2016 Prescription Drug List Effective May, 2016

Transcription

1 2016 Prescription Drug List Effective May, 2016 AmbetterofArkansas.com

2 Formulary Introduction FORMULARY The Ambetter of Arkansas Formulary, or Preferred Drug List, is a guide to available brand and generic drugs that are approved by the Food and Drug Administration (FDA) and covered through your prescription drug benefit. Generic drugs have the same active ingredients as their brand name counterparts and should be considered the first line of treatment. The FDA requires generics to be safe and work the same as brand name drugs. If there is no generic available, there may be more than one brand name drug to treat a condition. Preferred brand name drugs are listed on Tier 2 to help identify brand drugs that are clinically appropriate, safe, and cost-effective treatment options, if a generic medication on the formulary is not suitable for your condition. Please note, the Formulary is not meant to be a complete list of the drugs covered under your prescription benefit. Not all dosage forms or strengths of a drug may be covered. This list is periodically reviewed and updated and may be subject to change. Drugs may be added or removed, or additional requirements may be added in order to approve continued usage of a specific drug. pecific prescription benefit plan designs may not cover certain products or categories, regardless of their appearance in this document. Please check your benefits for coverage limitations and your share of cost for your drugs. Drug List Key: Brand name drugs are listed in CAP and generic drugs are lower case. Drugs are covered under different copay tiers depending on your benefit: Tier 0 - No copayment for those drugs that are used for prevention and are mandated by Affordable Care Act. elect oral contraceptives, vitamin D, folic acid for women of child bearing age, over-the-counter (OTC) aspirin, and smoking cessation products may be covered under this tier. Certain age or gender limits apply. Tier 1 - Lowest copayment for those drugs that offer the greatest value compared to other drugs used to treat similar conditions. elect over-the-counter (OTC), generic or brand name drugs may be covered under this tier. Tier 2 - Medium copayment covers brand name drugs that are generally more affordable, or may be preferred compared to other drugs to treat the same conditions. Tier 3 - Highest copayment covers higher cost brand name drugs. This tier may also cover non-specialty drugs that are not on the Preferred Drug List but approval has been granted for coverage. Tier 4 - Coverage for this tier is for specialty drugs used to treat complex, chronic conditions that may require special handling, storage or clinical management. For members who do not have a four Tier plan, these drugs may be covered under Tier 3. Prior Authorization for Non-Formulary Drugs To obtain prior authorization for a non-formulary drug, your provider must fill out the Prior Authorization form. U cript will respond via fax or phone within 48 hours of receipt of all necessary information, except during weekends and holidays. If the request is disapproved, the notice of disapproval will contain a clear explanation of the specific reasons for disapproving the prior authorization request, or if the request was incomplete, the explanation will identify the missing material information that is necessary to complete the request.

3 LEGEND TIER DECRIPTION 0 Preventative 1 Generics 2 Preferred Brands 3 Non-Preferred Brands 4 pecialty TYPE DECRIPTION Prior Authorization Prior Authorization required before prescription can be filled. T tep Therapy Requires trial and failure of one or more preferred products prior to coverage. GL Gender Limit Drug is limited to specific gender. AL Age Limit Drug is limited to specific age. Max Daily Dose A limit on the number of times the drug can be taken per day. MPL Max Package Limit A limit on the amount of drug covered per prescription. MFL Max Fill Limit There is a limit on the number of times this drug can be refilled. MD1 Max Days upply There is a limit on the amount of this drug that is covered. C Custom This drug has unique restrictions. FAL MAL pecialty Drug Female Age Limit Male Age Limit pecialty drugs are high-cost drugs used to treat complex or rare conditions, such as multiple sclerosis, rheumatoid arthritis, hepatitis C, and hemophilia. This prescription drug may only be covered if you are a female and meet the minimum or maximum age limit. This prescription drug may only be covered if you are a male and meet the minimum or maximum age limit. GE 2 LAT UPDATED 05/2016

4 LIT OF COVERED OVER-THE-COUNTER MEDICATION PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION ANALGEIC NONTEROIDAL ANTI-INFLAMMATORY DRUG aspirin tab delayed release 81 mg generic 0 ibuprofen susp 100 mg/5ml ANTI-ADDICTION/UBTANCE ABUE TREATMENT AGENT MOKING CEATION AGENT COMMIT BRAND 0 FAL MAL Female - 55 to 79 yrs old Male - 45 to 79 yrs old NICODERM CQ BRAND 0 1 per day NICORETTE BRAND 0 NICORETTE MINI BRAND 0 NICORETTE REFILL BRAND 0 NICORETTE TARTER KIT BRAND 0 nicotine (patch 24hr 7 mg/24hr, patch 24hr 21 mg/24hr, patch 24hr 14 mg/24hr) generic 0 1 per day NICOTINE KIT MG/24HR BRAND 0 NICOTINE MINI BRAND 0 nicotine polacrilex generic 0 ANTIEMETIC ANTIEMETIC, OTHER meclizine hcl (tab 12.5 mg, tab 25 mg) ANTIFUNGAL clotrimazole (topical) (cream, soln) clotrimazole vaginal cream 1% GYNE-LOTRIMIN BRAND 1 LOTRIMIN ULTRA BRAND 2 MPL 1 / 30 days GE 3 LAT UPDATED 05/2016

5 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION CARDIOVACULAR AGENT DYLIPIDEMIC, OTHER niacin tab cr 750 mg DENTAL AND ORAL AGENT stannous fluoride conc 0.63% generic 0 DERMATOLOGICAL AGENT benzoyl peroxide (foam 5.3%, gel 5%, gel 10%, liq 4%, liq 10%, lotion 6%) AL At least 12 yrs old hydrocortisone (topical) (cream, oint) lactic acid (ammonium lactate) (cream, lotion) lidocaine hcl gel 2% NOXYL-4 CREAMY WAH BRAND 3 AL At least 12 yrs old GATROINTETINAL AGENT GATROINTETINAL AGENT, OTHER loperamide hcl cap 2 mg HITAMINE2 (H2) RECEPTOR ANTAGONIT cimetidine famotidine tab 20 mg ranitidine hcl tab 150 mg LAXATIVE bisacodyl tab delayed release 5 mg calcium polycarbophil docusate calcium docusate sodium (cap 100 mg, cap 250 mg) PROTON PUMP INHIBITOR CV OMEPRAZOLE BRAND 1 2 per day EQ OMEPRAZOLE BRAND 1 2 per day EQL OMEPRAZOLE BRAND 1 2 per day GNP OMEPRAZOLE BRAND 1 2 per day GE 4 LAT UPDATED 05/2016

6 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION HM OMEPRAZOLE BRAND 1 2 per day KL OMEPRAZOLE BRAND 1 2 per day lansoprazole 1 per day NEXIUM 24HR CAP DR 20 MG BRAND 1 2 per day omeprazole delayed release tab 20 mg 2 per day omeprazole magnesium 4 per day OMEPRAZOLE TAB DR 20 MG BRAND 1 2 per day omeprazole-sodium bicarbonate 1 per day PREVACID 24HR BRAND 1 1 per day PRILOEC OTC BRAND 1 4 per day PX OMEPRAZOLE BRAND 1 2 per day RA OMEPRAZOLE BRAND 1 2 per day B OMEPRAZOLE BRAND 1 2 per day M OMEPRAZOLE BRAND 1 2 per day W OMEPRAZOLE BRAND 1 2 per day TGT OMEPRAZOLE BRAND 1 2 per day ZEGERID OTC BRAND 1 1 per day GENITOURINARY AGENT GENITOURINARY AGENT, OTHER GYNOL II BRAND 0 TODAY PONGE BRAND 0 HORMONAL AGENT, TIMULANT/REPLACEMENT/MODIFYING (EX HORMONE/MODIFIER) ETROGEN levonorgestrel (emergency oc) generic 0 GL Female PLAN B ONE-TEP BRAND 0 GL Female GE 5 LAT UPDATED 05/2016

7 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION MICELLANEOU THERAPEUTIC AGENT AIMCO LUBRICATED BRAND 0 ELEXA NATURAL FEEL BRAND 0 ELEXA TIMULATING BRAND 0 ELEXA ULTRA ENITIVE BRAND 0 FANTAY LUBRICATED BRAND 0 FANTAY LUBRICATED/PERMICIDE BRAND 0 FC FEMALE CONDOM BRAND 0 FC2 FEMALE CONDOM BRAND 0 KAMELEON LUBRICATED BRAND 0 KIMONO BRAND 0 KIMONO MICRO THIN PLU BRAND 0 KIMONO PLU BRAND 0 KIMONO P BRAND 0 KIMONO P PLU BRAND 0 KIMONO ENATION BRAND 0 KIMONO ENATION PLU BRAND 0 MAXX BRAND 0 MAXX PLU BRAND 0 NOVA MAX PLU KETONE TET BRAND 1 PRECIION XTRA KETONE BRAND 1 PREMIUM CONDOM LUBRICATED BRAND 0 PT NEL KETONE TET BRAND 1 REALITY LATEX/ULTRA TEXTURED BRAND 0 REALITY LATEX/ULTRA THIN BRAND 0 TROJAN MAGNUM WARM ENATION BRAND 0 TROJAN UPRA PERMICIDAL BRAND 0 TROJAN TWITED PLEAURE BRAND 0 TRUTEX COLOR CONDOM + LUBE BRAND 0 TRUTEX LUB/RIBBED/TUDDED BRAND 0 TRUTEX LUB/PERMICIDE EX T BRAND 0 GE 6 LAT UPDATED 05/2016

8 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION TRUTEX LUB/PERMICIDE XL BRAND 0 TRUTEX LUBRICATED BRAND 0 TRUTEX LUBRICATED EX LARGE BRAND 0 TRUTEX LUBRICATED EXTRA T BRAND 0 TRUTEX LUBRICATED/PERMICIDE BRAND 0 TRUTEX NATURAL CONDOM + LUBE BRAND 0 TRUTEX RIA LUB/PERMICIDE BRAND 0 TRUTEX RIA LUBRICATED BRAND 0 TRUTEX-NONOXYNOL-9/RIB/TUD BRAND 0 OPHTHALMIC AGENT OPHTHALMIC AGENT, OTHER ketotifen fumarate (ophth) ZADITOR BRAND 1 REPIRATORY TRACT/PULMONARY AGENT ANTI-INFLAMMATORIE, INHALED CORTICOTEROID fluticasone propionate (nasal) MPL 1 / 30 days ANTIHITAMINE ALLEGRA ALLERGY CHILDREN (TAB 30 MG, TAB DIP 30 MG) ALLEGRA ALLERGY CHILDREN UPENION 30 MG/5ML BRAND 1 2 per day BRAND 1 MD1 900 ML / 30 DAY ALLEGRA ALLERGY TAB 180 MG BRAND 1 1 per day ALLEGRA ALLERGY TAB 60 MG BRAND 1 2 per day cetirizine hcl (cap 10 mg, chew tab 5 mg, chew tab 10 mg, tab 5 mg, tab 10 mg) 1 per day cetirizine hcl oral soln 1 mg/ml (5 mg/5ml) MD1 300 ML / 30 DAY CLARITIN (CAP 10 MG, CHEW TAB 5 MG, YRUP 5 MG/5ML, TAB 10 MG) BRAND 1 CLARITIN REDITAB BRAND 1 diphenhydramine hcl (cap 50 mg, elixir 12.5 mg/5ml) GE 7 LAT UPDATED 05/2016

9 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION fexofenadine hcl susp 30 mg/5ml (6 mg/ml) MD1 900 ML / 30 DAY fexofenadine hcl tab 180 mg 1 per day fexofenadine hcl tab 60 mg 2 per day loratadine (rapidly-disintegrating tab 10 mg, syrup 5 mg/5ml, tab 10 mg) ZYRTEC ALLERGY (CAP 10 MG, TAB 10 MG) BRAND 1 1 per day ZYRTEC CHILDREN ALLERGY (CHEW TAB 5 MG, CHEW TAB 10 MG) ZYRTEC CHILDREN ALLERGY (YRUP 1 MG/ML, YRUP 5 MG/5ML) BRAND 1 1 per day BRAND 1 MD1 300 / 30 DAY ZYRTEC CHILDREN HIVE RELIEF BRAND 1 MD1 300 ML / 30 DAY ZYRTEC HIVE RELIEF BRAND 1 1 per day REPIRATORY TRACT AGENT, OTHER cetirizine-pseudoephedrine 2 per day CLARITIN-D 12 HOUR BRAND 1 2 per day CLARITIN-D 24 HOUR BRAND 1 1 per day fexofenadine-pseudoephedrine tab sr 12hr mg fexofenadine-pseudoephedrine tab sr 24hr mg loratadine & pseudoephedrine tab sr 12hr mg loratadine & pseudoephedrine tab sr 24hr mg 2 per day 1 per day 2 per day 1 per day ZYRTEC-D ALLERGY & CONGETION BRAND 1 2 per day THERAPEUTIC NUTRIENT/MINERAL/ELECTROLYTE ELECTROLYTE/MINERAL REPLACEMENT FER-IN-OL BRAND 0 AL Up to 1 yrs old ferrous sulfate (tab 325 mg mg elemental fe), tab ec 325 mg mg fe equivalent)) ferrous sulfate soln 75 mg/ml (15 mg/ml elemental fe) generic 0 generic 0 AL Up to 1 yrs old GE 8 LAT UPDATED 05/2016

10 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION cholecalciferol tab 400 unit generic 0 DRIDOL BRAND 0 ergocalciferol soln 8000 unit/ml generic 0 ergocalciferol tab 400 unit generic 0 AL At least 65 yrs old folic acid (tab 1 mg, tab 400 mcg) generic 0 FAL niacin (tab 50 mg, tab 100 mg, tab 250 mg, tab 500 mg) Female - 12 to 55 yrs old GE 9 LAT UPDATED 05/2016

11 LIT OF COVERED PRECRIPTION MEDICATION PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION ANALGEIC NONTEROIDAL ANTI-INFLAMMATORY DRUG celecoxib (cap 50 mg, cap 100 mg, cap 200 mg) 2 per day celecoxib cap 400 mg choline & magnesium salicylates tab 1000 mg diclofenac potassium 1 per day diclofenac sodium (tab delayed release 25 mg, tab delayed release 50 mg, tab delayed release 75 mg, tab sr 24hr 100 mg) diclofenac w/ misoprostol diflunisal tab 500 mg etodolac (cap 200 mg, cap 300 mg, tab 400 mg, tab 500 mg) fenoprofen calcium tab 600 mg 1 per day FLECTOR BRAND 3 flurbiprofen (tab 50 mg, tab 100 mg) 2 per day ibuprofen (susp 100 mg/5ml, tab 400 mg, tab 600 mg, tab 800 mg) indomethacin (cap 25 mg, cap 50 mg, cap cr 75 mg) ketoprofen (cap 50 mg, cap 75 mg) ketorolac tromethamine tab 10 mg MD1 20 / 30 DAY meclofenamate sodium (cap 50 mg, cap 100 mg) mefenamic acid cap 250 mg meloxicam (tab 7.5 mg, tab 15 mg) 1 per day meloxicam susp 7.5 mg/5ml GE 10 LAT UPDATED 05/2016

12 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION MOBIC UPENION 7.5 MG/5ML BRAND 1 nabumetone naproxen (susp 125 mg/5ml, tab 250 mg, tab 375 mg, tab 500 mg, tab ec 500 mg) naproxen sodium tab 550 mg oxaprozin piroxicam (cap 10 mg, cap 20 mg) salsalate sulindac (tab 150 mg, tab 200 mg) tolmetin sodium OPIOID ANALGEIC, LONG-ACTING BUTRAN BRAND 3 MD1 4 / 28 DAY EMBEDA BRAND 3 2 per day EXALGO (TB24 DETER 12 MG, TB24 DETER 16 MG, TB24 DETER 8 MG) BRAND 2 2 per day EXALGO TB24 DETER 32 MG BRAND 2 1 per day fentanyl (patch 72hr 25, patch 72hr 100, patch 72hr 12, patch 72hr 75, patch 72hr 50) MD1 10 / 30 DAY hydromorphone hcl (tab er 24hr deter 12 mg, tab er 24hr deter 8 mg, tab er 24hr deter 16 mg) 2 per day hydromorphone hcl tab er 24hr deter 32 mg generic 2 levorphanol tartrate 1 per day methadone hcl conc 10 mg/ml MD1 300 ML / 30 DAY methadone hcl soln 10 mg/5ml MD ML / 30 DAY methadone hcl soln 5 mg/5ml MD ML / 30 DAY METHADONE HCL OLUTION 10 MG/ML BRAND 1 GE 11 LAT UPDATED 05/2016

13 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION methadone hcl tab 10 mg 10 per day methadone hcl tab 5 mg 4 per day methadone hcl tab for oral susp 40 mg 2 per day METHADOE BRAND 1 MD1 300 ML / 30 DAY METHADOE UGAR-FREE BRAND 1 MD1 300 ML / 30 DAY morphine sulfate (cap sr 24hr 80 mg, cap sr 24hr 20 mg, cap sr 24hr 50 mg, cap sr 24hr 30 mg, cap sr 24hr 100 mg, cap sr 24hr 60 mg) 2 per day morphine sulfate (tab 15 mg, tab 30 mg, tab 60 mg, tab 100 mg, tab 200 mg) 2 per day NUCYNTA ER BRAND 2 2 per day oxycodone hcl (tab er deter 10 mg, tab er deter 20 mg, tab er deter 40 mg, tab er deter 80 mg) 2 per day OXYCONTIN (TB12 DETER 40 MG, TB12 DETER 80 MG, TB12 DETER 20 MG, TB12 DETER 10 MG) BRAND 3 2 per day OXYCONTIN (TB12 DETER 60 MG, TB12 DETER 30 MG, TB12 DETER 15 MG) BRAND 3 oxymorphone hcl (tab sr 5 mg, tab sr 7.5 mg, tab sr 15 mg, tab sr 30 mg) generic 3 2 per day tramadol hcl (tab sr 24hr biphasic release 300 mg, tab sr 24hr 300 mg, tab sr 24hr 200 mg, tab sr 24hr 100 mg) 1 per day ZOHYDRO ER BRAND 3 2 per day OPIOID ANALGEIC, HORT-ACTING acetaminophen w/ codeine soln mg/5ml MD ML / 30 DAY acetaminophen w/ codeine tab mg 13 per day acetaminophen w/ codeine tab mg 12 per day acetaminophen w/ codeine tab mg 6 per day butalbital-acetaminophen-caff w/ cod cap mg 6 per day GE 12 LAT UPDATED 05/2016

14 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION butalbital-aspirin-caffeine w/cod 6 per day butorphanol tartrate (inj 1 mg/ml, inj 2 mg/ml) butorphanol tartrate nasal soln 10 mg/ml MPL 1 / 30 days codeine sulfate (oral soln 30 mg/5ml, tab 15 mg) fentanyl citrate (fentnyl citrte lozenge hndle 200 mcg, fentnyl citrte lozenge hndle 400 mcg, fentnyl citrte lozenge hndle 600 mcg, fentnyl citrte lozenge hndle 800 mcg, fentnyl citrte lozenge hndle 1200 mcg, fentnyl citrte lozenge hndle 1600 mcg) 4 per day hydrocodone-acetaminophen (soln mg/15ml, soln mg/15ml, tab mg) hydrocodone-acetaminophen (tab mg, tab mg, tab mg, tab mg) hydrocodone-acetaminophen (tab mg, tab mg, tab mg) hydrocodone-acetaminophen (tab mg, tab mg, tab mg) hydrocodone-acetaminophen (tab mg, tab mg, tab mg) hydrocodone-acetaminophen (tab mg, tab mg) hydrocodone-acetaminophen soln mg/15ml hydrocodone-ibuprofen (tab mg, tab mg, tab mg) 8 per day 13 per day 12 per day 6 per day 5 per day MD ML / 30 DAY hydrocodone-ibuprofen tab mg 5 per day hydromorphone hcl (liqd 1 mg/ml, preservative free (pf) inj 10 mg/ml) hydromorphone hcl (tab 2 mg, tab 4 mg, tab 8 mg) meperidine hcl (inj 25 mg/ml, inj 50 mg/ml, inj 100 mg/ml) 8 per day meperidine hcl (tab 50 mg, tab 100 mg) 6 per day GE 13 LAT UPDATED 05/2016

15 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION meperidine hcl oral soln 50 mg/5ml MD1 500 ML / CLAIM morphine sulfate (inj 0.5 mg/ml, inj 1 mg/ml) morphine sulfate (tab 15 mg, tab 30 mg) 6 per day morphine sulfate oral soln 10 mg/5ml MD ML / 30 DAY morphine sulfate oral soln 20 mg/5ml MD ML / 30 DAY nalbuphine hcl 8 per day NUCYNTA BRAND 2 6 per day oxycodone hcl (tab 5 mg, tab 10 mg, tab 15 mg, tab 20 mg) 12 per day oxycodone hcl tab 30 mg 24 per day oxycodone w/ acetaminophen (tab mg, tab mg, tab mg) 12 per day oxycodone w/ acetaminophen tab mg 8 per day oxycodone-ibuprofen 1 per day oxymorphone hcl (tab 5 mg, tab 10 mg) 12 per day pentazocine w/ naloxone TALWIN BRAND 3 tramadol hcl tab 50 mg 8 per day tramadol-acetaminophen 8 per day ZOLVIT BRAND 2 ANETHETIC LOCAL ANETHETIC lidocaine hcl (local anesth.) (inj 0.5%, inj 1%, preservative free (pf) inj 0.5%, preservative free (pf) inj 1%, preservative free (pf) inj 2%, preservative free (pf) inj 4%) lidocaine hcl laryngotracheal soln 4% lidocaine hcl viscous soln 2% MD1 120 ML / 30 DAY XYLOCAINE OLUTION 1 % BRAND 3 GE 14 LAT UPDATED 05/2016

16 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION ANTI-ADDICTION/UBTANCE ABUE TREATMENT AGENT ALCOHOL DETERRENT/ANTI-CRAVING acamprosate calcium CAMPRAL BRAND 2 disulfiram naltrexone hcl tab 50 mg OPIOID DEPENDENCE TREATMENT buprenorphine hcl (sl tab 2 mg, sl tab 8 mg) buprenorphine hcl inj 0.3 mg/ml (base equiv) UBOXONE (FILM MG, FILM 4-1 MG) BRAND 3 UBOXONE (FILM 8-2 MG, FILM 12-3 MG) BRAND 3 3 per day 3 per day 2 per day OPIOID REVERAL AGENT naloxone hcl (inj 0.4 mg/ml, inj 1 mg/ml) MOKING CEATION AGENT bupropion hcl (smoking deterrent) generic 0 2 per day CHANTIX BRAND 0 2 per day CHANTIX CONTINUING MONTH K BRAND 0 2 per day CHANTIX TARTING MONTH K BRAND 0 NICOTROL BRAND 0 MPL 1 / claim NICOTROL N BRAND 0 MPL 1 / claim ZYBAN BRAND 0 2 per day ANTIBACTERIAL AMINOGLYCOIDE amikacin sulfate (inj 1 gm/4ml, inj 500 mg/2ml) GE 15 LAT UPDATED 05/2016

17 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION gentamicin in saline (gentamicsale j 0.8 mg/ml, gentamicsale j 1 mg/ml, gentamicsale j 1.2 mg/ml, gentamicsale j 1.6 mg/ml) GENTAMICIN IN ALINE (GENTAMICALE OLUTION , GENTAMICALE OLUTION ) gentamicin sulfate (inj 40 mg/ml, iv soln 10 mg/ml) BRAND 1 gentamicin sulfate (ophth) (oint, soln) kanamycin sulfate generic 3 neomycin sulfate paromomycin sulfate streptomycin sulfate for inj 1 gm generic 3 TOBRADEX OINTMENT % BRAND 3 tobramycin (ophth) tobramycin sulfate (inj 10 mg/ml, inj 80 mg/2ml (40 mg/ml)) TOBRAMYCIN ULFATE IN ALINE BRAND 1 ANTIBACTERIAL, OTHER acetic acid ALTABAX (1 %, OINTMENT 1 %) BRAND 2 bacitracin intramuscular for soln unit generic 3 chloramphenicol sodium succinate generic 4 pecialty Drug clindamycin hcl (cap 75 mg, cap 150 mg, cap 300 mg) clindamycin palmitate hydrochloride clindamycin phosphate (inj 9 gm/60ml, inj 300 mg/2ml, inj 600 mg/4ml, inj 900 mg/6ml, iv soln 300 mg/2ml, iv soln 600 mg/4ml, iv soln 900 mg/6ml) clindamycin phosphate (topical) (foam, gel, lotion, soln) AL At least 12 yrs old clindamycin phosphate vaginal CUBICIN BRAND 3 GE 16 LAT UPDATED 05/2016

18 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION LINCOCIN BRAND 3 LINEZOLID IN ODIUM CHLORIDE BRAND 1 linezolid iv soln 600 mg/300ml (2 mg/ml) linezolid tab 600 mg mafenide acetate generic 3 methenamine hippurate metronidazole (tab 250 mg, tab 500 mg) C 2 per day QL: 14 day supply/claim metronidazole (topical) (cream 0.75%, gel 0.75%, gel 1%, lotion 0.75%) metronidazole vaginal MONUROL BRAND 3 mupirocin calcium (topical) mupirocin oint 2% nitrofurantoin nitrofurantoin macrocrystal (cap 50 mg, cap 100 mg) nitrofurantoin monohyd macro polymyxin b sulfate for inj unit ULFAMYLON (CREAM 85 MG/GM, CKET 5 %) BRAND 3 trimethoprim tab 100 mg TYGACIL BRAND 3 vancomycin hcl (cap 125 mg, cap 250 mg) vancomycin hcl (inj 10 gm, inj 500 mg, inj 1000 mg) VIBATIV RECON OLN 750 MG BRAND 3 XIFAXAN BRAND 3 C AL 4 per day QL: 10 day supply/claim At least 12 yrs old GE 17 LAT UPDATED 05/2016

19 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION BETA-LACTAM, CEPHALOPORIN CEDAX (CAP 400 MG, RECON UP 90 MG/5ML, RECON UP 180 MG/5ML) cefaclor (cap 250 mg, cap 500 mg, for susp 125 mg/5ml, for susp 250 mg/5ml, for susp 375 mg/5ml) BRAND 3 cefaclor monohydrate cefadroxil (cap 500 mg, for susp 250 mg/5ml, for susp 500 mg/5ml, tab 1 gm) cefazolin sodium (inj 1 gm, inj 10 gm, inj 20 gm, inj 500 mg) cefdinir (cap 300 mg, for susp 125 mg/5ml, for susp 250 mg/5ml) AL At least 2 yrs old cefditoren pivoxil (tab 200 mg, tab 400 mg) generic 3 CEFDITOREN PIVOXIL TAB 200 MG BRAND 3 cefepime hcl (inj 1 gm, inj 2 gm) cefixime cefotaxime sodium (inj 1 gm, inj 2 gm, inj 10 gm) cefotetan disodium generic 3 cefoxitin sodium cefpodoxime proxetil (for susp 50 mg/5ml, for susp 100 mg/5ml, tab 100 mg, tab 200 mg) cefprozil (for susp 125 mg/5ml, for susp 250 mg/5ml, tab 250 mg, tab 500 mg) ceftazidime (inj 1 gm, inj 2 gm, inj 6 gm) CEFTIBUTEN CAP 400 MG BRAND 1 CEFTIBUTEN RECON UP 180 MG/5ML BRAND 3 CEFTIN RECON UP 125 MG/5ML BRAND 2 ceftriaxone sodium (inj 1 gm, inj 2 gm, inj 250 mg, inj 500 mg) cefuroxime axetil (for susp 125 mg/5ml, tab 250 mg, tab 500 mg) cefuroxime sodium (inj 1.5 gm, inj 7.5 gm, inj 750 mg) GE 18 LAT UPDATED 05/2016

20 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION cephalexin (cap 250 mg, cap 500 mg, cap 750 mg, for susp 125 mg/5ml, for susp 250 mg/5ml, tab 250 mg, tab 500 mg) PECTRACEF BRAND 3 UPRAX (RECON UP 100 MG/5ML, RECON UP 200 MG/5ML, TAB 400 MG) BRAND 2 TEFLARO BRAND 3 BETA-LACTAM, OTHER AZACTAM IN DEXTROE BRAND 3 aztreonam imipenem-cilastatin INVANZ BRAND 3 meropenem BETA-LACTAM, PENICILLIN amoxicillin & pot clavulanate (chew tab mg, chew tab mg, for susp mg/5ml, for susp mg/5ml, for susp mg/5ml, for susp mg/5ml, tab mg, tab mg, tab mg, tab sr 12hr mg) amoxicillin (cap 250 mg, cap 500 mg, chew tab 125 mg, chew tab 250 mg, for susp 125 mg/5ml, for susp 200 mg/5ml, for susp 250 mg/5ml, for susp 400 mg/5ml, tab 500 mg, tab 875 mg) ampicillin & sulbactam sodium (inj gm, inj 2-1 gm, iv soln 10-5 gm) ampicillin (cap 250 mg, cap 500 mg) AMPICILLIN (RECON UP 125, RECON UP 250) BRAND 1 ampicillin sodium (inj 1 gm, iv soln 10 gm) dicloxacillin sodium nafcillin sodium (inj 1 gm, inj 10 gm) oxacillin sodium (inj 1 gm, inj 10 gm) PENICILLIN G POT IN DEXTROE (PENICILLOLUTION 40000, PENICILLOLUTION 60000) BRAND 1 GE 19 LAT UPDATED 05/2016

21 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION penicillin g potassium for inj unit PENICILLIN G PROCAINE BRAND 3 penicillin g sodium generic 3 penicillin v potassium (for soln 125 mg/5ml, for soln 250 mg/5ml, tab 250 mg, tab 500 mg) piperacillin sodium-tazobactam sodium (sodtazobactam sod inj 2.25 gm ( gm), sodtazobactam sod inj 4.5 gm (4-0.5 gm), sodiumtazobactam sodium inj gm, sodiumtazobactam sodium inj gm, sodiumtazobactam sodium inj gm, sodiumtazobactam sodium inj gm) TIMENTIN RECON OLN 3.1 GM BRAND 3 MACROLIDE AZAITE BRAND 3 azithromycin (iv soln 500 mg, powd pack susp 1 gm, susp 100 mg/5ml) azithromycin for susp 200 mg/5ml MPL 1 / claim azithromycin tab 250 mg C Limited to 6 tablets per claim azithromycin tab 500 mg C Limited to 4 tablets per claim azithromycin tab 600 mg MD1 8 / 28 DAY clarithromycin (for susp 125 mg/5ml, for susp 250 mg/5ml, tab 250 mg, tab 500 mg, tab sr 24hr 500 mg) DIFICID BRAND 2 E.E BRAND 3 E.E.. GRANULE BRAND 3 ERY-TAB BRAND 3 ERYPED 200 BRAND 3 ERYPED 400 BRAND 3 erythromycin (acne aid) (pads, soln) AL At least 12 yrs old erythromycin (ophth) ERYTHROMYCIN BAE (TAB 250 MG, TAB 500 MG) BRAND 3 GE 20 LAT UPDATED 05/2016

22 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION ERYTHROMYCIN ETHYLUCCINATE TAB 400 MG BRAND 3 erythromycin w/ delayed release particles cap 250 mg generic 3 KETEK BRAND 3 ZITHROMAX CKET 1 GM BRAND 1 C 2 per day QL: 10 day supply/claim QUINOLONE AVELOX (OLUTION 400 MG/250ML, TAB 400 MG) BRAND 3 AVELOX ABC CK BRAND 3 BEIVANCE BRAND 3 CETRAXAL BRAND 1 CIPRO IN D5W OLUTION 200 MG/100ML BRAND 3 ciprofloxacin (for oral susp 250 mg/5ml (5%) (5 gm/100ml), for oral susp 500 mg/5ml (10%) (10 gm/100ml), iv soln 400 mg/40ml (1%)) ciprofloxacin 200 mg/100ml in d5w generic 3 ciprofloxacin hcl (ophth) ciprofloxacin hcl (otic) ciprofloxacin hcl (tab 100 mg, tab 250 mg, tab 500 mg, tab 750 mg) ciprofloxacin-ciprofloxacin hcl FACTIVE BRAND 3 gatifloxacin (ophth) levofloxacin (iv soln 25 mg/ml, oral soln 25 mg/ml, tab 250 mg, tab 500 mg, tab 750 mg) levofloxacin (ophth) levofloxacin in d5w iv soln 500 mg/100ml moxifloxacin hcl tab 400 mg (base equiv) NOROXIN BRAND 3 ofloxacin ofloxacin (ophth) GE 21 LAT UPDATED 05/2016

23 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION ofloxacin (otic) ZYMAXID BRAND 3 ULFONAMIDE silver sulfadiazine sulfacetamide sodium ophth soln 10% MPL 1 / Claim sulfadiazine tab 500 mg sulfamethoxazole-trimethoprim (iv soln mg/5ml, susp mg/5ml, tab mg, tab mg) TETRACYCLINE demeclocycline hcl (tab 150 mg, tab 300 mg) doxycycline (monohydrate) (cap 50 mg, cap 100 mg, tab 100 mg) doxycycline hyclate (cap 50 mg, cap 100 mg, tab 20 mg, tab 100 mg) 2 per day 2 per day doxycycline hyclate for inj 100 mg doxycycline monohydrate cap 75 mg minocycline hcl (cap 50 mg, cap 75 mg, cap 100 mg, tab 50 mg, tab 75 mg, tab 100 mg) 3 per day tetracycline hcl (cap 250 mg, cap 500 mg) 8 per day ANTICONVULANT ANTICONVULANT, OTHER levetiracetam (inj 500 mg/5ml (100 mg/ml), oral soln 100 mg/ml) levetiracetam (tab 250 mg, tab 500 mg, tab 750 mg, tab sr 24hr 750 mg, tab sr 24hr 500 mg) MD1 900 / 30 DAY 4 per day levetiracetam tab 1000 mg 3 per day POTIGA BRAND 3 3 per day CALCIUM CHANNEL MODIFYING AGENT CELONTIN BRAND 3 4 per day ethosuximide cap 250 mg 6 per day GE 22 LAT UPDATED 05/2016

24 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION ethosuximide soln 250 mg/5ml MD1 900 ML / 30 DAY zonisamide (cap 25 mg, cap 50 mg, cap 100 mg) 6 per day GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENT DIATAT ACUDIAL BRAND 3 MPL 1 / claim DIATAT PEDIATRIC BRAND 3 MPL 1 / claim diazepam (anticonvulsant) generic 3 MPL 1 / claim divalproex sodium (tab delayed release 125 mg, tab delayed release 250 mg, tab delayed release 500 mg, tab sr 24 hr 500 mg, tab sr 24 hr 250 mg) gabapentin (cap 100 mg, cap 300 mg, cap 400 mg, tab 600 mg, tab 800 mg) gabapentin oral soln 250 mg/5ml MD ML / 30 DAY ONFI (TAB 5 MG, TAB 10 MG, TAB 20 MG) BRAND 3 2 per day ONFI UPENION 2.5 MG/ML BRAND 3 MD1 480 ML / 30 DAY phenobarbital (elixir 20 mg/5ml, tab 16.2 mg, tab 30 mg, tab 32.4 mg, tab 64.8 mg, tab 97.2 mg, tab 100 mg) primidone ABRIL BRAND 4 tiagabine hcl valproate sodium valproic acid GLUTAMATE REDUCING AGENT 6 per day pecialty Drug felbamate susp 600 mg/5ml MD1 900 ML / 30 DAY felbamate tab 400 mg 9 per day felbamate tab 600 mg 6 per day GE 23 LAT UPDATED 05/2016

25 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION lamotrigine (tab 25 mg, tab 100 mg, tab 150 mg, tab 200 mg, tab chewable dispersible 5 mg, tab chewable dispersible 25 mg) topiramate (tab 100 mg, tab 200 mg) 2 per day topiramate (tab 25 mg, tab 50 mg) 4 per day topiramate sprinkle cap 15 mg 6 per day topiramate sprinkle cap 25 mg 8 per day ODIUM CHANNEL AGENT BANZEL UPENION 40 MG/ML BRAND 2 MD ML / 30 DAY BANZEL TAB 200 MG BRAND 2 BANZEL TAB 400 MG BRAND 2 carbamazepine (cap sr 200 mg, tab sr 200 mg) carbamazepine (cap sr 300 mg, tab sr 400 mg) T T 2 per day 8 per day 6 per day 4 per day carbamazepine (chew tab 100 mg, susp 100 mg/5ml, tab 200 mg) carbamazepine cap sr 12hr 100 mg T DILANTIN (CAP 30 MG, CAP 100 MG, UPENION 125 MG/5ML) BRAND 2 DILANTIN INFATAB BRAND 2 EQUETRO CAP ER 12H 100 MG BRAND 3 EQUETRO CAP ER 12H 200 MG BRAND 3 EQUETRO CAP ER 12H 300 MG BRAND 3 T T T 2 per day 8 per day 4 per day GE 24 LAT UPDATED 05/2016

