List of Covered Drugs (Formulary)

Transcription

1 Amerigroup STAR+PLUS MMP (Medicare-Medicaid Plan) List of Covered Drugs (Formulary) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. Member Services: (TTY 711) Monday through Friday from 8 a.m. to 8 p.m. local time TXDMKT Y0005_H8786_15_23464_R CMS Approved 02/26/2015 Formulary ID: Version: 12 Issued 09/01/2015

2 Amerigroup STAR+PLUS MMP (Medicare-Medicaid Plan) 2015 List of Covered Drugs (Formulary) This is a list of drugs that members can get in Amerigroup STAR+PLUS MMP (Medicare-Medicaid Plan). Amerigroup STAR+PLUS MMP is a health plan that contracts with both Medicare and Texas Medicaid to provide benefits of both programs to enrollees. Benefits, List of Covered Drugs, 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 Amerigroup STAR+PLUS MMP s up-to-date List of Covered Drugs online at Limitations, co-payments and restrictions may apply. For more information, call Amerigroup STAR+PLUS MMP Member Services or read the Amerigroup STAR+PLUS MMP Member Handbook. Copays for prescription drugs may vary based on the level of Extra Help you receive. Please contact the plan for more details. You can ask for this information in other formats, such as audio, Braille or large print. Call (TTY 711). The call is free. You can get this information for free in other languages. Call (TTY 711). The call is free.? If you have questions, please call Amerigroup STAR+PLUS MMP at (TTY 711), Monday through Friday from 8 a.m. to 8 p.m. The call is free. For more information, visit Y0005_H8786_15_22941_T_012 CMS Approved 02/19/2015 TXDMKT

3 Frequently Asked Questions (FAQ) Find answers here to questions you have about this List of Covered Drugs. You can read all of the FAQ to learn more, or look for a question and answer. 1. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the Drug List for short.) The drugs on the List of Covered Drugs that starts on page 10 are the drugs covered by Amerigroup STAR+PLUS MMP. 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. Amerigroup STAR+PLUS MMP will cover all medically necessary drugs on the Drug List if: your doctor or other prescriber says you need them to get better or stay healthy, and you fill the prescription at an Amerigroup STAR+PLUS MMP network pharmacy. Amerigroup STAR+PLUS MMP may have additional steps to access certain drugs (see question #5 below). You can also see an up-to-date list of drugs that we cover on our website at or call Member Services at (TTY 711). 2. Does the Drug List ever change? Yes. Amerigroup STAR+PLUS MMP may add or remove drugs on the Drug List during the year. Generally, the Drug List will only change if: a cheaper drug comes along that works as well as a drug on the Drug List now, or we learn that a drug is not safe. We may also change our rules about drugs. For example, we could: Decide to require or not require prior approval for a drug. (Prior approval is permission from Amerigroup STAR+PLUS MMP before you can get a drug.) Add or change the amount of a drug you can get (called quantity limits ). Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.)? If you have questions, please call Amerigroup STAR+PLUS MMP at (TTY 711), Monday through Friday from 8 a.m. to 8 p.m. The call is free. For more information, visit Y0005_H8786_15_22941_T_012 CMS Approved 02/19/2015 TXDMKT

4 (For more information on these drug rules, see page 3.) We will tell you when a Medicare Part D drug you are taking is removed from the Drug List. We will also tell you when we change our rules for covering a Medicare Part D drug. Questions 3, 4, and 7 below have more information on what happens when the Drug List changes. You can always check Amerigroup STAR+PLUS MMP s up-to-date Drug List online at You can also call Member Services to check the current Drug List at (TTY 711). 3. What happens when a cheaper drug comes along that works as well as a drug on the Drug List now? If you are taking a Medicare Part D drug that is removed because a cheaper drug that works just as well comes along, we will tell you. We will tell you at least 60 days before we remove it from the Drug List or when you ask for a refill. Then you can get a 60-day supply of the drug before the change to the Drug List is made. You will get a letter in the mail letting you know about the change. 4. What happens when we find out a drug is not safe? If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we will take it off the Drug List right away. We will also send you a letter telling you that. Please contact your prescribing doctor as soon as you get the letter. 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: Prior approval (or prior authorization): For some drugs, you or your doctor or other prescriber must get approval from Amerigroup STAR+PLUS MMP before you fill your prescription. If you don t get approval, Amerigroup STAR+PLUS MMP may not cover the drug. Quantity limits: Sometimes Amerigroup STAR+PLUS MMP limits the amount of a drug you can get. Step therapy: Sometimes Amerigroup STAR+PLUS MMP 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.? If you have questions, please call Amerigroup STAR+PLUS MMP at (TTY 711), Monday through Friday from 8 a.m. to 8 p.m. The call is free. For more information, visit Y0005_H8786_15_22941_T_012 CMS Approved 02/19/2015 TXDMKT

5 You can find out if your drug has any additional requirements or limits by looking in the tables on pages You can also get more information by visiting our website at We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. You can ask for an exception from these limits. Please see question 11 for more information on exceptions. If you are in a nursing home or other long-term care facility and need a drug that is not on the Drug List, or if you cannot easily get the drug you need, we can help. We will cover a 31-day emergency supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new Amerigroup STAR+PLUS MMP member. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception. Please see question 11 for more information about exceptions. 6. How will you know if the drug you want has limitations or if there are required actions to take to get the drug? The List of Covered Drugs on page 10 has a column labeled Necessary actions, restrictions, or limits in use. 7. What happens if we change our rules on how we cover some drugs? For example, if we add prior authorization (approval), quantity limits, and/or step therapy restrictions on a drug. We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions on a drug. We will tell you at least 60 days before the restriction is added or when you next ask for a refill. Then, you can get a 60-day supply of the drug before the change to the Drug List is made. This gives you time to talk to your doctor or other prescriber about what to do next. 8. How can you find a drug on the Drug List? There are two ways to find a drug: You can search alphabetically (if you know how to spell the drug), or You can search by medical condition. To search alphabetically, go to the Alphabetical Listing section. You can find it on page 125, then look for the name of your drug in the list.? If you have questions, please call Amerigroup STAR+PLUS MMP at (TTY 711), Monday through Friday from 8 a.m. to 8 p.m. The call is free. For more information, visit Y0005_H8786_15_22941_T_012 CMS Approved 02/19/2015 TXDMKT

6 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 Drug List? If you don t see your drug on the Drug List, call Member Services at (TTY 711) and ask about it. If you learn that Amerigroup STAR+PLUS MMP will not cover the drug, you can do one of these things: Ask Member Services for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or You can ask the health plan to make an exception to cover your drug. Please see question 11 for more information about exceptions. 10. What if you are a new Amerigroup STAR+PLUS MMP member and can t find your drug on the Drug List or have a problem getting your drug? We can help. We may cover a temporary 30-day supply of your drug during the first 90 days you are a member of Amerigroup STAR+PLUS MMP. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception. We will cover a 30-day supply of your drug if: you are taking a drug that is not on our Drug List, or health plan rules do not let you get the amount ordered by your prescriber, or the drug requires prior approval by Amerigroup STAR+PLUS MMP, or you are taking a drug that is part of a step therapy restriction. If you live in a nursing home or other long-term care facility, you may refill your prescription for as long as 98 days. You may refill the drug multiple times during the 90 days. This gives your prescriber time to change your drugs to ones on the Drug List or ask for an exception. We will cover a temporary 30-day supply of your drug to cover level-of-care changes. 11. Can you ask for an exception to cover your drug?? If you have questions, please call Amerigroup STAR+PLUS MMP at (TTY 711), Monday through Friday from 8 a.m. to 8 p.m. The call is free. For more information, visit Y0005_H8786_15_22941_T_012 CMS Approved 02/19/2015 TXDMKT

7 Yes. You can ask Amerigroup STAR+PLUS MMP to make an exception to cover a drug that is not on the Drug List. You can also ask us to change the rules on your drug. For example, Amerigroup STAR+PLUS MMP may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more. Other examples: You can ask us to drop step therapy restrictions or prior approval requirements. 12. How long does it take to get an exception? First, we must receive a statement from your prescriber supporting your request for an exception. After we receive the statement, we will give you a decision on your exception request within 72 hours. If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, we will give you a decision within 24 hours of receiving your prescriber s supporting statement. 13. How can you ask for an exception? To ask for an exception, call your service coordinator. Your service coordinator will work with you and your provider to help you ask for an exception. 14. What are generic drugs? Generic drugs are made up of the same active ingredients as brand-name drugs. They usually cost less than the brand-name drug and usually don t have well-known names. Generic drugs are approved by the Food and Drug Administration (FDA). Amerigroup STAR+PLUS MMP covers both brand-name drugs and generic drugs. 15. What are OTC drugs? OTC stands for over-the-counter. Amerigroup STAR+PLUS MMP covers some OTC drugs when they are written as prescriptions by your provider. You can read the Amerigroup STAR+PLUS MMP Drug List to see what OTC drugs are covered.? If you have questions, please call Amerigroup STAR+PLUS MMP at (TTY 711), Monday through Friday from 8 a.m. to 8 p.m. The call is free. For more information, visit Y0005_H8786_15_22941_T_012 CMS Approved 02/19/2015 TXDMKT

8 16. Does Amerigroup STAR+PLUS MMP cover OTC non-drug products? Amerigroup STAR+PLUS MMP covers some OTC non-drug products when they are written as prescriptions by your provider. You can read the Amerigroup STAR+PLUS MMP Drug List to see what OTC non-drug products are covered. 17. What is your copay? You can read the Amerigroup STAR+PLUS MMP Drug List to learn about the copay for each drug. Amerigroup STAR+PLUS MMP 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. Tier 1 drugs have the lowest copay. They are Medicare preferred brand-name and generic drugs. The copay will be from $0 to $2.65 depending on your level of Medicaid eligibility. Tier 2 drugs have a medium copay. They are Medicare non-preferred brand-name and generic drugs. The copay will be from $0 to $6.60 depending on your level of Medicaid eligibility. Tier 3 and Tier 4 drugs do not have a copay. List of Covered Drugs The list of covered drugs below gives you information about the drugs covered by Amerigroup STAR+PLUS MMP. If you have trouble finding your drug in the list, turn to the Index that begins on page 125. The first column of the chart lists the name of the drug. Brand-name drugs are capitalized (e.g., ABELCET ) and generic drugs are listed in lower-case italics (e.g., fluconazole). The information in the necessary actions, restrictions, or limits in use column tells you if Amerigroup STAR+PLUS MMP has any rules for covering your drug. Note: The asterisk (*) next to a drug means the drug is not a Part D drug. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs. These drugs also have different rules for appeals. An appeal is a formal way of asking us to review a coverage decision and to change it if you think we made a mistake. For example, we might decide that a drug that you want is not covered or is no longer covered by Medicare or Medicaid. If you or your doctor disagrees with our decision, you can? If you have questions, please call Amerigroup STAR+PLUS MMP at (TTY 711), Monday through Friday from 8 a.m. to 8 p.m. The call is free. For more information, visit Y0005_H8786_15_22941_T_012 CMS Approved 02/19/2015 TXDMKT

9 appeal. To ask for instructions on how to appeal, call Member Services at (TTY 711). You can also read the Member Handbook to learn how to appeal a decision. Here are the meanings of the codes used in the Necessary actions, restrictions, or limits in use column: B/D: This prescription 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. HI: Home Infusion. This prescription drug may be covered under our medical benefit. For more information, call Member Services. LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information, please call Member Services. MO: Mail-Order Drug. This prescription drug is available through our mail-order service, as well as through our retail network pharmacies. Consider using mail order for your long-term (maintenance) medications (such as high blood pressure medications). Retail network pharmacies may be more appropriate for short-term prescriptions (such as antibiotics). PAR: Prior Authorization required. The plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don t get approval, we may not cover the drug. QLL: Quantity Limit. For certain drugs, the plan limits the amount of the drug that we will cover. ST: Step Therapy. In some cases, the plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.? If you have questions, please call Amerigroup STAR+PLUS MMP at (TTY 711), Monday through Friday from 8 a.m. to 8 p.m. The call is free. For more information, visit Y0005_H8786_15_22941_T_012 CMS Approved 02/19/2015 TXDMKT

10 List of drugs by medical condition Name of Drug ANTI - INFECTIVES ANTIFUNGAL AGENTS ABELCET $0-$6.60 (Tier 2) B/D PAR; MO AMBISOME $0-$6.60 (Tier 2) B/D PAR; MO amphotericin b $0-$6.60 (Tier 2) B/D PAR; MO CANCIDAS $0-$6.60 (Tier 2) B/D PAR; MO clotrimazole mucous membrane $0-$6.60 (Tier 2) MO ERAXIS(WATER DILUENT) $0-$6.60 (Tier 2) PAR; MO fluconazole $0-$6.60 (Tier 2) MO fluconazole in dextrose(iso-o) $0-$6.60 (Tier 2) fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/100 ml fluconazole in nacl (iso-osm) intravenous piggyback 400 mg/200 ml $0-$6.60 (Tier 2) MO $0-$6.60 (Tier 2) flucytosine $0-$6.60 (Tier 2) MO griseofulvin microsize oral suspension $0-$6.60 (Tier 2) MO griseofulvin ultramicrosize $0-$6.60 (Tier 2) MO itraconazole $0-$6.60 (Tier 2) PAR; MO ketoconazole oral $0-$6.60 (Tier 2) MO NOXAFIL ORAL SUSPENSION $0-$6.60 (Tier 2) PAR; MO; QLL (630 per 30 days) nystatin oral suspension $0-$6.60 (Tier 2) MO nystatin oral tablet $0-$6.60 (Tier 2) MO terbinafine hcl oral $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) voriconazole intravenous $0-$6.60 (Tier 2) MO voriconazole oral suspension for reconstitution $0-$6.60 (Tier 2) PAR; MO; QLL (300 per 30 days) voriconazole oral tablet 200 mg $0-$6.60 (Tier 2) PAR; MO; QLL (60 per 30 days) voriconazole oral tablet 50 mg $0-$6.60 (Tier 2) PAR; MO; QLL (120 per 30 days) 9

11 ANTIVIRALS abacavir $0-$6.60 (Tier 2) MO abacavir-lamivudine-zidovudine $0-$6.60 (Tier 2) MO acyclovir oral capsule $0-$6.60 (Tier 2) MO acyclovir oral suspension 200 mg/5 ml $0-$6.60 (Tier 2) MO acyclovir oral tablet $0-$6.60 (Tier 2) MO acyclovir sodium intravenous recon soln 500 mg $0-$6.60 (Tier 2) B/D PAR acyclovir sodium intravenous solution $0-$6.60 (Tier 2) B/D PAR; MO adefovir $0-$6.60 (Tier 2) MO amantadine hcl oral capsule $0-$6.60 (Tier 2) MO amantadine hcl oral tablet $0-$6.60 (Tier 2) MO APTIVUS ORAL CAPSULE $0-$6.60 (Tier 2) MO APTIVUS ORAL SOLUTION $0-$6.60 (Tier 2) ATRIPLA $0-$6.60 (Tier 2) MO BARACLUDE $0-$6.60 (Tier 2) PAR; MO cidofovir $0-$6.60 (Tier 2) B/D PAR; MO COMPLERA $0-$6.60 (Tier 2) MO CRIXIVAN ORAL CAPSULE 200 MG, 400 MG $0-$6.60 (Tier 2) MO didanosine $0-$6.60 (Tier 2) MO EDURANT $0-$6.60 (Tier 2) MO EMTRIVA $0-$6.60 (Tier 2) MO entecavir $0-$6.60 (Tier 2) PAR; MO EPIVIR HBV ORAL SOLUTION $0-$6.60 (Tier 2) MO EPIVIR ORAL SOLUTION $0-$6.60 (Tier 2) MO EPZICOM $0-$6.60 (Tier 2) MO EVOTAZ $0-$6.60 (Tier 2) MO famciclovir oral tablet 125 mg, 250 mg $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) famciclovir oral tablet 500 mg $0-$6.60 (Tier 2) MO; QLL (21 per 7 days) foscarnet $0-$6.60 (Tier 2) B/D PAR; MO FUZEON SUBCUTANEOUS RECON SOLN $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) 10

12 ganciclovir sodium $0-$6.60 (Tier 2) MO HARVONI $0-$6.60 (Tier 2) PAR; MO; QLL (28 per 28 days) INTELENCE ORAL TABLET 100 MG, 200 MG $0-$6.60 (Tier 2) MO INTELENCE ORAL TABLET 25 MG $0-$6.60 (Tier 2) INVIRASE $0-$6.60 (Tier 2) MO ISENTRESS $0-$6.60 (Tier 2) MO KALETRA $0-$6.60 (Tier 2) MO lamivudine $0-$6.60 (Tier 2) MO lamivudine-zidovudine $0-$6.60 (Tier 2) MO LEXIVA $0-$6.60 (Tier 2) MO nevirapine $0-$6.60 (Tier 2) MO NORVIR $0-$6.60 (Tier 2) MO OLYSIO $0-$6.60 (Tier 2) PAR; MO PREZCOBIX $0-$6.60 (Tier 2) MO PREZISTA ORAL SUSPENSION $0-$6.60 (Tier 2) MO PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG $0-$6.60 (Tier 2) MO RELENZA DISKHALER $0-$6.60 (Tier 2) MO; QLL (60 per 180 days) RESCRIPTOR $0-$6.60 (Tier 2) MO RETROVIR INTRAVENOUS $0-$6.60 (Tier 2) MO REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG $0-$6.60 (Tier 2) MO REYATAZ ORAL POWDER IN PACKET $0-$6.60 (Tier 2) MO ribasphere oral capsule $0-$6.60 (Tier 2) PAR; MO ribasphere oral tablet 200 mg $0-$6.60 (Tier 2) PAR; MO ribavirin oral capsule $0-$6.60 (Tier 2) PAR; MO ribavirin oral tablet 200 mg $0-$6.60 (Tier 2) PAR; MO rimantadine $0-$6.60 (Tier 2) MO SELZENTRY $0-$6.60 (Tier 2) MO SOVALDI $0-$6.60 (Tier 2) PAR; MO 11

13 stavudine $0-$6.60 (Tier 2) MO STRIBILD $0-$6.60 (Tier 2) MO SUSTIVA $0-$6.60 (Tier 2) MO SYNAGIS $0-$6.60 (Tier 2) PAR; MO; LA TAMIFLU ORAL CAPSULE 30 MG $0-$6.60 (Tier 2) MO; QLL (84 per 1 day) TAMIFLU ORAL CAPSULE 45 MG $0-$6.60 (Tier 2) MO; QLL (42 per 1 day) TAMIFLU ORAL CAPSULE 75 MG $0-$6.60 (Tier 2) MO; QLL (56 per 365 days) TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION TIVICAY $0-$6.60 (Tier 2) MO TRIUMEQ $0-$6.60 (Tier 2) MO TRIZIVIR $0-$6.60 (Tier 2) MO TRUVADA $0-$6.60 (Tier 2) MO TYBOST $0-$6.60 (Tier 2) MO $0-$6.60 (Tier 2) MO; QLL (360 per 180 days) TYZEKA $0-$6.60 (Tier 2) PAR; MO valacyclovir $0-$6.60 (Tier 2) MO; QLL (30 per 1 day) VALCYTE ORAL TABLET $0-$6.60 (Tier 2) MO valganciclovir $0-$6.60 (Tier 2) MO VIDEX 2 GRAM PEDIATRIC $0-$6.60 (Tier 2) MO VIDEX 4 GRAM PEDIATRIC $0-$6.60 (Tier 2) MO VIEKIRA PAK $0-$6.60 (Tier 2) PAR; MO VIRACEPT ORAL TABLET $0-$6.60 (Tier 2) MO VIRAMUNE XR $0-$6.60 (Tier 2) MO VIRAZOLE $0-$6.60 (Tier 2) PAR; MO VIREAD ORAL POWDER $0-$6.60 (Tier 2) MO; QLL (240 per 30 days) VIREAD ORAL TABLET $0-$6.60 (Tier 2) MO VITEKTA $0-$6.60 (Tier 2) MO ZIAGEN ORAL SOLUTION $0-$6.60 (Tier 2) MO zidovudine $0-$6.60 (Tier 2) MO CEPHALOSPORINS 12

14 cefaclor oral capsule $0-$6.60 (Tier 2) MO cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml $0-$6.60 (Tier 2) MO cefaclor oral tablet extended release 12 hr $0-$6.60 (Tier 2) MO cefadroxil oral capsule $0-$6.60 (Tier 2) MO cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml $0-$6.60 (Tier 2) MO cefadroxil oral tablet $0-$6.60 (Tier 2) MO cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml $0-$6.60 (Tier 2) MO cefazolin injection recon soln 1 gram, 500 mg $0-$6.60 (Tier 2) MO cefazolin injection recon soln 10 gram, 100 gram, 20 gram, 300 g $0-$6.60 (Tier 2) cefazolin intravenous $0-$6.60 (Tier 2) cefdinir $0-$6.60 (Tier 2) MO cefepime $0-$6.60 (Tier 2) MO cefoxitin in dextrose, iso-osm $0-$6.60 (Tier 2) cefoxitin intravenous recon soln 1 gram $0-$6.60 (Tier 2) MO cefoxitin intravenous recon soln 10 gram, 2 gram $0-$6.60 (Tier 2) cefpodoxime $0-$6.60 (Tier 2) MO cefprozil $0-$6.60 (Tier 2) MO ceftazidime injection recon soln 1 gram, 2 gram $0-$6.60 (Tier 2) MO ceftazidime injection recon soln 6 gram $0-$6.60 (Tier 2) ceftriaxone in dextrose,iso-os $0-$6.60 (Tier 2) MO ceftriaxone injection recon soln 1 gram, 2 gram, 250 mg, 500 mg $0-$6.60 (Tier 2) MO ceftriaxone injection recon soln 10 gram $0-$6.60 (Tier 2) ceftriaxone intravenous recon soln $0-$6.60 (Tier 2) MO cefuroxime axetil oral tablet $0-$6.60 (Tier 2) MO cefuroxime sodium injection recon soln 1.5 gram, 750 mg $0-$6.60 (Tier 2) MO cefuroxime sodium intravenous $0-$6.60 (Tier 2) 13

15 cephalexin oral capsule 250 mg, 500 mg $0-$2.65 (Tier 1) MO cephalexin oral suspension for reconstitution $0-$2.65 (Tier 1) MO cephalexin oral tablet $0-$2.65 (Tier 1) MO TEFLARO $0-$6.60 (Tier 2) MO ERYTHROMYCINS / OTHER MACROLIDES azithromycin intravenous $0-$6.60 (Tier 2) MO azithromycin oral suspension for reconstitution $0-$6.60 (Tier 2) MO azithromycin oral tablet $0-$6.60 (Tier 2) MO clarithromycin oral suspension for reconstitution $0-$6.60 (Tier 2) MO clarithromycin oral tablet $0-$6.60 (Tier 2) MO clarithromycin oral tablet extended release 24 hr $0-$6.60 (Tier 2) MO; QLL (28 per 1 day) ery-tab $0-$6.60 (Tier 2) MO erythrocin (as stearate) oral tablet 250 mg $0-$6.60 (Tier 2) MO ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG $0-$6.60 (Tier 2) erythromycin ethylsuccinate oral tablet $0-$6.60 (Tier 2) MO erythromycin oral tablet $0-$6.60 (Tier 2) MO MISCELLANEOUS ANTIINFECTIVES ALBENZA $0-$6.60 (Tier 2) MO ALINIA ORAL SUSPENSION FOR RECONSTITUTION $0-$6.60 (Tier 2) MO; QLL (180 per 3 days) ALINIA ORAL TABLET $0-$6.60 (Tier 2) MO amikacin injection solution 1,000 mg/4 ml, 500 mg/2 ml $0-$6.60 (Tier 2) MO atovaquone $0-$6.60 (Tier 2) PAR; MO atovaquone-proguanil $0-$6.60 (Tier 2) MO AZACTAM IN DEXTROSE (ISO-OSM) $0-$6.60 (Tier 2) aztreonam $0-$6.60 (Tier 2) MO baciim $0-$6.60 (Tier 2) BILTRICIDE $0-$6.60 (Tier 2) MO CAPASTAT $0-$6.60 (Tier 2) 14

16 CAYSTON $0-$6.60 (Tier 2) PAR; MO; LA chloramphenicol sod succinate $0-$6.60 (Tier 2) chloroquine phosphate oral $0-$6.60 (Tier 2) MO clindamycin hcl $0-$6.60 (Tier 2) MO clindamycin phosphate injection $0-$6.60 (Tier 2) MO clindamycin phosphate intravenous solution 300 mg/2 ml, 900 mg/6 ml clindamycin phosphate intravenous solution 600 mg/4 ml $0-$6.60 (Tier 2) $0-$6.60 (Tier 2) MO colistin (colistimethate na) $0-$6.60 (Tier 2) MO DAPSONE $0-$6.60 (Tier 2) MO DARAPRIM $0-$6.60 (Tier 2) MO ethambutol $0-$6.60 (Tier 2) MO gentamicin injection $0-$6.60 (Tier 2) MO gentamicin sulfate (ped) (pf) $0-$6.60 (Tier 2) MO gentamicin sulfate (pf) intravenous solution 100 mg/10 ml GENTAMICIN SULFATE (PF) INTRAVENOUS SOLUTION 60 MG/6 ML gentamicin sulfate (pf) intravenous solution 80 mg/8 ml $0-$6.60 (Tier 2) MO $0-$6.60 (Tier 2) $0-$6.60 (Tier 2) hydroxychloroquine oral $0-$2.65 (Tier 1) MO imipenem-cilastatin $0-$6.60 (Tier 2) MO INVANZ INJECTION $0-$6.60 (Tier 2) MO isoniazid oral $0-$2.65 (Tier 1) MO ivermectin oral $0-$6.60 (Tier 2) MO linezolid intravenous $0-$6.60 (Tier 2) linezolid oral $0-$6.60 (Tier 2) PAR; MO; QLL (28 per 1 day) linezolid-0.9% sodium chloride $0-$6.60 (Tier 2) mefloquine $0-$6.60 (Tier 2) MO MEPRON $0-$6.60 (Tier 2) PAR; MO 15

17 meropenem $0-$6.60 (Tier 2) MO metro i.v. $0-$6.60 (Tier 2) MO metronidazole in nacl (iso-os) $0-$6.60 (Tier 2) MO metronidazole oral $0-$6.60 (Tier 2) MO MYCOBUTIN $0-$6.60 (Tier 2) MO NEBUPENT $0-$6.60 (Tier 2) B/D PAR; MO neomycin $0-$6.60 (Tier 2) MO paromomycin $0-$6.60 (Tier 2) MO PASER $0-$6.60 (Tier 2) MO PENTAM $0-$6.60 (Tier 2) MO PRIFTIN $0-$6.60 (Tier 2) MO PRIMAQUINE $0-$6.60 (Tier 2) MO pyrazinamide $0-$6.60 (Tier 2) MO rifabutin $0-$6.60 (Tier 2) MO rifampin intravenous $0-$6.60 (Tier 2) MO rifampin oral $0-$6.60 (Tier 2) MO RIFATER $0-$6.60 (Tier 2) MO STREPTOMYCIN INTRAMUSCULAR $0-$6.60 (Tier 2) MO STROMECTOL $0-$6.60 (Tier 2) MO SYNERCID $0-$6.60 (Tier 2) tobramycin in % nacl $0-$6.60 (Tier 2) B/D PAR; MO; QLL (280 per 28 days) tobramycin sulfate injection recon soln $0-$6.60 (Tier 2) tobramycin sulfate injection solution $0-$6.60 (Tier 2) MO TRECATOR $0-$6.60 (Tier 2) MO TYGACIL $0-$6.60 (Tier 2) MO XIFAXAN ORAL TABLET 550 MG $0-$6.60 (Tier 2) MO ZYVOX INTRAVENOUS PARENTERAL SOLUTION 200 MG/100 ML ZYVOX INTRAVENOUS PARENTERAL SOLUTION 600 MG/300 ML $0-$6.60 (Tier 2) $0-$6.60 (Tier 2) MO 16

18 ZYVOX ORAL SUSPENSION FOR RECONSTITUTION $0-$6.60 (Tier 2) PAR; MO; QLL (1800 per 1 day) ZYVOX ORAL TABLET $0-$6.60 (Tier 2) PAR; MO; QLL (28 per 1 day) PENICILLINS amoxicillin oral capsule $0-$2.65 (Tier 1) MO amoxicillin oral suspension for reconstitution $0-$2.65 (Tier 1) MO amoxicillin oral tablet $0-$2.65 (Tier 1) MO amoxicillin oral tablet,chewable 125 mg, 250 mg $0-$2.65 (Tier 1) MO amoxicillin-pot clavulanate $0-$6.60 (Tier 2) MO ampicillin $0-$6.60 (Tier 2) MO ampicillin sodium injection $0-$6.60 (Tier 2) MO ampicillin sodium intravenous $0-$6.60 (Tier 2) ampicillin-sulbactam injection recon soln 1.5 gram, 3 gram $0-$6.60 (Tier 2) MO ampicillin-sulbactam injection recon soln 15 gram $0-$6.60 (Tier 2) ampicillin-sulbactam intravenous recon soln 1.5 gram ampicillin-sulbactam intravenous recon soln 3 gram $0-$6.60 (Tier 2) $0-$6.60 (Tier 2) MO BICILLIN C-R $0-$6.60 (Tier 2) MO BICILLIN L-A $0-$6.60 (Tier 2) MO dicloxacillin $0-$6.60 (Tier 2) MO nafcillin injection $0-$6.60 (Tier 2) MO nafcillin intravenous recon soln 2 gram $0-$6.60 (Tier 2) MO oxacillin injection $0-$6.60 (Tier 2) MO oxacillin intravenous $0-$6.60 (Tier 2) PENICILLIN G POT IN DEXTROSE $0-$6.60 (Tier 2) penicillin g potassium $0-$6.60 (Tier 2) MO penicillin g procaine intramuscular syringe 1.2 million unit/2 ml penicillin g procaine intramuscular syringe 600,000 unit/ml $0-$6.60 (Tier 2) MO $0-$6.60 (Tier 2) 17

19 penicillin g sodium $0-$6.60 (Tier 2) MO penicillin v potassium $0-$6.60 (Tier 2) MO piperacillin-tazobactam $0-$6.60 (Tier 2) MO QUINOLONES ciprofloxacin (mixture) oral tablet, er multiphase 24 hr 1,000 mg ciprofloxacin (mixture) oral tablet, er multiphase 24 hr 500 mg $0-$2.65 (Tier 1) MO; QLL (14 per 1 day) $0-$2.65 (Tier 1) MO; QLL (3 per 1 day) ciprofloxacin hcl oral tablet $0-$2.65 (Tier 1) MO ciprofloxacin lactate intravenous solution 200 mg/20 ml ciprofloxacin lactate intravenous solution 400 mg/40 ml $0-$2.65 (Tier 1) MO $0-$2.65 (Tier 1) levofloxacin intravenous $0-$6.60 (Tier 2) MO levofloxacin oral tablet $0-$6.60 (Tier 2) MO; QLL (14 per 1 day) moxifloxacin $0-$6.60 (Tier 2) MO; QLL (21 per 1 day) ofloxacin oral tablet 300 mg, 400 mg $0-$6.60 (Tier 2) SULFA'S / RELATED AGENTS sulfadiazine oral $0-$6.60 (Tier 2) MO sulfamethoxazole-trimethoprim $0-$2.65 (Tier 1) MO TETRACYCLINES demeclocycline oral $0-$6.60 (Tier 2) MO DOXY-100 $0-$6.60 (Tier 2) MO doxycycline hyclate intravenous $0-$6.60 (Tier 2) doxycycline hyclate oral capsule $0-$6.60 (Tier 2) MO doxycycline hyclate oral tablet 100 mg, 20 mg $0-$6.60 (Tier 2) MO doxycycline hyclate oral tablet 50 mg $0-$6.60 (Tier 2) doxycycline hyclate oral tablet,delayed release (dr/ec) doxycycline monohydrate oral capsule 100 mg, 150 mg, 50 mg $0-$6.60 (Tier 2) MO $0-$6.60 (Tier 2) MO doxycycline monohydrate oral capsule 75 mg $0-$6.60 (Tier 2) MO; QLL (60 per 1 day) 18

20 doxycycline monohydrate oral tablet $0-$6.60 (Tier 2) MO minocycline oral capsule $0-$6.60 (Tier 2) MO minocycline oral tablet $0-$6.60 (Tier 2) MO tetracycline $0-$6.60 (Tier 2) MO URINARY TRACT AGENTS MACRODANTIN ORAL CAPSULE 50 MG $0-$6.60 (Tier 2) PAR; MO methenamine hippurate $0-$6.60 (Tier 2) MO nitrofurantoin macrocrystal oral capsule 50 mg $0-$6.60 (Tier 2) PAR; MO trimethoprim $0-$6.60 (Tier 2) MO VANCOMYCIN VANCOMYCIN IN D5W INTRAVENOUS PIGGYBACK 1 GRAM/200 ML VANCOMYCIN IN D5W INTRAVENOUS PIGGYBACK 500 MG/100 ML $0-$6.60 (Tier 2) B/D PAR; MO $0-$6.60 (Tier 2) B/D PAR VANCOMYCIN IN DEXTROSE ISO-OSM $0-$6.60 (Tier 2) B/D PAR vancomycin intravenous $0-$6.60 (Tier 2) B/D PAR; MO VANCOMYCIN INTRAVENOUS 750 MG $0-$6.60 (Tier 2) B/D PAR; MO vancomycin oral capsule 125 mg $0-$6.60 (Tier 2) PAR; MO; QLL (40 per 1 day) vancomycin oral capsule 250 mg $0-$6.60 (Tier 2) PAR; MO; QLL (80 per 1 day) ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS amifostine crystalline $0-$6.60 (Tier 2) PAR; MO dexrazoxane hcl intravenous recon soln 250 mg $0-$6.60 (Tier 2) B/D PAR dexrazoxane hcl intravenous recon soln 500 mg $0-$6.60 (Tier 2) B/D PAR; MO ELITEK $0-$6.60 (Tier 2) PAR FUSILEV $0-$6.60 (Tier 2) B/D PAR; MO KEPIVANCE $0-$6.60 (Tier 2) leucovorin calcium injection recon soln 100 mg, 200 mg, 350 mg, 50 mg $0-$6.60 (Tier 2) B/D PAR; MO leucovorin calcium injection recon soln 500 mg $0-$6.60 (Tier 2) B/D PAR 19

21 leucovorin calcium oral $0-$6.60 (Tier 2) MO mesna $0-$6.60 (Tier 2) B/D PAR; MO MESNEX ORAL $0-$6.60 (Tier 2) MO XGEVA $0-$6.60 (Tier 2) PAR; MO; QLL (1.7 per 28 days) ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ABRAXANE $0-$6.60 (Tier 2) B/D PAR; MO AFINITOR $0-$6.60 (Tier 2) PAR; MO AFINITOR DISPERZ $0-$6.60 (Tier 2) PAR; MO ALIMTA $0-$6.60 (Tier 2) PAR; MO anastrozole $0-$6.60 (Tier 2) MO ARRANON $0-$6.60 (Tier 2) B/D PAR ARZERRA $0-$6.60 (Tier 2) B/D PAR; MO ASTAGRAF XL $0-$6.60 (Tier 2) B/D PAR; MO AVASTIN $0-$6.60 (Tier 2) PAR; MO azacitidine $0-$6.60 (Tier 2) PAR; MO azathioprine $0-$6.60 (Tier 2) B/D PAR; MO BELEODAQ $0-$6.60 (Tier 2) PAR; MO bexarotene $0-$6.60 (Tier 2) PAR; MO bicalutamide $0-$6.60 (Tier 2) MO BICNU $0-$6.60 (Tier 2) B/D PAR; MO bleomycin $0-$6.60 (Tier 2) B/D PAR; MO BLINCYTO $0-$6.60 (Tier 2) PAR; MO BOSULIF $0-$6.60 (Tier 2) PAR; MO BUSULFEX $0-$6.60 (Tier 2) B/D PAR CAPRELSA $0-$6.60 (Tier 2) PAR; MO; LA carboplatin intravenous solution $0-$6.60 (Tier 2) B/D PAR; MO CELLCEPT INTRAVENOUS $0-$6.60 (Tier 2) B/D PAR; MO CELLCEPT ORAL SUSPENSION FOR RECONSTITUTION $0-$6.60 (Tier 2) B/D PAR; MO cisplatin $0-$6.60 (Tier 2) B/D PAR; MO 20

22 cladribine $0-$6.60 (Tier 2) B/D PAR; MO CLOLAR $0-$6.60 (Tier 2) B/D PAR; MO COMETRIQ $0-$6.60 (Tier 2) PAR; MO COSMEGEN $0-$6.60 (Tier 2) B/D PAR; MO cyclophosphamide oral capsule $0-$6.60 (Tier 2) B/D PAR; MO cyclosporine intravenous $0-$6.60 (Tier 2) B/D PAR cyclosporine modified $0-$6.60 (Tier 2) B/D PAR; MO cyclosporine oral capsule $0-$6.60 (Tier 2) B/D PAR; MO CYRAMZA $0-$6.60 (Tier 2) PAR; MO cytarabine $0-$6.60 (Tier 2) B/D PAR; MO cytarabine (pf) injection solution 100 mg/5 ml (20 mg/ml), 2 gram/20 ml (100 mg/ml) $0-$6.60 (Tier 2) B/D PAR; MO cytarabine (pf) injection solution 20 mg/ml $0-$6.60 (Tier 2) B/D PAR dacarbazine $0-$6.60 (Tier 2) B/D PAR; MO daunorubicin intravenous solution $0-$6.60 (Tier 2) B/D PAR DAUNOXOME $0-$6.60 (Tier 2) B/D PAR; MO decitabine $0-$6.60 (Tier 2) B/D PAR; MO DOCEFREZ INTRAVENOUS RECON SOLN 20 MG docetaxel intravenous solution 10 mg/ml, 140 mg/7 ml (20 mg/ml), 160 mg/16 ml (10 mg/ml), 20 mg/2 ml (10 mg/ml) docetaxel intravenous solution 20 mg/ml (1 ml), 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml) $0-$6.60 (Tier 2) B/D PAR $0-$6.60 (Tier 2) B/D PAR $0-$6.60 (Tier 2) B/D PAR; MO DOXIL $0-$6.60 (Tier 2) B/D PAR; MO doxorubicin intravenous recon soln $0-$6.60 (Tier 2) B/D PAR doxorubicin intravenous solution $0-$6.60 (Tier 2) B/D PAR; MO DROXIA $0-$6.60 (Tier 2) MO EMCYT $0-$6.60 (Tier 2) MO epirubicin intravenous solution 200 mg/100 ml $0-$6.60 (Tier 2) B/D PAR epirubicin intravenous solution 50 mg/25 ml $0-$6.60 (Tier 2) B/D PAR; MO 21

