2016 Comprehensive List of Covered Drugs

Transcription

1 Healthcare Marketplace Comprehensive Exchange Drug List: CY Comprehensive List of Covered Drugs PLEASE READ: THIS DOCUMENT HAS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. Covered persons must use network pharmacies to get their prescription drugs. Your benefits, drug list, pharmacy network, premium and/or copayments/coinsurance may sometimes change. What is the Network Health Comprehensive Drug List? A comprehensive drug list is a list of drugs that are covered by your plan. Network Health works with a team of health care providers to choose drugs that provide quality treatment. Network Health covers drugs on our comprehensive drug list, as long as: The drug is medically necessary. The prescription is filled at a Network Health network pharmacy. Other plan rules are followed. For more information on how to fill your prescriptions, please review your plan document or other plan materials. Are all drugs covered by my benefit plan included on this Comprehensive Drug List? Yes. This comprehensive drug list is a list of drugs specifically covered by your plan. If you have questions about a medication that is not on the comprehensive drug list, please call customer service at , 24 hours a day, seven days a week. TTY/TDD users, please call Can the Comprehensive Drug List change? The drug list may change from time to time as described in the plan document or other plan materials. The enclosed comprehensive drug list is up to date as of 6/1/2016. To get updated information about the drugs covered by Network Health, please [visit networkhealth.com/benefits/individualdruglist.php or] call customer service at , 24 hours a day, seven days a week a I

2 Healthcare Marketplace Comprehensive Exchange Drug List: CY2016 What else could result in changes to the covered drug list? We remove drugs from our drug list right away and will let covered persons know when: The U.S. Food and Drug Administration (FDA) decides that a drug is unsafe. The drug maker removes the drug from the market. How do I use the Comprehensive Drug List? There are two ways to find your drug on the comprehensive drug list 1. Medical Condition The comprehensive drug list starts on page IX. The drugs on this list are grouped by the type of medical conditions they are used to treat. For example, drugs used to treat a heart condition are listed under Cardiotonics. If you know what your drug is used for, look for the category name in the list that starts on page IX. Then look under the category name for your drug. 2. Alphabetical Listing If you are not sure what category to look under, look for your drug in the Index that starts on page 134. The Index is an alphabetical list of all the drugs in this document. Both brand-name drugs and generic drugs are in the Index. Look in the Index and find your drug. Next to your drug, see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? Network Health covers both brand-name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand-name drug. Generic drugs usually cost less than brand-name drugs, but provide the same quality of treatment. Are there any restrictions on my coverage? Some covered drugs may have more requirements or limits on coverage. These requirements and limits may include the following. Prior Authorization: Network Health needs you (or your prescriber) to get prior approval or authorization for certain drugs. This means that you need to get approval from Network Health before you fill your prescriptions. If you don t get approval, Network Health may not cover the drug. Quantity Limits: For certain drugs, Network Health limits the amount of the drug that it will cover. For example, Network Health provides 12 tablets per prescription for Sumatriptan tablets a II

3 Healthcare Marketplace Comprehensive Exchange Drug List: CY2016 Step Therapy: Network Health needs you to try certain drugs as the first step to treat your medical condition before covering another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Network Health may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Network Health will then cover Drug B. You can find out if your drug has any special requirements or limits by looking on the comprehensive drug list that starts on page 134. You can also get more information about the restrictions for specific covered drugs by visiting networkhealth.com/benefits/individualdruglist.php. You can ask Network Health to make an exception to these restrictions or limits. See the section, How do I ask for an exception to Network Health s drug list? on page 4. Does the Plan cover prescription drugs that are considered Preventive Services under the Affordable Care Act? The U.S. Department of Health and Human Services (HHS) has adopted Guidelines for Preventive Services under the Affordable Care Act (ACA). Under the ACA, some pharmacy benefit plans may provide a range of preventive services for $0 Covered person cost share and are designated as tier 0 on this document. These items may include: Aspirin to Prevent Cardiovascular Disease Fluoride and/or Iron Supplementation in Children Folic Acid Supplementation for Women Expecting or Planning to be Pregnant Tobacco Use Counseling and Cessation Intervention Immunizations Women's Health Preventive Services (i.e., birth control, emergency contraception) A list of the preventive services covered under the Plan is available on our website at networkhealth.com/members/resources.php, or will be mailed to you upon request. You may request the list by calling the Network Health Customer Service number on your identification card. What if my drug is not on the Comprehensive Drug List? If your drug is not on this drug list, call customer service to confirm that your drug is not covered. If you learn that Network Health does not cover your drug, you have two choices: Ask customer service for a list of similar drugs that are covered by Network Health. When you get the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Network Health. Similar drugs that are preferred and covered by your plan s formulary may be easier to obtain and lower cost to you than non-preferred drugs a III

4 Healthcare Marketplace Comprehensive Exchange Drug List: CY2016 Ask Network Health to make an exception and cover your drug. Exception requests may include: o You can ask us to cover your drug, even if it is not on our drug list. o You can ask us to remove coverage restrictions or limits on your drug. For example, for certain drugs, Network Health limits the amount of the drug that we will cover. If your drug has this quantity limit, you can ask us to remove the limit and cover more. Generally, Network Health will only approve your request for an exception if the preferred drugs included on the plan s drug list are not as effective in treating your condition or cause you to have adverse medical effects. How do I find out if my exception is granted? When you ask for a drug list utilization restriction exception, please send a statement from your prescriber that supports your request. We will make our decision within three business days of receipt of the information necessary to make a decision. You can ask for an expedited (fast) exception if you or your prescriber believes that your health could be seriously harmed by waiting up to three business days for a decision. If your expedited (fast) request is granted, we will give you a decision no later than 24 hours after we get your prescriber s supporting statement. For more information For more information about your Network Health prescription drug coverage, please view your policy. Network Health s Comprehensive Drug List The drug list gives coverage information for all drugs covered by Network Health. If you have trouble finding your drug on the list, turn to the Index that starts on page 134. The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., LIPITOR). Generic drugs are listed in lower-case italics (e.g., atorvastatin). The information in the Requirements/Limits column tells you if Network Health has any special requirements for coverage of your drug. Tier Name Tier Definition a IV

5 Healthcare Marketplace Comprehensive Exchange Drug List: CY2016 Tier 0 Tier 1 Preventive drugs Adherence Generics(limited only to categories of antidiabetics,statins and hypertensive drugs Tier 2 Generic drugs Tier 3 Preferred brand drugs Tier 4 Non-preferred brand drugs Tier 5 Preferred Specialty Products Tier 6 Non-preferred Specialty Products Network Health Prestige Gold and Prestige Silver This table defines the standard copayment and/or coinsurance structure. Depending on your income level, your actual cost-share may be less. For more information, consult your policy. DRUG TIER 30-Day Supply 90-Day Supply Tier 0 $0.00 $0.00 Tier 1 $2.00 $4.00 Tier 2 $15.00 $30.00 Tier 3 $40.00 $ Tier 4 35% 35% Tier 5 30% N/A Tier 6 40% N/A a V

6 Healthcare Marketplace Comprehensive Exchange Drug List: CY2016 Network Health Prestige Bronze This table defines the standard copayment and/or coinsurance structure. Depending on your income level, your actual cost-share may be less. For more information, consult your policy. DRUG TIER 30-Day Supply 90-Day Supply Tier 0 $0.00 $0.00 Tier 1 $2.00 $4.00 Tier 2 20% 20% Tier 3 20% 20% Tier 4 35% 35% Tier 5 30% N/A Tier 6 40% N/A Network Health Prestige Silver HDHP This table defines the standard copayment and/or coinsurance structure. Depending on your income level, your actual cost-share may be less. For more information, consult your policy. DRUG TIER 30-Day Supply 90-Day Supply Tier 0 $0.00 $0.00 Tier 1 10% 10% Tier 2 10% 10% Tier 3 10% 10% Tier 4 35% 35% Tier 5 30% N/A a VI

7 Healthcare Marketplace Comprehensive Exchange Drug List: CY2016 Tier 6 40% N/A Network Health Prestige Bronze HDHP This table defines the standard copayment and/or coinsurance structure. Depending on your income level, your actual cost-share may be less. For more information, consult your policy. DRUG TIER 30-Day Supply 90-Day Supply Tier 0 $0.00 $0.00 Tier 1 20% 20% Tier 2 20% 20% Tier 3 20% 20% Tier 4 35% 35% Tier 5 30% N/A Tier 6 40% N/A Network Health Prestige Gold and Prestige Silver Native American Benefit This table defines the standard copayment and/or coinsurance structure. Depending on your income level, your actual cost-share may be less. For more information, consult your policy. DRUG TIER 30-Day Supply 90-Day Supply Tier 0 $0.00 $0.00 Tier 1 $2.00 $4.00 Tier 2 $15.00 $30.00 Tier 3 $40.00 $ Tier 4 35% 35% Tier 5 $0.00 N/A Tier 6 $0.00 N/A Network Health Prestige Bronze Native American Benefit This table defines the standard copayment and/or coinsurance structure. Depending on your income level, your actual cost-share may be less. For more information, consult your policy a VII

8 Healthcare Marketplace Comprehensive Exchange Drug List: CY2016 DRUG TIER 30-Day Supply 90-Day Supply Tier 0 $0.00 $0.00 Tier 1 $2.00 $4.00 Tier 2 20% 20% Tier 3 20% 20% Tier 4 35% 35% Tier 5 $0.00 N/A Tier 6 $0.00 N/A The information listed in this document was current at the time of posting, however, changes occur frequently. The actual copay/coinsurance will be determined at the time the prescription is filled. For more information about your benefits contact Network Health Customer Service at For additional prescription drug information, log onto caremark.com or call Caremark at HMO plans underwritten by Network Health Plan. POS plans underwritten by Network Health Insurance Corporation, or Network Health Insurance Corporation and Network Health Plan a VIII

9 Healthcare Marketplace Comprehensive Exchange Drug List: CY2016 Medication Class Page Number ADHD/ANTI-NARCOLEPSY 1 AMINOGLYCOSIDES 3 ANALGESICS/ANTI-INFLAMMATORY 4 ANALGESICS-NONNARCOTIC 6 ANALGESICS-OPIOD 7 ANDROGENS-ANABOLIC 12 ANORECTAL AGENTS 13 ANTHELMINTICS 13 ANTI-INFECTIVE AGENTS-MISC 13 ANTIANGINAL AGENTS 15 ANTIANXIETY AGENTS 16 ANTIARRHYTHMICS 18 ANTIASTHMATIC AND BRONCHODILATOR AGENTS 19 ANTICOAGULANTS 21 ANTICONVULSANTS 23 ANTIDEPRESSANTS 26 ANTIDIABETICS a IX

10 Healthcare Marketplace Comprehensive Exchange Drug List: CY2016 ANTIDIARRHEALS ANTIDOTES ANTIEMETICS ANTIFUNGALS ANTIHISTAMINES ANTIHYPERLIPIDEMICS 38 ANTIHYPERTENSIVES ANTIMALARIALS ANTIMYASTHENIC AGENTS ANTIMYCOBACTERIAL AGENTS ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ANTIPARKINSON AGENTS ANTIPSYCHOTICS/ANTIMANIC AGENTS ANTISEPTICS DISINFECTANTS 60 ANTIVIRALS 60 ASSORTED CLASSES 63 BETA BLOCKERS 65 BIOLOGICALS MISC a X

11 Healthcare Marketplace Comprehensive Exchange Drug List: CY2016 CALCIUM CHANNEL BLOCKERS 67 CARDIOTONICS 69 CARDIOVASCULAR AGENTS-MISC CEPHALOSPORINS CONTRACEPTIVES CORTICOSTEROIDS 76 COUGH/COLD/ALLERGY 78 DERMATOLOGICALS 79 DIETARY MANAGEMENT PRODUCTS 87 DIGESTIVE AIDS 87 DIURETICS 88 ENDOCRINE AND METABOLIC AGENTSMISC. 89 ESTROGENS 93 FLUOROQUINOLONES 97 GASTROINTESTINAL AGENTS-MISC. 98 GENITOURINARY AGENTS-MISC. 99 GOUT AGENTS HEMATOLOGICAL AGENTS-MISC a XI

12 Healthcare Marketplace Comprehensive Exchange Drug List: CY2016 HEMATOPOIETIC AGENTS 101 HEMOSTATICS 102 HYPNOTICS 102 LAXATIVES LOCAL ANESTHETICS-PARENTERAL MACROLIDES MEDICAL DEVICES 105 MIGRAINE PRODUCTS 106 MINERALS ELECTROLYTES MOUTH/THROAT/DENTAL AGENTS MULTIVITAMINS 110 MUSCULOSKELETAL THERAPY AGENTS NASAL AGENTS-SYSTEMIC AND TOPICAL NEUROMUSCULAR AGENTS OPHTHALMIC AGENTS 112 OTIC AGENTS 116 PASSIVE IMMUNIZING AGENTS 116 PENICILLINS PROGESTINS a XII

13 Healthcare Marketplace Comprehensive Exchange Drug List: CY2016 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS-MISC. 120 RESPIRATORY AGENTS-MISC. 123 SULFONAMIDES 123 TETRACYCLINES 124 THYROID AGENTS 124 TOXOIDS 126 ULCER DRUGS 126 URINARY ANTI-INFECTIVES 129 URINARY ANTISPASMODICS 130 VACCINES VAGINAL PRODUCTS VASOPRESSORS 133 VITAMINS a XIII

14 EXCH_CVSC 6T STND eff 06/01/2016 Drug Name Drug Tier Requirements/Limits ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS Amphetamines amphetamine-dextroamphetamine cap sr 2 QL (90 caps / 25 days) 24hr 5 mg amphetamine-dextroamphetamine cap sr 2 QL (90 caps / 25 days) 24hr 10 mg amphetamine-dextroamphetamine cap sr 2 QL (30 caps / 25 days) 24hr 15 mg amphetamine-dextroamphetamine cap sr 2 QL (30 caps / 25 days) 24hr 20 mg amphetamine-dextroamphetamine cap sr 2 QL (30 caps / 25 days) 24hr 25 mg amphetamine-dextroamphetamine cap sr 24hr 30 mg 2 QL (30 caps / 25 days) amphetamine-dextroamphetamine tab 5 2 QL (90 tabs / 25 days) mg amphetamine-dextroamphetamine tab QL (90 tabs / 25 days) mg amphetamine-dextroamphetamine tab 10 2 QL (90 tabs / 25 days) mg amphetamine-dextroamphetamine tab 2 QL (90 tabs / 25 days) 12.5 mg amphetamine-dextroamphetamine tab 15 2 QL (60 tabs / 25 days) mg amphetamine-dextroamphetamine tab 20 2 QL (60 tabs / 25 days) mg amphetamine-dextroamphetamine tab 30 2 QL (30 tabs / 25 days) mg dextroamphetamine sulfate cap sr 24hr 5 2 QL (120 caps / 25 days) mg dextroamphetamine sulfate cap sr 24hr 10 2 QL (120 caps / 25 days) mg dextroamphetamine sulfate cap sr 24hr 15 2 mg QL (60 caps / 25 days) dextroamphetamine sulfate oral solution 5 2 QL (1,200 ml / 25 days) mg/5ml dextroamphetamine sulfate tab 5 mg 2 QL (120 tabs / 25 days) dextroamphetamine sulfate tab 10 mg 2 QL (120 tabs / 25 days) methamphetamine hcl tab 5 mg 2 QL (150 tabs / 25 days) VYVANSE CAP 10MG 3 VYVANSE CAP 20MG 3 VYVANSE CAP 30MG 3 VYVANSE CAP 40MG 3 VYVANSE CAP 50MG 3 VYVANSE CAP 60MG 3 1

15 VYVANSE CAP 70MG 3 zenzedi tab 2.5mg 2 QL (120 tabs / 25 days) zenzedi tab 7.5mg 2 QL (120 tabs / 25 days) zenzedi tab 15mg 2 QL (60 tabs / 25 days) zenzedi tab 20mg 2 QL (60 tabs / 25 days) zenzedi tab 30mg 2 QL (30 tabs / 25 days) Attention-Deficit/Hyperactivity Disorder (ADHD) Agents guanfacine hcl tab sr 24hr 1 mg (base 2 ST; PA** equiv) guanfacine hcl tab sr 24hr 2 mg (base 2 ST; PA** equiv) guanfacine hcl tab sr 24hr 3 mg (base 2 ST; PA** equiv) guanfacine hcl tab sr 24hr 4 mg (base 2 ST; PA** equiv) STRATTERA CAP 10MG 3 STRATTERA CAP 18MG 3 STRATTERA CAP 25MG 3 STRATTERA CAP 40MG 3 STRATTERA CAP 60MG 3 STRATTERA CAP 80MG 3 STRATTERA CAP 100MG 3 Stimulants - Misc. dexmethylphenidate hcl cap sr 24 hr 5 mg 2 QL (60 caps / 25 days) dexmethylphenidate hcl cap sr 24 hr 10 2 QL (60 caps / 25 days) mg dexmethylphenidate hcl cap sr 24 hr 15 2 QL (60 caps / 25 days) mg dexmethylphenidate hcl cap sr 24 hr 20 2 QL (60 caps / 25 days) mg dexmethylphenidate hcl cap sr 24 hr 30 2 QL (30 caps / 25 days) mg dexmethylphenidate hcl cap sr 24 hr 40 2 QL (30 caps / 25 days) mg dexmethylphenidate hcl tab 2.5 mg 2 QL (120 tabs / 25 days) dexmethylphenidate hcl tab 5 mg 2 QL (120 tabs / 25 days) dexmethylphenidate hcl tab 10 mg 2 QL (60 tabs / 25 days) methylphenidate hcl cap cr 10 mg (cd) 2 QL (60 caps / 25 days) methylphenidate hcl cap cr 20 mg (cd) 2 QL (60 caps / 25 days) methylphenidate hcl cap cr 30 mg (cd) 2 QL (60 caps / 25 days) methylphenidate hcl cap cr 40 mg (cd) 2 QL (30 caps / 25 days) methylphenidate hcl cap cr 50 mg (cd) 2 QL (30 caps / 25 days) methylphenidate hcl cap cr 60 mg (cd) 2 QL (30 caps / 25 days) methylphenidate hcl cap sr 24hr 20 mg (la)2 QL (60 caps / 25 days) methylphenidate hcl cap sr 24hr 30 mg (la)2 QL (60 caps / 25 days) 2

16 methylphenidate hcl cap sr 24hr 40 mg (la)2 QL (30 caps / 25 days) methylphenidate hcl chew tab 2.5 mg 2 QL (180 chew tabs / 25 days) methylphenidate hcl chew tab 5 mg 2 QL (180 chew tabs / 25 days) methylphenidate hcl chew tab 10 mg 2 QL (180 chew tabs / 25 days) methylphenidate hcl soln 5 mg/5ml 2 QL (1800 ml / 25 days) methylphenidate hcl soln 10 mg/5ml 2 QL (900 ml / 25 days) methylphenidate hcl tab 5 mg 2 QL (180 tabs / 25 days) methylphenidate hcl tab 10 mg 2 QL (180 tabs / 25 days) methylphenidate hcl tab 20 mg 2 QL (90 tabs / 25 days) methylphenidate hcl tab cr 10 mg 2 QL (90 tabs / 25 days) methylphenidate hcl tab cr 20 mg 2 QL (90 tabs / 25 days) methylphenidate hcl tab sa osm 18 mg 2 QL (60 tabs / 25 days) methylphenidate hcl tab sa osm 27 mg 2 QL (60 tabs / 25 days) methylphenidate hcl tab sa osm 36 mg 2 QL (60 tabs / 25 days) methylphenidate hcl tab sa osm 54 mg 2 QL (30 tabs / 25 days) methylphenidate hcl tab sr 24hr 18 mg 2 QL (60 tabs / 25 days) methylphenidate hcl tab sr 24hr 27 mg 2 QL (60 tabs / 25 days) methylphenidate hcl tab sr 24hr 36 mg 2 QL (60 tabs / 25 days) methylphenidate hcl tab sr 24hr 54 mg 2 QL (30 tabs / 25 days) modafinil tab 100 mg 2 PA modafinil tab 200 mg 2 PA NUVIGIL TAB 50MG 3 PA NUVIGIL TAB 150MG 3 PA NUVIGIL TAB 200MG 3 PA NUVIGIL TAB 250MG 3 PA AMINOGLYCOSIDES Aminoglycosides amikacin sulfate inj 1 gm/4ml (250 mg/ml) 2 amikacin sulfate inj 500 mg/2ml (250 2 mg/ml) GENTAM/NACL INJ 0.9MG/ML 4 GENTAM/NACL INJ 1.4MG/ML 4 gentamicin in saline inj 0.8 mg/ml 2 gentamicin in saline inj 1 mg/ml 2 gentamicin in saline inj 1.2 mg/ml 2 gentamicin in saline inj 1.6 mg/ml 2 gentamicin in saline inj 2 mg/ml 2 gentamicin sulfate inj 10 mg/ml 2 gentamicin sulfate inj 40 mg/ml 2 gentamicin sulfate iv soln 10 mg/ml 2 3

17 kanamycin sulfate inj 333 mg/ml 2 NEO-FRADIN SOL 125/5ML 4 neomycin sulfate tab 500 mg 2 paromomycin sulfate cap 250 mg 2 streptomycin sulfate for inj 1 gm 2 TOBRA/NACL INJ 80/0.9 4 tobramycin nebu soln 300 mg/5ml 2 PA tobramycin sulfate for inj 1.2 gm 2 tobramycin sulfate inj 1.2 gm/30ml (40 2 mg/ml) (base equiv) tobramycin sulfate inj 2 gm/50ml (40 2 mg/ml) (base equiv) tobramycin sulfate inj 10 mg/ml (base 2 equivalent) tobramycin sulfate inj 80 mg/2ml (40 mg/ml) (base equiv) 2 ANALGESICS - ANTI-INFLAMMATORY Anti-TNF-alpha - Monoclonal Antibodies HUMIRA INJ 10MG/0.2 5 PA HUMIRA KIT 20MG/0.4 5 PA HUMIRA KIT 40MG/0.8 5 PA HUMIRA PEN INJ CROHNS 5 PA SIMPONI ARIA SOL 50MG/4ML 6 PA, ST SIMPONI INJ 50/0.5ML 6 PA, ST SIMPONI INJ 100MG/ML 6 PA, ST Antirheumatic - Enzyme Inhibitors XELJANZ TAB 5MG 6 PA, ST Antirheumatic Antimetabolites RHEUMATREX TAB 2.5MG 4 Interleukin-1 Blockers ARCALYST INJ 220MG 5 PA Interleukin-1 Receptor Antagonist (IL-1Ra) KINERET INJ 6 PA, ST Interleukin-6 Receptor Inhibitors ACTEMRA INJ 80MG/4ML 6 PA, ST ACTEMRA INJ 162/0.9 6 PA, ST ACTEMRA INJ 200/10ML 6 PA, ST ACTEMRA INJ 400/20ML 6 PA, ST Nonsteroidal Anti-inflammatory Agents (NSAIDs) celecoxib cap 50 mg 2 celecoxib cap 100 mg 2 celecoxib cap 200 mg 2 celecoxib cap 400 mg 2 4

18 diclofenac potassium tab 50 mg 2 diclofenac sodium tab delayed release 25 2 mg diclofenac sodium tab delayed release 50 2 mg diclofenac sodium tab delayed release 75 2 mg diclofenac sodium tab sr 24hr 100 mg 2 diclofenac w/ misoprostol tab delayed 2 release mg diclofenac w/ misoprostol tab delayed 2 release mg etodolac cap 200 mg 2 etodolac cap 300 mg 2 etodolac tab 400 mg 2 etodolac tab 500 mg 2 etodolac tab sr 24hr 400 mg 2 etodolac tab sr 24hr 500 mg 2 etodolac tab sr 24hr 600 mg 2 fenoprofen calcium cap 400 mg 2 fenoprofen calcium tab 600 mg 2 flurbiprofen tab 50 mg 2 flurbiprofen tab 100 mg 2 ibuprofen susp 100 mg/5ml 2 ibuprofen tab 400 mg 2 ibuprofen tab 600 mg 2 ibuprofen tab 800 mg 2 INDOCIN SUS 25MG/5ML 4 indomethacin cap 25 mg 2 indomethacin cap 50 mg 2 indomethacin cap cr 75 mg 2 ketoprofen cap 50 mg 2 ketoprofen cap 75 mg 2 ketoprofen cap sr 24hr 200 mg 2 ketorolac tromethamine im inj 60 mg/2ml 2 (30 mg/ml) ketorolac tromethamine inj 15 mg/ml 2 ketorolac tromethamine inj 30 mg/ml 2 ketorolac tromethamine inj 60 mg/2ml (30 2 mg/ml) ketorolac tromethamine inj 300 mg/10ml 2 (30 mg/ml) ketorolac tromethamine tab 10 mg 2 QL (20 tabs / 25 days) meclofenamate sodium cap 50 mg 2 meclofenamate sodium cap 100 mg 2 5

19 mefenamic acid cap 250 mg 2 meloxicam susp 7.5 mg/5ml 2 meloxicam tab 7.5 mg 2 meloxicam tab 15 mg 2 nabumetone tab 500 mg 2 nabumetone tab 750 mg 2 naproxen dr tab 375mg 2 naproxen dr tab 500mg 2 naproxen sodium tab 275 mg 2 naproxen sodium tab 550 mg 2 naproxen susp 125 mg/5ml 2 naproxen tab 250 mg 2 naproxen tab 375 mg 2 naproxen tab 500 mg 2 oxaprozin tab 600 mg 2 piroxicam cap 10 mg 2 piroxicam cap 20 mg 2 sulindac tab 150 mg 2 sulindac tab 200 mg 2 tolmetin sodium cap 400 mg 2 tolmetin sodium tab 200 mg 2 tolmetin sodium tab 600 mg 2 Pyrimidine Synthesis Inhibitors leflunomide tab 10 mg 2 leflunomide tab 20 mg 2 Selective Costimulation Modulators ORENCIA INJ 125MG/ML 6 PA, ST ORENCIA INJ 250MG 6 PA, ST Soluble Tumor Necrosis Factor Receptor Agents ENBREL INJ 25/0.5ML 5 PA ENBREL INJ 25MG 5 PA ENBREL INJ 50MG/ML 5 PA ENBREL SRCLK INJ 50MG/ML 5 PA ANALGESICS - NonNarcotic Analgesic Combinations alagesic lq sol 2 QL (720 ml / 25 days) butalbital-acetaminophen-caffeine cap 50-2 QL (48 caps / 25 days) mg butalbital-acetaminophen-caffeine cap 50-2 QL (48 caps / 25 days) mg butalbital-acetaminophen-caffeine tab mg 2 QL (48 tabs / 25 days) 6

20 butalbital-aspirin-caffeine cap QL (48 caps / 25 days) mg butalbital-aspirin-caffeine tab QL (48 tabs / 25 days) mg Salicylates aspirin chew tab 81 mg 0 QL (100 tabs / 30 days); OTC; $0 copay-age restriction applies aspirin low tab 81mg ec 0 QL (100 tabs / 30 days); OTC; $0 copay-age restriction applies aspirin tab 81 mg 0 QL (100 tabs / 30 days); OTC; $0 copay-age restriction applies aspirin tab 325 mg 0 QL (100 tabs / 30 days); OTC; $0 copay-age restriction applies aspirin tab delayed release 325 mg 0 QL (100 tabs / 30 days); OTC; $0 copay-age restriction applies diflunisal tab 500 mg 2 ANALGESICS - OPIOID Opioid Agonists ABSTRAL SUB 100MCG 3 QL (120 Units per 25 days), PA ABSTRAL SUB 200MCG 3 QL (120 Units per 25 days), PA ABSTRAL SUB 300MCG 3 QL (120 Units per 25 days), PA ABSTRAL SUB 400MCG 3 QL (120 Units per 25 days), PA ABSTRAL SUB 600MCG 3 QL (120 Units per 25 days), PA ABSTRAL SUB 800MCG 3 QL (120 Units per 25 days), PA astramorph inj 1mg/2ml 2 astramorph inj 2mg/2ml 2 CODEINE SULF SOL 30MG/5ML 3 codeine sulfate tab 15 mg 2 QL (42 tabs / 25 days) codeine sulfate tab 30 mg 2 QL (42 tabs / 25 days) codeine sulfate tab 60 mg 2 QL (42 tabs / 25 days) EMBEDA CAP MG 4 QL (60 caps / 25 days) EMBEDA CAP MG 4 QL (60 caps / 25 days) EMBEDA CAP 50-2MG 4 QL (60 caps / 25 days) EMBEDA CAP MG 4 QL (30 caps / 25 days) EMBEDA CAP MG 4 QL (30 caps / 25 days) EMBEDA CAP 100-4MG 4 QL (30 caps / 25 days) 7

21 fentanyl citrate lozenge on a handle 200 mcg fentanyl citrate lozenge on a handle 400 mcg fentanyl citrate lozenge on a handle 600 mcg fentanyl citrate lozenge on a handle 800 mcg fentanyl citrate lozenge on a handle 1200 mcg fentanyl citrate lozenge on a handle 1600 mcg 2 QL (120 lozenges / 25 days), PA 2 QL (120 lozenges / 25 days), PA 2 QL (120 lozenges / 25 days), PA 2 QL (120 lozenges / 25 days), PA 2 QL (120 lozenges / 25 days), PA 2 QL (120 lozenges / 25 days), PA fentanyl td patch 72hr 12 mcg/hr 2 QL (10 patches / 25 days) fentanyl td patch 72hr 25 mcg/hr 2 QL (10 patches / 25 days) fentanyl td patch 72hr 50 mcg/hr 2 QL (10 patches / 25 days) fentanyl td patch 72hr 75 mcg/hr 2 QL (10 patches / 25 days) fentanyl td patch 72hr 100 mcg/hr 2 QL (10 patches / 25 days) HYDROMORPHON SUP 3MG 4 QL (120 units / 25 days) hydromorphone hcl inj 1 mg/ml 2 hydromorphone hcl inj 2 mg/ml 2 hydromorphone hcl inj 4 mg/ml 2 hydromorphone hcl liqd 1 mg/ml 2 QL (600 ml / 25 days) hydromorphone hcl preservative free (pf) 2 inj 10 mg/ml hydromorphone hcl tab 2 mg 2 QL (180 tabs / 25 days) hydromorphone hcl tab 4 mg 2 QL (180 tabs / 25 days) hydromorphone hcl tab 8 mg 2 QL (180 tabs / 25 days) hydromorphone hcl tab er 24hr deter 8 mg 2 QL (30 tablets per 25 days) hydromorphone hcl tab er 24hr deter 12 mg hydromorphone hcl tab er 24hr deter 16 mg hydromorphone hcl tab er 24hr deter 32 mg 2 QL (30 tablets per 25 days) 2 QL (30 tablets per 25 days) 2 QL (30 tablets per 25 days) levorphanol tartrate tab 2 mg 2 QL (120 tabs / 25 days) meperidine hcl inj 10 mg/ml 2 meperidine hcl inj 25 mg/ml 2 meperidine hcl inj 50 mg/ml 2 meperidine hcl inj 100 mg/ml 2 meperidine hcl oral soln 50 mg/5ml 2 QL (90 ml / 25 days) meperidine hcl tab 50 mg 2 QL (18 tabs / 25 days) 8

22 meperidine hcl tab 100 mg 2 QL (18 tabs / 25 days) methadone hcl conc 10 mg/ml 2 QL (30mL / 25 days) methadone hcl soln 5 mg/5ml 2 QL (600 ml / 25 days) methadone hcl soln 10 mg/5ml 2 QL (300 ml / 25 days) methadone hcl tab 5 mg 2 QL (120 tabs / 25 days) methadone hcl tab 10 mg 2 QL (60 tabs / 25 days) methadone hcl tab for oral susp 40 mg 2 QL (9 tabs / 25 days) METHADONE INJ 10MG/ML 4 methadose tab 40mg 2 QL (9 tabs / 25 days) MORPHINE SUL INJ 2MG/ML 4 MORPHINE SUL INJ 4MG/ML 4 MORPHINE SUL INJ 5MG/ML 4 MORPHINE SUL INJ 8MG/ML 4 MORPHINE SUL INJ 150/30ML 4 MORPHINE SUL SUP 30MG 3 QL (180 supp / 25 days) morphine sulfate beads cap sr 24hr 30 mg 2 QL (60 caps / 25 days) morphine sulfate beads cap sr 24hr 45 mg 2 QL (60 caps / 25 days) morphine sulfate beads cap sr 24hr 60 mg 2 QL (60 caps / 25 days) morphine sulfate beads cap sr 24hr 75 mg 2 QL (30 caps / 25 days) morphine sulfate beads cap sr 24hr 90 mg 2 QL (30 caps / 25 days) morphine sulfate beads cap sr 24hr QL (30 caps / 25 days) mg morphine sulfate cap sr 24hr 10 mg 2 QL (60 caps / 25 days) morphine sulfate cap sr 24hr 20 mg 2 QL (60 caps / 25 days) morphine sulfate cap sr 24hr 30 mg 2 QL (60 caps / 25 days) morphine sulfate cap sr 24hr 50 mg 2 QL (60 caps / 25 days) morphine sulfate cap sr 24hr 60 mg 2 QL (60 caps / 25 days) morphine sulfate cap sr 24hr 80 mg 2 QL (60 caps / 25 days) morphine sulfate cap sr 24hr 100 mg 2 QL (60 caps / 25 days) morphine sulfate inj 8 mg/ml 2 morphine sulfate inj 10 mg/ml 2 morphine sulfate inj 15 mg/ml 2 morphine sulfate inj pf 1 mg/ml 2 morphine sulfate iv soln 1 mg/ml 2 morphine sulfate iv soln 25 mg/ml 2 morphine sulfate iv soln 50 mg/ml 2 morphine sulfate iv soln pf 4 mg/ml 2 morphine sulfate iv soln pf 8 mg/ml 2 morphine sulfate iv soln pf 10 mg/ml 2 morphine sulfate iv soln pf 15 mg/ml 2 morphine sulfate oral soln 10 mg/5ml 2 QL (900 ml / 25 days) morphine sulfate oral soln 20 mg/5ml 2 QL (900 ml / 25 days) 9

23 morphine sulfate oral soln 100 mg/5ml (20 2 QL (180 ml / 25 days) mg/ml) morphine sulfate suppos 5 mg 2 QL (180 supp / 25 days) morphine sulfate suppos 10 mg 2 QL (180 supp / 25 days) morphine sulfate suppos 20 mg 2 QL (180 supp / 25 days) morphine sulfate tab 15 mg 2 QL (180 tabs / 25 days) morphine sulfate tab 30 mg 2 QL (180 tabs / 25 days) morphine sulfate tab cr 15 mg 2 QL (120 tabs / 25 days) morphine sulfate tab cr 30 mg 2 QL (120 tabs / 25 days) morphine sulfate tab cr 60 mg 2 QL (120 tabs / 25 days) morphine sulfate tab cr 100 mg 2 QL (60 tabs / 25 days) morphine sulfate tab cr 200 mg 2 QL (60 tabs / 25 days) NUCYNTA ER TAB 50MG 3 QL (120 tabs / 25 days) NUCYNTA ER TAB 100MG 3 QL (120 tabs / 25 days) NUCYNTA ER TAB 150MG 3 QL (60 tabs / 25 days) NUCYNTA ER TAB 200MG 3 QL (60 tabs / 25 days) NUCYNTA ER TAB 250MG 3 QL (60 tabs / 25 days) NUCYNTA TAB 50MG 3 QL (360 tabs / 25 days) NUCYNTA TAB 75MG 3 QL (240 tabs / 25 days) NUCYNTA TAB 100MG 3 QL (180 tabs / 25 days) oxycodone hcl cap 5 mg 2 QL (180 caps / 25 days) oxycodone hcl conc 100 mg/5ml (20 2 QL (180 ml / 25 days) mg/ml) oxycodone hcl soln 5 mg/5ml 2 QL (900 ml / 25 days) oxycodone hcl tab 5 mg 2 QL (180 tabs / 25 days) oxycodone hcl tab 10 mg 2 QL (180 tabs / 25 days) oxycodone hcl tab 15 mg 2 QL (180 tabs / 25 days) oxycodone hcl tab 20 mg 2 QL (180 tabs / 25 days) oxycodone hcl tab 30 mg 2 QL (180 tabs / 25 days) oxycodone hcl tab er 12hr deter 10 mg 2 QL (120 tabs / 25 days) oxycodone hcl tab er 12hr deter 20 mg 2 QL (120 tabs / 25 days) oxycodone hcl tab er 12hr deter 40 mg 2 QL (120 tabs / 25 days) oxycodone hcl tab er 12hr deter 80 mg 2 QL (60 tabs / 25 days) OXYCONTIN TAB 10MG CR 3 QL (120 tabs / 25 days) OXYCONTIN TAB 15MG CR 3 QL (120 tabs / 25 days) OXYCONTIN TAB 20MG CR 3 QL (120 tabs / 25 days) OXYCONTIN TAB 30MG CR 3 QL (120 tabs / 25 days) OXYCONTIN TAB 40MG CR 3 QL (120 tabs / 25 days) OXYCONTIN TAB 60MG CR 3 QL (60 tabs / 25 days) OXYCONTIN TAB 80MG CR 3 QL (60 tabs / 25 days) oxymorphone hcl tab 5 mg 2 QL (180 tabs / 25 days) oxymorphone hcl tab 10 mg 2 QL (180 tabs / 25 days) oxymorphone hcl tab sr 12hr 5 mg 2 QL (120 tabs / 25 days) 10

24 oxymorphone hcl tab sr 12hr 7.5 mg 2 QL (120 tabs / 25 days) oxymorphone hcl tab sr 12hr 10 mg 2 QL (120 tabs / 25 days) oxymorphone hcl tab sr 12hr 15 mg 2 QL (120 tabs / 25 days) oxymorphone hcl tab sr 12hr 20 mg 2 QL (120 tabs / 25 days) oxymorphone hcl tab sr 12hr 30 mg 2 QL (60 tabs / 25 days) oxymorphone hcl tab sr 12hr 40 mg 2 QL (60 tabs / 25 days) tramadol hcl tab 50 mg 2 QL (240 tabs / 25 days) tramadol hcl tab sr 24hr 100 mg 2 QL (90 tabs / 25 days) tramadol hcl tab sr 24hr 200 mg 2 QL (30 tabs / 25 days) tramadol hcl tab sr 24hr 300 mg 2 QL (30 tabs / 25 days) Opioid Combinations acetaminophen w/ codeine soln QL (5000 ml / 25 days) mg/5ml acetaminophen w/ codeine tab mg 2 QL (400 tabs / 25 days) acetaminophen w/ codeine tab mg 2 QL (400 tabs / 25 days) acetaminophen w/ codeine tab mg 2 QL (400 tabs / 25 days) CAPITAL/COD SUS /5 4 QL (5000 ml / 25 days) endocet tab 5-325mg 2 QL (375 tabs / 25 days) endocet tab QL (375 tabs / 25 days) endocet tab mg 2 QL (375 tabs / 25 days) hydrocodone-acetaminophen soln QL (5540 ml / 25 days) mg/15ml hydrocodone-acetaminophen tab QL (375 tabs / 25 days) mg hydrocodone-acetaminophen tab mg 2 QL (400 tabs / 25 days) hydrocodone-acetaminophen tab mg 2 QL (375 tabs / 25 days) hydrocodone-acetaminophen tab QL (400 tabs / 25 days) mg hydrocodone-acetaminophen tab QL (375 tabs / 25 days) mg hydrocodone-acetaminophen tab QL (400 tabs / 25 days) mg hydrocodone-acetaminophen tab mg 2 QL (375 tabs / 25 days) oxycodone w/ acetaminophen tab QL (375 tabs / 25 days) mg oxycodone w/ acetaminophen tab QL (375 tabs / 25 days) mg oxycodone w/ acetaminophen tab QL (375 tabs / 25 days) mg oxycodone w/ acetaminophen tab QL (375 tabs / 25 days) mg oxycodone-aspirin tab mg 2 QL (375 tabs / 25 days) oxycodone-ibuprofen tab mg 2 QL (28 tabs / 25 days) PRIMLEV TAB 5-300MG 4 QL (400 tabs / 25 days) PRIMLEV TAB QL (400 tabs / 25 days) 11

25 PRIMLEV TAB MG 4 QL (400 tabs / 25 days) ROXICET SOL 5-325/5 4 QL (1850 ml / 25 days) roxicet tab 5-325mg 2 QL (375 tabs / 25 days) vicodin es tab QL (400 tabs / 25 days) vicodin hp tab mg 2 QL (400 tabs / 25 days) vicodin tab 5-300mg 2 QL (400 tabs / 25 days) zamicet sol mg 2 QL (5540 ml / 25 days) Opioid Partial Agonists buprenorphine hcl inj 0.3 mg/ml (base 2 equiv) buprenorphine hcl sl tab 2 mg (base equiv) 2 QL (90 tablets per 25 days), PA buprenorphine hcl sl tab 8 mg (base equiv) 2 QL (90 tablets per 25 days), PA buprenorphine hcl-naloxone hcl sl tab mg (base equiv) buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv) 2 QL (90 tabs per 25 days), PA 2 QL (90 tabs per 25 days), PA butorphanol tartrate inj 1 mg/ml 2 butorphanol tartrate inj 2 mg/ml 2 butorphanol tartrate nasal soln 10 mg/ml 2 QL (2 bottles per 25 days) BUTRANS DIS 5MCG/HR 4 QL (8 patches/25 days), PA BUTRANS DIS 7.5/HR 4 QL (8 patches/25 days), PA BUTRANS DIS 10MCG/HR 4 QL (8 patches/25 days), PA BUTRANS DIS 15MCG/HR 4 QL (4 patches/25 days), PA BUTRANS DIS 20MCG/HR 4 QL (4 patches/25 days), PA nalbuphine hcl inj 10 mg/ml 2 nalbuphine hcl inj 20 mg/ml 2 SUBOXONE MIS 2-0.5MG 3 QL (90 units per 25 days), PA SUBOXONE MIS 4-1MG 3 QL (90 units per 25 days), PA SUBOXONE MIS 8-2MG 3 QL (90 units per 25 days), PA SUBOXONE MIS 12-3MG 3 QL (60 films per 25 days), PA ANDROGENS-ANABOLIC Anabolic Steroids ANADROL-50 TAB 50MG 4 PA oxandrolone tab 2.5 mg 2 PA oxandrolone tab 10 mg 2 PA 12

26 Androgens ANDROXY TAB 10MG 4 PA danazol cap 50 mg 2 danazol cap 100 mg 2 danazol cap 200 mg 2 methyltestosterone cap 10 mg 2 PA testosterone cypionate im inj in oil PA mg/ml testosterone cypionate im inj in oil PA mg/ml testosterone enanthate im inj in oil PA mg/ml testosterone td gel 10mg/act (2%) 2 PA testosterone td gel 25 mg/2.5gm (1%) 2 PA ANORECTAL AGENTS Intrarectal Steroids colocort ene 100mg 2 Rectal Steroids procto-pak cre 1% 2 proctosol hc cre 2.5% 2 proctozone cre -hc 2.5% 2 Vasodilating Agents RECTIV OIN 0.4% 4 ANTHELMINTICS Anthelmintics ALBENZA TAB 200MG 3 BILTRICIDE TAB 600MG 4 ivermectin tab 3 mg 2 ANTI-INFECTIVE AGENTS - MISC. Anti-infective Agents - Misc. AZACTAM/DEX INJ 1GM 4 AZACTAM/DEX INJ 2GM 4 aztreonam for inj 1 gm 2 aztreonam for inj 2 gm 2 CAYSTON INH 75MG 5 PA FLAGYL ER TAB 750MG 4 metronidazole cap 375 mg 2 metronidazole in nacl 0.79% iv soln mg/100ml metronidazole tab 250 mg 2 metronidazole tab 500 mg 2 NEBUPENT INH 300MG 4 13

27 PENTAM 300 INJ 300MG 4 PRIMSOL SOL 50MG/5ML 3 tinidazole tab 250 mg 2 tinidazole tab 500 mg 2 trimethoprim tab 100 mg 2 vancomycin hcl cap 125 mg 2 ST; PA** vancomycin hcl cap 250 mg 2 ST; PA** vancomycin hcl for inj 10 gm 2 vancomycin hcl for inj 500 mg 2 vancomycin hcl for inj 1000 mg 2 vancomycin hcl for inj 5000 mg 2 VIBATIV INJ 250MG 4 VIBATIV INJ 750MG 4 XIFAXAN TAB 200MG 3 XIFAXAN TAB 550MG 3 PA Anti-infective Misc. - Combinations e.s.p. sus sulfamethoxazole-trimethoprim iv soln mg/5ml sulfamethoxazole-trimethoprim susp mg/5ml sulfamethoxazole-trimethoprim tab mg sulfamethoxazole-trimethoprim tab mg Antiprotozoal Agents ALINIA SUS 100/5ML 3 ALINIA TAB 500MG 3 atovaquone susp 750 mg/5ml 2 Carbapenems DORIBAX INJ 250MG 4 DORIBAX INJ 500MG 4 imipenem-cilastatin intravenous for soln mg imipenem-cilastatin intravenous for soln mg INVANZ INJ 1GM 4 meropenem iv for soln 1 gm 2 meropenem iv for soln 500 mg 2 Chloramphenicols chloramphenicol sodium succinate for iv inj 2 1 gm Cyclic Lipopeptides CUBICIN SOL 500MG 4 Glycylcyclines 14

28 TYGACIL INJ 50MG 4 Ketolides KETEK TAB 300MG 4 KETEK TAB 400MG 4 Leprostatics dapsone tab 25 mg 2 dapsone tab 100 mg 2 Lincosamides clindamycin hcl cap 75 mg 2 clindamycin hcl cap 150 mg 2 clindamycin hcl cap 300 mg 2 clindamycin palmitate hcl for soln 75 2 mg/5ml (base equiv) clindamycin phosphate inj 9 gm/60ml 2 clindamycin phosphate inj 300 mg/2ml 2 clindamycin phosphate inj 600 mg/4ml 2 clindamycin phosphate inj 900 mg/6ml 2 clindamycin phosphate iv soln 300 mg/2ml 2 clindamycin phosphate iv soln 600 mg/4ml 2 clindamycin phosphate iv soln 900 mg/6ml 2 LINCOCIN INJ 300MG/ML 4 lincomycin hcl inj 300 mg/ml 2 Oxazolidinones linezolid for susp 100 mg/5ml 2 linezolid in sodium chloride iv soln mg/300ml-0.9% linezolid iv soln 600 mg/300ml (2 mg/ml) 2 linezolid tab 600 mg 2 ZYVOX SUS 100MG/5M 3 Polymyxins polymyxin b sulfate for inj unit 2 ANTIANGINAL AGENTS Antianginals-Other RANEXA TAB 500MG 3 ST; PA** RANEXA TAB 1000MG 3 ST; PA** Nitrates DILATRATE SR CAP 40MG 4 isoditrate tab 40mg er 2 ISORDIL TAB 40MG 3 isosorbide dinitrate sl tab 2.5 mg 2 isosorbide dinitrate tab 5 mg 2 isosorbide dinitrate tab 10 mg 2 isosorbide dinitrate tab 20 mg 2 15

29 isosorbide dinitrate tab 30 mg 2 isosorbide dinitrate tab cr 40 mg 2 isosorbide mononitrate tab 10 mg 2 isosorbide mononitrate tab 20 mg 2 isosorbide mononitrate tab sr 24hr 30 mg 2 isosorbide mononitrate tab sr 24hr 60 mg 2 isosorbide mononitrate tab sr 24hr 120 mg 2 minitran dis 0.1mg/hr 2 minitran dis 0.2mg/hr 2 minitran dis 0.4mg/hr 2 minitran dis 0.6mg/hr 2 NITRO-BID OIN 2% 4 NITRO-DUR DIS 0.3MG/HR 3 NITRO-DUR DIS 0.8MG/HR 3 NITROGLYCER INJ 5MG/ML 4 nitroglycerin cap cr 2.5 mg 2 nitroglycerin cap cr 6.5 mg 2 nitroglycerin cap cr 9 mg 2 nitroglycerin iv soln 100 mcg/ml in d5w 2 nitroglycerin iv soln 200 mcg/ml in d5w 2 nitroglycerin iv soln 400 mcg/ml in d5w 2 nitroglycerin lingual aerosol 400 mcg/spray 2 nitroglycerin td patch 24hr 0.1 mg/hr 2 nitroglycerin td patch 24hr 0.2 mg/hr 2 nitroglycerin td patch 24hr 0.4 mg/hr 2 nitroglycerin td patch 24hr 0.6 mg/hr 2 nitroglycerin tl soln 0.4 mg/spray (400 2 mcg/spray) NITROSTAT SUB 0.3MG 3 NITROSTAT SUB 0.4MG 3 NITROSTAT SUB 0.6MG 3 ANTIANXIETY AGENTS Antianxiety Agents - Misc. buspirone hcl tab 5 mg 2 buspirone hcl tab 7.5 mg 2 buspirone hcl tab 10 mg 2 buspirone hcl tab 15 mg 2 buspirone hcl tab 30 mg 2 hydroxyzine hcl im soln 25 mg/ml 2 PA; High Risk Medications require PA for members age 65 and 16

30 hydroxyzine hcl im soln 50 mg/ml 2 PA; High Risk Medications require PA for members age 65 and hydroxyzine hcl syrup 10 mg/5ml 2 PA; High Risk Medications require PA for members age 65 and hydroxyzine hcl tab 10 mg 2 PA; High Risk Medications require PA for members age 65 and hydroxyzine hcl tab 25 mg 2 PA; High Risk Medications require PA for members age 65 and hydroxyzine hcl tab 50 mg 2 PA; High Risk Medications require PA for members age 65 and hydroxyzine pamoate cap 25 mg 2 PA; High Risk Medications require PA for members age 65 and hydroxyzine pamoate cap 50 mg 2 PA; High Risk Medications require PA for members age 65 and hydroxyzine pamoate cap 100 mg 2 PA; High Risk Medications require PA for members age 65 and meprobamate tab 200 mg 2 meprobamate tab 400 mg 2 Benzodiazepines ALPRAZOLAM CON 1 MG/ML 3 QL (120 ml / 25 days) alprazolam orally disintegrating tab 0.5 mg 2 QL (90 tabs / 25 days) alprazolam orally disintegrating tab QL (90 tabs / 25 days) mg alprazolam orally disintegrating tab 1 mg 2 QL (90 tabs / 25 days) alprazolam orally disintegrating tab 2 mg 2 QL (60 tabs / 25 days) alprazolam tab 0.5 mg 2 QL (90 tabs / 25 days) alprazolam tab 0.25 mg 2 QL (90 tabs / 25 days) alprazolam tab 1 mg 2 QL (90 tabs / 25 days) alprazolam tab 2 mg 2 QL (60 tabs / 25 days) clorazepate dipotassium tab 3.75 mg 2 QL (120 tabs / 25 days) clorazepate dipotassium tab 7.5 mg 2 QL (120 tabs / 25 days) clorazepate dipotassium tab 15 mg 2 QL (120 tabs / 25 days) diazepam con 5mg/ml 2 QL (240 ml / 25 days) diazepam oral soln 1 mg/ml 2 QL (1200 ml / 25 days) 17

31 diazepam tab 2 mg 2 QL (120 tabs / 25 days) diazepam tab 5 mg 2 QL (120 tabs / 25 days) diazepam tab 10 mg 2 QL (120 tabs / 25 days) lorazepam conc 2 mg/ml 2 QL (150 ml / 25 days) lorazepam tab 0.5 mg 2 QL (150 tabs / 25 days) lorazepam tab 1 mg 2 QL (150 tabs / 25 days) lorazepam tab 2 mg 2 QL (150 tabs / 25 days) oxazepam cap 10 mg 2 QL (120 caps / 25 days) oxazepam cap 15 mg 2 QL (120 caps / 25 days) oxazepam cap 30 mg 2 QL (120 caps / 25 days) ANTIARRHYTHMICS Antiarrhythmics Type I-A disopyramide phosphate cap 100 mg 2 disopyramide phosphate cap 150 mg 2 NORPACE CAP 100MG CR 3 NORPACE CAP 150MG CR 3 procainamide hcl inj 100 mg/ml 2 PROCAINAMIDE INJ 500MG/ML 4 Antiarrhythmics Type I-B lidocaine hcl iv inj 10 mg/ml 2 lidocaine hcl iv inj 20 mg/ml 2 lidocaine iv infusion in d5w inj 4 mg/ml 2 lidocaine iv infusion in d5w inj 8 mg/ml 2 mexiletine hcl cap 150 mg 2 mexiletine hcl cap 200 mg 2 mexiletine hcl cap 250 mg 2 Antiarrhythmics Type I-C flecainide acetate tab 50 mg 2 flecainide acetate tab 100 mg 2 flecainide acetate tab 150 mg 2 propafenone hcl cap sr 12hr 225 mg 2 propafenone hcl cap sr 12hr 325 mg 2 propafenone hcl cap sr 12hr 425 mg 2 propafenone hcl tab 150 mg 2 propafenone hcl tab 225 mg 2 propafenone hcl tab 300 mg 2 Antiarrhythmics Type III amiodarone hcl inj 150 mg/3ml (50 2 mg/ml) amiodarone hcl inj 450 mg/9ml (50 2 mg/ml) amiodarone hcl inj 900 mg/18ml (50 2 mg/ml) 18

32 amiodarone hcl tab 200 mg 2 amiodarone hcl tab 400 mg 2 MULTAQ TAB 400MG 4 PA NEXTERONE INJ 4 pacerone tab 100mg 2 pacerone tab 200mg 2 TIKOSYN CAP 125MCG 5 PA TIKOSYN CAP 250MCG 5 PA TIKOSYN CAP 500MCG 5 PA ANTIASTHMATIC AND BRONCHODILATOR AGENTS Anti-Inflammatory Agents cromolyn sodium soln nebu 20 mg/2ml 2 QL (2 boxes / 25 days) Bronchodilators - Anticholinergics ipratropium bromide inhal soln 0.02% 2 QL (5 boxes / 25 days) SPIRIVA AER RESPIMAT 3 SPIRIVA CAP HANDIHLR 3 SPIRIVA SPR RESPIMAT 3 Leukotriene Modulators montelukast sodium chew tab 4 mg (base 2 equiv) montelukast sodium chew tab 5 mg (base 2 equiv) montelukast sodium oral granules packet 4 2 mg (base equiv) montelukast sodium tab 10 mg (base 2 equiv) zafirlukast tab 10 mg 2 zafirlukast tab 20 mg 2 ZYFLO CR TAB 600MG 4 Selective Phosphodiesterase 4 (PDE4) Inhibitors DALIRESP TAB 500MCG 4 PA Steroid Inhalants ASMANEX 30 AER 110MCG 3 QL (2 inhalers / 25 days) ASMANEX 60 AER 220MCG 3 QL (2 inhalers per 25 days) ASMANEX 120 AER 220MCG 3 QL (1 inhaler per 25 days) ASMANEX HFA AER 100 MCG 3 QL (1 inhaler per 25 days) ASMANEX HFA AER 200 MCG 3 QL (1 inhaler per 25 days) budesonide inhalation susp 0.5 mg/2ml 2 QL (2 boxes / 25 days) budesonide inhalation susp 0.25 mg/2ml 2 QL (3 boxes / 25 days) budesonide inhalation susp 1 mg/2ml 2 QL (1 box / 25 days) 19

33 QVAR AER 40MCG 3 QVAR AER 80MCG 3 Sympathomimetics ADVAIR DISKU AER 100/50 3 ADVAIR DISKU AER 250/50 3 ADVAIR DISKU AER 500/50 3 ADVAIR HFA AER 45/21 3 ADVAIR HFA AER 115/21 3 ADVAIR HFA AER 230/21 3 albuterol sulfate soln nebu 0.5% (5 mg/ml)2 QL (3 boxes / 25 days) albuterol sulfate soln nebu 0.5% (5 mg/ml)2 QL (4 boxes / 25 days) albuterol sulfate soln nebu 0.63 mg/3ml 2 QL (5 boxes / 25 days) (base equiv) albuterol sulfate soln nebu 0.083% (2.5 2 QL (5 boxes / 25 days) mg/3ml) albuterol sulfate soln nebu 1.25 mg/3ml 2 QL (5 boxes / 25 days) (base equiv) albuterol sulfate syrup 2 mg/5ml 2 albuterol sulfate tab 2 mg 2 albuterol sulfate tab 4 mg 2 albuterol sulfate tab sr 12hr 4 mg 2 albuterol sulfate tab sr 12hr 8 mg 2 ARCAPTA CAP 75MCG 4 QL (30 caps / 25 days) BREO ELLIPTA INH QL (1 package / 25 days), PA BREO ELLIPTA INH QL (1 package / 25 days), PA BROVANA NEB 15MCG 4 QL (2 boxes / 25 days) COMBIVENT AER RESPIMAT 3 QL (2 inhalers / 25 days) ipratropium-albuterol nebu soln (3) 2 QL (6 boxes / 25 days) mg/3ml levalbuterol hcl soln nebu 0.31 mg/3ml 2 QL (300 ml / 25 days) (base equiv) levalbuterol hcl soln nebu 0.63 mg/3ml 2 QL (300 ml / 25 days) (base equiv) levalbuterol hcl soln nebu 1.25 mg/3ml 2 QL (300 ml / 25 days) (base equiv) levalbuterol hcl soln nebu conc QL (90 ml / 25 days) mg/0.5ml (base equiv) metaproterenol sulfate syrup 10 mg/5ml 2 metaproterenol sulfate tab 10 mg 2 metaproterenol sulfate tab 20 mg 2 PERFOROMIST NEB 20MCG 3 QL (2 boxes / 25 days) PROAIR HFA AER 3 QL (2 inhalers / 25 days) 20

