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

Transcription

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

27 Coverage Table December APO-FOSINOPRIL 10 MG TABLET OPEN None Yes APO-FOSINOPRIL 20 MG TABLET OPEN None Yes APO-FUROSEMIDE 20 MG TABLET OPEN None Yes APO-FUROSEMIDE 80 MG TABLET OPEN None Yes APO-GABAPENTIN 100 MG CAP None Yes APO-GABAPENTIN 300 MG CAP None Yes APO-GABAPENTIN 400 MG CAP None Yes APO-GABAPENTIN 600 MG TAB None Yes APO-GABAPENTIN 800 MG TAB None Yes APO-GEMFIBROZIL 300 MG CAP OPEN None Yes APO-GEMFIBROZIL 600 MG TAB OPEN None Yes APO-GLICLAZIDE 80 MG TABLET OPEN None Yes APO-GLICLAZIDE MR 30 MG TABLET OPEN None Yes APO-GLICLAZIDE MR 60 MG TABLET OPEN None Yes APO-GLIMEPIRIDE 1 MG TABLET OPEN None Yes APO-GLIMEPIRIDE 2 MG TABLET OPEN None Yes APO-GLIMEPIRIDE 4 MG TABLET OPEN None Yes APO-GLYBURIDE 2.5 MG TABLET OPEN None Yes APO-GLYBURIDE 5 MG TABLET OPEN None Yes APO-HALOPERIDOL 2 MG/ML CONC OPEN No APO-HALOPERIDOL LA 100 MG/ML OPEN No APO-HALOPERIDOL LA 50 MG/ML OPEN No APO-HYDRO 100 MG TABLET OPEN None No APO-HYDRO 12.5 MG TABLET OPEN None No APO-HYDRO 25 MG TABLET OPEN None Yes APO-HYDRO 50 MG TABLET OPEN None Yes APO-HYDROMORPHONE 2 MG OPEN TABLET Yes APO-HYDROMORPHONE 4 MG OPEN TABLET Yes APO-HYDROXYQUINE 200 MG TAB OPEN None Yes APO-HYDROXYZINE 10 MG CAP OPEN None Yes APO-HYDROXYZINE 25 MG CAP OPEN None Yes APO-HYDROXYZINE 50 MG CAP OPEN None Yes Page 27 Effective December 2015

28 Coverage Table December APO-IBUPROFEN 200 MG TABLET OPEN None Yes APO-IBUPROFEN 600 MG TABLET OPEN None Yes APO-IMATINIB 100 MG TABLET None Yes APO-IMATINIB 400 MG TABLET None Yes APO-IMIQUIMOD 5 % CREAM PACK None Yes APO-INDAPAMIDE 1.25 MG TAB OPEN None Yes APO-INDAPAMIDE 2.5 MG TAB OPEN None Yes APO-INDOMETHACIN 25 MG CAP OPEN None Yes APO-INDOMETHACIN 50 MG CAP OPEN None Yes APO-IPRAVENT 250 MCG/ML SOLN None Yes APO-IRBESARTAN 150 MG TABLET OPEN Yes APO-IRBESARTAN 300 MG TABLET OPEN Yes APO-IRBESARTAN 75 MG TABLET OPEN Yes APO-ISMN 60 MG TABLET SA OPEN None Yes APO-K 600 MG TABLET OPEN None No APO-KETOCONAZOLE 200 MG TAB OPEN None Yes APO-LACTULOSE 10 G/15 ML SOLN OPEN None No APO-LAMIVUE 150 MG TABLET OPEN Yes APO-LAMIVUE 300 MG TABLET OPEN Yes APO-LAMIV-ZIDOV MG TAB OPEN Yes APO-LAMOTRIGINE 100 MG TAB OPEN None Yes APO-LAMOTRIGINE 150 MG TAB OPEN None Yes APO-LAMOTRIGINE 25 MG TABLET OPEN None Yes APO-LANSOPRAZOLE DR 15 MG CAP None Yes APO-LANSOPRAZOLE DR 30 MG CAP None Yes APO-LATANOPROST % DROPS OPEN None Yes APO-LEFLUNOMIDE 10 MG TABLET OPEN None Yes APO-LEFLUNOMIDE 20 MG TABLET OPEN None Yes APO-LETROZOLE 2.5 MG TABLET None Yes APO-LEVETIRACETAM 250 MG TB None Yes APO-LEVETIRACETAM 500 MG TB None Yes Page 28 Effective December 2015

29 Coverage Table December APO-LEVETIRACETAM 750 MG TB None Yes APO-LEVOCARB CR MG TAB OPEN None Yes APO-LEVOCARB CR MG TAB OPEN None Yes APO-LEVOCARB MG TAB OPEN None Yes APO-LEVOCARB MG TAB OPEN None Yes APO-LEVOCARB MG TAB OPEN None Yes APO-LEVOCARB CR 25MG-100MG TAB OPEN None Yes APO-LEVOCARB CR 25MG-100MG TAB OPEN None Yes APO-LEVOFLOXACIN 250 MG TABLET None Yes APO-LEVOFLOXACIN 500 MG TABLET None Yes APO-LINEZOLID 600 MG TABLET None Yes APO-LISINOPRIL 10 MG TABLET OPEN None Yes APO-LISINOPRIL 20 MG TABLET OPEN None Yes APO-LISINOPRIL 5 MG TABLET OPEN None Yes APO-LISINOPRIL/HCTZ OPEN None Yes APO-LISINOPRIL/HCTZ 20/12.5 OPEN None Yes APO-LISINOPRIL/HCTZ 20/25 OPEN None Yes APO-LITHIUM CARB 150 MG CAP OPEN Yes APO-LITHIUM CARB 300 MG CAP OPEN Yes APO-LOPERAMIDE 2 MG TABLET None Yes APO-LORATAE 10 MG TABLET OPEN None Yes APO-LORAZEPAM 0.5 MG TABLET OPEN Yes APO-LORAZEPAM 0.5MG SUBL TAB OPEN Yes APO-LORAZEPAM 1 MG SUBL TAB OPEN Yes APO-LORAZEPAM 1 MG TABLET OPEN Yes APO-LORAZEPAM 2 MG SUBL TAB OPEN Yes APO-LORAZEPAM 2 MG TABLET OPEN Yes APO-LOSARTAN 100 MG TABLET OPEN Yes Page 29 Effective December 2015

30 Coverage Table December APO-LOSARTAN 25 MG TABLET OPEN Yes APO-LOSARTAN 50 MG TABLET OPEN Yes APO-LOSARTAN/HCTZ MG OPEN Yes APO-LOSARTAN/HCTZ MG TAB OPEN Yes APO-LOVASTATIN 20 MG TABLET OPEN None Yes APO-LOVASTATIN 40 MG TABLET OPEN None Yes APO-MEDROXY 10 MG TABLET OPEN None Yes APO-MEDROXY 100 MG TABLET OPEN None Yes APO-MEDROXY 2.5 MG TABLET OPEN None Yes APO-MEDROXY 5 MG TABLET OPEN None Yes APO-MELOXICAM 15 MG TABLET OPEN None Yes APO-MELOXICAM 7.5 MG TABLET OPEN None Yes APO-METFORMIN 500 MG TABLET OPEN None Yes APO-METFORMIN 850 MG TABLET OPEN None Yes APO-METHAZIDE 15 TABLET OPEN None No APO-METHOTREXATE 2.5 MG TAB OPEN None No APO-METHYLPHEN SR 20 MG TAB OPEN Yes APO-METHYLPHENIDATE 10 MG TB OPEN Yes APO-METHYLPHENIDATE 20 MG TB OPEN Yes APO-METHYLPHENIDATE 5 MG TAB OPEN No APO-METHYLPHENIDATE ER 54 MG Yes APO-METOPROLOL 100 MG CAPLET OPEN None Yes APO-METOPROLOL 100 MG TABLET OPEN None Yes APO-METOPROLOL 25 MG TABLET OPEN None No APO-METOPROLOL 50 MG CAPLET OPEN None Yes APO-METOPROLOL 50 MG TABLET OPEN None Yes APO-METOPROLOL SR 100 MG TAB OPEN None Yes APO-METOPROLOL SR 200 MG TAB OPEN None Yes Page 30 Effective December 2015

31 Coverage Table December APO-MINOCYCLINE 100 MG CAP OPEN None Yes APO-MINOCYCLINE 50 MG CAP OPEN None Yes APO-MIRTAZAPINE 30 MG TAB OPEN Yes APO-MOCLOBEMIDE 100 MG TAB OPEN Yes APO-MOCLOBEMIDE 150 MG TAB OPEN Yes APO-MOCLOBEMIDE 300 MG TAB OPEN Yes APO-MODAFINIL 100 MG TABLET Yes APO-MOMETASONE 50MCG NASAL SPR OPEN None Yes APO-MONTELUKAST 10 MG TABLET None Yes APO-MONTELUKAST 4 MG TAB CHEW None Yes APO-MONTELUKAST 5 MG TAB CHEW None Yes APO-NABUMETONE 500 MG TABLET OPEN None Yes APO-NAPRO-NA 275 MG TABLET OPEN None Yes APO-NAPRO-NA DS 550 MG TAB OPEN None Yes APO-NAPROXEN 125 MG TABLET OPEN None No APO-NAPROXEN 250 MG TABLET OPEN None Yes APO-NAPROXEN 375 MG TABLET OPEN None Yes APO-NAPROXEN 500 MG TABLET OPEN None Yes APO-NITRAZEPAM 10 MG TABLET OPEN No APO-NITRAZEPAM 5 MG TABLET OPEN No APO-NITROGLYCERIN 0.4 MG SPRAY OPEN None Yes APO-NORFLOX 400 MG TABLET OPEN None Yes APO-NORTRIPTYLINE 10 MG CAP OPEN Yes APO-NORTRIPTYLINE 25 MG CAP OPEN Yes APO-OFLOXACIN 0.3 % EYE DROPS OPEN None Yes APO-OLANZAPINE 10 MG TABLET Yes Page 31 Effective December 2015

32 Coverage Table December APO-OLANZAPINE 15 MG TABLET Yes APO-OLANZAPINE 2.5 MG TABLET Yes APO-OLANZAPINE 20 MG TABLET Yes APO-OLANZAPINE 5 MG TABLET Yes APO-OLANZAPINE 7.5 MG TABLET Yes APO-OLANZAPINE ODT 10 MG TAB Yes APO-OLANZAPINE ODT 15 MG TAB Yes APO-OLANZAPINE ODT 20 MG TAB Yes APO-OLANZAPINE ODT 5 MG TABLET Yes APO-OMEPRAZOLE 20 MG CAP DR OPEN Yes APO-ONDANSETRON 4 MG TABLET OPEN Limit of 3 tablets per cycle - first fill only. Special is required for higher Yes quantities and/or subsequent fills APO-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 APO-OXAZEPAM 10 MG TABLET OPEN Yes APO-OXAZEPAM 15 MG TABLET OPEN Yes APO-OXAZEPAM 30 MG TABLET OPEN Yes APO-OXTRIPHYLLINE 100 MG TAB OPEN None No APO-OXTRIPHYLLINE 300 MG TAB OPEN None No APO-OXYBUTYNIN 5 MG TABLET OPEN None Yes APO-OXYCODONE/ACET MG TB OPEN Yes Page 32 Effective December 2015

33 Coverage Table December APO-PANTOPRAZOLE DR 20 MG TAB OPEN Yes APO-PANTOPRAZOLE DR 40 MG TAB OPEN Yes APO-PAROXETINE 10 MG TABLET OPEN. Limit of 1 per day Yes without Special APO-PAROXETINE 20 MG TABLET OPEN Yes APO-PAROXETINE 30 MG TABLET OPEN Yes APO-PERAM 3-15 TABLET OPEN No APO-PHENYLBUTAZONE 100 MG TB OPEN None No APO-PINDOL 10 MG TABLET OPEN None Yes APO-PINDOL 15 MG TABLET OPEN None Yes APO-PINDOL 5 MG TABLET OPEN None Yes APO-PIOGLITAZONE 15 MG TAB None Yes APO-PIOGLITAZONE 30 MG TAB None Yes APO-PIOGLITAZONE 45 MG TAB None Yes APO-PIROXICAM 10 MG CAPSULE OPEN None Yes APO-PIROXICAM 20 MG CAPSULE OPEN None Yes APO-PRAMIPEXOLE 0.25 MG TAB OPEN None Yes APO-PRAMIPEXOLE 1 MG TABLET OPEN None Yes APO-PRAMIPEXOLE 1.5 MG TAB OPEN None Yes APO-PRAVASTATIN 10 MG TABLET OPEN None Yes APO-PRAVASTATIN 20 MG TABLET OPEN None Yes APO-PRAVASTATIN 40 MG TABLET OPEN None Yes APO-PRAZO 1 MG TABLET OPEN None Yes APO-PRAZO 2 MG TABLET OPEN None Yes APO-PRAZO 5 MG TABLET OPEN None Yes APO-PREDNISONE 1 MG TABLET OPEN None No APO-PREDNISONE 5 MG TABLET OPEN None Yes APO-PREDNISONE 50 MG TABLET OPEN None No APO-PREGABALIN 150 MG CAPSULE No Yes APO-PREGABALIN 225 MG CAPSULE No Yes APO-PREGABALIN 25 MG CAPSULE No Yes Page 33 Effective December 2015

34 Coverage Table December APO-PREGABALIN 300 MG CAPSULE No Yes APO-PREGABALIN 50 MG CAPSULE No Yes APO-PREGABALIN 75 MG CAPSULE No Yes APO-PROCAINAMIDE 250 MG CAP OPEN None No APO-PROCAINAMIDE 375 MG CAP OPEN None No APO-PROCAINAMIDE 500 MG CAP OPEN None No APO-PROPAFENONE 150 MG TAB OPEN None Yes APO-PROPAFENONE 300 MG TAB OPEN None Yes APO-PROPRANOLOL 120 MG TAB OPEN None Yes APO-PROPRANOLOL 20 MG TABLET OPEN None Yes APO-QUETIAPINE 100 MG TABLET OPEN Yes APO-QUETIAPINE 200 MG TABLET OPEN Yes APO-QUETIAPINE 25 MG TABLET OPEN Yes APO-QUETIAPINE 300 MG TABLET OPEN Yes APO-QUINAPRIL 10 MG TABLET OPEN None Yes APO-QUINAPRIL 20 MG TABLET OPEN None Yes APO-QUINAPRIL 40 MG TABLET OPEN None Yes APO-QUINAPRIL 5 MG TABLET OPEN None Yes APO-QUINIE 200 MG TABLET OPEN None No APO-QUININE 200 MG CAPSULE OPEN None No APO-QUININE 300 MG CAPSULE OPEN None No APO-RABEPRAZOLE DR 10 MG TAB OPEN Limit of 2 per day without Special Yes APO-RABEPRAZOLE EC 20 MG TAB OPEN Yes APO-RALOXIFENE 60 MG TABLET None Yes APO-RAMIPRIL 1.25 MG CAP OPEN None Yes APO-RAMIPRIL 10 MG CAPSULE OPEN None Yes APO-RAMIPRIL 2.5 MG CAPSULE OPEN None Yes APO-RAMIPRIL 5 MG CAPSULE OPEN None Yes APO-RANITIE 150 MG TABLET OPEN None Yes APO-RANITIE 300 MG TABLET OPEN None Yes Page 34 Effective December 2015

35 Coverage Table December APO-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 APO-REPAGLINIDE 1 MG TABLET Special Authorzation required if beneficiary has not had a paid claim for Gluconorm, Yes Glimepiride, or Glyburide in past year APO-REPAGLINIDE 2 MG TABLET Special Authorzation required if beneficiary has not had a paid claim for Gluconorm, Yes Glimepiride, or Glyburide in past year APO-RILUZOLE 50 MG TABLET None Yes APO-RISEDRONATE 35 MG TABLET None Yes APO-RISPERIDONE 0.25 MG TAB OPEN Yes APO-RISPERIDONE 0.5 MG TAB OPEN Yes APO-RISPERIDONE 1 MG TABLET OPEN Yes APO-RISPERIDONE 1 MG/ML SOL OPEN Yes APO-RISPERIDONE 2 MG TABLET OPEN Yes APO-RISPERIDONE 3 MG TABLET OPEN Yes APO-RISPERIDONE 4 MG TABLET OPEN Yes APO-RIVASTIGMINE 1.5 MG CAP None Yes APO-RIVASTIGMINE 3 MG CAPSULE None Yes APO-RIVASTIGMINE 4.5 MG CAP None Yes APO-RIVASTIGMINE 6 MG CAPSULE None Yes APO-RIZATRIPTAN 10 MG TABLET None Yes APO-RIZATRIPTAN 5 MG TABLET None Yes APO-RIZATRIPTAN RPD 10 MG TAB None Yes APO-RIZATRIPTAN RPD 5 MG TAB None Yes APO-ROPINIROLE 0.25 MG TABLET OPEN None Yes APO-ROPINIROLE 1 MG TABLET OPEN None Yes APO-ROPINIROLE 2 MG TABLET OPEN None Yes APO-ROPINIROLE 5 MG TABLET OPEN None Yes Page 35 Effective December 2015

36 Coverage Table December APO-ROSUVASTATIN 10 MG TABLET OPEN None Yes APO-ROSUVASTATIN 20 MG TABLET OPEN None Yes APO-ROSUVASTATIN 40 MG TABLET OPEN None Yes APO-ROSUVASTATIN 5 MG TABLET OPEN Yes APO-SALVENT 100 MCG INHALER OPEN None Yes APO-SALVENT 2 MG TABLET OPEN None Yes APO-SALVENT 4 MG TABLET OPEN None Yes APO-SELEGILINE 5 MG TABLET OPEN None Yes APO-SERTRALINE 100 MG CAP OPEN Yes APO-SERTRALINE 25 MG CAPSULE OPEN Yes APO-SERTRALINE 50 MG CAPSULE OPEN Yes APO-SILDENAFIL R 20 MG TABLET None Yes APO-SIMVASTATIN 10 MG TABLET OPEN None Yes APO-SIMVASTATIN 20 MG TABLET OPEN None Yes APO-SIMVASTATIN 40 MG TABLET OPEN None Yes APO-SIMVASTATIN 5 MG TABLET OPEN None Yes APO-SIMVASTATIN 80 MG TABLET OPEN None Yes APO-SOTALOL 160 MG TABLET OPEN None Yes APO-SOTALOL 80 MG TABLET OPEN None Yes APO-SUCRALFATE 1 GM TABLET OPEN None Yes APO-SULFATRIM MG TAB OPEN None Yes APO-SULFATRIM DS MG TAB OPEN None Yes APO-SULFATRIM PEDI TABLET OPEN None No APO-SULIN 150 MG TABLET OPEN None Yes APO-SULIN 200 MG TABLET OPEN None Yes APO-SUMATRIPTAN 100 MG TAB None Yes APO-SUMATRIPTAN 50 MG TABLET None Yes APO-TAMOX 10 MG TABLET OPEN None Yes APO-TAMOX 20 MG TABLET OPEN None Yes APO-TAMSULOSIN CR 0.4MG TABLET OPEN Yes APO-TELMISARTAN 40 MG TABLET OPEN Yes Page 36 Effective December 2015

37 Coverage Table December APO-TELMISARTAN 80 MG TABLET OPEN Yes APO-TEMAZEPAM 15 MG CAP OPEN Yes APO-TEMAZEPAM 30 MG CAP OPEN Yes APO-TERAZOSIN 1 MG TABLET OPEN None Yes APO-TERAZOSIN 10 MG TABLET OPEN None Yes APO-TERAZOSIN 2 MG TABLET OPEN None Yes APO-TERAZOSIN 5 MG TABLET OPEN None Yes APO-TERBINAFINE 250 MG TAB OPEN None Yes APO-THEO LA 100 MG TABLET OPEN None Yes APO-THEO LA 200 MG TABLET OPEN None Yes APO-THEO LA 300 MG TABLET OPEN None Yes APO-TICLOPIE 250 MG TAB OPEN None Yes APO-TIMOL 10 MG TABLET OPEN None Yes APO-TIMOL 20 MG TABLET OPEN None Yes APO-TIMOL 5 MG TABLET OPEN None Yes APO-TIMOP 0.25 % EYE DROPS OPEN None Yes APO-TIMOP 0.5 % EYE DROPS OPEN None Yes APO-TIMOP 0.5 % EYE GEL OPEN None Yes APO-TOPIRAMATE 100 MG TAB OPEN None Yes APO-TOPIRAMATE 200 MG TAB OPEN None Yes APO-TOPIRAMATE 25 MG TABLET OPEN None Yes APO-TRAZODONE 100 MG TABLET OPEN Yes APO-TRAZODONE 50 MG TABLET OPEN Yes APO-TRAZODONE D 150 MG TAB OPEN Yes APO-TRIAZIDE 50 MG-25 MG TAB OPEN None Yes APO-TRYPTOPHAN 1G TABLET OPEN Yes APO-TRYPTOPHAN 500 MG CAP OPEN Yes APO-TRYPTOPHAN 500 MG TAB OPEN Yes Page 37 Effective December 2015

38 Coverage Table December APO-VALACYCLOVIR 500 MG TAB OPEN None Yes APO-VALGANCICLOVIR 450 MG TAB None Yes APO-VALPROIC 250 MG CAPSULE OPEN None Yes APO-VALPROIC 250 MG/5 ML SYR OPEN None Yes APO-VALSARTAN 160 MG TABLET OPEN Yes APO-VALSARTAN 320 MG TABLET OPEN Yes APO-VALSARTAN 40 MG TABLET OPEN Yes APO-VALSARTAN 80 MG TABLET OPEN Yes APO-VALSARTAN/HCTZ MG TB OPEN Yes APO-VENLAFAXINE XR 150 MG CAP OPEN Yes APO-VENLAFAXINE XR 37.5 MG CAP OPEN Yes APO-VENLAFAXINE XR 75 MG CAP OPEN Yes APO-VERAP 120 MG TABLET OPEN None Yes APO-VERAP 80 MG TABLET OPEN None Yes APO-VERAP SR 120 MG TABLET OPEN None Yes APO-VERAP SR 180 MG TABLET OPEN None Yes APO-VERAP SR 240 MG TABLET OPEN None Yes APO-VORICONAZOLE 200 MG TABLET None Yes APO-VORICONAZOLE 50 MG TABLET None Yes APO-WARFARIN 1 MG TABLET OPEN None Yes APO-WARFARIN 10 MG TABLET OPEN None Yes APO-WARFARIN 2 MG TABLET OPEN None Yes APO-WARFARIN 2.5 MG TABLET OPEN None Yes APO-WARFARIN 3 MG TABLET OPEN None Yes APO-WARFARIN 4 MG TABLET OPEN None Yes APO-WARFARIN 5 MG TABLET OPEN None Yes APO-ZIDOVUE 100 MG CAPSULE OPEN No APO-ZOLMITRIPTAN 2.5 MG TABLET None Yes Page 38 Effective December 2015

39 Coverage Table December APO-ZOPICLONE 5 MG TABLET OPEN Yes APO-ZOPICLONE 7.5 MG TAB OPEN Yes APRESOLINE 20 MG/ML VIAL OPEN None No APRESOLINE TABLETS, 50MG OPEN None Yes APRI 21 TABLET OPEN Beneficiary gender must be female - under the age of 51 Yes APRI 28 TABLET OPEN Beneficiary gender must be female - under the age of 51 Yes APTIVUS 250 MG CAPSULE None No AQUASOL E DROPS 50I.U./ML OPEN Beneficiary must have eligibility under the CF Plan No ARALEN PHOSPHATE 250MG TAB OPEN None No ARANESP 10 MCG/0.4ML SYRINGE OPEN Can be dispensed by Hospital or RHA Clinic without prior approval No ARANESP 100 MCG/0.5 ML SYRINGE None No ARANESP 100MCG/ML SYRINGE OPEN Can be dispensed by Hospital or RHA Clinic without prior approval No ARANESP 10MCG/0.4ML SYRINGE OPEN Can be dispensed by Hospital or RHA Clinic without prior approval No ARANESP 130 MCG/0.65ML SYRINGE None No ARANESP 150 MCG/0.3 ML SYRINGE None No ARANESP 20 MCG/0.5 ML SYRINGE OPEN Can be dispensed by Hospital or RHA Clinic without prior approval No ARANESP 20 MCG/0.5ML SYRINGE OPEN Can be dispensed by Hospital or RHA Clinic without prior approval No ARANESP 200 MCG/0.4 ML SYRINGE None No ARANESP 200MCG/ML SYRINGE OPEN Can be dispensed by Hospital or RHA Clinic without prior approval No ARANESP 30 MCG/0.3 ML SYRINGE OPEN Can be dispensed by Hospital or RHA Clinic without prior approval No ARANESP 300 MCG/0.6 ML SYRINGE None No ARANESP 40 MCG/0.4 ML SYRINGE OPEN Can be dispensed by Hospital or RHA Clinic without prior approval No ARANESP 50 MCG/0.5 ML SYRINGE OPEN Can be dispensed by Hospital or RHA Clinic without prior approval No Page 39 Effective December 2015

40 Coverage Table December ARANESP 500 MCG/ML SYRING None No ARANESP 500 MCG/ML SYRINGE None No ARANESP 60 MCG/0.3 ML SYRINGE OPEN Can be dispensed by Hospital or RHA Clinic without prior approval No ARANESP 80 MCG/0.4 ML SYRINGE OPEN Can be dispensed by Hospital or RHA Clinic without prior approval No ARAVA 10 MG TABLET OPEN None Yes ARAVA 20 MG TABLET OPEN None Yes ARICEPT 10 MG TABLET None Yes ARICEPT 5 MG TABLET None Yes ARIMIDEX 1 MG TABLET None Yes ARISTOCORT - TAB 4MG OPEN None No ARISTOCORT C 0.5 % CREAM OPEN None No ARISTOCORT R 0.1 % CREAM OPEN None No ARISTOCORT R 0.1% OINTMENT OPEN None No ARISTOCORT-TAB 2MG OPEN None No ARISTOSPAN 20 MG/ML VIAL OPEN None No ARLI 6 MG TABLET OPEN None No AROMASIN 25 MG TABLET None Yes ARTECHOL TABLET OPEN None No ARTHROTEC 50 MG-200 MCG TABLET OPEN None Yes ARTHROTEC 75 MG-200 MCG TABLET OPEN None Yes ASACOL 400 MG TABLET EC OPEN None No ASACOL 800 MG TABLET EC OPEN None No ASEN - TAB 100MG OPEN None No ASEN - TAB 50MG OPEN None No ASMANEX TWISTHALER 200 MCG OPEN None No ASMANEX TWISTHALER 400 MCG OPEN None No ATACAND 16 MG TABLET OPEN Yes ATACAND 32 MG TABLET OPEN Yes ATACAND 8 MG TABLET OPEN Yes ATACAND PLUS MG TABLET OPEN Yes Page 40 Effective December 2015

41 Coverage Table December ATACAND PLUS 32 MG-25 MG TAB OPEN Yes ATACAND PLUS MG TABLET OPEN Yes ATARAX 10 MG/5 ML SYRUP OPEN None No ATARAX IM SOL 50MG/ML OPEN None No ATASOL 80 MG/ML DROPS OPEN Beneficiary must be less than 13 years old - RBP applied No ATASOL MG-15MG-30MG TAB OPEN Yes ATASOL MG-30MG-30MG TAB OPEN Yes ATENOL/CHLORTHAL MG TAB OPEN None Yes ATENOL/CHLORTHAL MG TAB OPEN None Yes ATENOLOL 100 MG TABLET OPEN None Yes ATENOLOL 50 MG TABLET OPEN None Yes ATIVAN 0.5 MG SUBLINGUAL TAB OPEN Yes ATIVAN 0.5 MG TABLET OPEN Yes ATIVAN 1 MG SUBLINGUAL TAB OPEN Yes ATIVAN 1 MG TABLET OPEN Yes ATIVAN 2 MG SUBLINGUAL TAB OPEN Yes ATIVAN 2 MG TABLET OPEN Yes ATIVAN 4MG/ML AMPOULE OPEN No ATORVASTATIN 10 MG TABLET OPEN None Yes ATORVASTATIN 10 MG TABLET OPEN None Yes ATORVASTATIN 20 MG TABLET OPEN None Yes ATORVASTATIN 20 MG TABLET OPEN None Yes ATORVASTATIN 40 MG TABLET OPEN None Yes ATORVASTATIN 40 MG TABLET OPEN None Yes ATORVASTATIN 80 MG TABLET OPEN None Yes Page 41 Effective December 2015

42 Coverage Table December ATORVASTATIN 80 MG TABLET OPEN None Yes ATRIPLA TABLET None No ATROPINE 0.6 MG/ML AMPUL OPEN None No ATROPINE SULF 0.6 MG/ML AMP OPEN None No ATROPINE SULF 0.6 MG/ML AMP OPEN None No ATROPINE SULF 1% EYE OINT OPEN None No ATROPISOL OPEN None No ATROVENT None Yes Can only be claimed if the Beneficiary does ATROVENT 20MCG INHALER OPEN not have an active Special No for Wet Nebulization ATROVENT 21 MCG (0.03 %) SPRAY OPEN None Yes ATROVENT HFA 20 MCG INHALER OPEN Can only be claimed if the Beneficiary does not have an active Special No for Wet Nebulization ATROVENT UDV 125MCG/ML None Yes ATROVENT UDV SOL INH 250MCG/ML None Yes AUBAGIO 14MG TABLET None No AURO-ALENDRONATE 10 MG TABLET No Yes AURO-ALENDRONATE 70 MG TABLET No Yes AURO-AMLODIPINE 10 MG TABLET OPEN None Yes AURO-AMLODIPINE 5 MG TABLET OPEN Yes AURO-AMOXICILLIN 250 MG CAP OPEN None Yes AURO-AMOXICILLIN 500 MG CAP OPEN None Yes AURO-ANASTROZOLE 1 MG TABLET None Yes AURO-CARVEDILOL 12.5 MG TABLET None Yes AURO-CARVEDILOL 25 MG TABLET None Yes AURO-CARVEDILOL 3.125MG TABLET None Yes AURO-CARVEDILOL 6.25 MG TABLET None Yes AURO-CEFIXIME 400 MG TABLET OPEN None Yes AURO-CEFPROZIL 250 MG TABLET OPEN None Yes AURO-CEFPROZIL 500 MG TABLET OPEN None Yes AURO-CEFUROXIME 250 MG TABLET OPEN None Yes AURO-CEFUROXIME 500 MG TABLET OPEN None Yes AURO-CIPROFLOXACIN 250 MG TAB OPEN None Yes AURO-CIPROFLOXACIN 500 MG TAB OPEN None Yes Page 42 Effective December 2015

43 Coverage Table December AURO-CIPROFLOXACIN 750 MG TAB OPEN None Yes AURO-CITALOPRAM 20 MG TABLET OPEN. Maximum of 1.5 tablets Yes daily AURO-CITALOPRAM 40 MG TABLET OPEN Yes AURO-CLOPIDOGREL 75 MG TABLET None Yes AURO-CYCLOBENZAPRINE 10 MG TAB OPEN None Yes AURO-DONEPEZIL 10 MG TABLET No Yes AURO-DONEPEZIL 5 MG TABLET No Yes AURO-EFAVIRENZ 600 MG TABLET OPEN Yes AURO-FINASTERIDE 5 MG TABLET Special required if beneficiary has not had a paid claim for an alpha Yes blocker or finasteride in past year AURO-FLUOXETINE 10 MG CAPSULE OPEN Yes AURO-FLUOXETINE 20 MG CAPSULE OPEN Yes AURO-GABAPENTIN 100 MG CAPSULE None Yes AURO-GABAPENTIN 300 MG CAPSULE None Yes AURO-GABAPENTIN 400 MG CAPSULE None Yes AURO-IRBESARTAN 150 MG TABLET OPEN Yes AURO-IRBESARTAN 300 MG TABLET OPEN Yes AURO-IRBESARTAN 75 MG TABLET OPEN Yes AURO-LAMOTRIGINE 100 MG TABLET OPEN None Yes AURO-LAMOTRIGINE 150 MG TABLET OPEN None Yes AURO-LAMOTRIGINE 25 MG TABLET OPEN None Yes AURO-LETROZOLE 2.5 MG TABLET None Yes AURO-LEVETIRACETAM 250 MG TAB None Yes AURO-LEVETIRACETAM 500 MG TAB None Yes AURO-LEVETIRACETAM 750 MG TAB None Yes AURO-LISINOPRIL 10 MG TABLET OPEN None Yes AURO-LISINOPRIL 20 MG TABLET OPEN None Yes Page 43 Effective December 2015

44 Coverage Table December AURO-LISINOPRIL 5 MG TABLET OPEN None Yes AURO-LOSARTAN 100 MG TABLET OPEN Yes AURO-LOSARTAN 25 MG TABLET OPEN Yes AURO-LOSARTAN 50 MG TABLET OPEN Yes AURO-MELOXICAM 15 MG TABLET OPEN None Yes AURO-MELOXICAM 7.5 MG TABLET OPEN None Yes AURO-MIRTAZAPINE 30 MG TABLET OPEN Yes AURO-MIRTAZAPINE OD 15 MG OPEN Yes AURO-MIRTAZAPINE OD 30 MG OPEN Yes AURO-MIRTAZAPINE OD 45 MG OPEN Yes AURO-MONTELUKAST 10 MG TABLET None Yes AURO-MONTELUKAST 4 MG TAB CHEW None Yes AURO-MONTELUKAST 5 MG TAB CHEW None Yes AURO-NEVIRAPINE 200 MG TABLET OPEN Yes AURO-PAROXETINE 10 MG TABLET OPEN. Limite of 1 per day Yes without Special AURO-PAROXETINE 20 MG TABLET OPEN Yes AURO-PAROXETINE 30 MG TABLET OPEN Yes AURO-PIOGLITAZONE 15 MG TABLET None Yes AURO-PIOGLITAZONE 30 MG TABLET None Yes AURO-PIOGLITAZONE 45 MG TABLET None Yes AURO-PREGABALIN 150MG CAPSULE None Yes AURO-PREGABALIN 25 MG CAPSULE None Yes AURO-PREGABALIN 50 MG CAPSULE None Yes Page 44 Effective December 2015

45 Coverage Table December AURO-PREGABALIN 75 MG CAPSULE None Yes AURO-QUETIAPINE 100 MG TABLET OPEN Yes AURO-QUETIAPINE 200 MG TABLET OPEN Yes AURO-QUETIAPINE 25 MG TABLET OPEN Yes AURO-QUETIAPINE 300 MG TABLET OPEN Yes AURO-RAMIPRIL 1.25 MG CAPSULE OPEN None Yes AURO-RAMIPRIL 10 MG CAPSULE OPEN None Yes AURO-RAMIPRIL 2.5 MG CAPSULE OPEN None Yes AURO-RAMIPRIL 5 MG CAPSULE OPEN None Yes AURO-RISEDRONATE 35 MG TABLET None Yes AURO-SERTRALINE 100 MG CAPSULE OPEN Yes AURO-SERTRALINE 25 MG CAPSULE OPEN Yes AURO-SERTRALINE 50 MG CAPSULE OPEN Yes AURO-SIMVASTATIN 10 MG TABLET OPEN None Yes AURO-SIMVASTATIN 20 MG TABLET OPEN None Yes AURO-SIMVASTATIN 40 MG TABLET OPEN None Yes AURO-SIMVASTATIN 5 MG TABLET OPEN None Yes AURO-SIMVASTATIN 80 MG TABLET OPEN None Yes AURO-TERBINAFINE 250 MG TABLET OPEN None Yes AURO-TOPIRAMATE 100 MG TABLET OPEN None Yes AURO-TOPIRAMATE 200 MG TABLET OPEN None Yes AURO-TOPIRAMATE 25 MG TABLET OPEN None Yes AURO-VALACYCLOVIR 500 MG TAB OPEN None Yes AURO-VALSARTAN 160 MG TABLET OPEN Yes AURO-VALSARTAN 40 MG TABLET OPEN Yes AURO-VALSARTAN 80 MG TABLET OPEN Yes Page 45 Effective December 2015

46 Coverage Table December AURO-VALSARTAN HCT MG OPEN Yes AURO-VALSARTAN HCT MG TB OPEN Yes AURO-VALSARTAN HCT MG OPEN Yes AURO-VALSARTAN HCT MG TB OPEN Yes AURO-VALSARTAN HCT MG OPEN Yes AVALIDE 150 MG/12.5 MG TABLET OPEN Yes AVALIDE 300 MG/12.5 MG TABLET OPEN Yes AVALIDE MG TABLET OPEN Yes AVAPRO 150 MG TABLET OPEN Yes AVAPRO 300 MG TABLET OPEN Yes AVAPRO 75 MG TABLET OPEN Yes AVELOX 400 MG TABLET None No AVENTYL 10 MG CAPSULE OPEN Yes AVENTYL 25 MG CAPSULE OPEN Yes AVIANE MCG-20 MCG TAB OPEN Beneficiary gender must be female - under the age of 51 Yes AVIANE MCG-20 MCG TAB OPEN Beneficiary gender must be female - under the age of 51 Yes AVODART 0.5 MG CAPSULE None Yes AVONEX 30 MCG/0.5 ML KIT None No AVONEX 30 MCG/0.5 ML KIT None No AVONEX 30MCG KIT None No AXERT 12.5 MG TABLET None Yes AXERT 6.25 MG TABLET None Yes Page 46 Effective December 2015

47 Coverage Table December AZARGA 1 %-0.5 % EYE DROPS OPEN None No AZATHIOPRINE 50 MG TABLET OPEN None Yes AZITHROMYCIN 100 MG/5 ML SUSP OPEN None Yes AZITHROMYCIN 200 MG/5 ML SUSP OPEN None Yes AZITHROMYCIN 250 MG TABLET OPEN Limit of 6 per day without Special Yes AZITHROMYCIN 250MG TABLET OPEN None Yes AZITHROMYCIN 600 MG TABLET None Yes AZMACORT OPEN None No AZOPT 1% EYE DROPS OPEN None No B COMPLEX 50 OPEN None No BACIGUENT FIRST AID OINT OPEN None No BACIGUENT OPH ONT 500UNIT/GM OPEN None No BACITIN 500 UNIT/GM OINTMENT OPEN None No BACITRACIN 500U/GM OINTMENT OPEN None No BACLOFEN 10 MG TABLET OPEN None Yes BACLOFEN 20 MG TABLET OPEN None Yes BACTERIOSTATIC NACL VIAL None No BACTROBAN 2 % CREAM OPEN None No BACTROBAN 2 % OINTMENT OPEN None Yes BANZEL 100 MG TABLET None No BANZEL 200 MG TABLET None No BANZEL 400 MG TABLET None No BARACLUDE 0.5 MG TABLET None Yes BARRIERE HC 1% CREAM OPEN None No BD ALCOHOL SWABS OPEN None No B-D ALCOHOL SWABS OPEN None No BD LATITUDE LANCETS OPEN None No BD LATITUDE TEST STRIPS OPEN a) Limited to 2500 per year without Special b) Beneficiary must have diabetic medication within previous year No history, otherwise Special is required BD MICROFINE NEEDLE 28G OPEN None No BD ULTRAFINE.5CC &.3CC 29G OPEN None No BD ULTRAFINE 1CC 29G SYRINGE OPEN None No BD ULTRAFINE 29G PEN NEEDLE OPEN None No Page 47 Effective December 2015

48 Coverage Table December BD ULTRAFINE 30G SYRINGE 0.3CC OPEN None No BD ULTRAFINE 30G SYRINGE 1/2 OPEN None No BD ULTRAFINE 30G SYRINGE 1CC OPEN None No BD ULTRAFINE 31G 5MM PEN NEEDL OPEN None No BD ULTRAFINE 31G 8MM PEN NEEDL OPEN None No BD ULTRAFINE 32G 4MM NANO NDL OPEN None No BD ULTRAFINE LANCET OPEN None No BECLOMETHASONE DP 50MCG INH OPEN None No BECONASE AQ 50MCG SPRAY OPEN None Yes BEDOZ 1000MCG/ML VIAL OPEN None No BELLERGAL SPACETABS OPEN No BENADRYL 12.5 MG/5 ML ELIXIR OPEN None No BENADRYL 25 MG CAPLET OPEN None No BENADRYL 50 MG CAPSULE OPEN None No BENADRYL CHILDREN'S LIQUID OPEN None No BENADRYL INJ. 50MG/ML OPEN None No BENAZEPRIL 10 MG TABLET OPEN None Yes BENAZEPRIL 20 MG TABLET OPEN None Yes BENAZEPRIL 5 MG TABLET OPEN None Yes BENOXYL 10 % LOTION OPEN None No BENOXYL 20 % LOTION OPEN None No BENOXYL 5 % LOTION OPEN None No BENTYLOL 10 MG TABLET OPEN None No BENTYLOL 10 MG/5 ML SYRUP OPEN None No BENTYLOL 20 MG TABLET OPEN None No BENURYL 500 MG TABLET OPEN None No BENZAC AC 10% GEL OPEN None No BENZAC W 10% GEL OPEN None No BENZAC W WASH 10% LIQUID OPEN None No BENZACLIN 1 %-5 % GEL OPEN None No BENZAGEL 10 10% ACNE GEL OPEN None No BENZAGEL 5% GEL OPEN None No BENZAGEL 5% LOTION OPEN None No BENZAGEL WASH 5 % LIQUID OPEN None No BENZAMYCIN 3 %-5 % GEL OPEN None No BENZTROPINE OMEGA 1 MG/ML LQ OPEN None No Page 48 Effective December 2015

49 Coverage Table December BEROTEC 100MCG INHALER OPEN None No BETACORT 0.1% SCALP LOTION OPEN None No BETADERM 0.05 % CREAM OPEN None Yes BETADERM 0.05 % OINTMENT OPEN None Yes BETADERM 0.1 % OINTMENT OPEN None Yes BETADERM 0.1% CREAM OPEN None Yes BETADERM 0.1% SCALP LOTION OPEN None Yes BETAE 10% VAGINAL SUPPOS OPEN None No BETAGAN 0.5 % EYE DROPS OPEN None Yes BETAGAN OPH SOLN 0.25% OPEN None Yes BETALOC 1 MG/ML VIAL OPEN None No BETALOC DURULES 200 MG TAB OPEN None No BETALOC TAB 100 MG OPEN None Yes BETALOC TAB 50 MG OPEN None Yes BETASERON 0.3 MG VIAL None No BETNESOL RETENTION ENEMA OPEN None No BETNESOL TABLETS OPEN None No BETOPTIC S 0.25 % EYE DROPS OPEN None No BEZALIP SR 400 MG TABLET OPEN None No BG STAR LANCETS OPEN None No BG STAR TEST STRIPS OPEN a) Limited to 2500 per year without Special b) Beneficiary must have diabetic medication within previous year No history, otherwise Special is required BG STAR TEST STRIPS OPEN a) Limited to 2500 per year without Special b) Beneficiary must have diabetic medication within previous year No history, otherwise Special is required BIAXIN 125 MG/5 ML SUSPENSION OPEN None Yes BIAXIN 250 MG/5 ML SUSPENSION OPEN None Yes BIAXIN BID 250 MG TABLET OPEN None Yes BIAXIN BID 500 MG TABLET OPEN None Yes BIAXIN XL 500 MG TABLET OPEN None Yes BICALUTAMIDE 50 MG TABLET OPEN None Yes BICILLIN L-A INJECTION SUS 120 OPEN None No Page 49 Effective December 2015

50 Coverage Table December BIPHENTIN 10 MG CAPSULE No BIPHENTIN 15 MG CAPSULE No BIPHENTIN 20 MG CAPSULE No BIPHENTIN 30 MG CAPSULE No BIPHENTIN 40 MG CAPSULE No BIPHENTIN 50 MG CAPSULE No BIPHENTIN 60 MG CAPSULE No BIPHENTIN 80 MG CAPSULE None No BIQUIN DURULES 250 MG TABLET OPEN None No BISACODYL 5MG SUPP OPEN None No BISACODYL 10 MG SUPPOSITORY OPEN None No BISACODYL-ODAN 5 MG TAB EC OPEN Reasonable Based Pricing is applied No BISACOLAX OPEN Reasonable Based Pricing is applied No BISOPROLOL 10 MG TABLET OPEN None Yes BISOPROLOL 10 MG TABLET OPEN None Yes BISOPROLOL 5 MG TABLET OPEN None Yes BISOPROLOL 5 MG TABLET OPEN None Yes BLENOXANE 15 UNIT VIAL OPEN None No BLEPH-10 10% EYE DROPS OPEN None No BLEPHAMIDE LIQUIFILM DROPS OPEN None No BLEPHAMIDE S.O.P. 0.2% OINT OPEN None No BRAVO 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 50 Effective December 2015

51 Coverage Table December BREEZE2 BLOOD GLUCOSE TEST STR OPEN a) Limited to 2500 per year without Special b) Beneficiary must have diabetic medication within previous year No history, otherwise Special is required BREEZE2 BLOOD GLUCOSE TEST STR OPEN a) Limited to 2500 per year without Special b) Beneficiary must have diabetic medication within previous year No history, otherwise Special is required BREO ELLIPTA MCG INHALER None No BREVICON 0.5/35 21 TAB OPEN Beneficiary gender must be female - under the age of 51 No BREVICON 0.5/35 21 TABLET OPEN Beneficiary gender must be female - under the age of 51 No BREVICON 0.5/35 21 TABLET OPEN Beneficiary gender must be female - under the age of 51 No BREVICON 0.5/35 28 TAB OPEN Beneficiary gender must be female - under the age of 51 No BREVICON 0.5/35 28 TABLET OPEN Beneficiary gender must be female - under the age of 51 No BREVICON 0.5/35 28 TABLET OPEN Beneficiary gender must be female - under the age of 51 No BREVICON 1/35 21 TAB OPEN Beneficiary gender must be female - under the age of 51 No BREVICON 1/35 21 TABLET OPEN Beneficiary gender must be female - under the age of 51 No BREVICON 1/35 21 TABLET OPEN Beneficiary gender must be female - under the age of 51 No BREVICON 1/35 28 TAB OPEN Beneficiary gender must be female - under the age of 51 No BREVICON 1/35 28 TABLET OPEN Beneficiary gender must be female - under the age of 51 No BREVICON 1/35 28 TABLET OPEN Beneficiary gender must be female - under the age of 51 No BRICANYL 0.5 MG TURBUHALER OPEN None No BRILINTA 90 MG TABLET None No Page 51 Effective December 2015

52 Coverage Table December BRIMONIE 0.2 % EYE DROPS OPEN None Yes BRIMONIE P 0.15 % EYE DROPS OPEN None Yes BROMOCRIPTINE 2.5 MG TABLET OPEN None Yes BROMOCRIPTINE 5 MG CAPSULE OPEN None Yes BUPROPION SR 100 MG TABLET OPEN a) Limited to 2 per day without Special b) Special Authorzation required if beneficiary has not had a paid Yes claim for an anti-depressant or Bupropion in past year BUPROPION SR 150 MG TABLET OPEN a) Limited to 2 per day without Special b) Special Authorzation required if beneficiary has not had a paid Yes claim for an anti-depressant or Bupropion in past year BUSCOPAN 10 MG TABLET OPEN None No BUSCOPAN 20 MG/ML AMPOULE OPEN None No BUSPAR TAB 10MG OPEN Yes BUTTERFLY SWABS #6893 OPEN None No C.E.S. 0.3 MG TABLET OPEN None No C.E.S MG TABLET OPEN None No C.E.S. 0.9 MG TABLET OPEN None No C.E.S MG TABLET OPEN None No CADUET 10 MG/10 MG TABLET None Yes CADUET 10 MG/20 MG TABLET None Yes CADUET 10 MG/40 MG TABLET None Yes CADUET 10 MG/80 MG TABLET None Yes CADUET 5 MG/10 MG TABLET None Yes CADUET 5 MG/20 MG TABLET None Yes CADUET 5 MG/40 MG TABLET None Yes CADUET 5 MG/80 MG TABLET None Yes CAFERGOT TABLET OPEN None No CAL OYSTER SHELL 250 MG TAB OPEN None No CALCIMAR 200 UNIT/ML VIAL OPEN None No CALCIUM 100 MG/5 ML LIQUID OPEN None No CALCIUM 500 MG TABLET OPEN None No CALCIUM 500 W/VIT D TABLET OPEN None No Page 52 Effective December 2015

53 Coverage Table December CALCIUM 500MG TABLET OPEN None No CALCIUM 650 MG/VIT D CAPLET OPEN None No CALCIUM CARB & VIT D3 TAB OPEN None No CALCIUM CARB 1.5GM TABLET OPEN None No CALCIUM CARBONATE 1250MG OPEN Beneficiary must have eligibility under the CF Plan No CALCIUM GLUCONATE 650MG TAB OPEN None No CALCIUM SANDOZ FORTE OPEN None No CALTRATE 600 TABLET OPEN None No CALTRATE 600 TABLET OPEN None No CALTRATE 600 W/ D TAB CHEW OPEN Beneficiary must have eligibility under the CF Plan No CALTRATE 600 WITH D TABLET OPEN None No CALTRATE PLUS TABLET OPEN Beneficiary must have eligibility under the CF Plan No CAMPRAL 333 MG TABLET EC None No CANDESARTAN 16 MG TABLET OPEN Yes CANDESARTAN 16 MG TABLET OPEN Yes CANDESARTAN 32 MG TABLET OPEN Yes CANDESARTAN 8 MG TABLET OPEN Yes CANDESARTAN 8 MG TABLET OPEN Yes CANDESARTAN HCT MG TAB OPEN Yes CANDESARTAN HCTZ MG TB OPEN Yes CANDESARTAN HCTZ MG TAB OPEN Yes CANDESARTAN PLUS MG TAB OPEN Yes CANDESARTAN PLUS MG TB OPEN Yes Page 53 Effective December 2015

54 Coverage Table December CANDESARTAN PLUS MG TAB OPEN Yes CANDESARTAN/HCT MG TAB OPEN Yes CANDESARTAN/HCTZ MG TB OPEN Yes CANDESARTAN/HCTZ MG TAB OPEN Yes CANDESARTAN/HCTZ MG TAB OPEN Yes CANDESARTAN/HCTZ MG TB OPEN Yes CANDESARTAN/HCTZ MG TAB OPEN Yes CANDESARTAN/HCTZ MG TAB OPEN Yes CANDISTATIN TOPICAL POWDER OPEN None No CANESTEN 1 10% VAGINAL CRM OPEN None No CANESTEN 1 DAY COMBI-PAK OPEN None No CANESTEN 1% TOPICAL CREAM OPEN None No CANESTEN 1% VAGINAL CREAM OPEN None No CANESTEN 100MG VAGINAL INSERTS OPEN None No CANESTEN 3 2% VAGINAL CREAM OPEN None No CANESTEN 3 DAY COMBI-PAK OPEN None No CAPEX 0.01 % SHAMPOO OPEN None No CAPOTEN TAB 100MG OPEN None Yes CAPOTEN TAB 12.5MG OPEN None Yes CAPOTEN TAB 25MG OPEN None Yes CAPOTEN TAB 50MG OPEN None Yes CARBACHOL 2 MG TABLET OPEN None No CARBAMAZEPINE 100 MG TAB CHEW OPEN None Yes CARBAMAZEPINE 100 MG/5 ML SUSP None Yes CARBAMAZEPINE 200 MG TAB CHEW OPEN None Yes CARBOLITH 150 MG CAPSULE OPEN Yes CARBOLITH 300 MG CAPSULE OPEN Yes Page 54 Effective December 2015

55 Coverage Table December CARBOLITH 600 MG CAPSULE OPEN No CARDIZEM OPEN None Yes CARDIZEM OPEN None Yes CARDIZEM CD 120 MG CAPSULE OPEN None Yes CARDIZEM CD 180 MG CAPSULE OPEN None Yes CARDIZEM CD 240 MG CAPSULE OPEN None Yes CARDURA 1 MG TABLET OPEN None Yes CARDURA 2 MG TABLET OPEN None Yes CARDURA 4 MG TABLET OPEN None Yes CARESENS N BLD GLUCOSE TST STR OPEN a) Limited to 2500 per year without Special b) Beneficiary must have diabetic medication within previous year No history, otherwise Special is required CARIPUL IV, POWDER SOLN 0.5MG None No CARIPUL IV, POWDER SOLN 1.5MG None No CARNITOR 100 MG/ML SOLUTION None No CARNITOR 330 MG TABLET None No CARVEDILOL 12.5 MG TABLET None Yes CARVEDILOL 12.5 MG TABLET None Yes CARVEDILOL 25 MG TABLET None Yes CARVEDILOL 25 MG TABLET None Yes CARVEDILOL MG TABLET None Yes CARVEDILOL MG TABLET None Yes CARVEDILOL 6.25 MG TABLET None Yes CARVEDILOL 6.25 MG TABLET None Yes CASODEX 50 MG TABLET OPEN None Yes CATAPRES 0.1 MG TABLET OPEN None Yes CATAPRES 0.2 MG TABLET OPEN None Yes CAYSTON 75MG/VIAL INHAL SOL None No CECLOR 125 MG/5 ML SUSPENSION OPEN None No CECLOR 250 MG CAPSULE OPEN None No CECLOR 250 MG/5 ML SUSPENSION OPEN None No CECLOR 500 MG CAPSULE OPEN None No CEDOCARD-SR 20 MG TABLET SA OPEN None No CEENU 10 MG CAPSULE OPEN None No Page 55 Effective December 2015

56 Coverage Table December CEENU 100 MG CAPSULE OPEN None No CEENU 40 MG CAPSULE OPEN None No CEFOTAXIME SOD 1 GRAM VIAL OPEN None Yes CEFOTAXIME SOD 2 GRAM VIAL OPEN None Yes CEFPROZIL 250 MG TABLET None Yes CEFPROZIL 500 MG TABLET OPEN None Yes CEFTAZIDIME 1GM VIAL OPEN Beneficiary must have eligibility under the CF Plan No CEFTAZIDIME 6 G VIAL BULK OPEN Beneficiary must have eligibility under the CF Plan No CEFTIN 125 MG/5 ML SUSPENSION OPEN None No CEFTIN 250 MG TABLET OPEN None Yes CEFTIN 500 MG TABLET OPEN None Yes CEFZIL 125 MG/5 ML SUSPENSION OPEN None Yes CEFZIL 250 MG TABLET OPEN None Yes CEFZIL 250 MG/5 ML SUSPENSION OPEN None Yes CEFZIL 500 MG TABLET OPEN None Yes CELEBREX 100 MG CAPSULE OPEN Limit of 2 per day without Special Yes CELEBREX 200 MG CAPSULE OPEN Limit of 2 per day without Special Yes CELECOXIB 100 MG CAPSULE OPEN Limit of 2 per day without Special Yes CELECOXIB 200 MG CAPSULE OPEN Limit of 2 per day without Special Yes CELESTODERM V 0.1 % CREAM OPEN None No CELESTODERM V 0.1 % OINTMENT OPEN None No CELESTODERM V/ % CREAM OPEN None No CELESTODERM V/ % OINT OPEN None No CELESTONE SOLUSPAN 6 MG/ML OPEN None No CELEXA 20 MG TABLET OPEN. Maximum of 1.5 tablets Yes daily CELEXA 40 MG TABLET OPEN Yes CELONTIN 300 MG CAPSULE OPEN None No CELSENTRI 150 MG TABLET None No Page 56 Effective December 2015

