(List of Covered Drugs)

Transcription

1 (List of Covered Drugs) This formulary was updated on 8/19/2015. For more recent information or other questions, please contact Florida Health Care Plans Member Services at or, for TTY users, TRS Relay 711. Hours of operation are 7 days a week, 8 am 8 pm, or visit Note to Members: Please review this document to make sure that it contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means Florida Health Care Plans (FHCP). When it refers to plan or our plan, it means Florida Health Care Plans (FHCP). This document includes a list of the drugs (formulary) for our plan which is current as of 8/19/2015. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front cover page. Disclaimers: You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change upon renewal of your plan. This information is available for free in other languages. Please contact our Member Services number at for additional information. (TTY users should call TRS Relay 711). Hours are 8 am to 8 pm, 7 days a week. Member Services also has free language interpreter services available for non-english speakers. Esta informacion esta disponible gratis en otros lenguajes. Por favor pongase en contacto con nuestro Servicios de Miembros a para informacion adicional. Usuarios de TTY deben de llamar TRS Relay 711. Horas son de 8 am hasta 8 pm, 7 dias de la semana. Servicios de Miembros tambien tiene servicios de interpretacion de lenguajes gratis disponible para personas que no hablan ingles. Form#:

2 FORMULARY INTRODUCTION Your prescription drug benefit provides coverage for drugs listed in the therapeutic drug classes of the FHCP Formulary. A Formulary is a listing of therapeutic drug classes, and a therapeutic drug class is defined as a group of similar drugs that are used to treat a specific condition. Any drug not listed in the FHCP Formulary is considered a non-covered drug and is subject to a higher out of pocket costs. This list represents the major therapeutic classes of the FHCP Formulary and should serve as a quick reference to you, your physician, or pharmacist for those covered drugs within the major therapeutic classes listed. If your physician prescribes a drug that is not covered, show your physician this list, and ask the physician to prescribe a drug from within the FHCP Formulary. The FHCP Formulary is developed by FHCP's Pharmacy and Therapeutics Committee. This committee, which meets quarterly, is made up of physicians, pharmacists, and nurses who review drugs on the basis of effectiveness, safety, tolerability, and cost. Since there are similar drugs within a therapeutic class to treat a specific condition, FHCP does not cover all drugs that are made, but only those selected by this committee. This Formulary does not represent all therapeutic classes of drugs and is subject to change. Information on drug coverage for a non-listed therapeutic drug class should be directed to a FHCP pharmacist or physician. s: All strengths and dosage forms of a listed drug are covered unless noted in the s column. For example, Clindamycin capsules say 150mg only in this s column. This means that FHCP only covers the 150mg strength and the 300mg strength is not covered. The brand names are listed in capital letters and in parentheses for ease of searching. For example, (CLEOCIN) is the brand name for clindamycin capsules Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization (PA): FHCP requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from FHCP before you fill your prescriptions. If you don t get approval, FHCP may not cover the drug. Quantity Limits (QL): For certain drugs, FHCP limits the amount of the drug that FHCP will cover. For example, FHCP provides 4 ounces per prescription for cough syrups. This may be in addition to a standard one-month or three-month supply. Step Therapy (ST): In some cases, FHCP requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, FHCP may not cover Drug B unless you try Drug A first. If Drug A does not work for you, FHCP will then cover Drug B. 75% Usage Rule Prescription refills will not be covered unless at least 75% of the previous prescription has been used by the Member (based on the dosage schedule prescribed by the physician). 90% Usage Rule Prescription refills for narcotics or controlled substances will not be covered unless at least 90% of the previous prescription has been used by the Member (based on the dosage schedule prescribed by the physician). Page 2 of 88

3 You can find out if your drug has any additional requirements or limits by looking in the formulary. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site Our contact information, along with the date we last updated the formulary, appears on the front cover page. You can ask FHCP to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the FHCP s formulary? for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. If you learn that FHCP does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by FHCP. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by FHCP. You can ask FHCP to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the Formulary? You can ask FHCP to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, FHCP limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, FHCP will only approve your request for an exception if the alternative drug is included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition, and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you must submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 14 days of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 14 days for a decision. If your request to expedite is granted, we must give you a decision no later than 24 to 72 hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing Member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a Member of our plan. For each of your drugs that is Page 3 of 88

4 not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a FHCP pharmacy. After your first 30- day supply, we will not pay for these drugs, even if you have been a Member of the plan less than 90-days. Medication Transition Program for new FHCP Members. In your Enrollment Packet, you will be provided with a Medication Transition Form. The completed Form will include the names of the medications, dosage, and prescribing physician s name as well as specific Member information and an Authorization to Release Protected Health Information Section that will allow FHCP s Clinical Pharmacist to obtain any necessary medical records from the prescribing physician. Once complete, the form is reviewed by a Clinical Pharmacist who will coordinate care with you and the physician(s) as needed. FHCP pharmacies will dispense a one-time 31 day supply of the current transition medication to allow you and our physician(s) to discuss possible Drug Formulary alternatives, request a prior authorization, or, in the event the physician(s) deems the non-formulary drug to be medically necessary, request a Formulary Exception. How much will my prescriptions Cost? Your pharmacy benefit and the drugs listed in the formulary are assigned TIERS. There are six (6) Tiers in the Formulary. Tier 1 (T1) Formulary Preferred Generic Tier 2 (T2) Formulary Non-Preferred Generic Tier 3 (T3) Formulary Preferred Brand Tier 4 (T4) Formulary Non-Preferred Brand Tier 5 (T5) Specialty Drugs Tier 6 (T6) Formulary Injectables The Formulary will indicate the Tier each drug is in. Generally, the higher the Tier, the higher your cost will be. Carefully review your Summary of Benefits Coverage to ascertain if you have a pharmacy benefit and/or any pharmacy benefit limitations. For more information For more detailed information about your FHCP prescription drug coverage, please review your Certificate of Coverage, your Summary of Benefits Coverage and other plan materials for your cost sharing and any benefit limitations (such as Generic Only option). If you have questions, please contact us. Note: FHCP s Formulary can also be found on our website at If you are unable to find a certain drug within this booklet, please check out our website, as it is updated more frequently. Non-Self Injected drugs are not covered. Antineoplastic and HIV medications are not listed in this document because these classes of drugs have an open formulary. All drugs in these classes are covered. Page 4 of 88

5 KEY FOR COVERAGE DETAILS COLUMN PA: Prior Authorization. - This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at , 7 days a week, 8 am 8 pm. TTY users should call TRS Relay 711. QL: Quantity Limit. ST: Step Therapy - This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at , 7 days a week, 8 am 8 pm. TTY users should call TRS Relay 711. * 75% Usage Rule Prescription refills will not be covered unless at least 75% of the previous prescription has been used by the Member (based on the dosage schedule prescribed by the physician). 90% Usage Rule Prescription refills for narcotics or controlled substances will not be covered unless at least 90% of the previous prescription has been used by the Member (based on the dosage schedule prescribed by the physician). HOW TO SEARCH FOR A DRUG IN THE FLORIDA HEALTH CARE PLAN PREFERRED DRUG LIST (FORMULARY) On the FHCP Website, click on the Members tab, click on Formulary Click on Commercial Formulary When the PDF file comes up, press Control F. A pop-up search text box will appear at the top of the page. Type the drug name for which you are searching and click the right arrow in the pop-up search text box to begin the search. To close the pop-up search text box, click on the x in the pop-up search text box. Page 5 of 88

6 Florida Health Care Plan- FHCP Commercial Formulary Effective (10:00) Antineoplastic Agents HYDROXYUREA CAPS 500MG T2 (HYDREA) MERCAPTOPURINE TABS 50MG T2 (PURINETHOL) METHOTREXATE TABS 2.5MG T2 (TREXALL) METHOTREXATE TABS 2.5MG T2 (TREXALL) Tier: T METHOTREXATE SODIUM SOLN 25MG/ML T6 (12:04) Autonomic Drugs» Parasympathomimetic (Cholinergic) Agents BETHANECHOL CHLORIDE TABS 10MG T2 (URECHOLINE) BETHANECHOL CHLORIDE TABS 25MG T2 (URECHOLINE) BETHANECHOL CHLORIDE TABS 5MG T2 (URECHOLINE) BETHANECHOL CHLORIDE TABS 50MG T2 (URECHOLINE) DONEPEZIL HCL TABS 10MG T2 not 23mg or XR, (ARICEPT) DONEPEZIL HCL TABS 5MG T2 not 23mg or XR, (ARICEPT) DONEPEZIL HCL TBDP 5MG T2 not 23mg or XR, (ARICEPT) DONEPEZIL HCL TBDP 10MG T2 not 23mg or XR, (ARICEPT) GALANTAMINE HYDROBROMIDE CP24 16MG T2 (RAZADYNE ER) GALANTAMINE HYDROBROMIDE CP24 8MG T2 (RAZADYNE ER) GALANTAMINE HYDROBROMIDE CP24 24MG T2 (RAZADYNE ER) GALANTAMINE HYDROBROMIDE SOLN 4MG/ML T2 (RAZADYNE) GALANTAMINE HYDROBROMIDE TABS 4MG T2 (RAZADYNE) GALANTAMINE HYDROBROMIDE TABS 8MG T2 (RAZADYNE) GALANTAMINE HYDROBROMIDE TABS 12MG T2 (RAZADYNE) PILOCARPINE HYDROCHLORIDE TABS 5MG T2 (SALAGEN) PYRIDOSTIGMINE BROMIDE TABS 60MG T2 (MESTINON) MESTINON TIMESPAN TBCR 180MG T3 Page 6 of 88

7 GUANIDINE HCL TABS 125MG T4 (12:08.08) Autonomic Drugs» Anticholinergic Agents» Antimuscarinics/Antispasmodics CHLORDIAZEPOXIDE HCL/CLIDINIUM BROMIDE CAPS 5MG; 2.5MG T2 (LIBRAX) DICYCLOMINE HCL CAPS 10MG T2 (BENTYL) DICYCLOMINE HCL TABS 20MG T2 (BENTYL) DICYCLOMINE HCL SOLN 10MG/5ML T2 (BENTYL) GLYCOPYRROLATE TABS 1MG T2 (ROBINUL) GLYCOPYRROLATE TABS 2MG T2 (ROBINUL) HYOMAX-SL SUBL 0.125MG T2 (LEVSIN) HYOSCYAMINE SULFATE ELIX 0.125MG/5ML T HYOSCYAMINE SULFATE SOLN 0.125MG/ML T2 QL HYOSCYAMINE SULFATE TABS 0.125MG T2 (LEVSIN) HYOSCYAMINE SULFATE SUBL 0.125MG T2 (LEVSIN) HYOSCYAMINE SULFATE ER TB MG T2 (LEVBID) HYOSYNE ELIX 0.125MG/5ML T HYOSYNE SOLN 0.125MG/ML T2 QL IPRATROPIUM BROMIDE SOLN 0.03% T2 QL (ATROVENT NASAL) IPRATROPIUM BROMIDE SOLN 0.06% T2 QL (ATROVENT NASAL) IPRATROPIUM BROMIDE SOLN 0.02% T2 QL (ATROVENT NEB) OSCIMIN TABS 0.125MG T2 (LEVSIN) OSCIMIN SR TB MG T2 (LEVBID) PROPANTHELINE BROMIDE TABS 15MG T2 (PRO-BANTHINE) ATROVENT HFA AERS 17MCG/ACT T3 QL SPIRIVA HANDIHALER CAPS 18MCG T3 QL SPIRIVA RESPIMAT AERS 2.5MCG/ACT T3 QL (12:12.04) Autonomic Drugs» Sympathomimetic (Adrenergic) Agents» alpha- Adrenergic Agonists MIDODRINE HCL TABS 2.5MG T2 (PRO-AMATINE) MIDODRINE HCL TABS 5MG T2 (PRO-AMATINE) MIDODRINE HCL TABS 10MG T2 (PRO-AMATINE) Page 7 of 88

8 (12: ) Autonomic Drugs» Sympathomimetic (Adrenergic) Agents» beta- Adrenergic Agonists» Selective beta-2-adrenergic Agonists ALBUTEROL SULFATE SYRP 2MG/5ML T2 (VENTOLIN) ALBUTEROL SULFATE TABS 2MG T2 (VENTOLIN) ALBUTEROL SULFATE TABS 4MG T2 (VENTOLIN) ALBUTEROL SULFATE NEBU 0.083% T2 QL (VENTOLIN) ALBUTEROL SULFATE NEBU 0.5% T2 QL (VENTOLIN) ALBUTEROL SULFATE NEBU 1.25MG/3ML T2 QL Only for under 2 years old, (ACCUNEB) ALBUTEROL SULFATE NEBU 0.63MG/3ML T2 QL Only for under 2 years old, (ACCUNEB) METAPROTERENOL SULFATE TABS 10MG T2 (ALUPENT) METAPROTERENOL SULFATE TABS 20MG T2 (ALUPENT) TERBUTALINE SULFATE TABS 5MG T2 (BRETHINE) TERBUTALINE SULFATE TABS 2.5MG T2 (BRETHINE) SEREVENT DISKUS AEPB 50MCG/DOSE T3 QL STRIVERDI RESPIMAT AERS 2.5MCG/ACT T3 QL VENTOLIN HFA AERS 108MCG/ACT T3 QL ADVAIR DISKUS AEPB 100MCG/DOSE; T4 QL 50MCG/DOSE ADVAIR DISKUS AEPB 250MCG/DOSE; 50MCG/DOSE ADVAIR DISKUS AEPB 500MCG/DOSE; 50MCG/DOSE ADVAIR HFA AERO 45MCG/ACT; 21MCG/ACT ADVAIR HFA AERO 115MCG/ACT; 21MCG/ACT ADVAIR HFA AERO 230MCG/ACT; 21MCG/ACT T4 T4 T4 T4 T4 QL QL QL QL QL (12:12.12) Autonomic Drugs» Sympathomimetic (Adrenergic) Agents» alpha- and beta- Adrenergic Agonists EPIPEN 2-PAK SOAJ 0.3MG/0.3ML T3 QL one pen per copay EPIPEN-JR 2-PAK SOAJ 0.15MG/0.3ML T3 QL one pen per copay Page 8 of 88

9 (12: ) Autonomic Drugs» Sympatholytic (Adrenergic Blocking) Agents» alpha- Adrenergic Blocking Agents» Non-selective alpha-adrenergic Blocking Agents ERGOLOID MESYLATES TABS 1MG T2 (HYDERGINE) (12: ) Autonomic Drugs» Sympatholytic (Adrenergic Blocking) Agents» alpha- Adrenergic Blocking Agents» Selective alpha-1-adrenergic Blocking Agents ALFUZOSIN HCL ER TB24 10MG T2 (UROXATRAL) TAMSULOSIN HCL CAPS 0.4MG T2 (FLOMAX) (12:20.04) Autonomic Drugs» Skeletal Muscle Relaxants» Centrally Acting Skeletal Muscle Relaxants CARISOPRODOL TABS 350MG T2 not cmpd or cod or 250mg (SOMA) CYCLOBENZAPRINE HCL TABS 10MG T2 not 5mg, (FLEXERIL) METHOCARBAMOL TABS 500MG T2 (ROBAXIN) METHOCARBAMOL TABS 750MG T2 (ROBAXIN) TIZANIDINE HCL TABS 2MG T2 (ZANAFLEX) TIZANIDINE HCL TABS 4MG T2 (ZANAFLEX) (12:20.12) Autonomic Drugs» Skeletal Muscle Relaxants» GABA-derivative Skeletal Muscle Relaxants BACLOFEN TABS 10MG T2 (LIORESAL) BACLOFEN TABS 20MG T2 (LIORESAL) (12:92) Autonomic Drugs» Autonomic Drugs, Miscellaneous NICOTROL INHALER INHA 10MG T3 PA; QL CHANTIX TABS 0.5MG T4 Page 9 of 88

10 CHANTIX TABS 1MG T CHANTIX CONTINUING MONTH PAK TABS 1MG T CHANTIX STARTING MONTH PAK TABS T4 (20:04.04) Blood Formation,Coagulation & Thrombosis» Antianemia Drugs» Iron Preparations FEROCON CAPS 75MG; 15MCG; T2 110MG; 0.5MG; 240MG FEROTRINSIC CAPS 75MG; 15MCG; 110MG; 0.5MG; 240MG TRICON CAPS 75MG; 15MCG; 110MG; 0.5MG; 240MG T2 T2 (20: ) Blood Formation,Coagulation & Thrombosis» Antithrombotic Agents» Anticoagulants» Coumarin Derivatives Tier: T WARFARIN SODIUM TABS 1MG T1 (COUMADIN) WARFARIN SODIUM TABS 2.5MG T1 (COUMADIN) WARFARIN SODIUM TABS 5MG T1 (COUMADIN) WARFARIN SODIUM TABS 7.5MG T1 (COUMADIN) WARFARIN SODIUM TABS 10MG T1 (COUMADIN) WARFARIN SODIUM TABS 2MG T1 (COUMADIN) WARFARIN SODIUM TABS 4MG T1 (COUMADIN) WARFARIN SODIUM TABS 3MG T1 (COUMADIN) WARFARIN SODIUM TABS 6MG T1 (COUMADIN) (20: ) Blood Formation,Coagulation & Thrombosis» Antithrombotic Agents» Anticoagulants» Direct Thrombin Inhibitors PRADAXA CAPS 150MG T3 PA PRADAXA CAPS 75MG T3 PA (20: ) Blood Formation,Coagulation & Thrombosis» Antithrombotic Agents» Anticoagulants» Direct Factor Xa Inhibitors Page 10 of 88

11 ELIQUIS TABS 2.5MG T3 PA ELIQUIS TABS 5MG T3 PA XARELTO TABS 15MG T3 ST XARELTO TABS 20MG T3 ST XARELTO TABS 10MG T3 ST Tier: T FONDAPARINUX SODIUM SOLN 2.5MG/0.5ML T6 PA (ARIXTRA) FONDAPARINUX SODIUM SOLN 5MG/0.4ML T6 PA (ARIXTRA) FONDAPARINUX SODIUM SOLN 7.5MG/0.6ML T6 PA (ARIXTRA) FONDAPARINUX SODIUM SOLN 10MG/0.8ML T6 PA (ARIXTRA) (20: ) Blood Formation,Coagulation & Thrombosis» Antithrombotic Agents» Anticoagulants» Heparins Tier: T ENOXAPARIN SODIUM SOLN 30MG/0.3ML T6 QL (LOVENOX) ENOXAPARIN SODIUM SOLN 40MG/0.4ML T6 QL (LOVENOX) ENOXAPARIN SODIUM SOLN 60MG/0.6ML T6 QL (LOVENOX) ENOXAPARIN SODIUM SOLN 80MG/0.8ML T6 QL (LOVENOX) ENOXAPARIN SODIUM SOLN 100MG/ML T6 QL (LOVENOX) ENOXAPARIN SODIUM SOLN 120MG/0.8ML T6 QL (LOVENOX) ENOXAPARIN SODIUM SOLN 150MG/ML T6 QL (LOVENOX) (20:12.14) Blood Formation,Coagulation & Thrombosis» Antithrombotic Agents» Platelet-reducing Agents ANAGRELIDE HYDROCHLORIDE CAPS 1MG T2 (AGRYLIN) ANAGRELIDE HYDROCHLORIDE CAPS 0.5MG T2 (AGRYLIN) (20:12.18) Blood Formation,Coagulation & Thrombosis» Antithrombotic Agents» Platelet-Aggregation Inhibitors CILOSTAZOL TABS 100MG T2 (PLETAL) CILOSTAZOL TABS 50MG T2 (PLETAL) CLOPIDOGREL TABS 75MG T2 (PLAVIX) TICLOPIDINE HCL TABS 250MG T2 for aspirin intolerant patients only, (TICLID) Page 11 of 88

12 AGGRENOX CP12 25MG; 200MG T BRILINTA TABS 90MG T4 PA (20:16) Blood Formation,Coagulation & Thrombosis» Hematopoietic Agents Tier: T ARANESP ALBUMIN FREE SOLN 200MCG/ML T5 PA ARANESP ALBUMIN FREE SOLN 300MCG/0.6ML T5 PA NEULASTA SOLN 6MG/0.6ML T NEUMEGA SOLR 5MG T NEUPOGEN SOLN 300MCG/ML T NEUPOGEN SOLN 480MCG/1.6ML T PROMACTA TABS 25MG T5 PA PROMACTA TABS 50MG T5 PA PROMACTA TABS 75MG T5 PA PROMACTA TABS 12.5MG T5 PA Tier: T ARANESP ALBUMIN FREE SOLN 40MCG/ML T6 PA ARANESP ALBUMIN FREE SOLN 60MCG/ML T6 PA ARANESP ALBUMIN FREE SOLN 100MCG/ML T6 PA ARANESP ALBUMIN FREE SOLN 25MCG/0.42ML T6 PA PROCRIT SOLN 2000UNIT/ML T6 PA PROCRIT SOLN 3000UNIT/ML T6 PA PROCRIT SOLN 4000UNIT/ML T6 PA PROCRIT SOLN 10000UNIT/ML T6 PA PROCRIT SOLN 20000UNIT/ML T6 PA PROCRIT SOLN 40000UNIT/ML T6 PA (20:24) Blood Formation,Coagulation & Thrombosis» Hemorrheologic Agents PENTOXIFYLLINE ER TBCR 400MG T2 (TRENTAL) Page 12 of 88

