NLPDP Coverage Status Table December Initial and maintenance fills are limited to a maximum 30 days

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1 Coverage Table December MEP TABLET OPEN No TABLET OPEN No TABLET OPEN No TC 10 MG/ML SOLUTION OPEN No TC 150 MG TABLET OPEN Yes TC 300 MG TABLET OPEN Yes TABLET OPEN No IHLES PASTE FORMULA 1934 OPEN None No ALBALON A/SULAMYD 10% 1:1 OPEN None No ABBOTT-CITALOPRAM 10 MG TABLET OPEN No ABBOTT-CITALOPRAM 20 MG TABLET OPEN. Maximum of 1.5 tablets daily. Yes ABBOTT-CITALOPRAM 40 MG TABLET OPEN Yes ABBOTT-CLOPIDOGREL 75 MG TAB None Yes ABBOTT-LEVETIRACETAM 250 MG TB None Yes ABBOTT-LEVETIRACETAM 500 MG TB None Yes ABBOTT-LEVETIRACETAM 750 MG TB None Yes ABBOTT-PANTOPRAZOLE DR 40MG TB OPEN ABBOTT-QUETIAPINE 100 MG TAB OPEN ABBOTT-QUETIAPINE 200 MG TAB OPEN ABBOTT-QUETIAPINE 25 MG TABLET OPEN ABBOTT-QUETIAPINE 300 MG TAB OPEN Yes Yes Yes Yes Yes Page 1 Effective December 2015

2 Coverage Table December ABBOTT-RABEPRAZOLE DR 10 MG TB OPEN Limit of 2 per day without Special Yes ABBOTT-TOPIRAMATE 100 MG TAB OPEN None Yes ABBOTT-TOPIRAMATE 200 MG TAB OPEN None Yes ABBOTT-TOPIRAMATE 25 MG TABLET OPEN None Yes ABENOL 120 MG SUPPOSITORY OPEN Beneficiary must be less than 13 years old - RBP applied No ABENOL 325 MG SUPPOSITORY OPEN Beneficiary must be less than 13 years old - RBP applied No ABILIFY 10 MG TABLET None No ABILIFY 15 MG TABLET None No ABILIFY 2 MG TABLET None No ABILIFY 20 MG TABLET None No ABILIFY 30 MG TABLET None No ABILIFY 5 MG TABLET None No ABILIFY MAINTENA ER 300MG VIAL maximum of 30 days. No ABILIFY MAINTENA ER 400MG VIAL maximum of 30 days. No AC BOYZ CHAMBER W/MOUTHPIECE OPEN Limit of one per year for children 5-12 yrs without Special No AC GIRLZ CHAMBER W/MOUTHPIECE OPEN Limit of one per year for children 5-12 yrs without Special No ACCOLATE 20 MG TABLET None No a) Limited to 2500 per year without Special b) Beneficiary must have ACCU-CHEK ADVANTAGE TEST STRIP OPEN diabetic medication within previous year No history, otherwise Special is required ACCU-CHEK AVIVA TEST STRIPS OPEN a) Limited to 2500 per year without Special b) Beneficiary must have diabetic medication within previous year history, otherwise Special is required. No Page 2 Effective December 2015

3 Coverage Table December ACCU-CHEK COMPACT TEST STRIP OPEN a) Limited to 2500 per year without Special b) Beneficiary must have diabetic medication within previous year No history, otherwise Special is required ACCU-CHEK FASTCLIX 6-LANCET DR OPEN None No ACCU-CHEK FASTCLIX 6-LANCET DR OPEN None No ACCUCHEK MOBILE TST STRIPS 100 OPEN a) Limited to 2500 per year without Special b) Beneficiary must have diabetic medication within previous year No history, otherwise Special is required ACCUCHEK MOBILE TST STRIPS 50 OPEN a) Limited to 2500 per year without Special b) Beneficiary must have diabetic medication within previous year No history, otherwise Special is required ACCU-CHEK MULTICLIX LANCETS OPEN None No ACCUPRIL 10 MG TABLET OPEN None Yes ACCUPRIL 20 MG TABLET OPEN None Yes ACCUPRIL 40 MG TABLET OPEN None Yes ACCUPRIL 5 MG TABLET OPEN None Yes ACCURETIC 10/12.5 MG TABLET OPEN None Yes ACCURETIC 20/12.5 MG TABLET OPEN None Yes ACCURETIC 20/25 MG TABLET OPEN None Yes ACCUTANE ROCHE 10 MG CAPSULE OPEN None No ACCUTANE ROCHE 40 MG CAPSULE OPEN None No ACCUTREND TEST STRIP OPEN a) Limited to 2500 per year without Special b) Beneficiary must have diabetic medication within previous year No history, otherwise Special is required ACEBUTOLOL 100 MG TABLET OPEN None Yes ACEBUTOLOL 200 MG TABLET OPEN None Yes ACEBUTOLOL 400 MG TABLET OPEN None Yes ACET 120 MG SUPPOSITORY OPEN Beneficiary must be less than 13 years old - RBP applied No Page 3 Effective December 2015

4 Coverage Table December ACET 160 MG SUPPOSITORY OPEN None No ACET 325 MG SUPPOSITORY OPEN Beneficiary must be less than 13 years old - RBP applied No ACET CODEINE ELIXIR OPEN No ACETAMINOPHEN 80 MG/ML DROPS OPEN Beneficiary must be less than 3 years old - RBP applied No ACETAMINOPHEN DROPS 80MG/ML Beneficiary must be less than 3 years old - OPEN US RBP applied No ACETAMINOPHEN SYRUP 160MG/5ML OPEN Reasonable Based Pricing is applied No ACETAZOLAMIDE 250 MG TABLET OPEN None No ACETAZONE FORTE C8 TABLET OPEN No ACETAZONE FORTE TABLET OPEN None No ACETEST OPEN None No ACETOXYL 10% ACNE GEL OPEN None No ACETYLCYSTEINE 200 MG/ML VIAL OPEN None No ACH-ALENDRONATE 10 MG TABLET None Yes ACH-ALENDRONATE 70 MG TABLET None Yes ACH-ANASTROZOLE 1 MG TABLET No Yes ACH-BICALUTAMIDE 50 MG TABLET OPEN None Yes ACH-CANDESARTAN 16 MG TABLET OPEN Yes ACH-CANDESARTAN 32 MG TABLET OPEN Yes ACH-CANDESARTAN 8 MG TABLET OPEN Yes ACH-CAPECITABINE 150 MG TABLET None Yes ACH-CAPECITABINE 500 MG TABLET None Yes ACH-EZETIMIBE 10 MG TABLET None Yes Special required if beneficiary ACH-FINASTERIDE 5 MG TABLET has not had a paid claim for an alpha Yes blocker or finasteride in past year ACH-FLUOXETINE 10 MG CAPSULE OPEN Yes ACH-FLUOXETINE 20 MG CAPSULE OPEN Yes Page 4 Effective December 2015