23 ERBITUX $0-$6.60 (Tier 2) PAR; MO ERIVEDGE $0-$6.60 (Tier 2) PAR; MO ERWINAZE $0-$6.60 (Tier 2) B/D PAR; MO ETOPOPHOS $0-$6.60 (Tier 2) B/D PAR; MO etoposide intravenous $0-$6.60 (Tier 2) B/D PAR; MO exemestane $0-$6.60 (Tier 2) MO FARESTON $0-$6.60 (Tier 2) MO FARYDAK ORAL CAPSULE 10 MG $0-$6.60 (Tier 2) PAR; MO; QLL (60 per 30 days) FARYDAK ORAL CAPSULE 15 MG, 20 MG $0-$6.60 (Tier 2) PAR; MO; QLL (30 per 30 days) FASLODEX $0-$6.60 (Tier 2) PAR; MO FIRMAGON KIT W DILUENT SYRINGE $0-$6.60 (Tier 2) B/D PAR; MO fludarabine intravenous recon soln $0-$6.60 (Tier 2) B/D PAR; MO fludarabine intravenous solution $0-$6.60 (Tier 2) B/D PAR fluorouracil intravenous $0-$6.60 (Tier 2) B/D PAR; MO flutamide $0-$6.60 (Tier 2) MO FOLOTYN $0-$6.60 (Tier 2) B/D PAR; MO GAZYVA $0-$6.60 (Tier 2) PAR; MO gemcitabine intravenous recon soln 1 gram, 200 mg $0-$6.60 (Tier 2) B/D PAR; MO gemcitabine intravenous recon soln 2 gram $0-$6.60 (Tier 2) B/D PAR gemcitabine intravenous solution $0-$6.60 (Tier 2) B/D PAR gengraf $0-$6.60 (Tier 2) B/D PAR; MO GILOTRIF $0-$6.60 (Tier 2) PAR; MO GLEEVEC $0-$6.60 (Tier 2) PAR; MO GLEOSTINE $0-$6.60 (Tier 2) MO HALAVEN $0-$6.60 (Tier 2) PAR; MO HERCEPTIN $0-$6.60 (Tier 2) PAR; MO HEXALEN $0-$6.60 (Tier 2) MO hydroxyurea $0-$6.60 (Tier 2) MO IBRANCE $0-$6.60 (Tier 2) PAR; MO; QLL (30 per 30 days) 22

24 ICLUSIG $0-$6.60 (Tier 2) PAR; MO idarubicin $0-$6.60 (Tier 2) B/D PAR IFEX $0-$6.60 (Tier 2) B/D PAR; MO ifosfamide intravenous recon soln 1 gram $0-$6.60 (Tier 2) B/D PAR; MO ifosfamide intravenous recon soln 3 gram $0-$6.60 (Tier 2) B/D PAR ifosfamide intravenous solution $0-$6.60 (Tier 2) B/D PAR IMBRUVICA $0-$6.60 (Tier 2) PAR; MO INLYTA $0-$6.60 (Tier 2) PAR; MO irinotecan intravenous solution 100 mg/5 ml, 40 mg/2 ml $0-$6.60 (Tier 2) B/D PAR; MO irinotecan intravenous solution 500 mg/25 ml $0-$6.60 (Tier 2) B/D PAR ISTODAX $0-$6.60 (Tier 2) PAR; MO IXEMPRA $0-$6.60 (Tier 2) B/D PAR; MO JAKAFI $0-$6.60 (Tier 2) PAR; MO JEVTANA $0-$6.60 (Tier 2) B/D PAR; MO KADCYLA $0-$6.60 (Tier 2) PAR; MO KEYTRUDA $0-$6.60 (Tier 2) PAR; MO LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG [1]/DAY) LENVIMA ORAL CAPSULE 14 MG (10 MG[1] -4 MG[1])/DAY, 20 MG/DAY (10 MG [2]/DAY) LENVIMA ORAL CAPSULE 24 MG (10 MG[2] -4 MG[1])/DAY letrozole $0-$6.60 (Tier 2) MO LEUKERAN $0-$6.60 (Tier 2) MO $0-$6.60 (Tier 2) PAR; MO; QLL (30 per 30 days) $0-$6.60 (Tier 2) PAR; MO; QLL (60 per 30 days) $0-$6.60 (Tier 2) PAR; MO; QLL (90 per 30 days) leuprolide $0-$6.60 (Tier 2) PAR; MO LOMUSTINE $0-$6.60 (Tier 2) MO LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG, 7.5 MG LUPRON DEPOT-PED INTRAMUSCULAR KIT 7.5 MG (PED) $0-$6.60 (Tier 2) PAR; MO $0-$6.60 (Tier 2) PAR; MO LYNPARZA $0-$6.60 (Tier 2) PAR; MO; QLL (480 per 30 days) 23

25 LYSODREN $0-$6.60 (Tier 2) MO MATULANE $0-$6.60 (Tier 2) MO megestrol oral suspension 400 mg/10 ml (10 ml) $0-$6.60 (Tier 2) PAR megestrol oral suspension 400 mg/10 ml (40 mg/ml) $0-$6.60 (Tier 2) PAR; MO megestrol oral tablet $0-$6.60 (Tier 2) PAR; MO MEKINIST $0-$6.60 (Tier 2) PAR; MO melphalan hcl $0-$6.60 (Tier 2) B/D PAR mercaptopurine $0-$6.60 (Tier 2) MO methotrexate sodium $0-$6.60 (Tier 2) MO methotrexate sodium (pf) injection recon soln $0-$6.60 (Tier 2) methotrexate sodium (pf) injection solution $0-$6.60 (Tier 2) MO mitomycin $0-$6.60 (Tier 2) B/D PAR; MO mitoxantrone $0-$6.60 (Tier 2) MO MUSTARGEN $0-$6.60 (Tier 2) B/D PAR; MO mycophenolate mofetil $0-$6.60 (Tier 2) B/D PAR; MO mycophenolate sodium $0-$6.60 (Tier 2) B/D PAR; MO NEXAVAR $0-$6.60 (Tier 2) PAR; MO; LA; QLL (120 per 30 days) NILANDRON $0-$6.60 (Tier 2) MO NIPENT $0-$6.60 (Tier 2) B/D PAR; MO NULOJIX $0-$6.60 (Tier 2) B/D PAR; MO octreotide acetate $0-$6.60 (Tier 2) PAR; MO ONCASPAR $0-$6.60 (Tier 2) B/D PAR; MO OPDIVO $0-$6.60 (Tier 2) PAR; MO oxaliplatin intravenous recon soln 100 mg $0-$6.60 (Tier 2) B/D PAR; MO oxaliplatin intravenous recon soln 50 mg $0-$6.60 (Tier 2) B/D PAR oxaliplatin intravenous solution $0-$6.60 (Tier 2) B/D PAR; MO paclitaxel $0-$6.60 (Tier 2) B/D PAR; MO PERJETA $0-$6.60 (Tier 2) PAR; MO 24

26 POMALYST $0-$6.60 (Tier 2) PAR; MO PROGRAF INTRAVENOUS $0-$6.60 (Tier 2) B/D PAR; MO PURIXAN $0-$6.60 (Tier 2) PAR; MO RAPAMUNE $0-$6.60 (Tier 2) B/D PAR; MO REVLIMID ORAL CAPSULE 10 MG $0-$6.60 (Tier 2) PAR; MO; LA; QLL (60 per 30 days) REVLIMID ORAL CAPSULE 15 MG, 2.5 MG, 20 MG, 25 MG $0-$6.60 (Tier 2) PAR; MO; LA; QLL (30 per 30 days) REVLIMID ORAL CAPSULE 5 MG $0-$6.60 (Tier 2) PAR; MO; LA; QLL (150 per 30 days) RITUXAN $0-$6.60 (Tier 2) PAR; MO SIMULECT INTRAVENOUS RECON SOLN 10 MG SIMULECT INTRAVENOUS RECON SOLN 20 MG $0-$6.60 (Tier 2) B/D PAR $0-$6.60 (Tier 2) B/D PAR; MO sirolimus $0-$6.60 (Tier 2) B/D PAR; MO SOLTAMOX $0-$6.60 (Tier 2) MO SOMATULINE DEPOT $0-$6.60 (Tier 2) MO SPRYCEL $0-$6.60 (Tier 2) PAR; MO STIVARGA $0-$6.60 (Tier 2) PAR; MO; QLL (120 per 30 days) SUTENT $0-$6.60 (Tier 2) PAR; MO SYNRIBO $0-$6.60 (Tier 2) PAR; MO TABLOID $0-$6.60 (Tier 2) MO tacrolimus oral $0-$6.60 (Tier 2) B/D PAR; MO TAFINLAR $0-$6.60 (Tier 2) PAR; MO tamoxifen $0-$6.60 (Tier 2) MO TARCEVA $0-$6.60 (Tier 2) PAR; MO TARGRETIN $0-$6.60 (Tier 2) PAR; MO TASIGNA $0-$6.60 (Tier 2) PAR; MO THALOMID ORAL CAPSULE 100 MG, 50 MG $0-$6.60 (Tier 2) PAR; MO; QLL (30 per 30 days) THALOMID ORAL CAPSULE 150 MG, 200 MG $0-$6.60 (Tier 2) PAR; MO; QLL (60 per 30 days) toposar $0-$6.60 (Tier 2) B/D PAR; MO 25

27 topotecan $0-$6.60 (Tier 2) B/D PAR; MO TORISEL $0-$6.60 (Tier 2) B/D PAR; MO TREANDA $0-$6.60 (Tier 2) B/D PAR; MO TRELSTAR $0-$6.60 (Tier 2) MO TRELSTAR DEPOT $0-$6.60 (Tier 2) TRELSTAR LA $0-$6.60 (Tier 2) tretinoin (chemotherapy) $0-$6.60 (Tier 2) MO TREXALL $0-$6.60 (Tier 2) MO TRISENOX $0-$6.60 (Tier 2) B/D PAR; MO TYKERB $0-$6.60 (Tier 2) PAR; MO; LA VECTIBIX $0-$6.60 (Tier 2) PAR; MO VELCADE $0-$6.60 (Tier 2) PAR; MO vinblastine intravenous solution $0-$6.60 (Tier 2) B/D PAR; MO vincasar pfs intravenous solution 1 mg/ml $0-$6.60 (Tier 2) B/D PAR vincasar pfs intravenous solution 2 mg/2 ml $0-$6.60 (Tier 2) B/D PAR; MO vincristine $0-$6.60 (Tier 2) B/D PAR; MO vinorelbine $0-$6.60 (Tier 2) B/D PAR; MO VOTRIENT $0-$6.60 (Tier 2) PAR; MO XALKORI $0-$6.60 (Tier 2) PAR; MO XTANDI $0-$6.60 (Tier 2) PAR; MO YERVOY $0-$6.60 (Tier 2) PAR; MO ZALTRAP $0-$6.60 (Tier 2) PAR; MO ZANOSAR $0-$6.60 (Tier 2) B/D PAR; MO ZELBORAF $0-$6.60 (Tier 2) PAR; MO ZOLINZA $0-$6.60 (Tier 2) PAR; MO ZORTRESS $0-$6.60 (Tier 2) B/D PAR; MO ZYDELIG $0-$6.60 (Tier 2) PAR; MO; QLL (60 per 30 days) ZYKADIA $0-$6.60 (Tier 2) PAR; MO ZYTIGA $0-$6.60 (Tier 2) PAR; MO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH 26

28 ANTICONVULSANTS APTIOM $0-$6.60 (Tier 2) ST; MO BANZEL ORAL SUSPENSION $0-$6.60 (Tier 2) PAR; MO; QLL (2400 per 30 days) BANZEL ORAL TABLET 200 MG $0-$6.60 (Tier 2) PAR; MO; QLL (480 per 30 days) BANZEL ORAL TABLET 400 MG $0-$6.60 (Tier 2) PAR; MO; QLL (240 per 30 days) carbamazepine oral capsule, er multiphase 12 hr $0-$6.60 (Tier 2) MO carbamazepine oral suspension 100 mg/5 ml $0-$6.60 (Tier 2) MO carbamazepine oral tablet $0-$6.60 (Tier 2) MO carbamazepine oral tablet extended release 12 hr $0-$6.60 (Tier 2) MO carbamazepine oral tablet,chewable $0-$6.60 (Tier 2) MO CELONTIN ORAL CAPSULE 300 MG $0-$6.60 (Tier 2) MO clonazepam oral tablet 0.5 mg $0-$6.60 (Tier 2) PAR; MO; QLL (1200 per 30 days) clonazepam oral tablet 1 mg $0-$6.60 (Tier 2) PAR; MO; QLL (600 per 30 days) clonazepam oral tablet 2 mg $0-$6.60 (Tier 2) PAR; MO; QLL (300 per 30 days) clonazepam oral tablet,disintegrating mg $0-$6.60 (Tier 2) PAR; MO; QLL (4800 per 30 days) clonazepam oral tablet,disintegrating 0.25 mg $0-$6.60 (Tier 2) PAR; MO; QLL (2400 per 30 days) clonazepam oral tablet,disintegrating 0.5 mg $0-$6.60 (Tier 2) PAR; MO; QLL (1200 per 30 days) clonazepam oral tablet,disintegrating 1 mg $0-$6.60 (Tier 2) PAR; MO; QLL (600 per 30 days) clonazepam oral tablet,disintegrating 2 mg $0-$6.60 (Tier 2) PAR; MO; QLL (300 per 30 days) diazepam rectal $0-$6.60 (Tier 2) MO; QLL (2 per 1 day) DILANTIN CAPSULES $0-$6.60 (Tier 2) MO DILANTIN EXTENDED CAPSULES $0-$6.60 (Tier 2) MO DILANTIN INFATABS $0-$6.60 (Tier 2) MO divalproex $0-$6.60 (Tier 2) MO epitol $0-$6.60 (Tier 2) MO EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 100 MG EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 200 MG EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 300 MG $0-$6.60 (Tier 2) MO; QLL (480 per 30 days) $0-$6.60 (Tier 2) MO; QLL (240 per 30 days) $0-$6.60 (Tier 2) MO; QLL (180 per 30 days) 27

29 ethosuximide $0-$6.60 (Tier 2) MO felbamate $0-$6.60 (Tier 2) MO fosphenytoin $0-$6.60 (Tier 2) B/D PAR; MO FYCOMPA ORAL TABLET 10 MG, 12 MG $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) FYCOMPA ORAL TABLET 2 MG $0-$6.60 (Tier 2) MO; QLL (180 per 30 days) FYCOMPA ORAL TABLET 4 MG $0-$6.60 (Tier 2) MO; QLL (90 per 30 days) FYCOMPA ORAL TABLET 6 MG $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) FYCOMPA ORAL TABLET 8 MG $0-$6.60 (Tier 2) MO; QLL (45 per 30 days) gabapentin oral capsule 100 mg $0-$6.60 (Tier 2) MO; QLL (1080 per 30 days) gabapentin oral capsule 300 mg $0-$6.60 (Tier 2) MO; QLL (360 per 30 days) gabapentin oral capsule 400 mg $0-$6.60 (Tier 2) MO; QLL (270 per 30 days) gabapentin oral solution 250 mg/5 ml $0-$6.60 (Tier 2) MO; QLL (2160 per 30 days) gabapentin oral solution 250 mg/5 ml (5 ml), 300 mg/6 ml (6 ml) $0-$6.60 (Tier 2) QLL (2160 per 30 days) gabapentin oral tablet 600 mg $0-$6.60 (Tier 2) MO; QLL (180 per 30 days) gabapentin oral tablet 800 mg $0-$6.60 (Tier 2) MO; QLL (135 per 30 days) GABITRIL $0-$6.60 (Tier 2) MO lamotrigine oral tablet $0-$6.60 (Tier 2) MO lamotrigine oral tablet, chewable dispersible $0-$6.60 (Tier 2) MO levetiracetam in nacl (iso-os) intravenous piggyback 1,000 mg/100 ml, 1,500 mg/100 ml levetiracetam in nacl (iso-os) intravenous piggyback 500 mg/100 ml $0-$6.60 (Tier 2) B/D PAR $0-$6.60 (Tier 2) B/D PAR; MO levetiracetam intravenous $0-$6.60 (Tier 2) B/D PAR; MO levetiracetam oral solution 100 mg/ml $0-$6.60 (Tier 2) MO levetiracetam oral solution 500 mg/5 ml (5 ml) $0-$6.60 (Tier 2) levetiracetam oral tablet $0-$6.60 (Tier 2) MO levetiracetam oral tablet extended release 24 hr 500 mg levetiracetam oral tablet extended release 24 hr 750 mg $0-$6.60 (Tier 2) MO; QLL (180 per 30 days) $0-$6.60 (Tier 2) MO; QLL (120 per 30 days) 28

30 LYRICA ORAL CAPSULE 100 MG $0-$6.60 (Tier 2) PAR; MO; QLL (180 per 30 days) LYRICA ORAL CAPSULE 150 MG $0-$6.60 (Tier 2) PAR; MO; QLL (120 per 30 days) LYRICA ORAL CAPSULE 200 MG $0-$6.60 (Tier 2) PAR; MO; QLL (90 per 30 days) LYRICA ORAL CAPSULE 225 MG, 300 MG $0-$6.60 (Tier 2) PAR; MO; QLL (60 per 30 days) LYRICA ORAL CAPSULE 25 MG $0-$6.60 (Tier 2) PAR; MO; QLL (720 per 30 days) LYRICA ORAL CAPSULE 50 MG $0-$6.60 (Tier 2) PAR; MO; QLL (360 per 30 days) LYRICA ORAL CAPSULE 75 MG $0-$6.60 (Tier 2) PAR; MO; QLL (240 per 30 days) LYRICA ORAL SOLUTION $0-$6.60 (Tier 2) PAR; MO; QLL (900 per 30 days) ONFI ORAL SUSPENSION $0-$6.60 (Tier 2) PAR; MO; QLL (480 per 30 days) ONFI ORAL TABLET 10 MG $0-$6.60 (Tier 2) PAR; MO; QLL (120 per 30 days) ONFI ORAL TABLET 20 MG $0-$6.60 (Tier 2) PAR; MO; QLL (60 per 30 days) oxcarbazepine $0-$6.60 (Tier 2) MO OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 300 MG OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 600 MG $0-$6.60 (Tier 2) MO; QLL (480 per 30 days) $0-$6.60 (Tier 2) MO; QLL (240 per 30 days) $0-$6.60 (Tier 2) MO; QLL (120 per 30 days) PEGANONE $0-$6.60 (Tier 2) MO phenobarbital oral elixir $0-$6.60 (Tier 2) PAR; MO; QLL (3000 per 30 days) phenobarbital oral tablet 100 mg $0-$6.60 (Tier 2) PAR; QLL (120 per 30 days) phenobarbital oral tablet 15 mg $0-$6.60 (Tier 2) PAR; MO; QLL (800 per 30 days) phenobarbital oral tablet 16.2 mg $0-$6.60 (Tier 2) PAR; MO; QLL (741 per 30 days) phenobarbital oral tablet 30 mg $0-$6.60 (Tier 2) PAR; MO; QLL (400 per 30 days) phenobarbital oral tablet 32.4 mg $0-$6.60 (Tier 2) PAR; MO; QLL (370 per 30 days) phenobarbital oral tablet 60 mg $0-$6.60 (Tier 2) PAR; MO; QLL (200 per 30 days) phenobarbital oral tablet 64.8 mg $0-$6.60 (Tier 2) PAR; MO; QLL (185 per 30 days) phenobarbital oral tablet 97.2 mg $0-$6.60 (Tier 2) PAR; MO; QLL (123 per 30 days) phenytoin oral suspension 100 mg/4 ml $0-$6.60 (Tier 2) phenytoin oral suspension 125 mg/5 ml $0-$6.60 (Tier 2) MO phenytoin oral tablet,chewable $0-$6.60 (Tier 2) MO 29

31 phenytoin sodium extended $0-$6.60 (Tier 2) MO phenytoin sodium intravenous solution $0-$6.60 (Tier 2) B/D PAR; MO phenytoin sodium intravenous syringe $0-$6.60 (Tier 2) B/D PAR POTIGA ORAL TABLET 200 MG, 300 MG, 400 MG $0-$6.60 (Tier 2) MO; QLL (90 per 30 days) POTIGA ORAL TABLET 50 MG $0-$6.60 (Tier 2) MO; QLL (270 per 30 days) primidone $0-$6.60 (Tier 2) MO SABRIL $0-$6.60 (Tier 2) PAR; MO; LA; QLL (180 per 30 days) tiagabine $0-$6.60 (Tier 2) MO topiramate oral capsule, sprinkle $0-$6.60 (Tier 2) PAR; MO topiramate oral tablet $0-$6.60 (Tier 2) PAR; MO valproate sodium $0-$6.60 (Tier 2) B/D PAR; MO valproic acid $0-$6.60 (Tier 2) MO valproic acid (as sodium salt) oral solution 250 mg/5 ml valproic acid (as sodium salt) oral solution 250 mg/5 ml (5 ml), 500 mg/10 ml (10 ml) $0-$6.60 (Tier 2) MO $0-$6.60 (Tier 2) VIMPAT INTRAVENOUS $0-$6.60 (Tier 2) B/D PAR; QLL (1200 per 30 days) VIMPAT ORAL SOLUTION $0-$6.60 (Tier 2) MO; QLL (1200 per 30 days) VIMPAT ORAL TABLET 100 MG $0-$6.60 (Tier 2) MO; QLL (120 per 30 days) VIMPAT ORAL TABLET 150 MG $0-$6.60 (Tier 2) MO; QLL (80 per 30 days) VIMPAT ORAL TABLET 200 MG $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) VIMPAT ORAL TABLET 50 MG $0-$6.60 (Tier 2) MO; QLL (240 per 30 days) zonisamide $0-$6.60 (Tier 2) MO ANTIPARKINSONISM AGENTS APOKYN $0-$6.60 (Tier 2) PAR; MO; LA AZILECT $0-$6.60 (Tier 2) MO benztropine oral $0-$6.60 (Tier 2) PAR; MO bromocriptine $0-$6.60 (Tier 2) MO carbidopa-levodopa $0-$6.60 (Tier 2) MO 30

32 entacapone $0-$6.60 (Tier 2) MO NEUPRO $0-$6.60 (Tier 2) PAR; MO; QLL (30 per 30 days) pramipexole oral tablet $0-$6.60 (Tier 2) MO ropinirole oral tablet $0-$6.60 (Tier 2) MO selegiline hcl $0-$6.60 (Tier 2) MO TASMAR ORAL TABLET 100 MG $0-$6.60 (Tier 2) MO tolcapone $0-$6.60 (Tier 2) MO MIGRAINE / CLUSTER HEADACHE THERAPY ERGOMAR $0-$6.60 (Tier 2) MO MIGRANAL $0-$6.60 (Tier 2) MO; QLL (8 per 28 days) rizatriptan $0-$6.60 (Tier 2) MO; QLL (12 per 30 days) sumatriptan succinate oral $0-$6.60 (Tier 2) MO; QLL (9 per 30 days) sumatriptan succinate subcutaneous cartridge $0-$6.60 (Tier 2) MO; QLL (4 per 30 days) sumatriptan succinate subcutaneous pen injector $0-$6.60 (Tier 2) MO; QLL (4 per 30 days) sumatriptan succinate subcutaneous solution $0-$6.60 (Tier 2) MO; QLL (4 per 30 days) sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml $0-$6.60 (Tier 2) QLL (4 per 30 days) zolmitriptan $0-$6.60 (Tier 2) MO; QLL (9 per 30 days) ZOMIG NASAL $0-$6.60 (Tier 2) MO; QLL (6 per 30 days) MISCELLANEOUS NEUROLOGICAL THERAPY AMPYRA $0-$6.60 (Tier 2) PAR; MO; LA; QLL (60 per 30 days) COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML $0-$6.60 (Tier 2) PAR; MO; QLL (30 per 30 days) $0-$6.60 (Tier 2) PAR; MO; QLL (12 per 28 days) donepezil oral tablet 10 mg, 5 mg $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) donepezil oral tablet,disintegrating $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) EXELON TRANSDERMAL $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) galantamine oral capsule,ext rel. pellets 24 hr $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) galantamine oral solution $0-$6.60 (Tier 2) MO; QLL (180 per 30 days) galantamine oral tablet $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) 31

33 GILENYA $0-$6.60 (Tier 2) PAR; MO; QLL (30 per 30 days) GLATOPA $0-$6.60 (Tier 2) PAR; MO; QLL (30 per 30 days) NAMENDA ORAL SOLUTION $0-$6.60 (Tier 2) PAR; MO; QLL (300 per 30 days) NAMENDA ORAL TABLET 10 MG $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) NAMENDA ORAL TABLET 5 MG $0-$6.60 (Tier 2) MO; QLL (90 per 30 days) NAMENDA TITRATION PAK $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE PACK NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 24HR $0-$6.60 (Tier 2) PAR; MO; QLL (28 per 365 days) $0-$6.60 (Tier 2) PAR; MO; QLL (30 per 30 days) NUEDEXTA $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) rivastigmine tartrate $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) TECFIDERA $0-$6.60 (Tier 2) PAR; MO TYSABRI $0-$6.60 (Tier 2) MO; LA XENAZINE ORAL TABLET 12.5 MG $0-$6.60 (Tier 2) PAR; MO; LA; QLL (240 per 30 days) XENAZINE ORAL TABLET 25 MG $0-$6.60 (Tier 2) PAR; MO; LA; QLL (120 per 30 days) MUSCLE RELAXANTS / ANTISPASMODIC THERAPY baclofen $0-$6.60 (Tier 2) MO cyclobenzaprine oral tablet $0-$6.60 (Tier 2) PAR; MO dantrolene $0-$6.60 (Tier 2) MO MESTINON ORAL SYRUP $0-$6.60 (Tier 2) MO MESTINON TIMESPAN $0-$6.60 (Tier 2) MO pyridostigmine bromide $0-$6.60 (Tier 2) MO tizanidine oral tablet $0-$6.60 (Tier 2) MO NARCOTIC ANALGESICS ABSTRAL $0-$6.60 (Tier 2) PAR; MO; QLL (120 per 30 days) acetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), 240 mg-24 mg /10 ml (10 ml), 300 mg-30 mg /12.5 ml $0-$6.60 (Tier 2) QLL (4500 per 30 days) 32

34 acetaminophen-codeine oral solution mg/5 ml $0-$6.60 (Tier 2) MO; QLL (4500 per 30 days) acetaminophen-codeine oral tablet mg $0-$6.60 (Tier 2) MO; QLL (390 per 30 days) acetaminophen-codeine oral tablet mg $0-$6.60 (Tier 2) MO; QLL (360 per 30 days) acetaminophen-codeine oral tablet mg $0-$6.60 (Tier 2) MO; QLL (180 per 30 days) ACTIQ $0-$6.60 (Tier 2) PAR; MO; QLL (120 per 30 days) AVINZA ORAL CAPSULE, ER MULTIPHASE 24 HR 75 MG buprenorphine hcl injection syringe $0-$6.60 (Tier 2) $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) buprenorphine hcl sublingual tablet 2 mg $0-$6.60 (Tier 2) PAR; MO; QLL (240 per 30 days) buprenorphine hcl sublingual tablet 8 mg $0-$6.60 (Tier 2) PAR; MO; QLL (60 per 30 days) butalbital compound w/codeine $0-$6.60 (Tier 2) PAR; MO duramorph (pf) injection solution 0.5 mg/ml $0-$6.60 (Tier 2) B/D PAR; MO duramorph (pf) injection solution 1 mg/ml $0-$6.60 (Tier 2) B/D PAR endocet oral tablet mg, mg, mg $0-$6.60 (Tier 2) MO; QLL (360 per 30 days) fentanyl citrate $0-$6.60 (Tier 2) PAR; MO; QLL (120 per 30 days) fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr $0-$6.60 (Tier 2) ST; MO; QLL (15 per 30 days) FENTORA $0-$6.60 (Tier 2) PAR; MO; QLL (120 per 30 days) hydrocodone-acetaminophen oral solution mg/5 ml hydrocodone-acetaminophen oral solution mg/15 ml hydrocodone-acetaminophen oral tablet mg, mg, mg hydrocodone-acetaminophen oral tablet mg, mg, mg $0-$6.60 (Tier 2) QLL (2700 per 30 days) $0-$6.60 (Tier 2) MO; QLL (2700 per 30 days) $0-$6.60 (Tier 2) MO; QLL (390 per 30 days) $0-$6.60 (Tier 2) MO; QLL (360 per 30 days) hydrocodone-ibuprofen $0-$6.60 (Tier 2) MO; QLL (480 per 30 days) hydromorphone oral tablet 2 mg, 4 mg $0-$6.60 (Tier 2) MO; QLL (360 per 30 days) hydromorphone oral tablet 8 mg $0-$6.60 (Tier 2) MO; QLL (180 per 30 days) LAZANDA $0-$6.60 (Tier 2) PAR; MO; QLL (30 per 30 days) 33

35 levorphanol tartrate $0-$6.60 (Tier 2) MO; QLL (180 per 30 days) methadone injection $0-$6.60 (Tier 2) methadone intensol $0-$6.60 (Tier 2) MO; QLL (180 per 30 days) methadone oral concentrate $0-$6.60 (Tier 2) MO; QLL (180 per 30 days) methadone oral solution 10 mg/5 ml $0-$6.60 (Tier 2) MO; QLL (900 per 30 days) methadone oral solution 5 mg/5 ml $0-$6.60 (Tier 2) MO; QLL (1800 per 30 days) methadone oral tablet 10 mg $0-$6.60 (Tier 2) MO; QLL (180 per 30 days) methadone oral tablet 5 mg $0-$6.60 (Tier 2) MO; QLL (360 per 30 days) methadose oral concentrate $0-$6.60 (Tier 2) MO; QLL (180 per 30 days) morphine (pf) injection solution 0.5 mg/ml $0-$6.60 (Tier 2) B/D PAR morphine (pf) injection solution 1 mg/ml $0-$6.60 (Tier 2) B/D PAR; MO morphine (pf) intravenous patient control.analgesia soln 150 mg/30 ml morphine (pf) intravenous patient control.analgesia soln 30 mg/30 ml $0-$6.60 (Tier 2) MO $0-$6.60 (Tier 2) morphine concentrate oral solution $0-$6.60 (Tier 2) MO; QLL (270 per 30 days) morphine intravenous cartridge $0-$6.60 (Tier 2) MORPHINE INTRAVENOUS CARTRIDGE $0-$6.60 (Tier 2) morphine intravenous pt controlled analgesia syring morphine intravenous solution 100 mg/4 ml, 25 mg/ml, 250 mg/10 ml $0-$6.60 (Tier 2) B/D PAR $0-$6.60 (Tier 2) morphine intravenous solution 50 mg/ml $0-$6.60 (Tier 2) MO morphine intravenous syringe 2 mg/ml, 4 mg/ml $0-$6.60 (Tier 2) morphine oral capsule, er multiphase 24 hr 120 mg, 75 mg, 90 mg morphine oral capsule, er multiphase 24 hr 30 mg, 45 mg, 60 mg morphine oral capsule,extend.release pellets 100 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) morphine oral solution 20 mg/5 ml $0-$6.60 (Tier 2) MO; QLL (1350 per 30 days) morphine oral tablet 15 mg $0-$6.60 (Tier 2) MO; QLL (360 per 30 days) 34

36 morphine oral tablet 30 mg $0-$6.60 (Tier 2) MO; QLL (180 per 30 days) morphine oral tablet extended release 100 mg, 15 mg, 30 mg, 60 mg $0-$6.60 (Tier 2) MO; QLL (90 per 30 days) morphine oral tablet extended release 200 mg $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) oxycodone oral capsule $0-$6.60 (Tier 2) MO; QLL (360 per 30 days) oxycodone oral concentrate $0-$6.60 (Tier 2) MO; QLL (360 per 30 days) oxycodone oral tablet 10 mg, 5 mg $0-$6.60 (Tier 2) MO; QLL (360 per 30 days) oxycodone oral tablet 15 mg $0-$6.60 (Tier 2) MO; QLL (540 per 30 days) oxycodone oral tablet 20 mg, 30 mg $0-$6.60 (Tier 2) MO; QLL (180 per 30 days) oxycodone-acetaminophen oral tablet mg, mg, mg, mg $0-$6.60 (Tier 2) MO; QLL (360 per 30 days) oxycodone-aspirin $0-$6.60 (Tier 2) MO; QLL (360 per 30 days) ROXICET ORAL SOLUTION $0-$6.60 (Tier 2) MO; QLL (1800 per 30 days) SUBSYS $0-$6.60 (Tier 2) PAR; MO; LA; QLL (120 per 30 days) NON-NARCOTIC ANALGESICS acephen rectal suppository 120 mg, 650 mg $0 (Tier 4) MO; [*] acephen rectal suppository 325 mg $0 (Tier 4) [*] aceta-gesic $0 (Tier 4) [*] acetaminophen oral tablet 325 mg $0 (Tier 4) MO; [*] added strength pain reliever $0 (Tier 4) [*] all day pain relief $0 (Tier 4) [*] all day relief $0 (Tier 4) MO; [*] arthritis pain relief (acetam) $0 (Tier 4) [*] aspirin low-strength $0 (Tier 4) [*] aspirin oral tablet 325 mg $0 (Tier 4) MO; [*] aspirin oral tablet,chewable $0 (Tier 4) MO; [*] aspirin oral tablet,delayed release (dr/ec) 325 mg, 81 mg $0 (Tier 4) MO; [*] aspir-low $0 (Tier 4) MO; [*] 35

37 buprenorphine-naloxone sublingual tablet mg $0-$6.60 (Tier 2) PAR; MO; QLL (360 per 30 days) buprenorphine-naloxone sublingual tablet 8-2 mg $0-$6.60 (Tier 2) PAR; MO; QLL (90 per 30 days) butorphanol tartrate injection $0-$6.60 (Tier 2) MO butorphanol tartrate nasal $0-$6.60 (Tier 2) MO; QLL (5 per 28 days) child ibuprofen $0 (Tier 4) [*] children's aspirin $0 (Tier 4) MO; [*] children's ibuprofen $0 (Tier 4) MO; [*] children's mapap $0 (Tier 4) [*] children's medi-profen $0 (Tier 4) [*] children's medi-tabs suspension $0 (Tier 4) [*] children's pain & fever relief $0 (Tier 4) MO; [*] children's pain relief oral suspension $0 (Tier 4) [*] children's pain reliever oral suspension $0 (Tier 4) [*] children's pain reliever oral tablet,disintegrating $0 (Tier 4) [*] children's q-pap $0 (Tier 4) MO; [*] children's silapap $0 (Tier 4) [*] diclofenac potassium $0-$6.60 (Tier 2) MO diclofenac sodium oral $0-$6.60 (Tier 2) MO diflunisal $0-$6.60 (Tier 2) MO diphenhydramine-acetaminophen $0 (Tier 4) [*] ed-apap $0 (Tier 4) [*] effervescent pain relief oral tablet, effervescent 325-1,916-1,000 mg $0 (Tier 4) [*] enteric coated aspirin $0 (Tier 4) [*] etodolac oral capsule 200 mg $0-$6.60 (Tier 2) MO etodolac oral tablet $0-$6.60 (Tier 2) MO etodolac oral tablet extended release 24 hr $0-$6.60 (Tier 2) MO ex-strength medi-tabs pm $0 (Tier 4) [*] fenoprofen oral tablet $0-$6.60 (Tier 2) MO 36

38 flurbiprofen $0-$6.60 (Tier 2) MO headache formula added str $0 (Tier 4) [*] headache relief (asa-acet-caf) $0 (Tier 4) [*] HISTAFLEX $0 (Tier 4) [*] ibu-drops $0 (Tier 4) [*] ibuprofen jr strength $0 (Tier 4) [*] ibuprofen oral capsule $0 (Tier 4) [*] ibuprofen oral suspension $0-$6.60 (Tier 2) MO ibuprofen oral tablet 200 mg $0 (Tier 4) MO; [*] ibuprofen oral tablet 400 mg, 600 mg, 800 mg $0-$6.60 (Tier 2) MO infants ibu-drops $0 (Tier 4) [*] infant's ibuprofen $0 (Tier 4) [*] junior mapap $0 (Tier 4) MO; [*] lite coat aspirin $0 (Tier 4) [*] mapap (acetaminophen) oral capsule $0 (Tier 4) MO; [*] mapap (acetaminophen) oral elixir $0 (Tier 4) MO; [*] mapap (acetaminophen) oral liquid $0 (Tier 4) MO; [*] mapap (acetaminophen) oral suspension $0 (Tier 4) [*] mapap (acetaminophen) oral tablet $0 (Tier 4) MO; [*] mapap (acetaminophen) oral tablet,chewable $0 (Tier 4) MO; [*] mapap arthritis pain $0 (Tier 4) MO; [*] mapap extra strength $0 (Tier 4) MO; [*] mapap pm $0 (Tier 4) MO; [*] meclofenamate oral $0-$6.60 (Tier 2) MO medi-profen $0 (Tier 4) [*] medi-tabs oral tablet 325 mg $0 (Tier 4) [*] meloxicam oral suspension $0-$6.60 (Tier 2) MO; QLL (300 per 30 days) meloxicam oral tablet $0-$2.65 (Tier 1) MO; QLL (30 per 30 days) menstrual relief $0 (Tier 4) [*] migraine formula $0 (Tier 4) [*] 37

