Buckeye Community Health Plan Preferred Drug List

Transcription

1 Buckeye Community Health Plan Preferred Drug List Approved August 8, 2014 Effective October 1, 2014 Preferred Drug List Medication Locator Instructions: 1. With the PDF open, click on the Edit menu, then click Find 2. In the Find box type the name of the medication you want to locate 3. Click the Next button until you find the medication(s) you are looking for BCHP-MM

2 Buckeye Community Health Plan Pharmacy Program Buckeye Community Health Plan, Inc. (Buckeye) is committed to providing appropriate, high quality, and cost effective drug therapy to all Buckeye members. Buckeye works with providers and pharmacists to ensure that medications used to treat a variety of conditions and diseases are covered. Buckeye covers prescription medications and certain over- the-counter (OTC) medications when ordered by a physician/clinician. The pharmacy program does not cover all medications. Some medications require prior authorization (PA) or have limitations on age, dosage, and maximum quantities. This section provides an overview of the Buckeye pharmacy program. For more detailed information, please visit our website at The following program covers both the Covered Families & Children (CFC) and Aged, Blind or Disabled (ABD) Ohio Medicaid consumers who are enrolled in Buckeye. Plan Preferred Drug List and Prior Authorization List The Buckeye Preferred Drug List (PDL) describes the circumstances under which contracted pharmacy providers will be reimbursed for medications dispensed to members covered under the program. All drugs covered under the Ohio Medicaid program are available for Buckeye members. The PDL includes all drugs available without PA and those agents that have the restrictions of (ST). The PA list includes those drugs that require PA for coverage. The PDL applies to drugs you receive at retail pharmacies. The PDL is continually evaluated by the Buckeye Pharmacy and Therapeutics (P&T) Committee to promote the appropriate and cost-effective use of medications. The Committee is composed of the Buckeye Medical Director, Buckeye Pharmacy Director, and several Ohio primary care physicians, pharmacists, and specialists. The PDL does not: Require or prohibit the prescribing or dispensing of any medication Substitute for the independent professional judgment of the physician/clinician or pharmacist, or Relieve the physician/clinician or pharmacist of any obligation to the patient or others US Script With the exceptions of biopharmaceuticals and specialty drugs, Buckeye works with US Script to process all pharmacy claims for prescribed drugs. Some drugs on the Buckeye PDL and PA list require a PA and US Script is responsible for administering this process. US Script is our Pharmacy Benefit Manager. Follow these guidelines for efficient processing of your authorization requests: 1. Complete the Buckeye Community Health Plan/US Script form: Medication Prior Authorization Request Form. 2. Fax to US Script at Once approved, US Script notifies the prescriber by fax. 4. If the clinical information provided does not explain the medical necessity for the requested PA medication, US Script will deny the request and offer PDL alternatives to the prescriber by fax. 5. For urgent or after-hours requests, a pharmacy can provide up to a 72-hour emergency supply of medication by calling

3 Prior Authorization Process The Buckeye PDL includes a broad spectrum of brand name and generic drugs. Clinicians are encouraged to prescribe from the Buckeye PDL for their patients who are members of Buckeye. Some drugs will require PA and are listed on the PA list. In addition, all name brand drugs not listed on either the PDL or PA list will require prior authorization. If a request for authorization is needed the information should be submitted by your physician/clinician to US Script on the Buckeye Community Health Plan/US Script form: Medication Prior Authorization Request Form. This form should be faxed to US Script at This document is located on the Buckeye website at Buckeye will cover the medication if it is determined that: 1. There is a medical reason you need the specific medication. 2. Depending on the medication, other medications on the PDL have not worked. All reviews are performed by a licensed clinical pharmacist using the criteria established by the Buckeye P&T Committee. Once approved, US Script notifies the physician/clinician by fax. If the clinical information provided does not meet the coverage criteria for the requested medication Buckeye we will notify you and your physician/clinician of alternatives and provide information regarding the appeal process. The P&T committee has reviewed and approved, with input from its members and in consideration of medical evidence, the list of drugs requiring prior authorization. This PDL attempts to provide appropriate and cost-effective drug therapy to all members covered under the Buckeye pharmacy program. If a patient requires a brand name medication that does not appear on the PDL, the physician/clinician can make a PA request for the brand name medication. It is anticipated that such exceptions will be rare and that PDL medications will be appropriate to treat the vast majority of medical conditions. A phone or fax-in process is available for PA requests. US Script Contact : Prior Authorization Fax Prior Authorization Phone Mailing Address: 2425 W Shaw Ave, Fresno, CA When calling, please have patient information, including Medicaid number, complete diagnosis, medication history and current medications readily available. US Script will provide a decision to the request by fax or phone within 24 hours. When incomplete information is received to support medical necessity of a drug requiring PA, the request will be denied. If the request is approved, information in the on-line pharmacy claims processing system will be changed to allow the specific member to receive this specific drug. If the request is denied, information about the denial will be provided to the clinician. Clinicians are requested to utilize the PDL when prescribing medication for those patients covered by the Buckeye pharmacy program. If a pharmacist receives a prescription for a drug that requires a PA, the pharmacist should attempt to contact the clinician to request a change to a product included in the PDL. Phone Numbers for Buckeye Community Health Plan Member Services The phone and fax lines listed in the Prior Authorization Process section are dedicated to clinicians requesting PA medication items only. Members can not be assisted if they call the PA toll-free number. Buckeye Member Services may be reached at (TTY ).

4 Transition Period Buckeye members new to managed care will be able to receive their prescription drugs with no new PA requirements than traditional Fee-for-Service (FFS) Medicaid for 30 days they are enrolled in our plan if the prescription drug does not require PA by traditional FFS Medicaid. This means that if you needed a PA under traditional FFS Medicaid to get your prescriptions you will most likely still need a PA to get the same medication. If you have not needed PA under traditional FFS Medicaid to get your prescription you will not need PA from Buckeye to get the same medication for the first 30 days you are enrolled. This will allow you and your doctor time to consider other medications that do not require PA and to learn the steps to getting PA. Buckeye s PDL and PA List identify the drugs that will require PA once you have been a managed care member for 30 days. If you are not sure when you will need to have your medications prior authorized or you have other questions about continuing to get your medications, call member services at (TTY ). 72-Hour Emergency Supply Policy State and federal law require that a pharmacy dispense a 72-hour (3-day) supply of medication to any patient awaiting a PA determination. 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 PA request is ultimately approved or denied. The pharmacy must call the US Script Pharmacy Help Desk at for a prescription override to submit the 72-hour medication supply for payment. Some medications listed on the Buckeye PDL may require specific medications to be used before you can receive the step therapy medication. If Buckeye has a record that the required medication was tried first the ST medications are automatically covered. If Buckeye does not have a record that the required medication was tried, you or your physician/clinician may be required to provide additional information. If Buckeye does not grant PA we will notify you and your physician/clinician and provide information regarding the appeal process. Dispensing Limits, Quantity Limits, and Age Limits Drugs may be dispensed up to a maximum 31 day supply for each new or refill non-controlled substance. A total of 80 percent (80%) of the days supplied must have elapsed before the prescription can be refilled. A prescription can be filled after 26 days. Dispensing outside the quantity limit (QL) or age limits (AL) requires PA. Buckeye may limit how much of a medication you can get at one time. If the physician/clinician feels you have a medical reason for getting a larger amount, he or she can ask for PA. If Buckeye does not grant PA we will notify you and your physician/clinician and provide information regarding the appeal process. Some medications on the Buckeye PDL may have AL. These are set for certain drugs based on Food and Drug Administration (FDA) approved labeling and for safety concerns and quality standards of care. The AL aligns with current FDA alerts for the appropriate use of pharmaceuticals.

5 Gender Limits Some medications on the Buckeye PDL may be limited to one gender. These medications have a GL after them on the PDL. 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 you require a medication that does not appear on the PDL, you or your physician/clinician can make a medical necessity request for the medication. It is anticipated that such exceptions will be rare and that PDL medications will be appropriate to treat the vast majority of medical conditions. Buckeye 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. All reviews are performed by a licensed clinical pharmacist using the criteria established by the Buckeye P&T Committee. If the clinical information provided does not meet the coverage criteria for the requested medication Buckeye will notify you and your physician/clinician of alternatives and provide information regarding the appeal process. Appropriate Use and Safety Edits Your health and safety is a priority for Buckeye. One of the ways we address your safety is through Pointof-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. information about the drugs that are part of the Appropriate Use and Safety Edits can be found in the Appropriate Use and Safety Edits document located on the Buckeye website at DUR (Drug Utilization Review) Programs Buckeye will monitor ongoing prescribing of medications for clinical appropriateness. Buckeye reviews prescribing retrospectively to review for both safety and efficacy. Buckeye will work with US Script to review for such things as disease management, fraud and abuse (i.e. Coordinated Services Program), and prescriber profiling. Prescriber or member outreach may occur based on prescribing/dispensing patterns. Buckeye will continue to monitor for issues going forward and take action as needed. Mandatory Generic Substitution When generic drugs are available, the brand name drug will not be covered without Buckeye PA. Generic drugs have the same active ingredient and work the same as brand name drugs. If you or your physician/clinician feels a brand name drug is medically necessary, the physician/clinician can ask for PA.

6 We will cover the brand name drug according to our clinical guidelines if there is a medical reason you need the particular brand name drug. If Buckeye does not grant PA we will notify you and your physician/clinician and provide information regarding the appeal process. The provision is waived for the following products due to their narrow therapeutic index (NTI) as recognized by current medical and pharmaceutical literature: Aminophylline, Amiodarone, Carbamazepine, Clozapine, Cyclosporine, Digoxin, Disopyramide, Ethosuximide, Flecainide, L-thyroxine, Lithium, Phenytoin, Procainamide, Propafenone, Theophylline, Thyroid, Valproate Sodium, Valproic Acid, and Warfarin. Over-The-Counter Medications The pharmacy program covers a large selection of OTC medications. All covered OTC medications appear in the PDL. All OTC medications must be written on a valid prescription by a licensed physician/clinician in order to be reimbursed. Filling a Prescription You can have prescriptions filled at a Buckeye network pharmacy. If you decide to have a prescription filled at a network pharmacy you can locate a pharmacy near you by contacting a Buckeye Member Services Representative. At the pharmacy you will need to provide the pharmacist with your prescription and your Buckeye ID card. Please visit the Buckeye website at to access the Buckeye PDL, Buckeye PA lists, important forms, and provider/member information 24 hours a day, seven days a week. Mail Order Program Buckeye Community Health Plan offers a 90 day supply (3 month supply) of maintenance medications by mail. These drugs are used to treat long-term conditions or illnesses. You can find a list of covered maintenance medications in the Maintenance Drug Pharmacy Program document located on the Buckeye website at Please contact a Buckeye Member Service Representative if you have any questions. To transfer a current prescription or to have you doctor phone a prescription directly to our mail order pharmacy they may call RxDirect at

7 Buckeye Community Health Plan Pharmacy Program - Working with Our Pharmacy Benefit Managers Buckeye works with two Pharmacy Benefit Managers (PBMs). Health is the preferred provider of biopharmaceuticals and injectables for Buckeye. US Script administers all other prescribed drugs. Certain drugs require PA to be approved for payment by Buckeye. These include: Some Buckeye drugs listed on the PA list Most injectables including Procrit, Neulasta and Neupogen. Health Biopharmaceuticals and Injectables Health is the provider of biopharmaceuticals and injectables for Buckeye. Most injectables require PA to be approved for payment. Our Medical Director oversees the clinical review. Buckeye provides a number of biopharmaceutical products through the Biopharmaceutical Program. Most biopharmaceuticals and injectables require a PA to be approved for payment by Buckeye; however, PA requirements are programmed specific to the drug as indicated in the list provided in the Biopharmaceutical Program document located on the Buckeye website at Follow these guidelines for the most efficient processing of your authorization requests. Providers can request that Health deliver the specialty drug to the office/member. If you want Health to deliver the specialty drug to the office/member: 1. Fax the Health PA form to for PA. 2. If approved, Health will contact the provider or member for delivery confirmation. Pharmacy and Therapeutics Committee The Buckeye Pharmacy and Therapeutics (P&T) Committee continually evaluates the therapeutic classes included in the PDL. The Committee is composed of the Buckeye Medical Director, Buckeye Pharmacist, and several community based primary care physicians and specialists. The primary purpose of the Committee is to assist in developing and monitoring the Buckeye PDL and to establish programs and procedures that promote the appropriate and cost-effective use of medications. The P&T Committee schedules meetings at least twice yearly, and coordinates reviews with a national P&T Committee which meets at least 4 times a year. Changes to the Buckeye PDL are done in conjunction with the approval of the State of Ohio. Buckeye will meet with the State quarterly to review any proposed changes and update the PDL and PA lists accordingly based on the results of both the Buckeye P&T Committee and the requirements from the State of Ohio. Buckeye will follow all State policies regarding member notification when changes are made to the PA list. Unapproved Use of Preferred Medication Medication coverage under this program is limited to non-experimental indications as approved by the FDA. Other indications may also be covered if they are accepted as safe and effective using current medical and pharmaceutical reference texts and evidence-based medicine. Reimbursement decisions for

8 specific non-approved indications will be made by Buckeye. Experimental drugs and investigational drugs are not eligible for coverage. Benefit Exclusions The following drug categories are not part of the Buckeye PDL and are not covered by the 72-hour emergency supply policy: Fertility enhancing drugs Anorexia, weight loss, or weight gain drugs Immunizations and vaccines (except flu vaccine) Drug Efficacy Study Implementation (DESI) and Identical, Related and Similar (IRS) drugs that are classified as ineffective Infusion therapy and supplies Drugs and other agents used for cosmetic purposes or for hair growth Erectile dysfunction drugs prescribed to treat impotence DESI drugs products and known related drug products are defined as less than effective by the FDA 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. State programs may allow coverage of certain DESI drugs. Any DESI drugs that are covered are listed in the PDL. Newly Approved Products We review new drugs for safety and effectiveness for the first 12 months before adding them to the Buckeye Community PDL. During this period, access to these medications will be considered through the PA review process. If Buckeye does not grant PA we will notify you and your physician/clinician and provide information regarding the appeal process. Medical Benefits The following drugs and medical services are a part of the Buckeye medical benefit and are not available at the retail pharmacy: 1. Members will receive vaccines as a medical benefit under physician reimbursement if listed the vaccine covered under the vaccine for children program. 2. Cosmetic-botox is a medical benefit that is covered for non-cosmetic purposes only- it requires a PA from Buckeye. 3. Blood and blood products. 4. Those specialty injectable drugs available as a medical benefit. Most injectables require PA from Buckeye. Prescribers who request medical prior authorizations at US Script will be redirected to contact Buckeye Community Health Plan as applicable.

9 DME/Home Health Benefits The following medical services are a part of the Buckeye medical benefit and are not available at the retail pharmacy: 1. Enteral products 2. Nebulizers 3. Medical supplies Injectable Drugs Injections that are self-administered by the member and/or a family member and appear on the PDL are covered by the Buckeye pharmacy program. Insulin vials, Glucagon Kit, Epi-pen, Ana-Kit, Imitrex, and Depo-Provera IM are covered by Buckeye and do not require a PA. Pre-filled insulin cartridges and syringes require PA. All other injectables require PA. Coordinated Services Program Consumers eligible for Ohio Medicaid may be selected for enrollment in the Coordinated Services Program, or CSP. CSP enrollees must get medications filled at one pharmacy and coordinate medical services through their primary care provider. After being enrolled in CSP, the member will still be able to get all medically necessary Medicaid- covered health care services. However, the member must select one pharmacy to fill their prescriptions. If they go to a different pharmacy without approval, their medication will not be covered. The member also has a primary care provider (PCP) to coordinate their health care services with other providers. Except in an emergency, the member should contact their PCP before seeing other providers. By knowing the complete medical history, the PCP and pharmacy can take better care of the patient. A care manager will also contact the member to discuss care management services. We help keep you informed The Buckeye Pharmacy Director, a registered pharmacist, compiles current pharmacological policy and information about important seasonal topics such as Respiratory Syncytial Virus (RSV) and influenza. The information is consistent with published guidelines and is mailed to network providers as a service. The most current Buckeye PDL and PA List can be downloaded from our website at Contacts for Pharmacy Appeals/Grievances Members: In the event that a member disagrees with the decision regarding coverage of a medication, the member may file an appeal with Buckeye by calling Buckeye Member Services at (TTY ). Physicians / Clinicians: In the event that a clinician disagrees with the decision regarding coverage of a medication, the clinician may request an appeal by submitting additional information to Buckeye in writing to the Appeals Department at the following address:

10 Buckeye Community Health Plan 4349 Easton Way, Suite 200 Columbus, Ohio A decision will be rendered and the clinician will be notified with a mailed response. An expedited appeal may be requested at any time the provider believes the adverse determination might seriously jeopardize the life or health of a member by calling Buckeye at ext (TTY ). A response will be rendered the same day as receipt of complete information. In circumstances that require research, a same day response may not be possible. Abbreviations The following notations and abbreviations may be found throughout the drug listing in the limitations and restrictions column. DS: DS/DU: Max Days: Max Fills: Max Qty: Min DS: PA: Pkg Size: QL: Days Supply 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 Quantity Limit

11 Over-the-Counter Pharmacy Program T he Buckeye Community Health Plan pharmacy program covers a variety of OTC products. The products listed below are covered when a valid prescription from a licensed clinician that meets all the legal requirements for a prescription is presented to be filled at a Buckeye network pharmacy. Covered products are available in quantities up to a 30-day supply. Refer to the Buckeye Community Health Plan PDL for a complete listing of available OTC items. Please note that generic products must be prescribed when available. ANALGESICS & ANTIPYRETICS Acetaminophen generic tablets, elixir, drops, suppositories Aspirin generic tablets ANTACIDS Maalox generic tablets, liquid Mylanta DS generic liquid ANTHELMINTICS Pin-X Pyrantel pamoate tablets/chewable/suspension ANTI-DIARRHEALS Imodium A-D generic (loperamide) capsules Kaopectate (attapulgite) suspension Pepto-Bismol generic (pink bismuth) chewable/liquid ANTI-EMETIC Antivert generic (meclizine) ANTI-FLATULENTS Gas-X chewables generic simethicone 80mg Mylicon drops** generic simethicone 40 mg/0.6ml ANTI-HISTAMINES Benadryl generic (diphenhydramine) capsules, liquid Chlor-Trimeton generic (chlorpheniramine) tablets, liquid Claritin generic (loratadine) tablets, syrup Claritin-D generic (loratadine/ pseudoephedrine) tablets Zyrtec generic (cetirizxine) tablets/chewables/liquid CONTRACEPTIVES Condoms lubricated COUGH/EXPECTORANT/DECONGESTANT Dallergy drops (chlorpheniramine & phenylephrine liquid) 1-2 mg/ml Decon A drops (brompheniramine & phenylephrine liquid) 2-5 mg/ml Delsym DM Polistirex Liquid CR Dimetapp generic (brompheniramine & phenylephrine elixir) mg/5ml Mucinex generic (guaifenesin) tablets Robitussin generic (guaifenesin) syrup Robitussin DM generic (guaifenesin DM) syrup Sudafed generic (pseudoephedrine) tablets, liquid Triaminic generic AM, Night, soft chewable tablets DILUENTS Sodium chloride generic aerosol solution DME PRODUCTS Diabetic testing supplies (TRUEtest preferred) Gauze pad 2 x2, 3 x3, 4 x4 Peak Flow Meters Spacers OTIC PREPARATIONS Debrox drops generic (carbamide peroxide 6.5%) ELECTROLYTES Electrolyte solutions generic H2-RECEPTOR ANTAGONISTS Pepcid generic (famotidine) 10mg tablets Tagamet generic (cimetidine) 200mg tablets Zantac generic (ranitidine) 75mg tablets IRON PREPERATIONS Ferrous fumarate generic tablets Ferrous gluconate generic tablets Ferrous sulfate generic tablets, elixir, drops Polysaccharide Iron Complex generic capsules 150mg LAXATIVES Citrate of magnesium generic Colace generic (docusate sodium) capsules Dulcolax generic (bisacodyl) tablets, suppositories Fleet enema generic Metamucil generic (psyllium) Milk Of Magnesium generic MOM Miralax OTC Pediatric glycerin suppositories generic Senokot generic (senna) tablets Sorbitol oral solution 70% MINERALS Citracal generic (calcium citrate) - tablets Citracal+D generic (calcium citrate+d) tablets Magnesium oxide generic Neutra-phos/K powder generic Oscal 500+Vit D generic (calcium carbonate+d) tablets Tums Chew Tabs generic (calcium carbonate) Zinc sulfate generic capsules 220mg

12 NASAL Nasalcrom spray generic Saline nasal spray/gel/solution NSAIDS Ibuprofen generic tablets, chewable, liquid, drops Naproxen generic tablets NUTRITIONAL SUPPLEMENTS Omega-3 fatty acid capsules 1000mg, 1200mg OPHTHALMIC PREPARATIONS Alaway (ketotifen 0.025%) Artificial tears generic polyvinyl alcohol drops Lacri-lube generic (artificial tears) ointment Naphcon-A generic (naphazoline/pheniramine 0.025/0.3) Zaditor-OTC (ketotifen 0.025%) PEDICULICIDES NIX generic (permethrin) RID generic (pyrethrins/piperonyl butoxide) PROTON PUMP INHIBITORS (PPIS) Prevacid 24 HR capsules Prilosec OTC tablets SLEEPING AIDS Nytol generic (diphenhydramine sleep) tablets/capsules Unisom generic (doxylamine sleep) tablets SMOKING DETERRENTS Commit Lozenges NicoDerm CQ transdermal patch generic Nicorette DS gum generic Nicorette gum generic Nicotrol transdermal patch generic TOPICALS AmLactin generic Bacitracin ointment generic Benzoyl peroxide generic liquid/gel/lotion Calamine generic Capsaicin cream/gel/lotion generic Clotrimazole generic cream, vaginal cream/inserts Hibiclens generic (chlorhexidine gluconate liquid) 4% Hydrocortisone generic cream, lotion, ointment, solution Miconazole generic cream, vaginal cream/inserts Polysporin generic ointment Nupercainal generic (dibucaine rectal ointment) 1% Selsun Blue generic (selenium shampoo) 1% Tolnaftate generic cream Triple antibiotic ointment Vagistat generic (tioconazole vaginal ointment) 6.5% Xylocaine generic (lidocaine) gel 2% Zinc oxide ointment generic VITAMINS Folic acid generic Multi-vitamins with iron generic tablets, liquid, chewable Multi-vitamins generic tablets, liquid, chewable Niacin generic Prenatal vitamins generic tablets Pyridoxine generic tablets Slo-Niacin CR tablets Thiamine generic tablets

13 MEDICATION PRIOR AUTHORIZATION REQUEST FORM Buckeye Community Health Plan, Ohio Do Not Use This Form for Biopharmaceutical Products FAX this completed form to OR Mail requests to: US Script PA Dept / 2425 West Shaw Avenue / Fresno, CA Call to request a 72-hour supply of medication. I. Provider II. Member Prescriber name (print): Member name: Prescriber Specialty: Identification number: Fax: Phone: Date of Birth: Office Contact Name: Medication allergies: III. Drug (One drug request per form) Drug name and strength: Dosage form: Dosage interval (sig): Qty per Day: Diagnosis relevant to this request: Expected length of therapy: Medication History for this Diagnosis A. Is member currently treated on this medication? yes; How Long? [go to item B] no [skip items B & C; go to item D] B. Is this request for continuation of a previous approval? yes [go to item C] no [skip item C; go to item D] C. Has strength, dosage, or quantity required per day increased or decreased? yes [go to item D] D. Please indicate previous treatment and outcomes below. Drug Name Dates of Therapy (include strength and dosage) no [skip item D; indicate rationale for continuation in Section IV and submit form] Reason for Discontinuation NOTE: Confirmation of use will be made from member history on file; prior use of preferred drugs is a part of the exception criteria. The Buckeye Community Health Plan Preferred Drug List (PDL) is available on the Buckeye Community Health Plan website at IV. Rationale for Request / Pertinent Clinical (Required for all Prior Authorizations) Appropriate clinical information to support the request on Provider Signature: Date: the basis of medical necessity must be submitted. US Script will respond via fax or phone within 24 hours of receipt of all necessary information, except during weekends and holidays. Requests for prior authorization (PA) must include member name, ID#, and drug name. Incomplete forms will delay processing. Please include lab reports with requests when appropriate (e.g., Culture and Sensitivity; Hemoglobin A1C; Serum Creatinine; CD4; Hematocrit; WBC, etc.) *Contact Buckeye Community Health Plan at for Biopharmaceutical Products*

14 PENICILLINS Penicillin V Potassium Tab 250 Penicillin V Potassium Tab 500 Penicillin V Potassium For Soln 125 /5ML Penicillin V Potassium For Soln 250 /5ML Amoxicillin (Trihydrate) Cap 250 Amoxicillin (Trihydrate) Cap 500 Amoxicillin (Trihydrate) Tab 875 AMOXIL Amoxicillin (Trihydrate) Chew Tab 125 Amoxicillin (Trihydrate) Chew Tab 250 Amoxicillin (Trihydrate) Chew Tab 400 Amoxicillin (Trihydrate) For Susp 50 /ML Amoxicillin (Trihydrate) For Susp 125 /5ML Amoxicillin (Trihydrate) For Susp 125 /5ML Amoxicillin (Trihydrate) For Susp 250 /5ML Amoxicillin (Trihydrate) For Susp 400 /5ML Ampicillin Cap 250 Ampicillin Cap 500 Ampicillin For Susp 125 /5ML AUGMENTIN AUGMENTIN AUGMENTIN AUGMENTIN AUGMENTIN AUGMENTIN AUGMENTIN AUGMENTIN AUGMENTIN XR CEPHALOSPORINS Ampicillin For Susp 250 /5ML Dicloxacillin Sodium Cap 250 Dicloxacillin Sodium Cap 500 Amoxicillin & K Clavulanate Tab 250 Amoxicillin & K Clavulanate Tab 500 Amoxicillin & K Clavulanate Tab 875 Amoxicillin & K Clavulanate Chew Tab 200 Amoxicillin & K Clavulanate Chew Tab 250 Amoxicillin & K Clavulanate Chew Tab 400 Amoxicillin & K Clavulanate For Susp 125 /5ML Amoxicillin & K Clavulanate For Susp 200 /5ML Amoxicillin & K Clavulanate For Susp 250 /5ML Amoxicillin & K Clavulanate For Susp 400 /5ML Amoxicillin & K Clavulanate For Susp 600 /5ML Amoxicillin & K Clavulanate Tab SR 12HR Max Qty=30/claim Max Qty=30/claim Max Qty=20/claim Max Qty=20/claim Max Qty=30/claim Max Qty=20/claim Package Limit=2/claim Package Limit=2/claim Max Qty=40/30 days

15 DURICEF Cefadroxil Cap 500 Max Qty=20/claim CEFADROXIL 1 GM TABLET Max Qty=10/claim CEFADROXIL 250 /5 ML SUSP CEFADROXIL 500 /5 ML SUSP KEFLEX Cephalexin Cap 250 KEFLEX Cephalexin Cap 500 Cephalexin For Susp 125 /5ML Cephalexin For Susp 250 /5ML Cefaclor Cap 250 Cefaclor Cap 500 Cefaclor For Susp 125 /5ML Cefaclor For Susp 250 /5ML Cefaclor For Susp 375 /5ML Cefprozil Tab 250 Max Qty=20/claim Cefprozil Tab 500 Max Qty=20/claim Limit=2/claim; Pkg Size Cefprozil For Susp 125 /5ML 100: Package Limit=2/claim Cefprozil For Susp 250 /5ML Pkg Size 50: Package Limit=1/claim CEFTIN Cefuroxime Axetil Tab 250 Max Qty=20/claim CEFTIN Cefuroxime Axetil Tab 500 Max Qty=20/claim CEFTIN Cefuroxime Axetil For Susp 125 /5ML CEFTIN Susp 250 /5ML OMNI-PAC, OMNICEF Cefdinir Cap 300 Max Qty=20/claim OMNICEF Cefdinir For Susp 125 /5ML OMNICEF Cefdinir For Susp 250 /5ML MACROLIDES ERYC Erythromycin Tab 250 Erythromycin Tab 500 Erythromycin Tab Delayed Release 250 Erythromycin Tab Delayed Release 333 Erythromycin Tab Delayed Release 500 Erythromycin w/ Enteric Coated Particles Cap 250 Erythromycin w/ Enteric Coated Particles Tab 333 Erythromycin w/ Enteric Coated Particles Tab 500 Erythromycin Stearate Tab 250 Erythromycin Stearate Tab 500 Erythromycin Ethylsuccinate Tab 400 Erythromycin Ethylsuccinate Susp 200 /5ML Erythromycin Ethylsuccinate Susp 400 /5ML Erythromycin Ethylsuccinate For Susp 100 /2.5ML ERYTHROMYCIN ERYTHROMYCIN E-MYCIN, ERY-TAB ERY-TAB, ERYTHROMYCIN ERY-TAB ERYTHROMYCIN PCE PCE ERYTHROCIN, ERYTHROM ST ERYTHROCIN, ERYTHROM ST ERYPED