26 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION fosphenytoin sodium oxcarbazepine (tab 150 mg, tab 300 mg) 3 per day oxcarbazepine susp 300 mg/5ml (60 mg/ml) MD ML / 30 DAY oxcarbazepine tab 600 mg 4 per day PEGANONE BRAND 3 PHENYTEK CAP 200 MG BRAND 2 PHENYTEK CAP 300 MG BRAND 3 phenytoin (chew tab 50 mg, susp 125 mg/5ml) phenytoin sodium extended phenytoin sodium inj 50 mg/ml TEGRETOL (CHEW TAB 100 MG, UPENION 100 MG/5ML, TAB 200 MG) BRAND 2 VIMT (TAB 50 MG, TAB 100 MG, TAB 150 MG, TAB 200 MG) BRAND 3 2 per day VIMT OLUTION 10 MG/ML BRAND 3 MD ML / 30 DAY VIMT OLUTION 200 MG/20ML BRAND 3 MD ML / 30 DAY ANTIDEMENTIA AGENT CHOLINETERAE INHIBITOR donepezil hydrochloride (orally disintegrating tab 10 mg, tab 10 mg) donepezil hydrochloride (orally disintegrating tab 5 mg, tab 5 mg) galantamine hydrobromide (cap sr 24hr 8 mg, cap sr 24hr 24 mg, cap sr 24hr 16 mg) galantamine hydrobromide (tab 4 mg, tab 8 mg, tab 12 mg) 2 per day 1 per day 1 per day 2 per day galantamine hydrobromide oral soln 4 mg/ml 6 per day rivastigmine tartrate N-METHYL-D-ARTATE (NMDA) RECEPTOR ANTAGONIT memantine hcl tab 10 mg 2 per day GE 25 LAT UPDATED 05/2016

27 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION memantine hcl tab 5 mg 1 per day memantine hcl tab 5 mg (28) & 10 mg (21) titration pak NAMENDA TITRATION K BRAND 2 ANTIDEPREANT ANTIDEPREANT, OTHER bupropion hcl (tab 75 mg, tab 100 mg) 3 per day bupropion hcl (tab sr 100 mg, tab sr 150 mg, tab sr 200 mg) bupropion hcl (tab sr 24hr 150 mg, tab sr 24hr 300 mg) mirtazapine (orally disintegrating tab 15 mg, orally disintegrating tab 30 mg, orally disintegrating tab 45 mg, tab 7.5 mg, tab 15 mg, tab 30 mg, tab 45 mg) 2 per day 1 per day 1 per day perphenazine-amitriptyline 4 per day WELLBUTRIN R (R TAB ER 12H 150 MG, R TAB ER 12H 100 MG) BRAND 3 2 per day WELLBUTRIN TAB 75 MG BRAND 3 3 per day MONOAMINE OXIDAE INHIBITOR EMAM (9 MG/24HR, TCH 24HR 6 MG/24HR, TCH 24HR 9 MG/24HR, TCH 24HR 12 MG/24HR) BRAND 3 1 per day MARPLAN BRAND 2 6 per day phenelzine sulfate tranylcypromine sulfate RI/NRI (ELECTIVE EROTONIN REUPTAKE INHIBITOR/EROTONIN AND NOREPINEPHRINE REUPTAKE INHIBITOR BRINTELLIX BRAND 3 1 per day citalopram hydrobromide (tab 10 mg, tab 20 mg) 1.5 per day citalopram hydrobromide oral soln 10 mg/5ml MD1 600 ML / 30 DAY GE 26 LAT UPDATED 05/2016

28 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION citalopram hydrobromide tab 40 mg (base equiv) 1 per day escitalopram oxalate (tab 5 mg, tab 10 mg) 1.5 per day escitalopram oxalate soln 5 mg/5ml (base equiv) MD1 600 ML / 30 DAY escitalopram oxalate tab 20 mg (base equiv) 1 per day fluoxetine hcl (cap 10 mg, tab 10 mg, tab 60 mg) 1 per day fluoxetine hcl (cap 20 mg, tab 20 mg) 3 per day fluoxetine hcl (pmdd) cap 10 mg 1 per day fluoxetine hcl (pmdd) cap 20 mg 3 per day fluoxetine hcl cap 40 mg 2 per day fluoxetine hcl solution 20 mg/5ml MD1 600 ML / 30 DAY fluvoxamine maleate (tab 25 mg, tab 50 mg) 2 per day fluvoxamine maleate tab 100 mg 3 per day maprotiline hcl generic 3 nefazodone hcl generic 3 OLEPTRO BRAND 3 T 1 per day paroxetine hcl (tab 10 mg, tab 20 mg, tab 40 mg) 1 per day paroxetine hcl (tab sr 24hr 37.5 mg, tab sr 24hr 25 mg) 2 per day paroxetine hcl oral susp 10 mg/5ml (base equiv) generic 3 MD1 900 ML / 30 DAY paroxetine hcl tab 30 mg 2 per day paroxetine hcl tab sr 24hr 12.5 mg 1 per day XIL UPENION 10 MG/5ML BRAND 3 MD1 900 ML / 30 DAY GE 27 LAT UPDATED 05/2016

29 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION PRITIQ TAB ER 24H 100 MG BRAND 2 PRITIQ TAB ER 24H 25 MG BRAND 2 PRITIQ TAB ER 24H 50 MG BRAND 2 T T T 4 per day 1 per day 1 per day sertraline hcl (tab 25 mg, tab 50 mg) 1.5 per day sertraline hcl oral conc 20 mg/ml MD1 300 ML / 30 DAY sertraline hcl tab 100 mg 2 per day trazodone hcl (tab 50 mg, tab 100 mg, tab 150 mg, tab 300 mg) venlafaxine hcl (cap sr 24hr 150 mg, tab sr 24hr 150 mg) venlafaxine hcl (cap sr 24hr 37.5 mg, cap sr 24hr 75 mg, tab sr 24hr 75 mg, tab sr 24hr 37.5 mg) venlafaxine hcl (tab 25 mg, tab 37.5 mg, tab 50 mg, tab 75 mg, tab 100 mg) VENLAFAXINE HCL ER (ER TAB ER 24H 37.5 MG, ER TAB ER 24H 75 MG) 2 per day 1 per day 3 per day BRAND 3 1 per day VENLAFAXINE HCL ER TAB ER 24H 150 MG BRAND 1 2 per day VENLAFAXINE HCL ER TAB ER 24H 225 MG BRAND 1 1 per day VIIBRYD (TAB 10 MG, TAB 20 MG, TAB 40 MG) BRAND 2 1 per day VIIBRYD KIT 10 & 20 & 40 MG BRAND 2 MD1 1 / 365 DAY TRICYCLIC amitriptyline hcl (tab 10 mg, tab 25 mg, tab 50 mg, tab 75 mg, tab 100 mg, tab 150 mg) amoxapine generic 3 clomipramine hcl desipramine hcl (tab 10 mg, tab 25 mg, tab 50 mg, tab 75 mg, tab 100 mg, tab 150 mg) doxepin hcl (cap 10 mg, cap 25 mg, cap 50 mg, cap 75 mg, cap 100 mg, cap 150 mg, conc 10 mg/ml) GE 28 LAT UPDATED 05/2016

30 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION imipramine hcl (tab 10 mg, tab 25 mg, tab 50 mg) imipramine pamoate nortriptyline hcl (cap 10 mg, cap 25 mg, cap 50 mg, cap 75 mg) protriptyline hcl trimipramine maleate (cap 25 mg, cap 50 mg, cap 100 mg) ANTIEMETIC ANTIEMETIC, OTHER meclizine hcl (tab 12.5 mg, tab 25 mg) metoclopramide hcl (tab 5 mg, tab 10 mg) metoclopramide hcl inj 5 mg/ml C 6 per day LIMIT = 84 DAY UPPLY PER 365 DAY metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) C 60 per day LIMIT = 84 DAY UPPLY PER 365 DAY perphenazine prochlorperazine prochlorperazine maleate (tab 5 mg, tab 10 mg) TRANDERM-COP BRAND 2 trimethobenzamide hcl cap 300 mg EMETOGENIC THERAPY ADJUNCT ALOXI BRAND 3 ANZEMET (TAB 50 MG, TAB 100 MG) BRAND 3 MD1 5 / 30 DAY ANZEMET OLUTION 20 MG/ML BRAND 3 CEAMET BRAND 3 dronabinol EMEND (CAP 40 MG, CAP 125 MG) BRAND 2 MD1 2 / 30 DAY GE 29 LAT UPDATED 05/2016

31 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION EMEND CAP 80 MG BRAND 2 MD1 4 / 30 DAY granisetron hcl (inj 0.1 mg/ml, inj 1 mg/ml) granisetron hcl tab 1 mg MD1 10 / 30 DAY ondansetron MD1 30 / 30 DAY ondansetron hcl (tab 4 mg, tab 8 mg) MD1 30 / 30 DAY ondansetron hcl inj 4 mg/2ml (2 mg/ml) ondansetron hcl oral soln 4 mg/5ml MD1 100 ML / 30 DAY ondansetron hcl tab 24 mg MD1 4 / 28 DAY ANTIFUNGAL ABELCET BRAND 3 AMBIOME BRAND 3 AMPHOTEC RECON UP 50 MG BRAND 3 amphotericin b for inj 50 mg generic 3 CANCIDA BRAND 3 ciclopirox & vitamin e ciclopirox (gel 0.77%, shampoo 1%, solution 8%) ciclopirox olamine (cream, susp) clotrimazole (topical) (cream, soln) clotrimazole troche 10 mg econazole nitrate ERAXI (50 MG, RECON OLN 50 MG, 100 MG, RECON OLN 100 MG) BRAND 3 ERTACZO BRAND 3 MPL 1 / 30 days EXELDERM (CREAM 1 %, OLUTION 1 %) BRAND 3 MPL 1 / 30 days fluconazole (for susp 10 mg/ml, for susp 40 mg/ml, tab 50 mg, tab 100 mg, tab 150 mg, tab 200 mg) flucytosine griseofulvin microsize susp 125 mg/5ml T AL At least 2 yrs old GE 30 LAT UPDATED 05/2016

32 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION griseofulvin microsize tab 500 mg griseofulvin ultramicrosize GYNAZOLE-1 BRAND 3 itraconazole cap 100 mg ketoconazole (topical) (cream, shampoo) ketoconazole tab 200 mg 4 per day MENTAX BRAND 2 MPL 1 / 30 days MICONAZOLE 3 BRAND 3 MYCAMINE BRAND 3 NAFTIFINE HCL CREAM 1 % BRAND 1 MPL 1 / 30 days NAFTIN (CREAM 1 %, CREAM 2 %, GEL 1 %) BRAND 3 MPL 1 / 30 days NATACYN BRAND 2 MPL 1 / 30 days NOXAFIL UPENION 40 MG/ML BRAND 3 MD1 600 ML / 30 DAY nystatin (mouth-throat) nystatin (topical) (*nystatin topical powder**, nystatin cream unit/gm, nystatin oint unit/gm) nystatin tab unit nystatin-triamcinolone OXITAT (CREAM 1 %, LOTION 1 %) BRAND 2 MPL 1 / 30 days PORANOX OLUTION 10 MG/ML BRAND 3 MD1 600 ML / 30 DAY terbinafine hcl tab 250 mg 1 per day terconazole vaginal (cream 0.4%, cream 0.8%, suppos 80 mg) MPL 1 / Claim voriconazole (tab 50 mg, tab 200 mg) 4 per day ANTIGOUT AGENT allopurinol COLCHICINE TAB 0.6 MG BRAND 2 C QL: 6 caps/claim GE 31 LAT UPDATED 05/2016

33 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION colchicine tab 0.6 mg generic 2 C QL: 6 caps/claim colchicine w/ probenecid COLCRY BRAND 2 C QL: 6 caps/claim probenecid ULORIC BRAND 3 1 per day ANTIMIGRAINE AGENT ERGOT ALKALOID CAFERGOT BRAND 2 D.H.E. 45 BRAND 2 dihydroergotamine mesylate inj 1 mg/ml dihydroergotamine mesylate nasal spray 4 mg/ml T MD1 8 ML / 30 DAY ERGOMAR BRAND 3 MD1 20 / 30 DAY MIGRANAL BRAND 2 T MD1 8 ML / 30 DAY EROTONIN (5-HT) 1B/1D RECEPTOR AGONIT T AXERT TAB 12.5 MG BRAND 3 AL At least 12 yrs old MD1 12 / 30 DAY T AXERT TAB 6.25 MG BRAND 3 AL At least 12 yrs old MD1 9 / 30 DAY T FROVA BRAND 3 IMITREX (OLUTION 5, OLUTION 20) BRAND 1 naratriptan hcl AL At least 18 yrs old MD1 12 / 30 DAY AL At least 18 yrs old MD1 6 / 30 DAY AL At least 18 yrs old MD1 9 / 30 DAY GE 32 LAT UPDATED 05/2016

34 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION T RELX BRAND 3 AL At least 18 yrs old MD1 6 / 30 DAY rizatriptan benzoate (orally disintegrating tab 10 mg, tab 10 mg) rizatriptan benzoate (orally disintegrating tab 5 mg, tab 5 mg) AL At least 6 yrs old MD1 18 / 30 DAY AL At least 6 yrs old MD1 12 / 30 DAY sumatriptan (5, 20) AL At least 18 yrs old MD1 6 / 30 DAY sumatriptan succinate (inj 6, solution autoinjector 4, solution auto-injector 6, solution cartridge 4, solution cartridge 6, solution prefilled syringe 4, solution prefilled syringe 6) sumatriptan succinate (tab 25 mg, tab 50 mg, tab 100 mg) AL At least 18 yrs old MD1 4 / 30 DAY AL At least 18 yrs old MD1 9 / 30 DAY sumatriptan succinate inj 4 mg/0.5ml AL MPL At least 18 yrs old 2 / 30 days zolmitriptan (orally disintegrating tab 2.5 mg, orally disintegrating tab 5 mg, tab 2.5 mg, tab 5 mg) T AL At least 12 yrs old MD1 9 / 30 DAY ZOMIG (OLUTION 2.5 MG, OLUTION 5 MG) BRAND 2 T AL At least 12 yrs old MD1 6 / 30 DAY T ZOMIG (TAB 2.5 MG, TAB 5 MG) BRAND 2 AL At least 12 yrs old MD1 9 / 30 DAY T ZOMIG ZMT BRAND 2 AL At least 12 yrs old MD1 9 / 30 DAY GE 33 LAT UPDATED 05/2016

35 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION ANTIMYATHENIC AGENT RAYMTHOMIMETIC guanidine hcl generic 2 METINON (YRUP 60 MG/5ML, TAB ER 180 MG) BRAND 2 MYTELAE BRAND 3 pyridostigmine bromide ANTIMYCOBACTERIAL ANTIMYCOBACTERIAL, OTHER MYCOBUTIN BRAND 3 rifabutin ANTITUBERCULAR CATAT ULFATE BRAND 3 CYCLOERINE BRAND 3 4 per day ethambutol hcl (tab 100 mg, tab 400 mg) isoniazid (inj 100 mg/ml, tab 100 mg, tab 300 mg) IONIAZID YRUP 50 MG/5ML BRAND 1 ER BRAND 3 3 per day PRIFTIN BRAND 3 pyrazinamide RIFAMATE BRAND 3 rifampin (cap 150 mg, cap 300 mg, for inj 600 mg) RIFATER BRAND 3 6 per day EROMYCIN BRAND 3 4 per day TRECATOR BRAND 3 4 per day GE 34 LAT UPDATED 05/2016

36 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION ANTINEOPLATIC ALKYLATING AGENT ALKERAN TAB 2 MG BRAND 2 BICNU BRAND 4 BUULFEX BRAND 4 CEENU BRAND 4 cyclophosphamide generic 4 dacarbazine for inj 200 mg generic 4 DAUNOXOME BRAND 4 HEXALEN BRAND 4 IFEX RECON OLN 1 GM BRAND 4 ifosfamide & mesna generic 4 pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug ifosfamide (for inj 1 gm, iv inj 1 gm/20ml (50 mg/ml)) generic 4 pecialty Drug LEUKERAN BRAND 4 lomustine generic 4 MATULANE BRAND 4 pecialty Drug pecialty Drug pecialty Drug GE 35 LAT UPDATED 05/2016

37 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION melphalan hcl MUTARGEN BRAND 4 MYLERAN BRAND 4 TEMODAR BRAND 4 temozolomide generic 4 pecialty Drug pecialty Drug pecialty Drug pecialty Drug TREANDA (RECON OLN 25 MG, RECON OLN 100 MG) BRAND 4 pecialty Drug ZANOAR BRAND 4 pecialty Drug ANTIANDROGEN bicalutamide generic 4 CAODEX BRAND 4 flutamide generic 4 pecialty Drug pecialty Drug pecialty Drug NILANDRON BRAND 3 2 per day XTANDI BRAND 4 ZYTIGA BRAND 4 pecialty Drug pecialty Drug ANTIANGIOGENIC AGENT REVLIMID (CAP 2.5 MG, CAP 5 MG, CAP 10 MG, CAP 15 MG, CAP 25 MG) BRAND 4 pecialty Drug THALOMID BRAND 4 pecialty Drug GE 36 LAT UPDATED 05/2016

38 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION ANTIETROGEN/MODIFIER EMCYT BRAND 4 pecialty Drug FARETON BRAND 2 FALODEX (125 MG/2.5ML, OLUTION 250 MG/5ML) BRAND 4 pecialty Drug OLTAMOX BRAND 3 tamoxifen citrate (tab 10 mg, tab 20 mg) generic 0 ANTIMETABOLITE ALIMTA RECON OLN 500 MG BRAND 4 capecitabine generic 4 cladribine generic 4 CLOLAR BRAND 4 pecialty Drug pecialty Drug pecialty Drug cytarabine (for inj 100 mg, for inj 500 mg, inj pf 20 mg/ml, inj pf 100 mg/ml) generic 4 pecialty Drug DEPOCYT BRAND 4 DROXIA BRAND 3 floxuridine for inj 0.5 gm generic 4 fluorouracil inj 500 mg/10ml (50 mg/ml) generic 4 FOLOTYN OLUTION 20 MG/ML BRAND 4 gemcitabine hcl (inj 2 gm, inj 200 mg) generic 4 GEMZAR RECON OLN 200 MG BRAND 4 pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug GE 37 LAT UPDATED 05/2016

39 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION HYDREA BRAND 3 hydroxyurea mercaptopurine NIPENT BRAND 4 pentostatin generic 4 PURINETHOL BRAND 3 TABLOID BRAND 4 XELODA BRAND 4 pecialty Drug pecialty Drug pecialty Drug pecialty Drug ANTINEOPLATIC, OTHER ABRAXANE BRAND 4 ARRANON BRAND 4 azacitidine generic 4 bleomycin sulfate for inj 15 unit generic 4 CAMTH BRAND 4 pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug CAMPTOAR (OLUTION 40 MG/2ML, OLUTION 100 MG/5ML) BRAND 4 pecialty Drug carboplatin iv soln 50 mg/5ml generic 4 CERUBIDINE BRAND 4 pecialty Drug pecialty Drug GE 38 LAT UPDATED 05/2016

40 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION cisplatin inj 100 mg/100ml (1 mg/ml) generic 4 COMEGEN BRAND 4 DACOGEN BRAND 4 dactinomycin generic 4 pecialty Drug pecialty Drug pecialty Drug pecialty Drug daunorubicin hcl (for inj 20 mg, inj 5 mg/ml (base equiv)) generic 4 pecialty Drug decitabine generic 4 DOCEFREZ BRAND 4 pecialty Drug pecialty Drug DOCETAXEL (CONC 20 MG/ML, CONC 20 MG/0.5ML, OLUTION 20 MG/2ML) BRAND 4 pecialty Drug docetaxel (inj conc 20 mg/ml, inj conc 20 mg/0.5ml (40 mg/ml), soln iv infusion 20 mg/2ml) generic 4 pecialty Drug DOXIL BRAND 4 pecialty Drug doxorubicin hcl (for inj 10 mg, for inj 50 mg, inj 2 mg/ml) generic 4 pecialty Drug DOXORUBICIN HCL (RECON OLN 10 MG, RECON OLN 50 MG) BRAND 4 pecialty Drug doxorubicin hcl liposomal generic 4 pecialty Drug ELOXATIN (OLUTION 50 MG/10ML, OLUTION 100 MG/20ML) BRAND 4 pecialty Drug ELR BRAND 4 pecialty Drug GE 39 LAT UPDATED 05/2016

41 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION epirubicin hcl (inj 50, iv soln 50) generic 4 ERWINAZE BRAND 4 FLUDARA BRAND 4 pecialty Drug pecialty Drug pecialty Drug fludarabine phosphate (for inj 50 mg, inj 25 mg/ml) generic 4 pecialty Drug HALAVEN BRAND 4 pecialty Drug IDAMYCIN PF (OLUTION 5 MG/5ML, OLUTION 10 MG/10ML) BRAND 4 pecialty Drug idarubicin hcl (inj 5 mg/5ml, inj 10 mg/10ml) generic 4 irinotecan hcl (inj 40 mg/2ml, inj 100 mg/5ml) generic 4 ITODAX BRAND 4 IXEMPRA KIT RECON OLN 15 MG BRAND 4 JEVTANA BRAND 4 pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug leucovorin calcium (for inj 50 mg, for inj 100 mg, for inj 200 mg, for inj 350 mg, for inj 500 mg, inj 10 mg/ml, tab 5 mg, tab 10 mg, tab 15 mg, tab 25 mg) LEUCOVORIN CALCIUM RECON OLN 50 MG BRAND 1 LYODREN BRAND 4 mitomycin for inj 20 mg generic 4 pecialty Drug pecialty Drug GE 40 LAT UPDATED 05/2016

42 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/ml) generic 4 pecialty Drug NAVELBINE OLUTION 10 MG/ML BRAND 4 OFORTA BRAND 4 ONCAR BRAND 4 ONTAK BRAND 4 oxaliplatin (soln50mg/10ml, soln100mg/20ml) generic 4 pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug paclitaxel (conc 100 mg/16.7ml, conc 150 mg/25ml) generic 4 pecialty Drug PHOTOFRIN BRAND 4 PROLEUKIN BRAND 4 YLATRON BRAND 4 YNRIBO BRAND 4 pecialty Drug pecialty Drug pecialty Drug pecialty Drug TAXOTERE (CONC 20 MG/0.5ML, CONC 20 MG/ML) BRAND 4 pecialty Drug TENIPOIDE BRAND 4 thiotepa generic 4 TRIENOX BRAND 4 pecialty Drug pecialty Drug pecialty Drug GE 41 LAT UPDATED 05/2016

43 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION UVADEX BRAND 4 VALTAR BRAND 4 VELCADE BRAND 4 VIDAZA BRAND 4 vinblastine sulfate for inj 10 mg generic 4 vincristine sulfate generic 4 pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug vinorelbine tartrate (inj 10 mg/ml, inj 10 mg/ml (base equiv)) generic 4 pecialty Drug VORAXAZE BRAND 4 VUMON BRAND 4 ZALTRAP OLUTION 100 MG/4ML BRAND 4 ZOLINZA BRAND 4 pecialty Drug pecialty Drug pecialty Drug pecialty Drug AROMATAE INHIBITOR, 3RD GENERATION anastrozole tab 1 mg ARIMIDEX BRAND 4 AROMAIN BRAND 4 pecialty Drug exemestane generic 4 pecialty Drug FEMARA BRAND 4 GE 42 LAT UPDATED 05/2016

44 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION letrozole tab 2.5 mg ENZYME INHIBITOR ETOPOPHO BRAND 4 pecialty Drug etoposide (cap 50 mg, inj 1 gm/50ml (20 mg/ml), inj 100mg/5ml (20 mg/ml), inj 500mg/25ml (20 mg/ml)) generic 4 pecialty Drug HYCAMTIN BRAND 4 topotecan hcl for inj 4 mg generic 4 pecialty Drug pecialty Drug MOLECULAR TARGET INHIBITOR AFINITOR BRAND 4 BOULIF BRAND 4 CAPRELA BRAND 4 COMETRIQ (100 MG DAILY DOE) BRAND 4 COMETRIQ (140 MG DAILY DOE) BRAND 4 COMETRIQ (60 MG DAILY DOE) BRAND 4 ERIVEDGE BRAND 4 GLEEVEC BRAND 4 imatinib mesylate generic 4 pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug GE 43 LAT UPDATED 05/2016

45 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION INLYTA BRAND 4 JAKAFI BRAND 4 KYPROLI BRAND 4 NEXAVAR BRAND 4 pecialty Drug pecialty Drug pecialty Drug pecialty Drug NINLARO BRAND 4 MD1 4 / 28.0 DAY PRYCEL BRAND 4 TIVARGA BRAND 4 pecialty Drug pecialty Drug UTENT (CAP 12.5 MG, CAP 25 MG, CAP 50 MG) BRAND 4 pecialty Drug TARCEVA BRAND 4 TAIGNA BRAND 4 TORIEL BRAND 4 TYKERB BRAND 4 VANDETANIB BRAND 4 VOTRIENT BRAND 4 XALKORI BRAND 4 pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug GE 44 LAT UPDATED 05/2016

46 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION ZELBORAF BRAND 4 pecialty Drug MONOCLONAL ANTIBODIE ADCETRI BRAND 4 ARZERRA BRAND 4 AVATIN OLUTION 100 MG/4ML BRAND 4 BEXXAR BRAND 4 ERBITUX BRAND 4 HERCEPTIN BRAND 4 PERJETA BRAND 4 RITUXAN BRAND 4 VECTIBIX OLUTION 100 MG/5ML BRAND 4 YERVOY BRAND 4 pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug RETINOID bexarotene generic 4 NRETIN BRAND 3 MPL 1 / 30 days pecialty Drug TARGRETIN CAP 75 MG BRAND 4 MPL 1 / 30 days pecialty Drug GE 45 LAT UPDATED 05/2016

47 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION TARGRETIN GEL 1 % BRAND 4 tretinoin (chemotherapy) ANTIRAITIC ANTIHELMINTHIC ALBENZA BRAND 3 BILTRICIDE BRAND 3 ivermectin mebendazole chew tab 100 mg KLICE BRAND 3 TROMECTOL BRAND 3 pecialty Drug ANTIPROTOZOAL ALINIA (RECON UP 100 MG/5ML, TAB 500 MG) BRAND 2 atovaquone susp 750 mg/5ml atovaquone-proguanil hcl chloroquine phosphate (tab 250 mg, tab 500 mg) COARTEM BRAND 2 MD1 12 / 3 DAY C Limit of 3 claims every 180 days MD1 24 / 3 DAY C Limit of 3 claims every 180 days DARAPRIM BRAND 3 3 per day hydroxychloroquine sulfate MALARONE BRAND 2 MD1 12 / 3 DAY C Limit of 3 claims every 180 days mefloquine hcl MEPRON BRAND 3 NEBUPENT BRAND 3 PENTAM BRAND 3 PRIMAQUINE PHOPHATE TAB 26.3 MG BRAND 3 GE 46 LAT UPDATED 05/2016

48 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION primaquine phosphate tab 26.3 mg (15 mg base) generic 3 quinine sulfate cap 324 mg MD1 84 / 365 DAY PEDICULICIDE/CABICIDE EURAX BRAND 3 lindane generic 3 malathion NATROBA BRAND 1 permethrin PINOAD BRAND 2 ULEFIA BRAND 3 ANTIRKINON AGENT ANTICHOLINERGIC benztropine mesylate (inj 1 mg/ml, tab 0.5 mg, tab 1 mg, tab 2 mg) trihexyphenidyl hcl (elixir 0.4 mg/ml, tab 2 mg, tab 5 mg) ANTIRKINON AGENT, OTHER amantadine hcl (cap 100 mg, syrup 50 mg/5ml, tab 100 mg) CARBIDO-LEVODO-ENTACAPONE (TAB MG, TAB MG, TAB MG, TAB MG, TAB MG, TAB MG) carbidopa-levodopa-entacapone (tabs mg, tabs mg, tabs mg, tabs mg, tabs mg, tabs mg) BRAND 1 entacapone 8 per day TALEVO 100 BRAND 1 TALEVO 125 BRAND 1 TALEVO 150 BRAND 1 TALEVO 200 BRAND 1 TALEVO 50 BRAND 1 GE 47 LAT UPDATED 05/2016

49 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION TALEVO 75 BRAND 1 TAMAR BRAND 3 DOMINE AGONIT APOKYN BRAND 4 bromocriptine mesylate (cap 5 mg, tab 2.5 mg) NEUPRO BRAND 2 pecialty Drug pramipexole dihydrochloride (tab 0.25 mg, tab 0.5 mg, tab 0.75 mg, tab 1 mg, tab 1.5 mg) pramipexole dihydrochloride tab mg 4 per day ropinirole hydrochloride (tab 0.25 mg, tab 0.5 mg, tab 1 mg, tab 2 mg, tab 3 mg, tab 4 mg, tab 5 mg) ropinirole hydrochloride (tab sr 24hr 12 mg, tab sr 24hr 8 mg) T 2 per day ropinirole hydrochloride (tab sr 24hr 2 mg, tab sr 24hr 4 mg, tab sr 24hr 6 mg) T 1 per day DOMINE PRECUROR/L-AMINO ACID DECARBOXYLAE INHIBITOR carbidopa carbidopa-levodopa LODOYN BRAND 1 MONOAMINE OXIDAE B (MAO-B) INHIBITOR AZILECT BRAND 2 selegiline hcl (cap 5 mg, tab 5 mg) ANTIPYCHOTIC 1 per day 1T GENERATION/TYPICAL chlorpromazine hcl (inj 25 mg/ml, inj 50 mg/2ml) chlorpromazine hcl (tab 10 mg, tab 25 mg, tab 50 mg, tab 100 mg, tab 200 mg) generic 3 GE 48 LAT UPDATED 05/2016

50 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION fluphenazine hcl (elixir 2.5 mg/5ml, inj 2.5 mg/ml, oral conc 5 mg/ml, tab 1 mg, tab 2.5 mg, tab 5 mg, tab 10 mg) haloperidol haloperidol decanoate MFL 1 / 28 days haloperidol lactate inj 5 mg/ml loxapine succinate ORAP BRAND 3 pimozide thioridazine hcl thiothixene trifluoperazine hcl (tab 1 mg, tab 2 mg, tab 5 mg, tab 10 mg) 2ND GENERATION/ATYPICAL aripiprazole oral solution 1 mg/ml generic 3 AL At least 6 yrs old MD1 900 ML / 30 DAY FANAPT BRAND 2 FANAPT TITRATION CK BRAND 2 MPL 2 per day 2 / 365 days INVEGA (TAB ER 24H 1.5 MG, TAB ER 24H 3 MG, TAB ER 24H 9 MG) BRAND 2 1 per day INVEGA TAB ER 24H 6 MG BRAND 2 LATUDA BRAND 3 2 per day 1 per day olanzapine (tab 15 mg, tab 20 mg) 2 per day olanzapine (tab 2.5 mg, tab 5 mg, tab 7.5 mg, tab 10 mg) 1 per day olanzapine for im inj 10 mg MD1 6 / 28 DAY GE 49 LAT UPDATED 05/2016

51 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION quetiapine fumarate RIPERDAL CONTA BRAND 2 AL MFL At least 10 yrs old 2 per day 2 / 28 days risperidone (tab 0.25 mg, tab 0.5 mg, tab 1 mg, tab 2 mg, tab 3 mg) 2 per day risperidone (tab 0.25 mg, tab 0.5 mg, tab 1 mg, tab 2 mg, tab 3 mg, tab 4 mg) 2 per day risperidone soln 1 mg/ml MD1 240 ML / 30 DAY risperidone tab 4 mg 4 per day APHRI (L TAB 5 MG, L TAB 10 MG) BRAND 2 2 per day EROQUEL XR (TAB ER 24H 400 MG, TAB ER 24H 300 MG) BRAND 2 AL At least 10 yrs old 2 per day EROQUEL XR (TAB ER 24H 50 MG, TAB ER 24H 200 MG, TAB ER 24H 150 MG) BRAND 2 AL At least 10 yrs old 1 per day ziprasidone hcl AL At least 18 yrs old 2 per day TREATMENT-REITANT clozapine (tab 25 mg, tab 50 mg, tab 100 mg, tab 200 mg) ANTIVIRAL ANTI-CYTOMEGALOVIRU (CMV) AGENT cidofovir iv inj 75 mg/ml generic 3 FOCAVIR BRAND 3 ganciclovir sodium VALCYTE RECON OLN 50 MG/ML BRAND 2 MD1 540 ML / 30 DAY GE 50 LAT UPDATED 05/2016

52 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION VALCYTE TAB 450 MG BRAND 2 valganciclovir hcl VITIDE BRAND 3 ZIRGAN BRAND 2 ANTI-HETITI B (HBV) AGENT adefovir dipivoxil generic 4 4 per day 4 per day 1 per day pecialty Drug BARACLUDE (TAB 0.5 MG, TAB 1 MG) BRAND 4 1 per day pecialty Drug BARACLUDE OLUTION 0.05 MG/ML BRAND 4 MD1 600 ML / 30 DAY pecialty Drug entecavir generic 4 1 per day pecialty Drug EPIVIR HBV OLUTION 5 MG/ML BRAND 4 MD ML / 30 DAY pecialty Drug EPIVIR HBV TAB 100 MG BRAND 4 3 per day pecialty Drug HEPERA BRAND 4 1 per day pecialty Drug lamivudine (hbv) 3 per day pecialty Drug GE 51 LAT UPDATED 05/2016

53 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION TYZEKA BRAND 4 1 per day pecialty Drug ANTI-HETITI C (HCV) AGENT HARVONI BRAND 4 1 per day pecialty Drug INCIVEK BRAND 4 INFERGEN BRAND 4 INTRON A RECON OLN UNIT BRAND 4 6 per day pecialty Drug pecialty Drug pecialty Drug PEG-INTRON BRAND 4 MD1 4 / 28 DAY pecialty Drug PEG-INTRON REDIPEN BRAND 4 MD1 4 / 28 DAY pecialty Drug PEG-INTRON REDIPEN K 4 BRAND 4 MD1 4 / 28 DAY pecialty Drug PEGAY KIT 180 MCG/0.5ML BRAND 4 MD1 1 / 28 DAY pecialty Drug PEGAY PROCLICK BRAND 4 MPL 2 / 28 days pecialty Drug PEGAY OLUTION 180 MCG/0.5ML BRAND 4 MPL 2 / 28 days pecialty Drug GE 52 LAT UPDATED 05/2016

54 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION PEGAY OLUTION 180 MCG/ML BRAND 4 MPL 4 / 28 days pecialty Drug PEGINTRON BRAND 4 MD1 4 / 28 DAY pecialty Drug REBETOL OLUTION 40 MG/ML BRAND 4 MD ML / 30 DAY pecialty Drug ribavirin (hepatitis c) 7 per day OVALDI BRAND 4 1 per day pecialty Drug VICTRELI BRAND 4 12 per day pecialty Drug ANTI-HIV AGENT, INTEGRAE INHIBITOR (INTI) IENTRE (CHEW TAB 25 MG, CHEW TAB 100 MG) BRAND 2 IENTRE TAB 400 MG BRAND 2 2 per day TRIBILD BRAND 3 1 per day ANTI-HIV AGENT, NON-NUCLEOIDE REVERE TRANCRIPTAE INHIBITOR (NNRTI) ATRIPLA BRAND 3 1 per day COMPLERA BRAND 3 1 per day EDURANT BRAND 2 1 per day INTELENCE TAB 100 MG BRAND 2 4 per day INTELENCE TAB 200 MG BRAND 2 2 per day INTELENCE TAB 25 MG BRAND 2 8 per day GE 53 LAT UPDATED 05/2016

55 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION nevirapine susp 50 mg/5ml MD ML / 30 DAY nevirapine tab 200 mg 2 per day nevirapine tab sr 24hr 400 mg 1 per day RECRIPTOR TAB 100 MG BRAND 2 12 per day RECRIPTOR TAB 200 MG BRAND 2 6 per day UTIVA CAP 200 MG BRAND 2 2 per day UTIVA CAP 50 MG BRAND 2 3 per day UTIVA TAB 600 MG BRAND 2 1 per day VIRAMUNE UPENION 50 MG/5ML BRAND 2 MD ML / 30 DAY VIRAMUNE XR TAB ER 24H 100 MG BRAND 2 3 per day VIRAMUNE XR TAB ER 24H 400 MG BRAND 2 1 per day ANTI-HIV AGENT, NUCLEOIDE AND NUCLEOTIDE REVERE TRANCRIPTAE INHIBITOR (NRTI) abacavir sulfate 2 per day abacavir sulfate-lamivudine-zidovudine 2 per day didanosine (capsule 125 mg, capsule 200 mg) 2 per day didanosine (capsule 250 mg, capsule 400 mg) 1 per day EMTRIVA CAP 200 MG BRAND 2 1 per day EMTRIVA OLUTION 10 MG/ML BRAND 2 EPIVIR OLUTION 10 MG/ML BRAND 3 MD1 900 ML / 30 DAY EPIVIR TAB 150 MG BRAND 3 2 per day EPIVIR TAB 300 MG BRAND 3 1 per day EPZICOM BRAND 2 1 per day lamivudine oral soln 10 mg/ml MD1 900 ML / 30 DAY lamivudine tab 150 mg 2 per day lamivudine tab 300 mg 1 per day lamivudine-zidovudine 2 per day GE 54 LAT UPDATED 05/2016

56 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION RETROVIR OLUTION 10 MG/ML BRAND 1 stavudine (cap 15 mg, cap 20 mg, cap 30 mg, cap 40 mg) 2 per day stavudine for oral soln 1 mg/ml MD ML / 30 DAY TRIZIVIR BRAND 2 2 per day TRUVADA BRAND 2 VIDEX BRAND 2 VIREAD (POWDER 40 MG/GM, TAB 300 MG) BRAND 2 1 per day VIREAD (TAB 150 MG, TAB 200 MG, TAB 250 MG) BRAND 2 1 per day ZIAGEN OLUTION 20 MG/ML BRAND 2 zidovudine cap 100 mg 6 per day zidovudine syrup 10 mg/ml MD ML / 30 DAY zidovudine tab 300 mg 2 per day ANTI-HIV AGENT, OTHER FUZEON BRAND 4 MPL 1 / 30 days pecialty Drug ELZENTRY TAB 150 MG BRAND 2 2 per day ELZENTRY TAB 300 MG BRAND 2 4 per day TRIUMEQ BRAND 3 1 per day TYBOT BRAND 2 1 per day ANTI-HIV AGENT, PROTEAE INHIBITOR APTIVU CAP 250 MG BRAND 2 4 per day APTIVU OLUTION 100 MG/ML BRAND 2 MD1 300 ML / 30 DAY CRIXIVAN CAP 200 MG BRAND 2 9 per day CRIXIVAN CAP 400 MG BRAND 2 6 per day INVIRAE CAP 200 MG BRAND 2 10 per day GE 55 LAT UPDATED 05/2016

