Comprehensive PREFERRED DRUG LIST. Magnolia Health PDL

Transcription

1 Comprehensive PREFERRED DRUG LIST Magnolia Health PDL GE 1 LAST UPDATED 12/2014

2 Pharmacy Program Magnolia Health Plan is committed to providing appropriate, high quality, and cost effective drug therapy to all Magnolia Health Plan members. Magnolia Health Plan works with providers and pharmacists to ensure that medications used to treat a variety of conditions and diseases are covered. Magnolia Health Plan covers prescription medications and certain over-the-counter (OTC) medications when ordered by a Mississippi Medicaid enrolled, Magnolia Health Plan practitioner. The pharmacy program does not cover all medications. Some medications require prior authorization () or have limitations on age, dosage, and maximum quantities. Preferred Drug List The Magnolia Health Plan Preferred Drug List (PDL) is the list of covered drugs. The PDL applies to drugs members can receive at retail pharmacies. The Magnolia Health Plan PDL is continually evaluated by the Magnolia Health Plan Pharmacy and Therapeutics (P&T) Committee to promote the appropriate and cost-effective use of medications. The Committee is composed of the Magnolia Health Plan Medical Director, Magnolia Health Plan Pharmacy Director, and several Mississippi physicians, pharmacists, and other healthcare professionals. Pharmacy Benefit Manager Magnolia Health Plan works with US Script to process pharmacy claims for prescribed drugs. Some drugs on the Magnolia Health Plan PDL may require, US Script is responsible for administering this process. US Script is our Pharmacy Benefit Manager. Specialty Drugs Magnolia Health Plan contracts with a number of specialty pharmacies to ensure members have adequate access to the specialty drugs they require. All specialty drugs, such as biopharmaceuticals and injectables, require to be approved for payment by Magnolia Health Plan. requirements are programmed specific to the drug. A list of preferred specialty products can be found on the last page of the PDL. Prescription Limits In general, members age 21 and above may get up to six prescriptions per month. No more than two of the six prescriptions may be name brand products, including refills. Children under 21 years of age may get more than six prescriptions per month if medically necessary. The monthly prescription limits do not apply to diabetic testing supplies. These supplies include: alcohol pads, PDL blood glucose monitoring strips, glucose tabs, ketone testing strips, lancets, lancing devices, insulin syringes, and urine glucose test strips. Dispensing Limits Drugs may be dispensed up to a maximum of thirty-one (31) days supply for each new prescription or refill. A total of 75% of the days supply must have elapsed before the prescription can be refilled for non-controlled-substance PDL drugs. A total of 85% of the days supply must have elapsed before the prescription can be refilled for controlled substances and narcotic PDL drugs.

3 Appropriate Use and Safety Edits The health and safety the member is a priority for Magnolia Health Plan. One of the ways we address member safety is through point-of sale (POS) edits at the time a prescription is processed at the pharmacy. These edits are based on FDA recommendations and promote safe and effective medication utilization. Prior Authorizations Some medications listed on the Magnolia Health Plan PDL may require. The information should be submitted by the practitioner or pharmacist to US Script on the Medication Prior Authorization Form. This form should be faxed to US Script at This document can be found on the Magnolia Health Plan website. Magnolia Health Plan will cover the medication if it is determined that: 1. There is a medical reason the member needs the specific medication. 2. Depending on the medication, other medications on the PDL have not worked. Authorization requests are reviewed by a licensed clinical pharmacist using the criteria established by the Magnolia Health Plan P&T Committee. If the request is approved, US Script notifies the practitioner by fax. If the clinical information provided does not meet the coverage criteria for the requested medication, Magnolia Health Plan will notify the member and their practitioner of alternatives and provide information regarding the appeal process. Step Therapy Some medications listed on the Magnolia Health Plan PDL may require specific medications to be used before the member can receive the step therapy medication. If Magnolia Health Plan has a record that the required medication was tried first the step therapy medications are automatically covered. If Magnolia Health Plan does not have a record that the required medication was tried, the member s practitioner may be required to provide additional information. If authorization is not granted, Magnolia Health Plan will notify the member and their practitioner and provide information regarding the appeal process. Quantity Limits Magnolia Health Plan may limit how much of a certain medication a member can get at one time. If the practitioner feels the member has a medical reason for getting a greater amount, a may be requested. If Magnolia Health Plan does not grant we will notify the member and their practitioner and provide information regarding the appeal process. Age Limits Some medications on the Magnolia Health Plan PDL may have age limits. These are set for certain drugs based on FDA approved labeling and for safety concerns and quality standards of care. Age limits align with current FDA alerts for the appropriate use of pharmaceuticals.

4 Gender Limits Some medications on the Magnolia Health Plan PDL may be limited to one gender. These limits are set for certain drugs based on FDA approved labeling and for safety concerns and quality standards of care. Gender limits align with current FDA alerts for the appropriate use of pharmaceuticals. Medical Necessity Requests If the member requires a medication that does not appear on the PDL, the member s practitioner can make a medical necessity (MN) request for the medication. It is anticipated that such exceptions will be rare as the PDL medications are appropriate to treat the vast majority of medical conditions. For a MN request Magnolia Health Plan requires: Documentation of failure of at least two PDL agents within the same therapeutic class (provided two agents exist in the therapeutic category with comparable labeled indications) for the same diagnosis (e.g. migraine, neuropathic pain, etc.); or Documented intolerance or contraindication to at least two PDL agents within the same therapeutic class (provided two agents exist in the therapeutic category with comparable labeled indications); or Documented clinical history or presentation where the patient is not a candidate for any of the PDL agents for the indication. These requests are reviewed by a licensed clinical pharmacist using the criteria established by the Magnolia Health Plan P&T Committee. If the request is approved, US Script notifies the practitioner by fax. If the clinical information provided does not meet the coverage criteria for the requested medication, Magnolia Health Plan will notify the member and their practitioner of alternatives and provide information regarding the appeal process. 72 Hour Emergency Supply Policy State and Federal law require that a pharmacy dispense a 72 hour (3 day) supply of medication to any member awaiting determination as well as the need for an emergency supply of an acute care drug. The purpose is to avoid interruption of current therapy or delay in the initiation of therapy. All participating pharmacies are authorized to provide a 72 hour supply of medication and will be reimbursed for the ingredient cost and dispensing fee of the 72 hour supply of medication, whether or not the request is ultimately approved or denied. The pharmacy must call US Script at for a prescription override to submit the 72 hour medication supply for payment. Exclusions The following drug categories are not part of the Magnolia Health Plan PDL and are not covered by the 72 hour emergency supply policy: Fertility enhancing drugs Anorexia, weight loss, or weight gain drugs Experimental or investigational drugs Immunizations and vaccines (except flu vaccine)

5 Drug Efficacy Study Implementation (DESI) and Identical, Related and Similar (IRS) drugs that are classified as ineffective Infusion therapy and supplies Oral vitamins and minerals (except those listed in the PDL) Drugs and other agents used for cosmetic purposes or for hair growth Erectile dysfunction drugs prescribed to treat impotence Drugs eligible for coverage under Medicare Part D OTC drugs (except those listed in the PDL) Newly Approved Products Magnolia Health Plan reviews new drugs for safety and effectiveness before adding them to the PDL. During this period, access to these medications will be considered through the review process. If Magnolia Health Plan does not grant we will notify the member and their practitioner and provide information regarding the appeal process. Over-the-Counter Medications Magnolia Health Plan covers a variety of OTC medications. These medications can be found throughout the Magnolia Health Plan PDL. Magnolia Health Plan covers OTC products listed in the PDL if the member has a prescription from a licensed practitioner that meets all the legal requirements for a prescription. Tobacco Cessation Medications The following types of tobacco cessation medications will be covered by Magnolia: nicotine replacement products, Bupropion Hydrochloride, Varenicline Tartrate (Chantix). A physician s prescription will be required for all tobacco cessation medications. Each prescription will count toward the monthly limit. Magnolia authorizes benefits for tobacco cessation medications for the purpose of supporting members who are trying to quit tobacco use with the temporary assistance of nicotine replacement therapy. It is expected that utilization of these products will be in accordance with medical standards of practice, FDA guidelines, and manufacturers recommendations which generally limit product use to approximately 12 weeks. Generic Drugs When drugs are available, the brand name drug will not be covered without Magnolia Health Plan authorization. Generic drugs have the same active ingredient and work the same as brand name drugs. If the member or their practitioner feels a brand name drug is medically necessary, the practitioner request the drug using the process. We will cover the brand-name drug according to our clinical guidelines if there is a medical reason the member needs the particular brand-name drug. If Magnolia Health Plan does not grant authorization, we will notify the member and their practitioner and provide information regarding the appeal process.

6 The provision is waived for the following products due to their narrow therapeutic index (NTI) as recognized by current medical and pharmaceutical literature: Aminophylline, Carbamazepine, Cyclosporine, Digoxin, Disopyramide, Ethosuximide, Flecainide, L-Thyroxine, Lithium, Phenytoin, Procainamide, Theophylline, Thyroid, Valproic Acid, and Warfarin. Drug Efficacy Study and Implementation Drugs DESI products and known related drug products are defined as less than effective by the Food and Drug Administration because there is a lack of substantial evidence of effectiveness for all labeling indications and because a compelling justification for their medical need has not been established. DESI products are not covered by Magnolia Health Plan. Filling a Prescription A member can have prescriptions filled at a Magnolia Health Plan network pharmacy. If the member decides to have a prescription filled at a network pharmacy they can locate a pharmacy near them by contacting Magnolia Health Plan Member Services. At the pharmacy the member will need to provide the pharmacist with the prescription and their Magnolia Health Plan ID card. Abbreviations The following notations and abbreviations may be found throughout the drug listing in the limitations and restrictions column. DS/DU: Max Days Sply: Max Fills: Max Qty: Min DS: : Pkg Size: Days Supply per Dosage Unit Maximum Days Supply Maximum Fills (per a designated time period) Maximum Quantity (per claim or designated time period) Minimum Days Supply Prior Authorization Package Size Contact Information Magnolia Health Plan Phone: Fax: Website: US Script Phone: Fax: Help Desk: GE 6 LAST UPDATED 12/2014

7 LEGEND TYPE Quantity Limit DESCRIPTION There is a limit on the amount of drug covered per prescription, or within a specific time frame. Prior Authorization Prior Authorization required before prescription can be filled. ST Step Therapy Requires trial and failure of one or more preferred products prior to coverage. Gender Limit Drug is limited to specific gender. Age Limit Drug is limited to specific age. Max Daily Dose A limit on the number of times the drug can be taken per day MPL Max Package Limit A limit on the amount of drug covered per prescription. MFL Max Fill Limit There is a limit on the number of times this drug can be refilled. C Custom This drug has unique restrictions GE 7 LAST UPDATED 12/2014

8 LIST OF COVERED OVER-THE-COUNTER MEDICATIONS The Magnolia Health PDL pharmacy program covers a variety of OTC products. The products listed below are covered when the member has a prescription from a licensed clinician that meets all the legal requirements for a prescription and has it filled at a Magnolia Health PDL network pharmacy. Covered products are available in quantities up to a thirty (30) days supply. All other OTC drugs except insulins require. Please note that products must be prescribed when available. DRUG DESCRIPTION (OTC) /GEN LIMITS & RESTRICTIONS TERNATIVE MEDICINES ginger (zingiber officinalis) cap 250 mg 4 per day melatonin cap 3 mg melatonin cap 5 mg melatonin tab 3 mg melatonin tab 5 mg ANGESICS - ANTI-INFLAMMATORY ibuprofen cap 200 mg ibuprofen chew tab 100 mg ibuprofen susp 100 mg/5ml ibuprofen susp 40 mg/ml ibuprofen tab 100 mg ibuprofen tab 200 mg naproxen sodium tab 220 mg 62 / 31 days ANGESICS - NonNarcotic acetaminophen cap 500 mg acetaminophen chew tab 160 mg acetaminophen chew tab 80 mg acetaminophen dispersible tab 80 mg acetaminophen elixir 160 mg/5ml acetaminophen liquid 160 mg/5ml GE 8 LAST UPDATED 12/2014

9 DRUG DESCRIPTION (OTC) /GEN LIMITS & RESTRICTIONS acetaminophen soln 100 mg/ml 30 / 30 days acetaminophen soln 160 mg/5ml acetaminophen suppos 120 mg 12 / 31 days acetaminophen suppos 325 mg 12 / 31 days acetaminophen suppos 650 mg 12 / 31 days acetaminophen susp 160 mg/5ml acetaminophen susp 80 mg/0.8ml acetaminophen tab 325 mg acetaminophen tab 500 mg aspirin buffered (ca carb-mg carb-mg ox) tab 325 mg aspirin buffered tab 325 mg aspirin chew tab 81 mg aspirin suppos 300 mg 12 / 31 days aspirin suppos 600 mg 12 / 31 days aspirin tab 325 mg aspirin tab 81 mg aspirin tab delayed release 325 mg aspirin tab delayed release 500 mg aspirin tab delayed release 81 mg ANORECT AGENTS phenyleph-shark liver oil-cocoa butter suppos % 12 / 31 days phenylephrine-shark liver oil-mo-pet oint % 31 / 31 days pramoxine hcl rectal foam 1% 15 / claim ANTACIDS alum & mag hydroxide-simethicone susp mg/5ml aluminum hydroxide gel susp 320 mg/5ml 496 / 31 days GE 9 LAST UPDATED 12/2014

10 DRUG DESCRIPTION (OTC) /GEN LIMITS & RESTRICTIONS aluminum hydroxide gel susp 600 mg/5ml 496 / 31 days calcium carbonate (antacid) chew tab 500 mg magnesium oxide tab 400 mg sodium bicarbonate tab 325 mg 496 / 31 days sodium bicarbonate tab 650 mg 496 / 31 days ANTHELMINTICS PIN-X CHEW TAB MG pyrantel pamoate MFL 4 / claim 1 / 30 days pyrantel pamoate susp 144 mg/ml (50 mg/ml base equiv) MFL 60 / claim 1 / 30 days ANTIDIABETICS glucose chew tab 4 gm 50 / 30 days NOVOLIN 70/30 INNOLET (70-30) 100 UNIT/ML insulin isophane & reg (human) NOVOLIN N INNOLET 100 UNIT/ML insulin isophane (human) NOVOLIN N PENFILL 100 UNIT/ML insulin isophane (human) NOVOLIN R INNOLET 100 UNIT/ML insulin regular (human) NOVOLIN R PENFILL 100 UNIT/ML insulin regular (human) 40 / 30 days 40 / 30 days 40 / 30 days 40 / 30 days 40 / 30 days ANTIDIARRHES bismuth subsalicylate chew tab 262 mg bismuth subsalicylate susp 262 mg/15ml bismuth subsalicylate tab 262 mg loperamide hcl cap 2 mg loperamide hcl liq 1 mg/5ml (0.2 mg/ml) loperamide hcl tab 2 mg 2 per day ANTIEMETICS dimenhydrinate tab 50 mg 24 / claim GE 10 LAST UPDATED 12/2014

11 DRUG DESCRIPTION (OTC) /GEN LIMITS & RESTRICTIONS DRAMAMINE CHEW TAB 50 MG dimenhydrinate meclizine hcl chew tab 25 mg meclizine hcl tab 12.5 mg meclizine hcl tab 25 mg 24 / claim ANTIHISTAMINES ER-DRYL TAB 50 MG diphenhydramine hcl 4 per day cetirizine hcl chew tab 10 mg cetirizine hcl chew tab 5 mg cetirizine hcl oral soln 1 mg/ml (5 mg/5ml) 240 / claim At least 12 yrs old cetirizine hcl tab 10 mg cetirizine hcl tab 5 mg chlorpheniramine maleate syrup 2 mg/5ml 60 per day chlorpheniramine maleate tab 4 mg 120 / claim clemastine fumarate tab 1.34 mg (1 mg base equiv) 2 per day diphenhydramine hcl (sleep) tab 25 mg diphenhydramine hcl cap 25 mg 4 per day diphenhydramine hcl cap 50 mg 4 per day diphenhydramine hcl elixir 12.5 mg/5ml 240 / claim diphenhydramine hcl liquid 12.5 mg/5ml 240 / claim diphenhydramine hcl syrup 12.5 mg/5ml 240 / claim diphenhydramine hcl tab 25 mg 4 per day fexofenadine hcl tab 180 mg fexofenadine hcl tab 60 mg 2 per day loratadine rapidly-disintegrating tab 10 mg GE 11 LAST UPDATED 12/2014

12 DRUG DESCRIPTION (OTC) /GEN LIMITS & RESTRICTIONS loratadine syrup 5 mg/5ml 240 / claim loratadine tab 10 mg ANTISEPTICS & DISINFECTANTS chlorhexidine gluconate liquid 4% HIBICLENS LIQUID 4 % chlorhexidine gluconate CONTRACEPTIVES 1 / 21 days levonorgestrel tab 1.5 mg MFL 4 / 365 days COUGH/COLD/LERGY acetaminophen w/ dm liq mg/5ml BIOSPEC DMX LIQUID MG/5ML dextromethorphan-guaifenesin brompheniramine & phenylephrine elixir mg/5ml MFL 120 / 30 days 1 / 30 days brompheniramine & pseudoephedrine elixir 1-15 mg/5ml MFL 120 / 30 days 1 / 30 days cetirizine-pseudoephedrine tab sr 12hr mg 2 per day chlorphen-pseudoephedrine w/ apap cap mg chlorpheniramine & phenylephrine liquid 1-2 mg/ml chlorpheniramine & phenylephrine liquid mg/ml 30 / claim chlorpheniramine & phenylephrine syrup mg/5ml 240 / claim chlorpheniramine-dm liquid 2-15 mg/5ml 240 / claim CVS NAS MIST AERO SOLN 0.9 % saline 240 / claim dextromethorphan polistirex liquid cr 30 mg/5ml 240 / 6 days dextromethorphan-doxylamine-apap liquid mg/30ml GE 12 LAST UPDATED 12/2014

13 DRUG DESCRIPTION (OTC) /GEN LIMITS & RESTRICTIONS dextromethorphan-guaifenesin liquid mg/5ml 240 / claim dextromethorphan-guaifenesin liquid mg/5ml 240 / claim dextromethorphan-guaifenesin liquid mg/5ml dextromethorphan-guaifenesin liquid mg/5ml dextromethorphan-guaifenesin liquid mg/5ml dextromethorphan-guaifenesin syrup mg/5ml 240 / claim dextromethorphan-guaifenesin syrup mg/5ml 240 / claim dextromethorphan-guaifenesin tab sr 12hr mg 2 per day dextromethorphan-phenylephrine-apap cap mg DIMETAPP LONG ACT COUGH/COLD SYRUP MG/5ML chlorpheniramine-dm 240 / claim guaifenesin liquid 100 mg/5ml MFL 240 / 30 days 1 / 30 days guaifenesin syrup 100 mg/5ml 240 / 6 days guaifenesin tab sr 12hr 600 mg MFL 40 / 30 days 1 / 30 days guaifenesin-codeine soln mg/5ml LITTLE REMEDIES FOR COLDS LIQUID MG/ML dextromethorphan-phenylephrine-acetaminophen LOHIST-D LIQUID 2-30 MG/5ML chlorpheniramine & pseudoeph 240 / claim loratadine & pseudoephedrine tab sr 12hr mg 62 / 31 days 2 per day loratadine & pseudoephedrine tab sr 24hr mg MUCINEX MAXIMUM STRENGTH TAB ER 12H 1200 MG guaifenesin 2 per day phenylephrine-chlorphen-dm liquid mg/ml 60 / 6 days phenylephrine-chlorphen-dm liquid mg/5ml 240 / claim GE 13 LAST UPDATED 12/2014

14 DRUG DESCRIPTION (OTC) /GEN LIMITS & RESTRICTIONS phenylephrine-chlorphen-dm liquid mg/5ml 240 / claim phenylephrine-chlorphen-dm liquid mg/ml 30 / 6 days phenylephrine-chlorphen-dm syrup mg/5ml 240 / claim phenylephrine-chlorphen-dm syrup mg/5ml 240 / claim phenylephrine-dm soln mg/5ml 240 / claim phenylephrine-guaifenesin liqd mg/5ml 240 / 6 days phenylephrine-pyrilamine-dm syrup mg/5ml 240 / claim pseudoeph-doxylamine-dm w/ apap cap mg pseudoeph-doxylamine-dm w/apap liq mg/30ml pseudoephed-bromphen-dm elixir mg/5ml 240 / claim pseudoephed-bromphen-dm syrup mg/5ml 240 / claim pseudoephed-chlorphen-dm liq mg/5ml 240 / claim pseudoephed-chlorphen-dm liq mg/5ml 240 / claim pseudoephedrine w/ apap-dm cap mg pseudoephedrine w/ cod-gg soln mg/5ml 240 / 6 days pseudoephedrine w/ dm-gg liquid mg/5ml 240 / 6 days pseudoephedrine-guaifenesin syrup mg/5ml 240 / claim pseudoephedrine-guaifenesin tab sr 12hr mg 210 / claim pseudoephedrine-ibuprofen susp mg/5ml pseudoephedrine-ibuprofen tab mg sodium chloride aero soln 0.9% 240 / claim sodium chloride soln nebu 0.9% TRIAMINIC COLD/COUGH DAY TIME SOLUTION MG/5ML phenylephrine-dm TRIAMINIC COLD/COUGH DAY TIME SYRUP MG/5ML phenylephrine-dm 240 / claim 240 / claim GE 14 LAST UPDATED 12/2014

15 DRUG DESCRIPTION (OTC) /GEN LIMITS & RESTRICTIONS DERMATOLOGICS *emollient - cream** *emollient - lotion** *neomycin-bacitracin-polymyxin oint*** MPL 1 / claim *skin protectants misc - cream*** *soap & cleansers - liquid*** A-200 GEL % pyrethrins-piperonyl butoxide ACNE MEDICATION 5 LOTION 5 % benzoyl peroxide bacitracin oint 500 unit/gm MPL 2 / claim bacitracin zinc oint 500 unit/gm 30 / claim benzoyl peroxide gel 10% benzoyl peroxide gel 5% benzoyl peroxide liq 10% benzoyl peroxide liq 5% benzoyl peroxide lotion 10% camphor & menthol lotion % MPL 1 / claim capsaicin cream 0.025% capsaicin cream 0.075% MPL 1 / claim capsaicin cream 0.1% MPL 1 / claim CAPZASIN-P CREAM % capsaicin CASTIVA WARMING LOTION % capsaicin CLEAN & CLEAR ADVANTAGE 3-IN-1 LOTION 5 % benzoyl peroxide MPL 1 / claim MPL 1 / claim clotrimazole cream 1% MPL 1 / claim clotrimazole soln 1% MPL 1 / claim GE 15 LAST UPDATED 12/2014

16 DRUG DESCRIPTION (OTC) /GEN LIMITS & RESTRICTIONS coal tar shampoo 0.5% dibucaine oint 1% 30 / claim dibucaine rectal ointment 1% 30 / claim diphenhydramine hcl cream 2% hydrocortisone cream 0.5% 30 / claim hydrocortisone cream 1% MPL 1 / claim hydrocortisone lotion 1% MPL 1 / claim hydrocortisone oint 0.5% 30 / claim hydrocortisone oint 1% MPL 60 / 30 days 1 / 30 days hydrocortisone-aloe vera cream 1% 30 / claim KERYT GEL 3 % salicylic acid 30 / claim lactic acid (ammonium lactate) cream 12% MPL 1 / claim lactic acid (ammonium lactate) lotion 12% MPL 1 / 31 days LICIDE TREATMENT KIT pyrethrins-piperonyl butoxide lidocaine hcl gel 2% 30 / claim miconazole nitrate cream 2% MPL 45 / claim 1 / claim neomycin-polymyxin w/ pramoxine cream 1% MPL 1 / claim NIX LICE CONTROL LIQUID 0.25 % permethrin permethrin aerosol 0.5% permethrin creme rinse 1% permethrin lotion 1% MPL 1 / claim permethrin spray & pyrethins-piperonyl butoxide shamp kit POLYSPORIN POWDER UNIT/GM bacitracin-polymyxin b GE 16 LAST UPDATED 12/2014

17 DRUG DESCRIPTION (OTC) /GEN LIMITS & RESTRICTIONS pyreth-piperonyl butox sham-permeth aero-nit remover gel kit pyrethrins-piperonyl butoxide liq % MPL 1 / claim pyrethrins-piperonyl butoxide shampoo 0.3-3% pyrethrins-piperonyl butoxide shampoo % pyrethrins-piperonyl butoxide shampoo kit % salicylic acid gel 6% SCHOOLTIME SHAMPOO SHAMPOO nit remover selenium sulfide lotion 1% 240 / claim terbinafine hcl cream 1% MPL 1 / claim tolnaftate aerosol 1% MPL 30 / claim 1 / claim tolnaftate aerosol pow 1% MPL 30 / claim 1 / claim tolnaftate cream 1% 30 / claim zinc oxide oint 20% MPL 1 / claim DIAGNOSTIC PRODUCTS NOVA MAX PLUS KETONE TEST STRIP ketone blood test PRECISION XTRA KETONE STRIP ketone blood test PTS NELS KETONE TEST STRIP ketone blood test 30 / 30 days 30 / 30 days 30 / 30 days GASTROINTESTIN AGENTS - MISC. simethicone chew tab 80 mg simethicone liquid 40 mg/0.6ml 31 / 31 days simethicone susp 40 mg/0.6ml 31 / 31 days HEMATOPOIETIC AGENTS carbonyl iron chew tab 15 mg (elemental iron) GE 17 LAST UPDATED 12/2014

18 DRUG DESCRIPTION (OTC) /GEN LIMITS & RESTRICTIONS ferrous fumarate tab 325 mg (106 mg elemental fe) 2 per day FERROUS UCONATE TAB 225 (27 FE) MG ferrous gluconate ferrous gluconate tab 240 mg (27 mg elemental fe) ferrous gluconate tab 324 mg (38 mg elemental iron) ferrous gluconate tab 325 mg ferrous gluconate tab 325 mg (36 mg elemental fe) ferrous gluconate tab 325 mg (37.5 mg elemental fe) ferrous sulfate dried tab cr 160 mg (50 mg fe equivalent) ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental fe) 16 per day ferrous sulfate soln 75 mg/ml (15 mg/ml elemental fe) 3.4 per day ferrous sulfate tab 325 mg (65 mg elemental fe) ferrous sulfate tab ec 324 mg (65 mg fe equivalent) ferrous sulfate tab ec 325 mg (65 mg fe equivalent) folic acid tab 1 mg folic acid tab 400 mcg folic acid tab 800 mcg IRON TAB 246 (28 FE) MG ferrous gluconate polysaccharide iron complex cap 150 mg (iron equivalent) HYPNOTICS diphenhydramine hcl (sleep) cap 50 mg diphenhydramine hcl (sleep) tab 25 mg diphenhydramine hcl (sleep) tab 50 mg doxylamine succinate (sleep) tab 25 mg LAXATIVES *multiple vitamins w/ minerals tab cr** *sodium phosphates - enema*** GE 18 LAST UPDATED 12/2014

19 DRUG DESCRIPTION (OTC) /GEN LIMITS & RESTRICTIONS bisacodyl suppos 10 mg 12 / claim bisacodyl tab delayed release 5 mg calcium polycarbophil tab 625 mg 10 per day docusate sodium cap 100 mg 3 per day docusate sodium cap 250 mg 3 per day docusate sodium cap 50 mg docusate sodium liquid 150 mg/15ml docusate sodium syrup 60 mg/15ml docusate sodium tab 100 mg 3 per day glycerin suppos 2 gm magnesium citrate soln magnesium hydroxide susp 400 mg/5ml 992 / 31 days polyethylene glycol 3350 oral packet polyethylene glycol 3350 oral powder 34 per day psyllium cap 0.52 gm psyllium powder 100% psyllium powder 28.3% psyllium powder 30% psyllium powder 30.9% psyllium powder 33% psyllium powder 48.57% psyllium powder 50% psyllium powder 58.6% psyllium powder 68% senna tab 187 mg sennosides tab 8.6 mg sennosides-docusate sodium tab mg 4 per day GE 19 LAST UPDATED 12/2014

20 DRUG DESCRIPTION (OTC) /GEN LIMITS & RESTRICTIONS sorbitol oral solution 70% sorbitol rectal solution 70% sorbitol solution (bulk) MEDIC DEVICES *alcohol swabs*** 400 / claim *gauze pads & dressings - pads 2" x 2"*** *gauze pads & dressings - pads 3" x 3"*** *gauze pads & dressings - pads 4" x 4"*** *respiratory therapy supplies - misc** 1 / 360 days ARI CHAMBER DEVICE spacer/aerosol-holding chambers 2 / 360 days condoms latex lubricated 36 / claim KIMONO MICRO THIN MISC condoms latex non-lubricated - male NESSI SCER WITH MASK LARGE DEVICE spacer/aerosol-holding chambers NESSI SCER WITH MASK SM/MED DEVICE spacer/aerosol-holding chambers NESSI SCER WITH MOUTHPIECE DEVICE spacer/aerosol-holding chambers OPTICHAMBER FACE MASK-LARGE MISC spacer/aerosol-holding chambers OPTICHAMBER FACE MASK-MEDIUM MISC spacer/aerosol-holding chambers OPTICHAMBER FACE MASK-SML MISC spacer/aerosol-holding chambers TRUSTEX NON-LUBRICATED MISC condoms latex non-lubricated - male TRUSTEX RIA NON-LUBRICATED MISC condoms latex non-lubricated - male 36 / claim 2 / 360 days 2 / 360 days 2 / 360 days 2 / 360 days 2 / 360 days 2 / 360 days 36 / claim 36 / claim MINERS & ELECTROLYTES *oral electrolyte solution*** GE 20 LAST UPDATED 12/2014