5 Coverage Table December ACH-LETROZOLE 2.5 MG TABLET None Yes ACH-PIOGLITAZONE 15 MG TABLET None Yes ACH-PIOGLITAZONE 30 MG TABLET None Yes ACH-PIOGLITAZONE 45 MG TABLET None Yes ACLAVULANA 250 MG-62.5 MG/5 ML OPEN None Yes ACT ALENDRONATE 40 MG TABLET None Yes ACT ALENDRONATE 70 MG TABLET None Yes ACT AMLODIPINE 10 MG TABLET OPEN None Yes ACT AMLODIPINE 2.5 MG TABLET OPEN None No ACT AMLODIPINE 5 MG TABLET OPEN Yes ACT ANASTROZOLE 1 MG TABLET None Yes ACT ATENOLOL 100 MG TABLET OPEN None Yes ACT ATENOLOL 50 MG TABLET OPEN None Yes ACT ATORVASTATIN 10 MG TABLET OPEN None Yes ACT ATORVASTATIN 20 MG TABLET OPEN None Yes ACT ATORVASTATIN 40 MG TABLET OPEN None Yes ACT ATORVASTATIN 80 MG TABLET OPEN None Yes ACT AZITHROMYCIN 250 MG TAB OPEN None Yes ACT AZITHROMYCIN 600 MG TAB None Yes ACT BETAHISTINE 16 MG TABLET OPEN None Yes ACT BETAHISTINE 24 MG TABLET OPEN None Yes ACT BICALUTAMIDE 50 MG TABLET OPEN None Yes ACT BOSENTAN 125 MG TABLET None Yes ACT BOSENTAN 62.5 MG TABLET None Yes Special Authorzation required if beneficiary ACT CABERGOLINE 0.5 MG TABLET has not had a paid claim for Dostinex, Yes Norprolac, or Bromocriptine in past year ACT CANDESARTAN 16 MG TABLET OPEN Yes ACT CANDESARTAN 32 MG TABLET OPEN Yes ACT CANDESARTAN 8 MG TABLET OPEN Yes ACT CELECOXIB 100 MG CAPSULE OPEN Limit of 2 per day without Special Yes Page 5 Effective December 2015

6 Coverage Table December ACT CELECOXIB 100 MG CAPSULE OPEN Limit of 2 per day without Special Yes ACT CELECOXIB 200 MG CAPSULE OPEN Limit of 2 per day without Special Yes ACT CELECOXIB 200 MG CAPSULE OPEN Limit of 2 per day without Special Yes ACT CIPROFLOXACIN 250MG TABLET OPEN None Yes ACT CIPROFLOXACIN 500MG TABLET OPEN None Yes ACT CIPROFLOXACIN 750MG TABLET OPEN None Yes ACT CITALOPRAM 20 MG TABLET OPEN. Maximum of 1.5 tablets Yes daily ACT CITALOPRAM 40 MG TABLET OPEN Yes ACT CLOMIPRAMINE 10 MG TABLET OPEN Yes ACT CLOMIPRAMINE 25 MG TABLET OPEN Yes ACT CLOMIPRAMINE 50 MG TABLET OPEN Yes ACT CLOPIDOGREL 75 MG TABLET None Yes ACT DILTIAZEM CD 120 MG CAP OPEN None Yes ACT DILTIAZEM CD 180 MG CAP OPEN None Yes ACT DILTIAZEM CD 240 MG CAP OPEN None Yes ACT DILTIAZEM CD 300 MG CAP OPEN None Yes ACT DILTIAZEM T ER 120 MG CAP OPEN None Yes ACT DILTIAZEM T ER 180 MG CAP OPEN None Yes ACT DILTIAZEM T ER 240 MG CAP OPEN None Yes ACT DILTIAZEM T ER 300 MG CAP OPEN None Yes ACT DILTIAZEM T ER 360 MG CAP OPEN None Yes ACT DONEPEZIL 10 MG TABLET No Yes ACT DONEPEZIL 5 MG TABLET No Yes ACT DUTASTERIDE 0.5 MG CAPSULE None Yes ACT ENALAPRIL 16 MG(20 MG) TAB OPEN None Yes ACT ENALAPRIL 2 MG (2.5MG) TAB OPEN None Yes ACT ENALAPRIL 4 MG (5 MG) TAB OPEN None Yes ACT ENALAPRIL 8 MG (10 MG) TAB OPEN None Yes Page 6 Effective December 2015

7 Coverage Table December ACT ETIDROCAL MG TABS OPEN None Yes ACT ETIDRONATE 200 MG TABLET OPEN None Yes ACT EXEMESTANE 25 MG TABLET None Yes ACT EZETIMIBE 10 MG TABLET None Yes ACT FAMCICLOVIR 125 MG TABLET OPEN None Yes ACT FAMCICLOVIR 250 MG TABLET OPEN None Yes ACT FAMCICLOVIR 500 MG TABLET OPEN None Yes ACT FINASTERIDE 5 MG TABLET Special required if beneficiary has not had a paid claim for an alpha Yes blocker or finasteride in past year ACT FLUCONAZOLE 100 MG TABLET OPEN None Yes ACT FLUCONAZOLE 50 MG TABLET OPEN None Yes ACT FLUOXETINE 10 MG CAPSULE OPEN Yes ACT FLUOXETINE 20 MG CAPSULE OPEN Yes ACT FLUVOXAMINE 100 MG TABLET OPEN Yes ACT FLUVOXAMINE 50 MG TABLET OPEN Yes ACT GABAPENTIN 100 MG CAPSULE None Yes ACT GABAPENTIN 300 MG CAPSULE None Yes ACT GABAPENTIN 400 MG CAPSULE None Yes ACT GLICLAZIDE MR 30 MG TABLET OPEN None Yes ACT IMATINIB 100 MG TABLET None Yes ACT IMATINIB 400 MG TABLET None Yes ACT IRBESARTAN 150 MG TABLET OPEN Yes ACT IRBESARTAN 300 MG TABLET OPEN Yes ACT IRBESARTAN 75 MG TABLET OPEN Yes ACT LATANOPROST-TIMOL OPH SOL OPEN None Yes ACT LEVETIRACETAM 250 MG TAB None Yes ACT LEVETIRACETAM 500 MG TAB None Yes ACT LEVETIRACETAM 750 MG TAB None Yes ACT LEVOFLOXACIN 250 MG TABLET None Yes Page 7 Effective December 2015