57 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION INVIRAE TAB 500 MG BRAND 2 4 per day KALETRA (TAB MG, TAB MG) BRAND 2 4 per day KALETRA OLUTION MG/5ML BRAND 2 MD1 375 ML / 30 DAY LEXIVA UPENION 50 MG/ML BRAND 2 MD ML / 30 DAY LEXIVA TAB 700 MG BRAND 2 4 per day NORVIR (CAP 100 MG, TAB 100 MG) BRAND 2 12 per day NORVIR OLUTION 80 MG/ML BRAND 2 MD1 450 ML / 30 DAY PREZITA (TAB 75 MG, TAB 150 MG, TAB 400 MG, TAB 600 MG) BRAND 2 2 per day PREZITA UPENION 100 MG/ML BRAND 2 MD1 360 ML / 30 DAY PREZITA TAB 800 MG BRAND 2 1 per day REYATAZ (CAP 150 MG, CAP 200 MG) BRAND 2 2 per day REYATAZ CAP 100 MG BRAND 2 4 per day REYATAZ CAP 300 MG BRAND 2 1 per day VIRACEPT TAB 250 MG BRAND 2 10 per day VIRACEPT TAB 625 MG BRAND 2 4 per day ANTI-INFLUENZA AGENT RELENZA DIKHALER BRAND 2 MPL 1 / 30 days rimantadine hydrochloride 2 per day TAMIFLU (CAP 45 MG, CAP 75 MG) BRAND 2 MD1 10 / 30 DAY TAMIFLU CAP 30 MG BRAND 2 MD1 20 / 30 DAY TAMIFLU RECON UP 6 MG/ML BRAND 2 MD1 120 ML / 30 DAY ANTIHERPETIC AGENT acyclovir (tab 400 mg, tab 800 mg) 5 per day acyclovir cap 200 mg MD1 50 / 30 DAY acyclovir susp 200 mg/5ml MD1 400 ML / 30 DAY acyclovir topical GE 56 LAT UPDATED 05/2016

58 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION DENAVIR BRAND 3 famciclovir (tab 125 mg, tab 250 mg) famciclovir tab 500 mg trifluridine 3 per day 4 per day valacyclovir hcl tab 1 gm 4 per day valacyclovir hcl tab 500 mg 2 per day ZOVIRAX CREAM 5 % BRAND 3 ANXIOLYTIC ANXIOLYTIC, OTHER buspirone hcl (tab 7.5 mg, tab 10 mg, tab 15 mg, tab 30 mg) buspirone hcl tab 5 mg 1 per day meprobamate BENZODIAZEPINE alprazolam (tab 0.25 mg, tab 0.5 mg, tab 1 mg, tab 2 mg) 4 per day clonazepam (tab 0.5 mg, tab 1 mg, tab 2 mg) diazepam (tab 2 mg, tab 5 mg, tab 10 mg) 4 per day lorazepam (tab 0.5 mg, tab 2 mg) 3 per day lorazepam tab 1 mg 4 per day BIPOLAR AGENT MOOD TABILIZER lithium lithium carbonate (cap 150 mg, cap 300 mg, cap 600 mg, tab 300 mg, tab cr 300 mg, tab cr 450 mg) GE 57 LAT UPDATED 05/2016

59 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION BLOOD GLUCOE REGULATOR ANTIDIABETIC AGENT acarbose 3 per day ACTOPLU MET BRAND 2 2 per day AVANDIA BRAND 3 1 per day BYETTA 10 MCG PEN BRAND 2 BYETTA 5 MCG PEN BRAND 2 MD1 1.2 ML / 30 DAY MD1 2.4 ML / 30 DAY chlorpropamide tab 100 mg 3 per day CYCLOET BRAND 3 6 per day glimepiride (tab 1 mg, tab 2 mg) 1 per day glimepiride tab 4 mg 2 per day glipizide (tab 5 mg, tab 10 mg) 4 per day glipizide (tab sr 24hr 2.5 mg, tab sr 24hr 5 mg, tab sr 24hr 10 mg) glipizide-metformin hcl (tab mg, tab mg) 2 per day 2 per day glipizide-metformin hcl tab mg 4 per day glyburide (tab 1.25 mg, tab 2.5 mg, tab 5 mg) 4 per day glyburide micronized 4 per day GLYBURIDE TAB 5 MG BRAND 1 4 per day glyburide-metformin (tab mg, tab mg) 2 per day glyburide-metformin tab mg 4 per day GLYET BRAND 3 3 per day INVOKANA BRAND 3 JANUVIA BRAND 2 1 per day 1 per day GE 58 LAT UPDATED 05/2016

60 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION metformin hcl (tab sr 24hr osmotic 1000 mg, tab sr 24hr 750 mg) 2 per day metformin hcl tab 1000 mg 2.5 per day metformin hcl tab 500 mg 5 per day metformin hcl tab 850 mg 3 per day metformin hcl tab sr 24hr 500 mg 4 per day nateglinide 3 per day ONGLYZA BRAND 3 1 per day pioglitazone hcl 1 per day pioglitazone hcl-metformin hcl 2 per day PRANDIMET BRAND 3 2 per day PRANDIN BRAND 3 4 per day repaglinide 4 per day YMLINPEN 120 BRAND 2 YMLINPEN 60 BRAND 2 MD ML / 30 DAY MD1 6 ML / 30 DAY tolazamide 4 per day tolbutamide 6 per day TRADJENTA BRAND 2 1 per day VICTOZA BRAND 2 MD1 9 ML / 30 DAY GLYCEMIC AGENT GLUCAGEN DIAGNOTIC BRAND 3 MPL 12 / 365 days GLUCAGEN HYPOKIT BRAND 3 MPL 12 / 365 days GLUCAGON EMERGENCY BRAND 3 MPL 12 / 365 days PROGLYCEM BRAND 3 GE 59 LAT UPDATED 05/2016

61 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION INULIN APIDRA BRAND 2 APIDRA OLOTAR BRAND 3 HUMALOG BRAND 2 HUMALOG KWIKPEN OLN PEN 100 UNIT/ML BRAND 2 HUMALOG MIX 50/50 BRAND 2 HUMALOG MIX 50/50 KWIKPEN BRAND 2 HUMALOG MIX 50/50 PEN BRAND 2 HUMALOG MIX 75/25 BRAND 2 HUMALOG MIX 75/25 KWIKPEN BRAND 2 HUMALOG MIX 75/25 PEN BRAND 2 HUMALOG PEN BRAND 2 HUMULIN 70/30 BRAND 2 HUMULIN 70/30 KWIKPEN BRAND 2 HUMULIN 70/30 PEN BRAND 2 HUMULIN N BRAND 2 HUMULIN N KWIKPEN BRAND 2 HUMULIN N PEN BRAND 2 HUMULIN R BRAND 2 HUMULIN R U-500 (CONCENTRATED) BRAND 2 LANTU BRAND 2 LANTU OLOTAR BRAND 2 LEVEMIR BRAND 2 LEVEMIR FLEXPEN BRAND 2 LEVEMIR FLEXTOUCH BRAND 2 NOVOLIN 70/30 BRAND 2 NOVOLIN 70/30 RELION BRAND 2 NOVOLIN N BRAND 2 NOVOLIN N RELION BRAND 2 NOVOLIN R BRAND 2 GE 60 LAT UPDATED 05/2016

62 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION NOVOLIN R RELION BRAND 2 NOVOLOG BRAND 2 NOVOLOG FLEXPEN BRAND 2 NOVOLOG MIX 70/30 BRAND 2 NOVOLOG MIX 70/30 FLEXPEN BRAND 2 NOVOLOG PENFILL BRAND 2 RELION 70/30 BRAND 2 RELION N BRAND 2 RELION R BRAND 2 BLOOD PRODUCT/MODIFIER/VOLUME EXNDER ANTICOAGULANT COUMADIN BRAND 2 ELIQUI BRAND 2 MD1 74 / 30 DAY enoxaparin sodium (inj 100 mg/ml, inj 150 mg/ml) generic 4 MD1 60 / 30 DAY pecialty Drug enoxaparin sodium (inj 80, inj 120) generic 4 enoxaparin sodium inj 30 mg/0.3ml generic 4 enoxaparin sodium inj 300 mg/3ml generic 4 enoxaparin sodium inj 40 mg/0.4ml generic 4 enoxaparin sodium inj 60 mg/0.6ml generic 4 MD1 48 / 30 DAY pecialty Drug MD1 18 ML / 30 DAY pecialty Drug MD1 180 ML / 30 DAY pecialty Drug MD1 24 ML / 30 DAY pecialty Drug MD1 36 ML / 30 DAY pecialty Drug fondaparinux sodium generic 4 C is required for treatment that is longer than 9 days every 180 days pecialty Drug GE 61 LAT UPDATED 05/2016

63 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION FRAGMIN (OLUTION 2500 UNIT/0.2ML, OLUTION 5000 UNIT/0.2ML, OLUTION 7500 UNIT/0.3ML, OLUTION UNIT/ML, OLUTION UNIT/0.5ML, OLUTION UNIT/0.6ML, OLUTION UNT/0.72ML, OLUTION UNIT/ML) BRAND 4 pecialty Drug HERIN (PORCINE) IN NACL (HER(PORCE) OLUTION , HER(PORCE) OLUTION ) heparin sodium (porcine) (inj 5000, inj 10000, inj 20000) BRAND 1 heparin sodium (porcine) 40 unit/ml in d5w PRADAXA (CAP 75 MG, CAP 150 MG) BRAND 2 2 per day warfarin sodium (tab 1 mg, tab 2 mg, tab 2.5 mg, tab 3 mg, tab 4 mg, tab 5 mg, tab 6 mg, tab 7.5 mg, tab 10 mg) XARELTO BRAND 2 1 per day BLOOD FORMATION MODIFIER anagrelide hcl ARANEP (ALBUMIN FREE) (OLN PRYR 150 MCG/0.3ML, OLN PRYR 200 MCG/0.4ML, OLN PRYR 300 MCG/0.6ML, OLN PRYR 500 MCG/ML, OLUTION 40 MCG/ML, OLUTION 60 MCG/ML, OLUTION 100 MCG/ML) BRAND 4 pecialty Drug ARANEP (ALBUMIN FREE) OLUTION 25 MCG/ML BRAND 4 pecialty Drug EPOGEN BRAND 4 pecialty Drug LEUKINE (RECON OLN 250 MCG, OLUTION 500 MCG/ML) BRAND 4 pecialty Drug MOZOBIL BRAND 4 NEULATA BRAND 4 NEULATA ONPRO BRAND 4 pecialty Drug pecialty Drug pecialty Drug GE 62 LAT UPDATED 05/2016

64 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION NEUPOGEN BRAND 4 NPLATE BRAND 4 OMONTY OLUTION 10 MG/ML BRAND 3 PROCRIT BRAND 4 PROMACTA BRAND 4 pecialty Drug pecialty Drug pecialty Drug pecialty Drug COAGULANT tranexamic acid (iv soln 1000 mg/10ml (100 mg/ml), tab 650 mg) PLATELET MODIFYING AGENT AGGRENOX BRAND 2 aspirin-dipyridamole BRILINTA TAB 90 MG BRAND 2 cilostazol clopidogrel bisulfate tab 300 mg (base equiv) 2 per day 2 per day clopidogrel bisulfate tab 75 mg (base equiv) 1 per day dipyridamole EFFIENT BRAND 2 1 per day REOPRO BRAND 3 ticlopidine hcl CARDIOVACULAR AGENT ALPHA-ADRENERGIC AGONIT clonidine hcl (tab 0.1 mg, tab 0.2 mg, tab 0.3 mg) 8 per day guanabenz acetate GE 63 LAT UPDATED 05/2016

65 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION guanfacine hcl methyldopa (tab 250 mg, tab 500 mg) 6 per day methyldopate hcl generic 3 midodrine hcl ALPHA-ADRENERGIC BLOCKING AGENT DIBENZYLINE BRAND 3 doxazosin mesylate phenoxybenzamine hcl generic 3 prazosin hcl (cap 1 mg, cap 2 mg, cap 5 mg) 4 per day ANGIOTENIN II RECEPTOR ANTAGONIT BENICAR BRAND 2 1 per day candesartan cilexetil 1 per day EDARBI BRAND 3 eprosartan mesylate T T 1 per day 1 per day irbesartan 1 per day losartan potassium 1 per day MICARDI BRAND 3 1 per day telmisartan 1 per day TEVETEN TAB 400 MG BRAND 3 TEVETEN TAB 600 MG BRAND 3 T T 2 per day 1 per day valsartan 1 per day ANGIOTENIN-CONVERTING ENZYME (ACE) INHIBITOR benazepril hcl captopril GE 64 LAT UPDATED 05/2016

66 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION enalapril maleate fosinopril sodium lisinopril moexipril hcl perindopril erbumine quinapril hcl ramipril trandolapril ANTIARRHYTHMIC amiodarone hcl (inj 150 mg/3ml (50 mg/ml), tab 100 mg, tab 200 mg, tab 400 mg) disopyramide phosphate (cap 100 mg, cap 150 mg) flecainide acetate mexiletine hcl (cap 150 mg, cap 200 mg, cap 250 mg) MULTAQ BRAND 3 PROCAINAMIDE HCL OLUTION 500 MG/ML BRAND 1 propafenone hcl quinidine sulfate sotalol hcl (tab 80 mg, tab 120 mg, tab 160 mg) 2 per day sotalol hcl tab 240 mg TIKOYN BRAND 2 BETA-ADRENERGIC BLOCKING AGENT acebutolol hcl (cap 200 mg, cap 400 mg) atenolol (tab 25 mg, tab 50 mg, tab 100 mg) betaxolol hcl bisoprolol fumarate BYTOLIC (TAB 2.5 MG, TAB 5 MG, TAB 10 MG) BRAND 2 1 per day BYTOLIC TAB 20 MG BRAND 2 2 per day carvedilol GE 65 LAT UPDATED 05/2016

67 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION labetalol hcl (iv soln 5 mg/ml, tab 100 mg, tab 200 mg, tab 300 mg) LEVATOL BRAND 3 metoprolol succinate metoprolol tartrate (inj 1 mg/ml, tab 25 mg, tab 50 mg, tab 100 mg) nadolol (tab 20 mg, tab 40 mg, tab 80 mg) pindolol propranolol hcl (cap sr 24hr 80 mg, cap sr 24hr 60 mg, cap sr 24hr 120 mg, cap sr 24hr 160 mg, inj 1 mg/ml, oral soln 20 mg/5ml, oral soln 40 mg/5ml, tab 10 mg, tab 20 mg, tab 40 mg, tab 60 mg, tab 80 mg) timolol maleate (tab 5 mg, tab 10 mg, tab 20 mg) CALCIUM CHANNEL BLOCKING AGENT amlodipine besylate diltiazem hcl (cap sr 12hr 90 mg, cap sr 12hr 120 mg, cap sr 12hr 60 mg, cap sr 24hr 240 mg, cap sr 24hr 120 mg, cap sr 24hr 180 mg, iv soln 50 mg/10ml (5 mg/ml), tab 30 mg, tab 60 mg, tab 90 mg, tab 120 mg) diltiazem hcl coated beads diltiazem hcl extended release beads (beads cap sr 24hr 360 mg, beads cap sr 24hr 180 mg, beads cap sr 24hr 300 mg, beads cap sr 24hr 240 mg, beads cap sr 24hr 120 mg) DILTIAZEM HCL RECON OLN 100 MG BRAND 1 felodipine isradipine nicardipine hcl (cap 20 mg, cap 30 mg, iv soln 2.5 mg/ml) nifedipine (cap 10 mg, cap 20 mg, tab sr 24hr 60 mg, tab sr 24hr osmotic 60 mg, tab sr 24hr osmotic 30 mg, tab sr 24hr osmotic 90 mg, tab sr 24hr 30 mg, tab sr 24hr 90 mg) nimodipine GE 66 LAT UPDATED 05/2016

68 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION nisoldipine (tab sr 24hr 30 mg, tab sr 24hr 8.5 mg, tab sr 24hr 17 mg, tab sr 24hr 34 mg, tab sr 24hr 40 mg, tab sr 24hr 20 mg) verapamil hcl (cap sr 24hr 100 mg, cap sr 24hr 240 mg, cap sr 24hr 120 mg, cap sr 24hr 180 mg, cap sr 24hr 360 mg, cap sr 24hr 200 mg, cap sr 24hr 300 mg, iv soln 2.5 mg/ml, tab 40 mg, tab 80 mg, tab 120 mg, tab cr 120 mg, tab cr 180 mg, tab cr 240 mg) CARDIOVACULAR AGENT, OTHER amiloride & hydrochlorothiazide amlodipine besylate-benazepril hcl atenolol & chlorthalidone benazepril & hydrochlorothiazide BIDIL BRAND 2 digoxin (inj 0.25 mg/ml, oral soln 0.05 mg/ml, tab 125 mcg (0.125 mg), tab 250 mcg (0.25 mg)) enalapril maleate & hydrochlorothiazide fosinopril sodium & hydrochlorothiazide LANOXIN (OLUTION 0.25 MG/ML, TAB 62.5 MCG, TAB 125 MCG, TAB MCG, TAB 250 MCG) BRAND 2 lisinopril & hydrochlorothiazide losartan potassium & hydrochlorothiazide 1 per day pentoxifylline tab cr 400 mg 3 per day RANEXA TAB ER 12H 500 MG BRAND 2 3 per day spironolactone & hydrochlorothiazide TEKTURNA BRAND 2 1 per day triamterene & hydrochlorothiazide (cap mg, tab mg, tab mg) valsartan-hydrochlorothiazide DIURETIC, CARBONIC ANHYDRAE INHIBITOR acetazolamide cap sr 12hr 500 mg 2 per day GE 67 LAT UPDATED 05/2016

69 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION acetazolamide sodium acetazolamide tab 125 mg 8 per day acetazolamide tab 250 mg 4 per day DIURETIC, LOOP bumetanide (tab 0.5 mg, tab 1 mg, tab 2 mg) 5 per day bumetanide inj 0.25 mg/ml EDECRIN BRAND 3 16 per day furosemide (inj 10 mg/ml, oral soln 8 mg/ml, oral soln 10 mg/ml, tab 20 mg, tab 40 mg, tab 80 mg) torsemide (iv soln 20 mg/2ml (10 mg/ml), tab 5 mg, tab 10 mg, tab 20 mg, tab 100 mg) DIURETIC, POTAIUM-RING amiloride hcl tab 5 mg DYRENIUM BRAND 3 3 per day eplerenone spironolactone (tab 25 mg, tab 50 mg, tab 100 mg) DIURETIC, THIAZIDE chlorothiazide chlorthalidone hydrochlorothiazide (cap 12.5 mg, tab 12.5 mg, tab 25 mg, tab 50 mg) 2 per day indapamide tab 1.25 mg 1 per day indapamide tab 2.5 mg 2 per day methyclothiazide tab 5 mg metolazone 2 per day DYLIPIDEMIC, FIBRIC ACID DERIVATIVE fenofibrate (tab 48 mg, tab 54 mg, tab 145 mg, tab 160 mg) fenofibrate micronized (cap 67 mg, cap 134 mg, cap 200 mg) 1 per day 1 per day GE 68 LAT UPDATED 05/2016

70 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION gemfibrozil tab 600 mg 2 per day DYLIPIDEMIC, HMG COA REDUCTAE INHIBITOR ALTOPREV BRAND 3 T 1 per day atorvastatin calcium (tab 10 mg, tab 20 mg, tab 40 mg, tab 80 mg) 1 per day CRETOR BRAND 2 T 1 per day fluvastatin sodium cap 20 mg generic 3 1 per day fluvastatin sodium cap 40 mg generic 3 2 per day LIVALO BRAND 3 T 1 per day lovastatin (tab 10 mg, tab 20 mg) 1 per day lovastatin tab 40 mg 2 per day pravastatin sodium 1 per day simvastatin 1 per day DYLIPIDEMIC, OTHER ADVICOR (TAB ER 24H MG, TAB ER 24H MG, TAB ER 24H MG) BRAND 3 1 per day ADVICOR TAB ER 24H MG BRAND 3 2 per day cholestyramine light powder 4 gm/dose MD1 720 GM / 30 DAY cholestyramine light powder packets 4 gm 6 per day cholestyramine powder 4 gm/dose MD1 756 GM / 30 DAY cholestyramine powder packets 4 gm 6 per day colestipol hcl (granule packets 5 gm, granules 5 gm) 6 per day colestipol hcl tab 1 gm 16 per day GE 69 LAT UPDATED 05/2016

71 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION niacin (antihyperlipidemic) 2 per day NIAN (TAB ER 500 MG, TAB ER 750 MG) BRAND 2 2 per day NIAN TAB ER 1000 MG BRAND 2 omega-3-acid ethyl esters T T 2 per day 4 per day IMCOR (TAB ER 24H MG, TAB ER 24H MG, TAB ER 24H MG, TAB ER 24H MG) BRAND 2 1 per day IMCOR TAB ER 24H MG BRAND 2 VYTORIN BRAND 2 T 2 per day 1 per day WELCHOL CKET 3.75 GM BRAND 2 1 per day WELCHOL TAB 625 MG BRAND 2 7 per day ZETIA BRAND 2 T 1 per day VAODILATOR, DIRECT-ACTING ARTERIAL hydralazine hcl (inj 20 mg/ml, tab 10 mg, tab 25 mg, tab 50 mg, tab 100 mg) minoxidil (tab 2.5 mg, tab 10 mg) VAODILATOR, DIRECT-ACTING ARTERIAL/VENOU isosorbide dinitrate (tab 5 mg, tab 10 mg, tab 20 mg, tab 30 mg, tab cr 40 mg) isosorbide mononitrate (tab 20 mg, tab sr 24hr 120 mg, tab sr 24hr 30 mg, tab sr 24hr 60 mg) MONOKET TAB 20 MG BRAND 3 NITRO-BID BRAND 3 nitroglycerin (iv soln 5 mg/ml, td patch 24hr 0.4 mg/hr, td patch 24hr 0.1 mg/hr, td patch 24hr 0.2 mg/hr, td patch 24hr 0.6 mg/hr) NITROTAT BRAND 2 GE 70 LAT UPDATED 05/2016

72 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION CENTRAL NERVOU YTEM AGENT ATTENTION DEFICIT HYPERACTIVITY DIORDER AGENT, AMPHETAMINE amphetamine-dextroamphetamine (cap sr 24hr 30 mg, cap sr 24hr 20 mg, cap sr 24hr 25 mg) amphetamine-dextroamphetamine (cap sr 24hr 5 mg, cap sr 24hr 10 mg) amphetamine-dextroamphetamine (tab 5 mg, tab 7.5 mg, tab 10 mg, tab 12.5 mg, tab 15 mg, tab 20 mg) amphetamine-dextroamphetamine cap sr 24hr 15 mg AL 6 to 18 yrs old 2 per day C required for age > 18 AL 6 to 18 yrs old 1 per day C required for age > 18 AL AL At least 6 yrs old 3 per day 6 to 18 yrs old C required for age > 18 amphetamine-dextroamphetamine tab 30 mg AL At least 6 yrs old DEOXYN BRAND 3 AL At least 6 yrs old 5 per day dextroamphetamine sulfate (cap sr 24hr 15 mg, cap sr 24hr 10 mg) AL 6 to 18 yrs old 4 per day C required for age > 18 dextroamphetamine sulfate (tab 5 mg, tab 10 mg) AL At least 6 yrs old 4 per day dextroamphetamine sulfate cap sr 24hr 5 mg AL 6 to 18 yrs old C required for age > 18 methamphetamine hcl generic 3 AL At least 6 yrs old 5 per day VYVANE BRAND 2 AL 6 to 17 yrs old 1 per day C required for age > 18 GE 71 LAT UPDATED 05/2016

73 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION ATTENTION DEFICIT HYPERACTIVITY DIORDER AGENT, NON-AMPHETAMINE dexmethylphenidate hcl (tab 2.5 mg, tab 5 mg, tab 10 mg) AL At least 6 yrs old 2 per day guanfacine hcl (adhd) AL At least 6 yrs old 1 per day INTUNIV BRAND 2 AL At least 6 yrs old 1 per day methylphenidate hcl (cap cr 10 mg, cap cr 20 mg, cap cr 30 mg, cap cr 40 mg, cap cr 50 mg, cap cr 60 mg, tab sa osm 18 mg, tab sa osm 27 mg, tab sr 24hr 27 mg, tab sr 24hr 18 mg) AL 6 to 18 yrs old 1 per day methylphenidate hcl (cap sr 24hr 20 mg (la), cap sr 24hr 40 mg, cap sr 24hr 40 mg (la), cap sr 24hr 20 mg) AL 6 to 18 yrs old methylphenidate hcl (cap sr 24hr 30 mg (la), cap sr 24hr 30 mg, tab cr 10 mg, tab cr 20 mg) AL 6 to 18 yrs old 3 per day methylphenidate hcl (soln 5, soln 10) AL At least 6 yrs old MD1 900 / 30 DAY methylphenidate hcl (tab 5 mg, tab 10 mg, tab 20 mg) AL At least 6 yrs old 5 per day methylphenidate hcl (tab sa osm 36 mg, tab sa osm 54 mg, tab sr 24hr 36 mg, tab sr 24hr 54 mg) AL 6 to 18 yrs old 2 per day METHYLPHENIDATE HCL ER (ER TAB ER 24H 27 MG, ER TAB ER 24H 18 MG) BRAND 1 AL 6 to 18 yrs old 1 per day METHYLPHENIDATE HCL ER (ER TAB ER 24H 54 MG, ER TAB ER 24H 36 MG) BRAND 1 AL 6 to 18 yrs old 2 per day TRATTERA (CAP 10 MG, CAP 18 MG, CAP 25 MG, CAP 40 MG) BRAND 2 AL At least 6 yrs old 2 per day GE 72 LAT UPDATED 05/2016

74 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION CENTRAL NERVOU YTEM, OTHER butalbital-acetaminophen-caffeine (cap mg, cap mg, cap mg, tab mg, tab mg) butalbital-aspirin-caffeine cap mg HORIZANT TAB ER 600 MG BRAND 3 NUEDEXTA BRAND 3 ORBIVAN BRAND 2 RILUTEK BRAND 3 tetrabenazine generic 4 XENAZINE BRAND 4 pecialty Drug pecialty Drug FIBROMYALGIA AGENT duloxetine hcl (cap 20 mg, cap 30 mg, cap 60 mg) 2 per day LYRICA (CAP 225 MG, CAP 300 MG) BRAND 2 2 per day LYRICA (CAP 25 MG, CAP 50 MG, CAP 75 MG, CAP 100 MG, CAP 150 MG, CAP 200 MG) BRAND 2 3 per day LYRICA OLUTION 20 MG/ML BRAND 2 MD1 900 ML / 30 DAY AVELLA BRAND 2 2 per day AVELLA TITRATION CK BRAND 2 MULTIPLE CLEROI AGENT AMPYRA BRAND 4 AVONEX BRAND 4 AVONEX PEN BRAND 4 pecialty Drug pecialty Drug pecialty Drug GE 73 LAT UPDATED 05/2016

75 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION AVONEX PREFILLED BRAND 4 BETAERON BRAND 4 COXONE BRAND 4 EXTAVIA BRAND 4 GILENYA BRAND 4 glatiramer acetate generic 4 REBIF BRAND 4 REBIF REBIDOE BRAND 4 REBIF REBIDOE TITRATION CK BRAND 4 REBIF TITRATION CK BRAND 4 TYABRI BRAND 4 pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug DENTAL AND ORAL AGENT ARETIN BRAND 3 cevimeline hcl chlorhexidine gluconate (mouth-throat) GEL-KAM ORAL CARE RINE BRAND 0 KEPIVANCE BRAND 4 pecialty Drug GE 74 LAT UPDATED 05/2016

76 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION pilocarpine hcl (oral) stannous fluoride conc 0.63% generic 0 triamcinolone acetonide (mouth) DERMATOLOGICAL AGENT acitretin (cap 10 mg, cap 17.5 mg) 1 per day acitretin cap 25 mg 2 per day adapalene (cream, gel) adapalene gel 0.3% ADALENE LOTION 0.1 % BRAND 1 AZELEX BRAND 3 AL T AL T AL T AL At least 12 yrs old At least 12 yrs old At least 12 yrs old At least 12 yrs old benzoyl peroxide (foam 5.3%, foam 9.8%, gel 5%, gel 10%, liq 4%, liq 7%, liq 10%, lotion 6%) AL At least 12 yrs old benzoyl peroxide-erythromycin AL MPL At least 12 yrs old 1 / Claim calcipotriene (cream, oint, soln (50 mcg/ml)) MPL 1 / claim calcipotriene-betamethasone dipropionate T calcitriol (topical) MPL 1 / Claim clindamycin phosphate swab 1% AL At least 12 yrs old clindamycin phosphate-benzoyl peroxide AL At least 12 yrs old clindamycin phosphate-benzoyl peroxide (refrigerate) AL At least 12 yrs old clotrimazole w/ betamethasone (cream, lotion) CORTIPORIN (CREAM , OINTMENT 1 %) BRAND 2 GE 75 LAT UPDATED 05/2016

77 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION diclofenac sodium (actinic keratoses) MPL 1 / claim diclofenac sodium gel 1% DIFFERIN LOTION 0.1 % BRAND 2 T AL At least 12 yrs old ELIDEL BRAND 2 EPIDUO BRAND 3 FINACEA GEL 15 % BRAND 2 finasteride (alopecia) AL MPL T AL At least 2 yrs old 1 / 30 days At least 12 yrs old fluorouracil (topical) (soln 2%, soln 5%) MPL 1 / claim fluorouracil cream 5% MPL 1 / Claim hydrocortisone (topical) (cream 1%, cream 2.5%, lotion 2.5%, oint 1%, oint 2.5%) imiquimod cream 5% MD1 12 / CLAIM isotretinoin (cap 10 mg, cap 20 mg, cap 30 mg, cap 40 mg) generic 3 AL At least 12 yrs old lactic acid (ammonium lactate) (cream, lotion) lidocaine (oint, patch) lidocaine hcl (gel 2%, soln 4%) lidocaine-prilocaine cream % LIDODERM BRAND 2 methoxsalen rapid 4 per day OXORALEN BRAND 2 OXORALEN ULTRA BRAND 2 4 per day PICATO BRAND 2 podofilox PRUDOXIN BRAND 3 RECTIV BRAND 3 GE 76 LAT UPDATED 05/2016

78 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION REGRANEX BRAND 3 ANTYL BRAND 3 selenium sulfide MPL 1 / Claim OLARAZE BRAND 2 MPL 1 / claim ORIATANE (CAP 10 MG, CAP 17.5 MG) BRAND 2 1 per day ORIATANE CAP 25 MG BRAND 2 2 per day TELARA BRAND 4 sulfacetamide sodium (acne) AL MPL pecialty Drug At least 12 yrs old 1 / Claim sulfacetamide sodium w/ sulfur (cream 10-5%, wash 9-4.5%) T AL At least 12 yrs old sulfacetamide sodium w/ sulfur emulsion 10-5% AL At least 12 yrs old YNERA BRAND 3 TACLONEX BRAND 3 T tacrolimus (topical) TAZORAC BRAND 2 AL MPL At least 2 yrs old 1 / 30 days tretinoin (cream 0.025%, cream 0.05%, cream 0.1%, gel 0.01%, gel 0.025%) AL At least 12 yrs old tretinoin microsphere gel 0.1% AL At least 12 yrs old VECTICAL BRAND 1 MPL 1 / Claim VELTIN BRAND 3 VEREGEN BRAND 3 VOLTAREN GEL 1 % BRAND 2 ZIANA BRAND 3 T AL T AL At least 12 yrs old At least 12 yrs old GE 77 LAT UPDATED 05/2016

79 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION ZONALON BRAND 3 ENZYME REPLACEMENT/MODIFIER ADAGEN BRAND 4 ALDURAZYME BRAND 4 pecialty Drug pecialty Drug BUPHENYL (POWDER 3 GM/TP, TAB 500 MG) BRAND 3 CEREZYME BRAND 4 CREON BRAND 2 CYTADANE BRAND 4 pecialty Drug pecialty Drug CYTAGON BRAND 3 ELAPRAE BRAND 4 ELELYO BRAND 4 FABRAZYME RECON OLN 35 MG BRAND 4 KUVAN TAB OL 100 MG BRAND 4 LUMIZYME BRAND 4 MYOZYME BRAND 4 NAGLAZYME BRAND 4 ORFADIN BRAND 4 pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug GE 78 LAT UPDATED 05/2016

80 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION NCREAZE BRAND 2 pancrelipase (lipase-protease-amylase) sodium phenylbutyrate generic 3 UCRAID BRAND 3 VPRIV BRAND 4 ZAVECA BRAND 4 pecialty Drug pecialty Drug ZENPEP (CP DR RT , CP DR RT 5000, CP DR RT 10000, CP DR RT 15000, CP DR RT 20000, CP DR RT 25000) BRAND 2 GATROINTETINAL AGENT ANTIMODIC, GATROINTETINAL atropine sulfate (inj 0.1 mg/ml, inj 0.4 mg/ml, inj 1 mg/ml) ATROPINE ULFATE OLUTION 0.05 MG/ML BRAND 1 CANTIL BRAND 3 chlordiazepoxide hcl-clidinium bromide dicyclomine hcl (cap 10 mg, oral soln 10 mg/5ml, tab 20 mg) glycopyrrolate (inj 4 mg/20ml (0.2 mg/ml), tab 1 mg, tab 2 mg) methscopolamine bromide GATROINTETINAL AGENT, OTHER CHOLBAM BRAND 4 diphenoxylate w/ atropine (liq mg/5ml, tab mg) ENTEREG BRAND 3 loperamide hcl cap 2 mg MOTOFEN BRAND 3 pecialty Drug RELITOR (KIT 12 MG/0.6ML, OLUTION 8 MG/0.4ML, OLUTION 12 MG/0.6ML) BRAND 2 GE 79 LAT UPDATED 05/2016

81 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION ursodiol (cap 300 mg, tab 250 mg, tab 500 mg) HITAMINE2 (H2) RECEPTOR ANTAGONIT cimetidine (tab 200 mg, tab 300 mg, tab 400 mg, tab 800 mg) cimetidine hcl MD1 600 ML / 30 DAY famotidine (inj 20 mg/2ml, inj 40 mg/4ml, inj 200 mg/20ml, inj 500 mg/50ml, tab 20 mg, tab 40 mg) famotidine for susp 40 mg/5ml MD1 300 ML / 30 DAY FAMOTIDINE PREMIXED BRAND 1 nizatidine (cap 150 mg, cap 300 mg) nizatidine oral soln 15 mg/ml MD1 600 ML / 30 DAY ranitidine hcl (cap 150 mg, cap 300 mg, inj 150 mg/6ml (25 mg/ml), tab 150 mg, tab 300 mg) ranitidine hcl syrup 15 mg/ml (75 mg/5ml) MD1 600 ML / 30 DAY IRRITABLE BOWEL YNDROME AGENT alosetron hcl AMITIZA BRAND 2 LOTRONEX BRAND 2 LAXATIVE GOLYTELY RECON OLN 236 GM BRAND 0 lactulose lactulose (encephalopathy) MOVIPREP BRAND 2 OMOPREP BRAND 3 2 per day peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm generic 0 PREPOPIK BRAND 3 UPREP BOWEL PREP BRAND 0 VIICOL BRAND 3 MD1 40 / 180 DAY GE 80 LAT UPDATED 05/2016

82 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION PROTECTANT CARAFATE UPENION 1 GM/10ML BRAND 2 MD ML / 30 DAY CARAFATE TAB 1 GM BRAND 2 4 per day misoprostol (tab 100 mcg, tab 200 mcg) 4 per day sucralfate tab 1 gm 4 per day PROTON PUMP INHIBITOR DEXILANT BRAND 3 T 1 per day esomeprazole magnesium cap delayed release 20 mg (base eq) 2 per day lansoprazole cap delayed release 15 mg 1 per day lansoprazole cap delayed release 30 mg NEXIUM CAP DR 20 MG BRAND 1 2 per day omeprazole (cap 10 mg, cap 20 mg, cap 40 mg) omeprazole-sodium bicarbonate cap mg 2 per day 1 per day pantoprazole sodium ec tab 20 mg (base equiv) 1 per day pantoprazole sodium ec tab 40 mg (base equiv) rabeprazole sodium 1 per day GENITOURINARY AGENT ANTIMODIC, URINARY DETROL LA BRAND 3 ENABLEX BRAND 3 flavoxate hcl 1 per day 1 per day MYRBETRIQ BRAND 3 oxybutynin chloride (syrup 5 mg/5ml, tab 5 mg, tab sr 24hr 15 mg, tab sr 24hr 10 mg, tab sr 24hr 5 mg) GE 81 LAT UPDATED 05/2016

83 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION tolterodine tartrate (cap sr 24hr 4 mg, cap sr 24hr 2 mg) 1 per day tolterodine tartrate (tab 1 mg, tab 2 mg) TOVIAZ BRAND 3 1 per day trospium chloride cap sr 24hr 60 mg 1 per day trospium chloride tab 20 mg VEICARE BRAND 2 1 per day BENIGN PROTATIC HYPERTROPHY AGENT alfuzosin hcl 1 per day AVODART BRAND 2 CIALI TAB 5 MG BRAND 3 dutasteride finasteride tab 5 mg RAFLO BRAND 2 tamsulosin hcl terazosin hcl GENITOURINARY AGENT, OTHER 1 per day 1 per day 1 per day bethanechol chloride 4 per day CUPRIMINE BRAND 3 ELMIRON BRAND 2 glycine irrigation soln 1.5% phenazopyridine hcl (tab 100 mg, tab 200 mg) potassium citrate tab cr 10 meq (1080 mg) REECTIOL BRAND 1 GE 82 LAT UPDATED 05/2016

