2016 List of Covered Drugs

Transcription

1 1 UnitedHealthcare Connected for MyCare Ohio (Medicare-Medicaid Plan) 2016 List of Covered Drugs (Formulary) This is a list of drugs that members can get in UnitedHealthcare Connected for MyCare Ohio. UnitedHealthcare Connected for MyCare Ohio (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Ohio Medicaid to provide benefits of both programs to enrollees. The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you. Benefits and/or co-payments may change on January 1 of each year. You can always check UnitedHealthcare Connected for MyCare Ohio s up-to-date List of Covered Drugs online at Limitations, co-pays, and restrictions may apply. For more information, call UnitedHealthcare Connected for MyCare Ohio Member Services or read the UnitedHealthcare Connected for MyCare Ohio Member Handbook. Co-pays for prescription drugs may vary based on the level of Extra Help you receive. Please contact the plan for more details. You can get this information for free in other formats, such as large print, braille or audio. Call , TTY 711. The call is free. You can get this information for free in other languages. Call , TTY 711. The call is free. Usted puede obtener esta información de forma gratuita en otros idiomas. Llame al , TTY 711. Las llamadas son gratuitas. If you have questions, please call UnitedHealthcare Connected for MyCare Ohio at , TTY 711, 7 a.m. 8 p.m. local time, Monday Friday; voice mail available 24 hours a day/7 days a week. The call is free. For more information, visit or O O Connecting Medicare Medicaid Medicare Approved Formulary File ID , Version 13 H2531_150629_153725_FINAL6 Approved Last updated June 1, 2016

2 2 2 Frequently Asked Questions (FAQ) Find answers here to questions you have about this List of Covered Drugs. You can read all of the FAQ to learn more, or look for a question and answer. 1 What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the Drug List for short.) The drugs on the List of Covered Drugs that starts on page 9 are the drugs covered by UnitedHealthcare Connected for MyCare Ohio. These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as network pharmacies..unitedhealthcare Connected for MyCare Ohio will cover all medically necessary drugs on the Drug List if: your doctor or other prescriber says you need them to get better or stay healthy, and you fill the prescription at a UnitedHealthcare Connected for MyCare Ohio network pharmacy. UnitedHealthcare Connected for MyCare Ohio may have additional steps to access certain drugs (see question #5 below). You can also see an up-to-date list of drugs that we cover on our website at or call Member Services at , TTY Does the Drug List ever change? Yes. UnitedHealthcare Connected for MyCare Ohio may add or remove drugs on the Drug List during the year. Generally, the Drug List will only change if: a cheaper drug comes along that works as well as a drug on the Drug List now, or we learn that a drug is not safe. We may also change our rules about drugs. For example, we could: Decide to require or not require prior approval for a drug. (Prior approval is permission from UnitedHealthcare Connected for MyCare Ohio before you can get a drug.) Add or change the amount of a drug you can get (called quantity limits ). Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.) If you have questions, please call UnitedHealthcare Connected for MyCare Ohio at , TTY 711, 7 a.m. 8 p.m. local time, Monday Friday; voice mail available 24 hours a day/7 days a week. The call is free. For more information, visit

3 3 (For more information on these drug rules, see pages 3, 4 and 9.) We will tell you when a drug you are taking is removed from the Drug List. We will also tell you when we change our rules for covering a drug. Questions 3, 4, and 7 below have more information on what happens when the Drug List changes. You can always check UnitedHealthcare Connected for MyCare Ohio s up-to-date Drug List online at You can also call Member Services to check the current Drug List at , TTY What happens when a cheaper drug comes along that works as well as a drug on the Drug List now? If you are taking a drug that is removed because a cheaper drug that works just as well comes along, we will tell you. We will tell you at least 60 days before we remove it from the Drug List or when you ask for a refill. Then you can get a 60-day supply of the drug before the change to the Drug List is made. You will receive a letter letting you know about the change. Contact your doctor or other prescriber to make sure this cheaper drug will work for you. 4 What happens when we find out a drug is not safe? If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we will take it off the Drug List right away. We will also send you a letter telling you that. Contact your doctor or other prescriber and ask about your other options. 5 Are there any restrictions or limits on drug coverage? Or are there any required actions to take in order to get certain drugs? Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases you or your doctor or other prescriber must do something before you can get the drug. For example: Prior approval (or prior authorization): For some drugs, you or your doctor or other prescriber must get approval from UnitedHealthcare Connected for MyCare Ohio before you fill your prescription. If you don t get approval, UnitedHealthcare Connected for MyCare Ohio may not cover the drug. Quantity limits: Sometimes UnitedHealthcare Connected for MyCare Ohio limits the amount of a drug you can get. If you have questions, please call UnitedHealthcare Connected for MyCare Ohio at , TTY 711, 7 a.m. 8 p.m. local time, Monday Friday; voice mail available 24 hours a day/7 days a week. The call is free. For more information, visit

4 4 4 Step therapy: Sometimes UnitedHealthcare Connected for MyCare Ohio requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn t work for you, then we will cover the second. You can find out if your drug has any additional requirements or limits by looking in the tables on pages You can also get more information by visiting our website at We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. You can ask for an exception from these limits. Please see question 11 for more information on exceptions. If you are in a nursing home or other long-term care facility and need a drug that is not on the Drug List, or if you cannot easily get the drug you need, we can help. We will cover a 31-day emergency supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new UnitedHealthcare Connected for MyCare Ohio member. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception. Please see question 11 for more information about exceptions. 6 How will you know if the drug you want has limitations or if there are required actions to take to get the drug? The List of Covered Drugs on pages has a column labeled. 7 What happens if we change our rules on how we cover some drugs? For example, if we add prior authorization (approval), quantity limits, and/or step therapy restrictions on a drug. We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions on a drug. We will tell you at least 60 days before the restriction is added or when you next ask for a refill. Then, you can get a 60-day supply of the drug before the change to the Drug List is made. This gives you time to talk to your doctor or other prescriber about what to do next. If you have questions, please call UnitedHealthcare Connected for MyCare Ohio at , TTY 711, 7 a.m. 8 p.m. local time, Monday Friday; voice mail available 24 hours a day/7 days a week. The call is free. For more information, visit

5 5 5 8 How can you find a drug on the Drug List? There are two ways to find a drug: You can search alphabetically (if you know how to spell the drug), or You can search by medical condition. To search alphabetically, go to the Alphabetical Listing section. You can find it after the List of Covered Drugs section. Find the name of your drug. The page number where you can find the drug will be next to it. To search by medical condition, find the section labeled List of drugs by medical condition on pages The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, Cardiovascular Agents. That is where you will find drugs that treat heart conditions. 9 What if the drug you want to take is not on the Drug List? If you don t see your drug on the Drug List, call Member Services at , TTY 711 and ask about it. If you learn that UnitedHealthcare Connected for MyCare Ohio will not cover the drug, you can do one of these things: Ask Member Services for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or You can ask the health plan to make an exception to cover your drug. Please see question 11 for more information about exceptions. 10 What if you are a new UnitedHealthcare Connected for MyCare Ohio member and can t find your drug on the Drug List or have a problem getting your drug? We can help. We may cover a temporary 30-day supply of your drug during the first 90 days you are a member of UnitedHealthcare Connected for MyCare Ohio. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception. We will cover a 30-day supply of your drug if: you are taking a drug that is not on our Drug List, or health plan rules do not let you get the amount ordered by your prescriber, or If you have questions, please call UnitedHealthcare Connected for MyCare Ohio at , TTY 711, 7 a.m. 8 p.m. local time, Monday Friday; voice mail available 24 hours a day/7 days a week. The call is free. For more information, visit

6 6 6 the drug requires prior approval by UnitedHealthcare Connected for MyCare Ohio, or you are taking a drug that is part of a step therapy restriction. If you live in a nursing home or other long-term care facility, you may refill your prescription for as long as 91 and may be up to 98 days. You may refill the drug multiple times during your first 90 days in the plan. This gives your prescriber time to change your drugs to ones on the Drug List or ask for an exception. You may have an unplanned transition, like a hospital discharge or a change in your level of care, after the first 90 days of your plan membership. If this happens and your doctor prescribes a drug that s not on the drug list, or if it s difficult for you to get your drugs, you are required to use your plan s exception process. You may ask for a one-time emergency supply of up to 30 days to give you time to talk to your doctor about other treatment options or to try to get a formulary exception. 11 Can you ask for an exception to cover your drug? Yes. You can ask UnitedHealthcare Connected for MyCare Ohio to make an exception to cover a drug that is not on the Drug List. You can also ask us to change the rules on your drug. For example, UnitedHealthcare Connected for MyCare Ohio may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more. Other examples: You can ask us to drop step therapy restrictions or prior approval requirements. 12 How long does it take to get an exception? First, we must receive a statement from your prescriber supporting your request for an exception. After we receive the statement, we will give you a decision on your exception request within 72 hours. If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, we will give you a decision within 24 hours of receiving your prescriber s supporting statement. If you have questions, please call UnitedHealthcare Connected for MyCare Ohio at , TTY 711, 7 a.m. 8 p.m. local time, Monday Friday; voice mail available 24 hours a day/7 days a week. The call is free. For more information, visit

7 How can you ask for an exception? To ask for an exception, call Member Services. A Member Services representative will work with you and your provider to help you ask for an exception. 14 What are generic drugs? Generic drugs are made up of the same active ingredients as brand name drugs. They usually cost less than the brand name drug and usually don t have well-known names. Generic drugs are approved by the Food and Drug Administration (FDA). UnitedHealthcare Connected for MyCare Ohio covers both brand name drugs and generic drugs. 15 What are OTC drugs? OTC stands for over-the-counter. UnitedHealthcare Connected for MyCare Ohio covers some OTC drugs when they are written as prescriptions by your provider. You can read the UnitedHealthcare Connected for MyCare Ohio Drug List to see what OTC drugs are covered. 16 Does UnitedHealthcare Connected for MyCare Ohio cover OTC nondrug products? UnitedHealthcare Connected for MyCare Ohio covers some OTC non-drug products when they are written as prescriptions by your provider. You can read the UnitedHealthcare Connected for MyCare Ohio Drug List to see what OTC non-drug products are covered. If you have questions, please call UnitedHealthcare Connected for MyCare Ohio at , TTY 711, 7 a.m. 8 p.m. local time, Monday Friday; voice mail available 24 hours a day/7 days a week. The call is free. For more information, visit

8 What is your copay? You can read the UnitedHealthcare Connected for MyCare Ohio Drug List to learn about the copay for each drug. UnitedHealthcare Connected for MyCare Ohio members living in nursing homes or other long-term care facilities will have no copays. Some members getting longterm care in the community will also have no copays. Copays are listed by tiers. Tiers are groups of drugs with the same copay. Tier 1 drugs have the lowest copay. They are generic drugs. The copay will be from $1.20 to $2.95, depending on your level of Medicaid eligibility. Tier 2 drugs have a medium copay. They are brand name drugs. The copay will be from $3.60 to $7.40, depending on your level of Medicaid eligibility. Tier 3 drugs have a copay of $0. They are OTCs/Non-Part D drugs. If you have questions, please call UnitedHealthcare Connected for MyCare Ohio at , TTY 711, 7 a.m. 8 p.m. local time, Monday Friday; voice mail available 24 hours a day/7 days a week. The call is free. For more information, visit

9 91 For Track Refered Purpose List of Covered Drugs by Medical Condition The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, Cardiovascular Agents. That is where you will find drugs that treat heart conditions. The List of Covered Drugs that begins on the next page gives you information about the drugs covered by UnitedHealthcare Connected for MyCare Ohio. If you have trouble finding your drug in the list, turn to the Index that begins on page 123. The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g., CRESTOR) and generic drugs are listed in lower-case italics (e.g., simvastatin). The information in the column tells you if UnitedHealthcare Connected for MyCare Ohio has any rules for covering your drug. Utilization Management Restrictions PA - Prior approval (or prior authorization) For some drugs, you or your doctor or other prescriber must get approval from UnitedHealthcare Connected for MyCare Ohio before you fill your prescription. If you don t get approval, UnitedHealthcare Connected for MyCare Ohio may not cover the drug. QL - Quantity limits Sometimes UnitedHealthcare Connected for MyCare Ohio limits the amount of a drug you can get. ST - Step therapy Sometimes UnitedHealthcare Connected for MyCare Ohio requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn t work for you, then we will cover the second. Other Special Requirements for Coverage B/D - Medicare Part B or Part D Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide the plan with more information about how this drug will be used to make sure it s correctly covered by Medicare. HRM - High Risk Medication This drug is known as a high risk medication (HRM) for Medicare members 65 and older. This drug may cause side effects if taken on a regular basis. We suggest you talk with your doctor to see if an alternative drug is available to treat your condition. Note: If you are 65 or older, you may need to get a prior authorization (PA) or formulary exception from the health plan before the plan will cover a high risk medication (HRM). If you are under 65, the prior authorization (PA) will not apply to you until the first time you get your prescription filled after turning 65. 9

10 1For 10 Track Refered Purpose 10 LA - Limited Access Drugs are considered limited access if the FDA says the drug can be given out only by certain facilities or doctors. These drugs may require extra handling, provider coordination or patient education that can t be done at a network pharmacy. For Track Refered Purpose Note: The asterisk (*) next to a drug means the drug is not a Part D drug. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving Extra Help to pay for your prescriptions, you will not get any Extra Help to pay for these drugs. These drugs also have different rules for appeals. An appeal is a formal way of asking us to review a coverage decision and to change it if you think we made a mistake. For example, we might decide that a drug that you want is not covered or is no longer covered by Medicare or Medicaid. If you or your doctor disagrees with our decision, you can appeal. To ask for instructions on how to appeal, call Member Services at , TTY 711. You can also read the Member Handbook to learn how to appeal a decision. Analgesics Analgesics Acephen acephen (suppository)* Acetaminophen acetaminophen (suppository)* Fever Reducer Childrens fever reducer childrens (suppository)* Feverall Adults feverall adults (suppository)* Feverall Childrens feverall childrens (suppository)* Feverall Infants feverall infants (suppository)* Feverall Junior Strength feverall junior strength (suppository)* Nonsteroidal Anti-inflammatory Drugs Advil advil (200mg capsule, 200mg tablet)* Advil Junior Strength advil junior strength (100mg tablet, 100mg tablet chewable)* All Day Pain Relief all day pain relief (tablet)* You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

11 2For 11 Track Refered Purpose 11 All Day Relief all day relief (tablet)* Aspir-81 aspir-81 (tablet delayed-release)* Aspirin aspirin (325mg tablet, 325mg tablet delayed-release, 81mg tablet delayed-release, 81mg tablet chewable)* Aspirin Adult Low Strength aspirin adult low strength (tablet chewable)* Aspirin Childrens aspirin childrens (tablet chewable)* Aspirin EC aspirin ec (tablet delayed-release)* Aspirin EC Low Dose aspirin ec low dose (tablet delayed-release)* Aspirin Enteric Coated Adult Low Strength aspirin enteric coated adult low strength (tablet delayedrelease)* Aspirin Low Dose aspirin low dose (81mg tablet chewable, 81mg tablet delayed-release)* Aspirin Low Strength aspirin low strength (tablet chewable)* Aspir-Low aspir-low (tablet delayed-release)* Childrens Advil childrens advil (suspension)* Childrens Aspirin childrens aspirin (tablet chewable)* Childrens Aspirin Low Strength childrens aspirin low strength (tablet chewable)* Childrens Ibuprofen childrens ibuprofen (otc only) (40mg/ml suspension)* Diclofenac Potassium diclofenac potassium (tablet immediate-release) Diclofenac Sodium diclofenac sodium (1% gel) PA Diclofenac Sodium DR diclofenac sodium dr (tablet delayed-release) Diclofenac Sodium ER diclofenac sodium er (tablet extended-release 24 hour) Diflunisal diflunisal (tablet) Ecpirin ecpirin (tablet delayed-release)* Enteric Coated Aspirin enteric coated aspirin (tablet delayed-release)* Etodolac etodolac (200mg capsule, 300mg capsule, 400mg tablet immediate-release, 500mg tablet immediate-release) Flector FLECTOR (PATCH) $3.60-$7.40 (Tier 2) PA, QL Flurbiprofen flurbiprofen (tablet) GNP Adult Aspirin Low Strength gnp adult aspirin low strength (81mg tablet chewable, 81mg tablet delayed-release)* You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

12 3For 12 Track Refered Purpose 12 GNP All Day Pain Relief gnp all day pain relief (tablet)* GNP Aspirin gnp aspirin (tablet delayed-release)* GNP Aspirin Low Dose gnp aspirin low dose (tablet delayed-release)* GNP Ibuprofen gnp ibuprofen (otc only) (200mg tablet)* GNP Ibuprofen Junior Strength gnp ibuprofen junior strength (otc only) (100mg tablet chewable)* HM Aspirin hm aspirin (325mg tablet, 81mg tablet chewable)* HM Aspirin EC hm aspirin ec (tablet delayed-release)* HM Aspirin EC Low Dose hm aspirin ec low dose (tablet delayed-release)* HM Cold & Sinus Relief hm cold & sinus relief (tablet)* HM Ibuprofen hm ibuprofen (otc only) (200mg capsule, 200mg tablet)* HM Ibuprofen IB hm ibuprofen ib (otc only) (200mg tablet)* HM Ibuprofen Infants hm ibuprofen infants (otc only) (50mg/1.25ml suspension)* HM Naproxen Sodium hm naproxen sodium (otc only) (220mg tablet immediaterelease)* Ibu-Drops ibu-drops (otc only) (suspension)* Ibu-Drops Infants ibu-drops infants (otc only) (suspension)* Ibuprofen ibuprofen (otc only) (200mg capsule, 200mg tablet)* Ibuprofen Junior Strength ibuprofen junior strength (otc only) (100mg tablet chewable)* Ibuprofen ibuprofen (rx only) (100mg/5ml suspension, 400mg tablet, 600mg tablet, 800mg tablet) Infants Ibuprofen infants ibuprofen (otc only) (50mg/1.25ml suspension)* Ketoprofen ketoprofen (capsule immediate-release) Ketorolac Tromethamine ketorolac tromethamine (15mg/ml injection, 30mg/ml injection) Meloxicameloxicam (15mg tablet, 7.5mg tablet) Meloxicam MELOXICAM (7.5MG/5ML SUSPENSION) $3.60-$7.40 (Tier 2) Miniprin Low Dose miniprin low dose (tablet delayed-release)* Naproxen naproxen (rx only) (125mg/5ml suspension, 250mg tablet immediate-release, 375mg tablet immediate-release, 500mg tablet immediate-release) Naproxen DR naproxen dr (rx only) (375mg tablet delayed-release, 500mg tablet delayed-release) (generic ec-naprosyn) Naproxen Sodium naproxen sodium (otc only) (220mg capsule immediaterelease, 220mg tablet immediate-release)* Naproxen Sodium naproxen sodium (rx only) (275mg tablet immediate-release, 550mg tablet immediate-release) Provil provil (tablet)* QC Aspirin qc aspirin (325mg tablet, 325mg tablet delayed-release)*

13 4For 13 Track Refered Purpose 13 QC Aspirin Low Dose qc aspirin low dose (tablet delayed-release)* QC Childrens Aspirin qc childrens aspirin (tablet chewable)* QC Ibuprofen qc ibuprofen (otc only) (200mg tablet)* QC Ibuprofen IB qc ibuprofen ib (otc only) (200mg tablet)* QC Naproxen Sodium qc naproxen sodium (otc only) (220mg tablet immediaterelease)* SB Aspirin sb aspirin (81mg tablet delayed-release)* SB Ibuprofen sb ibuprofen (otc only) (200mg tablet)* SB Naproxen Sodium sb naproxen sodium (otc only) (220mg tablet immediaterelease)* SM All Day Pain Relief sm all day pain relief (220mg tablet immediate-release)* SM Aspirin Adult Low Strength sm aspirin adult low strength (81mg tablet chewable, 81mg tablet delayed-release)* SM Aspirin Enteric Coated sm aspirin enteric coated (tablet delayed-release)* SM Childrens Aspirin sm childrens aspirin (tablet chewable)* SM Ibuprofen sm ibuprofen (otc only) (200mg tablet)* SM Ibuprofen IB sm ibuprofen ib (otc only) (200mg tablet)* SM Infants Ibuprofen sm infants ibuprofen (otc only) (50mg/1.25ml suspension)* SM Naproxen Sodium sm naproxen sodium (otc only) (220mg capsule immediaterelease, 220mg tablet immediate-release)* Sulindac sulindac (tablet) Voltaren VOLTAREN (GEL) $3.60-$7.40 (Tier 2) PA Opioid Analgesics, Long-acting Embeda EMBEDA (CAPSULE EXTENDED-RELEASE) $3.60-$7.40 (Tier 2) QL Fentanyl fentanyl (100mcg/hr patch 72 hour, 12mcg/hr patch 72 hour, 25mcg/hr patch 72 hour, 50mcg/hr patch 72 hour, 75mcg/hr patch 72 hour) Hydromorphone HCl ER hydromorphone hcl er (12mg tablet extended-release 24 hour abuse-deterrent, 16mg tablet extended-release 24 hour abuse-deterrent, 8mg tablet extended-release 24 hour abuse-deterrent) QL QL You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

14 5For 14 Track Refered Purpose 14 Hydromorphone HCl ER HYDROMORPHONE HCL ER (32MG TABLET EXTENDED-RELEASE 24 HOUR ABUSE- $3.60-$7.40 (Tier 2) QL DETERRENT) Levorphanol Tartrate levorphanol tartrate (tablet) QL Methadone HCl methadone hcl (10mg tablet, 5mg tablet, 10mg/5ml oral solution, 5mg/5ml oral solution) QL Methadone HCl METHADONE HCL (10MG/ML INJECTION) $3.60-$7.40 (Tier 2) Morphine Sulfate ER morphine sulfate er (tablet extended-release) (generic ms contin) QL Nucynta ER NUCYNTA ER (TABLET EXTENDED-RELEASE 12 HOUR) $3.60-$7.40 (Tier 2) QL Opioid Analgesics, Short-acting Abstral ABSTRAL (TABLET SUBLINGUAL) $3.60-$7.40 (Tier 2) PA, QL Acetaminophen/Codeine acetaminophen/codeine (120mg-12mg/5ml oral solution, 300mg-15mg tablet, 300mg-30mg tablet, 300mg-60mg tablet) QL Butorphanol Tartrate butorphanol tartrate (10mg/ml nasal solution) QL Butorphanol Tartrate butorphanol tartrate (1mg/ml injection, 2mg/ml injection) Codeine Sulfate codeine sulfate (tablet) QL Duramorph DURAMORPH (INJECTION) $3.60-$7.40 (Tier 2) Endocet endocet (tablet) QL Hydrocodone Bitartrate/Acetaminophen hydrocodone bitartrate/acetaminophen (7.5mg-325mg/ 15ml oral solution) QL Hydrocodone/Acetaminophen hydrocodone/acetaminophen (10mg-325mg tablet, 2.5mg-325mg tablet, 5mg-325mg tablet, 7.5mg-325mg tablet) QL Hydrocodone/Ibuprofen hydrocodone/ibuprofen (7.5mg-200mg tablet) QL Hydromorphone HCl hydromorphone hcl (1mg/ml liquid, 2mg tablet immediaterelease, 4mg tablet immediate-release, 8mg tablet QL immediate-release) Hydromorphone HCl hydromorphone hcl (500mg/50ml injection) Lorcet lorcet (tablet) QL Lorcet HD lorcet hd (tablet) QL Lorcet Plus lorcet plus (tablet) QL Lortab lortab (tablet) QL Morphine Sulfate morphine sulfate (100mg/5ml oral solution, 10mg/5ml oral solution, 20mg/5ml oral solution) QL Morphine Sulfate MORPHINE SULFATE (10MG/ML INJECTION, 2MG/ML INJECTION, 4MG/ML INJECTION, 8MG/ML INJECTION) $3.60-$7.40 (Tier 2)

15 6For 15 Track Refered Purpose 15 Morphine Sulfate MORPHINE SULFATE (15MG TABLET IMMEDIATE-RELEASE, 30MG TABLET $3.60-$7.40 (Tier 2) QL IMMEDIATE-RELEASE) Nalbuphine HCl nalbuphine hcl (injection) Oxycodone HCl oxycodone hcl (100mg/5ml concentrate, 10mg tablet immediate-release, 15mg tablet immediate-release, 20mg tablet immediate-release, 30mg tablet immediate-release, 5mg tablet immediate-release, 5mg/5ml oral solution) QL Oxycodone/Acetaminophen oxycodone/acetaminophen (10mg-325mg tablet, 2.5mg-325mg tablet, 5mg-325mg tablet, 7.5mg-325mg tablet) QL Oxycodone/Aspirin oxycodone/aspirin (tablet) QL Oxycodone/Ibuprofen oxycodone/ibuprofen (tablet) QL Tramadol HCl tramadol hcl (tablet immediate-release) QL Tramadol HCl/Acetaminophen tramadol hcl/acetaminophen (tablet) QL Trezix trezix (320.5mg-30mg-16mg capsule) QL Anesthetics Local Anesthetics Lidocaine lidocaine (otc only) (cream)* Lidocaine HCl lidocaine hcl (rx only) (0.5% injection, 2% injection) B/D, PA Lidocaine HCl lidocaine hcl (rx only) (4% external solution) Lidocaine HCl lidocaine hcl (rx only) (2% gel) Lidocaine Viscous lidocaine viscous (rx only) (2% solution) Lidocaine lidocaine (rx only) (5% ointment) Lidocaine lidocaine (rx only) (5% patch) PA, QL Lidocaine/Prilocaine lidocaine/prilocaine (cream) Lidocream lidocream (cream)* QC AZO qc azo (tablet)* Anti-Addiction/Substance Abuse Treatment Agents You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

16 7For 16 Track Refered Purpose 16 Alcohol Deterrents/Anti-craving Acamprosate Calcium DR acamprosate calcium dr (tablet delayed-release) Disulfiram disulfiram (tablet) Naltrexone HCl naltrexone hcl (tablet) Vivitrol VIVITROL (INJECTION) $3.60-$7.40 (Tier 2) PA Opioid Dependence Treatments Buprenorphine HCl buprenorphine hcl (0.3mg/ml injection) Buprenorphine HCl buprenorphine hcl (2mg tablet sublingual, 8mg tablet sublingual) QL Buprenorphine HCl/Naloxone HCl buprenorphine hcl/naloxone hcl (tablet sublingual) PA, QL Naloxone HCl naloxone hcl (injection) Narcan NARCAN (LIQUID) $3.60-$7.40 (Tier 2) Suboxone SUBOXONE (FILM) $3.60-$7.40 (Tier 2) PA, QL Smoking Cessation Agents Buproban buproban (tablet extended-release 12 hour) Chantix CHANTIX (TABLET) $3.60-$7.40 (Tier 2) Chantix Continuing Month Pak CHANTIX CONTINUING MONTH PAK (TABLET) $3.60-$7.40 (Tier 2) Chantix Starting Month Pak CHANTIX STARTING MONTH PAK (TABLET) $3.60-$7.40 (Tier 2) GNP Nicotine Mini Lozenge gnp nicotine mini lozenge* GNP Nicotine Polacrilex gnp nicotine polacrilex (2mg gum, 4mg gum, 2mg lozenge, 4mg lozenge)* GNP Nicotine Polacrilex Mini gnp nicotine polacrilex mini (lozenge)* HM Nicotine Polacrilex hm nicotine polacrilex (2mg gum, 4mg gum, 2mg lozenge, 4mg lozenge)* HM Nicotine Transdermal System hm nicotine transdermal system (patch 24 hour)* HM Nicotine Transdermal System Step 3 hm nicotine transdermal system step 3 (patch 24 hour)* NicoDerm CQ nicoderm cq (patch 24 hour)* NICOrelief nicorelief (gum)* Nicorette nicorette (2mg gum, 4mg gum, 2mg lozenge, 4mg lozenge)* Nicorette Mini nicorette mini (lozenge)* Nicorette Starter Kit nicorette starter kit (gum)* Nicotine nicotine (patch 24 hour)* Nicotine Polacrilex nicotine polacrilex (2mg gum, 4mg gum, 2mg lozenge, 4mg lozenge)* Nicotine Transdermal System nicotine transdermal system (patch 24 hour)* Nicotrol Inhaler NICOTROL INHALER $3.60-$7.40 (Tier 2)

17 8For 17 Track Refered Purpose 17 SM Nicotine sm nicotine (14mg/24hr patch 24 hour, 21mg/24hr patch 24 hour, 7mg/24hr patch 24 hour, 2mg lozenge, 4mg gum)* SM Nicotine Polacrilex sm nicotine polacrilex (2mg gum, 4mg gum, 4mg lozenge)* Antibacterials Aminoglycosides Amikacin Sulfate amikacin sulfate (injection) Bethkis BETHKIS (NEBULIZED SOLUTION) $3.60-$7.40 (Tier 2) B/D, PA Gentak gentak (ophthalmic ointment) Gentamicin Sulfate gentamicin sulfate (0.1% cream, 0.1% ointment, 0.3% ophthalmic ointment, 0.3% ophthalmic solution, 10mg/ml injection, 40mg/ml injection) Gentamicin Sulfate/0.9% Sodium Chloride gentamicin sulfate/0.9% sodium chloride (injection) Isotonic Gentamicin isotonic gentamicin (injection) Neomycin Sulfate neomycin sulfate (tablet) Paromomycin Sulfate paromomycin sulfate (capsule) Streptomycin Sulfate streptomycin sulfate (injection) TOBI (NEBULIZED SOLUTION) $3.60-$7.40 (Tier 2) B/D, PA Podhaler TOBI PODHALER (CAPSULE) $3.60-$7.40 (Tier 2) PA Tobradex TOBRADEX (OPHTHALMIC OINTMENT) $3.60-$7.40 (Tier 2) Tobramycin tobramycin (nebulized solution) B/D, PA Tobramycin Sulfate tobramycin sulfate (0.3% ophthalmic solution, 10mg/ml injection, 80mg/2ml injection) Tobrex TOBREX (0.3% OPHTHALMIC OINTMENT) $3.60-$7.40 (Tier 2) Antibacterials, Other BACiiM baciim (injection) Bacitracin bacitracin (otc only) (500unit/gm ointment)* Bacitracin Zinc bacitracin zinc (otc only) (ointment)* Bacitracin bacitracin (rx only) (50000unit injection, 500unit/gm ophthalmic ointment) You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

18 9For 18 Track Refered Purpose 18 Bacitracin/Neomycin/Polymyxin bacitracin/neomycin/polymyxin (otc only) (ointment)* Bactroban Nasal BACTROBAN NASAL (OINTMENT) $3.60-$7.40 (Tier 2) PA Betadine Surgical Scrub betadine surgical scrub (external solution)* Chloramphenicol Sodium Succinate chloramphenicol sodium succinate (injection) Clindamycin HCl clindamycin hcl (capsule immediate-release) Clindamycin Palmitate HCl clindamycin palmitate hcl (oral solution) Clindamycin Phosphate clindamycin phosphate (2% cream, 600mg/4ml injection) Clindamycin Phosphate D5W clindamycin phosphate in d5w (injection) Colistimethate Sodium colistimethate sodium (injection) Cubicin CUBICIN (INJECTION) $3.60-$7.40 (Tier 2) Dalvance DALVANCE (INJECTION) $3.60-$7.40 (Tier 2) PA Double Antibiotic double antibiotic (ointment)* GNP Bacitracin Zinc gnp bacitracin zinc (otc only) (ointment)* GNP Povidone-Iodine gnp povidone-iodine (external solution)* GNP Triple Antibiotic gnp triple antibiotic (ointment)* GNP Triple Antibiotic Plus gnp triple antibiotic plus (ointment)* HM Bacitracin hm bacitracin (otc only) (ointment)* HM Double Antibiotic hm double antibiotic (ointment)* HM Povidone-Iodine hm povidone-iodine (external solution)* HM Triple Antibiotic hm triple antibiotic (ointment)* Lincocin LINCOCIN (INJECTION) $3.60-$7.40 (Tier 2) Lincomycin HCl lincomycin hcl (injection) Linezolid linezolid (100mg/5ml suspension, 600mg/300ml injection) PA Linezolid LINEZOLID (600MG TABLET) $3.60-$7.40 (Tier 2) PA, QL Methenamine Hippurate methenamine hippurate (tablet) Metronidazole metronidazole (0.75% cream, 0.75% gel, 1% gel, 0.75% lotion, 250mg tablet immediate-release, 500mg tablet immediate-release, 375mg capsule immediate-release) Metronidazole in NaCl 0.79% metronidazole in nacl 0.79% (injection) Metronidazole Vaginal metronidazole vaginal (gel) Mupirocin mupirocin (2% ointment) Neomycin/Polymyxin B Sulfates neomycin/polymyxin b sulfates (rx only) (irrigation solution) Nitrofurantoin nitrofurantoin (suspension) Nitrofurantoin Macrocrystals nitrofurantoin macrocrystals (100mg capsule, 50mg capsule) (generic macrodantin) Nitrofurantoin Monohydrate 100mg Capsule nitrofurantoin monohydrate 100mg capsule (generic macrobid) Operand Scrub operand scrub (external solution)* Polymyxin B Sulfate polymyxin b sulfate (injection)

19 For Track Refered Purpose 19 Povidone-Iodine povidone-iodine (10% external solution, 10% ointment)* Primsol PRIMSOL (ORAL SOLUTION) $3.60-$7.40 (Tier 2) QC Bacitracin qc bacitracin (otc only) (ointment)* SM Double Antibiotic sm double antibiotic (ointment)* SM Triple Antibiotic sm triple antibiotic (ointment)* Synercid SYNERCID (INJECTION) $3.60-$7.40 (Tier 2) Tinidazole tinidazole (tablet) Trimethoprim trimethoprim (tablet) Triple Antibiotic triple antibiotic (ointment)* Tygacil TYGACIL (INJECTION) $3.60-$7.40 (Tier 2) Vancocin HCl VANCOCIN HCL (CAPSULE) $3.60-$7.40 (Tier 2) PA Vancomycin HCl vancomycin hcl (1000mg injection, 10gm injection, 500mg injection) Vancomycin HCl vancomycin hcl (125mg capsule, 250mg capsule) PA Vandazole VANDAZOLE (GEL) $3.60-$7.40 (Tier 2) Xifaxan XIFAXAN (TABLET) $3.60-$7.40 (Tier 2) PA Zyvox ZYVOX (100MG/5ML SUSPENSION, 600MG/ 300ML INJECTION) $3.60-$7.40 (Tier 2) PA Beta-lactam, Cephalosporins Cefaclor cefaclor (250mg capsule immediate-release, 500mg capsule immediate-release) Cefadroxil cefadroxil (250mg/5ml suspension, 500mg/5ml suspension, 500mg capsule) Cefazolin Sodium cefazolin sodium (10gm injection, 1gm injection, 500mg injection, 1gm/50ml injection) Cefdinir cefdinir (125mg/5ml suspension, 250mg/5ml suspension, 300mg capsule) Cefepime cefepime (1gm injection, 2gm injection) Cefepime CEFEPIME (1GM/50ML INJECTION, 2GM/50ML $3.60-$7.40 (Tier 2) INJECTION) Cefixime cefixime (suspension) You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

20 For Track Refered Purpose 20 Cefotaxime Sodium cefotaxime sodium (injection) Cefotetan cefotetan (injection) Cefoxitin Sodium cefoxitin sodium (10gm injection, 1gm injection, 2gm injection) Cefoxitin Sodium CEFOXITIN SODIUM (1GM-4% INJECTION, 2GM-2.2% INJECTION) $3.60-$7.40 (Tier 2) Cefpodoxime Proxetil cefpodoxime proxetil (100mg tablet, 200mg tablet, 100mg/ 5ml suspension, 50mg/5ml suspension) Cefprozil cefprozil (125mg/5ml suspension, 250mg/5ml suspension, 250mg tablet, 500mg tablet) Ceftazidime ceftazidime (injection) Ceftazidime/Dextrose CEFTAZIDIME/DEXTROSE (INJECTION) $3.60-$7.40 (Tier 2) Ceftriaxone Sodium ceftriaxone sodium (10gm injection, 1gm injection, 2gm injection, 250mg injection, 500mg injection) Cefuroxime Axetil cefuroxime axetil (tablet) Cefuroxime Sodium cefuroxime sodium (injection) Cephalexin cephalexin (125mg/5ml suspension, 250mg/5ml suspension, 250mg capsule, 500mg capsule, 750mg capsule) Fortaz FORTAZ (1GM INJECTION, 2GM INJECTION, 2GM INJECTION, 6GM INJECTION) $3.60-$7.40 (Tier 2) Suprax suprax (100mg tablet chewable, 200mg tablet chewable, 100mg/5ml suspension, 200mg/5ml suspension) Suprax SUPRAX (400MG CAPSULE, 500MG/5ML SUSPENSION) $3.60-$7.40 (Tier 2) Tazicef tazicef (injection) Zerbaxa ZERBAXA (INJECTION) $3.60-$7.40 (Tier 2) PA Beta-lactam, Other Azactam in Iso-Osmotic Dextrose AZACTAM IN ISO-OSMOTIC DEXTROSE $3.60-$7.40 (Tier 2) (INJECTION) Aztreonam aztreonam (injection) Doribax DORIBAX (500MG INJECTION) $3.60-$7.40 (Tier 2) Imipenem/Cilastatin imipenem/cilastatin (injection) Invanz INVANZ (INJECTION) $3.60-$7.40 (Tier 2) Meropenem meropenem (injection) Beta-lactam, Penicillins Amoxicillin amoxicillin (capsule, oral suspension, tablet, tablet chewable)

21 For Track Refered Purpose 21 Amoxicillin/Clavulanate Potassium amoxicillin/clavulanate potassium (oral suspension, tablet chewable, tablet immediate-release) (generic augmentin) Amoxicillin/Clavulanate Potassium ER amoxicillin/clavulanate potassium er (tablet extendedrelease 12 hour) Ampicillin ampicillin (125mg/5ml suspension, 250mg/5ml suspension, 250mg capsule, 500mg capsule) Ampicillin Sodium ampicillin sodium (10gm injection, 125mg injection, 1gm injection) Ampicillin-Sulbactam ampicillin-sulbactam (10gm-5gm injection, 1gm-0.5gm injection, 2gm-1gm injection) Bactocill in Dextrose BACTOCILL IN DEXTROSE (INJECTION) $3.60-$7.40 (Tier 2) Bicillin C-R BICILLIN C-R (INJECTION) $3.60-$7.40 (Tier 2) Bicillin L-A BICILLIN L-A (INJECTION) $3.60-$7.40 (Tier 2) Dicloxacillin Sodium dicloxacillin sodium (capsule) Nafcillin Sodium nafcillin sodium (injection) Nallpen/Dextrose NALLPEN/DEXTROSE (INJECTION) $3.60-$7.40 (Tier 2) Oxacillin Sodium oxacillin sodium (injection) Penicillin G Potassium penicillin g potassium (injection) Penicillin G Procaine penicillin g procaine (injection) Penicillin G Sodium penicillin g sodium (injection) Penicillin V Potassium penicillin v potassium (125mg/5ml oral solution, 250mg/ 5ml oral solution, 250mg tablet, 500mg tablet) Piperacillin Sodium/Tazobactam Sodium piperacillin sodium/tazobactam sodium (injection) Macrolides Azithromycin azithromycin (100mg/5ml oral suspension, 200mg/5ml oral suspension, 250mg tablet, 500mg tablet, 600mg tablet, 500mg injection) Clarithromycin clarithromycin (125mg/5ml suspension, 250mg/5ml suspension, 250mg tablet, 500mg tablet) Clarithromycin ER clarithromycin er (tablet extended-release 24 hour) Dificid DIFICID (TABLET) $3.60-$7.40 (Tier 2) PA E.E.S. 400 e.e.s. 400 (tablet) You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

22 For Track Refered Purpose 22 Granules E.E.S. GRANULES (SUSPENSION) $3.60-$7.40 (Tier 2) EryPed 200 ERYPED 200 (SUSPENSION) $3.60-$7.40 (Tier 2) EryPed 400 ERYPED 400 (SUSPENSION) $3.60-$7.40 (Tier 2) Ery-Tab ery-tab (tablet delayed-release) Erythrocin Lactobionate erythrocin lactobionate (injection) Erythromycin erythromycin (250mg capsule delayed-release, 5mg/gm ophthalmic ointment) Erythromycin Base erythromycin base (tablet) Erythromycin Ethylsuccinate erythromycin ethylsuccinate (tablet) Ilotycin ilotycin (ophthalmic ointment) Zmax ZMAX (SUSPENSION) $3.60-$7.40 (Tier 2) Quinolones Avelox AVELOX (400MG/250ML-0.8% INJECTION) $3.60-$7.40 (Tier 2) Ciprofloxacin ciprofloxacin (250mg/5ml suspension, 500mg/5ml suspension, 400mg/40ml injection) Ciprofloxacin ER ciprofloxacin er (tablet extended-release 24 hour) Ciprofloxacin HCl ciprofloxacin hcl (0.3% ophthalmic solution, 100mg tablet immediate-release, 250mg tablet immediate-release, 500mg tablet immediate-release, 750mg tablet immediaterelease) Ciprofloxacin I.V. in D5W ciprofloxacin i.v. in d5w (injection) Levofloxacin levofloxacin (0.5% ophthalmic solution, 250mg tablet, 500mg tablet, 750mg tablet, 25mg/ml injection, 25mg/ml oral solution) Levofloxacin D5W levofloxacin in d5w (injection) Moxeza MOXEZA (OPHTHALMIC SOLUTION) $3.60-$7.40 (Tier 2) Moxifloxacin HCl moxifloxacin hcl (400mg tablet) Moxifloxacin HCl MOXIFLOXACIN HCL (400MG/250ML $3.60-$7.40 (Tier 2) INJECTION) Ofloxacin ofloxacin (0.3% ophthalmic solution, 0.3% otic solution, 400mg tablet) Sulfonamides Silver Sulfadiazine silver sulfadiazine (cream) Sodium Sulfacetamide sodium sulfacetamide (10% ophthalmic solution) SSD (CREAM) $3.60-$7.40 (Tier 2) Sulfacetamide Sodium sulfacetamide sodium (ophthalmic ointment) Sulfadiazine sulfadiazine (tablet)

23 For Track Refered Purpose 23 Sulfamethoxazole/Trimethoprim sulfamethoxazole/trimethoprim (200mg-40mg/5ml suspension, 400mg-80mg tablet, 400mg-80mg/5ml injection) Sulfamethoxazole/Trimethoprim DS sulfamethoxazole/trimethoprim ds (tablet) Tetracyclines Demeclocycline HCl demeclocycline hcl (tablet) Doxy 100 doxy 100 (injection) Doxycycline doxycycline (150mg capsule immediate-release, 75mg capsule immediate-release, 25mg/5ml suspension) Doxycycline Hyclate doxycycline hyclate (100mg capsule immediate-release, 50mg capsule immediate-release, 100mg injection, 100mg tablet immediate-release, 20mg tablet immediate-release) Doxycycline Monohydrate doxycycline monohydrate (100mg capsule, 50mg capsule, 100mg tablet, 150mg tablet, 50mg tablet, 75mg tablet) Minocycline HCl minocycline hcl (100mg capsule immediate-release, 50mg capsule immediate-release, 75mg capsule immediaterelease) Tetracycline HCl TETRACYCLINE HCL (CAPSULE) $3.60-$7.40 (Tier 2) Vibramycin VIBRAMYCIN (50MG/5ML SYRUP) $3.60-$7.40 (Tier 2) Anticonvulsants Anticonvulsants, Other Fycompa FYCOMPA (TABLET) $3.60-$7.40 (Tier 2) Levetiracetam levetiracetam (1000mg tablet immediate-release, 250mg tablet immediate-release, 500mg tablet immediate-release, 750mg tablet immediate-release, 100mg/ml oral solution, 500mg/5ml injection) Levetiracetam LEVETIRACETAM (1000MG/100ML INJECTION, 1500MG/100ML INJECTION, 500MG/100ML $3.60-$7.40 (Tier 2) INJECTION) Levetiracetam ER levetiracetam er (tablet extended-release 24 hour) Potiga POTIGA (TABLET) $3.60-$7.40 (Tier 2) QL You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