13 (20:28.16) Blood Formation,Coagulation & Thrombosis» Antihemorrhagic Agents» Hemostatics AMINOCAPROIC ACID SYRP 25% T2 (AMICAR) AMINOCAPROIC ACID TABS 500MG T2 (AMICAR) AMINOCAPROIC ACID TABS 1000MG T2 (AMICAR) (24: ) Cardiovascular Drugs» Cardiac Drugs» Antiarrhythmic Agents» Class Ia Antiarrhythmics DISOPYRAMIDE PHOSPHATE CAPS 100MG T2 (NORPACE) DISOPYRAMIDE PHOSPHATE CAPS 150MG T2 (NORPACE) QUINIDINE GLUCONATE CR TBCR 324MG T2 (QUINAGLUTE) QUINIDINE SULFATE TABS 300MG T QUINIDINE SULFATE TABS 200MG T QUINIDINE SULFATE ER TBCR 300MG T NORPACE CR CP12 100MG T NORPACE CR CP12 150MG T4 (24: ) Cardiovascular Drugs» Cardiac Drugs» Antiarrhythmic Agents» Class Ib Antiarrhythmics MEXILETINE HCL CAPS 150MG T2 (MEXITIL) MEXILETINE HCL CAPS 200MG T2 (MEXITIL) MEXILETINE HCL CAPS 250MG T2 (MEXITIL) (24: ) Cardiovascular Drugs» Cardiac Drugs» Antiarrhythmic Agents» Class Ic Antiarrhythmics FLECAINIDE ACETATE TABS 50MG T2 (TAMBOCOR) FLECAINIDE ACETATE TABS 100MG T2 (TAMBOCOR) FLECAINIDE ACETATE TABS 150MG T2 (TAMBOCOR) PROPAFENONE HCL TABS 150MG T2 not SR, (RYTHMOL) Page 13 of 88

14 PROPAFENONE HCL TABS 300MG T2 not SR, (RYTHMOL) PROPAFENONE HCL TABS 225MG T2 not SR, (RYTHMOL) (24: ) Cardiovascular Drugs» Cardiac Drugs» Antiarrhythmic Agents» Class III Antiarrhythmics AMIODARONE HCL TABS 200MG T2 (CORDARONE) TIKOSYN CAPS 125MCG T TIKOSYN CAPS 250MCG T TIKOSYN CAPS 500MCG T4 (24:04.08) Cardiovascular Drugs» Cardiac Drugs» Cardiotonic Agents DIGOX TABS 125MCG T2 (LANOXIN) DIGOX TABS 250MCG T2 (LANOXIN) DIGOXIN SOLN 0.05MG/ML T2 (LANOXIN) (24:04.92) Cardiovascular Drugs» Cardiac Drugs» Cardiac Drugs, Miscellaneous RANEXA TB12 500MG T3 PA RANEXA TB MG T3 PA (24:06.04) Cardiovascular Drugs» Antilipemic Agents» Bile Acid Sequestrants CHOLESTYRAMINE PACK 4GM T2 QL (QUESTRAN) CHOLESTYRAMINE LIGHT POWD 4GM/DOSE T2 QL (QUESTRAN LITE) WELCHOL TABS 625MG T4 PA (24:06.05) Cardiovascular Drugs» Antilipemic Agents» Cholesterol Absorption Page 14 of 88

15 Inhibitors ZETIA TABS 10MG T3 (24:06.06) Cardiovascular Drugs» Antilipemic Agents» Fibric Acid Derivatives FENOFIBRATE TABS 48MG T2 (TRICOR) FENOFIBRATE TABS 145MG T2 (TRICOR) FENOFIBRIC ACID DR CPDR 45MG T2 (TRILIPIX) FENOFIBRIC ACID DR CPDR 135MG T2 (TRILIPIX) GEMFIBROZIL TABS 600MG T2 (LOPID) (24:06.08) Cardiovascular Drugs» Antilipemic Agents» HMG-CoA Reductase Inhibitors Tier: T LOVASTATIN TABS 10MG T1 (MEVACOR) LOVASTATIN TABS 20MG T1 (MEVACOR) LOVASTATIN TABS 40MG T1 (MEVACOR) ATORVASTATIN CALCIUM TABS 10MG T2 (LIPITOR) ATORVASTATIN CALCIUM TABS 20MG T2 (LIPITOR) ATORVASTATIN CALCIUM TABS 40MG T2 (LIPITOR) ATORVASTATIN CALCIUM TABS 80MG T2 (LIPITOR) PRAVASTATIN SODIUM TABS 10MG T2 (PRAVACHOL) PRAVASTATIN SODIUM TABS 20MG T2 (PRAVACHOL) PRAVASTATIN SODIUM TABS 40MG T2 (PRAVACHOL) PRAVASTATIN SODIUM TABS 80MG T2 (PRAVACHOL) SIMVASTATIN TABS 10MG T2 (ZOCOR) SIMVASTATIN TABS 20MG T2 (ZOCOR) SIMVASTATIN TABS 40MG T2 (ZOCOR) SIMVASTATIN TABS 80MG T2 (ZOCOR) SIMVASTATIN TABS 5MG T2 (ZOCOR) CRESTOR TABS 10MG T CRESTOR TABS 20MG T CRESTOR TABS 40MG T3 Page 15 of 88

16 CRESTOR TABS 5MG T3 (24:06.92) Cardiovascular Drugs» Antilipemic Agents» Antilipemic Agents, Miscellaneous NIACIN ER TBCR 500MG T2 (NIASPAN) NIACIN ER TBCR 750MG T2 (NIASPAN) NIACIN ER TBCR 1000MG T2 (NIASPAN) OMEGA-3-ACID ETHYL ESTERS CAPS 375MG; 465MG; 1GM T2 (LOVAZA) (24:08.16) Cardiovascular Drugs» Hypotensive Agents» Central Alpha-Agonists Tier: T CLONIDINE HCL TABS 0.2MG T1 (CATAPRES) not ER CLONIDINE HCL TABS 0.1MG T1 (CATAPRES) not ER CLONIDINE HCL TABS 0.3MG T2 (CATAPRES) not ER GUANFACINE HCL TABS 1MG T2 (TENEX) GUANFACINE HCL TABS 2MG T2 (TENEX) METHYLDOPA TABS 250MG T2 (ALDOMET) METHYLDOPA TABS 500MG T2 (ALDOMET) (24:08.20) Cardiovascular Drugs» Hypotensive Agents» Direct Vasodilators HYDRALAZINE HCL TABS 10MG T2 (APRESOLINE) HYDRALAZINE HCL TABS 25MG T2 (APRESOLINE) HYDRALAZINE HCL TABS 25MG T2 (APRESOLINE) HYDRALAZINE HCL TABS 50MG T2 (APRESOLINE) MINOXIDIL TABS 2.5MG T2 (LONITEN) MINOXIDIL TABS 10MG T2 (LONITEN) (24:08.32) Cardiovascular Drugs» Hypotensive Agents» Peripheral Adrenergic Inhibitors Page 16 of 88

17 RESERPINE TABS 0.1MG T RESERPINE TABS 0.25MG T2 (24:12.08) Cardiovascular Drugs» Vasodilating Agents» Nitrates and Nitrites ISOSORBIDE DINITRATE TABS 5MG T2 (ISORDIL) ISOSORBIDE DINITRATE TABS 10MG T2 (ISORDIL) ISOSORBIDE DINITRATE TABS 20MG T2 (ISORDIL) ISOSORBIDE DINITRATE TABS 30MG T2 (ISORDIL) ISOSORBIDE DINITRATE ER TBCR 40MG T2 (SORBITRATE) ISOSORBIDE MONONITRATE ER TB24 30MG T2 (IMDUR) ISOSORBIDE MONONITRATE ER TB24 60MG T2 (IMDUR) ISOSORBIDE MONONITRATE ER TB24 120MG T2 (IMDUR) NITRO-BID OINT 2% T2 QL NITROGLYCERIN PT24 0.2MG/HR T2 (MINITRAN) NITROGLYCERIN PT24 0.4MG/HR T2 (MINITRAN) NITROGLYCERIN PT24 0.6MG/HR T2 (MINITRAN) NITROGLYCERIN ER CPCR 2.5MG T NITROGLYCERIN ER CPCR 6.5MG T NITROGLYCERIN ER CPCR 9MG T NITROGLYCERIN TRANSDERMAL PT24 0.1MG/HR T2 (MINITRAN) NITROSTAT SUBL 0.3MG T NITROSTAT SUBL 0.4MG T NITROSTAT SUBL 0.6MG T3 (24:12.12) Cardiovascular Drugs» Vasodilating Agents» Phosphodiesterase Type 5 Inhibitors SILDENAFIL CITRATE TABS 20MG T2 PA (REVATIO) (24:12.92) Cardiovascular Drugs» Vasodilating Agents» Vasodilating Agents, Miscellaneous DIPYRIDAMOLE TABS 25MG T2 (PERSANTINE) DIPYRIDAMOLE TABS 50MG T2 (PERSANTINE) Page 17 of 88

18 DIPYRIDAMOLE TABS 75MG T2 (PERSANTINE) (24:20) Cardiovascular Drugs» alpha-adrenergic Blocking Agents Tier: T TERAZOSIN HCL CAPS 1MG T1 (HYTRIN) TERAZOSIN HCL CAPS 2MG T1 (HYTRIN) TERAZOSIN HCL CAPS 5MG T1 (HYTRIN) TERAZOSIN HCL CAPS 10MG T1 (HYTRIN) DOXAZOSIN MESYLATE TABS 1MG T2 not XL, (CARDURA) DOXAZOSIN MESYLATE TABS 2MG T2 not XL, (CARDURA) DOXAZOSIN MESYLATE TABS 4MG T2 not XL, (CARDURA) DOXAZOSIN MESYLATE TABS 8MG T2 not XL, (CARDURA) PRAZOSIN HCL CAPS 1MG T2 (MINIPRESS) PRAZOSIN HCL CAPS 2MG T2 (MINIPRESS) PRAZOSIN HCL CAPS 5MG T2 (MINIPRESS) (24:24) Cardiovascular Drugs» beta-adrenergic Blocking Agents Tier: T ATENOLOL TABS 25MG T1 (TENORMIN) ATENOLOL TABS 50MG T1 (TENORMIN) ATENOLOL TABS 100MG T1 (TENORMIN) CARVEDILOL TABS 25MG T1 (COREG) CARVEDILOL TABS 3.125MG T1 (COREG) CARVEDILOL TABS 6.25MG T1 (COREG) CARVEDILOL TABS 12.5MG T1 (COREG) METOPROLOL TARTRATE TABS 50MG T1 not HCT, (LOPRESSOR) METOPROLOL TARTRATE TABS 100MG T1 not HCT, (LOPRESSOR) METOPROLOL TARTRATE TABS 25MG T1 not HCT, (LOPRESSOR) PROPRANOLOL HCL TABS 10MG T1 not LA, (INDERAL) PROPRANOLOL HCL TABS 20MG T1 not LA, (INDERAL) PROPRANOLOL HCL TABS 40MG T1 not LA, (INDERAL) PROPRANOLOL HCL TABS 60MG T1 not LA, (INDERAL) PROPRANOLOL HCL TABS 80MG T1 not LA, (INDERAL) Page 18 of 88

19 ACEBUTOLOL HCL CAPS 200MG T2 (SECTRAL) ACEBUTOLOL HCL CAPS 400MG T2 (SECTRAL) LABETALOL HCL TABS 100MG T2 (TRANDATE) LABETALOL HCL TABS 200MG T2 (TRANDATE) LABETALOL HCL TABS 300MG T2 (TRANDATE) PROPRANOLOL HCL SOLN 20MG/5ML T2 (INDERAL) PROPRANOLOL HCL SOLN 40MG/5ML T2 (INDERAL) SOTALOL HCL TABS 160MG T2 (BETAPACE) SOTALOL HCL TABS 80MG T2 (BETAPACE) SOTALOL HCL TABS 120MG T2 (BETAPACE) SOTALOL HCL TABS 240MG T2 (BETAPACE) COREG CR CP24 10MG T COREG CR CP24 20MG T COREG CR CP24 40MG T COREG CR CP24 80MG T3 (24:28.08) Cardiovascular Drugs» Calcium-Channel Blocking Agents» Dihydropyridines AFEDITAB CR TB24 30MG T2 (ADALAT CC) AFEDITAB CR TB24 60MG T2 (ADALAT CC) AMLODIPINE BESYLATE TABS 2.5MG T2 (NORVASC) AMLODIPINE BESYLATE TABS 5MG T2 (NORVASC) AMLODIPINE BESYLATE TABS 10MG T2 (NORVASC) NIFEDIPINE CAPS 20MG T2 not XL, (PROCARDIA) NIFEDIPINE CAPS 10MG T2 not XL, (PROCARDIA) NIFEDIPINE ER TB24 90MG T2 (ADALAT CC) NIFEDIPINE ER TB24 30MG T2 (ADALAT CC) NIFEDIPINE ER TB24 60MG T2 (ADALAT CC) NIMODIPINE CAPS 30MG T4 (NIMOTOP) (24:28.92) Cardiovascular Drugs» Calcium-Channel Blocking Agents» Calcium-Channel Blocking Agents, Misc Page 19 of 88

20 DILTIAZEM CD CP24 120MG T2 not 360, (CARDIZEM CD) DILTIAZEM CD CP24 180MG T2 not 360, (CARDIZEM CD) DILTIAZEM CD CP24 240MG T2 not 360, (CARDIZEM CD) DILTIAZEM CD CP24 300MG T2 not 360, (CARDIZEM CD) DILTIAZEM HCL TABS 30MG T2 not SR, (CARDIZEM) DILTIAZEM HCL TABS 60MG T2 not SR, (CARDIZEM) DILTIAZEM HCL TABS 90MG T2 not SR, (CARDIZEM) DILTIAZEM HCL TABS 120MG T2 not SR, (CARDIZEM) VERAPAMIL HCL TABS 80MG T2 (CALAN) VERAPAMIL HCL TABS 120MG T2 (CALAN) VERAPAMIL HCL TABS 40MG T2 (CALAN) VERAPAMIL HCL ER TBCR 180MG T2 (CALAN-SR) VERAPAMIL HCL ER TBCR 240MG T2 (CALAN-SR) VERAPAMIL HCL ER TBCR 120MG T2 (CALAN-SR) (24:32.04) Cardiovascular Drugs» Renin-Angiotensin-Aldosterone Sys Inhib» Angiotensin-Converting Enzyme Inhibitors Tier: T BENAZEPRIL HCL TABS 20MG T1 not HCT, (LOTENSIN) BENAZEPRIL HCL TABS 5MG T1 not HCT, (LOTENSIN) BENAZEPRIL HCL TABS 10MG T1 not HCT, (LOTENSIN) BENAZEPRIL HCL TABS 40MG T1 not HCT, (LOTENSIN) LISINOPRIL TABS 2.5MG T1 (PRINIVIL) LISINOPRIL TABS 5MG T1 (PRINIVIL) LISINOPRIL TABS 10MG T1 (PRINIVIL) LISINOPRIL TABS 20MG T1 (PRINIVIL) LISINOPRIL TABS 40MG T1 (PRINIVIL) LISINOPRIL/HYDROCHLOROTHIAZIDE TABS 12.5MG; 10MG T1 (ZESTORETIC) LISINOPRIL/HYDROCHLOROTHIAZIDE TABS 12.5MG; 20MG T1 (ZESTORETIC) LISINOPRIL/HYDROCHLOROTHIAZIDE TABS 25MG; 20MG T1 (ZESTORETIC) ENALAPRIL MALEATE TABS 2.5MG T2 (VASOTEC) ENALAPRIL MALEATE TABS 5MG T2 (VASOTEC) ENALAPRIL MALEATE TABS 10MG T2 (VASOTEC) ENALAPRIL MALEATE TABS 20MG T2 (VASOTEC) FOSINOPRIL SODIUM TABS 10MG T2 not HCT, (MONOPRIL) FOSINOPRIL SODIUM TABS 20MG T2 not HCT, (MONOPRIL) FOSINOPRIL SODIUM TABS 40MG T2 not HCT, Page 20 of 88

21 (MONOPRIL) LISINOPRIL TABS 30MG T2 (ZESTRIL) RAMIPRIL CAPS 1.25MG T2 (ALTACE) RAMIPRIL CAPS 2.5MG T2 (ALTACE) RAMIPRIL CAPS 5MG T2 (ALTACE) RAMIPRIL CAPS 10MG T2 (ALTACE) (24:32.08) Cardiovascular Drugs» Renin-Angiotensin-Aldosterone Sys Inhib» Angiotensin II Receptor Antagonists LOSARTAN POTASSIUM TABS 25MG T2 (COZAAR) LOSARTAN POTASSIUM TABS 50MG T2 (COZAAR) LOSARTAN POTASSIUM TABS 100MG T2 (COZAAR) LOSARTAN POTASSIUM TABS 100MG T2 (COZAAR) LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE TABS 12.5MG; 100MG T2 (HYZAAR) LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE TABS 12.5MG; 50MG T2 (HYZAAR) LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE TABS 25MG; 100MG T2 (HYZAAR) TELMISARTAN TABS 40MG T2 (MICARDIS) not HCT TELMISARTAN TABS 80MG T2 (MICARDIS) not HCT TELMISARTAN TABS 20MG T2 not HCT VALSARTAN TABS 40MG T2 not HCT VALSARTAN TABS 80MG T2 not HCT VALSARTAN TABS 160MG T2 not HCT VALSARTAN TABS 320MG T2 not HCT (24:32.20) Cardiovascular Drugs» Renin-Angiotensin-Aldosterone Sys Inhib» Mineralocorticoid (Aldost) Recept Antag SPIRONOLACTONE TABS 25MG T2 (ALDACTONE) SPIRONOLACTONE TABS 50MG T2 (ALDACTONE) SPIRONOLACTONE/HYDROCHLOROTHIAZIDE TABS 25MG; 25MG T2 (ALDACTAZIDE) (24:32.40) Cardiovascular Drugs» Renin-Angiotensin-Aldosterone Sys Inhib» Renin Inhibitors TEKTURNA TABS 150MG T4 ST TEKTURNA TABS 300MG T4 ST Page 21 of 88

22 (28: ) Central Nervous System Agents» Analgesics and Antipyretics» Nonsteroidal Anti-inflammatory Agents» Salicylates SALSALATE TABS 500MG T2 (DISALCID) SALSALATE TABS 750MG T2 (DISALCID) (28: ) Central Nervous System Agents» Analgesics and Antipyretics» Nonsteroidal Anti-inflammatory Agents» Other Nonsteroidal Anti-inflammatory Agents Tier: T IBUPROFEN TABS 400MG T1 (MOTRIN) IBUPROFEN TABS 800MG T1 (MOTRIN) IBUPROFEN TABS 600MG T1 (MOTRIN) MELOXICAM TABS 7.5MG T1 (MOBIC) MELOXICAM TABS 15MG T1 (MOBIC) NAPROXEN TABS 375MG T1 (NAPROSYN) NAPROXEN TABS 500MG T1 (NAPROSYN) DICLOFENAC SODIUM DR TBEC 50MG T2 not XR, (VOLTAREN) DICLOFENAC SODIUM DR TBEC 75MG T2 not XR, (VOLTAREN) DICLOFENAC SODIUM DR TBEC 25MG T2 not XR, (VOLTAREN) ETODOLAC TABS 400MG T2 (LODINE) ETODOLAC TABS 500MG T2 (LODINE) ETODOLAC CAPS 200MG T2 (LODINE) ETODOLAC CAPS 300MG T2 (LODINE) ETODOLAC ER TB24 600MG T2 (LODINE XL) ETODOLAC ER TB24 500MG T2 (LODINE XL) ETODOLAC ER TB24 400MG T2 (LODINE XL) FENOPROFEN CALCIUM TABS 600MG T2 (NALFON) INDOMETHACIN CAPS 25MG T2 (INDOCIN) INDOMETHACIN CAPS 50MG T2 (INDOCIN) INDOMETHACIN ER CPCR 75MG T2 (INDOCIN-SR) KETOPROFEN CAPS 50MG T2 not 25mg or ER 200mg, (ORUDIS) KETOPROFEN CAPS 75MG T2 not 25mg or ER 200mg, (ORUDIS) KETOROLAC TROMETHAMINE TABS 10MG T2 QL (TORADOL) 20 tabs per 31 days MECLOFENAMATE SODIUM CAPS 50MG T2 (MECLOMEN) MECLOFENAMATE SODIUM CAPS 100MG T2 (MECLOMEN) Page 22 of 88

