(Comprehensive list of covered drugs)

Standard Plan 015 Prescription Drug Formulary (Comprehensive list of covered drugs) +306$SSURYHG)RUPXODU\)LOH6XEPLVVLRQ,'9HUVLRQ1XPEHU16 This document contains information about the drugs we cover in this plan. )RUPRUHUHFHQWLQIRUPDWLRQRURWKHUTXHVWLRQV SOHDVHFRQWDFW%OXH0HGLFDUH5[&XVWRPHU6HUYLFHV at 1-888-7-1 RUIRU 77<XVHUV1-888-7-15 DPWRSPGDLO\RU visit www.bcbsnc.com/member/medicare. 7KLVIRUPXODU\ZDVXSGDWHGRQ 1/01/015 + Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. + + %HQHÀWVIRUPXODU\SKDUPDF\QHWZRUNSUHPLXP DQGRUFRSD\PHQWVFRLQVXUDQFHPD\FKDQJHRQ January 1 of each year. This information may be available in a different format. Please contact Customer Service at the QXPEHUVOLVWHGDERYHLI\RXQHHGSODQLQIRUPDWLRQ in another format or language. Blue Cross Blue Shield of North Carolina is a PDP plan with a Medicare contract. Enrollment in Blue Cross Blue Shield of North Carolina depends on contract renewal. Y0079_6770 CMS Accepted 0801

When this drug list (formulary) refers to we, us, or our, it means Blue Cross and Blue Shield of North Carolina. When it refers to plan or our plan, it means Blue Medicare Rx Standard. This document includes a list of the drugs (formulary) for our plan which is current as of 1/01/015. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 015 and from time to time during the year. What is the Blue Medicare Rx Standard Formulary? A formulary is a list of covered drugs selected by Blue Medicare Rx Standard in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Blue Medicare Rx Standard will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Blue Medicare Rx Standard network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 015 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 015 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of December 1, 015. To get updated information about the drugs covered by Blue Medicare Rx Standard, please contact us. Our contact information appears on the front and back cover pages. If non-maintenance formulary changes occur during the plan year, members will be provided notice and the printable formulary will updated and posted on our website at www.bcbsnc.com/member/medicare. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart i

condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 101. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? Blue Medicare Rx Standard covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: x x x : Blue Medicare Rx Standard requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Blue Medicare Rx Standard before you fill your prescriptions. If you don t get approval, Blue Medicare Rx Standard may not cover the drug. Quantity : For certain drugs, Blue Medicare Rx Standard limits the amount of the drug that Blue Medicare Rx Standard will cover. For example, Blue Medicare Rx Standard provides per prescription for alfuzosin ER. This may be in addition to a standard one-month or three-month supply. : In some cases, Blue Medicare Rx Standard 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, Blue Medicare Rx Standard may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Blue Medicare Rx Standard will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask Blue Medicare Rx Standard to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the Blue Medicare Rx Standard s formulary? on page iii for information about how to request an exception. ii

What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Services and ask if your drug is covered. If you learn that Blue Medicare Rx Standard does not cover your drug, you have two options: x x You can ask Customer Services for a list of similar drugs that are covered by Blue Medicare Rx Standard. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Blue Medicare Rx Standard. You can ask Blue Medicare Rx Standard to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the Blue Medicare Rx Standard s Formulary? You can ask Blue Medicare Rx Standard to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. x You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. x x You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Blue Medicare Rx Standard limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, Blue Medicare Rx Standard will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 7 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 7 hours for a decision. If your request to expedite is granted, we must give you a decision no later than hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will iii

cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a maximum of 98-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. Circumstances exist in which unplanned transitions for current members could arise and in which prescribed drug regimens may not be on the formulary. These circumstances usually involve level of care changes in which a member is changing from one treatment setting to another. For these unplanned transitions, you must use our exceptions and appeals process. Coverage determinations and redeterminations will be processed as expeditiously as your health condition requires. In order to prevent a temporary gap in care when a member is discharged to home, members are permitted to have a full outpatient supply available to continue therapy once their limited supply provided at discharge is exhausted. This outpatient supply is available in advance of discharge from a Part A stay. When a member is admitted to or discharged from an LTC facility, he or she does not have access to the remainder of the previously dispensed prescription. We will ensure you have a refill upon admission or discharge. A one-time override of the refill too soon edits, are provided, for each medication which would be impacted due to a member being admitted to or discharged from an LTC facility. Early refill edits are not used to limit appropriate and necessary access to a member s Part D benefit, and such members are allowed to access a refill upon admission or discharge. For more information For more detailed information about your Blue Medicare Rx Standard prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Blue Medicare Rx Standard, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800- MEDICARE (1-800-633-7) hours a day/7 days a week. TTY users should call 1-877-86-08. Or, visit www.medicare.gov. iv

Blue Medicare Rx Standard s Formulary The formulary below provides coverage information about the drugs covered by Blue Medicare Rx Standard. If you have trouble finding your drug in the list, turn to the Index that begins on page 101. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., LANTUS) and generic drugs are listed in lower-case italics (e.g., metformin). The next column tells you whether your drug may be covered by Medicare Part B or Part D, depending on the circumstances of its use. The information in the column tells you if Blue Medicare Rx Standard has any special requirements for coverage of your drug. Most of the drugs on our formulary are also available by mail order. If you have questions about mail order please contact Customer Service. Our contact information appears on the front and back cover pages. The Drug Table includes a column titled,. This column indicates what tier each drug is listed under. The following copayments are associated with the corresponding tiers if you receive the drugs at an in-network pharmacy. These copayments apply during the initial coverage phase. Refer to your Evidence of Coverage for details about your benefits during the coverage gap and catastrophic coverage. After the $30 deductible, the following amounts apply: Preferred Retail Retail Pharmacy for a Preferred Mail Order Long Term Care Pharmacy for a 30 30 day supply Pharmacy for a 90 Pharmacy for a 31 Tier Number day supply day supply day supply Tier 1 Preferred $ copayment $10 copayment $0 copayment $10 copayment Generic Tier Non- $10 copayment $33 copayment $5 copayment $33 copayment Preferred Generic Tier 3 - Preferred $0 copayment $5 copayment $100 copayment $5 copayment Brand Tier Non- $85 copayment $95 copayment $1.50 copayment $95 copayment Preferred Brand Tier 5 Specialty 5% coinsurance 5% coinsurance 5% coinsurance 5% coinsurance X Drugs that may be covered by Medicare Part B or Medicare Part D depending on the circumstance Utilization Management:, Quantity, * Limited distribution drug. This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Customer Services at 1-888-7-1 or, for TTY users, 1-888-7-15, 8 a.m. to 8 p.m. daily Quantity limit restrictions apply. Restriction amounts are listed beginning on page 79. # High Risk Medication (HRM). Medicine that may be unsafe in patients greater than 65 years of age. Our formulary does include coverage for some of these drugs, but alternatives may be found in lower co-pay tiers. Please discuss with your doctor if there are alternatives to these medications that would be appropriate for you to use. ^ We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. v

Dosage Form Abbreviations Key act actuation aer, aero aerosol cap capsules chew tab chewable tablets conc concentrate conj conjugate CR controlled-release crys crystals DR delayed-release deter deterrent ec enteric coated ER, extended, extended rel, XL, XR extended-release g, gm gram hr hour IR immediate-release inh, inhal inhalation inj injection im intramuscular iv intravenous liqd liquid LA long acting mcg microgram meq milliequivalent mg milligram ml milliliter nebu nebules NF non-formulary odt, orally disintegrating tab orally disintegrating tablets oint ointment op, ophth ophthalmic pow, powd powder pf preservative-free sl sublingual soln solution suppos suppositories susp suspension sr sustained-release tab tablets td transdermal tl translingual unt unit vac Vaccine vi

Analgesics acetaminophen w/ codeine soln 10-1 mg/5ml acetaminophen w/ codeine tab 300-15 mg acetaminophen w/ codeine tab 300-30 mg acetaminophen w/ codeine tab 300-60 mg butorphanol tartrate inj 1 mg/ml butorphanol tartrate inj mg/ml diclofenac potassium tab 50 mg diclofenac sodium tab delayed release 5 mg diclofenac sodium tab delayed release 50 mg diclofenac sodium tab delayed release 75 mg diclofenac sodium tab sr hr 100 mg etodolac cap 00 mg etodolac cap 300 mg etodolac tab 00 mg etodolac tab 500 mg fentanyl citrate lozenge on a handle 00 mcg fentanyl citrate lozenge on a handle 00 mcg fentanyl citrate lozenge on a handle 600 mcg fentanyl citrate lozenge on a handle 800 mcg fentanyl citrate lozenge on a handle 100 mcg fentanyl citrate lozenge on a handle 1600 mcg fentanyl td patch 7hr 1 mcg/hr fentanyl td patch 7hr 5 mcg/hr fentanyl td patch 7hr 50 mcg/hr fentanyl td patch 7hr 75 mcg/hr fentanyl td patch 7hr 100 mcg/hr hydrocodone-acetaminophen soln 7.5-35 mg/15ml hydrocodone-acetaminophen tab 10-35 mg hydrocodone-acetaminophen tab 5-300 mg hydrocodone-acetaminophen tab 7.5-300 mg hydrocodone-acetaminophen tab 5-35 mg hydrocodone-acetaminophen tab 7.5-35 mg hydrocodone-acetaminophen tab 10-300 mg hydromorphone hcl liqd 1 mg/ml hydromorphone hcl preservative free (pf) inj 10 mg/ml X hydromorphone hcl tab mg hydromorphone hcl tab mg hydromorphone hcl tab 8 mg ibuprofen tab 00 mg 1 ibuprofen tab 600 mg 1 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 1

ibuprofen tab 800 mg 1 ketorolac tromethamine tab 10 mg# LAZANDA - fentanyl citrate nasal spray 100 mcg/act LAZANDA - fentanyl citrate nasal spray 00 mcg/act meloxicam tab 7.5 mg 1 meloxicam tab 15 mg 1 methadone hcl tab 5 mg methadone hcl tab 10 mg MORPHINE SULFATE - morphine sulfate tab 15 mg MORPHINE SULFATE - morphine sulfate tab 30 mg morphine sulfate inj pf 0.5 mg/ml X morphine sulfate inj pf 1 mg/ml X morphine sulfate tab cr 15 mg morphine sulfate tab cr 30 mg morphine sulfate tab cr 60 mg morphine sulfate tab cr 100 mg morphine sulfate tab cr 00 mg nabumetone tab 500 mg nabumetone tab 750 mg naproxen tab 50 mg 1 naproxen tab 375 mg 1 naproxen tab 500 mg 1 oxycodone hcl tab 5 mg oxycodone hcl tab 10 mg oxycodone hcl tab 15 mg oxycodone hcl tab 0 mg oxycodone hcl tab 30 mg oxycodone w/ acetaminophen tab.5-35 mg oxycodone w/ acetaminophen tab 5-35 mg oxycodone w/ acetaminophen tab 7.5-35 mg oxycodone w/ acetaminophen tab 10-35 mg sulindac tab 150 mg sulindac tab 00 mg tramadol hcl tab 50 mg VOLTAREN - diclofenac sodium gel 1% ZOHYDRO ER - hydrocodone bitartrate cap sr 1hr abusedeterrent 10 mg ZOHYDRO ER - hydrocodone bitartrate cap sr 1hr abusedeterrent 15 mg ZOHYDRO ER - hydrocodone bitartrate cap sr 1hr abusedeterrent 0 mg ZOHYDRO ER - hydrocodone bitartrate cap sr 1hr abusedeterrent 30 mg ZOHYDRO ER - hydrocodone bitartrate cap sr 1hr abusedeterrent 0 mg 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM)

ZOHYDRO ER - hydrocodone bitartrate cap sr 1hr abusedeterrent 50 mg ZOHYDRO ER - hydrocodone bitartrate cap sr 1hr 10 mg ZOHYDRO ER - hydrocodone bitartrate cap sr 1hr 15 mg ZOHYDRO ER - hydrocodone bitartrate cap sr 1hr 0 mg ZOHYDRO ER - hydrocodone bitartrate cap sr 1hr 30 mg ZOHYDRO ER - hydrocodone bitartrate cap sr 1hr 0 mg ZOHYDRO ER - hydrocodone bitartrate cap sr 1hr 50 mg Anesthetics lidocaine hcl gel % lidocaine hcl local inj 1% lidocaine hcl local preservative free (pf) inj 1% lidocaine hcl soln % lidocaine hcl viscous soln % lidocaine patch 5% lidocaine-prilocaine cream.5-.5% Anti-Addiction/Substance Abuse Treatment Agents acamprosate calcium tab delayed release 333 mg buprenorphine hcl sl tab mg buprenorphine hcl sl tab 8 mg buprenorphine hcl-naloxone hcl sl tab -0.5 mg buprenorphine hcl-naloxone hcl sl tab 8- mg bupropion hcl (smoking deterrent) tab sr 1hr 150 mg CHANTIX - varenicline tartrate tab 0.5 mg CHANTIX - varenicline tartrate tab 1 mg CHANTIX CONTINUING MONTH - varenicline tartrate tab 1 mg CHANTIX STARTING MONTH PACK - varenicline tartrate tab 0.5 mg x 11 & tab 1 mg x pack disulfiram tab 50 mg disulfiram tab 500 mg naloxone hcl inj 0. mg/ml naloxone hcl inj 1 mg/ml naltrexone hcl tab 50 mg NICOTROL INHALER - nicotine inhaler system 10 mg ( mg delivered) NICOTROL NS - nicotine nasal spray 10 mg/ml (0.5 mg/spray) SUBOXONE - buprenorphine hclnaloxone hcl sl film -0.5 mg SUBOXONE - buprenorphine hclnaloxone hcl sl film -1 mg SUBOXONE - buprenorphine hclnaloxone hcl sl film 8- mg SUBOXONE - buprenorphine hclnaloxone hcl sl film 1-3 mg 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 3

Antibacterials amikacin sulfate inj 500 mg/ml (50 mg/ml) amikacin sulfate inj 1 gm/ml (50 mg/ml) amoxicillin (trihydrate) cap 1 50 mg amoxicillin (trihydrate) cap 500 mg amoxicillin (trihydrate) for susp 15 mg/5ml amoxicillin (trihydrate) for susp 00 mg/5ml amoxicillin (trihydrate) for susp 50 mg/5ml amoxicillin (trihydrate) for susp 00 mg/5ml amoxicillin (trihydrate) tab 500 mg amoxicillin (trihydrate) tab 875 mg amoxicillin & k clavulanate chew tab 00-8.5 mg amoxicillin & k clavulanate chew tab 00-57 mg amoxicillin & k clavulanate tab 50-15 mg amoxicillin & k clavulanate tab 500-15 mg amoxicillin & k clavulanate tab 875-15 mg AMPICILLIN - ampicillin for susp 15 mg/5ml AMPICILLIN - ampicillin for susp 50 mg/5ml ampicillin & sulbactam sodium for inj -1 gm ampicillin cap 50 mg 1 ampicillin cap 500 mg ampicillin sodium for inj 50 mg ampicillin sodium for inj 500 mg ampicillin sodium for inj 1 gm ampicillin sodium for inj gm AVELOX - moxifloxacin hcl 00 mg/50ml in sodium chloride 0.8% inj azithromycin for susp 100 mg/5ml azithromycin for susp 00 mg/5ml azithromycin iv for soln 500 mg azithromycin tab 50 mg azithromycin tab 500 mg azithromycin tab 600 mg aztreonam for inj 1 gm aztreonam for inj gm BICILLIN L-A - penicillin g benzathine intramuscular susp 600000 unit/ml BICILLIN L-A - penicillin g benzathine intramuscular susp 100000 unit/ml BICILLIN L-A - penicillin g benzathine intramuscular susp 00000 unit/ml cefaclor cap 50 mg cefaclor cap 500 mg 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM)

cefazolin sodium for inj 500 mg cefazolin sodium for inj 1 gm cefdinir cap 300 mg cefdinir for susp 15 mg/5ml cefdinir for susp 50 mg/5ml cefepime hcl for inj 1 gm cefepime hcl for inj gm cefotaxime sodium for inj 500 mg cefotaxime sodium for inj 1 gm cefotaxime sodium for inj gm cefotaxime sodium for inj 10 gm cefoxitin sodium for iv soln 1 gm cefoxitin sodium for iv soln gm cefprozil tab 50 mg cefprozil tab 500 mg ceftazidime for inj 1 gm ceftazidime for inj gm ceftazidime for inj 6 gm ceftazidime for iv soln 1 gm ceftazidime for iv soln gm ceftriaxone sodium for inj 50 mg ceftriaxone sodium for inj 500 mg ceftriaxone sodium for inj 1 gm ceftriaxone sodium for inj gm ceftriaxone sodium for inj 10 gm ceftriaxone sodium for iv soln 1 gm ceftriaxone sodium for iv soln gm cefuroxime axetil tab 50 mg cefuroxime axetil tab 500 mg cefuroxime sodium for inj 750 mg cefuroxime sodium for inj 1.5 gm cefuroxime sodium for inj 7.5 gm cefuroxime sodium for iv soln 1.5 gm cephalexin cap 50 mg 1 cephalexin cap 500 mg cephalexin for susp 15 mg/5ml cephalexin for susp 50 mg/5ml CHLORAMPHENICOL SODIUM SUCCINATE - chloramphenicol sodium succinate for iv inj 1 gm ciprofloxacin hcl tab 100 mg ciprofloxacin hcl tab 50 mg ciprofloxacin hcl tab 500 mg ciprofloxacin hcl tab 750 mg ciprofloxacin iv soln 00 mg/0ml (1%) ciprofloxacin iv soln 00 mg/0ml (1%) ciprofloxacin 00 mg/100ml in d5w ciprofloxacin 00 mg/00ml in d5w clarithromycin for susp 15 mg/5ml clarithromycin for susp 50 mg/5ml clarithromycin tab 50 mg 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 5

clarithromycin tab 500 mg clindamycin hcl cap 75 mg clindamycin hcl cap 150 mg clindamycin hcl cap 300 mg clindamycin phosphate inj 300 mg/ml clindamycin phosphate inj 600 mg/ml clindamycin phosphate inj 900 mg/6ml clindamycin phosphate inj 9 gm/60ml clindamycin phosphate iv soln 600 mg/ml clindamycin phosphate iv soln 900 mg/6ml clindamycin phosphate vaginal cream % colistimethate sodium for inj 150 mg DALVANCE - dalbavancin hcl for 5 iv soln 500 mg dicloxacillin sodium cap 50 mg dicloxacillin sodium cap 500 mg doxycycline hyclate cap 50 mg doxycycline hyclate cap 100 mg doxycycline hyclate for inj 100 mg doxycycline hyclate tab 100 mg ERY-TAB - erythromycin tab delayed release 50 mg ERY-TAB - erythromycin tab delayed release 333 mg ERY-TAB - erythromycin tab delayed release 500 mg ERYTHROCIN LACTOBIONATE - erythromycin lactobionate for inj 500 mg ERYTHROCIN LACTOBIONATE - erythromycin lactobionate for inj 1000 mg ERYTHROMYCIN BASE - erythromycin tab 50 mg ERYTHROMYCIN BASE - erythromycin tab 500 mg gentamicin sulfate inj 10 mg/ml gentamicin sulfate inj 0 mg/ml gentamicin sulfate iv soln 10 mg/ ml imipenem-cilastatin intravenous for soln 50 mg imipenem-cilastatin intravenous for soln 500 mg levofloxacin in d5w iv soln 50 mg/50ml levofloxacin in d5w iv soln 500 mg/100ml levofloxacin in d5w iv soln 750 mg/150ml levofloxacin iv soln 5 mg/ml levofloxacin oral soln 5 mg/ml levofloxacin tab 50 mg levofloxacin tab 500 mg 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 6