24 For Track Refered Purpose 24 Calcium Channel Modifying Agents Celontin CELONTIN (CAPSULE) $3.60-$7.40 (Tier 2) Ethosuximide ethosuximide (250mg capsule, 250mg/5ml oral solution) Zonisamide zonisamide (capsule) Gamma-aminobutyric Acid (GABA) Augmenting Agents Diastat AcuDial DIASTAT ACUDIAL (GEL) $3.60-$7.40 (Tier 2) Diastat Pediatric DIASTAT PEDIATRIC (GEL) $3.60-$7.40 (Tier 2) Diazepam DIAZEPAM (10MG GEL, 2.5MG GEL, 20MG GEL) $3.60-$7.40 (Tier 2) Divalproex Sodium divalproex sodium (capsule sprinkle delayed-release) Divalproex Sodium DR divalproex sodium dr (tablet delayed-release) Divalproex Sodium ER divalproex sodium er (tablet extended-release 24 hour) Gabapentin gabapentin (100mg capsule, 300mg capsule, 400mg capsule, 250mg/5ml oral solution, 600mg tablet, 800mg tablet) Gabitril GABITRIL (12MG TABLET, 16MG TABLET) $3.60-$7.40 (Tier 2) QL Onfi ONFI (10MG TABLET, 20MG TABLET) $3.60-$7.40 (Tier 2) QL Onfi ONFI (2.5MG/ML SUSPENSION) $3.60-$7.40 (Tier 2) Phenobarbital phenobarbital (100mg tablet, 15mg tablet, 16.2mg tablet, 30mg tablet, 32.4mg tablet, 60mg tablet, 64.8mg tablet, 97.2mg tablet, 20mg/5ml elixir) Primidone primidone (tablet) Sabril SABRIL (500MG PACKET, 500MG TABLET) $3.60-$7.40 (Tier 2) PA, QL, LA Tiagabine HCl tiagabine hcl (tablet) Valproate Sodium valproate sodium (100mg/ml injection) Valproic Acid valproic acid (250mg capsule, 250mg/5ml syrup) Glutamate Reducing Agents Felbamate felbamate (400mg tablet, 600mg tablet, 600mg/5ml suspension) Felbatol FELBATOL (600MG/5ML SUSPENSION) $3.60-$7.40 (Tier 2) Lamotrigine lamotrigine (100mg tablet immediate-release, 150mg tablet immediate-release, 200mg tablet immediate-release, 25mg tablet immediate-release, 25mg tablet chewable, 5mg tablet chewable) Topiramate topiramate (100mg tablet immediate-release, 200mg tablet immediate-release, 25mg tablet immediate-release, 50mg tablet immediate-release, 15mg capsule sprinkle immediaterelease, 25mg capsule sprinkle immediate-release) Sodium Channel Agents

25 For Track Refered Purpose 25 Aptiom APTIOM (TABLET) $3.60-$7.40 (Tier 2) QL Banzel BANZEL (200MG TABLET, 400MG TABLET, 40MG/ML SUSPENSION) Carbamazepine carbamazepine (100mg tablet chewable, 100mg/5ml suspension, 200mg tablet immediate-release) Carbamazepine ER carbamazepine er (capsule extended-release 12 hour, tablet extended-release 12 hour) $3.60-$7.40 (Tier 2) Dilantin dilantin (capsule) Dilantin INFATABS dilantin infatabs (tablet chewable) Epitol epitol (tablet) Fosphenytoin Sodium fosphenytoin sodium (injection) Oxcarbazepine oxcarbazepine (150mg tablet, 300mg tablet, 600mg tablet, 300mg/5ml suspension) Peganone PEGANONE (TABLET) $3.60-$7.40 (Tier 2) Phenytek phenytek (capsule) Phenytoin phenytoin (125mg/5ml suspension, 50mg tablet chewable) Phenytoin Sodium phenytoin sodium (injection) Phenytoin Sodium Extended phenytoin sodium extended (capsule) Tegretol-XR TEGRETOL-XR (100MG TABLET EXTENDED- RELEASE 12 HOUR) $3.60-$7.40 (Tier 2) Vimpat VIMPAT (100MG TABLET, 150MG TABLET, 200MG TABLET, 50MG TABLET, 10MG/ML $3.60-$7.40 (Tier 2) QL ORAL SOLUTION) Vimpat VIMPAT (200MG/20ML INJECTION) $3.60-$7.40 (Tier 2) PA Antidementia Agents Cholinesterase Inhibitors Donepezil HCl donepezil hcl (10mg tablet dispersible, 5mg tablet dispersible, 10mg tablet immediate-release, 5mg tablet immediate-release) QL You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

26 For Track Refered Purpose 26 Exelon EXELON (13.3MG/24HR PATCH 24 HOUR, 4.6MG/24HR PATCH 24 HOUR, 9.5MG/24HR $3.60-$7.40 (Tier 2) QL, ST PATCH 24 HOUR) Rivastigmine Tartrate rivastigmine tartrate (capsule immediate-release) QL Rivastigmine Transdermal System rivastigmine transdermal system (patch 24 hour) QL, ST N-methyl-D-aspartate (NMDA) Receptor Antagonist Memantine HCl memantine hcl (10mg tablet, 5mg tablet, 2mg/ml oral solution) PA, QL Memantine HCl Titration Pak MEMANTINE HCL TITRATION PAK (TABLET) $3.60-$7.40 (Tier 2) PA Namenda NAMENDA (10MG/5ML ORAL SOLUTION) $3.60-$7.40 (Tier 2) PA, QL Namenda XR NAMENDA XR (CAPSULE EXTENDED-RELEASE 24 HOUR) $3.60-$7.40 (Tier 2) PA, QL Namenda XR Titration Pack NAMENDA XR TITRATION PACK (CAPSULE EXTENDED-RELEASE 24 HOUR) $3.60-$7.40 (Tier 2) PA, QL Antidepressants Antidepressants, Other Bupropion HCl bupropion hcl (tablet immediate-release) Bupropion HCl SR bupropion hcl sr (tablet extended-release 12 hour) Bupropion HCl XL bupropion hcl xl (tablet extended-release 24 hour) Mirtazapine mirtazapine (tablet immediate-release) Mirtazapine ODT mirtazapine odt (tablet dispersible) Monoamine Oxidase Inhibitors Emsam EMSAM (PATCH 24 HOUR) $3.60-$7.40 (Tier 2) QL Marplan MARPLAN (TABLET) $3.60-$7.40 (Tier 2) Phenelzine Sulfate phenelzine sulfate (tablet) Tranylcypromine Sulfate tranylcypromine sulfate (tablet) SSRI/SNRI (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors) Brintellix BRINTELLIX (TABLET) $3.60-$7.40 (Tier 2) QL Citalopram HBr citalopram hbr (10mg tablet, 20mg tablet, 40mg tablet, 10mg/5ml oral solution) Escitalopram Oxalate escitalopram oxalate (10mg tablet, 20mg tablet, 5mg tablet, 5mg/5ml oral solution) Fetzima FETZIMA (CAPSULE EXTENDED-RELEASE 24 HOUR) $3.60-$7.40 (Tier 2) QL, ST

27 For Track Refered Purpose 27 Fetzima Titration Pack FETZIMA TITRATION PACK (CAPSULE EXTENDED-RELEASE 24 HOUR THERAPY PACK) $3.60-$7.40 (Tier 2) ST Fluoxetine DR fluoxetine dr (capsule delayed-release) Fluoxetine HCl fluoxetine hcl (10mg capsule immediate-release, 20mg capsule immediate-release, 40mg capsule immediaterelease, 20mg/5ml oral solution) Fluvoxamine Maleate fluvoxamine maleate (tablet) Maprotiline HCl maprotiline hcl (tablet) Nefazodone HCl nefazodone hcl (tablet) Paroxetine HCl paroxetine hcl (tablet immediate-release) Paxil PAXIL (10MG/5ML SUSPENSION) $3.60-$7.40 (Tier 2) Pristiq PRISTIQ (TABLET EXTENDED-RELEASE 24 HOUR) $3.60-$7.40 (Tier 2) QL Sertraline HCl sertraline hcl (100mg tablet, 25mg tablet, 50mg tablet, 20mg/ml concentrate) Trazodone HCl trazodone hcl (tablet) Venlafaxine HCl venlafaxine hcl (tablet immediate-release) Venlafaxine HCl ER venlafaxine hcl er (150mg capsule extended-release 24 hour, 37.5mg capsule extended-release 24 hour, 75mg capsule extended-release 24 hour) Viibryd VIIBRYD (TABLET) $3.60-$7.40 (Tier 2) QL Viibryd Starter Pack VIIBRYD STARTER PACK (KIT) $3.60-$7.40 (Tier 2) QL Tricyclics Amitriptyline HCl amitriptyline hcl (tablet) Amoxapine amoxapine (tablet) Clomipramine HCl clomipramine hcl (capsule) Desipramine HCl desipramine hcl (tablet) Doxepin HCl doxepin hcl (100mg capsule, 10mg capsule, 150mg capsule, 25mg capsule, 50mg capsule, 75mg capsule, 10mg/ml concentrate) Imipramine HCl imipramine hcl (tablet) You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

28 For Track Refered Purpose 28 Imipramine Pamoate imipramine pamoate (capsule) Nortriptyline HCl nortriptyline hcl (10mg capsule, 25mg capsule, 50mg capsule, 75mg capsule, 10mg/5ml oral solution) Protriptyline HCl protriptyline hcl (tablet) Surmontil SURMONTIL (CAPSULE) $3.60-$7.40 (Tier 2) Trimipramine Maleate trimipramine maleate (capsule) Antiemetics Antiemetics, Other Anti-Nausea anti-nausea (oral solution)* Compro compro (suppository) Dimenhydrinate dimenhydrinate (tablet)* Driminate driminate (tablet)* Formula EM formula em (oral solution)* HM Anti-Nausea hm anti-nausea (oral solution)* HM Motion Sickness Relief hm motion sickness relief (tablet)* Hydroxyzine Pamoate hydroxyzine pamoate (capsule) Meclizine HCl meclizine hcl (otc only) (tablet chewable)* Meclizine HCl meclizine hcl (rx only) (tablet immediate-release) Metoclopramide HCl metoclopramide hcl (10mg tablet immediate-release, 5mg tablet immediate-release, 5mg/5ml oral solution, 5mg/ml injection) Motion Sickness motion sickness (tablet)* Motion-Time motion-time (tablet chewable)* Perphenazine perphenazine (tablet) Prochlorperazine prochlorperazine (suppository) Prochlorperazine Edisylate prochlorperazine edisylate (injection) Prochlorperazine Maleate prochlorperazine maleate (tablet) Transderm-Scop TRANSDERM-SCOP (PATCH 72 HOUR) $3.60-$7.40 (Tier 2) Travel Sickness travel sickness (25mg tablet chewable, 50mg tablet)* Emetogenic Therapy Adjuncts Aloxi ALOXI (INJECTION) $3.60-$7.40 (Tier 2) Anzemet ANZEMET (100MG TABLET, 50MG TABLET) $3.60-$7.40 (Tier 2) B/D, PA Cesamet CESAMET (CAPSULE) $3.60-$7.40 (Tier 2) PA Dronabinol dronabinol (capsule) PA, QL Emend EMEND (CAPSULE, PACK) $3.60-$7.40 (Tier 2) PA Emend EMEND (150MG INJECTION) $3.60-$7.40 (Tier 2) Granisetron HCl granisetron hcl (0.1mg/ml injection, 1mg/ml injection)

29 For Track Refered Purpose 29 Granisetron HCl granisetron hcl (1mg tablet) B/D, PA, QL Ondansetron HCl ondansetron hcl (24mg tablet immediate-release, 4mg tablet immediate-release, 8mg tablet immediate-release, B/D, PA 4mg/5ml oral solution) Ondansetron HCl ondansetron hcl (4mg/2ml injection) Ondansetron ODT ondansetron odt (tablet dispersible) B/D, PA Sancuso SANCUSO (PATCH) $3.60-$7.40 (Tier 2) Antifungals Antifungals Day Vaginal 3 day vaginal (cream)* Abelcet ABELCET (INJECTION) $3.60-$7.40 (Tier 2) B/D, PA Alevazol alevazol (ointment)* AmBisome AMBISOME (INJECTION) $3.60-$7.40 (Tier 2) B/D, PA Amphotericin B amphotericin b (injection) B/D, PA Ancobon ANCOBON (CAPSULE) $3.60-$7.40 (Tier 2) Antifungal antifungal (cream)* Anti-Fungal Powder anti-fungal powder* Athletes Foot AF Cream athletes foot af cream* Baza Antifungal baza antifungal (cream)* Cancidas CANCIDAS (INJECTION) $3.60-$7.40 (Tier 2) Carrington Antifungal carrington antifungal (cream)* Ciclopirox ciclopirox (0.77% gel, 0.77% suspension, 1% shampoo) Ciclopirox Nail Lacquer ciclopirox nail lacquer (external solution) Ciclopirox Olamine ciclopirox olamine (cream) Clotrimazole clotrimazole (otc only) (cream)* Clotrimazole clotrimazole (rx only) (1% cream, 1% external solution, 10mg troche) Critic-Aid Clear AF critic-aid clear af (ointment)* Desenex Shake Powder desenex shake powder* Econazole Nitrate econazole nitrate (cream) You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

30 For Track Refered Purpose 30 Eraxis ERAXIS (INJECTION) $3.60-$7.40 (Tier 2) Fluconazole fluconazole (100mg tablet, 150mg tablet, 200mg tablet, 50mg tablet, 10mg/ml suspension, 40mg/ml suspension) Fluconazole in Dextrose fluconazole in dextrose (injection) Fluconazole in NaCl fluconazole in nacl (injection) Flucytosine flucytosine (capsule) Fungoid Tincture fungoid tincture (external solution)* Fungoid-D fungoid-d (cream)* GNP Clotrimazole 3 gnp clotrimazole 3 (otc only) (cream)* GNP Miconazole 1 gnp miconazole 1 (otc only) (kit)* GNP Miconazole 3 gnp miconazole 3 (otc only) (kit)* GNP Miconazorb AF gnp miconazorb af (powder)* GNP Terbinafine HCl gnp terbinafine hcl (otc only) (cream)* GNP Tioconazole 1 gnp tioconazole 1 (ointment)* GNP Tolnaftate gnp tolnaftate (cream)* Griseofulvin Microsize griseofulvin microsize (125mg/5ml suspension, 500mg tablet) Griseofulvin Ultramicrosize griseofulvin ultramicrosize (tablet) Itraconazole itraconazole (capsule) PA, QL Jock Itch Spray jock itch spray (aerosol powder)* Ketoconazole ketoconazole (2% cream, 2% foam, 2% shampoo, 200mg tablet) Lamisil LAMISIL (RX ONLY) (125MG PACKET, 187.5MG PACKET) $3.60-$7.40 (Tier 2) Lamisil Advanced lamisil advanced (otc only) (gel)* Lamisil AF Defense lamisil af defense (otc only) (aerosol powder)* Lamisil AT lamisil at (otc only) (cream)* Lamisil AT Spray lamisil at spray (otc only) (external solution)* Lotrimin AF lotrimin af (otc only) (powder)* Lotrimin Ultra lotrimin ultra (otc only) (cream)* Mentax MENTAX (CREAM) $3.60-$7.40 (Tier 2) Miconazole miconazole (otc only) (2% cream)* Miconazole 1 miconazole 1 (otc only) (kit)* Miconazole 3 miconazole 3 (rx only) (suppository) Miconazole 3 Combo Pack miconazole 3 combo pack (otc only) (kit)* Miconazole 7 miconazole 7 (otc only) (100mg suppository, 2% cream)* Miconazole Nitrate miconazole nitrate (otc only) (100mg suppository, 2% cream)* Miconazorb AF miconazorb af (powder)*

31 For Track Refered Purpose 31 Micro Guard micro guard (powder)* Mycamine MYCAMINE (INJECTION) $3.60-$7.40 (Tier 2) Natacyn NATACYN (SUSPENSION) $3.60-$7.40 (Tier 2) Noxafil NOXAFIL (100MG TABLET DELAYED-RELEASE) $3.60-$7.40 (Tier 2) PA Noxafil NOXAFIL (40MG/ML SUSPENSION) $3.60-$7.40 (Tier 2) Nyamyc nyamyc (powder) Nystatin nystatin (cream, ointment, powder, suspension, tablet) Nystop nystop (powder) ONMEL (TABLET) $3.60-$7.40 (Tier 2) PA QC 3 Day Vaginal Cream qc 3 day vaginal cream* QC Athletes Foot qc athletes foot (cream)* QC Tolnaftate qc tolnaftate (cream)* Remedy Antifungal remedy antifungal (2% cream, 2% powder)* SM 3-Day Vaginal sm 3-day vaginal (cream)* SM Antifungal Miconazole sm antifungal miconazole (cream)* SM Antifungal Tolnaftate sm antifungal tolnaftate (cream)* SM Athletes Foot sm athletes foot (cream)* SM Clotrimazole Vaginal sm clotrimazole vaginal (otc only) (cream)* SM Miconazole 7 sm miconazole 7 (otc only) (100mg suppository, 2% cream)* SM Tioconazole-1 sm tioconazole-1 (ointment)* Soothe & Cool INZO Antifungal Cream soothe & cool inzo antifungal cream* Sporanox SPORANOX (10MG/ML ORAL SOLUTION) $3.60-$7.40 (Tier 2) PA Terbinafine HCl terbinafine hcl (otc only) (cream)* Terbinafine HCl terbinafine hcl (rx only) (tablet) Terconazole terconazole (0.4% cream, 0.8% cream, 80mg suppository) Tinactin tinactin (aerosol)* Tioconazole-1 tioconazole-1 (ointment)* Tolnaftate tolnaftate (1% cream, 1% external solution, 1% powder)* Vagistat-1 vagistat-1 (ointment)* You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

32 For Track Refered Purpose 32 Vagistat-3 vagistat-3 (kit)* Vfend VFEND (200MG TABLET, 50MG TABLET, 40MG/ $3.60-$7.40 (Tier 2) ML SUSPENSION) Voriconazole voriconazole (200mg injection, 200mg tablet, 50mg tablet, 40mg/ml suspension) Zazole zazole (0.4% cream) Zazole ZAZOLE (0.8% CREAM) $3.60-$7.40 (Tier 2) Zeasorb-AF zeasorb-af (powder)* Antigout Agents Antigout Agents Allopurinol allopurinol (tablet) Colchicine COLCHICINE (0.6MG TABLET) (GENERIC COLCRYS) $3.60-$7.40 (Tier 2) QL Colcrys COLCRYS (TABLET) $3.60-$7.40 (Tier 2) QL Probenecid probenecid (tablet) Probenecid/Colchicine probenecid/colchicine (tablet) Uloric ULORIC (TABLET) $3.60-$7.40 (Tier 2) ST Antimigraine Agents Ergot Alkaloids Dihydroergotamine Mesylate dihydroergotamine mesylate (1mg/ml injection) Migergot migergot (suppository) Serotonin (5-HT) 1b/1d Receptor Agonists Naratriptan HCl naratriptan hcl (tablet) QL Rizatriptan Benzoate rizatriptan benzoate (tablet immediate-release) QL Rizatriptan Benzoate ODT rizatriptan benzoate odt (tablet dispersible) QL Sumatriptan SUMATRIPTAN (NASAL SOLUTION) $3.60-$7.40 (Tier 2) QL Sumatriptan Succinate sumatriptan succinate (100mg tablet, 25mg tablet, 50mg tablet, 6mg/0.5ml injection) QL Sumatriptan Succinate Refill SUMATRIPTAN SUCCINATE REFILL (4MG/0.5ML INJECTION) $3.60-$7.40 (Tier 2) QL Sumatriptan Succinate Refill sumatriptan succinate refill (6mg/0.5ml injection) QL Sumavel DosePro SUMAVEL DOSEPRO (INJECTION) $3.60-$7.40 (Tier 2) Antimyasthenic Agents Parasympathomimetics Guanidine HCl GUANIDINE HCL (TABLET)

33 For Track Refered Purpose 33 Mestinon MESTINON (60MG/5ML SYRUP) $3.60-$7.40 (Tier 2) Mestinon Timespan MESTINON TIMESPAN (TABLET EXTENDED- RELEASE) Pyridostigmine Bromide pyridostigmine bromide (180mg tablet extended-release, 60mg tablet) Antimycobacterials $3.60-$7.40 (Tier 2) Antimycobacterials, Other Dapsone dapsone (tablet) Rifabutin rifabutin (capsule) Antituberculars Capastat Sulfate CAPASTAT SULFATE (INJECTION) $3.60-$7.40 (Tier 2) Ethambutol HCl ethambutol hcl (tablet) Isoniazid isoniazid (100mg tablet, 300mg tablet, 100mg/ml injection, 50mg/5ml syrup) Paser paser (packet) Priftin PRIFTIN (TABLET) $3.60-$7.40 (Tier 2) Pyrazinamide pyrazinamide (tablet) Rifampin rifampin (150mg capsule, 300mg capsule, 600mg injection) Rifater RIFATER (TABLET) $3.60-$7.40 (Tier 2) Sirturo SIRTURO (TABLET) $3.60-$7.40 (Tier 2) PA Trecator TRECATOR (TABLET) $3.60-$7.40 (Tier 2) Antineoplastics Alkylating Agents BiCNU BICNU (INJECTION) $3.60-$7.40 (Tier 2) Busulfex BUSULFEX (INJECTION) $3.60-$7.40 (Tier 2) Cyclophosphamide CYCLOPHOSPHAMIDE (CAPSULE) $3.60-$7.40 (Tier 2) B/D, PA Dacarbazine dacarbazine (injection) You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

34 For Track Refered Purpose 34 Gleostine GLEOSTINE (CAPSULE) $3.60-$7.40 (Tier 2) Hexalen HEXALEN (CAPSULE) $3.60-$7.40 (Tier 2) PA Ifosfamide ifosfamide (injection) Leukeran LEUKERAN (TABLET) $3.60-$7.40 (Tier 2) Matulane MATULANE (CAPSULE) $3.60-$7.40 (Tier 2) LA Melphalan HCl melphalan hcl (injection) Mustargen MUSTARGEN (INJECTION) $3.60-$7.40 (Tier 2) Treanda TREANDA (INJECTION) $3.60-$7.40 (Tier 2) PA Valchlor VALCHLOR (GEL) $3.60-$7.40 (Tier 2) PA, LA Zanosar ZANOSAR (INJECTION) $3.60-$7.40 (Tier 2) Antiandrogens Bicalutamide bicalutamide (tablet) Flutamide flutamide (capsule) Nilandron NILANDRON (TABLET) $3.60-$7.40 (Tier 2) Xtandi XTANDI (CAPSULE) $3.60-$7.40 (Tier 2) PA, QL Zytiga ZYTIGA (TABLET) $3.60-$7.40 (Tier 2) PA, QL Antiangiogenic Agents Pomalyst POMALYST (CAPSULE) $3.60-$7.40 (Tier 2) PA Revlimid REVLIMID (CAPSULE) $3.60-$7.40 (Tier 2) PA, LA Thalomid THALOMID (CAPSULE) $3.60-$7.40 (Tier 2) PA Antiestrogens/Modifiers Emcyt EMCYT (CAPSULE) $3.60-$7.40 (Tier 2) Fareston FARESTON (TABLET) $3.60-$7.40 (Tier 2) Faslodex FASLODEX (INJECTION) $3.60-$7.40 (Tier 2) Soltamox SOLTAMOX (ORAL SOLUTION) $3.60-$7.40 (Tier 2) Tamoxifen Citrate tamoxifen citrate (tablet) Antimetabolites Adrucil adrucil (injection) B/D, PA Alimta ALIMTA (INJECTION) $3.60-$7.40 (Tier 2) PA Cladribine cladribine (injection) B/D, PA Clolar CLOLAR (INJECTION) $3.60-$7.40 (Tier 2) Cytarabine Aqueous cytarabine aqueous (injection) B/D, PA Droxia DROXIA (CAPSULE) $3.60-$7.40 (Tier 2) Elitek ELITEK (INJECTION) $3.60-$7.40 (Tier 2) Fluorouracil fluorouracil (2.5gm/50ml injection) B/D, PA

35 For Track Refered Purpose 35 Folotyn FOLOTYN (INJECTION) $3.60-$7.40 (Tier 2) Gemcitabine HCl gemcitabine hcl (injection) Gemzar GEMZAR (INJECTION) $3.60-$7.40 (Tier 2) Hydroxyurea hydroxyurea (capsule) Lonsurf LONSURF (TABLET) $3.60-$7.40 (Tier 2) PA, QL Mercaptopurine mercaptopurine (tablet) Nipent NIPENT (INJECTION) $3.60-$7.40 (Tier 2) Purixan PURIXAN (SUSPENSION) $3.60-$7.40 (Tier 2) PA Tabloid TABLOID (TABLET) $3.60-$7.40 (Tier 2) PA Antineoplastics, Other Abraxane ABRAXANE (INJECTION) $3.60-$7.40 (Tier 2) PA Alecensa ALECENSA (CAPSULE) $3.60-$7.40 (Tier 2) PA, QL Amifostine amifostine (injection) Arranon ARRANON (INJECTION) $3.60-$7.40 (Tier 2) Azacitidine azacitidine (injection) PA Beleodaq BELEODAQ (INJECTION) $3.60-$7.40 (Tier 2) PA Bleomycin Sulfate bleomycin sulfate (injection) B/D, PA Carboplatin carboplatin (injection) Cisplatin cisplatin (injection) Cosmegen COSMEGEN (INJECTION) $3.60-$7.40 (Tier 2) Dacogen DACOGEN (INJECTION) $3.60-$7.40 (Tier 2) Daunorubicin HCl daunorubicin hcl (injection) DaunoXome DAUNOXOME (INJECTION) $3.60-$7.40 (Tier 2) Decitabine decitabine (injection) Dexrazoxane dexrazoxane (injection) PA Docefrez DOCEFREZ (INJECTION) $3.60-$7.40 (Tier 2) Docetaxel docetaxel (80mg/4ml injection) Docetaxel DOCETAXEL (80MG/8ML INJECTION) $3.60-$7.40 (Tier 2) Doxil DOXIL (INJECTION) $3.60-$7.40 (Tier 2) You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

36 For Track Refered Purpose 36 Doxorubicin HCl doxorubicin hcl (injection) B/D, PA Epirubicin HCl epirubicin hcl (injection) Erwinaze ERWINAZE (INJECTION) $3.60-$7.40 (Tier 2) Farydak FARYDAK (CAPSULE) $3.60-$7.40 (Tier 2) PA Fludarabine Phosphate fludarabine phosphate (injection) Fusilev FUSILEV (INJECTION) $3.60-$7.40 (Tier 2) Halaven HALAVEN (INJECTION) $3.60-$7.40 (Tier 2) PA Ibrance IBRANCE (CAPSULE) $3.60-$7.40 (Tier 2) PA, QL Idarubicin HCl idarubicin hcl (injection) Irinotecan irinotecan (injection) Istodax ISTODAX (INJECTION) $3.60-$7.40 (Tier 2) PA Ixempra Kit IXEMPRA KIT (INJECTION) $3.60-$7.40 (Tier 2) Jevtana JEVTANA (INJECTION) $3.60-$7.40 (Tier 2) PA Leucovorin Calcium leucovorin calcium (100mg injection, 350mg injection, 10mg tablet, 15mg tablet, 25mg tablet, 5mg tablet) Levoleucovorin Calcium levoleucovorin calcium (injection) Lynparza LYNPARZA (CAPSULE) $3.60-$7.40 (Tier 2) PA, QL Mesna mesna (injection) Mesnex MESNEX (400MG TABLET) $3.60-$7.40 (Tier 2) Mitomycin mitomycin (injection) Mitoxantrone HCl mitoxantrone hcl (injection) Ninlaro NINLARO (CAPSULE) $3.60-$7.40 (Tier 2) PA, QL Oncaspar ONCASPAR (INJECTION) $3.60-$7.40 (Tier 2) Oxaliplatin oxaliplatin (injection) Paclitaxel paclitaxel (injection) Proleukin PROLEUKIN (INJECTION) $3.60-$7.40 (Tier 2) PA Synribo SYNRIBO (INJECTION) $3.60-$7.40 (Tier 2) PA Taxotere TAXOTERE (INJECTION) $3.60-$7.40 (Tier 2) Thiotepa thiotepa (injection) Trisenox TRISENOX (INJECTION) $3.60-$7.40 (Tier 2) Velcade VELCADE (INJECTION) $3.60-$7.40 (Tier 2) PA Vidaza VIDAZA (INJECTION) $3.60-$7.40 (Tier 2) PA Vinblastine Sulfate vinblastine sulfate (injection) B/D, PA Vincasar PFS vincasar pfs (injection) B/D, PA Vincristine Sulfate vincristine sulfate (injection) B/D, PA Vinorelbine Tartrate vinorelbine tartrate (injection) Zaltrap ZALTRAP (INJECTION) $3.60-$7.40 (Tier 2) PA Zolinza ZOLINZA (CAPSULE) $3.60-$7.40 (Tier 2) PA

37 For Track Refered Purpose 37 Zydelig ZYDELIG (TABLET) $3.60-$7.40 (Tier 2) PA, QL Zykadia ZYKADIA (CAPSULE) $3.60-$7.40 (Tier 2) PA, QL Aromatase Inhibitors, 3rd Generation Anastrozole anastrozole (tablet) Exemestane exemestane (tablet) Letrozole letrozole (tablet) Enzyme Inhibitors Etopophos ETOPOPHOS (INJECTION) $3.60-$7.40 (Tier 2) Etoposide etoposide (injection) Hycamtin HYCAMTIN (INJECTION) $3.60-$7.40 (Tier 2) Toposar toposar (injection) Topotecan HCl topotecan hcl (injection) Molecular Target Inhibitors Afinitor AFINITOR (TABLET) $3.60-$7.40 (Tier 2) PA Afinitor Disperz AFINITOR DISPERZ (TABLET SOLUBLE) $3.60-$7.40 (Tier 2) PA Bosulif BOSULIF (TABLET) $3.60-$7.40 (Tier 2) PA Caprelsa CAPRELSA (TABLET) $3.60-$7.40 (Tier 2) PA, LA Cometriq COMETRIQ (KIT) $3.60-$7.40 (Tier 2) PA Cotellic COTELLIC (TABLET) $3.60-$7.40 (Tier 2) PA, QL, LA Erivedge ERIVEDGE (CAPSULE) $3.60-$7.40 (Tier 2) PA Gilotrif GILOTRIF (TABLET) $3.60-$7.40 (Tier 2) PA Iclusig ICLUSIG (15MG TABLET) $3.60-$7.40 (Tier 2) PA, LA Iclusig ICLUSIG (45MG TABLET) $3.60-$7.40 (Tier 2) PA Imatinib Mesylate imatinib mesylate (tablet) PA Imbruvica IMBRUVICA (CAPSULE) $3.60-$7.40 (Tier 2) PA Inlyta INLYTA (TABLET) $3.60-$7.40 (Tier 2) PA Iressa IRESSA (TABLET) $3.60-$7.40 (Tier 2) PA, QL Jakafi JAKAFI (TABLET) $3.60-$7.40 (Tier 2) PA, LA You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

38 For Track Refered Purpose 38 Lenvima LENVIMA (CAPSULE THERAPY PACK) $3.60-$7.40 (Tier 2) PA Mekinist MEKINIST (TABLET) $3.60-$7.40 (Tier 2) PA Nexavar NEXAVAR (TABLET) $3.60-$7.40 (Tier 2) PA Odomzo ODOMZO (CAPSULE) $3.60-$7.40 (Tier 2) PA, QL, LA Sprycel SPRYCEL (TABLET) $3.60-$7.40 (Tier 2) PA Stivarga STIVARGA (TABLET) $3.60-$7.40 (Tier 2) PA Sutent SUTENT (CAPSULE) $3.60-$7.40 (Tier 2) PA Tafinlar TAFINLAR (CAPSULE) $3.60-$7.40 (Tier 2) PA Tarceva TARCEVA (TABLET) $3.60-$7.40 (Tier 2) PA Tasigna TASIGNA (CAPSULE) $3.60-$7.40 (Tier 2) PA Tykerb TYKERB (TABLET) $3.60-$7.40 (Tier 2) PA Votrient VOTRIENT (TABLET) $3.60-$7.40 (Tier 2) PA Xalkori XALKORI (CAPSULE) $3.60-$7.40 (Tier 2) PA, LA Zelboraf ZELBORAF (TABLET) $3.60-$7.40 (Tier 2) PA Monoclonal Antibodies Avastin AVASTIN (INJECTION) $3.60-$7.40 (Tier 2) PA Cyramza CYRAMZA (INJECTION) $3.60-$7.40 (Tier 2) PA Darzalex DARZALEX (INJECTION) $3.60-$7.40 (Tier 2) PA, LA Empliciti EMPLICITI (INJECTION) $3.60-$7.40 (Tier 2) PA Erbitux ERBITUX (INJECTION) $3.60-$7.40 (Tier 2) PA Herceptin HERCEPTIN (INJECTION) $3.60-$7.40 (Tier 2) PA Kadcyla KADCYLA (INJECTION) $3.60-$7.40 (Tier 2) PA Keytruda KEYTRUDA (INJECTION) $3.60-$7.40 (Tier 2) PA Opdivo OPDIVO (INJECTION) $3.60-$7.40 (Tier 2) PA Perjeta PERJETA (INJECTION) $3.60-$7.40 (Tier 2) PA Rituxan RITUXAN (INJECTION) $3.60-$7.40 (Tier 2) PA Sylvant SYLVANT (INJECTION) $3.60-$7.40 (Tier 2) PA Tagrisso TAGRISSO (TABLET) $3.60-$7.40 (Tier 2) PA, QL, LA Vectibix VECTIBIX (INJECTION) $3.60-$7.40 (Tier 2) PA Yervoy YERVOY (INJECTION) $3.60-$7.40 (Tier 2) PA Retinoids Bexarotene bexarotene (capsule) PA Panretin PANRETIN (GEL) $3.60-$7.40 (Tier 2) PA Targretin TARGRETIN (1% GEL, 75MG CAPSULE) $3.60-$7.40 (Tier 2) PA Tretinoin tretinoin (10mg capsule) Antiparasitics

39 For Track Refered Purpose 39 Anthelmintics Albenza ALBENZA (TABLET) $3.60-$7.40 (Tier 2) Biltricide BILTRICIDE (TABLET) $3.60-$7.40 (Tier 2) Ivermectin ivermectin (tablet) Reeses Pinworm Medicine reeses pinworm medicine (suspension)* Antiprotozoals Alinia ALINIA (100MG/5ML SUSPENSION, 500MG TABLET) $3.60-$7.40 (Tier 2) Atovaquone atovaquone (suspension) Atovaquone/Proguanil HCl atovaquone/proguanil hcl (tablet) (generic malarone) Chloroquine Phosphate chloroquine phosphate (tablet) Coartem COARTEM (TABLET) $3.60-$7.40 (Tier 2) DARAPRIM (TABLET) $3.60-$7.40 (Tier 2) Hydroxychloroquine Sulfate hydroxychloroquine sulfate (tablet) Mefloquine HCl mefloquine hcl (tablet) Mepron MEPRON (SUSPENSION) $3.60-$7.40 (Tier 2) Nebupent NEBUPENT (INHALATION SOLUTION) $3.60-$7.40 (Tier 2) B/D, PA Pentam 300 PENTAM 300 (INJECTION) $3.60-$7.40 (Tier 2) Primaquine Phosphate primaquine phosphate (tablet) Quinine Sulfate quinine sulfate (capsule) PA Pediculicides/Scabicides Complete Lice Treatment Kit complete lice treatment kit* GNP Lice Solution Kit gnp lice solution kit* GNP Lice Treatment gnp lice treatment (liquid)* HM Lice Killing Maximum Strength hm lice killing maximum strength (shampoo)* HM Lice Treatment hm lice treatment (lotion)* Lice Killing Maximum Strength lice killing maximum strength (shampoo)* Lice Treatment Creme Rinse lice treatment creme rinse (liquid)* You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

40 For Track Refered Purpose 40 Lindane lindane (1% lotion, 1% shampoo) Malathion malathion (lotion) Permethrin permethrin (otc only) (lotion)* Permethrin permethrin (rx only) (cream) SB Lice Killing Maximum Strength sb lice killing maximum strength (shampoo)* SM Lice Killing Maximum Strength sm lice killing maximum strength (shampoo)* SM Lice Treatment sm lice treatment (lotion)* Antiparkinson Agents Anticholinergics Benztropine Mesylate benztropine mesylate (0.5mg tablet, 1mg tablet, 2mg tablet, 1mg/ml injection) Trihexyphenidyl HCl trihexyphenidyl hcl (0.4mg/ml elixir, 2mg tablet, 5mg tablet) Antiparkinson Agents, Other Amantadine HCl amantadine hcl (100mg capsule, 100mg tablet, 50mg/5ml syrup) Entacapone entacapone (tablet) Tolcapone tolcapone (tablet) Dopamine Agonists Apokyn APOKYN (INJECTION) $3.60-$7.40 (Tier 2) PA Bromocriptine Mesylate bromocriptine mesylate (2.5mg tablet, 5mg capsule) Pramipexole Dihydrochloride pramipexole dihydrochloride (tablet immediate-release) Ropinirole HCl ropinirole hcl (tablet immediate-release) Dopamine Precursors/L-Amino Acid Decarboxylase Inhibitors Carbidopa/Levodopa carbidopa/levodopa (tablet immediate-release) Carbidopa/Levodopa ER carbidopa/levodopa er (tablet extended-release) Carbidopa/Levodopa ODT carbidopa/levodopa odt (tablet dispersible) Monoamine Oxidase B (MAO-B) Inhibitors Azilect AZILECT (TABLET) $3.60-$7.40 (Tier 2) Selegiline HCl selegiline hcl (5mg capsule, 5mg tablet) Zelapar ZELAPAR (TABLET DISPERSIBLE) $3.60-$7.40 (Tier 2) Antipsychotics 1st Generation/Typical Chlorpromazine HCl chlorpromazine hcl (100mg tablet, 10mg tablet, 200mg tablet, 25mg tablet, 50mg tablet, 50mg/2ml injection)

41 For Track Refered Purpose 41 Fluphenazine Decanoate fluphenazine decanoate (injection) Fluphenazine HCl fluphenazine hcl (10mg tablet, 1mg tablet, 2.5mg tablet, 5mg tablet, 2.5mg/5ml elixir, 2.5mg/ml injection, 5mg/ml concentrate) Haloperidol haloperidol (0.5mg tablet, 10mg tablet, 1mg tablet, 20mg tablet, 2mg tablet, 5mg tablet, 2mg/ml concentrate) Haloperidol Decanoate haloperidol decanoate (injection) Haloperidol Lactate haloperidol lactate (injection) Loxapine Succinate loxapine succinate (10mg capsule, 5mg capsule) QL Loxapine Succinate loxapine succinate (25mg capsule, 50mg capsule) Molindone HCl molindone hcl (tablet) Orap ORAP (TABLET) $3.60-$7.40 (Tier 2) Pimozide pimozide (tablet) Thioridazine HCl thioridazine hcl (tablet) Thiothixene thiothixene (capsule) Trifluoperazine HCl trifluoperazine hcl (tablet) 2nd Generation/Atypical Abilify Maintena ABILIFY MAINTENA (INJECTION) $3.60-$7.40 (Tier 2) Aripiprazole aripiprazole (tablet) QL Aripiprazole ODT aripiprazole odt (tablet dispersible) QL Fanapt FANAPT (TABLET) $3.60-$7.40 (Tier 2) QL, ST Fanapt Titration Pack FANAPT TITRATION PACK (TABLET) $3.60-$7.40 (Tier 2) ST Geodon GEODON (20MG INJECTION) $3.60-$7.40 (Tier 2) Invega INVEGA (TABLET EXTENDED-RELEASE 24 HOUR) $3.60-$7.40 (Tier 2) QL Invega Sustenna INVEGA SUSTENNA (INJECTION) $3.60-$7.40 (Tier 2) Invega Trinza INVEGA TRINZA (INJECTION) $3.60-$7.40 (Tier 2) PA Latuda LATUDA (TABLET) $3.60-$7.40 (Tier 2) QL Olanzapine olanzapine (10mg injection) You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

42 For Track Refered Purpose 42 Olanzapine olanzapine (10mg tablet immediate-release, 15mg tablet immediate-release, 2.5mg tablet immediate-release, 20mg tablet immediate-release, 5mg tablet immediate-release, QL 7.5mg tablet immediate-release) Olanzapine ODT olanzapine odt (tablet dispersible) QL Paliperidone ER paliperidone er (tablet extended-release 24 hour) QL Quetiapine Fumarate quetiapine fumarate (tablet immediate-release) QL Rexulti REXULTI (TABLET) $3.60-$7.40 (Tier 2) QL Risperdal Consta RISPERDAL CONSTA (INJECTION) $3.60-$7.40 (Tier 2) Risperidone risperidone (0.25mg tablet, 0.5mg tablet, 1mg tablet, 2mg tablet, 3mg tablet, 4mg tablet, 1mg/ml oral solution) Risperidone ODT risperidone odt (tablet dispersible) Saphris SAPHRIS (TABLET SUBLINGUAL) $3.60-$7.40 (Tier 2) QL Seroquel XR SEROQUEL XR (TABLET EXTENDED-RELEASE 24 HOUR) $3.60-$7.40 (Tier 2) QL Vraylar VRAYLAR (1.5MG CAPSULE, 3MG CAPSULE, 4.5MG CAPSULE, 6MG CAPSULE) $3.60-$7.40 (Tier 2) QL, ST Vraylar VRAYLAR (1.5-3MG CAPSULE THERAPY PACK) $3.60-$7.40 (Tier 2) ST Ziprasidone HCl ziprasidone hcl (capsule) QL Zyprexa Relprevv ZYPREXA RELPREVV (INJECTION) $3.60-$7.40 (Tier 2) Treatment-Resistant Clozapine clozapine (tablet immediate-release) Clozapine ODT CLOZAPINE ODT (TABLET DISPERSIBLE) $3.60-$7.40 (Tier 2) QL Fazaclo FAZACLO (100MG TABLET DISPERSIBLE) $3.60-$7.40 (Tier 2) QL Versacloz VERSACLOZ (SUSPENSION) $3.60-$7.40 (Tier 2) Antivirals Anti-cytomegalovirus (CMV) Agents Cidofovir cidofovir (injection) Ganciclovir ganciclovir (injection) B/D, PA Valcyte VALCYTE (450MG TABLET, 50MG/ML ORAL SOLUTION) $3.60-$7.40 (Tier 2) Valganciclovir valganciclovir (tablet) Zirgan ZIRGAN (GEL) $3.60-$7.40 (Tier 2) Anti-hepatitis B (HBV) Agents Adefovir Dipivoxil adefovir dipivoxil (tablet) Baraclude BARACLUDE (0.05MG/ML ORAL SOLUTION) $3.60-$7.40 (Tier 2)

43 For Track Refered Purpose 43 Entecavir entecavir (tablet) Epivir HBV EPIVIR HBV (5MG/ML ORAL SOLUTION) $3.60-$7.40 (Tier 2) Hepsera HEPSERA (TABLET) $3.60-$7.40 (Tier 2) Lamivudine lamivudine (100mg tablet) Tyzeka TYZEKA (TABLET) $3.60-$7.40 (Tier 2) Anti-hepatitis C (HCV) Agents Daklinza DAKLINZA (TABLET) $3.60-$7.40 (Tier 2) PA, QL Harvoni HARVONI (TABLET) $3.60-$7.40 (Tier 2) PA, QL Intron A INTRON A (INJECTION) $3.60-$7.40 (Tier 2) PA Intron A w/diluent INTRON A W/DILUENT (INJECTION) $3.60-$7.40 (Tier 2) PA Olysio OLYSIO (CAPSULE) $3.60-$7.40 (Tier 2) PA, QL Pegasys PEGASYS (INJECTION) $3.60-$7.40 (Tier 2) PA Pegasys ProClick PEGASYS PROCLICK (INJECTION) $3.60-$7.40 (Tier 2) PA PegIntron PEGINTRON (INJECTION) $3.60-$7.40 (Tier 2) PA PegIntron Redipen PEGINTRON REDIPEN (INJECTION) $3.60-$7.40 (Tier 2) PA Ribasphere ribasphere (200mg capsule, 200mg tablet, 400mg tablet, 600mg tablet) Ribavirin ribavirin (200mg capsule, 200mg tablet) Sovaldi SOVALDI (TABLET) $3.60-$7.40 (Tier 2) PA, QL Sylatron SYLATRON (INJECTION) $3.60-$7.40 (Tier 2) PA Antiherpetic Agents Acyclovir acyclovir (200mg capsule, 200mg/5ml suspension, 400mg tablet, 800mg tablet) Acyclovir Sodium acyclovir sodium (injection) B/D, PA Famciclovir famciclovir (tablet) QL Trifluridine trifluridine (ophthalmic solution) Valacyclovir HCl valacyclovir hcl (tablet) QL Anti-HIV Agents, Integrase Inhibitors (INSTI) Evotaz EVOTAZ (TABLET) $3.60-$7.40 (Tier 2) QL You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