34 PROVENTIL AER HFA 3 QL (2 inhalers / 25 days) SEREVENT DIS AER 50MCG 4 QL (1 inhaler / 25 days) terbutaline sulfate inj 1 mg/ml 2 terbutaline sulfate tab 2.5 mg 2 terbutaline sulfate tab 5 mg 2 VENTOLIN HFA AER 3 QL (2 inhalers / 25 days) XOPENEX HFA AER 4 QL (2 inhalers per 25 days), ST; PA** Xanthines aminophylline inj 25 mg/ml 2 ELIXOPHYLLIN ELX 80/15ML 4 LUFYLLIN TAB 200MG 4 LUFYLLIN TAB 400MG 4 THEO-24 CAP 100MG CR 4 THEO-24 CAP 200MG CR 4 THEO-24 CAP 300MG CR 4 THEO-24 CAP 400MG ER 4 theochron tab 100mg cr 2 theochron tab 200mg cr 2 theochron tab 300mg cr 2 theophylline soln 80 mg/15ml 2 theophylline tab sr 12hr 450 mg 2 theophylline tab sr 24hr 400 mg 2 theophylline tab sr 24hr 600 mg 2 ANTICOAGULANTS Coumarin Anticoagulants COUMADIN INJ 5 MG 4 jantoven tab 1mg 2 jantoven tab 2.5mg 2 jantoven tab 2mg 2 jantoven tab 3mg 2 jantoven tab 4mg 2 jantoven tab 5mg 2 jantoven tab 6mg 2 jantoven tab 7.5mg 2 jantoven tab 10mg 2 warfarin sodium tab 1 mg 2 warfarin sodium tab 2 mg 2 warfarin sodium tab 2.5 mg 2 warfarin sodium tab 3 mg 2 warfarin sodium tab 4 mg 2 21

35 warfarin sodium tab 5 mg 2 warfarin sodium tab 6 mg 2 warfarin sodium tab 7.5 mg 2 warfarin sodium tab 10 mg 2 Direct Factor Xa Inhibitors ELIQUIS TAB 2.5MG 3 ELIQUIS TAB 5MG 3 XARELTO STAR TAB 15/20MG 3 XARELTO TAB 10MG 3 XARELTO TAB 15MG 3 XARELTO TAB 20MG 3 Heparins And Heparinoid-Like Agents enoxaparin sodium inj 30 mg/0.3ml 2 enoxaparin sodium inj 40 mg/0.4ml 2 enoxaparin sodium inj 60 mg/0.6ml 2 enoxaparin sodium inj 80 mg/0.8ml 2 enoxaparin sodium inj 100 mg/ml 2 enoxaparin sodium inj 120 mg/0.8ml 2 enoxaparin sodium inj 150 mg/ml 2 enoxaparin sodium inj 300 mg/3ml 2 fondaparinux sodium subcutaneous inj mg/0.5ml fondaparinux sodium subcutaneous inj 5 2 mg/0.4ml fondaparinux sodium subcutaneous inj mg/0.6ml fondaparinux sodium subcutaneous inj 10 2 mg/0.8ml FRAGMIN INJ 2500/0.2 4 FRAGMIN INJ 5000/0.2 4 FRAGMIN INJ 7500/0.3 4 FRAGMIN INJ 10000/ML 4 FRAGMIN INJ 12500UNT 4 FRAGMIN INJ 15000UNT 4 FRAGMIN INJ 18000UNT 4 FRAGMIN INJ 25000/ML 4 FRAGMIN INJ 95000UNT 4 heparin sodium (porcine) inj 1000 unit/ml 2 heparin sodium (porcine) inj 5000 unit/ml 2 heparin sodium (porcine) inj unit/ml 2 heparin sodium (porcine) inj unit/ml 2 heparin sodium (porcine) pf inj unit/0.5ml Thrombin Inhibitors 22

36 ARGATROBAN INJ 125/125 4 argatroban inj 250 mg/2.5ml (concentrate 2 for iv infusion) ARGATROBAN INJ 250/250 4 ANTICONVULSANTS Anticonvulsants - Benzodiazepines clonazepam tab 0.5 mg 2 clonazepam tab 1 mg 2 clonazepam tab 2 mg 2 ONFI SUS 2.5MG/ML 4 PA ONFI TAB 5MG 4 PA ONFI TAB 10MG 4 PA ONFI TAB 20MG 4 PA Anticonvulsants - Misc. BANZEL SUS 40MG/ML 4 PA BANZEL TAB 200MG 4 PA BANZEL TAB 400MG 4 PA carbamazepine cap sr 12hr 100 mg 2 carbamazepine cap sr 12hr 200 mg 2 carbamazepine cap sr 12hr 300 mg 2 carbamazepine chew tab 100 mg 2 carbamazepine susp 100 mg/5ml 2 carbamazepine tab 200 mg 2 carbamazepine tab sr 12hr 100 mg 2 carbamazepine tab sr 12hr 200 mg 2 carbamazepine tab sr 12hr 400 mg 2 epitol tab 200mg 2 gabapentin cap 100 mg 2 gabapentin cap 300 mg 2 gabapentin cap 400 mg 2 gabapentin oral soln 250 mg/5ml 2 gabapentin tab 600 mg 2 gabapentin tab 800 mg 2 LAMICTAL CHW 2MG 3 LAMICTAL KIT START 35 4 LAMICTAL KIT START 49 4 LAMICTAL KIT START 98 4 LAMICTAL ODT KIT 4 LAMICTAL XR KIT 4 lamotrigine orally disintegrating tab 25 mg 2 lamotrigine orally disintegrating tab 50 mg 2 lamotrigine orally disintegrating tab mg 23

37 lamotrigine orally disintegrating tab mg lamotrigine tab 25 mg 2 lamotrigine tab 100 mg 2 lamotrigine tab 150 mg 2 lamotrigine tab 200 mg 2 lamotrigine tab chewable dispersible 5 mg 2 lamotrigine tab chewable dispersible 25 mg2 lamotrigine tab disp 25 (14) & 50 mg (14) 2 & 100 mg (7) kit lamotrigine tab disp 25 mg (21) & 50 mg 2 (7) titration kit lamotrigine tab disp 50 mg (42) & 100 mg 2 (14) titration kit lamotrigine tab sr 24hr 25 mg 2 lamotrigine tab sr 24hr 50 mg 2 lamotrigine tab sr 24hr 100 mg 2 lamotrigine tab sr 24hr 200 mg 2 lamotrigine tab sr 24hr 250 mg 2 lamotrigine tab sr 24hr 300 mg 2 LEVETIRACETA INJ 5MG/ML 4 LEVETIRACETA INJ 10MG/ML 4 LEVETIRACETA INJ 15MG/ML 4 levetiracetam inj 500 mg/5ml (100 mg/ml) 2 levetiracetam oral soln 100 mg/ml 2 levetiracetam tab 250 mg 2 levetiracetam tab 500 mg 2 levetiracetam tab 750 mg 2 levetiracetam tab 1000 mg 2 levetiracetam tab sr 24hr 500 mg 2 levetiracetam tab sr 24hr 750 mg 2 LYRICA CAP 25MG 4 ST; PA** LYRICA CAP 50MG 4 ST; PA** LYRICA CAP 75MG 4 ST; PA** LYRICA CAP 100MG 4 ST; PA** LYRICA CAP 150MG 4 ST; PA** LYRICA CAP 200MG 4 ST; PA** LYRICA CAP 225MG 4 ST; PA** LYRICA CAP 300MG 4 ST; PA** LYRICA SOL 20MG/ML 4 ST; PA** oxcarbazepine susp 300 mg/5ml (60 2 mg/ml) oxcarbazepine tab 150 mg 2 oxcarbazepine tab 300 mg 2 24

38 oxcarbazepine tab 600 mg 2 POTIGA TAB 50MG 4 PA POTIGA TAB 200MG 4 PA POTIGA TAB 300MG 4 PA POTIGA TAB 400MG 4 PA primidone tab 50 mg 2 primidone tab 250 mg 2 TEGRETOL-XR TAB 100MG 3 topiramate sprinkle cap 15 mg 2 topiramate sprinkle cap 25 mg 2 topiramate tab 25 mg 2 topiramate tab 50 mg 2 topiramate tab 100 mg 2 topiramate tab 200 mg 2 VIMPAT INJ 200MG/20 4 PA VIMPAT SOL 10MG/ML 4 PA VIMPAT TAB 50MG 4 PA VIMPAT TAB 100MG 4 PA VIMPAT TAB 150MG 4 PA VIMPAT TAB 200MG 4 PA zonisamide cap 25 mg 2 zonisamide cap 50 mg 2 zonisamide cap 100 mg 2 Carbamates felbamate susp 600 mg/5ml 2 felbamate tab 400 mg 2 felbamate tab 600 mg 2 GABA Modulators GABITRIL TAB 12MG 3 GABITRIL TAB 16MG 3 SABRIL POW 500MG 5 PA SABRIL TAB 500MG 5 PA tiagabine hcl tab 2 mg 2 tiagabine hcl tab 4 mg 2 Hydantoins DILANTIN CAP 30MG 4 fosphenytoin sodium inj 100 mg/2ml 2 (phenytoin equiv) fosphenytoin sodium inj 500 mg/10ml 2 (phenytoin equiv) PEGANONE TAB 250MG 4 PHENYTEK CAP 200MG 2 PHENYTEK CAP 300MG 2 25

39 phenytoin chew tab 50 mg 2 phenytoin sodium extended cap 100 mg 2 phenytoin sodium extended cap 200 mg 2 phenytoin sodium extended cap 300 mg 2 phenytoin sodium inj 50 mg/ml 2 phenytoin susp 125 mg/5ml 2 Succinimides CELONTIN CAP 300MG 4 ethosuximide cap 250 mg 2 ethosuximide soln 250 mg/5ml 2 Valproic Acid divalproex sodium cap delayed release 2 sprinkle 125 mg divalproex sodium tab delayed release mg divalproex sodium tab delayed release mg divalproex sodium tab delayed release mg divalproex sodium tab sr 24 hr 250 mg 2 divalproex sodium tab sr 24 hr 500 mg 2 STAVZOR CAP 125MG 4 STAVZOR CAP 250MG 4 STAVZOR CAP 500MG 4 valproate sodium inj 100 mg/ml 2 valproate sodium syrup 250 mg/5ml (base 2 equiv) valproic acid cap 250 mg 2 ANTIDEPRESSANTS Alpha-2 Receptor Antagonists (Tetracyclics) mirtazapine orally disintegrating tab 15 mg 2 mirtazapine orally disintegrating tab 30 mg 2 mirtazapine orally disintegrating tab 45 mg 2 mirtazapine tab 7.5 mg 2 mirtazapine tab 15 mg 2 mirtazapine tab 30 mg 2 mirtazapine tab 45 mg 2 Antidepressants - Misc. APLENZIN TAB 174MG 4 APLENZIN TAB 348MG 4 APLENZIN TAB 522MG 4 bupropion hcl tab 75 mg 2 bupropion hcl tab 100 mg 2 bupropion hcl tab sr 12hr 100 mg 2 26

40 bupropion hcl tab sr 12hr 150 mg 2 bupropion hcl tab sr 12hr 200 mg 2 bupropion hcl tab sr 24hr 150 mg 2 bupropion hcl tab sr 24hr 300 mg 2 maprotiline hcl tab 25 mg 2 maprotiline hcl tab 50 mg 2 maprotiline hcl tab 75 mg 2 Monoamine Oxidase Inhibitors (MAOIs) EMSAM DIS 6MG/24HR 4 EMSAM DIS 9MG/24HR 4 EMSAM DIS 12MG/24H 4 MARPLAN TAB 10MG 4 phenelzine sulfate tab 15 mg 2 tranylcypromine sulfate tab 10 mg 2 Selective Serotonin Reuptake Inhibitors (SSRIs) citalopram hydrobromide oral soln 10 2 mg/5ml citalopram hydrobromide tab 10 mg (base 2 equiv) citalopram hydrobromide tab 20 mg (base 2 equiv) citalopram hydrobromide tab 40 mg (base 2 equiv) escitalopram oxalate soln 5 mg/5ml (base 2 equiv) escitalopram oxalate tab 5 mg (base 2 equiv) escitalopram oxalate tab 10 mg (base 2 equiv) escitalopram oxalate tab 20 mg (base 2 equiv) fluoxetine hcl cap 10 mg 2 fluoxetine hcl cap 20 mg 2 fluoxetine hcl cap 40 mg 2 fluoxetine hcl cap delayed release 90 mg 2 fluoxetine hcl solution 20 mg/5ml 2 fluoxetine hcl tab 10 mg 2 fluoxetine hcl tab 20 mg 2 FLUOXETINE TAB 60MG 4 fluvoxamine maleate cap sr 24hr 100 mg 2 fluvoxamine maleate cap sr 24hr 150 mg 2 fluvoxamine maleate tab 25 mg 2 fluvoxamine maleate tab 50 mg 2 fluvoxamine maleate tab 100 mg 2 paroxetine hcl tab 10 mg 2 27

41 paroxetine hcl tab 20 mg 2 paroxetine hcl tab 30 mg 2 paroxetine hcl tab 40 mg 2 paroxetine hcl tab sr 24hr 12.5 mg 2 paroxetine hcl tab sr 24hr 25 mg 2 paroxetine hcl tab sr 24hr 37.5 mg 2 sertraline hcl oral conc 20 mg/ml 2 sertraline hcl tab 25 mg 2 sertraline hcl tab 50 mg 2 sertraline hcl tab 100 mg 2 Serotonin Modulators nefazodone hcl tab 50 mg 2 nefazodone hcl tab 100 mg 2 nefazodone hcl tab 150 mg 2 nefazodone hcl tab 200 mg 2 nefazodone hcl tab 250 mg 2 trazodone hcl tab 50 mg 2 trazodone hcl tab 100 mg 2 trazodone hcl tab 150 mg 2 trazodone hcl tab 300 mg 2 VIIBRYD KIT 4 ST; PA** VIIBRYD KIT STARTER 4 ST; PA** VIIBRYD TAB 10MG 4 ST; PA** VIIBRYD TAB 20MG 4 ST; PA** VIIBRYD TAB 40MG 4 ST; PA** Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) duloxetine hcl cap 20 mg 2 duloxetine hcl cap 30 mg 2 duloxetine hcl cap 60 mg 2 venlafaxine hcl cap sr 24hr 37.5 mg (base 2 equivalent) venlafaxine hcl cap sr 24hr 75 mg (base 2 equivalent) venlafaxine hcl cap sr 24hr 150 mg (base 2 equivalent) venlafaxine hcl tab 25 mg 2 venlafaxine hcl tab 37.5 mg 2 venlafaxine hcl tab 50 mg 2 venlafaxine hcl tab 75 mg 2 venlafaxine hcl tab 100 mg 2 venlafaxine hcl tab sr 24hr 37.5 mg (base 2 equivalent) venlafaxine hcl tab sr 24hr 75 mg (base 2 equivalent) 28

42 venlafaxine hcl tab sr 24hr 150 mg (base 2 equivalent) venlafaxine hcl tab sr 24hr 225 mg (base 2 equivalent) Tricyclic Agents amitriptyline hcl tab 10 mg 2 QL (150 tabs / 25 days); QL applies to members age 65 and amitriptyline hcl tab 25 mg 2 QL (60 tabs / 25 days); QL applies to members age 65 and amitriptyline hcl tab 50 mg 2 QL (30 tabs / 25 days); QL applies to members age 65 and amitriptyline hcl tab 75 mg 2 Members 65 and subject to PA amitriptyline hcl tab 100 mg 2 Members 65 and subject to PA amitriptyline hcl tab 150 mg 2 Members 65 and subject to PA amoxapine tab 25 mg 2 QL (90 tabs / 25 days); QL applies to members age 65 and amoxapine tab 50 mg 2 QL (90 tabs / 25 days); QL applies to members age 65 and amoxapine tab 100 mg 2 QL (90 tabs / 25 days); QL applies to members age 65 and amoxapine tab 150 mg 2 QL (60 tabs / 25 days); QL applies to members age 65 and clomipramine hcl cap 25 mg 2 QL (150 caps / 25 days); QL applies to members age 65 and clomipramine hcl cap 50 mg 2 QL (150 caps / 25 days); QL applies to members age 65 and clomipramine hcl cap 75 mg 2 QL (90 caps / 25 days); QL applies to members age 65 and desipramine hcl tab 10 mg 2 QL (90 tabs / 25 days); QL applies to members age 65 and desipramine hcl tab 25 mg 2 QL (90 tabs / 25 days); QL applies to members age 65 and desipramine hcl tab 50 mg 2 QL (90 tabs / 25 days); QL applies to members age 65 and 29

43 desipramine hcl tab 75 mg 2 QL (60 tabs / 25 days); QL applies to members age 65 and desipramine hcl tab 100 mg 2 QL (30 tabs / 25 days); QL applies to members age 65 and desipramine hcl tab 150 mg 2 QL (30 tabs / 25 days); QL applies to members age 65 and doxepin hcl cap 10 mg 2 QL (90 caps / 25 days); QL applies to members age 65 and doxepin hcl cap 25 mg 2 QL (90 caps / 25 days); QL applies to members age 65 and doxepin hcl cap 50 mg 2 QL (90 caps / 25 days); QL applies to members age 65 and doxepin hcl cap 75 mg 2 QL (60 caps / 25 days); QL applies to members age 65 and doxepin hcl cap 100 mg 2 QL (30 caps / 25 days); QL applies to members age 65 and doxepin hcl cap 150 mg 2 QL (30 caps / 25 days); QL applies to members age 65 and doxepin hcl conc 10 mg/ml 2 QL (450 ml / 25 days); QL applies to members age 65 and imipramine hcl tab 10 mg 2 QL (120 tabs / 25 days); QL applies to members age 65 and imipramine hcl tab 25 mg 2 QL (120 tabs / 25 days); QL applies to members age 65 and imipramine hcl tab 50 mg 2 QL (60 tabs / 25 days); QL applies to members age 65 and imipramine pamoate cap 75 mg 2 QL (30 caps / 25 days); QL applies to members age 65 and imipramine pamoate cap 100 mg 2 QL (30 caps / 25 days); QL applies to members age 65 and imipramine pamoate cap 125 mg 2 Members 65 and subject to PA imipramine pamoate cap 150 mg 2 Members 65 and subject to PA nortriptyline hcl cap 10 mg 2 QL (150 caps / 25 days); QL applies to members age 65 and 30

44 nortriptyline hcl cap 25 mg 2 QL (60 caps / 25 days); QL applies to members age 65 and nortriptyline hcl cap 50 mg 2 QL (30 caps / 25 days); QL applies to members age 65 and nortriptyline hcl cap 75 mg 2 Members 65 and subject to PA nortriptyline hcl soln 10 mg/5ml 2 QL (750 ml / 25 days); QL applies to members age 65 and protriptyline hcl tab 5 mg 2 QL (90 tabs / 25 days); QL applies to members age 65 and protriptyline hcl tab 10 mg 2 QL (60 tabs / 25 days); QL applies to members age 65 and SURMONTIL CAP 25MG 4 QL (60 caps / 25 days); QL applies to members age 65 and SURMONTIL CAP 50MG 4 QL (60 caps / 25 days); QL applies to members age 65 and SURMONTIL CAP 100MG 4 QL (30 caps / 25 days); QL applies to members age 65 and trimipramine maleate cap 25 mg 2 QL (60 caps / 25 days); QL applies to members age 65 and trimipramine maleate cap 50 mg 2 QL (60 caps / 25 days); QL applies to members age 65 and trimipramine maleate cap 100 mg 2 QL (30 caps / 25 days); QL applies to members age 65 and ANTIDIABETICS Alpha-Glucosidase Inhibitors acarbose tab 25 mg 2 acarbose tab 50 mg 2 acarbose tab 100 mg 2 GLYSET TAB 25MG 4 GLYSET TAB 50MG 4 GLYSET TAB 100MG 4 Antidiabetic - Amylin Analogs SYMLINPEN 60 INJ 1000MCG 4 PA SYMLNPEN 120 INJ 1000MCG 4 PA Antidiabetic Combinations glipizide-metformin hcl tab mg 1 glipizide-metformin hcl tab mg 1 31

45 glipizide-metformin hcl tab mg 1 glyburide-metformin tab mg 1 PA; High Risk Medications require PA for members age 65 and glyburide-metformin tab mg 1 PA; High Risk Medications require PA for members age 65 and glyburide-metformin tab mg 1 PA; High Risk Medications require PA for members age 65 and JANUMET TAB MG 3 JANUMET TAB JANUMET XR TAB MG 3 JANUMET XR TAB JANUMET XR TAB JENTADUETO TAB JENTADUETO TAB JENTADUETO TAB pioglitazone hcl-glimepiride tab 30-2 mg 1 pioglitazone hcl-glimepiride tab 30-4 mg 1 pioglitazone hcl-metformin hcl tab mg pioglitazone hcl-metformin hcl tab mg repaglinide-metformin hcl tab mg 1 repaglinide-metformin hcl tab mg 1 Biguanides metformin hcl tab 500 mg 1 metformin hcl tab 850 mg 1 metformin hcl tab 1000 mg 1 metformin hcl tab sr 24hr 500 mg 1 metformin hcl tab sr 24hr 750 mg 1 metformin hcl tab sr 24hr osmotic 500 mg 1 metformin hcl tab sr 24hr osmotic mg Diabetic Other GLUCAGON KIT 1MG 3 PROGLYCEM SUS 50MG/ML 4 Dipeptidyl Peptidase-4 (DPP-4) Inhibitors JANUVIA TAB 25MG 3 JANUVIA TAB 50MG 3 JANUVIA TAB 100MG 3 TRADJENTA TAB 5MG 3 32

46 Dopamine Receptor Agonists - Antidiabetic CYCLOSET TAB 0.8MG 4 Incretin Mimetic Agents (GLP-1 Receptor Agonists) TRULICITY INJ 0.75/0.5 3 TRULICITY INJ 1.5/0.5 3 VICTOZA INJ 18MG/3ML 3 Insulin APIDRA INJ SOLOSTAR 3 APIDRA INJ U HUMALOG INJ 100/ML 4 HUMALOG KWIK INJ 100/ML 4 HUMALOG KWIK INJ 200/ML 4 HUMALOG MIX INJ 50/50 4 HUMALOG MIX INJ 50/50KWP 4 HUMALOG MIX INJ 75/25KWP 4 HUMALOG MIX SUS 75/25 4 HUMULIN INJ 70/30 4 OTC HUMULIN INJ 70/30KWP 4 OTC HUMULIN N INJ U OTC HUMULIN N INJ U-100KWP 4 OTC HUMULIN R INJ U OTC HUMULIN R INJ U LANTUS INJ 100/ML 3 LANTUS INJ SOLOSTAR 3 LEVEMIR INJ 3 LEVEMIR INJ FLEXTOUC 3 NOVOLIN INJ 70/30 3 OTC;RELION not covered NOVOLIN N INJ U OTC;RELION not covered NOVOLIN R INJ U OTC;RELION not covered NOVOLOG INJ 100/ML 3 NOVOLOG INJ FLEXPEN 3 NOVOLOG INJ PENFILL 3 NOVOLOG MIX INJ 70/30 3 NOVOLOG MIX INJ FLEXPEN 3 Insulin Sensitizing Agents pioglitazone hcl tab 15 mg (base equiv) 1 pioglitazone hcl tab 30 mg (base equiv) 1 pioglitazone hcl tab 45 mg (base equiv) 1 Meglitinide Analogues nateglinide tab 60 mg 1 nateglinide tab 120 mg 1 33

47 repaglinide tab 0.5 mg 1 repaglinide tab 1 mg 1 repaglinide tab 2 mg 1 Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors FARXIGA TAB 5MG 3 FARXIGA TAB 10MG 3 JARDIANCE TAB 10MG 3 JARDIANCE TAB 25MG 3 Sulfonylureas chlorpropamide tab 100 mg 1 chlorpropamide tab 250 mg 1 glimepiride tab 1 mg 1 glimepiride tab 2 mg 1 glimepiride tab 4 mg 1 glipizide tab 5 mg 1 glipizide tab 10 mg 1 glipizide tab sr 24hr 2.5 mg 1 glipizide tab sr 24hr 5 mg 1 glipizide tab sr 24hr 10 mg 1 glyburide micronized tab 1.5 mg 1 PA; High Risk Medications require PA for members age 65 and glyburide micronized tab 3 mg 1 PA; High Risk Medications require PA for members age 65 and glyburide micronized tab 6 mg 1 PA; High Risk Medications require PA for members age 65 and glyburide tab 1.25 mg 1 PA; High Risk Medications require PA for members age 65 and glyburide tab 2.5 mg 1 PA; High Risk Medications require PA for members age 65 and glyburide tab 5 mg 1 PA; High Risk Medications require PA for members age 65 and tolazamide tab 250 mg 1 tolazamide tab 500 mg 1 tolbutamide tab 500 mg 1 ANTIDIARRHEALS 34

48 Antiperistaltic Agents diphenoxylate w/ atropine liq mg/5ml diphenoxylate w/ atropine tab mg loperamide hcl cap 2 mg 2 loperamide hcl tab 2 mg 2 MOTOFEN TAB 4 ANTIDOTES Antidotes - Chelating Agents CHEMET CAP 100MG 4 EXJADE TAB 125MG 5 PA EXJADE TAB 250MG 5 PA EXJADE TAB 500MG 5 PA FERRIPROX TAB 500MG 5 PA Opioid Antagonists naloxone hcl inj 0.4 mg/ml 2 naloxone hcl inj 1 mg/ml 2 naltrexone hcl tab 50 mg 2 NARCAN SPR 3 VIVITROL INJ 380MG 5 PA ANTIEMETICS 5-HT3 Receptor Antagonists ALOXI INJ 0.25MG/5 4 QL (5 ml / 15 days) ANZEMET TAB 50MG 4 QL (3 tabs / 15 days) ANZEMET TAB 100MG 4 QL (3 tabs / 15 days) granisetron hcl inj 0.1 mg/ml 2 QL (1 ml / 15 days) granisetron hcl inj 1 mg/ml 2 QL (1 ml / 15 days) granisetron hcl inj 4 mg/4ml (1 mg/ml) 2 QL (1 ml / 15 days) granisetron hcl tab 1 mg 2 QL (6 tabs / 15 days) GRANISOL SOL 2MG/10ML 4 ondansetron hcl inj 4 mg/2ml (2 mg/ml) 2 QL (10 ml / 15 days) ondansetron hcl inj 40 mg/20ml (2 mg/ml) 2 QL (10 ml / 15 days) ondansetron hcl oral soln 4 mg/5ml 2 QL (2 bottles / 15 days) ondansetron hcl tab 4 mg 2 QL (12 tabs / 15 days) ondansetron hcl tab 8 mg 2 QL (12 tabs / 15 days) ondansetron hcl tab 24 mg 2 QL (1 tab / 15 days) ondansetron orally disintegrating tab 4 mg 2 QL (12 tabs / 15 days) ondansetron orally disintegrating tab 8 mg 2 QL (12 tabs / 15 days) SANCUSO DIS 3.1MG 4 QL (1 patch / 15 days) ZUPLENZ MIS 4MG 4 QL (12 films / 15 days) ZUPLENZ MIS 8MG 4 QL (12 films / 15 days) 35

49 Antiemetics - Anticholinergic ANTIVERT TAB 50MG 3 dimenhydrinate tab 50 mg 2 meclizine hcl tab 12.5 mg 2 meclizine hcl tab 25 mg 2 TRANSDERM-SC DIS 1MG 4 trimethobenzamide hcl cap 300 mg 2 PA; High Risk Medications require PA for members age 65 and trimethobenzamide hcl inj 100 mg/ml 2 PA; High Risk Medications require PA for members age 65 and univert tab 32mg 2 Antiemetics - Miscellaneous CESAMET CAP 1MG 4 QL (18 caps / 25 days) dronabinol cap 2.5 mg 2 QL (60 caps / 25 days) dronabinol cap 5 mg 2 QL (60 caps / 25 days) dronabinol cap 10 mg 2 QL (60 caps / 25 days) Substance P/Neurokinin 1 (NK1) Receptor Antagonists EMEND CAP 40MG 4 QL (3 caps / 180 days) EMEND CAP 80MG 4 QL (2 caps / 15 days) EMEND CAP 125MG 4 QL (1 cap / 15 days) EMEND PAK 80 & QL (3 caps / 15 days) ANTIFUNGALS Antifungal - Glucan Synthesis Inhibitors (Echinocandins) CANCIDAS INJ 50MG 4 CANCIDAS INJ 70MG 4 ERAXIS INJ 50MG 4 ERAXIS INJ 100MG 4 MYCAMINE INJ 50MG 4 MYCAMINE INJ 100MG 4 Antifungals ABELCET INJ 5MG/ML 4 AMBISOME INJ 50MG 4 AMPHOTEC INJ 50MG 4 AMPHOTEC INJ 100MG 4 amphotericin b for inj 50 mg 2 BIO-STATIN CAP BIO-STATIN CAP griseofulvin microsize susp 125 mg/5ml 2 griseofulvin microsize tab 500 mg 2 griseofulvin ultramicrosize tab 125 mg 2 36

50 griseofulvin ultramicrosize tab 250 mg 2 LAMISIL GRA 125MG 4 PA LAMISIL GRA 187.5MG 4 PA nystatin oral powder 2 nystatin tab unit 2 terbinafine hcl tab 250 mg 2 PA Imidazole-Related Antifungals fluconazole for susp 10 mg/ml 2 fluconazole for susp 40 mg/ml 2 fluconazole in dextrose inj 200 mg/100ml 2 fluconazole in dextrose inj 400 mg/200ml 2 fluconazole in nacl 0.9% inj 200 mg/100ml 2 fluconazole in nacl 0.9% inj 400 mg/200ml 2 fluconazole tab 50 mg 2 fluconazole tab 100 mg 2 fluconazole tab 150 mg 2 fluconazole tab 200 mg 2 FLUCONAZOLE/ INJ NACL itraconazole cap 100 mg 2 PA NOXAFIL SUS 40MG/ML 3 NOXAFIL TAB 100MG 3 SPORANOX SOL 10MG/ML 3 PA voriconazole for susp 40 mg/ml 2 PA voriconazole tab 50 mg 2 PA voriconazole tab 200 mg 2 PA ANTIHISTAMINES Antihistamines - Alkylamines brompheniramine tannate chew tab 12 mg 2 dexchlorpheniramine maleate syrup 2 2 mg/5ml Antihistamines - Ethanolamines arbinoxa sol 4mg/5ml 2 carbinoxamine maleate soln 4 mg/5ml 2 carbinoxamine maleate tab 4 mg 2 clemastine fumarate syrup 0.67 mg/5ml (0.5 mg/5ml base eq) 2 PA; High Risk Medications require PA for members age 65 and clemastine fumarate tab 2.68 mg 2 PA; High Risk Medications require PA for members age 65 and diphenhydramine hcl cap 25 mg 2 diphenhydramine hcl cap 50 mg 2 37

51 diphenhydramine hcl elixir 12.5 mg/5ml 2 diphenhydramine hcl inj 50 mg/ml 2 Antihistamines - Non-Sedating CLARINEX SYP 0.5MG/ML 4 desloratadine tab 5 mg 2 desloratadine tab orally disintegrating mg desloratadine tab orally disintegrating 5 2 mg levocetirizine dihydrochloride soln mg/5ml (0.5 mg/ml) levocetirizine dihydrochloride tab 5 mg 2 Antihistamines - Phenothiazines phenadoz sup 25mg 2 promethazine hcl inj 25 mg/ml 2 promethazine hcl inj 50 mg/ml 2 promethazine hcl suppos 12.5 mg 2 promethazine hcl suppos 25 mg 2 promethazine hcl syrup 6.25 mg/5ml 2 PA; High Risk Medications require PA for members age 65 and promethazine hcl tab 12.5 mg 2 PA; High Risk Medications require PA for members age 65 and promethazine hcl tab 25 mg 2 PA; High Risk Medications require PA for members age 65 and promethazine hcl tab 50 mg 2 PA; High Risk Medications require PA for members age 65 and promethegan sup 12.5mg 2 promethegan sup 25mg 2 promethegan sup 50mg 2 Antihistamines - Piperidines cyproheptadine hcl syrup 2 mg/5ml 2 cyproheptadine hcl tab 4 mg 2 ANTIHYPERLIPIDEMICS Antihyperlipidemics - Combinations VYTORIN TAB 10-10MG 3 VYTORIN TAB 10-20MG 3 VYTORIN TAB 10-40MG 3 VYTORIN TAB 10-80MG 3 38

52 Antihyperlipidemics - Misc. omega-3-acid ethyl esters cap 1 gm 2 PA Bile Acid Sequestrants cholestyramine light powder 4 gm/dose 2 cholestyramine light powder packets 4 gm 2 cholestyramine powder 4 gm/dose 2 cholestyramine powder packets 4 gm 2 colestipol hcl granule packets 5 gm 2 colestipol hcl granules 5 gm 2 colestipol hcl tab 1 gm 2 prevalite pow 4gm 2 WELCHOL PAK 3.75GM 3 WELCHOL TAB 625MG 3 Fibric Acid Derivatives choline fenofibrate cap dr 45 mg (fenofibric 2 acid equiv) choline fenofibrate cap dr 135 mg 2 (fenofibric acid equiv) fenofibrate cap 50 mg 2 fenofibrate cap 150 mg 2 fenofibrate micronized cap 43 mg 2 fenofibrate micronized cap 67 mg 2 fenofibrate micronized cap 130 mg 2 fenofibrate micronized cap 134 mg 2 fenofibrate micronized cap 200 mg 2 fenofibrate tab 48 mg 2 fenofibrate tab 54 mg 2 fenofibrate tab 145 mg 2 fenofibrate tab 160 mg 2 fenofibric acid tab 35 mg 2 fenofibric acid tab 105 mg 2 gemfibrozil tab 600 mg 2 HMG CoA Reductase Inhibitors atorvastatin calcium tab 10 mg (base 1 equivalent) atorvastatin calcium tab 20 mg (base 1 equivalent) atorvastatin calcium tab 40 mg (base 1 equivalent) atorvastatin calcium tab 80 mg (base 1 equivalent) CRESTOR TAB 5MG 3 CRESTOR TAB 10MG 3 CRESTOR TAB 20MG 3 39

53 CRESTOR TAB 40MG 3 fluvastatin sodium cap 20 mg 1 fluvastatin sodium cap 40 mg 1 LIVALO TAB 1MG 4 LIVALO TAB 2MG 4 LIVALO TAB 4MG 4 lovastatin tab 10 mg 1 lovastatin tab 20 mg 1 lovastatin tab 40 mg 1 pravastatin sodium tab 10 mg 1 pravastatin sodium tab 20 mg 1 pravastatin sodium tab 40 mg 1 pravastatin sodium tab 80 mg 1 simvastatin tab 5 mg 1 simvastatin tab 10 mg 1 simvastatin tab 20 mg 1 simvastatin tab 40 mg 1 simvastatin tab 80 mg 1 ST Intestinal Cholesterol Absorption Inhibitors ZETIA TAB 10MG 3 Nicotinic Acid Derivatives niacin tab cr 500 mg (antihyperlipidemic) 2 niacin tab cr 750 mg (antihyperlipidemic) 2 niacin tab cr 1000 mg (antihyperlipidemic) 2 PCSK-9 Inhibitors REPATHA INJ 140MG/ML 5 PA REPATHA SURE INJ 140MG/ML 5 PA ANTIHYPERTENSIVES ACE Inhibitors benazepril hcl tab 5 mg 1 benazepril hcl tab 10 mg 1 benazepril hcl tab 20 mg 1 benazepril hcl tab 40 mg 1 captopril tab 12.5 mg 1 captopril tab 25 mg 1 captopril tab 50 mg 1 captopril tab 100 mg 1 enalapril maleate tab 2.5 mg 1 enalapril maleate tab 5 mg 1 enalapril maleate tab 10 mg 1 enalapril maleate tab 20 mg 1 fosinopril sodium tab 10 mg 1 40

54 fosinopril sodium tab 20 mg 1 fosinopril sodium tab 40 mg 1 lisinopril tab 2.5 mg 1 lisinopril tab 5 mg 1 lisinopril tab 10 mg 1 lisinopril tab 20 mg 1 lisinopril tab 30 mg 1 lisinopril tab 40 mg 1 moexipril hcl tab 7.5 mg 1 moexipril hcl tab 15 mg 1 perindopril erbumine tab 2 mg 1 perindopril erbumine tab 4 mg 1 perindopril erbumine tab 8 mg 1 quinapril hcl tab 5 mg 1 quinapril hcl tab 10 mg 1 quinapril hcl tab 20 mg 1 quinapril hcl tab 40 mg 1 ramipril cap 1.25 mg 1 ramipril cap 2.5 mg 1 ramipril cap 5 mg 1 ramipril cap 10 mg 1 trandolapril tab 1 mg 1 trandolapril tab 2 mg 1 trandolapril tab 4 mg 1 Agents for Pheochromocytoma phenoxybenzamine hcl cap 10 mg 2 Angiotensin II Receptor Antagonists BENICAR TAB 5MG 4 ST; PA** BENICAR TAB 20MG 4 ST; PA** BENICAR TAB 40MG 4 ST; PA** candesartan cilexetil tab 4 mg 1 candesartan cilexetil tab 8 mg 1 candesartan cilexetil tab 16 mg 1 candesartan cilexetil tab 32 mg 1 EDARBI TAB 40MG 4 ST; PA** EDARBI TAB 80MG 4 ST; PA** eprosartan mesylate tab 600 mg 1 irbesartan tab 75 mg 1 irbesartan tab 150 mg 1 irbesartan tab 300 mg 1 losartan potassium tab 25 mg 1 losartan potassium tab 50 mg 1 losartan potassium tab 100 mg 1 41

55 telmisartan tab 20 mg 1 telmisartan tab 40 mg 1 telmisartan tab 80 mg 1 valsartan tab 40 mg 1 valsartan tab 80 mg 1 valsartan tab 160 mg 1 valsartan tab 320 mg 1 Antiadrenergic Antihypertensives clonidine hcl tab 0.1 mg 2 clonidine hcl tab 0.2 mg 2 clonidine hcl tab 0.3 mg 2 clonidine hcl td patch weekly 0.1 mg/24hr 2 clonidine hcl td patch weekly 0.2 mg/24hr 2 clonidine hcl td patch weekly 0.3 mg/24hr 2 doxazosin mesylate tab 1 mg 2 doxazosin mesylate tab 2 mg 2 doxazosin mesylate tab 4 mg 2 doxazosin mesylate tab 8 mg 2 guanfacine hcl tab 1 mg 2 guanfacine hcl tab 2 mg 2 methyldopa tab 250 mg 2 methyldopa tab 500 mg 2 methyldopate hcl inj 250 mg/5ml 2 prazosin hcl cap 1 mg 2 prazosin hcl cap 2 mg 2 prazosin hcl cap 5 mg 2 terazosin hcl cap 1 mg 2 terazosin hcl cap 2 mg 2 terazosin hcl cap 5 mg 2 terazosin hcl cap 10 mg 2 Antihypertensive Combinations amlodipine besylate-benazepril hcl cap mg amlodipine besylate-benazepril hcl cap mg amlodipine besylate-benazepril hcl cap mg amlodipine besylate-benazepril hcl cap mg amlodipine besylate-benazepril hcl cap mg amlodipine besylate-benazepril hcl cap mg amlodipine besylate-valsartan tab mg 42

56 amlodipine besylate-valsartan tab mg amlodipine besylate-valsartan tab mg amlodipine besylate-valsartan tab mg amlodipine-valsartan-hydrochlorothiazide 1 tab mg amlodipine-valsartan-hydrochlorothiazide 1 tab mg amlodipine-valsartan-hydrochlorothiazide 1 tab mg amlodipine-valsartan-hydrochlorothiazide 1 tab mg amlodipine-valsartan-hydrochlorothiazide 1 tab mg atenolol & chlorthalidone tab mg 2 atenolol & chlorthalidone tab mg 2 benazepril & hydrochlorothiazide tab mg benazepril & hydrochlorothiazide tab mg benazepril & hydrochlorothiazide tab mg benazepril & hydrochlorothiazide tab mg bisoprolol & hydrochlorothiazide tab mg bisoprolol & hydrochlorothiazide tab mg bisoprolol & hydrochlorothiazide tab mg candesartan cilexetil-hydrochlorothiazide 1 tab mg candesartan cilexetil-hydrochlorothiazide 1 tab mg candesartan cilexetil-hydrochlorothiazide 1 tab mg captopril & hydrochlorothiazide tab mg captopril & hydrochlorothiazide tab mg captopril & hydrochlorothiazide tab mg captopril & hydrochlorothiazide tab mg enalapril maleate & hydrochlorothiazide tab mg enalapril maleate & hydrochlorothiazide tab mg 43

57 fosinopril sodium & hydrochlorothiazide tab mg fosinopril sodium & hydrochlorothiazide tab mg irbesartan-hydrochlorothiazide tab mg irbesartan-hydrochlorothiazide tab mg lisinopril & hydrochlorothiazide tab mg lisinopril & hydrochlorothiazide tab mg lisinopril & hydrochlorothiazide tab mg losartan potassium & hydrochlorothiazide 1 tab mg losartan potassium & hydrochlorothiazide 1 tab mg losartan potassium & hydrochlorothiazide 1 tab mg metoprolol & hydrochlorothiazide tab mg metoprolol & hydrochlorothiazide tab mg metoprolol & hydrochlorothiazide tab mg moexipril-hydrochlorothiazide tab mg moexipril-hydrochlorothiazide tab mg moexipril-hydrochlorothiazide tab mg nadolol & bendroflumethiazide tab 40-5 mg2 nadolol & bendroflumethiazide tab 80-5 mg2 propranolol & hydrochlorothiazide tab mg propranolol & hydrochlorothiazide tab mg quinapril-hydrochlorothiazide tab mg quinapril-hydrochlorothiazide tab mg quinapril-hydrochlorothiazide tab mg1 telmisartan-amlodipine tab 40-5 mg 1 telmisartan-amlodipine tab mg 1 telmisartan-amlodipine tab 80-5 mg 1 telmisartan-amlodipine tab mg 1 telmisartan-hydrochlorothiazide tab mg 44

58 telmisartan-hydrochlorothiazide tab mg telmisartan-hydrochlorothiazide tab mg trandolapril-verapamil hcl tab cr mg 1 trandolapril-verapamil hcl tab cr mg 1 trandolapril-verapamil hcl tab cr mg 1 trandolapril-verapamil hcl tab cr mg 1 valsartan-hydrochlorothiazide tab mg valsartan-hydrochlorothiazide tab mg valsartan-hydrochlorothiazide tab mg valsartan-hydrochlorothiazide tab mg valsartan-hydrochlorothiazide tab mg Direct Renin Inhibitors TEKTURNA TAB 150MG 4 ST; PA** TEKTURNA TAB 300MG 4 ST; PA** Selective Aldosterone Receptor Antagonists (SARAs) eplerenone tab 25 mg 2 eplerenone tab 50 mg 2 Vasodilators hydralazine hcl inj 20 mg/ml 2 hydralazine hcl tab 10 mg 2 hydralazine hcl tab 25 mg 2 hydralazine hcl tab 50 mg 2 hydralazine hcl tab 100 mg 2 minoxidil tab 2.5 mg 2 minoxidil tab 10 mg 2 ANTIMALARIALS Antimalarial Combinations atovaquone-proguanil hcl tab mg 2 atovaquone-proguanil hcl tab mg 2 COARTEM TAB MG 4 Antimalarials chloroquine phosphate tab 250 mg 2 chloroquine phosphate tab 500 mg 2 DARAPRIM TAB 25MG 4 hydroxychloroquine sulfate tab 200 mg 2 mefloquine hcl tab 250 mg 2 PRIMAQUINE TAB 26.3MG 4 45

59 quinine sulfate cap 324 mg 2 quinine sulfate tab 260 mg 2 ANTIMYASTHENIC/CHOLINERGIC AGENTS Antimyasthenic/Cholinergic Agents GUANIDINE TAB 125MG 4 MESTINON SYP 60MG/5ML 3 pyridostigmine bromide tab 60 mg 2 pyridostigmine bromide tab cr 180 mg 2 REGONOL INJ 5MG/ML 4 ANTIMYCOBACTERIAL AGENTS Anti TB Combinations RIFAMATE CAP 3 RIFATER TAB 3 Antimycobacterial Agents CAPASTAT SUL INJ 1GM 3 cycloserine cap 250 mg 2 ethambutol hcl tab 100 mg 2 ethambutol hcl tab 400 mg 2 isoniazid inj 100 mg/ml 2 isoniazid syrup 50 mg/5ml 2 isoniazid tab 100 mg 2 isoniazid tab 300 mg 2 PASER GRA 4GM 4 PRIFTIN TAB 150MG 3 pyrazinamide tab 500 mg 2 rifabutin cap 150 mg 2 rifampin cap 150 mg 2 rifampin cap 300 mg 2 rifampin for inj 600 mg 2 TRECATOR TAB 250MG 3 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Alkylating Agents ALKERAN TAB 2MG 3 BICNU INJ 100MG 3 BUSULFEX INJ 6MG/ML 3 carboplatin iv for inj 150 mg 2 carboplatin iv soln 50 mg/5ml 2 carboplatin iv soln 150 mg/15ml 2 carboplatin iv soln 450 mg/45ml 2 carboplatin iv soln 600 mg/60ml 2 cisplatin inj 50 mg/50ml (1 mg/ml) 2 46

60 cisplatin inj 100 mg/100ml (1 mg/ml) 2 cisplatin inj 200 mg/200ml (1 mg/ml) 2 CYCLOPHOSPH CAP 25MG 3 CYCLOPHOSPH CAP 50MG 3 cyclophosphamide for inj 1 gm 2 cyclophosphamide for inj 2 gm 2 cyclophosphamide for inj 500 mg 2 cyclophosphamide tab 25 mg 2 cyclophosphamide tab 50 mg 2 ELOXATIN INJ 200MG 3 GLEOSTINE CAP 5MG 3 GLIADEL WAF 7.7MG 3 HEXALEN CAP 50MG 3 ifosfamide for inj 1 gm 2 ifosfamide iv inj 1 gm/20ml (50 mg/ml) 2 ifosfamide iv inj 3 gm/60ml (50 mg/ml) 2 LEUKERAN TAB 2MG 3 lomustine cap 10 mg 2 lomustine cap 40 mg 2 lomustine cap 100 mg 2 melphalan hcl for inj 50 mg (base equiv) 2 MYLERAN TAB 2MG 3 oxaliplatin for iv inj 50 mg 2 oxaliplatin for iv inj 100 mg 2 oxaliplatin iv soln 50 mg/10ml 2 oxaliplatin iv soln 100 mg/20ml 2 TEMODAR INJ 100MG 5 PA temozolomide cap 5 mg 5 PA temozolomide cap 20 mg 5 PA temozolomide cap 100 mg 5 PA temozolomide cap 140 mg 5 PA temozolomide cap 180 mg 5 PA temozolomide cap 250 mg 5 PA ZANOSAR INJ 1GM 3 Antimetabolites adrucil inj 500/10ml 2 ALIMTA INJ 100MG 3 ALIMTA INJ 500MG 3 ARRANON INJ 5MG/ML 3 azacitidine for inj 100 mg 5 PA capecitabine tab 150 mg 5 PA capecitabine tab 500 mg 5 PA cladribine iv soln 10 mg/10ml (1 mg/ml) 2 47

61 CLOLAR INJ 1MG/ML 3 cytarabine for inj 1 gm 2 cytarabine for inj 100 mg 2 cytarabine for inj 500 mg 2 cytarabine inj 20 mg/ml 2 cytarabine inj pf 20 mg/ml 2 cytarabine inj pf 100 mg/ml 2 decitabine for inj 50 mg 5 PA DEPOCYT INJ 50MG/5ML 3 floxuridine for inj 0.5 gm 2 fludarabine phosphate for inj 50 mg 2 fludarabine phosphate inj 25 mg/ml 2 fluorouracil inj 1 gm/20ml (50 mg/ml) 2 fluorouracil inj 2.5 gm/50ml (50 mg/ml) 2 fluorouracil inj 5 gm/100ml (50 mg/ml) 2 fluorouracil inj 500 mg/10ml (50 mg/ml) 2 gemcitabine hcl for inj 1 gm 2 gemcitabine hcl for inj 2 gm 2 gemcitabine hcl for inj 200 mg 2 mercaptopurine tab 50 mg 2 methotrexate sodium for inj 1 gm 2 methotrexate sodium inj 50 mg/2ml (25 2 mg/ml) methotrexate sodium inj 250 mg/10ml (25 2 mg/ml) methotrexate sodium inj pf 50 mg/2ml (25 2 mg/ml) methotrexate sodium inj pf 100 mg/4ml 2 (25 mg/ml) methotrexate sodium inj pf 200 mg/8ml 2 (25 mg/ml) methotrexate sodium inj pf 250 mg/10ml 2 (25 mg/ml) methotrexate sodium inj pf 1000 mg/40ml 2 (25 mg/ml) methotrexate sodium tab 2.5 mg (base 2 equiv) TABLOID TAB 40MG 3 TREXALL TAB 5MG 4 TREXALL TAB 7.5MG 4 TREXALL TAB 10MG 4 TREXALL TAB 15MG 4 Antineoplastic - Angiogenesis Inhibitors ZALTRAP INJ 100/4ML 5 PA ZALTRAP INJ 200/8ML 5 PA 48

62 Antineoplastic - Antibodies ARZERRA CON 100/5ML 5 PA ARZERRA CON 1000/50 5 PA ERBITUX INJ 100MG 5 PA ERBITUX INJ 200MG 5 PA GAZYVA INJ 25MG/ML 5 PA KADCYLA INJ 100MG 5 PA KADCYLA INJ 160MG 5 PA KEYTRUDA INJ 100MG/4M 5 PA KEYTRUDA SOL 50MG 5 PA RITUXAN INJ 100MG 5 PA RITUXAN INJ 500MG 5 PA YERVOY INJ 50MG 5 PA YERVOY INJ 200MG 5 PA Antineoplastic - Hedgehog Pathway Inhibitors ERIVEDGE CAP 150MG 5 PA Antineoplastic - Hormonal and Related Agents anastrozole tab 1 mg 2 bicalutamide tab 50 mg 2 DEPO-PROVERA INJ 400/ML 4 ELIGARD INJ 7.5MG 5 PA ELIGARD INJ 22.5MG 5 PA ELIGARD INJ 30MG 5 PA ELIGARD INJ 45MG 5 PA EMCYT CAP 140MG 3 exemestane tab 25 mg 2 FARESTON TAB 60MG 3 FASLODEX INJ 250MG 3 FIRMAGON INJ 80MG 5 PA FIRMAGON INJ 120MG 5 PA flutamide cap 125 mg 2 letrozole tab 2.5 mg 2 leuprolide acetate inj kit 5 mg/ml 5 PA LUPRON DEPOT INJ 3.75MG 5 PA LUPRON DEPOT INJ 7.5MG 5 PA LUPRON DEPOT INJ 11.25MG 5 PA LUPRON DEPOT INJ 22.5MG 5 PA LUPRON DEPOT INJ 30MG 5 PA LUPRON DEPOT INJ 45MG 5 PA LYSODREN TAB 500MG 3 megestrol acetate susp 40 mg/ml 2 megestrol acetate tab 20 mg 2 megestrol acetate tab 40 mg 2 49

63 NILANDRON TAB 150MG 3 tamoxifen citrate tab 10 mg (base equivalent) tamoxifen citrate tab 20 mg (base equivalent) TRELSTAR INJ 11.25MG 5 PA TRELSTAR MIX INJ 3.75MG 5 PA TRELSTAR MIX INJ 22.5MG 5 PA ZYTIGA TAB 250MG 5 PA Antineoplastic Antibiotics adriamycin inj 10mg 2 ADRIAMYCIN INJ 20MG 3 bleomycin sulfate for inj 15 unit 2 bleomycin sulfate for inj 30 unit 2 dactinomycin for inj 0.5 mg 2 daunorubicin hcl for inj 20 mg 2 daunorubicin hcl inj 5 mg/ml (base equiv) 2 DAUNOXOME INJ 2MG/ML 3 doxorubicin hcl for inj 10 mg 2 doxorubicin hcl for inj 50 mg 2 doxorubicin hcl inj 2 mg/ml 2 epirubicin hcl iv soln 50 mg/25ml (2 2 mg/ml) epirubicin hcl iv soln 200 mg/100ml (2 2 mg/ml) EPIRUBICIN INJ 50MG 3 idarubicin hcl iv inj 5 mg/5ml (1 mg/ml) 2 idarubicin hcl iv inj 10 mg/10ml (1 mg/ml) 2 idarubicin hcl iv inj 20 mg/20ml (1 mg/ml) 2 lipodox 50 inj 2mg/ml 2 lipodox inj 2mg/ml 2 mitomycin for iv soln 5 mg 2 mitomycin for iv soln 20 mg 2 mitomycin for iv soln 40 mg 2 mitoxantrone hcl inj conc 20 mg/10ml (2 5 PA mg/ml) mitoxantrone hcl inj conc 25 mg/12.5ml (2 5 PA mg/ml) mitoxantrone hcl inj conc 30 mg/15ml (2 5 PA mg/ml) Antineoplastic Combinations ifosfamide & mesna inj kit mg 2 2 $0 copay for women > 35 years for the primary prevention of breast cancer 2 $0 copay for women > 35 years for the primary prevention of breast cancer 50

64 Antineoplastic Enzyme Inhibitors AFINITOR DIS TAB 2MG 5 PA AFINITOR DIS TAB 3MG 5 PA AFINITOR DIS TAB 5MG 5 PA AFINITOR TAB 2.5MG 5 PA AFINITOR TAB 5MG 5 PA AFINITOR TAB 7.5MG 5 PA AFINITOR TAB 10MG 5 PA BOSULIF TAB 100MG 5 PA BOSULIF TAB 500MG 5 PA CAPRELSA TAB 100MG 5 PA CAPRELSA TAB 300MG 5 PA COMETRIQ KIT 60MG 5 PA COMETRIQ KIT 100MG 5 PA COMETRIQ KIT 140MG 5 PA FARYDAK CAP 10MG 5 PA FARYDAK CAP 15MG 5 PA FARYDAK CAP 20MG 5 PA GLEEVEC TAB 100MG 5 PA GLEEVEC TAB 400MG 5 PA IBRANCE CAP 75MG 5 PA IBRANCE CAP 100MG 5 PA IBRANCE CAP 125MG 5 PA ICLUSIG TAB 15MG 5 PA ICLUSIG TAB 45MG 5 PA imatinib mesylate tab 100 mg (base 5 PA equivalent) imatinib mesylate tab 400 mg (base 5 PA equivalent) IMBRUVICA CAP 140MG 5 PA INLYTA TAB 1MG 5 PA INLYTA TAB 5MG 5 PA JAKAFI TAB 5MG 5 PA JAKAFI TAB 10MG 5 PA JAKAFI TAB 15MG 5 PA JAKAFI TAB 20MG 5 PA JAKAFI TAB 25MG 5 PA LENVIMA CAP 10MG 5 PA LENVIMA CAP 14MG 5 PA LENVIMA CAP 20MG 5 PA LENVIMA CAP 24MG 5 PA LYNPARZA CAP 50MG 5 PA MEKINIST TAB 0.5MG 5 PA 51

65 MEKINIST TAB 2MG 5 PA NEXAVAR TAB 200MG 5 PA SPRYCEL TAB 20MG 5 PA SPRYCEL TAB 50MG 5 PA SPRYCEL TAB 70MG 5 PA SPRYCEL TAB 80MG 5 PA SPRYCEL TAB 100MG 5 PA SPRYCEL TAB 140MG 5 PA STIVARGA TAB 40MG 5 PA SUTENT CAP 12.5MG 5 PA SUTENT CAP 25MG 5 PA SUTENT CAP 37.5MG 5 PA SUTENT CAP 50MG 5 PA TAFINLAR CAP 50MG 5 PA TAFINLAR CAP 75MG 5 PA TARCEVA TAB 25MG 5 PA TARCEVA TAB 100MG 5 PA TARCEVA TAB 150MG 5 PA TORISEL SOL 25MG/ML 5 PA TYKERB TAB 250MG 5 PA VOTRIENT TAB 200MG 5 PA XALKORI CAP 200MG 5 PA XALKORI CAP 250MG 5 PA ZELBORAF TAB 240MG 5 PA ZOLINZA CAP 100MG 5 PA ZYDELIG TAB 100MG 5 PA ZYDELIG TAB 150MG 5 PA ZYKADIA CAP 150MG 5 PA Antineoplastic Enzymes ONCASPAR INJ 750/ML 5 PA Antineoplastic Radiopharmaceuticals QUADRAMET INJ 3 Antineoplastics - Immunomodulators POMALYST CAP 1MG 5 PA POMALYST CAP 2MG 5 PA POMALYST CAP 3MG 5 PA POMALYST CAP 4MG 5 PA Antineoplastics Misc. ACTIMMUNE INJ 2MU/0.5 5 PA ALFERON N INJ 5MU/ML 5 PA bexarotene cap 75 mg 5 PA dacarbazine for inj 100 mg 2 dacarbazine for inj 200 mg 2 52