21 DRUG DESCRIPTION (OTC) /GEN LIMITS & RESTRICTIONS calcium carbonate susp 1250 mg/5ml (500 mg/5ml elemental ca) calcium carbonate-cholecalciferol tab 500 mg-200 unit 500 / 30 days calcium carbonate-vitamin d chew tab 600 mg-400 unit 62 / 31 days calcium carbonate-vitamin d tab 250 mg-125 unit calcium carbonate-vitamin d tab 500 mg-125 unit calcium carbonate-vitamin d tab 500 mg-200 unit calcium carbonate-vitamin d tab 600 mg-200 unit 62 / 31 days calcium carbonate-vitamin d tab 600 mg-400 unit 62 / 31 days magnesium oxide cap 400 mg (elemental mg) (mg supplement) magnesium oxide tab 400 mg (240 mg elemental mg) oyster shell calcium tab 500 mg RVA-C TAB MG-UNIT calcium-ergocalciferol RA CCIUM HI-C/VITAMIN D TAB MG-UNIT calcium-cholecalciferol zinc sulfate cap 220 mg (50 mg elemental zn) MOUTH/THROAT/DENT AGENTS *artificial saliva - solution*** 900 / claim sodium fluoride rinse 0.2% stannous fluoride conc 0.63% MULTIVITAMINS *b-complex vitamin cap** *b-complex vitamin tab** *b-complex w/ c cap** *b-complex w/ c tab** *multiple vitamin tab** *multiple vitamins w/ iron tab** GE 21 LAST UPDATED 12/2014

22 DRUG DESCRIPTION (OTC) /GEN LIMITS & RESTRICTIONS *multiple vitamins w/ minerals tab** *pediatric multiple vitamin w/ c & fa chew tab** *pediatric multiple vitamin w/ c soln 35 mg/ml** 50 / claim *pediatric multiple vitamins w/ iron drops 10 mg/ml** 60 / claim *pediatric vitamins acd w/ iron drops 10 mg/ml*** 50 / claim *pediatric vitamins adc drops 1500 unit-400 unit-35 mg/ml*** 50 / claim *prenatal vit w/ fe fumarate-fa tab mg*** Up to 45 yrs old *vitamins w/ lipotropics cap** *vitamins w/ lipotropics tab** diphenhydramine-acetaminophen tab mg (sleep) KPN PRENAT TAB 0.1 MG prenatal multivit-min w/fe-fa Up to 45 yrs old MISSION PRENAT FA TAB prenatal vit w/ ferrous gluconate-folic acid Up to 45 yrs old MISSION PRENAT HP TAB prenatal vit w/ ferrous gluconate-folic acid Up to 45 yrs old MISSION PRENAT TAB prenatal vit w/ ferrous gluconate-folic acid Up to 45 yrs old NUTRICION PORVIDA 0.25 MG prenatal multivit-min w/fe-fa Up to 45 yrs old GE 22 LAST UPDATED 12/2014

23 DRUG DESCRIPTION (OTC) /GEN LIMITS & RESTRICTIONS PERRY PRENAT CAP MG prenatal vit w/ ferrous fumarate-folic acid Up to 45 yrs old PNV PRENAT PLUS MULTIVITAMIN TAB 27-1 MG prenatal vit w/ ferrous fumarate-folic acid Up to 45 yrs old PRESERVISION AREDS TAB multiple vitamins w/ minerals THERANAT CORE NUTRITION TAB 27-1 MG prenatal vit w/ ferrous fumarate-folic acid Up to 45 yrs old NAS AGENTS - SYSTEMIC AND TOPIC cromolyn sodium nasal aerosol soln 5.2 mg/act (4%) 26 / claim phenylephrine hcl tab 10 mg 24 / claim pseudoephedrine hcl liq 15 mg/5ml pseudoephedrine hcl syrup 30 mg/5ml pseudoephedrine hcl tab 30 mg pseudoephedrine hcl tab 60 mg pseudoephedrine hcl tab sr 12hr 120 mg 62 / 31 days saline nasal spray 0.65% MPL 1 / claim NUTRIENTS *omega-3 fatty acids cap 1000 mg** 6 per day *omega-3 fatty acids cap 1200 mg** 6 per day POLYCOSE glucose polymer POLYCOSE LIQUID glucose polymer POLYCOSE POWDER glucose polymer MPL 1 / 30 days MPL 1 / 30 days MPL 1 / 30 days GE 23 LAST UPDATED 12/2014

24 DRUG DESCRIPTION (OTC) /GEN LIMITS & RESTRICTIONS OPHTHMIC AGENTS *artificial tear ophth ointment*** 4 / claim *artificial tear ophth solution*** 4 / claim *white petrolatum-mineral oil ophth ointment*** MPL 1 / claim hypromellose ophth soln 0.4% 15 / claim ketotifen fumarate ophth soln 0.025% (base equiv) MPL 1 / claim naphazoline w/ pheniramine ophth soln % 15 / 30 days polyvinyl alcohol ophth soln 1.4% 15 / claim tetrahydrozoline hcl ophth soln 0.05% MPL 1 / 30 days OTIC AGENTS carbamide peroxide 6.5% otic soln 15 / 31 days PHARMACEUTIC ADJUVANTS *lanolin cream*** lanolin SIMPLYTHICK GEL xanthan gum (thickening) 1816 / claim At least 1 yrs old PSYCHOTHERAPEUTIC AND NEUROLOGIC AGENTS - MISC. nicotine polacrilex gum 2 mg nicotine polacrilex gum 4 mg nicotine polacrilex lozenge 2 mg nicotine polacrilex lozenge 4 mg nicotine td patch 24hr 14 mg/24hr 84 / 365 days nicotine td patch 24hr 21 mg/24hr 84 / 365 days nicotine td patch 24hr 7 mg/24hr 84 / 365 days ULCER DRUGS cimetidine tab 200 mg GE 24 LAST UPDATED 12/2014

25 DRUG DESCRIPTION (OTC) /GEN LIMITS & RESTRICTIONS famotidine tab 10 mg famotidine tab 20 mg lansoprazole cap delayed release 15 mg 4 per day omeprazole delayed release tab 20 mg 4 per day PRILOSEC OTC TAB DR 20 MG omeprazole magnesium 4 per day ranitidine hcl tab 150 mg 2 per day ranitidine hcl tab 75 mg 2 per day Uncategorized Unclassified *b-complex vitamin sublingual liquid** *dermatological products misc - cream** *multiple vitamins w/ minerals cap** *multiple vitamins w/ minerals chew tab** *multiple vitamins w/ minerals liquid** *omega-3 fatty acids cap delayed release 1000 mg** 6 per day *omega-3 fatty acids cap delayed release 1200 mg** 6 per day calcium carbonate-vitamin d cap 600 mg-200 unit 62 / 31 days cetirizine hcl cap 10 mg cholecalciferol chew tab 1000 unit 100 / claim cholecalciferol chew tab 2000 unit 100 / claim cholecalciferol chew tab 5000 unit 2 per day diphenhydramine hcl (sleep) tab disp 25 mg hydrocortisone acetate oint 1% MPL 1 / claim hydrocortisone gel 1% MPL 60 / 30 days 1 / 30 days GE 25 LAST UPDATED 12/2014

26 DRUG DESCRIPTION (OTC) /GEN LIMITS & RESTRICTIONS hydrocortisone soln 1% MPL 1 / claim melatonin tablet dispersible 5 mg miconazole nitrate aerosol 2% MPL 1 / claim miconazole nitrate aerosol pow 2% 45 / claim miconazole nitrate powder 2% MPL 1 / claim naproxen sodium cap 220 mg 62 / 31 days pyrithione zinc shampoo 1% 240 / claim sennosides cap 8.6 mg tolnaftate powder 1% MPL 30 / claim 1 / claim tolnaftate soln 1% 30 / claim vitamin e tab 400 unit 62 / 31 days VAGIN PRODUCTS clotrimazole vaginal cream 1% 45 / claim clotrimazole vaginal cream 2% 30 / claim ENCARE SUPPOS 100 MG nonoxynol-9 GYNOL II GEL 2 % nonoxynol-9 MPL 1 / claim MPL 1 / claim miconazole nitrate vaginal cream 2% 45 / claim miconazole nitrate vaginal cream 4% (200 mg/5gm) 45 / 31 days miconazole nitrate vaginal supp 200 mg & 2% cream 9 gm kit MPL 1 / claim miconazole nitrate vaginal suppos 100 mg 7 / claim nonoxynol-9 gel 4% OPTIONS GYNOL II CONTRACEPTIVE GEL 3 % nonoxynol-9 86 / claim tioconazole vaginal oint 6.5% 5 / claim GE 26 LAST UPDATED 12/2014

27 DRUG DESCRIPTION (OTC) /GEN LIMITS & RESTRICTIONS VCF VAGIN CONTRACEPTIVE FILM 28 % nonoxynol-9 VCF VAGIN CONTRACEPTIVE FOAM 12.5 % nonoxynol-9 MPL 1 / claim MPL 1 / claim VITAMINS ascorbic acid cap cr 500 mg 100 / 31 days ascorbic acid chew tab 250 mg 100 / 31 days ascorbic acid chew tab 500 mg 100 / 31 days ascorbic acid tab 1000 mg 100 / 31 days ascorbic acid tab 250 mg 100 / 31 days ascorbic acid tab 500 mg 100 / 31 days ascorbic acid tab cr 1000 mg 100 / 31 days ascorbic acid tab cr 500 mg 100 / 31 days cholecalciferol cap 1000 unit 100 / claim cholecalciferol cap 2000 unit 100 / claim cholecalciferol cap 5000 unit 2 per day cholecalciferol cap unit 8 / 30 days cholecalciferol tab 1000 unit 100 / claim cholecalciferol tab 2000 unit 100 / claim cholecalciferol tab 5000 unit 2 per day niacin cap cr 250 mg niacin cap cr 500 mg niacin tab 500 mg niacin tab cr 1000 mg niacin tab cr 250 mg niacin tab cr 500 mg niacin tab cr 750 mg GE 27 LAST UPDATED 12/2014

28 DRUG DESCRIPTION (OTC) /GEN LIMITS & RESTRICTIONS pyridoxine hcl tab 100 mg pyridoxine hcl tab 25 mg pyridoxine hcl tab 50 mg riboflavin tab 100 mg 100 / 31 days riboflavin tab 25 mg 100 / 31 days riboflavin tab 50 mg 100 / 31 days thiamine hcl tab 100 mg 100 / 31 days thiamine hcl tab 250 mg 100 / 31 days thiamine hcl tab 50 mg 100 / 31 days thiamine hcl tab 500 mg 100 / 31 days thiamine mononitrate tab 100 mg 100 / 31 days vitamin e cap 100 unit 62 / 31 days vitamin e cap 200 unit 62 / 31 days vitamin e cap 400 unit 62 / 31 days vitamin e chew tab 400 unit 62 / 31 days GE 28 LAST UPDATED 12/2014

29 PREFERRED DRUG LIST DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS amphetamine-dextroamphetamine cap sr 24hr 10 mg 6 to 18 yrs old amphetamine-dextroamphetamine cap sr 24hr 15 mg 6 to 18 yrs old amphetamine-dextroamphetamine cap sr 24hr 20 mg 6 to 18 yrs old 2 per day amphetamine-dextroamphetamine cap sr 24hr 25 mg 6 to 18 yrs old amphetamine-dextroamphetamine cap sr 24hr 30 mg 6 to 18 yrs old amphetamine-dextroamphetamine cap sr 24hr 5 mg 6 to 18 yrs old amphetamine-dextroamphetamine tab 10 mg 3 to 18 yrs old 2 per day amphetamine-dextroamphetamine tab 12.5 mg 3 to 18 yrs old 2 per day amphetamine-dextroamphetamine tab 15 mg 3 to 18 yrs old 2 per day amphetamine-dextroamphetamine tab 20 mg 3 to 18 yrs old 2 per day amphetamine-dextroamphetamine tab 30 mg 3 to 18 yrs old 2 per day amphetamine-dextroamphetamine tab 5 mg 3 to 18 yrs old 2 per day amphetamine-dextroamphetamine tab 7.5 mg 3 to 18 yrs old 2 per day GE 29 LAST UPDATED 12/2014

30 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS caffeine citrate inj 60 mg/3ml (10 mg/ml base equiv) MFL 45 / claim 2 / lifetime caffeine citrate oral soln 60 mg/3ml (10 mg/ml base equiv) MFL 45 / claim 2 / lifetime dextroamphetamine sulfate cap sr 24hr 10 mg 6 to 18 yrs old 2 per day dextroamphetamine sulfate cap sr 24hr 15 mg 6 to 18 yrs old 2 per day dextroamphetamine sulfate cap sr 24hr 5 mg 6 to 18 yrs old dextroamphetamine sulfate tab 10 mg 3 to 18 yrs old 3 per day dextroamphetamine sulfate tab 5 mg 3 to 18 yrs old 3 per day methylphenidate hcl cap cr 10 mg 6 to 18 yrs old methylphenidate hcl cap cr 20 mg 6 to 18 yrs old methylphenidate hcl cap cr 30 mg 6 to 18 yrs old methylphenidate hcl cap cr 40 mg 6 to 18 yrs old methylphenidate hcl cap cr 50 mg 6 to 18 yrs old methylphenidate hcl cap cr 60 mg 6 to 18 yrs old METHYLPHENIDATE HCL ER TAB ER 18 MG methylphenidate hcl 6 to 18 yrs old GE 30 LAST UPDATED 12/2014

31 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS METHYLPHENIDATE HCL ER TAB ER 27 MG methylphenidate hcl 6 to 18 yrs old METHYLPHENIDATE HCL ER TAB ER 36 MG methylphenidate hcl 6 to 18 yrs old 2 per day METHYLPHENIDATE HCL ER TAB ER 54 MG methylphenidate hcl 6 to 18 yrs old methylphenidate hcl tab 10 mg 3 to 18 yrs old 3 per day methylphenidate hcl tab 20 mg 3 to 18 yrs old 3 per day methylphenidate hcl tab 5 mg 3 to 18 yrs old 3 per day methylphenidate hcl tab cr 10 mg 6 to 18 yrs old 2 per day methylphenidate hcl tab cr 20 mg 6 to 18 yrs old methylphenidate hcl tab sa osm 18 mg 6 to 18 yrs old methylphenidate hcl tab sa osm 27 mg 6 to 18 yrs old methylphenidate hcl tab sa osm 36 mg 6 to 18 yrs old 2 per day methylphenidate hcl tab sa osm 54 mg 6 to 18 yrs old AMINOYCOSIDES neomycin sulfate tab 500 mg ANGESICS - ANTI-INFLAMMATORY CELEBREX CAP 100 MG celecoxib 62 / 31 days GE 31 LAST UPDATED 12/2014

32 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS CELEBREX CAP 200 MG celecoxib 62 / 31 days CELEBREX CAP 400 MG celecoxib 62 / 31 days CELEBREX CAP 50 MG celecoxib 62 / 31 days diclofenac potassium tab 50 mg diclofenac sodium tab delayed release 25 mg diclofenac sodium tab delayed release 50 mg diclofenac sodium tab delayed release 75 mg diclofenac sodium tab sr 24hr 100 mg ENBREL KIT 25 MG etanercept ENBREL SOLN PRSYR 25 MG/0.5ML etanercept ENBREL SOLN PRSYR 50 MG/ML etanercept ENBREL SURECLICK SOLN A-INJ 50 MG/ML etanercept etodolac cap 200 mg etodolac cap 300 mg etodolac tab 400 mg etodolac tab 500 mg etodolac tab sr 24hr 400 mg etodolac tab sr 24hr 500 mg etodolac tab sr 24hr 600 mg flurbiprofen tab 100 mg flurbiprofen tab 50 mg HUMIRA KIT 20 MG/0.4ML adalimumab HUMIRA KIT 40 MG/0.8ML adalimumab GE 32 LAST UPDATED 12/2014

33 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS HUMIRA PEN KIT 40 MG/0.8ML adalimumab ibuprofen tab 400 mg ibuprofen tab 600 mg ibuprofen tab 800 mg indomethacin cap 25 mg indomethacin cap 50 mg indomethacin cap cr 75 mg ketoprofen cap 50 mg ketoprofen cap 75 mg ketoprofen cap sr 24hr 200 mg ketorolac tromethamine tab 10 mg 20 / 30 days At least 17 yrs old leflunomide tab 10 mg leflunomide tab 20 mg meloxicam tab 15 mg meloxicam tab 7.5 mg nabumetone tab 500 mg nabumetone tab 750 mg naproxen sodium tab 275 mg naproxen sodium tab 550 mg naproxen susp 125 mg/5ml naproxen tab 250 mg naproxen tab 375 mg naproxen tab 500 mg naproxen tab ec 375 mg 2 per day naproxen tab ec 500 mg 2 per day oxaprozin tab 600 mg piroxicam cap 10 mg GE 33 LAST UPDATED 12/2014

34 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS piroxicam cap 20 mg quinapril hcl tab 10 mg quinapril hcl tab 20 mg RHEUMATREX TAB 2.5 MG methotrexate sodium (antirheumatic) sulindac tab 150 mg sulindac tab 200 mg tolmetin sodium cap 400 mg tolmetin sodium tab 200 mg tolmetin sodium tab 600 mg ANGESICS - NonNarcotic butalbital-acetaminophen tab mg butalbital-acetaminophen tab mg 6 per day butalbital-acetaminophen-caffeine cap mg 2 per day butalbital-acetaminophen-caffeine tab mg 2 per day butalbital-acetaminophen-caffeine tab mg 2 per day butalbital-aspirin-caffeine cap mg 2 per day butalbital-aspirin-caffeine tab mg 2 per day choline & magnesium salicylates liq 500 mg/5ml choline & magnesium salicylates tab 1000 mg choline & magnesium salicylates tab 500 mg choline & magnesium salicylates tab 750 mg diflunisal tab 500 mg PHRENILIN FORTE CAP MG butalbital-acetaminophen salsalate tab 500 mg salsalate tab 750 mg ANGESICS - OPIOID acetaminophen w/ codeine soln mg/5ml 30 per day GE 34 LAST UPDATED 12/2014

35 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS acetaminophen w/ codeine tab mg 2 per day acetaminophen w/ codeine tab mg 2 per day acetaminophen w/ codeine tab mg 2 per day butalbital-acetaminophen-caff w/ cod cap mg 2 per day butalbital-aspirin-caff w/ codeine cap mg 2 per day codeine sulfate tab 15 mg 2 per day codeine sulfate tab 60 mg 2 per day fentanyl td patch 72hr 100 mcg/hr 0.33 per day fentanyl td patch 72hr 12 mcg/hr 0.33 per day fentanyl td patch 72hr 25 mcg/hr 0.33 per day fentanyl td patch 72hr 50 mcg/hr 0.33 per day fentanyl td patch 72hr 75 mcg/hr 0.33 per day hydrocodone-acetaminophen soln mg/15ml 180 per day hydrocodone-acetaminophen soln mg/15ml 180 per day hydrocodone-acetaminophen tab mg 2 per day hydrocodone-acetaminophen tab mg 2 per day hydrocodone-acetaminophen tab mg 2 per day hydrocodone-acetaminophen tab mg 2 per day hydrocodone-acetaminophen tab mg 2 per day hydrocodone-acetaminophen tab mg 2 per day HYDROCODONE-ACETAMINOPHEN TAB MG hydrocodone-acetaminophen 2 per day hydrocodone-acetaminophen tab mg 2 per day HYDROCODONE-ACETAMINOPHEN TAB MG hydrocodone-acetaminophen 2 per day hydrocodone-acetaminophen tab mg 2 per day GE 35 LAST UPDATED 12/2014

36 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS hydrocodone-acetaminophen tab mg 2 per day hydrocodone-acetaminophen tab mg 2 per day hydrocodone-acetaminophen tab mg 2 per day hydrocodone-acetaminophen tab mg 2 per day hydrocodone-acetaminophen tab mg 2 per day hydrocodone-acetaminophen tab mg 2 per day HYDROCODONE-ACETAMINOPHEN TAB MG hydrocodone-acetaminophen 2 per day hydrocodone-acetaminophen tab mg 2 per day HYDROCODONE-ACETAMINOPHEN TAB MG hydrocodone-acetaminophen 2 per day hydrocodone-acetaminophen tab mg 2 per day hydromorphone hcl suppos 3 mg 12 / claim hydromorphone hcl tab 2 mg 2 per day hydromorphone hcl tab 4 mg 2 per day hydromorphone hcl tab 8 mg 2 per day meperidine hcl oral soln 50 mg/5ml 500 / claim meperidine hcl tab 100 mg 2 per day meperidine hcl tab 50 mg 2 per day methadone hcl tab 10 mg 2 per day methadone hcl tab 5 mg 2 per day morphine sulfate (concentrate) oral soln 20 mg/ml morphine sulfate oral soln 10 mg/5ml 500 / 30 days morphine sulfate oral soln 20 mg/5ml 500 / 30 days morphine sulfate suppos 10 mg 24 / claim morphine sulfate suppos 20 mg 24 / claim GE 36 LAST UPDATED 12/2014

37 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS morphine sulfate suppos 30 mg 24 / claim morphine sulfate suppos 5 mg 24 / claim morphine sulfate tab 30 mg 24 / claim 2 per day morphine sulfate tab cr 100 mg 2 per day morphine sulfate tab cr 15 mg 2 per day morphine sulfate tab cr 200 mg 2 per day morphine sulfate tab cr 30 mg 2 per day morphine sulfate tab cr 60 mg 2 per day oxycodone hcl cap 5 mg 2 per day oxycodone hcl conc 100 mg/5ml (20 mg/ml) 6 per day oxycodone hcl tab 15 mg 2 per day oxycodone hcl tab 30 mg 2 per day oxycodone hcl tab 5 mg 2 per day oxycodone hcl tab er 12hr deter 40 mg 2 per day oxycodone w/ acetaminophen cap mg 2 per day oxycodone w/ acetaminophen tab mg 2 per day oxycodone w/ acetaminophen tab mg 2 per day oxycodone w/ acetaminophen tab mg 2 per day oxycodone w/ acetaminophen tab mg 2 per day oxycodone w/ acetaminophen tab mg 2 per day oxycodone-aspirin tab mg 2 per day OXYCONTIN TB12 DETER 10 MG oxycodone hcl 2 per day GE 37 LAST UPDATED 12/2014

38 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS OXYCONTIN TB12 DETER 15 MG oxycodone hcl 2 per day OXYCONTIN TB12 DETER 20 MG oxycodone hcl 2 per day OXYCONTIN TB12 DETER 30 MG oxycodone hcl 2 per day OXYCONTIN TB12 DETER 40 MG oxycodone hcl 2 per day OXYCONTIN TB12 DETER 60 MG oxycodone hcl 2 per day OXYCONTIN TB12 DETER 80 MG oxycodone hcl 2 per day ROXICET SOLUTION MG/5ML oxycodone w/ acetaminophen ROXICET TAB MG oxycodone w/ acetaminophen 30 per day 2 per day tramadol hcl tab 50 mg 2 per day tramadol-acetaminophen tab mg 4 per day ANDROGENS-ANABOLIC ANDRODERM TCH 24HR 2 MG/24HR testosterone ANDRODERM TCH 24HR 4 MG/24HR testosterone ANDROXY TAB 10 MG fluoxymesterone METHITEST TAB 10 MG methyltestosterone testosterone cypionate im inj in oil 200 mg/ml ANORECT AGENTS ANPRAM-HC LOTION % hydrocortisone acetate w/ pramoxine 60 / claim GE 38 LAST UPDATED 12/2014

39 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS hydrocortisone acetate suppos 25 mg 2 per day hydrocortisone acetate w/ pramoxine rectal cream 1-1% 62 / 31 days hydrocortisone acetate w/ pramoxine rectal cream 2.5-1% 30 / claim hydrocortisone enema 100 mg/60ml 420 / claim hydrocortisone rectal cream 2.5% MPL 1 / claim pramoxine-hc cream 1-2.5% 30 / claim ANTI-INFECTIVE AGENTS - MISC. clindamycin hcl cap 150 mg clindamycin hcl cap 300 mg clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) 300 / claim dapsone tab 100 mg dapsone tab 25 mg erythromycin-sulfisoxazole for susp mg/5ml metronidazole tab 250 mg metronidazole tab 500 mg sulfamethoxazole-trimethoprim susp mg/5ml sulfamethoxazole-trimethoprim tab mg sulfamethoxazole-trimethoprim tab mg trimethoprim tab 100 mg vancomycin hcl for inj 1000 mg 14 / claim vancomycin hcl for inj 500 mg ANTIANGIN AGENTS isosorbide dinitrate sl tab 2.5 mg isosorbide dinitrate sl tab 5 mg isosorbide dinitrate tab 10 mg isosorbide dinitrate tab 20 mg isosorbide dinitrate tab 30 mg GE 39 LAST UPDATED 12/2014

40 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS isosorbide dinitrate tab 5 mg isosorbide dinitrate tab cr 40 mg isosorbide mononitrate tab 10 mg 2 per day isosorbide mononitrate tab 20 mg 2 per day isosorbide mononitrate tab sr 24hr 120 mg isosorbide mononitrate tab sr 24hr 30 mg isosorbide mononitrate tab sr 24hr 60 mg meloxicam tab 15 mg NITRO-BID OINTMENT 2 % nitroglycerin nitroglycerin cap cr 2.5 mg nitroglycerin cap cr 6.5 mg nitroglycerin cap cr 9 mg nitroglycerin sl tab 0.3 mg nitroglycerin sl tab 0.4 mg nitroglycerin sl tab 0.6 mg nitroglycerin td patch 24hr 0.1 mg/hr nitroglycerin td patch 24hr 0.2 mg/hr nitroglycerin td patch 24hr 0.4 mg/hr nitroglycerin td patch 24hr 0.6 mg/hr ANTIANXIETY AGENTS alprazolam tab 0.25 mg 2 per day alprazolam tab 0.5 mg 2 per day alprazolam tab 1 mg 2 per day alprazolam tab 2 mg 2 per day buspirone hcl tab 10 mg 3 per day buspirone hcl tab 15 mg 3 per day GE 40 LAST UPDATED 12/2014

41 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS buspirone hcl tab 30 mg 3 per day buspirone hcl tab 5 mg 3 per day buspirone hcl tab 7.5 mg 3 per day chlordiazepoxide hcl cap 10 mg 4 per day chlordiazepoxide hcl cap 25 mg 4 per day chlordiazepoxide hcl cap 5 mg 4 per day clorazepate dipotassium tab 15 mg 2 per day clorazepate dipotassium tab 3.75 mg 2 per day clorazepate dipotassium tab 7.5 mg 2 per day diazepam soln 1 mg/ml 500 / claim 1 / claim diazepam tab 10 mg Up to 21 yrs old 2 per day diazepam tab 2 mg 2 per day diazepam tab 5 mg 2 per day hydroxyzine hcl syrup 10 mg/5ml hydroxyzine hcl tab 10 mg hydroxyzine hcl tab 25 mg hydroxyzine hcl tab 50 mg hydroxyzine pamoate cap 100 mg hydroxyzine pamoate cap 25 mg hydroxyzine pamoate cap 50 mg lorazepam tab 0.5 mg 2 per day lorazepam tab 1 mg 4 per day lorazepam tab 2 mg 2 per day meprobamate tab 200 mg GE 41 LAST UPDATED 12/2014

42 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS meprobamate tab 400 mg oxazepam cap 10 mg 2 per day oxazepam cap 15 mg 2 per day oxazepam cap 30 mg 2 per day ANTIARRHYTHMICS amiodarone hcl tab 200 mg disopyramide phosphate cap 100 mg disopyramide phosphate cap 150 mg flecainide acetate tab 100 mg flecainide acetate tab 150 mg flecainide acetate tab 50 mg mexiletine hcl cap 150 mg mexiletine hcl cap 200 mg mexiletine hcl cap 250 mg NORCE CR CAP ER 12H 150 MG disopyramide phosphate propafenone hcl tab 150 mg propafenone hcl tab 225 mg propafenone hcl tab 300 mg quinidine gluconate tab cr 324 mg quinidine sulfate tab 200 mg quinidine sulfate tab 300 mg quinidine sulfate tab cr 300 mg TIKOSYN CAP 125 MCG dofetilide TIKOSYN CAP 250 MCG dofetilide TIKOSYN CAP 500 MCG dofetilide ANTIASTHMATIC AND BRONCHODILATOR AGENTS ADVAIR DISKUS AER POW BA MCG/DOSE fluticasone-salmeterol 60 / 30 days GE 42 LAST UPDATED 12/2014