8 Coverage Table December ACT LEVOFLOXACIN 500 MG TABLET None Yes ACT LISINOPRIL 10 MG TABLET OPEN None Yes ACT LISINOPRIL 20 MG TABLET OPEN None Yes ACT LISINOPRIL 5 MG TABLET OPEN None Yes ACT LOSARTAN 100 MG TABLET OPEN Yes ACT LOSARTAN 25 MG TABLET OPEN Yes ACT LOSARTAN 50 MG TABLET OPEN Yes ACT LOVASTATIN 20 MG TABLET OPEN None Yes ACT LOVASTATIN 40 MG TABLET OPEN None Yes ACT MELOXICAM 15 MG TABLET OPEN None Yes ACT MELOXICAM 7.5 MG TABLET OPEN None Yes ACT METFORMIN 500 MG TABLET OPEN None Yes ACT METFORMIN 850 MG TABLET OPEN None Yes ACT NABILONE 0.5 MG CAPSULE OPEN Yes ACT NABILONE 1 MG CAPSULE OPEN Yes ACT OLANZAPINE 10 MG TABLET Yes ACT OLANZAPINE 15 MG TABLET Yes ACT OLANZAPINE 2.5 MG TABLET Yes ACT OLANZAPINE 20 MG TABLET Yes ACT OLANZAPINE 5 MG TABLET Yes ACT OLANZAPINE 7.5 MG TABLET Yes ACT OLANZAPINE ODT 10 MG TAB Yes ACT OLANZAPINE ODT 15 MG TAB Yes Page 8 Effective December 2015

9 Coverage Table December ACT OLANZAPINE ODT 20 MG TAB Yes ACT OLANZAPINE ODT 5 MG TABLET Yes Limit of 3 tablets per cycle - first fill only ACT ONDANSETRON 4 MG TABLET OPEN Special is required for higher Yes quantities and/or subsequent fills ACT ONDANSETRON 8 MG TABLET OPEN Limit of 3 tablets per cycle - first fill only. Special is required for higher Yes quantities and/or subsequent fills ACT PANTOPRAZOLE DR 40 MG TAB OPEN Yes ACT PAROXETINE 10 MG TABLET OPEN. Limit of 1 per day Yes without Special ACT PAROXETINE 20 MG TABLET OPEN Yes ACT PAROXETINE 30 MG TABLET OPEN Yes ACT PIOGLITAZONE 15 MG TABLET None Yes ACT PIOGLITAZONE 30 MG TABLET None Yes ACT PIOGLITAZONE 45 MG TABLET None Yes ACT PRAMIPEXOLE 0.25 MG TABLET OPEN None Yes ACT PRAMIPEXOLE 1 MG TABLET OPEN None Yes ACT PRAMIPEXOLE 1.5 MG TABLET OPEN None Yes ACT PRAVASTATIN 10 MG TABLET OPEN None Yes ACT PRAVASTATIN 20 MG TABLET OPEN None Yes ACT PRAVASTATIN 40 MG TABLET OPEN None Yes ACT PREGABALIN 150 MG CAPSULE No Yes ACT PREGABALIN 225 MG CAPSULE No Yes ACT PREGABALIN 25 MG CAPSULE No Yes ACT PREGABALIN 300 MG CAPSULE No Yes ACT PREGABALIN 50 MG CAPSULE No Yes ACT PREGABALIN 75 MG CAPSULE No Yes ACT QUETIAPINE 100 MG TABLET OPEN Yes Page 9 Effective December 2015

10 Coverage Table December ACT QUETIAPINE 200 MG TABLET OPEN Yes ACT QUETIAPINE 25 MG TABLET OPEN Yes ACT QUETIAPINE 300 MG TABLET OPEN Yes ACT RALOXIFENE 60 MG TABLET None Yes ACT RAMIPRIL 1.25 MG CAPSULE OPEN None Yes ACT RAMIPRIL 10 MG CAPSULE OPEN None Yes ACT RAMIPRIL 2.5 MG CAPSULE OPEN None Yes ACT RAMIPRIL 5 MG CAPSULE OPEN None Yes ACT RANITIE 150 MG TABLET OPEN None Yes ACT RANITIE 300 MG TABLET OPEN None Yes ACT REPAGLINIDE 0.5 MG TABLET Special Authorzation required if beneficiary has not had a paid claim for Gluconorm, Yes Glimepiride, or Glyburide in past year ACT REPAGLINIDE 1 MG TABLET Special Authorzation required if beneficiary has not had a paid claim for Gluconorm, Yes Glimepiride, or Glyburide in past year ACT REPAGLINIDE 2 MG TABLET Special Authorzation required if beneficiary has not had a paid claim for Gluconorm, Yes Glimepiride, or Glyburide in past year ACT RISPERIDONE 0.25 MG TABLET OPEN Yes ACT RISPERIDONE 0.5 MG TABLET OPEN Yes ACT RISPERIDONE 1 MG TABLET OPEN Yes ACT RISPERIDONE 2 MG TABLET OPEN Yes ACT RISPERIDONE 3 MG TABLET OPEN Yes ACT RISPERIDONE 4 MG TABLET OPEN Yes ACT RIZATRIPTAN 10 MG TABLET None Yes ACT RIZATRIPTAN ODT 10 MG TAB None Yes ACT RIZATRIPTAN ODT 5 MG TAB None Yes Page 10 Effective December 2015