44 For Track Refered Purpose 44 Genvoya GENVOYA (TABLET) $3.60-$7.40 (Tier 2) QL Isentress ISENTRESS (100MG PACKET, 100MG TABLET CHEWABLE, 25MG TABLET CHEWABLE, 400MG $3.60-$7.40 (Tier 2) QL TABLET) Prezcobix PREZCOBIX (TABLET) $3.60-$7.40 (Tier 2) QL Stribild STRIBILD (TABLET) $3.60-$7.40 (Tier 2) QL Tivicay TIVICAY (TABLET) $3.60-$7.40 (Tier 2) QL Triumeq TRIUMEQ (TABLET) $3.60-$7.40 (Tier 2) QL Tybost TYBOST (TABLET) $3.60-$7.40 (Tier 2) QL Vitekta VITEKTA (TABLET) $3.60-$7.40 (Tier 2) QL Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI) Atripla ATRIPLA (TABLET) $3.60-$7.40 (Tier 2) QL Complera COMPLERA (TABLET) $3.60-$7.40 (Tier 2) QL Edurant EDURANT (TABLET) $3.60-$7.40 (Tier 2) QL Intelence INTELENCE (TABLET) $3.60-$7.40 (Tier 2) QL Nevirapine nevirapine (200mg tablet immediate-release) QL Nevirapine NEVIRAPINE (50MG/5ML SUSPENSION) $3.60-$7.40 (Tier 2) QL Nevirapine ER nevirapine er (tablet extended-release 24 hour) QL Odefsey ODEFSEY (TABLET) $3.60-$7.40 (Tier 2) QL Rescriptor RESCRIPTOR (TABLET) $3.60-$7.40 (Tier 2) QL Sustiva SUSTIVA (200MG CAPSULE, 50MG CAPSULE, 600MG TABLET) $3.60-$7.40 (Tier 2) QL Viramune VIRAMUNE (50MG/5ML SUSPENSION) $3.60-$7.40 (Tier 2) QL Viramune XR VIRAMUNE XR (TABLET EXTENDED-RELEASE 24 HOUR) $3.60-$7.40 (Tier 2) QL Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI) Abacavir abacavir (tablet) QL Abacavir Sulfate/Lamivudine/Zidovudine abacavir sulfate/lamivudine/zidovudine (tablet) QL Combivir COMBIVIR (TABLET) $3.60-$7.40 (Tier 2) QL Didanosine didanosine (capsule delayed-release) QL Emtriva EMTRIVA (10MG/ML ORAL SOLUTION, 200MG CAPSULE) $3.60-$7.40 (Tier 2) QL Epivir EPIVIR (10MG/ML ORAL SOLUTION) $3.60-$7.40 (Tier 2) QL Epzicom EPZICOM (TABLET) $3.60-$7.40 (Tier 2) QL Lamivudine lamivudine (10mg/ml oral solution, 150mg tablet, 300mg tablet) QL Lamivudine/Zidovudine lamivudine/zidovudine (tablet) QL

45 For Track Refered Purpose 45 Retrovir IV Infusion RETROVIR IV INFUSION (INJECTION) $3.60-$7.40 (Tier 2) Stavudine stavudine (15mg capsule, 20mg capsule, 30mg capsule, 40mg capsule, 1mg/ml oral solution) QL Trizivir TRIZIVIR (TABLET) $3.60-$7.40 (Tier 2) QL Truvada TRUVADA (TABLET) $3.60-$7.40 (Tier 2) QL Videx Pediatric VIDEX PEDIATRIC (ORAL SOLUTION) $3.60-$7.40 (Tier 2) QL Viread VIREAD (150MG TABLET, 200MG TABLET, 250MG TABLET, 300MG TABLET, 40MG/GM $3.60-$7.40 (Tier 2) QL POWDER) Ziagen ZIAGEN (20MG/ML ORAL SOLUTION) $3.60-$7.40 (Tier 2) QL Zidovudine zidovudine (100mg capsule, 300mg tablet, 50mg/5ml syrup) QL Anti-HIV Agents, Other Fuzeon FUZEON (INJECTION) $3.60-$7.40 (Tier 2) QL Selzentry SELZENTRY (TABLET) $3.60-$7.40 (Tier 2) QL Anti-HIV Agents, Protease Inhibitors Aptivus APTIVUS (100MG/ML ORAL SOLUTION, 250MG CAPSULE) $3.60-$7.40 (Tier 2) QL Crixivan CRIXIVAN (CAPSULE) $3.60-$7.40 (Tier 2) QL Invirase INVIRASE (200MG CAPSULE, 500MG TABLET) $3.60-$7.40 (Tier 2) QL Kaletra KALETRA (100MG-25MG TABLET, 200MG-50MG TABLET, 400MG-100MG/5ML ORAL SOLUTION) $3.60-$7.40 (Tier 2) QL Lexiva LEXIVA (50MG/ML SUSPENSION, 700MG TABLET) $3.60-$7.40 (Tier 2) QL Norvir NORVIR (100MG CAPSULE, 100MG TABLET, 80MG/ML ORAL SOLUTION) $3.60-$7.40 (Tier 2) QL Prezista PREZISTA (100MG/ML SUSPENSION, 150MG TABLET, 600MG TABLET, 75MG TABLET, 800MG TABLET) $3.60-$7.40 (Tier 2) QL You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

46 For Track Refered Purpose 46 Reyataz REYATAZ (150MG CAPSULE, 200MG CAPSULE, 300MG CAPSULE, 50MG PACKET) $3.60-$7.40 (Tier 2) QL Viracept VIRACEPT (TABLET) $3.60-$7.40 (Tier 2) QL Anti-influenza Agents Relenza Diskhaler RELENZA DISKHALER (AEROSOL POWDER) $3.60-$7.40 (Tier 2) QL Rimantadine HCl rimantadine hcl (tablet) Tamiflu TAMIFLU (30MG CAPSULE, 45MG CAPSULE, 75MG CAPSULE, 6MG/ML SUSPENSION) Antivirals $3.60-$7.40 (Tier 2) QL Virazole VIRAZOLE (INHALATION SOLUTION) $3.60-$7.40 (Tier 2) Anxiolytics Anxiolytics, Other Buspirone HCl buspirone hcl (tablet) Hydroxyzine HCl hydroxyzine hcl (10mg tablet, 25mg tablet, 50mg tablet, 10mg/5ml syrup, 25mg/ml injection, 50mg/ml injection) Benzodiazepines Alprazolam alprazolam (tablet immediate-release) QL Chlordiazepoxide HCl chlordiazepoxide hcl (capsule) Clonazepam clonazepam (tablet immediate-release) QL Clonazepam ODT clonazepam odt (tablet dispersible) QL Clorazepate Dipotassium clorazepate dipotassium (tablet) QL Diazepam diazepam (10mg tablet, 2mg tablet, 5mg tablet) QL Diazepam diazepam (1mg/ml oral solution) Diazepam Intensol diazepam intensol (5mg/ml concentrate) QL Lorazepam lorazepam (tablet) QL Lorazepam Intensol lorazepam intensol (2mg/ml concentrate) QL Bipolar Agents Mood Stabilizers Equetro EQUETRO (CAPSULE EXTENDED-RELEASE 12 $3.60-$7.40 (Tier 2) HOUR) Lithium LITHIUM (ORAL SOLUTION) $3.60-$7.40 (Tier 2) Lithium Carbonate lithium carbonate (150mg capsule immediate-release, 300mg capsule immediate-release, 600mg capsule immediate-release, 300mg tablet immediate-release) Lithium Carbonate ER lithium carbonate er (tablet extended-release)

47 For Track Refered Purpose 47 Blood Glucose Regulators Antidiabetic Agents Acarbose acarbose (tablet) QL Avandia AVANDIA (TABLET) $3.60-$7.40 (Tier 2) PA, QL Bydureon BYDUREON (INJECTION) $3.60-$7.40 (Tier 2) QL Byetta BYETTA (INJECTION) $3.60-$7.40 (Tier 2) QL Cycloset CYCLOSET (TABLET) $3.60-$7.40 (Tier 2) PA, QL Farxiga FARXIGA (TABLET) $3.60-$7.40 (Tier 2) QL Glimepiride glimepiride (tablet) QL Glipizide glipizide (tablet immediate-release) QL Glipizide ER glipizide er (tablet extended-release 24 hour) QL Glipizide/Metformin HCl glipizide/metformin hcl (tablet) QL Jardiance JARDIANCE (TABLET) $3.60-$7.40 (Tier 2) QL Jentadueto JENTADUETO (TABLET) $3.60-$7.40 (Tier 2) QL Kombiglyze XR KOMBIGLYZE XR (TABLET EXTENDED-RELEASE 24 HOUR) $3.60-$7.40 (Tier 2) QL Metformin HCl metformin hcl (tablet immediate-release) QL Metformin HCl ER metformin hcl er (1000mg tablet extended-release 24 hour) (generic fortamet), (500mg tablet extended-release 24 hour, 750mg tablet extended-release 24 hour) (generic QL glucophage xr) Nateglinide nateglinide (tablet) QL Nesina NESINA (TABLET) $3.60-$7.40 (Tier 2) QL Onglyza ONGLYZA (TABLET) $3.60-$7.40 (Tier 2) QL Pioglitazone HCl pioglitazone hcl (tablet) QL Pioglitazone HCl/Glimepiride pioglitazone hcl/glimepiride (tablet) QL Pioglitazone HCl/Metformin HCl pioglitazone hcl/metformin hcl (tablet) QL Repaglinide repaglinide (tablet) QL Repaglinide/Metformin HCl repaglinide/metformin hcl (tablet) QL Riomet RIOMET (ORAL SOLUTION) $3.60-$7.40 (Tier 2) QL You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

48 For Track Refered Purpose 48 SymlinPen 120 SYMLINPEN 120 (INJECTION) $3.60-$7.40 (Tier 2) PA SymlinPen 60 SYMLINPEN 60 (INJECTION) $3.60-$7.40 (Tier 2) PA Synjardy SYNJARDY (TABLET) $3.60-$7.40 (Tier 2) QL Tradjenta TRADJENTA (TABLET) $3.60-$7.40 (Tier 2) QL Xigduo XR XIGDUO XR (TABLET EXTENDED-RELEASE 24 HOUR) Glycemic Agents $3.60-$7.40 (Tier 2) QL Glucagen HypoKit GLUCAGEN HYPOKIT (INJECTION) $3.60-$7.40 (Tier 2) Glucagon Emergency Kit GLUCAGON EMERGENCY KIT (INJECTION) $3.60-$7.40 (Tier 2) Glucose glucose (tablet chewable)* Glutose 15 glutose 15 (gel)* Proglycem PROGLYCEM (SUSPENSION) $3.60-$7.40 (Tier 2) SM Glucose sm glucose (tablet chewable)* Insulins Humalog Cartridge HUMALOG CARTRIDGE (INJECTION) $3.60-$7.40 (Tier 2) Humalog KwikPen HUMALOG KWIKPEN (INJECTION) $3.60-$7.40 (Tier 2) Humalog Mix 50/50 KwikPen HUMALOG MIX 50/50 KWIKPEN (INJECTION) $3.60-$7.40 (Tier 2) Humalog Mix 50/50 Vial HUMALOG MIX 50/50 VIAL (INJECTION) $3.60-$7.40 (Tier 2) Humalog Mix 75/25 KwikPen HUMALOG MIX 75/25 KWIKPEN (INJECTION) $3.60-$7.40 (Tier 2) Humalog Mix 75/25 Vial HUMALOG MIX 75/25 VIAL (INJECTION) $3.60-$7.40 (Tier 2) Humalog Vial HUMALOG VIAL (INJECTION) $3.60-$7.40 (Tier 2) Humulin 70/30 KwikPen HUMULIN 70/30 KWIKPEN (INJECTION) $3.60-$7.40 (Tier 2) Humulin 70/30 Vial HUMULIN 70/30 VIAL (INJECTION) $3.60-$7.40 (Tier 2) Humulin N KwikPen HUMULIN N KWIKPEN (INJECTION) $3.60-$7.40 (Tier 2) Humulin N Vial HUMULIN N VIAL (INJECTION) $3.60-$7.40 (Tier 2) Humulin R U-500 KwikPen HUMULIN R U-500 KWIKPEN (INJECTION) $3.60-$7.40 (Tier 2) Humulin R U-500 Vial HUMULIN R U-500 VIAL (CONCENTRATED) $3.60-$7.40 (Tier 2) (INJECTION) Humulin R Vial HUMULIN R VIAL (INJECTION) $3.60-$7.40 (Tier 2) Lantus SoloStar LANTUS SOLOSTAR (INJECTION) $3.60-$7.40 (Tier 2) Lantus Vial LANTUS VIAL (INJECTION) $3.60-$7.40 (Tier 2) Levemir FlexTouch LEVEMIR FLEXTOUCH (INJECTION) $3.60-$7.40 (Tier 2) Levemir Vial LEVEMIR VIAL (INJECTION) $3.60-$7.40 (Tier 2) Toujeo SoloStar TOUJEO SOLOSTAR (INJECTION) $3.60-$7.40 (Tier 2) Blood Products/Modifiers/Volume Expanders

49 For Track Refered Purpose 49 Anticoagulants Coumadin COUMADIN (TABLET) $3.60-$7.40 (Tier 2) Eliquis ELIQUIS (TABLET) $3.60-$7.40 (Tier 2) PA, QL Enoxaparin Sodium enoxaparin sodium (injection) QL Fondaparinux Sodium fondaparinux sodium (injection) Heparin Sodium heparin sodium (injection) B/D, PA Heparin Sodium/D5W HEPARIN SODIUM/D5W (INJECTION) $3.60-$7.40 (Tier 2) B/D, PA Jantoven jantoven (tablet) Pradaxa PRADAXA (CAPSULE) $3.60-$7.40 (Tier 2) PA, QL Warfarin Sodium warfarin sodium (tablet) Xarelto XARELTO (TABLET) $3.60-$7.40 (Tier 2) PA, QL Xarelto Starter Pack XARELTO STARTER PACK (TABLET THERAPY PACK) $3.60-$7.40 (Tier 2) PA, QL Blood Formation Modifiers Anagrelide HCl anagrelide hcl (capsule) Aranesp Albumin Free ARANESP ALBUMIN FREE (INJECTION) $3.60-$7.40 (Tier 2) PA Granix GRANIX (INJECTION) $3.60-$7.40 (Tier 2) PA Leukine LEUKINE (INJECTION) $3.60-$7.40 (Tier 2) PA Mozobil MOZOBIL (INJECTION) $3.60-$7.40 (Tier 2) PA Neulasta NEULASTA (INJECTION) $3.60-$7.40 (Tier 2) PA Neupogen NEUPOGEN (INJECTION) $3.60-$7.40 (Tier 2) PA Procrit PROCRIT (INJECTION) $3.60-$7.40 (Tier 2) PA Promacta PROMACTA (TABLET) $3.60-$7.40 (Tier 2) PA Blood Products/Modifiers/Volume Expanders Argatroban ARGATROBAN (INJECTION) $3.60-$7.40 (Tier 2) B/D, PA Coagulants Tranexamic Acid tranexamic acid (1000mg/10ml injection, 650mg tablet) You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

50 For Track Refered Purpose 50 Platelet Modifying Agents Aggrenox AGGRENOX (CAPSULE EXTENDED-RELEASE 12 HOUR) $3.60-$7.40 (Tier 2) QL Aspirin/Dipyridamole ASPIRIN/DIPYRIDAMOLE (CAPSULE EXTENDED- RELEASE 12 HOUR) $3.60-$7.40 (Tier 2) QL Brilinta BRILINTA (TABLET) $3.60-$7.40 (Tier 2) QL Cilostazol cilostazol (tablet) Clopidogrel clopidogrel (75mg tablet) QL Effient EFFIENT (TABLET) $3.60-$7.40 (Tier 2) QL Cardiovascular Agents Alpha-adrenergic Agonists Clonidine HCl clonidine hcl (0.1mg tablet immediate-release, 0.2mg tablet immediate-release, 0.3mg tablet immediate-release, 0.1mg/ 24hr patch weekly, 0.2mg/24hr patch weekly, 0.3mg/24hr patch weekly) Methyldopa methyldopa (tablet) Methyldopate HCl methyldopate hcl (injection) Midodrine HCl midodrine hcl (tablet) Alpha-adrenergic Blocking Agents Dibenzyline DIBENZYLINE (CAPSULE) $3.60-$7.40 (Tier 2) Doxazosin Mesylate doxazosin mesylate (tablet) Phenoxybenzamine HCl phenoxybenzamine hcl (capsule) Prazosin HCl prazosin hcl (capsule) Angiotensin II Receptor Antagonists Benicar BENICAR (TABLET) $3.60-$7.40 (Tier 2) QL Candesartan Cilexetil candesartan cilexetil (tablet) QL Eprosartan Mesylate eprosartan mesylate (tablet) QL Irbesartan irbesartan (tablet) QL Losartan Potassium losartan potassium (tablet) QL Telmisartan telmisartan (tablet) QL Valsartan valsartan (tablet) QL Angiotensin-converting Enzyme (ACE) Inhibitors Benazepril HCl benazepril hcl (tablet) QL Captopril captopril (tablet) QL Enalapril Maleate enalapril maleate (tablet) QL

51 For Track Refered Purpose 51 Epaned EPANED (ORAL SOLUTION) $3.60-$7.40 (Tier 2) Fosinopril Sodium fosinopril sodium (tablet) QL Lisinopril lisinopril (tablet) QL Moexipril HCl moexipril hcl (tablet) QL Perindopril Erbumine perindopril erbumine (tablet) QL Quinapril HCl quinapril hcl (tablet) QL Ramipril ramipril (capsule) QL Trandolapril trandolapril (tablet) QL Antiarrhythmics Amiodarone HCl amiodarone hcl (200mg tablet, 50mg/ml injection) Flecainide Acetate flecainide acetate (tablet) Mexiletine HCl mexiletine hcl (capsule) Multaq MULTAQ (TABLET) $3.60-$7.40 (Tier 2) QL Pacerone pacerone (200mg tablet) Procainamide HCl procainamide hcl (injection) Propafenone HCl propafenone hcl (tablet) Propafenone HCl ER propafenone hcl er (capsule extended-release 12 hour) Quinidine Gluconate QUINIDINE GLUCONATE (INJECTION) $3.60-$7.40 (Tier 2) Quinidine Gluconate CR quinidine gluconate cr (tablet extended-release) Quinidine Sulfate quinidine sulfate (tablet) Sotalol HCl sotalol hcl (af) (tablet) Sotalol HCl sotalol hcl (tablet) Tikosyn TIKOSYN (CAPSULE) $3.60-$7.40 (Tier 2) Beta-adrenergic Blocking Agents Atenolol atenolol (tablet) Bystolic BYSTOLIC (TABLET) $3.60-$7.40 (Tier 2) QL Carvedilol carvedilol (tablet immediate-release) Labetalol HCl labetalol hcl (100mg tablet, 200mg tablet, 300mg tablet, 5mg/ml injection) You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

52 For Track Refered Purpose 52 Metoprolol Succinate ER metoprolol succinate er (tablet extended-release 24 hour) Metoprolol Tartrate metoprolol tartrate (100mg tablet immediate-release, 25mg tablet immediate-release, 50mg tablet immediate-release, 1mg/ml injection) Nadolol nadolol (tablet) Pindolol pindolol (tablet) Propranolol HCl propranolol hcl (tablet immediate-release, 1mg/ml injection, oral solution) Propranolol HCl ER propranolol hcl er (capsule extended-release 24 hour) Timolol Maleate timolol maleate (10mg tablet, 20mg tablet, 5mg tablet) Calcium Channel Blocking Agents Amlodipine Besylate amlodipine besylate (tablet) Cardene IV CARDENE IV (INJECTION) $3.60-$7.40 (Tier 2) Cartia XT cartia xt (capsule extended-release 24 hour) Diltiazem CD diltiazem cd (240mg capsule extended-release 24 hour) (generic cardizem cd) Diltiazem HCl diltiazem hcl (100mg injection, 50mg/10ml injection, tablet immediate-release) Diltiazem HCl ER diltiazem hcl er (120mg capsule extended-release 24 hour, 300mg capsule extended-release 24 hour) (generic cardizem cd) Dilt-XR dilt-xr (capsule extended-release 24 hour) Nicardipine HCl nicardipine hcl (2.5mg/ml injection, 20mg capsule, 30mg capsule) Nimodipine nimodipine (capsule) Verapamil HCl verapamil hcl (120mg tablet immediate-release, 40mg tablet immediate-release, 80mg tablet immediate-release, 2.5mg/ml injection) Verapamil HCl ER verapamil hcl er (120mg tablet extended-release, 180mg tablet extended-release, 240mg tablet extended-release) Cardiovascular Agents, Other Amiloride/Hydrochlorothiazide amiloride/hydrochlorothiazide (tablet) Amlodipine Besylate/Atorvastatin Calcium amlodipine besylate/atorvastatin calcium (tablet) QL Amlodipine Besylate/Benazepril HCl amlodipine besylate/benazepril hcl (capsule) QL Atenolol/Chlorthalidone atenolol/chlorthalidone (tablet) Benazepril HCl/Hydrochlorothiazide benazepril hcl/hydrochlorothiazide (tablet) QL Benicar HCT BENICAR HCT (TABLET) $3.60-$7.40 (Tier 2) QL Candesartan Cilexetil/Hydrochlorothiazide candesartan cilexetil/hydrochlorothiazide (tablet) QL Captopril/Hydrochlorothiazide captopril/hydrochlorothiazide (tablet) QL

53 For Track Refered Purpose 53 Demser DEMSER (CAPSULE) $3.60-$7.40 (Tier 2) Digitek digitek (tablet) Digoxin DIGOXIN (0.05MG/ML ORAL SOLUTION) $3.60-$7.40 (Tier 2) Digoxin digoxin (0.25mg/ml injection, 125mcg tablet, 250mcg tablet) Enalapril Maleate/Hydrochlorothiazide enalapril maleate/hydrochlorothiazide (tablet) QL Entresto ENTRESTO (TABLET) $3.60-$7.40 (Tier 2) PA, QL Fosinopril Sodium/Hydrochlorothiazide fosinopril sodium/hydrochlorothiazide (tablet) QL Irbesartan/Hydrochlorothiazide irbesartan/hydrochlorothiazide (tablet) QL Lanoxin LANOXIN (125MCG TABLET, 187.5MCG TABLET, 250MCG TABLET, 62.5MCG TABLET) $3.60-$7.40 (Tier 2) Lisinopril/Hydrochlorothiazide lisinopril/hydrochlorothiazide (tablet) QL Losartan Potassium/Hydrochlorothiazide losartan potassium/hydrochlorothiazide (tablet) QL Methyldopa/Hydrochlorothiazide methyldopa/hydrochlorothiazide (tablet) Metoprolol/Hydrochlorothiazide metoprolol/hydrochlorothiazide (tablet) Moexipril/Hydrochlorothiazide moexipril/hydrochlorothiazide (tablet) QL Northera NORTHERA (CAPSULE) $3.60-$7.40 (Tier 2) PA, QL Pentoxifylline ER pentoxifylline er (tablet extended-release) Propranolol/Hydrochlorothiazide propranolol/hydrochlorothiazide (tablet) Quinapril/Hydrochlorothiazide quinapril/hydrochlorothiazide (tablet) QL Ranexa RANEXA (TABLET EXTENDED-RELEASE 12 HOUR) $3.60-$7.40 (Tier 2) QL Spironolactone/Hydrochlorothiazide spironolactone/hydrochlorothiazide (tablet) Telmisartan/Amlodipine telmisartan/amlodipine (tablet) QL Telmisartan/Hydrochlorothiazide telmisartan/hydrochlorothiazide (tablet) QL Triamterene/Hydrochlorothiazide triamterene/hydrochlorothiazide (capsule, tablet) Valsartan/Hydrochlorothiazide valsartan/hydrochlorothiazide (tablet) QL Diuretics, Carbonic Anhydrase Inhibitors Acetazolamide acetazolamide (tablet immediate-release) Acetazolamide ER acetazolamide er (capsule extended-release 12 hour) You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

54 For Track Refered Purpose 54 Acetazolamide Sodium acetazolamide sodium (injection) Diuretics, Loop Bumetanide bumetanide (0.25mg/ml injection, 0.5mg tablet, 1mg tablet, 2mg tablet) Furosemide furosemide (10mg/ml injection) B/D, PA Furosemide furosemide (10mg/ml oral solution, 8mg/ml oral solution, 20mg tablet, 40mg tablet, 80mg tablet) Torsemide torsemide (tablet) Diuretics, Potassium-sparing Amiloride HCl amiloride hcl (tablet) Eplerenone eplerenone (tablet) Spironolactone spironolactone (tablet) Diuretics, Thiazide Chlorothiazide chlorothiazide (tablet) Chlorothiazide Sodium chlorothiazide sodium (injection) B/D, PA Chlorthalidone chlorthalidone (tablet) Diuril DIURIL (SUSPENSION) $3.60-$7.40 (Tier 2) Hydrochlorothiazide hydrochlorothiazide (12.5mg capsule, 12.5mg tablet, 25mg tablet, 50mg tablet) Indapamide indapamide (tablet) Methyclothiazide methyclothiazide (tablet) Metolazone metolazone (tablet) Dyslipidemics, Fibric Acid Derivatives Fenofibrate fenofibrate (145mg tablet, 48mg tablet) (generic tricor), (160mg tablet, 54mg tablet) (generic lofibra) Fenofibrate Micronized fenofibrate micronized (67mg capsule, 134mg capsule, 200mg capsule) (generic lofibra) Fenofibric Acid FENOFIBRIC ACID (TABLET) $3.60-$7.40 (Tier 2) Fenofibric Acid DR fenofibric acid dr (capsule delayed-release) (generic trilipix) Gemfibrozil gemfibrozil (tablet) Dyslipidemics, HMG CoA Reductase Inhibitors Atorvastatin Calcium atorvastatin calcium (tablet) QL Crestor CRESTOR (TABLET) $3.60-$7.40 (Tier 2) QL Fluvastatin fluvastatin (capsule immediate-release) QL Lovastatin lovastatin (tablet immediate-release) QL Pravastatin Sodium pravastatin sodium (tablet) QL

55 For Track Refered Purpose 55 Simvastatin simvastatin (tablet) QL Dyslipidemics, Other Cholestyramine Light cholestyramine light (packet) Colestipol HCl colestipol hcl (1gm tablet, 5gm granules) Juxtapid JUXTAPID (CAPSULE) $3.60-$7.40 (Tier 2) PA Kynamro KYNAMRO (INJECTION) $3.60-$7.40 (Tier 2) PA Niacor niacor (tablet) Niacin ER niacin er (rx only) (tablet extended-release) Omega-3-Acid Ethyl Esters omega-3-acid ethyl esters (capsule) (generic lovaza) QL Praluent PRALUENT (INJECTION) $3.60-$7.40 (Tier 2) PA, QL, LA Prevalite prevalite (powder) Repatha REPATHA (INJECTION) $3.60-$7.40 (Tier 2) PA, QL Repatha SureClick REPATHA SURECLICK (INJECTION) $3.60-$7.40 (Tier 2) PA, QL Vascepa VASCEPA (CAPSULE) $3.60-$7.40 (Tier 2) Vytorin VYTORIN (TABLET) $3.60-$7.40 (Tier 2) QL Welchol WELCHOL (3.75GM PACKET, 625MG TABLET) $3.60-$7.40 (Tier 2) Zetia ZETIA (TABLET) $3.60-$7.40 (Tier 2) QL Vasodilators, Direct-acting Arterial Hydralazine HCl hydralazine hcl (100mg tablet, 10mg tablet, 25mg tablet, 50mg tablet, 20mg/ml injection) Minoxidil minoxidil (tablet) Vasodilators, Direct-acting Arterial/Venous Isosorbide Dinitrate isosorbide dinitrate (tablet immediate-release) Isosorbide Dinitrate ER isosorbide dinitrate er (tablet extended-release) Isosorbide Mononitrate isosorbide mononitrate (tablet immediate-release) Isosorbide Mononitrate ER isosorbide mononitrate er (tablet extended-release 24 hour) Minitran minitran (patch 24 hour) Nitro-Bid nitro-bid (ointment) Nitroglycerin nitroglycerin (injection) You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

56 For Track Refered Purpose 56 Nitroglycerin Lingual nitroglycerin lingual (translingual solution) Nitroglycerin Transdermal nitroglycerin transdermal (patch 24 hour) Nitrostat NITROSTAT (TABLET SUBLINGUAL) $3.60-$7.40 (Tier 2) Central Nervous System Agents Attention Deficit Hyperactivity Disorder Agents, Amphetamines Amphetamine/Dextroamphetamine amphetamine/dextroamphetamine (capsule extendedrelease 24 hour, tablet immediate-release) QL Dexedrine dexedrine (10mg tablet, 5mg tablet) QL Dextroamphetamine Sulfate dextroamphetamine sulfate (tablet immediate-release) QL Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines Clonidine HCl ER clonidine hcl er (tablet extended-release 12 hour) Dexmethylphenidate HCl dexmethylphenidate hcl (tablet immediate-release) QL Dexmethylphenidate HCl ER dexmethylphenidate hcl er (capsule extended-release 24 hour) Guanfacine ER guanfacine er (tablet extended-release 24 hour) Methylphenidate HCl methylphenidate hcl (10mg tablet immediate-release, 20mg tablet immediate-release, 5mg tablet immediate-release) (generic ritalin), (10mg/5ml oral solution, 5mg/5ml oral QL solution) Methylphenidate HCl ER methylphenidate hcl er (10mg tablet extended-release, 20mg tablet extended-release) QL Strattera STRATTERA (CAPSULE) $3.60-$7.40 (Tier 2) QL, ST Central Nervous System, Other Namzaric NAMZARIC (CAPSULE EXTENDED-RELEASE 24 HOUR) $3.60-$7.40 (Tier 2) PA, QL Nuedexta NUEDEXTA (CAPSULE) $3.60-$7.40 (Tier 2) PA Rilutek RILUTEK (TABLET) $3.60-$7.40 (Tier 2) Riluzole riluzole (tablet) Tetrabenazine tetrabenazine (tablet) PA, QL Xenazine XENAZINE (TABLET) $3.60-$7.40 (Tier 2) PA, QL, LA Fibromyalgia Agents Duloxetine HCl duloxetine hcl (20mg capsule delayed-release, 30mg capsule delayed-release, 60mg capsule delayed-release) Lyrica LYRICA (100MG CAPSULE, 150MG CAPSULE, 200MG CAPSULE, 225MG CAPSULE, 25MG CAPSULE, 300MG CAPSULE, 50MG CAPSULE, 75MG CAPSULE, 20MG/ML ORAL SOLUTION) QL $3.60-$7.40 (Tier 2) QL

57 For Track Refered Purpose 57 Savella SAVELLA (TABLET) $3.60-$7.40 (Tier 2) Savella Titration Pack SAVELLA TITRATION PACK $3.60-$7.40 (Tier 2) Multiple Sclerosis Agents Ampyra AMPYRA (TABLET EXTENDED-RELEASE 12 HOUR) $3.60-$7.40 (Tier 2) PA, QL Aubagio AUBAGIO (TABLET) $3.60-$7.40 (Tier 2) PA, QL Avonex AVONEX (INJECTION) $3.60-$7.40 (Tier 2) PA Avonex Pen AVONEX PEN (INJECTION) $3.60-$7.40 (Tier 2) PA Betaseron BETASERON (INJECTION) $3.60-$7.40 (Tier 2) PA Copaxone COPAXONE (INJECTION) $3.60-$7.40 (Tier 2) PA Gilenya GILENYA (CAPSULE) $3.60-$7.40 (Tier 2) PA, QL Glatopa glatopa (injection) PA Rebif REBIF (INJECTION) $3.60-$7.40 (Tier 2) PA Rebif Rebidose REBIF REBIDOSE (INJECTION) $3.60-$7.40 (Tier 2) PA Rebif Rebidose Titration Pack REBIF REBIDOSE TITRATION PACK (INJECTION) $3.60-$7.40 (Tier 2) PA Rebif Titration Pack REBIF TITRATION PACK (INJECTION) $3.60-$7.40 (Tier 2) PA Tecfidera TECFIDERA (CAPSULE DELAYED-RELEASE) $3.60-$7.40 (Tier 2) PA, QL Tecfidera Starter Pack TECFIDERA STARTER PACK $3.60-$7.40 (Tier 2) PA Tysabri TYSABRI (INJECTION) $3.60-$7.40 (Tier 2) PA Dental and Oral Agents Dental and Oral Agents Chlorhexidine Gluconate Oral Rinse chlorhexidine gluconate oral rinse (solution) Kepivance KEPIVANCE (INJECTION) $3.60-$7.40 (Tier 2) Periogard periogard (solution) Pilocarpine HCl pilocarpine hcl (5mg tablet, 7.5mg tablet) Triamcinolone in Orabase triamcinolone in orabase (paste) Dermatological Agents You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

58 For Track Refered Purpose 58 Dermatological Agents 8-MOP (CAPSULE) $3.60-$7.40 (Tier 2) Acitretin acitretin (capsule) Acne Medication acne medication (lotion)* Acne Medication 5 acne medication 5 (lotion)* Adapalene adapalene (0.1% cream, 0.1% gel) Aloe Vesta Protective aloe vesta protective (ointment)* Ameriphor ameriphor (ointment)* Amlactin amlactin (lotion)* Ammonium Lactate ammonium lactate (rx only) (12% cream, 12% lotion) Avita AVITA (0.025% CREAM, 0.025% GEL) $3.60-$7.40 (Tier 2) PA Bacteriostatic Water for Injection/Benzyl Alcohol bacteriostatic water for injection/benzyl alcohol (injection)* Baza Protect baza protect (cream)* Benzoin Compound Tincture benzoin compound tincture* Benzoyl Peroxide benzoyl peroxide (otc only) (10% gel, 5% gel, 2.5% gel)* Benzoyl Peroxide Cleanser benzoyl peroxide cleanser (otc only) (lotion)* Benzoyl Peroxide Wash benzoyl peroxide wash (otc only) (liquid)* Beta Care Betatar Gel beta care betatar gel (shampoo)* BPO Creamy Wash Complete Pack bpo creamy wash complete pack (kit)* Calcipotriene calcipotriene (0.005% cream, 0.005% external solution) Calcitriol CALCITRIOL (3MCG/GM OINTMENT) $3.60-$7.40 (Tier 2) Carac CARAC (CREAM) $3.60-$7.40 (Tier 2) Claravis claravis (capsule) PA Clindamycin Phosphate clindamycin phosphate (1% external solution, 1% gel, 1% lotion, 1% swab) Clindamycin/Benzoyl Peroxide clindamycin/benzoyl peroxide (gel) (generic benzaclin) Clotrimazole/Betamethasone Dipropionate clotrimazole/betamethasone dipropionate (1%-0.05% cream, 1%-0.05% lotion) Dermacerin dermacerin (cream)* Dermamed dermamed (ointment)* DHS Tar dhs tar (shampoo)* DHS Tar Gel dhs tar gel (shampoo)* DHS Zinc dhs zinc (shampoo)* Diclofenac Sodium diclofenac sodium (3% gel) PA Doxepin HCl DOXEPIN HCL (CREAM) $3.60-$7.40 (Tier 2) Elidel ELIDEL (CREAM) $3.60-$7.40 (Tier 2) ST Ery ery (2% pad) Erythromycin erythromycin (2% external solution, 2% gel)

59 For Track Refered Purpose 59 Erythromycin/Benzoyl Peroxide erythromycin/benzoyl peroxide (gel) Fluorouracil fluorouracil (2% external solution, 5% external solution, 5% cream) Genteal PM genteal pm (ointment)* GNP Capsaicin gnp capsaicin (cream)* GNP Hemorrhoidal gnp hemorrhoidal (14%-71.9%-0.25%-3% ointment, 85.5%-0.25%-3% suppository)* Hemorrhoid hemorrhoid (suppository)* Hemorrhoidal Suppositories hemorrhoidal suppositories* Hem-Prep hem-prep (suppository)* Imiquimod imiquimod (cream) Ionil-T ionil-t (shampoo)* Major-Prep Hemorrhoidal major-prep hemorrhoidal (ointment)* Methoxsalen methoxsalen (capsule) PA Minerin minerin (cream)* Mirvaso MIRVASO (GEL) $3.60-$7.40 (Tier 2) PA Moisturizing Cream moisturizing cream* Nail Scrub nail scrub (liquid)* Nutraplus nutraplus (10% cream, 10% lotion)* ORA-Sweet SF ora-sweet sf (syrup)* Oxsoralen Ultra OXSORALEN ULTRA (CAPSULE) $3.60-$7.40 (Tier 2) PA Panoxyl Wash panoxyl wash (liquid)* Panoxyl-4 Creamy Wash panoxyl-4 creamy wash (liquid)* Pedi-Boro Soak Paks pedi-boro soak paks (packet)* Periguard periguard (ointment)* Petrolatum petrolatum (ointment)* Picato PICATO (GEL) $3.60-$7.40 (Tier 2) Podofilox podofilox (external solution) Preparation H preparation h (ointment)* PRUDOXIN (CREAM) $3.60-$7.40 (Tier 2) Puralube puralube (ointment)* You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

60 For Track Refered Purpose 60 QC Hemorrhoidal qc hemorrhoidal (suppository)* Refresh P.M. refresh p.m. (ointment)* Regranex REGRANEX (GEL) $3.60-$7.40 (Tier 2) PA Remedy Nutrashield remedy nutrashield (cream)* Remedy Skin Repair remedy skin repair (cream)* RisaBal-pH risabal-ph (cream)* Salactic Film salactic film (external solution)* Sal-Plant sal-plant (gel)* Santyl SANTYL (OINTMENT) $3.60-$7.40 (Tier 2) Selenium Sulfide selenium sulfide (lotion) Sensi-Care Protective Barrier sensi-care protective barrier (ointment)* Soothe & Cool Free Moisture Barrier soothe & cool free moisture barrier (ointment)* Soothe & Cool Protect Moisture Barrier soothe & cool protect moisture barrier (ointment)* Soriatane SORIATANE (CAPSULE) $3.60-$7.40 (Tier 2) Systane Nighttime systane nighttime (ointment)* Tacrolimus tacrolimus (0.03% ointment, 0.1% ointment) ST Tazorac TAZORAC (0.05% CREAM, 0.1% CREAM) $3.60-$7.40 (Tier 2) PA Tretinoin tretinoin (0.01% gel, 0.025% gel, 0.025% cream, 0.05% cream, 0.1% cream) PA Tretinoin Microsphere tretinoin microsphere (gel) PA Trixaicin trixaicin (cream)* Trixaicin HP trixaicin hp (cream)* Urea urea (10% cream, 10% lotion)* Ureacin-10 ureacin-10 (lotion)* Uvadex UVADEX (INJECTION) $3.60-$7.40 (Tier 2) Ziks Arthritis Pain Relief ziks arthritis pain relief (cream)* Zyclara ZYCLARA (CREAM) $3.60-$7.40 (Tier 2) PA Zyclara Pump ZYCLARA PUMP (CREAM) $3.60-$7.40 (Tier 2) PA Enzyme Replacement/Modifiers Enzyme Replacement/Modifiers Adagen ADAGEN (INJECTION) $3.60-$7.40 (Tier 2) LA Aldurazyme ALDURAZYME (INJECTION) $3.60-$7.40 (Tier 2) Buphenyl BUPHENYL (POWDER) $3.60-$7.40 (Tier 2) Cerezyme CEREZYME (INJECTION) $3.60-$7.40 (Tier 2) PA Creon CREON (CAPSULE DELAYED-RELEASE) $3.60-$7.40 (Tier 2) Cystadane CYSTADANE (POWDER) $3.60-$7.40 (Tier 2) Cystagon CYSTAGON (CAPSULE) $3.60-$7.40 (Tier 2) LA

61 For Track Refered Purpose 61 Elaprase ELAPRASE (INJECTION) $3.60-$7.40 (Tier 2) Elelyso ELELYSO (INJECTION) $3.60-$7.40 (Tier 2) PA, LA Fabrazyme FABRAZYME (INJECTION) $3.60-$7.40 (Tier 2) Kuvan KUVAN (100MG TABLET SOLUBLE, 500MG PACKET) $3.60-$7.40 (Tier 2) Lactrase lactrase (capsule)* Lumizyme LUMIZYME (INJECTION) $3.60-$7.40 (Tier 2) Myozyme MYOZYME (INJECTION) $3.60-$7.40 (Tier 2) Naglazyme NAGLAZYME (INJECTION) $3.60-$7.40 (Tier 2) Orfadin ORFADIN (CAPSULE) $3.60-$7.40 (Tier 2) LA Procysbi PROCYSBI (CAPSULE DELAYED-RELEASE) $3.60-$7.40 (Tier 2) RAVICTI (LIQUID) $3.60-$7.40 (Tier 2) Sodium Phenylbutyrate sodium phenylbutyrate (powder) Strensiq STRENSIQ (INJECTION) $3.60-$7.40 (Tier 2) PA, LA Sucraid SUCRAID (ORAL SOLUTION) $3.60-$7.40 (Tier 2) LA VPRIVPRIV (INJECTION) $3.60-$7.40 (Tier 2) PA Zavesca ZAVESCA (CAPSULE) $3.60-$7.40 (Tier 2) PA, LA Zenpep ZENPEP (CAPSULE DELAYED-RELEASE) $3.60-$7.40 (Tier 2) Gastrointestinal Agents Antispasmodics, Gastrointestinal Atropine Sulfate ATROPINE SULFATE (INJECTION) $3.60-$7.40 (Tier 2) Cuvposa CUVPOSA (ORAL SOLUTION) $3.60-$7.40 (Tier 2) Dicyclomine HCl dicyclomine hcl (10mg capsule, 10mg/5ml oral solution, 20mg tablet) Glycopyrrolate glycopyrrolate (4mg/20ml injection) Methscopolamine Bromide methscopolamine bromide (tablet) Gastrointestinal Agents, Other Acid Gone acid gone (suspension)* You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

62 For Track Refered Purpose 62 Acidophilus/Citrus Pectin acidophilus/citrus pectin (tablet)* Acidophilus/L-Sporogenes Extra Strength acidophilus/l-sporogenes extra strength (tablet)* Almacone Double Strength almacone double strength (suspension)* Aluminum Hydroxide aluminum hydroxide (suspension)* Antacid antacid (suspension)* Antacid Anti-Gas Maximum Strength antacid anti-gas maximum strength (suspension)* Antacid Fast Relief antacid fast relief (suspension)* Antacid Maximum Strength antacid maximum strength (suspension)* Antacid Plus Anti-Gas Fast Acting antacid plus anti-gas fast acting (suspension)* Anti-Diarrheal anti-diarrheal (tablet)* Bismatrol bismatrol (suspension)* Bismatrol Maximum Strength bismatrol maximum strength (suspension)* Castor Oil castor oil* Chenodal chenodal (tablet) Cromolyn Sodium cromolyn sodium (rx only) (100mg/5ml concentrate) Diocto diocto (50mg/5ml liquid, 60mg/15ml syrup)* Diphenoxylate/Atropine diphenoxylate/atropine (2.5mg-0.025mg tablet, 2.5mg-0.025mg/5ml liquid) Doc-Q-Lace doc-q-lace (capsule)* Docu docu (liquid)* Docusate Calcium docusate calcium (otc only) (capsule)* Docusate Sodium docusate sodium (otc only) (capsule)* Docusil docusil (capsule)* Docusol Mini docusol mini (enema)* DOK dok (100mg capsule, 250mg capsule, 100mg tablet)* Enema Ready-To-Use enema ready-to-use* Enemeez Mini enemeez mini (enema)* Enemeez Plus enemeez plus (enema)* Fast Acting Antacid Plus Anti-Gas Maximum Strength fast acting antacid plus anti-gas maximum strength (suspension)* Fiber Laxative fiber laxative (tablet)* Fiber Therapy fiber therapy (powder)* Fish Oil fish oil (capsule delayed-release, capsule immediaterelease)* Fleet Enema fleet enema* Fleet Enema Six Pack fleet enema six pack* Fleet Oil fleet oil (enema)* Fleet Pediatric fleet pediatric (enema)*