23 MELOXICAM SUSP 7.5MG/5ML T2 QL (MOBIC) NABUMETONE TABS 500MG T2 (RELAFEN) NABUMETONE TABS 750MG T2 (RELAFEN) NAPROXEN TABS 250MG T2 (NAPROSYN) NAPROXEN SODIUM TABS 550MG T2 (ANAPROX-DS) PIROXICAM CAPS 10MG T2 (FELDENE) PIROXICAM CAPS 20MG T2 (FELDENE) SULINDAC TABS 200MG T2 (CLINORIL) SULINDAC TABS 150MG T2 (CLINORIL) (28:08.08) Central Nervous System Agents» Analgesics and Antipyretics» Opiate Agonists ACETAMINOPHEN/CODEINE TABS 300MG; 15MG T2 (TYLENOL W/CODEINE) ACETAMINOPHEN/CODEINE TABS 300MG; 60MG T2 (TYLENOL W/CODEINE) ACETAMINOPHEN/CODEINE SOLN 120MG/5ML; 12MG/5ML T2 (TYLENOL W/CODEINE) ACETAMINOPHEN/CODEINE #3 TABS 300MG; 30MG T2 (TYLENOL W/CODEINE) ASCOMP/CODEINE CAPS 325MG; 50MG; 40MG; 30MG T2 (FIORINAL W/CODEINE) BUTALBITAL/ASPIRIN/CAFFEINE/CODEINE CAPS 325MG; 50MG; 40MG; 30MG CODEINE SULFATE TABS 15MG T CODEINE SULFATE TABS 30MG T2 T2 (FIORINAL W/CODEINE) FENTANYL PT72 25MCG/HR T2 PA (DURAGESIC) FENTANYL PT72 50MCG/HR T2 PA (DURAGESIC) FENTANYL PT72 75MCG/HR T2 PA (DURAGESIC) FENTANYL PT72 100MCG/HR T2 PA (DURAGESIC) FENTANYL PT72 12MCG/HR T2 PA (DURAGESIC) HYDROCODONE BITARTRATE/ACETAMINOPHEN SOLN 325MG/15ML; 7.5MG/15ML HYDROCODONE/ACETAMINOPHEN TABS 325MG; 5MG T2 (NORCO) HYDROCODONE/ACETAMINOPHEN TABS 325MG; 7.5MG T2 (NORCO) HYDROCODONE/ACETAMINOPHEN TABS 325MG; 10MG T2 (NORCO) HYDROMORPHONE HCL TABS 4MG T2 (DILAUDID) HYDROMORPHONE HCL TABS 2MG T2 (DILAUDID) HYDROMORPHONE HCL TABS 8MG T2 (DILAUDID) HYDROMORPHONE HCL LIQD 1MG/ML T2 (DILAUDID) MEPERIDINE HCL TABS 100MG T2 (DEMEROL) MEPERIDINE HCL TABS 50MG T2 (DEMEROL) METHADONE HCL SOLN 5MG/5ML T2 (DOLOPHINE) METHADONE HCL TABS 5MG T2 (DOLOPHINE) METHADONE HCL TABS 10MG T2 (DOLOPHINE) MORPHINE SULFATE TABS 15MG T2 (MSIR) T2 QL Page 23 of 88

24 MORPHINE SULFATE TABS 30MG T2 (MSIR) MORPHINE SULFATE SOLN 10MG/5ML T2 (ROXANOL) MORPHINE SULFATE SOLN 20MG/5ML T2 (ROXANOL) MORPHINE SULFATE SOLN 20MG/ML T2 (ROXANOL) MORPHINE SULFATE SOLN 100MG/5ML T2 (ROXANOL) MORPHINE SULFATE ER TBCR 60MG T2 (MS CONTIN) MORPHINE SULFATE ER TBCR 100MG T2 (MS CONTIN) MORPHINE SULFATE ER TBCR 15MG T2 (MS CONTIN) MORPHINE SULFATE ER TBCR 30MG T2 (MS CONTIN) MORPHINE SULFATE ER TBCR 200MG T2 (MS CONTIN) OXYCODONE HCL TABS 15MG T2 IR only OXYCODONE HCL TABS 5MG T2 IR only OXYCODONE HCL TABS 30MG T2 IR only OXYCODONE HCL TABS 10MG T2 IR only OXYCODONE HCL TABS 20MG T2 IR only OXYCODONE/ACETAMINOPHEN TABS 325MG; 5MG T2 (PERCOCET) 5mg/325mg only ROXICET SOLN 325MG/5ML; 5MG/5ML T ROXICET TABS 325MG; 5MG T2 (PERCOCET) 5mg/325mg only TRAMADOL HCL TABS 50MG T2 (ULTRAM) not ER (28:08.12) Central Nervous System Agents» Analgesics and Antipyretics» Opiate Partial Agonists BUPRENORPHINE HCL SUBL 2MG T2 PA (SUBUTEX) BUPRENORPHINE HCL SUBL 8MG T2 PA (SUBUTEX) BUPRENORPHINE HCL/NALOXONE HCL SUBL 8MG; 2MG T2 PA (SUBOXONE) BUPRENORPHINE HCL/NALOXONE HCL SUBL 2MG; 0.5MG T2 PA (SUBOXONE) SUBOXONE FILM 2MG; 0.5MG T4 PA SUBOXONE FILM 4MG; 1MG T4 PA SUBOXONE FILM 8MG; 2MG T4 PA SUBOXONE FILM 12MG; 3MG T4 PA (28:08.92) Central Nervous System Agents» Analgesics and Antipyretics» Analgesics and Antipyretics, Misc BUTALBITAL/ACETAMINOPHEN/CAFFEINE TABS 325MG; 50MG; T2 40MG not Capsules, (FIORICET) Page 24 of 88

25 BUTALBITAL/ACETAMINOPHEN/CAFFEINE TABS 325MG; 50MG; 40MG T2 not Capsules, (FIORICET) (28:10) Central Nervous System Agents» Opiate Antagonists NALTREXONE HCL TABS 50MG T2 tabs only, (REVIA) (28:12.04) Central Nervous System Agents» Anticonvulsants» Barbiturates PRIMIDONE TABS 250MG T2 (MYSOLINE) PRIMIDONE TABS 50MG T2 (MYSOLINE) (28:12.08) Central Nervous System Agents» Anticonvulsants» Benzodiazepines CLONAZEPAM TABS 0.5MG T2 (KLONOPIN) CLONAZEPAM TABS 1MG T2 (KLONOPIN) CLONAZEPAM TABS 2MG T2 (KLONOPIN) CLONAZEPAM ODT TBDP 0.125MG T2 (KLONOPIN) CLONAZEPAM ODT TBDP 0.25MG T2 (KLONOPIN) CLONAZEPAM ODT TBDP 0.5MG T2 (KLONOPIN) ONFI TABS 5MG T4 PA ONFI TABS 10MG T4 PA ONFI TABS 20MG T4 PA ONFI SUSP 2.5MG/ML T4 QL (28:12.12) Central Nervous System Agents» Anticonvulsants» Hydantoins PHENYTOIN SUSP 125MG/5ML T2 (DILANTIN) PHENYTOIN INFATABS CHEW 50MG T2 (DILANTIN) PHENYTOIN SODIUM EXTENDED CAPS 100MG T2 (DILANTIN) Page 25 of 88

26 DILANTIN CAPS 30MG T3 (28:12.20) Central Nervous System Agents» Anticonvulsants» Succinimides ETHOSUXIMIDE CAPS 250MG T2 (ZARONTIN) ETHOSUXIMIDE SOLN 250MG/5ML T2 (ZARONTIN) CELONTIN CAPS 300MG T4 (28:12.92) Central Nervous System Agents» Anticonvulsants» Anticonvulsants, Miscellaneous CARBAMAZEPINE TABS 200MG T2 not XR (TEGRETOL) CARBAMAZEPINE CHEW 100MG T2 not XR (TEGRETOL) CARBAMAZEPINE SUSP 100MG/5ML T2 not XR (TEGRETOL) DIVALPROEX SODIUM CPSP 125MG T2 (DEPAKOTE SPRINKLES) DIVALPROEX SODIUM DR TBEC 125MG T2 (DEPAKOTE) DIVALPROEX SODIUM DR TBEC 250MG T2 (DEPAKOTE) DIVALPROEX SODIUM DR TBEC 500MG T2 (DEPAKOTE) DIVALPROEX SODIUM ER TB24 250MG T2 (DEPAKOTE ER) DIVALPROEX SODIUM ER TB24 500MG T2 (DEPAKOTE ER) FELBAMATE SUSP 600MG/5ML T2 (FELBATOL) FELBAMATE TABS 400MG T2 (FELBATOL) FELBAMATE TABS 600MG T2 (FELBATOL) GABAPENTIN CAPS 100MG T2 (NEURONTIN) GABAPENTIN CAPS 300MG T2 (NEURONTIN) GABAPENTIN CAPS 400MG T2 (NEURONTIN) GABAPENTIN TABS 600MG T2 (NEURONTIN) GABAPENTIN TABS 800MG T2 (NEURONTIN) GABAPENTIN SOLN 250MG/5ML T2 (NEURONTIN) LAMOTRIGINE TABS 25MG T2 not XR or ODT, (LAMICTAL) LAMOTRIGINE TABS 100MG T2 not XR or ODT, (LAMICTAL) LAMOTRIGINE TABS 150MG T2 not XR or ODT, (LAMICTAL) LAMOTRIGINE TABS 200MG T2 not XR or ODT, (LAMICTAL) LAMOTRIGINE CHEW 5MG T2 not XR or ODT, (LAMICTAL) LAMOTRIGINE CHEW 25MG T2 not XR or ODT, (LAMICTAL) Page 26 of 88

27 LEVETIRACETAM SOLN 100MG/ML T2 (KEPPRA) LEVETIRACETAM TABS 250MG T2 (KEPPRA) LEVETIRACETAM TABS 500MG T2 (KEPPRA) LEVETIRACETAM TABS 1000MG T2 (KEPPRA) LEVETIRACETAM TABS 750MG T2 (KEPPRA) LEVETIRACETAM ER TB24 500MG T2 (KEPPRA ER) LEVETIRACETAM ER TB24 750MG T2 (KEPPRA ER) OXCARBAZEPINE TABS 150MG T2 (TRILEPTAL) OXCARBAZEPINE TABS 600MG T2 (TRILEPTAL) OXCARBAZEPINE TABS 300MG T2 (TRILEPTAL) OXCARBAZEPINE SUSP 300MG/5ML T2 (TRILEPTAL) TIAGABINE HYDROCHLORIDE TABS 2MG T2 (GABITRIL) TIAGABINE HYDROCHLORIDE TABS 4MG T2 (GABITRIL) TOPIRAMATE CPSP 15MG T2 (TOPAMAX) TOPIRAMATE CPSP 25MG T2 (TOPAMAX) TOPIRAMATE TABS 200MG T2 (TOPAMAX) TOPIRAMATE TABS 25MG T2 (TOPAMAX) TOPIRAMATE TABS 50MG T2 (TOPAMAX) TOPIRAMATE TABS 100MG T2 (TOPAMAX) VALPROIC ACID SYRP 250MG/5ML T2 (DEPAKENE) VALPROIC ACID CAPS 250MG T2 (DEPAKENE) ZONISAMIDE CAPS 25MG T2 (ZONEGRAN) ZONISAMIDE CAPS 50MG T2 (ZONEGRAN) ZONISAMIDE CAPS 100MG T2 (ZONEGRAN) BANZEL TABS 400MG T4 PA BANZEL SUSP 40MG/ML T4 PA GABITRIL TABS 16MG T LYRICA SOLN 20MG/ML T4 ST LYRICA CAPS 25MG T4 ST; QL LYRICA CAPS 50MG T4 ST; QL LYRICA CAPS 75MG T4 ST; QL LYRICA CAPS 100MG T4 ST; QL LYRICA CAPS 150MG T4 ST; QL LYRICA CAPS 200MG T4 ST; QL LYRICA CAPS 300MG T4 ST; QL LYRICA CAPS 225MG T4 ST; QL POTIGA TABS 50MG T POTIGA TABS 200MG T POTIGA TABS 300MG T POTIGA TABS 400MG T SABRIL TABS 500MG T4 PA Page 27 of 88

28 SABRIL PACK 500MG T4 PA VIMPAT TABS 50MG T4 PA VIMPAT TABS 100MG T4 PA VIMPAT TABS 150MG T4 PA VIMPAT TABS 200MG T4 PA VIMPAT SOLN 10MG/ML T4 PA (28: ) Central Nervous System Agents» Psychotherapeutic Agents» Antidepressants» Monoamine Oxidase Inhibitors PHENELZINE SULFATE TABS 15MG T2 (NARDIL) TRANYLCYPROMINE SULFATE TABS 10MG T2 (PARNATE) MARPLAN TABS 10MG T4 (28: ) Central Nervous System Agents» Psychotherapeutic Agents» Antidepressants» Selective Serotonin- and Norepinephrine-reuptake Inhibitors DESVENLAFAXINE ER TB24 50MG T DESVENLAFAXINE ER TB24 100MG T DULOXETINE HCL CPEP 20MG T2 (CYMBALTA) DULOXETINE HCL CPEP 30MG T2 (CYMBALTA) DULOXETINE HCL CPEP 60MG T2 (CYMBALTA) VENLAFAXINE HCL TABS 75MG T2 (EFFEXOR) VENLAFAXINE HCL TABS 100MG T2 (EFFEXOR) VENLAFAXINE HCL TABS 25MG T2 (EFFEXOR) VENLAFAXINE HCL TABS 37.5MG T2 (EFFEXOR) VENLAFAXINE HCL TABS 50MG T2 (EFFEXOR) VENLAFAXINE HCL ER CP MG T2 (EFFEXOR) VENLAFAXINE HCL ER CP24 75MG T2 (EFFEXOR) VENLAFAXINE HCL ER CP24 150MG T2 (EFFEXOR) PRISTIQ TB24 50MG T PRISTIQ TB24 100MG T3 Page 28 of 88

29 (28: ) Central Nervous System Agents» Psychotherapeutic Agents» Antidepressants» Selective Serotonin-reuptake Inhibitors Tier: T CITALOPRAM HYDROBROMIDE SOLN 10MG/5ML T1 (CELEXA) CITALOPRAM HYDROBROMIDE TABS 10MG T1 (CELEXA) CITALOPRAM HYDROBROMIDE TABS 20MG T1 (CELEXA) CITALOPRAM HYDROBROMIDE TABS 40MG T1 (CELEXA) FLUOXETINE HCL CAPS 10MG T1 not 40mg, (PROZAC) FLUOXETINE HCL CAPS 20MG T1 not 40mg, (PROZAC) ESCITALOPRAM OXALATE TABS 5MG T2 (LEXAPRO) ESCITALOPRAM OXALATE TABS 10MG T2 (LEXAPRO) ESCITALOPRAM OXALATE TABS 20MG T2 (LEXAPRO) ESCITALOPRAM OXALATE SOLN 5MG/5ML T2 (LEXAPRO) FLUOXETINE HCL SOLN 20MG/5ML T2 (PROZAC) FLUVOXAMINE MALEATE TABS 25MG T2 not CR, (LUVOX) FLUVOXAMINE MALEATE TABS 50MG T2 not CR, (LUVOX) FLUVOXAMINE MALEATE TABS 100MG T2 not CR, (LUVOX) PAROXETINE HCL TABS 10MG T2 (PAXIL) PAROXETINE HCL TABS 20MG T2 (PAXIL) PAROXETINE HCL TABS 40MG T2 (PAXIL) PAROXETINE HCL TABS 30MG T2 (PAXIL) PAROXETINE HCL ER TB MG T2 (PAXIL CR) PAROXETINE HCL ER TB24 25MG T2 (PAXIL CR) PAROXETINE HCL ER TB MG T2 (PAXIL CR) SERTRALINE HCL CONC 20MG/ML T2 (ZOLOFT) SERTRALINE HCL TABS 25MG T2 not 50mg, (ZOLOFT) SERTRALINE HCL TABS 100MG T2 not 50mg, (ZOLOFT) PAXIL SUSP 10MG/5ML T4 (28: ) Central Nervous System Agents» Psychotherapeutic Agents» Antidepressants» Serotonin Modulators Tier: T TRAZODONE HCL TABS 50MG T1 not 300mg, (DESYREL) TRAZODONE HCL TABS 100MG T1 not 300mg, (DESYREL) Page 29 of 88

30 NEFAZODONE HCL TABS 100MG T2 (SERZONE) NEFAZODONE HCL TABS 200MG T2 (SERZONE) NEFAZODONE HCL TABS 250MG T2 (SERZONE) NEFAZODONE HCL TABS 150MG T2 (SERZONE) NEFAZODONE HCL TABS 50MG T2 (SERZONE) TRAZODONE HCL TABS 150MG T2 not 300mg, (DESYREL) BRINTELLIX TABS 5MG T4 PA BRINTELLIX TABS 10MG T4 PA BRINTELLIX TABS 20MG T4 PA VIIBRYD TABS 10MG T VIIBRYD TABS 20MG T VIIBRYD TABS 40MG T4 (28: ) Central Nervous System Agents» Psychotherapeutic Agents» Antidepressants» Tricyclics and Other Norepinephrine-reuptake Inhibitors Tier: T AMITRIPTYLINE HCL TABS 10MG T1 (ELAVIL) AMITRIPTYLINE HCL TABS 25MG T1 (ELAVIL) AMITRIPTYLINE HCL TABS 50MG T1 (ELAVIL) AMITRIPTYLINE HCL TABS 75MG T1 (ELAVIL) AMITRIPTYLINE HCL TABS 100MG T1 (ELAVIL) NORTRIPTYLINE HCL CAPS 10MG T1 (PAMELOR) NORTRIPTYLINE HCL CAPS 25MG T1 (PAMELOR) AMITRIPTYLINE HCL TABS 150MG T2 (ELAVIL) AMOXAPINE TABS 25MG T2 (ASENDIN) AMOXAPINE TABS 50MG T2 (ASENDIN) AMOXAPINE TABS 100MG T2 (ASENDIN) AMOXAPINE TABS 150MG T2 (ASENDIN) CLOMIPRAMINE HCL CAPS 25MG T2 (ANAFRANIL) CLOMIPRAMINE HCL CAPS 50MG T2 (ANAFRANIL) CLOMIPRAMINE HCL CAPS 75MG T2 (ANAFRANIL) DESIPRAMINE HCL TABS 10MG T2 (NORPRAMIN) DESIPRAMINE HCL TABS 25MG T2 (NORPRAMIN) Page 30 of 88

31 DESIPRAMINE HCL TABS 50MG T2 (NORPRAMIN) DESIPRAMINE HCL TABS 75MG T2 (NORPRAMIN) DESIPRAMINE HCL TABS 100MG T2 (NORPRAMIN) DESIPRAMINE HCL TABS 150MG T2 (NORPRAMIN) DOXEPIN HCL CAPS 10MG T2 (SINEQUAN) DOXEPIN HCL CAPS 25MG T2 (SINEQUAN) DOXEPIN HCL CAPS 50MG T2 (SINEQUAN) DOXEPIN HCL CAPS 75MG T2 (SINEQUAN) DOXEPIN HCL CAPS 100MG T2 (SINEQUAN) DOXEPIN HCL CAPS 150MG T2 (SINEQUAN) DOXEPIN HCL CONC 10MG/ML T2 (SINEQUAN) IMIPRAMINE HCL TABS 10MG T2 not PM, (TOFRANIL) IMIPRAMINE HCL TABS 25MG T2 not PM, (TOFRANIL) IMIPRAMINE HCL TABS 50MG T2 not PM, (TOFRANIL) MAPROTILINE HCL TABS 25MG T2 (LUDIOMIL) MAPROTILINE HCL TABS 50MG T2 (LUDIOMIL) MAPROTILINE HCL TABS 75MG T2 (LUDIOMIL) NORTRIPTYLINE HCL CAPS 50MG T2 (PAMELOR) NORTRIPTYLINE HCL CAPS 75MG T2 (PAMELOR) NORTRIPTYLINE HCL SOLN 10MG/5ML T2 (PAMELOR) PROTRIPTYLINE HCL TABS 5MG T2 (VIVACTIL) PROTRIPTYLINE HCL TABS 10MG T2 (VIVACTIL) (28: ) Central Nervous System Agents» Psychotherapeutic Agents» Antidepressants» Miscellaneous Antidepressants BUPROBAN TB12 150MG T2 (ZYBAN) BUPROPION HCL TABS 75MG T2 (WELLBUTRIN) BUPROPION HCL TABS 100MG T2 (WELLBUTRIN) BUPROPION HCL SR TB12 100MG T2 not 200mg (WELLBUTRIN SR) BUPROPION HCL SR TB12 150MG T2 not 200mg (WELLBUTRIN SR) BUPROPION HCL XL TB24 150MG T2 (WELLBUTRIN XL) BUPROPION HCL XL TB24 300MG T2 (WELLBUTRIN XL) MIRTAZAPINE TABS 15MG T2 (REMERON) MIRTAZAPINE TABS 30MG T2 (REMERON) MIRTAZAPINE TABS 7.5MG T2 (REMERON) MIRTAZAPINE TABS 45MG T2 (REMERON) MIRTAZAPINE TBDP 15MG T2 (REMERON) MIRTAZAPINE ODT TBDP 30MG T2 (REMERON) MIRTAZAPINE ODT TBDP 45MG T2 (REMERON) Page 31 of 88