11 Coverage Table December ACT ROPINIROLE 0.25 MG TABLET OPEN None Yes ACT ROPINIROLE 1 MG TABLET OPEN None Yes ACT ROPINIROLE 2 MG TABLET OPEN None Yes ACT ROPINIROLE 5 MG TABLET OPEN None Yes ACT ROSUVASTATIN 10 MG TABLET OPEN None Yes ACT ROSUVASTATIN 20 MG TABLET OPEN None Yes ACT ROSUVASTATIN 40 MG TABLET OPEN None Yes ACT ROSUVASTATIN 5 MG TABLET OPEN Yes ACT SERTRALINE 100 MG CAPSULE OPEN Yes ACT SERTRALINE 25 MG CAPSULE OPEN Yes ACT SERTRALINE 50 MG CAPSULE OPEN Yes ACT SIMVASTATIN 10 MG TABLET OPEN None Yes ACT SIMVASTATIN 20 MG TABLET OPEN None Yes ACT SIMVASTATIN 40 MG TABLET OPEN None Yes ACT SIMVASTATIN 5 MG TABLET OPEN None Yes ACT SIMVASTATIN 80 MG TABLET OPEN None Yes ACT SOLIFENACIN 10MG TABLET OPEN Limited to 1 per day without Special. Special authorization required if beneficiary has not had a paid Yes claim for Ditropan RR or a long acting urinary agent in past year ACT SOLIFENACIN 5MG TABLET OPEN Limited to 1 per day without Special. Special authorization required if beneficiary has not had a paid Yes claim for Ditropan RR or a long acting urinary agent in past year ACT SUMATRIPTAN 100 MG TABLET None Yes ACT SUMATRIPTAN 25 MG TABLET None Yes ACT SUMATRIPTAN 50 MG TABLET None Yes ACT TELMISARTAN 40 MG TABLET OPEN Yes ACT TELMISARTAN 80 MG TABLET OPEN Yes Page 11 Effective December 2015

12 Coverage Table December ACT TELMISARTAN/HCT 80-25MG TB OPEN Yes ACT TEMOZOLOMIDE 100 MG CAP None Yes ACT TEMOZOLOMIDE 140 MG CAP None Yes ACT TEMOZOLOMIDE 20 MG CAPSULE None Yes ACT TEMOZOLOMIDE 250 MG CAP None Yes ACT TERBINAFINE 250 MG TABLET OPEN None Yes ACT TOPIRAMATE 100 MG TABLET OPEN None Yes ACT TOPIRAMATE 200 MG TABLET OPEN None Yes ACT TOPIRAMATE 25 MG TABLET OPEN None Yes ACT VALSARTAN 160 MG TABLET OPEN Yes ACT VALSARTAN 320 MG TABLET OPEN Yes ACT VALSARTAN 40 MG TABLET OPEN Yes ACT VALSARTAN 80 MG TABLET OPEN Yes ACT VENLAFAXINE XR 150 MG CAP OPEN Yes ACT VENLAFAXINE XR 37.5 MG CAP OPEN Yes ACT VENLAFAXINE XR 75 MG CAP OPEN Yes ACT ZOPICLONE 5 MG TABLET OPEN Yes ACT ZOPICLONE 7.5 MG TABLET OPEN Yes ACTEMRA 200 MG/10 ML VIAL None No ACTEMRA 400 MG/20 ML VIAL None No ACTEMRA 80 MG/4 ML VIAL None No ACTI-B12 50MCG/ML LIQUID OPEN None No ACTONEL 30 MG TABLET None Yes ACTONEL 35 MG TABLET None Yes ACTONEL 5 MG TABLET None Yes ACTOS 15 MG TABLET None Yes ACTOS 30 MG TABLET None Yes Page 12 Effective December 2015

13 Coverage Table December ACTOS 45 MG TABLET None Yes ACULAR 0.5% EYE DROPS OPEN None Yes ACUVAIL 0.45 % EYE DROPS OPEN None No ACYCLOVIR 200 MG TABLET OPEN None Yes ACYCLOVIR 400 MG TABLET OPEN None Yes ACYCLOVIR 800 MG TABLET OPEN None Yes ADALAT - CAP 10MG OPEN None Yes ADALAT XL 20 MG TABLET OPEN None No ADALAT XL 30 MG TABLET OPEN None Yes ADALAT XL 60 MG TABLET OPEN None Yes ADDIPAK SODIUM CL 0.9% SOLN None No ADEMPAS 0.5MG TABLET None No ADEMPAS 1.5MG TABLET None No ADEMPAS 1MG TABLET None No ADEMPAS 2.5MG TABLET None No ADEMPAS 2MG TABLET None No ADRENALIN CL 1:1000 VIAL OPEN None No ADRENALINE 1:1000 NASAL SOLN OPEN None No ADRIAMYCIN RDF 10 MG VIAL OPEN None No ADRIAMYCIN RDF 50 MG VIAL OPEN None No ADRUCIL 50MG/ML VIAL OPEN None No ADVAIR 100 DISKUS DSK/DEV None No ADVAIR MCG INHALER None No ADVAIR 250 DISKUS DSK/DEV None No ADVAIR MCG INHALER None No ADVAIR 500 DISKUS DSK/DEV None No ADVICOR 1000 MG/20 MG TABLET OPEN None No ADVICOR 1000 MG/40 MG TAB OPEN None No ADVICOR 500 MG/20 MG TABLET OPEN None No AEROCHAMBER AC BOYZ CHAMBER OPEN Limit of one per year for children 5-12 yrs without Special No AEROCHAMBER AC GIRLZ CHAMBER OPEN Limit of one per year for children 5-12 yrs without Special No AEROCHAMBER MAX W/ADULT MASK OPEN Limit of one per year without Special No Page 13 Effective December 2015

14 Coverage Table December AEROCHAMBER MAX W/CHILD MASK OPEN AEROCHAMBER MAX W/INFANT MASK OPEN AEROCHAMBER MAX W/MOUTHPIECE OPEN AEROCHAMBER+FLOW VU/MASK (LRG) AEROCHAMBER+FLOW VU/MASK (MED) OPEN OPEN AEROCHAMBER+FLOW VU/MASK (SM) OPEN AEROCHAMBER+FLOW VU/MOUTHPIECE OPEN AEROTRACH PLUS VALVED HOLG OPEN a) Limit of one per year without Special b) Child must be 6 years old or less a) Limit of one per year without Special b) Child must be 2 years old or less Limit of one per year without Special a) Limit of one per year without Special b) Child must be older than 6 years a) Limit of one per year without Special b) Child must be between ages of 1 and 6 a) Limit of one per year without Special b) Child must be younger than 2 years a) Limit of one per year without Special b) Child must be older than 6 years Limit of one per year without Special No No No No No No No No AFINITOR 10 MG TABLET No No AFINITOR 2.5 MG TABLET No No AFINITOR 5 MG TABLET No No AGENERASE 150 MG CAPSULE OPEN No AGGRENOX 25 MG-200 MG CAP None No AGRYLIN 0.5 MG CAPSULE OPEN None Yes AIROMIR 100 MCG INHALER OPEN None Yes AKINETON 2 MG TABLET OPEN None No ALBALON 0.1 % EYE DROPS OPEN None No ALBALON-A EYE DROPS OPEN None No ALCOHOL ISOPROPYLIQUE LIQ OPEN None No ALCOHOL PREP - SWABS OPEN None No ALCOJEL 70% GEL OPEN None No ALCOMICIN 3MG/ML EYE DROPS OPEN None No Page 14 Effective December 2015