39 nabumetone $0-$6.60 (Tier 2) MO nalbuphine injection $0-$6.60 (Tier 2) MO naloxone injection solution $0-$6.60 (Tier 2) MO naloxone injection syringe 0.4 mg/ml $0-$6.60 (Tier 2) naloxone injection syringe 1 mg/ml $0-$6.60 (Tier 2) MO naltrexone oral $0-$6.60 (Tier 2) MO naproxen $0-$6.60 (Tier 2) MO naproxen sodium oral tablet 220 mg $0 (Tier 4) MO; [*] naproxen sodium oral tablet 275 mg, 550 mg $0-$6.60 (Tier 2) MO non-aspirin pain relief oral tablet 500 mg $0 (Tier 4) [*] non-aspirin pm $0 (Tier 4) [*] oxaprozin $0-$6.60 (Tier 2) MO pain & fever $0 (Tier 4) MO; [*] pain relief oral tablet 500 mg $0 (Tier 4) [*] pain reliever extra strength $0 (Tier 4) [*] pain reliever oral tablet $0 (Tier 4) [*] pain reliever pm ex-strength $0 (Tier 4) [*] piroxicam $0-$6.60 (Tier 2) MO q-pap extra strength $0 (Tier 4) MO; [*] q-pap oral drops $0 (Tier 4) MO; [*] q-pap oral liquid $0 (Tier 4) MO; [*] q-pap oral tablet 325 mg $0 (Tier 4) [*] q-pap oral tablet 500 mg $0 (Tier 4) MO; [*] silapap $0 (Tier 4) [*] SUBOXONE SUBLINGUAL FILM 12-3 MG $0-$6.60 (Tier 2) PAR; MO; QLL (60 per 30 days) SUBOXONE SUBLINGUAL FILM MG $0-$6.60 (Tier 2) PAR; MO; QLL (360 per 30 days) SUBOXONE SUBLINGUAL FILM 4-1 MG $0-$6.60 (Tier 2) PAR; MO; QLL (180 per 30 days) SUBOXONE SUBLINGUAL FILM 8-2 MG $0-$6.60 (Tier 2) PAR; MO; QLL (90 per 30 days) sulindac oral $0-$6.60 (Tier 2) MO tolmetin $0-$6.60 (Tier 2) MO 38

40 tramadol oral tablet $0-$6.60 (Tier 2) MO; QLL (240 per 30 days) tramadol-acetaminophen $0-$6.60 (Tier 2) MO; QLL (240 per 30 days) VOLTAREN GEL TOPICAL GEL 1 % $0-$6.60 (Tier 2) MO; QLL (1000 per 30 days) PSYCHOTHERAPEUTIC DRUGS ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING $0-$6.60 (Tier 2) MO; QLL (1 per 28 days) $0-$6.60 (Tier 2) QLL (1 per 28 days) ABILIFY ORAL TABLET 10 MG $0-$6.60 (Tier 2) MO; QLL (90 per 30 days) ABILIFY ORAL TABLET 15 MG, 20 MG $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) ABILIFY ORAL TABLET 2 MG $0-$6.60 (Tier 2) MO; QLL (450 per 30 days) ABILIFY ORAL TABLET 30 MG $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) ABILIFY ORAL TABLET 5 MG $0-$6.60 (Tier 2) MO; QLL (180 per 30 days) ADASUVE $0-$6.60 (Tier 2) alprazolam oral tablet $0-$6.60 (Tier 2) MO; QLL (90 per 30 days) amitriptyline $0-$6.60 (Tier 2) PAR; MO amoxapine $0-$6.60 (Tier 2) MO amphetamine salt combo oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 5 mg, 7.5 mg $0-$6.60 (Tier 2) PAR; MO; QLL (90 per 30 days) amphetamine salt combo oral tablet 30 mg $0-$6.60 (Tier 2) PAR; MO; QLL (60 per 30 days) aripiprazole oral tablet 10 mg $0-$6.60 (Tier 2) MO; QLL (90 per 30 days) aripiprazole oral tablet 15 mg, 20 mg $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) aripiprazole oral tablet 2 mg $0-$6.60 (Tier 2) MO; QLL (450 per 30 days) aripiprazole oral tablet 30 mg $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) aripiprazole oral tablet 5 mg $0-$6.60 (Tier 2) MO; QLL (180 per 30 days) BRINTELLIX ORAL TABLET 10 MG $0-$6.60 (Tier 2) ST; MO; QLL (60 per 30 days) BRINTELLIX ORAL TABLET 20 MG $0-$6.60 (Tier 2) ST; MO; QLL (30 per 30 days) BRINTELLIX ORAL TABLET 5 MG $0-$6.60 (Tier 2) ST; MO; QLL (120 per 30 days) bupropion hcl oral tablet 100 mg $0-$6.60 (Tier 2) MO; QLL (135 per 30 days) bupropion hcl oral tablet 75 mg $0-$6.60 (Tier 2) MO; QLL (180 per 30 days) bupropion hcl oral tablet extended release 100 mg $0-$6.60 (Tier 2) MO; QLL (120 per 30 days) 39

41 bupropion hcl oral tablet extended release 150 mg, 200 mg bupropion hcl oral tablet extended release 24 hr 150 mg bupropion hcl oral tablet extended release 24 hr 300 mg $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) $0-$6.60 (Tier 2) MO; QLL (90 per 30 days) $0-$6.60 (Tier 2) MO; QLL (45 per 30 days) buspirone $0-$6.60 (Tier 2) MO chlorpromazine $0-$6.60 (Tier 2) PAR; MO citalopram oral solution $0-$2.65 (Tier 1) MO; QLL (600 per 30 days) citalopram oral tablet 10 mg $0-$2.65 (Tier 1) MO; QLL (120 per 30 days) citalopram oral tablet 20 mg $0-$2.65 (Tier 1) MO; QLL (60 per 30 days) citalopram oral tablet 40 mg $0-$2.65 (Tier 1) MO; QLL (30 per 30 days) clomipramine $0-$6.60 (Tier 2) PAR; MO clorazepate dipotassium $0-$6.60 (Tier 2) MO; QLL (120 per 30 days) clozapine oral tablet 100 mg $0-$6.60 (Tier 2) MO; QLL (270 per 30 days) clozapine oral tablet 200 mg $0-$6.60 (Tier 2) QLL (135 per 30 days) clozapine oral tablet 25 mg $0-$6.60 (Tier 2) MO; QLL (1080 per 30 days) clozapine oral tablet 50 mg $0-$6.60 (Tier 2) MO; QLL (540 per 30 days) clozapine oral tablet,disintegrating 100 mg $0-$6.60 (Tier 2) QLL (270 per 30 days) clozapine oral tablet,disintegrating 12.5 mg $0-$6.60 (Tier 2) QLL (2160 per 30 days) clozapine oral tablet,disintegrating 150 mg $0-$6.60 (Tier 2) QLL (180 per 30 days) clozapine oral tablet,disintegrating 200 mg $0-$6.60 (Tier 2) QLL (135 per 30 days) clozapine oral tablet,disintegrating 25 mg $0-$6.60 (Tier 2) QLL (1080 per 30 days) desipramine oral $0-$6.60 (Tier 2) MO DESVENLAFAXINE FUMARATE ORAL TABLET EXTENDED RELEASE 24HR 100 MG DESVENLAFAXINE FUMARATE ORAL TABLET EXTENDED RELEASE 24HR 50 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR 100 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR 50 MG $0-$6.60 (Tier 2) MO; QLL (120 per 30 days) $0-$6.60 (Tier 2) MO; QLL (240 per 30 days) $0-$6.60 (Tier 2) MO; QLL (120 per 30 days) $0-$6.60 (Tier 2) MO; QLL (240 per 30 days) 40

42 DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 100 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 50 MG dextroamphetamine oral capsule, extended release 10 mg, 5 mg dextroamphetamine oral capsule, extended release 15 mg $0-$6.60 (Tier 2) QLL (120 per 30 days) $0-$6.60 (Tier 2) QLL (240 per 30 days) $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) $0-$6.60 (Tier 2) MO; QLL (120 per 30 days) dextroamphetamine oral tablet 10 mg $0-$6.60 (Tier 2) PAR; MO; QLL (180 per 30 days) dextroamphetamine oral tablet 5 mg $0-$6.60 (Tier 2) PAR; MO; QLL (90 per 30 days) diazepam injection solution $0-$6.60 (Tier 2) diazepam injection syringe $0-$6.60 (Tier 2) MO diazepam intensol $0-$6.60 (Tier 2) PAR; MO; QLL (240 per 30 days) diazepam oral concentrate $0-$6.60 (Tier 2) PAR; QLL (240 per 30 days) diazepam oral solution 5 mg/5 ml $0-$6.60 (Tier 2) MO; QLL (1200 per 30 days) diazepam oral tablet 10 mg $0-$6.60 (Tier 2) PAR; MO; QLL (120 per 30 days) diazepam oral tablet 2 mg $0-$6.60 (Tier 2) PAR; MO; QLL (600 per 30 days) diazepam oral tablet 5 mg $0-$6.60 (Tier 2) PAR; MO; QLL (240 per 30 days) doxepin oral $0-$6.60 (Tier 2) PAR; MO duloxetine oral capsule,delayed release(dr/ec) 20 mg duloxetine oral capsule,delayed release(dr/ec) 30 mg duloxetine oral capsule,delayed release(dr/ec) 40 mg duloxetine oral capsule,delayed release(dr/ec) 60 mg $0-$6.60 (Tier 2) MO; QLL (180 per 30 days) $0-$6.60 (Tier 2) MO; QLL (120 per 30 days) $0-$6.60 (Tier 2) MO; QLL (90 per 30 days) $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) EMSAM $0-$6.60 (Tier 2) PAR; MO; QLL (30 per 30 days) ergoloid $0-$6.60 (Tier 2) PAR; MO escitalopram oxalate oral solution $0-$2.65 (Tier 1) MO; QLL (600 per 30 days) escitalopram oxalate oral tablet 10 mg $0-$2.65 (Tier 1) MO; QLL (60 per 30 days) escitalopram oxalate oral tablet 20 mg $0-$2.65 (Tier 1) MO; QLL (30 per 30 days) 41

43 escitalopram oxalate oral tablet 5 mg $0-$2.65 (Tier 1) MO; QLL (120 per 30 days) FANAPT ORAL TABLET 1 MG $0-$6.60 (Tier 2) MO; QLL (720 per 30 days) FANAPT ORAL TABLET 10 MG $0-$6.60 (Tier 2) MO; QLL (72 per 30 days) FANAPT ORAL TABLET 12 MG $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) FANAPT ORAL TABLET 2 MG $0-$6.60 (Tier 2) MO; QLL (360 per 30 days) FANAPT ORAL TABLET 4 MG $0-$6.60 (Tier 2) MO; QLL (180 per 30 days) FANAPT ORAL TABLET 6 MG $0-$6.60 (Tier 2) MO; QLL (120 per 30 days) FANAPT ORAL TABLET 8 MG $0-$6.60 (Tier 2) MO; QLL (90 per 30 days) FANAPT ORAL TABLETS,DOSE PACK $0-$6.60 (Tier 2) MO; QLL (8 per 30 days) FAZACLO ORAL TABLET,DISINTEGRATING 100 MG FAZACLO ORAL TABLET,DISINTEGRATING 12.5 MG FAZACLO ORAL TABLET,DISINTEGRATING 150 MG FAZACLO ORAL TABLET,DISINTEGRATING 200 MG FAZACLO ORAL TABLET,DISINTEGRATING 25 MG FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 80 MG FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 20 MG FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 40 MG $0-$6.60 (Tier 2) QLL (270 per 30 days) $0-$6.60 (Tier 2) QLL (2160 per 30 days) $0-$6.60 (Tier 2) QLL (180 per 30 days) $0-$6.60 (Tier 2) QLL (135 per 30 days) $0-$6.60 (Tier 2) QLL (1080 per 30 days) $0-$6.60 (Tier 2) PAR; MO; QLL (28 per 365 days) $0-$6.60 (Tier 2) PAR; MO; QLL (30 per 30 days) $0-$6.60 (Tier 2) PAR; MO; QLL (180 per 30 days) $0-$6.60 (Tier 2) PAR; MO; QLL (90 per 30 days) fluoxetine oral capsule 10 mg $0-$2.65 (Tier 1) MO; QLL (240 per 30 days) fluoxetine oral capsule 20 mg $0-$2.65 (Tier 1) MO; QLL (120 per 30 days) fluoxetine oral capsule 40 mg $0-$2.65 (Tier 1) MO; QLL (60 per 30 days) fluoxetine oral solution $0-$2.65 (Tier 1) MO; QLL (600 per 30 days) fluoxetine oral tablet 10 mg $0-$2.65 (Tier 1) MO; QLL (240 per 30 days) fluoxetine oral tablet 20 mg $0-$2.65 (Tier 1) MO; QLL (120 per 30 days) 42

44 fluphenazine decanoate $0-$6.60 (Tier 2) MO fluphenazine hcl $0-$6.60 (Tier 2) MO fluvoxamine oral tablet 100 mg $0-$6.60 (Tier 2) MO; QLL (90 per 30 days) fluvoxamine oral tablet 25 mg $0-$6.60 (Tier 2) MO; QLL (360 per 30 days) fluvoxamine oral tablet 50 mg $0-$6.60 (Tier 2) MO; QLL (180 per 30 days) GEODON INTRAMUSCULAR $0-$6.60 (Tier 2) MO guanfacine oral tablet extended release 24 hr $0-$6.60 (Tier 2) PAR; MO; QLL (30 per 30 days) guanidine $0-$6.60 (Tier 2) MO haloperidol $0-$6.60 (Tier 2) MO haloperidol decanoate $0-$6.60 (Tier 2) MO haloperidol lactate $0-$6.60 (Tier 2) MO imipramine hcl $0-$6.60 (Tier 2) PAR; MO INTUNIV ER $0-$6.60 (Tier 2) PAR; MO; QLL (30 per 30 days) INVEGA ORAL TABLET EXTENDED RELEASE 24HR 1.5 MG INVEGA ORAL TABLET EXTENDED RELEASE 24HR 3 MG INVEGA ORAL TABLET EXTENDED RELEASE 24HR 6 MG INVEGA ORAL TABLET EXTENDED RELEASE 24HR 9 MG $0-$6.60 (Tier 2) MO; QLL (240 per 30 days) $0-$6.60 (Tier 2) MO; QLL (120 per 30 days) $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) $0-$6.60 (Tier 2) MO; QLL (40 per 30 days) INVEGA SUSTENNA $0-$6.60 (Tier 2) MO; QLL (2 per 28 days) INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 410 MG/1.315 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 546 MG/1.75 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 819 MG/2.625 ML KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 100 MG $0-$6.60 (Tier 2) MO; QLL (0.875 per 90 days) $0-$6.60 (Tier 2) MO; QLL (1.315 per 90 days) $0-$6.60 (Tier 2) MO; QLL (1.75 per 90 days) $0-$6.60 (Tier 2) MO; QLL (2.625 per 90 days) $0-$6.60 (Tier 2) MO; QLL (120 per 30 days) 43

45 KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 50 MG $0-$6.60 (Tier 2) MO; QLL (240 per 30 days) LATUDA ORAL TABLET 120 MG $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) LATUDA ORAL TABLET 20 MG $0-$6.60 (Tier 2) MO; QLL (240 per 30 days) LATUDA ORAL TABLET 40 MG $0-$6.60 (Tier 2) MO; QLL (120 per 30 days) LATUDA ORAL TABLET 60 MG $0-$6.60 (Tier 2) MO; QLL (75 per 30 days) LATUDA ORAL TABLET 80 MG $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) lithium carbonate $0-$6.60 (Tier 2) MO lithium citrate oral solution 8 meq/5 ml $0-$6.60 (Tier 2) MO lorazepam oral tablet $0-$6.60 (Tier 2) MO; QLL (90 per 30 days) loxapine succinate $0-$6.60 (Tier 2) MO maprotiline oral tablet 25 mg $0-$6.60 (Tier 2) MO; QLL (270 per 30 days) maprotiline oral tablet 50 mg $0-$6.60 (Tier 2) MO; QLL (135 per 30 days) maprotiline oral tablet 75 mg $0-$6.60 (Tier 2) MO MARPLAN $0-$6.60 (Tier 2) MO medi-sleep $0 (Tier 4) [*] methylphenidate oral tablet $0-$6.60 (Tier 2) PAR; MO; QLL (90 per 30 days) mirtazapine oral tablet 15 mg $0-$6.60 (Tier 2) MO; QLL (90 per 30 days) mirtazapine oral tablet 30 mg $0-$6.60 (Tier 2) MO; QLL (45 per 30 days) mirtazapine oral tablet 45 mg $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) mirtazapine oral tablet 7.5 mg $0-$6.60 (Tier 2) MO; QLL (180 per 30 days) mirtazapine oral tablet,disintegrating 15 mg $0-$6.60 (Tier 2) MO; QLL (90 per 30 days) mirtazapine oral tablet,disintegrating 30 mg $0-$6.60 (Tier 2) MO; QLL (45 per 30 days) mirtazapine oral tablet,disintegrating 45 mg $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) modafinil oral tablet 100 mg $0-$6.60 (Tier 2) PAR; MO; QLL (30 per 30 days) modafinil oral tablet 200 mg $0-$6.60 (Tier 2) PAR; MO; QLL (60 per 30 days) nefazodone oral tablet 100 mg $0-$6.60 (Tier 2) MO; QLL (180 per 30 days) nefazodone oral tablet 150 mg $0-$6.60 (Tier 2) MO; QLL (120 per 30 days) nefazodone oral tablet 200 mg $0-$6.60 (Tier 2) MO; QLL (90 per 30 days) nefazodone oral tablet 250 mg $0-$6.60 (Tier 2) MO; QLL (72 per 30 days) 44

46 nefazodone oral tablet 50 mg $0-$6.60 (Tier 2) MO; QLL (360 per 30 days) nortriptyline $0-$6.60 (Tier 2) MO olanzapine intramuscular $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) olanzapine oral tablet 10 mg $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) olanzapine oral tablet 15 mg $0-$6.60 (Tier 2) MO; QLL (40 per 30 days) olanzapine oral tablet 2.5 mg $0-$6.60 (Tier 2) MO; QLL (240 per 30 days) olanzapine oral tablet 20 mg $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) olanzapine oral tablet 5 mg $0-$6.60 (Tier 2) MO; QLL (120 per 30 days) olanzapine oral tablet 7.5 mg $0-$6.60 (Tier 2) MO; QLL (80 per 30 days) olanzapine oral tablet,disintegrating 10 mg $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) olanzapine oral tablet,disintegrating 15 mg $0-$6.60 (Tier 2) MO; QLL (40 per 30 days) olanzapine oral tablet,disintegrating 20 mg $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) olanzapine oral tablet,disintegrating 5 mg $0-$6.60 (Tier 2) MO; QLL (120 per 30 days) ORAP $0-$6.60 (Tier 2) MO paroxetine hcl oral tablet 10 mg $0-$2.65 (Tier 1) MO; QLL (180 per 30 days) paroxetine hcl oral tablet 20 mg $0-$2.65 (Tier 1) MO; QLL (90 per 30 days) paroxetine hcl oral tablet 30 mg $0-$2.65 (Tier 1) MO; QLL (60 per 30 days) paroxetine hcl oral tablet 40 mg $0-$2.65 (Tier 1) MO; QLL (45 per 30 days) paroxetine hcl oral tablet extended release 24 hr 12.5 mg paroxetine hcl oral tablet extended release 24 hr 25 mg paroxetine hcl oral tablet extended release 24 hr 37.5 mg $0-$2.65 (Tier 1) MO; QLL (180 per 30 days) $0-$2.65 (Tier 1) MO; QLL (90 per 30 days) $0-$2.65 (Tier 1) MO; QLL (60 per 30 days) PAXIL ORAL SUSPENSION $0-$6.60 (Tier 2) MO; QLL (900 per 30 days) perphenazine $0-$6.60 (Tier 2) MO phenelzine $0-$6.60 (Tier 2) MO PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 100 MG PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG $0-$6.60 (Tier 2) PAR; MO; QLL (120 per 30 days) $0-$6.60 (Tier 2) PAR; MO; QLL (480 per 30 days) 45

47 PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 50 MG protriptyline $0-$6.60 (Tier 2) MO $0-$6.60 (Tier 2) PAR; MO; QLL (240 per 30 days) quetiapine oral tablet 100 mg $0-$2.65 (Tier 1) MO; QLL (240 per 30 days) quetiapine oral tablet 200 mg $0-$2.65 (Tier 1) MO; QLL (120 per 30 days) quetiapine oral tablet 25 mg $0-$2.65 (Tier 1) MO; QLL (960 per 30 days) quetiapine oral tablet 300 mg $0-$2.65 (Tier 1) MO; QLL (80 per 30 days) quetiapine oral tablet 400 mg $0-$2.65 (Tier 1) MO; QLL (60 per 30 days) quetiapine oral tablet 50 mg $0-$2.65 (Tier 1) MO; QLL (480 per 30 days) RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 12.5 MG/2 ML, 25 MG/2 ML, 37.5 MG/2 ML RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 50 MG/2 ML $0-$6.60 (Tier 2) MO; QLL (2 per 28 days) $0-$6.60 (Tier 2) MO risperidone oral solution $0-$2.65 (Tier 1) MO; QLL (480 per 30 days) risperidone oral tablet 0.25 mg $0-$2.65 (Tier 1) MO; QLL (1920 per 30 days) risperidone oral tablet 0.5 mg $0-$2.65 (Tier 1) MO; QLL (960 per 30 days) risperidone oral tablet 1 mg $0-$2.65 (Tier 1) MO; QLL (480 per 30 days) risperidone oral tablet 2 mg $0-$2.65 (Tier 1) MO; QLL (240 per 30 days) risperidone oral tablet 3 mg $0-$2.65 (Tier 1) MO; QLL (160 per 30 days) risperidone oral tablet 4 mg $0-$2.65 (Tier 1) MO; QLL (120 per 30 days) risperidone oral tablet,disintegrating 0.25 mg $0-$2.65 (Tier 1) MO; QLL (1920 per 30 days) risperidone oral tablet,disintegrating 0.5 mg $0-$2.65 (Tier 1) MO; QLL (960 per 30 days) risperidone oral tablet,disintegrating 1 mg $0-$2.65 (Tier 1) MO; QLL (480 per 30 days) risperidone oral tablet,disintegrating 2 mg $0-$2.65 (Tier 1) MO; QLL (240 per 30 days) risperidone oral tablet,disintegrating 3 mg $0-$2.65 (Tier 1) MO; QLL (160 per 30 days) risperidone oral tablet,disintegrating 4 mg $0-$2.65 (Tier 1) MO; QLL (120 per 30 days) ROZEREM $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 10 MG SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 2.5 MG $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) $0-$6.60 (Tier 2) MO; QLL (240 per 30 days) 46

48 SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 5 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 200 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 300 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 400 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 50 MG $0-$6.60 (Tier 2) MO; QLL (120 per 30 days) $0-$6.60 (Tier 2) MO; QLL (160 per 30 days) $0-$6.60 (Tier 2) MO; QLL (120 per 30 days) $0-$6.60 (Tier 2) MO; QLL (80 per 30 days) $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) $0-$6.60 (Tier 2) MO; QLL (480 per 30 days) sertraline oral concentrate $0-$2.65 (Tier 1) MO; QLL (300 per 30 days) sertraline oral tablet 100 mg $0-$2.65 (Tier 1) MO; QLL (60 per 30 days) sertraline oral tablet 25 mg $0-$2.65 (Tier 1) MO; QLL (240 per 30 days) sertraline oral tablet 50 mg $0-$2.65 (Tier 1) MO; QLL (120 per 30 days) sleep aid (doxylamine) $0 (Tier 4) [*] STRATTERA ORAL CAPSULE 10 MG, 18 MG, 25 MG, 40 MG STRATTERA ORAL CAPSULE 100 MG, 60 MG, 80 MG $0-$6.60 (Tier 2) PAR; MO; QLL (60 per 30 days) $0-$6.60 (Tier 2) PAR; MO; QLL (30 per 30 days) SURMONTIL $0-$6.60 (Tier 2) PAR; MO temazepam oral capsule 15 mg, 22.5 mg, 30 mg $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) thioridazine $0-$6.60 (Tier 2) PAR; MO thiothixene $0-$6.60 (Tier 2) MO tranylcypromine $0-$6.60 (Tier 2) MO trazodone $0-$6.60 (Tier 2) MO trifluoperazine $0-$6.60 (Tier 2) MO venlafaxine oral capsule,extended release 24hr 150 mg venlafaxine oral capsule,extended release 24hr 37.5 mg $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) $0-$6.60 (Tier 2) MO; QLL (180 per 30 days) 47

49 venlafaxine oral capsule,extended release 24hr 75 mg $0-$6.60 (Tier 2) MO; QLL (90 per 30 days) venlafaxine oral tablet 100 mg $0-$6.60 (Tier 2) MO; QLL (113 per 30 days) venlafaxine oral tablet 25 mg $0-$6.60 (Tier 2) MO; QLL (450 per 30 days) venlafaxine oral tablet 37.5 mg $0-$6.60 (Tier 2) MO; QLL (300 per 30 days) venlafaxine oral tablet 50 mg $0-$6.60 (Tier 2) MO; QLL (225 per 30 days) venlafaxine oral tablet 75 mg $0-$6.60 (Tier 2) MO; QLL (150 per 30 days) venlafaxine oral tablet extended release 24hr 150 mg VENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 225 MG venlafaxine oral tablet extended release 24hr 37.5 mg venlafaxine oral tablet extended release 24hr 75 mg $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) $0-$6.60 (Tier 2) MO; QLL (180 per 30 days) $0-$6.60 (Tier 2) MO; QLL (90 per 30 days) VERSACLOZ $0-$6.60 (Tier 2) LA; QLL (600 per 30 days) VIIBRYD ORAL TABLET 10 MG $0-$6.60 (Tier 2) ST; MO; QLL (120 per 30 days) VIIBRYD ORAL TABLET 20 MG $0-$6.60 (Tier 2) ST; MO; QLL (60 per 30 days) VIIBRYD ORAL TABLET 40 MG $0-$6.60 (Tier 2) ST; MO; QLL (30 per 30 days) VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)-20 MG (7)-40 MG (16) $0-$6.60 (Tier 2) ST; MO; QLL (30 per 30 days) XYREM $0-$6.60 (Tier 2) PAR; MO; LA; QLL (540 per 30 days) zaleplon oral capsule 10 mg $0-$6.60 (Tier 2) PAR; MO; QLL (60 per 30 days) zaleplon oral capsule 5 mg $0-$6.60 (Tier 2) PAR; MO; QLL (30 per 30 days) zenzedi oral tablet 10 mg $0-$6.60 (Tier 2) PAR; MO; QLL (180 per 30 days) zenzedi oral tablet 5 mg $0-$6.60 (Tier 2) PAR; MO; QLL (90 per 30 days) ziprasidone hcl oral capsule 20 mg $0-$6.60 (Tier 2) MO; QLL (240 per 30 days) ziprasidone hcl oral capsule 40 mg $0-$6.60 (Tier 2) MO; QLL (120 per 30 days) ziprasidone hcl oral capsule 60 mg, 80 mg $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) zolpidem oral tablet $0-$6.60 (Tier 2) PAR; MO; QLL (30 per 30 days) 48

50 ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG, 405 MG ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 300 MG $0-$6.60 (Tier 2) LA $0-$6.60 (Tier 2) MO; LA CARDIOVASCULAR, HYPERTENSION / LIPIDS ANTIARRHYTHMIC AGENTS amiodarone intravenous solution $0-$6.60 (Tier 2) B/D PAR; MO amiodarone intravenous syringe $0-$6.60 (Tier 2) B/D PAR amiodarone oral $0-$6.60 (Tier 2) MO flecainide $0-$6.60 (Tier 2) MO lidocaine (pf) intravenous solution $0-$6.60 (Tier 2) MO lidocaine (pf) intravenous syringe 100 mg/5 ml (2 %), 50 mg/5 ml (1 %) $0-$6.60 (Tier 2) mexiletine $0-$6.60 (Tier 2) MO MULTAQ $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) pacerone oral tablet 100 mg, 200 mg, 400 mg $0-$6.60 (Tier 2) MO procainamide injection solution 100 mg/ml $0-$6.60 (Tier 2) MO procainamide injection solution 500 mg/ml $0-$6.60 (Tier 2) propafenone oral tablet $0-$6.60 (Tier 2) MO quinidine sulfate tablets oral tablet 200 mg, 300 mg $0-$6.60 (Tier 2) MO sorine oral tablet 120 mg, 160 mg, 80 mg $0-$6.60 (Tier 2) MO sorine oral tablet 240 mg $0-$6.60 (Tier 2) sotalol af $0-$6.60 (Tier 2) MO sotalol oral $0-$6.60 (Tier 2) MO TIKOSYN $0-$6.60 (Tier 2) MO ANTIHYPERTENSIVE THERAPY acebutolol oral $0-$2.65 (Tier 1) MO afeditab cr $0-$6.60 (Tier 2) MO 49

51 amiloride oral $0-$6.60 (Tier 2) MO amiloride-hydrochlorothiazide $0-$6.60 (Tier 2) MO amlodipine oral tablet 10 mg, 2.5 mg $0-$2.65 (Tier 1) MO; QLL (30 per 30 days) amlodipine oral tablet 5 mg $0-$2.65 (Tier 1) MO; QLL (45 per 30 days) amlodipine-benazepril $0-$2.65 (Tier 1) MO amlodipine-valsartan $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) amlodipine-valsartan-hcthiazid $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) atenolol $0-$2.65 (Tier 1) MO atenolol-chlorthalidone $0-$2.65 (Tier 1) MO AZOR $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) benazepril $0-$2.65 (Tier 1) MO benazepril-hydrochlorothiazide $0-$2.65 (Tier 1) MO betaxolol oral $0-$6.60 (Tier 2) MO bisoprolol fumarate $0-$6.60 (Tier 2) MO bisoprolol-hydrochlorothiazide $0-$6.60 (Tier 2) MO bumetanide $0-$6.60 (Tier 2) MO BYSTOLIC $0-$6.60 (Tier 2) MO candesartan oral tablet 16 mg, 4 mg, 8 mg $0-$2.65 (Tier 1) MO; QLL (60 per 30 days) candesartan oral tablet 32 mg $0-$2.65 (Tier 1) MO; QLL (30 per 30 days) candesartan-hydrochlorothiazid oral tablet mg candesartan-hydrochlorothiazid oral tablet mg, mg $0-$2.65 (Tier 1) MO; QLL (60 per 30 days) $0-$2.65 (Tier 1) MO; QLL (30 per 30 days) captopril $0-$2.65 (Tier 1) MO captopril-hydrochlorothiazide $0-$2.65 (Tier 1) MO cartia xt $0-$6.60 (Tier 2) MO carvedilol $0-$2.65 (Tier 1) MO chlorothiazide $0-$6.60 (Tier 2) MO chlorothiazide sodium $0-$6.60 (Tier 2) MO chlorthalidone oral tablet 25 mg, 50 mg $0-$6.60 (Tier 2) MO 50

52 clonidine hcl oral tablet $0-$2.65 (Tier 1) MO clonidine patches $0-$6.60 (Tier 2) MO; QLL (4 per 28 days) COREG CR $0-$6.60 (Tier 2) ST; MO DEMSER $0-$6.60 (Tier 2) MO diltiazem hcl intravenous $0-$6.60 (Tier 2) diltiazem hcl oral capsule, extended release $0-$6.60 (Tier 2) MO diltiazem hcl oral capsule,ext release degradable $0-$6.60 (Tier 2) MO diltiazem hcl oral capsule,extended release 12 hr $0-$6.60 (Tier 2) MO diltiazem hcl oral capsule,extended release 24hr $0-$6.60 (Tier 2) MO diltiazem hcl oral tablet $0-$6.60 (Tier 2) MO diltiazem hcl oral tablet extended release 24 hr 180 mg, 300 mg, 420 mg diltiazem hcl oral tablet extended release 24 hr 240 mg, 360 mg $0-$6.60 (Tier 2) $0-$6.60 (Tier 2) MO dilt-xr $0-$6.60 (Tier 2) MO doxazosin $0-$6.60 (Tier 2) MO enalapril maleate $0-$2.65 (Tier 1) MO enalapril-hydrochlorothiazide $0-$2.65 (Tier 1) MO eplerenone $0-$6.60 (Tier 2) MO eprosartan $0-$2.65 (Tier 1) MO; QLL (30 per 30 days) felodipine $0-$6.60 (Tier 2) MO fosinopril $0-$2.65 (Tier 1) MO fosinopril-hydrochlorothiazide $0-$2.65 (Tier 1) MO furosemide injection $0-$6.60 (Tier 2) MO furosemide oral solution 10 mg/ml, 40 mg/5 ml $0-$2.65 (Tier 1) MO furosemide oral tablet $0-$2.65 (Tier 1) MO hydralazine $0-$6.60 (Tier 2) MO hydrochlorothiazide $0-$2.65 (Tier 1) MO indapamide $0-$2.65 (Tier 1) MO irbesartan $0-$2.65 (Tier 1) MO; QLL (30 per 30 days) 51

53 irbesartan-hydrochlorothiazide oral tablet mg irbesartan-hydrochlorothiazide oral tablet mg $0-$2.65 (Tier 1) MO; QLL (60 per 30 days) $0-$2.65 (Tier 1) MO; QLL (30 per 30 days) isradipine $0-$6.60 (Tier 2) MO labetalol intravenous solution $0-$6.60 (Tier 2) MO labetalol oral $0-$6.60 (Tier 2) MO lisinopril $0-$2.65 (Tier 1) MO lisinopril-hydrochlorothiazide $0-$2.65 (Tier 1) MO losartan oral tablet 100 mg $0-$2.65 (Tier 1) MO; QLL (30 per 30 days) losartan oral tablet 25 mg, 50 mg $0-$2.65 (Tier 1) MO; QLL (60 per 30 days) losartan-hydrochlorothiazide $0-$2.65 (Tier 1) MO; QLL (30 per 30 days) methyclothiazide $0-$6.60 (Tier 2) MO metolazone $0-$2.65 (Tier 1) MO metoprolol succinate $0-$6.60 (Tier 2) MO metoprolol ta-hydrochlorothiaz $0-$6.60 (Tier 2) MO metoprolol tartrate intravenous solution $0-$6.60 (Tier 2) MO metoprolol tartrate intravenous syringe $0-$6.60 (Tier 2) metoprolol tartrate oral $0-$2.65 (Tier 1) MO minoxidil oral $0-$6.60 (Tier 2) MO moexipril $0-$2.65 (Tier 1) MO moexipril-hydrochlorothiazide $0-$2.65 (Tier 1) MO nadolol $0-$2.65 (Tier 1) MO nadolol-bendroflumethiazide $0-$6.60 (Tier 2) MO nicardipine $0-$6.60 (Tier 2) MO nifedical xl $0-$6.60 (Tier 2) MO nifedipine oral tablet extended release $0-$6.60 (Tier 2) MO nifedipine oral tablet extended release 24hr $0-$6.60 (Tier 2) MO nimodipine $0-$6.60 (Tier 2) MO perindopril erbumine $0-$2.65 (Tier 1) MO 52

54 pindolol $0-$6.60 (Tier 2) MO prazosin oral $0-$6.60 (Tier 2) MO propranolol intravenous $0-$6.60 (Tier 2) propranolol oral $0-$6.60 (Tier 2) MO propranolol-hydrochlorothiazid $0-$6.60 (Tier 2) MO quinapril $0-$2.65 (Tier 1) MO quinapril-hydrochlorothiazide $0-$2.65 (Tier 1) MO ramipril $0-$2.65 (Tier 1) MO spironolactone $0-$2.65 (Tier 1) MO spironolacton-hydrochlorothiaz $0-$2.65 (Tier 1) MO taztia xt $0-$6.60 (Tier 2) MO TEKTURNA $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) TEKTURNA HCT $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) telmisartan oral tablet 20 mg, 40 mg $0-$2.65 (Tier 1) MO; QLL (30 per 30 days) telmisartan oral tablet 80 mg $0-$2.65 (Tier 1) MO; QLL (60 per 30 days) telmisartan-amlodipine $0-$2.65 (Tier 1) MO; QLL (30 per 30 days) telmisartan-hydrochlorothiazid oral tablet mg, mg telmisartan-hydrochlorothiazid oral tablet mg $0-$2.65 (Tier 1) MO; QLL (30 per 30 days) $0-$2.65 (Tier 1) MO; QLL (60 per 30 days) terazosin $0-$2.65 (Tier 1) MO timolol maleate oral $0-$6.60 (Tier 2) MO torsemide oral $0-$2.65 (Tier 1) MO trandolapril $0-$2.65 (Tier 1) MO triamterene-hydrochlorothiazid oral capsule mg $0-$2.65 (Tier 1) MO triamterene-hydrochlorothiazid oral tablet $0-$2.65 (Tier 1) MO TRIBENZOR $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) valsartan oral tablet 160 mg $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) valsartan oral tablet 320 mg $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) valsartan oral tablet 40 mg, 80 mg $0-$6.60 (Tier 2) MO; QLL (90 per 30 days) 53

