How To Get A Drug Plan To Pay For A Prescription From Acpa

Transcription

1 +B/LVW2I'UXJV5B$SSURYHG 2015 List of Covered s (Formulary) FOR MORE INFORMATION, contact Member Services at from 8 a.m. to 8 p.m., seven days a week. TTY users call 711. On weekends and Federal holidays, you may be asked to leave a message. Your call will be returned the next business day , Version Number 14 UpdatedϬ4 Ϭϭ ϮϬϭϱ

2 H1723_LISTOFDRUGS15R_Approved Absolute Total Care 2015 List of Covered s (Formulary) This List of s is current as of April 1, For more recent information or other questions, please call Absolute Total Care at from 8 a.m. to 8 p.m., seven days a week. On weekends and Federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users call 711. The call is free. For more information, visit This is a list of drugs that members can get in Absolute Total Care (ATC). Absolute Total Care (ATC) is a health plan that contracts with both Medicare and South Carolina Healthy Connections Medicaid to provide benefits of both programs to enrollees. Benefits, List of Covered s, pharmacy and provider networks, and/or copayments may change from time to time throughout the year and on January 1 of each year. You can always check ATC s up-to-date List of Covered s online at Limitations and restrictions may apply. For more information, call ATC Member Services or read the ATC Member Handbook. You can ask for this information in other formats, such as Braille or large print. Call The call is free. You can get this information for free in other languages. Call The call is free. Hours are from 8 a.m. to 8 p.m., seven days a week. On weekends and Federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users call 711. The call is free. Usted puede obtener esta información de forma gratuita en otros idiomas. Llamar La llamada es gratuita. Horario es de 8 am a 8 pm los siete días de la semana. Los fines de semana y días feriados federales, se le puede pedir que deje un mensaje. Su llamada será devuelta dentro del siguiente día hábil. Usuarios de TTY deben llamar al 711. La llamada es gratuita ,Version Number14 Updated4? If you have questions, please call Absolute Total Care at from 8 a.m. to 8 p.m., seven days a week. On weekends and Federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users call 711. The call is free. For more information, visit 1

3 Frequently Asked Questions (FAQ) Find answers here to questions you have about this List of Covered s. You can read all of the FAQ to learn more, or look for a question and answer. 1. What prescription drugs are on the List of Covered s? (We call the List of Covered s the List for short.) The drugs on the List of Covered s that starts on page 10 are the drugs covered by ATC. These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as network pharmacies. o ATC will cover all medically necessary drugs on the List if: x your doctor or other prescriber says you need them to get better or stay healthy, and x you fill the prescription at a ATC network pharmacy. o ATC may have additional steps to access certain drugs (see question #5 below). You can also see an up-to-date list of drugs that we cover on our website at or call Member Services at Does the List ever change? Yes. ATC may add or remove drugs on the List during the year. Generally, the List will only change if: x a cheaper drug comes along that works as well as a drug on the List now, or x we learn that a drug is not safe. We may also change our rules about drugs. For example, we could: x Decide to require or not require prior approval for a drug. (Prior approval is permission from ATC before you can get a drug.) x Add or change the amount of a drug you can get (called quantity limits ). x Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.)? If you have questions, please call Absolute Total Care at from 8 a.m. to 8 p.m., seven days a week. On weekends and Federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users call 711. The call is free. For more information, visit 2

4 (For more information on these drug rules, see page 4.) We will tell you when a drug you are taking is removed from the List. We will also tell you when we change our rules for covering a drug. Questions 3, 4, and 7 below have more information on what happens when the List changes. o You can always check ATC s up to date List online at You can also call Member Services to check the current List at What happens when a cheaper drug comes along that works as well as a drug on the List now? If you are taking a drug that is removed because a cheaper drug that works just as well comes along, we will tell you. We will tell you at least 60 days before we remove it from the List or when you ask for a refill. Then you can get a 60-day supply of the drug before the change to the List is made. We will mail you a notice if you are taking a drug, and we change our rules for covering it. You will receive the notice by mail at least 60 days before we change the drug rules or remove the drug from our List of Covered s. For example, if you are taking a drug, and we add prior authorization (approval), quantity limits, and/or step therapy, the notice you receive will explain the new rules. We must tell you of this change at least 60 days before it becomes effective. Or, we have to tell you when you request a refill of the drug. If we tell you when you refill your drug, you will receive a 60-day supply of the drug. For more information on these drug rules, see page 3. If you have questions about the notice you receive from ATC, call Member Services at from 8 a.m. to 8 p.m., seven days a week. On weekends and Federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users call What happens when we find out a drug is not safe? If the Food and Administration (FDA) says a drug you are taking is not safe, we will take it off the List right away. We will also send you a letter telling you that. If you have any questions after being notified of the change, you should contact the doctor who prescribed the drug for you.? If you have questions, please call Absolute Total Care at from 8 a.m. to 8 p.m., seven days a week. On weekends and Federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users call 711. The call is free. For more information, visit 3

5 5. Are there any restrictions or limits on drug coverage? Or are there any required actions to take in order to get certain drugs? Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases you must do something before you can get the drug. For example: x Prior approval (or prior authorization): For some drugs, you or your doctor or other prescriber must get approval from ATC before you fill your prescription. If you don t get approval, ATC may not cover the drug. x Quantity limits: Sometimes ATC limits the amount of a drug you can get. x Step therapy: Sometimes ATC requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn t work for you, then we will cover the second. You can find out if your drug has any additional requirements or limits by looking in the tables on pages 9. You can also get more information by visiting our web site at We have posted online a document that explains our prior authorization restrictions. You may also ask us to send you a copy. You can ask for an exception from these limits. Please see question 11 for more information on exceptions. o If you are in a nursing home or other long-term care facility and need a drug that is not on the List, or if you cannot easily get the drug you need, we can help. We will cover a 31-day emergency supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new ATC member. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the List you can take instead or whether to request an exception. Please see question 11 for more information about exceptions. 6. How will you know if the drug you want has limitations or if there are required actions to take to get the drug? The List of Covered s on page 10 has a column labeled Necessary actions, restrictions, or limits on use.? If you have questions, please call Absolute Total Care at from 8 a.m. to 8 p.m., seven days a week. On weekends and Federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users call 711. The call is free. For more information, visit 4

6 7. What happens if we change our rules on how we cover some drugs? For example, if we add prior authorization (approval), quantity limits, and/or step therapy restrictions on a drug. We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions on a drug. We will tell you at least 60 days before the restriction is added or when you next ask for a refill. Then, you can get a 60-day supply of the drug before the change to the List is made. This gives you time to talk to your doctor or other prescriber about what to do next. 8. How can you find a drug on the List? There are two ways to find a drug: x You can search alphabetically (if you know how to spell the drug), or x You can search by medical condition. To search alphabetically, go to the Alphabetical Listing section. You can find it by reviewing the index of drugs beginning on page 87. To search by medical condition, find the section labeled List of drugs by medical condition on page 10. Then find your medical condition. For example, if you have a heart condition, you should look in that category. That is where you will find drugs that treat heart conditions. 9. What if the drug you want to take is not on the List? If you don t see your drug on the List, call Member Services at and ask about it. If you learn that ATC will not cover the drug, you can do one of these things: x Ask Member Services for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the List that is like the one you want to take. Or x You can ask the health plan to make an exception to cover your drug. Please see question 11 for more information about exceptions.? If you have questions, please call Absolute Total Care at from 8 a.m. to 8 p.m., seven days a week. On weekends and Federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users call 711. The call is free. For more information, visit 5

7 10. What if you are a new ATC member and can t find your drug on the List or have a problem getting your drug? We can help. We will cover a temporary 30-day supply of your Part D drug and a 90-day supply of your Healthy Connections Medicaid drugs during the first 180 days you are a member of ATC. This will give you time to talk to your doctor or other prescriber. He or she will determine if there is a similar drug on the List you can take instead or whether to request an exception. We will cover a temporary supply of your drug if: x you are taking a drug that is not on our List, or x health plan rules do not let you get the amount ordered by your prescriber, or x the drug requires prior approval by ATC, or x you are taking a drug that is part of a step therapy restriction. If you live in a nursing home or other long-term care facility, you may refill your prescription for as long as 91 to 98 days for Part D drugs and 90 days for non-part D drugs. You may refill the drug multiple times during this time period. This gives your prescriber time to change your drugs to ones on the List or ask for an exception. Throughout the plan year, you may have a change in your treatment setting (the place where you get and take your medicine) because of the level of care you require. Such transitions may include, but are not limited to: Members who are discharged from a hospital or skilled-nursing facility to a home setting Members who are admitted to a hospital or skilled-nursing facility from a home setting Members who transfer from one skilled-nursing facility to another and are served by a different pharmacy Members who end their skilled-nursing facility Medicare Part A stay (where payments include all pharmacy charges) and who now need to use their Part D plan benefit Members who give up Hospice Status and go back to standard Medicare Part A and B coverage Members discharged from chronic psychiatric hospitals with highly individualized drug regimes For these changes in treatment settings, ATC will cover as much as a 31-day temporary supply of a Part D-covered drug when you fill your prescription at a network pharmacy. If you change treatment? If you have questions, please call Absolute Total Care at from 8 a.m. to 8 p.m., seven days a week. On weekends and Federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users call 711. The call is free. For more information, visit 6

8 settings multiple times within the same month, you may have to request an exception or prior authorization and get approval for continued coverage of your drug. We will review these requests for continuation of therapy on a case-by-case basis when you are on a stabilized drug regimen that, if changed, is known to have risks. To ask for a temporary supply of a drug, call Member Services. 11. Can you ask for an exception to cover your drug? Yes. You can ask ATC to make an exception to cover a drug that is not on the List. You can also ask us to change the rules on your drug. x For example, ATC may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more. x Other examples: You can ask us to drop step therapy restrictions or prior approval requirements. 12. How long does it take to get an exception? First, we must receive a statement from your prescriber supporting your request for an exception. After we receive the statement, we will give you a decision on your exception request within 72 hours. If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, we will give you a decision within 24 hours of receiving your prescriber s supporting statement. 13. How can you ask for an exception? To ask for an exception, call Member Services at from 8 a.m. to 8 p.m., seven days a week. On weekends and Federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users call 711. A Member Services representative will work with you and your provider to help you ask for an exception.? If you have questions, please call Absolute Total Care at from 8 a.m. to 8 p.m., seven days a week. On weekends and Federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users call 711. The call is free. For more information, visit 7

9 14. What are generic drugs? Generic drugs are made up of the same active ingredients as brand name drugs. They usually cost less than the brand name drug and usually don t have well-known names. Generic drugs are approved by the Food and Administration (FDA). ATC covers both brand name drugs and generic drugs. 15. What are OTC drugs? OTC stands for over-the-counter. ATC covers some OTC drugs when they are written as prescriptions by your provider. You can read the ATC List to see what OTC drugs are covered. 16. Does ATC cover OTC non-drug products? ATC covers some OTC non-drug products when they are written as prescriptions by your provider. You can read the ATC List to see what OTC non-drug products are covered. 17. What is your copay? You can read the ATC List to learn about the copay for each drug. ATC members living in nursing homes or other long-term care facilities will have no copays. Some members getting long-term care in the community will also have no copays. Copays are listed by tiers. Tiers are groups of drugs with the same copay. x Tier 1 drugs are generic drugs. The copay will be $0. x Tier 2 drugs are brand name drugs. The copay will be $0. x Tier 3 drugs are Healthy Connections Medicaid OTC. The copay will be $0.? If you have questions, please call Absolute Total Care at from 8 a.m. to 8 p.m., seven days a week. On weekends and Federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users call 711. The call is free. For more information, visit 8

10 List of Covered s The list of covered drugs that begins on the next page gives you information about the drugs covered by ATC. If you have trouble finding your drug in the list, turn to the Index that begins on page 87. The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g., HUMALOG) and generic drugs are listed in lower-case italics (e.g., amoxicillin). The information in the necessary actions, restrictions, or limits on use column tells you if ATC has any rules for covering your drug. Abbreviations B/D DP LA PA QL MO Descriptions This prescription drug has a Part B versus D administrative prior authorization requirement. This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. is not a Part D drug LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at , 8:00 am to 8:00 pm seven days a week. TTY/TDD users should call 711. This prescription requires you or your physician to get prior authorization. This means that you will need to get approval from ATC before you fill your prescriptions. If you don't get approval, ATC may not cover the drug. For certain drugs, ATC limits the amount of the drug that ATC will cover. For example, ATC provides 30 tablets per prescription for Januvia. This may be in addition to a standard one-month or three-month supply. This prescription drug is eligible for a 90-day supply through our mail order service as well as through our retail network pharmacies. Consider using mail order for your longterm (maintenance) medications (such as high blood pressure medications). Retail network pharmacies may be more appropriate for short-term prescriptions (such as antibiotics). Note: The DP next to a drug means the drug is not a Part D drug. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving Extra Help to pay for your prescriptions, you will not get any Extra Help to pay for these drugs. These drugs also have different rules for appeals. An appeal is a formal way of asking us to review a coverage decision and to change it if you think we made a mistake. For example, we might decide that a drug that you want is not covered or is no longer covered by Medicare or Healthy Connections Medicaid. If you or your doctor disagrees with our decision, you can appeal. To ask for instructions on how to appeal, call Member Services at You can also read the Member Handbook to learn how to appeal a decision.? If you have questions, please call Absolute Total Care at from 8 a.m. to 8 p.m., seven days a week. On weekends and Federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users call 711. The call is free. For more information, visit 9

11 Analgesics Analgesics butalbital/acetaminophen/caffeine/codeine capsule 325mg; 1 50mg; 40mg; 30mg butalbital/acetaminophen/caffeine capsule 325mg; 50mg; 1 40mg butalbital/acetaminophen/caffeine tablet 325mg; 50mg; 40mg 1 butalbital/acetaminophen tablet 325mg; 50mg 1 butalbital/aspirin/caffeine capsule 325mg; 50mg; 40mg 1 butalbital/aspirin/caffeine tablet 325mg; 50mg; 40mg 1 GRALISE STARTER MISCELLANEOUS 0 2 GRALISE TABLET 300MG 2 GRALISE TABLET 600MG 2 Nonsteroidal Anti-inflammatory s diclofenac potassium tablet 50mg 1 MO diclofenac sodium dr tablet delayed release 25mg 1 diclofenac sodium dr tablet delayed release 50mg 1 diclofenac sodium dr tablet delayed release 75mg 1 diclofenac sodium er tablet extended release 24 hour 100mg 1 diflunisal tablet 500mg 1 etodolac er tablet extended release 24 hour 400mg 1 etodolac er tablet extended release 24 hour 500mg 1 etodolac er tablet extended release 24 hour 600mg 1 etodolac capsule 200mg 1 etodolac capsule 300mg 1 etodolac tablet 400mg 1 etodolac tablet 500mg 1 fenoprofen calcium tablet 600mg 1 flurbiprofen tablet 100mg 1 flurbiprofen tablet 50mg 1 ibuprofen suspension 100mg/5ml 1 ibuprofen tablet 400mg 1 ibuprofen tablet 600mg 1 ibuprofen tablet 800mg 1 indomethacin er capsule extended release 75mg 1 PA (Anti-inflammatory Agents) indomethacin capsule 25mg 1 PA (Anti-inflammatory Agents) indomethacin capsule 50mg 1 PA (Anti-inflammatory Agents) ketoprofen er capsule extended release 24 hour 200mg 1 QL (30 EA per 30 days) ketoprofen capsule 50mg 1 ketoprofen capsule 75mg 1 ketorolac tromethamine injection 15mg/ml 1 ketorolac tromethamine injection 30mg/ml 1 meclofenamate sodium capsule 100mg 1 meclofenamate sodium capsule 50mg 1 meloxicam suspension 7.5mg/5ml 1 meloxicam tablet 15mg 1 QL (30 EA per 30 days) meloxicam tablet 7.5mg 1 QL (30 EA per 30 days) nabumetone tablet 500mg 1 nabumetone tablet 750mg 1 Page 1 of 103

12 naproxen dr tablet delayed release 375mg 1 naproxen dr tablet delayed release 500mg 1 naproxen sodium tablet 275mg 1 naproxen sodium tablet 550mg 1 naproxen suspension 125mg/5ml 1 naproxen tablet 250mg 1 naproxen tablet 375mg 1 naproxen tablet 500mg 1 oxaprozin tablet 600mg 1 piroxicam capsule 10mg 1 piroxicam capsule 20mg 1 sulindac tablet 150mg 1 sulindac tablet 200mg 1 tolmetin sodium capsule 400mg 1 tolmetin sodium tablet 200mg 1 MO tolmetin sodium tablet 600mg 1 Opioid Analgesics, Long-acting fentanyl patch 72 hour 100mcg/hr 1 QL (10 EA per 30 days) fentanyl patch 72 hour 12mcg/hr 1 QL (10 EA per 30 days) fentanyl patch 72 hour 25mcg/hr 1 QL (10 EA per 30 days) fentanyl patch 72 hour 50mcg/hr 1 QL (10 EA per 30 days) fentanyl patch 72 hour 75mcg/hr 1 QL (10 EA per 30 days) levorphanol tartrate tablet 2mg 1 QL (240 EA per 30 days) METHADONE HCL INJECTION 10MG/ML 2 methadone hcl solution 10mg/5ml 1 methadone hcl solution 5mg/5ml 1 methadone hcl tablet 10mg 1 methadone hcl tablet 5mg 1 methadose tablet 10mg 1 morphine sulfate er tablet extended release 100mg 1 QL (180 EA per 30 days) morphine sulfate er tablet extended release 15mg 1 QL (120 EA per 30 days) morphine sulfate er tablet extended release 200mg 1 QL (120 EA per 30 days) morphine sulfate er tablet extended release 30mg 1 QL (120 EA per 30 days) morphine sulfate er tablet extended release 60mg 1 QL (120 EA per 30 days) Opioid Analgesics, Short-acting acetaminophen/codeine #3 tablet 300mg; 30mg 1 QL (390 EA per 30 days) acetaminophen/codeine tablet 300mg; 15mg 1 QL (390 EA per 30 days) acetaminophen/codeine tablet 300mg; 60mg 1 QL (390 EA per 30 days) ascomp/codeine capsule 325mg; 50mg; 40mg; 30mg 1 butorphanol tartrate injection 1mg/ml 1 butorphanol tartrate injection 2mg/ml 1 butorphanol tartrate solution 10mg/ml 1 DEMEROL INJECTION 50MG/ML 2 duramorph injection 0.5mg/ml 1 duramorph injection 1mg/ml 1 endocet tablet 325mg; 10mg 1 QL (360 EA per 30 days) endocet tablet 325mg; 5mg 1 QL (360 EA per 30 days) endocet tablet 325mg; 7.5mg 1 QL (360 EA per 30 days) Page 2 of 103

13 fentanyl citrate oral transmucosal lozenge on a handle 1200mcg 1 QL (120 EA per 30 days) PA (Fentanyl Citrate Oral Transmucosal) fentanyl citrate oral transmucosal lozenge on a handle 1600mcg 1 QL (120 EA per 30 days) PA (Fentanyl Citrate Oral Transmucosal) fentanyl citrate oral transmucosal lozenge on a handle 200mcg 1 QL (120 EA per 30 days) PA (Fentanyl Citrate Oral Transmucosal) fentanyl citrate oral transmucosal lozenge on a handle 400mcg 1 QL (120 EA per 30 days) PA (Fentanyl Citrate Oral Transmucosal) fentanyl citrate oral transmucosal lozenge on a handle 600mcg 1 QL (120 EA per 30 days) PA (Fentanyl Citrate Oral Transmucosal) fentanyl citrate oral transmucosal lozenge on a handle 800mcg 1 QL (120 EA per 30 days) PA (Fentanyl Citrate Oral Transmucosal) hydrocodone bitartrate/acetaminophen tablet 325mg; 2.5mg 1 QL (360 EA per 30 days) hydrocodone bitartrate/acetaminophen tablet 750mg; 10mg 1 QL (150 EA per 30 days) hydrocodone/acetaminophen tablet 325mg; 10mg 1 QL (360 EA per 30 days) hydrocodone/acetaminophen tablet 325mg; 5mg 1 QL (360 EA per 30 days) hydrocodone/acetaminophen tablet 325mg; 7.5mg 1 QL (360 EA per 30 days) hydrocodone/acetaminophen tablet 500mg; 10mg 1 QL (240 EA per 30 days) hydrocodone/acetaminophen tablet 500mg; 5mg 1 QL (240 EA per 30 days) hydrocodone/acetaminophen tablet 500mg; 7.5mg 1 QL (240 EA per 30 days) hydrocodone/acetaminophen tablet 650mg; 10mg 1 hydrocodone/acetaminophen tablet 650mg; 7.5mg 1 QL (180 EA per 30 days) hydrocodone/acetaminophen tablet 660mg; 10mg 1 QL (180 EA per 30 days) hydrocodone/acetaminophen tablet 750mg; 7.5mg 1 QL (150 EA per 30 days) hydromorphone hcl injection 500mg/50ml 1 hydromorphone hcl tablet 2mg 1 hydromorphone hcl tablet 4mg 1 hydromorphone hcl tablet 8mg 1 LAZANDA SOLUTION 100MCG/ACT 2 QL (600 EA per 30 days) PA (Lazanda) LAZANDA SOLUTION 400MCG/ACT 2 QL (150 EA per 30 days) PA (Lazanda) meperidine hcl injection 100mg/ml 1 meperidine hcl injection 25mg/ml 1 meperidine hcl injection 50mg/ml 1 morphine sulfate solution 10mg/5ml 1 morphine sulfate solution 20mg/5ml 1 morphine sulfate solution 20mg/ml 1 morphine sulfate tablet 15mg 1 morphine sulfate tablet 30mg 1 nalbuphine hcl injection 10mg/ml 1 nalbuphine hcl injection 20mg/ml 1 oxycodone hcl tablet 10mg 1 Page 3 of 103

14 oxycodone hcl tablet 15mg 1 oxycodone hcl tablet 20mg 1 oxycodone hcl tablet 30mg 1 oxycodone hcl tablet 5mg 1 oxycodone/acetaminophen capsule 500mg; 5mg 1 oxycodone/acetaminophen tablet 325mg; 10mg 1 QL (360 EA per 30 days) oxycodone/acetaminophen tablet 325mg; 5mg 1 QL (360 EA per 30 days) oxycodone/acetaminophen tablet 325mg; 7.5mg 1 QL (360 EA per 30 days) oxycodone/acetaminophen tablet 500mg; 7.5mg 1 QL (240 EA per 30 days) oxycodone/acetaminophen tablet 650mg; 10mg 1 roxicet tablet 325mg; 5mg 1 QL (360 EA per 30 days) stagesic capsule 500mg; 5mg 1 QL (240 EA per 30 days) TALWIN INJECTION 30MG/ML 2 tramadol hcl tablet 50mg 1 QL (240 EA per 30 days) tramadol hydrochloride/acetaminophen tablet 325mg; 37.5mg 1 QL (240 EA per 30 days) Anesthetics Local Anesthetics lidocaine hcl jelly gel 2% 1 lidocaine hcl jelly gel 2% 1 lidocaine hcl injection 0.5% 1 lidocaine hcl injection 1% 1 lidocaine hcl solution 4% 1 lidocaine viscous solution 2% 1 lidocaine/prilocaine cream 2.5%; 2.5% 1 lidocaine ointment 5% 1 lidocaine patch 5% 1 QL (90 EA per 30 days) PA (Anesthetics) XYLOCAINE-MPF INJECTION 1% 2 Anti-Addiction/Substance Abuse Treatment Agents Alcohol Deterrents/Anti-craving acamprosate calcium dr tablet delayed release 333mg 1 disulfiram tablet 250mg 1 disulfiram tablet 500mg 1 Opioid Dependence Treatments buprenorphine hcl injection 0.3mg/ml 1 buprenorphine hcl tablet sublingual 2mg 1 buprenorphine hcl tablet sublingual 8mg 1 naltrexone hcl tablet 50mg 1 SUBOXONE FILM 12MG; 3MG 2 SUBOXONE FILM 2MG; 0.5MG 2 SUBOXONE FILM 4MG; 1MG 2 SUBOXONE FILM 8MG; 2MG 2 SUBOXONE TABLET SUBLINGUAL 2MG; 0.5MG 2 SUBOXONE TABLET SUBLINGUAL 8MG; 2MG 2 ZUBSOLV TABLET SUBLINGUAL 1.4MG; 0.36MG 2 ZUBSOLV TABLET SUBLINGUAL 5.7MG; 1.4MG 2 Opioid Reversal Agents naloxone hcl injection 1mg/ml 1 Smoking Cessation Agents Page 4 of 103

15 buproban tablet extended release 12 hour 150mg 1 CHANTIX STARTING MONTH PAK TABLET 0 2 CHANTIX TABLET 0.5MG 2 QL (56 EA per 28 days) CHANTIX TABLET 1MG 2 QL (56 EA per 28 days) NICOTROL NS SOLUTION 10MG/ML 2 Antibacterials Aminoglycosides amikacin sulfate injection 500mg/2ml 1 AMIKACIN SULFATE INJECTION 50MG/ML 2 gentak ointment 0.3% 1 GENTAMICIN SULFATE/0.9% SODIUM CHLORIDE 2 INJECTION 0.9MG/ML; 0.9% GENTAMICIN SULFATE/0.9% SODIUM CHLORIDE 2 INJECTION 1.4MG/ML; 0.9% gentamicin sulfate/0.9% sodium chloride injection 1.6mg/ml; 1 0.9% gentamicin sulfate/0.9% sodium chloride injection 1mg/ml; 1 0.9% gentamicin sulfate cream 0.1% 1 gentamicin sulfate injection 10mg/ml 1 gentamicin sulfate injection 40mg/ml 1 gentamicin sulfate ointment 0.1% 1 gentamicin sulfate ointment 0.3% 1 gentamicin sulfate solution 0.3% 1 isotonic gentamicin injection 0.8mg/ml; 0.9% 1 isotonic gentamicin injection 1.2mg/ml; 0.9% 1 neomycin sulfate tablet 500mg 1 neomycin/polymyxin b sulfates solution 40mg/ml; unit/ml paromomycin sulfate capsule 250mg 1 STREPTOMYCIN SULFATE INJECTION 1GM 2 TOBRAMYCIN SULFATE/SODIUM CHLORIDE 2 INJECTION 0.9%; 0.8MG/ML tobramycin sulfate injection 10mg/ml 1 tobramycin sulfate injection 80mg/2ml 1 tobramycin sulfate solution 0.3% 1 Antibacterials, Other alcohol preps pad 1 baciim injection 50000unit 1 BACITRACIN INJECTION 50000UNIT 2 CHLORAMPHENICOL SODIUM SUCCINATE 2 INJECTION 1GM CLEOCIN IN D5W INJECTION 300MG/50ML; 5% 2 CLEOCIN IN D5W INJECTION 600MG/50ML; 5% 2 CLEOCIN IN D5W INJECTION 900MG/50ML; 5% 2 CLEOCIN PEDIATRIC GRANULES SOLUTION 2 RECONSTITUTED 75MG/5ML clindamycin hcl capsule 150mg 1 clindamycin hcl capsule 300mg 1 Page 5 of 103

16 clindamycin hcl capsule 75mg 1 clindamycin palmitate hcl solution reconstituted 75mg/5ml 1 clindamycin phosphate add-vantage injection 150mg/ml 1 clindamycin phosphate in d5w injection 300mg/50ml; 5% 1 clindamycin phosphate in d5w injection 600mg/50ml; 5% 1 clindamycin phosphate in d5w injection 900mg/50ml; 5% 1 clindamycin phosphate cream 2% 1 clindamycin phosphate gel 1% 1 clindamycin phosphate lotion 1% 1 clindamycin phosphate solution 1% 1 clindamycin phosphate swab 1% 1 colistimethate sodium injection 150mg 1 B/D CUBICIN INJECTION 500MG 2 LINCOCIN INJECTION 300MG/ML 2 linezolid injection 2mg/ml 1 methenamine hippurate tablet 1gm 1 metronidazole in nacl 0.79% injection 500mg/100ml; 0.79% 1 metronidazole vaginal gel 0.75% 1 metronidazole cream 0.75% 1 metronidazole gel 0.75% 1 metronidazole lotion 0.75% 1 metronidazole tablet 250mg 1 metronidazole tablet 500mg 1 mupirocin ointment 2% 1 neomycin/polymyxin/bacitracin/hydrocortisone ointment 1 400unit/gm; 1%; 0.5%; 10000unit/gm neomycin/polymyxin/hydrocortisone suspension 1%; 1 3.5mg/ml; 10000unit/ml nitrofurantoin macrocrystals capsule 100mg 1 PA (Antibacterials) nitrofurantoin macrocrystals capsule 50mg 1 PA (Antibacterials) nitrofurantoin monohydrate capsule 100mg 1 PA (Antibacterials) polymyxin b sulfate injection unit 1 PRIMSOL SOLUTION 50MG/5ML 2 silver sulfadiazine cream 1% 1 ssd cream 1% 1 SYNERCID INJECTION 350MG; 150MG 2 trimethoprim tablet 100mg 1 TYGACIL INJECTION 50MG 2 vancomycin hcl capsule 125mg 1 vancomycin hcl capsule 250mg 1 vancomycin hcl injection 1000mg 1 vancomycin hcl injection 10gm 1 vancomycin hcl injection 500mg 1 vandazole gel 0.75% 1 XIFAXAN TABLET 200MG 2 ZYVOX INJECTION 2MG/ML 2 ZYVOX SUSPENSION RECONSTITUTED 100MG/5ML 2 QL (600 ML per 10 days) ZYVOX TABLET 600MG 2 QL (20 EA per 10 days) Beta-lactam, Cephalosporins Page 6 of 103

17 Name Tier cefaclor er tablet extended release 12 hour 500mg 1 cefaclor capsule 250mg 1 cefaclor capsule 500mg 1 cefadroxil capsule 500mg 1 cefadroxil suspension reconstituted 250mg/5ml 1 cefadroxil suspension reconstituted 500mg/5ml 1 cefadroxil tablet 1gm 1 cefazolin sodium injection 10gm 1 cefazolin sodium injection 1gm 1 CEFAZOLIN SODIUM INJECTION 1GM; 5% 2 cefazolin sodium injection 500mg 1 cefdinir capsule 300mg 1 cefdinir suspension reconstituted 125mg/5ml 1 cefdinir suspension reconstituted 250mg/5ml 1 cefepime injection 1gm 1 cefepime injection 2gm 1 cefotaxime sodium injection 10gm 1 cefotaxime sodium injection 1gm 1 cefotaxime sodium injection 2gm 1 cefotaxime sodium injection 500mg 1 cefoxitin sodium injection 10gm 1 cefoxitin sodium injection 1gm 1 cefoxitin sodium injection 2gm 1 cefpodoxime proxetil tablet 100mg 1 cefpodoxime proxetil tablet 200mg 1 cefprozil suspension reconstituted 125mg/5ml 1 cefprozil suspension reconstituted 250mg/5ml 1 cefprozil tablet 250mg 1 cefprozil tablet 500mg 1 ceftazidime injection 1gm 1 ceftazidime injection 2gm 1 ceftazidime injection 6gm 1 ceftriaxone sodium injection 10gm 1 ceftriaxone sodium injection 1gm 1 ceftriaxone sodium injection 1gm 1 ceftriaxone sodium injection 1gm 1 ceftriaxone sodium injection 1gm 1 ceftriaxone sodium injection 1gm 1 ceftriaxone sodium injection 1gm 1 ceftriaxone sodium injection 1gm 1 ceftriaxone sodium injection 1gm 1 ceftriaxone sodium injection 1gm 1 ceftriaxone sodium injection 1gm 1 ceftriaxone sodium injection 1gm 1 ceftriaxone sodium injection 1gm 1 ceftriaxone sodium injection 1gm 1 ceftriaxone sodium injection 1gm 1 ceftriaxone sodium injection 1gm 1 ceftriaxone sodium injection 1gm 1 Requirements/Limits Page 7 of 103

18 Name Tier ceftriaxone sodium injection 1gm 1 ceftriaxone sodium injection 1gm 1 ceftriaxone sodium injection 1gm 1 ceftriaxone sodium injection 1gm 1 ceftriaxone sodium injection 1gm 1 ceftriaxone sodium injection 1gm 1 ceftriaxone sodium injection 250mg 1 ceftriaxone sodium injection 2gm 1 ceftriaxone sodium injection 2gm 1 ceftriaxone sodium injection 2gm 1 ceftriaxone sodium injection 2gm 1 ceftriaxone sodium injection 2gm 1 ceftriaxone sodium injection 2gm 1 ceftriaxone sodium injection 2gm 1 ceftriaxone sodium injection 2gm 1 ceftriaxone sodium injection 2gm 1 ceftriaxone sodium injection 2gm 1 ceftriaxone sodium injection 2gm 1 ceftriaxone sodium injection 2gm 1 ceftriaxone sodium injection 2gm 1 ceftriaxone sodium injection 2gm 1 ceftriaxone sodium injection 2gm 1 ceftriaxone sodium injection 2gm 1 ceftriaxone sodium injection 2gm 1 ceftriaxone sodium injection 2gm 1 ceftriaxone sodium injection 2gm 1 ceftriaxone sodium injection 2gm 1 ceftriaxone sodium injection 2gm 1 ceftriaxone sodium injection 500mg 1 cefuroxime axetil tablet 250mg 1 cefuroxime axetil tablet 500mg 1 cefuroxime sodium injection 1.5gm 1 cefuroxime sodium injection 7.5gm 1 cefuroxime sodium injection 750mg 1 cephalexin capsule 250mg 1 cephalexin capsule 500mg 1 cephalexin suspension reconstituted 125mg/5ml 1 cephalexin suspension reconstituted 250mg/5ml 1 cephalexin tablet 250mg 1 cephalexin tablet 500mg 1 CLAFORAN INJECTION 10GM 2 CLAFORAN INJECTION 1GM 2 CLAFORAN INJECTION 2GM 2 CLAFORAN INJECTION 500MG 2 FORTAZ INJECTION 1GM 2 FORTAZ INJECTION 2GM 2 SUPRAX CAPSULE 400MG 2 SUPRAX SUSPENSION RECONSTITUTED 100MG/5ML 2 SUPRAX SUSPENSION RECONSTITUTED 200MG/5ML 2 Requirements/Limits Page 8 of 103

19 SUPRAX SUSPENSION RECONSTITUTED 500MG/5ML 2 SUPRAX TABLET CHEWABLE 100MG 2 SUPRAX TABLET CHEWABLE 200MG 2 SUPRAX TABLET 400MG 2 TEFLARO INJECTION 400MG 2 TEFLARO INJECTION 600MG 2 Beta-lactam, Other AZACTAM IN ISO-OSMOTIC DEXTROSE INJECTION 1GM; 0 AZACTAM IN ISO-OSMOTIC DEXTROSE INJECTION 2 2GM; 0 AZACTAM INJECTION 1GM 2 aztreonam injection 1gm 1 imipenem/cilastatin injection 250mg; 250mg 1 imipenem/cilastatin injection 500mg; 500mg 1 INVANZ INJECTION 1GM 2 meropenem injection 500mg 1 Beta-lactam, Penicillins amoxicillin/clavulanate potassium er tablet extended release 12 hour 1000mg; 62.5mg amoxicillin/clavulanate potassium suspension reconstituted 1 200mg/5ml; 28.5mg/5ml amoxicillin/clavulanate potassium suspension reconstituted 1 250mg/5ml; 62.5mg/5ml amoxicillin/clavulanate potassium suspension reconstituted 1 400mg/5ml; 57mg/5ml amoxicillin/clavulanate potassium suspension reconstituted 1 600mg/5ml; 42.9mg/5ml amoxicillin/clavulanate potassium tablet chewable 200mg; mg amoxicillin/clavulanate potassium tablet chewable 400mg; 1 57mg amoxicillin/clavulanate potassium tablet 250mg; 125mg 1 amoxicillin/clavulanate potassium tablet 500mg; 125mg 1 amoxicillin/clavulanate potassium tablet 875mg; 125mg 1 amoxicillin capsule 250mg 1 amoxicillin capsule 500mg 1 amoxicillin suspension reconstituted 125mg/5ml 1 amoxicillin suspension reconstituted 200mg/5ml 1 amoxicillin suspension reconstituted 250mg/5ml 1 amoxicillin suspension reconstituted 400mg/5ml 1 amoxicillin tablet chewable 125mg 1 amoxicillin tablet chewable 250mg 1 amoxicillin tablet 500mg 1 amoxicillin tablet 875mg 1 ampicillin sodium injection 10gm 1 AMPICILLIN SODIUM INJECTION 125MG 2 ampicillin sodium injection 1gm 1 ampicillin-sulbactam injection 10gm; 5gm 1 Tier 2 1 Requirements/Limits Page 9 of 103