43 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS ADVAIR DISKUS AER POW BA MCG/DOSE fluticasone-salmeterol ADVAIR DISKUS AER POW BA MCG/DOSE fluticasone-salmeterol ADVAIR HFA AEROSOL MCG/ACT fluticasone-salmeterol ADVAIR HFA AEROSOL MCG/ACT fluticasone-salmeterol ADVAIR HFA AEROSOL MCG/ACT fluticasone-salmeterol 60 / 30 days 60 / 30 days 12 / 30 days 12 / 30 days 12 / 30 days albuterol sulfate soln nebu 0.083% (2.5 mg/3ml) 375 / 25 days albuterol sulfate soln nebu 0.5% (5 mg/ml) 2 per day albuterol sulfate soln nebu 0.63 mg/3ml (base equiv) 375 / 30 days albuterol sulfate soln nebu 1.25 mg/3ml (base equiv) 375 / 30 days albuterol sulfate syrup 2 mg/5ml albuterol sulfate tab 2 mg albuterol sulfate tab 4 mg albuterol sulfate tab sr 12hr 4 mg albuterol sulfate tab sr 12hr 8 mg aminophylline tab 100 mg aminophylline tab 200 mg ATROVENT HFA AERO SOLN 17 MCG/ACT ipratropium bromide hfa 26 / 30 days budesonide inhalation susp 0.25 mg/2ml 120 / 30 days Up to 6 yrs old budesonide inhalation susp 0.5 mg/2ml 120 / 30 days Up to 6 yrs old COMBIVENT AEROSOL MCG/ACT ipratropium-albuterol COMBIVENT RESPIMAT AERO SOLN MCG/ACT ipratropium-albuterol 4 / 30 days GE 43 LAST UPDATED 12/2014

44 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS cromolyn sodium soln nebu 20 mg/2ml 240 / 30 days DULERA AEROSOL MCG/ACT mometasone furoate-formoterol fumarate dihydrate DULERA AEROSOL MCG/ACT mometasone furoate-formoterol fumarate dihydrate dyphylline tab 200 mg FLOVENT DISKUS AER POW BA 100 MCG/BLIST fluticasone propionate (inhalation) FLOVENT DISKUS AER POW BA 250 MCG/BLIST fluticasone propionate (inhalation) FLOVENT DISKUS AER POW BA 50 MCG/BLIST fluticasone propionate (inhalation) FLOVENT HFA AEROSOL 110 MCG/ACT fluticasone propionate hfa FLOVENT HFA AEROSOL 220 MCG/ACT fluticasone propionate hfa FLOVENT HFA AEROSOL 44 MCG/ACT fluticasone propionate hfa FORADIL AEROLIZER CAP 12 MCG formoterol fumarate 13 / claim 13 / claim 2 per day 2 per day 60 / 25 days 12 / 25 days 12 / 25 days 11 / 25 days 2 per day ipratropium bromide inhal soln 0.02% 375 / 25 days ipratropium-albuterol nebu soln (3) mg/3ml 12 per day LUFYLLIN TAB 400 MG dyphylline metaproterenol sulfate syrup 10 mg/5ml 30 per day metaproterenol sulfate tab 10 mg metaproterenol sulfate tab 20 mg montelukast sodium chew tab 4 mg (base equiv) montelukast sodium chew tab 5 mg (base equiv) montelukast sodium oral granules packet 4 mg (base equiv) montelukast sodium tab 10 mg (base equiv) GE 44 LAST UPDATED 12/2014

45 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS PROAIR HFA AERO SOLN 108 (90 BASE) MCG/ACT albuterol sulfate PROVENTIL HFA AERO SOLN 108 (90 BASE) MCG/ACT albuterol sulfate PULMICORT FLEXHER AER POW BA 180 MCG/ACT budesonide (inhalation) PULMICORT FLEXHER AER POW BA 90 MCG/ACT budesonide (inhalation) MPL 2 / 30 days MPL 2 / 30 days 1 / 25 days 1 / 25 days PULMICORT SUSPENSION 1 MG/2ML budesonide (inhalation) 60 / 30 days Up to 6 yrs old SEREVENT DISKUS AER POW BA 50 MCG/DOSE salmeterol xinafoate SPIRIVA HANDIHER CAP 18 MCG tiotropium bromide monohydrate SYMBICORT AEROSOL MCG/ACT budesonide-formoterol fumarate dihydrate SYMBICORT AEROSOL MCG/ACT budesonide-formoterol fumarate dihydrate terbutaline sulfate tab 2.5 mg terbutaline sulfate tab 5 mg THEO-24 CAP ER 24H 100 MG theophylline THEO-24 CAP ER 24H 200 MG theophylline THEO-24 CAP ER 24H 300 MG theophylline THEO-24 CAP ER 24H 400 MG theophylline theophylline elixir 80 mg/15ml 2 per day 11 / claim 11 / claim theophylline soln 80 mg/15ml 475 / claim theophylline tab sr 12hr 100 mg theophylline tab sr 12hr 200 mg theophylline tab sr 12hr 300 mg theophylline tab sr 12hr 450 mg GE 45 LAST UPDATED 12/2014

46 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS theophylline tab sr 24hr 400 mg theophylline tab sr 24hr 600 mg VENTOLIN HFA AERO SOLN 108 (90 BASE) MCG/ACT albuterol sulfate MPL 2 / 30 days ANTICOAGULANTS enoxaparin sodium inj 100 mg/ml MFL 3 / 180 days enoxaparin sodium inj 120 mg/0.8ml MFL 3 / 180 days enoxaparin sodium inj 150 mg/ml MFL 3 / 180 days enoxaparin sodium inj 30 mg/0.3ml MFL 3 / 180 days enoxaparin sodium inj 300 mg/3ml MFL 3 / 180 days enoxaparin sodium inj 40 mg/0.4ml MFL 3 / 180 days enoxaparin sodium inj 60 mg/0.6ml MFL 3 / 180 days enoxaparin sodium inj 80 mg/0.8ml MFL 3 / 180 days heparin sodium (porcine) inj 1000 unit/ml heparin sodium (porcine) inj unit/ml heparin sodium (porcine) inj unit/ml heparin sodium (porcine) inj 5000 unit/ml heparin sodium (porcine) pf inj 5000 unit/0.5ml warfarin sodium tab 1 mg warfarin sodium tab 10 mg warfarin sodium tab 2 mg warfarin sodium tab 2.5 mg warfarin sodium tab 3 mg warfarin sodium tab 4 mg warfarin sodium tab 5 mg warfarin sodium tab 6 mg warfarin sodium tab 7.5 mg XARELTO TAB 10 MG rivaroxaban 35 / 180 days GE 46 LAST UPDATED 12/2014

47 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS ANTICONVULSANTS carbamazepine chew tab 100 mg carbamazepine susp 100 mg/5ml carbamazepine tab 200 mg carbamazepine tab sr 12hr 200 mg carbamazepine tab sr 12hr 400 mg clonazepam tab 0.5 mg 4 per day clonazepam tab 1 mg 4 per day clonazepam tab 2 mg 4 per day diazepam rectal gel delivery system 10 mg 1 / claim Up to 21 yrs old diazepam rectal gel delivery system 2.5 mg 1 / claim Up to 21 yrs old diazepam rectal gel delivery system 20 mg 1 / claim Up to 21 yrs old DILANTIN CAP 30 MG phenytoin sodium extended divalproex sodium cap sprinkle 125 mg divalproex sodium tab delayed release 125 mg divalproex sodium tab delayed release 250 mg divalproex sodium tab delayed release 500 mg divalproex sodium tab sr 24 hr 250 mg divalproex sodium tab sr 24 hr 500 mg ethosuximide cap 250 mg ethosuximide soln 250 mg/5ml felbamate susp 600 mg/5ml felbamate tab 400 mg felbamate tab 600 mg gabapentin cap 100 mg 4 per day GE 47 LAST UPDATED 12/2014

48 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS gabapentin cap 300 mg 4 per day gabapentin cap 400 mg 4 per day gabapentin oral soln 250 mg/5ml gabapentin tab 600 mg 4 per day gabapentin tab 800 mg 4 per day GABITRIL TAB 12 MG tiagabine hcl GABITRIL TAB 16 MG tiagabine hcl lamotrigine tab 100 mg lamotrigine tab 150 mg lamotrigine tab 200 mg lamotrigine tab 25 mg lamotrigine tab chewable dispersible 25 mg lamotrigine tab chewable dispersible 5 mg levetiracetam oral soln 100 mg/ml 30 per day levetiracetam tab 250 mg 4 per day levetiracetam tab 500 mg 4 per day levetiracetam tab 750 mg 4 per day oxcarbazepine susp 300 mg/5ml (60 mg/ml) oxcarbazepine tab 150 mg oxcarbazepine tab 300 mg oxcarbazepine tab 600 mg phenytoin chew tab 50 mg phenytoin sodium extended cap 100 mg phenytoin susp 125 mg/5ml primidone tab 250 mg primidone tab 50 mg GE 48 LAST UPDATED 12/2014

49 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS TEGRETOL-XR TAB ER 12H 100 MG carbamazepine tiagabine hcl tab 2 mg tiagabine hcl tab 4 mg topiramate sprinkle cap 15 mg 6 per day topiramate sprinkle cap 25 mg 8 per day topiramate tab 100 mg 3 per day topiramate tab 200 mg 3 per day topiramate tab 25 mg 3 per day topiramate tab 50 mg 3 per day valproate sodium syrup 250 mg/5ml (base equiv) valproic acid cap 250 mg zonisamide cap 100 mg zonisamide cap 25 mg zonisamide cap 50 mg ANTIDEPRESSANTS amitriptyline hcl tab 10 mg amitriptyline hcl tab 100 mg amitriptyline hcl tab 150 mg amitriptyline hcl tab 25 mg amitriptyline hcl tab 50 mg amitriptyline hcl tab 75 mg amoxapine tab 100 mg amoxapine tab 150 mg amoxapine tab 25 mg amoxapine tab 50 mg BRINTELLIX TAB 10 MG vortioxetine hbr ST At least 18 yrs old GE 49 LAST UPDATED 12/2014

50 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS BRINTELLIX TAB 20 MG vortioxetine hbr ST At least 18 yrs old BRINTELLIX TAB 5 MG vortioxetine hbr ST At least 18 yrs old bupropion hcl tab 100 mg 3 per day bupropion hcl tab 75 mg 3 per day bupropion hcl tab sr 12hr 100 mg 2 per day bupropion hcl tab sr 12hr 150 mg 2 per day bupropion hcl tab sr 12hr 200 mg 2 per day bupropion hcl tab sr 24hr 150 mg bupropion hcl tab sr 24hr 300 mg citalopram hydrobromide oral soln 10 mg/5ml 240 / 30 days citalopram hydrobromide tab 10 mg (base equiv) 1.5 per day citalopram hydrobromide tab 20 mg (base equiv) 1.5 per day citalopram hydrobromide tab 40 mg (base equiv) clomipramine hcl cap 25 mg clomipramine hcl cap 50 mg clomipramine hcl cap 75 mg desipramine hcl tab 10 mg desipramine hcl tab 100 mg desipramine hcl tab 150 mg desipramine hcl tab 25 mg 2 per day desipramine hcl tab 50 mg desipramine hcl tab 75 mg doxepin hcl cap 10 mg GE 50 LAST UPDATED 12/2014

51 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS doxepin hcl cap 100 mg doxepin hcl cap 150 mg doxepin hcl cap 25 mg doxepin hcl cap 50 mg doxepin hcl cap 75 mg doxepin hcl conc 10 mg/ml escitalopram oxalate tab 10 mg (base equiv) escitalopram oxalate tab 20 mg (base equiv) escitalopram oxalate tab 5 mg (base equiv) fluoxetine hcl cap 10 mg 4 per day fluoxetine hcl cap 20 mg 4 per day fluoxetine hcl cap 40 mg At least 7 yrs old 2 per day fluoxetine hcl solution 20 mg/5ml 120 / 30 days Up to 6 yrs old fluoxetine hcl tab 10 mg Up to 12 yrs old 4 per day fluoxetine hcl tab 20 mg 4 per day fluvoxamine maleate tab 100 mg 3 per day fluvoxamine maleate tab 25 mg 2 per day fluvoxamine maleate tab 50 mg 2 per day imipramine hcl tab 10 mg imipramine hcl tab 25 mg imipramine hcl tab 50 mg maprotiline hcl tab 25 mg maprotiline hcl tab 50 mg maprotiline hcl tab 75 mg GE 51 LAST UPDATED 12/2014

52 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS mirtazapine orally disintegrating tab 15 mg mirtazapine orally disintegrating tab 30 mg mirtazapine orally disintegrating tab 45 mg mirtazapine tab 15 mg mirtazapine tab 30 mg mirtazapine tab 45 mg mirtazapine tab 7.5 mg nefazodone hcl tab 100 mg nefazodone hcl tab 150 mg nefazodone hcl tab 200 mg nefazodone hcl tab 250 mg nefazodone hcl tab 50 mg nortriptyline hcl cap 10 mg nortriptyline hcl cap 25 mg nortriptyline hcl cap 50 mg nortriptyline hcl cap 75 mg nortriptyline hcl soln 10 mg/5ml 20 per day paroxetine hcl oral susp 10 mg/5ml (base equiv) 40 per day paroxetine hcl tab 10 mg 2 per day paroxetine hcl tab 20 mg 2 per day paroxetine hcl tab 30 mg 2 per day paroxetine hcl tab 40 mg 2 per day phenelzine sulfate tab 15 mg sertraline hcl oral conc 20 mg/ml 10 per day sertraline hcl tab 100 mg 2 per day sertraline hcl tab 25 mg 1.5 per day GE 52 LAST UPDATED 12/2014

53 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS sertraline hcl tab 50 mg 1.5 per day tranylcypromine sulfate tab 10 mg trazodone hcl tab 100 mg trazodone hcl tab 150 mg trazodone hcl tab 300 mg 2 per day trazodone hcl tab 50 mg venlafaxine hcl cap sr 24hr 150 mg (base equivalent) 2 per day venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent) 2 per day venlafaxine hcl cap sr 24hr 75 mg (base equivalent) 2 per day VENLAFAXINE HCL ER TAB ER 24H 225 MG venlafaxine hcl venlafaxine hcl tab 100 mg venlafaxine hcl tab 25 mg venlafaxine hcl tab 37.5 mg venlafaxine hcl tab 50 mg venlafaxine hcl tab 75 mg venlafaxine hcl tab sr 24hr 150 mg (base equivalent) 2 per day venlafaxine hcl tab sr 24hr 37.5 mg (base equivalent) venlafaxine hcl tab sr 24hr 75 mg (base equivalent) 2 per day VIIBRYD KIT 10 & 20 & 40 MG vilazodone hcl 30 / 365 days VIIBRYD TAB 10 MG vilazodone hcl VIIBRYD TAB 20 MG vilazodone hcl VIIBRYD TAB 40 MG vilazodone hcl ANTIDIABETICS APIDRA SOLUTION 100 UNIT/ML insulin glulisine 40 / 30 days GE 53 LAST UPDATED 12/2014

54 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS glimepiride tab 1 mg glimepiride tab 2 mg glimepiride tab 4 mg 2 per day glipizide tab 10 mg glipizide tab 5 mg glipizide tab sr 24hr 10 mg glipizide tab sr 24hr 2.5 mg glipizide tab sr 24hr 5 mg glipizide-metformin hcl tab mg glipizide-metformin hcl tab mg glipizide-metformin hcl tab mg UCAGEN HYPOKIT RECON SOLN 1 MG glucagon hcl (rdna) UCAGEN RECON SOLN 1 MG glucagon hcl (rdna) UCAGON EMERGENCY KIT 1 MG glucagon (rdna) glyburide micronized tab 1.5 mg glyburide micronized tab 3 mg glyburide micronized tab 6 mg glyburide tab 1.25 mg glyburide tab 2.5 mg glyburide tab 5 mg glyburide-metformin tab mg glyburide-metformin tab mg glyburide-metformin tab mg HUMOG MIX 50/50 SUSPENSION (50-50) 100 UNIT/ML insulin lispro protamine & lispro (human) HUMOG MIX 75/25 SUSPENSION (75-25) 100 UNIT/ML insulin lispro protamine & lispro (human) 1 / claim 40 / 30 days 40 / 30 days GE 54 LAST UPDATED 12/2014

55 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS HUMOG SOLUTION 100 UNIT/ML insulin lispro (human) HUMULIN 70/30 SUSPENSION (70-30) 100 UNIT/ML insulin isophane & reg (human) HUMULIN N SUSPENSION 100 UNIT/ML insulin isophane (human) HUMULIN R SOLUTION 100 UNIT/ML insulin regular (human) JENTADUETO TAB MG linagliptin-metformin hcl JENTADUETO TAB MG linagliptin-metformin hcl JENTADUETO TAB MG linagliptin-metformin hcl KOMBIYZE XR TAB ER 24H MG saxagliptin-metformin hcl KOMBIYZE XR TAB ER 24H MG saxagliptin-metformin hcl KOMBIYZE XR TAB ER 24H MG saxagliptin-metformin hcl LANTUS SOLUTION 100 UNIT/ML insulin glargine 40 / 30 days 40 / 30 days 40 / 30 days 40 / 30 days 2 per day 2 per day 2 per day 2 per day 30 / 30 days metformin hcl tab 1000 mg 2 per day metformin hcl tab 500 mg 5 per day metformin hcl tab 850 mg 3 per day metformin hcl tab sr 24hr 500 mg 4 per day metformin hcl tab sr 24hr 750 mg 2 per day NOVOLIN 70/30 RELION SUSPENSION (70-30) 100 UNIT/ML insulin isophane & reg (human) NOVOLIN 70/30 SUSPENSION (70-30) 100 UNIT/ML insulin isophane & reg (human) NOVOLIN N RELION SUSPENSION 100 UNIT/ML insulin isophane (human) 40 / 30 days 40 / 30 days 40 / 30 days GE 55 LAST UPDATED 12/2014

56 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS NOVOLIN N SUSPENSION 100 UNIT/ML insulin isophane (human) NOVOLIN R RELION SOLUTION 100 UNIT/ML insulin regular (human) NOVOLIN R SOLUTION 100 UNIT/ML insulin regular (human) NOVOLOG MIX 70/30 SUSPENSION (70-30) 100 UNIT/ML insulin aspart protamine & aspart (human) NOVOLOG SOLUTION 100 UNIT/ML insulin aspart 40 / 30 days 40 / 30 days 40 / 30 days 40 / 30 days 40 / 30 days ONYZA TAB 2.5 MG saxagliptin hcl At least 18 yrs old ONYZA TAB 5 MG saxagliptin hcl At least 18 yrs old pioglitazone hcl tab 15 mg (base equiv) pioglitazone hcl tab 30 mg (base equiv) pioglitazone hcl tab 45 mg (base equiv) pioglitazone hcl-metformin hcl tab mg 2 per day pioglitazone hcl-metformin hcl tab mg 2 per day RELION 70/30 SUSPENSION (70-30) 100 UNIT/ML insulin isophane & reg (human) RELION N SUSPENSION 100 UNIT/ML insulin isophane (human) RELION R SOLUTION 100 UNIT/ML insulin regular (human) 40 / 30 days 40 / 30 days 40 / 30 days TRADJENTA TAB 5 MG linagliptin At least 18 yrs old ANTIDIARRHES diphenoxylate w/ atropine liq mg/5ml diphenoxylate w/ atropine tab mg GE 56 LAST UPDATED 12/2014

57 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS paregoric 2 mg/5ml ANTIDOTES CHEMET CAP 100 MG succimer naltrexone hcl tab 50 mg ANTIEMETICS ondansetron hcl oral soln 4 mg/5ml 50 / claim ondansetron hcl tab 24 mg 1 / 14 days ondansetron hcl tab 4 mg 2 per day ondansetron hcl tab 8 mg 2 per day ondansetron orally disintegrating tab 4 mg ondansetron orally disintegrating tab 8 mg ANTIFUNGS fluconazole for susp 10 mg/ml 70 / claim fluconazole for susp 40 mg/ml 70 / claim fluconazole tab 100 mg fluconazole tab 150 mg 2 / claim fluconazole tab 200 mg 2 per day fluconazole tab 50 mg 7 / claim griseofulvin microsize susp 125 mg/5ml griseofulvin microsize tab 500 mg griseofulvin ultramicrosize tab 125 mg griseofulvin ultramicrosize tab 250 mg itraconazole cap 100 mg nystatin tab unit 6 per day terbinafine hcl tab 250 mg 90 / 120 days GE 57 LAST UPDATED 12/2014

58 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS ANTIHISTAMINES cyproheptadine hcl syrup 2 mg/5ml cyproheptadine hcl tab 4 mg dexchlorpheniramine maleate syrup 2 mg/5ml diphenhydramine hcl cap 50 mg 4 per day fexofenadine hcl tab 30 mg 2 per day promethazine hcl suppos 12.5 mg 12 / claim At least 2 yrs old promethazine hcl suppos 25 mg 12 / claim At least 2 yrs old promethazine hcl suppos 50 mg At least 2 yrs old promethazine hcl syrup 6.25 mg/5ml 240 / claim At least 2 yrs old promethazine hcl tab 12.5 mg At least 2 yrs old promethazine hcl tab 25 mg At least 2 yrs old promethazine hcl tab 50 mg At least 2 yrs old ANTIHYPERLIPIDEMICS atorvastatin calcium tab 10 mg (base equivalent) ST atorvastatin calcium tab 20 mg (base equivalent) ST atorvastatin calcium tab 40 mg (base equivalent) atorvastatin calcium tab 80 mg (base equivalent) cholestyramine light powder 4 gm/dose cholestyramine light powder packets 4 gm cholestyramine powder 4 gm/dose cholestyramine powder packets 4 gm GE 58 LAST UPDATED 12/2014

59 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS colestipol hcl granule packets 5 gm colestipol hcl granules 5 gm colestipol hcl tab 1 gm 2 per day fenofibrate micronized cap 134 mg fenofibrate micronized cap 200 mg fenofibrate micronized cap 67 mg 2 per day fenofibrate tab 160 mg fenofibrate tab 54 mg 3 per day gemfibrozil tab 600 mg 2 per day lovastatin tab 10 mg lovastatin tab 20 mg lovastatin tab 40 mg 2 per day NIACOR TAB 500 MG niacin (antihyperlipidemic) pravastatin sodium tab 10 mg pravastatin sodium tab 20 mg pravastatin sodium tab 40 mg pravastatin sodium tab 80 mg simvastatin tab 10 mg simvastatin tab 20 mg simvastatin tab 40 mg simvastatin tab 5 mg ANTIHYPERTENSIVES amlodipine besylate-benazepril hcl cap mg amlodipine besylate-benazepril hcl cap mg GE 59 LAST UPDATED 12/2014

60 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS amlodipine besylate-benazepril hcl cap 5-10 mg amlodipine besylate-benazepril hcl cap 5-20 mg atenolol & chlorthalidone tab mg atenolol & chlorthalidone tab mg benazepril & hydrochlorothiazide tab mg benazepril & hydrochlorothiazide tab mg benazepril & hydrochlorothiazide tab mg benazepril & hydrochlorothiazide tab mg benazepril hcl tab 10 mg benazepril hcl tab 20 mg benazepril hcl tab 40 mg 2 per day benazepril hcl tab 5 mg bisoprolol & hydrochlorothiazide tab mg bisoprolol & hydrochlorothiazide tab mg captopril & hydrochlorothiazide tab mg 2 per day captopril & hydrochlorothiazide tab mg 2 per day captopril & hydrochlorothiazide tab mg 2 per day captopril & hydrochlorothiazide tab mg 2 per day captopril tab 100 mg 3 per day captopril tab 12.5 mg 3 per day captopril tab 25 mg 3 per day captopril tab 50 mg 3 per day clonidine hcl tab 0.1 mg clonidine hcl tab 0.2 mg clonidine hcl tab 0.3 mg GE 60 LAST UPDATED 12/2014

61 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS doxazosin mesylate tab 1 mg doxazosin mesylate tab 2 mg doxazosin mesylate tab 4 mg doxazosin mesylate tab 8 mg DUTOPROL TAB ER 24H MG metoprolol & hydrochlorothiazide DUTOPROL TAB ER 24H MG metoprolol & hydrochlorothiazide DUTOPROL TAB ER 24H MG metoprolol & hydrochlorothiazide enalapril maleate & hydrochlorothiazide tab mg 2 per day enalapril maleate & hydrochlorothiazide tab mg 2 per day enalapril maleate tab 10 mg 2 per day enalapril maleate tab 2.5 mg 2 per day enalapril maleate tab 20 mg 2 per day enalapril maleate tab 5 mg 2 per day fosinopril sodium & hydrochlorothiazide tab mg fosinopril sodium & hydrochlorothiazide tab mg fosinopril sodium tab 10 mg fosinopril sodium tab 20 mg fosinopril sodium tab 40 mg guanabenz acetate tab 4 mg guanabenz acetate tab 8 mg guanfacine hcl tab 1 mg guanfacine hcl tab 2 mg hydralazine hcl tab 10 mg hydralazine hcl tab 100 mg hydralazine hcl tab 25 mg GE 61 LAST UPDATED 12/2014

62 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS hydralazine hcl tab 50 mg irbesartan tab 150 mg irbesartan tab 300 mg irbesartan tab 75 mg irbesartan-hydrochlorothiazide tab mg irbesartan-hydrochlorothiazide tab mg lisinopril & hydrochlorothiazide tab mg 2 per day lisinopril & hydrochlorothiazide tab mg 2 per day lisinopril & hydrochlorothiazide tab mg lisinopril tab 10 mg 2 per day lisinopril tab 2.5 mg lisinopril tab 20 mg 2 per day lisinopril tab 30 mg 2 per day lisinopril tab 40 mg 2 per day lisinopril tab 5 mg 2 per day losartan potassium & hydrochlorothiazide tab mg losartan potassium & hydrochlorothiazide tab mg losartan potassium & hydrochlorothiazide tab mg losartan potassium tab 100 mg losartan potassium tab 25 mg losartan potassium tab 50 mg methyldopa tab 250 mg methyldopa tab 500 mg metoprolol & hydrochlorothiazide tab mg 2 per day metoprolol & hydrochlorothiazide tab mg 2 per day GE 62 LAST UPDATED 12/2014

63 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS metoprolol & hydrochlorothiazide tab mg 2 per day minoxidil tab 10 mg minoxidil tab 2.5 mg prazosin hcl cap 1 mg prazosin hcl cap 2 mg prazosin hcl cap 5 mg propranolol & hydrochlorothiazide tab mg propranolol & hydrochlorothiazide tab mg quinapril hcl tab 10 mg quinapril hcl tab 20 mg quinapril hcl tab 40 mg 2 per day quinapril hcl tab 5 mg ramipril cap 1.25 mg 2 per day ramipril cap 10 mg 2 per day ramipril cap 2.5 mg 2 per day ramipril cap 5 mg 2 per day reserpine tab 0.1 mg reserpine tab 0.25 mg terazosin hcl cap 1 mg terazosin hcl cap 10 mg terazosin hcl cap 2 mg terazosin hcl cap 5 mg trandolapril tab 1 mg 4 per day trandolapril tab 2 mg 4 per day trandolapril tab 4 mg 4 per day valsartan tab 160 mg ST GE 63 LAST UPDATED 12/2014

64 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS valsartan tab 320 mg ST valsartan tab 40 mg ST valsartan tab 80 mg ST valsartan-hydrochlorothiazide tab mg ST valsartan-hydrochlorothiazide tab mg ST valsartan-hydrochlorothiazide tab mg ST valsartan-hydrochlorothiazide tab mg ST valsartan-hydrochlorothiazide tab mg ST ANTIMARIS chloroquine phosphate tab 250 mg 60 / 30 days chloroquine phosphate tab 500 mg 8 / 56 days COARTEM TAB MG artemether-lumefantrine hydroxychloroquine sulfate tab 200 mg mefloquine hcl tab 250 mg primaquine phosphate tab 26.3 mg (15 mg base) 24 / claim ANTIMYASTHENIC/CHOLINERGIC AGENTS MESTINON TAB ER 180 MG pyridostigmine bromide pyridostigmine bromide tab 60 mg ANTIMYCOBACTERI AGENTS ethambutol hcl tab 100 mg GE 64 LAST UPDATED 12/2014

65 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS ethambutol hcl tab 400 mg ISONIAZID SYRUP 50 MG/5ML isoniazid isoniazid tab 100 mg isoniazid tab 300 mg pyrazinamide tab 500 mg rifampin cap 150 mg rifampin cap 300 mg TRECATOR TAB 250 MG ethionamide ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES KERAN TAB 2 MG melphalan anastrozole tab 1 mg bicalutamide tab 50 mg cyclophosphamide tab 25 mg cyclophosphamide tab 50 mg exemestane tab 25 mg ST FARESTON TAB 60 MG toremifene citrate flutamide cap 125 mg hydroxyurea cap 500 mg letrozole tab 2.5 mg ST leucovorin calcium tab 10 mg leucovorin calcium tab 15 mg leucovorin calcium tab 25 mg leucovorin calcium tab 5 mg LEUKERAN TAB 2 MG chlorambucil megestrol acetate susp 40 mg/ml GE 65 LAST UPDATED 12/2014