57 Coverage Table December CELSENTRI 300 MG TABLET None No CERUBIE 20 MG VIAL OPEN None No CESAMET 0.5 MG CAPSULE OPEN Yes CESAMET 1 MG CAPSULE OPEN Yes CETAMIDE 10% OPHTH OINTMENT OPEN None No CHAMPIX 0.5 MG TABLET OPEN Open benefit for Foundation Plan, Access Plan and 65+ Plan for 12 weeks therapy No per year CHAMPIX CONTINUATION PACK OPEN Open benefit for Foundation Plan, Access Plan and 65+ Plan for 12 weeks therapy No per year CHAMPIX STARTER PACK OPEN Open benefit for Foundation Plan, Access Plan and 65+ Plan for 12 weeks therapy No per year CHEMSTRIP 9 OPEN None No CHEMSTRIP UG 5000 OPEN None No CHILDREN'S ACETAMINOPHEN DPS 8 OPEN Beneficiary must be less than 3 years old - RBP applied No CHILDREN'S ACETAMINOPHEN ELIXI OPEN Beneficiary must be less than 3 years old - RBP applied No CHILDREN'S ACETAMINOPHEN ELIXI OPEN Beneficiary must be less than 13 years old - RBP applied No CHILDREN'S ACETAMINOPHEN ELIXI OPEN Beneficiary must be less than 13 years old - RBP applied No CHILDREN'S ACETAMINOPHEN ORAL OPEN Beneficiary must be less than 13 years old - RBP applied No CHILDREN'S ACETAMINOPHEN SUSPE OPEN Reasonable Based Pricing is applied No CHILDREN'S ACETAMINOPHEN SUSPE OPEN CHILDREN'S ACETAMINOPHEN SYRUP OPEN CHILD'S ACETAMIN 160 MG/5 ML OPEN Beneficiary must be less than 13 years old - RBP applied Beneficiary must be less than 13 years old - RBP applied Beneficiary must be less than 13 years old - RBP applied No No No Page 57 Effective December 2015

58 Coverage Table December CHILDS MOTION SICK 15 MG/5 ML OPEN Beneficiary must be less than 13 years old - RBP applied No CHILD'S MOTRIN 100 MG/5 ML OPEN Beneficiary must have eligibility under the CF Plan No CHLORAX 5 MG-2.5 MG CAPSULE OPEN Yes CHLORDIAZEPOXIDE 10 MG CAP OPEN No CHLORDIAZEPOXIDE 10 MG CAPSULE OPEN Yes CHLORDIAZEPOXIDE 25 MG CAPSULE OPEN Yes CHLORDIAZEPOXIDE 5 MG CAPSULE OPEN Yes CHLOROMYCETIN 1 GM VIAL OPEN None No CHLORPROMANYL 20MG/ML SYRUP OPEN No CHLORPROMANYL 40 MG/ML SYRUP OPEN No CHLORPROPAMIDE 100 MG TABLET OPEN None No CHLORTHALIDONE 50 MG TABLET OPEN None Yes CHLOR-TRIPOLON 12 MG REPETAB OPEN None No CHLORTRIPOLON 2.5 MG/5 ML SYR OPEN None No CHLOR-TRIPOLON 4 MG TABLET OPEN None No CHOLEDYL 100 MG/5 ML ELIXIR OPEN None No CHOLEDYL EXPECTORANT ELIXIR OPEN None No CHOLEDYL SA TABLETS 400MG OPEN None No CHOLEDYL SA TABLETS 600MG OPEN None No CICATRIN POWDER OPEN None No CILAZAPRIL 1 MG TABLET OPEN None Yes CILAZAPRIL 2.5 MG TABLET OPEN None Yes CILAZAPRIL 5 MG TABLET OPEN None Yes CILOXAN 0.3 % EYE DROPS OPEN None Yes CIMETIE 300 MG TABLET OPEN None No CIPRO 250 MG TABLET OPEN None Yes CIPRO 500 MG TABLET OPEN None Yes CIPRO 500 MG/5 ML SUSPENSION OPEN None No Page 58 Effective December 2015

59 Coverage Table December CIPRO 750 MG TABLET OPEN None Yes CIPRO HC OTIC SUSPENSION OPEN None No CIPRO XL 1,000 MG TABLET OPEN None No CIPRODEX DROPS SUSP None No CIPROFLOXACIN 0.3 % EYE DROP OPEN None Yes CIPROFLOXACIN 250 MG TABLET OPEN None Yes CIPROFLOXACIN 250 MG TABLET OPEN None Yes CIPROFLOXACIN 250 MG TABLET OPEN None Yes CIPROFLOXACIN 500 MG TABLET OPEN None Yes CIPROFLOXACIN 500 MG TABLET OPEN None Yes CIPROFLOXACIN 500 MG TABLET OPEN None Yes CIPROFLOXACIN 750 MG TABLET OPEN None Yes CIPROFLOXACIN 750 MG TABLET OPEN None Yes CITALOPRAM 20 MG TABLET OPEN. Maximum of 1.5 tablets Yes daily CITALOPRAM 20 MG TABLET OPEN. Maximum of 1.5 tablets Yes daily CITALOPRAM 20 MG TABLET OPEN. Maximum of 1.5 tablets Yes daily CITALOPRAM 20MG TABLET OPEN. Maximum of 1.5 Yes tablets daily CITALOPRAM 40 MG TABLET OPEN Yes CITALOPRAM 40 MG TABLET OPEN Yes CITALOPRAM 40 MG TABLET OPEN Yes CITALOPRAM 40MG TABLET OPEN. Yes CITALOPRAM-ODAN 20 MG TAB OPEN. Maximum of 1.5 tablets daily. Yes Page 59 Effective December 2015

60 Coverage Table December CITALOPRAM-ODAN 40 MG TAB OPEN Yes CLAFORAN 1G VIAL OPEN None Yes CLAFORAN 2G VIAL OPEN None Yes CLARIPEX 500MG CAPSULE OPEN None No CLARITHROMYCIN 125 MG/5ML SUSP OPEN None Yes CLARITHROMYCIN 125 MG/5ML SUSP OPEN None Yes CLARITHROMYCIN 250 MG/5ML SUSP OPEN None Yes CLARITHROMYCIN 250 MG/5ML SUSP OPEN None Yes CLARITHROMYCIN XL 500 MG TAB OPEN None Yes CLARITIN 10 MG TABLET OPEN None Yes CLARITIN KIDS 5 MG/5 ML SOLN OPEN Beneficiary must be less than 13 years old - RBP applied No CLARUS 10 MG CAPSULE OPEN None No CLARUS 40 MG CAPSULE OPEN None No CLAVULIN 125 MG/5 ML SUSP OPEN None Yes CLAVULIN 200 SUSPENSION OPEN None No CLAVULIN 250 MG/5 ML SUSP OPEN None Yes CLAVULIN 250 TAB OPEN None Yes CLAVULIN 400 SUSPENSION OPEN None No CLAVULIN 500 F TABLET OPEN None Yes CLAVULIN 875 TABLET OPEN Beneficiary must have eligibility under the CF Plan Yes CLIMARA MG/DAY PATCH OPEN None No CLIMARA MG/24 H PTCH OPEN None No CLIMARA MG/DAY PATCH OPEN None No CLIMARA MG/24 H PTCH OPEN None No CLINDOXYL 1 %-5 % GEL OPEN None No CLINDOXYL ADV 1 %-3 % GEL OPEN None No CLINITEST OPEN None No CLOMID 50 MG TABLET OPEN None No CLOPIDOGREL 75 MG TABLET None Yes CLOPIDOGREL 75 MG TABLET No Yes CLOPIXOL 10 MG TABLET OPEN No CLOPIXOL 25 MG TABLET OPEN No Page 60 Effective December 2015

61 Coverage Table December CLOPIXOL 500MG/ML AMPOULE OPEN No CLOPIXOL DEPOT 200 MG/ML AMP OPEN No CLOPIXOL TABLETS 40MG OPEN No CLORAZEPATE 15 MG CAPSULE OPEN Yes CLORAZEPATE 3.75 MG CAPSULE OPEN Yes CLORAZEPATE 7.5 MG CAPSULE OPEN Yes CLOTRIMADERM 1 % CREAM OPEN None No CLOTRIMADERM 1 % VAG CREAM OPEN None No CLOTRIMADERM 2 % VAG CREAM OPEN None No CLOZARIL 100 MG TABLET No CLOZARIL 25 MG TABLET No CO CILAZAPRIL 2.5 MG TABLET OPEN None Yes CO CILAZAPRIL 5 MG TABLET OPEN None Yes CO CLONAZEPAM 0.5 MG TABLET OPEN Yes CO CLONAZEPAM 1 MG TABLET OPEN Yes CO CLONAZEPAM 2 MG TABLET OPEN Yes CO DICLO-MISO 50 MG-200 MCG OPEN None Yes CO DICLO-MISO 75 MG-200 MCG OPEN None Yes CO FENTANYL 100 MCG/HR PATCH Yes CO FENTANYL 12 MCG/HR PATCH Yes CO FENTANYL 25 MCG/HR PATCH Yes CO FENTANYL 50 MCG/HR PATCH Yes Page 61 Effective December 2015

62 Coverage Table December CO FENTANYL 75 MCG/HR PATCH Yes CO NORFLOXACIN 400 MG TAB OPEN None Yes CO TEMAZEPAM 15 MG CAPSULE OPEN Yes CO TEMAZEPAM 30 MG CAPSULE OPEN Yes CO VALACYCLOVIR 500 MG TABLET OPEN None Yes CODEINE CONTIN 100 MG TABLET No CODEINE CONTIN 150 MG TABLET No CODEINE CONTIN 200 MG TABLET No CODEINE CONTIN 50 MG TABLET No CODEINE PHOS 25 MG/5 ML SIROP OPEN No CODEINE PHOS 30 MG/ML AMP OPEN No CODEINE PHOS TAB 15MG OPEN No CODEINE PHOS TAB 15MG OPEN No CODEINE PHOS TAB 30MG OPEN No CODEINE PHOSPHATE 15 MG TAB OPEN No CODEINE TAB 30MG OPEN No CODULAX 5 MG TABLET OPEN Reasonable Based Pricing is applied No COGENTIN 1MG/ML AMPUL OPEN None No COGENTIN TAB 2MG OPEN None No COLACE 100 MG CAPSULE OPEN Reasonable Based Pricing is applied No COLACE 60 MG/15 ML SYRUP OPEN Beneficiary must be less than 13 years old - RBP applied No COLCHICINE 0.6 MG TABLET OPEN None No Page 62 Effective December 2015

63 Coverage Table December COLCHICINE 0.6 MG TABLET OPEN None No COLCHICINE 1 MG TABLET OPEN None No COLCHICINE 1 MG TABLET OPEN None No COLCHICINE TAB 0.6MG OPEN None No COLESTID 1GM TABLET OPEN None No COLESTID GRANULES OPEN None No COLESTID ORANGE 7.5 GRANULE OPEN None No COLYTE SOLUTION OPEN Beneficiary must have eligibility under the CF Plan. No COMBANTRIN 125 MG TABLET OPEN None No COMBIGAN 0.2%-0.5% EYE DROPS OPEN None No COMBIVENT INHALER OPEN Can only be claimed if the Beneficiary does not have an active Special No for Wet Nebulization COMBIVENT RESPIMAT INHALER OPEN Can only be claimed if the Beneficiary does not have an active Special No for Wet Nebulization COMBIVENT UDV INHALATION SOLN None Yes COMBIVIR 150 MG-300 MG TABLET OPEN Yes COMBO STERINEB MG/2.5ML None Yes COMPANION 2 LANCET OPEN None No COMPANION STRIPS STP 40% OPEN a) Limited to 2500 per year without Special b) Beneficiary must have diabetic medication within previous year No history, otherwise Special is required COMPLERA 200 MG-25MG-300MG TAB None No COMPOUND W LIQUID 20% OPEN None No COMTAN 200 MG TABLET OPEN None Yes CONCERTA 18 MG TABLET Yes CONCERTA 27 MG TABLET Yes CONCERTA 36 MG TABLET Yes Page 63 Effective December 2015

64 Coverage Table December CONCERTA 54 MG TABLET Yes CONDYLINE 0.5 % TOPICAL SOLN OPEN None No CONJ ESTROGENS MG TAB OPEN None No CONJ ESTROGENS 1.25 MG TAB OPEN None No CONTOUR BLOOD GLUCOSE OPEN a) Limited to 2500 per year without Special b) Beneficiary must have diabetic medication within previous year No history, otherwise Special is required CONTOUR NEXT BLD GLUCO TSTRIPS OPEN a) Limited to 2500 per year without Special b) Beneficiary must have diabetic medication within previous year No history, otherwise Special is required COPAXONE 20 MG/ML SYRINGE None No COPTIN ORAL SUSPENSION OPEN None No COPTIN TABLET OPEN None No CORDARONE 200 MG TABLET OPEN None Yes COREG (CARVEDILOL) TABLETS, 12 None Yes COREG (CARVEDILOL) TABLETS, 25 None Yes COREG (CARVEDILOL) TABLETS, 3. None Yes COREG (CARVEDILOL) TABLETS, 6. None Yes COREG 12.5MG None No CORGARD TAB 160MG OPEN None Yes CORGARD TAB 40MG OPEN None Yes CORGARD TAB 80MG OPEN None Yes CORTAMED 2.5% OINTMENT OPEN None No CORTATE 0.5% CREAM OPEN None No CORTATE 0.5% LOTION OPEN None No CORTATE 0.5% OINTMENT OPEN None No CORTATE 1% CREAM OPEN None No CORTATE 1% OINTMENT OPEN None No CORTEF 10 MG TABLET OPEN None No CORTEF 20 MG TABLET OPEN None No CORTENEMA 100 MG/60 ML ENEMA OPEN None No CORTIFOAM 10% RECTAL FOAM OPEN None No Page 64 Effective December 2015

65 Coverage Table December CORTISONE ACETATE 25 MG TAB OPEN None No CORTISPORIN OPEN None No CORTISPORIN EYE/EAR DROPS OPEN None No CORTISPORIN OINTMENT OPEN None No CORTISPORIN OTIC SOLUTION OPEN None No CORTODERM 0.5% OINTMENT OPEN None No CORTODERM 1 % OINTMENT OPEN None No CORTONE TAB 25MG OPEN None No CORTONE TAB 5MG OPEN None No COSMEGEN 0.5 MG VIAL OPEN None No COSOPT 2 %-0.5 % EYE DROPS OPEN None Yes COTAZYM CAPSULE None No COTAZYM ECS 20 CAPSULE None No COTAZYM ECS 4 CAPSULE None No COTAZYM ECS 8 CAPSULE None No COUMA 1 MG TABLET OPEN None Yes COUMA 10 MG TABLET OPEN None Yes COUMA 2 MG TABLET OPEN None Yes COUMA 2.5 MG TABLET OPEN None Yes COUMA 3 MG TABLET OPEN None Yes COUMA 4 MG TABLET OPEN None Yes COUMA 5 MG TABLET OPEN None Yes COUMA 6 MG TABLET OPEN None Yes COVERA-HS 180 MG SR TABLET OPEN None No COVERA-HS 240 MG SR TABLET OPEN None No COVERSYL 2 MG TABLET None No COVERSYL 4 MG TABLET OPEN None No COVERSYL 8 MG TABLET OPEN None No COVERSYL PLUS 4 MG-1.25 MG TAB OPEN None No COVERSYL PLUS HD MG TAB OPEN No COZAAR 100 MG TABLET OPEN Yes COZAAR 25 MG TABLET OPEN Yes COZAAR 50 MG TABLET OPEN Yes Page 65 Effective December 2015

66 Coverage Table December CREON 5 CAPSULE EC None No CREON 6 CAPSULE EC None No CREON MINIMICROSPHERES 10 CAP None No CREON MINIMICROSPHERES 25 CAP None No CRESTOR 10 MG TABLET OPEN None Yes CRESTOR 20 MG TABLET OPEN None Yes CRESTOR 40 MG TABLET OPEN None Yes CRIXIVAN 200 MG CAPSULE OPEN No CRIXIVAN 400 MG CAPSULE OPEN No CROMOLYN 2 % EYE DROPS OPEN None No CTP MG TABLET OPEN No CUPRIMINE 125MG CAPSULE OPEN None No CUPRIMINE 250 MG CAPSULE OPEN None No CYANOCOBALAMIN 1000 MCG/ML OPEN None No CYANOCOBALAMIN 1000MCG/ML OPEN None No CYCLEN 21 TABLET OPEN Beneficiary gender must be female - under the age of 51 No CYCLEN 28 TABLET OPEN Beneficiary gender must be female - under the age of 51 No CYCLOBENZAPRINE 10 MG TABLET OPEN None Yes CYCLOCORT 0.1 % CREAM OPEN None Yes CYCLOCORT 0.1 % LOTION OPEN None Yes CYCLOCORT 0.1 % OINTMENT OPEN None Yes CYCLOGYL 1 % EYE DROPS OPEN None No CYCLOMEN 100 MG CAPSULE OPEN None No CYCLOMEN 200 MG CAPSULE OPEN None No CYCLOMEN 50 MG CAPSULE OPEN None No CYESTRA MCG-2 MG TABLET None No CYKLOKAPRON 500 MG TABLET OPEN None Yes CYMBALTA 30 MG CAPSULE None No CYMBALTA 60 MG CAPSULE None No CYPROTERONE 50 MG TABLET OPEN None Yes CYSTAGON 150MG CAPSULE OPEN Can be dispensed by Hospital or RHA Clinic without prior approval No Page 66 Effective December 2015

67 Coverage Table December CYTOMEL 25 MCG TABLET OPEN None No CYTOMEL 5 MCG TABLET OPEN None No CYTOSAR 1 GRAM VIAL OPEN None No CYTOSAR 100 MG VIAL OPEN None No CYTOSAR 2 GRAM VIAL OPEN None No CYTOTEC 100 MCG OPEN None Yes CYTOTEC 200 MCG OPEN None Yes CYTOVENE 250 MG CAPSULE OPEN Can be dispensed by Hospital or RHA Clinic without prior approval No CYTOVENE 500 MG VIAL OPEN Can be dispensed by Hospital or RHA Clinic without prior approval No CYTOXAN 25 MG TABLET OPEN None No CYTOXAN 50 MG TABLET OPEN None No D VI SOL INFANTS 400U/ML DP OPEN None No DALACIN C 150 MG CAPSULE OPEN None Yes DALACIN C 300 MG CAPSULE OPEN None Yes DALACIN C 75 MG/5 ML SOLUTION OPEN None No DALACIN T 1 % SOLUTION OPEN None No DALMANE 15 MG CAPSULE OPEN Yes DANTRIUM 100 MG CAPSULE OPEN None No DANTRIUM 25 MG CAPSULE OPEN None No DAPSONE100 MG TABLET OPEN None No DARAPRIM 25 MG TABLET OPEN None No DARVON-N 100 MG PULVULE OPEN No DDAVP 0.1 MG TABLET OPEN None Yes DDAVP 0.2 MG TABLET OPEN None Yes DDAVP 10 MCG NASAL SPRAY OPEN None Yes DDAVP 4MCG/ML AMPOULE OPEN None No DDAVP MELT 120 MCG TAB SL OPEN None No DDAVP MELT 60 MCG TABLET SL OPEN None No DDAVP RHINYLE 0.1 MG/ML NASAL OPEN None No DECADRON TAB 0.5MG OPEN None No DECADRON TAB 4MG OPEN None No DECA-DURABOLIN 100 MG/ML VL OPEN No Page 67 Effective December 2015

68 Coverage Table December DECLOMYCIN - TAB 300MG OPEN None No DECLOMYCIN 150 MG TABLET OPEN None No DELATESTRYL 200 MG/ML VIAL OPEN No DELESTROGEN 10 MG/ML VIAL OPEN No DELTASONE 50MG OPEN None No DELTASONE 5MG OPEN None Yes DEMEROL 100 MG/ML AMPOULE OPEN No DEMEROL 50 MG TABLET OPEN No DEMEROL 50 MG/ML AMPOULE OPEN No DEMEROL 75 MG/ML AMPOULE OPEN No DEMULEN 30 (21) TABLET OPEN Beneficiary gender must be female - under the age of 51 No DEMULEN 30 (28) TABLET OPEN Beneficiary gender must be female - under the age of 51 No DEPAKENE 250 MG CAPSULE OPEN None Yes DEPAKENE 250 MG/5 ML SOLUTION OPEN None Yes DEPAKENE CAP 500MG OPEN None Yes DEPO-MEDROL 20 MG/ML VIAL OPEN None No DEPO-MEDROL 40 MG/ML VIAL OPEN None No DEPO-MEDROL 40 MG/ML VIAL OPEN None No DEPO-MEDROL 80 MG/ML VIAL OPEN None No DEPO-MEDROL 80 MG/ML VIAL OPEN None No DEPO-MEDROL/LIDOCAINE VIAL OPEN None No DEPO-PROVERA 150 MG/ML VIAL OPEN None No DEPO-PROVERA 50 MG/ML VIAL OPEN None No DEPO-TESTOSTERONE 100 MG/ML OPEN No DERMA-SMOOTHE/FS 0.01% OIL OPEN None No DERMAZIN 1% CREAM OPEN None No DERMOVATE 0.05% CREAM OPEN None Yes DERMOVATE 0.05% OINTMENT OPEN None Yes Page 68 Effective December 2015

69 Coverage Table December DERMOVATE 0.05% SCALP LOT OPEN None Yes DESFERAL 2GM VIAL OPEN None No DESFERAL 500 MG VIAL OPEN None No DESIPRAMINE 10 MG TABLET OPEN Yes DESIPRAMINE 100 MG TABLET OPEN Yes DESIPRAMINE 25 MG TABLET OPEN Yes DESIPRAMINE 50 MG TABLET OPEN Yes DESIPRAMINE 75 MG TABLET OPEN Yes DESMOPRESSIN 10 MCG SPRAY OPEN None Yes DESQUAM X 5% GEL OPEN None No DESQUAM-X 10% GEL OPEN None No DESQUAM-X WASH LOT 10% OPEN None No DESYREL DIVIDOSE TABLET 150 MG OPEN Yes DESYREL TAB 100MG OPEN Yes DESYREL TAB 50MG OPEN Yes DETROL 1 MG TABLET OPEN a) Limited to 2 per day without Special b) Special Authorzation required if beneficiary has not had a paid No claim for Ditropan RR or a long acting urinary agent in past year DETROL 2 MG TABLET OPEN a) Limited to 2 per day without Special b) Special Authorzation required if beneficiary has not had a paid claim for Ditropan RR or a long acting urinary agent in past year. No Page 69 Effective December 2015

70 Coverage Table December DETROL LA 2 MG CAPSULE OPEN a) Limited to 1 per day without Special b) Special Authorzation required if beneficiary has not had a paid No claim for Ditropan RR or a long acting urinary agent in past year DETROL LA 4 MG CAPSULE OPEN a) Limited to 1 per day without Special b) Special Authorzation required if beneficiary has not had a paid No claim for Ditropan RR or a long acting urinary agent in past year DEXAMETHASONE SP 4 MG/ML VIAL OPEN None No DEXAMETHASONE SP 4 MG/ML VL OPEN None No DEXASONE 0.5 MG TABLET OPEN None No DEXASONE 0.75 MG TABLET OPEN None No DEXASONE 4 MG TABLET OPEN None No DEXEDRINE 10 MG SPANSULE OPEN No DEXEDRINE 15 MG SPANSULE OPEN No DEXEDRINE 5 MG TABLET OPEN No DEXIRON 50 MG/ML AMPUL None No D-FORTE 50,000 UNIT CAPSULE OPEN None No DIABETA 2.5 MG TABLET OPEN None Yes DIABETA 5 MG TABLET OPEN None Yes DIACOMIT 250 MG CAPSULE None No DIACOMIT 250 MG POWDER PACKET None No DIACOMIT 500 MG CAPSULE None No DIACOMIT 500 MG POWDER PACKET None No DIAMICRON 80 MG TABLET OPEN None Yes DIAMICRON MR 30 MG TABLET OPEN None Yes DIAMICRON MR 60 MG TAB SA OPEN None Yes DIAMOX SEQUELS 500MG CAP OPEN None No DIAMOX TABLETS 250MG OPEN None No DIANE MCG-2 MG TABLET None No DIARR-EZE 0.2 MG/ML LIQUID None No DIARR-EZE 2 MG TABLET None No Page 70 Effective December 2015

71 Coverage Table December DIASTAT 5 MG/ML KIT (2 PACKS) No DIASTIX OPEN None No DIAZEPAM 5MG TABLET OPEN No DIAZEPAM 10 MG TABLET OPEN No DIAZEPAM 2 2 MG TABLET OPEN No DIAZEPAM 5 MG TABLET OPEN No DIAZEPAM 5 MG/ML AMPOULE OPEN No DICETEL 100 MG TABLET OPEN None No DICETEL 50 MG TABLET OPEN None No DICLECTIN TABLET OPEN None No DICLOFENAC EC 50 MG TABLET OPEN None Yes DICLOFENAC SR 75 MG TABLET OPEN None Yes DICLOTEC 100MG SUPPOSITORY OPEN None No DICLOTEC 50MG SUPPOSITORY OPEN None No DICYCLOMINE HCL 10 MG CAP OPEN None No DICYCLOMINE HCL 10 MG/ML AMP OPEN None No DIDROCAL PACK OPEN None Yes DIDRONEL TAB 200MG OPEN None Yes DIFFERIN 0.1% CREAM None No DIFFERIN 0.1% GEL None No DIFICID 200 MG TABLET None No DIFLUCAN 50 MG/5 ML VIAL OPEN None No DIFLUCAN ONE 150 MG CAPSULE OPEN None Yes DIFLUCAN TAB 100MG OPEN None Yes DIFLUCAN TAB 50MG OPEN None Yes DIFLUNISAL 250 MG TABLET OPEN None Yes DIHYDROERGOTAMINE 1 MG/ML AMP OPEN None No DILANTIN 100 MG CAPSULE OPEN None No DILANTIN 125 MG/5 ML SUSP OPEN None Yes DILANTIN 30 MG CAPSULE OPEN None No DILANTIN 30 MG/5 ML SUSPENSION OPEN None No Page 71 Effective December 2015

72 Coverage Table December DILANTIN 50 MG INFATABS OPEN None No DILAUDID 1 MG TABLET OPEN No DILAUDID 1 MG/ML LIQUID OPEN No DILAUDID 2 MG TABLET OPEN Yes DILAUDID 2 MG/ML AMPUL OPEN No DILAUDID 3 MG SUPPOSITORY OPEN No DILAUDID 4 MG TABLET OPEN Yes DILAUDID 8 MG TABLET OPEN No DILAUDID HP 10 MG/ML AMPUL OPEN No DILTIAZEM CD 120 MG CAPSULE OPEN None Yes DILTIAZEM CD 180 MG CAPSULE OPEN None Yes DILTIAZEM CD 240 MG CAPSULE OPEN None Yes DILTIAZEM CD 300 MG CAPSULE OPEN None Yes DILTIAZEM T ER 120 MG CAPSULE OPEN None Yes DILTIAZEM T ER 180 MG CAPSULE OPEN None Yes DILTIAZEM T ER 240 MG CAP OPEN None Yes DILTIAZEM T ER 300 MG CAP OPEN None Yes DILTIAZEM T ER 360 MG CAP OPEN None Yes DIMENHYDRINATE 50 MG/ML VIAL OPEN None No DIMENHYDRINATE 50MG TABLET OPEN Reasonable Based Pricing is applied No DIMENHYDRINATE 50MG/ML VIAL OPEN None No DIOCHLORAM 0.5% EYE DROPS OPEN None No DIODOQUIN 650 MG TABLET OPEN None No DIOGENT 3 MG/ML EYE DROPS OPEN None No DIOPRED 1% EYE DROPS OPEN None No DIOVAN 160 MG TABLET OPEN Yes DIOVAN 320 MG TABLET OPEN Yes Page 72 Effective December 2015

73 Coverage Table December DIOVAN 40 MG TABLET OPEN Yes DIOVAN 80 MG TABLET OPEN Yes DIOVAN-HCT MG TABLET OPEN Yes DIOVAN-HCT MG TABLET OPEN Yes DIOVAN-HCT MG TAB OPEN Yes DIOVAN-HCT MG TAB OPEN Yes DIOVAN-HCT MG TABLET OPEN Yes DIOVOL EX TAB OPEN None No DIOVOL EX XSTR SUSPENSION OPEN None No DIOVOL SUSPENSION OPEN None No DIOVOL TABLET CHEWABLE OPEN None No DIPENTUM 250 MG CAPSULE OPEN None No DIPHENHYDRAMINE 50 MG/ML VL OPEN None No DIPROGEN CREAM OPEN None No DIPROGEN OINTMENT OPEN None No DIPROLENE 0.05 % CREAM OPEN None No DIPROLENE 0.05 % LOTION OPEN None No DIPROLENE 0.05 % OINTMENT OPEN None No DIPROSALIC 0.05 %-2 % LOTION OPEN None Yes DIPROSALIC 0.05 %-3 % OINTMENT OPEN None No DIPROSONE 0.05 % CREAM OPEN None No DIPROSONE 0.05 % LOTION OPEN None No DIPROSONE 0.05 % OINTMENT OPEN None No DITROPAN TABLETS 5MG OPEN None Yes DITROPAN XL 10 MG TABLET OPEN a) Limited to 3 per day without Special b) Special Authorzation required if beneficiary has not had a paid claim for Ditropan RR or a long acting urinary agent in past year. No Page 73 Effective December 2015

74 Coverage Table December DITROPAN XL 5 MG TABLET OPEN a) Limited to 1 per day without Special b) Special Authorzation required if beneficiary has not had a paid No claim for Ditropan RR or a long acting urinary agent in past year DIVALPROEX DR 500 MG TABLET OPEN No Yes DIVALPROEX EC 125 MG TABLET OPEN No Yes DIVALPROEX EC 250 MG TABLET OPEN No Yes DIXARIT MG TABLET OPEN None Yes DOCUSATE CALCIUM 240 MG CAP OPEN Reasonable Based Pricing is applied No DOCUSATE CALCIUM 240 MG CAP OPEN Reasonable Based Pricing is applied No DOCUSATE CALCIUM 240 MG CAP OPEN Reasonable Based Pricing is applied No DOCUSATE CALCIUM CAP 240MG USP OPEN Reasonable Based Pricing is applied No DOCUSATE SOD 20 MG/5 ML SYRUP OPEN Beneficiary must be less than 13 years old - RBP applied No DOCUSATE SODIUM 100 MG CAP OPEN Reasonable Based Pricing is applied No DOCUSATE SODIUM 100 MG CAP OPEN Reasonable Based Pricing is applied No DOCUSATE SODIUM 100 MG CAPSULE OPEN Reasonable Based Pricing is applied No DOM-BENZYDAMINE 1.5 MG/ML LQ OPEN None No DOM-CARVEDILOL 12.5 MG TAB None No DOM-CARVEDILOL 25 MG TABLET None No DOM-CARVEDILOL MG TAB None No DOM-CARVEDILOL 6.25 MG TAB None No DOM-GABAPENTIN 100 MG CAP None No DOM-GABAPENTIN 300 MG CAP None No DOM-GABAPENTIN 400 MG CAP None No DOM-LOPERAMIDE 2 MG TABLET None No DOMPERIDONE 10 MG TABLET OPEN None Yes DOMPERIDONE 10 MG TABLET OPEN None Yes DONEPEZIL HCL 10MG TABLET None Yes DONEPEZIL HCL 5MG TABLET None Yes DORZOLAMIDE/TIMOLOL 2-0.5% DRP OPEN None Yes DORZOTIMOLOL 2-0.5% EYE DROPS OPEN None Yes DOSTINEX 0.5 MG TABLET Special Authorzation required if beneficiary has not had a paid claim for Dostinex, Norprolac, or Bromocriptine in past year. Yes Page 74 Effective December 2015

75 Coverage Table December DOVOBET 50 MCG-0.5 MG/GRAM GEL None No DOVONEX 0.005% SCALP SOLN None No DOVONEX 50MCG/GM CREAM OPEN None No DOVONEX 50MCG/GM OINTMENT OPEN None No DOXYCIN 100 MG CAPSULE OPEN None No DOXYCIN 100 MG TABLET OPEN None No DOXYCYCLINE 100 MG CAPSULE OPEN None Yes DOXYCYCLINE 100 MG TABLET OPEN None Yes DRISDOL 8288 U/ML DROPS OPEN None No DULCOLAX 10 MG SUPPOSITORY OPEN Reasonable Based Pricing is applied No DULCOLAX 5 MG SUPPOSITORY OPEN None No DULCOLAX 5 MG TABLET EC OPEN Reasonable Based Pricing is applied No DUOTRAV PQ 0.5%-0.004% EYE DRP OPEN None No DUOVENT UDV INH SOLUTION None No DURAGESIC 100MCG/HR PATCH Yes DURAGESIC 12 MCG/HR PATCH Yes DURAGESIC 25 MCG/HR PATCH Yes DURAGESIC 50MCG/HR PATCH Yes DURAGESIC 75MCG/HR PATCH Yes DURAGESIC MAT 100 MCG/HR PATCH Yes DURAGESIC MAT 12 MCG/HR PATCH Yes DURAGESIC MAT 25 MCG/HR PATCH Yes DURAGESIC MAT 50 MCG/HR PATCH Yes DURAGESIC MAT 75 MCG/HR PATCH Yes DURALITH TAB 300MG OPEN Yes DURICEF 500 MG CAPSULE OPEN None No Page 75 Effective December 2015

76 Coverage Table December DUVOID 10 MG TABLET OPEN None No DUVOID 25 MG TABLET OPEN None No DUVOID 50 MG TABLET OPEN None No DYAZIDE TAB OPEN None Yes DYRENIUM 100 OPEN None No DYRENIUM 50 OPEN None No EASY TEST STRIPS STP OPEN a) Limited to 2500 per year without Special b) Beneficiary must have diabetic medication within previous year No history, otherwise Special is required ECOSTATIN 1% TOPICAL CREAM OPEN None No ECOSTATIN 150 MG VAG OVULES OPEN None No EDECRIN 25 MG TABLET OPEN None No EDECRIN TAB 50MG OPEN None No EDURANT 25 MG TABLET None No EES MG/5 ML SUSP OPEN None No EES MG/5 ML SUSP OPEN None No EES MG TABLET OPEN None No EFFEXOR XR 150 MG CAPSULE OPEN Yes EFFEXOR XR 37.5 MG CAP OPEN Yes EFFEXOR XR 75 MG CAPSULE OPEN Yes EFUDEX 5% CREAM OPEN None No ELAVIL 10 MG TABLET OPEN Yes ELAVIL 25 MG TABLET OPEN Yes ELAVIL 50 MG TABLET OPEN Yes ELAVIL 75 MG TAB OPEN No ELAVIL 75 MG TABLET OPEN No Page 76 Effective December 2015

77 Coverage Table December ELAVIL TABLET 50MG OPEN Yes ELDEPRYL - 5MG TAB OPEN None Yes ELIGARD 22.5 MG(28.2) SYRING OPEN None No ELIGARD 30 MG DISP SYRINGE OPEN None No ELIGARD 45 MG DISP SYRINGE OPEN None No ELIGARD 7.5 MG(10.2) SYRINGE OPEN None No ELIQUIS 2.5 MG TABLET None No ELIQUIS 5 MG TABLET None No ELMIRON 100 MG CAPSULE OPEN None No ELOCOM 0.1 % CREAM OPEN None Yes ELOCOM 0.1 % LOTION OPEN None Yes ELOCOM 0.1 % OINTMENT OPEN None Yes ELTROXIN 0.3 MG TABLET OPEN None No ELTROXIN 100 MCG TABLET OPEN None No ELTROXIN 150 MCG TABLET OPEN None No ELTROXIN 200 MCG TABLET OPEN None No ELTROXIN 50 MCG TABLET OPEN None No EMAE 0.05% OPH SOLUTION Special Authorzation required if beneficiary has not had a paid claim for Emadine, Patanol, Cromolyn Sodium or No Levocabastine in past year EMCYT 140 MG CAPSULE OPEN None No EMEND 125 MG CAPSULE None No EMEND 80 MG CAPSULE None No EMEND TRI-PACK None No EMO-CORT 1 % CREAM OPEN None No EMO-CORT 1 % LOTION OPEN None No EMO-CORT 2.5 % CREAM OPEN None No EMO-CORT 2.5 % LOTION OPEN None No EMO-CORT 2.5% LOTION OPEN None No EMPRACET-30 OPEN No Page 77 Effective December 2015

78 Coverage Table December ENABLEX 15 MG ER TABLET OPEN a) Limited to 1 per day without Special b) Special Authorzation required if beneficiary has not had a paid No claim for Ditropan RR or a long acting urinary agent in past year ENABLEX 7.5 MG ER TABLET OPEN a) Limited to 1 per day without Special b) Special Authorzation required if beneficiary has not had a paid No claim for Ditropan RR or a long acting urinary agent in past year ENALAPRIL 16 MG (20 MG) TABLET OPEN None Yes ENALAPRIL 2 MG (2.5 MG) TABLET OPEN None Yes ENALAPRIL 4 MG (5 MG) TABLET OPEN None Yes ENALAPRIL 8 MG (10 MG) TABLET OPEN None Yes ENALAPRIL/HCTZ 4MG(5MG)-12.5MG OPEN None Yes ENALAPRIL/HCTZ 8MG(10 MG)-25MG OPEN None Yes ENBREL 25 MG KIT None No ENBREL 50 MG/ML SYRINGE None No ENTACYL GRANULES OPEN None No ENTOCORT 0.02 MG/ML ENEMA None No ENTOCORT 3 MG SR CAPSULE None No ENTROPHEN MG TAB EC OPEN None No ENTROPHEN 650 MG TAB EC OPEN None Yes EPIPEN 0.3 MG AUTO-INJECTOR OPEN Limit of one per year without Special No EPIPEN JR 0.15 MG AUTOINJECTOR OPEN Limit of one per year without Special No EPIVAL EC 125 MG TABLET OPEN None Yes EPIVAL EC 250 MG TABLET OPEN None Yes EPIVAL EC 500 MG TABLET OPEN None Yes EPREX 10,000 UNIT/ML SYRINGE OPEN Can be dispensed by Hospital or RHA Clinic without prior approval No EPREX 1000 UNIT/0.5 ML SYRINGE OPEN Can be dispensed by Hospital or RHA Clinic without prior approval No EPREX UNITS/ML OPEN Can be dispensed by Hospital or RHA Clinic without prior approval No Page 78 Effective December 2015

79 Coverage Table December EPREX 10000U/ML VIAL OPEN Can be dispensed by Hospital or RHA Clinic without prior approval No EPREX 20,000 UNIT/0.5 ML SYRG None No EPREX 2000 UNIT/0.5 ML SYRINGE OPEN Can be dispensed by Hospital or RHA Clinic without prior approval No EPREX U/ML VIAL None No EPREX 30,000 UNIT/0.75 ML SYRG None No EPREX 3000 UNIT/0.3 ML SYRINGE OPEN Can be dispensed by Hospital or RHA Clinic without prior approval No EPREX 40,000 UNIT/ML SYRINGE None No EPREX 4000 UNIT/0.4 ML SYRINGE OPEN Can be dispensed by Hospital or RHA Clinic without prior approval No EPREX 5000 UNIT/0.5 ML SYRINGE OPEN Can be dispensed by Hospital or RHA Clinic without prior approval No EPREX 6000 UNIT/0.6 ML SYRINGE OPEN Can be dispensed by Hospital or RHA Clinic without prior approval No EPREX 8000 UNIT/0.8 ML SYRINGE OPEN Can be dispensed by Hospital or RHA Clinic without prior approval No EPURIS 10 MG CAPSULE OPEN None No EPURIS 20 MG CAPSULE OPEN None No EPURIS 30 MG CAPSULE OPEN None No EPURIS 40 MG CAPSULE OPEN None No ERGAMISOL TAB 50MG OPEN None No ERGODRYL CAPSULE OPEN None No ERIVEDGE 150MG CAPSULE No No ERYBID 500 MG TABLET OPEN None No ERYTHRO-BASE 250 MG TAB OPEN None No ERYTHRO-ES 600 MG TABLET OPEN None No ERYTHROMYCINE 250 MG TABLET OPEN None No ERYTHROMYCINE 5 MG/GM ONGUENT OPEN None No ERYTHRO-S 250 MG TABLET OPEN None Yes ERYTHRO-S 500 MG TABLET OPEN None Yes ESBRIET 267 MG CAPSULE None No ESME MCG-20 MCG TABLET OPEN Beneficiary gender must be female - under the age of 51 Yes Page 79 Effective December 2015

80 Coverage Table December ESME MCG-20 MCG TABLET OPEN Beneficiary gender must be female - under the age of 51 Yes ESTALIS 140/50 MCG/DAY PATCH OPEN None No ESTALIS 250/50 MCG/DAY PATCH OPEN None No ESTALIS SEQUI PATCH OPEN None No ESTALIS SEQUI PATCH OPEN None No ESTRACE 0.5 MG TABLET OPEN None No ESTRACE 1 MG TABLET OPEN None No ESTRACE 2 MG TABLET OPEN None No ESTRACOMB PATCH OPEN None No ESTRADERM MG/24 HR PATCH OPEN None No ESTRADERM 0.05 MG PATCH OPEN None No ESTRADERM 0.1 MG/24 HR PATCH OPEN None No ESTRADIOL DERM 100 MCG/24 HR OPEN None Yes ESTRADIOL DERM 50 MCG/24 HR OPEN None Yes ESTRADIOL DERM 75 MCG/24 HR OPEN None Yes ESTRADOT 100 MCG/24 HR PATCH OPEN None Yes ESTRADOT 25 MCG/24 HR PATCH OPEN None No ESTRADOT 37.5MCG/24HR PATCH OPEN None No ESTRADOT 50 MCG/24 HR PATCH OPEN None Yes ESTRADOT 75MCG/24HR PATCH OPEN None Yes ESTRING 2 MG VAGINAL RING OPEN None No ESTROGEL 0.06 % GEL OPEN None No ETIBI 100 MG TABLET OPEN None No ETIBI 400 MG TABLET OPEN None No ETRAFON 2-10 TABLET OPEN No ETRAFON-A TABLET OPEN No ETRAFON-D TABLET OPEN No ETRAFON-F TABLET OPEN No EUFLEX 250 MG TABLET OPEN None Yes EUGLUCON 2.5 MG TABLET OPEN None No EUGLUCON 5 MG TABLET OPEN None No EUMOVATE 0.05% CREAM OPEN None No Page 80 Effective December 2015

81 Coverage Table December EUMOVATE 0.05% OINTMENT OPEN None No EURAX 10% CREAM OPEN None No EURO D 400U CAPSULE OPEN None No EURO FOLIC 5 MG TABLET OPEN None No EURO-FER 300 MG CAPSULE OPEN Beneficiary must have eligibility under the CF Plan No EURO-FERROUS SULF 60 MG TAB OPEN Beneficiary must have eligibility under the CF Plan No EVISTA 60 MG TABLET None Yes EXELON 1.5 MG CAPSULE None Yes EXELON 2 MG/ML SOLUTION None No EXELON 3 MG CAPSULE None Yes EXELON 4.5 MG CAPSULE None Yes EXELON 6 MG CAPSULE None Yes EXJADE 125 MG TABLET None No EXJADE 250 MG TABLET None No EXJADE 500 MG TABLET None No EXTAVIA 0.3 MG VIAL None No EYLEA 2 MG/0.05 ML VIAL None No a) Limited to 2500 per year without Special b) Beneficiary must have EZ HEALTH GLUCOSE TEST STRIPS OPEN diabetic medication within previous year No history, otherwise Special is required EZ HEALTH GLUCOSE TEST STRIPS OPEN a) Limited to 2500 per year without Special b) Beneficiary must have diabetic medication within previous year No history, otherwise Special is required EZ HEALTH LANCETS (100) OPEN None No EZETIMIBE 10 MG TABLET None Yes EZETIMIBE 10 MG TABLET None Yes EZETROL 10 MG TABLET None Yes FAMVIR 125 MG TABLET OPEN None Yes FAMVIR 250 MG TABLET OPEN None Yes FAMVIR 500 MG TABLET OPEN None Yes FELDENE CAP 10MG OPEN None Yes Page 81 Effective December 2015

82 Coverage Table December FELDENE CAP 20MG OPEN None Yes FELDENE SUP 20MG OPEN None No FEMARA 2.5 MG TABLET None Yes FENOFIBRATE-S 100 MG TABLET OPEN None Yes FENOFIBRATE-S 160 MG TABLET OPEN None Yes FENTANYL MATRX 12 MCG/HR PATCH Yes FENTANYL MATRX 25 MCG/HR PATCH Yes FENTANYL MATRX 50 MCG/HR PATCH Yes FENTANYL MATRX 75 MCG/HR PATCH Yes FENTANYL MATX 100 MCG/HR PATCH Yes FER-IN-SOL 15 MG/ML DROPS OPEN None No FER-IN-SOL 150 MG/5 ML SYRUP OPEN None No FERMENTOL 100 MG/30 ML LIQUID OPEN None No FERO-GRAD FILMTAB 325 MG TAB OPEN None No FERROUS FUMARATE 300 MG TAB OPEN None No FERROUS GLUCONATE 300 MG TAB OPEN None No FERROUS GLUCONATE 300MG TAB OPEN None No FERROUS GLUCONATE TAB 300MG OPEN None No FERROUS SULFATE 300 MG TAB OPEN None No FERROUS SULFATE TAB 300MG OPEN None No FERROUS SULPHATE 300 MG TAB OPEN None No FEXICAM 20MG SUPPOSITORY OPEN None No FIBYRAX TAB 469MG OPEN None No FINACEA 15 % GEL OPEN None No FINGERSTIX 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 FIORINAL C 1/2 CAPSULE OPEN Yes Page 82 Effective December 2015

83 Coverage Table December FIORINAL C 1/4 CAPSULE OPEN Yes FIORINAL CAPSULE OPEN Yes FIORINAL TABLET OPEN No FLAGYL 10 % CREAM OPEN None No FLAGYL MG OPEN None No FLAGYL 500 MG CAPSULE OPEN None Yes FLAGYSTATIN VAGINAL CREAM OPEN None No FLAGYSTATIN VAGINAL OVULE OPEN None No FLAGYSTATIN VAGINAL SUPP OPEN None No FLAMAZINE 1 % CREAM OPEN None No FLAREX 0.1 % EYE DROPS OPEN None No FLECAINIDE 100 MG TABLET OPEN None Yes FLECAINIDE 50 MG TABLET OPEN None Yes FLEET ENEMA OPEN None No FLEET ENEMA PEDIATRIC OPEN None No FLEET MINERAL OIL ENEMA OPEN None No FLEXERIL -(10MG) OPEN None Yes FLINTSTONES COMPLETE TABLETS OPEN Beneficiary must have eligibility under the CF Plan No FLINTSTONES MULTI VITS TAB OPEN Beneficiary must have eligibility under the CF Plan No FLINTSTONES MULTIVIT TB CHW OPEN Beneficiary must have eligibility under the CF Plan No FLOCTAFENINE 200 MG TABLET OPEN None Yes FLOCTAFENINE 400 MG TABLET OPEN None Yes FLOLAN 0.5 MG VIAL None No FLOLAN 1.5 MG VIAL None No FLOMAX OPEN Limit of 2 per day without Special Yes FLOMAX CR 0.4MG TABLET OPEN Yes FLONASE 50 MCG NASAL SPRAY OPEN None No FLORINEF 0.1 MG TABLET OPEN None No Page 83 Effective December 2015

84 Coverage Table December FLOVENT DISKUS 100MCG/BLS OPEN Can only be claimed if the Beneficiary does not have an active Special No for Wet Nebulization FLOVENT DISKUS 250MCG/BLS OPEN Can only be claimed if the Beneficiary does not have an active Special No for Wet Nebulization FLOVENT DISKUS 500MCG/BLS OPEN Can only be claimed if the Beneficiary does not have an active Special No for Wet Nebulization FLOVENT HFA 125 MCG INHALER OPEN Can only be claimed if the Beneficiary does not have an active Special No for Wet Nebulization FLOVENT HFA 250 MCG INHALER OPEN Can only be claimed if the Beneficiary does not have an active Special No for Wet Nebulization FLOVENT HFA 50 MCG INHALER OPEN Can only be claimed if the Beneficiary does not have an active Special No for Wet Nebulization FLOVENT INHALERS - AEM INH-ORL OPEN None No FLOVENT INHALERS - AEM INH-ORL OPEN None No FLOXIN TABLETS 300MG OPEN None Yes FLOXIN TABLETS 400MG OPEN None Yes FLUAD 45 MCG/0.5 ML SYRINGE OPEN None No FLUANXOL 0.5 MG TABLET OPEN No FLUANXOL 3 MG TABLET OPEN No FLUANXOL DEPOT 100 MG/ML VL OPEN No FLUANXOL DEPOT 20 MG/ML AMPUL OPEN No FLUDARA 10 MG TABLET None No FLULAVAL TETRA 15MCG/0.5ML SUS OPEN None No FLUMIST QUAD NASAL SPRAY OPEN None No FLUNARIZINE 5 MG CAPSULE OPEN None Yes FLUODERM 0.01% CREAM OPEN None No FLUODERM 0.025% CREAM OPEN None No Page 84 Effective December 2015

85 Coverage Table December FLUODERM 0.025% OINTMENT OPEN None No FLUOROURACIL 50 MG/ML VIAL OPEN None No FLUOTIC 20 MG TABLET OPEN None No FLUOXETINE 10 MG CAPSULE OPEN Yes FLUOXETINE 10 MG CAPSULE OPEN Yes FLUOXETINE 20 MG CAPSULE OPEN Yes FLUOXETINE 20 MG CAPSULE OPEN Yes FLUOXETINE 20 MG/5 ML SOLUTION OPEN Yes FLUPHENAZINE 1 MG TABLET OPEN No FLUPHENAZINE 5 MG TABLET OPEN No FLURAZEPAM 15 MG CAPSULE OPEN Yes FLURAZEPAM 15 MG CAPSULE OPEN No FLURAZEPAM 30 MG CAPSULE OPEN Yes FLUTICASONE 50 MCG NASAL SPRAY OPEN Can only be claimed if the Beneficiary does not have an active Special No for Wet Nebulization FLUZONE QUAD 60 MCG/0.5ML VIAL OPEN None No FML FORTE 0.25% EYE DROPS OPEN None No FML LIQUIFILM 0.1% EYE DROP OPEN None No FOLIC ACID 5 MG TABLET OPEN None No FOLIC ACID TABLETS 5MG OPEN None No FORA TD-THIN STERILE LANCETS OPEN None No FORA TEST N GO 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 85 Effective December 2015

86 Coverage Table December FORADIL 12MCG INH CAPSULE None No FORMULEX 10 MG CAPSULE OPEN None No FORTAZ 1 GM VIAL OPEN None No FORTAZ 2GM VIAL OPEN None No FORTAZ 500MG VIAL OPEN None No FOSAMAX None Yes FOSAMAX 40 MG TABLET None Yes FOSAMAX 70 MG TABLET None Yes FOSAVANCE 70 MG-5600 UNIT TAB None Yes FOSINOPRIL 10 MG TABLET OPEN None Yes FOSINOPRIL 20 MG TABLET OPEN None Yes FRAGMIN 10,000 UNIT/0.4 ML SYR None No FRAGMIN 10,000 UNIT/ML AMPUL None No FRAGMIN 12,500 UNIT/0.5 ML SYR None No FRAGMIN 15,000 UNIT/0.6 ML SYR None No FRAGMIN 18,000 UNIT/0.72ML SYR None No FRAGMIN 2,500 UNIT/0.2 ML SYR None No FRAGMIN 25,000 UNIT/ML VIAL None No FRAGMIN 25000U/ML SYRINGE None No FRAGMIN 3500 UNIT/0.28 ML SYR None No FRAGMIN 7,500 UNIT/0.3 ML SYR None No FREESTYLE LANCETS OPEN None No FREESTYLE LITE TEST STRIPS OPEN a) Limited to 2500 per year without Special b) Beneficiary must have diabetic medication within previous year No history, otherwise Special is required FREESTYLE LITE TEST 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 FREESTYLE PRECISION BLOOD GLUC 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 86 Effective December 2015

87 Coverage Table December FREESTYLE TEST STRIPS OPEN a) Limited to 2500 per year without Special b) Beneficiary must have diabetic medication within previous year No history, otherwise Special is required FRISIUM 10 MG TABLET OPEN Yes FROBEN 100 MG TABLET OPEN None No FROBEN 50 MG TABLET OPEN None No FROBEN SR 200 MG CAPSULE OPEN None No FUCI 2% CREAM OPEN None No FUCI 2% OINTMENT OPEN None No FUCI 250 MG TABLET OPEN None No FUCI H CREAM OPEN None No FULVICIN U/F 250MG TABLET OPEN None No FULVICIN U/F 500MG TABLET OPEN None No FUNGIZONE 50 MG VIAL OPEN Can be dispensed by Hospital or RHA Clinic without prior approval No FUROSEMIDE 10 MG/ML AMPOULE OPEN None No FUROSEMIDE 20MG TABLET OPEN None Yes FUROSEMIDE 40 MG TABLET OPEN None Yes FUROSEMIDE 80 MG TABLET OPEN None Yes FXT MG CAPSULE OPEN No FYCOMPA 10 MG TABLET No No FYCOMPA 12 MG TABLET No No FYCOMPA 2 MG TABLET No No FYCOMPA 4 MG TABLET No No FYCOMPA 6 MG TABLET No No FYCOMPA 8 MG TABLET No No GABAPENTIN 100 MG CAPSULE None Yes GABAPENTIN 100 MG CAPSULE None Yes GABAPENTIN 100 MG CAPSULE None Yes GABAPENTIN 300 MG CAPSULE None Yes GABAPENTIN 300 MG CAPSULE None Yes GABAPENTIN 300 MG CAPSULE None Yes GABAPENTIN 400 MG CAPSULE None Yes Page 87 Effective December 2015