63 For Track Refered Purpose 63 Gas Relief gas relief (20mg/0.3ml suspension, 80mg tablet chewable)* Gas Relief Maximum Strength gas relief maximum strength (tablet chewable)* Gas-X Extra Strength gas-x extra strength (tablet chewable)* Gattex GATTEX (INJECTION) $3.60-$7.40 (Tier 2) PA Gaviscon gaviscon (suspension)* Glycerin glycerin (liquid)* GNP Antacid Anti-Gas gnp antacid anti-gas (suspension)* GNP Antacid Maximum Strength gnp antacid maximum strength (suspension)* GNP Anti-Diarrheal gnp anti-diarrheal (tablet)* GNP Castor Oil gnp castor oil* GNP Docusate Calcium gnp docusate calcium (capsule)* GNP Enema gnp enema* GNP Fiber Therapy gnp fiber therapy (tablet)* GNP Fish Oil gnp fish oil (capsule delayed-release, capsule immediaterelease)* GNP Foaming Antacid gnp foaming antacid (80mg-20mg tablet chewable, 95mg/ 15ml-358mg/15ml suspension)* GNP Gas Relief gnp gas relief (tablet chewable)* GNP Gas Relief Extra Strength gnp gas relief extra strength (tablet chewable)* GNP Gas Relief Maximum Strength gnp gas relief maximum strength (tablet chewable)* GNP Infants Gas Relief gnp infants gas relief (suspension)* GNP K-Pec gnp k-pec (suspension)* GNP Loperamide HCl gnp loperamide hcl (otc only) (suspension)* GNP Masanti Maximum Strength gnp masanti maximum strength (suspension)* GNP Masanti Regular Strength gnp masanti regular strength (suspension)* GNP Natural Fiber gnp natural fiber (powder)* GNP Stomach Relief gnp stomach relief (suspension)* GNP Stomach Relief Maximum Strength gnp stomach relief maximum strength (suspension)* GNP Stool Softener gnp stool softener (100mg capsule, 50mg/5ml liquid, 60mg/15ml syrup)* You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

64 For Track Refered Purpose 64 Hemorrhoidal hemorrhoidal (14%-71.9%-0.25%-3% ointment, 14%-74.9%-0.25% ointment, 85.5%-0.25%-3% suppository)* HM Advanced Antacid Maximum Strength hm advanced antacid maximum strength (suspension)* HM Antacid Anti-Gas Extra Strength hm antacid anti-gas extra strength (suspension)* HM Antacid/Antigas hm antacid/antigas (suspension)* HM Anti-Diarrheal hm anti-diarrheal (tablet)* HM Castor Oil hm castor oil* HM Enema hm enema* HM Enema Mineral Oil hm enema mineral oil* HM Fiber hm fiber (0.52gm capsule, 28.3% powder, 30.9% powder, 48.57% powder, 58.6% powder, 500mg tablet)* HM Fish Oil hm fish oil (capsule delayed-release)* HM Gas Relief hm gas relief (tablet chewable)* HM Gas Relief Infants Drops hm gas relief infants drops (suspension)* HM Loperamide HCl hm loperamide hcl (otc only) (suspension)* HM Stomach Relief hm stomach relief (suspension)* HM Stomach Relief Maximum Strength hm stomach relief maximum strength (suspension)* HM Stool Softener hm stool softener (capsule)* Infants Gas Relief infants gas relief (suspension)* Infants Simethicone infants simethicone (suspension)* Kao-Tin kao-tin (240mg capsule, 262mg/15ml suspension)* Konsyl konsyl (28.3% powder, 30.9% powder, 60.3% powder, 71.67% powder, 520mg capsule, 60.3% packet)* Konsyl-D konsyl-d (powder)* Loperamide HCl loperamide hcl (otc only) (1mg/5ml liquid, 1mg/7.5ml suspension)* Loperamide HCl loperamide hcl (rx only) (2mg capsule) Metamucil metamucil (powder)* Metamucil Multihealth Fiber metamucil multihealth fiber (powder)* Metamucil Original Texture metamucil original texture (powder)* Metamucil Smooth Texture metamucil smooth texture (powder)* Metamucil Smooth Texture Sugar Free metamucil smooth texture sugar free (powder)* Mi-Acid mi-acid (suspension)* Mi-Acid Gas Relief mi-acid gas relief (tablet chewable)* Mi-Acid Maximum Strength mi-acid maximum strength (suspension)* Milantex milantex (suspension)* Milantex Extra Strength milantex extra strength (suspension)* Mintox mintox (suspension)*

65 For Track Refered Purpose 65 Mintox Maximum Strength mintox maximum strength (suspension)* MYTAB GAS mytab gas (tablet chewable)* MYTAB GAS Maximum Strength mytab gas maximum strength (tablet chewable)* Natural Fiber Laxative natural fiber laxative (powder)* Natural Fiber Therapy natural fiber therapy (powder)* Omega-3 Fish Oil omega-3 fish oil (capsule)* Pedia-Lax pedia-lax (liquid)* Peptic Relief peptic relief (suspension)* Pink Bismuth Maximum Strength pink bismuth maximum strength (suspension)* QC Antacid qc antacid (suspension)* QC Antacid/Anti-Gas qc antacid/anti-gas (suspension)* QC Antacid/Anti-Gas Maximum Strength qc antacid/anti-gas maximum strength (suspension)* QC Anti-Diarrheal qc anti-diarrheal (tablet)* QC Castor Oil qc castor oil* QC Docusate Calcium qc docusate calcium (capsule)* QC Fiber Laxative qc fiber laxative (capsule)* QC Gas Relief qc gas relief (tablet chewable)* QC Gas Relief Extra Strength qc gas relief extra strength (tablet chewable)* QC Natural Vegetable qc natural vegetable (powder)* QC Pink Bismuth qc pink bismuth (suspension)* QC Senna qc senna (tablet)* QC Stool Softener qc stool softener (capsule)* Reguloid reguloid (0.52gm capsule, 28.3% powder, 48.57% powder, 58.6% powder)* Relistor RELISTOR (INJECTION) $3.60-$7.40 (Tier 2) PA Rulox rulox (suspension)* SB Antacid Anti-Gas sb antacid anti-gas (suspension)* SB Bismuth sb bismuth (suspension)* Sea-Omega 30 sea-omega 30 (capsule)* Sea-Omega 50 sea-omega 50 (capsule)* Senexon senexon (8.6mg tablet, 8.8mg/5ml liquid)* You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

66 For Track Refered Purpose 66 Senna senna (8.6mg tablet, 8.8mg/5ml syrup)* Senna Lax senna lax (tablet)* Senna Prompt senna prompt (capsule)* Senna-Tabs senna-tabs (tablet)* Senna-Time senna-time (tablet)* Senno senno (tablet)* Serostim SEROSTIM (INJECTION) $3.60-$7.40 (Tier 2) PA Silace silace (150mg/15ml liquid, 60mg/15ml syrup)* Simethicone simethicone (40mg/0.6ml suspension, 80mg tablet chewable)* SM Antacid Advanced Maximum Strength sm antacid advanced maximum strength (suspension)* SM Antacid Anti-Gas sm antacid anti-gas (suspension)* SM Antacid Maximum Strength sm antacid maximum strength (suspension)* SM Antacid/Antigas sm antacid/antigas (suspension)* SM Anti-Diarrheal sm anti-diarrheal (1mg/5ml liquid, 2mg tablet)* SM Castor Oil sm castor oil* SM Docusate Calcium sm docusate calcium (capsule)* SM Enema sm enema* SM Fiber sm fiber (powder)* SM Fiber Laxative sm fiber laxative (0.52gm capsule, 500mg tablet, 625mg tablet)* SM Foaming Antacid sm foaming antacid (tablet chewable)* SM Gas Relief sm gas relief (tablet chewable)* SM Gas Relief Drops Infants sm gas relief drops infants (suspension)* SM Gas Relief Infants Drops sm gas relief infants drops (suspension)* SM Loperamide HCl sm loperamide hcl (otc only) (suspension)* SM Omega-3 Fish Oil sm omega-3 fish oil (capsule)* SM Oral Saline Laxative sm oral saline laxative (oral solution)* SM Stomach Relief sm stomach relief (suspension)* SM Stomach Relief Maximum Strength sm stomach relief maximum strength (suspension)* SM Stool Softener sm stool softener (capsule)* Sodium Bicarbonate sodium bicarbonate (tablet)* Stomach Relief stomach relief (suspension)* Stomach Relief Maximum Strength stomach relief maximum strength (suspension)* Stool Softener stool softener (capsule)* Stool Softener Extra Strength stool softener extra strength (capsule)* Stool Softener Laxative DC stool softener laxative dc (capsule)* Ursodiol ursodiol (250mg tablet, 500mg tablet, 300mg capsule)

67 For Track Refered Purpose 67 Zorbtive ZORBTIVE (INJECTION) $3.60-$7.40 (Tier 2) PA Histamine2 (H2) Receptor Antagonists Acid Reducer acid reducer (tablet)* Cimetidine cimetidine (rx only) (tablet) Cimetidine HCl cimetidine hcl (rx only) (oral solution) Famotidine famotidine (otc only) (10mg tablet)* Famotidine Premixed famotidine premixed (rx only) (injection) Famotidine famotidine (rx only) (20mg tablet, 40mg tablet, 20mg/2ml injection) GNP Acid Reducer gnp acid reducer (tablet)* Heartburn Relief heartburn relief (tablet)* HM Famotidine hm famotidine (otc only) (10mg tablet)* QC Acid Controller qc acid controller (tablet)* Ranitidine HCl ranitidine hcl (rx only) (150mg capsule, 300mg capsule, 150mg tablet, 300mg tablet, 150mg/6ml injection) SM Acid Reducer sm acid reducer (tablet)* Irritable Bowel Syndrome Agents Alosetron HCl alosetron hcl (tablet) PA Amitiza AMITIZA (CAPSULE) $3.60-$7.40 (Tier 2) QL Linzess LINZESS (CAPSULE) $3.60-$7.40 (Tier 2) QL Laxatives Bisac-Evac bisac-evac (suppository)* Bisacodyl bisacodyl (suppository)* Bisacodyl EC bisacodyl ec (tablet delayed-release)* Biscolax biscolax (suppository)* ClearLax clearlax (powder)* Constulose constulose (oral solution) Copper Trace Metal copper trace metal (injection)* Doc-Q-Lax doc-q-lax (tablet)* You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

68 For Track Refered Purpose 68 Docusate Sodium & Senna Stimulant Laxative/Stool Softener docusate sodium & senna stimulant laxative/stool softener (tablet)* DOK PLUS dok plus (tablet)* Ducodyl ducodyl (tablet delayed-release)* Enulose enulose (oral solution) Fiber Tabs fiber tabs (tablet)* Fiber-Lax fiber-lax (tablet)* Fleet Bisacodyl fleet bisacodyl (enema)* Fleet Laxative fleet laxative (tablet delayed-release)* GaviLAX gavilax (powder)* GaviLyte-C gavilyte-c (oral solution) GaviLyte-G gavilyte-g (oral solution) GaviLyte-H gavilyte-h (kit) GaviLyte-N/Flavor Pack gavilyte-n/flavor pack (oral solution) Generlac generlac (oral solution) Glycolax glycolax (powder)* GNP Bisa-Lax gnp bisa-lax (tablet delayed-release)* GNP Clearlax gnp clearlax (powder)* GNP Fiber-Caps gnp fiber-caps (tablet)* GNP Laxative gnp laxative (10mg suppository, 5mg tablet delayedrelease)* GNP Lubricant Eye Drops gnp lubricant eye drops (ophthalmic solution)* GNP Milk of Magnesia gnp milk of magnesia (suspension)* GNP Senna Plus gnp senna plus (tablet)* GNP Stool Softener/Stimulant Laxative gnp stool softener/stimulant laxative (tablet)* GNP Ultra Lubricant Eye Drops gnp ultra lubricant eye drops (ophthalmic solution)* HealthyLax healthylax (packet)* HM Clearlax hm clearlax (powder)* HM Laxative hm laxative (tablet delayed-release)* HM Milk of Magnesia hm milk of magnesia (suspension)* HM Senna-S hm senna-s (tablet)* HM Stool Softener/Laxative hm stool softener/laxative (tablet)* Konsyl Fiber konsyl fiber (tablet)* Lactulose lactulose (oral solution) Laxative laxative (10mg suppository, 5mg tablet delayed-release)* Lubricant Eye Drops Dry Eye Therapy lubricant eye drops dry eye therapy (ophthalmic solution)* Magnesium Oxide magnesium oxide (otc only) (tablet)* Mag-Tab SR mag-tab sr (otc only) (tablet extended-release)* Manganese Trace Metal manganese trace metal (injection)*

69 For Track Refered Purpose 69 Milk of Magnesia milk of magnesia (suspension)* Milk of Magnesia Concentrate milk of magnesia concentrate (suspension)* Miralax miralax (otc only) (packet, powder)* PEG-3350/Electrolytes peg-3350/electrolytes (oral solution) (generic golytely) PEG-3350/NaCl/Na Bicarbonate/KCl PEG-3350/NACL/NA BICARBONATE/KCL (ORAL $3.60-$7.40 (Tier 2) SOLUTION) (GENERIC NULYTELY) Polyethylene Glycol 3350 Powder polyethylene glycol 3350 powder (rx only) (generic miralax) QC Enema qc enema* QC Gentle Laxative qc gentle laxative (10mg suppository, 5mg tablet delayedrelease)* QC Milk of Magnesia qc milk of magnesia (suspension)* QC Senna-S qc senna-s (tablet)* QC Stool Softener Plus Laxative qc stool softener plus laxative (tablet)* Senexon-S senexon-s (tablet)* Senna Plus senna plus (tablet)* Sennalax-S sennalax-s (tablet)* Senna-S senna-s (tablet)* Sennosides/Docusate Sodium sennosides/docusate sodium (tablet)* SM Clearlax sm clearlax (powder)* SM Gentle Laxative sm gentle laxative (tablet delayed-release)* SM Laxative sm laxative (suppository)* SM Lubricant Eye Drops sm lubricant eye drops (ophthalmic solution)* SM Milk of Magnesia sm milk of magnesia (suspension)* SM Natural Laxative Plus Stool Softener sm natural laxative plus stool softener (tablet)* SM Stool Softener Plus Laxative sm stool softener plus laxative (tablet)* SM Womans Laxative sm womans laxative (tablet delayed-release)* Stimulant Laxative stimulant laxative (tablet delayed-release)* Suprep Bowel Prep SUPREP BOWEL PREP (ORAL SOLUTION) $3.60-$7.40 (Tier 2) Systane systane (ophthalmic solution)* Systane Gel systane gel* Systane Ultra systane ultra (ophthalmic solution)* You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

70 For Track Refered Purpose 70 TriLyte trilyte (oral solution) Womans Laxative womans laxative (tablet delayed-release)* Protectants Carafate CARAFATE (1GM/10ML SUSPENSION) $3.60-$7.40 (Tier 2) Misoprostol misoprostol (tablet) Sucralfate sucralfate (tablet) Proton Pump Inhibitors Esomeprazole Magnesium esomeprazole magnesium (rx only) (capsule delayedrelease) (generic nexium) QL Esomeprazole Sodium esomeprazole sodium (rx only) (injection) GNP Omeprazole gnp omeprazole (otc only) (20mg tablet delayed-release)* HM Omeprazole hm omeprazole (otc only) (20mg tablet delayed-release)* Nexium NEXIUM (RX ONLY) (10MG PACKET, 2.5MG PACKET, 20MG PACKET, 40MG PACKET, 5MG $3.60-$7.40 (Tier 2) PACKET) Nexium NEXIUM (RX ONLY) (20MG CAPSULE DELAYED- RELEASE, 40MG CAPSULE DELAYED-RELEASE) $3.60-$7.40 (Tier 2) QL Omeprazole omeprazole (otc only) (20mg tablet delayed-release)* Omeprazole omeprazole (rx only) (10mg capsule delayed-release, 40mg capsule delayed-release) QL Omeprazole omeprazole (rx only) (20mg capsule delayed-release) Pantoprazole Sodium pantoprazole sodium (tablet delayed-release) QL Prilosec OTC prilosec otc (tablet delayed-release)* SM Omeprazole sm omeprazole (otc only) (20mg tablet delayed-release)* Genitourinary Agents Antispasmodics, Urinary Myrbetriq MYRBETRIQ (TABLET EXTENDED-RELEASE 24 HOUR) $3.60-$7.40 (Tier 2) Oxybutynin Chloride oxybutynin chloride (5mg tablet immediate-release, 5mg/ 5ml syrup) Oxybutynin Chloride ER oxybutynin chloride er (tablet extended-release 24 hour) QL Vesicare VESICARE (TABLET) $3.60-$7.40 (Tier 2) QL Benign Prostatic Hypertrophy Agents Alfuzosin HCl ER alfuzosin hcl er (tablet extended-release 24 hour) Finasteride finasteride (5mg tablet) (generic proscar) Rapaflo RAPAFLO (CAPSULE) $3.60-$7.40 (Tier 2) QL

71 For Track Refered Purpose 71 Tamsulosin HCl tamsulosin hcl (capsule) Terazosin HCl terazosin hcl (capsule) Genitourinary Agents, Other Bethanechol Chloride bethanechol chloride (tablet) Cuprimine CUPRIMINE (CAPSULE) $3.60-$7.40 (Tier 2) ST Depen Titratabs DEPEN TITRATABS (TABLET) $3.60-$7.40 (Tier 2) Elmiron ELMIRON (CAPSULE) $3.60-$7.40 (Tier 2) Lithostat LITHOSTAT (TABLET) $3.60-$7.40 (Tier 2) Phosphate Binders Calcium Acetate calcium acetate (capsule) Eliphos eliphos (tablet) Fosrenol FOSRENOL (1000MG PACKET, 750MG PACKET, 1000MG TABLET CHEWABLE, 500MG TABLET $3.60-$7.40 (Tier 2) CHEWABLE, 750MG TABLET CHEWABLE) PhosLo PHOSLO (CAPSULE) $3.60-$7.40 (Tier 2) Phoslyra PHOSLYRA (ORAL SOLUTION) $3.60-$7.40 (Tier 2) Renagel RENAGEL (TABLET) $3.60-$7.40 (Tier 2) ST Renvela RENVELA (0.8GM PACKET, 2.4GM PACKET, 800MG TABLET) $3.60-$7.40 (Tier 2) Velphoro VELPHORO (TABLET CHEWABLE) $3.60-$7.40 (Tier 2) Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) A-Hydrocort a-hydrocort (injection) Ala Cort ala cort (cream) Alclometasone Dipropionate alclometasone dipropionate (0.05% cream, 0.05% ointment) Augmented Betamethasone Dipropionate augmented betamethasone dipropionate (0.05% gel, 0.05% lotion, 0.05% ointment) You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

72 For Track Refered Purpose 72 Beta HC beta hc (lotion)* Betamethasone Dipropionate betamethasone dipropionate (0.05% cream, 0.05% lotion, 0.05% ointment) Betamethasone Valerate betamethasone valerate (0.1% cream, 0.1% lotion, 0.1% ointment) Clobetasol Propionate clobetasol propionate (0.05% external solution, 0.05% gel, 0.05% ointment, 0.05% shampoo) Clobetasol Propionate E clobetasol propionate e (cream) Cormax Scalp Application cormax scalp application (external solution) Cortisone Acetate cortisone acetate (tablet) Depo-Medrol DEPO-MEDROL (20MG/ML INJECTION) $3.60-$7.40 (Tier 2) Desonide desonide (0.05% ointment) Desoximetasone desoximetasone (0.05% cream, 0.25% cream) Dexamethasone dexamethasone (0.5mg tablet, 0.75mg tablet, 1.5mg tablet, 1mg tablet, 2mg tablet, 4mg tablet, 6mg tablet, 0.5mg/5ml elixir) Dexamethasone Intensol dexamethasone intensol (1mg/ml concentrate) Dexamethasone Sodium Phosphate dexamethasone sodium phosphate (10mg/ml injection, 120mg/30ml injection) Fludrocortisone Acetate fludrocortisone acetate (tablet) Fluocinolone Acetonide fluocinolone acetonide (0.01% cream, 0.025% cream, 0.01% external solution, 0.025% ointment) Fluocinonide fluocinonide (0.05% external solution, 0.05% gel, 0.05% ointment) Fluocinonide-E fluocinonide-e (cream) Fluticasone Propionate fluticasone propionate (0.005% ointment, 0.05% cream) GNP Hydrocortisone gnp hydrocortisone (otc only) (0.5% cream)* Halobetasol Propionate halobetasol propionate (0.05% cream, 0.05% ointment) Hydro Skin Maximum Strength hydro skin maximum strength (lotion)* Hydrocortisone hydrocortisone (otc only) (0.5% cream, 1% cream, 0.5% ointment)* Hydrocortisone Butyrate hydrocortisone butyrate (rx only) (0.1% ointment) Hydrocortisone Valerate hydrocortisone valerate (rx only) (0.2% cream, 0.2% ointment) Hydrocortisone hydrocortisone (rx only) (1% cream, 2.5% cream, 1% ointment, 2.5% ointment, 10mg tablet, 20mg tablet, 5mg tablet, 2.5% lotion) Hydrocortisone/Aloe hydrocortisone/aloe (otc only) (cream)* Kenalog-10 KENALOG-10 (INJECTION) $3.60-$7.40 (Tier 2) Kenalog-40 KENALOG-40 (INJECTION) $3.60-$7.40 (Tier 2) Methylprednisolone methylprednisolone (tablet)

73 For Track Refered Purpose 73 Methylprednisolone Acetate methylprednisolone acetate (injection) Methylprednisolone Dose Pack methylprednisolone dose pack (tablet) Methylprednisolone Sodium Succinate methylprednisolone sodium succinate (injection) Millipred millipred (5mg tablet) Mometasone Furoate mometasone furoate (0.1% cream, 0.1% external solution, 0.1% ointment) Prednicarbate PREDNICARBATE (0.1% CREAM) $3.60-$7.40 (Tier 2) Prednicarbate prednicarbate (0.1% ointment) Prednisolone Sodium Phosphate prednisolone sodium phosphate (15mg/5ml oral solution, 25mg/5ml oral solution, 5mg/5ml oral solution) Prednisone prednisone (10mg tablet, 1mg tablet, 2.5mg tablet, 20mg tablet, 50mg tablet, 5mg tablet, 5mg/5ml oral solution) Prednisone Intensol prednisone intensol (5mg/ml concentrate) SM Hydrocortisone sm hydrocortisone (otc only) (cream)* Solu-Cortef SOLU-CORTEF (INJECTION) $3.60-$7.40 (Tier 2) Solu-Medrol SOLU-MEDROL (2GM INJECTION) $3.60-$7.40 (Tier 2) Triamcinolone Acetonide triamcinolone acetonide (cream, lotion, ointment) Triderm triderm (cream) Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) Chorionic Gonadotropin CHORIONIC GONADOTROPIN (INJECTION) $3.60-$7.40 (Tier 2) PA Desmopressin Acetate DESMOPRESSIN ACETATE (0.01% NASAL RHINAL TUBE SOLUTION) $3.60-$7.40 (Tier 2) Desmopressin Acetate desmopressin acetate (0.01% nasal spray solution, 0.1mg tablet, 0.2mg tablet, 4mcg/ml injection) Genotropin GENOTROPIN (12MG INJECTION, 5MG INJECTION) $3.60-$7.40 (Tier 2) PA Genotropin Miniquick GENOTROPIN MINIQUICK (INJECTION) $3.60-$7.40 (Tier 2) PA Humatrope HUMATROPE (INJECTION) $3.60-$7.40 (Tier 2) PA Humatrope Combo Pack HUMATROPE COMBO PACK (INJECTION) $3.60-$7.40 (Tier 2) PA You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

74 For Track Refered Purpose 74 Increlex INCRELEX (INJECTION) $3.60-$7.40 (Tier 2) PA Norditropin FlexPro NORDITROPIN FLEXPRO (INJECTION) $3.60-$7.40 (Tier 2) PA Novarel NOVAREL (INJECTION) $3.60-$7.40 (Tier 2) PA Nutropin AQ NUTROPIN AQ (INJECTION) $3.60-$7.40 (Tier 2) PA Omnitrope OMNITROPE (INJECTION) $3.60-$7.40 (Tier 2) PA Pregnyl w/diluent Benzyl Alcohol/NaCl PREGNYL W/DILUENT BENZYL ALCOHOL/ NACL (INJECTION) $3.60-$7.40 (Tier 2) PA Saizen SAIZEN (INJECTION) $3.60-$7.40 (Tier 2) PA Zomacton ZOMACTON (INJECTION) $3.60-$7.40 (Tier 2) PA Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) Korlym KORLYM (TABLET) $3.60-$7.40 (Tier 2) PA, QL Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) Androgens Anadrol-50 ANADROL-50 (TABLET) $3.60-$7.40 (Tier 2) PA Androderm ANDRODERM (PATCH 24 HOUR) $3.60-$7.40 (Tier 2) PA, QL Androgel ANDROGEL (1.62% PACKET) $3.60-$7.40 (Tier 2) PA Androgel Pump ANDROGEL PUMP (1.62% GEL) $3.60-$7.40 (Tier 2) PA Danazol danazol (capsule) Oxandrolone oxandrolone (tablet) PA, QL Testosterone Cypionate testosterone cypionate (injection) Testosterone Enanthate testosterone enanthate (injection) Estrogens Alora ALORA (PATCH TWICE WEEKLY) $3.60-$7.40 (Tier 2) Amethia amethia (tablet) Amethyst amethyst (tablet) Apri apri (tablet) Aranelle aranelle (tablet) Ashlyna ashlyna (tablet) Aubraubra (tablet) Aviane aviane (tablet) Balziva balziva (tablet) Bekyree bekyree (tablet) Blisovi 24 Fe blisovi 24 fe (tablet) Blisovi Fe 1.5/30 blisovi fe 1.5/30 (tablet)

75 For Track Refered Purpose 75 Blisovi Fe 1/20 blisovi fe 1/20 (tablet) Briellyn briellyn (tablet) Climara Pro CLIMARA PRO (PATCH WEEKLY) $3.60-$7.40 (Tier 2) Cryselle-28 cryselle-28 (tablet) Cyclafem cyclafem (tablet) Delyla delyla (tablet) Desogestrel/Ethinyl Estradiol desogestrel/ethinyl estradiol (tablet) Drospirenone/Ethinyl Estradiol drospirenone/ethinyl estradiol (tablet) Duavee DUAVEE (TABLET) $3.60-$7.40 (Tier 2) Elestrin ELESTRIN (GEL) $3.60-$7.40 (Tier 2) Emoquette emoquette (tablet) Enpresse-28 enpresse-28 (tablet) Estradiol estradiol (0.025mg/24hr patch weekly, 0.05mg/24hr patch weekly, 0.06mg/24hr patch weekly, 0.075mg/24hr patch weekly, 0.1mg/24hr patch weekly, 37.5mcg/24hr patch weekly, 0.5mg tablet, 1mg tablet, 2mg tablet) Estradiol Valerate estradiol valerate (injection) Estring ESTRING (RING) $3.60-$7.40 (Tier 2) Falmina falmina (tablet) Gianvi gianvi (tablet) Gildagia gildagia (tablet) Gildess 1.5/30 gildess 1.5/30 (tablet) Gildess 24 Fe gildess 24 fe (tablet) Introvale introvale (tablet) Jinteli jinteli (tablet) Juleber juleber (tablet) Junel 1.5/30 junel 1.5/30 (tablet) Junel 1/20 junel 1/20 (tablet) Junel Fe 1.5/30 junel fe 1.5/30 (tablet) Junel Fe 1/20 junel fe 1/20 (tablet) Junel Fe 24 junel fe 24 (tablet) You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

76 For Track Refered Purpose 76 Kaitlib Fe kaitlib fe (tablet chewable) Kariva kariva (tablet) Kelnor 1/35 kelnor 1/35 (tablet) Kimidess kimidess (tablet) LARIN 1.5/30 larin 1.5/30 (tablet) LARIN 1/20 larin 1/20 (tablet) LARIN Fe 1.5/30 larin fe 1.5/30 (tablet) LARIN Fe 1/20 larin fe 1/20 (tablet) Layolis Fe layolis fe (tablet chewable) Leena LEENA (TABLET) $3.60-$7.40 (Tier 2) Lessina lessina (tablet) Levonest levonest (tablet) Levonorgestrel and Ethinyl Estradiol levonorgestrel and ethinyl estradiol (rx only) (tablet) Levonorgestrel/Ethinyl Estradiol levonorgestrel/ethinyl estradiol (rx only) (tablet) Levora 0.15/30-28 levora 0.15/30-28 (tablet) Lomedia 24 Fe lomedia 24 fe (tablet) Loryna loryna (tablet) Lutera lutera (tablet) Marlissa marlissa (tablet) Menest menest (tablet) Microgestin 1.5/30 microgestin 1.5/30 (tablet) Microgestin 1/20 microgestin 1/20 (tablet) Microgestin Fe microgestin fe (tablet) Microgestin Fe 1.5/30 microgestin fe 1.5/30 (tablet) MonoNessa MONONESSA (TABLET) $3.60-$7.40 (Tier 2) Necon 0.5/35-28 necon 0.5/35-28 (tablet) Necon 1/35 necon 1/35 (tablet) Necon 1/50-28 NECON 1/50-28 (TABLET) $3.60-$7.40 (Tier 2) Necon 10/11-28 necon 10/11-28 (tablet) Necon 7/7/7 NECON 7/7/7 (TABLET) $3.60-$7.40 (Tier 2) Nikki nikki (tablet) Norethindrone & Ethinyl Estradiol Ferrous Fumarate norethindrone & ethinyl estradiol ferrous fumarate (tablet chewable) Norethindrone Acetate/Ethinyl Estradiol/Ferrous Fumarate norethindrone acetate/ethinyl estradiol/ferrous fumarate (tablet) Norgestimate/Ethinyl Estradiol norgestimate/ethinyl estradiol (tablet) Nortrel 0.5/35 nortrel 0.5/35 (28) (tablet) Nortrel 1/35 nortrel 1/35 (tablet)

77 For Track Refered Purpose 77 Nortrel 7/7/7 nortrel 7/7/7 (tablet) NuvaRing NUVARING (RING) $3.60-$7.40 (Tier 2) Ocella OCELLA (TABLET) $3.60-$7.40 (Tier 2) Ogestrel ogestrel (tablet) Orsythia orsythia (tablet) Pimtrea pimtrea (tablet) Pirmella 1/35 pirmella 1/35 (tablet) Portia-28 portia-28 (tablet) Premarin PREMARIN (TABLET, VAGINAL CREAM) $3.60-$7.40 (Tier 2) Premphase PREMPHASE (TABLET) $3.60-$7.40 (Tier 2) Prempro PREMPRO (TABLET) $3.60-$7.40 (Tier 2) Previfem previfem (tablet) Quasense quasense (tablet) Reclipsen reclipsen (tablet) Setlakin setlakin (tablet) Sprintec 28 sprintec 28 (tablet) Sronyx sronyx (tablet) Tarina Fe 1/20 tarina fe 1/20 (tablet) Tri-Legest Fe tri-legest fe (tablet) Tri-Lo-Estarylla tri-lo-estarylla (tablet) Tri-Lo-Sprintec tri-lo-sprintec (tablet) Trinessa TRINESSA (TABLET) $3.60-$7.40 (Tier 2) Tri-Previfem tri-previfem (tablet) Tri-Sprintec tri-sprintec (tablet) Trivora-28 trivora-28 (tablet) Velivet velivet (tablet) Vestura vestura (tablet) Vienva vienva (tablet) Vyfemla vyfemla (tablet) Fe WYMZYA FE (TABLET CHEWABLE) $3.60-$7.40 (Tier 2) You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

78 For Track Refered Purpose 78 Zenchent zenchent (tablet) Zenchent Fe zenchent fe (tablet chewable) Zovia 1/35E zovia 1/35e (tablet) Zovia 1/50E zovia 1/50e (tablet) Progestins Camila camila (tablet) Crinone CRINONE (GEL) $3.60-$7.40 (Tier 2) Deblitane deblitane (tablet) Depo-Provera DEPO-PROVERA (INJECTION) $3.60-$7.40 (Tier 2) Errin errin (tablet) Fallback Solo fallback solo (tablet)* Jolivette JOLIVETTE (TABLET) $3.60-$7.40 (Tier 2) Levonorgestrel levonorgestrel (otc only) (tablet)* Lyza lyza (tablet) Makena MAKENA (INJECTION) $3.60-$7.40 (Tier 2) PA Medroxyprogesterone Acetate medroxyprogesterone acetate (10mg tablet, 2.5mg tablet, 5mg tablet, 150mg/ml injection) Megace ES MEGACE ES (SUSPENSION) $3.60-$7.40 (Tier 2) Megace Oral MEGACE ORAL (SUSPENSION) $3.60-$7.40 (Tier 2) Megestrol Acetate megestrol acetate (20mg tablet, 40mg tablet, 40mg/ml suspension, 625mg/5ml suspension) My Way my way (otc only) (tablet)* Next Choice One Dose next choice one dose (otc only) (tablet)* Nora-BE NORA-BE (TABLET) $3.60-$7.40 (Tier 2) Norethindrone norethindrone (tablet) Norethindrone Acetate norethindrone acetate (tablet) Norlyroc norlyroc (tablet) Opcicon One-Step opcicon one-step (otc only) (tablet)* Plan B One-Step plan b one-step (otc only) (tablet)* Sharobel sharobel (tablet) Take Action take action (tablet)* Selective Estrogen Receptor Modifying Agents Raloxifene HCl raloxifene hcl (tablet) QL Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)

79 For Track Refered Purpose 79 Levothyroxine Sodium LEVOTHYROXINE SODIUM (100MCG $3.60-$7.40 (Tier 2) INJECTION) Levothyroxine Sodium levothyroxine sodium (tablet) Levoxyl LEVOXYL (TABLET) $3.60-$7.40 (Tier 2) Liothyronine Sodium liothyronine sodium (10mcg/ml injection, 25mcg tablet, 50mcg tablet, 5mcg tablet) Synthroid SYNTHROID (TABLET) $3.60-$7.40 (Tier 2) Thyrolar THYROLAR (TABLET) $3.60-$7.40 (Tier 2) Unithroid UNITHROID (TABLET) $3.60-$7.40 (Tier 2) Hormonal Agents, Suppressant (Adrenal) Hormonal Agents, Suppressant (Adrenal) Lysodren LYSODREN (TABLET) $3.60-$7.40 (Tier 2) Hormonal Agents, Suppressant (Parathyroid) Hormonal Agents, Suppressant (Parathyroid) Sensipar SENSIPAR (TABLET) $3.60-$7.40 (Tier 2) QL Hormonal Agents, Suppressant (Pituitary) Hormonal Agents, Suppressant (Pituitary) Cabergoline cabergoline (tablet) Egrifta EGRIFTA (INJECTION) $3.60-$7.40 (Tier 2) PA Firmagon FIRMAGON (INJECTION) $3.60-$7.40 (Tier 2) PA Leuprolide Acetate leuprolide acetate (injection) PA Lupaneta Pack LUPANETA PACK (KIT) $3.60-$7.40 (Tier 2) PA Lupron Depot LUPRON DEPOT (INJECTION) $3.60-$7.40 (Tier 2) PA Lupron Depot-PED LUPRON DEPOT-PED (INJECTION) $3.60-$7.40 (Tier 2) PA Octreotide Acetate octreotide acetate (injection) PA Sandostatin LAR Depot SANDOSTATIN LAR DEPOT (INJECTION) $3.60-$7.40 (Tier 2) PA Signifor SIGNIFOR (INJECTION) $3.60-$7.40 (Tier 2) PA You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

80 For Track Refered Purpose 80 Somatuline Depot SOMATULINE DEPOT (INJECTION) $3.60-$7.40 (Tier 2) PA Somavert SOMAVERT (INJECTION) $3.60-$7.40 (Tier 2) PA Synarel SYNAREL (NASAL SOLUTION) $3.60-$7.40 (Tier 2) Trelstar Mixject TRELSTAR MIXJECT (INJECTION) $3.60-$7.40 (Tier 2) PA Hormonal Agents, Suppressant (Thyroid) Antithyroid Agents Methimazole methimazole (tablet) Propylthiouracil propylthiouracil (tablet) Immunological Agents Angioedema (HAE) Agents Berinert BERINERT (INJECTION) $3.60-$7.40 (Tier 2) PA, LA Cinryze CINRYZE (INJECTION) $3.60-$7.40 (Tier 2) PA, LA Firazyr FIRAZYR (INJECTION) $3.60-$7.40 (Tier 2) PA Ruconest RUCONEST (INJECTION) $3.60-$7.40 (Tier 2) PA Immune Suppressants Azathioprine azathioprine (tablet) B/D, PA Cellcept CELLCEPT (200MG/ML SUSPENSION) $3.60-$7.40 (Tier 2) PA Cellcept Intravenous CELLCEPT INTRAVENOUS (INJECTION) $3.60-$7.40 (Tier 2) PA Cimzia CIMZIA (INJECTION) $3.60-$7.40 (Tier 2) PA Cyclosporine cyclosporine (100mg capsule, 25mg capsule) B/D, PA Cyclosporine cyclosporine (50mg/ml injection) Cyclosporine Modified cyclosporine modified (100mg capsule, 25mg capsule, 50mg capsule, 100mg/ml oral solution) B/D, PA Enbrel ENBREL (INJECTION) $3.60-$7.40 (Tier 2) PA Enbrel SureClick ENBREL SURECLICK (INJECTION) $3.60-$7.40 (Tier 2) PA Gengraf gengraf (100mg capsule, 25mg capsule, 100mg/ml oral solution) B/D, PA Humira HUMIRA (INJECTION) $3.60-$7.40 (Tier 2) PA Humira Pediatric Crohns Disease Starter Pack HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK (INJECTION) $3.60-$7.40 (Tier 2) PA Humira Pen HUMIRA PEN (INJECTION) $3.60-$7.40 (Tier 2) PA Humira Pen Crohns Disease Starter Pack HUMIRA PEN CROHNS DISEASE STARTER PACK (INJECTION) $3.60-$7.40 (Tier 2) PA Kineret KINERET (INJECTION) $3.60-$7.40 (Tier 2) PA Methotrexate methotrexate (tablet)

81 For Track Refered Purpose 81 Methotrexate Sodium methotrexate sodium (injection) Mycophenolate Mofetil mycophenolate mofetil (200mg/ml suspension, 250mg capsule, 500mg tablet) PA Mycophenolic Acid DR mycophenolic acid dr (tablet delayed-release) B/D, PA Nulojix NULOJIX (INJECTION) $3.60-$7.40 (Tier 2) PA Orencia ORENCIA (125MG/ML INJECTION, 250MG INJECTION) $3.60-$7.40 (Tier 2) PA Prograf PROGRAF (5MG/ML INJECTION) $3.60-$7.40 (Tier 2) PA Rapamune RAPAMUNE (1MG TABLET, 2MG TABLET, 1MG/ ML ORAL SOLUTION) $3.60-$7.40 (Tier 2) B/D, PA Remicade REMICADE (INJECTION) $3.60-$7.40 (Tier 2) PA Sandimmune SANDIMMUNE (100MG CAPSULE, 100MG/ML ORAL SOLUTION) $3.60-$7.40 (Tier 2) B/D, PA Simponi SIMPONI (INJECTION) $3.60-$7.40 (Tier 2) PA Simponi Aria SIMPONI ARIA (INJECTION) $3.60-$7.40 (Tier 2) PA Sirolimus sirolimus (tablet) B/D, PA Stelara STELARA (INJECTION) $3.60-$7.40 (Tier 2) PA Tacrolimus tacrolimus (0.5mg capsule, 1mg capsule, 5mg capsule) PA Torisel TORISEL (INJECTION) $3.60-$7.40 (Tier 2) Trexall trexall (tablet) Xeljanz XELJANZ (TABLET) $3.60-$7.40 (Tier 2) PA, QL Xeljanz XR XELJANZ XR (TABLET EXTENDED-RELEASE 24 HOUR) $3.60-$7.40 (Tier 2) PA, QL Zortress ZORTRESS (TABLET) $3.60-$7.40 (Tier 2) PA Immunizing Agents, Passive Atgam ATGAM (INJECTION) $3.60-$7.40 (Tier 2) BIVIGAM (INJECTION) $3.60-$7.40 (Tier 2) PA Carimune Nanofiltered CARIMUNE NANOFILTERED (INJECTION) $3.60-$7.40 (Tier 2) PA Flebogamma DIF FLEBOGAMMA DIF (INJECTION) $3.60-$7.40 (Tier 2) PA Gamastan S/D GAMASTAN S/D (INJECTION) $3.60-$7.40 (Tier 2) PA You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

82 For Track Refered Purpose 82 Gammagard Liquid GAMMAGARD LIQUID (INJECTION) $3.60-$7.40 (Tier 2) PA Gammaked GAMMAKED (INJECTION) $3.60-$7.40 (Tier 2) PA Gammaplex GAMMAPLEX (INJECTION) $3.60-$7.40 (Tier 2) PA Gamunex-C GAMUNEX-C (INJECTION) $3.60-$7.40 (Tier 2) PA Octagam OCTAGAM (INJECTION) $3.60-$7.40 (Tier 2) PA Privigen PRIVIGEN (INJECTION) $3.60-$7.40 (Tier 2) PA Thymoglobulin THYMOGLOBULIN (INJECTION) $3.60-$7.40 (Tier 2) Varizig VARIZIG (INJECTION) $3.60-$7.40 (Tier 2) Immunomodulators Actemra ACTEMRA (162MG/0.9ML INJECTION, 200MG/ 10ML INJECTION, 400MG/20ML INJECTION, $3.60-$7.40 (Tier 2) PA 80MG/4ML INJECTION) Actimmune ACTIMMUNE (INJECTION) $3.60-$7.40 (Tier 2) Arcalyst ARCALYST (INJECTION) $3.60-$7.40 (Tier 2) PA, LA Benlysta BENLYSTA (INJECTION) $3.60-$7.40 (Tier 2) PA Ilaris ILARIS (INJECTION) $3.60-$7.40 (Tier 2) PA, LA Leflunomide leflunomide (tablet) Otezla OTEZLA (TABLET THERAPY PACK, 30MG TABLET) $3.60-$7.40 (Tier 2) PA Ridaura RIDAURA (CAPSULE) $3.60-$7.40 (Tier 2) Simulect SIMULECT (INJECTION) $3.60-$7.40 (Tier 2) Synagis SYNAGIS (INJECTION) $3.60-$7.40 (Tier 2) PA Vaccines ActHIB ACTHIB (INJECTION) $3.60-$7.40 (Tier 2) Adacel ADACEL (INJECTION) $3.60-$7.40 (Tier 2) Vaccine BCG VACCINE (INJECTION) $3.60-$7.40 (Tier 2) Bexsero BEXSERO (INJECTION) $3.60-$7.40 (Tier 2) Boostrix BOOSTRIX (INJECTION) $3.60-$7.40 (Tier 2) Cervarix CERVARIX (INJECTION) $3.60-$7.40 (Tier 2) Daptacel DAPTACEL (INJECTION) $3.60-$7.40 (Tier 2) Diphtheria/Tetanus Toxoids Adsorbed Pediatric DIPHTHERIA/TETANUS TOXOIDS ADSORBED PEDIATRIC (INJECTION) $3.60-$7.40 (Tier 2) Engerix-B ENGERIX-B (INJECTION) $3.60-$7.40 (Tier 2) B/D, PA Gardasil GARDASIL (INJECTION) $3.60-$7.40 (Tier 2) Gardasil 9 GARDASIL 9 (INJECTION) $3.60-$7.40 (Tier 2) Havrix HAVRIX (INJECTION) $3.60-$7.40 (Tier 2)