20 ampicillin-sulbactam injection 2gm; 1gm 1 ampicillin capsule 250mg 1 ampicillin capsule 500mg 1 ampicillin suspension reconstituted 125mg/5ml 1 ampicillin suspension reconstituted 250mg/5ml 1 BACTOCILL IN DEXTROSE INJECTION 0; 1GM/50ML 2 BACTOCILL IN DEXTROSE INJECTION 0; 2GM/50ML 2 BICILLIN C-R INJECTION UNIT/ML; UNIT/ML BICILLIN C-R INJECTION UNIT/2ML; UNIT/2ML BICILLIN L-A INJECTION UNIT/2ML 2 BICILLIN L-A INJECTION UNIT/4ML 2 BICILLIN L-A INJECTION UNIT/ML 2 dicloxacillin sodium capsule 250mg 1 dicloxacillin sodium capsule 500mg 1 nafcillin sodium injection 10gm 1 nafcillin sodium injection 1gm 1 NALLPEN/DEXTROSE INJECTION 0; 1GM/50ML 2 oxacillin sodium injection 10gm 1 oxacillin sodium injection 2gm 1 PENICILLIN G POTASSIUM IN ISO-OSMOTIC 2 DEXTROSE INJECTION 0; 40000UNIT/ML PENICILLIN G POTASSIUM IN ISO-OSMOTIC 2 DEXTROSE INJECTION 0; 60000UNIT/ML penicillin g potassium injection unit 1 PENICILLIN G PROCAINE INJECTION UNIT/ML 2 PENICILLIN G SODIUM INJECTION UNIT 2 penicillin v potassium solution reconstituted 125mg/5ml 1 penicillin v potassium solution reconstituted 250mg/5ml 1 penicillin v potassium tablet 250mg 1 penicillin v potassium tablet 500mg 1 PFIZERPEN-G INJECTION UNIT 2 piperacillin sodium/tazobactam sodium injection 4gm; 0.5gm 1 TIMENTIN INJECTION 0.1GM; 3GM 2 ZOSYN INJECTION 3GM; 0.375GM 2 ZOSYN INJECTION 5%; 2GM/50ML; 0.25GM/50ML 2 ZOSYN INJECTION 5%; 3GM/50ML; 0.375GM/50ML 2 Macrolides azithromycin injection 500mg 1 azithromycin suspension reconstituted 100mg/5ml 1 QL (15 ML per 5 days) azithromycin suspension reconstituted 200mg/5ml 1 QL (22.5 ML per 5 days) azithromycin tablet 250mg 1 QL (6 EA per 5 days) azithromycin tablet 500mg 1 QL (3 EA per 3 days) azithromycin tablet 600mg 1 QL (8 EA per 28 days) clarithromycin er tablet extended release 24 hour 500mg 1 clarithromycin suspension reconstituted 125mg/5ml 1 clarithromycin suspension reconstituted 250mg/5ml 1 clarithromycin tablet 250mg 1 QL (28 EA per 14 days) Page 10 of 103

21 clarithromycin tablet 500mg 1 QL (42 EA per 21 days) e.e.s. 400 tablet 400mg 1 e.e.s. granules suspension reconstituted 200mg/5ml 1 ERY-TAB TABLET DELAYED RELEASE 250MG 2 ERY-TAB TABLET DELAYED RELEASE 333MG 2 ERY-TAB TABLET DELAYED RELEASE 500MG 2 ERYPED 400 SUSPENSION RECONSTITUTED 2 400MG/5ML ERYTHROCIN LACTOBIONATE INJECTION 500MG 2 erythrocin stearate tablet 250mg 1 erythromycin base tablet 250mg 1 erythromycin base tablet 500mg 1 erythromycin ointment 5mg/gm 1 erythromycin solution 2% 1 KETEK TABLET 300MG 2 KETEK TABLET 400MG 2 QL (20 EA per 10 days) ZMAX SUSPENSION RECONSTITUTED 2GM 2 Quinolones AVELOX INJECTION 400MG/250ML; 0.8% 2 ciprofloxacin hcl solution 0.3% 1 ciprofloxacin hcl tablet 100mg 1 ciprofloxacin hcl tablet 250mg 1 ciprofloxacin hcl tablet 500mg 1 ciprofloxacin hcl tablet 750mg 1 ciprofloxacin i.v.-in d5w injection 200mg/100ml; 5% 1 ciprofloxacin injection 400mg/40ml 1 LEVAQUIN INJECTION 5%; 750MG/150ML 2 levofloxacin in d5w injection 5%; 500mg/100ml 1 levofloxacin injection 25mg/ml 1 levofloxacin solution 25mg/ml 1 levofloxacin tablet 250mg 1 QL (10 EA per 10 days) levofloxacin tablet 500mg 1 QL (14 EA per 14 days) levofloxacin tablet 750mg 1 QL (14 EA per 14 days) ofloxacin solution 0.3% 1 ofloxacin solution 0.3% 1 ofloxacin tablet 200mg 1 ofloxacin tablet 300mg 1 ofloxacin tablet 400mg 1 Sulfonamides sodium sulfacetamide solution 10% 1 sulfacetamide sodium suspension 10% 1 sulfadiazine tablet 500mg 1 sulfamethoxazole/trimethoprim ds tablet 800mg; 160mg 1 SULFAMETHOXAZOLE/TRIMETHOPRIM INJECTION 2 400MG/5ML; 80MG/5ML sulfamethoxazole/trimethoprim suspension 200mg/5ml; 1 40mg/5ml sulfamethoxazole/trimethoprim tablet 400mg; 80mg 1 Tetracyclines Page 11 of 103

22 demeclocycline hcl tablet 150mg 1 demeclocycline hcl tablet 300mg 1 doxycycline hyclate capsule 100mg 1 doxycycline hyclate capsule 50mg 1 doxycycline hyclate tablet 100mg 1 doxycycline hyclate tablet 20mg 1 minocycline hcl capsule 100mg 1 minocycline hcl capsule 50mg 1 minocycline hcl capsule 75mg 1 Anticonvulsants Anticonvulsants, Other APTIOM TABLET 200MG 2 QL (30 EA per 30 days) MO APTIOM TABLET 400MG 2 QL (30 EA per 30 days) MO APTIOM TABLET 600MG 2 QL (60 EA per 30 days) MO APTIOM TABLET 800MG 2 QL (30 EA per 30 days) MO FYCOMPA TABLET 10MG 2 QL (30 EA per 30 days) MO FYCOMPA TABLET 12MG 2 QL (30 EA per 30 days) MO FYCOMPA TABLET 2MG 2 QL (30 EA per 30 days) MO FYCOMPA TABLET 4MG 2 QL (30 EA per 30 days) MO FYCOMPA TABLET 6MG 2 QL (30 EA per 30 days) MO FYCOMPA TABLET 8MG 2 QL (30 EA per 30 days) MO levetiracetam injection 500mg/5ml 1 levetiracetam solution 100mg/ml 1 levetiracetam tablet 1000mg 1 QL (90 EA per 30 days) levetiracetam tablet 250mg 1 QL (180 EA per 30 days) MO levetiracetam tablet 500mg 1 QL (180 EA per 30 days) levetiracetam tablet 750mg 1 QL (120 EA per 30 days) POTIGA TABLET 200MG 2 QL (90 EA per 30 days) POTIGA TABLET 300MG 2 QL (90 EA per 30 days) POTIGA TABLET 400MG 2 QL (90 EA per 30 days) POTIGA TABLET 50MG 2 QL (180 EA per 30 days) MO Calcium Channel Modifying Agents CELONTIN CAPSULE 300MG 2 ethosuximide capsule 250mg 1 ethosuximide solution 250mg/5ml 1 LYRICA CAPSULE 100MG 2 QL (90 EA per 30 days) LYRICA CAPSULE 150MG 2 QL (60 EA per 30 days) LYRICA CAPSULE 200MG 2 QL (60 EA per 30 days) LYRICA CAPSULE 225MG 2 QL (60 EA per 30 days) LYRICA CAPSULE 25MG 2 QL (90 EA per 30 days) LYRICA CAPSULE 300MG 2 QL (60 EA per 30 days) LYRICA CAPSULE 50MG 2 QL (90 EA per 30 days) LYRICA CAPSULE 75MG 2 QL (90 EA per 30 days) LYRICA SOLUTION 20MG/ML 2 zonisamide capsule 100mg 1 zonisamide capsule 25mg 1 zonisamide capsule 50mg 1 Gamma-aminobutyric Acid (GABA) Augmenting Agents clonazepam odt tablet dispersible 0.125mg 1 QL (150 EA per 30 days) Page 12 of 103

23 clonazepam odt tablet dispersible 0.25mg 1 QL (150 EA per 30 days) clonazepam odt tablet dispersible 0.5mg 1 QL (150 EA per 30 days) clonazepam odt tablet dispersible 1mg 1 QL (150 EA per 30 days) clonazepam odt tablet dispersible 2mg 1 QL (300 EA per 30 days) clonazepam tablet 0.5mg 1 QL (150 EA per 30 days) clonazepam tablet 1mg 1 QL (150 EA per 30 days) clonazepam tablet 2mg 1 QL (300 EA per 30 days) diazepam gel 10mg 1 QL (50 EA per 30 days) diazepam gel 2.5mg 1 QL (24.9 EA per 30 days) diazepam gel 20mg 1 QL (100 EA per 30 days) divalproex sodium dr tablet delayed release 125mg 1 divalproex sodium dr tablet delayed release 250mg 1 divalproex sodium dr tablet delayed release 500mg 1 divalproex sodium er tablet extended release 24 hour 250mg 1 divalproex sodium er tablet extended release 24 hour 500mg 1 divalproex sodium capsule sprinkle 125mg 1 gabapentin capsule 100mg 1 gabapentin capsule 300mg 1 gabapentin capsule 400mg 1 gabapentin solution 250mg/5ml 1 gabapentin tablet 600mg 1 gabapentin tablet 800mg 1 GABITRIL TABLET 12MG 2 QL (90 EA per 30 days) GABITRIL TABLET 16MG 2 QL (90 EA per 30 days) ONFI SUSPENSION 2.5MG/ML 2 MO ONFI TABLET 10MG 2 ONFI TABLET 20MG 2 ONFI TABLET 5MG 2 phenobarbital elixir 20mg/5ml 1 phenobarbital tablet 100mg 1 phenobarbital tablet 15mg 1 phenobarbital tablet 16.2mg 1 phenobarbital tablet 30mg 1 phenobarbital tablet 32.4mg 1 phenobarbital tablet 60mg 1 phenobarbital tablet 64.8mg 1 phenobarbital tablet 97.2mg 1 primidone tablet 250mg 1 primidone tablet 50mg 1 SABRIL PACKET 500MG 2 QL (360 EA per 30 days) SABRIL TABLET 500MG 2 QL (360 EA per 30 days) tiagabine hydrochloride tablet 2mg 1 QL (90 EA per 30 days) tiagabine hydrochloride tablet 4mg 1 valproate sodium injection 500mg/5ml 1 valproic acid capsule 250mg 1 valproic acid syrup 250mg/5ml 1 Glutamate Reducing Agents felbamate suspension 600mg/5ml 1 felbamate tablet 400mg 1 Page 13 of 103

24 felbamate tablet 600mg 1 lamotrigine tablet chewable 25mg 1 lamotrigine tablet chewable 5mg 1 lamotrigine tablet 100mg 1 lamotrigine tablet 150mg 1 lamotrigine tablet 200mg 1 lamotrigine tablet 25mg 1 QUDEXY XR CAPSULE ER 24 HOUR SPRINKLE 100MG 2 QL (30 EA per 30 days) MO QUDEXY XR CAPSULE ER 24 HOUR SPRINKLE 150MG 2 QL (60 EA per 30 days) MO QUDEXY XR CAPSULE ER 24 HOUR SPRINKLE 200MG 2 QL (60 EA per 30 days) MO QUDEXY XR CAPSULE ER 24 HOUR SPRINKLE 25MG 2 QL (30 EA per 30 days) MO QUDEXY XR CAPSULE ER 24 HOUR SPRINKLE 50MG 2 QL (30 EA per 30 days) MO topiramate er capsule er 24 hour sprinkle 100mg 1 QL (30 EA per 30 days) MO topiramate er capsule er 24 hour sprinkle 150mg 1 QL (60 EA per 30 days) MO topiramate er capsule er 24 hour sprinkle 200mg 1 QL (60 EA per 30 days) MO topiramate er capsule er 24 hour sprinkle 25mg 1 QL (30 EA per 30 days) MO topiramate er capsule er 24 hour sprinkle 50mg 1 QL (30 EA per 30 days) MO topiramate capsule sprinkle 15mg 1 topiramate capsule sprinkle 25mg 1 topiramate tablet 100mg 1 topiramate tablet 200mg 1 topiramate tablet 25mg 1 topiramate tablet 50mg 1 TROKENDI XR CAPSULE EXTENDED RELEASE 24 2 QL (90 EA per 30 days) MO HOUR 100MG TROKENDI XR CAPSULE EXTENDED RELEASE 24 2 QL (60 EA per 30 days) MO HOUR 200MG TROKENDI XR CAPSULE EXTENDED RELEASE 24 2 QL (30 EA per 30 days) MO HOUR 25MG TROKENDI XR CAPSULE EXTENDED RELEASE 24 2 QL (30 EA per 30 days) MO HOUR 50MG Sodium Channel Agents BANZEL SUSPENSION 40MG/ML 2 BANZEL TABLET 200MG 2 QL (240 EA per 30 days) BANZEL TABLET 400MG 2 QL (240 EA per 30 days) carbamazepine er capsule extended release 12 hour 100mg 1 carbamazepine er capsule extended release 12 hour 200mg 1 carbamazepine er capsule extended release 12 hour 300mg 1 carbamazepine er tablet extended release 12 hour 200mg 1 carbamazepine er tablet extended release 12 hour 400mg 1 carbamazepine suspension 100mg/5ml 1 carbamazepine tablet chewable 100mg 1 carbamazepine tablet 200mg 1 CARBATROL CAPSULE EXTENDED RELEASE 12 2 HOUR 100MG CARBATROL CAPSULE EXTENDED RELEASE 12 2 HOUR 200MG CARBATROL CAPSULE EXTENDED RELEASE 12 HOUR 300MG 2 Page 14 of 103

25 CEREBYX INJECTION 500MG PE/10ML 2 DILANTIN INFATABS TABLET CHEWABLE 50MG 2 DILANTIN-125 SUSPENSION 125MG/5ML 2 DILANTIN CAPSULE 100MG 2 DILANTIN CAPSULE 30MG 2 epitol tablet 200mg 1 fosphenytoin sodium injection 100mg pe/2ml 1 oxcarbazepine suspension 300mg/5ml 1 oxcarbazepine tablet 150mg 1 oxcarbazepine tablet 300mg 1 oxcarbazepine tablet 600mg 1 OXTELLAR XR TABLET EXTENDED RELEASE 24 2 QL (60 EA per 30 days) MO HOUR 150MG OXTELLAR XR TABLET EXTENDED RELEASE 24 2 QL (90 EA per 30 days) MO HOUR 300MG OXTELLAR XR TABLET EXTENDED RELEASE 24 2 QL (120 EA per 30 days) MO HOUR 600MG PEGANONE TABLET 250MG 2 PHENYTEK CAPSULE 200MG 2 PHENYTEK CAPSULE 300MG 2 phenytoin infatabs tablet chewable 50mg 1 phenytoin sodium extended capsule 100mg 1 phenytoin sodium extended capsule 200mg 1 phenytoin sodium extended capsule 300mg 1 phenytoin sodium injection 50mg/ml 1 phenytoin suspension 125mg/5ml 1 phenytoin tablet chewable 50mg 1 TEGRETOL-XR TABLET EXTENDED RELEASE 12 2 HOUR 100MG TEGRETOL-XR TABLET EXTENDED RELEASE 12 2 HOUR 200MG TEGRETOL-XR TABLET EXTENDED RELEASE 12 2 HOUR 400MG TEGRETOL SUSPENSION 100MG/5ML 2 TEGRETOL TABLET 200MG 2 VIMPAT INJECTION 200MG/20ML 2 VIMPAT SOLUTION 10MG/ML 2 VIMPAT TABLET 100MG 2 VIMPAT TABLET 150MG 2 QL (60 EA per 30 days) VIMPAT TABLET 200MG 2 QL (60 EA per 30 days) VIMPAT TABLET 50MG 2 Antidementia Agents Antidementia Agents, Other ergoloid mesylates tablet 1mg 1 Cholinesterase Inhibitors donepezil hcl tablet dispersible 10mg 1 QL (30 EA per 30 days) donepezil hcl tablet dispersible 5mg 1 QL (30 EA per 30 days) donepezil hcl tablet 10mg 1 QL (30 EA per 30 days) donepezil hcl tablet 5mg 1 QL (30 EA per 30 days) Page 15 of 103

26 galantamine hydrobromide capsule extended release 24 hour 1 QL (30 EA per 30 days) 16mg galantamine hydrobromide capsule extended release 24 hour 1 QL (30 EA per 30 days) 24mg galantamine hydrobromide capsule extended release 24 hour 1 QL (30 EA per 30 days) 8mg galantamine hydrobromide solution 4mg/ml 1 galantamine hydrobromide tablet 12mg 1 QL (60 EA per 30 days) galantamine hydrobromide tablet 4mg 1 QL (180 EA per 30 days) galantamine hydrobromide tablet 8mg 1 QL (90 EA per 30 days) rivastigmine tartrate capsule 1.5mg 1 QL (60 EA per 30 days) rivastigmine tartrate capsule 3mg 1 QL (60 EA per 30 days) rivastigmine tartrate capsule 4.5mg 1 QL (60 EA per 30 days) rivastigmine tartrate capsule 6mg 1 QL (60 EA per 30 days) N-methyl-D-aspartate (NMDA) Receptor Antagonist NAMENDA TITRATION PAK TABLET 0 2 NAMENDA SOLUTION 10MG/5ML 2 QL (360 ML per 30 days) NAMENDA TABLET 10MG 2 QL (60 EA per 30 days) NAMENDA TABLET 5MG 2 QL (60 EA per 30 days) Antidepressants Antidepressants, Other BRINTELLIX TABLET 10MG 2 MO BRINTELLIX TABLET 20MG 2 MO BRINTELLIX TABLET 5MG 2 MO budeprion sr tablet extended release 12 hour 100mg 1 budeprion sr tablet extended release 12 hour 150mg 1 bupropion hcl sr tablet extended release 12 hour 100mg 1 bupropion hcl sr tablet extended release 12 hour 150mg 1 bupropion hcl sr tablet extended release 12 hour 200mg 1 bupropion hcl xl tablet extended release 24 hour 150mg 1 QL (30 EA per 30 days) bupropion hcl xl tablet extended release 24 hour 300mg 1 QL (30 EA per 30 days) bupropion hcl tablet 100mg 1 bupropion hcl tablet 75mg 1 maprotiline hcl tablet 25mg 1 maprotiline hcl tablet 50mg 1 maprotiline hcl tablet 75mg 1 mirtazapine odt tablet dispersible 30mg 1 mirtazapine odt tablet dispersible 45mg 1 mirtazapine tablet dispersible 15mg 1 mirtazapine tablet 15mg 1 mirtazapine tablet 30mg 1 mirtazapine tablet 45mg 1 mirtazapine tablet 7.5mg 1 nefazodone hcl tablet 100mg 1 nefazodone hcl tablet 150mg 1 nefazodone hcl tablet 200mg 1 nefazodone hcl tablet 250mg 1 nefazodone hcl tablet 50mg 1 trazodone hcl tablet 100mg 1 Page 16 of 103

27 trazodone hcl tablet 150mg 1 trazodone hcl tablet 300mg 1 trazodone hcl tablet 50mg 1 Monoamine Oxidase Inhibitors EMSAM PATCH 24 HOUR 12MG/24HR 2 EMSAM PATCH 24 HOUR 6MG/24HR 2 EMSAM PATCH 24 HOUR 9MG/24HR 2 MARPLAN TABLET 10MG 2 phenelzine sulfate tablet 15mg 1 tranylcypromine sulfate tablet 10mg 1 SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitor citalopram hydrobromide solution 10mg/5ml 1 citalopram hydrobromide tablet 10mg 1 citalopram hydrobromide tablet 20mg 1 citalopram hydrobromide tablet 40mg 1 desvenlafaxine er tablet extended release 24 hour 100mg 1 QL (30 EA per 30 days) desvenlafaxine er tablet extended release 24 hour 50mg 1 QL (30 EA per 30 days) duloxetine hcl capsule delayed release particles 20mg 1 QL (60 EA per 30 days) MO duloxetine hcl capsule delayed release particles 30mg 1 QL (60 EA per 30 days) MO duloxetine hcl capsule delayed release particles 60mg 1 QL (60 EA per 30 days) MO escitalopram oxalate solution 5mg/5ml 1 escitalopram oxalate tablet 10mg 1 QL (30 EA per 30 days) escitalopram oxalate tablet 20mg 1 QL (30 EA per 30 days) escitalopram oxalate tablet 5mg 1 QL (30 EA per 30 days) FETZIMA TITRATION PACK CAPSULE ER 24 HOUR 2 THERAPY PACK 0 FETZIMA CAPSULE EXTENDED RELEASE 24 HOUR 2 MO 120MG FETZIMA CAPSULE EXTENDED RELEASE 24 HOUR 2 MO 20MG FETZIMA CAPSULE EXTENDED RELEASE 24 HOUR 2 MO 40MG FETZIMA CAPSULE EXTENDED RELEASE 24 HOUR 2 MO 80MG fluoxetine hcl capsule 10mg 1 fluoxetine hcl capsule 20mg 1 fluoxetine hcl capsule 40mg 1 fluoxetine hcl solution 20mg/5ml 1 fluoxetine hcl tablet 10mg 1 fluvoxamine maleate tablet 100mg 1 fluvoxamine maleate tablet 25mg 1 fluvoxamine maleate tablet 50mg 1 KHEDEZLA TABLET EXTENDED RELEASE 24 HOUR 2 QL (120 EA per 30 days) MO 100MG KHEDEZLA TABLET EXTENDED RELEASE 24 HOUR 2 QL (30 EA per 30 days) MO 50MG paroxetine hcl er tablet extended release 24 hour 37.5mg 1 paroxetine hcl tablet 10mg 1 Page 17 of 103

28 paroxetine hcl tablet 20mg 1 paroxetine hcl tablet 30mg 1 paroxetine hcl tablet 40mg 1 PAXIL SUSPENSION 10MG/5ML 2 sertraline hcl concentrate 20mg/ml 1 sertraline hcl tablet 100mg 1 sertraline hcl tablet 25mg 1 sertraline hcl tablet 50mg 1 venlafaxine hcl er capsule extended release 24 hour 150mg 1 QL (30 EA per 30 days) venlafaxine hcl er capsule extended release 24 hour 37.5mg 1 QL (30 EA per 30 days) venlafaxine hcl er capsule extended release 24 hour 75mg 1 QL (30 EA per 30 days) venlafaxine hcl er tablet extended release 24 hour 150mg 1 QL (30 EA per 30 days) venlafaxine hcl er tablet extended release 24 hour 225mg 1 QL (30 EA per 30 days) venlafaxine hcl er tablet extended release 24 hour 37.5mg 1 QL (30 EA per 30 days) venlafaxine hcl er tablet extended release 24 hour 75mg 1 QL (30 EA per 30 days) venlafaxine hcl tablet 100mg 1 QL (90 EA per 30 days) venlafaxine hcl tablet 25mg 1 QL (90 EA per 30 days) venlafaxine hcl tablet 37.5mg 1 QL (90 EA per 30 days) venlafaxine hcl tablet 50mg 1 QL (90 EA per 30 days) venlafaxine hcl tablet 75mg 1 QL (90 EA per 30 days) VIIBRYD KIT 0 2 VIIBRYD TABLET 10MG 2 VIIBRYD TABLET 20MG 2 VIIBRYD TABLET 40MG 2 Tricyclics amitriptyline hcl tablet 100mg 1 amitriptyline hcl tablet 10mg 1 amitriptyline hcl tablet 150mg 1 amitriptyline hcl tablet 25mg 1 amitriptyline hcl tablet 50mg 1 amitriptyline hcl tablet 75mg 1 amoxapine tablet 100mg 1 amoxapine tablet 150mg 1 amoxapine tablet 25mg 1 amoxapine tablet 50mg 1 chlordiazepoxide/amitriptyline tablet 12.5mg; 5mg 1 chlordiazepoxide/amitriptyline tablet 25mg; 10mg 1 clomipramine hcl capsule 25mg 1 clomipramine hcl capsule 50mg 1 clomipramine hcl capsule 75mg 1 desipramine hcl tablet 100mg 1 desipramine hcl tablet 10mg 1 desipramine hcl tablet 150mg 1 desipramine hcl tablet 25mg 1 desipramine hcl tablet 50mg 1 desipramine hcl tablet 75mg 1 doxepin hcl capsule 100mg 1 doxepin hcl capsule 10mg 1 doxepin hcl capsule 25mg 1 Page 18 of 103

29 doxepin hcl capsule 50mg 1 doxepin hcl capsule 75mg 1 doxepin hcl concentrate 10mg/ml 1 imipramine hcl tablet 10mg 1 imipramine hcl tablet 25mg 1 imipramine hcl tablet 50mg 1 imipramine pamoate capsule 100mg 1 imipramine pamoate capsule 125mg 1 imipramine pamoate capsule 150mg 1 imipramine pamoate capsule 75mg 1 nortriptyline hcl capsule 10mg 1 nortriptyline hcl capsule 25mg 1 nortriptyline hcl capsule 50mg 1 nortriptyline hcl capsule 75mg 1 nortriptyline hcl solution 10mg/5ml 1 MO perphenazine/amitriptyline tablet 10mg; 2mg 1 perphenazine/amitriptyline tablet 10mg; 4mg 1 perphenazine/amitriptyline tablet 25mg; 2mg 1 perphenazine/amitriptyline tablet 25mg; 4mg 1 perphenazine/amitriptyline tablet 50mg; 4mg 1 protriptyline hcl tablet 10mg 1 protriptyline hcl tablet 5mg 1 SURMONTIL CAPSULE 100MG 2 MO SURMONTIL CAPSULE 25MG 2 MO SURMONTIL CAPSULE 50MG 2 MO trimipramine maleate capsule 100mg 1 trimipramine maleate capsule 25mg 1 trimipramine maleate capsule 50mg 1 Antiemetics Antiemetics, Other meclizine hcl tablet 12.5mg 1 meclizine hcl tablet 25mg 1 phenadoz suppository 12.5mg 1 PA (High Risk Medications) phenadoz suppository 25mg 1 PA (High Risk Medications) promethazine hcl injection 25mg/ml 1 PA (High Risk Medications) promethazine hcl injection 50mg/ml 1 PA (High Risk Medications) promethazine hcl suppository 12.5mg 1 PA (High Risk Medications) promethazine hcl suppository 25mg 1 PA (High Risk Medications) promethazine hcl suppository 50mg 1 PA (High Risk Medications) promethazine hcl syrup 6.25mg/5ml 1 PA (High Risk Medications) promethazine hcl tablet 12.5mg 1 PA (High Risk Medications) promethazine hcl tablet 25mg 1 PA (High Risk Medications) promethazine hcl tablet 50mg 1 PA (High Risk Medications) promethegan suppository 25mg 1 PA (High Risk Medications) TRANSDERM-SCOP PATCH 72 HOUR 1MG/3DAYS 2 QL (10 EA per 30 days) trimethobenzamide hcl capsule 300mg 1 PA (High Risk Medications) Emetogenic Therapy Adjuncts dronabinol capsule 10mg 1 B/D dronabinol capsule 2.5mg 1 B/D Page 19 of 103

30 dronabinol capsule 5mg 1 B/D EMEND CAPSULE 0 2 QL (3 EA per 14 days) B/D EMEND CAPSULE 40MG 2 QL (1 EA per 14 days) B/D granisetron hcl injection 0.1mg/ml 1 granisetron hcl injection 1mg/ml 1 ondansetron hcl injection 4mg/2ml 1 ondansetron hcl solution 4mg/5ml 1 ondansetron hcl tablet 24mg 1 ondansetron hcl tablet 4mg 1 QL (90 EA per 30 days) ondansetron hcl tablet 8mg 1 QL (90 EA per 30 days) ondansetron odt tablet dispersible 4mg 1 QL (90 EA per 30 days) ondansetron odt tablet dispersible 8mg 1 QL (90 EA per 30 days) Antifungals Antifungals ABELCET INJECTION 5MG/ML 2 AMBISOME INJECTION 50MG 2 AMPHOTERICIN B INJECTION 50MG 2 CANCIDAS INJECTION 50MG 2 CANCIDAS INJECTION 70MG 2 ciclopirox olamine cream 0.77% 1 ciclopirox suspension 0.77% 1 clotrimazole cream 1% 1 clotrimazole solution 1% 1 clotrimazole troche 10mg 1 econazole nitrate cream 1% 1 fluconazole in dextrose injection 56mg/ml; 400mg/200ml 1 fluconazole suspension reconstituted 10mg/ml 1 fluconazole suspension reconstituted 40mg/ml 1 fluconazole tablet 100mg 1 fluconazole tablet 150mg 1 QL (1 EA per 10 days) fluconazole tablet 200mg 1 fluconazole tablet 50mg 1 flucytosine capsule 250mg 1 flucytosine capsule 500mg 1 griseofulvin microsize tablet 500mg 1 griseofulvin ultramicrosize tablet 125mg 1 griseofulvin ultramicrosize tablet 250mg 1 itraconazole capsule 100mg 1 ketoconazole cream 2% 1 ketoconazole shampoo 2% 1 ketoconazole tablet 200mg 1 miconazole 3 suppository 200mg 1 QL (12 EA per 30 days) MYCAMINE INJECTION 100MG 2 MYCAMINE INJECTION 50MG 2 NAFTIN CREAM 1% 2 NAFTIN GEL 1% 2 NATACYN SUSPENSION 5% 2 NOXAFIL SUSPENSION 40MG/ML 2 NOXAFIL TABLET DELAYED RELEASE 100MG 2 Page 20 of 103

31 nyamyc powder unit/gm 1 nystatin/triamcinolone cream unit/gm; 0.1% 1 nystatin/triamcinolone ointment unit/gm; 0.1% 1 nystatin cream unit/gm 1 nystatin ointment unit/gm 1 nystatin powder unit/gm 1 nystatin suspension unit/ml 1 nystatin tablet unit 1 nystop powder unit/gm 1 pedi-dri powder unit/gm 1 SPORANOX SOLUTION 10MG/ML 2 terbinafine hcl tablet 250mg 1 terconazole cream 0.4% 1 QL (90 GM per 30 days) terconazole cream 0.8% 1 terconazole suppository 80mg 1 QL (3 EA per 30 days) voriconazole injection 200mg 1 voriconazole tablet 200mg 1 voriconazole tablet 50mg 1 Antigout Agents Antigout Agents allopurinol tablet 100mg 1 allopurinol tablet 300mg 1 ALOPRIM INJECTION 500MG 2 colchicine capsule 0.6mg 1 MO COLCRYS TABLET 0.6MG 2 mitigare capsule 0.6mg 1 MO probenecid/colchicine tablet 0.5mg; 500mg 1 MO probenecid tablet 500mg 1 Antimigraine Agents Antimigraine Agents BOTOX INJECTION 100UNIT 2 PA (Miscellaneous Therapeutic Agents - Botox) Ergot Alkaloids dihydroergotamine mesylate injection 1mg/ml 1 ERGOMAR TABLET SUBLINGUAL 2MG 2 migergot suppository 100mg; 2mg 1 Serotonin (5-HT) 1b/1d Receptor Agonists IMITREX STATDOSE REFILL INJECTION 4MG/0.5ML 2 IMITREX SOLUTION 20MG/ACT 2 IMITREX SOLUTION 5MG/ACT 2 naratriptan hcl tablet 1mg 1 naratriptan hcl tablet 2.5mg 1 rizatriptan benzoate odt tablet dispersible 10mg 1 rizatriptan benzoate odt tablet dispersible 5mg 1 rizatriptan benzoate tablet 10mg 1 rizatriptan benzoate tablet 5mg 1 sumatriptan succinate injection 6mg/0.5ml 1 sumatriptan succinate injection 6mg/0.5ml 1 sumatriptan succinate tablet 100mg 1 Page 21 of 103

32 sumatriptan succinate tablet 25mg 1 sumatriptan succinate tablet 50mg 1 Antimyasthenic Agents Parasympathomimetics GUANIDINE HCL TABLET 125MG 2 MESTINON TIMESPAN TABLET EXTENDED RELEASE 2 180MG MESTINON SYRUP 60MG/5ML 2 pyridostigmine bromide tablet 60mg 1 Antimycobacterials Antimycobacterials, Other DAPSONE TABLET 100MG 2 DAPSONE TABLET 25MG 2 MYCOBUTIN CAPSULE 150MG 2 rifabutin capsule 150mg 1 Antituberculars CAPASTAT SULFATE INJECTION 1GM 2 ethambutol hcl tablet 100mg 1 ethambutol hcl tablet 400mg 1 ISONIAZID INJECTION 100MG/ML 2 isoniazid syrup 50mg/5ml 1 isoniazid tablet 100mg 1 isoniazid tablet 300mg 1 PASER PACKET 4GM 2 PRIFTIN TABLET 150MG 2 pyrazinamide tablet 500mg 1 rifampin capsule 150mg 1 rifampin capsule 300mg 1 rifampin injection 600mg 1 RIFATER TABLET 50MG; 300MG; 120MG 2 SEROMYCIN CAPSULE 250MG 2 TRECATOR TABLET 250MG 2 Antineoplastics Alkylating Agents ALKERAN INJECTION 50MG 2 B/D BICNU INJECTION 100MG 2 BUSULFEX INJECTION 6MG/ML 2 cyclophosphamide capsule 25mg 1 B/D cyclophosphamide capsule 50mg 1 B/D cyclophosphamide tablet 25mg 1 B/D cyclophosphamide tablet 50mg 1 B/D dacarbazine injection 200mg 1 HEXALEN CAPSULE 50MG 2 IFEX INJECTION 1GM 2 ifosfamide injection 1gm 1 LEUKERAN TABLET 2MG 2 lomustine capsule 100mg 1 lomustine capsule 10mg 1 lomustine capsule 40mg 1 Page 22 of 103

33 MATULANE CAPSULE 50MG 2 melphalan hydrochloride injection 50mg 1 MUSTARGEN INJECTION 10MG 2 thiotepa injection 15mg 1 TREANDA INJECTION 100MG 2 TREANDA INJECTION 45MG/0.5ML 2 VALCHLOR GEL 0.016% 2 ZANOSAR INJECTION 1GM 2 Antiandrogens bicalutamide tablet 50mg 1 QL (30 EA per 30 days) flutamide capsule 125mg 1 NILANDRON TABLET 150MG 2 QL (60 EA per 30 days) XTANDI CAPSULE 40MG 2 QL (120 EA per 30 days) ZYTIGA TABLET 250MG 2 Antiangiogenic Agents POMALYST CAPSULE 1MG 2 POMALYST CAPSULE 2MG 2 POMALYST CAPSULE 3MG 2 POMALYST CAPSULE 4MG 2 REVLIMID CAPSULE 10MG 2 LA REVLIMID CAPSULE 15MG 2 LA REVLIMID CAPSULE 2.5MG 2 REVLIMID CAPSULE 20MG 2 REVLIMID CAPSULE 25MG 2 LA REVLIMID CAPSULE 5MG 2 LA THALOMID CAPSULE 100MG 2 THALOMID CAPSULE 150MG 2 THALOMID CAPSULE 200MG 2 THALOMID CAPSULE 50MG 2 Antiestrogens/Modifiers EMCYT CAPSULE 140MG 2 FARESTON TABLET 60MG 2 FASLODEX INJECTION 250MG/5ML 2 SOLTAMOX SOLUTION 10MG/5ML 2 tamoxifen citrate tablet 10mg 1 tamoxifen citrate tablet 20mg 1 Antimetabolites ALIMTA INJECTION 500MG 2 ARRANON INJECTION 5MG/ML 2 cladribine injection 1mg/ml 1 CLOLAR INJECTION 1MG/ML 2 cytarabine aqueous injection 100mg/ml 1 cytarabine aqueous injection 20mg/ml 1 cytarabine injection 500mg 1 DROXIA CAPSULE 200MG 2 DROXIA CAPSULE 300MG 2 DROXIA CAPSULE 400MG 2 ELITEK INJECTION 1.5MG 2 fluorouracil injection 2.5gm/50ml 1 Page 23 of 103