32 (28: ) Central Nervous System Agents» Psychotherapeutic Agents» Antipsychotics» Atypical Antipsychotics ARIPIPRAZOLE TABS 2MG T2 PA ARIPIPRAZOLE TABS 5MG T2 PA (ABILIFY) ARIPIPRAZOLE TABS 10MG T2 PA (ABILIFY) ARIPIPRAZOLE TABS 15MG T2 PA (ABILIFY) ARIPIPRAZOLE TABS 20MG T2 PA (ABILIFY) ARIPIPRAZOLE TABS 30MG T2 PA (ABILIFY) CLOZAPINE TABS 25MG T2 (CLOZARIL) CLOZAPINE TABS 50MG T2 (CLOZARIL) CLOZAPINE TABS 200MG T2 (CLOZARIL) CLOZAPINE TABS 100MG T2 (CLOZARIL) OLANZAPINE TABS 2.5MG T2 PA (ZYPREXA) OLANZAPINE TABS 5MG T2 PA (ZYPREXA) OLANZAPINE TABS 7.5MG T2 PA (ZYPREXA) OLANZAPINE TABS 10MG T2 PA (ZYPREXA) OLANZAPINE TABS 15MG T2 PA (ZYPREXA) OLANZAPINE TABS 20MG T2 PA (ZYPREXA) OLANZAPINE ODT TBDP 5MG T2 PA OLANZAPINE ODT TBDP 20MG T2 (ZYPREXA ODT) OLANZAPINE ODT TBDP 10MG T2 PA (ZYPREXA ODT) OLANZAPINE ODT TBDP 15MG T2 PA (ZYPREXA ODT) QUETIAPINE FUMARATE TABS 100MG T2 (SEROQUEL) QUETIAPINE FUMARATE TABS 200MG T2 (SEROQUEL) QUETIAPINE FUMARATE TABS 300MG T2 (SEROQUEL) QUETIAPINE FUMARATE TABS 50MG T2 (SEROQUEL) QUETIAPINE FUMARATE TABS 400MG T2 (SEROQUEL) QUETIAPINE FUMARATE TABS 25MG T2 (SEROQUEL) RISPERIDONE TABS 0.25MG T2 (RISPERDAL) RISPERIDONE TABS 0.5MG T2 (RISPERDAL) RISPERIDONE TABS 1MG T2 (RISPERDAL) RISPERIDONE TABS 2MG T2 (RISPERDAL) RISPERIDONE TABS 4MG T2 (RISPERDAL) RISPERIDONE TABS 3MG T2 (RISPERDAL) RISPERIDONE SOLN 1MG/ML T2 (RISPERDAL) RISPERIDONE M-TAB TBDP 0.5MG T2 (RISPERDAL-M) RISPERIDONE M-TAB TBDP 1MG T2 (RISPERDAL-M) RISPERIDONE M-TAB TBDP 2MG T2 (RISPERDAL-M) ZIPRASIDONE HCL CAPS 20MG T2 PA (GEODON) ZIPRASIDONE HCL CAPS 40MG T2 PA (GEODON) ZIPRASIDONE HCL CAPS 60MG T2 PA (GEODON) ZIPRASIDONE HCL CAPS 80MG T2 PA (GEODON) Page 32 of 88

33 INVEGA TB24 3MG T INVEGA TB24 6MG T INVEGA TB24 9MG T ABILIFY SOLN 1MG/ML T4 PA ABILIFY DISCMELT TBDP 10MG T4 PA ABILIFY DISCMELT TBDP 15MG T4 PA FANAPT TABS 1MG T4 PA FANAPT TABS 2MG T4 PA FANAPT TABS 4MG T4 PA FANAPT TABS 6MG T4 PA FANAPT TABS 8MG T4 PA FANAPT TABS 10MG T4 PA FANAPT TABS 12MG T4 PA LATUDA TABS 20MG T4 PA LATUDA TABS 40MG T4 PA LATUDA TABS 60MG T4 PA LATUDA TABS 80MG T4 PA LATUDA TABS 120MG T4 PA SAPHRIS SUBL 5MG T4 PA SAPHRIS SUBL 10MG T4 PA SAPHRIS SUBL 2.5MG T4 PA SEROQUEL XR TB24 50MG T4 PA SEROQUEL XR TB24 150MG T4 PA SEROQUEL XR TB24 200MG T4 PA SEROQUEL XR TB24 300MG T4 PA SEROQUEL XR TB24 400MG T4 PA Tier: T ABILIFY MAINTENA SUSR 300MG T6 PA ABILIFY MAINTENA SUSR 400MG T6 PA (28: ) Central Nervous System Agents» Psychotherapeutic Agents» Antipsychotics» Butyrophenones HALOPERIDOL TABS 2MG T2 (HALDOL) HALOPERIDOL TABS 1MG T2 (HALDOL) Page 33 of 88

34 HALOPERIDOL TABS 5MG T2 (HALDOL) HALOPERIDOL TABS 0.5MG T2 (HALDOL) HALOPERIDOL CONC 2MG/ML T2 (HALDOL) HALOPERIDOL TABS 10MG T2 (HALDOL) HALOPERIDOL TABS 20MG T2 (HALDOL) (28: ) Central Nervous System Agents» Psychotherapeutic Agents» Antipsychotics» Phenothiazines CHLORPROMAZINE HCL TABS 25MG T2 (THORAZINE) CHLORPROMAZINE HCL TABS 50MG T2 (THORAZINE) CHLORPROMAZINE HCL TABS 10MG T2 (THORAZINE) CHLORPROMAZINE HCL TABS 100MG T2 (THORAZINE) CHLORPROMAZINE HCL TABS 200MG T2 (THORAZINE) COMPRO SUPP 25MG T2 QL (COMPAZINE SUPPOSITORIES) FLUPHENAZINE HCL CONC 5MG/ML T2 (PROLIXIN) FLUPHENAZINE HCL ELIX 2.5MG/5ML T2 (PROLIXIN) FLUPHENAZINE HCL TABS 1MG T2 (PROLIXIN) FLUPHENAZINE HCL TABS 2.5MG T2 (PROLIXIN) FLUPHENAZINE HCL TABS 5MG T2 (PROLIXIN) FLUPHENAZINE HCL TABS 10MG T2 (PROLIXIN) PERPHENAZINE TABS 2MG T2 (TRILAFON) PERPHENAZINE TABS 4MG T2 (TRILAFON) PERPHENAZINE TABS 8MG T2 (TRILAFON) PERPHENAZINE TABS 16MG T2 (TRILAFON) PROCHLORPERAZINE SUPP 25MG T2 QL (COMPAZINE SUPPOSITORIES) PROCHLORPERAZINE MALEATE TABS 5MG T2 (COMPAZINE) PROCHLORPERAZINE MALEATE TABS 10MG T2 (COMPAZINE) THIORIDAZINE HCL TABS 10MG T2 (MELLARIL) THIORIDAZINE HCL TABS 25MG T2 (MELLARIL) THIORIDAZINE HCL TABS 50MG T2 (MELLARIL) THIORIDAZINE HCL TABS 100MG T2 (MELLARIL) TRIFLUOPERAZINE HCL TABS 1MG T2 (STELAZINE) TRIFLUOPERAZINE HCL TABS 2MG T2 (STELAZINE) TRIFLUOPERAZINE HCL TABS 5MG T2 (STELAZINE) TRIFLUOPERAZINE HCL TABS 10MG T2 (STELAZINE) (28: ) Central Nervous System Agents» Psychotherapeutic Agents» Antipsychotics» Thioxanthenes Page 34 of 88

35 THIOTHIXENE CAPS 1MG T2 (NAVANE) THIOTHIXENE CAPS 2MG T2 (NAVANE) THIOTHIXENE CAPS 5MG T2 (NAVANE) THIOTHIXENE CAPS 10MG T2 (NAVANE) (28: ) Central Nervous System Agents» Psychotherapeutic Agents» Antipsychotics» Miscellaneous Antipsychotics LOXAPINE CAPS 5MG T2 (LOXITANE) LOXAPINE CAPS 10MG T2 (LOXITANE) LOXAPINE CAPS 25MG T2 (LOXITANE) LOXAPINE CAPS 50MG T2 (LOXITANE) ORAP TABS 1MG T ORAP TABS 2MG T4 (28:20.04) Central Nervous System Agents» Anorexigenic Agents and Respiratory and CNS Stimulants» Amphetamines ADDERALL XR CP MG; 1.25MG; 1.25MG; 1.25MG T2 QL (ADDERALL XR) ADDERALL XR CP24 2.5MG; 2.5MG; 2.5MG; 2.5MG ADDERALL XR CP MG; 3.75MG; 3.75MG; 3.75MG T2 QL (ADDERALL XR) T2 QL (ADDERALL XR) ADDERALL XR CP24 5MG; 5MG; 5MG; 5MG ADDERALL XR CP MG; 6.25MG; 6.25MG; 6.25MG ADDERALL XR CP24 7.5MG; 7.5MG; 7.5MG; 7.5MG T2 QL (ADDERALL XR) T2 QL (ADDERALL XR) T2 QL (ADDERALL XR) DEXTROAMPHETAMINE SULFATE TABS 5MG T2 (DEXTROSTAT) DEXTROAMPHETAMINE SULFATE TABS 10MG T2 (DEXTROSTAT) DEXTROAMPHETAMINE SULFATE ER CP24 10MG T2 (DEXEDRINE CR) DEXTROAMPHETAMINE SULFATE ER CP24 15MG T2 (DEXEDRINE CR) DEXTROAMPHETAMINE SULFATE ER CP24 5MG T2 (DEXEDRINE CR) Page 35 of 88

36 VYVANSE CAPS 20MG T3 QL VYVANSE CAPS 30MG T3 QL VYVANSE CAPS 40MG T3 QL VYVANSE CAPS 50MG T3 QL VYVANSE CAPS 60MG T3 QL VYVANSE CAPS 70MG T3 QL (28:20.32) Central Nervous System Agents» Anorexigenic Agents and Respiratory and CNS Stimulants» Respiratory and CNS Stimulants METADATE ER TBCR 20MG T2 (RITALIN SR) METHYLPHENIDATE HCL TABS 5MG T2 (RITALIN) METHYLPHENIDATE HCL TABS 10MG T2 (RITALIN) METHYLPHENIDATE HCL TABS 20MG T2 (RITALIN) METHYLPHENIDATE HCL CD CPCR 50MG T2 QL (METADATE CD) METHYLPHENIDATE HCL CD CPCR 60MG T2 QL (METADATE CD) METHYLPHENIDATE HCL CD CPCR 10MG T2 QL (METADATE CD) METHYLPHENIDATE HCL CD CPCR 20MG T2 QL (METADATE CD) METHYLPHENIDATE HCL CD CPCR 30MG T2 QL (METADATE CD) METHYLPHENIDATE HCL CD CPCR 40MG T2 QL (METADATE CD) METHYLPHENIDATE HCL ER TBCR 18MG T2 QL (CONCERTA) METHYLPHENIDATE HCL ER TBCR 27MG T2 QL (CONCERTA) METHYLPHENIDATE HCL ER TBCR 36MG T2 QL (CONCERTA) METHYLPHENIDATE HCL ER TBCR 54MG T2 QL (CONCERTA) METHYLPHENIDATE HCL ER TBCR 20MG T2 (RITALIN SR) METHYLPHENIDATE HCL SR TBCR 20MG T2 (RITALIN SR) METHYLPHENIDATE HYDROCHLORIDE SOLN 5MG/5ML T2 (METHYLIN) METHYLPHENIDATE HYDROCHLORIDE SOLN 10MG/5ML T2 (METHYLIN) (28:20.80) Central Nervous System Agents» Anorexigenic Agents and Respiratory and CNS Stimulants» Wakefulness-promoting Agents MODAFINIL TABS 100MG T2 PA; QL (PROVIGIL) MODAFINIL TABS 200MG T2 PA; QL (PROVIGIL) (28:24.04) Central Nervous System Agents» Anxiolytics, Sedatives, and Hypnotics» Barbiturates Page 36 of 88

37 PHENOBARBITAL TABS 16.2MG T PHENOBARBITAL TABS 32.4MG T PHENOBARBITAL TABS 64.8MG T PHENOBARBITAL TABS 97.2MG T PHENOBARBITAL SOLN 20MG/5ML T2 (28:24.08) Central Nervous System Agents» Anxiolytics, Sedatives, and Hypnotics» Benzodiazepines ALPRAZOLAM TABS 0.25MG T2 not XR, (XANAX) ALPRAZOLAM TABS 0.5MG T2 not XR, (XANAX) ALPRAZOLAM TABS 1MG T2 not XR, (XANAX) ALPRAZOLAM TABS 2MG T2 not XR, (XANAX) CHLORDIAZEPOXIDE HCL CAPS 10MG T2 (LIBRIUM) CHLORDIAZEPOXIDE HCL CAPS 5MG T2 (LIBRIUM) CHLORDIAZEPOXIDE HCL CAPS 25MG T2 (LIBRIUM) CLORAZEPATE DIPOTASSIUM TABS 3.75MG T2 (TRANXENE) CLORAZEPATE DIPOTASSIUM TABS 7.5MG T2 (TRANXENE) CLORAZEPATE DIPOTASSIUM TABS 15MG T2 (TRANXENE) DIAZEPAM SOLN 1MG/ML T2 (VALIUM) DIAZEPAM TABS 2MG T2 (VALIUM) DIAZEPAM TABS 5MG T2 (VALIUM) DIAZEPAM TABS 10MG T2 (VALIUM) FLURAZEPAM HCL CAPS 15MG T2 (DALMANE) FLURAZEPAM HCL CAPS 30MG T2 (DALMANE) LORAZEPAM TABS 0.5MG T2 (ATIVAN) LORAZEPAM TABS 1MG T2 (ATIVAN) LORAZEPAM TABS 2MG T2 (ATIVAN) LORAZEPAM CONC 2MG/ML T2 QL (ATIVAN) TEMAZEPAM CAPS 15MG T2 not 7.5mg, (RESTORIL) TEMAZEPAM CAPS 30MG T2 not 7.5mg, (RESTORIL) DIAZEPAM GEL 2.5MG T4 PA; QL (DIASTAT) DIAZEPAM GEL 10MG T4 PA; QL (DIASTAT) DIAZEPAM GEL 20MG T4 PA; QL (DIASTAT) (28:24.92) Central Nervous System Agents» Anxiolytics, Sedatives, and Hypnotics» Page 37 of 88

38 Anxiolytics, Sedatives, & Hypnotics Misc BUSPIRONE HCL TABS 30MG T2 (BUSPAR) BUSPIRONE HCL TABS 5MG T2 (BUSPAR) BUSPIRONE HCL TABS 15MG T2 (BUSPAR) BUSPIRONE HCL TABS 10MG T2 (BUSPAR) HYDROXYZINE HCL SYRP 10MG/5ML T2 (ATARAX) HYDROXYZINE HCL TABS 10MG T2 (ATARAX) HYDROXYZINE HCL TABS 25MG T2 (ATARAX) HYDROXYZINE HCL TABS 50MG T2 (ATARAX) HYDROXYZINE HCL SOLN 10MG/5ML T2 (ATARAX) HYDROXYZINE PAMOATE CAPS 25MG T2 (VISTARIL) HYDROXYZINE PAMOATE CAPS 50MG T2 (VISTARIL) HYDROXYZINE PAMOATE CAPS 100MG T2 (VISTARIL) MEPROBAMATE TABS 400MG T2 (EQUANIL) MEPROBAMATE TABS 200MG T2 (EQUANIL) ZALEPLON CAPS 5MG T2 (SONATA) ZALEPLON CAPS 10MG T2 (SONATA) ZOLPIDEM TARTRATE TABS 5MG T2 (AMBIEN) ZOLPIDEM TARTRATE TABS 10MG T2 (AMBIEN) (28:28) Central Nervous System Agents» Antimanic Agents Tier: T LITHIUM CARBONATE CAPS 300MG T1 (ESKALITH) LITHIUM SOLN 8MEQ/5ML T2 PA LITHIUM CARBONATE CAPS 150MG T2 (ESKALITH) LITHIUM CARBONATE ER TBCR 450MG T2 (ESKALITH-CR) LITHIUM CARBONATE ER TBCR 300MG T2 (LITHOBID) (28:32.28) Central Nervous System Agents» Antimigraine Agents» Selective Serotonin Agonists RIZATRIPTAN BENZOATE TABS 5MG T2 QL (MAXALT) RIZATRIPTAN BENZOATE TABS 10MG T2 QL (MAXALT) RIZATRIPTAN BENZOATE ODT TBDP 5MG T2 QL (MAXALT) RIZATRIPTAN BENZOATE ODT TBDP 10MG T2 QL (MAXALT) Page 38 of 88

39 SUMATRIPTAN SOLN 20MG/ACT T2 QL (IMITREX) SUMATRIPTAN SOLN 5MG/ACT T2 QL (IMITREX) SUMATRIPTAN SUCCINATE SOAJ 4MG/0.5ML T2 QL (IMITREX) SUMATRIPTAN SUCCINATE SOAJ 6MG/0.5ML T2 QL (IMITREX) SUMATRIPTAN SUCCINATE TABS 100MG T2 QL (IMITREX) SUMATRIPTAN SUCCINATE TABS 25MG T2 QL (IMITREX) SUMATRIPTAN SUCCINATE TABS 50MG T2 QL (IMITREX) (28:32.92) Central Nervous System Agents» Antimigraine Agents» Antimigraine Agents, Miscellaneous ISOMETHEPTENE/DICHLORALPHENAZONE/ACETAMINOPHEN CAPS 325MG; 100MG; T2 65MG (MIDRIN) MIGERGOT SUPP 100MG; 2MG T2 QL (CAFERGOT) (28:36.04) Central Nervous System Agents» Antiparkinsonian Agents» Adamantanes AMANTADINE HCL SYRP 50MG/5ML T2 (SYMMETREL) AMANTADINE HCL CAPS 100MG T2 (SYMMETREL) (28:36.08) Central Nervous System Agents» Antiparkinsonian Agents» Anticholinergic Agents BENZTROPINE MESYLATE TABS 0.5MG T2 (COGENTIN) BENZTROPINE MESYLATE TABS 1MG T2 (COGENTIN) BENZTROPINE MESYLATE TABS 2MG T2 (COGENTIN) TRIHEXYPHENIDYL HCL ELIX 0.4MG/ML T2 (ARTANE) TRIHEXYPHENIDYL HCL TABS 2MG T2 (ARTANE) TRIHEXYPHENIDYL HCL TABS 5MG T2 (ARTANE) (28:36.12) Central Nervous System Agents» Antiparkinsonian Agents» COMT Inhibitors ENTACAPONE TABS 200MG T2 (COMTAN) (28:36.16) Central Nervous System Agents» Antiparkinsonian Agents» Dopamine Precursors Page 39 of 88

40 CARBIDOPA/LEVODOPA TABS 10MG; 100MG T2 (SINEMET) CARBIDOPA/LEVODOPA TABS 25MG; 100MG T2 (SINEMET) CARBIDOPA/LEVODOPA TABS 25MG; 100MG T2 (SINEMET) CARBIDOPA/LEVODOPA TABS 25MG; 250MG T2 (SINEMET) CARBIDOPA/LEVODOPA ER TBCR 50MG; 200MG T2 (SINEMET CR) (28: ) Central Nervous System Agents» Antiparkinsonian Agents» Dopamine Receptor Agonists» Ergot-derivative Dopamine Receptor Agonists BROMOCRIPTINE MESYLATE CAPS 5MG T2 (PARLODEL) BROMOCRIPTINE MESYLATE TABS 2.5MG T2 (PARLODEL) CABERGOLINE TABS 0.5MG T2 (DOSTINEX) (28: ) Central Nervous System Agents» Antiparkinsonian Agents» Dopamine Receptor Agonists» Nonergot-derivative Dopamine Receptor Agonists PRAMIPEXOLE DIHYDROCHLORIDE TABS 0.125MG T2 not ER, (MIRAPEX) PRAMIPEXOLE DIHYDROCHLORIDE TABS 0.25MG T2 not ER, (MIRAPEX) PRAMIPEXOLE DIHYDROCHLORIDE TABS 0.5MG T2 not ER, (MIRAPEX) PRAMIPEXOLE DIHYDROCHLORIDE TABS 1MG T2 not ER, (MIRAPEX) PRAMIPEXOLE DIHYDROCHLORIDE TABS 1.5MG T2 not ER, (MIRAPEX) PRAMIPEXOLE DIHYDROCHLORIDE TABS 0.75MG T2 not ER, (MIRAPEX) ROPINIROLE ER TB24 12MG T2 (REQUIP-XL) ROPINIROLE ER TB24 2MG T2 (REQUIP-XL) ROPINIROLE ER TB24 4MG T2 (REQUIP-XL) ROPINIROLE ER TB24 8MG T2 (REQUIP-XL) ROPINIROLE ER TB24 6MG T2 (REQUIP-XL) ROPINIROLE HCL TABS 0.25MG T2 (REQUIP) ROPINIROLE HCL TABS 0.5MG T2 (REQUIP) ROPINIROLE HCL TABS 1MG T2 (REQUIP) ROPINIROLE HCL TABS 2MG T2 (REQUIP) ROPINIROLE HCL TABS 3MG T2 (REQUIP) ROPINIROLE HCL TABS 4MG T2 (REQUIP) ROPINIROLE HCL TABS 5MG T2 (REQUIP) (28:36.32) Central Nervous System Agents» Antiparkinsonian Agents» Monoamine Oxidase B Inhibitors Page 40 of 88

41 SELEGILINE HCL TABS 5MG T2 (ELDEPRYL) SELEGILINE HCL CAPS 5MG T2 (ELDEPRYL) EMSAM PT24 6MG/24HR T4 PA; QL EMSAM PT24 9MG/24HR T4 PA; QL (28:40) Central Nervous System Agents» Fibromyalgia Agents SAVELLA TABS 100MG T3 PA SAVELLA TABS 12.5MG T3 PA SAVELLA TABS 25MG T3 PA SAVELLA TABS 50MG T3 PA SAVELLA TITRATION PACK MISC T3 PA; QL (28:92) Central Nervous System Agents» Central Nervous System Agents, Misc ACAMPROSATE CALCIUM DR TBEC 333MG T2 (CAMPRAL) GUANFACINE ER TB24 1MG T2 PA; QL (INTUNIV) GUANFACINE ER TB24 2MG T2 PA; QL (INTUNIV) GUANFACINE ER TB24 3MG T2 PA; QL (INTUNIV) GUANFACINE ER TB24 4MG T2 PA; QL (INTUNIV) NAMENDA SOLN 10MG/5ML T NAMENDA TABS 5MG T3 not XR NAMENDA TABS 10MG T3 not XR NAMENDA TITRATION PAK TABS T STRATTERA CAPS 10MG T STRATTERA CAPS 25MG T STRATTERA CAPS 40MG T STRATTERA CAPS 18MG T STRATTERA CAPS 60MG T STRATTERA CAPS 80MG T STRATTERA CAPS 100MG T3 Page 41 of 88