84 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION sodium chloride (gu irrigant) sodium chloride iv soln 0.9% sodium citrate & citric acid ORBITOL (OLUTION 3 %, OLUTION 3.3 %) BRAND 1 ORBITOL-MANNITOL BRAND 1 TENDRA BRAND 3 MD1 4 / 30 DAY PHOPHATE BINDER calcium acetate (phosphate binder) FORENOL (CHEW TAB 500 MG, CHEW TAB 750 MG, CHEW TAB 1000 MG) BRAND 2 PHOLYRA BRAND 2 RENAGEL BRAND 3 HORMONAL AGENT, TIMULANT/REPLACEMENT/MODIFYING (ADRENAL) A-HYDROCORT BRAND 1 alclometasone dipropionate amcinonide (lotion, oint) generic 3 amcinonide cream 0.1% betamethasone dipropionate (topical) (cream, lotion, oint) betamethasone dipropionate augmented (cream, lotion, oint) betamethasone valerate (aerosol foam 0.12%, cream 0.1%, lotion 0.1%, oint 0.1%) clobetasol propionate (cream, foam, gel, oint, soln) clobetasol propionate emollient base CLODERM BRAND 3 CLODERM PUMP BRAND 3 CORDRAN (CREAM 0.05 %, LOTION 0.05 %, TAPE 4 MCG/QCM) BRAND 3 cortisone acetate tab 25 mg DEPO-MEDROL UPENION 20 MG/ML BRAND 3 GE 83 LAT UPDATED 05/2016

85 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION desonide (cream, lotion, oint) desoximetasone (cream 0.25%, gel 0.05%, oint 0.25%) dexamethasone (elixir 0.5 mg/5ml, soln 0.5 mg/5ml, tab 0.5 mg, tab 0.75 mg, tab 1 mg, tab 1.5 mg, tab 2 mg, tab 4 mg, tab 6 mg) DEXAMETHAONE INTENOL BRAND 1 dexamethasone sodium phosphate (inj 4 mg/ml, inj 20 mg/5ml, inj 120 mg/30ml) diflorasone diacetate cream 0.05% generic 2 diflorasone diacetate oint 0.05% fludrocortisone acetate tab 0.1 mg fluocinolone acetonide (cream 0.01%, cream 0.025%, oil 0.01% (scalp oil), oint 0.025%, soln 0.01%) fluocinonide (cream, gel, oint, soln) fluocinonide emulsified base fluticasone propionate (cream 0.05%, lotion 0.05%, oint 0.005%) halobetasol propionate HALOG BRAND 3 hydrocortisone hydrocortisone acetate (rectal) hydrocortisone butyrate (cream, oint, soln) hydrocortisone valerate KENALOG UPENION 40 MG/ML BRAND 3 MEDROL TAB 2 MG BRAND 3 methylprednisolone (tab 4 mg, tab 4 mg dose pack, tab 8 mg, tab 16 mg, tab 32 mg, tab therapy pack 4 mg (21)) methylprednisolone acetate (inj susp 40 mg/ml, inj susp 80 mg/ml) methylprednisolone sod succ MILLIPRED (OLUTION 10 MG/5ML, TAB 5 MG) BRAND 3 GE 84 LAT UPDATED 05/2016

86 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION MILLIPRED DP BRAND 3 MILLIPRED DP 12-DAY BRAND 3 mometasone furoate (cream, oint, solution (lotion)) ORAPRED ODT BRAND 3 prednicarbate prednisolone sodium phosphate (phosph soln 6.7 (5 base), phosphate soln 15 (base equiv)) PREDNIOLONE ODIUM PHOPHATE OLUTION 25 MG/5ML prednisolone syrup 15 mg/5ml (usp solution equivalent) prednisone (oral soln 5 mg/5ml, tab 1 mg, tab 2.5 mg, tab 5 mg, tab 10 mg, tab 20 mg, tab 50 mg) BRAND 1 OLU-CORTEF RECON OLN 250 MG BRAND 3 OLU-MEDROL RECON OLN 2 GM BRAND 3 triamcinolone acetonide (topical) (cream 0.025%, cream 0.1%, cream 0.5%, lotion 0.025%, lotion 0.1%, oint 0.025%, oint 0.1%, oint 0.5%) VERIPRED 20 BRAND 3 HORMONAL AGENT, TIMULANT/REPLACEMENT/MODIFYING (PITUITARY) chorionic gonadotropin for inj unit generic 4 pecialty Drug desmopressin acetate inj 4 mcg/ml desmopressin acetate spray desmopressin acetate spray refrigerated desmopressin acetate tab 0.1 mg desmopressin acetate tab 0.2 mg 6 per day 8 per day GENOTROPIN MINIQUICK RECON OLN 0.2 MG BRAND 4 pecialty Drug GE 85 LAT UPDATED 05/2016

87 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION GENOTROPIN RECON OLN 5 MG BRAND 4 HUMATROPE BRAND 4 INCRELEX BRAND 4 NORDITROPIN BRAND 4 pecialty Drug pecialty Drug pecialty Drug pecialty Drug NORDITROPIN FLEXPRO (OLUTION 5, OLUTION 10, OLUTION 15) BRAND 4 pecialty Drug NORDITROPIN NORDIFLEX PEN (PEN OLUTION 5, PEN OLUTION 10, PEN OLUTION 15) BRAND 4 pecialty Drug NUTROPIN BRAND 4 NUTROPIN AQ BRAND 4 NUTROPIN AQ NUPIN 10 BRAND 4 NUTROPIN AQ PEN OLUTION 10 MG/2ML BRAND 4 OMNITROPE (OLUTION 5, OLUTION 10) BRAND 4 AIZEN BRAND 4 AIZEN CLICK.EAY BRAND 4 EROTIM BRAND 4 TIMATE BRAND 4 pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug GE 86 LAT UPDATED 05/2016

88 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION TEV-TROPIN BRAND 4 ZOMACTON BRAND 4 ZORBTIVE BRAND 4 pecialty Drug pecialty Drug pecialty Drug HORMONAL AGENT, TIMULANT/REPLACEMENT/MODIFYING (EX HORMONE/MODIFIER) ANDROGEN ANADROL-50 BRAND 3 ANDRODERM (TCH 24HR 4 MG/24HR, TCH 24HR 2 MG/24HR) BRAND 2 1 per day ANDROXY BRAND 3 danazol (cap 50 mg, cap 100 mg, cap 200 mg) METHITET BRAND 3 oxandrolone (tab 2.5 mg, tab 10 mg) testosterone cypionate (j oil 100 mg/ml, j oil 200 mg/ml) testosterone enanthate im inj in oil 200 mg/ml ETROGEN ALORA BRAND 3 GL Female BEYAZ BRAND 0 GL Female BREVICON (28) BRAND 0 GL Female CENETIN BRAND 3 GL Female CLIMARA PRO BRAND 3 GL Female CYCLEA BRAND 0 GL Female DEPO-ETRADIOL BRAND 3 GL Female DEOGEN BRAND 0 GL Female desogestrel & ethinyl estradiol generic 0 GL Female desogestrel-ethinyl estradiol (biphasic) generic 0 GL Female GE 87 LAT UPDATED 05/2016

89 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION desogestrel-ethinyl estradiol (triphasic) generic 0 GL Female DIVIGEL (GEL 0.25 MG/0.25GM, GEL 0.5 MG/0.5GM, GEL 1 MG/GM) BRAND 3 GL Female drospirenone-ethinyl estradiol generic 0 GL Female ELETRIN BRAND 3 GL Female ENJUVIA BRAND 3 GL Female ETRACE CREAM 0.1 MG/GM BRAND 3 GL Female ETRADERM BRAND 3 GL Female estradiol (tab 0.5 mg, tab 1 mg, tab 2 mg, td patch twice weekly mg/24hr, td patch twice weekly mg/24hr, td patch twice weekly 0.05 mg/24hr, td patch twice weekly mg/24hr, td patch twice weekly 0.1 mg/24hr, td patch weekly mg/24hr, td patch weekly mg/24hr (37.5 mcg/24hr), td patch weekly 0.05 mg/24hr, td patch weekly 0.06 mg/24hr, td patch weekly mg/24hr, td patch weekly 0.1 mg/24hr) GL Female estradiol valerate GL Female ETRAORB BRAND 3 GL Female ETROGEL BRAND 3 GL Female estropipate GL Female ETROTEP FE BRAND 0 GL Female ethynodiol diacet & eth estrad generic 0 GL Female EVAMIT BRAND 3 GL Female FEMCON FE BRAND 0 GL Female FEMRING BRAND 3 GL Female GENERE FE BRAND 0 GL Female levonorgestrel & eth estradiol generic 0 GL Female levonorgestrel (emergency oc) generic 0 GL Female levonorgestrel-eth estradiol (triphasic) generic 0 GL Female GE 88 LAT UPDATED 05/2016

90 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION levonorgestrel-ethinyl estradiol (91-day) generic 0 GL Female levonorgestrel-ethinyl estradiol (continuous) generic 0 GL Female LO LOETRIN FE BRAND 0 GL Female LO/OVRAL (28) BRAND 0 GL Female LOETRIN 1.5/30 (21) BRAND 0 GL Female LOETRIN 1/20 (21) BRAND 0 GL Female LOETRIN 24 FE BRAND 0 GL Female LOETRIN FE 1.5/30 BRAND 0 GL Female LOETRIN FE 1/20 BRAND 0 GL Female LOEAONIQUE BRAND 0 GL Female MENET BRAND 3 GL Female MENOTAR BRAND 3 GL Female MINATRIN 24 FE BRAND 0 GL Female MINIVELLE (TCH TW MG/24HR, TCH TW 0.05 MG/24HR, TCH TW MG/24HR, TCH TW 0.1 MG/24HR) BRAND 3 GL Female MIRCETTE BRAND 0 GL Female MODICON (28) BRAND 0 GL Female NATAZIA BRAND 0 GL Female NECON 10/11 (28) BRAND 0 GL Female NORDETTE (28) BRAND 0 GL Female norethin acet & estrad-fe generic 0 GL Female norethindrone & eth estradiol generic 0 GL Female norethindrone & ethinyl estradiol-fe generic 0 GL Female norethindrone acet & eth estra generic 0 GL Female norethindrone acetate-ethinyl estradiol-fe generic 0 GL Female norethindrone-eth estradiol (triphasic) generic 0 GL Female GE 89 LAT UPDATED 05/2016

91 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION norgestimate-ethinyl estradiol generic 0 GL Female norgestimate-ethinyl estradiol (triphasic) generic 0 GL Female norgestrel & ethinyl estradiol generic 0 GL Female NORINYL 1+35 (28) BRAND 0 GL Female NUVARING BRAND 0 GL Female OGETREL BRAND 0 GL Female ORTHO EVRA BRAND 0 GL Female ORTHO TRI-CYCLEN (28) BRAND 0 GL Female ORTHO TRI-CYCLEN LO BRAND 0 GL Female ORTHO-CEPT (28) BRAND 0 GL Female ORTHO-CYCLEN (28) BRAND 0 GL Female ORTHO-NOVUM 1/35 (28) BRAND 0 GL Female ORTHO-NOVUM 7/7/7 (28) BRAND 0 GL Female OVCON-35 (28) BRAND 0 GL Female PLAN B BRAND 0 GL Female PLAN B ONE-TEP BRAND 0 GL Female PREMARIN (CREAM MG/GM, RECON OLN 25 MG, TAB 0.3 MG, TAB 0.45 MG, TAB MG, TAB 0.9 MG, TAB 1.25 MG) BRAND 2 GL Female PREMPHAE BRAND 2 GL Female PREMPRO BRAND 2 GL Female AFYRAL BRAND 0 GL Female EAONALE BRAND 0 GL Female EAONIQUE BRAND 0 GL Female TRI-NORINYL (28) BRAND 0 GL Female VIVELLE-DOT BRAND 3 GL Female XULANE BRAND 0 GL Female GE 90 LAT UPDATED 05/2016

92 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION YAMIN 28 BRAND 0 GL Female YAZ BRAND 0 GL Female ZOVIA 1/50E (28) BRAND 0 GL Female PROGETERONE AGONIT/ANTAGONIT ELLA BRAND 0 GL Female PROGETIN AYGETIN BRAND 0 DEPO-PROVERA UPENION 150 MG/ML BRAND 0 GL Female DEPO-UBQ PROVERA 104 BRAND 0 GL Female IMPLANON BRAND 0 GL Female LILETTA BRAND 0 GL Female medroxyprogesterone acetate medroxyprogesterone acetate (contraceptive) generic 0 GL Female MEGACE E BRAND 3 MEGACE ORAL BRAND 3 megestrol acetate (appetite) generic 3 megestrol acetate (susp 40 mg/ml, tab 20 mg, tab 40 mg) MIRENA BRAND 0 GL Female NEXPLANON BRAND 0 GL Female NOR-QD BRAND 0 GL Female norethindrone (contraceptive) generic 0 GL Female norethindrone acetate tab 5 mg generic 0 ORTHO MICRONOR BRAND 0 GL Female progesterone micronized (cap 100 mg, cap 200 mg) KYLA BRAND 0 GL Female GE 91 LAT UPDATED 05/2016

93 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION ELECTIVE ETROGEN RECEPTOR MODIFYING AGENT EVITA (TAB 60 MG, 60 MG) BRAND 2 raloxifene hcl generic 0 KELID BRAND 3 HORMONAL AGENT, TIMULANT/REPLACEMENT/MODIFYING (THYROID) levothyroxine sodium (for iv inj 100 mcg, for iv inj 500 mcg, tab 25 mcg, tab 50 mcg, tab 75 mcg, tab 88 mcg, tab 100 mcg, tab 112 mcg, tab 125 mcg, tab 137 mcg, tab 150 mcg, tab 175 mcg, tab 200 mcg, tab 300 mcg) GL GL Female 1 per day Female 1 per day liothyronine sodium (iv soln 10 mcg/ml, tab 5 mcg, tab 25 mcg, tab 50 mcg) THYROLAR-1 BRAND 3 THYROLAR-1/2 BRAND 3 THYROLAR-1/4 BRAND 3 THYROLAR-2 BRAND 3 THYROLAR-3 BRAND 3 HORMONAL AGENT, UPPREANT (RATHYROID) ENIR BRAND 4 pecialty Drug HORMONAL AGENT, UPPREANT (PITUITARY) cabergoline ELIGARD BRAND 4 FIRMAGON BRAND 4 leuprolide acetate inj kit 5 mg/ml generic 4 LUPRON DEPOT BRAND 4 pecialty Drug pecialty Drug pecialty Drug pecialty Drug GE 92 LAT UPDATED 05/2016

94 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION LUPRON DEPOT-PED (KIT 7.5 MG, KIT MG, KIT 15 MG, KIT 30 MG (PED)) BRAND 4 pecialty Drug octreotide acetate generic 4 ANDOTATIN BRAND 4 OMATULINE DEPOT BRAND 4 pecialty Drug pecialty Drug pecialty Drug OMAVERT (RECON OLN 10 MG, RECON OLN 15 MG, RECON OLN 20 MG) BRAND 4 pecialty Drug YNAREL BRAND 4 TRELTAR BRAND 4 TRELTAR DEPOT MIXJECT BRAND 4 TRELTAR LA MIXJECT BRAND 4 TRELTAR MIXJECT BRAND 4 ZOLADEX BRAND 4 pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug HORMONAL AGENT, UPPREANT (THYROID) ANTITHYROID AGENT methimazole (tab 5 mg, tab 10 mg) propylthiouracil GE 93 LAT UPDATED 05/2016

95 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION IMMUNOLOGICAL AGENT IMMUNE UPPREANT AZAAN BRAND 3 azathioprine sodium azathioprine tab 50 mg CELLCEPT INTRAVENOU BRAND 3 CIMZIA BRAND 4 CIMZIA PREFILLED BRAND 4 CIMZIA TARTER KIT BRAND 4 pecialty Drug pecialty Drug pecialty Drug cyclosporine (cap 25 mg, cap 100 mg, iv soln 50 mg/ml) cyclosporine modified (for microemulsion) (cap 25 mg, cap 50 mg, cap 100 mg, oral soln 100 mg/ml) ENBREL (OLN PRYR 25 MG/0.5ML, OLN PRYR 50 MG/ML) BRAND 4 pecialty Drug ENBREL RECON OLN 25 MG BRAND 4 pecialty Drug ENBREL URECLICK BRAND 4 pecialty Drug HUMIRA (PREF Y KT 20 MG/0.4ML, PREF Y KT 40 MG/0.8ML) BRAND 4 pecialty Drug HUMIRA PEDIATRIC CROHN TART BRAND 4 HUMIRA PEN BRAND 4 HUMIRA PEN-CROHN TARTER BRAND 4 HUMIRA PEN-PORIAI TARTER BRAND 4 pecialty Drug pecialty Drug pecialty Drug pecialty Drug GE 94 LAT UPDATED 05/2016

96 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION KINERET BRAND 4 pecialty Drug methotrexate sodium (for inj 1 gm, inj 25 mg/ml, inj 50 mg/2ml (25 mg/ml), inj 250 mg/10ml (25 mg/ml), inj pf 25 mg/ml, tab 2.5 mg (base equiv)) mycophenolate mofetil (cap 250 mg, tab 500 mg) pecialty Drug mycophenolate sodium MYFORTIC BRAND 2 NULOJIX BRAND 4 pecialty Drug ORENCIA (RECON OLN 250 MG, OLN PRYR 125 MG/ML) BRAND 4 pecialty Drug PROGRAF (CAP 1 MG, OLUTION 5 MG/ML) BRAND 2 REMICADE BRAND 4 RHEUMATREX BRAND 4 IMPONI (OLN A-INJ 50, OLN PRYR 50) BRAND 4 sirolimus (tab 0.5 mg, tab 1 mg, tab 2 mg) tacrolimus (cap 0.5 mg, cap 1 mg, cap 5 mg) TREXALL BRAND 4 XELJANZ BRAND 4 ZORTRE BRAND 4 pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug IMMUNIZING AGENT, IVE ATGAM BRAND 4 pecialty Drug GE 95 LAT UPDATED 05/2016

97 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION CARIMUNE NF RECON OLN 3 GM BRAND 4 GAMMAGARD /D BRAND 4 GAMMAGARD /D LE IGA BRAND 4 GAMMAGARD OLUTION 1 GM/10ML BRAND 4 GAMMAKED OLUTION 1 GM/10ML BRAND 4 GAMUNEX-C OLUTION 1 GM/10ML BRAND 4 HIZENTRA BRAND 4 HIZENTRA 20% BRAND 4 THYMOGLOBULIN BRAND 4 pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug IMMUNOMODULATOR ACTEMRA (OLUTION 80 MG/4ML, OLUTION 200 MG/10ML, OLUTION 400 MG/20ML) BRAND 4 pecialty Drug ACTIMMUNE BRAND 4 ARCALYT BRAND 4 pecialty Drug pecialty Drug leflunomide 1 per day RIDAURA BRAND 3 IMULECT BRAND 3 GE 96 LAT UPDATED 05/2016

98 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION VACCINE ADACEL BRAND 0 AFLURIA BRAND 0 AFLURIA PREERVATIVE FREE BRAND 0 AGRIFLU BRAND 0 BOOTRIX BRAND 0 FLUARIX BRAND 0 FLUARIX QUADRIVALENT BRAND 0 FLUCELVAX BRAND 0 FLULAVAL BRAND 0 FLULAVAL QUADRIVALENT BRAND 0 FLUVIRIN BRAND 0 FLUVIRIN PREERVATIVE FREE BRAND 0 FLUZONE BRAND 0 FLUZONE HIGH-DOE BRAND 0 FLUZONE PEDIATRIC PF BRAND 0 FLUZONE PREERVATIVE FREE BRAND 0 FLUZONE QUADRIVALENT (UP PRYR 0.5 ML, UPENION, UPENION 0.5 ML) BRAND 0 MENACTRA BRAND 0 MENOMUNE BRAND 0 MENVEO BRAND 0 PNEUMOVAX 23 BRAND 0 PREVNAR 13 BRAND 0 ZOTAVAX BRAND 0 AL At least 50 yrs old INFLAMMATORY BOWEL DIEAE AGENT AMINOALICYLATE APRIO BRAND 2 AACOL BRAND 2 12 per day AACOL HD BRAND 2 6 per day GE 97 LAT UPDATED 05/2016

99 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION balsalazide disodium CANAA BRAND 2 DIPENTUM BRAND 2 LIALDA BRAND 2 mesalamine enema 4 gm PENTAA BRAND 2 GLUCOCORTICOID budesonide delayed release particles cap 3 mg hydrocortisone (intrarectal) hydrocortisone rectal cream 2.5% ULFONAMIDE sulfasalazine (tab 500 mg, tab delayed release 500 mg) METABOLIC BONE DIEAE AGENT ACTONEL TAB 150 MG BRAND 2 MD1 1 / 28 DAY ACTONEL TAB 30 MG BRAND 2 1 per day alendronate sodium (tab 35 mg, tab 70 mg) MD1 4 / 28 DAY alendronate sodium (tab 5 mg, tab 10 mg, tab 40 mg) 1 per day AREDIA RECON OLN 30 MG BRAND 4 pecialty Drug ATELVIA BRAND 2 BONIVA OLUTION 3 MG/3ML BRAND 4 pecialty Drug calcitonin (salmon) MPL 1 / 30 days calcitriol (cap 0.25 mcg, cap 0.5 mcg, inj 1 mcg/ml, oral soln 1 mcg/ml) doxercalciferol (cap 0.5 mcg, cap 1 mcg, cap 2.5 mcg, inj 4 mcg/2ml (2 mcg/ml)) GE 98 LAT UPDATED 05/2016

100 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION etidronate disodium FORTEO BRAND 4 MPL 1 / 28 days pecialty Drug FOAMAX PLU D BRAND 3 MD1 4 / 28 DAY ibandronate sodium iv soln 3 mg/3ml (base equivalent) generic 4 pecialty Drug ibandronate sodium tab 150 mg (base equivalent) MD1 1 / 28 DAY pamidronate disodium (for inj 30 mg, for inj 90 mg, iv soln 3 mg/ml, iv soln 9 mg/ml) generic 4 pecialty Drug MIDRONATE DIODIUM OLUTION 6 MG/ML BRAND 4 pecialty Drug paricalcitol (cap 1 mcg, cap 2 mcg, cap 4 mcg, iv soln 2 mcg/ml, iv soln 5 mcg/ml) PROLIA BRAND 4 RECLAT BRAND 4 risedronate sodium (tab 5 mg, tab 30 mg) pecialty Drug pecialty Drug 1 per day risedronate sodium tab 150 mg risedronate sodium tab 35 mg MD1 1 / 28 DAY MD1 4 / 28 DAY risedronate sodium tab delayed release 35 mg XGEVA BRAND 4 pecialty Drug ZEMPLAR (CAP 1 MCG, CAP 2 MCG, CAP 4 MCG, OLUTION 2 MCG/ML, OLUTION 5 MCG/ML) BRAND 3 GE 99 LAT UPDATED 05/2016

101 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION zoledronic acid (inj conc for infusion 4 mg/5ml, soln 5 mg/100ml) generic 4 pecialty Drug ZOLEDRONIC ACID (RECON OLN 4 MG, OLUTION 4 MG/100ML) BRAND 4 pecialty Drug ZOMETA BRAND 4 pecialty Drug MICELLANEOU THERAPEUTIC AGENT *lancets*** MD1 200 / 30 DAY 1T CHOICE LANCET UPER THIN BRAND 1 MD1 200 / 30 DAY 1T CHOICE LANCET THIN BRAND 1 MD1 200 / 30 DAY 1T CHOICE LANCET ULTRA THIN BRAND 1 MD1 200 / 30 DAY 1T CHOICE PEN NEEDLE BRAND 1 MD1 150 / 30 DAY 1T TIER UNIFINE PENTIP BRAND 1 MD1 150 / 30 DAY 1T TIER UNIFINE PENTIP PLU BRAND 1 MD1 150 / 30 DAY 1T TIER UNILET COMFORTOUCH BRAND 1 MD1 200 / 30 DAY ACCU-CHEK ACTIVE GLUCOE CONT BRAND 1 ACCU-CHEK AVIVA OLUTION BRAND 1 ACCU-CHEK COMFORT CURVE LINEAR BRAND 1 ACCU-CHEK COMFORT CURVE OLUTION BRAND 1 ACCU-CHEK COMCT BLUE CONTROL BRAND 1 ACCU-CHEK COMCT PLU CONTROL BRAND 1 ACCU-CHEK FATCLIX LANCET BRAND 1 MD1 200 / 30 DAY ACCU-CHEK INTANT CONTROL BRAND 1 ACCU-CHEK MULTICLIX LANCET BRAND 1 MD1 200 / 30 DAY ACCU-CHEK AFE-T PRO LANCET BRAND 1 MD1 200 / 30 DAY ACCU-CHEK MARTVIEW CONTROL BRAND 1 ACCU-CHEK OFT TOUCH LANCET BRAND 1 MD1 200 / 30 DAY ACCU-CHEK OFTCLIX LANCET DEV MIC BRAND 1 GE 100 LAT UPDATED 05/2016

102 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION ACCU-CHEK OFTCLIX LANCET BRAND 1 MD1 200 / 30 DAY ACCUURE INULIN YRINGE BRAND 1 MD1 450 / 90 DAY ACCUTREND GLUCOE CONTROL BRAND 1 acetone (urine) test MPL 1 / 30 Days ACTI-LANCE 28G BRAND 1 MD1 200 / 30 DAY ACTI-LANCE LITE LANCET 28G BRAND 1 MD1 200 / 30 DAY ACTI-LANCE PECIAL LANCET 17G BRAND 1 MD1 200 / 30 DAY ACTI-LANCE UNIVERAL 23G BRAND 1 MD1 200 / 30 DAY ACURA CONTROL (OLUTION LOW, OLUTION NORMAL) BRAND 1 ADJUTABLE LANCING DEVICE BRAND 1 ADVANCE INTUITION CONTROL BRAND 1 ADVOCATE CONTROL OLUTION LIQUID LOW BRAND 1 ADVOCATE INULIN PEN NEEDLE BRAND 1 MD1 150 / 30 DAY ADVOCATE INULIN YRINGE BRAND 1 MD1 450 / 90 DAY ADVOCATE LANCET BRAND 1 MD1 200 / 30 DAY ADVOCATE LANCET 30G BRAND 1 MD1 200 / 30 DAY ADVOCATE LANCING DEVICE BRAND 1 ADVOCATE RAPID-AFE LANCING BRAND 1 ADVOCATE REDI-CODE+ CONTROL OLUTION LOW BRAND 1 ADVOCATE AFETY LANCET BRAND 1 MD1 200 / 30 DAY ADVOCATE AFETY LANCET 26G BRAND 1 MD1 200 / 30 DAY AF LANCET UPER THIN BRAND 1 MD1 200 / 30 DAY AGAMATRIX CONTROL (OLUTION, OLUTION NORMAL) BRAND 1 AGAMATRIX ULTRA-THIN LANCET BRAND 1 MD1 200 / 30 DAY ALTERNATE ITE LANCING DEVICE BRAND 1 GE 101 LAT UPDATED 05/2016

103 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION amiodarone hcl (bulk) ANTI-TICK INULIN YRINGE BRAND 1 MD1 450 / 90 DAY AQUA LANCE ADJUTABLE LANCING BRAND 1 ACENIA AUTODIC CONTROL BRAND 1 ACENIA AUTODIC CONTROL BRAND 1 AURE 3 CONTROL BRAND 1 AURE 4 CONTROL LEVEL 1 & 2 BRAND 1 AURE COMFORT LANCET 28G BRAND 1 MD1 200 / 30 DAY AURE COMFORT LANCET 30G BRAND 1 MD1 200 / 30 DAY AURE DOE CONTROL BRAND 1 AURE DOE NORM/HIGH CONTROL BRAND 1 AURE HAEMOLANCE PLU HIGH BRAND 1 MD1 200 / 30 DAY AURE HAEMOLANCE PLU LOW BRAND 1 MD1 200 / 30 DAY AURE HAEMOLANCE PLU MICRO BRAND 1 MD1 200 / 30 DAY AURE HAEMOLANCE PLU NORMAL BRAND 1 MD1 200 / 30 DAY AURE HAEMOLANCE PLU PED BRAND 1 MD1 200 / 30 DAY AURE ID INULIN AFETY YR BRAND 1 MD1 450 / 90 DAY AURE LANCE LANCET BRAND 1 MD1 200 / 30 DAY AURE LANCE LANCET 21G BRAND 1 MD1 200 / 30 DAY AURE LANCE PLU AFETY 25G BRAND 1 MD1 200 / 30 DAY AURE LANCE PLU AFETY 30G BRAND 1 MD1 200 / 30 DAY AURE LANCET BRAND 1 MD1 200 / 30 DAY AURE PRIM CONTROL LEVEL 1&2 BRAND 1 AURE PRO CONTROL LEVEL 1 & 2 BRAND 1 ATOVAQUONE POWDER BRAND 1 AURORA HEALTHCARE LANCET BRAND 1 MD1 200 / 30 DAY AURORA LANCET UPER THIN 30G BRAND 1 MD1 200 / 30 DAY AURORA LANCET THIN 23G BRAND 1 MD1 200 / 30 DAY GE 102 LAT UPDATED 05/2016

104 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION AURORA PEN NEEDLE BRAND 1 MD1 150 / 30 DAY AURORA UNIFINE PENTIP BRAND 1 MD1 150 / 30 DAY AUTO-LANCET BRAND 1 AUTO-LANCET MINI BRAND 1 AUTOLET IMPREION BRAND 1 AUTOLET LANCING DEVICE BRAND 1 AUTOLET MINI BRAND 1 BAYER BREEZE 2 CONTROL (2 LIQUID LOW, 2 LIQUID NORMAL) BAYER CONTOUR (LIQUID LOW, LIQUID NORMAL) BRAND 1 BRAND 1 BAYER CONTOUR NEXT CONTROL BRAND 1 BAYER MICROLET 2 LANCING DEVIC BRAND 1 BAYER MICROLET LANCET BRAND 1 MD1 200 / 30 DAY BD AUTOHIELD (MIC 8MM, MIC 12MM) BRAND 1 MD1 150 / 30 DAY BD INULIN YR ULTRAFINE II BRAND 1 MD1 450 / 90 DAY BD INULIN YRINGE (MIC 25G 1" 1 ML, MIC 25G 5/8" 1 ML, MIC 26G 1/2" 1 ML, MIC 27G 1/2" 1 ML, MIC 28G 1/2" 1 ML, MIC 29G 1/2" 0.5 ML, MIC 29G 1/2" 1 ML, MIC 30G 1/2" 0.5 ML, MIC 31G 5/16" 0.3 ML) BRAND 1 MD1 450 / 90 DAY BD INULIN YRINGE HALF-UNIT BRAND 1 MD1 450 / 90 DAY BD INULIN YRINGE MICROFINE BRAND 1 MD1 450 / 90 DAY BD INULIN YRINGE MIC U ML BRAND 1 MD1 150 / 30 DAY BD INULIN YRINGE ULTRAFINE (MIC 29G 1/2" 0.5 ML, MIC 29G 1/2" 0.3 ML, MIC 29G 1/2" 1 ML, MIC 30G 1/2" 1 ML, MIC 30G 1/2" 0.3 ML, MIC 30G 1/2" 0.5 ML, MIC 31G 15/64" 1 ML, MIC 31G 5/16" 1 ML, MIC 31G 5/16" 0.5 ML, MIC 31G 5/16" 0.3 ML) BRAND 1 MD1 450 / 90 DAY BD INTEGRA INULIN YRINGE BRAND 1 MD1 450 / 90 DAY BD INTEGRA YRINGE BRAND 1 MD1 450 / 90 DAY BD LANCET DEVICE BRAND 1 GE 103 LAT UPDATED 05/2016

105 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION BD LANCET ULTRAFINE 30G BRAND 1 MD1 200 / 30 DAY BD LANCET ULTRAFINE 33G BRAND 1 MD1 200 / 30 DAY BD MICROTAINER LANCET BRAND 1 MD1 200 / 30 DAY BD PEN NEEDLE MINI U/F BRAND 1 MD1 150 / 30 DAY BD PEN NEEDLE NANO U/F BRAND 1 MD1 150 / 30 DAY BD PEN NEEDLE HORT U/F BRAND 1 MD1 150 / 30 DAY BD PEN NEEDLE ULTRAFINE BRAND 1 MD1 150 / 30 DAY BD AFETY-LOK INULIN YRINGE BRAND 1 MD1 450 / 90 DAY BD AFETYGLIDE INULIN YRINGE BRAND 1 MD1 450 / 90 DAY blood glucose calibration blood glucose monitoring supplies MD1 1 / 730 DAY BULLEYE MINI AFETY LANCET BRAND 1 MD1 200 / 30 DAY BULLEYE AFETY LANCET BRAND 1 MD1 200 / 30 DAY CARDIOCOM LANCING DEVICE BRAND 1 CAREFINE PEN NEEDLE BRAND 1 MD1 150 / 30 DAY CAREONE ADVANCED LANCING DEV BRAND 1 CAREONE INULIN YRINGE BRAND 1 MD1 450 / 90 DAY CAREONE LANCET THIN 23G BRAND 1 MD1 200 / 30 DAY CAREONE LANCET ULTRA THIN 28G BRAND 1 MD1 200 / 30 DAY CAREONE ULTIGUARD INULIN YR BRAND 1 MD1 450 / 90 DAY CAREONE UNIFINE PENTIP BRAND 1 MD1 150 / 30 DAY CAREONE UNIFINE PENTIP PLU BRAND 1 MD1 150 / 30 DAY CAREEN CONTROL A BRAND 1 CAYA BRAND 0 CHEK-TIX CONTROL BRAND 1 MPL 1 / 30 Days CHEMTRIP K BRAND 1 MPL 1 / 30 Days CLEANLET LANCET 28G BRAND 1 MD1 200 / 30 DAY GE 104 LAT UPDATED 05/2016

106 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION CLEVER CHEK LANCET BRAND 1 MD1 200 / 30 DAY CLEVER CHOICE GLUCOE CONTROL LIQUID LOW BRAND 1 CLICKFINE PEN NEEDLE BRAND 1 MD1 150 / 30 DAY clindamycin phosphate (bulk) CLINDAMYCIN PHOPHATE POWDER BRAND 1 CLOERCARE BRAND 1 COAGUCHEK LANCET BRAND 1 MD1 200 / 30 DAY COMFORT AIT INULIN YRINGE BRAND 1 MD1 450 / 90 DAY COMFORT AURED LANCET 28G BRAND 1 MD1 200 / 30 DAY COMFORT AURED LANCET 33G BRAND 1 MD1 200 / 30 DAY COMFORT EZ INULIN YRINGE BRAND 1 MD1 450 / 90 DAY COMFORT EZ PEN NEEDLE (PEN MIC 31G 5, PEN MIC 31G 6, PEN MIC 31G 8, PEN MIC 32G 4, PEN MIC 32G 6, PEN MIC 32G 5) BRAND 1 MD1 150 / 30 DAY COMFORT LANCET BRAND 1 MD1 200 / 30 DAY CONTROL BRAND 1 CV INULIN YRINGE BRAND 1 MD1 450 / 90 DAY CV LANCET 21G BRAND 1 MD1 200 / 30 DAY CV LANCET MICRO THIN 33G BRAND 1 MD1 200 / 30 DAY CV LANCET ORIGINAL BRAND 1 MD1 200 / 30 DAY CV LANCET THIN BRAND 1 MD1 200 / 30 DAY CV LANCET THIN 26G BRAND 1 MD1 200 / 30 DAY CV LANCET ULTRA THIN 30G BRAND 1 MD1 200 / 30 DAY CV LANCING DEVICE BRAND 1 CV ULTRA THIN LANCET BRAND 1 MD1 200 / 30 DAY DIATAR EAY TET II LANCET BRAND 1 MD1 200 / 30 DAY DIATAR EAY TET LANCET BRAND 1 MD1 200 / 30 DAY GE 105 LAT UPDATED 05/2016

107 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION DIATRUE CONTROL LEVEL 1 BRAND 1 DIATRUE CONTROL LEVEL 2 BRAND 1 DROPLET LANCET ULTRA THIN 30G BRAND 1 MD1 200 / 30 DAY DROPLET LANCING DEVICE BRAND 1 DRUG MART LANCET THIN 26G BRAND 1 MD1 200 / 30 DAY DRUG MART LANCET ULTRA THIN BRAND 1 MD1 200 / 30 DAY DRUG MART LANCING DEVICE BRAND 1 DRUG MART ON-THE-GO LANCET 30G BRAND 1 MD1 200 / 30 DAY DRUG MART ULTRA COMFORT YR BRAND 1 MD1 450 / 90 DAY DRUG MART UNIFINE PENTIP BRAND 1 MD1 150 / 30 DAY DRUG MART UNIFINE PENTIP PLU BRAND 1 MD1 150 / 30 DAY DRUG MART UNILET LANCET 28G BRAND 1 MD1 200 / 30 DAY DRUG MART UNILET LANCET 30G BRAND 1 MD1 200 / 30 DAY DUANE READE LANCET ALTERN ITE BRAND 1 MD1 200 / 30 DAY DUANE READE LANCET UPER THIN BRAND 1 MD1 200 / 30 DAY DUANE READE LANCET ULTRA THIN BRAND 1 MD1 200 / 30 DAY DUANE READE UNIFINE PENTIP BRAND 1 MD1 150 / 30 DAY E-Z JECT LANCET MICRO-THIN 33G BRAND 1 MD1 200 / 30 DAY E-Z JECT LANCET UPER THIN 30G BRAND 1 MD1 200 / 30 DAY E-Z JECT LANCET BRAND 1 MD1 200 / 30 DAY E-Z JECT LANCET 21G BRAND 1 MD1 200 / 30 DAY E-Z JECT LANCET THIN 26G BRAND 1 MD1 200 / 30 DAY EAY COMFORT INULIN YRINGE BRAND 1 MD1 450 / 90 DAY EAY COMFORT LANCET BRAND 1 MD1 200 / 30 DAY EAY COMFORT PEN NEEDLE BRAND 1 MD1 150 / 30 DAY EAY MINI LANCING DEVICE BRAND 1 EAY PLU CONTROL (OLUTION LOW, OLUTION NORMAL) BRAND 1 GE 106 LAT UPDATED 05/2016