66 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS megestrol acetate tab 20 mg megestrol acetate tab 40 mg mercaptopurine tab 50 mg methotrexate sodium inj 25 mg/ml methotrexate sodium inj pf 25 mg/ml methotrexate sodium tab 2.5 mg (base equiv) MYLERAN TAB 2 MG busulfan tamoxifen citrate tab 10 mg (base equivalent) tamoxifen citrate tab 20 mg (base equivalent) TREXL TAB 10 MG methotrexate sodium TREXL TAB 15 MG methotrexate sodium TREXL TAB 5 MG methotrexate sodium TREXL TAB 7.5 MG methotrexate sodium ANTIRKINSON AGENTS amantadine hcl cap 100 mg amantadine hcl syrup 50 mg/5ml benztropine mesylate tab 0.5 mg benztropine mesylate tab 1 mg benztropine mesylate tab 2 mg bromocriptine mesylate cap 5 mg bromocriptine mesylate tab 2.5 mg carbidopa & levodopa tab mg carbidopa & levodopa tab mg carbidopa & levodopa tab mg carbidopa & levodopa tab cr mg carbidopa & levodopa tab cr mg GE 66 LAST UPDATED 12/2014

67 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS carbidopa tab 25 mg ropinirole hydrochloride tab 0.25 mg 6 per day ropinirole hydrochloride tab 0.5 mg 3 per day ropinirole hydrochloride tab 1 mg 3 per day ropinirole hydrochloride tab 2 mg 3 per day ropinirole hydrochloride tab 3 mg 6 per day ropinirole hydrochloride tab 4 mg 6 per day ropinirole hydrochloride tab 5 mg 3 per day selegiline hcl cap 5 mg selegiline hcl tab 5 mg trihexyphenidyl hcl elixir 0.4 mg/ml 500 / 31 days trihexyphenidyl hcl tab 2 mg trihexyphenidyl hcl tab 5 mg ANTIPSYCHOTICS/ANTIMANIC AGENTS ABILIFY DISCMELT TAB DISP 10 MG aripiprazole At least 6 yrs old ABILIFY DISCMELT TAB DISP 15 MG aripiprazole At least 6 yrs old ABILIFY SOLUTION 1 MG/ML aripiprazole 750 / 30 days At least 6 yrs old ABILIFY TAB 10 MG aripiprazole At least 6 yrs old ABILIFY TAB 15 MG aripiprazole At least 6 yrs old GE 67 LAST UPDATED 12/2014

68 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS ABILIFY TAB 2 MG aripiprazole At least 6 yrs old ABILIFY TAB 20 MG aripiprazole At least 6 yrs old ABILIFY TAB 30 MG aripiprazole At least 6 yrs old ABILIFY TAB 5 MG aripiprazole At least 6 yrs old chlorpromazine hcl tab 10 mg 10 per day chlorpromazine hcl tab 100 mg 3 per day chlorpromazine hcl tab 200 mg 3 per day chlorpromazine hcl tab 25 mg 3 per day chlorpromazine hcl tab 50 mg 3 per day clozapine tab 100 mg At least 18 yrs old 9 per day clozapine tab 200 mg At least 18 yrs old 3 per day clozapine tab 25 mg At least 18 yrs old 3 per day clozapine tab 50 mg At least 18 yrs old 3 per day fluphenazine decanoate inj 25 mg/ml fluphenazine hcl tab 1 mg fluphenazine hcl tab 10 mg GE 68 LAST UPDATED 12/2014

69 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS fluphenazine hcl tab 2.5 mg fluphenazine hcl tab 5 mg haloperidol decanoate im soln 100 mg/ml haloperidol decanoate im soln 50 mg/ml haloperidol lactate oral conc 2 mg/ml haloperidol tab 0.5 mg 3 per day haloperidol tab 1 mg 3 per day haloperidol tab 10 mg 3 per day haloperidol tab 2 mg haloperidol tab 20 mg haloperidol tab 5 mg lithium carbonate cap 150 mg lithium carbonate cap 300 mg lithium carbonate cap 600 mg lithium carbonate tab 300 mg lithium carbonate tab cr 300 mg lithium carbonate tab cr 450 mg lithium oral solution 8 meq/5ml loxapine succinate cap 10 mg 4 per day loxapine succinate cap 25 mg 4 per day loxapine succinate cap 5 mg 4 per day loxapine succinate cap 50 mg 4 per day olanzapine tab 10 mg At least 13 yrs old olanzapine tab 15 mg At least 13 yrs old olanzapine tab 2.5 mg At least 13 yrs old GE 69 LAST UPDATED 12/2014

70 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS olanzapine tab 20 mg At least 13 yrs old olanzapine tab 5 mg At least 13 yrs old olanzapine tab 7.5 mg At least 13 yrs old perphenazine tab 16 mg 4 per day perphenazine tab 2 mg 4 per day perphenazine tab 4 mg 4 per day perphenazine tab 8 mg 4 per day prochlorperazine maleate tab 10 mg (base equivalent) prochlorperazine maleate tab 5 mg (base equivalent) prochlorperazine suppos 25 mg quetiapine fumarate tab 100 mg At least 10 yrs old 2 per day quetiapine fumarate tab 200 mg At least 10 yrs old 2 per day At least 10 yrs old quetiapine fumarate tab 25 mg 2 per day MFL 1 / year quetiapine fumarate tab 300 mg At least 10 yrs old 2 per day quetiapine fumarate tab 400 mg At least 10 yrs old 2 per day At least 10 yrs old quetiapine fumarate tab 50 mg 2 per day MFL 1 / year risperidone orally disintegrating tab 0.25 mg At least 5 yrs old 2 per day GE 70 LAST UPDATED 12/2014

71 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS risperidone orally disintegrating tab 0.5 mg At least 5 yrs old 2 per day risperidone orally disintegrating tab 1 mg At least 5 yrs old 2 per day risperidone orally disintegrating tab 2 mg At least 5 yrs old 2 per day risperidone orally disintegrating tab 3 mg At least 5 yrs old 2 per day risperidone orally disintegrating tab 4 mg At least 5 yrs old 2 per day risperidone soln 1 mg/ml At least 5 yrs old 4 per day risperidone tab 0.25 mg At least 5 yrs old 2 per day risperidone tab 0.5 mg At least 5 yrs old 2 per day risperidone tab 1 mg At least 5 yrs old 2 per day risperidone tab 2 mg At least 5 yrs old 2 per day risperidone tab 3 mg At least 5 yrs old 2 per day risperidone tab 4 mg At least 5 yrs old 2 per day thioridazine hcl tab 10 mg 3 per day thioridazine hcl tab 100 mg 3 per day thioridazine hcl tab 25 mg 3 per day GE 71 LAST UPDATED 12/2014

72 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS thioridazine hcl tab 50 mg 3 per day thiothixene cap 1 mg 3 per day thiothixene cap 10 mg 3 per day thiothixene cap 2 mg 3 per day thiothixene cap 5 mg 3 per day trifluoperazine hcl tab 1 mg 3 per day trifluoperazine hcl tab 10 mg 3 per day trifluoperazine hcl tab 2 mg 3 per day trifluoperazine hcl tab 5 mg 3 per day ziprasidone hcl cap 20 mg At least 18 yrs old 2 per day ziprasidone hcl cap 40 mg At least 18 yrs old 2 per day ziprasidone hcl cap 60 mg At least 18 yrs old 2 per day ziprasidone hcl cap 80 mg At least 18 yrs old 2 per day ANTISEPTICS & DISINFECTANTS formaldehyde solution 10% 90 / claim ANTIVIRS abacavir sulfate tab 300 mg (base equiv) 2 per day abacavir sulfate-lamivudine-zidovudine tab mg 2 per day acyclovir cap 200 mg 50 / 30 days acyclovir susp 200 mg/5ml 400 / 30 days acyclovir tab 400 mg 2 per day GE 72 LAST UPDATED 12/2014

73 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS acyclovir tab 800 mg 50 / 30 days APTIVUS CAP 250 MG tipranavir APTIVUS SOLUTION 100 MG/ML tipranavir ATRIPLA TAB MG efavirenz-emtricitabine-tenofovir disoproxil fumarate COMPLERA TAB MG emtricitabine-rilpivirine-tenofovir disoproxil fumarate CRIXIVAN CAP 100 MG indinavir sulfate CRIXIVAN CAP 200 MG indinavir sulfate CRIXIVAN CAP 400 MG indinavir sulfate 4 per day 10 per day 6 per day 9 per day 6 per day didanosine delayed release capsule 125 mg didanosine delayed release capsule 200 mg didanosine delayed release capsule 250 mg didanosine delayed release capsule 400 mg EDURANT TAB 25 MG rilpivirine hcl EMTRIVA CAP 200 MG emtricitabine EMTRIVA SOLUTION 10 MG/ML emtricitabine EPIVIR SOLUTION 10 MG/ML lamivudine EPZICOM TAB MG abacavir sulfate-lamivudine 24 per day 30 per day INCIVEK TAB 375 MG telaprevir INTELENCE TAB 100 MG etravirine INTELENCE TAB 200 MG etravirine 4 per day 2 per day GE 73 LAST UPDATED 12/2014

74 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS INTELENCE TAB 25 MG etravirine INVIRASE CAP 200 MG saquinavir mesylate INVIRASE TAB 500 MG saquinavir mesylate ISENTRESS TAB 400 MG raltegravir potassium KETRA SOLUTION MG/5ML lopinavir-ritonavir KETRA TAB MG lopinavir-ritonavir KETRA TAB MG lopinavir-ritonavir 4 per day 10 per day 4 per day 2 per day 320 / 32 days 4 per day 6 per day lamivudine tab 150 mg 2 per day lamivudine tab 300 mg lamivudine-zidovudine tab mg 2 per day LEXIVA SUSPENSION 50 MG/ML fosamprenavir calcium LEXIVA TAB 700 MG fosamprenavir calcium 56 per day 4 per day nevirapine susp 50 mg/5ml 40 per day nevirapine tab 200 mg 2 per day nevirapine tab sr 24hr 400 mg NORVIR CAP 100 MG ritonavir NORVIR SOLUTION 80 MG/ML ritonavir NORVIR TAB 100 MG ritonavir 12 per day 15 per day 12 per day PEG-INTRON KIT 120 MCG/0.5ML peginterferon alfa-2b PEG-INTRON KIT 150 MCG/0.5ML peginterferon alfa-2b GE 74 LAST UPDATED 12/2014

75 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS PEG-INTRON KIT 50 MCG/0.5ML peginterferon alfa-2b PEG-INTRON KIT 80 MCG/0.5ML peginterferon alfa-2b PEG-INTRON REDIPEN KIT 120 MCG/0.5ML peginterferon alfa-2b PEG-INTRON REDIPEN KIT 150 MCG/0.5ML peginterferon alfa-2b PEG-INTRON REDIPEN KIT 50 MCG/0.5ML peginterferon alfa-2b PEG-INTRON REDIPEN KIT 80 MCG/0.5ML peginterferon alfa-2b PEG-INTRON REDIPEN K 4 KIT 120 MCG/0.5ML peginterferon alfa-2b PEG-INTRON REDIPEN K 4 KIT 150 MCG/0.5ML peginterferon alfa-2b PEG-INTRON REDIPEN K 4 KIT 50 MCG/0.5ML peginterferon alfa-2b PEG-INTRON REDIPEN K 4 KIT 80 MCG/0.5ML peginterferon alfa-2b PEGASYS KIT 180 MCG/0.5ML peginterferon alfa-2a PEGASYS PROCLICK SOLUTION 135 MCG/0.5ML peginterferon alfa-2a PEGASYS PROCLICK SOLUTION 180 MCG/0.5ML peginterferon alfa-2a PEGASYS SOLUTION 180 MCG/0.5ML peginterferon alfa-2a PEGASYS SOLUTION 180 MCG/ML peginterferon alfa-2a PREZISTA TAB 150 MG darunavir ethanolate PREZISTA TAB 400 MG darunavir ethanolate PREZISTA TAB 600 MG darunavir ethanolate 3 per day 2 per day 2 per day GE 75 LAST UPDATED 12/2014

76 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS PREZISTA TAB 75 MG darunavir ethanolate PREZISTA TAB 800 MG darunavir ethanolate 2 per day RELENZA DISKHER AER POW BA 5 MG/BLISTER zanamivir MPL At least 5 yrs old 1 / 30 days RESCRIPTOR TAB 100 MG delavirdine mesylate RESCRIPTOR TAB 200 MG delavirdine mesylate REYATAZ CAP 100 MG atazanavir sulfate REYATAZ CAP 150 MG atazanavir sulfate REYATAZ CAP 200 MG atazanavir sulfate REYATAZ CAP 300 MG atazanavir sulfate SELZENTRY TAB 150 MG maraviroc SELZENTRY TAB 300 MG maraviroc 12 per day 6 per day 2 per day 2 per day 2 per day 2 per day 2 per day 2 per day stavudine cap 15 mg 2 per day stavudine cap 20 mg 2 per day stavudine cap 30 mg 2 per day stavudine cap 40 mg 2 per day stavudine for oral soln 1 mg/ml 80 per day STRIBILD TAB MG elvitegravir-cobicistat-emtricitabine-tenofovir SUSTIVA CAP 200 MG efavirenz SUSTIVA CAP 50 MG efavirenz 2 per day GE 76 LAST UPDATED 12/2014

77 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS SUSTIVA TAB 600 MG efavirenz TAMIFLU CAP 30 MG oseltamivir phosphate MFL 20 / 30 days 1 /80 days TAMIFLU CAP 45 MG oseltamivir phosphate MFL 10 / 30 days 1 /80 days TAMIFLU CAP 75 MG oseltamivir phosphate MFL 10 / 30 days 1 /80 days TAMIFLU RECON SUSP 12 MG/ML oseltamivir phosphate 75 / 30 days TAMIFLU RECON SUSP 6 MG/ML oseltamivir phosphate MFL 120 / 30 days 1 /80 days TRUVADA TAB MG emtricitabine-tenofovir disoproxil fumarate valacyclovir hcl tab 1 gm 21 / 21 days valacyclovir hcl tab 500 mg 42 / 21 days VCYTE TAB 450 MG valganciclovir hcl 2 per day VICTRELIS CAP 200 MG boceprevir VIDEX RECON SOLN 2 GM didanosine VIDEX RECON SOLN 4 GM didanosine VIRACEPT POWDER 50 MG/GM nelfinavir mesylate VIRACEPT TAB 250 MG nelfinavir mesylate VIRACEPT TAB 625 MG nelfinavir mesylate VIREAD POWDER 40 MG/GM tenofovir disoproxil fumarate VIREAD TAB 150 MG tenofovir disoproxil fumarate 20 per day 20 per day 36 per day 9 per day 4 per day 240 / 30 days GE 77 LAST UPDATED 12/2014

78 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS VIREAD TAB 200 MG tenofovir disoproxil fumarate VIREAD TAB 250 MG tenofovir disoproxil fumarate VIREAD TAB 300 MG tenofovir disoproxil fumarate ZIAGEN SOLUTION 20 MG/ML abacavir sulfate 30 per day zidovudine cap 100 mg 6 per day zidovudine syrup 10 mg/ml 60 per day zidovudine tab 300 mg 2 per day ASSORTED CLASSES *sodium polystyrene sulfonate powder** 454 / claim AZASAN TAB 100 MG azathioprine AZASAN TAB 75 MG azathioprine azathioprine tab 50 mg CELLCEPT RECON SUSP 200 MG/ML mycophenolate mofetil CUPRIMINE CAP 250 MG penicillamine 3 per day 3 per day 15 per day cyclosporine cap 100 mg 4 per day cyclosporine cap 25 mg 4 per day cyclosporine modified cap 100 mg 4 per day cyclosporine modified cap 25 mg 4 per day cyclosporine modified cap 50 mg 4 per day cyclosporine modified oral soln 100 mg/ml 8 per day GE 78 LAST UPDATED 12/2014

79 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS cyclosporine oral soln 100 mg/ml 8 per day mycophenolate mofetil cap 250 mg 2 per day mycophenolate mofetil tab 500 mg 4 per day mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv) mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv) RAMUNE SOLUTION 1 MG/ML sirolimus RAMUNE TAB 1 MG sirolimus RAMUNE TAB 2 MG sirolimus sirolimus tab 0.5 mg sodium polystyrene sulfonate oral susp 15 gm/60ml 2 per day 4 per day 4 per day 6 per day 2 per day tacrolimus cap 0.5 mg 3 per day tacrolimus cap 1 mg 3 per day tacrolimus cap 5 mg 3 per day BETA BLOCKERS acebutolol hcl cap 200 mg acebutolol hcl cap 400 mg atenolol tab 100 mg 2 per day atenolol tab 25 mg 2 per day atenolol tab 50 mg 2 per day bisoprolol fumarate tab 10 mg bisoprolol fumarate tab 5 mg carvedilol tab 12.5 mg 3 per day carvedilol tab 25 mg 4 per day GE 79 LAST UPDATED 12/2014

80 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS carvedilol tab mg 3 per day carvedilol tab 6.25 mg 3 per day COREG CR CAP ER 24H 10 MG carvedilol phosphate COREG CR CAP ER 24H 20 MG carvedilol phosphate COREG CR CAP ER 24H 40 MG carvedilol phosphate COREG CR CAP ER 24H 80 MG carvedilol phosphate estradiol tab 0.5 mg estradiol tab 1 mg estradiol tab 2 mg HEMANGEOL SOLUTION 4.28 MG/ML propranolol hcl labetalol hcl tab 100 mg 3 per day labetalol hcl tab 200 mg 6 per day labetalol hcl tab 300 mg 8 per day metoprolol succinate tab sr 24hr 100 mg metoprolol succinate tab sr 24hr 200 mg 2 per day metoprolol succinate tab sr 24hr 25 mg metoprolol succinate tab sr 24hr 50 mg metoprolol tartrate tab 100 mg 2 per day metoprolol tartrate tab 25 mg 2 per day metoprolol tartrate tab 50 mg 3 per day nadolol tab 20 mg 2 per day nadolol tab 40 mg 2 per day nadolol tab 80 mg 2 per day GE 80 LAST UPDATED 12/2014

81 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS pindolol tab 10 mg pindolol tab 5 mg PREMARIN TAB 0.3 MG estrogens, conjugated PREMARIN TAB 0.45 MG estrogens, conjugated PREMARIN TAB MG estrogens, conjugated PREMARIN TAB 0.9 MG estrogens, conjugated PREMARIN TAB 1.25 MG estrogens, conjugated propranolol hcl cap sr 24hr 120 mg 2 per day propranolol hcl cap sr 24hr 160 mg 2 per day propranolol hcl cap sr 24hr 60 mg 2 per day propranolol hcl cap sr 24hr 80 mg 2 per day propranolol hcl oral soln 20 mg/5ml propranolol hcl oral soln 40 mg/5ml propranolol hcl tab 10 mg propranolol hcl tab 20 mg propranolol hcl tab 40 mg propranolol hcl tab 60 mg propranolol hcl tab 80 mg sotalol hcl (afib/afl) tab 120 mg 2 per day sotalol hcl (afib/afl) tab 160 mg 2 per day sotalol hcl (afib/afl) tab 80 mg 2 per day sotalol hcl tab 120 mg 2 per day GE 81 LAST UPDATED 12/2014

82 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS sotalol hcl tab 160 mg 2 per day sotalol hcl tab 240 mg sotalol hcl tab 80 mg 2 per day timolol maleate tab 10 mg timolol maleate tab 20 mg timolol maleate tab 5 mg CCIUM CHANNEL BLOCKERS amlodipine besylate tab 10 mg amlodipine besylate tab 2.5 mg amlodipine besylate tab 5 mg diltiazem hcl cap sr 12hr 120 mg 2 per day diltiazem hcl cap sr 12hr 60 mg 2 per day diltiazem hcl cap sr 12hr 90 mg 2 per day diltiazem hcl cap sr 24hr 120 mg diltiazem hcl cap sr 24hr 180 mg diltiazem hcl cap sr 24hr 240 mg 2 per day diltiazem hcl coated beads cap sr 24hr 120 mg diltiazem hcl coated beads cap sr 24hr 180 mg diltiazem hcl coated beads cap sr 24hr 240 mg 2 per day diltiazem hcl coated beads cap sr 24hr 300 mg diltiazem hcl coated beads tab sr 24hr 180 mg diltiazem hcl coated beads tab sr 24hr 240 mg 2 per day diltiazem hcl coated beads tab sr 24hr 300 mg diltiazem hcl extended release beads cap sr 24hr 120 mg diltiazem hcl extended release beads cap sr 24hr 180 mg GE 82 LAST UPDATED 12/2014

83 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS diltiazem hcl extended release beads cap sr 24hr 240 mg 2 per day diltiazem hcl extended release beads cap sr 24hr 300 mg diltiazem hcl extended release beads cap sr 24hr 360 mg diltiazem hcl extended release beads cap sr 24hr 420 mg diltiazem hcl tab 120 mg 3 per day diltiazem hcl tab 30 mg 3 per day diltiazem hcl tab 60 mg 3 per day diltiazem hcl tab 90 mg 3 per day felodipine tab sr 24hr 10 mg felodipine tab sr 24hr 2.5 mg felodipine tab sr 24hr 5 mg nicardipine hcl cap 20 mg nicardipine hcl cap 30 mg nifedipine cap 10 mg 4 per day nifedipine cap 20 mg 4 per day nifedipine tab sr 24hr 30 mg nifedipine tab sr 24hr 60 mg 2 per day nifedipine tab sr 24hr 90 mg nifedipine tab sr 24hr osmotic 30 mg nifedipine tab sr 24hr osmotic 60 mg 2 per day nifedipine tab sr 24hr osmotic 90 mg verapamil hcl cap sr 24hr 120 mg 2 per day verapamil hcl cap sr 24hr 180 mg 2 per day verapamil hcl cap sr 24hr 240 mg 2 per day verapamil hcl cap sr 24hr 360 mg GE 83 LAST UPDATED 12/2014

84 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS verapamil hcl tab 120 mg 3 per day verapamil hcl tab 40 mg 3 per day verapamil hcl tab 80 mg 3 per day verapamil hcl tab cr 120 mg 2 per day verapamil hcl tab cr 180 mg 2 per day verapamil hcl tab cr 240 mg 2 per day CARDIOTONICS digoxin oral soln 0.05 mg/ml digoxin tab 125 mcg (0.125 mg) digoxin tab 250 mcg (0.25 mg) CARDIOVASCULAR AGENTS - MISC. papaverine hcl cap cr 150 mg CEPHOSPORINS cefaclor cap 250 mg cefaclor cap 500 mg cefaclor for susp 125 mg/5ml cefaclor for susp 250 mg/5ml cefaclor for susp 375 mg/5ml cefdinir cap 300 mg ST 20 / claim cefdinir for susp 125 mg/5ml ST MPL 1 / claim cefdinir for susp 250 mg/5ml ST MPL 1 / claim cefprozil for susp 125 mg/5ml cefprozil for susp 250 mg/5ml cefprozil tab 250 mg 20 / claim GE 84 LAST UPDATED 12/2014

85 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS cefprozil tab 500 mg 20 / claim CEFTIN RECON SUSP 250 MG/5ML cefuroxime axetil 100 / claim Up to 12 yrs old ceftriaxone sodium for inj 1 gm MFL 3 / claim 1 / 30 days ceftriaxone sodium for inj 250 mg MFL 3 / claim 1 / 30 days ceftriaxone sodium for inj 500 mg MFL 3 / claim 1 / 30 days ceftriaxone sodium for iv soln 1 gm MFL 3 / claim 1 / 30 days cefuroxime axetil for susp 125 mg/5ml 100 / claim Up to 12 yrs old cefuroxime axetil tab 250 mg 20 / claim cefuroxime axetil tab 500 mg 20 / claim cephalexin cap 250 mg cephalexin cap 500 mg cephalexin for susp 125 mg/5ml cephalexin for susp 250 mg/5ml CONTRACEPTIVES DEPO-SUBQ PROVERA 104 SUSPENSION 104 MG/0.65ML medroxyprogesterone acetate (contraceptive) 1 / claim desogest-eth estrad & eth estrad tab /0.01 mg(21/5) desogest-ethin est tab / / mg-mg desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg GE 85 LAST UPDATED 12/2014

86 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS drospirenone-ethinyl estradiol tab mg drospirenone-ethinyl estradiol tab mg ELLA TAB 30 MG ulipristal acetate 4 / 365 days ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg levonorg-eth est tab mg(84) & eth est tab 0.01mg(7) levonorgestrel & ethinyl estradiol (91-day) tab mg 91 / claim levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg 1 / 21 days levonorgestrel tab 0.75 mg MFL 4 / 365 days levonorgestrel-eth estra tab / / mgmcg medroxyprogesterone acetate im susp 150 mg/ml 1 / claim NECON 1/50 (28) TAB 1-50 MG-MCG norethindrone & mestranol NECON 10/11 (28) TAB 35 MCG norethindrone-eth estradiol (biphasic) norelgestromin-ethinyl estradiol td ptwk mcg/24hr 3 / claim GE 86 LAST UPDATED 12/2014

87 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg norethindrone & ethinyl estradiol tab 1 mg-35 mcg norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg norethindrone tab 0.35 mg norethindrone-eth estradiol tab / /1-35 mgmcg norethindrone-eth estradiol tab /1-35/ mg-mcg norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg norgestimate-eth estrad tab / / mgmcg norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg 2 per day NORINYL 1+50 (28) TAB 1-50 MG-MCG norethindrone & mestranol GE 87 LAST UPDATED 12/2014

88 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS NUVARING RING MG/24HR etonogestrel-ethinyl estradiol 1 / claim OGESTREL TAB MG-MCG norgestrel & ethinyl estradiol ZOVIA 1/50E (28) TAB 1-50 MG-MCG ethynodiol diacet & eth estrad CORTICOSTEROIDS cortisone acetate tab 25 mg dexamethasone elixir 0.5 mg/5ml DEXAMETHASONE INTENSOL CONC 1 MG/ML dexamethasone dexamethasone sodium phosphate inj 120 mg/30ml 150 / 30 days dexamethasone sodium phosphate inj 20 mg/5ml 150 / 30 days dexamethasone sodium phosphate inj 4 mg/ml 150 / 30 days dexamethasone soln 0.5 mg/5ml dexamethasone tab 0.5 mg dexamethasone tab 0.75 mg dexamethasone tab 1 mg dexamethasone tab 1.5 mg dexamethasone tab 2 mg dexamethasone tab 4 mg dexamethasone tab 6 mg fludrocortisone acetate tab 0.1 mg hydrocortisone tab 10 mg hydrocortisone tab 20 mg hydrocortisone tab 5 mg methylprednisolone tab 4 mg methylprednisolone tab 4 mg dose pack methylprednisolone tab 8 mg GE 88 LAST UPDATED 12/2014

89 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS MILLIPRED TAB 5 MG prednisolone prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base) prednisolone sod phosphate oral soln 15 mg/5ml (base equiv) prednisolone syrup 15 mg/5ml (usp solution equivalent) PREDNISONE INTENSOL CONC 5 MG/ML prednisone prednisone oral soln 5 mg/5ml prednisone tab 1 mg prednisone tab 10 mg prednisone tab 10 mg dose pack prednisone tab 2.5 mg prednisone tab 20 mg prednisone tab 5 mg prednisone tab 5 mg dose pack prednisone tab 50 mg VERIPRED 20 SOLUTION 20 MG/5ML prednisolone sodium phosphate 15ml / 30 days 240 / claim 150 / claim COUGH/COLD/LERGY acetylcysteine inhal soln 10% acetylcysteine inhal soln 20% benzonatate cap 100 mg At least 10 yrs old 30 / 30 days benzonatate cap 200 mg At least 10 yrs old MFL 1 / 30 days brompheniramine & pseudoephedrine tab sr 12hr 6-45 mg MFL 14 / 30 days 1 / 30 days chlorphen-pe-methscopolamine syrup mg/5ml 240 / 6 days chlorpheniramine & pseudoephedrine cap cr mg 2 per day GE 89 LAST UPDATED 12/2014

90 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS At least 3 yrs old chlorpheniramine tan-phenylephrine tan susp mg/5ml C From age 3-5:Daily Dose=10; From ages 6 and older: Daily Dose 20 DLERGY CHEW TAB MG chlorpheniramine-phenylephrine-methscopolamine 60 / claim 3 to 7 yrs old DLERGY PE TAB ER 12H MG chlorpheniramine-phenylephrine-methscopolamine DEHISTINE SYRUP MG/5ML chlorpheniramine-phenylephrine-methscopolamine DELTUSS DMX LIQUID MG/5ML pseudoephed-bromphen-dm guaifenesin-codeine liquid mg/5ml hydrocodone w/ homatropine syrup mg/5ml 62 / 31 days 240 / 6 days phenyleph-chlorphen w/ dm-gg syrup mg/5ml 240 / 6 days phenyleph-chlorphen w/ dm-gg syrup mg/5ml phenylephrine-chlorphen-dm syrup mg/5ml 240 / claim phenylephrine-chlorphen-dm syrup mg/5ml 240 / claim phenylephrine-chlorphen-dm tab sr 12hr mg phenylephrine-promethazine w/ codeine syrup mg/5ml 240 / claim At least 2 yrs old promethazine & phenylephrine syrup mg/5ml 240 / claim At least 2 yrs old promethazine w/ codeine syrup mg/5ml 240 / claim At least 2 yrs old promethazine-dm syrup mg/5ml 240 / claim At least 2 yrs old pseudoephed-bromphen-dm syrup mg/5ml 240 / claim pseudoephedrine-methscopolamine tab sr 12hr mg GE 90 LAST UPDATED 12/2014