15 Coverage Table December ALDACTAZIDE 25 MG-25 MG TABLET OPEN None Yes ALDACTAZIDE 50 MG-50 MG TABLET OPEN None Yes ALDACTONE 100 MG TABLET OPEN None No ALDACTONE 25 MG TABLET OPEN None No ALDARA P 5 % CREAM PACKET None Yes ALDOMET TAB 250MG OPEN None Yes ALENDRONATE 70 MG TABLET None Yes ALENDRONATE 70 MG-D UNIT None Yes ALENDRONATE-FC 70 MG TABLET None Yes ALERTEC 100 MG TABLET Yes ALERTONIC LIQUID OPEN None No ALESSE MCG-20 MCG TAB OPEN Beneficiary gender must be female - under the age of 51 Yes ALESSE MCG-20 MCG TAB OPEN Beneficiary gender must be female - under the age of 51 Yes ALKERAN 2 MG TABLET OPEN None No ALLEGRA 12 HOUR 60 MG TABLET OPEN None No ALLEGRA 12 HOUR 60MG TABLET OPEN None No ALLERDRYL 25 MG CAPSULE OPEN None No ALLERDRYL 50 MG CAPSULE OPEN None No ALLERGY FORMULA 25 MG TAB T OPEN None No ALLERGY RELIEF X-TRA 10 MG TAB OPEN None Yes ALLERGY SERUMS OPEN None No ALLERJECT 0.15MG AUTO-INJECTOR OPEN Limit of one per year without Special No ALLERJECT 0.3 MG AUTO-INJECTOR OPEN Limit of one per year without Special No ALLOPURINOL 100 MG TABLET OPEN None No ALLOPURINOL 300 MG TABLET OPEN None Yes ALLOPURINOL 300 MG TABLET OPEN None No ALOMIDE 0.1% EYE DROPS OPEN None No ALPHAGAN 0.2% OPH SOLUTION OPEN None Yes ALPHAGAN P 0.15% DROPS OPEN None Yes ALPRAZOLAM 0.25 MG TABLET OPEN Yes Page 15 Effective December 2015

16 Coverage Table December ALPRAZOLAM 0.5 MG TABLET OPEN Yes ALTACE 1.25 MG CAPSULE OPEN None Yes ALTACE 10 MG CAPSULE OPEN None Yes ALTACE 2.5 MG CAPSULE OPEN None Yes ALTACE 5 MG CAPSULE OPEN None Yes ALTACE HCT MG TABLET OPEN None Yes ALTACE HCT MG TABLET OPEN None Yes ALTACE HCT MG TABLET OPEN None Yes ALTACE HCT MG TABLET OPEN None Yes ALTACE HCT 5-25 MG TABLET OPEN None Yes ALTI-DOXYCYCLINE-CAP 100MG OPEN None No ALTI-LOPERAMIDE - 2MG CAPLET None No ALTI-TRIAZOLAM TAB 0.125MG OPEN No ALUGEL SUSPENSION OPEN None No ALUPENT SYR 10MG/5.0ML OPEN None Yes ALVESCO 100 MCG INHALER OPEN Can only be claimed if the Beneficiary does not have an active Special No for Wet Nebulization ALVESCO 200 MCG INHALER OPEN Can only be claimed if the Beneficiary does not have an active Special No for Wet Nebulization ALYSENA MCG-20 MCG TAB OPEN Beneficiary gender must be female - under the age of 51 Yes ALYSENA MCG-20 MCG TAB OPEN Beneficiary gender must be female - under the age of 51 Yes AMARYL 1 MG TABLET OPEN None Yes AMARYL 2 MG TABLET OPEN None Yes AMARYL 4 MG TABLET OPEN None Yes AMERGE 1 MG TABLET None Yes AMERGE 2.5 MG TABLET None Yes AMICAR 500MG TABLET OPEN None No AMIKACIN SULF 500 MG/2 ML VIAL OPEN Beneficiary must have eligibility under the CF Plan No AMIKIN 250MG/ML VIAL OPEN None No AMIODARONE 200 MG TABLET OPEN None Yes Page 16 Effective December 2015

17 Coverage Table December AMIODARONE 200 MG TABLET OPEN None Yes AMITRIPTYLINE HCL TAB 25MG OPEN No AMITRIPTYLINE HCL TAB 50MG OPEN No AMLODIPINE 10 MG TABLET OPEN None Yes AMLODIPINE 10 MG TABLET OPEN None Yes AMLODIPINE 10 MG TABLET OPEN None Yes AMLODIPINE 10 MG TABLET OPEN None Yes AMLODIPINE 5 MG TABLET OPEN Yes AMLODIPINE 5 MG TABLET OPEN Yes AMLODIPINE 5 MG TABLET OPEN Yes AMLODIPINE 5 MG TABLET OPEN Yes AMLODIPINE/ATORVAS 10-10MG TAB None Yes AMLODIPINE/ATORVAS 10-20MG TAB None Yes AMLODIPINE/ATORVAS 10-40MG TAB None Yes AMLODIPINE/ATORVAS 10-80MG TAB None Yes AMLODIPINE/ATORVAS 5-10 MG TAB None Yes AMLODIPINE/ATORVAS 5-20 MG TAB None Yes AMLODIPINE/ATORVAS 5-40 MG TAB None Yes AMLODIPINE/ATORVAS 5-80 MG TAB None Yes AMLODIPINE-ATORVAS 10-10MG TAB None Yes AMLODIPINE-ATORVAS 10-10MG TAB None Yes AMLODIPINE-ATORVAS 10-20MG TAB None Yes AMLODIPINE-ATORVAS 10-20MG TAB None Yes AMLODIPINE-ATORVAS 10-40MG TAB None Yes AMLODIPINE-ATORVAS 10-80MG TAB None Yes AMLODIPINE-ATORVAS 5-10 MG TAB None Yes AMLODIPINE-ATORVAS 5-10 MG TAB None Yes AMLODIPINE-ATORVAS 5-20 MG TAB None Yes AMLODIPINE-ATORVAS 5-20 MG TAB None Yes AMLODIPINE-ATORVAS 5-40 MG TAB None Yes AMLODIPINE-ATORVAS 5-80 MG TAB None Yes Page 17 Effective December 2015