55 valsartan-hydrochlorothiazide $0-$2.65 (Tier 1) MO; QLL (30 per 30 days) verapamil intravenous solution $0-$6.60 (Tier 2) MO verapamil intravenous syringe $0-$6.60 (Tier 2) verapamil oral $0-$6.60 (Tier 2) MO CARDIAC GLYCOSIDES DIGITEK ORAL TABLET 125 MCG $0-$2.65 (Tier 1) MO; QLL (30 per 30 days) digox oral tablet 125 mcg $0-$2.65 (Tier 1) MO; QLL (30 per 30 days) digoxin oral solution 50 mcg/ml $0-$6.60 (Tier 2) MO digoxin oral tablet 125 mcg $0-$2.65 (Tier 1) MO; QLL (30 per 30 days) LANOXIN ORAL TABLET 125 MCG $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) LANOXIN ORAL TABLET 62.5 MCG $0-$6.60 (Tier 2) MO COAGULATION THERAPY AGGRENOX $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) aspirin-dipyridamole $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) BRILINTA $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) cilostazol $0-$6.60 (Tier 2) MO clopidogrel oral tablet 300 mg $0-$6.60 (Tier 2) MO; QLL (1 per 30 days) clopidogrel oral tablet 75 mg $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) COUMADIN ORAL $0-$6.60 (Tier 2) MO EFFIENT $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) ELIQUIS $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) enoxaparin subcutaneous solution $0-$6.60 (Tier 2) MO; QLL (84 per 30 days) enoxaparin subcutaneous syringe 100 mg/ml, 150 mg/ml enoxaparin subcutaneous syringe 120 mg/0.8 ml, 80 mg/0.8 ml $0-$6.60 (Tier 2) MO; QLL (28 per 30 days) $0-$6.60 (Tier 2) MO; QLL (22.4 per 30 days) enoxaparin subcutaneous syringe 30 mg/0.3 ml $0-$6.60 (Tier 2) MO; QLL (8.4 per 30 days) enoxaparin subcutaneous syringe 40 mg/0.4 ml $0-$6.60 (Tier 2) MO; QLL (11.2 per 30 days) enoxaparin subcutaneous syringe 60 mg/0.6 ml $0-$6.60 (Tier 2) MO; QLL (16.8 per 30 days) fondaparinux subcutaneous syringe 10 mg/0.8 ml $0-$6.60 (Tier 2) MO; QLL (24 per 30 days) 54

56 fondaparinux subcutaneous syringe 2.5 mg/0.5 ml $0-$6.60 (Tier 2) MO; QLL (15 per 30 days) fondaparinux subcutaneous syringe 5 mg/0.4 ml $0-$6.60 (Tier 2) MO; QLL (12 per 30 days) fondaparinux subcutaneous syringe 7.5 mg/0.6 ml $0-$6.60 (Tier 2) MO; QLL (18 per 30 days) FRAGMIN SUBCUTANEOUS SOLUTION $0-$6.60 (Tier 2) ST; MO FRAGMIN SUBCUTANEOUS SYRINGE $0-$6.60 (Tier 2) ST; MO heparin (porcine) in 5 % dex intravenous parenteral solution 12,500 unit/250 ml, 25,000 unit/250 ml(100 unit/ml) heparin (porcine) in 5 % dex intravenous parenteral solution 25,000 unit/500 ml (50 unit/ml) heparin (porcine) in nacl (pf) intravenous parenteral solution 1,000 unit/500 ml, 2,000 unit/1,000 ml $0-$6.60 (Tier 2) B/D PAR $0-$6.60 (Tier 2) B/D PAR; MO $0-$6.60 (Tier 2) B/D PAR heparin (porcine) injection cartridge $0-$6.60 (Tier 2) B/D PAR; MO heparin (porcine) injection solution $0-$6.60 (Tier 2) B/D PAR; MO HEPARIN(PORCINE) IN 0.45% NACL INTRAVENOUS PARENTERAL SOLUTION 12,500 UNIT/250 ML heparin(porcine) in 0.45% nacl intravenous parenteral solution 25,000 unit/250 ml, 25,000 unit/500 ml $0-$6.60 (Tier 2) B/D PAR $0-$6.60 (Tier 2) B/D PAR heparin, porcine (pf) injection $0-$6.60 (Tier 2) B/D PAR; MO jantoven $0-$2.65 (Tier 1) MO MEPHYTON $0 (Tier 3) MO; [*] pentoxifylline $0-$6.60 (Tier 2) MO PRADAXA $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) PROMACTA ORAL TABLET 12.5 MG, 25 MG, 75 MG $0-$6.60 (Tier 2) PAR; MO; LA; QLL (30 per 30 days) PROMACTA ORAL TABLET 50 MG $0-$6.60 (Tier 2) PAR; MO; LA; QLL (60 per 30 days) tranexamic acid intravenous $0-$6.60 (Tier 2) MO vitamin k1 injection $0 (Tier 3) MO; [*] warfarin $0-$2.65 (Tier 1) MO 55

57 XARELTO ORAL TABLET 10 MG, 20 MG $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) XARELTO ORAL TABLET 15 MG $0-$6.60 (Tier 2) MO; QLL (42 per 30 days) XARELTO ORAL TABLETS,DOSE PACK $0-$6.60 (Tier 2) MO; QLL (51 per 365 days) LIPID/CHOLESTEROL LOWERING AGENTS amlodipine-atorvastatin $0-$2.65 (Tier 1) MO; QLL (30 per 30 days) atorvastatin $0-$2.65 (Tier 1) MO; QLL (30 per 30 days) cholestyramine (with sugar) $0-$6.60 (Tier 2) MO cholestyramine light $0-$6.60 (Tier 2) MO colestipol $0-$6.60 (Tier 2) MO CRESTOR $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) fenofibrate nanocrystallized $0-$6.60 (Tier 2) MO fenofibrate oral tablet 160 mg, 54 mg $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) gemfibrozil oral $0-$6.60 (Tier 2) MO lovastatin oral tablet 10 mg, 20 mg $0-$2.65 (Tier 1) MO; QLL (30 per 30 days) lovastatin oral tablet 40 mg $0-$2.65 (Tier 1) MO; QLL (60 per 30 days) niacin oral capsule, extended release 250 mg $0 (Tier 4) MO; [*] niacin oral tablet 100 mg, 50 mg, 500 mg $0 (Tier 4) MO; [*] niacin oral tablet extended release 24 hr 1,000 mg, 750 mg $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) niacin oral tablet extended release 24 hr 500 mg $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) niacin oral tablet extended release 250 mg, 500 mg $0 (Tier 4) MO; [*] NIACOR $0-$2.65 (Tier 1) MO omega-3 acid ethyl esters $0-$6.60 (Tier 2) PAR; MO pravastatin $0-$2.65 (Tier 1) MO; QLL (30 per 30 days) prevalite $0-$6.60 (Tier 2) MO simvastatin $0-$2.65 (Tier 1) MO; QLL (30 per 30 days) SLO-NIACIN ORAL TABLET EXTENDED RELEASE 250 MG $0 (Tier 4) MO; [*] 56

58 slo-niacin oral tablet extended release 500 mg $0 (Tier 4) MO; [*] WELCHOL $0-$6.60 (Tier 2) MO ZETIA $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) MISCELLANEOUS CARDIOVASCULAR AGENTS RANEXA $0-$6.60 (Tier 2) PAR; MO VECAMYL $0-$6.60 (Tier 2) NITRATES isosorbide dinitrate oral $0-$6.60 (Tier 2) MO isosorbide mononitrate $0-$6.60 (Tier 2) MO nitro-bid $0-$6.60 (Tier 2) MO nitroglycerin intravenous $0-$6.60 (Tier 2) B/D PAR nitroglycerin transdermal patch 24 hour $0-$6.60 (Tier 2) MO NITROSTAT $0-$2.65 (Tier 1) MO DERMATOLOGICALS/TOPICAL THERAPY ANTIPSORIATIC / ANTISEBORRHEIC acitretin $0-$6.60 (Tier 2) MO calcipotriene topical cream $0-$6.60 (Tier 2) MO; QLL (120 per 30 days) calcipotriene topical ointment $0-$6.60 (Tier 2) MO; QLL (120 per 30 days) calcipotriene topical solution $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) selenium sulfide topical suspension $0-$6.60 (Tier 2) MO BURN THERAPY silver sulfadiazine $0-$6.60 (Tier 2) MO ssd $0-$6.60 (Tier 2) MO MISCELLANEOUS DERMATOLOGICALS ALOE VERA TOPICAL CREAM $0 (Tier 4) MO; [*] ALOE VERA TOPICAL GEL $0 (Tier 4) MO; [*] ALOE VERA TOPICAL LIQUID $0 (Tier 4) [*] ALOE VERA TOPICAL LOTION $0 (Tier 4) [*] ammonium lactate topical $0-$6.60 (Tier 2) MO 57

59 anti-itch (diphenhydramine) topical aerosol,spray $0 (Tier 4) [*] anti-itch(diphenhyd) with zinc topical cream % $0 (Tier 4) [*] dermabase $0 (Tier 4) MO; [*] diclofenac sodium topical gel $0-$6.60 (Tier 2) PAR; MO; QLL (100 per 30 days) DR. SMITH'S DIAPER $0 (Tier 4) MO; [*] DR. SMITH'S DIAPER RASH $0 (Tier 4) [*] DR. SMITH'S RASH-SKIN TOPICAL AEROSOL,SPRAY $0 (Tier 4) [*] ELIDEL $0-$6.60 (Tier 2) PAR; MO; QLL (60 per 1 day) fluorouracil topical cream 5 % $0-$6.60 (Tier 2) MO fluorouracil topical solution $0-$6.60 (Tier 2) MO imiquimod $0-$6.60 (Tier 2) MO ITCH-X TOPICAL GEL $0 (Tier 4) MO; [*] MEDICATED BODY POWDER TOPICAL POWDER 0.15 % $0 (Tier 4) [*] methoxsalen rapid $0-$6.60 (Tier 2) PAR; MO METHYL SALICYLATE-ALOE VERA $0 (Tier 4) MO; [*] mobisyl $0 (Tier 4) MO; [*] OXSORALEN $0-$6.60 (Tier 2) MO PANRETIN $0-$6.60 (Tier 2) MO podofilox $0-$6.60 (Tier 2) MO PROPYLENE GLYCOL $0 (Tier 4) MO; [*] PROTOPIC $0-$6.60 (Tier 2) PAR; MO; QLL (60 per 1 day) SARNA ANTI-ITCH $0 (Tier 4) MO; [*] tacrolimus topical $0-$6.60 (Tier 2) PAR; MO; QLL (60 per 1 day) THERA-GESIC TOPICAL CREAM 15-1 % $0 (Tier 4) MO; [*] trixaicin $0 (Tier 4) MO; [*] TRIXAICIN HP $0 (Tier 4) MO; [*] U-CORT $0-$6.60 (Tier 2) MO UVADEX $0-$6.60 (Tier 2) 58

60 VALCHLOR $0-$6.60 (Tier 2) MO vits a and d-white pet-lanolin topical ointment $0 (Tier 4) MO; [*] white petrolatum topical ointment $0 (Tier 4) MO; [*] zinc oxide topical ointment 20 % $0 (Tier 4) MO; [*] THERAPY FOR ACNE ACNE MEDICATION TOPICAL GEL $0 (Tier 4) MO; [*] ACNE MEDICATION TOPICAL LOTION 10 % $0 (Tier 4) MO; [*] adapalene topical gel 0.3 % $0-$6.60 (Tier 2) MO adapalene topical gel with pump $0-$6.60 (Tier 2) MO amnesteem $0-$6.60 (Tier 2) MO benzoyl peroxide topical foam $0 (Tier 4) [*] benzoyl peroxide topical gel 10 %, 2.5 %, 5 % $0 (Tier 4) MO; [*] clindamycin phosphate topical $0-$6.60 (Tier 2) MO DIFFERIN TOPICAL GEL 0.3 % $0-$6.60 (Tier 2) MO DIFFERIN TOPICAL GEL WITH PUMP $0-$6.60 (Tier 2) MO ery pads $0-$6.60 (Tier 2) MO erythromycin with ethanol $0-$6.60 (Tier 2) MO erythromycin-benzoyl peroxide $0-$6.60 (Tier 2) MO metronidazole topical cream $0-$6.60 (Tier 2) MO metronidazole topical gel 0.75 % $0-$6.60 (Tier 2) MO metronidazole topical lotion $0-$6.60 (Tier 2) MO rosadan topical cream $0-$6.60 (Tier 2) MO TAZORAC $0-$6.60 (Tier 2) PAR; MO tretinoin topical $0-$6.60 (Tier 2) MO; QLL (45 per 30 days) TRETIN-X CREAM KIT $0-$6.60 (Tier 2) MO TOPICAL ANESTHETICS caldyphen topical lotion 1-8 % $0 (Tier 4) [*] dibucaine $0 (Tier 4) MO; [*] lidocaine (pf) injection solution 10 mg/ml (1 %), 20 mg/ml (2 %), 40 mg/ml (4 %), 5 mg/ml (0.5 %) $0-$6.60 (Tier 2) MO 59

61 lidocaine (pf) injection solution 15 mg/ml (1.5 %) $0-$6.60 (Tier 2) lidocaine hcl injection solution 10 mg/ml (1 %), 20 mg/ml (2 %) $0-$6.60 (Tier 2) MO lidocaine hcl laryngotracheal $0-$6.60 (Tier 2) MO lidocaine hcl mucous membrane gel $0-$6.60 (Tier 2) MO lidocaine hcl mucous membrane jelly in applicator $0-$6.60 (Tier 2) MO lidocaine hcl mucous membrane solution 2 % $0-$6.60 (Tier 2) lidocaine hcl mucous membrane solution 4 % (40 mg/ml) $0-$6.60 (Tier 2) MO lidocaine hcl urethral $0-$6.60 (Tier 2) lidocaine topical adhesive patch,medicated $0-$6.60 (Tier 2) PAR; MO; QLL (90 per 30 days) LIDOCAINE TOPICAL CREAM $0 (Tier 4) [*] lidocaine topical ointment $0-$6.60 (Tier 2) MO lidocaine viscous $0-$6.60 (Tier 2) MO lidocaine-prilocaine $0-$6.60 (Tier 2) MO TOPICAL ANTIBACTERIALS bacitracin topical ointment $0 (Tier 4) MO; [*] bacitracin zinc topical ointment $0 (Tier 4) MO; [*] gentamicin topical $0-$6.60 (Tier 2) MO mupirocin ointment $0-$6.60 (Tier 2) MO povidone-iodine topical ointment $0 (Tier 4) MO; [*] povidone-iodine topical solution 10 % $0 (Tier 4) [*] sulfacetamide sodium (acne) $0-$6.60 (Tier 2) MO SULFAMYLON TOPICAL CREAM $0-$6.60 (Tier 2) MO triple antibiotic plus $0 (Tier 4) [*] triple antibiotic topical ointment $0 (Tier 4) MO; [*] TOPICAL ANTIFUNGALS antifungal (tolnaftate) topical powder $0 (Tier 4) MO; [*] antifungal cream $0 (Tier 4) [*] antifungal spray $0 (Tier 4) [*] 60

62 ciclodan topical solution $0-$6.60 (Tier 2) PAR; MO ciclopirox topical cream $0-$6.60 (Tier 2) MO ciclopirox topical gel $0-$6.60 (Tier 2) MO ciclopirox topical shampoo $0-$6.60 (Tier 2) MO ciclopirox topical solution $0-$6.60 (Tier 2) PAR; MO ciclopirox topical suspension $0-$6.60 (Tier 2) MO clotrim antifungal $0 (Tier 4) [*] clotrimazole 1% cream $0 (Tier 4) [*] clotrimazole topical $0-$6.60 (Tier 2) MO clotrimazole-betamethasone $0-$6.60 (Tier 2) MO econazole topical $0-$6.60 (Tier 2) MO fungoid tincture topical tincture $0 (Tier 4) MO; [*] ketoconazole topical $0-$6.60 (Tier 2) MO miconazole nitrate topical cream $0 (Tier 4) MO; [*] nystatin topical $0-$6.60 (Tier 2) MO nystatin-triamcinolone $0-$6.60 (Tier 2) MO nystop $0-$6.60 (Tier 2) MO terbinafine hcl topical $0 (Tier 4) MO; [*] tolnaftate topical cream $0 (Tier 4) [*] tolnaftate topical powder $0 (Tier 4) [*] zeasorb (miconazole) $0 (Tier 4) MO; [*] TOPICAL ANTIVIRALS acyclovir topical $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) DENAVIR $0-$6.60 (Tier 2) MO; QLL (5 per 1 day) TOPICAL CORTICOSTEROIDS ala-cort topical cream $0-$6.60 (Tier 2) MO alclometasone $0-$6.60 (Tier 2) MO amcinonide $0-$6.60 (Tier 2) MO betamethasone dipropionate $0-$6.60 (Tier 2) MO betamethasone valerate topical cream $0-$6.60 (Tier 2) MO 61

63 betamethasone valerate topical lotion $0-$6.60 (Tier 2) MO betamethasone valerate topical ointment $0-$6.60 (Tier 2) MO betamethasone, augmented $0-$6.60 (Tier 2) MO CAPEX $0-$6.60 (Tier 2) MO clobetasol topical cream $0-$6.60 (Tier 2) MO clobetasol topical foam $0-$6.60 (Tier 2) MO clobetasol topical gel $0-$6.60 (Tier 2) MO clobetasol topical ointment $0-$6.60 (Tier 2) MO clobetasol topical solution $0-$6.60 (Tier 2) MO clobetasol-emollient topical cream $0-$6.60 (Tier 2) MO cormax topical solution $0-$6.60 (Tier 2) MO desonide $0-$6.60 (Tier 2) MO desoximetasone $0-$6.60 (Tier 2) MO diflorasone $0-$6.60 (Tier 2) MO fluocinolone $0-$6.60 (Tier 2) MO fluocinolone-shower cap $0-$6.60 (Tier 2) MO fluocinonide topical cream 0.05 % $0-$6.60 (Tier 2) MO fluocinonide topical gel $0-$6.60 (Tier 2) MO fluocinonide topical ointment $0-$6.60 (Tier 2) MO fluocinonide topical solution $0-$6.60 (Tier 2) MO fluocinonide-e $0-$6.60 (Tier 2) MO fluticasone topical $0-$6.60 (Tier 2) MO halobetasol propionate $0-$6.60 (Tier 2) MO HALOG $0-$6.60 (Tier 2) MO hydro skin topical cream $0 (Tier 4) [*] hydro skin topical lotion $0 (Tier 4) MO; [*] hydrocortisone topical cream 0.5 % $0 (Tier 4) MO; [*] hydrocortisone topical cream 1 %, 2.5 % $0-$6.60 (Tier 2) MO hydrocortisone topical lotion 2.5 % $0-$6.60 (Tier 2) MO hydrocortisone topical ointment 0.5 % $0 (Tier 4) MO; [*] 62

64 hydrocortisone topical ointment 1 %, 2.5 % $0-$6.60 (Tier 2) MO hydrocortisone valerate $0-$6.60 (Tier 2) MO hydrocortisone-min oil-wht pet $0-$6.60 (Tier 2) MO mometasone $0-$6.60 (Tier 2) MO triamcinolone acetonide topical cream $0-$6.60 (Tier 2) MO triamcinolone acetonide topical lotion $0-$6.60 (Tier 2) MO triamcinolone acetonide topical ointment %, 0.1 %, 0.5 % $0-$6.60 (Tier 2) MO trianex $0-$6.60 (Tier 2) MO triderm topical cream $0-$6.60 (Tier 2) MO TOPICAL ENZYMES SANTYL $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) TOPICAL SCABICIDES / PEDICULICIDES lindane $0-$6.60 (Tier 2) MO permethrin topical cream $0-$6.60 (Tier 2) MO permethrin topical liquid $0 (Tier 4) MO; [*] DIAGNOSTICS / MISCELLANEOUS AGENTS ANTIDOTES acetylcysteine intravenous $0-$6.60 (Tier 2) B/D PAR; MO IRRIGATING SOLUTIONS lactated ringers irrigation $0-$6.60 (Tier 2) B/D PAR; MO neomycin-polymyxin b gu $0-$6.60 (Tier 2) MO ringers irrigation $0-$6.60 (Tier 2) B/D PAR; MO MISCELLANEOUS AGENTS ADAGEN $0-$6.60 (Tier 2) MO alendronate oral tablet 40 mg $0-$2.65 (Tier 1) MO; QLL (30 per 30 days) anagrelide $0-$6.60 (Tier 2) MO ARALAST NP $0-$6.60 (Tier 2) PAR; MO; LA BUPHENYL ORAL TABLET $0-$6.60 (Tier 2) PAR; MO CALCIUM WITH BORON $0 (Tier 4) [*] 63

65 cevimeline $0-$6.60 (Tier 2) MO CLINIMIX 4.25%/D5W SULFIT FREE $0-$6.60 (Tier 2) B/D PAR CLINIMIX E 2.75%/D10W SUL FREE $0-$6.60 (Tier 2) B/D PAR CLINIMIX E 2.75%/D5W SULF FREE $0-$6.60 (Tier 2) B/D PAR d10 % & 0.45 % sodium chloride $0-$6.60 (Tier 2) B/D PAR d2.5 %-0.45 % sodium chloride $0-$6.60 (Tier 2) B/D PAR d5 % and 0.9 % sodium chloride $0-$6.60 (Tier 2) B/D PAR; MO d5 %-0.45 % sodium chloride $0-$6.60 (Tier 2) B/D PAR; MO dextrose 10 % and 0.2 % nacl $0-$6.60 (Tier 2) B/D PAR dextrose 10 % in water (d10w) intravenous parenteral solution $0-$6.60 (Tier 2) B/D PAR; MO dextrose 25 % in water (d25w) $0-$6.60 (Tier 2) B/D PAR dextrose 30 % in water (d30w) $0-$6.60 (Tier 2) B/D PAR dextrose 40 % in water (d40w) $0-$6.60 (Tier 2) B/D PAR dextrose 5 % in water (d5w) $0-$6.60 (Tier 2) B/D PAR; MO dextrose 5 %-lactated ringers $0-$6.60 (Tier 2) B/D PAR; MO dextrose 5%-0.2 % sod chloride $0-$6.60 (Tier 2) B/D PAR dextrose 5%-0.3 % sod.chloride $0-$6.60 (Tier 2) B/D PAR dextrose 50 % in water (d50w) intravenous parenteral solution dextrose 50 % in water (d50w) intravenous syringe $0-$6.60 (Tier 2) B/D PAR; MO $0-$6.60 (Tier 2) B/D PAR dextrose 70 % in water (d70w) $0-$6.60 (Tier 2) B/D PAR; MO dextrose with sodium chloride $0-$6.60 (Tier 2) B/D PAR disulfiram $0-$6.60 (Tier 2) MO EXJADE $0-$6.60 (Tier 2) PAR; MO; LA GLUTOSE 15 $0 (Tier 4) MO; [*] GLUTOSE 45 $0 (Tier 4) MO; [*] INCRELEX $0-$6.60 (Tier 2) PAR; MO; LA levocarnitine (with sugar) $0-$6.60 (Tier 2) B/D PAR; MO levocarnitine oral tablet $0-$6.60 (Tier 2) B/D PAR; MO 64

66 midodrine $0-$6.60 (Tier 2) MO ORFADIN $0-$6.60 (Tier 2) LA pilocarpine hcl oral $0-$6.60 (Tier 2) MO RENAGEL $0-$6.60 (Tier 2) ST; MO RENVELA ORAL POWDER IN PACKET 0.8 GRAM RENVELA ORAL POWDER IN PACKET 2.4 GRAM $0-$6.60 (Tier 2) MO; QLL (180 per 30 days) $0-$6.60 (Tier 2) MO; QLL (90 per 30 days) RENVELA ORAL TABLET $0-$6.60 (Tier 2) MO; QLL (270 per 30 days) riluzole $0-$6.60 (Tier 2) MO sodium chloride 0.9 % intravenous $0-$6.60 (Tier 2) MO sodium chloride irrigation $0-$6.60 (Tier 2) MO sodium polystyrene (sorb free) $0-$6.60 (Tier 2) sodium polystyrene sulfonate oral powder $0-$6.60 (Tier 2) MO sodium polystyrene sulfonate oral suspension $0-$6.60 (Tier 2) sodium polystyrene sulfonate rectal $0-$6.60 (Tier 2) SODIUM POLYSTYRENE SULFONATE RECTAL $0-$6.60 (Tier 2) sps oral $0-$6.60 (Tier 2) MO sps rectal $0-$6.60 (Tier 2) SUSPENDOL-S $0 (Tier 4) MO; [*] SYPRINE $0-$6.60 (Tier 2) MO water for irrigation, sterile $0-$6.60 (Tier 2) B/D PAR; MO ZEMAIRA $0-$6.60 (Tier 2) PAR; MO; LA MISCELLANEOUS DEVICES aquabase $0 (Tier 4) MO; [*] FATTIBASE $0 (Tier 4) MO; [*] polybase $0 (Tier 4) MO; [*] NEUTRACEUTICALS central vite $0 (Tier 4) [*] complete premium vitamin $0 (Tier 4) [*] 65

67 spectravite performance $0 (Tier 4) [*] SMOKING DETERRENTS buproban $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) CHANTIX $0-$6.60 (Tier 2) PAR; MO; QLL (60 per 30 days) CHANTIX CONTINUING MONTH BOX $0-$6.60 (Tier 2) PAR; MO; QLL (56 per 28 days) CHANTIX STARTING MONTH BOX $0-$6.60 (Tier 2) PAR; MO; QLL (53 per 365 days) NICODERM CQ $0 (Tier 4) MO; [*]; QLL (30 per 30 days) nicorelief buccal gum $0 (Tier 4) MO; [*] NICORETTE BUCCAL GUM $0 (Tier 4) MO; [*] NICORETTE BUCCAL LOZENGE $0 (Tier 4) MO; [*]; QLL (20 per 1 day) nicotine (polacrilex) buccal gum $0 (Tier 4) MO; [*] nicotine (polacrilex) buccal lozenge $0 (Tier 4) MO; [*]; QLL (20 per 1 day) nicotine transdermal patch 24 hour 14 mg/24 hr, 21 mg/24 hr, 7 mg/24 hr $0 (Tier 4) MO; [*]; QLL (30 per 30 days) NICOTROL NS $0-$6.60 (Tier 2) MO; QLL (120 per 30 days) EAR, NOSE / THROAT MEDICATIONS MISCELLANEOUS AGENTS azelastine nasal $0-$6.60 (Tier 2) MO; QLL (30 per 25 days) chlorhexidine gluconate mucous membrane $0-$6.60 (Tier 2) MO deep sea nasal $0 (Tier 4) [*] ENTSOL NASAL GEL $0 (Tier 4) [*] ipratropium bromide nasal $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) nasal decongestant (oxymetazl) $0 (Tier 4) [*] nasal spray (oxymetazoline) $0 (Tier 4) [*] nasal spray 12 hour nasal spray,non-aerosol $0 (Tier 4) [*] nasal spray long acting $0 (Tier 4) [*] nose drops $0 (Tier 4) [*] nrs nasal relief $0 (Tier 4) [*] paroex oral rinse $0-$6.60 (Tier 2) MO periogard $0-$6.60 (Tier 2) MO 66

68 triamcinolone acetonide dental $0-$6.60 (Tier 2) MO TYZINE NASAL DROPS 0.05 % $0-$6.60 (Tier 2) MO MISCELLANEOUS OTIC PREPARATIONS acetic acid otic $0-$6.60 (Tier 2) MO acetic acid-aluminum acetate $0-$6.60 (Tier 2) MO ear drops (carbamide peroxide) $0 (Tier 4) [*] ear wax removal system otic drops $0 (Tier 4) [*] ear wax treatment $0 (Tier 4) [*] fluocinolone acetonide oil $0-$6.60 (Tier 2) MO hydrocortisone-acetic acid $0-$6.60 (Tier 2) MO ofloxacin otic $0-$6.60 (Tier 2) MO OTIC STEROID / ANTIBIOTIC CIPRODEX $0-$6.60 (Tier 2) MO COLY-MYCIN S $0-$6.60 (Tier 2) MO neomycin-polymyxin-hc otic $0-$6.60 (Tier 2) MO ENDOCRINE/DIABETES ADRENAL HORMONES ACTHAR H.P. $0-$6.60 (Tier 2) PAR; MO cortisone $0-$6.60 (Tier 2) MO dexamethasone $0-$6.60 (Tier 2) MO dexamethasone sodium phos (pf) $0-$6.60 (Tier 2) MO dexamethasone sodium phosphate injection $0-$6.60 (Tier 2) MO fludrocortisone $0-$6.60 (Tier 2) MO hydrocortisone oral $0-$6.60 (Tier 2) MO methylprednisolone acetate $0-$6.60 (Tier 2) MO methylprednisolone sodium succ injection recon soln 125 mg, 40 mg $0-$6.60 (Tier 2) MO methylprednisolone sodium succ intravenous $0-$6.60 (Tier 2) MO methylprednisolone tablets $0-$6.60 (Tier 2) MO prednisolone oral solution 15 mg/5 ml $0-$6.60 (Tier 2) MO 67

69 prednisolone sodium phosphate oral solution 15 mg/5 ml, 5 mg base/5 ml (6.7 mg/5 ml) prednisolone sodium phosphate oral tablet,disintegrating $0-$6.60 (Tier 2) MO $0-$6.60 (Tier 2) MO prednisone intensol $0-$6.60 (Tier 2) MO prednisone oral solution $0-$6.60 (Tier 2) MO prednisone oral tablet $0-$2.65 (Tier 1) MO prednisone oral tablets,dose pack $0-$2.65 (Tier 1) MO triamcinolone acetonide injection suspension 10 mg/ml triamcinolone acetonide injection suspension 40 mg/ml ANTITHYROID AGENTS $0-$6.60 (Tier 2) MO $0-$6.60 (Tier 2) IOSAT $0 (Tier 4) [*] methimazole oral tablet 10 mg, 5 mg $0-$6.60 (Tier 2) MO propylthiouracil $0-$6.60 (Tier 2) MO THYROSAFE $0 (Tier 4) [*] DIABETES THERAPY acarbose oral tablet 100 mg $0-$6.60 (Tier 2) MO; QLL (90 per 30 days) acarbose oral tablet 25 mg $0-$6.60 (Tier 2) MO; QLL (360 per 30 days) acarbose oral tablet 50 mg $0-$6.60 (Tier 2) MO; QLL (180 per 30 days) alcohol pads $0-$2.65 (Tier 1) BYDUREON $0-$6.60 (Tier 2) MO; QLL (4 per 28 days) BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (250 MCG/ML) 1.2 ML $0-$6.60 (Tier 2) MO; QLL (2.4 per 30 days) $0-$6.60 (Tier 2) MO; QLL (1.2 per 30 days) CYCLOSET $0-$6.60 (Tier 2) ST; MO; QLL (180 per 30 days) GAUZE PADS 2 X 2 $0-$2.65 (Tier 1) QLL (200 per 30 days) glimepiride oral tablet 1 mg $0-$2.65 (Tier 1) MO; QLL (240 per 30 days) glimepiride oral tablet 2 mg $0-$2.65 (Tier 1) MO; QLL (120 per 30 days) glimepiride oral tablet 4 mg $0-$2.65 (Tier 1) MO; QLL (60 per 30 days) 68

70 glipizide oral tablet 10 mg $0-$2.65 (Tier 1) MO; QLL (120 per 30 days) glipizide oral tablet 5 mg $0-$2.65 (Tier 1) MO; QLL (240 per 30 days) glipizide oral tablet extended release 24hr 10 mg $0-$2.65 (Tier 1) MO; QLL (60 per 30 days) glipizide oral tablet extended release 24hr 2.5 mg $0-$2.65 (Tier 1) MO; QLL (240 per 30 days) glipizide oral tablet extended release 24hr 5 mg $0-$2.65 (Tier 1) MO; QLL (120 per 30 days) glipizide-metformin oral tablet mg $0-$2.65 (Tier 1) MO; QLL (240 per 30 days) glipizide-metformin oral tablet mg, mg $0-$2.65 (Tier 1) MO; QLL (120 per 30 days) GLUCAGEN HYPOKIT $0-$6.60 (Tier 2) MO GLUCAGON EMERGENCY KIT (HUMAN) $0-$6.60 (Tier 2) MO HUMALOG KWIKPEN $0-$6.60 (Tier 2) MO HUMALOG MIX $0-$6.60 (Tier 2) MO HUMALOG MIX KWIKPEN $0-$6.60 (Tier 2) MO HUMALOG MIX $0-$6.60 (Tier 2) MO HUMALOG MIX KWIKPEN $0-$6.60 (Tier 2) MO HUMALOG SUBCUTANEOUS CARTRIDGE $0-$6.60 (Tier 2) MO HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML (PREFILLED SYRINGE) $0-$6.60 (Tier 2) MO $0-$6.60 (Tier 2) HUMULIN 70/30 $0-$6.60 (Tier 2) MO HUMULIN 70/30 KWIKPEN $0-$6.60 (Tier 2) MO HUMULIN N $0-$6.60 (Tier 2) MO HUMULIN N KWIKPEN $0-$6.60 (Tier 2) MO HUMULIN R $0-$6.60 (Tier 2) MO HUMULIN R U-500 "CONCENTRATED" $0-$6.60 (Tier 2) MO INSULIN PEN NEEDLE $0-$2.65 (Tier 1) MO; QLL (200 per 30 days) INSULIN SYRINGE (DISP) U ML $0-$2.65 (Tier 1) MO; QLL (200 per 30 days) INSULIN SYRINGE (DISP) U ML $0-$2.65 (Tier 1) QLL (200 per 30 days) INSULIN SYRINGE (DISP) U-100 1/2 ML $0-$2.65 (Tier 1) QLL (200 per 30 days) JANUMET $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) 69

71 JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-1,000 MG, MG $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) JANUVIA ORAL TABLET 100 MG $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) JANUVIA ORAL TABLET 25 MG $0-$6.60 (Tier 2) MO; QLL (120 per 30 days) JANUVIA ORAL TABLET 50 MG $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) JENTADUETO $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 24 HR 2.5-1,000 MG KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 24 HR 5-1,000 MG, MG $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) LANTUS $0-$6.60 (Tier 2) MO LANTUS SOLOSTAR $0-$6.60 (Tier 2) MO LEVEMIR $0-$6.60 (Tier 2) MO LEVEMIR FLEXTOUCH $0-$6.60 (Tier 2) MO metformin oral tablet 1,000 mg $0-$2.65 (Tier 1) MO; QLL (76 per 30 days) metformin oral tablet 500 mg $0-$2.65 (Tier 1) MO; QLL (153 per 30 days) metformin oral tablet 850 mg $0-$2.65 (Tier 1) MO; QLL (90 per 30 days) metformin oral tablet extended release 24 hr 500 mg metformin oral tablet extended release 24 hr 750 mg metformin oral tablet extended release 24hr 1,000 mg metformin oral tablet extended release 24hr 500 mg $0-$2.65 (Tier 1) MO; QLL (120 per 30 days) $0-$2.65 (Tier 1) MO; QLL (80 per 30 days) $0-$2.65 (Tier 1) MO; QLL (75 per 30 days) $0-$2.65 (Tier 1) MO; QLL (150 per 30 days) nateglinide oral tablet 120 mg $0-$6.60 (Tier 2) MO; QLL (90 per 30 days) nateglinide oral tablet 60 mg $0-$6.60 (Tier 2) MO; QLL (180 per 30 days) NEEDLES, INSULIN DISP.,SAFETY $0-$2.65 (Tier 1) QLL (200 per 30 days) ONGLYZA ORAL TABLET 2.5 MG $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) ONGLYZA ORAL TABLET 5 MG $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) 70

72 pioglitazone oral tablet 15 mg $0-$2.65 (Tier 1) MO; QLL (90 per 30 days) pioglitazone oral tablet 30 mg $0-$2.65 (Tier 1) MO; QLL (45 per 30 days) pioglitazone oral tablet 45 mg $0-$2.65 (Tier 1) MO; QLL (30 per 30 days) pioglitazone-glimepiride $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) pioglitazone-metformin $0-$6.60 (Tier 2) MO; QLL (90 per 30 days) PRANDIMET $0-$6.60 (Tier 2) MO; QLL (150 per 30 days) PROGLYCEM $0-$6.60 (Tier 2) MO SYMLINPEN 120 $0-$6.60 (Tier 2) PAR; MO; QLL (11 per 30 days) SYMLINPEN 60 $0-$6.60 (Tier 2) PAR; MO; QLL (6 per 30 days) TANZEUM $0-$6.60 (Tier 2) MO; QLL (4 per 28 days) tolazamide oral tablet 250 mg $0-$2.65 (Tier 1) MO; QLL (120 per 30 days) tolazamide oral tablet 500 mg $0-$2.65 (Tier 1) MO; QLL (60 per 30 days) tolbutamide $0-$2.65 (Tier 1) MO; QLL (180 per 30 days) TOUJEO SOLOSTAR $0-$6.60 (Tier 2) MO TRADJENTA $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) TRULICITY $0-$6.60 (Tier 2) MO; QLL (2 per 28 days) VICTOZA 2-PAK $0-$6.60 (Tier 2) MO; QLL (9 per 30 days) VICTOZA 3-PAK $0-$6.60 (Tier 2) MO; QLL (9 per 30 days) MISCELLANEOUS HORMONES ALDURAZYME $0-$6.60 (Tier 2) PAR; MO ANDRODERM $0-$6.60 (Tier 2) PAR; MO; QLL (30 per 30 days) ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 1.25 GRAM/ ACTUATION (1 %) ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP MG/1.25 GRAM (1.62 %) ANDROGEL TRANSDERMAL GEL IN PACKET 1 % (25 MG/2.5GRAM), 1 % (50 MG/5 GRAM) ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM) $0-$6.60 (Tier 2) PAR; MO; QLL (300 per 30 days) $0-$6.60 (Tier 2) PAR; MO; QLL (150 per 30 days) $0-$6.60 (Tier 2) PAR; MO; QLL (300 per 30 days) $0-$6.60 (Tier 2) PAR; MO; QLL (30 per 30 days) 71