91 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS sodium chloride flush iv soln 0.9% sodium chloride inj 0.9% sodium chloride inj 3% sodium chloride iv soln 0.9% sodium chloride soln nebu 0.9% sodium chloride soln nebu 10% sodium chloride soln nebu 3% DERMATOLOGICS *nystatin topical powder** MPL 1 / claim acyclovir oint 5% 30 / 30 days aluminum chloride soln 20% MPL 1 / claim APEXICON E CREAM 0.05 % diflorasone diacetate emollient base MPL 1 / claim betamethasone dipropionate augmented cream 0.05% MPL 1 / claim betamethasone dipropionate augmented gel 0.05% MPL 1 / claim betamethasone dipropionate augmented lotion 0.05% MPL 1 / claim betamethasone dipropionate augmented oint 0.05% MPL 1 / claim betamethasone dipropionate cream 0.05% MPL 60 / claim 1 / claim betamethasone dipropionate lotion 0.05% 60 / claim betamethasone dipropionate oint 0.05% MPL 60 / claim 1 / claim betamethasone valerate cream 0.1% MPL 1 / claim betamethasone valerate lotion 0.1% 60 / claim betamethasone valerate oint 0.1% MPL 1 / claim calcipotriene cream 0.005% 60 / claim calcipotriene soln 0.005% (50 mcg/ml) 60 / claim GE 91 LAST UPDATED 12/2014

92 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS CARAC CREAM 0.5 % fluorouracil (topical) 30 / claim clindamycin phosphate gel 1% MPL 1 / claim clindamycin phosphate lotion 1% MPL 1 / claim clindamycin phosphate soln 1% clindamycin phosphate swab 1% clindamycin phosphate-benzoyl peroxide gel 1-5% MPL 1 / 30 days clobetasol propionate cream 0.05% MPL 1 / claim clobetasol propionate emollient base cream 0.05% MPL 1 / claim clobetasol propionate gel 0.05% MPL 1 / claim clobetasol propionate oint 0.05% MPL 1 / claim clobetasol propionate soln 0.05% MPL 1 / claim clotrimazole w/ betamethasone cream % MPL 1 / claim clotrimazole w/ betamethasone lotion % 30 / claim desonide cream 0.05% MPL 1 / claim desonide lotion 0.05% MPL 1 / claim desonide oint 0.05% MPL 1 / claim desoximetasone cream 0.25% MPL 2 / claim desoximetasone gel 0.05% MPL 1 / claim desoximetasone oint 0.25% MPL 1 / claim DIFLORASONE DIACETATE CREAM 0.05 % diflorasone diacetate MPL 1 / claim diflorasone diacetate oint 0.05% MPL 1 / claim DRITHO-CREME HP CREAM 1 % anthralin econazole nitrate cream 1% 30 / claim ELIDEL CREAM 1 % pimecrolimus 30 / 30 days At least 2 yrs old GE 92 LAST UPDATED 12/2014

93 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS EPIFOAM FOAM 1-1 % pramoxine-hc erythromycin gel 2% MPL 1 / claim erythromycin soln 2% EURAX CREAM 10 % crotamiton EURAX LOTION 10 % crotamiton 60 / claim MPL 1 / claim fluocinolone acetonide cream 0.01% MPL 1 / claim fluocinolone acetonide cream 0.025% MPL 1 / claim fluocinolone acetonide oint 0.025% MPL 1 / claim fluocinolone acetonide soln 0.01% 60 / claim fluocinonide cream 0.05% MPL 1 / claim fluocinonide emulsified base cream 0.05% MPL 1 / claim fluocinonide gel 0.05% MPL 1 / claim fluocinonide oint 0.05% MPL 1 / claim fluocinonide soln 0.05% MPL 1 / claim fluorouracil cream 5% 40 / claim fluorouracil soln 2% 10 / claim fluorouracil soln 5% 10 / claim fluticasone propionate cream 0.05% MPL 1 / 30 days fluticasone propionate oint 0.005% MPL 1 / claim gentamicin sulfate cream 0.1% MPL 1 / claim gentamicin sulfate oint 0.1% MPL 1 / claim halobetasol propionate cream 0.05% MPL 1 / claim halobetasol propionate oint 0.05% MPL 1 / claim hydrocortisone butyrate cream 0.1% MPL 1 / claim GE 93 LAST UPDATED 12/2014

94 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS hydrocortisone butyrate oint 0.1% MPL 1 / claim hydrocortisone butyrate soln 0.1% MPL 1 / claim hydrocortisone cream 2.5% MPL 1 / claim hydrocortisone lotion 2.5% MPL 1 / claim hydrocortisone oint 2.5% MPL 1 / claim hydrocortisone valerate cream 0.2% MPL 1 / claim hydrocortisone valerate oint 0.2% MPL 1 / claim hydroquinone cream 4% MPL 1 / claim hydroquinone emulsion 4% MPL 1 / claim imiquimod cream 5% 48 / 180 days ST isotretinoin cap 10 mg 12 to 22 yrs old 2 per day ST isotretinoin cap 20 mg 12 to 22 yrs old 2 per day ST isotretinoin cap 40 mg 12 to 22 yrs old 2 per day ketoconazole cream 2% MPL 1 / claim ketoconazole shampoo 2% 120 / claim lidocaine hcl cream 3% MPL 1 / claim lidocaine oint 5% MPL 1 / claim lidocaine-prilocaine cream % MPL 1 / claim malathion lotion 0.5% MFL 59 / claim 2 / 30 days GE 94 LAST UPDATED 12/2014

95 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS metronidazole cream 0.75% 45 / claim metronidazole gel 0.75% 45 / claim metronidazole lotion 0.75% mometasone furoate cream 0.1% MPL 1 / claim mometasone furoate oint 0.1% MPL 1 / claim mometasone furoate solution 0.1% (lotion) MPL 1 / claim mupirocin calcium cream 2% MPL 1 / claim mupirocin oint 2% MPL 1 / claim nystatin cream unit/gm MPL 1 / claim nystatin oint unit/gm MPL 1 / claim nystatin-triamcinolone cream unit/gm-% MPL 1 / claim nystatin-triamcinolone oint unit/gm-% MPL 1 / claim permethrin cream 5% MPL 1 / claim podofilox soln 0.5% 4 / claim prednicarbate cream 0.1% MPL 1 / claim prednicarbate oint 0.1% MPL 1 / claim PROTOPIC OINTMENT 0.03 % tacrolimus (topical) 30 / 30 days At least 2 yrs old PROTOPIC OINTMENT 0.1 % tacrolimus (topical) 30 / 30 days At least 16 yrs old selenium sulfide lotion 2.5% 120 / claim silver sulfadiazine cream 1% MPL 1 / claim sulfacetamide sodium liquid 10% MPL 1 / claim sulfacetamide sodium lotion 10% (acne) 120 / claim GE 95 LAST UPDATED 12/2014

96 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS SULFACETAMIDE SODIUM LOTION % sulfacetamide sodium-urea sulfacetamide sodium w/ sulfur cleansing cloth 10-5% MPL 1 / claim sulfacetamide sodium w/ sulfur cream 10-5% MPL 1 / claim sulfacetamide sodium w/ sulfur emulsion 10-5% MPL 1 / claim sulfacetamide sodium w/ sulfur lotion 10-5% MPL 1 / claim sulfacetamide sodium w/ sulfur susp 10-5% 30 / claim TAZORAC CREAM 0.05 % tazarotene TAZORAC CREAM 0.1 % tazarotene TAZORAC GEL 0.05 % tazarotene TAZORAC GEL 0.1 % tazarotene MPL 1 / claim MPL 1 / claim MPL 1 / claim MPL 1 / claim tretinoin cream 0.025% 20 / claim Up to 21 yrs old tretinoin cream 0.05% 20 / 30 days Up to 21 yrs old tretinoin cream 0.1% 20 / 30 days Up to 21 yrs old tretinoin gel 0.01% 15 / 30 days Up to 21 yrs old tretinoin gel 0.025% MPL Up to 21 yrs old 1 / 30 days triamcinolone acetonide cream 0.025% MPL 1 / claim triamcinolone acetonide cream 0.1% MPL 1 / claim triamcinolone acetonide cream 0.5% 15 / claim triamcinolone acetonide lotion 0.025% 60 / claim GE 96 LAST UPDATED 12/2014

97 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS triamcinolone acetonide lotion 0.1% 60 / claim triamcinolone acetonide oint 0.025% MPL 1 / claim triamcinolone acetonide oint 0.1% MPL 1 / claim urea cream 40% MPL 1 / claim urea lotion 40% MPL 1 / claim ZOVIRAX CREAM 5 % acyclovir topical ZOVIRAX OINTMENT 5 % acyclovir topical MPL 1 / claim MPL 1 / claim DIAGNOSTIC PRODUCTS CHEK-STIX CONTROL STRIP acetone (urine) test CHEMSTRIP K STRIP acetone (urine) test KETOCARE acetone (urine) test KETOCARE STRIP acetone (urine) test KETOSTIX STRIP acetone (urine) test RELION KETONE STRIP acetone (urine) test TRUETEST TEST STRIP glucose blood TRUETRACK TEST STRIP glucose blood 5 per day 5 per day DIGESTIVE AIDS CREON CP DR RT UNIT pancrelipase (lipase-protease-amylase) CREON CP DR RT UNIT pancrelipase (lipase-protease-amylase) CREON CP DR RT 6000 UNIT pancrelipase (lipase-protease-amylase) GE 97 LAST UPDATED 12/2014

98 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS NCREAZE CP DR RT UNIT pancrelipase (lipase-protease-amylase) NCREAZE CP DR RT UNIT pancrelipase (lipase-protease-amylase) NCREAZE CP DR RT UNIT pancrelipase (lipase-protease-amylase) NCREAZE CP DR RT 4200 UNIT pancrelipase (lipase-protease-amylase) pancrelipase (lip-prot-amyl) dr cap unit ZENPEP CP DR RT UNIT pancrelipase (lipase-protease-amylase) ZENPEP CP DR RT UNIT pancrelipase (lipase-protease-amylase) ZENPEP CP DR RT UNIT pancrelipase (lipase-protease-amylase) ZENPEP CP DR RT UNIT pancrelipase (lipase-protease-amylase) ZENPEP CP DR RT UNIT pancrelipase (lipase-protease-amylase) DIURETICS acetazolamide cap sr 12hr 500 mg acetazolamide tab 125 mg acetazolamide tab 250 mg amiloride & hydrochlorothiazide tab 5-50 mg amiloride hcl tab 5 mg 4 per day bumetanide tab 0.5 mg bumetanide tab 1 mg bumetanide tab 2 mg chlorothiazide tab 250 mg 2 per day chlorothiazide tab 500 mg 4 per day chlorthalidone tab 50 mg furosemide inj 10 mg/ml GE 98 LAST UPDATED 12/2014

99 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS furosemide oral soln 10 mg/ml furosemide oral soln 8 mg/ml furosemide tab 20 mg furosemide tab 40 mg furosemide tab 80 mg hydrochlorothiazide cap 12.5 mg hydrochlorothiazide tab 12.5 mg hydrochlorothiazide tab 25 mg hydrochlorothiazide tab 50 mg indapamide tab 1.25 mg indapamide tab 2.5 mg methazolamide tab 25 mg methazolamide tab 50 mg metolazone tab 10 mg metolazone tab 2.5 mg metolazone tab 5 mg spironolactone & hydrochlorothiazide tab mg spironolactone tab 100 mg spironolactone tab 25 mg spironolactone tab 50 mg torsemide tab 10 mg torsemide tab 100 mg torsemide tab 20 mg torsemide tab 5 mg triamterene & hydrochlorothiazide cap mg triamterene & hydrochlorothiazide tab mg triamterene & hydrochlorothiazide tab mg ENDOCRINE AND METABOLIC AGENTS - MISC. ACTONEL TAB 30 MG risedronate sodium GE 99 LAST UPDATED 12/2014

100 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS ACTONEL TAB 35 MG risedronate sodium 4 / 28 days ACTONEL TAB 5 MG risedronate sodium alendronate sodium oral soln 70 mg/75ml 10.8 per day alendronate sodium tab 10 mg alendronate sodium tab 35 mg 0.15 per day alendronate sodium tab 40 mg alendronate sodium tab 5 mg alendronate sodium tab 70 mg 0.15 per day calcitonin (salmon) nasal soln 200 unit/act 4 / 30 days calcitriol cap 0.25 mcg calcitriol cap 0.5 mcg desmopressin acetate nasal soln 0.01% (refrigerated) 5 / claim desmopressin acetate nasal spray soln 0.01% 5 / claim desmopressin acetate nasal spray soln 0.01% (refrigerated) 5 / claim desmopressin acetate tab 0.1 mg 3 per day desmopressin acetate tab 0.2 mg 3 per day levocarnitine oral soln 1 gm/10ml (10%) 30 per day levocarnitine tab 330 mg 3 per day MIACCIN SOLUTION 200 UNIT/ML calcitonin (salmon) 2 / 30 days NORDITROPIN FLEXPRO SOLUTION 10 MG/1.5ML somatropin GE 100 LAST UPDATED 12/2014

101 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS NORDITROPIN FLEXPRO SOLUTION 15 MG/1.5ML somatropin NORDITROPIN FLEXPRO SOLUTION 5 MG/1.5ML somatropin NORDITROPIN NORDIFLEX PEN SOLUTION 10 MG/1.5ML somatropin NORDITROPIN NORDIFLEX PEN SOLUTION 15 MG/1.5ML somatropin NORDITROPIN NORDIFLEX PEN SOLUTION 30 MG/3ML somatropin NORDITROPIN NORDIFLEX PEN SOLUTION 5 MG/1.5ML somatropin NORDITROPIN SOLUTION 15 MG/1.5ML somatropin NORDITROPIN SOLUTION 5 MG/1.5ML somatropin raloxifene hcl tab 60 mg TEV-TROPIN RECON SOLN 5 MG somatropin FLUOROQUINOLONES ciprofloxacin hcl tab 100 mg (base equiv) 6 / claim ciprofloxacin hcl tab 250 mg (base equiv) ciprofloxacin hcl tab 500 mg (base equiv) ciprofloxacin hcl tab 750 mg (base equiv) levofloxacin tab 250 mg 14 / claim levofloxacin tab 500 mg 14 / claim levofloxacin tab 750 mg 14 / claim GE 101 LAST UPDATED 12/2014

102 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS ofloxacin tab 200 mg 56 / claim ofloxacin tab 300 mg 56 / claim ofloxacin tab 400 mg 56 / claim OFLOXACIN TAB 400 MG ofloxacin 56 / claim GASTROINTESTIN AGENTS - MISC. ASACOL TAB DR 400 MG mesalamine 12 per day balsalazide disodium cap 750 mg 9 per day calcium acetate (phosphate binder) cap 667 mg (169 mg ca) DELZICOL CAP DR 400 MG mesalamine lactulose (encephalopathy) solution 10 gm/15ml 6 per day mesalamine enema 4 gm 60 per day metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) metoclopramide hcl tab 10 mg metoclopramide hcl tab 5 mg PENTASA CAP ER 250 MG mesalamine PENTASA CAP ER 500 MG mesalamine SFROWASA ENEMA 4 GM/60ML mesalamine sulfasalazine tab 500 mg sulfasalazine tab delayed release 500 mg 8 per day 8 per day ursodiol cap 300 mg 3 per day ursodiol tab 250 mg 7 per day GENITOURINARY AGENTS - MISCELLANEOUS ELMIRON CAP 100 MG pentosan polysulfate sodium 3 per day GE 102 LAST UPDATED 12/2014

103 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS finasteride tab 5 mg phenazopyridine hcl tab 100 mg phenazopyridine hcl tab 200 mg potassium citrate & citric acid powder pack mg potassium citrate tab cr 10 meq (1080 mg) potassium citrate tab cr 5 meq (540 mg) sodium chloride inj 0.9% sodium chloride irrigation soln 0.9% sodium chloride iv soln 0.9% sodium citrate & citric acid soln mg/5ml 500 / 30 days tamsulosin hcl cap 0.4 mg 2 per day GOUT AGENTS allopurinol tab 100 mg allopurinol tab 300 mg colchicine tab 0.6 mg MFL 6 / claim 1 / 30 days colchicine w/ probenecid tab mg probenecid tab 500 mg HEMATOLOGIC AGENTS - MISC. cilostazol tab 100 mg 2 per day cilostazol tab 50 mg 2 per day clopidogrel bisulfate tab 75 mg (base equiv) dipyridamole tab 25 mg dipyridamole tab 50 mg dipyridamole tab 75 mg EFFIENT TAB 10 MG prasugrel hcl EFFIENT TAB 5 MG prasugrel hcl GE 103 LAST UPDATED 12/2014

104 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS pentoxifylline tab cr 400 mg HEMATOPOIETIC AGENTS *ferrous fumarate-fa-b complex-c-zn-mg-mn-cu tab mg*** cyanocobalamin inj 1000 mcg/ml DROXIA CAP 200 MG hydroxyurea (sickle cell anemia) DROXIA CAP 300 MG hydroxyurea (sickle cell anemia) DROXIA CAP 400 MG hydroxyurea (sickle cell anemia) HEMOSTATICS aminocaproic acid syrup 25% 60 / claim aminocaproic acid tab 500 mg 24 / claim 30 / 5 days tranexamic acid tab 650 mg 12 to 49 yrs old MFL 1 / month HYPNOTICS flurazepam hcl cap 15 mg FLURAZEM HCL CAP 15 MG flurazepam hcl flurazepam hcl cap 30 mg FLURAZEM HCL CAP 30 MG flurazepam hcl phenobarbital elixir 20 mg/5ml phenobarbital tab 100 mg phenobarbital tab 15 mg phenobarbital tab 16.2 mg phenobarbital tab 30 mg phenobarbital tab 32.4 mg GE 104 LAST UPDATED 12/2014

105 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS phenobarbital tab 60 mg phenobarbital tab 64.8 mg phenobarbital tab 97.2 mg temazepam cap 15 mg temazepam cap 30 mg triazolam tab mg triazolam tab 0.25 mg ST zaleplon cap 10 mg At least 18 yrs old ST zaleplon cap 5 mg At least 18 yrs old zolpidem tartrate tab 10 mg zolpidem tartrate tab 5 mg LAXATIVES lactulose solution 10 gm/15ml peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm MPL 1 / claim peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm MPL 1 / claim peg 3350-kcl-sod bicarb-nacl for soln 420 gm MPL 1 / claim MACROLIDES azithromycin for susp 100 mg/5ml 15 / claim azithromycin for susp 200 mg/5ml MPL 2 / claim azithromycin powd pack for susp 1 gm 2 / claim azithromycin tab 250 mg 6 / claim azithromycin tab 500 mg 4 per day GE 105 LAST UPDATED 12/2014

106 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS azithromycin tab 600 mg 8 / 28 days clarithromycin for susp 125 mg/5ml MPL 1 / claim clarithromycin for susp 250 mg/5ml MPL 1 / claim clarithromycin tab 250 mg 28 / claim clarithromycin tab 500 mg 28 / claim clarithromycin tab sr 24hr 500 mg 14 / claim ERY-TAB TAB DR 250 MG erythromycin base ERY-TAB TAB DR 333 MG erythromycin base ERY-TAB TAB DR 500 MG erythromycin base ERYPED 400 RECON SUSP 400 MG/5ML erythromycin ethylsuccinate erythromycin ethylsuccinate for susp 200 mg/5ml erythromycin ethylsuccinate tab 400 mg erythromycin w/ delayed release particles cap 250 mg PCE TAB DR 333 MG erythromycin base (coated) PCE TAB DR 500 MG erythromycin base (coated) MEDIC DEVICES *blood glucose calibration - liquid*** 1 / 90 days *blood glucose monitoring kit w/ device*** *lancet devices*** 1 / 180 days *lancets*** 200 / 30 days 1ST TIER UNIFINE PENTIPS MISC 31G X 5 MM insulin pen needle 1ST TIER UNIFINE PENTIPS MISC 32G X 4 MM insulin pen needle 5 per day 5 per day GE 106 LAST UPDATED 12/2014

107 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS 1ST TIER UNIFINE PENTIPS PLUS MISC 31G X 5 MM insulin pen needle 1ST TIER UNIFINE PENTIPS PLUS MISC 32G X 4 MM insulin pen needle ADVOCATE INSULIN PEN NEEDLES MISC 31G X 5 MM insulin pen needle AURORA UNIFINE PENTIPS MISC 31G X 5 MM insulin pen needle AURORA UNIFINE PENTIPS MISC 32G X 4 MM insulin pen needle BD AUTOSHIELD MISC 29G X 8MM insulin pen needle BD INSULIN SYRINGE MICROFINE MISC 27G X 5/8" 1 ML insulin syringe/needle u-100 BD INSULIN SYRINGE MICROFINE MISC 28G X 1/2" 0.3 ML insulin syringe/needle u-100 BD INSULIN SYRINGE MISC 25G X 1" 1 ML insulin syringe/needle u-100 BD INSULIN SYRINGE MISC 25G X 5/8" 1 ML insulin syringe/needle u-100 BD INSULIN SYRINGE MISC 26G X 1/2" 1 ML insulin syringe/needle u-100 BD INSULIN SYRINGE MISC 30G X 1/2" 0.5 ML insulin syringe/needle u-100 BD INSULIN SYRINGE ULTRAFINE MISC 30G X 1/2" 0.3 ML insulin syringe/needle u-100 BD INSULIN SYRINGE ULTRAFINE MISC 30G X 1/2" 0.5 ML insulin syringe/needle u-100 BD INSULIN SYRINGE ULTRAFINE MISC 30G X 1/2" 1 ML insulin syringe/needle u-100 BD INSULIN SYRINGE ULTRAFINE MISC 31G X 15/64" 1 ML insulin syringe/needle u per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 150 / 30 days GE 107 LAST UPDATED 12/2014

108 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS BD INTEGRA SYRINGE MISC 25G X 1" 1 ML insulin syringe/needle u-100 BD PEN NEEDLE MINI U/F MISC 31G X 5 MM insulin pen needle BD PEN NEEDLE NANO U/F MISC 32G X 4 MM insulin pen needle BD PEN NEEDLE ULTRAFINE MISC 29G X 12.7MM insulin pen needle CAREONE UNIFINE PENTIPS MISC 31G X 5 MM insulin pen needle CAREONE UNIFINE PENTIPS MISC 32G X 4 MM insulin pen needle CAREONE UNIFINE PENTIPS PLUS MISC 31G X 5 MM insulin pen needle CAREONE UNIFINE PENTIPS PLUS MISC 32G X 4 MM insulin pen needle CLICKFINE PEN NEEDLES MISC 32G X 4 MM insulin pen needle COMFORT EZ INSULIN SYRINGE MISC 30G X 1/2" 0.3 ML insulin syringe/needle u-100 COMFORT EZ INSULIN SYRINGE MISC 30G X 1/2" 0.5 ML insulin syringe/needle u-100 COMFORT EZ INSULIN SYRINGE MISC 30G X 1/2" 1 ML insulin syringe/needle u-100 COMFORT EZ PEN NEEDLES MISC 31G X 5 MM insulin pen needle COMFORT EZ PEN NEEDLES MISC 32G X 4 MM insulin pen needle CVS INSULIN SYRINGE MISC 30G X 1/2" 0.3 ML insulin syringe/needle u-100 CVS INSULIN SYRINGE MISC 30G X 1/2" 0.5 ML insulin syringe/needle u-100 DRUG MART UNIFINE PENTIPS MISC 31G X 5 MM insulin pen needle DRUG MART UNIFINE PENTIPS MISC 32G X 4 MM insulin pen needle 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day GE 108 LAST UPDATED 12/2014

109 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS EASY COMFORT INSULIN SYRINGE MISC 30G X 1/2" 0.5 ML insulin syringe/needle u-100 EASY COMFORT INSULIN SYRINGE MISC 30G X 1/2" 1 ML insulin syringe/needle u-100 EASY COMFORT PEN NEEDLES MISC 31G X 5 MM insulin pen needle EASY TOUCH INSULIN SAFETY SYR MISC 30G X 1/2" 1 ML insulin syringe/needle u-100 EASY TOUCH INSULIN SYRINGE MISC 27G X 1/2" 0.5 ML insulin syringe/needle u-100 EASY TOUCH INSULIN SYRINGE MISC 30G X 1/2" 0.3 ML insulin syringe/needle u-100 EASY TOUCH INSULIN SYRINGE MISC 30G X 1/2" 0.5 ML insulin syringe/needle u-100 EASY TOUCH INSULIN SYRINGE MISC 30G X 1/2" 1 ML insulin syringe/needle u-100 EASY TOUCH PEN NEEDLES MISC 31G X 5 MM insulin pen needle EASY TOUCH PEN NEEDLES MISC 32G X 4 MM insulin pen needle EASY TOUCH PEN NEEDLES MISC 32G X 5 MM insulin pen needle EASY TOUCH PEN NEEDLES MISC 32G X 6 MM insulin pen needle FIFTY50 PEN NEEDLES MISC 31G X 5 MM insulin pen needle FREDS PHARMACY UNIFINE PENTIP+ MISC 31G X 5 MM insulin pen needle FREDS PHARMACY UNIFINE PENTIPS MISC 32G X 4 MM insulin pen needle 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day GE 109 LAST UPDATED 12/2014

110 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS OB EASE INJECT PEN NEEDLES MISC 31G X 5 MM insulin pen needle OB EASE INJECT PEN NEEDLES MISC 32G X 4 MM insulin pen needle OB INJECT EASE INSULIN SYR MISC 30G X 1/2" 0.3 ML insulin syringe/needle u-100 OB INJECT EASE INSULIN SYR MISC 30G X 1/2" 0.5 ML insulin syringe/needle u-100 OB INJECT EASE INSULIN SYR MISC 30G X 1/2" 1 ML insulin syringe/needle u-100 UCOPRO INSULIN SYRINGE MISC 30G X 1/2" 0.3 ML insulin syringe/needle u-100 UCOPRO INSULIN SYRINGE MISC 30G X 1/2" 0.5 ML insulin syringe/needle u-100 UCOPRO INSULIN SYRINGE MISC 30G X 1/2" 1 ML insulin syringe/needle u-100 H-E-B INCONTROL PEN NEEDLES MISC 31G X 5 MM insulin pen needle H-E-B INCONTROL PEN NEEDLES MISC 32G X 4 MM insulin pen needle HETHWISE UNIFINE PENTIPS MISC 32G X 4 MM insulin pen needle HETHY ACCENTS UNIFINE PENTIP MISC 31G X 5 MM insulin pen needle HETHY ACCENTS UNIFINE PENTIP MISC 32G X 4 MM insulin pen needle HY-VEE INSULIN SYRINGE 30G X 1/2" 0.3 ML insulin syringe/needle u-100 HY-VEE INSULIN SYRINGE 30G X 1/2" 0.5 ML insulin syringe/needle u-100 HY-VEE INSULIN SYRINGE 30G X 1/2" 1 ML insulin syringe/needle u per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day GE 110 LAST UPDATED 12/2014

111 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS INSPIREASE BAGS MISC spacer/aerosol-holding chamber supplies - bags INSPIREASE MOUTHPIECE MISC spacer/aerosol-holding chamber supplies - mouthpieces INSPIREASE RESERVOIR BAGS MISC spacer/aerosol-holding chamber supplies - bags 3 / 180 days 1 / 180 days 3 / 180 days insulin pen needle 29 g x 12 mm (1/2") 5 per day insulin pen needle 31 g x 6 mm (1/4") 5 per day insulin pen needle 31 g x 8 mm (1/3" or 5/16") 5 per day insulin syringe (disp) u ml 5 per day INSULIN SYRINGE/NEEDLE MISC 27G X 1/2" 0.5 ML insulin syringe/needle u per day insulin syringe/needle u ml 31 x 5/16" 5 per day insulin syringe/needle u ml 31 x 5/16" 5 per day insulin syringe/needle u-100 1/2 ml 31 x 5/16" 5 per day INSUPEN PEN NEEDLES MISC 32G X 4 MM insulin pen needle INSUPEN SENSITIVE MISC 32G X 6 MM insulin pen needle INSUPEN ULTRAFIN MISC 30G X 8 MM insulin pen needle LEADER UNIFINE PENTIPS MISC 31G X 5 MM insulin pen needle LEADER UNIFINE PENTIPS MISC 32G X 4 MM insulin pen needle LEADER UNIFINE PENTIPS PLUS MISC 31G X 5 MM insulin pen needle LEADER UNIFINE PENTIPS PLUS MISC 32G X 4 MM insulin pen needle LITE TOUCH PEN NEEDLES MISC 31G X 5 MM insulin pen needle LITETOUCH PEN NEEDLES MISC 29G X 12.7MM insulin pen needle 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day GE 111 LAST UPDATED 12/2014