18 Coverage Table December AMLODIPINE-ODAN 10 MG TABLET OPEN None Yes AMLODIPINE-ODAN 5 MG TABLET OPEN Yes AMOXICILLIN 250 MG CAPSULE OPEN None Yes AMOXICILLIN 250 MG/5 ML SUSP OPEN None Yes AMOXICILLIN 500 MG CAPSULE OPEN None Yes AMOXIL-125 PWS 125MG/5ML OPEN None Yes AMOXIL-250 PWS 250MG/5ML OPEN None Yes AMPHOJEL 320 MG/5 ML SUSP OPEN None No AMPHOJEL 600 MG TABLET OPEN None No AMPICILLIN CAPS 250MG OPEN None No AMPICILLIN CAPS 500MG OPEN None No AMYL NITRITE VITRELLAE BPC LIQ OPEN No ANAFRANIL 10 MG TABLET OPEN Yes ANAFRANIL 25 MG TABLET OPEN Yes ANAFRANIL 50 MG TABLET OPEN Yes ANANDRON 50 MG TABLET OPEN None No ANAPROX 275 MG TABLET OPEN None Yes ANAPROX DS 550 MG TABLET OPEN None Yes ANDRIOL 40 MG CAPSULE Yes ANDROCUR 50 MG TABLET OPEN None Yes ANDROCUR DEPOT 300 MG/3 ML AMP OPEN None No ANDRODERM 2.5 MG/24 HR PATCH No ANDRODERM 5 MG/24 HR PATCH No ANDROGEL 25 MG/2.5 G GEL PKT No ANDROGEL 50 MG/5 G GEL PKT No ANODAN-HC 0.5 %-0.5 % OINTMENT OPEN None Yes ANODAN-HC 10 MG-10 MG SUPP OPEN None Yes Page 18 Effective December 2015

19 Coverage Table December ANORO ELLIPTA MCG INH None No ANSAID 100 MG TABLET OPEN None Yes ANSAID 50 MG TABLET OPEN None Yes ANTHRAFORTE 1% OINTMENT OPEN None No ANTHRAFORTE 2% OINTMENT OPEN None No ANTHRANOL 0.1% CREAM OPEN None No ANTHRANOL 0.2% CREAM OPEN None No ANTI-DIARRHEAL 2 MG TABLET None No ANTI-NAUSEANT 50 MG TABLET OPEN Reasonable Based Pricing is applied No ANTI-NAUSEANT 50 MG TABLET OPEN Reasonable Based Pricing is applied No ANTI-NAUSEANT TABLET OPEN Reasonable Based Pricing is applied No ANUGESIC-HC OINTMENT OPEN None Yes ANUGESIC-HC SUPPOSITORY OPEN None Yes ANUSOL-HC OINTMENT OPEN None Yes ANUSOL-HC SUPPOSITORY OPEN None Yes ANZEMET 100 MG TABLET OPEN Limit of 1 per cycle - first fill only. Special required for higher quantity No and/or subsequent fills ANZEMET 50 MG TABLET OPEN Limit of 1 per cycle - first fill only. Special required for higher quantity No and/or subsequent fills APIDRA (3ML CART) SPECIAL PRIC None No APIDRA (SOLOSTAR) 3ML SPEC PRI None No APIDRA 100 UNIT/ML CARTRIDGE None No APIDRA 100 UNIT/ML VIAL None No APIDRA 10ML VIAL SPECIAL None No APIDRA SOLOSTAR 100 UNIT/ML None No APO- LATANOPROST/TIMOL OPH SOL OPEN None Yes APO PEN VK 125 MG/5 ML SUSP OPEN None Yes APO PEN VK 300 MG/5 ML SUSP OPEN None Yes APO-ACEBUTOLOL 100 MG TABLET OPEN None Yes APO-ACEBUTOLOL 200 MG TABLET OPEN None Yes APO-ACEBUTOLOL 400 MG TABLET OPEN None Yes APO-ACYCLOVIR 200 MG TABLET OPEN None Yes APO-ACYCLOVIR 400 MG TABLET OPEN None Yes APO-ACYCLOVIR 800 MG TABLET OPEN None Yes APO-ADEFOVIR 10 MG TABLET None Yes Page 19 Effective December 2015

20 Coverage Table December APO-ALENDRONATE 10 MG TABLET None Yes APO-ALENDRONATE 70 MG TABLET None Yes APO-ALLOPURINOL 100 MG TABLET OPEN None Yes APO-ALLOPURINOL 100 MG TABLET OPEN No Yes APO-ALLOPURINOL 200 MG TABLET OPEN None Yes APO-ALLOPURINOL 200 MG TABLET OPEN No Yes APO-ALLOPURINOL 300 MG TABLET OPEN None Yes APO-ALLOPURINOL 300 MG TABLET OPEN No Yes APO-ALMOTRIPTAN 12.5 MG TABLET None Yes APO-ALMOTRIPTAN 6.25 MG TABLET None Yes APO-ALPRAZ 0.25 MG TABLET OPEN Yes APO-ALPRAZ 0.5 MG TABLET OPEN Yes APO-ALPRAZ 1 MG TABLET OPEN Yes APO-ALPRAZ TS 2 MG TABLET OPEN Yes APO-AMILZIDE 5 MG-50 MG TABLET OPEN None Yes APO-AMIODARONE 200 MG TABLET OPEN None Yes APO-AMITRIPTYLINE 10 MG TABLET OPEN Yes APO-AMITRIPTYLINE 25 MG TABLET OPEN Yes APO-AMITRIPTYLINE 50 MG TABLET OPEN Yes APO-AMLODIPINE 10 MG TABLET OPEN None Yes APO-AMLODIPINE 5 MG TABLET OPEN Limit 1.5 per day without Special. Yes APO-AMOXI 125 MG/5 ML SUSP OPEN None Yes APO-AMOXI 250 MG CAPSULE OPEN None Yes APO-AMOXI 250 MG/5 ML SUSP OPEN None Yes APO-AMOXI 500 MG CAPSULE OPEN None Yes APO-AMOXI CLAV 250 TABLET OPEN None Yes APO-AMOXI CLAV 500 TABLET OPEN None Yes APO-AMOXI CLAV TAB OPEN None Yes APO-AMOXI CLAV SUSPENSION OPEN None Yes Page 20 Effective December 2015