66 hydroxyurea cap 500 mg 2 INTRON A INJ 10MU 5 PA INTRON A INJ 18MU 5 PA INTRON A INJ 25MU 5 PA INTRON A INJ 50MU 5 PA MATULANE CAP 50MG 3 NIPENT INJ 10MG 3 PHOTOFRIN INJ 75MG 3 SYNRIBO INJ 3.5MG 5 PA THERACYS INJ 3 TICE BCG INJ 3 tretinoin cap 10 mg 2 TRISENOX SOL 10MG/10M 3 UVADEX INJ 20MCG/ML 3 Chemotherapy Adjuncts KEPIVANCE INJ 6.25MG 3 Chemotherapy Rescue/Antidote Agents amifostine crystalline for inj 500 mg 2 dexrazoxane for inj 250 mg 2 dexrazoxane for inj 500 mg 2 leucovorin calcium for inj 50 mg 2 leucovorin calcium for inj 100 mg 2 leucovorin calcium for inj 200 mg 2 leucovorin calcium for inj 350 mg 2 leucovorin calcium tab 5 mg 2 leucovorin calcium tab 10 mg 2 leucovorin calcium tab 15 mg 2 leucovorin calcium tab 25 mg 2 LEUCOVORIN INJ CALCIUM 3 mesna inj 100 mg/ml 2 MESNEX TAB 400MG 3 Mitotic Inhibitors ABRAXANE INJ 100MG 3 DOCEFREZ INJ 20MG 3 DOCEFREZ INJ 80MG 3 docetaxel for inj conc 20 mg/ml 2 docetaxel for inj conc 80 mg/4ml (20 2 mg/ml) DOCETAXEL INJ 20/0.5ML 3 DOCETAXEL INJ 20MG/2ML 3 DOCETAXEL INJ 80MG/2ML 3 DOCETAXEL INJ 80MG/8ML 3 DOCETAXEL INJ 140/7ML 3 53

67 DOCETAXEL INJ 160/8ML 3 DOCETAXEL INJ 160/16ML 3 DOCETAXEL INJ 200MG/20 3 DOCETAXEL INJ NON-ALC 3 DOCETAXEL INJ NON-ALCO 3 ETOPOPHOS INJ 100MG 3 etoposide cap 50 mg 2 etoposide inj 100 mg/5ml (20 mg/ml) 2 paclitaxel iv conc 30 mg/5ml (6 mg/ml) 2 paclitaxel iv conc 100 mg/16.7ml (6 2 mg/ml) paclitaxel iv conc 150 mg/25ml (6 mg/ml) 2 paclitaxel iv conc 300 mg/50ml (6 mg/ml) 2 TENIPOSIDE INJ 50MG/5ML 3 toposar inj 20mg/ml 2 toposar inj 100/5ml 2 VINBLASTINE INJ 10MG 3 vinblastine sulfate inj 1 mg/ml 2 vincasar pfs inj 1mg/ml 2 vincristine sulfate iv soln 1 mg/ml 2 vinorelbine tartrate inj 10 mg/ml (base 2 equiv) vinorelbine tartrate inj 50 mg/5ml (10 2 mg/ml) (base equiv) Topoisomerase I Inhibitors CAMPTOSAR INJ 300/15ML 3 HYCAMTIN CAP 0.25MG 5 PA HYCAMTIN CAP 1MG 5 PA irinotecan hcl inj 40 mg/2ml (20 mg/ml) 2 irinotecan hcl inj 100 mg/5ml (20 mg/ml) 2 irinotecan hcl inj 500 mg/25ml (20 mg/ml) 2 topotecan hcl for inj 4 mg 2 TOPOTECAN INJ 4MG/4ML 3 ANTIPARKINSON AGENTS Antiparkinson Adjuvants carbidopa tab 25 mg 2 Antiparkinson Anticholinergics benztropine mesylate inj 1 mg/ml 2 benztropine mesylate tab 0.5 mg 2 benztropine mesylate tab 1 mg 2 benztropine mesylate tab 2 mg 2 trihexyphenidyl hcl elixir 0.4 mg/ml 2 trihexyphenidyl hcl tab 2 mg 2 54

68 trihexyphenidyl hcl tab 5 mg 2 Antiparkinson COMT Inhibitors entacapone tab 200 mg 2 tolcapone tab 100 mg 2 Antiparkinson Dopaminergics amantadine hcl cap 100 mg 2 amantadine hcl syrup 50 mg/5ml 2 amantadine hcl tab 100 mg 2 APOKYN INJ 10MG/ML 5 PA bromocriptine mesylate cap 5 mg 2 bromocriptine mesylate tab 2.5 mg 2 carbidopa & levodopa orally disintegrating 2 tab mg carbidopa & levodopa orally disintegrating 2 tab mg carbidopa & levodopa orally disintegrating 2 tab mg carbidopa & levodopa tab mg 2 carbidopa & levodopa tab mg 2 carbidopa & levodopa tab mg 2 carbidopa & levodopa tab cr mg 2 carbidopa & levodopa tab cr mg 2 carbidopa-levodopa-entacapone tabs mg carbidopa-levodopa-entacapone tabs mg carbidopa-levodopa-entacapone tabs mg carbidopa-levodopa-entacapone tabs mg carbidopa-levodopa-entacapone tabs mg carbidopa-levodopa-entacapone tabs mg MIRAPEX ER TAB 2.25MG 3 MIRAPEX ER TAB 3.75MG 3 pramipexole dihydrochloride tab 0.5 mg 2 pramipexole dihydrochloride tab 0.25 mg 2 pramipexole dihydrochloride tab 0.75 mg 2 pramipexole dihydrochloride tab mg 2 pramipexole dihydrochloride tab 1 mg 2 pramipexole dihydrochloride tab 1.5 mg 2 pramipexole dihydrochloride tab sr 24hr mg pramipexole dihydrochloride tab sr 24hr mg 55

69 pramipexole dihydrochloride tab sr 24hr mg pramipexole dihydrochloride tab sr 24hr mg pramipexole dihydrochloride tab sr 24hr 3 2 mg pramipexole dihydrochloride tab sr 24hr mg ropinirole hydrochloride tab 0.5 mg 2 ropinirole hydrochloride tab 0.25 mg 2 ropinirole hydrochloride tab 1 mg 2 ropinirole hydrochloride tab 2 mg 2 ropinirole hydrochloride tab 3 mg 2 ropinirole hydrochloride tab 4 mg 2 ropinirole hydrochloride tab 5 mg 2 Antiparkinson Monoamine Oxidase Inhibitors AZILECT TAB 0.5MG 3 AZILECT TAB 1MG 3 selegiline hcl cap 5 mg 2 selegiline hcl tab 5 mg 2 ZELAPAR TAB 1.25MG 4 ANTIPSYCHOTICS/ANTIMANIC AGENTS Antimanic Agents lithium carbonate cap 150 mg 2 lithium carbonate cap 300 mg 2 lithium carbonate cap 600 mg 2 lithium carbonate tab 300 mg 2 lithium carbonate tab cr 300 mg 2 lithium carbonate tab cr 450 mg 2 LITHIUM SOL 8MEQ/5ML 4 Antipsychotics - Misc. GEODON INJ 20MG 4 LATUDA TAB 20MG 3 ST; PA** LATUDA TAB 40MG 3 ST; PA** LATUDA TAB 60MG 3 ST; PA** LATUDA TAB 80MG 3 ST; PA** LATUDA TAB 120MG 3 ST; PA** ziprasidone hcl cap 20 mg 2 ziprasidone hcl cap 40 mg 2 ziprasidone hcl cap 60 mg 2 ziprasidone hcl cap 80 mg 2 Benzisoxazoles FANAPT PAK 4 ST; PA** 56

70 FANAPT TAB 1MG 4 ST; PA** FANAPT TAB 2MG 4 ST; PA** FANAPT TAB 4MG 4 ST; PA** FANAPT TAB 6MG 4 ST; PA** FANAPT TAB 8MG 4 ST; PA** FANAPT TAB 10MG 4 ST; PA** FANAPT TAB 12MG 4 ST; PA** INVEGA SUST INJ 39/ INVEGA SUST INJ 78/0.5ML 4 INVEGA SUST INJ 117/ INVEGA SUST INJ 156MG/ML 4 INVEGA SUST INJ 234/1.5 4 INVEGA TAB 1.5MG 4 ST; PA** INVEGA TAB 3MG 4 ST; PA** INVEGA TAB 6MG 4 ST; PA** INVEGA TAB 9MG 4 ST; PA** paliperidone tab sr 24hr 1.5 mg 2 paliperidone tab sr 24hr 3 mg 2 paliperidone tab sr 24hr 6 mg 2 paliperidone tab sr 24hr 9 mg 2 RISPERDAL INJ 12.5MG 3 PA RISPERDAL INJ 25MG 3 PA RISPERDAL INJ 37.5MG 3 PA RISPERDAL INJ 50MG 3 PA risperidone orally disintegrating tab 0.5 mg 2 risperidone orally disintegrating tab mg risperidone orally disintegrating tab 1 mg 2 risperidone orally disintegrating tab 2 mg 2 risperidone orally disintegrating tab 3 mg 2 risperidone orally disintegrating tab 4 mg 2 risperidone soln 1 mg/ml 2 risperidone tab 0.5 mg 2 risperidone tab 0.25 mg 2 risperidone tab 1 mg 2 risperidone tab 2 mg 2 risperidone tab 3 mg 2 risperidone tab 4 mg 2 Butyrophenones haloperidol decanoate im soln 50 mg/ml 2 haloperidol decanoate im soln 100 mg/ml 2 haloperidol lactate inj 5 mg/ml 2 haloperidol lactate oral conc 2 mg/ml 2 57

71 haloperidol tab 0.5 mg 2 haloperidol tab 1 mg 2 haloperidol tab 2 mg 2 haloperidol tab 5 mg 2 haloperidol tab 10 mg 2 haloperidol tab 20 mg 2 Dibenzapines clozapine orally disintegrating tab 12.5 mg 2 clozapine orally disintegrating tab 25 mg 2 clozapine orally disintegrating tab 100 mg 2 clozapine orally disintegrating tab 150 mg 2 clozapine orally disintegrating tab 200 mg 2 clozapine tab 25 mg 2 clozapine tab 50 mg 2 clozapine tab 100 mg 2 clozapine tab 200 mg 2 loxapine succinate cap 5 mg 2 loxapine succinate cap 10 mg 2 loxapine succinate cap 25 mg 2 loxapine succinate cap 50 mg 2 olanzapine for im inj 10 mg 2 olanzapine orally disintegrating tab 5 mg 2 olanzapine orally disintegrating tab 10 mg 2 olanzapine orally disintegrating tab 15 mg 2 olanzapine orally disintegrating tab 20 mg 2 olanzapine tab 2.5 mg 2 olanzapine tab 5 mg 2 olanzapine tab 7.5 mg 2 olanzapine tab 10 mg 2 olanzapine tab 15 mg 2 olanzapine tab 20 mg 2 quetiapine fumarate tab 25 mg 2 quetiapine fumarate tab 50 mg 2 quetiapine fumarate tab 100 mg 2 quetiapine fumarate tab 200 mg 2 quetiapine fumarate tab 300 mg 2 quetiapine fumarate tab 400 mg 2 SAPHRIS SUB 2.5MG 4 ST; PA** SAPHRIS SUB 5MG 4 ST; PA** SAPHRIS SUB 10MG 4 ST; PA** SEROQUEL XR TAB 50MG 3 ST; PA** SEROQUEL XR TAB 150MG 3 ST; PA** SEROQUEL XR TAB 200MG 3 ST; PA** 58

72 SEROQUEL XR TAB 300MG 3 ST; PA** SEROQUEL XR TAB 400MG 3 ST; PA** Phenothiazines CHLORPROMAZ INJ 25MG/ML 4 CHLORPROMAZ INJ 50MG/2ML 4 chlorpromazine hcl tab 10 mg 2 chlorpromazine hcl tab 25 mg 2 chlorpromazine hcl tab 50 mg 2 chlorpromazine hcl tab 100 mg 2 chlorpromazine hcl tab 200 mg 2 compro sup 25mg 2 fluphenazine decanoate inj 25 mg/ml 2 fluphenazine hcl elixir 2.5 mg/5ml 2 fluphenazine hcl inj 2.5 mg/ml 2 fluphenazine hcl oral conc 5 mg/ml 2 fluphenazine hcl tab 1 mg 2 fluphenazine hcl tab 2.5 mg 2 fluphenazine hcl tab 5 mg 2 fluphenazine hcl tab 10 mg 2 perphenazine tab 2 mg 2 perphenazine tab 4 mg 2 perphenazine tab 8 mg 2 perphenazine tab 16 mg 2 prochlorperazine edisylate inj 5 mg/ml 2 prochlorperazine maleate tab 5 mg (base 2 equivalent) prochlorperazine maleate tab 10 mg (base 2 equivalent) prochlorperazine suppos 25 mg 2 thioridazine hcl tab 10 mg 2 thioridazine hcl tab 25 mg 2 thioridazine hcl tab 50 mg 2 thioridazine hcl tab 100 mg 2 trifluoperazine hcl tab 1 mg 2 trifluoperazine hcl tab 2 mg 2 trifluoperazine hcl tab 5 mg 2 trifluoperazine hcl tab 10 mg 2 Quinolinone Derivatives ABILIFY DISC TAB 10MG 3 ABILIFY DISC TAB 15MG 3 aripiprazole oral solution 1 mg/ml 2 aripiprazole tab 2 mg 2 aripiprazole tab 5 mg 2 59

73 aripiprazole tab 10 mg 2 ARIPIPRAZOLE TAB 10MG ODT 3 aripiprazole tab 15 mg 2 ARIPIPRAZOLE TAB 15MG ODT 3 aripiprazole tab 20 mg 2 aripiprazole tab 30 mg 2 Thioxanthenes thiothixene cap 1 mg 2 thiothixene cap 2 mg 2 thiothixene cap 5 mg 2 thiothixene cap 10 mg 2 ANTISEPTICS DISINFECTANTS Antiseptic Combinations IV PREP WIPE PAD 3 Chlorine Antiseptics PHISOHEX LIQ 3% 4 ANTIVIRALS Antiretrovirals abacavir sulfate tab 300 mg (base equiv) 2 abacavir sulfate-lamivudine-zidovudine tab mg APTIVUS CAP 250MG 3 APTIVUS SOL 3 ATRIPLA TAB 3 COMPLERA TAB 3 CRIXIVAN CAP 200MG 3 CRIXIVAN CAP 400MG 3 didanosine delayed release capsule 125 mg2 didanosine delayed release capsule 200 mg2 didanosine delayed release capsule 250 mg2 didanosine delayed release capsule 400 mg2 EDURANT TAB 25MG 3 EMTRIVA CAP 200MG 3 EMTRIVA SOL 10MG/ML 3 EPZICOM TAB EVOTAZ TAB FUZEON INJ 90MG 5 PA GENVOYA TAB 3 INTELENCE TAB 25MG 3 INTELENCE TAB 100MG 3 INTELENCE TAB 200MG 3 INVIRASE CAP 200MG 3 60

74 INVIRASE TAB 500MG 3 ISENTRESS CHW 25MG 3 ISENTRESS CHW 100MG 3 ISENTRESS POW 100MG 3 ISENTRESS TAB 400MG 3 KALETRA SOL 3 KALETRA TAB MG 3 KALETRA TAB MG 3 lamivudine oral soln 10 mg/ml 2 lamivudine tab 150 mg 2 lamivudine tab 300 mg 2 lamivudine-zidovudine tab mg 2 LEXIVA SUS 50MG/ML 3 LEXIVA TAB 700MG 3 nevirapine susp 50 mg/5ml 2 nevirapine tab 200 mg 2 nevirapine tab sr 24hr 100 mg 2 nevirapine tab sr 24hr 400 mg 2 NORVIR CAP 100MG 3 NORVIR SOL 80MG/ML 3 NORVIR TAB 100MG 3 PREZCOBIX TAB PREZISTA SUS 100MG/ML 3 PREZISTA TAB 75MG 3 PREZISTA TAB 150MG 3 PREZISTA TAB 400MG 3 PREZISTA TAB 600MG 3 PREZISTA TAB 800MG 3 RESCRIPTOR TAB 100 MG 3 RESCRIPTOR TAB 200MG 3 RETROVIR INJ 10MG/ML 3 REYATAZ CAP 100MG 3 REYATAZ CAP 150MG 3 REYATAZ CAP 200MG 3 REYATAZ CAP 300MG 3 REYATAZ POW 50MG 3 SELZENTRY TAB 150MG 3 SELZENTRY TAB 300MG 3 stavudine cap 15 mg 2 stavudine cap 20 mg 2 stavudine cap 30 mg 2 stavudine cap 40 mg 2 stavudine for oral soln 1 mg/ml 2 61

75 STRIBILD TAB 3 SUSTIVA CAP 50MG 3 SUSTIVA CAP 200MG 3 SUSTIVA TAB 600MG 3 TIVICAY TAB 50MG 3 TRIUMEQ TAB 3 TRUVADA TAB TYBOST TAB 150MG 3 VIDEX SOL 2GM 3 VIDEX SOL 4GM 3 VIRACEPT TAB 250MG 3 VIRACEPT TAB 625MG 3 VIRAMUNE XR TAB 100MG 3 VIREAD POW 40MG/GM 3 VIREAD TAB 150MG 3 VIREAD TAB 200MG 3 VIREAD TAB 250MG 3 VIREAD TAB 300MG 3 VITEKTA TAB 85MG 3 VITEKTA TAB 150MG 3 ZIAGEN SOL 20MG/ML 3 zidovudine cap 100 mg 2 zidovudine syrup 10 mg/ml 2 zidovudine tab 300 mg 2 CMV Agents cidofovir iv inj 75 mg/ml 2 foscarnet sodium inj 24 mg/ml 2 VALCYTE SOL 50MG/ML 4 valganciclovir hcl tab 450 mg (base 2 equivalent) Hepatitis Agents adefovir dipivoxil tab 10 mg 2 PA BARACLUDE SOL.05MG/ML 3 entecavir tab 0.5 mg 2 entecavir tab 1 mg 2 EPIVIR HBV SOL 5MG/ML 3 HARVONI TAB MG 5 PA INFERGEN INJ 9MCG 5 PA INFERGEN INJ 15MCG 5 PA lamivudine tab 100 mg (hbv) 2 PEGASYS INJ 5 PA PEGASYS INJ 180MCG/M 5 PA PEGASYS INJ PROCLICK 5 PA 62

76 PEGASYS KIT 5 PA REBETOL SOL 40MG/ML 5 PA ribasphere cap 200mg 2 PA ribasphere tab 200mg 2 PA ribasphere tab 400mg 2 PA ribasphere tab 600mg 2 PA ribavirin cap 200 mg 2 PA ribavirin tab 200 mg 2 PA SOVALDI TAB 400MG 5 PA TYZEKA TAB 600MG 5 PA Herpes Agents acyclovir cap 200 mg 2 acyclovir sodium for inj 500 mg 2 acyclovir sodium for inj 1000 mg 2 acyclovir sodium iv soln 50 mg/ml 2 acyclovir susp 200 mg/5ml 2 acyclovir tab 400 mg 2 acyclovir tab 800 mg 2 famciclovir tab 125 mg 2 famciclovir tab 250 mg 2 famciclovir tab 500 mg 2 valacyclovir hcl tab 1 gm 2 valacyclovir hcl tab 500 mg 2 Influenza Agents RELENZA MIS DISKHALE 3 QL (2 inhalers / 90 days) rimantadine hydrochloride tab 100 mg 2 TAMIFLU CAP 30MG 3 QL (28 caps / 90 days) TAMIFLU CAP 45MG 3 QL (14 caps / 90 days) TAMIFLU CAP 75MG 3 QL (14 caps / 90 days) TAMIFLU SUS 6MG/ML 3 QL (180 ml / 90 days) Respiratory Syncytial Virus (RSV) Agents VIRAZOLE INH 6GM 4 ASSORTED CLASSES Chelating Agents DEPEN TITRA TAB 250MG 4 SYPRINE CAP 250MG 4 Immunomodulators REVLIMID CAP 2.5MG 5 PA REVLIMID CAP 5MG 5 PA REVLIMID CAP 10MG 5 PA REVLIMID CAP 15MG 5 PA 63

77 REVLIMID CAP 20MG 5 PA REVLIMID CAP 25MG 5 PA THALOMID CAP 50MG 5 PA THALOMID CAP 100MG 5 PA THALOMID CAP 150MG 5 PA THALOMID CAP 200MG 5 PA Immunosuppressive Agents ATGAM INJ 250MG 4 AZASAN TAB 75 MG 4 AZASAN TAB 100MG 4 azathioprine tab 50 mg 2 CELLCEPT IV INJ 500MG 4 cyclosporine cap 25 mg 2 cyclosporine cap 100 mg 2 cyclosporine iv soln 50 mg/ml 2 cyclosporine modified cap 25 mg 2 cyclosporine modified cap 50 mg 2 cyclosporine modified cap 100 mg 2 cyclosporine modified oral soln 100 mg/ml 2 gengraf cap 25mg 2 gengraf cap 100mg 2 gengraf sol 100mg/ml 2 mycophenolate mofetil cap 250 mg 2 mycophenolate mofetil for oral susp mg/ml mycophenolate mofetil tab 500 mg 2 mycophenolate sodium tab dr 180 mg 2 (mycophenolic acid equiv) mycophenolate sodium tab dr 360 mg 2 (mycophenolic acid equiv) NULOJIX INJ 250MG 4 PROGRAF INJ 5MG/ML 4 RAPAMUNE SOL 1MG/ML 3 SANDIMMUNE SOL 100MG/ML 4 SIMULECT INJ 10MG 4 SIMULECT INJ 20MG 4 sirolimus tab 0.5 mg 2 sirolimus tab 1 mg 2 sirolimus tab 2 mg 2 tacrolimus cap 0.5 mg 2 tacrolimus cap 1 mg 2 tacrolimus cap 5 mg 2 THYMOGLOBULN INJ 25MG 4 ZORTRESS TAB 0.5MG 3 64

78 ZORTRESS TAB 0.25MG 3 ZORTRESS TAB 0.75MG 3 Irrigation Solutions physiolyte sol 2 physiosol sol irrigat 2 tis-u-sol sol 2 Potassium Removing Resins kionex sus 15gm/60 2 sodium polystyrene sulfonate oral susp 15 2 gm/60ml sodium polystyrene sulfonate rectal susp 2 30 gm/120ml Systemic Lupus Erythematosus Agents BENLYSTA INJ 120MG 5 PA BENLYSTA INJ 400MG 5 PA BETA BLOCKERS Alpha-Beta Blockers carvedilol tab mg 2 carvedilol tab 6.25 mg 2 carvedilol tab 12.5 mg 2 carvedilol tab 25 mg 2 COREG CR CAP 10MG 4 COREG CR CAP 20MG 4 COREG CR CAP 40MG 4 COREG CR CAP 80MG 4 labetalol hcl iv soln 5 mg/ml 2 labetalol hcl tab 100 mg 2 labetalol hcl tab 200 mg 2 labetalol hcl tab 300 mg 2 Beta Blockers Cardio-Selective acebutolol hcl cap 200 mg 2 acebutolol hcl cap 400 mg 2 atenolol tab 25 mg 2 atenolol tab 50 mg 2 atenolol tab 100 mg 2 betaxolol hcl tab 10 mg 2 betaxolol hcl tab 20 mg 2 bisoprolol fumarate tab 5 mg 2 bisoprolol fumarate tab 10 mg 2 BYSTOLIC TAB 2.5MG 4 BYSTOLIC TAB 5MG 4 BYSTOLIC TAB 10MG 4 BYSTOLIC TAB 20MG 4 65

79 metoprolol succinate tab sr 24hr 25 mg 2 (tartrate equiv) metoprolol succinate tab sr 24hr 50 mg 2 (tartrate equiv) metoprolol succinate tab sr 24hr 100 mg 2 (tartrate equiv) metoprolol succinate tab sr 24hr 200 mg 2 (tartrate equiv) metoprolol tartrate inj 1 mg/ml 2 metoprolol tartrate tab 25 mg 2 metoprolol tartrate tab 50 mg 2 metoprolol tartrate tab 100 mg 2 Beta Blockers Non-Selective LEVATOL TAB 20MG 4 nadolol tab 20 mg 2 nadolol tab 40 mg 2 nadolol tab 80 mg 2 pindolol tab 5 mg 2 pindolol tab 10 mg 2 propranolol hcl cap sr 24hr 60 mg 2 propranolol hcl cap sr 24hr 80 mg 2 propranolol hcl cap sr 24hr 120 mg 2 propranolol hcl cap sr 24hr 160 mg 2 propranolol hcl inj 1 mg/ml 2 propranolol hcl oral soln 20 mg/5ml 2 propranolol hcl oral soln 40 mg/5ml 2 propranolol hcl tab 10 mg 2 propranolol hcl tab 20 mg 2 propranolol hcl tab 40 mg 2 propranolol hcl tab 60 mg 2 propranolol hcl tab 80 mg 2 sorine tab 80mg 2 sorine tab 120mg 2 sorine tab 160mg 2 sorine tab 240mg 2 sotalol hcl (afib/afl) tab 80 mg 2 sotalol hcl (afib/afl) tab 120 mg 2 sotalol hcl (afib/afl) tab 160 mg 2 SOTALOL HCL INJ 150/10ML 4 sotalol hcl tab 80 mg 2 sotalol hcl tab 120 mg 2 sotalol hcl tab 160 mg 2 sotalol hcl tab 240 mg 2 timolol maleate tab 5 mg 2 66

80 timolol maleate tab 10 mg 2 timolol maleate tab 20 mg 2 BIOLOGICALS MISC Biologicals Misc ADAGEN INJ 250/ML 5 PA CALCIUM CHANNEL BLOCKERS Calcium Channel Blockers afeditab tab 30mg cr 2 afeditab tab 60mg cr 2 amlodipine besylate tab 2.5 mg 2 amlodipine besylate tab 5 mg 2 amlodipine besylate tab 10 mg 2 CARDENE IV INJ 40/200ML 4 CARDENE IV SOL 20/200ML 4 CARDIZEM LA TAB 120MG 3 cartia xt cap 120/24hr 2 cartia xt cap 180/24hr 2 cartia xt cap 240/24hr 2 cartia xt cap 300/24hr 2 diltiazem hcl cap sr 12hr 60 mg 2 diltiazem hcl cap sr 12hr 90 mg 2 diltiazem hcl cap sr 12hr 120 mg 2 diltiazem hcl cap sr 24hr 120 mg 2 diltiazem hcl cap sr 24hr 180 mg 2 diltiazem hcl cap sr 24hr 240 mg 2 diltiazem hcl coated beads cap sr 24hr mg diltiazem hcl coated beads cap sr 24hr mg diltiazem hcl coated beads cap sr 24hr mg diltiazem hcl coated beads cap sr 24hr mg diltiazem hcl coated beads cap sr 24hr mg diltiazem hcl extended release beads cap sr2 24hr 120 mg diltiazem hcl extended release beads cap sr2 24hr 180 mg diltiazem hcl extended release beads cap sr2 24hr 240 mg diltiazem hcl extended release beads cap sr2 24hr 300 mg diltiazem hcl extended release beads cap sr2 24hr 360 mg 67

81 diltiazem hcl extended release beads cap sr2 24hr 420 mg diltiazem hcl iv soln 25 mg/5ml (5 mg/ml) 2 diltiazem hcl iv soln 50 mg/10ml (5 2 mg/ml) diltiazem hcl iv soln 125 mg/25ml (5 2 mg/ml) diltiazem hcl tab 30 mg 2 diltiazem hcl tab 60 mg 2 diltiazem hcl tab 90 mg 2 diltiazem hcl tab 120 mg 2 DILTIAZEM INJ 100MG 4 felodipine tab sr 24hr 2.5 mg 2 felodipine tab sr 24hr 5 mg 2 felodipine tab sr 24hr 10 mg 2 isradipine cap 2.5 mg 2 isradipine cap 5 mg 2 matzim la tab 180mg/24 2 matzim la tab 240mg/24 2 matzim la tab 300mg/24 2 matzim la tab 360mg/24 2 matzim la tab 420mg/24 2 nicardipine hcl cap 20 mg 2 nicardipine hcl cap 30 mg 2 nicardipine hcl iv soln 2.5 mg/ml 2 nifedical xl tab 30mg 2 nifedical xl tab 60mg 2 nifedipine tab sr 24hr 30 mg 2 nifedipine tab sr 24hr 60 mg 2 nifedipine tab sr 24hr 90 mg 2 nifedipine tab sr 24hr osmotic release 30 2 mg nifedipine tab sr 24hr osmotic release 60 2 mg nifedipine tab sr 24hr osmotic release 90 2 mg nimodipine cap 30 mg 2 nisoldipine tab sr 24hr 8.5 mg 2 nisoldipine tab sr 24hr 17 mg 2 nisoldipine tab sr 24hr 20 mg 2 nisoldipine tab sr 24hr 25.5 mg 2 nisoldipine tab sr 24hr 30 mg 2 nisoldipine tab sr 24hr 34 mg 2 nisoldipine tab sr 24hr 40 mg 2 taztia xt cap 120mg/

82 taztia xt cap 180mg/24 2 taztia xt cap 240mg/24 2 taztia xt cap 300mg/24 2 taztia xt cap 360mg/24 2 verapamil hcl cap sr 24hr 100 mg 2 verapamil hcl cap sr 24hr 120 mg 2 verapamil hcl cap sr 24hr 180 mg 2 verapamil hcl cap sr 24hr 200 mg 2 verapamil hcl cap sr 24hr 240 mg 2 verapamil hcl cap sr 24hr 300 mg 2 verapamil hcl cap sr 24hr 360 mg 2 verapamil hcl iv soln 2.5 mg/ml 2 verapamil hcl tab 40 mg 2 verapamil hcl tab 80 mg 2 verapamil hcl tab 120 mg 2 verapamil hcl tab cr 120 mg 2 verapamil hcl tab cr 180 mg 2 verapamil hcl tab cr 240 mg 2 CARDIOTONICS Cardiac Glycosides digox tab 0.25mg 2 digox tab 0.125mg 2 digoxin inj 0.25 mg/ml 2 digoxin oral soln 0.05 mg/ml 2 digoxin tab 125 mcg (0.125 mg) 2 digoxin tab 250 mcg (0.25 mg) 2 LANOXIN PED INJ 0.1MG/ML 4 LANOXIN TAB MG 3 LANOXIN TAB MG 3 CARDIOVASCULAR AGENTS - MISC. Cardiovascular Agents Misc. - Combinations amlodipine besylate-atorvastatin calcium 1 tab mg amlodipine besylate-atorvastatin calcium 1 tab mg amlodipine besylate-atorvastatin calcium 1 tab mg amlodipine besylate-atorvastatin calcium 1 tab 5-10 mg amlodipine besylate-atorvastatin calcium 1 tab 5-20 mg amlodipine besylate-atorvastatin calcium 1 tab 5-40 mg 69

83 amlodipine besylate-atorvastatin calcium 1 tab 5-80 mg amlodipine besylate-atorvastatin calcium 1 tab mg amlodipine besylate-atorvastatin calcium 1 tab mg amlodipine besylate-atorvastatin calcium 1 tab mg amlodipine besylate-atorvastatin calcium 1 tab mg Prostaglandin Vasodilators epoprostenol sodium for inj 0.5 mg 5 PA epoprostenol sodium for inj 1.5 mg 5 PA REMODULIN INJ 1MG/ML 5 PA REMODULIN INJ 2.5MG/ML 5 PA REMODULIN INJ 5MG/ML 5 PA REMODULIN INJ 10MG/ML 5 PA TYVASO START SOL 0.6MG/ML 5 PA VENTAVIS SOL 10MCG/ML 5 PA VENTAVIS SOL 20MCG/ML 5 PA Pulmonary Hypertension - Endothelin Receptor Antagonists LETAIRIS TAB 5MG 5 PA LETAIRIS TAB 10MG 5 PA TRACLEER TAB 62.5MG 5 PA TRACLEER TAB 125MG 5 PA Pulmonary Hypertension - Phosphodiesterase Inhibitors ADCIRCA TAB 20MG 5 PA, ST sildenafil citrate iv soln 10 mg/12.5ml 5 PA (base equivalent) sildenafil citrate tab 20 mg 5 PA CEPHALOSPORINS Cephalosporins - 1st Generation cefadroxil cap 500 mg 2 cefadroxil for susp 250 mg/5ml 2 cefadroxil for susp 500 mg/5ml 2 cefadroxil tab 1 gm 2 CEFAZOL/DEX SOL 1GM 4 CEFAZOL/DEX SOL 2GM 4 CEFAZOLIN INJ 1GM/50ML 4 cefazolin sodium for inj 1 gm 2 cefazolin sodium for inj 10 gm 2 cefazolin sodium for inj 20 gm 2 cefazolin sodium for inj 500 mg 2 cefazolin sodium for iv soln 1 gm 2 70

84 CEFAZOLIN SOL 4 cephalexin cap 250 mg 2 cephalexin cap 500 mg 2 cephalexin cap 750 mg 2 cephalexin for susp 125 mg/5ml 2 cephalexin for susp 250 mg/5ml 2 cephalexin tab 250 mg 2 cephalexin tab 500 mg 2 Cephalosporins - 2nd Generation cefaclor cap 250 mg 2 cefaclor cap 500 mg 2 CEFACLOR ER TAB 500MG 3 cefaclor for susp 125 mg/5ml 2 cefaclor for susp 250 mg/5ml 2 cefaclor for susp 375 mg/5ml 2 CEFOTET/DEX INJ % 4 CEFOTET/DEX INJ % 4 cefotetan disodium for inj 1 gm 2 cefotetan disodium for inj 2 gm 2 cefotetan disodium for inj 10 gm 2 CEFOXITIN INJ 1GM 4 CEFOXITIN INJ 2GM 4 cefoxitin sodium for inj 10 gm 2 cefoxitin sodium for iv soln 1 gm 2 cefoxitin sodium for iv soln 2 gm 2 cefprozil for susp 125 mg/5ml 2 cefprozil for susp 250 mg/5ml 2 cefprozil tab 250 mg 2 cefprozil tab 500 mg 2 CEFTIN SUS 125/5ML 3 CEFTIN SUS 250/5ML 3 CEFUROX/DEXT INJ 1.5GM 4 CEFUROX/DEXT INJ 750MG 4 cefuroxime axetil tab 250 mg 2 cefuroxime axetil tab 500 mg 2 CEFUROXIME INJ 7.5GM 4 CEFUROXIME INJ 75GM 4 CEFUROXIME INJ 225GM 4 cefuroxime sodium for inj 1.5 gm 2 cefuroxime sodium for inj 7.5 gm 2 cefuroxime sodium for inj 750 mg 2 cefuroxime sodium for iv soln 1.5 gm 2 MEFOXIN INJ 1GM/50ML 4 71

85 MEFOXIN INJ 2GM/50ML 4 ZINACEF INJ 750MG 4 ZINACEF/H20 INJ 1.5GM PB 4 Cephalosporins - 3rd Generation CEDAX SUS 90MG/5ML 4 cefdinir cap 300 mg 2 cefdinir for susp 125 mg/5ml 2 cefdinir for susp 250 mg/5ml 2 cefditoren pivoxil tab 200 mg (base 2 equivalent) cefditoren pivoxil tab 400 mg (base 2 equivalent) cefixime for susp 100 mg/5ml 2 cefixime for susp 200 mg/5ml 2 cefotaxime sodium for inj 1 gm 2 cefotaxime sodium for inj 2 gm 2 cefotaxime sodium for inj 10 gm 2 cefotaxime sodium for inj 500 mg 2 cefpodoxime proxetil for susp 50 mg/5ml 2 cefpodoxime proxetil for susp 100 mg/5ml 2 cefpodoxime proxetil tab 100 mg 2 cefpodoxime proxetil tab 200 mg 2 ceftazidime for inj 2 gm 2 CEFTAZIDIME INJ 100GM 4 CEFTAZIDIME/ SOL D5W 1GM 4 CEFTAZIDIME/ SOL D5W 2GM 4 ceftibuten cap 400 mg 2 ceftibuten for susp 180 mg/5ml 2 ceftriaxone sodium for inj 1 gm 2 ceftriaxone sodium for inj 2 gm 2 ceftriaxone sodium for inj 10 gm 2 ceftriaxone sodium for inj 250 mg 2 ceftriaxone sodium for inj 500 mg 2 ceftriaxone sodium for iv soln 1 gm 2 ceftriaxone sodium for iv soln 2 gm 2 CLAFORAN INJ 1GM 4 CLAFORAN INJ 2GM 4 FORTAZ INJ 1GM 4 FORTAZ INJ 2GM 4 FORTAZ INJ 500MG 4 SUPRAX CAP 400MG 3 SUPRAX CHW 100MG 3 SUPRAX CHW 200MG 3 72

86 SUPRAX SUS 500/5ML 3 SUPRAX TAB 400MG 3 tazicef inj 1gm 2 tazicef inj 2gm 2 tazicef inj 6gm 2 Cephalosporins - 4th Generation cefepime hcl for inj 1 gm 2 cefepime hcl for inj 2 gm 2 CEFEPIME INJ 1GM 4 CEFEPIME INJ 2GM 4 MAXIPIME INJ 1GM 4 MAXIPIME INJ 2GM 4 Cephalosporins - 5th Generation TEFLARO INJ 400MG 4 TEFLARO INJ 600MG 4 CONTRACEPTIVES Combination Contraceptives - Oral altavera tab 0 alyacen tab 1/35 0 alyacen tab 7/7/7 0 amethia tab 0 amethyst tab 90-20mcg 0 apri tab 0 aranelle tab 0 aviane tab 0 azurette tab 28 day 0 BEYAZ TAB 0 caziant pak 0 cesia pak 0 chateal tab 0.15/30 0 cryselle-28 tab 28 tabs 0 cyclafem tab 1/35 0 cyclafem tab 7/7/7 0 dasetta tab 1/35 0 dasetta tab 7/7/7 0 drospirenone-ethinyl estradiol tab mg elinest tab 0 emoquette tab 0 enpresse-28 tab 0 falmina tab 0 gianvi tab mg 0 gildess fe tab 1.5/

87 gildess fe tab 1/20 0 gildess tab 1.5/30 0 gildess tab 1/20 0 introvale tab 0 jolessa tab 0 junel 1.5/30 tab 0 junel 1/20 tab 0 junel fe tab 1.5/30 0 junel fe tab 1/20 0 kariva tab 28 day 0 kelnor tab 1/35 0 kurvelo tab 0.15/30 0 leena tab 0 lessina tab 0 levonest tab 0 levonorg-eth est tab mg(84) & eth 0 est tab 0.01mg(7) levonorgestrel & ethinyl estradiol (91-day) 0 tab mg levonorgestrel & ethinyl estradiol tab mg-30 mcg levora-28 tab 0.15/30 0 LO LOESTRIN TAB 0 LO MINASTRIN PAK FE 0 lomedia 24 tab fe 0 loryna tab mg 0 low-ogestrel tab 0 lutera tab 0 marlissa tab 0.15/30 0 MINASTRIN 24 CHW FE 0 mono-linyah tab mononessa tab 0 myzilra tab 0 NATAZIA TAB 0 necon tab 0.5/35 0 necon tab 1/35 0 necon tab 1/ necon tab 7/7/7 0 NECON TAB 10/ norethindrone & ethinyl estradiol-fe chew 0 tab 0.8 mg-25 mcg norgestimate & ethinyl estradiol tab mg-35 mcg norgestimate-eth estrad tab / / mg-mcg 74

88 norgestimate-eth estrad tab / / mg-mcg nortrel tab 0.5/35 0 nortrel tab 1/35 0 nortrel tab 7/7/7 0 ocella tab mg 0 ogestrel tab 0 orsythia tab 0 ORTHO TRI- TAB CYCLN LO 0 portia-28 tab 0 previfem tab 0 QUARTETTE TAB 0 quasense tab 0 reclipsen tab 0 SAFYRAL TAB 0 solia tab 0 sprintec 28 tab 28 day 0 sronyx tab 0 syeda tab mg 0 tilia fe tab 0 tri-linyah tab 0 tri-previfem tab 0 tri-sprintec tab 0 trinessa tab 0 trivora-28 tab 0 velivet pak 0 vestura tab mg 0 viorele tab 0 wera tab 0.5/35 0 zarah tab mg 0 zenchent fe chw 0.4mg-35 0 zenchent tab 0 zovia 1/35e tab 0 zovia 1/50e tab 0 Combination Contraceptives - Transdermal xulane dis Combination Contraceptives - Vaginal NUVARING MIS 0 QL (13 / 300 days) Copper Contraceptives - IUD PARAGARD IUD T380A 0 QL (1 unit / 300 days) Emergency Contraceptives ELLA TAB 30MG 0 levonorgestrel tab 0.75 mg 0 75

89 levonorgestrel tab 1.5 mg 0 Progestin Contraceptives - IUD LILETTA IUD 52MG 0 QL (1 / 300 days) MIRENA IUD SYSTEM 0 QL (1 / 300 days) SKYLA IUD 13.5MG 0 QL (1 / 300 days) Progestin Contraceptives - Implants IMPLANON IMP 68MG 0 QL (1 / 300 days) NEXPLANON IMP 68MG 0 QL (1 / 300 days) Progestin Contraceptives - Injectable DEPO-SQ PROV INJ QL (4 inj / 300 days) medroxyprogesterone acetate im susp QL (4 inj / 300 days) mg/ml Progestin Contraceptives - Oral camila tab 0.35mg 0 errin tab 0.35mg 0 heather tab 0.35mg 0 jolivette tab 0.35mg 0 nora-be tab 0.35mg 0 norethindrone tab 0.35 mg 0 CORTICOSTEROIDS Glucocorticosteroids a-hydrocort inj 100mg 2 a-methapred inj 40mg 2 a-methapred inj 125mg 2 budesonide delayed release particles cap 3 2 mg cortisone acetate tab 25 mg 2 DEPO-MEDROL INJ 20MG/ML 4 DEXAMETHASON CON 1MG/ML 3 dexamethasone elixir 0.5 mg/5ml 2 dexamethasone sod phosphate 2 preservative free inj 10 mg/ml dexamethasone sodium phosphate inj 4 2 mg/ml dexamethasone sodium phosphate inj 10 2 mg/ml dexamethasone sodium phosphate inj 20 2 mg/5ml dexamethasone sodium phosphate inj mg/10ml dexamethasone sodium phosphate inj mg/30ml dexamethasone soln 0.5 mg/5ml 2 dexamethasone tab 0.5 mg 2 76

90 dexamethasone tab 0.75 mg 2 dexamethasone tab 1 mg 2 dexamethasone tab 1.5 mg 2 dexamethasone tab 2 mg 2 dexamethasone tab 4 mg 2 dexamethasone tab 6 mg 2 DEXPAK PAK 6 DAY 4 DEXPAK PAK 10 DAY 4 DEXPAK PAK 13 DAY 4 hydrocortisone tab 5 mg 2 hydrocortisone tab 10 mg 2 hydrocortisone tab 20 mg 2 MEDROL TAB 2MG 3 methylprednisolone acetate inj susp 40 2 mg/ml methylprednisolone acetate inj susp 80 2 mg/ml methylprednisolone sodium succinate for 2 inj 40 mg methylprednisolone sodium succinate for 2 inj 125 mg methylprednisolone sodium succinate for 2 inj 500 mg methylprednisolone sodium succinate for 2 inj 1000 mg methylprednisolone tab 4 mg 2 methylprednisolone tab 8 mg 2 methylprednisolone tab 16 mg 2 methylprednisolone tab 32 mg 2 methylprednisolone tab therapy pack 4 mg 2 (21) MILLIPRED DP PAK 5MG 4 MILLIPRED SOL 10MG/5ML 4 MILLIPRED TAB 5MG 4 prednisolone sod phos orally disintegr tab 2 10 mg (base eq) prednisolone sod phos orally disintegr tab 2 15 mg (base eq) prednisolone sod phos orally disintegr tab 2 30 mg (base eq) prednisolone sod phosph oral soln mg/5ml (5 mg/5ml base) prednisolone sod phosphate oral soln 15 2 mg/5ml (base equiv) prednisolone sodium phosphate oral soln 2 25 mg/5ml (base eq) 77

91 prednisolone syrup 15 mg/5ml (usp 2 solution equivalent) PREDNISONE CON 5MG/ML 3 prednisone oral soln 5 mg/5ml 2 prednisone tab 1 mg 2 prednisone tab 2.5 mg 2 prednisone tab 5 mg 2 prednisone tab 10 mg 2 prednisone tab 20 mg 2 prednisone tab 50 mg 2 prednisone tab therapy pack 5 mg (21) 2 prednisone tab therapy pack 5 mg (48) 2 prednisone tab therapy pack 10 mg (21) 2 prednisone tab therapy pack 10 mg (48) 2 SOLU-CORTEF INJ 100MG 4 SOLU-CORTEF INJ 250MG 4 SOLU-CORTEF INJ 500MG 4 SOLU-CORTEF INJ 1000MG 4 SOLU-MEDROL INJ 2GM 4 VERIPRED 20 SOL 20MG/5ML 4 Mineralocorticoids fludrocortisone acetate tab 0.1 mg 2 COUGH/COLD/ALLERGY Antitussives benzonatate cap 100 mg 2 benzonatate cap 200 mg 2 hydrocodone w/ homatropine syrup mg/5ml hydrocodone w/ homatropine tab mg 2 hydromet syp 5-1.5/5 2 tussigon tab 5-1.5mg 2 Cough/Cold/Allergy Combinations ALLFEN CDX LIQ 3 cheratussin syp /5 2 OTC NORTUSS-EX LIQ /5 3 prometh vc syp plain 2 prometh vc/ syp codeine 2 promethazine w/ codeine syrup mg/5ml promethazine-dm syrup mg/5ml 2 pseudoephed-bromphen-dm syrup mg/5ml tgq 50pse/3 syp brm/30dm 2 78

92 Misc. Respiratory Inhalants sodium chloride soln nebu 0.9% 2 sodium chloride soln nebu 3% 2 sodium chloride soln nebu 7% 2 sodium chloride soln nebu 10% 2 Mucolytics acetylcysteine inhal soln 10% 2 acetylcysteine inhal soln 20% 2 DERMATOLOGICALS Acne Products ACANYA GEL % 4 ST; PA** adapalene cream 0.1% 2 PA; PA applies for members age 35 and adapalene gel 0.1% 2 PA; PA applies for members age 35 and adapalene gel 0.3% 2 PA; PA applies for members age 35 and adapalene lotion 0.1% 2 PA; PA applies for members age 35 and AKNE-MYCIN OIN 2% 4 ST; PA** amnesteem cap 10mg 2 PA amnesteem cap 20mg 2 PA amnesteem cap 40mg 2 PA ATRALIN GEL 0.05% 4 PA; PA applies for members age 35 and avar cleanse emu 10-5% 2 avar-e emoll cre 10-5% 2 avar-e green cre 10-5% 2 avita cre 0.025% 2 PA; PA applies for members age 35 and avita gel 0.025% 2 PA; PA applies for members age 35 and AZELEX CRE 20% 4 ST; PA** BENZAMYCIN GEL PAK 3 benzepro aer 5.3% 2 BENZIQ GEL 5.25% 3 BENZIQ LS GEL 2.75% 3 benziq wash liq 5.25% 2 benzoyl per liq 10% wash 2 79

93 benzoyl peroxide foam 5.3% 2 benzoyl peroxide foam 9.8% 2 benzoyl peroxide-erythromycin gel 5-3% 2 bp wash liq 2.5% 2 bp wash liq 7% 2 BPO CLOTHS MIS 3% 3 bpo cloths mis 6% 2 BPO CLOTHS MIS 9% 3 BPO GEL 4% 3 BPO GEL 8% 3 cerisa wash emu 10-1% 2 claravis cap 10mg 2 PA claravis cap 20mg 2 PA claravis cap 30mg 2 PA claravis cap 40mg 2 PA clearplex x gel 10% 2 clindamax gel 1% 2 clindamax lot 10mg/ml 2 clindamycin phosph-benzoyl peroxide 2 (refrig) gel 1.2 (1)-5% clindamycin phosphate foam 1% 2 clindamycin phosphate gel 1% 2 clindamycin phosphate lotion 1% 2 clindamycin phosphate soln 1% 2 clindamycin phosphate swab 1% 2 clindamycin phosphate-benzoyl peroxide 2 gel 1-5% EPIDUO FORTE GEL % 4 EPIDUO GEL % 4 ery pad 2% 2 erythromycin gel 2% 2 erythromycin pads 2% 2 erythromycin soln 2% 2 myorisan cap 10mg 2 PA myorisan cap 20mg 2 PA myorisan cap 40mg 2 PA oscion clnsr lot 6% 2 pr benzoyl liq 7% wash 2 sss 10-5 aer 10-5% 2 sulfacetamide sodium lotion 10% (acne) 2 sulfacetamide sodium w/ sulfur cleanser % sulfacetamide sodium w/ sulfur cleanser 10-2% 2 80

94 sulfacetamide sodium w/ sulfur cleansing 2 cloth 10-5% sulfacetamide sodium w/ sulfur cleansing 2 pad 10-4% sulfacetamide sodium w/ sulfur cream % sulfacetamide sodium w/ sulfur cream % sulfacetamide sodium w/ sulfur cream % sulfacetamide sodium w/ sulfur lotion % sulfacetamide sodium w/ sulfur lotion % sulfacetamide sodium w/ sulfur wash 9-4% 2 sulfacetamide sodium w/ sulfur wash % sulfacleanse sus 8-4% 2 TRETIN-X CRE 0.075% 4 PA; PA applies for members age 35 and TRETIN-X CRE % 4 PA; PA applies for members age 35 and tretinoin cream 0.1% 2 PA; PA applies for members age 35 and tretinoin cream 0.05% 2 PA; PA applies for members age 35 and tretinoin cream 0.025% 2 PA; PA applies for members age 35 and tretinoin gel 0.01% 2 PA; PA applies for members age 35 and tretinoin gel 0.05% 2 PA; PA applies for members age 35 and tretinoin gel 0.025% 2 PA; PA applies for members age 35 and tretinoin microsphere gel 0.1% 2 PA; PA applies for members age 35 and tretinoin microsphere gel 0.04% 2 PA; PA applies for members age 35 and VELTIN GEL 4 PA; PA applies for members age 35 and 81

95 ZIANA GEL 4 PA; PA applies for members age 35 and Agents for External Genital and Perianal Warts VEREGEN OIN 15% 4 Anti-inflammatory Agents - Topical diclofenac sodium gel 1% 2 VOLTAREN GEL 1% 4 ST; PA** Antibiotics - Topical ALTABAX OIN 1% 4 CORTISPORIN CRE 0.5% 4 CORTISPORIN OIN 1% 4 gentamicin sulfate cream 0.1% 2 gentamicin sulfate oint 0.1% 2 mupirocin oint 2% 2 Antifungals - Topical ciclopirox gel 0.77% 2 ciclopirox kit 8% 2 ciclopirox olamine cream 0.77% (base 2 equiv) ciclopirox olamine susp 0.77% (base 2 equiv) ciclopirox shampoo 1% 2 ciclopirox solution 8% 2 clotrimazole cream 1% 2 CLOTRIMAZOLE CRY 4 clotrimazole soln 1% 2 clotrimazole w/ betamethasone cream % clotrimazole w/ betamethasone lotion % econazole nitrate cream 1% 2 ERTACZO CRE 2% 4 EXELDERM CRE 1% 4 EXELDERM SOL 1% 4 ketoconazole cream 2% 2 ketoconazole shampoo 2% 2 ketodan aer 2% 2 MENTAX CRE 1% 4 naftifine hcl cream 1% 2 naftifine hcl cream 2% 2 NAFTIN CRE 2% 4 NAFTIN GEL 1% 4 NAFTIN GEL 2% 4 82

96 nyamyc pow nystatin cream unit/gm 2 nystatin oint unit/gm 2 nystatin topical powder 2 nystatin-triamcinolone cream unit/gm-% nystatin-triamcinolone oint unit/gm-% nystop pow oxiconazole nitrate cream 1% 2 OXISTAT CRE 1% 4 OXISTAT LOT 1% 4 XOLEGEL GEL 2% 4 Antineoplastic or Premalignant Lesion Agents - Topical FLUOROPLEX CRE 1% 4 fluorouracil cream 0.5% 2 fluorouracil cream 5% 2 fluorouracil soln 2% 2 fluorouracil soln 5% 2 PANRETIN GEL 0.1% 4 PICATO GEL 0.05% 4 PICATO GEL 0.015% 4 TARGRETIN GEL 1% 5 PA Antipruritics - Topical doxepin hcl cream 5% 2 prudoxin cre 5% 2 Antipsoriatics acitretin cap 10 mg 2 acitretin cap 17.5 mg 2 acitretin cap 25 mg 2 calcipotriene cream 0.005% 2 calcipotriene oint 0.005% 2 calcipotriene soln 0.005% (50 mcg/ml) 2 calcitrene oin 0.005% 2 calcitriol oint 3 mcg/gm 2 methoxsalen rapid cap 10 mg 2 8-MOP CAP 10MG 4 STELARA INJ 45MG/0.5 6 PA, ST STELARA INJ 90MG/ML 6 PA, ST TAZORAC CRE 0.1% 3 PA TAZORAC CRE 0.05% 3 PA TAZORAC GEL 0.1% 3 PA TAZORAC GEL 0.05% 3 PA 83

97 Antiseborrheic Products selenium sulfide lotion 2.5% 2 selenium sulfide-pyrithione zinc in urea 2 shampoo 2.25% Antivirals - Topical acyclovir oint 5% 2 DENAVIR CRE 1% 4 Burn Products silver sulfadiazine cream 1% 2 ssd cre 1% 2 SULFAMYLON CRE 85MG/GM 4 Corticosteroids - Topical ala cort cre 1% 2 alclometasone dipropionate cream 0.05% 2 alclometasone dipropionate oint 0.05% 2 alphatrex gel 0.05% 2 amcinonide cream 0.1% 2 amcinonide lotion 0.1% 2 AMCINONIDE OIN 0.1% 3 apexicon oin 0.05% 2 betamethasone dipropionate augmented 2 cream 0.05% betamethasone dipropionate augmented 2 lotion 0.05% betamethasone dipropionate augmented 2 oint 0.05% betamethasone dipropionate cream 0.05% 2 betamethasone dipropionate lotion 0.05% 2 betamethasone dipropionate oint 0.05% 2 betamethasone valerate aerosol foam % betamethasone valerate cream 0.1% 2 betamethasone valerate lotion 0.1% 2 betamethasone valerate oint 0.1% 2 calcipotriene-betamethasone dipropionate 2 oint % CAPEX SHA 0.01% 4 clobetasol propionate cream 0.05% 2 clobetasol propionate foam 0.05% 2 clobetasol propionate gel 0.05% 2 clobetasol propionate lotion 0.05% 2 clobetasol propionate oint 0.05% 2 clobetasol propionate shampoo 0.05% 2 clobetasol propionate soln 0.05% 2 84

98 clobetasol propionate spray 0.05% 2 clocortolone pivalate cream 0.1% 2 CORDRAN 24X3 TAP 4MCG/CM 4 CORDRAN CRE 0.05% 4 CORDRAN LOT 0.05% 4 CORDRAN OIN 0.05% 4 DESONATE GEL 0.05% 4 desonide cream 0.05% 2 desonide lotion 0.05% 2 desonide oint 0.05% 2 DESOWEN OINT KIT 0.05% 4 desoximetasone cream 0.05% 2 desoximetasone cream 0.25% 2 desoximetasone gel 0.05% 2 desoximetasone oint 0.05% 2 desoximetasone oint 0.25% 2 diflorasone diacetate cream 0.05% 2 diflorasone diacetate oint 0.05% 2 fluocin acet oil 0.01% sc 2 fluocin acet oil body 2 fluocinolone acetonide cream 0.01% 2 fluocinolone acetonide cream 0.025% 2 fluocinolone acetonide oint 0.025% 2 fluocinolone acetonide soln 0.01% 2 fluocinonide cream 0.1% 2 fluocinonide cream 0.05% 2 fluocinonide gel 0.05% 2 fluocinonide oint 0.05% 2 fluocinonide soln 0.05% 2 fluticasone propionate cream 0.05% 2 fluticasone propionate lotion 0.05% 2 fluticasone propionate oint 0.005% 2 halobetasol propionate cream 0.05% 2 halobetasol propionate oint 0.05% 2 HALOG CRE 0.1% 4 HALOG OIN 0.1% 4 hydrocortisone butyrate cream 0.1% 2 hydrocortisone butyrate hydrophilic lipo 2 base cream 0.1% hydrocortisone butyrate oint 0.1% 2 hydrocortisone butyrate soln 0.1% 2 hydrocortisone cream 1% 2 hydrocortisone cream 2.5% 2 85