73 ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (40.5 MG/2.5 GRAM) $0-$6.60 (Tier 2) PAR; MO; QLL (60 per 30 days) androxy $0-$6.60 (Tier 2) PAR; MO cabergoline $0-$6.60 (Tier 2) MO calcitonin (salmon) $0-$6.60 (Tier 2) MO; QLL (4 per 30 days) calcitriol intravenous solution 1 mcg/ml $0-$6.60 (Tier 2) B/D PAR; MO calcitriol oral $0-$6.60 (Tier 2) B/D PAR; MO CEREZYME INTRAVENOUS RECON SOLN 400 UNIT $0-$6.60 (Tier 2) PAR; MO danazol oral $0-$6.60 (Tier 2) MO desmopressin injection $0-$6.60 (Tier 2) MO desmopressin nasal $0-$6.60 (Tier 2) MO desmopressin oral $0-$6.60 (Tier 2) MO doxercalciferol intravenous $0-$6.60 (Tier 2) B/D PAR doxercalciferol oral $0-$6.60 (Tier 2) B/D PAR; MO ELAPRASE $0-$6.60 (Tier 2) PAR; MO FABRAZYME $0-$6.60 (Tier 2) PAR; MO HECTOROL INTRAVENOUS SOLUTION 2 MCG/ML (1 ML) HECTOROL INTRAVENOUS SOLUTION 4 MCG/2 ML $0-$6.60 (Tier 2) PAR $0-$6.60 (Tier 2) PAR; MO HECTOROL ORAL $0-$6.60 (Tier 2) PAR; MO KUVAN ORAL TABLET,SOLUBLE $0-$6.60 (Tier 2) PAR; MO MYOZYME $0-$6.60 (Tier 2) PAR; MO NAGLAZYME $0-$6.60 (Tier 2) PAR; MO; LA oxandrolone oral tablet 10 mg $0-$6.60 (Tier 2) PAR; MO; QLL (60 per 30 days) oxandrolone oral tablet 2.5 mg $0-$6.60 (Tier 2) PAR; MO; QLL (120 per 30 days) pamidronate $0-$6.60 (Tier 2) B/D PAR; MO paricalcitol oral $0-$6.60 (Tier 2) B/D PAR; MO SENSIPAR ORAL TABLET 30 MG, 60 MG $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) SENSIPAR ORAL TABLET 90 MG $0-$6.60 (Tier 2) MO; QLL (120 per 30 days) 72

74 SOMAVERT $0-$6.60 (Tier 2) PAR; MO; LA STIMATE $0-$6.60 (Tier 2) MO SYNAREL $0-$6.60 (Tier 2) PAR; MO TESTIM $0-$6.60 (Tier 2) PAR; MO; QLL (300 per 30 days) testosterone cypionate $0-$6.60 (Tier 2) MO testosterone enanthate $0-$6.60 (Tier 2) MO ZAVESCA $0-$6.60 (Tier 2) PAR; MO; LA ZEMPLAR INTRAVENOUS $0-$6.60 (Tier 2) B/D PAR; MO zoledronic acid intravenous recon soln $0-$6.60 (Tier 2) PAR zoledronic acid intravenous solution $0-$6.60 (Tier 2) PAR; MO ZOMETA INTRAVENOUS SOLUTION 4 MG/100 ML THYROID HORMONES $0-$6.60 (Tier 2) PAR; MO levothyroxine oral $0-$6.60 (Tier 2) MO levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg $0-$6.60 (Tier 2) MO liothyronine oral $0-$6.60 (Tier 2) MO SYNTHROID $0-$6.60 (Tier 2) MO unithroid oral tablet 100 mcg, 112 mcg, 125 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg GASTROENTEROLOGY ANTIDIARRHEALS / ANTISPASMODICS $0-$6.60 (Tier 2) MO anti-diarrheal (loperamide) oral tablet $0 (Tier 4) MO; [*] atropine injection syringe 0.05 mg/ml, 0.1 mg/ml $0-$6.60 (Tier 2) bismatrol oral suspension 262 mg/15 ml $0 (Tier 4) MO; [*] bismatrol oral suspension 525 mg/15 ml $0 (Tier 4) [*] bismatrol oral tablet,chewable $0 (Tier 4) [*] dicyclomine oral capsule $0-$6.60 (Tier 2) MO dicyclomine oral solution $0-$6.60 (Tier 2) MO 73

75 dicyclomine oral tablet $0-$6.60 (Tier 2) MO diphenoxylate-atropine $0-$6.60 (Tier 2) MO glycopyrrolate oral $0-$6.60 (Tier 2) MO kao-tin (bismuth subsalicylat) $0 (Tier 4) [*] loperamide oral capsule $0-$6.60 (Tier 2) MO loperamide oral liquid 1 mg/5 ml $0 (Tier 4) MO; [*] loperamide oral liquid 1 mg/7.5 ml $0 (Tier 4) [*] medi-bismuth $0 (Tier 4) [*] opium tincture oral tincture $0-$6.60 (Tier 2) MO peptic relief oral tablet,chewable $0 (Tier 4) [*] pink bismuth maximum strength $0 (Tier 4) [*] pink bismuth oral suspension 262 mg/15 ml $0 (Tier 4) [*] pink bismuth oral tablet,chewable $0 (Tier 4) MO; [*] stomach relief max strength $0 (Tier 4) [*] stomach relief oral suspension 262 mg/15 ml $0 (Tier 4) [*] stomach relief oral tablet,chewable $0 (Tier 4) [*] MISCELLANEOUS GASTROINTESTINAL AGENTS acid gone antacid $0 (Tier 4) [*] actidose/sorbitol oral suspension 50 gram/240 ml $0 (Tier 4) [*] almacone oral suspension $0 (Tier 4) [*] almacone-2 $0 (Tier 4) [*] alosetron $0-$6.60 (Tier 2) PAR; MO; QLL (60 per 30 days) aluminum hydroxide gel oral suspension 320 mg/5 ml $0 (Tier 4) MO; [*] AMITIZA $0-$6.60 (Tier 2) MO antacid anti-gas oral suspension $0 (Tier 4) [*] antacid extra-strength oral suspension mg/5 ml $0 (Tier 4) [*] antacid oral suspension $0 (Tier 4) [*] antacid plus anti-gas oral suspension mg/5 ml $0 (Tier 4) [*] 74

76 antacid tablet $0 (Tier 4) [*] antacid with simethicone oral suspension $0 (Tier 4) [*] antacid-simethicone ds $0 (Tier 4) [*] anti-nausea liquid $0 (Tier 4) [*] anu-med $0 (Tier 4) MO; [*] APRISO $0-$6.60 (Tier 2) MO ASACOL HD $0-$6.60 (Tier 2) MO balsalazide $0-$6.60 (Tier 2) MO bisac-evac $0 (Tier 4) MO; [*] bisacodyl oral $0 (Tier 4) MO; [*] bisacodyl rectal $0 (Tier 4) MO; [*] biscolax $0 (Tier 4) MO; [*] budesonide oral $0-$6.60 (Tier 2) MO CANASA $0-$6.60 (Tier 2) MO CIMZIA $0-$6.60 (Tier 2) PAR; MO; QLL (6 per 28 days) CIMZIA POWDER FOR RECONST $0-$6.60 (Tier 2) PAR; MO; QLL (6 per 28 days) CIMZIA STARTER KIT $0-$6.60 (Tier 2) PAR; MO; QLL (6 per 28 days) COLACE ORAL CAPSULE 100 MG $0 (Tier 4) MO; [*] colocort $0-$6.60 (Tier 2) MO compro $0-$6.60 (Tier 2) PAR; MO constulose $0-$6.60 (Tier 2) MO CREON $0-$6.60 (Tier 2) MO CYSTADANE $0-$6.60 (Tier 2) MO DELZICOL $0-$6.60 (Tier 2) MO dimenhydrinate oral $0 (Tier 4) MO; [*] diocto oral liquid $0 (Tier 4) [*] diocto oral syrup $0 (Tier 4) MO; [*] DIPENTUM $0-$6.60 (Tier 2) MO doc-q-lace oral capsule $0 (Tier 4) MO; [*] doc-q-lax $0 (Tier 4) MO; [*] 75

77 docu $0 (Tier 4) MO; [*] docusate calcium $0 (Tier 4) MO; [*] docusate sodium oral capsule $0 (Tier 4) MO; [*] DOCUSOL $0 (Tier 4) [*] DOCUSOL KIDS $0 (Tier 4) [*] DOCUSOL PLUS $0 (Tier 4) [*] dok oral capsule 100 mg $0 (Tier 4) MO; [*] dok oral capsule 250 mg $0 (Tier 4) [*] dok oral tablet $0 (Tier 4) MO; [*] dok plus $0 (Tier 4) [*] dronabinol $0-$6.60 (Tier 2) B/D PAR; MO; QLL (120 per 30 days) EMEND ORAL CAPSULE 125 MG $0-$6.60 (Tier 2) B/D PAR; MO; QLL (4 per 30 days) EMEND ORAL CAPSULE 40 MG $0-$6.60 (Tier 2) B/D PAR; MO; QLL (1 per 1 day) EMEND ORAL CAPSULE 80 MG $0-$6.60 (Tier 2) B/D PAR; MO; QLL (8 per 30 days) EMEND ORAL CAPSULE,DOSE PACK $0-$6.60 (Tier 2) B/D PAR; MO; QLL (12 per 30 days) enema rectal enema 19-7 gram/118 ml $0 (Tier 4) [*] ENEMEEZ $0 (Tier 4) MO; [*] ENEMEEZ PLUS $0 (Tier 4) MO; [*] enulose $0-$6.60 (Tier 2) MO fiber (calcium polycarbophil) $0 (Tier 4) MO; [*] fiber laxative (ca polycarbo) $0 (Tier 4) [*] fiber laxative (psyllium husk) $0 (Tier 4) [*] fiber oral powder $0 (Tier 4) [*] fiber smooth $0 (Tier 4) [*] fiber smooth (sucrose) $0 (Tier 4) [*] fiber-lax $0 (Tier 4) MO; [*] FLEET PEDIATRIC $0 (Tier 4) MO; [*] formula em solution $0 (Tier 4) [*] gas relief oral capsule $0 (Tier 4) [*] 76

78 gas relief oral tablet,chewable $0 (Tier 4) MO; [*] gavilyte-c $0-$6.60 (Tier 2) MO gavilyte-g $0-$6.60 (Tier 2) MO gavilyte-n $0-$6.60 (Tier 2) MO generlac $0-$6.60 (Tier 2) MO gentle laxative oral $0 (Tier 4) [*] hemorrhoidal rectal ointment $0 (Tier 4) MO; [*] hydrocortisone rectal enema $0-$6.60 (Tier 2) MO infants gas relief $0 (Tier 4) [*] kao-tin (docusate calcium) $0 (Tier 4) [*] konsyl (sugar) oral powder 3.4 gram/12 gram $0 (Tier 4) MO; [*] konsyl sugar-free oral powder $0 (Tier 4) MO; [*] lactulose $0-$6.60 (Tier 2) MO laxative maximum strength $0 (Tier 4) [*] laxative-senna $0 (Tier 4) [*] LIALDA $0-$6.60 (Tier 2) MO LINZESS $0-$6.60 (Tier 2) MO liquid antacid oral suspension mg/5 ml $0 (Tier 4) [*] LOTRONEX $0-$6.60 (Tier 2) PAR; MO; QLL (60 per 30 days) magnesium oral tablet 250 mg $0 (Tier 4) [*] MAGTAB $0 (Tier 4) MO; [*] MAJOR-PREP HEMORRHOIDAL RECTAL OINTMENT % $0 (Tier 4) [*] masanti double strength $0 (Tier 4) [*] meclizine oral tablet 12.5 mg, 25 mg $0-$6.60 (Tier 2) MO meclizine oral tablet,chewable $0 (Tier 4) MO; [*] medi-natural $0 (Tier 4) [*] mesalamine rectal $0-$6.60 (Tier 2) MO mesalamine with cleansing wipe $0-$6.60 (Tier 2) MO 77

79 metoclopramide hcl injection solution $0-$6.60 (Tier 2) MO metoclopramide hcl injection syringe $0-$6.60 (Tier 2) metoclopramide hcl oral solution $0-$6.60 (Tier 2) MO metoclopramide hcl oral tablet $0-$6.60 (Tier 2) MO mi-acid gas relief $0 (Tier 4) [*] mi-acid oral suspension $0 (Tier 4) MO; [*] milk of magnesia $0 (Tier 4) MO; [*] milk of magnesia concentrated $0 (Tier 4) MO; [*] mineral oil laxative $0 (Tier 4) MO; [*] mintox maximum strength $0 (Tier 4) MO; [*] mytab gas $0 (Tier 4) [*] mytab gas maximum strength $0 (Tier 4) [*] natural fiber laxative oral powder 3.4 gram/7 gram $0 (Tier 4) [*] natural fiber laxative therapy $0 (Tier 4) [*] ondansetron hcl (pf) injection solution $0-$6.60 (Tier 2) MO ondansetron hcl (pf) injection syringe $0-$6.60 (Tier 2) ondansetron hcl intravenous solution $0-$6.60 (Tier 2) MO ondansetron hcl oral solution $0-$6.60 (Tier 2) B/D PAR; MO; QLL (450 per 30 days) ondansetron hcl oral tablet 24 mg $0-$6.60 (Tier 2) B/D PAR; QLL (30 per 30 days) ondansetron hcl oral tablet 4 mg, 8 mg $0-$6.60 (Tier 2) B/D PAR; MO; QLL (90 per 30 days) ondansetron odt $0-$6.60 (Tier 2) B/D PAR; MO; QLL (90 per 30 days) peg 3350-electrolytes oral recon soln gram peg 3350-electrolytes oral recon soln gram $0-$6.60 (Tier 2) MO $0-$6.60 (Tier 2) peg3350 $0 (Tier 4) [*] peg-3350 with flavor packs $0-$6.60 (Tier 2) peg-electrolyte soln $0-$6.60 (Tier 2) PENTASA $0-$6.60 (Tier 2) MO 78

80 polyethylene glycol 3350 oral $0-$6.60 (Tier 2) MO prochlorperazine edisylate $0-$6.60 (Tier 2) PAR; MO prochlorperazine maleate oral $0-$6.60 (Tier 2) PAR; MO prochlorperazine maleate rectal $0-$6.60 (Tier 2) PAR; MO procto-pak $0-$6.60 (Tier 2) MO proctosol hc $0-$6.60 (Tier 2) MO proctozone-hc $0-$6.60 (Tier 2) MO reguloid oral capsule $0 (Tier 4) [*] RELISTOR SUBCUTANEOUS SOLUTION $0-$6.60 (Tier 2) PAR; MO RELISTOR SUBCUTANEOUS SYRINGE $0-$6.60 (Tier 2) PAR; MO REMICADE $0-$6.60 (Tier 2) PAR; MO RULOX $0 (Tier 4) [*] sani-supp (adult) $0 (Tier 4) MO; [*] sani-supp (infant) $0 (Tier 4) MO; [*] senexon $0 (Tier 4) MO; [*] senna lax $0 (Tier 4) MO; [*] senna oral syrup 8.8 mg/5 ml $0 (Tier 4) MO; [*] senna oral tablet $0 (Tier 4) [*] senna plus $0 (Tier 4) MO; [*] senna with docusate sodium $0 (Tier 4) [*] senna-gen $0 (Tier 4) MO; [*] SENNALAX-S $0 (Tier 4) MO; [*] senna-s $0 (Tier 4) MO; [*] silace oral liquid $0 (Tier 4) MO; [*] silace oral syrup $0 (Tier 4) [*] simethicone oral capsule 180 mg $0 (Tier 4) [*] simethicone oral drops,suspension $0 (Tier 4) MO; [*] simethicone oral tablet,chewable 125 mg $0 (Tier 4) [*] sodium bicarbonate oral tablet 650 mg $0 (Tier 4) MO; [*] stool softener oral capsule 100 mg $0 (Tier 4) [*] 79

81 stool softener-laxative $0 (Tier 4) [*] sulfasalazine $0-$6.60 (Tier 2) MO sulfazine $0-$6.60 (Tier 2) MO sulfazine ec $0-$6.60 (Tier 2) MO travel sickness $0 (Tier 4) [*] travel sickness (meclizine) $0 (Tier 4) MO; [*] ursodiol $0-$6.60 (Tier 2) MO ULCER THERAPY acid reducer (famotidine) oral tablet 20 mg $0 (Tier 4) [*] DEXILANT $0-$6.60 (Tier 2) ST; MO; QLL (30 per 30 days) famotidine (pf) $0-$6.60 (Tier 2) MO famotidine (pf)-nacl (iso-os) $0-$6.60 (Tier 2) famotidine intravenous $0-$6.60 (Tier 2) MO famotidine oral suspension $0-$6.60 (Tier 2) MO famotidine oral tablet 10 mg $0 (Tier 4) MO; [*] famotidine oral tablet 20 mg, 40 mg $0-$6.60 (Tier 2) MO heartburn relief 24 hour (lansoprazole) oral capsule,delayed release(dr/ec) 15 mg $0 (Tier 4) [*]; QLL (30 per 30 days) lansoprazole oral capsule,delayed release(dr/ec) $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) misoprostol $0-$6.60 (Tier 2) MO omeprazole oral capsule,delayed release(dr/ec) $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) omeprazole oral tablet,delayed release (dr/ec) $0 (Tier 4) MO; [*] pantoprazole oral $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) PRILOSEC OTC $0 (Tier 4) MO; [*] ranitidine hcl injection $0-$6.60 (Tier 2) MO ranitidine hcl oral syrup $0-$6.60 (Tier 2) MO ranitidine hcl oral tablet 150 mg, 300 mg $0-$6.60 (Tier 2) MO ranitidine hcl oral tablet 75 mg $0 (Tier 4) MO; [*] sucralfate oral tablet $0-$6.60 (Tier 2) MO ZEGERID OTC $0 (Tier 4) MO; [*] 80

82 IMMUNOLOGY, VACCINES / BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ACTIMMUNE $0-$6.60 (Tier 2) PAR; MO ARANESP (IN POLYSORBATE) $0-$6.60 (Tier 2) PAR; MO ARCALYST $0-$6.60 (Tier 2) PAR; MO AVONEX (WITH ALBUMIN) $0-$6.60 (Tier 2) PAR; MO; QLL (4 per 28 days) AVONEX INTRAMUSCULAR PEN INJECTOR KIT $0-$6.60 (Tier 2) PAR; MO; QLL (4 per 28 days) AVONEX INTRAMUSCULAR SYRINGE $0-$6.60 (Tier 2) PAR; MO; QLL (4 per 28 days) AVONEX INTRAMUSCULAR SYRINGE KIT $0-$6.60 (Tier 2) PAR; MO; QLL (4 per 28 days) EXTAVIA SUBCUTANEOUS KIT $0-$6.60 (Tier 2) PAR; MO EXTAVIA SUBCUTANEOUS RECON SOLN $0-$6.60 (Tier 2) PAR GENOTROPIN $0-$6.60 (Tier 2) PAR; MO GENOTROPIN MINIQUICK $0-$6.60 (Tier 2) PAR; MO HUMATROPE INJECTION CARTRIDGE 12 MG (36 UNIT), 24 MG (72 UNIT) $0-$6.60 (Tier 2) PAR; MO ILARIS (PF) $0-$6.60 (Tier 2) PAR; MO; LA INTRON A INJECTION $0-$6.60 (Tier 2) PAR; MO LEUKINE INJECTION RECON SOLN $0-$6.60 (Tier 2) PAR; MO MOZOBIL $0-$6.60 (Tier 2) PAR; MO NEULASTA SUBCUTANEOUS SYRINGE $0-$6.60 (Tier 2) PAR; MO; QLL (2 per 28 days) NEUMEGA $0-$6.60 (Tier 2) PAR; MO; QLL (21 per 21 days) NEUPOGEN $0-$6.60 (Tier 2) PAR; MO NORDITROPIN FLEXPRO $0-$6.60 (Tier 2) PAR; MO NORDITROPIN NORDIFLEX $0-$6.60 (Tier 2) PAR; MO PEGASYS $0-$6.60 (Tier 2) PAR; MO PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 180 MCG/0.5 ML $0-$6.60 (Tier 2) PAR; MO PEGINTRON $0-$6.60 (Tier 2) PAR; MO PEGINTRON REDIPEN $0-$6.60 (Tier 2) PAR; MO PROCRIT $0-$6.60 (Tier 2) PAR; MO; QLL (12 per 28 days) 81

83 PROLEUKIN $0-$6.60 (Tier 2) B/D PAR; MO REBIF (WITH ALBUMIN) $0-$6.60 (Tier 2) PAR; MO REBIF REBIDOSE $0-$6.60 (Tier 2) PAR; MO REBIF TITRATION PACK $0-$6.60 (Tier 2) PAR; MO SYLATRON $0-$6.60 (Tier 2) PAR; MO VACCINES / MISCELLANEOUS IMMUNOLOGICALS ACTHIB (PF) $0-$2.65 (Tier 1) MO ADACEL(TDAP ADOLESN/ADULT)(PF) $0-$2.65 (Tier 1) MO ATGAM $0-$6.60 (Tier 2) B/D PAR BCG VACCINE, LIVE (PF) $0-$6.60 (Tier 2) BEXSERO (PF) $0-$6.60 (Tier 2) BOOSTRIX TDAP $0-$2.65 (Tier 1) MO CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN 12 GRAM, 6 GRAM $0-$6.60 (Tier 2) PAR; MO CERVARIX VACCINE (PF) $0-$2.65 (Tier 1) MO COMVAX (PF) $0-$2.65 (Tier 1) MO DAPTACEL (DTAP PEDIATRIC) (PF) $0-$2.65 (Tier 1) MO ENGERIX-B (PF) $0-$2.65 (Tier 1) B/D PAR; MO ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SUSPENSION ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE $0-$2.65 (Tier 1) B/D PAR; MO $0-$2.65 (Tier 1) B/D PAR GAMASTAN S/D $0-$6.60 (Tier 2) PAR; MO GAMMAGARD LIQUID $0-$6.60 (Tier 2) PAR; MO GAMMAGARD S-D (IGA < 1 MCG/ML) $0-$6.60 (Tier 2) PAR; MO GAMMAPLEX $0-$6.60 (Tier 2) PAR; MO GAMUNEX-C $0-$6.60 (Tier 2) PAR; MO GARDASIL (PF) $0-$6.60 (Tier 2) MO GARDASIL 9 (PF) $0-$6.60 (Tier 2) MO 82

84 HAVRIX (PF) INTRAMUSCULAR SUSPENSION HAVRIX (PF) INTRAMUSCULAR SYRINGE 1,440 ELISA UNIT/ML HAVRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT/0.5 ML $0-$2.65 (Tier 1) MO $0-$2.65 (Tier 1) MO $0-$2.65 (Tier 1) IMOVAX RABIES VACCINE (PF) $0-$6.60 (Tier 2) MO INFANRIX (DTAP) (PF) $0-$6.60 (Tier 2) MO IPOL $0-$2.65 (Tier 1) MO IXIARO (PF) $0-$6.60 (Tier 2) MO MENACTRA (PF) INTRAMUSCULAR SOLUTION $0-$6.60 (Tier 2) MO MENOMUNE - A/C/Y/W-135 $0-$6.60 (Tier 2) MENOMUNE - A/C/Y/W-135 (PF) $0-$6.60 (Tier 2) MO MENVEO A-C-Y-W-135-DIP (PF) $0-$6.60 (Tier 2) MO M-M-R II (PF) $0-$2.65 (Tier 1) MO PEDVAX HIB (PF) $0-$2.65 (Tier 1) MO PROQUAD (PF) $0-$6.60 (Tier 2) QUADRACEL (PF) $0-$6.60 (Tier 2) RABAVERT (PF) $0-$6.60 (Tier 2) MO RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCG/ML RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 5 MCG/0.5 ML $0-$2.65 (Tier 1) B/D PAR; MO $0-$2.65 (Tier 1) B/D PAR; MO $0-$2.65 (Tier 1) B/D PAR ROTARIX $0-$6.60 (Tier 2) ROTATEQ VACCINE $0-$2.65 (Tier 1) MO tetanus toxoid,adsorbed (pf) $0-$2.65 (Tier 1) MO TETANUS,DIPHTHERIA TOX PED(PF) $0-$6.60 (Tier 2) MO TETANUS-DIPHTHERIA TOXOIDS-TD $0-$2.65 (Tier 1) MO THYMOGLOBULIN $0-$6.60 (Tier 2) B/D PAR 83

85 TICE BCG $0-$6.60 (Tier 2) MO TRUMENBA $0-$6.60 (Tier 2) TWINRIX (PF) $0-$2.65 (Tier 1) MO TYPHIM VI INTRAMUSCULAR SOLUTION $0-$6.60 (Tier 2) TYPHIM VI INTRAMUSCULAR SYRINGE $0-$6.60 (Tier 2) MO VAQTA (PF) INTRAMUSCULAR SUSPENSION $0-$6.60 (Tier 2) MO VAQTA (PF) INTRAMUSCULAR SYRINGE $0-$6.60 (Tier 2) VARIVAX (PF) $0-$6.60 (Tier 2) MO VARIZIG INTRAMUSCULAR RECON SOLN $0-$6.60 (Tier 2) MO VARIZIG INTRAMUSCULAR SOLUTION $0-$6.60 (Tier 2) YF-VAX (PF) $0-$6.60 (Tier 2) MO ZOSTAVAX (PF) $0-$6.60 (Tier 2) MO MUSCULOSKELETAL / RHEUMATOLOGY GOUT THERAPY allopurinol $0-$2.65 (Tier 1) MO colchicine-probenecid $0-$6.60 (Tier 2) MO COLCRYS $0-$6.60 (Tier 2) MO probenecid $0-$6.60 (Tier 2) MO ULORIC $0-$6.60 (Tier 2) ST; MO OSTEOPOROSIS THERAPY alendronate oral solution $0-$6.60 (Tier 2) MO; QLL (300 per 28 days) alendronate oral tablet 10 mg, 5 mg $0-$2.65 (Tier 1) MO; QLL (30 per 30 days) alendronate oral tablet 35 mg, 70 mg $0-$2.65 (Tier 1) MO; QLL (4 per 28 days) BONIVA INTRAVENOUS $0-$6.60 (Tier 2) B/D PAR; MO EVISTA $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) FORTEO $0-$6.60 (Tier 2) PAR; MO; QLL (3 per 28 days) ibandronate intravenous solution $0-$6.60 (Tier 2) B/D PAR; MO ibandronate intravenous syringe $0-$6.60 (Tier 2) MO ibandronate oral $0-$6.60 (Tier 2) MO; QLL (1 per 28 days) 84

86 PROLIA $0-$6.60 (Tier 2) PAR; MO; QLL (2 per 365 days) raloxifene $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) OTHER RHEUMATOLOGICALS ACTEMRA INTRAVENOUS $0-$6.60 (Tier 2) PAR; MO DEPEN TITRATABS $0-$6.60 (Tier 2) MO ENBREL SUBCUTANEOUS RECON SOLN $0-$6.60 (Tier 2) PAR; MO; QLL (8 per 28 days) ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5ML (0.51) ENBREL SUBCUTANEOUS SYRINGE 50 MG/ML (0.98 ML) $0-$6.60 (Tier 2) PAR; MO; QLL (4.08 per 28 days) $0-$6.60 (Tier 2) PAR; MO; QLL (8 per 28 days) ENBREL SURECLICK $0-$6.60 (Tier 2) PAR; MO; QLL (8 per 28 days) HUMIRA CROHN'S DIS START PCK $0-$6.60 (Tier 2) PAR; MO; QLL (4.8 per 365 days) HUMIRA PED CROHN'S STARTER PK $0-$6.60 (Tier 2) PAR; MO; QLL (4.8 per 365 days) HUMIRA PEN $0-$6.60 (Tier 2) PAR; MO; QLL (3.2 per 28 days) HUMIRA PSORIASIS STARTER PACK $0-$6.60 (Tier 2) PAR; MO; QLL (3.2 per 28 days) HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, 20 MG/0.4 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML $0-$6.60 (Tier 2) PAR; MO; QLL (2 per 28 days) $0-$6.60 (Tier 2) PAR; MO; QLL (3.2 per 28 days) KINERET $0-$6.60 (Tier 2) PAR; MO; QLL (28 per 28 days) leflunomide $0-$6.60 (Tier 2) MO RIDAURA $0-$6.60 (Tier 2) MO SAVELLA ORAL TABLET 100 MG $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) SAVELLA ORAL TABLET 12.5 MG $0-$6.60 (Tier 2) MO; QLL (480 per 30 days) SAVELLA ORAL TABLET 25 MG $0-$6.60 (Tier 2) MO; QLL (240 per 30 days) SAVELLA ORAL TABLET 50 MG $0-$6.60 (Tier 2) MO; QLL (120 per 30 days) SAVELLA ORAL TABLETS,DOSE PACK $0-$6.60 (Tier 2) MO; QLL (1 per 365 days) SIMPONI $0-$6.60 (Tier 2) PAR; MO; QLL (1 per 28 days) OBSTETRICS / GYNECOLOGY ESTROGENS / PROGESTINS camila $0-$6.60 (Tier 2) MO 85

87 DEPO-PROVERA INTRAMUSCULAR SOLUTION 400 MG/ML $0-$6.60 (Tier 2) MO errin $0-$6.60 (Tier 2) MO ESTRACE VAGINAL $0-$6.60 (Tier 2) MO estradiol oral $0-$6.60 (Tier 2) PAR; MO estradiol transdermal patch weekly $0-$6.60 (Tier 2) PAR; MO; QLL (4 per 28 days) ESTRING $0-$6.60 (Tier 2) MO; QLL (1 per 90 days) lyza $0-$6.60 (Tier 2) MO medroxyprogesterone $0-$6.60 (Tier 2) MO MENEST $0-$6.60 (Tier 2) PAR; MO nora-be $0-$6.60 (Tier 2) MO norethindrone (contraceptive) $0-$6.60 (Tier 2) MO norethindrone acetate $0-$6.60 (Tier 2) MO PREMARIN ORAL $0-$6.60 (Tier 2) MO PREMARIN VAGINAL $0-$6.60 (Tier 2) MO progesterone micronized $0-$6.60 (Tier 2) ST; MO VAGIFEM $0-$6.60 (Tier 2) MO MISCELLANEOUS OB/GYN clindamycin phosphate vaginal $0-$6.60 (Tier 2) MO clotrimazole vaginal cream $0 (Tier 4) MO; [*] metronidazole vaginal $0-$6.60 (Tier 2) MO miconazole 7 $0 (Tier 4) MO; [*] miconazole nitrate vaginal cream $0 (Tier 4) MO; [*] miconazole nitrate vaginal suppository $0 (Tier 4) [*] miconazole-3 vaginal suppository $0-$6.60 (Tier 2) MO; QLL (6 per 30 days) NUVARING $0-$6.60 (Tier 2) MO ORTHO EVRA $0-$6.60 (Tier 2) MO terconazole $0-$6.60 (Tier 2) MO tioconazole-1 $0 (Tier 4) [*] tranexamic acid oral $0-$6.60 (Tier 2) MO 86

88 XULANE $0-$6.60 (Tier 2) MO zazole vaginal cream 0.4 % $0-$6.60 (Tier 2) ORAL CONTRACEPTIVES / RELATED AGENTS altavera (28) $0-$6.60 (Tier 2) MO alyacen 1/35 (28) $0-$6.60 (Tier 2) MO alyacen 7/7/7 (28) $0-$6.60 (Tier 2) MO apri $0-$6.60 (Tier 2) MO aranelle (28) $0-$6.60 (Tier 2) MO aviane $0-$6.60 (Tier 2) MO azurette (28) $0-$6.60 (Tier 2) MO caziant (28) $0-$6.60 (Tier 2) MO cryselle (28) $0-$6.60 (Tier 2) MO drospirenone-ethinyl estradiol $0-$6.60 (Tier 2) MO econtra ez $0 (Tier 4) [*] elinest $0-$6.60 (Tier 2) MO ELLA $0-$6.60 (Tier 2) MO enpresse $0-$6.60 (Tier 2) MO fallback solo $0 (Tier 4) [*] falmina (28) $0-$6.60 (Tier 2) MO gildagia $0-$6.60 (Tier 2) MO gildess fe $0-$6.60 (Tier 2) MO junel 1.5/30 (21) $0-$6.60 (Tier 2) MO junel 1/20 (21) $0-$6.60 (Tier 2) MO junel fe 1.5/30 (28) $0-$6.60 (Tier 2) MO junel fe 1/20 (28) $0-$6.60 (Tier 2) MO kariva (28) $0-$6.60 (Tier 2) MO kelnor 1/35 (28) $0-$6.60 (Tier 2) MO lessina $0-$6.60 (Tier 2) MO levonest (28) $0-$6.60 (Tier 2) MO 87

89 levonorgestrel-ethinyl estrad oral tablet mg levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month $0-$6.60 (Tier 2) MO $0-$6.60 (Tier 2) MO low-ogestrel (28) $0-$6.60 (Tier 2) MO lutera (28) $0-$6.60 (Tier 2) MO marlissa $0-$6.60 (Tier 2) MO microgestin 1.5/30 (21) $0-$6.60 (Tier 2) MO microgestin 1/20 (21) $0-$6.60 (Tier 2) MO microgestin fe 1.5/30 (28) $0-$6.60 (Tier 2) MO microgestin fe 1/20 (28) $0-$6.60 (Tier 2) MO mono-linyah $0-$6.60 (Tier 2) MO mononessa (28) $0-$6.60 (Tier 2) MO my way $0 (Tier 4) [*] myzilra $0-$6.60 (Tier 2) MO necon 0.5/35 (28) $0-$6.60 (Tier 2) MO necon 1/35 (28) $0-$6.60 (Tier 2) MO necon 1/50 (28) $0-$6.60 (Tier 2) MO necon 10/11 (28) $0-$6.60 (Tier 2) MO necon 7/7/7 (28) $0-$6.60 (Tier 2) MO next choice one dose $0 (Tier 4) [*] norgestimate-ethinyl estradiol $0-$6.60 (Tier 2) MO nortrel 0.5/35 (28) $0-$6.60 (Tier 2) MO nortrel 1/35 (21) $0-$6.60 (Tier 2) MO nortrel 1/35 (28) $0-$6.60 (Tier 2) MO nortrel 7/7/7 (28) $0-$6.60 (Tier 2) MO ocella $0-$6.60 (Tier 2) MO ogestrel (28) $0-$6.60 (Tier 2) MO opcicon one-step $0 (Tier 4) [*] PLAN B ONE-STEP $0 (Tier 4) MO; [*] 88

90 portia $0-$6.60 (Tier 2) MO previfem $0-$6.60 (Tier 2) MO reclipsen (28) $0-$6.60 (Tier 2) MO sprintec (28) $0-$6.60 (Tier 2) MO syeda $0-$6.60 (Tier 2) MO tri-previfem (28) $0-$6.60 (Tier 2) MO tri-sprintec (28) $0-$6.60 (Tier 2) MO trivora (28) $0-$6.60 (Tier 2) MO velivet triphasic regimen (28) $0-$6.60 (Tier 2) MO viorele (28) $0-$6.60 (Tier 2) MO zarah $0-$6.60 (Tier 2) MO zenchent (28) $0-$6.60 (Tier 2) MO zovia 1/35e (28) $0-$6.60 (Tier 2) MO zovia 1/50e (28) $0-$6.60 (Tier 2) MO OPHTHALMOLOGY ANTIBIOTICS ak-poly-bac $0-$6.60 (Tier 2) MO bacitracin ophthalmic $0-$6.60 (Tier 2) MO bacitracin-polymyxin b ophthalmic $0-$6.60 (Tier 2) MO ciprofloxacin hcl ophthalmic $0-$2.65 (Tier 1) MO erythromycin ophthalmic $0-$6.60 (Tier 2) MO gentak ophthalmic ointment $0-$6.60 (Tier 2) MO gentamicin ophthalmic $0-$6.60 (Tier 2) MO NATACYN $0-$6.60 (Tier 2) MO neomycin-bacitracin-polymyxin $0-$6.60 (Tier 2) MO neomycin-polymyxin-gramicidin $0-$6.60 (Tier 2) MO neo-polycin $0-$6.60 (Tier 2) ofloxacin ophthalmic $0-$6.60 (Tier 2) MO polycin $0-$6.60 (Tier 2) polymyxin b sulf-trimethoprim $0-$6.60 (Tier 2) MO 89

91 tobramycin $0-$6.60 (Tier 2) MO VIGAMOX $0-$6.60 (Tier 2) MO ANTIVIRALS trifluridine $0-$6.60 (Tier 2) MO ZIRGAN $0-$6.60 (Tier 2) MO BETA-BLOCKERS betaxolol ophthalmic $0-$6.60 (Tier 2) MO carteolol $0-$6.60 (Tier 2) MO levobunolol ophthalmic drops 0.5 % $0-$6.60 (Tier 2) MO metipranolol $0-$6.60 (Tier 2) MO timolol maleate ophthalmic $0-$6.60 (Tier 2) MO TIMOPTIC OCUDOSE (PF) $0-$6.60 (Tier 2) MO CHOLINESTERASE INHIBITOR MIOTICS PHOSPHOLINE IODIDE $0-$6.60 (Tier 2) MO CYCLOPLEGIC MYDRIATICS tropicamide ophthalmic $0-$6.60 (Tier 2) MO MISCELLANEOUS OPHTHALMOLOGICS akwa tears $0 (Tier 4) MO; [*] akwa tears (polyvinyl alcohol) $0 (Tier 4) MO; [*] artificial tears (petro/min) $0 (Tier 4) MO; [*] artificial tears (polyvin alc) $0 (Tier 4) MO; [*] azelastine ophthalmic $0-$6.60 (Tier 2) MO cromolyn ophthalmic $0-$6.60 (Tier 2) MO FRESHKOTE $0 (Tier 4) MO; [*] ISOPTO TEARS $0 (Tier 4) MO; [*] lubricating plus $0 (Tier 4) [*] lubrifresh pm $0 (Tier 4) [*] MURO 128 OPHTHALMIC DROPS $0 (Tier 4) MO; [*] natural balance $0 (Tier 4) MO; [*] nature's tears $0 (Tier 4) [*] 90

