONTELUKA TEVA-ACEBUTOLOL TEVA-ACYCLOVIR TEVA-ALENDRONATE TEVA- ALENDRONATE/CHOLECALCIFER OL TEVA-ALFUZOSIN PR TEVA-ALPRAZOL TEVA-AMIODARONE TEVA-AMITRIPTYLINE TEVA-AMLODIPINE TEVA-AMPICILLIN TEVA-ANAROZOLE TEVA-ATENOL TEVA-ATENOLTHALIDONE TEVA-ATORVAATIN TEVA-AZITHROMYCIN TEVA-BENZYDAMINE TEVA-BETAHIINE TEVA-BICALUTAMIDE TEVA-BIPOPROLOL TEVA-BOSENTAN TEVA-BROMAZEPAM TEVA-CANDESARTAN TEVA-CANDESARTAN/HCTZ TEVA-CAPECITABINE TEVA-CAPTORIL TEVA-CARBAMAZ TEVA-CEFADROXIL Page I-23 of 26

296 Page Page Page TEVA-CELECOXIB 57 TEVA-ROSUVAATIN 35 TOLBUTAMIDE 122 TEVA-CHLOROQUINE 13 TEVA-SIMVAATIN 36 TOLNAFTATE 128 TEVA-CHLORPROMAZINE 79 TEVA-TAMOXIFEN 17 TOLOXIN 31 TEVA-CILAZAPRIL 46 TEVA-TAMSULOSIN 24 TOLTERODINE 135 TEVA-CILAZAPRIL/HCTZ 47 TEVA-TAMSULOSIN CR 24 TOPAMAX 71 TEVA-CIMETINE 110 TEVA-TELMISARTAN 53 TOPAMAX SPRINKLE 71 TEVA-CIPROFLOXACIN 5 TEVA-TELMISARTAN HCTZ 54 TOPICORT 130 TEVA-CITALOPRAM 73 TEVA-TERAZOSIN 39 TOPIRAMATE 71 TEVA-CLARITHROMYCIN 3 TEVA-TICLOPIDINE 30 TOPIRAMATE 71 TEVA-CLAVAMOXIN 4 TEVA-TIMOL 43 TR- VI-SOL 138 TEVA-CLINDAMYCIN 6 TEVA-TRAVOPRO Z 104 TRACLEER 38 TEVA-CLOBAZAM 87 TEVA-VALACYCLOVIR 12 TRAJENTA 120 TEVA-CLOBETASOL 130 TEVA-VALGANCICLOVIR 12 TRANDATE 41 TEVA-CLONAZEPAM TEVA-CLONIDINE TEVA-CLOPAMINE TEVA-CLOPIDOGREL TEVA-CLOXIN TEVA-COMBO ERINEBS TEVA-CYCLOPRINE TEVA-CYPROTERONE/ETHINYL ERADIOL TEVA-DESIPRAMINE TEVA-DESMOPRESSIN TEVA-DICLOFENAC TEVA-DICLOFENAC SR TEVA-DIFLUNISAL TEVA-DILTAZEM CD TEVA-DILTIAZEM TEVA-DILTIAZEM ER TEVA-DIMENATE TEVA-DIVALPROEX TEVA-DONEPEZIL TEVA-DORZOTIMOL TEVA-DUTAERIDE TEVA-EFAVIRENZ TEVA-ENTACAPONE TEVA-ESCITALOPRAM TEVA-EXEMEANE TEVA-EZETIMIBE TEVA-FENTANYL TEVA-FLUTAMIDE TEVA-FLUVAATIN TEVA-GALANTAMINE ER TEVA-HYDROMORPHONE TEVA-IMATINIB TEVA-IRBESARTAN TEVA-IRBESARTAN/HCT TEVA-LACTULOSE TEVA-LAMIVUDINE/ZIDOVUDINE TEVA-LATANOPRO/TIMOLOL TEVA-LETROZOLE TEVA-LOSARTAN TEVA-LOSARTAN HCTZ TEVA-METOPROL TEVA-METOPROL-B TEVA-MODAFINIL TEVA-MYCOPHENOLATE TEVA-NABILONE TEVA-NEVIRAPINE TEVA-OMEPRAZOLE TEVA-PREGABALIN TEVA-QUETIAPINE XR TEVA-RIZATRIPTAN RDT TEVA-VALSARTAN TEVA-VALSARTAN/HCTZ TEVA-VORICONAZOLE TEVA-ZOLMITRIPTAN TEVA-ZOLMITRIPTAN