levofloxacin tab 750 mg linezolid iv soln mg/ml 5 linezolid tab 600 mg meropenem iv for soln 500 mg meropenem iv for soln 1 gm metronidazole in nacl 0.79% iv soln 500 mg/100ml metronidazole tab 50 mg metronidazole tab 500 mg metronidazole vaginal gel 0.75% minocycline hcl cap 50 mg 1 minocycline hcl cap 75 mg minocycline hcl cap 100 mg NAFCILLIN SODIUM - nafcillin sodium for iv soln 1 gm NAFCILLIN SODIUM - nafcillin sodium for iv soln gm nafcillin sodium for inj 1 gm nafcillin sodium for inj gm nafcillin sodium for inj 10 gm neomycin sulfate tab 500 mg nitrofurantoin macrocrystalline cap 50 mg# nitrofurantoin macrocrystalline cap 100 mg# nitrofurantoin monohydrate macrocrystalline cap 100 mg# paromomycin sulfate cap 50 mg penicillin g potassium for inj 5000000 unit PENICILLIN G POTASSIUM IN DEXTROSE - penicillin g potassium inj 0000 unit/ml in dextrose PENICILLIN G POTASSIUM IN DEXTROSE - penicillin g potassium inj 0000 unit/ml in dextrose PENICILLIN G POTASSIUM IN DEXTROSE - penicillin g potassium inj 60000 unit/ml in dextrose penicillin v potassium for soln 15 mg/5ml penicillin v potassium for soln 50 mg/5ml penicillin v potassium tab 50 mg penicillin v potassium tab 500 mg piperacillin sodium-tazobactam sodium for inj -0.5 gm piperacillin sodium-tazobactam sodium for inj 3-0.375 gm piperacillin sodium-tazobactam sodium for inj -0.5 gm SIVEXTRO - tedizolid phosphate tab 00 mg SIVEXTRO - tedizolid phosphate for iv soln 00 mg STREPTOMYCIN SULFATE - streptomycin sulfate for inj 1 gm SULFADIAZINE - sulfadiazine tab 500 mg 5 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 7

sulfamethoxazole-trimethoprim susp 00-0 mg/5ml sulfamethoxazole-trimethoprim 1 tab 00-80 mg sulfamethoxazole-trimethoprim 1 tab 800-160 mg SULFAMETHOXAZOLE/ TRIMETHOPRIM - sulfamethoxazole-trimethoprim iv soln 00-80 mg/5ml SUPRAX - cefixime cap 00 mg SUPRAX - cefixime chew tab 100 mg SUPRAX - cefixime chew tab 00 mg SYNERCID - quinupristindalfopristin for inj 500 mg 5 (150-350 mg) TEFLARO - ceftaroline fosamil for iv soln 00 mg TEFLARO - ceftaroline fosamil for iv soln 600 mg TETRACYCLINE HCL - tetracycline hcl cap 50 mg TETRACYCLINE HCL - tetracycline hcl cap 500 mg tobramycin sulfate inj 10 mg/ml tobramycin sulfate inj 80 mg/ml (0 mg/ml) tobramycin sulfate inj 1. gm/30ml (0 mg/ml) tobramycin sulfate inj gm/50ml (0 mg/ml) trimethoprim tab 100 mg TYGACIL - tigecycline for iv soln 50 mg vancomycin hcl cap 15 mg 5 vancomycin hcl cap 50 mg 5 vancomycin hcl for inj 500 mg vancomycin hcl for inj 1000 mg vancomycin hcl for inj 5000 mg vancomycin hcl for inj 10 gm XIFAXAN - rifaximin tab 550 mg 5 ZYVOX - linezolid tab 600 mg ZYVOX - linezolid for susp 100 mg/5ml ZYVOX - linezolid iv soln mg/ml 5 Anticonvulsants APTIOM - eslicarbazepine acetate tab 00 mg APTIOM - eslicarbazepine acetate tab 00 mg APTIOM - eslicarbazepine acetate tab 600 mg APTIOM - eslicarbazepine acetate tab 800 mg BANZEL - rufinamide susp 5 0 mg/ml BANZEL - rufinamide tab 00 mg BANZEL - rufinamide tab 00 mg 5 carbamazepine cap sr 1hr 100 mg carbamazepine cap sr 1hr 00 mg 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 8

carbamazepine cap sr 1hr 300 mg carbamazepine chew tab 100 mg 1 carbamazepine susp 100 mg/5ml carbamazepine tab sr 1hr 00 mg carbamazepine tab sr 1hr 00 mg carbamazepine tab 00 mg 1 CELONTIN - methsuximide cap 300 mg clonazepam orally disintegrating tab 0.15 mg clonazepam orally disintegrating tab 0.5 mg clonazepam orally disintegrating tab 0.5 mg clonazepam orally disintegrating tab 1 mg clonazepam orally disintegrating tab mg clonazepam tab 0.5 mg clonazepam tab 1 mg clonazepam tab mg clorazepate dipotassium tab 3.75 mg clorazepate dipotassium tab 7.5 mg clorazepate dipotassium tab 15 mg DIAZEPAM - diazepam soln 1 mg/ml DIAZEPAM - diazepam rectal gel delivery system.5 mg DIAZEPAM - diazepam rectal gel delivery system 10 mg DIAZEPAM - diazepam rectal gel delivery system 0 mg diazepam tab mg diazepam tab 5 mg diazepam tab 10 mg DILANTIN - phenytoin sodium extended cap 30 mg divalproex sodium cap sprinkle 15 mg divalproex sodium tab delayed release 15 mg divalproex sodium tab delayed release 50 mg divalproex sodium tab delayed release 500 mg divalproex sodium tab sr hr 50 mg divalproex sodium tab sr hr 500 mg ethosuximide cap 50 mg ethosuximide soln 50 mg/5ml felbamate susp 600 mg/5ml felbamate tab 00 mg felbamate tab 600 mg fosphenytoin sodium inj 100 mg/ml 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 9

fosphenytoin sodium inj 500 mg/10ml FYCOMPA - perampanel tab mg FYCOMPA - perampanel tab mg FYCOMPA - perampanel tab 6 mg FYCOMPA - perampanel tab 8 mg FYCOMPA - perampanel tab 10 mg FYCOMPA - perampanel tab 1 mg gabapentin cap 100 mg 1 gabapentin cap 300 mg gabapentin cap 00 mg gabapentin oral soln 50 mg/5ml gabapentin tab 600 mg gabapentin tab 800 mg LAMICTAL ODT - lamotrigine orally disintegrating tab 5 mg LAMICTAL ODT - lamotrigine orally disintegrating tab 50 mg LAMICTAL ODT - lamotrigine orally disintegrating tab 100 mg LAMICTAL ODT - lamotrigine orally disintegrating tab 00 mg lamotrigine orally disintegrating tab 5 mg lamotrigine orally disintegrating tab 50 mg lamotrigine orally disintegrating tab 100 mg lamotrigine orally disintegrating tab 00 mg lamotrigine tab chewable dispersible 5 mg lamotrigine tab chewable dispersible 5 mg lamotrigine tab 5 mg lamotrigine tab 100 mg 1 lamotrigine tab 150 mg lamotrigine tab 00 mg levetiracetam inj 500 mg/5ml (100 mg/ml) levetiracetam oral soln 100 mg/ml levetiracetam tab 50 mg levetiracetam tab 500 mg levetiracetam tab 750 mg levetiracetam tab 1000 mg LYRICA - pregabalin soln 0 mg/ 3 ml LYRICA - pregabalin cap 5 mg 3 LYRICA - pregabalin cap 50 mg 3 LYRICA - pregabalin cap 75 mg 3 LYRICA - pregabalin cap 100 mg 3 LYRICA - pregabalin cap 150 mg 3 LYRICA - pregabalin cap 00 mg 3 LYRICA - pregabalin cap 5 mg 3 LYRICA - pregabalin cap 300 mg 3 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 10

ONFI - clobazam suspension.5 mg/ml ONFI - clobazam tab 5 mg ONFI - clobazam tab 10 mg ONFI - clobazam tab 0 mg oxcarbazepine susp 300 mg/5ml (60 mg/ml) oxcarbazepine tab 150 mg oxcarbazepine tab 300 mg oxcarbazepine tab 600 mg PEGANONE - ethotoin tab 50 mg PHENOBARBITAL - phenobarbital tab 15 mg# PHENOBARBITAL - phenobarbital tab 30 mg# PHENOBARBITAL - phenobarbital tab 60 mg# PHENOBARBITAL - phenobarbital tab 100 mg# phenobarbital elixir 0 mg/5ml# PHENOBARBITAL SODIUM - phenobarbital sodium inj 65 mg/ ml# phenobarbital sodium inj 130 mg/ ml# phenobarbital tab 16. mg# phenobarbital tab 3. mg# phenobarbital tab 6.8 mg# phenobarbital tab 97. mg# phenytoin chew tab 50 mg phenytoin sodium extended cap 100 mg phenytoin sodium extended cap 00 mg phenytoin sodium extended cap 300 mg phenytoin susp 15 mg/5ml POTIGA - ezogabine tab 50 mg POTIGA - ezogabine tab 00 mg POTIGA - ezogabine tab 300 mg POTIGA - ezogabine tab 00 mg primidone tab 50 mg primidone tab 50 mg SABRIL - vigabatrin tab 500 mg SABRIL - vigabatrin powd pack 500 mg TEGRETOL-XR - carbamazepine tab sr 1hr 100 mg tiagabine hcl tab mg tiagabine hcl tab mg topiramate sprinkle cap 15 mg topiramate sprinkle cap 5 mg topiramate tab 5 mg 1 topiramate tab 50 mg 1 topiramate tab 100 mg topiramate tab 00 mg valproate sodium inj 100 mg/ml valproate sodium syrup 50 mg/5ml valproic acid cap 50 mg 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 11

VIMPAT - lacosamide tab 50 mg 3 VIMPAT - lacosamide tab 100 mg 3 VIMPAT - lacosamide tab 150 mg 3 VIMPAT - lacosamide tab 00 mg 3 VIMPAT - lacosamide iv inj 3 00 mg/0ml (10 mg/ml) VIMPAT - lacosamide oral 3 solution 10 mg/ml zonisamide cap 5 mg zonisamide cap 50 mg zonisamide cap 100 mg Antidementia Agents donepezil hydrochloride orally disintegrating tab 5 mg donepezil hydrochloride orally disintegrating tab 10 mg donepezil hydrochloride tab 5 mg donepezil hydrochloride tab 1 10 mg donepezil hydrochloride tab 3 mg ergoloid mesylates tab 1 mg# EXELON - rivastigmine td patch 3 hr.6 mg/hr EXELON - rivastigmine td patch 3 hr 9.5 mg/hr EXELON - rivastigmine td patch 3 hr 13.3 mg/hr galantamine hydrobromide cap sr hr 8 mg galantamine hydrobromide cap sr hr 16 mg galantamine hydrobromide cap sr hr mg galantamine hydrobromide oral soln mg/ml galantamine hydrobromide tab mg galantamine hydrobromide tab 8 mg galantamine hydrobromide tab 1 mg memantine hcl oral solution mg/ ml memantine hcl tab 5 mg memantine hcl tab 10 mg memantine hcl tab 5 mg (8) & 10 mg (1) titration pak NAMENDA - memantine hcl oral solution mg/ml NAMENDA - memantine hcl tab 5 mg NAMENDA - memantine hcl tab 10 mg NAMENDA TITRATION PAK - memantine hcl tab 5 mg (8) & 10 mg (1) titration pak NAMENDA XR - memantine hcl cap sr hr 7 mg NAMENDA XR - memantine hcl cap sr hr 1 mg NAMENDA XR - memantine hcl cap sr hr 1 mg 3 3 3 3 3 3 3 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 1

NAMENDA XR - memantine hcl 3 cap sr hr 8 mg NAMENDA XR TITRATION PACK 3 - memantine hcl cap sr hr 7 mg & 1 mg & 1 mg & 8 mg pack rivastigmine tartrate cap 1.5 mg rivastigmine tartrate cap 3 mg rivastigmine tartrate cap.5 mg rivastigmine tartrate cap 6 mg rivastigmine td patch hr.6 mg/hr rivastigmine td patch hr 9.5 mg/hr rivastigmine td patch hr 13.3 mg/hr Antidepressants ABILIFY - aripiprazole tab mg ABILIFY - aripiprazole tab 5 mg ABILIFY - aripiprazole tab 10 mg ABILIFY - aripiprazole tab 15 mg ABILIFY - aripiprazole tab 0 mg ABILIFY - aripiprazole tab 30 mg ABILIFY MAINTENA - aripiprazole im for extended release susp 300 mg ABILIFY MAINTENA - aripiprazole im for extended release susp 00 mg amitriptyline hcl tab 10 mg# amitriptyline hcl tab 5 mg# amitriptyline hcl tab 50 mg# amitriptyline hcl tab 75 mg# amitriptyline hcl tab 100 mg# amitriptyline hcl tab 150 mg# AMOXAPINE - amoxapine tab 5 mg AMOXAPINE - amoxapine tab 50 mg AMOXAPINE - amoxapine tab 100 mg AMOXAPINE - amoxapine tab 150 mg ARIPIPRAZOLE ODT - aripiprazole orally disintegrating tab 10 mg ARIPIPRAZOLE ODT - aripiprazole orally disintegrating tab 15 mg aripiprazole oral solution 1 mg/ml aripiprazole tab mg aripiprazole tab 5 mg aripiprazole tab 10 mg aripiprazole tab 15 mg aripiprazole tab 0 mg aripiprazole tab 30 mg BRINTELLIX - vortioxetine hbr tab 5 mg BRINTELLIX - vortioxetine hbr tab 10 mg BRINTELLIX - vortioxetine hbr tab 0 mg 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 13

bupropion hcl tab sr 1hr 100 mg bupropion hcl tab sr 1hr 150 mg bupropion hcl tab sr 1hr 00 mg bupropion hcl tab sr hr 150 mg bupropion hcl tab sr hr 300 mg bupropion hcl tab 75 mg bupropion hcl tab 100 mg citalopram hydrobromide oral soln 10 mg/5ml citalopram hydrobromide tab 1 10 mg citalopram hydrobromide tab 1 0 mg citalopram hydrobromide tab 0 mg 1 clomipramine hcl cap 5 mg# clomipramine hcl cap 50 mg# clomipramine hcl cap 75 mg# desipramine hcl tab 10 mg desipramine hcl tab 5 mg desipramine hcl tab 50 mg desipramine hcl tab 75 mg desipramine hcl tab 100 mg desipramine hcl tab 150 mg doxepin hcl cap 10 mg# doxepin hcl cap 5 mg# doxepin hcl cap 50 mg# doxepin hcl cap 100 mg# doxepin hcl cap 150 mg# doxepin hcl conc 10 mg/ml# duloxetine hcl enteric coated pellets cap 0 mg duloxetine hcl enteric coated pellets cap 30 mg duloxetine hcl enteric coated pellets cap 60 mg EMSAM - selegiline td patch hr 5 6 mg/hr EMSAM - selegiline td patch hr 5 9 mg/hr EMSAM - selegiline td patch hr 5 1 mg/hr escitalopram oxalate soln 5 mg/5ml escitalopram oxalate tab 5 mg 1 escitalopram oxalate tab 10 mg 1 escitalopram oxalate tab 0 mg 1 FETZIMA - levomilnacipran hcl cap sr hr 0 mg FETZIMA - levomilnacipran hcl cap sr hr 0 mg FETZIMA - levomilnacipran hcl cap sr hr 80 mg FETZIMA - levomilnacipran hcl cap sr hr 10 mg FETZIMA TITRATION PACK - levomilnacipran hcl cap sr hr 0 & 0 mg therapy pack fluoxetine hcl cap 10 mg 1 fluoxetine hcl cap 0 mg 1 fluoxetine hcl cap 0 mg 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 1

fluoxetine hcl solution 0 mg/5ml fluoxetine hcl tab 10 mg fluoxetine hcl tab 0 mg fluvoxamine maleate tab 5 mg fluvoxamine maleate tab 50 mg fluvoxamine maleate tab 100 mg imipramine hcl tab 10 mg# imipramine hcl tab 5 mg# imipramine hcl tab 50 mg# MAPROTILINE HCL - maprotiline hcl tab 5 mg MAPROTILINE HCL - maprotiline hcl tab 50 mg MAPROTILINE HCL - maprotiline hcl tab 75 mg MARPLAN - isocarboxazid tab 10 mg mirtazapine orally disintegrating tab 15 mg mirtazapine orally disintegrating tab 30 mg mirtazapine orally disintegrating tab 5 mg mirtazapine tab 7.5 mg mirtazapine tab 15 mg 1 mirtazapine tab 30 mg 1 mirtazapine tab 5 mg NEFAZODONE HCL - nefazodone hcl tab 100 mg NEFAZODONE HCL - nefazodone hcl tab 150 mg NEFAZODONE HCL - nefazodone hcl tab 00 mg nefazodone hcl tab 50 mg nefazodone hcl tab 50 mg NORTRIPTYLINE HCL - nortriptyline hcl soln 10 mg/5ml nortriptyline hcl cap 10 mg 1 nortriptyline hcl cap 5 mg 1 nortriptyline hcl cap 50 mg 1 nortriptyline hcl cap 75 mg paroxetine hcl tab sr hr 1.5 mg paroxetine hcl tab sr hr 5 mg paroxetine hcl tab sr hr 37.5 mg paroxetine hcl tab 10 mg 1 paroxetine hcl tab 0 mg 1 paroxetine hcl tab 30 mg 1 paroxetine hcl tab 0 mg 1 PAXIL - paroxetine hcl oral susp 10 mg/5ml phenelzine sulfate tab 15 mg PRISTIQ - desvenlafaxine succinate tab sr hr 5 mg PRISTIQ - desvenlafaxine succinate tab sr hr 50 mg PRISTIQ - desvenlafaxine succinate tab sr hr 100 mg protriptyline hcl tab 5 mg protriptyline hcl tab 10 mg 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 15

quetiapine fumarate tab 5 mg quetiapine fumarate tab 50 mg quetiapine fumarate tab 100 mg quetiapine fumarate tab 00 mg quetiapine fumarate tab 300 mg quetiapine fumarate tab 00 mg REXULTI - brexpiprazole tab 0.5 mg REXULTI - brexpiprazole tab 0.5 mg REXULTI - brexpiprazole tab 1 mg REXULTI - brexpiprazole tab mg REXULTI - brexpiprazole tab 3 mg REXULTI - brexpiprazole tab mg SEROQUEL XR - quetiapine fumarate tab sr hr 50 mg SEROQUEL XR - quetiapine fumarate tab sr hr 150 mg SEROQUEL XR - quetiapine fumarate tab sr hr 00 mg SEROQUEL XR - quetiapine fumarate tab sr hr 300 mg SEROQUEL XR - quetiapine fumarate tab sr hr 00 mg sertraline hcl oral conc 0 mg/ml sertraline hcl tab 5 mg 1 sertraline hcl tab 50 mg 1 sertraline hcl tab 100 mg 1 SURMONTIL - trimipramine maleate cap 5 mg# SURMONTIL - trimipramine maleate cap 50 mg# SURMONTIL - trimipramine maleate cap 100 mg# tranylcypromine sulfate tab 10 mg trazodone hcl tab 50 mg 1 trazodone hcl tab 100 mg 1 trazodone hcl tab 150 mg 1 trazodone hcl tab 300 mg trimipramine maleate cap 5 mg# trimipramine maleate cap 50 mg# trimipramine maleate cap 100 mg# venlafaxine hcl cap sr hr 37.5 mg venlafaxine hcl cap sr hr 75 mg venlafaxine hcl cap sr hr 150 mg venlafaxine hcl tab 5 mg venlafaxine hcl tab 37.5 mg venlafaxine hcl tab 50 mg venlafaxine hcl tab 75 mg venlafaxine hcl tab 100 mg VIIBRYD - vilazodone hcl tab 10 mg VIIBRYD - vilazodone hcl tab 0 mg 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 16