16 E.E.S. GRAN, ERYPED 200 Erythromycin Ethylsuccinate For Susp 200 /5ML Erythromycin Ethylsuccinate For Susp 400 /5ML ERYPED 400 ZITHROMAX Azithromycin Tab 250 Max Qty=6/claim ZITHROMAX Azithromycin Tab 500 Max Qty=3/claim ZITHROMAX Azithromycin Tab 600 Max Qty=8/28 days ZITHROMAX ZITHROMAX Azithromycin For Susp 100 /5ML Azithromycin For Susp 200 /5ML Pkg Size 15: Package Limit=1/claim; Pkg Size 30: Package Limit=2/claim; Pkg Size 22.5: Package Limit=2/claim Azithromycin Powd Pack for Susp 1 GM Max Qty=2/claim BIAXIN Clarithromycin Tab 250 Max Qty=28/claim BIAXIN Clarithromycin Tab 500 Max Qty=28/claim BIAXIN Clarithromycin For Susp 125 /5ML BIAXIN Clarithromycin For Susp 250 /5ML BIAXIN XL Clarithromycin Tab SR 24HR 500 Max Qty=14/claim TETRACYCLINES Doxycycline Hyclate Cap 50 VIBRAMYCIN Doxycycline Hyclate Cap 100 PERIOSTAT DOXYCYCLINE HYCLATE 20 T VIBRATAB Doxycycline Hyclate Tab 100 MINOCIN Minocycline HCl Cap 50 Minocycline HCl Cap 75 MINOCIN Minocycline HCl Cap 100 Tetracycline HCl Cap 250 Tetracycline HCl Cap 500 FLUOROQUINOLONES Ciprofloxacin HCl Tab 100 (Base Equiv) Max Qty=6/claim CIPRO Ciprofloxacin HCl Tab 250 (Base Equiv) CIPRO Ciprofloxacin HCl Tab 500 (Base Equiv) CIPRO Ciprofloxacin HCl Tab 750 (Base Equiv) LEVAQUIN Levofloxacin Tab 250 Max Qty=14/claim; LEVAQUIN Levofloxacin Tab 500 Max Qty=14/claim; LEVAQUIN Levofloxacin Tab 750 Max Qty=14/claim; Ofloxacin Tab 200 Max Qty=56/claim Ofloxacin Tab 300 Max Qty=56/claim Ofloxacin Tab 400 Max Qty=56/claim AMINOGLYCOSIDES Neomycin Sulfate Tab 500 SULFONAMIDES Sulfisoxazole Acetyl Susp 500 /5ML GANTRIS PED ANTIMYCOBACTERIAL AGENTS MYAMBUTOL Ethambutol HCl Tab 100 MYAMBUTOL Ethambutol HCl Tab 400 TRECATOR Tab 250mg

17 Isoniazid Tab 100 Isoniazid Tab 300 Isoniazid Syrup 50 /5ML Pyrazinamide Tab 500 MYCOBUTIN 150 CAPSULE RIFADIN Rifampin Cap 150 RIFADIN Rifampin Cap 300 ANTIFUNGALS GRIFULVIN V Tab 500 GRIFULVIN V Griseofulvin Microsize Susp 125 /5ML GRIS-PEG Tab 125 GRIS-PEG, GRISEOFULVIN Tab 250 Nystatin Tab U Daily Dosage=6 LAMISIL Terbinafine HCl Tab 250 Max Qty=90/120 days; Ketoconazole Tab 200 DIFLUCAN Fluconazole Tab 50 Max Qty=3/14 days DIFLUCAN Fluconazole Tab 100 DIFLUCAN Fluconazole Tab 150 Max Qty=2/claim DIFLUCAN Fluconazole Tab 200 DIFLUCAN Fluconazole For Susp 10 /ML Max Qty=70/claim DIFLUCAN Fluconazole For Susp 40 /ML Max Qty=70/claim ANTIVIRALS SELZENTRY Tab 150 SELZENTRY Tab 300 TIVICAY 50 TABLET ISENTRESS Tab 400 (Base Equiv) ISENTRESS 100 TABLET CHE AGENERASE Cap 50 AGENERASE Soln 15 /ML REYATAZ Cap 100 (Base Equiv) REYATAZ Cap 150 (Base Equiv) REYATAZ Cap 200 (Base Equiv) REYATAZ Cap 300 (Base Equiv) PREZISTA Tab 75 (Base Equiv) PREZISTA Tab 150 (Base Equiv) PREZISTA Tab 300 (Base Equiv) PREZISTA Tab 400 (Base Equiv) PREZISTA Tab 600 (Base Equiv) PREZISTA 800 TABLET PREZISTA 100 /ML SUSPENSI LEXIVA Tab 700 (Base Equiv) LEXIVA Susp 50 /ML (Base Equiv) CRIXIVAN Cap 100 CRIXIVAN Cap 200 Daily Dosage=4 Daily Dosage=3 Daily Dosage=4 Daily Dosage=4 Daily Dosage=56 Daily Dosage=6 Daily Dosage=9 Biopharmacy benefit via Biopharmacy benefit via Biopharmacy benefit via Biopharmacy benefit via

18 CRIXIVAN Cap 333 CRIXIVAN Cap 400 VIRACEPT Tab 250 VIRACEPT Tab 625 VIRACEPT Oral Powder 50 /GM NORVIR Cap 100 NORVIR Tab 100 NORVIR Oral Soln 80 /ML INVIRASE Cap 200 INVIRASE Tab 500 APTIVUS Cap 250 APTIVUS Oral Soln 100 /ML Daily Dosage=6 Daily Dosage=9 Daily Dosage=4 Daily Dosage= Daily Dosage=4 Daily Dosage=4 0 ZIAGEN ZIAGEN Tab 300 (Base Equiv) ZIAGEN Soln 20 /ML (Base Equiv) Daily Dosage=30 VIDEX For Soln 2 GM 0 VIDEX For Soln 4 GM VIDEX EC Didanosine Delayed Release Capsule 125 VIDEX EC Didanosine Delayed Release Capsule 200 VIDEX EC Didanosine Delayed Release Capsule 250 VIDEX EC Didanosine Delayed Release Capsule 400 EMTRIVA Caps 200 EMTRIVA Soln 10 /ML EPIVIR EPIVIR Tab 150 EPIVIR EPIVIR Tab 300 EPIVIR Oral Soln 10 /ML Daily Dosage=30 ZERIT Stavudine Cap 15 ZERIT Stavudine Cap 20 ZERIT Stavudine Cap 30 ZERIT Stavudine Cap 40 ZERIT Stavudine For Oral Soln 1 /ML Daily Dosage=80 RETROVIR Zidovudine Cap 100 Daily Dosage=6 RETROVIR Zidovudine Tab 300 RETROVIR Zidovudine Syrup 10 /ML Daily Dosage=60 VIREAD Tab 150 VIREAD Tab 200 VIREAD Tab 250 VIREAD Tab 300 VIREAD POWDER Max dose= 240/30 days RESCRIPTOR Tab RESCRIPTOR Tab 200 Daily Dosage=6 SUSTIVA Cap 50 SUSTIVA Cap 100 SUSTIVA Cap 200 SUSTIVA Tab 600 INTELENCE Tab 25 Daily Dosage=4 INTELENCE Tab 100 Daily Dosage=4 INTELENCE 200 TABLET VIRAMUNE VIRAMUNE Tab 200 VIRAMUNE Susp 50 /5ML Daily Dosage=40 VIRAMUNE XR 100 TABLET EDURANT HCl Tab 25 EPZICOM Tab TRUVADA Tab COMBIVIR COMBIVIR Tab KALETRA Cap Daily Dosage=6

19 COMPLERA TABLET KALETRA Tab KALETRA Tab KALETRA Soln /5ML (80-20 /ML) TRIZIVIR Tab ATRIPLA Tab COMPLERA Daily Dosage=4 Daily Dosage=4 Max Qty=480/30 days Ganciclovir Cap 250 Daily Dosage=6 Ganciclovir Cap 500 Daily Dosage=6 VALCYTE Tab 450 ZOVIRAX Acyclovir Cap 200 Max Qty=50/30 days ZOVIRAX Acyclovir Tab 400 ZOVIRAX Acyclovir Tab 800 Max Qty=50/30 days ZOVIRAX Acyclovir Susp 200 /5ML Max Qty=400/30 days VALTREX Valacyclovir HCl Tab 500 Max Qty=42/31 days VALTREX Valacyclovir HCl Tab 1 GM Max Qty=21/31 days FLUMADINE Max DS/DU=Lesser Of Rimantadine Hydrochloride Tab 100 Max Days Sply=10/Max Qty=20 TAMIFLU Cap 30 (Base Equiv) Max Qty=20/30 days; Max fill=1/180 days TAMIFLU Cap 45 (Base Equiv) Max Qty=10/30 days; Max fill=1/180 days TAMIFLU Cap 75 (Base Equiv) Max Qty=10/30 days; Max fill=1/180 days TAMIFLU Susp 12 /ML (Base Equiv) Max Qty=75/30 days; Max fill=1/180 days Limited to Ages 5 and RELENZA 5 /BLISTER Older ; Package Limit=1/30 days ANTIMALARIALS Chloroquine Phosphate Tab 250 ARALEN Chloroquine Phosphate Tab 500 PLAQUENIL LARIAM ANTHELMINTICS VERMOX Hydroxychloroquine Sulfate Tab 200 Mefloquine HCl Tab 250 PRIMAQUINE Tab 26.3 QUALAQUIN 324 CAPSULE COARTEM Tab Mebendazole Chew Tab 100 Pyrantel Pamoate Susp 250 /5ML (50 /ML Base Equiv) Max Qty=24/claim Max Qty=120/claim ANTI-INFECTIVE AGENTS - MISCELLANEOUS FLAGYL Metronidazole Tab 250 FLAGYL Metronidazole Tab 500 TRIMPEX Trimethoprim Tab 100 Vancomycin HCl For Inj 500 CLEOCIN Clindamycin HCl Cap 150 CLEOCIN Clindamycin HCl Cap 300 Clindamycin Palmitate HCl For Soln CLEOCIN PED 75 /5ML (Base Equiv) Dapsone Tab 25 Dapsone Tab 100 MEPRON 750 /5 ML SUSPENSI Erythromycin & Sulfisoxazole For PEDIAZOLE Susp /5ML Max Qty=14/30 days Max Qty=300/claim

20 Sulfamethoxazole-Trimethoprim Tab BACTRIM, SEPTRA BACTRIM DS, SEPTRA Sulfamethoxazole-Trimethoprim Tab DS Sulfamethoxazole-Trimethoprim Susp /5ML ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES MYLERAN Tab 2 LEUKERAN Tab 2 Cyclophosphamide Tab 25 Cyclophosphamide Tab 50 ALKERAN Tab 2 CEENU Cap 10 CEENU Cap 40 CEENU Cap 100 PURINETHOL Mercaptopurine Tab 50 Methotrexate Sodium Tab 2.5 (Base Equiv) Methotrexate Sodium Tab 5 (Base Equiv) TREXALL Tab 7.5 (Base Equiv) TREXALL Tab 10 (Base Equiv) TREXALL Tab 15 (Base Equiv) Methotrexate Sodium Inj 25 /ML CASODEX ARIMIDEX Methotrexate Sodium Inj PF 25 /ML TESLAC Tab 50 LYSODREN Tab 500 Bicalutamide Tab 50 Flutamide Cap 125 Tamoxifen Citrate Tab 10 (Base Equivalent) Tamoxifen Citrate Tab 20 (Base Equivalent) Anastrozole Tab 1 AROMASIN AROMASIN Tab 25 FEMARA Letrozole Tab 2.5 MEGACE ORAL HYDREA CORTICOSTEROIDS Megestrol Acetate Tab 20 Megestrol Acetate Tab 40 Megestrol Acetate Susp 40 /ML Etoposide Cap 50 Hydroxyurea Cap 500 Leucovorin Calcium Tab 5 Leucovorin Calcium Tab 10 Leucovorin Calcium Tab 15 Leucovorin Calcium Tab 25 Cortisone Acetate Tab 25 Dexamethasone Tab 0.5 Dexamethasone Tab 0.75 Dexamethasone Tab 1 Dexamethasone Tab 1.5 Dexamethasone Tab 2 Dexamethasone Tab 4 Dexamethasone Tab 6 Dexamethasone Elixir 0.5 /5ML Prior use of Anastrozole Prior use of Anastrozole

21 Dexamethasone Conc 1 /ML Dexamethasone Soln 0.5 /5ML CORTEF CORTEF CORTEF MEDROL MEDROL MEDROL MEDROL MEDROL PRELONE ORAPRED PEDIAPRED STERAPRED STERAPRED DS ANDROGENS-ANABOLIC DEPO-TESTOST ESTROGENS Dexamethasone sodium phosphate 4mg/mL Inj Hydrocortisone Tab 5 Hydrocortisone Tab 10 Hydrocortisone Tab 20 Methylprednisolone Tab 4 Methylprednisolone Tab 8 METHYLPREDNISOLONE 16 TA METHYLPREDNISOLONE 32 TA Methylprednisolone Tab 4 Dose Pack MILLIPRED Tab 5 Prednisolone Syrup 5 /5ML Prednisolone Syrup 15 /5ML Prednisolone Sod Phosphate Oral Soln 15 /5ML (Base Equiv) Prednisolone Sod Phosph Oral Soln 6.7 /5ML (5 /5ML Base) VERIPRED 20 Oral Soln 20 /5ML (Base Equiv) Prednisone Tab 1 Prednisone Tab 2.5 Prednisone Tab 5 Prednisone Tab 10 Prednisone Tab 20 Prednisone Tab 50 Prednisone Conc 5 /ML Prednisone Oral Soln 5 /5ML Prednisone Tab 5 Dose Pack Prednisone Tab 10 Dose Pack Fludrocortisone Acetate Tab 0.1 DANAZOL 50 CAPSULE DANAZOL 100 CAPSULE DANAZOL 200 CAPSULE ANDRODERM Patch 24HR 2 /24HR ANDRODERM Patch 24HR 2.5 /24HR ANDRODERM Patch 24HR 4 /24HR ANDRODERM Patch 24HR 5 /24HR Testosterone Cypionate IM in Oil 200 /ML PREMARIN Tab 0.3 PREMARIN Tab 0.45 PREMARIN Tab PREMARIN Tab 0.9 PREMARIN Tab 1.25 QL = 1 dispense/month Max Qty=150/claim Max Qty=4/30 days Limited to Female ; Limited to Female ; Limited to Female ; Limited to Female ; Limited to Female ;

22 ESTRACE Estradiol Tab 0.5 Limited to Female ESTRACE Estradiol Tab 1 Limited to Female ESTRACE Estradiol Tab 2 Limited to Female CLIMARA CLIMARA CLIMARA CLIMARA CLIMARA CLIMARA OGEN OGEN OGEN ESTRATEST HS ALORA Patch Biweekly /24HR ALORA Patch Biweekly 0.05 /24HR Estradiol TD Patch Biweekly 0.05 /24HR ALORA Patch Biweekly /24HR ALORA Patch Biweekly 0.1 /24HR Estradiol TD Patch Biweekly 0.1 /24HR Estradiol TD Patch Weekly /24HR Estradiol TD Patch Weekly /24HR (37.5 MCG/24HR) Estradiol TD Patch Weekly 0.05 /24HR Estradiol TD Patch Weekly 0.06 /24HR Estradiol TD Patch Weekly /24HR Estradiol TD Patch Weekly 0.1 /24HR Estropipate Tab 0.75 Estropipate Tab 1.5 Estropipate Tab 3 Esterified Estrogens & Methyltestosterone Tab Limited to Female; Max DS/DU=Lesser Of Max Days Sply=28/Max Qty=8 Limited to Female; Max DS/DU=Lesser Of Max Days Sply=28/Max Qty=8 Limited to Female; Max DS/DU=Lesser Of Max Days Sply=28/Max Qty=8 Limited to Female; Max DS/DU=Lesser Of Max Days Sply=28/Max Qty=8 Limited to Female; Max DS/DU=Lesser Of Max Days Sply=28/Max Qty=8 Limited to Female; Max DS/DU=Lesser Of Max Days Sply=28/Max Qty=8 Limited to Female; Max DS/DU=Lesser Of Max Days Sply=28/Max Qty=4 Limited to Female; Max DS/DU=Lesser Of Max Days Sply=28/Max Qty=4 Limited to Female; Max DS/DU=Lesser Of Max Days Sply=28/Max Qty=4 Limited to Female; Max DS/DU=Lesser Of Max Days Sply=28/Max Qty=4 Limited to Female; Max DS/DU=Lesser Of Max Days Sply=28/Max Qty=4 Limited to Female; Max DS/DU=Lesser Of Max Days Sply=28/Max Qty=4 Limited to Female; Daily Dosage=1 Limited to Female; Daily Dosage=1 Limited to Female; Daily Dosage=2 ESTRATEST Esterified Estrogens & Methyltestosterone Tab PREMPRO Tab Limited to Female

23 PREMPRO Tab PREMPRO Tab PREMPRO Tab ACTIVELLA TABLET CONTRACEPTIVES NOR-QD, ORTHO MICRON DEPO-PROVERA PLAN B PLAN B COMBIPATCH TD PTTW /DAY COMBIPATCH TD PTTW /DAY Norethindrone Tab 0.35 Medroxyprogesterone Acetate IM Susp 150 /ML DEPO-SQ PROV Subcutaneous Susp 104 /0.65ML Levonorgestrel Tab 0.75 PLAN B Tab 1.5 ELLA Tab 30 ORTHO EVRA TD PTWK MCG/24HR NUVARING VA Ring /24HR Limited to Female; Max Qty=1/claim; Min DS=84 Limited to Female; Max Qty=1/claim; Min DS=84 Limited to Female; Max Qty=4/365 days Max Qty=4/365 days; 1/21 days Max Qty=4/365 days Max Qty=3/claim; Min DS=28 Limited to Female; Max Qty=1/claim DESOGEN, DESOGEN- Desogestrel & Ethinyl Estradiol Tab 28, ORTHO-CEPT MCG Desogest-Eth Estrad & Eth Estrad Tab /.01 (21/5) Limited to Female Limited to Female YAZ YASMIN 28 Drospirenone-Ethinyl Estradiol Tab Drospirenone-Ethinyl Estradiol Tab Ethynodiol Diacetate & Ethinyl Estradiol Tab 1-35MCG Limited to Female Limited to Female Limited to Female ZOVIA 1/50E Tab 1-50MCG Limited to Female NORDETTE, NORDETTE-28 OVCON-35 BREVICON, MODICON NORINYL, ORTHO- NOVUM LOESTRIN LOESTRIN 21 LO/OVRAL, LO/OVRAL-28 Levonorgestrel & Ethinyl Estradiol Tab MCG Levonorgestrel & Ethinyl Estradiol Tab MCG Norethindrone & Ethinyl Estradiol Tab MCG Norethindrone & Ethinyl Estradiol Tab MCG Norethindrone & Ethinyl Estradiol Tab 1-35MCG OVCON TABLET Norethindrone Ace & Ethinyl Estradiol Tab 1-20MCG Norethindrone Ace & Ethinyl Estradiol Tab MCG Norethindrone & Mestranol Tab 1-50MCG Norgestrel & Ethinyl Estradiol Tab MCG NECON, NORINYL Limited to Female Limited to Female Limited to Female Limited to Female Limited to Female Limited to Female Limited to Female Limited to Female Limited to Female Limited to Female; Daily Dosage=2 OGESTREL Tab MCG Limited to Female ORTHO-CYCLEN Norgestimate & Ethinyl Estradiol Tab MCG Limited to Female

24 LOESTRIN FE Norethindrone Ace & Ethinyl Estradiol-FE Tab 1-20MCG LOESTRIN 24-FE Tab 1-20 MCG (24 Limited to Female LOESTRIN FE MIRCETTE 28 DAY TABLET CYCLESSA ORTHO-NOVUM TRI-NORINYL Norethindrone Ace & Ethinyl Estradiol-FE Tab MCG MIRCETTE 28 DAY TABLET NECON Tab /1-35 -MCG (10/11) Desogest-Ethinyl Estrad Tab / / Levonorgestrel-Eth Estrad Tab.05-30/ / MCG ORTHO-NOVUM Tab / /1-35 -MCG Norethindrone-Eth Estradiol Tab /1-35/ MCG Limited to Female Limited to Female Limited to Female Limited to Female Norgestimate-Eth Estrad Tab / / MCG ORTHO TRI-, ORTHO TRI-CY ORTHO TRI- Norgestimate-Eth Estrad Tab / / MCG PROGESTINS SEASONALE SEASONIQUE PROVERA PROVERA PROVERA AYGESTIN Levonorgestrel & Ethinyl Estradiol (91-Day) Tab SEASONIQUE Tab (84) & Eth Est Tab 0.01(7) Medroxyprogesterone Acetate Tab 2.5 Medroxyprogesterone Acetate Tab 5 Medroxyprogesterone Acetate Tab 10 Norethindrone Acetate Tab 5 Limited to Female; Max Qty=91/claim; Min DS=91 Limited to Female; Max Qty=91/claim; Min DS=91 PROMETRIUM PROMETRIUM 100 CAPSULE Max Qty=30/30 days PROMETRIUM PROMETRIUM 200 CAPSULE Max Qty=30/30 days ANTIDIABETICS Insulin Aspart Inj 100 U/ML NOVOLOG VIALS Max Qty=40/30 days Insulin Glargine Inj 100 U/ML LANTUS VIALS Max Qty=30/30 days APIDRA 100 UNITS/ML VIAL Max Qty=40/30 days Insulin Lispro (Human) Inj 100 U/ML HUMALOG VIALS Max Qty=40/30 days HUMULIN R, Insulin Regular (Human) Inj 100 HUMULIN R, U/ML NOVOLIN R, Max Qty=40/30 days RELION R VIALS Insulin Regular (Human) Inj 100 U/ML HUMULIN R 500 UNITS/ML VIAL HUMULIN R, HUMULIN R, NOVOLIN R, RELION R VIALS Max Qty=40/30 days

25 Insulin Isophane (Human) Inj 100 U/ML Insulin Isophane (Human) Inj 100 U/ML Insulin Aspart & Aspart Prot (Human) Inj 100 U/ML (30-70) HUMULIN N, HUMULIN N PN, HUMULIN N PN, NOVOLIN N, RELION N VIALS HUMULIN N, HUMULIN N PN, HUMULIN N PN, NOVOLIN N, RELION N VIALS NOVOLOG MIX VIALS Max Qty=40/30 days Max Qty=40/30 days Max Qty=40/30 days Insulin Lispro Prot & Lispro (Human) Inj 100 Unit/ML (75-25) HUMALOG MIX VIALS Max Qty=40/30 days Insulin Lispro Prot & Lispro (Human) Inj 100 Unit/ML (50-50) HUMALOG MIX VIALS Max Qty=40/30 days Insulin Isophane & Regular (Human) Inj 100 U/ML (70-30) HUMULIN, NOVOLIN, NOVOLIN 70/, RELION 70/30 VIALS Max Qty=40/30 days Insulin Isophane & Regular (Human) Inj 100 U/ML (70-30) HUMULIN, NOVOLIN, NOVOLIN 70/, RELION 70/30 VIALS Max Qty=40/30 days CHLORPROPAMIDE 100 TABLE DIABINESE CHLORPROPAMIDE 250 TABLE AMARYL Glimepiride Tab 1 AMARYL Glimepiride Tab 2 AMARYL Glimepiride Tab 4 GLUCOTROL Glipizide Tab 5 GLUCOTROL Glipizide Tab 10 GLUCOTROL XL Glipizide Tab SR 24HR 2.5 GLUCOTROL XL Glipizide Tab SR 24HR 5 GLUCOTROL XL Glipizide Tab SR 24HR 10 Glyburide Tab 1.25 MICRONASE Glyburide Tab 2.5 MICRONASE Glyburide Tab 5 GLYNASE GLYNASE GLYNASE Glyburide Micronized Tab 1.5 Glyburide Micronized Tab 3 Glyburide Micronized Tab 6 TOLAZAMIDE 250 TABLET TOLAZAMIDE 500 TABLET TOLBUTAMIDE 500 TABLET GLUCOPHAGE Metformin HCl Tab 500 Daily Dosage=4 GLUCOPHAGE Metformin HCl Tab 850 GLUCOPHAGE Metformin HCl Tab 1000 GLUCOPHAGE Metformin HCl Tab SR 24HR 500 Daily Dosage=4 GLUCOPHAGE Metformin HCl Tab SR 24HR 750 Daily Dosage=3 STARLIX NATEGLINIDE 60 TABLET STARLIX NATEGLINIDE 120 TABLET

26 Glucagon (rdna) For Inj Kit 1 Max Fills=1/30 days; GLUCAGEN Inj 1 (Base Equiv) Max Fills=1/30 days; Glucose Chew Tab 4 GM Max Qty=50/30 days Glucose Chew Tab 5 GM Max Qty=50/30 days GLUTOSE 15 GEL PRECOSE ACARBOSE 25 TABLET Daily Dosage=3 PRECOSE ACARBOSE 50 TABLET Daily Dosage=3 PRECOSE ACARBOSE 100 TABLET Daily Dosage=3 TRADJENTA TAB 5 ONGLYZA 2.5 TABLET ONGLYZA 5 TABLET ACTOS Tab 15 (Base Equiv) ACTOS Tab 30 (Base Equiv) ACTOS Tab 45 (Base Equiv) JENTADUETO JENTADUETO JENTADUETO KOMBIGLYZE XR 2.5-1,000 METAGLIP METAGLIP METAGLIP GLUCOVANCE GLUCOVANCE GLUCOVANCE THYROID AGENTS SYNTHROID SYNTHROID SYNTHROID SYNTHROID SYNTHROID SYNTHROID SYNTHROID SYNTHROID SYNTHROID SYNTHROID KOMBIGLYZE XR TABL KOMBIGLYZE XR 5-1,000 TA Glipizide-Metformin HCl Tab Glipizide-Metformin HCl Tab Glipizide-Metformin HCl Tab Glyburide-Metformin Tab Glyburide-Metformin Tab Glyburide-Metformin Tab ACTOPLUS MET Tab ACTOPLUS MET Tab Levothyroxine Sodium Tab Levothyroxine Sodium Tab 0.05 Levothyroxine Sodium Tab Levothyroxine Sodium Tab Levothyroxine Sodium Tab 0.1 Levothyroxine Sodium Tab Levothyroxine Sodium Tab Levothyroxine Sodium Tab Levothyroxine Sodium Tab 0.15 Levothyroxine Sodium Tab 0.175

27 SYNTHROID Levothyroxine Sodium Tab 0.2 SYNTHROID CYTOMEL CYTOMEL Levothyroxine Sodium Tab 0.3 Liothyronine Sodium Tab 5 MCG Liothyronine Sodium Tab 25 MCG CYTOMEL ARMOUR THYRO ARMOUR THYRO ARMOUR THYRO TAPAZOLE TAPAZOLE Liothyronine Sodium Tab 50 MCG THYROLAR-1/4 Tab 15 THYROLAR-1/2 Tab 30 THYROLAR-1 Tab 60 THYROLAR-2 Tab 120 THYROLAR-3 Tab 180 ARMOUR Thyroid Tab 15 (1/4 Grain) ARMOUR Thyroid Tab 30 (1/2 Grain) Thyroid Tab 32.5 ARMOUR Thyroid Tab 60 (1 Grain) Thyroid Tab 65 Thyroid Tab 90 (1 1/2 Grain) ARMOUR Thyroid Tab 120 (2 Grain) Thyroid Tab 130 ARMOUR Thyroid Tab 180 (3 Grain) Thyroid Tab 195 ARMOUR Thyroid Tab 240 (4 Grain) ARMOUR Thyroid Tab 300 (5 Grain) Methimazole Tab 5 Methimazole Tab 10 Propylthiouracil Tab 50 NATURE-THROI, WESTHROID NATURE-THROI, WESTHROID NATURE-THROI, WESTHROID NATURE-THROI, WESTHROID OXYTOCICS METHERGINE METHERGINE Tab 0.2 ENDOCRINE AND METABOLIC AGENTS - MISCELLANEOUS FOSAMAX Alendronate Sodium Tab 5 FOSAMAX Alendronate Sodium Tab 10 FOSAMAX Alendronate Sodium Tab 35 Daily Dosage=.15 FOSAMAX Alendronate Sodium Tab 40 FOSAMAX Alendronate Sodium Tab 70 Daily Dosage=.15 MIACALCIN FOSAMAX Oral Soln 70 /75ML MIACALCIN Inj 200 IU/ML Calcitonin (Salmon) Nasal Soln 200 IU/ACT EVISTA HCl Tab Max Qty=2/claim Min DS=30; Package Limit=1/claim DDAVP Desmopressin Acetate Tab 0.1 DDAVP Desmopressin Acetate Tab 0.2 DDAVP DDAVP Desmopressin Acetate Nasal Soln 0.01% (Refrigerated) Desmopressin Acetate Nasal Spray Soln 0.01% (Refrigerated) Desmopressin Acetate Nasal Spray Soln 0.01% Max Qty=5/claim Max Qty=5/claim Max Qty=5/claim