112 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS MONOJECT INSULIN SYRINGE MISC 25G X 5/8" 1 ML insulin syringe/needle u-100 MONOJECT INSULIN SYRINGE MISC 27G X 1/2" 1 ML insulin syringe/needle u-100 NOVOFINE AUTOCOVER MISC 30G X 8 MM insulin pen needle NOVOFINE MISC 30G X 8 MM insulin pen needle NOVOFINE MISC 32G X 6 MM insulin pen needle NOVOTWIST MISC 30G X 8 MM insulin pen needle NOVOTWIST MISC 32G X 5 MM insulin pen needle ORTHO DIAPHRAGM L-FLEX DIAPHRAGM 65 MM diaphragm arc-spring ORTHO DIAPHRAGM L-FLEX DIAPHRAGM 70 MM diaphragm arc-spring ORTHO DIAPHRAGM L-FLEX DIAPHRAGM 75 MM diaphragm arc-spring ORTHO DIAPHRAGM L-FLEX DIAPHRAGM 80 MM diaphragm arc-spring PC UNIFINE PENTIPS MISC 31G X 5 MM insulin pen needle PEN NEEDLES 3/16" MISC 31G X 5 MM insulin pen needle PEN NEEDLES 5/16" MISC 30G X 8 MM insulin pen needle PRECISION SURE-DOSE SYRINGE MISC 30G X 3/8" 0.5 ML insulin syringe/needle u-100 PREFERRED PLUS UNIFINE PENTIPS MISC 31G X 5 MM insulin pen needle PREFERRED PLUS UNIFINE PENTIPS MISC 32G X 4 MM insulin pen needle 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day GE 112 LAST UPDATED 12/2014

113 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS PRODIGY MINI PEN NEEDLES MISC 31G X 5 MM insulin pen needle PX INSULIN SYRINGE MISC 30G X 1/2" 0.3 ML insulin syringe/needle u-100 PX INSULIN SYRINGE MISC 30G X 1/2" 0.5 ML insulin syringe/needle u-100 PX INSULIN SYRINGE MISC 30G X 1/2" 1 ML insulin syringe/needle u-100 QC UNIFINE PENTIPS MISC 32G X 4 MM insulin pen needle RA PEN NEEDLES MISC 31G X 5 MM insulin pen needle RELION PEN NEEDLES MISC 32G X 4 MM insulin pen needle SHOPKO UNIFINE PENTIPS MISC 31G X 5 MM insulin pen needle SHOPKO UNIFINE PENTIPS MISC 32G X 4 MM insulin pen needle SURE COMFORT INSULIN SYRINGE MISC 30G X 1/2" 0.3 ML insulin syringe/needle u-100 SURE COMFORT INSULIN SYRINGE MISC 30G X 1/2" 0.5 ML insulin syringe/needle u-100 SURE COMFORT INSULIN SYRINGE MISC 30G X 1/2" 1 ML insulin syringe/needle u-100 SURE COMFORT PEN NEEDLES MISC 29G X 12.7MM insulin pen needle SURE COMFORT PEN NEEDLES MISC 30G X 8 MM insulin pen needle SURE COMFORT PEN NEEDLES MISC 31G X 5 MM insulin pen needle SURE COMFORT PEN NEEDLES MISC 32G X 4 MM insulin pen needle SURE-FINE PEN NEEDLES MISC 29G X 12.7MM insulin pen needle 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day GE 113 LAST UPDATED 12/2014

114 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS SURE-FINE PEN NEEDLES MISC 31G X 5 MM insulin pen needle TERUMO INSULIN SYRINGE MISC 27G X 1/2" 0.5 ML insulin syringe/needle u-100 TERUMO INSULIN SYRINGE MISC 30G X 3/8" 0.3 ML insulin syringe/needle u-100 TERUMO INSULIN SYRINGE MISC 30G X 3/8" 0.5 ML insulin syringe/needle u-100 THINPRO INSULIN SYRINGE MISC 30G X 3/8" 0.3 ML insulin syringe/needle u-100 THINPRO INSULIN SYRINGE MISC 30G X 3/8" 0.5 ML insulin syringe/needle u-100 TRUERESULT BLOOD UCOSE KIT W/DEVICE blood glucose monitoring supplies TRUETRACK UCOSE CONTROL LIQUID HIGH blood glucose calibration TRUETRACK UCOSE CONTROL LIQUID LOW blood glucose calibration ULTICARE INSULIN SYRINGE MISC 30G X 1/2" 0.3 ML insulin syringe/needle u-100 ULTICARE INSULIN SYRINGE MISC 30G X 1/2" 0.5 ML insulin syringe/needle u-100 ULTICARE INSULIN SYRINGE MISC 30G X 1/2" 1 ML insulin syringe/needle u-100 ULTICARE MICRO PEN NEEDLES MISC 32G X 4 MM insulin pen needle ULTICARE PEN NEEDLES MISC 29G X 12.7MM insulin pen needle ULTILET INSULIN SYRINGE MISC 29G X 7/16" 0.3 ML insulin syringe/needle u-100 ULTILET INSULIN SYRINGE MISC 29G X 7/16" 0.5 ML insulin syringe/needle u-100 ULTILET INSULIN SYRINGE MISC 29G X 7/16" 1 ML insulin syringe/needle u-100 ULTRA COMFORT INSULIN SYRINGE MISC 30G X 1/2" 0.5 ML insulin syringe/needle u per day 5 per day 5 per day 5 per day 5 per day 5 per day 1 / 90 days 1 / 90 days 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day GE 114 LAST UPDATED 12/2014

115 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS ULTRA COMFORT INSULIN SYRINGE MISC 30G X 1/2" 1 ML insulin syringe/needle u-100 ULTRA-THIN II MINI PEN NEEDLE MISC 31G X 5 MM insulin pen needle ULTRA-THIN II PEN NEEDLES MISC 29G X 12.7MM insulin pen needle UNIFINE PENTIPS MISC 31G X 5 MM insulin pen needle UNIFINE PENTIPS MISC 32G X 4 MM insulin pen needle UNIFINE PENTIPS PLUS MISC 32G X 4 MM insulin pen needle VANISHPOINT INSULIN SYRINGE MISC 30G X 1/2" 0.5 ML insulin syringe/needle u-100 VIDA MIA UNIFINE PENTIPS MISC 32G X 4 MM insulin pen needle WEGMANS UNIFINE PENTIPS PLUS MISC 31G X 5 MM insulin pen needle WEGMANS UNIFINE PENTIPS PLUS MISC 32G X 4 MM insulin pen needle 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day 5 per day MIGRAINE PRODUCTS acetaminophen-isometheptene-dichloral cap mg AXERT TAB 12.5 MG almotriptan malate AXERT TAB 6.25 MG almotriptan malate dihydroergotamine mesylate inj 1 mg/ml dihydroergotamine mesylate nasal spray 4 mg/ml ergotamine w/ caffeine tab mg RELX TAB 20 MG eletriptan hydrobromide RELX TAB 40 MG eletriptan hydrobromide 6 / 30 days 6 / 30 days 6 / 30 days 6 / 30 days GE 115 LAST UPDATED 12/2014

116 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS sumatriptan nasal spray 20 mg/act 6 / 30 days At least 12 yrs old sumatriptan nasal spray 5 mg/act 6 / 30 days At least 12 yrs old sumatriptan succinate inj 6 mg/0.5ml 2 / 30 days At least 12 yrs old sumatriptan succinate solution auto-injector 6 mg/0.5ml 2 / 30 days At least 12 yrs old sumatriptan succinate solution prefilled syringe 6 mg/0.5ml 2 / 30 days At least 12 yrs old sumatriptan succinate tab 100 mg 9 / 30 days At least 12 yrs old sumatriptan succinate tab 25 mg 9 / 30 days At least 12 yrs old sumatriptan succinate tab 50 mg 9 / 30 days At least 12 yrs old zolmitriptan orally disintegrating tab 2.5 mg 6 / 30 days zolmitriptan orally disintegrating tab 5 mg 6 / 30 days zolmitriptan tab 2.5 mg 6 / 30 days zolmitriptan tab 5 mg 6 / 30 days ZOMIG SOLUTION 5 MG zolmitriptan ZOMIG TAB 5 MG zolmitriptan 6 / 30 days 6 / 30 days MINERS & ELECTROLYTES FLURA-DROPS SOLUTION 0.55 (0.25 F) MG/DROP sodium fluoride KLOR-CON M15 TAB ER 15 MEQ potassium chloride microencapsulated crystals cr GE 116 LAST UPDATED 12/2014

117 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS pot phos monobasic w/sod phos di & monobas tab mg potassium bicarbonate effer tab 25 meq potassium chloride cap cr 10 meq 8 per day potassium chloride cap cr 8 meq potassium chloride microencapsulated crys cr tab 10 meq potassium chloride microencapsulated crys cr tab 20 meq potassium chloride oral liq 10% (20 meq/15ml) potassium chloride oral liq 20% (40 meq/15ml) potassium chloride powder packet 20 meq potassium chloride powder packet 25 meq potassium chloride tab cr 10 meq potassium chloride tab cr 8 meq (600 mg) sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf) sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf) sodium fluoride chew tab 1 mg f (from 2.2 mg naf) sodium fluoride soln mg/drop f (0.275 mg/drop naf) sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf) SSKI SOLUTION 1 GM/ML potassium iodide MOUTH/THROAT/DENT AGENTS chlorhexidine gluconate soln 0.12% lidocaine hcl viscous soln 2% 100 / claim nystatin susp unit/ml 120 / claim pilocarpine hcl tab 5 mg 6 per day sodium fluoride cream 1.1% MPL 1 / claim sodium fluoride gel 1.1% (0.5% f) MPL 1 / claim sodium fluoride paste 1.1% 106 / claim GE 117 LAST UPDATED 12/2014

118 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS stannous fluoride conc 0.63% triamcinolone acetonide dental paste 0.1% 5 / claim MULTIVITAMINS *b-complex w/ c & folic acid cap 1 mg*** *b-complex w/ c & folic acid tab 1 mg*** *pediatric multiple vitamins w/ fl-fe drops mg/ml** 50 / claim Up to 13 yrs old *pediatric multiple vitamins w/ fluoride chew tab 0.25 mg*** Up to 13 yrs old *pediatric multiple vitamins w/ fluoride chew tab 0.5 mg*** Up to 13 yrs old *pediatric multiple vitamins w/ fluoride chew tab 1 mg*** 30 / 30 days Up to 13 yrs old *pediatric multiple vitamins w/ fluoride soln 0.25 mg/ml*** 50 / claim Up to 13 yrs old *pediatric multiple vitamins w/ fluoride soln 0.5 mg/ml*** 50 / claim Up to 13 yrs old *pediatric vitamins acd fluoride & fe drops mg/ml*** 50 / claim Up to 13 yrs old *pediatric vitamins acd w/ fluoride soln 0.25 mg/ml*** 50 / claim Up to 13 yrs old *pediatric vitamins acd w/ fluoride soln 0.5 mg/ml*** 50 / claim Up to 13 yrs old *prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg*** Up to 45 yrs old *prenatal vit w/ fe fumarate-fa tab 60-1 mg*** Up to 45 yrs old GE 118 LAST UPDATED 12/2014

119 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS *prenatal vit w/ fe fumarate-fa tab 65-1 mg*** Up to 45 yrs old CAVAN PRENAT/EC CCIUM TAB DR 28-1 MG prenatal without a vit w/ fe fumarate-folic acid Up to 45 yrs old COMPLETE-RF PRENAT TAB 90-1 MG prenatal without a w/ fe carbonyl-docusate-folic acid Up to 45 yrs old COMPLETENATE CHEW TAB 29-1 MG prenatal vit w/ ferrous fumarate-folic acid Up to 45 yrs old ESCAVITE LQ LIQUID MG/ML ped multivitamins w/fl & iron 50 / claim Up to 13 yrs old GESTICARE TAB DR 28-1 MG prenatal without a vit w/ fe fumarate-folic acid Up to 45 yrs old MYNAT CAP prenatal multivit-min w/fe-fa Up to 45 yrs old MYNATE 90 PLUS TAB ER prenatal vit w/ docusate-fe fumarate-folic acid Up to 45 yrs old NATACHEW CHEW TAB 29-1 MG prenatal vit w/ ferrous fumarate-folic acid Up to 45 yrs old NAT-V RX TAB 29-1 MG prenatal vit w/ iron carbonyl-folic acid Up to 45 yrs old GE 119 LAST UPDATED 12/2014

120 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS NATVIT TAB prenatal vit w/ ferrous fumarate-folic acid Up to 45 yrs old O-C PRENAT TAB prenatal vit w/ ferrous fumarate-folic acid Up to 45 yrs old PRENAFIRST TAB 17-1 MG prenatal vit w/ ferrous fumarate-folic acid Up to 45 yrs old PRENATABS FA TAB prenatal vit w/ ferrous fumarate-folic acid Up to 45 yrs old PRENATABS RX TAB 29-1 MG prenatal vit w/ iron carbonyl-folic acid Up to 45 yrs old PRENAT 19 CHEW TAB prenatal vit w/ ferrous fumarate-folic acid Up to 45 yrs old PRENAT 19 CHEW TAB 29-1 MG prenatal vit w/ ferrous fumarate-folic acid Up to 45 yrs old PRENAT 19 TAB 29-1 MG prenatal vit w/ docusate-fe fumarate-folic acid Up to 45 yrs old PRENAT PLUS IRON TAB 29-1 MG prenatal vit w/ iron carbonyl-folic acid Up to 45 yrs old RE PRENAT MULTIVITAMIN/IRON CHEW TAB 29-1 MG prenatal vit w/ ferrous fumarate-folic acid Up to 45 yrs old GE 120 LAST UPDATED 12/2014

121 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS RE-NATA 29 OB TAB 29-1 MG prenatal vit w/ iron carbonyl-folic acid Up to 45 yrs old SE-NAT 19 CHEW TAB 29-1 MG prenatal vit w/ ferrous fumarate-folic acid Up to 45 yrs old SE-NAT 90 TAB ER 90-1 MG prenatal vit w/ docusate-fe fumarate-folic acid Up to 45 yrs old VENAT-FA TAB 29-1 MG prenatal vit w/ ferrous fumarate-folic acid Up to 45 yrs old VINATE CCIUM TAB 27-1 MG prenatal vit w/ iron carbonyl-fe gluconate-folic acid Up to 45 yrs old VINATE M TAB 27-1 MG prenatal vit w/ selenium-fe fumarate-folic acid Up to 45 yrs old VITASPIRE TAB 29-1 MG prenatal without a vit w/ iron carbonyl-folic acid Up to 45 yrs old VOL-TAB RX TAB 29-1 MG prenatal vit w/ iron carbonyl-folic acid Up to 45 yrs old MUSCULOSKELET THERAPY AGENTS baclofen tab 10 mg baclofen tab 20 mg chlorzoxazone tab 500 mg cyclobenzaprine hcl tab 10 mg 3 per day GE 121 LAST UPDATED 12/2014

122 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS cyclobenzaprine hcl tab 5 mg 3 per day methocarbamol tab 500 mg methocarbamol tab 750 mg tizanidine hcl tab 2 mg ST tizanidine hcl tab 4 mg ST NAS AGENTS - SYSTEMIC AND TOPIC ADRENIN SOLUTION 0.1 % epinephrine hcl (nasal) BACTROBAN NAS OINTMENT 2 % mupirocin calcium flunisolide nasal soln 25 mcg/act (0.025%) 25 / claim flunisolide nasal soln 29 mcg/act (0.025%) fluticasone propionate nasal susp 50 mcg/act 16 / claim ipratropium bromide nasal soln 0.03% (21 mcg/spray) 30 / 25 days ipratropium bromide nasal soln 0.06% (42 mcg/spray) 15 / 30 days NASONEX SUSPENSION 50 MCG/ACT mometasone furoate (nasal) ST 17 / claim At least 2 yrs old triamcinolone acetonide nasal aerosol suspension 55 mcg/act ST 17 / claim At least 2 yrs old OPHTHMIC AGENTS OCRIL SOLUTION 2 % nedocromil sodium (ophth) ST 5 / claim OMIDE SOLUTION 0.1 % lodoxamide tromethamine ST 10 / claim apraclonidine hcl ophth soln 0.5% (base equivalent) atropine sulfate ophth soln 1% MPL 1 / claim GE 122 LAST UPDATED 12/2014

123 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS azelastine hcl ophth soln 0.05% ST 6 / claim AZOPT SUSPENSION 1 % brinzolamide MPL 1 / claim bacitracin ophth oint 500 unit/gm 4 / claim bacitracin-polymyxin b ophth oint 4 / claim betaxolol hcl ophth soln 0.5% MPL 1 / claim BLEPHAMIDE S.O.P. OINTMENT % sulfacetamide sod-prednisolone BLEPHAMIDE SUSPENSION % sulfacetamide sod-prednisolone 4 / claim MPL 1 / claim brimonidine tartrate ophth soln 0.2% MPL 1 / claim carteolol hcl ophth soln 1% MFL 1 / 30 days CILOXAN OINTMENT 0.3 % ciprofloxacin hcl (ophth) 4 / claim ciprofloxacin hcl ophth soln 0.3% MPL 1 / claim cromolyn sodium ophth soln 4% 10 / claim CYCLOGYL SOLUTION 0.5 % cyclopentolate hcl 15 / claim cyclopentolate hcl ophth soln 1% MPL 1 / claim cyclopentolate hcl ophth soln 2% MPL 1 / claim dexamethasone sodium phosphate ophth soln 0.1% 5 / claim diclofenac sodium ophth soln 0.1% MPL 1 / claim dorzolamide hcl ophth soln 2% 10 / claim dorzolamide hcl-timolol maleate ophth soln mg/ml 10 / claim erythromycin ophth oint 5 mg/gm 4 / claim fluorometholone ophth susp 0.1% MPL 1 / claim flurbiprofen sodium ophth soln 0.03% 3 / claim GE 123 LAST UPDATED 12/2014

124 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS FML OINTMENT 0.1 % fluorometholone (ophth) 4 / claim gentamicin sulfate ophth oint 0.3% 4 / claim gentamicin sulfate ophth soln 0.3% MPL 1 / claim homatropine hbr ophth soln 5% MPL 1 / claim IOPIDINE SOLUTION 1 % apraclonidine hcl ISOPTO CARBACHOL SOLUTION 1.5 % carbachol (ophth) ISOPTO CARBACHOL SOLUTION 3 % carbachol (ophth) ISOPTO HOMATROPINE SOLUTION 2 % homatropine hbr 5 / claim ketorolac tromethamine ophth soln 0.4% MFL 1 / 30 days ketorolac tromethamine ophth soln 0.5% MPL 1 / claim latanoprost ophth soln 0.005% 3 / claim levobunolol hcl ophth soln 0.5% MPL 1 / claim metipranolol ophth soln 0.3% neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin neomycin-polymy-gramicid op sol mgunt-mg/ml 4 / claim 10 / claim neomycin-polymyxin-dexamethasone ophth oint 0.1% 4 / claim neomycin-polymyxin-dexamethasone ophth susp 0.1% 5 / claim neomycin-polymyxin-hc ophth susp 8 / claim NEVANAC SUSPENSION 0.1 % nepafenac 3 / claim ofloxacin ophth soln 0.3% MPL 1 / claim phenylephrine hcl ophth soln 2.5% MPL 1 / claim GE 124 LAST UPDATED 12/2014

125 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS pilocarpine hcl ophth soln 1% pilocarpine hcl ophth soln 2% pilocarpine hcl ophth soln 4% POLY-PRED SUSPENSION 0.5 % neomycin-polymyx-pred acetate 5 / claim polymyxin b-trimethoprim ophth soln unit/ml-0.1% 10 / claim PRED MILD SUSPENSION 0.12 % prednisolone acetate (ophth) PRED-G SUSPENSION % gentamicin-prednisolone acetate 10 / claim MPL 1 / claim prednisolone acetate ophth susp 1% MPL 1 / claim prednisolone sodium phosphate ophth soln 1% MPL 15ml / 30 days 1 / claim sulfacetamide sodium ophth oint 10% 4 / claim sulfacetamide sodium ophth soln 10% 15 / claim sulfacetamide sodium-prednisolone ophth soln (0.25)% SULFACETAMIDE-PREDNISOLONE SUSPENSION % sulfacetamide sod-prednisolone MPL 1 / claim MPL 1 / claim timolol maleate ophth gel forming soln 0.25% MPL 1 / claim timolol maleate ophth gel forming soln 0.5% MPL 1 / claim timolol maleate ophth soln 0.25% MPL 1 / claim timolol maleate ophth soln 0.5% MPL 1 / claim TIMOPTIC OCUDOSE SOLUTION 0.25 % timolol maleate (ophth) TIMOPTIC OCUDOSE SOLUTION 0.5 % timolol maleate (ophth) TOBRADEX OINTMENT % tobramycin-dexamethasone MPL 1 / claim MPL 1 / claim 4 / claim tobramycin ophth soln 0.3% 5 / claim GE 125 LAST UPDATED 12/2014

126 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS tobramycin-dexamethasone ophth susp % MPL 1 / claim TOBREX OINTMENT 0.3 % tobramycin (ophth) 4 / claim trifluridine ophth soln 1% 8 / claim tropicamide ophth soln 0.5% 15 / claim tropicamide ophth soln 1% MPL 1 / claim VEXOL SUSPENSION 1 % rimexolone VIGAMOX SOLUTION 0.5 % moxifloxacin hcl (ophth) MPL 1 / claim 3 / claim OTIC AGENTS acetic acid otic soln 2% 15 / claim antipyrine-benzocaine otic soln mg/ml ( %) MPL 1 / claim CIPRODEX SUSPENSION % ciprofloxacin-dexamethasone 8 / claim fluocinolone acetonide (otic) oil 0.01% MPL 1 / 30 days hydrocortisone w/ acetic acid otic soln 1-2% 10 / claim neomycin-polymyxin-hc otic soln 1% 10 / claim neomycin-polymyxin-hc otic susp 3.5 mg/ml unit/ml- 1% MPL 10 / claim 1 / claim ofloxacin otic soln 0.3% MPL 1 / claim pramoxine-chloroxylenol otic liquid 1-0.1% MFL 1 / 30 days pramoxine-hc-chloroxylenol aqueous otic soln mg/ml MPL 1 / 30 days pramoxine-hc-chloroxylenol otic soln mg/ml MPL 1 / 30 days OXYTOCICS methylergonovine maleate tab 0.2 mg SSIVE IMMUNIZING AGENTS HYPERRHO S/D INJECTABLE 300 MCG rho d immune globulin (human) GE 126 LAST UPDATED 12/2014

127 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS RHOGAM ULTRA-FILTERED PLUS INJECTABLE 300 MCG rho d immune globulin (human) PENICILLINS amoxicillin & k clavulanate chew tab mg 20 / claim amoxicillin & k clavulanate chew tab mg 20 / claim amoxicillin & k clavulanate for susp mg/5ml MPL 1 / claim amoxicillin & k clavulanate for susp mg/5ml MPL 1 / claim amoxicillin & k clavulanate for susp mg/5ml MPL 1 / claim amoxicillin & k clavulanate for susp mg/5ml MPL 2 / claim amoxicillin & k clavulanate tab mg 30 / claim amoxicillin & k clavulanate tab mg 20 / claim amoxicillin & k clavulanate tab mg 20 / claim amoxicillin & k clavulanate tab sr 12hr mg 40 / 30 days amoxicillin (trihydrate) cap 250 mg amoxicillin (trihydrate) cap 500 mg amoxicillin (trihydrate) chew tab 125 mg amoxicillin (trihydrate) for susp 125 mg/5ml amoxicillin (trihydrate) for susp 200 mg/5ml amoxicillin (trihydrate) for susp 250 mg/5ml amoxicillin (trihydrate) for susp 400 mg/5ml amoxicillin (trihydrate) tab 500 mg amoxicillin (trihydrate) tab 875 mg ampicillin cap 250 mg ampicillin cap 500 mg ampicillin for susp 125 mg/5ml ampicillin for susp 250 mg/5ml AUGMENTIN RECON SUSP MG/5ML amoxicillin & pot clavulanate MPL 1 / claim GE 127 LAST UPDATED 12/2014

128 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS dicloxacillin sodium cap 250 mg dicloxacillin sodium cap 500 mg penicillin v potassium for soln 125 mg/5ml penicillin v potassium for soln 250 mg/5ml penicillin v potassium tab 250 mg penicillin v potassium tab 500 mg PROGESTINS medroxyprogesterone acetate tab 10 mg medroxyprogesterone acetate tab 2.5 mg medroxyprogesterone acetate tab 5 mg norethindrone acetate tab 5 mg progesterone micronized cap 100 mg 30 / 30 days progesterone micronized cap 200 mg 20 / 30 days PSYCHOTHERAPEUTIC AND NEUROLOGIC AGENTS - MISC. bupropion hcl (smoking deterrent) tab sr 12hr 150 mg 2 per day CHANTIX CONTINUING MONTH K TAB 1 MG varenicline tartrate 84 / 365 days 2 per day CHANTIX STARTING MONTH K TAB 0.5 MG X 11 & 1 MG X 42 varenicline tartrate 53 / claim CHANTIX TAB 0.5 MG varenicline tartrate 84 / 365 days 2 per day CHANTIX TAB 1 MG varenicline tartrate 84 / 365 days 2 per day COXONE KIT 20 MG/ML glatiramer acetate COXONE SOLN PRSYR 40 MG/ML glatiramer acetate disulfiram tab 250 mg donepezil hydrochloride orally disintegrating tab 10 mg GE 128 LAST UPDATED 12/2014

129 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS donepezil hydrochloride orally disintegrating tab 5 mg donepezil hydrochloride tab 10 mg donepezil hydrochloride tab 5 mg ergoloid mesylates tab 1 mg EXELON TCH 24HR 4.6 MG/24HR rivastigmine EXELON TCH 24HR 9.5 MG/24HR rivastigmine EXELON SOLUTION 2 MG/ML rivastigmine tartrate 6 per day EXTAVIA KIT 0.3 MG interferon beta-1b galantamine hydrobromide cap sr 24hr 16 mg galantamine hydrobromide cap sr 24hr 24 mg galantamine hydrobromide cap sr 24hr 8 mg galantamine hydrobromide oral soln 4 mg/ml 6 per day galantamine hydrobromide tab 12 mg 2 per day galantamine hydrobromide tab 4 mg 2 per day galantamine hydrobromide tab 8 mg 2 per day NAMENDA SOLUTION 10 MG/5ML memantine hcl 10 per day NAMENDA TAB 10 MG memantine hcl 2 per day NAMENDA TAB 5 MG memantine hcl 2 per day NAMENDA TITRATION K TAB 5 (28)-10 (21) MG memantine hcl MPL 1 / 28 days GE 129 LAST UPDATED 12/2014

130 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS NAMENDA XR CAP ER 24H 14 MG memantine hcl NAMENDA XR CAP ER 24H 21 MG memantine hcl NAMENDA XR CAP ER 24H 28 MG memantine hcl NAMENDA XR CAP ER 24H 7 MG memantine hcl 2 per day 2 per day 2 per day 2 per day perphenazine-amitriptyline tab 2-10 mg 4 per day perphenazine-amitriptyline tab 2-25 mg 4 per day perphenazine-amitriptyline tab 4-10 mg 4 per day perphenazine-amitriptyline tab 4-25 mg 4 per day rivastigmine tartrate cap 1.5 mg 2 per day rivastigmine tartrate cap 3 mg 2 per day rivastigmine tartrate cap 4.5 mg 2 per day rivastigmine tartrate cap 6 mg 2 per day SAVELLA TAB 100 MG milnacipran hcl 2 per day SAVELLA TAB 12.5 MG milnacipran hcl 2 per day SAVELLA TAB 25 MG milnacipran hcl 2 per day SAVELLA TAB 50 MG milnacipran hcl 2 per day SAVELLA TITRATION CK MISC 12.5 & 25 & 50 MG milnacipran hcl 55 / 365 days GE 130 LAST UPDATED 12/2014

131 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS TETRACYCLINES doxycycline hyclate cap 100 mg doxycycline hyclate cap 50 mg doxycycline hyclate for inj 100 mg doxycycline hyclate tab 100 mg minocycline hcl cap 100 mg minocycline hcl cap 50 mg minocycline hcl cap 75 mg tetracycline hcl cap 250 mg tetracycline hcl cap 500 mg THYROID AGENTS ARMOUR THYROID TAB 15 MG thyroid ARMOUR THYROID TAB 180 MG thyroid ARMOUR THYROID TAB 240 MG thyroid ARMOUR THYROID TAB 300 MG thyroid levothyroxine sodium tab 100 mcg levothyroxine sodium tab 112 mcg levothyroxine sodium tab 125 mcg levothyroxine sodium tab 137 mcg levothyroxine sodium tab 150 mcg levothyroxine sodium tab 175 mcg levothyroxine sodium tab 200 mcg levothyroxine sodium tab 25 mcg levothyroxine sodium tab 300 mcg levothyroxine sodium tab 50 mcg levothyroxine sodium tab 75 mcg levothyroxine sodium tab 88 mcg GE 131 LAST UPDATED 12/2014