VIIBRYD - vilazodone hcl tab 0 mg VIIBRYD - vilazodone hcl tab starter kit 10 (7) & 0 (7) & 0 (16) mg VIIBRYD STARTER PACK - vilazodone hcl tab starter kit 10 (7) & 0 (3) mg Antiemetics ALOXI - palonosetron hcl iv soln 0.5 mg/5ml CHLORPROMAZINE HCL - chlorpromazine hcl inj 5 mg/ml CHLORPROMAZINE HCL - chlorpromazine hcl inj 50 mg/ml chlorpromazine hcl tab 10 mg chlorpromazine hcl tab 5 mg chlorpromazine hcl tab 50 mg chlorpromazine hcl tab 100 mg chlorpromazine hcl tab 00 mg diphenhydramine hcl inj 50 mg/ml dronabinol cap.5 mg X dronabinol cap 5 mg X dronabinol cap 10 mg X EMEND - aprepitant capsule therapy pack 80 & 15 mg EMEND - fosaprepitant dimeglumine for iv infusion 150 mg EMEND - aprepitant capsule 0 mg 3 X 3 X EMEND - aprepitant capsule 3 X 80 mg EMEND - aprepitant capsule 3 X 15 mg meclizine hcl tab 1.5 mg metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) metoclopramide hcl tab 5 mg 1 metoclopramide hcl tab 10 mg 1 ondansetron hcl inj mg/ml ( mg/ml) ondansetron hcl inj 0 mg/0ml ( mg/ml) ondansetron orally disintegrating X tab mg ondansetron orally disintegrating X tab 8 mg perphenazine tab mg perphenazine tab mg perphenazine tab 8 mg perphenazine tab 16 mg prochlorperazine edisylate inj 5 mg/ml prochlorperazine maleate tab 5 mg prochlorperazine maleate tab 10 mg prochlorperazine suppos 5 mg promethazine hcl syrup 6.5 mg/5ml# 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 17

Antifungals AMBISOME - amphotericin b 5 X liposome iv for susp 50 mg AMPHOTERICIN B - X amphotericin b for inj 50 mg CANCIDAS - caspofungin acetate 5 for iv soln 50 mg CANCIDAS - caspofungin acetate 5 for iv soln 70 mg clotrimazole troche 10 mg CRESEMBA - isavuconazonium sulfate cap 186 mg CRESEMBA - isavuconazonium sulfate for iv soln 37 mg fluconazole for susp 10 mg/ml fluconazole for susp 0 mg/ml fluconazole in dextrose inj 00 mg/100ml fluconazole in dextrose inj 00 mg/00ml fluconazole in nacl 0.9% inj 00 mg/100ml fluconazole in nacl 0.9% inj 00 mg/00ml fluconazole tab 50 mg fluconazole tab 100 mg fluconazole tab 150 mg fluconazole tab 00 mg flucytosine cap 50 mg 5 flucytosine cap 500 mg 5 griseofulvin microsize susp 15 mg/5ml itraconazole cap 100 mg ketoconazole tab 00 mg MYCAMINE - micafungin sodium for iv soln 50 mg MYCAMINE - micafungin sodium 5 for iv soln 100 mg NOXAFIL - posaconazole susp 0 mg/ml NOXAFIL - posaconazole iv soln 300 mg/16.7ml (18 mg/ml) nystatin susp 100000 unit/ml terbinafine hcl tab 50 mg 1 terconazole vaginal cream 0.% terconazole vaginal cream 0.8% voriconazole for inj 00 mg voriconazole for susp 0 mg/ml voriconazole tab 50 mg voriconazole tab 00 mg Antigout Agents allopurinol tab 100 mg 1 allopurinol tab 300 mg 1 colchicine w/ probenecid tab 0.5-500 mg COLCRYS - colchicine tab 0.6 mg 3 probenecid tab 500 mg ULORIC - febuxostat tab 0 mg 3 ULORIC - febuxostat tab 80 mg 3 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 18

Anti-Inflammatory Agents diclofenac potassium tab 50 mg diclofenac sodium tab delayed release 5 mg diclofenac sodium tab delayed release 50 mg diclofenac sodium tab delayed release 75 mg diclofenac sodium tab sr hr 100 mg etodolac cap 00 mg etodolac cap 300 mg etodolac tab 00 mg etodolac tab 500 mg ibuprofen tab 00 mg 1 ibuprofen tab 600 mg 1 ibuprofen tab 800 mg 1 meloxicam tab 7.5 mg 1 meloxicam tab 15 mg 1 nabumetone tab 500 mg nabumetone tab 750 mg naproxen tab 50 mg 1 naproxen tab 375 mg 1 naproxen tab 500 mg 1 sulindac tab 150 mg sulindac tab 00 mg VOLTAREN - diclofenac sodium gel 1% Antimigraine Agents butalbital-acetaminophen-caff w/ cod cap 50-300-0-30 mg# butalbital-acetaminophen-caff w/ cod cap 50-35-0-30 mg# butalbital-aspirin-caff w/ codeine cap 50-35-0-30 mg# divalproex sodium cap sprinkle 15 mg divalproex sodium tab delayed release 15 mg divalproex sodium tab delayed release 50 mg divalproex sodium tab delayed release 500 mg divalproex sodium tab sr hr 50 mg divalproex sodium tab sr hr 500 mg MIGERGOT - ergotamine w/ caffeine suppos -100 mg MIGRANAL - dihydroergotamine mesylate nasal spray mg/ml naratriptan hcl tab 1 mg naratriptan hcl tab.5 mg propranolol hcl inj 1 mg/ml propranolol hcl tab 10 mg 1 propranolol hcl tab 0 mg 1 propranolol hcl tab 0 mg 1 propranolol hcl tab 80 mg 1 rizatriptan benzoate orally disintegrating tab 5 mg 3 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 19

rizatriptan benzoate orally disintegrating tab 10 mg rizatriptan benzoate tab 5 mg rizatriptan benzoate tab 10 mg SUMATRIPTAN - sumatriptan nasal spray 5 mg/act SUMATRIPTAN - sumatriptan nasal spray 0 mg/act SUMATRIPTAN SUCCINATE - sumatriptan succinate solution prefilled syringe 6 mg/0.5ml sumatriptan succinate inj 6 mg/0.5ml sumatriptan succinate solution auto-injector mg/0.5ml sumatriptan succinate solution auto-injector 6 mg/0.5ml sumatriptan succinate solution cartridge mg/0.5ml sumatriptan succinate solution cartridge 6 mg/0.5ml sumatriptan succinate tab 5 mg sumatriptan succinate tab 50 mg sumatriptan succinate tab 100 mg topiramate sprinkle cap 15 mg topiramate sprinkle cap 5 mg topiramate tab 5 mg 1 topiramate tab 50 mg 1 topiramate tab 100 mg topiramate tab 00 mg Antimyasthenic Agents GUANIDINE HCL - guanidine hcl tab 15 mg MESTINON - pyridostigmine bromide syrup 60 mg/5ml pyridostigmine bromide tab 60 mg Antimycobacterials CAPASTAT SULFATE - capreomycin sulfate for inj 1 gm DAPSONE - dapsone tab 5 mg DAPSONE - dapsone tab 100 mg ethambutol hcl tab 100 mg ethambutol hcl tab 00 mg ISONIAZID - isoniazid inj 100 mg/ ml isoniazid tab 100 mg 1 isoniazid tab 300 mg 1 PASER - aminosalicylic acid cr granules packet gm PRIFTIN - rifapentine tab 150 mg pyrazinamide tab 500 mg rifabutin cap 150 mg rifampin cap 150 mg rifampin cap 300 mg rifampin for inj 600 mg SEROMYCIN - cycloserine cap 50 mg TRECATOR - ethionamide tab 50 mg 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 0

Antineoplastics ABRAXANE - paclitaxel proteinbound particles for iv susp 100 mg AFINITOR - everolimus tab.5 mg 5 AFINITOR - everolimus tab 5 mg AFINITOR - everolimus tab 7.5 mg AFINITOR - everolimus tab 10 mg AFINITOR DISPERZ - everolimus tab for oral susp mg AFINITOR DISPERZ - everolimus tab for oral susp 3 mg AFINITOR DISPERZ - everolimus tab for oral susp 5 mg ALIMTA - pemetrexed disodium 5 for iv soln 100 mg ALIMTA - pemetrexed disodium 5 for iv soln 500 mg amifostine crystalline for inj 5 500 mg anastrozole tab 1 mg ARRANON - nelarabine iv soln 5 mg/ml ARZERRA - ofatumumab conc for iv infusion 100 mg/5ml* ARZERRA - ofatumumab conc for iv infusion 1000 mg/50ml* AVASTIN - bevacizumab iv soln 100 mg/ml (for infusion)* 5 5 5 5 AVASTIN - bevacizumab iv soln 5 00 mg/16ml (for infusion)* azacitidine for inj 100 mg 5 BELEODAQ - belinostat for iv inj 5 500 mg bexarotene cap 75 mg bicalutamide tab 50 mg BICNU - carmustine for inj 100 mg bleomycin sulfate for inj 15 unit X bleomycin sulfate for inj 30 unit X BLINCYTO - blinatumomab for iv infusion 35 mcg 5 BOSULIF - bosutinib tab 100 mg BOSULIF - bosutinib tab 500 mg BUSULFEX - busulfan inj 6 mg/ml 5 CAPRELSA - vandetanib tab 100 mg* CAPRELSA - vandetanib tab 300 mg* carboplatin iv soln 50 mg/5ml carboplatin iv soln 150 mg/15ml carboplatin iv soln 50 mg/5ml carboplatin iv soln 600 mg/60ml CISPLATIN - cisplatin inj 00 mg/00ml (1 mg/ml) cisplatin inj 50 mg/50ml (1 mg/ml) cisplatin inj 100 mg/100ml (1 mg/ ml) cladribine inj 1 mg/ml 5 X 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 1

CLOLAR - clofarabine iv soln 5 1 mg/ml COMETRIQ - cabozantinib s- malate cap 3 x 0 mg (60 mg dose) kit* COMETRIQ - cabozantinib s-mal cap 1 x 80 mg & 1 x 0 mg (100 dose) kit* COMETRIQ - cabozantinib s-mal cap 1 x 80 mg & 3 x 0 mg (10 dose) kit* COSMEGEN - dactinomycin for 5 inj 0.5 mg CYCLOPHOSPHAMIDE - X cyclophosphamide cap 5 mg CYCLOPHOSPHAMIDE - X cyclophosphamide cap 50 mg cyclophosphamide for inj 500 mg cyclophosphamide for inj 1 gm cyclophosphamide for inj gm CYRAMZA - ramucirumab iv soln 5 100 mg/10ml (for infusion) CYRAMZA - ramucirumab iv soln 5 500 mg/50ml (for infusion) cytarabine inj pf 0 mg/ml X cytarabine inj pf 100 mg/ml X cytarabine inj 0 mg/ml X DACARBAZINE - dacarbazine for inj 100 mg dacarbazine for inj 00 mg daunorubicin hcl for inj 0 mg daunorubicin hcl inj 5 mg/ml DAUNOXOME - daunorubicin 5 citrate liposome inj mg/ml decitabine for inj 50 mg 5 dexrazoxane for inj 50 mg 5 dexrazoxane for inj 500 mg 5 DOCETAXEL - docetaxel for inj 5 conc 0 mg/ml DOCETAXEL - docetaxel for inj 5 conc 80 mg/ml (0 mg/ml) DOCETAXEL - docetaxel for inj 5 conc 10 mg/7ml (0 mg/ml) DOCETAXEL - docetaxel soln for 5 iv infusion 0 mg/ml DOCETAXEL - docetaxel soln for 5 iv infusion 80 mg/8ml DOCETAXEL - docetaxel soln for 5 iv infusion 160 mg/16ml DOCETAXEL - docetaxel soln for 5 iv infusion 00 mg/0ml docetaxel for inj conc 0 mg/ml 5 docetaxel for inj conc 80 mg/ml 5 (0 mg/ml) DOXIL - doxorubicin hcl liposomal X inj (for iv infusion) mg/ml doxorubicin hcl for inj 10 mg X doxorubicin hcl for inj 50 mg X doxorubicin hcl inj mg/ml X doxorubicin hcl liposomal inj (for iv infusion) mg/ml ELITEK - rasburicase for iv soln 1.5 mg X 5 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM)

ELITEK - rasburicase for iv soln 5 7.5 mg EMCYT - estramustine phosphate sodium cap 10 mg epirubicin hcl iv soln 50 mg/5ml ( mg/ml) epirubicin hcl iv soln 00 mg/100ml ( mg/ml) ERBITUX - cetuximab iv soln 5 100 mg/50ml ( mg/ml) ERBITUX - cetuximab iv soln 5 00 mg/100ml ( mg/ml) ERIVEDGE - vismodegib cap 150 mg* ERWINAZE - asparaginase 5 erwinia chrysanthemi for inj 10000 unit ETOPOPHOS - etoposide phosphate iv for inj 100 mg etoposide inj 100 mg/5ml (0 mg/ ml) etoposide inj 500 mg/5ml (0 mg/ml) etoposide inj 1 gm/50ml (0 mg/ ml) exemestane tab 5 mg FARESTON - toremifene citrate tab 60 mg FARYDAK - panobinostat lactate cap 10 mg FARYDAK - panobinostat lactate cap 15 mg 5 FARYDAK - panobinostat lactate cap 0 mg FASLODEX - fulvestrant inj 5 50 mg/5ml FLUDARABINE PHOSPHATE - fludarabine phosphate inj 5 mg/ml fludarabine phosphate for inj 50 mg fludarabine phosphate inj 5 mg/ ml fluorouracil inj 500 mg/10ml X (50 mg/ml) fluorouracil inj 1 gm/0ml (50 mg/ X ml) fluorouracil inj.5 gm/50ml X (50 mg/ml) fluorouracil inj 5 gm/100ml X (50 mg/ml) flutamide cap 15 mg FOLOTYN - pralatrexate iv inj 5 0 mg/ml FOLOTYN - pralatrexate iv inj 5 0 mg/ml GAZYVA - obinutuzumab soln 5 for iv infusion 1000 mg/0ml (5 mg/ml) gemcitabine hcl for inj 00 mg 5 gemcitabine hcl for inj 1 gm 5 gemcitabine hcl for inj gm 5 GILOTRIF - afatinib dimaleate tab 0 mg 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 3

GILOTRIF - afatinib dimaleate tab 30 mg GILOTRIF - afatinib dimaleate tab 0 mg GLEEVEC - imatinib mesylate tab 100 mg GLEEVEC - imatinib mesylate tab 00 mg GLEOSTINE - lomustine cap 10 mg GLEOSTINE - lomustine cap 0 mg GLEOSTINE - lomustine cap 100 mg HALAVEN - eribulin mesylate inj 5 1 mg/ml (0.5 mg/ml) HERCEPTIN - trastuzumab for iv 5 soln 0 mg HEXALEN - altretamine cap 50 mg hydroxyurea cap 500 mg IBRANCE - palbociclib cap 75 mg IBRANCE - palbociclib cap 100 mg IBRANCE - palbociclib cap 15 mg ICLUSIG - ponatinib hcl tab 15 mg ICLUSIG - ponatinib hcl tab 5 mg idarubicin hcl iv inj 5 mg/5ml (1 mg/ml) 5 idarubicin hcl iv inj 10 mg/10ml 5 (1 mg/ml) idarubicin hcl iv inj 0 mg/0ml 5 (1 mg/ml) IFOSFAMIDE - ifosfamide for inj 3 gm ifosfamide for inj 1 gm IMBRUVICA - ibrutinib cap 10 mg INLYTA - axitinib tab 1 mg* INLYTA - axitinib tab 5 mg* IRESSA - gefitinib tab 50 mg IRINOTECAN - irinotecan hcl inj 500 mg/5ml (0 mg/ml) irinotecan hcl inj 0 mg/ml (0 mg/ml) irinotecan hcl inj 100 mg/5ml (0 mg/ml) ISTODAX - romidepsin for iv inj 10 mg IXEMPRA KIT - ixabepilone for iv infusion 15 mg IXEMPRA KIT - ixabepilone for iv infusion 5 mg JAKAFI - ruxolitinib phosphate tab 5 mg* JAKAFI - ruxolitinib phosphate tab 10 mg* JAKAFI - ruxolitinib phosphate tab 15 mg* JAKAFI - ruxolitinib phosphate tab 0 mg* 5 5 5 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM)

JAKAFI - ruxolitinib phosphate tab 5 mg* JEVTANA - cabazitaxel inj 5 60 mg/1.5ml (for iv infusion) KADCYLA - ado-trastuzumab 5 emtansine for iv soln 100 mg KADCYLA - ado-trastuzumab 5 emtansine for iv soln 160 mg KEYTRUDA - pembrolizumab iv 5 soln 100 mg/ml (5 mg/ml) KEYTRUDA - pembrolizumab for 5 iv soln 50 mg LENVIMA 10MG DAILY DOSE - lenvatinib cap therapy pack 10 mg LENVIMA 1MG DAILY DOSE - lenvatinib cap therapy pack 10 & mg LENVIMA 0MG DAILY DOSE - lenvatinib cap therapy pack 10 () mg LENVIMA MG DAILY DOSE - lenvatinib cap therapy pack 10 () & mg letrozole tab.5 mg 1 LEUCOVORIN CALCIUM - leucovorin calcium tab 10 mg LEUCOVORIN CALCIUM - leucovorin calcium tab 15 mg leucovorin calcium for inj 50 mg leucovorin calcium for inj 100 mg leucovorin calcium for inj 00 mg leucovorin calcium for inj 350 mg leucovorin calcium tab 5 mg leucovorin calcium tab 5 mg LEUKERAN - chlorambucil tab 3 mg LOMUSTINE - lomustine cap 10 mg LOMUSTINE - lomustine cap 0 mg LOMUSTINE - lomustine cap 100 mg LONSURF - trifluridine-tipiracil tab 15-6.1 mg LONSURF - trifluridine-tipiracil tab 0-8.19 mg LYNPARZA - olaparib cap 50 mg MATULANE - procarbazine hcl cap 50 mg* MEKINIST - trametinib dimethyl sulfoxide tab 0.5 mg MEKINIST - trametinib dimethyl sulfoxide tab mg melphalan hcl for inj 50 mg 5 mercaptopurine tab 50 mg mesna inj 100 mg/ml MESNEX - mesna tab 00 mg methotrexate sodium for inj 1 gm methotrexate sodium inj pf 5 mg/ 1 ml methotrexate sodium inj 5 mg/ml 1 methotrexate sodium tab.5 mg X 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 5

mitomycin for iv soln 5 mg mitomycin for iv soln 0 mg mitomycin for iv soln 0 mg mitoxantrone hcl inj conc 0 mg/10ml ( mg/ml) mitoxantrone hcl inj conc 5 mg/1.5ml ( mg/ml) mitoxantrone hcl inj conc 30 mg/15ml ( mg/ml) MUSTARGEN - mechlorethamine hcl for inj 10 mg NEXAVAR - sorafenib tosylate tab 00 mg* NILANDRON - nilutamide tab 150 mg NIPENT - pentostatin for inj 5 10 mg ODOMZO - sonidegib phosphate cap 00 mg ONCASPAR - pegaspargase inj 5 750 unit/ml OPDIVO - nivolumab iv soln 5 0 mg/ml OPDIVO - nivolumab iv soln 5 100 mg/10ml oxaliplatin iv soln 50 mg/10ml 5 oxaliplatin iv soln 100 mg/0ml 5 oxaliplatin for iv inj 50 mg 5 oxaliplatin for iv inj 100 mg 5 paclitaxel iv conc 30 mg/5ml (6 mg/ml) paclitaxel iv conc 100 mg/16.7ml (6 mg/ml) paclitaxel iv conc 300 mg/50ml (6 mg/ml) PANRETIN - alitretinoin gel 0.1% 5 PERJETA - pertuzumab soln for iv infusion 0 mg/1ml (30 mg/ ml)* POMALYST - pomalidomide cap 1 mg* POMALYST - pomalidomide cap mg* POMALYST - pomalidomide cap 3 mg* POMALYST - pomalidomide cap mg* PROLEUKIN - aldesleukin for iv soln 000000 unit PURIXAN - mercaptopurine susp 000 mg/100ml (0 mg/ml) REVLIMID - lenalidomide caps.5 mg* REVLIMID - lenalidomide cap 5 mg* REVLIMID - lenalidomide cap 10 mg* REVLIMID - lenalidomide cap 15 mg* REVLIMID - lenalidomide cap 0 mg* REVLIMID - lenalidomide cap 5 mg* 5 5 5 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 6