92 PATADAY $0-$6.60 (Tier 2) MO PATANOL $0-$6.60 (Tier 2) MO PAZEO $0-$6.60 (Tier 2) MO puralube $0 (Tier 4) MO; [*] REFRESH CELLUVISC $0 (Tier 4) MO; [*] REFRESH LACRI-LUBE $0 (Tier 4) MO; [*] REFRESH PLUS $0 (Tier 4) MO; [*] RESTASIS $0-$6.60 (Tier 2) MO sodium chloride ophthalmic $0 (Tier 4) MO; [*] NON-STEROIDAL ANTI-INFLAMMATORY AGENTS flurbiprofen sodium $0-$6.60 (Tier 2) MO ILEVRO $0-$6.60 (Tier 2) MO ketorolac ophthalmic $0-$6.60 (Tier 2) MO NEVANAC $0-$6.60 (Tier 2) MO ORAL DRUGS FOR GLAUCOMA acetazolamide oral $0-$6.60 (Tier 2) MO acetazolamide sodium $0-$6.60 (Tier 2) MO methazolamide oral $0-$6.60 (Tier 2) MO OTHER GLAUCOMA DRUGS AZOPT $0-$6.60 (Tier 2) MO bimatoprost $0-$6.60 (Tier 2) MO COMBIGAN $0-$6.60 (Tier 2) MO dorzolamide $0-$6.60 (Tier 2) MO dorzolamide-timolol $0-$6.60 (Tier 2) MO latanoprost $0-$6.60 (Tier 2) MO LUMIGAN OPHTHALMIC DROPS 0.01 % $0-$6.60 (Tier 2) MO TRAVATAN Z $0-$6.60 (Tier 2) MO; QLL (5 per 30 days) travoprost (benzalkonium) $0-$6.60 (Tier 2) MO STEROID-ANTIBIOTIC COMBINATIONS neomycin-bacitracin-poly-hc $0-$6.60 (Tier 2) MO 91

93 neomycin-polymyxin b-dexameth $0-$6.60 (Tier 2) MO neomycin-polymyxin-hc ophthalmic $0-$6.60 (Tier 2) MO neo-polycin hc $0-$6.60 (Tier 2) tobramycin-dexamethasone $0-$6.60 (Tier 2) MO STEROIDS dexamethasone sodium phosphate ophthalmic $0-$6.60 (Tier 2) MO fluorometholone $0-$6.60 (Tier 2) MO prednisolone acetate $0-$6.60 (Tier 2) MO prednisolone sodium phosphate ophthalmic $0-$6.60 (Tier 2) MO STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE S.O.P. $0-$6.60 (Tier 2) MO sulfacetamide-prednisolone $0-$6.60 (Tier 2) MO SULFONAMIDES sulfacetamide sodium ophthalmic drops $0-$6.60 (Tier 2) MO SYMPATHOMIMETICS ALPHAGAN P OPHTHALMIC DROPS 0.1 % $0-$6.60 (Tier 2) MO apraclonidine $0-$6.60 (Tier 2) MO brimonidine $0-$6.60 (Tier 2) MO VASOCONSTRICTOR DECONGESTANTS eye drops (tetrahydrozoline) $0 (Tier 4) [*] naphazoline $0-$6.60 (Tier 2) MO opti-clear $0 (Tier 4) [*] RESPIRATORY AND ALLERGY ANTIHISTAMINE / ANTIALLERGENIC AGENTS 12 hour decongestant $0 (Tier 4) [*] adult tussin chest congestion $0 (Tier 4) [*] ALA-HIST DM $0 (Tier 4) MO; [*] ala-hist ir $0 (Tier 4) MO; [*] ALA-HIST PE $0 (Tier 4) MO; [*] 92

94 alavert d-12 allergy-sinus $0 (Tier 4) MO; [*] ALDEX GS $0 (Tier 4) [*] all day allergy (cetirizine) oral tablet $0 (Tier 4) MO; [*]; QLL (30 per 30 days) all day allergy (cetirizine) oral tablet,chewable 10 mg $0 (Tier 4) MO; [*] all day allergy-d $0 (Tier 4) MO; [*] ALLER-CHLOR ORAL SYRUP $0 (Tier 4) [*] aller-chlor oral tablet $0 (Tier 4) MO; [*] allergy (chlorpheniramine) $0 (Tier 4) MO; [*] allergy 4-hour $0 (Tier 4) [*] allergy relief (clemastine) $0 (Tier 4) MO; [*] allergy relief (loratadine) oral solution $0 (Tier 4) [*] allergy relief (loratadine) oral tablet $0 (Tier 4) MO; [*]; QLL (30 per 30 days) allergy relief (loratadine) oral tablet,disintegrating allergy relief d-24 $0 (Tier 4) [*] allergy relief(diphenhydramin) oral liquid $0 (Tier 4) [*] allerhist-1 $0 (Tier 4) [*] $0 (Tier 4) [*]; QLL (30 per 30 days) allfen dm $0 (Tier 4) MO; [*] ALL-NITE COLD-FLU ORAL LIQUID MG/15 ML $0 (Tier 4) [*] ap-hist dm $0 (Tier 4) [*] aprodine $0 (Tier 4) MO; [*] arbinoxa $0-$6.60 (Tier 2) PAR; MO banophen allergy $0 (Tier 4) MO; [*] banophen oral capsule 25 mg $0 (Tier 4) MO; [*] banophen oral capsule 50 mg $0 (Tier 4) [*] banophen oral liquid $0 (Tier 4) MO; [*] benzonatate oral capsule 100 mg, 200 mg $0 (Tier 3) MO; [*] bp 8 cough $0 (Tier 4) [*] BROMFED DM $0 (Tier 3) MO; [*] 93

95 brompheniramine-pseudoeph-dm oral syrup $0 (Tier 3) MO; [*] brotapp $0 (Tier 4) MO; [*] brotapp dm $0 (Tier 4) [*] cetirizine oral solution 1 mg/ml $0 (Tier 4) MO; [*]; QLL (300 per 30 days) cetirizine oral tablet $0 (Tier 4) MO; [*]; QLL (30 per 30 days) cetirizine oral tablet,chewable $0 (Tier 4) MO; [*] cetirizine-pseudoephedrine $0 (Tier 4) MO; [*] cheratussin ac $0 (Tier 4) MO; [*] cheratussin dac $0 (Tier 4) MO; [*] chest congestion relief oral tablet $0 (Tier 4) [*] chest congestion relief pe $0 (Tier 4) [*] child delsym cough+chest dm $0 (Tier 4) [*] CHILD DELSYM COUGH+COLD $0 (Tier 4) [*] child mucinex chest congestion $0 (Tier 4) [*] CHILD MUCINEX CONGESTION-COUGH $0 (Tier 4) [*] CHILD MUCINEX M-S COLD DAY-NTE $0 (Tier 4) [*] CHILD MUCINEX STUFFY NOSE-COLD $0 (Tier 4) MO; [*] children's allergy (diphenhyd) oral liquid $0 (Tier 4) [*] children's cetirizine oral solution $0 (Tier 4) [*]; QLL (300 per 30 days) children's cetirizine oral tablet,chewable $0 (Tier 4) MO; [*] CHILDREN'S CLARITIN ORAL TABLET,CHEWABLE $0 (Tier 4) MO; [*] children's cold & cough dm $0 (Tier 4) [*] CHILDREN'S MUCINEX COLD-FEVER $0 (Tier 4) [*] children's mucinex cough $0 (Tier 4) [*] CHILDREN'S MUCINEX MULTI-SYMP $0 (Tier 4) [*] CHILDREN'S MUCINEX NIGHT TIME $0 (Tier 4) [*] children's silfedrine $0 (Tier 4) [*] child's all day allergy(cetir) $0 (Tier 4) [*]; QLL (300 per 30 days) CHLO TUSS $0 (Tier 4) MO; [*] 94

96 CHLO TUSS EX $0 (Tier 4) [*] chlorpheniramine maleate oral tablet $0 (Tier 4) [*] chlorpheniramine maleate oral tablet extended release $0 (Tier 4) MO; [*] CLARITIN-D 12 HOUR $0 (Tier 4) MO; [*] clemastine oral tablet 2.68 mg $0-$6.60 (Tier 2) PAR; MO codeine-guaifenesin $0 (Tier 4) MO; [*] complete allergy medicine oral capsule $0 (Tier 4) [*] complete allergy oral liquid $0 (Tier 4) [*] CONGESTION RELIEF (IBUPROF-PE) $0 (Tier 4) [*] cough dm er $0 (Tier 4) [*] cough syrup dm $0 (Tier 4) [*] cough-sore throat night $0 (Tier 4) [*] cpm-pseudoephed-hydrocodone $0 (Tier 3) MO; [*] DALLERGY (CHLORPHENIRAMINE-PE) ORAL DROPS MG/ML DALLERGY (DEXBROMPHENIRAMN-PE) ORAL TABLET $0 (Tier 4) [*] $0 (Tier 4) MO; [*] dayhist allergy $0 (Tier 4) [*] DAYTIME COLD & FLU RELIEF ORAL CAPSULE MG $0 (Tier 4) [*] daytime liquid capsules $0 (Tier 4) [*] DECONEX DMX $0 (Tier 4) MO; [*] DECONEX IR $0 (Tier 4) MO; [*] DELSYM 12 HOUR $0 (Tier 4) MO; [*] delsym cough+chest congest dm $0 (Tier 4) [*] DELSYM COUGH+COLD DAYTIME $0 (Tier 4) [*] DELSYM COUGH+COLD NIGHTTIME $0 (Tier 4) [*] dextromethorphan polistirex $0 (Tier 4) [*] dimaphen (pe) $0 (Tier 4) [*] dimaphen dm $0 (Tier 4) MO; [*] 95

97 diphenhist oral liquid $0 (Tier 4) MO; [*] diphenhist oral tablet 25 mg $0 (Tier 4) MO; [*] diphenhydramine hcl injection solution 50 mg/ml $0-$6.60 (Tier 2) PAR; MO diphenhydramine hcl injection syringe $0-$6.60 (Tier 2) PAR; MO diphenhydramine hcl oral capsule $0 (Tier 4) MO; [*] DURAFLU $0 (Tier 4) MO; [*] ed a-hist $0 (Tier 4) MO; [*] ed a-hist dm oral liquid $0 (Tier 4) MO; [*] ED A-HIST DM ORAL TABLET $0 (Tier 4) [*] ed a-hist pse $0 (Tier 4) [*] ed bron gp $0 (Tier 4) [*] ED CHLORPED D $0 (Tier 4) [*] ed chlorped jr $0 (Tier 4) [*] ED-CHLORPED $0 (Tier 4) [*] ed-chlortan $0 (Tier 4) MO; [*] endacof - dm $0 (Tier 4) [*] endacof-c $0 (Tier 4) MO; [*] epinephrine injection solution 1 mg/ml (1:1,000) $0-$6.60 (Tier 2) MO epinephrine injection syringe 0.1 mg/ml (1:10,000) $0-$6.60 (Tier 2) MO EPIPEN 2-PAK $0-$6.60 (Tier 2) MO; QLL (2 per 1 day) EPIPEN JR 2-PAK $0-$6.60 (Tier 2) MO; QLL (2 per 1 day) FEXOFENADINE ORAL SUSPENSION $0 (Tier 4) [*] fexofenadine oral tablet 180 mg, 60 mg $0 (Tier 4) MO; [*] guaiatussin ac $0 (Tier 4) [*] guaifenesin ac $0 (Tier 4) [*] guaifenesin oral liquid $0 (Tier 4) [*] guaifenesin oral tablet extended release 12hr $0 (Tier 4) MO; [*] HISTEX (TRIPROLIDINE) $0 (Tier 4) [*] HISTEX DM $0 (Tier 4) [*] HISTEX PD $0 (Tier 4) [*] 96

98 HISTEX PE $0 (Tier 4) [*] hydrocodone-chlorpheniramine $0 (Tier 3) MO; [*] hydrocodone-homatropine oral syrup mg/5 ml $0 (Tier 3) MO; [*] hydrocodone-homatropine oral tablet $0 (Tier 3) MO; [*] hydromet $0 (Tier 3) MO; [*] iophen c-nr $0 (Tier 4) MO; [*] iophen dm-nr $0 (Tier 4) MO; [*] iophen-nr $0 (Tier 4) MO; [*] J-MAX $0 (Tier 4) MO; [*] J-TAN D PD $0 (Tier 4) MO; [*] J-TAN PD $0 (Tier 4) MO; [*] kidkare cough/cold $0 (Tier 4) [*] levocetirizine oral tablet $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) LODRANE D $0 (Tier 4) MO; [*] lohist - d $0 (Tier 4) MO; [*] lohist peb dm $0 (Tier 4) [*] lohist-dm $0 (Tier 3) MO; [*] lorata-dine d $0 (Tier 4) [*] loratadine oral solution $0 (Tier 4) MO; [*] loratadine oral tablet $0 (Tier 4) MO; [*]; QLL (30 per 30 days) loratadine oral tablet,disintegrating $0 (Tier 4) MO; [*]; QLL (30 per 30 days) loratadine-d $0 (Tier 4) MO; [*] LORTUSS DM $0 (Tier 4) MO; [*] lortuss ex oral syrup $0 (Tier 4) [*] LORTUSS LQ $0 (Tier 4) [*] mapap cold formula $0 (Tier 4) [*] mapap sinus max strength (pe) $0 (Tier 4) [*] maxiphen $0 (Tier 4) MO; [*] MAXIPHEN DM $0 (Tier 4) [*] 97

99 medi-phedryl $0 (Tier 4) [*] medi-tussin dm diabetic $0 (Tier 4) [*] M-END DMX $0 (Tier 4) [*] M-END MAX D $0 (Tier 4) MO; [*] mucaphed $0 (Tier 4) [*] MUCINEX $0 (Tier 4) MO; [*] MUCINEX COLD & SINUS $0 (Tier 4) [*] MUCINEX COLD-FLU & SORE THROAT $0 (Tier 4) [*] MUCINEX COUGH MINI-MELTS $0 (Tier 4) MO; [*] mucinex d $0 (Tier 4) MO; [*] mucinex d maximum strength $0 (Tier 4) MO; [*] mucinex dm $0 (Tier 4) MO; [*] MUCINEX FAST-MAX COLD-FLU-THRT ORAL TABLET $0 (Tier 4) [*] MUCINEX FAST-MAX COLD-SINUS $0 (Tier 4) [*] MUCINEX FAST-MAX CONGEST-COUGH ORAL LIQUID MUCINEX FAST-MAX CONGEST-COUGH ORAL TABLET MUCINEX FAST-MAX DAY-NITE CONG ORAL TABLETS, SEQUENTIAL $0 (Tier 4) MO; [*] $0 (Tier 4) [*] $0 (Tier 4) [*] mucinex fast-max dm max $0 (Tier 4) [*] MUCINEX FAST-MAX NITE COLD-FLU $0 (Tier 4) [*] MUCINEX FAST-MAX SEVERE COLD ORAL LIQUID MUCINEX FST-MX DY-NT CLD (DPH) ORAL LIQUID, SEQUENTIAL MUCINEX MINI-MELTS ORAL GRANULES IN PACKET 100 MG $0 (Tier 4) [*] $0 (Tier 4) [*] $0 (Tier 4) MO; [*] MUCINEX SINUS-MAX D-N (DIPHEN) $0 (Tier 4) [*] MUCINEX SINUS-MAX PRESSUR-PAIN ORAL TABLET $0 (Tier 4) [*] 98

100 MUCINEX SINUS-MAX SEV CONGESTN ORAL TABLET $0 (Tier 4) [*] mucus relief er oral tablet extended release 12hr $0 (Tier 4) [*] mucus relief oral tablet 400 mg $0 (Tier 4) MO; [*] mucus relief sinus $0 (Tier 4) [*] nasal decongestant (pe) oral tablet 10 mg $0 (Tier 4) [*] nasal decongestant (pseudoeph) oral tablet $0 (Tier 4) [*] NASOPEN PE $0 (Tier 4) [*] nighttime cough $0 (Tier 4) [*] nighttime sleep aid (diphen) oral tablet $0 (Tier 4) [*] NINJACOF $0 (Tier 4) [*] NINJACOF-A $0 (Tier 4) [*] NINJACOF-XG $0 (Tier 4) [*] NITE TIME COLD-FLU RELIEF ORAL CAPSULE $0 (Tier 4) [*] NIVA-HIST DM $0 (Tier 4) MO; [*] NIVANEX DMX $0 (Tier 4) MO; [*] nohist-dm $0 (Tier 4) [*] nohist-lq $0 (Tier 4) [*] non-drowsy allergy $0 (Tier 4) [*]; QLL (30 per 30 days) NOREL AD $0 (Tier 4) MO; [*] organ-i nr $0 (Tier 4) MO; [*] PAIN RELIEF SINUS PE $0 (Tier 4) [*] PEDIATEX TDM $0 (Tier 4) [*] pediatric cough & cold oral liquid mg/5 ml $0 (Tier 4) [*] phenylhistine dh $0 (Tier 4) MO; [*] POLY HIST PD $0 (Tier 4) [*] POLY-HIST DM (THONZYLAMINE) $0 (Tier 4) [*] poly-tussin $0 (Tier 4) [*] poly-tussin d $0 (Tier 4) [*] 99

101 POLY-VENT DM ORAL TABLET MG $0 (Tier 4) [*] POLY-VENT IR ORAL TABLET MG $0 (Tier 4) MO; [*] PRO-CHLO $0 (Tier 4) [*] PRO-CLEAR AC $0 (Tier 4) MO; [*] promethazine injection solution $0-$6.60 (Tier 2) PAR; MO promethazine vc-codeine $0 (Tier 3) MO; [*] promethazine-codeine $0 (Tier 3) MO; [*] promethazine-dm $0 (Tier 3) MO; [*] promethegan rectal suppository 12.5 mg $0-$6.60 (Tier 2) PAR; MO pseudoephedrine hcl oral liquid $0 (Tier 4) MO; [*] pseudoephedrine hcl oral tablet 30 mg $0 (Tier 4) MO; [*] PYRILAMINE-PHENYLEPHRINE ORAL TABLET $0 (Tier 4) [*] q-dryl oral capsule $0 (Tier 4) [*] q-dryl oral liquid $0 (Tier 4) MO; [*] q-tussin $0 (Tier 4) [*] q-tussin dm $0 (Tier 4) [*] quenalin $0 (Tier 4) [*] RESCON $0 (Tier 4) [*] RESCON-DM $0 (Tier 4) MO; [*] rescon-gg $0 (Tier 4) MO; [*] RESPAIRE-30 $0 (Tier 4) MO; [*] restfully sleep $0 (Tier 4) [*] REZIRA $0 (Tier 3) MO; [*] robafen $0 (Tier 4) MO; [*] robafen cf oral liquid $0 (Tier 4) [*] robafen dm $0 (Tier 4) MO; [*] robafen dm cough $0 (Tier 4) [*] RU-HIST D $0 (Tier 4) MO; [*] 100

102 RYMED (DEXCHLORPHENIRAMINE-PE) $0 (Tier 4) MO; [*] rynex dm $0 (Tier 4) [*] rynex pe $0 (Tier 4) [*] rynex pse $0 (Tier 4) [*] siladryl sa $0 (Tier 4) [*] silphen cough $0 (Tier 4) [*] siltussin dm das $0 (Tier 4) [*] siltussin sa $0 (Tier 4) MO; [*] siltussin-dm $0 (Tier 4) [*] SORE THROAT & COUGH LOZENGE $0 (Tier 4) [*] STAHIST AD ORAL LIQUID $0 (Tier 4) [*] STAHIST AD ORAL TABLET $0 (Tier 4) MO; [*] sudogest $0 (Tier 4) MO; [*] sudogest 12-hour $0 (Tier 4) MO; [*] sudogest pe $0 (Tier 4) MO; [*] sudogest sinus & allergy $0 (Tier 4) [*] suphedrine pe $0 (Tier 4) [*] tussin dm oral liquid $0 (Tier 4) [*] tussin dm oral syrup mg/5 ml $0 (Tier 4) [*] tussin expectorant $0 (Tier 4) [*] tussin oral liquid $0 (Tier 4) [*] TUSSIONEX PENNKINETIC ER $0 (Tier 3) MO; [*] VANACOF $0 (Tier 4) MO; [*] VANACOF DM $0 (Tier 4) [*] VANACOF-8 $0 (Tier 4) [*] VANAHIST PD $0 (Tier 4) [*] virtussin ac $0 (Tier 4) MO; [*] VITUZ $0 (Tier 3) MO; [*] ZONATUSS $0 (Tier 3) MO; [*] ZUTRIPRO $0 (Tier 3) MO; [*] 101

103 PULMONARY AGENTS acetylcysteine solution $0-$6.60 (Tier 2) B/D PAR; MO ADVAIR DISKUS $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) ADVAIR HFA $0-$6.60 (Tier 2) MO; QLL (12 per 30 days) AEROSPAN $0-$6.60 (Tier 2) MO; QLL (18 per 30 days) albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %) albuterol sulfate inhalation solution for nebulization 2.5 mg/0.5 ml, 5 mg/ml albuterol sulfate oral syrup $0-$2.65 (Tier 1) MO albuterol sulfate oral tablet $0-$6.60 (Tier 2) MO albuterol sulfate oral tablet extended release 12 hr $0-$6.60 (Tier 2) MO $0-$2.65 (Tier 1) B/D PAR; MO; QLL (360 per 30 days) $0-$2.65 (Tier 1) B/D PAR; MO; QLL (60 per 30 days) ANORO ELLIPTA $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) ARNUITY ELLIPTA $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) ASMANEX HFA $0-$6.60 (Tier 2) MO; QLL (13 per 30 days) ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (30 DOSES) ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (7 DOSES), 220 MCG (14 DOSES) ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 220 MCG (120 DOSES), 220 MCG (30 DOSES), 220 MCG (60 DOSES) $0-$6.60 (Tier 2) MO; QLL (0.14 per 30 days) $0-$6.60 (Tier 2) $0-$6.60 (Tier 2) MO; QLL (0.24 per 30 days) ATROVENT HFA $0-$6.60 (Tier 2) MO; QLL (26 per 30 days) BREO ELLIPTA $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) COMBIVENT RESPIMAT $0-$6.60 (Tier 2) MO; QLL (8 per 30 days) cromolyn inhalation $0-$6.60 (Tier 2) B/D PAR; MO; QLL (240 per 30 days) cromolyn nasal $0 (Tier 4) MO; [*] DALIRESP $0-$6.60 (Tier 2) PAR; MO; QLL (30 per 30 days) 102

104 DULERA $0-$6.60 (Tier 2) MO; QLL (13 per 30 days) FIRAZYR $0-$6.60 (Tier 2) PAR; MO FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION, 50 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) $0-$6.60 (Tier 2) MO; QLL (240 per 30 days) $0-$6.60 (Tier 2) MO; QLL (12 per 30 days) $0-$6.60 (Tier 2) MO; QLL (24 per 30 days) $0-$6.60 (Tier 2) MO; QLL (11 per 30 days) $0-$6.60 (Tier 2) MO; QLL (75 per 30 days) fluticasone nasal $0-$6.60 (Tier 2) MO; QLL (16 per 30 days) FORADIL AEROLIZER $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) ipratropium bromide inhalation $0-$6.60 (Tier 2) B/D PAR; MO ipratropium-albuterol $0-$6.60 (Tier 2) B/D PAR; MO; QLL (540 per 30 days) KALYDECO ORAL TABLET $0-$6.60 (Tier 2) PAR; MO; QLL (60 per 30 days) LETAIRIS $0-$6.60 (Tier 2) PAR; MO; LA; QLL (30 per 30 days) levalbuterol hcl inhalation solution for nebulization 0.31 mg/3 ml, 1.25 mg/0.5 ml, 1.25 mg/3 ml levalbuterol hcl inhalation solution for nebulization 0.63 mg/3 ml metaproterenol oral $0-$6.60 (Tier 2) MO $0-$6.60 (Tier 2) B/D PAR; MO; QLL (270 per 30 days) $0-$6.60 (Tier 2) B/D PAR; MO; QLL (540 per 30 days) montelukast $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) NASONEX $0-$6.60 (Tier 2) MO; QLL (17 per 30 days) PERFOROMIST $0-$6.60 (Tier 2) B/D PAR; MO; QLL (120 per 30 days) PROAIR HFA $0-$6.60 (Tier 2) MO; QLL (18 per 30 days) PULMOZYME $0-$6.60 (Tier 2) B/D PAR; MO 103

105 QVAR INHALATION AEROSOL 40 MCG/ACTUATION QVAR INHALATION AEROSOL 80 MCG/ACTUATION $0-$6.60 (Tier 2) MO; QLL (9 per 30 days) $0-$6.60 (Tier 2) MO; QLL (18 per 30 days) S2 RACEPINEPHRINE $0 (Tier 4) MO; [*] SEREVENT DISKUS $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) sildenafil oral $0-$6.60 (Tier 2) PAR; MO; QLL (90 per 30 days) SPIRIVA RESPIMAT $0-$6.60 (Tier 2) MO; QLL (4 per 30 days) SPIRIVA WITH HANDIHALER $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) terbutaline oral $0-$6.60 (Tier 2) MO terbutaline subcutaneous $0-$6.60 (Tier 2) MO theophylline oral tablet extended release $0-$6.60 (Tier 2) MO theophylline oral tablet extended release 12 hr $0-$6.60 (Tier 2) MO TRACLEER $0-$6.60 (Tier 2) PAR; MO; LA; QLL (60 per 30 days) VENTAVIS $0-$6.60 (Tier 2) PAR; MO XOLAIR $0-$6.60 (Tier 2) PAR; MO; LA; QLL (6 per 28 days) zafirlukast $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) UROLOGICALS ANTICHOLINERGICS / ANTISPASMODICS oxybutynin chloride oral syrup $0-$6.60 (Tier 2) MO; QLL (600 per 30 days) oxybutynin chloride oral tablet $0-$6.60 (Tier 2) MO; QLL (120 per 30 days) oxybutynin chloride oral tablet extended release 24hr 10 mg, 15 mg oxybutynin chloride oral tablet extended release 24hr 5 mg $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) tolterodine oral capsule,extended release 24hr $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) tolterodine oral tablet $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) trospium oral tablet $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin $0-$6.60 (Tier 2) MO finasteride oral tablet 5 mg $0-$6.60 (Tier 2) MO 104

106 tamsulosin $0-$6.60 (Tier 2) MO CHOLINERGIC STIMULANTS bethanechol chloride $0-$6.60 (Tier 2) MO MISCELLANEOUS UROLOGICALS CIALIS ORAL TABLET 2.5 MG, 5 MG $0-$6.60 (Tier 2) PAR; MO; QLL (30 per 30 days) CYSTAGON $0-$6.60 (Tier 2) MO; LA potassium citrate oral tablet extended release 10 meq (1,080 mg), 5 meq (540 mg) URINARY ANESTHETICS $0-$6.60 (Tier 2) MO azo-tabs $0 (Tier 4) [*] VITAMINS, HEMATINICS / ELECTROLYTES ELECTROLYTES antacid ext str (calcium carb) $0 (Tier 4) [*] antacid extra-strength oral tablet,chewable 200 mg calcium (500 mg), 300 mg (750 mg) antacid oral tablet,chewable 200 mg calcium (500 mg) $0 (Tier 4) [*] $0 (Tier 4) [*] CALCET CREAMY BITES $0 (Tier 4) MO; [*] calci-chew $0 (Tier 4) MO; [*] calcitrate $0 (Tier 4) MO; [*] CALCITRATE-VITAMIN D $0 (Tier 4) MO; [*] calcium d oral tablet 500 mg(1,250mg) -200 unit $0 (Tier 4) MO; [*] calcium 500 oral tablet $0 (Tier 4) [*] calcium 500 with d $0 (Tier 4) MO; [*] calcium 600 $0 (Tier 4) [*] calcium d(3) oral tablet 600 mg(1,500mg) unit, 600 mg(1,500mg) -400 unit $0 (Tier 4) MO; [*] calcium acetate oral capsule $0-$2.65 (Tier 1) MO calcium antacid oral tablet,chewable 200 mg calcium (500 mg) $0 (Tier 4) MO; [*] 105

107 calcium antacid oral tablet,chewable 300 mg (750 mg) $0 (Tier 4) [*] calcium carbonate oral suspension $0 (Tier 4) MO; [*] calcium carbonate oral tablet 260 mg calcium (648 mg), 500 mg calcium (1,250 mg), 600 mg (1,500 mg) calcium carbonate oral tablet 650 mg calcium (1,625 mg) calcium carbonate oral tablet,chewable 500 mg calcium (1,250 mg) calcium carbonate-vitamin d3 oral tablet 500 mg(1,250mg) -200 unit, 500 mg(1,250mg) -400 unit, 500mg (1,250mg) -600 unit calcium carbonate-vitamin d3 oral tablet 600 mg(1,500mg) -200 unit, 600 mg(1,500mg) -400 unit CALCIUM CARBONATE-VITAMIN D3 ORAL TABLET 600 MG(1,500MG) -800 UNIT calcium carbonate-vitamin d3 oral tablet,chewable $0 (Tier 4) MO; [*] $0 (Tier 4) [*] $0 (Tier 4) [*] $0 (Tier 4) [*] $0 (Tier 4) MO; [*] $0 (Tier 4) MO; [*] $0 (Tier 4) MO; [*] calcium citrate + d with mag $0 (Tier 4) [*] calcium citrate oral tablet 200 mg (950 mg) $0 (Tier 4) [*] calcium citrate-vitamin d3 oral tablet mgunit calcium citrate-vitamin d3 oral tablet mgunit, mg-unit $0 (Tier 4) [*] $0 (Tier 4) MO; [*] calcium gluconate oral tablet 45 mg (500 mg) $0 (Tier 4) MO; [*] calcium with vitamin d $0 (Tier 4) [*] CALCIUM-MAGNESIUM $0 (Tier 4) [*] calcium-magnesium-zinc oral tablet, mg $0 (Tier 4) [*] cal-gest antacid $0 (Tier 4) MO; [*] CALTRATE D $0 (Tier 4) MO; [*] chelated zinc $0 (Tier 4) MO; [*] 106

108 citrus calcium oral tablet mg-unit $0 (Tier 4) MO; [*] dextrose-kcl-nacl $0-$6.60 (Tier 2) B/D PAR ENFAMIL ENFALYTE $0 (Tier 4) [*] hi-cal plus vit d $0 (Tier 4) [*] klor-con 10 $0-$6.60 (Tier 2) MO klor-con 8 $0-$6.60 (Tier 2) MO klor-con m10 $0-$6.60 (Tier 2) MO klor-con m15 $0-$6.60 (Tier 2) MO klor-con m20 $0-$6.60 (Tier 2) MO K-TAB ORAL TABLET EXTENDED RELEASE 8 MEQ $0-$6.60 (Tier 2) lactated ringers intravenous $0-$6.60 (Tier 2) B/D PAR; MO laxative dietary supplement $0 (Tier 4) [*] mag-delay $0 (Tier 4) MO; [*] MAGNESIUM (OXIDE/AA CHELATE) $0 (Tier 4) MO; [*] MAGNESIUM AMINO ACID CHELATE ORAL TABLET 27 MG MAGNESIUM GLUCONATE ORAL TABLET 30 MG (550 MG) $0 (Tier 4) [*] $0 (Tier 4) [*] MAGNESIUM ORAL TABLET 30 MG $0 (Tier 4) [*] magnesium oxide oral capsule 500 mg $0 (Tier 4) [*] magnesium oxide oral tablet 400 mg, 420 mg, 500 mg $0 (Tier 4) MO; [*] magnesium sulfate in water $0-$6.60 (Tier 2) magnesium sulfate injection solution $0-$6.60 (Tier 2) MO magnesium sulfate injection syringe $0-$6.60 (Tier 2) MG-PLUS-PROTEIN $0 (Tier 4) MO; [*] MONOCAL $0 (Tier 4) MO; [*] NORMOSOL-R $0-$6.60 (Tier 2) B/D PAR NORMOSOL-R IN 5 % DEXTROSE $0-$6.60 (Tier 2) B/D PAR oral electrolytes $0 (Tier 4) [*] 107

109 oralyte $0 (Tier 4) [*] ORAZINC $0 (Tier 4) MO; [*] OS-CAL D3 ORAL TABLET $0 (Tier 4) MO; [*] OSTEO-PORETICAL $0 (Tier 4) MO; [*] oysco 500/d oral tablet $0 (Tier 4) MO; [*] oysco d $0 (Tier 4) MO; [*] oysco-500 $0 (Tier 4) MO; [*] oyst-cal-500 $0 (Tier 4) MO; [*] oyster shell + d3 $0 (Tier 4) [*] oyster shell calcium $0 (Tier 4) MO; [*] oyster shell calcium & mag $0 (Tier 4) [*] oyster shell calcium 500 $0 (Tier 4) MO; [*] oyster shell calcium-vit d3 oral tablet mgunit, 500 mg(1,250mg) -400 unit $0 (Tier 4) MO; [*] PEDIALYTE ADVANCED CARE $0 (Tier 4) [*] pedialyte freezer pops $0 (Tier 4) [*] pedialyte oral solution $0 (Tier 4) MO; [*] pedialyte singles $0 (Tier 4) [*] pediatric electrolyte oral solution $0 (Tier 4) [*] pediatric freezer pops $0 (Tier 4) [*] potassium chlorid-d5-0.45%nacl intravenous parenteral solution 10 meq/l, 30 meq/l, 40 meq/l potassium chlorid-d5-0.45%nacl intravenous parenteral solution 20 meq/l potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l potassium chloride in lr-d5 intravenous parenteral solution 20 meq/l potassium chloride in lr-d5 intravenous parenteral solution 40 meq/l $0-$6.60 (Tier 2) B/D PAR $0-$6.60 (Tier 2) B/D PAR; MO $0-$6.60 (Tier 2) B/D PAR $0-$6.60 (Tier 2) B/D PAR $0-$6.60 (Tier 2) B/D PAR; MO $0-$6.60 (Tier 2) B/D PAR 108

110 potassium chloride intravenous piggyback 10 meq/100 ml, 20 meq/100 ml, 20 meq/50 ml, 30 meq/100 ml, 40 meq/100 ml potassium chloride intravenous piggyback 10 meq/50 ml $0-$6.60 (Tier 2) B/D PAR $0-$6.60 (Tier 2) B/D PAR; MO potassium chloride intravenous solution $0-$6.60 (Tier 2) B/D PAR; MO potassium chloride oral capsule, extended release $0-$6.60 (Tier 2) MO potassium chloride oral tablet extended release $0-$6.60 (Tier 2) MO potassium chloride oral tablet,er particles/crystals $0-$6.60 (Tier 2) MO potassium chloride-0.45 % nacl $0-$6.60 (Tier 2) B/D PAR potassium chloride-d5-0.2%nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.2%nacl intravenous parenteral solution 30 meq/l, 40 meq/l potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.9%nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.9%nacl intravenous parenteral solution 40 meq/l $0-$6.60 (Tier 2) B/D PAR; MO $0-$6.60 (Tier 2) B/D PAR $0-$6.60 (Tier 2) B/D PAR $0-$6.60 (Tier 2) B/D PAR; MO $0-$6.60 (Tier 2) B/D PAR ringers intravenous $0-$6.60 (Tier 2) B/D PAR selenium oral tablet 100 mcg, 50 mcg $0 (Tier 4) MO; [*] selenium oral tablet 200 mcg $0 (Tier 4) [*] selenium oral tablet,delayed release (dr/ec) $0 (Tier 4) MO; [*] SLOW-MAG $0 (Tier 4) MO; [*] sodium chloride 0.45 % intravenous parenteral solution $0-$6.60 (Tier 2) MO sodium chloride 0.45 % intravenous piggyback $0-$6.60 (Tier 2) sodium chloride 3 % $0-$6.60 (Tier 2) MO sodium chloride 5 % $0-$6.60 (Tier 2) sodium chloride intravenous $0-$6.60 (Tier 2) B/D PAR; MO super calcium $0 (Tier 4) [*] TPN ELECTROLYTES $0-$6.60 (Tier 2) B/D PAR 109