88 Coverage Table December GABAPENTIN 400 MG CAPSULE None Yes GABAPENTIN 400 MG CAPSULE None Yes GABAPENTIN 600 MG TABLET None Yes GABAPENTIN 600 MG TABLET No Yes GABAPENTIN 600 MG TABLET None Yes GABAPENTIN 800 MG TABLET None Yes GABAPENTIN 800 MG TABLET No Yes GABAPENTIN 800 MG TABLET None Yes GALEXOS 150 MG CAPSULE No GARAMYCIN 0.1% CREAM OPEN None No GARAMYCIN 0.1% OINTMENT OPEN None No GARAMYCIN 0.3 % OPH DROPS OPEN None No GARAMYCIN 0.3 % OPH OINTMENT OPEN None No GARAMYCIN 0.3 % OTIC DROPS OPEN None No GARAMYCIN 40MG/ML VIAL OPEN None No GARAMYCIN PED 10MG/ML VIAL OPEN None No GARASONE OPHTH/OTIC DROPS OPEN None No GARASONE OPHTHALMIC OINT OPEN None No GD-AMLODIPINE 10 MG TABLET OPEN None Yes GD-AMLODIPINE 5 MG TABLET OPEN Yes GD-ATORVASTATIN 10 MG TABLET OPEN None Yes GD-ATORVASTATIN 20 MG TABLET OPEN None Yes GD-ATORVASTATIN 40 MG TABLET OPEN None Yes GD-ATORVASTATIN 80 MG TABLET OPEN None Yes GD-AZITHROMYCIN 100MG/5ML SUSP OPEN No Yes GD-AZITHROMYCIN 200MG/5ML SUSP OPEN No Yes GD-AZITHROMYCIN 250 MG TABLET OPEN Limit of 6 per day without Special Yes GD-CELECOXIB 100 MG CAPSULE OPEN Limit of 2 per day without Special Yes GD-CELECOXIB 200 MG CAPSULE OPEN Limit of 2 per day without Special Yes GD-DICLOFEN/MISOPR 50MG-200MCG OPEN None Yes GD-DICLOFEN/MISOPR 75MG-200MCG OPEN None Yes GD-GABAPENTIN 100 MG CAPSULE None Yes Page 88 Effective December 2015

89 Coverage Table December GD-GABAPENTIN 300 MG CAPSULE None Yes GD-GABAPENTIN 400 MG CAPSULE None Yes GD-GABAPENTIN 600 MG TABLET None Yes GD-GABAPENTIN 800 MG TABLET None Yes GD-LATANOPROST % DROPS OPEN None Yes GD-LATANOPROST/TIMOLOL OPH OPEN None Yes GD-MIRTAZAPINE OD 15 MG TABLET OPEN Yes GD-MIRTAZAPINE OD 30 MG TABLET OPEN Yes GD-MIRTAZAPINE OD 45 MG TABLET OPEN Yes GD-PREGABALIN 150 MG CAPSULE None Yes GD-PREGABALIN 225 MG CAPSULE None Yes GD-PREGABALIN 25 MG CAPSULE None Yes GD-PREGABALIN 300 MG CAPSULE None Yes GD-PREGABALIN 50 MG CAPSULE None Yes GD-PREGABALIN 75 MG CAPSULE None Yes GD-SERTRALINE 100 MG CAPSULE OPEN Yes GD-SERTRALINE 25 MG CAPSULE OPEN Yes GD-SERTRALINE 50 MG CAPSULE OPEN Yes GD-TOPIRAMATE 100 MG TABLET OPEN None Yes GD-TOPIRAMATE 200 MG TABLET OPEN None Yes GD-TOPIRAMATE 25 MG TABLET OPEN None Yes GD-TRANEXAMIC ACID 500 MG TAB OPEN None Yes GD-VENLAFAXINE XR 150 MG CAP OPEN Yes GD-VENLAFAXINE XR 37.5 MG CAP OPEN Yes GD-VENLAFAXINE XR 75 MG CAP OPEN Yes GELUSIL EXTRA STR TABLET CHEW OPEN None No GELUSIL SUSPENSION OPEN None No GELUSIL TABLET OPEN None No Page 89 Effective December 2015

90 Coverage Table December GEN-CLOZAPINE 100 MG TABLET No GEN-CLOZAPINE 200 MG TABLET No GEN-CLOZAPINE 25 MG TABLET No GEN-CLOZAPINE 50 MG TABLET No GEN-DILTIAZEM SR 60 MG CAP OPEN None No GENTAINE VIOLET 1% SOLUTION OPEN None No GENTAMICIN 0.3 % EYE OINTMENT OPEN None No GENTAMICIN 40 MG/ML VIAL OPEN None No GENTEAL 0.3% GEL OPEN None No GENTRASUL OPH OINTMENT 3MG/GM OPEN None No GILENYA 0.5 MG CAPSULE None No GIOTRIF 20MG TABLET None No GIOTRIF 30MG TABLET None No GIOTRIF 40MG TABLET None No GLEEVEC 100 MG CAPSULE None No GLEEVEC 100 MG TABLET None Yes GLEEVEC 400 MG TABLET None Yes GLICLAZIDE 80 MG TABLET OPEN None Yes GLO EASE INJ PEN NDLS 29G 12MM OPEN None No GLOB EASE INJ PEN NDLS 31G 5MM OPEN None No GLOB EASE INJ PEN NDLS 31G 8MM OPEN None No GLOB EASE INJ PEN NDLS 32G 4MM OPEN None No GLUCAGEN HYPOKIT 1 MG VIAL OPEN None No GLUCAGON 1 MG VIAL OPEN None No GLUCAGON AMPOULE 666 1MG OPEN None No GLUCOBAY 100 MG TABLET None No GLUCOBAY 50 MG TABLET None No a) Limited to 2500 per year without Special b) Beneficiary must have GLUCOMETER ENCORE TEST STRIP OPEN diabetic medication within previous year history, otherwise Special is required. No Page 90 Effective December 2015

91 Coverage Table December GLUCONORM 0.5 MG TABLET Special Authorzation required if beneficiary has not had a paid claim for Gluconorm, Yes Glimepiride, or Glyburide in past year GLUCONORM 1 MG TABLET Special Authorzation required if beneficiary has not had a paid claim for Gluconorm, Yes Glimepiride, or Glyburide in past year GLUCONORM 2 MG TABLET Special Authorzation required if beneficiary has not had a paid claim for Gluconorm, Yes Glimepiride, or Glyburide in past year GLUCOPHAGE 500 MG TABLET OPEN None Yes GLUCOPHAGE 850 MG TABLET OPEN None Yes GLUCOSCAN GM 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 GLUCOSTIX TEST STRIPS OPEN a) Limited to 2500 per year without Special b) Beneficiary must have diabetic medication within previous year No history, otherwise Special is required GLYBURIDE 2.5 MG TABLET OPEN None Yes GLYBURIDE 5 MG TABLET OPEN None Yes GLYCERIN SUPP (ADULT ) 260 OPEN None No GLYCERIN SUPP FOR INFANTS & CH OPEN None No GLYCON 500 MG TABLET OPEN None Yes GM 23G LANCET OPEN None No GM KIDS 25G LANCET OPEN None No GOLYTELY SOLUTION OPEN Limit of one fill per year without Special. No GPI-LACTULOSE 667 MG/ML SOL OPEN None No GRAMCAL OPEN None No GRANISETRON 1 MG TABLET OPEN Limit of 2 per cycle - first fill only. Special required for higher quantities Yes and/or subsequent fills GRAVERGOL CAPSULE OPEN None No GRAVOL 100 MG SUPPOSITORY OPEN None No Page 91 Effective December 2015

92 Coverage Table December GRAVOL 50 MG SUPPOSITORY OPEN None No GRAVOL 50 MG TABLET OPEN Reasonable Based Pricing is applied No GRAVOL IM 50 MG/ML VIAL OPEN None No GRAVOL KIDS 15 MG/5 ML LIQUID OPEN Beneficiary must be less than 13 years old - RBP applied No GRAVOL KIDS 25 MG SUPPOSITORY OPEN None No GYNECURE VAGINAL OINTMENT 6.5% OPEN None No HABITROL 14 MG/24 HR PATCH Contraindication to Zyban and Champix No HABITROL 21 MG/24 HR PATCH Contraindication to Zyban and Champix No HABITROL 7 MG/24 HR PATCH Contraindication to Zyban and Champix No HALCION OPEN Yes HALOG 0.1% CREAM OPEN None No HALOG 0.1% OINTMENT OPEN None No HALOG 0.1% SOLUTION OPEN None No HALOPERIDOL 1.0MG TABLET OPEN No HALOPERIDOL 5.0MG TABLET OPEN No HALOPERIDOL 5 MG/ML AMPOULE OPEN No HALOPERIDOL LA 100 MG/ML VL OPEN No HALOPERIDOL LA 50 MG/ML VIAL OPEN No HARVONI MG TABLET No HEMASTIX OPEN None No HEPALEAN 10000U/ML VIAL OPEN None No HEPALEAN 1000U/ML VIAL OPEN None No HEPARIN 10000U/ML INJECTION OPEN None No HEPARIN LEO UNIT/ML VIAL OPEN None No HEPSERA 10 MG TABLET None Yes HERPLEX-D 0.1% LIQUID OPEN None No HIP-REX 1GM TABLET OPEN None No HIVID 0.75 MG TABLET OPEN No Page 92 Effective December 2015

93 Coverage Table December HOLKIRA PAK MG No HP-PAC KIT OPEN Limit of one pack every 90 days without Special No HUMALOG 1.5ML(SPECIAL ) None No HUMALOG 100 UNIT/ML CARTRIDGE None No HUMALOG 100 UNIT/ML PEN None No HUMALOG 100 UNIT/ML VIAL None No HUMALOG 10ML(SPECIAL ) None No HUMALOG 3ML (SPECIAL ) None No HUMALOG KWIKPEN None No HUMALOG KWIKPEN 100 UNIT/ML None No HUMATROPE 12 MG CARTRIDGE OPEN Open benefit only if Beneficiary is eligible under the Growth Hormone Plan No HUMATROPE 24 MG CARTRIDGE OPEN Open benefit only if Beneficiary is eligible under the Growth Hormone Plan No HUMATROPE 5 MG VIAL OPEN Open benefit only if Beneficiary is eligible under the Growth Hormone Plan No HUMATROPE 6 MG CARTRIDGE OPEN Open benefit only if Beneficiary is eligible under the Growth Hormone Plan No HUMIRA 40 MG/0.8 ML KIT None No HUMULIN 20/80 100U/ML CARTG OPEN None No HUMULIN 30/ U/ML CART OPEN None No HUMULIN 30/ U/ML VIAL OPEN None No HUMULIN L LENTE 100U/ML VL OPEN None No HUMULIN N 100 UNIT/ML CARTRIDG OPEN None No HUMULIN N 100 UNIT/ML VIAL OPEN None No HUMULIN N KWIKPEN 100 UNIT/ML OPEN None No HUMULIN R 100 UNIT/ML CARTRDG OPEN None No HUMULIN R 100 UNIT/ML VIAL OPEN None No HUMULIN R KWIKPEN 100 UNIT/ML OPEN None No HUMULIN U 100U/ML VIAL OPEN None No HYCORT 100 MG/60 ML ENEMA OPEN None No HYDERGINE 1 MG TABLET OPEN None No HYDERM 0.5% CREAM OPEN None No HYDERM 1 % CREAM OPEN None No HYDRALAZINE 10 MG TABLET OPEN None Yes Page 93 Effective December 2015

94 Coverage Table December HYDRALAZINE 25 MG TABLET OPEN None Yes HYDRALAZINE 50 MG TABLET OPEN None Yes HYDREA 500 MG CAPSULE OPEN None Yes HYDROCHLOROTHIAZIDE 12.5MG TAB OPEN None No HYDROCHLOROTHIAZIDE 25 MG TAB OPEN None Yes HYDROCHLOROTHIAZIDE 50 MG TAB OPEN None Yes HYDROCHLOROTHIAZIDE 50 MG TAB OPEN None Yes HYDROCHLOROTHIAZIDE TABLETS 25 OPEN None No HYDROCHLOROTHIAZIDE TABLETS 50 OPEN None No HYDROCORTISONE 0.5% CREAM OPEN None No HYDROCORTISONE 1% CREAM OPEN None No HYDROCORTISONE OINTMENT 0.5% OPEN None No HYDRODIURIL TAB 25MG OPEN None Yes HYDROMORPH CONTIN 12 MG CAP No HYDROMORPH CONTIN 18 MG CAP No HYDROMORPH CONTIN 24 MG CAP No HYDROMORPH CONTIN 3 MG CAP No HYDROMORPH CONTIN 30 MG CAP No HYDROMORPH CONTIN 4.5 MG CAP No HYDROMORPH CONTIN 6 MG CAP No HYDROMORPH CONTIN 9 MG CAPSULE No HYDROMORPHONE 10 MG/ML VIAL OPEN No HYDROMORPHONE HCL 2 MG/ML OPEN No HYDROVAL 0.2 % CREAM OPEN None No Page 94 Effective December 2015

95 Coverage Table December HYDROVAL 0.2% OINTMENT OPEN None No HYDROXYUREA 500 MG OPEN None Yes HYPER-SAL 7% None No HYTAKEROL OPEN None No HYTRIN 1 MG TABLET OPEN None Yes HYTRIN 1 MG-2 MG-5 MG START PK OPEN None No HYTRIN 10 MG TABLET OPEN None Yes HYTRIN 2 MG TABLET OPEN None Yes HYTRIN 5 MG TABLET OPEN None Yes HYZAAR MG TABLET OPEN Yes HYZAAR MG TABLET OPEN Yes HYZAAR DS MG TABLET OPEN Yes IBAVYR 400 MG TABLET None No IBAVYR 600 MG TABLET None No IBUPROFEN TAB 200MG OPEN None No IDARAC OPEN None Yes IDARAC OPEN None Yes ILETIN II NPH 100U/ML VIAL OPEN None No IMBRUVICA 140 MG CAPSULE None No IMDUR 60 MG TABLET SA OPEN None Yes IMIPRAMINE 10 MG TABLET OPEN Yes IMIPRAMINE 10MG TABLET OPEN No IMIPRAMINE 25 MG TABLET OPEN Yes IMIPRAMINE 50 MG TABLET OPEN Yes IMIPRAMINE 75 MG TABLET OPEN No IMIPRAMINE HYDROCHLORIDE TABLE OPEN No IMIPRAMINE HYDROCHLORIDE TABLE OPEN No Page 95 Effective December 2015

96 Coverage Table December IMITREX 20 MG NASAL SPRAY None No IMITREX 5 MG NASAL SPRAY None No IMITREX 6 MG/0.5 ML VIAL None Yes IMITREX DF - TAB 25MG None Yes IMITREX DF 100 MG TABLET None Yes IMITREX DF 50 MG TABLET None Yes IMODIUM 2 MG CAPLET None Yes IMODIUM ADV MG CHEW TAB None No IMODIUM COMPLETE MG TAB None No IMODIUM QUICK DISSOLVE 2MG TAB None No IMOVANE 5 MG TABLET OPEN Yes IMOVANE 7.5 MG TABLET OPEN Yes IMOVANE 7.5MG TABLET OPEN No IMURAN 50 MG TABLET OPEN None Yes INCIVEK 375 MG TABLET No No INDERAL-10 TAB 10MG OPEN None Yes INDERAL-20 TAB 20MG OPEN None Yes INDERAL-40 TAB 40MG OPEN None Yes INDERAL-LA 120 MG CAPSULE OPEN None No INDERAL-LA 160 MG CAPSULE OPEN None No INDERAL-LA 60 MG CAPSULE OPEN None No INDERAL-LA 80 MG CAPSULE OPEN None No INDOCID SUP 100MG OPEN None No INDOCID SUP 50MG OPEN None No INFANTS ACETAMIN 80 MG/ML SUSP OPEN Beneficiary must be less than 3 years old - RBP applied No INFANTS' ACETAMINOPHEN DROPS 8 OPEN Beneficiary must be less than 3 years old - RBP applied No INFANT'S TYLENOL SUSPENSION DR OPEN Beneficiary must be less than 3 years old - RBP applied No INFLAMASE FORTE 1% DROPS OPEN None No INFLAMASE MILD OPEN None No INFUFER 50 MG/ML VIAL None No INHIBACE 2.5 MG TABLET OPEN None Yes Page 96 Effective December 2015

97 Coverage Table December INHIBACE 5 MG TABLET OPEN None Yes INHIBACE PLUS TABLET OPEN None Yes INHIBACE TAB 1MG OPEN None Yes INLYTA 1 MG TABLET None No INLYTA 5 MG TABLET None No INNOHEP 10,000 UNIT/.5 ML SYR None No INNOHEP 10,000 UNIT/ML VIAL None No INNOHEP 12,000 UNIT/0.6 ML SYR None No INNOHEP 14,000 UNIT/0.7 ML SYR None No INNOHEP 16,000 UNIT/0.8 ML SYR None No INNOHEP 18,000 UNIT/0.9 ML SYR None No INNOHEP 2,500 UNIT/.25 ML SYR None No INNOHEP UNIT/ML VIAL None No INNOHEP 3,500 UNIT/0.35 ML SYR None No INNOHEP 4,500 UNIT/0.45 ML SYR None No INNOHEP 8,000 UNIT/0.4 ML SYR None No INSPRA 25 MG TABLET None No INSPRA 50 MG TABLET None No INSULIN PEN NEEDLE 4MM 32G OPEN None No INSULIN PEN NEEDLE 6MM 31G OPEN None No INSULIN PEN NEEDLE 6MM 32G OPEN None No INSULIN PEN NEEDLE 8MM 31G OPEN None No INSULIN PEN NEEDLE 8MM 32G OPEN None No INSULIN SYRINGES 0.3CC 31G OPEN None No INSULIN SYRINGES 0.5CC 31G OPEN None No INSULIN SYRINGES 1CC 31G OPEN None No INTAL 1 MG INHALER OPEN None No INTAL NEBULIZER 1% None Yes INTAL SPINCAPS 20MG OPEN None No INTELENCE 100 MG TABLET OPEN No INTELENCE 200 MG TABLET OPEN No INTRON A 18 MU/1.2 ML PEN None No INTRON A 30 MU/1.2 ML PEN None No INTRON A 60 MU/1.2 ML PEN None No Page 97 Effective December 2015

98 Coverage Table December INVEGA SUSTENNA 100 MG/ML No INVEGA SUSTENNA 150 MG/1.5 ML No INVEGA SUSTENNA 50 MG/0.5 ML No INVEGA SUSTENNA 75 MG/0.75 ML No INVIRASE 200 MG CAPSULE OPEN No INVIRASE 500 MG TABLET OPEN No INVOKANA 100 MG TABLET None No INVOKANA 300 MG TABLET None No IODAMINOL 10MG TABLET OPEN None No IOPIE 0.5% SOLUTION OPEN None No IOPIE 1% EYE DROPS OPEN None No IRBESARTAN 150 MG TABLET OPEN Yes IRBESARTAN 150 MG TABLET OPEN Yes IRBESARTAN 300 MG TABLET OPEN Yes IRBESARTAN 300 MG TABLET OPEN Yes IRBESARTAN 75 MG TABLET OPEN Yes IRBESARTAN 75 MG TABLET OPEN Yes IRBESARTAN HCT MG TAB OPEN Yes IRBESARTAN HCT MG TAB OPEN Yes IRBESARTAN HCT MG TAB OPEN Yes IRBESARTAN HCT MG TAB OPEN Yes Page 98 Effective December 2015

99 Coverage Table December IRBESARTAN HCT MG TAB OPEN IRBESARTAN HCT MG TAB OPEN IRBESARTAN HCTZ MG TAB OPEN IRBESARTAN HCTZ MG TAB OPEN IRBESARTAN HCTZ 300 MG-12.5 MG OPEN IRBESARTAN HCTZ MG TAB OPEN IRBESARTAN HCTZ MG TAB OPEN IRBESARTAN/HCT MG TAB OPEN IRBESARTAN/HCT 300 MG-25MG TAB OPEN IRBESARTAN/HCT MG TAB OPEN IRBESARTAN/HCTZ MG TAB OPEN IRBESARTAN/HCTZ MG TAB OPEN IRBESARTAN/HCTZ MG TAB OPEN IRBESARTAN/HCTZ MG TAB OPEN IRBESARTAN-HCTZ MG TAB OPEN IRBESARTAN-HCTZ MG TAB OPEN IRBESARTAN-HCTZ MG TB OPEN IRBESARTAN-HCTZ MG TAB OPEN Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Page 99 Effective December 2015

100 Coverage Table December IRBESARTAN-HCTZ MG TAB OPEN Yes IRBESARTAN-HCTZ MG TAB OPEN Yes IRBESARTAN-HCTZ MG TAB OPEN Yes IRBESARTAN-HCTZ MG TAB OPEN Yes IRBESARTN/HCTZ MG TAB OPEN Yes IRBESARTN/HCTZ MG TAB OPEN Yes IRBESARTN/HCTZ MG TAB OPEN Yes IRBESARTN/HCTZ MG TAB OPEN Yes IRBESARTN/HCTZ MG TAB OPEN Yes IRBESARTN-HCTZ MG TAB OPEN Yes ISDN 10 MG TABLET OPEN None Yes ISDN 30 MG TABLET OPEN None Yes ISDN 5 MG TABLET SUBLINGUAL OPEN None No ISENTRESS 400 MG TABLET OPEN No ISOPTIN SR 120 MG TABLET OPEN None Yes ISOPTIN SR 180 MG TABLET OPEN None Yes ISOPTIN SR 240 MG TABLET OPEN None Yes ISOPTIN TAB 120MG OPEN None Yes ISOPTIN TAB 80MG OPEN None Yes ISOPTO ATROPINE 1 % EYE DROPS OPEN None No ISOPTO CARBACHOL 1.5% DROPS OPEN None No ISOPTO CARBACHOL 3% DROPS OPEN None No ISOPTO CARPINE 1 % DROPS OPEN None No ISOPTO CARPINE 2 % DROPS OPEN None No ISOPTO CARPINE 4% DROPS OPEN None No ISOPTO HOMATROPINE 2 % DROPS OPEN None No Page 100 Effective December 2015

101 Coverage Table December ISOPTO HOMATROPINE 5 % DROPS OPEN None No ISOPTO TEARS 0.5 % DROPS OPEN None No ISOPTO TEARS 1 % DROPS OPEN None No ISORDIL 10 TITRADOSE TABLETS 1 OPEN None Yes ISORDIL 30 TITRADOSE TABLETS 3 OPEN None Yes ISOTAMINE 300 MG TABLET OPEN None No ISOTAMINE 50 MG/5 ML SYRUP OPEN None No ISOTAMINE POWDER OPEN None No ITEST BLOOD GLUCOSE 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 JAKAVI 10 MG TABLET None No JAKAVI 15 MG TABLET None No JAKAVI 20 MG TABLET None No JAKAVI 5 MG TABLET None No JAMP OLANZAPINE ODT 10 MG TAB Yes JAMP OLANZAPINE ODT 15 MG TAB Yes JAMP OLANZAPINE ODT 20 MG TAB Yes JAMP OLANZAPINE ODT 5 MG TAB Yes JAMP-ALENDRONATE 70 MG TABLET None Yes JAMP-ALPRAZOLAM 0.25 MG TABLET OPEN Yes JAMP-ALPRAZOLAM 0.5 MG TABLET OPEN Yes JAMP-ALPRAZOLAM 1 MG TABLET OPEN Yes JAMP-AMLODIPINE 10 MG TABLET OPEN None Yes JAMP-AMLODIPINE 2.5 MG TABLET OPEN None No JAMP-AMLODIPINE 5 MG TABLET OPEN Yes JAMP-ANASTROZOLE 1 MG TABLET None Yes Page 101 Effective December 2015

102 Coverage Table December JAMP-ATENOLOL 100 MG TABLET OPEN None Yes JAMP-ATENOLOL 25 MG TABLET OPEN None No JAMP-ATENOLOL 50 MG TABLET OPEN None Yes JAMP-ATORVASTATIN 10 MG TABLET OPEN None Yes JAMP-ATORVASTATIN 20 MG TABLET OPEN None Yes JAMP-ATORVASTATIN 40 MG TABLET OPEN None Yes JAMP-ATORVASTATIN 80 MG TABLET OPEN None Yes JAMP-BICALUTAMIDE 50 MG TABLET OPEN None Yes JAMP-CANDESARTAN 16 MG TABLET OPEN Yes JAMP-CANDESARTAN 32 MG TABLET OPEN Yes JAMP-CANDESARTAN 8 MG TABLET OPEN Yes JAMP-CARVEDILOL 12.5 MG TABLET None Yes JAMP-CARVEDILOL 25 MG TABLET None Yes JAMP-CARVEDILOL MG TAB None Yes JAMP-CARVEDILOL 6.25 MG TABLET None Yes JAMP-CELECOXIB 100 MG CAPSULE OPEN Limit of 2 per day without Special Yes JAMP-CELECOXIB 200 MG CAPSULE OPEN Limit of 2 per day without Special Yes JAMP-CIPROFLOXACIN 250 MG TAB OPEN None Yes JAMP-CIPROFLOXACIN 500 MG TAB OPEN None Yes JAMP-CIPROFLOXACIN 750 MG TAB OPEN None Yes JAMP-CITALOPRAM 20 MG TABLET OPEN. Maximum of 1.5 tablets Yes daily JAMP-CITALOPRAM 40 MG TABLET OPEN Yes JAMP-CLOPIDOGREL 75 MG TABLET None Yes JAMP-COLCHICINE 0.6 MG TABLET OPEN None No JAMP-CYCLOBENZAPRINE 10 MG TAB OPEN None Yes JAMP-DICYCLOMINE HCL 20 MG TAB OPEN None No JAMP-DIMENHYDRINATE 50 MG TAB OPEN None No JAMP-DOMPERIDONE 10 MG TABLET OPEN None Yes JAMP-DONEPEZIL 10 MG TABLET No Yes Page 102 Effective December 2015

103 Coverage Table December JAMP-DONEPEZIL 5 MG TABLET No Yes JAMP-EZETIMIBE 10 MG TABLET None Yes Special required if beneficiary JAMP-FINASTERIDE 5 MG TABLET has not had a paid claim for an alpha Yes blocker or finasteride in past year JAMP-FLUCONAZOLE 150 MG CAP OPEN None Yes JAMP-FLUOXETINE 10 MG CAPSULE OPEN Yes JAMP-FLUOXETINE 20 MG CAPSULE OPEN Yes JAMP-FOLIC ACID 5 MG TABLET OPEN None No JAMP-FOSINOPRIL 10 MG TABLET OPEN None Yes JAMP-FOSINOPRIL 20 MG TABLET OPEN None Yes JAMP-GABAPENTIN 100 MG CAPSULE None Yes JAMP-GABAPENTIN 300 MG CAPSULE None Yes JAMP-GABAPENTIN 400 MG CAPSULE None Yes JAMP-GABAPENTIN 600 MG TABLET None Yes JAMP-GABAPENTIN 800 MG TABLET None Yes JAMP-INDAPAMIDE 1.25 MG TABLET OPEN None Yes JAMP-INDAPAMIDE 2.5 MG TABLET OPEN None Yes JAMP-IRBESARTAN 150 MG TABLET OPEN Yes JAMP-IRBESARTAN 300 MG TABLET OPEN Yes JAMP-IRBESARTAN 75 MG TABLET OPEN Yes JAMP-LACTULOSE ORAL SOLN OPEN None No JAMP-LETROZOLE 2.5 MG TABLET None Yes JAMP-LEVETIRACETAM 250 MG TAB No Yes JAMP-LEVETIRACETAM 500 MG TAB No Yes JAMP-LEVETIRACETAM 750 MG TAB No Yes JAMP-LISINOPRIL 10 MG TABLET OPEN None Yes JAMP-LISINOPRIL 20 MG TABLET OPEN None Yes JAMP-LISINOPRIL 5 MG TABLET OPEN None Yes JAMP-LOSARTAN 100 MG TABLET OPEN Yes Page 103 Effective December 2015

104 Coverage Table December JAMP-LOSARTAN 25 MG TABLET OPEN Yes JAMP-LOSARTAN 50 MG TABLET OPEN Yes JAMP-METFORMIN 500 MG TABLET OPEN None Yes JAMP-METFORMIN 850 MG TABLET OPEN None Yes JAMP-METFORMIN BLKBERRY 500 MG OPEN None Yes JAMP-METFORMIN BLKBERRY 850 MG OPEN None Yes JAMP-METOPROLOL-L 100 MG TAB OPEN None Yes JAMP-METOPROLOL-L 50 MG TAB OPEN None Yes JAMP-MONTELUKAST 10 MG TABLET None Yes JAMP-OMEPRAZOLE DR 20 MG TAB OPEN Yes JAMP-ONDANSETRON 4 MG TABLET OPEN Limit of 3 tablets per cycle - first fill only. Special is required for higher Yes quantities and/or subsequent fills JAMP-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 JAMP-PANTOPRAZOLE 40 MG TABLET OPEN Yes JAMP-PANTOPRAZOLE DR 20 MG TAB OPEN Yes JAMP-PAROXETINE 10 MG TABLET OPEN. Limit of 1 per day Yes without Special JAMP-PAROXETINE 20 MG TABLET OPEN Yes JAMP-PAROXETINE 30 MG TABLET OPEN Yes JAMP-PIOGLITAZONE 15 MG TABLET None Yes JAMP-PIOGLITAZONE 30 MG TABLET None Yes JAMP-PIOGLITAZONE 45 MG TABLET None Yes JAMP-PRAVASTATIN 10 MG TABLET OPEN None Yes JAMP-PRAVASTATIN 20 MG TABLET OPEN None Yes JAMP-PRAVASTATIN 40 MG TABLET OPEN None Yes Page 104 Effective December 2015

105 Coverage Table December JAMP-QUETIAPINE 100 MG TABLET OPEN Yes JAMP-QUETIAPINE 200 MG TABLET OPEN Yes JAMP-QUETIAPINE 25 MG TABLET OPEN Yes JAMP-QUETIAPINE 300 MG TABLET OPEN Yes JAMP-RAMIPRIL 1.25 MG CAPSULE OPEN None Yes JAMP-RAMIPRIL 10 MG CAPSULE OPEN None Yes JAMP-RAMIPRIL 2.5 MG CAPSULE OPEN None Yes JAMP-RAMIPRIL 5 MG CAPSULE OPEN None Yes JAMP-RISEDRONATE 35 MG TABLET None Yes JAMP-RISPERIDONE 0.25 MG TAB OPEN Yes JAMP-RISPERIDONE 0.5 MG TABLET OPEN Yes JAMP-RISPERIDONE 1 MG TABLET OPEN Yes JAMP-RISPERIDONE 2 MG TABLET OPEN Yes JAMP-RISPERIDONE 3 MG TABLET OPEN Yes JAMP-RISPERIDONE 4 MG TABLET OPEN Yes JAMP-RIZATRIPTAN 10 MG TABLET None Yes JAMP-RIZATRIPTAN 5 MG TABLET None Yes JAMP-ROPINIROLE 0.25 MG TABLET OPEN None Yes JAMP-ROPINIROLE 1 MG TABLET OPEN None Yes JAMP-ROPINIROLE 2 MG TABLET OPEN None Yes JAMP-ROPINIROLE 5 MG TABLET OPEN None Yes JAMP-ROSUVASTATIN 10 MG TABLET OPEN None Yes JAMP-ROSUVASTATIN 20 MG TABLET OPEN None Yes JAMP-ROSUVASTATIN 40 MG TABLET OPEN None Yes JAMP-ROSUVASTATIN 5 MG TABLET OPEN Yes Page 105 Effective December 2015

106 Coverage Table December JAMP-SERTRALINE 100 MG CAPSULE OPEN Yes JAMP-SERTRALINE 25 MG CAPSULE OPEN Yes JAMP-SERTRALINE 50 MG CAPSULE OPEN Yes JAMP-SIMVASTATIN 10 MG TABLET OPEN None Yes JAMP-SIMVASTATIN 10 MG TABLET OPEN None Yes JAMP-SIMVASTATIN 20 MG TABLET OPEN None Yes JAMP-SIMVASTATIN 20 MG TABLET OPEN None Yes JAMP-SIMVASTATIN 40 MG TABLET OPEN None Yes JAMP-SIMVASTATIN 40 MG TABLET OPEN None Yes JAMP-SIMVASTATIN 5 MG TABLET OPEN None Yes JAMP-SIMVASTATIN 5 MG TABLET OPEN None Yes JAMP-SIMVASTATIN 80 MG TABLET OPEN None Yes JAMP-SIMVASTATIN 80 MG TABLET OPEN None Yes JAMP-SOTALOL 160 MG TABLET OPEN None Yes JAMP-SOTALOL 80 MG TABLET OPEN None Yes JAMP-VALACYCLOVIR 500MG TABLET OPEN None Yes JAMP-VANCOMYCIN 125 MG CAPSULE OPEN None Yes JAMP-VANCOMYCIN 250 MG CAPSULE OPEN None Yes JAMP-ZOLMITRIPTAN 2.5 MG TAB None Yes JAMP-ZOPICLONE 5 MG TABLET OPEN Yes JAMP-ZOPICLONE 7.5 MG TABLET OPEN Yes JAMP-ZOPICLONE 7.5 MG TABLET OPEN Yes JANUMET MG TABLET None No JANUMET MG TABLET None No JANUMET MG TABLET None No JANUVIA 100 MG TABLET None No JAYDESS 14MCG/24HR (3 YRS) IUD OPEN None No JECTOFER 50 MG/ML OPEN None No JENTADUETO 2.5 MG-1,000 MG TAB No No JENTADUETO 2.5 MG-500 MG TAB No No JENTADUETO 2.5 MG-850 MG TAB No No Page 106 Effective December 2015

107 Coverage Table December JETREA INTRAVIT INJ 2.5MG/ML None No K-10 10% SOLUTION OPEN None No KADIAN 10 MG CAPSULE OPEN No KADIAN 100 MG CAPSULE OPEN No KADIAN 20 MG CAPSULE OPEN No KADIAN 50 MG CAPSULE OPEN No KALETRA MG TABLET OPEN No KALETRA 200 MG-50 MG TABLET OPEN No KALETRA MG/5 ML SOLN OPEN No KALETRA CAPSULE OPEN No KALYDECO 150 MG TABLET No KAOCHLOR 10% LIQUID OPEN None No KAON 20MEQ/15ML ELIXIR OPEN None No KAOPECTATE 600 MG/15 ML SUSP OPEN None No KAOPECTATE 750 MG/15 ML SUSP OPEN None No KAYEXALATE POWDER OPEN None No K-DUR 20 MEQ TABLET ER OPEN None No KEFZOL OPEN None No KEFZOL OPEN None No KEMADRIN 0.5MG/ML ELIXIR OPEN None No KEMADRIN 5MG TABLET OPEN None No KEMSOL 70% SOLUTION OPEN None No KENACOMB CREAM OPEN None Yes KENACOMB MILD CREAM OPEN None No KENACOMB MILD OINTMENT OPEN None No KENACOMB OINTMENT OPEN None Yes KENALOG 0.1% CREAM OPEN None No KENALOG 0.1% OINTMENT OPEN None No Page 107 Effective December 2015

108 Coverage Table December KENALOG IN ORABASE PASTE OPEN None No KENALOG MG/ML VIAL OPEN None No KENALOG MG/ML VIAL OPEN None No KEPPRA 250 MG TABLET None Yes KEPPRA 500 MG TABLET None Yes KEPPRA 750 MG TABLET None Yes KERALYT GEL 6% OPEN None No KETODERM 2% CREAM OPEN None Yes KETO-DIASTIX OPEN None No KETOPROFEN 50 MG CAPSULE OPEN None Yes KETOPROFEN SR 200 MG TABLET OPEN None Yes KETOPROFEN-E EC 100 MG TABLET OPEN None Yes KETOPROFEN-E EC 50 MG TABLET OPEN None Yes KETOROLAC 0.5 % EYE DROPS OPEN None Yes KETOROLAC 10 MG TABLET OPEN None Yes KETOROLAC TROMET 30 MG/ML VIAL OPEN None No KETOSTIX OPEN None No KIDROLASE 10000U VIAL OPEN None No KIVEXA 600 MG-300 MG TABLET OPEN No K-LOR 20MEQ PACKET OPEN None No K-LYTE 25MEQ TABLET EFFERV OPEN None No K-LYTE/CL 25MEQ PACKET OPEN None No KOMBOGLYZE 2.5 MG-1,000 MG TAB None No KOMBOGLYZE 2.5 MG-500 MG TAB None No KOMBOGLYZE 2.5 MG-850 MG TAB None No KWELLADA CREAM OPEN None No KWELLADA-P 1 % LIQUID OPEN None No KWELLADA-P 5 % LOTION OPEN None No KYTRIL 1 MG TABLET OPEN Limit of 2 per cycle - first fill only. Special required for higher quantities Yes and/or subsequent fills LABSTIX OPEN None No LACTULOSE 10 G/15 ML SOLUTION Beneficiary must have eligibility under the CF Plan and previous authorization No LACTULOSE 10 GM/15 ML SOLUTION OPEN None No LACTULOSE SYRUP OPEN None No Page 108 Effective December 2015

109 Coverage Table December LAMICTAL 100 MG TABLET OPEN None Yes LAMICTAL 150 MG TABLET OPEN None Yes LAMICTAL 2 MG TABLET OPEN None No LAMICTAL 25 MG TABLET OPEN None Yes LAMICTAL 5 MG TAB CHEW/DISP OPEN None No LAMISIL 1% CREAM OPEN None No LAMISIL 250 MG TABLET OPEN None Yes LAMIVUE-ZIDOV MG TAB OPEN Yes LAMIVUE-ZIDOV MG TAB OPEN Yes LAMOTRIGINE 100 MG TABLET OPEN None Yes LAMOTRIGINE 150 MG TABLET OPEN None Yes LAMOTRIGINE 25 MG TABLET OPEN None Yes LANOXIN MG TABLET OPEN None Yes LANOXIN MG TABLET OPEN None Yes LANOXIN 0.25 MG TABLET OPEN None Yes LANOXIN 0.25MG/ML VIAL OPEN None No LANSOPRAZOLE DR 15 MG CAPSULE None Yes LANSOPRAZOLE DR 15 MG CAPSULE None Yes LANSOPRAZOLE DR 30 MG CAPSULE None Yes LANSOPRAZOLE DR 30 MG CAPSULE None Yes LANSOPRAZOLE DR 30 MG CAPSULE None Yes LANTUS 100 UNIT/ML CARTRIDGE None No LANTUS 100 UNIT/ML VIAL None No LANTUS SOLOSTR 100 UNIT/ML PEN None No LANVIS 40 MG TABLET OPEN None No LARGACTIL 100 MG SUPPOSITORY OPEN No LARGACTIL 100 MG/5 ML LIQUID OPEN No LARGACTIL 25 MG/5 ML LIQUID OPEN No LARGACTIL 25MG/ML AMPOULE OPEN No LARGACTIL 40 MG/ML DROPS OPEN No Page 109 Effective December 2015

110 Coverage Table December LARGACTIL TAB 25MG OPEN Yes LARGACTIL TAB 50MG OPEN Yes LARGACTIL TAB 100MG OPEN Yes LASIX 10 MG/ML ORAL SOLN OPEN None No LASIX 20 MG TABLET OPEN None Yes LASIX 40 MG TABLET OPEN None Yes LASIX SPECIAL 500 MG TABLET OPEN None No LASSAR'S PASTE OPEN None No LATANOPROST % EYE DROPS OPEN None Yes LATUDA 120 MG TABLET No LATUDA 20 MG TABLET No LATUDA 40 MG TABLET No LATUDA 60 MG TABLET No LATUDA 80 MG TABLET No a) Limited to 2500 per year without Special b) Beneficiary must have LB BLOOD GLUCOSE TEST 100CT. OPEN diabetic medication within previous year No history, otherwise Special is required LECTOPAM 3 MG TABLET OPEN Yes LECTOPAM 6 MG TABLET OPEN Yes LECTOPAM TAB 1.5MG OPEN Yes LEDERLE LEUCOVORIN 5 MG TAB OPEN None No LEFLUNOMIDE 10 MG TABLET OPEN None Yes LEFLUNOMIDE 20 MG TABLET OPEN None Yes LENTE ILENTIN II 100U/ML OPEN None No Page 110 Effective December 2015

111 Coverage Table December LESCOL 20 MG CAPSULE OPEN None Yes LESCOL 40 MG CAPSULE OPEN None Yes LESCOL XL 80 MG TABLET OPEN None No LETROZOLE 2.5 MG TABLET None Yes LEUKERAN 2 MG TABLET OPEN None No LEVAQUIN 250 MG TABLET None Yes LEVAQUIN 500 MG TABLET None Yes LEVATE 75 MG TABLET OPEN No LEVEMIR 100 UNIT/ML PENFILL None No LEVEMIR FLEXTOUCH 100 UNIT/ML None No LEVETIRACETAM 250 MG TABLET None Yes LEVETIRACETAM 500 MG TABLET None Yes LEVETIRACETAM 750 MG TABLET None Yes LEVOBUNOLOL 0.5 % EYE DROPS OPEN None Yes LEVOCARBIDOPA 10 MG-100 MG TAB OPEN None Yes LEVOCARBIDOPA 25 MG-100 MG TAB OPEN None Yes LEVOCARBIDOPA 25 MG-250 MG TAB OPEN None Yes LEVO-T 100MCG TABLET OPEN None No LEVO-T 125MCG TABLET OPEN None No LEVO-T 150MCG TABLET OPEN None No LEVO-T 200MCG TABLET OPEN None No LEVO-T 25MCG TABLET OPEN None No LEVO-T 300MCG TABLET OPEN None No LEVO-T 50MCG TABLET OPEN None No LEVO-T 75MCG TABLET OPEN None No LEVSIN MG TABLET SL OPEN None No LIBRAX CAPSULE OPEN Yes LIDEMOL 0.05% EMOLLIENT CRM OPEN None No LIDEX 0.05% CREAM OPEN None No LIDEX 0.05% GEL OPEN None No LIDEX 0.05% OINTMENT OPEN None No LIFE BRAND ALCOHOL SWABS OPEN None No Page 111 Effective December 2015

112 Coverage Table December LIFE BRAND BLOOD GLUCOSE TEST OPEN a) Limited to 2500 per year without Special b) Beneficiary must have diabetic medication within previous year No history, otherwise Special is required LIFE BRAND PEN NEEDLES 31G 6MM OPEN None No LIFE BRAND PEN NEEDLES 31G 8MM OPEN None No LIFE BRAND ULTRA THIN LANCETS OPEN None No LIFESCAN LANCET OPEN None No LINCOCIN 300 MG/ML VIAL OPEN None No LINESSA 21 TABLET OPEN Beneficiary gender must be female - under the age of 51 No LINESSA 28 TABLET OPEN Beneficiary gender must be female - under the age of 51 No LIN-MEGESTROL 40MG TABLET OPEN None No LIORESAL 10 MG TABLET OPEN None Yes LIORESAL D.S. 20 MG TABLET OPEN None Yes LIPIDIL MICRO 200 MG CAPSULE OPEN None Yes LIPIDIL SUPRA 100 MG TABLET OPEN None Yes LIPIDIL SUPRA 160 MG TABLET OPEN None Yes LIPITOR 10 MG TABLET OPEN None Yes LIPITOR 20 MG TABLET OPEN None Yes LIPITOR 40 MG TABLET OPEN None Yes LIPITOR 80 MG TABLET OPEN None Yes LIQUIFILM TEARS 1.4% DROPS OPEN None No LISINOPRIL 10 MG TABLET OPEN None Yes LISINOPRIL 10 MG TABLET OPEN None Yes LISINOPRIL 20 MG TABLET OPEN None Yes LISINOPRIL 20 MG TABLET OPEN None Yes LISINOPRIL 5 MG TABLET OPEN None Yes LISINOPRIL 5 MG TABLET OPEN None Yes LISINOPRIL HCT MG TAB OPEN None Yes LISINOPRIL HCT 20MG-12.5MG TAB OPEN None Yes LISINOPRIL HCT 20MG-25MG TAB OPEN None Yes LISINOPRIL/HCTZ MG TAB OPEN None Yes LISINOPRIL/HCTZ MG TAB OPEN None Yes LISINOPRIL/HCTZ MG TAB OPEN None Yes Page 112 Effective December 2015

113 Coverage Table December LITHANE 150 MG CAPSULE OPEN No LITHANE 300 MG CAPSULE OPEN No LITHMAX 300 MG TABLET ER OPEN Yes LIVOSTIN 0.05 % EYE DROPS OPEN None No LIVOSTIN 0.05 % NASAL SPRAY OPEN None No LOCACORTEN VIOFORM CREAM OPEN None No LOCACORTEN VIOFORM EARDROPS OPEN None No LODALIS 625 MG TABLET OPEN None No LOESTRIN 1.5/30 (21) TABLET OPEN Beneficiary gender must be female - under the age of 51 No LOESTRIN 1.5/30 (28) TABLET OPEN Beneficiary gender must be female - under the age of 51 No LOMOTIL TABLET OPEN No LONITEN 10 MG TABLET OPEN None No LONITEN 2.5 MG TABLET OPEN None No LOPERACAP 2 MG TABLET OPEN Can be dispensed by Hospital or RHA Clinic without prior approval No LOPERAMIDE-2 2 MG CAPSULE None No LOPID 300 MG CAPSULE OPEN None Yes LOPID 600 MG TABLET OPEN None Yes LOPRESOR 100 MG TABLET OPEN None Yes LOPRESOR 50 MG TABLET OPEN None Yes LOPRESOR SR 100 MG TABLET OPEN None Yes LOPRESOR SR 200 MG TABLET OPEN None Yes LOPROX 1 % CREAM OPEN None No LOPROX 1 % LOTION OPEN None No LORAZEPAM 0.5 MG TABLET OPEN Yes LORAZEPAM 1 MG TABLET OPEN Yes LORAZEPAM 2 MG TABLET OPEN Yes Page 113 Effective December 2015

114 Coverage Table December LORAZEPAM INJ 4 MG/ML VIAL OPEN LOSARTAN 100 MG TABLET OPEN LOSARTAN 100 MG TABLET OPEN LOSARTAN 25 MG TABLET OPEN LOSARTAN 25 MG TABLET OPEN LOSARTAN 50 MG TABLET OPEN LOSARTAN 50 MG TABLET OPEN LOSARTAN HCT 50 MG-12.5 MG TAB OPEN LOSARTAN HCT DS MG TAB OPEN LOSARTAN HCTZ 100 MG-25 MG TAB OPEN LOSARTAN HCTZ 100 MG-25 MG TAB OPEN LOSARTAN HCTZ MG TAB OPEN LOSARTAN HCTZ 50 MG-12.5MG TAB OPEN LOSARTAN HCTZ 50 MG-12.5MG TAB OPEN LOSARTAN HCTZ MG TAB OPEN LOSARTAN/HCT 100 MG-25 MG TAB OPEN LOSARTAN/HCT MG TAB OPEN LOSARTAN/HCT MG TAB OPEN No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Page 114 Effective December 2015

115 Coverage Table December LOSARTAN/HCT MG TABLET OPEN Yes LOSARTAN/HCT 50 MG-12.5 MG TAB OPEN Yes LOSARTAN/HCT MG TABLET OPEN Yes LOSARTAN/HCTZ 100/12.5MG TAB OPEN Yes LOSARTAN/HCTZ MG TAB OPEN Yes LOSARTAN/HCTZ 50 MG-12.5MG TAB OPEN Yes LOSARTAN/HCTZ 50 MG-12.5MG TAB OPEN Yes LOSARTAN/HCTZ DS MG TAB OPEN Yes LOSARTAN-HCTZ 100 MG-25 MG TAB OPEN Yes LOSARTAN-HCTZ MG TAB OPEN Yes LOSARTAN-HCTZ MG TAB OPEN Yes LOSARTAN-HCTZ 50 MG-12.5MG TAB OPEN Yes LOSARTAN-HCTZ 50 MG-12.5MG TAB OPEN Yes LOSEC DR 10 MG TABLET OPEN Yes LOSEC DR 20 MG TABLET OPEN Yes LOTENSIN 10MG OPEN None Yes LOTENSIN 20 MG TABLET OPEN None Yes LOTENSIN 5 MG TABLET OPEN None Yes LOTRIDERM 1 %-0.05 % CREAM OPEN None No LOVASTATIN 20 MG TABLET OPEN None Yes LOVASTATIN 40 MG TABLET OPEN None Yes LOVENOX 100 MG/ML SYRINGE None No Page 115 Effective December 2015

116 Coverage Table December LOVENOX 30 MG/0.3 ML SYRINGE None No LOVENOX 300 MG/3 ML VIAL None No LOVENOX 40MG/0.4ML SYRINGE None No LOVENOX 60 MG/0.6 ML SYRINGE None No LOVENOX 80 MG/0.8 ML SYRINGE None No LOVENOX HP 120 MG/0.8 ML SYRG None No LOVENOX HP 150 MG/ML SYRINGE None No LOXAPAC - TAB 10MG OPEN Yes LOXAPAC - TAB 5MG OPEN Yes LOXAPAC IM 50 MG/ML AMPOULE OPEN No LOXAPAC ORAL CONCENTRATE-LIQ 2 OPEN No LOXAPAC TABLETS - 25 MG OPEN Yes LOZIDE 1.25 MG TABLET OPEN None Yes LOZIDE 2.5 MG TABLET OPEN None Yes LUCENTIS 2.3 MG/0.23 ML VIAL None No LUDIOMIL TAB 75MG OPEN Yes LUMIGAN 0.03% EYE DROPS OPEN None No LUMIGAN RC 0.01 % EYE DROPS OPEN None No LUPRON 1 MG/0.2 ML KIT OPEN None No LUPRON DEPOT MG SYRINGE OPEN None No LUPRON DEPOT 22.5 MG SYRINGE OPEN None No LUPRON DEPOT 3.75 MG SYRINGE OPEN None No LUPRON DEPOT 30 MG SYRINGE KIT OPEN None No LUPRON DEPOT 7.5MG SYRINGE KIT OPEN None No LUTERA MCG-20 MCG TAB OPEN Beneficiary gender must be female - under the age of 51 Yes LUTERA MCG-20 MCG TAB OPEN Beneficiary gender must be female - under the age of 51 Yes LUVOX 100 MG TABLET OPEN Yes Page 116 Effective December 2015

117 Coverage Table December LUVOX 50 MG TABLET OPEN Yes LYDERM 0.05% CREAM OPEN None No LYDERM 0.05% GEL OPEN None No LYDERM 0.05% OINTMENT OPEN None No M.O.S. 1 MG/ML SYRUP OPEN No M.O.S. 10 MG SUPPOSITORY OPEN No M.O.S. 10 MG TABLET OPEN No M.O.S. 10 MG/ML SYRUP OPEN No M.O.S. 20 MG TABLET OPEN No M.O.S. 30 MG SUPPOSITORY OPEN No M.O.S. 40 MG TABLET OPEN No M.O.S. 5 MG/ML SYRUP OPEN No M.O.S. 60 MG TABLET OPEN No M.O.S. CONC 20 MG/ML LIQUID OPEN No M.O.S. CONC 50 MG/ML LIQUID OPEN No M.O.S. SR 30 MG TABLET OPEN No M.O.S. SR 60 MG TABLET OPEN No M.O.S. SULPHATE 10 MG TABLET OPEN No M.O.S. SULPHATE 5 MG TABLET OPEN No MAALOX TABLETS CHERRY FLAVOUR OPEN None No MAALOX TC SUSPENSION OPEN None No Page 117 Effective December 2015

118 Coverage Table December MAALOX TC TABLET OPEN None No MACROBID 100 MG CAPSULE OPEN None No MACRODANTIN (100 MG) OPEN None Yes MACRODANTIN (50 MG) OPEN None Yes MAGIC BULLET SUPPOSITORIES 10M OPEN None No MAJEPTIL 10 MG TABLET OPEN No MANDELAMINE 500 MG TABLET OPEN None No MANERIX 150 MG TABLET OPEN Yes MANERIX 300 MG TABLET OPEN Yes MAR-ALLOPURINOL 100 MG TABLET OPEN No Yes MAR-ALLOPURINOL 200 MG TABLET OPEN No Yes MAR-ALLOPURINOL 300 MG TABLET OPEN No Yes MAR-AMLODIPINE 10 MG TABLET OPEN None Yes MAR-AMLODIPINE 5 MG TABLET OPEN Yes MAR-ANASTROZOLE 1 MG TABLET None Yes MAR-ATENOLOL 100 MG TABLET OPEN None Yes MAR-ATENOLOL 50 MG TABLET OPEN None Yes MAR-CELECOXIB 100 MG CAPSULE OPEN Limit of 2 per day without Special Yes MAR-CELECOXIB 200 MG CAPSULE OPEN Limit of 2 per day without Special Yes MAR-CIPROFLOXACIN 250 MG TAB OPEN None Yes MAR-CIPROFLOXACIN 500 MG TAB OPEN None Yes MAR-CIPROFLOXACIN 750 MG TAB OPEN None Yes MAR-CITALOPRAM 20 MG TABLET OPEN. Maximum of 1.5 tablets Yes daily MAR-CITALOPRAM 40 MG TABLET OPEN Yes MAR-CLOPIDOGREL 75 MG TABLET None Yes MAR-DOMPERIDONE 10 MG TABLET OPEN None Yes MAR-DONEPEZIL 10 MG TABLET No Yes MAR-DONEPEZIL 5 MG TABLET No Yes Page 118 Effective December 2015

119 Coverage Table December MAR-EZETIMIBE 10 MG TABLET None Yes MAR-FLUOXETINE 10 MG CAPSULE OPEN Yes MAR-FLUOXETINE 20 MG CAPSULE OPEN Yes MAR-GABAPENTIN 100 MG CAP None Yes MAR-GABAPENTIN 300 MG CAP None Yes MAR-GABAPENTIN 400 MG CAP None Yes MAR-GALANTAMINE ER 16 MG CAP None Yes MAR-GALANTAMINE ER 24 MG CAP None Yes MAR-GALANTAMINE ER 8 MG CAP None Yes MARINOL 2.5 MG CAPSULE OPEN No MARINOL 5 MG CAPSULE OPEN No MAR-LETROZOLE 2.5 MG TABLET None Yes MAR-METFORMIN 500 MG TABLET OPEN None Yes MAR-METFORMIN 850 MG TABLET OPEN None Yes MAR-MONTELUKAST 10 MG TABLET None Yes MAR-MONTELUKAST 4 MG TAB CHEW None Yes MAR-MONTELUKAST 5 MG TAB CHEW None Yes MAR-OLANZAPINE 10 MG TABLET Yes MAR-OLANZAPINE 15 MG TABLET Yes MAR-OLANZAPINE 2.5 MG TABLET Yes MAR-OLANZAPINE 5 MG TABLET Yes MAR-OLANZAPINE 7.5 MG TABLET Yes MAR-OLANZAPINE ODT 10 MG TAB Yes MAR-OLANZAPINE ODT 15 MG TAB Yes MAR-OLANZAPINE ODT 5 MG TABLET Yes Page 119 Effective December 2015