99 hydrocortisone lotion 2.5% 2 hydrocortisone oint 1% 2 hydrocortisone oint 2.5% 2 hydrocortisone valerate cream 0.2% 2 hydrocortisone valerate oint 0.2% 2 lokara lot 0.05% 2 mometasone furoate cream 0.1% 2 mometasone furoate oint 0.1% 2 mometasone furoate solution 0.1% (lotion) 2 PEDIADERM HC KIT 4 PEDIADERM TA KIT 4 prednicarbate cream 0.1% 2 prednicarbate oint 0.1% 2 scalacort lot 2% 2 TACLONEX SUS 4 TEXACORT SOL 2.5% 4 triamcinolone acetonide aerosol soln mg/gm triamcinolone acetonide cream 0.1% 2 triamcinolone acetonide cream 0.5% 2 triamcinolone acetonide cream 0.025% 2 triamcinolone acetonide lotion 0.1% 2 triamcinolone acetonide lotion 0.025% 2 triamcinolone acetonide oint 0.1% 2 triamcinolone acetonide oint 0.5% 2 triamcinolone acetonide oint 0.025% 2 TRIANEX OIN 0.05% 4 triderm cre 0.1% 2 VERDESO AER 0.05% 4 Emollients laclotion lot 12% 2 lactic acid (ammonium lactate) cream 12% 2 lactic acid (ammonium lactate) lotion 10% 2 lactic acid (ammonium lactate) lotion 12% 2 Enzymes - Topical SANTYL OIN 250/GM 4 Immunomodulating Agents - Topical imiquimod cream 5% 2 ZYCLARA CRE 3.75% 4 ZYCLARA PUMP CRE 2.5% 4 Immunosuppressive Agents - Topical ELIDEL CRE 1% 3 ST; PA** tacrolimus oint 0.1% 2 ST; PA** 86

100 tacrolimus oint 0.03% 2 ST; PA** Keratolytic/Antimitotic Agents CONDYLOX GEL 0.5% 4 podofilox soln 0.5% 2 Local Anesthetics - Topical lidocaine hcl cream 3% 2 lidocaine hcl gel 2% 2 lidocaine hcl lotion 3% 2 lidocaine hcl soln 4% 2 lidocaine oint 5% 2 lidocaine patch 5% 2 lidocaine-prilocaine cream % 2 lidocaine-prilocaine cream kit % 2 pramox gel 1% 2 SYNERA DIS 70-70MG 4 Rosacea Agents FINACEA GEL 15% 4 metronidazole cream 0.75% 2 metronidazole gel 0.75% 2 metronidazole gel 1% 2 metronidazole lotion 0.75% 2 rosadan cre 0.75% 2 Scabicides Pediculicides acticin cre 5% 2 EURAX CRE 10% 4 EURAX LOT 10% 4 lindane lotion 1% 2 lindane shampoo 1% 2 malathion lotion 0.5% 2 permethrin cream 5% 2 SKLICE LOT 0.5% 4 spinosad susp 0.9% 2 ULESFIA LOT 5% 4 Wound Care Products REGRANEX GEL 0.01% 4 DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS Dietary Management Products folbic tab 2 DIGESTIVE AIDS Digestive Enzymes CREON CAP 3000UNIT 3 CREON CAP 6000UNIT 3 87

101 CREON CAP 12000UNT 3 CREON CAP 24000UNT 3 CREON CAP 36000UNT 3 SUCRAID SOL 8500/ML 4 ULTRESA CAP 13800UNT 3 ULTRESA CAP 20700UNT 3 ULTRESA CAP 23000UNT 3 VIOKACE TAB 3 VIOKACE TAB ZENPEP CAP 3000UNIT 3 ZENPEP CAP 5000UNIT 3 ZENPEP CAP 10000UNT 3 ZENPEP CAP 15000UNT 3 ZENPEP CAP 20000UNT 3 ZENPEP CAP 25000UNT 3 ZENPEP CAP 40000UNT 3 DIURETICS Carbonic Anhydrase Inhibitors acetazolamide cap sr 12hr 500 mg 2 acetazolamide sodium for inj 500 mg 2 acetazolamide tab 125 mg 2 acetazolamide tab 250 mg 2 methazolamide tab 25 mg 2 methazolamide tab 50 mg 2 Diuretic Combinations ALDACTAZIDE TAB 50/50 3 amiloride & hydrochlorothiazide tab mg spironolactone & hydrochlorothiazide tab mg triamterene & hydrochlorothiazide cap mg triamterene & hydrochlorothiazide cap mg triamterene & hydrochlorothiazide tab mg triamterene & hydrochlorothiazide tab mg Loop Diuretics bumetanide inj 0.25 mg/ml 2 bumetanide tab 0.5 mg 2 bumetanide tab 1 mg 2 bumetanide tab 2 mg 2 EDECRIN TAB 25MG 4 88

102 ethacrynate sodium for inj 50 mg 2 furosemide inj 10 mg/ml 2 furosemide oral soln 8 mg/ml 2 furosemide oral soln 10 mg/ml 2 furosemide tab 20 mg 2 furosemide tab 40 mg 2 furosemide tab 80 mg 2 SOD EDECRIN INJ 50MG 4 TORSEMIDE INJ 20MG/2ML 4 TORSEMIDE INJ 50MG/5ML 4 torsemide tab 5 mg 2 torsemide tab 10 mg 2 torsemide tab 20 mg 2 torsemide tab 100 mg 2 Potassium Sparing Diuretics amiloride hcl tab 5 mg 2 DYRENIUM CAP 50MG 4 DYRENIUM CAP 100MG 4 spironolactone tab 25 mg 2 spironolactone tab 50 mg 2 spironolactone tab 100 mg 2 Thiazides and Thiazide-Like Diuretics chlorothiazide sodium for inj 500 mg 2 chlorothiazide tab 250 mg 2 chlorothiazide tab 500 mg 2 chlorthalidone tab 25 mg 2 chlorthalidone tab 50 mg 2 chlorthalidone tab 100 mg 2 DIURIL SUS 250/5ML 4 hydrochlorothiazide cap 12.5 mg 2 hydrochlorothiazide tab 12.5 mg 2 hydrochlorothiazide tab 25 mg 2 hydrochlorothiazide tab 50 mg 2 indapamide tab 1.25 mg 2 indapamide tab 2.5 mg 2 methyclothiazide tab 5 mg 2 metolazone tab 2.5 mg 2 metolazone tab 5 mg 2 metolazone tab 10 mg 2 ENDOCRINE AND METABOLIC AGENTS - MISC. Bone Density Regulators alendronate sodium oral soln 70 mg/75ml 2 89

103 alendronate sodium tab 5 mg 2 alendronate sodium tab 10 mg 2 alendronate sodium tab 35 mg 2 alendronate sodium tab 40 mg 2 alendronate sodium tab 70 mg 2 calcitonin (salmon) nasal soln 200 unit/act 2 FORTEO SOL 600/2.4 5 PA FOSAMAX + D TAB ST; PA** FOSAMAX + D TAB ST; PA** ibandronate sodium iv soln 3 mg/3ml 2 (base equivalent) ibandronate sodium tab 150 mg (base 2 equivalent) MIACALCIN INJ 200/ML 4 pamidronate disodium for inj 30 mg 2 pamidronate disodium for inj 90 mg 2 pamidronate disodium iv soln 3 mg/ml 2 pamidronate disodium iv soln 9 mg/ml 2 PAMIDRONATE INJ 6MG/ML 4 PROLIA SOL 60MG/ML 5 PA risedronate sodium tab 5 mg 2 risedronate sodium tab 30 mg 2 risedronate sodium tab 35 mg 2 risedronate sodium tab 150 mg 2 risedronate sodium tab delayed release 35 2 mg XGEVA INJ 5 PA zoledronic acid inj conc for iv infusion 4 5 PA mg/5ml zoledronic acid iv soln 5 mg/100ml 5 PA ZOLEDRONIC INJ 4MG/100 5 PA ZOMETA INJ 4MG/100 5 PA Fertility Regulators chorionic gonadotropin for inj unit 5 PA novarel inj 10000unt 5 PA pregnyl inj 10000unt 5 PA Growth Hormone Receptor Antagonists SOMAVERT INJ 10MG 5 PA SOMAVERT INJ 15MG 5 PA SOMAVERT INJ 20MG 5 PA SOMAVERT INJ 25MG 5 PA SOMAVERT INJ 30MG 5 PA Growth Hormones GENOTROPIN INJ 0.2MG 6 PA, ST 90

104 GENOTROPIN INJ 0.4MG 6 PA, ST GENOTROPIN INJ 0.6MG 6 PA, ST GENOTROPIN INJ 0.8MG 6 PA, ST GENOTROPIN INJ 1.2MG 6 PA, ST GENOTROPIN INJ 1.4MG 6 PA, ST GENOTROPIN INJ 1.6MG 6 PA, ST GENOTROPIN INJ 1.8MG 6 PA, ST GENOTROPIN INJ 1MG 6 PA, ST GENOTROPIN INJ 2MG 6 PA, ST GENOTROPIN INJ 5MG 6 PA, ST GENOTROPIN INJ 12MG 6 PA, ST HUMATROPE INJ 5MG 5 PA HUMATROPE INJ 6MG 5 PA HUMATROPE INJ 12MG 5 PA HUMATROPE INJ 24MG 5 PA NORDITROPIN INJ 5/1.5ML 5 PA NORDITROPIN INJ 10/1.5ML 5 PA NORDITROPIN INJ 15/1.5ML 5 PA NORDITROPIN INJ 30/3ML 5 PA NUTROPIN AQ INJ 10MG/2ML 6 PA, ST NUTROPIN AQ INJ 20MG/2ML 6 PA, ST NUTROPIN AQ INJ NUSPIN 5 6 PA, ST NUTROPIN INJ 10MG 6 PA, ST OMNITROPE INJ 5.8MG 6 PA, ST OMNITROPE INJ 5/1.5ML 6 PA, ST OMNITROPE INJ 10/1.5ML 6 PA, ST SAIZEN INJ 5MG 6 PA, ST SAIZEN INJ 8.8MG 6 PA, ST SEROSTIM INJ 4MG 5 PA SEROSTIM INJ 5MG 5 PA SEROSTIM INJ 6MG 5 PA ZORBTIVE INJ 8.8MG 5 PA Hormone Receptor Modulators raloxifene hcl tab 60 mg 2 $0 copay for women > 35 years for the primary prevention of breast cancer Insulin-Like Growth Factors (Somatomedins) INCRELEX INJ 40MG/4ML 5 PA LHRH/GnRH Agonist Analog Pituitary Suppressants LUPR DEP-PED INJ 7.5MG 5 PA LUPR DEP-PED INJ 11.25MG 5 PA LUPR DEP-PED INJ 15MG 5 PA LUPR DEP-PED INJ 30MG 5 PA 91

105 SYNAREL SOL 2MG/ML 3 Metabolic Modifiers ALDURAZYME INJ 2.9MG/5M 5 PA BUPHENYL TAB 500MG 5 PA calcitriol cap 0.5 mcg 2 calcitriol cap 0.25 mcg 2 calcitriol inj 1 mcg/ml 2 calcitriol oral soln 1 mcg/ml 2 CARBAGLU TAB 200MG 5 PA CYSTADANE POW 5 doxercalciferol cap 0.5 mcg 2 doxercalciferol cap 1 mcg 2 doxercalciferol cap 2.5 mcg 2 doxercalciferol inj 4 mcg/2ml (2 mcg/ml) 2 ELAPRASE INJ 6MG/3ML 5 PA FABRAZYME INJ 5MG 5 PA FABRAZYME INJ 35MG 5 PA KUVAN POW 100MG 5 PA KUVAN POW 500MG 5 PA KUVAN TAB 100MG 5 PA MYOZYME INJ 50MG 5 PA NAGLAZYME INJ 1MG/ML 5 PA ORFADIN CAP 2MG 5 PA ORFADIN CAP 5MG 5 PA ORFADIN CAP 10MG 5 PA paricalcitol cap 1 mcg 2 paricalcitol cap 2 mcg 2 paricalcitol cap 4 mcg 2 paricalcitol iv soln 2 mcg/ml 2 paricalcitol iv soln 5 mcg/ml 2 SENSIPAR TAB 30MG 5 PA SENSIPAR TAB 60MG 5 PA SENSIPAR TAB 90MG 5 PA sodium phenylbutyrate oral powder 3 2 PA gm/teaspoonful Posterior Pituitary Hormones desmopressin acetate inj 4 mcg/ml 2 desmopressin acetate nasal soln 0.01% 2 (refrigerated) desmopressin acetate nasal spray soln % desmopressin acetate nasal spray soln % (refrigerated) desmopressin acetate tab 0.1 mg 2 92

106 desmopressin acetate tab 0.2 mg 2 Prolactin Inhibitors cabergoline tab 0.5 mg 2 Somatostatic Agents octreotide acetate inj 50 mcg/ml ( PA mg/ml) octreotide acetate inj 100 mcg/ml (0.1 5 PA mg/ml) octreotide acetate inj 200 mcg/ml (0.2 5 PA mg/ml) octreotide acetate inj 500 mcg/ml (0.5 5 PA mg/ml) octreotide acetate inj 1000 mcg/ml (1 5 PA mg/ml) SANDOSTATIN KIT LAR 10MG 5 PA SANDOSTATIN KIT LAR 20MG 5 PA SANDOSTATIN KIT LAR 30MG 5 PA SOMATULINE INJ 60/0.2ML 5 PA SOMATULINE INJ 90/0.3ML 5 PA SOMATULINE INJ 120/.5ML 5 PA Vasopressin Receptor Antagonists SAMSCA TAB 15MG 5 PA SAMSCA TAB 30MG 5 PA ESTROGENS Estrogen Combinations CLIMARA PRO DIS WEEKLY 3 estradiol & norethindrone acetate tab mg estradiol & norethindrone acetate tab mg jinteli tab 1mg-5mcg 2 mimvey tab 1-0.5mg 2 norethindrone acetate-ethinyl estradiol tab mg-2.5 mcg Estrogens CENESTIN TAB 0.3MG 4 PA; High Risk Medications require PA for members age 65 and CENESTIN TAB 0.9MG 4 PA; High Risk Medications require PA for members age 65 and CENESTIN TAB 0.45MG 4 PA; High Risk Medications require PA for members age 65 and 93

107 CENESTIN TAB 0.625MG 4 PA; High Risk Medications require PA for members age 65 and CENESTIN TAB 1.25MG 4 PA; High Risk Medications require PA for members age 65 and DEPO-ESTRADI INJ 5MG/ML 4 DIVIGEL GEL 0.5MG 4 PA; High Risk Medications require PA for members age 65 and DIVIGEL GEL 0.25MG 4 PA; High Risk Medications require PA for members age 65 and DIVIGEL GEL 1MG/GM 4 PA; High Risk Medications require PA for members age 65 and ELESTRIN GEL 0.06% 4 PA; High Risk Medications require PA for members age 65 and ENJUVIA TAB 0.3MG 4 PA; High Risk Medications require PA for members age 65 and ENJUVIA TAB 0.9MG 4 PA; High Risk Medications require PA for members age 65 and ENJUVIA TAB 0.45MG 4 PA; High Risk Medications require PA for members age 65 and ENJUVIA TAB 0.625MG 4 PA; High Risk Medications require PA for members age 65 and ENJUVIA TAB 1.25MG 4 PA; High Risk Medications require PA for members age 65 and estradiol tab 0.5 mg 2 PA; High Risk Medications require PA for members age 65 and estradiol tab 1 mg 2 PA; High Risk Medications require PA for members age 65 and 94

108 estradiol tab 2 mg 2 PA; High Risk Medications require PA for members age 65 and estradiol td patch twice weekly 0.1 mg/24hr estradiol td patch twice weekly 0.05 mg/24hr estradiol td patch twice weekly mg/24hr estradiol td patch twice weekly mg/24hr estradiol td patch twice weekly mg/24hr 2 PA; High Risk Medications require PA for members age 65 and 2 PA; High Risk Medications require PA for members age 65 and 2 PA; High Risk Medications require PA for members age 65 and 2 PA; High Risk Medications require PA for members age 65 and 2 PA; High Risk Medications require PA for members age 65 and estradiol td patch weekly 0.1 mg/24hr 2 PA; High Risk Medications require PA for members age 65 and estradiol td patch weekly 0.05 mg/24hr 2 PA; High Risk Medications require PA for members age 65 and estradiol td patch weekly 0.06 mg/24hr 2 PA; High Risk Medications require PA for members age 65 and estradiol td patch weekly mg/24hr 2 PA; High Risk Medications require PA for members age 65 and estradiol td patch weekly mg/24hr 2 PA; High Risk Medications require PA for members age 65 and estradiol td patch weekly mg/24hr (37.5 mcg/24hr) estradiol valerate im in oil 10 mg/ml 2 estradiol valerate im in oil 20 mg/ml 2 estradiol valerate im in oil 40 mg/ml 2 2 PA; High Risk Medications require PA for members age 65 and 95

109 ESTROGEL GEL 4 PA; High Risk Medications require PA for members age 65 and estropipate tab 0.75 mg 2 PA; High Risk Medications require PA for members age 65 and estropipate tab 1.5 mg 2 PA; High Risk Medications require PA for members age 65 and estropipate tab 3 mg 2 PA; High Risk Medications require PA for members age 65 and EVAMIST SPR 1.53MG 4 PA; High Risk Medications require PA for members age 65 and MENEST TAB 0.3MG 4 PA; High Risk Medications require PA for members age 65 and MENEST TAB 0.625MG 4 PA; High Risk Medications require PA for members age 65 and MENEST TAB 1.25MG 4 PA; High Risk Medications require PA for members age 65 and MENEST TAB 2.5MG 4 PA; High Risk Medications require PA for members age 65 and MENOSTAR DIS 14MCG 4 PA; High Risk Medications require PA for members age 65 and ortho-est tab PA; High Risk Medications require PA for members age 65 and ortho-est tab PA; High Risk Medications require PA for members age 65 and PREMARIN INJ 25MG 4 PREMARIN TAB 0.3MG 4 PA; High Risk Medications require PA for members age 65 and 96

110 PREMARIN TAB 0.9MG 4 PA; High Risk Medications require PA for members age 65 and PREMARIN TAB 0.45MG 4 PA; High Risk Medications require PA for members age 65 and PREMARIN TAB 0.625MG 4 PA; High Risk Medications require PA for members age 65 and PREMARIN TAB 1.25MG 4 PA; High Risk Medications require PA for members age 65 and FLUOROQUINOLONES Fluoroquinolones AVELOX INJ 4 ciprofloxacin 200 mg/100ml in d5w 2 ciprofloxacin 400 mg/200ml in d5w 2 ciprofloxacin for oral susp 250 mg/5ml 2 (5%) (5 gm/100ml) ciprofloxacin for oral susp 500 mg/5ml 2 (10%) (10 gm/100ml) ciprofloxacin hcl tab 100 mg (base equiv) 2 ciprofloxacin hcl tab 250 mg (base equiv) 2 ciprofloxacin hcl tab 500 mg (base equiv) 2 ciprofloxacin hcl tab 750 mg (base equiv) 2 ciprofloxacin iv soln 200 mg/20ml (1%) 2 ciprofloxacin iv soln 400 mg/40ml (1%) 2 ciprofloxacin-ciprofloxacin hcl tab sr 24hr mg (base eq) ciprofloxacin-ciprofloxacin hcl tab sr 24hr mg(base eq) FACTIVE TAB 320MG 4 levofloxacin in d5w iv soln 250 mg/50ml 2 levofloxacin in d5w iv soln 500 mg/100ml 2 levofloxacin in d5w iv soln 750 mg/150ml 2 levofloxacin iv soln 25 mg/ml 2 levofloxacin oral soln 25 mg/ml 2 levofloxacin tab 250 mg 2 levofloxacin tab 500 mg 2 levofloxacin tab 750 mg 2 moxifloxacin hcl tab 400 mg (base equiv) 2 NOROXIN TAB 400MG 4 ofloxacin tab 200 mg 2 97

111 ofloxacin tab 300 mg 2 ofloxacin tab 400 mg 2 GASTROINTESTINAL AGENTS - MISC. Gallstone Solubilizing Agents ursodiol cap 300 mg 2 ursodiol tab 250 mg 2 ursodiol tab 500 mg 2 Gastrointestinal Antiallergy Agents cromolyn sodium oral conc 100 mg/5ml 2 Gastrointestinal Stimulants metoclopramide hcl inj 5 mg/ml 2 metoclopramide hcl orally disintegrating 2 tab 5 mg metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) 2 metoclopramide hcl tab 5 mg 2 metoclopramide hcl tab 10 mg 2 Inflammatory Bowel Agents APRISO CAP 0.375GM 3 balsalazide disodium cap 750 mg 2 CANASA SUP 1000MG 3 CIMZIA KIT 6 PA, ST CIMZIA KIT STARTER 6 PA, ST CIMZIA PREFL KIT 200MG/ML 6 PA, ST DIPENTUM CAP 250MG 4 mesalamine enema 4 gm 2 mesalamine rectal enema 4 gm & cleanser 2 wipe kit REMICADE INJ 100MG 6 PA, ST sulfasalazine tab 500 mg 2 sulfasalazine tab delayed release 500 mg 2 Intestinal Acidifiers enulose sol 10gm/15 2 generlac sol 10gm/15 2 Irritable Bowel Syndrome (IBS) Agents alosetron hcl tab 0.5 mg (base equiv) 2 PA alosetron hcl tab 1 mg (base equiv) 2 PA LINZESS CAP 145MCG 3 LINZESS CAP 290MCG 3 Peripheral Opioid Receptor Antagonists MOVANTIK TAB 12.5MG 3 MOVANTIK TAB 25MG 3 Phosphate Binder Agents 98

112 calcium acetate (phosphate binder) cap mg (169 mg ca) calcium acetate (phosphate binder) tab mg FOSRENOL CHW 500MG 4 FOSRENOL CHW 750MG 4 FOSRENOL CHW 1000MG 4 FOSRENOL POW 750MG 4 FOSRENOL POW 1000MG 4 PHOSLYRA SOL 4 RENVELA PAK 0.8GM 3 RENVELA PAK 2.4GM 3 RENVELA TAB 800MG 3 GENITOURINARY AGENTS - MISCELLANEOUS Alkalinizers potassium citrate tab cr 5 meq (540 mg) 2 potassium citrate tab cr 10 meq (1080 mg)2 potassium citrate tab cr 15 meq (1620 mg)2 Cystinosis Agents CYSTAGON CAP 50MG 5 PA CYSTAGON CAP 150MG 5 PA Genitourinary Irrigants sodium chloride irrigation soln 0.9% 2 Interstitial Cystitis Agents ELMIRON CAP 100MG 4 Prostatic Hypertrophy Agents alfuzosin hcl tab sr 24hr 10 mg 2 AVODART CAP 0.5MG 4 CARDURA XL TAB 4MG 4 ST; PA** CARDURA XL TAB 8MG 4 ST; PA** CIALIS TAB 2.5MG 4 QL (30 tabs / 25 days), PA CIALIS TAB 5MG 4 QL (30 tabs / 25 days), PA dutasteride cap 0.5 mg 2 dutasteride-tamsulosin hcl cap mg 2 finasteride tab 5 mg 2 JALYN CAP 4 RAPAFLO CAP 4MG 4 ST; PA** RAPAFLO CAP 8MG 4 ST; PA** tamsulosin hcl cap 0.4 mg 2 Urinary Analgesics phenazopyridine hcl tab 100 mg 2 99

113 phenazopyridine hcl tab 200 mg 2 GOUT AGENTS Gout Agent Combinations colchicine w/ probenecid tab mg 2 Gout Agents allopurinol sodium for inj 500 mg 2 allopurinol tab 100 mg 2 allopurinol tab 300 mg 2 colchicine tab 0.6 mg 2 ULORIC TAB 40MG 4 ST; PA** ULORIC TAB 80MG 4 ST; PA** Uricosurics probenecid tab 500 mg 2 HEMATOLOGICAL AGENTS - MISC. Bradykinin B2 Receptor Antagonists FIRAZYR INJ 30MG/3ML 5 PA Hematorheologic Agents pentoxifylline tab cr 400 mg 2 Platelet Aggregation Inhibitors anagrelide hcl cap 0.5 mg 2 anagrelide hcl cap 1 mg 2 aspirin-dipyridamole cap sr 12hr mg BRILINTA TAB 60MG 3 BRILINTA TAB 90MG 3 cilostazol tab 50 mg 2 cilostazol tab 100 mg 2 clopidogrel bisulfate tab 75 mg (base 2 equiv) clopidogrel bisulfate tab 300 mg (base 2 equiv) dipyridamole tab 25 mg 2 PA; High Risk Medications require PA for members age 65 and dipyridamole tab 50 mg 2 PA; High Risk Medications require PA for members age 65 and dipyridamole tab 75 mg 2 PA; High Risk Medications require PA for members age 65 and EFFIENT TAB 5MG 3 EFFIENT TAB 10MG 3 100

114 ticlopidine hcl tab 250 mg 2 ZONTIVITY TAB 2.08MG 3 HEMATOPOIETIC AGENTS Agents for Gaucher Disease CEREZYME INJ 400UNIT 5 PA ELELYSO INJ 200UNIT 5 PA VPRIV INJ 400UNIT 5 PA ZAVESCA CAP 100MG 5 PA Agents for Sickle Cell Anemia DROXIA CAP 200MG 3 DROXIA CAP 300MG 3 DROXIA CAP 400MG 3 Cobalamins cyanocobalamin inj 1000 mcg/ml 2 Folic Acid/Folates folic acid tab 1 mg 2 folic acid tab 400 mcg 0 QL (100 tabs / 30 days); OTC; $0 copay for women ages 55 and under folic acid tab 800 mcg 0 QL (100 tabs / 30 days); OTC; $0 copay for women ages 55 and under Hematopoietic Growth Factors ARANESP INJ 10MCG 5 PA ARANESP INJ 25MCG 5 PA ARANESP INJ 40MCG 5 PA ARANESP INJ 60MCG 5 PA ARANESP INJ 100MCG 5 PA ARANESP INJ 150MCG 5 PA ARANESP INJ 200MCG 5 PA ARANESP INJ 300MCG 5 PA ARANESP INJ 500MCG 5 PA LEUKINE INJ 250MCG 5 PA LEUKINE INJ 500 MCG 5 PA NEULASTA INJ 6MG/0.6M 5 PA NEULASTA KIT 6MG/0.6M 5 PA NEUPOGEN INJ 300/0.5 5 PA NEUPOGEN INJ 300MCG 5 PA NEUPOGEN INJ 480/0.8 5 PA NEUPOGEN INJ 480MCG 5 PA OMONTYS INJ 10MG/ML 5 PA OMONTYS INJ 20MG/2ML 5 PA 101

115 PROCRIT INJ 2000/ML 5 PA PROCRIT INJ 3000/ML 5 PA PROCRIT INJ 4000/ML 5 PA PROCRIT INJ 10000/ML 5 PA PROCRIT INJ 20000/ML 5 PA PROCRIT INJ 40000/ML 5 PA PROMACTA TAB 12.5MG 5 PA PROMACTA TAB 25MG 5 PA PROMACTA TAB 50MG 5 PA PROMACTA TAB 75MG 5 PA Iron FER-IN-SOL DRO 15MG/ML 0 OTC; $0 for ages 6-12 months FERROUS SUL LIQ 220/5ML 0 OTC; $0 for ages 6-12 months FERROUS SULF SYP 300/5ML 0 OTC; $0 for ages 6-12 months ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental fe) ferrous sulfate soln 75 mg/ml (15 mg/ml elemental fe) 0 OTC; $0 for ages 6-12 months 0 OTC; $0 for ages 6-12 months ICAR PEDS SUS GRAPE 0 OTC; $0 for ages 6-12 months MYKIDZ IRON SUS 15/1.5ML 0 OTC; $0 for ages 6-12 months wee care sus 15/ OTC; $0 for ages 6-12 months Stem Cell Mobilizers MOZOBIL INJ 5 PA HEMOSTATICS Hemostatics - Systemic tranexamic acid iv soln 1000 mg/10ml 2 (100 mg/ml) tranexamic acid tab 650 mg 2 HYPNOTICS Barbiturate Hypnotics phenobarbital elixir 20 mg/5ml 2 phenobarbital tab 15 mg 2 phenobarbital tab 16.2 mg 2 phenobarbital tab 30 mg 2 phenobarbital tab 32.4 mg 2 phenobarbital tab 60 mg 2 phenobarbital tab 64.8 mg 2 phenobarbital tab 97.2 mg 2 102

116 phenobarbital tab 100 mg 2 Non-Barbiturate Hypnotics eszopiclone tab 1 mg 2 QL (15 tablets/25 days) eszopiclone tab 2 mg 2 QL (15 tablets/25 days) eszopiclone tab 3 mg 2 QL (15 tablets/25 days) temazepam cap 7.5 mg 2 QL (15 caps / 25 days) temazepam cap 15 mg 2 QL (15 caps / 25 days) temazepam cap 22.5 mg 2 QL (15 caps / 25 days) temazepam cap 30 mg 2 QL (15 caps / 25 days) zaleplon cap 5 mg 2 QL (15 caps / 25 days) zaleplon cap 10 mg 2 QL (15 caps / 25 days) zolpidem tartrate tab 5 mg 2 QL (15 tabs / 25 days) zolpidem tartrate tab 10 mg 2 QL (15 tabs / 25 days) zolpidem tartrate tab cr 6.25 mg 2 QL (15 tabs / 25 days) zolpidem tartrate tab cr 12.5 mg 2 QL (15 tabs / 25 days) Selective Melatonin Receptor Agonists ROZEREM TAB 8MG 4 QL (15 tabs / 25 days), ST; PA** LAXATIVES Laxative Combinations COLYTE/FLAVR SOL PACKS 3 gavilyte-c sol 2 gavilyte-g sol 2 gavilyte-h kit 0 $0 copay for members age 50 through 74 gavilyte-n sol flav pk 2 GOLYTELY SOL 3 MOVIPREP SOL 3 $0 copay for members age 50 through 74 peg 3350-kcl-na bicarb-nacl-na sulfate for 2 soln 236 gm peg 3350-kcl-na bicarb-nacl-na sulfate for 2 soln 240 gm peg 3350-kcl-sod bicarb-nacl for soln gm PREPOPIK PAK 0 $0 copay for members age 50 through 74 SUPREP BOWEL SOL PREP 4 $0 copay for members age 50 through 74 Laxatives - Miscellaneous KRISTALOSE PAK 10GM 4 KRISTALOSE PAK 20GM 4 lactulose solution 10 gm/15ml 2 polyethylene glycol 3350 oral packet 2 103

117 polyethylene glycol 3350 oral powder 2 Saline Laxatives OSMOPREP TAB 1.5GM 4 LOCAL ANESTHETICS-Parenteral Local Anesthetics - Amides LIDO/DEXTROS INJ 5-7.5% 4 lidocaine hcl local inj 0.5% 2 lidocaine hcl local inj 1% 2 lidocaine hcl local inj 1.5% 2 lidocaine hcl local inj 2% 2 lidocaine hcl local preservative free (pf) inj 2 0.5% lidocaine hcl local preservative free (pf) inj 2 1% lidocaine hcl local preservative free (pf) inj 2 2% lidocaine hcl local preservative free (pf) inj 2 4% MACROLIDES Azithromycin azithromycin for susp 100 mg/5ml 2 azithromycin for susp 200 mg/5ml 2 azithromycin iv for soln 500 mg 2 azithromycin powd pack for susp 1 gm 2 azithromycin tab 250 mg 2 azithromycin tab 500 mg 2 azithromycin tab 600 mg 2 ZMAX SUS 2GM 4 Clarithromycin clarithromycin for susp 125 mg/5ml 2 clarithromycin for susp 250 mg/5ml 2 clarithromycin tab 250 mg 2 clarithromycin tab 500 mg 2 clarithromycin tab sr 24hr 500 mg 2 Erythromycins e.e.s. 400 tab 400mg 2 E.E.S. GRAN SUS 200/5ML 3 ery-tab tab 250mg ec 2 ery-tab tab 333mg ec 2 ery-tab tab 500mg ec 2 ERYPED SUS 200/5ML 3 ERYPED SUS 400/5ML 3 ERYTHROCIN INJ 500MG 4 104

118 ERYTHROCIN INJ 1000MG 4 erythrocin tab 250mg 2 erythromycin ethylsuccinate tab 400 mg 2 erythromycin tab 250 mg 2 erythromycin tab 500 mg 2 erythromycin w/ delayed release particles 2 cap 250 mg PCE TAB 333MG EC 4 PCE TAB 500MG EC 4 Fidaxomicin DIFICID TAB 200MG 3 PA MEDICAL DEVICES Contraceptives CAYA DPR 0 QL (1 / 300 days) FC2 FEMALE MIS CONDOM 0 OTC FEMCAP MIS 22MM 0 QL (1 / 300 days) FEMCAP MIS 26MM 0 QL (1 / 300 days) FEMCAP MIS 30MM 0 QL (1 / 300 days) OMNIFLEX DPR 0 QL (1 / 300 days) ORTHO COIL DPR KIT 50 0 QL (1 / 300 days) ORTHO COIL DPR KIT QL (1 / 300 days) ORTHO COIL DPR KIT QL (1 / 300 days) ORTHO FLAT DPR KIT 55 0 QL (1 / 300 days) ORTHO FLAT DPR KIT 60 0 QL (1 / 300 days) ORTHO FLAT DPR KIT 65 0 QL (1 / 300 days) ORTHO FLAT DPR KIT 70 0 QL (1 / 300 days) ORTHO FLAT DPR KIT 75 0 QL (1 / 300 days) ORTHO FLAT DPR KIT 80 0 QL (1 / 300 days) ORTHO FLAT DPR KIT 85 0 QL (1 / 300 days) ORTHO FLAT DPR KIT 90 0 QL (1 / 300 days) ORTHO FLAT DPR KIT 95 0 QL (1 / 300 days) ORTHO FLEX DPR 65MM 0 QL (1 / 300 days) ORTHO FLEX DPR 70MM 0 QL (1 / 300 days) ORTHO FLEX DPR 75MM 0 QL (1 / 300 days) ORTHO FLEX DPR 80MM 0 QL (1 / 300 days) PRENTIF MIS 22MM 0 QL (1 / 300 days) PRENTIF MIS 25MM 0 QL (1 / 300 days) PRENTIF MIS 28MM 0 QL (1 / 300 days) PRENTIF MIS 31MM 0 QL (1 / 300 days) PRENTIF MIS FITTING 0 QL (1 / 300 days) WIDE-SEAL DPR KIT 60 0 QL (1 / 300 days) WIDE-SEAL DPR KIT 65 0 QL (1 / 300 days) WIDE-SEAL DPR KIT 70 0 QL (1 / 300 days) 105

119 WIDE-SEAL DPR KIT 75 0 QL (1 / 300 days) WIDE-SEAL DPR KIT 80 0 QL (1 / 300 days) WIDE-SEAL DPR KIT 85 0 QL (1 / 300 days) WIDE-SEAL DPR KIT 90 0 QL (1 / 300 days) WIDE-SEAL DPR KIT 95 0 QL (1 / 300 days) Diabetic Supplies ALCOHOL PREP WIPES AND SWABS 3 OTC BLOOD GLUCOSE CALIBRATION SOLUTION 3 OTC INSULIN PEN NEEDLES/SYRINGES 3 OTC LANCETS 3 OTC LANCING DEVICE 3 OTC ONETOUCH BLOOD GLUCOSE TEST KITS 3 OTC ONETOUCH BLOOD GLUCOSE TEST STRIPS 3 OTC Parenteral Therapy Supplies HUMATROPEN MIS FOR 6MG 3 HUMATROPEN MIS FOR 12MG 3 HUMATROPEN MIS FOR 24MG 3 Respiratory Therapy Supplies ADULT RESPIRATORY MASK 3 ADULT RESPIRATORY MASK 3 OTC PEDIATRIC RESPIRATORY MASK 3 PEDIATRIC RESPIRATORY MASK 3 OTC MIGRAINE PRODUCTS Migraine Combinations CAFERGOT TAB 1-100MG 3 Migraine Products dihydroergotamine mesylate inj 1 mg/ml 2 dihydroergotamine mesylate nasal spray 4 2 QL (8 kits / 25 days) mg/ml ERGOMAR SUB 2MG 4 Serotonin Agonists almotriptan malate tab 6.25 mg 2 QL (12 tabs / 25 days) almotriptan malate tab 12.5 mg 2 QL (12 tabs / 25 days) FROVA TAB 2.5MG 4 QL (18 tabs / 25 days) frovatriptan succinate tab 2.5 mg (base 2 QL (18 tabs / 25 days) equivalent) naratriptan hcl tab 1 mg (base equiv) 2 QL (12 tabs / 25 days) naratriptan hcl tab 2.5 mg (base equiv) 2 QL (12 tabs / 25 days) RELPAX TAB 20MG 4 QL (12 tabs / 25 days), ST; PA** RELPAX TAB 40MG 4 QL (12 tabs / 25 days), ST; PA** rizatriptan benzoate oral disintegrating tab 2 QL (18 tabs / 25 days) 5 mg (base eq) 106

120 rizatriptan benzoate oral disintegrating tab 2 QL (18 tabs / 25 days) 10 mg (base eq) rizatriptan benzoate tab 5 mg (base 2 QL (18 tabs / 25 days) equivalent) rizatriptan benzoate tab 10 mg (base 2 QL (18 tabs / 25 days) equivalent) sumatriptan nasal spray 5 mg/act 2 QL (24 sprays / 25 days) sumatriptan nasal spray 20 mg/act 2 QL (12 sprays / 25 days) sumatriptan succinate inj 4 mg/0.5ml 2 QL (12 units / 25 days) sumatriptan succinate inj 6 mg/0.5ml 2 QL (12 vials per 25 days) sumatriptan succinate solution autoinjector 2 QL (6 kits / 25 days) 4 mg/0.5ml sumatriptan succinate solution autoinjector 2 QL (12 units / 25 days) 6 mg/0.5ml sumatriptan succinate solution cartridge 4 2 QL (12 units / 25 days) mg/0.5ml sumatriptan succinate solution cartridge 6 2 QL (12 units / 25 days) mg/0.5ml sumatriptan succinate solution prefilled 2 QL (12 units / 25 days) syringe 6 mg/0.5ml sumatriptan succinate tab 25 mg 2 QL (12 tabs / 25 days) sumatriptan succinate tab 50 mg 2 QL (12 tabs / 25 days) sumatriptan succinate tab 100 mg 2 QL (12 tabs / 25 days) zolmitriptan orally disintegrating tab QL (12 tabs / 25 days) mg zolmitriptan orally disintegrating tab 5 mg 2 QL (12 tabs / 25 days) zolmitriptan tab 2.5 mg 2 QL (12 tabs / 25 days) zolmitriptan tab 5 mg 2 QL (12 tabs / 25 days) ZOMIG NASAL SPR 5MG 4 QL (12 sprays / 25 days) ZOMIG SPR 2.5MG 4 QL (12 sprays / 25 days) MINERALS ELECTROLYTES Chloride AMMONIUM CHL INJ 5MEQ/ML 4 Electrolyte Mixtures ISOLYTE-S INJ 4 kcl 20 meq/l (0.15%) in nacl 0.9% inj 2 kcl 20 meq/l (0.15%) in nacl 0.45% inj 2 kcl 40 meq/l (0.3%) in nacl 0.9% inj 2 NORMOSOL -R INJ 4 PLASMA-LYTE INJ PLASMA-LYTE INJ -A 4 107

121 Fluoride fluor-a-day dro 0.125mg 0 $0 applies for ages 5 and under FLUORABON DRO 0 $0 applies for ages 5 and under fluoritab chw 0.5mg f 0 $0 applies for ages 5 and under fluoritab chw 0.25mg f 0 $0 applies for ages 5 and under fluoritab chw 2.2mg 2 flura-drops dro 0.25mg f 0 $0 applies for ages 5 and under flura-drops dro 0.125mg 0 $0 applies for ages 5 and under ludent chw 0.5mg f 0 $0 applies for ages 5 and under ludent chw 0.25mg f 0 $0 applies for ages 5 and under ludent chw 1mg f 2 LURIDE CHW 0.5MG F 0 $0 applies for ages 5 and under LURIDE CHW 0.25MG F 0 $0 applies for ages 5 and under LURIDE DRO 0.5MG/ML 0 $0 applies for ages 5 and under nafrinse chw 1mg f 2 sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf) sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf) sodium fluoride chew tab 1 mg f (from 2.2 mg naf) sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf) sodium fluoride tab 0.5 mg f (from 1.1 mg naf) sodium fluoride tab 1 mg f (from 2.2 mg naf) Magnesium MAGNESIUM SU INJ 2/50ML 4 MAGNESIUM SU INJ 4/100ML 4 MAGNESIUM SU INJ 20/500ML 4 MAGNESIUM SU INJ 40/ MAGNESIUM SU INJ 80MG/ML 4 magnesium sulfate inj 50% 2 MG SO4/D5W INJ 10MG/ML 4 MG SO4/D5W INJ 20MG/ML 4 Potassium 0 $0 applies for ages 5 and under 0 $0 applies for ages 5 and under 2 0 $0 applies for ages 5 and under 0 $0 applies for ages 5 and under 2 108

122 klor-con 8 tab 8meq er 2 klor-con 10 tab 10meq er 2 KLOR-CON M15 TAB 15MEQ ER 3 klor-con m20 tab 20meq er 2 potassium chloride cap cr 8 meq 2 potassium chloride cap cr 10 meq 2 potassium chloride inj 2 meq/ml 2 potassium chloride inj 10 meq/50ml 2 potassium chloride inj 10 meq/100ml 2 potassium chloride inj 20 meq/50ml 2 potassium chloride inj 20 meq/100ml 2 potassium chloride inj 40 meq/100ml 2 potassium chloride microencapsulated crys 2 cr tab 10 meq potassium chloride microencapsulated crys 2 cr tab 20 meq potassium chloride oral soln 10% (20 2 meq/15ml) potassium chloride oral soln 20% (40 2 meq/15ml) potassium chloride tab cr 8 meq (600 mg) 2 potassium chloride tab cr 10 meq 2 potassium chloride tab cr 20 meq ( mg) Sodium sodium chloride flush iv soln 0.9% 2 sodium chloride inj 0.9% 2 sodium chloride inj 0.45% 2 sodium chloride inj 2.5 meq/ml (14.6%) 2 sodium chloride inj 3% 2 sodium chloride inj 4 meq/ml (23.4%) 2 sodium chloride inj 5% 2 sodium chloride iv soln 0.9% 2 MOUTH/THROAT/DENTAL AGENTS Anesthetics Topical Oral lidocaine hcl laryngotracheal soln 4% 2 lidocaine hcl viscous soln 2% 2 Anti-infectives - Throat clotrimazole troche 10 mg 2 nystatin susp unit/ml 2 ORAVIG TAB 50MG 4 Antiseptics - Mouth/Throat chlorhexidine gluconate soln 0.12% 2 periogard sol 0.12% 2 109

123 Steroids - Mouth/Throat oralone pst 0.1% 2 triamcinolone acetonide dental paste 0.1% 2 Throat Products - Misc. cevimeline hcl cap 30 mg 2 pilocarpine hcl tab 5 mg 2 pilocarpine hcl tab 7.5 mg 2 MULTIVITAMINS Ped MV w/ Fluoride multi-vit/fl dro 0.5mg/ml 2 multi-vit/fl dro 0.25mg 2 multivit/fl chw 0.5mg 2 multivit/fl chw 0.25mg 2 multivit/fl chw 1mg 2 mvc-fluoride chw 0.5mg 2 mvc-fluoride chw 1mg 2 QUFLORA PED CHW 0.5MG 4 QUFLORA PED CHW 0.25MG 4 QUFLORA PED CHW 1MG 4 quflora ped dro 0.5mg/ml 2 quflora ped dro 0.25mg 2 tri-vit/fl dro 0.5mg 2 tri-vit/fl dro 0.25mg 2 tri-vit/fluo dro 0.25mg 2 tri-vita/fl dro 0.25mg 2 vit a/c/d/fl dro 0.25mg 2 Ped Multi Vitamins w/fl FE multi-vit/fe dro /fl multi-vit/fl dro /fe tri-vit/fe dro /fl Prenatal Vitamins CITRANATAL CAP HARMONY 3 CITRANATAL MIS 90 DHA 3 CITRANATAL MIS B-CALM 3 CITRANATAL PAK ASSURE 3 CITRANATAL PAK DHA 3 CITRANATAL TAB RX 3 prenatabs rx tab 2 MUSCULOSKELETAL THERAPY AGENTS Central Muscle Relaxants baclofen tab 10 mg 2 baclofen tab 20 mg 2 110

124 carisoprodol tab 250 mg 2 PA; High Risk Medications require PA for members age 65 and carisoprodol tab 350 mg 2 PA; High Risk Medications require PA for members age 65 and chlorzoxazone tab 500 mg 2 cyclobenzaprine hcl tab 5 mg 2 PA; High Risk Medications require PA for members age 65 and cyclobenzaprine hcl tab 7.5 mg 2 PA; High Risk Medications require PA for members age 65 and cyclobenzaprine hcl tab 10 mg 2 PA; High Risk Medications require PA for members age 65 and metaxalone tab 400 mg 2 PA; High Risk Medications require PA for members age 65 and metaxalone tab 800 mg 2 PA; High Risk Medications require PA for members age 65 and methocarbamol tab 500 mg 2 PA; High Risk Medications require PA for members age 65 and methocarbamol tab 750 mg 2 PA; High Risk Medications require PA for members age 65 and orphenadrine citrate inj 30 mg/ml 2 orphenadrine citrate tab sr 12hr 100 mg 2 PA; High Risk Medications require PA for members age 65 and tizanidine hcl cap 2 mg (base equivalent) 2 tizanidine hcl cap 4 mg (base equivalent) 2 tizanidine hcl cap 6 mg (base equivalent) 2 tizanidine hcl tab 2 mg (base equivalent) 2 tizanidine hcl tab 4 mg (base equivalent) 2 Direct Muscle Relaxants dantrolene sodium cap 25 mg 2 dantrolene sodium cap 50 mg 2 dantrolene sodium cap 100 mg 2 111

125 Muscle Relaxant Combinations orphenadrine w/ aspirin & caffeine tab mg 2 PA; High Risk Medications require PA for members age 65 and NASAL AGENTS - SYSTEMIC AND TOPICAL Nasal Anti-infectives BACTROBAN OIN NASAL 2% 4 Nasal Antiallergy azelastine hcl nasal spray 0.1% (137 2 QL (2 bottles / 25 days) mcg/spray) azelastine hcl nasal spray 0.15% ( QL (2 bottles / 25 days) mcg/spray) olopatadine hcl nasal soln 0.6% 2 QL (1 container / 25 days) Nasal Anticholinergics ipratropium bromide nasal soln 0.03% (21 2 mcg/spray) ipratropium bromide nasal soln 0.06% (42 2 mcg/spray) Nasal Steroids budesonide nasal susp 32 mcg/act 2 QL (2 containers / 25 days) flunisolide nasal soln 25 mcg/act (0.025%) 2 QL (3 containers / 25 days) fluticasone propionate nasal susp 50 mcg/act triamcinolone acetonide nasal aerosol suspension 55 mcg/act Sympathomimetic Decongestants TYZINE PED DRO 0.05% 4 TYZINE SOL 0.1% 4 NEUROMUSCULAR AGENTS ALS Agents riluzole tab 50 mg 2 Neuromuscular Blocking Agent - Neurotoxins BOTOX INJ 100UNIT 5 PA BOTOX INJ 200UNIT 5 PA XEOMIN INJ 50 UNIT 5 PA XEOMIN INJ 100UNIT 5 PA XEOMIN INJ 200UNIT 5 PA OPHTHALMIC AGENTS Artificial Tears and Lubricants LACRISERT MIS 5MG OP 4 2 QL (1 container / 25 days) 2 QL (1 container / 25 days) 112

126 Beta-blockers - Ophthalmic betaxolol hcl ophth soln 0.5% 2 BETIMOL SOL 0.5% 4 BETIMOL SOL 0.25% 4 BETOPTIC-S SUS 0.25% OP 3 carteolol hcl ophth soln 1% 2 COMBIGAN SOL 0.2/0.5% 3 dorzolamide hcl-timolol maleate ophth soln mg/ml ISTALOL SOL 0.5% OP 4 levobunolol hcl ophth soln 0.5% 2 levobunolol hcl ophth soln 0.25% 2 metipranolol ophth soln 0.3% 2 timolol maleate ophth gel forming soln 2 0.5% timolol maleate ophth gel forming soln % timolol maleate ophth soln 0.5% 2 timolol maleate ophth soln 0.25% 2 TIMOPTIC OCU SOL 0.5% OP 3 TIMOPTIC OCU SOL 0.25% OP 3 Cycloplegic Mydriatics atropine sulfate ophth soln 1% 2 homatropaire sol 5% op 2 homatropine hbr ophth soln 5% 2 ISO HOMATROP SOL 2% OP 4 tropicamide ophth soln 0.5% 2 tropicamide ophth soln 1% 2 Miotics PHOSPHOLINE SOL 0.125%OP 4 PILOPINE HS GEL 4% OP 4 Ophthalmic Adrenergic Agents ALPHAGAN P SOL 0.1% 4 apraclonidine hcl ophth soln 0.5% (base 2 equivalent) brimonidine tartrate ophth soln 0.2% 2 brimonidine tartrate ophth soln 0.15% 2 IOPIDINE SOL 1% OP 4 Ophthalmic Anti-infectives AZASITE SOL 1% 4 bacitracin ophth oint 500 unit/gm 2 bacitracin-polymyxin b ophth oint 2 BESIVANCE SUS 0.6% 4 CILOXAN OIN 0.3% OP 3 113

127 ciprofloxacin hcl ophth soln 0.3% 2 erythromycin ophth oint 5 mg/gm 2 gatifloxacin ophth soln 0.5% 2 gentak oin 0.3% op 2 gentamicin sulfate ophth oint 0.3% 2 gentamicin sulfate ophth soln 0.3% 2 ilotycin oin op 2 levofloxacin ophth soln 0.5% 2 MOXEZA SOL 0.5% 4 NATACYN SUS 5% OP 3 neomycin-polymy-gramicid op sol mg-unt-mg/ml ofloxacin ophth soln 0.3% 2 polycin oin op 2 polymyxin b-trimethoprim ophth soln unit/ml-0.1% romycin oin op 2 sulfacetamide sodium ophth oint 10% 2 sulfacetamide sodium ophth soln 10% 2 tobramycin ophth soln 0.3% 2 TOBREX OIN 0.3% OP 3 trifluridine ophth soln 1% 2 VIGAMOX DRO 0.5% 3 ZIRGAN GEL 0.15% 4 Ophthalmic Decongestants naphazoline hcl ophth soln 0.1% 2 phenylephrine hcl ophth soln 2.5% 2 phenylephrine hcl ophth soln 10% 2 Ophthalmic Immunomodulators RESTASIS EMU 0.05% 4 Ophthalmic Local Anesthetics parcaine sol 0.5% op 2 proparacaine hcl ophth soln 0.5% 2 Ophthalmic Steroids ALREX SUS 0.2% 4 bacitracin-polymyxin-neomycin-hc ophth 2 oint 1% BLEPHAMIDE OIN S.O.P. 3 BLEPHAMIDE SUS OP 3 dexamethasone sodium phosphate ophth 2 soln 0.1% DUREZOL EMU 0.05% 4 FLAREX SUS 0.1% OP 4 fluorometholone ophth susp 0.1% 2 114

128 FML FORTE SUS 0.25% OP 4 FML OIN 0.1% OP 4 LOTEMAX GEL 0.5% 4 LOTEMAX OIN 0.5% 4 LOTEMAX SUS 0.5% 4 MAXIDEX SUS 0.1% OP 4 neomycin-polymyxin-dexamethasone 2 ophth oint 0.1% neomycin-polymyxin-dexamethasone 2 ophth susp 0.1% neomycin-polymyxin-hc ophth susp 2 poly-dex oin 0.1% op 2 PRED MILD SUS 0.12% OP 3 PRED SOD PHO SOL 1% OP 3 prednisolone acetate ophth susp 1% 2 sulfacetamide sodium-prednisolone ophth 2 soln (0.25)% TOBRADEX OIN % 3 tobramycin-dexamethasone ophth susp % VEXOL SUS 1% OP 4 Ophthalmics - Misc. ALOCRIL SOL 2% 4 ALOMIDE SOL 0.1% OP 4 azelastine hcl ophth soln 0.05% 2 AZOPT SUS 1% OP 4 BEPREVE DRO 1.5% 4 bromfenac sodium ophth soln 0.09% (base 2 equiv) (once-daily) bromfenac sodium ophth soln 0.09% (base 2 equivalent) cromolyn sodium ophth soln 4% 2 diclofenac sodium ophth soln 0.1% 2 dorzolamide hcl ophth soln 2% 2 EMADINE SOL 0.05% OP 4 epinastine hcl ophth soln 0.05% 2 flurbiprofen sodium ophth soln 0.03% 2 ketorolac tromethamine ophth soln 0.4% 2 ketorolac tromethamine ophth soln 0.5% 2 ketotifen fumarate ophth soln 0.025% 2 (base equiv) LASTACAFT SOL 0.25% 4 NEVANAC SUS 0.1% 4 olopatadine hcl ophth soln 0.1% (base 2 equivalent) 115

129 PATADAY SOL 0.2% 4 PATANOL SOL 0.1% OP 4 Prostaglandins - Ophthalmic bimatoprost ophth soln 0.03% 2 latanoprost ophth soln 0.005% 2 LUMIGAN SOL 0.01% 4 ST; PA** TRAVATAN Z DRO 0.004% 4 ST; PA** ZIOPTAN DRO % 4 ST; PA** OTIC AGENTS Otic Agents - Miscellaneous acetic acid 2% in aluminum acetate otic 2 soln acetic acid otic soln 2% 2 Otic Anti-infectives ofloxacin otic soln 0.3% 2 Otic Combinations CIPRO HC SUS OTIC 4 CIPRODEX SUS % 3 CORTISPORIN SUS -TC OTIC 4 neomycin-polymyxin-hc otic soln 1% 2 neomycin-polymyxin-hc otic susp mg/ml unit/ml-1% Otic Steroids fluocinolone acetonide (otic) oil 0.01% 2 hydrocortisone w/ acetic acid otic soln 1-2 2% PASSIVE IMMUNIZING AGENTS Immune Serums BIVIGAM INJ 10% 5 PA CARIMUNE NF INJ 3GM 5 PA CARIMUNE NF INJ 6GM 5 PA CARIMUNE NF INJ 12GM 5 PA FLEBOGAMMA INJ 10/200ML 5 PA FLEBOGAMMA INJ 20/400ML 5 PA FLEBOGAMMA INJ DIF 5% 5 PA FLEBOGAMMA INJ DIF 10% 5 PA GAMASTAN S/D INJ 5 PA GAMMAGARD INJ 1GM/10ML 5 PA GAMMAGARD INJ 2.5GM/25 5 PA GAMMAGARD INJ 5GM/50ML 5 PA GAMMAGARD INJ 10GM/100 5 PA GAMMAGARD INJ 20GM/200 5 PA 116

130 GAMMAGARD INJ 30GM/300 5 PA GAMMAGARD SD INJ 2.5GM HU 5 PA GAMMAGARD SD INJ 5GM HU 5 PA GAMMAGARD SD INJ 10GM HU 5 PA GAMMAKED INJ 1GM/10ML 5 PA GAMMAKED INJ 2.5GM/25 5 PA GAMMAKED INJ 5GM/50ML 5 PA GAMMAKED INJ 10GM/100 5 PA GAMMAKED INJ 20GM/200 5 PA GAMMAPLEX INJ 2.5GM 5 PA GAMMAPLEX INJ 5GM 5 PA GAMMAPLEX INJ 10GM 5 PA GAMMAPLEX INJ 20GM 5 PA GAMUNEX-C INJ 1GM/10ML 5 PA GAMUNEX-C INJ 2.5GM/25 5 PA GAMUNEX-C INJ 5GM/50ML 5 PA GAMUNEX-C INJ 10GM/100 5 PA GAMUNEX-C INJ 20GM/200 5 PA GAMUNEX-C INJ 40/400ML 5 PA HIZENTRA INJ 1GM/5ML 5 PA HIZENTRA INJ 2GM/10ML 5 PA HIZENTRA INJ 4GM/20ML 5 PA HIZENTRA INJ 10/50ML 5 PA OCTAGAM INJ 1GM 5 PA OCTAGAM INJ 2.5GM 5 PA OCTAGAM INJ 2GM/20ML 5 PA OCTAGAM INJ 5GM 5 PA OCTAGAM INJ 5GM/50ML 5 PA OCTAGAM INJ 10/100ML 5 PA OCTAGAM INJ 10GM 5 PA OCTAGAM INJ 20/200ML 5 PA OCTAGAM INJ 25GM 5 PA PRIVIGEN INJ 5 GRAMS 5 PA PRIVIGEN INJ 10GRAMS 5 PA PRIVIGEN INJ 20GRAMS 5 PA PRIVIGEN INJ 40GRAMS 5 PA PENICILLINS Aminopenicillins amoxicillin (trihydrate) cap 250 mg 2 amoxicillin (trihydrate) cap 500 mg 2 amoxicillin (trihydrate) chew tab 125 mg 2 amoxicillin (trihydrate) chew tab 250 mg 2 117