83 For Track Refered Purpose 83 Imovax Rabies IMOVAX RABIES (H.D.C.V.) (INJECTION) $3.60-$7.40 (Tier 2) B/D, PA Infanrix INFANRIX (INJECTION) $3.60-$7.40 (Tier 2) Inactivated IPV IPOL INACTIVATED IPV (INJECTION) $3.60-$7.40 (Tier 2) Ixiaro IXIARO (INJECTION) $3.60-$7.40 (Tier 2) Menactra MENACTRA (INJECTION) $3.60-$7.40 (Tier 2) Menomune-A/C/Y/W-135 MENOMUNE-A/C/Y/W-135 (INJECTION) $3.60-$7.40 (Tier 2) Menveo MENVEO (INJECTION) $3.60-$7.40 (Tier 2) II M-M-R II (INJECTION) $3.60-$7.40 (Tier 2) Pedvax HIB PEDVAX HIB (INJECTION) $3.60-$7.40 (Tier 2) ProQuad PROQUAD (INJECTION) $3.60-$7.40 (Tier 2) Quadracel QUADRACEL (INJECTION) $3.60-$7.40 (Tier 2) Rabavert RABAVERT (INJECTION) $3.60-$7.40 (Tier 2) B/D, PA Recombivax HB RECOMBIVAX HB (INJECTION) $3.60-$7.40 (Tier 2) B/D, PA Rotarix ROTARIX (SUSPENSION) $3.60-$7.40 (Tier 2) RotaTeq ROTATEQ (ORAL SOLUTION) $3.60-$7.40 (Tier 2) Tenivac TENIVAC (INJECTION) $3.60-$7.40 (Tier 2) Tetanus/Diphtheria Toxoids-Adsorbed Adult TETANUS/DIPHTHERIA TOXOIDS-ADSORBED ADULT (INJECTION) $3.60-$7.40 (Tier 2) Trumenba TRUMENBA (INJECTION) $3.60-$7.40 (Tier 2) Twinrix TWINRIX (INJECTION) $3.60-$7.40 (Tier 2) Typhim Vi TYPHIM VI (INJECTION) $3.60-$7.40 (Tier 2) VAQTA (INJECTION) $3.60-$7.40 (Tier 2) Varivax VARIVAX (INJECTION) $3.60-$7.40 (Tier 2) YF-Vax YF-VAX (INJECTION) $3.60-$7.40 (Tier 2) Zostavax ZOSTAVAX (INJECTION) $3.60-$7.40 (Tier 2) PA Inflammatory Bowel Disease Agents Aminosalicylates Apriso APRISO (CAPSULE EXTENDED-RELEASE 24 HOUR) $3.60-$7.40 (Tier 2) QL You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

84 For Track Refered Purpose 84 Balsalazide Disodium balsalazide disodium (capsule) Canasa CANASA (SUPPOSITORY) $3.60-$7.40 (Tier 2) Dipentum DIPENTUM (CAPSULE) $3.60-$7.40 (Tier 2) Giazo GIAZO (TABLET) $3.60-$7.40 (Tier 2) Lialda LIALDA (TABLET DELAYED-RELEASE) $3.60-$7.40 (Tier 2) QL Mesalamine mesalamine (kit) sfrowasa SFROWASA (ENEMA) $3.60-$7.40 (Tier 2) QL Glucocorticoids Budesonide budesonide (3mg capsule delayed-release) Colocort colocort (enema) Entocort EC ENTOCORT EC (CAPSULE DELAYED-RELEASE) $3.60-$7.40 (Tier 2) Hydrocortisone HYDROCORTISONE (RX ONLY) (100MG/60ML ENEMA) $3.60-$7.40 (Tier 2) Procto-Pak procto-pak (cream) Proctosol HC proctosol hc (cream) Proctozone-HC proctozone-hc (cream) Uceris UCERIS (9MG TABLET EXTENDED-RELEASE 24 HOUR) $3.60-$7.40 (Tier 2) ST Sulfonamides Sulfasalazine sulfasalazine (500mg tablet delayed-release, 500mg tablet immediate-release) Metabolic Bone Disease Agents Metabolic Bone Disease Agents Alendronate Sodium alendronate sodium (10mg tablet, 35mg tablet, 40mg tablet, 5mg tablet, 70mg tablet) QL Alendronate Sodium alendronate sodium (70mg/75ml oral solution) Binosto BINOSTO (TABLET EFFERVESCENT) $3.60-$7.40 (Tier 2) QL Calcitonin-Salmon calcitonin-salmon (nasal solution) Calcitriol calcitriol (0.25mcg capsule, 0.5mcg capsule, 1mcg/ml injection, 1mcg/ml oral solution) B/D, PA Doxercalciferol doxercalciferol (0.5mcg capsule, 1mcg capsule, 2.5mcg capsule) B/D, PA, QL Doxercalciferol doxercalciferol (4mcg/2ml injection) B/D, PA Etidronate Disodium etidronate disodium (tablet) Forteo FORTEO (INJECTION) $3.60-$7.40 (Tier 2) PA, QL Miacalcin MIACALCIN (200UNIT/ML INJECTION) $3.60-$7.40 (Tier 2) PA

85 For Track Refered Purpose 85 Natpara NATPARA (INJECTION) $3.60-$7.40 (Tier 2) PA Pamidronate Disodium pamidronate disodium (injection) B/D, PA Paricalcitol paricalcitol (1mcg capsule, 2mcg capsule) B/D, PA, QL Paricalcitol PARICALCITOL (2MCG/ML INJECTION, 5MCG/ ML INJECTION) $3.60-$7.40 (Tier 2) B/D, PA Paricalcitol paricalcitol (4mcg capsule) B/D, PA Prolia PROLIA (INJECTION) $3.60-$7.40 (Tier 2) PA Rocaltrol ROCALTROL (0.25MCG CAPSULE, 0.5MCG CAPSULE, 1MCG/ML ORAL SOLUTION) $3.60-$7.40 (Tier 2) B/D, PA Xgeva XGEVA (INJECTION) $3.60-$7.40 (Tier 2) PA Zemplar ZEMPLAR (2MCG/ML INJECTION, 5MCG/ML INJECTION) $3.60-$7.40 (Tier 2) B/D, PA Zoledronic Acid zoledronic acid (4mg/5ml injection) B/D, PA Zoledronic Acid zoledronic acid (5mg/100ml injection) PA Zometa ZOMETA (INJECTION) $3.60-$7.40 (Tier 2) B/D, PA Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents ACE Aerosol Cloud Enhancer ace aerosol cloud enhancer* Adult Mask Large adult mask large* Aerochamber Mini Aerosol Chamber aerochamber mini aerosol chamber* Aerochamber MV aerochamber mv* Aerochamber Plus Flow Vu aerochamber plus flow vu* Aerochamber Plus Flow Vu aerochamber plus flow vu* Aerochamber Plus Flow Vu/Large Mask aerochamber plus flow vu/large mask* Aerochamber Plus Flow Vu/Mask aerochamber plus flow vu/mask* Aerochamber Plus Flow Vu/Medium Mask aerochamber plus flow vu/medium mask* Aerochamber Plus Flow Vu/Small Mask aerochamber plus flow vu/small mask* Aerochamber Plus/Small Mask aerochamber plus/small mask* Aerochamber Z-Stat Plus Valved Holding Chamber w/flow Vu aerochamber z-stat plus valved holding chamber w/flow vu* You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

86 For Track Refered Purpose 86 Aerochamber Z-Stat Plus/Flowsignal aerochamber z-stat plus/flowsignal* Aerochamber Z-Stat Plus/Large Mask aerochamber z-stat plus/large mask* Aerochamber Z-Stat Plus/Medium Mask aerochamber z-stat plus/medium mask* Aerochamber Z-Stat Plus/Small Mask aerochamber z-stat plus/small mask* Aerochamber/Flow Signal aerochamber/flow signal* Aerogear Asthma Action aerogear asthma action (kit)* Aerotrach Plus aerotrach plus* Aimsco Lubricated aimsco lubricated* Airzone Peak Flow Meter airzone peak flow meter (device)* Alcohol Prep Pads alcohol prep pads Amlactin Ultra amlactin ultra (cream)* Assess Full Range Peak Flow Meter assess full range peak flow meter (device)* Asthma Check Meter-Zone System asthma check meter-zone system (device)* Asthmamentor asthmamentor (device)* Asthmapack for Children asthmapack for children (kit)* Botox BOTOX (INJECTION) $3.60-$7.40 (Tier 2) PA, QL BreatheRite Valved MDI Chamber/Collapsible breatherite valved mdi chamber/collapsible (device)* BreatheRite Valved MDI Chamber/Rigid breatherite valved mdi chamber/rigid (device)* Co Q-10 co q-10 (capsule)* Co Q-10 Plus co q-10 plus (capsule)* Co-Enzyme Q-10 co-enzyme q-10 (capsule)* Cyto-Q Max cyto-q max (liquid)* Easivent easivent* E-Z Spacer e-z spacer (device)* Fantasy Lubricated fantasy lubricated* Fantasy Lubricated/Spermicide fantasy lubricated/spermicide* Fomepizole fomepizole (injection) Gauze gauze (non-medicated 2x2) In-Check Inspiratory Flow Meter/Nasal with Mask in-check inspiratory flow meter/nasal with mask (device)* In-Check Inspiratory Flow Meter/Oral in-check inspiratory flow meter/oral (device)* Inspirachamber/Anti-Static Valved/Mouthpiece inspirachamber/anti-static valved/mouthpiece (device)* Inspirachamber/Soother Mask/Inspiramask/Medium inspirachamber/soother mask/inspiramask/medium (device)* Inspirachamber/Soother Mask/Inspiramask/Small inspirachamber/soother mask/inspiramask/small (device)* Insulin Syringes, Needles insulin syringes, needles Kanuma KANUMA (INJECTION) $3.60-$7.40 (Tier 2) PA Kimono Lubricated kimono lubricated* Kimono Micro Thin kimono micro thin*

87 For Track Refered Purpose 87 Kimono Micro Thin Plus Spermicide Lubricated kimono micro thin plus spermicide lubricated* Kimono Sensation Lubricated kimono sensation lubricated* Kimono Sensation Plus Spermicide Lubricated kimono sensation plus spermicide lubricated* Liq-10 liq-10 (syrup)* LiteAire liteaire (device)* Maxx Lubricated maxx lubricated* Methylergonovine Maleate methylergonovine maleate (0.2mg tablet) Microchamber microchamber* Microlife Digital Peak Flow Meter microlife digital peak flow meter (device)* Microspacer microspacer* Mini Wright AFS Peak Flow Meter Low Range mini wright afs peak flow meter low range (device)* Mini Wright Peak Flow Meter mini wright peak flow meter (device)* Myalept MYALEPT (INJECTION) $3.60-$7.40 (Tier 2) PA Natural Coenzyme Q10 natural coenzyme q10 (capsule)* Nessi Spacer/Large Mask nessi spacer/large mask (device)* Nessi Spacer/Mouthpiece nessi spacer/mouthpiece (device)* Nessi Spacer/Small/Med Mask nessi spacer/small/med mask (device)* Optichamber Diamond optichamber diamond (holding chamber)* Optichamber Diamond/Large Face Mask optichamber diamond/large face mask (device)* Optichamber Diamond/Medium Face Mask optichamber diamond/medium face mask* Optichamber Diamond/Small Face Mask optichamber diamond/small face mask* Ora-Blend ora-blend (suspension)* Ora-Blend SF ora-blend sf (suspension)* Peak Air Peak Flow Meter Adult/Pediatric peak air peak flow meter adult/pediatric (device)* Pediatric Medium Mask pediatric medium mask* Pediatric Small Mask pediatric small mask* Personal Best Full Range personal best full range (device)* Personal Best Low Range personal best low range (device)* Piko 1 Electronic piko 1 electronic (device)* Pocket Chamber pocket chamber (device)* You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

88 For Track Refered Purpose 88 Pocket Peak Flow Meter pocket peak flow meter (device)* Premium Condoms Lubricated premium condoms lubricated* PrimeAire Dual-Valved Holding Chamber primeaire dual-valved holding chamber (device)* Q-Gel Mega q-gel mega (capsule)* Rite Flo rite flo (device)* Sesame Oil sesame oil* Sidestream Pediatric Facemask/Tucker the Turtle sidestream pediatric facemask/tucker the turtle* Silicone Mask for BreatheRite Chamber/Infant silicone mask for breatherite chamber/infant* Silicone Mask for BreatheRite Chamber/Pediatric silicone mask for breatherite chamber/pediatric* Sterile Water for Injection sterile water for injection* Sterile Water Irrigation STERILE WATER IRRIGATION (IRRIGATION $3.60-$7.40 (Tier 2) SOLUTION) Systane Balance Restorative Formula systane balance restorative formula (ophthalmic solution)* Trustex Lubricated trustex lubricated* Trustex Lubricated Extra Large trustex lubricated extra large* Trustex Lubricated Extra Strength trustex lubricated extra strength* Trustex Lubricated/Ribbed/Studded trustex lubricated/ribbed/studded* Trustex Lubricated/Spermicide trustex lubricated/spermicide* Trustex Lubricated/Spermicide Extra Large trustex lubricated/spermicide extra large* Trustex Lubricated/Spermicide Extra Strength trustex lubricated/spermicide extra strength* Trustex Non-Lubricated trustex non-lubricated* Trustex with Nonoxynol-9/Ribbed/Studded trustex with nonoxynol-9/ribbed/studded* Trustex/Ria Lubricated trustex/ria lubricated* Trustex/Ria Lubricated Spermicide trustex/ria lubricated spermicide* Trustex/Ria Lubricated/Spermicide trustex/ria lubricated/spermicide* Trustex/Ria Non-Lubricated trustex/ria non-lubricated* TruZone Peak Flow Meter truzone peak flow meter (device)* Valved Holding Chamber valved holding chamber (device)* Vortex Holding Chamber/Mask/Childs vortex holding chamber/mask/childs (device)* Vortex Holding Chamber/Mask/Toddler vortex holding chamber/mask/toddler (device)* Vortex Valved Holding Chamber vortex valved holding chamber (device)* WatchHaler watchhaler (device)* Ophthalmic Agents Ophthalmic Agents, Other Akwa Tears akwa tears (ointment)* Alaway alaway (ophthalmic solution)*

89 For Track Refered Purpose 89 Alaway Childrens Allergy Eye Itch Relief alaway childrens allergy eye itch relief (ophthalmic solution)* Artificial Tears artificial tears (ointment, ophthalmic solution)* Bacitracin/Polymyxin B bacitracin/polymyxin b (rx only) (ophthalmic ointment) Bion Tears bion tears (ophthalmic solution)* Blephamide BLEPHAMIDE (SUSPENSION) $3.60-$7.40 (Tier 2) Blephamide S.O.P. blephamide s.o.p. (ointment) Cystaran CYSTARAN (OPHTHALMIC SOLUTION) $3.60-$7.40 (Tier 2) Dermaphor dermaphor (ointment)* Freshkote freshkote (ophthalmic solution)* Genteal Mild genteal mild (ophthalmic solution)* Genteal Mild to Moderate genteal mild to moderate (ophthalmic solution)* Genteal Severe genteal severe (gel)* GNP Artificial Tears gnp artificial tears (ophthalmic solution)* GNP Eye Itch Relief gnp eye itch relief (ophthalmic solution)* GNP Itchy Eye gnp itchy eye (ophthalmic solution)* GNP Lubricating Plus Eye Drops gnp lubricating plus eye drops (ophthalmic solution)* HM Artificial Tears hm artificial tears (ophthalmic solution)* HM Eye Itch Relief hm eye itch relief (ophthalmic solution)* HM Lubricating Plus hm lubricating plus (ophthalmic solution)* Isopto Tears isopto tears (ophthalmic solution)* Ketotifen Fumarate ketotifen fumarate (ophthalmic solution)* Lacrisert LACRISERT (INSERT) $3.60-$7.40 (Tier 2) Lastacaft LASTACAFT (OPHTHALMIC SOLUTION) $3.60-$7.40 (Tier 2) Lubricating Plus Eye Drops lubricating plus eye drops (0.5% ophthalmic solution)* Naphazoline HCl naphazoline hcl (ophthalmic solution) Neomycin/Bacitracin/Polymyxin neomycin/bacitracin/polymyxin (rx only) (ophthalmic ointment) Neomycin/Polymyxin/Bacitracin/Hydrocortisone neomycin/polymyxin/bacitracin/hydrocortisone (rx only) (ophthalmic ointment) You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

90 For Track Refered Purpose 90 Neomycin/Polymyxin/Dexamethasone neomycin/polymyxin/dexamethasone (0.1% ophthalmic ointment, 0.1% ophthalmic suspension) Neomycin/Polymyxin/Gramicidin neomycin/polymyxin/gramicidin (ophthalmic solution) Neomycin/Polymyxin/Hydrocortisone neomycin/polymyxin/hydrocortisone (rx only) (1% ophthalmic suspension) Opti-Clear opti-clear (ophthalmic solution)* Ora-Plus ora-plus (liquid)* Polymyxin B Sulfate/Trimethoprim Sulfate polymyxin b sulfate/trimethoprim sulfate (ophthalmic solution) Proparacaine HCl proparacaine hcl (ophthalmic solution) Pure & Gentle Lubricant pure & gentle lubricant (ophthalmic solution)* Refresh Celluvisc refresh celluvisc (ophthalmic solution)* Refresh Plus refresh plus (ophthalmic solution)* Restasis RESTASIS (EMULSION) $3.60-$7.40 (Tier 2) SM Artificial Tears sm artificial tears (ophthalmic solution)* SM Eye Itch Relief sm eye itch relief (ophthalmic solution)* Sulfacetamide Sodium/Prednisolone Sodium Phosphate sulfacetamide sodium/prednisolone sodium phosphate (ophthalmic solution) Systane Overnight Therapy Lubricant Eye systane overnight therapy lubricant eye (gel)* Tears Naturale tears naturale (ophthalmic solution)* Tears Naturale Forte tears naturale forte (ophthalmic solution)* Tears Naturale II tears naturale ii (ophthalmic solution)* Tears Pure tears pure (ophthalmic solution)* Tobradex ST TOBRADEX ST (OPHTHALMIC SUSPENSION) $3.60-$7.40 (Tier 2) Tobramycin/Dexamethasone tobramycin/dexamethasone (ophthalmic suspension) Zaditor zaditor (ophthalmic solution)* Ophthalmic Anti-allergy Agents Azelastine HCl azelastine hcl (0.05% ophthalmic solution) Bepreve BEPREVE (OPHTHALMIC SOLUTION) $3.60-$7.40 (Tier 2) Cromolyn Sodium cromolyn sodium (rx only) (4% ophthalmic solution) Epinastine HCl epinastine hcl (ophthalmic solution) Olopatadine HCl olopatadine hcl (ophthalmic solution) Pataday PATADAY (OPHTHALMIC SOLUTION) $3.60-$7.40 (Tier 2) Patanol PATANOL (OPHTHALMIC SOLUTION) $3.60-$7.40 (Tier 2) Pazeo PAZEO (OPHTHALMIC SOLUTION) $3.60-$7.40 (Tier 2) Ophthalmic Antiglaucoma Agents Alphagan P ALPHAGAN P (0.1% OPHTHALMIC SOLUTION) $3.60-$7.40 (Tier 2) Apraclonidine apraclonidine (ophthalmic solution)

91 For Track Refered Purpose 91 Betaxolol HCl betaxolol hcl (0.5% ophthalmic solution) Brimonidine Tartrate BRIMONIDINE TARTRATE (0.15% OPHTHALMIC $3.60-$7.40 (Tier 2) SOLUTION) Brimonidine Tartrate brimonidine tartrate (0.2% ophthalmic solution) Carteolol HCl carteolol hcl (ophthalmic solution) Combigan COMBIGAN (OPHTHALMIC SOLUTION) $3.60-$7.40 (Tier 2) Dorzolamide HCl dorzolamide hcl (ophthalmic solution) Dorzolamide HCl/Timolol Maleate dorzolamide hcl/timolol maleate (ophthalmic solution) Levobunolol HCl levobunolol hcl (ophthalmic solution) Methazolamide methazolamide (tablet) Metipranolol metipranolol (ophthalmic solution) Phospholine Iodide PHOSPHOLINE IODIDE (OPHTHALMIC $3.60-$7.40 (Tier 2) SOLUTION) Pilocarpine HCl PILOCARPINE HCL (1% OPHTHALMIC SOLUTION, 2% OPHTHALMIC SOLUTION, 4% $3.60-$7.40 (Tier 2) OPHTHALMIC SOLUTION) Timolol Maleate timolol maleate (0.25% ophthalmic solution, 0.5% ophthalmic solution) Timolol Maleate Ophthalmic Gel Forming TIMOLOL MALEATE OPHTHALMIC GEL $3.60-$7.40 (Tier 2) FORMING (GEL FORM SOLUTION) Ophthalmic Anti-inflammatories Dexamethasone Sodium Phosphate dexamethasone sodium phosphate (0.1% ophthalmic solution) Diclofenac Sodium diclofenac sodium (0.1% ophthalmic solution) Durezol DUREZOL (EMULSION) $3.60-$7.40 (Tier 2) Fluorometholone FLUOROMETHOLONE (OPHTHALMIC $3.60-$7.40 (Tier 2) SUSPENSION) Flurbiprofen Sodium flurbiprofen sodium (ophthalmic solution) Ilevro ILEVRO (SUSPENSION) $3.60-$7.40 (Tier 2) You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

92 For Track Refered Purpose 92 Ketorolac Tromethamine ketorolac tromethamine (0.4% ophthalmic solution, 0.5% ophthalmic solution) Lotemax LOTEMAX (0.5% GEL, 0.5% OINTMENT, 0.5% $3.60-$7.40 (Tier 2) SUSPENSION) Nevanac NEVANAC (SUSPENSION) $3.60-$7.40 (Tier 2) Prednisolone Acetate PREDNISOLONE ACETATE (OPHTHALMIC $3.60-$7.40 (Tier 2) SUSPENSION) Prednisolone Sodium Phosphate prednisolone sodium phosphate (1% ophthalmic solution) Prolensa PROLENSA (OPHTHALMIC SOLUTION) $3.60-$7.40 (Tier 2) Ophthalmic Prostaglandin and Prostamide Analogs Latanoprost latanoprost (ophthalmic solution) Lumigan LUMIGAN (OPHTHALMIC SOLUTION) $3.60-$7.40 (Tier 2) Travatan Z TRAVATAN Z (OPHTHALMIC SOLUTION) $3.60-$7.40 (Tier 2) Travoprost travoprost (ophthalmic solution) Respiratory Tract Agents, Other Eye Drops Allergy Relief eye drops allergy relief (ophthalmic solution)* Otic Agents Otic Agents Acetic Acid acetic acid (otic solution) Ear Drops ear drops (otic solution)* Ear Wax Removal Drops ear wax removal drops (otic solution)* Ear Wax Removal Kit ear wax removal kit (otic solution)* Ear Wax Removal System ear wax removal system (ophthalmic solution)* Fluocinolone Acetonide fluocinolone acetonide (0.01% otic oil) GNP Ear Drops gnp ear drops (otic solution)* GNP Ear Systems gnp ear systems (otic solution)* HM Earwax Removal Aid hm earwax removal aid (otic solution)* HM Earwax Removal Kit hm earwax removal kit (otic solution)* Hydrocortisone/Acetic Acid hydrocortisone/acetic acid (rx only) (otic solution) Neomycin/Polymyxin/Hydrocortisone neomycin/polymyxin/hydrocortisone (rx only) (1% otic solution, 1% otic suspension) QC Ear Wax Removal Drops qc ear wax removal drops (otic solution)* Respiratory Tract/Pulmonary Agents Antihistamines Alavert alavert (tablet dispersible)*

93 For Track Refered Purpose 93 Alavert Allergy/Sinus alavert allergy/sinus (tablet extended-release 12 hour)* All Day Allergy all day allergy (tablet)* All Day Allergy Childrens all day allergy childrens (tablet chewable)* Aller-Chlor aller-chlor (2mg/5ml syrup, 4mg tablet)* Aller-Ease aller-ease (tablet)* Allergy & Congestion Relief allergy & congestion relief (tablet extended-release 12 hour)* Allergy allergy (10mg tablet dispersible, 10mg tablet, 25mg tablet, 4mg tablet, 25mg capsule)* Allergy Relief allergy relief (10mg tablet dispersible, 10mg tablet, 25mg tablet)* Allergy Relief Child allergy relief child (syrup)* Allergy Relief D-24 allergy relief d-24 (tablet extended-release 24 hour)* Allergy Relief/Nasal Decongestant allergy relief/nasal decongestant (tablet extended-release 24 hour)* Allergy Tablets allergy tablets* Allergy-Time allergy-time (tablet)* Allerhist-1 allerhist-1 (tablet)* Azelastine HCl azelastine hcl (0.1% nasal solution) QL Azelastine HCl azelastine hcl (0.15% nasal solution) Banophen banophen (12.5mg/5ml liquid, 2%-0.1% cream, 25mg capsule, 50mg capsule, 25mg tablet)* Cetirizine HCl cetirizine hcl (otc only) (10mg tablet chewable, 5mg tablet chewable, 10mg tablet, 5mg tablet)* Cetirizine HCl cetirizine hcl (rx only) (syrup) Childrens Loratadine childrens loratadine (otc only) (5mg/5ml oral solution, 5mg/ 5ml syrup)* Chlorpheniramine Maleate chlorpheniramine maleate (otc only) (12mg tablet extendedrelease, 4mg tablet)* Claritin claritin (otc only) (10mg capsule, 10mg tablet, 5mg tablet chewable, 5mg/5ml syrup)* Claritin Reditabs claritin reditabs (otc only) (tablet dispersible)* You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

94 For Track Refered Purpose 94 Claritin-D 12 Hour claritin-d 12 hour (otc only) (tablet extended-release 12 hour)* Claritin-D 24 Hour claritin-d 24 hour (tablet extended-release 24 hour)* Clemastine Fumarate clemastine fumarate (otc only) (tablet)* Complete Allergy Medicine complete allergy medicine (capsule)* Cyproheptadine HCl cyproheptadine hcl (rx only) (4mg tablet) Dayhist Allergy 12 Hour Relief dayhist allergy 12 hour relief (tablet)* Diphenhist diphenhist (otc only) (12.5mg/5ml liquid, 25mg capsule, 25mg tablet)* Diphenhydramine HCl diphenhydramine hcl (otc only) (25mg capsule, 50mg capsule, 25mg tablet)* Diphenhydramine HCl diphenhydramine hcl (rx only) (50mg/ml injection) B/D, PA ED Chlorped chlorped (liquid)* ED Chlorped Jr chlorped jr (syrup)* ED Chlortan ed chlortan (tablet)* Fexofenadine HCl fexofenadine hcl (otc only) (tablet)* GNP All Day Allergy gnp all day allergy (tablet)* GNP Allergy & Congestion Relief gnp allergy & congestion relief (tablet extended-release 24 hour)* GNP Allergy gnp allergy (25mg capsule, 25mg tablet, 4mg tablet)* GNP Allergy Relief gnp allergy relief (10mg tablet dispersible, 180mg tablet)* GNP Allergy Relief for Kids gnp allergy relief for kids (tablet dispersible)* GNP Dayhist Allergy gnp dayhist allergy (tablet)* GNP Loratadine gnp loratadine (otc only) (10mg tablet, 5mg/5ml syrup)* GNP Loratadine Childrens gnp loratadine childrens (otc only) (syrup)* GNP Loratadine-D 12 Hour gnp loratadine-d 12 hour (otc only) (tablet extended-release 12 hour)* GNP Loratadine-D 24 Hour gnp loratadine-d 24 hour (otc only) (tablet extended-release 24 hour)* GNP Nighttime Sleep Aid gnp nighttime sleep aid (tablet)* Goodsense All Day Allergy goodsense all day allergy (tablet)* HM All Day Allergy hm all day allergy (tablet)* HM Allergy & Congestion hm allergy & congestion (tablet extended-release 12 hour)* HM Allergy hm allergy (tablet)* HM Allergy Relief & Nasal Decongestant hm allergy relief & nasal decongestant (tablet extendedrelease 24 hour)* HM Allergy Relief hm allergy relief (10mg tablet dispersible, 10mg tablet, 4mg tablet)* HM Allergy Multi Symptom hm allergy multi symptom (capsule)* HM Fexofenadine HCl hm fexofenadine hcl (otc only) (tablet)*

95 For Track Refered Purpose 95 HM Loratadine Childrens hm loratadine childrens (otc only) (syrup)* Levocetirizine Dihydrochloride levocetirizine dihydrochloride (5mg tablet) QL Loratadine loratadine (otc only) (tablet)* Loratadine Childrens loratadine childrens (otc only) (5mg/5ml oral solution, 5mg/ 5ml syrup)* Loratadine Hives Relief loratadine hives relief (otc only) (oral solution)* Loratadine-D 12 Hour loratadine-d 12 hour (otc only) (tablet extended-release 12 hour)* Loratadine-D 24 Hour loratadine-d 24 hour (otc only) (tablet extended-release 24 hour)* Mucinex Allergy mucinex allergy (tablet)* Multi-Symptom Allergy multi-symptom allergy (capsule)* Nighttime Sleep Aid nighttime sleep aid (tablet)* Pharbechlor pharbechlor (tablet)* Pharbedryl pharbedryl (capsule)* Phenadoz phenadoz (12.5mg suppository) Phenergan phenergan (12.5mg suppository, 25mg suppository) Promethazine HCl promethazine hcl (12.5mg suppository, 25mg suppository, 12.5mg tablet, 25mg tablet, 50mg tablet, 25mg/ml injection, 50mg/ml injection, 6.25mg/5ml syrup) Promethegan promethegan (25mg suppository) QC All Day Allergy qc all day allergy (tablet)* QC Allergy Relief qc allergy relief (tablet dispersible)* QC Chlor-Pheniramine qc chlor-pheniramine (tablet)* QC Complete Allergy Medicine qc complete allergy medicine (tablet)* QC Loratadine Allergy Relief qc loratadine allergy relief (otc only) (tablet)* QC Loratadine-D qc loratadine-d (otc only) (tablet extended-release 24 hour)* Q-Dryl q-dryl (capsule)* SB Allergy sb allergy (tablet)* SB Loratadine OTC Only) sb loratadine otc only) (tablet)* Siladryl Allergy siladryl allergy (liquid)* You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

96 For Track Refered Purpose 96 SM All Day Allergy sm all day allergy (tablet)* SM Allergy 4 Hour sm allergy 4 hour (tablet)* SM Allergy Relief sm allergy relief (1.34mg tablet, 25mg tablet, 10mg tablet dispersible, 25mg capsule)* SM Allergy Relief Loratadine sm allergy relief loratadine (otc only) (tablet)* SM Childrens Loratadine sm childrens loratadine (otc only) (syrup)* SM Fexofenadine HCl sm fexofenadine hcl (otc only) (tablet)* SM Loratadine sm loratadine (otc only) (syrup)* SM Loratadine Allergy Relief sm loratadine allergy relief (otc only) (tablet dispersible)* SM Lorata-Dine D sm lorata-dine d (otc only) (tablet extended-release 24 hour)* SM Loratadine-D 12 Hour sm loratadine-d 12 hour (otc only) (tablet extended-release 12 hour)* Vanahist PD vanahist pd (liquid)* Anti-inflammatories, Inhaled Corticosteroids Arnuity Ellipta ARNUITY ELLIPTA (AEROSOL POWDER) $3.60-$7.40 (Tier 2) QL Budesonide budesonide (0.25mg/2ml suspension, 0.5mg/2ml suspension, 1mg/2ml suspension) B/D, PA Flovent Diskus FLOVENT DISKUS (AEROSOL POWDER) $3.60-$7.40 (Tier 2) QL Flovent HFA FLOVENT HFA (AEROSOL) $3.60-$7.40 (Tier 2) Flunisolide flunisolide (nasal solution) Fluticasone Propionate fluticasone propionate (50mcg/act suspension) Mometasone Furoate mometasone furoate (50mcg/act suspension) Nasonex NASONEX (SUSPENSION) $3.60-$7.40 (Tier 2) Pulmicort PULMICORT (1MG/2ML SUSPENSION) $3.60-$7.40 (Tier 2) B/D, PA Antileukotrienes Montelukast Sodium montelukast sodium (10mg tablet, 4mg packet, 4mg tablet chewable, 5mg tablet chewable) QL Zafirlukast zafirlukast (tablet) QL Zyflo ZYFLO (TABLET) $3.60-$7.40 (Tier 2) ST Zyflo CR ZYFLO CR (TABLET EXTENDED-RELEASE 12 HOUR) $3.60-$7.40 (Tier 2) ST Bronchodilators, Anticholinergic Atrovent HFA ATROVENT HFA (AEROSOL SOLUTION) $3.60-$7.40 (Tier 2) Ipratropium Bromide ipratropium bromide (0.02% inhalation solution) B/D, PA Ipratropium Bromide ipratropium bromide (0.03% nasal solution, 0.06% nasal solution) Spiriva HandiHaler SPIRIVA HANDIHALER (CAPSULE) $3.60-$7.40 (Tier 2) QL

97 For Track Refered Purpose 97 Spiriva Respimat SPIRIVA RESPIMAT (AEROSOL SOLUTION) $3.60-$7.40 (Tier 2) QL Bronchodilators, Sympathomimetic Albuterol Sulfate albuterol sulfate (0.083% nebulized solution, 0.5% nebulized solution, 0.63mg/3ml nebulized solution, B/D, PA 1.25mg/3ml nebulized solution) Albuterol Sulfate albuterol sulfate (2mg tablet immediate-release, 4mg tablet immediate-release) Brovana BROVANA (NEBULIZED SOLUTION) $3.60-$7.40 (Tier 2) B/D, PA EpiPen EPIPEN (INJECTION) $3.60-$7.40 (Tier 2) Levalbuterol levalbuterol (nebulized solution) B/D, PA Metaproterenol Sulfate metaproterenol sulfate (10mg tablet, 20mg tablet, 10mg/ 5ml syrup) Perforomist PERFOROMIST (NEBULIZED SOLUTION) $3.60-$7.40 (Tier 2) B/D, PA, QL ProAir HFA PROAIR HFA (AEROSOL SOLUTION) $3.60-$7.40 (Tier 2) ProAir RespiClick PROAIR RESPICLICK (AEROSOL POWDER) $3.60-$7.40 (Tier 2) Serevent Diskus SEREVENT DISKUS (AEROSOL POWDER) $3.60-$7.40 (Tier 2) QL Terbutaline Sulfate terbutaline sulfate (1mg/ml injection) Cystic Fibrosis Agents Cayston CAYSTON (INHALATION SOLUTION) $3.60-$7.40 (Tier 2) PA, LA Kalydeco KALYDECO (50MG PACKET, 75MG PACKET) $3.60-$7.40 (Tier 2) PA, QL Orkambi ORKAMBI (TABLET) $3.60-$7.40 (Tier 2) PA, QL, LA Mast Cell Stabilizers Cromolyn Sodium cromolyn sodium (otc only) (nasal aerosol solution)* Phosphodiesterase Inhibitors, Airways Disease Aminophylline aminophylline (injection) Daliresp DALIRESP (TABLET) $3.60-$7.40 (Tier 2) PA, QL Theophylline theophylline (oral solution) Theophylline CR theophylline cr (tablet extended-release 12 hour) You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

98 For Track Refered Purpose 98 Theophylline ER theophylline er (300mg tablet extended-release 12 hour, 450mg tablet extended-release 12 hour, 400mg tablet extended-release 24 hour, 600mg tablet extended-release 24 hour) Pulmonary Antihypertensives Adcirca ADCIRCA (TABLET) $3.60-$7.40 (Tier 2) PA, QL Adempas ADEMPAS (TABLET) $3.60-$7.40 (Tier 2) PA Letairis LETAIRIS (TABLET) $3.60-$7.40 (Tier 2) PA, LA Opsumit OPSUMIT (TABLET) $3.60-$7.40 (Tier 2) PA, LA Orenitram ORENITRAM (0.125MG TABLET EXTENDED- RELEASE, 0.25MG TABLET EXTENDED- $3.60-$7.40 (Tier 2) PA, QL RELEASE, 1MG TABLET EXTENDED-RELEASE) Orenitram ORENITRAM (2.5MG TABLET EXTENDED- RELEASE) $3.60-$7.40 (Tier 2) PA Remodulin REMODULIN (INJECTION) $3.60-$7.40 (Tier 2) PA, LA Revatio REVATIO (20MG TABLET) $3.60-$7.40 (Tier 2) PA, QL Sildenafil sildenafil (10mg/12.5ml injection) PA Sildenafil sildenafil (20mg tablet) (generic revatio) PA, QL Tracleer TRACLEER (TABLET) $3.60-$7.40 (Tier 2) PA, QL Tyvaso TYVASO (INHALATION SOLUTION) $3.60-$7.40 (Tier 2) PA Ventavis VENTAVIS (INHALATION SOLUTION) $3.60-$7.40 (Tier 2) PA, LA Respiratory Tract Agents, Other Hour Decongestant 12 hour decongestant (tablet extended-release 12 hour)* Hour Nasal Spray 12 hour nasal spray (nasal solution)* Acetylcysteine acetylcysteine (inhalation solution) B/D, PA Advair Diskus ADVAIR DISKUS (AEROSOL POWDER) $3.60-$7.40 (Tier 2) QL Advair HFA ADVAIR HFA (AEROSOL) $3.60-$7.40 (Tier 2) All Day Allergy D all day allergy d (tablet extended-release 12 hour)* All Day Allergy D-12 all day allergy d-12 (tablet extended-release 12 hour)* All Day Allergy-D all day allergy-d (tablet extended-release 12 hour)* Allergy Multi-Symptom allergy multi-symptom (tablet)* All-Nite Multi-Symptom Cold/Flu Relief all-nite multi-symptom cold/flu relief (liquid)* Anti-Itch anti-itch (cream)* Aprodine aprodine (tablet)* Aralast NP ARALAST NP (INJECTION) $3.60-$7.40 (Tier 2) PA, LA Benzonatate benzonatate (capsule)* Breo Ellipta BREO ELLIPTA (AEROSOL POWDER) $3.60-$7.40 (Tier 2)

99 For Track Refered Purpose 99 Bromfed DM bromfed dm (syrup)* Bromphen/Pseudoephedrine HCl/Dextromethorphan HBr bromphen/pseudoephedrine hcl/dextromethorphan hbr (syrup)* Brotapp brotapp (liquid)* Brotapp DM brotapp dm (liquid)* Brovex PEB brovex peb (liquid)* Brovex PSB brovex psb (liquid)* Capcof capcof (syrup)* Capmist DM capmist dm (tablet)* Capron DM capron dm (liquid)* Cetirizine HCl/Pseudoephedrine HCl ER cetirizine hcl/pseudoephedrine hcl er (otc only) (tablet extended-release 12 hour)* Cheratussin AC cheratussin ac (syrup)* Cheratussin DAC cheratussin dac (oral solution)* Chest Congestion Relief chest congestion relief (tablet)* Childrens Cold & Allergy childrens cold & allergy (elixir)* Childrens Mucus Relief Cough childrens mucus relief cough (liquid)* Childrens Mucus Relief Expectorant childrens mucus relief expectorant (liquid)* Childrens Pain Relief Plus Multi-Symptom Cold childrens pain relief plus multi-symptom cold (suspension)* Codituss DM codituss dm (syrup)* Cold Head Congestion Daytime cold head congestion daytime (tablet)* Cold Head Congestion Nighttime cold head congestion nighttime (tablet)* Cold Head Congestion Severe Daytime cold head congestion severe daytime (tablet)* Cold Multi-Symptom Daytime cold multi-symptom daytime (tablet)* Cold Multi-Symptom Nighttime cold multi-symptom nighttime (tablet)* Cold Multi-Symptom Severe Daytime cold multi-symptom severe daytime (tablet)* Cold/Allergy Childrens cold/allergy childrens (elixir)* Cold/Cough Childrens cold/cough childrens (elixir)* Cold/Cough DM Childrens cold/cough dm childrens (elixir)* Cold/Cough/Sore Throat Childrens cold/cough/sore throat childrens (liquid)* You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

100 For Track Refered Purpose 100 Conex Cold/Allergy conex cold/allergy (1mg/5ml-30mg/5ml oral solution, 2mg-60mg tablet)* Coricidin HBP Nighttime Multi-Symptom Cold coricidin hbp nighttime multi-symptom cold (liquid)* Cough & Sore Throat Day Time cough & sore throat day time (liquid)* Cough DM cough dm (liquid extended-release)* Cough Syrup cough syrup* Coughtab coughtab (tablet)* Cromolyn Sodium cromolyn sodium (rx only) (20mg/2ml nebulized solution) B/D, PA Dallergy dallergy (liquid)* Day Time Cold/Flu Relief day time cold/flu relief (liquid)* Day Time Cough day time cough (liquid)* Day Time Multi-Symptom Cold/Flu Relief day time multi-symptom cold/flu relief (capsule)* Decongestant 12 Hour Maximum Strength decongestant 12 hour maximum strength (tablet extendedrelease 12 hour)* Deep Sea Nasal Spray deep sea nasal spray (nasal solution)* Delsym delsym (liquid extended-release)* Delsym Cough + Chest Congestion DM delsym cough + chest congestion dm (liquid)* Delsym Cough + Chest Congestion DM Childrens delsym cough + chest congestion dm childrens (liquid)* Delsym Cough + Cold Daytime delsym cough + cold daytime (liquid)* Delsym Cough + Cold Nighttime delsym cough + cold nighttime (liquid)* Delsym Cough + Cold Nighttime Childrens delsym cough + cold nighttime childrens (liquid)* Delsym Night Time Cough/Cold delsym night time cough/cold (liquid)* Delsym Night Time Cough/Cold Childrens delsym night time cough/cold childrens (liquid)* Delsym Night Time Multi-Symptom delsym night time multi-symptom (liquid)* Dextromethorphan Polistirex dextromethorphan polistirex (liquid extended-release)* Dextromethorphan/Guaifenesin dextromethorphan/guaifenesin (oral solution)* Diabetic Siltussin DAS-Na diabetic siltussin das-na (liquid)* Diabetic Siltussin-DM diabetic siltussin-dm (liquid)* Diabetic Siltussin-DM Maximum Strength diabetic siltussin-dm maximum strength (liquid)* Diabetic Tussin diabetic tussin (liquid)* Diabetic Tussin DM diabetic tussin dm (liquid)* Diabetic Tussin Maximum Strength diabetic tussin maximum strength (liquid)* Dimaphen Childrens dimaphen childrens (elixir)* Dimaphen DM Cold/Cough Childrens dimaphen dm cold/cough childrens (elixir)* Dimetapp Cold & Allergy dimetapp cold & allergy (elixir)* Dimetapp DM Cold & Cough dimetapp dm cold & cough (liquid)* Dimetapp Long Acting Cough Plus Cold dimetapp long acting cough plus cold (syrup)* Dimetapp Multi-Symptom Cold & Flu dimetapp multi-symptom cold & flu (liquid)* Dimetapp Nighttime Cold & Congestion dimetapp nighttime cold & congestion (liquid)*