RITUXAN - rituximab iv soln 100 mg/10ml* RITUXAN - rituximab iv soln 500 mg/50ml* SOLTAMOX - tamoxifen citrate oral soln 10 mg/5ml SPRYCEL - dasatinib tab 0 mg SPRYCEL - dasatinib tab 50 mg SPRYCEL - dasatinib tab 70 mg SPRYCEL - dasatinib tab 80 mg SPRYCEL - dasatinib tab 100 mg SPRYCEL - dasatinib tab 10 mg STIVARGA - regorafenib tab 0 mg* SUTENT - sunitinib malate cap 1.5 mg SUTENT - sunitinib malate cap 5 mg SUTENT - sunitinib malate cap 37.5 mg SUTENT - sunitinib malate cap 50 mg SYLATRON - peginterferon alfa-b for inj kit 00 mcg SYLATRON - peginterferon alfa-b for inj kit 300 mcg SYLATRON - peginterferon alfa-b for inj kit 600 mcg SYLATRON - peginterferon alfa-b for inj kit x 00 mcg SYLATRON - peginterferon alfa-b for inj kit x 300 mcg SYLATRON - peginterferon alfa-b for inj kit x 600 mcg SYLVANT - siltuximab for iv 5 infusion 100 mg SYLVANT - siltuximab for iv 5 infusion 00 mg SYNRIBO - omacetaxine 5 mepesuccinate for inj 3.5 mg TABLOID - thioguanine tab 0 mg TAFINLAR - dabrafenib mesylate cap 50 mg TAFINLAR - dabrafenib mesylate cap 75 mg tamoxifen citrate tab 10 mg tamoxifen citrate tab 0 mg TARCEVA - erlotinib hcl tab 5 mg TARCEVA - erlotinib hcl tab 100 mg TARCEVA - erlotinib hcl tab 150 mg TARGRETIN - bexarotene cap 75 mg TARGRETIN - bexarotene gel 1% 5 TASIGNA - nilotinib hcl cap 150 mg TASIGNA - nilotinib hcl cap 00 mg TEMODAR - temozolomide for iv soln 100 mg THALOMID - thalidomide cap 50 mg 5 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 7

THALOMID - thalidomide cap 100 mg THALOMID - thalidomide cap 150 mg THALOMID - thalidomide cap 00 mg THIOTEPA - thiotepa for inj 5 15 mg topotecan hcl for inj mg 5 TORISEL - temsirolimus soln for 5 iv infusion 5 mg/ml TREANDA - bendamustine hcl iv 5 soln 5 mg/0.5ml (90 mg/ml) TREANDA - bendamustine hcl iv 5 soln 180 mg/ml (90 mg/ml) TREANDA - bendamustine hcl for 5 iv soln 5 mg TREANDA - bendamustine hcl for 5 iv soln 100 mg tretinoin cap 10 mg TRISENOX - arsenic trioxide inj 10 mg/10ml (1 mg/ml) TYKERB - lapatinib ditosylate tab 50 mg* UNITUXIN - dinutuximab iv soln 5 17.5 mg/5ml (3.5 mg/ml) UVADEX - methoxsalen soln 0 mcg/ml VECTIBIX - panitumumab iv soln 5 100 mg/5ml VECTIBIX - panitumumab iv soln 5 00 mg/0ml VELCADE - bortezomib for inj 5 3.5 mg VINBLASTINE SULFATE - X vinblastine sulfate inj 1 mg/ml vincristine sulfate iv soln 1 mg/ml vinorelbine tartrate inj 10 mg/ml vinorelbine tartrate inj 50 mg/5ml (10 mg/ml) VOTRIENT - pazopanib hcl tab 00 mg* XALKORI - crizotinib cap 00 mg* XALKORI - crizotinib cap 50 mg* XTANDI - enzalutamide cap 0 mg* YERVOY - ipilimumab soln for iv infusion 50 mg/10ml (5 mg/ml)* YERVOY - ipilimumab soln for iv infusion 00 mg/0ml (5 mg/ ml)* ZALTRAP - ziv-aflibercept iv soln 100 mg/ml (for infusion) ZALTRAP - ziv-aflibercept iv soln 00 mg/8ml (for infusion) ZANOSAR - streptozocin for inj 1 gm ZELBORAF - vemurafenib tab 0 mg* 5 5 5 5 ZOLINZA - vorinostat cap 100 mg ZYDELIG - idelalisib tab 100 mg ZYDELIG - idelalisib tab 150 mg ZYKADIA - ceritinib cap 150 mg 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 8

ZYTIGA - abiraterone acetate tab 50 mg* Antiparasitics ALBENZA - albendazole tab 00 mg ALINIA - nitazoxanide tab 500 mg ALINIA - nitazoxanide for susp 100 mg/5ml atovaquone susp 750 mg/5ml 5 atovaquone-proguanil hcl tab 6.5-5 mg atovaquone-proguanil hcl tab 50-100 mg BILTRICIDE - praziquantel tab 600 mg chloroquine phosphate tab 50 mg chloroquine phosphate tab 500 mg COARTEM - artemetherlumefantrine tab 0-10 mg DARAPRIM - pyrimethamine tab 5 mg hydroxychloroquine sulfate tab 00 mg ivermectin tab 3 mg mefloquine hcl tab 50 mg NEBUPENT - pentamidine isethionate for nebulization soln 300 mg PENTAM 300 - pentamidine isethionate for soln 300 mg X X permethrin cream 5% PRIMAQUINE PHOSPHATE - primaquine phosphate tab 6.3 mg STROMECTOL - ivermectin tab 3 3 mg Antiparkinson Agents amantadine hcl cap 100 mg amantadine hcl syrup 50 mg/5ml APOKYN - apomorphine hydrochloride inj 10 mg/ml* AZILECT - rasagiline mesylate tab 0.5 mg AZILECT - rasagiline mesylate tab 1 mg 5 3 3 benztropine mesylate tab 0.5 mg# benztropine mesylate tab 1 mg# benztropine mesylate tab mg# carbidopa & levodopa orally disintegrating tab 10-100 mg carbidopa & levodopa orally disintegrating tab 5-100 mg carbidopa & levodopa orally disintegrating tab 5-50 mg carbidopa & levodopa tab cr 5-100 mg carbidopa & levodopa tab cr 50-00 mg carbidopa & levodopa tab 10-100 mg carbidopa & levodopa tab 5-100 mg 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 9

carbidopa & levodopa tab 5-50 mg carbidopa tab 5 mg diphenhydramine hcl inj 50 mg/ml entacapone tab 00 mg NEUPRO - rotigotine td patch hr 1 mg/hr NEUPRO - rotigotine td patch hr mg/hr NEUPRO - rotigotine td patch hr 3 mg/hr NEUPRO - rotigotine td patch hr mg/hr NEUPRO - rotigotine td patch hr 6 mg/hr NEUPRO - rotigotine td patch hr 8 mg/hr pramipexole dihydrochloride tab 0.15 mg pramipexole dihydrochloride tab 0.5 mg pramipexole dihydrochloride tab 0.5 mg pramipexole dihydrochloride tab 0.75 mg pramipexole dihydrochloride tab 1 mg pramipexole dihydrochloride tab 1.5 mg ropinirole hydrochloride tab 0.5 mg 1 1 1 ropinirole hydrochloride tab 0.5 mg ropinirole hydrochloride tab 1 mg ropinirole hydrochloride tab mg ropinirole hydrochloride tab 3 mg ropinirole hydrochloride tab mg ropinirole hydrochloride tab 5 mg selegiline hcl tab 5 mg Antipsychotics ABILIFY - aripiprazole tab mg ABILIFY - aripiprazole tab 5 mg ABILIFY - aripiprazole tab 10 mg ABILIFY - aripiprazole tab 15 mg ABILIFY - aripiprazole tab 0 mg ABILIFY - aripiprazole tab 30 mg ABILIFY MAINTENA - aripiprazole im for extended release susp 300 mg ABILIFY MAINTENA - aripiprazole im for extended release susp 00 mg ADASUVE - loxapine aerosol powder breath activated 10 mg ARIPIPRAZOLE ODT - aripiprazole orally disintegrating tab 10 mg ARIPIPRAZOLE ODT - aripiprazole orally disintegrating tab 15 mg aripiprazole oral solution 1 mg/ml aripiprazole tab mg 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 30

aripiprazole tab 5 mg aripiprazole tab 10 mg aripiprazole tab 15 mg aripiprazole tab 0 mg aripiprazole tab 30 mg CHLORPROMAZINE HCL - chlorpromazine hcl inj 5 mg/ml CHLORPROMAZINE HCL - chlorpromazine hcl inj 50 mg/ml chlorpromazine hcl tab 10 mg chlorpromazine hcl tab 5 mg chlorpromazine hcl tab 50 mg chlorpromazine hcl tab 100 mg chlorpromazine hcl tab 00 mg clozapine tab 5 mg clozapine tab 50 mg clozapine tab 100 mg clozapine tab 00 mg FANAPT - iloperidone tab 1 mg FANAPT - iloperidone tab mg FANAPT - iloperidone tab mg FANAPT - iloperidone tab 6 mg FANAPT - iloperidone tab 8 mg FANAPT - iloperidone tab 10 mg FANAPT - iloperidone tab 1 mg FANAPT TITRATION PACK - iloperidone tab 1 mg & mg & mg & 6 mg titration pak FAZACLO - clozapine orally disintegrating tab 1.5 mg FAZACLO - clozapine orally disintegrating tab 5 mg FAZACLO - clozapine orally disintegrating tab 100 mg FAZACLO - clozapine orally disintegrating tab 150 mg FAZACLO - clozapine orally disintegrating tab 00 mg fluphenazine decanoate inj 5 mg/ml FLUPHENAZINE HCL - fluphenazine hcl elixir.5 mg/5ml FLUPHENAZINE HCL - fluphenazine hcl oral conc 5 mg/ml FLUPHENAZINE HCL - fluphenazine hcl inj.5 mg/ml fluphenazine hcl tab 1 mg fluphenazine hcl tab.5 mg fluphenazine hcl tab 5 mg fluphenazine hcl tab 10 mg GEODON - ziprasidone mesylate for inj 0 mg haloperidol decanoate im soln 50 mg/ml haloperidol decanoate im soln 100 mg/ml haloperidol lactate inj 5 mg/ml 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 31

haloperidol lactate oral conc mg/ml haloperidol tab 0.5 mg haloperidol tab 1 mg haloperidol tab mg haloperidol tab 5 mg haloperidol tab 10 mg haloperidol tab 0 mg INVEGA - paliperidone tab sr hr 1.5 mg INVEGA - paliperidone tab sr hr 3 mg INVEGA - paliperidone tab sr hr 6 mg INVEGA - paliperidone tab sr hr 9 mg INVEGA SUSTENNA - paliperidone palmitate im extended-release susp 39 mg/0.5ml INVEGA SUSTENNA - paliperidone palmitate im extended-release susp 78 mg/0.5ml INVEGA SUSTENNA - paliperidone palmitate im extend-release susp 117 mg/0.75ml INVEGA SUSTENNA - paliperidone palmitate im extended-release susp 156 mg/ ml INVEGA SUSTENNA - paliperidone palmitate im extended-release susp 3 mg/1.5ml INVEGA TRINZA - paliperidone palmitate im extend-release susp 73 mg/0.875ml INVEGA TRINZA - paliperidone palmitate im extend-release susp 10 mg/1.315ml INVEGA TRINZA - paliperidone palmitate im extend-release susp 56 mg/1.75ml INVEGA TRINZA - paliperidone palmitate im extend-release susp 819 mg/.65ml LATUDA - lurasidone hcl tab 0 mg LATUDA - lurasidone hcl tab 0 mg LATUDA - lurasidone hcl tab 60 mg LATUDA - lurasidone hcl tab 80 mg LATUDA - lurasidone hcl tab 10 mg loxapine succinate cap 5 mg loxapine succinate cap 10 mg loxapine succinate cap 5 mg loxapine succinate cap 50 mg olanzapine for im inj 10 mg 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 3

olanzapine orally disintegrating tab 5 mg olanzapine orally disintegrating tab 10 mg olanzapine orally disintegrating tab 15 mg olanzapine orally disintegrating tab 0 mg olanzapine tab.5 mg olanzapine tab 5 mg olanzapine tab 7.5 mg olanzapine tab 10 mg olanzapine tab 15 mg olanzapine tab 0 mg ORAP - pimozide tab 1 mg ORAP - pimozide tab mg paliperidone tab sr hr 1.5 mg paliperidone tab sr hr 3 mg paliperidone tab sr hr 6 mg paliperidone tab sr hr 9 mg perphenazine tab mg perphenazine tab mg perphenazine tab 8 mg perphenazine tab 16 mg pimozide tab 1 mg pimozide tab mg prochlorperazine edisylate inj 5 mg/ml prochlorperazine maleate tab 5 mg prochlorperazine maleate tab 10 mg prochlorperazine suppos 5 mg quetiapine fumarate tab 5 mg quetiapine fumarate tab 50 mg quetiapine fumarate tab 100 mg quetiapine fumarate tab 00 mg quetiapine fumarate tab 300 mg quetiapine fumarate tab 00 mg REXULTI - brexpiprazole tab 0.5 mg REXULTI - brexpiprazole tab 0.5 mg REXULTI - brexpiprazole tab 1 mg REXULTI - brexpiprazole tab mg REXULTI - brexpiprazole tab 3 mg REXULTI - brexpiprazole tab mg RISPERDAL CONSTA - risperidone microspheres for inj 1.5 mg RISPERDAL CONSTA - risperidone microspheres for inj 5 mg RISPERDAL CONSTA - risperidone microspheres for inj 37.5 mg 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 33

RISPERDAL CONSTA - risperidone microspheres for inj 50 mg risperidone orally disintegrating tab 0.5 mg risperidone orally disintegrating tab 0.5 mg risperidone orally disintegrating tab 1 mg risperidone orally disintegrating tab mg risperidone orally disintegrating tab 3 mg risperidone orally disintegrating tab mg risperidone soln 1 mg/ml risperidone tab 0.5 mg risperidone tab 0.5 mg risperidone tab 1 mg risperidone tab mg risperidone tab 3 mg risperidone tab mg SAPHRIS - asenapine maleate sl tab.5 mg SAPHRIS - asenapine maleate sl tab 5 mg SAPHRIS - asenapine maleate sl tab 10 mg SEROQUEL XR - quetiapine fumarate tab sr hr 50 mg SEROQUEL XR - quetiapine fumarate tab sr hr 150 mg SEROQUEL XR - quetiapine fumarate tab sr hr 00 mg SEROQUEL XR - quetiapine fumarate tab sr hr 300 mg SEROQUEL XR - quetiapine fumarate tab sr hr 00 mg thioridazine hcl tab 10 mg# thioridazine hcl tab 5 mg# thioridazine hcl tab 50 mg# thioridazine hcl tab 100 mg# thiothixene cap 1 mg thiothixene cap mg thiothixene cap 5 mg thiothixene cap 10 mg trifluoperazine hcl tab 1 mg trifluoperazine hcl tab mg trifluoperazine hcl tab 5 mg trifluoperazine hcl tab 10 mg VERSACLOZ - clozapine susp 50 mg/ml ziprasidone hcl cap 0 mg ziprasidone hcl cap 0 mg ziprasidone hcl cap 60 mg ziprasidone hcl cap 80 mg ZYPREXA RELPREVV - olanzapine pamoate for extended rel im susp 10 mg ZYPREXA RELPREVV - olanzapine pamoate for extended rel im susp 300 mg 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 3

ZYPREXA RELPREVV - olanzapine pamoate for extended rel im susp 05 mg Antispasticity Agents baclofen tab 10 mg 1 baclofen tab 0 mg 1 tizanidine hcl tab mg tizanidine hcl tab mg Antivirals abacavir sulfate tab 300 mg abacavir sulfate-lamivudinezidovudine tab 300-150-300 mg acyclovir cap 00 mg acyclovir sodium for inj 500 mg X acyclovir sodium iv soln 50 mg/ml X acyclovir susp 00 mg/5ml acyclovir tab 00 mg acyclovir tab 800 mg adefovir dipivoxil tab 10 mg 5 amantadine hcl cap 100 mg amantadine hcl syrup 50 mg/5ml APTIVUS - tipranavir cap 50 mg APTIVUS - tipranavir oral soln 100 mg/ml ATRIPLA - efavirenzemtricitabine-tenofovir df tab 600-00-300 mg BARACLUDE - entecavir oral soln 0.05 mg/ml BARACLUDE - entecavir tab 5 0.5 mg BARACLUDE - entecavir tab 5 1 mg COMPLERA - emtricitabinerilpivirine-tenofovir df tab 00-5-300 mg CRIXIVAN - indinavir sulfate cap 00 mg CRIXIVAN - indinavir sulfate cap 00 mg DAKLINZA - daclatasvir dihydrochloride tab 30 mg DAKLINZA - daclatasvir dihydrochloride tab 60 mg didanosine delayed release capsule 15 mg didanosine delayed release capsule 00 mg didanosine delayed release capsule 50 mg didanosine delayed release capsule 00 mg EDURANT - rilpivirine hcl tab 5 mg EMTRIVA - emtricitabine caps 00 mg EMTRIVA - emtricitabine soln 10 mg/ml entecavir tab 0.5 mg 5 entecavir tab 1 mg 5 EPIVIR - lamivudine oral soln 10 mg/ml 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 35

EPIVIR HBV - lamivudine oral soln 5 mg/ml (hbv) EPZICOM - abacavir sulfatelamivudine tab 600-300 mg EVOTAZ - atazanavir sulfatecobicistat tab 300-150 mg FUZEON - enfuvirtide for inj 90 mg ganciclovir sodium for inj 500 mg X HARVONI - ledipasvir-sofosbuvir tab 90-00 mg INTELENCE - etravirine tab 5 mg INTELENCE - etravirine tab 100 mg INTELENCE - etravirine tab 00 mg INTRON A - interferon alfa-b inj 5 6000000 unit/ml INTRON A - interferon alfa-b inj 5 10000000 unit/ml INTRON A W/DILUENT - 5 interferon alfa-b for inj 10000000 unit INTRON A W/DILUENT - 5 interferon alfa-b for inj 18000000 unit INTRON A W/DILUENT - 5 interferon alfa-b for inj 50000000 unit INVIRASE - saquinavir mesylate cap 00 mg INVIRASE - saquinavir mesylate tab 500 mg ISENTRESS - raltegravir potassium tab 00 mg ISENTRESS - raltegravir potassium packet for susp 100 mg ISENTRESS - raltegravir potassium chew tab 5 mg ISENTRESS - raltegravir potassium chew tab 100 mg KALETRA - lopinavir-ritonavir soln 00-100 mg/5ml (80-0 mg/ml) KALETRA - lopinavir-ritonavir tab 100-5 mg KALETRA - lopinavir-ritonavir tab 00-50 mg lamivudine oral soln 10 mg/ml lamivudine tab 100 mg (hbv) lamivudine tab 150 mg lamivudine tab 300 mg lamivudine-zidovudine tab 150-300 mg LEXIVA - fosamprenavir calcium tab 700 mg LEXIVA - fosamprenavir calcium susp 50 mg/ml NEVIRAPINE - nevirapine susp 50 mg/5ml nevirapine tab sr hr 00 mg nevirapine tab 00 mg 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 36