108 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION EAY PLU II CONTROL OLUTION LOW BRAND 1 EAY TEP CONTROL (OLUTION LOW, OLUTION NORMAL) EAY TALK CONTROL (OLUTION LOW, OLUTION NORMAL) BRAND 1 BRAND 1 EAY TOUCH CONTROL HIGH & LOW BRAND 1 EAY TOUCH HEALTHPRO CONTROL BRAND 1 EAY TOUCH INULIN AFETY YR BRAND 1 MD1 450 / 90 DAY EAY TOUCH INULIN YRINGE BRAND 1 MD1 450 / 90 DAY EAY TOUCH LANCET 21G BRAND 1 MD1 200 / 30 DAY EAY TOUCH LANCET 23G BRAND 1 MD1 200 / 30 DAY EAY TOUCH LANCET 26G BRAND 1 MD1 200 / 30 DAY EAY TOUCH LANCET 26G/TWIT BRAND 1 MD1 200 / 30 DAY EAY TOUCH LANCET 28G BRAND 1 MD1 200 / 30 DAY EAY TOUCH LANCET 28G/TWIT BRAND 1 MD1 200 / 30 DAY EAY TOUCH LANCET 30G BRAND 1 MD1 200 / 30 DAY EAY TOUCH LANCET 30G/TWIT BRAND 1 MD1 200 / 30 DAY EAY TOUCH LANCET 32G BRAND 1 MD1 200 / 30 DAY EAY TOUCH LANCET 32G/TWIT BRAND 1 MD1 200 / 30 DAY EAY TOUCH LANCET 33G/TWIT BRAND 1 MD1 200 / 30 DAY EAY TOUCH LANCING DEVICE BRAND 1 EAY TOUCH PEN NEEDLE BRAND 1 MD1 150 / 30 DAY EAY TOUCH AFETY LANCET 21G BRAND 1 MD1 200 / 30 DAY EAY TOUCH AFETY LANCET 23G BRAND 1 MD1 200 / 30 DAY EAY TOUCH AFETY LANCET 26G BRAND 1 MD1 200 / 30 DAY EAY TOUCH AFETY LANCET 28G BRAND 1 MD1 200 / 30 DAY EAY TRAK CONTROL (OLUTION LOW, OLUTION NORMAL) BRAND 1 GE 107 LAT UPDATED 05/2016

109 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION EAY TWIT & CAP LANCET BRAND 1 MD1 200 / 30 DAY EAYGLUCO CONTROL (OLUTION LOW, OLUTION NORMAL) BRAND 1 EAYMAX 15 LEVEL 1 CONTROL BRAND 1 EAYMAX 15 LEVEL 2 CONTROL BRAND 1 EAYMAX CONTROL (OLUTION LOW, OLUTION NORMAL) ECLIPE CONTROL (LIQUID LOW, OLUTION NORMAL) BRAND 1 BRAND 1 ELEMENT COMCT CONTROL 2 BRAND 1 ELEMENT COMCT CONTROL 3 BRAND 1 ELEMENT CONTROL (LIQUID LOW, LIQUID NORMAL) ELEMENT PLU CONTROL (OLUTION LOW, OLUTION NORMAL) BRAND 1 BRAND 1 EMBRACE CONTROL BRAND 1 EMBRACE EVO CONTROL LEVEL 1 BRAND 1 EMBRACE EVO CONTROL LEVEL 2 BRAND 1 EMBRACE LANCET ULTRA THIN 30G BRAND 1 MD1 200 / 30 DAY EMBRACE PRO GLUCOE CONTROL BRAND 1 ENVIION CONTROL (OLUTION LOW, OLUTION NORMAL) BRAND 1 EQL COLOR LANCET 21G BRAND 1 MD1 200 / 30 DAY EQL COLOR LANCET MICRO 33G BRAND 1 MD1 200 / 30 DAY EQL INULIN YRINGE BRAND 1 MD1 450 / 90 DAY EQL HORT PEN NEEDLE BRAND 1 MD1 150 / 30 DAY EQL UPER THIN LANCET 30G BRAND 1 MD1 200 / 30 DAY EQL THIN LANCET 26G BRAND 1 MD1 200 / 30 DAY EQL ULTRA COMFORT INULIN YR BRAND 1 MD1 450 / 90 DAY EQL ULTRA HORT PEN NEEDLE BRAND 1 MD1 150 / 30 DAY EVENCARE CONTROL LOW/HIGH BRAND 1 GE 108 LAT UPDATED 05/2016

110 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION EVENCARE G2 LOW/HIGH CONTROL BRAND 1 EVENCARE G3 LOW/HIGH CONTROL BRAND 1 EVOLUTION CONTROL BRAND 1 EXCEL COMFORT POINT PEN NEEDLE (PEN MIC 29G 12MM, PEN MIC 31G 6 MM, PEN MIC 31G 8 MM) BRAND 1 MD1 150 / 30 DAY EXEL COMFORT POINT INULIN YR BRAND 1 MD1 450 / 90 DAY EZ MART BLOOD GLUCOE LANCET BRAND 1 MD1 200 / 30 DAY EZ-LET LANCET 21G BRAND 1 MD1 200 / 30 DAY EZ-LET LANCET 26G BRAND 1 MD1 200 / 30 DAY EZ-LET LANCET 28G BRAND 1 MD1 200 / 30 DAY EZ-LET LANCET 30G BRAND 1 MD1 200 / 30 DAY FEMCAP BRAND 0 FIFTY50 CONTROL 2.0 BRAND 1 FIFTY50 LANCING DEVICE BRAND 1 FIFTY50 PEN NEEDLE (PEN MIC 5, PEN MIC 8) BRAND 1 MD1 150 / 30 DAY FIFTY50 AFETY EAL LANCET BRAND 1 MD1 200 / 30 DAY FIFTY50 UPERIOR COMFORT YR BRAND 1 MD1 450 / 90 DAY FINE 30 BRAND 1 MD1 200 / 30 DAY FINGERTIX LANCET BRAND 1 MD1 200 / 30 DAY fluticasone propionate (bulk) FLUTICAONE PROPIONATE POWDER BRAND 1 FORA CONTROL (OLUTION LOW, OLUTION NORMAL) BRAND 1 FORA LANCET BRAND 1 MD1 200 / 30 DAY FORA LANCING DEVICE BRAND 1 FORACARE GDH CONTROL (OLUTION LOW, OLUTION NORMAL) FORTICARE CONTROL (OLUTION LOW, OLUTION NORMAL) BRAND 1 BRAND 1 GE 109 LAT UPDATED 05/2016

111 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION FRED PHARMACY AUTOLET LANCING BRAND 1 FRED PHARMACY UNIFINE PENTIP+ BRAND 1 MD1 150 / 30 DAY FRED PHARMACY UNIFINE PENTIP BRAND 1 MD1 150 / 30 DAY FRED PHARMACY UNILET LANC 28G BRAND 1 MD1 200 / 30 DAY FRED PHARMACY UNILET LANC 30G BRAND 1 MD1 200 / 30 DAY FREETYLE CONTROL OLUTION BRAND 1 FREETYLE LANCET BRAND 1 MD1 200 / 30 DAY FREETYLE PRECIION IN YR BRAND 1 MD1 450 / 90 DAY FREETYLE UNITICK II LANCET BRAND 1 MD1 200 / 30 DAY GE100 CONTROL BRAND 1 GLOBAL EAE INJECT PEN NEEDLE BRAND 1 MD1 150 / 30 DAY GLOBAL INJECT EAE INULIN YR BRAND 1 MD1 450 / 90 DAY GLOBAL INJECT EAE LANCET 28G BRAND 1 MD1 200 / 30 DAY GLOBAL INJECT EAE LANCET 30G BRAND 1 MD1 200 / 30 DAY GLOBAL LANCING DEVICE BRAND 1 GLUCOCARD 01 CONTROL BRAND 1 GLUCOCARD EXPREION CONTROL BRAND 1 GLUCOCARD HINE CONTROL BRAND 1 GLUCOCARD X-ENOR CONTROL BRAND 1 GLUCOCOM CONTROL LIQUID NORMAL BRAND 1 GLUCOCOM LANCET 28G BRAND 1 MD1 200 / 30 DAY GLUCOCOM LANCET 30G BRAND 1 MD1 200 / 30 DAY GLUCOCOM LANCET 33G BRAND 1 MD1 200 / 30 DAY GLUCOLAB CONTROL (LIQUID LOW, LIQUID NORMAL) BRAND 1 GLUCOLET 2 AUTOMATIC LANCING BRAND 1 GLUCOPRO INULIN YRINGE BRAND 1 MD1 450 / 90 DAY glucose blood MD1 100 / 30 DAY GE 110 LAT UPDATED 05/2016

112 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION GLUCOE CONTROL BRAND 1 GLUCOOURCE LANCET DEVICE BRAND 1 GLUCOOURCE LANCET BRAND 1 MD1 200 / 30 DAY GMATE CONTROL LEVEL 2 BRAND 1 GNP CLICKFINE PEN NEEDLE BRAND 1 MD1 150 / 30 DAY GNP INULIN YRINGE BRAND 1 MD1 450 / 90 DAY GNP LANCET BRAND 1 MD1 200 / 30 DAY GNP LANCET 21G BRAND 1 MD1 200 / 30 DAY GNP LANCET MICRO THIN 33G BRAND 1 MD1 200 / 30 DAY GNP LANCET UPER THIN 30G BRAND 1 MD1 200 / 30 DAY GNP LANCET THIN BRAND 1 MD1 200 / 30 DAY GNP LANCET THIN 26G BRAND 1 MD1 200 / 30 DAY GNP MICRO THIN LANCET 33G BRAND 1 MD1 200 / 30 DAY GNP UPER THIN LANCET 30G BRAND 1 MD1 200 / 30 DAY GNP ULTRA COM INULIN YRINGE BRAND 1 MD1 450 / 90 DAY H&H THINLET LANCET 26G BRAND 1 MD1 200 / 30 DAY H&H THINLET LANCET 30G BRAND 1 MD1 200 / 30 DAY H-E-B INCONTROL ADV LANCING BRAND 1 H-E-B INCONTROL LANCET 28G BRAND 1 MD1 200 / 30 DAY H-E-B INCONTROL LANCET 30G BRAND 1 MD1 200 / 30 DAY H-E-B INCONTROL PEN NEEDLE BRAND 1 MD1 150 / 30 DAY HAEMOLANCE BRAND 1 MD1 200 / 30 DAY HAEMOLANCE LOW FLOW LANCET BRAND 1 MD1 200 / 30 DAY HAEMOLANCE PLU BRAND 1 MD1 200 / 30 DAY HAEMOLANCE PLU HIGH FLOW BRAND 1 MD1 200 / 30 DAY HAEMOLANCE PLU LOW FLOW BRAND 1 MD1 200 / 30 DAY GE 111 LAT UPDATED 05/2016

113 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION HAEMOLANCE PLU MAX FLOW BRAND 1 MD1 200 / 30 DAY HAEMOLANCE PLU PEDIATRIC FLOW BRAND 1 MD1 200 / 30 DAY HEALTH CARE LANCING DEVICE BRAND 1 HEALTHWIE LANCET 30G BRAND 1 MD1 200 / 30 DAY HEALTHWIE LANCING PEN BRAND 1 HEALTHWIE MINI PEN NEEDLE BRAND 1 MD1 150 / 30 DAY HEALTHWIE PEN NEEDLE BRAND 1 MD1 150 / 30 DAY HEALTHWIE HORT PEN NEEDLE BRAND 1 MD1 150 / 30 DAY HEALTHWIE UNIFINE PENTIP BRAND 1 MD1 150 / 30 DAY HEALTHY ACCENT LANCING DEVICE BRAND 1 HEALTHY ACCENT UNIFINE PENTIP BRAND 1 MD1 150 / 30 DAY HEALTHY ACCENT UNILET LANCET BRAND 1 MD1 200 / 30 DAY HM LANCET MICRO THIN 33G BRAND 1 MD1 200 / 30 DAY HM LANCET ULTRA THIN 30G BRAND 1 MD1 200 / 30 DAY HY-VEE INULIN YRINGE BRAND 1 MD1 450 / 90 DAY IN TOUCH GLUCOE CONTROL BRAND 1 IN TOUCH LANCING DEVICE BRAND 1 IN TOUCH TERILE LANCET 30G BRAND 1 MD1 200 / 30 DAY INFINITY CONTROL (OLUTION LOW, OLUTION NORMAL) BRAND 1 insulin pen needle MD1 150 / 30 DAY INULIN YRINGE BRAND 1 MD1 450 / 90 DAY INULIN YRINGE/NEEDLE (MIC 27G 0.5 ML, 28G 0.5 ML, 28G 1 ML, MIC 28G 1 ML, MIC 28G 0.5 ML) BRAND 1 MD1 450 / 90 DAY insulin syringe/needle u-100 MD1 450 / 90 DAY INUPEN PEN NEEDLE MIC 32G X 4 MM BRAND 1 MD1 150 / 30 DAY INUPEN ENITIVE MIC 32G X 6 MM BRAND 1 MD1 150 / 30 DAY GE 112 LAT UPDATED 05/2016

114 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION INUPEN ULTRAFIN BRAND 1 MD1 150 / 30 DAY KETOCARE BRAND 1 MPL 1 / 30 Days KETOTIX BRAND 1 MPL 1 / 30 Days KINNEY LANCET BRAND 1 MD1 200 / 30 DAY KINNEY THIN LANCET BRAND 1 MD1 200 / 30 DAY KINRAY INULIN YRINGE BRAND 1 MD1 450 / 90 DAY KMART VALU INULIN YRINGE 29G MIC U ML KMART VALU INULIN YRINGE 30G MIC U ML BRAND 1 MD1 150 / 30 DAY BRAND 1 MD1 150 / 30 DAY KROGER INULIN YRINGE BRAND 1 MD1 450 / 90 DAY KROGER LANCET 21G BRAND 1 MD1 200 / 30 DAY KROGER LANCET MICRO THIN 33G BRAND 1 MD1 200 / 30 DAY KROGER LANCET UPER THIN BRAND 1 MD1 200 / 30 DAY KROGER LANCET THIN 26G BRAND 1 MD1 200 / 30 DAY KROGER LANCET ULTRATHIN 30G BRAND 1 MD1 200 / 30 DAY KROGER LANCING DEVICE BRAND 1 KROGER PEN NEEDLE BRAND 1 MD1 150 / 30 DAY LADY LITE LANCET BRAND 1 MD1 200 / 30 DAY LANCET DEVICE BRAND 1 LANCET DEVICE WITH EJECTOR BRAND 1 lancet devices LANCET 28G BRAND 1 MD1 200 / 30 DAY LANCET 30G BRAND 1 MD1 200 / 30 DAY LANCET MICRO THIN 33G BRAND 1 MD1 200 / 30 DAY LANCET MIC BRAND 1 MD1 200 / 30 DAY LANCET UPER THIN 28G BRAND 1 MD1 200 / 30 DAY LANCET THIN BRAND 1 MD1 200 / 30 DAY GE 113 LAT UPDATED 05/2016

115 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION LANCET ULTRA FINE BRAND 1 MD1 200 / 30 DAY LANCET ULTRA THIN BRAND 1 MD1 200 / 30 DAY LANCET ULTRA THIN 30G BRAND 1 MD1 200 / 30 DAY LANCING DEVICE BRAND 1 LANZO BRAND 1 LEADER ADVANCED LANCING DEVICE BRAND 1 LEADER INULIN YRINGE BRAND 1 MD1 450 / 90 DAY LEADER UNIFINE PENTIP BRAND 1 MD1 150 / 30 DAY LEADER UNIFINE PENTIP PLU BRAND 1 MD1 150 / 30 DAY LIBERTY GLUCOE CONTROL (LIQUID NORMAL, OLUTION, OLUTION NORMAL) BRAND 1 LIBERTY GLUCOE CONTROL MID BRAND 1 LIBERTY MEDICAL LANCET BRAND 1 MD1 200 / 30 DAY LIBERTY MINI LANCING DEVICE BRAND 1 LITE TOUCH LANCET BRAND 1 MD1 200 / 30 DAY LITE TOUCH LANCING DEVICE BRAND 1 LITE TOUCH LANCING PEN BRAND 1 LITE TOUCH PEN NEEDLE BRAND 1 MD1 150 / 30 DAY LITETOUCH INULIN YRINGE BRAND 1 MD1 450 / 90 DAY LITETOUCH LANCET BRAND 1 MD1 200 / 30 DAY LITETOUCH PEN NEEDLE BRAND 1 MD1 150 / 30 DAY LIVE BETTER ADV LANCING DEVICE BRAND 1 LIVE BETTER LANCET UPER THIN BRAND 1 MD1 200 / 30 DAY LIVE BETTER LANCET ULTRA THIN BRAND 1 MD1 200 / 30 DAY LIVE BETTER PEN NEEDLE BRAND 1 MD1 150 / 30 DAY LONG INULIN YRINGE BRAND 1 MD1 450 / 90 DAY LONG LANCET TANDARD BRAND 1 MD1 200 / 30 DAY LONG LANCET THIN BRAND 1 MD1 200 / 30 DAY GE 114 LAT UPDATED 05/2016

116 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION LONG LANCET ULTRA THIN BRAND 1 MD1 200 / 30 DAY MAGELLAN INULIN AFETY YR BRAND 1 MD1 450 / 90 DAY MAJOR COMFORT LANCET BRAND 1 MD1 200 / 30 DAY MAXI-COMFORT INULIN YRINGE BRAND 1 MD1 450 / 90 DAY MAXIMA CONTROL BRAND 1 MEDI-LANCE LANCET BRAND 1 MD1 200 / 30 DAY MEDIC INULIN YRINGE BRAND 1 MD1 450 / 90 DAY MEDICHOICE AFETY LANCET BRAND 1 MD1 200 / 30 DAY MEDICHOICE AFETY LANCET EXTRA BRAND 1 MD1 200 / 30 DAY MEDICHOICE AFETY LANCET NORM BRAND 1 MD1 200 / 30 DAY MEDICINE HOPPE LANCET BRAND 1 MD1 200 / 30 DAY MEDICINE HOPPE LANCET THIN BRAND 1 MD1 200 / 30 DAY MEDICINE HOPPE PEN NEEDLE BRAND 1 MD1 150 / 30 DAY MEDIENE GLUCOE KETONE CONTR BRAND 1 MEDIENE HI/MID/LOW CONTROL BRAND 1 MEDIENE HIGH/LOW CONTROL BRAND 1 MEDIENE MID CONTROL BRAND 1 MEDIENE THIN LANCET BRAND 1 MD1 200 / 30 DAY MEDLANCE EXTRA 21G BRAND 1 MD1 200 / 30 DAY MEDLANCE LITE 25G BRAND 1 MD1 200 / 30 DAY MEDLANCE PLU EXTRA 21G BRAND 1 MD1 200 / 30 DAY MEDLANCE PLU LANCET BRAND 1 MD1 200 / 30 DAY MEDLANCE PLU LITE 25G BRAND 1 MD1 200 / 30 DAY MEDLANCE PLU PECIAL 0.8MM BRAND 1 MD1 200 / 30 DAY MEDLANCE PLU UPERLITE 30G BRAND 1 MD1 200 / 30 DAY MEDLANCE PLU UNIVERAL 21G BRAND 1 MD1 200 / 30 DAY MEDLANCE UNIVERAL 21G BRAND 1 MD1 200 / 30 DAY GE 115 LAT UPDATED 05/2016

117 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION MEIJER LANCET BRAND 1 MD1 200 / 30 DAY MEIJER LANCET THIN BRAND 1 MD1 200 / 30 DAY MEIJER LANCET UNIVERAL 30G BRAND 1 MD1 200 / 30 DAY MEIJER LANCET UNIVERAL 33G BRAND 1 MD1 200 / 30 DAY MEIJER PEN NEEDLE BRAND 1 MD1 150 / 30 DAY MEIJER UPER THIN LANCET BRAND 1 MD1 200 / 30 DAY metaproterenol sulfate powder MICRODOT CONTROL BRAND 1 MICRODOT CONTROL HIGH/LOW BRAND 1 MICROLET LANCET BRAND 1 MD1 200 / 30 DAY MICROTAINER AFETY FLOW LANCET BRAND 1 MD1 200 / 30 DAY MINI LANCING DEVICE BRAND 1 MONOJECT INULIN YRINGE (MIC 25G 5/8" 1 ML, MIC 27G 1/2" 1 ML, MIC 28G 1/2" 0.5 ML, MIC 28G 1/2" 1 ML, MIC 29G 1/2" 1 ML, MIC 29G 1/2" 0.3 ML, MIC 29G 1/2" 0.5 ML, MIC 30G 5/16" 0.3 ML, MIC 30G 5/16" 0.5 ML, MIC 30G 5/16" 1 ML, MIC 31G 5/16" 1 ML) MONOJECT INULIN YRINGE MIC U ML BRAND 1 MD1 450 / 90 DAY BRAND 1 MD1 150 / 30 DAY MONOJECT ULTRA COMFORT YRINGE BRAND 1 MD1 450 / 90 DAY MONOLET LANCET BRAND 1 MD1 200 / 30 DAY MONOLET OPD LANCET BRAND 1 MD1 200 / 30 DAY MONOLETTOR AFETY LANCET BRAND 1 MD1 200 / 30 DAY MOORE MONO INULIN YRINGE BRAND 1 MD1 450 / 90 DAY M INULIN YRINGE BRAND 1 MD1 450 / 90 DAY MYGLUCOHEALTH CONTROL BRAND 1 MYGLUCOHEALTH LANCET 30G BRAND 1 MD1 200 / 30 DAY NETGROUP LANCET BRAND 1 MD1 200 / 30 DAY GE 116 LAT UPDATED 05/2016

118 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION NEUTEK 2TEK CONTROL BRAND 1 NOVA MAX PLU GLU/KET CONTROL BRAND 1 NOVA AFETY LANCET 23G BRAND 1 MD1 200 / 30 DAY NOVA AFETY LANCET 28G BRAND 1 MD1 200 / 30 DAY NOVA UREFLEX LANCET BRAND 1 MD1 200 / 30 DAY NOVA UREFLEX LANCING DEVICE BRAND 1 NOVOFINE BRAND 1 MD1 150 / 30 DAY NOVOFINE AUTOCOVER BRAND 1 MD1 150 / 30 DAY NOVOFINE PLU BRAND 1 MD1 150 / 30 DAY NOVOTWIT BRAND 1 MD1 150 / 30 DAY nystatin (bulk) powder OMNIFLEX DIAPHRAGM BRAND 0 ON CALL EXPRE GLUCOE CONTR BRAND 1 ON CALL LANCET BRAND 1 MD1 200 / 30 DAY ON CALL LANCING DEVICE BRAND 1 ON CALL PLU GLUCOE CONTROL BRAND 1 ON CALL PLU LANCET BRAND 1 MD1 200 / 30 DAY ON CALL PLU LANCING DEVICE BRAND 1 ON CALL VIVID GLUCOE CONTROL BRAND 1 ONETOUCH DELICA LANCET 33G BRAND 1 MD1 200 / 30 DAY ONETOUCH DELICA LANCET FINE BRAND 1 MD1 200 / 30 DAY ONETOUCH DELICA LANCING DEV BRAND 1 ONETOUCH FINEPOINT LANCET BRAND 1 MD1 200 / 30 DAY ONETOUCH LANCET BRAND 1 MD1 200 / 30 DAY ONETOUCH ULTRA CONTROL BRAND 1 ONETOUCH ULTRAOFT LANCET BRAND 1 MD1 200 / 30 DAY ONETOUCH VERIO OLUTION BRAND 1 OPTUMRX GLUCOE CONTROL BRAND 1 GE 117 LAT UPDATED 05/2016

119 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION ORINI INULIN YRINGE BRAND 1 MD1 450 / 90 DAY ORTHO DIAPHRAGM ALL-FLEX BRAND 0 ORTHO DIAPHRAGM COIL BRAND 0 ORTHO DIAPHRAGM FLAT BRAND 0 RAGARD INTRAUTERINE COPPER BRAND 0 GL Female PC LANCET UPER THIN 30G BRAND 1 MD1 200 / 30 DAY PC UNIFINE PENTIP BRAND 1 MD1 150 / 30 DAY PEN NEEDLE BRAND 1 MD1 150 / 30 DAY PEN NEEDLE 3/16" BRAND 1 MD1 150 / 30 DAY PEN NEEDLE 5/16" BRAND 1 MD1 150 / 30 DAY PENTIP BRAND 1 MD1 150 / 30 DAY PERFECT LANCET 28G BRAND 1 MD1 200 / 30 DAY PERFECT LANCET 30G BRAND 1 MD1 200 / 30 DAY PHARMACIT CHOICE LANCET BRAND 1 MD1 200 / 30 DAY PHARMACY COUNTER LANCET BRAND 1 MD1 200 / 30 DAY PHIOHEX BRAND 1 POCKETCHEM EZ CONTROL BRAND 1 PRECIION GLUCOE KETONE CONTR BRAND 1 PRECIION URE-DOE YRINGE BRAND 1 MD1 450 / 90 DAY PRECIION UREDOE PLU YR BRAND 1 MD1 450 / 90 DAY PREFERRED PLU INULIN YRINGE BRAND 1 MD1 450 / 90 DAY PREFERRED PLU LANCET COLORED BRAND 1 MD1 200 / 30 DAY PREFERRED PLU LANCET THIN BRAND 1 MD1 200 / 30 DAY PREFERRED PLU UNIFINE PENTIP BRAND 1 MD1 150 / 30 DAY PRENTIF FITTING ET BRAND 0 PRETIGE GLUCOE CONTROL LIQUID LOW PRODIGY CONTROL OLUTION OLUTION LOW BRAND 1 BRAND 1 GE 118 LAT UPDATED 05/2016

120 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION PRODIGY INULIN YRINGE BRAND 1 MD1 450 / 90 DAY PRODIGY LANCET 21G BRAND 1 MD1 200 / 30 DAY PRODIGY LANCET 26G BRAND 1 MD1 200 / 30 DAY PRODIGY LANCET 28G BRAND 1 MD1 200 / 30 DAY PRODIGY LANCING DEVICE BRAND 1 PRODIGY MINI PEN NEEDLE BRAND 1 MD1 150 / 30 DAY PRODIGY AFETY LANCET 26G BRAND 1 MD1 200 / 30 DAY PRODIGY HORT PEN NEEDLE BRAND 1 MD1 150 / 30 DAY PRODIGY TWIT TOP LANCET 28G BRAND 1 MD1 200 / 30 DAY PX ADVANCED LANCING DEVICE BRAND 1 PX EXTRA HORT PEN NEEDLE BRAND 1 MD1 150 / 30 DAY PX INULIN YRINGE BRAND 1 MD1 450 / 90 DAY PX LANCET AUTO INJECTOR BRAND 1 PX LANCET BRAND 1 MD1 200 / 30 DAY PX LANCET ULTRA THIN BRAND 1 MD1 200 / 30 DAY PX MINI PEN NEEDLE BRAND 1 MD1 150 / 30 DAY PX PEN NEEDLE BRAND 1 MD1 150 / 30 DAY QC ADVANCED LANCING DEVICE BRAND 1 QC INULIN YRINGE (MIC 29G 1/2" 0.5 ML, MIC 29G 1/2" 1 ML, MIC 29G 1/2" 0.3 ML, MIC 31G 5/16" 1 ML, MIC 31G 5/16" 0.5 ML) BRAND 1 MD1 450 / 90 DAY QC LANCET UPER THIN 30G BRAND 1 MD1 200 / 30 DAY QC LANCET ULTRA THIN BRAND 1 MD1 200 / 30 DAY QC PEN NEEDLE BRAND 1 MD1 150 / 30 DAY QC UNIFINE PENTIP BRAND 1 MD1 150 / 30 DAY QUICKTEK CONTROL OLUTION BRAND 1 QUINTET CONTROL HIGH/NORMAL BRAND 1 GE 119 LAT UPDATED 05/2016

121 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION RA E-ZJECT COLOR LANCET 33G BRAND 1 MD1 200 / 30 DAY RA E-ZJECT LANCET 28G BRAND 1 MD1 200 / 30 DAY RA E-ZJECT LANCET THIN 26G BRAND 1 MD1 200 / 30 DAY RA E-ZJECT LANCET THIN 28G BRAND 1 MD1 200 / 30 DAY RA E-ZJECT LANCET ULTRA THIN BRAND 1 MD1 200 / 30 DAY RA INULIN YRINGE BRAND 1 MD1 450 / 90 DAY RA LANCING DEVICE BRAND 1 RA PEN NEEDLE BRAND 1 MD1 150 / 30 DAY REFUAH PLU GLUCOE CONTROL BRAND 1 RELI-ON INULIN YRINGE MIC 29G X 1/2" 1 ML BRAND 1 MD1 450 / 90 DAY RELION INULIN YRINGE BRAND 1 MD1 450 / 90 DAY RELION LANCET MICRO-THIN 33G BRAND 1 MD1 200 / 30 DAY RELION LANCET TANDARD 21G BRAND 1 MD1 200 / 30 DAY RELION LANCET THIN 26G BRAND 1 MD1 200 / 30 DAY RELION LANCET ULTRA-THIN 30G BRAND 1 MD1 200 / 30 DAY RELION LANCING DEVICE MIC BRAND 1 RELION MINI PEN NEEDLE BRAND 1 MD1 150 / 30 DAY RELION PEN NEEDLE BRAND 1 MD1 150 / 30 DAY RELION HORT PEN NEEDLE BRAND 1 MD1 150 / 30 DAY RELION ULTRA THIN LANCET 30G BRAND 1 MD1 200 / 30 DAY RELION ULTRA THIN PLU LANCET BRAND 1 MD1 200 / 30 DAY RENEW ADV CARTRIDGE REFILL BRAND 1 MD1 200 / 30 DAY RENEW ADVANCED LANCING DEVICE BRAND 1 REXALL LANCET ULTRA THIN 30G BRAND 1 MD1 200 / 30 DAY RIGHTET GC300 CONTROL LIQUID NORMAL BRAND 1 RIGHTET GD500 LANCING DEVICE BRAND 1 GE 120 LAT UPDATED 05/2016

122 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION RIGHTET GL300 LANCET BRAND 1 MD1 200 / 30 DAY AFENAP INULIN YRINGE BRAND 1 MD1 450 / 90 DAY AFETY LANCET 21G/PREURE ACT BRAND 1 MD1 200 / 30 DAY AFETY LANCET 28G/PREURE ACT BRAND 1 MD1 200 / 30 DAY AFETY LANCET 2MM BRAND 1 MD1 200 / 30 DAY AFETY LANCET BRAND 1 MD1 200 / 30 DAY AFETY LANCET 21G BRAND 1 MD1 200 / 30 DAY AFETY LANCET 28G BRAND 1 MD1 200 / 30 DAY AFETY LET LANCET BRAND 1 MD1 200 / 30 DAY AFETY EAL LANCET BRAND 1 MD1 200 / 30 DAY AFETY-GLIDE YRINGE BRAND 1 MD1 450 / 90 DAY APCARE TWIT TOP LANCET BRAND 1 MD1 200 / 30 DAY B INULIN YRINGE BRAND 1 MD1 450 / 90 DAY B LANCET THIN BRAND 1 MD1 200 / 30 DAY B LANCET ULTRA THIN BRAND 1 MD1 200 / 30 DAY CHNUCK INULIN YRINGE BRAND 1 MD1 450 / 90 DAY HOPKO AUTOLET LANCING DEVICE BRAND 1 HOPKO ON-THE-GO LANCET 30G BRAND 1 MD1 200 / 30 DAY HOPKO UNIFINE PENTIP BRAND 1 MD1 150 / 30 DAY HOPKO UNILET LANCET 28G BRAND 1 MD1 200 / 30 DAY HOPKO UNILET LANCET 30G BRAND 1 MD1 200 / 30 DAY IMPLE DIAGNOTIC LANCING DEV BRAND 1 M INULIN YRINGE BRAND 1 MD1 450 / 90 DAY M LANCET 21G BRAND 1 MD1 200 / 30 DAY M LANCET 33G BRAND 1 MD1 200 / 30 DAY M UPER THIN LANCET 30G BRAND 1 MD1 200 / 30 DAY GE 121 LAT UPDATED 05/2016

123 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION M THIN LANCET 26G BRAND 1 MD1 200 / 30 DAY MART DIABETE VANTAGE LANCET BRAND 1 MD1 200 / 30 DAY MART DIABETE VANTAGE LANCING BRAND 1 MART ENE COLOR LANCET 33G BRAND 1 MD1 200 / 30 DAY MART ENE TANDARD LANCET BRAND 1 MD1 200 / 30 DAY MART ENE UPER THIN LANCET BRAND 1 MD1 200 / 30 DAY MART ENE THIN LANCET 26G BRAND 1 MD1 200 / 30 DAY MARTET CONTROL MEDIUM BRAND 1 MARTET LANCET 28G BRAND 1 MD1 200 / 30 DAY sodium polystyrene sulfonate (bulk) OLARTEK GLUCOE CONTROL BRAND 1 OLU V2 CONTROL OLUTION LOW BRAND 1 OLU V2 LANCET 28G BRAND 1 MD1 200 / 30 DAY OLU V2 LANCING DEVICE BRAND 1 OLU V2 TWIT LANCET 30G BRAND 1 MD1 200 / 30 DAY stannous fluoride (bulk) generic 0 TERILANCE TL BRAND 1 MD1 200 / 30 DAY UPER THIN LANCET BRAND 1 MD1 200 / 30 DAY URE COMFORT INULIN YRINGE BRAND 1 MD1 450 / 90 DAY URE COMFORT LANCET 28G BRAND 1 MD1 200 / 30 DAY URE COMFORT LANCET 30G BRAND 1 MD1 200 / 30 DAY URE COMFORT LANCING PEN BRAND 1 URE COMFORT PEN NEEDLE BRAND 1 MD1 150 / 30 DAY URE EDGE GLUCOE CONTROL (OLUTION LOW, OLUTION NORMAL) BRAND 1 URE-FINE PEN NEEDLE BRAND 1 MD1 150 / 30 DAY URE-JECT INULIN YRINGE BRAND 1 MD1 450 / 90 DAY URE-LANCE FLAT LANCET BRAND 1 MD1 200 / 30 DAY GE 122 LAT UPDATED 05/2016

124 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION URE-LANCE LANCET 26G BRAND 1 MD1 200 / 30 DAY URE-LANCE THIN LANCET 28G BRAND 1 MD1 200 / 30 DAY URE-LANCE ULTRA THIN LANCET BRAND 1 MD1 200 / 30 DAY URE-PEN BRAND 1 URE-TET EAYPLU CONTROL BRAND 1 URE-TOUCH LANCET UNIVERAL BRAND 1 MD1 200 / 30 DAY URECHEK CONTROL OLUTION (OLUTION LIQUID LOW, OLUTION LIQUID NORMAL) BRAND 1 URELITE LANCET BRAND 1 MD1 200 / 30 DAY URETEP GLUCOE CONTROL BRAND 1 URETEP PRO LOW GLUCOE BRAND 1 URETEP PRO NORMAL GLUCOE BRAND 1 TAI DOC CONTROL BRAND 1 TECHLITE AT LANCET BRAND 1 MD1 200 / 30 DAY TECHLITE LANCET BRAND 1 MD1 200 / 30 DAY TECHLITE LANCET 30G BRAND 1 MD1 200 / 30 DAY TELCARE GLUCOE CONTROL BRAND 1 TERUMO INULIN YRINGE (MIC 27G 1/2" 0.5 ML, MIC 27G 1/2" 1 ML, MIC 28G 1/2" 0.5 ML, MIC 28G 1/2" 1 ML, MIC 29G 1/2" 0.5 ML, MIC 29G 1/2" 0.3 ML, MIC 29G 1/2" 1 ML, MIC 30G 3/8" 0.5 ML, MIC 30G 3/8" 0.3 ML) BRAND 1 MD1 450 / 90 DAY TERUMO URGUARD INULIN YR BRAND 1 MD1 450 / 90 DAY TGT ADVANCED LANCING DEVICE BRAND 1 TGT LANCET ALTERNATE ITE BRAND 1 MD1 200 / 30 DAY TGT LANCET MICRO THIN 33G BRAND 1 MD1 200 / 30 DAY TGT LANCET UPER THIN 30G BRAND 1 MD1 200 / 30 DAY TGT LANCET THIN 23G BRAND 1 MD1 200 / 30 DAY TGT LANCET THIN 26G BRAND 1 MD1 200 / 30 DAY GE 123 LAT UPDATED 05/2016