101 For Track Refered Purpose Diphenhydramine HCl/Zinc Acetate diphenhydramine hcl/zinc acetate (otc only) (cream)* Dristan Cold dristan cold (tablet)* ED A-Hist ed a-hist (liquid)* ED A-Hist DM ed a-hist dm (liquid)* ED A-Hist PSE ed a-hist pse (tablet)* ED Bron GP ed bron gp (liquid)* ED Chlorped D chlorped d (liquid)* EndaCof-DM endacof-dm (liquid)* Esbriet ESBRIET (CAPSULE) $3.60-$7.40 (Tier 2) PA, QL, LA Exefen-IR exefen-ir (tablet)* Extra Action Cough extra action cough (syrup)* Glassia GLASSIA (INJECTION) $3.60-$7.40 (Tier 2) PA, LA GNP 12 Hour Nasal Spray gnp 12 hour nasal spray (nasal solution)* GNP All Day Allergy-D gnp all day allergy-d (tablet extended-release 12 hour)* GNP Allergy Multi-Symptom gnp allergy multi-symptom (tablet)* GNP Allergy Plus Severe Sinus Headache Maximum Strength gnp allergy plus severe sinus headache maximum strength (tablet)* GNP Anti-Itch gnp anti-itch (cream)* GNP Childrens Pain Relief Plus Cold gnp childrens pain relief plus cold (suspension)* GNP Childrens Plus Cough & Sore Throat gnp childrens plus cough & sore throat (liquid)* GNP Childrens Plus Multi-Symptom Cold gnp childrens plus multi-symptom cold (suspension)* GNP Cold & Allergy Childrens gnp cold & allergy childrens (elixir)* GNP Cold & Allergy Maximum Strength gnp cold & allergy maximum strength (tablet)* GNP Cold & Cough Childrens gnp cold & cough childrens (elixir)* GNP Cold Head Congestion Night Time gnp cold head congestion night time (tablet)* GNP Cold Head Congestion Severe Daytime gnp cold head congestion severe daytime (tablet)* GNP Cold Multi-Symptom Daytime gnp cold multi-symptom daytime (tablet)* GNP Cold Multi-Symptom Nighttime gnp cold multi-symptom nighttime (tablet)* GNP Cold Relief Head Congestion Severe Daytime gnp cold relief head congestion severe daytime (tablet)* GNP Cold Relief Multi-Symptom Daytime gnp cold relief multi-symptom daytime (tablet)* GNP Cold Relief Multi-Symptom Severe Daytime gnp cold relief multi-symptom severe daytime (tablet)* 101 You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

102 For Track Refered Purpose 102 GNP Cold Severe Congestion/Daytime gnp cold severe congestion/daytime (tablet)* GNP Cough DM ER gnp cough dm er (liquid extended-release)* GNP Cough Relief gnp cough relief (liquid)* GNP Day Time Cold & Flu gnp day time cold & flu (capsule)* GNP Day Time Cold/Flu gnp day time cold/flu (capsule)* GNP Day Time Cold/Flu Relief gnp day time cold/flu relief (liquid)* GNP Day Time Sinus gnp day time sinus (capsule)* GNP Flu Relief Therapy Severe Cold Daytime gnp flu relief therapy severe cold daytime (liquid)* GNP Flu Relief Therapy Severe Cold Nighttime gnp flu relief therapy severe cold nighttime (liquid)* GNP Mucus ER gnp mucus er (tablet extended-release 12 hour)* GNP Mucus Relief gnp mucus relief (tablet)* GNP Mucus Relief Cold & Sinus gnp mucus relief cold & sinus (tablet)* GNP Mucus Relief Cold Flu & Sore Throat gnp mucus relief cold flu & sore throat (tablet)* GNP Mucus Relief Cough Childrens gnp mucus relief cough childrens (liquid)* GNP Mucus Relief DM gnp mucus relief dm (tablet)* GNP Mucus Relief Severe Congestion & Cold gnp mucus relief severe congestion & cold (tablet)* GNP Mucus ER gnp mucus er (tablet extended-release 12 hour)* GNP Multi-Symptom Cold Nighttime gnp multi-symptom cold nighttime (liquid)* GNP Nasal Decongestant gnp nasal decongestant (tablet)* GNP Nasal Decongestant PE Maximum Strength gnp nasal decongestant pe maximum strength (tablet)* GNP Nasal Spray gnp nasal spray (nasal solution)* GNP Nasal Spray Extra Moisturizing gnp nasal spray extra moisturizing (nasal solution)* GNP Night Time Cold & Flu gnp night time cold & flu (capsule)* GNP Night Time Cold & Flu Multi-Symptom gnp night time cold & flu multi-symptom (capsule)* GNP Night Time Cold & Flu Multi-Symptom gnp night time cold & flu multi-symptom (liquid)* GNP Night Time Cold/Flu Relief gnp night time cold/flu relief (liquid)* GNP Night Time Cough gnp night time cough (liquid)* GNP Night Time Sinus gnp night time sinus (capsule)* GNP No Drip Nasal Spray gnp no drip nasal spray (nasal solution)* GNP Nose Drops Extra Strength gnp nose drops extra strength (nasal solution)* GNP Pseudoephedrine HCl 12 Hour gnp pseudoephedrine hcl 12 hour (tablet extended-release 12 hour)* GNP Pseudoephedrine HCl ER gnp pseudoephedrine hcl er (tablet extended-release 12 hour)* GNP Sinus Congestion & Pain Daytime gnp sinus congestion & pain daytime (tablet)* GNP Sinus Congestion/Pain Nighttime gnp sinus congestion/pain nighttime (tablet)* GNP Sinus Relief Congestion & Pain Daytime/Nighttime gnp sinus relief congestion & pain daytime/nighttime* GNP Sinus Relief Congestion & Pain Nighttime gnp sinus relief congestion & pain nighttime (tablet)* GNP Suphedrin gnp suphedrin (liquid)*

103 For Track Refered Purpose 103 GNP Tab Tussin gnp tab tussin (tablet)* GNP Tab Tussin DM gnp tab tussin dm (tablet)* GNP Triacting Night Time Cold & Cough Childrens gnp triacting night time cold & cough childrens (liquid)* GNP Tussin gnp tussin (syrup)* GNP Tussin CF Cough & Cold gnp tussin cf cough & cold (syrup)* GNP Tussin CF Max Multi-Symptom Cold gnp tussin cf max multi-symptom cold (liquid)* GNP Tussin Cough Long Acting gnp tussin cough long acting (syrup)* GNP Tussin DM gnp tussin dm (liquid)* GNP Tussin DM Cough gnp tussin dm cough (liquid)* GNP Tussin DM Max gnp tussin dm max (liquid)* GNP Tussin DM Max Cough & Chest Congestion gnp tussin dm max cough & chest congestion (liquid)* GNP Tussin Night Time gnp tussin night time (liquid)* Guaiatussin AC guaiatussin ac (syrup)* Guaifenesin guaifenesin (100mg/5ml oral solution, 200mg/10ml oral solution, 300mg/15ml oral solution, 200mg tablet)* Guaifenesin AC guaifenesin ac (syrup)* Guaifenesin DAC guaifenesin dac (oral solution)* Guaifenesin ER guaifenesin er (tablet extended-release 12 hour)* Guaifenesin/Codeine guaifenesin/codeine (oral solution)* Guaifenesin-DM guaifenesin-dm (syrup)* HM Allergy Complete-D hm allergy complete-d (tablet extended-release 12 hour)* HM Chest Congestion Relief hm chest congestion relief (tablet)* HM Chest Congestion Relief DM hm chest congestion relief dm (tablet)* HM Cold & Allergy Childrens hm cold & allergy childrens (elixir)* HM Cold & Cough Childrens hm cold & cough childrens (elixir)* HM Cough DM hm cough dm (liquid extended-release)* HM Cough Relief hm cough relief (liquid)* HM Day Time hm day time (capsule)* HM Mucus ER hm mucus er (tablet extended-release 12 hour)* HM Nasal Decongestant hm nasal decongestant (tablet)* You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

104 For Track Refered Purpose 104 HM Nasal Decongestant 12 Hour hm nasal decongestant 12 hour (tablet extended-release 12 hour)* HM Nasal Decongestant PE hm nasal decongestant pe (tablet)* HM Nasal Spray hm nasal spray (nasal solution)* HM Night Time Cold & Flu hm night time cold & flu (liquid)* HM Night Time Multi Symptom Cold & Flu hm night time multi symptom cold & flu (capsule)* HM Nose Drops Extra Strength hm nose drops extra strength (nasal solution)* HM Saline Nasal Spray hm saline nasal spray (nasal solution)* HM Sinus Nasal Spray hm sinus nasal spray (nasal solution)* HM Tussin Adult hm tussin adult (liquid)* HM Tussin Adult Cough & Chest Congestion DM hm tussin adult cough & chest congestion dm (liquid)* HM Tussin Adult Multi-Symptom Cold hm tussin adult multi-symptom cold (liquid)* Hydrocodone Bitartrate/Homatropine Methylbromide hydrocodone bitartrate/homatropine methylbromide (1.5mg-5mg tablet, 1.5mg/5ml-5mg/5ml syrup)* Hydrocodone Polistirex/Chlorpheniramine Polistirex hydrocodone polistirex/chlorpheniramine polistirex (liquid extended-release)* Hydromet hydromet (syrup)* Intense Cough Reliever Extra Strength intense cough reliever extra strength (liquid)* Iophen C-NR iophen c-nr (liquid)* Iophen DM-NR iophen dm-nr (liquid)* Iophen-NR iophen-nr (liquid)* Itch Relief Extra Strength itch relief extra strength (cream)* J-TAN D PD j-tan d pd (liquid)* Kalydeco KALYDECO (150MG TABLET) $3.60-$7.40 (Tier 2) PA, QL Kidkare Cough/Cold kidkare cough/cold (liquid)* Liquituss GG liquituss gg (liquid)* LoHist-D lohist-d (liquid)* LoHist-DM lohist-dm (syrup)* LoHist-PEB lohist-peb (liquid)* Long Acting Nasal Spray long acting nasal spray (nasal solution)* Lortuss EX lortuss ex (liquid)* Mapap Sinus Maximum Strength Congestion and Pain mapap sinus maximum strength congestion and pain (tablet)* M-Clear WC m-clear wc (oral solution)* M-END PE m-end pe (liquid)* M-END WC m-end wc (liquid)* Mucinex mucinex (tablet extended-release 12 hour)* Mucinex Chest Congestion Childrens mucinex chest congestion childrens (liquid)* Mucinex Childrens Cold Cough & Sore Throat mucinex childrens cold cough & sore throat (liquid)*

105 For Track Refered Purpose 105 Mucinex Childrens Multi-Symptom Cold & Fever mucinex childrens multi-symptom cold & fever (liquid)* Mucinex Childrens Multi-Symptom Cold mucinex childrens multi-symptom cold (liquid)* Mucinex Cold for Kids mucinex cold for kids (liquid)* Mucinex Congestion & Cough Childrens mucinex congestion & cough childrens (liquid)* Mucinex Cough Childrens mucinex cough childrens (liquid)* Mucinex D mucinex d (tablet extended-release 12 hour)* Mucinex DM Maximum Strength mucinex dm maximum strength (tablet extended-release 12 hour)* Mucinex DM mucinex dm (tablet extended-release 12 hour)* Mucinex DM Maximum Strength mucinex dm maximum strength (tablet extended-release 12 hour)* Mucinex Fast-Max Cold & Sinus mucinex fast-max cold & sinus (tablet)* Mucinex Fast-Max Cold Flu & Sore Throat mucinex fast-max cold flu & sore throat (tablet, liquid)* Mucinex Fast-Max DM Max mucinex fast-max dm max (liquid)* Mucinex Fast-Max Night Time Cold & Flu mucinex fast-max night time cold & flu (tablet, liquid)* Mucinex Fast-Max Severe Cold mucinex fast-max severe cold (tablet, liquid)* Mucinex Fast-Max Severe Congestion & Cold mucinex fast-max severe congestion & cold (tablet)* Mucinex Fast-Max Severe Congestion & Cough mucinex fast-max severe congestion & cough (liquid)* Mucinex for Kids mucinex for kids (packet)* Mucinex Maximum Strength mucinex maximum strength (tablet extended-release 12 hour)* Mucinex Multi-Symptom Cold Night Time Childrens mucinex multi-symptom cold night time childrens (liquid)* Mucinex Nasal Spray Full Force mucinex nasal spray full force (nasal solution)* Mucinex Nasal Spray Moisture Smart mucinex nasal spray moisture smart (nasal solution)* Mucinex Sinus-Max Full Force mucinex sinus-max full force (nasal solution)* Mucinex Sinus-Max Pressure & Pain mucinex sinus-max pressure & pain (tablet)* Mucinex Sinus-Max Severe Congestion Relief mucinex sinus-max severe congestion relief (tablet)* Mucinex Stuffy Nose & Cold Childrens mucinex stuffy nose & cold childrens (liquid)* Mucosa mucosa (tablet)* Mucosa DM mucosa dm (tablet)* Mucus DM mucus dm (tablet extended-release 12 hour)* You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

106 For Track Refered Purpose 106 Mucus DM Max mucus dm max (tablet extended-release 12 hour)* Mucus ER mucus er (tablet extended-release 12 hour)* Mucus Relief mucus relief (tablet)* Mucus Relief Childrens mucus relief childrens (liquid)* Mucus Relief Cold/Sinus Maximum Strength mucus relief cold/sinus maximum strength (liquid)* Mucus Relief Cough Childrens mucus relief cough childrens (liquid)* Mucus Relief DM mucus relief dm (tablet)* Mucus Relief Severe Congestion/Cough mucus relief severe congestion/cough (liquid)* Mucus DM mucus dm (tablet extended-release 12 hour)* Mucus ER mucus er (tablet extended-release 12 hour)* Muro 128 muro 128 (5% ointment, 5% ophthalmic solution)* Nasal Decongestant nasal decongestant (1% nasal solution, 30mg tablet, 30mg/ 5ml liquid, 30mg/5ml syrup)* Nasal Decongestant PE nasal decongestant pe (tablet)* Nasal Decongestant PE Maximum Strength nasal decongestant pe maximum strength (tablet)* Nasal Decongestant Spray nasal decongestant spray (nasal solution)* Nasal Spray 12 Hour nasal spray 12 hour (nasal solution)* Nasal Spray Anti-Drip nasal spray anti-drip (nasal solution)* Nasal Spray X-Moist nasal spray x-moist (nasal solution)* Night Time Multi-Symptom Cold/Flu Relief night time multi-symptom cold/flu relief (capsule)* Nighttime Sinus Congestion & Pain nighttime sinus congestion & pain (tablet)* Nite Time Cough nite time cough (liquid)* Nite Time Multi-Symptom Cold/Flu Relief nite time multi-symptom cold/flu relief (liquid)* Nite-Time Cold/Flu nite-time cold/flu (capsule)* Nite-Time Multi-Symptom Cold/Flu Relief nite-time multi-symptom cold/flu relief (liquid)* NoHist-DM nohist-dm (liquid)* NoHist-LQ nohist-lq (liquid)* NRS Nasal Relief nrs nasal relief (nasal solution)* Ocean for Kids ocean for kids (nasal solution)* Ocean Nasal Spray ocean nasal spray (nasal solution)* Ofev OFEV (CAPSULE) $3.60-$7.40 (Tier 2) PA, QL, LA Organ-I NR organ-i nr (tablet)* Pain Relief Cold Severe Congestion pain relief cold severe congestion (tablet)* Pain Relief Sinus PE Daytime pain relief sinus pe daytime (tablet)* Pedia Relief Cough/Cold pedia relief cough/cold (liquid)* Pediatric Cough/Cold pediatric cough/cold (liquid)* Phenylhistine DH phenylhistine dh (liquid)* Pro-Clear AC pro-clear ac (syrup)*

107 For Track Refered Purpose Prolastin-C PROLASTIN-C (INJECTION) $3.60-$7.40 (Tier 2) PA, LA Promethazine VC/Codeine promethazine vc/codeine (syrup)* Promethazine/Codeine promethazine/codeine (syrup)* Promethazine/Dextromethorphan promethazine/dextromethorphan (syrup)* Promethazine-DM promethazine-dm (syrup)* PRO-RED AC pro-red ac (syrup)* Pseudoephedrine HCl pseudoephedrine hcl (tablet)* Pseudoephedrine HCl ER pseudoephedrine hcl er (tablet extended-release 12 hour)* Pulmozyme PULMOZYME (INHALATION SOLUTION) $3.60-$7.40 (Tier 2) B/D, PA QC Allergy Relief Multi-Symptom Daytime qc allergy relief multi-symptom daytime (tablet)* QC Cold Relief Plus Multi-Symptom Childrens qc cold relief plus multi-symptom childrens (suspension)* QC Cough Relief qc cough relief (liquid)* QC Cough/Sore Throat Nighttime qc cough/sore throat nighttime (liquid)* QC Medifin Mucus Relief Childrens qc medifin mucus relief childrens (liquid)* QC Nighttime Cold/Flu Relief qc nighttime cold/flu relief (liquid)* QC Nighttime Cough qc nighttime cough (liquid)* QC No Drip Nasal Relief qc no drip nasal relief (nasal solution)* QC Sinus Pain Relief qc sinus pain relief (tablet)* QC Suphedrine qc suphedrine (tablet)* QC Suphedrine Maximum Strength qc suphedrine maximum strength (tablet extended-release 12 hour)* QC Suphedrine PE qc suphedrine pe (tablet)* QC Tussin CF qc tussin cf (liquid)* Q-Tapp q-tapp (elixir)* Q-Tapp DM q-tapp dm (elixir)* Q-Tussin q-tussin (oral solution)* Q-Tussin DM q-tussin dm (syrup)* Relcof C relcof c (oral solution)* Rescon DM rescon dm (syrup)* Rescon-GG rescon-gg (liquid)* Respaire-30 respaire-30 (capsule)* 107 You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

108 For Track Refered Purpose 108 Rhinaris rhinaris (gel)* Robafen robafen (syrup)* Robafen CF Cough & Cold robafen cf cough & cold (syrup)* Robafen DM robafen dm (syrup)* Robafen DM Cough Clear robafen dm cough clear (syrup)* Robitussin Childrens Cough & Cold CF robitussin childrens cough & cold cf (liquid)* Robitussin Childrens Cough Long-Acting robitussin childrens cough long-acting (syrup)* Robitussin Childrens Cough/Cold Long-Acting robitussin childrens cough/cold long-acting (liquid)* Robitussin Cold+flu Daytime robitussin cold+flu daytime (capsule)* Robitussin Cold+flu Nighttime robitussin cold+flu nighttime (capsule)* Robitussin Lingering Coldlong-Acting Cough robitussin lingering coldlong-acting cough (liquid)* Robitussin Mucus + Chest Congestion robitussin mucus + chest congestion (liquid)* Robitussin Peak Cold Cough+ Chest Congestion DM robitussin peak cold cough+ chest congestion dm (liquid)* Robitussin Peak Cold Cough+ Chest Congestion DM Max Strength robitussin peak cold cough+ chest congestion dm max strength (liquid)* Robitussin Peak Cold DM robitussin peak cold dm (syrup)* Robitussin Peak Cold Multi-Symptom Cold robitussin peak cold multi-symptom cold (liquid)* Robitussin Peak Cold Multi-Symptom Cold Maximum Strength robitussin peak cold multi-symptom cold maximum strength (liquid)* Robitussin Peak Cold Nasal Relief robitussin peak cold nasal relief (tablet)* Robitussin Peak Cold Nighttime Multi-Symptom Cold robitussin peak cold nighttime multi-symptom cold (liquid)* Robitussin Peak Cold Nighttime Nasal Relief robitussin peak cold nighttime nasal relief (tablet)* Rydex rydex (liquid)* Rynex DM rynex dm (liquid)* Rynex PE rynex pe (elixir)* Rynex PSE rynex pse (liquid)* Saline Mist saline mist (nasal solution)* Saline Nasal Spray saline nasal spray (nasal solution)* SB Anti-Itch Maximum Strength sb anti-itch maximum strength (cream)* SB Cold & Cough HBP sb cold & cough hbp (tablet)* SB Cold Head Congestion Severe Daytime sb cold head congestion severe daytime (tablet)* SB Cold Multi-Symptom Severe Daytime sb cold multi-symptom severe daytime (tablet)* SB Cough Control CF sb cough control cf (liquid)* SB Cough Control DM sb cough control dm (liquid)* SB Cough Control DM Max sb cough control dm max (liquid)* SB Cough Relief sb cough relief (liquid)* SB Coughtab sb coughtab (tablet)* SB Flu Maximum Strength HBP sb flu maximum strength hbp (tablet)* SB Sinus & Allergy Maximum Strength sb sinus & allergy maximum strength (tablet)*

109 For Track Refered Purpose 109 SB Sinus Congestion & Pain Daytime sb sinus congestion & pain daytime (tablet)* SB Sinus Congestion & Pain Daytime/Nighttime sb sinus congestion & pain daytime/nighttime* SB Sinus Congestion & Pain Severe Daytime sb sinus congestion & pain severe daytime (tablet)* Sea Soft Nasal Mist sea soft nasal mist (nasal solution)* Siltussin SA siltussin sa (syrup)* Siltussin-DM siltussin-dm (syrup)* Sinus Congestion & Pain Daytime sinus congestion & pain daytime (tablet)* Sinus Nasal Spray sinus nasal spray (nasal solution)* SM 12 Hour Sinus Decongestant sm 12 hour sinus decongestant (tablet extended-release 12 hour)* SM 12-Hour No Drip sm 12-hour no drip (nasal solution)* SM All Day Allergy-D sm all day allergy-d (tablet extended-release 12 hour)* SM Allergy Multi-Symptom sm allergy multi-symptom (tablet)* SM Anti-Itch Extra Strength sm anti-itch extra strength (cream)* SM Childrens Pain Relief Plus Multi-Symptom Cold sm childrens pain relief plus multi-symptom cold (suspension)* SM Cold & Allergy Childrens sm cold & allergy childrens (elixir)* SM Cold & Cough DM Childrens sm cold & cough dm childrens (elixir)* SM Cold Head Congestion Severe Day Time sm cold head congestion severe day time (tablet)* SM Cough Relief sm cough relief (syrup)* SM Day Time Cold & Flu Relief sm day time cold & flu relief (liquid)* SM Day Time PE Cold & Flu Relief sm day time pe cold & flu relief (capsule)* SM Flu Relief Therapy Severe Cold Nighttime sm flu relief therapy severe cold nighttime (liquid)* SM Mucus ER sm mucus er (tablet extended-release 12 hour)* SM Mucus Relief Cough Childrens sm mucus relief cough childrens (liquid)* SM Nasal Decongestant Maximum Strength sm nasal decongestant maximum strength (tablet)* SM Nasal Decongestant PE sm nasal decongestant pe (tablet)* SM Nasal Spray Moisturizing sm nasal spray moisturizing (nasal solution)* SM Nasal Spray Saline sm nasal spray saline (nasal solution)* SM Nasal Spray Sinus sm nasal spray sinus (nasal solution)* SM Nite Time Cold & Flu sm nite time cold & flu (liquid)* You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

110 For Track Refered Purpose 110 SM Nite Time Cold & Flu Relief sm nite time cold & flu relief (325mg-15mg-6.25mg capsule, 500mg/15ml-15mg/15ml-6.25mg/15ml liquid)* SM Nite Time Cough sm nite time cough (liquid)* SM Nose Drops Nasal Decongestant Extra Strength sm nose drops nasal decongestant extra strength (nasal solution)* SM Tussin sm tussin (syrup)* SM Tussin CF sm tussin cf (liquid)* SM Tussin DM sm tussin dm (syrup)* SM Tussin DM Cough/Chest Congestion sm tussin dm cough/chest congestion (syrup)* SM Tussin DM Max Cough/Chest Congestion sm tussin dm max cough/chest congestion (liquid)* Sodium Chloride sodium chloride (otc only) (5% ointment, 5% ophthalmic solution)* Stiolto Respimat STIOLTO RESPIMAT (AEROSOL SOLUTION) $3.60-$7.40 (Tier 2) QL Sudogest sudogest (tablet)* Sudogest 12 Hour sudogest 12 hour (tablet extended-release 12 hour)* Sudogest PE sudogest pe (tablet)* Sudogest Sinus & Allergy sudogest sinus & allergy (tablet)* Symbicort SYMBICORT (AEROSOL) $3.60-$7.40 (Tier 2) Tessalon Perles tessalon perles (capsule)* Triacting Nightime Cold & Cough Childrens triacting nightime cold & cough childrens (liquid)* Triaminic Cold & Allergy triaminic cold & allergy (syrup)* Triaminic Cold & Cough Day Time Childrens triaminic cold & cough day time childrens (syrup)* Triaminic Cough & Congestion Childrens triaminic cough & congestion childrens (syrup)* Triaminic Cough & Sore Throat triaminic cough & sore throat (suspension)* Triaminic Multi-Symptom Fever triaminic multi-symptom fever (syrup)* Triaminic Night Time Cold & Cough triaminic night time cold & cough (syrup)* Tusnel tusnel (liquid)* Tusnel Diabetic tusnel diabetic (liquid)* Tusnel Pediatric tusnel pediatric (liquid)* Tussigon tussigon (tablet)* Tussin tussin (syrup)* Tussin CF tussin cf (liquid)* Tussin CF Cough & Cold tussin cf cough & cold (liquid)* Tussin CF Max Multi-Symptom tussin cf max multi-symptom (liquid)* Tussin Chest Congestion tussin chest congestion (syrup)* Tussin Cough tussin cough (syrup)* Tussin DM tussin dm (liquid, syrup)* Tussin DM Max tussin dm max (liquid)* Tussin Mucus + Chest Congestion tussin mucus + chest congestion (syrup)*

111 For Track Refered Purpose Tussionex Pennkinetic Extended-Release tussionex pennkinetic extended-release (liquid extendedrelease)* Tussi-Pres PE Pediatric tussi-pres pe pediatric (liquid)* Tyzine Pediatric Nasal Drops tyzine pediatric nasal drops (nasal solution) Vicks Dayquil Mucus Control DM vicks dayquil mucus control dm (liquid)* Virtussin A/C virtussin a/c (oral solution)* Virtussin DAC virtussin dac (oral solution)* Zemaira ZEMAIRA (INJECTION) $3.60-$7.40 (Tier 2) PA, LA Zonatuss zonatuss (capsule)* Respiratory Tract/Pulmonary Agents Combivent Respimat COMBIVENT RESPIMAT (AEROSOL SOLUTION) $3.60-$7.40 (Tier 2) Ipratropium Bromide/Albuterol Sulfate ipratropium bromide/albuterol sulfate (inhalation solution) B/D, PA Xolair XOLAIR (INJECTION) $3.60-$7.40 (Tier 2) PA Skeletal Muscle Relaxants Skeletal Muscle Relaxants Baclofen baclofen (tablet) Cyclobenzaprine HCl cyclobenzaprine hcl (7.5mg tablet) PA, HRM Dantrolene Sodium dantrolene sodium (capsule) Gablofen GABLOFEN (INJECTION) $3.60-$7.40 (Tier 2) B/D, PA Lioresal Intrathecal LIORESAL INTRATHECAL (INJECTION) $3.60-$7.40 (Tier 2) B/D, PA Orphenadrine Citrate orphenadrine citrate (injection) Tizanidine HCl tizanidine hcl (2mg tablet, 4mg tablet) Sleep Disorder Agents GABA Receptor Modulators Temazepam temazepam (capsule) QL Zaleplon zaleplon (capsule) QL, HRM Zolpidem Tartrate zolpidem tartrate (tablet immediate-release) QL, HRM 111 You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

112 For Track Refered Purpose 112 Sleep Disorders, Other Belsomra BELSOMRA (TABLET) $3.60-$7.40 (Tier 2) QL Hetlioz HETLIOZ (CAPSULE) $3.60-$7.40 (Tier 2) PA, QL Modafinil modafinil (tablet) PA, QL Rozerem ROZEREM (TABLET) $3.60-$7.40 (Tier 2) QL Xyrem XYREM (ORAL SOLUTION) $3.60-$7.40 (Tier 2) PA, QL, LA Therapeutic Nutrients/Minerals/Electrolytes Electrolyte/Mineral Modifiers Chemet CHEMET (CAPSULE) $3.60-$7.40 (Tier 2) Exjade EXJADE (TABLET SOLUBLE) $3.60-$7.40 (Tier 2) PA Ferriprox FERRIPROX (100MG/ML ORAL SOLUTION, 500MG TABLET) $3.60-$7.40 (Tier 2) PA Jadenu JADENU (TABLET) $3.60-$7.40 (Tier 2) PA Kionex kionex (powder) Samsca SAMSCA (TABLET) $3.60-$7.40 (Tier 2) PA, QL Sodium Polystyrene Sulfonate sodium polystyrene sulfonate (suspension) Syprine SYPRINE (CAPSULE) $3.60-$7.40 (Tier 2) ST Electrolyte/Mineral Replacement Calcet Petites calcet petites (tablet)* Calci-Chew calci-chew (tablet chewable)* Calci-Mix calci-mix (capsule)* Calcionate calcionate (syrup)* Calcitrate calcitrate (tablet)* Calcium calcium (tablet)* Calcium+D3 calcium+d3 (tablet)* Calcium 600+D calcium 600+d (tablet)* Calcium Carbonate calcium carbonate (1250mg tablet, 648mg tablet, 1250mg/ 5ml suspension)* Calcium Citrate+D calcium citrate+d (tablet)* Calcium High Potency + Vitamin D calcium high potency + vitamin d (tablet)* Calcium Lactate calcium lactate (tablet)* Calcium Oyster Shell calcium oyster shell (tablet)* Calcium Plus Vitamin D3 calcium plus vitamin d3 (capsule)* Calcium/Vitamin D calcium/vitamin d (tablet)* Calcium/Vitamin D/Minerals calcium/vitamin d/minerals (tablet chewable)* Calphron calphron (tablet)*

113 For Track Refered Purpose Caltrate 600+D Plus Minerals caltrate 600+d plus minerals (tablet chewable)* Calvite P&D calvite p&d (tablet)* Carbaglu CARBAGLU (TABLET) $3.60-$7.40 (Tier 2) LA Chromium Chloride chromium chloride (injection)* Citrus Calcium/Vitamin D citrus calcium/vitamin d (tablet)* Citrus Calcium+D citrus calcium+d (tablet)* Dexferrum dexferrum (injection)* Duofer duofer (tablet)* Enfamil Enfalyte enfamil enfalyte (oral solution)* Fer-In-Sol fer-in-sol (oral solution)* Feraheme feraheme (injection)* Ferate ferate (tablet)* Fer-Iron fer-iron (oral solution)* Ferosul ferosul (elixir)* Ferrex 150 ferrex 150 (capsule)* Ferrlecit ferrlecit (injection)* Ferrous Drops ferrous drops (oral solution)* Ferrous Gluconate ferrous gluconate (tablet)* Ferrous Sulfate ferrous sulfate (140mg tablet extended-release, 15mg/ml oral solution, 220mg/5ml elixir, 220mg/5ml liquid, 325mg tablet)* GNP Calcium 500+D3 gnp calcium 500+d3 (tablet)* GNP Calcium 500/D gnp calcium 500/d (tablet)* GNP Calcium Citrate+D3 gnp calcium citrate+d3 (tablet)* GNP Calcium Plus 600+D gnp calcium plus 600+d (tablet)* GNP Calcuim/Vitamin D/Minerals gnp calcuim/vitamin d/minerals (tablet chewable)* GNP Iron gnp iron (200mg tablet, 45mg tablet extended-release)* GNP Magnesium Citrate gnp magnesium citrate (oral solution)* GNP Pediatric Electrolyte gnp pediatric electrolyte (oral solution)* GNP Slow Release Iron gnp slow release iron (tablet extended-release)* HM Calcium/Vitamin D hm calcium/vitamin d (tablet)* 113 You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

114 For Track Refered Purpose 114 HM Magnesium Citrate hm magnesium citrate (oral solution)* HM Pediatric Electrolyte hm pediatric electrolyte (solution)* Iferex 150 iferex 150 (capsule)* Infed infed (injection)* Iron iron (otc only) (tablet)* Iron Chews Pediatric iron chews pediatric (otc only) (tablet chewable)* Isolyte-S ISOLYTE-S (INJECTION) $3.60-$7.40 (Tier 2) Klor-Con 10 KLOR-CON 10 (TABLET EXTENDED-RELEASE) $3.60-$7.40 (Tier 2) Klor-Con 8 KLOR-CON 8 (TABLET EXTENDED-RELEASE) $3.60-$7.40 (Tier 2) Klor-Con M15 klor-con m15 (tablet extended-release) Klor-Con M20 klor-con m20 (tablet extended-release) Klor-Con Sprinkle klor-con sprinkle (capsule extended-release) K-Tab K-TAB (10MEQ TABLET EXTENDED-RELEASE, $3.60-$7.40 (Tier 2) 8MEQ TABLET EXTENDED-RELEASE) L-Citrulline l-citrulline (powder)* Mag-Delay mag-delay (tablet extended-release)* Mag-G mag-g (tablet)* Magnebind 300 magnebind 300 (tablet)* Magnesium Citrate magnesium citrate (oral solution)* Magnesium Sulfate MAGNESIUM SULFATE (1GM/2ML-50% $3.60-$7.40 (Tier 2) INJECTION) Magnesium Sulfate magnesium sulfate (5gm/10ml-50% injection) Magonate magonate (1000mg/5ml liquid, 500mg tablet)* My Kidz Iron 10 my kidz iron 10 (suspension)* Normosol-R NORMOSOL-R (INJECTION) $3.60-$7.40 (Tier 2) NovaFerrum 50 novaferrum 50 (capsule)* NovaFerrum Pediatric Drops novaferrum pediatric drops (liquid)* Oralyte oralyte (oral solution)* Oralyte Freezer Pops oralyte freezer pops (oral solution)* Oysco 500+D oysco 500+d (tablet chewable)* Oyster Shell Calcium oyster shell calcium (tablet)* Oyster Shell Calcium/Vitamin D oyster shell calcium/vitamin d (tablet)* Pedialyte pedialyte (oral solution)* Pedialyte Advanced Care pedialyte advanced care (oral solution)* Pedialyte Freezer Pops pedialyte freezer pops (oral solution)* Pediatric Electrolyte pediatric electrolyte (oral solution)* Pediatric Electrolyte Freezer Pops pediatric electrolyte freezer pops (oral solution)* Pediatric Electrolyte/Zinc pediatric electrolyte/zinc (oral solution)*

115 For Track Refered Purpose Peleverus peleverus (ointment, 0.25% liquid)* Peleverus Clear peleverus clear (ointment)* Peleverus Gold peleverus gold (ointment)* Physiolyte PHYSIOLYTE (IRRIGATION SOLUTION) $3.60-$7.40 (Tier 2) Physiosol Irrigation PHYSIOSOL IRRIGATION (IRRIGATION SOLUTION) $3.60-$7.40 (Tier 2) Plasma-Lyte A PLASMA-LYTE A (INJECTION) $3.60-$7.40 (Tier 2) Plasma-Lyte-148 PLASMA-LYTE-148 (INJECTION) $3.60-$7.40 (Tier 2) Poly-Iron 150 poly-iron 150 (capsule)* Potassium Chloride POTASSIUM CHLORIDE (10% ORAL SOLUTION, 20% ORAL SOLUTION) $3.60-$7.40 (Tier 2) Potassium Chloride POTASSIUM CHLORIDE (10MEQ/100ML INJECTION, 20MEQ/100ML INJECTION, 40MEQ/ $3.60-$7.40 (Tier 2) B/D, PA 100ML INJECTION) Potassium Chloride potassium chloride (2meq/ml injection) B/D, PA Potassium Chloride 0.15% /NaCl 0.45% Viaflex potassium chloride 0.15% /nacl 0.45% viaflex (injection) B/D, PA Potassium Chloride 0.15%/NaCl 0.9% POTASSIUM CHLORIDE 0.15%/NACL 0.9% (INJECTION) $3.60-$7.40 (Tier 2) B/D, PA Potassium Chloride 0.3%/ NaCl 0.9% POTASSIUM CHLORIDE 0.3%/ NACL 0.9% (INJECTION) $3.60-$7.40 (Tier 2) B/D, PA Potassium Chloride ER potassium chloride er (10meq capsule extended-release, 8meq capsule extended-release, 10meq microencapsulated tablet extended-release, 20meq microencapsulated tablet extended-release, 8meq tablet extended-release) Potassium Citrate ER potassium citrate er (tablet extended-release) Profe profe (capsule)* QC Ferrous Sulfate qc ferrous sulfate (tablet)* QC Magnesium Citrate qc magnesium citrate (oral solution)* Risacal-D risacal-d (tablet)* Slow-Mag slow-mag (tablet delayed-release)* 115 You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

116 For Track Refered Purpose 116 SM Calcium Citrate w/vitamin D3 sm calcium citrate w/vitamin d3 (tablet)* SM Iron sm iron (tablet)* SM Pediatric Electrolyte sm pediatric electrolyte (oral solution)* Sodium Chloride sodium chloride (rx only) (0.9% injection) Sodium Chloride SODIUM CHLORIDE (RX ONLY) (2.5MEQ/ML $3.60-$7.40 (Tier 2) INJECTION, 3% INJECTION, 5% INJECTION) Sodium Chloride 0.45% Viaflex SODIUM CHLORIDE 0.45% VIAFLEX (INJECTION) $3.60-$7.40 (Tier 2) Sodium Chloride 0.9% SODIUM CHLORIDE 0.9% (IRRIGATION $3.60-$7.40 (Tier 2) SOLUTION) Sodium Fluoride sodium fluoride (tablet) Venofer venofer (injection)* Zinc Sulfate zinc sulfate (220mg capsule)* Zinc Trace Metal zinc trace metal (injection)* Therapeutic Nutrients/Minerals/Electrolytes Aminosyn 7%/Electrolytes AMINOSYN 7%/ELECTROLYTES (INJECTION) $3.60-$7.40 (Tier 2) B/D, PA Aminosyn 8.5%/Electrolytes AMINOSYN 8.5%/ELECTROLYTES (INJECTION) $3.60-$7.40 (Tier 2) B/D, PA Aminosyn II AMINOSYN II (INJECTION) $3.60-$7.40 (Tier 2) B/D, PA Aminosyn II 8.5%/Electrolytes AMINOSYN II 8.5%/ELECTROLYTES (INJECTION) $3.60-$7.40 (Tier 2) B/D, PA Aminosyn M AMINOSYN M (INJECTION) $3.60-$7.40 (Tier 2) B/D, PA Aminosyn-HBC AMINOSYN-HBC (INJECTION) $3.60-$7.40 (Tier 2) B/D, PA Aminosyn-PF AMINOSYN-PF (INJECTION) $3.60-$7.40 (Tier 2) B/D, PA Aminosyn-RF AMINOSYN-RF (INJECTION) $3.60-$7.40 (Tier 2) B/D, PA Clinisol SF 15% clinisol sf 15% (injection) B/D, PA Dextrose 10% Flex Container DEXTROSE 10% FLEX CONTAINER (INJECTION) $3.60-$7.40 (Tier 2) Dextrose 10%/NaCl 0.2% DEXTROSE 10%/NACL 0.2% (INJECTION) $3.60-$7.40 (Tier 2) Dextrose 10%/NaCl 0.45% DEXTROSE 10%/NACL 0.45% (INJECTION) $3.60-$7.40 (Tier 2) Dextrose 2.5%/Sodium Chloride 0.45% DEXTROSE 2.5%/SODIUM CHLORIDE 0.45% (INJECTION) $3.60-$7.40 (Tier 2) Dextrose 5% DEXTROSE 5% (INJECTION) $3.60-$7.40 (Tier 2) Dextrose 5%/NaCl 0.2% DEXTROSE 5%/NACL 0.2% (INJECTION) $3.60-$7.40 (Tier 2) Dextrose 5%/NaCl 0.225% DEXTROSE 5%/NACL 0.225% (INJECTION) $3.60-$7.40 (Tier 2) Dextrose 5%/NaCl 0.33% DEXTROSE 5%/NACL 0.33% (INJECTION) $3.60-$7.40 (Tier 2) Dextrose 5%/NaCl 0.45% DEXTROSE 5%/NACL 0.45% (INJECTION) $3.60-$7.40 (Tier 2) Dextrose 5%/NaCl 0.9% DEXTROSE 5%/NACL 0.9% (INJECTION) $3.60-$7.40 (Tier 2) Dextrose 5%/Potassium Chloride 0.15% DEXTROSE 5%/POTASSIUM CHLORIDE 0.15% (INJECTION) $3.60-$7.40 (Tier 2) B/D, PA FreAmine HBC 6.9% FREAMINE HBC 6.9% (INJECTION) $3.60-$7.40 (Tier 2) B/D, PA

117 For Track Refered Purpose HepatAmine HEPATAMINE (INJECTION) $3.60-$7.40 (Tier 2) B/D, PA Intralipid INTRALIPID (INJECTION) $3.60-$7.40 (Tier 2) B/D, PA Ionosol-B/Dextrose 5% IONOSOL-B/DEXTROSE 5% (INJECTION) $3.60-$7.40 (Tier 2) Ionosol-MB/Dextrose 5% IONOSOL-MB/DEXTROSE 5% (INJECTION) $3.60-$7.40 (Tier 2) Isolyte-P/Dextrose 5% ISOLYTE-P/DEXTROSE 5% (INJECTION) $3.60-$7.40 (Tier 2) KCl 0.075%/D5W/NaCl 0.45% KCL 0.075%/D5W/NACL 0.45% (INJECTION) $3.60-$7.40 (Tier 2) KCl 0.15%/D5W/LR KCL 0.15%/D5W/LR (INJECTION) $3.60-$7.40 (Tier 2) KCl 0.15%/D5W/NaCl 0.2% KCL 0.15%/D5W/NACL 0.2% (INJECTION) $3.60-$7.40 (Tier 2) KCl 0.15%/D5W/NaCl 0.225% KCL 0.15%/D5W/NACL 0.225% (INJECTION) $3.60-$7.40 (Tier 2) KCl 0.15%/D5W/NaCl 0.9% KCL 0.15%/D5W/NACL 0.9% (INJECTION) $3.60-$7.40 (Tier 2) KCl 0.3%/D5W/NaCl 0.45% KCL 0.3%/D5W/NACL 0.45% (INJECTION) $3.60-$7.40 (Tier 2) KCl 0.3%/D5W/NaCl 0.9% KCL 0.3%/D5W/NACL 0.9% (INJECTION) $3.60-$7.40 (Tier 2) Lactated Ringers Dextrose 5% Viaflex LACTATED RINGERS DEXTROSE 5% VIAFLEX (INJECTION) $3.60-$7.40 (Tier 2) Lactated Ringers Irrigation LACTATED RINGERS IRRIGATION (IRRIGATION SOLUTION) $3.60-$7.40 (Tier 2) Lactated Ringers Viaflex LACTATED RINGERS VIAFLEX (INJECTION) $3.60-$7.40 (Tier 2) Levocarnitine levocarnitine (1gm/10ml oral solution, 200mg/ml injection, 330mg tablet) B/D, PA Nephramine NEPHRAMINE (INJECTION) $3.60-$7.40 (Tier 2) B/D, PA Normosol-M in D5W NORMOSOL-M IN D5W (INJECTION) $3.60-$7.40 (Tier 2) Normosol-R in D5W NORMOSOL-R IN D5W (INJECTION) $3.60-$7.40 (Tier 2) NutreStore NUTRESTORE (PACKET) $3.60-$7.40 (Tier 2) Nutrilipid NUTRILIPID (INJECTION) $3.60-$7.40 (Tier 2) B/D, PA Plasma-Lyte-56/D5W PLASMA-LYTE-56/D5W (INJECTION) $3.60-$7.40 (Tier 2) Plenamine plenamine (injection) B/D, PA Potassium Chloride 0.15% D5W/NaCl 0.33% POTASSIUM CHLORIDE 0.15% D5W/NACL 0.33% (INJECTION) $3.60-$7.40 (Tier 2) Potassium Chloride 0.15% D5W/NaCl 0.45% POTASSIUM CHLORIDE 0.15% D5W/NACL 0.45% (INJECTION) $3.60-$7.40 (Tier 2) 117 You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