28 CARNITOR Levocarnitine Tab 330 Daily Dosage=3 CARNITOR, Levocarnitine Oral Soln 1 CARNITOR SF GM/10ML (10%) Daily Dosage=30 CARNITOR, Levocarnitine Oral Soln 1 CARNITOR SF GM/10ML (10%) Daily Dosage=30 ROCALTROL Calcitriol Cap 0.25 MCG ROCALTROL Calcitriol Cap 0.5 MCG ROCALTROL CALCITRIOL 1 MCG/ML SOLUTIO CARDIOTONICS LANOXIN Digoxin Tab LANOXIN Digoxin Tab 0.25 Digoxin Oral Soln 0.05 /ML ANTIANGINAL AGENTS ISORDIL Isosorbide Dinitrate Tab 5 Isosorbide Dinitrate Tab 10 Isosorbide Dinitrate Tab 20 Isosorbide Dinitrate Tab 30 ISORDIL 40 TABLET Isosorbide Dinitrate Tab CR 40 Isosorbide Dinitrate SL Tab 2.5 Isosorbide Dinitrate SL Tab 5 MONOKET Isosorbide Mononitrate Tab 10 ISMO, MONOKET Isosorbide Mononitrate Tab 20 IMDUR Isosorbide Mononitrate Tab SR 24HR 30 IMDUR Isosorbide Mononitrate Tab SR 24HR 60 IMDUR Isosorbide Mononitrate Tab SR 24HR 120 Nitroglycerin Cap CR 2.5 Nitroglycerin Cap CR 6.5 Nitroglycerin Cap CR 9 NITROSTAT SL Tab 0.3 NITROSTAT SL Tab 0.4 NITROSTAT SL Tab 0.6 NITRO-BID Oint 2% NITRO-DUR Nitroglycerin TD Patch 24HR 0.1 /HR NITRO-DUR Nitroglycerin TD Patch 24HR 0.2 /HR NITRO-DUR Nitroglycerin TD Patch 24HR 0.4 /HR NITRO-DUR Nitroglycerin TD Patch 24HR 0.6 /HR BETA BLOCKERS CORGARD Nadolol Tab 20 CORGARD Nadolol Tab 40 CORGARD Nadolol Tab 80 Nadolol Tab 160 Pindolol Tab 5 Pindolol Tab 10 Propranolol HCl Tab 10 Propranolol HCl Tab 20 Propranolol HCl Tab 40 Propranolol HCl Tab 60 Propranolol HCl Tab 80 Propranolol HCl Oral Soln 20 /5ML

29 INDERAL LA INDERAL LA INDERAL LA INDERAL LA BETAPACE BETAPACE BETAPACE BETAPACE Propranolol HCl Oral Soln 40 /5ML Propranolol HCl Cap SR 24HR 60 Propranolol HCl Cap SR 24HR 80 Propranolol HCl Cap SR 24HR 120 Propranolol HCl Cap SR 24HR 160 Sotalol HCl Tab 80 Sotalol HCl Tab 120 Sotalol HCl Tab 160 Sotalol HCl Tab 240 BETAPACE AF Sotalol HCl (AFIB/AFL) Tab 80 BETAPACE AF Sotalol HCl (AFIB/AFL) Tab 120 BETAPACE AF Sotalol HCl (AFIB/AFL) Tab 160 Timolol Maleate Tab 5 Timolol Maleate Tab 10 Timolol Maleate Tab 20 SECTRAL Acebutolol HCl Cap 200 SECTRAL Acebutolol HCl Cap 400 TENORMIN Atenolol Tab 25 TENORMIN Atenolol Tab 50 TENORMIN Atenolol Tab 100 KERLONE BETAXOLOL 10 TABLET KERLONE BETAXOLOL 20 TABLET ZEBETA Bisoprolol Fumarate Tab 5 ZEBETA Bisoprolol Fumarate Tab 10 TOPROL XL Metoprolol Succinate Tab SR 24HR 25 TOPROL XL Metoprolol Succinate Tab SR 24HR 50 TOPROL XL Metoprolol Succinate Tab SR 24HR 100 TOPROL XL Metoprolol Succinate Tab SR 24HR 200 Metoprolol Tartrate Tab 25 LOPRESSOR Metoprolol Tartrate Tab 50 Daily Dosage=3 LOPRESSOR Metoprolol Tartrate Tab 100 COREG Carvedilol Tab Daily Dosage=3 COREG Carvedilol Tab 6.25 Daily Dosage=3 COREG Carvedilol Tab 12.5 Daily Dosage=3 COREG Carvedilol Tab 25 Daily Dosage=4 TRANDATE Labetalol HCl Tab 100 Daily Dosage=3 TRANDATE Labetalol HCl Tab 200 Daily Dosage=6 TRANDATE Labetalol HCl Tab 300 Daily Dosage=8 CALCIUM CHANNEL BLOCKERS NORVASC Amlodipine Besylate Tab 2.5 NORVASC Amlodipine Besylate Tab 5 NORVASC Amlodipine Besylate Tab 10 CARDIZEM Diltiazem HCl Tab 30 Daily Dosage=3 CARDIZEM Diltiazem HCl Tab 60 Daily Dosage=3 CARDIZEM Diltiazem HCl Tab 90 Daily Dosage=3 CARDIZEM Diltiazem HCl Tab 120 Daily Dosage=3 Diltiazem HCl Cap SR 12HR 60 Diltiazem HCl Cap SR 12HR 90 Diltiazem HCl Cap SR 12HR 120

30 DILACOR XR DILACOR XR DILACOR XR TIAZAC TIAZAC TIAZAC TIAZAC TIAZAC TIAZAC CARDIZEM CD CARDIZEM CD CARDIZEM CD CARDIZEM CD CARDIZEM CD Diltiazem HCl Cap SR 24HR 120 Diltiazem HCl Cap SR 24HR 180 Diltiazem HCl Cap SR 24HR 240 Diltiazem HCl Extended Release Beads Cap SR 24HR 120 Diltiazem HCl Extended Release Beads Cap SR 24HR 180 Diltiazem HCl Extended Release Beads Cap SR 24HR 240 Diltiazem HCl Extended Release Beads Cap SR 24HR 300 Diltiazem HCl Extended Release Beads Cap SR 24HR 360 Diltiazem HCl Extended Release Beads Cap SR 24HR 420 Diltiazem HCl Coated Beads Cap SR 24HR 120 Diltiazem HCl Coated Beads Cap SR 24HR 180 Diltiazem HCl Coated Beads Cap SR 24HR 240 Diltiazem HCl Coated Beads Cap SR 24HR 300 CARDIZEM CD 360 CAPSULE CARDIZEM LA 120 TABLET CARDIZEM LA CARDIZEM LA CARDIZEM LA CARDIZEM LA CARDIZEM LA 180 TABLET CARDIZEM LA 240 TABLET CARDIZEM LA 300 TABLET CARDIZEM LA 360 TABLET CARDIZEM LA CARDIZEM LA 420 TABLET PLENDIL Felodipine Tab SR 24HR 2.5 PLENDIL Felodipine Tab SR 24HR 5 PLENDIL Felodipine Tab SR 24HR 10 Nicardipine HCl Cap 20 Daily Dosage=3 Nicardipine HCl Cap 30 Daily Dosage=3 PROCARDIA Nifedipine Cap 10 Daily Dosage=4 Nifedipine Cap 20 Daily Dosage=4 ADALAT CC Nifedipine Tab SR 24HR 30 ADALAT CC Nifedipine Tab SR 24HR 60 ADALAT CC Nifedipine Tab SR 24HR 90 PROCARDIA XL Nifedipine Tab SR 24HR Osmotic 30 PROCARDIA XL Nifedipine Tab SR 24HR Osmotic 60 PROCARDIA XL Nifedipine Tab SR 24HR Osmotic 90 CALAN Verapamil HCl Tab 40 Daily Dosage=3 CALAN Verapamil HCl Tab 80 Daily Dosage=3 CALAN Verapamil HCl Tab 120 Daily Dosage=3 CALAN SR, ISOPTIN SR Verapamil HCl Tab CR 120 CALAN SR, ISOPTIN SR Verapamil HCl Tab CR 180

31 CALAN SR, ISOPTIN SR VERELAN VERELAN VERELAN VERELAN ANTIARRHYTHMICS NORPACE NORPACE Verapamil HCl Tab CR 240 Verapamil HCl Cap SR 24HR 120 Verapamil HCl Cap SR 24HR 180 Verapamil HCl Cap SR 24HR 240 Verapamil HCl Cap SR 24HR 360 Disopyramide Phosphate Cap 100 Disopyramide Phosphate Cap 150 NORPACE CR 100 CAPSULE PRONESTYL NORPACE SR 12HR 150 Procainamide HCl Cap 250 Procainamide HCl Cap 500 Procainamide HCl Tab CR 750 Quinidine Gluconate Tab CR 324 Quinidine Sulfate Tab 200 Quinidine Sulfate Tab 300 Quinidine Sulfate Tab CR 300 TAMBOCOR TAMBOCOR TAMBOCOR RYTHMOL RYTHMOL RYTHMOL CORDARONE PACERONE Mexiletine HCl Cap 150 Mexiletine HCl Cap 200 Mexiletine HCl Cap 250 Flecainide Acetate Tab 50 Flecainide Acetate Tab 100 Flecainide Acetate Tab 150 Propafenone HCl Tab 150 Propafenone HCl Tab 225 Propafenone HCl Tab 300 Amiodarone HCl Tab 200 AMIODARONE HCL 400 TABLE TIKOSYN Cap 125 MCG (0.125 ) TIKOSYN Cap 250 MCG (0.25 ) TIKOSYN Cap 500 MCG (0.5 ) ANTIHYPERTENSIVES LOTENSIN Benazepril HCl Tab 5 LOTENSIN Benazepril HCl Tab 10 LOTENSIN Benazepril HCl Tab 20 LOTENSIN Benazepril HCl Tab 40 CAPOTEN Captopril Tab 12.5 Daily Dosage=3 CAPOTEN Captopril Tab 25 Daily Dosage=3 CAPOTEN Captopril Tab 50 Daily Dosage=3 CAPOTEN Captopril Tab 100 Daily Dosage=3 VASOTEC Enalapril Maleate Tab 2.5 VASOTEC Enalapril Maleate Tab 5 VASOTEC Enalapril Maleate Tab 10 VASOTEC Enalapril Maleate Tab 20 MONOPRIL Fosinopril Sodium Tab 10 MONOPRIL Fosinopril Sodium Tab 20 MONOPRIL Fosinopril Sodium Tab 40 ZESTRIL Lisinopril Tab 2.5 PRINIVIL, ZESTRIL Lisinopril Tab 5 Biopharmacy benefit via Biopharmacy benefit via Biopharmacy benefit via

32 PRINIVIL, ZESTRIL Lisinopril Tab 10 PRINIVIL, ZESTRIL Lisinopril Tab 20 ZESTRIL Lisinopril Tab 30 ZESTRIL Lisinopril Tab 40 UNIVASC MOEXIPRIL HCL 7.5 TABLET UNIVASC MOEXIPRIL HCL 15 TABLET ACEON PERINDOPRIL ERBUMINE 2 T ACEON PERINDOPRIL ERBUMINE 4 T ACEON PERINDOPRIL ERBUMINE 8 T ACCUPRIL Quinapril HCl Tab 5 ACCUPRIL Quinapril HCl Tab 10 ACCUPRIL Quinapril HCl Tab 20 ACCUPRIL Quinapril HCl Tab 40 ALTACE Ramipril Cap 1.25 ALTACE Ramipril Cap 2.5 ALTACE Ramipril Cap 5 ALTACE Ramipril Cap 10 MAVIK Trandolapril Tab 1 MAVIK Trandolapril Tab 2 MAVIK Trandolapril Tab 4 Irbesartan 75 TABLET Irbesartan 150 TABLET Irbesartan 300 TABLET COZAAR Losartan Potassium Tab 25 COZAAR Losartan Potassium Tab 50 COZAAR Losartan Potassium Tab 100 DIOVAN Tab 40 DIOVAN Tab 80 DIOVAN Tab 160 DIOVAN Tab 320 ; Step Therapy ; Step Therapy ; Step Therapy ; Step Therapy Prior use of Lisinopril, Enalapril, Fosinopril, Ramipril, Losartan Prior use of Lisinopril, Enalapril, Fosinopril, Ramipril, Losartan Prior use of Lisinopril, Enalapril, Fosinopril, Ramipril, Losartan Prior use of Lisinopril, Enalapril, Fosinopril, Ramipril, Losartan CATAPRES CATAPRES CATAPRES TENEX TENEX CARDURA CARDURA CARDURA CARDURA MINIPRESS MINIPRESS MINIPRESS HYTRIN Clonidine HCl Tab 0.1 Clonidine HCl Tab 0.2 Clonidine HCl Tab 0.3 Guanabenz Acetate Tab 4 Guanabenz Acetate Tab 8 Guanfacine HCl Tab 1 Guanfacine HCl Tab 2 Methyldopa Tab 250 Methyldopa Tab 500 Doxazosin Mesylate Tab 1 Doxazosin Mesylate Tab 2 Doxazosin Mesylate Tab 4 Doxazosin Mesylate Tab 8 Prazosin HCl Cap 1 Prazosin HCl Cap 2 Prazosin HCl Cap 5 Terazosin HCl Cap 1

33 HYTRIN HYTRIN HYTRIN APRESOLINE LOTREL LOTREL LOTREL LOTREL LOTREL LOTREL LOTENSIN HCT LOTENSIN HCT LOTENSIN HCT LOTENSIN HCT CAPOZIDE CAPOZIDE CAPOZIDE CAPOZIDE Terazosin HCl Cap 2 Terazosin HCl Cap 5 Terazosin HCl Cap 10 Reserpine Tab 0.1 Reserpine Tab 0.25 Hydralazine HCl Tab 10 Hydralazine HCl Tab 25 Hydralazine HCl Tab 50 Hydralazine HCl Tab 100 Minoxidil Tab 2.5 Minoxidil Tab 10 Benazepril HCl-Amlodipine Besylate Cap Benazepril HCl-Amlodipine Besylate Cap 10-5 Benazepril HCl-Amlodipine Besylate Cap 20-5 AMLODIPINE-BENAZEPRIL 5-40 Amlodipine Besylate-Benazepril HCl Cap AMLODIPINE-BENAZEPRIL Benazepril & Hydrochlorothiazide Tab Benazepril & Hydrochlorothiazide Tab Benazepril & Hydrochlorothiazide Tab Benazepril & Hydrochlorothiazide Tab Captopril & Hydrochlorothiazide Tab Captopril & Hydrochlorothiazide Tab Captopril & Hydrochlorothiazide Tab Captopril & Hydrochlorothiazide Tab Daily Dosage=3 0 Daily Dosage=3 Enalapril Maleate & Hydrochlorothiazide Tab VASERETIC Enalapril Maleate & Hydrochlorothiazide Tab MONOPRIL HCT MONOPRIL HCT PRINZIDE, ZESTORETIC PRINZIDE, ZESTORETIC PRINZIDE, ZESTORETIC Fosinopril Sodium & Hydrochlorothiazide Tab Fosinopril Sodium & Hydrochlorothiazide Tab Lisinopril & Hydrochlorothiazide Tab Lisinopril & Hydrochlorothiazide Tab Lisinopril & Hydrochlorothiazide Tab UNIRETIC MOEXIPRIL-HCTZ UNIRETIC UNIRETIC MOEXIPRIL-HCTZ TAB MOEXIPRIL-HCTZ TAB

34 ACCURETIC ACCURETIC ACCURETIC TENORETIC TENORETIC ZIAC ZIAC ZIAC QUINAPRIL-HCTZ TAB QUINAPRIL-HCTZ TAB QUINAPRIL-HCTZ TAB Atenolol & Chlorthalidone Tab Atenolol & Chlorthalidone Tab Bisoprolol & Hydrochlorothiazide Tab Bisoprolol & Hydrochlorothiazide Tab Bisoprolol & Hydrochlorothiazide Tab LOPRESS HCT LOPRESS HCT LOPRESS HCT CORZIDE CORZIDE AVALIDE AVALIDE HYZAAR HYZAAR HYZAAR Metoprolol & Hydrochlorothiazide Tab Metoprolol & Hydrochlorothiazide Tab Metoprolol & Hydrochlorothiazide Tab DUTOPROL TABLET DUTOPROL TABLET DUTOPROL TABLET NADOLOL-BENDROFLU 40-5 T NADOLOL-BENDROFLU 80-5 T Propranolol & Hydrochlorothiazide Tab Propranolol & Hydrochlorothiazide Tab Irbesartan-Hydrochlorothiazide Irbesartan-Hydrochlorothiazide Losartan Potassium & Hydrochlorothiazide Tab Losartan Potassium & Hydrochlorothiazide Tab Losartan Potassium & Hydrochlorothiazide Tab DIOVAN HCT Tab DIOVAN HCT Tab DIOVAN HCT Tab ; Step Therapy ; Step Therapy ; Step Therapy Prior use of Lisinopril, Enalapril, Fosinopril, Ramipril, Losartan- HCT Prior use of Lisinopril, Enalapril, Fosinopril, Ramipril, Losartan- HCT Prior use of Lisinopril, Enalapril, Fosinopril, Ramipril, Losartan- HCT

35 DIOVAN HCT Tab DIOVAN HCT Tab METHYLDOPA-HCTZ T METHYLDOPA-HCTZ T ; Step Therapy ; Step Therapy Prior use of Lisinopril, Enalapril, Fosinopril, Ramipril, Losartan- HCT Prior use of Lisinopril, Enalapril, Fosinopril, Ramipril, Losartan- HCT Hydralazine & HCTZ Cap Hydralazine & HCTZ Cap DIURETICS DIAMOX SEQUE NEPTAZANE NEPTAZANE LASIX LASIX LASIX Acetazolamide Tab 125 Acetazolamide Tab 250 Acetazolamide Cap SR 12HR 500 Methazolamide Tab 25 Methazolamide Tab 50 Bumetanide Tab 0.5 Bumetanide Tab 1 Bumetanide Tab 2 Furosemide Tab 20 Furosemide Tab 40 Furosemide Tab 80 Furosemide Oral Soln 8 /ML Furosemide Oral Soln 10 /ML DEMADEX Torsemide Tab 5 DEMADEX Torsemide Tab 10 DEMADEX Torsemide Tab 20 DEMADEX Torsemide Tab 100 MIDAMOR AMILORIDE HCL 5 TABLET Daily Dosage=4 ALDACTONE ALDACTONE ALDACTONE MICROZIDE Spironolactone Tab 25 Spironolactone Tab 50 Spironolactone Tab 100 CHLOROTHIAZIDE 250 TABLE CHLOROTHIAZIDE 500 TABLE Chlorthalidone Tab 25 Chlorthalidone Tab 50 Chlorthalidone Tab 100 Hydrochlorothiazide Cap 12.5 ZAROXOLYN ZAROXOLYN ZAROXOLYN ALDACTAZIDE HYDROCHLOROTHIAZIDE 12.5 Hydrochlorothiazide Tab 25 Hydrochlorothiazide Tab 50 Indapamide Tab 1.25 Indapamide Tab 2.5 Metolazone Tab 2.5 Metolazone Tab 5 Metolazone Tab 10 AMILORIDE HCL-HCTZ 5-50 Spironolactone & Hydrochlorothiazide Tab 25-25

36 DYAZIDE Triamterene & Hydrochlorothiazide Cap Triamterene & Hydrochlorothiazide Cap MAXZIDE-25 MAXZIDE Triamterene & Hydrochlorothiazide Tab Triamterene & Hydrochlorothiazide Tab VASOPRESSORS PROAMATINE PROAMATINE PROAMATINE Midodrine HCl Tab 2.5 Midodrine HCl Tab 5 Midodrine HCl Tab 10 Epinephrine Inj Device 0.15 /0.3ML (1:2000) Epinephrine Inj Device 0.3 /0.3ML (1:1000) Epinephrine Inj Device 0.3 /0.3ML (1:1000) Epinephrine Inj Device 0.3 /0.3ML (1:1000) EPIPEN-JR ADRENACLICK, EPINEPHRINE, EPIPEN, EPIPEN 2- PAK, TWINJECT... ADRENACLICK, EPINEPHRINE, EPIPEN, EPIPEN 2- PAK, TWINJECT... ADRENACLICK, EPINEPHRINE, EPIPEN, EPIPEN 2- PAK, TWINJECT... Max Qty=2/30 days Max Qty=2/30 days Max Qty=2/30 days Max Qty=2/30 days ANTIHYPERLIPIDEMICS QUESTRAN Cholestyramine Powder 4 GM QUESTRAN Cholestyramine Powder Packets 4 GM QUESTRAN Cholestyramine Light Powder 4 GM/DOSE QUESTRAN Cholestyramine Light Powder Packets 4 GM COLESTID Colestipol HCl Tab 1 GM LOFIBRA Fenofibrate Tab 54 Daily Dosage=3 LOFIBRA Fenofibrate Tab 160 LOFIBRA Fenofibrate Micronized Cap 67 LOFIBRA Fenofibrate Micronized Cap 134 LOFIBRA Fenofibrate Micronized Cap 200 LOPID Gemfibrozil Tab 600 Atorvastatin Calcium Tab 10 (Base Equivalent) Atorvastatin Calcium Tab 20 (Base Equivalent) Atorvastatin Calcium Tab 40 (Base Equivalent) Atorvastatin Calcium Tab 80 (Base Equivalent) MEVACOR Lovastatin Tab 10 MEVACOR Lovastatin Tab 20 MEVACOR Lovastatin Tab 40 PRAVACHOL Pravastatin Sodium Tab 10 PRAVACHOL Pravastatin Sodium Tab 20 PRAVACHOL Pravastatin Sodium Tab 40 PRAVACHOL Pravastatin Sodium Tab 80 ZOCOR Simvastatin Tab 5

37 ZOCOR Simvastatin Tab 10 ZOCOR Simvastatin Tab 20 ZOCOR Simvastatin Tab 40 CARDIOVASCULAR AGENTS - MISCELLANEOUS NIACINOL NIACIN FLUSH FREE 500 CA Papaverine HCl Cap CR 150 ANTIHISTAMINES Chlorpheniramine Maleate Cap CR 8 Chlorpheniramine Maleate Cap CR 12 CHLOR-TRIMET Chlorpheniramine Maleate Tab 4 Max Qty= 120/claim CHLOR-TRIMET CHLOR-TRIMET TAVIST, TAVIST-1 CHLORPHENIRAMINE ER 12 T ED CHLORPED DROPS Chlorpheniramine Maleate Syrup 2 /5ML Dexchlorpheniramine Maleate Tab CR 4 Dexchlorpheniramine Maleate Syrup 2 /5ML Clemastine Fumarate Tab 1.34 BENADRYL, BENADRYL DF BENADRYL, BENADRYL ALG BENADRYL, BENADRYL ALG BENADRYL ALL CLEMASTINE FUM 2.68 TAB Diphenhydramine HCl Cap 25 Diphenhydramine HCl Cap 50 Diphenhydramine HCl Tab 25 Diphenhydramine HCl Tab 25 Diphenhydramine HCl Tab 50 Diphenhydramine HCl Liquid 12.5 /5ML Diphenhydramine HCl Elixir 12.5 /5ML Diphenhydramine HCl Syrup 12.5 /5ML Promethazine HCl Tab 12.5 Promethazine HCl Tab 25 Promethazine HCl Tab 50 Promethazine HCl Syrup 6.25 /5ML Promethazine HCl Suppos 12.5 Promethazine HCl Suppos 25 Promethazine HCl Suppos 50 Cyproheptadine HCl Tab 4 Cyproheptadine HCl Syrup 2 /5ML Cetirizine HCl Tab 5 Daily Dosage=4 Daily Dosage=4 Daily Dosage=4 Daily Dosage=4 Daily Dosage=4 Max Qty= 240/claim Max Qty= 240/claim Max Qty= 240/claim Limited to Ages 2 and Older Limited to Ages 2 and Older Limited to Ages 2 and Older Limited to Ages 2 and Older Limited to Ages 2 and Older; Max Qty=12/claim Limited to Ages 2 and Older; Max Qty=12/claim Limited to Ages 2 and Older; Max Qty=12/claim

38 ZYRTEC, ZYRTEC ALLGY, ZYRTEC Cetirizine HCl Tab 10 HIVES ZYRTEC CHILD Cetirizine HCl Chew Tab 5 ZYRTEC, ZYRTEC CHILD Cetirizine HCl Chew Tab 10 ZYRTEC CHILD, ZYRTEC HIVES Cetirizine HCl Syrup 5 /5ML Max Qty= 240/claim FEXOFENADINE HCL 30 TABLET FEXOFENADINE HCL 60 TABLET FEXOFENADINE HCL 180 TABLET CLARITIN Loratadine Tab 10 CHILD'S CLARITIN 5 TAB C CLARITIN Loratadine Syrup 5 /5ML Max Qty= 240/claim CLARITIN, CLARITIN RDT Loratadine Rapidly-Disintegrating Tab 10 Branded/MS; Max Qty=31/31 days NASAL AGENTS - SYSTEMIC AND TOPICAL SUDAFD NASAL, SUDAFED, SUDAFED Pseudoephedrine HCl Tab 30 CONG Pseudoephedrine HCl Tab 60 SUDAFED CHLD Pseudoephedrine HCl Liq 15 /5ML Pseudoephedrine HCl Liq 30 /5ML Pseudoephedrine HCl Syrup 30 /5ML PEDIACARE Pseudoephedrine HCl Soln 7.5 /0.8ML Pseudoephedrine HCl Tab SR 12HR 120 Max Qty=62/31 days SUDAFED PE NASAL DECONGESTANT PE 10 Max Qty=24/claim PEDIACARE Phenylephrine HCl Soln 2.5 /5ML ADRENALIN HCl Nasal Soln 0.1% AFRIN, AFRIN 12 HR, AFRIN NODRIP, AFRIN SINUS, DRISTAN... AFRIN, AFRIN 12 HR, AFRIN NODRIP, AFRIN SINUS, DRISTAN... NEO-SYNEPHRI AFRIN 0.05% NOSE SPRAY MUCINEX FULL FORCE NASAL SP NOSE DROPS NASALIDE Flunisolide Nasal Soln 0.025% Max Qty=25/30 days NASAREL Flunisolide Nasal Soln 29 MCG/ACT FLONASE Fluticasone Propionate Nasal Susp 50 MCG/ACT Max Qty=16/30 days NASACORT AQ NASONEX Nasal Susp 50 MCG/ACT NASACORT AQ Nasal Inhal 55 MCG/ACT BACTROBAN Nasal Oint 2% Limited to Ages 2 and Older ; Max Qty=17/30 days; - Flonase Limited to Ages 2 and Older ; Max Qty=17/30 days; - Flonase - Flonase - Flonase