OD TEVETEN TEVETEN PLUS THEO ER THEOLAIR THEOPHYLLINE THEOPHYLLINE THIAMAZOLE THIAMIJECT THIAMINE THIAMINE THIAMINE HCL THIOGUANINE THIOPROPERAZINE MESYLATE THIOTHIXENE THRIVE THYROGEN THYROID THYROID THYROTROPIN ALFA TIAMOL TIAPROFENIC ACID TIAZAC TIAZAC XC TICAGRELOR TICLOPIDINE TICLOPIDINE HCL TIMOLOL TIMOLOL MALEATE TIMOLOL MALEATE, TRAVOPRO TIMOLOL MALEATE-EX TIMOPTIC TIMOPTIC-XE TINACTIN TINACTIN AEROSOL TINZAPARIN SODIUM TIOTROPIUM BROMIDE MONOHYDRATE TIPRANAVIR TIVICAY TIZANIDINE HCL TOBRADEX TOBRAMYCIN TOBREX TOCILIZUMAB TOLBUTAMIDE TRANDOLAPRIL TRANEXAMIC ACID TRANEXAMIC ACID TRANSDERMAL NICOTINE TRANSDERM-NITRO TRANYLCYPROMINE SULFATE TRAVATAN Z TRAVEL AID TRAVEL TABLET TRAVOPRO TRAZODONE TRAZODONE HCL TRAZOREL TRELAR TRELAR LA TRETINOIN TRIAMCINOLONE TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE (5ML) TRIAMCINOLONE DIACETATE TRIAMTERENE, HYDROCHLOROTHIAZIDE TRIATEC-30 TRIAZOLAM TRICIRA LO 21 TRICIRA LO 28 TRI-CYCLEN 21 TRI-CYCLEN 28 TRI-CYCLEN LO 21 TRI-CYCLEN LO 28 TRIDESILON TRIFLUOPERAZINE TRIFLUOPERAZINE HCL TRIFLURIDINE TRIHEXYPHENIDYL TRIHEXYPHENIDYL HCL TRIMETHOPRIM TRIMETHOPRIM TRIMIPRAMINE TRIMIPRAMINE MALEATE TRINIPATCH TRIPTORELIN PAMOATE TRIQUILAR 21 TRIQUILAR 28 TRIZIVIR TROPICAMIDE TROSEC TROSPIUM CHLORIDE TRUETE TRUETRACK Page I-24 of 26

297 TRUETRACK (ON) TRUSOPT TRUVADA TUDORZA GENUAIR TWINJECT TWYNA TYLENOL TYLENOL EXTRA RENGTH TYLENOL JR RENGTH FAMELTS TYLENOL JUNIOR RENGTH TYLENOL WITH CODEINE NO.2 TYLENOL WITH CODEINE NO.3 ULCIDINE ULORIC ULTICARE INSULIN SYRINGE ULTICARE LOW DEAD SPACE SYRINGE ULTICARE PEN NEEDLES ULTICARE PEN NEEDLES WITH SHARP CONTAINER ULTICARE SYGINGES WITH ULTIGUARD ULTICARE SYRINGE ULTICARE SYRINGES WITH ULTIGUARD ULTILET CLASSIC LANCETS ULTRAFLEX MM/110CM ULTRAFLEX MM/60CM ULTRAFLEX MM/80CM ULTRAFLEX - 1 8MM/110CM ULTRAFLEX - 1 8MM/60CM ULTRAFLEX - 1 8MM/80CM ULTRASE MS 4 ULTRASE MT 12 ULTRASE MT 20 ULTRAVATE UNIFINE PENTIPS (OWEN MUMFORD) UNIPHYL UREMOL HC URISPAS URSO URSO DS URSODIOL UEKINUMAB VAGIFEM 10 VALACYCLOVIR HCL VALCYTE VALGANCICLOVIR HCL VALISONE VALIUM VALPROATE, SODIUM VALPROIC ACID VALSARTAN VALSARTAN VALSARTAN HCT