111 zinc $0 (Tier 4) [*] zinc gluconate oral lozenge 10 mg $0 (Tier 4) [*] zinc gluconate oral tablet 100 mg $0 (Tier 4) [*] zinc gluconate oral tablet 50 mg $0 (Tier 4) MO; [*] zinc sulfate oral capsule $0 (Tier 4) MO; [*] zinc sulfate oral tablet $0 (Tier 4) [*] ZINC-15 $0 (Tier 4) MO; [*] zinc-220 $0 (Tier 4) [*] MISCELLANEOUS NUTRITION PRODUCTS AMINOSYN 8.5 % $0-$6.60 (Tier 2) B/D PAR AMINOSYN 8.5 %-ELECTROLYTES $0-$6.60 (Tier 2) B/D PAR AMINOSYN II 10 % $0-$6.60 (Tier 2) B/D PAR AMINOSYN II 7 % $0-$6.60 (Tier 2) B/D PAR AMINOSYN II 8.5 % $0-$6.60 (Tier 2) B/D PAR AMINOSYN II 8.5 %-ELECTROLYTES $0-$6.60 (Tier 2) B/D PAR AMINOSYN M 3.5 % $0-$6.60 (Tier 2) B/D PAR AMINOSYN-HBC 7% $0-$6.60 (Tier 2) B/D PAR AMINOSYN-PF 10 % $0-$6.60 (Tier 2) B/D PAR AMINOSYN-PF 7 % (SULFITE-FREE) $0-$6.60 (Tier 2) B/D PAR CALCIUM CITRATE MALATE-VIT D3 $0 (Tier 4) [*] CLINIMIX 5%/D15W SULFITE FREE $0-$6.60 (Tier 2) B/D PAR CLINIMIX 5%/D25W SULFITE-FREE $0-$6.60 (Tier 2) B/D PAR CLINIMIX 2.75%/D5W SULFIT FREE $0-$6.60 (Tier 2) B/D PAR CLINIMIX 4.25%/D10W SULF FREE $0-$6.60 (Tier 2) B/D PAR CLINIMIX 4.25%-D20W SULF-FREE $0-$6.60 (Tier 2) B/D PAR CLINIMIX 4.25%-D25W SULF-FREE $0-$6.60 (Tier 2) B/D PAR CLINIMIX 5%-D20W(SULFITE-FREE) $0-$6.60 (Tier 2) B/D PAR CLINIMIX E 4.25%/D10W SUL FREE $0-$6.60 (Tier 2) CLINIMIX E 4.25%/D25W SUL FREE $0-$6.60 (Tier 2) B/D PAR CLINIMIX E 4.25%/D5W SULF FREE $0-$6.60 (Tier 2) B/D PAR 110

112 CLINIMIX E 5%/D15W SULFIT FREE $0-$6.60 (Tier 2) B/D PAR CLINIMIX E 5%/D20W SULFIT FREE $0-$6.60 (Tier 2) B/D PAR CLINIMIX E 5%/D25W SULFIT FREE $0-$6.60 (Tier 2) B/D PAR CLINISOL SF 15 % $0-$6.60 (Tier 2) B/D PAR; MO FORTAVIT $0 (Tier 3) [*] freamine iii 10 % $0-$6.60 (Tier 2) B/D PAR HEPATAMINE 8% $0-$6.60 (Tier 2) B/D PAR intralipid intravenous emulsion 20 % $0-$6.60 (Tier 2) B/D PAR; MO ISOLYTE-P IN 5 % DEXTROSE $0-$6.60 (Tier 2) B/D PAR NORMOSOL-M IN 5 % DEXTROSE $0-$6.60 (Tier 2) B/D PAR NORMOSOL-R PH 7.4 $0-$6.60 (Tier 2) B/D PAR PLASMA-LYTE 148 $0-$6.60 (Tier 2) B/D PAR PLASMA-LYTE-56 IN 5 % DEXTROSE $0-$6.60 (Tier 2) B/D PAR travasol 10 % $0-$6.60 (Tier 2) B/D PAR; MO TROPHAMINE 10 % $0-$6.60 (Tier 2) B/D PAR; MO TROPHAMINE 6% $0-$6.60 (Tier 2) B/D PAR VITAMINS / HEMATINICS ABANEU-SL $0 (Tier 4) [*] acerola c-500 $0 (Tier 4) [*] actical $0 (Tier 4) MO; [*] adults 50+ daily formula $0 (Tier 4) [*] adults' daily formula $0 (Tier 4) [*] ALBA-LYBE $0 (Tier 4) [*] animal shape vitamins $0 (Tier 4) [*] apatate forte $0 (Tier 4) [*] APETEX $0 (Tier 4) [*] APETIGEN $0 (Tier 4) [*] apetigen plus oral liquid $0 (Tier 4) [*] APETIGEN PLUS ORAL TABLET $0 (Tier 4) MO; [*] AQUADEKS $0 (Tier 4) MO; [*] 111

113 aquasol e $0 (Tier 4) MO; [*] ascorbic acid oral tablet $0 (Tier 4) [*] ascorbic acid oral tablet extended release 1,000 mg ascorbic acid oral tablet extended release 1,500 mg $0 (Tier 4) MO; [*] $0 (Tier 4) [*] ascorbic acid oral tablet,chewable $0 (Tier 4) [*] b complex 1 $0 (Tier 4) MO; [*] B COMPLEX W-VIT C $0 (Tier 4) [*] b complex-vitamin b12 $0 (Tier 4) MO; [*] bal b-100 $0 (Tier 4) [*] bal b-50 $0 (Tier 4) [*] balance b-100 $0 (Tier 4) [*] balance b-50 $0 (Tier 4) [*] balanced b-100 oral tablet 0.4 mg, 100 mg $0 (Tier 4) [*] balanced b-150 $0 (Tier 4) [*] balanced b-50 oral tablet $0 (Tier 4) [*] b-complex oral tablet $0 (Tier 4) [*] b-complex with vitamin c oral capsule $0 (Tier 4) MO; [*] b-complex with vitamin c oral tablet $0 (Tier 4) MO; [*] b-complex with vitamin c oral tablet extended release $0 (Tier 4) [*] bee-zee $0 (Tier 4) [*] beta carotene oral capsule 25,000 unit $0 (Tier 4) MO; [*] BIOCAL $0 (Tier 4) [*] biosupp $0 (Tier 4) [*] biotin oral capsule 2,500 mcg, 5 mg $0 (Tier 4) MO; [*] biotin oral tablet 1 mg, 300 mcg $0 (Tier 4) MO; [*] biovol $0 (Tier 4) [*] C 1000-BIOFLAVONOIDS-ROSE HIPS $0 (Tier 4) [*] c complex $0 (Tier 4) [*] 112

114 c-500 oral tablet,chewable $0 (Tier 4) [*] CALCET PETITES $0 (Tier 4) MO; [*] calcium minerals oral tablet 600 mg calcium- 200 unit calcium 600 with vitamin d3 oral capsule 600 mg(1,500mg) -400 unit $0 (Tier 4) [*] $0 (Tier 4) [*] CALCIUM CARB-MAG OX-ZINC GLUC $0 (Tier 4) [*] calcium carbonate-vit d3-min $0 (Tier 4) [*] calcium plus $0 (Tier 4) [*] calcium soft chew oral tablet,chewable mg-unit-mcg $0 (Tier 4) [*] calcium-magnesium-copper-zinc $0 (Tier 4) [*] calcium-vitamin d3-vitamin k oral tablet,chewable mg-unit-mcg $0 (Tier 4) [*] calvite p&d $0 (Tier 4) [*] centamin $0 (Tier 4) [*] centavite a-z complete-mineral $0 (Tier 4) [*] central vite with lutein $0 (Tier 4) [*] central-vite cardio $0 (Tier 4) [*] CENTRAL-VITE ENERGY $0 (Tier 4) [*] central-vite men's under 50 $0 (Tier 4) [*] central-vite oral tablet mg-mcg $0 (Tier 4) [*] central-vite select $0 (Tier 4) [*] central-vite senior $0 (Tier 4) [*] CENTRAL-VITE WOMEN'S MATURE $0 (Tier 4) [*] central-vite women's under 50 $0 (Tier 4) [*] CENTRUM COMPLETE $0 (Tier 4) MO; [*] CENTRUM KIDS $0 (Tier 4) MO; [*] CENTRUM MEN $0 (Tier 4) [*] CENTRUM ORAL LIQUID $0 (Tier 4) MO; [*] CENTRUM ORAL TABLET,CHEWABLE $0 (Tier 4) [*] 113

115 CENTRUM SILVER ORAL TABLET $0 (Tier 4) MO; [*] CENTRUM SILVER WOMEN $0 (Tier 4) MO; [*] CENTRUM SPECIALIST HEART $0 (Tier 4) MO; [*] CENTRUM ULTRA MEN'S $0 (Tier 4) [*] century adults 50+ $0 (Tier 4) [*] century cardio $0 (Tier 4) [*] century oral tablet mg-mcg $0 (Tier 4) [*] CENTURY ULTIMATE MEN'S ORAL TABLET 8 MG IRON- 200 MCG-600 MCG $0 (Tier 4) [*] century ultimate women's $0 (Tier 4) [*] cerovite $0 (Tier 4) MO; [*] cerovite advanced formula $0 (Tier 4) MO; [*] cerovite jr $0 (Tier 4) [*] certavite with lutein $0 (Tier 4) [*] certavite-antioxid (iron gluc) oral liquid 9 mg iron/15 ml $0 (Tier 4) MO; [*] certavite-antioxidant $0 (Tier 4) MO; [*] chewable-vite $0 (Tier 4) MO; [*] chewable-vite with iron $0 (Tier 4) [*] child vitamin with minerals $0 (Tier 4) [*] children's chewable complete oral tablet,chewable $0 (Tier 4) [*] children's chewable vitamin $0 (Tier 4) [*] children's chewables $0 (Tier 4) [*] children's chewables extra c $0 (Tier 4) [*] children's chewables with iron $0 (Tier 4) [*] children's iron $0 (Tier 4) [*] childs chew vite $0 (Tier 4) [*] child's chewable vitamins/iron $0 (Tier 4) [*] child's vitamin with iron $0 (Tier 4) [*] child's vitamin with vitamin c $0 (Tier 4) [*] 114

116 childs/iron $0 (Tier 4) MO; [*] cholecalciferol (vitamin d3) oral drops 400 unit/ml $0 (Tier 4) MO; [*] compete $0 (Tier 4) [*] complete multivitamin oral tablet $0 (Tier 4) [*] complete multivitamin-mineral oral tablet $0 (Tier 4) [*] complete oral tablet $0 (Tier 4) [*] complete senior oral tablet mg-mcgmcg $0 (Tier 4) MO; [*] complex b-100 oral tablet extended release $0 (Tier 4) MO; [*] CORAL CALCIUM ORAL CAPSULE MG-MG-UNIT, MG-MG-UNIT $0 (Tier 4) [*] corvita $0 (Tier 3) MO; [*] CORVITE $0 (Tier 3) MO; [*] CORVITE FREE $0 (Tier 3) MO; [*] cyanocobalamin (vitamin b-12) oral liquid $0 (Tier 4) [*] cyanocobalamin (vitamin b-12) oral tablet 1,000 mcg, 500 mcg cyanocobalamin (vitamin b-12) oral tablet extended release $0 (Tier 4) [*] $0 (Tier 4) [*] daily energy $0 (Tier 4) [*] daily multiple for men $0 (Tier 4) [*] daily multiple for men 50+ $0 (Tier 4) [*] DAILY MULTIPLE FOR WOMEN $0 (Tier 4) [*] daily multiple for women 50+ $0 (Tier 4) [*] daily multiple oral tablet $0 (Tier 4) [*] DAILY MULTIPLE ORAL TABLET MCG-MG $0 (Tier 4) [*] daily multiple vitamins/iron $0 (Tier 4) [*] daily multivitamin-minerals $0 (Tier 4) [*] daily vitamin with iron $0 (Tier 4) [*] daily vitamin with iron and ca $0 (Tier 4) [*] 115

117 daily vites/iron $0 (Tier 4) MO; [*] daily-vite $0 (Tier 4) MO; [*] dialyvite 800 $0 (Tier 4) MO; [*] DIALYVITE 800 WITH IRON $0 (Tier 3) MO; [*] DIALYVITE 800 WITH ZINC 15 $0 (Tier 4) MO; [*] DIALYVITE 800 WITH ZINC 50 $0 (Tier 4) MO; [*] dino-life $0 (Tier 4) [*] dino-life with extra c $0 (Tier 4) [*] dino-life with iron-zinc $0 (Tier 4) [*] DRISDOL ORAL CAPSULE $0 (Tier 3) MO; [*] duofer $0 (Tier 4) [*] ECEE PLUS $0 (Tier 4) MO; [*] ENLYTE (FERROUS GLYCINE) $0 (Tier 3) MO; [*] ergocalciferol (vitamin d2) oral capsule $0 (Tier 3) MO; [*] ergocalciferol (vitamin d2) oral drops $0 (Tier 4) MO; [*] ezfe 200 $0 (Tier 4) MO; [*] fe c $0 (Tier 4) MO; [*] ferate oral tablet 240 mg (27 mg iron) $0 (Tier 4) MO; [*] FERGON $0 (Tier 4) MO; [*] FER-IN-SOL $0 (Tier 4) MO; [*] fer-iron $0 (Tier 4) [*] ferosul oral solution $0 (Tier 4) [*] ferosul oral tablet $0 (Tier 4) MO; [*] ferretts $0 (Tier 4) MO; [*] FERRETTS IPS $0 (Tier 4) MO; [*] ferrex 150 $0 (Tier 4) MO; [*] FERRIMIN 150 $0 (Tier 4) MO; [*] ferrocite $0 (Tier 4) MO; [*] ferro-time $0 (Tier 4) MO; [*] ferrous fumarate oral tablet 324 mg (106 mg iron) $0 (Tier 4) MO; [*] 116

118 ferrous gluconate oral tablet 236 mg (27 mg iron) $0 (Tier 4) [*] ferrous gluconate oral tablet 240 mg (27 mg iron), 324 mg (37.5 mg iron), 324 mg (38 mg iron), 325 mg (36 mg iron) $0 (Tier 4) MO; [*] ferrous sulfate oral drops $0 (Tier 4) MO; [*] ferrous sulfate oral liquid $0 (Tier 4) MO; [*] ferrous sulfate oral solution $0 (Tier 4) MO; [*] ferrous sulfate oral tablet 325 mg (65 mg iron) $0 (Tier 4) MO; [*] FERROUS SULFATE ORAL TABLET EXTENDED RELEASE $0 (Tier 4) MO; [*] ferrous sulfate oral tablet,delayed release (dr/ec) $0 (Tier 4) MO; [*] ferrousul $0 (Tier 4) [*] fluoritab oral tablet,chewable 1 mg fluoride (2.2 mg) $0-$6.60 (Tier 2) MO folbee ar $0 (Tier 4) MO; [*] folic acid injection $0 (Tier 3) MO; [*] folic acid oral tablet 1 mg $0 (Tier 3) MO; [*] FOLIC ACID-VIT B6-VIT B12 ORAL TABLET MG $0 (Tier 4) [*] folitab $0 (Tier 4) MO; [*] foltabs 800 $0 (Tier 4) MO; [*] fosfree $0 (Tier 4) MO; [*] fruity vitamin $0 (Tier 4) [*] full spectrum b-vitamin c $0 (Tier 4) [*] gummy dinos oral tablet,chewable 200 mcg $0 (Tier 4) [*] gummy swirls $0 (Tier 4) [*] hair vitamins $0 (Tier 4) [*] hair,skin & nails oral tablet $0 (Tier 4) [*] HARD NAIL $0 (Tier 4) [*] HEMOCYTE $0 (Tier 4) MO; [*] high potency iron $0 (Tier 4) [*] 117

119 honey bears $0 (Tier 4) [*] honey bears with iron-zinc $0 (Tier 4) [*] I.L.X. B-12 $0 (Tier 4) MO; [*] ICAPS $0 (Tier 4) MO; [*] ICAPS AREDS ORAL TABLET,DELAYED RELEASE (DR/EC) $0 (Tier 4) MO; [*] ICAPS MV $0 (Tier 4) MO; [*] icaps plus $0 (Tier 4) [*] ICAR ORAL SUSPENSION $0 (Tier 4) MO; [*] ICAR-C $0 (Tier 4) MO; [*] iferex 150 $0 (Tier 4) MO; [*] INTEGRA $0 (Tier 4) MO; [*] iron (ferrous sulfate) $0 (Tier 4) [*] iron high potency $0 (Tier 4) [*] iron oral tablet 325 mg (65 mg iron) $0 (Tier 4) [*] iron oral tablet extended release 159 mg (45 mg iron) $0 (Tier 4) [*] iron-vitamin c $0 (Tier 4) MO; [*] LIFE-PACK MEN'S $0 (Tier 4) [*] LIFE-PACK WOMEN'S $0 (Tier 4) [*] little animals $0 (Tier 4) [*] little animals-iron oral tablet,chewable $0 (Tier 4) [*] lysiplex plus oral liquid $0 (Tier 4) MO; [*] macuvite eye care $0 (Tier 4) [*] MEDTYCHOLL-B COMPLEX-LIVER $0 (Tier 4) [*] mega multi for women $0 (Tier 4) [*] mega multiple/chelated mineral $0 (Tier 4) [*] mega multivitamin for men $0 (Tier 4) [*] mega multivitamin with mineral oral tablet mg-mcg-mcg $0 (Tier 4) [*] men's 50+ daily formula $0 (Tier 4) [*] 118

120 men's multi-vitamin $0 (Tier 4) [*] MERIBIN $0 (Tier 4) MO; [*] MULTICHEW $0 (Tier 3) MO; [*] multi-day $0 (Tier 4) [*] multi-delyn $0 (Tier 4) MO; [*] multi-delyn with iron $0 (Tier 4) [*] multilex $0 (Tier 4) MO; [*] multilex-t&m $0 (Tier 4) MO; [*] multiple vitamin-minerals $0 (Tier 4) [*] multiple vitamins $0 (Tier 4) [*] multi-vitamin hp/minerals $0 (Tier 4) [*] multivitamin oral tablet $0 (Tier 4) MO; [*] multivitamin with iron $0 (Tier 4) [*] multivitamin with minerals oral tablet $0 (Tier 4) MO; [*] multi-vitamins with iron $0 (Tier 4) [*] myferon 150 $0 (Tier 4) MO; [*] my-vitalife $0 (Tier 4) [*] NEPHROCAPS $0 (Tier 4) MO; [*] nephronex $0 (Tier 4) [*] nephronex-sl $0 (Tier 4) MO; [*] NEPHRO-VITE $0 (Tier 4) MO; [*] NOVAFERRUM 125 $0 (Tier 4) [*] NOVAFERRUM 50 $0 (Tier 4) [*] NOVAFERRUM ORAL DROPS $0 (Tier 4) [*] NU-IRON $0 (Tier 4) MO; [*] NUTRICAP $0 (Tier 3) [*] NUTRIVIT $0 (Tier 4) [*] once daily $0 (Tier 4) [*] ONCOVITE $0 (Tier 4) MO; [*] one daily energy oral tablet $0 (Tier 4) [*] 119

121 one daily essential oral tablet, 0.4 mg $0 (Tier 4) [*] one daily maximum $0 (Tier 4) [*] ONE DAILY MEN'S 50+ $0 (Tier 4) [*] one daily multi-vit w-mineral $0 (Tier 4) [*] one daily multivitamin oral tablet $0 (Tier 4) [*] one daily oral tablet $0 (Tier 4) [*] one daily plus iron $0 (Tier 4) [*] one daily with iron $0 (Tier 4) [*] ONE DAILY WOMEN 50 PLUS $0 (Tier 4) [*] one daily women's oral tablet mg $0 (Tier 4) [*] one-tablet-daily $0 (Tier 4) [*] oyster shell calcium with d $0 (Tier 4) [*] oyster shell calcium-vit d3 oral tablet 500 mg(1,250mg) -200 unit $0 (Tier 4) MO; [*] pantothenic acid $0 (Tier 4) MO; [*] PERIDIN-C $0 (Tier 4) MO; [*] poly-iron $0 (Tier 4) MO; [*] polysaccharide iron complex $0 (Tier 4) [*] poly-vita $0 (Tier 4) [*] poly-vita (iron) $0 (Tier 4) [*] poly-vitamin $0 (Tier 4) [*] poly-vitamin with iron oral drops 1,500 unit-400 unit-10 mg/ml $0 (Tier 4) [*] polyvitamin/iron $0 (Tier 4) [*] poly-vitamins $0 (Tier 4) [*] PRENATAL VITAMIN ORAL TABLET $0-$6.60 (Tier 2) PREVENT $0 (Tier 4) [*] PRO FE $0 (Tier 4) MO; [*] PROFERRIN ES $0 (Tier 4) MO; [*] prosight $0 (Tier 4) [*] 120

122 PROTECT IRON $0 (Tier 3) [*] pyridoxine oral tablet 100 mg, 25 mg, 50 mg $0 (Tier 4) [*] RABANO YODADO $0 (Tier 4) [*] rena-vite $0 (Tier 4) MO; [*] riboflavin (vitamin b2) oral tablet 100 mg $0 (Tier 4) [*] risacal-d $0 (Tier 4) MO; [*] sentry oral tablet mg-mcg-mcgmcg $0 (Tier 4) [*] sentry senior oral tablet mcg $0 (Tier 4) [*] SIDEROL ORAL TABLET $0 (Tier 4) MO; [*] slow release iron oral tablet extended release 143 mg (45 mg iron), 159 mg (45 mg iron), 47.5 mg iron $0 (Tier 4) [*] sodium fluoride oral tablet $0-$6.60 (Tier 2) sodium fluoride oral tablet,chewable 1 mg fluoride (2.2 mg) $0-$6.60 (Tier 2) MO soft chews calcium $0 (Tier 4) [*] spectravite adult 50+ oral tablet $0 (Tier 4) [*] spectravite advanced formula $0 (Tier 4) [*] spectravite men's $0 (Tier 4) [*] spectravite senior oral tablet mcg $0 (Tier 4) [*] spectravite ultra women $0 (Tier 4) [*] spectravite ultra women's sr $0 (Tier 4) [*] strawberry c $0 (Tier 4) [*] stress formula $0 (Tier 4) [*] stress formula 600 c $0 (Tier 4) [*] stress formula advanced $0 (Tier 4) [*] STRESS FORMULA ENERGY $0 (Tier 4) [*] stress formula with iron $0 (Tier 4) MO; [*] stress formula with iron(sulf) $0 (Tier 4) [*] stress formula with zinc $0 (Tier 4) MO; [*] 121

123 STROVITE FORTE $0 (Tier 3) MO; [*] STROVITE ONE $0 (Tier 3) MO; [*] SUPER B COMPLEX + C $0 (Tier 4) [*] super b complex-vitamin c $0 (Tier 4) [*] super b/c $0 (Tier 4) [*] super b-50 complex $0 (Tier 4) [*] super multiple oral tablet $0 (Tier 4) [*] super multivitamin $0 (Tier 4) [*] super thera vite m $0 (Tier 4) [*] superplex-t $0 (Tier 4) [*] SUPERVITE (EC) $0 (Tier 3) MO; [*] support $0 (Tier 4) MO; [*] SUPPORT-500 $0 (Tier 3) MO; [*] tab a vite oral tablet mg $0 (Tier 4) MO; [*] tab-a-vite $0 (Tier 4) MO; [*] tab-a-vite/iron $0 (Tier 4) MO; [*] tab-a-vite-minerals $0 (Tier 4) [*] TANDEM DUAL ACTION $0 (Tier 4) MO; [*] thera $0 (Tier 4) [*] thera-m oral tablet $0 (Tier 4) [*] therapeutic liquid $0 (Tier 4) [*] therapeutic m + beta-carotene $0 (Tier 4) [*] therapeutic-m oral tablet 9 mg iron-400 mcg $0 (Tier 4) [*] therapeutic-m vitamin/minerals oral tablet mg $0 (Tier 4) [*] thera-tabs $0 (Tier 4) [*] theratrum complete with lutein $0 (Tier 4) [*] thiamine hcl oral tablet 100 mg $0 (Tier 4) [*] thiamine hcl oral tablet 250 mg $0 (Tier 4) MO; [*] total b/c $0 (Tier 4) [*] 122

124 totalday multiple $0 (Tier 4) [*] TRI-VI-SOL $0 (Tier 4) MO; [*] tri-vita $0 (Tier 4) [*] tri-vitamin $0 (Tier 4) MO; [*] ultra b-100 complex oral tablet $0 (Tier 4) [*] v-c forte $0 (Tier 3) MO; [*] vic-forte $0 (Tier 3) [*] VITA-BEE WITH C $0 (Tier 4) MO; [*] vitamin a oral capsule 10,000 unit $0 (Tier 4) MO; [*] vitamin a oral capsule 8,000 unit $0 (Tier 4) [*] vitamin b complex $0 (Tier 4) [*] vitamin b complex with c $0 (Tier 4) [*] vitamin b-1 $0 (Tier 4) MO; [*] vitamin b-100 complex $0 (Tier 4) [*] vitamin b-12 oral tablet $0 (Tier 4) MO; [*] vitamin b-12 oral tablet extended release 1,000 mcg vitamin b-12 oral tablet extended release 2,000 mcg $0 (Tier 4) MO; [*] $0 (Tier 4) [*] vitamin b-12 sublingual tablet 2,500 mcg $0 (Tier 4) MO; [*] vitamin b-2 oral tablet 100 mg, 25 mg $0 (Tier 4) MO; [*] vitamin b-6 oral tablet 100 mg, 25 mg, 50 mg $0 (Tier 4) MO; [*] vitamin b-6 oral tablet 200 mg $0 (Tier 4) [*] vitamin c cough drops $0 (Tier 4) [*] vitamin c drops $0 (Tier 4) [*] vitamin c oral capsule, extended release $0 (Tier 4) MO; [*] vitamin c oral lozenge $0 (Tier 4) [*] VITAMIN C ORAL POWDER EFFERVESCENT IN PACKET $0 (Tier 4) [*] vitamin c oral syrup $0 (Tier 4) MO; [*] vitamin c oral tablet 1,000 mg, 250 mg, 500 mg $0 (Tier 4) MO; [*] 123

125 vitamin c oral tablet extended release 1,000 mg $0 (Tier 4) [*] vitamin c oral tablet extended release 500 mg $0 (Tier 4) MO; [*] vitamin c oral tablet,chewable 250 mg, 500 mg $0 (Tier 4) MO; [*] vitamin c with rose hips oral tablet $0 (Tier 4) MO; [*] vitamin c with rose hips oral tablet extended release 1,000 mg $0 (Tier 4) [*] vitamin d2 $0 (Tier 3) MO; [*] vitamin e (dl, acetate) oral capsule 400 unit $0 (Tier 4) MO; [*] vitamin e acetate $0 (Tier 4) [*] vitamin e mixed oral capsule $0 (Tier 4) [*] vitamin e oral capsule 1,000 unit, 100 unit, 200 unit, 400 unit $0 (Tier 4) MO; [*] vitamin e oral capsule 600 unit $0 (Tier 4) [*] VITAMIN E ORAL DROPS 100 UNIT/0.25 ML $0 (Tier 4) [*] vitamin e oral drops 50 unit/ml $0 (Tier 4) [*] vitamins & minerals $0 (Tier 4) [*] vitamins a and d $0 (Tier 4) [*] vitamins b complex oral capsule $0 (Tier 4) MO; [*] vitamins for hair oral tablet $0 (Tier 4) [*] wee care $0 (Tier 4) [*] WHOLE SOURCE MULTI-VITAMINS $0 (Tier 4) [*] women's daily formula oral tablet 18 mg iron-400 mcg-500 mg ca $0 (Tier 4) [*] ZINC (WITH A & C) LOZENGES $0 (Tier 4) [*] zinc sulfate-vitamin c $0 (Tier 4) [*] zoo chews $0 (Tier 4) [*] zoo friends complete $0 (Tier 4) [*] zoo friends oral tablet,chewable 15 mg, 300 mcg $0 (Tier 4) [*] zoo friends original $0 (Tier 4) [*] 124

126 Index 1 12 hour decongestant A abacavir abacavir-lamivudine-zidovudine.. 10 ABANEU-SL ABELCET... 9 ABILIFY ABILIFY MAINTENA ABRAXANE ABSTRAL acarbose acebutolol acephen acerola c aceta-gesic acetaminophen acetaminophen-codeine... 32, 33 acetazolamide acetazolamide sodium acetic acid acetic acid-aluminum acetate acetylcysteine... 63, 102 acid gone antacid acid reducer (famotidine) acitretin ACNE MEDICATION ACTEMRA ACTHAR H.P ACTHIB (PF) actical actidose/sorbitol ACTIMMUNE ACTIQ acyclovir... 10, 61 acyclovir sodium ADACEL(TDAP ADOLESN/ADULT)(PF) ADAGEN adapalene ADASUVE added strength pain reliever adefovir adult tussin chest congestion adults 50+ daily formula adults' daily formula ADVAIR DISKUS ADVAIR HFA AEROSPAN afeditab cr AFINITOR AFINITOR DISPERZ AGGRENOX ak-poly-bac akwa tears akwa tears (polyvinyl alcohol) ala-cort ALA-HIST DM ala-hist ir ALA-HIST PE alavert d-12 allergy-sinus ALBA-LYBE ALBENZA albuterol sulfate alclometasone alcohol pads ALDEX GS ALDURAZYME alendronate... 63, 84 alfuzosin ALIMTA ALINIA all day allergy (cetirizine) all day allergy-d all day pain relief all day relief aller-chlor ALLER-CHLOR allergy (chlorpheniramine) allergy 4-hour allergy relief (clemastine) allergy relief (loratadine) allergy relief d allergy relief(diphenhydramin) allerhist allfen dm ALL-NITE COLD-FLU allopurinol almacone almacone ALOE VERA alosetron ALPHAGAN P alprazolam altavera (28) aluminum hydroxide gel alyacen 1/35 (28) alyacen 7/7/7 (28) amantadine hcl AMBISOME... 9 amcinonide amifostine crystalline amikacin amiloride amiloride-hydrochlorothiazide AMINOSYN 8.5 % AMINOSYN 8.5 %-ELECTROLYTES110 AMINOSYN II 10 % AMINOSYN II 7 % AMINOSYN II 8.5 % AMINOSYN II 8.5 %- ELECTROLYTES AMINOSYN M 3.5 % AMINOSYN-HBC 7% AMINOSYN-PF 10 % AMINOSYN-PF 7 % (SULFITE-FREE)110 amiodarone AMITIZA amitriptyline amlodipine amlodipine-atorvastatin amlodipine-benazepril amlodipine-valsartan amlodipine-valsartan-hcthiazid ammonium lactate amnesteem amoxapine amoxicillin amoxicillin-pot clavulanate amphetamine salt combo amphotericin b... 9 ampicillin ampicillin sodium ampicillin-sulbactam AMPYRA anagrelide anastrozole ANDRODERM ANDROGEL... 71, 72 androxy animal shape vitamins ANORO ELLIPTA antacid... 74,

127 antacid anti-gas antacid ext str (calcium carb) antacid extra-strength... 74, 105 antacid plus anti-gas antacid tablet antacid with simethicone antacid-simethicone ds anti-diarrheal (loperamide) antifungal (tolnaftate) antifungal cream antifungal spray anti-itch (diphenhydramine) anti-itch(diphenhyd) with zinc anti-nausea liquid anu-med apatate forte APETEX APETIGEN apetigen plus APETIGEN PLUS ap-hist dm APOKYN apraclonidine apri APRISO aprodine APTIOM APTIVUS aquabase AQUADEKS aquasol e ARALAST NP aranelle (28) ARANESP (IN POLYSORBATE) arbinoxa ARCALYST aripiprazole ARNUITY ELLIPTA ARRANON arthritis pain relief (acetam) artificial tears (petro/min) artificial tears (polyvin alc) ARZERRA ASACOL HD ascorbic acid ASMANEX HFA ASMANEX TWISTHALER aspirin aspirin low-strength aspirin-dipyridamole aspir-low ASTAGRAF XL atenolol atenolol-chlorthalidone ATGAM atorvastatin atovaquone atovaquone-proguanil ATRIPLA atropine ATROVENT HFA AVASTIN aviane AVINZA AVONEX AVONEX (WITH ALBUMIN) azacitidine AZACTAM IN DEXTROSE (ISO- OSM) azathioprine azelastine... 66, 90 AZILECT azithromycin AZOPT AZOR azo-tabs aztreonam azurette (28) B b complex B COMPLEX W-VIT C b complex-vitamin b baciim bacitracin... 60, 89 bacitracin zinc bacitracin-polymyxin b baclofen bal b bal b balance b balance b balanced b balanced b balanced b balsalazide banophen banophen allergy BANZEL BARACLUDE BCG VACCINE, LIVE (PF) b-complex b-complex with vitamin c bee-zee BELEODAQ benazepril benazepril-hydrochlorothiazide benzonatate benzoyl peroxide benztropine beta carotene betamethasone dipropionate betamethasone valerate... 61, 62 betamethasone, augmented betaxolol... 50, 90 bethanechol chloride bexarotene BEXSERO (PF) bicalutamide BICILLIN C-R BICILLIN L-A BICNU BILTRICIDE bimatoprost BIOCAL biosupp biotin biovol bisac-evac bisacodyl biscolax bismatrol bisoprolol fumarate bisoprolol-hydrochlorothiazide bleomycin BLEPHAMIDE S.O.P BLINCYTO BONIVA BOOSTRIX TDAP BOSULIF bp 8 cough BREO ELLIPTA BRILINTA brimonidine BRINTELLIX BROMFED DM bromocriptine brompheniramine-pseudoeph-dm94 brotapp brotapp dm budesonide

128 bumetanide BUPHENYL buprenorphine hcl buprenorphine-naloxone buproban bupropion hcl... 39, 40 buspirone BUSULFEX butalbital compound w/codeine.. 33 butorphanol tartrate BYDUREON BYETTA BYSTOLIC C C 1000-BIOFLAVONOIDS-ROSE HIPS c complex c cabergoline CALCET CREAMY BITES CALCET PETITES calci-chew calcipotriene calcitonin (salmon) calcitrate CALCITRATE-VITAMIN D calcitriol calcium calcium d calcium 500 with d calcium calcium d(3) calcium minerals calcium 600 with vitamin d calcium acetate calcium antacid , 106 CALCIUM CARB-MAG OX-ZINC GLUC calcium carbonate calcium carbonate-vit d3-min calcium carbonate-vitamin d CALCIUM CARBONATE-VITAMIN D calcium citrate calcium citrate + d with mag CALCIUM CITRATE MALATE-VIT D calcium citrate-vitamin d calcium gluconate calcium plus calcium soft chew CALCIUM WITH BORON calcium with vitamin d CALCIUM-MAGNESIUM calcium-magnesium-copper-zinc 113 calcium-magnesium-zinc calcium-vitamin d3-vitamin k caldyphen cal-gest antacid CALTRATE D calvite p&d camila CANASA CANCIDAS... 9 candesartan candesartan-hydrochlorothiazid.. 50 CAPASTAT CAPEX CAPRELSA captopril captopril-hydrochlorothiazide carbamazepine carbidopa-levodopa carboplatin CARIMUNE NF NANOFILTERED carteolol cartia xt carvedilol CAYSTON caziant (28) cefaclor cefadroxil cefazolin cefazolin in dextrose (iso-os) cefdinir cefepime cefoxitin cefoxitin in dextrose, iso-osm cefpodoxime cefprozil ceftazidime ceftriaxone ceftriaxone in dextrose,iso-os cefuroxime axetil cefuroxime sodium CELLCEPT CELLCEPT INTRAVENOUS CELONTIN centamin centavite a-z complete-mineral. 113 central vite central vite with lutein central-vite central-vite cardio CENTRAL-VITE ENERGY central-vite men's under central-vite select central-vite senior CENTRAL-VITE WOMEN'S MATURE central-vite women's under CENTRUM CENTRUM COMPLETE CENTRUM KIDS CENTRUM MEN CENTRUM SILVER CENTRUM SILVER WOMEN CENTRUM SPECIALIST HEART CENTRUM ULTRA MEN'S century century adults century cardio CENTURY ULTIMATE MEN'S century ultimate women's cephalexin CEREZYME cerovite cerovite advanced formula cerovite jr certavite with lutein certavite-antioxid (iron gluc) certavite-antioxidant CERVARIX VACCINE (PF) cetirizine cetirizine-pseudoephedrine cevimeline CHANTIX CHANTIX CONTINUING MONTH BOX CHANTIX STARTING MONTH BOX. 66 chelated zinc cheratussin ac cheratussin dac chest congestion relief chest congestion relief pe chewable-vite chewable-vite with iron child delsym cough+chest dm CHILD DELSYM COUGH+COLD child ibuprofen

129 child mucinex chest congestion CHILD MUCINEX CONGESTION- COUGH CHILD MUCINEX M-S COLD DAY- NTE CHILD MUCINEX STUFFY NOSE- COLD child vitamin with minerals children's allergy (diphenhyd) children's aspirin children's cetirizine children's chewable complete children's chewable vitamin children's chewables children's chewables extra c children's chewables with iron CHILDREN'S CLARITIN children's cold & cough dm children's ibuprofen children's iron children's mapap children's medi-profen children's medi-tabs suspension.. 36 CHILDREN'S MUCINEX COLD- FEVER children's mucinex cough CHILDREN'S MUCINEX MULTI- SYMP CHILDREN'S MUCINEX NIGHT TIME children's pain & fever relief children's pain relief children's pain reliever children's q-pap children's silapap children's silfedrine child's all day allergy(cetir) childs chew vite child's chewable vitamins/iron child's vitamin with iron child's vitamin with vitamin c childs/iron CHLO TUSS CHLO TUSS EX chloramphenicol sod succinate chlorhexidine gluconate chloroquine phosphate chlorothiazide chlorothiazide sodium chlorpheniramine maleate chlorpromazine chlorthalidone cholecalciferol (vitamin d3) cholestyramine (with sugar) cholestyramine light CIALIS ciclodan ciclopirox cidofovir cilostazol CIMZIA CIMZIA POWDER FOR RECONST.. 75 CIMZIA STARTER KIT CIPRODEX ciprofloxacin (mixture) ciprofloxacin hcl... 18, 89 ciprofloxacin lactate cisplatin citalopram citrus calcium cladribine clarithromycin CLARITIN-D 12 HOUR clemastine clindamycin hcl clindamycin phosphate...15, 59, 86 CLINIMIX 5%/D15W SULFITE FREE CLINIMIX 5%/D25W SULFITE- FREE CLINIMIX 2.75%/D5W SULFIT FREE CLINIMIX 4.25%/D10W SULF FREE110 CLINIMIX 4.25%/D5W SULFIT FREE CLINIMIX 4.25%-D20W SULF-FREE110 CLINIMIX 4.25%-D25W SULF-FREE110 CLINIMIX 5%-D20W(SULFITE- FREE) CLINIMIX E 2.75%/D10W SUL FREE CLINIMIX E 2.75%/D5W SULF FREE CLINIMIX E 4.25%/D10W SUL FREE CLINIMIX E 4.25%/D25W SUL FREE CLINIMIX E 4.25%/D5W SULF FREE CLINIMIX E 5%/D15W SULFIT FREE CLINIMIX E 5%/D20W SULFIT FREE CLINIMIX E 5%/D25W SULFIT FREE CLINISOL SF 15 % clobetasol clobetasol-emollient CLOLAR clomipramine clonazepam clonidine hcl clonidine patches clopidogrel clorazepate dipotassium clotrim antifungal clotrimazole... 9, 61, 86 clotrimazole 1% cream clotrimazole-betamethasone clozapine codeine-guaifenesin COLACE colchicine-probenecid COLCRYS colestipol colistin (colistimethate na) colocort COLY-MYCIN S COMBIGAN COMBIVENT RESPIMAT COMETRIQ compete COMPLERA complete complete allergy complete allergy medicine complete multivitamin complete multivitamin-mineral complete premium vitamin complete senior complex b compro COMVAX (PF) CONGESTION RELIEF (IBUPROF- PE) constulose COPAXONE 20 MG/ML CORAL CALCIUM COREG CR