120 Coverage Table December MAR-ONDANSETRON 4 MG TABLET OPEN Limit of 3 tablets per cycle - first fill only. Special is required for higher Yes quantities and/or subsequent fills MAR-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 MAR-PANTOPRAZOLE DR 40 MG TAB OPEN Yes MAR-PAROXETINE 10 MG TABLET OPEN. Initial and Maintenance fills Yes are limited to a maximum of 30 days MAR-PAROXETINE 20 MG TABLET OPEN Yes MAR-PAROXETINE 30 MG TABLET OPEN Yes MAR-PREGABALIN 150 MG CAPSULE None Yes MAR-PREGABALIN 25 MG CAPSULE None Yes MAR-PREGABALIN 50 MG CAPSULE None Yes MAR-PREGABALIN 75 MG CAPSULE None Yes MAR-QUETIAPINE 100 MG TABLET OPEN Yes MAR-QUETIAPINE 200 MG TABLET OPEN Yes MAR-QUETIAPINE 25 MG TABLET OPEN Yes MAR-QUETIAPINE 300 MG TABLET OPEN Yes MAR-RAMIPRIL 10 MG CAPSULE OPEN None Yes MAR-RAMIPRIL 2.5 MG CAPSULE OPEN None Yes MAR-RAMIPRIL 5 MG CAPSULE OPEN None Yes MAR-RISPERIDONE 0.25 MG TABLET OPEN Yes MAR-RISPERIDONE 0.5 MG TABLET OPEN Yes MAR-RISPERIDONE 1 MG TABLET OPEN Yes Page 120 Effective December 2015

121 Coverage Table December MAR-RISPERIDONE 2 MG TABLET OPEN Yes MAR-RISPERIDONE 3 MG TABLET OPEN Yes MAR-RISPERIDONE 4 MG TABLET OPEN Yes MAR-RIZATRIPTAN 10 MG TABLET None Yes MAR-RIZATRIPTAN 5 MG TABLET None Yes MAR-ROSUVASTATIN 10 MG TABLET OPEN None Yes MAR-ROSUVASTATIN 20 MG TABLET OPEN None Yes MAR-ROSUVASTATIN 40 MG TABLET OPEN None Yes MAR-ROSUVASTATIN 5 MG TABLET OPEN Yes MAR-SERTRALINE 100 MG CAPSULE OPEN Yes MAR-SERTRALINE 25 MG CAPSULE OPEN Yes MAR-SERTRALINE 50 MG CAPSULE OPEN Yes MAR-SIMVASTATIN 10 MG TABLET OPEN None Yes MAR-SIMVASTATIN 20 MG TABLET OPEN None Yes MAR-SIMVASTATIN 40 MG TABLET OPEN None Yes MAR-SIMVASTATIN 5 MG TABLET OPEN None Yes MAR-SIMVASTATIN 80 MG TABLET OPEN None Yes MAR-VALACYCLOVIR 500MG TABLET OPEN None Yes MARVELON 21 TABLET OPEN Beneficiary gender must be female - under the age of 51 Yes MARVELON 28 TABLET OPEN Beneficiary gender must be female - under the age of 51 Yes MAR-ZOLMITRIPTAN 2.5 MG TABLET None Yes MAR-ZOPICLONE 5 MG TABLET OPEN Yes MAR-ZOPICLONE 7.5 MG TABLET OPEN Yes MATERNA TAB OPEN Beneficiary gender must be female - under the age of 51 No Page 121 Effective December 2015

122 Coverage Table December MATERNA TABLET OPEN Beneficiary gender must be female - under the age of 51 No MATERNA TABLET OPEN Beneficiary gender must be female - under the age of 51 No MATERNA-TAB OPEN Beneficiary gender must be female - under the age of 51 No MATULANE 50 MG CAPSULE OPEN None No MAVIK 0.5 MG CAPSULE OPEN None No MAVIK 1 MG CAPSULE OPEN None No MAVIK 2 MG CAPSULE OPEN None No MAVIK 4 MG CAPSULE OPEN None No MAXALT 10 MG TABLET None Yes MAXALT 5 MG TABLET None Yes MAXALT RPD 10 MG TABLET None Yes MAXALT RPD 5 MG TABLET None Yes MAXIDEX 0.1% EYE DROPS OPEN None No MAXIDEX 0.1% OINTMENT OPEN None No MAXITROL EYE DROPS OPEN None No MAXITROL EYE OINTMENT OPEN None No MAZEPINE 200 MG TABLET OPEN None No MED-ANASTROZOLE 1 MG TABLET None Yes MED-CYPROTERONE 50 MG TABLET OPEN None Yes MED-DUTASTERIDE 0.5 MG CAPSULE None Yes a) Limited to 2500 per year without Special b) Beneficiary must have MEDI+ SURE BLD GLUCOSE TEST ST OPEN diabetic medication within previous year No history, otherwise Special is required MEDISENSE THIN LANCETS OPEN None No MED-LETROZOLE 2.5 MG TABLET None Yes MED-RIVASTIGMINE 1.5 MG CAP No Yes MED-RIVASTIGMINE 3 MG CAPSULE No Yes MED-RIVASTIGMINE 4.5 MG CAP No Yes MED-RIVASTIGMINE 6 MG CAPSULE No Yes MEDROL 4 MG TABLET OPEN None No MEDROL ACNE LOTION OPEN None No MEDROL TOPICAL 0.25% CREAM OPEN None No Page 122 Effective December 2015

123 Coverage Table December MEFENAMIC 250 MG CAPSULE OPEN None Yes MEFOXIN PWS 1GM/VIAL OPEN None No MEGACE OPEN None Yes MEGESTROL 160 MG TABLET OPEN None Yes MEGESTROL 40 MG TABLET OPEN None Yes MEKINIST 0.5 MG TABLET None No MEKINIST 2 MG TABLET None No MELOXICAM 15 MG TABLET OPEN None Yes MELOXICAM 7.5 MG TABLET OPEN None Yes MEPERIE HCL 100 MG/ML OPEN No MEPERIE HCL 50 MG/ML AMPL OPEN No MEPERIE HCL 75 MG/ML AMPL OPEN No MEPHYTON 5MG TABLETS OPEN Beneficiary must have eligibility under the CF Plan No MERCAPTOPURINE 50 MG TABLET OPEN None Yes MEROPENEM 1 GRAM VIAL OPEN Beneficiary must have eligibility under the CF Plan Yes MERREM IV 1 GRAM VIAL OPEN Beneficiary must have eligibility under the CF Plan Yes MESASAL 500 MG TABLET EC OPEN None No M-ESLON 10 MG CAPSULE SR OPEN No M-ESLON 100 MG CAPSULE SR OPEN No M-ESLON 15 MG CAPSULE SR OPEN No M-ESLON 200 MG CAPSULE SR OPEN No M-ESLON 30 MG CAPSULE SR OPEN No M-ESLON 60 MG CAPSULE SR OPEN No MESTINON 60 MG TABLET OPEN None No MESTINON SR 180 MG TABLET OPEN None No Page 123 Effective December 2015

124 Coverage Table December METADOL 1 MG TABLET No METADOL 1 MG/ML SOLUTION No METADOL 10 MG TABLET No METADOL 10 MG/ML LIQUID No METADOL 25 MG TABLET No METADOL 5 MG TABLET No METAMUCIL FIBRE THERAPY PWD OPEN None No METAMUCIL FIBRE THERAPY S/F OPEN None No METAMUCIL FIBRE THERAPY-SM.TEX OPEN None No METAMUCIL POWDER SUGAR FREE OPEN None No METFORMIN 500 MG TABLET OPEN None Yes METFORMIN 500 MG TABLET OPEN None Yes METFORMIN 850 MG TABLET OPEN None Yes METFORMIN 850 MG TABLET OPEN None Yes METFORMIN FC 500 MG TABLET OPEN None Yes METFORMIN FC 850 MG TABLET OPEN None Yes METHADOSE 10 MG/ML ORAL CONC Must be prescribed by authorized No METHAZOLAMIDE 50 MG TAB OPEN None No METHOPRAZINE 2 MG TABLET OPEN Yes METHOPRAZINE 25 MG TABLET OPEN Yes METHOPRAZINE 5 MG TABLET OPEN Yes METHOPRAZINE 50 MG TABLET OPEN Yes METHOTREXATE 10 MG TABLET OPEN None No METHOTREXATE 2.5 MG TABLET OPEN None No METHOTREXATE 25 MG/ML VIAL OPEN None No METHOTREXATE 25 MG/ML VIAL OPEN None No METHOTREXATE 25 MG/ML VIAL OPEN None Yes Page 124 Effective December 2015

125 Coverage Table December METHOTREXATE 50 MG/2 ML VL OPEN None Yes METHOTREXATE SOD 25 MG/ML VL OPEN None No METHOTREXATE-LIQ IM IV IAR INT OPEN None No METHOXISAL C 1/2 TABLET OPEN No METHOXISAL C 1/4 TABLET OPEN No METHYLDOPA 125 MG TABLET OPEN None Yes METHYLDOPA 250 MG TABLET OPEN None Yes METHYLDOPA 500 MG TABLET OPEN None Yes METHYLPHENIDATE ER 27 MG TAB Yes METHYLPHENIDATE ER 36 MG TAB Yes METHYLPHENIDATE ER 54 MG TAB Yes METOCLOPRAMIDE 5 MG/ML VIAL OPEN None No METONIA 10 MG TABLET OPEN None Yes METONIA 5 MG TABLET OPEN None Yes METONIA 5 MG/5 ML SOLUTION OPEN None Yes METOPROLOL 100 MG TABLET OPEN None Yes METOPROLOL 50 MG TABLET OPEN None Yes METRETON TABLET OPEN None No METROCREAM 0.75% CREAM OPEN None No METROGEL 0.75% GEL OPEN None No METROGEL 1 % GEL OPEN None No METROLOTION 0.75% LOTION OPEN None No METRONIDAZOLE 250 MG TAB OPEN None Yes METRONIDAZOLE 500 MG CAP OPEN None Yes MEVACOR 20 MG TABLET OPEN None Yes MEVACOR 40 MG TABLET OPEN None Yes MEZAVANT 1.2 G TABLET EC OPEN None No MICARDIS 40 MG TABLET OPEN Yes MICARDIS 80 MG TABLET OPEN Yes Page 125 Effective December 2015

126 Coverage Table December MICARDIS PLUS 80 MG-12.5MG TAB OPEN Yes MICARDIS PLUS MG TABLET OPEN Yes MICATIN 2% CREAM OPEN None No MICRO-K EXTENCAPS OPEN None No MICRO-K-10 EXTENCAPS SRC 750MG OPEN None No MICROLAX MICRO 90-9MG/ML ENEMA OPEN None No MICROLET LANCET OPEN None No MICRONOR 0.35 MG TABLET OPEN Beneficiary gender must be female - under the age of 51 Yes MIDAMOR 5 MG TABLET OPEN None Yes MIDAMOR TABLETS 5MG OPEN None Yes MIDAZOLAM 1 MG/ML VIAL OPEN For use in End of Life Palliative Care only. No Not Available MIDAZOLAM 5 MG/ML VIAL OPEN For use in End of Life Palliative Care only. No Not Available MIGRANAL 0.5 MG/SPRAY NASAL OPEN None No MINESTRIN 1/20 (21) TABLET OPEN Beneficiary gender must be female - under the age of 51 No MINESTRIN 1/20 (28) TABLET OPEN Beneficiary gender must be female - under the age of 51 No MINIPRESS 1 MG TABLET OPEN None Yes MINIPRESS 2 MG TABLET OPEN None Yes MINIPRESS 5 MG TABLET OPEN None Yes MINITRAN 0.2 MG/HR PATCH OPEN None No MINITRAN 0.4 MG/HR PATCH OPEN None No MINITRAN 0.6 MG/HR PATCH OPEN None No MINOCIN 100 MG CAPSULE OPEN None Yes MINOCIN 50 MG CAPSULE OPEN None Yes MIN-OVRAL 21 TAB OPEN Beneficiary gender must be female - under the age of 51 No MIN-OVRAL 21 TABLET OPEN Beneficiary gender must be female - under the age of 51 Yes MIN-OVRAL 28 TAB OPEN Beneficiary gender must be female - under the age of 51 No MIN-OVRAL 28 TABLET OPEN Beneficiary gender must be female - under the age of 51 Yes MINT-ALENDRONATE 10 MG TABLET No Yes Page 126 Effective December 2015

127 Coverage Table December MINT-ALENDRONATE 70 MG TABLET No Yes MINT-AMLODIPINE 10 MG TABLET OPEN None Yes MINT-AMLODIPINE 5 MG TABLET OPEN Yes MINT-ANASTROZOLE 1 MG TABLET None Yes MINT-ATENOL 100 MG TABLET OPEN None Yes MINT-ATENOL 25 MG TABLET OPEN None No MINT-ATENOL 50 MG TABLET OPEN None Yes MINT-CELECOXIB 100 MG CAPSULE OPEN Limit of 2 per day without Special Yes MINT-CELECOXIB 200 MG CAPSULE OPEN Limit of 2 per day without Special Yes MINT-CIPROFLOX 250 MG TABLET OPEN None Yes MINT-CIPROFLOX 500 MG TABLET OPEN None Yes MINT-CIPROFLOX 750 MG TABLET OPEN None Yes MINT-CIPROFLOXACIN 250 MG TAB OPEN None Yes MINT-CIPROFLOXACIN 500 MG TAB OPEN None Yes MINT-CIPROFLOXACIN 750 MG TAB OPEN None Yes MINT-CITALOPRAM 10 MG TABLET OPEN No MINT-CITALOPRAM 20 MG TAB OPEN. Maximum of 1.5 tablets Yes daily MINT-CITALOPRAM 40 MG TAB OPEN Yes MINT-CLOPIDOGREL 75 MG TABLET None Yes MINT-DUTASTERIDE 0.5 MG CAPS None Yes MINT-EZETIMIBE 10 MG TABLET None Yes Special required if beneficiary MINT-FINASTERIDE 5 MG TABLET has not had a paid claim for an alpha Yes blocker or finasteride in past year MINT-FLUOXETINE 10 MG CAPSULE OPEN Yes MINT-FLUOXETINE 20 MG CAPSULE OPEN Yes MINT-GLICLAZIDE MR 30 MG TAB OPEN None Yes Page 127 Effective December 2015

128 Coverage Table December MINT-IRBESARTAN 150 MG TABLET OPEN Yes MINT-IRBESARTAN 300 MG TABLET OPEN Yes MINT-LOSARTAN 100 MG TABLET OPEN Yes MINT-LOSARTAN 25 MG TABLET OPEN Yes MINT-LOSARTAN 50 MG TABLET OPEN Yes MINT-METFORMIN 500 MG TABLET OPEN No Yes MINT-METFORMIN 850 MG TABLET OPEN No Yes MINT-MONTELUKAST 10 MG TABLET None Yes MINT-MONTELUKAST 4 MG TAB CHEW None Yes MINT-MONTELUKAST 5 MG TAB CHEW None Yes Limit of 3 tablets per cycle - first fill only MINT-ONDANSETRON 4 MG TAB OPEN Special is required for higher Yes quantities and/or subsequent fills MINT-ONDANSETRON 8 MG TAB OPEN Limit of 3 tablets per cycle - first fill only. Special is required for higher Yes quantities and/or subsequent fills MINT-PANTOPRAZOLE DR 40 MG TAB OPEN Yes MINT-PAROXETINE 20 MG TABLET OPEN Yes MINT-PAROXETINE 30 MG TABLET OPEN Yes MINT-PIOGLITAZONE 15 MG TABLET None Yes MINT-PIOGLITAZONE 30 MG TABLET None Yes MINT-PIOGLITAZONE 45 MG TABLET None Yes MINT-PRAVASTATIN 10 MG TABLET OPEN None Yes MINT-PRAVASTATIN 20 MG TABLET OPEN None Yes MINT-PRAVASTATIN 40 MG TABLET OPEN None Yes MINT-PREGABALIN 150 MG CAPSULE None Yes MINT-PREGABALIN 25 MG CAPSULE None Yes MINT-PREGABALIN 50 MG CAPSULE None Yes MINT-PREGABALIN 75 MG CAPSULE None Yes Page 128 Effective December 2015

129 Coverage Table December MINT-RAMIPRIL 10 MG CAPSULE OPEN None Yes MINT-RAMIPRIL 2.5 MG CAPSULE OPEN None Yes MINT-RAMIPRIL 5 MG CAPSULE OPEN None Yes MINT-RISPERIDONE 0.25 MG TAB OPEN Yes MINT-RISPERIDONE 0.5 MG TABLET OPEN Yes MINT-RISPERIDONE 1 MG TABLET OPEN Yes MINT-RISPERIDONE 2 MG TABLET OPEN Yes MINT-RISPERIDONE 3 MG TABLET OPEN Yes MINT-RISPERIDONE 4 MG TABLET OPEN Yes MINT-RIVASTIGMINE 1.5 MG CAP None Yes MINT-RIVASTIGMINE 3 MG CAP None Yes MINT-RIVASTIGMINE 4.5 MG CAP None Yes MINT-RIVASTIGMINE 6 MG CAP None Yes MINT-RIZATRIPTAN ODT 10 MG TAB None Yes MINT-RIZATRIPTAN ODT 5 MG TAB None Yes MINT-ROSUVASTATIN 10 MG TABLET OPEN None Yes MINT-ROSUVASTATIN 20 MG TABLET OPEN None Yes MINT-ROSUVASTATIN 40 MG TABLET OPEN None Yes MINT-ROSUVASTATIN 5 MG TABLET OPEN Yes MINT-SERTRALINE 100 MG CAPSULE OPEN Yes MINT-SERTRALINE 25 MG CAPSULE OPEN Yes MINT-SERTRALINE 50 MG CAPSULE OPEN Yes MINT-SIMVASTATIN 10 MG TABLET OPEN None Yes MINT-SIMVASTATIN 20 MG TABLET OPEN None Yes MINT-SIMVASTATIN 40 MG TABLET OPEN None Yes MINT-SIMVASTATIN 5 MG TABLET OPEN None Yes MINT-SIMVASTATIN 80 MG TABLET OPEN None Yes Page 129 Effective December 2015

130 Coverage Table December MINT-TOPIRAMATE 100 MG TABLET OPEN None Yes MINT-TOPIRAMATE 200 MG TABLET OPEN None Yes MINT-TOPIRAMATE 25 MG TABLET OPEN None Yes MINT-ZOLMITRIPTAN 2.5 MG TAB None Yes MINT-ZOPICLONE 5 MG TABLET OPEN Yes MINT-ZOPICLONE 7.5 MG TABLET OPEN Yes MIOCARPINE OPHTHALMIC SOLUTION OPEN None No MIOCARPINE OPHTHALMIC SOLUTION OPEN None No MIOCARPINE OPHTHALMIC SOLUTION OPEN None No MIRAPEX 0.25 MG TABLET OPEN None Yes MIRAPEX 1 MG TABLET OPEN None Yes MIRAPEX 1.5 MG TABLET OPEN None Yes MIRENA INTRAUTERINE SYSTEM OPEN None No MIRTAZAPINE 30 MG TABLET OPEN Yes MIRVALA 21 TABLET OPEN Beneficiary gender must be female - under the age of 51 Yes MIRVALA 28 TABLET OPEN Beneficiary gender must be female - under the age of 51 Yes MISOPROSTOL 100 MCG TABLET OPEN None Yes MISOPROSTOL 200 MCG TABLET OPEN None Yes MOBICOX 15 MG TABLET OPEN None Yes MOBICOX 7.5 MG TABLET OPEN None Yes MODECATE 25MG/ML VIAL OPEN No MODECATE CONC 100 MG/ML AMP OPEN No MODITEN ENANTHATE INJ 25MG/ML OPEN No MODITEN HCL TAB 10MG OPEN None No MODULON 200 MG TABLET OPEN None Yes MODULON TAB 100MG OPEN None Yes MODURET OPEN None Yes MOGADON 10 MG TABLET OPEN No Page 130 Effective December 2015

131 Coverage Table December MOGADON 5 MG TABLET OPEN No MONISTAT MG VAG OVULE OPEN None No MONISTAT 3 DUAL PAK 400 MG-2 % OPEN None No MONISTAT 7 100MG VAG SUPPOS OPEN None No MONISTAT 7 2 % VAGINAL CREAM OPEN None No MONISTAT 7 DUAL-PAK 100 MG-2 % OPEN None No MONISTAT DERM 2 % CREAM OPEN None No MONITAN 100 OPEN None Yes MONITAN 200 OPEN None Yes MONITAN 400 OPEN None Yes MONOCOR -(10MG) OPEN None Yes MONOCOR -(5MG) OPEN None Yes MONOJECT ALCOHOL WIPES OPEN None No MONOJECT SYR 1/2CC, 1CC & 3/10 OPEN None No MONOLET LANCET OPEN None No MONOPRIL 10 MG TABLET OPEN None Yes MONOPRIL 20 MG TABLET OPEN None Yes MONTELUKAST 10 MG TABLET None Yes MONTELUKAST 10 MG TABLET None Yes MONTELUKAST 4 MG TABLET CHEW None Yes MONTELUKAST 4 MG TABLET CHEW None Yes MONTELUKAST 4 MG TABLET CHEW None Yes MONTELUKAST 5 MG TABLET CHEW None Yes MONTELUKAST 5 MG TABLET CHEW None Yes MONTELUKAST 5 MG TABLET CHEW None Yes MONTELUKAST SODIUM 10 MG TAB None Yes MONUROL 3 GRAM PACKET None No MORPHINE HP MG/ML VIAL OPEN No MORPHINE HP MG/ML VIAL OPEN No MORPHINE SR 100 MG TABLET OPEN Yes MORPHINE SR 15 MG TABLET OPEN Yes Page 131 Effective December 2015

132 Coverage Table December MORPHINE SR 30 MG TABLET OPEN Yes MORPHINE SR 60 MG TABLET OPEN Yes MORPHINE SULF 10 MG/ML AMP OPEN No MORPHINE SULF 10 MG/ML AMP OPEN No MORPHINE SULF 15 MG/ML AMP OPEN No MORPHINE SULF 15 MG/ML VIAL OPEN No MORPHINE SULFATE 2 MG/ML VIAL OPEN No MOTILIUM TAB 10MG OPEN None Yes MOTRIN 200 MG TABLET OPEN None Yes MOTRIN 400 MG TABLET OPEN None Yes MOVISSE 0.35 MG TABLET OPEN Beneficiary gender must be female - under the age of 51 Yes MPD THIN LANCET OPEN None No MPD ULTRA THIN LANCET OPEN None No MS CONTIN 100 MG TABLET OPEN Yes MS CONTIN 15 MG TABLET OPEN Yes MS CONTIN 200 MG TABLET OPEN Yes MS CONTIN 30 MG TABLET OPEN Yes MS CONTIN 60 MG TABLET OPEN Yes MS IR SUP 30MG OPEN No MS IR SUP 10MG OPEN No MS IR SUP 20MG OPEN No Page 132 Effective December 2015

133 Coverage Table December MS-IR 10 MG TABLET OPEN No MS-IR 20 MG TABLET OPEN No MS-IR 30 MG TABLET OPEN No MS-IR 5 MG TABLET OPEN No MUCAINE SUSPENSION OPEN None No MUCOMYST 20% VIAL OPEN None No MULTISTIX OPEN None No MULTIVITAMIN MINERAL PLUS OPEN Beneficiary must have eligibility under the CF Plan No MURO 128 SOLN 5% OPEN None No MURO-128 5% OINTMENT OPEN None No MUSTARGEN 10 MG VIAL OPEN None No MVW COMPLETE FORMULA CHEWABLES None No MYAMBUTOL TABLETS MG OPEN None No MYCOBUTIN 150 MG CAPSULE None No MYCOSTATIN U/G POWDER OPEN None No MYCOSTATIN U/GM CREAM OPEN None No MYCOSTATIN ONT IU/GM OPEN None No MYCOSTATIN ORAL SUSPENSION 100 OPEN None No MYCOSTATIN VAG 25000U/G CRM OPEN None No MYDFRIN 2.5% EYE DROPS OPEN None No MYDRIACYL 0.5% EYE DROPS OPEN None No MYDRIACYL 1% EYE DROPS OPEN None No MYGLUCOHEALTH TEST STRIPS OPEN None No MYLAN-ACEBUTOLOL (S) 200 MG TB OPEN None Yes MYLAN-ACEBUTOLOL (TYPE S) 100 OPEN None Yes MYLAN-ACEBUTOLOL (TYPE S) 400 OPEN None Yes MYLAN-ACEBUTOLOL 100 MG TABLET OPEN None Yes MYLAN-ACEBUTOLOL 200 MG TABLET OPEN None Yes MYLAN-ACEBUTOLOL 400 MG TABLET OPEN None Yes MYLAN-ACYCLOVIR 200 MG TABLET OPEN None Yes MYLAN-ACYCLOVIR 400 MG TABLET OPEN None Yes Page 133 Effective December 2015

134 Coverage Table December MYLAN-ACYCLOVIR 800 MG TABLET OPEN None Yes MYLAN-ALENDRONATE 10 MG TABLET None Yes MYLAN-ALENDRONATE 70 MG TABLET None Yes MYLAN-ALMOTRIPTAN 12.5 MG TAB No Yes MYLAN-ALMOTRIPTAN 6.25 MG TAB None Yes MYLAN-ALPRAZOLAM 0.25 MG TAB OPEN Yes MYLAN-ALPRAZOLAM 0.5 MG TABLET OPEN Yes MYLAN-ALPRAZOLAM 1 MG TABLET OPEN Yes MYLAN-ALPRAZOLAM 2 MG TABLET OPEN Yes MYLAN-AMANTAE 100 MG CAP OPEN None Yes MYLAN-AMIODARONE 200 MG TABLET OPEN None Yes MYLAN-AMLODIPINE 10 MG TABLET OPEN None Yes MYLAN-AMLODIPINE 5 MG TABLET OPEN Yes MYLAN-AMOXICILLIN 250 MG CAP OPEN None Yes MYLAN-AMOXICILLIN 500 MG CAP OPEN None Yes MYLAN-ANAGRELIDE 0.5 MG CAP OPEN None Yes MYLAN-ANASTROZOLE 1 MG TABLET None Yes MYLAN-ATENOLOL 100 MG TABLET OPEN None Yes MYLAN-ATENOLOL 25 MG TABLET OPEN None No MYLAN-ATENOLOL 50 MG TABLET OPEN None Yes MYLAN-ATORVASTATIN 10 MG TAB OPEN None Yes MYLAN-ATORVASTATIN 20 MG TAB OPEN None Yes MYLAN-ATORVASTATIN 40 MG TAB OPEN None Yes MYLAN-ATORVASTATIN 80 MG TAB OPEN None Yes MYLAN-AZATHIOPRINE 50 MG TAB OPEN None Yes MYLAN-AZITHROMYCIN 250 MG TAB OPEN None Yes MYLAN-BACLOFEN 10 MG TABLET OPEN None Yes MYLAN-BACLOFEN 20 MG TABLET OPEN None Yes MYLAN-BECLO AQ 50 MCG SPRAY OPEN None Yes MYLAN-BICALUTAMIDE 50 MG TAB OPEN None Yes MYLAN-BISOPROLOL 10 MG TABLET OPEN None Yes MYLAN-BISOPROLOL 5 MG TABLET OPEN None Yes Page 134 Effective December 2015

135 Coverage Table December MYLAN-BOSENTAN 125 MG TABLET None Yes MYLAN-BOSENTAN 62.5 MG TABLET None Yes MYLAN-BUDESONIDE AQ 100 MCG OPEN None Yes MYLAN-BUDESONIDE AQ 64 MCG SPY OPEN None Yes MYLAN-BUPRENOR/NALOX 2-0.5MG None Yes MYLAN-BUPRENOR/NALOX 8-2MG None Yes a) Limited to 1 per day without Special b) Special Authorzation MYLAN-BUPROPION XL 150 MG TAB OPEN required if beneficiary has not had a paid Yes claim for an anti-depressant or Bupropion in past year MYLAN-BUPROPION XL 300 MG TAB OPEN a) Limited to 1 per day without Special b) Special Authorzation required if beneficiary has not had a paid Yes claim for an anti-depressant or Bupropion in past year MYLAN-CANDESARTAN 16 MG TABLET OPEN Yes MYLAN-CANDESARTAN 32 MG TABLET OPEN Yes MYLAN-CANDESARTAN 8 MG TABLET OPEN Yes MYLAN-CAPTOPRIL 100 MG TABLET OPEN None Yes MYLAN-CAPTOPRIL 12.5 MG TABLET OPEN None Yes MYLAN-CAPTOPRIL 25 MG TABLET OPEN None Yes MYLAN-CAPTOPRIL 50 MG TABLET OPEN None Yes MYLAN-CARBAMAZE CR 200 MG TAB OPEN None Yes MYLAN-CARBAMAZE CR 400 MG TAB OPEN None Yes MYLAN-CARVEDILOL 12.5 MG TAB None Yes MYLAN-CARVEDILOL 25 MG TABLET None Yes MYLAN-CARVEDILOL MG TAB None Yes MYLAN-CARVEDILOL 6.25 MG TAB None Yes MYLAN-CELECOXIB 100 MG CAPSULE OPEN Limit of 2 per day without Special Yes MYLAN-CELECOXIB 200 MG CAPSULE OPEN Limit of 2 per day without Special Yes MYLAN-CILAZAPRIL 1 MG TABLET OPEN None Yes Page 135 Effective December 2015

136 Coverage Table December MYLAN-CILAZAPRIL 2.5 MG TABLET OPEN None Yes MYLAN-CILAZAPRIL 5 MG TABLET OPEN None Yes MYLAN-CIMETIE 300 MG TABLET OPEN None Yes MYLAN-CIMETIE 400 MG TABLET OPEN None Yes MYLAN-CIMETIE 600 MG TABLET OPEN None Yes MYLAN-CIMETIE 800 MG TABLET OPEN None Yes MYLAN-CIPROFLOXACIN 250 MG TAB OPEN None Yes MYLAN-CIPROFLOXACIN 500 MG TAB OPEN None Yes MYLAN-CIPROFLOXACIN 750 MG TAB OPEN None Yes MYLAN-CITALOPRAM 20 MG TABLET OPEN. Maximum of 1.5 tablets Yes daily MYLAN-CITALOPRAM 40 MG TABLET OPEN Yes MYLAN-CLARITHROMYCIN 250 MG TB OPEN None Yes MYLAN-CLARITHROMYCIN 500 MG TB OPEN None Yes MYLAN-CLINDAMYCIN 150 MG CAP OPEN None Yes MYLAN-CLINDAMYCIN 300 MG CAP OPEN None Yes MYLAN-CLOBETASOL 0.05% CREAM OPEN None Yes MYLAN-CLOBETASOL 0.05% OINT OPEN None Yes MYLAN-CLOBETASOL 0.05% SOLN OPEN None Yes MYLAN-CLONAZEPAM 0.5 MG TABLET OPEN Yes MYLAN-CLONAZEPAM 2 MG TABLET OPEN Yes MYLAN-CLOPIDOGREL 75 MG TABLET None Yes MYLAN-CYCLOBENZAPRINE 10 MG TB OPEN None Yes MYLAN-DOMPERIDONE 10 MG TABLET OPEN None Yes MYLAN-DONEPEZIL 10 MG TABLET No Yes MYLAN-DONEPEZIL 5 MG TABLET No Yes MYLAN-DOXAZOSIN 1 MG TABLET OPEN None Yes MYLAN-DOXAZOSIN 2 MG TABLET OPEN None Yes MYLAN-DOXAZOSIN 4 MG TABLET OPEN None Yes MYLAN-EFAVIRENZ 600 MG TABLET OPEN Yes MYLAN-ENALAPRIL 16 MG (20 MG) OPEN None Yes Page 136 Effective December 2015

137 Coverage Table December MYLAN-ENALAPRIL 2 MG (2.5 MG) OPEN None Yes MYLAN-ENALAPRIL 4 MG (5 MG) TB OPEN None Yes MYLAN-ENALAPRIL 8 MG (10 MG) OPEN None Yes MYLAN-ENTACAPONE 200 MG TABLET OPEN None Yes MYLAN-ETI-CAL CAREPAC TAB OPEN None Yes MYLAN-ETIDRONATE 200 MG TABLET OPEN None Yes MYLAN-EZETIMIBE 10 MG TABLET None Yes MYLAN-FENOFIBRATE MICRO 200 MG OPEN None Yes MYLAN-FINASTERIDE 5 MG TABLET None Yes MYLAN-FLUCONAZOLE 100 MG TAB OPEN None Yes MYLAN-FLUCONAZOLE 50 MG TABLET OPEN None Yes MYLAN-FLUOXETINE 10 MG CAPSULE OPEN Yes MYLAN-FLUOXETINE 20 MG CAPSULE OPEN Yes MYLAN-FOSINOPRIL 10 MG TABLET OPEN None Yes MYLAN-FOSINOPRIL 20 MG TABLET OPEN None Yes MYLAN-GABAPENTIN 100 MG CAP None Yes MYLAN-GABAPENTIN 300 MG CAP None Yes MYLAN-GABAPENTIN 400 MG CAP None Yes MYLAN-GABAPENTIN 600 MG TABLET None Yes MYLAN-GABAPENTIN 800 MG TABLET None Yes MYLAN-GALANTAMINE ER 16 MG CAP None Yes MYLAN-GALANTAMINE ER 24 MG CAP None Yes MYLAN-GALANTAMINE ER 8 MG CAP None Yes MYLAN-GEMFIBROZIL 300 MG CAP OPEN None Yes MYLAN-GEMFIBROZIL 600 MG TAB OPEN None Yes MYLAN-GLICLAZIDE 80 MG TABLET OPEN None Yes MYLAN-GLYBE 2.5 MG TABLET OPEN None Yes MYLAN-GLYBE 5 MG TABLET OPEN None Yes MYLAN-HYDROXYCHLOROQ 200 MG TB OPEN None Yes MYLAN-HYDROXYUREA 500 MG CAP OPEN None Yes MYLAN-INDAPAMIDE 1.25 MG TAB OPEN None Yes MYLAN-INDAPAMIDE 2.5 MG TABLET OPEN None Yes MYLAN-IPRATROPIUM 250 MCG/ML None Yes Page 137 Effective December 2015

138 Coverage Table December MYLAN-IRBESARTAN 150 MG TABLET OPEN Yes MYLAN-IRBESARTAN 300 MG TABLET OPEN Yes MYLAN-IRBESARTAN 75 MG TABLET OPEN Yes MYLAN-LAMOTRIGINE 100 MG TAB OPEN None Yes MYLAN-LAMOTRIGINE 150 MG TAB OPEN None Yes MYLAN-LAMOTRIGINE 25 MG TABLET OPEN None Yes MYLAN-LANSOPRAZOLE DR 15MG CAP None Yes MYLAN-LANSOPRAZOLE DR 30MG CAP None Yes MYLAN-LEFLUNOMIDE 10 MG TABLET OPEN None Yes MYLAN-LEFLUNOMIDE 20 MG TABLET OPEN None Yes MYLAN-LEVOFLOXACIN 250 MG TAB None Yes MYLAN-LEVOFLOXACIN 500 MG TAB None Yes MYLAN-LISINOPRIL 10 MG TABLET OPEN None Yes MYLAN-LISINOPRIL 20 MG TABLET OPEN None Yes MYLAN-LISINOPRIL 5 MG TABLET OPEN None Yes MYLAN-LISINOPRIL HCTZ OPEN None Yes MYLAN-LISINOPRIL HCTZ 20/12.5 OPEN None Yes MYLAN-LISINOPRIL HCTZ 20/25 OPEN None Yes MYLAN-LOSARTAN 100 MG TABLET OPEN Yes MYLAN-LOSARTAN 25 MG TABLET OPEN Yes MYLAN-LOSARTAN 50 MG TABLET OPEN Yes MYLAN-LOVASTATIN 20 MG TABLET OPEN None Yes MYLAN-LOVASTATIN 40 MG TABLET OPEN None Yes MYLAN-MELOXICAM 15 MG TABLET OPEN None Yes MYLAN-MELOXICAM 7.5 MG TABLET OPEN None Yes MYLAN-METFORMIN 500 MG TABLET OPEN None Yes MYLAN-METFORMIN 850 MG TABLET OPEN None Yes MYLAN-METOPROLOL(TYPE L) 100MG OPEN None Yes MYLAN-METOPROLOL(TYPE L) 25 MG OPEN None No Page 138 Effective December 2015

139 Coverage Table December MYLAN-METOPROLOL(TYPE L) 50 MG OPEN None Yes MYLAN-MINOCYCLINE 100 MG CAP OPEN None Yes MYLAN-MINOCYCLINE 50 MG CAP OPEN None Yes MYLAN-MIRTAZAPINE 15 MG TABLET OPEN No MYLAN-MIRTAZAPINE 30 MG TABLET OPEN Yes MYLAN-MONTELUKAST 10 MG TABLET None Yes MYLAN-MONTELUKAST 4 MG TB CHEW None Yes MYLAN-MONTELUKAST 5 MG TB CHEW None Yes MYLAN-NABUMETONE 500 MG TABLET OPEN None Yes MYLAN-NEVIRAPINE 200 MG TABLET OPEN Yes MYLAN-NIFEDIPINE ER 30 MG TAB OPEN None Yes MYLAN-NIFEDIPINE ER 60 MG TAB OPEN None Yes MYLAN-NITRO 0.2 MG/HR PATCH OPEN None Yes MYLAN-NITRO 0.4 MG/DOSE SPRAY OPEN None No MYLAN-NITRO 0.4 MG/HR PATCH OPEN None Yes MYLAN-NITRO 0.6 MG/HR PATCH OPEN None Yes MYLAN-NITRO 0.8 MG/HR PATCH OPEN None Yes MYLAN-OLANZAPINE 10 MG TABLET Yes MYLAN-OLANZAPINE 15 MG TABLET Yes MYLAN-OLANZAPINE 2.5 MG TABLET Yes MYLAN-OLANZAPINE 5 MG TABLET Yes MYLAN-OLANZAPINE 7.5 MG TABLET Yes MYLAN-OLANZAPINE ODT 10 MG TAB Yes MYLAN-OLANZAPINE ODT 15 MG TAB Yes Page 139 Effective December 2015

140 Coverage Table December MYLAN-OLANZAPINE ODT 20 MG TAB Yes MYLAN-OLANZAPINE ODT 5 MG TAB Yes MYLAN-OMEPRAZOLE 20 MG CAP DR OPEN Yes MYLAN-OMEPRAZOLE DR 10 MG CAP OPEN Yes MYLAN-ONDANSETRON 4 MG TABLET OPEN Limit of 3 tablets per cycle - first fill only. Special is required for higher Yes quantities and/or subsequent fills MYLAN-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 MYLAN-OXYBUTYNIN 5 MG TABLET OPEN None Yes MYLAN-PANTOPRAZOLE DR 40 MG TB OPEN Yes MYLAN-PAROXETINE 10 MG TABLET OPEN. Limit of 1 per day Yes without Special MYLAN-PAROXETINE 20 MG TABLET OPEN Yes MYLAN-PAROXETINE 30 MG TABLET OPEN Yes MYLAN-PIOGLITAZONE 15 MG TAB None Yes MYLAN-PIOGLITAZONE 30 MG TAB None Yes MYLAN-PIOGLITAZONE 45 MG TAB None Yes MYLAN-PRAMIPEXOLE 0.25 MG TAB OPEN None Yes MYLAN-PRAMIPEXOLE 1 MG TABLET OPEN None Yes MYLAN-PRAMIPEXOLE 1.5 MG TAB OPEN None Yes MYLAN-PRAVASTIN 10 MG TABLET OPEN None Yes MYLAN-PRAVASTIN 20 MG TABLET OPEN None Yes MYLAN-PRAVASTIN 40 MG TABLET OPEN None Yes MYLAN-PROPAFENONE 150 MG TAB OPEN None Yes MYLAN-PROPAFENONE 300 MG TAB OPEN None Yes MYLAN-QUETIAPINE 100 MG TABLET OPEN Yes Page 140 Effective December 2015

141 Coverage Table December MYLAN-QUETIAPINE 200 MG TABLET OPEN Yes MYLAN-QUETIAPINE 25 MG TABLET OPEN Yes MYLAN-QUETIAPINE 300 MG TABLET OPEN Yes MYLAN-RABEPRAZOLE EC 10 MG TAB OPEN Limit of 2 per day without Special Yes MYLAN-RABEPRAZOLE EC 20 MG TAB OPEN Yes MYLAN-RAMIPRIL 1.25 MG CAPSULE OPEN None Yes MYLAN-RAMIPRIL 10 MG CAPSULE OPEN None Yes MYLAN-RAMIPRIL 2.5 MG CAPSULE OPEN None Yes MYLAN-RAMIPRIL 5 MG CAPSULE OPEN None Yes MYLAN-RANITIE 150 MG TABLET OPEN None Yes MYLAN-RANITIE 300 MG TABLET OPEN None Yes MYLAN-RILUZOLE 50 MG TABLET None Yes MYLAN-RISEDRONATE 35 MG TABLET None Yes MYLAN-RISPERIDONE 0.25 MG TAB OPEN Yes MYLAN-RISPERIDONE 0.5 MG TAB OPEN Yes MYLAN-RISPERIDONE 1 MG TABLET OPEN Yes MYLAN-RISPERIDONE 2 MG TABLET OPEN Yes MYLAN-RISPERIDONE 3 MG TABLET OPEN Yes MYLAN-RISPERIDONE 4 MG TABLET OPEN Yes MYLAN-RISPERIDONE ODT 1 MG TAB Yes MYLAN-RISPERIDONE ODT 2 MG TAB Yes MYLAN-RISPERIDONE ODT 3 MG TAB Yes Page 141 Effective December 2015

142 Coverage Table December MYLAN-RISPERIDONE ODT 4 MG TAB Yes MYLAN-RIZATRIPTAN ODT 10 MG TB None Yes MYLAN-RIZATRIPTAN ODT 5 MG TAB None Yes MYLAN-ROSUVASTATIN 10 MG TAB OPEN None Yes MYLAN-ROSUVASTATIN 20 MG TAB OPEN None Yes MYLAN-ROSUVASTATIN 40 MG TAB OPEN None Yes MYLAN-ROSUVASTATIN 5 MG TABLET OPEN Yes MYLAN-SELEGILINE 5 MG TABLET OPEN None Yes MYLAN-SERTRALINE 100 MG CAP OPEN Yes MYLAN-SERTRALINE 25 MG CAPSULE OPEN Yes MYLAN-SERTRALINE 50 MG CAPSULE OPEN Yes MYLAN-SIMVASTATIN 10 MG TABLET OPEN None Yes MYLAN-SIMVASTATIN 20 MG TABLET OPEN None Yes MYLAN-SIMVASTATIN 40 MG TABLET OPEN None Yes MYLAN-SIMVASTATIN 5 MG TABLET OPEN None Yes MYLAN-SIMVASTATIN 80 MG TABLET OPEN None Yes MYLAN-SOTALOL 160 MG TABLET OPEN None Yes MYLAN-SOTALOL 80 MG TABLET OPEN None Yes MYLAN-SUMATRIPTAN 100 MG TAB None Yes MYLAN-SUMATRIPTAN 25 MG TABLET None Yes MYLAN-SUMATRIPTAN 50 MG TABLET None Yes MYLANTA PLAIN DS SUSPENSION OPEN None No MYLAN-TAMOXIFEN 10 MG TABLET OPEN None Yes MYLAN-TAMOXIFEN 20 MG TABLET OPEN None Yes MYLAN-TAMSULOSIN 0.4 MG CAP SA OPEN Limit of 2 per day without Special Yes MYLAN-TELMISARTAN 40 MG TABLET OPEN Yes MYLAN-TELMISARTAN 80 MG TABLET OPEN Yes MYLAN-TERAZOSIN 1 MG TABLET OPEN None Yes MYLAN-TERAZOSIN 10 MG TABLET OPEN None Yes Page 142 Effective December 2015

143 Coverage Table December MYLAN-TERAZOSIN 2 MG TABLET OPEN None Yes MYLAN-TERAZOSIN 5 MG TABLET OPEN None Yes MYLAN-TERBINAFINE 250 MG TAB OPEN None Yes MYLAN-TICLOPIE 250 MG TAB OPEN None Yes MYLAN-TIZANIE 4 MG TABLET Special Authorzation required if beneficiary has not had a paid claim for Baclofen or Yes Zanaflex in past year MYLAN-TOPIRAMATE 100 MG TABLET OPEN None Yes MYLAN-TOPIRAMATE 200 MG TABLET OPEN None Yes MYLAN-TOPIRAMATE 25 MG TABLET OPEN None Yes MYLAN-TRAZODONE 100 MG TABLET OPEN Yes MYLAN-TRAZODONE 50 MG TABLET OPEN Yes MYLAN-VALACYCLOVIR 500 MG TAB OPEN None Yes MYLAN-VALSARTAN 160 MG TABLET OPEN Yes MYLAN-VALSARTAN 320 MG TABLET OPEN Yes MYLAN-VALSARTAN 40 MG TABLET OPEN Yes MYLAN-VALSARTAN 80 MG TABLET OPEN Yes MYLAN-VALSARTAN HCTZ MG OPEN Yes MYLAN-VALSARTAN HCTZ MG OPEN Yes MYLAN-VENLAFAXINE XR 150 MG CP OPEN Yes MYLAN-VENLAFAXINE XR 37.5 MG OPEN Yes MYLAN-VENLAFAXINE XR 75 MG CAP OPEN Yes MYLAN-VERAPAMIL 120 MG TABLET OPEN None Yes MYLAN-VERAPAMIL 80 MG TABLET OPEN None Yes MYLAN-VERAPAMIL SR 120 MG TAB OPEN None Yes MYLAN-VERAPAMIL SR 180 MG TAB OPEN None Yes Page 143 Effective December 2015

144 Coverage Table December MYLAN-VERAPAMIL SR 240 MG TAB OPEN None Yes MYLAN-WARFARIN 1 MG TABLET OPEN None Yes MYLAN-WARFARIN 10 MG TABLET OPEN None Yes MYLAN-WARFARIN 2 MG TABLET OPEN None Yes MYLAN-WARFARIN 2.5 MG TABLET OPEN None Yes MYLAN-WARFARIN 3 MG TABLET OPEN None Yes MYLAN-WARFARIN 4 MG TABLET OPEN None Yes MYLAN-WARFARIN 5 MG TABLET OPEN None Yes MYLAN-WARFARIN 6 MG TABLET OPEN None Yes MYLAN-ZOLMITRIPT ODT 2.5MG TAB None Yes MYLAN-ZOPICLONE 5 MG TABLET OPEN Yes MYLAN-ZOPICLONE 7.5 MG TABLET OPEN Yes MYLERAN 2 MG TABLET OPEN None No MYL-LETROZOLE 2.5 MG TABLET None Yes MYL-PREGABALIN 150 MG CAPSULE None Yes MYL-PREGABALIN 25 MG CAPSULE None Yes MYL-PREGABALIN 300 MG CAPSULE None Yes MYL-PREGABALIN 50 MG CAPSULE None Yes MYL-PREGABALIN 75 MG CAPSULE None Yes MYL-RANITIE 150 MG TABLET OPEN None Yes MYL-RANITIE 300 MG TABLET OPEN None Yes MYOCHRYSINE 10 MG/ML AMPOULE OPEN None No MYOCHRYSINE 25 MG/ML AMPOULE OPEN None No MYOCHRYSINE 50 MG/ML AMPOULE OPEN None No MYRBETRIQ ER 25 MG TABLET None No MYRBETRIQ ER 50 MG TABLET None No MYSOLINE 250MG TABLET OPEN None No NADOLOL 160 MG TABLET OPEN None Yes NADOLOL 40 MG TABLET OPEN None Yes NADOLOL 80 MG TABLET OPEN None Yes NADOPEN V 200 OPEN None Yes NADOPEN V TAB IU OPEN None Yes NADOSTINE IU/GM CREAM OPEN None No NADOSTINE IU/GM OINT OPEN None No NADOSTINE U/ML SUSP OPEN None No Page 144 Effective December 2015

145 Coverage Table December NADOSTINE VAGINAL TABLET OPEN None No NALCROM 100 MG CAPSULE OPEN None No NALFON TAB 600MG OPEN None No NAPHCON A % EYE DROPS OPEN None No NAPROSYN 500 MG SUPPOSITORIES OPEN None No NAPROSYN 500 MG TABLETS OPEN None Yes NAPROSYN SR 750 MG TABLET OPEN None No NAPROXEN 125 MG/5 ML SUSP OPEN None No NAPROXEN 250 MG TABLET OPEN None Yes NAPROXEN 375 MG TABLET OPEN None No NAPROXEN 375 MG TABLET OPEN None Yes NAPROXEN 500 MG TABLET OPEN None Yes NAPROXEN SODIUM 275 MG TABLET OPEN None Yes NAPROXEN SODIUM DS 550 MG TAB OPEN None Yes NARDIL 15 MG TABLET OPEN No NASACORT 100MCG INHALER OPEN None No NASACORT AQ 55 MCG NASAL SPRAY OPEN None No NASONEX 50 MCG NASAL SPRAY OPEN None Yes NAT-ALPRAZOLAM 0.25 MG TABLET OPEN Yes NAT-ALPRAZOLAM 0.5MG TABLET OPEN Yes NAT-ANASTROZOLE 1 MG TABLET None Yes NAT-CITALOPRAM 20 MG TABLET OPEN. Maximum of 1.5 tablets Yes daily NAT-CITALOPRAM 40 MG TABLET OPEN Yes NAT-DONEPEZIL 10 MG TABLET No Yes NAT-DONEPEZIL 5 MG TABLET No Yes NAT-LETROZOLE 2.5 MG TABLET None Yes NAT-OMEPRAZOLE DR 20MG TABLET OPEN Yes NAT-ONDANSETRON 4 MG TABLET OPEN Limit of 3 tablets per cycle - first fill only. Special is required for higher quantities and/or subsequent fills Yes Page 145 Effective December 2015

146 Coverage Table December NAT-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 NAT-QUETIAPINE 100MG TABLET OPEN Yes NAT-QUETIAPINE 200MG TABLET OPEN Yes NAT-QUETIAPINE 25MG TABLET OPEN Yes NAT-QUETIAPINE 300MG TABLET OPEN Yes NAT-RIZATRIPTAN ODT 10 MG TAB None Yes NAT-RIZATRIPTAN ODT 5 MG TAB None Yes NAT-ZOLMITRIPTAN 2.5 MG TABLET None Yes NAVANE 10 MG CAPSULE OPEN No NAVANE 2 MG CAPSULE OPEN No NAVANE 5 MG CAPSULE OPEN No NEBCIN INJ 10MG/ML OPEN None No NEBCIN INJ 40MG/ML OPEN None No NEBUSAL 7% None No NEGGRAM 500 MG CAPLET OPEN None No NEMBUTAL SODIUM CAP 100MG OPEN No NEO-CORTEF 0.5% OINTMENT OPEN None No NEO-CORTEF 1% OINTMENT OPEN None No NEO-MEDROL ACNE LOTION OPEN None No NEO-MEDROL CREAM OPEN None No NEORAL 100 MG CAPSULE OPEN None Yes NEORAL 100 MG/ML SOLUTION OPEN None Yes NEORAL 25 MG CAPSULE OPEN None No NEORAL 50 MG CAPSULE OPEN None No NEOSPORIN CREAM OPEN None No NEOSPORIN EYE/EAR DROPS OPEN None No NEOSPORIN IRRIGATING SOLN OPEN None No Page 146 Effective December 2015

147 Coverage Table December NEOSPORIN OINTMENT OPEN None No NEOSPORIN OPHTHALMIC OINTMENT OPEN None No NEOSTIGMINE 0.5 MG/ML VIAL OPEN None No NEOSTIGMINE 2.5 MG/ML VIAL OPEN None No NEOSTIGMINE MS 1 MG/ML VIAL OPEN None No NEOTOPIC OINTMENT OPEN None No NEPTAZANE TABLETS 50MG OPEN None No NERISALIC OILY CREAM OPEN None No NERISONE 0.1 % CREAM OPEN None No NERISONE 0.1 % OILY CREAM OPEN None No NERISONE 0.1 % OINTMENT OPEN None No NETROMYCIN 100MG/ML VIAL OPEN None No NETROMYCIN 50MG/ML VIAL OPEN None No NEULEPTIL 10 MG CAPSULE OPEN No NEULEPTIL 10 MG/ML DROPS OPEN No NEULEPTIL 20 MG CAPSULE OPEN No NEULEPTIL 5 MG CAPSULE OPEN No NEUPOGEN 300MCG/ML VIAL OPEN Can be dispensed by Hospital or RHA Clinic without prior approval No NEURONTIN 100 MG CAPSULE None Yes NEURONTIN 300 MG CAPSULE None Yes NEURONTIN 400 MG CAPSULE None Yes NEURONTIN 600 MG TABLET None Yes NEURONTIN 800 MG TABLET None Yes NEXAVAR 200 MG TABLET None No NIACIN 100 MG TABLET OPEN None No NIACIN 50 MG TABLET OPEN None No NIACIN 500 MG TABLET OPEN None No NIACIN 500 MG TABLET OPEN None No NIACIN 500 MG TABLET OPEN None No NIFEDIPINE 10 MG CAPSULE OPEN None Yes NIFEDIPINE 5 MG CAPSULE OPEN None Yes NILSTAT 25000U/G VAG CREAM OPEN None No Page 147 Effective December 2015

148 Coverage Table December NITRO-DUR 0.2 MG/HR PATCH OPEN None Yes NITRO-DUR 0.3MG/HR PATCH OPEN None No NITRO-DUR 0.4 MG/HR PATCH OPEN None Yes NITRO-DUR 0.6 MG/HR PATCH OPEN None Yes NITRO-DUR 0.8 MG/HR PATCH OPEN None Yes NITROFURANTOIN 100 MG TABLET OPEN None No NITROFURANTOIN 50 MG TABLET OPEN None No NITROL 2% OINTMENT OPEN None No NITROLINGUAL 0.4 MG/DOSE SPR OPEN None Yes NITROSTAT 0.3MG TAB SUBLINGUAL OPEN None No NITROSTAT 0.6 MG TABLET SL OPEN None No NIZORAL CREAM 2% OPEN None Yes NOLVADEX TAB 10MG OPEN None Yes NOLVADEX-D 20 MG TABLET OPEN None Yes NOOTROPIL 800MG TALBLET OPEN Can be dispensed by Hospital or RHA Clinic without prior approval No NORFLEX 30 MG/ML VIAL OPEN None No NORGESIC FORTE TABLET OPEN None No NORGESIC TABLET OPEN None No NORITATE 1% CREAM OPEN None No NOROXIN OPEN None Yes NORPACE CR 150MG TABLET SA OPEN None No NORPRAMIN 25MG TAB OPEN Yes NORPRAMIN 50MG TAB OPEN Yes NORPROLAC MG TABLET Special Authorzation required if beneficiary has not had a paid claim for Dostinex, No Norprolac, or Bromocriptine in past year NORPROLAC MG TABLET Special Authorzation required if beneficiary has not had a paid claim for Dostinex, No Norprolac, or Bromocriptine in past year NORVASC 10 MG TABLET OPEN None Yes NORVASC 5 MG TABLET OPEN Yes NORVIR 100 MG TABLET OPEN No Page 148 Effective December 2015