42 XYREM SOLN 500MG/ML T4 Tier: T XENAZINE TABS 25MG T5 PA (36:26) Diagnostic Agents» Diabetes Mellitus BAYER BREEZE 2 TEST DISC DISK T2 1 box per copay (TEST STRIPS) BAYER CONTOUR BLOOD GLUCOSE TEST STRIPS STRP T2 1 box per copay (TEST STRIPS) BAYER CONTOUR NEXT BLOOD GLUCOSE TEST STRP T2 1 box per copay (TEST STRIPS) FREESTYLE LITE TEST STRIPS STRP T2 1 box per copay (TEST STRIPS) (4:04.04) Antihistamine Drugs» First Generation Antihistamines» Ethanolamine Derivatives CLEMASTINE FUMARATE SYRP 0.67MG/5ML T2 QL syrup only, (TAVIST) (4:04.12) Antihistamine Drugs» First Generation Antihistamines» Phenothiazine Derivatives PROMETHAZINE HCL TABS 25MG T2 (PHENERGAN) PROMETHAZINE HCL TABS 50MG T2 (PHENERGAN) PROMETHAZINE HCL TABS 12.5MG T2 (PHENERGAN) PROMETHAZINE HCL SUPP 12.5MG T2 QL (PHENERGAN) PROMETHAZINE HCL SUPP 25MG T2 QL (PHENERGAN) PROMETHAZINE HCL PLAIN SYRP 6.25MG/5ML T2 QL (PHENERGAN) PROMETHAZINE VC PLAIN SYRP 5MG/5ML; 6.25MG/5ML T2 QL (PHENERGAN) PROMETHEGAN SUPP 50MG T2 QL (PHENERGAN) PROMETHEGAN SUPP 25MG T2 QL (PHENERGAN) PROMETHEGAN SUPP 12.5MG T2 QL (PHENERGAN) (4:04.92) Antihistamine Drugs» First Generation Antihistamines» Derivatives, Page 42 of 88

43 Miscellaneous CYPROHEPTADINE HCL TABS 4MG T2 (PERIACTIN) CYPROHEPTADINE HCL SYRP 2MG/5ML T2 QL (PERIACTIN) (4:08) Antihistamine Drugs» Second Generation Antihistamines LEVOCETIRIZINE DIHYDROCHLORIDE TABS 5MG T2 (XYZAL) (40:08) Electrolytic, Caloric, and Water Balance» Alkalinizing Agents CYTRA-K SOLN 334MG/5ML; T2 1100MG/5ML POTASSIUM CITRATE ER TBCR 15MEQ T POTASSIUM CITRATE ER TBCR 540MG T2 (UROCIT-K) POTASSIUM CITRATE ER TBCR 1080MG T2 (UROCIT-K) (40:10) Electrolytic, Caloric, and Water Balance» Ammonia Detoxicants GENERLAC SOLN 10GM/15ML T2 QL limit 1pt/31days, (CEPHULAC) LACTULOSE SOLN 10GM/15ML T2 QL limit 1pt/31days, (CEPHULAC) LACTULOSE SOLN 10GM/15ML T2 QL limit 1pt/31days, (CEPHULAC) BUPHENYL TABS 500MG T4 PA (40:12) Electrolytic, Caloric, and Water Balance» Replacement Preparations CALCIUM ACETATE CAPS 667MG T2 (PHOSLO) K-EFFERVESCENT TBEF 25MEQ T2 (K-LYTE) K-VESCENT TBEF 25MEQ T2 (K-LYTE) KLOR-CON PACK 20MEQ T KLOR-CON 8 TBCR 8MEQ T2 (SLOW-K) Page 43 of 88

44 PHOSPHA 250 NEUTRAL TABS 155MG; 852MG; 130MG T POTASSIUM CHLORIDE LIQD 10% T POTASSIUM CHLORIDE LIQD 20% T POTASSIUM CHLORIDE SOLN 10% T POTASSIUM CHLORIDE PACK 20MEQ T POTASSIUM CHLORIDE CR TBCR 10MEQ T2 (K-TAB) POTASSIUM CHLORIDE SR TBCR 8MEQ T2 (SLOW-K) K-PHOS TABS 500MG T4 (40:18.18) Electrolytic, Caloric, and Water Balance» Ion-removing Agents» Potassiumremoving Agents KIONEX POWD T2 (KAYEXELATE) SPS SUSP 15GM/60ML T2 (KAYEXALATE) (40:18.19) Electrolytic, Caloric, and Water Balance» Ion-removing Agents» Phosphateremoving Agents FOSRENOL CHEW 500MG T4 PA FOSRENOL CHEW 750MG T4 PA FOSRENOL CHEW 1000MG T4 PA (40:28.08) Electrolytic, Caloric, and Water Balance» Diuretics» Loop Diuretics Tier: T BUMETANIDE TABS 0.5MG T1 (BUMEX) BUMETANIDE TABS 1MG T1 (BUMEX) FUROSEMIDE TABS 20MG T1 (LASIX) FUROSEMIDE TABS 40MG T1 (LASIX) FUROSEMIDE TABS 80MG T1 (LASIX) BUMETANIDE TABS 2MG T2 (BUMEX) FUROSEMIDE SOLN 10MG/ML T2 (LASIX) Page 44 of 88

45 FUROSEMIDE SOLN 8MG/ML T2 (LASIX) EDECRIN TABS 25MG T3 sulfa allergic pts (40:28.16) Electrolytic, Caloric, and Water Balance» Diuretics» Potassium-sparing Diuretics Tier: T TRIAMTERENE/HYDROCHLOROTHIAZIDE CAPS 25MG; 37.5MG T1 (DYAZIDE) TRIAMTERENE/HYDROCHLOROTHIAZIDE TABS 50MG; 75MG T1 (MAXZIDE) TRIAMTERENE/HYDROCHLOROTHIAZIDE TABS 25MG; 37.5MG T1 (MAXZIDE) AMILORIDE HCL TABS 5MG T2 (MIDAMOR) (40:28.20) Electrolytic, Caloric, and Water Balance» Diuretics» Thiazide Diuretics Tier: T HYDROCHLOROTHIAZIDE TABS 25MG T1 (HYDRODIURIL) HYDROCHLOROTHIAZIDE TABS 50MG T1 (HYDRODIURIL) CHLOROTHIAZIDE TABS 500MG T2 (DIURIL) CHLOROTHIAZIDE TABS 250MG T2 (DIURIL) METHYCLOTHIAZIDE TABS 5MG T2 (ENDURON) DIURIL SUSP 250MG/5ML T4 (40:28.24) Electrolytic, Caloric, and Water Balance» Diuretics» Thiazide-like Diuretics CHLORTHALIDONE TABS 50MG T2 (HYGROTON) CHLORTHALIDONE TABS 25MG T2 (HYGROTON) METOLAZONE TABS 2.5MG T2 (ZAROXOLYN) Page 45 of 88

46 METOLAZONE TABS 10MG T2 (ZAROXOLYN) METOLAZONE TABS 5MG T2 (ZAROXOLYN) (40:40) Electrolytic, Caloric, and Water Balance» Uricosuric Agents PROBENECID TABS 500MG T2 (BENEMID) PROBENECID/COLCHICINE TABS 0.5MG; 500MG T2 (COLBENEMID) (48:08) Respiratory Tract Agents» Antitussives BENZONATATE CAPS 100MG T2 (TESSALON PERLES) BENZONATATE CAPS 200MG T2 (TESSALON PERLES) CHERATUSSIN AC SYRP 10MG/5ML; 100MG/5ML CHERATUSSIN DAC SOLN 10MG/5ML; 100MG/5ML; 30MG/5ML GUAIFENESIN DAC SOLN 10MG/5ML; 100MG/5ML; 30MG/5ML GUAIFENESIN/CODEINE SOLN 10MG/5ML; 100MG/5ML HYDROCODONE BITARTRATE/HOMATROPINE METHYLBROMIDE SYRP 1.5MG/5ML; 5MG/5ML T2 QL (ROBITUSSIN AC) T2 QL (ROBITUSSIN DAC) T2 QL (ROBITUSSIN DAC) T2 QL (ROBITUSSIN AC) T2 QL (HYCODAN) HYDROMET SYRP 1.5MG/5ML; 5MG/5ML PROMETHAZINE VC/CODEINE SYRP 10MG/5ML; 5MG/5ML; 6.25MG/5ML PROMETHAZINE-DM SYRP 15MG/5ML; 6.25MG/5ML PROMETHAZINE/CODEINE SYRP 10MG/5ML; 6.25MG/5ML T2 QL (HYCODAN) T2 QL (PHENERGAN) T2 QL (PHENERGAN) T2 QL (PHENERGAN) (48:10.24) Respiratory Tract Agents» Anti-inflammatory Agents» Leukotriene Modifiers MONTELUKAST SODIUM TABS 10MG T2 (SINGULAIR) MONTELUKAST SODIUM CHEW 4MG T2 (SINGULAIR) MONTELUKAST SODIUM CHEW 5MG T2 (SINGULAIR) MONTELUKAST SODIUM PACK 4MG T2 (SINGULAIR) ZYFLO CR TB12 600MG T4 Page 46 of 88

47 (48:10.32) Respiratory Tract Agents» Anti-inflammatory Agents» Mast-cell Stabilizers CROMOLYN SODIUM CONC 100MG/5ML T2 (GASTROCROM) CROMOLYN SODIUM NEBU 20MG/2ML T2 (INTAL NEB) (48:24) Respiratory Tract Agents» Mucolytic Agents Tier: T PULMOZYME SOLN 1MG/ML T6 PA; QL (48:48) Respiratory Tract Agents» Vasodilating Agents Tier: T TRACLEER TABS 62.5MG T5 PA TRACLEER TABS 125MG T5 PA (48:92) Respiratory Tract Agents» Respiratory Tract Agents, Miscellaneous Tier: T XOLAIR SOLR 150MG T5 PA (52:02) Eye, Ear, Nose & Throat Preparations» Antiallergic Agents AZELASTINE HCL SOLN 0.1% T2 QL (ASTELIN) CROMOLYN SODIUM SOLN 4% T2 QL (CROLOM) OLOPATADINE HCL SOLN 0.6% T2 QL (PATANASE) ALOMIDE SOLN 0.1% T3 QL (52:04.04) Eye, Ear, Nose & Throat Preparations» Anti-infectives» Antibacterials BACITRACIN OINT 500UNIT/GM T2 QL (POLYSPORIN Page 47 of 88

48 OPHTHALMIC) BACITRACIN/POLYMYXIN B OINT 500UNIT/GM; 10000UNIT/GM T2 QL (POLYSPORIN OPHTHALMIC) CIPROFLOXACIN HCL SOLN 0.3% T2 QL (CILOXAN) ERYTHROMYCIN OINT 5MG/GM T2 QL (ILOTYCIN) ERYTHROMYCIN OINT 5MG/GM T2 QL (ILOTYCIN) GENTAK OINT 0.3% T2 QL (GARAMYCIN) GENTAMICIN SULFATE OINT 0.3% T2 QL (GARAMYCIN) GENTAMICIN SULFATE SOLN 0.3% T2 QL (GARAMYCIN) LEVOFLOXACIN SOLN 0.5% T2 QL (LEVAQUIN) NEO-POLYCIN OINT 400UNIT/GM; 3.5MG/GM; 10000UNIT/GM T2 QL (NEOSPORIN OPHTH OINT) NEOMYCIN/BACITRACIN/POLYMYXIN OINT 400UNIT/GM; 5MG/GM; 10000UNIT/GM T2 QL (NEOSPORIN OPHTH OINT) NEOMYCIN/POLYMYXIN/GRAMICIDIN SOLN 0.025MG/ML; 1.75MG/ML; 10000UNIT/ML T2 QL (NEOSPORIN OPHTH SOLN) OFLOXACIN SOLN 0.3% T2 QL (FLOXIN) OFLOXACIN SOLN 0.3% T2 QL (OCUFLOX) POLYMYXIN B SULFATE/TRIMETHOPRIM SULFATE SOLN 10000UNIT/ML; 0.1% T2 QL (POLYTRIM) SODIUM SULFACETAMIDE SOLN 10% T2 QL (BLEPH-10) SULFACETAMIDE SODIUM SOLN 10% T2 QL (BLEPH-10) TOBRAMYCIN SULFATE SOLN 0.3% T2 QL (TOBREX) CILOXAN OINT 0.3% T3 QL MOXEZA SOLN 0.5% T3 QL TOBREX OINT 0.3% T3 QL VIGAMOX SOLN 0.5% T3 QL (52:04.16) Eye, Ear, Nose & Throat Preparations» Anti-infectives» Antifungals NATACYN SUSP 5% T3 QL (52:04.20) Eye, Ear, Nose & Throat Preparations» Anti-infectives» Antivirals TRIFLURIDINE SOLN 1% T2 QL (VIROPTIC) Page 48 of 88

49 ZIRGAN GEL 0.15% T4 QL (52:04.92) Eye, Ear, Nose & Throat Preparations» Anti-infectives» EENT Anti-infectives, Miscellaneous CHLORHEXIDINE GLUCONATE SOLN 0.12% T2 QL (PERIDEX) (52:08.08) Eye, Ear, Nose & Throat Preparations» Anti-inflammatory Agents» Corticosteroids DEXAMETHASONE SODIUM PHOSPHATE SOLN 0.1% T2 QL (DECADRON OPHTH) FLUNISOLIDE SOLN 0.025% T2 QL (NASALIDE) FLUOCINOLONE ACETONIDE OIL 0.01% T2 QL (DERMOTIC) FLUOROMETHOLONE SUSP 0.1% T2 QL (FML) FLUTICASONE PROPIONATE SUSP 50MCG/ACT T2 QL (FLONASE) NEO-POLYCIN HC OINT 400UNIT/GM; 1%; 3.5MG/GM; 10000UNIT/GM T2 QL (CORTISPORIN) NEOMYCIN/POLYMYXIN/BACITRACIN/HYDROCORTISONE OINT 400UNIT/GM; 1%; 0.5%; 10000UNIT/GM T2 QL (CORTISPORIN) NEOMYCIN/POLYMYXIN/DEXAMETHASONE OINT 0.1%; 3.5MG/GM; 10000UNIT/GM T2 QL (MAXITROL) NEOMYCIN/POLYMYXIN/DEXAMETHASONE SUSP 0.1%; 3.5MG/ML; 10000UNIT/ML NEOMYCIN/POLYMYXIN/HC SOLN 1%; 3.5MG/ML; 10000UNIT/ML NEOMYCIN/POLYMYXIN/HYDROCORTISONE SUSP 1%; 3.5MG/ML; 10000UNIT/ML T2 QL (MAXITROL) T2 QL (CORTISPORIN) T2 QL (CORTISPORIN) PREDNISOLONE ACETATE SUSP 1% T2 QL (PRED-FORTE) PREDNISOLONE SODIUM PHOSPHATE SOLN 1% T2 QL (INFLAMASE FORTE) SULFACETAMIDE SODIUM/PREDNISOLONE SODIUM PHOSPHATE SOLN 0.23%; 10% T2 QL (VASOCIDIN) TOBRAMYCIN/DEXAMETHASONE SUSP 0.1%; 0.3% T2 QL (TOBRADEX) BLEPHAMIDE SUSP 0.2%; 10% T3 QL Page 49 of 88

50 BLEPHAMIDE S.O.P. OINT 0.2%; 10% T3 QL CIPRODEX SUSP 0.3%; 0.1% T3 QL FML OINT 0.1% T3 QL FML FORTE SUSP 0.25% T3 QL PRED MILD SUSP 0.12% T3 QL PRED-G SUSP 0.3%; 1% T3 QL PRED-G S.O.P. OINT 0.3%; 0.6% T3 QL TOBRADEX OINT 0.1%; 0.3% T3 QL ALREX SUSP 0.2% T4 QL LOTEMAX SUSP 0.5% T4 QL LOTEMAX OINT 0.5% T4 QL LOTEMAX GEL 0.5% T4 QL (52:08.20) Eye, Ear, Nose & Throat Preparations» Anti-inflammatory Agents» Nonsteroidal Anti-inflammatory Agents DICLOFENAC SODIUM SOLN 0.1% T2 QL (VOLTAREN) FLURBIPROFEN SODIUM SOLN 0.03% T2 QL (OCUFEN) KETOROLAC TROMETHAMINE SOLN 0.4% T2 QL (ACULAR LS) KETOROLAC TROMETHAMINE SOLN 0.5% T2 QL (ACULAR) ILEVRO SUSP 0.3% T3 QL NEVANAC SUSP 0.1% T3 QL (52:08.92) Eye, Ear, Nose & Throat Preparations» Anti-inflammatory Agents» EENT Anti-inflammatory Agents, Misc RESTASIS EMUL 0.05% T3 QL (52:16) Eye, Ear, Nose & Throat Preparations» Local Anesthetics ANTIPYRINE/BENZOCAINE SOLN 5.4%; 1.4% T2 QL (AURALGAN) LIDOCAINE VISCOUS SOLN 2% T2 QL (XYLOCAINE) Page 50 of 88

51 PROPARACAINE HCL SOLN 0.5% T2 QL (ALCAINE) (52:24) Eye, Ear, Nose & Throat Preparations» Mydriatics ATROPINE SULFATE SOLN 1% T2 QL ATROPINE SULFATE OINT 1% T2 QL CYCLOPENTOLATE HCL SOLN 1% T2 QL (CYCLOGYL) HOMATROPAIRE SOLN 5% T2 (ISOPTO HOMATROPINE) TROPICAMIDE SOLN 0.5% T2 QL TROPICAMIDE SOLN 1% T2 QL CYCLOGYL SOLN 0.5% T3 QL ISOPTO HOMATROPINE SOLN 2% T3 QL (52:40.04) Eye, Ear, Nose & Throat Preparations» Antiglaucoma Agents» alpha- Adrenergic Agonists BRIMONIDINE TARTRATE SOLN 0.2% T2 QL not P, (ALPHAGAN) (52:40.08) Eye, Ear, Nose & Throat Preparations» Antiglaucoma Agents» beta- Adrenergic Blocking Agents Tier: T LEVOBUNOLOL HCL SOLN 0.5% T1 QL (BETAGAN) TIMOLOL MALEATE SOLN 0.5% T1 QL not XE, (TIMOPTIC) TIMOLOL MALEATE SOLN 0.25% T1 QL not XE, (TIMOPTIC) BETAXOLOL HCL SOLN 0.5% T2 QL (KERLONE) CARTEOLOL HCL SOLN 1% T2 QL (OCUPRESS) LEVOBUNOLOL HCL SOLN 0.25% T2 QL (BETAGAN) BETOPTIC-S SUSP 0.25% T3 QL Page 51 of 88

52 (52:40.12) Eye, Ear, Nose & Throat Preparations» Antiglaucoma Agents» Carbonic Anhydrase Inhibitors ACETAZOLAMIDE TABS 250MG T2 (DIAMOX) ACETAZOLAMIDE TABS 125MG T2 (DIAMOX) ACETAZOLAMIDE ER CP12 500MG T2 (DIAMOX CR) DORZOLAMIDE HCL SOLN 2% T2 QL (TRUSOPT) DORZOLAMIDE HCL/TIMOLOL MALEATE SOLN 22.3MG/ML; 6.8MG/ML T2 QL (COSOPT) METHAZOLAMIDE TABS 50MG T2 (NEPTAZANE) METHAZOLAMIDE TABS 25MG T2 (NEPTAZANE) (52:40.20) Eye, Ear, Nose & Throat Preparations» Antiglaucoma Agents» Miotics PILOCARPINE HCL SOLN 1% T2 QL PILOCARPINE HCL SOLN 2% T2 QL PILOCARPINE HCL SOLN 4% T2 QL ISOPTO CARBACHOL SOLN 1.5% T3 QL ISOPTO CARBACHOL SOLN 3% T3 QL PHOSPHOLINE IODIDE SOLR 0.125% T3 (52:40.28) Eye, Ear, Nose & Throat Preparations» Antiglaucoma Agents» Prostaglandin Analogs LATANOPROST SOLN 0.005% T2 QL (XALATAN) TRAVATAN Z SOLN 0.004% T3 QL (52:92) Eye, Ear, Nose & Throat Preparations» EENT Drugs, Miscellaneous Page 52 of 88