21 Coverage Table December APO-AMPI 250 MG CAPSULE OPEN None Yes APO-AMPI 500 MG CAPSULE OPEN None Yes APO-ANASTROZOLE 1 MG TABLET None Yes APO-ATENIDONE MG TAB OPEN None Yes APO-ATENIDONE MG TAB OPEN None Yes APO-ATENOL 100 MG TABLET OPEN None Yes APO-ATENOL 50 MG TABLET OPEN None Yes APO-ATORVASTATIN 10 MG TABLET OPEN None Yes APO-ATORVASTATIN 20 MG TABLET OPEN None Yes APO-ATORVASTATIN 40 MG TABLET OPEN None Yes APO-ATORVASTATIN 80 MG TABLET OPEN None Yes APO-AZATHIOPRINE 50 MG TAB OPEN None Yes APO-AZITHROMYCIN 250 MG TAB OPEN None Yes APO-AZITHROMYCIN Z 250 MG TAB OPEN None Yes APO-BACLOFEN 10 MG TABLET OPEN None Yes APO-BACLOFEN 20 MG TABLET OPEN None Yes APO-BECLOMETHASON 50MCG SPR OPEN None Yes APO-BENZYDAMINE 0.15% RINSE OPEN None No APO-BICALUTAMIDE 50 MG TAB OPEN None Yes APO-BISACODYL 10 MG SUPP OPEN Reasonable Based Pricing is applied No APO-BISACODYL 5 MG TABLET EC OPEN Reasonable Based Pricing is applied No APO-BISOPROLOL 10 MG TABLET OPEN None Yes APO-BISOPROLOL 5 MG TABLET OPEN None Yes APO-BRIMONIE 0.2 % DROPS OPEN None Yes APO-BROMAZEPAM 1.5 MG TABLET OPEN Yes APO-BROMAZEPAM 3 MG TABLET OPEN Yes APO-BROMAZEPAM 6 MG TABLET OPEN Yes APO-BUSPIRONE 10 MG TABLET OPEN Yes APO-CAL 250 MG TABLET OPEN None No APO-CAL 500 TABLET OPEN None No APO-CANDESARTAN 16 MG TABLET OPEN Yes Page 21 Effective December 2015

22 Coverage Table December APO-CANDESARTAN 32 MG TABLET OPEN Yes APO-CANDESARTAN 8 MG TABLET OPEN Yes APO-CAPTO 100 MG TABLET OPEN None Yes APO-CAPTO 12.5 MG TABLET OPEN None Yes APO-CAPTO 25 MG TABLET OPEN None Yes APO-CAPTO 50 MG TABLET OPEN None Yes APO-CAPTO 6.25 MG TABLET OPEN None No APO-CARVEDILOL 12.5 MG TAB None Yes APO-CARVEDILOL 25 MG TABLET None Yes APO-CARVEDILOL MG TAB None Yes APO-CARVEDILOL 6.25 MG TAB None Yes APO-CEFPROZIL 125 MG/5 ML OPEN None Yes APO-CEFPROZIL 250 MG TABLET OPEN None Yes APO-CEFPROZIL 250 MG/5 ML OPEN None Yes APO-CEFPROZIL 500 MG TABLET OPEN None Yes APO-CEFUROXIME 250 MG TABLET OPEN None Yes APO-CEFUROXIME 500 MG TABLET OPEN None Yes APO-CELECOXIB 100 MG CAPSULE OPEN Limit of 2 per day without Special Yes APO-CELECOXIB 200 MG CAPSULE OPEN Limit of 2 per day without Special Yes APO-CEPHALEX 250 MG TABLET OPEN None Yes APO-CEPHALEX 500 MG TABLET OPEN None Yes APO-CETIRIZINE 10 MG TABLET OPEN None Yes APO-CHLORHEX 0.12% MOUTHWAS None No APO-CHLORPROPAMIDE 100 MG TAB OPEN None Yes APO-CHLORPROPAMIDE 250 MG TAB OPEN None Yes APO-CILAZAPRIL 1 MG TABLET OPEN None Yes APO-CILAZAPRIL 2.5 MG TAB OPEN None Yes APO-CILAZAPRIL 5 MG TABLET OPEN None Yes APO-CILAZAPRIL/HCTZ TABLET OPEN None Yes APO-CIMETIE 300 MG TABLET OPEN None Yes APO-CIMETIE 300 MG/5 ML LQ OPEN None No APO-CIMETIE 400 MG TABLET OPEN None Yes APO-CIMETIE 600 MG TABLET OPEN None Yes Page 22 Effective December 2015

23 Coverage Table December APO-CIMETIE 800 MG TABLET OPEN None Yes APO-CIPROFLOX 0.3 % EYE DROPS OPEN None Yes APO-CIPROFLOX 250 MG TABLET OPEN None Yes APO-CIPROFLOX 500 MG TABLET OPEN None Yes APO-CIPROFLOX 750 MG TABLET OPEN None Yes APO-CITALOPRAM 20 MG TABLET OPEN. Maximum of 1.5 tablets Yes daily APO-CITALOPRAM 40 MG TABLET OPEN Yes APO-CLARITHROMYCIN 250 MG OPEN None Yes APO-CLARITHROMYCIN 500 MG OPEN None Yes APO-CLARITHROMYCIN XL 500MG TB OPEN None Yes APO-CLINDAMYCIN 150 MG CAPS OPEN None Yes APO-CLINDAMYCIN 300 MG CAPS OPEN None Yes APO-CLOBAZAM 10 MG TABLET OPEN Yes APO-CLOMIPRAMINE 10 MG TAB OPEN Yes APO-CLOMIPRAMINE 25 MG TAB OPEN Yes APO-CLOMIPRAMINE 50 MG TAB OPEN Yes APO-CLONAZEPAM 0.5 MG TABLET OPEN Yes APO-CLONAZEPAM 2 MG TABLET OPEN Yes APO-CLOPIDOGREL 75 MG TABLET None Yes APO-CLOXI 125 MG/5 ML SUSP OPEN None Yes APO-CLOXI 250 MG CAPSULE OPEN None Yes APO-CLOXI 500 MG CAPSULE OPEN None Yes APO-CLOZAPINE 100 MG TABLET No APO-CLOZAPINE 25 MG TABLET No APO-CYCLOBENZAPRINE 10 MG TB OPEN None Yes APO-CYCLOSPORINE 100 MG/ML SOL OPEN None Yes Page 23 Effective December 2015