131 amoxicillin (trihydrate) for susp mg/5ml amoxicillin (trihydrate) for susp mg/5ml amoxicillin (trihydrate) for susp mg/5ml amoxicillin (trihydrate) for susp mg/5ml amoxicillin (trihydrate) tab 500 mg 2 amoxicillin (trihydrate) tab 875 mg 2 ampicillin cap 250 mg 2 ampicillin cap 500 mg 2 ampicillin for susp 125 mg/5ml 2 ampicillin for susp 250 mg/5ml 2 ampicillin sodium for inj 1 gm 2 ampicillin sodium for inj 2 gm 2 ampicillin sodium for inj 10 gm 2 ampicillin sodium for inj 125 mg 2 ampicillin sodium for inj 250 mg 2 ampicillin sodium for inj 500 mg 2 ampicillin sodium for iv soln 1 gm 2 ampicillin sodium for iv soln 2 gm 2 ampicillin sodium for iv soln 10 gm 2 Natural Penicillins BICILLIN L-A INJ BICILLIN L-A INJ BICILLIN L-A INJ PEN G PROC INJ PENICILL GK/ INJ DEX 1MU 4 PENICILL GK/ INJ DEX 2MU 4 PENICILL GK/ INJ DEX 3MU 4 penicillin g potassium for inj unit 2 penicillin g potassium for inj unit2 penicillin g sodium for inj unit 2 penicillin v potassium for soln 125 mg/5ml 2 penicillin v potassium for soln 250 mg/5ml 2 penicillin v potassium tab 250 mg 2 penicillin v potassium tab 500 mg 2 pfizerpen-g inj 20mu 2 Penicillin Combinations amoxicillin & k clavulanate chew tab mg amoxicillin & k clavulanate chew tab mg 118

132 amoxicillin & k clavulanate for susp mg/5ml amoxicillin & k clavulanate for susp mg/5ml amoxicillin & k clavulanate for susp mg/5ml amoxicillin & k clavulanate for susp mg/5ml amoxicillin & k clavulanate tab mg2 amoxicillin & k clavulanate tab mg2 amoxicillin & k clavulanate tab mg2 amoxicillin & k clavulanate tab sr 12hr mg ampicillin & sulbactam sodium for inj gm ampicillin & sulbactam sodium for inj gm ampicillin & sulbactam sodium for inj gm ampicillin & sulbactam sodium for iv soln gm ampicillin & sulbactam sodium for iv soln gm ampicillin & sulbactam sodium for iv soln gm AUGMENTIN SUS 125/5ML 3 BICILLIN C-R INJ 900/300 4 BICILLIN C-R INJ piperacillin sod-tazobactam na for inj gm ( gm) piperacillin sod-tazobactam sod for inj gm ( gm) piperacillin sod-tazobactam sod for inj gm (4-0.5 gm) piperacillin sod-tazobactam sod for inj gm ( gm) TIMENTIN INJ 3.1GM 4 TIMENTIN INJ 31GM 4 ZOSYN SOL GM 4 ZOSYN SOL G 4 ZOSYN SOL GM 4 Penicillinase-Resistant Penicillins BACTOCILL INJ DEX 1GM 4 BACTOCILL INJ DEX 2GM 4 dicloxacillin sodium cap 250 mg 2 dicloxacillin sodium cap 500 mg 2 nafcillin sodium for inj 1 gm 2 119

133 nafcillin sodium for inj 2 gm 2 nafcillin sodium for inj 10 gm 2 nafcillin sodium for iv soln 1 gm 2 nafcillin sodium for iv soln 2 gm 2 NALLPEN/DEX INJ 1GM/50ML 4 NALLPEN/DEX INJ 2GM/100 4 oxacillin sodium for inj 1 gm 2 oxacillin sodium for inj 2 gm 2 oxacillin sodium for inj 10 gm 2 PROGESTINS Progestins medroxyprogesterone acetate tab 2.5 mg 2 medroxyprogesterone acetate tab 5 mg 2 medroxyprogesterone acetate tab 10 mg 2 megestrol acetate susp 625 mg/5ml 2 norethindrone acetate tab 5 mg 2 progesterone micronized cap 100 mg 2 progesterone micronized cap 200 mg 2 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. Agents for Chemical Dependency acamprosate calcium tab delayed release 2 PA 333 mg disulfiram tab 250 mg 2 disulfiram tab 500 mg 2 Anti-Cataplectic Agents XYREM SOL 500MG/ML 3 PA Antidementia Agents donepezil hydrochloride orally 2 disintegrating tab 5 mg donepezil hydrochloride orally 2 disintegrating tab 10 mg donepezil hydrochloride tab 5 mg 2 donepezil hydrochloride tab 10 mg 2 donepezil hydrochloride tab 23 mg 2 EXELON DIS 4.6MG/24 4 PA EXELON DIS 9.5MG/24 4 PA EXELON DIS 13.3/24 4 PA EXELON SOL 2MG/ML 3 PA galantamine hydrobromide cap sr 24hr 8 2 mg galantamine hydrobromide cap sr 24hr 16 mg 2 120

134 galantamine hydrobromide cap sr 24hr 24 2 mg galantamine hydrobromide oral soln 4 2 mg/ml galantamine hydrobromide tab 4 mg 2 galantamine hydrobromide tab 8 mg 2 galantamine hydrobromide tab 12 mg 2 memantine hcl oral solution 2 mg/ml 2 PA; PA applies for members less than 30 years of age memantine hcl tab 5 mg 2 PA; PA applies for members less than 30 years of age memantine hcl tab 5 mg (28) & 10 mg (21) titration pak 2 PA; PA applies for members less than 30 years of age memantine hcl tab 10 mg 2 PA; PA applies for members less than 30 years of age NAMENDA SOL 10MG/5ML 3 PA; PA applies for members less than 30 years of age NAMENDA XR CAP 7MG 3 PA; PA applies for members less than 30 years of age NAMENDA XR CAP 14MG 3 PA; PA applies for members less than 30 years of age NAMENDA XR CAP 21MG 3 PA; PA applies for members less than 30 years of age NAMENDA XR CAP 28MG 3 PA; PA applies for members less than 30 years of age NAMENDA XR CAP TITRATIO 3 PA; PA applies for members less than 30 years of age rivastigmine tartrate cap 1.5 mg 2 PA rivastigmine tartrate cap 3 mg 2 PA rivastigmine tartrate cap 4.5 mg 2 PA rivastigmine tartrate cap 6 mg 2 PA rivastigmine td patch 24hr 4.6 mg/24hr 2 PA rivastigmine td patch 24hr 9.5 mg/24hr 2 PA rivastigmine td patch 24hr 13.3 mg/24hr 2 PA Fibromyalgia Agents SAVELLA MIS TITR PAK 4 SAVELLA TAB 12.5MG 4 SAVELLA TAB 25MG 4 SAVELLA TAB 50MG 4 121

135 SAVELLA TAB 100MG 4 Movement Disorder Drug Therapy tetrabenazine tab 12.5 mg 5 PA tetrabenazine tab 25 mg 5 PA Multiple Sclerosis Agents AMPYRA TAB 10MG 5 PA AUBAGIO TAB 7MG 5 PA AUBAGIO TAB 14MG 5 PA BETASERON INJ 0.3MG 5 PA COPAXONE INJ 20MG/ML 5 PA COPAXONE INJ 40MG/ML 5 PA GILENYA CAP 0.5MG 5 PA glatiramer acetate soln prefilled syringe 20 5 PA mg/ml REBIF INJ 22/0.5 5 PA REBIF INJ 44/0.5 5 PA REBIF REBIDO INJ 22/0.5 5 PA REBIF REBIDO INJ 44/0.5 5 PA REBIF REBIDO INJ TITRATN 5 PA REBIF TITRTN INJ PACK 5 PA TYSABRI INJ 300/15ML 5 PA Postherpetic Neuralgia (PHN) Agents GRALISE STAR MIS 300/600 4 ST; PA** GRALISE TAB 300MG 4 ST; PA** GRALISE TAB 600MG 4 ST; PA** Pseudobulbar Affect (PBA) Agents NUEDEXTA CAP 20-10MG 3 Psychotherapeutic and Neurological Agents - Misc. ergoloid mesylates tab 1 mg 2 ORAP TAB 1MG 4 ORAP TAB 2MG 4 pimozide tab 1 mg 2 pimozide tab 2 mg 2 Smoking Deterrents buproban tab 150mg 0 $0 limited to 2 treatment cycles/year bupropion hcl (smoking deterrent) tab sr 12hr 150 mg 0 $0 limited to 2 treatment cycles/year CHANTIX PAK 0.5& 1MG 0 $0 limited to 2 treatment cycles/year CHANTIX PAK 1MG 0 $0 limited to 2 treatment cycles/year CHANTIX TAB 0.5MG 0 $0 limited to 2 treatment cycles/year 122

136 CHANTIX TAB 1MG 0 $0 limited to 2 treatment cycles/year nicotine polacrilex gum 2 mg 0 OTC; $0 limited to 2 treatment cycles/year nicotine polacrilex gum 4 mg 0 OTC; $0 limited to 2 treatment cycles/year nicotine polacrilex lozenge 2 mg 0 OTC; $0 limited to 2 treatment cycles/year nicotine polacrilex lozenge 4 mg 0 OTC; $0 limited to 2 treatment cycles/year nicotine td patch 24hr 7 mg/24hr 0 OTC; $0 limited to 2 treatment cycles/year nicotine td patch 24hr 14 mg/24hr 0 OTC; $0 limited to 2 treatment cycles/year nicotine td patch 24hr 21 mg/24hr 0 OTC; $0 limited to 2 treatment cycles/year NICOTROL INH 0 QL (max 168 days per year); $0 limited to 2 treatment cycles/year NICOTROL NS SPR 10MG/ML 0 QL (max 168 days per year); $0 limited to 2 treatment cycles/year sm nicotine dis 7mg/24hr 0 OTC; $0 limited to 2 treatment cycles/year sm nicotine dis 14mg/24h 0 OTC; $0 limited to 2 treatment cycles/year sm nicotine dis 21mg 0 OTC; $0 limited to 2 treatment cycles/year thrive gum 4mg mint 0 OTC; $0 limited to 2 treatment cycles/year RESPIRATORY AGENTS - MISC. Alpha-Proteinase Inhibitor (Human) ARALAST NP INJ 400MG 5 PA ARALAST NP INJ 500MG 5 PA ARALAST NP INJ 800MG 5 PA ARALAST NP INJ 1000MG 5 PA GLASSIA INJ 5 PA PROLASTIN-C INJ 1000MG 5 PA ZEMAIRA INJ 1000MG 5 PA Cystic Fibrosis Agents KALYDECO PAK 50MG 5 PA KALYDECO PAK 75MG 5 PA KALYDECO TAB 150MG 5 PA ORKAMBI TAB PA SULFONAMIDES Sulfonamides 123

137 SULFADIAZINE TAB 500MG 4 TETRACYCLINES Tetracyclines avidoxy tab 100mg 2 demeclocycline hcl tab 150 mg 2 demeclocycline hcl tab 300 mg 2 doxy 100 inj 100mg 2 doxycycline hyclate cap 50 mg 2 doxycycline hyclate cap 100 mg 2 doxycycline hyclate for inj 100 mg 2 doxycycline hyclate tab 20 mg 2 doxycycline hyclate tab 100 mg 2 doxycycline hyclate tab delayed release 75 2 mg doxycycline hyclate tab delayed release mg doxycycline hyclate tab delayed release mg doxycycline monohydrate cap 50 mg 2 doxycycline monohydrate cap 75 mg 2 doxycycline monohydrate cap 100 mg 2 doxycycline monohydrate cap 150 mg 2 doxycycline monohydrate for susp 25 2 mg/5ml doxycycline monohydrate tab 50 mg 2 doxycycline monohydrate tab 75 mg 2 doxycycline monohydrate tab 150 mg 2 minocycline hcl cap 50 mg 2 minocycline hcl cap 75 mg 2 minocycline hcl cap 100 mg 2 minocycline hcl tab 50 mg 2 minocycline hcl tab 75 mg 2 minocycline hcl tab 100 mg 2 minocycline hcl tab sr 24hr 45 mg 2 minocycline hcl tab sr 24hr 90 mg 2 minocycline hcl tab sr 24hr 135 mg 2 morgidox cap 1x100mg 2 tetracycline hcl cap 250 mg 2 tetracycline hcl cap 500 mg 2 VIBRAMYCIN SYP 50MG/5ML 4 THYROID AGENTS Antithyroid Agents methimazole tab 5 mg 2 124

138 methimazole tab 10 mg 2 propylthiouracil tab 50 mg 2 Thyroid Hormones levothyroxine sodium tab 25 mcg 2 levothyroxine sodium tab 50 mcg 2 levothyroxine sodium tab 75 mcg 2 levothyroxine sodium tab 88 mcg 2 levothyroxine sodium tab 100 mcg 2 levothyroxine sodium tab 112 mcg 2 levothyroxine sodium tab 125 mcg 2 levothyroxine sodium tab 137 mcg 2 levothyroxine sodium tab 150 mcg 2 levothyroxine sodium tab 175 mcg 2 levothyroxine sodium tab 200 mcg 2 levothyroxine sodium tab 300 mcg 2 levoxyl tab 25mcg 2 levoxyl tab 50mcg 2 levoxyl tab 75mcg 2 levoxyl tab 88mcg 2 levoxyl tab 100mcg 2 levoxyl tab 112mcg 2 levoxyl tab 125mcg 2 levoxyl tab 137mcg 2 levoxyl tab 150mcg 2 levoxyl tab 175mcg 2 levoxyl tab 200mcg 2 liothyronine sodium iv soln 10 mcg/ml 2 liothyronine sodium tab 5 mcg 2 liothyronine sodium tab 25 mcg 2 liothyronine sodium tab 50 mcg 2 SYNTHROID TAB 25MCG 3 SYNTHROID TAB 50MCG 3 SYNTHROID TAB 75MCG 3 SYNTHROID TAB 88MCG 3 SYNTHROID TAB 100MCG 3 SYNTHROID TAB 112MCG 3 SYNTHROID TAB 125MCG 3 SYNTHROID TAB 137MCG 3 SYNTHROID TAB 150MCG 3 SYNTHROID TAB 175MCG 3 SYNTHROID TAB 200MCG 3 SYNTHROID TAB 300MCG 3 THYROLAR-1 TAB 60MG 4 125

139 THYROLAR-1/2 TAB 30MG 4 THYROLAR-1/4 TAB 15MG 4 THYROLAR-2 TAB 120MG 4 THYROLAR-3 TAB 180MG 4 unithroid tab 25mcg 2 unithroid tab 50mcg 2 unithroid tab 75mcg 2 unithroid tab 88mcg 2 unithroid tab 100mcg 2 unithroid tab 112mcg 2 unithroid tab 125mcg 2 unithroid tab 200mcg 2 unithroid tab 300mcg 2 TOXOIDS Toxoid Combinations ADACEL INJ 0 BOOSTRIX INJ 0 DAPTACEL INJ 0 $0 copay for members age 18 and younger DIP/TET PED INJ 25-5LFU 0 $0 copay for members age 18 and younger INFANRIX INJ 0 $0 copay for members age 18 and younger KINRIX INJ 0 $0 copay for members age 18 and younger PEDIARIX INJ 0.5ML 0 $0 copay for members age 18 and younger PENTACEL INJ 0 $0 copay for members age 18 and younger TENIVAC INJ 5-2LF 0 $0 copay for members age 19 and TET/DIP TOX INJ 2-2 LF 0 $0 copay for members age 19 and TRIPEDIA SUS P/F 0 $0 copay for members age 18 and younger ULCER DRUGS Antispasmodics ATROPEN INJ 0.5MG 4 ATROPEN INJ 0.25MG 4 ATROPEN INJ 1MG 4 ATROPEN INJ 2MG 4 atropine sulfate inj 0.1 mg/ml 2 atropine sulfate inj 0.4 mg/ml 2 atropine sulfate inj 0.8 mg/ml 2 126

140 atropine sulfate inj 0.05 mg/ml 2 atropine sulfate inj 1 mg/ml 2 BENTYL INJ 10MG/ML 4 CANTIL TAB 25MG 4 chlordiazepoxide hcl-clidinium bromide cap mg CUVPOSA SOL 1MG/5ML 3 dicyclomine hcl cap 10 mg 2 dicyclomine hcl inj 10 mg/ml 2 dicyclomine hcl oral soln 10 mg/5ml 2 dicyclomine hcl tab 20 mg 2 ed-spaz tab 0.125mg 2 glycopyrrolate inj 0.2 mg/ml 2 glycopyrrolate inj 0.4 mg/2ml (0.2 mg/ml) 2 glycopyrrolate inj 1 mg/5ml (0.2 mg/ml) 2 glycopyrrolate inj 4 mg/20ml (0.2 mg/ml) 2 glycopyrrolate tab 1 mg 2 glycopyrrolate tab 2 mg 2 hyomax-sl sub 0.125mg 2 hyoscyamine sulfate tab mg 2 hyoscyamine sulfate tab disp mg 2 hyoscyamine sulfate tab sl mg 2 hyoscyamine sulfate tab sr 12hr mg 2 methscopolamine bromide tab 2.5 mg 2 methscopolamine bromide tab 5 mg 2 nulev tab 0.125mg 2 oscimin sr tab 0.375mg 2 oscimin sub 0.125mg 2 oscimin tab 0.125mg 2 symax fastab tab 0.125mg 2 symax-sl sub 0.125mg 2 H-2 Antagonists cimetidine hcl soln 300 mg/5ml 2 cimetidine tab 200 mg 2 cimetidine tab 300 mg 2 cimetidine tab 400 mg 2 cimetidine tab 800 mg 2 famotidine for susp 40 mg/5ml 2 famotidine in nacl 0.9% iv soln 20 2 mg/50ml famotidine inj 20 mg/2ml 2 famotidine inj 40 mg/4ml 2 famotidine inj 200 mg/20ml 2 127

141 famotidine inj 500 mg/50ml 2 famotidine tab 20 mg 2 famotidine tab 40 mg 2 nizatidine cap 150 mg 2 nizatidine cap 300 mg 2 nizatidine oral soln 15 mg/ml 2 ranitidine hcl cap 150 mg 2 ranitidine hcl cap 300 mg 2 ranitidine hcl inj 50 mg/2ml (25 mg/ml) 2 ranitidine hcl inj 150 mg/6ml (25 mg/ml) 2 ranitidine hcl inj 1000 mg/40ml (25 2 mg/ml) ranitidine hcl syrup 15 mg/ml (75 mg/5ml) 2 ranitidine hcl tab 150 mg 2 ranitidine hcl tab 300 mg 2 ZANTAC INJ 50/50ML 4 ZANTAC TAB 25MG EF 4 Misc. Anti-Ulcer CARAFATE SUS 1GM/10ML 4 sucralfate tab 1 gm 2 Proton Pump Inhibitors DEXILANT CAP 30MG DR 4 QL (90 caps / 365 days), ST; PA** DEXILANT CAP 60MG DR 4 QL (90 caps / 365 days), ST; PA** esomeprazole magnesium cap delayed 2 QL (90 caps / 365 days) release 20 mg (base eq) esomeprazole magnesium cap delayed 2 QL (90 caps / 365 days) release 40 mg (base eq) esomeprazole sodium for intravenous soln 2 20 mg (base equiv) esomeprazole sodium for intravenous soln 2 40 mg (base equiv) lansoprazole cap delayed release 15 mg 2 QL (90 caps / 365 days) lansoprazole cap delayed release 30 mg 2 QL (90 caps / 365 days) NEXIUM GRA 2.5MG DR 4 QL (90 packets / 365 days) NEXIUM GRA 5MG DR 4 QL (90 packets / 365 days) NEXIUM GRA 10MG DR 4 QL (90 packets / 365 days) NEXIUM GRA 20MG DR 4 QL (90 packets / 365 days) NEXIUM GRA 40MG DR 4 QL (90 packets / 365 days) omeprazole cap delayed release 10 mg 2 QL (90 caps / 365 days) 128

142 omeprazole cap delayed release 20 mg 2 QL (90 caps / 365 days) omeprazole cap delayed release 40 mg 2 QL (90 caps / 365 days) pantoprazole sodium ec tab 20 mg (base 2 QL (90 tabs / 365 days) equiv) pantoprazole sodium ec tab 40 mg (base 2 QL (90 tabs / 365 days) equiv) rabeprazole sodium ec tab 20 mg 2 QL (90 tabs / 365 days) Ulcer Drugs - Prostaglandins misoprostol tab 100 mcg 2 misoprostol tab 200 mcg 2 Ulcer Therapy Combinations omeprazole-sodium bicarbonate cap 20-2 QL (90 caps / 365 days) 1100 mg omeprazole-sodium bicarbonate cap mg 2 QL (90 caps / 365 days) URINARY ANTI-INFECTIVES Urinary Anti-infectives MACRODANTIN CAP 25MG 3 PA; High Risk Medications require PA for members age 65 and ; PA applies to greater than cumulative 90 days of therapy per year methenamine hippurate tab 1 gm 2 MONUROL PAK GRANULES 4 nitrofurantoin macrocrystalline cap 25 mg 2 PA; High Risk Medications require PA for members age 65 and ; PA applies to greater than cumulative 90 days of therapy per year nitrofurantoin macrocrystalline cap 50 mg 2 PA; High Risk Medications require PA for members age 65 and ; PA applies to greater than cumulative 90 days of therapy per year nitrofurantoin macrocrystalline cap 100 mg 2 PA; High Risk Medications require PA for members age 65 and ; PA applies to greater than cumulative 90 days of therapy per year 129

143 nitrofurantoin monohydrate macrocrystalline cap 100 mg 2 PA; High Risk Medications require PA for members age 65 and ; PA applies to greater than cumulative 90 days of therapy per year nitrofurantoin susp 25 mg/5ml 2 PA; High Risk Medications require PA for members age 65 and ; PA applies to greater than cumulative 90 days of therapy per year URINARY ANTISPASMODICS Beta-3 Adrenergic Agonists MYRBETRIQ TAB 25MG 4 ST; PA** MYRBETRIQ TAB 50MG 4 ST; PA** Urinary Antispasmodics bethanechol chloride tab 5 mg 2 bethanechol chloride tab 10 mg 2 bethanechol chloride tab 25 mg 2 bethanechol chloride tab 50 mg 2 darifenacin hydrobromide tab sr 24hr mg (base equiv) darifenacin hydrobromide tab sr 24hr 15 2 mg (base equiv) ENABLEX TAB 7.5MG 4 ENABLEX TAB 15MG 4 flavoxate hcl tab 100 mg 2 GELNIQUE GEL 3% 4 ST; PA** GELNIQUE GEL 10% 4 ST; PA** oxybutynin chloride syrup 5 mg/5ml 2 oxybutynin chloride tab 5 mg 2 oxybutynin chloride tab sr 24hr 5 mg 2 oxybutynin chloride tab sr 24hr 10 mg 2 oxybutynin chloride tab sr 24hr 15 mg 2 OXYTROL DIS 3.9MG/24 4 ST; PA** tolterodine tartrate cap sr 24hr 2 mg 2 tolterodine tartrate cap sr 24hr 4 mg 2 tolterodine tartrate tab 1 mg 2 tolterodine tartrate tab 2 mg 2 TOVIAZ TAB 4MG 4 ST; PA** TOVIAZ TAB 8MG 4 ST; PA** trospium chloride cap sr 24hr 60 mg 2 trospium chloride tab 20 mg 2 130

144 VESICARE TAB 5MG 4 ST; PA** VESICARE TAB 10MG 4 ST; PA** VACCINES Bacterial Vaccines ACTHIB INJ 0 $0 copay for members age 18 and younger BEXSERO INJ 0 HIBERIX SOL 10MCG 0 $0 copay for members age 18 and younger MENACTRA INJ 0 MENHIBRIX INJ 0 $0 copay for members age 18 and younger MENOMUNE INJ A/C/Y/W 0 MENVEO INJ 0 PEDVAX HIB INJ 0 $0 copay for members age 18 and younger PNEUMOVAX 23 INJ 25/0.5 0 PREVNAR 13 INJ 0 TRUMENBA INJ 0 Mixed Vaccine Combinations COMVAX INJ 0 $0 copay for members age 18 and younger Viral Vaccines AFLURIA INJ AFLURIA INJ PF CERVARIX INJ 0 ENGERIX-B INJ 10/0.5ML 0 ENGERIX-B INJ 20MCG/ML 0 FLUBLOK SOL FLUCELVAX INJ FLUMIST QUAD SUS FLUVIRIN INJ FLUZONE HD INJ PF FLUZONE INJ INTRADRM 0 FLUZONE QUAD INJ FLUZONE SPLT INJ GARDASIL 9 INJ 0 GARDASIL INJ 0 HAVRIX INJ 720UNIT 0 HAVRIX INJ 1440UNIT 0 INFLUENZA A SPR 09 H1N1 0 IPOL INJ INACTIVE 0 $0 copay for members age 18 and younger M-M-R II INJ 0 131

145 PROQUAD INJ 0 $0 copay for members age 18 and younger RECOMBIVA HB INJ 5MCG/0.5 0 RECOMBIVA HB INJ 10MCG/ML 0 RECOMBIVA-HB INJ 40MCG/ML 0 ROTARIX SUS 0 $0 copay for members age 18 and younger ROTATEQ SOL 0 $0 copay for members age 18 and younger TWINRIX INJ 0 $0 copay for members age 19 and VAQTA INJ 25/0.5ML 0 VAQTA INJ 50UNT/ML 0 VARIVAX INJ 0 ZOSTAVAX INJ 0 $0 copay for members age 19 and VAGINAL PRODUCTS Spermicides CONCEPTROL GEL 4% 0 OTC ENCARE SUP 100MG 0 OTC GYNOL II GEL 3% 0 OTC SHUR-SEAL GEL 2% 0 OTC TODAY SPONGE MIS 0 OTC VCF VAGINAL AER CONTRACP 0 OTC VCF VAGINAL MIS CONTRACP 0 OTC Vaginal Anti-infectives CLEOCIN SUP 100MG 3 clindamycin phosphate vaginal cream 2% 2 GYNAZOLE-1 CRE 2% 4 metronidazole vaginal gel 0.75% 2 miconazole 3 kit combo pk 2 miconazole 3 sup 200mg 2 terconazole vaginal cream 0.4% 2 terconazole vaginal suppos 80 mg 2 vandazole gel 0.75% 2 zazole cre 0.4% 2 zazole cre 0.8% 2 zazole sup 80mg 2 Vaginal Estrogens ESTRACE VAG CRE 0.1MG/GM 3 ESTRING MIS 2MG 4 FEMRING MIS 0.1MG/24 4 FEMRING MIS 0.05/24H 4 PREMARIN VAG CRE 0.625MG 4 132

146 VAGIFEM TAB 10MCG 4 Vaginal Progestins CRINONE GEL 4% VAG 3 CRINONE GEL 8% VAG 3 VASOPRESSORS Anaphylaxis Therapy Agents epinephrine hcl inj 1 mg/ml 2 epinephrine hcl soln prefilled syringe mg/ml epinephrine solution auto-injector mg/0.3ml (1:1000) epinephrine solution auto-injector mg/0.15ml (1:1000) EPIPEN 2-PAK INJ 0.3MG 3 EPIPEN-JR INJ 2-PAK 3 Vasopressors midodrine hcl tab 2.5 mg 2 midodrine hcl tab 5 mg 2 midodrine hcl tab 10 mg 2 VITAMINS Oil Soluble Vitamins BABY SUPER DRO DAILY D3 0 OTC; $0 applies for ages 65 and bio-d-mulsio liq 400unit 0 OTC; $0 applies for ages 65 and child vit d chw 400unit 0 OTC; $0 applies for ages 65 and cholecalciferol cap 400 unit 0 OTC; $0 applies for ages 65 and D-VI-SOL LIQ 400UNIT 0 OTC; $0 applies for ages 65 and decara cap 50000unt 2 OTC ergocalciferol cap unit 2 MEPHYTON TAB 5MG 3 pedia d-vite dro 400unit 0 OTC; $0 applies for ages 65 and sm vitamin d tab 400unit 0 OTC; $0 applies for ages 65 and VITAMIN D2 TAB 400UNIT 0 OTC; $0 applies for ages 65 and VITAMIN D3 LIQ 1000UNIT 0 OTC; $0 applies for ages 65 and VITAMIN D3 LIQ 1200UNIT 0 OTC; $0 applies for ages 65 and 133

147 Index 8 8-MOP CAP 10MG 83 A a-hydrocort inj 100mg 76 a-methapred inj 125mg 76 a-methapred inj 40mg 76 abacavir sulfate tab 300 mg (base equiv) 60 abacavir sulfate-lamivudine-zidovudine tab mg 60 ABELCET INJ 5MG/ML 36 ABILIFY DISC TAB 10MG 59 ABILIFY DISC TAB 15MG 59 ABRAXANE INJ 100MG 53 ABSTRAL SUB 100MCG 7 ABSTRAL SUB 200MCG 7 ABSTRAL SUB 300MCG 7 ABSTRAL SUB 400MCG 7 ABSTRAL SUB 600MCG 7 ABSTRAL SUB 800MCG 7 acamprosate calcium tab delayed release 333 mg 120 ACANYA GEL % 79 acarbose tab 100 mg 31 acarbose tab 25 mg 31 acarbose tab 50 mg 31 acebutolol hcl cap 200 mg 65 acebutolol hcl cap 400 mg 65 acetaminophen w/ codeine soln mg/5ml 11 acetaminophen w/ codeine tab mg 11 acetaminophen w/ codeine tab mg 11 acetaminophen w/ codeine tab mg 11 acetazolamide cap sr 12hr 500 mg 88 acetazolamide sodium for inj 500 mg 88 acetazolamide tab 125 mg 88 acetazolamide tab 250 mg 88 acetic acid 2% in aluminum acetate otic soln 116 acetic acid otic soln 2% 116 acetylcysteine inhal soln 10% 79 acetylcysteine inhal soln 20% 79 acitretin cap 10 mg 83 acitretin cap 17.5 mg 83 acitretin cap 25 mg 83 ACTEMRA INJ 162/0.9 4 ACTEMRA INJ 200/10ML 4 ACTEMRA INJ 400/20ML 4 ACTEMRA INJ 80MG/4ML 4 ACTHIB INJ 131 acticin cre 5% 87 ACTIMMUNE INJ 2MU/ acyclovir cap 200 mg 63 acyclovir oint 5% 84 acyclovir sodium for inj 1000 mg 63 acyclovir sodium for inj 500 mg 63 acyclovir sodium iv soln 50 mg/ml 63 acyclovir susp 200 mg/5ml 63 acyclovir tab 400 mg 63 acyclovir tab 800 mg 63 ADACEL INJ 126 ADAGEN INJ 250/ML 67 adapalene cream 0.1% 79 adapalene gel 0.1% 79 adapalene gel 0.3% 79 adapalene lotion 0.1% 79 ADCIRCA TAB 20MG 70 adefovir dipivoxil tab 10 mg 62 adriamycin inj 10mg 50 ADRIAMYCIN INJ 20MG 50 adrucil inj 500/10ml 47 ADULT RESPIRATORY MASK 106 ADVAIR DISKU AER 100/50 20 ADVAIR DISKU AER 250/50 20 ADVAIR DISKU AER 500/50 20 ADVAIR HFA AER 115/21 20 ADVAIR HFA AER 230/21 20 ADVAIR HFA AER 45/21 20 afeditab tab 30mg cr 67 afeditab tab 60mg cr 67 AFINITOR DIS TAB 2MG 51 AFINITOR DIS TAB 3MG 51 AFINITOR DIS TAB 5MG 51 AFINITOR TAB 10MG 51 AFINITOR TAB 2.5MG 51 AFINITOR TAB 5MG 51 AFINITOR TAB 7.5MG 51 AFLURIA INJ AFLURIA INJ PF AKNE-MYCIN OIN 2% 79 ala cort cre 1% 84 alagesic lq sol 6 ALBENZA TAB 200MG 13 albuterol sulfate soln nebu 0.083% (2.5 mg/3ml) 20 albuterol sulfate soln nebu 0.5% (5 mg/ml) 20 albuterol sulfate soln nebu 0.63 mg/3ml (base equiv) 20 albuterol sulfate soln nebu 1.25 mg/3ml (base equiv) 20 albuterol sulfate syrup 2 mg/5ml 20 albuterol sulfate tab 2 mg 20 albuterol sulfate tab 4 mg 20 albuterol sulfate tab sr 12hr 4 mg 20 albuterol sulfate tab sr 12hr 8 mg 20 alclometasone dipropionate cream 0.05% 84 alclometasone dipropionate oint 0.05% 84 ALCOHOL PREP WIPES AND SWABS 106 ALDACTAZIDE TAB 50/50 88 ALDURAZYME INJ 2.9MG/5M 92 alendronate sodium oral soln

148 mg/75ml 89 alendronate sodium tab 10 mg 90 alendronate sodium tab 35 mg 90 alendronate sodium tab 40 mg 90 alendronate sodium tab 5 mg 90 alendronate sodium tab 70 mg 90 ALFERON N INJ 5MU/ML 52 alfuzosin hcl tab sr 24hr 10 mg 99 ALIMTA INJ 100MG 47 ALIMTA INJ 500MG 47 ALINIA SUS 100/5ML 14 ALINIA TAB 500MG 14 ALKERAN TAB 2MG 46 ALLFEN CDX LIQ 78 allopurinol sodium for inj 500 mg 100 allopurinol tab 100 mg 100 allopurinol tab 300 mg 100 almotriptan malate tab 12.5 mg 106 almotriptan malate tab 6.25 mg 106 ALOCRIL SOL 2% 115 ALOMIDE SOL 0.1% OP 115 alosetron hcl tab 0.5 mg (base equiv) 98 alosetron hcl tab 1 mg (base equiv) 98 ALOXI INJ 0.25MG/5 35 ALPHAGAN P SOL 0.1% 113 alphatrex gel 0.05% 84 ALPRAZOLAM CON 1 MG/ML 17 alprazolam orally disintegrating tab 0.25 mg 17 alprazolam orally disintegrating tab 0.5 mg 17 alprazolam orally disintegrating tab 1 mg 17 alprazolam orally disintegrating tab 2 mg 17 alprazolam tab 0.25 mg 17 alprazolam tab 0.5 mg 17 alprazolam tab 1 mg 17 alprazolam tab 2 mg 17 ALREX SUS 0.2% 114 ALTABAX OIN 1% 82 altavera tab 73 alyacen tab 1/35 73 alyacen tab 7/7/7 73 amantadine hcl cap 100 mg 55 amantadine hcl syrup 50 mg/5ml 55 amantadine hcl tab 100 mg 55 AMBISOME INJ 50MG 36 amcinonide cream 0.1% 84 amcinonide lotion 0.1% 84 AMCINONIDE OIN 0.1% 84 amethia tab 73 amethyst tab 90-20mcg 73 amifostine crystalline for inj 500 mg 53 amikacin sulfate inj 1 gm/4ml (250 mg/ml) 3 amikacin sulfate inj 500 mg/2ml (250 mg/ml) 3 amiloride & hydrochlorothiazide tab 5-50 mg 88 amiloride hcl tab 5 mg 89 aminophylline inj 25 mg/ml 21 amiodarone hcl inj 150 mg/3ml (50 mg/ml) 18 amiodarone hcl inj 450 mg/9ml (50 mg/ml) 18 amiodarone hcl inj 900 mg/18ml (50 mg/ml) 18 amiodarone hcl tab 200 mg 19 amiodarone hcl tab 400 mg 19 amitriptyline hcl tab 10 mg 29 amitriptyline hcl tab 100 mg 29 amitriptyline hcl tab 150 mg 29 amitriptyline hcl tab 25 mg 29 amitriptyline hcl tab 50 mg 29 amitriptyline hcl tab 75 mg 29 amlodipine besylate tab 10 mg 67 amlodipine besylate tab 2.5 mg 67 amlodipine besylate tab 5 mg 67 amlodipine besylate-atorvastatin calcium tab mg 70 amlodipine besylate-atorvastatin calcium tab mg 70 amlodipine besylate-atorvastatin calcium tab mg 70 amlodipine besylate-atorvastatin calcium tab mg 70 amlodipine besylate-atorvastatin calcium tab mg 69 amlodipine besylate-atorvastatin calcium tab mg 69 amlodipine besylate-atorvastatin calcium tab mg 69 amlodipine besylate-atorvastatin calcium tab 5-10 mg 69 amlodipine besylate-atorvastatin calcium tab 5-20 mg 69 amlodipine besylate-atorvastatin calcium tab 5-40 mg 69 amlodipine besylate-atorvastatin calcium tab 5-80 mg 70 amlodipine besylate-benazepril hcl cap mg 42 amlodipine besylate-benazepril hcl cap mg 42 amlodipine besylate-benazepril hcl cap mg 42 amlodipine besylate-benazepril hcl cap 5-10 mg 42 amlodipine besylate-benazepril hcl cap 5-20 mg 42 amlodipine besylate-benazepril hcl cap 5-40 mg 42 amlodipine besylate-valsartan tab mg 43 amlodipine besylate-valsartan tab mg 43 amlodipine besylate-valsartan tab mg 42 amlodipine besylate-valsartan tab mg 43 amlodipine-valsartan-hydrochlorothiazide 135

149 tab mg 43 amlodipine-valsartan-hydrochlorothiazide tab mg 43 amlodipine-valsartan-hydrochlorothiazide tab mg 43 amlodipine-valsartan-hydrochlorothiazide tab mg 43 amlodipine-valsartan-hydrochlorothiazide tab mg 43 AMMONIUM CHL INJ 5MEQ/ML 107 amnesteem cap 10mg 79 amnesteem cap 20mg 79 amnesteem cap 40mg 79 amoxapine tab 100 mg 29 amoxapine tab 150 mg 29 amoxapine tab 25 mg 29 amoxapine tab 50 mg 29 amoxicillin & k clavulanate chew tab mg 118 amoxicillin & k clavulanate chew tab mg 118 amoxicillin & k clavulanate for susp mg/5ml 119 amoxicillin & k clavulanate for susp mg/5ml 119 amoxicillin & k clavulanate for susp mg/5ml 119 amoxicillin & k clavulanate for susp mg/5ml 119 amoxicillin & k clavulanate tab mg 119 amoxicillin & k clavulanate tab mg 119 amoxicillin & k clavulanate tab mg 119 amoxicillin & k clavulanate tab sr 12hr mg 119 amoxicillin (trihydrate) cap 250 mg 117 amoxicillin (trihydrate) cap 500 mg 117 amoxicillin (trihydrate) chew tab 125 mg 117 amoxicillin (trihydrate) chew tab 250 mg 117 amoxicillin (trihydrate) for susp 125 mg/5ml 118 amoxicillin (trihydrate) for susp 200 mg/5ml 118 amoxicillin (trihydrate) for susp 250 mg/5ml 118 amoxicillin (trihydrate) for susp 400 mg/5ml 118 amoxicillin (trihydrate) tab 500 mg 118 amoxicillin (trihydrate) tab 875 mg 118 amphetamine-dextroamphetamine cap sr 24hr 10 mg 1 amphetamine-dextroamphetamine cap sr 24hr 15 mg 1 amphetamine-dextroamphetamine cap sr 24hr 20 mg 1 amphetamine-dextroamphetamine cap sr 24hr 25 mg 1 amphetamine-dextroamphetamine cap sr 24hr 30 mg 1 amphetamine-dextroamphetamine cap sr 24hr 5 mg 1 amphetamine-dextroamphetamine tab 10 mg 1 amphetamine-dextroamphetamine tab 12.5 mg 1 amphetamine-dextroamphetamine tab 15 mg 1 amphetamine-dextroamphetamine tab 20 mg 1 amphetamine-dextroamphetamine tab 30 mg 1 amphetamine-dextroamphetamine tab 5 mg 1 amphetamine-dextroamphetamine tab 7.5 mg 1 AMPHOTEC INJ 100MG 36 AMPHOTEC INJ 50MG 36 amphotericin b for inj 50 mg 36 ampicillin & sulbactam sodium for inj gm 119 ampicillin & sulbactam sodium for inj 10-5 gm 119 ampicillin & sulbactam sodium for inj 2-1 gm 119 ampicillin & sulbactam sodium for iv soln gm 119 ampicillin & sulbactam sodium for iv soln 10-5 gm 119 ampicillin & sulbactam sodium for iv soln 2-1 gm 119 ampicillin cap 250 mg 118 ampicillin cap 500 mg 118 ampicillin for susp 125 mg/5ml 118 ampicillin for susp 250 mg/5ml 118 ampicillin sodium for inj 1 gm 118 ampicillin sodium for inj 10 gm 118 ampicillin sodium for inj 125 mg 118 ampicillin sodium for inj 2 gm 118 ampicillin sodium for inj 250 mg 118 ampicillin sodium for inj 500 mg 118 ampicillin sodium for iv soln 1 gm 118 ampicillin sodium for iv soln 10 gm 118 ampicillin sodium for iv soln 2 gm 118 AMPYRA TAB 10MG 122 ANADROL-50 TAB 50MG 12 anagrelide hcl cap 0.5 mg 100 anagrelide hcl cap 1 mg 100 anastrozole tab 1 mg 49 ANDROXY TAB 10MG 13 ANTIVERT TAB 50MG 36 ANZEMET TAB 100MG 35 ANZEMET TAB 50MG 35 apexicon oin 0.05% 84 APIDRA INJ SOLOSTAR 33 APIDRA INJ U APLENZIN TAB 174MG 26 APLENZIN TAB 348MG 26 APLENZIN TAB 522MG 26 APOKYN INJ 10MG/ML

150 apraclonidine hcl ophth soln 0.5% (base equivalent) 113 apri tab 73 APRISO CAP 0.375GM 98 APTIVUS CAP 250MG 60 APTIVUS SOL 60 ARALAST NP INJ 1000MG 123 ARALAST NP INJ 400MG 123 ARALAST NP INJ 500MG 123 ARALAST NP INJ 800MG 123 aranelle tab 73 ARANESP INJ 100MCG 101 ARANESP INJ 10MCG 101 ARANESP INJ 150MCG 101 ARANESP INJ 200MCG 101 ARANESP INJ 25MCG 101 ARANESP INJ 300MCG 101 ARANESP INJ 40MCG 101 ARANESP INJ 500MCG 101 ARANESP INJ 60MCG 101 arbinoxa sol 4mg/5ml 37 ARCALYST INJ 220MG 4 ARCAPTA CAP 75MCG 20 ARGATROBAN INJ 125/ argatroban inj 250 mg/2.5ml (concentrate for iv infusion) 23 ARGATROBAN INJ 250/ aripiprazole oral solution 1 mg/ml 59 aripiprazole tab 10 mg 60 ARIPIPRAZOLE TAB 10MG ODT 60 aripiprazole tab 15 mg 60 ARIPIPRAZOLE TAB 15MG ODT 60 aripiprazole tab 2 mg 59 aripiprazole tab 20 mg 60 aripiprazole tab 30 mg 60 aripiprazole tab 5 mg 59 ARRANON INJ 5MG/ML 47 ARZERRA CON 100/5ML 49 ARZERRA CON 1000/50 49 ASMANEX 120 AER 220MCG 19 ASMANEX 30 AER 110MCG 19 ASMANEX 60 AER 220MCG 19 ASMANEX HFA AER 100 MCG 19 ASMANEX HFA AER 200 MCG 19 aspirin chew tab 81 mg 7 aspirin low tab 81mg ec 7 aspirin tab 325 mg 7 aspirin tab 81 mg 7 aspirin tab delayed release 325 mg 7 aspirin-dipyridamole cap sr 12hr mg 100 astramorph inj 1mg/2ml 7 astramorph inj 2mg/2ml 7 atenolol & chlorthalidone tab mg43 atenolol & chlorthalidone tab mg 43 atenolol tab 100 mg 65 atenolol tab 25 mg 65 atenolol tab 50 mg 65 ATGAM INJ 250MG 64 atorvastatin calcium tab 10 mg (base equivalent) 39 atorvastatin calcium tab 20 mg (base equivalent) 39 atorvastatin calcium tab 40 mg (base equivalent) 39 atorvastatin calcium tab 80 mg (base equivalent) 39 atovaquone susp 750 mg/5ml 14 atovaquone-proguanil hcl tab mg 45 atovaquone-proguanil hcl tab mg 45 ATRALIN GEL 0.05% 79 ATRIPLA TAB 60 ATROPEN INJ 0.25MG 126 ATROPEN INJ 0.5MG 126 ATROPEN INJ 1MG 126 ATROPEN INJ 2MG 126 atropine sulfate inj 0.05 mg/ml 127 atropine sulfate inj 0.1 mg/ml 126 atropine sulfate inj 0.4 mg/ml 126 atropine sulfate inj 0.8 mg/ml 126 atropine sulfate inj 1 mg/ml 127 atropine sulfate ophth soln 1% 113 AUBAGIO TAB 14MG 122 AUBAGIO TAB 7MG 122 AUGMENTIN SUS 125/5ML 119 avar cleanse emu 10-5% 79 avar-e emoll cre 10-5% 79 avar-e green cre 10-5% 79 AVELOX INJ 97 aviane tab 73 avidoxy tab 100mg 124 avita cre 0.025% 79 avita gel 0.025% 79 AVODART CAP 0.5MG 99 azacitidine for inj 100 mg 47 AZACTAM/DEX INJ 1GM 13 AZACTAM/DEX INJ 2GM 13 AZASAN TAB 100MG 64 AZASAN TAB 75 MG 64 AZASITE SOL 1% 113 azathioprine tab 50 mg 64 azelastine hcl nasal spray 0.1% (137 mcg/spray) 112 azelastine hcl nasal spray 0.15% (205.5 mcg/spray) 112 azelastine hcl ophth soln 0.05% 115 AZELEX CRE 20% 79 AZILECT TAB 0.5MG 56 AZILECT TAB 1MG 56 azithromycin for susp 100 mg/5ml 104 azithromycin for susp 200 mg/5ml 104 azithromycin iv for soln 500 mg 104 azithromycin powd pack for susp 1 gm 104 azithromycin tab 250 mg 104 azithromycin tab 500 mg 104 azithromycin tab 600 mg 104 AZOPT SUS 1% OP 115 aztreonam for inj 1 gm

151 aztreonam for inj 2 gm 13 azurette tab 28 day 73 B BABY SUPER DRO DAILY D3 133 bacitracin ophth oint 500 unit/gm 113 bacitracin-polymyxin b ophth oint 113 bacitracin-polymyxin-neomycin-hc ophth oint 1% 114 baclofen tab 10 mg 110 baclofen tab 20 mg 110 BACTOCILL INJ DEX 1GM 119 BACTOCILL INJ DEX 2GM 119 BACTROBAN OIN NASAL 2% 112 balsalazide disodium cap 750 mg 98 BANZEL SUS 40MG/ML 23 BANZEL TAB 200MG 23 BANZEL TAB 400MG 23 BARACLUDE SOL.05MG/ML 62 benazepril & hydrochlorothiazide tab mg 43 benazepril & hydrochlorothiazide tab mg 43 benazepril & hydrochlorothiazide tab mg 43 benazepril & hydrochlorothiazide tab mg 43 benazepril hcl tab 10 mg 40 benazepril hcl tab 20 mg 40 benazepril hcl tab 40 mg 40 benazepril hcl tab 5 mg 40 BENICAR TAB 20MG 41 BENICAR TAB 40MG 41 BENICAR TAB 5MG 41 BENLYSTA INJ 120MG 65 BENLYSTA INJ 400MG 65 BENTYL INJ 10MG/ML 127 BENZAMYCIN GEL PAK 79 benzepro aer 5.3% 79 BENZIQ GEL 5.25% 79 BENZIQ LS GEL 2.75% 79 benziq wash liq 5.25% 79 benzonatate cap 100 mg 78 benzonatate cap 200 mg 78 benzoyl per liq 10% wash 79 benzoyl peroxide foam 5.3% 80 benzoyl peroxide foam 9.8% 80 benzoyl peroxide-erythromycin gel 5-3% 80 benztropine mesylate inj 1 mg/ml 54 benztropine mesylate tab 0.5 mg 54 benztropine mesylate tab 1 mg 54 benztropine mesylate tab 2 mg 54 BEPREVE DRO 1.5% 115 BESIVANCE SUS 0.6% 113 betamethasone dipropionate augmented cream 0.05% 84 betamethasone dipropionate augmented lotion 0.05% 84 betamethasone dipropionate augmented oint 0.05% 84 betamethasone dipropionate cream 0.05% 84 betamethasone dipropionate lotion 0.05% 84 betamethasone dipropionate oint 0.05% 84 betamethasone valerate aerosol foam 0.12% 84 betamethasone valerate cream 0.1% 84 betamethasone valerate lotion 0.1% 84 betamethasone valerate oint 0.1% 84 BETASERON INJ 0.3MG 122 betaxolol hcl ophth soln 0.5% 113 betaxolol hcl tab 10 mg 65 betaxolol hcl tab 20 mg 65 bethanechol chloride tab 10 mg 130 bethanechol chloride tab 25 mg 130 bethanechol chloride tab 5 mg 130 bethanechol chloride tab 50 mg 130 BETIMOL SOL 0.25% 113 BETIMOL SOL 0.5% 113 BETOPTIC-S SUS 0.25% OP 113 bexarotene cap 75 mg 52 BEXSERO INJ 131 BEYAZ TAB 73 bicalutamide tab 50 mg 49 BICILLIN C-R INJ BICILLIN C-R INJ 900/ BICILLIN L-A INJ BICILLIN L-A INJ BICILLIN L-A INJ BICNU INJ 100MG 46 BILTRICIDE TAB 600MG 13 bimatoprost ophth soln 0.03% 116 bio-d-mulsio liq 400unit 133 BIO-STATIN CAP BIO-STATIN CAP bisoprolol & hydrochlorothiazide tab mg 43 bisoprolol & hydrochlorothiazide tab mg 43 bisoprolol & hydrochlorothiazide tab mg 43 bisoprolol fumarate tab 10 mg 65 bisoprolol fumarate tab 5 mg 65 BIVIGAM INJ 10% 116 bleomycin sulfate for inj 15 unit 50 bleomycin sulfate for inj 30 unit 50 BLEPHAMIDE OIN S.O.P. 114 BLEPHAMIDE SUS OP 114 BLOOD GLUCOSE CALIBRATION SOLUTION 106 BOOSTRIX INJ 126 BOSULIF TAB 100MG 51 BOSULIF TAB 500MG 51 BOTOX INJ 100UNIT 112 BOTOX INJ 200UNIT 112 bp wash liq 2.5% 80 bp wash liq 7% 80 BPO CLOTHS MIS 3%

152 bpo cloths mis 6% 80 BPO CLOTHS MIS 9% 80 BPO GEL 4% 80 BPO GEL 8% 80 BREO ELLIPTA INH BREO ELLIPTA INH BRILINTA TAB 60MG 100 BRILINTA TAB 90MG 100 brimonidine tartrate ophth soln 0.15% 113 brimonidine tartrate ophth soln 0.2% 113 bromfenac sodium ophth soln 0.09% (base equiv) (once-daily) 115 bromfenac sodium ophth soln 0.09% (base equivalent) 115 bromocriptine mesylate cap 5 mg 55 bromocriptine mesylate tab 2.5 mg 55 brompheniramine tannate chew tab 12 mg 37 BROVANA NEB 15MCG 20 budesonide delayed release particles cap 3 mg 76 budesonide inhalation susp 0.25 mg/2ml 19 budesonide inhalation susp 0.5 mg/2ml 19 budesonide inhalation susp 1 mg/2ml 19 budesonide nasal susp 32 mcg/act 112 bumetanide inj 0.25 mg/ml 88 bumetanide tab 0.5 mg 88 bumetanide tab 1 mg 88 bumetanide tab 2 mg 88 BUPHENYL TAB 500MG 92 buprenorphine hcl inj 0.3 mg/ml (base equiv) 12 buprenorphine hcl sl tab 2 mg (base equiv) 12 buprenorphine hcl sl tab 8 mg (base equiv) 12 buprenorphine hcl-naloxone hcl sl tab mg (base equiv) 12 buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv) 12 buproban tab 150mg 122 bupropion hcl (smoking deterrent) tab sr 12hr 150 mg 122 bupropion hcl tab 100 mg 26 bupropion hcl tab 75 mg 26 bupropion hcl tab sr 12hr 100 mg 26 bupropion hcl tab sr 12hr 150 mg 27 bupropion hcl tab sr 12hr 200 mg 27 bupropion hcl tab sr 24hr 150 mg 27 bupropion hcl tab sr 24hr 300 mg 27 buspirone hcl tab 10 mg 16 buspirone hcl tab 15 mg 16 buspirone hcl tab 30 mg 16 buspirone hcl tab 5 mg 16 buspirone hcl tab 7.5 mg 16 BUSULFEX INJ 6MG/ML 46 butalbital-acetaminophen-caffeine cap mg 6 butalbital-acetaminophen-caffeine cap mg 6 butalbital-acetaminophen-caffeine tab mg 6 butalbital-aspirin-caffeine cap mg 7 butalbital-aspirin-caffeine tab mg 7 butorphanol tartrate inj 1 mg/ml 12 butorphanol tartrate inj 2 mg/ml 12 butorphanol tartrate nasal soln 10 mg/ml 12 BUTRANS DIS 10MCG/HR 12 BUTRANS DIS 15MCG/HR 12 BUTRANS DIS 20MCG/HR 12 BUTRANS DIS 5MCG/HR 12 BUTRANS DIS 7.5/HR 12 BYSTOLIC TAB 10MG 65 BYSTOLIC TAB 2.5MG 65 BYSTOLIC TAB 20MG 65 BYSTOLIC TAB 5MG 65 C cabergoline tab 0.5 mg 93 CAFERGOT TAB 1-100MG 106 calcipotriene cream 0.005% 83 calcipotriene oint 0.005% 83 calcipotriene soln 0.005% (50 mcg/ml) 83 calcipotriene-betamethasone dipropionate oint % 84 calcitonin (salmon) nasal soln 200 unit/act 90 calcitrene oin 0.005% 83 calcitriol cap 0.25 mcg 92 calcitriol cap 0.5 mcg 92 calcitriol inj 1 mcg/ml 92 calcitriol oint 3 mcg/gm 83 calcitriol oral soln 1 mcg/ml 92 calcium acetate (phosphate binder) cap 667 mg (169 mg ca) 99 calcium acetate (phosphate binder) tab 667 mg 99 camila tab 0.35mg 76 CAMPTOSAR INJ 300/15ML 54 CANASA SUP 1000MG 98 CANCIDAS INJ 50MG 36 CANCIDAS INJ 70MG 36 candesartan cilexetil tab 16 mg 41 candesartan cilexetil tab 32 mg 41 candesartan cilexetil tab 4 mg 41 candesartan cilexetil tab 8 mg 41 candesartan cilexetil-hydrochlorothiazide tab mg 43 candesartan cilexetil-hydrochlorothiazide tab mg 43 candesartan cilexetil-hydrochlorothiazide tab mg 43 CANTIL TAB 25MG 127 CAPASTAT SUL INJ 1GM 46 capecitabine tab 150 mg 47 capecitabine tab 500 mg 47 CAPEX SHA 0.01%