VALSARTAN, HYDROCHLOROTHIAZIDE VALSARTAN-HCTZ VALTREX VARENICLINE VASERETIC VASOTEC VENLAFAXINE HCL Page VENLAFAXINE XR VENOFER VENOMIL HONEY BEE VENOM VENOMIL MIXED VESPID VENOM PROTEIN VENOMIL WASP VENOM PROTEIN VENOMIL WHITE FACED HORNET VENOM PROTEIN VENOMIL YELLOW JACKET VENOM PROTEIN VENTOLIN VENTOLIN HFA VENTOLIN PF VEPESID VERAPAMIL VERAPAMIL HCL VERMOX VERSEL VERTEPORFIN VESANOID VESICARE VESPULA SPP VENOM PROTEIN EXTRACT VFEND VICTRELIS VICTRELIS TRIPLE VIDEX EC VIDEXTRA VIGABATRIN VIGAMOX VIMPAT VINCRIINE SULFATE VINCRIINE SULFATE VIOKASE VIRACEPT VIRAMUNE VIRAMUNE XR VIREAD VIROPTIC VISANNE VISKAZIDE VISKEN VISUDYNE VIT A VIT B12 VIT C VITAMIN A VITAMIN A VITAMIN A ACID VITAMIN B1 VITAMIN B12 VITAMIN B3 VITAMIN B6 VITAMIN C VITAMIN D VITAMIN D VITAMIN E VITAMIN E VITAMIN E NATUAL SOURCE VOLIBRIS VOLTAREN VOLTAREN SR VORICONAZOLE Page VYVANSE WAMPOLE MINERAL CALCIUM WARFARIN WARFARIN SODIUM WASP VENOM PROTEIN WASP VENOM PROTEIN WATER WATER FOR INJECTION (QC) WEBCOL ALCOHOL PREP WELLBUTRIN SR WELLBUTRIN XL WHITE FACED HORNET VENOM WHITE FACED HORNET VENOM PROTEIN WHITE FACED HORNET VENOM PROTEIN, YELLOW HORNET VENOM PROTEIN, YELLOW JACKET VENOM PROTEIN WINPRED XALACOM XALATAN XANAX XANAX TS XARELTO XATRAL XELODA XEOMIN XGEVA XYLAC XYLOCAINE VISCOUS YASMIN 21 YASMIN 28 YAZ YELLOW HORNET VENOM PROTEIN YELLOW HORNET VENOM PROTEIN YELLOW JACKET HORNET VENOM PROTEIN YELLOW JACKET VENOM PROTEIN YELLOW JACKET VENOM PROTEIN ZADITEN ZAFIRLUKA ZAMINE 21 ZAMINE 28 ZANAFLEX ZANTAC ZARAH 21 ZARAH 28 ZARONTIN ZAROXOLYN ZEASORB AF ZELDOX ZENHALE ZERIT ZEORETIC ZERIL ZIAGEN ZIDOVUDINE ZINC OXIDE ZINC OXIDE CREAM 15% ZINCOFAX EXTRA RENGTH Page Page I-25 of 26

298 ZIPRASIDONE HCL MONOHYDRATE ZITHROMAX ZOCOR ZODERM ZOFRAN ZOFRAN ODT ZOLADEX ZOLADEX LA ZOLEDRONIC ACID ZOLEDRONIC ACID ZOLMITRIPTAN ZOLMITRIPTAN ZOLMITRIPTAN ODT ZOLOFT ZOMIG ZOMIG RAPIMELT ZORIX ZOVIRAX ZUCLOPENTHIXOL DIHYDROCHLORIDE ZYBAN ZYLOPRIM ZYM-AMLODIPINE ZYMAR ZYM-CARVEDILOL ZYM-CLONAZEPAM ZYM-FLUOXETINE ZYM-MIRTAZAPINE ZYM-ONDANSETRON ZYM-PIOGLITAZONE ZYM-SIMVAATIN ZYM-TOPIRAMATE ZYPREXA ZYPREXA ZYDIS ZYVOXAM Page Page Page Page I-26 of 26