39 ATROVENT NAS ATROVENT NAS NASALCROM Ipratropium Bromide Nasal Soln 0.03% (21 MCG/SPRAY) Ipratropium Bromide Nasal Soln 0.06% (42 MCG/SPRAY) Cromolyn Sodium Nasal Aerosol Soln 5.2 /ACT (4%) Max Qty=31/30 days Max Qty=15/30 days Max Qty=26/30 days OCEAN NASAL Saline Nasal Spray 0.65% HYCODAN TESSALON PER TESSALON TRIAMINIC VICKS DAYQUI, VICKS NATURE DELSYM COUGH/COLD/ALLERGY AYR NASAL Soln 0.65% Saline Nasal Gel Hydrocodone w/ Homatropine Syrup /5ML Benzonatate Cap 100 Benzonatate Cap 200 Dextromethorphan HBr Liquid 7.5 /5ML DAY TIME COUGH LIQUID COUGH RELIEF LIQUID ROBITUSSIN PEDIATRIC COUGH Dextromethorphan Polistirex Liquid CR 30 /5ML GUAIFENESIN 200 TABLET DELSYM Max Qty=30/30 days; Max Fills=1/30 days Max Qty=240/6 days Max Qty=240/6 days ALLFEN MUCUS RELIEF 400 TABLET ORGANIDIN NR Guaifenesin Liquid 100 /5ML ROBITUSSIN Guaifenesin Syrup 100 /5ML Max Qty=240/6 days HUMIBID, MUCINEX MUCINEX Tab SR 12HR 600 DURATUSS G MUCINEX Tab SR 12HR 1200 Acetylcysteine Inhal Soln 10% Acetylcysteine Inhal Soln 20% Sodium Chloride Soln Nebu 0.45% EXCEDRIN SIN CEPACOL CHLD ADVIL COLD/ CHILD MOTRIN ALLERX-D BROVEX PEB DIMETAPP CLD Sodium Chloride Soln Nebu 0.9% Sodium Chloride Soln Nebu 3% Sodium Chloride Soln Nebu 10% Sodium Chloride Aero Soln 0.9% SINUS CONGESTION-PAIN CAPLE Pseudoephedrine w/ Acetaminophen Liquid (TYLENOL CHLD) /5ML Pseudoephedrine-Ibuprofen Tab Pseudoephedrine-Ibuprofen Susp /5ML Phenylephrine-APAP-Caffeine Tab Pseudoephedrine-Methscopolamine Tab SR 12HR LOHIST-PEB LIQUID DECON-A (Brompheniramine & Phenylephrine) Liqd 2-5 /ML DIMETAPP COLD & ALLERGY ELI Max Qty=240/claim Max Qty=120/30 days

40 DECON-A (Brompheniramine & Phenylephrine) Elixir 2-5 /5ML Brompheniramine & Pseudoephedrine Cap CR 6-60 Daily Dosage=4 BROMFED BROVEX PSB ZYRTEC-D ALG ED-A-HIST ED A-HIST DALLERGY RONDEC DECONAMINE DECONAMINE HISTEX DECONAMINE RYNATAN PED Brompheniramine & Pseudoephedrine Cap CR LOHIST-PSB LIQUID Brompheniramine & Pseudoephedrine Elixir 1-15 /5ML Brompheniramine & Pseudoephedrine Syrup 4-45 /5ML Brompheniramine & Pseudoephedrine Cap SR 12HR Brompheniramine & Pseudoephedrine Tab SR 12HR Cetirizine-Pseudoephedrine Tab SR 12HR ED-A-HIST TABLET COLD & ALLERGY TABLET ED A-HIST LIQUID Chlorpheniramine & Phenylephrine Liquid 1-2 /ML Chlorpheniramine & Phenylephrine Liquid /ML Chlorpheniramine & Phenylephrine Syrup /5ML Chlorpheniramine & Pseudoephedrine Cap CR SUDOGEST COLD & ALLERGY TAB LOHIST-D (Chlorpheniramine & Pseudoephedrine) Liquid 2-30 /5ML Chlorpheniramine & Pseudoephedrine Syrup 2-30 /5ML Chlorpheniramine & Pseudoephedrine Soln 2-30 /5ML Chlorpheniramine Tan- Phenylephrine Tan Susp /5ML Diphenhydramine & Pseudoephedrine Cap CR Diphenhydramine & Pseudoephedrine Tab Diphenhydramine & Pseudoephedrine Liquid /5ML Daily Dosage=4 Max Qty=240/claim Max Qty=240/claim Legend; Max Qty=30/claim Max Qty=240/claim Max Qty=240/claim Max Qty=240/claim Limited to Ages 3 and Older ; > 6 Daily Dosage=20; From age 3 through 5: Daily Dosage=10 Max Qty=240/claim

41 CLARITIN-D CLARITIN-D ACTIFED ALLERFRIM SYRUP TRIAMINIC NT NALEX-A EXTENDRYL DURAHIST PE SCOT-TUSSIN NOTUSS-DC Loratadine & Pseudoephedrine Tab SR 12HR Loratadine & Pseudoephedrine Tab SR 24HR Promethazine & Phenylephrine Syrup /5ML APRODINE TABLET Triprolidine & Pseudoephedrine Syrup /5ML DIMETAPP COLD & CONGEST LIQ CHILD DELSYM COUGH-COLD NIG Chlorphen-Ptolox-Phenyleph Liquid /5ML Chlorphen Tan-Pyrilamine Tan-PE Tan Susp /5ML DALLERGY (Chlorphen-PE- Methscopolamine) Tab DALLERGY (Chlorpheniramine-PE- Methscopolamine) Chew Tab Chlorphen-PE-Methscopolamine Syrup /5ML DEHISTINE (Chlorpheniramine-PE- Methscopolamine) Syrup /5ML Chlorphen-PE-Methscopolamine Tab SR 12HR DALLERGY PE (Chlorphen-PE- Methscopolamine) Tab SR 12HR ALLERGY MULTI-SYMPTOM CAPLE Chlorphen-Pseudoephedrine w/ APAP Cap FLU RELIEF THERAPY NIGHT LI ADT ROBITUSSIN COUGH- COLD-FLU Phenir-PE w/ Sod Salicyl & Caff Cit Liq /5ML ENDACOF-DC LIQUID Promethazine w/ Codeine Syrup /5ML PRO-CLEAR AC SYRUP Phenylephrine-Promethazine w/ Codeine Syrup /5ML PRO-RED AC SYRUP PHENYLHISTINE DH LIQUID Phenyleph-Chlorphen w/ Hydrocodone Syrup /5ML Phenyleph-Chlorphen w/ Hydrocodone Syrup /5ML Brand; Limited to Ages 2 and Older ; Max Qty=240/6 days 0 Limited to Ages 3 and Older; Limited to Ages 7 and Under; Max Qty=60/claim Max Qty=248/31 days Max Qty=240/6 days Max Qty=62/31 days Max Qty=62/31 days Limited to Ages 2 and Older ; Max Qty=240/claim Limited to Ages 2 and Older ; Max Qty=240/claim Max Qty=240/claim Max Qty=240/claim Phenyleph-Pyrilamine w/ Hydrocodone Syrup /5ML Max Qty=240/claim

42 NYQUIL COUGH, VICKS NYQUIL DIMETAPP DM PHENABID DM CODIMAL DM TRIAMINIC COMTREX COLD, THERAFLU SEV TYLENOL CHLD TYLENOL COLD, TYLENOL WARM Phenyleph-Pyrilamine w/ Hydrocodone Syrup /5ML *PE-Pheniramine-COD-Sod Salicylate-Sod Cit-Caff Liquid*** Acetaminophen w/ DM Liq /5ML TRIACTING COLD & COUGH LIQU Pseudoephedrine-DM Liqd /5ML Pseudoephedrine-DM Elixir /5ML Pseudoephedrine-DM Soln /0.8ML Chlorpheniramine-DM Liquid 2-15 /5ML DIMETAPP (Chlorpheniramine- DM) Syrup /5ML TRICODENE SF (Chlorpheniramine-DM) Syrup 2-10 /5ML NITE TIME COUGH LIQUID Promethazine-DM Syrup /5ML DIMETAPP DM COLD & COUGH EL Phenylephrine-Chlorphen-DM Chew Tab SR 12HR Phenylephrine-Chlorphen-DM Tab SR 12HR Phenylephrine-Pyrilamine-DM Syrup /5ML Pseudoephed-Chlorphen-DM Liq /5ML Pseudoephed-Chlorphen-DM Liq /5ML RESCON-DM LIQUID Pseudoephed-Bromphen-DM Liquid /5ML Pseudoephed-Bromphen-DM Elixir /5ML Pseudoephed-Bromphen-DM Syrup /5ML Pseudoephed-Bromphen-DM Syrup /5ML COLD HEAD CONGESTION CAPLET ADLT ROBITUSSIN COUGH- COLD- DELSYM MULTI-SYMPTOM NIGHT Max Qty=240/claim Max Qty=240/claim Max Qty=240/claim Max Qty=31/claim; Max Qty=30/6 days Max Qty=240/claim Max Qty=240/claim Limited to Ages 2 and Older ; Max Qty=240/claim Max Qty=240/claim Max Qty=240/claim Max Qty=240/claim Max Qty=240/claim Max Qty=240/claim Max Qty=240/claim Pseudoeph-Chlorphen-DM w/ APAP Syrup /20ML Pseudoeph-Doxylamine-DM w/ APAP Cap Pseudoeph-Doxylamine-DM w/ APAP Cap NYQUIL Pseudoeph-Doxylamine-DM w/ APAP Liq /30ML

43 MUCINEX COLD RESCON-GG NUMONYL NR DAY TIME COLD MULTI- SYMPTOM CAPLET Pseudoeph-Doxylamine-DM w/apap Liquid /30ML Phenylephrine-Guaifenesin Liqd /5ML Phenylephrine-Guaifenesin Liqd /5ML Phenylephrine-Potassium Guaiacolsulfonate Liqd 5-75 /5ML RESPAIRE-30 CAPSULE Pseudoephedrine-Guaifenesin Syrup /5ML MUCINEX D (Pseudoephedrine- Guaifenesin) Tab SR 12HR GUAIMAX-D (Pseudoephedrine- Guaifenesin) Tab SR 12HR MUCINEX D (Pseudoephedrine- Guaifenesin) Tab SR 12HR Phenylephrine-Chlorphen-GG Soln /ML CHEST CONGEST-PAIN RLF PE T LUSONEX PLUS (Phenylephrine- APAP-GG) Tab SR 12HR Dextromethorphan-Phenylephrine- APAP Cap Dextromethorphan-Phenyl-APAP Tab Max Qty=240/6 days Max Qty=240/claim Max Qty=210/claim Max Qty=210/claim Max Qty=60/claim; Max Qty=30/6 days TYLENOL COLD DAY TIME COLD & FLU RELIEF LITTLE COLDS (Dextromethorphan-Phenylephrine- APAP) Liqd /ML PRO-CLEAR TUSSI-ORGANI PROLEX DM GNP DAY TIME Pseudoephedrine w/ APAP-DM Caps Pseudoephedrine w/ APAP-DM Cap Pseudoephedrine w/ APAP-DM Liq /30ML PRO-CLEAR CAPS DIABETIC, DIABETIC TUS, TUSSO, Guaifenesin-Codeine Liquid /5ML Guaifenesin-Codeine Liquid /5ML Guaifenesin-Codeine Soln /5ML Dextromethorphan-Pot Guaiacolsulfonate Liqd /5ML CORICIDIN (Dextromethorphan- Guaifenesin) Cap MUCUS RELIEF DM TABLET DAYTIME MUCUS RELIEF DM LIQ Dextromethorphan-Guaifenesin Liquid /5ML

44 CHERACOL, CHERACOL-D ROBITUSSIN, ROBITUSSN DM Dextromethorphan-Guaifenesin Liquid /5ML Dextromethorphan-Guaifenesin Liquid /5ML BIOSPEC DMX, TRISPEC DMX (Dextromethorphan-Guaifenesin) Liquid /5ML SCOT-TUSSIN (Dextromethorphan- Guaifenesin) Liquid /5ML NORTUSS-EX (Dextromethorphan- Guaifenesin) Liquid /5ML Dextromethorphan-Guaifenesin Liquid /5ML Max Qty=240/claim Max Qty=240/claim HT-TUSS DM (Dextromethorphan- Guaifenesin) Elixir /5ML Max Qty=240/claim ROBITUSSN DM ROBITUSSN DM SCOT-TUSSIN MUCINEX CGH CORICIDAN CO ROBITUSSIN DONATUSSIN Dextromethorphan-Guaifenesin Syrup /5ML Dextromethorphan-Guaifenesin Syrup /5ML Dextromethorphan-Guaifenesin Syrup /5ML MUCINEX CGH (Dextromethorphan-Guaifenesin) Granules Packet MUCINEX DM (Dextromethorphan- Guaifenesin) Tab SR 12HR Dextromethorphan-Guaifenesin Tab SR 12HR Hydrocodone-Guaifenesin Tab Hydrocodone-Guaifenesin Liquid /5ML Hydrocodone-Guaifenesin Syrup 3-90 /5ML Hydrocodone-Guaifenesin Syrup /5ML Hydrocodone-Guaifenesin Tab SR 12HR Hydrocodone-Guaifenesin Tab SR 12HR ROBITUSSIN COUGH-COLD CF SY CHILD MUCINEX MULTI- SYMPTOM Phenylephrine w/ Hydrocodone-GG Syrup /5ML Pseudoephedrine w/ COD-GG Soln /5ML CAPMIST DM TABLET TUSNEL PEDIATRIC LIQUID Pseudoephedrine w/ DM-GG Liquid /5ML ADT ROBITUSSIN COUGH- COLD D DONATUSSIN DM SYRUP Pseudoephedrine w/ Hydrocodone- GG Liqd /5ML Max Qty=240/claim Max Qty=240/claim Max Qty=240/claim Max Qty=210/claim; Max Qty=240/claim Max Qty=240/6 days Max Qty=240/6 days

45 Pseudoephedrine w/ Hydrocodone- GG Liqd /5ML Pseudoephedrine w/ Hydrocodone- GG Elixir /5ML Max Qty=240/6 days TYLENOL COLD TYLENOL COLD TYLENOL COLD, TYLENOL WARM Pseudoephedrine-DM-GG w/ APAP Liq /15ML Phenyleph-Chlorphen w/ DM-GG Syrup /5ML DONATUSSIN (Phenyleph- Chlorphen w/ DM-GG) Syrup /5ML COLD MULTI-SYMPTOM CAPLET COLD HEAD CONGESTION CAPLET COLD MULTI-SYMPTOM DAYTIME Dextromethorphan-APAP- Chlorpheniramine Cap DIABETIC Max Qty=248/31 days Max Qty=240/claim TRIAMINIC FLU COUGH- FEVER S CHILD'S MAPAP COUGH-SINUS CHLD TYLENOL S CLEAR COUGH, Dextromethorphan-Doxylamine- TYLENOL CGH, APAP Liquid TYLENOL WARM /30ML ANTIASTHMATIC AND BRONCHODILATOR AGENTS Ipratropium Bromide Inhal Soln 0.02% ATROVENT HFA Inhal Aerosol 17 MCG/ACT SPIRIVA Inhal Cap 18 MCG (Base Equiv) Cromolyn Sodium Soln Nebu 20 INTAL /2ML Albuterol Inhal Aerosol 90 PROVENTIL MCG/ACT Albuterol Sulfate Tab 2 Albuterol Sulfate Tab 4 VENTOLIN Albuterol Sulfate Syrup 2 /5ML Max Qty=375/25 days Package Limit=2/month Min DS=25; Package Limit=1/claim Daily Dosage=8 Package Limit=2/month Albuterol Sulfate Soln Nebu 0.083% 2.5 ACCUNEB ACCUNEB VOSPIRE ER VOSPIRE ER Albuterol Sulfate Soln Nebu 0.5% (5 /ML) Albuterol Sulfate Soln Nebu 0.5% (5 /ML) Albuterol Sulfate Soln Nebu 0.63 /3ML (Base Equiv) Albuterol Sulfate Soln Nebu 1.25 /3ML (Base Equiv) PROAIR HFA, VENTOLIN HFA Inhal Aero 120 MCG/ACT (100MCG Base Equiv) Albuterol Sulfate Tab SR 12HR 4 Albuterol Sulfate Tab SR 12HR 8 FORADIL Inhal Cap 12 MCG PROAIR HFA, VENTOLIN HFA Max Qty=375/30 days Max Qty=375/30 days Package Limit=2/month Min DS=30; Package Limit=1/claim

46 Metaproterenol Sulfate Tab 10 Metaproterenol Sulfate Tab 20 BRETHINE BRETHINE DUONEB Metaproterenol Sulfate Syrup 10 /5ML Metaproterenol Sulfate Soln Nebu 0.4% Metaproterenol Sulfate Soln Nebu 0.6% SEREVENT DIS Aer Pow BA 50 MCG/DOSE (Base Equiv) Terbutaline Sulfate Tab 2.5 Terbutaline Sulfate Tab 5 EPHEDRINE SU 25 CAPSULE Ipratropium-Albuterol Nebu Soln (/3ML COMBIVENT Aerosol MCG/ACT (20-120MCG/ACT) COMBIVENT RESPIMAT 20 mcg- 100 mcg/actuation SYMBICORT MCG INHALE SYMBICORT MCG INHAL ADVAIR HFA Inhal Aerosol MCG/ACT ADVAIR HFA Inhal Aerosol MCG/ACT ADVAIR HFA Inhal Aerosol MCG/ACT ADVAIR HFA Aer Powder BA MCG/DOSE ADVAIR HFA Aer Powder BA MCG/DOSE ADVAIR HFA Aer Powder BA MCG/DOSE DULERA 100 MCG/5 MCG INHALE DULERA 200 MCG/5 MCG INHALE Aminophylline Tab 100 Aminophylline Tab 200 LUFYLLIN Tab 200 LUFYLLIN Tab 400 Theophylline Elixir 80 /15ML Theophylline solution 80/15ML Theophylline Cap SR 12HR 125 THEO-24 Cap SR 24HR 100 THEO-24 Cap SR 24HR 200 THEO-24 Cap SR 24HR 300 THEO-24 Cap SR 24HR 400 Theophylline Tab SR 12HR 100 Daily Dosage=30 Min DS=30; Package Limit=1/claim 2 Max Qty=12/claim Max Qty=12/claim Max Qty=12/claim Max Qty=60/claim Max Qty=60/claim Max Qty=60/claim Max Qty = 475/dispense THEO-DUR Theophylline Tab SR 12HR 200 QUIBRON-T SR, THEO- Theophylline Tab SR 12HR 300 DUR Theophylline Tab SR 12HR 450

47 UNIPHYL Theophylline Tab SR 24HR 400 UNIPHYL Theophylline Tab SR 24HR 600 QVAR Inhal Aero Soln 40 MCG/ACT QVAR Inhal Aero Soln 80 MCG/ACT Package Limit=2/month Package Limit=2/month PULMICORT PULMICORT Susp 0.25 /2ML Max Qty=120/claim PULMICORT PULMICORT Susp 0.5 /2ML Max Qty=120/claim PULMICORT Susp 1 /2ML Max Qty=60/30 days FLOVENT DISK Aer Pow BA 50 MCG/BLISTER FLOVENT DISK Aer Pow BA 100 MCG/BLISTER FLOVENT DISK Aer Pow BA 250 MCG/BLISTER FLOVENT HFA Inhal Aerosol 44 MCG/ACT FLOVENT HFA Inhal Aerosol 110 MCG/ACT FLOVENT HFA Inhal Aerosol 220 MCG/ACT SINGULAIR Tab 10 (Base Equiv) SINGULAIR Chew Tab 4 (Base Equiv) SINGULAIR Chew Tab 5 (Base Equiv) SINGULAIR Oral Granules Packet 4 (Base Equiv) ; Step Therapy Allergic rhinitis: prior use of Loratidine OTC, Zyrtec OTC, Fluticasone spray LAXATIVES MILK OF MAGN FLEET FLEET QUIBRON-300 Cap Magnesium Hydroxide Susp 400 /5ML MILK OF MAGNESIA CONCENTRAT Magnesium Citrate Soln ORAL SALINE LAXATIVE LIQUID *Sodium Phosphates - Enema*** *Sodium Phosphates - Enema*** Max Qty=992/31 days DULCOLAX Bisacodyl Tab Delayed Release 5 FLEET BISACODYL 10 ENEMA DULCOLAX Bisacodyl Suppos 10 Max Qty=12/claim Senna Tab 187 Senna Powder SENOKOT, SENOKOT SENNA Tab 8.6 2GO SENNA SYRUP CITRUCEL FIBER THERAPY 500 CAPLET FIBERCON FIBER LAXATIVE 625 CAPLE Daily Dose=10 METAMUCIL Psyllium Cap 0.52 GM NATURAL VEG Psyllium Powder 28%

48 NATURAL VEG Psyllium Powder 28.3% NATURAL VEG Psyllium Powder 30% NATURAL VEG Psyllium Powder 30.9% NATURAL VEG Psyllium Powder 30.9% NATURAL VEG Psyllium Powder 33% NATURAL VEG Psyllium Powder METAMUCIL 48.57% NATURAL VEG Psyllium Powder 50% KONSYL-D POWDER Psyllium Powder 58.6% KONSYL-ORANGE POWDER Psyllium Powder 68% KONSYL EASY MIX FORMULA POW EVAC, KONSYL Psyllium Powder 100% FLEET MINERL, FLEET MINERAL OIL ENEMA FLEET OIL ENEMEEZ PLUS MINI ENEMA DOCUSATE CAL 240 CAPSULE COLACE Docusate Sodium Cap 50 COLACE Docusate Sodium Cap 100 Daily Dosage=3 Docusate Sodium Cap 250 Daily Dosage=3 Docusate Sodium Tab 100 COLACE Docusate Sodium Liquid 150 /15ML COLACE Docusate Sodium Syrup 60 /15ML ENEMEEZ MINI ENEMA Glycerin Suppos 1.5 GM Max Qty=12/claim Glycerin Suppos 3 GM Max Qty=24/claim Lactulose Solution 10 GM/15ML MIRALAX Polyethylene Glycol 3350 Oral Powder Daily Dosage=36 MIRALAX SENOKOT S NULYTELY Polyethylene Glycol 3350 Oral Packet Sorbitol Oral Solution 70% Phenolphthalein-DSS Tab SENNA S (Sennosides-Docusate Sodium Tab ) FLEET PREP (Bisacodyl-Sod Biphos/Sod Phos) Prep Kit PEG 3350-KCl-Sod Bicarb-NaCl For Soln 420 GM HALFLYTELY Bisacodyl Tab & PEG 3350-KCl-Sod Bicarb-NaCl For Soln Kit PEG 3350-KCl-Na Bicarb-NaCl-Na Sulfate Soln 6 GM/100ML COLYTE WITH FLAVOR PACKS Daily Dosage=4 GOLYTELY COLYTE, COLYTE/FLAVR PEG 3350-KCl-Na Bicarb-NaCl-Na Sulfate For Soln 236 GM PEG 3350-KCl-Na Bicarb-NaCl-Na Sulfate For Soln 240 GM GOLYTELY PACKET

49 ANTIDIARRHEALS LOMOTIL LOMOTIL IMODIUM A-D KAOPECTATE PEPTO-BISMOL PEPTO-BISMOL PEPTO-BISMOL Diphenoxylate w/ Atropine Tab Diphenoxylate w/ Atropine Liq /5ML Loperamide HCl Cap 2 ANTI-DIARRHEAL 2 CAPLET Loperamide HCl Liq 1 /5ML Attapulgite Liq 750 /15ML Attapulgite Susp 750 /15ML Bismuth Subsalicylate Chew Tab 262 Bismuth Subsalicylate Susp 527 /30ML Bismuth Subsalicylate Susp 527 /30ML PEPTO-BISMOL PINK BISMUTH MAX-STR SUSP ANTACIDS ACIDOPHILUS X-STR CAPTAB ACIDOPHILUS CAPLET Aluminum Hydroxide Gel Susp 320 /5ML Aluminum Hydroxide Gel Susp 600 /5ML Max Qty=496/31 days Sodium Bicarbonate Tab 325 Max Qty=100/31 days Sodium Bicarbonate Tab 650 Max Qty=100/31 days TUMS, TUMS LASTING MAG-OX 400 CALCIUM CARBONATE 648 TA Calcium Carbonate (Antacid) Chew Tab 500 Magnesium Oxide Tab 400 MAALOX SUS Aluminum & Magnesium Hydroxides Susp /5ML Max Qty=744/31 days GAVISCON GAVISCON FOAMING ANTACID LIQUID FOAMING ANTACID TABLET CHEW MYLANTA MYLANTA, MYLANTA DS MYLANTA, MYLANTA DS ULCER DRUGS LEVSIN SYMAX DUOTAB LEVSIN/SL LEVSIN LEVSIN LEVSINEX Alum & Mag Hydroxide-Simethicone Susp /5ML ANTACID PLUS SUSPENSION MAALOX MAXIMUM STRENGTH SUS Hyoscyamine Sulfate Tab Hyoscyamine Sulfate Tab CR LEVSIN Tab SL Hyoscyamine Sulfate Elixir /5ML LEVSIN Inj 0.5 /ML Hyoscyamine Sulfate Soln /ML Hyoscyamine Sulfate Soln /ML Hyoscyamine Sulfate Powder Hyoscyamine Sulfate Cap SR 12HR Max Qty=744/31 days

50 ANASPAZ LEVBID ROBINUL ROBINUL FORT BENTYL BENTYL BENTYL DONNATAL DONNATAL TAGAMET, TAGAMET HB Hyoscyamine Sulfate Orally Disintegrating Tab Hyoscyamine Sulfate Tab Disp 0.25 Hyoscyamine Sulfate Tab SR 12HR GLYCOPYRROLATE 1 TABLET GLYCOPYRROLATE 2 TABLET PROPANTHELINE 15 TABLET Dicyclomine HCl Cap 10 Dicyclomine HCl Tab 20 Dicyclomine HCl Oral Soln 10 /5ML Belladonna Alkaloids-Phenobarbital Tab 16.2 Belladonna Alkaloids-Phenobarbital Elixir 16 /5ML Cimetidine Tab 200 Cimetidine Tab 300 Cimetidine Tab 400 Cimetidine Tab 800 Cimetidine HCl Soln 300 /5ML Daily Dosage=4 Daily Dosage=4 Daily Dosage=4 Daily Dosage=4 Max Qty=496/31 days TALADINE, ZANTAC Ranitidine HCl Cap 150 TALADINE, ZANTAC Ranitidine HCl Cap 300 ZANTAC Ranitidine HCl Tab 75 ZANTAC Ranitidine HCl Tab 150 ZANTAC Ranitidine HCl Tab 300 ZANTAC Ranitidine HCl Syrup 75 /5ML 0 PEPCID AC PEPCID, PEPCID AC PEPCID PEPCID CYTOTEC CYTOTEC PREVACID, PREVACID 24H PREVACID Famotidine Tab 10 Famotidine Tab 20 Famotidine Tab 40 PEPCID Susp 40 /5ML AXID AR Tab 75 Misoprostol Tab 100 MCG Misoprostol Tab 200 MCG Lansoprazole Cap Delayed Release 15 LANSOPRAZOLE DR 30 CAPSU PA, Legend; OTC: Daily Dosage=4 PRILOSEC PRILOSEC PRILOSEC Lansoprazole Tab Delayed Release Orally Disintegrating 15 Lansoprazole Tab Delayed Release Orally Disintegrating 30 OMEPRAZOLE DR 20 TABLET Omeprazole suspension compounding kit 2/Ml OMEPRAZOLE DR 10 CAPSULE Omeprazole Cap Delayed Release 20 Omeprazole Cap Delayed Release 40 PRILOSEC OTC (Omeprazole Magnesium Delayed Release Tab 20 Base Equiv) Max Qty=300 Daily Dosage=4 Daily Dosage=4

51 PROTONIX PROTONIX CARAFATE OMEPRAZOLE MAG DR 20.6 C PANTOPRAZOLE SOD DR 20 T PANTOPRAZOLE SOD DR 40 T Sucralfate Tab 1 GM SUCRALFATE 1 GM/10 ML SUSP ZEGERID ANTIEMETICS DRAMAMINE ANTIVERT ANTIVERT BONINE TIGAN ZOFRAN ODT ZOFRAN ODT ZOFRAN ZOFRAN ZOFRAN ZOFRAN ZOFRAN ZOFRAN EMETROL DIGESTIVE AIDS ZEGERID OTC (Omeprazole- Sodium Bicarbonate Cap ) ZEGERID (Omeprazole-Sodium Bicarbonate Powd Pack for Susp ) ZEGERID (Omeprazole-Sodium Bicarbonate Powd Pack for Susp ) DIMENHYDRINATE 50 TABLET Meclizine HCl Tab 12.5 Meclizine HCl Tab 25 MECLIZINE 25 TABLET CHEW TRIMETHOBENZAMIDE 300 CA Ondansetron Orally Disintegrating Tab 4 Ondansetron Orally Disintegrating Tab 8 Ondansetron HCl Tab 4 Ondansetron HCl Tab 8 Ondansetron HCl Tab 24 Ondansetron HCl Inj 2 /ML Ondansetron HCl Inj 4 /2ML (2 /ML) Ondansetron HCl Inj 40 /20ML (2 /ML) Ondansetron HCl Oral Soln 4 /5ML ANTI-NAUSEA LIQUID LACTRASE 250 CAPSULE CREON (Pancrelipase (Lip-Prot- Amyl) DR Cap Unit) ZENPEP (Pancrelipase (Lip-Prot- Amyl) DR Cap Unit) PANCREAZE (Pancrelipase (Lip- Prot-Amyl) DR Cap Unit) ZENPEP (Pancrelipase (Lip-Prot- Amyl) DR Cap Unit) CREON (Pancrelipase (Lip-Prot- Amyl) DR Cap Unit) ZENPEP (Pancrelipase (Lip-Prot- Amyl) DR Cap Unit) Max DS=90/365 days; Max DS=90/365 days; Max DS=90/365 days; Max DS=90/365 days; Max Qty=1/14 days Max Qty=50/31 days