118 For Track Refered Purpose 118 Potassium Chloride 0.22% D5W/NaCl 0.45% POTASSIUM CHLORIDE 0.22% D5W/NACL 0.45% (INJECTION) $3.60-$7.40 (Tier 2) Potassium Chloride 0.3%/D5W POTASSIUM CHLORIDE 0.3%/D5W (INJECTION) $3.60-$7.40 (Tier 2) B/D, PA Premasol premasol (injection) B/D, PA Procalamine PROCALAMINE (INJECTION) $3.60-$7.40 (Tier 2) B/D, PA Prosol PROSOL (INJECTION) $3.60-$7.40 (Tier 2) B/D, PA Ringers Injection RINGERS INJECTION $3.60-$7.40 (Tier 2) Ringers Irrigation RINGERS IRRIGATION (IRRIGATION SOLUTION) $3.60-$7.40 (Tier 2) Sodium Lactate SODIUM LACTATE (INJECTION) $3.60-$7.40 (Tier 2) Electrolytes TPN ELECTROLYTES (INJECTION) $3.60-$7.40 (Tier 2) Travasol TRAVASOL (INJECTION) $3.60-$7.40 (Tier 2) B/D, PA Trophamine TROPHAMINE (INJECTION) $3.60-$7.40 (Tier 2) B/D, PA VP-PNV-DHA vp-pnv-dha (capsule) Vitamins Alpha Lipoic Acid alpha lipoic acid (capsule)* Animal Shapes animal shapes (tablet chewable)* Animal Shapes + Iron animal shapes + iron (tablet chewable)* AquADEKs aquadeks (tablet chewable, capsule, liquid)* Aqua-E aqua-e (liquid)* Aquasol A Parenteral aquasol a parenteral (injection)* Aqueous Vitamin D Infants aqueous vitamin d infants (liquid)* Aqueous Vitamin E aqueous vitamin e (oral solution)* Arginine arginine (tablet)* B-Complex Plus Vitamin C b-complex plus vitamin c (tablet)* Biotin biotin (capsule)* Calciferol calciferol (oral solution)* Centamin centamin (liquid)* Centavite A-Z Complete Multivitamin/Minerals centavite a-z complete multivitamin/minerals (tablet)* Centrum centrum (liquid)* Centrum Adults centrum adults (tablet)* Centrum Silver centrum silver (tablet)* Centrum Ultra Womens centrum ultra womens (tablet)* Cerovite Advanced Formula cerovite advanced formula (tablet, liquid)* Cerovite Jr cerovite jr (tablet chewable)* Certavite/Antioxidants certavite/antioxidants (tablet, liquid)* Chewable Vite Childrens chewable vite childrens (tablet chewable)* Chewable Vite with Iron/Childrens chewable vite with iron/childrens (tablet chewable)*

119 For Track Refered Purpose 119 Childrens Chewable Vitamins childrens chewable vitamins (tablet chewable)* Childrens Chewable Vitamins/Iron childrens chewable vitamins/iron (tablet chewable)* Complete complete (tablet)* Cyanocobalamin cyanocobalamin (injection)* D 5000 d 5000 (tablet)* D3 High Potency d3 high potency (capsule)* D3 Super Strength d3 super strength (capsule)* D3-50 d3-50 (capsule)* Daily Multiple Vitamins daily multiple vitamins (tablet)* Daily Vite daily vite (tablet)* Daily-Vite/Iron/Beta-Carotene daily-vite/iron/beta-carotene (tablet)* Dialyvite 800 dialyvite 800 (tablet)* Dialyvite Vitamin D3 Max dialyvite vitamin d3 max (tablet)* Drisdol drisdol (rx only) (50000unit capsule, 8000unit/ml oral solution)* D-Vi-Sol d-vi-sol (liquid)* D-Vita d-vita (liquid)* Enfamil Expecta enfamil expecta* Ergocalciferol ergocalciferol (otc only) (oral solution)* EZFE Forte ezfe forte (capsule)* Folic Acid folic acid (rx only) (1mg tablet, 5mg/ml injection)* Folitab 500 folitab 500 (tablet extended-release)* Fosfree fosfree (tablet)* Geravim geravim (liquid)* Geriaton geriaton (liquid)* GNP Century gnp century (tablet)* GNP Century Adults 50+ Senior gnp century adults 50+ senior (tablet)* GNP Century Ultimate Mens Complete gnp century ultimate mens complete (tablet)* GNP Century Ultimate Mens Senior Formula gnp century ultimate mens senior formula (tablet)* GNP Century Ultimate Womens Complete gnp century ultimate womens complete (tablet)* GNP Century Ultimate Womens Senior Formula gnp century ultimate womens senior formula (tablet)* You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

120 For Track Refered Purpose 120 GNP Childrens Chewables/Extra C gnp childrens chewables/extra c (tablet chewable)* GNP Childrens Chewables/Iron gnp childrens chewables/iron (tablet chewable)* GNP Daily Prenatal gnp daily prenatal (otc only) (tablet)* GNP Essential One Daily gnp essential one daily (tablet)* GNP Little Ones Childrens gnp little ones childrens (tablet chewable)* GNP Niacin TR gnp niacin tr (otc only) (tablet extended-release)* GNP One Daily Maximum gnp one daily maximum (tablet)* GNP One Daily Plus Iron gnp one daily plus iron (tablet)* GNP Prenatal gnp prenatal (otc only) (tablet)* Healthy Eyes healthy eyes (tablet)* HM Complete hm complete (tablet)* HM Complete 50+ hm complete 50+ (tablet)* HM Glucose hm glucose (tablet chewable)* HM Niacin hm niacin (tablet extended-release)* HM One Daily/Iron hm one daily/iron (tablet)* HM Vitamin B Complex/Vitamin C hm vitamin b complex/vitamin c (tablet)* Hydroxocobalamin hydroxocobalamin (injection)* I-Caps i-caps (capsule)* Infuvite infuvite (injection)* Infuvite Adult infuvite adult (injection)* Infuvite Pediatric infuvite pediatric (injection)* I-Vite i-vite (tablet)* L-Arginine l-arginine (powder)* L-Glutamine l-glutamine (powder)* M.V.I. 12 without Vitamin K m.v.i. 12 without vitamin k (injection)* M.V.I. Adult m.v.i. adult (injection)* M.V.I. Pediatric m.v.i. pediatric (injection)* Maximum D3 maximum d3 (capsule)* Mephyton mephyton (tablet)* Meribin meribin (capsule)* Multi-Delyn multi-delyn (liquid)* Multi-Delyn/Iron multi-delyn/iron (liquid)* Multilex multilex (tablet)* Multilex T&M multilex t&m (tablet)* Multi-Vitamins multi-vitamins (tablet)* My Kidz Iron my kidz iron (suspension)* Nephro-Vite nephro-vite (tablet)* Niacin ER niacin er (otc only) (capsule extended-release)*

121 For Track Refered Purpose 121 Niacin Flush Free Formula niacin flush free formula (otc only) (capsule)* Niacin SR niacin sr (otc only) (capsule extended-release)* Niacin TR niacin tr (otc only) (250mg capsule extended-release, 500mg capsule extended-release, 500mg tablet extendedrelease, 750mg tablet extended-release)* NovaFerrum 125 novaferrum 125 (liquid)* Ocuvite Adult 50+ ocuvite adult 50+ (capsule)* Once Daily once daily (tablet)* Once Daily/Iron once daily/iron (tablet)* One Daily one daily (tablet)* One Daily Mens one daily mens (tablet)* Oyster Shell Calcium + Vitamin D oyster shell calcium + vitamin d (tablet)* Phos-NaK Powder Concentrate phos-nak powder concentrate (packet)* Poly Vitamin poly vitamin (tablet chewable)* Polyvitamin polyvitamin (oral solution)* Polyvitamin/Iron polyvitamin/iron (oral solution, tablet chewable)* Prenatal prenatal (otc only) (tablet)* Preservision Areds 2 preservision areds 2 (capsule)* Profe Forte profe forte (capsule)* QC Childrens Chewable Vitamins/Extra C qc childrens chewable vitamins/extra c (tablet chewable)* QC Childrens Chewable Vitamins/Iron qc childrens chewable vitamins/iron (tablet chewable)* QC Daily Multivitamins/Iron qc daily multivitamins/iron (tablet)* QC Maximum Daily Multivitamin/Multimineral qc maximum daily multivitamin/multimineral (tablet)* QC Multi-Vite qc multi-vite (tablet)* QC Multi-Vite 50 & Over qc multi-vite 50 & over (tablet)* QC Prenatal qc prenatal (otc only) (tablet)* QC Therin-M qc therin-m (tablet)* QC Womens Daily Multivitamin qc womens daily multivitamin (tablet)* Rena-Vite rena-vite (tablet)* Sentry sentry (tablet)* Sentry Senior sentry senior (tablet)* You can find information on what the symbols and abbreviations in this table mean by going to pages 9 and 10. CAPITALIZED = brand name drug lower-case italics = generic drug * For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

122 For Track Refered Purpose 122 Slo-Niacin slo-niacin (otc only) (tablet extended-release)* SM Complete Advanced Formula sm complete advanced formula (tablet)* SM Complete Senior Formula sm complete senior formula (tablet)* Stress Formula stress formula (tablet)* Stress Formula w/iron stress formula w/iron (tablet)* Stress Formula/Zinc stress formula/zinc (tablet)* Stuart One stuart one (capsule)* Superplex-T superplex-t (tablet)* TAB-A-VITE tab-a-vite (tablet)* TAB-A-VITE w/beta Carotene tab-a-vite w/beta carotene (tablet)* TAB-A-VITE Womens tab-a-vite womens (tablet)* TAB-A-VITE/Iron tab-a-vite/iron (tablet)* TGT Glucose tgt glucose (tablet chewable)* Thera thera (tablet)* Thera M Plus thera m plus (tablet)* Thera/Beta-Carotene thera/beta-carotene (tablet)* Thera-M thera-m (tablet)* Therems therems (tablet)* Therems-H therems-h (tablet)* Therems-M therems-m (tablet)* Thiamine HCl thiamine hcl (injection)* Tri-Vita tri-vita (oral solution)* Tri-Vitamin tri-vitamin (oral solution)* Unicomplex-M unicomplex-m (tablet)* Vita-Bee/C vita-bee/c (tablet)* Vitamin B Complex-C vitamin b complex-c (capsule)* Vitamin C vitamin c (tablet)* Vitamin D vitamin d (rx only) (1000unit capsule, 2000unit capsule, 400unit/ml liquid, 50000unit capsule)* Vitamin D3 vitamin d3 (otc only) (10000unit capsule, 50000unit capsule, 5000unit capsule, 1000unit tablet, 5000unit tablet, 400unit/ml liquid)* Vitamin D3 Super Strength vitamin d3 super strength (otc only) (tablet)* Vitamin K1 vitamin k1 (rx only) (injection)* Zoo Friends zoo friends (tablet chewable)* Zoo Friends Complete zoo friends complete (tablet chewable)* Zoo Friends Gummies zoo friends gummies (tablet chewable)* Zoo Friends Plus Extra C zoo friends plus extra c (tablet chewable)* Zoo Friends Plus Iron zoo friends plus iron (tablet chewable)*

123 123 For Track Refered Purpose Index of Drugs # 12 Hour Decongestant Hour Nasal Spray Day Vaginal MOP A A-Hydrocort...71 Abacavir...44 Abacavir Sulfate/ Lamivudine/Zidovudine. 44 Abelcet...29 Abilify Maintena...41 Abraxane Abstral Acamprosate Calcium DR16 Acarbose ACE Aerosol Cloud Enhancer...85 Acephen Acetaminophen Acetaminophen/Codeine.14 Acetazolamide...53 Acetazolamide ER...53 Acetazolamide Sodium...54 Acetic Acid...92 Acetylcysteine...98 Acid Gone Acid Reducer...67 Acidophilus/Citrus Pectin.62 Acidophilus/L-Sporogenes Extra Strength...62 Acitretin...58 Acne Medication...58 Acne Medication Actemra ActHIB...82 Actimmune...82 Acyclovir Acyclovir Sodium...43 Adacel Adagen...60 Adapalene...58 Adcirca...98 Adefovir Dipivoxil Adempas Adrucil...34 Adult Mask Large Advair Diskus...98 Advair HFA...98 Advil Advil Junior Strength Aerochamber Mini Aerosol Chamber...85 Aerochamber MV Aerochamber Plus Flow Vu...85 Aerochamber Plus Flow Vu/ Large Mask Aerochamber Plus Flow Vu/ Mask Aerochamber Plus Flow Vu/ Medium Mask...85 Aerochamber Plus Flow Vu/ Small Mask...85 Aerochamber Plus/Small Mask Aerochamber Z-Stat Plus Valved Holding Chamber w/flow Vu...85 Aerochamber Z-Stat Plus/ Flowsignal...86 Aerochamber Z-Stat Plus/ Large Mask Aerochamber Z-Stat Plus/ Medium Mask...86 Aerochamber Z-Stat Plus/ Small Mask...86 Aerochamber/Flow Signal...86 Aerogear Asthma Action.. 86 Aerotrach Plus...86 Afinitor...37 Afinitor Disperz...37 Aggrenox...50 Aimsco Lubricated...86 Airzone Peak Flow Meter..86 Akwa Tears Ala Cort Alavert Alavert Allergy/Sinus Alaway...88 Alaway Childrens Allergy Eye Itch Relief...89 Albenza Albuterol Sulfate Alclometasone Dipropionate...71 Alcohol Prep Pads Aldurazyme Alecensa...35 Alendronate Sodium...84

124 Alevazol...29 Alfuzosin HCl ER Alimta...34 Alinia...39 All Day Allergy All Day Allergy Childrens.. 93 All Day Allergy D All Day Allergy D All Day Allergy-D All Day Pain Relief All Day Relief...11 All-Nite Multi-Symptom Cold/Flu Relief...98 Aller-Chlor...93 Aller-Ease...93 Allergy Allergy & Congestion Relief...93 Allergy Multi-Symptom Allergy Relief...93 Allergy Relief Child...93 Allergy Relief D Allergy Relief/Nasal Decongestant Allergy Tablets...93 Allergy-Time Allerhist Allopurinol Almacone Double Strength...62 Aloe Vesta Protective...58 Alora Alosetron HCl Aloxi Alpha Lipoic Acid Alphagan P Alprazolam Aluminum Hydroxide...62 Amantadine HCl AmBisome...29 Ameriphor Amethia...74 Amethyst...74 Amifostine Amikacin Sulfate...17 Amiloride HCl Amiloride/ Hydrochlorothiazide...52 Aminophylline...97 Aminosyn 7%/Electrolytes Aminosyn 8.5%/Electrolytes Aminosyn II Aminosyn II 8.5%/ Electrolytes Aminosyn M Aminosyn-HBC Aminosyn-PF Aminosyn-RF Amiodarone HCl...51 Amitiza...67 Amitriptyline HCl...27 Amlactin...58 Amlactin Ultra...86 Amlodipine Besylate...52 Amlodipine Besylate/ Atorvastatin Calcium Amlodipine Besylate/ Benazepril HCl...52 Ammonium Lactate Amoxapine...27 Amoxicillin...20 Amoxicillin/Clavulanate Potassium...21 Amoxicillin/Clavulanate Potassium ER Amphetamine/ Dextroamphetamine Amphotericin B...29 Ampicillin...21 Ampicillin Sodium Ampicillin-Sulbactam...21 Ampyra...57 Anadrol Anagrelide HCl...49 Anastrozole Ancobon...29 Androderm...74 Androgel...74 Androgel Pump...74 Animal Shapes Animal Shapes + Iron Antacid...62 Antacid Anti-Gas Maximum Strength...62 Antacid Fast Relief Antacid Maximum Strength...62 Antacid Plus Anti-Gas Fast Acting...62 Anti-Diarrheal Anti-Fungal Powder...29

125 Anti-Itch Anti-Nausea...28 Antifungal Anzemet...28 Apokyn...40 Apraclonidine Apri...74 Apriso Aprodine...98 Aptiom...25 Aptivus Aqua-E AquADEKs Aquasol A Parenteral Aqueous Vitamin D Infants Aqueous Vitamin E Aralast NP...98 Aranelle...74 Aranesp Albumin Free Arcalyst Argatroban Arginine Aripiprazole...41 Aripiprazole ODT Arnuity Ellipta...96 Arranon Artificial Tears...89 Ashlyna Aspir Aspir-Low...11 Aspirin Aspirin Adult Low Strength...11 Aspirin Childrens Aspirin EC Aspirin EC Low Dose...11 Aspirin Enteric Coated Adult Low Strength...11 Aspirin Low Dose Aspirin Low Strength Aspirin/Dipyridamole...50 Assess Full Range Peak Flow Meter...86 Asthma Check Meter-Zone System...86 Asthmamentor...86 Asthmapack for Children..86 Atenolol...51 Atenolol/Chlorthalidone...52 Atgam...81 Athletes Foot AF Cream...29 Atorvastatin Calcium...54 Atovaquone...39 Atovaquone/Proguanil HCl...39 Atripla Atropine Sulfate Atrovent HFA Aubagio Aubra...74 Augmented Betamethasone Dipropionate Avandia Avastin...38 Avelox...22 Aviane...74 Avita Avonex Avonex Pen...57 Azacitidine...35 Azactam in Iso-Osmotic Dextrose...20 Azathioprine...80 Azelastine HCl...90, 93 Azilect...40 Azithromycin...21 Aztreonam...20 B B-Complex Plus Vitamin C BACiiM...17 Bacitracin...17 Bacitracin Zinc Bacitracin/Neomycin/ Polymyxin...18 Bacitracin/Polymyxin B...89 Baclofen Bacteriostatic Water for Injection/Benzyl Alcohol 58 Bactocill in Dextrose Bactroban Nasal Balsalazide Disodium Balziva Banophen...93 Banzel...25 Baraclude Baza Antifungal...29 Baza Protect BCG Vaccine...82 Bekyree...74 Beleodaq... 35

126 Belsomra Benazepril HCl Benazepril HCl/ Hydrochlorothiazide...52 Benicar...50 Benicar HCT Benlysta Benzoin Compound Tincture Benzonatate...98 Benzoyl Peroxide...58 Benzoyl Peroxide Cleanser...58 Benzoyl Peroxide Wash...58 Benztropine Mesylate...40 Bepreve...90 Berinert Beta Care Betatar Gel Beta HC Betadine Surgical Scrub...18 Betamethasone Dipropionate Betamethasone Valerate.. 72 Betaseron Betaxolol HCl...91 Bethanechol Chloride...71 Bethkis Bexarotene...38 Bexsero...82 Bicalutamide...34 Bicillin C-R...21 Bicillin L-A...21 BiCNU Biltricide...39 Binosto...84 Bion Tears...89 Biotin Bisac-Evac...67 Bisacodyl Bisacodyl EC Biscolax...67 Bismatrol...62 Bismatrol Maximum Strength...62 BIVIGAM...81 Bleomycin Sulfate...35 Blephamide...89 Blephamide S.O.P...89 Blisovi 24 Fe Blisovi Fe 1.5/ Blisovi Fe 1/ Boostrix...82 Bosulif Botox BPO Creamy Wash Complete Pack...58 BreatheRite Valved MDI Chamber/Collapsible...86 BreatheRite Valved MDI Chamber/Rigid Breo Ellipta...98 Briellyn...75 Brilinta Brimonidine Tartrate...91 Brintellix Bromfed DM Bromocriptine Mesylate...40 Bromphen/ Pseudoephedrine HCl/ Dextromethorphan HBr..99 Brotapp Brotapp DM Brovana...97 Brovex PEB...99 Brovex PSB...99 Budesonide... 84, 96 Bumetanide Buphenyl Buprenorphine HCl...16 Buprenorphine HCl/ Naloxone HCl...16 Buproban Bupropion HCl Bupropion HCl SR Bupropion HCl XL Buspirone HCl...46 Busulfex Butorphanol Tartrate Bydureon...47 Byetta Bystolic...51 C Cabergoline Calcet Petites Calci-Chew Calci-Mix Calciferol Calcionate Calcipotriene Calcitonin-Salmon Calcitrate...112

127 Calcitriol...58, 84 Calcium Calcium 600+D Calcium Acetate Calcium Carbonate Calcium Citrate+D Calcium High Potency + Vitamin D Calcium Lactate Calcium Oyster Shell Calcium Plus Vitamin D Calcium+D Calcium/Vitamin D Calcium/Vitamin D/Minerals Calphron Caltrate 600+D Plus Minerals Calvite P&D Camila Canasa...84 Cancidas...29 Candesartan Cilexetil...50 Candesartan Cilexetil/ Hydrochlorothiazide...52 Capastat Sulfate...33 Capcof...99 Capmist DM...99 Caprelsa...37 Capron DM Captopril Captopril/ Hydrochlorothiazide...52 Carac Carafate Carbaglu Carbamazepine...25 Carbamazepine ER...25 Carbidopa/Levodopa...40 Carbidopa/Levodopa ER. 40 Carbidopa/Levodopa ODT...40 Carboplatin Cardene IV Carimune Nanofiltered...81 Carrington Antifungal Carteolol HCl Cartia XT...52 Carvedilol...51 Castor Oil...62 Cayston...97 Cefaclor...19 Cefadroxil Cefazolin Sodium Cefdinir...19 Cefepime...19 Cefixime...19 Cefotaxime Sodium Cefotetan...20 Cefoxitin Sodium Cefpodoxime Proxetil...20 Cefprozil...20 Ceftazidime...20 Ceftazidime/Dextrose...20 Ceftriaxone Sodium Cefuroxime Axetil Cefuroxime Sodium...20 Cellcept...80 Cellcept Intravenous...80 Celontin...24 Centamin Centavite A-Z Complete Multivitamin/Minerals Centrum Centrum Adults Centrum Silver Centrum Ultra Womens..118 Cephalexin Cerezyme Cerovite Advanced Formula Cerovite Jr Certavite/Antioxidants Cervarix...82 Cesamet...28 Cetirizine HCl...93 Cetirizine HCl/ Pseudoephedrine HCl ER...99 Chantix...16 Chantix Continuing Month Pak Chantix Starting Month Pak...16 Chemet Chenodal...62 Cheratussin AC...99 Cheratussin DAC...99 Chest Congestion Relief...99 Chewable Vite Childrens118

128 Chewable Vite with Iron/ Childrens Childrens Advil Childrens Aspirin Childrens Aspirin Low Strength...11 Childrens Chewable Vitamins Childrens Chewable Vitamins/Iron Childrens Cold & Allergy...99 Childrens Ibuprofen Childrens Loratadine Childrens Mucus Relief Cough...99 Childrens Mucus Relief Expectorant...99 Childrens Pain Relief Plus Multi-Symptom Cold Chloramphenicol Sodium Succinate...18 Chlordiazepoxide HCl Chlorhexidine Gluconate Oral Rinse...57 Chloroquine Phosphate...39 Chlorothiazide Chlorothiazide Sodium...54 Chlorpheniramine Maleate...93 Chlorpromazine HCl Chlorthalidone...54 Cholestyramine Light...55 Chorionic Gonadotropin...73 Chromium Chloride Ciclopirox Ciclopirox Nail Lacquer...29 Ciclopirox Olamine...29 Cidofovir...42 Cilostazol Cimetidine Cimetidine HCl...67 Cimzia...80 Cinryze Ciprofloxacin...22 Ciprofloxacin ER...22 Ciprofloxacin HCl Ciprofloxacin I.V. in D5W..22 Cisplatin Citalopram HBr Citrus Calcium+D Citrus Calcium/Vitamin D Cladribine Claravis...58 Clarithromycin Clarithromycin ER Claritin Claritin Reditabs Claritin-D 12 Hour...94 Claritin-D 24 Hour...94 ClearLax...67 Clemastine Fumarate Climara Pro Clindamycin HCl...18 Clindamycin Palmitate HCl...18 Clindamycin Phosphate...18, 58 Clindamycin Phosphate in D5W Clindamycin/Benzoyl Peroxide...58 Clinisol SF 15% Clobetasol Propionate...72 Clobetasol Propionate E...72 Clolar Clomipramine HCl...27 Clonazepam...46 Clonazepam ODT...46 Clonidine HCl Clonidine HCl ER...56 Clopidogrel Clorazepate Dipotassium. 46 Clotrimazole...29 Clotrimazole/ Betamethasone Dipropionate Clozapine...42 Clozapine ODT...42 Co Q Co Q-10 Plus Co-Enzyme Q Coartem...39 Codeine Sulfate Codituss DM...99 Colchicine Colcrys Cold Head Congestion Daytime Cold Head Congestion Nighttime Cold Head Congestion Severe Daytime... 99

129 Cold Multi-Symptom Daytime Cold Multi-Symptom Nighttime Cold Multi-Symptom Severe Daytime Cold/Allergy Childrens...99 Cold/Cough Childrens...99 Cold/Cough DM Childrens...99 Cold/Cough/Sore Throat Childrens...99 Colestipol HCl Colistimethate Sodium...18 Colocort Combigan...91 Combivent Respimat Combivir Cometriq...37 Complera...44 Complete Complete Allergy Medicine...94 Complete Lice Treatment Kit...39 Compro...28 Conex Cold/Allergy Constulose Copaxone...57 Copper Trace Metal...67 Coricidin HBP Nighttime Multi-Symptom Cold Cormax Scalp Application72 Cortisone Acetate...72 Cosmegen...35 Cotellic Cough & Sore Throat Day Time Cough DM Cough Syrup Coughtab Coumadin...49 Creon...60 Crestor...54 Crinone Critic-Aid Clear AF...29 Crixivan Cromolyn Sodium... 62, 90, 97, 100 Cryselle Cubicin...18 Cuprimine...71 Cuvposa...61 Cyanocobalamin Cyclafem...75 Cyclobenzaprine HCl Cyclophosphamide...33 Cycloset Cyclosporine...80 Cyclosporine Modified Cyproheptadine HCl...94 Cyramza...38 Cystadane Cystagon...60 Cystaran...89 Cytarabine Aqueous Cyto-Q Max D D D-Vi-Sol D-Vita D3 High Potency D3 Super Strength D Dacarbazine...33 Dacogen Daily Multiple Vitamins Daily Vite Daily-Vite/Iron/Beta- Carotene Daklinza Daliresp...97 Dallergy Dalvance...18 Danazol...74 Dantrolene Sodium Dapsone Daptacel...82 DARAPRIM Darzalex Daunorubicin HCl...35 DaunoXome...35 Day Time Cold/Flu Relief Day Time Cough Day Time Multi-Symptom Cold/Flu Relief Dayhist Allergy 12 Hour Relief...94 Deblitane Decitabine Decongestant 12 Hour Maximum Strength

130 Deep Sea Nasal Spray Delsym Delsym Cough + Chest Congestion DM Delsym Cough + Chest Congestion DM Childrens Delsym Cough + Cold Daytime Delsym Cough + Cold Nighttime Delsym Cough + Cold Nighttime Childrens Delsym Night Time Cough/ Cold Delsym Night Time Cough/ Cold Childrens Delsym Night Time Multi- Symptom Delyla...75 Demeclocycline HCl Demser...53 Depen Titratabs Depo-Medrol...72 Depo-Provera...78 Dermacerin Dermamed Dermaphor...89 Desenex Shake Powder Desipramine HCl Desmopressin Acetate...73 Desogestrel/Ethinyl Estradiol...75 Desonide Desoximetasone...72 Dexamethasone...72 Dexamethasone Intensol..72 Dexamethasone Sodium Phosphate... 72, 91 Dexedrine Dexferrum Dexmethylphenidate HCl..56 Dexmethylphenidate HCl ER...56 Dexrazoxane...35 Dextroamphetamine Sulfate...56 Dextromethorphan Polistirex Dextromethorphan/ Guaifenesin Dextrose 10% Flex Container Dextrose 10%/NaCl 0.2% Dextrose 10%/NaCl 0.45% Dextrose 2.5%/Sodium Chloride 0.45% Dextrose 5% Dextrose 5%/NaCl 0.2% 116 Dextrose 5%/NaCl 0.225% Dextrose 5%/NaCl 0.33% Dextrose 5%/NaCl 0.45% Dextrose 5%/NaCl 0.9% 116 Dextrose 5%/Potassium Chloride 0.15% DHS Tar DHS Tar Gel...58 DHS Zinc Diabetic Siltussin DAS-Na Diabetic Siltussin-DM Diabetic Siltussin-DM Maximum Strength Diabetic Tussin Diabetic Tussin DM Diabetic Tussin Maximum Strength Dialyvite Dialyvite Vitamin D3 Max119 Diastat AcuDial...24 Diastat Pediatric...24 Diazepam... 24, 46 Diazepam Intensol...46 Dibenzyline...50 Diclofenac Potassium...11 Diclofenac Sodium...11, 58, 91 Diclofenac Sodium DR...11 Diclofenac Sodium ER...11 Dicloxacillin Sodium Dicyclomine HCl Didanosine Dificid...21 Diflunisal Digitek Digoxin Dihydroergotamine Mesylate...32 Dilantin Dilantin INFATABS...25

131 Dilt-XR...52 Diltiazem CD...52 Diltiazem HCl...52 Diltiazem HCl ER Dimaphen Childrens Dimaphen DM Cold/Cough Childrens Dimenhydrinate...28 Dimetapp Cold & Allergy100 Dimetapp DM Cold & Cough Dimetapp Long Acting Cough Plus Cold Dimetapp Multi-Symptom Cold & Flu Dimetapp Nighttime Cold & Congestion Diocto...62 Dipentum...84 Diphenhist Diphenhydramine HCl...94 Diphenhydramine HCl/Zinc Acetate Diphenoxylate/Atropine Diphtheria/Tetanus Toxoids Adsorbed Pediatric...82 Disulfiram...16 Diuril...54 Divalproex Sodium...24 Divalproex Sodium DR...24 Divalproex Sodium ER Doc-Q-Lace Doc-Q-Lax...67 Docefrez Docetaxel...35 Docu Docusate Calcium...62 Docusate Sodium...62 Docusate Sodium & Senna Stimulant Laxative/Stool Softener...68 Docusil Docusol Mini...62 DOK DOK PLUS Donepezil HCl Doribax...20 Dorzolamide HCl Dorzolamide HCl/Timolol Maleate...91 Double Antibiotic...18 Doxazosin Mesylate Doxepin HCl... 27, 58 Doxercalciferol Doxil...35 Doxorubicin HCl Doxy Doxycycline...23 Doxycycline Hyclate...23 Doxycycline Monohydrate23 Driminate Drisdol Dristan Cold Dronabinol...28 Drospirenone/Ethinyl Estradiol Droxia Duavee Ducodyl...68 Duloxetine HCl Duofer Duramorph...14 Durezol...91 E E-Z Spacer...86 E.E.S E.E.S. Granules Ear Drops...92 Ear Wax Removal Drops...92 Ear Wax Removal Kit Ear Wax Removal System 92 Easivent...86 Econazole Nitrate Ecpirin ED A-Hist ED A-Hist DM ED A-Hist PSE ED Bron GP ED Chlorped...94 ED Chlorped D ED Chlorped Jr ED Chlortan Edurant Effient Egrifta Elaprase...61 Elelyso...61 Elestrin Elidel...58 Eliphos Eliquis...49 Elitek...34

132 Elmiron...71 Embeda Emcyt...34 Emend...28 Emoquette...75 Empliciti Emsam...26 Emtriva Enalapril Maleate Enalapril Maleate/ Hydrochlorothiazide...53 Enbrel...80 Enbrel SureClick...80 EndaCof-DM Endocet...14 Enema Ready-To-Use...62 Enemeez Mini...62 Enemeez Plus...62 Enfamil Enfalyte Enfamil Expecta Engerix-B Enoxaparin Sodium Enpresse Entacapone...40 Entecavir...43 Enteric Coated Aspirin Entocort EC...84 Entresto...53 Enulose Epaned...51 Epinastine HCl...90 EpiPen...97 Epirubicin HCl Epitol...25 Epivir...44 Epivir HBV Eplerenone...54 Eprosartan Mesylate Epzicom...44 Equetro Eraxis...30 Erbitux Ergocalciferol Erivedge...37 Errin Erwinaze Ery Ery-Tab...22 EryPed EryPed Erythrocin Lactobionate...22 Erythromycin... 22, 58 Erythromycin Base Erythromycin Ethylsuccinate...22 Erythromycin/Benzoyl Peroxide...59 Esbriet Escitalopram Oxalate...26 Esomeprazole Magnesium...70 Esomeprazole Sodium...70 Estradiol...75 Estradiol Valerate...75 Estring Ethambutol HCl...33 Ethosuximide...24 Etidronate Disodium Etodolac...11 Etopophos...37 Etoposide Evotaz...43 Exefen-IR Exelon...26 Exemestane Exjade Extra Action Cough Eye Drops Allergy Relief EZFE Forte F Fabrazyme...61 Fallback Solo...78 Falmina Famciclovir...43 Famotidine Famotidine Premixed Fanapt Fanapt Titration Pack Fantasy Lubricated...86 Fantasy Lubricated/ Spermicide Fareston...34 Farxiga...47 Farydak Faslodex Fast Acting Antacid Plus Anti-Gas Maximum Strength...62 Fazaclo...42 Felbamate...24 Felbatol... 24

133 Fenofibrate...54 Fenofibrate Micronized Fenofibric Acid...54 Fenofibric Acid DR...54 Fentanyl Fer-In-Sol Fer-Iron Feraheme Ferate Ferosul Ferrex Ferriprox Ferrlecit Ferrous Drops Ferrous Gluconate Ferrous Sulfate Fetzima...26 Fetzima Titration Pack...27 Fever Reducer Childrens..10 Feverall Adults...10 Feverall Childrens...10 Feverall Infants Feverall Junior Strength Fexofenadine HCl...94 Fiber Laxative Fiber Tabs Fiber Therapy Fiber-Lax Finasteride...70 Firazyr...80 Firmagon Fish Oil Flebogamma DIF...81 Flecainide Acetate...51 Flector Fleet Bisacodyl...68 Fleet Enema...62 Fleet Enema Six Pack...62 Fleet Laxative...68 Fleet Oil...62 Fleet Pediatric...62 Flovent Diskus...96 Flovent HFA Fluconazole...30 Fluconazole in Dextrose Fluconazole in NaCl...30 Flucytosine Fludarabine Phosphate...36 Fludrocortisone Acetate...72 Flunisolide Fluocinolone Acetonide...72, 92 Fluocinonide...72 Fluocinonide-E Fluorometholone Fluorouracil...34, 59 Fluoxetine DR...27 Fluoxetine HCl...27 Fluphenazine Decanoate..41 Fluphenazine HCl...41 Flurbiprofen...11 Flurbiprofen Sodium...91 Flutamide...34 Fluticasone Propionate... 72, 96 Fluvastatin Fluvoxamine Maleate...27 Folic Acid Folitab Folotyn...35 Fomepizole Fondaparinux Sodium...49 Formula EM Fortaz...20 Forteo Fosfree Fosinopril Sodium Fosinopril Sodium/ Hydrochlorothiazide...53 Fosphenytoin Sodium Fosrenol...71 FreAmine HBC 6.9% Freshkote...89 Fungoid Tincture Fungoid-D...30 Furosemide...54 Fusilev Fuzeon Fycompa...23 G Gabapentin Gabitril...24 Gablofen Gamastan S/D...81 Gammagard Liquid...82 Gammaked Gammaplex Gamunex-C...82 Ganciclovir Gardasil...82

134 Gardasil Gas Relief Gas Relief Maximum Strength...63 Gas-X Extra Strength...63 Gattex Gauze GaviLAX GaviLyte-C...68 GaviLyte-G...68 GaviLyte-H...68 GaviLyte-N/Flavor Pack Gaviscon...63 Gemcitabine HCl Gemfibrozil...54 Gemzar Generlac Gengraf...80 Genotropin...73 Genotropin Miniquick...73 Gentak...17 Gentamicin Sulfate...17 Gentamicin Sulfate/0.9% Sodium Chloride...17 Genteal Mild...89 Genteal Mild to Moderate.89 Genteal PM Genteal Severe...89 Genvoya...44 Geodon...41 Geravim Geriaton Gianvi...75 Giazo Gildagia...75 Gildess 1.5/ Gildess 24 Fe Gilenya Gilotrif Glassia Glatopa Gleostine...34 Glimepiride...47 Glipizide...47 Glipizide ER Glipizide/Metformin HCl Glucagen HypoKit...48 Glucagon Emergency Kit. 48 Glucose...48 Glutose Glycerin...63 Glycolax Glycopyrrolate GNP 12 Hour Nasal Spray GNP Acid Reducer GNP Adult Aspirin Low Strength...11 GNP All Day Allergy GNP All Day Allergy-D GNP All Day Pain Relief...12 GNP Allergy GNP Allergy & Congestion Relief...94 GNP Allergy Multi-Symptom GNP Allergy Plus Severe Sinus Headache Maximum Strength GNP Allergy Relief...94 GNP Allergy Relief for Kids...94 GNP Antacid Anti-Gas...63 GNP Antacid Maximum Strength...63 GNP Anti-Diarrheal...63 GNP Anti-Itch GNP Artificial Tears...89 GNP Aspirin GNP Aspirin Low Dose GNP Bacitracin Zinc GNP Bisa-Lax GNP Calcium 500+D GNP Calcium 500/D GNP Calcium Citrate+D GNP Calcium Plus 600+D GNP Calcuim/Vitamin D/ Minerals GNP Capsaicin...59 GNP Castor Oil...63 GNP Century GNP Century Adults 50+ Senior GNP Century Ultimate Mens Complete GNP Century Ultimate Mens Senior Formula GNP Century Ultimate Womens Complete...119

135 GNP Century Ultimate Womens Senior Formula GNP Childrens Chewables/ Extra C GNP Childrens Chewables/ Iron GNP Childrens Pain Relief Plus Cold GNP Childrens Plus Cough & Sore Throat GNP Childrens Plus Multi- Symptom Cold GNP Clearlax...68 GNP Clotrimazole GNP Cold & Allergy Childrens GNP Cold & Allergy Maximum Strength GNP Cold & Cough Childrens GNP Cold Head Congestion Night Time GNP Cold Head Congestion Severe Daytime GNP Cold Multi-Symptom Daytime GNP Cold Multi-Symptom Nighttime GNP Cold Relief Head Congestion Severe Daytime GNP Cold Relief Multi- Symptom Daytime GNP Cold Relief Multi- Symptom Severe Daytime GNP Cold Severe Congestion/Daytime GNP Cough DM ER GNP Cough Relief GNP Daily Prenatal GNP Day Time Cold & Flu GNP Day Time Cold/Flu 102 GNP Day Time Cold/Flu Relief GNP Day Time Sinus GNP Dayhist Allergy...94 GNP Docusate Calcium...63 GNP Ear Drops GNP Ear Systems...92 GNP Enema...63 GNP Essential One Daily120 GNP Eye Itch Relief...89 GNP Fiber Therapy GNP Fiber-Caps...68 GNP Fish Oil GNP Flu Relief Therapy Severe Cold Daytime GNP Flu Relief Therapy Severe Cold Nighttime.102 GNP Foaming Antacid GNP Gas Relief...63 GNP Gas Relief Extra Strength...63 GNP Gas Relief Maximum Strength...63 GNP Hemorrhoidal GNP Hydrocortisone GNP Ibuprofen...12 GNP Ibuprofen Junior Strength...12 GNP Infants Gas Relief GNP Iron GNP Itchy Eye GNP K-Pec...63 GNP Laxative...68 GNP Lice Solution Kit...39 GNP Lice Treatment...39 GNP Little Ones Childrens GNP Loperamide HCl GNP Loratadine GNP Loratadine Childrens...94 GNP Loratadine-D 12 Hour...94 GNP Loratadine-D 24 Hour...94 GNP Lubricant Eye Drops68 GNP Lubricating Plus Eye Drops GNP Magnesium Citrate 113 GNP Masanti Maximum Strength...63 GNP Masanti Regular Strength...63 GNP Miconazole GNP Miconazole GNP Miconazorb AF...30 GNP Milk of Magnesia GNP Mucus ER GNP Mucus Relief GNP Mucus Relief Cold & Sinus...102

136 GNP Mucus Relief Cold Flu & Sore Throat GNP Mucus Relief Cough Childrens GNP Mucus Relief DM GNP Mucus Relief Severe Congestion & Cold GNP Multi-Symptom Cold Nighttime GNP Nasal Decongestant GNP Nasal Decongestant PE Maximum Strength.102 GNP Nasal Spray GNP Nasal Spray Extra Moisturizing GNP Natural Fiber...63 GNP Niacin TR GNP Nicotine Mini Lozenge...16 GNP Nicotine Polacrilex GNP Nicotine Polacrilex Mini...16 GNP Night Time Cold & Flu GNP Night Time Cold & Flu Multi-Symptom GNP Night Time Cold/Flu Relief GNP Night Time Cough. 102 GNP Night Time Sinus GNP Nighttime Sleep Aid.94 GNP No Drip Nasal Spray GNP Nose Drops Extra Strength GNP Omeprazole GNP One Daily Maximum GNP One Daily Plus Iron120 GNP Pediatric Electrolyte GNP Povidone-Iodine...18 GNP Prenatal GNP Pseudoephedrine HCl 12 Hour GNP Pseudoephedrine HCl ER GNP Senna Plus...68 GNP Sinus Congestion & Pain Daytime GNP Sinus Congestion/Pain Nighttime GNP Sinus Relief Congestion & Pain Daytime/Nighttime GNP Sinus Relief Congestion & Pain Nighttime GNP Slow Release Iron..113 GNP Stomach Relief...63 GNP Stomach Relief Maximum Strength...63 GNP Stool Softener...63 GNP Stool Softener/ Stimulant Laxative...68 GNP Suphedrin GNP Tab Tussin GNP Tab Tussin DM GNP Terbinafine HCl...30 GNP Tioconazole GNP Tolnaftate...30 GNP Triacting Night Time Cold & Cough Childrens GNP Triple Antibiotic...18 GNP Triple Antibiotic Plus18 GNP Tussin GNP Tussin CF Cough & Cold GNP Tussin CF Max Multi- Symptom Cold GNP Tussin Cough Long Acting GNP Tussin DM GNP Tussin DM Cough..103 GNP Tussin DM Max GNP Tussin DM Max Cough & Chest Congestion GNP Tussin Night Time..103 GNP Ultra Lubricant Eye Drops Goodsense All Day Allergy...94 Granisetron HCl...28, 29 Granix...49 Griseofulvin Microsize Griseofulvin Ultramicrosize...30 Guaiatussin AC Guaifenesin Guaifenesin AC Guaifenesin DAC Guaifenesin ER Guaifenesin-DM Guaifenesin/Codeine Guanfacine ER...56

137 Guanidine HCl...32 H Halaven Halobetasol Propionate Haloperidol...41 Haloperidol Decanoate Haloperidol Lactate...41 Harvoni...43 Havrix...82 Healthy Eyes HealthyLax Heartburn Relief...67 Hem-Prep Hemorrhoid...59 Hemorrhoidal...64 Hemorrhoidal Suppositories...59 Heparin Sodium...49 Heparin Sodium/D5W...49 HepatAmine Hepsera Herceptin...38 Hetlioz Hexalen...34 HM Advanced Antacid Maximum Strength...64 HM All Day Allergy...94 HM Allergy...94 HM Allergy & Congestion. 94 HM Allergy Complete-D..103 HM Allergy Multi Symptom...94 HM Allergy Relief...94 HM Allergy Relief & Nasal Decongestant HM Antacid Anti-Gas Extra Strength...64 HM Antacid/Antigas HM Anti-Diarrheal HM Anti-Nausea...28 HM Artificial Tears HM Aspirin HM Aspirin EC...12 HM Aspirin EC Low Dose.12 HM Bacitracin...18 HM Calcium/Vitamin D HM Castor Oil...64 HM Chest Congestion Relief HM Chest Congestion Relief DM HM Clearlax HM Cold & Allergy Childrens HM Cold & Cough Childrens HM Cold & Sinus Relief...12 HM Complete HM Complete HM Cough DM HM Cough Relief HM Day Time HM Double Antibiotic HM Earwax Removal Aid..92 HM Earwax Removal Kit HM Enema HM Enema Mineral Oil HM Eye Itch Relief...89 HM Famotidine HM Fexofenadine HCl...94 HM Fiber...64 HM Fish Oil HM Gas Relief HM Gas Relief Infants Drops...64 HM Glucose HM Ibuprofen HM Ibuprofen IB HM Ibuprofen Infants...12 HM Laxative HM Lice Killing Maximum Strength...39 HM Lice Treatment HM Loperamide HCl...64 HM Loratadine Childrens. 95 HM Lubricating Plus HM Magnesium Citrate HM Milk of Magnesia...68 HM Motion Sickness Relief...28 HM Mucus ER HM Naproxen Sodium HM Nasal Decongestant 103 HM Nasal Decongestant 12 Hour HM Nasal Decongestant PE HM Nasal Spray HM Niacin HM Nicotine Polacrilex...16