53 ACETIC ACID SOLN 2% T2 QL (VOSOL) ACETIC ACID/ALUMINUM ACETATE SOLN 2% T2 QL (DOMBORO OTIC) APRACLONIDINE SOLN 0.5% T2 QL (IOPIDINE) (56:08) Gastrointestinal Drugs» Antidiarrhea Agents DIPHENOXYLATE/ATROPINE LIQD 0.025MG/5ML; T2 2.5MG/5ML (LOMOTIL) DIPHENOXYLATE/ATROPINE TABS 0.025MG; 2.5MG T2 (LOMOTIL) LOPERAMIDE HCL CAPS 2MG T2 (IMODIUM) (56:12) Gastrointestinal Drugs» Cathartics and Laxatives GOLYTELY SOLR 236GM; 2.97GM; T2 QL 6.74GM; 5.86GM; 22.74GM (56:14) Gastrointestinal Drugs» Cholelitholytic Agents URSODIOL CAPS 300MG T2 (ACTIGALL) (56:16) Gastrointestinal Drugs» Digestants PANCRELIPASE CPEP 27000UNIT; T2 5000UNIT; 17000UNIT CREON CPEP 15000UNIT; T3 3000UNIT; 9500UNIT CREON CPEP 30000UNIT; 6000UNIT; 19000UNIT CREON CPEP 60000UNIT; 12000UNIT; 38000UNIT T3 T3 Page 53 of 88

54 CREON CPEP UNIT; 24000UNIT; 76000UNIT CREON CPEP UNIT; 36000UNIT; UNIT PANCREAZE CPEP 43750UNIT; 10500UNIT; 25000UNIT PANCREAZE CPEP 70000UNIT; 16800UNIT; 40000UNIT PANCREAZE CPEP 61000UNIT; 21000UNIT; 37000UNIT T3 T3 T3 T3 T ZENPEP CPEP 27000UNIT; T4 5000UNIT; 17000UNIT ZENPEP CPEP 55000UNIT; 10000UNIT; 34000UNIT ZENPEP CPEP 82000UNIT; 15000UNIT; 51000UNIT ZENPEP CPEP UNIT; 20000UNIT; 68000UNIT ZENPEP CPEP UNIT; 25000UNIT; 85000UNIT T4 T4 T4 T4 (56:22.08) Gastrointestinal Drugs» Antiemetics» Antihistamines TRIMETHOBENZAMIDE HCL CAPS 300MG T2 (TIGAN) (56:22.20) Gastrointestinal Drugs» Antiemetics» 5-HT3 Receptor Antagonists ONDANSETRON HCL TABS 4MG T2 QL (ZOFRAN) ONDANSETRON HCL TABS 8MG T2 QL (ZOFRAN) ONDANSETRON HCL SOLN 4MG/5ML T2 QL (ZOFRAN) ONDANSETRON ODT TBDP 4MG T2 QL (ZOFRAN) ONDANSETRON ODT TBDP 8MG T2 QL (ZOFRAN) (56:22.92) Gastrointestinal Drugs» Antiemetics» Antiemetics, Miscellaneous Page 54 of 88

55 DRONABINOL CAPS 2.5MG T2 PA; QL (MARINOL) DRONABINOL CAPS 5MG T2 PA; QL (MARINOL) DRONABINOL CAPS 10MG T2 PA; QL (MARINOL) Tier: T EMEND CAPS 80MG T6 PA EMEND CAPS 40MG T6 PA EMEND CAPS T6 PA (56:28.12) Gastrointestinal Drugs» Antiulcer Agents and Acid Suppressants» Histamine H2-Antagonists Tier: T RANITIDINE HCL TABS 150MG T1 (ZANTAC) RANITIDINE HCL TABS 300MG T1 (ZANTAC) CIMETIDINE TABS 300MG T2 (TAGAMET) CIMETIDINE TABS 400MG T2 (TAGAMET) CIMETIDINE TABS 800MG T2 (TAGAMET) CIMETIDINE HCL SOLN 300MG/5ML T2 (TAGAMET) RANITIDINE HCL SYRP 75MG/5ML T2 (ZANTAC) RANITIDINE HCL SYRP 15MG/ML T2 (ZANTAC) (56:28.28) Gastrointestinal Drugs» Antiulcer Agents and Acid Suppressants» Prostaglandins MISOPROSTOL TABS 100MCG T2 (CYTOTEC) MISOPROSTOL TABS 200MCG T2 (CYTOTEC) (56:28.32) Gastrointestinal Drugs» Antiulcer Agents and Acid Suppressants» Protectants SUCRALFATE TABS 1GM T2 (CARAFATE) Page 55 of 88

56 CARAFATE SUSP 1GM/10ML T3 (56:28.36) Gastrointestinal Drugs» Antiulcer Agents and Acid Suppressants» Protonpump Inhibitors LANSOPRAZOLE CPDR 15MG T2 not Solutab,(PREVACID) LANSOPRAZOLE CPDR 30MG T2 not Solutab,(PREVACID) OMEPRAZOLE CPDR 20MG T2 (PRILOSEC) OMEPRAZOLE CPDR 10MG T2 (PRILOSEC) PANTOPRAZOLE SODIUM TBEC 20MG T2 (PROTONIX) PANTOPRAZOLE SODIUM TBEC 40MG T2 (PROTONIX) PROTONIX PACK 40MG T3 (56:32) Gastrointestinal Drugs» Prokinetic Agents Tier: T METOCLOPRAMIDE HCL TABS 10MG T1 (REGLAN) METOCLOPRAMIDE HCL TABS 5MG T2 (REGLAN) METOCLOPRAMIDE HCL SOLN 5MG/5ML T2 (REGLAN) (56:36) Gastrointestinal Drugs» Anti-inflammatory Agents ALOSETRON HYDROCHLORIDE TABS 0.5MG T2 PA ALOSETRON HYDROCHLORIDE TABS 1MG T2 PA BALSALAZIDE DISODIUM CAPS 750MG T2 (COLAZAL) MESALAMINE ENEM 4GM T2 QL (ROWASA) ASACOL HD TBEC 800MG T CANASA SUPP 1000MG T3 QL Page 56 of 88

57 DIPENTUM CAPS 250MG T4 (56:92) Gastrointestinal Drugs» GI Drugs, Miscellaneous LINZESS CAPS 145MCG T3 PA LINZESS CAPS 290MCG T3 PA MOVANTIK TABS 12.5MG T3 PA MOVANTIK TABS 25MG T3 PA AMITIZA CAPS 8MCG T4 PA AMITIZA CAPS 24MCG T4 PA (64:00) Heavy Metal Antagonists CUPRIMINE CAPS 250MG T3 Tier: T EXJADE TBSO 125MG T5 PA EXJADE TBSO 250MG T5 PA EXJADE TBSO 500MG T5 PA (68:04) Hormones and Synthetic Substitutes» Adrenals BUDESONIDE CP24 3MG T2 PA (ENTOCORT EC) BUDESONIDE SUSP 0.25MG/2ML T2 PA; QL (PULMICORT RESPULES) BUDESONIDE SUSP 0.5MG/2ML T2 PA; QL (PULMICORT RESPULES) CORTISONE ACETATE TABS 25MG T2 (CORTONE) DEXAMETHASONE SOLN 0.5MG/5ML T2 (DECADRON) DEXAMETHASONE TABS 0.5MG T2 (DECADRON) DEXAMETHASONE TABS 0.75MG T2 (DECADRON) DEXAMETHASONE TABS 1MG T2 (DECADRON) Page 57 of 88

58 DEXAMETHASONE TABS 1.5MG T2 (DECADRON) DEXAMETHASONE TABS 4MG T2 (DECADRON) DEXAMETHASONE TABS 6MG T2 (DECADRON) DEXAMETHASONE ELIX 0.5MG/5ML T2 (DECADRON) DEXAMETHASONE INTENSOL CONC 1MG/ML T2 QL (DECADRON) FLUDROCORTISONE ACETATE TABS 0.1MG T2 (FLORINEF) HYDROCORTISONE TABS 5MG T2 (CORTEF) HYDROCORTISONE TABS 10MG T2 (CORTEF) HYDROCORTISONE TABS 20MG T2 (CORTEF) METHYLPREDNISOLONE TABS 4MG T2 (MEDROL) METHYLPREDNISOLONE TABS 16MG T2 (MEDROL) METHYLPREDNISOLONE DOSE PACK TABS 4MG T2 (MEDROL) PREDNISOLONE SOLN 15MG/5ML T2 (PRELONE) PREDNISOLONE SODIUM PHOSPHATE SOLN 5MG/5ML T2 (ORAPRED) PREDNISONE TABS 10MG T2 (DELTASONE) PREDNISONE TABS 20MG T2 (DELTASONE) PREDNISONE TABS 50MG T2 (DELTASONE) PREDNISONE SOLN 5MG/5ML T2 (DELTASONE) PREDNISONE TABS 5MG T2 (DELTASONE) PREDNISONE TABS 1MG T2 (DELTASONE) PREDNISONE TABS 2.5MG T2 (DELTASONE) ARNUITY ELLIPTA AEPB 100MCG/ACT T ARNUITY ELLIPTA AEPB 200MCG/ACT T ASMANEX HFA AERO 100MCG/ACT T ASMANEX HFA AERO 200MCG/ACT T ASMANEX TWISTHALER 120 METERED DOSES AEPB 220MCG/INH T3 QL ASMANEX TWISTHALER 30 METERED DOSES AEPB 220MCG/INH T3 QL ASMANEX TWISTHALER 30 METERED DOSES AEPB 110MCG/INH T3 QL ASMANEX TWISTHALER 60 METERED DOSES AEPB 220MCG/INH T3 QL FLOVENT DISKUS AEPB 50MCG/BLIST T3 QL FLOVENT DISKUS AEPB 250MCG/BLIST T3 QL FLOVENT DISKUS AEPB 100MCG/BLIST T3 QL FLOVENT HFA AERO 44MCG/ACT T3 QL FLOVENT HFA AERO 110MCG/ACT T3 QL FLOVENT HFA AERO 220MCG/ACT T3 QL PULMICORT SUSP 1MG/2ML T3 PA; QL Page 58 of 88

59 BREO ELLIPTA AEPB 100MCG/INH; 25MCG/INH DULERA AERO 5MCG/ACT; 200MCG/ACT DULERA AERO 5MCG/ACT; 100MCG/ACT QVAR AERS 40MCG/ACT T4 QL QVAR AERS 80MCG/ACT T4 QL T4 T4 T4 QL QL SYMBICORT AERO 160MCG/ACT; 4.5MCG/ACT SYMBICORT AERO 80MCG/ACT; 4.5MCG/ACT T4 T4 QL QL (68:08) Hormones and Synthetic Substitutes» Androgens ANDROXY TABS 10MG T2 (HALOTESTIN) DANAZOL CAPS 100MG T2 (DANOCRINE) DANAZOL CAPS 200MG T2 (DANOCRINE) DANAZOL CAPS 50MG T2 (DANOCRINE) OXANDROLONE TABS 2.5MG T2 PA (OXANDRIN) TESTOSTERONE GEL 1% T2 QL (TESTIM) ANADROL-50 TABS 50MG T4 PA ANDROGEL GEL 40.5MG/2.5GM T4 QL only 1.62% Tier: T TESTOSTERONE CYPIONATE SOLN 200MG/ML T6 QL (68:12) Hormones and Synthetic Substitutes» Contraceptives APRI TABS 0.15MG; 30MCG T2 (DESOGEN) CAMILA TABS 0.35MG T2 (MICRONOR) CRYSELLE-28 TABS 30MCG; 0.3MG T2 (LO-OVRAL) CYCLAFEM 1/35 TABS 35MCG; 1MG T2 not 7/7/7, (ORTHO NOVUM) ENPRESSE-28 TABS T2 (TRIPHASIL) ERRIN TABS 0.35MG T2 (MICRONOR) GIANVI TABS 3MG; 0.02MG T2 (YAZ) GILDESS FE 1.5/30 TABS 30MCG; 75MG; 1.5MG GILDESS FE 1/20 TABS 20MCG; 75MG; 1MG Page 59 of 88 T2 T2 (LOESTRIN-FE) (LOESTRIN-FE)

60 JUNEL FE 1.5/30 TABS 30MCG; 75MG; 1.5MG JUNEL FE 1/20 TABS 20MCG; 75MG; 1MG T2 T2 (LOESTRIN-FE) (LOESTRIN-FE) KELNOR 1/35 TABS 35MCG; 1MG T2 (DEMULEN) LEVORA 0.15/30-28 TABS 30MCG; 0.15MG T2 (NORDETTE) LOW-OGESTREL TABS 30MCG; 0.3MG T2 (LO-OVRAL) MONONESSA TABS 35MCG; 0.25MG T2 not LO, (ORTHO CYCLEN) MYZILRA TABS T2 (TRIPHASIL) NECON 1/35 TABS 35MCG; 1MG T2 not 7/7/7, (ORTHO NOVUM) NECON 1/50-28 TABS 50MCG; 1MG T2 not 7/7/7, (ORTHO NOVUM) NECON 10/11-28 TABS 35MCG T2 not 7/7/7, (ORTHO NOVUM) NORETHINDRONE TABS 0.35MG T2 (MICRONOR) NORTREL 0.5/35 (28) TABS 35MCG; 0.5MG T2 not 7/7/7, (ORTHO NOVUM) NORTREL 1/35 TABS 35MCG; 1MG T2 not 7/7/7, (ORTHO NOVUM) OGESTREL TABS 50MCG; 0.5MG T2 (OVRAL) ORSYTHIA TABS 20MCG; 0.1MG T2 (ALESSE) PORTIA-28 TABS 0.03MG; 0.15MG T2 (NORDETTE) PREVIFEM TABS 35MCG; 0.25MG T2 not LO, (ORTHO CYCLEN) RECLIPSEN TABS 0.15MG; 30MCG T2 (DESOGEN) SPRINTEC 28 TABS 35MCG; 0.25MG T2 not LO, (ORTHO CYCLEN) TRI-SPRINTEC TABS T2 not LO, (ORTHO TRICYCLEN) TRINESSA TABS T2 not LO, (ORTHO TRICYCLEN) TRIVORA-28 TABS T2 (TRIPHASIL) ZOVIA 1/35E TABS 35MCG; 1MG T2 (DEMULEN) ZOVIA 1/50E TABS 50MCG; 1MG T2 (DEMULEN) (68:16.04) Hormones and Synthetic Substitutes» Estrogens and Antiestrogens» Estrogens Tier: T ESTRADIOL TABS 2MG T1 (ESTRACE) ESTRADIOL TABS 1MG T1 (ESTRACE) ESTRADIOL TABS 0.5MG T1 (ESTRACE) EEMT TABS 1.25MG; 2.5MG T2 (ESTRATEST) ESTERIFIED ESTROGENS/METHYLTESTOSTERONE TABS 1.25MG; 2.5MG T2 (ESTRATEST) Page 60 of 88

61 ESTERIFIED ESTROGENS/METHYLTESTOSTERONE HS TABS 0.625MG; 1.25MG T2 (ESTRATEST HS) ESTRADIOL PTWK 0.025MG/24HR T2 not PRO, (CLIMARA) ESTRADIOL PTWK 37.5MCG/24HR T2 not PRO, (CLIMARA) ESTRADIOL PTWK 0.05MG/24HR T2 not PRO, (CLIMARA) ESTRADIOL PTWK 0.06MG/24HR T2 not PRO, (CLIMARA) ESTRADIOL PTWK 0.075MG/24HR T2 not PRO, (CLIMARA) ESTRADIOL PTWK 0.1MG/24HR T2 not PRO, (CLIMARA) ESTROPIPATE TABS 0.75MG T2 (OGEN) ESTROPIPATE TABS 1.5MG T2 (OGEN) ESTROPIPATE TABS 3MG T2 (OGEN) PREMARIN TABS 0.3MG T PREMARIN TABS 0.45MG T PREMARIN TABS 0.625MG T PREMARIN TABS 0.9MG T PREMARIN TABS 1.25MG T PREMARIN CREA 0.625MG/GM T3 QL PREMPHASE TABS 0.625MG; 5MG T PREMPRO TABS 0.3MG; 1.5MG T PREMPRO TABS 0.45MG; 1.5MG T PREMPRO TABS 0.625MG; 2.5MG T PREMPRO TABS 0.625MG; 5MG T ESTRACE CREA 0.1MG/GM T4 QL MENEST TABS 0.3MG T4 PA MENEST TABS 0.625MG T4 PA MENEST TABS 1.25MG T4 PA MENEST TABS 2.5MG T4 PA (68:16.12) Hormones and Synthetic Substitutes» Estrogens and Antiestrogens» Estrogen Agonist-Antagonists RALOXIFENE HYDROCHLORIDE TABS 60MG T2 (EVISTA) Page 61 of 88

62 DUAVEE TABS 20MG; 0.45MG T3 (68:18) Hormones and Synthetic Substitutes» Gonadotropins SYNAREL SOLN 2MG/ML T4 PA; QL (68:20.02) Hormones and Synthetic Substitutes» Antidiabetic Agents» Alpha- Glucosidase Inhibitors ACARBOSE TABS 25MG T2 (PRECOSE) ACARBOSE TABS 50MG T2 (PRECOSE) ACARBOSE TABS 100MG T2 (PRECOSE) (68:20.03) Hormones and Synthetic Substitutes» Antidiabetic Agents» Amylinomimetics SYMLINPEN 120 SOPN 2700MCG/2.7ML T3 PA SYMLINPEN 60 SOPN 1500MCG/1.5ML T3 PA (68:20.04) Hormones and Synthetic Substitutes» Antidiabetic Agents» Biguanides Tier: T METFORMIN HCL TABS 500MG T1 (GLUCOPHAGE) METFORMIN HCL TABS 1000MG T1 (GLUCOPHAGE) METFORMIN HCL TABS 850MG T1 (GLUCOPHAGE) METFORMIN HCL ER TB24 500MG T2 (GLUCOPHAGE) METFORMIN HCL ER TB24 750MG T2 (GLUCOPHAGE) (68:20.05) Hormones and Synthetic Substitutes» Antidiabetic Agents» Dipeptidyl Peptidase-4 (DPP-4) Inhibitors Page 62 of 88

63 JENTADUETO TABS 2.5MG; 500MG T3 ST JENTADUETO TABS 2.5MG; 850MG T3 ST JENTADUETO TABS 2.5MG; 1000MG T3 ST TRADJENTA TABS 5MG T3 ST JANUVIA TABS 50MG T4 PA; QL JANUVIA TABS 25MG T4 PA; QL JANUVIA TABS 100MG T4 PA; QL ONGLYZA TABS 2.5MG T4 PA; QL ONGLYZA TABS 5MG T4 PA; QL (68:20.06) Hormones and Synthetic Substitutes» Antidiabetic Agents» Incretin Mimetics BYETTA SOPN 5MCG/0.02ML T3 PA; QL BYETTA SOPN 10MCG/0.04ML T3 PA; QL TANZEUM PEN 30MG T3 ST TANZEUM PEN 50MG T3 ST BYDUREON SUSR 2MG T4 PA; QL (68:20.08) Hormones and Synthetic Substitutes» Antidiabetic Agents» Insulins HUMULIN R U-500 (CONCENTRATED) SOLN 500UNIT/ML T3 QL no Pens LEVEMIR SOLN 100UNIT/ML T3 QL no Pens NOVOLIN 70/30 SUSP 30UNIT/ML; 70UNIT/ML T3 QL no Pens NOVOLIN N SUSP 100UNIT/ML T3 QL no Pens NOVOLIN R SOLN 100UNIT/ML T3 QL no Pens NOVOLOG SOLN 100UNIT/ML T3 QL no Pens NOVOLOG MIX 70/30 SUSP 30UNIT/ML; 70UNIT/ML T3 QL no Pens LANTUS SOLN 100UNIT/ML T4 QL no Pens Page 63 of 88

64 (68:20.16) Hormones and Synthetic Substitutes» Antidiabetic Agents» Meglitinides NATEGLINIDE TABS 60MG T2 (STARLIX) NATEGLINIDE TABS 120MG T2 (STARLIX) (68:20.18) Hormones and Synthetic Substitutes» Antidiabetic Agents» Sodium-glucose Cotransporter 2 (SGLT2) Inhibitors FARXIGA TABS 5MG T3 ST FARXIGA TABS 10MG T3 ST JARDIANCE TABS 10MG T3 ST JARDIANCE TABS 25MG T3 ST (68:20.20) Hormones and Synthetic Substitutes» Antidiabetic Agents» Sulfonylureas Tier: T GLIMEPIRIDE TABS 1MG T1 (AMARYL) GLIMEPIRIDE TABS 2MG T1 (AMARYL) GLIMEPIRIDE TABS 4MG T1 (AMARYL) GLIPIZIDE TABS 10MG T1 not XL, (GLUCOTROL) GLIPIZIDE TABS 5MG T1 not XL, (GLUCOTROL) GLYBURIDE TABS 2.5MG T1 (DIABETA) GLYBURIDE TABS 5MG T1 (DIABETA) CHLORPROPAMIDE TABS 100MG T2 (DIABINESE) CHLORPROPAMIDE TABS 250MG T2 (DIABINESE) GLYBURIDE TABS 1.25MG T2 (DIABETA) GLYBURIDE MICRONIZED TABS 3MG T2 (MICRONASE) TOLAZAMIDE TABS 250MG T2 (TOLINASE) TOLAZAMIDE TABS 500MG T2 (TOLINASE) TOLBUTAMIDE TABS 500MG T2 (TOLINASE) (68:20.28) Hormones and Synthetic Substitutes» Antidiabetic Agents» Thiazolidinediones Page 64 of 88