52 PANCREAZE (Pancrelipase (Lip- Prot-Amyl) DR Cap Unit) CREON (Pancrelipase (Lip-Prot- Amyl) DR Cap Unit) ZENPEP (Pancrelipase (Lip-Prot- Amyl) DR Cap Unit) PANCREAZE (Pancrelipase (Lip- Prot-Amyl) DR Cap Unit) ZENPEP (Pancrelipase (Lip-Prot- Amyl) DR Cap Unit) PANCREAZE (Pancrelipase (Lip- Prot-Amyl) DR Cap Unit) CREON (Pancrelipase (Lip-Prot- Amyl) DR Cap Unit) ZENPEP (Pancrelipase (Lip-Prot- Amyl) DR Cap Unit) Amylase-Lipase-Protease Cap U GASTROINTESTINAL AGENTS - MISCELLANEOUS ACTIGALL Ursodiol Cap 300 URSO 250 Ursodiol Tab 250 Daily Dosage=7 URSO FORTE URSODIOL 500 TABLET GAS-X Simethicone Chew Tab 80 GAS-X EX-STR, MYLANTA GAS GAS-X EX-STR 125 TAB CHE Simethicone Liquid 40 /0.6ML MYLICON, MYLICON Simethicone Susp 40 /0.6ML INFA REGLAN Metoclopramide HCl Tab 5 REGLAN Metoclopramide HCl Tab 10 Metoclopramide HCl Soln 5 /5ML Lactulose (Encephalopathy) Solution 10 GM/15ML BALSALAZIDE DISODIUM 750 COLAZAL PENTASA Cap CR 250 PENTASA Cap CR 500 ASACOL Tab Delayed Release 400 MESALAMINE 4 GM/60 ML ROWASA ENEMA SFROWASA (Mesalamine Sulfite- Free (SF)) Enema 4 GM/60ML DELZICOL DR 400 CAPSULE AZULFIDINE Sulfasalazine Tab 500 Sulfasalazine Tab Delayed Release AZULFIDINE 500 Calcium Acetate (Phosphate Binder) PHOSLO Cap 667 ELIPHOS ELIPHOS 667 TABLET URINARY ANTI-INFECTIVES Methenamine Mandelate Tab 0.5 GM Max Qty=31/31 days Max Qty=31/31 days Daily Dosage=9 Daily Dosage=8 Daily Dosage=8 2 Daily Dose= 1 unit Daily Dosage=6

53 Methenamine Mandelate Tab 1 GM FURADANTIN FURADANTIN Susp 25 /5ML Daily Dosage=40 MACRODANTIN MACRODANTIN MACROBID MACRODANTIN 25 CAPSULE Nitrofurantoin Macrocrystalline Cap 50 Nitrofurantoin Macrocrystalline Cap 100 Nitrofurantoin Monohydrate Macrocrystalline Cap 100 URELLE TABLET *Methenamine-Hyos-Meth Blue-Sod Phos-Phen Sal Tab 81.6 *** URINARY ANTISPASMODICS URECHOLINE Bethanechol Chloride Tab 5 URECHOLINE Bethanechol Chloride Tab 10 URECHOLINE Bethanechol Chloride Tab 25 URECHOLINE Bethanechol Chloride Tab 50 URISPAS Flavoxate HCl Tab 100 DITROPAN Oxybutynin Chloride Tab 5 Max Qty=93/31 days DITROPAN Oxybutynin Chloride Syrup 5 /5ML Max Qty=496/31 days DITROPAN XL Oxybutynin Chloride Tab SR 24HR 5 Max Qty=62/31 days DITROPAN XL Oxybutynin Chloride Tab SR 24HR 10 Max Qty=62/31 days DITROPAN XL Oxybutynin Chloride Tab SR 24HR 15 Max Qty=62/31 days SANCTURA TROSPIUM CHLORIDE 20 Tab VAGINAL PRODUCTS CLEOCIN Clindamycin Phosphate Vaginal Cream 2% Clindamycin Phosphate (One Dose) Vaginal Cream 2% METROGEL-VAG Metronidazole Vaginal Gel 0.75% Min DS=30; Package Limit=1/claim NYSTATIN VAGINAL TABLET GYNAZOLE-1 (One Dose) Vaginal Cream 2% GYNE-LOTRIM CLOTRIMAZOLE INSERT GYNE-LOTRIM, MYCELEX-7 Clotrimazole Vaginal Cream 1% Max Qty=45/31 days GYNE-LOTRIMI Clotrimazole Vaginal Cream 2% Max Qty=31/31 days MONISTAT 7 Miconazole Nitrate Vaginal Cream 2% Max Qty=45/31 days MONISTAT 3 Miconazole Nitrate Vaginal Cream 4% (200 /5GM) Max Qty=45/31 days MONISTAT 7 Miconazole Nitrate Vaginal Suppos 100 Max Qty=7/31 days MICONAZOLE 3 Vaginal Suppos 200 Max Qty=3/31 days MONISTAT 3 Miconazole Nitrate Vaginal Supp 200 & 2% Cream 9 GM Kit MONISTAT 1 MICONAZOLE 1 COMBINATION PA TERAZOL 7 Terconazole Vaginal Cream 0.4% TERAZOL 3 Terconazole Vaginal Cream 0.8% TERAZOL 3 Terconazole Vaginal Suppos 80

54 MONISTAT 1, VAGISTAT-1 Tioconazole Vaginal Oint 6.5% VCF VAGINAL (Nonoxynol-9) Foam 12.5% GYNOL II, SHUR-SEAL (Nonoxynol-9) Gel 2% KY PLUS (Nonoxynol-9) Gel 2.2% GYNOL II (Nonoxynol-9) Gel 3% CONCEPTROL Nonoxynol-9 Gel 4% ENCARE (Nonoxynol-9) Vaginal Suppos 100 VCF VAGINAL (Nonoxynol-9) Film 28% CONCEPTROL (Nonoxynol-9) Vaginal Insert 150 ESTRACE VAG Cream 0.1 /GM PREMARIN VAG Cream /GM GENITOURINARY AGENTS - MISCELLANEOUS Potassium Citrate Tab CR 540 (5 UROCIT-K 5 MEQ) Potassium Citrate Tab CR 1080 UROCIT-K 10 (10 MEQ) Sodium Citrate & Citric Acid Soln BICITRA, SHOHLS /5ML PYRIDIUM Phenazopyridine HCl Tab 100 Max Qty=43/31 days Max Qty=43/30 days Max Qty=500/30 days PYRIDIUM Phenazopyridine HCl Tab 200 SODIUM CHLORIDE 0.45% IRRIG Sodium Chloride Irrigation Soln 0.9% PROSCAR Finasteride Tab 5 FLOMAX Tamsulosin HCl Cap 0.4 ANTIANXIETY AGENTS XANAX Alprazolam Tab 0.25 Daily Dosage=4 XANAX Alprazolam Tab 0.5 Daily Dosage=4 XANAX Alprazolam Tab 1 Daily Dosage=4 XANAX Alprazolam Tab 2 Daily Dosage=4 Alprazolam Conc 1 /ML LIBRIUM Chlordiazepoxide HCl Cap 5 Daily Dosage=4 LIBRIUM Chlordiazepoxide HCl Cap 10 Daily Dosage=4 LIBRIUM Chlordiazepoxide HCl Cap 25 Daily Dosage=4 TRANXENE T Clorazepate Dipotassium Tab 3.75 Daily Dosage=3 TRANXENE T Clorazepate Dipotassium Tab 7.5 Daily Dosage=3 TRANXENE T Clorazepate Dipotassium Tab 15 Daily Dosage=3 VALIUM Diazepam Tab 2 Daily Dosage=4 VALIUM Diazepam Tab 5 Daily Dosage=4 VALIUM Diazepam Tab 10 Daily Dosage=4 Diazepam Conc 5 /ML Diazepam Soln 1 /ML ATIVAN Lorazepam Tab 0.5 Daily Dosage=3 ATIVAN Lorazepam Tab 1 Daily Dosage=4 ATIVAN Lorazepam Tab 2 Daily Dosage=3 Oxazepam Cap 10 Daily Dosage=4 Oxazepam Cap 15 Daily Dosage=4

55 Oxazepam Cap 30 Daily Dosage=4 BUSPAR Buspirone HCl Tab 5 Daily Dosage=3 Buspirone HCl Tab 7.5 Daily Dosage=3 BUSPAR Buspirone HCl Tab 10 Daily Dosage=3 BUSPAR Buspirone HCl Tab 15 Daily Dosage=3 BUSPAR Buspirone HCl Tab 30 Daily Dosage=3 Hydroxyzine HCl Tab 10 Hydroxyzine HCl Tab 25 Hydroxyzine HCl Tab 50 Hydroxyzine HCl Syrup 10 /5ML VISTARIL Hydroxyzine Pamoate Cap 25 VISTARIL Hydroxyzine Pamoate Cap 50 Hydroxyzine Pamoate Cap 100 Meprobamate Tab 200 Meprobamate Tab 400 ANTIDEPRESSANTS Mirtazapine Tab 7.5 REMERON Mirtazapine Tab 15 REMERON Mirtazapine Tab 30 REMERON Mirtazapine Tab 45 REMERON SLTB Mirtazapine Orally Disintegrating Tab 15 REMERON SLTB Mirtazapine Orally Disintegrating Tab 30 REMERON SLTB Mirtazapine Orally Disintegrating Tab 45 NARDIL NARDIL Tab 15 PARNATE Tranylcypromine Sulfate Tab 10 Nefazodone HCl Tab 50 Nefazodone HCl Tab 100 Nefazodone HCl Tab 150 Nefazodone HCl Tab 200 Nefazodone HCl Tab 250 Trazodone HCl Tab 50 Trazodone HCl Tab 100 Trazodone HCl Tab 150 Trazodone HCl Tab 300 CELEXA Citalopram Hydrobromide Tab 10 (Base Equiv).5 CELEXA Citalopram Hydrobromide Tab 20 (Base Equiv).5 CELEXA Citalopram Hydrobromide Tab 40 (Base Equiv) CELEXA Citalopram Hydrobromide Oral Soln 10 /5ML LEXAPRO Escitalopram 5 tab LEXAPRO Escitalopram 10 tab LEXAPRO Escitalopram 20 tab PROZAC Fluoxetine HCl Cap 10 Daily Dose=4 PROZAC Fluoxetine HCl Cap 20 Daily Dose=4 Fluoxetine HCl Tab 10 Daily Dose=4 RAPIFLUX Fluoxetine HCl Tab 20 Daily Dose=4 FLUOXETINE HCL 40 CAPSUL PROZAC Fluoxetine HCl Solution 20 /5ML Fluvoxamine Maleate Tab 25 Daily Dose=2 Fluvoxamine Maleate Tab 50 Daily Dose=2 Fluvoxamine Maleate Tab 100 Daily Dose=3 PAXIL Paroxetine HCl Tab 10 Daily Dose=2

56 PAXIL Paroxetine HCl Tab 20 Daily Dose=2 PAXIL Paroxetine HCl Tab 30 Daily Dose=2 PAXIL Paroxetine HCl Tab 40 Daily Dose=2 PAXIL Paroxetine HCl Oral Susp 10 /5ML (Base Equiv) Daily Dose=40 ZOLOFT Sertraline HCl Tab 25.5 ZOLOFT Sertraline HCl Tab 50.5 ZOLOFT Sertraline HCl Tab 100 ZOLOFT Sertraline HCl Oral Conc 20 /ML EFFEXOR Venlafaxine HCl Tab 25 EFFEXOR Venlafaxine HCl Tab 37.5 EFFEXOR Venlafaxine HCl Tab 50 EFFEXOR Venlafaxine HCl Tab 75 EFFEXOR Venlafaxine HCl Tab 100 EFFEXOR XR Venlafaxine HCl Cap SR 24HR 37.5 Daily Dose=2 EFFEXOR XR Venlafaxine HCl Cap SR 24HR 75 Daily Dose=2 EFFEXOR XR Venlafaxine HCl Cap SR 24HR 150 Daily Dose=2 VENLAFAXINE Venlafaxine HCl Tab SR 24HR 37.5 (Base Equivalent) VENLAFAXINE Venlafaxine HCl Tab SR 24HR 75 (Base Equivalent) VENLAFAXINE Venlafaxine HCl Tab SR 24HR 150 (Base Equivalent) Venlafaxine HCl Tab SR 24HR 225 (Base Equivalent) Amitriptyline HCl Tab 10 Amitriptyline HCl Tab 25 Amitriptyline HCl Tab 50 Amitriptyline HCl Tab 75 Amitriptyline HCl Tab 100 Amitriptyline HCl Tab 150 Amoxapine Tab 25 Amoxapine Tab 50 Amoxapine Tab 100 Amoxapine Tab 150 ANAFRANIL Clomipramine HCl Cap 25 ANAFRANIL Clomipramine HCl Cap 50 ANAFRANIL Clomipramine HCl Cap 75 NORPRAMIN Desipramine HCl Tab 10 NORPRAMIN Desipramine HCl Tab 25 NORPRAMIN Desipramine HCl Tab 50 NORPRAMIN Desipramine HCl Tab 75 NORPRAMIN Desipramine HCl Tab 100 NORPRAMIN Desipramine HCl Tab 150 Doxepin HCl Cap 10 Doxepin HCl Cap 25 Doxepin HCl Cap 50 Doxepin HCl Cap 75 Doxepin HCl Cap 100 Doxepin HCl Cap 150 Doxepin HCl Conc 10 /ML TOFRANIL Imipramine HCl Tab 10 TOFRANIL Imipramine HCl Tab 25 TOFRANIL Imipramine HCl Tab 50 Imipramine Pamoate Cap 75 Imipramine Pamoate Cap 100 Daily Dosage=3 Imipramine Pamoate Cap 125 Imipramine Pamoate Cap 150 PAMELOR Nortriptyline HCl Cap 10 PAMELOR Nortriptyline HCl Cap 25

57 PAMELOR PAMELOR Nortriptyline HCl Cap 50 Nortriptyline HCl Cap 75 PAMELOR Nortriptyline HCl Soln 10 /5ML Daily Dose=20 VIVACTIL PROTRIPTYLINE HCL 10 TAB Benefit Cls (81006) Maprotiline HCl Tab 25 Antidepressants: Max Fills=2/30 days Benefit Cls (81006) Maprotiline HCl Tab 50 Antidepressants: Max Fills=2/30 days Benefit Cls (81006) Maprotiline HCl Tab 75 Antidepressants: Max Fills=2/30 days WELLBUTRIN Bupropion HCl Tab 75 Daily Dosage=3 WELLBUTRIN Bupropion HCl Tab 100 Daily Dosage=3 WELLBUTRIN Bupropion HCl Tab SR 12HR 100 WELLBUTRIN Bupropion HCl Tab SR 12HR 150 WELLBUTRIN Bupropion HCl Tab SR 12HR 200 WELLBUTRIN Bupropion HCl Tab SR 24HR 150 WELLBUTRIN Bupropion HCl Tab SR 24HR 300 ANTIPSYCHOTICS/ANTIMANIC AGENTS RISPERDAL Risperidone Tab 0.25 Limited to Ages 5 and Older ; RISPERDAL RISPERDAL RISPERDAL RISPERDAL RISPERDAL RISPERDAL RISPERDAL M RISPERDAL M RISPERDAL M RISPERDAL M Risperidone Tab 0.5 Risperidone Tab 1 Risperidone Tab 2 Risperidone Tab 3 Risperidone Tab 4 Risperidone Soln 1 /ML RISPERIDONE 0.25 ODT Risperidone Orally Disintegrating Tab 0.5 Risperidone Orally Disintegrating Tab 1 Risperidone Orally Disintegrating Tab 2 Risperidone Orally Disintegrating Tab 3 Limited to Ages 5 and Older ; Limited to Ages 5 and Older ; Limited to Ages 5 and Older ; Limited to Ages 5 and Older ; Limited to Ages 5 and Older ; Limited to Ages 5 and Older ; 2)Daily Dosage=4 Limited to Ages 5 and Older ; Limited to Ages 5 and Older ; Limited to Ages 5 and Older ; Limited to Ages 5 and Older ; Limited to Ages 5 and Older ;

58 RISPERDAL M Risperidone Orally Disintegrating Tab 4 Limited to Ages 5 and Older ; HALDOL DECAN HALDOL DECAN HALDOL DECAN HALDOL DECAN Haloperidol Tab 0.5 Haloperidol Tab 1 Haloperidol Tab 2 Haloperidol Tab 5 Haloperidol Tab 10 Haloperidol Tab 20 Haloperidol Lactate Oral Conc 2 /ML Haloperidol Decanoate IM Soln 50 /ML Haloperidol Decanoate IM Soln 50 /ML Haloperidol Decanoate IM Soln 100 /ML Haloperidol Decanoate IM Soln 100 /ML Daily Dosage=3 Daily Dosage=3 Daily Dosage=3 CLOZARIL CLOZARIL SEROQUEL SEROQUEL SEROQUEL SEROQUEL SEROQUEL Clozapine Tab 25 Clozapine Tab 50 Clozapine Tab 100 Clozapine Tab 200 Quetiapine Fumarate (SEROQUEL)Tab 25 Quetiapine Fumarate (SEROQUEL) Tab 50 Quetiapine Fumarate (SEROQUEL) Tab 100 Quetiapine Fumarate (SEROQUEL) Tab 200 Quetiapine Fumarate (SEROQUEL) Tab 300 Limited to Ages 18 and Older; Daily Dosage=3 Limited to Ages 18 and Older; Daily Dosage=3 Limited to Ages 18 and Older; Daily Dosage=9 Limited to Ages 18 and Older; Daily Dosage=3 Limited to Ages 10 and Older; Limited to Ages 10 and Older; Limited to Ages 10 and Older; Limited to Ages 10 and Older Limited to Ages 10 and Older; SEROQUEL Quetiapine Fumarate (SEROQUEL) Tab 400 Limited to Ages 10 and Older; Max Qty=62/31 days; LOXITANE Loxapine Succinate Cap 5 Daily Dosage=4 LOXITANE Loxapine Succinate Cap 10 Daily Dosage=4 LOXITANE Loxapine Succinate Cap 25 Daily Dosage=4 LOXITANE Loxapine Succinate Cap 50 Daily Dosage=4 ZYPREXA Olanzapine (ZYPREXA) Tab 2.5 Limited to Ages 13 and Older; ZYPREXA ZYPREXA ZYPREXA Olanzapine (ZYPREXA) Tab 5 Olanzapine (ZYPREXA)Tab 7.5 Olanzapine (ZYPREXA)Tab 10 Limited to Ages 13 and Older; Limited to Ages 13 and Older; Limited to Ages 13 and Older;

59 ZYPREXA Olanzapine (ZYPREXA) Tab 15 Limited to Ages 13 and Older; ZYPREXA COMPAZINE Olanzapine (ZYPREXA) Tab 20 Chlorpromazine HCl Tab 10 Chlorpromazine HCl Tab 25 Chlorpromazine HCl Tab 50 Chlorpromazine HCl Tab 100 Chlorpromazine HCl Tab 200 Fluphenazine HCl Tab 1 Fluphenazine HCl Tab 2.5 Fluphenazine HCl Tab 5 Fluphenazine HCl Tab 10 FLUPHENAZINE 2.5 /5 ML EL FLUPHENAZINE 5 /ML CONC FLUPHENAZINE 2.5 /ML VIAL Fluphenazine Decanoate Inj 25 /ML Perphenazine Tab 2 Perphenazine Tab 4 Perphenazine Tab 8 Perphenazine Tab 16 Prochlorperazine Suppos 25 Prochlorperazine Maleate Tab 5 Limited to Ages 13 and Older; Daily Dosage=3 Daily Dosage=3 Daily Dosage=3 Daily Dosage=3 Daily Dosage=3 Daily Dosage=4 Daily Dosage=4 Daily Dosage=4 Daily Dosage=4 Prochlorperazine Maleate Tab 10 Thioridazine HCl Tab 10 Daily Dosage=3 Thioridazine HCl Tab 25 Daily Dosage=3 Thioridazine HCl Tab 50 Daily Dosage=3 Thioridazine HCl Tab 100 Daily Dosage=3 Trifluoperazine HCl Tab 1 Daily Dosage=3 Trifluoperazine HCl Tab 2 Daily Dosage=3 Trifluoperazine HCl Tab 5 Daily Dosage=3 Trifluoperazine HCl Tab 10 Daily Dosage=3 Thiothixene Cap 1 Daily Dosage=3 NAVANE Thiothixene Cap 2 Daily Dosage=3 NAVANE Thiothixene Cap 5 Daily Dosage=3 NAVANE Thiothixene Cap 10 Daily Dosage=3 GEODON Ziprasidone (GEODON) HCl Cap 20 Limited to Ages 18 and Older; GEODON GEODON GEODON Ziprasidone (GEODON) HCl Cap 40 Ziprasidone (GEODON) HCl Cap 60 Ziprasidone (GEODON) HCl Cap 80 Ziprasidone Mesylate (GEODON) For Inj 20 (Base Equivalent) Lithium Carbonate Cap 150 Lithium Carbonate Cap 300 Lithium Carbonate Cap 600 Lithium Carbonate Tab 300 Limited to Ages 18 and Older; Limited to Ages 18 and Older; Limited to Ages 18 and Older; Limited to Ages 18 and Older;

60 LITHOBID Lithium Carbonate Tab CR 300 Lithium Carbonate Tab CR 450 HYPNOTICS Lithium Citrate Oral Soln 8 meq/5ml Phenobarbital Tab 15 Phenobarbital Tab 16.2 Phenobarbital Tab 30 Phenobarbital Tab 32.4 Phenobarbital Tab 60 Phenobarbital Tab 64.8 Phenobarbital Tab 97.2 Phenobarbital Tab 100 Phenobarbital Elixir 20 /5ML SOMNOTE (Chloral Hydrate) Cap 500 Chloral Hydrate Syrup 500 /5ML Daily Dose=1 Daily Dose= 240/claim Chloral Hydrate Suppos 500 PROSOM ESTAZOLAM 1 TABLET PROSOM ESTAZOLAM 2 TABLET DALMANE Flurazepam HCl Cap 15 Daily Dose=1 DALMANE Flurazepam HCl Cap 30 Daily Dose=1 RESTORIL Temazepam Cap 15 Daily Dose=1 RESTORIL Temazepam Cap 30 Daily Dose=1 Triazolam Tab Daily Dose=1 HALCION Triazolam Tab 0.25 Daily Dose=1 SONATA Zaleplon Cap 5 Daily Dose=1, Step- Therapy SONATA Zaleplon Cap 10 Daily Dose=1, Step- Therapy AMBIEN Zolpidem Tartrate Tab 5 Daily Dose=1 AMBIEN Zolpidem Tartrate Tab 10 Daily Dose=1 UNISOM Doxylamine Succinate (Sleep) Tab 25 Diphenhydramine (sleep) NYTOL MX-STR Diphenhydramine HCl (Sleep) Tab 50 ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS Dextroamphetamine Sulfate Tab 5 Limited to Ages 3 and Older; Prior use of Zolpidem IR Prior use of Zolpidem IR DEXTROSTAT DEXEDRINE DEXEDRINE DEXEDRINE ADDERALL ADDERALL Dextroamphetamine Sulfate Tab 10 Dextroamphetamine Sulfate Cap SR 24HR 5 Dextroamphetamine Sulfate Cap SR 24HR 10 Dextroamphetamine Sulfate Cap SR 24HR 15 Amphetamine-Dextroamphetamine Tab 5 Amphetamine-Dextroamphetamine Tab 7.5 Limited to Ages 3 and Older; Limited to Ages 6 and Older; Limited to Ages 6 and Older; Limited to Ages 6 and Older; Limited to Ages 21 and Under; Limited to Ages 3 and Older ; Daily Dosage=2 Limited to Ages 3 and Older;

61 ADDERALL Amphetamine-Dextroamphetamine Tab 10 Limited to Ages 3 and Older; ADDERALL ADDERALL ADDERALL ADDERALL ADDERALL XR Amphetamine-Dextroamphetamine Tab 12.5 Amphetamine-Dextroamphetamine Tab 15 Amphetamine-Dextroamphetamine Tab 20 Amphetamine-Dextroamphetamine Tab 30 Amphetamine-Dextroamphetamine Cap (ADDERALL XR) SR 24HR 5 Limited to Ages 3 and Older; Limited to Ages 3 and Older; Limited to Ages 3 and Older; Limited to Ages 3 and Older; Limited to Ages 6 and Older; ADDERALL XR Amphetamine-Dextroamphetamine Cap (ADDERALL XR) SR 24HR 10 Limited to Ages 6 and Older; ADDERALL XR Amphetamine-Dextroamphetamine Cap (ADDERALL XR) SR 24HR 15 Limited to Ages 6 and Older; ADDERALL XR Amphetamine-Dextroamphetamine Cap (ADDERALL XR) SR 24HR 20 Limited to Ages 6 and Older; ADDERALL XR Amphetamine-Dextroamphetamine Cap (ADDERALL XR) SR 24HR 25 Limited to Ages 6 and Older; ADDERALL XR CAFCIT FOCALIN FOCALIN FOCALIN Amphetamine-Dextroamphetamine Cap (ADDERALL XR) SR 24HR 30 Caffeine Citrate Oral Soln 60 /3ML (10 /ML Base Equiv) Caffeine Citrate Powder Dexmethylphenidate HCl Tab 2.5 Dexmethylphenidate HCl Tab 5 Dexmethylphenidate HCl Tab 10 METADATE CD Cap CR 10 METADATE CD Cap CR 20 METADATE CD Cap CR 30 Limited to Ages 6 and Older; Limited to Ages 6 and Older; Max Qty=45/claim; Max Fills=2/lifetime Limited to Ages 6 and Older; Limited to Ages 6 and Older; Limited to Ages 6 and Older; Limited to Ages 6 and Older; Limited to Ages 6 and Older; Limited to Ages 6 and Older;

62 METADATE CD Cap CR 40 Limited to Ages 6 and Older; METADATE CD Cap CR 50 Limited to Ages 6 and Older; METADATE CD Cap CR 60 Limited to Ages 6 and Older; RITALIN RITALIN RITALIN METADATE Methylphenidate HCl Tab 5 Methylphenidate HCl Tab 10 Methylphenidate HCl Tab 20 Methylphenidate HCl Tab CR 10 Limited to Ages 6 and Older; Daily Dosage=3 Limited to Ages 6 and Older; Daily Dosage=3 Limited to Ages 6 and Older; Daily Dosage=3 Limited to Ages 6 and Older; RITALIN, RITALIN SR Methylphenidate HCl Tab CR 20 Methylphenidate HCl Tab SA OSM (CONCERTA) 18 Methylphenidate HCl Tab SA OSM (CONCERTA) 27 Methylphenidate HCl Tab SA OSM (CONCERTA) 36 Methylphenidate HCl Tab SA OSM (CONCERTA) 54 Limited to Ages 6 and Older; Limited to Ages 6 and Older; Limited to Ages 6 and Older; Limited to Ages 6 and Older; Limited to Ages 6 and Older; METHYLPHENIDATE 5 /5 METHYLIN ML S METHYLPHENIDATE 10 /5 METHYLIN ML PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISCELLANEOUS ORAP 1 TABLET ORAP 2 TABLET ARICEPT Donepezil Hydrochloride Tab 5 Max Qty=31/31 days ARICEPT ARICEPT ODT ARICEPT ODT RAZADYNE RAZADYNE RAZADYNE RAZADYNE RAZADYNE ER RAZADYNE ER Donepezil Hydrochloride Tab 10 DONEPEZIL HCL ODT 5 TABL DONEPEZIL HCL ODT 10 TAB Galantamine Hydrobromide Tab 4 Galantamine Hydrobromide Tab 8 Galantamine Hydrobromide Tab 12 Galantamine Hydrobromide Oral Soln 4 /ML Galantamine Hydrobromide Cap SR 24HR 8 Galantamine Hydrobromide Cap SR 24HR 16 Max Qty=31/31 days Max Qty=31/31 days Max Qty=31/31 days Daily Dosage=6