130 cormax cortisone corvita CORVITE CORVITE FREE COSMEGEN cough dm er cough syrup dm cough-sore throat night COUMADIN cpm-pseudoephed-hydrocodone. 95 CREON CRESTOR CRIXIVAN cromolyn... 90, 102 cryselle (28) cyanocobalamin (vitamin b-12) cyclobenzaprine cyclophosphamide CYCLOSET cyclosporine cyclosporine modified CYRAMZA CYSTADANE CYSTAGON cytarabine cytarabine (pf) D d10 % & 0.45 % sodium chloride. 64 d2.5 %-0.45 % sodium chloride d5 % and 0.9 % sodium chloride.. 64 d5 %-0.45 % sodium chloride dacarbazine daily energy daily multiple DAILY MULTIPLE daily multiple for men daily multiple for men DAILY MULTIPLE FOR WOMEN daily multiple for women daily multiple vitamins/iron daily multivitamin-minerals daily vitamin with iron daily vitamin with iron and ca daily vites/iron daily-vite DALIRESP DALLERGY (CHLORPHENIRAMINE- PE) DALLERGY (DEXBROMPHENIRAMN-PE) danazol dantrolene DAPSONE DAPTACEL (DTAP PEDIATRIC) (PF) 82 DARAPRIM daunorubicin DAUNOXOME dayhist allergy DAYTIME COLD & FLU RELIEF (PE) 95 daytime liquid capsules decitabine DECONEX DMX DECONEX IR deep sea nasal DELSYM 12 HOUR delsym cough+chest congest dm. 95 DELSYM COUGH+COLD DAYTIME 95 DELSYM COUGH+COLD NIGHTTIME DELZICOL demeclocycline DEMSER DENAVIR DEPEN TITRATABS DEPO-PROVERA 400 MG/ML dermabase desipramine desmopressin desonide desoximetasone DESVENLAFAXINE... 40, 41 DESVENLAFAXINE FUMARATE dexamethasone dexamethasone sodium phos (pf) 67 dexamethasone sodium phosphate... 67, 92 DEXILANT dexrazoxane hcl dextroamphetamine dextromethorphan polistirex dextrose 10 % and 0.2 % nacl dextrose 10 % in water (d10w) dextrose 25 % in water (d25w) dextrose 30 % in water (d30w) dextrose 40 % in water (d40w) dextrose 5 % in water (d5w) dextrose 5 %-lactated ringers dextrose 5%-0.2 % sod chloride dextrose 5%-0.3 % sod.chloride dextrose 50 % in water (d50w) dextrose 70 % in water (d70w) dextrose with sodium chloride dextrose-kcl-nacl dialyvite DIALYVITE 800 WITH IRON DIALYVITE 800 WITH ZINC DIALYVITE 800 WITH ZINC diazepam... 27, 41 diazepam intensol dibucaine diclofenac potassium diclofenac sodium... 36, 58 dicloxacillin dicyclomine... 73, 74 didanosine DIFFERIN diflorasone diflunisal DIGITEK digox digoxin DILANTIN CAPSULES DILANTIN EXTENDED CAPSULES DILANTIN INFATABS diltiazem hcl dilt-xr dimaphen (pe) dimaphen dm dimenhydrinate dino-life dino-life with extra c dino-life with iron-zinc diocto DIPENTUM diphenhist diphenhydramine hcl diphenhydramineacetaminophen diphenoxylate-atropine disulfiram divalproex DOCEFREZ docetaxel doc-q-lace doc-q-lax docu docusate calcium docusate sodium

131 DOCUSOL DOCUSOL KIDS DOCUSOL PLUS dok dok plus donepezil dorzolamide dorzolamide-timolol doxazosin doxepin doxercalciferol DOXIL doxorubicin DOXY doxycycline hyclate doxycycline monohydrate... 18, 19 DR. SMITH'S DIAPER DR. SMITH'S DIAPER RASH DR. SMITH'S RASH-SKIN DRISDOL dronabinol drospirenone-ethinyl estradiol DROXIA DULERA duloxetine duofer DURAFLU duramorph (pf) E ear drops (carbamide peroxide) ear wax removal system ear wax treatment ECEE PLUS econazole econtra ez ed a-hist ed a-hist dm ED A-HIST DM ed a-hist pse ed bron gp ED CHLORPED D ed chlorped jr ed-apap ED-CHLORPED ed-chlortan EDURANT effervescent pain relief EFFIENT ELAPRASE ELIDEL elinest ELIQUIS ELITEK ELLA EMCYT EMEND EMSAM EMTRIVA enalapril maleate enalapril-hydrochlorothiazide ENBREL ENBREL SURECLICK endacof - dm endacof-c endocet enema ENEMEEZ ENEMEEZ PLUS ENFAMIL ENFALYTE ENGERIX-B (PF) ENGERIX-B PEDIATRIC (PF) ENLYTE (FERROUS GLYCINE) enoxaparin enpresse entacapone entecavir enteric coated aspirin ENTSOL enulose epinephrine EPIPEN 2-PAK EPIPEN JR 2-PAK epirubicin epitol EPIVIR EPIVIR HBV eplerenone eprosartan EPZICOM EQUETRO ERAXIS(WATER DILUENT)... 9 ERBITUX ergocalciferol (vitamin d2) ergoloid ERGOMAR ERIVEDGE errin ERWINAZE ery pads ery-tab ERYTHROCIN erythrocin (as stearate) erythromycin... 14, 89 erythromycin ethylsuccinate erythromycin with ethanol erythromycin-benzoyl peroxide escitalopram oxalate... 41, 42 ESTRACE estradiol ESTRING ethambutol ethosuximide etodolac ETOPOPHOS etoposide EVISTA EVOTAZ EXELON exemestane EXJADE ex-strength medi-tabs pm EXTAVIA eye drops (tetrahydrozoline) ezfe F FABRAZYME fallback solo falmina (28) famciclovir famotidine famotidine (pf) famotidine (pf)-nacl (iso-os) FANAPT FARESTON FARYDAK FASLODEX FATTIBASE FAZACLO fe c felbamate felodipine fenofibrate fenofibrate micronized fenofibrate nanocrystallized fenoprofen fentanyl fentanyl citrate FENTORA ferate FERGON

132 FER-IN-SOL fer-iron ferosul ferretts FERRETTS IPS ferrex FERRIMIN ferrocite ferro-time ferrous fumarate ferrous gluconate ferrous sulfate FERROUS SULFATE ferrousul FETZIMA fexofenadine FEXOFENADINE fiber fiber (calcium polycarbophil) fiber laxative (ca polycarbo) fiber laxative (psyllium husk) fiber smooth fiber smooth (sucrose) fiber-lax finasteride FIRAZYR FIRMAGON KIT W DILUENT SYRINGE flecainide FLEET PEDIATRIC FLOVENT DISKUS FLOVENT HFA fluconazole... 9 fluconazole in dextrose(iso-o)... 9 fluconazole in nacl (iso-osm)... 9 flucytosine... 9 fludarabine fludrocortisone flunisolide fluocinolone fluocinolone acetonide oil fluocinolone-shower cap fluocinonide fluocinonide-e fluoritab fluorometholone fluorouracil... 22, 58 fluoxetine fluphenazine decanoate fluphenazine hcl flurbiprofen flurbiprofen sodium flutamide fluticasone... 62, 103 fluvoxamine folbee ar folic acid FOLIC ACID-VIT B6-VIT B folitab FOLOTYN foltabs fondaparinux... 54, 55 FORADIL AEROLIZER formula em solution FORTAVIT FORTEO foscarnet fosfree fosinopril fosinopril-hydrochlorothiazide fosphenytoin FRAGMIN freamine iii 10 % FRESHKOTE fruity vitamin full spectrum b-vitamin c fungoid tincture furosemide FUSILEV FUZEON FYCOMPA G gabapentin GABITRIL galantamine GAMASTAN S/D GAMMAGARD LIQUID GAMMAGARD S-D (IGA < 1 MCG/ML) GAMMAPLEX GAMUNEX-C ganciclovir sodium GARDASIL (PF) GARDASIL 9 (PF) gas relief... 76, 77 GAUZE PADS 2 X gavilyte-c gavilyte-g gavilyte-n GAZYVA gemcitabine gemfibrozil generlac gengraf GENOTROPIN GENOTROPIN MINIQUICK gentak gentamicin... 15, 60, 89 gentamicin sulfate (ped) (pf) gentamicin sulfate (pf) GENTAMICIN SULFATE (PF) gentle laxative GEODON gildagia gildess fe GILENYA GILOTRIF GLATOPA GLEEVEC GLEOSTINE glimepiride glipizide glipizide-metformin GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) GLUTOSE GLUTOSE glycopyrrolate griseofulvin microsize... 9 griseofulvin ultramicrosize... 9 guaiatussin ac guaifenesin guaifenesin ac guanfacine guanidine gummy dinos gummy swirls H hair vitamins hair,skin & nails HALAVEN halobetasol propionate HALOG haloperidol haloperidol decanoate haloperidol lactate HARD NAIL HARVONI HAVRIX (PF)

133 headache formula added str headache relief (asa-acet-caf) heartburn relief 24 hour (lansoprazole) HECTOROL HEMOCYTE hemorrhoidal heparin (porcine) heparin (porcine) in 5 % dex heparin (porcine) in nacl (pf) heparin(porcine) in 0.45% nacl HEPARIN(PORCINE) IN 0.45% NACL heparin, porcine (pf) HEPATAMINE 8% HERCEPTIN HEXALEN hi-cal plus vit d high potency iron HISTAFLEX HISTEX (TRIPROLIDINE) HISTEX DM HISTEX PD HISTEX PE honey bears honey bears with iron-zinc HUMALOG HUMALOG KWIKPEN HUMALOG MIX HUMALOG MIX KWIKPEN.. 69 HUMALOG MIX HUMALOG MIX KWIKPEN.. 69 HUMATROPE HUMIRA HUMIRA CROHN'S DIS START PCK 85 HUMIRA PED CROHN'S STARTER PK HUMIRA PEN HUMIRA PSORIASIS STARTER PACK HUMULIN 70/ HUMULIN 70/30 KWIKPEN HUMULIN N HUMULIN N KWIKPEN HUMULIN R HUMULIN R U hydralazine hydro skin hydrochlorothiazide hydrocodone-acetaminophen hydrocodone-chlorpheniramine.. 97 hydrocodone-homatropine hydrocodone-ibuprofen hydrocortisone... 62, 63, 67, 77 hydrocortisone valerate hydrocortisone-acetic acid hydrocortisone-min oil-wht pet hydromet hydromorphone hydroxychloroquine hydroxyurea I I.L.X. B ibandronate IBRANCE ibu-drops ibuprofen ibuprofen jr strength ICAPS ICAPS AREDS ICAPS MV icaps plus ICAR ICAR-C ICLUSIG idarubicin iferex IFEX ifosfamide ILARIS (PF) ILEVRO IMBRUVICA imipenem-cilastatin imipramine hcl imiquimod IMOVAX RABIES VACCINE (PF) INCRELEX indapamide INFANRIX (DTAP) (PF) infants gas relief infants ibu-drops infant's ibuprofen INLYTA INSULIN PEN NEEDLE INSULIN SYRINGE (DISP) U ML INSULIN SYRINGE (DISP) U ML INSULIN SYRINGE (DISP) U-100 1/2 ML INTEGRA INTELENCE intralipid INTRON A INTUNIV ER INVANZ INVEGA INVEGA SUSTENNA INVEGA TRINZA INVIRASE iophen c-nr iophen dm-nr iophen-nr IOSAT IPOL ipratropium bromide... 66, 103 ipratropium-albuterol irbesartan irbesartan-hydrochlorothiazide irinotecan iron iron (ferrous sulfate) iron high potency iron-vitamin c ISENTRESS ISOLYTE-P IN 5 % DEXTROSE isoniazid ISOPTO TEARS isosorbide dinitrate isosorbide mononitrate isradipine ISTODAX ITCH-X itraconazole... 9 ivermectin IXEMPRA IXIARO (PF) J JAKAFI jantoven JANUMET JANUMET XR JANUVIA JENTADUETO JEVTANA J-MAX J-TAN D PD J-TAN PD junel 1.5/30 (21) junel 1/20 (21)

134 junel fe 1.5/30 (28) junel fe 1/20 (28) junior mapap K KADCYLA KALETRA KALYDECO kao-tin (bismuth subsalicylat) kao-tin (docusate calcium) kariva (28) kelnor 1/35 (28) KEPIVANCE ketoconazole... 9, 61 ketorolac KEYTRUDA KHEDEZLA... 43, 44 kidkare cough/cold KINERET klor-con klor-con klor-con m klor-con m klor-con m KOMBIGLYZE XR konsyl (sugar) konsyl sugar-free K-TAB KUVAN L labetalol lactated ringers... 63, 107 lactulose lamivudine lamivudine-zidovudine lamotrigine LANOXIN lansoprazole LANTUS LANTUS SOLOSTAR latanoprost LATUDA laxative dietary supplement laxative maximum strength laxative-senna LAZANDA leflunomide LENVIMA lessina LETAIRIS letrozole leucovorin calcium... 19, 20 LEUKERAN LEUKINE leuprolide levalbuterol hcl LEVEMIR LEVEMIR FLEXTOUCH levetiracetam levetiracetam in nacl (iso-os) levobunolol levocarnitine levocarnitine (with sugar) levocetirizine levofloxacin levonest (28) levonorgestrel-ethinyl estrad levorphanol tartrate levothyroxine levoxyl LEXIVA LIALDA lidocaine LIDOCAINE lidocaine (pf)...49, 59, 60 lidocaine hcl lidocaine viscous lidocaine-prilocaine LIFE-PACK MEN'S LIFE-PACK WOMEN'S lindane linezolid linezolid-0.9% sodium chloride LINZESS liothyronine liquid antacid lisinopril lisinopril-hydrochlorothiazide lite coat aspirin lithium carbonate lithium citrate little animals little animals-iron LODRANE D lohist - d lohist peb dm lohist-dm LOMUSTINE loperamide loratadine lorata-dine d loratadine-d lorazepam LORTUSS DM lortuss ex LORTUSS LQ losartan losartan-hydrochlorothiazide LOTRONEX lovastatin low-ogestrel (28) loxapine succinate lubricating plus lubrifresh pm LUMIGAN LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG, 7.5 MG.. 23 LUPRON DEPOT-PED lutera (28) LYNPARZA LYRICA lysiplex plus LYSODREN lyza M MACRODANTIN macuvite eye care mag-delay magnesium MAGNESIUM MAGNESIUM (OXIDE/AA CHELATE) MAGNESIUM AMINO ACID CHELATE MAGNESIUM GLUCONATE magnesium oxide magnesium sulfate magnesium sulfate in water MAGTAB MAJOR-PREP HEMORRHOIDAL mapap (acetaminophen) mapap arthritis pain mapap cold formula mapap extra strength mapap pm mapap sinus max strength (pe) maprotiline marlissa MARPLAN masanti double strength MATULANE

135 maxiphen MAXIPHEN DM meclizine meclofenamate medi-bismuth MEDICATED BODY POWDER medi-natural medi-phedryl medi-profen medi-sleep medi-tabs medi-tussin dm diabetic medroxyprogesterone MEDTYCHOLL-B COMPLEX-LIVER118 mefloquine mega multi for women mega multiple/chelated mineral 118 mega multivitamin for men mega multivitamin with mineral 118 megestrol MEKINIST meloxicam melphalan hcl MENACTRA (PF) M-END DMX M-END MAX D MENEST MENOMUNE - A/C/Y/W MENOMUNE - A/C/Y/W-135 (PF). 83 men's 50+ daily formula men's multi-vitamin menstrual relief MENVEO A-C-Y-W-135-DIP (PF) MEPHYTON MEPRON mercaptopurine MERIBIN meropenem mesalamine mesalamine with cleansing wipe. 77 mesna MESNEX MESTINON MESTINON TIMESPAN metaproterenol metformin methadone methadone intensol methadose methazolamide methenamine hippurate methimazole methotrexate sodium methotrexate sodium (pf) methoxsalen rapid methyclothiazide METHYL SALICYLATE-ALOE VERA. 58 methylphenidate methylprednisolone acetate methylprednisolone sodium succ 67 methylprednisolone tablets metipranolol metoclopramide hcl metolazone metoprolol succinate metoprolol ta-hydrochlorothiaz.. 52 metoprolol tartrate metro i.v metronidazole...16, 59, 86 metronidazole in nacl (iso-os) mexiletine MG-PLUS-PROTEIN mi-acid mi-acid gas relief miconazole miconazole nitrate... 61, 86 miconazole microgestin 1.5/30 (21) microgestin 1/20 (21) microgestin fe 1.5/30 (28) microgestin fe 1/20 (28) midodrine migraine formula MIGRANAL milk of magnesia milk of magnesia concentrated mineral oil laxative minocycline minoxidil mintox maximum strength mirtazapine misoprostol mitomycin mitoxantrone M-M-R II (PF) mobisyl modafinil moexipril moexipril-hydrochlorothiazide mometasone MONOCAL mono-linyah mononessa (28) montelukast morphine... 34, 35 MORPHINE morphine (pf) morphine concentrate moxifloxacin MOZOBIL mucaphed MUCINEX MUCINEX COLD & SINUS MUCINEX COLD-FLU & SORE THROAT MUCINEX COUGH MINI-MELTS mucinex d mucinex d maximum strength mucinex dm MUCINEX FAST-MAX COLD-FLU- THRT MUCINEX FAST-MAX COLD-SINUS 98 MUCINEX FAST-MAX CONGEST- COUGH MUCINEX FAST-MAX DAY-NITE CONG mucinex fast-max dm max MUCINEX FAST-MAX NITE COLD- FLU MUCINEX FAST-MAX SEVERE COLD MUCINEX FST-MX DY-NT CLD (DPH) MUCINEX MINI-MELTS MUCINEX SINUS-MAX D-N (DIPHEN) MUCINEX SINUS-MAX PRESSUR- PAIN MUCINEX SINUS-MAX SEV CONGESTN mucus relief mucus relief er mucus relief sinus MULTAQ MULTICHEW multi-day multi-delyn multi-delyn with iron multilex multilex-t&m

136 multiple vitamin-minerals multiple vitamins multivitamin multi-vitamin hp/minerals multivitamin with iron multivitamin with minerals multi-vitamins with iron mupirocin ointment MURO MUSTARGEN my way MYCOBUTIN mycophenolate mofetil mycophenolate sodium myferon MYOZYME mytab gas mytab gas maximum strength my-vitalife myzilra N nabumetone nadolol nadolol-bendroflumethiazide nafcillin NAGLAZYME nalbuphine naloxone naltrexone NAMENDA NAMENDA TITRATION PAK NAMENDA XR naphazoline naproxen naproxen sodium nasal decongestant (oxymetazl).. 66 nasal decongestant (pe) nasal decongestant (pseudoeph). 99 nasal spray (oxymetazoline) nasal spray 12 hour nasal spray long acting NASONEX NASOPEN PE NATACYN nateglinide natural balance natural fiber laxative natural fiber laxative therapy nature's tears NEBUPENT necon 0.5/35 (28) necon 1/35 (28) necon 1/50 (28) necon 10/11 (28) necon 7/7/7 (28) NEEDLES, INSULIN DISP.,SAFETY.. 70 nefazodone... 44, 45 neomycin neomycin-bacitracin-poly-hc neomycin-bacitracin-polymyxin.. 89 neomycin-polymyxin b gu neomycin-polymyxin b-dexameth 92 neomycin-polymyxin-gramicidin. 89 neomycin-polymyxin-hc... 67, 92 neo-polycin neo-polycin hc NEPHROCAPS nephronex nephronex-sl NEPHRO-VITE NEULASTA NEUMEGA NEUPOGEN NEUPRO NEVANAC nevirapine NEXAVAR next choice one dose niacin NIACOR nicardipine NICODERM CQ nicorelief NICORETTE nicotine nicotine (polacrilex) NICOTROL NS nifedical xl nifedipine nighttime cough nighttime sleep aid (diphen) NILANDRON nimodipine NINJACOF NINJACOF-A NINJACOF-XG NIPENT NITE TIME COLD-FLU RELIEF nitro-bid nitrofurantoin macrocrystal nitroglycerin NITROSTAT NIVA-HIST DM NIVANEX DMX nohist-dm nohist-lq non-aspirin pain relief non-aspirin pm non-drowsy allergy nora-be NORDITROPIN FLEXPRO NORDITROPIN NORDIFLEX NOREL AD norethindrone (contraceptive) norethindrone acetate norgestimate-ethinyl estradiol NORMOSOL-M IN 5 % DEXTROSE111 NORMOSOL-R NORMOSOL-R IN 5 % DEXTROSE 107 NORMOSOL-R PH nortrel 0.5/35 (28) nortrel 1/35 (21) nortrel 1/35 (28) nortrel 7/7/7 (28) nortriptyline NORVIR nose drops NOVAFERRUM NOVAFERRUM NOVAFERRUM NOXAFIL... 9 nrs nasal relief NUEDEXTA NU-IRON NULOJIX NUTRICAP NUTRIVIT NUVARING nystatin... 9, 61 nystatin-triamcinolone nystop O ocella octreotide acetate ofloxacin... 18, 67, 89 ogestrel (28) olanzapine OLYSIO omega-3 acid ethyl esters omeprazole

137 ONCASPAR once daily ONCOVITE ondansetron hcl ondansetron hcl (pf) ondansetron odt one daily one daily energy one daily essential one daily maximum ONE DAILY MEN'S one daily multi-vit w-mineral one daily multivitamin one daily plus iron one daily with iron ONE DAILY WOMEN 50 PLUS one daily women's one-tablet-daily ONFI ONGLYZA opcicon one-step OPDIVO opium tincture opti-clear oral electrolytes oralyte ORAP ORAZINC ORFADIN organ-i nr ORTHO EVRA OS-CAL D OSTEO-PORETICAL oxacillin oxaliplatin oxandrolone oxaprozin oxcarbazepine OXSORALEN OXTELLAR XR oxybutynin chloride oxycodone oxycodone-acetaminophen oxycodone-aspirin oysco 500/d oysco d oysco oyst-cal oyster shell + d oyster shell calcium oyster shell calcium & mag oyster shell calcium oyster shell calcium with d oyster shell calcium-vit d3. 108, 120 P pacerone paclitaxel pain & fever pain relief PAIN RELIEF SINUS PE pain reliever pain reliever extra strength pain reliever pm ex-strength pamidronate PANRETIN pantoprazole pantothenic acid paricalcitol paroex oral rinse paromomycin paroxetine hcl PASER PATADAY PATANOL PAXIL PAZEO pedialyte PEDIALYTE ADVANCED CARE pedialyte freezer pops pedialyte singles PEDIATEX TDM pediatric cough & cold pediatric electrolyte pediatric freezer pops PEDVAX HIB (PF) peg 3350-electrolytes peg peg-3350 with flavor packs PEGANONE PEGASYS PEGASYS PROCLICK peg-electrolyte soln PEGINTRON PEGINTRON REDIPEN PENICILLIN G POT IN DEXTROSE.. 17 penicillin g potassium penicillin g procaine penicillin g sodium penicillin v potassium PENTAM PENTASA pentoxifylline peptic relief PERFOROMIST PERIDIN-C perindopril erbumine periogard PERJETA permethrin perphenazine phenelzine phenobarbital phenylhistine dh phenytoin phenytoin sodium phenytoin sodium extended PHOSPHOLINE IODIDE pilocarpine hcl pindolol pink bismuth pink bismuth maximum strength. 74 pioglitazone pioglitazone-glimepiride pioglitazone-metformin piperacillin-tazobactam piroxicam PLAN B ONE-STEP PLASMA-LYTE PLASMA-LYTE-56 IN 5 % DEXTROSE podofilox POLY HIST PD polybase polycin polyethylene glycol POLY-HIST DM (THONZYLAMINE). 99 poly-iron polymyxin b sulf-trimethoprim polysaccharide iron complex poly-tussin poly-tussin d POLY-VENT DM POLY-VENT IR poly-vita poly-vita (iron) poly-vitamin poly-vitamin with iron polyvitamin/iron poly-vitamins POMALYST

138 portia potassium chlorid-d5-0.45%nacl 108 potassium chloride potassium chloride in 0.9%nacl. 108 potassium chloride in 5 % dex potassium chloride in lr-d potassium chloride-0.45 % nacl. 109 potassium chloride-d5-0.2%nacl 109 potassium chloride-d5-0.3%nacl 109 potassium chloride-d5-0.9%nacl 109 potassium citrate POTIGA povidone-iodine PRADAXA pramipexole PRANDIMET pravastatin prazosin prednisolone prednisolone acetate prednisolone sodium phosphate68, 92 prednisone prednisone intensol PREMARIN PRENATAL VITAMIN ORAL TABLET120 prevalite PREVENT previfem PREZCOBIX PREZISTA PRIFTIN PRILOSEC OTC PRIMAQUINE primidone PRISTIQ... 45, 46 PRO FE PROAIR HFA probenecid procainamide PRO-CHLO prochlorperazine edisylate prochlorperazine maleate prochlorperazine maleate rectal.. 79 PRO-CLEAR AC PROCRIT procto-pak proctosol hc proctozone-hc PROFERRIN ES progesterone micronized PROGLYCEM PROGRAF PROLEUKIN PROLIA PROMACTA promethazine promethazine vc-codeine promethazine-codeine promethazine-dm promethegan propafenone propranolol propranolol-hydrochlorothiazid.. 53 PROPYLENE GLYCOL propylthiouracil PROQUAD (PF) prosight PROTECT IRON PROTOPIC protriptyline pseudoephedrine hcl PULMOZYME puralube PURIXAN pyrazinamide pyridostigmine bromide pyridoxine PYRILAMINE-PHENYLEPHRINE Q q-dryl q-pap q-pap extra strength q-tussin q-tussin dm QUADRACEL (PF) quenalin quetiapine quinapril quinapril-hydrochlorothiazide quinidine sulfate tablets QVAR R RABANO YODADO RABAVERT (PF) raloxifene ramipril RANEXA ranitidine hcl RAPAMUNE REBIF (WITH ALBUMIN) REBIF REBIDOSE REBIF TITRATION PACK reclipsen (28) RECOMBIVAX HB (PF) REFRESH CELLUVISC REFRESH LACRI-LUBE REFRESH PLUS reguloid RELENZA DISKHALER RELISTOR REMICADE RENAGEL rena-vite RENVELA RESCON RESCON-DM rescon-gg RESCRIPTOR RESPAIRE RESTASIS restfully sleep RETROVIR REVLIMID REYATAZ REZIRA ribasphere ribavirin riboflavin (vitamin b2) RIDAURA rifabutin rifampin RIFATER riluzole rimantadine ringers... 63, 109 risacal-d RISPERDAL CONSTA risperidone RITUXAN rivastigmine tartrate rizatriptan robafen robafen cf robafen dm robafen dm cough ropinirole rosadan ROTARIX ROTATEQ VACCINE ROXICET

139 ROZEREM RU-HIST D RULOX RYMED (DEXCHLORPHENIRAMINE-PE)101 rynex dm rynex pe rynex pse S S2 RACEPINEPHRINE SABRIL sani-supp (adult) sani-supp (infant) SANTYL SAPHRIS (BLACK CHERRY)... 46, 47 SARNA ANTI-ITCH SAVELLA selegiline hcl selenium selenium sulfide SELZENTRY senexon senna senna lax senna plus senna with docusate sodium senna-gen SENNALAX-S senna-s SENSIPAR sentry sentry senior SEREVENT DISKUS SEROQUEL XR sertraline SIDEROL silace siladryl sa silapap sildenafil silphen cough siltussin dm das siltussin sa siltussin-dm silver sulfadiazine simethicone SIMPONI SIMULECT simvastatin sirolimus sleep aid (doxylamine) slo-niacin SLO-NIACIN slow release iron SLOW-MAG sodium bicarbonate sodium chloride... 65, 91, 109 sodium chloride 0.45 % sodium chloride 0.9 % sodium chloride 3 % sodium chloride 5 % sodium fluoride sodium polystyrene (sorb free) sodium polystyrene sulfonate SODIUM POLYSTYRENE SULFONATE soft chews calcium SOLTAMOX SOMATULINE DEPOT SOMAVERT SORE THROAT & COUGH LOZENGE sorine sotalol sotalol af SOVALDI spectravite adult spectravite advanced formula spectravite men's spectravite performance spectravite senior spectravite ultra women spectravite ultra women's sr SPIRIVA RESPIMAT SPIRIVA WITH HANDIHALER spironolactone spironolacton-hydrochlorothiaz.. 53 sprintec (28) SPRYCEL sps ssd STAHIST AD stavudine STIMATE STIVARGA stomach relief stomach relief max strength stool softener stool softener-laxative STRATTERA strawberry c STREPTOMYCIN stress formula stress formula 600 c stress formula advanced STRESS FORMULA ENERGY stress formula with iron stress formula with iron(sulf) stress formula with zinc STRIBILD STROMECTOL STROVITE FORTE STROVITE ONE SUBOXONE SUBSYS sucralfate sudogest sudogest 12-hour sudogest pe sudogest sinus & allergy sulfacetamide sodium sulfacetamide sodium (acne) sulfacetamide-prednisolone sulfadiazine sulfamethoxazole-trimethoprim.. 18 SULFAMYLON sulfasalazine sulfazine sulfazine ec sulindac sumatriptan succinate SUPER B COMPLEX + C super b complex-vitamin c super b/c super b-50 complex super calcium super multiple super multivitamin super thera vite m superplex-t SUPERVITE (EC) suphedrine pe support SUPPORT SURMONTIL SUSPENDOL-S SUSTIVA SUTENT syeda SYLATRON

140 SYMLINPEN SYMLINPEN SYNAGIS SYNAREL SYNERCID SYNRIBO SYNTHROID SYPRINE T tab a vite tab-a-vite tab-a-vite/iron tab-a-vite-minerals TABLOID tacrolimus... 25, 58 TAFINLAR TAMIFLU tamoxifen tamsulosin TANDEM DUAL ACTION TANZEUM TARCEVA TARGRETIN TASIGNA TASMAR TAZORAC taztia xt TECFIDERA TEFLARO TEKTURNA TEKTURNA HCT telmisartan telmisartan-amlodipine telmisartan-hydrochlorothiazid temazepam terazosin terbinafine hcl... 9, 61 terbutaline terconazole TESTIM testosterone cypionate testosterone enanthate tetanus toxoid,adsorbed (pf) TETANUS,DIPHTHERIA TOX PED(PF) TETANUS-DIPHTHERIA TOXOIDS- TD tetracycline THALOMID theophylline thera THERA-GESIC thera-m therapeutic liquid therapeutic m + beta-carotene therapeutic-m therapeutic-m vitamin/minerals 122 thera-tabs theratrum complete with lutein 122 thiamine hcl thioridazine thiothixene THYMOGLOBULIN THYROSAFE tiagabine TICE BCG TIKOSYN timolol maleate... 53, 90 TIMOPTIC OCUDOSE (PF) tioconazole TIVICAY tizanidine tobramycin tobramycin in % nacl tobramycin sulfate tobramycin-dexamethasone tolazamide tolbutamide tolcapone tolmetin tolnaftate tolterodine topiramate toposar topotecan TORISEL torsemide total b/c totalday multiple TOUJEO SOLOSTAR TPN ELECTROLYTES TRACLEER TRADJENTA tramadol tramadol-acetaminophen trandolapril tranexamic acid... 55, 86 tranylcypromine travasol 10 % TRAVATAN Z travel sickness travel sickness (meclizine) travoprost (benzalkonium) trazodone TREANDA TRECATOR TRELSTAR TRELSTAR DEPOT TRELSTAR LA tretinoin tretinoin (chemotherapy) TRETIN-X CREAM KIT TREXALL triamcinolone acetonide.. 63, 67, 68 triamterene-hydrochlorothiazid trianex TRIBENZOR triderm trifluoperazine trifluridine trimethoprim triple antibiotic triple antibiotic plus tri-previfem (28) TRISENOX tri-sprintec (28) TRIUMEQ TRI-VI-SOL tri-vita tri-vitamin trivora (28) trixaicin TRIXAICIN HP TRIZIVIR TROPHAMINE 10 % TROPHAMINE 6% tropicamide trospium TRULICITY TRUMENBA TRUVADA tussin tussin dm tussin expectorant TUSSIONEX PENNKINETIC ER TWINRIX (PF) TYBOST TYGACIL TYKERB TYPHIM VI

141 TYSABRI TYZEKA TYZINE U U-CORT ULORIC ultra b-100 complex unithroid ursodiol UVADEX V VAGIFEM valacyclovir VALCHLOR VALCYTE valganciclovir valproate sodium valproic acid valproic acid (as sodium salt) valsartan valsartan-hydrochlorothiazide VANACOF VANACOF DM VANACOF VANAHIST PD vancomycin VANCOMYCIN VANCOMYCIN IN D5W VANCOMYCIN IN DEXTROSE ISO- OSM VAQTA (PF) VARIVAX (PF) VARIZIG v-c forte VECAMYL VECTIBIX VELCADE velivet triphasic regimen (28) venlafaxine... 47, 48 VENLAFAXINE VENTAVIS verapamil VERSACLOZ vic-forte VICTOZA 2-PAK VICTOZA 3-PAK VIDEX 2 GRAM PEDIATRIC VIDEX 4 GRAM PEDIATRIC VIEKIRA PAK VIGAMOX VIIBRYD VIMPAT vinblastine vincasar pfs vincristine vinorelbine viorele (28) VIRACEPT VIRAMUNE XR VIRAZOLE VIREAD virtussin ac VITA-BEE WITH C vitamin a vitamin b complex vitamin b complex with c vitamin b vitamin b-100 complex vitamin b vitamin b vitamin b vitamin c , 124 VITAMIN C vitamin c cough drops vitamin c drops vitamin c with rose hips vitamin d vitamin e VITAMIN E vitamin e (dl, acetate) vitamin e acetate vitamin e mixed vitamin k vitamins & minerals vitamins a and d vitamins b complex vitamins for hair VITEKTA vits a and d-white pet-lanolin VITUZ VOLTAREN GEL voriconazole... 9 VOTRIENT W warfarin water for irrigation, sterile wee care WELCHOL white petrolatum WHOLE SOURCE MULTI- VITAMINS women's daily formula X XALKORI XARELTO XENAZINE XGEVA XIFAXAN XOLAIR XTANDI XULANE XYREM Y YERVOY YF-VAX (PF) Z zafirlukast zaleplon ZALTRAP ZANOSAR zarah ZAVESCA zazole zeasorb (miconazole) ZEGERID OTC ZELBORAF ZEMAIRA ZEMPLAR zenchent (28) zenzedi ZETIA ZIAGEN zidovudine zinc ZINC (WITH A & C) LOZENGES zinc gluconate zinc oxide zinc sulfate zinc sulfate-vitamin c ZINC zinc ziprasidone hcl ZIRGAN zoledronic acid ZOLINZA zolmitriptan zolpidem ZOMETA ZOMIG

142 ZONATUSS zonisamide zoo chews zoo friends zoo friends complete zoo friends original ZORTRESS ZOSTAVAX (PF) zovia 1/35e (28) zovia 1/50e (28) ZUTRIPRO ZYDELIG ZYKADIA ZYPREXA RELPREVV ZYTIGA ZYVOX... 16,

143 Have questions? Call us toll free at (TTY 711) Monday through Friday from 8 a.m. to 8 p.m. local time. Or visit Amerigroup STAR+PLUS MMP (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Texas Medicaid to provide benefits of both programs to enrollees. The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you. Benefits and/or co-pays may change on January 1 of each year. Limitations, co-pays and restrictions may apply. For more information, call Amerigroup STAR+PLUS MMP Member Services or read the Amerigroup STAR+PLUS MMP Member Handbook. Co-pays for prescription drugs may vary based on the level of Extra Help you receive. Please contact the plan for more details. You can get this information for free in other languages. Call us at (TTY 711), Monday through Friday from 8 a.m. to 8 p.m. local time. The call is free. Usted puede obtener esta información gratuitamente en otros idiomas. Llame al (TTY 711) de lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratuita. You can get this information for free in other formats, such as large print, braille, or audio. Call us at (TTY 711), Monday through Friday from 8 a.m. to 8 p.m. local time. The call is free. Y0005_H8786_15_23464_R CMS Approved 02/26/2015 Formulary ID: Version: 12 Issued 09/01/2015