NORVIR - ritonavir cap 100 mg NORVIR - ritonavir tab 100 mg NORVIR - ritonavir oral soln 80 mg/ml OLYSIO - simeprevir sodium cap 150 mg PEG-INTRON - peginterferon alfa-b for inj kit 50 mcg/0.5ml PEG-INTRON - peginterferon alfa-b for inj kit 80 mcg/0.5ml PEG-INTRON - peginterferon alfa-b for inj kit 10 mcg/0.5ml PEG-INTRON - peginterferon alfa-b for inj kit 150 mcg/0.5ml PEG-INTRON REDIPEN - peginterferon alfa-b for inj kit 50 mcg/0.5ml PEG-INTRON REDIPEN - peginterferon alfa-b for inj kit 80 mcg/0.5ml PEG-INTRON REDIPEN - peginterferon alfa-b for inj kit 10 mcg/0.5ml PEG-INTRON REDIPEN - peginterferon alfa-b for inj kit 150 mcg/0.5ml PEG-INTRON REDIPEN PAK - peginterferon alfa-b for inj kit 50 mcg/0.5ml PEG-INTRON REDIPEN PAK - peginterferon alfa-b for inj kit 80 mcg/0.5ml PEG-INTRON REDIPEN PAK - peginterferon alfa-b for inj kit 10 mcg/0.5ml PEG-INTRON REDIPEN PAK - peginterferon alfa-b for inj kit 150 mcg/0.5ml PEGASYS - peginterferon alfa-a inj 180 mcg/ml PEGASYS - peginterferon alfa-a inj 180 mcg/0.5ml PEGASYS PROCLICK - peginterferon alfa-a inj 135 mcg/0.5ml PEGASYS PROCLICK - peginterferon alfa-a inj 180 mcg/0.5ml PREZCOBIX - darunavircobicistat tab 800-150 mg PREZISTA - darunavir ethanolate susp 100 mg/ml PREZISTA - darunavir ethanolate tab 75 mg PREZISTA - darunavir ethanolate tab 150 mg PREZISTA - darunavir ethanolate tab 600 mg PREZISTA - darunavir ethanolate tab 800 mg RESCRIPTOR - delavirdine mesylate tab 100 mg RESCRIPTOR - delavirdine mesylate tab 00 mg 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 37

RETROVIR IV INFUSION - zidovudine iv soln 10 mg/ml REYATAZ - atazanavir sulfate oral powder packet 50 mg REYATAZ - atazanavir sulfate cap 100 mg REYATAZ - atazanavir sulfate cap 150 mg REYATAZ - atazanavir sulfate cap 00 mg REYATAZ - atazanavir sulfate cap 300 mg ribavirin cap 00 mg ribavirin tab 00 mg rimantadine hydrochloride tab 100 mg SELZENTRY - maraviroc tab 150 mg SELZENTRY - maraviroc tab 300 mg SOVALDI - sofosbuvir tab 00 mg stavudine cap 15 mg stavudine cap 0 mg stavudine cap 30 mg stavudine cap 0 mg stavudine for oral soln 1 mg/ml STRIBILD - elvitegrav-cobicisemtricitab-tenofov tab 150-150-00-300 mg SUSTIVA - efavirenz tab 600 mg SUSTIVA - efavirenz cap 50 mg SUSTIVA - efavirenz cap 00 mg SYLATRON - peginterferon alfa-b for inj kit 00 mcg SYLATRON - peginterferon alfa-b for inj kit 300 mcg SYLATRON - peginterferon alfa-b for inj kit 600 mcg SYLATRON - peginterferon alfa-b for inj kit x 00 mcg SYLATRON - peginterferon alfa-b for inj kit x 300 mcg SYLATRON - peginterferon alfa-b for inj kit x 600 mcg TAMIFLU - oseltamivir phosphate for susp 6 mg/ml TAMIFLU - oseltamivir phosphate cap 30 mg TAMIFLU - oseltamivir phosphate cap 5 mg TAMIFLU - oseltamivir phosphate cap 75 mg TECHNIVIE - ombitasvirparitaprevir-ritonavir tab 1.5-75-50 mg TIVICAY - dolutegravir sodium tab 50 mg TRIUMEQ - abacavirdolutegravir-lamivudine tab 600-50-300 mg TRUVADA - emtricitabinetenofovir disoproxil fumarate tab 00-300 mg TYBOST - cobicistat tab 150 mg 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 38

TYZEKA - telbivudine tab 600 mg valacyclovir hcl tab 500 mg valacyclovir hcl tab 1 gm VALCYTE - valganciclovir hcl tab 5 50 mg VALCYTE - valganciclovir hcl for 5 soln 50 mg/ml valganciclovir hcl tab 50 mg 5 VIDEX - didanosine for soln gm VIDEX - didanosine for soln gm VIEKIRA PAK - ombitasparitapre-riton & dasab tab pak 1.5-75-50 & 50 mg VIRACEPT - nelfinavir mesylate tab 50 mg VIRACEPT - nelfinavir mesylate tab 65 mg VIRAMUNE - nevirapine susp 50 mg/5ml VIRAMUNE XR - nevirapine tab sr hr 100 mg VIRAZOLE - ribavirin for inhal 5 soln 6 gm VIREAD - tenofovir disoproxil fumarate oral powder 0 mg/gm VIREAD - tenofovir disoproxil fumarate tab 150 mg VIREAD - tenofovir disoproxil fumarate tab 00 mg VIREAD - tenofovir disoproxil fumarate tab 50 mg VIREAD - tenofovir disoproxil fumarate tab 300 mg VITEKTA - elvitegravir tab 85 mg VITEKTA - elvitegravir tab 150 mg ZIAGEN - abacavir sulfate soln 0 mg/ml zidovudine cap 100 mg zidovudine syrup 10 mg/ml zidovudine tab 300 mg Anxiolytics buspirone hcl tab 5 mg 1 buspirone hcl tab 7.5 mg buspirone hcl tab 10 mg 1 buspirone hcl tab 15 mg 1 buspirone hcl tab 30 mg clonazepam orally disintegrating tab 0.15 mg clonazepam orally disintegrating tab 0.5 mg clonazepam orally disintegrating tab 0.5 mg clonazepam orally disintegrating tab 1 mg clonazepam orally disintegrating tab mg clonazepam tab 0.5 mg clonazepam tab 1 mg clonazepam tab mg clorazepate dipotassium tab 3.75 mg 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 39

clorazepate dipotassium tab 7.5 mg clorazepate dipotassium tab 15 mg DIAZEPAM - diazepam soln 1 mg/ml diazepam tab mg diazepam tab 5 mg diazepam tab 10 mg doxepin hcl cap 10 mg# doxepin hcl cap 5 mg# doxepin hcl cap 50 mg# doxepin hcl cap 100 mg# doxepin hcl cap 150 mg# doxepin hcl conc 10 mg/ml# duloxetine hcl enteric coated pellets cap 0 mg duloxetine hcl enteric coated pellets cap 30 mg duloxetine hcl enteric coated pellets cap 60 mg escitalopram oxalate soln 5 mg/5ml escitalopram oxalate tab 5 mg 1 escitalopram oxalate tab 10 mg 1 escitalopram oxalate tab 0 mg 1 lorazepam tab 0.5 mg 1 lorazepam tab 1 mg 1 lorazepam tab mg 1 paroxetine hcl tab sr hr 1.5 mg paroxetine hcl tab sr hr 5 mg paroxetine hcl tab sr hr 37.5 mg paroxetine hcl tab 10 mg 1 paroxetine hcl tab 0 mg 1 paroxetine hcl tab 30 mg 1 paroxetine hcl tab 0 mg 1 PAXIL - paroxetine hcl oral susp 10 mg/5ml sertraline hcl oral conc 0 mg/ml sertraline hcl tab 5 mg 1 sertraline hcl tab 50 mg 1 sertraline hcl tab 100 mg 1 venlafaxine hcl cap sr hr 37.5 mg venlafaxine hcl cap sr hr 75 mg venlafaxine hcl cap sr hr 150 mg venlafaxine hcl tab 5 mg venlafaxine hcl tab 37.5 mg venlafaxine hcl tab 50 mg venlafaxine hcl tab 75 mg venlafaxine hcl tab 100 mg Bipolar Agents ABILIFY - aripiprazole tab mg ABILIFY - aripiprazole tab 5 mg ABILIFY - aripiprazole tab 10 mg ABILIFY - aripiprazole tab 15 mg 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 0

ABILIFY - aripiprazole tab 0 mg ABILIFY - aripiprazole tab 30 mg ABILIFY MAINTENA - aripiprazole im for extended release susp 300 mg ABILIFY MAINTENA - aripiprazole im for extended release susp 00 mg ARIPIPRAZOLE ODT - aripiprazole orally disintegrating tab 10 mg ARIPIPRAZOLE ODT - aripiprazole orally disintegrating tab 15 mg aripiprazole oral solution 1 mg/ml aripiprazole tab mg aripiprazole tab 5 mg aripiprazole tab 10 mg aripiprazole tab 15 mg aripiprazole tab 0 mg aripiprazole tab 30 mg divalproex sodium cap sprinkle 15 mg divalproex sodium tab delayed release 15 mg divalproex sodium tab delayed release 50 mg divalproex sodium tab delayed release 500 mg divalproex sodium tab sr hr 50 mg divalproex sodium tab sr hr 500 mg EQUETRO - carbamazepine cap sr 1hr 100 mg EQUETRO - carbamazepine cap sr 1hr 00 mg EQUETRO - carbamazepine cap sr 1hr 300 mg LAMICTAL ODT - lamotrigine orally disintegrating tab 5 mg LAMICTAL ODT - lamotrigine orally disintegrating tab 50 mg LAMICTAL ODT - lamotrigine orally disintegrating tab 100 mg LAMICTAL ODT - lamotrigine orally disintegrating tab 00 mg lamotrigine orally disintegrating tab 5 mg lamotrigine orally disintegrating tab 50 mg lamotrigine orally disintegrating tab 100 mg lamotrigine orally disintegrating tab 00 mg lamotrigine tab chewable dispersible 5 mg lamotrigine tab chewable dispersible 5 mg lamotrigine tab 5 mg lamotrigine tab 100 mg 1 lamotrigine tab 150 mg lamotrigine tab 00 mg 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 1

LITHIUM - lithium oral solution 8 meq/5ml lithium carbonate cap 150 mg 1 lithium carbonate cap 300 mg 1 lithium carbonate cap 600 mg lithium carbonate tab cr 300 mg lithium carbonate tab cr 50 mg lithium carbonate tab 300 mg 1 olanzapine for im inj 10 mg olanzapine orally disintegrating tab 5 mg olanzapine orally disintegrating tab 10 mg olanzapine orally disintegrating tab 15 mg olanzapine orally disintegrating tab 0 mg olanzapine tab.5 mg olanzapine tab 5 mg olanzapine tab 7.5 mg olanzapine tab 10 mg olanzapine tab 15 mg olanzapine tab 0 mg quetiapine fumarate tab 5 mg quetiapine fumarate tab 50 mg quetiapine fumarate tab 100 mg quetiapine fumarate tab 00 mg quetiapine fumarate tab 300 mg quetiapine fumarate tab 00 mg RISPERDAL CONSTA - risperidone microspheres for inj 1.5 mg RISPERDAL CONSTA - risperidone microspheres for inj 5 mg RISPERDAL CONSTA - risperidone microspheres for inj 37.5 mg RISPERDAL CONSTA - risperidone microspheres for inj 50 mg risperidone orally disintegrating tab 0.5 mg risperidone orally disintegrating tab 0.5 mg risperidone orally disintegrating tab 1 mg risperidone orally disintegrating tab mg risperidone orally disintegrating tab 3 mg risperidone orally disintegrating tab mg risperidone soln 1 mg/ml risperidone tab 0.5 mg risperidone tab 0.5 mg risperidone tab 1 mg risperidone tab mg risperidone tab 3 mg risperidone tab mg 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM)

SEROQUEL XR - quetiapine fumarate tab sr hr 50 mg SEROQUEL XR - quetiapine fumarate tab sr hr 150 mg SEROQUEL XR - quetiapine fumarate tab sr hr 00 mg SEROQUEL XR - quetiapine fumarate tab sr hr 300 mg SEROQUEL XR - quetiapine fumarate tab sr hr 00 mg valproic acid cap 50 mg ziprasidone hcl cap 0 mg ziprasidone hcl cap 0 mg ziprasidone hcl cap 60 mg ziprasidone hcl cap 80 mg Blood Glucose Regulators acarbose tab 5 mg acarbose tab 50 mg acarbose tab 100 mg ALCOHOL SWABS 3 BYDUREON - exenatide extended release for susp peninjector mg BYDUREON - exenatide extended release for inj susp mg CYCLOSET - bromocriptine mesylate tab 0.8 mg GAUZE PADS " X " 3 glimepiride tab 1 mg 1 glimepiride tab mg 1 glimepiride tab mg 1 glipizide tab sr hr.5 mg glipizide tab sr hr 5 mg glipizide tab sr hr 10 mg glipizide tab 5 mg 1 glipizide tab 10 mg 1 GLUCAGEN HYPOKIT - glucagon hcl (rdna) for inj 1 mg 3 GLYBURIDE - glyburide tab 1.5 mg# GLYBURIDE - glyburide tab.5 mg# GLYBURIDE - glyburide tab 5 mg# glyburide micronized tab 1.5 mg# glyburide micronized tab 3 mg# glyburide micronized tab 6 mg# glyburide tab 1.5 mg# glyburide tab.5 mg# glyburide tab 5 mg# HUMALOG - insulin lispro (human) soln cartridge 100 unit/ ml HUMALOG - insulin lispro (human) inj 100 unit/ml HUMALOG KWIKPEN - insulin lispro (human) soln pen-injector 100 unit/ml 3 3 3 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 3

HUMALOG KWIKPEN - insulin 3 lispro (human) soln pen-injector 00 unit/ml HUMALOG MIX 50/50 - insulin 3 lispro prot & lispro (human) inj 100 unit/ml (50-50) HUMALOG MIX 50/50 KWIKPEN 3 - insulin lispro prot & lispro sus pen-inj 100 unit/ml (50-50) HUMALOG MIX 75/5 - insulin 3 lispro prot & lispro (human) inj 100 unit/ml (75-5) HUMALOG MIX 75/5 KWIKPEN 3 - insulin lispro prot & lispro sus pen-inj 100 unit/ml (75-5) HUMAPEN LUXURA HD 3 HUMULIN N - insulin nph (human)(isophane) inj 100 unit/ ml HUMULIN N KWIKPEN - insulin nph (human)(isophane) susp pen-injector 100 unit/ml HUMULIN N U-100 PEN - insulin nph (human)(isophane) susp pen-injector 100 unit/ml HUMULIN R - insulin regular (human) inj 100 unit/ml HUMULIN R U-500 (CONCENTRATE) - insulin regular (human) inj 500 unit/ml HUMULIN 70/30 - insulin nph isophane & regular human inj 100 unit/ml (70-30) 3 3 3 3 3 3 HUMULIN 70/30 KWIKPEN - 3 insulin nph & regular susp peninj 100 unit/ml (70-30) HUMULIN 70/30 PEN - insulin 3 nph & regular susp pen-inj 100 unit/ml (70-30) INSULIN SYRINGE/NEEDLE 3 INVOKANA - canagliflozin tab 100 mg INVOKANA - canagliflozin tab 300 mg JANUMET - sitagliptin-metformin hcl tab 50-500 mg JANUMET - sitagliptin-metformin hcl tab 50-1000 mg JANUMET XR - sitagliptinmetformin hcl tab sr hr 50-500 mg JANUMET XR - sitagliptinmetformin hcl tab sr hr 50-1000 mg JANUMET XR - sitagliptinmetformin hcl tab sr hr 100-1000 mg JANUVIA - sitagliptin phosphate tab 5 mg JANUVIA - sitagliptin phosphate tab 50 mg JANUVIA - sitagliptin phosphate tab 100 mg JENTADUETO - linagliptinmetformin hcl tab.5-500 mg 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM)

JENTADUETO - linagliptinmetformin hcl tab.5-850 mg JENTADUETO - linagliptinmetformin hcl tab.5-1000 mg KOMBIGLYZE XR - saxagliptinmetformin hcl tab sr hr.5-1000 mg KOMBIGLYZE XR - saxagliptinmetformin hcl tab sr hr 5-500 mg KOMBIGLYZE XR - saxagliptinmetformin hcl tab sr hr 5-1000 mg LANTUS - insulin glargine inj 100 unit/ml LANTUS SOLOSTAR - insulin glargine soln pen-injector 100 unit/ml metformin hcl tab sr hr 500 mg 1 metformin hcl tab sr hr 750 mg metformin hcl tab 500 mg 1 metformin hcl tab 850 mg 1 metformin hcl tab 1000 mg 1 nateglinide tab 60 mg nateglinide tab 10 mg ONGLYZA - saxagliptin hcl tab.5 mg ONGLYZA - saxagliptin hcl tab 5 mg pioglitazone hcl tab 15 mg pioglitazone hcl tab 30 mg 3 pioglitazone hcl tab 5 mg PROGLYCEM - diazoxide susp 50 mg/ml SYMLINPEN 10 - pramlintide acetate pen-inj 700 mcg/.7ml (1000 mcg/ml) SYMLINPEN 60 - pramlintide acetate pen-inj 1500 mcg/1.5ml (1000 mcg/ml) TOUJEO SOLOSTAR - insulin glargine soln pen-injector 300 unit/ml TRADJENTA - linagliptin tab 5 mg VICTOZA - liraglutide soln peninjector 18 mg/3ml (6 mg/ml) WELCHOL - colesevelam hcl tab 3 65 mg WELCHOL - colesevelam hcl 3 packet for susp 3.75 gm Blood Products/Modifiers/Volume Expanders AGGRENOX - aspirindipyridamole cap sr 1hr 5-00 mg anagrelide hcl cap 0.5 mg anagrelide hcl cap 1 mg BRILINTA - ticagrelor tab 60 mg 3 BRILINTA - ticagrelor tab 90 mg 3 cilostazol tab 50 mg cilostazol tab 100 mg clopidogrel bisulfate tab 75 mg 1 EFFIENT - prasugrel hcl tab 5 mg 3 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 5

EFFIENT - prasugrel hcl tab 3 10 mg enoxaparin sodium inj 30 mg/0.3ml enoxaparin sodium inj 0 mg/0.ml enoxaparin sodium inj 60 mg/0.6ml enoxaparin sodium inj 80 mg/0.8ml enoxaparin sodium inj 100 mg/ml enoxaparin sodium inj 10 mg/0.8ml enoxaparin sodium inj 150 mg/ml enoxaparin sodium inj 300 mg/3ml EPOGEN - epoetin alfa inj 000 unit/ml EPOGEN - epoetin alfa inj 3000 unit/ml EPOGEN - epoetin alfa inj 000 unit/ml EPOGEN - epoetin alfa inj 10000 unit/ml EPOGEN - epoetin alfa inj 0000 unit/ml fondaparinux sodium subcutaneous inj.5 mg/0.5ml fondaparinux sodium subcutaneous inj 5 mg/0.ml fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml fondaparinux sodium subcutaneous inj 10 mg/0.8ml GRANIX - tbo-filgrastim soln prefilled syringe 300 mcg/0.5ml GRANIX - tbo-filgrastim soln prefilled syringe 80 mcg/0.8ml heparin sodium (porcine) inj 1000 unit/ml heparin sodium (porcine) inj 5000 unit/ml heparin sodium (porcine) inj 10000 unit/ml heparin sodium (porcine) inj 0000 unit/ml heparin sodium (porcine) pf inj 5000 unit/0.5ml heparin sodium (porcine) 0 unit/ ml in d5w LEUKINE - sargramostim lyophilized for inj 50 mcg MOZOBIL - plerixafor subcutaneous inj mg/1.ml (0 mg/ml) NEUMEGA - oprelvekin for inj 5 mg PRADAXA - dabigatran etexilate mesylate cap 75 mg PRADAXA - dabigatran etexilate mesylate cap 150 mg PROCRIT - epoetin alfa inj 000 unit/ml PROCRIT - epoetin alfa inj 3000 unit/ml 5 5 5 5 5 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 6