24 Coverage Table December APO-DESMOPRESSIN 0.1 MG TAB OPEN None Yes APO-DESMOPRESSIN 0.2 MG TAB OPEN None Yes APO-DEXAMETHASONE 0.5 MG TAB OPEN None No APO-DEXAMETHASONE 4 MG TAB OPEN None No APO-DIAZEPAM 10 MG TABLET OPEN Yes APO-DIAZEPAM 2 MG TABLET OPEN Yes APO-DIAZEPAM 5 MG TABLET OPEN Yes APO-DICLO DR 25 MG TABLET OPEN None Yes APO-DICLO DR 50 MG TABLET OPEN None Yes APO-DICLO SR 100 MG TABLET OPEN None Yes APO-DICLO SR 75 MG TABLET OPEN None Yes APO-DICLOFENAC 0.1 % EYE DROPS OPEN None Yes APO-DIFLUNISAL 500 MG TABLET OPEN None Yes APO-DILTIAZ 30 MG TABLET OPEN None Yes APO-DILTIAZ 60 MG TABLET OPEN None Yes APO-DILTIAZ CD 120 MG CAP OPEN None Yes APO-DILTIAZ CD 180 MG CAP OPEN None Yes APO-DILTIAZ CD 240 MG CAP OPEN None Yes APO-DILTIAZ CD 300 MG CAP OPEN None Yes APO-DIMENHYDRINATE 50 MG TAB OPEN Reasonable Based Pricing is applied No APO-DIPYRIDAMOLE FC 25 MG TB OPEN None Yes APO-DIPYRIDAMOLE FC 50 MG TB OPEN None Yes APO-DIPYRIDAMOLE FC 75 MG TB OPEN None Yes APO-DIPYRIDAMOLE SC 50 MG TB OPEN None No APO-DIVALPROEX EC 125 MG TAB OPEN None Yes APO-DIVALPROEX EC 250 MG TAB OPEN None Yes APO-DIVALPROEX EC 500 MG TAB OPEN None Yes APO-DOCUSATE CALC 240 MG CAP OPEN Reasonable Based Pricing is applied No APO-DOCUSATE SOD 100 MG CAP OPEN Reasonable Based Pricing is applied No APO-DOMPERIDONE 10 MG TABLET OPEN None Yes APO-DONEPEZIL 10 MG TABLET No Yes APO-DONEPEZIL 5 MG TABLET No Yes APO-DORZO-TIMOP 2%-0.5% DROPS OPEN None Yes APO-DOXAZOSIN 1 MG TABLET OPEN None Yes Page 24 Effective December 2015

25 Coverage Table December APO-DOXAZOSIN 2 MG TABLET OPEN None Yes APO-DOXAZOSIN 4 MG TABLET OPEN None Yes APO-DOXEPIN OPEN Yes APO-DOXEPIN 10 MG CAPSULE OPEN No APO-DOXEPIN 25 MG CAPSULE OPEN Yes APO-DOXEPIN 50 MG CAPSULE OPEN No APO-DOXEPIN 75 MG CAPSULE OPEN No APO-DOXY 100 MG CAPSULE OPEN None Yes APO-DOXY-TABS 100 MG TABLET OPEN None Yes APO-DUTASTERIDE 0.5 MG CAPSULE None Yes APO-ENALAPRIL 10 MG TABLET OPEN None Yes APO-ENALAPRIL 2.5 MG TABLET OPEN None Yes APO-ENALAPRIL 20 MG TABLET OPEN None Yes APO-ENALAPRIL 5 MG TABLET OPEN None Yes APO-ENALAPRIL/HCTZ MG TB OPEN None Yes APO-ENALAPRIL/HCTZ MG OPEN None Yes APO-ENTECAVIR 0.5 MG TABLET None Yes APO-EXEMESTANE 25 MG TABLET None Yes APO-EZETIMIBE 10 MG TABLET None Yes APO-FAMCICLOVIR 125 MG TAB OPEN None Yes APO-FAMCICLOVIR 250 MG TAB OPEN None Yes APO-FAMCICLOVIR 500 MG TAB OPEN None Yes APO-FENO MICRO 67 MG CAPSULE OPEN None Yes APO-FENOFIBRATE 100 MG CAP OPEN None Yes APO-FENO-MICRO 200 MG CAP OPEN None Yes APO-FENO-SUPER 100 MG TAB OPEN None Yes APO-FENO-SUPER 160 MG TAB OPEN None Yes APO-FENTANYL MATRIX 100 MCG/HR Yes APO-FENTANYL MATRIX 100 MCG/HR Yes Page 25 Effective December 2015

26 Coverage Table December APO-FENTANYL MATRIX 25 MCG/HR Yes APO-FENTANYL MATRIX 25 MCG/HR Yes APO-FENTANYL MATRIX 50 MCG/HR Yes APO-FENTANYL MATRIX 50 MCG/HR Yes APO-FENTANYL MATRX 75 MCG/HR Yes APO-FENTANYL MATRX 75 MCG/HR Yes APO-FERROUS GLUCONATE OPEN None No APO-FERROUS SU 300 MG TAB EC OPEN None No APO-FERROUS SULFATE-FC TAB 300 OPEN None No APO-FINASTERIDE 5 MG TABLET Special required if beneficiary has not had a paid claim for an alpha Yes blocker or finasteride in past year APO-FLUCONAZOLE 100 MG TAB OPEN None Yes APO-FLUCONAZOLE 150 MG CAP OPEN None Yes APO-FLUCONAZOLE 50 MG TABLET OPEN None Yes APO-FLUOXETINE 10 MG CAPSULE OPEN Yes APO-FLUOXETINE 20 MG CAPSULE OPEN Yes APO-FLUPHENAZINE 2 MG TAB OPEN No APO-FLUPHENAZINE 25 MG/ML VL OPEN No APO-FLURBIPROFEN 100 MG TAB OPEN None Yes APO-FLURBIPROFEN 50 MG TAB OPEN None Yes APO-FLUTAMIDE 250 MG TABLET OPEN None Yes APO-FLUVOXAMINE 100 MG TAB OPEN Yes APO-FLUVOXAMINE 50 MG TABLET OPEN Yes APO-FOLIC ACID 5 MG TABLET OPEN None No Page 26 Effective December 2015

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