149 Coverage Table December NORVIR 80 MG/ML SOLUTION OPEN No NORVIR SEC 100 MG CAPSULE OPEN No NOVA T IUD OPEN Beneficiary gender must be female - under the age of 51 No NOVAMILOR 5 MG-50 MG TABLET OPEN None Yes NOVAMOXIN 125 MG/5 ML SUSP OPEN None Yes NOVAMOXIN 125 MG/5 ML SUSP OPEN None No NOVAMOXIN 250 MG CAPSULE OPEN None Yes NOVAMOXIN 250 MG/5 ML SUSP OPEN None Yes NOVAMOXIN 250 MG/5 ML SUSP OPEN None No NOVAMOXIN 500 MG CAPSULE OPEN None Yes NOVASEN DR 650 MG TABLET OPEN None Yes NOVO GLUCOSE TEST STRIPS OPEN a) Limited to 2500 per year without Special b) Beneficiary must have diabetic medication within previous year No history, otherwise Special is required NOVO TWIST 30G TIP NEEDLES OPEN None No NOVO TWIST 32G TIP NEEDLES OPEN None No NOVO-ATORVASTATIN 10 MG TABLET OPEN None Yes NOVO-ATORVASTATIN 20 MG TABLET OPEN None Yes NOVO-ATORVASTATIN 40 MG TABLET OPEN None Yes NOVO-ATORVASTATIN 80 MG TABLET OPEN None Yes NOVO-AZITHROMYCIN 100 MG/5 ML OPEN None Yes NOVO-AZITHROMYCIN 200 MG/5 ML OPEN None Yes NOVO-AZITHROMYCIN 250 MG TAB OPEN None Yes NOVO-BENZYDAMINE 0.15% SOLN OPEN None No NOVO-CHLORPROMAZINE 10MG TB OPEN No NOVO-CILAZAPRIL/HCTZ 5/12.5 OPEN None Yes NOVO-CIMETINE 150MG/ML VIAL OPEN None No NOVO-CIMETINE 300 MG TABLET OPEN None Yes NOVO-CIMETINE 400 MG TABLET OPEN None Yes NOVO-CIMETINE 600 MG TABLET OPEN None Yes NOVO-CIPROFLOXACIN 250 MG TB OPEN None Yes Page 149 Effective December 2015

150 Coverage Table December NOVO-CLAVAMOXIN 875 TABLET OPEN None Yes NOVO-CLOBAZAM 10 MG TABLET OPEN Yes NOVO-CLOBETASOL 0.05% CREAM OPEN None Yes NOVO-CLOBETASOL 0.05% OINT OPEN None Yes NOVO-CLOXIN 125 MG/5 ML SOLN OPEN None Yes NOVO-CLOXIN 250 MG CAPSULE OPEN None Yes NOVO-CLOXIN 500 MG CAPSULE OPEN None Yes NOVO-CYCLOPRINE 10 MG TABLET OPEN None Yes NOVO-DESIPRAMINE 25 MG TAB OPEN No NOVO-DIFENAC 100 MG SUPPOS OPEN None No NOVO-DIFENAC 50 MG SUPPOS OPEN None No NOVO-DIFLUNISAL 250 MG TABLET OPEN None Yes NOVO-DIFLUNISAL 500 MG TABLET OPEN None Yes NOVO-DIPIRADOL 50MG TABLET OPEN None No NOVO-DOCUSATE 100 MG CAPSULE OPEN Reasonable Based Pricing is applied No NOVO-DOXEPIN 150 MG CAPSULE OPEN Yes NOVO-ETIDRONATECAL COMBO OPEN None Yes NOVO-FENOFIB MIC 67 MG CAP OPEN None Yes NOVO-FENOFIBRATE MIC 200MG CAP OPEN None Yes NOVO-FERROGLUC 300 MG TABLET OPEN None No NOVO-FERROGLUC 300 MG TABLET OPEN None No NOVOFINE 28G PEN NEEDLE OPEN None No NOVOFINE 30G 6MM PEN NEEDLE OPEN None No NOVOFINE 30G 8MM PEN NEEDLE OPEN None No NOVOFINE 32G TIP (ETW) 6MM OPEN None No NOVOFINE PLUS 32G 4 MM OPEN None No NOVO-FLUCONAZOLE 100 MG TAB OPEN None Yes NOVO-FLUCONAZOLE 50 MG TAB OPEN None Yes NOVO-FLUVOXAMINE 100 MG TAB OPEN Yes NOVO-FLUVOXAMINE 50 MG TAB OPEN Yes NOVO-GESIC-C15 TABLET OPEN No Page 150 Effective December 2015

151 Coverage Table December NOVO-GESIC-C30 TABLET OPEN No NOVO-GLIMEPIRIDE 1 MG TABLET OPEN None Yes NOVO-GLIMEPIRIDE 2 MG TABLET OPEN None Yes NOVO-GLIMEPIRIDE 4 MG TABLET OPEN None Yes NOVO-HYDROCORT 0.5% CREAM OPEN None No NOVO-HYDROCORT 1% CREAM OPEN None No NOVO-HYDROXYZIN 10 MG CAP OPEN None Yes NOVO-HYDROXYZIN 25 MG CAP OPEN None Yes NOVO-HYDROXYZIN 50 MG CAP OPEN None Yes NOVO-HYLAZIN TAB 10MG USP OPEN None Yes NOVO-IPRAMIDE 250 MCG/ML SOL None Yes NOVO-KETO 100MG SUPPOSITORY OPEN None No NOVO-KETOROLAC 10 MG TABLET OPEN None Yes NOVO-LENTE-K 8MEQ TABLET OPEN None No NOVOLIN 30/70 OPEN None No NOVOLIN GE 10/90 100U/ML CT OPEN None No NOVOLIN GE 20/80 100U/ML CT OPEN None No NOVOLIN GE 30/ UNIT/ML OPEN None No NOVOLIN GE 30/ UNIT/ML OPEN None No NOVOLIN GE 40/ UNIT/ML OPEN None No NOVOLIN GE 50/ UNIT/ML OPEN None No NOVOLIN GE LENTE INJ SC 100U/M OPEN None No NOVOLIN GE NPH 100 UNIT/ML VL OPEN None No NOVOLIN GE NPH PEN 100 UNIT/ML OPEN None No NOVOLIN GE TORONTO 100 UNIT/ML OPEN None No NOVOLIN GE TORONTO 100 UNIT/ML OPEN None No NOVOLIN GE ULTRALENTE INJ SUS OPEN None No NOVOLIN NPH 100 OPEN None No NOVO-LOPERAMIDE 2 MG TABLET None No NOVO-METHACIN 100MG SUPP OPEN None No NOVO-METHACIN 50MG SUPP OPEN None No NOVO-MEXILETINE 100 MG CAP OPEN None Yes NOVO-MEXILETINE 200 MG CAP OPEN None Yes NOVO-NIDAZOL 250 MG TABLET OPEN None Yes NOVO-PEN-VK 300 MG/5 ML SUSP OPEN None Yes NOVO-PEN-VK MG TAB OPEN None Yes Page 151 Effective December 2015

152 Coverage Table December NOVO-PERIDOL 0.5 MG TABLET OPEN Yes NOVO-PERIDOL 1 MG TABLET OPEN Yes NOVO-PERIDOL 10 MG TABLET OPEN Yes NOVO-PERIDOL 2 MG TABLET OPEN Yes NOVO-PERIDOL 20 MG TABLET OPEN No NOVO-PERIDOL 5 MG TABLET OPEN Yes NOVO-PHENIRAM 4 MG TABLET OPEN None No NOVO-PROFEN 200 MG TABLET OPEN None Yes NOVO-PROFEN 400 MG TABLET OPEN None Yes NOVO-PROFEN 600 MG TABLET OPEN None Yes NOVORAPID 100 UNIT/ML CART None No NOVORAPID 100 UNIT/ML VIAL None No NOVORAPID 10ML SPECIAL None No NOVORAPID 3ML SPECIAL None No NOVO-RYTHRO 100MG/5ML SUSP OPEN None No NOVO-RYTHRO EES 200 MG/5 ML OPEN None No NOVO-RYTHRO EES 400 MG/5 ML OPEN None No NOVO-RYTHRO EST 125 MG/5 ML OPEN None No NOVO-RYTHRO EST 250 MG/5 ML OPEN None No NOVO-SALBUTAMOL HFA 100 MCG OPEN Beneficiary must have eligibility under the CF Plan Yes NOVO-SALMOL TAB 2MG OPEN None Yes NOVO-SALMOL TAB 4MG OPEN None Yes NOVO-SOTALOL 160 MG TABLET OPEN None Yes NOVO-SOTALOL 80 MG TABLET OPEN None Yes NOVO-TETRA 125MG/5ML SUSP OPEN None No NOVO-TRIPRAMINE 100 MG TAB OPEN No NOVO-TRIPTYN 10 MG TABLET OPEN Yes Page 152 Effective December 2015

153 Coverage Table December NOVO-TRIPTYN 25 MG TABLET OPEN Yes NOVO-TRIPTYN 50 MG TABLET OPEN Yes NOVO-VALPROIC 250 MG CAPSULE OPEN None Yes NOVO-VALPROIC 500 MG CAPSULE OPEN None Yes NOVO-VERAMIL SR 240 MG TAB OPEN None Yes NOVO-VITE TABLET OPEN Can be dispensed by Hospital or RHA Clinic without prior approval No NOVO-WARFARIN 1 MG TABLET OPEN None Yes NOVO-WARFARIN 2 MG TABLET OPEN None Yes NOVO-WARFARIN 2.5 MG TABLET OPEN None Yes NOVO-WARFARIN 3 MG TABLET OPEN None Yes NOVO-WARFARIN 4 MG TABLET OPEN None Yes NOVO-WARFARIN 5 MG TABLET OPEN None Yes NOVO-ZOPICLONE 5 MG TABLET OPEN Yes NOZINAN 25 MG/5 ML LIQUID OPEN No NOZINAN 25 MG/ML AMPOULE OPEN For use in End of Life Palliative Care only. No Not Available NOZINAN 40MG/ML DROPS OPEN No NOZINAN 5MG TAB OPEN Yes NOZINAN TAB 25MG OPEN Yes NOZINAN TAB 2MG OPEN Yes NOZINAN TAB 50MG OPEN Yes NU-AMPI 125 MG/5 ML SUSP OPEN None No NUBAIN 10 MG/ML VIAL OPEN No NUBAIN 20 MG/ML VIAL OPEN No NUL-CAL D 400 TABLET OPEN Beneficiary must have eligibility under the CF Plan No Page 153 Effective December 2015

154 Coverage Table December NUVARING VAGINAL RING OPEN None No NYADERM 100,000 UNIT/GM CREAM OPEN None No NYADERM U/GM OINTMENT OPEN None No NYADERM U/ML SUSP OPEN None No NYADERM 25,000 UNIT VAGINAL CR OPEN None No NYSTATIN 100,000 UNIT/GM CREAM OPEN None No NYSTATIN 100,000 UNIT/GM OINT OPEN None No NYSTATIN 100,000 UNIT/ML SUSP OPEN None No O-CALCIUM W/VITAMIN D TAB OPEN None No O-CALCIUM W/VITAMIN D TAB OPEN None No OCPHYL 100 MCG/ML SYRINGE OPEN None Yes OCPHYL 50 MCG/ML SYRINGE OPEN None Yes OCPHYL 500 MCG/ML SYRINGE OPEN None Yes OCUFEN 0.03% EYE DROPS OPEN None No OCUFLOX 0.3 % EYE DROPS OPEN None Yes ODAN K-20 TABLETS OPEN None No OESCLIM 25 MCG/24 HR PATCH OPEN None No OESCLIM 50 MCG/24 HR PATCH OPEN None No OESTRILIN 0.1% CREME VAG OPEN None No OESTRILIN 250MCG CONES VAG OPEN None No OFLOXACIN 200 MG TABLET OPEN None Yes OFLOXACIN 300 MG TABLET OPEN None Yes OFLOXACIN 400 MG TABLET OPEN None Yes OGEN MG TABLET OPEN None No OGEN 1.25 MG TABLET OPEN None No OGEN 2.5 MG TABLET OPEN None No OLANZAPINE 10 MG TABLET Yes OLANZAPINE 10 MG TABLET Yes OLANZAPINE 15 MG TABLET Yes OLANZAPINE 15 MG TABLET Yes OLANZAPINE 2.5 MG TABLET Yes Page 154 Effective December 2015

155 Coverage Table December OLANZAPINE 2.5 MG TABLET Yes OLANZAPINE 5 MG TABLET Yes OLANZAPINE 5 MG TABLET Yes OLANZAPINE 7.5 MG TABLET Yes OLANZAPINE 7.5 MG TABLET Yes OLANZAPINE ODT 10 MG TABLET Yes OLANZAPINE ODT 10 MG TABLET Yes OLANZAPINE ODT 15 MG TABLET Yes OLANZAPINE ODT 15 MG TABLET Yes OLANZAPINE ODT 20 MG TABLET Yes OLANZAPINE ODT 5 MG TABLET Yes OLANZAPINE ODT 5 MG TABLET Yes OLESTYR 4 G/5 G POWDER PACKET OPEN None Yes OLESTYR 4 G/9 G POWDER PACKET OPEN None Yes OLMETEC 20 MG TABLET None No OLMETEC 40 MG TABLET None No OLMETEC PLUS MG TABLET None No OLMETEC PLUS MG TABLET None No OLMETEC PLUS MG TABLET None No OMEPRAZOLE 20 MG CAPSULE DR OPEN Yes OMEPRAZOLE 20 MG CAPSULE DR OPEN Yes OMEPRAZOLE MAG DR 20 MG TABLET OPEN Yes Page 155 Effective December 2015

156 Coverage Table December OMNITROPE 10 MG/1.5 ML CARTRDG OPEN Open benefit only if Beneficiary is eligible under the Growth Hormone Plan No OMNITROPE 5 MG/1.5 ML CARTRIDG OPEN Open benefit only if Beneficiary is eligible under the Growth Hormone Plan No ONBREZ BREEZHALER 75 MCG CAP None No a) Limited to 2500 per year without Special b) Beneficiary must have ON-CALL PLUS TEST STRIPS 100'S OPEN diabetic medication within previous year No history, otherwise Special is required ON-CALL PLUS TEST STRIPS 25'S OPEN a) Limited to 2500 per year without Special b) Beneficiary must have diabetic medication within previous year No history, otherwise Special is required ON-CALL PLUS TEST STRIPS 50'S OPEN a) Limited to 2500 per year without Special b) Beneficiary must have diabetic medication within previous year No history, otherwise Special is required ONDANSETRON 4 MG TABLET OPEN Limit of 3 tablets per cycle - first fill only. Special is required for higher Yes quantities and/or subsequent fills ONDANSETRON 4 MG/5 ML OPEN Limit of 3 tablets per cycle - first fill only. Special is required for higher Yes quantities and/or subsequent fills 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 ONDANSETRON-ODAN 4 MG TAB OPEN Limit of 3 tablets per cycle - first fill only. Special is required for higher Yes quantities and/or subsequent fills ONDANSETRON-ODAN 8 MG TAB OPEN Limit of 3 tablets per cycle - first fill only. Special is required for higher quantities and/or subsequent fills Yes Page 156 Effective December 2015

157 Coverage Table December ONDISSOLVE ODF 4 MG FILM OPEN Limit of 3 tablets per cycle - first fill only. Special is required for higher Yes quantities and/or subsequent fills ONDISSOLVE ODF 8 MG FILM OPEN Limit of 3 tablets per cycle - first fill only. Special is required for higher Yes quantities and/or subsequent fills ONE TCH VERIO TEST 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 ONE TCH VERIO TEST 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 ONE TOUCH DELICA 30G LANCETS OPEN None No ONE TOUCH DELICA 33G LANCETS OPEN None No ONE TOUCH FINEPOINT LANCETS OPEN None No ONE TOUCH ULTRA TEST STRIPS OPEN a) Limited to 2500 per year without Special b) Beneficiary must have diabetic medication within previous year No history, otherwise Special is required ONE TOUCH ULTRASOFT LANCETS OPEN None No ONE-ALPHA 0.25 MCG CAPSULE OPEN None No ONE-ALPHA 1MCG CAPSULE OPEN None No ONGLYZA 2.5 MG TABLET None No ONGLYZA 5 MG TABLET None No OPHTHO-CHLORAM LIQ 0.5% OPEN None No OPTICHAMBER INHALER OPEN Limit of one per year without Special No OPTICHAMBER MASK (LARGE) OPEN Limit of one per year without Special No OPTICHAMBER MASK (MEDIUM) OPEN Limit of one per year without Special No Page 157 Effective December 2015

158 Coverage Table December OPTICHAMBER MASK (SMALL) OPEN Limit of one per year without Special No OPTICHAMBER VALVE OPEN Limit of one per year without Special No OPTICROM 2% EYE DROPS OPEN None No OPTIMINE 1 MG TABLET OPEN None No ORACORT 0.1% DENTAL PASTE OPEN None No ORAFEN 100MG SUPPOSITORY OPEN None No ORAP 2 MG TABLET OPEN Yes ORAP 4 MG TABLET OPEN Yes ORCIPRENALINE 10 MG/5 ML SYRUP OPEN None Yes ORENCIA 250 MG VIAL None No ORIFER F TABLET OPEN Beneficiary gender must be female - under the age of 51 No ORTHO 0.5/35 (21) TABLET OPEN Beneficiary gender must be female - under the age of 51 No ORTHO 0.5/35 (28) TABLET OPEN Beneficiary gender must be female - under the age of 51 No ORTHO 1/35 (21) TABLET OPEN Beneficiary gender must be female - under the age of 51 No ORTHO 1/35 (28) TABLET OPEN Beneficiary gender must be female - under the age of 51 No ORTHO 7/7/7 (21) TABLET OPEN Beneficiary gender must be female - under the age of 51 No ORTHO 7/7/7 (28) TABLET OPEN Beneficiary gender must be female - under the age of 51 No ORTHO DIAPHRAGM KIT OPEN Beneficiary gender must be female - under the age of 51 No ORTHO-CEPT 21 TABLET OPEN Beneficiary gender must be female - under the age of 51 No ORTHO-CEPT 28 TABLET OPEN Beneficiary gender must be female - under the age of 51 No ORTHO-NOVUM 1/50 21 TABLET OPEN Beneficiary gender must be female - under the age of 51 No ORUDIS SR-200 OPEN None Yes Page 158 Effective December 2015

159 Coverage Table December OS-CAL 250 MG OPEN None No OS-CAL 500 MG TABLET OPEN None No OS-CAL D 500 MG TABLET OPEN None No OSTO-D2 50,000 UNIT CAPSULE OPEN None No OSTOFORTE 50000IU CAPSULE OPEN None No OVIMA 21 TABLET OPEN Beneficiary gender must be female - under the age of 51 Yes OVIMA 28 TABLET OPEN Beneficiary gender must be female - under the age of 51 Yes OVRAL 21 TAB OPEN Beneficiary gender must be female - under the age of 51 No OVRAL 21 TABLET OPEN Beneficiary gender must be female - under the age of 51 No OVRAL 28 TABLET OPEN Beneficiary gender must be female - under the age of 51 No OVRAL 28TAB OPEN Beneficiary gender must be female - under the age of 51 No OXCARBAZEPINE 150 MG TABLET None Yes OXCARBAZEPINE 300 MG TABLET None Yes OXCARBAZEPINE 600 MG TABLET None Yes OXEZE TURBUHALER 12 MCG/DOSE None No OXEZE TURBUHALER 6 MCG/DOSE None No OXSORALEN 1% LOTION OPEN None No OXSORALEN 10 MG CAPSULE OPEN None No OXSORALEN-ULTRA 10 MG CAP OPEN None No OXY.IR 20 MG TABLET OPEN Yes OXYBUTYNIN 5 MG TABLET OPEN None Yes OXYDERM 10% LOTION OPEN None No OXYDERM 20% LOTION OPEN None No OXY-IR 10 MG TABLET OPEN Yes OXY-IR 5 MG TABLET OPEN Yes PALAFER 300 MG CAPSULE OPEN None No PALAFER 300 MG/5 ML SUSP OPEN None No PALAFER CF CAPSULE OPEN None No Page 159 Effective December 2015

160 Coverage Table December PAL-TIZANIE 4 MG TABLET Special Authorzation required if beneficiary has not had a paid claim for Baclofen or Yes Zanaflex in past year PALUDRINE 100MG TABLET OPEN None No PANCREASE CAPSULE None No PANCREASE ENTERIC COATED CAP None No PANCREASE MT 10 CAP None No PANCREASE MT 16 CAP None No PANCREASE MT 4 CAP None No PANECTYL 2.5 MG TABLET OPEN None No PANECTYL 5 MG TABLET OPEN None No PANOXYL 10 % GEL OPEN None No PANOXYL 10% BAR OPEN None No PANOXYL 15% GEL OPEN None No PANOXYL 20 % GEL OPEN None No PANOXYL 5 % GEL OPEN None No PANOXYL AQUAGEL 10 - GEL 10% OPEN None No PANOXYL AQUAGEL 20 - GEL TOP 2 OPEN None No PANOXYL WASH 5 % LOTION OPEN None No PANTOLOC DR 20 MG TABLET OPEN Yes PANTOLOC DR 40 MG TABLET OPEN Yes PANTOPRAZOLE DR 20 MG TABLET OPEN Yes PANTOPRAZOLE DR 40 MG TABLET OPEN Yes PANTOPRAZOLE DR 40 MG TABLET OPEN Yes PANTOPRAZOLE DR 40 MG TABLET OPEN Yes PAPAVERINE HCL 65 MG/2 ML VIAL OPEN None No PARA SPECIAL POUX/LENTES OPEN None No PARAFON FORTE TABLET OPEN None No PAREGORIQUE TINCTUE OPEN No Page 160 Effective December 2015

161 Coverage Table December PARIET EC 10 MG TABLET OPEN Limit of 2 per day without Special Yes PARIET EC 20 MG TABLET OPEN Yes PARLODEL CAP 5MG OPEN None Yes PARLODEL TAB 2.5MG OPEN None Yes PARNATE 10 MG TABLET OPEN No PAROXETINE 10 MG TABLET OPEN. Limit of 1 per day Yes without Special PAROXETINE 10 MG TABLET OPEN. Limit of 1 per day Yes without Special PAROXETINE 20 MG TABLET OPEN Yes PAROXETINE 20 MG TABLET OPEN Yes PAROXETINE 30 MG TABLET OPEN Yes PAROXETINE 30 MG TABLET OPEN Yes PARSITAN 50 MG TABLET OPEN None No PATADAY 0.2 % EYE DROPS OPEN None No PATANOL 0.1% OPH DROPS OPEN None No PAT-GALANTAMINE ER 16 MG CAP None Yes PAT-GALANTAMINE ER 24 MG CAP None Yes PAT-GALANTAMINE ER 8 MG CAP None Yes PAXIL 10 MG TABLET OPEN. Limit of 1 per day Yes without Special PAXIL 20 MG TABLET OPEN Yes PAXIL 30 MG TABLET OPEN Yes PCE 333 MG TABLET OPEN None No Page 161 Effective December 2015

162 Coverage Table December PDP-ACETAMINOPHEN 160 MG/5 ML OPEN Beneficiary must be less than 13 years old - RBP applied No PDP-ACETAMINOPHEN 80 MG/ML DRP OPEN Beneficiary must be less than 3 years old - RBP applied No PDP-BENZTROPINE 1 MG TABLET OPEN None No PDP-BENZTROPINE 2 MG TABLET OPEN None No PDP-DESONIDE 0.05 % CREAM OPEN None Yes PDP-DESONIDE 0.05 % OINTMENT OPEN None Yes PDP-ERYTHROMYCIN 5 MG/G OINT OPEN None No PDP-ISONIAZID 100 MG TABLET OPEN None No PDP-ISONIAZID 300 MG TABLET OPEN None No PDP-ISONIAZID 50 MG/5 ML SOLN OPEN None No PDP-PROCYCLIE 2.5 MG TABLET OPEN None No PDP-PROCYCLIE 2.5 MG/5 ML OPEN None No PDP-PROCYCLIE 5 MG TABLET OPEN None No PDP-PYRAZINAMIDE 500 MG TABLET OPEN None No PEDIAPRED 5 MG/5 ML LIQ OPEN Beneficiary must be less than 13 years old No PEDIATRIX 160 MG/5 ML SOLN OPEN Beneficiary must be less than 13 years old - RBP applied No PEDIATRIX 80 MG/ML DROPS OPEN Beneficiary must be less than 3 years old - RBP applied No PEDIAVIT D 400U/ML SOLUTION OPEN Beneficiary must have eligibility under the CF Plan No PEDIAZOLE SUSPENSION OPEN None No PEG GRAM/DOSE POWDER OPEN None No PEGASYS 180 MCG/0.5 ML SYRNGE None No PEGASYS RBV 200MG-180MCG/0.5ML None No PEGASYS RBV COMBO.PKG (VIAL) None No PEGETRON 200 MG-150 MCG/0.5 ML None No PEGETRON 200 MG-50 MCG/0.5 ML None No PEGETRON COMBO PACK None No PEGETRON COMBO PACK None No PEGETRON COMBO PACK None No PEGETRON REDIPEN 200 MG-100MCG None No PEGETRON REDIPEN 200 MG-120MCG None No PEGETRON REDIPEN 200 MG-150MCG None No PEGETRON REDIPEN 200 MG-80 MCG None No Page 162 Effective December 2015

163 Coverage Table December PEGLYTE SOLUTION OPEN Limit of one per year without Special No PEGLYTE SOLUTION OPEN Limit of one per year without Special No PENGLOBE TAB 400 MG OPEN None No PENTACARINAT 300MG VIAL OPEN None No PENTAMYCETIN 0.25% EYE DROP OPEN None No PENTAMYCETIN 0.5% SOLUTION OPEN None No PENTAMYCETIN 1% EYE OINT OPEN None No PENTAMYCETIN/HC EYE/EAR DRP OPEN None No PENTAMYCETIN/HC EYE/EAR ONT OPEN None No PENTASA 1 GRAM SUPPOSITORY OPEN None No PENTASA 250MG SR TABLET OPEN None No PENTASA 500 MG SR TABLET OPEN None No PENTASA ER 1 GRAM TABLET OPEN None No PENTOXIFYLLINE SR 400 MG TAB OPEN None Yes PEN-VEE 180 MG/5 ML SUSP OPEN None No PEN-VEE 300 MG TABLET OPEN None No PEN-VEE 300 MG/5 ML SUSP OPEN None No PEN-VK 300 MG TABLET OPEN None Yes PERCOCET MG TABLET OPEN Yes PERCOCET DEMI MG TAB OPEN No PERCODAN OPEN Yes PERCODAN DEMI TABLET OPEN No PERIACTIN TAB 4MG OPEN None No PERI-COLACE CAPSULE OPEN None No PERMAX 0.05 MG TABLET OPEN None No PERMAX 0.25 MG TABLET OPEN None No PERMAX 1 MG TABLET OPEN None No PERNOX LEMON CREAM OPEN None No PERNOX LEMON CREAM OPEN None No PERPHENAZINE 16 MG TABLET OPEN No Page 163 Effective December 2015

164 Coverage Table December PERPHENAZINE 2 MG TABLET OPEN No PERPHENAZINE 4 MG TABLET OPEN No PERPHENAZINE 8 MG TABLET OPEN No PERSANTINE 5 MG/ML AMPOULE OPEN None No PERSANTINE TAB 25MG OPEN None Yes PERSANTINE TAB 50MG OPEN None Yes PERSANTINE TAB 75MG OPEN None Yes PHARIXIA 0.15 % MOUTHWASH OPEN None No PHARMORUBICIN RDF 10 MG VIAL OPEN None No PHARMORUBICIN RDF 50 MG VIAL OPEN None No PHAZYME 95 MG CAPSULE OPEN None No PHENAZO 100 MG TABLET OPEN None No PHENAZO 200 MG TABLET OPEN None No PHENERGAN 25MG/ML AMPOULE OPEN None No PHENOBARB 100 MG TAB OPEN No PHENOBARB 15 MG TABLET OPEN No PHENOBARB 30 MG TABLET OPEN No PHENOBARB 5 MG/ML ELIXIR OPEN No PHENOBARB 60 MG TABLET OPEN No PHENOBARBITAL 100 MG TABLET OPEN No PHENOBARBITAL 120 MG/ML AMP OPEN For use in End of Life Palliative Care only. No Not Available PHENOBARBITAL 15 MG TABLET OPEN No PHENOBARBITAL 30 MG TABLET OPEN No PHENOBARBITAL 30 MG/ML AMP OPEN No Page 164 Effective December 2015

165 Coverage Table December PHENOBARBITAL 60 MG TABLET OPEN No PHENOBARBITAL TABLET 100MG OPEN No PHOSPHATE-NOVARTIS TAB EFF OPEN None No PHYLLOCONTIN 225 MG TAB SA OPEN None No PHYLLOCONTIN-350 TABLET SA OPEN None No PILOPINE HS 4% GEL OPEN None No PIMOZIDE 2 MG TABLET OPEN Yes PIMOZIDE 4 MG TABLET OPEN Yes PIPORTIL L4 25 MG/ML AMPOULE OPEN No PIPORTIL L4 50 MG/ML AMPOULE OPEN No PLACIDYL CAP 200MG OPEN No PLACIDYL CAP 500MG OPEN No PLAQUENIL 200 MG TABLET OPEN None Yes PLAVIX 75 MG TABLET None Yes PLENDIL 10 MG TABLET OPEN None Yes PLENDIL 2.5 MG TABLET SA OPEN None No PLENDIL 5 MG TABLET OPEN None Yes PMS-ACETAMINOPHEN 120 MG SUP OPEN Beneficiary must be less than 13 years old - RBP applied No PMS-ACETAMINOPHEN 325 MG SUP OPEN Beneficiary must be less than 13 years old - RBP applied No PMS-ALENDRONATE-FC 70 MG TAB None Yes PMS-AMANTAE 100 MG CAP OPEN None Yes PMS-AMANTAE 50 MG/5 ML SYR OPEN None Yes PMS-AMIODARONE 100 MG TAB OPEN None No PMS-AMIODARONE 200 MG TABLET OPEN None Yes PMS-AMLODIPINE 10 MG TABLET OPEN None Yes PMS-AMLODIPINE 2.5 MG TABLET OPEN None No Page 165 Effective December 2015

166 Coverage Table December PMS-AMLODIPINE 5 MG TABLET OPEN Yes PMS-AMOXICILLIN 125 MG/5 ML OPEN None Yes PMS-AMOXICILLIN 250 MG CAP OPEN None Yes PMS-AMOXICILLIN 250 MG/5 ML OPEN None Yes PMS-AMOXICILLIN 500 MG CAP OPEN None Yes PMS-ANAGRELIDE 0.5 MG CAP OPEN None Yes PMS-ANASTROZOLE 1 MG TABLET None Yes PMS-ATENOLOL 100 MG TABLET OPEN None Yes PMS-ATENOLOL 25 MG TABLET OPEN None No PMS-ATENOLOL 50 MG TABLET OPEN None Yes PMS-ATORVASTATIN 10 MG TABLET OPEN None Yes PMS-ATORVASTATIN 10 MG TABLET OPEN No Yes PMS-ATORVASTATIN 20 MG TABLET OPEN No Yes PMS-ATORVASTATIN 40 MG TABLET OPEN No Yes PMS-ATORVASTATIN 80 MG TABLET OPEN No Yes PMS-AZITHROMYCIN 100MG/5ML SUS OPEN None Yes PMS-AZITHROMYCIN 200MG/5ML SUS OPEN None Yes PMS-AZITHROMYCIN 250 MG TAB OPEN None Yes PMS-AZITHROMYCIN 600 MG TAB None Yes PMS-BACLOFEN 10 MG TABLET OPEN None Yes PMS-BACLOFEN 20 MG TABLET OPEN None Yes PMS-BENZTROPINE 2 MG TABLET OPEN None No PMS-BETAHISTINE 16 MG TABLET OPEN None Yes PMS-BETAHISTINE 24 MG TABLET OPEN None Yes PMS-BETHANECHOL CL 10 MG TAB OPEN None No PMS-BETHANECHOL CL 25 MG TAB OPEN None No PMS-BICALUTAMIDE 50 MG TAB OPEN None Yes PMS-BISACODYL 10 MG SUPPOS OPEN Reasonable Based Pricing is applied No PMS-BISACODYL 5 MG TABLET EC OPEN Reasonable Based Pricing is applied No PMS-BISOPROLOL 10 MG TABLET OPEN None Yes PMS-BISOPROLOL 5 MG TABLET OPEN None Yes PMS-BOSENTAN 125 MG TABLET None Yes PMS-BOSENTAN 62.5 MG TABLET None Yes PMS-BRIMONIE 0.2% DROPS OPEN None Yes Page 166 Effective December 2015

167 Coverage Table December PMS-BUPROPION SR 100 MG TABLET OPEN a) Limited to 2 per day without Special b) Special Authorzation required if beneficiary has not had a paid Yes claim for an anti-depressant or Bupropion in past year PMS-BUPROPION SR 150 MG TABLET OPEN a) Limited to 2 per day without Special b) Special Authorzation required if beneficiary has not had a paid Yes claim for an anti-depressant or Bupropion in past year PMS-BUSPIRONE 10 MG TABLET OPEN Yes PMS-CANDESARTAN 16 MG TABLET OPEN Yes PMS-CANDESARTAN 32 MG TABLET OPEN Yes PMS-CANDESARTAN 8 MG TABLET OPEN Yes PMS-CARBAMAZE CR 200 MG TAB OPEN None Yes PMS-CARBAMAZE CR 400 MG TAB OPEN None Yes PMS-CARBAMAZEPIN 100MG CHEW TB OPEN None Yes PMS-CARBAMAZEPIN 200MG CHEW TB OPEN None Yes PMS-CARVEDILOL 12.5 MG TAB None Yes PMS-CARVEDILOL 25 MG TAB None Yes PMS-CARVEDILOL MG TAB None Yes PMS-CARVEDILOL 6.25 MG TAB None Yes PMS-CELECOXIB 100 MG CAPSULE OPEN Limit of 2 per day without Special Yes PMS-CELECOXIB 200 MG CAPSULE OPEN Limit of 2 per day without Special Yes PMS-CHLORAL HYD 500 MG/5 ML OPEN No PMS-CILAZAPRIL 1 MG TABLET OPEN None Yes PMS-CILAZAPRIL 2.5 MG TABLET OPEN None Yes PMS-CILAZAPRIL 5 MG TABLET OPEN None Yes Page 167 Effective December 2015

168 Coverage Table December PMS-CIPROFLOXACIN 250 MG TAB OPEN None Yes PMS-CIPROFLOXACIN 500 MG TAB OPEN None Yes PMS-CIPROFLOXACIN 750 MG TAB OPEN None Yes PMS-CITALOPRAM 10 MG TABLET OPEN No PMS-CITALOPRAM 20 MG TABLET OPEN. Maximum of 1.5 tablets Yes daily PMS-CITALOPRAM 40 MG TABLET OPEN Yes PMS-CLARITHROMYCIN 250 MG OPEN None Yes PMS-CLARITHROMYCIN 500 MG OPEN None Yes PMS-CLOBAZAM 10 MG TABLET OPEN Yes PMS-CLOBETASOL 0.05 % CREAM OPEN None Yes PMS-CLOBETASOL 0.05% OINT OPEN None Yes PMS-CLONAZEPAM 0.5 MG TABLET OPEN Yes PMS-CLONAZEPAM 1 MG TABLET OPEN Yes PMS-CLONAZEPAM 2 MG TABLET OPEN Yes PMS-CLONAZEPAM R 0.5 MG TAB OPEN Yes PMS-CLOPIDOGREL 75 MG TABLET None Yes PMS-CODEINE 15 MG TABLET OPEN No PMS-CYCLOBENZAPRINE 10 MG TA OPEN None Yes PMS-CYPROHEPTAE 4 MG TAB OPEN None No PMS-DEFEROXAMINE 500 MG VIAL OPEN None No PMS-DESMOPRESSIN 0.1 MG TAB OPEN None Yes PMS-DESMOPRESSIN 0.2 MG TAB OPEN None Yes PMS-DEXAMETH SP 10 MG/ML VL OPEN None No PMS-DEXAMETHASONE 0.5 MG TAB OPEN None No PMS-DEXAMETHASONE 2 MG TAB OPEN None No PMS-DEXAMETHASONE 4 MG TAB OPEN None No Page 168 Effective December 2015

169 Coverage Table December PMS-DIAZEPAM 10 MG TABLET OPEN No PMS-DIAZEPAM 2 MG TABLET OPEN No PMS-DIAZEPAM 5 MG/5 ML SOLN OPEN No PMS-DICLOFENAC 100 MG SUPP OPEN None No PMS-DICLOFENAC 50 MG SUPP OPEN None No PMS-DICLOFENAC DR 25 MG TABLET OPEN None Yes PMS-DICLOFENAC EC 50 MG TABLET OPEN None Yes PMS-DICLOFENAC SR 100 MG TAB OPEN None Yes PMS-DICLOFENAC SR 75 MG TAB OPEN None Yes PMS-DILTIAZEM CD 120 MG CAP OPEN None Yes PMS-DILTIAZEM CD 180 MG CAP OPEN None Yes PMS-DILTIAZEM CD 240 MG CAP OPEN None Yes PMS-DILTIAZEM CD 300 MG CAP OPEN None Yes PMS-DIMENHYDRINATE 15 MG/5 ML OPEN Beneficiary must be less than 13 years old - RBP applied No PMS-DIPHENHYDRAMINE 50 MG CA OPEN None No PMS-DOCUSATE CAL 240 MG CAP OPEN Reasonable Based Pricing is applied No PMS-DOCUSATE SOD 100 MG CAP OPEN Reasonable Based Pricing is applied No PMS-DOCUSATE SOD 4 MG/ML SYRUP OPEN Beneficiary must be less than 13 years old - RBP applied No PMS-DOMPERIDONE 10 MG TABLET OPEN None Yes PMS-DONEPEZIL 10 MG TABLET No Yes PMS-DONEPEZIL 5 MG TABLET No Yes PMS-DOXAZOSIN 1 MG TABLET OPEN None Yes PMS-DOXAZOSIN 2 MG TABLET OPEN None Yes PMS-DOXAZOSIN 4 MG TABLET OPEN None Yes PMS-DUTASTERIDE 0.5 MG CAPSULE None Yes PMS-ENALAPRIL 16 MG (20 MG) TB OPEN None Yes PMS-ENALAPRIL 2 MG (2.5 MG) TB OPEN None Yes PMS-ENALAPRIL 4 MG (5 MG) TAB OPEN None Yes PMS-ENALAPRIL 8 MG (10 MG) TAB OPEN None Yes PMS-ENTECAVIR 0.5 MG TABLET None Yes PMS-EZETIMIBE 10 MG TABLET None Yes PMS-FAMCICLOVIR 125 MG TAB OPEN None Yes Page 169 Effective December 2015

170 Coverage Table December PMS-FAMCICLOVIR 250 MG TAB OPEN None Yes PMS-FAMCICLOVIR 500 MG TAB OPEN None Yes PMS-FENTANYL MTX 100 MCG/HR Yes PMS-FENTANYL MTX 12 MCG/HR Yes PMS-FENTANYL MTX 25 MCG/HR Yes PMS-FENTANYL MTX 50 MCG/HR Yes PMS-FENTANYL MTX 75 MCG/HR Yes PMS-FERROUS SULF 15 MG/ML P OPEN Beneficiary must have eligibility under the CF Plan No PMS-FERROUS SULF 150 MG/5 ML OPEN None No PMS-FERROUS SULF 300 MG TAB OPEN None No PMS-FINASTERIDE 5 MG TABLET Special required if beneficiary has not had a paid claim for an alpha Yes blocker or finasteride in past year PMS-FLUCONAZOLE 100 MG TAB OPEN None Yes PMS-FLUCONAZOLE 150 MG CAP OPEN None Yes PMS-FLUCONAZOLE 50 MG TABLET OPEN None Yes PMS-FLUOXETINE 10 MG CAPSULE OPEN Yes PMS-FLUOXETINE 20 MG CAPSULE OPEN Yes PMS-FLUOXETINE 20 MG/5 ML SOL No PMS-FLUPHEN DEC 100 MG/ML OPEN No PMS-FLUPHENAZINE 25 MG/ML VL OPEN No PMS-GABAPENTIN 100 MG CAP None Yes PMS-GABAPENTIN 300 MG CAP None Yes PMS-GABAPENTIN 400 MG CAP None Yes PMS-GABAPENTIN 600 MG TABLET None Yes PMS-GABAPENTIN 800 MG TABLET None Yes Page 170 Effective December 2015

171 Coverage Table December PMS-GALANTAMINE ER 16 MG CAP No Yes PMS-GALANTAMINE ER 24 MG CAP No Yes PMS-GALANTAMINE ER 8 MG CAP No Yes PMS-GEMFIBROZIL 300 MG CAP OPEN None Yes PMS-GENTAMICIN 0.1% OINT OPEN None No PMS-GENTAMICIN 0.3% DROPS OPEN None No PMS-GLYBURIDE 5 MG TABLET OPEN None Yes PMS-HALOPERIDOL 2 MG/ML SOLN OPEN No PMS-HYDROXYZINE 2 MG/ML SYR OPEN None No PMS-IMATINIB 100 MG TABLET None Yes PMS-IMATINIB 400 MG TABLET None Yes PMS-INDAPAMIDE 1.25 MG TAB OPEN None Yes PMS-INDAPAMIDE 2.5 MG TABLET OPEN None Yes PMS-IPRATROPIUM 0.03 % SPRAY OPEN None Yes PMS-IPRATROPIUM 250 MCG/2 ML None Yes PMS-IPRATROPIUM 250 MCG/ML None Yes PMS-IPRATROPIUM 250 MCG/ML NEB None Yes PMS-IPRATROPIUM 500 MCG/2 ML None Yes PMS-IRBESARTAN 150 MG TABLET OPEN Yes PMS-IRBESARTAN 300 MG TABLET OPEN Yes PMS-IRBESARTAN 75 MG TABLET OPEN Yes PMS-ISMN 60 MG TABLET SA OPEN None Yes PMS-ISONIAZID 50 MG TABLET OPEN None No PMS-ISOSORBIDE 30 MG TABLET OPEN None No PMS-KETOPROFEN 100 MG SUPP OPEN None No PMS-KETOPROFEN 50 MG SUPPOS OPEN None No PMS-KETOTIFEN 1 MG TABLET OPEN None No PMS-KETOTIFEN 1 MG/5 ML SYRUP OPEN None No PMS-LACTULOSE 10 GM/15ML SYRUP OPEN None No PMS-LAMOTRIGINE 100 MG TAB OPEN None Yes PMS-LAMOTRIGINE 150 MG TAB OPEN None Yes PMS-LAMOTRIGINE 25 MG TABLET OPEN None Yes PMS-LANSOPRAZOLE DR 15 MG CAP None Yes Page 171 Effective December 2015

172 Coverage Table December PMS-LANSOPRAZOLE DR 30 MG CAP None Yes PMS-LATANOPROST 50UG/ML OPH OPEN None Yes PMS-LEFLUNOMIDE 10 MG TAB OPEN None Yes PMS-LEFLUNOMIDE 20 MG TAB OPEN None Yes PMS-LETROZOLE 2.5 MG TABLET None Yes PMS-LEVAZINE 2/25 TABLET OPEN None No PMS-LEVAZINE 4/25 TABLET OPEN None No PMS-LEVETIRACETAM 250 MG TB None Yes PMS-LEVETIRACETAM 500 MG TB None Yes PMS-LEVETIRACETAM 750 MG TB None Yes PMS-LEVOCARB CR 25MG-100MG TAB OPEN None Yes PMS-LEVOCARB CR MG TAB OPEN None Yes PMS-LEVOFLOXACIN 250 MG TABLET None Yes PMS-LEVOFLOXACIN 500 MG TABLET None Yes PMS-LINDANE 1% LOTION OPEN None No PMS-LINDANE 1% SHAMPOO OPEN None No PMS-LISINOPRIL 10 MG TABLET OPEN None Yes PMS-LISINOPRIL 20 MG TABLET OPEN None Yes PMS-LISINOPRIL 5 MG TABLET OPEN None Yes PMS-LITHIUM CARB 150 MG CAP OPEN Yes PMS-LITHIUM CARB 300 MG CAP OPEN Yes PMS-LOPERAMIDE 0.2 MG/ML SOL None No PMS-LOPERAMIDE HCL 2 MG TAB None No PMS-LORAZEPAM 0.5 MG TABLET OPEN Yes PMS-LORAZEPAM 1 MG TABLET OPEN Yes PMS-LORAZEPAM 2 MG TABLET OPEN Yes PMS-LOSARTAN 100 MG TABLET OPEN Yes PMS-LOSARTAN 25 MG TABLET OPEN Yes PMS-LOSARTAN 50 MG TABLET OPEN Yes Page 172 Effective December 2015

173 Coverage Table December PMS-LOVASTATIN 20 MG TABLET OPEN None Yes PMS-LOVASTATIN 40 MG TABLET OPEN None Yes PMS-LOXAPINE 25 MG/ML SOLN OPEN No PMS-MELOXICAM 15 MG TABLET OPEN None Yes PMS-MELOXICAM 7.5 MG TABLET OPEN None Yes PMS-METFORMIN 500 MG TABLET OPEN None Yes PMS-METFORMIN 850 MG TABLET OPEN None Yes PMS-METHYLPHENIDATE 10 MG TAB OPEN Yes PMS-METHYLPHENIDATE 20 MG TAB OPEN Yes PMS-METHYLPHENIDATE 5 MG TAB OPEN No PMS-METHYLPHENIDATE ER 18MG Yes PMS-METOPROLOL-L 100 MG TAB OPEN None Yes PMS-METOPROLOL-L 25 MG TAB OPEN None No PMS-METOPROLOL-L 50 MG TAB OPEN None Yes PMS-METRONIDAZOLE 500 MG CAP OPEN None Yes PMS-MINOCYCLINE 100 MG CAP OPEN None Yes PMS-MINOCYCLINE 50 MG CAP OPEN None Yes PMS-MIRTAZAPINE 15 MG TABLET OPEN No PMS-MIRTAZAPINE 30 MG TABLET OPEN Yes PMS-MONTELUKAST 10 MG TAB None Yes PMS-MONTELUKAST 4 MG TAB CHEW None Yes PMS-MONTELUKAST 5 MG TAB CHEW None Yes PMS-NABILONE 0.5 MG CAPSULE OPEN Yes PMS-NABILONE 1 MG CAPSULE OPEN Yes PMS-NAPROXEN 500 MG SUPPOS OPEN None No PMS-NEVIRAPINE 200 MG TABLET OPEN Yes PMS-NORFLOXACIN 400 MG TAB OPEN None Yes Page 173 Effective December 2015

174 Coverage Table December PMS-NORTRIPTYLINE 10 MG CAP OPEN Yes PMS-NORTRIPTYLINE 25 MG CAP OPEN Yes PMS-NYLIDRIN 6 MG TABLET OPEN None No PMS-NYSTATIN UNT/ML SUS OPEN None No PMS-OLANZAPINE 10 MG TABLET Yes PMS-OLANZAPINE 15 MG TABLET Yes PMS-OLANZAPINE 2.5 MG TAB Yes PMS-OLANZAPINE 20 MG TABLET Yes PMS-OLANZAPINE 5 MG TABLET Yes PMS-OLANZAPINE 7.5 MG TAB Yes PMS-OLANZAPINE ODT 10 MG TAB Yes PMS-OLANZAPINE ODT 15 MG TAB Yes PMS-OLANZAPINE ODT 20 MG TAB Yes PMS-OLANZAPINE ODT 5 MG TABLET Yes PMS-OMEPRAZOLE 20 MG CAP DR OPEN Yes PMS-OMEPRAZOLE DR 20 MG TABLET OPEN Yes PMS-ONDANSETRON 4 MG TABLET OPEN Limit of 3 tablets per cycle - first fill only. Special is required for higher Yes quantities and/or subsequent fills PMS-ONDANSETRON 8 MG TABLET OPEN Limit of 3 tablets per cycle - first fill only. Special is required for higher quantities and/or subsequent fills Yes Page 174 Effective December 2015

175 Coverage Table December PMS-OPIUM & BELLADONNA SUPP OPEN No PMS-OXYBUTYNIN 5 MG TABLET OPEN None Yes PMS-OXYBUTYNIN 5 MG/5 ML SYRUP OPEN None No PMS-OXYCODONE 10 MG TABLET OPEN Yes PMS-OXYCODONE 20 MG TABLET OPEN Yes PMS-OXYCODONE 5 MG TABLET OPEN Yes PMS-PANTOPRAZOLE DR 40 MG TAB OPEN Yes PMS-PAROXETINE 10 MG TABLET OPEN. Limit of 1 per day Yes without Special PMS-PAROXETINE 20 MG TABLET OPEN Yes PMS-PAROXETINE 30 MG TABLET OPEN Yes PMS-PAROXETINE 40 MG TABLET OPEN No PMS-PERPHENAZINE 3.2 MG/ML OPEN No PMS-PINDOLOL 10 MG TABLET OPEN None Yes PMS-PINDOLOL 15 MG TABLET OPEN None Yes PMS-PINDOLOL 5 MG TABLET OPEN None Yes PMS-PIOGLITAZONE 15 MG TAB None Yes PMS-PIOGLITAZONE 30 MG TAB None Yes PMS-PIOGLITAZONE 45 MG TAB None Yes PMS-PIROXICAM 10 MG SUPP OPEN None No PMS-PIROXICAM 20 MG SUPP OPEN None No PMS-POTASSIUM CHL 20 MEQ/15ML OPEN None No PMS-PRAMIPEXOLE 0.25 MG TAB OPEN None Yes PMS-PRAMIPEXOLE 1 MG TABLET OPEN None Yes PMS-PRAMIPEXOLE 1.5 MG TAB OPEN None Yes PMS-PRAVASTATIN 10 MG TABLET OPEN None Yes PMS-PRAVASTATIN 20 MG TABLET OPEN None Yes Page 175 Effective December 2015

176 Coverage Table December PMS-PRAVASTATIN 40 MG TAB OPEN None Yes PMS-PREGABALIN 150 MG CAPSULE None Yes PMS-PREGABALIN 225 MG CAPSULE None Yes PMS-PREGABALIN 25 MG CAPSULE None Yes PMS-PREGABALIN 300 MG CAPSULE None Yes PMS-PREGABALIN 50 MG CAPSULE None Yes PMS-PREGABALIN 75 MG CAPSULE None Yes PMS-PROCHLORPERAZ 10 MG TAB OPEN None No PMS-PROCHLORPERAZ 5 MG TAB OPEN None No PMS-PROCHLORPERAZINE 10MG SUPP OPEN None No PMS-PROPAFENONE 150 MG TAB OPEN None Yes PMS-PROPAFENONE 300 MG TAB OPEN None Yes PMS-QUETIAPINE 100 MG TABLET OPEN Yes PMS-QUETIAPINE 200 MG TABLET OPEN Yes PMS-QUETIAPINE 25 MG TABLET OPEN Yes PMS-QUETIAPINE 300 MG TABLET OPEN Yes PMS-QUETIAPINE 50 MG TABLET OPEN No PMS-RABEPRAZOLE EC 10 MG TB OPEN Limit of 2 per day without Special Yes PMS-RABEPRAZOLE EC 20 MG TB OPEN Yes PMS-RALOXIFENE 60 MG TABLET None Yes PMS-RAMIPRIL 1.25 MG CAPSULE OPEN None Yes PMS-RAMIPRIL 10 MG CAPSULE OPEN None Yes PMS-RAMIPRIL 2.5 MG CAPSULE OPEN None Yes PMS-RAMIPRIL 5 MG CAPSULE OPEN None Yes PMS-RAMIPRIL-HCTZ MG OPEN None Yes PMS-RAMIPRIL-HCTZ MG TAB OPEN None Yes PMS-RAMIPRIL-HCTZ MG OPEN None Yes PMS-RAMIPRIL-HCTZ MG TB OPEN None Yes PMS-RAMIPRIL-HCTZ 5-25 MG TAB OPEN None Yes Page 176 Effective December 2015

177 Coverage Table December PMS-RANITIE 150 MG TAB T OPEN None Yes PMS-RANITIE 300 MG TAB T OPEN None Yes PMS-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 PMS-REPAGLINIDE 1 MG TABLET Special Authorzation required if beneficiary has not had a paid claim for Gluconorm, Yes Glimepiride, or Glyburide in past year PMS-REPAGLINIDE 2 MG TABLET Special Authorzation required if beneficiary has not had a paid claim for Gluconorm, Yes Glimepiride, or Glyburide in past year PMS-RISEDRONATE 35 MG TABLET None Yes PMS-RISPERIDONE 0.25 MG TAB OPEN Yes PMS-RISPERIDONE 0.5 MG TAB OPEN Yes PMS-RISPERIDONE 1 MG TABLET OPEN Yes PMS-RISPERIDONE 1 MG/ML SOL OPEN Yes PMS-RISPERIDONE 2 MG TABLET OPEN Yes PMS-RISPERIDONE 3 MG ODT Yes PMS-RISPERIDONE 3 MG TABLET OPEN Yes PMS-RISPERIDONE 4 MG ODT Yes PMS-RISPERIDONE 4 MG TABLET OPEN Yes PMS-RISPERIDONE ODT 1 MG Yes PMS-RISPERIDONE ODT 2 MG Yes PMS-RIVASTIGMINE 1.5 MG CAP None Yes PMS-RIVASTIGMINE 3 MG CAPSULE None Yes PMS-RIVASTIGMINE 4.5 MG CAP None Yes Page 177 Effective December 2015