153 CAPITAL/COD SUS /5 11 CAPRELSA TAB 100MG 51 CAPRELSA TAB 300MG 51 captopril & hydrochlorothiazide tab mg 43 captopril & hydrochlorothiazide tab mg 43 captopril & hydrochlorothiazide tab mg 43 captopril & hydrochlorothiazide tab mg 43 captopril tab 100 mg 40 captopril tab 12.5 mg 40 captopril tab 25 mg 40 captopril tab 50 mg 40 CARAFATE SUS 1GM/10ML 128 CARBAGLU TAB 200MG 92 carbamazepine cap sr 12hr 100 mg 23 carbamazepine cap sr 12hr 200 mg 23 carbamazepine cap sr 12hr 300 mg 23 carbamazepine chew tab 100 mg 23 carbamazepine susp 100 mg/5ml 23 carbamazepine tab 200 mg 23 carbamazepine tab sr 12hr 100 mg 23 carbamazepine tab sr 12hr 200 mg 23 carbamazepine tab sr 12hr 400 mg 23 carbidopa & levodopa orally disintegrating tab mg 55 carbidopa & levodopa orally disintegrating tab mg 55 carbidopa & levodopa orally disintegrating tab mg 55 carbidopa & levodopa tab mg 55 carbidopa & levodopa tab mg 55 carbidopa & levodopa tab mg 55 carbidopa & levodopa tab cr mg 55 carbidopa & levodopa tab cr mg 55 carbidopa tab 25 mg 54 carbidopa-levodopa-entacapone tabs mg 55 carbidopa-levodopa-entacapone tabs mg 55 carbidopa-levodopa-entacapone tabs mg 55 carbidopa-levodopa-entacapone tabs mg 55 carbidopa-levodopa-entacapone tabs mg 55 carbidopa-levodopa-entacapone tabs mg 55 carbinoxamine maleate soln 4 mg/5ml 37 carbinoxamine maleate tab 4 mg 37 carboplatin iv for inj 150 mg 46 carboplatin iv soln 150 mg/15ml 46 carboplatin iv soln 450 mg/45ml 46 carboplatin iv soln 50 mg/5ml 46 carboplatin iv soln 600 mg/60ml 46 CARDENE IV INJ 40/200ML 67 CARDENE IV SOL 20/200ML 67 CARDIZEM LA TAB 120MG 67 CARDURA XL TAB 4MG 99 CARDURA XL TAB 8MG 99 CARIMUNE NF INJ 12GM 116 CARIMUNE NF INJ 3GM 116 CARIMUNE NF INJ 6GM 116 carisoprodol tab 250 mg 111 carisoprodol tab 350 mg 111 carteolol hcl ophth soln 1% 113 cartia xt cap 120/24hr 67 cartia xt cap 180/24hr 67 cartia xt cap 240/24hr 67 cartia xt cap 300/24hr 67 carvedilol tab 12.5 mg 65 carvedilol tab 25 mg 65 carvedilol tab mg 65 carvedilol tab 6.25 mg 65 CAYA DPR 105 CAYSTON INH 75MG 13 caziant pak 73 CEDAX SUS 90MG/5ML 72 cefaclor cap 250 mg 71 cefaclor cap 500 mg 71 CEFACLOR ER TAB 500MG 71 cefaclor for susp 125 mg/5ml 71 cefaclor for susp 250 mg/5ml 71 cefaclor for susp 375 mg/5ml 71 cefadroxil cap 500 mg 70 cefadroxil for susp 250 mg/5ml 70 cefadroxil for susp 500 mg/5ml 70 cefadroxil tab 1 gm 70 CEFAZOL/DEX SOL 1GM 70 CEFAZOL/DEX SOL 2GM 70 CEFAZOLIN INJ 1GM/50ML 70 cefazolin sodium for inj 1 gm 70 cefazolin sodium for inj 10 gm 70 cefazolin sodium for inj 20 gm 70 cefazolin sodium for inj 500 mg 70 cefazolin sodium for iv soln 1 gm 70 CEFAZOLIN SOL 71 cefdinir cap 300 mg 72 cefdinir for susp 125 mg/5ml 72 cefdinir for susp 250 mg/5ml 72 cefditoren pivoxil tab 200 mg (base equivalent) 72 cefditoren pivoxil tab 400 mg (base equivalent) 72 cefepime hcl for inj 1 gm 73 cefepime hcl for inj 2 gm 73 CEFEPIME INJ 1GM 73 CEFEPIME INJ 2GM 73 cefixime for susp 100 mg/5ml 72 cefixime for susp 200 mg/5ml 72 cefotaxime sodium for inj 1 gm 72 cefotaxime sodium for inj 10 gm 72 cefotaxime sodium for inj 2 gm 72 cefotaxime sodium for inj 500 mg 72 CEFOTET/DEX INJ % 71 CEFOTET/DEX INJ % 71 cefotetan disodium for inj 1 gm 71 cefotetan disodium for inj 10 gm 71 cefotetan disodium for inj 2 gm

154 CEFOXITIN INJ 1GM 71 CEFOXITIN INJ 2GM 71 cefoxitin sodium for inj 10 gm 71 cefoxitin sodium for iv soln 1 gm 71 cefoxitin sodium for iv soln 2 gm 71 cefpodoxime proxetil for susp 100 mg/5ml 72 cefpodoxime proxetil for susp 50 mg/5ml 72 cefpodoxime proxetil tab 100 mg 72 cefpodoxime proxetil tab 200 mg 72 cefprozil for susp 125 mg/5ml 71 cefprozil for susp 250 mg/5ml 71 cefprozil tab 250 mg 71 cefprozil tab 500 mg 71 ceftazidime for inj 2 gm 72 CEFTAZIDIME INJ 100GM 72 CEFTAZIDIME/ SOL D5W 1GM 72 CEFTAZIDIME/ SOL D5W 2GM 72 ceftibuten cap 400 mg 72 ceftibuten for susp 180 mg/5ml 72 CEFTIN SUS 125/5ML 71 CEFTIN SUS 250/5ML 71 ceftriaxone sodium for inj 1 gm 72 ceftriaxone sodium for inj 10 gm 72 ceftriaxone sodium for inj 2 gm 72 ceftriaxone sodium for inj 250 mg 72 ceftriaxone sodium for inj 500 mg 72 ceftriaxone sodium for iv soln 1 gm 72 ceftriaxone sodium for iv soln 2 gm 72 CEFUROX/DEXT INJ 1.5GM 71 CEFUROX/DEXT INJ 750MG 71 cefuroxime axetil tab 250 mg 71 cefuroxime axetil tab 500 mg 71 CEFUROXIME INJ 225GM 71 CEFUROXIME INJ 7.5GM 71 CEFUROXIME INJ 75GM 71 cefuroxime sodium for inj 1.5 gm 71 cefuroxime sodium for inj 7.5 gm 71 cefuroxime sodium for inj 750 mg 71 cefuroxime sodium for iv soln 1.5 gm 71 celecoxib cap 100 mg 4 celecoxib cap 200 mg 4 celecoxib cap 400 mg 4 celecoxib cap 50 mg 4 CELLCEPT IV INJ 500MG 64 CELONTIN CAP 300MG 26 CENESTIN TAB 0.3MG 93 CENESTIN TAB 0.45MG 93 CENESTIN TAB 0.625MG 94 CENESTIN TAB 0.9MG 93 CENESTIN TAB 1.25MG 94 cephalexin cap 250 mg 71 cephalexin cap 500 mg 71 cephalexin cap 750 mg 71 cephalexin for susp 125 mg/5ml 71 cephalexin for susp 250 mg/5ml 71 cephalexin tab 250 mg 71 cephalexin tab 500 mg 71 CEREZYME INJ 400UNIT 101 cerisa wash emu 10-1% 80 CERVARIX INJ 131 CESAMET CAP 1MG 36 cesia pak 73 cevimeline hcl cap 30 mg 110 CHANTIX PAK 0.5& 1MG 122 CHANTIX PAK 1MG 122 CHANTIX TAB 0.5MG 122 CHANTIX TAB 1MG 123 chateal tab 0.15/30 73 CHEMET CAP 100MG 35 cheratussin syp /5 78 child vit d chw 400unit 133 chloramphenicol sodium succinate for iv inj 1 gm 14 chlordiazepoxide hcl-clidinium bromide cap mg 127 chlorhexidine gluconate soln 0.12% 109 chloroquine phosphate tab 250 mg 45 chloroquine phosphate tab 500 mg 45 chlorothiazide sodium for inj 500 mg 89 chlorothiazide tab 250 mg 89 chlorothiazide tab 500 mg 89 CHLORPROMAZ INJ 25MG/ML 59 CHLORPROMAZ INJ 50MG/2ML 59 chlorpromazine hcl tab 10 mg 59 chlorpromazine hcl tab 100 mg 59 chlorpromazine hcl tab 200 mg 59 chlorpromazine hcl tab 25 mg 59 chlorpromazine hcl tab 50 mg 59 chlorpropamide tab 100 mg 34 chlorpropamide tab 250 mg 34 chlorthalidone tab 100 mg 89 chlorthalidone tab 25 mg 89 chlorthalidone tab 50 mg 89 chlorzoxazone tab 500 mg 111 cholecalciferol cap 400 unit 133 cholestyramine light powder 4 gm/dose 39 cholestyramine light powder packets 4 gm 39 cholestyramine powder 4 gm/dose 39 cholestyramine powder packets 4 gm 39 choline fenofibrate cap dr 135 mg (fenofibric acid equiv) 39 choline fenofibrate cap dr 45 mg (fenofibric acid equiv) 39 chorionic gonadotropin for inj unit 90 CIALIS TAB 2.5MG 99 CIALIS TAB 5MG 99 ciclopirox gel 0.77% 82 ciclopirox kit 8% 82 ciclopirox olamine cream 0.77% (base equiv) 82 ciclopirox olamine susp 0.77% (base equiv) 82 ciclopirox shampoo 1% 82 ciclopirox solution 8% 82 cidofovir iv inj 75 mg/ml 62 cilostazol tab 100 mg

155 cilostazol tab 50 mg 100 CILOXAN OIN 0.3% OP 113 cimetidine hcl soln 300 mg/5ml 127 cimetidine tab 200 mg 127 cimetidine tab 300 mg 127 cimetidine tab 400 mg 127 cimetidine tab 800 mg 127 CIMZIA KIT 98 CIMZIA KIT STARTER 98 CIMZIA PREFL KIT 200MG/ML 98 CIPRO HC SUS OTIC 116 CIPRODEX SUS % 116 ciprofloxacin 200 mg/100ml in d5w 97 ciprofloxacin 400 mg/200ml in d5w 97 ciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml) 97 ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml) 97 ciprofloxacin hcl ophth soln 0.3% 114 ciprofloxacin hcl tab 100 mg (base equiv) 97 ciprofloxacin hcl tab 250 mg (base equiv) 97 ciprofloxacin hcl tab 500 mg (base equiv) 97 ciprofloxacin hcl tab 750 mg (base equiv) 97 ciprofloxacin iv soln 200 mg/20ml (1%) 97 ciprofloxacin iv soln 400 mg/40ml (1%) 97 ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000 mg(base eq) 97 ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg (base eq) 97 cisplatin inj 100 mg/100ml (1 mg/ml) 47 cisplatin inj 200 mg/200ml (1 mg/ml) 47 cisplatin inj 50 mg/50ml (1 mg/ml) 46 citalopram hydrobromide oral soln 10 mg/5ml 27 citalopram hydrobromide tab 10 mg (base equiv) 27 citalopram hydrobromide tab 20 mg (base equiv) 27 citalopram hydrobromide tab 40 mg (base equiv) 27 CITRANATAL CAP HARMONY 110 CITRANATAL MIS 90 DHA 110 CITRANATAL MIS B-CALM 110 CITRANATAL PAK ASSURE 110 CITRANATAL PAK DHA 110 CITRANATAL TAB RX 110 cladribine iv soln 10 mg/10ml (1 mg/ml) 47 CLAFORAN INJ 1GM 72 CLAFORAN INJ 2GM 72 claravis cap 10mg 80 claravis cap 20mg 80 claravis cap 30mg 80 claravis cap 40mg 80 CLARINEX SYP 0.5MG/ML 38 clarithromycin for susp 125 mg/5ml 104 clarithromycin for susp 250 mg/5ml 104 clarithromycin tab 250 mg 104 clarithromycin tab 500 mg 104 clarithromycin tab sr 24hr 500 mg 104 clearplex x gel 10% 80 clemastine fumarate syrup 0.67 mg/5ml (0.5 mg/5ml base eq) 37 clemastine fumarate tab 2.68 mg 37 CLEOCIN SUP 100MG 132 CLIMARA PRO DIS WEEKLY 93 clindamax gel 1% 80 clindamax lot 10mg/ml 80 clindamycin hcl cap 150 mg 15 clindamycin hcl cap 300 mg 15 clindamycin hcl cap 75 mg 15 clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) 15 clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5% 80 clindamycin phosphate foam 1% 80 clindamycin phosphate gel 1% 80 clindamycin phosphate inj 300 mg/2ml 15 clindamycin phosphate inj 600 mg/4ml 15 clindamycin phosphate inj 9 gm/60ml 15 clindamycin phosphate inj 900 mg/6ml 15 clindamycin phosphate iv soln 300 mg/2ml 15 clindamycin phosphate iv soln 600 mg/4ml 15 clindamycin phosphate iv soln 900 mg/6ml 15 clindamycin phosphate lotion 1% 80 clindamycin phosphate soln 1% 80 clindamycin phosphate swab 1% 80 clindamycin phosphate vaginal cream 2% 132 clindamycin phosphate-benzoyl peroxide gel 1-5% 80 clobetasol propionate cream 0.05% 84 clobetasol propionate foam 0.05% 84 clobetasol propionate gel 0.05% 84 clobetasol propionate lotion 0.05% 84 clobetasol propionate oint 0.05% 84 clobetasol propionate shampoo 0.05% 84 clobetasol propionate soln 0.05% 84 clobetasol propionate spray 0.05% 85 clocortolone pivalate cream 0.1% 85 CLOLAR INJ 1MG/ML 48 clomipramine hcl cap 25 mg 29 clomipramine hcl cap 50 mg 29 clomipramine hcl cap 75 mg 29 clonazepam tab 0.5 mg 23 clonazepam tab 1 mg 23 clonazepam tab 2 mg 23 clonidine hcl tab 0.1 mg 42 clonidine hcl tab 0.2 mg 42 clonidine hcl tab 0.3 mg 42 clonidine hcl td patch weekly 0.1 mg/24hr 42 clonidine hcl td patch weekly 0.2 mg/24hr 42 clonidine hcl td patch weekly

156 mg/24hr 42 clopidogrel bisulfate tab 300 mg (base equiv) 100 clopidogrel bisulfate tab 75 mg (base equiv) 100 clorazepate dipotassium tab 15 mg 17 clorazepate dipotassium tab 3.75 mg 17 clorazepate dipotassium tab 7.5 mg 17 clotrimazole cream 1% 82 CLOTRIMAZOLE CRY 82 clotrimazole soln 1% 82 clotrimazole troche 10 mg 109 clotrimazole w/ betamethasone cream % 82 clotrimazole w/ betamethasone lotion % 82 clozapine orally disintegrating tab 100 mg 58 clozapine orally disintegrating tab 12.5 mg 58 clozapine orally disintegrating tab 150 mg 58 clozapine orally disintegrating tab 200 mg 58 clozapine orally disintegrating tab 25 mg 58 clozapine tab 100 mg 58 clozapine tab 200 mg 58 clozapine tab 25 mg 58 clozapine tab 50 mg 58 COARTEM TAB MG 45 CODEINE SULF SOL 30MG/5ML 7 codeine sulfate tab 15 mg 7 codeine sulfate tab 30 mg 7 codeine sulfate tab 60 mg 7 colchicine tab 0.6 mg 100 colchicine w/ probenecid tab mg 100 colestipol hcl granule packets 5 gm 39 colestipol hcl granules 5 gm 39 colestipol hcl tab 1 gm 39 colocort ene 100mg 13 COLYTE/FLAVR SOL PACKS 103 COMBIGAN SOL 0.2/0.5% 113 COMBIVENT AER RESPIMAT 20 COMETRIQ KIT 100MG 51 COMETRIQ KIT 140MG 51 COMETRIQ KIT 60MG 51 COMPLERA TAB 60 compro sup 25mg 59 COMVAX INJ 131 CONCEPTROL GEL 4% 132 CONDYLOX GEL 0.5% 87 COPAXONE INJ 20MG/ML 122 COPAXONE INJ 40MG/ML 122 CORDRAN 24X3 TAP 4MCG/CM 85 CORDRAN CRE 0.05% 85 CORDRAN LOT 0.05% 85 CORDRAN OIN 0.05% 85 COREG CR CAP 10MG 65 COREG CR CAP 20MG 65 COREG CR CAP 40MG 65 COREG CR CAP 80MG 65 cortisone acetate tab 25 mg 76 CORTISPORIN CRE 0.5% 82 CORTISPORIN OIN 1% 82 CORTISPORIN SUS -TC OTIC 116 COUMADIN INJ 5 MG 21 CREON CAP 12000UNT 88 CREON CAP 24000UNT 88 CREON CAP 3000UNIT 87 CREON CAP 36000UNT 88 CREON CAP 6000UNIT 87 CRESTOR TAB 10MG 39 CRESTOR TAB 20MG 39 CRESTOR TAB 40MG 40 CRESTOR TAB 5MG 39 CRINONE GEL 4% VAG 133 CRINONE GEL 8% VAG 133 CRIXIVAN CAP 200MG 60 CRIXIVAN CAP 400MG 60 cromolyn sodium ophth soln 4% 115 cromolyn sodium oral conc 100 mg/5ml 98 cromolyn sodium soln nebu 20 mg/2ml 19 cryselle-28 tab 28 tabs 73 CUBICIN SOL 500MG 14 CUVPOSA SOL 1MG/5ML 127 cyanocobalamin inj 1000 mcg/ml 101 cyclafem tab 1/35 73 cyclafem tab 7/7/7 73 cyclobenzaprine hcl tab 10 mg 111 cyclobenzaprine hcl tab 5 mg 111 cyclobenzaprine hcl tab 7.5 mg 111 CYCLOPHOSPH CAP 25MG 47 CYCLOPHOSPH CAP 50MG 47 cyclophosphamide for inj 1 gm 47 cyclophosphamide for inj 2 gm 47 cyclophosphamide for inj 500 mg 47 cyclophosphamide tab 25 mg 47 cyclophosphamide tab 50 mg 47 cycloserine cap 250 mg 46 CYCLOSET TAB 0.8MG 33 cyclosporine cap 100 mg 64 cyclosporine cap 25 mg 64 cyclosporine iv soln 50 mg/ml 64 cyclosporine modified cap 100 mg 64 cyclosporine modified cap 25 mg 64 cyclosporine modified cap 50 mg 64 cyclosporine modified oral soln 100 mg/ml 64 cyproheptadine hcl syrup 2 mg/5ml 38 cyproheptadine hcl tab 4 mg 38 CYSTADANE POW 92 CYSTAGON CAP 150MG 99 CYSTAGON CAP 50MG 99 cytarabine for inj 1 gm 48 cytarabine for inj 100 mg 48 cytarabine for inj 500 mg 48 cytarabine inj 20 mg/ml 48 cytarabine inj pf 100 mg/ml 48 cytarabine inj pf 20 mg/ml

157 D D-VI-SOL LIQ 400UNIT 133 dacarbazine for inj 100 mg 52 dacarbazine for inj 200 mg 52 dactinomycin for inj 0.5 mg 50 DALIRESP TAB 500MCG 19 danazol cap 100 mg 13 danazol cap 200 mg 13 danazol cap 50 mg 13 dantrolene sodium cap 100 mg 111 dantrolene sodium cap 25 mg 111 dantrolene sodium cap 50 mg 111 dapsone tab 100 mg 15 dapsone tab 25 mg 15 DAPTACEL INJ 126 DARAPRIM TAB 25MG 45 darifenacin hydrobromide tab sr 24hr 15 mg (base equiv) 130 darifenacin hydrobromide tab sr 24hr 7.5 mg (base equiv) 130 dasetta tab 1/35 73 dasetta tab 7/7/7 73 daunorubicin hcl for inj 20 mg 50 daunorubicin hcl inj 5 mg/ml (base equiv) 50 DAUNOXOME INJ 2MG/ML 50 decara cap 50000unt 133 decitabine for inj 50 mg 48 demeclocycline hcl tab 150 mg 124 demeclocycline hcl tab 300 mg 124 DENAVIR CRE 1% 84 DEPEN TITRA TAB 250MG 63 DEPO-ESTRADI INJ 5MG/ML 94 DEPO-MEDROL INJ 20MG/ML 76 DEPO-PROVERA INJ 400/ML 49 DEPO-SQ PROV INJ DEPOCYT INJ 50MG/5ML 48 desipramine hcl tab 10 mg 29 desipramine hcl tab 100 mg 30 desipramine hcl tab 150 mg 30 desipramine hcl tab 25 mg 29 desipramine hcl tab 50 mg 29 desipramine hcl tab 75 mg 30 desloratadine tab 5 mg 38 desloratadine tab orally disintegrating 2.5 mg 38 desloratadine tab orally disintegrating 5 mg 38 desmopressin acetate inj 4 mcg/ml 92 desmopressin acetate nasal soln 0.01% (refrigerated) 92 desmopressin acetate nasal spray soln 0.01% 92 desmopressin acetate nasal spray soln 0.01% (refrigerated) 92 desmopressin acetate tab 0.1 mg 92 desmopressin acetate tab 0.2 mg 93 DESONATE GEL 0.05% 85 desonide cream 0.05% 85 desonide lotion 0.05% 85 desonide oint 0.05% 85 DESOWEN OINT KIT 0.05% 85 desoximetasone cream 0.05% 85 desoximetasone cream 0.25% 85 desoximetasone gel 0.05% 85 desoximetasone oint 0.05% 85 desoximetasone oint 0.25% 85 DEXAMETHASON CON 1MG/ML 76 dexamethasone elixir 0.5 mg/5ml 76 dexamethasone sod phosphate preservative free inj 10 mg/ml 76 dexamethasone sodium phosphate inj 10 mg/ml 76 dexamethasone sodium phosphate inj 100 mg/10ml 76 dexamethasone sodium phosphate inj 120 mg/30ml 76 dexamethasone sodium phosphate inj 20 mg/5ml 76 dexamethasone sodium phosphate inj 4 mg/ml 76 dexamethasone sodium phosphate ophth soln 0.1% 114 dexamethasone soln 0.5 mg/5ml 76 dexamethasone tab 0.5 mg 76 dexamethasone tab 0.75 mg 77 dexamethasone tab 1 mg 77 dexamethasone tab 1.5 mg 77 dexamethasone tab 2 mg 77 dexamethasone tab 4 mg 77 dexamethasone tab 6 mg 77 dexchlorpheniramine maleate syrup 2 mg/5ml 37 DEXILANT CAP 30MG DR 128 DEXILANT CAP 60MG DR 128 dexmethylphenidate hcl cap sr 24 hr 10 mg 2 dexmethylphenidate hcl cap sr 24 hr 15 mg 2 dexmethylphenidate hcl cap sr 24 hr 20 mg 2 dexmethylphenidate hcl cap sr 24 hr 30 mg 2 dexmethylphenidate hcl cap sr 24 hr 40 mg 2 dexmethylphenidate hcl cap sr 24 hr 5 mg 2 dexmethylphenidate hcl tab 10 mg 2 dexmethylphenidate hcl tab 2.5 mg 2 dexmethylphenidate hcl tab 5 mg 2 DEXPAK PAK 10 DAY 77 DEXPAK PAK 13 DAY 77 DEXPAK PAK 6 DAY 77 dexrazoxane for inj 250 mg 53 dexrazoxane for inj 500 mg 53 dextroamphetamine sulfate cap sr 24hr 10 mg 1 dextroamphetamine sulfate cap sr 24hr 15 mg 1 dextroamphetamine sulfate cap sr 24hr 5 mg 1 144

158 dextroamphetamine sulfate oral solution 5 mg/5ml 1 dextroamphetamine sulfate tab 10 mg 1 dextroamphetamine sulfate tab 5 mg 1 diazepam con 5mg/ml 17 diazepam oral soln 1 mg/ml 17 diazepam tab 10 mg 18 diazepam tab 2 mg 18 diazepam tab 5 mg 18 diclofenac potassium tab 50 mg 5 diclofenac sodium gel 1% 82 diclofenac sodium ophth soln 0.1% 115 diclofenac sodium tab delayed release 25 mg 5 diclofenac sodium tab delayed release 50 mg 5 diclofenac sodium tab delayed release 75 mg 5 diclofenac sodium tab sr 24hr 100 mg 5 diclofenac w/ misoprostol tab delayed release mg 5 diclofenac w/ misoprostol tab delayed release mg 5 dicloxacillin sodium cap 250 mg 119 dicloxacillin sodium cap 500 mg 119 dicyclomine hcl cap 10 mg 127 dicyclomine hcl inj 10 mg/ml 127 dicyclomine hcl oral soln 10 mg/5ml 127 dicyclomine hcl tab 20 mg 127 didanosine delayed release capsule 125 mg 60 didanosine delayed release capsule 200 mg 60 didanosine delayed release capsule 250 mg 60 didanosine delayed release capsule 400 mg 60 DIFICID TAB 200MG 105 diflorasone diacetate cream 0.05% 85 diflorasone diacetate oint 0.05% 85 diflunisal tab 500 mg 7 digox tab 0.125mg 69 digox tab 0.25mg 69 digoxin inj 0.25 mg/ml 69 digoxin oral soln 0.05 mg/ml 69 digoxin tab 125 mcg (0.125 mg) 69 digoxin tab 250 mcg (0.25 mg) 69 dihydroergotamine mesylate inj 1 mg/ml 106 dihydroergotamine mesylate nasal spray 4 mg/ml 106 DILANTIN CAP 30MG 25 DILATRATE SR CAP 40MG 15 diltiazem hcl cap sr 12hr 120 mg 67 diltiazem hcl cap sr 12hr 60 mg 67 diltiazem hcl cap sr 12hr 90 mg 67 diltiazem hcl cap sr 24hr 120 mg 67 diltiazem hcl cap sr 24hr 180 mg 67 diltiazem hcl cap sr 24hr 240 mg 67 diltiazem hcl coated beads cap sr 24hr 120 mg 67 diltiazem hcl coated beads cap sr 24hr 180 mg 67 diltiazem hcl coated beads cap sr 24hr 240 mg 67 diltiazem hcl coated beads cap sr 24hr 300 mg 67 diltiazem hcl coated beads cap sr 24hr 360 mg 67 diltiazem hcl extended release beads cap sr 24hr 120 mg 67 diltiazem hcl extended release beads cap sr 24hr 180 mg 67 diltiazem hcl extended release beads cap sr 24hr 240 mg 67 diltiazem hcl extended release beads cap sr 24hr 300 mg 67 diltiazem hcl extended release beads cap sr 24hr 360 mg 67 diltiazem hcl extended release beads cap sr 24hr 420 mg 68 diltiazem hcl iv soln 125 mg/25ml (5 mg/ml) 68 diltiazem hcl iv soln 25 mg/5ml (5 mg/ml) 68 diltiazem hcl iv soln 50 mg/10ml (5 mg/ml) 68 diltiazem hcl tab 120 mg 68 diltiazem hcl tab 30 mg 68 diltiazem hcl tab 60 mg 68 diltiazem hcl tab 90 mg 68 DILTIAZEM INJ 100MG 68 dimenhydrinate tab 50 mg 36 DIP/TET PED INJ 25-5LFU 126 DIPENTUM CAP 250MG 98 diphenhydramine hcl cap 25 mg 37 diphenhydramine hcl cap 50 mg 37 diphenhydramine hcl elixir 12.5 mg/5ml 38 diphenhydramine hcl inj 50 mg/ml 38 diphenoxylate w/ atropine liq mg/5ml 35 diphenoxylate w/ atropine tab mg 35 dipyridamole tab 25 mg 100 dipyridamole tab 50 mg 100 dipyridamole tab 75 mg 100 disopyramide phosphate cap 100 mg 18 disopyramide phosphate cap 150 mg 18 disulfiram tab 250 mg 120 disulfiram tab 500 mg 120 DIURIL SUS 250/5ML 89 divalproex sodium cap delayed release sprinkle 125 mg 26 divalproex sodium tab delayed release 125 mg 26 divalproex sodium tab delayed release 250 mg 26 divalproex sodium tab delayed release 500 mg 26 divalproex sodium tab sr 24 hr 250 mg 26 divalproex sodium tab sr 24 hr 500 mg 26 DIVIGEL GEL 0.25MG

159 DIVIGEL GEL 0.5MG 94 DIVIGEL GEL 1MG/GM 94 DOCEFREZ INJ 20MG 53 DOCEFREZ INJ 80MG 53 docetaxel for inj conc 20 mg/ml 53 docetaxel for inj conc 80 mg/4ml (20 mg/ml) 53 DOCETAXEL INJ 140/7ML 53 DOCETAXEL INJ 160/16ML 54 DOCETAXEL INJ 160/8ML 54 DOCETAXEL INJ 20/0.5ML 53 DOCETAXEL INJ 200MG/20 54 DOCETAXEL INJ 20MG/2ML 53 DOCETAXEL INJ 80MG/2ML 53 DOCETAXEL INJ 80MG/8ML 53 DOCETAXEL INJ NON-ALC 54 DOCETAXEL INJ NON-ALCO 54 donepezil hydrochloride orally disintegrating tab 10 mg 120 donepezil hydrochloride orally disintegrating tab 5 mg 120 donepezil hydrochloride tab 10 mg 120 donepezil hydrochloride tab 23 mg 120 donepezil hydrochloride tab 5 mg 120 DORIBAX INJ 250MG 14 DORIBAX INJ 500MG 14 dorzolamide hcl ophth soln 2% 115 dorzolamide hcl-timolol maleate ophth soln mg/ml 113 doxazosin mesylate tab 1 mg 42 doxazosin mesylate tab 2 mg 42 doxazosin mesylate tab 4 mg 42 doxazosin mesylate tab 8 mg 42 doxepin hcl cap 10 mg 30 doxepin hcl cap 100 mg 30 doxepin hcl cap 150 mg 30 doxepin hcl cap 25 mg 30 doxepin hcl cap 50 mg 30 doxepin hcl cap 75 mg 30 doxepin hcl conc 10 mg/ml 30 doxepin hcl cream 5% 83 doxercalciferol cap 0.5 mcg 92 doxercalciferol cap 1 mcg 92 doxercalciferol cap 2.5 mcg 92 doxercalciferol inj 4 mcg/2ml (2 mcg/ml) 92 doxorubicin hcl for inj 10 mg 50 doxorubicin hcl for inj 50 mg 50 doxorubicin hcl inj 2 mg/ml 50 doxy 100 inj 100mg 124 doxycycline hyclate cap 100 mg 124 doxycycline hyclate cap 50 mg 124 doxycycline hyclate for inj 100 mg 124 doxycycline hyclate tab 100 mg 124 doxycycline hyclate tab 20 mg 124 doxycycline hyclate tab delayed release 100 mg 124 doxycycline hyclate tab delayed release 150 mg 124 doxycycline hyclate tab delayed release 75 mg 124 doxycycline monohydrate cap 100 mg 124 doxycycline monohydrate cap 150 mg 124 doxycycline monohydrate cap 50 mg 124 doxycycline monohydrate cap 75 mg 124 doxycycline monohydrate for susp 25 mg/5ml 124 doxycycline monohydrate tab 150 mg 124 doxycycline monohydrate tab 50 mg 124 doxycycline monohydrate tab 75 mg 124 dronabinol cap 10 mg 36 dronabinol cap 2.5 mg 36 dronabinol cap 5 mg 36 drospirenone-ethinyl estradiol tab mg 73 DROXIA CAP 200MG 101 DROXIA CAP 300MG 101 DROXIA CAP 400MG 101 duloxetine hcl cap 20 mg 28 duloxetine hcl cap 30 mg 28 duloxetine hcl cap 60 mg 28 DUREZOL EMU 0.05% 114 dutasteride cap 0.5 mg 99 dutasteride-tamsulosin hcl cap mg 99 DYRENIUM CAP 100MG 89 DYRENIUM CAP 50MG 89 E e.e.s. 400 tab 400mg 104 E.E.S. GRAN SUS 200/5ML 104 e.s.p. sus econazole nitrate cream 1% 82 ed-spaz tab 0.125mg 127 EDARBI TAB 40MG 41 EDARBI TAB 80MG 41 EDECRIN TAB 25MG 88 EDURANT TAB 25MG 60 EFFIENT TAB 10MG 100 EFFIENT TAB 5MG 100 ELAPRASE INJ 6MG/3ML 92 ELELYSO INJ 200UNIT 101 ELESTRIN GEL 0.06% 94 ELIDEL CRE 1% 86 ELIGARD INJ 22.5MG 49 ELIGARD INJ 30MG 49 ELIGARD INJ 45MG 49 ELIGARD INJ 7.5MG 49 elinest tab 73 ELIQUIS TAB 2.5MG 22 ELIQUIS TAB 5MG 22 ELIXOPHYLLIN ELX 80/15ML 21 ELLA TAB 30MG 75 ELMIRON CAP 100MG 99 ELOXATIN INJ 200MG 47 EMADINE SOL 0.05% OP 115 EMBEDA CAP 100-4MG 7 EMBEDA CAP MG 7 EMBEDA CAP MG 7 EMBEDA CAP 50-2MG 7 146

160 EMBEDA CAP MG 7 EMBEDA CAP MG 7 EMCYT CAP 140MG 49 EMEND CAP 125MG 36 EMEND CAP 40MG 36 EMEND CAP 80MG 36 EMEND PAK 80 & emoquette tab 73 EMSAM DIS 12MG/24H 27 EMSAM DIS 6MG/24HR 27 EMSAM DIS 9MG/24HR 27 EMTRIVA CAP 200MG 60 EMTRIVA SOL 10MG/ML 60 ENABLEX TAB 15MG 130 ENABLEX TAB 7.5MG 130 enalapril maleate & hydrochlorothiazide tab mg 43 enalapril maleate & hydrochlorothiazide tab mg 43 enalapril maleate tab 10 mg 40 enalapril maleate tab 2.5 mg 40 enalapril maleate tab 20 mg 40 enalapril maleate tab 5 mg 40 ENBREL INJ 25/0.5ML 6 ENBREL INJ 25MG 6 ENBREL INJ 50MG/ML 6 ENBREL SRCLK INJ 50MG/ML 6 ENCARE SUP 100MG 132 endocet tab mg 11 endocet tab 5-325mg 11 endocet tab ENGERIX-B INJ 10/0.5ML 131 ENGERIX-B INJ 20MCG/ML 131 ENJUVIA TAB 0.3MG 94 ENJUVIA TAB 0.45MG 94 ENJUVIA TAB 0.625MG 94 ENJUVIA TAB 0.9MG 94 ENJUVIA TAB 1.25MG 94 enoxaparin sodium inj 100 mg/ml 22 enoxaparin sodium inj 120 mg/0.8ml 22 enoxaparin sodium inj 150 mg/ml 22 enoxaparin sodium inj 30 mg/0.3ml 22 enoxaparin sodium inj 300 mg/3ml 22 enoxaparin sodium inj 40 mg/0.4ml 22 enoxaparin sodium inj 60 mg/0.6ml 22 enoxaparin sodium inj 80 mg/0.8ml 22 enpresse-28 tab 73 entacapone tab 200 mg 55 entecavir tab 0.5 mg 62 entecavir tab 1 mg 62 enulose sol 10gm/15 98 EPIDUO FORTE GEL % 80 EPIDUO GEL % 80 epinastine hcl ophth soln 0.05% 115 epinephrine hcl inj 1 mg/ml 133 epinephrine hcl soln prefilled syringe 0.1 mg/ml 133 epinephrine solution auto-injector 0.15 mg/0.15ml (1:1000) 133 epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000) 133 EPIPEN 2-PAK INJ 0.3MG 133 EPIPEN-JR INJ 2-PAK 133 epirubicin hcl iv soln 200 mg/100ml (2 mg/ml) 50 epirubicin hcl iv soln 50 mg/25ml (2 mg/ml) 50 EPIRUBICIN INJ 50MG 50 epitol tab 200mg 23 EPIVIR HBV SOL 5MG/ML 62 eplerenone tab 25 mg 45 eplerenone tab 50 mg 45 epoprostenol sodium for inj 0.5 mg 70 epoprostenol sodium for inj 1.5 mg 70 eprosartan mesylate tab 600 mg 41 EPZICOM TAB ERAXIS INJ 100MG 36 ERAXIS INJ 50MG 36 ERBITUX INJ 100MG 49 ERBITUX INJ 200MG 49 ergocalciferol cap unit 133 ergoloid mesylates tab 1 mg 122 ERGOMAR SUB 2MG 106 ERIVEDGE CAP 150MG 49 errin tab 0.35mg 76 ERTACZO CRE 2% 82 ery pad 2% 80 ery-tab tab 250mg ec 104 ery-tab tab 333mg ec 104 ery-tab tab 500mg ec 104 ERYPED SUS 200/5ML 104 ERYPED SUS 400/5ML 104 ERYTHROCIN INJ 1000MG 105 ERYTHROCIN INJ 500MG 104 erythrocin tab 250mg 105 erythromycin ethylsuccinate tab 400 mg 105 erythromycin gel 2% 80 erythromycin ophth oint 5 mg/gm 114 erythromycin pads 2% 80 erythromycin soln 2% 80 erythromycin tab 250 mg 105 erythromycin tab 500 mg 105 erythromycin w/ delayed release particles cap 250 mg 105 escitalopram oxalate soln 5 mg/5ml (base equiv) 27 escitalopram oxalate tab 10 mg (base equiv) 27 escitalopram oxalate tab 20 mg (base equiv) 27 escitalopram oxalate tab 5 mg (base equiv) 27 esomeprazole magnesium cap delayed release 20 mg (base eq) 128 esomeprazole magnesium cap delayed release 40 mg (base eq) 128 esomeprazole sodium for intravenous soln 20 mg (base equiv) 128 esomeprazole sodium for intravenous soln 40 mg (base equiv)

161 ESTRACE VAG CRE 0.1MG/GM 132 estradiol & norethindrone acetate tab mg 93 estradiol & norethindrone acetate tab mg 93 estradiol tab 0.5 mg 94 estradiol tab 1 mg 94 estradiol tab 2 mg 95 estradiol td patch twice weekly mg/24hr 95 estradiol td patch twice weekly mg/24hr 95 estradiol td patch twice weekly 0.05 mg/24hr 95 estradiol td patch twice weekly mg/24hr 95 estradiol td patch twice weekly 0.1 mg/24hr 95 estradiol td patch weekly mg/24hr 95 estradiol td patch weekly mg/24hr (37.5 mcg/24hr) 95 estradiol td patch weekly 0.05 mg/24hr 95 estradiol td patch weekly 0.06 mg/24hr 95 estradiol td patch weekly mg/24hr 95 estradiol td patch weekly 0.1 mg/24hr 95 estradiol valerate im in oil 10 mg/ml 95 estradiol valerate im in oil 20 mg/ml 95 estradiol valerate im in oil 40 mg/ml 95 ESTRING MIS 2MG 132 ESTROGEL GEL 96 estropipate tab 0.75 mg 96 estropipate tab 1.5 mg 96 estropipate tab 3 mg 96 eszopiclone tab 1 mg 103 eszopiclone tab 2 mg 103 eszopiclone tab 3 mg 103 ethacrynate sodium for inj 50 mg 89 ethambutol hcl tab 100 mg 46 ethambutol hcl tab 400 mg 46 ethosuximide cap 250 mg 26 ethosuximide soln 250 mg/5ml 26 etodolac cap 200 mg 5 etodolac cap 300 mg 5 etodolac tab 400 mg 5 etodolac tab 500 mg 5 etodolac tab sr 24hr 400 mg 5 etodolac tab sr 24hr 500 mg 5 etodolac tab sr 24hr 600 mg 5 ETOPOPHOS INJ 100MG 54 etoposide cap 50 mg 54 etoposide inj 100 mg/5ml (20 mg/ml) 54 EURAX CRE 10% 87 EURAX LOT 10% 87 EVAMIST SPR 1.53MG 96 EVOTAZ TAB EXELDERM CRE 1% 82 EXELDERM SOL 1% 82 EXELON DIS 13.3/ EXELON DIS 4.6MG/ EXELON DIS 9.5MG/ EXELON SOL 2MG/ML 120 exemestane tab 25 mg 49 EXJADE TAB 125MG 35 EXJADE TAB 250MG 35 EXJADE TAB 500MG 35 F FABRAZYME INJ 35MG 92 FABRAZYME INJ 5MG 92 FACTIVE TAB 320MG 97 falmina tab 73 famciclovir tab 125 mg 63 famciclovir tab 250 mg 63 famciclovir tab 500 mg 63 famotidine for susp 40 mg/5ml 127 famotidine in nacl 0.9% iv soln 20 mg/50ml 127 famotidine inj 20 mg/2ml 127 famotidine inj 200 mg/20ml 127 famotidine inj 40 mg/4ml 127 famotidine inj 500 mg/50ml 128 famotidine tab 20 mg 128 famotidine tab 40 mg 128 FANAPT PAK 56 FANAPT TAB 10MG 57 FANAPT TAB 12MG 57 FANAPT TAB 1MG 57 FANAPT TAB 2MG 57 FANAPT TAB 4MG 57 FANAPT TAB 6MG 57 FANAPT TAB 8MG 57 FARESTON TAB 60MG 49 FARXIGA TAB 10MG 34 FARXIGA TAB 5MG 34 FARYDAK CAP 10MG 51 FARYDAK CAP 15MG 51 FARYDAK CAP 20MG 51 FASLODEX INJ 250MG 49 FC2 FEMALE MIS CONDOM 105 felbamate susp 600 mg/5ml 25 felbamate tab 400 mg 25 felbamate tab 600 mg 25 felodipine tab sr 24hr 10 mg 68 felodipine tab sr 24hr 2.5 mg 68 felodipine tab sr 24hr 5 mg 68 FEMCAP MIS 22MM 105 FEMCAP MIS 26MM 105 FEMCAP MIS 30MM 105 FEMRING MIS 0.05/24H 132 FEMRING MIS 0.1MG/ fenofibrate cap 150 mg 39 fenofibrate cap 50 mg 39 fenofibrate micronized cap 130 mg 39 fenofibrate micronized cap 134 mg 39 fenofibrate micronized cap 200 mg 39 fenofibrate micronized cap 43 mg 39 fenofibrate micronized cap 67 mg 39 fenofibrate tab 145 mg

162 fenofibrate tab 160 mg 39 fenofibrate tab 48 mg 39 fenofibrate tab 54 mg 39 fenofibric acid tab 105 mg 39 fenofibric acid tab 35 mg 39 fenoprofen calcium cap 400 mg 5 fenoprofen calcium tab 600 mg 5 fentanyl citrate lozenge on a handle 1200 mcg 8 fentanyl citrate lozenge on a handle 1600 mcg 8 fentanyl citrate lozenge on a handle 200 mcg 8 fentanyl citrate lozenge on a handle 400 mcg 8 fentanyl citrate lozenge on a handle 600 mcg 8 fentanyl citrate lozenge on a handle 800 mcg 8 fentanyl td patch 72hr 100 mcg/hr 8 fentanyl td patch 72hr 12 mcg/hr 8 fentanyl td patch 72hr 25 mcg/hr 8 fentanyl td patch 72hr 50 mcg/hr 8 fentanyl td patch 72hr 75 mcg/hr 8 FER-IN-SOL DRO 15MG/ML 102 FERRIPROX TAB 500MG 35 FERROUS SUL LIQ 220/5ML 102 FERROUS SULF SYP 300/5ML 102 ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental fe) 102 ferrous sulfate soln 75 mg/ml (15 mg/ml elemental fe) 102 FINACEA GEL 15% 87 finasteride tab 5 mg 99 FIRAZYR INJ 30MG/3ML 100 FIRMAGON INJ 120MG 49 FIRMAGON INJ 80MG 49 FLAGYL ER TAB 750MG 13 FLAREX SUS 0.1% OP 114 flavoxate hcl tab 100 mg 130 FLEBOGAMMA INJ 10/200ML 116 FLEBOGAMMA INJ 20/400ML 116 FLEBOGAMMA INJ DIF 10% 116 FLEBOGAMMA INJ DIF 5% 116 flecainide acetate tab 100 mg 18 flecainide acetate tab 150 mg 18 flecainide acetate tab 50 mg 18 floxuridine for inj 0.5 gm 48 FLUBLOK SOL FLUCELVAX INJ fluconazole for susp 10 mg/ml 37 fluconazole for susp 40 mg/ml 37 fluconazole in dextrose inj 200 mg/100ml 37 fluconazole in dextrose inj 400 mg/200ml 37 fluconazole in nacl 0.9% inj 200 mg/100ml 37 fluconazole in nacl 0.9% inj 400 mg/200ml 37 fluconazole tab 100 mg 37 fluconazole tab 150 mg 37 fluconazole tab 200 mg 37 fluconazole tab 50 mg 37 FLUCONAZOLE/ INJ NACL fludarabine phosphate for inj 50 mg 48 fludarabine phosphate inj 25 mg/ml 48 fludrocortisone acetate tab 0.1 mg 78 FLUMIST QUAD SUS flunisolide nasal soln 25 mcg/act (0.025%) 112 fluocin acet oil 0.01% sc 85 fluocin acet oil body 85 fluocinolone acetonide (otic) oil 0.01% 116 fluocinolone acetonide cream 0.01% 85 fluocinolone acetonide cream 0.025% 85 fluocinolone acetonide oint 0.025% 85 fluocinolone acetonide soln 0.01% 85 fluocinonide cream 0.05% 85 fluocinonide cream 0.1% 85 fluocinonide gel 0.05% 85 fluocinonide oint 0.05% 85 fluocinonide soln 0.05% 85 fluor-a-day dro 0.125mg 108 FLUORABON DRO 108 fluoritab chw 0.25mg f 108 fluoritab chw 0.5mg f 108 fluoritab chw 2.2mg 108 fluorometholone ophth susp 0.1% 114 FLUOROPLEX CRE 1% 83 fluorouracil cream 0.5% 83 fluorouracil cream 5% 83 fluorouracil inj 1 gm/20ml (50 mg/ml) 48 fluorouracil inj 2.5 gm/50ml (50 mg/ml) 48 fluorouracil inj 5 gm/100ml (50 mg/ml) 48 fluorouracil inj 500 mg/10ml (50 mg/ml) 48 fluorouracil soln 2% 83 fluorouracil soln 5% 83 fluoxetine hcl cap 10 mg 27 fluoxetine hcl cap 20 mg 27 fluoxetine hcl cap 40 mg 27 fluoxetine hcl cap delayed release 90 mg 27 fluoxetine hcl solution 20 mg/5ml 27 fluoxetine hcl tab 10 mg 27 fluoxetine hcl tab 20 mg 27 FLUOXETINE TAB 60MG 27 fluphenazine decanoate inj 25 mg/ml 59 fluphenazine hcl elixir 2.5 mg/5ml 59 fluphenazine hcl inj 2.5 mg/ml 59 fluphenazine hcl oral conc 5 mg/ml 59 fluphenazine hcl tab 1 mg 59 fluphenazine hcl tab 10 mg 59 fluphenazine hcl tab 2.5 mg 59 fluphenazine hcl tab 5 mg 59 flura-drops dro 0.125mg 108 flura-drops dro 0.25mg f 108 flurbiprofen sodium ophth soln 0.03% 115 flurbiprofen tab 100 mg 5 flurbiprofen tab 50 mg 5 149

163 flutamide cap 125 mg 49 fluticasone propionate cream 0.05% 85 fluticasone propionate lotion 0.05% 85 fluticasone propionate nasal susp 50 mcg/act 112 fluticasone propionate oint 0.005% 85 fluvastatin sodium cap 20 mg 40 fluvastatin sodium cap 40 mg 40 FLUVIRIN INJ fluvoxamine maleate cap sr 24hr 100 mg 27 fluvoxamine maleate cap sr 24hr 150 mg 27 fluvoxamine maleate tab 100 mg 27 fluvoxamine maleate tab 25 mg 27 fluvoxamine maleate tab 50 mg 27 FLUZONE HD INJ PF FLUZONE INJ INTRADRM 131 FLUZONE QUAD INJ FLUZONE SPLT INJ FML FORTE SUS 0.25% OP 115 FML OIN 0.1% OP 115 folbic tab 87 folic acid tab 1 mg 101 folic acid tab 400 mcg 101 folic acid tab 800 mcg 101 fondaparinux sodium subcutaneous inj 10 mg/0.8ml 22 fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml 22 fondaparinux sodium subcutaneous inj 5 mg/0.4ml 22 fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml 22 FORTAZ INJ 1GM 72 FORTAZ INJ 2GM 72 FORTAZ INJ 500MG 72 FORTEO SOL 600/ FOSAMAX + D TAB FOSAMAX + D TAB foscarnet sodium inj 24 mg/ml 62 fosinopril sodium & hydrochlorothiazide tab mg 44 fosinopril sodium & hydrochlorothiazide tab mg 44 fosinopril sodium tab 10 mg 40 fosinopril sodium tab 20 mg 41 fosinopril sodium tab 40 mg 41 fosphenytoin sodium inj 100 mg/2ml (phenytoin equiv) 25 fosphenytoin sodium inj 500 mg/10ml (phenytoin equiv) 25 FOSRENOL CHW 1000MG 99 FOSRENOL CHW 500MG 99 FOSRENOL CHW 750MG 99 FOSRENOL POW 1000MG 99 FOSRENOL POW 750MG 99 FRAGMIN INJ 10000/ML 22 FRAGMIN INJ 12500UNT 22 FRAGMIN INJ 15000UNT 22 FRAGMIN INJ 18000UNT 22 FRAGMIN INJ 2500/ FRAGMIN INJ 25000/ML 22 FRAGMIN INJ 5000/ FRAGMIN INJ 7500/ FRAGMIN INJ 95000UNT 22 FROVA TAB 2.5MG 106 frovatriptan succinate tab 2.5 mg (base equivalent) 106 furosemide inj 10 mg/ml 89 furosemide oral soln 10 mg/ml 89 furosemide oral soln 8 mg/ml 89 furosemide tab 20 mg 89 furosemide tab 40 mg 89 furosemide tab 80 mg 89 FUZEON INJ 90MG 60 G gabapentin cap 100 mg 23 gabapentin cap 300 mg 23 gabapentin cap 400 mg 23 gabapentin oral soln 250 mg/5ml 23 gabapentin tab 600 mg 23 gabapentin tab 800 mg 23 GABITRIL TAB 12MG 25 GABITRIL TAB 16MG 25 galantamine hydrobromide cap sr 24hr 16 mg 120 galantamine hydrobromide cap sr 24hr 24 mg 121 galantamine hydrobromide cap sr 24hr 8 mg 120 galantamine hydrobromide oral soln 4 mg/ml 121 galantamine hydrobromide tab 12 mg 121 galantamine hydrobromide tab 4 mg 121 galantamine hydrobromide tab 8 mg 121 GAMASTAN S/D INJ 116 GAMMAGARD INJ 10GM/ GAMMAGARD INJ 1GM/10ML 116 GAMMAGARD INJ 2.5GM/ GAMMAGARD INJ 20GM/ GAMMAGARD INJ 30GM/ GAMMAGARD INJ 5GM/50ML 116 GAMMAGARD SD INJ 10GM HU 117 GAMMAGARD SD INJ 2.5GM HU 117 GAMMAGARD SD INJ 5GM HU 117 GAMMAKED INJ 10GM/ GAMMAKED INJ 1GM/10ML 117 GAMMAKED INJ 2.5GM/ GAMMAKED INJ 20GM/ GAMMAKED INJ 5GM/50ML 117 GAMMAPLEX INJ 10GM 117 GAMMAPLEX INJ 2.5GM 117 GAMMAPLEX INJ 20GM 117 GAMMAPLEX INJ 5GM 117 GAMUNEX-C INJ 10GM/ GAMUNEX-C INJ 1GM/10ML 117 GAMUNEX-C INJ 2.5GM/ GAMUNEX-C INJ 20GM/ GAMUNEX-C INJ 40/400ML

164 GAMUNEX-C INJ 5GM/50ML 117 GARDASIL 9 INJ 131 GARDASIL INJ 131 gatifloxacin ophth soln 0.5% 114 gavilyte-c sol 103 gavilyte-g sol 103 gavilyte-h kit 103 gavilyte-n sol flav pk 103 GAZYVA INJ 25MG/ML 49 GELNIQUE GEL 10% 130 GELNIQUE GEL 3% 130 gemcitabine hcl for inj 1 gm 48 gemcitabine hcl for inj 2 gm 48 gemcitabine hcl for inj 200 mg 48 gemfibrozil tab 600 mg 39 generlac sol 10gm/15 98 gengraf cap 100mg 64 gengraf cap 25mg 64 gengraf sol 100mg/ml 64 GENOTROPIN INJ 0.2MG 90 GENOTROPIN INJ 0.4MG 91 GENOTROPIN INJ 0.6MG 91 GENOTROPIN INJ 0.8MG 91 GENOTROPIN INJ 1.2MG 91 GENOTROPIN INJ 1.4MG 91 GENOTROPIN INJ 1.6MG 91 GENOTROPIN INJ 1.8MG 91 GENOTROPIN INJ 12MG 91 GENOTROPIN INJ 1MG 91 GENOTROPIN INJ 2MG 91 GENOTROPIN INJ 5MG 91 gentak oin 0.3% op 114 GENTAM/NACL INJ 0.9MG/ML 3 GENTAM/NACL INJ 1.4MG/ML 3 gentamicin in saline inj 0.8 mg/ml 3 gentamicin in saline inj 1 mg/ml 3 gentamicin in saline inj 1.2 mg/ml 3 gentamicin in saline inj 1.6 mg/ml 3 gentamicin in saline inj 2 mg/ml 3 gentamicin sulfate cream 0.1% 82 gentamicin sulfate inj 10 mg/ml 3 gentamicin sulfate inj 40 mg/ml 3 gentamicin sulfate iv soln 10 mg/ml 3 gentamicin sulfate oint 0.1% 82 gentamicin sulfate ophth oint 0.3% 114 gentamicin sulfate ophth soln 0.3% 114 GENVOYA TAB 60 GEODON INJ 20MG 56 gianvi tab mg 73 gildess fe tab 1.5/30 73 gildess fe tab 1/20 74 gildess tab 1.5/30 74 gildess tab 1/20 74 GILENYA CAP 0.5MG 122 GLASSIA INJ 123 glatiramer acetate soln prefilled syringe 20 mg/ml 122 GLEEVEC TAB 100MG 51 GLEEVEC TAB 400MG 51 GLEOSTINE CAP 5MG 47 GLIADEL WAF 7.7MG 47 glimepiride tab 1 mg 34 glimepiride tab 2 mg 34 glimepiride tab 4 mg 34 glipizide tab 10 mg 34 glipizide tab 5 mg 34 glipizide tab sr 24hr 10 mg 34 glipizide tab sr 24hr 2.5 mg 34 glipizide tab sr 24hr 5 mg 34 glipizide-metformin hcl tab mg 31 glipizide-metformin hcl tab mg 31 glipizide-metformin hcl tab mg 32 GLUCAGON KIT 1MG 32 glyburide micronized tab 1.5 mg 34 glyburide micronized tab 3 mg 34 glyburide micronized tab 6 mg 34 glyburide tab 1.25 mg 34 glyburide tab 2.5 mg 34 glyburide tab 5 mg 34 glyburide-metformin tab mg 32 glyburide-metformin tab mg 32 glyburide-metformin tab mg 32 glycopyrrolate inj 0.2 mg/ml 127 glycopyrrolate inj 0.4 mg/2ml (0.2 mg/ml) 127 glycopyrrolate inj 1 mg/5ml (0.2 mg/ml) 127 glycopyrrolate inj 4 mg/20ml (0.2 mg/ml) 127 glycopyrrolate tab 1 mg 127 glycopyrrolate tab 2 mg 127 GLYSET TAB 100MG 31 GLYSET TAB 25MG 31 GLYSET TAB 50MG 31 GOLYTELY SOL 103 GRALISE STAR MIS 300/ GRALISE TAB 300MG 122 GRALISE TAB 600MG 122 granisetron hcl inj 0.1 mg/ml 35 granisetron hcl inj 1 mg/ml 35 granisetron hcl inj 4 mg/4ml (1 mg/ml) 35 granisetron hcl tab 1 mg 35 GRANISOL SOL 2MG/10ML 35 griseofulvin microsize susp 125 mg/5ml 36 griseofulvin microsize tab 500 mg 36 griseofulvin ultramicrosize tab 125 mg 36 griseofulvin ultramicrosize tab 250 mg 37 guanfacine hcl tab 1 mg 42 guanfacine hcl tab 2 mg 42 guanfacine hcl tab sr 24hr 1 mg (base equiv) 2 guanfacine hcl tab sr 24hr 2 mg (base equiv) 2 guanfacine hcl tab sr 24hr 3 mg (base equiv) 2 guanfacine hcl tab sr 24hr 4 mg (base equiv) 2 GUANIDINE TAB 125MG 46 GYNAZOLE-1 CRE 2% 132 GYNOL II GEL 3%