63 RAZADYNE ER Galantamine Hydrobromide Cap SR 24HR 24 EXELON Rivastigmine Tartrate Cap 1.5 EXELON Rivastigmine Tartrate Cap 3 EXELON Rivastigmine Tartrate Cap 4.5 EXELON Rivastigmine Tartrate Cap 6 NAMENDA 5 TABLET NAMENDA 10 TABLET ZYBAN Bupropion HCl (Smoking Deterrent) Tab SR 150 Max Day Supply=84 per 365 days, Daily dose = 2 NICODERM 21, NICODERM CQ NICODERM CQ NICODERM CQ NICORETTE, NICORETTE ST NICORETTE, NICORETTE ST Nicotine TD Patch 24HR 7 /24HR Nicotine TD Patch 24HR 14 /24HR Nicotine TD Patch 24HR 21 /24HR Nicotine Polacrilex Gum 2 Nicotine Polacrilex Gum 4 COMMIT, NICORETTE Nicotine Polacrilex Lozenge 2 COMMIT, NICORETTE Nicotine Polacrilex Lozenge 4 PROZAC ANTABUSE ANTABUSE LIMBITROL LIMBITROL DS ANALGESICS - NonNarcotic ST JOSEPH BAYER CHILD Fluoxetine HCl (SARAFEM PMDD) Cap 10 Fluoxetine HCl (SARAFEM PMDD) Cap 20 ANTABUSE Tab 250 ANTABUSE 500 TABLET Chlordiazepoxide-Amitriptyline Tab Chlordiazepoxide-Amitriptyline Tab Perphenazine-Amitriptyline Tab 2-10 Perphenazine-Amitriptyline Tab 2-25 Perphenazine-Amitriptyline Tab 4-10 Perphenazine-Amitriptyline Tab 4-25 Perphenazine-Amitriptyline Tab 4-50 Aspirin Tab 81 Aspirin Tab 325 Aspirin Chew Tab 75 Aspirin Chew Tab 81 Aspirin Tab Delayed Release 81 Max Qty=84/365 days Max Qty=84/365 days Max Qty=84/365 days Max Day Supply=84 per 365 days Max Day Supply=84 per 365 days Max Day Supply=84 per 365 days Max Day Supply=84 per 365 days Max Qty=124/31 days Max Qty=124/31 days ECOTRIN, THERAP BAYER ECOTRIN M/S Aspirin Tab Delayed Release 325 Aspirin Tab Delayed Release 500 Aspirin Suppos 60 Aspirin Suppos 120 Aspirin Suppos 200 Aspirin Suppos 300 Aspirin Suppos 600 Diflunisal Tab 500 Max Qty=12/31 days Max Qty=12/31 days Max Qty=12/31 days Max Qty=12/31 days Max Qty=12/31 days

64 BUFFERIN TYLENOL TYLENOL TYLENOL 8 HR, TYLENOL ARTH Salsalate Tab 500 Salsalate Tab 750 Aspirin Buffered (Ca Carb-Mg Carb- Mg Ox) Tab 324 Aspirin Buffered (Ca Carb-Mg Carb- Mg Ox) Tab 325 Aspirin Buffered (Mg Carbonate-Al Aminoace) Tab 325 Aspirin Buffered Tab 325 Choline & Magnesium Salicylates Tab 1000 Acetaminophen Cap 500 Acetaminophen Tab 160 Acetaminophen Tab 325 Acetaminophen Tab 500 Acetaminophen Tab CR 650 Acetaminophen Chew Tab 80 Acetaminophen Chew Tab 160 Acetaminophen Liquid 160 /5ML Acetaminophen Elixir 160 /5ML TYLENOL INF TYLENOL CHLD, TYLENOL INF Acetaminophen Susp 80 /0.8ML Acetaminophen Susp 160 /5ML Acetaminophen Soln 100 /ML Acetaminophen Soln 160 /5ML PHRENILIN SEDAPAP ESGIC ESGIC-PLUS ESGIC, FIORICET ESGIC-PLUS FIORINAL ANALGESICS - OPIOID DURAGESIC DURAGESIC Acetaminophen Suppos 120 Acetaminophen Suppos 325 Acetaminophen Suppos 650 Aspirin-APAP-Salicylamide-Caffeine Tab PHRENILIN (Butalbital- Acetaminophen) Cap Butalbital-Acetaminophen Tab Butalbital-Acetaminophen Tab Butalbital-Acetaminophen-Caffeine Cap ESGIC PLUS CAPSULE Butalbital-Acetaminophen-Caffeine Tab Butalbital-Acetaminophen-Caffeine Tab Butalbital-Aspirin-Caffeine Cap Butalbital-Aspirin-Caffeine Tab Codeine Sulfate Tab 15 Codeine Sulfate Tab 30 Codeine Sulfate Tab 60 Fentanyl TD Patch 72HR 12.5 MCG/HR Fentanyl TD Patch 72HR 25 MCG/HR Max Qty=12/31 days Max Qty=12/31 days Max Qty=12/31 days QL=0.33/day QL=0.33/day

65 DURAGESIC Fentanyl TD Patch 72HR 50 MCG/HR QL=0.33/day DURAGESIC Fentanyl TD Patch 72HR 75 MCG/HR QL=0.33/day DURAGESIC Fentanyl TD Patch 72HR 100 MCG/HR QL=0.33/day DILAUDID Hydromorphone HCl Tab 2 Daily Dosage=8 DILAUDID Hydromorphone HCl Tab 4 Daily Dosage=8 DILAUDID Hydromorphone HCl Tab 8 Daily Dosage=8 DILAUDID-5 DILAUDID-5 1 /ML LIQUID Daily Dosage=80 Hydromorphone HCl Suppos 3 Max= 12/claim DEMEROL Meperidine HCl Tab 50 Daily Dosage=4 DEMEROL Meperidine HCl Tab 100 Daily Dosage=4 Meperidine HCl Oral Soln 50 /5ML DOLOPHINE Methadone HCl Tab 5 Daily Dosage=4 DOLOPHINE Methadone HCl Tab 10 0 METHADONE METHADONE 10 /ML ORAL CON 0 METHADONE 5 /5 ML SOLUTIO Daily Dosage=30 METHADONE 10 /5 ML SOLUTI Daily Dosage=60 Morphine Sulfate Tab 15 Daily Dosage=6 Morphine Sulfate Tab 30 Daily Dosage=6 Morphine Sulfate Oral Soln 10 /5ML Max Qty=500/31 days Morphine Sulfate Oral Soln 10 /5ML Max Qty=500/31 days Morphine Sulfate Oral Soln 20 /5ML Max Qty=500/31 days ROXANOL Morphine Sulfate Oral Soln 20 /ML Max Qty=240/claim Morphine Sulfate Suppos 5 Max Qty=24/claim Morphine Sulfate Suppos 10 Max Qty=24/claim Morphine Sulfate Suppos 20 Max Qty=24/claim Morphine Sulfate Suppos 30 Max Qty=24/claim MS CONTIN Morphine Sulfate Tab SR 12HR 15 Daily Dosage=3 MS CONTIN Morphine Sulfate Tab SR 12HR 30 Daily Dosage=3 MS CONTIN Morphine Sulfate Tab SR 12HR 60 Daily Dosage=3 MS CONTIN Morphine Sulfate Tab SR 12HR 100 Daily Dosage=3 MS CONTIN Morphine Sulfate Tab SR 12HR 200 Daily Dosage=3 OXYCODONE, OXYIR Oxycodone HCl Cap 5 Daily Dose=2 ROXICODONE Oxycodone HCl Tab 5 Daily Dose=2 OXYCODONE HCL 10 TABLET Daily Dose=2 ROXICODONE Oxycodone HCl Tab 15 Daily Dose=2 OXYCODONE HCL 20 TABLET Daily Dose=2 ROXICODONE Oxycodone HCl Tab 30 Daily Dose=2 ROXICODONE Oxycodone HCl Conc 20 /ML Daily Dosage=6 ROXICODONE OXYCODONE HCL 5 /5 ML SOL ULTRAM Tramadol HCl Tab 50 Daily Dosage=8

66 TYLOX Oxycodone w/ Acetaminophen Cap Daily Dosage=6 PERCOCET PERCOCET TABLET PERCOCET PERCOCET PERCOCET PERCOCET PERCOCET TYLENOL/COD TYLENOL/COD Oxycodone w/ Acetaminophen Tab ROXICET Tab Oxycodone w/ Acetaminophen Tab Oxycodone w/ Acetaminophen Tab Oxycodone w/ Acetaminophen Tab Oxycodone w/ Acetaminophen Tab ROXICET (Oxycodone w/ Acetaminophen) Soln /5ML Oxycodone w/ Aspirin Tab Full Strength Oxycodone w/ Aspirin Tab Full Strength Acetaminophen w/ Codeine Tab Acetaminophen w/ Codeine Tab Acetaminophen w/ Codeine Tab Acetaminophen w/ Codeine Soln /5ML Daily Dosage=6 Daily Dosage=6 Daily Dosage=6 Daily Dosage=6 Daily Dosage=6 Daily Dosage=6 Daily Dosage=30 Daily Dosage=6 Daily Dosage=6 Daily Dosage=6 Daily Dosage=6 Daily Dosage=6 Daily Dosage=30 Aspirin w/ Codeine Tab Daily Dosage=6 FIORICET/COD FIORINAL/COD NORCO LORTAB, LORTAB 5, VICODIN LORTAB LORTAB ANEXSIA, LORCET PLUS LORCET ANEXSIA VICODIN ES NORCO NORCO LORTAB Aspirin w/ Codeine Tab Butalbital-Acetaminophen-Caff w/ COD Cap Butalbital-Aspirin-Caff w/ Codeine Cap Hydrocodone-Acetaminophen Tab HYDROCODON- ACETAMINOPH Hydrocodone-Acetaminophen Tab Hydrocodone-Acetaminiphen Tab Hydrocodone-Acetaminophen Tab Hydrocodone-Acetaminophen Tab Hydrocodone-Acetaminophen Tab Hydrocodone-Acetaminophen Tab Hydrocodone-Acetaminophen Tab Hydrocodone-Acetaminophen Tab Hydrocodone-Acetaminophen Tab Hydrocodone-Acetaminophen Tab /15 ML Hydrocodone-Acetaminophen Soln /15ML Daily Dosage=6 Daily Dosage=6 Daily Dosage=4 Daily Dosage=6 Daily Dosage=8 Daily Dosage=6 Daily Dosage=6 Daily Dosage=6 Daily Dosage=6 Daily Dosage=6 Daily Dosage=5 2 Daily Dosage=8 20

67 ANALGESICS - ANTI-INFLAMMATORY CATAFLAM Diclofenac Potassium Tab 50 Diclofenac Sodium Tab Delayed Release 25 Diclofenac Sodium Tab Delayed Release 50 Diclofenac Sodium Tab Delayed VOLTAREN Release 75 Diclofenac Sodium Tab SR 24HR VOLTAREN-XR 100 Etodolac Cap 200 Etodolac Cap 300 Etodolac Tab 400 Etodolac Tab 500 Etodolac Tab SR 24HR 400 Etodolac Tab SR 24HR 500 Etodolac Tab SR 24HR 600 FENOPROFEN 600 TABLET ANSAID ADVIL, NUPRIN Flurbiprofen Tab 50 Flurbiprofen Tab 100 Ibuprofen Tab 200 Ibuprofen Tab 400 Ibuprofen Tab 600 Ibuprofen Tab 800 Ibuprofen (CHILD ADVIL, CHILD MOTRIN) Chew Tab 50 CHILD MOTRIN, MOTRIN JR ST CHILD ADVIL, INFANT ADVIL, MOTRIN, MOTRIN INFAN ADVIL CHILD, CHILD MOTRIN, MOTRIN, MOTRIN CHILD INDOCIN SR TORADOL ORAL MOBIC MOBIC NAPROSYN NAPROSYN Ibuprofen Chew (CHILD ADVIL, CHILD MOTRIN)Tab 100 Ibuprofen Susp 40 /ML Ibuprofen Susp 100 /5ML Indomethacin Cap 25 Indomethacin Cap 50 Indomethacin Cap CR 75 INDOCIN 25 /5 ML SUSPENSI INDOCIN 50 SUPPOSITORY Ketoprofen Cap 50 Ketoprofen Cap 75 Ketoprofen Cap SR 24HR 200 Ketorolac Tromethamine Tab 10 MECLOFENAMATE 50 CAPSULE MECLOFENAMATE 100 CAPSUL Meloxicam Tab 7.5 Meloxicam Tab 15 MELOXICAM 7.5 /5 ML SUSP Nabumetone Tab 500 Nabumetone Tab 750 Naproxen Tab 250 Naproxen Tab 375 Limited to Ages 16 and Older; Max Qty=20/30 days

68 NAPROSYN Naproxen Tab 500 EC-NAPROSYN Naproxen Tab EC 375 EC-NAPROSYN Naproxen Tab EC 500 NAPROSYN Naproxen Susp 125 /5ML ALEVE Naproxen Sodium Tab 220 Max Qty=62/31 days ANAPROX Naproxen Sodium Tab 275 ANAPROX DS Naproxen Sodium Tab 550 DAYPRO Oxaprozin Tab 600 FELDENE Piroxicam Cap 10 FELDENE Piroxicam Cap 20 Sulindac Tab 150 CLINORIL Sulindac Tab 200 RIDAURA 3 CAPSULE RHEUMATREX (Methotrexate Sodium) Tab 2.5 (Antirheumatic) ARAVA Leflunomide Tab 10 ARAVA Leflunomide Tab 20 MIGRAINE PRODUCTS D.H.E. 45 Dihydroergotamine Mesylate Inj 1 /ML MIGRANAL Nasal Spray 4 /ML IMITREX IMITREX IMITREX IMITREX IMITREX MIDRIN CAFERGOT GOUT AGENTS ZYLOPRIM ZYLOPRIM Sumatriptan Nasal Spray 5 /ACT Sumatriptan Nasal Spray 20 /ACT Sumatriptan Succinate Tab 25 Sumatriptan Succinate Tab 50 Sumatriptan Succinate Tab 100 Sumatriptan Succinate Inj 6 /0.5ML Sumatriptan Succinate Inj 6 /0.5ML Sumatriptan Succinate Inj Kit 4 /0.5ML Sumatriptan Succinate Inj Kit 4 /0.5ML Sumatriptan Succinate Inj Kit Sumatriptan Succinate Inj Kit Acetaminophen-Isometheptene- Dichloral Cap Ergotamine w/ Caffeine Tab Allopurinol Tab 100 Allopurinol Tab 300 Probenecid Tab 500 Limited to Ages 12 and Older ; Max Qty=6/30 days Limited to Ages 12 and Older ; Max Qty=6/30 days Limited to Ages 12 and Older ; Max Qty=9/30 days Limited to Ages 12 and Older ; Max Qty=9/30 days Limited to Ages 12 and Older ; Max Qty=9/30 days Limited to Ages 12 and Older ; Max Qty=2/30 days Limited to Ages 12 and Older ; Max Qty=2/30 days Limited to Ages 12 and Older ; Max Qty=2/30 days Limited to Ages 12 and Older ; Max Qty=2/30 days Limited to Ages 12 and Older ; Max Qty=2/30 days Limited to Ages 12 and Older ; Max Qty=2/30 days

69 Colchicine w/ Probenecid Tab ANTICONVULSANTS KLONOPIN Clonazepam Tab 0.5 Daily Dosage=4 KLONOPIN Clonazepam Tab 1 Daily Dosage=4 KLONOPIN Clonazepam Tab 2 Daily Dosage=4 DIASTAT PED Gel Delivery System 2.5 Max Qty=1/claim DIASTAT ACDL Gel Delivery System 10 Max Qty=1/claim DIASTAT ACDL Gel Delivery System 20 Max Qty=1/claim FELBATOL FELBATOL Tab 400 FELBATOL FELBATOL DILANTIN-125 DILANTIN PHENYTEK PHENYTEK ZARONTIN ZARONTIN DEPAKOTE FELBATOL Tab 600 FELBATOL Susp 600 /5ML GABITRIL Tab 2 GABITRIL Tab 4 GABITRIL Tab 12 GABITRIL Tab 16 DILANTIN Chew Tab 50 Phenytoin (Dilantin) Susp 125 /5ML Dilantin Extended Cap 30 Phenytoin Sodium (Dilantin) Extended Cap 100 PHENYTEK 200 CAPSULE PHENYTEK 300 CAPSULE Ethosuximide Cap 250 Ethosuximide Soln 250 /5ML Divalproex Sodium (DEPAKOTE) Tab Delayed Release 125 DEPAKOTE DEPAKOTE DEPAKOTE SPR DEPAKOTE ER DEPAKOTE ER DEPAKENE DEPAKENE TEGRETOL TEGRETOL TEGRETOL TEGRETOL CARBATROL CARBATROL CARBATROL Divalproex Sodium (DEPAKOTE) Tab Delayed Release 250 Divalproex Sodium (DEPAKOTE)Tab Delayed Release 500 Divalproex Sodium (DEPAKOTE) Cap Sprinkle 125 Divalproex Sodium (DEPAKOTE ER) Tab SR 24 HR 250 Divalproex Sodium (DEPAKOTE ER)Tab SR 24 HR 500 Valproate Sodium Syrup 250 /5ML Valproic Acid Cap 250 Carbamazepine Tab 200 Carbamazepine Chew Tab 100 Carbamazepine Susp 100 /5ML Carbamazepine Susp 100 /5ML CARBATROL ER 100 CAPSULE CARBATROL ER 200 CAPSULE CARBATROL ER 300 CAPSULE

70 Carbamazepine Tab SR 12HR 100 TEGRETOL XR Carbamazepine Tab SR 12HR 200 TEGRETOL XR Carbamazepine Tab SR 12HR 400 NEURONTIN Gabapentin Cap 100 Daily Dosage=4 NEURONTIN Gabapentin Cap 300 Daily Dosage=4 NEURONTIN Gabapentin Cap 400 Daily Dosage=4 Gabapentin Tab 100 Daily Dosage=4 Gabapentin Tab 300 Daily Dosage=4 Gabapentin Tab 400 Daily Dosage=4 NEURONTIN Gabapentin Tab 600 Daily Dosage=4 NEURONTIN Gabapentin Tab 800 Daily Dosage=4 NEURONTIN LAMICTAL LAMICTAL LAMICTAL LAMICTAL LAMICTAL LAMICTAL Gabapentin Oral Soln 250 /5ML Lamotrigine Tab 25 Lamotrigine Tab 100 Lamotrigine Tab 150 Lamotrigine Tab 200 Lamotrigine Tab Chewable Dispersible 5 Lamotrigine Tab Chewable Dispersible 25 KEPPRA Levetiracetam Tab 250 Daily Dosage=4 KEPPRA Levetiracetam Tab 500 Daily Dosage=4 KEPPRA Levetiracetam Tab 750 Daily Dosage=4 KEPPRA Levetiracetam Tab 1000 Daily Dosage=4 KEPPRA Levetiracetam Soln 100 /ML 6 TRILEPTAL TRILEPTAL TRILEPTAL Oxcarbazepine Tab 150 Oxcarbazepine Tab 300 Oxcarbazepine Tab 600 Oxcarbazepine Susp 300 /5ML (60 /ML) MYSOLINE Primidone Tab 50 MYSOLINE Primidone Tab 250 TOPAMAX Topiramate Tab 25 Daily Dosage=3 TOPAMAX Topiramate Tab 50 Daily Dosage=3 TOPAMAX Topiramate Tab 100 Daily Dosage=3 TOPAMAX Topiramate Tab 200 Daily Dosage=3 TOPAMAX SPR Topiramate Sprinkle Cap 15 Max Qty=100/30 days TOPAMAX SPR Topiramate Sprinkle Cap 25 Max Qty=100/30 days ZONEGRAN ZONEGRAN ANTIPARKINSON AGENTS ARTANE PARLODEL PARLODEL Zonisamide Cap 25 Zonisamide Cap 50 Zonisamide Cap 100 Benztropine Mesylate Tab 0.5 Benztropine Mesylate Tab 1 Benztropine Mesylate Tab 2 Trihexyphenidyl HCl Tab 2 Trihexyphenidyl HCl Tab 5 Trihexyphenidyl HCl Elixir 0.4 /ML COMTAN 200 TABLET Amantadine HCl Cap 100 Amantadine HCl Syrup 50 /5ML Bromocriptine Mesylate Cap 5 Bromocriptine Mesylate Tab 2.5 Max Qty=500/31 days

71 MIRAPEX MIRAPEX PRAMIPEXOLE TABLET PRAMIPEXOLE 0.25 TABLET Daily Dosage=3 Daily Dosage=3 MIRAPEX PRAMIPEXOLE 0.5 TABLET Daily Dosage=3 MIRAPEX PRAMIPEXOLE 0.75 TABLET Daily Dosage=3 MIRAPEX PRAMIPEXOLE 1 TABLET Daily Dosage=3 MIRAPEX PRAMIPEXOLE 1.5 TABLET Daily Dosage=3 REQUIP Ropinirole Hydrochloride (REQUIP) Tab 0.25 Daily Dosage=6 REQUIP Ropinirole Hydrochloride (REQUIP) Tab 0.5 Daily Dosage=3 REQUIP Ropinirole Hydrochloride (REQUIP) Tab 1 Daily Dosage=3 REQUIP Ropinirole Hydrochloride (REQUIP) Tab 2 Daily Dosage=3 REQUIP Ropinirole Hydrochloride (REQUIP) Tab 3 Daily Dosage=6 REQUIP Ropinirole Hydrochloride (REQUIP) Tab 4 Daily Dosage=6 REQUIP Ropinirole Hydrochloride (REQUIP) Tab 5 Daily Dosage=3 SINEMET Carbidopa & Levodopa Tab SINEMET Carbidopa & Levodopa Tab SINEMET Carbidopa & Levodopa Tab SINEMET CR Carbidopa & Levodopa Tab CR SINEMET CR Carbidopa & Levodopa Tab CR ELDEPRYL Selegiline HCl Cap 5 Selegiline HCl Tab 5 MUSCULOSKELETAL THERAPY AGENTS Baclofen Tab 10 Baclofen Tab 20 PARAFON FORT Chlorzoxazone Tab 500 FLEXERIL Cyclobenzaprine HCl Tab 5 Max Qty=93/31 days FLEXERIL Cyclobenzaprine HCl Tab 10 Daily Dosage=3 ROBAXIN ROBAXIN-750 Methocarbamol Tab 500 Methocarbamol Tab 750 Orphenadrine Citrate Tab SR 12HR 100 Tizanidine HCl Tab 2 ZANAFLEX Tizanidine HCl Tab 4 DANTRIUM Dantrolene Sodium Cap 25 DANTRIUM Dantrolene Sodium Cap 50 DANTRIUM Dantrolene Sodium Cap 100 ANTIMYASTHENIC AGENTS MESTINON Pyridostigmine Bromide Tab 60 Pyridostigmine Bromide (MESTINON) Tab CR 180 MESTINON 60 /5 ML SYRUP MESTINON VITAMINS Thiamine HCl Tab 50 Thiamine HCl Tab 100 Max Qty=100/31 days Max Qty=100/31 days

72 Thiamine HCl Tab 250 Max Qty=100/31 days Thiamine HCl Tab 500 Max Qty=100/31 days Thiamine Mononitrate Tab 100 Max Qty=100/31 days Riboflavin Tab 25 Max Qty=100/31 days Riboflavin Tab 50 Max Qty=100/31 days SLO-NIACIN SLO-NIACIN SLO-NIACIN DRISDOL DRISDOL D-VI-SOL AQUASOL E MULTIVITAMINS Riboflavin Tab 100 Niacin Cap CR 125 Niacin Cap CR 250 Niacin Cap CR 500 Niacin Tab 500 Niacin Tab CR 250 Niacin Tab CR 500 Niacin Tab CR 500 Niacin Tab CR 750 Niacin Tab CR 1000 Pyridoxine HCl Tab 25 Pyridoxine HCl Tab 50 Pyridoxine HCl Tab 100 Ascorbic Acid Tab 250 Ascorbic Acid Tab 500 Ascorbic Acid Tab 1000 Ergocalciferol Cap IU DRISDOL 8,000 UNITS/ML DROP VITAMIN D 1,000 UNITS VITAMIN D 2,000 UNITS VITAMIN D3 5,000 UNIT CAPSU MAXIMUM D3 10,000 UNITS CAP VITAMIN D 1,000 UNIT TABLET VITAMIN D-3 2,000 UNIT TABL VITAMIN D3 5,000 UNIT TABLE VITAMIN D3 50,000 UNIT TABLE D-VI-SOL 400 UNITS/ML DROP VITAMIN D3 5,000 UNIT/ML DR Vitamin E Cap 100 IU Vitamin E Cap 200 IU Vitamin E Cap 400 IU Vitamin E Chew Tab 400 IU AQUASOL E 50 UNIT/ML DROPS AQUA-E LIQUID MEPHYTON Tab 5 *B-Complex Vitamin Cap** *B-Complex Vitamin Tab** *B-Complex w/ C Cap** VI-STRESS TABLET Max Qty=100/31 days Max Qty=100/31 days Max Qty=100/31 days Max Qty=100/31 days Max Qty=8/30 days Max Qty=62/31 days Max Qty=62/31 days Max Qty=62/31 days Max Qty=62/31 days

73 NEPHROCAPS *B-Complex w/ C & Folic Acid Cap 1 *** CEFOL, MILCO-B- FORT, STROVITE VITABEE WITH VIT C CAPLET NEPHRO-VITE NEPHRO-VITE TABLET NEPHRO-VITE *B-Complex w/ C & Folic Acid Tab 1 *** *B-Complex w/ C-Min-Fe & Folic Acid Tab *** GERI-TONIC LIQUID CARDENZ, LYSIPLEX, ONE-A-DAY, *Multiple Vitamin Tab** THERAGRAN THERA-PLUS LIQUID GERITOL EXT *Multiple Vitamins w/ Iron Tab** THERAMILL OCUVITE SOFTGEL THERAMILL PRESERVISION AREDS 2 SOFTGE THERAMILL AQUADEKS SOFTGEL CAROMEGA, CENTRUM, FEMTABS, FOSFREE, ONE-A- DAY... ADV DIABETIC, B-50 FORMULA*Multiple Vitamins w/ Minerals Tab** B-PLEX PLUS CENTRUM, SENETONIC TRI-VI-SOL POLY-VI-SOL POLY-VI-SOL CEROVITE LIQUID *Pediatric Vitamins ADC Drops 1500IU-400IU-35 /ML*** MULTI-DELYN LIQUID *Pediatric Multiple Vitamin w/ C Soln 35 /ML** *Pediatric Multiple Vitamin w/ C & FA Chew Tab** *Pediatric Multiple Vitamin w/ C & FA Chew Tab** ZOO FRIENDS TABLET CHEWABLE ZOO FRIENDS COMPLETE TAB CH VITAMAX *Pediatric Multiple Vitamin w/ Minerals & C Chew Tab 60 ** AQUADEKS PEDIATRIC LIQUID *Pediatric Multiple Vitamins w/ Iron Chew Tab 15 ** *Pediatric Multiple Vitamins w/ Iron Chew Tab 15 ** MULTI-DELYN WITH IRON LIQUI *Pediatric Multiple Vitamins w/ Iron Drops 10 /ML** MYKIDZ IRON SUSPENSION Max Qty=50/claim Max Qty=50/claim TRI-VI-SOL *Pediatric Vitamins ACD w/ Iron Drops 10 /ML*** *Pediatric Vitamins ACD w/ Fluoride Chew Tab 1 *** *Pediatric Vitamins ACD w/ Fluoride Soln 0.25 /ML*** *Pediatric Vitamins ACD w/ Fluoride Soln 0.5 /ML*** *Pediatric Multiple Vitamins w/ Fluoride Chew Tab 0.25 *** Max Qty=50/claim Max Qty=50/claim