34 Name Tier FOLOTYN INJECTION 40MG/2ML 2 gemcitabine hcl injection 1gm 1 hydroxyurea capsule 500mg 1 mercaptopurine tablet 50mg 1 pentostatin injection 10mg 1 PURIXAN SUSPENSION 2000MG/100ML 2 TABLOID TABLET 40MG 2 Antineoplastics, Other ABRAXANE INJECTION 900MG; 100MG 2 adriamycin injection 2mg/ml 1 amifostine injection 500mg 1 azacitidine injection 100mg 1 BELEODAQ INJECTION 500MG 2 bleomycin sulfate injection 30unit 1 CAMPTOSAR INJECTION 100MG/5ML 2 carboplatin injection 150mg/15ml 1 cisplatin injection 100mg/100ml 1 COSMEGEN INJECTION 0.5MG 2 DACOGEN INJECTION 50MG 2 dactinomycin injection 0.5mg 1 DAUNORUBICIN HCL INJECTION 5MG/ML 2 decitabine injection 50mg 1 dexrazoxane injection 250mg 1 DOCEFREZ INJECTION 20MG 2 DOCEFREZ INJECTION 80MG 2 DOCETAXEL INJECTION 80MG/4ML 2 DOCETAXEL INJECTION 80MG/8ML 2 DOXIL INJECTION 2MG/ML 2 doxorubicin hcl injection 2mg/ml 1 ELLENCE INJECTION 200MG/100ML 2 epirubicin hcl injection 50mg/25ml 1 fludarabine phosphate injection 50mg 1 FUSILEV INJECTION 50MG 2 GILOTRIF TABLET 20MG 2 GILOTRIF TABLET 30MG 2 GILOTRIF TABLET 40MG 2 HALAVEN INJECTION 1MG/2ML 2 IDAMYCIN PFS INJECTION 20MG/20ML 2 idarubicin hcl injection 10mg/10ml 1 irinotecan injection 100mg/5ml 1 ISTODAX INJECTION 10MG 2 IXEMPRA KIT INJECTION 45MG 2 JEVTANA INJECTION 60MG/1.5ML 2 leucovorin calcium injection 100mg 1 leucovorin calcium injection 350mg 1 leucovorin calcium tablet 10mg 1 leucovorin calcium tablet 15mg 1 leucovorin calcium tablet 25mg 1 leucovorin calcium tablet 5mg 1 Requirements/Limits Page 24 of 103

35 lipodox 50 injection 2mg/ml 1 lipodox injection 2mg/ml 1 LYNPARZA CAPSULE 50MG 2 QL (480 EA per 30 days) mesna injection 100mg/ml 1 MESNEX INJECTION 100MG/ML 2 MESNEX TABLET 400MG 2 mitomycin injection 20mg 1 mitoxantrone hcl injection 2mg/ml 1 ONCASPAR INJECTION 750UNIT/ML 2 oxaliplatin injection 100mg/20ml 1 paclitaxel injection 300mg/50ml 1 PROLEUKIN INJECTION UNIT 2 SYLATRON INJECTION 200MCG 2 SYLATRON INJECTION 300MCG 2 SYLATRON INJECTION 600MCG 2 SYNRIBO INJECTION 3.5MG 2 TRISENOX INJECTION 10MG/10ML 2 VELCADE INJECTION 3.5MG 2 VINBLASTINE SULFATE INJECTION 1MG/ML 2 vincristine sulfate injection 1mg/ml 1 vinorelbine tartrate injection 50mg/5ml 1 ZINECARD INJECTION 250MG 2 ZOLINZA CAPSULE 100MG 2 Antineoplastics ZALTRAP INJECTION 100MG/4ML 2 ZYKADIA CAPSULE 150MG 2 QL (150 EA per 30 days) Aromatase Inhibitors, 3rd Generation anastrozole tablet 1mg 1 QL (30 EA per 30 days) exemestane tablet 25mg 1 letrozole tablet 2.5mg 1 Enzyme Inhibitors ETOPOPHOS INJECTION 100MG 2 etoposide injection 500mg/25ml 1 toposar injection 1gm/50ml 1 topotecan hcl injection 4mg 1 ZYDELIG TABLET 100MG 2 QL (60 EA per 30 days) ZYDELIG TABLET 150MG 2 QL (60 EA per 30 days) Molecular Target Inhibitors AFINITOR DISPERZ TABLET SOLUBLE 2MG 2 AFINITOR DISPERZ TABLET SOLUBLE 3MG 2 AFINITOR DISPERZ TABLET SOLUBLE 5MG 2 AFINITOR TABLET 10MG 2 AFINITOR TABLET 2.5MG 2 AFINITOR TABLET 5MG 2 AFINITOR TABLET 7.5MG 2 BOSULIF TABLET 100MG 2 BOSULIF TABLET 500MG 2 CAPRELSA TABLET 100MG 2 CAPRELSA TABLET 300MG 2 Page 25 of 103

36 COMETRIQ KIT 0 2 COMETRIQ KIT 0 2 COMETRIQ KIT 20MG 2 ERIVEDGE CAPSULE 150MG 2 GLEEVEC TABLET 100MG 2 GLEEVEC TABLET 400MG 2 ICLUSIG TABLET 15MG 2 QL (90 EA per 30 days) IMBRUVICA CAPSULE 140MG 2 QL (120 EA per 30 days) INLYTA TABLET 1MG 2 INLYTA TABLET 5MG 2 JAKAFI TABLET 10MG 2 JAKAFI TABLET 15MG 2 JAKAFI TABLET 20MG 2 JAKAFI TABLET 25MG 2 JAKAFI TABLET 5MG 2 MEKINIST TABLET 0.5MG 2 MEKINIST TABLET 2MG 2 NEXAVAR TABLET 200MG 2 SPRYCEL TABLET 100MG 2 SPRYCEL TABLET 140MG 2 SPRYCEL TABLET 20MG 2 SPRYCEL TABLET 50MG 2 SPRYCEL TABLET 70MG 2 SPRYCEL TABLET 80MG 2 STIVARGA TABLET 40MG 2 SUTENT CAPSULE 12.5MG 2 SUTENT CAPSULE 25MG 2 SUTENT CAPSULE 37.5MG 2 SUTENT CAPSULE 50MG 2 TAFINLAR CAPSULE 50MG 2 TAFINLAR CAPSULE 75MG 2 TARCEVA TABLET 100MG 2 TARCEVA TABLET 150MG 2 TARCEVA TABLET 25MG 2 TASIGNA CAPSULE 150MG 2 TASIGNA CAPSULE 200MG 2 TYKERB TABLET 250MG 2 VOTRIENT TABLET 200MG 2 QL (120 EA per 30 days) XALKORI CAPSULE 200MG 2 XALKORI CAPSULE 250MG 2 ZELBORAF TABLET 240MG 2 Monoclonal Antibodies ARZERRA INJECTION 100MG/5ML 2 AVASTIN INJECTION 100MG/4ML 2 ERBITUX INJECTION 100MG/50ML 2 HERCEPTIN INJECTION 440MG 2 KADCYLA INJECTION 100MG 2 KEYTRUDA INJECTION 50MG 2 OPDIVO INJECTION 40MG/4ML 2 Page 26 of 103

37 PERJETA INJECTION 420MG/14ML 2 RITUXAN INJECTION 10MG/ML 2 SYLVANT INJECTION 100MG 2 VECTIBIX INJECTION 100MG/5ML 2 YERVOY INJECTION 50MG/10ML 2 Retinoids PANRETIN GEL 0.1% 2 TARGRETIN CAPSULE 75MG 2 TARGRETIN GEL 1% 2 tretinoin capsule 10mg 1 Antiparasitics Anthelmintics ALBENZA TABLET 200MG 2 ivermectin tablet 3mg 1 STROMECTOL TABLET 3MG 2 Antiprotozoals ALINIA SUSPENSION RECONSTITUTED 100MG/5ML 2 ALINIA TABLET 500MG 2 atovaquone/proguanil hcl tablet 250mg; 100mg 1 atovaquone suspension 750mg/5ml 1 chloroquine phosphate tablet 250mg 1 chloroquine phosphate tablet 500mg 1 COARTEM TABLET 20MG; 120MG 2 DARAPRIM TABLET 25MG 2 hydroxychloroquine sulfate tablet 200mg 1 mefloquine hcl tablet 250mg 1 MEPRON SUSPENSION 750MG/5ML 2 NEBUPENT SOLUTION RECONSTITUTED 300MG 2 B/D PENTAM 300 INJECTION 300MG 2 PRIMAQUINE PHOSPHATE TABLET 26.3MG 2 quinine sulfate capsule 324mg 1 QL (80 EA per 365 days) tinidazole tablet 250mg 1 tinidazole tablet 500mg 1 Pediculicides/Scabicides lindane lotion 1% 1 malathion lotion 0.5% 1 permethrin cream 5% 1 Antiparkinson Agents Anticholinergics benztropine mesylate injection 1mg/ml 1 benztropine mesylate tablet 0.5mg 1 PA (High Risk Medications) benztropine mesylate tablet 1mg 1 PA (High Risk Medications) benztropine mesylate tablet 2mg 1 PA (High Risk Medications) trihexyphenidyl hcl elixir 0.4mg/ml 1 PA (High Risk Medications) trihexyphenidyl hcl tablet 2mg 1 PA (High Risk Medications) trihexyphenidyl hcl tablet 5mg 1 PA (High Risk Medications) Antiparkinson Agents, Other entacapone tablet 200mg 1 QL (240 EA per 30 days) TASMAR TABLET 100MG 2 Page 27 of 103

38 Dopamine Agonists APOKYN INJECTION 10MG/ML 2 bromocriptine mesylate capsule 5mg 1 bromocriptine mesylate tablet 2.5mg 1 NEUPRO PATCH 24 HOUR 1MG/24HR 2 QL (30 EA per 30 days) NEUPRO PATCH 24 HOUR 2MG/24HR 2 QL (30 EA per 30 days) NEUPRO PATCH 24 HOUR 3MG/24HR 2 QL (30 EA per 30 days) NEUPRO PATCH 24 HOUR 4MG/24HR 2 QL (30 EA per 30 days) NEUPRO PATCH 24 HOUR 6MG/24HR 2 QL (30 EA per 30 days) NEUPRO PATCH 24 HOUR 8MG/24HR 2 QL (30 EA per 30 days) pramipexole dihydrochloride tablet 0.125mg 1 pramipexole dihydrochloride tablet 0.25mg 1 pramipexole dihydrochloride tablet 0.5mg 1 pramipexole dihydrochloride tablet 0.75mg 1 pramipexole dihydrochloride tablet 1.5mg 1 pramipexole dihydrochloride tablet 1mg 1 ropinirole hcl tablet 0.25mg 1 ropinirole hcl tablet 0.5mg 1 ropinirole hcl tablet 1mg 1 ropinirole hcl tablet 2mg 1 ropinirole hcl tablet 3mg 1 ropinirole hcl tablet 4mg 1 ropinirole hcl tablet 5mg 1 Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors carbidopa/levodopa er tablet extended release 25mg; 100mg 1 carbidopa/levodopa er tablet extended release 50mg; 200mg 1 carbidopa/levodopa odt tablet dispersible 10mg; 100mg 1 carbidopa/levodopa odt tablet dispersible 25mg; 100mg 1 carbidopa/levodopa odt tablet dispersible 25mg; 250mg 1 carbidopa/levodopa tablet 10mg; 100mg 1 carbidopa/levodopa tablet 25mg; 100mg 1 carbidopa/levodopa tablet 25mg; 250mg 1 STALEVO 100 TABLET 25MG; 200MG; 100MG 2 STALEVO 125 TABLET 31.25MG; 200MG; 125MG 2 STALEVO 150 TABLET 37.5MG; 200MG; 150MG 2 STALEVO 200 TABLET 50MG; 200MG; 200MG 2 STALEVO 50 TABLET 12.5MG; 200MG; 50MG 2 STALEVO 75 TABLET 18.75MG; 200MG; 75MG 2 Monoamine Oxidase B (MAO-B) Inhibitors AZILECT TABLET 0.5MG 2 QL (30 EA per 30 days) AZILECT TABLET 1MG 2 QL (30 EA per 30 days) ELDEPRYL CAPSULE 5MG 2 selegiline hcl capsule 5mg 1 selegiline hcl tablet 5mg 1 ZELAPAR TABLET DISPERSIBLE 1.25MG 2 Antipsychotics 1st Generation/Typical CHLORPROMAZINE HCL INJECTION 25MG/ML 2 chlorpromazine hcl tablet 100mg 1 Page 28 of 103

39 Name Tier chlorpromazine hcl tablet 10mg 1 chlorpromazine hcl tablet 200mg 1 chlorpromazine hcl tablet 25mg 1 chlorpromazine hcl tablet 50mg 1 compro suppository 25mg 1 FLUPHENAZINE DECANOATE INJECTION 25MG/ML 2 fluphenazine hcl concentrate 5mg/ml 1 fluphenazine hcl elixir 2.5mg/5ml 1 FLUPHENAZINE HCL INJECTION 2.5MG/ML 2 fluphenazine hcl tablet 10mg 1 fluphenazine hcl tablet 1mg 1 fluphenazine hcl tablet 2.5mg 1 fluphenazine hcl tablet 5mg 1 haloperidol decanoate injection 100mg/ml 1 haloperidol decanoate injection 50mg/ml 1 haloperidol lactate injection 5mg/ml 1 haloperidol concentrate 2mg/ml 1 haloperidol tablet 0.5mg 1 haloperidol tablet 10mg 1 haloperidol tablet 1mg 1 haloperidol tablet 20mg 1 haloperidol tablet 2mg 1 haloperidol tablet 5mg 1 loxapine succinate capsule 10mg 1 loxapine succinate capsule 25mg 1 loxapine succinate capsule 50mg 1 loxapine succinate capsule 5mg 1 ORAP TABLET 1MG 2 ORAP TABLET 2MG 2 perphenazine tablet 16mg 1 perphenazine tablet 2mg 1 perphenazine tablet 4mg 1 perphenazine tablet 8mg 1 PROCHLORPERAZINE EDISYLATE INJECTION 2 5MG/ML prochlorperazine maleate tablet 10mg 1 prochlorperazine maleate tablet 5mg 1 thioridazine hcl tablet 100mg 1 thioridazine hcl tablet 10mg 1 thioridazine hcl tablet 25mg 1 thioridazine hcl tablet 50mg 1 thiothixene capsule 10mg 1 thiothixene capsule 1mg 1 thiothixene capsule 2mg 1 thiothixene capsule 5mg 1 trifluoperazine hcl tablet 10mg 1 trifluoperazine hcl tablet 1mg 1 trifluoperazine hcl tablet 2mg 1 trifluoperazine hcl tablet 5mg 1 Requirements/Limits Page 29 of 103

40 2nd Generation/Atypical ABILIFY DISCMELT TABLET DISPERSIBLE 10MG 2 QL (60 EA per 30 days) ABILIFY DISCMELT TABLET DISPERSIBLE 15MG 2 QL (60 EA per 30 days) ABILIFY MAINTENA INJECTION 300MG 2 QL (1 EA per 30 days) ABILIFY INJECTION 9.75MG/1.3ML 2 ABILIFY SOLUTION 1MG/ML 2 ABILIFY TABLET 10MG 2 QL (30 EA per 30 days) ABILIFY TABLET 15MG 2 QL (30 EA per 30 days) ABILIFY TABLET 20MG 2 QL (30 EA per 30 days) ABILIFY TABLET 2MG 2 QL (30 EA per 30 days) ABILIFY TABLET 30MG 2 QL (30 EA per 30 days) ABILIFY TABLET 5MG 2 QL (30 EA per 30 days) FANAPT TITRATION PACK TABLET 0 2 FANAPT TABLET 10MG 2 QL (60 EA per 30 days) FANAPT TABLET 12MG 2 QL (60 EA per 30 days) FANAPT TABLET 1MG 2 QL (60 EA per 30 days) FANAPT TABLET 2MG 2 QL (60 EA per 30 days) FANAPT TABLET 4MG 2 QL (60 EA per 30 days) FANAPT TABLET 6MG 2 QL (60 EA per 30 days) FANAPT TABLET 8MG 2 QL (60 EA per 30 days) GEODON INJECTION 20MG 2 INVEGA SUSTENNA INJECTION 117MG/0.75ML 2 QL (0.75 ML per 28 days) INVEGA SUSTENNA INJECTION 156MG/ML 2 QL (1 ML per 28 days) INVEGA SUSTENNA INJECTION 234MG/1.5ML 2 QL (1.5 ML per 28 days) INVEGA SUSTENNA INJECTION 39MG/0.25ML 2 QL (0.25 ML per 28 days) INVEGA SUSTENNA INJECTION 78MG/0.5ML 2 QL (0.5 ML per 28 days) INVEGA TABLET EXTENDED RELEASE 24 HOUR 2 QL (30 EA per 30 days) 1.5MG INVEGA TABLET EXTENDED RELEASE 24 HOUR 3MG 2 QL (30 EA per 30 days) INVEGA TABLET EXTENDED RELEASE 24 HOUR 6MG 2 QL (60 EA per 30 days) INVEGA TABLET EXTENDED RELEASE 24 HOUR 9MG 2 QL (30 EA per 30 days) LATUDA TABLET 120MG 2 QL (30 EA per 30 days) LATUDA TABLET 20MG 2 QL (30 EA per 30 days) LATUDA TABLET 40MG 2 QL (30 EA per 30 days) LATUDA TABLET 60MG 2 QL (30 EA per 30 days) LATUDA TABLET 80MG 2 QL (30 EA per 30 days) olanzapine odt tablet dispersible 10mg 1 olanzapine odt tablet dispersible 15mg 1 olanzapine odt tablet dispersible 20mg 1 olanzapine odt tablet dispersible 5mg 1 olanzapine injection 10mg 1 olanzapine tablet 10mg 1 olanzapine tablet 15mg 1 olanzapine tablet 2.5mg 1 olanzapine tablet 20mg 1 olanzapine tablet 5mg 1 olanzapine tablet 7.5mg 1 quetiapine fumarate tablet 100mg 1 quetiapine fumarate tablet 200mg 1 Page 30 of 103

41 quetiapine fumarate tablet 25mg 1 quetiapine fumarate tablet 300mg 1 quetiapine fumarate tablet 400mg 1 quetiapine fumarate tablet 50mg 1 RISPERDAL CONSTA INJECTION 12.5MG 2 RISPERDAL CONSTA INJECTION 25MG 2 RISPERDAL CONSTA INJECTION 37.5MG 2 RISPERDAL CONSTA INJECTION 50MG 2 risperidone odt tablet dispersible 0.25mg 1 risperidone odt tablet dispersible 0.5mg 1 risperidone odt tablet dispersible 1mg 1 risperidone odt tablet dispersible 2mg 1 risperidone odt tablet dispersible 3mg 1 risperidone odt tablet dispersible 4mg 1 risperidone solution 1mg/ml 1 risperidone tablet 0.25mg 1 risperidone tablet 0.5mg 1 risperidone tablet 1mg 1 risperidone tablet 2mg 1 risperidone tablet 3mg 1 risperidone tablet 4mg 1 SAPHRIS TABLET SUBLINGUAL 10MG 2 QL (60 EA per 30 days) SAPHRIS TABLET SUBLINGUAL 5MG 2 QL (60 EA per 30 days) ziprasidone hcl capsule 20mg 1 ziprasidone hcl capsule 40mg 1 ziprasidone hcl capsule 60mg 1 ziprasidone hcl capsule 80mg 1 Treatment-Resistant clozapine odt tablet dispersible 100mg 1 QL (90 EA per 30 days) clozapine odt tablet dispersible 12.5mg 1 QL (90 EA per 30 days) clozapine odt tablet dispersible 25mg 1 QL (90 EA per 30 days) clozapine tablet 100mg 1 clozapine tablet 200mg 1 clozapine tablet 25mg 1 clozapine tablet 50mg 1 FAZACLO TABLET DISPERSIBLE 100MG 2 QL (90 EA per 30 days) FAZACLO TABLET DISPERSIBLE 12.5MG 2 QL (90 EA per 30 days) FAZACLO TABLET DISPERSIBLE 150MG 2 QL (180 EA per 30 days) FAZACLO TABLET DISPERSIBLE 200MG 2 QL (120 EA per 30 days) FAZACLO TABLET DISPERSIBLE 25MG 2 QL (90 EA per 30 days) VERSACLOZ SUSPENSION 50MG/ML 2 Antispasticity Agents Antispasticity Agents baclofen tablet 10mg 1 baclofen tablet 20mg 1 dantrolene sodium capsule 100mg 1 dantrolene sodium capsule 25mg 1 dantrolene sodium capsule 50mg 1 tizanidine hcl tablet 2mg 1 Page 31 of 103

42 tizanidine hcl tablet 4mg 1 Antivirals Anti-cytomegalovirus (CMV) Agents cidofovir injection 75mg/ml 1 FOSCARNET SODIUM INJECTION 24MG/ML 2 ganciclovir injection 500mg 1 VALCYTE SOLUTION RECONSTITUTED 50MG/ML 2 VALCYTE TABLET 450MG 2 valganciclovir tablet 450mg 1 MO VISTIDE INJECTION 75MG/ML 2 Anti-hepatitis B (HBV) Agents adefovir dipivoxil tablet 10mg 1 BARACLUDE SOLUTION 0.05MG/ML 2 BARACLUDE TABLET 0.5MG 2 BARACLUDE TABLET 1MG 2 entecavir tablet 0.5mg 1 MO entecavir tablet 1mg 1 MO EPIVIR HBV SOLUTION 5MG/ML 2 INTRON A INJECTION 18MU 2 INTRON A INJECTION 50MU 2 INTRON-A W/DILUENT INJECTION 10MU 2 INTRON-A INJECTION UNIT/ML 2 lamivudine tablet 100mg 1 MO TYZEKA TABLET 600MG 2 Anti-hepatitis C (HCV) Agents INCIVEK TABLET 375MG 2 INFERGEN INJECTION 15MCG/0.5ML 2 PA (Immunological Agents - Infergen) OLYSIO CAPSULE 150MG 2 QL (28 EA per 28 days) PA (Immunological Agents - Olysio) PEG-INTRON REDIPEN INJECTION 120MCG/0.5ML 2 PA (Immunological Agents - Peg-Intron, Pegasys) PEG-INTRON REDIPEN INJECTION 150MCG/0.5ML 2 PA (Immunological Agents - Peg-Intron, Pegasys) PEG-INTRON REDIPEN INJECTION 50MCG/0.5ML 2 PA (Immunological Agents - Peg-Intron, Pegasys) PEG-INTRON REDIPEN INJECTION 80MCG/0.5ML 2 PA (Immunological Agents - Peg-Intron, Pegasys) PEG-INTRON INJECTION 120MCG/0.5ML 2 PA (Immunological Agents - Peg-Intron, Pegasys) PEG-INTRON INJECTION 150MCG/0.5ML 2 PA (Immunological Agents - Peg-Intron, Pegasys) PEG-INTRON INJECTION 50MCG/0.5ML 2 PA (Immunological Agents - Peg-Intron, Pegasys) PEG-INTRON INJECTION 80MCG/0.5ML 2 PA (Immunological Agents - Peg-Intron, Pegasys) PEGASYS PROCLICK INJECTION 135MCG/0.5ML 2 PA (Immunological Agents - Peg-Intron, Pegasys) Page 32 of 103

43 PEGASYS INJECTION 180MCG/0.5ML 2 PA (Immunological Agents - Peg-Intron, Pegasys) PEGASYS INJECTION 180MCG/ML 2 PA (Immunological Agents - Peg-Intron, Pegasys) REBETOL SOLUTION 40MG/ML 2 ribasphere ribapak tablet 0 1 ribasphere ribapak tablet 400mg 1 ribasphere ribapak tablet 600mg 1 ribasphere tablet 200mg 1 ribasphere tablet 400mg 1 ribasphere tablet 600mg 1 ribavirin capsule 200mg 1 ribavirin tablet 200mg 1 SOVALDI TABLET 400MG 2 QL (28 EA per 28 days) PA (Immunological Agents - Sovaldi) VICTRELIS CAPSULE 200MG 2 VIRAZOLE SOLUTION RECONSTITUTED 6GM 2 Anti-HIV Agents, Integrase Inhibitors (INSTI) ISENTRESS PACKET 100MG 2 MO ISENTRESS TABLET CHEWABLE 100MG 2 ISENTRESS TABLET CHEWABLE 25MG 2 ISENTRESS TABLET 400MG 2 TIVICAY TABLET 50MG 2 MO Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI) COMPLERA TABLET 200MG; 25MG; 300MG 2 EDURANT TABLET 25MG 2 INTELENCE TABLET 100MG 2 INTELENCE TABLET 200MG 2 INTELENCE TABLET 25MG 2 MO nevirapine er tablet extended release 24 hour 400mg 1 MO nevirapine suspension 50mg/5ml 1 nevirapine tablet 200mg 1 RESCRIPTOR TABLET 100MG 2 RESCRIPTOR TABLET 200MG 2 STRIBILD TABLET 150MG; 150MG; 200MG; 300MG 2 SUSTIVA CAPSULE 200MG 2 SUSTIVA CAPSULE 50MG 2 SUSTIVA TABLET 600MG 2 VIRAMUNE XR TABLET EXTENDED RELEASE 24 2 HOUR 100MG VIRAMUNE XR TABLET EXTENDED RELEASE 24 2 HOUR 400MG VIRAMUNE SUSPENSION 50MG/5ML 2 Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI) abacavir sulfate/lamivudine/zidovudine tablet 300mg; 150mg; 1 MO 300mg abacavir tablet 300mg 1 Page 33 of 103

44 didanosine capsule delayed release 125mg 1 didanosine capsule delayed release 200mg 1 didanosine capsule delayed release 250mg 1 didanosine capsule delayed release 400mg 1 EMTRIVA CAPSULE 200MG 2 EMTRIVA SOLUTION 10MG/ML 2 EPIVIR SOLUTION 10MG/ML 2 EPZICOM TABLET 600MG; 300MG 2 lamivudine/zidovudine tablet 150mg; 300mg 1 lamivudine solution 10mg/ml 1 MO lamivudine tablet 150mg 1 lamivudine tablet 300mg 1 RETROVIR IV INFUSION INJECTION 10MG/ML 2 stavudine capsule 15mg 1 stavudine capsule 20mg 1 stavudine capsule 30mg 1 stavudine capsule 40mg 1 stavudine solution reconstituted 1mg/ml 1 TRIUMEQ TABLET 600MG; 50MG; 300MG 2 MO TRUVADA TABLET 200MG; 300MG 2 VIDEX PEDIATRIC SOLUTION RECONSTITUTED 2GM 2 VIREAD POWDER 40MG/GM 2 VIREAD TABLET 150MG 2 VIREAD TABLET 200MG 2 VIREAD TABLET 250MG 2 VIREAD TABLET 300MG 2 ZIAGEN SOLUTION 20MG/ML 2 zidovudine capsule 100mg 1 zidovudine syrup 50mg/5ml 1 zidovudine tablet 300mg 1 Anti-HIV Agents, Other FUZEON INJECTION 90MG 2 SELZENTRY TABLET 150MG 2 SELZENTRY TABLET 300MG 2 TYBOST TABLET 150MG 2 MO Anti-HIV Agents, Protease Inhibitors APTIVUS CAPSULE 250MG 2 APTIVUS SOLUTION 100MG/ML 2 CRIXIVAN CAPSULE 200MG 2 CRIXIVAN CAPSULE 400MG 2 INVIRASE CAPSULE 200MG 2 INVIRASE TABLET 500MG 2 KALETRA SOLUTION 400MG/5ML; 100MG/5ML 2 KALETRA TABLET 100MG; 25MG 2 KALETRA TABLET 200MG; 50MG 2 LEXIVA SUSPENSION 50MG/ML 2 LEXIVA TABLET 700MG 2 NORVIR CAPSULE 100MG 2 NORVIR SOLUTION 80MG/ML 2 Page 34 of 103

45 NORVIR TABLET 100MG 2 PREZISTA SUSPENSION 100MG/ML 2 PREZISTA TABLET 150MG 2 PREZISTA TABLET 400MG 2 PREZISTA TABLET 600MG 2 PREZISTA TABLET 75MG 2 PREZISTA TABLET 800MG 2 REYATAZ CAPSULE 100MG 2 REYATAZ CAPSULE 150MG 2 REYATAZ CAPSULE 200MG 2 REYATAZ CAPSULE 300MG 2 REYATAZ PACKET 50MG 2 VIRACEPT TABLET 250MG 2 VIRACEPT TABLET 625MG 2 Anti-influenza Agents amantadine hcl capsule 100mg 1 amantadine hcl syrup 50mg/5ml 1 amantadine hcl tablet 100mg 1 RELENZA DISKHALER AEROSOL POWDER BREATH 2 QL (56 EA per 180 days) ACTIVATED 5MG/BLISTER rimantadine hcl tablet 100mg 1 TAMIFLU CAPSULE 30MG 2 QL (84 EA per 180 days) TAMIFLU CAPSULE 45MG 2 QL (42 EA per 180 days) TAMIFLU CAPSULE 75MG 2 QL (28 EA per 180 days) TAMIFLU SUSPENSION RECONSTITUTED 6MG/ML 2 QL (540 ML per 180 days) Antiherpetic Agents acyclovir sodium injection 50mg/ml 1 acyclovir capsule 200mg 1 acyclovir suspension 200mg/5ml 1 acyclovir tablet 400mg 1 acyclovir tablet 800mg 1 DENAVIR CREAM 1% 2 famciclovir tablet 125mg 1 QL (60 EA per 30 days) famciclovir tablet 250mg 1 QL (60 EA per 30 days) famciclovir tablet 500mg 1 QL (60 EA per 30 days) trifluridine solution 1% 1 valacyclovir hcl tablet 1000mg 1 QL (30 EA per 30 days) valacyclovir hcl tablet 500mg 1 QL (30 EA per 30 days) ZOVIRAX CREAM 5% 2 QL (30 GM per 30 days) ZOVIRAX OINTMENT 5% 2 QL (30 GM per 30 days) Antivirals ATRIPLA TABLET 600MG; 200MG; 300MG 2 Anxiolytics Anxiolytics, Other buspirone hcl tablet 10mg 1 buspirone hcl tablet 15mg 1 buspirone hcl tablet 30mg 1 buspirone hcl tablet 5mg 1 buspirone hcl tablet 7.5mg 1 Page 35 of 103

46 meprobamate tablet 200mg 1 PA (High Risk Medications) meprobamate tablet 400mg 1 PA (High Risk Medications) Benzodiazepines ALPRAZOLAM INTENSOL CONCENTRATE 1MG/ML 2 alprazolam tablet 0.25mg 1 QL (120 EA per 30 days) alprazolam tablet 0.5mg 1 QL (150 EA per 30 days) alprazolam tablet 1mg 1 QL (150 EA per 30 days) alprazolam tablet 2mg 1 QL (150 EA per 30 days) clorazepate dipotassium tablet 15mg 1 QL (90 EA per 30 days) clorazepate dipotassium tablet 3.75mg 1 QL (90 EA per 30 days) clorazepate dipotassium tablet 7.5mg 1 QL (90 EA per 30 days) DIAZEPAM INTENSOL CONCENTRATE 5MG/ML 2 diazepam tablet 10mg 1 QL (120 EA per 30 days) diazepam tablet 2mg 1 QL (120 EA per 30 days) diazepam tablet 5mg 1 QL (120 EA per 30 days) LORAZEPAM INTENSOL CONCENTRATE 2MG/ML 2 lorazepam tablet 0.5mg 1 QL (120 EA per 30 days) lorazepam tablet 1mg 1 QL (150 EA per 30 days) lorazepam tablet 2mg 1 QL (150 EA per 30 days) triazolam tablet 0.125mg 1 QL (30 EA per 30 days) triazolam tablet 0.25mg 1 QL (30 EA per 30 days) Bipolar Agents Mood Stabilizers lithium carbonate er tablet extended release 300mg 1 lithium carbonate er tablet extended release 450mg 1 lithium carbonate capsule 150mg 1 lithium carbonate capsule 300mg 1 lithium carbonate capsule 600mg 1 lithium carbonate tablet 300mg 1 lithium solution 8meq/5ml 1 LITHOBID TABLET EXTENDED RELEASE 300MG 2 Blood Glucose Regulators Antidiabetic Agents acarbose tablet 100mg 1 QL (90 EA per 30 days) acarbose tablet 25mg 1 QL (90 EA per 30 days) acarbose tablet 50mg 1 QL (90 EA per 30 days) AVANDARYL TABLET 1MG; 4MG 2 QL (30 EA per 30 days) AVANDARYL TABLET 2MG; 4MG 2 QL (30 EA per 30 days) AVANDARYL TABLET 2MG; 8MG 2 QL (30 EA per 30 days) AVANDARYL TABLET 4MG; 4MG 2 QL (30 EA per 30 days) AVANDARYL TABLET 4MG; 8MG 2 QL (30 EA per 30 days) BYETTA INJECTION 10MCG/0.04ML 2 QL (2.4 ML per 30 days) PA (Blood Glucose Regulators) BYETTA INJECTION 5MCG/0.02ML 2 PA (Blood Glucose Regulators) CYCLOSET TABLET 0.8MG 2 DUETACT TABLET 2MG; 30MG 2 QL (30 EA per 30 days) DUETACT TABLET 4MG; 30MG 2 QL (30 EA per 30 days) FARXIGA TABLET 10MG 2 QL (30 EA per 30 days) MO FARXIGA TABLET 5MG 2 QL (30 EA per 30 days) MO Page 36 of 103

47 glimepiride tablet 1mg 1 QL (30 EA per 30 days) glimepiride tablet 2mg 1 QL (30 EA per 30 days) glimepiride tablet 4mg 1 QL (60 EA per 30 days) glipizide er tablet extended release 24 hour 10mg 1 QL (60 EA per 30 days) glipizide er tablet extended release 24 hour 2.5mg 1 QL (30 EA per 30 days) glipizide er tablet extended release 24 hour 5mg 1 QL (30 EA per 30 days) glipizide/metformin hcl tablet 2.5mg; 250mg 1 QL (120 EA per 30 days) glipizide/metformin hcl tablet 2.5mg; 500mg 1 QL (120 EA per 30 days) glipizide/metformin hcl tablet 5mg; 500mg 1 QL (120 EA per 30 days) glipizide tablet 10mg 1 QL (120 EA per 30 days) glipizide tablet 5mg 1 QL (90 EA per 30 days) glyburide micronized tablet 1.5mg 1 QL (30 EA per 30 days) PA (High Risk Medication - Glyburide) glyburide micronized tablet 3mg 1 QL (30 EA per 30 days) PA (High Risk Medication - Glyburide) glyburide micronized tablet 6mg 1 QL (60 EA per 30 days) PA (High Risk Medication - Glyburide) glyburide/metformin hcl tablet 1.25mg; 250mg 1 QL (120 EA per 30 days) PA (High Risk Medication - Glyburide) glyburide/metformin hcl tablet 2.5mg; 500mg 1 QL (120 EA per 30 days) PA (High Risk Medication - Glyburide) glyburide/metformin hcl tablet 5mg; 500mg 1 QL (120 EA per 30 days) PA (High Risk Medication - Glyburide) glyburide tablet 1.25mg 1 QL (30 EA per 30 days) PA (High Risk Medication - Glyburide) glyburide tablet 2.5mg 1 QL (30 EA per 30 days) PA (High Risk Medication - Glyburide) glyburide tablet 5mg 1 PA (High Risk Medication - Glyburide) GLYSET TABLET 100MG 2 QL (90 EA per 30 days) GLYSET TABLET 25MG 2 QL (90 EA per 30 days) GLYSET TABLET 50MG 2 QL (90 EA per 30 days) JANUVIA TABLET 100MG 2 QL (30 EA per 30 days) JANUVIA TABLET 25MG 2 QL (30 EA per 30 days) JANUVIA TABLET 50MG 2 QL (30 EA per 30 days) JENTADUETO TABLET 2.5MG; 1000MG 2 QL (60 EA per 30 days) JENTADUETO TABLET 2.5MG; 500MG 2 QL (60 EA per 30 days) JENTADUETO TABLET 2.5MG; 850MG 2 QL (60 EA per 30 days) KOMBIGLYZE XR TABLET EXTENDED RELEASE 24 2 QL (60 EA per 30 days) HOUR 1000MG; 2.5MG KOMBIGLYZE XR TABLET EXTENDED RELEASE 24 2 QL (30 EA per 30 days) HOUR 1000MG; 5MG KOMBIGLYZE XR TABLET EXTENDED RELEASE 24 2 QL (30 EA per 30 days) HOUR 500MG; 5MG metformin hcl er tablet extended release 24 hour 500mg 1 QL (120 EA per 30 days) metformin hcl er tablet extended release 24 hour 750mg 1 QL (90 EA per 30 days) metformin hcl tablet 1000mg 1 QL (60 EA per 30 days) metformin hcl tablet 500mg 1 QL (120 EA per 30 days) metformin hcl tablet 850mg 1 QL (90 EA per 30 days) Page 37 of 103