PROCRIT - epoetin alfa inj 000 unit/ml PROCRIT - epoetin alfa inj 10000 unit/ml PROCRIT - epoetin alfa inj 0000 unit/ml PROCRIT - epoetin alfa inj 0000 unit/ml PROMACTA - eltrombopag olamine tab 1.5 mg* PROMACTA - eltrombopag olamine tab 5 mg* PROMACTA - eltrombopag olamine tab 50 mg* PROMACTA - eltrombopag olamine tab 75 mg* tranexamic acid inj 100 mg/ml tranexamic acid tab 650 mg warfarin sodium tab 1 mg 1 warfarin sodium tab mg 1 warfarin sodium tab.5 mg 1 warfarin sodium tab 3 mg 1 warfarin sodium tab mg 1 warfarin sodium tab 5 mg 1 warfarin sodium tab 6 mg 1 warfarin sodium tab 7.5 mg 1 warfarin sodium tab 10 mg 1 XARELTO - rivaroxaban tab 10 mg XARELTO - rivaroxaban tab 15 mg XARELTO - rivaroxaban tab 0 mg XARELTO STARTER PACK - rivaroxaban tab starter therapy pack 15 mg & 0 mg Cardiovascular Agents acetazolamide cap sr 1hr 500 mg acetazolamide tab 50 mg amiloride hcl tab 5 mg amiodarone hcl tab 00 mg 1 amiodarone hcl tab 00 mg amlodipine besylate tab.5 mg 1 amlodipine besylate tab 5 mg 1 amlodipine besylate tab 10 mg 1 amlodipine besylate-valsartan tab 5-160 mg amlodipine besylate-valsartan tab 5-30 mg amlodipine besylate-valsartan tab 10-160 mg amlodipine besylate-valsartan tab 10-30 mg amlodipine-valsartanhydrochlorothiazide tab 5-160-1.5 mg amlodipine-valsartanhydrochlorothiazide tab 5-160-5 mg amlodipine-valsartanhydrochlorothiazide tab 10-160-1.5 mg 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 7

amlodipine-valsartanhydrochlorothiazide tab 10-160-5 mg amlodipine-valsartanhydrochlorothiazide tab 10-30-5 mg atenolol tab 5 mg 1 atenolol tab 50 mg 1 atenolol tab 100 mg 1 atorvastatin calcium tab 10 mg 1 atorvastatin calcium tab 0 mg atorvastatin calcium tab 0 mg atorvastatin calcium tab 80 mg AZOR - amlodipine besylateolmesartan medoxomil tab 5-0 mg AZOR - amlodipine besylateolmesartan medoxomil tab 5-0 mg AZOR - amlodipine besylateolmesartan medoxomil tab 10-0 mg AZOR - amlodipine besylateolmesartan medoxomil tab 10-0 mg benazepril & hydrochlorothiazide tab 5-6.5 mg benazepril & hydrochlorothiazide tab 10-1.5 mg benazepril & hydrochlorothiazide tab 0-1.5 mg benazepril & hydrochlorothiazide tab 0-5 mg benazepril hcl tab 5 mg 1 benazepril hcl tab 10 mg 1 benazepril hcl tab 0 mg 1 benazepril hcl tab 0 mg 1 BENICAR - olmesartan medoxomil tab 5 mg BENICAR - olmesartan medoxomil tab 0 mg BENICAR - olmesartan medoxomil tab 0 mg BENICAR HCT - olmesartan medoxomil-hydrochlorothiazide tab 0-1.5 mg BENICAR HCT - olmesartan medoxomil-hydrochlorothiazide tab 0-1.5 mg BENICAR HCT - olmesartan medoxomil-hydrochlorothiazide tab 0-5 mg bumetanide inj 0.5 mg/ml bumetanide tab 0.5 mg 1 bumetanide tab 1 mg 1 bumetanide tab mg 1 captopril tab 1.5 mg 1 captopril tab 5 mg 1 captopril tab 50 mg captopril tab 100 mg carvedilol tab 3.15 mg 1 carvedilol tab 6.5 mg 1 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 8

carvedilol tab 1.5 mg 1 carvedilol tab 5 mg 1 CHLORTHALIDONE - chlorthalidone tab 5 mg cholestyramine light powder packets gm cholestyramine light powder gm/dose cholestyramine powder packets gm cholestyramine powder gm/ dose clonidine hcl tab 0.1 mg 1 clonidine hcl tab 0. mg 1 clonidine hcl tab 0.3 mg 1 colestipol hcl granule packets 5 gm colestipol hcl granules 5 gm colestipol hcl tab 1 gm CORLANOR - ivabradine hcl tab 5 mg CORLANOR - ivabradine hcl tab 7.5 mg CRESTOR - rosuvastatin calcium tab 5 mg CRESTOR - rosuvastatin calcium tab 10 mg CRESTOR - rosuvastatin calcium tab 0 mg CRESTOR - rosuvastatin calcium tab 0 mg DEMSER - metyrosine cap 50 mg DIBENZYLINE - phenoxybenzamine hcl cap 10 mg DIGOXIN - digoxin oral soln 0.05 mg/ml# 5 digoxin tab 15 mcg (0.15 mg)# digoxin tab 50 mcg (0.5 mg)# diltiazem hcl cap sr 1hr 60 mg diltiazem hcl cap sr 1hr 90 mg diltiazem hcl cap sr 1hr 10 mg diltiazem hcl cap sr hr 10 mg diltiazem hcl cap sr hr 180 mg diltiazem hcl cap sr hr 0 mg diltiazem hcl coated beads cap sr hr 10 mg diltiazem hcl coated beads cap sr hr 180 mg diltiazem hcl coated beads cap sr hr 0 mg diltiazem hcl coated beads cap sr hr 300 mg diltiazem hcl coated beads cap sr hr 360 mg diltiazem hcl extended release beads cap sr hr 10 mg diltiazem hcl extended release beads cap sr hr 180 mg diltiazem hcl extended release beads cap sr hr 0 mg 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 9

diltiazem hcl extended release beads cap sr hr 300 mg diltiazem hcl extended release beads cap sr hr 360 mg diltiazem hcl extended release beads cap sr hr 0 mg diltiazem hcl tab 30 mg 1 diltiazem hcl tab 60 mg 1 diltiazem hcl tab 90 mg diltiazem hcl tab 10 mg 1 doxazosin mesylate tab 1 mg 1 doxazosin mesylate tab mg 1 doxazosin mesylate tab mg 1 doxazosin mesylate tab 8 mg 1 enalapril maleate & hydrochlorothiazide tab 5-1.5 mg 1 enalapril maleate & 1 hydrochlorothiazide tab 10-5 mg enalapril maleate tab.5 mg 1 enalapril maleate tab 5 mg 1 enalapril maleate tab 10 mg 1 enalapril maleate tab 0 mg 1 EXFORGE - amlodipine besylatevalsartan tab 5-160 mg EXFORGE - amlodipine besylatevalsartan tab 5-30 mg EXFORGE - amlodipine besylatevalsartan tab 10-160 mg EXFORGE - amlodipine besylatevalsartan tab 10-30 mg EXFORGE HCT - amlodipinevalsartan-hydrochlorothiazide tab 5-160-1.5 mg EXFORGE HCT - amlodipinevalsartan-hydrochlorothiazide tab 5-160-5 mg EXFORGE HCT - amlodipinevalsartan-hydrochlorothiazide tab 10-160-1.5 mg EXFORGE HCT - amlodipinevalsartan-hydrochlorothiazide tab 10-160-5 mg EXFORGE HCT - amlodipinevalsartan-hydrochlorothiazide tab 10-30-5 mg fenofibrate micronized cap 67 mg fenofibrate micronized cap 13 mg fenofibrate micronized cap 00 mg fenofibrate tab 8 mg fenofibrate tab 5 mg fenofibrate tab 15 mg fenofibrate tab 160 mg flecainide acetate tab 50 mg flecainide acetate tab 100 mg flecainide acetate tab 150 mg fosinopril sodium tab 10 mg 1 fosinopril sodium tab 0 mg 1 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 50

fosinopril sodium tab 0 mg 1 furosemide inj 10 mg/ml furosemide oral soln 10 mg/ml furosemide tab 0 mg 1 furosemide tab 0 mg 1 furosemide tab 80 mg 1 gemfibrozil tab 600 mg hydralazine hcl tab 10 mg hydralazine hcl tab 5 mg hydralazine hcl tab 50 mg hydralazine hcl tab 100 mg hydrochlorothiazide cap 1.5 mg 1 hydrochlorothiazide tab 1.5 mg 1 hydrochlorothiazide tab 5 mg 1 hydrochlorothiazide tab 50 mg 1 irbesartan tab 75 mg 1 irbesartan tab 150 mg irbesartan tab 300 mg irbesartan-hydrochlorothiazide tab 150-1.5 mg irbesartan-hydrochlorothiazide tab 300-1.5 mg isosorbide dinitrate tab 5 mg isosorbide dinitrate tab 10 mg isosorbide dinitrate tab 0 mg isosorbide mononitrate tab sr hr 30 mg isosorbide mononitrate tab sr hr 60 mg 1 1 isosorbide mononitrate tab sr hr 10 mg labetalol hcl tab 100 mg labetalol hcl tab 00 mg labetalol hcl tab 300 mg lisinopril & hydrochlorothiazide 1 tab 10-1.5 mg lisinopril & hydrochlorothiazide 1 tab 0-1.5 mg lisinopril & hydrochlorothiazide 1 tab 0-5 mg lisinopril tab.5 mg 1 lisinopril tab 5 mg 1 lisinopril tab 10 mg 1 lisinopril tab 0 mg 1 lisinopril tab 30 mg 1 lisinopril tab 0 mg 1 losartan potassium & hydrochlorothiazide tab 50-1.5 mg losartan potassium & hydrochlorothiazide tab 100-1.5 mg losartan potassium & hydrochlorothiazide tab 100-5 mg 1 1 1 losartan potassium tab 5 mg 1 losartan potassium tab 50 mg 1 losartan potassium tab 100 mg 1 lovastatin tab 10 mg 1 lovastatin tab 0 mg 1 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 51

lovastatin tab 0 mg 1 methazolamide tab 5 mg methazolamide tab 50 mg metoprolol succinate tab sr hr 5 mg metoprolol succinate tab sr hr 50 mg metoprolol succinate tab sr hr 100 mg metoprolol succinate tab sr hr 00 mg metoprolol tartrate tab 5 mg 1 metoprolol tartrate tab 50 mg 1 metoprolol tartrate tab 100 mg 1 mexiletine hcl cap 150 mg mexiletine hcl cap 00 mg mexiletine hcl cap 50 mg midodrine hcl tab.5 mg midodrine hcl tab 5 mg midodrine hcl tab 10 mg minoxidil tab.5 mg minoxidil tab 10 mg MULTAQ - dronedarone hcl tab 00 mg niacin tab cr 500 mg niacin tab cr 750 mg niacin tab cr 1000 mg nifedipine tab sr hr 30 mg nifedipine tab sr hr 60 mg 3 nifedipine tab sr hr 90 mg nifedipine tab sr hr osmotic release 30 mg nifedipine tab sr hr osmotic release 60 mg nifedipine tab sr hr osmotic release 90 mg nitroglycerin td patch hr 0.1 mg/ hr nitroglycerin td patch hr 0. mg/ hr nitroglycerin td patch hr 0. mg/ hr nitroglycerin td patch hr 0.6 mg/ hr NITROSTAT - nitroglycerin sl tab 3 0.3 mg NITROSTAT - nitroglycerin sl tab 3 0. mg NITROSTAT - nitroglycerin sl tab 3 0.6 mg NORTHERA - droxidopa cap 100 mg NORTHERA - droxidopa cap 00 mg NORTHERA - droxidopa cap 300 mg omega-3-acid ethyl esters cap 1 gm pentoxifylline tab cr 00 mg phenoxybenzamine hcl cap 10 mg 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 5

pindolol tab 5 mg pindolol tab 10 mg pravastatin sodium tab 10 mg 1 pravastatin sodium tab 0 mg 1 pravastatin sodium tab 0 mg pravastatin sodium tab 80 mg prazosin hcl cap 1 mg prazosin hcl cap mg prazosin hcl cap 5 mg propafenone hcl cap sr 1hr 5 mg propafenone hcl cap sr 1hr 35 mg propafenone hcl cap sr 1hr 5 mg propafenone hcl tab 150 mg propafenone hcl tab 5 mg propafenone hcl tab 300 mg propranolol hcl inj 1 mg/ml propranolol hcl tab 10 mg 1 propranolol hcl tab 0 mg 1 propranolol hcl tab 0 mg 1 propranolol hcl tab 80 mg 1 quinapril hcl tab 5 mg 1 quinapril hcl tab 10 mg 1 quinapril hcl tab 0 mg 1 quinapril hcl tab 0 mg 1 QUINIDINE SULFATE - quinidine sulfate tab 00 mg quinidine sulfate tab 300 mg ramipril cap 1.5 mg 1 ramipril cap.5 mg 1 ramipril cap 5 mg 1 ramipril cap 10 mg RANEXA - ranolazine tab sr 1hr 500 mg RANEXA - ranolazine tab sr 1hr 1000 mg 3 3 simvastatin tab 5 mg 1 simvastatin tab 10 mg 1 simvastatin tab 0 mg 1 simvastatin tab 0 mg 1 simvastatin tab 80 mg 1 sotalol hcl (afib/afl) tab 80 mg sotalol hcl (afib/afl) tab 10 mg sotalol hcl (afib/afl) tab 160 mg sotalol hcl tab 80 mg 1 sotalol hcl tab 10 mg sotalol hcl tab 160 mg sotalol hcl tab 0 mg spironolactone tab 5 mg 1 spironolactone tab 50 mg spironolactone tab 100 mg TEKTURNA - aliskiren fumarate tab 150 mg TEKTURNA - aliskiren fumarate tab 300 mg telmisartan tab 0 mg 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 53

telmisartan tab 0 mg telmisartan tab 80 mg telmisartan-hydrochlorothiazide tab 0-1.5 mg telmisartan-hydrochlorothiazide tab 80-1.5 mg telmisartan-hydrochlorothiazide tab 80-5 mg terazosin hcl cap 1 mg 1 terazosin hcl cap mg 1 terazosin hcl cap 5 mg 1 terazosin hcl cap 10 mg 1 TIKOSYN - dofetilide cap 15 mcg (0.15 mg) TIKOSYN - dofetilide cap 50 mcg (0.5 mg) TIKOSYN - dofetilide cap 500 mcg (0.5 mg) triamterene & hydrochlorothiazide 1 cap 37.5-5 mg triamterene & hydrochlorothiazide 1 tab 37.5-5 mg triamterene & hydrochlorothiazide 1 tab 75-50 mg TRIBENZOR - olmesartanamlodipine-hydrochlorothiazide tab 0-5-1.5 mg TRIBENZOR - olmesartanamlodipine-hydrochlorothiazide tab 0-5-1.5 mg TRIBENZOR - olmesartanamlodipine-hydrochlorothiazide tab 0-5-5 mg TRIBENZOR - olmesartanamlodipine-hydrochlorothiazide tab 0-10-1.5 mg TRIBENZOR - olmesartanamlodipine-hydrochlorothiazide tab 0-10-5 mg verapamil hcl tab cr 10 mg verapamil hcl tab cr 180 mg verapamil hcl tab cr 0 mg verapamil hcl tab 80 mg 1 verapamil hcl tab 10 mg 1 VYTORIN - ezetimibe-simvastatin tab 10-10 mg VYTORIN - ezetimibe-simvastatin tab 10-0 mg VYTORIN - ezetimibe-simvastatin tab 10-0 mg VYTORIN - ezetimibe-simvastatin tab 10-80 mg WELCHOL - colesevelam hcl tab 3 65 mg WELCHOL - colesevelam hcl 3 packet for susp 3.75 gm ZETIA - ezetimibe tab 10 mg Central Nervous System Agents amphetaminedextroamphetamine cap sr hr 5 mg 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 5

amphetaminedextroamphetamine cap sr hr 10 mg amphetaminedextroamphetamine cap sr hr 15 mg amphetaminedextroamphetamine cap sr hr 0 mg amphetaminedextroamphetamine cap sr hr 5 mg amphetaminedextroamphetamine cap sr hr 30 mg AMPYRA - dalfampridine tab sr 1hr 10 mg* AVONEX - interferon beta-1a im prefilled syringe kit 30 mcg/0.5ml AVONEX - interferon beta-1a for im inj kit 30mcg (33mcg(6.6 mu)/vial) AVONEX PEN - interferon beta-1a im auto-injector kit 30 mcg/0.5ml BETASERON - interferon beta-1b for inj kit 0.3 mg clonidine hcl tab sr 1hr 0.1 mg COPAXONE - glatiramer acetate soln prefilled syringe 0 mg/ml COPAXONE - glatiramer acetate soln prefilled syringe 0 mg/ml dexmethylphenidate hcl tab.5 mg dexmethylphenidate hcl tab 5 mg dexmethylphenidate hcl tab 10 mg dextroamphetamine sulfate tab 5 mg dextroamphetamine sulfate tab 10 mg duloxetine hcl enteric coated pellets cap 0 mg duloxetine hcl enteric coated pellets cap 30 mg duloxetine hcl enteric coated pellets cap 60 mg Glatopa - glatiramer acetate soln prefilled syringe 0 mg/ml LYRICA - pregabalin soln 0 mg/ 3 ml LYRICA - pregabalin cap 5 mg 3 LYRICA - pregabalin cap 50 mg 3 LYRICA - pregabalin cap 75 mg 3 LYRICA - pregabalin cap 100 mg 3 LYRICA - pregabalin cap 150 mg 3 LYRICA - pregabalin cap 00 mg 3 LYRICA - pregabalin cap 5 mg 3 LYRICA - pregabalin cap 300 mg 3 methylphenidate hcl tab cr 0 mg methylphenidate hcl tab 5 mg methylphenidate hcl tab 10 mg methylphenidate hcl tab 0 mg 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 55

mitoxantrone hcl inj conc 0 mg/10ml ( mg/ml) mitoxantrone hcl inj conc 5 mg/1.5ml ( mg/ml) mitoxantrone hcl inj conc 30 mg/15ml ( mg/ml) NUEDEXTA - dextromethorphan 3 hbr-quinidine sulfate cap 0-10 mg PLEGRIDY - peginterferon beta-1a soln pen-injector 15 mcg/0.5ml PLEGRIDY - peginterferon beta-1a soln prefilled syringe 15 mcg/0.5ml PLEGRIDY STARTER PACK - peginterferon beta-1a soln peninj 63 & 9 mcg/0.5ml pack PLEGRIDY STARTER PACK - peginterferon beta-1a soln pref syr 63 & 9 mcg/0.5ml pack riluzole tab 50 mg 5 STRATTERA - atomoxetine hcl cap 10 mg STRATTERA - atomoxetine hcl cap 18 mg STRATTERA - atomoxetine hcl cap 5 mg STRATTERA - atomoxetine hcl cap 0 mg STRATTERA - atomoxetine hcl cap 60 mg STRATTERA - atomoxetine hcl cap 80 mg STRATTERA - atomoxetine hcl cap 100 mg TECFIDERA - dimethyl fumarate capsule delayed release 10 mg TECFIDERA - dimethyl fumarate capsule delayed release 0 mg TECFIDERA STARTER PACK - dimethyl fumarate capsule dr starter pack 10 mg & 0 mg tetrabenazine tab 1.5 mg* tetrabenazine tab 5 mg* TYSABRI - natalizumab for iv inj conc 300 mg/15ml* XENAZINE - tetrabenazine tab 1.5 mg* XENAZINE - tetrabenazine tab 5 mg* Dental and Oral Agents chlorhexidine gluconate soln 1 0.1% doxycycline hyclate cap 50 mg doxycycline hyclate cap 100 mg doxycycline hyclate for inj 100 mg doxycycline hyclate tab 100 mg KEPIVANCE - palifermin for iv inj 5 6.5 mg pilocarpine hcl tab 5 mg pilocarpine hcl tab 7.5 mg 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 56