138 HM Nicotine Transdermal System...16 HM Nicotine Transdermal System Step HM Night Time Cold & Flu HM Night Time Multi Symptom Cold & Flu HM Nose Drops Extra Strength HM Omeprazole HM One Daily/Iron HM Pediatric Electrolyte.114 HM Povidone-Iodine HM Saline Nasal Spray HM Senna-S...68 HM Sinus Nasal Spray HM Stomach Relief...64 HM Stomach Relief Maximum Strength...64 HM Stool Softener...64 HM Stool Softener/Laxative...68 HM Triple Antibiotic HM Tussin Adult HM Tussin Adult Cough & Chest Congestion DM..104 HM Tussin Adult Multi- Symptom Cold HM Vitamin B Complex/ Vitamin C Humalog Cartridge...48 Humalog KwikPen Humalog Mix 50/50 KwikPen...48 Humalog Mix 50/50 Vial.. 48 Humalog Mix 75/25 KwikPen...48 Humalog Mix 75/25 Vial.. 48 Humalog Vial Humatrope...73 Humatrope Combo Pack. 73 Humira...80 Humira Pediatric Crohns Disease Starter Pack...80 Humira Pen...80 Humira Pen Crohns Disease Starter Pack...80 Humulin 70/30 KwikPen..48 Humulin 70/30 Vial...48 Humulin N KwikPen...48 Humulin N Vial Humulin R U-500 KwikPen...48 Humulin R U-500 Vial...48 Humulin R Vial...48 Hycamtin...37 Hydralazine HCl Hydro Skin Maximum Strength...72 Hydrochlorothiazide...54 Hydrocodone Bitartrate/ Acetaminophen...14 Hydrocodone Bitartrate/ Homatropine Methylbromide Hydrocodone Polistirex/ Chlorpheniramine Polistirex Hydrocodone/ Acetaminophen...14 Hydrocodone/Ibuprofen...14 Hydrocortisone... 72, 84 Hydrocortisone Butyrate...72 Hydrocortisone Valerate Hydrocortisone/Acetic Acid...92 Hydrocortisone/Aloe Hydromet Hydromorphone HCl Hydromorphone HCl ER..13, 14 Hydroxocobalamin Hydroxychloroquine Sulfate...39 Hydroxyurea...35 Hydroxyzine HCl Hydroxyzine Pamoate I I-Caps I-Vite Ibrance Ibu-Drops...12 Ibu-Drops Infants Ibuprofen Ibuprofen Junior Strength 12 Iclusig Idarubicin HCl...36 Iferex Ifosfamide...34 Ilaris...82 Ilevro Ilotycin Imatinib Mesylate...37 Imbruvica...37 Imipenem/Cilastatin...20

139 Imipramine HCl Imipramine Pamoate Imiquimod Imovax Rabies...83 In-Check Inspiratory Flow Meter/Nasal with Mask.. 86 In-Check Inspiratory Flow Meter/Oral Increlex...74 Indapamide...54 Infanrix...83 Infants Gas Relief...64 Infants Ibuprofen...12 Infants Simethicone Infed Infuvite Infuvite Adult Infuvite Pediatric Inlyta...37 Inspirachamber/Anti-Static Valved/Mouthpiece...86 Inspirachamber/Soother Mask/Inspiramask/ Medium Inspirachamber/Soother Mask/Inspiramask/Small...86 Insulin Syringes, Needles. 86 Intelence Intense Cough Reliever Extra Strength Intralipid Intron A Intron A w/diluent Introvale Invanz Invega...41 Invega Sustenna Invega Trinza Invirase...45 Ionil-T...59 Ionosol-B/Dextrose 5% Ionosol-MB/Dextrose 5% Iophen C-NR Iophen DM-NR Iophen-NR IPOL Inactivated IPV Ipratropium Bromide Ipratropium Bromide/ Albuterol Sulfate Irbesartan...50 Irbesartan/ Hydrochlorothiazide...53 Iressa Irinotecan...36 Iron Iron Chews Pediatric Isentress...44 Isolyte-P/Dextrose 5% Isolyte-S Isoniazid...33 Isopto Tears Isosorbide Dinitrate Isosorbide Dinitrate ER Isosorbide Mononitrate Isosorbide Mononitrate ER...55 Isotonic Gentamicin...17 Istodax...36 Itch Relief Extra Strength104 Itraconazole...30 Ivermectin...39 Ixempra Kit Ixiaro J J-TAN D PD Jadenu Jakafi Jantoven Jardiance...47 Jentadueto Jevtana...36 Jinteli Jock Itch Spray Jolivette...78 Juleber Junel 1.5/ Junel 1/ Junel Fe 1.5/ Junel Fe 1/ Junel Fe Juxtapid K K-Tab Kadcyla Kaitlib Fe...76 Kaletra Kalydeco... 97, 104 Kanuma Kao-Tin...64 Kariva...76

140 KCl 0.075%/D5W/NaCl 0.45% KCl 0.15%/D5W/LR KCl 0.15%/D5W/NaCl 0.2% KCl 0.15%/D5W/NaCl 0.225% KCl 0.15%/D5W/NaCl 0.9% KCl 0.3%/D5W/NaCl 0.45% KCl 0.3%/D5W/NaCl 0.9% Kelnor 1/ Kenalog Kenalog Kepivance...57 Ketoconazole...30 Ketoprofen Ketorolac Tromethamine.12, 92 Ketotifen Fumarate...89 Keytruda Kidkare Cough/Cold Kimidess Kimono Lubricated Kimono Micro Thin...86 Kimono Micro Thin Plus Spermicide Lubricated...87 Kimono Sensation Lubricated Kimono Sensation Plus Spermicide Lubricated...87 Kineret...80 Kionex Klor-Con Klor-Con Klor-Con M Klor-Con M Klor-Con Sprinkle Kombiglyze XR...47 Konsyl...64 Konsyl Fiber Konsyl-D...64 Korlym Kuvan Kynamro L L-Arginine L-Citrulline L-Glutamine Labetalol HCl...51 Lacrisert Lactated Ringers Dextrose 5% Viaflex Lactated Ringers Irrigation Lactated Ringers Viaflex.117 Lactrase Lactulose Lamisil Lamisil Advanced Lamisil AF Defense Lamisil AT...30 Lamisil AT Spray...30 Lamivudine... 43, 44 Lamivudine/Zidovudine...44 Lamotrigine...24 Lanoxin Lantus SoloStar...48 Lantus Vial...48 LARIN 1.5/ LARIN 1/ LARIN Fe 1.5/ LARIN Fe 1/ Lastacaft Latanoprost...92 Latuda Laxative...68 Layolis Fe...76 Leena...76 Leflunomide...82 Lenvima Lessina...76 Letairis...98 Letrozole...37 Leucovorin Calcium...36 Leukeran...34 Leukine Leuprolide Acetate...79 Levalbuterol Levemir FlexTouch...48 Levemir Vial...48 Levetiracetam...23 Levetiracetam ER Levobunolol HCl...91 Levocarnitine Levocetirizine Dihydrochloride...95 Levofloxacin...22 Levofloxacin in D5W...22 Levoleucovorin Calcium... 36

141 Levonest Levonorgestrel Levonorgestrel and Ethinyl Estradiol Levonorgestrel/Ethinyl Estradiol Levora 0.15/ Levorphanol Tartrate Levothyroxine Sodium...79 Levoxyl Lexiva Lialda...84 Lice Killing Maximum Strength...39 Lice Treatment Creme Rinse...39 Lidocaine...15 Lidocaine HCl...15 Lidocaine Viscous Lidocaine/Prilocaine...15 Lidocream Lincocin Lincomycin HCl...18 Lindane...40 Linezolid Linzess Lioresal Intrathecal Liothyronine Sodium Liq Liquituss GG Lisinopril Lisinopril/ Hydrochlorothiazide...53 LiteAire...87 Lithium Lithium Carbonate...46 Lithium Carbonate ER...46 Lithostat LoHist-D LoHist-DM LoHist-PEB Lomedia 24 Fe...76 Long Acting Nasal Spray Lonsurf...35 Loperamide HCl Loratadine Loratadine Childrens Loratadine Hives Relief Loratadine-D 12 Hour...95 Loratadine-D 24 Hour...95 Lorazepam Lorazepam Intensol Lorcet Lorcet HD Lorcet Plus Lortab...14 Lortuss EX Loryna Losartan Potassium Losartan Potassium/ Hydrochlorothiazide...53 Lotemax...92 Lotrimin AF...30 Lotrimin Ultra Lovastatin Loxapine Succinate Lubricant Eye Drops Dry Eye Therapy Lubricating Plus Eye Drops...89 Lumigan...92 Lumizyme...61 Lupaneta Pack...79 Lupron Depot Lupron Depot-PED...79 Lutera Lynparza Lyrica...56 Lysodren...79 Lyza...78 M M-Clear WC M-END PE M-END WC M-M-R II...83 M.V.I. 12 without Vitamin K M.V.I. Adult M.V.I. Pediatric Mag-Delay Mag-G Mag-Tab SR...68 Magnebind Magnesium Citrate Magnesium Oxide Magnesium Sulfate Magonate Major-Prep Hemorrhoidal.59 Makena Malathion...40

142 Manganese Trace Metal Mapap Sinus Maximum Strength Congestion and Pain Maprotiline HCl Marlissa...76 Marplan...26 Matulane...34 Maximum D Maxx Lubricated Meclizine HCl Medroxyprogesterone Acetate Mefloquine HCl Megace ES...78 Megace Oral Megestrol Acetate Mekinist...38 Meloxicam...12 Melphalan HCl...34 Memantine HCl...26 Memantine HCl Titration Pak...26 Menactra...83 Menest Menomune-A/C/Y/W Mentax Menveo Mephyton Mepron...39 Mercaptopurine Meribin Meropenem Mesalamine...84 Mesna...36 Mesnex...36 Mestinon...33 Mestinon Timespan Metamucil...64 Metamucil Multihealth Fiber...64 Metamucil Original Texture...64 Metamucil Smooth Texture...64 Metamucil Smooth Texture Sugar Free...64 Metaproterenol Sulfate...97 Metformin HCl...47 Metformin HCl ER Methadone HCl...14 Methazolamide...91 Methenamine Hippurate...18 Methimazole Methotrexate...80 Methotrexate Sodium...81 Methoxsalen Methscopolamine Bromide...61 Methyclothiazide...54 Methyldopa Methyldopa/ Hydrochlorothiazide...53 Methyldopate HCl...50 Methylergonovine Maleate...87 Methylphenidate HCl...56 Methylphenidate HCl ER.. 56 Methylprednisolone Methylprednisolone Acetate...73 Methylprednisolone Dose Pack...73 Methylprednisolone Sodium Succinate...73 Metipranolol...91 Metoclopramide HCl Metolazone Metoprolol Succinate ER..52 Metoprolol Tartrate...52 Metoprolol/ Hydrochlorothiazide...53 Metronidazole...18 Metronidazole in NaCl 0.79% Metronidazole Vaginal...18 Mexiletine HCl Mi-Acid Mi-Acid Gas Relief...64 Mi-Acid Maximum Strength...64 Miacalcin Miconazole...30 Miconazole Miconazole Miconazole 3 Combo Pack...30 Miconazole Miconazole Nitrate Miconazorb AF...30 Micro Guard...31 Microchamber...87 Microgestin 1.5/

143 Microgestin 1/ Microgestin Fe...76 Microgestin Fe 1.5/ Microlife Digital Peak Flow Meter...87 Microspacer...87 Midodrine HCl Migergot Milantex...64 Milantex Extra Strength...64 Milk of Magnesia Milk of Magnesia Concentrate Millipred Minerin Mini Wright AFS Peak Flow Meter Low Range Mini Wright Peak Flow Meter...87 Miniprin Low Dose Minitran Minocycline HCl...23 Minoxidil...55 Mintox...64 Mintox Maximum Strength...65 Miralax...69 Mirtazapine...26 Mirtazapine ODT...26 Mirvaso...59 Misoprostol Mitomycin...36 Mitoxantrone HCl...36 Modafinil Moexipril HCl...51 Moexipril/ Hydrochlorothiazide...53 Moisturizing Cream...59 Molindone HCl Mometasone Furoate. 73, 96 MonoNessa...76 Montelukast Sodium...96 Morphine Sulfate... 14, 15 Morphine Sulfate ER...14 Motion Sickness Motion-Time...28 Moxeza...22 Moxifloxacin HCl...22 Mozobil Mucinex Mucinex Allergy Mucinex Chest Congestion Childrens Mucinex Childrens Cold Cough & Sore Throat Mucinex Childrens Multi- Symptom Cold Mucinex Childrens Multi- Symptom Cold & Fever105 Mucinex Cold for Kids Mucinex Congestion & Cough Childrens Mucinex Cough Childrens Mucinex D Mucinex DM Mucinex DM Maximum Strength Mucinex Fast-Max Cold & Sinus Mucinex Fast-Max Cold Flu & Sore Throat Mucinex Fast-Max DM Max Mucinex Fast-Max Night Time Cold & Flu Mucinex Fast-Max Severe Cold Mucinex Fast-Max Severe Congestion & Cold Mucinex Fast-Max Severe Congestion & Cough Mucinex for Kids Mucinex Maximum Strength Mucinex Multi-Symptom Cold Night Time Childrens Mucinex Nasal Spray Full Force Mucinex Nasal Spray Moisture Smart Mucinex Sinus-Max Full Force Mucinex Sinus-Max Pressure & Pain Mucinex Sinus-Max Severe Congestion Relief Mucinex Stuffy Nose & Cold Childrens Mucosa Mucosa DM Mucus DM...105, 106 Mucus DM Max Mucus ER

144 Mucus Relief Mucus Relief Childrens Mucus Relief Cold/Sinus Maximum Strength Mucus Relief Cough Childrens Mucus Relief DM Mucus Relief Severe Congestion/Cough Multaq Multi-Delyn Multi-Delyn/Iron Multi-Symptom Allergy Multi-Vitamins Multilex Multilex T&M Mupirocin Muro Mustargen My Kidz Iron My Kidz Iron My Way Myalept Mycamine...31 Mycophenolate Mofetil...81 Mycophenolic Acid DR Myozyme Myrbetriq MYTAB GAS...65 MYTAB GAS Maximum Strength...65 N Nadolol...52 Nafcillin Sodium...21 Naglazyme Nail Scrub...59 Nalbuphine HCl Nallpen/Dextrose Naloxone HCl Naltrexone HCl...16 Namenda...26 Namenda XR Namenda XR Titration Pack...26 Namzaric...56 Naphazoline HCl...89 Naproxen...12 Naproxen DR...12 Naproxen Sodium Naratriptan HCl Narcan...16 Nasal Decongestant Nasal Decongestant PE. 106 Nasal Decongestant PE Maximum Strength Nasal Decongestant Spray Nasal Spray 12 Hour Nasal Spray Anti-Drip Nasal Spray X-Moist Nasonex...96 Natacyn...31 Nateglinide...47 Natpara Natural Coenzyme Q Natural Fiber Laxative...65 Natural Fiber Therapy...65 Nebupent...39 Necon 0.5/ Necon 1/ Necon 1/ Necon 10/ Necon 7/7/ Nefazodone HCl Neomycin Sulfate Neomycin/Bacitracin/ Polymyxin...89 Neomycin/Polymyxin B Sulfates...18 Neomycin/Polymyxin/ Bacitracin/Hydrocortisone...89 Neomycin/Polymyxin/ Dexamethasone Neomycin/Polymyxin/ Gramicidin Neomycin/Polymyxin/ Hydrocortisone...90, 92 Nephramine Nephro-Vite Nesina Nessi Spacer/Large Mask87 Nessi Spacer/Mouthpiece...87 Nessi Spacer/Small/Med Mask Neulasta...49 Neupogen Nevanac...92 Nevirapine Nevirapine ER...44 Nexavar...38 Nexium...70

145 Next Choice One Dose Niacin ER...55, 120 Niacin Flush Free Formula Niacin SR Niacin TR Niacor...55 Nicardipine HCl...52 NicoDerm CQ...16 NICOrelief...16 Nicorette Nicorette Mini Nicorette Starter Kit...16 Nicotine...16 Nicotine Polacrilex...16 Nicotine Transdermal System...16 Nicotrol Inhaler...16 Night Time Multi-Symptom Cold/Flu Relief Nighttime Sinus Congestion & Pain Nighttime Sleep Aid...95 Nikki...76 Nilandron...34 Nimodipine...52 Ninlaro...36 Nipent...35 Nite Time Cough Nite Time Multi-Symptom Cold/Flu Relief Nite-Time Cold/Flu Nite-Time Multi-Symptom Cold/Flu Relief Nitro-Bid...55 Nitrofurantoin...18 Nitrofurantoin Macrocrystals...18 Nitrofurantoin Monohydrate 100mg Capsule Nitroglycerin...55 Nitroglycerin Lingual...56 Nitroglycerin Transdermal56 Nitrostat...56 NoHist-DM NoHist-LQ Nora-BE...78 Norditropin FlexPro...74 Norethindrone Norethindrone & Ethinyl Estradiol Ferrous Fumarate...76 Norethindrone Acetate...78 Norethindrone Acetate/ Ethinyl Estradiol/Ferrous Fumarate...76 Norgestimate/Ethinyl Estradiol Norlyroc Normosol-M in D5W Normosol-R Normosol-R in D5W Northera...53 Nortrel 0.5/ Nortrel 1/ Nortrel 7/7/ Nortriptyline HCl...28 Norvir NovaFerrum NovaFerrum NovaFerrum Pediatric Drops Novarel...74 Noxafil NRS Nasal Relief Nucynta ER...14 Nuedexta Nulojix...81 Nutraplus...59 NutreStore Nutrilipid Nutropin AQ...74 NuvaRing...77 Nyamyc Nystatin Nystop...31 O Ocean for Kids Ocean Nasal Spray Ocella Octagam...82 Octreotide Acetate Ocuvite Adult Odefsey...44 Odomzo...38 Ofev Ofloxacin...22 Ogestrel Olanzapine...41, 42 Olanzapine ODT Olopatadine HCl Olysio...43

146 Omega-3 Fish Oil...65 Omega-3-Acid Ethyl Esters...55 Omeprazole Omnitrope Oncaspar...36 Once Daily Once Daily/Iron Ondansetron HCl...29 Ondansetron ODT...29 One Daily One Daily Mens Onfi Onglyza...47 ONMEL Opcicon One-Step...78 Opdivo...38 Operand Scrub Opsumit Opti-Clear...90 Optichamber Diamond Optichamber Diamond/ Large Face Mask Optichamber Diamond/ Medium Face Mask...87 Optichamber Diamond/ Small Face Mask...87 Ora-Blend Ora-Blend SF Ora-Plus ORA-Sweet SF...59 Oralyte Oralyte Freezer Pops Orap...41 Orencia...81 Orenitram...98 Orfadin Organ-I NR Orkambi...97 Orphenadrine Citrate Orsythia...77 Otezla Oxacillin Sodium...21 Oxaliplatin...36 Oxandrolone...74 Oxcarbazepine...25 Oxsoralen Ultra Oxybutynin Chloride Oxybutynin Chloride ER Oxycodone HCl...15 Oxycodone/Acetaminophen...15 Oxycodone/Aspirin...15 Oxycodone/Ibuprofen...15 Oysco 500+D Oyster Shell Calcium Oyster Shell Calcium + Vitamin D Oyster Shell Calcium/ Vitamin D P Pacerone Paclitaxel...36 Pain Relief Cold Severe Congestion Pain Relief Sinus PE Daytime Paliperidone ER...42 Pamidronate Disodium Panoxyl Wash...59 Panoxyl-4 Creamy Wash...59 Panretin...38 Pantoprazole Sodium...70 Paricalcitol...85 Paromomycin Sulfate Paroxetine HCl Paser...33 Pataday Patanol Paxil Pazeo...90 Peak Air Peak Flow Meter Adult/Pediatric...87 Pedi-Boro Soak Paks...59 Pedia Relief Cough/Cold Pedia-Lax...65 Pedialyte Pedialyte Advanced Care Pedialyte Freezer Pops Pediatric Cough/Cold Pediatric Electrolyte Pediatric Electrolyte Freezer Pops Pediatric Electrolyte/Zinc Pediatric Medium Mask...87 Pediatric Small Mask...87 Pedvax HIB PEG-3350/Electrolytes... 69

147 PEG-3350/NaCl/Na Bicarbonate/KCl Peganone...25 Pegasys...43 Pegasys ProClick...43 PegIntron...43 PegIntron Redipen...43 Peleverus Peleverus Clear Peleverus Gold Penicillin G Potassium...21 Penicillin G Procaine Penicillin G Sodium...21 Penicillin V Potassium Pentam Pentoxifylline ER...53 Peptic Relief...65 Perforomist...97 Periguard...59 Perindopril Erbumine...51 Periogard...57 Perjeta Permethrin...40 Perphenazine Personal Best Full Range. 87 Personal Best Low Range87 Petrolatum...59 Pharbechlor Pharbedryl...95 Phenadoz Phenelzine Sulfate...26 Phenergan...95 Phenobarbital...24 Phenoxybenzamine HCl Phenylhistine DH Phenytek...25 Phenytoin Phenytoin Sodium...25 Phenytoin Sodium Extended...25 Phos-NaK Powder Concentrate PhosLo...71 Phoslyra Phospholine Iodide...91 Physiolyte Physiosol Irrigation Picato Piko 1 Electronic Pilocarpine HCl...57, 91 Pimozide...41 Pimtrea...77 Pindolol...52 Pink Bismuth Maximum Strength...65 Pioglitazone HCl Pioglitazone HCl/ Glimepiride...47 Pioglitazone HCl/Metformin HCl Piperacillin Sodium/ Tazobactam Sodium...21 Pirmella 1/ Plan B One-Step Plasma-Lyte A Plasma-Lyte Plasma-Lyte-56/D5W Plenamine Pocket Chamber Pocket Peak Flow Meter...88 Podofilox...59 Poly Vitamin Poly-Iron Polyethylene Glycol 3350 Powder Polymyxin B Sulfate Polymyxin B Sulfate/ Trimethoprim Sulfate Polyvitamin Polyvitamin/Iron Pomalyst Portia Potassium Chloride Potassium Chloride 0.15% / NaCl 0.45% Viaflex Potassium Chloride 0.15% D5W/NaCl 0.33% Potassium Chloride 0.15% D5W/NaCl 0.45% Potassium Chloride 0.15%/ NaCl 0.9% Potassium Chloride 0.22% D5W/NaCl 0.45% Potassium Chloride 0.3%/ NaCl 0.9% Potassium Chloride 0.3%/ D5W Potassium Chloride ER Potassium Citrate ER Potiga Povidone-Iodine...19 Pradaxa...49

148 Praluent...55 Pramipexole Dihydrochloride...40 Pravastatin Sodium Prazosin HCl...50 Prednicarbate...73 Prednisolone Acetate Prednisolone Sodium Phosphate... 73, 92 Prednisone...73 Prednisone Intensol Pregnyl w/diluent Benzyl Alcohol/NaCl Premarin Premasol Premium Condoms Lubricated Premphase...77 Prempro...77 Prenatal Preparation H Preservision Areds Prevalite Previfem...77 Prezcobix...44 Prezista...45 Priftin...33 Prilosec OTC Primaquine Phosphate PrimeAire Dual-Valved Holding Chamber Primidone...24 Primsol Pristiq...27 Privigen Pro-Clear AC PRO-RED AC ProAir HFA ProAir RespiClick Probenecid...32 Probenecid/Colchicine Procainamide HCl Procalamine Prochlorperazine Prochlorperazine Edisylate...28 Prochlorperazine Maleate 28 Procrit...49 Procto-Pak...84 Proctosol HC Proctozone-HC...84 Procysbi...61 Profe Profe Forte Proglycem Prograf Prolastin-C Prolensa...92 Proleukin Prolia...85 Promacta Promethazine HCl Promethazine VC/Codeine Promethazine-DM Promethazine/Codeine Promethazine/ Dextromethorphan Promethegan...95 Propafenone HCl...51 Propafenone HCl ER Proparacaine HCl Propranolol HCl Propranolol HCl ER...52 Propranolol/ Hydrochlorothiazide...53 Propylthiouracil ProQuad Prosol Protriptyline HCl...28 Provil...12 PRUDOXIN...59 Pseudoephedrine HCl Pseudoephedrine HCl ER Pulmicort Pulmozyme Puralube Pure & Gentle Lubricant Purixan Pyrazinamide...33 Pyridostigmine Bromide Q Q-Dryl...95 Q-Gel Mega...88 Q-Tapp Q-Tapp DM Q-Tussin Q-Tussin DM QC 3 Day Vaginal Cream. 31 QC Acid Controller...67 QC All Day Allergy...95

149 QC Allergy Relief QC Allergy Relief Multi- Symptom Daytime QC Antacid...65 QC Antacid/Anti-Gas...65 QC Antacid/Anti-Gas Maximum Strength...65 QC Anti-Diarrheal...65 QC Aspirin...12 QC Aspirin Low Dose...13 QC Athletes Foot QC AZO QC Bacitracin QC Castor Oil QC Childrens Aspirin...13 QC Childrens Chewable Vitamins/Extra C QC Childrens Chewable Vitamins/Iron QC Chlor-Pheniramine QC Cold Relief Plus Multi- Symptom Childrens QC Complete Allergy Medicine QC Cough Relief QC Cough/Sore Throat Nighttime QC Daily Multivitamins/Iron QC Docusate Calcium...65 QC Ear Wax Removal Drops...92 QC Enema...69 QC Ferrous Sulfate QC Fiber Laxative...65 QC Gas Relief...65 QC Gas Relief Extra Strength...65 QC Gentle Laxative QC Hemorrhoidal QC Ibuprofen...13 QC Ibuprofen IB...13 QC Loratadine Allergy Relief...95 QC Loratadine-D...95 QC Magnesium Citrate QC Maximum Daily Multivitamin/Multimineral QC Medifin Mucus Relief Childrens QC Milk of Magnesia QC Multi-Vite QC Multi-Vite 50 & Over. 121 QC Naproxen Sodium...13 QC Natural Vegetable QC Nighttime Cold/Flu Relief QC Nighttime Cough QC No Drip Nasal Relief.107 QC Pink Bismuth...65 QC Prenatal QC Senna...65 QC Senna-S QC Sinus Pain Relief QC Stool Softener QC Stool Softener Plus Laxative QC Suphedrine QC Suphedrine Maximum Strength QC Suphedrine PE QC Therin-M QC Tolnaftate QC Tussin CF QC Womens Daily Multivitamin Quadracel...83 Quasense Quetiapine Fumarate...42 Quinapril HCl Quinapril/ Hydrochlorothiazide...53 Quinidine Gluconate...51 Quinidine Gluconate CR...51 Quinidine Sulfate Quinine Sulfate...39 R Rabavert Raloxifene HCl Ramipril...51 Ranexa...53 Ranitidine HCl Rapaflo...70 Rapamune...81 RAVICTI Rebif Rebif Rebidose Rebif Rebidose Titration Pack...57 Rebif Titration Pack Reclipsen...77 Recombivax HB...83

150 Reeses Pinworm Medicine...39 Refresh Celluvisc...90 Refresh P.M Refresh Plus...90 Regranex Reguloid Relcof C Relenza Diskhaler...46 Relistor Remedy Antifungal...31 Remedy Nutrashield Remedy Skin Repair...60 Remicade Remodulin...98 Rena-Vite Renagel...71 Renvela Repaglinide...47 Repaglinide/Metformin HCl...47 Repatha Repatha SureClick Rescon DM Rescon-GG Rescriptor...44 Respaire Restasis...90 Retrovir IV Infusion Revatio Revlimid Rexulti...42 Reyataz Rhinaris Ribasphere...43 Ribavirin...43 Ridaura...82 Rifabutin Rifampin Rifater...33 Rilutek Riluzole Rimantadine HCl Ringers Injection Ringers Irrigation Riomet...47 RisaBal-pH Risacal-D Risperdal Consta...42 Risperidone...42 Risperidone ODT...42 Rite Flo...88 Rituxan Rivastigmine Tartrate...26 Rivastigmine Transdermal System...26 Rizatriptan Benzoate...32 Rizatriptan Benzoate ODT32 Robafen Robafen CF Cough & Cold Robafen DM Robafen DM Cough Clear Robitussin Childrens Cough & Cold CF Robitussin Childrens Cough Long-Acting Robitussin Childrens Cough/Cold Long-Acting Robitussin Cold+flu Daytime Robitussin Cold+flu Nighttime Robitussin Lingering Coldlong-Acting Cough Robitussin Mucus + Chest Congestion Robitussin Peak Cold Cough+ Chest Congestion DM Robitussin Peak Cold Cough+ Chest Congestion DM Max Strength Robitussin Peak Cold DM Robitussin Peak Cold Multi- Symptom Cold Robitussin Peak Cold Multi- Symptom Cold Maximum Strength Robitussin Peak Cold Nasal Relief Robitussin Peak Cold Nighttime Multi-Symptom Cold Robitussin Peak Cold Nighttime Nasal Relief..108 Rocaltrol...85 Ropinirole HCl...40 Rotarix RotaTeq Rozerem...112

151 Ruconest Rulox Rydex Rynex DM Rynex PE Rynex PSE S Sabril...24 Saizen...74 Sal-Plant...60 Salactic Film...60 Saline Mist Saline Nasal Spray Samsca Sancuso...29 Sandimmune Sandostatin LAR Depot Santyl...60 Saphris Savella...57 Savella Titration Pack SB Allergy...95 SB Antacid Anti-Gas SB Anti-Itch Maximum Strength SB Aspirin...13 SB Bismuth SB Cold & Cough HBP SB Cold Head Congestion Severe Daytime SB Cold Multi-Symptom Severe Daytime SB Cough Control CF SB Cough Control DM SB Cough Control DM Max SB Cough Relief SB Coughtab SB Flu Maximum Strength HBP SB Ibuprofen SB Lice Killing Maximum Strength...40 SB Loratadine OTC Only).95 SB Naproxen Sodium...13 SB Sinus & Allergy Maximum Strength SB Sinus Congestion & Pain Daytime SB Sinus Congestion & Pain Daytime/Nighttime SB Sinus Congestion & Pain Severe Daytime Sea Soft Nasal Mist Sea-Omega Sea-Omega Selegiline HCl...40 Selenium Sulfide...60 Selzentry Senexon...65 Senexon-S Senna Senna Lax Senna Plus...69 Senna Prompt Senna-S...69 Senna-Tabs...66 Senna-Time...66 Sennalax-S Senno...66 Sennosides/Docusate Sodium...69 Sensi-Care Protective Barrier...60 Sensipar...79 Sentry Sentry Senior Serevent Diskus Seroquel XR...42 Serostim...66 Sertraline HCl Sesame Oil...88 Setlakin sfrowasa...84 Sharobel Sidestream Pediatric Facemask/Tucker the Turtle...88 Signifor...79 Silace...66 Siladryl Allergy...95 Sildenafil Silicone Mask for BreatheRite Chamber/ Infant Silicone Mask for BreatheRite Chamber/ Pediatric Siltussin SA Siltussin-DM Silver Sulfadiazine Simethicone...66 Simponi...81 Simponi Aria... 81

152 Simulect...82 Simvastatin...55 Sinus Congestion & Pain Daytime Sinus Nasal Spray Sirolimus...81 Sirturo...33 Slo-Niacin Slow-Mag SM 12 Hour Sinus Decongestant SM 12-Hour No Drip SM 3-Day Vaginal SM Acid Reducer SM All Day Allergy...96 SM All Day Allergy-D SM All Day Pain Relief...13 SM Allergy 4 Hour...96 SM Allergy Multi-Symptom SM Allergy Relief SM Allergy Relief Loratadine...96 SM Antacid Advanced Maximum Strength...66 SM Antacid Anti-Gas...66 SM Antacid Maximum Strength...66 SM Antacid/Antigas...66 SM Anti-Diarrheal...66 SM Anti-Itch Extra Strength SM Antifungal Miconazole...31 SM Antifungal Tolnaftate.. 31 SM Artificial Tears...90 SM Aspirin Adult Low Strength...13 SM Aspirin Enteric Coated...13 SM Athletes Foot SM Calcium Citrate w/ Vitamin D SM Castor Oil SM Childrens Aspirin...13 SM Childrens Loratadine..96 SM Childrens Pain Relief Plus Multi-Symptom Cold SM Clearlax...69 SM Clotrimazole Vaginal...31 SM Cold & Allergy Childrens SM Cold & Cough DM Childrens SM Cold Head Congestion Severe Day Time SM Complete Advanced Formula SM Complete Senior Formula SM Cough Relief SM Day Time Cold & Flu Relief SM Day Time PE Cold & Flu Relief SM Docusate Calcium...66 SM Double Antibiotic...19 SM Enema...66 SM Eye Itch Relief SM Fexofenadine HCl SM Fiber SM Fiber Laxative...66 SM Flu Relief Therapy Severe Cold Nighttime.109 SM Foaming Antacid...66 SM Gas Relief...66 SM Gas Relief Drops Infants...66 SM Gas Relief Infants Drops...66 SM Gentle Laxative SM Glucose SM Hydrocortisone SM Ibuprofen...13 SM Ibuprofen IB...13 SM Infants Ibuprofen SM Iron SM Laxative...69 SM Lice Killing Maximum Strength...40 SM Lice Treatment...40 SM Loperamide HCl...66 SM Lorata-Dine D SM Loratadine...96 SM Loratadine Allergy Relief...96 SM Loratadine-D 12 Hour 96 SM Lubricant Eye Drops...69 SM Miconazole SM Milk of Magnesia...69 SM Mucus ER SM Mucus Relief Cough Childrens SM Naproxen Sodium...13

153 SM Nasal Decongestant Maximum Strength SM Nasal Decongestant PE SM Nasal Spray Moisturizing SM Nasal Spray Saline SM Nasal Spray Sinus SM Natural Laxative Plus Stool Softener...69 SM Nicotine SM Nicotine Polacrilex SM Nite Time Cold & Flu109 SM Nite Time Cold & Flu Relief SM Nite Time Cough SM Nose Drops Nasal Decongestant Extra Strength SM Omega-3 Fish Oil SM Omeprazole...70 SM Oral Saline Laxative SM Pediatric Electrolyte. 116 SM Stomach Relief SM Stomach Relief Maximum Strength...66 SM Stool Softener SM Stool Softener Plus Laxative SM Tioconazole SM Triple Antibiotic...19 SM Tussin SM Tussin CF SM Tussin DM SM Tussin DM Cough/ Chest Congestion SM Tussin DM Max Cough/ Chest Congestion SM Womans Laxative...69 Sodium Bicarbonate...66 Sodium Chloride , 116 Sodium Chloride 0.45% Viaflex Sodium Chloride 0.9% Sodium Fluoride Sodium Lactate Sodium Phenylbutyrate...61 Sodium Polystyrene Sulfonate Sodium Sulfacetamide...22 Soltamox...34 Solu-Cortef Solu-Medrol...73 Somatuline Depot...80 Somavert Soothe & Cool Free Moisture Barrier...60 Soothe & Cool INZO Antifungal Cream...31 Soothe & Cool Protect Moisture Barrier...60 Soriatane...60 Sotalol HCl Sovaldi...43 Spiriva HandiHaler Spiriva Respimat...97 Spironolactone...54 Spironolactone/ Hydrochlorothiazide...53 Sporanox Sprintec Sprycel Sronyx SSD...22 Stavudine...45 Stelara Sterile Water for Injection. 88 Sterile Water Irrigation...88 Stimulant Laxative Stiolto Respimat Stivarga Stomach Relief...66 Stomach Relief Maximum Strength...66 Stool Softener...66 Stool Softener Extra Strength...66 Stool Softener Laxative DC...66 Strattera...56 Strensiq...61 Streptomycin Sulfate Stress Formula Stress Formula w/iron Stress Formula/Zinc Stribild Stuart One Suboxone Sucraid...61 Sucralfate...70 Sudogest Sudogest 12 Hour Sudogest PE

154 Sudogest Sinus & Allergy Sulfacetamide Sodium...22 Sulfacetamide Sodium/ Prednisolone Sodium Phosphate Sulfadiazine...22 Sulfamethoxazole/ Trimethoprim Sulfamethoxazole/ Trimethoprim DS...23 Sulfasalazine...84 Sulindac...13 Sumatriptan Sumatriptan Succinate...32 Sumatriptan Succinate Refill...32 Sumavel DosePro...32 Superplex-T Suprax...20 Suprep Bowel Prep...69 Surmontil Sustiva...44 Sutent Sylatron Sylvant...38 Symbicort SymlinPen SymlinPen Synagis...82 Synarel Synercid...19 Synjardy Synribo...36 Synthroid Syprine Systane Systane Balance Restorative Formula Systane Gel...69 Systane Nighttime Systane Overnight Therapy Lubricant Eye...90 Systane Ultra...69 T TAB-A-VITE TAB-A-VITE w/beta Carotene TAB-A-VITE Womens TAB-A-VITE/Iron Tabloid Tacrolimus... 60, 81 Tafinlar Tagrisso Take Action...78 Tamiflu Tamoxifen Citrate Tamsulosin HCl...71 Tarceva Targretin Tarina Fe 1/ Tasigna Taxotere...36 Tazicef...20 Tazorac Tears Naturale...90 Tears Naturale Forte Tears Naturale II...90 Tears Pure...90 Tecfidera...57 Tecfidera Starter Pack...57 Tegretol-XR Telmisartan Telmisartan/Amlodipine Telmisartan/ Hydrochlorothiazide...53 Temazepam Tenivac...83 Terazosin HCl...71 Terbinafine HCl...31 Terbutaline Sulfate Terconazole Tessalon Perles Testosterone Cypionate...74 Testosterone Enanthate...74 Tetanus/Diphtheria Toxoids- Adsorbed Adult Tetrabenazine...56 Tetracycline HCl TGT Glucose Thalomid...34 Theophylline Theophylline CR Theophylline ER...98 Thera Thera M Plus Thera-M Thera/Beta-Carotene Therems Therems-H Therems-M Thiamine HCl

155 Thioridazine HCl Thiotepa...36 Thiothixene Thymoglobulin Thyrolar...79 Tiagabine HCl...24 Tikosyn...51 Timolol Maleate... 52, 91 Timolol Maleate Ophthalmic Gel Forming Tinactin Tinidazole Tioconazole Tivicay Tizanidine HCl TOBI...17 TOBI Podhaler...17 Tobradex Tobradex ST...90 Tobramycin...17 Tobramycin Sulfate...17 Tobramycin/ Dexamethasone Tobrex Tolcapone Tolnaftate...31 Topiramate...24 Toposar...37 Topotecan HCl...37 Torisel...81 Torsemide Toujeo SoloStar TPN Electrolytes Tracleer...98 Tradjenta...48 Tramadol HCl Tramadol HCl/ Acetaminophen...15 Trandolapril...51 Tranexamic Acid...49 Transderm-Scop...28 Tranylcypromine Sulfate...26 Travasol Travatan Z Travel Sickness...28 Travoprost Trazodone HCl...27 Treanda...34 Trecator...33 Trelstar Mixject...80 Tretinoin...38, 60 Tretinoin Microsphere Trexall...81 Trezix Tri-Legest Fe...77 Tri-Lo-Estarylla Tri-Lo-Sprintec...77 Tri-Previfem...77 Tri-Sprintec...77 Tri-Vita Tri-Vitamin Triacting Nightime Cold & Cough Childrens Triamcinolone Acetonide. 73 Triamcinolone in Orabase57 Triaminic Cold & Allergy.110 Triaminic Cold & Cough Day Time Childrens Triaminic Cough & Congestion Childrens Triaminic Cough & Sore Throat Triaminic Multi-Symptom Fever Triaminic Night Time Cold & Cough Triamterene/ Hydrochlorothiazide...53 Triderm...73 Trifluoperazine HCl Trifluridine Trihexyphenidyl HCl...40 TriLyte...70 Trimethoprim...19 Trimipramine Maleate...28 Trinessa Triple Antibiotic...19 Trisenox Triumeq...44 Trivora Trixaicin...60 Trixaicin HP...60 Trizivir Trophamine Trumenba...83 Trustex Lubricated Trustex Lubricated Extra Large...88 Trustex Lubricated Extra Strength...88 Trustex Lubricated/Ribbed/ Studded... 88

156 Trustex Lubricated/ Spermicide Trustex Lubricated/ Spermicide Extra Large..88 Trustex Lubricated/ Spermicide Extra Strength...88 Trustex Non-Lubricated Trustex with Nonoxynol-9/ Ribbed/Studded...88 Trustex/Ria Lubricated Trustex/Ria Lubricated Spermicide Trustex/Ria Lubricated/ Spermicide Trustex/Ria Non-Lubricated...88 Truvada...45 TruZone Peak Flow Meter88 Tusnel Tusnel Diabetic Tusnel Pediatric Tussi-Pres PE Pediatric Tussigon Tussin Tussin CF Tussin CF Cough & Cold Tussin CF Max Multi- Symptom Tussin Chest Congestion Tussin Cough Tussin DM Tussin DM Max Tussin Mucus + Chest Congestion Tussionex Pennkinetic Extended-Release Twinrix...83 Tybost...44 Tygacil...19 Tykerb Typhim Vi...83 Tysabri...57 Tyvaso Tyzeka...43 Tyzine Pediatric Nasal Drops U Uceris Uloric Unicomplex-M Unithroid Urea Ureacin Ursodiol...66 Uvadex V Vagistat Vagistat Valacyclovir HCl...43 Valchlor...34 Valcyte...42 Valganciclovir Valproate Sodium...24 Valproic Acid Valsartan...50 Valsartan/ Hydrochlorothiazide...53 Valved Holding Chamber. 88 Vanahist PD Vancocin HCl...19 Vancomycin HCl...19 Vandazole...19 VAQTA Varivax...83 Varizig...82 Vascepa...55 Vectibix Velcade Velivet...77 Velphoro Venlafaxine HCl...27 Venlafaxine HCl ER...27 Venofer Ventavis...98 Verapamil HCl Verapamil HCl ER...52 Versacloz Vesicare Vestura...77 Vfend Vibramycin Vicks Dayquil Mucus Control DM Vidaza...36 Videx Pediatric Vienva...77 Viibryd Viibryd Starter Pack Vimpat... 25

157 Vinblastine Sulfate...36 Vincasar PFS Vincristine Sulfate...36 Vinorelbine Tartrate...36 Viracept...46 Viramune Viramune XR...44 Virazole Viread Virtussin A/C Virtussin DAC Vita-Bee/C Vitamin B Complex-C Vitamin C Vitamin D Vitamin D Vitamin D3 Super Strength Vitamin K Vitekta Vivitrol...16 Voltaren...13 Voriconazole...32 Vortex Holding Chamber/ Mask/Childs...88 Vortex Holding Chamber/ Mask/Toddler...88 Vortex Valved Holding Chamber...88 Votrient...38 VP-PNV-DHA VPRIV Vraylar Vyfemla Vytorin W Warfarin Sodium...49 WatchHaler Welchol Womans Laxative WYMZYA Fe X Xalkori...38 Xarelto Xarelto Starter Pack Xeljanz...81 Xeljanz XR Xenazine Xgeva...85 Xifaxan...19 Xigduo XR Xolair Xtandi Xyrem Y Yervoy...38 YF-Vax Z Zaditor...90 Zafirlukast...96 Zaleplon Zaltrap Zanosar...34 Zavesca...61 Zazole...32 Zeasorb-AF...32 Zelapar...40 Zelboraf...38 Zemaira Zemplar...85 Zenchent Zenchent Fe...78 Zenpep...61 Zerbaxa...20 Zetia...55 Ziagen Zidovudine Ziks Arthritis Pain Relief...60 Zinc Sulfate Zinc Trace Metal Ziprasidone HCl...42 Zirgan Zmax...22 Zoledronic Acid...85 Zolinza...36 Zolpidem Tartrate Zomacton Zometa...85 Zonatuss Zonisamide Zoo Friends Zoo Friends Complete Zoo Friends Gummies Zoo Friends Plus Extra C Zoo Friends Plus Iron Zorbtive...67 Zortress...81 Zostavax...83 Zovia 1/35E...78

158 Zovia 1/50E...78 Zyclara...60 Zyclara Pump Zydelig...37 Zyflo Zyflo CR...96 Zykadia...37 Zyprexa Relprevv...42 Zytiga...34 Zyvox If you have questions, please call UnitedHealthcare Connected for MyCare Ohio at , TTY 711, 7 a.m. 8 p.m. local time, Monday Friday; voice mail available 24 hours a day/7 days a week. The call is free. For more information, visit or Medicare Approved Formulary File ID , Version 13 H2531_150629_153725_FINAL6 Approved UHOH16HM _005 Last updated June 1, 2016