65 PIOGLITAZONE HCL TABS 45MG T2 ST (ACTOS) PIOGLITAZONE HCL TABS 30MG T2 ST (ACTOS) PIOGLITAZONE HCL TABS 15MG T2 ST (ACTOS) (68:22.12) Hormones and Synthetic Substitutes» Antihypoglycemic Agents» Glycogenolytic Agents GLUCAGON EMERGENCY KIT KIT 1MG T3 QL (68:22.92) Hormones and Synthetic Substitutes» Antihypoglycemic Agents» Antihypoglycemic Agents, Miscellaneous PROGLYCEM SUSP 50MG/ML T4 (68:24) Hormones and Synthetic Substitutes» Parathyroid CALCITONIN SALMON SOLN 200UNIT/ACT T2 QL (MIACALCIN) Tier: T FORTEO SOLN 600MCG/2.4ML T5 PA (68:28) Hormones and Synthetic Substitutes» Pituitary DESMOPRESSIN ACETATE TABS 0.2MG T2 (DDAVP) DESMOPRESSIN ACETATE TABS 0.1MG T2 (DDAVP) DESMOPRESSIN ACETATE SOLN 0.01% T2 QL (DDAVP) (68:30.04) Hormones and Synthetic Substitutes» Somatotropin Agonists and Antagonists» Somatotropin Agonists Tier: T OMNITROPE SOLN 5MG/1.5ML T6 PA Page 65 of 88

66 OMNITROPE SOLN 10MG/1.5ML T6 PA OMNITROPE SOLR 5.8MG T6 PA (68:32) Hormones and Synthetic Substitutes» Progestins Tier: T MEDROXYPROGESTERONE ACETATE TABS 10MG T1 (PROVERA) MEDROXYPROGESTERONE ACETATE TABS 2.5MG T1 (PROVERA) MEDROXYPROGESTERONE ACETATE TABS 5MG T1 (PROVERA) MEDROXYPROGESTERONE ACETATE SUSP 150MG/ML T2 QL (DEPO-PROVERA) NORETHINDRONE ACETATE TABS 5MG T2 (AYGESTIN) (68:36.04) Hormones and Synthetic Substitutes» Thyroid and Antithyroid Agents» Thyroid Agents Tier: T LEVOTHYROXINE SODIUM TABS 25MCG T1 (SYNTHROID, LEVOXYL, LEVOTHROID, UNITHROID LEVOTHYROXINE SODIUM TABS 50MCG T1 (SYNTHROID, LEVOXYL, LEVOTHROID, UNITHROID LEVOTHYROXINE SODIUM TABS 75MCG T1 (SYNTHROID, LEVOXYL, LEVOTHROID, UNITHROID LEVOTHYROXINE SODIUM TABS 88MCG T1 (SYNTHROID, LEVOXYL, LEVOTHROID, UNITHROID LEVOTHYROXINE SODIUM TABS 100MCG T1 (SYNTHROID, LEVOXYL, LEVOTHROID, UNITHROID LEVOTHYROXINE SODIUM TABS 112MCG T1 (SYNTHROID, LEVOXYL, LEVOTHROID, UNITHROID LEVOTHYROXINE SODIUM TABS 125MCG T1 (SYNTHROID, LEVOXYL, LEVOTHROID, UNITHROID LEVOTHYROXINE SODIUM TABS 150MCG T1 (SYNTHROID, LEVOXYL, LEVOTHROID, UNITHROID LEVOTHYROXINE SODIUM TABS 175MCG T1 (SYNTHROID, LEVOXYL, LEVOTHROID, UNITHROID Page 66 of 88

67 LEVOTHYROXINE SODIUM TABS 200MCG T1 (SYNTHROID, LEVOXYL, LEVOTHROID, UNITHROID LEVOTHYROXINE SODIUM TABS 300MCG T1 (SYNTHROID, LEVOXYL, LEVOTHROID, UNITHROID LEVOTHYROXINE SODIUM TABS 137MCG T1 (SYNTHROID, LEVOXYL, LEVOTHROID, UNITHROID LIOTHYRONINE SODIUM TABS 5MCG T2 (CYTOMEL) LIOTHYRONINE SODIUM TABS 25MCG T2 (CYTOMEL) LIOTHYRONINE SODIUM TABS 50MCG T2 (CYTOMEL) (68:36.08) Hormones and Synthetic Substitutes» Thyroid and Antithyroid Agents» Antithyroid Agents METHIMAZOLE TABS 5MG T2 (TAPAZOLE) METHIMAZOLE TABS 10MG T2 (TAPAZOLE) PROPYLTHIOURACIL TABS 50MG T2 (PTU) (76:00) Oxytocics METHYLERGONOVINE MALEATE TABS 0.2MG T2 (METHERGINE) (8:08) Anti-infective Agents» Anthelmintics IVERMECTIN TABS 3MG T2 (STROMECTOL) ALBENZA TABS 200MG T4 (8:12.02) Anti-infective Agents» Antibacterials» Aminoglycosides Page 67 of 88

68 NEOMYCIN SULFATE TABS 500MG T2 Tier: T TOBI NEBU 300MG/5ML T5 (8: ) Anti-infective Agents» Antibacterials» Cephalosporins» First Generation Cephalosporins CEFADROXIL SUSR 250MG/5ML T2 QL Susp Only (DURICEF) CEFADROXIL SUSR 500MG/5ML T2 QL Susp Only (DURICEF) CEPHALEXIN CAPS 250MG T2 (KEFLEX) CEPHALEXIN CAPS 500MG T2 (KEFLEX) CEPHALEXIN SUSR 125MG/5ML T2 QL (KEFLEX) CEPHALEXIN SUSR 250MG/5ML T2 QL (KEFLEX) (8: ) Anti-infective Agents» Antibacterials» Cephalosporins» Second Generation Cephalosporins CEFACLOR CAPS 250MG T2 (CECLOR) CEFACLOR CAPS 500MG T2 (CECLOR) CEFPROZIL TABS 250MG T2 (CEFZIL) CEFPROZIL TABS 500MG T2 (CEFZIL) CEFPROZIL SUSR 125MG/5ML T2 QL (CEFZIL) CEFPROZIL SUSR 250MG/5ML T2 QL (CEFZIL) CEFUROXIME AXETIL TABS 250MG T2 tabs only, (CEFTIN) CEFUROXIME AXETIL TABS 500MG T2 tabs only, (CEFTIN) (8: ) Anti-infective Agents» Antibacterials» Cephalosporins» Third Generation Cephalosporins CEFDINIR CAPS 300MG T2 (OMNICEF) CEFDINIR SUSR 250MG/5ML T2 QL (OMNICEF) CEFDINIR SUSR 125MG/5ML T2 QL (OMNICEF) CEFIXIME SUSR 100MG/5ML T2 QL CEFIXIME SUSR 200MG/5ML T2 QL (SUPRAX) Page 68 of 88

69 SUPRAX TABS 400MG T SUPRAX CAPS 400MG T4 (8: ) Anti-infective Agents» Antibacterials» Macrolides» Erythromycins E.S.P. SUSR 200MG/5ML; 600MG/5ML T2 QL (PEDIAZOLE) E.E.S. 400 TABS 400MG T ERYTHROCIN STEARATE TABS 250MG T ERYTHROMYCIN CPEP 250MG T ERYTHROMYCIN ETHYLSUCCINATE TABS 400MG T3 (8: ) Anti-infective Agents» Antibacterials» Macrolides» Other Macrolides AZITHROMYCIN TABS 600MG T2 (ZITHROMAX) AZITHROMYCIN TABS 250MG T2 (ZITHROMAX) AZITHROMYCIN TABS 500MG T2 (ZITHROMAX) AZITHROMYCIN SUSR 200MG/5ML T2 QL (ZITHROMAX) AZITHROMYCIN SUSR 100MG/5ML T2 QL (ZITHROMAX) CLARITHROMYCIN SUSR 125MG/5ML T2 QL (BIAXIN) CLARITHROMYCIN SUSR 250MG/5ML T2 QL (BIAXIN) CLARITHROMYCIN TABS 500MG T2 not XL, (BIAXIN) CLARITHROMYCIN TABS 250MG T2 not XL, (BIAXIN) (8: ) Anti-infective Agents» Antibacterials» Penicillins» Natural Penicillins PENICILLIN V POTASSIUM TABS 250MG T2 (PEN VEE K) PENICILLIN V POTASSIUM TABS 500MG T2 (PEN VEE K) PENICILLIN V POTASSIUM SOLR 125MG/5ML T2 QL (PEN VEE K) PENICILLIN V POTASSIUM SOLR 250MG/5ML T2 QL (PEN VEE K) (8: ) Anti-infective Agents» Antibacterials» Penicillins» Aminopenicillins Page 69 of 88

70 AMOXICILLIN CHEW 125MG T2 (AMOXIL) AMOXICILLIN CHEW 250MG T2 (AMOXIL) AMOXICILLIN TABS 875MG T2 (AMOXIL) AMOXICILLIN CAPS 250MG T2 (AMOXIL) AMOXICILLIN CAPS 500MG T2 (AMOXIL) AMOXICILLIN SUSR 250MG/5ML T2 QL (AMOXIL) AMOXICILLIN SUSR 200MG/5ML T2 QL (AMOXIL) AMOXICILLIN SUSR 400MG/5ML T2 QL (AMOXIL) AMOXICILLIN SUSR 125MG/5ML T2 QL (AMOXIL) AMOXICILLIN/CLAVULANATE POTASSIUM CHEW 200MG; 28.5MG T2 (AUGMENTIN) AMOXICILLIN/CLAVULANATE POTASSIUM CHEW 400MG; 57MG T2 (AUGMENTIN) AMOXICILLIN/CLAVULANATE POTASSIUM TABS 250MG; 125MG T2 (AUGMENTIN) AMOXICILLIN/CLAVULANATE POTASSIUM TABS 875MG; 125MG T2 (AUGMENTIN) AMOXICILLIN/CLAVULANATE POTASSIUM TABS 500MG; 125MG T2 (AUGMENTIN) AMOXICILLIN/CLAVULANATE POTASSIUM SUSR 600MG/5ML; 42.9MG/5ML AMOXICILLIN/CLAVULANATE POTASSIUM SUSR 250MG/5ML; 62.5MG/5ML AMOXICILLIN/CLAVULANATE POTASSIUM SUSR 200MG/5ML; 28.5MG/5ML AMOXICILLIN/CLAVULANATE POTASSIUM SUSR 400MG/5ML; 57MG/5ML T2 QL (AUGMENTIN) T2 QL (AUGMENTIN) T2 QL (AUGMENTIN) T2 QL (AUGMENTIN) AMOXICILLIN/CLAVULANATE POTASSIUM ER TB MG; 62.5MG T2 (AUGMENTIN XR) AMPICILLIN CAPS 250MG T2 (PRINCIPEN, OMNIPEN, POLYCILLIN) AMPICILLIN CAPS 500MG T2 (PRINCIPEN, OMNIPEN, POLYCILLIN) AMPICILLIN SUSR 125MG/5ML T2 QL (PRINCIPEN, OMNIPEN, POLYCILLIN) AMPICILLIN SUSR 250MG/5ML T2 QL (PRINCIPEN, OMNIPEN, POLYCILLIN) (8: ) Anti-infective Agents» Antibacterials» Penicillins» Penicillinase-resistant Penicillins DICLOXACILLIN SODIUM CAPS 250MG T2 caps only (DYCILL) DICLOXACILLIN SODIUM CAPS 500MG T2 caps only (DYCILL) (8:12.18) Anti-infective Agents» Antibacterials» Quinolones Page 70 of 88

71 CIPROFLOXACIN HCL TABS 250MG T2 not Susp or XR, (CIPRO) CIPROFLOXACIN HCL TABS 500MG T2 not Susp or XR, (CIPRO) CIPROFLOXACIN HCL TABS 750MG T2 not Susp or XR, (CIPRO) LEVOFLOXACIN SOLN 25MG/ML T2 (LEVAQUIN) LEVOFLOXACIN TABS 250MG T2 (LEVAQUIN) LEVOFLOXACIN TABS 500MG T2 (LEVAQUIN) LEVOFLOXACIN TABS 750MG T2 (LEVAQUIN) (8:12.20) Anti-infective Agents» Antibacterials» Sulfonamides SULFADIAZINE TABS 500MG T SULFAMETHOXAZOLE/TRIMETHOPRIM SUSP 200MG/5ML; 40MG/5ML T2 (BACTRIM, SEPTRA) SULFAMETHOXAZOLE/TRIMETHOPRIM TABS 400MG; 80MG T2 (BACTRIM, SEPTRA) SULFAMETHOXAZOLE/TRIMETHOPRIM DS TABS 800MG; 160MG T2 (BACTRIM DS, SEPTRA DS) SULFASALAZINE TABS 500MG T2 not EN, (AZULFIDINE) SULFAZINE TABS 500MG T2 not EN, (AZULFIDINE) (8:12.24) Anti-infective Agents» Antibacterials» Tetracyclines DOXYCYCLINE HYCLATE TABS 20MG T2 (PERIOSTAT) DOXYCYCLINE HYCLATE CAPS 50MG T2 (VIBRAMYCIN) DOXYCYCLINE HYCLATE CAPS 100MG T2 (VIBRAMYCIN) DOXYCYCLINE HYCLATE TABS 100MG T2 (VIBRATABS) DOXYCYCLINE MONOHYDRATE CAPS 50MG T2 (MONODOX) DOXYCYCLINE MONOHYDRATE CAPS 100MG T2 (MONODOX) MINOCYCLINE HCL CAPS 50MG T2 (MINOCIN) MINOCYCLINE HCL CAPS 100MG T2 (MINOCIN) TETRACYCLINE HCL CAPS 250MG T2 (SUMYCIN) TETRACYCLINE HCL CAPS 500MG T2 (SUMYCIN) (8: ) Anti-infective Agents» Antibacterials» Antibacterials, Miscellaneous» Lincomycins CLINDAMYCIN HCL CAPS 150MG T2 150mg caps and Suspension only, (CLEOCIN) CLINDAMYCIN PALMITATE HCL SOLR 75MG/5ML T2 (CLEOCIN) Page 71 of 88

72 CLINDAMYCIN PALMITATE HCL SOLR 75MG/5ML T2 (CLEOCIN) (8: ) Anti-infective Agents» Antibacterials» Antibacterials, Miscellaneous» Oxazolidinones ZYVOX TABS 600MG T3 PA ZYVOX SUSR 100MG/5ML T3 PA (8:14.04) Anti-infective Agents» Antifungals» Allylamines TERBINAFINE HCL TABS 250MG T2 (LAMISIL) (8:14.08) Anti-infective Agents» Antifungals» Azoles FLUCONAZOLE TABS 50MG T2 (DIFLUCAN) FLUCONAZOLE TABS 100MG T2 (DIFLUCAN) FLUCONAZOLE TABS 200MG T2 (DIFLUCAN) FLUCONAZOLE SUSR 10MG/ML T2 QL (DIFLUCAN) FLUCONAZOLE SUSR 40MG/ML T2 QL (DIFLUCAN) FLUCONAZOLE TABS 150MG T2 QL (DIFLUCAN) ITRACONAZOLE CAPS 100MG T2 PA (SPORONOX) KETOCONAZOLE TABS 200MG T2 not shampoo, (NIZORAL) VORICONAZOLE SUSR 40MG/ML T2 QL (VFEND) SPORANOX SOLN 10MG/ML T4 PA (8:14.28) Anti-infective Agents» Antifungals» Polyenes NYSTATIN SUSP UNIT/ML T2 not Powder NYSTATIN TABS UNIT T2 not PWD (8:14.32) Anti-infective Agents» Antifungals» Pyrimidines Page 72 of 88

73 FLUCYTOSINE CAPS 250MG T2 (ANCOBON) FLUCYTOSINE CAPS 500MG T2 (ANCOBON) (8:14.92) Anti-infective Agents» Antifungals» Antifungals, Miscellaneous GRISEOFULVIN MICROSIZE SUSP 125MG/5ML T2 suspension only, (GRIFULVIN V SUSP) (8:16.04) Anti-infective Agents» Antimycobacterials» Antituberculosis Agents ETHAMBUTOL HCL TABS 100MG T2 (MYAMBUTAL) ETHAMBUTOL HCL TABS 400MG T2 (MYAMBUTAL) ISONIAZID TABS 100MG T2 (LANIAZID) ISONIAZID TABS 300MG T2 (LANIAZID) PYRAZINAMIDE TABS 500MG T RIFABUTIN CAPS 150MG T RIFAMPIN CAPS 300MG T2 (RIFADIN) RIFAMPIN CAPS 150MG T2 (RIFADIN) PASER PACK 4GM T PRIFTIN TABS 150MG T TRECATOR TABS 250MG T4 (8:16.92) Anti-infective Agents» Antimycobacterials» Antimycobacterials, Miscellaneous DAPSONE TABS 100MG T DAPSONE TABS 25MG T4 (8:18.04) Anti-infective Agents» Antivirals» Adamantanes RIMANTADINE HCL TABS 100MG T2 (FLUMADINE) Page 73 of 88

74 (8:18.20) Anti-infective Agents» Antivirals» Interferons Tier: T PEG-INTRON KIT 150MCG/0.5ML T5 PA PEG-INTRON KIT 80MCG/0.5ML T5 PA PEG-INTRON KIT 120MCG/0.5ML T5 PA PEG-INTRON KIT 50MCG/0.5ML T5 PA PEG-INTRON REDIPEN KIT 120MCG/0.5ML T5 PA PEG-INTRON REDIPEN KIT 80MCG/0.5ML T5 PA PEG-INTRON REDIPEN KIT 150MCG/0.5ML T5 PA PEGASYS SOLN 180MCG/0.5ML T5 PA (8:18.28) Anti-infective Agents» Antivirals» Neuraminidase Inhibitors RELENZA DISKHALER AEPB 5MG/BLISTER T TAMIFLU SUSR 6MG/ML T4 QL under 2 years of age only, susp. only (8:18.32) Anti-infective Agents» Antivirals» Nucleosides and Nucleotides ACYCLOVIR CAPS 200MG T2 (ZOVIRAX) ACYCLOVIR TABS 400MG T2 (ZOVIRAX) ACYCLOVIR TABS 800MG T2 (ZOVIRAX) ACYCLOVIR SUSP 200MG/5ML T2 (ZOVIRAX) ENTECAVIR TABS 0.5MG T ENTECAVIR TABS 1MG T VALACYCLOVIR HCL TABS 500MG T2 (VALTREX) VALACYCLOVIR HCL TABS 1GM T2 (VALTREX) VALGANCICLOVIR TABS 450MG T VALCYTE SOLR 50MG/ML T TYZEKA TABS 600MG T4 PA Page 74 of 88

75 Tier: T ADEFOVIR DIPIVOXIL TABS 10MG T5 PA Tier: T RIBAVIRIN CAPS 200MG T6 (8: ) Anti-infective Agents» Antivirals» HCV Antivirals» HCV Polymerase Inhibitors Tier: T SOVALDI TABS 400MG T5 PA (8: ) Anti-infective Agents» Antivirals» HCV Antivirals» HCV Protease Inhibitors Tier: T OLYSIO CAPS 150MG T5 PA VICTRELIS CAPS 200MG T5 PA (8: ) Anti-infective Agents» Antivirals» HCV Antivirals» HCV Replication Complex Inhibitors Tier: T VIEKIRA PAK TBPK 250MG; 12.5MG; T5 PA 75MG; 50MG (8:30.04) Anti-infective Agents» Antiprotozoals» Amebicides PAROMOMYCIN SULFATE CAPS 250MG T3 (8:30.08) Anti-infective Agents» Antiprotozoals» Antimalarials ATOVAQUONE/PROGUANIL HCL TABS 250MG; 100MG T2 (MALARONE) ATOVAQUONE/PROGUANIL HCL TABS 62.5MG; 25MG T2 (MALARONE) Page 75 of 88

76 CHLOROQUINE PHOSPHATE TABS 250MG T2 (ARALEN) CHLOROQUINE PHOSPHATE TABS 500MG T2 (ARALEN) HYDROXYCHLOROQUINE SULFATE TABS 200MG T2 (PLAQUENIL) MEFLOQUINE HCL TABS 250MG T2 (LARIAM) DARAPRIM TABS 25MG T4 (8:30.92) Anti-infective Agents» Antiprotozoals» Antiprotozoals, Miscellaneous ATOVAQUONE SUSP 750MG/5ML T2 (MEPRON) METRONIDAZOLE TABS 250MG T2 (FLAGYL) METRONIDAZOLE TABS 500MG T2 (FLAGYL) ALINIA TABS 500MG T3 (8:36) Anti-infective Agents» Urinary Anti-infectives NITROFURANTOIN MACROCRYSTALS CAPS 50MG T2 (MACRODANTIN) NITROFURANTOIN MACROCRYSTALS CAPS 100MG T2 (MACRODANTIN) NITROFURANTOIN MONOHYDRATE CAPS 100MG T2 (MACROBID) TRIMETHOPRIM TABS 100MG T2 (TRIMPEX) UROQID #2 TABS 500MG; 500MG T3 (84:04.04) Skin and Mucous Membrane Preparations» Anti-infectives» Antibacterials CLINDAMYCIN PHOSPHATE CREA 2% T2 QL Vaginal only (CLEOCIN) ERYTHROMYCIN SOLN 2% T2 QL (A/T/S) GENTAMICIN SULFATE OINT 0.1% T2 QL (GARAMYCIN) GENTAMICIN SULFATE CREA 0.1% T2 QL (GARAMYCIN) METRONIDAZOLE CREA 0.75% T2 QL (METROCREAM) Page 76 of 88