Dermatological Agents acitretin cap 10 mg 5 acitretin cap 17.5 mg 5 acitretin cap 5 mg 5 benzoyl peroxideerythromycin gel 5-3% calcipotriene cream 0.005% calcipotriene soln 0.005% (50 mcg/ml) ciclopirox solution 8% clobetasol propionate cream 0.05% clobetasol propionate emollient base cream 0.05% clobetasol propionate gel 0.05% clobetasol propionate oint 0.05% clobetasol propionate soln 0.05% ELIDEL - pimecrolimus cream 1% FINACEA - azelaic acid foam 15% FINACEA - azelaic acid gel 15% fluocinonide cream 0.05% fluocinonide emulsified base cream 0.05% fluocinonide gel 0.05% fluorouracil cream 5% GENTAMICIN SULFATE - gentamicin sulfate cream 0.1% GENTAMICIN SULFATE - gentamicin sulfate oint 0.1% hydrocortisone cream 1% hydrocortisone cream.5% hydrocortisone lotion.5% hydrocortisone oint 1% hydrocortisone oint.5% imiquimod cream 5% isotretinoin cap 10 mg isotretinoin cap 0 mg isotretinoin cap 30 mg isotretinoin cap 0 mg ketoconazole cream % ketoconazole shampoo % lactic acid (ammonium lactate) cream 1% lactic acid (ammonium lactate) lotion 1% methoxsalen rapid cap 10 mg 5 metronidazole cream 0.75% metronidazole gel 0.75% metronidazole lotion 0.75% mupirocin oint % nystatin cream 100000 unit/gm nystatin oint 100000 unit/gm nystatin topical powder nystatin-triamcinolone cream 100000-0.1 unit/gm-% SANTYL - collagenase oint 50 3 unit/gm selenium sulfide lotion.5% 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 57

silver sulfadiazine cream 1% sulfacetamide sodium lotion 10% TAZORAC - tazarotene cream 0.05% TAZORAC - tazarotene cream 0.1% TAZORAC - tazarotene gel 0.05% TAZORAC - tazarotene gel 0.1% TRIAMCINOLONE ACETONIDE - triamcinolone acetonide oint 0.5% triamcinolone acetonide cream 0.05% triamcinolone acetonide cream 0.1% triamcinolone acetonide cream 0.5% triamcinolone acetonide oint 0.05% triamcinolone acetonide oint 0.1% UVADEX - methoxsalen soln 0 mcg/ml VALCHLOR - mechlorethamine 5 hcl gel 0.016%* VOLTAREN - diclofenac sodium gel 1% Enzyme Replacements/Modifiers ADAGEN - pegademase bovine 5 inj 50 unit/ml* ALDURAZYME - laronidase soln for iv infusion.9 mg/5ml (500 unit/5ml)* 5 BUPHENYL - sodium 5 phenylbutyrate tab 500 mg CEREZYME - imiglucerase for inj 5 00 unit* CREON - pancrelipase (lip-protamyl) dr cap 3000-9500-15000 3 unit CREON - pancrelipase (lip-protamyl) dr cap 6000-19000-30000 3 unit CREON - pancrelipase 3 (lip-prot-amyl) dr cap 1000-38000-60000 unit CREON - pancrelipase 3 (lip-prot-amyl) dr cap 000-76000-10000 unit CREON - pancrelipase 3 (lip-prot-amyl) dr cap 36000-11000-180000 unit CYSTADANE - betaine powder 5 for oral solution CYSTAGON - cysteamine bitartrate cap 50 mg* CYSTAGON - cysteamine bitartrate cap 150 mg* ELAPRASE - idursulfase soln for 5 iv infusion 6 mg/3ml ( mg/ml) ELELYSO - taliglucerase alfa for 5 inj 00 unit* FABRAZYME - agalsidase beta 5 for iv soln 5 mg* FABRAZYME - agalsidase beta 5 for iv soln 35 mg* 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 58

KUVAN - sapropterin dihydrochloride soluble tab 100 mg* KUVAN - sapropterin dihydrochloride powder packet 100 mg* KUVAN - sapropterin dihydrochloride powder packet 500 mg* MYOZYME - alglucosidase alfa 5 for iv soln 50 mg NAGLAZYME - galsulfase soln for 5 iv infusion 1 mg/ml* ORFADIN - nitisinone cap mg* 5 ORFADIN - nitisinone cap 5 mg* 5 ORFADIN - nitisinone cap 10 mg* 5 sodium phenylbutyrate oral powder 3 gm/teaspoonful VPRIV - velaglucerase alfa for inj 00 unit ZAVESCA - miglustat cap 100 mg* ZENPEP - pancrelipase (lip-protamyl) dr cap 3000-10000-16000 unit ZENPEP - pancrelipase (lip-protamyl) dr cap 5000-17000-7000 unit ZENPEP - pancrelipase (lip-prot-amyl) dr cap 10000-3000-55000 unit 5 5 5 3 3 3 ZENPEP - pancrelipase 3 (lip-prot-amyl) dr cap 15000-51000-8000 unit ZENPEP - pancrelipase 3 (lip-prot-amyl) dr cap 0000-68000-109000 unit ZENPEP - pancrelipase 3 (lip-prot-amyl) dr cap 5000-85000-136000 unit ZENPEP - pancrelipase 3 (lip-prot-amyl) dr cap 0000-136000-18000 unit Gastrointestinal Agents alosetron hcl tab 0.5 mg 5 alosetron hcl tab 1 mg 5 AMITIZA - lubiprostone cap 8 mcg AMITIZA - lubiprostone cap mcg CHENODAL - chenodiol tab 5 50 mg* dicyclomine hcl tab 0 mg esomeprazole sodium for intravenous soln 0 mg esomeprazole sodium for intravenous soln 0 mg famotidine inj 0 mg/ml famotidine inj 0 mg/ml famotidine inj 00 mg/0ml famotidine tab 0 mg 1 famotidine tab 0 mg 1 glycopyrrolate tab 1 mg 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 59

glycopyrrolate tab mg lactulose (encephalopathy) solution 10 gm/15ml lactulose solution 10 gm/15ml LINZESS - linaclotide cap 15 mcg LINZESS - linaclotide cap 90 mcg loperamide hcl cap mg LOTRONEX - alosetron hcl tab 5 0.5 mg LOTRONEX - alosetron hcl tab 5 1 mg methscopolamine bromide tab.5 mg methscopolamine bromide tab 5 mg metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) metoclopramide hcl tab 5 mg 1 metoclopramide hcl tab 10 mg 1 misoprostol tab 100 mcg misoprostol tab 00 mcg NEXIUM - esomeprazole magnesium for delayed release susp pack.5 mg NEXIUM - esomeprazole magnesium for delayed release susp packet 5 mg NEXIUM - esomeprazole magnesium for delayed release susp packet 10 mg NEXIUM - esomeprazole magnesium for delayed release susp packet 0 mg NEXIUM - esomeprazole magnesium for delayed release susp packet 0 mg NEXIUM - esomeprazole magnesium cap delayed release 0 mg NEXIUM - esomeprazole magnesium cap delayed release 0 mg nizatidine cap 150 mg nizatidine cap 300 mg omeprazole cap delayed release 10 mg omeprazole cap delayed release 0 mg omeprazole cap delayed release 0 mg pantoprazole sodium ec tab 0 mg pantoprazole sodium ec tab 0 mg peg 3350-kcl-sod bicarb-nacl for soln 0 gm peg 3350-kcl-na bicarb-nacl-na sulfate for soln 36 gm peg 3350-kcl-na bicarb-nacl-na sulfate for soln 0 gm polyethylene glycol 3350 oral packet 1 1 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 60

polyethylene glycol 3350 oral powder ranitidine hcl syrup 15 mg/ml (75 mg/5ml) ranitidine hcl tab 150 mg 1 ranitidine hcl tab 300 mg 1 RELISTOR - methylnaltrexone bromide inj kit 1 mg/0.6ml RELISTOR - methylnaltrexone bromide inj 8 mg/0.ml (0 mg/ ml) RELISTOR - methylnaltrexone bromide inj 1 mg/0.6ml (0 mg/ml) sucralfate tab 1 gm ursodiol cap 300 mg XIFAXAN - rifaximin tab 550 mg 5 Genitourinary Agents AVODART - dutasteride cap 0.5 mg bethanechol chloride tab 5 mg bethanechol chloride tab 10 mg bethanechol chloride tab 5 mg bethanechol chloride tab 50 mg calcium acetate cap 667 mg calcium acetate tab 667 mg DEPEN TITRATABS - penicillamine tab 50 mg doxazosin mesylate tab 1 mg 1 doxazosin mesylate tab mg 1 doxazosin mesylate tab mg 1 doxazosin mesylate tab 8 mg 1 finasteride tab 5 mg FOSRENOL - lanthanum carbonate chew tab 500 mg FOSRENOL - lanthanum carbonate chew tab 750 mg FOSRENOL - lanthanum carbonate chew tab 1000 mg FOSRENOL - lanthanum carbonate oral powder pack 750 mg FOSRENOL - lanthanum carbonate oral powder pack 1000 mg methylergonovine maleate tab 0. mg MYRBETRIQ - mirabegron tab sr hr 5 mg MYRBETRIQ - mirabegron tab sr hr 50 mg oxybutynin chloride syrup 5 mg/5ml oxybutynin chloride tab 5 mg prazosin hcl cap 1 mg prazosin hcl cap mg prazosin hcl cap 5 mg RENVELA - sevelamer carbonate tab 800 mg RENVELA - sevelamer carbonate packet 0.8 gm RENVELA - sevelamer carbonate packet. gm 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 61

tamsulosin hcl cap 0. mg terazosin hcl cap 1 mg 1 terazosin hcl cap mg 1 terazosin hcl cap 5 mg 1 terazosin hcl cap 10 mg 1 tolterodine tartrate cap sr hr mg tolterodine tartrate cap sr hr mg TOVIAZ - fesoterodine fumarate tab sr hr mg TOVIAZ - fesoterodine fumarate tab sr hr 8 mg VESICARE - solifenacin succinate tab 5 mg VESICARE - solifenacin succinate tab 10 mg Hormonal Agents, Stimulant/Replacement/ Modifying (Adrenal) CORTISONE ACETATE - cortisone acetate tab 5 mg dexamethasone elixir 0.5 mg/5ml dexamethasone sodium phosphate inj mg/ml dexamethasone sodium phosphate inj 0 mg/5ml dexamethasone sodium phosphate inj 10 mg/30ml dexamethasone tab 0.5 mg 1 dexamethasone tab 0.75 mg 1 dexamethasone tab 1.5 mg 1 dexamethasone tab mg 1 dexamethasone tab 6 mg fludrocortisone acetate tab 0.1 mg methylprednisolone sodium succinate for inj 0 mg methylprednisolone sodium succinate for inj 15 mg methylprednisolone sodium succinate for inj 1000 mg methylprednisolone tab mg dose pack methylprednisolone tab mg X methylprednisolone tab 8 mg X methylprednisolone tab 16 mg X methylprednisolone tab 3 mg X MYALEPT - metreleptin for subcutaneous inj 11.3 mg PREDNISONE - prednisone tab X 50 mg PREDNISONE - prednisone oral X soln 5 mg/5ml PREDNISONE - prednisone tab 1 5 mg dose pack PREDNISONE - prednisone tab 1 10 mg dose pack prednisone tab 1 mg X prednisone tab.5 mg 1 X prednisone tab 5 mg 1 X prednisone tab 10 mg 1 X prednisone tab 0 mg 1 X 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 6

Hormonal Agents, Stimulant/Replacement/ Modifying (Pituitary) chorionic gonadotropin for inj 10000 unit desmopressin acetate inj mcg/ ml desmopressin acetate nasal soln 0.01% (refrigerated) desmopressin acetate nasal spray soln 0.01% desmopressin acetate nasal spray soln 0.01% (refrigerated) desmopressin acetate tab 0.1 mg desmopressin acetate tab 0. mg INCRELEX - mecasermin inj 5 0 mg/ml (10 mg/ml)* OMNITROPE - somatropin for inj 5.8 mg OMNITROPE - somatropin inj 5 mg/1.5ml OMNITROPE - somatropin inj 10 mg/1.5ml STIMATE - desmopressin acetate nasal soln 1.5 mg/ml Hormonal Agents, Stimulant/Replacement/ Modifying (Sex Hormones/Modifiers) ANDRODERM - testosterone td patch hr mg/hr ANDRODERM - testosterone td patch hr mg/hr ANDROGEL - testosterone td gel 5 mg/.5gm (1%) ANDROGEL - testosterone td gel 50 mg/5gm (1%) ANDROGEL - testosterone td gel 0.5 mg/1.5gm (1.6%) ANDROGEL - testosterone td gel 0.5 mg/.5gm (1.6%) ANDROGEL PUMP - testosterone td gel 1.5 mg/act (1%) ANDROGEL PUMP - testosterone td gel 0.5 mg/act (1.6%) ANDROID - methyltestosterone cap 10 mg ANDROXY - fluoxymesterone tab 10 mg danazol cap 50 mg danazol cap 100 mg danazol cap 00 mg DEPO-PROVERA - medroxyprogesterone acetate im susp 00 mg/ml desogest-eth estrad & eth estrad tab 0.15-0.0/0.01 mg(1/5) desogest-ethin est tab 0.1-0.05/0.15-0.05/0.15-0.05mgmg desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg DIVIGEL - estradiol td gel 0.5 mg/0.5gm (0.1%)# DIVIGEL - estradiol td gel 0.5 mg/0.5gm (0.1%)# 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 63

DIVIGEL - estradiol td gel 1 mg/ gm (0.1%)# drospirenone-ethinyl estradiol tab 3-0.0 mg drospirenone-ethinyl estradiol tab 3-0.03 mg ELLA - ulipristal acetate tab 30 mg ESTRACE - estradiol vaginal cream 0.1 mg/gm estradiol tab 0.5 mg# estradiol tab 1 mg# estradiol tab mg# estradiol td patch weekly 0.05 mg/hr# estradiol td patch weekly 0.0375 mg/hr (37.5 mcg/hr)# estradiol td patch weekly 0.05 mg/hr# estradiol td patch weekly 0.06 mg/hr# estradiol td patch weekly 0.075 mg/hr# estradiol td patch weekly 0.1 mg/hr# estropipate tab 0.75 mg# estropipate tab 1.5 mg# ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg 3 levonorg-eth est tab 0.1-0.0mg(8) & eth est tab 0.01mg(7) levonorg-eth est tab 0.15-0.03mg(8) & eth est tab 0.01mg(7) levonorgestrel & ethinyl estradiol (91-day) tab 0.15-0.03 mg levonorgestrel & ethinyl estradiol tab 0.1 mg-0 mcg levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg levonorgestrel-eth estra tab 0.05-30/0.075-0/0.15-30mgmcg levonorgestrel-ethinyl estradiol (continuous) tab 90-0 mcg medroxyprogesterone acetate im susp 150 mg/ml medroxyprogesterone acetate tab 1.5 mg medroxyprogesterone acetate tab 1 5 mg medroxyprogesterone acetate tab 1 10 mg megestrol acetate susp 0 mg/ ml# megestrol acetate tab 0 mg# megestrol acetate tab 0 mg# MENEST - esterified estrogens tab 0.3 mg# MENEST - esterified estrogens tab 0.65 mg# 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 6

MENEST - esterified estrogens tab 1.5 mg# MENEST - esterified estrogens tab.5 mg# methyltestosterone cap 10 mg norethindrone & ethinyl estradiol tab 0. mg-35 mcg norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg norethindrone & ethinyl estradiol tab 1 mg-35 mcg norethindrone & ethinyl estradiolfe chew tab 0. mg-35 mcg norethindrone & ethinyl estradiolfe chew tab 0.8 mg-5 mcg norethindrone ac-ethinyl estrad-fe tab 1-0/1-30/1-35 mg-mcg norethindrone ace & ethinyl estradiol tab 1 mg-0 mcg norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg norethindrone ace & ethinyl estradiol-fe tab 1 mg-0 mcg norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg norethindrone ace-ethinyl estradiol-fe tab 1 mg-0 mcg () norethindrone acetate tab 5 mg norethindrone tab 0.35 mg norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg-mcg norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg-mcg norgestimate & ethinyl estradiol tab 0.5 mg-35 mcg norgestimate-eth estrad tab 0.18-35/0.15-35/0.5-35 mgmcg norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg oxandrolone tab.5 mg oxandrolone tab 10 mg PREMARIN - estrogens, 3 conjugated vaginal cream 0.65 mg/gm raloxifene hcl tab 60 mg testosterone cypionate im inj in oil 100 mg/ml testosterone cypionate im inj in oil 00 mg/ml VAGIFEM - estradiol vaginal tab 3 10 mcg Hormonal Agents, Stimulant/Replacement/ Modifying (Thyroid) levothyroxine sodium tab 5 mcg 1 levothyroxine sodium tab 50 mcg 1 levothyroxine sodium tab 75 mcg 1 levothyroxine sodium tab 88 mcg 1 levothyroxine sodium tab 1 100 mcg levothyroxine sodium tab 11 mcg 1 levothyroxine sodium tab 15 mcg 1 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 65

levothyroxine sodium tab 1 137 mcg levothyroxine sodium tab 1 150 mcg levothyroxine sodium tab 175 mcg levothyroxine sodium tab 1 00 mcg levothyroxine sodium tab 300 mcg liothyronine sodium tab 5 mcg liothyronine sodium tab 5 mcg liothyronine sodium tab 50 mcg Hormonal Agents, Suppressant (Adrenal) LYSODREN - mitotane tab 3 500 mg Hormonal Agents, Suppressant (Parathyroid) SENSIPAR - cinacalcet hcl tab 30 mg SENSIPAR - cinacalcet hcl tab 60 mg SENSIPAR - cinacalcet hcl tab 90 mg Hormonal Agents, Suppressant (Pituitary) cabergoline tab 0.5 mg ELIGARD - leuprolide acetate for subcutaneous inj kit 7.5 mg ELIGARD - leuprolide acetate (3 month) for subcutaneous inj kit.5mg ELIGARD - leuprolide acetate ( month) for subcutaneous inj kit 30 mg ELIGARD - leuprolide acetate (6 5 month) for subcutaneous inj kit 5 mg FIRMAGON - degarelix acetate for inj 80 mg FIRMAGON - degarelix acetate 5 for inj 10 mg leuprolide acetate inj kit 5 mg/ml LUPRON DEPOT - leuprolide acetate for inj kit 3.75 mg LUPRON DEPOT - leuprolide acetate for inj kit 7.5 mg LUPRON DEPOT - leuprolide acetate (3 month) for inj kit 11.5 mg LUPRON DEPOT - leuprolide acetate (3 month) for inj kit.5 mg LUPRON DEPOT - leuprolide acetate ( month) for inj kit 30 mg LUPRON DEPOT - leuprolide acetate (6 month) for inj kit 5 mg octreotide acetate inj 50 mcg/ml (0.05 mg/ml) octreotide acetate inj 100 mcg/ml (0.1 mg/ml) octreotide acetate inj 00 mcg/ml (0. mg/ml) 5 5 5 5 5 5 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 66

octreotide acetate inj 500 mcg/ml (0.5 mg/ml) octreotide acetate inj 1000 mcg/ ml (1 mg/ml) SOMATULINE DEPOT - lanreotide acetate extended release inj 60 mg/0.ml SOMATULINE DEPOT - lanreotide acetate extended release inj 90 mg/0.3ml SOMATULINE DEPOT - lanreotide acetate extended release inj 10 mg/0.5ml SOMAVERT - pegvisomant for inj 10 mg* SOMAVERT - pegvisomant for inj 15 mg* SOMAVERT - pegvisomant for inj 0 mg* SOMAVERT - pegvisomant for inj 5 mg* SOMAVERT - pegvisomant for inj 30 mg* SYNAREL - nafarelin acetate nasal soln mg/ml TRELSTAR - triptorelin pamoate for im susp 3.75 mg TRELSTAR - triptorelin pamoate for im susp 11.5 mg TRELSTAR MIXJECT - triptorelin pamoate for im susp 3.75 mg TRELSTAR MIXJECT - triptorelin pamoate for im susp 11.5 mg 5 5 5 5 5 TRELSTAR MIXJECT - triptorelin 5 pamoate for im susp.5 mg Hormonal Agents, Suppressant (Thyroid) methimazole tab 5 mg 1 methimazole tab 10 mg propylthiouracil tab 50 mg Immunological Agents ACTHIB - haemophilus b polysaccharide conjugate vaccine for inj ACTIMMUNE - 5 interferon gamma-1b inj 100 mcg/0.5ml (000000 unit/0.5ml)* ADACEL - tet tox-diph-acell pertuss ad inj 5--15.5 lf-lfmcg/0.5ml ARCALYST - rilonacept for inj 0 mg* azathioprine tab 50 mg X BCG VACCINE - bcg vaccine inj BEXSERO - meningococcal vac b (recomb adsorbed) inj prefilled syringe BOOSTRIX - tet tox-diph-acell pertuss ad inj 5-.5-18.5 lf-lfmcg/0.5ml CELLCEPT - mycophenolate mofetil for oral susp 00 mg/ml CELLCEPT INTRAVENOUS - mycophenolate mofetil hcl for iv soln 500 mg 5 X X 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 67