48 nateglinide tablet 120mg 1 QL (90 EA per 30 days) nateglinide tablet 60mg 1 QL (90 EA per 30 days) ONGLYZA TABLET 2.5MG 2 QL (30 EA per 30 days) ONGLYZA TABLET 5MG 2 QL (30 EA per 30 days) pioglitazone hcl/metformin hcl tablet 500mg; 15mg 1 QL (90 EA per 30 days) pioglitazone hcl/metformin hcl tablet 850mg; 15mg 1 QL (90 EA per 30 days) pioglitazone hcl tablet 15mg 1 QL (30 EA per 30 days) pioglitazone hcl tablet 30mg 1 QL (30 EA per 30 days) pioglitazone hcl tablet 45mg 1 QL (30 EA per 30 days) repaglinide tablet 0.5mg 1 MO repaglinide tablet 1mg 1 MO repaglinide tablet 2mg 1 MO SYMLINPEN 120 INJECTION 2700MCG/2.7ML 2 PA (Blood Glucose Regulators - Amylinomimetics) SYMLINPEN 60 INJECTION 1500MCG/1.5ML 2 PA (Blood Glucose Regulators - Amylinomimetics) tolbutamide tablet 500mg 1 TRADJENTA TABLET 5MG 2 QL (30 EA per 30 days) Glycemic Agents GLUCAGEN HYPOKIT INJECTION 1MG 2 GLUCAGON EMERGENCY KIT INJECTION 1MG 2 PROGLYCEM SUSPENSION 50MG/ML 2 Insulins APIDRA SOLOSTAR INJECTION 100UNIT/ML 2 QL (30 ML per 30 days) APIDRA INJECTION 100UNIT/ML 2 QL (40 ML per 30 days) HUMALOG KWIKPEN INJECTION 100UNIT/ML 2 QL (40 ML per 30 days) HUMALOG MIX 50/50 KWIKPEN INJECTION 2 QL (40 ML per 30 days) 50UNIT/ML; 50UNIT/ML HUMALOG MIX 50/50 INJECTION 50UNIT/ML; 2 QL (40 ML per 30 days) 50UNIT/ML HUMALOG MIX 75/25 KWIKPEN INJECTION 2 QL (40 ML per 30 days) 25UNIT/ML; 75UNIT/ML HUMALOG MIX 75/25 INJECTION 25UNIT/ML; 2 QL (40 ML per 30 days) 75UNIT/ML HUMALOG INJECTION 100UNIT/ML 2 QL (40 ML per 30 days) HUMULIN 70/30 PEN INJECTION 30UNIT/ML; 2 QL (40 ML per 30 days) 70UNIT/ML HUMULIN 70/30 INJECTION 30UNIT/ML; 70UNIT/ML 2 QL (40 ML per 30 days) HUMULIN N U-100 PEN INJECTION 100UNIT/ML 2 QL (40 ML per 30 days) HUMULIN N INJECTION 100UNIT/ML 2 QL (40 ML per 30 days) HUMULIN R U-500 (CONCENTRATED) INJECTION 2 500UNIT/ML HUMULIN R INJECTION 100UNIT/ML 2 QL (40 ML per 30 days) LANTUS SOLOSTAR INJECTION 100UNIT/ML 2 LANTUS INJECTION 100UNIT/ML 2 QL (30 ML per 30 days) LEVEMIR FLEXTOUCH INJECTION 100UNIT/ML 2 LEVEMIR INJECTION 100UNIT/ML 2 QL (30 ML per 30 days) NOVOLIN 70/30 INJECTION 30UNIT/ML; 70UNIT/ML 2 QL (40 ML per 30 days) NOVOLIN N INJECTION 100UNIT/ML 2 QL (40 ML per 30 days) Page 38 of 103

49 NOVOLIN R INJECTION 100UNIT/ML 2 QL (40 ML per 30 days) NOVOLOG FLEXPEN INJECTION 100UNIT/ML 2 QL (40 ML per 30 days) NOVOLOG MIX 70/30 PREFILLED FLEXPEN 2 QL (40 ML per 30 days) INJECTION 30UNIT/ML; 70UNIT/ML NOVOLOG MIX 70/30 INJECTION 30UNIT/ML; 2 QL (40 ML per 30 days) 70UNIT/ML NOVOLOG INJECTION 100UNIT/ML 2 QL (40 ML per 30 days) Blood Products/Modifiers/Volume Expanders Anticoagulants COUMADIN INJECTION 5MG 2 COUMADIN TABLET 10MG 2 COUMADIN TABLET 1MG 2 COUMADIN TABLET 2.5MG 2 COUMADIN TABLET 2MG 2 COUMADIN TABLET 3MG 2 COUMADIN TABLET 4MG 2 COUMADIN TABLET 5MG 2 COUMADIN TABLET 6MG 2 COUMADIN TABLET 7.5MG 2 enoxaparin sodium injection 100mg/ml 1 enoxaparin sodium injection 120mg/0.8ml 1 enoxaparin sodium injection 150mg/ml 1 enoxaparin sodium injection 300mg/3ml 1 enoxaparin sodium injection 30mg/0.3ml 1 enoxaparin sodium injection 40mg/0.4ml 1 enoxaparin sodium injection 60mg/0.6ml 1 enoxaparin sodium injection 80mg/0.8ml 1 fondaparinux sodium injection 10mg/0.8ml 1 fondaparinux sodium injection 2.5mg/0.5ml 1 fondaparinux sodium injection 5mg/0.4ml 1 fondaparinux sodium injection 7.5mg/0.6ml 1 FRAGMIN INJECTION 10000UNIT/ML 2 FRAGMIN INJECTION 25000UNIT/ML 2 FRAGMIN INJECTION 2500UNIT/0.2ML 2 FRAGMIN INJECTION 5000UNIT/0.2ML 2 FRAGMIN INJECTION 7500UNIT/0.3ML 2 heparin sodium/d5w injection 5%; 100unit/ml 1 heparin sodium/d5w injection 5%; 40unit/ml 1 heparin sodium/d5w injection 5%; 50unit/ml 1 heparin sodium/nacl 0.9% injection 2unit/ml; 0.9% 1 heparin sodium injection 10000unit/ml 1 heparin sodium injection 1000unit/ml 1 heparin sodium injection 20000unit/ml 1 heparin sodium injection 5000unit/ml 1 jantoven tablet 10mg 1 jantoven tablet 1mg 1 jantoven tablet 2.5mg 1 jantoven tablet 2mg 1 jantoven tablet 3mg 1 Page 39 of 103

50 jantoven tablet 4mg 1 jantoven tablet 5mg 1 jantoven tablet 6mg 1 jantoven tablet 7.5mg 1 PRADAXA CAPSULE 150MG 2 PRADAXA CAPSULE 75MG 2 warfarin sodium tablet 10mg 1 warfarin sodium tablet 1mg 1 warfarin sodium tablet 2.5mg 1 warfarin sodium tablet 2mg 1 warfarin sodium tablet 3mg 1 warfarin sodium tablet 4mg 1 warfarin sodium tablet 5mg 1 warfarin sodium tablet 6mg 1 warfarin sodium tablet 7.5mg 1 XARELTO STARTER PACK TABLET THERAPY PACK 0 2 XARELTO TABLET 10MG 2 XARELTO TABLET 15MG 2 XARELTO TABLET 20MG 2 Blood Formation Modifiers anagrelide hydrochloride capsule 0.5mg 1 anagrelide hydrochloride capsule 1mg 1 ARANESP ALBUMIN FREE INJECTION 100MCG/ML 2 PA (Blood Products/Modifiers/ Volume Expanders) ARANESP ALBUMIN FREE INJECTION 150MCG/0.3ML 2 PA (Blood Products/Modifiers/ Volume Expanders) ARANESP ALBUMIN FREE INJECTION 200MCG/0.4ML 2 PA (Blood Products/Modifiers/ Volume Expanders) ARANESP ALBUMIN FREE INJECTION 200MCG/ML 2 PA (Blood Products/Modifiers/ Volume Expanders) ARANESP ALBUMIN FREE INJECTION 25MCG/0.42ML 2 PA (Blood Products/Modifiers/ Volume Expanders) ARANESP ALBUMIN FREE INJECTION 25MCG/ML 2 PA (Blood Products/Modifiers/ Volume Expanders) ARANESP ALBUMIN FREE INJECTION 300MCG/ML 2 PA (Blood Products/Modifiers/ Volume Expanders) ARANESP ALBUMIN FREE INJECTION 40MCG/0.4ML 2 PA (Blood Products/Modifiers/ Volume Expanders) ARANESP ALBUMIN FREE INJECTION 40MCG/ML 2 PA (Blood Products/Modifiers/ Volume Expanders) ARANESP ALBUMIN FREE INJECTION 500MCG/ML 2 PA (Blood Products/Modifiers/ Volume Expanders) ARANESP ALBUMIN FREE INJECTION 60MCG/ML 2 PA (Blood Products/Modifiers/ Volume Expanders) EPOGEN INJECTION 10000UNIT/ML 2 PA (Blood Products/Modifiers/ Volume Expanders) EPOGEN INJECTION 20000UNIT/ML 2 PA (Blood Products/Modifiers/ Volume Expanders) Page 40 of 103

51 EPOGEN INJECTION 2000UNIT/ML 2 PA (Blood Products/Modifiers/ Volume Expanders) EPOGEN INJECTION 3000UNIT/ML 2 PA (Blood Products/Modifiers/ Volume Expanders) EPOGEN INJECTION 4000UNIT/ML 2 PA (Blood Products/Modifiers/ Volume Expanders) GRANIX INJECTION 300MCG/0.5ML 2 GRANIX INJECTION 480MCG/0.8ML 2 LEUKINE INJECTION 250MCG 2 NEULASTA INJECTION 6MG/0.6ML 2 NEUMEGA INJECTION 5MG 2 NEUPOGEN INJECTION 300MCG/0.5ML 2 NEUPOGEN INJECTION 480MCG/0.8ML 2 NEUPOGEN INJECTION 480MCG/1.6ML 2 PROCRIT INJECTION 10000UNIT/ML 2 PA (Blood Products/Modifiers/ Volume Expanders) PROCRIT INJECTION 20000UNIT/ML 2 PA (Blood Products/Modifiers/ Volume Expanders) PROCRIT INJECTION 2000UNIT/ML 2 PA (Blood Products/Modifiers/ Volume Expanders) PROCRIT INJECTION 3000UNIT/ML 2 PA (Blood Products/Modifiers/ Volume Expanders) PROCRIT INJECTION 40000UNIT/ML 2 PA (Blood Products/Modifiers/ Volume Expanders) PROCRIT INJECTION 4000UNIT/ML 2 PA (Blood Products/Modifiers/ Volume Expanders) PROMACTA TABLET 25MG 2 QL (90 EA per 30 days) PA (Blood Products/Modifiers/ Volume Expanders - Promacta) PROMACTA TABLET 50MG 2 QL (30 EA per 30 days) PA (Blood Products/Modifiers/ Volume Expanders - Promacta) Coagulants tranexamic acid injection 100mg/ml 1 tranexamic acid tablet 650mg 1 Platelet Modifying Agents AGGRENOX CAPSULE EXTENDED RELEASE 12 HOUR 2 QL (60 EA per 30 days) 25MG; 200MG BRILINTA TABLET 90MG 2 QL (60 EA per 30 days) cilostazol tablet 100mg 1 cilostazol tablet 50mg 1 clopidogrel tablet 300mg 1 clopidogrel tablet 75mg 1 QL (30 EA per 30 days) dipyridamole tablet 25mg 1 PA (High Risk Medications) dipyridamole tablet 50mg 1 PA (High Risk Medications) dipyridamole tablet 75mg 1 PA (High Risk Medications) EFFIENT TABLET 10MG 2 QL (30 EA per 30 days) EFFIENT TABLET 5MG 2 QL (30 EA per 30 days) Page 41 of 103

52 ticlopidine hcl tablet 250mg 1 QL (60 EA per 30 days) PA (High Risk Medications) Cardiovascular Agents Alpha-adrenergic Agonists clonidine hcl er tablet extended release 12 hour 0.1mg 1 MO clonidine hcl tablet 0.1mg 1 clonidine hcl tablet 0.2mg 1 clonidine hcl tablet 0.3mg 1 guanfacine hcl tablet 1mg 1 PA (High Risk Medications) guanfacine hcl tablet 2mg 1 PA (High Risk Medications) methyldopa/hydrochlorothiazide tablet 15mg; 250mg 1 methyldopa/hydrochlorothiazide tablet 25mg; 250mg 1 methyldopa tablet 250mg 1 PA (High Risk Medications) methyldopa tablet 500mg 1 PA (High Risk Medications) METHYLDOPATE HCL INJECTION 250MG/5ML 2 midodrine hcl tablet 10mg 1 midodrine hcl tablet 2.5mg 1 midodrine hcl tablet 5mg 1 Alpha-adrenergic Blocking Agents prazosin hcl capsule 1mg 1 prazosin hcl capsule 2mg 1 prazosin hcl capsule 5mg 1 reserpine tablet 0.25mg 1 PA (High Risk Medications) MO Angiotensin II Receptor Antagonists candesartan cilexetil/hydrochlorothiazide tablet 16mg; 1 QL (30 EA per 30 days) MO 12.5mg candesartan cilexetil/hydrochlorothiazide tablet 32mg; 1 QL (30 EA per 30 days) MO 12.5mg candesartan cilexetil/hydrochlorothiazide tablet 32mg; 25mg 1 QL (30 EA per 30 days) MO candesartan cilexetil tablet 16mg 1 QL (30 EA per 30 days) MO candesartan cilexetil tablet 32mg 1 QL (30 EA per 30 days) MO candesartan cilexetil tablet 4mg 1 QL (30 EA per 30 days) MO candesartan cilexetil tablet 8mg 1 QL (30 EA per 30 days) MO eprosartan mesylate tablet 600mg 1 QL (30 EA per 30 days) MO irbesartan/hydrochlorothiazide tablet 12.5mg; 150mg 1 QL (30 EA per 30 days) MO irbesartan/hydrochlorothiazide tablet 12.5mg; 300mg 1 QL (30 EA per 30 days) MO irbesartan tablet 150mg 1 QL (30 EA per 30 days) irbesartan tablet 300mg 1 QL (30 EA per 30 days) MO irbesartan tablet 75mg 1 QL (30 EA per 30 days) losartan potassium/hydrochlorothiazide tablet 12.5mg; 100mg 1 QL (30 EA per 30 days) losartan potassium/hydrochlorothiazide tablet 12.5mg; 50mg 1 QL (30 EA per 30 days) losartan potassium/hydrochlorothiazide tablet 25mg; 100mg 1 QL (30 EA per 30 days) losartan potassium tablet 100mg 1 QL (30 EA per 30 days) losartan potassium tablet 25mg 1 QL (30 EA per 30 days) losartan potassium tablet 50mg 1 QL (30 EA per 30 days) telmisartan/hydrochlorothiazide tablet 12.5mg; 40mg 1 QL (30 EA per 30 days) MO telmisartan/hydrochlorothiazide tablet 12.5mg; 80mg 1 QL (30 EA per 30 days) MO telmisartan/hydrochloroth tablet 25mg; 80mg 1 QL (30 EA per 30 days) MO telmisartan tablet 20mg 1 QL (30 EA per 30 days) MO Page 42 of 103

53 telmisartan tablet 40mg 1 QL (30 EA per 30 days) MO telmisartan tablet 80mg 1 QL (30 EA per 30 days) MO valsartan/hydrochlorothiazide tablet 12.5mg; 160mg 1 QL (30 EA per 30 days) valsartan/hydrochlorothiazide tablet 12.5mg; 320mg 1 QL (30 EA per 30 days) valsartan/hydrochlorothiazide tablet 12.5mg; 80mg 1 QL (30 EA per 30 days) valsartan/hydrochlorothiazide tablet 25mg; 160mg 1 QL (30 EA per 30 days) valsartan/hydrochlorothiazide tablet 25mg; 320mg 1 QL (30 EA per 30 days) valsartan tablet 160mg 1 QL (30 EA per 30 days) MO valsartan tablet 320mg 1 QL (30 EA per 30 days) MO valsartan tablet 40mg 1 QL (30 EA per 30 days) MO valsartan tablet 80mg 1 QL (30 EA per 30 days) MO Angiotensin-converting Enzyme (ACE) Inhibitors benazepril hcl/hydrochlorothiazide tablet 10mg; 12.5mg 1 benazepril hcl/hydrochlorothiazide tablet 20mg; 12.5mg 1 benazepril hcl/hydrochlorothiazide tablet 20mg; 25mg 1 benazepril hcl/hydrochlorothiazide tablet 5mg; 6.25mg 1 benazepril hcl tablet 10mg 1 QL (30 EA per 30 days) benazepril hcl tablet 20mg 1 QL (30 EA per 30 days) benazepril hcl tablet 40mg 1 QL (60 EA per 30 days) benazepril hcl tablet 5mg 1 QL (30 EA per 30 days) captopril/hydrochlorothiazide tablet 25mg; 15mg 1 captopril/hydrochlorothiazide tablet 25mg; 25mg 1 captopril/hydrochlorothiazide tablet 50mg; 15mg 1 captopril/hydrochlorothiazide tablet 50mg; 25mg 1 captopril tablet 100mg 1 captopril tablet 12.5mg 1 captopril tablet 25mg 1 captopril tablet 50mg 1 enalapril maleate/hydrochlorothiazide tablet 10mg; 25mg 1 enalapril maleate/hydrochlorothiazide tablet 5mg; 12.5mg 1 enalapril maleate tablet 10mg 1 enalapril maleate tablet 2.5mg 1 enalapril maleate tablet 20mg 1 enalapril maleate tablet 5mg 1 fosinopril sodium/hydrochlorothiazide tablet 10mg; 12.5mg 1 fosinopril sodium/hydrochlorothiazide tablet 20mg; 12.5mg 1 fosinopril sodium tablet 10mg 1 fosinopril sodium tablet 20mg 1 fosinopril sodium tablet 40mg 1 lisinopril/hydrochlorothiazide tablet 12.5mg; 10mg 1 lisinopril/hydrochlorothiazide tablet 12.5mg; 20mg 1 lisinopril/hydrochlorothiazide tablet 25mg; 20mg 1 lisinopril tablet 10mg 1 QL (30 EA per 30 days) lisinopril tablet 2.5mg 1 QL (30 EA per 30 days) lisinopril tablet 20mg 1 QL (30 EA per 30 days) lisinopril tablet 30mg 1 QL (30 EA per 30 days) lisinopril tablet 40mg 1 QL (30 EA per 30 days) lisinopril tablet 5mg 1 QL (30 EA per 30 days) quinapril hcl tablet 10mg 1 QL (60 EA per 30 days) Page 43 of 103

54 quinapril hcl tablet 20mg 1 QL (60 EA per 30 days) quinapril hcl tablet 40mg 1 QL (60 EA per 30 days) quinapril hcl tablet 5mg 1 QL (60 EA per 30 days) quinapril/hydrochlorothiazide tablet 12.5mg; 10mg 1 QL (30 EA per 30 days) quinapril/hydrochlorothiazide tablet 12.5mg; 20mg 1 QL (30 EA per 30 days) quinapril/hydrochlorothiazide tablet 25mg; 20mg 1 QL (30 EA per 30 days) ramipril capsule 1.25mg 1 QL (60 EA per 30 days) ramipril capsule 10mg 1 QL (60 EA per 30 days) ramipril capsule 2.5mg 1 QL (60 EA per 30 days) ramipril capsule 5mg 1 QL (60 EA per 30 days) trandolapril tablet 1mg 1 QL (30 EA per 30 days) trandolapril tablet 2mg 1 QL (30 EA per 30 days) trandolapril tablet 4mg 1 QL (60 EA per 30 days) Antiarrhythmics amiodarone hcl injection 50mg/ml 1 amiodarone hcl tablet 200mg 1 amiodarone hcl tablet 400mg 1 disopyramide phosphate capsule 100mg 1 disopyramide phosphate capsule 150mg 1 flecainide acetate tablet 100mg 1 flecainide acetate tablet 150mg 1 flecainide acetate tablet 50mg 1 mexiletine hcl capsule 150mg 1 mexiletine hcl capsule 200mg 1 mexiletine hcl capsule 250mg 1 MULTAQ TABLET 400MG 2 QL (60 EA per 30 days) MO pacerone tablet 100mg 1 pacerone tablet 200mg 1 pacerone tablet 400mg 1 PROCAINAMIDE HCL INJECTION 100MG/ML 2 PROCAINAMIDE HCL INJECTION 500MG/ML 2 propafenone hcl tablet 150mg 1 propafenone hcl tablet 225mg 1 propafenone hcl tablet 300mg 1 quinidine gluconate cr tablet extended release 324mg 1 QUINIDINE GLUCONATE INJECTION 80MG/ML 2 quinidine sulfate er tablet extended release 300mg 1 quinidine sulfate tablet 200mg 1 quinidine sulfate tablet 300mg 1 sorine tablet 120mg 1 sorine tablet 160mg 1 sorine tablet 240mg 1 sorine tablet 80mg 1 sotalol hcl (af) tablet 120mg 1 sotalol hcl tablet 160mg 1 sotalol hcl tablet 240mg 1 sotalol hcl tablet 80mg 1 TIKOSYN CAPSULE 125MCG 2 QL (60 EA per 30 days) TIKOSYN CAPSULE 250MCG 2 QL (60 EA per 30 days) Page 44 of 103

55 TIKOSYN CAPSULE 500MCG 2 QL (60 EA per 30 days) Beta-adrenergic Blocking Agents acebutolol hcl capsule 200mg 1 acebutolol hcl capsule 400mg 1 atenolol/chlorthalidone tablet 100mg; 25mg 1 atenolol/chlorthalidone tablet 50mg; 25mg 1 atenolol tablet 100mg 1 atenolol tablet 25mg 1 atenolol tablet 50mg 1 betaxolol hcl tablet 10mg 1 betaxolol hcl tablet 20mg 1 bisoprolol fumarate/hydrochlorothiazide tablet 10mg; 6.25mg 1 bisoprolol fumarate/hydrochlorothiazide tablet 2.5mg; 6.25mg 1 bisoprolol fumarate/hydrochlorothiazide tablet 5mg; 6.25mg 1 bisoprolol fumarate tablet 10mg 1 bisoprolol fumarate tablet 5mg 1 carvedilol tablet 12.5mg 1 QL (60 EA per 30 days) carvedilol tablet 25mg 1 QL (60 EA per 30 days) carvedilol tablet 3.125mg 1 QL (60 EA per 30 days) carvedilol tablet 6.25mg 1 QL (60 EA per 30 days) labetalol hcl injection 5mg/ml 1 labetalol hcl tablet 100mg 1 labetalol hcl tablet 200mg 1 labetalol hcl tablet 300mg 1 metoprolol succinate er tablet extended release 24 hour 1 100mg metoprolol succinate er tablet extended release 24 hour 1 200mg metoprolol succinate er tablet extended release 24 hour 25mg 1 metoprolol succinate er tablet extended release 24 hour 50mg 1 metoprolol tartrate injection 1mg/ml 1 metoprolol tartrate tablet 100mg 1 metoprolol tartrate tablet 25mg 1 metoprolol tartrate tablet 50mg 1 metoprolol/hydrochlorothiazide tablet 25mg; 100mg 1 metoprolol/hydrochlorothiazide tablet 25mg; 50mg 1 metoprolol/hydrochlorothiazide tablet 50mg; 100mg 1 nadolol/bendroflumethiazide tablet 5mg; 40mg 1 nadolol/bendroflumethiazide tablet 5mg; 80mg 1 nadolol tablet 20mg 1 nadolol tablet 40mg 1 nadolol tablet 80mg 1 pindolol tablet 10mg 1 pindolol tablet 5mg 1 propranolol hcl er capsule extended release 24 hour 120mg 1 propranolol hcl er capsule extended release 24 hour 160mg 1 propranolol hcl er capsule extended release 24 hour 60mg 1 propranolol hcl er capsule extended release 24 hour 80mg 1 propranolol hcl injection 1mg/ml 1 Page 45 of 103

56 propranolol hcl solution 20mg/5ml 1 propranolol hcl solution 40mg/5ml 1 propranolol hcl tablet 10mg 1 propranolol hcl tablet 20mg 1 propranolol hcl tablet 40mg 1 propranolol hcl tablet 60mg 1 propranolol hcl tablet 80mg 1 propranolol/hydrochlorothiazide tablet 25mg; 40mg 1 propranolol/hydrochlorothiazide tablet 25mg; 80mg 1 timolol maleate tablet 10mg 1 timolol maleate tablet 20mg 1 timolol maleate tablet 5mg 1 Calcium Channel Blocking Agents afeditab cr tablet extended release 24 hour 30mg 1 QL (30 EA per 30 days) afeditab cr tablet extended release 24 hour 60mg 1 QL (30 EA per 30 days) amlodipine besylate/benazepril hcl capsule 10mg; 40mg 1 QL (30 EA per 30 days) amlodipine besylate/benazepril hcl capsule 5mg; 40mg 1 QL (30 EA per 30 days) amlodipine besylate/benazepril hydrochloride capsule 10mg; 1 QL (30 EA per 30 days) 20mg amlodipine besylate/benazepril hydrochloride capsule 2.5mg; 1 QL (30 EA per 30 days) 10mg amlodipine besylate/benazepril hydrochloride capsule 5mg; 1 QL (30 EA per 30 days) 10mg amlodipine besylate/benazepril hydrochloride capsule 5mg; 1 QL (30 EA per 30 days) 20mg amlodipine besylate/valsartan tablet 10mg; 160mg 1 QL (30 EA per 30 days) MO amlodipine besylate/valsartan tablet 10mg; 320mg 1 QL (30 EA per 30 days) MO amlodipine besylate/valsartan tablet 5mg; 160mg 1 QL (30 EA per 30 days) MO amlodipine besylate/valsartan tablet 5mg; 320mg 1 QL (30 EA per 30 days) MO amlodipine besylate tablet 10mg 1 QL (30 EA per 30 days) amlodipine besylate tablet 2.5mg 1 QL (30 EA per 30 days) amlodipine besylate tablet 5mg 1 QL (30 EA per 30 days) amlodipine/valsartan/hctz tablet 10mg; 12.5mg; 160mg 1 QL (30 EA per 30 days) MO amlodipine/valsartan/hctz tablet 10mg; 25mg; 160mg 1 QL (30 EA per 30 days) MO amlodipine/valsartan/hctz tablet 10mg; 25mg; 320mg 1 QL (30 EA per 30 days) MO amlodipine/valsartan/hctz tablet 5mg; 12.5mg; 160mg 1 QL (30 EA per 30 days) MO amlodipine/valsartan/hctz tablet 5mg; 25mg; 160mg 1 QL (30 EA per 30 days) MO cartia xt capsule extended release 24 hour 120mg 1 QL (30 EA per 30 days) cartia xt capsule extended release 24 hour 180mg 1 QL (30 EA per 30 days) cartia xt capsule extended release 24 hour 240mg 1 QL (30 EA per 30 days) cartia xt capsule extended release 24 hour 300mg 1 QL (30 EA per 30 days) dilt-cd capsule extended release 24 hour 300mg 1 QL (30 EA per 30 days) dilt-xr capsule extended release 24 hour 120mg 1 QL (60 EA per 30 days) dilt-xr capsule extended release 24 hour 180mg 1 QL (90 EA per 30 days) dilt-xr capsule extended release 24 hour 240mg 1 QL (60 EA per 30 days) diltiazem cd capsule extended release 24 hour 240mg 1 QL (30 EA per 30 days) diltiazem hcl er capsule extended release 12 hour 120mg 1 diltiazem hcl er capsule extended release 12 hour 60mg 1 diltiazem hcl er capsule extended release 12 hour 90mg 1 Page 46 of 103

57 diltiazem hcl er capsule extended release 24 hour 120mg 1 QL (30 EA per 30 days) diltiazem hcl er capsule extended release 24 hour 180mg 1 diltiazem hcl er capsule extended release 24 hour 300mg 1 QL (30 EA per 30 days) diltiazem hcl er capsule extended release 24 hour 360mg 1 QL (30 EA per 30 days) diltiazem hcl er capsule extended release 24 hour 420mg 1 QL (30 EA per 30 days) DILTIAZEM HCL INJECTION 100MG 2 diltiazem hcl injection 50mg/10ml 1 diltiazem hcl tablet 120mg 1 diltiazem hcl tablet 30mg 1 diltiazem hcl tablet 60mg 1 diltiazem hcl tablet 90mg 1 felodipine er tablet extended release 24 hour 10mg 1 QL (30 EA per 30 days) felodipine er tablet extended release 24 hour 2.5mg 1 QL (30 EA per 30 days) felodipine er tablet extended release 24 hour 5mg 1 QL (30 EA per 30 days) matzim la tablet extended release 24 hour 180mg 1 matzim la tablet extended release 24 hour 240mg 1 matzim la tablet extended release 24 hour 300mg 1 matzim la tablet extended release 24 hour 360mg 1 QL (30 EA per 30 days) matzim la tablet extended release 24 hour 420mg 1 QL (30 EA per 30 days) nicardipine hcl capsule 20mg 1 nicardipine hcl capsule 30mg 1 nifediac cc tablet extended release 24 hour 90mg 1 QL (30 EA per 30 days) nifedical xl tablet extended release 24 hour 30mg 1 QL (30 EA per 30 days) nifedical xl tablet extended release 24 hour 60mg 1 QL (30 EA per 30 days) nifedipine er tablet extended release 24 hour 30mg 1 QL (30 EA per 30 days) nifedipine er tablet extended release 24 hour 60mg 1 QL (30 EA per 30 days) nifedipine er tablet extended release 24 hour 90mg 1 QL (30 EA per 30 days) taztia xt capsule extended release 24 hour 120mg 1 QL (30 EA per 30 days) taztia xt capsule extended release 24 hour 180mg 1 QL (30 EA per 30 days) taztia xt capsule extended release 24 hour 240mg 1 QL (30 EA per 30 days) taztia xt capsule extended release 24 hour 300mg 1 QL (30 EA per 30 days) taztia xt capsule extended release 24 hour 360mg 1 QL (30 EA per 30 days) verapamil hcl er capsule extended release 24 hour 100mg 1 QL (30 EA per 30 days) verapamil hcl er capsule extended release 24 hour 120mg 1 QL (30 EA per 30 days) verapamil hcl er capsule extended release 24 hour 180mg 1 QL (30 EA per 30 days) verapamil hcl er capsule extended release 24 hour 200mg 1 QL (30 EA per 30 days) verapamil hcl er capsule extended release 24 hour 240mg 1 QL (30 EA per 30 days) verapamil hcl er capsule extended release 24 hour 300mg 1 QL (30 EA per 30 days) verapamil hcl er tablet extended release 180mg 1 verapamil hcl er tablet extended release 240mg 1 verapamil hcl sr capsule extended release 24 hour 360mg 1 verapamil hcl injection 2.5mg/ml 1 verapamil hcl tablet 120mg 1 verapamil hcl tablet 40mg 1 verapamil hcl tablet 80mg 1 Cardiovascular Agents, Other DEMSER CAPSULE 250MG 2 digitek tablet 0.125mg 1 PA (High Risk Medication - Digoxin) MO Page 47 of 103

58 digitek tablet 0.25mg 1 PA (High Risk Medication - Digoxin) MO digoxin injection 0.25mg/ml 1 PA (High Risk Medication - Digoxin) digoxin solution 0.05mg/ml 1 PA (High Risk Medication - Digoxin) digoxin tablet 125mcg 1 digoxin tablet 250mcg 1 PA (High Risk Medication - Digoxin) LANOXIN PEDIATRIC INJECTION 0.1MG/ML 2 PA (High Risk Medication - Digoxin) LANOXIN INJECTION 0.25MG/ML 2 PA (High Risk Medication - Digoxin) LANOXIN TABLET 125MCG 2 LANOXIN TABLET 250MCG 2 PA (High Risk Medication - Digoxin) pentoxifylline er tablet extended release 400mg 1 RANEXA TABLET EXTENDED RELEASE 12 HOUR 1000MG 2 QL (60 EA per 30 days) PA (Cardiovascular Agents) MO RANEXA TABLET EXTENDED RELEASE 12 HOUR 500MG 2 QL (90 EA per 30 days) PA (Cardiovascular Agents) MO TEKTURNA HCT TABLET 150MG; 12.5MG 2 QL (30 EA per 30 days) TEKTURNA HCT TABLET 150MG; 25MG 2 QL (30 EA per 30 days) TEKTURNA HCT TABLET 300MG; 12.5MG 2 QL (30 EA per 30 days) TEKTURNA HCT TABLET 300MG; 25MG 2 QL (30 EA per 30 days) TEKTURNA TABLET 150MG 2 QL (30 EA per 30 days) TEKTURNA TABLET 300MG 2 QL (30 EA per 30 days) Diuretics, Carbonic Anhydrase Inhibitors acetazolamide sodium injection 500mg 1 acetazolamide tablet 125mg 1 acetazolamide tablet 250mg 1 Diuretics, Loop bumetanide injection 0.25mg/ml 1 bumetanide tablet 0.5mg 1 bumetanide tablet 1mg 1 bumetanide tablet 2mg 1 furosemide injection 10mg/ml 1 furosemide injection 10mg/ml 1 furosemide solution 10mg/ml 1 furosemide solution 8mg/ml 1 furosemide tablet 20mg 1 furosemide tablet 40mg 1 furosemide tablet 80mg 1 TORSEMIDE INJECTION 20MG/2ML 2 torsemide tablet 100mg 1 torsemide tablet 10mg 1 torsemide tablet 20mg 1 torsemide tablet 5mg 1 Diuretics, Potassium-sparing Page 48 of 103

59 amiloride hcl tablet 5mg 1 amiloride/hydrochlorothiazide tablet 5mg; 50mg 1 eplerenone tablet 25mg 1 eplerenone tablet 50mg 1 spironolactone/hydrochlorothiazide tablet 25mg; 25mg 1 spironolactone tablet 100mg 1 spironolactone tablet 25mg 1 spironolactone tablet 50mg 1 triamterene/hydrochlorothiazide capsule 25mg; 37.5mg 1 triamterene/hydrochlorothiazide capsule 25mg; 50mg 1 MO triamterene/hydrochlorothiazide tablet 25mg; 37.5mg 1 triamterene/hydrochlorothiazide tablet 50mg; 75mg 1 Diuretics, Thiazide chlorothiazide sodium injection 500mg 1 chlorothiazide tablet 250mg 1 chlorothiazide tablet 500mg 1 chlorthalidone tablet 25mg 1 chlorthalidone tablet 50mg 1 hydrochlorothiazide capsule 12.5mg 1 hydrochlorothiazide tablet 12.5mg 1 hydrochlorothiazide tablet 25mg 1 hydrochlorothiazide tablet 50mg 1 indapamide tablet 1.25mg 1 indapamide tablet 2.5mg 1 methyclothiazide tablet 5mg 1 metolazone tablet 10mg 1 metolazone tablet 2.5mg 1 metolazone tablet 5mg 1 Dyslipidemics, Fibric Acid Derivatives fenofibrate micronized capsule 134mg 1 QL (30 EA per 30 days) fenofibrate micronized capsule 200mg 1 QL (30 EA per 30 days) fenofibrate micronized capsule 67mg 1 QL (30 EA per 30 days) fenofibrate capsule 130mg 1 QL (30 EA per 30 days) MO fenofibrate capsule 43mg 1 QL (30 EA per 30 days) MO fenofibrate tablet 145mg 1 QL (30 EA per 30 days) fenofibrate tablet 160mg 1 QL (30 EA per 30 days) fenofibrate tablet 48mg 1 QL (30 EA per 30 days) fenofibrate tablet 54mg 1 QL (30 EA per 30 days) gemfibrozil tablet 600mg 1 QL (60 EA per 30 days) Dyslipidemics, HMG CoA Reductase Inhibitors atorvastatin calcium tablet 10mg 1 QL (30 EA per 30 days) atorvastatin calcium tablet 20mg 1 QL (30 EA per 30 days) atorvastatin calcium tablet 40mg 1 QL (30 EA per 30 days) atorvastatin calcium tablet 80mg 1 QL (30 EA per 30 days) lovastatin tablet 10mg 1 QL (30 EA per 30 days) lovastatin tablet 20mg 1 QL (30 EA per 30 days) lovastatin tablet 40mg 1 QL (60 EA per 30 days) pravastatin sodium tablet 10mg 1 QL (30 EA per 30 days) pravastatin sodium tablet 20mg 1 QL (30 EA per 30 days) Page 49 of 103

60 pravastatin sodium tablet 40mg 1 QL (30 EA per 30 days) pravastatin sodium tablet 80mg 1 QL (30 EA per 30 days) simvastatin tablet 10mg 1 QL (30 EA per 30 days) simvastatin tablet 20mg 1 QL (30 EA per 30 days) simvastatin tablet 40mg 1 QL (30 EA per 30 days) simvastatin tablet 5mg 1 QL (30 EA per 30 days) simvastatin tablet 80mg 1 QL (30 EA per 30 days) Dyslipidemics, Other cholestyramine light packet 4gm 1 colestipol hcl granules 5gm 1 colestipol hcl tablet 1gm 1 niacin er tablet extended release 1000mg 1 QL (60 EA per 30 days) MO niacin er tablet extended release 500mg 1 QL (30 EA per 30 days) MO niacin er tablet extended release 750mg 1 QL (60 EA per 30 days) MO niacor tablet 500mg 1 omega-3-acid ethyl esters capsule 375mg; 465mg; 1gm 1 QL (120 EA per 30 days) MO prevalite powder 4gm/dose 1 WELCHOL PACKET 3.75GM 2 WELCHOL TABLET 625MG 2 ZETIA TABLET 10MG 2 QL (30 EA per 30 days) Vasodilators, Direct-acting Arterial/Venous BIDIL TABLET 37.5MG; 20MG 2 QL (180 EA per 30 days) isosorbide dinitrate er tablet extended release 40mg 1 isosorbide dinitrate tablet sublingual 2.5mg 1 isosorbide dinitrate tablet 10mg 1 isosorbide dinitrate tablet 20mg 1 isosorbide dinitrate tablet 30mg 1 isosorbide dinitrate tablet 5mg 1 isosorbide mononitrate er tablet extended release 24 hour 1 120mg isosorbide mononitrate er tablet extended release 24 hour 1 30mg isosorbide mononitrate er tablet extended release 24 hour 1 60mg isosorbide mononitrate tablet 10mg 1 isosorbide mononitrate tablet 20mg 1 NITRO-DUR PATCH 24 HOUR 0.3MG/HR 2 NITRO-DUR PATCH 24 HOUR 0.8MG/HR 2 nitroglycerin transdermal patch 24 hour 0.1mg/hr 1 NITROGLYCERIN INJECTION 5MG/ML 2 nitroglycerin patch 24 hour 0.2mg/hr 1 nitroglycerin patch 24 hour 0.4mg/hr 1 nitroglycerin patch 24 hour 0.6mg/hr 1 NITROSTAT TABLET SUBLINGUAL 0.3MG 2 NITROSTAT TABLET SUBLINGUAL 0.4MG 2 NITROSTAT TABLET SUBLINGUAL 0.6MG 2 Vasodilators, Direct-acting Arterial hydralazine hcl injection 20mg/ml 1 hydralazine hcl tablet 100mg 1 Page 50 of 103