178 Coverage Table December PMS-RIZATRIPTAN RDT 10 MG TAB None Yes PMS-RIZATRIPTAN RDT 5 MG TAB None Yes PMS-ROPINIROLE 0.25 MG TABLET OPEN None Yes PMS-ROPINIROLE 1 MG TABLET OPEN None Yes PMS-ROPINIROLE 2 MG TABLET OPEN None Yes PMS-ROPINIROLE 5 MG TABLET OPEN None Yes PMS-ROSUVASTATIN 10 MG TABLET OPEN None Yes PMS-ROSUVASTATIN 20 MG TABLET OPEN None Yes PMS-ROSUVASTATIN 40 MG TABLET OPEN None Yes PMS-ROSUVASTATIN 5 MG TABLET OPEN Yes PMS-SALBUTAMOL 1.25 MG/2.5 ML None Yes PMS-SALBUTAMOL 5 MG/2.5ML SOLN None Yes PMS-SENNOSIDES 12 MG TABLET OPEN None No PMS-SENNOSIDES 8.6 MG TAB OPEN None No PMS-SERTRALINE 100 MG CAP OPEN Yes PMS-SERTRALINE 25 MG CAPSULE OPEN Yes PMS-SERTRALINE 50 MG CAPSULE OPEN Yes PMS-SIMVASTATIN 10 MG TABLET OPEN None Yes PMS-SIMVASTATIN 20 MG TABLET OPEN None Yes PMS-SIMVASTATIN 40 MG TABLET OPEN None Yes PMS-SIMVASTATIN 5 MG TABLET OPEN None Yes PMS-SIMVASTATIN 80 MG TABLET OPEN None Yes PMS-SOD CROMOGLYCATE 1% SOL None Yes PMS-SOTALOL 160 MG TABLET OPEN None Yes PMS-SOTALOL 80 MG TABLET OPEN None Yes PMS-SULFASALAZ 500 MG TAB EC OPEN None No PMS-SULFASALAZINE 500 MG TAB OPEN None No PMS-SUMATRIPTAN 100 MG TAB None Yes PMS-SUMATRIPTAN 25 MG TABLET None Yes PMS-SUMATRIPTAN 50 MG TABLET None Yes PMS-TAMOXIFEN 10 MG TABLET OPEN None No PMS-TAMOXIFEN 20 MG TABLET OPEN None No Page 178 Effective December 2015

179 Coverage Table December PMS-TELMISARTAN 40 MG TABLET OPEN Yes PMS-TELMISARTAN 80 MG TABLET OPEN Yes PMS-TERAZOSIN 1 MG TABLET OPEN None Yes PMS-TERAZOSIN 10 MG TABLET OPEN None Yes PMS-TERAZOSIN 2 MG TABLET OPEN None Yes PMS-TERAZOSIN 5 MG TABLET OPEN None Yes PMS-TERBINAFINE 250 MG TABLET OPEN None Yes PMS-TESTOSTERONE 40 MG CAPSULE Yes PMS-THEOPHYLLINE 80 MG/15 ML OPEN None No PMS-THIORIDAZINE 30MG/ML OPEN No PMS-TIMOLOL 0.25 % EYE DROPS OPEN None Yes PMS-TIMOLOL 0.5 % DROPS OPEN None Yes PMS-TOPIRAMATE 100 MG TABLET OPEN None Yes PMS-TOPIRAMATE 200 MG TABLET OPEN None Yes PMS-TOPIRAMATE 25 MG TABLET OPEN None Yes PMS-TRAZODONE 100 MG TABLET OPEN Yes PMS-TRAZODONE 50 MG TABLET OPEN Yes PMS-TRIFLUOPERAZINE 10 MG/ML OPEN No PMS-URSODIOL C 250 MG TABLET None No PMS-URSODIOL C 500 MG TABLET None No PMS-VALACYCLOVIR 500 MG TAB OPEN None Yes PMS-VALPROIC 250 MG/5 ML SYR OPEN None Yes PMS-VALPROIC 500 MG EC CAP OPEN None Yes PMS-VALPROIC ACID 250 MG CAP OPEN None Yes PMS-VALSARTAN 160 MG TABLET OPEN Yes PMS-VALSARTAN 320 MG TABLET OPEN Yes PMS-VALSARTAN 40 MG TABLET OPEN Yes Page 179 Effective December 2015

180 Coverage Table December PMS-VALSARTAN 80 MG TABLET OPEN Yes PMS-VENLAFAXINE XR 150 MG OPEN Yes PMS-VENLAFAXINE XR 37.5 MG OPEN Yes PMS-VENLAFAXINE XR 75 MG CP OPEN Yes PMS-VERAPAMIL SR 240 MG TABLET OPEN None Yes PMS-YOHIMBINE 2 MG TABLET OPEN None No PMS-ZOLMITRIPTAN 2.5 MG TABLET None Yes PMS-ZOLMITRIPTAN ODT 2.5MG TAB None Yes PMS-ZOPICLONE 5 MG TABLET OPEN Yes PMS-ZOPICLONE 7.5 MG TABLET OPEN Yes POLY-VI-SOL DROPS INFANTS OPEN Beneficiary must have eligibility under the CF Plan No POMALYST 1MG CAPSULE None No POMALYST 2MG CAPSULE None No POMALYST 3MG CAPSULE None No POMALYST 4MG CAPSULE None No PONDOCILLIN 175 MG/5 ML SUSP OPEN None No PONDOCILLIN 500 MG TABLET OPEN None No PONSTAN 250 MG CAPSULE OPEN None Yes PORTIA 21 TABLET OPEN Beneficiary gender must be female - under the age of 51 Yes PORTIA 28 TABLET OPEN Beneficiary gender must be female - under the age of 51 Yes POTABA 0.5GM TABLET OPEN None No POTABA 2GM PACKET OPEN None No POTABA 500 MG CAPSULE OPEN None No POTASSIUM ROUGIER OPEN None No PRADAXA 110 MG CAPSULE None No PRADAXA 150 MG CAPSULE None No PRAMIPEXOLE 0.25 MG TAB OPEN None Yes PRAMIPEXOLE 0.25 MG TABLET OPEN None Yes Page 180 Effective December 2015

181 Coverage Table December PRAMIPEXOLE 1 MG TABLET OPEN None Yes PRAMIPEXOLE 1 MG TABLET OPEN None Yes PRAMIPEXOLE 1.5 MG TAB OPEN None Yes PRAMOX HC 1 %-1 % CREAM OPEN None No PRAMOX HC 1 %-1 % LOTION OPEN None No PRAVACHOL 10 MG TABLET OPEN None Yes PRAVACHOL 20 MG TABLET OPEN None Yes PRAVACHOL 40 MG TABLET OPEN None Yes PRAVASTATIN 10 MG TABLET OPEN None Yes PRAVASTATIN 20 MG TABLET OPEN None Yes PRAVASTATIN 40 MG TABLET OPEN None Yes PRECISION PLUS QID 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 PRECISION PLUS TEST STRIPS OPEN a) Limited to 2500 per year without Special b) Beneficiary must have diabetic medication within previous year No history, otherwise Special is required PRED FORTE 1% EYE DROPS OPEN None Yes PRED MILD 0.12% EYE DROPS OPEN None No PREDNISONE 5MG TABLET OPEN None No PREGABALIN 150 MG CAPSULE None Yes PREGABALIN 150 MG CAPSULE None Yes PREGABALIN 150 MG CAPSULE None Yes PREGABALIN 25 MG CAPSULE None Yes PREGABALIN 25 MG CAPSULE None Yes PREGABALIN 25 MG CAPSULE None Yes PREGABALIN 300 MG CAPSULE None Yes PREGABALIN 50 MG CAPSULE None Yes PREGABALIN 50 MG CAPSULE None Yes PREGABALIN 50 MG CAPSULE None Yes PREGABALIN 75 MG CAPSULE None Yes PREGABALIN 75 MG CAPSULE None Yes PREGABALIN 75 MG CAPSULE None Yes Page 181 Effective December 2015

182 Coverage Table December PREMARIN 0.3 MG TABLET OPEN None No PREMARIN MG TABLET OPEN None No PREMARIN 0.9 MG TABLET OPEN None No PREMARIN 1.25 MG TABLET OPEN None No PREMARIN 25 MG VIAL OPEN None No PREMARIN ER 0.3 MG TABLET OPEN None No PREMARIN ER MG TABLET OPEN None No PREMARIN ER 1.25 MG TABLET OPEN None No PREMARIN VAGINAL CREAM/APPL OPEN None No PREMPLUS TABLET OPEN None No PREMPLUS TABLET OPEN None No PRENAVITE FORTE OPEN Beneficiary gender must be female - under the age of 51 No PREVACID 15 MG CAPSULE None Yes PREVACID 30 MG CAPSULE None Yes PREVACID FASTAB 15 MG TAB None No PREVACID FASTAB 30 MG TAB None No PREVEX B 0.1 % CREAM OPEN None No PREVEX HC 1% CREAM OPEN None No PREZISTA 150 MG TABLET None No PREZISTA 300 MG TABLET None No PREZISTA 400 MG TABLET None No PREZISTA 600 MG TABLET None No PREZISTA 75 MG TABLET None No PREZISTA 800 MG TABLET None No PRIMIDONE 125 MG TABLET OPEN None No PRIMIDONE 250 MG TABLET OPEN None No PRINIVIL OPEN None No PRINIVIL 10 MG TABLET OPEN None Yes PRINIVIL 20 MG TABLET OPEN None Yes PRINIVIL 5 MG TABLET OPEN None Yes PRINZIDE 10/12.5 TABLET OPEN None Yes PRINZIDE 20/12.5 TABLET OPEN None Yes PRINZIDE 20/25 TABLET OPEN None No PRO-AMOX 125 MG/5 ML SUSP OPEN None No PRO-AMOX 250 MG/5 ML SUSP OPEN None No PROAVIL TAB OPEN None No Page 182 Effective December 2015

183 Coverage Table December PRO-BANTHINE 15 MG TABLET OPEN None No PRO-BANTHINE 7.5 MG TABLET OPEN None No PROBETA OPHTHALMIC SOL OPEN None No PROCAN SR 250 MG TABLET SA OPEN None No PROCAN SR 500 MG TABLET SA OPEN None No PROCAN SR 750 MG TABLET SA OPEN None No PROCHLORAZINE 10 MG TABLET OPEN None No PROCHLORAZINE 5 MG TABLET OPEN None No PROCTODAN HC SUPPOSITORY OPEN None Yes PROCTODAN-HC OINTMENT OPEN None Yes PROCTOFOAM HC RECTAL FOAM OPEN None No PROCTOL OINTMENT OPEN None Yes PROCTOL SUPPOSITORY OPEN None Yes PROCTOSEDYL OINTMENT OPEN None Yes PROCTOSEDYL SUPPOSITORY OPEN None Yes PROCYCLID 5MG TABLET OPEN None No PROCYTOX 200 MG VIAL OPEN None No PROCYTOX 25 MG TABLET OPEN None No PROCYTOX 50 MG TABLET OPEN None No PROCYTOX 500 MG VIAL OPEN None No PRODIEM PLAIN POWDER OPEN None No PROFASI HP 10000U VIAL OPEN None No PROGLYCEM 100 MG CAPSULE OPEN None No PROGLYCEM 50MG/ML SUSP OPEN None No PROLIA 60 MG/ML SYRINGE None No PROLOPA 12.5/50 CAPSULE OPEN None No PROLOPA 25/100 CAPSULE OPEN None No PROLOPA 50/200 CAPSULE OPEN None No PROLOPRIM 200 TAB 200MG OPEN None Yes PROMETHAZINE HCL 25 MG/ML AMP OPEN None No PRONESTYL-SR 500MG TABLET OPEN None No PROPADERM % CREAM OPEN None No PROPADERM 0.025% LOTION OPEN None No PROPAFENONE 150 MG TABLET OPEN None Yes PROPAFENONE 300 MG TABLET OPEN None Yes PROPANTHEL 15MG TABLET OPEN None No PROPYLTHYRACIL 100 MG TAB OPEN None No Page 183 Effective December 2015

184 Coverage Table December PROPYL-THYRACIL 50 MG TABLET OPEN None No PROSCAR 5 MG TABLET Special required if beneficiary has not had a paid claim for an alpha Yes blocker or finasteride in past year PROSTIGMIN 1:2000 VIAL OPEN None No PROSTIGMIN 1:400 VIAL OPEN None No PROSTIGMIN 15 MG TABLET OPEN None No PROSTIN E2 0.5 MG TABLET OPEN None No PROTOPIC 0.03 % OINTMENT None No PROTOPIC 0.1 % OINTMENT None No PROTRIN DF MG TAB OPEN None No PROTRIN TABLET OPEN None No PROTROPIN - KIT IM SC 5MG/VIAL OPEN None No PROVERA 10 MG TABLET OPEN None Yes PROVERA 100MG TABLETS OPEN None Yes PROVERA 2.5 MG TABLET OPEN None Yes PROVERA 5 MG TABLET OPEN None Yes PROVERA-PAK 5 MG TABLET OPEN None No PROZAC 10 MG CAPSULE OPEN Yes PROZAC 20 MG CAPSULE OPEN Yes PULMICORT 100 MCG TURBUHALER OPEN Can only be claimed if the Beneficiary does not have an active Special No for Wet Nebulization PULMICORT 200 MCG TURBUHALER OPEN Can only be claimed if the Beneficiary does not have an active Special No for Wet Nebulization PULMICORT 400 MCG TURBUHALER OPEN Can only be claimed if the Beneficiary does not have an active Special No for Wet Nebulization PULMICORT NEBUAMP 0.25 MG/2 ML None No PULMICORT NEBUAMP 0.5 MG/2 ML None No PULMICORT NEBUAMP 1 MG/2 ML None No PULMOZYME 1 MG/ML AMPOULE OPEN Beneficiary must have eligibility under the CF Plan No PURINETHOL 50 MG TABLET OPEN None Yes Page 184 Effective December 2015

185 Coverage Table December PYRIDIUM 100MG OPEN None No PYRIDIUM 200 MG TABLET OPEN None No QUETIAPINE 100 MG TABLET OPEN Yes QUETIAPINE 100 MG TABLET OPEN Yes QUETIAPINE 100 MG TABLET OPEN Yes QUETIAPINE 200 MG TABLET OPEN Yes QUETIAPINE 200 MG TABLET OPEN Yes QUETIAPINE 200 MG TABLET OPEN Yes QUETIAPINE 25 MG TABLET OPEN Yes QUETIAPINE 25 MG TABLET OPEN Yes QUETIAPINE 25 MG TABLET OPEN Yes QUETIAPINE 300 MG TABLET OPEN Yes QUETIAPINE 300 MG TABLET OPEN Yes QUETIAPINE 300 MG TABLET OPEN Yes QUIBRON-T/SR 300MG TAB SA OPEN None No QUINAPRIL/HCTZ MG TAB OPEN None Yes QUINAPRIL/HCTZ MG TAB OPEN None Yes QUINAPRIL/HCTZ MG TAB OPEN None Yes QUININE SULFATE 200 MG CAP OPEN None No QUININE SULFATE 300 MG CAP OPEN None No QUININE SULFATE CAPSULES 300MG OPEN None No QUININE SULFATE TAB 300 MG OPEN None No QUINTASA 1GM/100ML ENEMA OPEN None No QUINTASA 4GM/100ML ENEMA OPEN None No Page 185 Effective December 2015

186 Coverage Table December QVAR 100 MCG/DOSE INHALER OPEN Can only be claimed if the Beneficiary does not have an active Special No for Wet Nebulization QVAR 50 MCG/DOSE INHALER OPEN Can only be claimed if the Beneficiary does not have an active Special No for Wet Nebulization RABEPRAZOLE EC 10 MG TABLET OPEN Limit of 2 per day without Special Yes RABEPRAZOLE EC 10 MG TABLET OPEN Limit of 2 per day without Special Yes RABEPRAZOLE EC 20 MG TABLET OPEN Yes RABEPRAZOLE EC 20 MG TABLET OPEN Yes RABEPRAZOLE EC 20 MG TABLET OPEN Yes RAMIPRIL 1.25 MG CAPSULE OPEN None Yes RAMIPRIL 10 MG CAPSULE OPEN None Yes RAMIPRIL 10 MG CAPSULE OPEN None Yes RAMIPRIL 10 MG CAPSULE OPEN None Yes RAMIPRIL 2.5 MG CAPSULE OPEN None Yes RAMIPRIL 2.5 MG CAPSULE OPEN None Yes RAMIPRIL 2.5 MG CAPSULE OPEN None Yes RAMIPRIL 5 MG CAPSULE OPEN None Yes RAMIPRIL 5 MG CAPSULE OPEN None Yes RAMIPRIL 5 MG CAPSULE OPEN None Yes RAMIPRIL-HCTZ 10 MG-12.5MG TAB OPEN None Yes RAMIPRIL-HCTZ 10 MG-25 MG TAB OPEN None Yes RAMIPRIL-HCTZ 5 MG-12.5 MG TAB OPEN None Yes RAMIPRIL-HCTZ 5 MG-25 MG TAB OPEN None Yes RAN-ALENDRONATE 10 MG TABLET None Yes RAN-ALENDRONATE 70 MG TABLET None Yes RAN-AMLODIPINE 10 MG TABLET OPEN None Yes RAN-AMLODIPINE 5 MG TABLET OPEN Yes RAN-ANASTROZOLE 1 MG TABLET None Yes RAN-ATENOLOL 100 MG TABLET OPEN None Yes Page 186 Effective December 2015

187 Coverage Table December RAN-ATENOLOL 25 MG TABLET OPEN None No RAN-ATENOLOL 50 MG TABLET OPEN None Yes RAN-ATORVASTATIN 10 MG TABLET OPEN None Yes RAN-ATORVASTATIN 20 MG TABLET OPEN None Yes RAN-ATORVASTATIN 40 MG TABLET OPEN None Yes RAN-ATORVASTATIN 80 MG TABLET OPEN None Yes RAN-BICALUTAMIDE 50 MG TABLET OPEN None Yes RAN-CANDESARTAN 16 MG TABLET OPEN Yes RAN-CANDESARTAN 32 MG TABLET OPEN Yes RAN-CANDESARTAN 8 MG TABLET OPEN Yes RAN-CARVEDILOL 12.5 MG TAB None Yes RAN-CARVEDILOL 25 MG TABLET None Yes RAN-CARVEDILOL MG TAB None Yes RAN-CARVEDILOL 6.25 MG TAB None Yes RAN-CEFPROZIL 125 MG/5 ML SUSP OPEN None Yes RAN-CEFPROZIL 250 MG TABLET OPEN None Yes RAN-CEFPROZIL 250 MG/5 ML OPEN None Yes RAN-CEFPROZIL 500 MG TABLET OPEN None Yes RAN-CELECOXIB 100 MG CAPSULE OPEN Limit of 2 per day without Special Yes RAN-CELECOXIB 200 MG CAPSULE OPEN Limit of 2 per day without Special Yes RAN-CIPROFLOX 250 MG TABLET OPEN None Yes RAN-CIPROFLOX 500 MG TABLET OPEN None Yes RAN-CIPROFLOX 750 MG TABLET OPEN None Yes RAN-CITALO 20 MG TABLET OPEN. Maximum of 1.5 tablets Yes daily RAN-CITALO 40 MG TABLET OPEN Yes RAN-CITALOPRAM 20 MG TABLET OPEN. Maximum of 1.5 tablets daily. No Page 187 Effective December 2015

188 Coverage Table December RAN-CITALOPRAM 40 MG TABLET OPEN No RAN-CLARITHROMYCIN 250 MG TAB OPEN None Yes RAN-CLARITHROMYCIN 500 MG TAB OPEN None Yes RAN-CLOPIDOGREL 75 MG TABLET None Yes RAN-DOMPERIDONE 10 MG TABLET OPEN None Yes RAN-DONEPEZIL 10 MG TABLET No Yes RAN-DONEPEZIL 5 MG TABLET No Yes RAN-ENALAPRIL 16 MG (20MG) TAB OPEN None Yes RAN-ENALAPRIL 2 MG (2.5MG) TAB OPEN None Yes RAN-ENALAPRIL 4 MG (5 MG) TAB OPEN None Yes RAN-ENALAPRIL 8 MG (10 MG) TAB OPEN None Yes RAN-EZETIMIBE 10 MG TABLET None Yes RAN-FENTANYL MATRIX 100 MCG/HR Yes RAN-FENTANYL MATRIX 12 MCG/HR Yes RAN-FENTANYL MATRIX 25 MCG/HR Yes RAN-FENTANYL MATRIX 50 MCG/HR Yes RAN-FENTANYL MATRIX 75 MCG/HR Yes Special required if beneficiary RAN-FINASTERIDE 5 MG TABLET has not had a paid claim for an alpha Yes blocker or finasteride in past year RAN-FLUOXETINE 10 MG CAPSULE OPEN Yes RAN-FLUOXETINE 20 MG CAPSULE OPEN Yes RAN-FOSINOPRIL 10 MG TABLET OPEN None Yes RAN-FOSINOPRIL 20 MG TABLET OPEN None Yes RAN-GABAPENTIN 100 MG CAPSULE None Yes RAN-GABAPENTIN 300 MG CAPSULE None Yes RAN-GABAPENTIN 400 MG CAPSULE None Yes RAN-IRBESARTAN 150 MG TABLET OPEN Yes Page 188 Effective December 2015

189 Coverage Table December RAN-IRBESARTAN 300 MG TAB OPEN Yes RAN-IRBESARTAN 75 MG TABLET OPEN Yes RANITIE 150 MG TABLET OPEN None No RANITIE 150 MG TABLET OPEN None Yes RANITIE 150 MG TABLET OPEN None Yes RANITIE 300 MG TABLET OPEN None Yes RANITIE 300 MG TABLET OPEN None Yes RAN-LANSOPRAZOLE DR 15 MG CAP None Yes RAN-LANSOPRAZOLE DR 30 MG CAP None Yes RAN-LETROZOLE 2.5 MG TABLET None Yes RAN-LEVETIRACETAM 250 MG TAB None Yes RAN-LEVETIRACETAM 500 MG TAB None Yes RAN-LEVETIRACETAM 750 MG TAB None Yes RAN-LISINOPRIL 10 MG TABLET OPEN None Yes RAN-LISINOPRIL 20 MG TABLET OPEN None Yes RAN-LISINOPRIL 5 MG TABLET OPEN None Yes RAN-LOSARTAN 100 MG TABLET OPEN Yes RAN-LOSARTAN 25 MG TABLET OPEN Yes RAN-LOSARTAN 50 MG TABLET OPEN Yes RAN-METFORMIN 500 MG TABLET OPEN None Yes RAN-METFORMIN 850 MG TABLET OPEN None Yes RAN-MONTELUKAST 10 MG TAB None Yes RAN-MONTELUKAST 4 MG TAB CHEW None Yes RAN-MONTELUKAST 5 MG TAB CHEW None Yes RAN-NABILONE 0.5 MG CAPSULE OPEN Yes RAN-NABILONE 1 MG CAPSULE OPEN Yes RAN-OLANZAPINE 10 MG TABLET Yes RAN-OLANZAPINE 15 MG TABLET Yes Page 189 Effective December 2015

190 Coverage Table December RAN-OLANZAPINE 2.5 MG TABLET Yes RAN-OLANZAPINE 5 MG TABLET Yes RAN-OLANZAPINE 7.5 MG TABLET Yes RAN-OLANZAPINE ODT 10 MG TAB Yes RAN-OLANZAPINE ODT 15 MG TAB Yes RAN-OLANZAPINE ODT 20 MG TAB Yes RAN-OLANZAPINE ODT 5 MG TABLET Yes RAN-OMEPRAZOLE 20 MG CAP DR OPEN Yes RAN-OMEPRAZOLE DR 20 MG TABLET OPEN Yes RAN-ONDANSETRON 4 MG TABLET OPEN Limit of 3 tablets per cycle - first fill only. Special is required for higher Yes quantities and/or subsequent fills RAN-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 RAN-PANTOPRAZOLE DR 20 MG TAB OPEN Yes RAN-PANTOPRAZOLE DR 40 MG TAB OPEN Yes RAN-PIOGLITAZONE 15 MG TABLET None Yes RAN-PIOGLITAZONE 30 MG TABLET None Yes RAN-PIOGLITAZONE 45 MG TABLET None Yes RAN-PRAVASTATIN 10 MG TAB OPEN None Yes RAN-PRAVASTATIN 20 MG TAB OPEN None Yes RAN-PRAVASTATIN 40 MG TAB OPEN None Yes RAN-PREGABALIN 150 MG CAPSULE None Yes RAN-PREGABALIN 225 MG CAPSULE None Yes RAN-PREGABALIN 25 MG CAPSULE None Yes Page 190 Effective December 2015

191 Coverage Table December RAN-PREGABALIN 300 MG CAPSULE None Yes RAN-PREGABALIN 50 MG CAPSULE None Yes RAN-PREGABALIN 75 MG CAPSULE None Yes RAN-QUETIAPINE 100 MG TABLET OPEN Yes RAN-QUETIAPINE 200 MG TABLET OPEN Yes RAN-QUETIAPINE 25 MG TABLET OPEN Yes RAN-QUETIAPINE 300 MG TABLET OPEN Yes RAN-RABEPRAZOLE EC 10 MG TAB OPEN Limit of 2 per day without Special Yes RAN-RABEPRAZOLE EC 20 MG TAB OPEN Yes RAN-RAMIPRIL 1.25 MG CAP OPEN None Yes RAN-RAMIPRIL 10 MG CAPSULE OPEN None Yes RAN-RAMIPRIL 2.5 MG CAPSULE OPEN None Yes RAN-RAMIPRIL 5 MG CAPSULE OPEN None Yes RAN-RANITIE 150 MG TABLET OPEN None Yes RAN-RANITIE 300 MG TABLET OPEN None Yes RAN-RISPERIDONE 0.25 MG TABLET OPEN Yes RAN-RISPERIDONE 0.5 MG TABLET OPEN Yes RAN-RISPERIDONE 1 MG TABLET OPEN Yes RAN-RISPERIDONE 2 MG TABLET OPEN Yes RAN-RISPERIDONE 3 MG TABLET OPEN Yes RAN-RISPERIDONE 4 MG TABLET OPEN Yes RAN-ROPINIROLE 0.25 MG TABLET OPEN None Yes RAN-ROPINIROLE 1 MG TABLET OPEN None Yes RAN-ROPINIROLE 2 MG TABLET OPEN None Yes RAN-ROPINIROLE 5 MG TABLET OPEN None Yes Page 191 Effective December 2015

192 Coverage Table December RAN-ROSUVASTATIN 10 MG TABLET OPEN None Yes RAN-ROSUVASTATIN 20 MG TABLET OPEN None Yes RAN-ROSUVASTATIN 40 MG TABLET OPEN None Yes RAN-ROSUVASTATIN 5 MG TABLET OPEN Yes RAN-SERTRALINE 100 MG CAPSULE OPEN Yes RAN-SERTRALINE 25 MG CAPSULE OPEN Yes RAN-SERTRALINE 50 MG CAPSULE OPEN Yes RAN-SIMVASTATIN 10 MG TABLET OPEN None Yes RAN-SIMVASTATIN 20 MG TABLET OPEN None Yes RAN-SIMVASTATIN 40 MG TABLET OPEN None Yes RAN-SIMVASTATIN 5 MG TABLET OPEN None Yes RAN-SIMVASTATIN 80 MG TABLET OPEN None Yes RAN-TOPIRAMATE 100 MG TABLET OPEN None Yes RAN-TOPIRAMATE 200 MG TABLET OPEN None Yes RAN-TOPIRAMATE 25 MG TABLET OPEN None Yes RAN-VALSARTAN 160 MG TABLET OPEN Yes RAN-VALSARTAN 40 MG TABLET OPEN Yes RAN-VALSARTAN 80 MG TABLET OPEN Yes RAN-VENLAFAXINE XR 150 MG CAP OPEN Yes RAN-VENLAFAXINE XR 37.5 MG CAP OPEN Yes RAN-VENLAFAXINE XR 75 MG CAP OPEN Yes RAN-ZOPICLONE 5 MG TABLET OPEN Yes RAN-ZOPICLONE 7.5 MG TABLET OPEN Yes Page 192 Effective December 2015

193 Coverage Table December RAPID RESP BLD GLUCOSE TST STR OPEN a) Limited to 2500 per year without Special b) Beneficiary must have diabetic medication within previous year No history, otherwise Special is required RATIO-ACLAVULAN /5 OPEN None Yes RATIO-ACLAVULANAT MG OPEN None Yes RATIO-ACLAVULANAT MG OPEN None Yes RATIO-ACYCLOVIR 200 MG TAB OPEN None Yes RATIO-ACYCLOVIR 400 MG TAB OPEN None Yes RATIO-ACYCLOVIR800 MG TAB OPEN None Yes RATIO-ALENDRONATE 70 MG TAB None Yes RATIO-AMCINONIDE 0.1 % CREAM OPEN None Yes RATIO-AMCINONIDE 0.1 % LOTION OPEN None Yes RATIO-AMCINONIDE 0.1 % OINT OPEN None Yes RATIO-AMIODARONE 200 MG TAB OPEN None Yes RATIO-AMLODIPINE 10 MG TABLET OPEN None Yes RATIO-AMLODIPINE 5 MG TABLET OPEN Yes RATIO-ATENOLOL 100 MG TABLET OPEN None Yes RATIO-ATENOLOL 50 MG TABLET OPEN None Yes RATIO-ATORVASTATIN 10 MG TAB OPEN None Yes RATIO-ATORVASTATIN 20 MG TAB OPEN None Yes RATIO-ATORVASTATIN 40 MG TAB OPEN None Yes RATIO-ATORVASTATIN 80 MG TAB OPEN None Yes RATIO-AZITHROMYCIN 250 MG TA OPEN None Yes RATIO-BACLOFEN 10 MG TABLET OPEN None Yes RATIO-BACLOFEN 20 MG TABLET OPEN None Yes RATIO-BENZYDAMINE 0.15% SOL OPEN None No RATIO-BICALUTAMIDE 50 MG TAB OPEN None Yes RATIO-BISACODYL 10 MG SUPP OPEN Reasonable Based Pricing is applied No RATIO-BRIMONIE 0.2 % DROPS OPEN None Yes RATIO-BUPROPION SR 100 MG TAB OPEN a) Limited to 2 per day without Special b) Special Authorzation required if beneficiary has not had a paid claim for an anti-depressant or Bupropion in past year. Yes Page 193 Effective December 2015

194 Coverage Table December RATIO-BUPROPION SR 150 MG TAB OPEN a) Limited to 2 per day without Special b) Special Authorzation required if beneficiary has not had a paid Yes claim for an anti-depressant or Bupropion in past year RATIO-CARVEDILOL 12.5 MG TAB None Yes RATIO-CARVEDILOL 25 MG TAB None Yes RATIO-CARVEDILOL MG TAB None Yes RATIO-CARVEDILOL 6.25 MG TAB None Yes RATIO-CEFUROXIME 250 MG TAB OPEN None Yes RATIO-CEFUROXIME 500 MG TAB OPEN None Yes RATIO-CIPROFLOXACN 250 MG TB OPEN None Yes RATIO-CIPROFLOXACN 500 MG TB OPEN None Yes RATIO-CIPROFLOXACN 750 MG TB OPEN None Yes RATIO-CITALOPRAM 20 MG TAB OPEN. Maximum of 1.5 tablets Yes daily RATIO-CITALOPRAM 40 MG TAB OPEN Yes RATIO-CLARITHROMYCIN 250 MG OPEN None Yes RATIO-CLARITHROMYCIN 500 MG OPEN None Yes RATIO-CLOBETASOL 0.05 % CREAM OPEN None Yes RATIO-CLOBETASOL 0.05% LOT OPEN None Yes RATIO-CLOBETASOL 0.05% OINT OPEN None Yes RATIO-CLONAZEPAM 0.5 MG TAB OPEN Yes RATIO-CLONAZEPAM 2 MG TABLET OPEN Yes RATIO-CODEINE 25 MG/5 ML SYRP OPEN No RATIO-CODEINE PHOS 15 MG TAB OPEN No RATIO-CODEINE PHOS 30 MG TAB OPEN No RATIO-DEXAMETHASONE 0.5 MG OPEN None No RATIO-DEXAMETHASONE 4 MG TAB OPEN None No RATIO-DILTIAZEM CD 120 MG CP OPEN None Yes Page 194 Effective December 2015

195 Coverage Table December RATIO-DILTIAZEM CD 180 MG CP OPEN None Yes RATIO-DILTIAZEM CD 300 MG CP OPEN None Yes RATIO-DOC NA 20 MG/5 ML SYRUP OPEN Beneficiary must be less than 13 years old - RBP applied No RATIO-DOMPERIDONE 10 MG TAB OPEN None Yes RATIO-ECTOSONE 0.05 % CREAM OPEN None Yes RATIO-ECTOSONE 0.05 % LOTION OPEN None No RATIO-ECTOSONE 0.1 % CREAM OPEN None Yes RATIO-ECTOSONE 0.1% LOTION OPEN None No RATIO-ECTOSONE 0.1% SCALP LOT OPEN None Yes RATIO-EMTEC-30 TABLET OPEN No RATIO-FENOFIBR MC 200 MG CAP OPEN None Yes RATIO-FINASTERIDE 5 MG TABLET Special required if beneficiary has not had a paid claim for an alpha Yes blocker or finasteride in past year RATIO-FLUNISOLIDE.025% ASP OPEN None No RATIO-FLUOXETINE 10 MG CAP OPEN Yes RATIO-FLUOXETINE 20 MG CAP OPEN Yes RATIO-FLUVOXAMINE 100 MG TAB OPEN Yes RATIO-FLUVOXAMINE 50 MG TAB OPEN Yes RATIO-GABAPENTIN 100 MG CAP None Yes RATIO-GABAPENTIN 400 MG CAP None Yes RATIO-GENTAMICIN 0.1% CREAM OPEN None No RATIO-GENTAMICIN 0.1% OINT OPEN None No RATIO-GLIMEPIRIDE 1MG TAB OPEN None Yes RATIO-GLIMEPIRIDE 2MG TAB OPEN None Yes RATIO-GLIMEPIRIDE 4MG TAB OPEN None Yes RATIO-GLYBURIDE 2.5 MG TAB OPEN None Yes RATIO-GLYBURIDE 5 MG TABLET OPEN None Yes RATIO-HALOPERIDOL 0.5 MG TAB OPEN No Page 195 Effective December 2015

196 Coverage Table December RATIO-HALOPERIDOL 1 MG TAB OPEN No RATIO-HALOPERIDOL 10 MG TAB OPEN No RATIO-HALOPERIDOL 2 MG TAB OPEN No RATIO-HALOPERIDOL 2 MG/ML OPEN No RATIO-HALOPERIDOL 5 MG TAB OPEN No RATIO-HEMCORT HC % OINT OPEN None No RATIO-HEMCORT HC SUPPOS OPEN None No RATIO-HERACLINE LIQUID OPEN None No RATIO-INDOMETHACIN 100 MG OPEN None No RATIO-INDOMETHACIN 50 MG SUP OPEN None No RATIO-IPRA SAL UDV SOLUTION None Yes RATIO-IPRATROPIUM 21MCG INH OPEN None No RATIO-IPRATROPIUM 250 MCG/2 ML None Yes RATIO-IPRATROPIUM 250 MCG/ML None Yes RATIO-IRBESARTAN 150 MG TABLET OPEN Yes RATIO-IRBESARTAN 300 MG TABLET OPEN Yes RATIO-IRBESARTAN 75 MG TABLET OPEN Yes RATIO-IRBESARTAN HCTZ MG OPEN Yes RATIO-KETOROLAC 0.5% DROPS OPEN None Yes RATIO-LACTULOSE 10 GM/15ML SOL OPEN None No RATIO-LACTULOSE 667 MG/ML OPEN None No RATIO-LACTULOSE 667 MG/ML OPEN None No RATIO-LAMOTRIGINE 100 MG TAB OPEN None Yes RATIO-LAMOTRIGINE 150 MG TAB OPEN None Yes RATIO-LAMOTRIGINE 25 MG TAB OPEN None Yes RATIO-LENOLTEC NO 2 TABLET OPEN Yes Page 196 Effective December 2015

197 Coverage Table December RATIO-LENOLTEC NO 3 TABLET OPEN Yes RATIO-LENOLTEC NO 4 TABLET OPEN No RATIO-LEVOBUNOLOL 0.25 % DROPS OPEN None Yes RATIO-LEVOBUNOLOL 0.5% EYE DRP OPEN None Yes RATIO-LISINOPRIL P 10 MG TB OPEN None Yes RATIO-LISINOPRIL P 20 MG TB OPEN None Yes RATIO-LISINOPRIL P 5 MG TAB OPEN None Yes RATIO-LOVASTATIN 20 MG TAB OPEN None Yes RATIO-LOVASTATIN 40 MG TAB OPEN None Yes RATIO-METFORMIN 500 MG TAB OPEN None Yes RATIO-METFORMIN 850 MG TAB OPEN None Yes RATIO-MOMETASONE 0.1 % OINT OPEN None Yes RATIO-MORPHINE 1 MG/ML SYRUP OPEN No RATIO-MORPHINE 10 MG/ML SYRP OPEN No RATIO-MORPHINE 20 MG/ML SYRP OPEN No RATIO-MORPHINE 5 MG/ML SYRUP OPEN No RATIO-NAPROXEN 250 MG TABLET OPEN None No RATIO-NYSTATIN UNIT/G OPEN None No RATIO-NYSTATIN 100MU TABLET OPEN None No RATIO-NYSTATIN TABLET OPEN None No RATIO-OMEPRAZOLE DR 20 MG TAB OPEN Yes RATIO-ONDANSETRON 4 MG TAB OPEN Limit of 3 tablets per cycle - first fill only. Special is required for higher Yes quantities and/or subsequent fills RATIO-ONDANSETRON 8 MG TAB OPEN Limit of 3 tablets per cycle - first fill only. Special is required for higher Yes quantities and/or subsequent fills RATIO-OXYCOCET MG TABLET OPEN Yes Page 197 Effective December 2015

198 Coverage Table December RATIO-OXYCODAN TAB OPEN Yes RATIO-PAROXETINE 10 MG TAB No RATIO-PAROXETINE 20 MG TAB OPEN Yes RATIO-PAROXETINE 30 MG TAB OPEN Yes RATIO-PIOGLITAZONE 15 MG TAB None Yes RATIO-PIOGLITAZONE 30 MG TAB None Yes RATIO-PIOGLITAZONE 45 MG TAB None Yes RATIO-PREDNISOLONE 1% DROPS OPEN None Yes RATIO-PROCTOSONE OINT OPEN None No RATIO-PROCTOSONE SUPP OPEN None No RATIO-RAMIPRIL 15 MG CAPSULE OPEN None Yes RATIO-RANITIE 150 MG TAB OPEN None Yes RATIO-RISEDRONATE 35 MG TABLET None Yes RATIO-RIVASTIGMINE 1.5 MG CAP None Yes RATIO-RIVASTIGMINE 3 MG CAP None Yes RATIO-RIVASTIGMINE 4.5 MG CAP None Yes RATIO-RIVASTIGMINE 6 MG CAP None Yes RATIO-SALBUTAMOL 1 MG/ML SOL None Yes RATIO-SALBUTAMOL 1.25 MG/2.5ML None Yes RATIO-SALBUTAMOL 5 MG/2.5 ML None Yes RATIO-SALBUTAMOL 5 MG/ML SOLN None Yes RATIO-SILDENAFIL R 20 MG TAB None Yes RATIO-SOTALOL 160 MG TABLET OPEN None Yes RATIO-SOTALOL 80 MG TABLET OPEN None Yes RATIO-TAMSULOSIN 0.4 MG CAP OPEN Limit of 2 per day without Special Yes RATIO-TECNAL C 1/2 CAPSULE OPEN Yes RATIO-TECNAL C 1/4 CAPSULE OPEN Yes RATIO-TECNAL CAPSULE OPEN Yes Page 198 Effective December 2015

199 Coverage Table December RATIO-TECNAL TABLET OPEN No RATIO-TERAZOSIN 1 MG TABLET OPEN None Yes RATIO-TERAZOSIN 10 MG TABLET OPEN None Yes RATIO-TERAZOSIN 2 MG TABLET OPEN None Yes RATIO-TERAZOSIN 5 MG TABLET OPEN None Yes RATIO-THEO-BRONC SYRUP OPEN None No RATIO-TOPILENE 0.05 % CREAM OPEN None No RATIO-TOPILENE 0.05 % OINT OPEN None No RATIO-TOPISALIC 0.05%-2 % LOT OPEN None Yes RATIO-TOPISONE 0.05 % OINT OPEN None No RATIO-TOPISONE 0.05% CREAM OPEN None No RATIO-TOPISONE 0.05% LOTION OPEN None No RATIO-TRIACOMB CREAM OPEN None Yes RATIO-VALPROIC 50 MG/ML SYR OPEN None Yes RATIO-ZOPICLONE 5 MG TABLET OPEN Yes RATIO-ZOPICLONE 7.5 MG TAB OPEN Yes REACTINE 10 MG TABLET OPEN None Yes REBIF 11MCG KIT None No REBIF 132 MCG/1.5 ML CARTRIDGE None No REBIF 22 MCG/0.5 ML SYRINGE None No REBIF 44 MCG/0.5 ML SYRINGE None No REBIF 66 MCG/1.5 ML CARTRIDGE None No REBIF INITIATION PACK None No RECLIPSEN 21 TABLET OPEN Beneficiary gender must be female - under the age of 51 Yes RECLIPSEN 28 TABLET OPEN Beneficiary gender must be female - under the age of 51 Yes RECTOCORT SUP OPEN None No REDDY-ATORVASTATIN 10 MG TAB OPEN None Yes REDDY-ATORVASTATIN 20 MG TAB OPEN None Yes REDDY-ATORVASTATIN 40 MG TAB OPEN None Yes REDDY-ATORVASTATIN 80 MG TAB OPEN None Yes REFRESH TEARS 0.5% EYE DROP OPEN None No REGLAN TAB 10MG OPEN None Yes Page 199 Effective December 2015

200 Coverage Table December REGULAR ILETIN II 100U/ML OPEN None No RELAFEN TABLETS 500MG OPEN None Yes RELAFEN TABLETS 750MG OPEN None Yes RELENZA 5 MG DISKHALER None No REMERON 30 MG TABLET OPEN Yes REMERON RD 15 MG TAB RAPDIS OPEN Yes REMERON RD 30 MG TAB RAPDIS OPEN Yes REMERON RD 45 MG TAB RAPDIS OPEN Yes REMICADE 100 MG VIAL None No REMINYL 12 MG TABLET None No REMINYL 4 MG TABLET None No REMINYL 8 MG TABLET None No REMINYL ER 16 MG CAPSULE None Yes REMINYL ER 24 MG CAPSULE None Yes REMINYL ER 8 MG CAPSULE None Yes REMODULIN 1 MG/ML VIAL None No REMODULIN 10 MG/ML VIAL None No REMODULIN 2.5 MG/ML VIAL None No REMODULIN 5 MG/ML VIAL None No RENAGEL 800 MG TABLET None No RENEDIL 10 MG TABLET SA OPEN None Yes RENEDIL 2.5 MG TABLET SA OPEN None No RENEDIL 5 MG TABLET SA OPEN None Yes REPLAVITE OPEN Can be dispensed by Hospital or RHA Clinic without prior approval No REPLAVITE TABLET OPEN Can be dispensed by Hospital or RHA Clinic without prior approval No REQUIP 0.25 MG TABLET OPEN None Yes REQUIP 1 MG TABLET OPEN None Yes REQUIP 2 MG TABLET OPEN None Yes REQUIP 5 MG TABLET OPEN None Yes RESCRIPTOR 100 MG TABLET OPEN No Page 200 Effective December 2015

201 Coverage Table December RESTORIL 15 MG CAPSULE OPEN Yes RESTORIL 30 MG CAPSULE OPEN Yes RESULTZ 50% LIQUID OPEN None No RETIN-A 0.01 % GEL OPEN None No RETIN-A 0.01% CREAM OPEN None No RETIN-A % GEL OPEN None No RETIN-A 0.025% CREAM OPEN None No RETIN-A 0.05 % CREAM OPEN None No RETIN-A 0.1 % CREAM OPEN None No REVATIO 20 MG TABLET None Yes REVLIMID 10MG CAPSULE None No REVLIMID 15MG CAPSULE None No REVLIMID 25 MG CAPSULE None No REVLIMID 5MG CAPSULE None No REYATAZ 150 MG CAPSULE OPEN No REYATAZ 200 MG CAPSULE OPEN No REYATAZ 300 MG CAPSULE OPEN No RHINALAR 0.025% NASAL SPRAY OPEN None No RHINARIS-CS 2 % NASAL MIST OPEN None No RHINOCORT 100MCG TURBUHALER OPEN None No RHINOCORT AQUA 64 MCG SPRAY OPEN None Yes RHODACINE 100 MG SUPP Y OPEN None No RHODACINE 50 MG SUPPOSITORY OPEN None No RHODIS 100 MG SUPPOSITORY OPEN None No RHODIS 50MG CAPSULE OPEN None No RHO-HALOPERIDOL 100MG/ML VL OPEN No RHOVANE 7.5 MG TABLET OPEN Yes RHOXAL-LOPERAMIDE 2 MG TAB None No RIDAURA 3 MG CAPSULE OPEN None No RIFA 150 MG CAPSULE OPEN None No Page 201 Effective December 2015

202 Coverage Table December RIFA 300 MG CAPSULE OPEN None No RIFATER TABLET OPEN None No RIGHTEST GS100 TEST STRIPS OPEN a) Limited to 2500 per year without Special b) Beneficiary must have diabetic medication within previous year No history, otherwise Special is required RIGHTEST GS100 TEST STRIPS OPEN a) Limited to 2500 per year without Special b) Beneficiary must have diabetic medication within previous year No history, otherwise Special is required RILUTEK 50 MG TABLET None Yes RIMSO-50 50% SOLUTION OPEN None No RIOPAN SUS 480MG/5ML OPEN None No RIOPAN TAB 480MG OPEN None No RISEDRONATE 35 MG TABLET None Yes RISEDRONATE 35 MG TABLET None Yes RISPERDAL 0.25 MG TABLET OPEN Yes RISPERDAL 0.5 MG TABLET OPEN Yes RISPERDAL 1 MG TABLET OPEN Yes RISPERDAL 1 MG/ML ORAL SOLN OPEN Yes RISPERDAL 2 MG TABLET OPEN Yes RISPERDAL 3 MG TABLET OPEN Yes RISPERDAL 4 MG TABLET OPEN Yes RISPERDAL CONSTA 12.5 MG/2 ML No RISPERDAL CONSTA 25 MG/2 ML No Page 202 Effective December 2015

203 Coverage Table December RISPERDAL CONSTA 37.5 MG/2 ML RISPERDAL CONSTA 50 MG/2 ML RISPERDAL M 0.5 MG TABLET RISPERDAL M 1 MG TABLET RISPERDAL M 2 MG TABLET RISPERDAL M 3 MG TABLET RISPERDAL M 4 MG TABLET RISPERIDONE 0.25 MG TABLET OPEN RISPERIDONE 0.25 MG TABLET OPEN RISPERIDONE 0.5 MG TABLET OPEN RISPERIDONE 0.5 MG TABLET OPEN RISPERIDONE 1 MG TABLET OPEN RISPERIDONE 1 MG TABLET OPEN RISPERIDONE 2 MG TABLET OPEN RISPERIDONE 2 MG TABLET OPEN RISPERIDONE 3 MG TABLET OPEN RISPERIDONE 3 MG TABLET OPEN RISPERIDONE 4 MG TABLET OPEN No No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Page 203 Effective December 2015

204 Coverage Table December RISPERIDONE 4 MG TABLET OPEN Yes RISPERIDONE ODT 0.5 MG TABLET Yes RITALIN 10 MG TABLET OPEN Yes RITALIN 20 MG TABLET OPEN Yes RITALIN SR 20 MG TABLET OPEN Yes RITUXAN 10 MG/ML VIAL None No RIVA-LOPERAMIDE 2 MG TABLET None No RIVOTRIL 0.5 MG TABLET OPEN Yes RIVOTRIL 2 MG TABLET OPEN Yes RIZATRIPTAN ODT 10MG None Yes RIZATRIPTAN ODT 5MG None Yes ROBAXACET MG TABLET OPEN None No ROBAXACET TABLET OPEN None No ROBAXACET-8 TABLET OPEN No ROBAXIN 500 MG TABLET OPEN None No ROBAXIN MG TABLET OPEN None No ROBAXISAL C 1/2 TABLET OPEN No ROBAXISAL C 1/4 TABLET OPEN No ROBAXISAL TABLET OPEN None No ROBAXISAL-C 1/8 TABLET OPEN No ROCALTROL 0.25 MCG CAPSULE OPEN None No ROCALTROL 0.5MCG CAPSULE OPEN None No ROFACT 150 MG CAPSULE OPEN None No ROFACT 300 MG CAPSULE OPEN None No ROPINIROLE 0.25 MG TABLET OPEN None Yes ROPINIROLE 0.25 MG TABLET OPEN None Yes Page 204 Effective December 2015

205 Coverage Table December ROPINIROLE 1 MG TABLET OPEN None Yes ROPINIROLE 1 MG TABLET OPEN None Yes ROPINIROLE 2 MG TABLET OPEN None Yes ROPINIROLE 2 MG TABLET OPEN None Yes ROPINIROLE 5 MG TABLET OPEN None Yes ROPINIROLE 5 MG TABLET OPEN None Yes ROSASOL 1 % CREAM OPEN None No ROSUVASTATIN 5 MG TABLET OPEN Yes ROSUVASTATIN 10 MG TABLET OPEN None Yes ROSUVASTATIN 10 MG TABLET OPEN None Yes ROSUVASTATIN 20 MG TABLET OPEN None Yes ROSUVASTATIN 20 MG TABLET OPEN None Yes ROSUVASTATIN 40 MG TABLET OPEN None Yes ROSUVASTATIN 40 MG TABLET OPEN None Yes ROSUVASTATIN 5 MG TABLET OPEN Yes ROUGIER CALCIUM LIQUID OPEN None No ROVAMYCINE '250' 750MU CAP OPEN None No ROVAMYCINE 500 CAPSULE OPEN None No RUBION MCG/ML VIAL OPEN None No RYTHMODAN 100 MG CAPSULE OPEN None No RYTHMODAN 150 MG CAPSULE OPEN None No RYTHMODAN LA 250 MG TABLET OPEN None No RYTHMOL 150 MG TABLET OPEN None Yes RYTHMOL 300 MG TABLET OPEN None Yes S.A.S. 3GM/100ML ENEMA OPEN None No S.A.S.-ENTERIC 500MG TAB EC OPEN None No SAB-NAPROXEN 500 MG SUPP OPEN None No SABRIL 500 MG PACKET OPEN None No SABRIL 500 MG TABLET OPEN None No SAIZEN 10U VIAL OPEN Open benefit only if Beneficiary is eligible under the Growth Hormone Plan No SAIZEN 12 MG/1.5 ML CARTRIDGE OPEN Open benefit only if Beneficiary is eligible under the Growth Hormone Plan No SAIZEN 20 MG/2.5 ML CARTRIDGE OPEN Open benefit only if Beneficiary is eligible under the Growth Hormone Plan No Page 205 Effective December 2015

206 Coverage Table December SAIZEN 5 MG VIAL OPEN Open benefit only if Beneficiary is eligible under the Growth Hormone Plan No SAIZEN 6 MG/1.03 ML CARTRIDGE OPEN Open benefit only if Beneficiary is eligible under the Growth Hormone Plan No SAIZEN 8.8 MG VIAL OPEN Open benefit only if Beneficiary is eligible under the Growth Hormone Plan No SALAZOPYRIN 3GM/100ML ENEMA OPEN None No SALAZOPYRIN 500 MG EN-TABS OPEN None No SALAZOPYRIN 500 MG TABLET OPEN None No SALBUTAMOL 2.5 MG/2.5 ML SOLN None Yes SALBUTAMOL HFA 100 MCG INHALER OPEN None Yes SALBUTAMOL NEBUAMP 0.2% None No SALOFALK 1000 MG SUPPOSITORY OPEN None No SALOFALK 2 GRAM/60 ML ENEMA OPEN None No SALOFALK 250 MG SUPPOSITORY OPEN None No SALOFALK 4 GRAM/60 ML ENEMA OPEN None No SALOFALK 500 MG SUPPOSITORY OPEN None No SALOFALK 500 MG TABLET EC OPEN None No SAN-CARBAMAZEPINE CR 200 MG OPEN None Yes SAN-CARBAMAZEPINE CR 400 MG OPEN None Yes SAND VENLAFAXINE XR 37.5 MG OPEN Yes SANDOMIGRAN 0.5 MG TABLET OPEN None No SANDOMIGRAN DS 1 MG TABLET OPEN None No SANDOSTATIN 0.05 MG/ML AMP OPEN None Yes SANDOSTATIN 0.1 MG/ML AMP OPEN None Yes SANDOSTATIN 0.2 MG/ML VIAL OPEN None No SANDOSTATIN 0.5 MG/ML AMP OPEN None Yes SANDOSTATIN LAR 10 MG VIAL OPEN None No SANDOSTATIN LAR 20 MG VIAL OPEN None No SANDOSTATIN LAR 30 MG VIAL OPEN None No SANDOZ ALENDR/CHOL 70MG/5600IU No Yes SANDOZ ALENDRONATE 10 MG TAB None Yes SANDOZ ALENDRONATE 70 MG TAB None Yes SANDOZ ALMOTRIPTAN 12.5 MG TAB None Yes SANDOZ AMIODARONE 200 MG TAB OPEN None Yes SANDOZ AMLODIPINE 10 MG TABLET OPEN None Yes Page 206 Effective December 2015

207 Coverage Table December SANDOZ AMLODIPINE 5 MG TABLET OPEN Yes SANDOZ ANAGRELIDE 0.5 MG CAP OPEN None Yes SANDOZ ANASTROZOLE 1 MG TABLET None Yes SANDOZ ANUZINC HC OINTMENT OPEN None Yes SANDOZ ANUZINC HC PLUS SUPP OPEN None Yes SANDOZ ANUZINC HC SUPP OPEN None Yes SANDOZ ATORVASTATIN 10 MG TAB OPEN None Yes SANDOZ ATORVASTATIN 20 MG TAB OPEN None Yes SANDOZ ATORVASTATIN 40 MG TAB OPEN None Yes SANDOZ ATORVASTATIN 80 MG TAB OPEN None Yes SANDOZ AZITHROMYCIN 100 MG/5 OPEN None Yes SANDOZ AZITHROMYCIN 200 MG/5 OPEN None Yes SANDOZ AZITHROMYCIN 250 MG TAB OPEN None Yes SANDOZ BICALUTAMIDE 50 MG TAB OPEN None Yes SANDOZ BISOPROLOL 10 MG TAB OPEN None Yes SANDOZ BISOPROLOL 5 MG TAB OPEN None Yes SANDOZ BOSENTAN 125 MG TABLET None Yes SANDOZ BOSENTAN 62.5 MG TABLET None Yes a) Limited to 2 per day without Special b) Special Authorzation SANDOZ BUPROPION SR 100 MG TAB OPEN required if beneficiary has not had a paid Yes claim for an anti-depressant or Bupropion in past year SANDOZ BUPROPION SR 150 MG TAB OPEN a) Limited to 2 per day without Special b) Special Authorzation required if beneficiary has not had a paid Yes claim for an anti-depressant or Bupropion in past year SANDOZ CANDESARTAN 16 MG TAB OPEN Yes SANDOZ CANDESARTAN 32 MG TAB OPEN Yes SANDOZ CANDESARTAN 32 MG TAB OPEN Yes Page 207 Effective December 2015