132 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS liothyronine sodium tab 25 mcg liothyronine sodium tab 5 mcg liothyronine sodium tab 50 mcg methimazole tab 10 mg methimazole tab 5 mg NATURE-THROID TAB 130 MG thyroid NATURE-THROID TAB 195 MG thyroid NATURE-THROID TAB 32.5 MG thyroid propylthiouracil tab 50 mg thyroid tab 120 mg (2 grain) thyroid tab 30 mg (1/2 grain) thyroid tab 60 mg (1 grain) thyroid tab 90 mg (1 1/2 grain) THYROLAR-1 TAB 60 ( ) MG (MCG) liotrix (t3-t4) THYROLAR-1/2 TAB 30 ( ) MG (MCG) liotrix (t3-t4) THYROLAR-1/4 TAB 15 ( ) MG (MCG) liotrix (t3-t4) THYROLAR-2 TAB 120 (25-100) MG (MCG) liotrix (t3-t4) THYROLAR-3 TAB 180 ( ) MG (MCG) liotrix (t3-t4) WESTHROID TAB 130 MG thyroid WESTHROID TAB 195 MG thyroid WESTHROID TAB 32.5 MG thyroid WESTHROID-P TAB 130 MG thyroid GE 132 LAST UPDATED 12/2014

133 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS WESTHROID-P TAB 32.5 MG thyroid WP THYROID TAB 130 MG thyroid WP THYROID TAB 32.5 MG thyroid ULCER DRUGS cimetidine hcl soln 300 mg/5ml 27 per day cimetidine tab 300 mg cimetidine tab 400 mg cimetidine tab 800 mg dicyclomine hcl cap 10 mg dicyclomine hcl oral soln 10 mg/5ml 40 per day dicyclomine hcl tab 20 mg famotidine tab 40 mg FIRST-OMEPRAZOLE SUSPENSION 2 MG/ML omeprazole 300 / 30 days glycopyrrolate tab 1 mg 4 per day glycopyrrolate tab 2 mg 4 per day hyoscyamine sulfate elixir mg/5ml hyoscyamine sulfate soln mg/ml hyoscyamine sulfate tab mg hyoscyamine sulfate tab cr mg (0.125 mg ir/0.25 mg cr) hyoscyamine sulfate tab disp mg hyoscyamine sulfate tab sl mg hyoscyamine sulfate tab sr 12hr mg 4 per day misoprostol tab 100 mcg misoprostol tab 200 mcg omeprazole cap delayed release 20 mg 4 per day GE 133 LAST UPDATED 12/2014

134 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS omeprazole cap delayed release 40 mg 2 per day OMEPRAZOLE+SYRSPEND SF KA SUSPENSION 2 MG/ML omeprazole pb-hyoscy-atrop-scopol elix mg/5ml pb-hyoscy-atrop-scopol tab mg 300 / 30 days ranitidine hcl cap 150 mg 2 per day ranitidine hcl cap 300 mg ranitidine hcl syrup 15 mg/ml (75 mg/5ml) Up to 6 yrs old 20 per day ranitidine hcl tab 150 mg 2 per day ranitidine hcl tab 300 mg 2 per day sucralfate susp 1 gm/10ml 420 / claim Up to 6 yrs old sucralfate tab 1 gm 4 per day Uncategorized Unclassified AEROSN AERO SOLN 80 MCG/ACT flunisolide hfa ORA TCH TW MG/24HR estradiol ORA TCH TW 0.05 MG/24HR estradiol ORA TCH TW MG/24HR estradiol ORA TCH TW 0.1 MG/24HR estradiol 8.9 / 30 days 0.29 per day 0.29 per day 0.29 per day 0.29 per day alprazolam orally disintegrating tab 0.25 mg 2 per day alprazolam orally disintegrating tab 0.5 mg 2 per day GE 134 LAST UPDATED 12/2014

135 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS alprazolam orally disintegrating tab 1 mg 2 per day alprazolam orally disintegrating tab 2 mg 2 per day APIDRA SOLOSTAR SOLN PEN 100 UNIT/ML insulin glulisine 30ml / 30 days azithromycin iv for soln 500 mg 4 per day calcipotriene oint 0.005% 60 / claim carbamazepine cap sr 12hr 200 mg carbidopa & levodopa orally disintegrating tab mg carbidopa & levodopa orally disintegrating tab mg carbidopa & levodopa orally disintegrating tab mg cefadroxil cap 500 mg cefadroxil for susp 250 mg/5ml cefadroxil for susp 500 mg/5ml cefadroxil tab 1 gm clindamycin phosphate foam 1% clobetasol propionate foam 0.05% MPL 1 / claim clobetasol propionate lotion 0.05% MPL 1 / claim clobetasol propionate shampoo 0.05% MPL 1 / claim clonazepam orally disintegrating tab 0.5 mg 4 per day clonazepam orally disintegrating tab 1 mg 4 per day clonazepam orally disintegrating tab 2 mg 4 per day clozapine orally disintegrating tab 100 mg At least 18 yrs old 9 per day clozapine orally disintegrating tab 25 mg At least 18 yrs old 3 per day COMBITCH TCH TW MG/DAY estradiol & norethindrone acetate 8 / 28 days GE 135 LAST UPDATED 12/2014

136 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS COMBITCH TCH TW MG/DAY estradiol & norethindrone acetate 8 / 28 days cyclophosphamide cap 25 mg cyclophosphamide cap 50 mg doxycycline hyclate tab delayed release 100 mg erythromycin pads 2% esterified estrogens & methyltestosterone tab mg esterified estrogens & methyltestosterone tab mg estradiol & norethindrone acetate tab mg estradiol & norethindrone acetate tab mg estradiol td patch weekly mg/24hr 4 / 28 days estradiol td patch weekly mg/24hr (37.5 mcg/24hr) 4 / 28 days estradiol td patch weekly 0.05 mg/24hr 4 / 28 days estradiol td patch weekly 0.06 mg/24hr 4 / 28 days estradiol td patch weekly mg/24hr 4 / 28 days estradiol td patch weekly 0.1 mg/24hr 4 / 28 days estropipate tab 0.75 mg estropipate tab 1.5 mg estropipate tab 3 mg 2 per day GE 136 LAST UPDATED 12/2014

137 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS fluticasone propionate lotion 0.05% MPL 1 / 30 days HUMOG KWIKPEN SOLN PEN 100 UNIT/ML insulin lispro (human) HUMOG MIX 50/50 KWIKPEN SUSP PEN (50-50) 100 UNIT/ML insulin lispro protamine & lispro (human) HUMOG MIX 50/50 PEN SUSP PEN (50-50) 100 UNIT/ML insulin lispro protamine & lispro (human) HUMOG MIX 75/25 KWIKPEN SUSP PEN (75-25) 100 UNIT/ML insulin lispro protamine & lispro (human) HUMOG MIX 75/25 PEN SUSP PEN (75-25) 100 UNIT/ML insulin lispro protamine & lispro (human) HUMOG PEN SOLN PEN 100 UNIT/ML insulin lispro (human) HUMOG SOLN CART 100 UNIT/ML insulin lispro (human) HUMULIN 70/30 KWIKPEN SUSP PEN (70-30) 100 UNIT/ML insulin isophane & reg (human) HUMULIN 70/30 PEN SUSP PEN (70-30) 100 UNIT/ML insulin isophane & reg (human) HUMULIN N KWIKPEN SUSP PEN 100 UNIT/ML insulin isophane (human) HUMULIN N PEN SUSP PEN 100 UNIT/ML insulin isophane (human) 30ml / 30 days 30ml / 30 days 30ml / 30 days 30ml / 30 days 30ml / 30 days 30ml / 30 days 30ml / 30 days 30ml / 30 days 30ml / 30 days 30ml / 30 days 30ml / 30 days ketoconazole foam 2% MPL 1 / claim LANTUS SOLOSTAR SOLN PEN 100 UNIT/ML insulin glargine levothyroxine sodium for inj 200 mcg 30ml / 30 days lidocaine hcl lotion 3% MPL 1 / claim lidocaine patch 5% MPL 1 / claim MINIVELLE TCH TW MG/24HR estradiol 0.29 per day GE 137 LAST UPDATED 12/2014

138 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS minocycline hcl tab 100 mg minocycline hcl tab 50 mg minocycline hcl tab 75 mg morphine sulfate cap sr 24hr 100 mg 2 per day morphine sulfate cap sr 24hr 30 mg 2 per day morphine sulfate cap sr 24hr 60 mg 2 per day NOVOLOG FLEXPEN SOLN PEN 100 UNIT/ML insulin aspart NOVOLOG MIX 70/30 FLEXPEN SUSP PEN (70-30) 100 UNIT/ML insulin aspart protamine & aspart (human) NOVOLOG PENFILL SOLN CART 100 UNIT/ML insulin aspart 30ml / 30 days 30ml / 30 days 30ml / 30 days olanzapine for im inj 10 mg At least 13 yrs old olanzapine orally disintegrating tab 10 mg At least 13 yrs old olanzapine orally disintegrating tab 15 mg At least 13 yrs old olanzapine orally disintegrating tab 20 mg At least 13 yrs old olanzapine orally disintegrating tab 5 mg At least 13 yrs old PREMPHASE TAB MG conjugated estrogens-medroxyprogesterone acetate 28 / 28 days PREMPRO TAB MG conjugated estrogens-medroxyprogesterone acetate PREMPRO TAB MG conjugated estrogens-medroxyprogesterone acetate GE 138 LAST UPDATED 12/2014

139 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS PREMPRO TAB MG conjugated estrogens-medroxyprogesterone acetate PREMPRO TAB MG conjugated estrogens-medroxyprogesterone acetate SPINOSAD SUSPENSION 0.9 % spinosad MFL 120 / 1 claim At least 4 yrs old 2 / 30 days sulfacetamide sodium w/ sulfur foam 10-5% MPL 1 / claim tizanidine hcl cap 2 mg ST tizanidine hcl cap 4 mg ST urea gel 40% MPL 1 / claim URINARY ANTI-INFECTIVES *methenamine-hyos-meth blue-sod phos-phen sal tab 81.6 mg*** methenamine mandelate tab 0.5 gm methenamine mandelate tab 1 gm nitrofurantoin macrocrystalline cap 100 mg nitrofurantoin macrocrystalline cap 50 mg nitrofurantoin monohydrate macrocrystalline cap 100 mg nitrofurantoin susp 25 mg/5ml Up to 6 yrs old 40 per day URINARY ANTISSMODICS bethanechol chloride tab 10 mg bethanechol chloride tab 25 mg bethanechol chloride tab 5 mg bethanechol chloride tab 50 mg flavoxate hcl tab 100 mg oxybutynin chloride syrup 5 mg/5ml 480 / 30 days GE 139 LAST UPDATED 12/2014

140 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS oxybutynin chloride tab 5 mg 3 per day oxybutynin chloride tab sr 24hr 10 mg 2 per day oxybutynin chloride tab sr 24hr 15 mg 2 per day oxybutynin chloride tab sr 24hr 5 mg 2 per day tolterodine tartrate cap sr 24hr 2 mg tolterodine tartrate cap sr 24hr 4 mg tolterodine tartrate tab 1 mg 2 per day tolterodine tartrate tab 2 mg 2 per day trospium chloride tab 20 mg 2 per day VAGIN PRODUCTS clindamycin phosphate vaginal cream 2% 40 / claim ESTRACE CREAM 0.1 MG/GM estradiol vaginal GYNAZOLE-1 CREAM 2 % butoconazole nitrate (one dose) 43 / 30 days metronidazole vaginal gel 0.75% 45 / claim MICONAZOLE 3 SUPPOS 200 MG miconazole nitrate vaginal 3 / claim PREMARIN CREAM MG/GM estrogens, conjugated vaginal 43 / 30 days terconazole vaginal cream 0.4% 45 / claim terconazole vaginal cream 0.8% 20 / claim terconazole vaginal suppos 80 mg 3 / claim VASOPRESSORS epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000) 2 / 30 days EPIPEN JR 2-K SOLN A-INJ 0.15 MG/0.3ML epinephrine 2 / 30 days GE 140 LAST UPDATED 12/2014

141 DRUG DESCRIPTION (RX) /GEN LIMITS & RESTRICTIONS EPIPEN JR SOLN A-INJ 0.15 MG/0.3ML epinephrine midodrine hcl tab 10 mg midodrine hcl tab 2.5 mg midodrine hcl tab 5 mg 2 / 30 days VITAMINS cholecalciferol cap unit 8 / 30 days ergocalciferol cap unit MEPHYTON TAB 5 MG phytonadione GE 141 LAST UPDATED 12/2014

142 Index of covered drugs 1 1st Tier Unifine Pentips 106 1st Tier Unifine Pentips Plus 107 A A Abacavir Sulfate 72,78 Abacavir Sulfate-Lamivudine 73 Abacavir Sulfate-Lamivudine-Zidovudine 72 Abilify 67,68 Abilify Discmelt 67 Acebutolol HCl 79 Acetaminophen 8,9 Acetaminophen w/ Codeine 34,35 Acetaminophen w/ DM 12 Acetaminophen-Isometheptene- Dichloralphenazone 115 Acetazolamide 98 Acetic Acid (Otic) 126 Acetone (Urine) Test 97 Acetylcysteine 89 Acne Medication 5 15 Actonel 99,100 Acyclovir 72,73 Acyclovir Topical 91,97 Adalimumab 32,33 Adrenalin 122 Advair Diskus 42,43 Advair HFA 43 Advocate Insulin Pen Needles 107 Aerospan 134 Albuterol Sulfate 43,45,46 Alcohol Swabs 20 Alendronate Sodium 100 Aler-Dryl 11 Alkeran 65 Allopurinol 103 Almotriptan Malate 115 Alocril 122 Alomide 122 Alora 134 Alprazolam 40,134,135 Alum & Mag Hydrox-Simethicone 9 Aluminum Chloride 91 Aluminum Hydroxide Gel 9,10 Amantadine HCl 66 Amiloride & Hydrochlorothiazide 98 Amiloride HCl 98 Aminocaproic Acid 104 Aminophylline 43 Amiodarone HCl 42 Amitriptyline HCl 49 Amlodipine Besylate 82 Amlodipine Besylate-Benazepril HCl 59,60 Amoxapine 49 Amoxicillin 127 Amoxicillin & Pot Clavulanate 127 Amphetamine-Dextroamphetamine 29 Ampicillin 127 Analpram-HC 38 Anastrozole 65 Androderm 38 Androxy 38 Anthralin 92 Antipyrine-Benzocaine 126 ApexiCon E 91 Apidra 53 Apidra SoloStar 135 Apraclonidine HCl 122,124 Aptivus 73 Arial Chamber 20 Aripiprazole 67,68 Armour Thyroid 131 Artemether-Lumefantrine 64 Artificial Saliva 21 Artificial Tear Ointment 24 Artificial Tear Solution 24 Asacol 102 Ascorbic Acid 27 Aspirin 9 Aspirin Buffered 9 GE 142 LAST UPDATED 12/2014

143 Aspirin Buffered (Cal Carb-Mag Carb-Mag Oxide) 9 Atazanavir Sulfate 76 Atenolol 79 Atenolol & Chlorthalidone 60 Atorvastatin Calcium 58 Atripla 73 Atropine Sulfate (Ophthalmic) 122 Atrovent HFA 43 Augmentin 127 Aurora Unifine Pentips 107 Axert 115 Azasan 78 Azathioprine 78 Azelastine HCl (Ophth) 123 Azithromycin 105,106,135 Azopt 123 B B Complex w/ C 21 B-Complex Vitamins 21,25 B-Complex w/ C & Folic Acid 118 Bacitracin (Ophthalmic) 123 Bacitracin (Topical) 15 Bacitracin Zinc 15 Bacitracin-Polymyxin B 16 Bacitracin-Polymyxin B (Ophth) 123 Baclofen 121 Bactroban Nasal 122 Balsalazide Disodium 102 BD AutoShield 107 BD Insulin Syringe 107 BD Insulin Syringe MicroFine 107 BD Insulin Syringe Ultrafine 107 BD Integra Syringe 108 BD Pen Needle Mini U/F 108 BD Pen Needle Nano U/F 108 BD Pen Needle Ultrafine 108 Benazepril & Hydrochlorothiazide 60 Benazepril HCl 60 Benzonatate 89 Benzoyl Peroxide 15 Benztropine Mesylate 66 Betamethasone Dipropionate (Topical) 91 Betamethasone Dipropionate Augmented 91 Betamethasone Valerate 91 Betaxolol HCl (Ophth) 123 Bethanechol Chloride 139 Bicalutamide 65 Biospec DMX 12 Bisacodyl 19 Bismuth Subsalicylate 10 Bisoprolol & Hydrochlorothiazide 60 Bisoprolol Fumarate 79 Blephamide 123 Blephamide S.O.P. 123 Blood Glucose Calibration 106,114 Blood Glucose Monitoring Supplies 106,114 Boceprevir 77 Brimonidine Tartrate 123 Brintellix 49,50 Brinzolamide 123 Bromocriptine Mesylate 66 Brompheniramine & Phenyleph 12 Brompheniramine & Pseudoeph 12,89 Budesonide (Inhalation) 43,45 Budesonide-Formoterol Fumarate Dihydrate 45 Bumetanide 98 Bupropion HCl 50 Bupropion HCl (Smoking Deterrent) 128 Buspirone HCl 40,41 Busulfan 66 Butalbital-Acetaminophen 34 Butalbital-Acetaminophen-Caffeine 34 Butalbital-Acetaminophen-Caffeine w/ Codeine 35 Butalbital-Aspirin-Caffeine 34 Butalbital-Aspirin-Caffeine w/cod 35 Butoconazole Nitrate (One Dose) 140 C Caffeine Citrate 30 Calcipotriene 91,135 Calcitonin (Salmon) 100 GE 143 LAST UPDATED 12/2014

144 Calcitriol 100 Calcium Acetate (Phosphate Binder) 102 Calcium Carbonate 21 Calcium Carbonate (Antacid) 10 Calcium Carbonate-Cholecalciferol 21 Calcium Carbonate-Vitamin D 21,25 Calcium Polycarbophil 19 Calcium-Cholecalciferol 21 Calcium-Ergocalciferol 21 Camphor & Menthol 15 Capsaicin 15 Captopril 60 Captopril & Hydrochlorothiazide 60 Capzasin-P 15 Carac 92 Carbachol (Ophth) 124 Carbamazepine 47,49,135 Carbamide Peroxide (Otic) 24 Carbidopa 67 Carbidopa-Levodopa 66,135 Carbonyl Iron 17 CareOne Unifine Pentips 108 CareOne Unifine Pentips Plus 108 Carteolol HCl (Ophth) 123 Carvedilol 79,80 Carvedilol Phosphate 80 Castiva Warming 15 Cavan Prenatal/EC Calcium 119 Cefaclor 84 Cefadroxil 135 Cefdinir 84 Cefprozil 84,85 Ceftin 85 Ceftriaxone Sodium 85 Cefuroxime Axetil 85 CeleBREX 31,32 Celecoxib 31,32 CellCept 78 Cephalexin 85 Cetirizine HCl 11,25 Cetirizine-Pseudoephedrine 12 Chantix 128 Chantix Continuing Month Pak 128 Chantix Starting Month Pak 128 Chek-Stix Control 97 Chemet 57 Chemstrip K 97 Chlorambucil 65 Chlordiazepoxide HCl 41 Chlorhexidine Gluconate 12 Chlorhexidine Gluconate (Mouth-Throat) 117 Chloroquine Phosphate 64 Chlorothiazide 98 Chlorpheniramine & Phenylephrine 12 Chlorpheniramine & Pseudoeph 13,89 Chlorpheniramine Maleate 11 Chlorpheniramine Tannate-Phenylephrine Tannate 90 Chlorpheniramine-DM 12,13 Chlorpheniramine-Phenylephrine- Methscopolamine 89,90 Chlorpheniramine-Pseudoephedrine-Acetaminophen12 Chlorpromazine HCl 68 Chlorthalidone 98 Chlorzoxazone 121 Cholecalciferol 25,27,141 Cholestyramine 58 Cholestyramine Light 58 Choline & Mag Salicylate 34 Cilostazol 103 Ciloxan 123 Cimetidine 24,133 Cimetidine HCl 133 Ciprodex 126 Ciprofloxacin HCl 101 Ciprofloxacin HCl (Ophth) 123 Ciprofloxacin-Dexamethasone 126 Citalopram Hydrobromide 50 Clarithromycin 106 Clean & Clear Advantage 3-in-1 15 Clemastine Fumarate 11 Clickfine Pen Needles 108 Clindamycin HCl 39 GE 144 LAST UPDATED 12/2014

145 Clindamycin Palmitate Hydrochloride 39 Clindamycin Phosphate (Topical) 92,135 Clindamycin Phosphate Vaginal 140 Clindamycin Phosphate-Benzoyl Peroxide 92 Clobetasol Propionate 92,135 Clobetasol Propionate Emollient Base 92 Clomipramine HCl 50 Clonazepam 47,135 Clonidine HCl 60 Clopidogrel Bisulfate 103 Clorazepate Dipotassium 41 Clotrimazole (Topical) 15 Clotrimazole Vaginal 26 Clotrimazole w/ Betamethasone 92 Clozapine 68,135 Coal Tar Extract 16 Coartem 64 Codeine Sulfate 35 Colchicine 103 Colchicine w/ Probenecid 103 Colestipol HCl 59 CombiPatch 135,136 Combivent 43 Combivent Respimat 43 Comfort EZ Insulin Syringe 108 Comfort EZ Pen Needles 108 Complera 73 Complete-RF Prenatal 119 CompleteNate 119 Condoms Latex Lubricated - Male 20 Condoms Latex Non-Lubricated - Male 20 Conjugated Estrogens-Medroxyprogesterone Acetate 138,139 Copaxone 128 Coreg CR 80 Cortisone Acetate 88 Creon 97 Crixivan 73 Cromolyn Sodium 44 Cromolyn Sodium (Nasal) 23 Cromolyn Sodium (Ophth) 123 Crotamiton 93 Cuprimine 78 CVS Insulin Syringe 108 CVS Nasal Mist 12 Cyanocobalamin 104 Cyclobenzaprine HCl 121,122 Cyclogyl 123 Cyclopentolate HCl 123 Cyclophosphamide 65,136 Cyclosporine 78,79 Cyclosporine Modified (For Microemulsion) 78 Cyproheptadine HCl 58 D Dallergy 90 Dallergy PE 90 Dapsone 39 Darunavir Ethanolate 75,76 Dehistine 90 Delavirdine Mesylate 76 Deltuss DMX 90 Delzicol 102 Depo-SubQ Provera Dermatological Products, Misc. 25 Desipramine HCl 50 Desmopressin Acetate 100 Desmopressin Acetate Refrigerated 100 Desmopressin Acetate Spray 100 Desmopressin Acetate Spray Refrigerated 100 Desogestrel & Ethinyl Estradiol 85 Desogestrel-Ethinyl Estradiol (Biphasic) 85 Desogestrel-Ethinyl Estradiol (Triphasic) 85 Desonide 92 Desoximetasone 92 Dexamethasone 88 Dexamethasone Intensol 88 Dexamethasone Sodium Phosphate 88 Dexamethasone Sodium Phosphate (Ophth) 123 Dexchlorpheniramine Maleate 58 Dextroamphetamine Sulfate 30 Dextromethorphan Polistirex 12 GE 145 LAST UPDATED 12/2014

146 Dextromethorphan-Doxylamine-Acetaminophen 12 Dextromethorphan-Guaifenesin 12,13 Dextromethorphan-Phenylephrine-Acetaminophen 13 Dextrose (Diabetic Use) 10 Diaphragm Arc-Spring 112 Diazepam 41 Diazepam (Anticonvulsant) 47 Dibucaine 16 Dibucaine (Rectal) 16 Diclofenac Potassium 32 Diclofenac Sodium 32 Diclofenac Sodium (Ophth) 123 Dicloxacillin Sodium 128 Dicyclomine HCl 133 Didanosine 73,77 Diflorasone Diacetate 92 Diflorasone Diacetate Emollient Base 91 Diflunisal 34 Digoxin 84 Dihydroergotamine Mesylate 115 Dilantin 47 Diltiazem HCl 82,83 Diltiazem HCl Coated Beads 82 Diltiazem HCl Extended Release Beads 82,83 Dimenhydrinate 10,11 Dimetapp Long Act Cough/Cold 13 Diphenhydramine HCl 11,58 Diphenhydramine HCl (Sleep) 11,18,25 Diphenhydramine HCl (Topical) 16 Diphenhydramine-Acetaminophen (sleep) 22 Diphenoxylate w/ Atropine 56 Dipyridamole 103 Disopyramide Phosphate 42 Disulfiram 128 Divalproex Sodium 47 Docusate Sodium 19 Dofetilide 42 Donepezil Hydrochloride 128,129 Dorzolamide HCl 123 Dorzolamide HCl-Timolol Maleate 123 Doxazosin Mesylate 61 Doxepin HCl 50,51 Doxycycline Hyclate 131,136 Doxylamine Succinate (Sleep) 18 Dramamine 11 Dritho-Creme HP 92 Drospirenone-Ethinyl Estradiol 86 Droxia 104 Drug Mart Unifine Pentips 108 Dulera 44 Dutoprol 61 Dyphylline 44 E Easy Comfort Insulin Syringe 109 Easy Comfort Pen Needles 109 Easy Touch Insulin Safety Syr 109 Easy Touch Insulin Syringe 109 Easy Touch Pen Needles 109 Econazole Nitrate 92 Edurant 73 Efavirenz 76,77 Efavirenz-Emtricitabine-Tenofovir Disoproxil Fumarate 73 Effient 103 Eletriptan Hydrobromide 115 Elidel 92 Ella 86 Elmiron 102 Elvitegravir-Cobicistat-Emtricitabine-Tenofovir 76 Emollient 15 Emtricitabine 73 Emtricitabine-Rilpivirine-Tenofovir Disoproxil Fumarate 73 Emtricitabine-Tenofovir Disoproxil Fumarate 77 Emtriva 73 Enalapril Maleate 61 Enalapril Maleate & Hydrochlorothiazide 61 Enbrel 32 Enbrel SureClick 32 Encare 26 Enoxaparin Sodium 46 GE 146 LAST UPDATED 12/2014

147 Epifoam 93 Epinephrine 140,141 Epinephrine HCl (Nasal) 122 EpiPen Jr 141 EpiPen Jr 2-Pak 140 Epivir 73 Epzicom 73 Ergocalciferol 141 Ergoloid Mesylates 129 Ergotamine w/ Caffeine 115 Ery-Tab 106 EryPed Erythromycin (Acne Aid) 93,136 Erythromycin (Ophth) 123 Erythromycin Base 106 Erythromycin Base (Coated) 106 Erythromycin Ethylsuccinate 106 Erythromycin-Sulfisoxazole 39 Escavite LQ 119 Escitalopram Oxalate 51 Esterified Estrogens & Methyltestosterone 136 Estrace 140 Estradiol 80,134,136,137 Estradiol & Norethindrone Acetate 135,136 Estradiol Vaginal 140 Estrogens, Conjugated 81 Estrogens, Conjugated Vaginal 140 Estropipate 136 Etanercept 32 Ethambutol HCl 64,65 Ethionamide 65 Ethosuximide 47 Ethynodiol Diacet & Eth Estrad 86,88 Etodolac 32 Etonogestrel-Ethinyl Estradiol 88 Etravirine 73,74 Eurax 93 Exelon 129 Exemestane 65 Extavia 129 F Famotidine 25,133 Fareston 65 Felbamate 47 Felodipine 83 Fenofibrate 59 Fenofibrate Micronized 59 Fentanyl 35 Ferrous Fumarate 18 Ferrous Fumarate-FA-B Complex-C-Zn-Mg-Mn-Cu 104 Ferrous Gluconate 18 Ferrous Sulfate 18 Ferrous Sulfate Dried 18 Fexofenadine HCl 11,58 Fifty50 Pen Needles 109 Finasteride 103 First-Omeprazole 133 Flavoxate HCl 139 Flecainide Acetate 42 Flovent Diskus 44 Flovent HFA 44 Fluconazole 57 Fludrocortisone Acetate 88 Flunisolide (Nasal) 122 Flunisolide HFA 134 Fluocinolone Acetonide 93 Fluocinolone Acetonide (Otic) 126 Fluocinonide 93 Fluocinonide Emulsified Base 93 Fluorometholone (Ophth) 123,124 Fluorouracil (Topical) 92,93 Fluoxetine HCl 51 Fluoxymesterone 38 Fluphenazine Decanoate 68 Fluphenazine HCl 68,69 Flura-Drops 116 Flurazepam HCl 104 Flurbiprofen 32 Flurbiprofen Sodium 123 Flutamide 65 GE 147 LAST UPDATED 12/2014