61 hydralazine hcl tablet 10mg 1 hydralazine hcl tablet 25mg 1 hydralazine hcl tablet 50mg 1 minoxidil tablet 10mg 1 minoxidil tablet 2.5mg 1 Central Nervous System Agents Attention Deficit Hyperactivity Disorder Agents, Amphetamines amphetamine/dextroamphetamine tablet 1.25mg; 1.25mg; 1.25mg; 1.25mg Page 51 of 103 Tier Requirements/Limits 1 QL (90 EA per 30 days) amphetamine/dextroamphetamine tablet 1.875mg; 1.875mg; 1 QL (90 EA per 30 days) 1.875mg; 1.875mg amphetamine/dextroamphetamine tablet 2.5mg; 2.5mg; 1 QL (90 EA per 30 days) 2.5mg; 2.5mg amphetamine/dextroamphetamine tablet 3.125mg; 3.125mg; 1 QL (90 EA per 30 days) 3.125mg; 3.125mg amphetamine/dextroamphetamine tablet 3.75mg; 3.75mg; 1 QL (90 EA per 30 days) 3.75mg; 3.75mg amphetamine/dextroamphetamine tablet 5mg; 5mg; 5mg; 5mg 1 QL (60 EA per 30 days) amphetamine/dextroamphetamine tablet 7.5mg; 7.5mg; 1 QL (60 EA per 30 days) 7.5mg; 7.5mg dextroamphetamine sulfate tablet 10mg 1 dextroamphetamine sulfate tablet 5mg 1 Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines guanfacine er tablet extended release 24 hour 1mg 1 QL (30 EA per 30 days) MO guanfacine er tablet extended release 24 hour 2mg 1 QL (30 EA per 30 days) MO guanfacine er tablet extended release 24 hour 3mg 1 QL (30 EA per 30 days) MO guanfacine er tablet extended release 24 hour 4mg 1 QL (30 EA per 30 days) MO INTUNIV TABLET EXTENDED RELEASE 24 HOUR 1MG 2 QL (30 EA per 30 days) INTUNIV TABLET EXTENDED RELEASE 24 HOUR 2MG 2 QL (30 EA per 30 days) INTUNIV TABLET EXTENDED RELEASE 24 HOUR 3MG 2 QL (30 EA per 30 days) INTUNIV TABLET EXTENDED RELEASE 24 HOUR 4MG 2 QL (30 EA per 30 days) METADATE CD CAPSULE EXTENDED RELEASE 20MG 2 QL (60 EA per 30 days) METADATE CD CAPSULE EXTENDED RELEASE 30MG 2 methylphenidate hcl cd capsule extended release 10mg 1 QL (30 EA per 30 days) methylphenidate hcl cd capsule extended release 20mg 1 QL (30 EA per 30 days) methylphenidate hcl cd capsule extended release 20mg 1 QL (30 EA per 30 days) methylphenidate hcl cd capsule extended release 30mg 1 QL (30 EA per 30 days) methylphenidate hcl cd capsule extended release 30mg 1 QL (30 EA per 30 days) methylphenidate hcl cd capsule extended release 40mg 1 QL (30 EA per 30 days) methylphenidate hcl cd capsule extended release 40mg 1 QL (30 EA per 30 days) methylphenidate hcl cd capsule extended release 50mg 1 QL (30 EA per 30 days) methylphenidate hcl cd capsule extended release 60mg 1 QL (30 EA per 30 days) methylphenidate hcl er tablet extended release 20mg 1 QL (90 EA per 30 days) methylphenidate hcl tablet 10mg 1 QL (90 EA per 30 days) methylphenidate hcl tablet 20mg 1 QL (90 EA per 30 days) methylphenidate hcl tablet 5mg 1 QL (90 EA per 30 days) STRATTERA CAPSULE 100MG 2 QL (60 EA per 30 days) STRATTERA CAPSULE 10MG 2 QL (60 EA per 30 days)

62 STRATTERA CAPSULE 18MG 2 QL (60 EA per 30 days) STRATTERA CAPSULE 25MG 2 QL (60 EA per 30 days) STRATTERA CAPSULE 40MG 2 QL (60 EA per 30 days) STRATTERA CAPSULE 60MG 2 QL (60 EA per 30 days) STRATTERA CAPSULE 80MG 2 QL (60 EA per 30 days) Central Nervous System, Other NUEDEXTA CAPSULE 20MG; 10MG 2 QL (60 EA per 30 days) riluzole tablet 50mg 1 XENAZINE TABLET 12.5MG 2 QL (180 EA per 30 days) PA (Miscellaneous Therapeutic Agents - Xenazine) XENAZINE TABLET 25MG 2 QL (120 EA per 30 days) PA (Miscellaneous Therapeutic Agents - Xenazine) Fibromyalgia Agents SAVELLA TITRATION PACK MISCELLANEOUS 0 2 SAVELLA TABLET 100MG 2 QL (60 EA per 30 days) SAVELLA TABLET 12.5MG 2 QL (60 EA per 30 days) SAVELLA TABLET 25MG 2 QL (60 EA per 30 days) SAVELLA TABLET 50MG 2 QL (60 EA per 30 days) Multiple Sclerosis Agents AUBAGIO TABLET 14MG 2 QL (30 EA per 30 days) AUBAGIO TABLET 7MG 2 QL (30 EA per 30 days) AVONEX INJECTION 30MCG/0.5ML 2 AVONEX INJECTION 30MCG/VIAL 2 BETASERON INJECTION 0.3MG 2 COPAXONE INJECTION 20MG/ML 2 GILENYA CAPSULE 0.5MG 2 REBIF TITRATION PACK INJECTION 0 2 REBIF INJECTION 22MCG/0.5ML 2 REBIF INJECTION 44MCG/0.5ML 2 TYSABRI INJECTION 300MG/15ML 2 Dental and Oral Agents Dental and Oral Agents chlorhexidine gluconate oral rinse solution 0.12% 1 KEPIVANCE INJECTION 6.25MG 2 periogard solution 0.12% 1 pilocarpine hcl tablet 7.5mg 1 pilocarpine hydrochloride tablet 5mg 1 triamcinolone in orabase paste 0.1% 1 Dermatological Agents Dermatological Agents adapalene cream 0.1% 1 adapalene gel 0.1% 1 ammonium lactate cream 12% 1 ammonium lactate lotion 12% 1 calcipotriene cream 0.005% 1 QL (240 GM per 30 days) calcipotriene solution 0.005% 1 QL (60 ML per 30 days) claravis capsule 10mg 1 Page 52 of 103

63 claravis capsule 20mg 1 claravis capsule 30mg 1 claravis capsule 40mg 1 clindamycin/benzoyl peroxide gel 5%; 1% 1 clotrimazole/betamethasone dipropionate cream 0.05%; 1% 1 clotrimazole/betamethasone dipropionate lotion 0.05%; 1% 1 curity gauze pads 2"x2" pad 1 QL (204 EA per 30 days) ELIDEL CREAM 1% 2 QL (60 GM per 30 days) PA (Dermatological Agents) erythromycin/benzoyl peroxide gel 5%; 3% 1 fluorouracil cream 5% 1 fluorouracil solution 2% 1 fluorouracil solution 5% 1 imiquimod cream 5% 1 QL (24 EA per 30 days) laclotion lotion 12% 1 methoxsalen capsule 10mg 1 OXSORALEN LOTION 1% 2 PICATO GEL 0.015% 2 PICATO GEL 0.05% 2 podofilox solution 0.5% 1 PROTOPIC OINTMENT 0.03% 2 QL (60 GM per 30 days) PA (Dermatological Agents) PROTOPIC OINTMENT 0.1% 2 QL (60 GM per 30 days) PA (Dermatological Agents) SANTYL OINTMENT 250UNIT/GM 2 selenium sulfide lotion 2.5% 1 SORIATANE CAPSULE 10MG 2 SORIATANE CAPSULE 17.5MG 2 SORIATANE CAPSULE 25MG 2 tacrolimus ointment 0.03% 1 QL (60 GM per 30 days) PA (Dermatological Agents) tacrolimus ointment 0.1% 1 QL (60 GM per 30 days) PA (Dermatological Agents) TAZORAC CREAM 0.05% 2 TAZORAC CREAM 0.1% 2 TAZORAC GEL 0.05% 2 TAZORAC GEL 0.1% 2 tretinoin cream 0.025% 1 tretinoin cream 0.05% 1 tretinoin cream 0.1% 1 tretinoin gel 0.01% 1 QL (90 GM per 30 days) tretinoin gel 0.025% 1 QL (90 GM per 30 days) UVADEX INJECTION 20MCG/ML 2 VEREGEN OINTMENT 15% 2 QL (15 GM per 30 days) VOLTAREN GEL 1% 2 ZONALON CREAM 5% 2 Enzyme Replacement/Modifiers Enzyme Replacement/Modifiers ADAGEN INJECTION 250UNIT/ML 2 Page 53 of 103

64 ALDURAZYME INJECTION 2.9MG/5ML 2 BUPHENYL TABLET 500MG 2 CEREZYME INJECTION 400UNIT 2 CREON CAPSULE DELAYED RELEASE PARTICLES UNIT; 24000UNIT; 76000UNIT CREON CAPSULE DELAYED RELEASE PARTICLES UNIT; 3000UNIT; 9500UNIT CREON CAPSULE DELAYED RELEASE PARTICLES UNIT; 36000UNIT; UNIT CREON CAPSULE DELAYED RELEASE PARTICLES UNIT; 6000UNIT; 19000UNIT CREON CAPSULE DELAYED RELEASE PARTICLES UNIT; 12000UNIT; 38000UNIT CYSTADANE POWDER 0 2 CYSTAGON CAPSULE 150MG 2 CYSTAGON CAPSULE 50MG 2 ELAPRASE INJECTION 6MG/3ML 2 ELELYSO INJECTION 200UNIT 2 FABRAZYME INJECTION 35MG 2 KUVAN TABLET SOLUBLE 100MG 2 PA (Enzyme Replacements/ Modifiers - Kuvan) LUMIZYME INJECTION 50MG 2 NAGLAZYME INJECTION 1MG/ML 2 PANCREAZE CAPSULE DELAYED RELEASE 2 PARTICLES 17500UNIT; 4200UNIT; 10000UNIT PANCREAZE CAPSULE DELAYED RELEASE 2 PARTICLES 43750UNIT; 10500UNIT; 25000UNIT PANCREAZE CAPSULE DELAYED RELEASE 2 PARTICLES 61000UNIT; 21000UNIT; 37000UNIT PANCREAZE CAPSULE DELAYED RELEASE 2 PARTICLES 70000UNIT; 16800UNIT; 40000UNIT sodium phenylbutyrate powder 3gm/tsp 1 SUCRAID SOLUTION 8500UNIT/ML 2 VPRIV INJECTION 400UNIT 2 ZAVESCA CAPSULE 100MG 2 ZENPEP CAPSULE DELAYED RELEASE PARTICLES UNIT; 20000UNIT; 68000UNIT ZENPEP CAPSULE DELAYED RELEASE PARTICLES UNIT; 25000UNIT; 85000UNIT ZENPEP CAPSULE DELAYED RELEASE PARTICLES UNIT; 3000UNIT; 10000UNIT ZENPEP CAPSULE DELAYED RELEASE PARTICLES 2 MO UNIT; 40000UNIT; UNIT ZENPEP CAPSULE DELAYED RELEASE PARTICLES UNIT; 5000UNIT; 17000UNIT ZENPEP CAPSULE DELAYED RELEASE PARTICLES UNIT; 10000UNIT; 34000UNIT ZENPEP CAPSULE DELAYED RELEASE PARTICLES 82000UNIT; 15000UNIT; 51000UNIT 2 Page 54 of 103

65 Gastrointestinal Agents Antispasmodics, Gastrointestinal ATROPINE SULFATE INJECTION 0.05MG/ML 2 atropine sulfate injection 0.1mg/ml 1 dicyclomine hcl capsule 10mg 1 dicyclomine hcl solution 10mg/5ml 1 dicyclomine hcl tablet 20mg 1 glycopyrrolate injection 4mg/20ml 1 glycopyrrolate tablet 1mg 1 glycopyrrolate tablet 2mg 1 methscopolamine bromide tablet 2.5mg 1 Gastrointestinal Agents, Other cromolyn sodium concentrate 100mg/5ml 1 diphenoxylate/atropine tablet 0.025mg; 2.5mg 1 loperamide hcl capsule 2mg 1 metoclopramide hcl injection 5mg/ml 1 metoclopramide hcl solution 5mg/5ml 1 metoclopramide hcl tablet 10mg 1 metoclopramide hcl tablet 5mg 1 RELISTOR INJECTION 12MG/0.6ML 2 ursodiol capsule 300mg 1 ursodiol tablet 250mg 1 ursodiol tablet 500mg 1 Histamine2 (H2) Receptor Antagonists cimetidine hcl solution 300mg/5ml 1 cimetidine tablet 200mg 1 cimetidine tablet 300mg 1 cimetidine tablet 400mg 1 cimetidine tablet 800mg 1 FAMOTIDINE PREMIXED INJECTION 0.4MG/ML; 0.9% 2 famotidine injection 20mg/2ml 1 famotidine tablet 20mg 1 famotidine tablet 40mg 1 ranitidine hcl capsule 150mg 1 ranitidine hcl capsule 300mg 1 ranitidine hcl injection 150mg/6ml 1 ranitidine hcl syrup 15mg/ml 1 ranitidine hcl tablet 150mg 1 ranitidine hcl tablet 300mg 1 ZANTAC INJECTION 25MG/ML 2 ZANTAC INJECTION 25MG/ML 2 ZANTAC INJECTION 50MG/50ML; 0.45% 2 Irritable Bowel Syndrome Agents AMITIZA CAPSULE 24MCG 2 AMITIZA CAPSULE 8MCG 2 LOTRONEX TABLET 0.5MG 2 QL (60 EA per 30 days) PA (Irritable Bowel Syndrome Agents) LOTRONEX TABLET 1MG 2 QL (60 EA per 30 days) PA (Irritable Bowel Syndrome Agents) Page 55 of 103

66 Laxatives constulose solution 10gm/15ml 1 enulose solution 10gm/15ml 1 gavilyte-c solution reconstituted 240gm; 2.98gm; 6.72gm; gm; 22.72gm gavilyte-g solution reconstituted 236gm; 2.97gm; 6.74gm; gm; 22.74gm gavilyte-n/flavor pack solution reconstituted 420gm; 1.48gm; gm; 11.2gm generlac solution 10gm/15ml 1 lactulose solution 10gm/15ml 1 NULYTELY/FLAVOR PACKS SOLUTION 2 RECONSTITUTED 420GM; 1.48GM; 5.72GM; 11.2GM polyethylene glycol 3350 powder 0 1 trilyte solution reconstituted 420gm; 1.48gm; 5.72gm; 11.2gm 1 Protectants misoprostol tablet 100mcg 1 misoprostol tablet 200mcg 1 sucralfate tablet 1gm 1 Proton Pump Inhibitors esomeprazole sodium injection 20mg 1 MO esomeprazole sodium injection 40mg 1 omeprazole capsule delayed release 10mg 1 QL (30 EA per 30 days) omeprazole capsule delayed release 20mg 1 QL (90 EA per 30 days) omeprazole capsule delayed release 40mg 1 QL (90 EA per 30 days) pantoprazole sodium tablet delayed release 20mg 1 QL (30 EA per 30 days) pantoprazole sodium tablet delayed release 40mg 1 QL (60 EA per 30 days) MO PROTONIX INJECTION 40MG 2 Genitourinary Agents Antispasmodics, Urinary flavoxate hcl tablet 100mg 1 oxybutynin chloride er tablet extended release 24 hour 10mg 1 oxybutynin chloride er tablet extended release 24 hour 15mg 1 oxybutynin chloride er tablet extended release 24 hour 5mg 1 oxybutynin chloride tablet 5mg 1 tolterodine tartrate er capsule extended release 24 hour 2mg 1 QL (30 EA per 30 days) MO tolterodine tartrate er capsule extended release 24 hour 4mg 1 QL (30 EA per 30 days) MO tolterodine tartrate tablet 1mg 1 QL (60 EA per 30 days) tolterodine tartrate tablet 2mg 1 QL (60 EA per 30 days) Benign Prostatic Hypertrophy Agents alfuzosin hcl er tablet extended release 24 hour 10mg 1 QL (30 EA per 30 days) AVODART CAPSULE 0.5MG 2 QL (30 EA per 30 days) doxazosin mesylate tablet 1mg 1 doxazosin mesylate tablet 2mg 1 doxazosin mesylate tablet 4mg 1 doxazosin mesylate tablet 8mg 1 finasteride tablet 5mg 1 QL (30 EA per 30 days) tamsulosin hcl capsule 0.4mg 1 QL (60 EA per 30 days) terazosin hcl capsule 10mg 1 Page 56 of 103

67 Name Tier terazosin hcl capsule 1mg 1 terazosin hcl capsule 2mg 1 terazosin hcl capsule 5mg 1 Genitourinary Agents, Other bethanechol chloride tablet 10mg 1 bethanechol chloride tablet 25mg 1 bethanechol chloride tablet 50mg 1 bethanechol chloride tablet 5mg 1 ELMIRON CAPSULE 100MG 2 Phosphate Binders calcium acetate capsule 667mg 1 calcium acetate tablet 667mg 1 ELIPHOS TABLET 667MG 2 FOSRENOL TABLET CHEWABLE 1000MG 2 FOSRENOL TABLET CHEWABLE 500MG 2 FOSRENOL TABLET CHEWABLE 750MG 2 RENVELA TABLET 800MG 2 Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) a-hydrocort injection 100mg 1 alclometasone dipropionate cream 0.05% 1 alclometasone dipropionate ointment 0.05% 1 amcinonide cream 0.1% 1 amcinonide lotion 0.1% 1 amcinonide ointment 0.1% 1 augmented betamethasone dipropionate cream 0.05% 1 augmented betamethasone dipropionate gel 0.05% 1 augmented betamethasone dipropionate lotion 0.05% 1 augmented betamethasone dipropionate ointment 0.05% 1 betamethasone dipropionate cream 0.05% 1 betamethasone dipropionate lotion 0.05% 1 betamethasone dipropionate ointment 0.05% 1 betamethasone valerate cream 0.1% 1 betamethasone valerate lotion 0.1% 1 betamethasone valerate ointment 0.1% 1 budesonide capsule extended release 24 hour 3mg 1 clobetasol propionate e cream 0.05% 1 clobetasol propionate gel 0.05% 1 clobetasol propionate ointment 0.05% 1 clobetasol propionate shampoo 0.05% 1 clobetasol propionate solution 0.05% 1 clodan shampoo 0.05% 1 cortisone acetate tablet 25mg 1 DEPO-MEDROL INJECTION 20MG/ML 2 desonide cream 0.05% 1 desonide lotion 0.05% 1 desonide ointment 0.05% 1 desoximetasone cream 0.05% 1 desoximetasone cream 0.25% 1 Requirements/Limits Page 57 of 103

68 Name Tier desoximetasone gel 0.05% 1 desoximetasone ointment 0.05% 1 desoximetasone ointment 0.25% 1 dexamethasone sodium phosphate injection 120mg/30ml 1 dexamethasone elixir 0.5mg/5ml 1 dexamethasone tablet 0.5mg 1 dexamethasone tablet 0.75mg 1 dexamethasone tablet 1.5mg 1 dexamethasone tablet 1mg 1 dexamethasone tablet 2mg 1 dexamethasone tablet 4mg 1 dexamethasone tablet 6mg 1 fludrocortisone acetate tablet 0.1mg 1 fluocinolone acetonide cream 0.01% 1 fluocinolone acetonide cream 0.025% 1 fluocinolone acetonide oil 0.01% 1 fluocinolone acetonide ointment 0.025% 1 fluocinolone acetonide solution 0.01% 1 fluocinonide-e cream 0.05% 1 fluocinonide gel 0.05% 1 fluocinonide ointment 0.05% 1 fluocinonide solution 0.05% 1 fluticasone propionate cream 0.05% 1 fluticasone propionate ointment 0.005% 1 halobetasol propionate cream 0.05% 1 halobetasol propionate ointment 0.05% 1 hydrocortisone butyrate cream 0.1% 1 hydrocortisone butyrate ointment 0.1% 1 hydrocortisone butyrate solution 0.1% 1 hydrocortisone valerate cream 0.2% 1 hydrocortisone valerate ointment 0.2% 1 hydrocortisone cream 1% 1 hydrocortisone cream 2.5% 1 hydrocortisone enema 100mg/60ml 1 hydrocortisone lotion 2.5% 1 hydrocortisone ointment 1% 1 hydrocortisone ointment 2.5% 1 hydrocortisone tablet 10mg 1 hydrocortisone tablet 20mg 1 hydrocortisone tablet 5mg 1 methylprednisolone acetate injection 40mg/ml 1 methylprednisolone acetate injection 80mg/ml 1 methylprednisolone dose pack tablet 4mg 1 methylprednisolone sodiumsuccinate injection 125mg 1 methylprednisolone sodiumsuccinate injection 1gm 1 methylprednisolone sodiumsuccinate injection 40mg 1 methylprednisolone tablet 16mg 1 methylprednisolone tablet 32mg 1 methylprednisolone tablet 4mg 1 Requirements/Limits Page 58 of 103

69 methylprednisolone tablet 8mg 1 mometasone furoate cream 0.1% 1 mometasone furoate ointment 0.1% 1 prednicarbate cream 0.1% 1 prednisolone sodium phosphate solution 15mg/5ml 1 prednisolone sodium phosphate solution 25mg/5ml 1 prednisolone sodium phosphate solution 5mg/5ml 1 prednisone solution 5mg/5ml 1 prednisone tablet 10mg 1 prednisone tablet 1mg 1 prednisone tablet 2.5mg 1 prednisone tablet 20mg 1 prednisone tablet 50mg 1 prednisone tablet 5mg 1 PROCTO-PAK CREAM 1% 2 proctocream hc cream 2.5% 1 proctosol hc cream 2.5% 1 proctozone-hc cream 2.5% 1 SOLU-CORTEF INJECTION 100MG 2 SOLU-CORTEF INJECTION 250MG 2 SOLU-MEDROL INJECTION 125MG 2 SOLU-MEDROL INJECTION 2GM 2 SOLU-MEDROL INJECTION 40MG 2 SOLU-MEDROL INJECTION 500MG 2 triamcinolone acetonide cream 0.025% 1 triamcinolone acetonide cream 0.1% 1 triamcinolone acetonide cream 0.5% 1 triamcinolone acetonide lotion 0.025% 1 triamcinolone acetonide lotion 0.1% 1 triamcinolone acetonide ointment 0.025% 1 triamcinolone acetonide ointment 0.1% 1 triamcinolone acetonide ointment 0.5% 1 triderm cream 0.1% 1 u-cort cream 1%; 10% 1 Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) chorionic gonadotropin injection 10000unit 1 desmopressin acetate injection 4mcg/ml 1 desmopressin acetate tablet 0.1mg 1 desmopressin acetate tablet 0.2mg 1 INCRELEX INJECTION 40MG/4ML 2 NORDITROPIN FLEXPRO INJECTION 15MG/1.5ML 2 PA (Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary)) NORDITROPIN FLEXPRO INJECTION 5MG/1.5ML 2 PA (Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary)) NORDITROPIN NORDIFLEX PEN INJECTION 30MG/3ML 2 PA (Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary)) NUTROPIN INJECTION 10MG 2 PA (Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary)) Page 59 of 103

70 pregnyl w/diluent benzyl alcohol/nacl injection 10000unit 1 SAIZEN CLICK.EASY INJECTION 8.8MG 2 PA (Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary)) SAIZEN INJECTION 5MG 2 PA (Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary)) SEROSTIM INJECTION 4MG 2 PA (Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary) - Serostim) SEROSTIM INJECTION 5MG 2 PA (Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary) - Serostim) SEROSTIM INJECTION 6MG 2 PA (Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary) - Serostim) STIMATE SOLUTION 1.5MG/ML 2 TEV-TROPIN INJECTION 5MG 2 PA (Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary)) ZORBTIVE INJECTION 8.8MG 2 PA (Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary) - Zorbtive) Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) KORLYM TABLET 300MG 2 QL (120 EA per 30 days) Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) Anabolic Steroids oxandrolone tablet 10mg 1 oxandrolone tablet 2.5mg 1 Androgens ANDRODERM PATCH 24 HOUR 2MG/24HR 2 ANDRODERM PATCH 24 HOUR 4MG/24HR 2 ANDROXY TABLET 10MG 2 danazol capsule 100mg 1 danazol capsule 200mg 1 danazol capsule 50mg 1 METHITEST TABLET 10MG 2 testosterone cypionate injection 100mg/ml 1 testosterone cypionate injection 200mg/ml 1 testosterone enanthate injection 200mg/ml 1 Estrogens ALORA PATCH TWICE WEEKLY 0.025MG/24HR 2 QL (8 EA per 28 days) PA (High Risk Medications) ALORA PATCH TWICE WEEKLY 0.05MG/24HR 2 QL (8 EA per 28 days) PA (High Risk Medications) ALORA PATCH TWICE WEEKLY 0.075MG/24HR 2 QL (8 EA per 28 days) PA (High Risk Medications) Page 60 of 103

71 ALORA PATCH TWICE WEEKLY 0.1MG/24HR 2 QL (8 EA per 28 days) PA (High Risk Medications) apri tablet 0.15mg; 30mcg 1 aranelle tablet 0; 0 1 aubra tablet 20mcg; 0.1mg 1 MO aviane tablet 20mcg; 0.1mg 1 balziva tablet 35mcg; 0.4mg 1 CLIMARA PRO PATCH WEEKLY 0.045MG/DAY; 0.015MG/DAY 2 QL (4 EA per 28 days) PA (High Risk Medications) cryselle-28 tablet 30mcg; 0.3mg 1 cyclafem 1/35 tablet 35mcg; 1mg 1 delyla tablet 20mcg; 0.1mg 1 MO DEPO-ESTRADIOL INJECTION 5MG/ML 2 desogestrel/ethinyl estradiol tablet 0; 0 1 MO enpresse-28 tablet 0; 0 1 ESTRACE CREAM 0.1MG/GM 2 estradiol valerate injection 20mg/ml 1 estradiol patch weekly 0.025mg/24hr 1 QL (4 EA per 28 days) PA (High Risk Medications) estradiol patch weekly 0.05mg/24hr 1 QL (4 EA per 28 days) PA (High Risk Medications) estradiol patch weekly 0.06mg/24hr 1 QL (4 EA per 28 days) PA (High Risk Medications) estradiol patch weekly 0.075mg/24hr 1 QL (4 EA per 28 days) PA (High Risk Medications) estradiol patch weekly 0.1mg/24hr 1 QL (4 EA per 28 days) PA (High Risk Medications) estradiol patch weekly 37.5mcg/24hr 1 QL (4 EA per 28 days) PA (High Risk Medications) estradiol tablet 0.5mg 1 PA (High Risk Medications) estradiol tablet 1mg 1 PA (High Risk Medications) estradiol tablet 2mg 1 PA (High Risk Medications) estropipate tablet 0.75mg 1 PA (High Risk Medications) estropipate tablet 1.5mg 1 PA (High Risk Medications) estropipate tablet 3mg 1 PA (High Risk Medications) falmina tablet 20mcg; 0.1mg 1 MO gildess 1.5/30 tablet 30mcg; 1.5mg 1 MO introvale tablet 0.03mg; 0.15mg 1 junel 1.5/30 tablet 30mcg; 1.5mg 1 junel 1/20 tablet 20mcg; 1mg 1 junel fe 1.5/30 tablet 30mcg; 75mg; 1.5mg 1 junel fe 1/20 tablet 20mcg; 75mg; 1mg 1 kariva tablet 0; 0 1 kelnor 1/35 tablet 35mcg; 1mg 1 larin 1.5/30 tablet 30mcg; 1.5mg 1 MO leena tablet 0; 0 1 lessina tablet 20mcg; 0.1mg 1 levora 0.15/30-28 tablet 30mcg; 0.15mg 1 loestrin 24 fe tablet 20mcg; 75mg; 1mg 1 Page 61 of 103

72 low-ogestrel tablet 30mcg; 0.3mg 1 lutera tablet 20mcg; 0.1mg 1 marlissa tablet 0.03mg; 0.15mg 1 MENEST TABLET 0.3MG 2 PA (High Risk Medications) MENEST TABLET 0.625MG 2 PA (High Risk Medications) MENEST TABLET 1.25MG 2 PA (High Risk Medications) MENEST TABLET 2.5MG 2 PA (High Risk Medications) microgestin 1.5/30 tablet 30mcg; 1.5mg 1 microgestin 1/20 tablet 20mcg; 1mg 1 microgestin fe 1.5/30 tablet 30mcg; 75mg; 1.5mg 1 microgestin fe tablet 20mcg; 75mg; 1mg 1 mononessa tablet 35mcg; 0.25mg 1 necon 0.5/35-28 tablet 35mcg; 0.5mg 1 necon 1/35 tablet 35mcg; 1mg 1 necon 10/11-28 tablet 35mcg; 0 1 necon 7/7/7 tablet 0; 0 1 nortrel 0.5/35 (28) tablet 35mcg; 0.5mg 1 nortrel 1/35 tablet 35mcg; 1mg 1 nortrel 1/35 tablet 35mcg; 1mg 1 nortrel 7/7/7 tablet 0; 0 1 OGESTREL TABLET 50MCG; 0.5MG 2 portia-28 tablet 0.03mg; 0.15mg 1 PREMARIN CREAM 0.625MG/GM 2 PREMARIN INJECTION 25MG 2 PREMARIN TABLET 0.3MG 2 QL (30 EA per 30 days) PA (High Risk Medications) PREMARIN TABLET 0.45MG 2 QL (30 EA per 30 days) PA (High Risk Medications) PREMARIN TABLET 0.625MG 2 QL (30 EA per 30 days) PA (High Risk Medications) PREMARIN TABLET 0.9MG 2 QL (30 EA per 30 days) PA (High Risk Medications) PREMARIN TABLET 1.25MG 2 QL (30 EA per 30 days) PA (High Risk Medications) PREMPHASE TABLET 0.625MG; 5MG 2 PA (High Risk Medications) PREMPRO TABLET 0.3MG; 1.5MG 2 QL (30 EA per 30 days) PA (High Risk Medications) PREMPRO TABLET 0.45MG; 1.5MG 2 QL (30 EA per 30 days) PA (High Risk Medications) PREMPRO TABLET 0.625MG; 2.5MG 2 QL (30 EA per 30 days) PA (High Risk Medications) PREMPRO TABLET 0.625MG; 5MG 2 QL (30 EA per 30 days) PA (High Risk Medications) previfem tablet 35mcg; 0.25mg 1 quasense tablet 0.03mg; 0.15mg 1 QL (91 EA per 91 days) sprintec 28 tablet 35mcg; 0.25mg 1 sronyx tablet 20mcg; 0.1mg 1 tri-previfem tablet 0; 0 1 tri-sprintec tablet 0; 0 1 Page 62 of 103

73 trinessa tablet 0; 0 1 trivora-28 tablet 0; 0 1 velivet tablet 0; 0 1 xulane patch weekly 35mcg/24hr; 150mcg/24hr 1 QL (3 EA per 28 days) MO zovia 1/35e tablet 35mcg; 1mg 1 zovia 1/50e tablet 50mcg; 1mg 1 Progesterone Agonists/Antagonists ELLA TABLET 30MG 2 QL (30 EA per 30 days) Progestins camila tablet 0.35mg 1 deblitane tablet 0.35mg 1 MO DEPO-SUBQ PROVERA 104 INJECTION 104MG/0.65ML 2 errin tablet 0.35mg 1 jolivette tablet 0.35mg 1 lyza tablet 0.35mg 1 MO medroxyprogesterone acetate injection 150mg/ml 1 medroxyprogesterone acetate tablet 10mg 1 medroxyprogesterone acetate tablet 2.5mg 1 medroxyprogesterone acetate tablet 5mg 1 megestrol acetate suspension 40mg/ml 1 PA (High Risk Medications) megestrol acetate tablet 20mg 1 megestrol acetate tablet 40mg 1 nora-be tablet 0.35mg 1 norethindrone acetate tablet 5mg 1 norethindrone tablet 0.35mg 1 MO norlyroc tablet 0.35mg 1 MO progesterone capsule 100mg 1 progesterone capsule 200mg 1 PROMETRIUM CAPSULE 100MG 2 PROMETRIUM CAPSULE 200MG 2 sharobel tablet 0.35mg 1 MO Selective Estrogen Receptor Modifying Agents EVISTA TABLET 60MG 2 QL (30 EA per 30 days) raloxifene hydrochloride tablet 60mg 1 QL (30 EA per 30 days) MO Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) CYTOMEL TABLET 25MCG 2 CYTOMEL TABLET 50MCG 2 CYTOMEL TABLET 5MCG 2 levothyroxine sodium tablet 100mcg 1 levothyroxine sodium tablet 112mcg 1 levothyroxine sodium tablet 125mcg 1 levothyroxine sodium tablet 137mcg 1 levothyroxine sodium tablet 150mcg 1 levothyroxine sodium tablet 175mcg 1 levothyroxine sodium tablet 200mcg 1 levothyroxine sodium tablet 25mcg 1 levothyroxine sodium tablet 300mcg 1 levothyroxine sodium tablet 50mcg 1 Page 63 of 103

74 Name Tier levothyroxine sodium tablet 75mcg 1 levothyroxine sodium tablet 88mcg 1 levoxyl tablet 100mcg 1 levoxyl tablet 112mcg 1 levoxyl tablet 125mcg 1 levoxyl tablet 137mcg 1 levoxyl tablet 150mcg 1 levoxyl tablet 175mcg 1 levoxyl tablet 200mcg 1 levoxyl tablet 25mcg 1 levoxyl tablet 50mcg 1 levoxyl tablet 75mcg 1 levoxyl tablet 88mcg 1 liothyronine sodium injection 10mcg/ml 1 liothyronine sodium tablet 25mcg 1 liothyronine sodium tablet 50mcg 1 liothyronine sodium tablet 5mcg 1 SYNTHROID TABLET 100MCG 2 SYNTHROID TABLET 112MCG 2 SYNTHROID TABLET 125MCG 2 SYNTHROID TABLET 137MCG 2 SYNTHROID TABLET 150MCG 2 SYNTHROID TABLET 175MCG 2 SYNTHROID TABLET 200MCG 2 SYNTHROID TABLET 25MCG 2 SYNTHROID TABLET 300MCG 2 SYNTHROID TABLET 50MCG 2 SYNTHROID TABLET 75MCG 2 SYNTHROID TABLET 88MCG 2 THYROLAR-1/2 TABLET 30MG 2 THYROLAR-1/4 TABLET 15MG 2 THYROLAR-1 TABLET 60MG 2 THYROLAR-2 TABLET 120MG 2 THYROLAR-3 TABLET 180MG 2 unithroid tablet 100mcg 1 unithroid tablet 112mcg 1 unithroid tablet 125mcg 1 unithroid tablet 137mcg 1 unithroid tablet 150mcg 1 unithroid tablet 175mcg 1 unithroid tablet 200mcg 1 unithroid tablet 25mcg 1 unithroid tablet 300mcg 1 unithroid tablet 50mcg 1 unithroid tablet 75mcg 1 unithroid tablet 88mcg 1 Hormonal Agents, Suppressant (Adrenal) Hormonal Agents, Suppressant (Adrenal) LYSODREN TABLET 500MG 2 Requirements/Limits Page 64 of 103