74 *Pediatric Multiple Vitamins w/ Fluoride Chew Tab 0.5 *** *Pediatric Multiple Vitamins w/ Fluoride Chew Tab 1 *** *Pediatric Multiple Vitamins w/ Fluoride Soln 0.25 /ML*** *Pediatric Multiple Vitamins w/ Fluoride Soln 0.5 /ML*** *Pediatric Multiple Vitamins w/ Fl- Fe Chew Tab ** *Pediatric Multiple Vitamins w/ Fl- Fe Chew Tab 1-12 ** *Pediatric Multiple Vitamins w/ Fl- Fe Drops /ML** *Pediatric Multiple Vitamins w/ Fl- Fe Drops /ML** *Pediatric Vitamins ACD Fluoride & Fe Drops /ML*** *Prenatal Vitamin Fast Dissolving Tab** POLY-VIT/FE CALNA Max Qty=50/claim Max Qty=50/claim Max Qty=50/claim Max Qty=50/claim *Prenatal Multivitamins & Minerals w/ Iron & FA Cap 0.1*** TYLER PRENAT *Prenatal Multivitamins & Minerals w/ Iron & FA Cap 1 *** MYNATAL *Prenatal Multivitamins & Minerals w/ Iron & FA Tab 0.1*** KPN *Prenatal Multivitamins & Minerals w/ Fe & FA Tab 0.25 *** NUTRICION *Prenatal Multivitamins & Minerals w/ Iron & FA Tab 0.8*** PRENATAL/FE *Prenatal Multivitamins & Minerals w/ Iron & FA Tab 1 *** NOVASTART *Prenatal Vit w/ Iron Carbonyl-FA Tab 29-1 *** *Prenatal Vit w/ Iron Carbonyl-FA Tab 50-1 *** *Prenatal Vit w/ Fe Fumarate-FA Cap *** *Prenatal Vit w/ Fe Fumarate-FA Tab 15-1 *** *Prenatal Vit w/ Fe Fumarate-FA Tab 17-1 *** NATELLE-EZ TABLET *Prenatal Vit w/ Fe Fumarate-FA Tab *** *Prenatal Vit w/ Fe Fumarate-FA Tab *** *Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 *** *Prenatal Vit w/ Fe Fumarate-FA Tab *** *Prenatal Vit w/ Fe Fumarate-FA Tab 29-1 *** *Prenatal Vit w/ Fe Fumarate-FA Tab *** PRENATABS RX PERRY PRENAT O-CAL PRENAFIRST PRENATAL PRENATAL, TRICARE PRENATAL, VOL- PLUS PRENATAL PRENATABS FA Limited to Female; Daily Dose=1 Limited to Female; Daily Dose=1 Limited to Female; Daily Dose=1 Limited to Female; Daily Dose=1 Limited to Female; Daily Dose=1 Limited to Female; Daily Dose=1

75 NATACHEW CITRANATAL *Prenatal Vit w/ Fe Fumarate-FA Tab 60-1 *** *Prenatal Vit w/ Fe Fumarate-FA Tab 65-1 *** *Prenatal Vit w/ Fe Fumarate-FA Tab 75-1 *** SE-NATAL ONE, TRINATAL RX, VINATE ONE MYNATAL PLUS, VITAFOL-OB NATALVIT *Prenatal Vit w/ Fe Fumarate-FA Chew Tab 29-1 *** PRENATAL 19 DAILY PRENATAL COMBO PACK *Prenatal Vit w/ Fe Gluconate-FA Tab *** MISSION PREN *Prenatal Vit w/ Fe Gluconate-FA Tab *** MISSION PREN *Prenatal Vit w/ Fe Sulfate-FA Tab *** PRENATAL *Prenatal Vit w/ Fe Polysac Cmplx- FA Tab 60-1 *** NIFEREX-PN *Prenatal Vit w/ Iron Carbonyl-Fe CAL-NATE, VINATE Gluc-FA Tab 27-1*** CAL *Prenatal w/o A Vit w/ Fe Fumarate- PRENATAL-U, FA Cap *** TRIVEEN-U Limited to Female; Daily Dose=1 Limited to Female; Daily Dose=1 Limited to Ages 50 and Under; Limited to Female; Daily Dose=1 Limited to Female; Daily Dose=1 Limited to Female; Daily Dose=1 Limited to Female; Daily Dose=1 Limited to Female; Daily Dose=1 Limited to Female; Daily Dose=1 Limited to Female; Daily Dose=1 Limited to Female; Daily Dose=1 *Prenatal w/o A Vit w/ Fe Fumarate- FA Tab DR 30-1 *** CAVAN, GESTICARE, TARON-EC CAL, TRINATE Limited to Female; Daily Dose=1 NOVANATAL *Prenatal w/o A Vit w/ Fe Carbonyl- FA Tab 29-1 *** PRENATABS, VITASPIRE Limited to Female; Daily Dose=1 *Prenatal without A w/ Fe Carbonyl- Docusate-FA Tab 90-1*** *Prenatal Vit w/ Sel-Fe Fumarate-FA Tab 27-1 *** *Prenatal Vit w/ DSS-Iron Carbonyl- FA Tab 90-1 *** *Prenatal Vit w/ DSS-Iron Carbonyl- FA Tab 90-1 *** *Prenatal Vit w/ DSS-Fe Fumarate- FA Tab 29-1 *** *Prenatal Vit w/ DSS-Fe Fumarate- FA Tab CR 90-1 *** COMPLETE-RF VINATE M INATAL ADV INATAL ADV PRENATAL 19 MYNATE 90 Limited to Female; Daily Dose=1 Limited to Female; Daily Dose=1 Limited to Female; Daily Dose=1 Limited to Female; Daily Dose=1 Limited to Female; Daily Dose=1 *Prenatal w/fe Polys Cmplx-FA-Ca MARNATAL-F Tab & Omega 3 Cap Pack*** TARON EC CALCIUM DHA COMB P *Vitamins w/ Lipotropics Cap** GERITOL, VITAFOL *Iron w/ Vitamin Tab** FEMIRON IBERET-500, IBERET- *Iron w/ Vitamin Tab CR** FOLIC MINERALS & ELECTROLYTES CALCI-MIX 1.25 GM CAPSULE ELEMENTAL CALCIUM 600 TA OS-CAL, OS-CAL 500 CALCIUM 500 TABLET CALCI-CHEW TABLET Calcium Carbonate Susp 1250 /5ML CALCITRATE 950 TABLET CALCIONATE 1.8 GM/5 ML SYRU Limited to Female; Daily Dose=1 Max Qty=500/30 days

76 CALCIUM GLUCONATE 650 TA CALCIUM LACTATE 648 TABL CALCIUM LACTATE 10GR TABLET Oyster Shell Calcium Tab 500 CALCET TABLET CALCIUM OYS SHELL 250 TA Calcium 500 w/ Vitamin D Tab OS-CAL MAGNEBIND 300 TABLET Calcium Carbonate-Vitamin D Tab IU Calcium Carbonate-Vitamin D Tab IU Calcium Carbonate-Vitamin D Tab IU OYSTER SHELL CALCIUM-VIT D Calcium Carbonate-Vitamin D Tab IU Calcium Carbonate-Vitamin D Tab Unit OYSCO 500+D TABLET CHEWABLE Max Qty=62/31 days Max Qty=62/31 days CITRACAL CITRUS CALCIUM-VIT D DICAL-D CALTRATE 600 CALVITE P&D TABLET CALTRATE 600+D PLUS TAB CHE SODIUM FLUORIDE 1 (2.2 M LURIDE LURIDE LURIDE LURIDE SLOW-MAG SLOW-MAG Sodium Fluoride Chew Tab 0.25 F (from 0.55 NaF) Sodium Fluoride Chew Tab 0.5 F (from 1.1 NaF) Sodium Fluoride Chew Tab 1 F (from 2.2 NaF) FLURA-DROPS Sodium Fluoride Soln /DROP F (0.275 /DROP NaF) FLURA-DROPS Sodium Fluoride Soln 0.25 /DROP F (from 0.55 /DROP NaF FLURA-DROPS Sodium Fluoride Soln 0.5 /ML F (from 1.1 /ML NaF) SSKI Soln 1 GM/ML MAGNESIUM DR 64 TABLET MAG DELAY 64 TABLET MAGONATE 27 TABLET MAGTRATE 500 TABLET MAGONATE 54 /5 ML LIQUID MAG-TAB SR 84 CAPLET SLOW-MAG 71.5 TABLET NEUTRA-PHOS Potassium & Sodium Phosphates For Soln /75ML PHOS-NAK PACKET Max Qty=68/31 days

77 K-PHOS K-PHOS NEUTRAL TABLET Potassium Bicarbonate Effer Tab 25 meq MICRO-K Potassium Chloride Cap CR 10 meq Potassium Chloride Tab CR 8 meq K-TABS K-LOR K-TABS EQUALYTE, PEDIALYTE, PEDIALYTE ST NUTRIENTS HEMATOPOIETIC AGENTS ICAR Potassium Chloride Tab CR 10 meq Potassium Chloride Oral Liq 10% Potassium Chloride Oral Liq 20% Potassium Chloride Powder Packet 20 meq Potassium Chloride Powder Packet 25 meq Potassium Chloride Microencapsulated CRYS CR Tab 10 meq KLOR-CON M15 Potassium Chloride Microencapsulated Crys CR Tab 15 meq Potassium Chloride Microencapsulated CRYS CR Tab 20 meq ZINC 50 TABLET Zinc Sulfate Cap 220 (50 Elemental Zn) CERALYTE 50, CERALYTE 70, CERASPORT, ENFALYTE *Oral Electrolyte Solution*** POLYCOSE Glucose Polymers Liqd POLYCOSE Glucose Polymers Powder 94% ARGININE 500 TABLET FISH OIL SOFTGEL *Omega-3 Fatty Acids Cap 1000 ** *Omega-3 Fatty Acids Cap 1000 ** *Omega-3 Fatty Acids Cap 1000 ** *Omega-3 Fatty Acids Cap 1200 ** FISH OIL 1,000 EC SOFTGE FISH OIL 1,200 SOFTGEL SEA OMEGA + D SOFTGEL SLOESTEROL POWDER Cyanocobalamin Inj 1000 MCG/ML Folic Acid Tab 200 MCG Folic Acid Tab 400 MCG Folic Acid Tab 800 MCG Folic Acid Tab 1 Carbonyl Iron Chew Tab 15 (Elemental Iron) MYKIDZ IRON 10 SUSPENSION Ferrous Sulfate Tab 83 Ferrous Sulfate Tab 325 (65 Elemental Fe) Max Qty=10/270 days

78 Ferrous Sulfate Tab 28 (Elemental Fe) FERROUS SULFATE ER 140 T SLOW RELEASE IRON 160 GM TA Ferrous Sulfate Tab EC 325 (65 Fe Equivalent) FEOSOL Ferrous Sulfate Elixir 220 /5ML (44 /5ML Elemental Fe) FER-IN-SOL Ferrous Sulfate Soln 75 /ML (15 /ML Elemental Fe) Daily Dosage=3.4 Ferrous Sulfate Soln 75 /0.6ML Daily Dosage=3.4 SLOW FE FERGON HEMOCYTE NIFEREX-150 ANTICOAGULANTS Ferrous Sulfate Dried Tab CR 160 (50 Fe Equivalent) Ferrous Gluconate Tab 216 Ferrous Gluconate Tab 240 Ferrous Gluconate Tab 300 Ferrous Gluconate Tab 324 (38 Elemental Iron) Ferrous Gluconate Tab 325 Ferrous Gluconate Tab 325 (36 Elemental Fe) Ferrous Gluconate Tab 325 (37.5 Elemental Fe) Ferrous Gluconate Tab 225 (27 Fe Equivalent) Ferrous Gluconate Tab 246 (28 Elemental Fe) Ferrous Fumarate Tab 325 (106 Elemental Fe) Polysaccharide Iron Complex Cap 150 PRO FE 180 CAPSULE DROXIA 200 CAPSULE DROXIA 300 CAPSULE DROXIA 400 CAPSULE BIFERA 28 TABLET POLYSACCHARIDE IRON FORTE FERREX 150 PLUS CAPSULE Heparin Sodium (Porcine) Inj 1000 U/ML Heparin Sodium (Porcine) Inj 5000 U/ML Heparin Sodium (Porcine) Inj U/ML Heparin Sodium (Porcine) Inj U/ML LOVENOX Enoxaparin Sodium Inj 30 /0.3ML LOVENOX 7 days supply per claim and 3 claim max at retail allowed - after that PA with Specialty required LOVENOX Enoxaparin Sodium Inj 40 /0.4ML LOVENOX 7 days supply per claim and 3 claim max at retail allowed - after that PA with Specialty required

79 LOVENOX Enoxaparin Sodium Inj 60 /0.6ML LOVENOX 7 days supply per claim and 3 claim max at retail allowed - after that PA with Specialty required LOVENOX Enoxaparin Sodium Inj 80 /0.8ML LOVENOX 7 days supply per claim and 3 claim max at retail allowed - after that PA with Specialty required LOVENOX Enoxaparin Sodium Inj 100 /ML LOVENOX 7 days supply per claim and 3 claim max at retail allowed - after that PA with Specialty required LOVENOX Enoxaparin Sodium Inj 120 /0.8ML LOVENOX 7 days supply per claim and 3 claim max at retail allowed - after that PA with Specialty required LOVENOX Enoxaparin Sodium Inj 150 /ML LOVENOX 7 days supply per claim and 3 claim max at retail allowed - after that PA with Specialty required LOVENOX Enoxaparin Sodium Inj 300 /3ML LOVENOX 7 days supply per claim and 3 claim max at retail allowed - after that PA with Specialty required COUMADIN COUMADIN COUMADIN COUMADIN COUMADIN COUMADIN COUMADIN COUMADIN COUMADIN Warfarin Sodium Tab 1 Warfarin Sodium Tab 2 Warfarin Sodium Tab 2.5 Warfarin Sodium Tab 3 Warfarin Sodium Tab 4 Warfarin Sodium Tab 5 Warfarin Sodium Tab 6 Warfarin Sodium Tab 7.5 Warfarin Sodium Tab 10 XARELTO TAB 10 Max Qty=35/6 months HEMOSTATICS AMICAR Aminocaproic Acid Tab 500 Max Qty=24/claim AMICAR Aminocaproic Acid Syrup 25% Max Qty=60/claim HEMATOLOGICAL AGENTS - MISCELLANEOUS HEMOFIL M UNITS VIA HEMOFIL M UNITS VIA KOATE-DVI 500 UNITS VIAL HEMOFIL M 801-1,700 UNITS V HEMOFIL M 1,701-2,000 UNITS MONOCLATE-P 1,000 UNITS KIT MONOCLATE-P 1,500 UNITS KIT RECOMBINATE UNIT VI RECOMBINATE UNIT VI

80 RECOMBINATE 801-1,240 UNIT RECOMBINATE 1,241-1,800 UNI RECOMBINATE 1,801-2,400 UNI KOGENATE FS 250 UNIT VIAL HELIXATE FS 250 UNIT VIAL KOGENATE FS 250 UNIT VIAL KOGENATE FS 500 UNIT VIAL HELIXATE FS 500 UNIT VIAL KOGENATE FS 500 UNIT VIAL KOGENATE FS 1,000 UNIT VIAL HELIXATE FS 1,000 UNIT VIAL KOGENATE FS 1,000 UNITS VIA KOGENATE FS 2,000 UNIT VIAL HELIXATE FS 2,000 UNIT VIAL KOGENATE FS 2,000 UNIT VIAL KOGENATE FS 3,000 UNIT VIAL HELIXATE FS 3,000 UNITS VIA KOGENATE FS 3,000 UNITS VIA ADVATE UNITS VIAL ADVATE UNITS VIAL ADVATE 801-1,200 UNITS VIAL ADVATE 1,201-1,800 UNITS VI ADVATE 1,801-2,400 UNITS VI ADVATE 2,400-3,600 UNITS VI XYNTHA 250 UNIT KIT XYNTHA 500 UNIT KIT XYNTHA 1,000 UNIT KIT XYNTHA 2,000 UNIT KIT XYNTHA 3,000 UNIT SYRINGE K HUMATE-P 600 UNIT VWF:RCO HUMATE-P 1,200 UNIT VWF:RCO HUMATE-P 2,400 UNIT VWF:RCO

81 ALPHANATE UNIT VIAL ALPHANATE UNIT VIAL ALPHANATE 1, UNIT VI ALPHANATE 1, UNIT VI FEIBA VH IMMU 1,750-3,250 U FEIBA VH IMMUNO UNI FEIBA NF UNIT VIAL FEIBA NF 1,750-3,250 UNIT V FEIBA VH IMMUNO 651-1,200 U FEIBA NF 651-1,200 UNIT VIA NOVOSEVEN RT 1,000 MCG VIAL NOVOSEVEN 1,200 MCG VIAL NOVOSEVEN RT 2,000 MCG VIAL NOVOSEVEN 2,400 MCG VIAL NOVOSEVEN RT 5,000 MCG VIAL NOVOSEVEN RT 8,000 MCG VIAL MONONINE 1,000 UNITS VIAL RIXUBIS 250 UNIT NOMINAL BENEFIX 250 UNIT VIAL RIXUBIS 500 UNIT NOMINAL BENEFIX 500 UNIT VIAL RIXUBIS 1,000 UNIT NOMINAL BENEFIX 1,000 UNIT VIAL RIXUBIS 2,000 UNIT NOMINAL BENEFIX 2,000 UNIT VIAL RIXUBIS 3,000 UNIT NOMINAL PROFILNINE SD 500 UNITS VIA PROFILNINE SD 1,000 UNITS V PROFILNINE SD 1,500 UNITS V BEBULIN VH INJ PERSANTINE Dipyridamole Tab 25 PERSANTINE Dipyridamole Tab 50 PERSANTINE Dipyridamole Tab 75 PLETAL Cilostazol Tab 50

82 PLETAL Cilostazol Tab 100 AGRYLIN ANAGRELIDE HCL 0.5 CAPSU ANAGRELIDE HCL 1 CAPSULE PLAVIX Clopidogrel Bisulfate (PLAVIX) Tab 75 (Base Equiv) TRENTAL Pentoxifylline Tab CR 400 OPHTHALMIC AGENTS Bacitracin Ophth Oint 500 U/GM Max Qty=4/31 days CILOXAN Ciprofloxacin HCl Ophth Soln 0.3% Ciprofloxacin HCl Ophth Oint 0.3% Erythromycin Ophth Oint 5 /GM GARAMYCIN Gentamicin Sulfate Ophth Soln 0.3% Package Limit=2/claim Gentamicin Sulfate Ophth Oint 0.3% Max Qty=4/31 days VIGAMOX Ophth Soln 0.5% Max Qty=3/claim OCUFLOX Ofloxacin Ophth Soln 0.3% Max Qty=10/31 days TOBREX Tobramycin Sulfate Ophth Soln 0.3% Max Qty=5/31 days TOBREX Ophth Oint 0.3% BLEPH-10 Sulfacetamide Sodium Ophth Soln 10% Max Qty=15/31 days Sulfacetamide Sodium Ophth Oint 10% Max Qty=4/31 days VIROPTIC Trifluridine Ophth Soln 1% Max Qty=8/31 days POLYSPORIN Bacitracin-Polymyxin B Ophth Oint Max Qty=4/31 days POLYTRIM Polymyxin B-Trimethoprim Ophth Soln UNITS/ML-0.1% NEOSPORIN REFRESH PLUS GENTEAL Neomycin-Bacitracin Zn-Polymyx 3.5(5)-400U-10000U Op Oint Neomycin-Polymyxin B-Gramicidin Ophth Soln REFRESH PLUS 0.5% EYE DROPS REFRESH CELLUVISC 1% EYE DR GENTEAL MILD 0.2% EYE DROPS GENTEAL MILD-MODERATE EYE D Hydroxypropyl Methylcellulose Ophth Soln 0.4% ISOPTO TEARS 0.5% EYE DROPS GENTEAL SEVERE 0.3% EYE GEL Max Qty=4/31 days Max Qty=10/31 days PREMIER VALU Polyvinyl Alcohol Ophth Soln 1.4% Max Qty=31/31 days AQUASITE AQUASITE AQUASITE SYSTANE BALANCE 0.6% EYE DR SM ARTIFICIAL TEARS TEARS NATURALE FORTE DROPS TEARS NATURALE FREE DROPS

83 AQUASITE TEARS NATURALE-II EYE DROPS AKWA TEARS, LACRI- LUBE, REFRESH P.M., SOOTHE NIGHT *Artificial Tear Ophth Ointment*** Max Qty=4/claim AKWA TEARS, LACRI- LUBE, REFRESH P.M., SOOTHE NIGHT *Artificial Tear Ophth Ointment*** Max Qty=4/claim SYSTANE, SYSTANE PF, SYSTANE ULTR TEARS NATURA TEARS NATURA Polyethylene Glycol-Polyvinyl Alcohol Ophth Soln 1-1% SYSTANE % EYE DROPS SYSTANE NIGHTTIME EYE OINT PURALUBE OPHTHALMIC OINTMEN Betaxolol HCl Ophth Soln 0.5% CARTEOLOL HCL 1% EYE DROPS Max Qty=31/31 days Package Limit=1/31 days Package Limit=1/31 days BETAGAN Levobunolol HCl Ophth Soln 0.25% BETAGAN Levobunolol HCl Ophth Soln 0.5% Max Qty=15/31 days BETIMOL 0.25% EYE DROPS BETIMOL 0.5% EYE DROPS Max Qty=15/31 days Max Qty=15/31 days TIMOPTIC Timolol Maleate Ophth Soln 0.25% Max Qty=15/31 days TIMOPTIC Timolol Maleate Ophth Soln 0.5% Max Qty=15/31 days TIMOPTIC-XE TIMOPTIC-XE COSOPT TIMOPTIC-XE 0.25% EYE SOLN Timolol Maleate Ophth Gel Forming Soln 0.5% Dorzolamide HCl-Timolol Maleate Ophth Soln /ML Package Limit=1/31 days Package Limit=1/31 days Max Qty=10/31 days Dexamethasone Sodium Phosphate Ophth Soln 0.1% FML LIQUIFLM Fluorometholone Ophth Susp 0.1% OMNIPRED, PRED FORTE FML S.O.P. Ophth Oint 0.1% Prednisolone Acetate (PRED MILD) Ophth Susp 0.12% Prednisolone Acetate Ophth Susp 1% Prednisolone Sodium Phosphate Ophth Soln 1% VEXOL Ophth Susp 1% PRED-G Ophth Susp 0.3-1% BLEPHAMIDE Ophth Susp % Sulfacetamide Sodium-Prednisolone Ophth Soln % Package Limit=1/31 days Max Qty=4/31 days Max Qty=10/31 days Package Limit=1/31 days Package Limit=1/31 days Package Limit=1/31 days Max Qty=10/31 days TOBRADEX BLEPHAMIDE Ophth Oint % Tobramycin-Dexamethasone Ophth Susp % TOBRADEX Ophth Oint % Package Limit=1/31 days Max Qty=4/31 days

84 MAXITROL Neomycin-Polymyxin- Dexamethasone Ophth Susp 0.1% Max Qty=10/31 days MAXITROL Neomycin-Polymyxin- Dexamethasone Ophth Oint 0.1% Max Qty=4/31 days CORTISPORIN Neomycin-Polymyxin-HC Ophth Susp Max Qty=15/31 days POLY-PRED Ophth Susp 0.5% (new) NEO-BACIT-POLY-HC EYE OINT XALATAN Latanoprost Ophth Soln 0.005% Max Qty=5/31 days ISO ATROPINE Atropine Sulfate Ophth Soln 1% Atropine Sulfate Ophth Oint 1% CYCLOGYL Ophth Soln 0.5% Max Qty=15/31 days CYCLOGYL CYCLOGYL Ophth Soln 1% CYCLOGYL CYCLOGYL Ophth Soln 2% Package Limit=1/31 days ISO HOMATROP (Homatropine HBr) Ophth Soln 2% ISO HOMATROP (Homatropine ISO HOMATROP HBr) Ophth Soln 5% Tropicamide Ophth Soln 0.5% MYDRIACYL Tropicamide Ophth Soln 1% ALBALON, NAPHCON Naphazoline HCl Ophth Soln 0.1% FORT MYDFRIN Phenylephrine HCl Ophth Soln 2.5% SUSTAINED DR, VISINE, VISINE EXTRA Tetrahydrozoline HCl Ophth Soln 0.05% ISO CARBACHO (Carbachol Ophth Soln) 1.5% ISO CARBACHO (Carbachol Ophth Soln) 3% ISO CARPINE Pilocarpine HCl Ophth Soln 0.5% ISOPTO CARP Pilocarpine HCl Ophth Soln 1% ISOPTO CARP Pilocarpine HCl Ophth Soln 2% ISOPTO CARP Pilocarpine HCl Ophth Soln 3% ISOPTO CARP Pilocarpine HCl Ophth Soln 4% Pilocarpine HCl Ophth Soln 6% Dipivefrin HCl Ophth Soln 0.1% IOPIDINE Ophth Soln 1% (Base Equivalent) Brimonidine Tartrate Ophth Soln 0.2% OPTIVAR OPTIVAR Ophth Soln 0.05% Max Qty=15/31 days Max Qty=5/31 days; Max Qty=5/31 days Max Qty= 1 package/30 days Package Limit=1/31 days Max Qty=6/31 days; CROLOM Cromolyn Sodium Ophth Soln 4% ZADITOR Ketotifen Fumarate Ophth Soln Package Limit=1/ % (Base Equiv) days ALOMIDE Ophth Soln 0.1% Max Qty=10/31 days; ALOCRIL Ophth Soln 2% Max Qty=5/31 days; AZOPT Ophth Susp 1% Package Limit=1/31 days TRUSOPT Dorzolamide HCl Ophth Soln 2% Max Qty=10/31 days MURO 128 MURO-128 5% EYE DROPS Package Limit=1/31 days MURO 128 MURO-128 5% EYE OINTMENT Package Limit=1/31 days VOLTAREN VOLTAREN Ophth Soln 0.1% Max Qty=3/31 days Prior use of Zaditor Prior use of Zaditor Prior use of Zaditor

85 OCUFEN Flurbiprofen Sodium Ophth Soln 0.03% ACULAR LS ACULAR LS Ophth Soln 0.4% ACULAR ACULAR Ophth Soln 0.5% Max Qty=5/31 days Package Limit=1/30 days Package Limit=1/31 days NEVANAC 0.1% DROPTAINER Max Qty=3/claim OTIC AGENTS FLOXIN OTIC Ofloxacin Otic Soln 0.3% Package Limit=1/31 days DERMOTIC DERMOTIC (Otic) Oil 0.01% Package Limit=1/30 days VOSOL HC Hydrocortisone w/ Acetic Acid Otic Soln 1-2% Max Qty=20/31 days VOSOL Acetic Acid Otic Soln 2% Max Qty=15/31 days Acetic Acid 2% in Aluminum Acetate Otic Soln DEBROX REED DEBROX 6.5% Otic Soln Max Qty=15/31 days CIPRODEX Otic Susp % CORTISPORIN, PEDIOTIC CORTISPORIN CORTANE-B, OTICIN HC CORTANE-B Neomycin-Polymyxin-HC Otic Susp 3.5 /ML U/ML-1% Neomycin-Polymyxin-HC Otic Soln 1% OTILAM NR (Benzocaine- Antipyrine) Otic Soln % Pramoxine-HC-Chloroxylenol Otic Soln /ML Pramoxine-HC-Chloroxylenol Aqueous Otic Soln /ML Max Qty=20/31 days Max Qty=10/claim Package Limit=1/30days Package Limit=1/30days Package Limit=1/30days MOUTH/THROAT/DENTAL AGENTS Nystatin Susp U/ML CLOTRIMAZOLE 10 MYCELEX TROCHE PERIDEX Chlorhexidine Gluconate Soln 0.12% Zinc Lozenge 15 Triamcinolone Acetonide Dental Paste 0.1% Lidocaine HCl Viscous Soln 2% PREVIDENT Sodium Fluoride Rinse 0.2% PREVIDENT Sodium Fluoride Cream 1.1% Sodium Fluoride Gel 1% PREVIDENT, THERA- FLUR-N Sodium Fluoride Gel 1.1% PREVIDENT Sodium Fluoride Paste 1.1% GEL-KAM Stannous Fluoride Conc 0.63% Artificial Saliva - Solution SALAGEN PILOCARPINE HCL 5 TABLET SALAGEN SALAGEN 7.5 TABLET ANORECTAL AGENTS ANUSOL-HC Hydrocortisone Rectal Cream 2.5% ANUSOL-HC Hydrocortisone Acetate Suppos 25 CORTENEMA Hydrocortisone Enema 100 /60ML PROCTOFOAM Pramoxine HCl Rectal Foam 1% Max Qty=100/claim; Compound: Max Qty=120/claim Max Qty=60/month