165 H halobetasol propionate cream 0.05% 85 halobetasol propionate oint 0.05% 85 HALOG CRE 0.1% 85 HALOG OIN 0.1% 85 haloperidol decanoate im soln 100 mg/ml 57 haloperidol decanoate im soln 50 mg/ml 57 haloperidol lactate inj 5 mg/ml 57 haloperidol lactate oral conc 2 mg/ml 57 haloperidol tab 0.5 mg 58 haloperidol tab 1 mg 58 haloperidol tab 10 mg 58 haloperidol tab 2 mg 58 haloperidol tab 20 mg 58 haloperidol tab 5 mg 58 HARVONI TAB MG 62 HAVRIX INJ 1440UNIT 131 HAVRIX INJ 720UNIT 131 heather tab 0.35mg 76 heparin sodium (porcine) inj 1000 unit/ml 22 heparin sodium (porcine) inj unit/ml 22 heparin sodium (porcine) inj unit/ml 22 heparin sodium (porcine) inj 5000 unit/ml 22 heparin sodium (porcine) pf inj 5000 unit/0.5ml 22 HEXALEN CAP 50MG 47 HIBERIX SOL 10MCG 131 HIZENTRA INJ 10/50ML 117 HIZENTRA INJ 1GM/5ML 117 HIZENTRA INJ 2GM/10ML 117 HIZENTRA INJ 4GM/20ML 117 homatropaire sol 5% op 113 homatropine hbr ophth soln 5% 113 HUMALOG INJ 100/ML 33 HUMALOG KWIK INJ 100/ML 33 HUMALOG KWIK INJ 200/ML 33 HUMALOG MIX INJ 50/50 33 HUMALOG MIX INJ 50/50KWP 33 HUMALOG MIX INJ 75/25KWP 33 HUMALOG MIX SUS 75/25 33 HUMATROPE INJ 12MG 91 HUMATROPE INJ 24MG 91 HUMATROPE INJ 5MG 91 HUMATROPE INJ 6MG 91 HUMATROPEN MIS FOR 12MG 106 HUMATROPEN MIS FOR 24MG 106 HUMATROPEN MIS FOR 6MG 106 HUMIRA INJ 10MG/0.2 4 HUMIRA KIT 20MG/0.4 4 HUMIRA KIT 40MG/0.8 4 HUMIRA PEN INJ CROHNS 4 HUMULIN INJ 70/30 33 HUMULIN INJ 70/30KWP 33 HUMULIN N INJ U HUMULIN N INJ U-100KWP 33 HUMULIN R INJ U HUMULIN R INJ U HYCAMTIN CAP 0.25MG 54 HYCAMTIN CAP 1MG 54 hydralazine hcl inj 20 mg/ml 45 hydralazine hcl tab 10 mg 45 hydralazine hcl tab 100 mg 45 hydralazine hcl tab 25 mg 45 hydralazine hcl tab 50 mg 45 hydrochlorothiazide cap 12.5 mg 89 hydrochlorothiazide tab 12.5 mg 89 hydrochlorothiazide tab 25 mg 89 hydrochlorothiazide tab 50 mg 89 hydrocodone w/ homatropine syrup mg/5ml 78 hydrocodone w/ homatropine tab mg 78 hydrocodone-acetaminophen soln mg/15ml 11 hydrocodone-acetaminophen tab mg 11 hydrocodone-acetaminophen tab mg 11 hydrocodone-acetaminophen tab mg 11 hydrocodone-acetaminophen tab mg 11 hydrocodone-acetaminophen tab mg 11 hydrocodone-acetaminophen tab mg 11 hydrocodone-acetaminophen tab mg 11 hydrocortisone butyrate cream 0.1% 85 hydrocortisone butyrate hydrophilic lipo base cream 0.1% 85 hydrocortisone butyrate oint 0.1% 85 hydrocortisone butyrate soln 0.1% 85 hydrocortisone cream 1% 85 hydrocortisone cream 2.5% 85 hydrocortisone lotion 2.5% 86 hydrocortisone oint 1% 86 hydrocortisone oint 2.5% 86 hydrocortisone tab 10 mg 77 hydrocortisone tab 20 mg 77 hydrocortisone tab 5 mg 77 hydrocortisone valerate cream 0.2% 86 hydrocortisone valerate oint 0.2% 86 hydrocortisone w/ acetic acid otic soln 1-2% 116 hydromet syp 5-1.5/5 78 HYDROMORPHON SUP 3MG 8 hydromorphone hcl inj 1 mg/ml 8 hydromorphone hcl inj 2 mg/ml 8 hydromorphone hcl inj 4 mg/ml 8 hydromorphone hcl liqd 1 mg/ml 8 hydromorphone hcl preservative free (pf) inj 10 mg/ml 8 hydromorphone hcl tab 2 mg 8 hydromorphone hcl tab 4 mg 8 hydromorphone hcl tab 8 mg 8 152

166 hydromorphone hcl tab er 24hr deter 12 mg 8 hydromorphone hcl tab er 24hr deter 16 mg 8 hydromorphone hcl tab er 24hr deter 32 mg 8 hydromorphone hcl tab er 24hr deter 8 mg 8 hydroxychloroquine sulfate tab 200 mg 45 hydroxyurea cap 500 mg 53 hydroxyzine hcl im soln 25 mg/ml 16 hydroxyzine hcl im soln 50 mg/ml 17 hydroxyzine hcl syrup 10 mg/5ml 17 hydroxyzine hcl tab 10 mg 17 hydroxyzine hcl tab 25 mg 17 hydroxyzine hcl tab 50 mg 17 hydroxyzine pamoate cap 100 mg 17 hydroxyzine pamoate cap 25 mg 17 hydroxyzine pamoate cap 50 mg 17 hyomax-sl sub 0.125mg 127 hyoscyamine sulfate tab mg 127 hyoscyamine sulfate tab disp mg127 hyoscyamine sulfate tab sl mg 127 hyoscyamine sulfate tab sr 12hr mg 127 I ibandronate sodium iv soln 3 mg/3ml (base equivalent) 90 ibandronate sodium tab 150 mg (base equivalent) 90 IBRANCE CAP 100MG 51 IBRANCE CAP 125MG 51 IBRANCE CAP 75MG 51 ibuprofen susp 100 mg/5ml 5 ibuprofen tab 400 mg 5 ibuprofen tab 600 mg 5 ibuprofen tab 800 mg 5 ICAR PEDS SUS GRAPE 102 ICLUSIG TAB 15MG 51 ICLUSIG TAB 45MG 51 idarubicin hcl iv inj 10 mg/10ml (1 mg/ml) 50 idarubicin hcl iv inj 20 mg/20ml (1 mg/ml) 50 idarubicin hcl iv inj 5 mg/5ml (1 mg/ml) 50 ifosfamide & mesna inj kit mg 50 ifosfamide for inj 1 gm 47 ifosfamide iv inj 1 gm/20ml (50 mg/ml) 47 ifosfamide iv inj 3 gm/60ml (50 mg/ml) 47 ilotycin oin op 114 imatinib mesylate tab 100 mg (base equivalent) 51 imatinib mesylate tab 400 mg (base equivalent) 51 IMBRUVICA CAP 140MG 51 imipenem-cilastatin intravenous for soln 250 mg 14 imipenem-cilastatin intravenous for soln 500 mg 14 imipramine hcl tab 10 mg 30 imipramine hcl tab 25 mg 30 imipramine hcl tab 50 mg 30 imipramine pamoate cap 100 mg 30 imipramine pamoate cap 125 mg 30 imipramine pamoate cap 150 mg 30 imipramine pamoate cap 75 mg 30 imiquimod cream 5% 86 IMPLANON IMP 68MG 76 INCRELEX INJ 40MG/4ML 91 indapamide tab 1.25 mg 89 indapamide tab 2.5 mg 89 INDOCIN SUS 25MG/5ML 5 indomethacin cap 25 mg 5 indomethacin cap 50 mg 5 indomethacin cap cr 75 mg 5 INFANRIX INJ 126 INFERGEN INJ 15MCG 62 INFERGEN INJ 9MCG 62 INFLUENZA A SPR 09 H1N1 131 INLYTA TAB 1MG 51 INLYTA TAB 5MG 51 INSULIN PEN NEEDLES/SYRINGES 106 INTELENCE TAB 100MG 60 INTELENCE TAB 200MG 60 INTELENCE TAB 25MG 60 INTRON A INJ 10MU 53 INTRON A INJ 18MU 53 INTRON A INJ 25MU 53 INTRON A INJ 50MU 53 introvale tab 74 INVANZ INJ 1GM 14 INVEGA SUST INJ 117/ INVEGA SUST INJ 156MG/ML 57 INVEGA SUST INJ 234/ INVEGA SUST INJ 39/ INVEGA SUST INJ 78/0.5ML 57 INVEGA TAB 1.5MG 57 INVEGA TAB 3MG 57 INVEGA TAB 6MG 57 INVEGA TAB 9MG 57 INVIRASE CAP 200MG 60 INVIRASE TAB 500MG 61 IOPIDINE SOL 1% OP 113 IPOL INJ INACTIVE 131 ipratropium bromide inhal soln 0.02% 19 ipratropium bromide nasal soln 0.03% (21 mcg/spray) 112 ipratropium bromide nasal soln 0.06% (42 mcg/spray) 112 ipratropium-albuterol nebu soln (3) mg/3ml 20 irbesartan tab 150 mg 41 irbesartan tab 300 mg 41 irbesartan tab 75 mg 41 irbesartan-hydrochlorothiazide tab mg 44 irbesartan-hydrochlorothiazide tab mg 44 irinotecan hcl inj 100 mg/5ml (20 153

167 mg/ml) 54 irinotecan hcl inj 40 mg/2ml (20 mg/ml)54 irinotecan hcl inj 500 mg/25ml (20 mg/ml) 54 ISENTRESS CHW 100MG 61 ISENTRESS CHW 25MG 61 ISENTRESS POW 100MG 61 ISENTRESS TAB 400MG 61 ISO HOMATROP SOL 2% OP 113 isoditrate tab 40mg er 15 ISOLYTE-S INJ 107 isoniazid inj 100 mg/ml 46 isoniazid syrup 50 mg/5ml 46 isoniazid tab 100 mg 46 isoniazid tab 300 mg 46 ISORDIL TAB 40MG 15 isosorbide dinitrate sl tab 2.5 mg 15 isosorbide dinitrate tab 10 mg 15 isosorbide dinitrate tab 20 mg 15 isosorbide dinitrate tab 30 mg 16 isosorbide dinitrate tab 5 mg 15 isosorbide dinitrate tab cr 40 mg 16 isosorbide mononitrate tab 10 mg 16 isosorbide mononitrate tab 20 mg 16 isosorbide mononitrate tab sr 24hr 120 mg 16 isosorbide mononitrate tab sr 24hr 30 mg 16 isosorbide mononitrate tab sr 24hr 60 mg 16 isradipine cap 2.5 mg 68 isradipine cap 5 mg 68 ISTALOL SOL 0.5% OP 113 itraconazole cap 100 mg 37 IV PREP WIPE PAD 60 ivermectin tab 3 mg 13 J JAKAFI TAB 10MG 51 JAKAFI TAB 15MG 51 JAKAFI TAB 20MG 51 JAKAFI TAB 25MG 51 JAKAFI TAB 5MG 51 JALYN CAP 99 jantoven tab 10mg 21 jantoven tab 1mg 21 jantoven tab 2.5mg 21 jantoven tab 2mg 21 jantoven tab 3mg 21 jantoven tab 4mg 21 jantoven tab 5mg 21 jantoven tab 6mg 21 jantoven tab 7.5mg 21 JANUMET TAB JANUMET TAB MG 32 JANUMET XR TAB JANUMET XR TAB JANUMET XR TAB MG 32 JANUVIA TAB 100MG 32 JANUVIA TAB 25MG 32 JANUVIA TAB 50MG 32 JARDIANCE TAB 10MG 34 JARDIANCE TAB 25MG 34 JENTADUETO TAB JENTADUETO TAB JENTADUETO TAB jinteli tab 1mg-5mcg 93 jolessa tab 74 jolivette tab 0.35mg 76 junel 1.5/30 tab 74 junel 1/20 tab 74 junel fe tab 1.5/30 74 junel fe tab 1/20 74 K KADCYLA INJ 100MG 49 KADCYLA INJ 160MG 49 KALETRA SOL 61 KALETRA TAB MG 61 KALETRA TAB MG 61 KALYDECO PAK 50MG 123 KALYDECO PAK 75MG 123 KALYDECO TAB 150MG 123 kanamycin sulfate inj 333 mg/ml 4 kariva tab 28 day 74 kcl 20 meq/l (0.15%) in nacl 0.45% inj107 kcl 20 meq/l (0.15%) in nacl 0.9% inj 107 kcl 40 meq/l (0.3%) in nacl 0.9% inj 107 kelnor tab 1/35 74 KEPIVANCE INJ 6.25MG 53 KETEK TAB 300MG 15 KETEK TAB 400MG 15 ketoconazole cream 2% 82 ketoconazole shampoo 2% 82 ketodan aer 2% 82 ketoprofen cap 50 mg 5 ketoprofen cap 75 mg 5 ketoprofen cap sr 24hr 200 mg 5 ketorolac tromethamine im inj 60 mg/2ml (30 mg/ml) 5 ketorolac tromethamine inj 15 mg/ml 5 ketorolac tromethamine inj 30 mg/ml 5 ketorolac tromethamine inj 300 mg/10ml (30 mg/ml) 5 ketorolac tromethamine inj 60 mg/2ml (30 mg/ml) 5 ketorolac tromethamine ophth soln 0.4% 115 ketorolac tromethamine ophth soln 0.5% 115 ketorolac tromethamine tab 10 mg 5 ketotifen fumarate ophth soln 0.025% (base equiv) 115 KEYTRUDA INJ 100MG/4M 49 KEYTRUDA SOL 50MG 49 KINERET INJ 4 KINRIX INJ 126 kionex sus 15gm/60 65 klor-con 10 tab 10meq er 109 klor-con 8 tab 8meq er

168 KLOR-CON M15 TAB 15MEQ ER 109 klor-con m20 tab 20meq er 109 KRISTALOSE PAK 10GM 103 KRISTALOSE PAK 20GM 103 kurvelo tab 0.15/30 74 KUVAN POW 100MG 92 KUVAN POW 500MG 92 KUVAN TAB 100MG 92 L labetalol hcl iv soln 5 mg/ml 65 labetalol hcl tab 100 mg 65 labetalol hcl tab 200 mg 65 labetalol hcl tab 300 mg 65 laclotion lot 12% 86 LACRISERT MIS 5MG OP 112 lactic acid (ammonium lactate) cream 12% 86 lactic acid (ammonium lactate) lotion 10% 86 lactic acid (ammonium lactate) lotion 12% 86 lactulose solution 10 gm/15ml 103 LAMICTAL CHW 2MG 23 LAMICTAL KIT START LAMICTAL KIT START LAMICTAL KIT START LAMICTAL ODT KIT 23 LAMICTAL XR KIT 23 LAMISIL GRA 125MG 37 LAMISIL GRA 187.5MG 37 lamivudine oral soln 10 mg/ml 61 lamivudine tab 100 mg (hbv) 62 lamivudine tab 150 mg 61 lamivudine tab 300 mg 61 lamivudine-zidovudine tab mg 61 lamotrigine orally disintegrating tab 100 mg 23 lamotrigine orally disintegrating tab 200 mg 24 lamotrigine orally disintegrating tab 25 mg 23 lamotrigine orally disintegrating tab 50 mg 23 lamotrigine tab 100 mg 24 lamotrigine tab 150 mg 24 lamotrigine tab 200 mg 24 lamotrigine tab 25 mg 24 lamotrigine tab chewable dispersible 25 mg 24 lamotrigine tab chewable dispersible 5 mg 24 lamotrigine tab disp 25 (14) & 50 mg (14) & 100 mg (7) kit 24 lamotrigine tab disp 25 mg (21) & 50 mg (7) titration kit 24 lamotrigine tab disp 50 mg (42) & 100 mg (14) titration kit 24 lamotrigine tab sr 24hr 100 mg 24 lamotrigine tab sr 24hr 200 mg 24 lamotrigine tab sr 24hr 25 mg 24 lamotrigine tab sr 24hr 250 mg 24 lamotrigine tab sr 24hr 300 mg 24 lamotrigine tab sr 24hr 50 mg 24 LANCETS 106 LANCING DEVICE 106 LANOXIN PED INJ 0.1MG/ML 69 LANOXIN TAB MG 69 LANOXIN TAB MG 69 lansoprazole cap delayed release 15 mg 128 lansoprazole cap delayed release 30 mg 128 LANTUS INJ 100/ML 33 LANTUS INJ SOLOSTAR 33 LASTACAFT SOL 0.25% 115 latanoprost ophth soln 0.005% 116 LATUDA TAB 120MG 56 LATUDA TAB 20MG 56 LATUDA TAB 40MG 56 LATUDA TAB 60MG 56 LATUDA TAB 80MG 56 leena tab 74 leflunomide tab 10 mg 6 leflunomide tab 20 mg 6 LENVIMA CAP 10MG 51 LENVIMA CAP 14MG 51 LENVIMA CAP 20MG 51 LENVIMA CAP 24MG 51 lessina tab 74 LETAIRIS TAB 10MG 70 LETAIRIS TAB 5MG 70 letrozole tab 2.5 mg 49 leucovorin calcium for inj 100 mg 53 leucovorin calcium for inj 200 mg 53 leucovorin calcium for inj 350 mg 53 leucovorin calcium for inj 50 mg 53 leucovorin calcium tab 10 mg 53 leucovorin calcium tab 15 mg 53 leucovorin calcium tab 25 mg 53 leucovorin calcium tab 5 mg 53 LEUCOVORIN INJ CALCIUM 53 LEUKERAN TAB 2MG 47 LEUKINE INJ 250MCG 101 LEUKINE INJ 500 MCG 101 leuprolide acetate inj kit 5 mg/ml 49 levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv) 20 levalbuterol hcl soln nebu 0.63 mg/3ml (base equiv) 20 levalbuterol hcl soln nebu 1.25 mg/3ml (base equiv) 20 levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base equiv) 20 LEVATOL TAB 20MG 66 LEVEMIR INJ 33 LEVEMIR INJ FLEXTOUC 33 LEVETIRACETA INJ 10MG/ML 24 LEVETIRACETA INJ 15MG/ML 24 LEVETIRACETA INJ 5MG/ML

169 levetiracetam inj 500 mg/5ml (100 mg/ml) 24 levetiracetam oral soln 100 mg/ml 24 levetiracetam tab 1000 mg 24 levetiracetam tab 250 mg 24 levetiracetam tab 500 mg 24 levetiracetam tab 750 mg 24 levetiracetam tab sr 24hr 500 mg 24 levetiracetam tab sr 24hr 750 mg 24 levobunolol hcl ophth soln 0.25% 113 levobunolol hcl ophth soln 0.5% 113 levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/ml) 38 levocetirizine dihydrochloride tab 5 mg 38 levofloxacin in d5w iv soln 250 mg/50ml97 levofloxacin in d5w iv soln 500 mg/100ml 97 levofloxacin in d5w iv soln 750 mg/150ml 97 levofloxacin iv soln 25 mg/ml 97 levofloxacin ophth soln 0.5% 114 levofloxacin oral soln 25 mg/ml 97 levofloxacin tab 250 mg 97 levofloxacin tab 500 mg 97 levofloxacin tab 750 mg 97 levonest tab 74 levonorg-eth est tab mg(84) & eth est tab 0.01mg(7) 74 levonorgestrel & ethinyl estradiol (91-day) tab mg 74 levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg 74 levonorgestrel tab 0.75 mg 75 levonorgestrel tab 1.5 mg 76 levora-28 tab 0.15/30 74 levorphanol tartrate tab 2 mg 8 levothyroxine sodium tab 100 mcg 125 levothyroxine sodium tab 112 mcg 125 levothyroxine sodium tab 125 mcg 125 levothyroxine sodium tab 137 mcg 125 levothyroxine sodium tab 150 mcg 125 levothyroxine sodium tab 175 mcg 125 levothyroxine sodium tab 200 mcg 125 levothyroxine sodium tab 25 mcg 125 levothyroxine sodium tab 300 mcg 125 levothyroxine sodium tab 50 mcg 125 levothyroxine sodium tab 75 mcg 125 levothyroxine sodium tab 88 mcg 125 levoxyl tab 100mcg 125 levoxyl tab 112mcg 125 levoxyl tab 125mcg 125 levoxyl tab 137mcg 125 levoxyl tab 150mcg 125 levoxyl tab 175mcg 125 levoxyl tab 200mcg 125 levoxyl tab 25mcg 125 levoxyl tab 50mcg 125 levoxyl tab 75mcg 125 levoxyl tab 88mcg 125 LEXIVA SUS 50MG/ML 61 LEXIVA TAB 700MG 61 LIDO/DEXTROS INJ 5-7.5% 104 lidocaine hcl cream 3% 87 lidocaine hcl gel 2% 87 lidocaine hcl iv inj 10 mg/ml 18 lidocaine hcl iv inj 20 mg/ml 18 lidocaine hcl laryngotracheal soln 4% 109 lidocaine hcl local inj 0.5% 104 lidocaine hcl local inj 1% 104 lidocaine hcl local inj 1.5% 104 lidocaine hcl local inj 2% 104 lidocaine hcl local preservative free (pf) inj 0.5% 104 lidocaine hcl local preservative free (pf) inj 1% 104 lidocaine hcl local preservative free (pf) inj 2% 104 lidocaine hcl local preservative free (pf) inj 4% 104 lidocaine hcl lotion 3% 87 lidocaine hcl soln 4% 87 lidocaine hcl viscous soln 2% 109 lidocaine iv infusion in d5w inj 4 mg/ml 18 lidocaine iv infusion in d5w inj 8 mg/ml 18 lidocaine oint 5% 87 lidocaine patch 5% 87 lidocaine-prilocaine cream % 87 lidocaine-prilocaine cream kit % 87 LILETTA IUD 52MG 76 LINCOCIN INJ 300MG/ML 15 lincomycin hcl inj 300 mg/ml 15 lindane lotion 1% 87 lindane shampoo 1% 87 linezolid for susp 100 mg/5ml 15 linezolid in sodium chloride iv soln 600 mg/300ml-0.9% 15 linezolid iv soln 600 mg/300ml (2 mg/ml) 15 linezolid tab 600 mg 15 LINZESS CAP 145MCG 98 LINZESS CAP 290MCG 98 liothyronine sodium iv soln 10 mcg/ml 125 liothyronine sodium tab 25 mcg 125 liothyronine sodium tab 5 mcg 125 liothyronine sodium tab 50 mcg 125 lipodox 50 inj 2mg/ml 50 lipodox inj 2mg/ml 50 lisinopril & hydrochlorothiazide tab mg 44 lisinopril & hydrochlorothiazide tab mg 44 lisinopril & hydrochlorothiazide tab mg 44 lisinopril tab 10 mg 41 lisinopril tab 2.5 mg 41 lisinopril tab 20 mg 41 lisinopril tab 30 mg 41 lisinopril tab 40 mg 41 lisinopril tab 5 mg 41 lithium carbonate cap 150 mg

170 lithium carbonate cap 300 mg 56 lithium carbonate cap 600 mg 56 lithium carbonate tab 300 mg 56 lithium carbonate tab cr 300 mg 56 lithium carbonate tab cr 450 mg 56 LITHIUM SOL 8MEQ/5ML 56 LIVALO TAB 1MG 40 LIVALO TAB 2MG 40 LIVALO TAB 4MG 40 LO LOESTRIN TAB 74 LO MINASTRIN PAK FE 74 lokara lot 0.05% 86 lomedia 24 tab fe 74 lomustine cap 10 mg 47 lomustine cap 100 mg 47 lomustine cap 40 mg 47 loperamide hcl cap 2 mg 35 loperamide hcl tab 2 mg 35 lorazepam conc 2 mg/ml 18 lorazepam tab 0.5 mg 18 lorazepam tab 1 mg 18 lorazepam tab 2 mg 18 loryna tab mg 74 losartan potassium & hydrochlorothiazide tab mg 44 losartan potassium & hydrochlorothiazide tab mg 44 losartan potassium & hydrochlorothiazide tab mg 44 losartan potassium tab 100 mg 41 losartan potassium tab 25 mg 41 losartan potassium tab 50 mg 41 LOTEMAX GEL 0.5% 115 LOTEMAX OIN 0.5% 115 LOTEMAX SUS 0.5% 115 lovastatin tab 10 mg 40 lovastatin tab 20 mg 40 lovastatin tab 40 mg 40 low-ogestrel tab 74 loxapine succinate cap 10 mg 58 loxapine succinate cap 25 mg 58 loxapine succinate cap 5 mg 58 loxapine succinate cap 50 mg 58 ludent chw 0.25mg f 108 ludent chw 0.5mg f 108 ludent chw 1mg f 108 LUFYLLIN TAB 200MG 21 LUFYLLIN TAB 400MG 21 LUMIGAN SOL 0.01% 116 LUPR DEP-PED INJ 11.25MG 91 LUPR DEP-PED INJ 15MG 91 LUPR DEP-PED INJ 30MG 91 LUPR DEP-PED INJ 7.5MG 91 LUPRON DEPOT INJ 11.25MG 49 LUPRON DEPOT INJ 22.5MG 49 LUPRON DEPOT INJ 3.75MG 49 LUPRON DEPOT INJ 30MG 49 LUPRON DEPOT INJ 45MG 49 LUPRON DEPOT INJ 7.5MG 49 LURIDE CHW 0.25MG F 108 LURIDE CHW 0.5MG F 108 LURIDE DRO 0.5MG/ML 108 lutera tab 74 LYNPARZA CAP 50MG 51 LYRICA CAP 100MG 24 LYRICA CAP 150MG 24 LYRICA CAP 200MG 24 LYRICA CAP 225MG 24 LYRICA CAP 25MG 24 LYRICA CAP 300MG 24 LYRICA CAP 50MG 24 LYRICA CAP 75MG 24 LYRICA SOL 20MG/ML 24 LYSODREN TAB 500MG 49 M M-M-R II INJ 131 MACRODANTIN CAP 25MG 129 MAGNESIUM SU INJ 2/50ML 108 MAGNESIUM SU INJ 20/500ML 108 MAGNESIUM SU INJ 4/100ML 108 MAGNESIUM SU INJ 40/ MAGNESIUM SU INJ 80MG/ML 108 magnesium sulfate inj 50% 108 malathion lotion 0.5% 87 maprotiline hcl tab 25 mg 27 maprotiline hcl tab 50 mg 27 maprotiline hcl tab 75 mg 27 marlissa tab 0.15/30 74 MARPLAN TAB 10MG 27 MATULANE CAP 50MG 53 matzim la tab 180mg/24 68 matzim la tab 240mg/24 68 matzim la tab 300mg/24 68 matzim la tab 360mg/24 68 matzim la tab 420mg/24 68 MAXIDEX SUS 0.1% OP 115 MAXIPIME INJ 1GM 73 MAXIPIME INJ 2GM 73 meclizine hcl tab 12.5 mg 36 meclizine hcl tab 25 mg 36 meclofenamate sodium cap 100 mg 5 meclofenamate sodium cap 50 mg 5 MEDROL TAB 2MG 77 medroxyprogesterone acetate im susp 150 mg/ml 76 medroxyprogesterone acetate tab 10 mg 120 medroxyprogesterone acetate tab 2.5 mg 120 medroxyprogesterone acetate tab 5 mg 120 mefenamic acid cap 250 mg 6 mefloquine hcl tab 250 mg 45 MEFOXIN INJ 1GM/50ML 71 MEFOXIN INJ 2GM/50ML 72 megestrol acetate susp 40 mg/ml 49 megestrol acetate susp 625 mg/5ml 120 megestrol acetate tab 20 mg 49 megestrol acetate tab 40 mg

171 MEKINIST TAB 0.5MG 51 MEKINIST TAB 2MG 52 meloxicam susp 7.5 mg/5ml 6 meloxicam tab 15 mg 6 meloxicam tab 7.5 mg 6 melphalan hcl for inj 50 mg (base equiv) 47 memantine hcl oral solution 2 mg/ml 121 memantine hcl tab 10 mg 121 memantine hcl tab 5 mg 121 memantine hcl tab 5 mg (28) & 10 mg (21) titration pak 121 MENACTRA INJ 131 MENEST TAB 0.3MG 96 MENEST TAB 0.625MG 96 MENEST TAB 1.25MG 96 MENEST TAB 2.5MG 96 MENHIBRIX INJ 131 MENOMUNE INJ A/C/Y/W 131 MENOSTAR DIS 14MCG 96 MENTAX CRE 1% 82 MENVEO INJ 131 meperidine hcl inj 10 mg/ml 8 meperidine hcl inj 100 mg/ml 8 meperidine hcl inj 25 mg/ml 8 meperidine hcl inj 50 mg/ml 8 meperidine hcl oral soln 50 mg/5ml 8 meperidine hcl tab 100 mg 9 meperidine hcl tab 50 mg 8 MEPHYTON TAB 5MG 133 meprobamate tab 200 mg 17 meprobamate tab 400 mg 17 mercaptopurine tab 50 mg 48 meropenem iv for soln 1 gm 14 meropenem iv for soln 500 mg 14 mesalamine enema 4 gm 98 mesalamine rectal enema 4 gm & cleanser wipe kit 98 mesna inj 100 mg/ml 53 MESNEX TAB 400MG 53 MESTINON SYP 60MG/5ML 46 metaproterenol sulfate syrup 10 mg/5ml 20 metaproterenol sulfate tab 10 mg 20 metaproterenol sulfate tab 20 mg 20 metaxalone tab 400 mg 111 metaxalone tab 800 mg 111 metformin hcl tab 1000 mg 32 metformin hcl tab 500 mg 32 metformin hcl tab 850 mg 32 metformin hcl tab sr 24hr 500 mg 32 metformin hcl tab sr 24hr 750 mg 32 metformin hcl tab sr 24hr osmotic 1000 mg 32 metformin hcl tab sr 24hr osmotic 500 mg 32 methadone hcl conc 10 mg/ml 9 methadone hcl soln 10 mg/5ml 9 methadone hcl soln 5 mg/5ml 9 methadone hcl tab 10 mg 9 methadone hcl tab 5 mg 9 methadone hcl tab for oral susp 40 mg 9 METHADONE INJ 10MG/ML 9 methadose tab 40mg 9 methamphetamine hcl tab 5 mg 1 methazolamide tab 25 mg 88 methazolamide tab 50 mg 88 methenamine hippurate tab 1 gm 129 methimazole tab 10 mg 125 methimazole tab 5 mg 124 methocarbamol tab 500 mg 111 methocarbamol tab 750 mg 111 methotrexate sodium for inj 1 gm 48 methotrexate sodium inj 250 mg/10ml (25 mg/ml) 48 methotrexate sodium inj 50 mg/2ml (25 mg/ml) 48 methotrexate sodium inj pf 100 mg/4ml (25 mg/ml) 48 methotrexate sodium inj pf 1000 mg/40ml (25 mg/ml) 48 methotrexate sodium inj pf 200 mg/8ml (25 mg/ml) 48 methotrexate sodium inj pf 250 mg/10ml (25 mg/ml) 48 methotrexate sodium inj pf 50 mg/2ml (25 mg/ml) 48 methotrexate sodium tab 2.5 mg (base equiv) 48 methoxsalen rapid cap 10 mg 83 methscopolamine bromide tab 2.5 mg 127 methscopolamine bromide tab 5 mg 127 methyclothiazide tab 5 mg 89 methyldopa tab 250 mg 42 methyldopa tab 500 mg 42 methyldopate hcl inj 250 mg/5ml 42 methylphenidate hcl cap cr 10 mg (cd) 2 methylphenidate hcl cap cr 20 mg (cd) 2 methylphenidate hcl cap cr 30 mg (cd) 2 methylphenidate hcl cap cr 40 mg (cd) 2 methylphenidate hcl cap cr 50 mg (cd) 2 methylphenidate hcl cap cr 60 mg (cd) 2 methylphenidate hcl cap sr 24hr 20 mg (la) 2 methylphenidate hcl cap sr 24hr 30 mg (la) 2 methylphenidate hcl cap sr 24hr 40 mg (la) 3 methylphenidate hcl chew tab 10 mg 3 methylphenidate hcl chew tab 2.5 mg 3 methylphenidate hcl chew tab 5 mg 3 methylphenidate hcl soln 10 mg/5ml 3 methylphenidate hcl soln 5 mg/5ml 3 methylphenidate hcl tab 10 mg 3 methylphenidate hcl tab 20 mg 3 methylphenidate hcl tab 5 mg 3 methylphenidate hcl tab cr 10 mg 3 methylphenidate hcl tab cr 20 mg 3 methylphenidate hcl tab sa osm 18 mg 3 methylphenidate hcl tab sa osm 27 mg 3 methylphenidate hcl tab sa osm 36 mg 3 158

172 methylphenidate hcl tab sa osm 54 mg 3 methylphenidate hcl tab sr 24hr 18 mg 3 methylphenidate hcl tab sr 24hr 27 mg 3 methylphenidate hcl tab sr 24hr 36 mg 3 methylphenidate hcl tab sr 24hr 54 mg 3 methylprednisolone acetate inj susp 40 mg/ml 77 methylprednisolone acetate inj susp 80 mg/ml 77 methylprednisolone sodium succinate for inj 1000 mg 77 methylprednisolone sodium succinate for inj 125 mg 77 methylprednisolone sodium succinate for inj 40 mg 77 methylprednisolone sodium succinate for inj 500 mg 77 methylprednisolone tab 16 mg 77 methylprednisolone tab 32 mg 77 methylprednisolone tab 4 mg 77 methylprednisolone tab 8 mg 77 methylprednisolone tab therapy pack 4 mg (21) 77 methyltestosterone cap 10 mg 13 metipranolol ophth soln 0.3% 113 metoclopramide hcl inj 5 mg/ml 98 metoclopramide hcl orally disintegrating tab 5 mg 98 metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) 98 metoclopramide hcl tab 10 mg 98 metoclopramide hcl tab 5 mg 98 metolazone tab 10 mg 89 metolazone tab 2.5 mg 89 metolazone tab 5 mg 89 metoprolol & hydrochlorothiazide tab mg 44 metoprolol & hydrochlorothiazide tab mg 44 metoprolol & hydrochlorothiazide tab mg 44 metoprolol succinate tab sr 24hr 100 mg (tartrate equiv) 66 metoprolol succinate tab sr 24hr 200 mg (tartrate equiv) 66 metoprolol succinate tab sr 24hr 25 mg (tartrate equiv) 66 metoprolol succinate tab sr 24hr 50 mg (tartrate equiv) 66 metoprolol tartrate inj 1 mg/ml 66 metoprolol tartrate tab 100 mg 66 metoprolol tartrate tab 25 mg 66 metoprolol tartrate tab 50 mg 66 metronidazole cap 375 mg 13 metronidazole cream 0.75% 87 metronidazole gel 0.75% 87 metronidazole gel 1% 87 metronidazole in nacl 0.79% iv soln 500 mg/100ml 13 metronidazole lotion 0.75% 87 metronidazole tab 250 mg 13 metronidazole tab 500 mg 13 metronidazole vaginal gel 0.75% 132 mexiletine hcl cap 150 mg 18 mexiletine hcl cap 200 mg 18 mexiletine hcl cap 250 mg 18 MG SO4/D5W INJ 10MG/ML 108 MG SO4/D5W INJ 20MG/ML 108 MIACALCIN INJ 200/ML 90 miconazole 3 kit combo pk 132 miconazole 3 sup 200mg 132 midodrine hcl tab 10 mg 133 midodrine hcl tab 2.5 mg 133 midodrine hcl tab 5 mg 133 MILLIPRED DP PAK 5MG 77 MILLIPRED SOL 10MG/5ML 77 MILLIPRED TAB 5MG 77 mimvey tab 1-0.5mg 93 MINASTRIN 24 CHW FE 74 minitran dis 0.1mg/hr 16 minitran dis 0.2mg/hr 16 minitran dis 0.4mg/hr 16 minitran dis 0.6mg/hr 16 minocycline hcl cap 100 mg 124 minocycline hcl cap 50 mg 124 minocycline hcl cap 75 mg 124 minocycline hcl tab 100 mg 124 minocycline hcl tab 50 mg 124 minocycline hcl tab 75 mg 124 minocycline hcl tab sr 24hr 135 mg 124 minocycline hcl tab sr 24hr 45 mg 124 minocycline hcl tab sr 24hr 90 mg 124 minoxidil tab 10 mg 45 minoxidil tab 2.5 mg 45 MIRAPEX ER TAB 2.25MG 55 MIRAPEX ER TAB 3.75MG 55 MIRENA IUD SYSTEM 76 mirtazapine orally disintegrating tab 15 mg 26 mirtazapine orally disintegrating tab 30 mg 26 mirtazapine orally disintegrating tab 45 mg 26 mirtazapine tab 15 mg 26 mirtazapine tab 30 mg 26 mirtazapine tab 45 mg 26 mirtazapine tab 7.5 mg 26 misoprostol tab 100 mcg 129 misoprostol tab 200 mcg 129 mitomycin for iv soln 20 mg 50 mitomycin for iv soln 40 mg 50 mitomycin for iv soln 5 mg 50 mitoxantrone hcl inj conc 20 mg/10ml (2 mg/ml) 50 mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/ml) 50 mitoxantrone hcl inj conc 30 mg/15ml (2 mg/ml) 50 modafinil tab 100 mg 3 modafinil tab 200 mg 3 moexipril hcl tab 15 mg

173 moexipril hcl tab 7.5 mg 41 moexipril-hydrochlorothiazide tab mg 44 moexipril-hydrochlorothiazide tab mg 44 moexipril-hydrochlorothiazide tab mg 44 mometasone furoate cream 0.1% 86 mometasone furoate oint 0.1% 86 mometasone furoate solution 0.1% (lotion) 86 mono-linyah tab mononessa tab 74 montelukast sodium chew tab 4 mg (base equiv) 19 montelukast sodium chew tab 5 mg (base equiv) 19 montelukast sodium oral granules packet 4 mg (base equiv) 19 montelukast sodium tab 10 mg (base equiv) 19 MONUROL PAK GRANULES 129 morgidox cap 1x100mg 124 MORPHINE SUL INJ 150/30ML 9 MORPHINE SUL INJ 2MG/ML 9 MORPHINE SUL INJ 4MG/ML 9 MORPHINE SUL INJ 5MG/ML 9 MORPHINE SUL INJ 8MG/ML 9 MORPHINE SUL SUP 30MG 9 morphine sulfate beads cap sr 24hr 120 mg 9 morphine sulfate beads cap sr 24hr 30 mg 9 morphine sulfate beads cap sr 24hr 45 mg 9 morphine sulfate beads cap sr 24hr 60 mg 9 morphine sulfate beads cap sr 24hr 75 mg 9 morphine sulfate beads cap sr 24hr 90 mg 9 morphine sulfate cap sr 24hr 10 mg 9 morphine sulfate cap sr 24hr 100 mg 9 morphine sulfate cap sr 24hr 20 mg 9 morphine sulfate cap sr 24hr 30 mg 9 morphine sulfate cap sr 24hr 50 mg 9 morphine sulfate cap sr 24hr 60 mg 9 morphine sulfate cap sr 24hr 80 mg 9 morphine sulfate inj 10 mg/ml 9 morphine sulfate inj 15 mg/ml 9 morphine sulfate inj 8 mg/ml 9 morphine sulfate inj pf 1 mg/ml 9 morphine sulfate iv soln 1 mg/ml 9 morphine sulfate iv soln 25 mg/ml 9 morphine sulfate iv soln 50 mg/ml 9 morphine sulfate iv soln pf 10 mg/ml 9 morphine sulfate iv soln pf 15 mg/ml 9 morphine sulfate iv soln pf 4 mg/ml 9 morphine sulfate iv soln pf 8 mg/ml 9 morphine sulfate oral soln 10 mg/5ml 9 morphine sulfate oral soln 100 mg/5ml (20 mg/ml) 10 morphine sulfate oral soln 20 mg/5ml 9 morphine sulfate suppos 10 mg 10 morphine sulfate suppos 20 mg 10 morphine sulfate suppos 5 mg 10 morphine sulfate tab 15 mg 10 morphine sulfate tab 30 mg 10 morphine sulfate tab cr 100 mg 10 morphine sulfate tab cr 15 mg 10 morphine sulfate tab cr 200 mg 10 morphine sulfate tab cr 30 mg 10 morphine sulfate tab cr 60 mg 10 MOTOFEN TAB 35 MOVANTIK TAB 12.5MG 98 MOVANTIK TAB 25MG 98 MOVIPREP SOL 103 MOXEZA SOL 0.5% 114 moxifloxacin hcl tab 400 mg (base equiv) 97 MOZOBIL INJ 102 MULTAQ TAB 400MG 19 multi-vit/fe dro /fl multi-vit/fl dro /fe multi-vit/fl dro 0.25mg 110 multi-vit/fl dro 0.5mg/ml 110 multivit/fl chw 0.25mg 110 multivit/fl chw 0.5mg 110 multivit/fl chw 1mg 110 mupirocin oint 2% 82 mvc-fluoride chw 0.5mg 110 mvc-fluoride chw 1mg 110 MYCAMINE INJ 100MG 36 MYCAMINE INJ 50MG 36 mycophenolate mofetil cap 250 mg 64 mycophenolate mofetil for oral susp 200 mg/ml 64 mycophenolate mofetil tab 500 mg 64 mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv) 64 mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv) 64 MYKIDZ IRON SUS 15/1.5ML 102 MYLERAN TAB 2MG 47 myorisan cap 10mg 80 myorisan cap 20mg 80 myorisan cap 40mg 80 MYOZYME INJ 50MG 92 MYRBETRIQ TAB 25MG 130 MYRBETRIQ TAB 50MG 130 myzilra tab 74 N nabumetone tab 500 mg 6 nabumetone tab 750 mg 6 nadolol & bendroflumethiazide tab 40-5 mg 44 nadolol & bendroflumethiazide tab 80-5 mg 44 nadolol tab 20 mg 66 nadolol tab 40 mg

174 nadolol tab 80 mg 66 nafcillin sodium for inj 1 gm 119 nafcillin sodium for inj 10 gm 120 nafcillin sodium for inj 2 gm 120 nafcillin sodium for iv soln 1 gm 120 nafcillin sodium for iv soln 2 gm 120 nafrinse chw 1mg f 108 naftifine hcl cream 1% 82 naftifine hcl cream 2% 82 NAFTIN CRE 2% 82 NAFTIN GEL 1% 82 NAFTIN GEL 2% 82 NAGLAZYME INJ 1MG/ML 92 nalbuphine hcl inj 10 mg/ml 12 nalbuphine hcl inj 20 mg/ml 12 NALLPEN/DEX INJ 1GM/50ML 120 NALLPEN/DEX INJ 2GM/ naloxone hcl inj 0.4 mg/ml 35 naloxone hcl inj 1 mg/ml 35 naltrexone hcl tab 50 mg 35 NAMENDA SOL 10MG/5ML 121 NAMENDA XR CAP 14MG 121 NAMENDA XR CAP 21MG 121 NAMENDA XR CAP 28MG 121 NAMENDA XR CAP 7MG 121 NAMENDA XR CAP TITRATIO 121 naphazoline hcl ophth soln 0.1% 114 naproxen dr tab 375mg 6 naproxen dr tab 500mg 6 naproxen sodium tab 275 mg 6 naproxen sodium tab 550 mg 6 naproxen susp 125 mg/5ml 6 naproxen tab 250 mg 6 naproxen tab 375 mg 6 naproxen tab 500 mg 6 naratriptan hcl tab 1 mg (base equiv) 106 naratriptan hcl tab 2.5 mg (base equiv) 106 NARCAN SPR 35 NATACYN SUS 5% OP 114 NATAZIA TAB 74 nateglinide tab 120 mg 33 nateglinide tab 60 mg 33 NEBUPENT INH 300MG 13 necon tab 0.5/35 74 necon tab 1/35 74 necon tab 1/ NECON TAB 10/ necon tab 7/7/7 74 nefazodone hcl tab 100 mg 28 nefazodone hcl tab 150 mg 28 nefazodone hcl tab 200 mg 28 nefazodone hcl tab 250 mg 28 nefazodone hcl tab 50 mg 28 NEO-FRADIN SOL 125/5ML 4 neomycin sulfate tab 500 mg 4 neomycin-polymy-gramicid op sol mg-unt-mg/ml 114 neomycin-polymyxin-dexamethasone ophth oint 0.1% 115 neomycin-polymyxin-dexamethasone ophth susp 0.1% 115 neomycin-polymyxin-hc ophth susp 115 neomycin-polymyxin-hc otic soln 1% 116 neomycin-polymyxin-hc otic susp 3.5 mg/ml unit/ml-1% 116 NEULASTA INJ 6MG/0.6M 101 NEULASTA KIT 6MG/0.6M 101 NEUPOGEN INJ 300/ NEUPOGEN INJ 300MCG 101 NEUPOGEN INJ 480/ NEUPOGEN INJ 480MCG 101 NEVANAC SUS 0.1% 115 nevirapine susp 50 mg/5ml 61 nevirapine tab 200 mg 61 nevirapine tab sr 24hr 100 mg 61 nevirapine tab sr 24hr 400 mg 61 NEXAVAR TAB 200MG 52 NEXIUM GRA 10MG DR 128 NEXIUM GRA 2.5MG DR 128 NEXIUM GRA 20MG DR 128 NEXIUM GRA 40MG DR 128 NEXIUM GRA 5MG DR 128 NEXPLANON IMP 68MG 76 NEXTERONE INJ 19 niacin tab cr 1000 mg (antihyperlipidemic) 40 niacin tab cr 500 mg (antihyperlipidemic) 40 niacin tab cr 750 mg (antihyperlipidemic) 40 nicardipine hcl cap 20 mg 68 nicardipine hcl cap 30 mg 68 nicardipine hcl iv soln 2.5 mg/ml 68 nicotine polacrilex gum 2 mg 123 nicotine polacrilex gum 4 mg 123 nicotine polacrilex lozenge 2 mg 123 nicotine polacrilex lozenge 4 mg 123 nicotine td patch 24hr 14 mg/24hr 123 nicotine td patch 24hr 21 mg/24hr 123 nicotine td patch 24hr 7 mg/24hr 123 NICOTROL INH 123 NICOTROL NS SPR 10MG/ML 123 nifedical xl tab 30mg 68 nifedical xl tab 60mg 68 nifedipine tab sr 24hr 30 mg 68 nifedipine tab sr 24hr 60 mg 68 nifedipine tab sr 24hr 90 mg 68 nifedipine tab sr 24hr osmotic release 30 mg 68 nifedipine tab sr 24hr osmotic release 60 mg 68 nifedipine tab sr 24hr osmotic release 90 mg 68 NILANDRON TAB 150MG 50 nimodipine cap 30 mg 68 NIPENT INJ 10MG 53 nisoldipine tab sr 24hr 17 mg 68 nisoldipine tab sr 24hr 20 mg 68 nisoldipine tab sr 24hr 25.5 mg

175 nisoldipine tab sr 24hr 30 mg 68 nisoldipine tab sr 24hr 34 mg 68 nisoldipine tab sr 24hr 40 mg 68 nisoldipine tab sr 24hr 8.5 mg 68 NITRO-BID OIN 2% 16 NITRO-DUR DIS 0.3MG/HR 16 NITRO-DUR DIS 0.8MG/HR 16 nitrofurantoin macrocrystalline cap 100 mg 129 nitrofurantoin macrocrystalline cap 25 mg 129 nitrofurantoin macrocrystalline cap 50 mg 129 nitrofurantoin monohydrate macrocrystalline cap 100 mg 130 nitrofurantoin susp 25 mg/5ml 130 NITROGLYCER INJ 5MG/ML 16 nitroglycerin cap cr 2.5 mg 16 nitroglycerin cap cr 6.5 mg 16 nitroglycerin cap cr 9 mg 16 nitroglycerin iv soln 100 mcg/ml in d5w 16 nitroglycerin iv soln 200 mcg/ml in d5w 16 nitroglycerin iv soln 400 mcg/ml in d5w 16 nitroglycerin lingual aerosol 400 mcg/spray 16 nitroglycerin td patch 24hr 0.1 mg/hr 16 nitroglycerin td patch 24hr 0.2 mg/hr 16 nitroglycerin td patch 24hr 0.4 mg/hr 16 nitroglycerin td patch 24hr 0.6 mg/hr 16 nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray) 16 NITROSTAT SUB 0.3MG 16 NITROSTAT SUB 0.4MG 16 NITROSTAT SUB 0.6MG 16 nizatidine cap 150 mg 128 nizatidine cap 300 mg 128 nizatidine oral soln 15 mg/ml 128 nora-be tab 0.35mg 76 NORDITROPIN INJ 10/1.5ML 91 NORDITROPIN INJ 15/1.5ML 91 NORDITROPIN INJ 30/3ML 91 NORDITROPIN INJ 5/1.5ML 91 norethindrone & ethinyl estradiol-fe chew tab 0.8 mg-25 mcg 74 norethindrone acetate tab 5 mg 120 norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5 mcg 93 norethindrone tab 0.35 mg 76 norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg 74 norgestimate-eth estrad tab / / mg-mcg 74 norgestimate-eth estrad tab / / mg-mcg 75 NORMOSOL -R INJ 107 NOROXIN TAB 400MG 97 NORPACE CAP 100MG CR 18 NORPACE CAP 150MG CR 18 nortrel tab 0.5/35 75 nortrel tab 1/35 75 nortrel tab 7/7/7 75 nortriptyline hcl cap 10 mg 30 nortriptyline hcl cap 25 mg 31 nortriptyline hcl cap 50 mg 31 nortriptyline hcl cap 75 mg 31 nortriptyline hcl soln 10 mg/5ml 31 NORTUSS-EX LIQ /5 78 NORVIR CAP 100MG 61 NORVIR SOL 80MG/ML 61 NORVIR TAB 100MG 61 novarel inj 10000unt 90 NOVOLIN INJ 70/30 33 NOVOLIN N INJ U NOVOLIN R INJ U NOVOLOG INJ 100/ML 33 NOVOLOG INJ FLEXPEN 33 NOVOLOG INJ PENFILL 33 NOVOLOG MIX INJ 70/30 33 NOVOLOG MIX INJ FLEXPEN 33 NOXAFIL SUS 40MG/ML 37 NOXAFIL TAB 100MG 37 NUCYNTA ER TAB 100MG 10 NUCYNTA ER TAB 150MG 10 NUCYNTA ER TAB 200MG 10 NUCYNTA ER TAB 250MG 10 NUCYNTA ER TAB 50MG 10 NUCYNTA TAB 100MG 10 NUCYNTA TAB 50MG 10 NUCYNTA TAB 75MG 10 NUEDEXTA CAP 20-10MG 122 nulev tab 0.125mg 127 NULOJIX INJ 250MG 64 NUTROPIN AQ INJ 10MG/2ML 91 NUTROPIN AQ INJ 20MG/2ML 91 NUTROPIN AQ INJ NUSPIN 5 91 NUTROPIN INJ 10MG 91 NUVARING MIS 75 NUVIGIL TAB 150MG 3 NUVIGIL TAB 200MG 3 NUVIGIL TAB 250MG 3 NUVIGIL TAB 50MG 3 nyamyc pow nystatin cream unit/gm 83 nystatin oint unit/gm 83 nystatin oral powder 37 nystatin susp unit/ml 109 nystatin tab unit 37 nystatin topical powder 83 nystatin-triamcinolone cream unit/gm-% 83 nystatin-triamcinolone oint unit/gm-% 83 nystop pow O ocella tab mg 75 OCTAGAM INJ 10/100ML 117 OCTAGAM INJ 10GM 117 OCTAGAM INJ 1GM 117 OCTAGAM INJ 2.5GM 117 OCTAGAM INJ 20/200ML

176 OCTAGAM INJ 25GM 117 OCTAGAM INJ 2GM/20ML 117 OCTAGAM INJ 5GM 117 OCTAGAM INJ 5GM/50ML 117 octreotide acetate inj 100 mcg/ml (0.1 mg/ml) 93 octreotide acetate inj 1000 mcg/ml (1 mg/ml) 93 octreotide acetate inj 200 mcg/ml (0.2 mg/ml) 93 octreotide acetate inj 50 mcg/ml (0.05 mg/ml) 93 octreotide acetate inj 500 mcg/ml (0.5 mg/ml) 93 ofloxacin ophth soln 0.3% 114 ofloxacin otic soln 0.3% 116 ofloxacin tab 200 mg 97 ofloxacin tab 300 mg 98 ofloxacin tab 400 mg 98 ogestrel tab 75 olanzapine for im inj 10 mg 58 olanzapine orally disintegrating tab 10 mg 58 olanzapine orally disintegrating tab 15 mg 58 olanzapine orally disintegrating tab 20 mg 58 olanzapine orally disintegrating tab 5 mg 58 olanzapine tab 10 mg 58 olanzapine tab 15 mg 58 olanzapine tab 2.5 mg 58 olanzapine tab 20 mg 58 olanzapine tab 5 mg 58 olanzapine tab 7.5 mg 58 olopatadine hcl nasal soln 0.6% 112 olopatadine hcl ophth soln 0.1% (base equivalent) 115 omega-3-acid ethyl esters cap 1 gm 39 omeprazole cap delayed release 10 mg 128 omeprazole cap delayed release 20 mg 129 omeprazole cap delayed release 40 mg 129 omeprazole-sodium bicarbonate cap mg 129 omeprazole-sodium bicarbonate cap mg 129 OMNIFLEX DPR 105 OMNITROPE INJ 10/1.5ML 91 OMNITROPE INJ 5.8MG 91 OMNITROPE INJ 5/1.5ML 91 OMONTYS INJ 10MG/ML 101 OMONTYS INJ 20MG/2ML 101 ONCASPAR INJ 750/ML 52 ondansetron hcl inj 4 mg/2ml (2 mg/ml)35 ondansetron hcl inj 40 mg/20ml (2 mg/ml) 35 ondansetron hcl oral soln 4 mg/5ml 35 ondansetron hcl tab 24 mg 35 ondansetron hcl tab 4 mg 35 ondansetron hcl tab 8 mg 35 ondansetron orally disintegrating tab 4 mg 35 ondansetron orally disintegrating tab 8 mg 35 ONETOUCH BLOOD GLUCOSE TEST KITS 106 ONETOUCH BLOOD GLUCOSE TEST STRIPS 106 ONFI SUS 2.5MG/ML 23 ONFI TAB 10MG 23 ONFI TAB 20MG 23 ONFI TAB 5MG 23 oralone pst 0.1% 110 ORAP TAB 1MG 122 ORAP TAB 2MG 122 ORAVIG TAB 50MG 109 ORENCIA INJ 125MG/ML 6 ORENCIA INJ 250MG 6 ORFADIN CAP 10MG 92 ORFADIN CAP 2MG 92 ORFADIN CAP 5MG 92 ORKAMBI TAB orphenadrine citrate inj 30 mg/ml 111 orphenadrine citrate tab sr 12hr 100 mg 111 orphenadrine w/ aspirin & caffeine tab mg 112 orsythia tab 75 ORTHO COIL DPR KIT ORTHO COIL DPR KIT ORTHO COIL DPR KIT ORTHO FLAT DPR KIT ORTHO FLAT DPR KIT ORTHO FLAT DPR KIT ORTHO FLAT DPR KIT ORTHO FLAT DPR KIT ORTHO FLAT DPR KIT ORTHO FLAT DPR KIT ORTHO FLAT DPR KIT ORTHO FLAT DPR KIT ORTHO FLEX DPR 65MM 105 ORTHO FLEX DPR 70MM 105 ORTHO FLEX DPR 75MM 105 ORTHO FLEX DPR 80MM 105 ORTHO TRI- TAB CYCLN LO 75 ortho-est tab ortho-est tab oscimin sr tab 0.375mg 127 oscimin sub 0.125mg 127 oscimin tab 0.125mg 127 oscion clnsr lot 6% 80 OSMOPREP TAB 1.5GM 104 oxacillin sodium for inj 1 gm 120 oxacillin sodium for inj 10 gm 120 oxacillin sodium for inj 2 gm 120 oxaliplatin for iv inj 100 mg 47 oxaliplatin for iv inj 50 mg 47 oxaliplatin iv soln 100 mg/20ml 47 oxaliplatin iv soln 50 mg/10ml 47 oxandrolone tab 10 mg 12 oxandrolone tab 2.5 mg