75 Hormonal Agents, Suppressant (Parathyroid) Hormonal Agents, Suppressant (Parathyroid) SENSIPAR TABLET 30MG 2 QL (60 EA per 30 days) SENSIPAR TABLET 60MG 2 QL (60 EA per 30 days) SENSIPAR TABLET 90MG 2 QL (120 EA per 30 days) Hormonal Agents, Suppressant (Pituitary) Hormonal Agents, Suppressant (Pituitary) cabergoline tablet 0.5mg 1 ELIGARD INJECTION 22.5MG 2 ELIGARD INJECTION 30MG 2 ELIGARD INJECTION 45MG 2 ELIGARD INJECTION 7.5MG 2 FIRMAGON INJECTION 120MG 2 FIRMAGON INJECTION 80MG 2 leuprolide acetate injection 1mg/0.2ml 1 LUPRON DEPOT-PED INJECTION 11.25MG 2 LUPRON DEPOT-PED INJECTION 15MG 2 LUPRON DEPOT INJECTION 11.25MG 2 LUPRON DEPOT INJECTION 22.5MG 2 LUPRON DEPOT INJECTION 3.75MG 2 LUPRON DEPOT INJECTION 30MG 2 LUPRON DEPOT INJECTION 7.5MG 2 octreotide acetate injection 1000mcg/ml 1 octreotide acetate injection 100mcg/ml 1 octreotide acetate injection 200mcg/ml 1 octreotide acetate injection 500mcg/ml 1 octreotide acetate injection 50mcg/ml 1 SOMATULINE DEPOT INJECTION 120MG/0.5ML 2 SOMATULINE DEPOT INJECTION 90MG/0.3ML 2 SOMAVERT INJECTION 10MG 2 PA (Hormonal Agents, Suppressant (Pituitary) - Somavert) SOMAVERT INJECTION 15MG 2 PA (Hormonal Agents, Suppressant (Pituitary) - Somavert) SOMAVERT INJECTION 20MG 2 PA (Hormonal Agents, Suppressant (Pituitary) - Somavert) SOMAVERT INJECTION 25MG 2 PA (Hormonal Agents, Suppressant (Pituitary) - Somavert) SOMAVERT INJECTION 30MG 2 PA (Hormonal Agents, Suppressant (Pituitary) - Somavert) SYNAREL SOLUTION 2MG/ML 2 TRELSTAR DEPOT MIXJECT INJECTION 3.75MG 2 TRELSTAR LA MIXJECT INJECTION 11.25MG 2 TRELSTAR MIXJECT INJECTION 22.5MG 2 Hormonal Agents, Suppressant (Thyroid) Antithyroid Agents methimazole tablet 10mg 1 methimazole tablet 5mg 1 propylthiouracil tablet 50mg 1 Immunological Agents Page 65 of 103

76 Angioedema (HAE) Agents CINRYZE INJECTION 500UNIT 2 QL (100 EA per 30 days) PA (Blood Products/Modifiers/ Volume Expanders - Cinryze) FIRAZYR INJECTION 30MG/3ML 2 QL (270 ML per 30 days) PA (Firazyr) Immune Suppressants azathioprine tablet 50mg 1 B/D CELLCEPT INTRAVENOUS INJECTION 500MG 2 B/D CELLCEPT SUSPENSION RECONSTITUTED 200MG/ML 2 B/D cyclosporine modified capsule 100mg 1 B/D cyclosporine modified capsule 25mg 1 B/D cyclosporine modified capsule 50mg 1 B/D cyclosporine modified solution 100mg/ml 1 B/D cyclosporine capsule 100mg 1 B/D cyclosporine capsule 25mg 1 B/D cyclosporine injection 50mg/ml 1 B/D ENBREL INJECTION 25MG/0.5ML 2 PA (Immunological Agents) ENBREL INJECTION 25MG 2 PA (Immunological Agents) ENBREL INJECTION 50MG/ML 2 PA (Immunological Agents) gengraf capsule 100mg 1 B/D gengraf capsule 25mg 1 B/D gengraf solution 100mg/ml 1 B/D HUMIRA PEN-CROHNS DISEASESTARTER INJECTION 2 PA (Immunological Agents) 40MG/0.8ML HUMIRA INJECTION 10MG/0.2ML 2 PA (Immunological Agents) HUMIRA INJECTION 20MG/0.4ML 2 PA (Immunological Agents) HUMIRA INJECTION 40MG/0.8ML 2 PA (Immunological Agents) KINERET INJECTION 100MG/0.67ML 2 QL (28 ML per 28 days) PA (Immunological Agents) methotrexate sodium injection 1gm 1 methotrexate tablet 2.5mg 1 mycophenolate mofetil capsule 250mg 1 B/D mycophenolate mofetil suspension reconstituted 200mg/ml 1 B/D mycophenolate mofetil tablet 500mg 1 B/D NULOJIX INJECTION 250MG 2 B/D ORENCIA INJECTION 125MG/ML 2 PA (Immunological Agents) ORENCIA INJECTION 250MG 2 PA (Immunological Agents) PROGRAF CAPSULE 0.5MG 2 B/D PROGRAF CAPSULE 1MG 2 B/D PROGRAF CAPSULE 5MG 2 B/D PROGRAF INJECTION 5MG/ML 2 B/D RAPAMUNE SOLUTION 1MG/ML 2 B/D RAPAMUNE TABLET 0.5MG 2 B/D RAPAMUNE TABLET 1MG 2 B/D RAPAMUNE TABLET 2MG 2 B/D REMICADE INJECTION 100MG 2 PA (Immunological Agents) sirolimus tablet 0.5mg 1 B/D sirolimus tablet 1mg 1 B/D Page 66 of 103

77 sirolimus tablet 2mg 1 B/D tacrolimus capsule 0.5mg 1 B/D tacrolimus capsule 1mg 1 B/D tacrolimus capsule 5mg 1 B/D TORISEL INJECTION 25MG/ML 2 ZORTRESS TABLET 0.25MG 2 B/D ZORTRESS TABLET 0.5MG 2 B/D ZORTRESS TABLET 0.75MG 2 B/D Immunizing Agents, Passive CARIMUNE NANOFILTERED INJECTION 6GM 2 B/D GAMASTAN S/D INJECTION 0 2 B/D GAMMAGARD LIQUID INJECTION 0 2 B/D GAMUNEX-C INJECTION 1GM/10ML 2 B/D THYMOGLOBULIN INJECTION 25MG 2 B/D Immunomodulators ACTIMMUNE INJECTION UNIT/0.5ML 2 ARCALYST INJECTION 220MG 2 ILARIS INJECTION 180MG 2 QL (1 EA per 28 days) PA (Immunological Agents - Ilaris) leflunomide tablet 10mg 1 QL (30 EA per 30 days) leflunomide tablet 20mg 1 QL (30 EA per 30 days) SIMULECT INJECTION 20MG 2 B/D SYNAGIS INJECTION 50MG/0.5ML 2 Vaccines ACTHIB INJECTION 0 2 ADACEL INJECTION 15.5MCG/0.5ML; 2LF/0.5ML; 2 5LF/0.5ML BOOSTRIX INJECTION 18.5MCG/0.5ML; 2.5LF/0.5ML; 2 5LF/0.5ML BOOSTRIX INJECTION 18.5MCG/0.5ML; 2.5LF/0.5ML; 2 5LF/0.5ML CERVARIX INJECTION 0 2 COMVAX INJECTION 7.5MCG/0.5ML; 5MCG/0.5ML 2 DAPTACEL INJECTION 10MCG/0.5ML; 15LF/0.5ML; 2 5LF/0.5ML DECAVAC INJECTION 2LFU; 5LFU 2 DIPHTHERIA/TETANUS TOXOIDS ADSORBED 2 PEDIATRIC INJECTION 25LFU/0.5ML; 5LFU/0.5ML ENGERIX-B INJECTION 10MCG/0.5ML 2 B/D ENGERIX-B INJECTION 10MCG/0.5ML 2 B/D ENGERIX-B INJECTION 20MCG/ML 2 B/D GARDASIL 9 INJECTION 0 2 GARDASIL 9 INJECTION 0 2 GARDASIL INJECTION 0 2 GARDASIL INJECTION 0 2 HAVRIX INJECTION 1440ELU/ML 2 HAVRIX INJECTION 720ELU/0.5ML 2 IMOVAX RABIES (H.D.C.V.) INJECTION 2.5UNIT/ML 2 Page 67 of 103

78 INFANRIX INJECTION 58MCG/0.5ML; 25LFU/0.5ML; 2 10LFU/0.5ML IPOL INACTIVATED IPV INJECTION 0 2 IPOL INACTIVATED IPV INJECTION 0 2 IXIARO INJECTION 0 2 M-M-R II W/DILUENT 10 DOSE INJECTION 0; 0; 0 2 MENACTRA INJECTION 0 2 MENOMUNE-A/C/Y/W-135 INJECTION 0 2 MENVEO INJECTION 0 2 PEDVAX HIB INJECTION 7.5MCG/0.5ML 2 PROQUAD INJECTION 0; 0; 0; 0 2 RABAVERT INJECTION 0 2 RECOMBIVAX HB INJECTION 10MCG/ML 2 B/D RECOMBIVAX HB INJECTION 10MCG/ML 2 B/D RECOMBIVAX HB INJECTION 40MCG/ML 2 B/D RECOMBIVAX HB INJECTION 5MCG/0.5ML 2 B/D ROTARIX SUSPENSION RECONSTITUTED 0 2 ROTATEQ SOLUTION 0 2 TETANUS TOXOID ADSORBED INJECTION 5LFU 2 TETANUS/DIPHTHERIA TOXOIDS-ADSORBED ADULT 2 INJECTION 2LF/0.5ML; 2LF/0.5ML TRUMENBA INJECTION 0 2 TWINRIX INJECTION 720ELU/ML; 20MCG/ML 2 TYPHIM VI INJECTION 25MCG/0.5ML 2 VAQTA INJECTION 25UNIT/0.5ML 2 VAQTA INJECTION 25UNIT/0.5ML 2 VAQTA INJECTION 50UNIT/ML 2 VARIVAX INJECTION 1350PFU/0.5ML 2 YF-VAX INJECTION 0 2 ZOSTAVAX INJECTION 19400UNT/0.65ML 2 Inflammatory Bowel Disease Agents Aminosalicylates balsalazide disodium capsule 750mg 1 MO DELZICOL CAPSULE DELAYED RELEASE 400MG 2 QL (180 EA per 30 days) DIPENTUM CAPSULE 250MG 2 mesalamine kit 4gm 1 Sulfonamides sulfasalazine tablet 500mg 1 sulfazine ec tablet delayed release 500mg 1 Metabolic Bone Disease Agents Metabolic Bone Disease Agents alendronate sodium tablet 10mg 1 QL (30 EA per 30 days) alendronate sodium tablet 40mg 1 QL (30 EA per 30 days) alendronate sodium tablet 5mg 1 QL (30 EA per 30 days) alendronate sodium tablet 70mg 1 QL (4 EA per 28 days) calcitonin-salmon solution 200unit/act 1 QL (4 ML per 30 days) calcitriol capsule 0.25mcg 1 calcitriol capsule 0.5mcg 1 calcitriol injection 1mcg/ml 1 Page 68 of 103

79 calcitriol solution 1mcg/ml 1 etidronate disodium tablet 200mg 1 etidronate disodium tablet 400mg 1 FORTEO INJECTION 600MCG/2.4ML 2 PA (metabolic bone disease agents - IV osteoporosis) fortical solution 200unit/act 1 QL (4 ML per 30 days) HECTOROL CAPSULE 0.5MCG 2 HECTOROL CAPSULE 2.5MCG 2 HECTOROL INJECTION 4MCG/2ML 2 ibandronate sodium tablet 150mg 1 QL (1 EA per 30 days) MO MIACALCIN INJECTION 200UNIT/ML 2 pamidronate disodium injection 30mg/10ml 1 PAMIDRONATE DISODIUM INJECTION 6MG/ML 2 pamidronate disodium injection 90mg/10ml 1 PROLIA INJECTION 60MG/ML 2 QL (1 ML per 180 days) PA (Metabolic Bone Disease Agents - Prolia) XGEVA INJECTION 120MG/1.7ML 2 zoledronic acid injection 4mg/5ml 1 zoledronic acid injection 5mg/100ml 1 ZOMETA INJECTION 4MG/100ML 2 Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents BD INSULIN SYRINGE SAFETYGLIDE/1ML/29G X 1/2" 2 MISCELLANEOUS BD INSULIN SYRINGE ULTRAFINE/0.3ML/31G X 5/16" 2 QL (200 EA per 30 days) MISCELLANEOUS BD INSULIN SYRINGE ULTRAFINE/0.5ML/30G X 1/2" 2 QL (200 EA per 30 days) MISCELLANEOUS BD INSULIN SYRINGE ULTRAFINE/1ML/31G X 5/16" 2 QL (200 EA per 30 days) MISCELLANEOUS BD PEN NEEDLE/ULTRAFINE/29G X 12.7MM 2 QL (200 EA per 30 days) MISCELLANEOUS intralipid injection 20gm/100ml 1 B/D INTRALIPID INJECTION 30GM/100ML 2 B/D lactated ringers irrigation solution 3meq/l; 109meq/l; 1 28meq/l; 4meq/l; 130meq/l levocarnitine injection 200mg/ml 1 levocarnitine solution 1gm/10ml 1 levocarnitine tablet 330mg 1 liposyn iii injection 2.5%; 30% 1 B/D methylergonovine maleate tablet 0.2mg 1 nutrilipid injection 20gm/100ml 1 B/D physiolyte solution 27meq/1000ml; 98meq/1000ml; 1 23meq/1000ml; 3meq/1000ml; 5meq/1000ml; 140meq/1000ml physiosol irrigation solution 30mg/100ml; 37mg/100ml; 1 222mg/100ml; 526mg/100ml; 502mg/100ml ringers irrigation solution 4.5meq/l; 156meq/l; 4meq/l; 1 147meq/l Page 69 of 103

80 sterile water irrigation solution 0 1 Ophthalmic Agents Ophthalmic Prostaglandin and Prostamide Analogs COMBIGAN SOLUTION 0.2%; 0.5% 2 latanoprost solution 0.005% 1 LUMIGAN SOLUTION 0.01% 2 LUMIGAN SOLUTION 0.03% 2 Ophthalmic Agents, Other bacitracin/polymyxin b ointment 500unit/gm; 10000unit/gm 1 naphazoline hcl solution 0.1% 1 neomycin/bacitracin/polymyxin ointment 400unit/gm; 1 5mg/gm; 10000unit/gm neomycin/polymyxin/gramicidin solution 0.025mg/ml; mg/ml; 10000unit/ml polymyxin b sulfate/trimethoprim sulfate solution unit/ml; 0.1% RESTASIS EMULSION 0.05% 2 Ophthalmic Anti-allergy Agents cromolyn sodium solution 4% 1 PATANOL SOLUTION 0.1% 2 Ophthalmic Anti-inflammatories dexamethasone sodium phosphate solution 0.1% 1 diclofenac sodium solution 0.1% 1 fluor-op suspension 0.1% 1 fluor-op suspension 0.1% 1 fluorometholone suspension 0.1% 1 flurbiprofen sodium solution 0.03% 1 ketorolac tromethamine solution 0.4% 1 QL (5 ML per 15 days) ketorolac tromethamine solution 0.5% 1 QL (5 ML per 15 days) LOTEMAX SUSPENSION 0.5% 2 neomycin/polymyxin/dexamethasone ointment 0.1%; 1 3.5mg/gm; 10000unit/gm neomycin/polymyxin/dexamethasone suspension 0.1%; 1 3.5mg/ml; 10000unit/ml PRED-G S.O.P. OINTMENT 0.3%; 0.6% 2 PRED-G SUSPENSION 0.3%; 1% 2 prednisolone acetate suspension 1% 1 prednisolone sodium phosphate solution 1% 1 sulfacetamide sodium/prednisolone sodium phosphate solution %; 10% TOBRADEX OINTMENT 0.1%; 0.3% 2 tobramycin/dexamethasone suspension 0.1%; 0.3% 1 Ophthalmic Antiglaucoma Agents acetazolamide er capsule extended release 12 hour 500mg 1 ALPHAGAN P SOLUTION 0.1% 2 betaxolol hcl solution 0.5% 1 brimonidine tartrate solution 0.15% 1 brimonidine tartrate solution 0.2% 1 carteolol hcl solution 1% 1 Page 70 of 103

81 dorzolamide hcl/timolol maleate solution 22.3mg/ml; 1 QL (20 ML per 30 days) 6.8mg/ml dorzolamide hcl solution 2% 1 QL (20 ML per 30 days) levobunolol hcl solution 0.25% 1 levobunolol hcl solution 0.25% 1 QL (30 ML per 30 days) levobunolol hcl solution 0.5% 1 methazolamide tablet 25mg 1 methazolamide tablet 50mg 1 metipranolol solution 0.3% 1 PHOSPHOLINE IODIDE SOLUTION RECONSTITUTED % PILOPINE HS GEL 4% 2 timolol maleate ophthalmic gel forming gel forming solution % timolol maleate ophthalmic gel forming gel forming solution 1 0.5% timolol maleate solution 0.25% 1 timolol maleate solution 0.5% 1 Otic Agents Otic Agents acetasol hc solution 2%; 1% 1 acetic acid solution 2% 1 CIPRODEX SUSPENSION 0.3%; 0.1% 2 hydrocortisone/acetic acid solution 2%; 1% 1 neomycin/polymyxin/hc solution 1%; 3.5mg/ml; 10000unit/ml 1 neomycin/polymyxin/hydrocortisone suspension 1%; 1 3.5mg/ml; 10000unit/ml Respiratory Tract/Pulmonary Agents Anti-inflammatories, Inhaled Corticosteroids ADVAIR DISKUS AEROSOL POWDER BREATH 2 QL (60 EA per 30 days) ACTIVATED 100MCG/DOSE; 50MCG/DOSE ADVAIR DISKUS AEROSOL POWDER BREATH 2 QL (60 EA per 30 days) ACTIVATED 250MCG/DOSE; 50MCG/DOSE ADVAIR DISKUS AEROSOL POWDER BREATH 2 QL (60 EA per 30 days) ACTIVATED 500MCG/DOSE; 50MCG/DOSE ADVAIR HFA AEROSOL 115MCG/ACT; 21MCG/ACT 2 ADVAIR HFA AEROSOL 230MCG/ACT; 21MCG/ACT 2 QL (12 GM per 30 days) ADVAIR HFA AEROSOL 45MCG/ACT; 21MCG/ACT 2 ASMANEX HFA AEROSOL 100MCG/ACT 2 MO ASMANEX HFA AEROSOL 200MCG/ACT 2 MO ASMANEX TWISTHALER 120 METERED DOSES 2 AEROSOL POWDER BREATH ACTIVATED 220MCG/INH ASMANEX TWISTHALER 14 METERED DOSES 2 AEROSOL POWDER BREATH ACTIVATED 220MCG/INH ASMANEX TWISTHALER 30 ME TERED DOSES AEROSOL POWDER BREATH ACTIVATED 220MCG/INH 2 Page 71 of 103

82 ASMANEX TWISTHALER 30 METERED DOSES 2 AEROSOL POWDER BREATH ACTIVATED 110MCG/INH ASMANEX TWISTHALER 60 METERED DOSES 2 AEROSOL POWDER BREATH ACTIVATED 220MCG/INH budesonide suspension 32mcg/act 1 MO DULERA AEROSOL 5MCG/ACT; 100MCG/ACT 2 DULERA AEROSOL 5MCG/ACT; 200MCG/ACT 2 FLOVENT DISKUS AEROSOL POWDER BREATH 2 ACTIVATED 100MCG/BLIST FLOVENT DISKUS AEROSOL POWDER BREATH 2 ACTIVATED 250MCG/BLIST FLOVENT DISKUS AEROSOL POWDER BREATH 2 ACTIVATED 50MCG/BLIST FLOVENT HFA AEROSOL 110MCG/ACT 2 QL (24 GM per 30 days) FLOVENT HFA AEROSOL 220MCG/ACT 2 QL (24 GM per 30 days) FLOVENT HFA AEROSOL 44MCG/ACT 2 QL (21.2 GM per 30 days) flunisolide solution 0.025% 1 MO flunisolide solution 29mcg/act 1 QL (50 ML per 30 days) fluticasone propionate suspension 50mcg/act 1 QL (32 GM per 30 days) SYMBICORT AEROSOL 160MCG/ACT; 4.5MCG/ACT 2 QL (10.2 GM per 30 days) SYMBICORT AEROSOL 80MCG/ACT; 4.5MCG/ACT 2 QL (10.2 GM per 30 days) triamcinolone acetonide aerosol 55mcg/act 1 QL (33 GM per 30 days) MO Antihistamines azelastine hcl solution 0.15% 1 MO azelastine hcl solution 137mcg/spray 1 QL (30 ML per 30 days) cyproheptadine hcl syrup 2mg/5ml 1 PA (High Risk Medications) cyproheptadine hcl tablet 4mg 1 PA (High Risk Medications) diphenhydramine hcl capsule 50mg 1 PA (High Risk Medications) diphenhydramine hcl injection 50mg/ml 1 HYDROXYZINE HCL INJECTION 25MG/ML 2 PA (High Risk Medications) hydroxyzine hcl injection 50mg/ml 1 PA (High Risk Medications) hydroxyzine hcl solution 10mg/5ml 1 PA (High Risk Medications) hydroxyzine hcl tablet 10mg 1 PA (High Risk Medications) hydroxyzine hcl tablet 25mg 1 PA (High Risk Medications) hydroxyzine hcl tablet 50mg 1 PA (High Risk Medications) hydroxyzine pamoate capsule 100mg 1 PA (High Risk Medications) hydroxyzine pamoate capsule 25mg 1 PA (High Risk Medications) hydroxyzine pamoate capsule 50mg 1 PA (High Risk Medications) levocetirizine dihydrochloride solution 2.5mg/5ml 1 levocetirizine dihydrochloride tablet 5mg 1 QL (30 EA per 30 days) olopatadine hcl solution 0.6% 1 Antileukotrienes montelukast sodium packet 4mg 1 QL (30 EA per 30 days) montelukast sodium tablet chewable 4mg 1 QL (30 EA per 30 days) montelukast sodium tablet chewable 5mg 1 QL (30 EA per 30 days) montelukast sodium tablet 10mg 1 QL (30 EA per 30 days) zafirlukast tablet 10mg 1 QL (60 EA per 30 days) Page 72 of 103

83 zafirlukast tablet 20mg 1 QL (60 EA per 30 days) ZYFLO CR TABLET EXTENDED RELEASE 12 HOUR 2 QL (120 EA per 30 days) 600MG Bronchodilators, Anticholinergic ATROVENT HFA AEROSOL SOLUTION 17MCG/ACT 2 QL (39 GM per 30 days) COMBIVENT RESPIMAT AEROSOL SOLUTION 2 QL (8 GM per 30 days) MO 100MCG/ACT; 20MCG/ACT ipratropium bromide/albuterol sulfate solution 2.5mg/3ml; 1 QL (540 ML per 30 days) B/D 0.5mg/3ml ipratropium bromide solution 0.02% 1 QL (300 ML per 30 days) B/D ipratropium bromide solution 0.03% 1 QL (30 ML per 30 days) ipratropium bromide solution 0.06% 1 QL (15 ML per 30 days) SPIRIVA HANDIHALER CAPSULE 18MCG 2 QL (30 EA per 30 days) SPIRIVA RESPIMAT AEROSOL SOLUTION 2 QL (8 GM per 30 days) MO 2.5MCG/ACT Bronchodilators, Sympathomimetic albuterol sulfate er tablet extended release 12 hour 4mg 1 albuterol sulfate er tablet extended release 12 hour 8mg 1 albuterol sulfate nebulization solution 0.083% 1 QL (1170 ML per 30 days) B/D albuterol sulfate nebulization solution 0.5% 1 QL (200 ML per 30 days) B/D albuterol sulfate nebulization solution 0.63mg/3ml 1 QL (1200 ML per 30 days) B/D albuterol sulfate nebulization solution 1.25mg/3ml 1 QL (1200 ML per 30 days) B/D albuterol sulfate syrup 2mg/5ml 1 albuterol sulfate tablet 2mg 1 albuterol sulfate tablet 4mg 1 EPIPEN 2-PAK INJECTION 0.3MG/0.3ML 2 QL (2 EA per 10 days) EPIPEN-JR 2-PAK INJECTION 0.15MG/0.3ML 2 QL (2 EA per 10 days) levalbuterol hcl nebulization solution 0.31mg/3ml 1 B/D levalbuterol hcl nebulization solution 0.63mg/3ml 1 B/D metaproterenol sulfate syrup 10mg/5ml 1 metaproterenol sulfate tablet 10mg 1 metaproterenol sulfate tablet 20mg 1 PROAIR HFA AEROSOL SOLUTION 108MCG/ACT 2 QL (36 GM per 30 days) SEREVENT DISKUS AEROSOL POWDER BREATH 2 QL (60 EA per 30 days) ACTIVATED 50MCG/DOSE terbutaline sulfate injection 1mg/ml 1 terbutaline sulfate tablet 2.5mg 1 terbutaline sulfate tablet 5mg 1 VENTOLIN HFA AEROSOL SOLUTION 108MCG/ACT 2 QL (36 GM per 30 days) XOPENEX HFA AEROSOL 45MCG/ACT 2 QL (45 GM per 30 days) XOPENEX NEBULIZATION SOLUTION 1.25MG/3ML 2 QL (450 ML per 30 days) B/D Cystic Fibrosis Agents CAYSTON SOLUTION RECONSTITUTED 75MG 2 PA (Antibacterials - Beta lactam, Other) PULMOZYME SOLUTION 1MG/ML 2 B/D TOBI PODHALER CAPSULE 28MG 2 tobramycin nebulization solution 300mg/5ml 1 B/D Mast Cell Stabilizers cromolyn sodium nebulization solution 20mg/2ml 1 QL (305 ML per 30 days) B/D Page 73 of 103

84 Phosphodiesterase Inhibitors, Airways Disease aminophylline injection 25mg/ml 1 DALIRESP TABLET 500MCG 2 ELIXOPHYLLIN ELIXIR 80MG/15ML 2 LUFYLLIN TABLET 200MG 2 LUFYLLIN TABLET 400MG 2 THEO-24 CAPSULE EXTENDED RELEASE 24 HOUR 0; 2 100MG THEO-24 CAPSULE EXTENDED RELEASE 24 HOUR 2 200MG THEO-24 CAPSULE EXTENDED RELEASE 24 HOUR 2 300MG THEO-24 CAPSULE EXTENDED RELEASE 24 HOUR 2 400MG theophylline cr tablet extended release 12 hour 100mg 1 theophylline cr tablet extended release 12 hour 200mg 1 theophylline er tablet extended release 12 hour 300mg 1 theophylline er tablet extended release 12 hour 450mg 1 theophylline er tablet extended release 24 hour 400mg 1 theophylline er tablet extended release 24 hour 600mg 1 theophylline solution 80mg/15ml 1 MO Pulmonary Antihypertensives LETAIRIS TABLET 10MG 2 LETAIRIS TABLET 5MG 2 ORENITRAM TABLET EXTENDED RELEASE 0.125MG 2 ORENITRAM TABLET EXTENDED RELEASE 0.25MG 2 ORENITRAM TABLET EXTENDED RELEASE 1MG 2 ORENITRAM TABLET EXTENDED RELEASE 2.5MG 2 sildenafil tablet 20mg 1 QL (90 EA per 30 days) PA (sildenafil - PAH) TRACLEER TABLET 125MG 2 QL (60 EA per 30 days) LA TRACLEER TABLET 62.5MG 2 QL (60 EA per 30 days) LA TYVASO SOLUTION 0.6MG/ML 2 B/D Respiratory Tract Agents, Other acetylcysteine solution 10% 1 B/D acetylcysteine solution 20% 1 B/D ARALAST NP INJECTION 400MG 2 PROLASTIN-C INJECTION 1000MG 2 promethazine vc plain syrup 5mg/5ml; 6.25mg/5ml 1 TYZINE PEDIATRIC NASAL DROPS SOLUTION 0.05% 2 XOLAIR INJECTION 150MG 2 PA (Respiratory Tract Agents) ZEMAIRA INJECTION 1000MG 2 Skeletal Muscle Relaxants Skeletal Muscle Relaxants chlorzoxazone tablet 500mg 1 PA (High Risk Medications) cyclobenzaprine hcl tablet 10mg 1 QL (90 EA per 30 days) PA (High Risk Medications) cyclobenzaprine hcl tablet 5mg 1 QL (90 EA per 30 days) PA (High Risk Medications) Page 74 of 103

85 methocarbamol tablet 500mg 1 PA (High Risk Medications) methocarbamol tablet 750mg 1 PA (High Risk Medications) orphenadrine citrate er tablet extended release 12 hour 1 PA (High Risk Medications) 100mg orphenadrine citrate injection 30mg/ml 1 Sleep Disorder Agents GABA Receptor Modulators flurazepam hcl capsule 15mg 1 QL (30 EA per 30 days) flurazepam hcl capsule 30mg 1 QL (30 EA per 30 days) temazepam capsule 15mg 1 QL (30 EA per 30 days) temazepam capsule 30mg 1 QL (30 EA per 30 days) zaleplon capsule 10mg 1 QL (90 EA per 365 days) PA (High Risk Medication - Nonbenzodiazepine Hypnotics) zaleplon capsule 5mg 1 QL (90 EA per 365 days) PA (High Risk Medication - Nonbenzodiazepine Hypnotics) zolpidem tartrate er tablet extended release 12.5mg 1 QL (90 EA per 365 days) PA (High Risk Medication - Nonbenzodiazepine Hypnotics) zolpidem tartrate er tablet extended release 6.25mg 1 QL (90 EA per 365 days) PA (High Risk Medication - Nonbenzodiazepine Hypnotics) zolpidem tartrate tablet 10mg 1 QL (90 EA per 365 days) PA (High Risk Medication - Nonbenzodiazepine Hypnotics) zolpidem tartrate tablet 5mg 1 QL (90 EA per 365 days) PA (High Risk Medication - Nonbenzodiazepine Hypnotics) Sleep Disorders, Other modafinil tablet 200mg 1 QL (30 EA per 30 days) PA (Central Nervous System Agents) ROZEREM TABLET 8MG 2 QL (30 EA per 30 days) XYREM SOLUTION 500MG/ML 2 QL (540 ML per 30 days) LA Therapeutic Nutrients/Minerals/Electrolytes Electrolyte/Mineral Modifiers CHEMET CAPSULE 100MG 2 DEPEN TITRATABS TABLET 250MG 2 EXJADE TABLET SOLUBLE 125MG 2 EXJADE TABLET SOLUBLE 250MG 2 EXJADE TABLET SOLUBLE 500MG 2 kionex powder 0 1 SODIUM LACTATE INJECTION 167MEQ/L 2 SODIUM LACTATE INJECTION 5MEQ/ML 2 sodium polystyrene sulfonate suspension 15gm/60ml 1 SYPRINE CAPSULE 250MG 2 Electrolyte/Mineral Replacement Page 75 of 103

86 AMINOSYN 7%/ELECTROLYTES INJECTION 2 B/D 124MEQ/L; 900MG/100ML; 690MG/100ML; 96MEQ/L; 900MG/100ML; 210MG/100ML; 510MG/100ML; 660MG/100ML; 510MG/100ML; 10MEQ/L; 280MG/100ML; 310MG/100ML; 30MMOLE/L; 65MEQ/L; 610MG/100ML; 300MG/100ML; 65MEQ/L; 370MG/100ML; 120MG/100ML; 44MG/100ML; 560MG/100ML aminosyn 8.5%/electrolytes injection 142meq/l; 1 B/D 1100mg/100ml; 850mg/100ml; 98meq/l; 1100mg/100ml; 260mg/100ml; 620mg/100ml; 810mg/100ml; 624mg/100ml; 10meq/l; 340mg/100ml; 380mg/100ml; 30meq/l; 65meq/l; 750mg/100ml; 370mg/100ml; 65meq/l; 460mg/100ml; 150mg/100ml; 44mg/100ml; 680mg/100ml aminosyn ii 8.5%/electrolytes injection 61meq/l; 1 B/D 844mg/100ml; 865mg/100ml; 595mg/100ml; 86meq/l; 627mg/100ml; 425mg/100ml; 255mg/100ml; 561mg/100ml; 850mg/100ml; 893mg/100ml; 10meq/l; 146mg/100ml; 253mg/100ml; 30mmole/l; 66meq/l; 614mg/100ml; 450mg/100ml; 80meq/l; 340mg/100ml; 170mg/100ml; 230mg/100ml; 425mg/100ml AMINOSYN II INJECTION 107.6MEQ/L; 1490MG/100ML; 2 B/D 1527MG/100ML; 1050MG/100ML; 1107MG/100ML; 750MG/100ML; 450MG/100ML; 990MG/100ML; 1500MG/100ML; 1575MG/100ML; 258MG/100ML; 447MG/100ML; 1083MG/100ML; 795MG/100ML; 50MEQ/L; 600MG/100ML; 300MG/100ML; 405MG/100ML; 750MG/100ML AMINOSYN II INJECTION 50.3MEQ/L; 695MG/100ML; 2 B/D 713MG/100ML; 490MG/100ML; 517MG/100ML; 350MG/100ML; 210MG/100ML; 462MG/100ML; 700MG/100ML; 735MG/100ML; 120MG/100ML; 209MG/100ML; 505MG/100ML; 371MG/100ML; 31.3MEQ/L; 280MG/100ML; 140MG/100ML; 189MG/100ML; 350MG/100ML AMINOSYN II INJECTION 61.1MEQ/L; 844MG/100ML; 2 B/D 865MG/100ML; 595MG/100ML; 627MG/100ML; 425MG/100ML; 255MG/100ML; 561MG/100ML; 850MG/100ML; 893MG/100ML; 146MG/100ML; 253MG/100ML; 614MG/100ML; 450MG/100ML; 33.3MEQ/L; 340MG/100ML; 170MG/100ML; 230MG/100ML; 425MG/100ML AMINOSYN II INJECTION 71.8MEQ/L; 993MG/100ML; 1018MG/100ML; 700MG/100ML; 738MG/100ML; 500MG/100ML; 300MG/100ML; 660MG/100ML; 1000MG/100ML; 1050MG/100ML; 172MG/100ML; 298MG/100ML; 722MG/100ML; 530MG/100ML; 45.3MEQ/L; 400MG/100ML; 200MG/100ML; 270MG/100ML; 500MG/100ML 2 B/D Page 76 of 103

87 AMINOSYN M INJECTION 65MEQ/L; 448MG/100ML; 2 B/D 343MG/100ML; 40MEQ/L; 448MG/100ML; 105MG/100ML; 252MG/100ML; 329MG/100ML; 252MG/100ML; 3MEQ/L; 140MG/100ML; 154MG/100ML; 3.5MMOLE/L; 13MEQ/L; 300MG/100ML; 147MG/100ML; 40MEQ/L; 182MG/100ML; 56MG/100ML; 31MG/100ML; 280MG/100ML AMINOSYN-HBC INJECTION 7.1MEQ/100ML; 2 B/D 660MG/100ML; 507MG/100ML; 4MEQ/100ML; 660MG/100ML; 154MG/100ML; 789MG/100ML; 1576MG/100ML; 265MG/100ML; 206MG/100ML; 1.12GM/100ML; 228MG/100ML; 448MG/100ML; 221MG/100ML; 272MG/100ML; 88MG/100ML; 33MG/100ML; 789MG/100ML AMINOSYN-PF 7% INJECTION 32.5MEQ/L; 2 B/D 490MG/100ML; 861MG/100ML; 370MG/100ML; 576MG/100ML; 270MG/100ML; 220MG/100ML; 534MG/100ML; 831MG/100ML; 475MG/100ML; 125MG/100ML; 10.69GM/L; 300MG/100ML; 570MG/100ML; 70GM/L; 347MG/100ML; 50MG/100ML; 360MG/100ML; 125MG/100ML; 44MG/100ML; 452MG/100ML AMINOSYN-PF INJECTION 46MEQ/L; 698MG/100ML; 2 B/D 1227MG/100ML; 527MG/100ML; 820MG/100ML; 385MG/100ML; 312MG/100ML; 760MG/100ML; 1200MG/100ML; 677MG/100ML; 180MG/100ML; 427MG/100ML; 812MG/100ML; 495MG/100ML; 3.4MEQ/L; 70MG/100ML; 512MG/100ML; 180MG/100ML; 44MG/100ML; 673MG/100ML AMINOSYN-RF INJECTION 113MEQ/L; 600MG/100ML; 2 B/D 429MG/100ML; 462MG/100ML; 726MG/100ML; 535MG/100ML; 726MG/100ML; 726MG/100ML; 330MG/100ML; 165MG/100ML; 528MG/100ML AMMONIUM CHLORIDE INJECTION 5MEQ/ML 2 CLINIMIX 2.75%/DEXTROSE 5% INJECTION 2 B/D 24MEQ/1000ML; 570MG/100ML; 316MG/100ML; 11MEQ/1000ML; 5GM/100ML; 283MG/100ML; 132MG/100ML; 165MG/100ML; 201MG/100ML; 159MG/100ML; 110MG/100ML; 154MG/100ML; 187MG/100ML; 138MG/100ML; 116MG/100ML; 50MG/100ML; 11MG/100ML; 160MG/100ML CLINIMIX 4.25%/DEXTROSE 10% INJECTION 37MEQ/L; 2 B/D 880MG/100ML; 489MG/100ML; 17MEQ/L; 10GM/100ML; 438MG/100ML; 204MG/100ML; 255MG/100ML; 311MG/100ML; 247MG/100ML; 170MG/100ML; 238MG/100ML; 289MG/100ML; 213MG/100ML; 179MG/100ML; 77MG/100ML; 17MG/100ML; 247MG/100ML Page 77 of 103