125 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION TGT LANCET ULTRA THIN 28G BRAND 1 MD1 200 / 30 DAY TGT LANCET ULTRA THIN 30G BRAND 1 MD1 200 / 30 DAY TGT LANCING DEVICE BRAND 1 THINPRO INULIN YRINGE (MIC 28G 1/2" 0.5 ML, MIC 28G 1/2" 1 ML, MIC 29G 1/2" 1 ML, MIC 29G 1/2" 0.3 ML, MIC 29G 1/2" 0.5 ML, MIC 30G 3/8" 0.5 ML, MIC 30G 3/8" 0.3 ML) BRAND 1 MD1 450 / 90 DAY TODAY HEALTH LANCING DEVICE BRAND 1 TODAY HEALTH MINI PEN NEEDLE BRAND 1 MD1 150 / 30 DAY TODAY HEALTH PEN NEEDLE BRAND 1 MD1 150 / 30 DAY TODAY HEALTH HORT PEN NEEDLE BRAND 1 MD1 150 / 30 DAY TODAY HEALTH THIN LANCET 28G BRAND 1 MD1 200 / 30 DAY TODAY HEALTH THIN LANCET 30G BRAND 1 MD1 200 / 30 DAY TOPCARE CLICKFINE PEN NEEDLE BRAND 1 MD1 150 / 30 DAY TOPCARE ULTRA COMFORT IN YR BRAND 1 MD1 450 / 90 DAY TRAVEL LANCET BRAND 1 MD1 200 / 30 DAY TRUE METRIX BLOOD GLUCOE TET BRAND 1 MD1 100 / 30 DAY TRUE METRIX LEVEL 1 BRAND 1 TRUE METRIX LEVEL 2 BRAND 1 TRUE METRIX METER BRAND 1 MD1 1 / 730 DAY TRUECONTROL GLUCOE CONT LEV 0 BRAND 1 TRUECONTROL GLUCOE CONT LEV 1 BRAND 1 TRUEDRAW LANCING DEVICE BRAND 1 TRUEPLU INULIN YRINGE BRAND 1 MD1 450 / 90 DAY TRUEPLU LANCET 26G BRAND 1 MD1 200 / 30 DAY TRUEPLU LANCET 28G BRAND 1 MD1 200 / 30 DAY TRUEPLU LANCET 30G BRAND 1 MD1 200 / 30 DAY TRUEPLU LANCET 33G BRAND 1 MD1 200 / 30 DAY GE 124 LAT UPDATED 05/2016

126 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION TRUEPLU AFETY LANCET 28G BRAND 1 MD1 200 / 30 DAY TRUEREULT BLOOD GLUCOE BRAND 1 MD1 1 / 730 DAY TRUETET CONTROL LEVEL 1 BRAND 1 TRUETET CONTROL LEVEL 2 BRAND 1 TRUETET CONTROL LEVEL 3 BRAND 1 TRUETET TET BRAND 1 MD1 100 / 30 DAY TRUETRACK GLUCOE CONTROL BRAND 1 TRUETRACK TET BRAND 1 MD1 100 / 30 DAY ULTI-LANCE AUTO-ADJUT DEVICE BRAND 1 ULTI-LANCE AUTOMATIC BRAND 1 ULTI-LANCE MINI ADJUTABLE BRAND 1 ULTICARE INULIN AFETY YR BRAND 1 MD1 450 / 90 DAY ULTICARE INULIN YRINGE (MIC 28G 1/2" 1 ML, MIC 28G 1/2" 0.5 ML, MIC 29G 1/2" 1 ML, MIC 29G 1/2" 0.3 ML, MIC 29G 1/2" 0.5 ML, MIC 30G 1/2" 1 ML, MIC 30G 5/16" 0.5 ML, MIC 30G 5/16" 1 ML, MIC 30G 1/2" 0.5 ML, MIC 30G 5/16" 0.3 ML, MIC 30G 1/2" 0.3 ML, MIC 31G 5/16" 0.5 ML, MIC 31G 5/16" 1 ML, MIC 31G 5/16" 0.3 ML) ULTICARE MICRO PEN NEEDLE MIC 32G X 4 MM BRAND 1 MD1 450 / 90 DAY BRAND 1 MD1 150 / 30 DAY ULTICARE MINI PEN NEEDLE BRAND 1 MD1 150 / 30 DAY ULTICARE PEN NEEDLE BRAND 1 MD1 150 / 30 DAY ULTICARE HORT PEN NEEDLE BRAND 1 MD1 150 / 30 DAY ULTICARE THIN LANCET 30G BRAND 1 MD1 200 / 30 DAY ULTILET BAIC LANCET 30G BRAND 1 MD1 200 / 30 DAY ULTILET CLAIC LANCET BRAND 1 MD1 200 / 30 DAY ULTILET INULIN YRINGE BRAND 1 MD1 450 / 90 DAY ULTILET INULIN YRINGE HORT BRAND 1 MD1 450 / 90 DAY ULTILET LANCET BRAND 1 MD1 200 / 30 DAY GE 125 LAT UPDATED 05/2016

127 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION ULTILET PEN NEEDLE BRAND 1 MD1 150 / 30 DAY ULTILET AFETY LANCET 23G BRAND 1 MD1 200 / 30 DAY ULTRA COMFORT INULIN YRINGE BRAND 1 MD1 450 / 90 DAY ULTRA THIN LANCET 28G BRAND 1 MD1 200 / 30 DAY ULTRA THIN LANCET 30G BRAND 1 MD1 200 / 30 DAY ULTRA-COMFORT INULIN YRINGE BRAND 1 MD1 450 / 90 DAY ULTRA-THIN II AUTO LANCET BRAND 1 MD1 200 / 30 DAY ULTRA-THIN II IN YR HORT BRAND 1 MD1 450 / 90 DAY ULTRA-THIN II INULIN YRINGE BRAND 1 MD1 450 / 90 DAY ULTRA-THIN II LANCET BRAND 1 MD1 200 / 30 DAY ULTRA-THIN II MINI PEN NEEDLE BRAND 1 MD1 150 / 30 DAY ULTRA-THIN II PEN NEEDLE HORT BRAND 1 MD1 150 / 30 DAY ULTRA-THIN II PEN NEEDLE BRAND 1 MD1 150 / 30 DAY ULTRATRAK PRO CONTROL BRAND 1 ULTRATRAK ULTIMATE CONTROL BRAND 1 UNIFINE PENTIP BRAND 1 MD1 150 / 30 DAY UNIFINE PENTIP PLU BRAND 1 MD1 150 / 30 DAY UNILET COMFORTOUCH LANCET BRAND 1 MD1 200 / 30 DAY UNILET EXCELITE BRAND 1 MD1 200 / 30 DAY UNILET EXCELITE II BRAND 1 MD1 200 / 30 DAY UNILET G.P. LANCET BRAND 1 MD1 200 / 30 DAY UNILET G.P. UPERLITE LANCET BRAND 1 MD1 200 / 30 DAY UNILET GP 28 ULTRA THIN BRAND 1 MD1 200 / 30 DAY UNILET LANCET BRAND 1 MD1 200 / 30 DAY UNILET MICRO-THIN 33G BRAND 1 MD1 200 / 30 DAY UNILET UPER-THIN 30G BRAND 1 MD1 200 / 30 DAY GE 126 LAT UPDATED 05/2016

128 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION UNILET UPERLITE LANCET BRAND 1 MD1 200 / 30 DAY UNILET ULTRA-THIN 28G BRAND 1 MD1 200 / 30 DAY UNITIK 3 GENTLE BRAND 1 MD1 200 / 30 DAY UNITIK AFETY LANCET 28G BRAND 1 MD1 200 / 30 DAY UNITIK AFETY LANCET 30G BRAND 1 MD1 200 / 30 DAY UNITRIP CONTROL OLUTION LOW BRAND 1 UNIVERAL 1 LANCET THIN 26G BRAND 1 MD1 200 / 30 DAY UNIVERAL 1 LANCET ULTRA THIN BRAND 1 MD1 200 / 30 DAY V-R MONO INULIN YRINGE BRAND 1 MD1 450 / 90 DAY VALUE HEALTH INULIN YRINGE BRAND 1 MD1 450 / 90 DAY VALUE PLU LANCET TANDARD 21G BRAND 1 MD1 200 / 30 DAY VALUE PLU LANCET UPER THIN BRAND 1 MD1 200 / 30 DAY VALUE PLU LANCET THIN 26G BRAND 1 MD1 200 / 30 DAY VALUE PLU LANCING DEVICE BRAND 1 VALUMARK LANCET UPER THIN 30G BRAND 1 MD1 200 / 30 DAY VALUMARK LANCET ULTRA THIN 28G BRAND 1 MD1 200 / 30 DAY VALUMARK PEN NEEDLE BRAND 1 MD1 150 / 30 DAY VANIHPOINT INULIN YRINGE BRAND 1 MD1 450 / 90 DAY VICTORY CONTROL LEVEL 1/2 BRAND 1 VIDA MIA AUTOLET LANCING DEV BRAND 1 VIDA MIA UNIFINE PENTIP BRAND 1 MD1 150 / 30 DAY VIDA MIA UNILET LANCET 28G BRAND 1 MD1 200 / 30 DAY VIDA MIA UNILET LANCET 30G BRAND 1 MD1 200 / 30 DAY VITOGARD BRAND 4 VOCAL POINT CONTROL OLUTION LOW BRAND 1 VP INULIN YRINGE BRAND 1 MD1 450 / 90 DAY W&F LANCET 26G BRAND 1 MD1 200 / 30 DAY GE 127 LAT UPDATED 05/2016

129 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION W&F LANCET COLORED 21G BRAND 1 MD1 200 / 30 DAY WALGREEN ADV TRAVEL LANCET BRAND 1 MD1 200 / 30 DAY WALGREEN LANCET BRAND 1 MD1 200 / 30 DAY WALGREEN LANCET MICRO THIN BRAND 1 MD1 200 / 30 DAY WALGREEN LANCET UPER THIN BRAND 1 MD1 200 / 30 DAY WALGREEN LANCING DEVICE BRAND 1 WALGREEN THIN LANCET BRAND 1 MD1 200 / 30 DAY WALGREEN ULTRA THIN LANCET BRAND 1 MD1 200 / 30 DAY water for irrigation, sterile WD MEDIC INULIN YRINGE BRAND 1 MD1 450 / 90 DAY WEGMAN UNIFINE PENTIP PLU BRAND 1 MD1 150 / 30 DAY WIDE-EAL DIAPHRAGM 60 BRAND 0 WIDE-EAL DIAPHRAGM 65 BRAND 0 WIDE-EAL DIAPHRAGM 70 BRAND 0 WIDE-EAL DIAPHRAGM 75 BRAND 0 WIDE-EAL DIAPHRAGM 80 BRAND 0 WIDE-EAL DIAPHRAGM 85 BRAND 0 WIDE-EAL DIAPHRAGM 90 BRAND 0 WIDE-EAL DIAPHRAGM 95 BRAND 0 XPRE CONTROL BRAND 1 OPHTHALMIC AGENT OPHTHALMIC AGENT, OTHER bacitracin (ophthalmic) generic 3 LACRIERT BRAND 3 LATACAFT BRAND 2 neomycin-bacitracin zn-polymyxin neomycin-polymy-dexameth (oint, susp) neomycin-polymyxin-hc (ophth) polymyxin b-trimethoprim GE 128 LAT UPDATED 05/2016

130 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION proparacaine hcl RETAI BRAND 2 tobramycin-dexamethasone tropicamide (soln 0.5%, soln 1%) OPHTHALMIC ANTI-ALLERGY AGENT ALOCRIL BRAND 3 ALOMIDE BRAND 3 azelastine hcl (ophth) MPL 1 / claim BEPREVE BRAND 3 cromolyn sodium (ophth) EMADINE BRAND 3 epinastine hcl (ophth) TADAY BRAND 2 TANOL BRAND 3 OPHTHALMIC ANTI-INFLAMMATORIE ALREX BRAND 2 bromfenac sodium (ophth) dexamethasone sodium phosphate (ophth) diclofenac sodium (ophth) DUREZOL BRAND 2 fluorometholone (ophth) flurbiprofen sodium FML BRAND 3 FML FORTE BRAND 3 ILEVRO BRAND 3 ketorolac tromethamine ophth soln 0.4% MPL 1 / claim ketorolac tromethamine ophth soln 0.5% MPL 1 / Claim LOTEMAX (GEL 0.5 %, OINTMENT 0.5 %, UPENION 0.5 %) BRAND 2 MAXIDEX BRAND 3 GE 129 LAT UPDATED 05/2016

131 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION NEVANAC BRAND 3 PRED MILD BRAND 3 prednisolone acetate (ophth) PREDNIOLONE ODIUM PHOPHATE OLUTION 1 % BRAND 3 VEXOL BRAND 3 OPHTHALMIC ANTIGLAUCOMA AGENT apraclonidine hcl AZOPT BRAND 2 MPL 1 / Claim betaxolol hcl (ophth) MPL 1 / Claim brimonidine tartrate MPL 1 / Claim carteolol hcl (ophth) COMBIGAN BRAND 2 dorzolamide hcl MPL 1 / Claim dorzolamide hcl-timolol maleate MPL 1 / Claim IOPIDINE OLUTION 1 % BRAND 3 levobunolol hcl MPL 1 / Claim methazolamide (tab 25 mg, tab 50 mg) 6 per day metipranolol PHOPHOLINE IODIDE BRAND 3 pilocarpine hcl timolol maleate (ophth) OPHTHALMIC PROTAGLANDIN AND PROTAMIDE ANALOG bimatoprost ophth soln 0.03% generic 3 latanoprost ophth soln 0.005% LUMIGAN OLUTION 0.01 % BRAND 3 T TRAVATAN Z BRAND 2 ZIOPTAN BRAND 2 GE 130 LAT UPDATED 05/2016

132 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION OTIC AGENT acetic acid (otic) antipyrine-benzocaine otic soln mg/ml ( %) CIPRO HC BRAND 3 CIPRODEX BRAND 2 COLY-MYCIN BRAND 3 CORTIPORIN OLUTION BRAND 2 CORTIPORIN-TC BRAND 3 fluocinolone acetonide (otic) hydrocortisone w/acetic acid neomycin-polymyxin-hc (otic) REPIRATORY TRACT/PULMONARY AGENT ANTI-INFLAMMATORIE, INHALED CORTICOTEROID ALVECO BRAND 3 MPL 1 / 30 days AMANEX 120 METERED DOE BRAND 2 MPL 1 / 30 days AMANEX 14 METERED DOE BRAND 2 MPL 1 / 30 days AMANEX 30 METERED DOE BRAND 2 MPL 1 / 30 days AMANEX 60 METERED DOE BRAND 2 MPL 1 / 30 days AMANEX 7 METERED DOE BRAND 2 MPL 1 / 30 days budesonide (nasal) MPL 1 / 30 days budesonide inhalation susp 0.25 mg/2ml generic 3 budesonide inhalation susp 1 mg/2ml MD1 120 ML / 30 DAY MD1 120 ML / 30 DAY FLOVENT DIKU BRAND 3 MPL 1 / 30 days GE 131 LAT UPDATED 05/2016

133 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION FLOVENT HFA BRAND 3 MPL 1 / 30 days flunisolide (nasal) MPL 1 / 30 days fluticasone propionate (nasal) MPL 1 / 30 days mometasone furoate (nasal) NAONEX BRAND 2 MPL MPL 2 / 30 days 2 / 30 days PULMICORT FLEXHALER AER POW BA 180 MCG/ACT BRAND 2 MPL 1 / 30 days PULMICORT FLEXHALER AER POW BA 90 MCG/ACT BRAND 2 MPL 1 / 30 Days PULMICORT UPENION 0.5 MG/2ML BRAND 3 PULMICORT UPENION 1 MG/2ML BRAND 2 MD1 120 ML / 30 DAY MD1 120 ML / 30 DAY QVAR BRAND 2 MPL 1 / 30 days RHINOCORT AQUA BRAND 3 MPL 1 / 30 days ANTIHITAMINE ALLEGRA TAB 60 MG BRAND 1 2 per day ATELIN BRAND 2 MPL 1 / 30 days ATEPRO BRAND 2 MPL 1 / 30 days azelastine hcl (0.1% (137 mcg/), 0.15% (205.5 mcg/), 137 mcg/(1 mg/ml)) carbinoxamine maleate (soln 4 mg/5ml, tab 4 mg) MPL 1 / 30 days cetirizine hcl MD1 300 ML / 30 DAY clemastine fumarate (syrup 0.67 (0.5 base eq), tab 2.68 mg) GE 132 LAT UPDATED 05/2016

134 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION cyproheptadine hcl (syrup 2 mg/5ml, tab 4 mg) desloratadine 1 per day DEXCHLORPHENIRAMINE MALEATE BRAND 3 diphenhydramine hcl (cap 50 mg, elixir 12.5 mg/5ml, inj 50 mg/ml) hydroxyzine hcl (im soln 50 mg/ml, syrup 10 mg/5ml, tab 10 mg, tab 25 mg, tab 50 mg) hydroxyzine pamoate (cap 25 mg, cap 50 mg, cap 100 mg) levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/ml) MD1 300 ML / 30 DAY levocetirizine dihydrochloride tab 5 mg 1 per day olopatadine hcl (nasal) promethazine hcl (inj 25 mg/ml, inj 50 mg/ml, suppos 12.5 mg, suppos 25 mg, syrup 6.25 mg/5ml, tab 12.5 mg, tab 25 mg, tab 50 mg) ANTILEUKOTRIENE montelukast sodium 1 per day zafirlukast 2 per day ZYFLO CR BRAND 3 4 per day BRONCHODILATOR, ANTICHOLINERGIC ATROVENT HFA BRAND 3 MPL 2 / 30 days INCRUE ELLIPTA BRAND 2 MPL 1 / 30 days ipratropium bromide inhal soln 0.02% MD1 450 ML / 30 DAY ipratropium bromide nasal soln 0.03% (21 mcg/spray) ipratropium bromide nasal soln 0.06% (42 mcg/spray) MD1 30 ML / 30 DAY PIRIVA HANDIHALER BRAND 2 1 per day PIRIVA REPIMAT BRAND 2 MPL 1 / 30 days GE 133 LAT UPDATED 05/2016

135 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION BRONCHODILATOR, YMTHOMIMETIC ADRENACLICK OLN A-INJ 0.3 MG/0.3ML BRAND 2 MFL 1 / claim albuterol sulfate (soln nebu 0.083% (2.5 mg/3ml), soln nebu 0.63 mg/3ml (base equiv), soln nebu 1.25 mg/3ml (base equiv)) albuterol sulfate (syrup 2 mg/5ml, tab 2 mg, tab 4 mg, tab sr 12hr 4 mg, tab sr 12hr 8 mg) 5 per day albuterol sulfate soln nebu 0.5% (5 mg/ml) MPL 3 / 30 days ARCAPTA NEOHALER BRAND 2 MPL 1 / 30 days AUVI-Q OLN A-INJ 0.3 MG/0.3ML BRAND 2 MFL 1 / claim BROVANA BRAND 3 MD1 120 ML / 30 DAY epinephrine hcl EPINEPHRINE OLN A-INJ 0.3 MG/0.3ML BRAND 2 MFL 1 / claim EPIPEN BRAND 2 MFL 1 / claim EPIPEN 2-K BRAND 2 MFL 1 / claim EPIPEN JR BRAND 2 MFL 1 / claim EPIPEN JR 2-K BRAND 2 MFL 1 / claim FORADIL AEROLIZER BRAND 2 2 per day levalbuterol hcl (soln nebu 0.31, soln nebu 0.63) 4 per day levalbuterol hcl soln nebu 1.25 mg/3ml (base equiv) levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base equiv) 4 per day MD1 60 ML / 30 DAY MAXAIR AUTOHALER BRAND 2 MPL 1 / 30 days metaproterenol sulfate (syrup 10 mg/5ml, tab 10 mg, tab 20 mg) PROAIR HFA BRAND 2 MPL 2 / 30 days GE 134 LAT UPDATED 05/2016

136 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION PROVENTIL HFA BRAND 2 MPL 2 / 30 days EREVENT DIKU BRAND 2 MPL 1 / 30 days terbutaline sulfate (inj 1 mg/ml, tab 2.5 mg, tab 5 mg) TWINJECT BRAND 2 MFL 1 / claim VENTOLIN HFA BRAND 2 MPL 2 / 30 days XOPENEX HFA BRAND 3 MPL 2 / 30 days CYTIC FIBROI AGENT CAYTON BRAND 4 KALYDECO TAB 150 MG BRAND 4 TOBI BRAND 4 tobramycin nebu soln 300 mg/5ml generic 4 pecialty Drug pecialty Drug pecialty Drug pecialty Drug PHOPHODIETERAE INHIBITOR, AIRWAY DIEAE aminophylline inj 25 mg/ml ELIXOPHYLLIN BRAND 1 LUFYLLIN BRAND 3 theophylline (tab sr 12hr 200 mg, tab sr 12hr 450 mg, tab sr 12hr 300 mg, tab sr 12hr 100 mg, tab sr 24hr 600 mg, tab sr 24hr 400 mg) PULMONARY ANTIHYPERTENIVE ADCIRCA BRAND 4 LETAIRI BRAND 4 REMODULIN BRAND 4 pecialty Drug pecialty Drug pecialty Drug GE 135 LAT UPDATED 05/2016

137 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION REVATIO (OLUTION 10 MG/12.5ML, TAB 20 MG) BRAND 4 pecialty Drug sildenafil citrate (pulmonary hypertension) (iv soln 10 mg/12.5ml (base equivalent), tab 20 mg) generic 4 pecialty Drug TRACLEER TAB 125 MG BRAND 4 2 per day pecialty Drug TRACLEER TAB 62.5 MG BRAND 4 VENTAVI BRAND 4 1 per day pecialty Drug pecialty Drug REPIRATORY TRACT AGENT, OTHER acetylcysteine (soln 10%, soln 20%) ADVAIR DIKU BRAND 2 ADVAIR HFA BRAND 2 ARALAT BRAND 4 MPL MPL 1 / 30 days 1 / 30 days pecialty Drug ARALAT NP (RECON OLN 400 MG, RECON OLN 800 MG, RECON OLN 1000 MG) BRAND 4 pecialty Drug benzonatate cap 100 mg benzonatate cap 200 mg C C 6 per day LIMIT=10 DAY UPPLY/CLAIM 3 per day LIMIT=10 DAY UPPLY/CLAIM BREO ELLIPTA BRAND 2 MPL 1 / 30 days cromolyn sodium soln nebu 20 mg/2ml MD1 240 ML / 30 DAY HYPERAL NEBU OLN 3.5 % BRAND 1 GE 136 LAT UPDATED 05/2016

138 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION ipratropium-albuterol 18 per day NEBUAL BRAND 1 PROLATIN RECON UP 1000 MG BRAND 4 PROLATIN-C BRAND 4 PULMOZYME BRAND 4 sodium chloride soln nebu 7% YMBICORT BRAND 2 TYZINE BRAND 3 XOLAIR BRAND 4 ZEMAIRA BRAND 4 MPL pecialty Drug pecialty Drug pecialty Drug 1 / 30 days pecialty Drug pecialty Drug KELETAL MUCLE RELAXANT baclofen (tab 10 mg, tab 20 mg) BOTOX BRAND 3 carisoprodol (tab 250 mg, tab 350 mg) chlorzoxazone tab 500 mg cyclobenzaprine hcl (tab 5 mg, tab 7.5 mg, tab 10 mg) dantrolene sodium (cap 25 mg, cap 50 mg, cap 100 mg) 3 per day 4 per day DYPORT BRAND 3 DYPORT (GLABELLAR LINE) BRAND 3 metaxalone tab 800 mg 4 per day methocarbamol (tab 500 mg, tab 750 mg) orphenadrine citrate tab sr 12hr 100 mg 2 per day GE 137 LAT UPDATED 05/2016

139 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION tizanidine hcl XEOMIN RECON OLN 50 UNIT BRAND 3 LEEP DIORDER AGENT GABA RECEPTOR MODULATOR estazolam T eszopiclone AL At least 18 yrs old 1 per day LUNETA BRAND 3 triazolam zaleplon cap 10 mg zaleplon cap 5 mg zolpidem tartrate (tab 5 mg, tab 10 mg) T AL AL AL AL At least 18 yrs old 1 per day At least 18 yrs old 2 per day At least 18 yrs old 1 per day At least 18 yrs old 1 per day LEEP DIORDER, OTHER modafinil tab 100 mg AL At least 16 yrs old 1 per day modafinil tab 200 mg AL At least 16 yrs old 2 per day NUVIGIL BRAND 2 AL At least 17 yrs old 1 per day ROZEREM BRAND 3 T AL At least 18 yrs old 1 per day GE 138 LAT UPDATED 05/2016

140 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION XYREM BRAND 4 MD1 540 ML / 30 DAY pecialty Drug THERAPEUTIC NUTRIENT/MINERAL/ELECTROLYTE ELECTROLYTE/MINERAL MODIFIER CHEMET BRAND 3 EXJADE BRAND 4 FERRIPROX TAB 500 MG BRAND 3 JADENU BRAND 4 AMCA BRAND 4 pecialty Drug pecialty Drug pecialty Drug sodium polystyrene sulfonate (*sodium powder**, sodium oral susp 15 gm/60ml) YPRINE BRAND 4 pecialty Drug ELECTROLYTE/MINERAL REPLACEMENT *parenteral electrolyte conc*** *peritoneal dialysis solutions 346 mosm/l** AMMONIUM CHLORIDE BRAND 3 calcium chloride inj 10% calcium gluconate inj 10% CARBAGLU BRAND 4 DEXTROE 5%/ELECTROLYTE #48 BRAND 1 dextrose in lactated ringers dextrose in ringers DIANEAL LOW CALCIUM/1.5% DEX BRAND 1 DIANEAL PD-2/1.5% DEXTROE BRAND 1 pecialty Drug GE 139 LAT UPDATED 05/2016

141 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION electrolyte-m in dextrose ferrous fumarate-folic acid 1 per day IONOOL-B IN D5W BRAND 1 IONOOL-MB IN D5W BRAND 1 irrigation solutions, physiological IOLYTE-P IN D5W BRAND 1 IOLYTE- BRAND 1 KCL IN DEXTROE-NACL OLUTION MEQ/L-%-% BRAND 1 KCL-LACTATED RINGER-D5W BRAND 1 KLOR-CON M15 BRAND 1 lactated ringer's MAGNEIUM ULFATE (OLUTION 2 GM/50ML, OLUTION 4 GM/50ML, OLUTION 4 GM/100ML, OLUTION 20 GM/500ML, OLUTION 40 GM/1000ML) BRAND 1 magnesium sulfate inj 50% NORMOOL-M IN D5W BRAND 1 NORMOOL-R PH 7.4 BRAND 1 PLAMA-LYTE 148 BRAND 1 PLAMA-LYTE A BRAND 1 PLAMA-LYTE-56 IN D5W BRAND 1 potassium acetate potassium bicarb & chloride potassium bicarbonate effer tab 25 meq potassium chloride (cap cr 8 meq, cap cr 10 meq, inj 2 meq/ml, inj 10 meq/100 ml, inj 10 meq/100ml, inj 20 meq/50ml, inj 20 meq/50 ml, inj 30 meq/100 ml, oral liq 10% (20 meq/15ml), oral soln 10% (20 meq/15ml), powder packet 20 meq, tab cr 8 meq (600 mg), tab cr 10 meq) POTAIUM CHLORIDE (OLUTION 10 MEQ/50ML, OLUTION 30 MEQ/100ML) BRAND 1 POTAIUM CHLORIDE ER TAB ER 8 MEQ BRAND 1 GE 140 LAT UPDATED 05/2016

142 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION potassium chloride in dextrose & sodium chloride (10 (0.07) 0.4j, 20 (0.1) 0.2% j, 20 (0.1) 0.33% j, 20 (0.1) 0.4j, 20 (0.1) 0.9% j, 30 (0.224%) 0.4j, 40 (0.3%) 0.4j) potassium chloride in dextrose (20 (0.1) j, 40 (0.3%) j) potassium chloride in nacl potassium chloride microencapsulated crystals cr potassium phosphates ringer's sodium acetate (inj 2, inj 4) sodium chloride (inj 0.45%, inj 2.5 meq/ml (14.6%), inj 3%, inj 4 meq/ml (23.4%), inj 5%) sodium phosphate ULTRABAG/DIANEAL PD-2/1.5% DEX BRAND 1 ULTRABAG/DIANEAL/1.5% DEXTROE BRAND 1 AMINOYN II IN DEXTROE 25% BRAND 3 CLINIMIX E/DEXTROE (5/20) BRAND 3 CLINIMIX/DEXTROE (2.75/5) BRAND 3 CLINIMIX/DEXTROE (4.25/10) BRAND 3 CLINIMIX/DEXTROE (4.25/25) BRAND 3 CLINIMIX/DEXTROE (4.25/5) BRAND 3 CLINIMIX/DEXTROE (5/25) BRAND 3 DRIDOL BRAND 0 ergocalciferol cap unit generic 0 folic acid tab 1 mg generic 0 FAL Female - 12 to 55 yrs old lactated ringer's (irrigation) ringer's irrigation GE 141 LAT UPDATED 05/2016

143 Index of covered drugs 1 1T CHOICE LANCET UPER THIN 100 1T CHOICE LANCET THIN 100 1T CHOICE LANCET ULTRA THIN 100 1T CHOICE PEN NEEDLE 100 1T TIER UNIFINE PENTIP 100 1T TIER UNIFINE PENTIP PLU 100 1T TIER UNILET COMFORTOUCH 100 A A-HYDROCORT 83 abacavir sulfate 54 abacavir sulfate-lamivudine-zidovudine 54 ABELCET 30 ABRAXANE 38 acamprosate calcium 15 acarbose 58 ACCU-CHEK ACTIVE GLUCOE CONT 100 ACCU-CHEK AVIVA 100 ACCU-CHEK COMFORT CURVE 100 ACCU-CHEK COMFORT CURVE LINEAR 100 ACCU-CHEK COMCT BLUE CONTROL 100 ACCU-CHEK COMCT PLU CONTROL 100 ACCU-CHEK FATCLIX LANCET 100 ACCU-CHEK INTANT CONTROL 100 ACCU-CHEK MULTICLIX LANCET 100 ACCU-CHEK AFE-T PRO LANCET 100 ACCU-CHEK MARTVIEW CONTROL 100 ACCU-CHEK OFT TOUCH LANCET 100 ACCU-CHEK OFTCLIX LANCET DEV 100 ACCU-CHEK OFTCLIX LANCET 101 ACCUURE INULIN YRINGE 101 ACCUTREND GLUCOE CONTROL 101 acebutolol hcl 65 acetaminophen w/ codeine 12 acetazolamide 67,68 acetazolamide sodium 68 acetic acid 16 acetic acid (otic) 131 acetone (urine) test 101 acetylcysteine 136 acitretin 75 ACTEMRA 96 ACTI-LANCE 28G 101 ACTI-LANCE LITE LANCET 28G 101 ACTI-LANCE PECIAL LANCET 17G 101 ACTI-LANCE UNIVERAL 23G 101 ACTIMMUNE 96 ACTONEL 98 ACTOPLU MET 58 ACURA CONTROL 101 acyclovir 56 acyclovir topical 56 ADACEL 97 ADAGEN 78 adapalene 75 ADALENE 75 ADCETRI 45 ADCIRCA 135 adefovir dipivoxil 51 ADJUTABLE LANCING DEVICE 101 ADRENACLICK 134 ADVAIR DIKU 136 ADVAIR HFA 136 ADVANCE INTUITION CONTROL 101 ADVICOR 69 ADVOCATE CONTROL OLUTION 101 ADVOCATE INULIN PEN NEEDLE 101 ADVOCATE INULIN YRINGE 101 ADVOCATE LANCET 101 ADVOCATE LANCET 30G 101 ADVOCATE LANCING DEVICE 101 ADVOCATE RAPID-AFE LANCING 101 ADVOCATE REDI-CODE+ CONTROL 101 ADVOCATE AFETY LANCET 101 ADVOCATE AFETY LANCET 26G 101 AF LANCET UPER THIN 101 AFINITOR 43 AFLURIA 97 AFLURIA PREERVATIVE FREE 97 AGAMATRIX CONTROL 101 GE 142 LAT UPDATED 05/2016

144 AGAMATRIX ULTRA-THIN LANCET 101 AGGRENOX 63 AGRIFLU 97 AIMCO LUBRICATED 6 ALBENZA 46 albuterol sulfate 134 alclometasone dipropionate 83 ALDURAZYME 78 alendronate sodium 98 alfuzosin hcl 82 ALIMTA 37 ALINIA 46 ALKERAN 35 ALLEGRA 132 ALLEGRA ALLERGY 7 ALLEGRA ALLERGY CHILDREN 7 allopurinol 31 ALOCRIL 129 ALOMIDE 129 ALORA 87 alosetron hcl 80 ALOXI 29 alprazolam 57 ALREX 129 ALTABAX 16 ALTERNATE ITE LANCING DEVICE 101 ALTOPREV 69 ALVECO 131 amantadine hcl 47 AMBIOME 30 amcinonide 83 amikacin sulfate 15 amiloride & hydrochlorothiazide 67 amiloride hcl 68 aminophylline 135 AMINOYN II IN DEXTROE 25% 141 amiodarone hcl 65 amiodarone hcl (bulk) 102 AMITIZA 80 amitriptyline hcl 28 amlodipine besylate 66 amlodipine besylate-benazepril hcl 67 AMMONIUM CHLORIDE 139 amoxapine 28 amoxicillin 19 amoxicillin & pot clavulanate 19 amphetamine-dextroamphetamine 71 AMPHOTEC 30 amphotericin b 30 ampicillin 19 AMPICILLIN 19 ampicillin & sulbactam sodium 19 ampicillin sodium 19 AMPYRA 73 ANADROL anagrelide hcl 62 anastrozole 42 ANDRODERM 87 ANDROXY 87 ANTI-TICK INULIN YRINGE 102 antipyrine-benzocaine 131 ANZEMET 29 APIDRA 60 APIDRA OLOTAR 60 APOKYN 48 apraclonidine hcl 130 APRIO 97 APTIVU 55 AQUA LANCE ADJUTABLE LANCING 102 ARALAT 136 ARALAT NP 136 ARANEP (ALBUMIN FREE) 62 ARCALYT 96 ARCAPTA NEOHALER 134 AREDIA 98 ARETIN 74 ARIMIDEX 42 aripiprazole 49 AROMAIN 42 ARRANON 38 ARZERRA 45 AACOL 97 GE 143 LAT UPDATED 05/2016

145 AACOL HD 97 ACENIA AUTODIC CONTROL 102 ACENIA AUTODIC CONTROL 102 AMANEX 120 METERED DOE 131 AMANEX 14 METERED DOE 131 AMANEX 30 METERED DOE 131 AMANEX 60 METERED DOE 131 AMANEX 7 METERED DOE 131 aspirin 3 aspirin-dipyridamole 63 AURE 3 CONTROL 102 AURE 4 CONTROL LEVEL 1 & AURE COMFORT LANCET 28G 102 AURE COMFORT LANCET 30G 102 AURE DOE CONTROL 102 AURE DOE NORM/HIGH CONTROL 102 AURE HAEMOLANCE PLU HIGH 102 AURE HAEMOLANCE PLU LOW 102 AURE HAEMOLANCE PLU MICRO 102 AURE HAEMOLANCE PLU NORMAL 102 AURE HAEMOLANCE PLU PED 102 AURE ID INULIN AFETY YR 102 AURE LANCE LANCET 102 AURE LANCE LANCET 21G 102 AURE LANCE PLU AFETY 25G 102 AURE LANCE PLU AFETY 30G 102 AURE LANCET 102 AURE PRIM CONTROL LEVEL 1&2 102 AURE PRO CONTROL LEVEL 1 & ATELIN 132 ATEPRO 132 ATELVIA 98 atenolol 65 atenolol & chlorthalidone 67 ATGAM 95 atorvastatin calcium 69 atovaquone 46 ATOVAQUONE 102 atovaquone-proguanil hcl 46 ATRIPLA 53 atropine sulfate 79 ATROPINE ULFATE 79 ATROVENT HFA 133 AURORA HEALTHCARE LANCET 102 AURORA LANCET UPER THIN 30G 102 AURORA LANCET THIN 23G 102 AURORA PEN NEEDLE 103 AURORA UNIFINE PENTIP 103 AUTO-LANCET 103 AUTO-LANCET MINI 103 AUTOLET IMPREION 103 AUTOLET LANCING DEVICE 103 AUTOLET MINI 103 AUVI-Q 134 AVANDIA 58 AVATIN 45 AVELOX 21 AVELOX ABC CK 21 AVODART 82 AVONEX 73 AVONEX PEN 73 AVONEX PREFILLED 74 AXERT 32 AYGETIN 91 azacitidine 38 AZACTAM IN DEXTROE 19 AZAAN 94 AZAITE 20 azathioprine 94 azathioprine sodium 94 azelastine hcl 132 azelastine hcl (ophth) 129 AZELEX 75 AZILECT 48 azithromycin 20 AZOPT 130 aztreonam 19 B bacitracin 16 bacitracin (ophthalmic) 128 baclofen 137 GE 144 LAT UPDATED 05/2016