208 Coverage Table December SANDOZ CANDESARTAN 8 MG OPEN TABLET Yes SANDOZ CAPECITABINE 150 MG TAB None Yes SANDOZ CAPECITABINE 500 MG TAB None Yes SANDOZ CEFPROZIL 125 MG/5ML OPEN None Yes SANDOZ CEFPROZIL 250 MG TAB OPEN None Yes SANDOZ CEFPROZIL 250 MG/5ML OPEN None Yes SANDOZ CEFPROZIL 500 MG TAB OPEN None Yes SANDOZ CIPROFLOXACIN 250MG TAB OPEN None Yes SANDOZ CIPROFLOXACIN 500MG TAB OPEN None Yes SANDOZ CIPROFLOXACIN 750MG TAB OPEN None Yes SANDOZ CITALOPRAM 20 MG TAB OPEN. Maximum of 1.5 tablets Yes daily SANDOZ CITALOPRAM 40 MG TAB OPEN Yes SANDOZ CLARITHROMYCN 250MG TAB OPEN None Yes SANDOZ CLARITHROMYCN 500MG TAB OPEN None Yes SANDOZ CLONAZEPAM 0.5 MG TAB OPEN Yes SANDOZ CLONAZEPAM 1 MG TAB OPEN Yes SANDOZ CLONAZEPAM 2 MG TAB OPEN Yes SANDOZ CLOPIDOGREL 75 MG TAB None Yes SANDOZ CORTIMYXIN OPH OINT OPEN None No SANDOZ CYCLOSPORINE 100 MG CAP OPEN None Yes SANDOZ DEXAMETHASONE 0.1% OPEN None No SANDOZ DICLOFENAC 100 MG OPEN None No SANDOZ DICLOFENAC 50 MG SUP OPEN None No SANDOZ DILTIAZEM CD 120 MG OPEN None Yes SANDOZ DILTIAZEM CD 180 MG OPEN None Yes SANDOZ DILTIAZEM CD 240 MG OPEN None Yes SANDOZ DILTIAZEM CD 300 MG OPEN None Yes SANDOZ DIMENHYDRINATE 100MG OPEN None No Page 208 Effective December 2015

209 Coverage Table December SANDOZ DIMENHYDRINATE 50 MG OPEN None No SANDOZ DONEPEZIL 10 MG TAB No Yes SANDOZ DONEPEZIL 5 MG TAB No Yes SANDOZ DORZOLAMIDE 2% EYE DROP OPEN None Yes SANDOZ DUTASTERIDE 0.5 MG CAP None Yes SANDOZ ENALAPRIL 16 MG (20 MG) OPEN None Yes SANDOZ ENALAPRIL 2 MG (2.5 MG) OPEN None Yes SANDOZ ENALAPRIL 4 MG (5 MG) OPEN None Yes SANDOZ ENALAPRIL 8 MG (10 MG) OPEN None Yes SANDOZ ENTACAPONE 200 MG TAB OPEN None Yes SANDOZ EYELUBE 0.5 % EYE DROPS OPEN None No SANDOZ EYELUBE 1 % EYE DROPS OPEN None No SANDOZ EZETIMIBE 10 MG TABLET None Yes SANDOZ FAMCICLOVIR 125 MG TAB OPEN None Yes SANDOZ FAMCICLOVIR 250 MG TAB OPEN None Yes SANDOZ FAMCICLOVIR 500 MG TAB OPEN None Yes SANDOZ FELODIPINE ER 10 MG TAB OPEN None Yes SANDOZ FELODIPINE ER 5 MG TAB OPEN None Yes SANDOZ FENOFIBRATE S 100 MG OPEN None Yes SANDOZ FENOFIBRATE S 160 MG OPEN None Yes SANDOZ FENTANYL MTX 100 MCG/HR Yes SANDOZ FENTANYL MTX 12 MCG/HR Yes SANDOZ FENTANYL MTX 25 MCG/HR Yes SANDOZ FENTANYL MTX 50 MCG/HR Yes SANDOZ FENTANYL MTX 75 MCG/HR Yes Special required if beneficiary SANDOZ FINASTERIDE 5 MG TABLET has not had a paid claim for an alpha Yes blocker or finasteride in past year SANDOZ FLUVASTATIN 20 MG CAP OPEN None Yes SANDOZ FLUVASTATIN 40 MG CAP OPEN None Yes Page 209 Effective December 2015

210 Coverage Table December SANDOZ FLUVOXAMINE 100 MG TAB OPEN Yes SANDOZ FLUVOXAMINE 50 MG TAB OPEN Yes SANDOZ GLIMEPIRIDE 1 MG TAB OPEN None Yes SANDOZ GLIMEPIRIDE 2 MG TAB OPEN None Yes SANDOZ GLIMEPIRIDE 4 MG TAB OPEN None Yes SANDOZ GLYBURIDE 2.5 MG TAB OPEN None Yes SANDOZ GLYBURIDE 5 MG TABLET OPEN None Yes SANDOZ IDOXURIE 0.1% LIQUID OPEN None No SANDOZ INDOMETHACIN 100 MG SUP OPEN None No SANDOZ INDOMETHACIN 50 MG SUPP OPEN None No SANDOZ IRBESARTAN 150 MG TAB OPEN Yes SANDOZ IRBESARTAN 300 MG TAB OPEN Yes SANDOZ IRBESARTAN 75 MG TABLET OPEN Yes SANDOZ LATANOPROST % DRP OPEN None Yes SANDOZ LEFLUNOMIDE 10 MG TAB OPEN None Yes SANDOZ LEFLUNOMIDE 20 MG TAB OPEN None Yes SANDOZ LETROZOLE 2.5 MG TABLET None Yes SANDOZ LEVOFLOXACIN 250 MG TAB None Yes SANDOZ LEVOFLOXACIN 500 MG TAB None Yes SANDOZ LINEZOLID 600 MG TABLET None Yes SANDOZ LISINOPRIL 10 MG TAB OPEN None Yes SANDOZ LISINOPRIL 20 MG TAB OPEN None Yes SANDOZ LISINOPRIL 5 MG TAB OPEN None Yes SANDOZ LOSARTAN 100 MG TABLET OPEN Yes SANDOZ LOSARTAN 25 MG TABLET OPEN Yes SANDOZ LOSARTAN 50 MG TABLET OPEN Yes SANDOZ LOSARTAN HCT MG OPEN Yes SANDOZ LOVASTATIN 20 MG TAB OPEN None Yes Page 210 Effective December 2015

211 Coverage Table December SANDOZ LOVASTATIN 40 MG TAB OPEN None Yes SANDOZ METFORMIN 500 MG TAB OPEN None Yes SANDOZ METFORMIN 850 MG TAB OPEN None Yes SANDOZ METHYLPHEN SR 20 MG TAB OPEN Yes SANDOZ METOPROLOL 50 MG TAB OPEN None Yes SANDOZ METOPROLOL SR 100 MG OPEN None Yes SANDOZ METOPROLOL SR 200 MG OPEN None Yes SANDOZ METOPROLOL(L) 100MG TAB OPEN None Yes SANDOZ MINOCYCLINE 100 MG CAP OPEN None Yes SANDOZ MINOCYCLINE 50 MG CAP OPEN None Yes SANDOZ MIRTAZAPINE 15 MG TAB OPEN No SANDOZ MIRTAZAPINE 30 MG TAB OPEN Yes SANDOZ MONTELUKAST 10 MG TAB None Yes SANDOZ MONTELUKAST 4 MG PACKET None Yes SANDOZ MORPHINE SR 15 MG TAB OPEN Yes SANDOZ MORPHINE SR 30 MG TAB OPEN Yes SANDOZ MORPHINE SR 60 MG TAB OPEN Yes SANDOZ NARATRIPTAN 2.5 MG TAB None Yes SANDOZ OFLOXACIN 0.3% EYE DROP OPEN None Yes SANDOZ OLANZAPINE 10 MG TABLET Yes SANDOZ OLANZAPINE 15 MG TABLET Yes SANDOZ OLANZAPINE 2.5 MG TAB Yes SANDOZ OLANZAPINE 5 MG TABLET Yes SANDOZ OLANZAPINE 7.5 MG TAB Yes Page 211 Effective December 2015

212 Coverage Table December SANDOZ OLANZAPINE ODT 10MG TAB Yes SANDOZ OLANZAPINE ODT 15MG TAB Yes SANDOZ OLANZAPINE ODT 20MG TAB Yes SANDOZ OLANZAPINE ODT 5 MG TAB Yes SANDOZ OMEPRAZOLE 20 MG CAP OPEN DR Yes SANDOZ OMEPRAZOLE DR 10 MG OPEN CAP Yes Limit of 3 tablets per cycle - first fill only SANDOZ ONDANSETRON 4 MG TAB OPEN Special is required for higher Yes quantities and/or subsequent fills SANDOZ ONDANSETRON 8 MG TAB OPEN Limit of 3 tablets per cycle - first fill only. Special is required for higher Yes quantities and/or subsequent fills SANDOZ OPIUM & BELLADONNA OPEN No SANDOZ OXYCODONE ACET MG OPEN Yes SANDOZ PANTOPRAZOLE DR 20MG OPEN TB Yes SANDOZ PANTOPRAZOLE DR 40MG OPEN TB Yes SANDOZ PAROXETINE 20 MG TAB OPEN Yes SANDOZ PAROXETINE 20 MG TABLET OPEN Yes SANDOZ PAROXETINE 30 MG TAB OPEN None Yes SANDOZ PAROXETINE 30 MG TABLET OPEN Yes SANDOZ PIOGLITAZONE 15 MG TAB None Yes SANDOZ PIOGLITAZONE 30 MG TAB None Yes SANDOZ PIOGLITAZONE 45 MG TAB None Yes SANDOZ PRAMIPEXOLE 0.25 MG TAB OPEN None Yes Page 212 Effective December 2015

213 Coverage Table December SANDOZ PRAMIPEXOLE 1 MG TABLET OPEN None Yes SANDOZ PRAMIPEXOLE 1.5 MG TAB OPEN None Yes SANDOZ PRAVASTATIN 10 MG TAB OPEN None Yes SANDOZ PREDNISOL 0.12% DRPS OPEN None No SANDOZ PREDNISOLONE 1 % DROPS OPEN None Yes SANDOZ PREGABALIN 150 MG CAP None Yes SANDOZ PREGABALIN 25 MG CAP None Yes SANDOZ PREGABALIN 300 MG CAP None Yes SANDOZ PREGABALIN 50 MG CAP None Yes SANDOZ PREGABALIN 75 MG CAP None Yes SANDOZ PROCTOMYXIN HC OINT OPEN None Yes SANDOZ PROCTOMYXIN HC SUPP OPEN None No SANDOZ QUETIAPINE 100 MG TAB OPEN Yes SANDOZ QUETIAPINE 200 MG TAB OPEN Yes SANDOZ QUETIAPINE 25 MG TABLET OPEN Yes SANDOZ QUETIAPINE 300 MG TAB OPEN Yes SANDOZ RABEPRAZOLE 10 MG TAB OPEN Limit of 2 per day without Special Yes SANDOZ RABEPRAZOLE EC 20 MG TB OPEN Yes SANDOZ RAMIPRIL 1.25 MG TAB OPEN None Yes SANDOZ RAMIPRIL 10 MG TAB OPEN None Yes SANDOZ RAMIPRIL 2.5 MG TAB OPEN None Yes SANDOZ RANITIE 150 MG TAB OPEN None Yes SANDOZ RANITIE 300 MG TAB OPEN None Yes SANDOZ REPAGLINIDE 0.5 MG TAB Special Authorzation required if beneficiary has not had a paid claim for Gluconorm, Yes Glimepiride, or Glyburide in past year SANDOZ REPAGLINIDE 1 MG TAB Special Authorzation required if beneficiary has not had a paid claim for Gluconorm, Glimepiride, or Glyburide in past year. Yes Page 213 Effective December 2015

214 Coverage Table December SANDOZ REPAGLINIDE 2 MG TAB Special Authorzation required if beneficiary has not had a paid claim for Gluconorm, Yes Glimepiride, or Glyburide in past year SANDOZ RISEDRONATE 35 MG TAB None Yes SANDOZ RISPERIDONE 0.25 MG OPEN No SANDOZ RISPERIDONE 0.25 MG TAB OPEN Yes SANDOZ RISPERIDONE 0.5 MG TAB OPEN Yes SANDOZ RISPERIDONE 1 MG TAB OPEN Yes SANDOZ RISPERIDONE 2 MG TAB OPEN Yes SANDOZ RISPERIDONE 3 MG TAB OPEN Yes SANDOZ RISPERIDONE 4 MG TAB OPEN Yes SANDOZ RIVASTIGMINE 1.5 MG CAP None Yes SANDOZ RIVASTIGMINE 3 MG CAP None Yes SANDOZ RIVASTIGMINE 4.5 MG CAP None Yes SANDOZ RIVASTIGMINE 6 MG CAP None Yes SANDOZ RIZATRIPTAN ODT 10MG TB None Yes SANDOZ RIZATRIPTAN ODT 5 MG TB None Yes SANDOZ ROSUVASTATIN 10 MG TAB OPEN None Yes SANDOZ ROSUVASTATIN 20 MG TAB OPEN None Yes SANDOZ ROSUVASTATIN 40 MG TAB OPEN None Yes SANDOZ ROSUVASTATIN 5 MG TAB OPEN Yes SANDOZ SALBUTAMOL 5 MG/ML NEB None Yes SANDOZ SERTRALINE 100 MG CAP OPEN Yes SANDOZ SERTRALINE 25 MG CAP OPEN Yes SANDOZ SERTRALINE 50 MG CAP OPEN Yes SANDOZ SIMVASTATIN 10 MG TAB OPEN None Yes Page 214 Effective December 2015

215 Coverage Table December SANDOZ SIMVASTATIN 20 MG TAB OPEN None Yes SANDOZ SIMVASTATIN 40 MG TAB OPEN None Yes SANDOZ SIMVASTATIN 80 MG TAB OPEN None Yes SANDOZ SOTALOL 160 MG TABLET OPEN None Yes SANDOZ SOTALOL 80 MG TABLET OPEN None Yes SANDOZ SUMATRIPTAN 100 MG TAB None Yes SANDOZ SUMATRIPTAN 50 MG TAB None Yes SANDOZ TAMSULOSIN 0.4 MG CAP OPEN Limit of 2 per day without Special Yes SANDOZ TAMSULOSIN 0.4 MG CP SA OPEN Limit of 2 per day without Special Yes SANDOZ TELMISARTAN 40 MG TAB OPEN Yes SANDOZ TELMISARTAN 80 MG TAB OPEN Yes SANDOZ TIMOLOL 0.25 % EYE DROP OPEN None Yes SANDOZ TIMOLOL 0.5 % EYE DROPS OPEN None Yes SANDOZ TOBRAMYCIN 0.3% DROP OPEN None Yes SANDOZ TOPIRAMATE 100 MG TAB OPEN None Yes SANDOZ TOPIRAMATE 100 MG TAB OPEN None Yes SANDOZ TOPIRAMATE 200 MG TAB OPEN None Yes SANDOZ TOPIRAMATE 200 MG TAB OPEN None Yes SANDOZ TOPIRAMATE 25 MG TAB OPEN None Yes SANDOZ TOPIRAMATE 25 MG TABLET OPEN None Yes SANDOZ VALACYCLOVIR 500MG TABL OPEN None Yes SANDOZ VALPROIC 250 MG CAP OPEN None Yes SANDOZ VALSARTAN 160 MG TABLET OPEN Yes SANDOZ VALSARTAN 320 MG TABLET OPEN Yes SANDOZ VALSARTAN 40 MG TABLET OPEN Yes SANDOZ VALSARTAN 80 MG TABLET OPEN Yes SANDOZ VENLAFAXINE XR 150MG CP OPEN Yes Page 215 Effective December 2015

216 Coverage Table December SANDOZ VENLAFAXINE XR 75 MG OPEN Yes SANDOZ VORICONAZOLE 200 MG TAB None Yes SANDOZ VORICONAZOLE 50 MG TAB None Yes SANDOZ ZOLMITRIPTAN 2.5 MG TAB None Yes SANDOZ ZOLMITRIPTAN ODT 2.5 MG None Yes SANDOZ ZOPICLONE 5 MG TABLET OPEN Yes SANDOZ-CELECOXIB 100 MG CAP OPEN Limit of 2 per day without Special Yes SANDOZ-CELECOXIB 200 MG CAP OPEN Limit of 2 per day without Special Yes SANDOZ-DICLOFEN SR 100 MG TAB OPEN None Yes SANDOZ-DICLOFEN SR 75 MG TAB OPEN None Yes SANDOZ-DICLOFENAC 100 MG SUPP OPEN None Yes SANDOZ-DICLOFENAC 50 MG SUP OPEN None Yes SANDOZ-DICLOFENAC DR 25 MG TAB OPEN None Yes SANDOZ-DICLOFENAC EC 50 MG TAB OPEN None Yes SANDOZ-PINDOLOL 10 MG TABLET OPEN None Yes SANDOZ-PINDOLOL 15 MG TABLET OPEN None Yes SANDOZ-PINDOLOL 5 MG TABLET OPEN None Yes SANDOZ-TAMSULOSIN CR 0.4 MG TB OPEN Yes SANDOZ-TERBINAFINE 250 MG TAB OPEN None Yes SANDZ LANSOPRAZOLE DR 15MG CAP None Yes SANDZ LANSOPRAZOLE DR 30MG CAP None Yes SANS-ACNE SOLUTION OPEN None No SANSERT 2 MG TABLET OPEN None No SAPHRIS 10 MG TAB SUBLINGUAL No SAPHRIS 5 MG TAB SUBLINGUAL No SARNA HC 1 % LOTION OPEN None No SARNA HC 2.5 % LOTION OPEN None No Page 216 Effective December 2015

217 Coverage Table December SCOPOLAMINE HYDRBRMDE 0.4 MG/ML AMP OPEN For use in End of Life Palliative Care only. No Not Available SCOPOLAMINE HYDRBRMDE 0.6 MG/ML AMP OPEN For use in End of Life Palliative Care only. No Not Available SDZ CELECOXIB 100 MG CAPSULE OPEN Limit of 2 per day without Special Yes SDZ CELECOXIB 200 MG CAPSULE OPEN Limit of 2 per day without Special Yes SDZ LATANOPROST-TIMOLOL OPH SO OPEN No Yes SECTRAL 100 MG TABLET OPEN None Yes SECTRAL 200 MG TABLET OPEN None Yes SECTRAL 400 MG TABLET OPEN None Yes SEEBRI BREEZHALER 50 MCG CAP None No SELAX 100 MG CAPSULE OPEN Reasonable Based Pricing is applied No SELECT 1/35 (21) TABLET OPEN Beneficiary gender must be female - under the age of 51 No SELECT 1/35 (28) TABLET OPEN Beneficiary gender must be female - under the age of 51 No SELECT LANCET OPEN None No SELEXID 185 MG TABLET OPEN None No SENNATAB TAB OPEN None No SENNOSIDES 8.6 MG TABLET OPEN None No SEPTA-AMLODIPINE 10 MG TABLET OPEN None Yes SEPTA-AMLODIPINE 5 MG TABLET OPEN Yes SEPTA-ATENOLOL 100 MG TABLET OPEN None Yes SEPTA-ATENOLOL 50 MG TABLET OPEN None Yes SEPTA-CIPROFLOXACIN 250 MG TAB OPEN None Yes SEPTA-CIPROFLOXACIN 500 MG TAB OPEN None Yes SEPTA-CIPROFLOXACIN 750 MG TAB OPEN None Yes SEPTA-CITALOPRAM 20 MG TABLET OPEN. Maximum of 1.5 tablets Yes daily SEPTA-CITALOPRAM 40 MG TABLET OPEN Yes SEPTA-DONEPEZIL 10 MG TABLET None Yes SEPTA-DONEPEZIL 5 MG TABLET None Yes Page 217 Effective December 2015

218 Coverage Table December SEPTA-LOSARTAN 100 MG TABLET OPEN Yes SEPTA-LOSARTAN 25 MG TABLET OPEN Yes SEPTA-LOSARTAN 50 MG TABLET OPEN Yes SEPTA-METFORMIN 500 MG TABLET OPEN None Yes SEPTA-METFORMIN 850 MG TABLET OPEN None Yes SEPTA-ONDANSETRON 4 MG TABLET OPEN Limit of 3 tablets per cycle - first fill only. Special is required for higher Yes quantities and/or subsequent fills SEPTA-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 SEPTA-ZOLMITRIPTAN ODT 2.5 MG None Yes SEPTA-ZOPICLONE 5 MG TABLET OPEN Yes SEPTA-ZOPICLONE 7.5 MG TABLET OPEN Yes SEPTRA OPEN None Yes SEPTRA 80 MG-400 MG/5 ML AMP OPEN None No SEPTRA DS TABLETS OPEN None Yes SEPTRA PEDIATRIC SUSPENSION OPEN None Yes SERAX TABLETS 15MG OPEN Yes SERAX TABLETS 30MG OPEN Yes SERC 16 MG TABLET OPEN None Yes SERC 24 MG TABLET OPEN None Yes SERC 8MG TABLET OPEN None No SEREVENT 25MCG/MD INHALER None No SEREVENT 50MCG DISKHALER None No SEREVENT 50MCG DISKHALER None No SEROPHENE 50 MG TABLET OPEN None No SEROQUEL 100 MG TABLET OPEN Yes Page 218 Effective December 2015

219 Coverage Table December SEROQUEL 150 MG OPEN Yes SEROQUEL 200 MG TABLET OPEN Yes SEROQUEL 25 MG TABLET OPEN Yes SEROQUEL 300 MG TABLET OPEN Yes SERTRALINE 100 MG CAPSULE OPEN Yes SERTRALINE 100 MG CAPSULE OPEN Yes SERTRALINE 25 MG CAPSULE OPEN Yes SERTRALINE 25 MG CAPSULE OPEN Yes SERTRALINE 50 MG CAPSULE OPEN Yes SERTRALINE 50 MG CAPSULE OPEN Yes SIBELIUM CAP 5MG OPEN None Yes SIDEKICK BG TEST STRIPS OPEN a) Limited to 2500 per year without Special b) Beneficiary must have diabetic medication within previous year No history, otherwise Special is required SILACE 60 MG/15 ML SYRUP OPEN Beneficiary must be less than 13 years old - RBP applied No SIMBRINZA 1%-0.2% EYE DROPS OPEN None No SIMPONI 50 MG/0.5 ML PEN None No SIMPONI 50 MG/0.5 ML SYRINGE None No SIMVASTATIN 10 MG TABLET OPEN None Yes SIMVASTATIN 10 MG TABLET OPEN None Yes SIMVASTATIN 10 MG TABLET OPEN None Yes SIMVASTATIN 20 MG TABLET OPEN None Yes SIMVASTATIN 20 MG TABLET OPEN None Yes SIMVASTATIN 20 MG TABLET OPEN None Yes Page 219 Effective December 2015

220 Coverage Table December SIMVASTATIN 40 MG TABLET OPEN None Yes SIMVASTATIN 40 MG TABLET OPEN None Yes SIMVASTATIN 40 MG TABLET OPEN None Yes SIMVASTATIN 5 MG TABLET OPEN None Yes SIMVASTATIN 5 MG TABLET OPEN None Yes SIMVASTATIN 5 MG TABLET OPEN None Yes SIMVASTATIN 80 MG TABLET OPEN None Yes SIMVASTATIN 80 MG TABLET OPEN None Yes SIMVASTATIN 80 MG TABLET OPEN None Yes SIMVASTATIN-ODAN 10 MG TABLET OPEN None Yes SIMVASTATIN-ODAN 20 MG TABLET OPEN None Yes SIMVASTATIN-ODAN 40 MG TABLET OPEN None Yes SIMVASTATIN-ODAN 5 MG TABLET OPEN None Yes SIMVASTATIN-ODAN 80 MG TABLET OPEN None Yes SINEMET MG TABLET OPEN None Yes SINEMET MG TABLET OPEN None Yes SINEMET MG TABLET OPEN None Yes SINEMET CR MG TABLET OPEN None Yes SINEMET CR MG TABLET OPEN None Yes SINEQUAN 25 MG CAPSULE OPEN Yes SINGULAIR 10 MG TABLET None Yes SINGULAIR 4 MG PACKET None Yes SINGULAIR 4 MG TABLET CHEW None Yes SINGULAIR 5 MG CHEW TABLET None Yes SINTROM 1 MG TABLET OPEN None No SINTROM 4 MG TABLET OPEN None No SLOW-FE 160 MG TABLET SA OPEN None No SLOW-FE FOLIC TABLET SA OPEN None No SLOW-K 600 MG TABLET SA OPEN None No SLOW-K 600 MG TABLET SA OPEN None No SLOW-TRASICOR 160MG TAB SA OPEN None No SLOW-TRASICOR 80MG SA TAB OPEN None No SOD AUROTHIOMALATE 50 MG/ML OPEN None No SODIUM AUROTHIOMAL 10 MG/ML OPEN None No SODIUM AUROTHIOMAL 25 MG/ML OPEN None No SODIUM CHLORIDE 0.9% INHL VIAL None No Page 220 Effective December 2015

221 Coverage Table December SODIUM CHLORIDE 0.9% VIAL None No SODIUM CHLORIDE 3% INJ OPEN Beneficiary must have eligibility under the CF Plan No SODIUM EDECRIN 50 MG VIAL OPEN None No SODIUM SULAMYD 10% OPH DROP OPEN None No SOFLAX 100 MG CAPSULE OPEN Reasonable Based Pricing is applied No SOFLAX 4 MG/ML SYRUP OPEN Beneficiary must be less than 13 years old - RBP applied No SOFRACORT EAR/EYE OINTMENT OPEN None No SOFRACORT EYE/EAR DROPS OPEN None No SOFRAMYCIN 0.5% EYE DROPS OPEN None No SOFRAMYCIN 0.5% EYE OINT OPEN None No SOFRAMYCIN NASAL SPRAY OPEN None No SOFRAMYCIN SKIN OINTMENT OPEN None No SOFT CLIX LANCET OPEN None No SOFTACT TEST STRIPS OPEN a) Limited to 2500 per year without Special b) Beneficiary must have diabetic medication within previous year No history, otherwise Special is required SOLU-CORTEF 100 MG ACT-O-VL OPEN None No SOLU-CORTEF 1GM ACT-O-VIAL OPEN None No SOLU-CORTEF 250 MG ACT-O-VL OPEN None No SOLU-CORTEF 500 MG ACT-O-VL OPEN None No SOLU-MEDROL 1 GM VIAL OPEN None No SOLU-MEDROL 125 MG ACT-O-VIAL OPEN None No SOLU-MEDROL 500 MG VIAL OPEN None No SOLYSTAT POWDER OPEN None No SOMA TABLETS 350MG OPEN None No SOMATULINE AUTOGEL OPEN None No SOMATULINE AUTOGEL OPEN None No SOMATULINE AUTOGEL OPEN None No SOMNOL 15 MG TABLET OPEN No SOMNOL 30 MG TABLET OPEN No SORIATANE 10 MG CAPSULE OPEN None No Page 221 Effective December 2015

222 Coverage Table December SORIATANE 25 MG CAPSULE OPEN None No SOTACOR TAB 160MG OPEN None Yes SOTACOR TAB 80MG OPEN None Yes SOTALOL 160 MG TABLET OPEN None Yes SOTALOL 80 MG TABLET OPEN None Yes SOURCE CF CHEWABLES OPEN Beneficiary must have eligibility under the CF Plan No SOURCE CF LIQUID OPEN Beneficiary must have eligibility under the CF Plan No SOVALDI 400 MG TABLET No SPIRIVA 18 MCG CAP HANDIHALER None No SPORANOX 100 MG CAPSULE None No SPRYCEL 100 MG TABLET None No SPRYCEL 140 MG TABLET None No SPRYCEL 20 MG TABLET None No SPRYCEL 50 MG TABLET None No SPRYCEL 70 MG TABLET None No SPRYCEL 80 MG TABLET None No SSD 1% CREAM OPEN None No STALEVO 100 TABLET OPEN None No STALEVO 125 TABLET OPEN None No STALEVO 150 TABLET OPEN None No STALEVO 50 TABLET OPEN None No STALEVO 75 TABLET OPEN None No STANLEY BLOOD GLUCOSE OPEN None No STATEX 1 MG/ML SYRUP OPEN No STATEX 10 MG SUPPOSITORY OPEN No STATEX 10 MG TABLET OPEN No STATEX 100 MG/5 ML DROPS OPEN No STATEX 20 MG SUPPOSITORY OPEN No Page 222 Effective December 2015

223 Coverage Table December STATEX 25 MG TABLET OPEN No STATEX 30 MG SUPPOSITORY OPEN No STATEX 5 MG SUPPOSITORY OPEN No STATEX 5 MG TABLET OPEN No STATEX 5 MG/ML SYRUP OPEN No STATEX 50 MG TABLET OPEN No STATEX 50 MG/ML DROPS OPEN No STATICIN 1.5% LOTION OPEN None No STELARA 45 MG/0.5 ML SYRINGE None No STELARA 90 MG/ML SYRINGE None No STEMETIL 10 MG SUPPOSITORY OPEN None No STEMETIL 10MG TABLET OPEN None No STEMETIL 5 MG/ML AMPOULE OPEN None No STEMETIL 5MG TABLET OPEN None No STEMETIL 5MG/5ML LIQUID OPEN None No STIEVA-A 0.01 % CREAM OPEN None No STIEVA-A 0.01% GEL OPEN None No STIEVA-A % CREAM OPEN None No STIEVA-A % GEL OPEN None No STIEVA-A 0.025% SOLUTION OPEN None No STIEVA-A 0.05 % CREAM OPEN None No STIEVA-A 0.05 % GEL OPEN None No STIEVA-A 0.05% SOLUTION OPEN None No STIEVA-A FORTE 0.1 % CREAM OPEN None No STIEVAMYCIN FORTE GEL OPEN None No STIEVAMYCIN MILD GEL OPEN None No STIEVAMYCIN REGULAR GEL OPEN None No STILBESTROL 0.1 MG TABLET OPEN None No STILBESTROL 0.5 MG TABLET OPEN None No STILBESTROL 1 MG TABLET OPEN None No Page 223 Effective December 2015

224 Coverage Table December STIVARGA 40 MG TABLET None No STOOL SOFTENER 100 MG CAP OPEN Reasonable Based Pricing is applied No STOOL SOFTENER 100 MG CAPSULE OPEN Reasonable Based Pricing is applied No STRIBILD MG TAB None No SUBOXONE 2 MG-0.5 MG TABLET None Yes SUBOXONE 8 MG-2 MG TABLET None Yes SULCRATE 1 GM TABLET OPEN None Yes SULCRATE PLUS 1 GM/5 ML SUSP OPEN None No SULCRATE SUS 100MG/ML OPEN None No SULFACET-R LOTION OPEN None No SULFADIAZINE TAB 7.7GR OPEN None No SULFAMETHOXAZOLE AND TRIMETHOP OPEN None No SULFAMETHOXAZOLE AND TRIMETHOP OPEN None No SULFAMYLON 8.5% CREAM OPEN None No SULFATE FERREUX 300 MG TAB OPEN None No SULFINPYRAZONE 200 MG TAB OPEN None Yes SUMATRIPTAN 100 MG TABLET None Yes SUMATRIPTAN 25 MG TABLET None Yes SUMATRIPTAN 50 MG TABLET None Yes SUMATRIPTAN DF 100 MG TABLET None Yes SUMATRIPTAN DF 50 MG TABLET None Yes SUN-BENZ 1.5 MG SOLUTION None No SUPEUDOL 10 MG SUPPOSITORY OPEN No SUPEUDOL 10 MG TABLET OPEN Yes SUPEUDOL 20 MG SUPPOSITORY OPEN No SUPEUDOL 20 MG TABLET OPEN Yes SUPEUDOL 5 MG TABLET OPEN No SUPRAX OPEN None No SUPRAX 100 MG/5 ML SUSPENSION OPEN None No SUPRAX 400 MG TABLET OPEN None Yes Page 224 Effective December 2015

225 Coverage Table December SUPREFACT 1 MG/ML VIAL OPEN None No SUPREFACT 100 MCG NASAL SPRAY OPEN None No SUPREFACT DEPOT 6.3 MG IMP OPEN None No SUPREFACT DEPOT 9.45 MG IMP OPEN None No SURE STEP TEST STRIPS OPEN a) Limited to 2500 per year without Special b) Beneficiary must have diabetic medication within previous year No history, otherwise Special is required SURFAK 240MG CAPSULES OPEN Reasonable Based Pricing is applied No SURGAM OPEN None Yes SURGAM 200MG TABLET OPEN None No SURGAM SR 300 MG CAPSULE SA OPEN None No SURGAM TAB 200MG OPEN None Yes SURMONTIL OPEN Yes SURMONTIL OPEN Yes SURMONTIL 100 OPEN Yes SURMONTIL 12.5 OPEN Yes SURMONTIL 75 OPEN Yes SUSTIVA 100 MG CAPSULE OPEN No SUSTIVA 200 MG CAPSULE OPEN No SUSTIVA 50 MG CAPSULE OPEN No SUSTIVA 600 MG TABLET OPEN Yes SUTENT 12.5 MG CAPSULE None No SUTENT 25 MG CAPSULE None No SUTENT 50 MG CAPSULE None No SYMBICORT 100 TURBUHALER None No SYMBICORT 200 TURBUHALER None No Page 225 Effective December 2015

226 Coverage Table December SYMMETREL CAPSULES 100MG OPEN None Yes SYMMETREL SYRUP 10MG/ML OPEN None Yes SYNALAR 0.01% SOLUTION OPEN None No SYNALAR 0.025% OINTMENT OPEN None No SYNALAR CREAM 0.025% OPEN None No SYNAREL 2 MG/ML NASAL SPRAY OPEN None No SYNPHASIC 21 TABLET OPEN Beneficiary gender must be female - under the age of 51 No SYNPHASIC 21 TABLET OPEN Beneficiary gender must be female - under the age of 51 No SYNPHASIC 21 TABLETS OPEN Beneficiary gender must be female - under the age of 51 No SYNPHASIC 28 TABLET OPEN Beneficiary gender must be female - under the age of 51 No SYNPHASIC 28 TABLET OPEN Beneficiary gender must be female - under the age of 51 No SYNPHASIC-28 TABLETS OPEN Beneficiary gender must be female - under the age of 51 No SYNTHROID 100 MCG TABLET OPEN None No SYNTHROID 112 MCG TABLET OPEN None No SYNTHROID 125 MCG TABLET OPEN None No SYNTHROID 137 MCG TABLET OPEN None No SYNTHROID 150 MCG TABLET OPEN None No SYNTHROID 175 MCG TABLET OPEN None No SYNTHROID 200 MCG TABLET OPEN None No SYNTHROID 25 MCG TABLET OPEN None No SYNTHROID 300 MCG TABLET OPEN None No SYNTHROID 50 MCG TABLET OPEN None No SYNTHROID 500MCG VIAL OPEN None No SYNTHROID 75 MCG TABLET OPEN None No SYNTHROID 88 MCG TABLET OPEN None No TAFINLAR 50 MG CAPSULE None No TAFINLAR 75 MG CAPSULE None No TALWIN 30 MG/ML AMPUL OPEN No TALWIN 50 MG TABLET OPEN No Page 226 Effective December 2015

227 Coverage Table December TAMBOCOR 100 MG TABLET OPEN None Yes TAMBOCOR 50 MG TABLET OPEN None Yes TAMIFLU 12 MG/ML SUSPENSION OPEN None No TAMIFLU 30 MG CAPSULE OPEN None No TAMIFLU 45 MG CAPSULE OPEN None No TAMIFLU 6 MG/ML SUSPENSION OPEN None No TAMIFLU 75 MG CAPSULE OPEN None No TAMSULOSIN CR 0.4 MG TABLET OPEN Yes TANTUM 0.15% LIQUID None No TAPAZOLE 10 MG TABLET OPEN None No TAPAZOLE 5 MG TABLET OPEN None No TARCEVA 100 MG TABLET None Yes TARCEVA 150 MG TABLET None Yes TARO-AMCINONIDE 0.1% CREAM OPEN None Yes TARO-ANASTROZOLE 1 MG TABLET None Yes TARO-CARBAMAZEPINE 100 MG A OPEN None Yes TARO-CARBAMAZEPINE 200 MG A OPEN None Yes TARO-CARBAMAZEPINE 200 MG TAB OPEN None Yes TARO-CARBAMAZEPINE TAB 200MG OPEN None No TARO-CLOBETASOL 0.05 % CREAM OPEN None Yes TARO-CLOBETASOL 0.05% OINT OPEN None Yes TARO-CLOBETASOL 0.05% SOL OPEN None Yes TARO-DOCUSATE 100 MG CAPSULE OPEN Reasonable Based Pricing is applied No TARO-MOMETASONE 0.1 % CREAM OPEN None Yes TARO-MOMETASONE 0.1% OINT OPEN None Yes TARO-MOMETASONE 0.1% SOLUTION OPEN None Yes TARO-MUPIROCIN 2% OINTMENT OPEN None Yes TARO-PHENYTOIN 125 MG/5 ML OPEN None Yes TARO-SUMATRIPTAN 6 MG/0.5 ML None Yes TARO-TEMOZOLOMIDE 100MG CAPSUL None Yes TARO-TEMOZOLOMIDE 140MG CAPSUL None Yes TARO-TEMOZOLOMIDE 20MG CAPSULE None Yes Page 227 Effective December 2015

228 Coverage Table December TARO-TEMOZOLOMIDE 250MG CAPSUL None Yes TARO-TEMOZOLOMIDE 5MG CAPSULE None Yes TARO-TERCONAZOLE 0.4% CREAM OPEN None Yes TARO-TESTOSTERONE 40 MG CAPS Yes TARO-WARFARIN 1 MG TABLET OPEN None Yes TARO-WARFARIN 10 MG TABLET OPEN None Yes TARO-WARFARIN 2 MG TABLET OPEN None Yes TARO-WARFARIN 2.5 MG TABLET OPEN None Yes TARO-WARFARIN 3 MG TABLET OPEN None Yes TARO-WARFARIN 4 MG TABLET OPEN None Yes TARO-WARFARIN 5 MG TABLET OPEN None Yes TARO-WARFARIN 6 MG TABLET OPEN None Yes TASIGNA 150 MG CAPSULE None No TASIGNA 200 MG CAPSULE None No TAVIST 1.34 MG TABLET OPEN None No TAZORAC 0.05% CREAM None No TAZORAC 0.05% GEL None No TAZORAC 0.1% CREAM None No TAZORAC 0.1% GEL None No TEAR GEL OPEN None No TEARS NATURALE EYE DROPS OPEN None No TEARS NATURALE II EYE DROPS OPEN None No TEARS NATURALE P.M. OINT OPEN None No TEBRAZID 500 MG TABLET OPEN None No TECFIDERA 120 MG CAPSULE None No TECFIDERA 240 MG CAPSULE None No TECTA DR 40 MG TABLET None No TEGRETOL 100 MG CHEWTABS OPEN None Yes TEGRETOL 100 MG/5 ML SUSP None Yes TEGRETOL 200 MG CHEWTABS OPEN None Yes TEGRETOL 200 MG TABLET OPEN None Yes TEGRETOL CR 200 MG SA TABLET OPEN None Yes TEGRETOL CR 400 MG TABLET T OPEN None Yes TELMISARTAN 40 MG TABLET OPEN Yes Page 228 Effective December 2015

229 Coverage Table December TELMISARTAN 40 MG TABLET OPEN TELMISARTAN 40 MG TABLET OPEN TELMISARTAN 40 MG TABLET OPEN TELMISARTAN 80 MG TABLET OPEN TELMISARTAN 80 MG TABLET OPEN TELMISARTAN 80 MG TABLET OPEN TELMISARTAN 80 MG TABLET OPEN TELMISARTAN HCT MG TAB OPEN TELMISARTAN HCT MG TAB OPEN TELMISARTAN HCTZ MG TAB OPEN TELMISARTAN HCTZ MG TAB OPEN TELMISARTAN HCTZ MG TAB OPEN TELMISARTAN HCTZ MG TAB OPEN TELMISARTAN HCTZ MG TAB OPEN TELMISARTAN HCTZ MG TAB OPEN TELMISARTAN/HCT MG TAB OPEN TELMISARTAN/HCTZ MG TAB OPEN TELMISARTAN/HCTZ MG TAB OPEN Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Page 229 Effective December 2015

230 Coverage Table December TELMISARTAN-HCTZ MG TAB OPEN Yes TELMISARTAN-HCTZ MG TAB OPEN Yes TELMISARTAN-HCTZ MG TAB OPEN Yes TELZIR 700 MG TABLET OPEN No TEMODAL 100 MG CAPSULE None Yes TEMODAL 140 MG CAPSULE None Yes TEMODAL 20 MG CAPSULE None Yes TEMODAL 250 MG CAPSULE None Yes TEMODAL 5 MG CAPSULE None Yes TEMPRA DOUBLE STR 160 MG/5 ML OPEN Beneficiary must be less than 13 years old - RBP applied No TEMPRA DOUBLE STRENGTH SYRUP Beneficiary must be less than 13 years old - OPEN 3 RBP applied No TEMPRA INFANT 80 MG/ML DROPS OPEN Beneficiary must be less than 3 years old - RBP applied No TENORETIC 100/25 TABLET OPEN None Yes TENORETIC 50/25 MG TABLET OPEN None Yes TENORMIN 100MG TABLET OPEN None Yes TENORMIN 50MG TABLET OPEN None Yes TENOXICAM 20 MG TABLET OPEN None Yes TEQUIN 400 MG TABLET None No TERAZOL 3 80 MG VAG OVULE OPEN None No TERAZOL 3 DUAL PAK 80MG-0.8 % OPEN None No TERAZOL 3 VAGINAL CREAM OPEN None No TERAZOL 7 0.4% VAG CREAM OPEN None Yes TERAZOSIN 1 MG TABLET OPEN None Yes TERAZOSIN 10 MG TABLET OPEN None Yes TERAZOSIN 2 MG TABLET OPEN None Yes TERAZOSIN 5 MG TABLET OPEN None Yes TERBINAFINE 250 MG TABLET OPEN None Yes TERBINAFINE 250 MG TABLET OPEN None Yes TERFLUZINE CONC 10 MG/ML OPEN No Page 230 Effective December 2015

231 Coverage Table December TESTIM 50 MG/5 GRAM (1%) GEL No TESTOSTERONE CYP 100 MG/ML OPEN No TETRACYCLINE 250 MG CAPSULE OPEN None No TETRACYCLINE 250 MG CAPSULE OPEN None Yes TEVA-ACEBUTOLOL 100 MG TABLET OPEN None Yes TEVA-ACEBUTOLOL 200 MG TABLET OPEN None Yes TEVA-ACEBUTOLOL 400 MG TABLET OPEN None Yes TEVA-ACYCLOVIR 200 MG TABLET OPEN None Yes TEVA-ACYCLOVIR 400 MG TABLET OPEN None Yes TEVA-ACYCLOVIR 800 MG TABLET OPEN None Yes TEVA-ALENDRONATE 10 MG TABLET None Yes TEVA-ALENDRONATE 70 MG TAB None Yes TEVA-ALPRAZOLAM 0.25 MG TABLET OPEN Yes TEVA-ALPRAZOLAM 0.5 MG TABLET OPEN Yes TEVA-AMIODARONE 200 MG TAB OPEN None Yes TEVA-AMLODIPINE 10 MG TABLET OPEN None Yes TEVA-AMLODIPINE 5 MG TABLET OPEN Yes TEVA-AMPICILLIN 250 MG CAPSULE OPEN None Yes TEVA-AMPICILLIN 500 MG CAPSULE OPEN None Yes TEVA-ANASTROZOLE 1 MG TABLET None Yes TEVA-ATENOLOL 25 MG TABLET OPEN None No TEVA-AZATHIOPRINE 50 MG TABLET OPEN None Yes TEVA-BETAHISTINE 16 MG TAB OPEN None Yes TEVA-BETAHISTINE 24 MG TABLET OPEN None Yes TEVA-BICALUTAMIDE 50 MG TAB OPEN None Yes TEVA-BISOPROLOL 10 MG TABLET OPEN None Yes TEVA-BISOPROLOL 5 MG TABLET OPEN None Yes TEVA-BOSENTAN 125 MG TABLET None Yes TEVA-BOSENTAN 62.5 MG TABLET None Yes TEVA-BROMAZEPAM 3 MG TABLET OPEN Yes Page 231 Effective December 2015

232 Coverage Table December TEVA-BROMAZEPAM 6 MG TABLET OPEN Yes TEVA-BUPRENOR/NALOX MG None Yes TEVA-BUPRENORPH/NALOX 8-2 MG None Yes TEVA-BUSPIRONE 10 MG TABLET OPEN Yes TEVA-CANDESARTAN 16 MG TABLET OPEN Yes TEVA-CANDESARTAN 32 MG TABLET OPEN Yes TEVA-CANDESARTAN 8 MG TABLET OPEN Yes TEVA-CAPECITABINE 150 MG TAB No Yes TEVA-CAPECITABINE 500 MG TAB No Yes TEVA-CAPTOPRIL 100 MG TABLET OPEN None Yes TEVA-CAPTOPRIL 12.5 MG TABLET OPEN None Yes TEVA-CAPTOPRIL 25 MG TABLET OPEN None Yes TEVA-CAPTOPRIL 50 MG TABLET OPEN None Yes TEVA-CARBAMAZEPINE 200 MG TAB OPEN None Yes TEVA-CELECOXIB 100 MG CAPSULE OPEN Limit of 2 per day without Special Yes TEVA-CELECOXIB 200 MG CAPSULE OPEN Limit of 2 per day without Special Yes TEVA-CEPHALEXIN 125 MG/5ML SUS OPEN None Yes TEVA-CEPHALEXIN 250 MG CAPSULE OPEN None No TEVA-CEPHALEXIN 250 MG TABLET OPEN None Yes TEVA-CEPHALEXIN 250 MG/5ML SUS OPEN None Yes TEVA-CEPHALEXIN 500 MG CAPSULE OPEN None No TEVA-CEPHALEXIN 500 MG TABLET OPEN None Yes TEVA-CHLOROQUINE 250 MG TABLET OPEN None No TEVA-CHLORPROMAZINE 100 MG TAB OPEN Yes TEVA-CHLORPROMAZINE 25 MG TAB OPEN Yes TEVA-CHLORPROMAZINE 50 MG TAB OPEN Yes TEVA-CILAZAPRIL 1 MG TABLET OPEN None Yes Page 232 Effective December 2015

233 Coverage Table December TEVA-CILAZAPRIL 2.5 MG TAB OPEN None Yes TEVA-CILAZAPRIL 5 MG TABLET OPEN None Yes TEVA-CIPROFLOXACIN 500 MG TAB OPEN None Yes TEVA-CIPROFLOXACIN 750 MG TAB OPEN None Yes TEVA-CITALOPRAM 20 MG TABLET OPEN. Maximum of 1.5 tablets Yes daily TEVA-CITALOPRAM 40 MG TABLET OPEN Yes TEVA-CLARITHROMYCIN 250 MG TAB OPEN None Yes TEVA-CLARITHROMYCIN 500 MG TAB OPEN None Yes TEVA-CLINDAMYCIN 150 MG CAP OPEN None Yes TEVA-CLINDAMYCIN 300 MG CAP OPEN None Yes TEVA-CLONAZEPAM 0.5 MG TAB OPEN Yes TEVA-CLONAZEPAM 2 MG TABLET OPEN Yes TEVA-CLONIE MG TAB OPEN None Yes TEVA-CLONIE 0.1 MG TABLET OPEN None Yes TEVA-CLONIE 0.2 MG TABLET OPEN None Yes TEVA-CLOPIDOGREL 75 MG TABLET None Yes TEVA-DESMOPRESSIN 0.1 MG TB OPEN None Yes TEVA-DESMOPRESSIN 0.2 MG TB OPEN None Yes TEVA-DICLOFENAC EC 25 MG TAB OPEN None Yes TEVA-DICLOFENAC EC 50 MG TAB OPEN None Yes TEVA-DICLOFENAC SR 100 MG TAB OPEN None Yes TEVA-DICLOFENAC SR 75 MG TAB OPEN None Yes TEVA-DILTIAZEM 30 MG TABLET OPEN None Yes TEVA-DILTIAZEM 60 MG TABLET OPEN None Yes TEVA-DILTIAZEM CD 120 MG CAP OPEN None Yes TEVA-DILTIAZEM CD 180 MG CAP OPEN None Yes TEVA-DILTIAZEM CD 240 MG CAP OPEN None Yes TEVA-DILTIAZEM CD 300 MG CAP OPEN None Yes TEVA-DILTIAZEM ER 120 MG CAP OPEN None Yes TEVA-DILTIAZEM ER 180 MG CAP OPEN None Yes TEVA-DILTIAZEM ER 240 MG CAP OPEN None Yes TEVA-DILTIAZEM ER 300 MG CAP OPEN None Yes Page 233 Effective December 2015

234 Coverage Table December TEVA-DILTIAZEM ER 360 MG CAP OPEN None Yes TEVA-DIMENATE 50 MG TABLET OPEN Reasonable Based Pricing is applied No TEVA-DIVALPROEX EC 125 MG TAB OPEN None Yes TEVA-DIVALPROEX EC 250 MG TAB OPEN None Yes TEVA-DIVALPROEX EC 500 MG TAB OPEN None Yes TEVA-DOCUSATE SOD 100 MG CAP OPEN Reasonable Based Pricing is applied No TEVA-DOMPERIDONE 10 MG TABLET OPEN None Yes TEVA-DONEPEZIL 10 MG TABLET No Yes TEVA-DONEPEZIL 5 MG TABLET No Yes TEVA-DORZOTIMOL 2-0.5% EYE DRP OPEN None Yes TEVA-DOXAZOSIN 1 MG TABLET OPEN None Yes TEVA-DOXAZOSIN 2 MG TABLET OPEN None Yes TEVA-DOXAZOSIN 4 MG TABLET OPEN None Yes TEVA-DOXYCYCLINE 100 MG CAP OPEN None Yes TEVA-DOXYCYCLINE 100 MG TABLET OPEN None Yes TEVA-DUTASTERIDE 0.5 MG CAP None Yes TEVA-EFAVIRENZ 600 MG TABLET OPEN Yes TEVA-ENALAPRIL 16 MG(20MG) TAB OPEN None Yes TEVA-ENALAPRIL 4 MG (5 MG) TAB OPEN None Yes TEVA-ENALAPRIL 8 MG(10 MG) TAB OPEN None Yes TEVA-ENTACAPONE 200 MG TABLET OPEN None Yes TEVA-ERLOTINIB 100 MG TABLET None Yes TEVA-ERLOTINIB 150 MG TABLET None Yes TEVA-EXEMESTANE 25 MG TABLET None Yes TEVA-EZETIMIBE 10 MG TABLET None Yes TEVA-FENOFIBRATE-S 100 MG TAB OPEN None Yes TEVA-FENOFIBRATE-S 160 MG TAB OPEN None Yes TEVA-FENTANYL 100 MCG/HR PATCH Yes TEVA-FENTANYL 12 MCG/HR PATCH Yes TEVA-FENTANYL 25 MCG/HR PATCH Yes TEVA-FENTANYL 50 MCG/HR PATCH Yes Page 234 Effective December 2015

235 Coverage Table December TEVA-FENTANYL 75 MCG/HR Yes Special required if beneficiary TEVA-FINASTERIDE 5 MG TABLET has not had a paid claim for an alpha Yes blocker or finasteride in past year TEVA-FLUOXETINE 10 MG CAP OPEN Yes TEVA-FLUOXETINE 20 MG CAP OPEN Yes TEVA-FLURPROFEN 100 MG TAB OPEN None Yes TEVA-FLUTAMIDE 250 MG TABLET OPEN None Yes TEVA-FLUVASTATIN 20 MG CAPSULE OPEN None Yes TEVA-FLUVASTATIN 40 MG CAPSULE OPEN None Yes TEVA-FOSINOPRIL 10 MG TABLET OPEN None Yes TEVA-FOSINOPRIL 20 MG TABLET OPEN None Yes TEVA-FUROSEMIDE 20 MG TABLET OPEN None Yes TEVA-FUROSEMIDE 40 MG TABLET OPEN None Yes TEVA-FUROSEMIDE 80 MG TABLET OPEN None Yes TEVA-GABAPENTIN 100 MG CAP None Yes TEVA-GABAPENTIN 300 MG CAP None Yes TEVA-GABAPENTIN 400 MG CAP None Yes TEVA-GABAPENTIN 600 MG TAB None Yes TEVA-GABAPENTIN 800 MG TAB None Yes TEVA-GALANTAMINE ER 16 MG CAP None Yes TEVA-GALANTAMINE ER 24 MG CAP None Yes TEVA-GALANTAMINE ER 8 MG CAP None Yes TEVA-GEMFIBROZIL 300 MG CAP OPEN None Yes TEVA-GEMFIBROZIL 600 MG TABLET OPEN None Yes TEVA-GLICAZIDE 80 MG TABLET OPEN None Yes TEVA-GLYBURIDE 2.5 MG TABLET OPEN None Yes TEVA-GLYBURIDE 5 MG TABLET OPEN None Yes TEVA-HYDROCHLOROTHIAZIDE 25MG OPEN None Yes TEVA-HYDROMORPHONE 2 MG TABLET TEVA-HYDROMORPHONE 4 MG TABLET OPEN OPEN Yes Yes Page 235 Effective December 2015