88 CLINIMIX 4.25%/DEXTROSE 20% INJECTION 37MEQ/L; 2 B/D 880MG/100ML; 489MG/100ML; 17MEQ/L; 20GM/100ML; 438MG/100ML; 204MG/100ML; 255MG/100ML; 311MG/100ML; 247MG/100ML; 170MG/100ML; 238MG/100ML; 289MG/100ML; 213MG/100ML; 179MG/100ML; 77MG/100ML; 17MG/100ML; 247MG/100ML CLINIMIX 4.25%/DEXTROSE 25% INJECTION 37MEQ/L; 2 B/D 880MG/100ML; 489MG/100ML; 17MEQ/L; 25GM/100ML; 438MG/100ML; 204MG/100ML; 255MG/100ML; 311MG/100ML; 247MG/100ML; 170MG/100ML; 238MG/100ML; 289MG/100ML; 213MG/100ML; 179MG/100ML; 77MG/100ML; 17MG/100ML; 247MG/100ML CLINIMIX 4.25%/DEXTROSE 5% INJECTION 37MEQ/L; 2 B/D 880MG/100ML; 489MG/100ML; 17MEQ/L; 5GM/100ML; 438MG/100ML; 204MG/100ML; 255MG/100ML; 311MG/100ML; 247MG/100ML; 170MG/100ML; 238MG/100ML; 289MG/100ML; 213MG/100ML; 179MG/100ML; 77MG/100ML; 17MG/100ML; 247MG/100ML CLINIMIX 5%/DEXTROSE 15% INJECTION 2 B/D 42MEQ/1000ML; 1035MG/100ML; 575MG/100ML; 20MEQ/1000ML; 15GM/100ML; 515MG/100ML; 240MG/100ML; 300MG/100ML; 365MG/100ML; 290MG/100ML; 200MG/100ML; 280MG/100ML; 340MG/100ML; 250MG/100ML; 210MG/100ML; 90MG/100ML; 20MG/100ML; 290MG/100ML CLINIMIX 5%/DEXTROSE 20% INJECTION 42MEQ/L; 2 B/D 1035MG/100ML; 575MG/100ML; 20MEQ/L; 20GM/100ML; 515MG/100ML; 240MG/100ML; 300MG/100ML; 365MG/100ML; 290MG/100ML; 200MG/100ML; 280MG/100ML; 340MG/100ML; 250MG/100ML; 210MG/100ML; 90MG/100ML; 20MG/100ML; 290MG/100ML CLINIMIX 5%/DEXTROSE 25% INJECTION 42MEQ/L; 2 B/D 1035MG/100ML; 575MG/100ML; 20MEQ/L; 25GM/100ML; 515MG/100ML; 240MG/100ML; 300MG/100ML; 365MG/100ML; 290MG/100ML; 200MG/100ML; 280MG/100ML; 340MG/100ML; 250MG/100ML; 210MG/100ML; 90MG/100ML; 20MG/100ML; 290MG/100ML Page 78 of 103

89 CLINIMIX E 2.75%/DEXTROSE 10% INJECTION 570MG/100ML; 316MG/100ML; 33MG/100ML; 10GM/100ML; 132MG/100ML; 165MG/100ML; 201MG/100ML; 159MG/100ML; 51MG/100ML; 110MG/100ML; 454MG/100ML; 154MG/100ML; 261MG/100ML; 187MG/100ML; 138MG/100ML; 217MG/100ML; 112MG/100ML; 116MG/100ML; 50MG/100ML; 11MG/100ML; 160MG/100ML CLINIMIX E 2.75%/DEXTROSE 5% INJECTION 570MG/100ML; 316MG/100ML; 33MG/100ML; 5GM/100ML; 132MG/100ML; 165MG/100ML; 201MG/100ML; 159MG/100ML; 51MG/100ML; 110MG/100ML; 454MG/100ML; 154MG/100ML; 261MG/100ML; 187MG/100ML; 138MG/100ML; 217MG/100ML; 112MG/100ML; 116MG/100ML; 50MG/100ML; 11MG/100ML; 160MG/100ML CLINIMIX E 4.25%/DEXTROSE 10% INJECTION 880MG/100ML; 489MG/100ML; 33MG/100ML; 10GM/100ML; 204MG/100ML; 255MG/100ML; 311MG/100ML; 247MG/100ML; 51MG/100ML; 170MG/100ML; 702MG/100ML; 238MG/100ML; 261MG/100ML; 289MG/100ML; 213MG/100ML; 297MG/100ML; 77MG/100ML; 179MG/100ML; 77MG/100ML; 17MG/100ML; 247MG/100ML CLINIMIX E 4.25%/DEXTROSE 25% INJECTION 880MG/100ML; 489MG/100ML; 33MG/100ML; 25GM/100ML; 204MG/100ML; 255MG/100ML; 311MG/100ML; 247MG/100ML; 51MG/100ML; 170MG/100ML; 702MG/100ML; 238MG/100ML; 261MG/100ML; 289MG/100ML; 213MG/100ML; 297MG/100ML; 77MG/100ML; 179MG/100ML; 77MG/100ML; 17MG/100ML; 247MG/100ML CLINIMIX E 4.25%/DEXTROSE 5% INJECTION 880MG/100ML; 489MG/100ML; 33MG/100ML; 5GM/100ML; 204MG/100ML; 255MG/100ML; 311MG/100ML; 247MG/100ML; 51MG/100ML; 170MG/100ML; 702MG/100ML; 238MG/100ML; 261MG/100ML; 289MG/100ML; 213MG/100ML; 297MG/100ML; 77MG/100ML; 179MG/100ML; 77MG/100ML; 17MG/100ML; 247MG/100ML CLINIMIX E 5%/DEXTROSE 15% INJECTION 1035MG/100ML; 575MG/100ML; 33MG/100ML; 15GM/100ML; 240MG/100ML; 300MG/100ML; 365MG/100ML; 290MG/100ML; 51MG/100ML; 200MG/100ML; 826MG/100ML; 280MG/100ML; 261MG/100ML; 340MG/100ML; 250MG/100ML; 340MG/100ML; 59MG/100ML; 210MG/100ML; 90MG/100ML; 20MG/100ML; 290MG/100ML 2 B/D 2 B/D 2 B/D 2 B/D 2 B/D 2 B/D Page 79 of 103

90 CLINIMIX E 5%/DEXTROSE 20% INJECTION 2 B/D 1035MG/100ML; 575MG/100ML; 33MG/100ML; 20GM/100ML; 240MG/100ML; 300MG/100ML; 365MG/100ML; 290MG/100ML; 51MG/100ML; 200MG/100ML; 826MG/100ML; 280MG/100ML; 261MG/100ML; 340MG/100ML; 250MG/100ML; 340MG/100ML; 59MG/100ML; 210MG/100ML; 90MG/100ML; 20MG/100ML; 290MG/100ML CLINIMIX E 5%/DEXTROSE 25% INJECTION 2 B/D 1035MG/100ML; 575MG/100ML; 33MG/100ML; 25GM/100ML; 240MG/100ML; 300MG/100ML; 365MG/100ML; 290MG/100ML; 51MG/100ML; 200MG/100ML; 826MG/100ML; 280MG/100ML; 261MG/100ML; 340MG/100ML; 250MG/100ML; 340MG/100ML; 59MG/100ML; 210MG/100ML; 90MG/100ML; 20MG/100ML; 290MG/100ML corvita 150 tablet 120mg; 15mcg; 1.25mg; 150mg; 10mg; 3 DP 25mg dexferrum injection 50mg/ml 3 DP dexferrum injection 50mg/ml 3 DP DEXTROSE 10%/NACL 0.45% INJECTION 10%; 0.45% 2 dextrose 10% flex container injection 10% 1 DEXTROSE 10%/NACL 0.2% INJECTION 10%; 0.2% 2 dextrose 2.5%/sodium chloride 0.45% injection 2.5%; 0.45% 1 dextrose 5%/nacl 0.2% injection 5%; 0.2% 1 DEXTROSE 5%/NACL 0.225% INJECTION 5%; 0.225% 2 dextrose 5%/nacl 0.33% injection 5%; 0.33% 1 dextrose 5%/nacl 0.45% injection 5%; 0.45% 1 dextrose 5%/nacl 0.9% injection 5%; 0.9% 1 dextrose 5%/potassium chloride 0.15% injection 5%; 20meq/l 1 dextrose 5% injection 5% 1 FERRAPLUS 90 TABLET 120MG; 12MCG; 50MG; 1MG; 3 DP 90MG FOLIVANE-F CAPSULE 40MG; 62.5MG; 1MG; 3MG; 3 DP 62.5MG FREAMINE HBC 6.9% INJECTION 59.3MEQ/L; 2 B/D 400MG/100ML; 580MG/100ML; 3MEQ/L; 14MG/100ML; 330MG/100ML; 160MG/100ML; 760MG/100ML; 1370MG/100ML; 410MG/100ML; 250MG/100ML; 320MG/100ML; 630MG/100ML; 330MG/100ML; 10MEQ/L; 200MG/100ML; 90MG/100ML; 880MG/100ML FREAMINE III 3% INJECTION 44MEQ/L; 210MG/100ML; 2 B/D 290MG/100ML; 41MEQ/L; 20MG/100ML; 420MG/100ML; 85MG/100ML; 210MG/100ML; 270MG/100ML; 220MG/100ML; 5MEQ/L; 160MG/100ML; 170MG/100ML; 7MMOLE/L; 24.5MEQ/L; 340MG/100ML; 180MG/100ML; 35MEQ/L; 120MG/100ML; 46MG/100ML; 200MG/100ML Page 80 of 103

91 hepatamine injection 62meq/l; 770mg/100ml; 600mg/100ml; 1 B/D 3meq/l; 20mg/100ml; 900mg/100ml; 240mg/100ml; 900mg/100ml; 1100mg/100ml; 610mg/100ml; 100mg/100ml; 100mg/100ml; 115mg/100ml; 800mg/100ml; 500mg/100ml; 100mg/100ml; 450mg/100ml; 66mg/100ml; 840mg/100ml infed injection 50mg/ml 3 DP IONOSOL-B/DEXTROSE 5% INJECTION 49MEQ/L; 5%; 2 25MEQ/L; 5MEQ/L; 13MEQ/L; 25MEQ/L; 57MEQ/L IONOSOL-MB/DEXTROSE 5% INJECTION 22MEQ/L; 2 5%; 23MEQ/L; 3MEQ/L; 3MEQ/L; 20MEQ/L; 25MEQ/L ISOLYTE-P/DEXTROSE 5% INJECTION 23MEQ/L; 2 23MEQ/L; 5%; 3MEQ/L; 3MEQ/L; 20MEQ/L; 25MEQ/L ISOLYTE-S INJECTION 27MEQ/L; 98MEQ/L; 23MEQ/L; 2 3MEQ/L; 5MEQ/L; 140MEQ/L kcl 0.075%/d5w/nacl 0.45% injection 5%; 10meq/l; 0.45% 1 KCL 0.15%/D5W/LR INJECTION 3MEQ/L; 149MEQ/L; 2 5%; 28MEQ/L; 24MEQ/L; 130MEQ/L kcl 0.15%/d5w/nacl 0.2% injection 5%; 20meq/l; 0.2% 1 KCL 0.15%/D5W/NACL 0.225% INJECTION 5%; 2 20MEQ/L; 0.225% kcl 0.15%/d5w/nacl 0.9% injection 5%; 20meq/l; 0.9% 1 kcl 0.3%/d5w/nacl 0.45% injection 5%; 40meq/l; 0.45% 1 KCL 0.3%/D5W/NACL 0.9% INJECTION 5%; 40MEQ/L; 2 0.9% klor-con 10 tablet extended release 10meq 1 klor-con 8 tablet extended release 8meq 1 klor-con m10 tablet extended release 10meq 1 klor-con m10 tablet extended release 10meq 1 klor-con m15 tablet extended release 15meq 1 klor-con m20 tablet extended release 20meq 1 lactated ringers dextrose 5% viaflex injection 2.7meq/l; 1 109meq/l; 5%; 28meq/l; 4meq/l; 130meq/l lactated ringers viaflex injection 3meq/l; 109meq/l; 28meq/l; 1 4meq/l; 130meq/l magnesium sulfate injection 50% 1 magnesium sulfate injection 50% 1 MOZOBIL INJECTION 24MG/1.2ML 2 PA (Mozobil) NEPHRAMINE INJECTION 44MEQ/L; 20MG/100ML; 2 B/D 250MG/100ML; 560MG/100ML; 880MG/100ML; 640MG/100ML; 880MG/100ML; 880MG/100ML; 6MEQ/L; 400MG/100ML; 200MG/100ML; 640MG/100ML normosol-m in d5w injection 16meq/l; 40meq/l; 5%; 3meq/l; 1 13meq/l; 40meq/l NORMOSOL-R IN D5W INJECTION 27MEQ/L; 98MEQ/L; 2 5%; 23MEQ/L; 3MEQ/L; 5MEQ/L; 140MEQ/L NORMOSOL-R INJECTION 27MEQ/L; 98MEQ/L; 2 23MEQ/L; 3MEQ/L; 5MEQ/L; 140MEQ/L PLASMA-LYTE A INJECTION 27MEQ/L; 98MEQ/L; 2 23MEQ/L; 3MEQ/L; 5MEQ/L; 140MEQ/L Page 81 of 103

92 PLASMA-LYTE-148 INJECTION 27MEQ/L; 98MEQ/L; 2 23MEQ/L; 3MEQ/L; 5MEQ/L; 140MEQ/L PLASMA-LYTE-56/D5W INJECTION 16MEQ/L; 2 40MEQ/L; 5%; 3MEQ/L; 13MEQ/L; 40MEQ/L potassium chloride 0.15% /nacl 0.45% viaflex injection 1 20meq/l; 0.45% potassium chloride 0.15% d5w/nacl 0.33% injection 5%; 1 20meq/l; 0.33% potassium chloride 0.15% d5w/nacl 0.45% injection 5%; 1 20meq/l; 0.45% potassium chloride 0.15%/nacl 0.9% injection 20meq/l; 0.9% 1 potassium chloride 0.22% d5w/nacl 0.45% injection 5%; 1 30meq/l; 0.45% POTASSIUM CHLORIDE 0.3%/ NACL 0.9% INJECTION 2 40MEQ/L; 0.9% potassium chloride 0.3%/d5w injection 5%; 40meq/l 1 potassium chloride er capsule extended release 10meq 1 potassium chloride er capsule extended release 8meq 1 potassium chloride er tablet extended release 10meq 1 potassium chloride er tablet extended release 20meq 1 potassium chloride er tablet extended release 8meq 1 MO potassium chloride sr tablet extended release 8meq 1 POTASSIUM CHLORIDE INJECTION 10MEQ/100ML 2 POTASSIUM CHLORIDE INJECTION 20MEQ/100ML 2 potassium chloride injection 2meq/ml 1 POTASSIUM CHLORIDE INJECTION 30MEQ/100ML 2 POTASSIUM CHLORIDE INJECTION 40MEQ/100ML 2 potassium citrate er tablet extended release 1080mg 1 potassium citrate er tablet extended release 15meq 1 MO potassium citrate er tablet extended release 540mg 1 PREMASOL INJECTION 52MEQ/L; 1760MG/100ML; 2 B/D 880MG/100ML; 34MEQ/L; 1760MG/100ML; 372MG/100ML; 406MG/100ML; 526MG/100ML; 492MG/100ML; 492MG/100ML; 526MG/100ML; 356MG/100ML; 356MG/100ML; 390MG/100ML; 34MG/100ML; 152MG/100ML premasol injection 56meq/l; 320mg/100ml; 730mg/100ml; 1 B/D 190mg/100ml; 3meq/l; 20mg/100ml; 300mg/100ml; 220mg/100ml; 290mg/100ml; 490mg/100ml; 840mg/100ml; 490mg/100ml; 200mg/100ml; 290mg/100ml; 410mg/100ml; 230mg/100ml; 5meq/l; 15mg/100ml; 250mg/100ml; 120mg/100ml; 140mg/100ml; 470mg/100ml PROCALAMINE INJECTION 47MEQ/L; 210MG/100ML; 290MG/100ML; 3MEQ/L; 41MEQ/L; 20MG/100ML; 420MG/100ML; 85MG/100ML; 210MG/100ML; 270MG/100ML; 220MG/100ML; 5MEQ/L; 160MG/100ML; 170MG/100ML; 7MMOLE/L; 24MEQ/L; 340MG/100ML; 180MG/100ML; 35MEQ/L; 120MG/100ML; 46MG/100ML; 200MG/100ML 2 B/D Page 82 of 103

93 PROSOL INJECTION 2.76GM/100ML; 1.96GM/100ML; 2 B/D 600MG/100ML; 1.02GM/100ML; 2.06GM/100ML; 1.18GM/100ML; 1.08GM/100ML; 1.08GM/100ML; 1.35GM/100ML; 760MG/100ML; 1GM/100ML; 1.34GM/100ML; 1.02GM/100ML; 980MG/100ML; 320MG/100ML; 50MG/100ML; 1.44GM/100ML ringers injection injection 4.5meq/l; 156meq/l; 4meq/l; 1 147meq/l sodium chloride 0.45% viaflex injection 0.45% 1 sodium chloride 0.9% solution 0.9% 1 sodium chloride injection 0.9% 1 sodium chloride injection 2.5meq/ml 1 sodium chloride injection 3% 1 sodium chloride injection 5% 1 sodium fluoride tablet 1mg 1 TARON FORTE CAPSULE 60MG; 0; 0; 25MCG; 80MG; 3 DP 1MG; 70MG tl icon capsule 75mg; 15mcg; 110mg; 0.5mg; 240mg 3 DP tpn electrolytes injection 29.5meq/20ml; 4.5meq/20ml; 1 35meq/20ml; 5meq/20ml; 20meq/20ml; 35meq/20ml TRAVASOL INJECTION 52MEQ/L; 1760MG/100ML; 2 B/D 880MG/100ML; 34MEQ/L; 1760MG/100ML; 372MG/100ML; 406MG/100ML; 526MG/100ML; 492MG/100ML; 492MG/100ML; 526MG/100ML; 356MG/100ML; 356MG/100ML; 390MG/100ML; 34MG/100ML; 152MG/100ML TROPHAMINE INJECTION 0; 0.32GM/100ML; 2 B/D 0.73GM/100ML; 0.19GM/100ML; 0.014GM/100ML; 0.22GM/100ML; 0.29GM/100ML; 0.49GM/100ML; 0.3GM/100ML; 0.84GM/100ML; 0.49GM/100ML; 0.2GM/100ML; 0.29GM/100ML; 0.41GM/100ML; 0.23GM/100ML; 0.05GM/100ML; 0.015GM/100ML; 0.25GM/100ML; 0.12GM/100ML; 0.14GM/100ML; 0.47GM/100ML TROPHAMINE INJECTION 97MEQ/L; 0.54GM/100ML; 2 B/D 1.2GM/100ML; 0.32GM/100ML; 0; 0; 0.5GM/100ML; 0.36GM/100ML; 0.48GM/100ML; 0.82GM/100ML; 1.4GM/100ML; 1.2GM/100ML; 0.34GM/100ML; 0.48GM/100ML; 0.68GM/100ML; 0.38GM/100ML; 5MEQ/L; 0.025GM/100ML; 0.42GM/100ML; 0.2GM/100ML; 0.24GM/100ML; 0.78GM/100ML UROCIT-K 10 TABLET EXTENDED RELEASE 1080MG 2 UROCIT-K 15 TABLET EXTENDED RELEASE 15MEQ 2 UROCIT-K 5 TABLET EXTENDED RELEASE 540MG 2 VENOFER INJECTION 20MG/ML 3 DP VENOFER INJECTION 20MG/ML 3 DP VENOFER INJECTION 20MG/ML 3 DP VENOFER INJECTION 20MG/ML 3 DP VENOFER INJECTION 20MG/ML 3 DP Page 83 of 103

94 VENOFER INJECTION 20MG/ML 3 DP VENOFER INJECTION 20MG/ML 3 DP Therapeutic Nutrients/Minerals/Electrolytes VASCULERA TABLET 30MG; 600MG 3 DP Vitamins ADVANCED AM/PM MISCELLANEOUS 0; 0; 0; 0; 0; 0; 0; 3 DP 10MG; 100MG; 650MG; 0; 50UNIT AQUASOL A PARENTERAL INJECTION 50000UNIT/ML 3 DP biocel tablet 500mg; 125mg; 300mcg; 10mg; 200unit; 1mg; 3 DP 33mg; 50mg; 25mg; 25mg; 25mg; 50mcg; 25mg; 100unit; 5000unit; 60mg corvita tablet 375mg; 750unit; 75mcg; 315unit; 150mcg; 3 DP 1mg; 70mcg; 125unit; 1.25mg; 13mg; 10mg; 7mg; 2.5mg; 35mg; 35mg; 5mg; 35mg; 3.4mg; 125mcg; 25mg; 35mg CORVITE 150 TABLET 100MCG; 120MG; 5MG; 20MCG; 3 DP 700MCG; 150MG; 300MCG; 10MG; 10MG; 25MG CORVITE FE TABLET 120MG; 5MG; 1000UNIT; 15MCG; 3 DP 15MG; 25MG; 1MG; 125MG; 10MG; 25MG CORVITE TABLET 375MG; 750UNIT; 75MCG; 315UNIT; 3 DP 150MCG; 1MG; 70MCG; 125UNIT; 1.25MG; 13MG; 10MG; 7MG; 2.5MG; 35MG; 35MG; 5MG; 35MG; 3.4MG; 125MCG; 25MG; 35MG cyanocobalamin injection 1000mcg/ml 3 DP cyanocobalamin injection 1000mcg/ml 3 DP cyanocobalamin injection 1000mcg/ml 3 DP cyanocobalamin injection 1000mcg/ml 3 DP DECARA CAPSULE 25000UNIT 3 DP DECARA CAPSULE 25000UNIT 3 DP decara capsule 50000unit 3 DP DRISDOL CAPSULE 50000UNIT 3 DP FOLIC ACID INJECTION 5MG/ML 3 DP FOLIC ACID INJECTION 5MG/ML 3 DP folic acid tablet 1mg 3 DP folic acid tablet 1mg 3 DP folic acid tablet 1mg 3 DP folic acid tablet 1mg 3 folic acid tablet 1mg 3 folic acid tablet 1mg 3 DP folic acid tablet 1mg 3 DP folic acid tablet 1mg 3 DP folic acid tablet 1mg 3 DP folic acid tablet 1mg 3 DP folic acid tablet 1mg 3 DP folic acid tablet 1mg 3 DP folic acid tablet 1mg 3 DP folic acid tablet 1mg 3 DP folic acid tablet 1mg 3 DP folic acid tablet 1mg 3 DP folic acid tablet 1mg 3 DP Page 84 of 103

95 folic acid tablet 1mg 3 DP folic acid tablet 1mg 3 DP HYDROXOCOBALAMIN INJECTION 1000MCG/ML 3 DP infuvite adult injection 200mg/5ml; 60mcg/5ml; 200unit/5ml; 3 DP 5mcg/5ml; 15mg/5ml; 600mcg/5ml; 40mg/5ml; 150mcg/5ml; 6mg/5ml; 3.6mg/5ml; 6mg/5ml; 10unit/5ml; 3300unit/5ml infuvite pediatric injection 80mg/5ml; 1mcg/5ml; 400unit/5ml; 3 DP 1mcg/5ml; 5mg/5ml; 140mcg/5ml; 17mg/5ml; 1mg/5ml; 1.4mg/5ml; 1.2mg/5ml; 7unit/5ml; 2300unit/5ml; 0.2mg/5ml infuvite pediatric injection 80mg/5ml; 1mcg/5ml; 400unit/5ml; 3 DP 1mcg/5ml; 5mg/5ml; 140mcg/5ml; 17mg/5ml; 1mg/5ml; 1.4mg/5ml; 1.2mg/5ml; 7unit/5ml; 2300unit/5ml; 0.2mg/5ml infuvite injection 200mg/10ml; 200unit/10ml; 5mcg/10ml; 3 DP 15mg/10ml; 600mcg/10ml; 40mg/10ml; 6mg/10ml; 3.6mg/10ml; 6mg/10ml; 10unit/10ml; 3300unit/10ml; 150mcg/10ml M.V.I. ADULT INJECTION 200MG/10ML; 60MCG/10ML; 3 DP 5MCG/10ML; 15MG/10ML; 5MCG/10ML; 600MCG/10ML; 40MG/10ML; 150MCG/10ML; 6MG/10ML; 3.6MG/10ML; 6MG/10ML; 10MG/10ML; 1MG/10ML M.V.I. ADULT INJECTION 200MG/10ML; 60MCG/10ML; 3 DP 5MCG/10ML; 15MG/10ML; 5MCG/10ML; 600MCG/10ML; 40MG/10ML; 150MCG/10ML; 6MG/10ML; 3.6MG/10ML; 6MG/10ML; 10MG/10ML; 1MG/10ML M.V.I. PEDIATRIC INJECTION 80MCG; 20MCG; 1MCG; 3 DP 140MCG; 17MG; 5MG; 200MCG; 1MG; 1.4MG; 1.2MG; 0.7MG; 10MCG; 7MG M.V.I.-12 WITHOUT VITAMIN K INJECTION 3 DP 200MG/10ML; 60MCG/10ML; 5MCG/10ML; 15MG/10ML; 200UNIT/10ML; 600MCG/10ML; 40MG/10ML; 6MG/10ML; 3.6MG/10ML; 6MG/10ML; 10UNIT/10ML; 3300UNIT/10ML MEPHYTON TABLET 5MG 3 DP NASCOBAL SOLUTION 500MCG/0.1ML 3 DP PHYSICIANS EZ USE B-12 COMPLIANCE KIT 3 DP INJECTION 1000MCG/ML PRENAPLUS TABLET 120MG; 0; 200MG; 400UNIT; 2 2MG; 12MCG; 27MG; 1MG; 20MG; 10MG; 3MG; 1.84MG; 22MG; 4000UNIT; 25MG PRENATABS OBN TABLET 120MG; 200MG; 400UNIT; 2 8MCG; 1MG; 29MG; 20MG; 150MCG; 3MG; 3MG; 3MG; 30UNIT; 15MG prenatabs rx tablet 120mg; 4000unit; 30mcg; 200mg; 7mg; 1 QL (30 EA per 30 days) 400unit; 3mg; 8mcg; 1mg; 29mg; 100mg; 20mg; 150mcg; 3mg; 3mg; 0; 3mg; 30unit; 15mg prenatal plus iron tablet 120mg; 0; 200mg; 400unit; 2mg; 12mcg; 1mg; 29mg; 20mg; 10mg; 3mg; 1.84mg; 22mg; 4000unit; 25mg 1 QL (30 EA per 30 days) Page 85 of 103

96 prenatal plus iron tablet 120mg; 0; 200mg; 400unit; 2mg; 1 QL (30 EA per 30 days) 12mcg; 1mg; 29mg; 20mg; 10mg; 3mg; 1.84mg; 22unit; 4000unit; 25mg prenatal plus iron tablet 120mg; 0; 200mg; 400unit; 2mg; 1 QL (30 EA per 30 days) 12mcg; 1mg; 29mg; 20mg; 10mg; 3mg; 1.84mg; 22unit; 4000unit; 25mg prenatal plus iron tablet 120mg; 0; 200mg; 400unit; 2mg; 1 QL (30 EA per 30 days) 12mcg; 1mg; 29mg; 20mg; 10mg; 3mg; 1.84mg; 22unit; 4000unit; 25mg PYRIDOXINE HCL INJECTION 100MG/ML 3 DP thiamine hcl injection 100mg/ml 3 DP thiamine hcl injection 100mg/ml 3 DP thiamine hcl injection 100mg/ml 3 DP tl gard rx tablet 1mg; 2.2mg; 25mg 3 DP VINATE ONE TABLET 80MG; 0; 0.03MG; 200MG; 2 400UNIT; 3MG; 2.5MCG; 60MG; 1MG; 100MG; 17MG; 7MG; 4MG; 1.6MG; 1.5MG; 15UNIT; 4000UNIT; 25MG vitacel tablet 500mg; 125mg; 300mcg; 25mg; 10mg; 1mg; 3 DP 33mg; 50mg; 25mg; 25mg; 50mcg; 25mg; 5000unit; 200unit; 100unit; 80mg vitamin d capsule 50000unit 3 DP vitamin d capsule 50000unit 3 DP vitamin d capsule 50000unit 3 DP vitamin d capsule 50000unit 3 DP vitamin d capsule 50000unit 3 DP vitamin d capsule 50000unit 3 DP vitamin d capsule 50000unit 3 DP VITAMIN K1 INJECTION 10MG/ML 3 DP vitamin k1 injection 1mg/0.5ml 3 DP vol-tab rx tablet 120mg; 4000unit; 30mcg; 200mg; 7mg; 1 QL (30 EA per 30 days) 400unit; 3mg; 8mcg; 1mg; 29mg; 100mg; 20mg; 150mcg; 3mg; 3mg; 3mg; 30unit; 15mg Unclassified No Classification FERAHEME INJECTION 510MG/17ML 3 DP FERAHEME INJECTION 510MG/17ML 3 DP Page 86 of 103

97 Index Name Page # abacavir 33 abacavir sulfate/lamivudine/zidovudine 33 ABELCET 20 ABILIFY 30 ABILIFY DISCMELT 30 ABILIFY MAINTENA 30 ABRAXANE 24 acamprosate calcium dr 4 acarbose 36 acebutolol hcl 45 acetaminophen/codeine 2 acetaminophen/codeine #3 2 acetasol hc 71 acetazolamide 48 acetazolamide er 70 acetazolamide sodium 48 acetic acid 71 acetylcysteine 74 ACTHIB 67 ACTIMMUNE 67 acyclovir 35 acyclovir sodium 35 ADACEL 67 ADAGEN 53 adapalene 52 adefovir dipivoxil 32 adriamycin 24 ADVAIR DISKUS 71 ADVAIR HFA 71 ADVANCED AM/PM 84 afeditab cr 46 AFINITOR 25 AFINITOR DISPERZ 25 AGGRENOX 41 a-hydrocort 57 ALBENZA 27 albuterol sulfate 73 albuterol sulfate er 73 alclometasone dipropionate 57 alcohol preps 5 ALDURAZYME 54 alendronate sodium 68 alfuzosin hcl er 56 ALIMTA 23 ALINIA 27 ALKERAN 22 allopurinol 21 Page 87 of 103 Name Page # ALOPRIM 21 ALORA 60 ALPHAGAN P 70 alprazolam 36 ALPRAZOLAM INTENSOL 36 amantadine hcl 35 AMBISOME 20 amcinonide 57 amifostine 24 amikacin sulfate 5 amiloride hcl 49 amiloride/hydrochlorothiazide 49 aminophylline 74 AMINOSYN 7%/ELECTROLYTES 76 aminosyn 8.5%/electrolytes 76 AMINOSYN II 76 aminosyn ii 8.5%/electrolytes 76 AMINOSYN M 77 AMINOSYN-HBC 77 AMINOSYN-PF 77 AMINOSYN-PF 7% 77 AMINOSYN-RF 77 amiodarone hcl 44 AMITIZA 55 amitriptyline hcl 18 amlodipine besylate 46 amlodipine besylate/benazepril hcl 46 amlodipine besylate/benazepril 46 hydrochloride amlodipine besylate/valsartan 46 amlodipine/valsartan/hctz 46 AMMONIUM CHLORIDE 77 ammonium lactate 52 amoxapine 18 amoxicillin 9 amoxicillin/clavulanate potassium 9 amoxicillin/clavulanate potassium er 9 amphetamine/dextroamphetamine 51 AMPHOTERICIN B 20 ampicillin 10 ampicillin sodium 9 ampicillin-sulbactam 9 anagrelide hydrochloride 40 anastrozole 25 ANDRODERM 60 ANDROXY 60 APIDRA 38 APIDRA SOLOSTAR 38 APOKYN 28 apri 61

98 Page # APTIOM 12 APTIVUS 34 AQUASOL A PARENTERAL 84 ARALAST NP 74 aranelle 61 ARANESP ALBUMIN FREE 40 ARCALYST 67 ARRANON 23 ARZERRA 26 ascomp/codeine 2 ASMANEX HFA 71 ASMANEX TWISTHALER METERED DOSES ASMANEX TWISTHALER 14 METERED 71 DOSES ASMANEX TWISTHALER 30 ME 71 TERED DOSES ASMANEX TWISTHALER 30 METERED 72 DOSES ASMANEX TWISTHALER 60 METERED 72 DOSES atenolol 45 atenolol/chlorthalidone 45 atorvastatin calcium 49 atovaquone 27 atovaquone/proguanil hcl 27 ATRIPLA 35 ATROPINE SULFATE 55 ATROVENT HFA 73 AUBAGIO 52 aubra 61 augmented betamethasone dipropionate 57 AVANDARYL 36 AVASTIN 26 AVELOX 11 aviane 61 AVODART 56 AVONEX 52 azacitidine 24 AZACTAM 9 AZACTAM IN ISO-OSMOTIC 9 DEXTROSE azathioprine 66 azelastine hcl 72 AZILECT 28 azithromycin 10 aztreonam 9 baciim 5 BACITRACIN 5 bacitracin/polymyxin b 70 Name Page # baclofen 31 BACTOCILL IN DEXTROSE 10 balsalazide disodium 68 balziva 61 BANZEL 14 BARACLUDE 32 BD INSULIN SYRINGE 69 SAFETYGLIDE/1ML/29G X 1/2" BD INSULIN SYRINGE 69 ULTRAFINE/0.3ML/31G X 5/16" BD INSULIN SYRINGE 69 ULTRAFINE/0.5ML/30G X 1/2" BD INSULIN SYRINGE 69 ULTRAFINE/1ML/31G X 5/16" BD PEN NEEDLE/ULTRAFINE/29G X MM BELEODAQ 24 benazepril hcl 43 benazepril hcl/hydrochlorothiazide 43 benztropine mesylate 27 betamethasone dipropionate 57 betamethasone valerate 57 BETASERON 52 betaxolol hcl 45 betaxolol hcl 70 bethanechol chloride 57 bicalutamide 23 BICILLIN C-R 10 BICILLIN L-A 10 BICNU 22 BIDIL 50 biocel 84 bisoprolol fumarate 45 bisoprolol fumarate/hydrochlorothiazide 45 bleomycin sulfate 24 BOOSTRIX 67 BOSULIF 25 BOTOX 21 BRILINTA 41 brimonidine tartrate 70 BRINTELLIX 16 bromocriptine mesylate 28 budeprion sr 16 budesonide 57 budesonide 72 bumetanide 48 BUPHENYL 54 buprenorphine hcl 4 buproban 5 bupropion hcl 16 Page 88 of 103

99 Page # bupropion hcl sr 16 bupropion hcl xl 16 buspirone hcl 35 BUSULFEX 22 butalbital/acetaminophen 1 butalbital/acetaminophen/caffeine 1 butalbital/acetaminophen/caffeine/codeine 1 butalbital/aspirin/caffeine 1 butorphanol tartrate 2 BYETTA 36 cabergoline 65 calcipotriene 52 calcitonin-salmon 68 calcitriol 68 calcium acetate 57 camila 63 CAMPTOSAR 24 CANCIDAS 20 candesartan cilexetil 42 candesartan cilexetil/hydrochlorothiazide 42 CAPASTAT SULFATE 22 CAPRELSA 25 captopril 43 captopril/hydrochlorothiazide 43 carbamazepine 14 carbamazepine er 14 CARBATROL 14 carbidopa/levodopa 28 carbidopa/levodopa er 28 carbidopa/levodopa odt 28 carboplatin 24 CARIMUNE NANOFILTERED 67 carteolol hcl 70 cartia xt 46 carvedilol 45 CAYSTON 73 cefaclor 7 cefaclor er 7 cefadroxil 7 cefazolin sodium 7 cefdinir 7 cefepime 7 cefotaxime sodium 7 cefoxitin sodium 7 cefpodoxime proxetil 7 cefprozil 7 ceftazidime 7 ceftriaxone sodium 7 cefuroxime axetil 8 cefuroxime sodium 8 Name Page # CELLCEPT 66 CELLCEPT INTRAVENOUS 66 CELONTIN 12 cephalexin 8 CEREBYX 15 CEREZYME 54 CERVARIX 67 CHANTIX 5 CHANTIX STARTING MONTH PAK 5 CHEMET 75 CHLORAMPHENICOL SODIUM 5 SUCCINATE chlordiazepoxide/amitriptyline 18 chlorhexidine gluconate oral rinse 52 chloroquine phosphate 27 chlorothiazide 49 chlorothiazide sodium 49 CHLORPROMAZINE HCL 28 chlorthalidone 49 chlorzoxazone 74 cholestyramine light 50 chorionic gonadotropin 59 ciclopirox 20 ciclopirox olamine 20 cidofovir 32 cilostazol 41 cimetidine 55 cimetidine hcl 55 CINRYZE 66 CIPRODEX 71 ciprofloxacin 11 ciprofloxacin hcl 11 ciprofloxacin i.v.-in d5w 11 cisplatin 24 citalopram hydrobromide 17 cladribine 23 CLAFORAN 8 claravis 52 clarithromycin 10 clarithromycin er 10 CLEOCIN IN D5W 5 CLEOCIN PEDIATRIC GRANULES 5 CLIMARA PRO 61 clindamycin hcl 5 clindamycin palmitate hcl 6 clindamycin phosphate 6 clindamycin phosphate add-vantage 6 clindamycin phosphate in d5w 6 clindamycin/benzoyl peroxide 53 CLINIMIX 2.75%/DEXTROSE 5% 77 Page 89 of 103