146 balsalazide disodium 98 BANZEL 24 BARACLUDE 51 BAYER BREEZE 2 CONTROL 103 BAYER CONTOUR 103 BAYER CONTOUR NEXT CONTROL 103 BAYER MICROLET 2 LANCING DEVIC 103 BAYER MICROLET LANCET 103 BD AUTOHIELD 103 BD INULIN YR ULTRAFINE II 103 BD INULIN YRINGE 103 BD INULIN YRINGE HALF-UNIT 103 BD INULIN YRINGE MICROFINE 103 BD INULIN YRINGE ULTRAFINE 103 BD INTEGRA INULIN YRINGE 103 BD INTEGRA YRINGE 103 BD LANCET DEVICE 103 BD LANCET ULTRAFINE 30G 104 BD LANCET ULTRAFINE 33G 104 BD MICROTAINER LANCET 104 BD PEN NEEDLE MINI U/F 104 BD PEN NEEDLE NANO U/F 104 BD PEN NEEDLE HORT U/F 104 BD PEN NEEDLE ULTRAFINE 104 BD AFETY-LOK INULIN YRINGE 104 BD AFETYGLIDE INULIN YRINGE 104 benazepril & hydrochlorothiazide 67 benazepril hcl 64 BENICAR 64 benzonatate 136 benzoyl peroxide 4,75 benzoyl peroxide-erythromycin 75 benztropine mesylate 47 BEPREVE 129 BEIVANCE 21 betamethasone dipropionate (topical) 83 betamethasone dipropionate augmented 83 betamethasone valerate 83 BETAERON 74 betaxolol hcl 65 betaxolol hcl (ophth) 130 bethanechol chloride 82 bexarotene 45 BEXXAR 45 BEYAZ 87 bicalutamide 36 BICNU 35 BIDIL 67 BILTRICIDE 46 bimatoprost 130 bisacodyl 4 bisoprolol fumarate 65 bleomycin sulfate 38 blood glucose calibration 104 blood glucose monitoring supplies 104 BONIVA 98 BOOTRIX 97 BOULIF 43 BOTOX 137 BREO ELLIPTA 136 BREVICON (28) 87 BRILINTA 63 brimonidine tartrate 130 BRINTELLIX 26 bromfenac sodium (ophth) 129 bromocriptine mesylate 48 BROVANA 134 budesonide 98 budesonide (inhalation) 131 budesonide (nasal) 131 BULLEYE MINI AFETY LANCET 104 BULLEYE AFETY LANCET 104 bumetanide 68 BUPHENYL 78 buprenorphine hcl 15 bupropion hcl 26 bupropion hcl (smoking deterrent) 15 buspirone hcl 57 BUULFEX 35 butalbital-acetaminophen-caffeine 73 butalbital-acetaminophen-caffeine w/ codeine 12 butalbital-aspirin-caffeine 73 GE 145 LAT UPDATED 05/2016

147 butalbital-aspirin-caffeine w/cod 13 butorphanol tartrate 13 BUTRAN 11 BYETTA 10 MCG PEN 58 BYETTA 5 MCG PEN 58 BYTOLIC 65 C cabergoline 92 CAFERGOT 32 calcipotriene 75 calcipotriene-betamethasone dipropionate 75 calcitonin (salmon) 98 calcitriol 98 calcitriol (topical) 75 calcium acetate (phosphate binder) 83 calcium chloride (dihydrate) 139 calcium gluconate 139 calcium polycarbophil 4 CAMTH 38 CAMPRAL 15 CAMPTOAR 38 CANAA 98 CANCIDA 30 candesartan cilexetil 64 CANTIL 79 CATAT ULFATE 34 capecitabine 37 CAPRELA 43 captopril 64 CARAFATE 81 CARBAGLU 139 carbamazepine 24 carbidopa 48 carbidopa-levodopa 48 CARBIDO-LEVODO-ENTACAPONE 47 carbidopa-levodopa-entacapone 47 carbinoxamine maleate 132 carboplatin 38 CARDIOCOM LANCING DEVICE 104 CAREFINE PEN NEEDLE 104 CAREONE ADVANCED LANCING DEV 104 CAREONE INULIN YRINGE 104 CAREONE LANCET THIN 23G 104 CAREONE LANCET ULTRA THIN 28G 104 CAREONE ULTIGUARD INULIN YR 104 CAREONE UNIFINE PENTIP 104 CAREONE UNIFINE PENTIP PLU 104 CAREEN CONTROL A 104 CARIMUNE NF 96 carisoprodol 137 carteolol hcl (ophth) 130 carvedilol 65 CAODEX 36 CAYA 104 CAYTON 135 CEDAX 18 CEENU 35 cefaclor 18 cefaclor monohydrate 18 cefadroxil 18 cefazolin sodium 18 cefdinir 18 cefditoren pivoxil 18 CEFDITOREN PIVOXIL 18 cefepime hcl 18 cefixime 18 cefotaxime sodium 18 cefotetan disodium 18 cefoxitin sodium 18 cefpodoxime proxetil 18 cefprozil 18 ceftazidime 18 CEFTIBUTEN 18 CEFTIN 18 ceftriaxone sodium 18 cefuroxime axetil 18 cefuroxime sodium 18 celecoxib 10 CELLCEPT INTRAVENOU 94 CELONTIN 22 CENETIN 87 GE 146 LAT UPDATED 05/2016

148 cephalexin 19 CEREZYME 78 CERUBIDINE 38 CEAMET 29 cetirizine hcl 7,132 cetirizine-pseudoephedrine 8 CETRAXAL 21 cevimeline hcl 74 CHANTIX 15 CHANTIX CONTINUING MONTH K 15 CHANTIX TARTING MONTH K 15 CHEK-TIX CONTROL 104 CHEMET 139 CHEMTRIP K 104 chloramphenicol sodium succinate 16 chlordiazepoxide hcl-clidinium bromide 79 chlorhexidine gluconate (mouth-throat) 74 chloroquine phosphate 46 chlorothiazide 68 chlorpromazine hcl 48 chlorpropamide 58 chlorthalidone 68 chlorzoxazone 137 CHOLBAM 79 cholecalciferol 9 cholestyramine 69 cholestyramine light 69 choline & mag salicylate 10 chorionic gonadotropin 85 CIALI 82 ciclopirox 30 ciclopirox & vitamin e 30 ciclopirox olamine 30 cidofovir 50 cilostazol 63 cimetidine 4,80 cimetidine hcl 80 CIMZIA 94 CIMZIA PREFILLED 94 CIMZIA TARTER KIT 94 CIPRO HC 131 CIPRO IN D5W 21 CIPRODEX 131 ciprofloxacin 21 ciprofloxacin hcl 21 ciprofloxacin hcl (ophth) 21 ciprofloxacin hcl (otic) 21 ciprofloxacin in d5w 21 ciprofloxacin-ciprofloxacin hcl 21 cisplatin 39 citalopram hydrobromide 26,27 cladribine 37 clarithromycin 20 CLARITIN 7 CLARITIN REDITAB 7 CLARITIN-D 12 HOUR 8 CLARITIN-D 24 HOUR 8 CLEANLET LANCET 28G 104 clemastine fumarate 132 CLEVER CHEK LANCET 105 CLEVER CHOICE GLUCOE CONTROL 105 CLICKFINE PEN NEEDLE 105 CLIMARA PRO 87 clindamycin hcl 16 clindamycin palmitate hydrochloride 16 clindamycin phosphate 16 CLINDAMYCIN PHOPHATE 105 clindamycin phosphate (bulk) 105 clindamycin phosphate (topical) 16,75 clindamycin phosphate vaginal 16 clindamycin phosphate-benzoyl peroxide 75 clindamycin phosphate-benzoyl peroxide (refrigerate) 75 CLINIMIX E/DEXTROE (5/20) 141 CLINIMIX/DEXTROE (2.75/5) 141 CLINIMIX/DEXTROE (4.25/10) 141 CLINIMIX/DEXTROE (4.25/25) 141 CLINIMIX/DEXTROE (4.25/5) 141 CLINIMIX/DEXTROE (5/25) 141 clobetasol propionate 83 clobetasol propionate emollient base 83 CLODERM 83 GE 147 LAT UPDATED 05/2016

149 CLODERM PUMP 83 CLOLAR 37 clomipramine hcl 28 clonazepam 57 clonidine hcl 63 clopidogrel bisulfate 63 CLOERCARE 105 clotrimazole 30 clotrimazole (topical) 3,30 clotrimazole vaginal 3 clotrimazole w/ betamethasone 75 clozapine 50 COAGUCHEK LANCET 105 COARTEM 46 codeine sulfate 13 COLCHICINE 31 colchicine 32 colchicine w/ probenecid 32 COLCRY 32 colestipol hcl 69 COLY-MYCIN 131 COMBIGAN 130 COMETRIQ (100 MG DAILY DOE) 43 COMETRIQ (140 MG DAILY DOE) 43 COMETRIQ (60 MG DAILY DOE) 43 COMFORT AIT INULIN YRINGE 105 COMFORT AURED LANCET 28G 105 COMFORT AURED LANCET 33G 105 COMFORT EZ INULIN YRINGE 105 COMFORT EZ PEN NEEDLE 105 COMFORT LANCET 105 COMMIT 3 COMPLERA 53 CONTROL 105 COXONE 74 CORDRAN 83 cortisone acetate 83 CORTIPORIN 75,131 CORTIPORIN-TC 131 COMEGEN 39 COUMADIN 61 CREON 78 CRETOR 69 CRIXIVAN 55 cromolyn sodium 136 cromolyn sodium (ophth) 129 CUBICIN 16 CUPRIMINE 82 CV INULIN YRINGE 105 CV LANCET 21G 105 CV LANCET MICRO THIN 33G 105 CV LANCET ORIGINAL 105 CV LANCET THIN 105 CV LANCET THIN 26G 105 CV LANCET ULTRA THIN 30G 105 CV LANCING DEVICE 105 CV OMEPRAZOLE 4 CV ULTRA THIN LANCET 105 CYCLEA 87 cyclobenzaprine hcl 137 cyclophosphamide 35 CYCLOERINE 34 CYCLOET 58 cyclosporine 94 cyclosporine modified (for microemulsion) 94 cyproheptadine hcl 133 CYTADANE 78 CYTAGON 78 cytarabine 37 D D.H.E dacarbazine 35 DACOGEN 39 dactinomycin 39 danazol 87 dantrolene sodium 137 DARAPRIM 46 daunorubicin hcl 39 DAUNOXOME 35 decitabine 39 demeclocycline hcl 22 GE 148 LAT UPDATED 05/2016

150 DENAVIR 57 DEPO-ETRADIOL 87 DEPO-MEDROL 83 DEPO-PROVERA 91 DEPO-UBQ PROVERA DEPOCYT 37 desipramine hcl 28 desloratadine 133 desmopressin acetate 85 desmopressin acetate spray 85 desmopressin acetate spray refrigerated 85 DEOGEN 87 desogestrel & ethinyl estradiol 87 desogestrel-ethinyl estradiol (biphasic) 87 desogestrel-ethinyl estradiol (triphasic) 88 desonide 84 desoximetasone 84 DEOXYN 71 DETROL LA 81 dexamethasone 84 DEXAMETHAONE INTENOL 84 dexamethasone sodium phosphate 84 dexamethasone sodium phosphate (ophth) 129 DEXCHLORPHENIRAMINE MALEATE 133 DEXILANT 81 dexmethylphenidate hcl 72 dextroamphetamine sulfate 71 DEXTROE 5%/ELECTROLYTE # dextrose in lactated ringers 139 dextrose in ringers 139 DIANEAL LOW CALCIUM/1.5% DEX 139 DIANEAL PD-2/1.5% DEXTROE 139 DIATAR EAY TET II LANCET 105 DIATAR EAY TET LANCET 105 DIATAT ACUDIAL 23 DIATAT PEDIATRIC 23 DIATRUE CONTROL LEVEL DIATRUE CONTROL LEVEL diazepam 57 diazepam (anticonvulsant) 23 DIBENZYLINE 64 diclofenac potassium 10 diclofenac sodium 10 diclofenac sodium (actinic keratoses) 76 diclofenac sodium (ophth) 129 diclofenac sodium (topical) 76 diclofenac w/ misoprostol 10 dicloxacillin sodium 19 dicyclomine hcl 79 didanosine 54 DIFFERIN 76 DIFICID 20 diflorasone diacetate 84 diflunisal 10 digoxin 67 dihydroergotamine mesylate 32 DILANTIN 24 DILANTIN INFATAB 24 diltiazem hcl 66 DILTIAZEM HCL 66 diltiazem hcl coated beads 66 diltiazem hcl extended release beads 66 DIPENTUM 98 diphenhydramine hcl 7,133 diphenoxylate w/ atropine 79 dipyridamole 63 disopyramide phosphate 65 disulfiram 15 divalproex sodium 23 DIVIGEL 88 DOCEFREZ 39 DOCETAXEL 39 docetaxel 39 docusate calcium 4 docusate sodium 4 donepezil hydrochloride 25 dorzolamide hcl 130 dorzolamide hcl-timolol maleate 130 doxazosin mesylate 64 doxepin hcl 28 doxercalciferol 98 DOXIL 39 GE 149 LAT UPDATED 05/2016

151 doxorubicin hcl 39 DOXORUBICIN HCL 39 doxorubicin hcl liposomal 39 doxycycline (monohydrate) 22 doxycycline hyclate 22 DRIDOL 9,141 dronabinol 29 DROPLET LANCET ULTRA THIN 30G 106 DROPLET LANCING DEVICE 106 drospirenone-ethinyl estradiol 88 DROXIA 37 DRUG MART LANCET THIN 26G 106 DRUG MART LANCET ULTRA THIN 106 DRUG MART LANCING DEVICE 106 DRUG MART ON-THE-GO LANCET 30G 106 DRUG MART ULTRA COMFORT YR 106 DRUG MART UNIFINE PENTIP 106 DRUG MART UNIFINE PENTIP PLU 106 DRUG MART UNILET LANCET 28G 106 DRUG MART UNILET LANCET 30G 106 DUANE READE LANCET ALTERN ITE 106 DUANE READE LANCET UPER THIN 106 DUANE READE LANCET ULTRA THIN 106 DUANE READE UNIFINE PENTIP 106 duloxetine hcl 73 DUREZOL 129 dutasteride 82 DYRENIUM 68 DYPORT 137 DYPORT (GLABELLAR LINE) 137 E E-Z JECT LANCET MICRO-THIN 33G 106 E-Z JECT LANCET UPER THIN 30G 106 E-Z JECT LANCET 106 E-Z JECT LANCET 21G 106 E-Z JECT LANCET THIN 26G 106 E.E E.E.. GRANULE 20 EAY COMFORT INULIN YRINGE 106 EAY COMFORT LANCET 106 EAY COMFORT PEN NEEDLE 106 EAY MINI LANCING DEVICE 106 EAY PLU CONTROL 106 EAY PLU II CONTROL 107 EAY TEP CONTROL 107 EAY TALK CONTROL 107 EAY TOUCH CONTROL HIGH & LOW 107 EAY TOUCH HEALTHPRO CONTROL 107 EAY TOUCH INULIN AFETY YR 107 EAY TOUCH INULIN YRINGE 107 EAY TOUCH LANCET 21G 107 EAY TOUCH LANCET 23G 107 EAY TOUCH LANCET 26G 107 EAY TOUCH LANCET 26G/TWIT 107 EAY TOUCH LANCET 28G 107 EAY TOUCH LANCET 28G/TWIT 107 EAY TOUCH LANCET 30G 107 EAY TOUCH LANCET 30G/TWIT 107 EAY TOUCH LANCET 32G 107 EAY TOUCH LANCET 32G/TWIT 107 EAY TOUCH LANCET 33G/TWIT 107 EAY TOUCH LANCING DEVICE 107 EAY TOUCH PEN NEEDLE 107 EAY TOUCH AFETY LANCET 21G 107 EAY TOUCH AFETY LANCET 23G 107 EAY TOUCH AFETY LANCET 26G 107 EAY TOUCH AFETY LANCET 28G 107 EAY TRAK CONTROL 107 EAY TWIT & CAP LANCET 108 EAYGLUCO CONTROL 108 EAYMAX 15 LEVEL 1 CONTROL 108 EAYMAX 15 LEVEL 2 CONTROL 108 EAYMAX CONTROL 108 ECLIPE CONTROL 108 econazole nitrate 30 EDARBI 64 EDECRIN 68 EDURANT 53 EFFIENT 63 ELAPRAE 78 electrolyte-m in dextrose 140 GE 150 LAT UPDATED 05/2016

152 ELELYO 78 ELEMENT COMCT CONTROL ELEMENT COMCT CONTROL ELEMENT CONTROL 108 ELEMENT PLU CONTROL 108 ELETRIN 88 ELEXA NATURAL FEEL 6 ELEXA TIMULATING 6 ELEXA ULTRA ENITIVE 6 ELIDEL 76 ELIGARD 92 ELIQUI 61 ELIXOPHYLLIN 135 ELLA 91 ELMIRON 82 ELOXATIN 39 ELR 39 EMADINE 129 EMBEDA 11 EMBRACE CONTROL 108 EMBRACE EVO CONTROL LEVEL EMBRACE EVO CONTROL LEVEL EMBRACE LANCET ULTRA THIN 30G 108 EMBRACE PRO GLUCOE CONTROL 108 EMCYT 37 EMEND 29,30 EMAM 26 EMTRIVA 54 ENABLEX 81 enalapril maleate 65 enalapril maleate & hydrochlorothiazide 67 ENBREL 94 ENBREL URECLICK 94 ENJUVIA 88 enoxaparin sodium 61 entacapone 47 entecavir 51 ENTEREG 79 ENVIION CONTROL 108 EPIDUO 76 epinastine hcl (ophth) 129 EPINEPHRINE 134 epinephrine hcl 134 EPIPEN 134 EPIPEN 2-K 134 EPIPEN JR 134 EPIPEN JR 2-K 134 epirubicin hcl 40 EPIVIR 54 EPIVIR HBV 51 eplerenone 68 EPOGEN 62 eprosartan mesylate 64 EPZICOM 54 EQ OMEPRAZOLE 4 EQL COLOR LANCET 21G 108 EQL COLOR LANCET MICRO 33G 108 EQL INULIN YRINGE 108 EQL OMEPRAZOLE 4 EQL HORT PEN NEEDLE 108 EQL UPER THIN LANCET 30G 108 EQL THIN LANCET 26G 108 EQL ULTRA COMFORT INULIN YR 108 EQL ULTRA HORT PEN NEEDLE 108 EQUETRO 24 ERAXI 30 ERBITUX 45 ergocalciferol 9,141 ERGOMAR 32 ERIVEDGE 43 ERTACZO 30 ERWINAZE 40 ERY-TAB 20 ERYPED ERYPED erythromycin (acne aid) 20 erythromycin (ophth) 20 ERYTHROMYCIN BAE 20 erythromycin base 21 ERYTHROMYCIN ETHYLUCCINATE 21 escitalopram oxalate 27 esomeprazole magnesium 81 GE 151 LAT UPDATED 05/2016

153 estazolam 138 ETRACE 88 ETRADERM 88 estradiol 88 estradiol valerate 88 ETRAORB 88 ETROGEL 88 estropipate 88 ETROTEP FE 88 eszopiclone 138 ethambutol hcl 34 ethosuximide 22,23 ethynodiol diacet & eth estrad 88 etidronate disodium 99 etodolac 10 ETOPOPHO 43 etoposide 43 EURAX 47 EVAMIT 88 EVENCARE CONTROL LOW/HIGH 108 EVENCARE G2 LOW/HIGH CONTROL 109 EVENCARE G3 LOW/HIGH CONTROL 109 EVITA 92 EVOLUTION CONTROL 109 EXALGO 11 EXCEL COMFORT POINT PEN NEEDLE 109 EXEL COMFORT POINT INULIN YR 109 EXELDERM 30 exemestane 42 EXJADE 139 EXTAVIA 74 EZ MART BLOOD GLUCOE LANCET 109 EZ-LET LANCET 21G 109 EZ-LET LANCET 26G 109 EZ-LET LANCET 28G 109 EZ-LET LANCET 30G 109 F FABRAZYME 78 FACTIVE 21 famciclovir 57 famotidine 4,80 FAMOTIDINE PREMIXED 80 FANAPT 49 FANAPT TITRATION CK 49 FANTAY LUBRICATED 6 FANTAY LUBRICATED/PERMICIDE 6 FARETON 37 FALODEX 37 FC FEMALE CONDOM 6 FC2 FEMALE CONDOM 6 felbamate 23 felodipine 66 FEMARA 42 FEMCAP 109 FEMCON FE 88 FEMRING 88 fenofibrate 68 fenofibrate micronized 68 fenoprofen calcium 10 fentanyl 11 fentanyl citrate 13 FER-IN-OL 8 FERRIPROX 139 ferrous fumarate-folic acid 140 ferrous sulfate 8 fexofenadine hcl 8 fexofenadine-pseudoephedrine 8 FIFTY50 CONTROL FIFTY50 LANCING DEVICE 109 FIFTY50 PEN NEEDLE 109 FIFTY50 AFETY EAL LANCET 109 FIFTY50 UPERIOR COMFORT YR 109 FINACEA 76 finasteride 82 finasteride (alopecia) 76 FINE FINGERTIX LANCET 109 FIRMAGON 92 flavoxate hcl 81 flecainide acetate 65 FLECTOR 10 GE 152 LAT UPDATED 05/2016

154 FLOVENT DIKU 131 FLOVENT HFA 132 floxuridine 37 FLUARIX 97 FLUARIX QUADRIVALENT 97 FLUCELVAX 97 fluconazole 30 flucytosine 30 FLUDARA 40 fludarabine phosphate 40 fludrocortisone acetate 84 FLULAVAL 97 FLULAVAL QUADRIVALENT 97 flunisolide (nasal) 132 fluocinolone acetonide 84 fluocinolone acetonide (otic) 131 fluocinonide 84 fluocinonide emulsified base 84 fluorometholone (ophth) 129 fluorouracil 37 fluorouracil (topical) 76 fluoxetine hcl 27 fluoxetine hcl (pmdd) 27 fluphenazine hcl 49 flurbiprofen 10 flurbiprofen sodium 129 flutamide 36 fluticasone propionate 84 FLUTICAONE PROPIONATE 109 fluticasone propionate (bulk) 109 fluticasone propionate (nasal) 7,132 fluvastatin sodium 69 FLUVIRIN 97 FLUVIRIN PREERVATIVE FREE 97 fluvoxamine maleate 27 FLUZONE 97 FLUZONE HIGH-DOE 97 FLUZONE PEDIATRIC PF 97 FLUZONE PREERVATIVE FREE 97 FLUZONE QUADRIVALENT 97 FML 129 FML FORTE 129 folic acid 9,141 FOLOTYN 37 fondaparinux sodium 61 FORA CONTROL 109 FORA LANCET 109 FORA LANCING DEVICE 109 FORACARE GDH CONTROL 109 FORADIL AEROLIZER 134 FORTEO 99 FORTICARE CONTROL 109 FOAMAX PLU D 99 FOCAVIR 50 fosinopril sodium 65 fosinopril sodium & hydrochlorothiazide 67 fosphenytoin sodium 25 FORENOL 83 FRAGMIN 62 FRED PHARMACY AUTOLET LANCING 110 FRED PHARMACY UNIFINE PENTIP+ 110 FRED PHARMACY UNIFINE PENTIP 110 FRED PHARMACY UNILET LANC 28G 110 FRED PHARMACY UNILET LANC 30G 110 FREETYLE CONTROL OLUTION 110 FREETYLE LANCET 110 FREETYLE PRECIION IN YR 110 FREETYLE UNITICK II LANCET 110 FROVA 32 furosemide 68 FUZEON 55 G gabapentin 23 galantamine hydrobromide 25 GAMMAGARD 96 GAMMAGARD /D 96 GAMMAGARD /D LE IGA 96 GAMMAKED 96 GAMUNEX-C 96 ganciclovir sodium 50 gatifloxacin (ophth) 21 GE 153 LAT UPDATED 05/2016

155 GE100 CONTROL 110 GEL-KAM ORAL CARE RINE 74 gemcitabine hcl 37 gemfibrozil 69 GEMZAR 37 GENERE FE 88 GENOTROPIN 86 GENOTROPIN MINIQUICK 85 gentamicin in saline 16 GENTAMICIN IN ALINE 16 gentamicin sulfate 16 gentamicin sulfate (ophth) 16 GILENYA 74 glatiramer acetate 74 GLEEVEC 43 glimepiride 58 glipizide 58 glipizide-metformin hcl 58 GLOBAL EAE INJECT PEN NEEDLE 110 GLOBAL INJECT EAE INULIN YR 110 GLOBAL INJECT EAE LANCET 28G 110 GLOBAL INJECT EAE LANCET 30G 110 GLOBAL LANCING DEVICE 110 GLUCAGEN DIAGNOTIC 59 GLUCAGEN HYPOKIT 59 GLUCAGON EMERGENCY 59 GLUCOCARD 01 CONTROL 110 GLUCOCARD EXPREION CONTROL 110 GLUCOCARD HINE CONTROL 110 GLUCOCARD X-ENOR CONTROL 110 GLUCOCOM CONTROL 110 GLUCOCOM LANCET 28G 110 GLUCOCOM LANCET 30G 110 GLUCOCOM LANCET 33G 110 GLUCOLAB CONTROL 110 GLUCOLET 2 AUTOMATIC LANCING 110 GLUCOPRO INULIN YRINGE 110 glucose blood 110 GLUCOE CONTROL 111 GLUCOOURCE LANCET DEVICE 111 GLUCOOURCE LANCET 111 glyburide 58 GLYBURIDE 58 glyburide micronized 58 glyburide-metformin 58 glycine (gu irrigant) 82 glycopyrrolate 79 GLYET 58 GMATE CONTROL LEVEL GNP CLICKFINE PEN NEEDLE 111 GNP INULIN YRINGE 111 GNP LANCET 111 GNP LANCET 21G 111 GNP LANCET MICRO THIN 33G 111 GNP LANCET UPER THIN 30G 111 GNP LANCET THIN 111 GNP LANCET THIN 26G 111 GNP MICRO THIN LANCET 33G 111 GNP OMEPRAZOLE 4 GNP UPER THIN LANCET 30G 111 GNP ULTRA COM INULIN YRINGE 111 GOLYTELY 80 granisetron hcl 30 griseofulvin microsize 30,31 griseofulvin ultramicrosize 31 guanabenz acetate 63 guanfacine hcl 64 guanfacine hcl (adhd) 72 guanidine hcl 34 GYNAZOLE-1 31 GYNE-LOTRIMIN 3 GYNOL II 5 H H&H THINLET LANCET 26G 111 H&H THINLET LANCET 30G 111 H-E-B INCONTROL ADV LANCING 111 H-E-B INCONTROL LANCET 28G 111 H-E-B INCONTROL LANCET 30G 111 H-E-B INCONTROL PEN NEEDLE 111 HAEMOLANCE 111 HAEMOLANCE LOW FLOW LANCET 111 GE 154 LAT UPDATED 05/2016

156 HAEMOLANCE PLU 111 HAEMOLANCE PLU HIGH FLOW 111 HAEMOLANCE PLU LOW FLOW 111 HAEMOLANCE PLU MAX FLOW 112 HAEMOLANCE PLU PEDIATRIC FLOW 112 HALAVEN 40 halobetasol propionate 84 HALOG 84 haloperidol 49 haloperidol decanoate 49 haloperidol lactate 49 HARVONI 52 HEALTH CARE LANCING DEVICE 112 HEALTHWIE LANCET 30G 112 HEALTHWIE LANCING PEN 112 HEALTHWIE MINI PEN NEEDLE 112 HEALTHWIE PEN NEEDLE 112 HEALTHWIE HORT PEN NEEDLE 112 HEALTHWIE UNIFINE PENTIP 112 HEALTHY ACCENT LANCING DEVICE 112 HEALTHY ACCENT UNIFINE PENTIP 112 HEALTHY ACCENT UNILET LANCET 112 HERIN (PORCINE) IN NACL 62 heparin sod (porcine) in d5w 62 heparin sodium (porcine) 62 HEPERA 51 HERCEPTIN 45 HEXALEN 35 HIZENTRA 96 HIZENTRA 20% 96 HM LANCET MICRO THIN 33G 112 HM LANCET ULTRA THIN 30G 112 HM OMEPRAZOLE 5 HORIZANT 73 HUMALOG 60 HUMALOG KWIKPEN 60 HUMALOG MIX 50/50 60 HUMALOG MIX 50/50 KWIKPEN 60 HUMALOG MIX 50/50 PEN 60 HUMALOG MIX 75/25 60 HUMALOG MIX 75/25 KWIKPEN 60 HUMALOG MIX 75/25 PEN 60 HUMALOG PEN 60 HUMATROPE 86 HUMIRA 94 HUMIRA PEDIATRIC CROHN TART 94 HUMIRA PEN 94 HUMIRA PEN-CROHN TARTER 94 HUMIRA PEN-PORIAI TARTER 94 HUMULIN 70/30 60 HUMULIN 70/30 KWIKPEN 60 HUMULIN 70/30 PEN 60 HUMULIN N 60 HUMULIN N KWIKPEN 60 HUMULIN N PEN 60 HUMULIN R 60 HUMULIN R U-500 (CONCENTRATED) 60 HY-VEE INULIN YRINGE 112 HYCAMTIN 43 hydralazine hcl 70 HYDREA 38 hydrochlorothiazide 68 hydrocodone-acetaminophen 13 hydrocodone-ibuprofen 13 hydrocortisone 84 hydrocortisone (intrarectal) 98 hydrocortisone (rectal) 98 hydrocortisone (topical) 4,76 hydrocortisone acetate (rectal) 84 hydrocortisone butyrate 84 hydrocortisone valerate 84 hydrocortisone w/acetic acid 131 hydromorphone hcl 11,13 hydroxychloroquine sulfate 46 hydroxyurea 38 hydroxyzine hcl 133 hydroxyzine pamoate 133 HYPERAL 136 I ibandronate sodium 99 ibuprofen 3,10 GE 155 LAT UPDATED 05/2016

157 IDAMYCIN PF 40 idarubicin hcl 40 IFEX 35 ifosfamide 35 ifosfamide & mesna 35 ILEVRO 129 imatinib mesylate 43 imipenem-cilastatin 19 imipramine hcl 29 imipramine pamoate 29 imiquimod 76 IMITREX 32 IMPLANON 91 IN TOUCH GLUCOE CONTROL 112 IN TOUCH LANCING DEVICE 112 IN TOUCH TERILE LANCET 30G 112 INCIVEK 52 INCRELEX 86 INCRUE ELLIPTA 133 indapamide 68 indomethacin 10 INFERGEN 52 INFINITY CONTROL 112 INLYTA 44 insulin pen needle 112 INULIN YRINGE 112 INULIN YRINGE/NEEDLE 112 insulin syringe/needle u INUPEN PEN NEEDLE 112 INUPEN ENITIVE 112 INUPEN ULTRAFIN 113 INTELENCE 53 INTRON A 52 INTUNIV 72 INVANZ 19 INVEGA 49 INVIRAE 55,56 INVOKANA 58 IONOOL-B IN D5W 140 IONOOL-MB IN D5W 140 IOPIDINE 130 ipratropium bromide 133 ipratropium bromide (nasal) 133 ipratropium-albuterol 137 irbesartan 64 irinotecan hcl 40 irrigation solutions, physiological 140 IENTRE 53 IOLYTE-P IN D5W 140 IOLYTE- 140 isoniazid 34 IONIAZID 34 isosorbide dinitrate 70 isosorbide mononitrate 70 isotretinoin 76 isradipine 66 ITODAX 40 itraconazole 31 ivermectin 46 IXEMPRA KIT 40 J JADENU 139 JAKAFI 44 JANUVIA 58 JEVTANA 40 K KALETRA 56 KALYDECO 135 KAMELEON LUBRICATED 6 kanamycin sulfate 16 KCL IN DEXTROE-NACL 140 KCL-LACTATED RINGER-D5W 140 KENALOG 84 KEPIVANCE 74 KETEK 21 KETOCARE 113 ketoconazole 31 ketoconazole (topical) 31 ketoprofen 10 ketorolac tromethamine 10 GE 156 LAT UPDATED 05/2016

158 ketorolac tromethamine (ophth) 129 KETOTIX 113 ketotifen fumarate (ophth) 7 KIMONO 6 KIMONO MICRO THIN PLU 6 KIMONO PLU 6 KIMONO P 6 KIMONO P PLU 6 KIMONO ENATION 6 KIMONO ENATION PLU 6 KINERET 95 KINNEY LANCET 113 KINNEY THIN LANCET 113 KINRAY INULIN YRINGE 113 KLOR-CON M KL OMEPRAZOLE 5 KMART VALU INULIN YRINGE 29G 113 KMART VALU INULIN YRINGE 30G 113 KROGER INULIN YRINGE 113 KROGER LANCET 21G 113 KROGER LANCET MICRO THIN 33G 113 KROGER LANCET UPER THIN 113 KROGER LANCET THIN 26G 113 KROGER LANCET ULTRATHIN 30G 113 KROGER LANCING DEVICE 113 KROGER PEN NEEDLE 113 KUVAN 78 KYPROLI 44 L labetalol hcl 66 LACRIERT 128 lactated ringer's 140 lactated ringer's (irrigation) 141 lactic acid (ammonium lactate) 4,76 lactulose 80 lactulose (encephalopathy) 80 LADY LITE LANCET 113 lamivudine 54 lamivudine (hbv) 51 lamivudine-zidovudine 54 lamotrigine 24 LANCET DEVICE 113 LANCET DEVICE WITH EJECTOR 113 lancet devices 113 lancets 100 LANCET 113 LANCET 28G 113 LANCET 30G 113 LANCET MICRO THIN 33G 113 LANCET UPER THIN 28G 113 LANCET THIN 113 LANCET ULTRA FINE 114 LANCET ULTRA THIN 114 LANCET ULTRA THIN 30G 114 LANCING DEVICE 114 LANOXIN 67 lansoprazole 5,81 LANTU 60 LANTU OLOTAR 60 LANZO 114 LATACAFT 128 latanoprost 130 LATUDA 49 LEADER ADVANCED LANCING DEVICE 114 LEADER INULIN YRINGE 114 LEADER UNIFINE PENTIP 114 LEADER UNIFINE PENTIP PLU 114 leflunomide 96 LETAIRI 135 letrozole 43 leucovorin calcium 40 LEUCOVORIN CALCIUM 40 LEUKERAN 35 LEUKINE 62 leuprolide acetate 92 levalbuterol hcl 134 LEVATOL 66 LEVEMIR 60 LEVEMIR FLEXPEN 60 LEVEMIR FLEXTOUCH 60 levetiracetam 22 GE 157 LAT UPDATED 05/2016

159 levobunolol hcl 130 levocetirizine dihydrochloride 133 levofloxacin 21 levofloxacin (ophth) 21 levofloxacin in d5w 21 levonorgestrel & eth estradiol 88 levonorgestrel (emergency oc) 5,88 levonorgestrel-eth estradiol (triphasic) 88 levonorgestrel-ethinyl estradiol (91-day) 89 levonorgestrel-ethinyl estradiol (continuous) 89 levorphanol tartrate 11 levothyroxine sodium 92 LEXIVA 56 LIALDA 98 LIBERTY GLUCOE CONTROL 114 LIBERTY GLUCOE CONTROL MID 114 LIBERTY MEDICAL LANCET 114 LIBERTY MINI LANCING DEVICE 114 lidocaine 76 lidocaine hcl 4,76 lidocaine hcl (local anesth.) 14 lidocaine hcl (mouth-throat) 14 lidocaine-prilocaine 76 LIDODERM 76 LILETTA 91 LINCOCIN 17 lindane 47 linezolid 17 LINEZOLID IN ODIUM CHLORIDE 17 liothyronine sodium 92 lisinopril 65 lisinopril & hydrochlorothiazide 67 LITE TOUCH LANCET 114 LITE TOUCH LANCING DEVICE 114 LITE TOUCH LANCING PEN 114 LITE TOUCH PEN NEEDLE 114 LITETOUCH INULIN YRINGE 114 LITETOUCH LANCET 114 LITETOUCH PEN NEEDLE 114 lithium 57 lithium carbonate 57 LIVALO 69 LIVE BETTER ADV LANCING DEVICE 114 LIVE BETTER LANCET UPER THIN 114 LIVE BETTER LANCET ULTRA THIN 114 LIVE BETTER PEN NEEDLE 114 LO LOETRIN FE 89 LO/OVRAL (28) 89 LODOYN 48 LOETRIN 1.5/30 (21) 89 LOETRIN 1/20 (21) 89 LOETRIN 24 FE 89 LOETRIN FE 1.5/30 89 LOETRIN FE 1/20 89 lomustine 35 LONG INULIN YRINGE 114 LONG LANCET TANDARD 114 LONG LANCET THIN 114 LONG LANCET ULTRA THIN 115 loperamide hcl 4,79 loratadine 8 loratadine & pseudoephedrine 8 lorazepam 57 losartan potassium 64 losartan potassium & hydrochlorothiazide 67 LOEAONIQUE 89 LOTEMAX 129 LOTRIMIN ULTRA 3 LOTRONEX 80 lovastatin 69 loxapine succinate 49 LUFYLLIN 135 LUMIGAN 130 LUMIZYME 78 LUNETA 138 LUPRON DEPOT 92 LUPRON DEPOT-PED 93 LYRICA 73 LYODREN 40 M mafenide acetate 17 GE 158 LAT UPDATED 05/2016