236 Coverage Table December TEVA-IMATINIB 100 MG TABLET None Yes TEVA-IMATINIB 400 MG TABLET None Yes TEVA-INDAPAMIDE 2.5 MG TAB OPEN None Yes TEVA-INDOMETHACIN 25 MG CAP OPEN None Yes TEVA-INDOMETHACIN 50 MG CAP OPEN None Yes TEVA-IPRATROPIUM 250 MCG/ML None Yes TEVA-IRBESARTAN 150 MG TABLET OPEN Yes TEVA-IRBESARTAN 300 MG TABLET OPEN Yes TEVA-IRBESARTAN 75 MG TABLET OPEN Yes TEVA-KETOCONAZOLE 200 MG TAB OPEN None Yes TEVA-LACTULOSE 10 G/15 ML SOLN OPEN None No TEVA-LAMOTRIGINE 100 MG TAB OPEN None Yes TEVA-LAMOTRIGINE 150 MG TAB OPEN None Yes TEVA-LAMOTRIGINE 25 MG TAB OPEN None Yes TEVA-LANSOPRAZOLE DR 15 MG CAP None Yes TEVA-LANSOPRAZOLE DR 30 MG CAP None Yes TEVA-LEFLUNOMIDE 10 MG TAB OPEN None Yes TEVA-LEFLUNOMIDE 20 MG TAB OPEN None Yes TEVA-LETROZOLE 2.5 MG TABLET None Yes TEVA-LEVOFLOXACIN 250 MG TAB None Yes TEVA-LEVOFLOXACIN 500 MG TAB None Yes TEVA-LISINOPRIL 10 MG TABLET OPEN None Yes TEVA-LISINOPRIL 10 MG TABLET OPEN None Yes TEVA-LISINOPRIL 20 MG TABLET OPEN None Yes TEVA-LISINOPRIL 20 MG TABLET OPEN None Yes TEVA-LISINOPRIL P 5 MG TABLET OPEN None Yes TEVA-LISINOPRIL Z 5 MG TAB OPEN None Yes TEVA-LISINOPRIL/HCTZ MG OPEN None Yes TEVA-LISINOPRIL/HCTZ MG OPEN None Yes TEVA-LISINOPRIL/HCTZ MG OPEN None Yes TEVA-LISINOPRIL/HCTZ MG OPEN None Yes TEVA-LISINOPRIL/HCTZ MG OPEN None Yes TEVA-LORAZEPAM 0.5 MG TABLET OPEN Yes Page 236 Effective December 2015

237 Coverage Table December TEVA-LORAZEPAM 1 MG TABLET OPEN Yes TEVA-LORAZEPAM 2 MG TABLET OPEN Yes TEVA-LOSARTAN 100 MG TABLET OPEN Yes TEVA-LOSARTAN 25 MG TABLET OPEN Yes TEVA-LOSARTAN 50 MG TABLET OPEN Yes TEVA-LOSARTAN/HCTZ MG OPEN Yes TEVA-LOSARTAN/HCTZ MG OPEN Yes TEVA-LOVASTATIN 20 MG TABLET OPEN None Yes TEVA-LOVASTATIN 40 MG TABLET OPEN None Yes TEVA-MAPROTILINE 25 MG TAB OPEN Yes TEVA-MAPROTILINE 50 MG TAB OPEN Yes TEVA-MAPROTILINE 75 MG TAB OPEN Yes TEVA-MEDROXYPROGEST 2.5 MG TAB OPEN None Yes TEVA-MEDROXYPROGESTERONE 10 MG OPEN None Yes TEVA-MEDROXYPROGESTERONE 5 MG OPEN None Yes TEVA-MELOXICAM 15 MG TABLET OPEN None Yes TEVA-MELOXICAM 7.5 MG TABLET OPEN None Yes TEVA-METFORMIN 500 MG TABLET OPEN None Yes TEVA-METFORMIN 850 MG TABLET OPEN None Yes TEVA-METHYLPHEN ER-C 18 MG TAB Yes TEVA-METHYLPHEN ER-C 27 MG TAB Yes Page 237 Effective December 2015

238 Coverage Table December TEVA-METHYLPHEN ER-C 36 MG TAB Yes TEVA-METHYLPHEN ER-C 54 MG TAB Yes TEVA-METOPROLOL 100 MG TABLET OPEN None Yes TEVA-METOPROLOL 100 MG TABLET OPEN None No TEVA-METOPROLOL 50 MG TABLET OPEN None Yes TEVA-METOPROLOL 50 MG TABLET OPEN None No TEVA-MINOCYCLINE 100 MG CAP OPEN None Yes TEVA-MINOCYCLINE 50 MG CAP OPEN None Yes TEVA-MIRTAZAPINE 30 MG TABLET OPEN Yes TEVA-MIRTAZAPINE OD 15 MG TAB OPEN Yes TEVA-MIRTAZAPINE OD 30 MG TAB OPEN Yes TEVA-MIRTAZAPINE OD 45 MG TAB OPEN Yes TEVA-MOCLOBEMIDE 100 MG TAB OPEN Yes TEVA-MOCLOBEMIDE 150 MG TAB OPEN Yes TEVA-MOCLOBEMIDE 300 MG TAB OPEN Yes TEVA-MONTELUKAST 10 MG TAB None Yes TEVA-MONTELUKAST 4 MG TAB None Yes TEVA-MONTELUKAST 5 MG TAB None Yes TEVA-MORPHINE SR 100 MG TAB OPEN Yes TEVA-MORPHINE SR 15 MG TAB OPEN None Yes TEVA-MORPHINE SR 200 MG TAB OPEN Yes TEVA-MORPHINE SR 30 MG TAB OPEN None Yes TEVA-MORPHINE SR 60 MG TAB OPEN Yes TEVA-NABILONE 0.5 MG CAPSULE OPEN Yes Page 238 Effective December 2015

239 Coverage Table December TEVA-NABILONE 1 MG CAPSULE OPEN Yes TEVA-NABUMETONE 500 MG TAB OPEN None Yes TEVA-NABUMETONE 750 MG TAB OPEN None Yes TEVA-NADOLOL 40 MG TABLET OPEN None Yes TEVA-NADOLOL 80 MG TABLET OPEN None Yes TEVA-NAPROXEN 250 MG TABLET OPEN None Yes TEVA-NAPROXEN 375 MG TABLET OPEN None Yes TEVA-NAPROXEN 500 MG TABLET OPEN None Yes TEVA-NAPROXEN SOD 275 MG TAB OPEN None Yes TEVA-NAPROXEN SOD DS 550MG TAB OPEN None Yes TEVA-NARATRIPTAN 1 MG TABLET None Yes TEVA-NARATRIPTAN 2.5 MG TABLET None Yes TEVA-NEVIRAPINE 200 MG TABLET OPEN Yes TEVA-NITROFURANTOIN 100 MG CAP OPEN None Yes TEVA-NITROFURANTOIN 50 MG CAP OPEN None Yes TEVA-NORFLOXACIN 400 MG TABLET OPEN None Yes TEVA-NORTRIPTYLINE 10 MG CAP OPEN Yes TEVA-NORTRIPTYLINE 25 MG CAP OPEN Yes TEVA-OLANZAPINE 10 MG TABLET Yes TEVA-OLANZAPINE 15 MG TABLET Yes TEVA-OLANZAPINE 2.5 MG TABLET Yes TEVA-OLANZAPINE 20 MG TABLET Yes TEVA-OLANZAPINE 5 MG TABLET Yes TEVA-OLANZAPINE 7.5 MG TABLET Yes TEVA-OLANZAPINE OD 10 MG TAB Yes Page 239 Effective December 2015

240 Coverage Table December TEVA-OLANZAPINE OD 15 MG TAB Yes TEVA-OLANZAPINE OD 20 MG TAB Yes TEVA-OLANZAPINE OD 5 MG TABLET Yes TEVA-OMEPRAZOLE DR 10 MG TAB OPEN Yes TEVA-OMEPRAZOLE DR 20 MG TAB OPEN Yes TEVA-ONDANSETRON 4 MG TABLET OPEN Limit of 3 tablets per cycle - first fill only. Special is required for higher Yes quantities and/or subsequent fills TEVA-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 TEVA-OXYBUTYNIN 5 MG TABLET OPEN None Yes TEVA-PANTOPRAZOLE DR 20 MG TAB OPEN Yes TEVA-PANTOPRAZOLE DR 40 MG TAB OPEN Yes TEVA-PAROXETINE 10 MG TABLET OPEN. Limit of 1 per day Yes without Special TEVA-PAROXETINE 20 MG TABLET OPEN Yes TEVA-PAROXETINE 30 MG TABLET OPEN Yes TEVA-PINDOLOL 10 MG TABLET OPEN None Yes TEVA-PINDOLOL 15 MG TABLET OPEN None Yes TEVA-PINDOLOL 5 MG TABLET OPEN None Yes TEVA-PIOGLITAZONE 15 MG TAB None Yes TEVA-PIOGLITAZONE 30 MG TAB None Yes TEVA-PIOGLITAZONE 45 MG TAB None Yes TEVA-PIROXICAM 10 MG CAPSULE OPEN None Yes TEVA-PIROXICAM 20 MG CAPSULE OPEN None Yes TEVA-PRAMIPEXOLE 0.25 MG TAB OPEN None Yes Page 240 Effective December 2015

241 Coverage Table December TEVA-PRAMIPEXOLE 1 MG TAB OPEN None Yes TEVA-PRAMIPEXOLE 1.5 MG TAB OPEN None Yes TEVA-PRAVASTATIN 10 MG TAB OPEN None Yes TEVA-PRAVASTATIN 20 MG TAB OPEN None Yes TEVA-PRAVASTATIN 40 MG TAB OPEN None Yes TEVA-PRAZOSIN 1 MG TABLET OPEN None Yes TEVA-PRAZOSIN 2 MG TABLET OPEN None Yes TEVA-PRAZOSIN 5 MG TABLET OPEN None Yes TEVA-PREDNISONE 5 MG TABLET OPEN None Yes TEVA-PREDNISONE 50 MG TABLET OPEN None No TEVA-PREGABALIN 150 MG CAPSULE None Yes TEVA-PREGABALIN 225 MG CAPSULE None Yes TEVA-PREGABALIN 25 MG CAPSULE None Yes TEVA-PREGABALIN 300 MG CAPSULE None Yes TEVA-PREGABALIN 50 MG CAPSULE None Yes TEVA-PREGABALIN 75 MG CAPSULE None Yes TEVA-PROPRANOLOL 10 MG TABLET OPEN None Yes TEVA-PROPRANOLOL 20 MG TABLET OPEN None Yes TEVA-PROPRANOLOL 40 MG TABLET OPEN None Yes TEVA-PROPRANOLOL 80 MG TABLET OPEN None Yes TEVA-QUETIAPINE 100 MG TABLET OPEN Yes TEVA-QUETIAPINE 150 MG TABLET OPEN Yes TEVA-QUETIAPINE 200 MG TABLET OPEN Yes TEVA-QUETIAPINE 25 MG TABLET OPEN Yes TEVA-QUETIAPINE 300 MG TABLET OPEN Yes TEVA-QUININE 200 MG CAPSULE OPEN None No TEVA-QUININE 300 MG CAPSULE OPEN None No TEVA-RABEPRAZOLE EC 10 MG OPEN Limit of 2 per day without Special Yes TEVA-RABEPRAZOLE EC 20 MG OPEN Yes TEVA-RALOXIFENE 60 MG TABLET None Yes Page 241 Effective December 2015

242 Coverage Table December TEVA-RAMIPRIL 10 MG CAPSULE OPEN None Yes TEVA-RAMIPRIL 2.5 MG CAP OPEN None Yes TEVA-RAMIPRIL 5 MG CAPSULE OPEN None Yes TEVA-RANITIE 15 MG/ML SOLN OPEN None Yes TEVA-RANITIE 150 MG TABLET OPEN None Yes TEVA-RANITIE 300 MG TABLET OPEN None Yes TEVA-RISEDRONATE 30 MG TABLET None Yes TEVA-RISEDRONATE 35 MG TABLET None Yes TEVA-RISEDRONATE 5 MG TABLET None Yes TEVA-RISPERIDONE 0.25 MG TAB OPEN Yes TEVA-RISPERIDONE 0.5 MG TAB OPEN Yes TEVA-RISPERIDONE 1 MG TABLET OPEN Yes TEVA-RISPERIDONE 2 MG TABLET OPEN Yes TEVA-RISPERIDONE 3 MG TABLET OPEN Yes TEVA-RISPERIDONE 4 MG TABLET OPEN Yes TEVA-RIZATRIPTAN ODT 10 MG TAB None Yes TEVA-RIZATRIPTAN ODT 5 MG TAB None Yes TEVA-ROSUVASTATIN 10 MG TABLET OPEN None Yes TEVA-ROSUVASTATIN 20 MG TABLET OPEN None Yes TEVA-ROSUVASTATIN 40 MG TABLET OPEN None Yes TEVA-ROSUVASTATIN 5 MG TABLET OPEN Yes TEVA-SALBUTAMOL 2.5 MG/2.5 ML None Yes TEVA-SALBUTAMOL 5 MG/2.5 ML None Yes TEVA-SELEGILINE 5 MG TABLET OPEN None Yes TEVA-SERTRALINE 100 MG CAPSULE OPEN Yes TEVA-SERTRALINE 25 MG CAPSULE OPEN Yes TEVA-SERTRALINE 50 MG CAPSULE OPEN Yes Page 242 Effective December 2015

243 Coverage Table December TEVA-SIMVASTATIN 10 MG TABLET OPEN None Yes TEVA-SIMVASTATIN 20 MG TAB OPEN None Yes TEVA-SIMVASTATIN 40 MG TAB OPEN None Yes TEVA-SIMVASTATIN 5 MG TABLET OPEN None Yes TEVA-SIMVASTATIN 80 MG TAB OPEN None Yes TEVA-SOLIFENACIN 10 MG TABLET OPEN a) Limited to 1 per day without Special b) Special Authorzation required if beneficiary has not had a paid Yes claim for Ditropan RR or a long acting urinary agent in past year TEVA-SOLIFENACIN 5 MG TABLET OPEN a) Limited to 1 per day without Special b) Special Authorzation required if beneficiary has not had a paid Yes claim for Ditropan RR or a long acting urinary agent in past year TEVA-SPIRONOLACT/HCTZ MG OPEN None Yes TEVA-SPIRONOLACT/HCTZ MG OPEN None Yes TEVA-SPIRONOLACTONE 100 MG TAB OPEN None No TEVA-SPIRONOLACTONE 25 MG TAB OPEN None No TEVA-SUCRALFATE 1 GM TABLET OPEN None Yes TEVA-SULINDAC 150 MG TABLET OPEN None Yes TEVA-SULINDAC 200 MG TABLET OPEN None Yes TEVA-SUMATRIPTAN 100 MG TAB None Yes TEVA-SUMATRIPTAN DF 100 MG None Yes TEVA-SUMATRIPTAN DF 25 MG None Yes TEVA-SUMATRIPTAN DF 50 MG None Yes TEVA-TAMOXIFEN 10 MG TABLET OPEN None Yes TEVA-TAMOXIFEN 20 MG TABLET OPEN None Yes TEVA-TAMSULOSIN 0.4 MG CAPSULE OPEN Limit of 2 per day without Special Yes TEVA-TAMSULOSIN CR 0.4 MG TAB OPEN Yes TEVA-TELMISARTAN 40 MG TABLET OPEN Yes TEVA-TELMISARTAN 80 MG TABLET OPEN Yes Page 243 Effective December 2015

244 Coverage Table December TEVA-TEMAZEPAM 15 MG CAPSULE OPEN Yes TEVA-TEMAZEPAM 30 MG CAPSULE OPEN Yes TEVA-TERAZOSIN 1 MG TABLET OPEN None Yes TEVA-TERAZOSIN 10 MG TABLET OPEN None Yes TEVA-TERAZOSIN 2 MG TABLET OPEN None Yes TEVA-TERAZOSIN 5 MG TABLET OPEN None Yes TEVA-TERBINAFINE 250 MG TABLET OPEN None Yes TEVA-THEOPHYLLINE SR 100MG TAB OPEN None Yes TEVA-THEOPHYLLINE SR 200MG TAB OPEN None Yes TEVA-THEOPHYLLINE SR 300MG TAB OPEN None Yes TEVA-TIAPROFENIC ACID 200MG TB OPEN None Yes TEVA-TIAPROFENIC ACID 300 MG OPEN None Yes TEVA-TICLOPIE 250 MG TAB OPEN None Yes TEVA-TIMOLOL 10 MG TABLET OPEN None Yes TEVA-TIMOLOL 20 MG TABLET OPEN None Yes TEVA-TIMOLOL 5 MG TABLET OPEN None Yes TEVA-TOPIRAMATE 100 MG TABLET OPEN None Yes TEVA-TOPIRAMATE 200 MG TABLET OPEN None Yes TEVA-TOPIRAMATE 25 MG TABLET OPEN None Yes TEVA-TRAZODONE 100 MG TABLET OPEN Yes TEVA-TRAZODONE 150 MG TABLET OPEN Yes TEVA-TRAZODONE 50 MG TABLET OPEN Yes TEVA-TRIAMTERENE/HCTZ MG OPEN None Yes TEVA-TRIMEL MG/5ML SUSP OPEN None Yes TEVA-TRIMEL 400 MG-80 MG TAB OPEN None Yes TEVA-TRIMEL DS MG TAB OPEN None Yes TEVA-TRYPTOPHAN 1 GM TABLET OPEN Yes TEVA-TRYPTOPHAN 500 MG CAPSULE OPEN Yes TEVA-TRYPTOPHAN 500 MG TABLET OPEN Yes Page 244 Effective December 2015

245 Coverage Table December TEVA-VALACYCLOVIR 500 MG TAB OPEN None Yes TEVA-VALGANCICLOVIR 450 MG TAB None Yes TEVA-VALSARTAN 160 MG TABLET OPEN Yes TEVA-VALSARTAN 320 MG TABLET OPEN Yes TEVA-VALSARTAN 40 MG TABLET OPEN Yes TEVA-VALSARTAN 80 MG TABLET OPEN Yes TEVA-VALSARTAN/HCTZ MG OPEN Yes TEVA-VALSARTAN/HCTZ MG OPEN Yes TEVA-VALSARTAN/HCTZ MG OPEN Yes TEVA-VALSARTAN/HCTZ MG OPEN Yes TEVA-VALSARTAN/HCTZ MG OPEN Yes TEVA-VENLAFAXINE XR 150 MG OPEN Yes TEVA-VENLAFAXINE XR 37.5 MG OPEN Yes TEVA-VENLAFAXINE XR 75 MG OPEN Yes TEVA-VORICONAZOLE 200 MG TAB None Yes TEVA-VORICONAZOLE 50 MG TABLET None Yes TEVA-ZOLMITRIPTAN 2.5 MG TAB None Yes TEVA-ZOLMITRIPTAN OD 2.5MG TAB None Yes TEVETEN 400 MG TABLET None No TEVETEN 600 MG TABLET None No TEVETEN PLUS TABLET None No THE MAGIC BULLET 10 MG SUPP OPEN None No THEO ER 400 MG TABLET OPEN None Yes THEO ER 600 MG TABLET OPEN None Yes THEOCHRON 100MG TABLET SA OPEN None No Page 245 Effective December 2015

246 Coverage Table December THEOCHRON 200MG TABLET SA OPEN None No THEOCHRON 300MG CAPLET SA OPEN None No THEO-DUR 300 MG OPEN None Yes THEOLAIR 80 MG/15 ML LIQUID OPEN None No THEOPHYLLINE 80 MG/15 ML ELIX OPEN None No THIAMINE HCL 100MG//ML AMP OPEN None No THIOTEPA 15MG VIAL OPEN None No THYROGEN 1.1 MG VIAL None No THYROID 125 MG TABLET OPEN None No THYROID 30 MG TABLET OPEN None No THYROID 60 MG TABLET OPEN None No TIAZAC 120 MG CAPSULE OPEN None Yes TIAZAC 180 MG CAPSULE OPEN None Yes TIAZAC 240 MG CAPSULE OPEN None Yes TIAZAC 300 MG CAPSULE OPEN None Yes TIAZAC 360 MG CAPSULE OPEN None Yes TIAZAC XC 120 MG TABLET OPEN None No TIAZAC XC 180 MG TABLET OPEN None No TIAZAC XC 240 MG TABLET OPEN None No TIAZAC XC 300 MG TABLET OPEN None No TIAZAC XC 360 MG TABLET OPEN None No TICLID 250MG TABLETS OPEN None Yes TICLOPIE 250 MG TABLET OPEN None Yes TILADE 2 MG INHALER OPEN None No TIMOLIDE TABLET OPEN None No TIMOLOL MAL-EX 0.25 % EYE GEL OPEN None Yes TIMOLOL MAL-EX 0.5% SUS DRP OPEN None Yes TIMOPTIC OPEN None Yes TIMOPTIC 0.5% OPHTH DROPS OPEN None Yes TIMOPTIC-XE 0.25 % EYE GEL OPEN None Yes TIMOPTIC-XE 0.5 % EYE GEL OPEN None Yes TIMPILO 2 EYE DROPS OPEN None No TIMPILO 4 EYE DROPS OPEN None No TINACTIN 1 % AEROSOL POWDER OPEN None No TINACTIN 1 % POWDER OPEN None No TINACTIN 1% CREAM OPEN None No TINACTIN 1% SOLUTION OPEN None No Page 246 Effective December 2015

247 Coverage Table December TINACTIN PLUS AREOSOL POWDER 1 OPEN None No TINACTIN PLUS POWDER 1% OPEN None No TIVICAY 50 MG TABLET No Special Authorzation required if beneficiary TIZANIE 4 MG TABLET has not had a paid claim for Baclofen or Yes Zanaflex in past year TOBRADEX OPHTHALMIC DROPS OPEN None No TOBRADEX OPHTHALMIC OINT OPEN None No TOBRAMYCIN 1.2 GM VIAL OPEN Beneficiary must have eligibility under the CF Plan No TOBRAMYCIN 1.2 GRAM VIAL OPEN Beneficiary must have eligibility under the CF Plan No TOBRAMYCIN 10 MG/ML VIAL OPEN Beneficiary must have eligibility under the CF Plan No TOBRAMYCIN 40 MG/ML VIAL OPEN None No TOBRAMYCIN INJ 10 MG/ML VIAL OPEN Beneficiary must have eligibility under the CF Plan No TOBRAMYCIN INJ 40 MG/ML VIAL OPEN None No TOBREX 0.3% OPHTHALMIC DROP OPEN None Yes TOBREX 0.3% OPHTHALMIC OINT OPEN None No TOFRANIL 25MG OPEN Yes TOFRANIL 50MG OPEN Yes TOFRANIL 75 MG TABLET OPEN No TOLBUTAMIDE 500MG TABLET OPEN None No TOLBUTAMIDE 500 MG TABLET OPEN None Yes TOLECTIN 600MG TABLET OPEN None No TOLOXIN 0.05 MG/ML SOLUTION OPEN None No TOLOXIN MG TABLET OPEN None Yes TOLOXIN MG TABLET OPEN None Yes TOLOXIN 0.25 MG TABLET OPEN None Yes TONOCARD TAB 400 MG OPEN None No TOPAMAX 100 MG TABLET OPEN None Yes TOPAMAX 200 MG TABLET OPEN None Yes Page 247 Effective December 2015

248 Coverage Table December TOPAMAX 25 MG TABLET OPEN None Yes TOPICORT 0.05 % GEL OPEN None No TOPICORT 0.25 % CREAM OPEN None No TOPICORT 0.25 % OINTMENT OPEN None No TOPICORT MILD 0.05 % CREAM OPEN None No TOPIRAMATE 100 MG TABLET OPEN No Yes TOPIRAMATE 100 MG TABLET OPEN No Yes TOPIRAMATE 100 MG TABLET OPEN No Yes TOPIRAMATE 200 MG TABLET OPEN No Yes TOPIRAMATE 200 MG TABLET OPEN No Yes TOPIRAMATE 25 MG TABLET OPEN None Yes TOPIRAMATE 25 MG TABLET OPEN No Yes TOPIRAMATE 25 MG TABLET OPEN No Yes TORADOL 10 MG TABLET OPEN None Yes TORADOL 30 MG/ML AMPOULE OPEN None No TOVIAZ 4 MG TABLET OPEN a) Limited to 1 per day without Special b) Special Authorzation required if beneficiary has not had a paid No claim for Ditropan RR or a long acting urinary agent in past year TOVIAZ 8 MG TABLET OPEN a) Limited to 1 per day without Special b) Special Authorzation required if beneficiary has not had a paid No claim for Ditropan RR or a long acting urinary agent in past year TRACLEER 125 MG TABLET None Yes TRACLEER 62.5 MG TABLET None Yes TRAJENTA 5 MG TABLET None No TRANDATE 100 MG TABLET OPEN None No TRANDATE 200 MG TABLET OPEN None No TRANEXAMIC ACID 500 MG TABLET OPEN None Yes TRANSDERM-NITRO 0.2 MG/HR OPEN None No TRANSDERM-NITRO 0.4 MG/HR OPEN None No TRANSDERM-NITRO 0.6 MG/HR OPEN None No TRASICOR 40 MG TABLET OPEN None No TRASICOR 80 MG TABLET OPEN None No TRAVATAN 0.004% EYE DROPS OPEN None No Page 248 Effective December 2015

249 Coverage Table December TRAVATAN Z 0.004% EYE DROPS OPEN None Yes TRAVEL 50 MG TABLET OPEN Reasonable Based Pricing is applied No TRAVELTABS 50MG OPEN Reasonable Based Pricing is applied No TRAVOPROST % EYE DROPS OPEN None Yes TRAVOPROST Z 0.004% EYE DROPS OPEN None Yes TRAVOPROST Z 0.004% EYE DROPS OPEN None Yes TRAZODONE 100 MG TABLET OPEN Yes TRAZODONE 150 MG TABLET OPEN Yes TRAZODONE 50 MG TABLET OPEN Yes TRELSTAR MG VIAL OPEN None No TRELSTAR 22.5 MG VIAL OPEN None No TRELSTAR 3.75 MG VIAL OPEN None No TRENTAL 400 MG TABLET SA OPEN None Yes TRIADERM 0.025% CREAM OPEN None No TRIADERM 0.1% CREAM OPEN None No TRIADERM 0.1% OINTMENT OPEN None No TRIAMCINOLONE ACE 10 MG/ML OPEN None No TRIAMCINOLONE ACE 40 MG/ML OPEN None No TRIAVIL 3-15 TABLET OPEN None No TRIAZOLAM MG TABLET OPEN Yes TRIAZOLAM 0.25 MG TABLET OPEN Yes TRICIRA LO (21) TABLET OPEN Beneficiary gender must be female - under the age of 51 Yes TRICIRA LO (28) TABLET OPEN Beneficiary gender must be female - under the age of 51 Yes TRI-CYCLEN 21 TABLET OPEN Beneficiary gender must be female - under the age of 51 No TRI-CYCLEN 28 TABLET OPEN Beneficiary gender must be female - under the age of 51 No TRI-CYCLEN LO (21) TABLET OPEN Beneficiary gender must be female - under the age of 51 Yes Page 249 Effective December 2015

250 Coverage Table December TRI-CYCLEN LO (28) TABLET OPEN Beneficiary gender must be female - under the age of 51 Yes TRIDESILON 0.05 % CREAM OPEN None Yes TRIFLUOPERAZINE 1 MG TABLET OPEN Yes TRIFLUOPERAZINE 10 MG TABLET OPEN Yes TRIFLUOPERAZINE 2 MG TABLET OPEN Yes TRIFLUOPERAZINE 20 MG TABLET OPEN No TRIFLUOPERAZINE 5 MG TABLET OPEN Yes TRIHEXYPHENIDYL 2 MG TABLET OPEN None No TRIHEXYPHENIDYL 5 MG TABLET OPEN None No TRILAFON 5 MG/ML AMPOULE OPEN No TRILEPTAL 150 MG TABLET None Yes TRILEPTAL 300 MG TABLET None Yes TRILEPTAL 60 MG/ML SUSP None No TRILEPTAL 600 MG TABLET None Yes TRIMEBUTINE 100 MG TABLET OPEN None Yes TRIMEBUTINE 200 MG TABLET OPEN None Yes TRIMETHOPRIM 100 MG TAB OPEN None Yes TRIMETHOPRIM 200 MG TAB OPEN None Yes TRIMIPRAMINE 100 MG TABLET OPEN Yes TRIMIPRAMINE 12.5 MG TABLET OPEN Yes TRIMIPRAMINE 25 MG TABLET OPEN Yes TRIMIPRAMINE 50 MG TABLET OPEN Yes TRIMIPRAMINE 75 MG CAPSULE OPEN Yes TRINALIN REPETABS OPEN None No TRINIPATCH 0.2 MG/HR PATCH OPEN None No Page 250 Effective December 2015

251 Coverage Table December TRINIPATCH 0.4 MG/HR PATCH OPEN None No TRINIPATCH 0.6 MG/HR PATCH OPEN None No TRIPHASIL 21 TAB OPEN Beneficiary gender must be female - under the age of 51 No TRIPHASIL 21 TABLET OPEN Beneficiary gender must be female - under the age of 51 No TRIPHASIL 28 TAB OPEN Beneficiary gender must be female - under the age of 51 No TRIPHASIL 28 TABLET OPEN Beneficiary gender must be female - under the age of 51 No TRIQUILAR 21 TABLET OPEN Beneficiary gender must be female - under the age of 51 No TRIQUILAR 28 TABLET OPEN Beneficiary gender must be female - under the age of 51 No TRIUMEQ 600 MG-50 MG-300MG TAB No TRIZIVIR TABLET OPEN No TROSEC 20 MG TABLET OPEN a) Limited to 1 per day without Special b) Special Authorzation required if beneficiary has not had a paid No claim for Ditropan RR or a long acting urinary agent in past year TROSYD AF CREAM 1% OPEN None No TRUE TRACK BG TEST STRIPS OPEN a) Limited to 2500 per year without Special b) Beneficiary must have diabetic medication within previous year No history, otherwise Special is required TRUETEST BLOOD GLUCOSE TEST ST 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 251 Effective December 2015

252 Coverage Table December TRUETEST BLOOD GLUCOSE TEST ST OPEN a) Limited to 2500 per year without Special b) Beneficiary must have diabetic medication within previous year No history, otherwise Special is required TRUSOPT 2% OPHTHALMIC SOLN OPEN None Yes TRUVADA TABLET None No TRYPTAN 1000 MG TABLET OPEN Yes TRYPTAN 500 MG CAPSULE OPEN Yes TRYPTAN 500 MG TABLET OPEN Yes TUDORZA GENUAIR 400MCG INHALER None No TUINAL PULVULE 303 OPEN No TUINAL PULVULE 304 OPEN No TWINJECT 0.15 MG AUTO-INJ OPEN Limit of one per year without Special No TWINJECT 0.3 MG AUTO-INJ OPEN Limit of one per year without Special No TWYNSTA 40 MG-10 MG TABLET OPEN None No TWYNSTA 40 MG-5 MG TABLET OPEN None No TWYNSTA 80 MG-10 MG TABLET OPEN None No TWYNSTA 80 MG-5 MG TABLET OPEN None No TYLENOL CHILDRENS ELIXIR 160MG OPEN Beneficiary must be less than 13 years old - RBP applied No TYLENOL DROPS 80MG/ML INFANTS OPEN Beneficiary must be less than 13 years old - RBP applied No TYLENOL W/CODEINE NO. 2 TABLET OPEN Yes TYLENOL W/CODEINE NO.4 TABLET OPEN No TYLENOL WITH CODEINE ELIXIR OPEN No Page 252 Effective December 2015

253 Coverage Table December TYLENOL WITH CODEINE NO.3 TAB OPEN Yes ULORIC 80 MG TABLET None No ULTIBRO BREEZHALER MCG No No ULTICARE PEN NDL 32 GAUGE X4MM OPEN None No ULTIMED INSULIN SYRINGE OPEN None No ULTIMED INSULIN SYRINGE OPEN None No ULTIMED INSULIN SYRINGE OPEN None No ULTIMED INSULIN SYRINGE OPEN None No ULTIMED PEN NEEDLES OPEN None No ULTIMED PEN NEEDLES. OPEN None No ULTIMED SYR W ULTIGUARD OPEN None No ULTIMED SYR W ULTIGUARD OPEN None No ULTIMED SYR W ULTIGUARD OPEN None No ULTIMED INSULIN SYRINGE OPEN None No ULTIMED INSULIN SYRINGE OPEN None No ULTIMED INSULIN SYRINGE OPEN None No ULTIMED INSULIN SYRINGE OPEN None No ULTIMED INSULIN SYRINGE OPEN None No ULTIMED INSULIN SYRINGE OPEN None No ULTIMED INSULIN SYRINGE OPEN None No ULTIMED INSULIN SYRINGE OPEN None No ULTIMED LOW DEAD SPACE SYRING OPEN None No ULTIMED PEN NEEDLES OPEN None No ULTIMED SR W ULTIGUARD OPEN None No ULTIMED SR W ULTIGUARD OPEN None No ULTIMED SR W ULTIGUARD OPEN None No ULTIMED SR W ULTIGUARD OPEN None No ULTIMED SR W ULTIGUARD OPEN None No ULTIMED SYR W ULTIGUARD OPEN None No ULTIMED SYR W ULTIGUARD OPEN None No ULTIMED SYR W ULTIGUARD OPEN None No ULTIMED SYR W ULTIGUARD OPEN None No ULTIMED SYRINGES OPEN None No ULTIMED SYRINGES OPEN None No ULTRA MOP 1% LOTION OPEN None No ULTRAMOP 10 MG CAPSULE OPEN None No Page 253 Effective December 2015

254 Coverage Table December ULTRAVATE 0.05 % CREAM None No ULTRAVATE 0.05 % OINTMENT None No UNIPHYL 400 MG TABLET OPEN None Yes UNIPHYL 600 MG TABLET OPEN None Yes URASAL GRANULES EFFERV OPEN None No URECHOLINE INJ 5MG/ML OPEN None No URECHOLINE TAB 25MG OPEN None No UREMOL 20% CREAM OPEN None No UREMOL HC 1 %-10 % CREAM OPEN None No UREMOL HC 1 %-10 % LOTION OPEN None No URISTIX OPEN None No UROMAX 10 MG TABLET SA OPEN a) Limited to 1 per day without Special b) Special Authorzation required if beneficiary has not had a paid No claim for Ditropan RR or a long acting urinary agent in past year UROMAX 15 MG TABLET SA OPEN a) Limited to 1 per day without Special b) Special Authorzation required if beneficiary has not had a paid No claim for Ditropan RR or a long acting urinary agent in past year URSO 250 MG TABLET None No URSO DS 500 MG TABLET None No URSOFALK None No UTILET CLASSIC LANCETS OPEN None No VAGIFEM MCG VAGINAL TAB OPEN None No VAGIFEM 25 MCG VAGINAL TABLET OPEN None No VALCYTE 450 MG TABLET None Yes VALISONE 0.1 % SCALP LOTION OPEN None Yes VALISONE-G 0.1 %-0.1 % CREAM OPEN None No VALISONE-G 0.1 %-0.1% OINTMENT OPEN None No VALIUM 5 MG TABLET OPEN Yes VALIUM INJ ROCHE 5MG/ML OPEN No VALSARTAN 160 MG TABLET OPEN Yes Page 254 Effective December 2015

255 Coverage Table December VALSARTAN 160 MG TABLET OPEN VALSARTAN 320 MG TABLET OPEN VALSARTAN 320 MG TABLET OPEN VALSARTAN 40 MG TABLET OPEN VALSARTAN 40 MG TABLET OPEN VALSARTAN 80 MG TABLET OPEN VALSARTAN 80 MG TABLET OPEN VALSARTAN HCT MG TAB OPEN VALSARTAN HCT MG TAB OPEN VALSARTAN HCT MG TAB OPEN VALSARTAN HCT MG TAB OPEN VALSARTAN HCT MG TABLET OPEN VALSARTAN HCT MG TABLET OPEN VALSARTAN HCT MG TAB OPEN VALSARTAN HCT MG TAB OPEN VALSARTAN HCT MG TAB OPEN VALSARTAN HCT MG TABLET OPEN VALSARTAN HCT MG TAB OPEN Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Page 255 Effective December 2015

256 Coverage Table December VALSARTAN HCT MG TAB OPEN Yes VALSARTAN HCT MG TAB OPEN Yes VALSARTAN HCTZ MG TAB OPEN Yes VALSARTAN HCTZ MG TAB OPEN Yes VALSARTAN HCTZ MG TAB OPEN Yes VALSARTAN/HCTZ MG TAB OPEN Yes VALSARTAN/HCTZ MG TAB OPEN Yes VALSARTAN/HCTZ MG TAB OPEN Yes VALSARTAN/HCTZ MG TAB OPEN Yes VALTREX 500 MG TABLET OPEN None Yes VANCOCIN 125 MG CAPSULE OPEN None Yes VANCOCIN 250 MG CAPSULE OPEN None Yes VANCOMYCIN HCL 125 MG CAPSULE OPEN None Yes VANCOMYCIN HCL 250 MG CAPSULE OPEN None Yes VANQUIN 10MG/ML SUSPENSION OPEN None No VAPONEFRIN 2.25% SOLUTION OPEN None No VASERETIC OPEN None Yes VASERETIC 8 (10)/25 TABLET OPEN None Yes VASOCI OPHTHALMIC SOLUTION OPEN None No VASOCON 0.1% OPHTH DROPS OPEN None No VASOCON A EYE DROPS OPEN None No VASOTEC 16 MG (20 MG) TABLET OPEN None Yes VASOTEC 2 MG (2.5 MG) TABLET OPEN None Yes VASOTEC 4 MG (5 MG) TABLET OPEN None Yes VASOTEC 8 MG (10 MG) TABLET OPEN None Yes VENLAFAXINE XR 150 MG CAPSULE OPEN Yes Page 256 Effective December 2015

257 Coverage Table December VENLAFAXINE XR 150 MG CAPSULE OPEN Yes VENLAFAXINE XR 150 MG CAPSULE OPEN Yes VENLAFAXINE XR 37.5 MG CAPSULE OPEN Yes VENLAFAXINE XR 37.5 MG CAPSULE OPEN Yes VENLAFAXINE XR 37.5 MG CAPSULE OPEN Yes VENLAFAXINE XR 75 MG CAPSULE OPEN Yes VENLAFAXINE XR 75 MG CAPSULE OPEN Yes VENLAFAXINE XR 75 MG CAPSULE OPEN Yes VENT-A-HALER OPEN None No VENTODISK 200MCG DISK OPEN None No VENTODISK 400MCG DISK OPEN None No VENTODISK DISKHALER OPEN None No VENTOLIN 0.4 MG/ML LIQUID OPEN None No VENTOLIN 5 MG/ML SOLUTION None Yes VENTOLIN HFA 100 MCG INHALER OPEN None Yes VENTOLIN INHALER OPEN None No VENTOLIN NEBULES 2.5 MG/2.5 ML None Yes VENTOLIN NEBULES 5 MG/2.5 ML None Yes VENTOLIN NEBULES P.F MG/ None Yes VEPESID 20 MG/ML VIAL OPEN None No VEPESID 50 MG CAPSULE OPEN None No VERMOX 100 MG TABLET OPEN None No VESICARE 10 MG TABLET OPEN a) Limited to 1 per day without Special b) Special Authorzation required if beneficiary has not had a paid claim for Ditropan RR or a long acting urinary agent in past year. Yes Page 257 Effective December 2015

258 Coverage Table December VESICARE 5 MG TABLET OPEN a) Limited to 1 per day without Special b) Special Authorzation required if beneficiary has not had a paid Yes claim for Ditropan RR or a long acting urinary agent in past year VFEND 200 MG TABLET None Yes VFEND 50 MG TABLET None Yes VIADERM KC CREAM OPEN None Yes VIADERM KC OINTMENT OPEN None Yes VIBRAMYCIN 100 MG CAPSULE OPEN None Yes VIBRA-TABS OPEN None Yes VIDEX 100 MG TABLET CHEW OPEN No VIDEX 150 MG TABLET CHEW OPEN No VIDEX 25 MG TABLET CHEW OPEN No VIDEX 50MG TABLET CHEW OPEN No VIDEX EC 125 MG CAPSULE EC OPEN No VIDEX EC 200 MG CAPSULE EC OPEN No VIDEX EC 250 MG CAPSULE OPEN No VIDEX EC 400 MG CAPSULE OPEN No VIDEX PEDIATRIC 4G SOLUTION OPEN No VIMPAT 100 MG TABLET None No VIMPAT 150 MG TABLET None No VIMPAT 200 MG TABLET None No VIMPAT 50 MG TABLET None No VIOFORM HYDROCORT 3 %-1% CREAM VIRACEPT 250 MG TABLET OPEN OPEN None No No Page 258 Effective December 2015

259 Coverage Table December VIRACEPT 50 MG/G POWDER OPEN No VIRACEPT 625 MG TABLET OPEN No VIRAMUNE 200 MG TABLET OPEN Yes VIRAMUNE XR 400 MG TABLET OPEN None No VIREAD 300 MG TABLET None No VIROPTIC 1 % EYE DROPS OPEN None No VISANNE 2 MG TABLET None No VISKAZIDE 10 MG-25 MG TABLET OPEN None No VISKAZIDE 10 MG-50 MG TABLET OPEN None No VISKEN 10 MG TABLET OPEN None Yes VISKEN 15 MG TABLET OPEN None Yes VISKEN 5 MG TABLET OPEN None Yes VIT. B-12 INJ 1000MCG OPEN None No VIT. B-12 INJ 1000MCG *FOR DEF OPEN None No VITAMIN A 10000IU CAPSULE OPEN None No VITAMIN A 25000IU CAPSULE OPEN None No VITAMIN A 50000IU CAPSULE OPEN None No VITAMIN A ACID 0.01 % GEL OPEN None No VITAMIN A ACID 0.01% CREAM OPEN None No VITAMIN A ACID % GEL OPEN None No VITAMIN A ACID 0.025% CREAM OPEN None No VITAMIN A ACID 0.05 % GEL OPEN None No VITAMIN A ACID 0.05% CREAM OPEN None No VITAMIN A ACID 0.1% CREAM OPEN None No VITAMIN A CAP 10000UNIT OPEN None No VITAMIN B1 100 MG TABLET OPEN None No VITAMIN B1 100 MG TABLET OPEN None No VITAMIN B1 50 MG TABLET OPEN None No VITAMIN B1 50 MG TABLET OPEN None No VITAMIN B1 TAB 100MG OPEN None No VITAMIN B1 TAB 100MG OPEN None No VITAMIN B MCG TABLET OPEN None No VITAMIN B MCG/ML AMP OPEN None No VITAMIN B MCG/ML VIAL OPEN None No Page 259 Effective December 2015

260 Coverage Table December VITAMIN B12 100MCG/ML AMP OPEN None No VITAMIN B12 100MCG/ML AMPUL OPEN None No VITAMIN B12 25MCG TABLET OPEN None No VITAMIN B12 TAB 100MCG OPEN None No VITAMIN B6 100 MG TABLET OPEN None No VITAMIN B6 100 MG TABLET OPEN None No VITAMIN B6 25 MG TABLET OPEN None No VITAMIN B6 25 MG TABLET OPEN None No VITAMIN B6 250 MG TABLET OPEN None No VITAMIN B6 50 MG TABLET OPEN None No VITAMIN B6 50 MG TABLET OPEN None No VITAMIN B6 50 MG TABLET OPEN None No VITAMIN B6 TAB 100MG OPEN None No VITAMIN B6 TAB 25MG OPEN None No VITAMIN B6 TAB 25MG OPEN None No VITAMIN D 1000 I.U. OPEN Beneficiary must have eligibility under the CF Plan No VITAMIN D 1000 UNITS OPEN Beneficiary must have eligibility under the CF Plan No VITAMIN D 1000U TABLET OPEN None No VITAMIN D 1000U TABLET OPEN Beneficiary must have eligibility under the CF Plan No VITAMIN D 1000U TABLET OPEN Beneficiary must have eligibility under the CF Plan No VITAMIN D 400IU TABLET OPEN None No VITAMIN D 400IU TABLET OPEN None No VITAMIN D3 1000U TABLET OPEN Beneficiary must have eligibility under the CF Plan No VITAMIN E 100IU CAPSULE OPEN Beneficiary must have eligibility under the CF Plan No VITAMIN E 200IU CAPSULE OPEN Beneficiary must have eligibility under the CF Plan No VITAMIN E 400I.U. CAPSULE OPEN Beneficiary must have eligibility under the CF Plan No VITAMIN E 400IU CAP NATURAL OPEN Beneficiary must have eligibility under the CF Plan No Page 260 Effective December 2015

261 Coverage Table December VITAMIN E 400IU CAPSULE OPEN Beneficiary must have eligibility under the CF Plan No VITAMIN E 400IU CAPSULES USP OPEN Beneficiary must have eligibility under the CF Plan No VITAMIN K1 10 MG/ML AMPOULE OPEN None No VITAMIN K1 10 MG/ML AMPOULE OPEN None No VITAMIN K1 2 MG/ML AMPOULE OPEN None No VITAMIN K1 2 MG/ML AMPOULE OPEN None No VIVELLE 100MCG OPEN None Yes VIVELLE 37.5MCG OPEN None No VIVELLE 50MCG OPEN None Yes VIVELLE 75MCG OPEN None Yes VIVOL OPEN Yes VOLIBRIS 10 MG TABLET None No VOLIBRIS 5MG TABLET None No VOLTAREN 100 MG SUPPOSITORY OPEN None Yes VOLTAREN 50 MG SUPPOSITORY OPEN None Yes VOLTAREN EC 50 MG TABLET OPEN None Yes VOLTAREN OPHTHA 0.1% DROPS OPEN None Yes VOLTAREN SR 100 MG TABLET OPEN None Yes VOLTAREN SR 75 MG TABLET OPEN None Yes VOLTAREN TAB 25MG OPEN None Yes VOTRIENT 200 MG TABLET None No WARFARIN 1 MG TABLET OPEN None Yes WARFARIN 10 MG TABLET OPEN None Yes WARFARIN 2 MG TABLET OPEN None Yes WARFARIN 2.5 MG TABLET OPEN None Yes WARFARIN 3 MG TABLET OPEN None Yes WARFARIN 4 MG TABLET OPEN None Yes WARFARIN 5 MG TABLET OPEN None Yes WARTEC 0.5 % TOP SOLUTION OPEN None No WELLBUTRIN SR OPEN a) Limited to 2 per day without Special b) Special Authorzation required if beneficiary has not had a paid claim for an anti-depressant or Bupropion in past year. Yes Page 261 Effective December 2015

262 Coverage Table December WELLBUTRIN SR 150 MG TABLET OPEN a) Limited to 2 per day without Special b) Special Authorzation required if beneficiary has not had a paid Yes claim for an anti-depressant or Bupropion in past year WELLBUTRIN XL 150 MG TABLET OPEN a) Limited to 1 per day without Special b) Special Authorzation required if beneficiary has not had a paid Yes claim for an anti-depressant or Bupropion in past year WELLBUTRIN XL 300 MG TABLET OPEN a) Limited to 1 per day without Special b) Special Authorzation required if beneficiary has not had a paid Yes claim for an anti-depressant or Bupropion in past year WESTCORT 0.2% CREAM OPEN None No WESTCORT 0.2% OINTMENT OPEN None No WINPRED 1 MG TABLET OPEN None No WYDASE INJECTION LIQ 150 UNITS OPEN None No XALACOM 50 MCG-5 MG/ML EYE DRP OPEN None Yes XALATAN % OPH SOLN OPEN None Yes XALKORI 200 MG CAPSULE None No XALKORI 250 MG CAPSULE None No XANAX 0.25 MG TABLET OPEN Yes XANAX 0.5 MG TABLET OPEN Yes XANAX 1 MG TABLET OPEN Yes XANAX 2 MG TABLET OPEN Yes XARELTO 10 MG TABLET None No XARELTO 15 MG TABLET None No XARELTO 20 MG TABLET None No XELODA 150 MG TABLET None Yes XELODA 500 MG TABLET None Yes XGEVA 120 MG/1.7 ML VIAL None No Page 262 Effective December 2015

263 Coverage Table December XTANDI 40 MG CAPSULE No No XYLAC 10 MG TABLET OPEN Yes XYLAC 2.5 MG TABLET OPEN No XYLAC 25 MG TABLET OPEN Yes XYLAC 5 MG TABLET OPEN Yes XYLAC 50 MG TABLET OPEN Yes XYLOCAINE VISCOUS 2 % SOLN OPEN None No YASMIN 21 TABLET OPEN Beneficiary gender must be female - under the age of 51 Yes YASMIN 28 TABLET OPEN Beneficiary gender must be female - under the age of 51 Yes YOCON 5.4 MG TABLET OPEN None No YOHIMBINE 2MG TABLET OPEN None No YOHIMBINE 5.4 MG TABLET OPEN None No YOHIMBINE HCL 2 MG TABLET OPEN None No YOHIMBINE TAB 6MG OPEN None No YOHIMBINE-ODAN 6 MG TABLET OPEN None No ZADITEN 1 MG TABLET OPEN None No ZADITEN 1 MG/5 ML SYRUP OPEN None No ZADITOR % EYE DROPS OPEN None No ZAMINE 21 TABLET OPEN Beneficiary gender must be female - under the age of 51 Yes ZAMINE 28 TABLET OPEN Beneficiary gender must be female - under the age of 51 Yes ZANTAC OPEN None Yes ZANTAC 150 MG TABLET OPEN None Yes ZANTAC 25 MG/ML VIAL OPEN None No ZANTAC 300 MG TABLET OPEN None Yes ZARAH 21 TABLET OPEN Beneficiary gender must be female - under the age of 51 Yes ZARAH 28 TABLET OPEN Beneficiary gender must be female - under the age of 51 Yes Page 263 Effective December 2015

264 Coverage Table December ZARONTIN 250 MG CAPSULE OPEN None No ZARONTIN 250 MG/5 ML SOLUTION OPEN None No ZAROXOLYN 2.5 MG TABLET OPEN None No ZEASORB AF 1 % MEDICATED POWD OPEN Beneficiary must have eligibility under the CF Plan No ZELBORAF 240 MG TABLET None No ZELDOX 20 MG CAPSULE No ZELDOX 40 MG CAPSULE No ZELDOX 60 MG CAPSULE No ZELDOX 80 MG CAPSULE No ZENHALE 100 MCG-5 MCG INHALER None No ZENHALE 200 MCG-5 MCG INHALER None No ZENHALE 50 MCG-5 MCG INHALER None No ZERIT 15 MG CAPSULE OPEN No ZERIT 1MG/ML PWS ORL SOLN OPEN No ZERIT 20 MG CAPSULE OPEN No ZERIT 30 MG CAPSULE OPEN No ZERIT 40 MG CAPSULE OPEN No ZESTORETIC 10/12.5 TABLET OPEN None Yes ZESTORETIC 20/12.5 TABLET OPEN None Yes ZESTORETIC 20/25 TABLET OPEN None Yes ZESTRIL 10 MG TABLET OPEN None Yes ZESTRIL 20 MG TABLET OPEN None Yes ZESTRIL 5 MG TABLET OPEN None Yes ZIAGEN 20 MG/ML LIQUID OPEN No ZIAGEN 300 MG TABLET OPEN No Page 264 Effective December 2015

265 Coverage Table December ZINACEF 1.5GM VIAL OPEN None No ZINDA-ANASTROZOLE 1 MG TABLET None Yes ZINDA-LETROZOLE 2.5 MG TABLET None Yes ZITHROMAX 100 MG/5 ML SUSP OPEN None Yes ZITHROMAX 200 MG/5 ML SUSP OPEN None Yes ZITHROMAX 250 MG TABLET OPEN None Yes ZITHROMAX 500 MG VIAL OPEN Can be dispensed by Hospital or RHA Clinic without prior approval No ZITHROMAX 600 MG TABLET None Yes ZOCOR 10 MG TABLET OPEN None Yes ZOCOR 20 MG TABLET OPEN None Yes ZOCOR 40 MG TABLET OPEN None Yes ZOCOR 5 MG TABLET OPEN None Yes ZOCOR 80 MG TABLET OPEN None Yes ZOFRAN 4 MG TABLET OPEN Limit of 3 tablets per cycle - first fill only. Special is required for higher Yes quantities and/or subsequent fills ZOFRAN 4 MG/5 ML ORAL SOLN OPEN Limit of 3 tablets per cycle - first fill only. Special is required for higher Yes quantities and/or subsequent fills ZOFRAN 8 MG TABLET OPEN Limit of 3 tablets per cycle - first fill only. Special is required for higher Yes quantities and/or subsequent fills ZOFRAN ODT 4 MG TABLET OPEN Limit of 3 tablets per cycle - first fill only. Special is required for higher Yes quantities and/or subsequent fills ZOFRAN ODT 8 MG TABLET OPEN Limit of 3 tablets per cycle - first fill only. Special is required for higher Yes quantities and/or subsequent fills ZOLADEX DEPOT 3.6 MG SYRINGE OPEN None No ZOLADEX LA DEPOT 10.8 MG SYR OPEN None No ZOLOFT 100 MG CAPSULE OPEN Yes ZOLOFT 25 MG CAPSULE OPEN Yes ZOLOFT 50 MG CAPSULE OPEN Yes Page 265 Effective December 2015

266 Coverage Table December ZOMIG 2.5 MG TABLET None Yes ZOMIG 2.5 MG/DOSE NASAL SPRY None No ZOMIG 5 MG/DOSE NASAL SPRAY None No ZOMIG RAPIMELT 2.5 MG TABLET None Yes ZOPICLONE 5 MG TABLET OPEN Yes ZOPICLONE 5 MG TABLET OPEN Yes ZOPICLONE 7.5 MG TABLET OPEN Yes ZOPICLONE 7.5 MG TABLET OPEN Yes ZOVIRAX 200 MG TABLET OPEN None Yes ZOVIRAX 200 MG/5 ML SUSP OPEN None No ZOVIRAX 400 MG TABLET OPEN None Yes ZOVIRAX 5 % CREAM OPEN None No ZOVIRAX 5 % OINTMENT OPEN None No ZOVIRAX 800 OPEN None Yes ZYBAN 150 MG TABLET OPEN Open benefit for Foundation Plan, Access Plan and 65+ Plan for 12 weeks therapy No per year ZYLOPRIM 100 OPEN None Yes ZYLOPRIM 100 MG TABLET OPEN None Yes ZYLOPRIM 200 OPEN None Yes ZYLOPRIM 200 MG TABLET OPEN None Yes ZYLOPRIM 300 MG TABLET OPEN None Yes ZYPREXA 10 MG TABLET Yes ZYPREXA 15 MG TABLET Yes ZYPREXA 2.5 MG TABLET Yes ZYPREXA 20 MG TABLET Yes ZYPREXA 5 MG TABLET Yes Page 266 Effective December 2015

267 Coverage Table December ZYPREXA 7.5 MG TABLET Yes ZYPREXA ZYDIS 10 MG TABLET Yes ZYPREXA ZYDIS 15 MG TABLET Yes ZYPREXA ZYDIS 20 MG TABLET Yes ZYPREXA ZYDIS 5 MG TABLET Yes ZYTIGA 250 MG TABLET No No ZYVOXAM 600 MG TABLET No Yes Page 267 Effective December 2015