100 Page # CLINIMIX 4.25%/DEXTROSE 10% 77 CLINIMIX 4.25%/DEXTROSE 20% 78 CLINIMIX 4.25%/DEXTROSE 25% 78 CLINIMIX 4.25%/DEXTROSE 5% 78 CLINIMIX 5%/DEXTROSE 15% 78 CLINIMIX 5%/DEXTROSE 20% 78 CLINIMIX 5%/DEXTROSE 25% 78 CLINIMIX E 2.75%/DEXTROSE 10% 79 CLINIMIX E 2.75%/DEXTROSE 5% 79 CLINIMIX E 4.25%/DEXTROSE 10% 79 CLINIMIX E 4.25%/DEXTROSE 25% 79 CLINIMIX E 4.25%/DEXTROSE 5% 79 CLINIMIX E 5%/DEXTROSE 15% 79 CLINIMIX E 5%/DEXTROSE 20% 80 CLINIMIX E 5%/DEXTROSE 25% 80 clobetasol propionate 57 clobetasol propionate e 57 clodan 57 CLOLAR 23 clomipramine hcl 18 clonazepam 13 clonazepam odt 12 clonidine hcl 42 clonidine hcl er 42 clopidogrel 41 clorazepate dipotassium 36 clotrimazole 20 clotrimazole/betamethasone dipropionate 53 clozapine 31 clozapine odt 31 COARTEM 27 colchicine 21 COLCRYS 21 colestipol hcl 50 colistimethate sodium 6 COMBIGAN 70 COMBIVENT RESPIMAT 73 COMETRIQ 26 COMPLERA 33 compro 29 COMVAX 67 constulose 56 COPAXONE 52 cortisone acetate 57 corvita 84 corvita CORVITE 84 CORVITE CORVITE FE 84 COSMEGEN 24 Name Page # COUMADIN 39 CREON 54 CRIXIVAN 34 cromolyn sodium 55 cromolyn sodium 70 cromolyn sodium 73 cryselle CUBICIN 6 curity gauze pads 2"x2" 53 cyanocobalamin 84 cyclafem 1/35 61 cyclobenzaprine hcl 74 cyclophosphamide 22 CYCLOSET 36 cyclosporine 66 cyclosporine modified 66 cyproheptadine hcl 72 CYSTADANE 54 CYSTAGON 54 cytarabine 23 cytarabine aqueous 23 CYTOMEL 63 dacarbazine 22 DACOGEN 24 dactinomycin 24 DALIRESP 74 danazol 60 dantrolene sodium 31 DAPSONE 22 DAPTACEL 67 DARAPRIM 27 DAUNORUBICIN HCL 24 deblitane 63 DECARA 84 DECAVAC 67 decitabine 24 delyla 61 DELZICOL 68 demeclocycline hcl 12 DEMEROL 2 DEMSER 47 DENAVIR 35 DEPEN TITRATABS 75 DEPO-ESTRADIOL 61 DEPO-MEDROL 57 DEPO-SUBQ PROVERA desipramine hcl 18 desmopressin acetate 59 desogestrel/ethinyl estradiol 61 desonide 57 Page 90 of 103

101 Page # desoximetasone 57 desvenlafaxine er 17 dexamethasone 58 dexamethasone sodium phosphate 58 dexamethasone sodium phosphate 70 dexferrum 80 dexrazoxane 24 dextroamphetamine sulfate 51 DEXTROSE 10%/NACL 0.45% 80 dextrose 10% flex container 80 DEXTROSE 10%/NACL 0.2% 80 dextrose 2.5%/sodium chloride 0.45% 80 dextrose 5% 80 dextrose 5%/nacl 0.2% 80 DEXTROSE 5%/NACL 0.225% 80 dextrose 5%/nacl 0.33% 80 dextrose 5%/nacl 0.45% 80 dextrose 5%/nacl 0.9% 80 dextrose 5%/potassium chloride 0.15% 80 diazepam 13 diazepam 36 DIAZEPAM INTENSOL 36 diclofenac potassium 1 diclofenac sodium 70 diclofenac sodium dr 1 diclofenac sodium er 1 dicloxacillin sodium 10 dicyclomine hcl 55 didanosine 34 diflunisal 1 digitek 47 digoxin 48 dihydroergotamine mesylate 21 DILANTIN 15 DILANTIN INFATABS 15 DILANTIN dilt-cd 46 diltiazem cd 46 DILTIAZEM HCL 47 diltiazem hcl er 46 dilt-xr 46 DIPENTUM 68 diphenhydramine hcl 72 diphenoxylate/atropine 55 DIPHTHERIA/TETANUS TOXOIDS 67 ADSORBED PEDIATRIC dipyridamole 41 disopyramide phosphate 44 disulfiram 4 divalproex sodium 13 Name Page # divalproex sodium dr 13 divalproex sodium er 13 DOCEFREZ 24 DOCETAXEL 24 donepezil hcl 15 dorzolamide hcl 71 dorzolamide hcl/timolol maleate 71 doxazosin mesylate 56 doxepin hcl 18 DOXIL 24 doxorubicin hcl 24 doxycycline hyclate 12 DRISDOL 84 dronabinol 19 DROXIA 23 DUETACT 36 DULERA 72 duloxetine hcl 17 duramorph 2 e.e.s e.e.s. granules 11 econazole nitrate 20 EDURANT 33 EFFIENT 41 ELAPRASE 54 ELDEPRYL 28 ELELYSO 54 ELIDEL 53 ELIGARD 65 ELIPHOS 57 ELITEK 23 ELIXOPHYLLIN 74 ELLA 63 ELLENCE 24 ELMIRON 57 EMCYT 23 EMEND 20 EMSAM 17 EMTRIVA 34 enalapril maleate 43 enalapril maleate/hydrochlorothiazide 43 ENBREL 66 endocet 2 ENGERIX-B 67 enoxaparin sodium 39 enpresse entacapone 27 entecavir 32 enulose 56 EPIPEN 2-PAK 73 Page 91 of 103

102 Page # EPIPEN-JR 2-PAK 73 epirubicin hcl 24 epitol 15 EPIVIR 34 EPIVIR HBV 32 eplerenone 49 EPOGEN 40 eprosartan mesylate 42 EPZICOM 34 ERBITUX 26 ergoloid mesylates 15 ERGOMAR 21 ERIVEDGE 26 errin 63 ERYPED ERY-TAB 11 ERYTHROCIN LACTOBIONATE 11 erythrocin stearate 11 erythromycin 11 erythromycin base 11 erythromycin/benzoyl peroxide 53 escitalopram oxalate 17 esomeprazole sodium 56 ESTRACE 61 estradiol 61 estradiol valerate 61 estropipate 61 ethambutol hcl 22 ethosuximide 12 etidronate disodium 69 etodolac 1 etodolac er 1 ETOPOPHOS 25 etoposide 25 EVISTA 63 exemestane 25 EXJADE 75 FABRAZYME 54 falmina 61 famciclovir 35 famotidine 55 FAMOTIDINE PREMIXED 55 FANAPT 30 FANAPT TITRATION PACK 30 FARESTON 23 FARXIGA 36 FASLODEX 23 FAZACLO 31 felbamate 13 felodipine er 47 Name Page # fenofibrate 49 fenofibrate micronized 49 fenoprofen calcium 1 fentanyl 2 fentanyl citrate oral transmucosal 3 FERAHEME 86 FERRAPLUS FETZIMA 17 FETZIMA TITRATION PACK 17 finasteride 56 FIRAZYR 66 FIRMAGON 65 flavoxate hcl 56 flecainide acetate 44 FLOVENT DISKUS 72 FLOVENT HFA 72 fluconazole 20 fluconazole in dextrose 20 flucytosine 20 fludarabine phosphate 24 fludrocortisone acetate 58 flunisolide 72 fluocinolone acetonide 58 fluocinonide 58 fluocinonide-e 58 fluorometholone 70 fluor-op 70 fluorouracil 23 fluorouracil 53 fluoxetine hcl 17 FLUPHENAZINE DECANOATE 29 fluphenazine hcl 29 flurazepam hcl 75 flurbiprofen 1 flurbiprofen sodium 70 flutamide 23 fluticasone propionate 58 fluticasone propionate 72 fluvoxamine maleate 17 FOLIC ACID 84 FOLIVANE-F 80 FOLOTYN 24 fondaparinux sodium 39 FORTAZ 8 FORTEO 69 fortical 69 FOSCARNET SODIUM 32 fosinopril sodium 43 fosinopril sodium/hydrochlorothiazide 43 fosphenytoin sodium 15 Page 92 of 103

103 Page # FOSRENOL 57 FRAGMIN 39 FREAMINE HBC 6.9% 80 FREAMINE III 3% 80 furosemide 48 FUSILEV 24 FUZEON 34 FYCOMPA 12 gabapentin 13 GABITRIL 13 galantamine hydrobromide 16 GAMASTAN S/D 67 GAMMAGARD LIQUID 67 GAMUNEX-C 67 ganciclovir 32 GARDASIL 67 GARDASIL 9 67 gavilyte-c 56 gavilyte-g 56 gavilyte-n/flavor pack 56 gemcitabine hcl 24 gemfibrozil 49 generlac 56 gengraf 66 gentak 5 gentamicin sulfate 5 GENTAMICIN SULFATE/0.9% SODIUM 5 CHLORIDE GEODON 30 gildess 1.5/30 61 GILENYA 52 GILOTRIF 24 GLEEVEC 26 glimepiride 37 glipizide 37 glipizide er 37 glipizide/metformin hcl 37 GLUCAGEN HYPOKIT 38 GLUCAGON EMERGENCY KIT 38 glyburide 37 glyburide micronized 37 glyburide/metformin hcl 37 glycopyrrolate 55 GLYSET 37 GRALISE 1 GRALISE STARTER 1 granisetron hcl 20 GRANIX 41 griseofulvin microsize 20 griseofulvin ultramicrosize 20 Name Page # guanfacine er 51 guanfacine hcl 42 GUANIDINE HCL 22 HALAVEN 24 halobetasol propionate 58 haloperidol 29 haloperidol decanoate 29 haloperidol lactate 29 HAVRIX 67 HECTOROL 69 heparin sodium 39 heparin sodium/d5w 39 heparin sodium/nacl 0.9% 39 hepatamine 81 HERCEPTIN 26 HEXALEN 22 HUMALOG 38 HUMALOG KWIKPEN 38 HUMALOG MIX 50/50 38 HUMALOG MIX 50/50 KWIKPEN 38 HUMALOG MIX 75/25 38 HUMALOG MIX 75/25 KWIKPEN 38 HUMIRA 66 HUMIRA PEN-CROHNS 66 DISEASESTARTER HUMULIN 70/30 38 HUMULIN 70/30 PEN 38 HUMULIN N 38 HUMULIN N U-100 PEN 38 HUMULIN R 38 HUMULIN R U-500 (CONCENTRATED) 38 hydralazine hcl 50 hydrochlorothiazide 49 hydrocodone bitartrate/acetaminophen 3 hydrocodone/acetaminophen 3 hydrocortisone 58 hydrocortisone butyrate 58 hydrocortisone valerate 58 hydrocortisone/acetic acid 71 hydromorphone hcl 3 HYDROXOCOBALAMIN 85 hydroxychloroquine sulfate 27 hydroxyurea 24 HYDROXYZINE HCL 72 hydroxyzine pamoate 72 ibandronate sodium 69 ibuprofen 1 ICLUSIG 26 IDAMYCIN PFS 24 idarubicin hcl 24 Page 93 of 103

104 Page # IFEX 22 ifosfamide 22 ILARIS 67 IMBRUVICA 26 imipenem/cilastatin 9 imipramine hcl 19 imipramine pamoate 19 imiquimod 53 IMITREX 21 IMITREX STATDOSE REFILL 21 IMOVAX RABIES (H.D.C.V.) 67 INCIVEK 32 INCRELEX 59 indapamide 49 indomethacin 1 indomethacin er 1 INFANRIX 68 infed 81 INFERGEN 32 infuvite 85 infuvite adult 85 infuvite pediatric 85 INLYTA 26 INTELENCE 33 intralipid 69 INTRON A 32 INTRON-A 32 INTRON-A W/DILUENT 32 introvale 61 INTUNIV 51 INVANZ 9 INVEGA 30 INVEGA SUSTENNA 30 INVIRASE 34 IONOSOL-B/DEXTROSE 5% 81 IONOSOL-MB/DEXTROSE 5% 81 IPOL INACTIVATED IPV 68 ipratropium bromide 73 ipratropium bromide/albuterol sulfate 73 irbesartan 42 irbesartan/hydrochlorothiazide 42 irinotecan 24 ISENTRESS 33 ISOLYTE-P/DEXTROSE 5% 81 ISOLYTE-S 81 ISONIAZID 22 isosorbide dinitrate 50 isosorbide dinitrate er 50 isosorbide mononitrate 50 isosorbide mononitrate er 50 Name Page # isotonic gentamicin 5 ISTODAX 24 itraconazole 20 ivermectin 27 IXEMPRA KIT 24 IXIARO 68 JAKAFI 26 jantoven 39 JANUVIA 37 JENTADUETO 37 JEVTANA 24 jolivette 63 junel 1.5/30 61 junel 1/20 61 junel fe 1.5/30 61 junel fe 1/20 61 KADCYLA 26 KALETRA 34 kariva 61 kcl 0.075%/d5w/nacl 0.45% 81 KCL 0.15%/D5W/LR 81 kcl 0.15%/d5w/nacl 0.2% 81 KCL 0.15%/D5W/NACL 0.225% 81 kcl 0.15%/d5w/nacl 0.9% 81 kcl 0.3%/d5w/nacl 0.45% 81 KCL 0.3%/D5W/NACL 0.9% 81 kelnor 1/35 61 KEPIVANCE 52 KETEK 11 ketoconazole 20 ketoprofen 1 ketoprofen er 1 ketorolac tromethamine 1 ketorolac tromethamine 70 KEYTRUDA 26 KHEDEZLA 17 KINERET 66 kionex 75 klor-con klor-con 8 81 klor-con m10 81 klor-con m15 81 klor-con m20 81 KOMBIGLYZE XR 37 KORLYM 60 KUVAN 54 labetalol hcl 45 laclotion 53 lactated ringers dextrose 5% viaflex 81 lactated ringers irrigation 69 Page 94 of 103

105 Page # lactated ringers viaflex 81 lactulose 56 lamivudine 32 lamivudine 34 lamivudine/zidovudine 34 lamotrigine 14 LANOXIN 48 LANOXIN PEDIATRIC 48 LANTUS 38 LANTUS SOLOSTAR 38 larin 1.5/30 61 latanoprost 70 LATUDA 30 LAZANDA 3 leena 61 leflunomide 67 lessina 61 LETAIRIS 74 letrozole 25 leucovorin calcium 24 LEUKERAN 22 LEUKINE 41 leuprolide acetate 65 levalbuterol hcl 73 LEVAQUIN 11 LEVEMIR 38 LEVEMIR FLEXTOUCH 38 levetiracetam 12 levobunolol hcl 71 levocarnitine 69 levocetirizine dihydrochloride 72 levofloxacin 11 levofloxacin in d5w 11 levora 0.15/ levorphanol tartrate 2 levothyroxine sodium 63 levoxyl 64 LEXIVA 34 lidocaine 4 lidocaine hcl 4 lidocaine hcl jelly 4 lidocaine viscous 4 lidocaine/prilocaine 4 LINCOCIN 6 lindane 27 linezolid 6 liothyronine sodium 64 lipodox 25 lipodox liposyn iii 69 Name Page # lisinopril 43 lisinopril/hydrochlorothiazide 43 lithium 36 lithium carbonate 36 lithium carbonate er 36 LITHOBID 36 loestrin 24 fe 61 lomustine 22 loperamide hcl 55 lorazepam 36 LORAZEPAM INTENSOL 36 losartan potassium 42 losartan potassium/hydrochlorothiazide 42 LOTEMAX 70 LOTRONEX 55 lovastatin 49 low-ogestrel 62 loxapine succinate 29 LUFYLLIN 74 LUMIGAN 70 LUMIZYME 54 LUPRON DEPOT 65 LUPRON DEPOT-PED 65 lutera 62 LYNPARZA 25 LYRICA 12 LYSODREN 64 lyza 63 M.V.I. ADULT 85 M.V.I. PEDIATRIC 85 M.V.I.-12 WITHOUT VITAMIN K 85 magnesium sulfate 81 malathion 27 maprotiline hcl 16 marlissa 62 MARPLAN 17 MATULANE 23 matzim la 47 meclizine hcl 19 meclofenamate sodium 1 medroxyprogesterone acetate 63 mefloquine hcl 27 megestrol acetate 63 MEKINIST 26 meloxicam 1 melphalan hydrochloride 23 MENACTRA 68 MENEST 62 MENOMUNE-A/C/Y/W MENVEO 68 Page 95 of 103

106 Page # meperidine hcl 3 MEPHYTON 85 meprobamate 36 MEPRON 27 mercaptopurine 24 meropenem 9 mesalamine 68 mesna 25 MESNEX 25 MESTINON 22 MESTINON TIMESPAN 22 METADATE CD 51 metaproterenol sulfate 73 metformin hcl 37 metformin hcl er 37 METHADONE HCL 2 methadose 2 methazolamide 71 methenamine hippurate 6 methimazole 65 METHITEST 60 methocarbamol 75 methotrexate 66 methotrexate sodium 66 methoxsalen 53 methscopolamine bromide 55 methyclothiazide 49 methyldopa 42 methyldopa/hydrochlorothiazide 42 METHYLDOPATE HCL 42 methylergonovine maleate 69 methylphenidate hcl 51 methylphenidate hcl cd 51 methylphenidate hcl er 51 methylprednisolone 58 methylprednisolone acetate 58 methylprednisolone dose pack 58 methylprednisolone sodiumsuccinate 58 metipranolol 71 metoclopramide hcl 55 metolazone 49 metoprolol succinate er 45 metoprolol tartrate 45 metoprolol/hydrochlorothiazide 45 metronidazole 6 metronidazole in nacl 0.79% 6 metronidazole vaginal 6 mexiletine hcl 44 MIACALCIN 69 miconazole 3 20 Name Page # microgestin 1.5/30 62 microgestin 1/20 62 microgestin fe 62 microgestin fe 1.5/30 62 midodrine hcl 42 migergot 21 minocycline hcl 12 minoxidil 51 mirtazapine 16 mirtazapine odt 16 misoprostol 56 mitigare 21 mitomycin 25 mitoxantrone hcl 25 M-M-R II W/DILUENT 10 DOSE 68 modafinil 75 mometasone furoate 59 mononessa 62 montelukast sodium 72 morphine sulfate 3 morphine sulfate er 2 MOZOBIL 81 MULTAQ 44 mupirocin 6 MUSTARGEN 23 MYCAMINE 20 MYCOBUTIN 22 mycophenolate mofetil 66 nabumetone 1 nadolol 45 nadolol/bendroflumethiazide 45 nafcillin sodium 10 NAFTIN 20 NAGLAZYME 54 nalbuphine hcl 3 NALLPEN/DEXTROSE 10 naloxone hcl 4 naltrexone hcl 4 NAMENDA 16 NAMENDA TITRATION PAK 16 naphazoline hcl 70 naproxen 2 naproxen dr 2 naproxen sodium 2 naratriptan hcl 21 NASCOBAL 85 NATACYN 20 nateglinide 38 NEBUPENT 27 necon 0.5/ Page 96 of 103

107 Page # necon 1/35 62 necon 10/ necon 7/7/7 62 nefazodone hcl 16 neomycin sulfate 5 neomycin/bacitracin/polymyxin 70 neomycin/polymyxin b sulfates 5 neomycin/polymyxin/bacitracin/hydrocortis 6 one neomycin/polymyxin/dexamethasone 70 neomycin/polymyxin/gramicidin 70 neomycin/polymyxin/hc 71 neomycin/polymyxin/hydrocortisone 6 neomycin/polymyxin/hydrocortisone 71 NEPHRAMINE 81 NEULASTA 41 NEUMEGA 41 NEUPOGEN 41 NEUPRO 28 nevirapine 33 nevirapine er 33 NEXAVAR 26 niacin er 50 niacor 50 nicardipine hcl 47 NICOTROL NS 5 nifediac cc 47 nifedical xl 47 nifedipine er 47 NILANDRON 23 NITRO-DUR 50 nitrofurantoin macrocrystals 6 nitrofurantoin monohydrate 6 NITROGLYCERIN 50 nitroglycerin transdermal 50 NITROSTAT 50 nora-be 63 NORDITROPIN FLEXPRO 59 NORDITROPIN NORDIFLEX PEN 59 norethindrone 63 norethindrone acetate 63 norlyroc 63 normosol-m in d5w 81 NORMOSOL-R 81 NORMOSOL-R IN D5W 81 nortrel 0.5/35 (28) 62 nortrel 1/35 62 nortrel 7/7/7 62 nortriptyline hcl 19 NORVIR 34 Name Page # NOVOLIN 70/30 38 NOVOLIN N 38 NOVOLIN R 39 NOVOLOG 39 NOVOLOG FLEXPEN 39 NOVOLOG MIX 70/30 39 NOVOLOG MIX 70/30 PREFILLED 39 FLEXPEN NOXAFIL 20 NUEDEXTA 52 NULOJIX 66 NULYTELY/FLAVOR PACKS 56 nutrilipid 69 NUTROPIN 59 nyamyc 21 nystatin 21 nystatin/triamcinolone 21 nystop 21 octreotide acetate 65 ofloxacin 11 OGESTREL 62 olanzapine 30 olanzapine odt 30 olopatadine hcl 72 OLYSIO 32 omega-3-acid ethyl esters 50 omeprazole 56 ONCASPAR 25 ondansetron hcl 20 ondansetron odt 20 ONFI 13 ONGLYZA 38 OPDIVO 26 ORAP 29 ORENCIA 66 ORENITRAM 74 orphenadrine citrate 75 orphenadrine citrate er 75 oxacillin sodium 10 oxaliplatin 25 oxandrolone 60 oxaprozin 2 oxcarbazepine 15 OXSORALEN 53 OXTELLAR XR 15 oxybutynin chloride 56 oxybutynin chloride er 56 oxycodone hcl 3 oxycodone/acetaminophen 4 pacerone 44 Page 97 of 103

108 Page # paclitaxel 25 pamidronate disodium 69 PANCREAZE 54 PANRETIN 27 pantoprazole sodium 56 paromomycin sulfate 5 paroxetine hcl 17 paroxetine hcl er 17 PASER 22 PATANOL 70 PAXIL 18 pedi-dri 21 PEDVAX HIB 68 PEGANONE 15 PEGASYS 33 PEGASYS PROCLICK 32 PEG-INTRON 32 PEG-INTRON REDIPEN 32 penicillin g potassium 10 PENICILLIN G POTASSIUM IN 10 ISO-OSMOTIC DEXTROSE PENICILLIN G PROCAINE 10 PENICILLIN G SODIUM 10 penicillin v potassium 10 PENTAM pentostatin 24 pentoxifylline er 48 periogard 52 PERJETA 27 permethrin 27 perphenazine 29 perphenazine/amitriptyline 19 PFIZERPEN-G 10 phenadoz 19 phenelzine sulfate 17 phenobarbital 13 PHENYTEK 15 phenytoin 15 phenytoin infatabs 15 phenytoin sodium 15 phenytoin sodium extended 15 PHOSPHOLINE IODIDE 71 PHYSICIANS EZ USE B COMPLIANCE KIT physiolyte 69 physiosol irrigation 69 PICATO 53 pilocarpine hcl 52 pilocarpine hydrochloride 52 PILOPINE HS 71 Name Page # pindolol 45 pioglitazone hcl 38 pioglitazone hcl/metformin hcl 38 piperacillin sodium/tazobactam sodium 10 piroxicam 2 PLASMA-LYTE A 81 PLASMA-LYTE PLASMA-LYTE-56/D5W 82 podofilox 53 polyethylene glycol polymyxin b sulfate 6 polymyxin b sulfate/trimethoprim sulfate 70 POMALYST 23 portia POTASSIUM CHLORIDE 82 potassium chloride 0.15% /nacl 0.45% 82 viaflex potassium chloride 0.15% d5w/nacl 0.33% 82 potassium chloride 0.15% d5w/nacl 0.45% 82 potassium chloride 0.15%/nacl 0.9% 82 potassium chloride 0.22% d5w/nacl 0.45% 82 POTASSIUM CHLORIDE 0.3%/ NACL % potassium chloride 0.3%/d5w 82 potassium chloride er 82 potassium chloride sr 82 potassium citrate er 82 POTIGA 12 PRADAXA 40 pramipexole dihydrochloride 28 pravastatin sodium 49 prazosin hcl 42 PRED-G 70 PRED-G S.O.P. 70 prednicarbate 59 prednisolone acetate 70 prednisolone sodium phosphate 59 prednisolone sodium phosphate 70 prednisone 59 pregnyl w/diluent benzyl alcohol/nacl 60 PREMARIN 62 PREMASOL 82 PREMPHASE 62 PREMPRO 62 PRENAPLUS 85 PRENATABS OBN 85 prenatabs rx 85 prenatal plus iron 85 prevalite 50 previfem 62 Page 98 of 103

109 Page # PREZISTA 35 PRIFTIN 22 PRIMAQUINE PHOSPHATE 27 primidone 13 PRIMSOL 6 PROAIR HFA 73 probenecid 21 probenecid/colchicine 21 PROCAINAMIDE HCL 44 PROCALAMINE 82 PROCHLORPERAZINE EDISYLATE 29 prochlorperazine maleate 29 PROCRIT 41 proctocream hc 59 PROCTO-PAK 59 proctosol hc 59 proctozone-hc 59 progesterone 63 PROGLYCEM 38 PROGRAF 66 PROLASTIN-C 74 PROLEUKIN 25 PROLIA 69 PROMACTA 41 promethazine hcl 19 promethazine vc plain 74 promethegan 19 PROMETRIUM 63 propafenone hcl 44 propranolol hcl 45 propranolol hcl er 45 propranolol/hydrochlorothiazide 46 propylthiouracil 65 PROQUAD 68 PROSOL 83 PROTONIX 56 PROTOPIC 53 protriptyline hcl 19 PULMOZYME 73 PURIXAN 24 pyrazinamide 22 pyridostigmine bromide 22 PYRIDOXINE HCL 86 quasense 62 QUDEXY XR 14 quetiapine fumarate 30 quinapril hcl 43 quinapril/hydrochlorothiazide 44 QUINIDINE GLUCONATE 44 quinidine gluconate cr 44 Name Page # quinidine sulfate 44 quinidine sulfate er 44 quinine sulfate 27 RABAVERT 68 raloxifene hydrochloride 63 ramipril 44 RANEXA 48 ranitidine hcl 55 RAPAMUNE 66 REBETOL 33 REBIF 52 REBIF TITRATION PACK 52 RECOMBIVAX HB 68 RELENZA DISKHALER 35 RELISTOR 55 REMICADE 66 RENVELA 57 repaglinide 38 RESCRIPTOR 33 reserpine 42 RESTASIS 70 RETROVIR IV INFUSION 34 REVLIMID 23 REYATAZ 35 ribasphere 33 ribasphere ribapak 33 ribavirin 33 rifabutin 22 rifampin 22 RIFATER 22 riluzole 52 rimantadine hcl 35 ringers injection 83 ringers irrigation 69 RISPERDAL CONSTA 31 risperidone 31 risperidone odt 31 RITUXAN 27 rivastigmine tartrate 16 rizatriptan benzoate 21 rizatriptan benzoate odt 21 ropinirole hcl 28 ROTARIX 68 ROTATEQ 68 roxicet 4 ROZEREM 75 SABRIL 13 SAIZEN 60 SAIZEN CLICK.EASY 60 SANTYL 53 Page 99 of 103

110 Page # SAPHRIS 31 SAVELLA 52 SAVELLA TITRATION PACK 52 selegiline hcl 28 selenium sulfide 53 SELZENTRY 34 SENSIPAR 65 SEREVENT DISKUS 73 SEROMYCIN 22 SEROSTIM 60 sertraline hcl 18 sharobel 63 sildenafil 74 silver sulfadiazine 6 SIMULECT 67 simvastatin 50 sirolimus 66 sodium chloride 83 sodium chloride 0.45% viaflex 83 sodium chloride 0.9% 83 sodium fluoride 83 SODIUM LACTATE 75 sodium phenylbutyrate 54 sodium polystyrene sulfonate 75 sodium sulfacetamide 11 SOLTAMOX 23 SOLU-CORTEF 59 SOLU-MEDROL 59 SOMATULINE DEPOT 65 SOMAVERT 65 SORIATANE 53 sorine 44 sotalol hcl 44 sotalol hcl (af) 44 SOVALDI 33 SPIRIVA HANDIHALER 73 SPIRIVA RESPIMAT 73 spironolactone 49 spironolactone/hydrochlorothiazide 49 SPORANOX 21 sprintec SPRYCEL 26 sronyx 62 ssd 6 stagesic 4 STALEVO STALEVO STALEVO STALEVO STALEVO Name Page # STALEVO stavudine 34 sterile water irrigation 70 STIMATE 60 STIVARGA 26 STRATTERA 51 STREPTOMYCIN SULFATE 5 STRIBILD 33 STROMECTOL 27 SUBOXONE 4 SUCRAID 54 sucralfate 56 sulfacetamide sodium 11 sulfacetamide sodium/prednisolone sodium 70 phosphate sulfadiazine 11 SULFAMETHOXAZOLE/TRIMETHOPRI 11 M sulfamethoxazole/trimethoprim ds 11 sulfasalazine 68 sulfazine ec 68 sulindac 2 sumatriptan succinate 21 SUPRAX 8 SURMONTIL 19 SUSTIVA 33 SUTENT 26 SYLATRON 25 SYLVANT 27 SYMBICORT 72 SYMLINPEN SYMLINPEN SYNAGIS 67 SYNAREL 65 SYNERCID 6 SYNRIBO 25 SYNTHROID 64 SYPRINE 75 TABLOID 24 tacrolimus 53 tacrolimus 67 TAFINLAR 26 TALWIN 4 TAMIFLU 35 tamoxifen citrate 23 tamsulosin hcl 56 TARCEVA 26 TARGRETIN 27 TARON FORTE 83 TASIGNA 26 Page 100 of 103

111 Page # TASMAR 27 TAZORAC 53 taztia xt 47 TEFLARO 9 TEGRETOL 15 TEGRETOL-XR 15 TEKTURNA 48 TEKTURNA HCT 48 telmisartan 42 telmisartan/hydrochloroth 42 telmisartan/hydrochlorothiazide 42 temazepam 75 terazosin hcl 56 terbinafine hcl 21 terbutaline sulfate 73 terconazole 21 testosterone cypionate 60 testosterone enanthate 60 TETANUS TOXOID ADSORBED 68 TETANUS/DIPHTHERIA 68 TOXOIDS-ADSORBED ADULT TEV-TROPIN 60 THALOMID 23 THEO theophylline 74 theophylline cr 74 theophylline er 74 thiamine hcl 86 thioridazine hcl 29 thiotepa 23 thiothixene 29 THYMOGLOBULIN 67 THYROLAR-1 64 THYROLAR-1/2 64 THYROLAR-1/4 64 THYROLAR-2 64 THYROLAR-3 64 tiagabine hydrochloride 13 ticlopidine hcl 42 TIKOSYN 44 TIMENTIN 10 timolol maleate 46 timolol maleate 71 timolol maleate ophthalmic gel forming 71 tinidazole 27 TIVICAY 33 tizanidine hcl 31 tl gard rx 86 tl icon 83 TOBI PODHALER 73 Name Page # TOBRADEX 70 tobramycin 73 tobramycin sulfate 5 TOBRAMYCIN SULFATE/SODIUM 5 CHLORIDE tobramycin/dexamethasone 70 tolbutamide 38 tolmetin sodium 2 tolterodine tartrate 56 tolterodine tartrate er 56 topiramate 14 topiramate er 14 toposar 25 topotecan hcl 25 TORISEL 67 TORSEMIDE 48 tpn electrolytes 83 TRACLEER 74 TRADJENTA 38 tramadol hcl 4 tramadol hydrochloride/acetaminophen 4 trandolapril 44 tranexamic acid 41 TRANSDERM-SCOP 19 tranylcypromine sulfate 17 TRAVASOL 83 trazodone hcl 16 TREANDA 23 TRECATOR 22 TRELSTAR DEPOT MIXJECT 65 TRELSTAR LA MIXJECT 65 TRELSTAR MIXJECT 65 tretinoin 27 tretinoin 53 triamcinolone acetonide 59 triamcinolone acetonide 72 triamcinolone in orabase 52 triamterene/hydrochlorothiazide 49 triazolam 36 triderm 59 trifluoperazine hcl 29 trifluridine 35 trihexyphenidyl hcl 27 trilyte 56 trimethobenzamide hcl 19 trimethoprim 6 trimipramine maleate 19 trinessa 63 tri-previfem 62 TRISENOX 25 Page 101 of 103

112 Page # tri-sprintec 62 TRIUMEQ 34 trivora TROKENDI XR 14 TROPHAMINE 83 TRUMENBA 68 TRUVADA 34 TWINRIX 68 TYBOST 34 TYGACIL 6 TYKERB 26 TYPHIM VI 68 TYSABRI 52 TYVASO 74 TYZEKA 32 TYZINE PEDIATRIC NASAL DROPS 74 u-cort 59 unithroid 64 UROCIT-K UROCIT-K UROCIT-K 5 83 ursodiol 55 UVADEX 53 valacyclovir hcl 35 VALCHLOR 23 VALCYTE 32 valganciclovir 32 valproate sodium 13 valproic acid 13 valsartan 43 valsartan/hydrochlorothiazide 43 vancomycin hcl 6 vandazole 6 VAQTA 68 VARIVAX 68 VASCULERA 84 VECTIBIX 27 VELCADE 25 velivet 63 venlafaxine hcl 18 venlafaxine hcl er 18 VENOFER 83 VENTOLIN HFA 73 verapamil hcl 47 verapamil hcl er 47 verapamil hcl sr 47 VEREGEN 53 VERSACLOZ 31 VICTRELIS 33 VIDEX PEDIATRIC 34 Name Page # VIIBRYD 18 VIMPAT 15 VINATE ONE 86 VINBLASTINE SULFATE 25 vincristine sulfate 25 vinorelbine tartrate 25 VIRACEPT 35 VIRAMUNE 33 VIRAMUNE XR 33 VIRAZOLE 33 VIREAD 34 VISTIDE 32 vitacel 86 vitamin d 86 VITAMIN K1 86 vol-tab rx 86 VOLTAREN 53 voriconazole 21 VOTRIENT 26 VPRIV 54 warfarin sodium 40 WELCHOL 50 XALKORI 26 XARELTO 40 XARELTO STARTER PACK 40 XENAZINE 52 XGEVA 69 XIFAXAN 6 XOLAIR 74 XOPENEX 73 XOPENEX HFA 73 XTANDI 23 xulane 63 XYLOCAINE-MPF 4 XYREM 75 YERVOY 27 YF-VAX 68 zafirlukast 72 zaleplon 75 ZALTRAP 25 ZANOSAR 23 ZANTAC 55 ZAVESCA 54 ZELAPAR 28 ZELBORAF 26 ZEMAIRA 74 ZENPEP 54 ZETIA 50 ZIAGEN 34 zidovudine 34 Page 102 of 103

113 Page 103 of 103 Name Page # ZINECARD 25 ziprasidone hcl 31 ZMAX 11 zoledronic acid 69 ZOLINZA 25 zolpidem tartrate 75 zolpidem tartrate er 75 ZOMETA 69 ZONALON 53 zonisamide 12 ZORBTIVE 60 ZORTRESS 67 ZOSTAVAX 68 ZOSYN 10 zovia 1/35e 63 zovia 1/50e 63 ZOVIRAX 35 ZUBSOLV 4 ZYDELIG 25 ZYFLO CR 73 ZYKADIA 25 ZYTIGA 23 ZYVOX 6

114 1441 Main Street, Suite 900 Columbia, SC Phone: TTY: FOR MORE INFORMATION, contact Member Services at from 8 a.m. to 8 p.m., seven days a week. TTY users call 711. On weekends and Federal holidays, you may be asked to leave a message. Your call will be returned the next business day , Version Number 14 Updated 04/01/2015