77 METRONIDAZOLE GEL 0.75% T2 QL (METROGEL) METRONIDAZOLE GEL 1% T2 QL (METROGEL) METRONIDAZOLE LOTN 0.75% T2 QL (METROLOTION) METRONIDAZOLE VAGINAL GEL 0.75% T2 QL (METROGEL) MUPIROCIN OINT 2% T2 QL (BACTROBAN) MUPIROCIN CREA 2% T2 QL (BACTROBAN) VANDAZOLE GEL 0.75% T2 QL (METROGEL) (84:04.06) Skin and Mucous Membrane Preparations» Anti-infectives» Antivirals ACYCLOVIR OINT 5% T2 QL not crm DENAVIR CREA 1% T4 QL (84: ) Skin and Mucous Membrane Preparations» Anti-infectives» Antifungals» Azoles CLOTRIMAZOLE TROC 10MG T2 PA; QL (MYCELEX TROCHES) CLOTRIMAZOLE LOZG 10MG T2 PA; QL (MYCELEX TROCHES) CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE LOTN 0.05%; 1% T2 QL (LOTRISONE) CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE CREA 0.05%; 1% T2 QL (LOTRISONE) CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE CREA 0.05%; 1% T2 QL (LOTRISONE) ECONAZOLE NITRATE CREA 1% T2 QL (SPECTAZOLE) KETOCONAZOLE CREA 2% T2 QL not shampoo, (NIZORAL) TERCONAZOLE CREA 0.4% T2 QL (TERAZOL) TERCONAZOLE CREA 0.8% T2 QL (TERAZOL) TERCONAZOLE SUPP 80MG T2 QL (TERAZOL) ZAZOLE CREA 0.4% T2 QL (TERAZOL) OXISTAT CREA 1% T3 QL OXISTAT LOTN 1% T3 QL (84: ) Skin and Mucous Membrane Preparations» Anti-infectives» Antifungals» Page 77 of 88

78 Hydroxypyridones CICLOPIROX GEL 0.77% T2 QL not Shampoo, (LOPROX) CICLOPIROX SUSP 0.77% T2 QL not Shampoo, (LOPROX) CICLOPIROX NAIL LACQUER SOLN 8% T2 QL (PENLAC) CICLOPIROX OLAMINE CREA 0.77% T2 QL not Shampoo, (LOPROX) (84: ) Skin and Mucous Membrane Preparations» Anti-infectives» Antifungals» Polyenes NYSTATIN OINT UNIT/GM T2 QL not PWD NYSTATIN CREA UNIT/GM T2 QL not PWD (84:04.12) Skin and Mucous Membrane Preparations» Anti-infectives» Scabicides and Pediculicides MALATHION LOTN 0.5% T2 QL (OVIDE) PERMETHRIN CREA 5% T2 QL (ELIMITE) (84:04.92) Skin and Mucous Membrane Preparations» Anti-infectives» Local Antiinfectives, Miscellaneous SELENIUM SULFIDE LOTN 2.5% T2 QL (SELSUN) SSD CREA 1% T2 QL (SILVADENE) (84:06) Skin and Mucous Membrane Preparations» Anti-inflammatory Agents BETAMETHASONE DIPROPIONATE CREA 0.05% T2 QL (DIPROSONE) BETAMETHASONE DIPROPIONATE OINT 0.05% T2 QL (DIPROSONE) BETAMETHASONE DIPROPIONATE LOTN 0.05% T2 QL (DIPROSONE) BETAMETHASONE VALERATE OINT 0.1% T2 QL (VALISONE) BETAMETHASONE VALERATE CREA 0.1% T2 QL (VALISONE) BETAMETHASONE VALERATE LOTN 0.1% T2 QL (VALISONE) Page 78 of 88

79 CLOBETASOL PROPIONATE GEL 0.05% T2 QL (TEMOVATE) CLOBETASOL PROPIONATE SOLN 0.05% T2 QL (TEMOVATE) CLOBETASOL PROPIONATE CREA 0.05% T2 QL (TEMOVATE) CLOBETASOL PROPIONATE OINT 0.05% T2 QL (TEMOVATE) CLOBETASOL PROPIONATE LOTN 0.05% T2 QL (TEMOVATE) CLOBETASOL PROPIONATE E CREA 0.05% T2 QL (TEMOVATE) COLOCORT ENEM 100MG/60ML T2 QL (CORTENEMA) DESONIDE LOTN 0.05% T2 QL (TRIDESILON) DESONIDE CREA 0.05% T2 QL (TRIDESILON) DESONIDE OINT 0.05% T2 QL (TRIDESILON) DESOXIMETASONE CREA 0.25% T2 QL not spray, (TOPICORT) DESOXIMETASONE OINT 0.25% T2 QL not spray, (TOPICORT) DESOXIMETASONE CREA 0.05% T2 QL not spray, (TOPICORT) DESOXIMETASONE OINT 0.05% T2 QL not spray, (TOPICORT) DESOXIMETASONE GEL 0.05% T2 QL not spray, (TOPICORT) DIFLORASONE DIACETATE OINT 0.05% T2 QL (MAXIFLOR) DIFLORASONE DIACETATE CREA 0.05% T2 QL (MAXIFLOR) FLUOCINOLONE ACETONIDE OINT 0.025% T2 QL (SYNALAR) FLUOCINOLONE ACETONIDE CREA 0.025% T2 QL (SYNALAR) FLUOCINOLONE ACETONIDE SOLN 0.01% T2 QL (SYNALAR) FLUOCINOLONE ACETONIDE CREA 0.01% T2 QL (SYNALAR) FLUOCINONIDE GEL 0.05% T2 QL (LIDEX) FLUOCINONIDE OINT 0.05% T2 QL (LIDEX) FLUOCINONIDE CREA 0.05% T2 QL (LIDEX) FLUOCINONIDE SOLN 0.05% T2 QL (LIDEX) FLUOCINONIDE-E CREA 0.05% T2 QL (LIDEX-E) FLUTICASONE PROPIONATE LOTN 0.05% T2 QL (CUTIVATE) FLUTICASONE PROPIONATE OINT 0.005% T2 QL (CUTIVATE) FLUTICASONE PROPIONATE CREA 0.05% T2 QL (CUTIVATE) HYDROCORTISONE ENEM 100MG/60ML T2 QL (CORTENEMA) HYDROCORTISONE CREA 2.5% T2 QL (HYTONE) HYDROCORTISONE OINT 2.5% T2 QL (HYTONE) HYDROCORTISONE LOTN 2.5% T2 QL (HYTONE) HYDROCORTISONE ACETATE SUPP 25MG T2 QL (ANUSOL HC) HYDROCORTISONE BUTYRATE CREA 0.1% T2 QL (LOCOID) HYDROCORTISONE BUTYRATE SOLN 0.1% T2 QL (LOCOID) HYDROCORTISONE BUTYRATE OINT 0.1% T2 QL (LOCOID) MOMETASONE FUROATE CREA 0.1% T2 QL (ELOCON) MOMETASONE FUROATE SOLN 0.1% T2 QL (ELOCON) MOMETASONE FUROATE OINT 0.1% T2 QL (ELOCON) NYSTATIN/TRIAMCINOLONE CREA UNIT/GM; 1MG/GM NYSTATIN/TRIAMCINOLONE OINT UNIT/GM; 0.1% T2 QL not PWD, (MYCOLOG) T2 QL not PWD, (MYCOLOG) PROCTOZONE-HC CREA 2.5% T2 QL (ANUSOL HC) Page 79 of 88

80 TRIAMCINOLONE ACETONIDE CREA 0.5% T2 QL (ARISTOCORT) TRIAMCINOLONE ACETONIDE CREA 0.025% T2 QL (ARISTOCORT) TRIAMCINOLONE ACETONIDE LOTN 0.1% T2 QL (ARISTOCORT) TRIAMCINOLONE ACETONIDE OINT 0.5% T2 QL (ARISTOCORT) TRIAMCINOLONE ACETONIDE OINT 0.025% T2 QL (ARISTOCORT) TRIAMCINOLONE ACETONIDE OINT 0.1% T2 QL (ARISTOCORT) TRIAMCINOLONE ACETONIDE LOTN 0.025% T2 QL (ARISTOCORT) TRIAMCINOLONE ACETONIDE CREA 0.1% T2 QL (ARISTOCORT) TRIAMCINOLONE ACETONIDE PSTE 0.1% T2 QL (KENALOG ORABASE) TRIAMCINOLONE IN ORABASE PSTE 0.1% T2 QL (KENALOG ORABASE) CORDRAN TAPE TAPE 4MCG/SQCM T3 QL CORDRAN TAPE TAPE 4MCG/SQCM T3 QL CORTISPORIN OINT 400UNIT/GM; 1%; 0.5%; 5000UNIT/GM CORTISPORIN CREA 0.5%; 0.5%; 10000UNIT/GM T3 T3 QL QL (84:08) Skin and Mucous Membrane Preparations» Antipruritics and Local Anesthetics LIDOCAINE PTCH 5% T2 PA (LIDODERM) LIDOCAINE OINT 5% T2 QL oint only, (XYLOCAINE) LIDOCAINE/PRILOCAINE CREA 2.5%; 2.5% T2 QL (EMLA) PHENAZOPYRIDINE HCL TABS 200MG T2 not 100mg, (PYRIDIUM) PRUDOXIN CREA 5% T2 QL (84:16) Skin and Mucous Membrane Preparations» Cell Stimulants and Proliferants TRETINOIN CREA 0.025% T2 PA; QL (RETIN-A) No PA required for 19 and under TRETINOIN CREA 0.1% T2 PA; QL (RETIN-A) No PA required for 19 and under TRETINOIN CREA 0.05% T2 PA; QL (RETIN-A) No PA required for 19 and under TRETINOIN CREA 0.025% T2 PA; QL (RETIN-A) No PA required for 19 and under TRETINOIN GEL 0.025% T2 PA; QL (RETIN-A) No PA required for 19 and Page 80 of 88

81 TRETINOIN GEL 0.01% T2 PA; QL (RETIN-A) No PA required for 19 and under under (84:28) Skin and Mucous Membrane Preparations» Keratolytic Agents X-VIATE LOTN 40% T2 QL X-VIATE CREA 40% T2 QL (84:50.06) Skin and Mucous Membrane Preparations» Depigmenting and Pigmenting Agents» Pigmenting Agents OXSORALEN LOTN 1% T3 QL OXSORALEN ULTRA CAPS 10MG T3 (84:92) Skin and Mucous Membrane Preparations» Skin and Mucous Membrane Agents, Misc CALCIPOTRIENE SOLN 0.005% T2 QL (DOVONEX) CALCIPOTRIENE CREA 0.005% T2 QL (DOVONEX) CALCIPOTRIENE OINT 0.005% T2 QL (DOVONEX) DICLOFENAC SODIUM GEL 3% T2 PA; QL (SOLARAZE) FLUOROURACIL SOLN 2% T2 QL (EFUDEX) FLUOROURACIL SOLN 5% T2 QL (EFUDEX) FLUOROURACIL CREA 5% T2 QL (EFUDEX) IMIQUIMOD CREA 5% T2 QL (ALDARA) PODOFILOX SOLN 0.5% T2 QL (CONDYLOX) VASOLEX OINT 788MG/GM; 87MG/GM; 90UNIT/GM T2 QL PANRETIN GEL 0.1% T ELIDEL CREA 1% T4 QL SANTYL OINT 250UNIT/GM T4 QL Page 81 of 88

82 TAZORAC GEL 0.1% T4 PA; QL TAZORAC GEL 0.05% T4 PA; QL TAZORAC CREA 0.05% T4 PA; QL TAZORAC CREA 0.1% T4 PA; QL VOLTAREN GEL 1% T4 PA Tier: T ACITRETIN CAPS 10MG T5 PA (SORIATANE) ACITRETIN CAPS 25MG T5 PA (SORIATANE) ACITRETIN CAPS 17.5MG T5 PA (SORIATANE) TARGRETIN GEL 1% T5 QL (86:12.04) Smooth Muscle Relaxants» Genitourinary Smooth Muscle Relaxants» Antimuscarinics FLAVOXATE HCL TABS 100MG T2 (URISPAS) OXYBUTYNIN CHLORIDE TABS 5MG T2 (DITROPAN) OXYBUTYNIN CHLORIDE SYRP 5MG/5ML T2 (DITROPAN) TOVIAZ TB24 4MG T TOVIAZ TB24 8MG T3 (86:16) Smooth Muscle Relaxants» Respiratory Smooth Muscle Relaxants THEOPHYLLINE CR TB12 200MG T2 (THEO-DUR) THEOPHYLLINE CR TB12 100MG T2 (THEO-DUR) THEOPHYLLINE ER TB12 450MG T2 (THEO-DUR) THEOPHYLLINE ER TB12 300MG T2 (THEO-DUR) (88:08) Vitamins» Vitamin B Complex FOLIC ACID TABS 1MG T2 (88:16) Vitamins» Vitamin D Page 82 of 88

83 CALCITRIOL SOLN 1MCG/ML T2 (ROCALTROL) CALCITRIOL CAPS 0.25MCG T2 (ROCALTROL) CALCITRIOL CAPS 0.5MCG T2 (ROCALTROL) PARICALCITOL CAPS 1MCG T2 PA PARICALCITOL CAPS 2MCG T2 PA PARICALCITOL CAPS 4MCG T2 PA (ZEMPLAR) VITAMIN D CAPS 50000UNIT T2 (88:24) Vitamins» Vitamin K Activity MEPHYTON TABS 5MG T3 (88:28) Vitamins» Multivitamin Preparations MULTI-VIT/FLUORIDE SOLN 35MG/ML; T2 QL 400UNIT/ML; 2MCG/ML; 8MG/ML; 0.4MG/ML; 0.6MG/ML; 0.25MG/ML; 0.5MG/ML; 5UNIT/ML; 1500UNIT/ML MULTI-VIT/FLUORIDE SOLN 35MG/ML; 400UNIT/ML; 2MCG/ML; 8MG/ML; 0.4MG/ML; 0.6MG/ML; 0.5MG/ML; 0.5MG/ML; 5UNIT/ML; 1500UNIT/ML MULTI-VIT/IRON/FLUORIDE SOLN 35MG/ML; 400UNIT/ML; 10MG/ML; 8MG/ML; 0.4MG/ML; 0.6MG/ML; 0.25MG/ML; 0.5MG/ML; 5UNIT/ML; 1500UNIT/ML T2 T2 QL QL Page 83 of 88

84 MULTIVITAMIN WITH FLUORIDE CHEW 60MG; 4.5MCG; 0.3MG; 13.5MG; 1.05MG; 1.2MG; 0.25MG; 1.05MG; 2500UNIT; 400UNIT; 15UNIT T PRENATAL PLUS TABS 120MG; 0; 200MG; 400UNIT; 2MG; 12MCG; 27MG; 1MG; 20MG; 10MG; 3MG; 1.84MG; 22MG; 4000UNIT; 25MG T2 (STUARTNATAL PLUS) TRI-VIT/FLUORIDE SOLN 35MG/ML; 400UNIT/ML; 0.25MG/ML; 1500UNIT/ML TRI-VIT/FLUORIDE SOLN 35MG/ML; 400UNIT/ML; 0.5MG/ML; 1500UNIT/ML TRI-VIT/FLUORIDE/IRON SOLN 35MG/ML; 0.25MG/ML; 10MG/ML; 1500UNIT/ML; 400UNIT/ML TRINATE TABS 120MG; 3000UNIT; 200MG; 400UNIT; 2MG; 12MCG; 28MG; 1MG; 25MG; 20MG; 25MG; 4MG; 1.8MG; 22MG; 25MG T2 QL (TRI-VI-FLOR) T2 QL (TRI-VI-FLOR) T2 QL (TRI-VI-FLOR W/IRON) T2 (STUARTNATAL PLUS-3) (92:04) Miscellaneous Therapeutic Agents» Alcohol Deterrents DISULFIRAM TABS 250MG T2 (ANTABUSE) DISULFIRAM TABS 500MG T2 (ANTABUSE) (92:08) Miscellaneous Therapeutic Agents» 5-alpha-Reductase Inhibitors FINASTERIDE TABS 5MG T2 (PROSCAR) Page 84 of 88

85 AVODART CAPS 0.5MG T3 (92:12) Miscellaneous Therapeutic Agents» Antidotes ACETYLCYSTEINE SOLN 10% T2 (MUCOMYST) ACETYLCYSTEINE SOLN 20% T2 (MUCOMYST) LEUCOVORIN CALCIUM TABS 5MG T2 (WELLCOVORIN) LEUCOVORIN CALCIUM TABS 10MG T2 (WELLCOVORIN) LEUCOVORIN CALCIUM TABS 15MG T2 (WELLCOVORIN) (92:16) Miscellaneous Therapeutic Agents» Antigout Agents Tier: T ALLOPURINOL TABS 300MG T1 (ZYLOPRIM) ALLOPURINOL TABS 100MG T1 (ZYLOPRIM) COLCHICINE TABS 0.6MG T2 (COLCRYS) (92:20) Miscellaneous Therapeutic Agents» Immunomodulatory Agents THALOMID CAPS 50MG T3 PA THALOMID CAPS 100MG T3 PA THALOMID CAPS 150MG T3 PA THALOMID CAPS 200MG T3 PA Tier: T AVONEX KIT 30MCG/VIAL T AVONEX KIT 30MCG/0.5ML T AVONEX PEN KIT 30MCG/0.5ML T BETASERON KIT 0.3MG T COPAXONE SOSY 20MG/ML T GILENYA CAPS 0.5MG T5 PA; QL REBIF SOLN 22MCG/0.5ML T REBIF SOLN 44MCG/0.5ML T5 Page 85 of 88

86 REBIF TITRATION PACK SOLN T5 (92:24) Miscellaneous Therapeutic Agents» Bone Resorption Inhibitors Tier: T ALENDRONATE SODIUM TABS 70MG T1 QL (FOSAMAX) ALENDRONATE SODIUM TABS 5MG T2 (FOSAMAX) ALENDRONATE SODIUM TABS 10MG T2 (FOSAMAX) ALENDRONATE SODIUM TABS 35MG T2 QL (FOSAMAX) Tier: T IBANDRONATE SODIUM SOLN 3MG/3ML T6 PA; QL PROLIA SOLN 60MG/ML T6 PA ZOLEDRONIC ACID SOLN 5MG/100ML T6 (RECLAST) (92:28) Miscellaneous Therapeutic Agents» Cariostatic Agents SF GEL 1.1% T2 QL (PREVIDENT) SODIUM FLUORIDE CHEW 0.25MG T2 (LURIDE) SODIUM FLUORIDE CHEW 1.1MG T2 (LURIDE) SODIUM FLUORIDE CHEW 1MG T2 (LURIDE) SODIUM FLUORIDE SOLN 0.5MG/ML T2 QL (LURIDE) (92:36) Miscellaneous Therapeutic Agents» Disease-modifying Antirheumatic Drugs LEFLUNOMIDE TABS 10MG T2 (ARAVA) LEFLUNOMIDE TABS 20MG T2 (ARAVA) Tier: T ENBREL KIT 25MG T5 PA ENBREL SOSY 50MG/ML T5 PA ENBREL SOSY 25MG/0.5ML T5 PA ENBREL SURECLICK SOAJ 50MG/ML T5 PA HUMIRA PSKT 40MG/0.8ML T5 PA Page 86 of 88

87 HUMIRA PEN PNKT 40MG/0.8ML T5 PA HUMIRA PEN-CROHNS DISEASESTARTER PNKT 40MG/0.8ML T5 PA XELJANZ TABS 5MG T5 PA (92:44) Miscellaneous Therapeutic Agents» Immunosuppressive Agents AZATHIOPRINE TABS 50MG T2 (IMURAN) CYCLOSPORINE MODIFIED CAPS 25MG T2 (NEORAL) CYCLOSPORINE MODIFIED CAPS 50MG T2 (NEORAL) CYCLOSPORINE MODIFIED CAPS 100MG T2 (NEORAL) CYCLOSPORINE MODIFIED SOLN 100MG/ML T2 (NEORAL) MYCOPHENOLATE MOFETIL TABS 500MG T2 (CELLCEPT) MYCOPHENOLATE MOFETIL CAPS 250MG T2 (CELLCEPT) MYCOPHENOLATE MOFETIL SUSR 200MG/ML T2 (CELLCEPT) Tier: T MYCOPHENOLIC ACID DR TBEC 180MG T MYCOPHENOLIC ACID DR TBEC 360MG T SIROLIMUS TABS 0.5MG T SIROLIMUS TABS 1MG T SIROLIMUS TABS 2MG T TACROLIMUS CAPS 0.5MG T6 (PROGRAF) TACROLIMUS CAPS 1MG T6 (PROGRAF) TACROLIMUS CAPS 5MG T6 (PROGRAF) ZORTRESS TABS 0.5MG T ZORTRESS TABS 0.75MG T ZORTRESS TABS 0.25MG T6 (92:56) Miscellaneous Therapeutic Agents» Protective Agents MESNEX TABS 400MG T4 (92:92) Miscellaneous Therapeutic Agents» Other Miscellaneous Therapeutic Agents SENSIPAR TABS 30MG T3 PA SENSIPAR TABS 60MG T3 PA SENSIPAR TABS 90MG T3 PA Page 87 of 88

88 ELMIRON CAPS 100MG T4 PA ZAVESCA CAPS 100MG T4 PA Tier: T KUVAN TBSO 100MG T5 PA ORFADIN CAPS 10MG T5 PA (94:00) Devices FINE 30 MISC T2 Page 88 of 88