148 Fluticasone Propionate 93,137 Fluticasone Propionate HFA 44 Fluticasone Propionate (Inhalation) 44 Fluticasone Propionate (Nasal) 122 Fluticasone-Salmeterol 42,43 Fluvoxamine Maleate 51 FML 124 Folic Acid 18 Foradil Aerolizer 44 Formaldehyde 72 Formoterol Fumarate 44 Fosamprenavir Calcium 74 Fosinopril Sodium 61 Fosinopril Sodium & Hydrochlorothiazide 61 Freds Pharmacy Unifine Pentip+ 109 Freds Pharmacy Unifine Pentips 109 Furosemide 98,99 G Gabapentin 47,48 Gabitril 48 Galantamine Hydrobromide 129 Gauze Pads & Dressings 20 Gemfibrozil 59 Gentamicin Sulfate (Ophth) 124 Gentamicin Sulfate (Topical) 93 Gentamicin-Prednisolone Acetate 125 Gesticare 119 Ginger (Zingiber officinalis) 8 Glatiramer Acetate 128 Glimepiride 54 Glipizide 54 Glipizide-Metformin HCl 54 Global Ease Inject Pen Needles 110 Global Inject Ease Insulin Syr 110 GlucaGen 54 GlucaGen HypoKit 54 Glucagon (rdna) 54 Glucagon Emergency 54 Glucagon HCl (rdna) 54 GlucoPro Insulin Syringe 110 Glucose Blood 97 Glucose Polymer 23 Glyburide 54 Glyburide Micronized 54 Glyburide-Metformin 54 Glycerin (Laxative) 19 Glycopyrrolate 133 Griseofulvin Microsize 57 Griseofulvin Ultramicrosize 57 Guaifenesin 13 Guaifenesin-Codeine 13,90 Guanabenz Acetate 61 Guanfacine HCl 61 Gynazole Gynol II 26 H H-E-B incontrol Pen Needles 110 Halobetasol Propionate 93 Haloperidol 69 Haloperidol Decanoate 69 Haloperidol Lactate 69 HealthWise Unifine Pentips 110 Healthy Accents Unifine Pentip 110 Hemangeol 80 Heparin Sodium (Porcine) 46 Hibiclens 12 Homatropine HBr 124 HumaLOG 55,137 HumaLOG KwikPen 137 HumaLOG Mix 50/50 54 HumaLOG Mix 50/50 KwikPen 137 HumaLOG Mix 50/50 Pen 137 HumaLOG Mix 75/25 54 HumaLOG Mix 75/25 KwikPen 137 HumaLOG Mix 75/25 Pen 137 HumaLOG Pen 137 Humira 32 Humira Pen 33 HumuLIN 70/30 55 HumuLIN 70/30 KwikPen 137 GE 148 LAST UPDATED 12/2014

149 HumuLIN 70/30 Pen 137 HumuLIN N 55 HumuLIN N KwikPen 137 HumuLIN N Pen 137 HumuLIN R 55 Hy-Vee Insulin Syringe 110 Hydralazine HCl 61,62 Hydrochlorothiazide 99 Hydrocodone w/ Homatropine 90 Hydrocodone-Acetaminophen 35,36 Hydrocortisone 88 Hydrocortisone (Intrarectal) 39 Hydrocortisone (Rectal) 39 Hydrocortisone (Topical) 16,25,26,94 Hydrocortisone Acetate (Rectal) 39 Hydrocortisone Acetate (Topical) 25 Hydrocortisone Acetate w/ Pramoxine 38,39 Hydrocortisone Butyrate 93,94 Hydrocortisone Valerate 94 Hydrocortisone w/acetic Acid 126 Hydrocortisone-Aloe Vera 16 Hydromorphone HCl 36 Hydroquinone 94 Hydroxychloroquine Sulfate 64 Hydroxyurea 65 Hydroxyurea (Sickle Cell Anemia) 104 Hydroxyzine HCl 41 Hydroxyzine Pamoate 41 Hyoscyamine Sulfate 133 HyperRHO S/D 126 Hypromellose (Ophth) 24 I Ibuprofen 8,33 Imipramine HCl 51 Imiquimod 94 Incivek 73 Indapamide 99 Indinavir Sulfate 73 Indomethacin 33 Inspirease Bags 111 Inspirease Mouthpiece 111 Inspirease Reservoir Bags 111 Insulin Aspart 56,138 Insulin Aspart Protamine & Aspart (Human) 56,138 Insulin Glargine 55,137 Insulin Glulisine 53,135 Insulin Isophane & Reg (Human) 10,55,56,137 Insulin Isophane (Human) 10,55,56,137 Insulin Lispro (Human) 55,137 Insulin Lispro Protamine & Lispro (Human) 54,137 Insulin Pen Needle 106,107,108,109,110,111,112,113,114,115 Insulin Regular (Human) 10,55,56 Insulin Syringe/Needle 111 Insulin Syringe/Needle U ,108,109,110,111,112,113,114,115 Insulin Syringes (Disposable) 111 Insupen Pen Needles 111 Insupen Sensitive 111 Insupen Ultrafin 111 Intelence 73,74 Interferon Beta-1b 129 Invirase 74 Iopidine 124 Ipratropium Bromide 44 Ipratropium Bromide (Nasal) 122 Ipratropium Bromide HFA 43 Ipratropium-Albuterol 43,44 Irbesartan 62 Irbesartan-Hydrochlorothiazide 62 Iron 18 Isentress 74 Isoniazid 65 Isopto Carbachol 124 Isopto Homatropine 124 Isosorbide Dinitrate 39,40 Isosorbide Mononitrate 40 Isotretinoin 94 Itraconazole 57 GE 149 LAST UPDATED 12/2014

150 J Jentadueto 55 K Kaletra 74 Keralyt 16 KetoCare 97 Ketoconazole (Topical) 94,137 Ketone Blood Test 17 Ketoprofen 33 Ketorolac Tromethamine 33 Ketorolac Tromethamine (Ophth) 124 Ketostix 97 Ketotifen Fumarate (Ophth) 24 Kimono Micro Thin 20 Klor-Con M Kombiglyze XR 55 KPN Prenatal 22 L Labetalol HCl 80 Lactic Acid (Ammonium Lactate) 16 Lactulose 105 Lactulose (Encephalopathy) 102 Lamivudine 73,74 Lamivudine-Zidovudine 74 Lamotrigine 48 Lancet Devices 106 Lancets 106 Lanolin 24 Lanolin (Topical) 24 Lansoprazole 25 Lantus 55 Lantus SoloStar 137 Latanoprost 124 Leader Unifine Pentips 111 Leader Unifine Pentips Plus 111 Leflunomide 33 Letrozole 65 Leucovorin Calcium 65 Leukeran 65 Levetiracetam 48 Levobunolol HCl 124 Levocarnitine (Metabolic Modifiers) 100 Levofloxacin 101 Levonorgestrel & Eth Estradiol 86 Levonorgestrel (Emergency OC) 12,86 Levonorgestrel-Eth Estradiol (Triphasic) 86 Levonorgestrel-Ethinyl Estradiol (91-Day) 86 Levothyroxine Sodium 131,137 Lexiva 74 Licide Treatment 16 Lidocaine 94,137 Lidocaine HCl 16,94,137 Lidocaine HCl (Mouth-Throat) 117 Lidocaine-Prilocaine 94 Linagliptin 56 Linagliptin-Metformin HCl 55 Liothyronine Sodium 132 Liotrix (T3-T4) 132 Lisinopril 62 Lisinopril & Hydrochlorothiazide 62 Lite Touch Pen Needles 111 Litetouch Pen Needles 111 Lithium 69 Lithium Carbonate 69 Little Remedies for Colds 13 Lodoxamide Tromethamine 122 LoHist-D 13 Loperamide HCl 10 Lopinavir-Ritonavir 74 Loratadine 11,12 Loratadine & Pseudoephedrine 13 Lorazepam 41 Losartan Potassium 62 Losartan Potassium & Hydrochlorothiazide 62 Lovastatin 59 Loxapine Succinate 69 Lufyllin 44 GE 150 LAST UPDATED 12/2014

151 M Magnesium Citrate 19 Magnesium Hydroxide 19 Magnesium Oxide 10 Magnesium Oxide (Mg Supplement) 21 Malathion 94 Maprotiline HCl 51 Maraviroc 76 Meclizine HCl 11 Medroxyprogesterone Acetate 128 Medroxyprogesterone Acetate (Contraceptive) 85,86 Mefloquine HCl 64 Megestrol Acetate 65,66 Melatonin 8,26 Meloxicam 33,40 Melphalan 65 Memantine HCl 129,130 Meperidine HCl 36 Mephyton 141 Meprobamate 41,42 Mercaptopurine 66 Mesalamine 102 Mestinon 64 Metaproterenol Sulfate 44 Metformin HCl 55 Methadone HCl 36 Methazolamide 99 Methenamine Mandelate 139 Methenamine-Hyosc-Methylene Blue-Sod Phos-Phenyl Sal 139 Methimazole 132 Methitest 38 Methocarbamol 122 Methotrexate Sodium 66 Methotrexate Sodium (Antirheumatic) 34 Methyldopa 62 Methylergonovine Maleate 126 Methylphenidate HCl 30,31 Methylphenidate HCl ER 30,31 Methylprednisolone 88 Methyltestosterone 38 Metipranolol 124 Metoclopramide HCl 102 Metolazone 99 Metoprolol & Hydrochlorothiazide 61,62,63 Metoprolol Succinate 80 Metoprolol Tartrate 80 Metronidazole 39 Metronidazole (Topical) 95 Metronidazole Vaginal 140 Mexiletine HCl 42 Miacalcin 100 Miconazole Miconazole Nitrate (Topical) 16,26 Miconazole Nitrate Vaginal 26,140 Midodrine HCl 141 Millipred 89 Milnacipran HCl 130 Minivelle 137 Minocycline HCl 131,138 Minoxidil 63 Mirtazapine 52 Misoprostol 133 Mission Prenatal 22 Mission Prenatal FA 22 Mission Prenatal HP 22 Mometasone Furoate 95 Mometasone Furoate (Nasal) 122 Mometasone Furoate-Formoterol Fumarate Dihydrate 44 Monoject Insulin Syringe 112 Montelukast Sodium 44 Morphine Sulfate 36,37,138 Moxifloxacin HCl (Ophth) 126 Mucinex Maximum Strength 13 Multiple Vitamin 21 Multiple Vitamins w/ Iron 21 Multiple Vitamins w/ Minerals 18,22,23,25 Mupirocin 95 Mupirocin Calcium 122 Mupirocin Calcium (Topical) 95 GE 151 LAST UPDATED 12/2014

152 Mycophenolate Mofetil 78,79 Mycophenolate Sodium 79 Myleran 66 Mynatal 119 Mynate 90 Plus 119 N Nabumetone 33 Nadolol 80 Naltrexone HCl 57 Namenda 129 Namenda Titration Pak 129 Namenda XR 130 Naphazoline w/ Pheniramine 24 Naproxen 33 Naproxen Sodium 8,26,33 Nasonex 122 NataChew 119 Natal-V RX 119 Natalvit 120 Nature-Throid 132 Necon 1/50 (28) 86 Necon 10/11 (28) 86 Nedocromil Sodium (Ophth) 122 Nefazodone HCl 52 Nelfinavir Mesylate 77 Neomycin Sulfate 31 Neomycin-Bacitracin Zn-Polymyxin 124 Neomycin-Bacitracin-Polymyxin 15 Neomycin-Polymy-Dexameth 124 Neomycin-Polymyx-Pred Acetate 125 Neomycin-Polymyxin w/ Pramoxine 16 Neomycin-Polymyxin-Gramicidin 124 Neomycin-Polymyxin-HC (Ophth) 124 Neomycin-Polymyxin-HC (Otic) 126 Nepafenac 124 Nessi Spacer with Mask Large 20 Nessi Spacer with Mask Sm/Med 20 Nessi Spacer with Mouthpiece 20 Nevanac 124 Nevirapine 74 Niacin 27 Niacin (Antihyperlipidemic) 59 Niacor 59 Nicardipine HCl 83 Nicotine 24 Nicotine Polacrilex 24 Nifedipine 83 Nit Remover 17 Nitro-Bid 40 Nitrofurantoin 139 Nitrofurantoin Macrocrystal 139 Nitrofurantoin Monohyd Macro 139 Nitroglycerin 40 Nix Lice Control 16 Nonoxynol-9 26,27 Norditropin 101 Norditropin FlexPro 100,101 Norditropin NordiFlex Pen 101 Norelgestromin-Ethinyl Estradiol 86 Norethin Acet & Estrad-Fe 87 Norethindrone & Eth Estradiol 87 Norethindrone & Mestranol 86,87 Norethindrone (Contraceptive) 87 Norethindrone Acet & Eth Estra 87 Norethindrone Acetate 128 Norethindrone-Eth Estradiol (Biphasic) 86 Norethindrone-Eth Estradiol (Triphasic) 87 Norgestimate-Ethinyl Estradiol 87 Norgestimate-Ethinyl Estradiol (Triphasic) 87 Norgestrel & Ethinyl Estradiol 87,88 Norinyl 1+50 (28) 87 Norpace CR 42 Nortriptyline HCl 52 Norvir 74 Nova Max Plus Ketone Test 17 NovoFine 112 NovoFine Autocover 112 NovoLIN 70/30 55 NovoLIN 70/30 Innolet 10 NovoLIN 70/30 ReliOn 55 NovoLIN N 56 GE 152 LAST UPDATED 12/2014

153 NovoLIN N Innolet 10 NovoLIN N PenFill 10 NovoLIN N ReliOn 55 NovoLIN R 56 NovoLIN R InnoLet 10 NovoLIN R PenFill 10 NovoLIN R ReliOn 56 NovoLOG 56 NovoLOG FlexPen 138 NovoLOG Mix 70/30 56 NovoLOG Mix 70/30 FlexPen 138 NovoLOG PenFill 138 NovoTwist 112 Nutricion Porvida 22 NuvaRing 88 Nystatin 57 Nystatin (Mouth-Throat) 117 Nystatin (Topical) 91,95 Nystatin-Triamcinolone 95 O O-Cal Prenatal 120 Ofloxacin 102 Ofloxacin (Ophth) 124 Ofloxacin (Otic) 126 Ogestrel 88 Olanzapine 69,70,138 Omega-3 Fatty Acids 23,25 Omeprazole 25,133,134 Omeprazole Magnesium 25 Omeprazole+Syrspend SF Alka 134 Ondansetron 57 Ondansetron HCl 57 Onglyza 56 OptiChamber Face Mask-Large 20 OptiChamber Face Mask-Medium 20 OptiChamber Face Mask-Small 20 Options Gynol II Contraceptive 26 Oral Electrolytes 20 Ortho Diaphragm All-Flex 112 Oseltamivir Phosphate 77 Oxaprozin 33 Oxazepam 42 Oxcarbazepine 48 Oxybutynin Chloride 139,140 Oxycodone HCl 37,38 Oxycodone w/ Acetaminophen 37,38 Oxycodone-Aspirin 37 OxyCONTIN 37,38 Oyster Shell 21 P Pancreaze 98 Pancrelipase (Lipase-Protease-Amylase) 97,98 Papaverine HCl 84 Paregoric 57 Paroxetine HCl 52 Parva-Cal 21 PC Unifine Pentips 112 PCE 106 Ped Multivitamins w/fl & Iron 118,119 Pediatric Multiple Vitamin w/ C 22 Pediatric Multiple Vitamin w/ C & FA 22 Pediatric Multiple Vitamins w/ Iron 22 Pediatric Multivitamins w/fl 118 Pediatric Vitamins ACD Fluoride & Iron 118 Pediatric Vitamins ACD w/ Fluoride 118 Pediatric Vitamins ACD w/ Iron 22 Pediatric Vitamins ADC 22 PEG 3350-KCl-Sod Bicarb-Sod Chloride-Sod Sulfate 105 PEG 3350-Potassium Chloride-Sod Bicarbonate-Sod Chloride 105 Peg-Intron 74,75 Peg-Intron Redipen 75 Peg-Intron Redipen Pak 4 75 Pegasys 75 Pegasys ProClick 75 Peginterferon alfa-2a 75 Peginterferon alfa-2b 74,75 Pen Needles 3/16" 112 Pen Needles 5/16" 112 GE 153 LAST UPDATED 12/2014

154 Penicillamine 78 Penicillin V Potassium 128 Pentasa 102 Pentosan Polysulfate Sodium 102 Pentoxifylline 104 Permethrin 16,95 Permethrin & Pyrethrins-Piperonyl Butoxide 16 Perphenazine 70 Perphenazine-Amitriptyline 130 Perry Prenatal 23 Phenazopyridine HCl 103 Phenelzine Sulfate 52 Phenobarbital 104,105 Phenobarbital-Hyoscyamine-Atropine-Scopolamine 134 Phenyleph-Promethazine w/ Cod 90 Phenylephrine HCl (Ophth) 124 Phenylephrine HCl (Oral) 23 Phenylephrine-Chlorphen-DM 13,14,90 Phenylephrine-Chlorpheniramine w/ DM-GG 90 Phenylephrine-DM 14 Phenylephrine-Guaifenesin 14 Phenylephrine-Pyrilamine-DM 14 Phenylephrine-Shark Liver Oil-Cocoa Butter 9 Phenylephrine-Shark Liver Oil-Mineral Oil-Petrolatum 9 Phenytoin 48 Phenytoin Sodium Extended 47,48 Phrenilin Forte 34 Phytonadione 141 Pilocarpine HCl 125 Pilocarpine HCl (Oral) 117 Pimecrolimus 92 Pin-X 10 Pindolol 81 Pioglitazone HCl 56 Pioglitazone HCl-Metformin HCl 56 Piroxicam 33,34 PNV Prenatal Plus Multivitamin 23 Podofilox 95 Poly-Pred 125 Polycose 23 Polyethylene Glycol Polymyxin B-Trimethoprim 125 Polysaccharide Iron Complex 18 Polysporin 16 Polyvinyl Alcohol 24 Pot Phosphate Monobasic w/ Sod Phosphate Dibasic & Monobasic 117 Potassium Bicarbonate 117 Potassium Chloride 117 Potassium Chloride Microencapsulated Crystals CR 116,117 Potassium Citrate (Alkalinizer) 103 Potassium Citrate-Citric Acid 103 Potassium Iodide 117 Pramoxine HCl (Rectal) 9 Pramoxine-Chloroxylenol 126 Pramoxine-HC 39,93 Pramoxine-HC-Chloroxylenol 126 Pramoxine-HC-Chloroxylenol Aqueous 126 Prasugrel HCl 103 Pravastatin Sodium 59 Prazosin HCl 63 Precision Sure-Dose Syringe 112 Precision Xtra Ketone 17 Pred Mild 125 Pred-G 125 Prednicarbate 95 Prednisolone 89 Prednisolone Acetate (Ophth) 125 Prednisolone Sodium Phosphate 89 Prednisolone Sodium Phosphate (Ophth) 125 Prednisone 89 PredniSONE Intensol 89 Preferred Plus Unifine Pentips 112 Premarin 81,140 Premphase 138 Prempro 138,139 PrenaFirst 120 Prenatabs FA 120 Prenatabs Rx 120 Prenatal Prenatal Multivit-Min w/fe-fa 22,119 GE 154 LAST UPDATED 12/2014

155 Prenatal Plus Iron 120 Prenatal Vit w/ Docusate-Fe Fumarate-Folic Acid 118,119,120,121 Prenatal Vit w/ Ferrous Fumarate-Folic Acid 22,23,118,119,120,121 Prenatal Vit w/ Ferrous Gluconate-Folic Acid 22 Prenatal Vit w/ Iron Carbonyl-Fe Gluconate-Folic Acid 121 Prenatal Vit w/ Iron Carbonyl-Folic Acid 119,120,121 Prenatal Vit w/ Selenium-Fe Fumarate-Folic Acid 121 Prenatal without A Vit w/ Fe Fumarate-Folic Acid 119 Prenatal without A Vit w/ Iron Carbonyl-Folic Acid 121 Prenatal without A w/ Fe Carbonyl-Docusate-Folic Acid 119 PreserVision AREDS 23 Prezista 75,76 PriLOSEC OTC 25 Primaquine Phosphate 64 Primidone 48 ProAir HFA 45 Probenecid 103 Prochlorperazine 70 Prochlorperazine Maleate 70 Prodigy Mini Pen Needles 113 Progesterone Micronized 128 Promethazine & Phenylephrine 90 Promethazine HCl 58 Promethazine w/codeine 90 Promethazine-DM 90 Propafenone HCl 42 Propranolol & Hydrochlorothiazide 63 Propranolol HCl 80,81 Propylthiouracil 132 Protopic 95 Proventil HFA 45 Pseudoephed-Bromphen-DM 14,90 Pseudoephed-Doxyl-DM w/ap 14 Pseudoephedrine HCl 23 Pseudoephedrine w/ Codeine-GG 14 Pseudoephedrine w/ DM-GG 14 Pseudoephedrine-Acetaminophen- Dextromethorphan 14 Pseudoephedrine-Chlorphen-DM 14 Pseudoephedrine-Guaifenesin 14 Pseudoephedrine-Ibuprofen 14 Pseudoephedrine-Methscopolamine 90 Psyllium 19 PTS Panels Ketone Test 17 Pulmicort 45 Pulmicort Flexhaler 45 PX Insulin Syringe 113 Pyrantel Pamoate 10 Pyrazinamide 65 Pyrethrins-Piperonyl Butoxide 15,16,17 Pyrethrins-Piperonyl Butoxide-Permethrin-Nit Remover 17 Pyridostigmine Bromide 64 Pyridoxine HCl 28 Pyrithione Zinc 26 Q QC Unifine Pentips 113 Quetiapine Fumarate 70 Quinapril HCl 34,63 Quinidine Gluconate 42 Quinidine Sulfate 42 R RA Calcium Hi-Cal/Vitamin D 21 RA Pen Needles 113 Raloxifene HCl 101 Raltegravir Potassium 74 Ramipril 63 Ranitidine HCl 25,134 Rapamune 79 RE Prenatal Multivitamin/Iron 120 RE-Nata 29 OB 121 Relenza Diskhaler 76 ReliOn 70/30 56 ReliOn Ketone 97 ReliOn N 56 GE 155 LAST UPDATED 12/2014

156 ReliOn Pen Needles 113 ReliOn R 56 Relpax 115 Rescriptor 76 Reserpine 63 Respiratory Therapy Supplies 20 Reyataz 76 Rheumatrex 34 Rho D Immune Globulin (Human) 126,127 RhoGAM Ultra-Filtered Plus 127 Riboflavin 28 Rifampin 65 Rilpivirine HCl 73 Rimexolone 126 Risedronate Sodium 99,100 Risperidone 70,71 Ritonavir 74 Rivaroxaban 46 Rivastigmine 129 Rivastigmine Tartrate 129,130 Ropinirole Hydrochloride 67 Roxicet 38 S Salicylic Acid 16,17 Saline 12,23 Salmeterol Xinafoate 45 Salsalate 34 Saquinavir Mesylate 74 Savella 130 Savella Titration Pack 130 Saxagliptin HCl 56 Saxagliptin-Metformin HCl 55 SchoolTime Shampoo 17 Se-Natal Se-Natal Selegiline HCl 67 Selenium Sulfide 17,95 Selzentry 76 Senna 19 Sennosides 19,26 Sennosides-Docusate Sodium 19 Serevent Diskus 45 Sertraline HCl 52,53 SfRowasa 102 Shopko Unifine Pentips 113 Silver Sulfadiazine 95 Simethicone 17 SimplyThick 24 Simvastatin 59 Sirolimus 79 Skin Protectants, Misc. 15 Soap & Cleansers 15 Sodium Bicarbonate (Antacid) 10 Sodium Chloride 91,103 Sodium Chloride (GU Irrigant) 103 Sodium Chloride (Inhalant) 14,91 Sodium Chloride Flush 91 Sodium Citrate & Citric Acid 103 Sodium Fluoride 116,117 Sodium Fluoride (Dental) 21,117 Sodium Phosphates 18 Sodium Polystyrene Sulfonate 78,79 Somatropin 100,101 Sorbitol 20 Sorbitol (Laxative) 20 Sotalol HCl 81,82 Sotalol HCl (AFIB/AFL) 81 Spacer/Aerosol-Holding Chamber Supplies - Bags 111 Spacer/Aerosol-Holding Chamber Supplies - Mouthpieces 111 Spacer/Aerosol-Holding Chambers 20 Spinosad 139 Spiriva HandiHaler 45 Spironolactone 99 Spironolactone & Hydrochlorothiazide 99 SSKI 117 Stannous Fluoride 21,118 Stavudine 76 Stribild 76 Succimer 57 Sucralfate 134 GE 156 LAST UPDATED 12/2014

157 Sulfacetamide Sod-Prednisolone 123,125 Sulfacetamide Sodium 95,96 Sulfacetamide Sodium (Acne) 95 Sulfacetamide Sodium (Ophth) 125 Sulfacetamide Sodium w/ Sulfur 96,139 Sulfacetamide Sodium-Urea 96 Sulfacetamide-Prednisolone 125 Sulfamethoxazole-Trimethoprim 39 Sulfasalazine 102 Sulindac 34 Sumatriptan 116 Sumatriptan Succinate 116 Sure Comfort Insulin Syringe 113 Sure Comfort Pen Needles 113 Sure-Fine Pen Needles 113,114 Sustiva 76,77 Symbicort 45 T Tacrolimus 79 Tacrolimus (Topical) 95 Tamiflu 77 Tamoxifen Citrate 66 Tamsulosin HCl 103 Tazarotene 96 Tazorac 96 TEGretol-XR 49 Telaprevir 73 Temazepam 105 Tenofovir Disoproxil Fumarate 77,78 Terazosin HCl 63 Terbinafine HCl 57 Terbinafine HCl (Topical) 17 Terbutaline Sulfate 45 Terconazole Vaginal 140 Terumo Insulin Syringe 114 Testosterone 38 Testosterone Cypionate 38 Tetracycline HCl 131 Tetrahydrozoline HCl (Ophth) 24 Tev-Tropin 101 Theo Theophylline 45,46 TheraNatal Core Nutrition 23 Thiamine HCl 28 Thiamine Mononitrate 28 Thinpro Insulin Syringe 114 Thioridazine HCl 71,72 Thiothixene 72 Thyroid 131,132,133 Thyrolar Thyrolar-1/2 132 Thyrolar-1/4 132 Thyrolar Thyrolar Tiagabine HCl 48,49 Tikosyn 42 Timolol Maleate 82 Timolol Maleate (Ophth) 125 Timoptic Ocudose 125 Tioconazole Vaginal 26 Tiotropium Bromide Monohydrate 45 Tipranavir 73 Tizanidine HCl 122,139 TobraDex 125 Tobramycin (Ophth) 125,126 Tobramycin-Dexamethasone 125,126 Tobrex 126 Tolmetin Sodium 34 Tolnaftate 17,26 Tolterodine Tartrate 140 Topiramate 49 Toremifene Citrate 65 Torsemide 99 Tradjenta 56 Tramadol HCl 38 Tramadol-Acetaminophen 38 Trandolapril 63 Tranexamic Acid 104 Tranylcypromine Sulfate 53 Trazodone HCl 53 Trecator 65 GE 157 LAST UPDATED 12/2014

158 Tretinoin 96 Trexall 66 Triamcinolone Acetonide (Mouth) 118 Triamcinolone Acetonide (Nasal) 122 Triamcinolone Acetonide (Topical) 96,97 Triaminic Cold/Cough Day Time 14 Triamterene & Hydrochlorothiazide 99 Triazolam 105 Trifluoperazine HCl 72 Trifluridine 126 Trihexyphenidyl HCl 67 Trimethoprim 39 Tropicamide 126 Trospium Chloride 140 TRUEresult Blood Glucose 114 TRUEtest Test 97 TrueTrack Glucose Control 114 TrueTrack Test 97 Trustex Non-Lubricated 20 Trustex Ria Non-Lubricated 20 Truvada 77 U Ulipristal Acetate 86 UltiCare Insulin Syringe 114 UltiCare Micro Pen Needles 114 UltiCare Pen Needles 114 Ultilet Insulin Syringe 114 Ultra Comfort Insulin Syringe 114,115 Ultra-Thin II Mini Pen Needle 115 Ultra-Thin II Pen Needles 115 Unifine Pentips 115 Unifine Pentips Plus 115 Urea 97,139 Ursodiol 102 V Valacyclovir HCl 77 Valcyte 77 Valganciclovir HCl 77 Valproate Sodium 49 Valproic Acid 49 Valsartan 63,64 Valsartan-Hydrochlorothiazide 64 Vancomycin HCl 39 VanishPoint Insulin Syringe 115 Varenicline Tartrate 128 VCF Vaginal Contraceptive 27 Venatal-FA 121 Venlafaxine HCl 53 Venlafaxine HCl ER 53 Ventolin HFA 46 Verapamil HCl 83,84 Veripred Vexol 126 Victrelis 77 Vida Mia Unifine Pentips 115 Videx 77 Vigamox 126 Viibryd 53 Vilazodone HCl 53 Vinate Calcium 121 Vinate M 121 Viracept 77 Viread 77,78 Vitamin E 26,28 Vitamins w/ Lipotropics 22 VitaSpire 121 Vol-Tab Rx 121 Vortioxetine HBr 49,50 W Warfarin Sodium 46 Wegmans Unifine Pentips Plus 115 Westhroid 132 Westhroid-P 132,133 White Petrolatum-Mineral Oil 24 WP Thyroid 133 X Xanthan Gum (Thickening) 24 Xarelto 46 GE 158 LAST UPDATED 12/2014

159 Z Zaleplon 105 Zanamivir 76 Zenpep 98 Ziagen 78 Zidovudine 78 Zinc Oxide (Topical) 17 Zinc Sulfate 21 Ziprasidone HCl 72 Zolmitriptan 116 Zolpidem Tartrate 105 Zomig 116 Zonisamide 49 Zovia 1/50E (28) 88 Zovirax 97 GE 159 LAST UPDATED 12/2014