177 oxaprozin tab 600 mg 6 oxazepam cap 10 mg 18 oxazepam cap 15 mg 18 oxazepam cap 30 mg 18 oxcarbazepine susp 300 mg/5ml (60 mg/ml) 24 oxcarbazepine tab 150 mg 24 oxcarbazepine tab 300 mg 24 oxcarbazepine tab 600 mg 25 oxiconazole nitrate cream 1% 83 OXISTAT CRE 1% 83 OXISTAT LOT 1% 83 oxybutynin chloride syrup 5 mg/5ml 130 oxybutynin chloride tab 5 mg 130 oxybutynin chloride tab sr 24hr 10 mg 130 oxybutynin chloride tab sr 24hr 15 mg 130 oxybutynin chloride tab sr 24hr 5 mg 130 oxycodone hcl cap 5 mg 10 oxycodone hcl conc 100 mg/5ml (20 mg/ml) 10 oxycodone hcl soln 5 mg/5ml 10 oxycodone hcl tab 10 mg 10 oxycodone hcl tab 15 mg 10 oxycodone hcl tab 20 mg 10 oxycodone hcl tab 30 mg 10 oxycodone hcl tab 5 mg 10 oxycodone hcl tab er 12hr deter 10 mg 10 oxycodone hcl tab er 12hr deter 20 mg 10 oxycodone hcl tab er 12hr deter 40 mg 10 oxycodone hcl tab er 12hr deter 80 mg 10 oxycodone w/ acetaminophen tab mg 11 oxycodone w/ acetaminophen tab mg 11 oxycodone w/ acetaminophen tab mg 11 oxycodone w/ acetaminophen tab mg 11 oxycodone-aspirin tab mg 11 oxycodone-ibuprofen tab mg 11 OXYCONTIN TAB 10MG CR 10 OXYCONTIN TAB 15MG CR 10 OXYCONTIN TAB 20MG CR 10 OXYCONTIN TAB 30MG CR 10 OXYCONTIN TAB 40MG CR 10 OXYCONTIN TAB 60MG CR 10 OXYCONTIN TAB 80MG CR 10 oxymorphone hcl tab 10 mg 10 oxymorphone hcl tab 5 mg 10 oxymorphone hcl tab sr 12hr 10 mg 11 oxymorphone hcl tab sr 12hr 15 mg 11 oxymorphone hcl tab sr 12hr 20 mg 11 oxymorphone hcl tab sr 12hr 30 mg 11 oxymorphone hcl tab sr 12hr 40 mg 11 oxymorphone hcl tab sr 12hr 5 mg 10 oxymorphone hcl tab sr 12hr 7.5 mg 11 OXYTROL DIS 3.9MG/ P pacerone tab 100mg 19 pacerone tab 200mg 19 paclitaxel iv conc 100 mg/16.7ml (6 mg/ml) 54 paclitaxel iv conc 150 mg/25ml (6 mg/ml) 54 paclitaxel iv conc 30 mg/5ml (6 mg/ml) 54 paclitaxel iv conc 300 mg/50ml (6 mg/ml) 54 paliperidone tab sr 24hr 1.5 mg 57 paliperidone tab sr 24hr 3 mg 57 paliperidone tab sr 24hr 6 mg 57 paliperidone tab sr 24hr 9 mg 57 pamidronate disodium for inj 30 mg 90 pamidronate disodium for inj 90 mg 90 pamidronate disodium iv soln 3 mg/ml 90 pamidronate disodium iv soln 9 mg/ml 90 PAMIDRONATE INJ 6MG/ML 90 PANRETIN GEL 0.1% 83 pantoprazole sodium ec tab 20 mg (base equiv) 129 pantoprazole sodium ec tab 40 mg (base equiv) 129 PARAGARD IUD T380A 75 parcaine sol 0.5% op 114 paricalcitol cap 1 mcg 92 paricalcitol cap 2 mcg 92 paricalcitol cap 4 mcg 92 paricalcitol iv soln 2 mcg/ml 92 paricalcitol iv soln 5 mcg/ml 92 paromomycin sulfate cap 250 mg 4 paroxetine hcl tab 10 mg 27 paroxetine hcl tab 20 mg 28 paroxetine hcl tab 30 mg 28 paroxetine hcl tab 40 mg 28 paroxetine hcl tab sr 24hr 12.5 mg 28 paroxetine hcl tab sr 24hr 25 mg 28 paroxetine hcl tab sr 24hr 37.5 mg 28 PASER GRA 4GM 46 PATADAY SOL 0.2% 116 PATANOL SOL 0.1% OP 116 PCE TAB 333MG EC 105 PCE TAB 500MG EC 105 pedia d-vite dro 400unit 133 PEDIADERM HC KIT 86 PEDIADERM TA KIT 86 PEDIARIX INJ 0.5ML 126 PEDIATRIC RESPIRATORY MASK 106 PEDVAX HIB INJ 131 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm 103 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm 103 peg 3350-kcl-sod bicarb-nacl for soln 420 gm 103 PEGANONE TAB 250MG 25 PEGASYS INJ 62 PEGASYS INJ 180MCG/M 62 PEGASYS INJ PROCLICK 62 PEGASYS KIT 63 PEN G PROC INJ

178 PENICILL GK/ INJ DEX 1MU 118 PENICILL GK/ INJ DEX 2MU 118 PENICILL GK/ INJ DEX 3MU 118 penicillin g potassium for inj unit 118 penicillin g potassium for inj unit 118 penicillin g sodium for inj unit118 penicillin v potassium for soln 125 mg/5ml 118 penicillin v potassium for soln 250 mg/5ml 118 penicillin v potassium tab 250 mg 118 penicillin v potassium tab 500 mg 118 PENTACEL INJ 126 PENTAM 300 INJ 300MG 14 pentoxifylline tab cr 400 mg 100 PERFOROMIST NEB 20MCG 20 perindopril erbumine tab 2 mg 41 perindopril erbumine tab 4 mg 41 perindopril erbumine tab 8 mg 41 periogard sol 0.12% 109 permethrin cream 5% 87 perphenazine tab 16 mg 59 perphenazine tab 2 mg 59 perphenazine tab 4 mg 59 perphenazine tab 8 mg 59 pfizerpen-g inj 20mu 118 phenadoz sup 25mg 38 phenazopyridine hcl tab 100 mg 99 phenazopyridine hcl tab 200 mg 100 phenelzine sulfate tab 15 mg 27 phenobarbital elixir 20 mg/5ml 102 phenobarbital tab 100 mg 103 phenobarbital tab 15 mg 102 phenobarbital tab 16.2 mg 102 phenobarbital tab 30 mg 102 phenobarbital tab 32.4 mg 102 phenobarbital tab 60 mg 102 phenobarbital tab 64.8 mg 102 phenobarbital tab 97.2 mg 102 phenoxybenzamine hcl cap 10 mg 41 phenylephrine hcl ophth soln 10% 114 phenylephrine hcl ophth soln 2.5% 114 PHENYTEK CAP 200MG 25 PHENYTEK CAP 300MG 25 phenytoin chew tab 50 mg 26 phenytoin sodium extended cap 100 mg 26 phenytoin sodium extended cap 200 mg 26 phenytoin sodium extended cap 300 mg 26 phenytoin sodium inj 50 mg/ml 26 phenytoin susp 125 mg/5ml 26 PHISOHEX LIQ 3% 60 PHOSLYRA SOL 99 PHOSPHOLINE SOL 0.125%OP 113 PHOTOFRIN INJ 75MG 53 physiolyte sol 65 physiosol sol irrigat 65 PICATO GEL 0.015% 83 PICATO GEL 0.05% 83 pilocarpine hcl tab 5 mg 110 pilocarpine hcl tab 7.5 mg 110 PILOPINE HS GEL 4% OP 113 pimozide tab 1 mg 122 pimozide tab 2 mg 122 pindolol tab 10 mg 66 pindolol tab 5 mg 66 pioglitazone hcl tab 15 mg (base equiv) 33 pioglitazone hcl tab 30 mg (base equiv) 33 pioglitazone hcl tab 45 mg (base equiv) 33 pioglitazone hcl-glimepiride tab 30-2 mg32 pioglitazone hcl-glimepiride tab 30-4 mg32 pioglitazone hcl-metformin hcl tab mg 32 pioglitazone hcl-metformin hcl tab mg 32 piperacillin sod-tazobactam na for inj gm ( gm) 119 piperacillin sod-tazobactam sod for inj 2.25 gm ( gm) 119 piperacillin sod-tazobactam sod for inj 4.5 gm (4-0.5 gm) 119 piperacillin sod-tazobactam sod for inj 40.5 gm ( gm) 119 piroxicam cap 10 mg 6 piroxicam cap 20 mg 6 PLASMA-LYTE INJ PLASMA-LYTE INJ -A 107 PNEUMOVAX 23 INJ 25/ podofilox soln 0.5% 87 poly-dex oin 0.1% op 115 polycin oin op 114 polyethylene glycol 3350 oral packet 103 polyethylene glycol 3350 oral powder 104 polymyxin b sulfate for inj unit 15 polymyxin b-trimethoprim ophth soln unit/ml-0.1% 114 POMALYST CAP 1MG 52 POMALYST CAP 2MG 52 POMALYST CAP 3MG 52 POMALYST CAP 4MG 52 portia-28 tab 75 potassium chloride cap cr 10 meq 109 potassium chloride cap cr 8 meq 109 potassium chloride inj 10 meq/100ml 109 potassium chloride inj 10 meq/50ml 109 potassium chloride inj 2 meq/ml 109 potassium chloride inj 20 meq/100ml 109 potassium chloride inj 20 meq/50ml 109 potassium chloride inj 40 meq/100ml 109 potassium chloride microencapsulated crys cr tab 10 meq 109 potassium chloride microencapsulated crys cr tab 20 meq 109 potassium chloride oral soln 10% (20 meq/15ml) 109 potassium chloride oral soln 20% (40 meq/15ml) 109 potassium chloride tab cr 10 meq 109 potassium chloride tab cr 20 meq (1500 mg)

179 potassium chloride tab cr 8 meq (600 mg) 109 potassium citrate tab cr 10 meq (1080 mg) 99 potassium citrate tab cr 15 meq (1620 mg) 99 potassium citrate tab cr 5 meq (540 mg) 99 POTIGA TAB 200MG 25 POTIGA TAB 300MG 25 POTIGA TAB 400MG 25 POTIGA TAB 50MG 25 pr benzoyl liq 7% wash 80 pramipexole dihydrochloride tab mg 55 pramipexole dihydrochloride tab 0.25 mg 55 pramipexole dihydrochloride tab 0.5 mg 55 pramipexole dihydrochloride tab 0.75 mg 55 pramipexole dihydrochloride tab 1 mg 55 pramipexole dihydrochloride tab 1.5 mg 55 pramipexole dihydrochloride tab sr 24hr mg 55 pramipexole dihydrochloride tab sr 24hr 0.75 mg 55 pramipexole dihydrochloride tab sr 24hr 1.5 mg 56 pramipexole dihydrochloride tab sr 24hr 2.25 mg 56 pramipexole dihydrochloride tab sr 24hr 3 mg 56 pramipexole dihydrochloride tab sr 24hr 4.5 mg 56 pramox gel 1% 87 pravastatin sodium tab 10 mg 40 pravastatin sodium tab 20 mg 40 pravastatin sodium tab 40 mg 40 pravastatin sodium tab 80 mg 40 prazosin hcl cap 1 mg 42 prazosin hcl cap 2 mg 42 prazosin hcl cap 5 mg 42 PRED MILD SUS 0.12% OP 115 PRED SOD PHO SOL 1% OP 115 prednicarbate cream 0.1% 86 prednicarbate oint 0.1% 86 prednisolone acetate ophth susp 1% 115 prednisolone sod phos orally disintegr tab 10 mg (base eq) 77 prednisolone sod phos orally disintegr tab 15 mg (base eq) 77 prednisolone sod phos orally disintegr tab 30 mg (base eq) 77 prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base) 77 prednisolone sod phosphate oral soln 15 mg/5ml (base equiv) 77 prednisolone sodium phosphate oral soln 25 mg/5ml (base eq) 77 prednisolone syrup 15 mg/5ml (usp solution equivalent) 78 PREDNISONE CON 5MG/ML 78 prednisone oral soln 5 mg/5ml 78 prednisone tab 1 mg 78 prednisone tab 10 mg 78 prednisone tab 2.5 mg 78 prednisone tab 20 mg 78 prednisone tab 5 mg 78 prednisone tab 50 mg 78 prednisone tab therapy pack 10 mg (21) 78 prednisone tab therapy pack 10 mg (48) 78 prednisone tab therapy pack 5 mg (21) 78 prednisone tab therapy pack 5 mg (48) 78 pregnyl inj 10000unt 90 PREMARIN INJ 25MG 96 PREMARIN TAB 0.3MG 96 PREMARIN TAB 0.45MG 97 PREMARIN TAB 0.625MG 97 PREMARIN TAB 0.9MG 97 PREMARIN TAB 1.25MG 97 PREMARIN VAG CRE 0.625MG 132 prenatabs rx tab 110 PRENTIF MIS 22MM 105 PRENTIF MIS 25MM 105 PRENTIF MIS 28MM 105 PRENTIF MIS 31MM 105 PRENTIF MIS FITTING 105 PREPOPIK PAK 103 prevalite pow 4gm 39 previfem tab 75 PREVNAR 13 INJ 131 PREZCOBIX TAB PREZISTA SUS 100MG/ML 61 PREZISTA TAB 150MG 61 PREZISTA TAB 400MG 61 PREZISTA TAB 600MG 61 PREZISTA TAB 75MG 61 PREZISTA TAB 800MG 61 PRIFTIN TAB 150MG 46 PRIMAQUINE TAB 26.3MG 45 primidone tab 250 mg 25 primidone tab 50 mg 25 PRIMLEV TAB MG 12 PRIMLEV TAB 5-300MG 11 PRIMLEV TAB PRIMSOL SOL 50MG/5ML 14 PRIVIGEN INJ 10GRAMS 117 PRIVIGEN INJ 20GRAMS 117 PRIVIGEN INJ 40GRAMS 117 PRIVIGEN INJ 5 GRAMS 117 PROAIR HFA AER 20 probenecid tab 500 mg 100 procainamide hcl inj 100 mg/ml 18 PROCAINAMIDE INJ 500MG/ML 18 prochlorperazine edisylate inj 5 mg/ml 59 prochlorperazine maleate tab 10 mg (base equivalent) 59 prochlorperazine maleate tab 5 mg (base equivalent)

180 prochlorperazine suppos 25 mg 59 PROCRIT INJ 10000/ML 102 PROCRIT INJ 2000/ML 102 PROCRIT INJ 20000/ML 102 PROCRIT INJ 3000/ML 102 PROCRIT INJ 4000/ML 102 PROCRIT INJ 40000/ML 102 procto-pak cre 1% 13 proctosol hc cre 2.5% 13 proctozone cre -hc 2.5% 13 progesterone micronized cap 100 mg 120 progesterone micronized cap 200 mg 120 PROGLYCEM SUS 50MG/ML 32 PROGRAF INJ 5MG/ML 64 PROLASTIN-C INJ 1000MG 123 PROLIA SOL 60MG/ML 90 PROMACTA TAB 12.5MG 102 PROMACTA TAB 25MG 102 PROMACTA TAB 50MG 102 PROMACTA TAB 75MG 102 prometh vc syp plain 78 prometh vc/ syp codeine 78 promethazine hcl inj 25 mg/ml 38 promethazine hcl inj 50 mg/ml 38 promethazine hcl suppos 12.5 mg 38 promethazine hcl suppos 25 mg 38 promethazine hcl syrup 6.25 mg/5ml 38 promethazine hcl tab 12.5 mg 38 promethazine hcl tab 25 mg 38 promethazine hcl tab 50 mg 38 promethazine w/ codeine syrup mg/5ml 78 promethazine-dm syrup mg/5ml 78 promethegan sup 12.5mg 38 promethegan sup 25mg 38 promethegan sup 50mg 38 propafenone hcl cap sr 12hr 225 mg 18 propafenone hcl cap sr 12hr 325 mg 18 propafenone hcl cap sr 12hr 425 mg 18 propafenone hcl tab 150 mg 18 propafenone hcl tab 225 mg 18 propafenone hcl tab 300 mg 18 proparacaine hcl ophth soln 0.5% 114 propranolol & hydrochlorothiazide tab mg 44 propranolol & hydrochlorothiazide tab mg 44 propranolol hcl cap sr 24hr 120 mg 66 propranolol hcl cap sr 24hr 160 mg 66 propranolol hcl cap sr 24hr 60 mg 66 propranolol hcl cap sr 24hr 80 mg 66 propranolol hcl inj 1 mg/ml 66 propranolol hcl oral soln 20 mg/5ml 66 propranolol hcl oral soln 40 mg/5ml 66 propranolol hcl tab 10 mg 66 propranolol hcl tab 20 mg 66 propranolol hcl tab 40 mg 66 propranolol hcl tab 60 mg 66 propranolol hcl tab 80 mg 66 propylthiouracil tab 50 mg 125 PROQUAD INJ 132 protriptyline hcl tab 10 mg 31 protriptyline hcl tab 5 mg 31 PROVENTIL AER HFA 21 prudoxin cre 5% 83 pseudoephed-bromphen-dm syrup mg/5ml 78 pyrazinamide tab 500 mg 46 pyridostigmine bromide tab 60 mg 46 pyridostigmine bromide tab cr 180 mg 46 Q QUADRAMET INJ 52 QUARTETTE TAB 75 quasense tab 75 quetiapine fumarate tab 100 mg 58 quetiapine fumarate tab 200 mg 58 quetiapine fumarate tab 25 mg 58 quetiapine fumarate tab 300 mg 58 quetiapine fumarate tab 400 mg 58 quetiapine fumarate tab 50 mg 58 QUFLORA PED CHW 0.25MG 110 QUFLORA PED CHW 0.5MG 110 QUFLORA PED CHW 1MG 110 quflora ped dro 0.25mg 110 quflora ped dro 0.5mg/ml 110 quinapril hcl tab 10 mg 41 quinapril hcl tab 20 mg 41 quinapril hcl tab 40 mg 41 quinapril hcl tab 5 mg 41 quinapril-hydrochlorothiazide tab mg 44 quinapril-hydrochlorothiazide tab mg 44 quinapril-hydrochlorothiazide tab mg 44 quinine sulfate cap 324 mg 46 quinine sulfate tab 260 mg 46 QVAR AER 40MCG 20 QVAR AER 80MCG 20 R rabeprazole sodium ec tab 20 mg 129 raloxifene hcl tab 60 mg 91 ramipril cap 1.25 mg 41 ramipril cap 10 mg 41 ramipril cap 2.5 mg 41 ramipril cap 5 mg 41 RANEXA TAB 1000MG 15 RANEXA TAB 500MG 15 ranitidine hcl cap 150 mg 128 ranitidine hcl cap 300 mg 128 ranitidine hcl inj 1000 mg/40ml (25 mg/ml) 128 ranitidine hcl inj 150 mg/6ml (25 mg/ml) 128 ranitidine hcl inj 50 mg/2ml (25 mg/ml) 128 ranitidine hcl syrup 15 mg/ml (75 167

181 mg/5ml) 128 ranitidine hcl tab 150 mg 128 ranitidine hcl tab 300 mg 128 RAPAFLO CAP 4MG 99 RAPAFLO CAP 8MG 99 RAPAMUNE SOL 1MG/ML 64 REBETOL SOL 40MG/ML 63 REBIF INJ 22/ REBIF INJ 44/ REBIF REBIDO INJ 22/ REBIF REBIDO INJ 44/ REBIF REBIDO INJ TITRATN 122 REBIF TITRTN INJ PACK 122 reclipsen tab 75 RECOMBIVA HB INJ 10MCG/ML 132 RECOMBIVA HB INJ 5MCG/ RECOMBIVA-HB INJ 40MCG/ML 132 RECTIV OIN 0.4% 13 REGONOL INJ 5MG/ML 46 REGRANEX GEL 0.01% 87 RELENZA MIS DISKHALE 63 RELPAX TAB 20MG 106 RELPAX TAB 40MG 106 REMICADE INJ 100MG 98 REMODULIN INJ 10MG/ML 70 REMODULIN INJ 1MG/ML 70 REMODULIN INJ 2.5MG/ML 70 REMODULIN INJ 5MG/ML 70 RENVELA PAK 0.8GM 99 RENVELA PAK 2.4GM 99 RENVELA TAB 800MG 99 repaglinide tab 0.5 mg 34 repaglinide tab 1 mg 34 repaglinide tab 2 mg 34 repaglinide-metformin hcl tab mg 32 repaglinide-metformin hcl tab mg 32 REPATHA INJ 140MG/ML 40 REPATHA SURE INJ 140MG/ML 40 RESCRIPTOR TAB 100 MG 61 RESCRIPTOR TAB 200MG 61 RESTASIS EMU 0.05% 114 RETROVIR INJ 10MG/ML 61 REVLIMID CAP 10MG 63 REVLIMID CAP 15MG 63 REVLIMID CAP 2.5MG 63 REVLIMID CAP 20MG 64 REVLIMID CAP 25MG 64 REVLIMID CAP 5MG 63 REYATAZ CAP 100MG 61 REYATAZ CAP 150MG 61 REYATAZ CAP 200MG 61 REYATAZ CAP 300MG 61 REYATAZ POW 50MG 61 RHEUMATREX TAB 2.5MG 4 ribasphere cap 200mg 63 ribasphere tab 200mg 63 ribasphere tab 400mg 63 ribasphere tab 600mg 63 ribavirin cap 200 mg 63 ribavirin tab 200 mg 63 rifabutin cap 150 mg 46 RIFAMATE CAP 46 rifampin cap 150 mg 46 rifampin cap 300 mg 46 rifampin for inj 600 mg 46 RIFATER TAB 46 riluzole tab 50 mg 112 rimantadine hydrochloride tab 100 mg 63 risedronate sodium tab 150 mg 90 risedronate sodium tab 30 mg 90 risedronate sodium tab 35 mg 90 risedronate sodium tab 5 mg 90 risedronate sodium tab delayed release 35 mg 90 RISPERDAL INJ 12.5MG 57 RISPERDAL INJ 25MG 57 RISPERDAL INJ 37.5MG 57 RISPERDAL INJ 50MG 57 risperidone orally disintegrating tab 0.25 mg 57 risperidone orally disintegrating tab 0.5 mg 57 risperidone orally disintegrating tab 1 mg 57 risperidone orally disintegrating tab 2 mg 57 risperidone orally disintegrating tab 3 mg 57 risperidone orally disintegrating tab 4 mg 57 risperidone soln 1 mg/ml 57 risperidone tab 0.25 mg 57 risperidone tab 0.5 mg 57 risperidone tab 1 mg 57 risperidone tab 2 mg 57 risperidone tab 3 mg 57 risperidone tab 4 mg 57 RITUXAN INJ 100MG 49 RITUXAN INJ 500MG 49 rivastigmine tartrate cap 1.5 mg 121 rivastigmine tartrate cap 3 mg 121 rivastigmine tartrate cap 4.5 mg 121 rivastigmine tartrate cap 6 mg 121 rivastigmine td patch 24hr 13.3 mg/24hr 121 rivastigmine td patch 24hr 4.6 mg/24hr 121 rivastigmine td patch 24hr 9.5 mg/24hr 121 rizatriptan benzoate oral disintegrating tab 10 mg (base eq) 107 rizatriptan benzoate oral disintegrating tab 5 mg (base eq) 106 rizatriptan benzoate tab 10 mg (base equivalent) 107 rizatriptan benzoate tab 5 mg (base equivalent) 107 romycin oin op 114 ropinirole hydrochloride tab 0.25 mg 56 ropinirole hydrochloride tab 0.5 mg 56 ropinirole hydrochloride tab 1 mg

182 ropinirole hydrochloride tab 2 mg 56 ropinirole hydrochloride tab 3 mg 56 ropinirole hydrochloride tab 4 mg 56 ropinirole hydrochloride tab 5 mg 56 rosadan cre 0.75% 87 ROTARIX SUS 132 ROTATEQ SOL 132 ROXICET SOL 5-325/5 12 roxicet tab 5-325mg 12 ROZEREM TAB 8MG 103 S SABRIL POW 500MG 25 SABRIL TAB 500MG 25 SAFYRAL TAB 75 SAIZEN INJ 5MG 91 SAIZEN INJ 8.8MG 91 SAMSCA TAB 15MG 93 SAMSCA TAB 30MG 93 SANCUSO DIS 3.1MG 35 SANDIMMUNE SOL 100MG/ML 64 SANDOSTATIN KIT LAR 10MG 93 SANDOSTATIN KIT LAR 20MG 93 SANDOSTATIN KIT LAR 30MG 93 SANTYL OIN 250/GM 86 SAPHRIS SUB 10MG 58 SAPHRIS SUB 2.5MG 58 SAPHRIS SUB 5MG 58 SAVELLA MIS TITR PAK 121 SAVELLA TAB 100MG 122 SAVELLA TAB 12.5MG 121 SAVELLA TAB 25MG 121 SAVELLA TAB 50MG 121 scalacort lot 2% 86 selegiline hcl cap 5 mg 56 selegiline hcl tab 5 mg 56 selenium sulfide lotion 2.5% 84 selenium sulfide-pyrithione zinc in urea shampoo 2.25% 84 SELZENTRY TAB 150MG 61 SELZENTRY TAB 300MG 61 SENSIPAR TAB 30MG 92 SENSIPAR TAB 60MG 92 SENSIPAR TAB 90MG 92 SEREVENT DIS AER 50MCG 21 SEROQUEL XR TAB 150MG 58 SEROQUEL XR TAB 200MG 58 SEROQUEL XR TAB 300MG 59 SEROQUEL XR TAB 400MG 59 SEROQUEL XR TAB 50MG 58 SEROSTIM INJ 4MG 91 SEROSTIM INJ 5MG 91 SEROSTIM INJ 6MG 91 sertraline hcl oral conc 20 mg/ml 28 sertraline hcl tab 100 mg 28 sertraline hcl tab 25 mg 28 sertraline hcl tab 50 mg 28 SHUR-SEAL GEL 2% 132 sildenafil citrate iv soln 10 mg/12.5ml (base equivalent) 70 sildenafil citrate tab 20 mg 70 silver sulfadiazine cream 1% 84 SIMPONI ARIA SOL 50MG/4ML 4 SIMPONI INJ 100MG/ML 4 SIMPONI INJ 50/0.5ML 4 SIMULECT INJ 10MG 64 SIMULECT INJ 20MG 64 simvastatin tab 10 mg 40 simvastatin tab 20 mg 40 simvastatin tab 40 mg 40 simvastatin tab 5 mg 40 simvastatin tab 80 mg 40 sirolimus tab 0.5 mg 64 sirolimus tab 1 mg 64 sirolimus tab 2 mg 64 SKLICE LOT 0.5% 87 SKYLA IUD 13.5MG 76 sm nicotine dis 14mg/24h 123 sm nicotine dis 21mg 123 sm nicotine dis 7mg/24hr 123 sm vitamin d tab 400unit 133 SOD EDECRIN INJ 50MG 89 sodium chloride flush iv soln 0.9% 109 sodium chloride inj 0.45% 109 sodium chloride inj 0.9% 109 sodium chloride inj 2.5 meq/ml (14.6%) 109 sodium chloride inj 3% 109 sodium chloride inj 4 meq/ml (23.4%) 109 sodium chloride inj 5% 109 sodium chloride irrigation soln 0.9% 99 sodium chloride iv soln 0.9% 109 sodium chloride soln nebu 0.9% 79 sodium chloride soln nebu 10% 79 sodium chloride soln nebu 3% 79 sodium chloride soln nebu 7% 79 sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf) 108 sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf) 108 sodium fluoride chew tab 1 mg f (from 2.2 mg naf) 108 sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf) 108 sodium fluoride tab 0.5 mg f (from 1.1 mg naf) 108 sodium fluoride tab 1 mg f (from 2.2 mg naf) 108 sodium phenylbutyrate oral powder 3 gm/teaspoonful 92 sodium polystyrene sulfonate oral susp 15 gm/60ml 65 sodium polystyrene sulfonate rectal susp 30 gm/120ml 65 solia tab 75 SOLU-CORTEF INJ 1000MG 78 SOLU-CORTEF INJ 100MG 78 SOLU-CORTEF INJ 250MG 78 SOLU-CORTEF INJ 500MG 78 SOLU-MEDROL INJ 2GM 78 SOMATULINE INJ 120/.5ML

183 SOMATULINE INJ 60/0.2ML 93 SOMATULINE INJ 90/0.3ML 93 SOMAVERT INJ 10MG 90 SOMAVERT INJ 15MG 90 SOMAVERT INJ 20MG 90 SOMAVERT INJ 25MG 90 SOMAVERT INJ 30MG 90 sorine tab 120mg 66 sorine tab 160mg 66 sorine tab 240mg 66 sorine tab 80mg 66 sotalol hcl (afib/afl) tab 120 mg 66 sotalol hcl (afib/afl) tab 160 mg 66 sotalol hcl (afib/afl) tab 80 mg 66 SOTALOL HCL INJ 150/10ML 66 sotalol hcl tab 120 mg 66 sotalol hcl tab 160 mg 66 sotalol hcl tab 240 mg 66 sotalol hcl tab 80 mg 66 SOVALDI TAB 400MG 63 spinosad susp 0.9% 87 SPIRIVA AER RESPIMAT 19 SPIRIVA CAP HANDIHLR 19 SPIRIVA SPR RESPIMAT 19 spironolactone & hydrochlorothiazide tab mg 88 spironolactone tab 100 mg 89 spironolactone tab 25 mg 89 spironolactone tab 50 mg 89 SPORANOX SOL 10MG/ML 37 sprintec 28 tab 28 day 75 SPRYCEL TAB 100MG 52 SPRYCEL TAB 140MG 52 SPRYCEL TAB 20MG 52 SPRYCEL TAB 50MG 52 SPRYCEL TAB 70MG 52 SPRYCEL TAB 80MG 52 sronyx tab 75 ssd cre 1% 84 sss 10-5 aer 10-5% 80 stavudine cap 15 mg 61 stavudine cap 20 mg 61 stavudine cap 30 mg 61 stavudine cap 40 mg 61 stavudine for oral soln 1 mg/ml 61 STAVZOR CAP 125MG 26 STAVZOR CAP 250MG 26 STAVZOR CAP 500MG 26 STELARA INJ 45MG/ STELARA INJ 90MG/ML 83 STIVARGA TAB 40MG 52 STRATTERA CAP 100MG 2 STRATTERA CAP 10MG 2 STRATTERA CAP 18MG 2 STRATTERA CAP 25MG 2 STRATTERA CAP 40MG 2 STRATTERA CAP 60MG 2 STRATTERA CAP 80MG 2 streptomycin sulfate for inj 1 gm 4 STRIBILD TAB 62 SUBOXONE MIS 12-3MG 12 SUBOXONE MIS 2-0.5MG 12 SUBOXONE MIS 4-1MG 12 SUBOXONE MIS 8-2MG 12 SUCRAID SOL 8500/ML 88 sucralfate tab 1 gm 128 sulfacetamide sodium lotion 10% (acne) 80 sulfacetamide sodium ophth oint 10% 114 sulfacetamide sodium ophth soln 10% 114 sulfacetamide sodium w/ sulfur cleanser 10-2% 80 sulfacetamide sodium w/ sulfur cleanser % 80 sulfacetamide sodium w/ sulfur cleansing cloth 10-5% 81 sulfacetamide sodium w/ sulfur cleansing pad 10-4% 81 sulfacetamide sodium w/ sulfur cream 10-2% 81 sulfacetamide sodium w/ sulfur cream 10-5% 81 sulfacetamide sodium w/ sulfur cream % 81 sulfacetamide sodium w/ sulfur lotion 10-5% 81 sulfacetamide sodium w/ sulfur lotion % 81 sulfacetamide sodium w/ sulfur wash 9-4% 81 sulfacetamide sodium w/ sulfur wash 9-4.5% 81 sulfacetamide sodium-prednisolone ophth soln (0.25)% 115 sulfacleanse sus 8-4% 81 SULFADIAZINE TAB 500MG 124 sulfamethoxazole-trimethoprim iv soln mg/5ml 14 sulfamethoxazole-trimethoprim susp mg/5ml 14 sulfamethoxazole-trimethoprim tab mg 14 sulfamethoxazole-trimethoprim tab mg 14 SULFAMYLON CRE 85MG/GM 84 sulfasalazine tab 500 mg 98 sulfasalazine tab delayed release 500 mg 98 sulindac tab 150 mg 6 sulindac tab 200 mg 6 sumatriptan nasal spray 20 mg/act 107 sumatriptan nasal spray 5 mg/act 107 sumatriptan succinate inj 4 mg/0.5ml 107 sumatriptan succinate inj 6 mg/0.5ml 107 sumatriptan succinate solution autoinjector 4 mg/0.5ml 107 sumatriptan succinate solution autoinjector 6 mg/0.5ml 107 sumatriptan succinate solution cartridge 4 mg/0.5ml 107 sumatriptan succinate solution cartridge 6 mg/0.5ml 107 sumatriptan succinate solution prefilled 170

184 syringe 6 mg/0.5ml 107 sumatriptan succinate tab 100 mg 107 sumatriptan succinate tab 25 mg 107 sumatriptan succinate tab 50 mg 107 SUPRAX CAP 400MG 72 SUPRAX CHW 100MG 72 SUPRAX CHW 200MG 72 SUPRAX SUS 500/5ML 73 SUPRAX TAB 400MG 73 SUPREP BOWEL SOL PREP 103 SURMONTIL CAP 100MG 31 SURMONTIL CAP 25MG 31 SURMONTIL CAP 50MG 31 SUSTIVA CAP 200MG 62 SUSTIVA CAP 50MG 62 SUSTIVA TAB 600MG 62 SUTENT CAP 12.5MG 52 SUTENT CAP 25MG 52 SUTENT CAP 37.5MG 52 SUTENT CAP 50MG 52 syeda tab mg 75 symax fastab tab 0.125mg 127 symax-sl sub 0.125mg 127 SYMLINPEN 60 INJ 1000MCG 31 SYMLNPEN 120 INJ 1000MCG 31 SYNAREL SOL 2MG/ML 92 SYNERA DIS 70-70MG 87 SYNRIBO INJ 3.5MG 53 SYNTHROID TAB 100MCG 125 SYNTHROID TAB 112MCG 125 SYNTHROID TAB 125MCG 125 SYNTHROID TAB 137MCG 125 SYNTHROID TAB 150MCG 125 SYNTHROID TAB 175MCG 125 SYNTHROID TAB 200MCG 125 SYNTHROID TAB 25MCG 125 SYNTHROID TAB 300MCG 125 SYNTHROID TAB 50MCG 125 SYNTHROID TAB 75MCG 125 SYNTHROID TAB 88MCG 125 SYPRINE CAP 250MG 63 T TABLOID TAB 40MG 48 TACLONEX SUS 86 tacrolimus cap 0.5 mg 64 tacrolimus cap 1 mg 64 tacrolimus cap 5 mg 64 tacrolimus oint 0.03% 87 tacrolimus oint 0.1% 86 TAFINLAR CAP 50MG 52 TAFINLAR CAP 75MG 52 TAMIFLU CAP 30MG 63 TAMIFLU CAP 45MG 63 TAMIFLU CAP 75MG 63 TAMIFLU SUS 6MG/ML 63 tamoxifen citrate tab 10 mg (base equivalent) 50 tamoxifen citrate tab 20 mg (base equivalent) 50 tamsulosin hcl cap 0.4 mg 99 TARCEVA TAB 100MG 52 TARCEVA TAB 150MG 52 TARCEVA TAB 25MG 52 TARGRETIN GEL 1% 83 tazicef inj 1gm 73 tazicef inj 2gm 73 tazicef inj 6gm 73 TAZORAC CRE 0.05% 83 TAZORAC CRE 0.1% 83 TAZORAC GEL 0.05% 83 TAZORAC GEL 0.1% 83 taztia xt cap 120mg/24 68 taztia xt cap 180mg/24 69 taztia xt cap 240mg/24 69 taztia xt cap 300mg/24 69 taztia xt cap 360mg/24 69 TEFLARO INJ 400MG 73 TEFLARO INJ 600MG 73 TEGRETOL-XR TAB 100MG 25 TEKTURNA TAB 150MG 45 TEKTURNA TAB 300MG 45 telmisartan tab 20 mg 42 telmisartan tab 40 mg 42 telmisartan tab 80 mg 42 telmisartan-amlodipine tab mg 44 telmisartan-amlodipine tab 40-5 mg 44 telmisartan-amlodipine tab mg 44 telmisartan-amlodipine tab 80-5 mg 44 telmisartan-hydrochlorothiazide tab mg 44 telmisartan-hydrochlorothiazide tab mg 45 telmisartan-hydrochlorothiazide tab mg 45 temazepam cap 15 mg 103 temazepam cap 22.5 mg 103 temazepam cap 30 mg 103 temazepam cap 7.5 mg 103 TEMODAR INJ 100MG 47 temozolomide cap 100 mg 47 temozolomide cap 140 mg 47 temozolomide cap 180 mg 47 temozolomide cap 20 mg 47 temozolomide cap 250 mg 47 temozolomide cap 5 mg 47 TENIPOSIDE INJ 50MG/5ML 54 TENIVAC INJ 5-2LF 126 terazosin hcl cap 1 mg 42 terazosin hcl cap 10 mg 42 terazosin hcl cap 2 mg 42 terazosin hcl cap 5 mg 42 terbinafine hcl tab 250 mg 37 terbutaline sulfate inj 1 mg/ml 21 terbutaline sulfate tab 2.5 mg 21 terbutaline sulfate tab 5 mg 21 terconazole vaginal cream 0.4% 132 terconazole vaginal suppos 80 mg 132 testosterone cypionate im inj in oil 100 mg/ml

185 testosterone cypionate im inj in oil 200 mg/ml 13 testosterone enanthate im inj in oil 200 mg/ml 13 testosterone td gel 10mg/act (2%) 13 testosterone td gel 25 mg/2.5gm (1%) 13 TET/DIP TOX INJ 2-2 LF 126 tetrabenazine tab 12.5 mg 122 tetrabenazine tab 25 mg 122 tetracycline hcl cap 250 mg 124 tetracycline hcl cap 500 mg 124 TEXACORT SOL 2.5% 86 tgq 50pse/3 syp brm/30dm 78 THALOMID CAP 100MG 64 THALOMID CAP 150MG 64 THALOMID CAP 200MG 64 THALOMID CAP 50MG 64 THEO-24 CAP 100MG CR 21 THEO-24 CAP 200MG CR 21 THEO-24 CAP 300MG CR 21 THEO-24 CAP 400MG ER 21 theochron tab 100mg cr 21 theochron tab 200mg cr 21 theochron tab 300mg cr 21 theophylline soln 80 mg/15ml 21 theophylline tab sr 12hr 450 mg 21 theophylline tab sr 24hr 400 mg 21 theophylline tab sr 24hr 600 mg 21 THERACYS INJ 53 thioridazine hcl tab 10 mg 59 thioridazine hcl tab 100 mg 59 thioridazine hcl tab 25 mg 59 thioridazine hcl tab 50 mg 59 thiothixene cap 1 mg 60 thiothixene cap 10 mg 60 thiothixene cap 2 mg 60 thiothixene cap 5 mg 60 thrive gum 4mg mint 123 THYMOGLOBULN INJ 25MG 64 THYROLAR-1 TAB 60MG 125 THYROLAR-1/2 TAB 30MG 126 THYROLAR-1/4 TAB 15MG 126 THYROLAR-2 TAB 120MG 126 THYROLAR-3 TAB 180MG 126 tiagabine hcl tab 2 mg 25 tiagabine hcl tab 4 mg 25 TICE BCG INJ 53 ticlopidine hcl tab 250 mg 101 TIKOSYN CAP 125MCG 19 TIKOSYN CAP 250MCG 19 TIKOSYN CAP 500MCG 19 tilia fe tab 75 TIMENTIN INJ 3.1GM 119 TIMENTIN INJ 31GM 119 timolol maleate ophth gel forming soln 0.25% 113 timolol maleate ophth gel forming soln 0.5% 113 timolol maleate ophth soln 0.25% 113 timolol maleate ophth soln 0.5% 113 timolol maleate tab 10 mg 67 timolol maleate tab 20 mg 67 timolol maleate tab 5 mg 66 TIMOPTIC OCU SOL 0.25% OP 113 TIMOPTIC OCU SOL 0.5% OP 113 tinidazole tab 250 mg 14 tinidazole tab 500 mg 14 tis-u-sol sol 65 TIVICAY TAB 50MG 62 tizanidine hcl cap 2 mg (base equivalent) 111 tizanidine hcl cap 4 mg (base equivalent) 111 tizanidine hcl cap 6 mg (base equivalent) 111 tizanidine hcl tab 2 mg (base equivalent) 111 tizanidine hcl tab 4 mg (base equivalent) 111 TOBRA/NACL INJ 80/0.9 4 TOBRADEX OIN % 115 tobramycin nebu soln 300 mg/5ml 4 tobramycin ophth soln 0.3% 114 tobramycin sulfate for inj 1.2 gm 4 tobramycin sulfate inj 1.2 gm/30ml (40 mg/ml) (base equiv) 4 tobramycin sulfate inj 10 mg/ml (base equivalent) 4 tobramycin sulfate inj 2 gm/50ml (40 mg/ml) (base equiv) 4 tobramycin sulfate inj 80 mg/2ml (40 mg/ml) (base equiv) 4 tobramycin-dexamethasone ophth susp % 115 TOBREX OIN 0.3% OP 114 TODAY SPONGE MIS 132 tolazamide tab 250 mg 34 tolazamide tab 500 mg 34 tolbutamide tab 500 mg 34 tolcapone tab 100 mg 55 tolmetin sodium cap 400 mg 6 tolmetin sodium tab 200 mg 6 tolmetin sodium tab 600 mg 6 tolterodine tartrate cap sr 24hr 2 mg 130 tolterodine tartrate cap sr 24hr 4 mg 130 tolterodine tartrate tab 1 mg 130 tolterodine tartrate tab 2 mg 130 topiramate sprinkle cap 15 mg 25 topiramate sprinkle cap 25 mg 25 topiramate tab 100 mg 25 topiramate tab 200 mg 25 topiramate tab 25 mg 25 topiramate tab 50 mg 25 toposar inj 100/5ml 54 toposar inj 20mg/ml 54 topotecan hcl for inj 4 mg 54 TOPOTECAN INJ 4MG/4ML 54 TORISEL SOL 25MG/ML 52 TORSEMIDE INJ 20MG/2ML 89 TORSEMIDE INJ 50MG/5ML 89 torsemide tab 10 mg

186 torsemide tab 100 mg 89 torsemide tab 20 mg 89 torsemide tab 5 mg 89 TOVIAZ TAB 4MG 130 TOVIAZ TAB 8MG 130 TRACLEER TAB 125MG 70 TRACLEER TAB 62.5MG 70 TRADJENTA TAB 5MG 32 tramadol hcl tab 50 mg 11 tramadol hcl tab sr 24hr 100 mg 11 tramadol hcl tab sr 24hr 200 mg 11 tramadol hcl tab sr 24hr 300 mg 11 trandolapril tab 1 mg 41 trandolapril tab 2 mg 41 trandolapril tab 4 mg 41 trandolapril-verapamil hcl tab cr mg 45 trandolapril-verapamil hcl tab cr mg 45 trandolapril-verapamil hcl tab cr mg 45 trandolapril-verapamil hcl tab cr mg 45 tranexamic acid iv soln 1000 mg/10ml (100 mg/ml) 102 tranexamic acid tab 650 mg 102 TRANSDERM-SC DIS 1MG 36 tranylcypromine sulfate tab 10 mg 27 TRAVATAN Z DRO 0.004% 116 trazodone hcl tab 100 mg 28 trazodone hcl tab 150 mg 28 trazodone hcl tab 300 mg 28 trazodone hcl tab 50 mg 28 TRECATOR TAB 250MG 46 TRELSTAR INJ 11.25MG 50 TRELSTAR MIX INJ 22.5MG 50 TRELSTAR MIX INJ 3.75MG 50 TRETIN-X CRE % 81 TRETIN-X CRE 0.075% 81 tretinoin cap 10 mg 53 tretinoin cream 0.025% 81 tretinoin cream 0.05% 81 tretinoin cream 0.1% 81 tretinoin gel 0.01% 81 tretinoin gel 0.025% 81 tretinoin gel 0.05% 81 tretinoin microsphere gel 0.04% 81 tretinoin microsphere gel 0.1% 81 TREXALL TAB 10MG 48 TREXALL TAB 15MG 48 TREXALL TAB 5MG 48 TREXALL TAB 7.5MG 48 tri-linyah tab 75 tri-previfem tab 75 tri-sprintec tab 75 tri-vit/fe dro /fl tri-vit/fl dro 0.25mg 110 tri-vit/fl dro 0.5mg 110 tri-vit/fluo dro 0.25mg 110 tri-vita/fl dro 0.25mg 110 triamcinolone acetonide aerosol soln mg/gm 86 triamcinolone acetonide cream 0.025% 86 triamcinolone acetonide cream 0.1% 86 triamcinolone acetonide cream 0.5% 86 triamcinolone acetonide dental paste 0.1% 110 triamcinolone acetonide lotion 0.025% 86 triamcinolone acetonide lotion 0.1% 86 triamcinolone acetonide nasal aerosol suspension 55 mcg/act 112 triamcinolone acetonide oint 0.025% 86 triamcinolone acetonide oint 0.1% 86 triamcinolone acetonide oint 0.5% 86 triamterene & hydrochlorothiazide cap mg 88 triamterene & hydrochlorothiazide cap mg 88 triamterene & hydrochlorothiazide tab mg 88 triamterene & hydrochlorothiazide tab mg 88 TRIANEX OIN 0.05% 86 triderm cre 0.1% 86 trifluoperazine hcl tab 1 mg 59 trifluoperazine hcl tab 10 mg 59 trifluoperazine hcl tab 2 mg 59 trifluoperazine hcl tab 5 mg 59 trifluridine ophth soln 1% 114 trihexyphenidyl hcl elixir 0.4 mg/ml 54 trihexyphenidyl hcl tab 2 mg 54 trihexyphenidyl hcl tab 5 mg 55 trimethobenzamide hcl cap 300 mg 36 trimethobenzamide hcl inj 100 mg/ml 36 trimethoprim tab 100 mg 14 trimipramine maleate cap 100 mg 31 trimipramine maleate cap 25 mg 31 trimipramine maleate cap 50 mg 31 trinessa tab 75 TRIPEDIA SUS P/F 126 TRISENOX SOL 10MG/10M 53 TRIUMEQ TAB 62 trivora-28 tab 75 tropicamide ophth soln 0.5% 113 tropicamide ophth soln 1% 113 trospium chloride cap sr 24hr 60 mg 130 trospium chloride tab 20 mg 130 TRULICITY INJ 0.75/ TRULICITY INJ 1.5/ TRUMENBA INJ 131 TRUVADA TAB tussigon tab 5-1.5mg 78 TWINRIX INJ 132 TYBOST TAB 150MG 62 TYGACIL INJ 50MG 15 TYKERB TAB 250MG 52 TYSABRI INJ 300/15ML 122 TYVASO START SOL 0.6MG/ML 70 TYZEKA TAB 600MG 63 TYZINE PED DRO 0.05%

187 TYZINE SOL 0.1% 112 U ULESFIA LOT 5% 87 ULORIC TAB 40MG 100 ULORIC TAB 80MG 100 ULTRESA CAP 13800UNT 88 ULTRESA CAP 20700UNT 88 ULTRESA CAP 23000UNT 88 unithroid tab 100mcg 126 unithroid tab 112mcg 126 unithroid tab 125mcg 126 unithroid tab 200mcg 126 unithroid tab 25mcg 126 unithroid tab 300mcg 126 unithroid tab 50mcg 126 unithroid tab 75mcg 126 unithroid tab 88mcg 126 univert tab 32mg 36 ursodiol cap 300 mg 98 ursodiol tab 250 mg 98 ursodiol tab 500 mg 98 UVADEX INJ 20MCG/ML 53 V VAGIFEM TAB 10MCG 133 valacyclovir hcl tab 1 gm 63 valacyclovir hcl tab 500 mg 63 VALCYTE SOL 50MG/ML 62 valganciclovir hcl tab 450 mg (base equivalent) 62 valproate sodium inj 100 mg/ml 26 valproate sodium syrup 250 mg/5ml (base equiv) 26 valproic acid cap 250 mg 26 valsartan tab 160 mg 42 valsartan tab 320 mg 42 valsartan tab 40 mg 42 valsartan tab 80 mg 42 valsartan-hydrochlorothiazide tab mg 45 valsartan-hydrochlorothiazide tab mg 45 valsartan-hydrochlorothiazide tab mg 45 valsartan-hydrochlorothiazide tab mg 45 valsartan-hydrochlorothiazide tab mg 45 vancomycin hcl cap 125 mg 14 vancomycin hcl cap 250 mg 14 vancomycin hcl for inj 10 gm 14 vancomycin hcl for inj 1000 mg 14 vancomycin hcl for inj 500 mg 14 vancomycin hcl for inj 5000 mg 14 vandazole gel 0.75% 132 VAQTA INJ 25/0.5ML 132 VAQTA INJ 50UNT/ML 132 VARIVAX INJ 132 VCF VAGINAL AER CONTRACP 132 VCF VAGINAL MIS CONTRACP 132 velivet pak 75 VELTIN GEL 81 venlafaxine hcl cap sr 24hr 150 mg (base equivalent) 28 venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent) 28 venlafaxine hcl cap sr 24hr 75 mg (base equivalent) 28 venlafaxine hcl tab 100 mg 28 venlafaxine hcl tab 25 mg 28 venlafaxine hcl tab 37.5 mg 28 venlafaxine hcl tab 50 mg 28 venlafaxine hcl tab 75 mg 28 venlafaxine hcl tab sr 24hr 150 mg (base equivalent) 29 venlafaxine hcl tab sr 24hr 225 mg (base equivalent) 29 venlafaxine hcl tab sr 24hr 37.5 mg (base equivalent) 28 venlafaxine hcl tab sr 24hr 75 mg (base equivalent) 28 VENTAVIS SOL 10MCG/ML 70 VENTAVIS SOL 20MCG/ML 70 VENTOLIN HFA AER 21 verapamil hcl cap sr 24hr 100 mg 69 verapamil hcl cap sr 24hr 120 mg 69 verapamil hcl cap sr 24hr 180 mg 69 verapamil hcl cap sr 24hr 200 mg 69 verapamil hcl cap sr 24hr 240 mg 69 verapamil hcl cap sr 24hr 300 mg 69 verapamil hcl cap sr 24hr 360 mg 69 verapamil hcl iv soln 2.5 mg/ml 69 verapamil hcl tab 120 mg 69 verapamil hcl tab 40 mg 69 verapamil hcl tab 80 mg 69 verapamil hcl tab cr 120 mg 69 verapamil hcl tab cr 180 mg 69 verapamil hcl tab cr 240 mg 69 VERDESO AER 0.05% 86 VEREGEN OIN 15% 82 VERIPRED 20 SOL 20MG/5ML 78 VESICARE TAB 10MG 131 VESICARE TAB 5MG 131 vestura tab mg 75 VEXOL SUS 1% OP 115 VIBATIV INJ 250MG 14 VIBATIV INJ 750MG 14 VIBRAMYCIN SYP 50MG/5ML 124 vicodin es tab vicodin hp tab mg 12 vicodin tab 5-300mg 12 VICTOZA INJ 18MG/3ML 33 VIDEX SOL 2GM 62 VIDEX SOL 4GM 62 VIGAMOX DRO 0.5% 114 VIIBRYD KIT 28 VIIBRYD KIT STARTER 28 VIIBRYD TAB 10MG 28 VIIBRYD TAB 20MG

188 VIIBRYD TAB 40MG 28 VIMPAT INJ 200MG/20 25 VIMPAT SOL 10MG/ML 25 VIMPAT TAB 100MG 25 VIMPAT TAB 150MG 25 VIMPAT TAB 200MG 25 VIMPAT TAB 50MG 25 VINBLASTINE INJ 10MG 54 vinblastine sulfate inj 1 mg/ml 54 vincasar pfs inj 1mg/ml 54 vincristine sulfate iv soln 1 mg/ml 54 vinorelbine tartrate inj 10 mg/ml (base equiv) 54 vinorelbine tartrate inj 50 mg/5ml (10 mg/ml) (base equiv) 54 VIOKACE TAB 88 VIOKACE TAB viorele tab 75 VIRACEPT TAB 250MG 62 VIRACEPT TAB 625MG 62 VIRAMUNE XR TAB 100MG 62 VIRAZOLE INH 6GM 63 VIREAD POW 40MG/GM 62 VIREAD TAB 150MG 62 VIREAD TAB 200MG 62 VIREAD TAB 250MG 62 VIREAD TAB 300MG 62 vit a/c/d/fl dro 0.25mg 110 VITAMIN D2 TAB 400UNIT 133 VITAMIN D3 LIQ 1000UNIT 133 VITAMIN D3 LIQ 1200UNIT 133 VITEKTA TAB 150MG 62 VITEKTA TAB 85MG 62 VIVITROL INJ 380MG 35 VOLTAREN GEL 1% 82 voriconazole for susp 40 mg/ml 37 voriconazole tab 200 mg 37 voriconazole tab 50 mg 37 VOTRIENT TAB 200MG 52 VPRIV INJ 400UNIT 101 VYTORIN TAB 10-10MG 38 VYTORIN TAB 10-20MG 38 VYTORIN TAB 10-40MG 38 VYTORIN TAB 10-80MG 38 VYVANSE CAP 10MG 1 VYVANSE CAP 20MG 1 VYVANSE CAP 30MG 1 VYVANSE CAP 40MG 1 VYVANSE CAP 50MG 1 VYVANSE CAP 60MG 1 VYVANSE CAP 70MG 2 W warfarin sodium tab 1 mg 21 warfarin sodium tab 10 mg 22 warfarin sodium tab 2 mg 21 warfarin sodium tab 2.5 mg 21 warfarin sodium tab 3 mg 21 warfarin sodium tab 4 mg 21 warfarin sodium tab 5 mg 22 warfarin sodium tab 6 mg 22 warfarin sodium tab 7.5 mg 22 wee care sus 15/ WELCHOL PAK 3.75GM 39 WELCHOL TAB 625MG 39 wera tab 0.5/35 75 WIDE-SEAL DPR KIT WIDE-SEAL DPR KIT WIDE-SEAL DPR KIT WIDE-SEAL DPR KIT WIDE-SEAL DPR KIT WIDE-SEAL DPR KIT WIDE-SEAL DPR KIT WIDE-SEAL DPR KIT X XALKORI CAP 200MG 52 XALKORI CAP 250MG 52 XARELTO STAR TAB 15/20MG 22 XARELTO TAB 10MG 22 XARELTO TAB 15MG 22 XARELTO TAB 20MG 22 XELJANZ TAB 5MG 4 XEOMIN INJ 100UNIT 112 XEOMIN INJ 200UNIT 112 XEOMIN INJ 50 UNIT 112 XGEVA INJ 90 XIFAXAN TAB 200MG 14 XIFAXAN TAB 550MG 14 XOLEGEL GEL 2% 83 XOPENEX HFA AER 21 xulane dis XYREM SOL 500MG/ML 120 Y YERVOY INJ 200MG 49 YERVOY INJ 50MG 49 Z zafirlukast tab 10 mg 19 zafirlukast tab 20 mg 19 zaleplon cap 10 mg 103 zaleplon cap 5 mg 103 ZALTRAP INJ 100/4ML 48 ZALTRAP INJ 200/8ML 48 zamicet sol mg 12 ZANOSAR INJ 1GM 47 ZANTAC INJ 50/50ML 128 ZANTAC TAB 25MG EF 128 zarah tab mg 75 ZAVESCA CAP 100MG 101 zazole cre 0.4% 132 zazole cre 0.8% 132 zazole sup 80mg 132 ZELAPAR TAB 1.25MG 56 ZELBORAF TAB 240MG 52 ZEMAIRA INJ 1000MG 123 zenchent fe chw 0.4mg zenchent tab

189 ZENPEP CAP 10000UNT 88 ZENPEP CAP 15000UNT 88 ZENPEP CAP 20000UNT 88 ZENPEP CAP 25000UNT 88 ZENPEP CAP 3000UNIT 88 ZENPEP CAP 40000UNT 88 ZENPEP CAP 5000UNIT 88 zenzedi tab 15mg 2 zenzedi tab 2.5mg 2 zenzedi tab 20mg 2 zenzedi tab 30mg 2 zenzedi tab 7.5mg 2 ZETIA TAB 10MG 40 ZIAGEN SOL 20MG/ML 62 ZIANA GEL 82 zidovudine cap 100 mg 62 zidovudine syrup 10 mg/ml 62 zidovudine tab 300 mg 62 ZINACEF INJ 750MG 72 ZINACEF/H20 INJ 1.5GM PB 72 ZIOPTAN DRO % 116 ziprasidone hcl cap 20 mg 56 ziprasidone hcl cap 40 mg 56 ziprasidone hcl cap 60 mg 56 ziprasidone hcl cap 80 mg 56 ZIRGAN GEL 0.15% 114 ZMAX SUS 2GM 104 zoledronic acid inj conc for iv infusion 4 mg/5ml 90 zoledronic acid iv soln 5 mg/100ml 90 ZOLEDRONIC INJ 4MG/ ZOLINZA CAP 100MG 52 zolmitriptan orally disintegrating tab 2.5 mg 107 zolmitriptan orally disintegrating tab 5 mg 107 zolmitriptan tab 2.5 mg 107 zolmitriptan tab 5 mg 107 zolpidem tartrate tab 10 mg 103 zolpidem tartrate tab 5 mg 103 zolpidem tartrate tab cr 12.5 mg 103 zolpidem tartrate tab cr 6.25 mg 103 ZOMETA INJ 4MG/ ZOMIG NASAL SPR 5MG 107 ZOMIG SPR 2.5MG 107 zonisamide cap 100 mg 25 zonisamide cap 25 mg 25 zonisamide cap 50 mg 25 ZONTIVITY TAB 2.08MG 101 ZORBTIVE INJ 8.8MG 91 ZORTRESS TAB 0.25MG 65 ZORTRESS TAB 0.5MG 64 ZORTRESS TAB 0.75MG 65 ZOSTAVAX INJ 132 ZOSYN SOL GM 119 ZOSYN SOL G 119 ZOSYN SOL GM 119 zovia 1/35e tab 75 zovia 1/50e tab 75 ZUPLENZ MIS 4MG 35 ZUPLENZ MIS 8MG 35 ZYCLARA CRE 3.75% 86 ZYCLARA PUMP CRE 2.5% 86 ZYDELIG TAB 100MG 52 ZYDELIG TAB 150MG 52 ZYFLO CR TAB 600MG 19 ZYKADIA CAP 150MG 52 ZYTIGA TAB 250MG 50 ZYVOX SUS 100MG/5M