86 ANALPRAM-HC ANALPRAM-HC PREPARATION Hydrocortisone Acetate w/ Pramoxine Rectal Cream 1-1% Hydrocortisone Acetate w/ Pramoxine Rectal Cream 2.5-1% ANALPRAM-HC (Hydrocortisone Acetate w/ Pramoxine) Rectal Lotn 2.5-1% Phenyleph-Shark Liver Oil-Cocoa Butter Suppos % Max Qty=62/31 days Max Qty=30/claim Max Qty=62/31 days Max Qty=12/31 days HEMORRHOIDAL CREAM PREPARATION PREPARATION DERMATOLOGICALS Phenylephrine-Shark Liver Oil-MO- Pet Oint % Phenylephrine-Shark Liver Oil-MO- Pet Oint % Max Qty=31/31 days Max Qty=31/31 days BENZAC AC, BENZAC W, DESQUAM-X Benzoyl Peroxide Liq 2.5% LAVOCLEN-4 CREAMY WASH BENZAC AC, BENZAC W, DESQUAM-X Benzoyl Peroxide Liq 5% BENZAC AC, BENZAC W, DESQUAM-X BENZAC AC, BENZAC W, DESQUAM-X LAVOCLEN-8 CREAMY WASH Benzoyl Peroxide Liq 10% Benzoyl Peroxide Liq 10% PANOXYL 10% FOAM Benzoyl Peroxide Foam 10% Benzoyl Peroxide Gel 2.5% Benzoyl Peroxide Gel 4% BENZAC AC Benzoyl Peroxide Gel 5% BENZAC AC Benzoyl Peroxide Gel 5% BENZAC AC, DESQUAM-X Benzoyl Peroxide Gel 10% BENZAC AC, DESQUAM-X Benzoyl Peroxide Gel 10% TRIAZ CLEANS TRIAZ 3% CLEANSER BENZOYL PEROX 4% CLEANSING Benzoyl Peroxide Lotion 5% TRIAZ CLEANS TRIAZ 6% CLEANSER TRIAZ CLEANS TRIAZ 9% CLEANSER Benzoyl Peroxide Lotion 10% ACCUTANE Benzoyl Peroxide-Sulfur Lotion 5-2% Benzoyl Peroxide-Sulfur Lotion 10-5% Isotretinoin Cap 10 Max Qty=62/31 days Max Qty=62/31 days Limited to Ages 21 and Under ; Daily Dosage=2; Prior use of topical antibiotics, antiinfectives, retinoids + oral antibiotics as 1st-line therapy

87 ACCUTANE ACCUTANE Isotretinoin Cap 20 CLARAVIS 30 CAPSULE Isotretinoin Cap 40 Limited to Ages 21 and Under ; Daily Dosage=2; Limited to Ages 21 and Under ; Daily Dosage=2; Limited to Ages 21 and Under ; Daily Dosage=2; RETIN-A Tretinoin Cream 0.025% Max Qty=20/claim RETIN-A Tretinoin Cream 0.05% Max Qty=20/claim RETIN-A Tretinoin Cream 0.1% Max Qty=20/claim RETIN-A Tretinoin Gel 0.01% Max Qty=15/claim RETIN-A Tretinoin Gel 0.025% CLEOCIN-T Clindamycin Phosphate Soln 1% CLEOCIN-T CLINDAGEL Gel 1% CLEOCIN-T Clindamycin Phosphate Lotion 1% Erythromycin Soln 2% ERYGEL Erythromycin Gel 2% KLARON Sulfacetamide Sodium Lotion 10% (Acne) BENZAMYCIN BENZAMYCIN GEL BENZACLIN BENZACLIN GEL PLEXION CLNS CLENIA FOAMING WASH Prior use of topical antibiotics, antiinfectives, retinoids + oral antibiotics as 1st-line therapy Prior use of topical antibiotics, antiinfectives, retinoids + oral antibiotics as 1st-line therapy Prior use of topical antibiotics, antiinfectives, retinoids + oral antibiotics as 1st-line therapy NOVACET NOVACET Sulfacetamide Sodium w/ Sulfur Susp 10-5% Sulfacetamide Sodium w/ Sulfur Lotion 10-5% Sulfacetamide Sodium w/ Sulfur Lotion 10-5% METROCREAM Metronidazole Cream 0.75% Metronidazole Gel 0.75% METROLOTION Metronidazole Lotion 0.75% BACIGUENT Bacitracin Oint 500 U/GM Bacitracin Zinc Oint 500 U/GM Bacitracin Zinc Oint 500 U/GM Gentamicin Sulfate Cream 0.1% Gentamicin Sulfate Oint 0.1% BACTROBAN Mupirocin Oint 2% BACTROBAN Cream 2% *Bacitracin-Polymyxin B Powder*** Pkg Size 30: Package Limit=1/claim Package Limit=1/31 days Package Limit=1/31 days Max DS/DU=Lesser Of Max Days Sply=30/Max Qty=45 Max DS/DU=Lesser Of Max Days Sply=31/Max Qty=45 Max Qty=30/claim Max Qty=30/claim Package Limit=1/31 days Package Limit=1/31 days POLYSPORIN *Bacitracin-Polymyxin B Oint***

88 NEOSPORIN, TRIPLE ANTIB NEOSPORIN, TRIPLE ANTIB NEOSPORIN *Neomycin-Bacitracin-Polymyxin Oint*** *Neomycin-Bacitracin-Polymyxin Oint*** Neomycin-Polymyxin w/ Pramoxine Cream 1% TRIPLE ANTIBIOTIC PLUS OINT PENLAC PENLAC 8% SOLUTION LOPROX CICLOPIROX 0.77% GEL LOPROX CICLOPIROX 0.77% TOPICAL SU LOPROX CICLOPIROX 0.77% CREAM *Nystatin Topical Powder** Nystatin Cream U/GM Nystatin Oint U/GM Package Limit=1/31 days Package Limit=1/31 days TINACTIN TOLNAFTATE 1% SOLUTION TINACTIN TOLNAFTATE 1% POWDER TINACTIN, TINACTIN JOCK ITCH 1% POWDER SPRAY POW TINACTIN Tolnaftate Cream 1% Max Qty=30/claim LAMISIL AT 1% GEL LAMISIL AT, LAMISIL AT C LOTRIMIN AF, MYCELEX OTC LAMISIL ANTIFUNGAL 1% SPRAY LAMISIL AT 1% SPRAY Terbinafine HCl Cream 1% Clotrimazole Soln 1% Clotrimazole Cream 1% Econazole Nitrate Cream 1% Ketoconazole Cream 2% Ketoconazole Shampoo 1% NIZORAL Ketoconazole Shampoo 2% FUNGOID 2% TINCTURE Package Limit=1/31 days Max Qty=30/claim Pkg Size 120: Package Limit=1/claim ZEASORB-AF 2% POWDER MICATIN Miconazole Nitrate Cream 2% PA, Legend ALOE VESTA ALOE VESTA 2% OINTMENT Clotrimazole w/ Betamethasone LOTRISONE Cream % Clotrimazole w/ Betamethasone LOTRISONE Lotion % Nystatin-Triamcinolone Cream U/GM-% Nystatin-Triamcinolone Oint U/GM-% BENADRYL M-S Diphenhydramine HCl Cream 2% DERMAREST Diphenhydramine HCl Gel 2% Max Qty=45/31 days Max Qty=31/31 days

89 BENADRYL, BENADRYL ITC Diphenhydramine-Zinc Acetate Cream 1-0.1% BENADRYL ANTI-ITCH 2% CREAM DOVONEX, DOVONX SCALP DRITHO-CRÈME (Anthralin Cream) 1% Calcipotriene Soln 0.005% (50 MCG/ML) DOVONEX Cream 0.005% CALCIPOTRIENE 0.005% OINTME TAZORAC Cream 0.05% TAZORAC Cream 0.1% TAZORAC Gel 0.05% TAZORAC Gel 0.1% SELSUN BLUE Selenium Sulfide Lotion 1% SELSUN Selenium Sulfide Lotion 2.5% OVACE PLUS, OVACE WASH Sulfacetamide Sodium Liquid 10% SEBULEX SEBULEX MEDICATED SHAMPOO CARMOL SCALP Sulfacetamide Sodium-Urea Lotion 10-10% ZOVIRAX Cream 5% ZOVIRAX Oint 5% Pkg Size 60: Package Limit=1/claim Pkg Size 60: Package Limit=1/claim Pkg Size 30: Package Limit=2/claim Pkg Size 30: Package Limit=2/claim Package Limit=1/31 days EFUDEX Fluorouracil Soln 2% Max Qty=10/31 days EFUDEX Fluorouracil Soln 5% Max Qty=10/31 days CARAC Cream 0.5% EFUDEX Fluorouracil Cream 5% Max Qty=40/31 days SULFAMYLON 8.5% CREAM SILVADENE Silver Sulfadiazine Cream 1% THERAPLEX T IONIL T SHAMPOO DENOREX THER BETATAR GEL SHAMPOO DIPROLENE AMCINONIDE 0.1% CREAM Betamethasone Dipropionate Cream 0.05% Betamethasone Dipropionate Lotion 0.05% Betamethasone Dipropionate Oint 0.05% Betamethasone Dipropionate Augmented Cream 0.05% Betamethasone Dipropionate Augmented Gel 0.05% Betamethasone Dipropionate Augmented Lotion 0.05% Betamethasone Dipropionate Augmented Oint 0.05% Betamethasone Valerate Cream 0.1% Betamethasone Valerate Lotion 0.1% Betamethasone Valerate Oint 0.1% TEMOVATE Clobetasol Propionate Soln 0.05%

90 TEMOVATE Clobetasol Propionate Cream 0.05% TEMOVATE Clobetasol Propionate Gel 0.05% TEMOVATE Clobetasol Propionate Oint 0.05% TEMOVATE E Clobetasol Propionate Emollient Base Cream 0.05% DESOWEN Desonide Cream 0.05% DESOWEN Desonide Lotion 0.05% DESOWEN Desonide Oint 0.05% Desoximetasone Cream 0.05% TOPICORT Desoximetasone Cream 0.25% TOPICORT Desoximetasone Gel 0.05% TOPICORT Desoximetasone Oint 0.25% Diflorasone Diacetate Cream 0.05% Diflorasone Diacetate Oint 0.05% Fluocinolone Acetonide Soln 0.01% Fluocinolone Acetonide Cream 0.01% Fluocinolone Acetonide Cream 0.025% Fluocinolone Acetonide Oint 0.025% Fluocinonide Soln 0.05% LIDEX Fluocinonide Cream 0.05% Fluocinonide Gel 0.05% Fluocinonide Oint 0.05% Fluocinonide Emulsified Base Cream 0.05% CUTIVATE Fluticasone Propionate Cream 0.05% Package Limit=1/30 days CUTIVATE Fluticasone Propionate Oint 0.005% Hydrocortisone Cream 0.5% Hydrocortisone Cream 0.5% Hydrocortisone Cream 1% Hydrocortisone Cream 1% HYTONE Hydrocortisone Cream 2.5% Hydrocortisone Lotion 1% Hydrocortisone Lotion 2.5% HYDROCORTISONE 0.5% OINTMEN Pkg JAR: Max Qty=120/30 days; Pkg TUBE: Package Limit=1/claim

91 Hydrocortisone Oint 1% Hydrocortisone Oint 2.5% Max Qty=60/30 days; Package Limit=1/30 days ANUSOL HC-1, TUCKS Hydrocortisone Acetate Oint 1% WESTCORT Hydrocortisone Valerate Cream 0.2% LOCOID Hydrocortisone Butyrate Soln 0.1% LOCOID Hydrocortisone Butyrate Cream 0.1% LOCOID Hydrocortisone Butyrate Oint 0.1% ELOCON Mometasone Furoate Cream 0.1% ELOCON Mometasone Furoate Oint 0.1% Triamcinolone Acetonide Cream 0.025% Triamcinolone Acetonide Cream 0.1% Triamcinolone Acetonide Cream 0.5% Triamcinolone Acetonide Lotion 0.025% Triamcinolone Acetonide Lotion 0.1% Triamcinolone Acetonide Oint 0.025% Triamcinolone Acetonide Oint 0.1% Triamcinolone Acetonide Oint 0.5% Pkg JAR: Max Qty=120/30 days; Pkg TUBE: Package Limit=1/claim Pramoxine-HC Aerosol Foam 1-1% Hydrocortisone-Aloe Vera Cream 1% ALPHA GLOW *Emollient - Lotion** ALPHA GLOW *Emollient - Lotion** DERMAPHOR OINTMENT LAC-HYDRIN LAC-HYDRIN Lactic Acid (Ammonium Lactate) Cream 12% Lactic Acid (Ammonium Lactate) Lotion 12% PETROLATUM BASE OINTMENT Package Limit=1/31 days Package Limit=1/31 days ATRAC-TAIN ATRAC-TAIN CREAM ATRAC-TAIN NUTRAPLUS 10% CREAM Urea Cream 40% CARMOL 10 UREA 10% LOTION CARMOL 40 Urea Lotion 40% CONDYLOX Podofilox Soln 0.5% WART OFF SALACTIC FILM SOLUTION KERALYT Salicylic Acid Gel 6%

92 COMPOUND W SAL-PLANT 17% GEL KERALYT (Salicylic Acid Gel) 3% Salicylic Acid 6% Shampoo Capsicum Oleoresin Cream 0.025% ZOSTRIX, ZOSTRIX ARTH ZOSTRIX, ZOSTRIX HP, ZOSTRIX SPRT, ZOSTRX FOOT Capsicum Oleoresin Cream 0.075% ZIKS ARTHRITIS PAIN RELIEF Capsaicin Cream 0.025% Capsaicin Cream 0.035% Capsaicin Cream 0.075% CAPZASIN-HP ARTHRITIS PAIN RELIEF 0.1% Capsaicin Gel 0.025% Capsaicin Gel 0.05% Capsaicin Gel 0.075% Capsaicin Lotion 0.035% Dibucaine Oint 1% LMX 4 LMX 4 4% CREAM Lidocaine Oint 5% LIDAMANTLE Lidocaine HCl Cream 3% XYLOCAINE Lidocaine HCl Gel 2% EMLA Lidocaine-Prilocaine Cream % Max Qty=30/claim LIDOCAINE-PRILOCAINE EMLA CREAM SCABICIDES/PEDICULOCIDES EURAX Cream 10% EURAX Lotion 10% Pkg Size 60: Package Limit=1/claim OVIDE OVIDE 0.5% LOTION NIX LICE Spray 0.25% NIX COMPLETE, NIX Permethrin Creme Rinse 1% CREM RIN Permethrin Aerosol 0.4% RID Permethrin Aerosol 0.5% ELIMITE Permethrin Cream 5% Permethrin Lotion 1% NATROBA 0.9% TOPICAL SUSP KLOUT *Nit Remover - Shampoo*** KLOUT LICE *Nit Remover - Kit*** Pyrethrins-Piperonyl Butoxide Liq % Pyrethrins-Piperonyl Butoxide Liq % Max Qty=1/14 days Max Qty=1/14 days

93 RID RID TEGRIN-LT PRONTO PRONTO A-200 Pyrethrins-Piperonyl Butoxide Liq 0.2-2% Pyrethrins-Piperonyl Butoxide Liq 0.3-3% Pyrethrins-Piperonyl Butoxide Liq % Pyrethrins-Piperonyl Butoxide Foam % Pyrethrins-Piperonyl Butoxide Gel 0.3-3% Pyrethrins-Piperonyl Butoxide Gel % Pyrethrins-Piperonyl Butoxide Shampoo 0.3-3% Pyrethrins-Piperonyl Butoxide Shampoo % Pyrethrins-Piperonyl Butoxide Shampoo Kit Pyrethrins Spray & Pyrethins- Piperonyl Butoxide Shamp Kit Pyreth-Piper But Spray & Pyreth- Piper But Shamp Kit Permethrin Spray & Pyrethins- Piperonyl Butoxide Shamp Kit RID COMPLETE Pyreth-Piperonyl Butox Sham- Permeth Aero-Nit Remover Gel Kit SEA-CLENS WOUND CLEANSER PELEVERUS WOUND 0.25% SPRAY WOUN'DRES WOUND DRESSING TRIAD WOUND DRESSING PASTE DRYSOL Aluminum Chloride Soln 20% DERMAMED MOISTURIZING DERMAGRAN SPRAY DERMAGRAN DERMAMED OINTMENT EUCERIN EUCERIN EUCERIN ALOE VESTA ALOE VESTA ALOE VESTA ALOE VESTA ALOE VESTA SAFE WASH SOLN Zinc Oxide Oint 20% CARRINGTON *Skin Protectants Misc - Cream*** DERMAGRAN *Skin Protectants Misc - Cream*** CARRINGTON *Skin Protectants Misc - Cream*** ALOE VESTA *Skin Protectants Misc - Ointment*** ALOE VESTA *Skin Protectants Misc - Ointment*** ABSORBASE *Skin Protectants Misc - Ointment*** ALOE VESTA *Skin Protectants Misc - Ointment*** ABSORBASE *Skin Protectants Misc - Ointment*** 4-N-1 WASH CREAM 4-N-1 CREAM

94 REMEDY SKIN REPAIR CREAM ALOE VESTA SKIN CONDITIONER NAIL SCRUB LOTION ANTISEPTICS & DISINFECTANTS ANTIDOTES BETADINE SKN, BETADINE SRG BETADINE REVIA DIAGNOSTIC PRODUCTS Chlorhexidine Gluconate Liquid 4% BETADINE 7.5% SCRUB POVIDONE-IODINE 10% SOLUTIO POVIDONE-IODINE 10% OINTMEN Ipecac Syrup CHEMET Cap 100 Naltrexone HCl Tab 50 Max Qty=946/claim ACETEST REAGENT TABLET KETOSTIX Acetone (Urine) Test Strip ALBUSTIX REAGENT STRIPS Max Qty=30/30 days MICRO-BUMINTEST KIT Max Qty=30/30 days Glucose Blood Test Strip TRUEtest strips Daily Dosage=5 CLINISTIX REAGENT STRIPS Max Qty=30/30 days CLINITEST REAGENT TABLET MEDICAL DEVICES NOVA MAX PLUS Ketone Blood Test Strip VH ESSENTIALS UTI STICK MULTISTIX 10 SG REAGENT STR KETO-DIASTIX REAGENT STRIPS Q-GEL MEGA 100 SOFTGEL CHEW Q 100 CHEWABLE TAB Melatonin Tab 3 Melatonin Tab 5 CYTO-Q MAX 100 /ML LIQUID LIQ-10 SYRUP Promethazine HCl (Bulk) Powder Insulin Syringe (Disp) U ML Insulin Syringe/Needle U-40 1 ML 26 x 1/2" Insulin Syringe/Needle U ML 28 x 1/2" Insulin Syringe/Needle U ML 29 x 1/2" Insulin Syringe/Needle U ML 30 x 3/8" Insulin Syringe/Needle U ML 30 x 5/16" Insulin Syringe/Needle U ML 30 x 1/2" Insulin Syringe/Needle U ML 30 x 7/16" Max Qty=30/30 days Max Qty=30/30 days Max Qty=30/30 days Max Qty=30/30 days Max Qty=155/30 days Max Qty=150/30 days Max Qty=150/30 days Max Qty=150/30 days Max Qty=150/30 days Max Qty=150/30 days Max Qty=150/30 days Max Qty=150/30 days

95 Insulin Syringe/Needle U-100 1/2 ML 27 x 1/2" Insulin Syringe/Needle U ML 28 G x 1" Insulin Syringe/Needle U-100 1/2 ML 29 x 7/16" Insulin Syringe/Needle U-100 1/2 ML 30 x 3/8" Insulin Syringe/Needle U-100 1/2 ML 30 x 7/16" Insulin Syringe/Needle U-100 1/2 ML 30 G x 1" Insulin Syringe/Needle U-100 1/2 ML 31 x 5/16" Insulin Syringe/Needle U-100 1/2 ML 28 x 1/2" Insulin Syringe/Needle U-100 1/2 ML 29 x 1" Insulin Syringe/Needle U-100 1/2 ML 28 x 1" Insulin Syringe/Needle U-100 1/2 ML 29 x 5/16" Insulin Syringe/Needle U-100 1/2 ML 29 x 1/2" Insulin Syringe/Needle U-100 1/2 ML 30 x 5/16" Insulin Syringe/Needle U-100 1/2 ML 30 x 1/2" Insulin Syringe/Needle U ML 25 x 5/8" Insulin Syringe/Needle U ML 25 x 1" Insulin Syringe/Needle U ML 26 x 1/2" Insulin Syringe/Needle U ML 27 x 1/2" Insulin Syringe/Needle U ML 27 x 5/8" Insulin Syringe/Needle U ML 28 x 5/16" Insulin Syringe/Needle U ML 28 x 1/2" Insulin Syringe/Needle U ML 30 G x 1" Insulin Syringe/Needle U ML 29 x 7/16" Insulin Syringe/Needle U ML 29 x 1/2" Insulin Syringe/Needle U ML 29 x 1" Insulin Syringe/Needle U ML 29 x 5/16" Insulin Syringe/Needle U ML 30 x 5/16" Insulin Syringe/Needle U ML 30 x 7/16" Insulin Syringe/Needle U ML 30 x 1/2" Insulin Syringe/Needle U ML 31 x 5/16" Insulin Syringe/Needle U ML 31 x 5/16" Insulin Syringe/Needle U ML 27.5 x 5/8" Max Qty=150/30 days Max Qty=150/30 days Max Qty=150/30 days Max Qty=150/30 days Max Qty=150/30 days Max Qty=150/30 days Max Qty=150/30 days Max Qty=150/30 days Max Qty=150/30 days Max Qty=150/30 days Max Qty=150/30 days Max Qty=150/30 days Max Qty=150/30 days Max Qty=150/30 days Max Qty=150/30 days Max Qty=150/30 days Max Qty=150/30 days Max Qty=150/30 days Max Qty=150/30 days Max Qty=150/30 days Max Qty=150/30 days Max Qty=150/30 days Max Qty=150/30 days Max Qty=150/30 days Max Qty=150/30 days Max Qty=150/30 days Max Qty=150/30 days Max Qty=150/30 days Max Qty=150/30 days Max Qty=150/30 days Max Qty=150/30 days Max Qty=150/30 days

96 Insulin Syringe/Needle U ML 29 x 1/2" Insulin Syringe/Needle U ML 29 x 7/16" Insulin Syringe/Needle U ML 29 x 5/16" Insulin Syringe/Needle U ML 29 x 1" Insulin Syringe/Needle U ML 30 x 1" Max Qty=150/30 days Max Qty=150/30 days Max Qty=150/30 days Max Qty=150/30 days Max Qty=150/30 days Insulin Pen Needle 29 G X 12 MM Max Qty=150/30 days Insulin Pen Needle 29 G X 12.7 MM Insulin Pen Needle 30 G X 8 MM Max Qty=150/30 days Insulin Pen Needle 31 G X 5 MM Max Qty=150/30 days Insulin Pen Needle 31 G X 6 MM Max Qty=150/30 days Insulin Pen Needle 31 G X 8 MM Max Qty=150/30 days *Respiratory Therapy Supplies - Misc** *Respiratory Therapy Supplies - Mouthpieces** Max Qty=1/360 days Max Qty=1/180 days AEROCHAMBER *Spacer/Aerosol- Holding Chambers - Device*** Max Qty=2/360 days INSPIREASE *Spacer/Aerosol- Holding Chamber Supplies - Bags*** Max Qty=3/180 days INSPIREASE *Spacer/Aerosol- Holding Chamber Supplies - Mouthpieces*** TRUZONE PEAK FLOW METER INNOVO INSULIN DOSER *Blood Glucose Calibration - Liquid*** *Blood Glucose Calibration - Liquid - High*** *Blood Glucose Calibration - Liquid - Normal*** *Blood Glucose Calibration - Liquid - Low*** *Blood Glucose Monitoring TRUEresult Devices**** Max Qty=2/360 days Max Qty=2/360 days Max Qty=1/90 days Max Qty=1/90 days Max Qty=1/90 days Max Qty=1/90 days Max Qty=1/730 days *Blood Glucose Monitoring Kit**** TRUEresult Max Qty=1/730 days *Blood Glucose Monitoring Kit w/ Device**** *Lancets**** *Lancet Devices**** *Gauze Pads & Dressings - Pads 2" X 2"*** *Gauze Pads & Dressings - Pads 3" X 3"*** *Gauze Pads & Dressings - Pads 4" X 4"*** Condoms Latex Lubricated TRUEresult Max Qty=1/730 days Max Qty=200/30 days Max Qty=1/180 days Max Qty=36/30 days

97 Condoms Latex Non-Lubricated FC CONDOM, FEMALE Diaphragm Arc-Spring 65 MM Diaphragm Arc-Spring 70 MM Diaphragm Arc-Spring 75 MM Diaphragm Arc-Spring 80 MM Diaphragm Arc-Spring Kit 55 MM Diaphragm Arc-Spring Kit 60 MM Diaphragm Arc-Spring Kit 65 MM Diaphragm Arc-Spring Kit 70 MM Diaphragm Arc-Spring Kit 75 MM Diaphragm Arc-Spring Kit 80 MM Diaphragm Arc-Spring Kit 85 MM Diaphragm Arc-Spring Kit 90 MM Diaphragm Arc-Spring Kit 95 MM ORTHO FLEX ORTHO FLEX ORTHO FLEX ORTHO FLEX ORTHO FLEX ORTHO FLEX ORTHO FLEX ORTHO FLEX ORTHO FLEX ORTHO FLEX ORTHO FLEX ORTHO FLEX ORTHO FLEX Pkg Size 12: Package Limit=1/30 days; Pkg Size 3: Package Limit=4/30 days Max Qty=36/30 days Diaphragm Coil Spring Kit 50 MM ORTHO COIL Max Qty=1/365 days Diaphragm Coil Spring Kit 100 MM Diaphragm Coil Spring Kit 105 MM Diaphragm Flat Spring Kit 55 MM Diaphragm Flat Spring Kit 60 MM Diaphragm Flat Spring Kit 65 MM Diaphragm Flat Spring Kit 70 MM Diaphragm Flat Spring Kit 75 MM Diaphragm Flat Spring Kit 80 MM Diaphragm Flat Spring Kit 85 MM Diaphragm Flat Spring Kit 90 MM Diaphragm Flat Spring Kit 95 MM *Alcohol Swabs*** ORTHO COIL ORTHO COIL ORTHO FLAT ORTHO FLAT ORTHO FLAT ORTHO FLAT ORTHO FLAT ORTHO FLAT ORTHO FLAT ORTHO FLAT ORTHO FLAT Max Qty=400/30 days PHARMACEUTICAL ADJUVANTS Simply Thick Age Limit > 1 ORA-SWEET-SF SYRUP ORA-BLEND SF SUSPENSION ORA-BLEND SUSPENSION ORA-SWEET ORAL SYRUP ORA-PLUS SUSPENDING VEHICLE SORBITOL 70% SOLUTION Lanolin HYDROPHILIC OINTMENT HYDROPHILIC PETROLATUM ASSORTED CLASSES SANDIMMUNE SANDIMMUNE NEORAL NEORAL CUPRIMINE Cap 125 CUPRIMINE Cap 250 Cyclosporine Cap 25 Cyclosporine Cap 100 Cyclosporine Oral Soln 100 /ML Cyclosporine Modified Cap 25 Cyclosporine Modified Cap 50 Cyclosporine Modified Cap 100

98 NEORAL CELLCEPT CELLCEPT Cyclosporine Modified Oral Soln 100 /ML Mycophenolate Mofetil Cap 250 Mycophenolate Mofetil Tab 500 CELLCEPT Oral Susp 200 /ML MYFORTIC (Mycophenolate Sodium Tab DR 180 (Mycophenolic Acid Equiv)) MYFORTIC (Mycophenolate Sodium Tab DR 360 (Mycophenolic Acid Equiv)) RAPAMUNE 0.5 TABLET RAPAMUNE Tab 1 RAPAMUNE Tab 2 RAPAMUNE Oral Soln 1 /ML PROGRAF Tacrolimus Cap 0.5 PROGRAF Tacrolimus Cap 1 PROGRAF Tacrolimus Cap 5 IMURAN Azathioprine Tab 50 Daily Dosage=3 Azathioprine (AZASAN) Tab 75 Daily Dosage=3 SPS KAYEXALATE Azathioprine ((AZASAN))Tab 100 Sodium Polystyrene Sulfonate Oral Susp 15 GM/60ML *Sodium Polystyrene Sulfonate Powder** STERILE WATER FOR IRRIGATIO Daily Dosage=3 Max Qty=454/claim