160 MAGELLAN INULIN AFETY YR 115 MAGNEIUM ULFATE 140 magnesium sulfate 140 MAJOR COMFORT LANCET 115 MALARONE 46 malathion 47 maprotiline hcl 27 MARPLAN 26 MATULANE 35 MAXAIR AUTOHALER 134 MAXI-COMFORT INULIN YRINGE 115 MAXIDEX 129 MAXIMA CONTROL 115 MAXX 6 MAXX PLU 6 mebendazole 46 meclizine hcl 3,29 meclofenamate sodium 10 MEDI-LANCE LANCET 115 MEDIC INULIN YRINGE 115 MEDICHOICE AFETY LANCET 115 MEDICHOICE AFETY LANCET EXTRA 115 MEDICHOICE AFETY LANCET NORM 115 MEDICINE HOPPE LANCET 115 MEDICINE HOPPE LANCET THIN 115 MEDICINE HOPPE PEN NEEDLE 115 MEDIENE GLUCOE KETONE CONTR 115 MEDIENE HI/MID/LOW CONTROL 115 MEDIENE HIGH/LOW CONTROL 115 MEDIENE MID CONTROL 115 MEDIENE THIN LANCET 115 MEDLANCE EXTRA 21G 115 MEDLANCE LITE 25G 115 MEDLANCE PLU EXTRA 21G 115 MEDLANCE PLU LANCET 115 MEDLANCE PLU LITE 25G 115 MEDLANCE PLU PECIAL 0.8MM 115 MEDLANCE PLU UPERLITE 30G 115 MEDLANCE PLU UNIVERAL 21G 115 MEDLANCE UNIVERAL 21G 115 MEDROL 84 medroxyprogesterone acetate 91 medroxyprogesterone acetate (contraceptive) 91 mefenamic acid 10 mefloquine hcl 46 MEGACE E 91 MEGACE ORAL 91 megestrol acetate 91 megestrol acetate (appetite) 91 MEIJER LANCET 116 MEIJER LANCET THIN 116 MEIJER LANCET UNIVERAL 30G 116 MEIJER LANCET UNIVERAL 33G 116 MEIJER PEN NEEDLE 116 MEIJER UPER THIN LANCET 116 meloxicam 10 melphalan hcl 36 memantine hcl 25,26 MENACTRA 97 MENET 89 MENOMUNE 97 MENOTAR 89 MENTAX 31 MENVEO 97 meperidine hcl 13,14 meprobamate 57 MEPRON 46 mercaptopurine 38 meropenem 19 mesalamine 98 METINON 34 metaproterenol sulfate 116,134 metaxalone 137 metformin hcl 59 methadone hcl 11,12 METHADONE HCL 11 METHADOE 12 METHADOE UGAR-FREE 12 methamphetamine hcl 71 methazolamide 130 methenamine hippurate 17 methimazole 93 GE 159 LAT UPDATED 05/2016

161 METHITET 87 methocarbamol 137 methotrexate sodium 95 methoxsalen rapid 76 methscopolamine bromide 79 methyclothiazide 68 methyldopa 64 methyldopate hcl 64 methylphenidate hcl 72 METHYLPHENIDATE HCL ER 72 methylprednisolone 84 methylprednisolone acetate 84 methylprednisolone sod succ 84 metipranolol 130 metoclopramide hcl 29 metolazone 68 metoprolol succinate 66 metoprolol tartrate 66 metronidazole 17 metronidazole (topical) 17 metronidazole vaginal 17 mexiletine hcl 65 MICARDI 64 MICONAZOLE 3 31 MICRODOT CONTROL 116 MICRODOT CONTROL HIGH/LOW 116 MICROLET LANCET 116 MICROTAINER AFETY FLOW LANCET 116 midodrine hcl 64 MIGRANAL 32 MILLIPRED 84 MILLIPRED DP 85 MILLIPRED DP 12-DAY 85 MINATRIN 24 FE 89 MINI LANCING DEVICE 116 MINIVELLE 89 minocycline hcl 22 minoxidil 70 MIRCETTE 89 MIRENA 91 mirtazapine 26 misoprostol 81 mitomycin 40 mitoxantrone hcl 41 MOBIC 11 modafinil 138 MODICON (28) 89 moexipril hcl 65 mometasone furoate 85 mometasone furoate (nasal) 132 MONOJECT INULIN YRINGE 116 MONOJECT ULTRA COMFORT YRINGE 116 MONOKET 70 MONOLET LANCET 116 MONOLET OPD LANCET 116 MONOLETTOR AFETY LANCET 116 montelukast sodium 133 MONUROL 17 MOORE MONO INULIN YRINGE 116 morphine sulfate 12,14 MOTOFEN 79 MOVIPREP 80 moxifloxacin hcl 21 MOZOBIL 62 M INULIN YRINGE 116 MULTAQ 65 mupirocin 17 mupirocin calcium (topical) 17 MUTARGEN 36 MYCAMINE 31 MYCOBUTIN 34 mycophenolate mofetil 95 mycophenolate sodium 95 MYFORTIC 95 MYGLUCOHEALTH CONTROL 116 MYGLUCOHEALTH LANCET 30G 116 MYLERAN 36 MYOZYME 78 MYRBETRIQ 81 MYTELAE 34 GE 160 LAT UPDATED 05/2016

162 N nabumetone 11 nadolol 66 nafcillin sodium 19 NAFTIFINE HCL 31 NAFTIN 31 NAGLAZYME 78 nalbuphine hcl 14 naloxone hcl 15 naltrexone hcl 15 NAMENDA TITRATION K 26 naproxen 11 naproxen sodium 11 naratriptan hcl 32 NAONEX 132 NATACYN 31 NATAZIA 89 nateglinide 59 NATROBA 47 NAVELBINE 41 NEBUPENT 46 NEBUAL 137 NECON 10/11 (28) 89 nefazodone hcl 27 neomycin sulfate 16 neomycin-bacitracin zn-polymyxin 128 neomycin-polymy-dexameth 128 neomycin-polymyxin-hc (ophth) 128 neomycin-polymyxin-hc (otic) 131 NETGROUP LANCET 116 NEULATA 62 NEULATA ONPRO 62 NEUPOGEN 63 NEUPRO 48 NEUTEK 2TEK CONTROL 117 NEVANAC 130 nevirapine 54 NEXAVAR 44 NEXIUM 81 NEXIUM 24HR 5 NEXPLANON 91 niacin 4,9 niacin (antihyperlipidemic) 70 NIAN 70 nicardipine hcl 66 NICODERM CQ 3 NICORETTE 3 NICORETTE MINI 3 NICORETTE REFILL 3 NICORETTE TARTER KIT 3 nicotine 3 NICOTINE 3 NICOTINE MINI 3 nicotine polacrilex 3 NICOTROL 15 NICOTROL N 15 nifedipine 66 NILANDRON 36 nimodipine 66 NINLARO 44 NIPENT 38 nisoldipine 67 NITRO-BID 70 nitrofurantoin 17 nitrofurantoin macrocrystal 17 nitrofurantoin monohyd macro 17 nitroglycerin 70 NITROTAT 70 nizatidine 80 NOR-QD 91 NORDETTE (28) 89 NORDITROPIN 86 NORDITROPIN FLEXPRO 86 NORDITROPIN NORDIFLEX PEN 86 norethin acet & estrad-fe 89 norethindrone & eth estradiol 89 norethindrone & ethinyl estradiol-fe 89 norethindrone (contraceptive) 91 norethindrone acet & eth estra 89 norethindrone acetate 91 norethindrone acetate-ethinyl estradiol-fe 89 GE 161 LAT UPDATED 05/2016

163 norethindrone-eth estradiol (triphasic) 89 norgestimate-ethinyl estradiol 90 norgestimate-ethinyl estradiol (triphasic) 90 norgestrel & ethinyl estradiol 90 NORINYL 1+35 (28) 90 NORMOOL-M IN D5W 140 NORMOOL-R PH NOROXIN 21 nortriptyline hcl 29 NORVIR 56 NOVA MAX PLU GLU/KET CONTROL 117 NOVA MAX PLU KETONE TET 6 NOVA AFETY LANCET 23G 117 NOVA AFETY LANCET 28G 117 NOVA UREFLEX LANCET 117 NOVA UREFLEX LANCING DEVICE 117 NOVOFINE 117 NOVOFINE AUTOCOVER 117 NOVOFINE PLU 117 NOVOLIN 70/30 60 NOVOLIN 70/30 RELION 60 NOVOLIN N 60 NOVOLIN N RELION 60 NOVOLIN R 60 NOVOLIN R RELION 61 NOVOLOG 61 NOVOLOG FLEXPEN 61 NOVOLOG MIX 70/30 61 NOVOLOG MIX 70/30 FLEXPEN 61 NOVOLOG PENFILL 61 NOVOTWIT 117 NOXAFIL 31 NPLATE 63 NUCYNTA 14 NUCYNTA ER 12 NUEDEXTA 73 NULOJIX 95 NUTROPIN 86 NUTROPIN AQ 86 NUTROPIN AQ NUPIN NUTROPIN AQ PEN 86 NUVARING 90 NUVIGIL 138 nystatin 31 nystatin (mouth-throat) 31 nystatin (topical) 31,117 nystatin-triamcinolone 31 O octreotide acetate 93 ofloxacin 21 ofloxacin (ophth) 21 ofloxacin (otic) 22 OFORTA 41 OGETREL 90 olanzapine 49 OLEPTRO 27 olopatadine hcl (nasal) 133 omega-3-acid ethyl esters 70 omeprazole 5,81 OMEPRAZOLE 5 omeprazole magnesium 5 omeprazole-sodium bicarbonate 5,81 OMNIFLEX DIAPHRAGM 117 OMNITROPE 86 OMONTY 63 ON CALL EXPRE GLUCOE CONTR 117 ON CALL LANCET 117 ON CALL LANCING DEVICE 117 ON CALL PLU GLUCOE CONTROL 117 ON CALL PLU LANCET 117 ON CALL PLU LANCING DEVICE 117 ON CALL VIVID GLUCOE CONTROL 117 ONCAR 41 ondansetron 30 ondansetron hcl 30 ONETOUCH DELICA LANCET 33G 117 ONETOUCH DELICA LANCET FINE 117 ONETOUCH DELICA LANCING DEV 117 ONETOUCH FINEPOINT LANCET 117 ONETOUCH LANCET 117 ONETOUCH ULTRA CONTROL 117 GE 162 LAT UPDATED 05/2016

164 ONETOUCH ULTRAOFT LANCET 117 ONETOUCH VERIO 117 ONFI 23 ONGLYZA 59 ONTAK 41 OPTUMRX GLUCOE CONTROL 117 ORAP 49 ORAPRED ODT 85 ORBIVAN 73 ORENCIA 95 ORFADIN 78 orphenadrine citrate 137 ORINI INULIN YRINGE 118 ORTHO DIAPHRAGM ALL-FLEX 118 ORTHO DIAPHRAGM COIL 118 ORTHO DIAPHRAGM FLAT 118 ORTHO EVRA 90 ORTHO MICRONOR 91 ORTHO TRI-CYCLEN (28) 90 ORTHO TRI-CYCLEN LO 90 ORTHO-CEPT (28) 90 ORTHO-CYCLEN (28) 90 ORTHO-NOVUM 1/35 (28) 90 ORTHO-NOVUM 7/7/7 (28) 90 OMOPREP 80 OVCON-35 (28) 90 oxacillin sodium 19 oxaliplatin 41 oxandrolone 87 oxaprozin 11 oxcarbazepine 25 OXITAT 31 OXORALEN 76 OXORALEN ULTRA 76 oxybutynin chloride 81 oxycodone hcl 12,14 oxycodone w/ acetaminophen 14 oxycodone-ibuprofen 14 OXYCONTIN 12 oxymorphone hcl 12,14 P paclitaxel 41 pamidronate disodium 99 MIDRONATE DIODIUM 99 NCREAZE 79 pancrelipase (lipase-protease-amylase) 79 NOXYL-4 CREAMY WAH 4 NRETIN 45 pantoprazole sodium 81 RAGARD INTRAUTERINE COPPER 118 parenteral electrolytes 139 paricalcitol 99 paromomycin sulfate 16 paroxetine hcl 27 ER 34 TADAY 129 TANOL 129 XIL 27 PC LANCET UPER THIN 30G 118 PC UNIFINE PENTIP 118 peg 3350-kcl-sod bicarb-sod chloride-sod sulfate 80 PEG-INTRON 52 PEG-INTRON REDIPEN 52 PEG-INTRON REDIPEN K 4 52 PEGANONE 25 PEGAY 52,53 PEGAY PROCLICK 52 PEGINTRON 53 PEN NEEDLE 118 PEN NEEDLE 3/16" 118 PEN NEEDLE 5/16" 118 PENICILLIN G POT IN DEXTROE 19 penicillin g potassium 20 PENICILLIN G PROCAINE 20 penicillin g sodium 20 penicillin v potassium 20 PENTAM 46 PENTAA 98 pentazocine w/ naloxone 14 PENTIP 118 GE 163 LAT UPDATED 05/2016

165 pentostatin 38 pentoxifylline 67 PERFECT LANCET 28G 118 PERFECT LANCET 30G 118 perindopril erbumine 65 peritoneal dialysis solutions 139 PERJETA 45 permethrin 47 perphenazine 29 perphenazine-amitriptyline 26 PHARMACIT CHOICE LANCET 118 PHARMACY COUNTER LANCET 118 phenazopyridine hcl 82 phenelzine sulfate 26 phenobarbital 23 phenoxybenzamine hcl 64 PHENYTEK 25 phenytoin 25 phenytoin sodium 25 phenytoin sodium extended 25 PHIOHEX 118 PHOLYRA 83 PHOPHOLINE IODIDE 130 PHOTOFRIN 41 PICATO 76 pilocarpine hcl 130 pilocarpine hcl (oral) 75 pimozide 49 pindolol 66 pioglitazone hcl 59 pioglitazone hcl-metformin hcl 59 piperacillin sodium-tazobactam sodium 20 piroxicam 11 PLAN B 90 PLAN B ONE-TEP 5,90 PLAMA-LYTE PLAMA-LYTE A 140 PLAMA-LYTE-56 IN D5W 140 PNEUMOVAX POCKETCHEM EZ CONTROL 118 podofilox 76 polymyxin b sulfate 17 polymyxin b-trimethoprim 128 potassium acetate 140 potassium bicarb & chloride 140 potassium bicarbonate 140 potassium chloride 140 POTAIUM CHLORIDE 140 POTAIUM CHLORIDE ER 140 potassium chloride in dextrose 141 potassium chloride in dextrose & sodium chloride 141 potassium chloride in nacl 141 potassium chloride microencapsulated crystals cr 141 potassium citrate (alkalinizer) 82 potassium phosphates 141 POTIGA 22 PRADAXA 62 pramipexole dihydrochloride 48 PRANDIMET 59 PRANDIN 59 pravastatin sodium 69 prazosin hcl 64 PRECIION GLUCOE KETONE CONTR 118 PRECIION URE-DOE YRINGE 118 PRECIION UREDOE PLU YR 118 PRECIION XTRA KETONE 6 PRED MILD 130 prednicarbate 85 prednisolone 85 prednisolone acetate (ophth) 130 prednisolone sodium phosphate 85 PREDNIOLONE ODIUM PHOPHATE 85,130 prednisone 85 PREFERRED PLU INULIN YRINGE 118 PREFERRED PLU LANCET COLORED 118 PREFERRED PLU LANCET THIN 118 PREFERRED PLU UNIFINE PENTIP 118 PREMARIN 90 PREMIUM CONDOM LUBRICATED 6 PREMPHAE 90 PREMPRO 90 PRENTIF FITTING ET 118 GE 164 LAT UPDATED 05/2016

166 PREPOPIK 80 PRETIGE GLUCOE CONTROL 118 PREVACID 24HR 5 PREVNAR PREZITA 56 PRIFTIN 34 PRILOEC OTC 5 PRIMAQUINE PHOPHATE 46 primaquine phosphate 47 primidone 23 PRITIQ 28 PROAIR HFA 134 probenecid 32 PROCAINAMIDE HCL 65 prochlorperazine 29 prochlorperazine maleate 29 PROCRIT 63 PRODIGY CONTROL OLUTION 118 PRODIGY INULIN YRINGE 119 PRODIGY LANCET 21G 119 PRODIGY LANCET 26G 119 PRODIGY LANCET 28G 119 PRODIGY LANCING DEVICE 119 PRODIGY MINI PEN NEEDLE 119 PRODIGY AFETY LANCET 26G 119 PRODIGY HORT PEN NEEDLE 119 PRODIGY TWIT TOP LANCET 28G 119 progesterone micronized 91 PROGLYCEM 59 PROGRAF 95 PROLATIN 137 PROLATIN-C 137 PROLEUKIN 41 PROLIA 99 PROMACTA 63 promethazine hcl 133 propafenone hcl 65 proparacaine hcl 129 propranolol hcl 66 propylthiouracil 93 protriptyline hcl 29 PROVENTIL HFA 135 PRUDOXIN 76 PT NEL KETONE TET 6 PULMICORT 132 PULMICORT FLEXHALER 132 PULMOZYME 137 PURINETHOL 38 PX ADVANCED LANCING DEVICE 119 PX EXTRA HORT PEN NEEDLE 119 PX INULIN YRINGE 119 PX LANCET AUTO INJECTOR 119 PX LANCET 119 PX LANCET ULTRA THIN 119 PX MINI PEN NEEDLE 119 PX OMEPRAZOLE 5 PX PEN NEEDLE 119 pyrazinamide 34 pyridostigmine bromide 34 Q QC ADVANCED LANCING DEVICE 119 QC INULIN YRINGE 119 QC LANCET UPER THIN 30G 119 QC LANCET ULTRA THIN 119 QC PEN NEEDLE 119 QC UNIFINE PENTIP 119 quetiapine fumarate 50 QUICKTEK CONTROL OLUTION 119 quinapril hcl 65 quinidine sulfate 65 quinine sulfate 47 QUINTET CONTROL HIGH/NORMAL 119 QVAR 132 R RA E-ZJECT COLOR LANCET 33G 120 RA E-ZJECT LANCET 28G 120 RA E-ZJECT LANCET THIN 26G 120 RA E-ZJECT LANCET THIN 28G 120 RA E-ZJECT LANCET ULTRA THIN 120 RA INULIN YRINGE 120 GE 165 LAT UPDATED 05/2016

167 RA LANCING DEVICE 120 RA OMEPRAZOLE 5 RA PEN NEEDLE 120 rabeprazole sodium 81 raloxifene hcl 92 ramipril 65 RANEXA 67 ranitidine hcl 4,80 RAFLO 82 REALITY LATEX/ULTRA TEXTURED 6 REALITY LATEX/ULTRA THIN 6 REBETOL 53 REBIF 74 REBIF REBIDOE 74 REBIF REBIDOE TITRATION CK 74 REBIF TITRATION CK 74 RECLAT 99 RECTIV 76 REFUAH PLU GLUCOE CONTROL 120 REGRANEX 77 RELENZA DIKHALER 56 RELI-ON INULIN YRINGE 120 RELION 70/30 61 RELION INULIN YRINGE 120 RELION LANCET MICRO-THIN 33G 120 RELION LANCET TANDARD 21G 120 RELION LANCET THIN 26G 120 RELION LANCET ULTRA-THIN 30G 120 RELION LANCING DEVICE 120 RELION MINI PEN NEEDLE 120 RELION N 61 RELION PEN NEEDLE 120 RELION R 61 RELION HORT PEN NEEDLE 120 RELION ULTRA THIN LANCET 30G 120 RELION ULTRA THIN PLU LANCET 120 RELITOR 79 RELX 33 REMICADE 95 REMODULIN 135 RENAGEL 83 RENEW ADV CARTRIDGE REFILL 120 RENEW ADVANCED LANCING DEVICE 120 REOPRO 63 repaglinide 59 RECRIPTOR 54 REECTIOL 82 RETAI 129 RETROVIR 55 REVATIO 136 REVLIMID 36 REXALL LANCET ULTRA THIN 30G 120 REYATAZ 56 RHEUMATREX 95 RHINOCORT AQUA 132 ribavirin (hepatitis c) 53 RIDAURA 96 rifabutin 34 RIFAMATE 34 rifampin 34 RIFATER 34 RIGHTET GC300 CONTROL 120 RIGHTET GD500 LANCING DEVICE 120 RIGHTET GL300 LANCET 121 RILUTEK 73 rimantadine hydrochloride 56 ringer's 141 ringer's irrigation 141 risedronate sodium 99 RIPERDAL CONTA 50 risperidone 50 RITUXAN 45 rivastigmine tartrate 25 rizatriptan benzoate 33 ropinirole hydrochloride 48 ROZEREM 138 ABRIL 23 AFENAP INULIN YRINGE 121 AFETY LANCET 21G/PREURE ACT 121 AFETY LANCET 28G/PREURE ACT 121 GE 166 LAT UPDATED 05/2016

168 AFETY LANCET 2MM 121 AFETY LANCET 121 AFETY LANCET 21G 121 AFETY LANCET 28G 121 AFETY LET LANCET 121 AFETY EAL LANCET 121 AFETY-GLIDE YRINGE 121 AFYRAL 90 AIZEN 86 AIZEN CLICK.EAY 86 salsalate 11 AMCA 139 ANDOTATIN 93 ANTYL 77 APHRI 50 APCARE TWIT TOP LANCET 121 AVELLA 73 AVELLA TITRATION CK 73 B INULIN YRINGE 121 B LANCET THIN 121 B LANCET ULTRA THIN 121 B OMEPRAZOLE 5 CHNUCK INULIN YRINGE 121 EAONALE 90 EAONIQUE 90 selegiline hcl 48 selenium sulfide 77 ELZENTRY 55 ENIR 92 EREVENT DIKU 135 EROMYCIN 34 EROQUEL XR 50 EROTIM 86 sertraline hcl 28 HOPKO AUTOLET LANCING DEVICE 121 HOPKO ON-THE-GO LANCET 30G 121 HOPKO UNIFINE PENTIP 121 HOPKO UNILET LANCET 28G 121 HOPKO UNILET LANCET 30G 121 sildenafil citrate (pulmonary hypertension) 136 silver sulfadiazine 22 IMCOR 70 IMPLE DIAGNOTIC LANCING DEV 121 IMPONI 95 IMULECT 96 simvastatin 69 sirolimus 95 KELID 92 KLICE 46 KYLA 91 M INULIN YRINGE 121 M LANCET 21G 121 M LANCET 33G 121 M OMEPRAZOLE 5 M UPER THIN LANCET 30G 121 M THIN LANCET 26G 122 MART DIABETE VANTAGE LANCET 122 MART DIABETE VANTAGE LANCING 122 MART ENE COLOR LANCET 33G 122 MART ENE TANDARD LANCET 122 MART ENE UPER THIN LANCET 122 MART ENE THIN LANCET 26G 122 MARTET CONTROL MEDIUM 122 MARTET LANCET 28G 122 sodium acetate 141 sodium chloride 83,141 sodium chloride (gu irrigant) 83 sodium chloride (inhalant) 137 sodium citrate & citric acid 83 sodium phenylbutyrate 79 sodium phosphate 141 sodium polystyrene sulfonate 139 sodium polystyrene sulfonate (bulk) 122 OLARAZE 77 OLARTEK GLUCOE CONTROL 122 OLTAMOX 37 OLU-CORTEF 85 OLU-MEDROL 85 OLU V2 CONTROL 122 OLU V2 LANCET 28G 122 OLU V2 LANCING DEVICE 122 OLU V2 TWIT LANCET 30G 122 GE 167 LAT UPDATED 05/2016

169 OMATULINE DEPOT 93 OMAVERT 93 ORBITOL 83 ORBITOL-MANNITOL 83 ORIATANE 77 sotalol hcl 65 OVALDI 53 PECTRACEF 19 PINOAD 47 PIRIVA HANDIHALER 133 PIRIVA REPIMAT 133 spironolactone 68 spironolactone & hydrochlorothiazide 67 PORANOX 31 PRYCEL 44 TALEVO TALEVO TALEVO TALEVO TALEVO TALEVO stannous fluoride 4,75 stannous fluoride (bulk) 122 stavudine 55 TELARA 77 TENDRA 83 TERILANCE TL 122 TIMATE 86 TIVARGA 44 TRATTERA 72,73 streptomycin sulfate 16 TRIBILD 53 TROMECTOL 46 UBOXONE 15 UCRAID 79 sucralfate 81 sulfacetamide sodium (acne) 77 sulfacetamide sodium (ophth) 22 sulfacetamide sodium w/ sulfur 77 sulfadiazine 22 sulfamethoxazole-trimethoprim 22 ULFAMYLON 17 sulfasalazine 98 sulindac 11 sumatriptan 33 sumatriptan succinate 33 UPER THIN LANCET 122 UPRAX 19 UPREP BOWEL PREP 80 URE COMFORT INULIN YRINGE 122 URE COMFORT LANCET 28G 122 URE COMFORT LANCET 30G 122 URE COMFORT LANCING PEN 122 URE COMFORT PEN NEEDLE 122 URE EDGE GLUCOE CONTROL 122 URE-FINE PEN NEEDLE 122 URE-JECT INULIN YRINGE 122 URE-LANCE FLAT LANCET 122 URE-LANCE LANCET 26G 123 URE-LANCE THIN LANCET 28G 123 URE-LANCE ULTRA THIN LANCET 123 URE-PEN 123 URE-TET EAYPLU CONTROL 123 URE-TOUCH LANCET UNIVERAL 123 URECHEK CONTROL OLUTION 123 URELITE LANCET 123 URETEP GLUCOE CONTROL 123 URETEP PRO LOW GLUCOE 123 URETEP PRO NORMAL GLUCOE 123 UTIVA 54 UTENT 44 W OMEPRAZOLE 5 YLATRON 41 YMBICORT 137 YMLINPEN YMLINPEN YNAREL 93 YNERA 77 YNRIBO 41 YPRINE 139 GE 168 LAT UPDATED 05/2016

170 T TABLOID 38 TACLONEX 77 tacrolimus 95 tacrolimus (topical) 77 TAI DOC CONTROL 123 TALWIN 14 TAMIFLU 56 tamoxifen citrate 37 tamsulosin hcl 82 TARCEVA 44 TARGRETIN 45,46 TAIGNA 44 TAMAR 48 TAXOTERE 41 TAZORAC 77 TECHLITE AT LANCET 123 TECHLITE LANCET 123 TECHLITE LANCET 30G 123 TEFLARO 19 TEGRETOL 25 TEKTURNA 67 TELCARE GLUCOE CONTROL 123 telmisartan 64 TEMODAR 36 temozolomide 36 TENIPOIDE 41 terazosin hcl 82 terbinafine hcl 31 terbutaline sulfate 135 terconazole vaginal 31 TERUMO INULIN YRINGE 123 TERUMO URGUARD INULIN YR 123 testosterone cypionate 87 testosterone enanthate 87 tetrabenazine 73 tetracycline hcl 22 TEV-TROPIN 87 TEVETEN 64 TGT ADVANCED LANCING DEVICE 123 TGT LANCET ALTERNATE ITE 123 TGT LANCET MICRO THIN 33G 123 TGT LANCET UPER THIN 30G 123 TGT LANCET THIN 23G 123 TGT LANCET THIN 26G 123 TGT LANCET ULTRA THIN 28G 124 TGT LANCET ULTRA THIN 30G 124 TGT LANCING DEVICE 124 TGT OMEPRAZOLE 5 THALOMID 36 theophylline 135 THINPRO INULIN YRINGE 124 thioridazine hcl 49 thiotepa 41 thiothixene 49 THYMOGLOBULIN 96 THYROLAR-1 92 THYROLAR-1/2 92 THYROLAR-1/4 92 THYROLAR-2 92 THYROLAR-3 92 tiagabine hcl 23 ticlopidine hcl 63 TIKOYN 65 TIMENTIN 20 timolol maleate 66 timolol maleate (ophth) 130 tizanidine hcl 138 TOBI 135 TOBRADEX 16 tobramycin 135 tobramycin (ophth) 16 tobramycin sulfate 16 TOBRAMYCIN ULFATE IN ALINE 16 tobramycin-dexamethasone 129 TODAY PONGE 5 TODAY HEALTH LANCING DEVICE 124 TODAY HEALTH MINI PEN NEEDLE 124 TODAY HEALTH PEN NEEDLE 124 TODAY HEALTH HORT PEN NEEDLE 124 TODAY HEALTH THIN LANCET 28G 124 GE 169 LAT UPDATED 05/2016

171 TODAY HEALTH THIN LANCET 30G 124 tolazamide 59 tolbutamide 59 tolmetin sodium 11 tolterodine tartrate 82 TOPCARE CLICKFINE PEN NEEDLE 124 TOPCARE ULTRA COMFORT IN YR 124 topiramate 24 topotecan hcl 43 TORIEL 44 torsemide 68 TOVIAZ 82 TRACLEER 136 TRADJENTA 59 tramadol hcl 12,14 tramadol-acetaminophen 14 trandolapril 65 tranexamic acid 63 TRANDERM-COP 29 tranylcypromine sulfate 26 TRAVATAN Z 130 TRAVEL LANCET 124 trazodone hcl 28 TREANDA 36 TRECATOR 34 TRELTAR 93 TRELTAR DEPOT MIXJECT 93 TRELTAR LA MIXJECT 93 TRELTAR MIXJECT 93 tretinoin 77 tretinoin (chemotherapy) 46 tretinoin microsphere 77 TREXALL 95 TRI-NORINYL (28) 90 triamcinolone acetonide (mouth) 75 triamcinolone acetonide (topical) 85 triamterene & hydrochlorothiazide 67 triazolam 138 trifluoperazine hcl 49 trifluridine 57 trihexyphenidyl hcl 47 trimethobenzamide hcl 29 trimethoprim 17 trimipramine maleate 29 TRIENOX 41 TRIUMEQ 55 TRIZIVIR 55 TROJAN MAGNUM WARM ENATION 6 TROJAN UPRA PERMICIDAL 6 TROJAN TWITED PLEAURE 6 tropicamide 129 trospium chloride 82 TRUE METRIX BLOOD GLUCOE TET 124 TRUE METRIX LEVEL TRUE METRIX LEVEL TRUE METRIX METER 124 TRUECONTROL GLUCOE CONT LEV TRUECONTROL GLUCOE CONT LEV TRUEDRAW LANCING DEVICE 124 TRUEPLU INULIN YRINGE 124 TRUEPLU LANCET 26G 124 TRUEPLU LANCET 28G 124 TRUEPLU LANCET 30G 124 TRUEPLU LANCET 33G 124 TRUEPLU AFETY LANCET 28G 125 TRUEREULT BLOOD GLUCOE 125 TRUETET CONTROL LEVEL TRUETET CONTROL LEVEL TRUETET CONTROL LEVEL TRUETET TET 125 TRUETRACK GLUCOE CONTROL 125 TRUETRACK TET 125 TRUTEX COLOR CONDOM + LUBE 6 TRUTEX LUB/RIBBED/TUDDED 6 TRUTEX LUB/PERMICIDE EX T 6 TRUTEX LUB/PERMICIDE XL 7 TRUTEX LUBRICATED 7 TRUTEX LUBRICATED EX LARGE 7 TRUTEX LUBRICATED EXTRA T 7 TRUTEX LUBRICATED/PERMICIDE 7 TRUTEX NATURAL CONDOM + LUBE 7 TRUTEX RIA LUB/PERMICIDE 7 GE 170 LAT UPDATED 05/2016

172 TRUTEX RIA LUBRICATED 7 TRUTEX-NONOXYNOL-9/RIB/TUD 7 TRUVADA 55 TWINJECT 135 TYBOT 55 TYGACIL 17 TYKERB 44 TYABRI 74 TYZEKA 52 TYZINE 137 U ULEFIA 47 ULORIC 32 ULTI-LANCE AUTO-ADJUT DEVICE 125 ULTI-LANCE AUTOMATIC 125 ULTI-LANCE MINI ADJUTABLE 125 ULTICARE INULIN AFETY YR 125 ULTICARE INULIN YRINGE 125 ULTICARE MICRO PEN NEEDLE 125 ULTICARE MINI PEN NEEDLE 125 ULTICARE PEN NEEDLE 125 ULTICARE HORT PEN NEEDLE 125 ULTICARE THIN LANCET 30G 125 ULTILET BAIC LANCET 30G 125 ULTILET CLAIC LANCET 125 ULTILET INULIN YRINGE 125 ULTILET INULIN YRINGE HORT 125 ULTILET LANCET 125 ULTILET PEN NEEDLE 126 ULTILET AFETY LANCET 23G 126 ULTRA COMFORT INULIN YRINGE 126 ULTRA THIN LANCET 28G 126 ULTRA THIN LANCET 30G 126 ULTRA-COMFORT INULIN YRINGE 126 ULTRA-THIN II AUTO LANCET 126 ULTRA-THIN II IN YR HORT 126 ULTRA-THIN II INULIN YRINGE 126 ULTRA-THIN II LANCET 126 ULTRA-THIN II MINI PEN NEEDLE 126 ULTRA-THIN II PEN NEEDLE HORT 126 ULTRA-THIN II PEN NEEDLE 126 ULTRABAG/DIANEAL PD-2/1.5% DEX 141 ULTRABAG/DIANEAL/1.5% DEXTROE 141 ULTRATRAK PRO CONTROL 126 ULTRATRAK ULTIMATE CONTROL 126 UNIFINE PENTIP 126 UNIFINE PENTIP PLU 126 UNILET COMFORTOUCH LANCET 126 UNILET EXCELITE 126 UNILET EXCELITE II 126 UNILET G.P. LANCET 126 UNILET G.P. UPERLITE LANCET 126 UNILET GP 28 ULTRA THIN 126 UNILET LANCET 126 UNILET MICRO-THIN 33G 126 UNILET UPER-THIN 30G 126 UNILET UPERLITE LANCET 127 UNILET ULTRA-THIN 28G 127 UNITIK 3 GENTLE 127 UNITIK AFETY LANCET 28G 127 UNITIK AFETY LANCET 30G 127 UNITRIP CONTROL 127 UNIVERAL 1 LANCET THIN 26G 127 UNIVERAL 1 LANCET ULTRA THIN 127 ursodiol 80 UVADEX 42 V V-R MONO INULIN YRINGE 127 valacyclovir hcl 57 VALCYTE 50,51 valganciclovir hcl 51 valproate sodium 23 valproic acid 23 valsartan 64 valsartan-hydrochlorothiazide 67 VALTAR 42 VALUE HEALTH INULIN YRINGE 127 VALUE PLU LANCET TANDARD 21G 127 VALUE PLU LANCET UPER THIN 127 VALUE PLU LANCET THIN 26G 127 GE 171 LAT UPDATED 05/2016

173 VALUE PLU LANCING DEVICE 127 VALUMARK LANCET UPER THIN 30G 127 VALUMARK LANCET ULTRA THIN 28G 127 VALUMARK PEN NEEDLE 127 vancomycin hcl 17 VANDETANIB 44 VANIHPOINT INULIN YRINGE 127 VECTIBIX 45 VECTICAL 77 VELCADE 42 VELTIN 77 venlafaxine hcl 28 VENLAFAXINE HCL ER 28 VENTAVI 136 VENTOLIN HFA 135 verapamil hcl 67 VEREGEN 77 VERIPRED VEICARE 82 VEXOL 130 VIBATIV 17 VICTORY CONTROL LEVEL 1/2 127 VICTOZA 59 VICTRELI 53 VIDA MIA AUTOLET LANCING DEV 127 VIDA MIA UNIFINE PENTIP 127 VIDA MIA UNILET LANCET 28G 127 VIDA MIA UNILET LANCET 30G 127 VIDAZA 42 VIDEX 55 VIIBRYD 28 VIMT 25 vinblastine sulfate 42 vincristine sulfate 42 vinorelbine tartrate 42 VIRACEPT 56 VIRAMUNE 54 VIRAMUNE XR 54 VIREAD 55 VIICOL 80 VITIDE 51 VITOGARD 127 VIVELLE-DOT 90 VOCAL POINT CONTROL 127 VOLTAREN 77 VORAXAZE 42 voriconazole 31 VOTRIENT 44 VP INULIN YRINGE 127 VPRIV 79 VUMON 42 VYTORIN 70 VYVANE 71 W W&F LANCET 26G 127 W&F LANCET COLORED 21G 128 WALGREEN ADV TRAVEL LANCET 128 WALGREEN LANCET 128 WALGREEN LANCET MICRO THIN 128 WALGREEN LANCET UPER THIN 128 WALGREEN LANCING DEVICE 128 WALGREEN THIN LANCET 128 WALGREEN ULTRA THIN LANCET 128 warfarin sodium 62 water for irrigation, sterile 128 WD MEDIC INULIN YRINGE 128 WEGMAN UNIFINE PENTIP PLU 128 WELCHOL 70 WELLBUTRIN 26 WELLBUTRIN R 26 WIDE-EAL DIAPHRAGM WIDE-EAL DIAPHRAGM WIDE-EAL DIAPHRAGM WIDE-EAL DIAPHRAGM WIDE-EAL DIAPHRAGM WIDE-EAL DIAPHRAGM WIDE-EAL DIAPHRAGM WIDE-EAL DIAPHRAGM X XALKORI 44 GE 172 LAT UPDATED 05/2016

174 XARELTO 62 XELJANZ 95 XELODA 38 XENAZINE 73 XEOMIN 138 XGEVA 99 XIFAXAN 17 XOLAIR 137 XOPENEX HFA 135 XPRE CONTROL 128 XTANDI 36 XULANE 90 XYLOCAINE 14 XYREM 139 Y YAMIN YAZ 91 YERVOY 45 Z ZADITOR 7 zafirlukast 133 zaleplon 138 ZALTRAP 42 ZANOAR 36 ZAVECA 79 ZEGERID OTC 5 ZELBORAF 45 ZEMAIRA 137 ZEMPLAR 99 ZENPEP 79 ZETIA 70 ZIAGEN 55 ZIANA 77 zidovudine 55 ZIOPTAN 130 ziprasidone hcl 50 ZIRGAN 51 ZITHROMAX 21 ZOHYDRO ER 12 ZOLADEX 93 zoledronic acid 100 ZOLEDRONIC ACID 100 ZOLINZA 42 zolmitriptan 33 zolpidem tartrate 138 ZOLVIT 14 ZOMACTON 87 ZOMETA 100 ZOMIG 33 ZOMIG ZMT 33 ZONALON 78 zonisamide 23 ZORBTIVE 87 ZORTRE 95 ZOTAVAX 97 ZOVIA 1/50E (28) 91 ZOVIRAX 57 ZYBAN 15 ZYFLO CR 133 ZYMAXID 22 ZYRTEC ALLERGY 8 ZYRTEC CHILDREN ALLERGY 8 ZYRTEC CHILDREN HIVE RELIEF 8 ZYRTEC HIVE RELIEF 8 ZYRTEC-D ALLERGY & CONGETION 8 ZYTIGA 36 GE 173 LAT UPDATED 05/2016

175 2015 Ambetter of Arkansas. All rights reserved. AMB15-C-AR-00174