CERVARIX - human papillomavirus (hpv) bival (type 16, 18) recmb vac inj CINRYZE - c1 esterase inhibitor (human) for iv inj 500 unit* COMVAX - haemophilus b polysac conj-hepatitis b (recomb) vac im susp cyclosporine cap 5 mg X cyclosporine cap 100 mg X cyclosporine iv soln 50 mg/ml X CYCLOSPORINE MODIFIED X - cyclosporine modified cap 50 mg cyclosporine modified cap 5 mg X cyclosporine modified cap 100 mg X cyclosporine modified oral soln X 100 mg/ml DAPTACEL - diph, acellular pert & tet tox inj 15 lf-10 mcg-5 lf/0.5ml DEPEN TITRATABS - penicillamine tab 50 mg DIPHTHERIA/TETANUS TOXOID - diphtheria-tetanus tox adsorbed (dt) im inj 5-5 unit/0.5ml ELIDEL - pimecrolimus cream 1% ENBREL - etanercept for subcutaneous inj kit 5 mg ENBREL - etanercept subcutaneous soln prefilled syringe 5 mg/0.5ml ENBREL - etanercept subcutaneous soln prefilled syringe 50 mg/ml ENBREL SURECLICK - etanercept subcutaneous solution auto-injector 50 mg/ml ENGERIX-B - hepatitis b vaccine (recombinant) susp 10 mcg/0.5ml ENGERIX-B - hepatitis b vaccine (recombinant) susp 0 mcg/ml FIRAZYR - icatibant acetate inj 30 mg/3ml GAMMAPLEX - immune globulin (human) iv soln.5 gm/50ml GAMMAPLEX - immune globulin (human) iv soln 5 gm/100ml GAMMAPLEX - immune globulin (human) iv soln 10 gm/00ml GAMMAPLEX - immune globulin (human) iv soln 0 gm/00ml GAMUNEX-C - immune globulin (human) iv or subcutaneous soln 1 gm/10ml GAMUNEX-C - immune globulin (human) iv or subcutaneous soln.5 gm/5ml GAMUNEX-C - immune globulin (human) iv or subcutaneous soln 5 gm/50ml X X 5 X 5 X 5 X 5 X 3 X 3 X 3 X 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 68

GAMUNEX-C - immune globulin (human) iv or subcutaneous soln 10 gm/100ml GAMUNEX-C - immune globulin (human) iv or subcutaneous soln 0 gm/00ml GAMUNEX-C - immune globulin (human) iv or subcutaneous soln 0 gm/00ml GARDASIL - human papillomavirus (hpv) quadrivalent recombinant vac inj GARDASIL 9 - human papillomavirus (hpv) 9-valent recomb vac susp pref syr GARDASIL 9 - human papillomavirus (hpv) 9-valent recomb vac im susp HAVRIX - hepatitis a vaccine inj susp 70 el unit/0.5ml HAVRIX - hepatitis a vaccine inj susp 10 el unit/ml HIBERIX - haemophilus b polysaccharide conjugate vac for inj 10 mcg HUMIRA - adalimumab prefilled syringe kit 10 mg/0.ml HUMIRA - adalimumab prefilled syringe kit 0 mg/0.ml HUMIRA - adalimumab prefilled syringe kit 0 mg/0.8ml 3 X 3 X 3 X HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK - adalimumab prefilled syringe kit 0 mg/0.8ml HUMIRA PEN - adalimumab peninjector kit 0 mg/0.8ml HUMIRA PEN-CROHNS DISEASE STARTER - adalimumab pen-injector kit 0 mg/0.8ml HUMIRA PEN-PSORIASIS STARTER - adalimumab peninjector kit 0 mg/0.8ml ILARIS - canakinumab for inj 180 mg* IMOVAX RABIES (H.D.C.V.) - X rabies virus vaccine, hdc inj INFANRIX - diph, acellular pert & tet tox inj 5 lf-58 mcg-10 lf/0.5ml IPOL INACTIVATED IPV - poliovirus vaccine, ipv injection IXIARO - japanese encephalitis vaccine inactivated adsorbed inj KINERET - anakinra subcutaneous soln prefilled syringe 100 mg/0.67ml KINRIX - diph-tetanus tox ad-acell pert & polio virus, ipv vac inj leflunomide tab 10 mg leflunomide tab 0 mg M-M-R II - measles, mumps & rubella virus vaccines for inj 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 69

MENACTRA - meningococcal (a, c, y, and w-135) conjugate vaccine inj MENOMUNE-A/C/Y/W-135 - meningococcal vaccine a, c, y, and w-135 inj MENVEO - meningococcal (a, c, y, and w-135) oligo conj vac for inj methotrexate sodium for inj 1 gm methotrexate sodium inj pf 5 mg/ 1 ml methotrexate sodium inj 5 mg/ml 1 methotrexate sodium tab.5 mg X mycophenolate mofetil cap 50 mg mycophenolate mofetil for oral susp 00 mg/ml mycophenolate mofetil tab 500 mg PEDVAX HIB - haemophilus b polysaccharide conj vac im susp 7.5 mcg/0.5 ml PENTACEL - diph-ac per-tet tox ad-poliov-haemoph b poly vac for im susp PROQUAD - measles-mumpsrubella-varicella virus vaccines for inj QUADRACEL - diph-tetanus tox ad-acell pert & polio virus, ipv vac inj X 5 X X RABAVERT - rabies vaccine, X pcec for inj RAPAMUNE - sirolimus oral soln 5 X 1 mg/ml RECOMBIVAX HB - hepatitis b X vaccine (recombinant) susp 5 mcg/0.5ml RECOMBIVAX HB - hepatitis b X vaccine (recombinant) susp 10 mcg/ml RECOMBIVAX HB - hepatitis b X vaccine (recombinant) susp 0 mcg/ml REMICADE - infliximab for iv inj 100 mg ROTARIX - rotavirus vaccine, live for oral susp ROTATEQ - rotavirus vaccine, live oral pentavalent soln SANDIMMUNE - cyclosporine X oral soln 100 mg/ml sirolimus tab 0.5 mg X sirolimus tab 1 mg X sirolimus tab mg 5 X SYNAGIS - palivizumab im soln 5 50 mg/0.5ml SYNAGIS - palivizumab im soln 5 100 mg/ml tacrolimus cap 0.5 mg X tacrolimus cap 1 mg X tacrolimus cap 5 mg X 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 70

TENIVAC - tetanus-diphtheria toxoids (td) inj 5- lfu TETANUS/DIPHTHERIA TOXOID - tetanus-diphtheria toxoids (td) inj - lf/0.5ml THALOMID - thalidomide cap 50 mg THALOMID - thalidomide cap 100 mg THALOMID - thalidomide cap 150 mg THALOMID - thalidomide cap 00 mg THYMOGLOBULIN - antithymocyte globulin for iv soln 5 mg (lymphocyte ig) TRUMENBA - meningococcal group b vaccine im susp prefilled syringe TWINRIX - hepatitis a (inact)-hep b (recomb) vac inj 70-0 elumcg/ml TYPHIM VI - typhoid vi polysaccharide intramuscular vac inj 5 mcg/0.5ml TYSABRI - natalizumab for iv inj conc 300 mg/15ml* VAQTA - hepatitis a vaccine inj susp 5 unit/0.5ml VAQTA - hepatitis a vaccine inj susp 50 unit/ml 3 5 X VARIVAX - varicella virus vac live for subcutaneous inj 1350 pfu/0.5ml YF-VAX - yellow fever vaccine subcutaneous inj ZORTRESS - everolimus tab X 0.5 mg ZORTRESS - everolimus tab 5 X 0.5 mg ZORTRESS - everolimus tab 5 X 0.75 mg ZOSTAVAX - zoster vaccine live for inj 1900 unit/0.65ml Inflammatory Bowel Disease Agents APRISO - mesalamine cap sr hr 0.375 gm balsalazide disodium cap 750 mg budesonide cap sr hr 3 mg 5 CANASA - mesalamine suppos 5 1000 mg DIPENTUM - olsalazine sodium cap 50 mg hydrocortisone enema 100 mg/60ml hydrocortisone rectal cream.5% LIALDA - mesalamine tab delayed release 1. gm mesalamine enema gm sulfasalazine tab 500 mg Metabolic Bone Disease Agents alendronate sodium tab 5 mg 1 alendronate sodium tab 10 mg 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 71

alendronate sodium tab 35 mg 1 alendronate sodium tab 70 mg 1 calcitonin (salmon) nasal soln 00 unit/act calcitriol cap 0.5 mcg calcitriol cap 0.5 mcg calcitriol inj 1 mcg/ml calcitriol oral soln 1 mcg/ml FORTEO - teriparatide (recombinant) inj 600 mcg/.ml ibandronate sodium iv soln 3 mg/3ml ibandronate sodium tab 150 mg MIACALCIN - calcitonin (salmon) inj 00 unit/ml paricalcitol cap 1 mcg paricalcitol cap mcg paricalcitol cap mcg paricalcitol iv soln mcg/ml paricalcitol iv soln 5 mcg/ml PROLIA - denosumab inj 60 mg/ ml XGEVA - denosumab inj 5 10 mg/1.7ml ZEMPLAR - paricalcitol iv soln 3 mcg/ml ZEMPLAR - paricalcitol iv soln 3 5 mcg/ml zoledronic acid inj conc for iv infusion mg/5ml zoledronic acid iv soln 5 mg/100ml ZOMETA - zoledronic acid iv soln 5 mg/100ml Ophthalmic Agents azelastine hcl ophth soln 0.05% BACITRACIN - bacitracin ophth oint 500 unit/gm brimonidine tartrate ophth soln 0.15% brimonidine tartrate ophth soln 0.% carteolol hcl ophth soln 1% ciprofloxacin hcl ophth soln 0.3% cromolyn sodium ophth soln % 1 dexamethasone sodium phosphate ophth soln 0.1% dorzolamide hcl ophth soln % erythromycin ophth oint 5 mg/gm fluorometholone ophth susp 0.1% flurbiprofen sodium ophth soln 0.03% gentamicin sulfate ophth oint 0.3% gentamicin sulfate ophth soln 0.3% ketorolac tromethamine ophth soln 0.% ketorolac tromethamine ophth soln 0.5% LACRISERT - artificial tear ophth insert 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 7

latanoprost ophth soln 0.005% NAPHAZOLINE HCL - naphazoline hcl ophth soln 0.1% NATACYN - natamycin ophth susp 5% neomycin-polymy-gramicid op sol 1.75-10000-0.05mg-unt-mg/ml neomycin-polymyxindexamethasone ophth oint 0.1% neomycin-polymyxindexamethasone ophth susp 0.1% ofloxacin ophth soln 0.3% PHOSPHOLINE IODIDE - echothiophate iodide ophth for soln 0.15% polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1% prednisolone acetate ophth susp 1% RESTASIS - cyclosporine (ophth) emulsion 0.05% sulfacetamide sodium ophth soln 10% sulfacetamide sodiumprednisolone ophth soln 10-0.3(0.5)% timolol maleate ophth gel forming soln 0.5% timolol maleate ophth gel forming soln 0.5% 3 timolol maleate ophth soln 0.5% 1 timolol maleate ophth soln 0.5% 1 tobramycin ophth soln 0.3% TRAVATAN Z - travoprost ophth 3 soln 0.00% trifluridine ophth soln 1% Otic Agents fluocinolone acetonide (otic) oil 0.01% hydrocortisone w/ acetic acid otic soln 1-% neomycin-polymyxin-hc otic soln 1% neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1% ofloxacin otic soln 0.3% Respiratory Tract/Pulmonary Agents acetylcysteine inhal soln 10% X acetylcysteine inhal soln 0% X ADCIRCA - tadalafil tab 0 mg ADVAIR DISKUS - fluticasonesalmeterol aer powder ba 100-50 mcg/dose ADVAIR DISKUS - fluticasonesalmeterol aer powder ba 50-50 mcg/dose ADVAIR DISKUS - fluticasonesalmeterol aer powder ba 500-50 mcg/dose ADVAIR HFA - fluticasonesalmeterol inhal aerosol 5-1 mcg/act 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 73

ADVAIR HFA - fluticasonesalmeterol inhal aerosol 115-1 mcg/act ADVAIR HFA - fluticasonesalmeterol inhal aerosol 30-1 mcg/act albuterol sulfate soln nebu X 0.083% (.5 mg/3ml) albuterol sulfate soln nebu 0.5% X (5 mg/ml) albuterol sulfate soln nebu X 0.63 mg/3ml albuterol sulfate soln nebu X 1.5 mg/3ml albuterol sulfate syrup mg/5ml albuterol sulfate tab mg albuterol sulfate tab mg ANORO ELLIPTA - umeclidiniumvilanterol aero powd ba 6.5-5 mcg/inh ARNUITY ELLIPTA - fluticasone furoate aerosol powder breath activ 100 mcg/act ARNUITY ELLIPTA - fluticasone furoate aerosol powder breath activ 00 mcg/act ASMANEX HFA - mometasone furoate inhal aerosol suspension 100 mcg/act ASMANEX HFA - mometasone furoate inhal aerosol suspension 00 mcg/act ASMANEX TWISTHALER 10 METERED DOSES - mometasone furoate inhal powd 0 mcg/inh ASMANEX TWISTHALER 1 METERED DOSES - mometasone furoate inhal powd 0 mcg/inh ASMANEX TWISTHALER 30 METERED DOSES - mometasone furoate inhal powd 110 mcg/inh ASMANEX TWISTHALER 30 METERED DOSES - mometasone furoate inhal powd 0 mcg/inh ASMANEX TWISTHALER 60 METERED DOSES - mometasone furoate inhal powd 0 mcg/inh ASMANEX TWISTHALER 7 METERED DOSES - mometasone furoate inhal powd 110 mcg/inh ASTEPRO - azelastine hcl nasal spray 0.15% (05.5 mcg/spray) ATROVENT HFA - ipratropium bromide hfa inhal aerosol 17 mcg/act azelastine hcl nasal spray 0.1% (137 mcg/spray) azelastine hcl nasal spray 0.15% (05.5 mcg/spray) 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 7

BREO ELLIPTA - fluticasone furoate-vilanterol aero powd ba 100-5 mcg/inh BREO ELLIPTA - fluticasone furoate-vilanterol aero powd ba 00-5 mcg/inh caffeine citrate oral soln 60 mg/3ml clemastine fumarate tab.68 mg# cromolyn sodium soln nebu 0 mg/ml DALIRESP - roflumilast tab 500 mcg DULERA - mometasone furoateformoterol fumarate aerosol 100-5 mcg/act DULERA - mometasone furoateformoterol fumarate aerosol 00-5 mcg/act EPIPEN -PAK - epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000) EPIPEN-JR -PAK - epinephrine solution auto-injector 0.15 mg/0.3ml (1:000) ESBRIET - pirfenidone cap 67 mg FLOVENT DISKUS - fluticasone propionate aer pow ba 50 mcg/ blister FLOVENT DISKUS - fluticasone propionate aer pow ba 100 mcg/blister X FLOVENT DISKUS - fluticasone propionate aer pow ba 50 mcg/blister FLOVENT HFA - fluticasone propionate hfa inhal aero mcg/act (50/valve) FLOVENT HFA - fluticasone propionate hfa inhal aer 110 mcg/act (15/valve) FLOVENT HFA - fluticasone propionate hfa inhal aer 0 mcg/act (50/valve) fluticasone propionate nasal susp 50 mcg/act FORADIL AEROLIZER - formoterol fumarate inhal cap 1 mcg GRASTEK - timothy grass pollen allergen ext tab sl 800 bau ipratropium bromide nasal soln 0.03% (1 mcg/spray) ipratropium bromide nasal soln 0.06% ( mcg/spray) KALYDECO - ivacaftor tab 150 mg KALYDECO - ivacaftor packet 50 mg KALYDECO - ivacaftor packet 75 mg LETAIRIS - ambrisentan tab 5 mg* LETAIRIS - ambrisentan tab 10 mg* 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 75

levocetirizine dihydrochloride tab 5 mg montelukast sodium chew tab mg montelukast sodium chew tab 5 mg montelukast sodium oral granules packet mg montelukast sodium tab 10 mg NASONEX - mometasone furoate nasal susp 50 mcg/act OFEV - nintedanib esylate cap 100 mg OFEV - nintedanib esylate cap 150 mg OPSUMIT - macitentan tab 10 mg* ORKAMBI - lumacaftor-ivacaftor tab 00-15 mg PROAIR HFA - albuterol sulfate inhal aero 108 mcg/act PROAIR RESPICLICK - albuterol sulfate aer pow ba 108 mcg/act PROLASTIN-C - alpha1- proteinase inhibitor (human) for iv soln 1000 mg* promethazine hcl syrup 6.5 mg/5ml# PULMOZYME - dornase alfa inhal soln 1 mg/ml QVAR - beclomethasone diprop inhal aero soln 0 mcg/act (50/ valve) 5 5 X QVAR - beclomethasone diprop inhal aero soln 80 mcg/act (100/ valve) RAGWITEK - short ragweed pollen allergen extract tab sl 1 amb a 1-u REMODULIN - treprostinil sodium inj 1 mg/ml* REMODULIN - treprostinil sodium inj.5 mg/ml* REMODULIN - treprostinil sodium inj 5 mg/ml* REMODULIN - treprostinil sodium inj 10 mg/ml* SEREVENT DISKUS - salmeterol xinafoate aer pow ba 50 mcg/ dose 5 X 5 X 5 X 5 X sildenafil citrate tab 0 mg SPIRIVA HANDIHALER - tiotropium bromide monohydrate inhal cap 18 mcg SPIRIVA RESPIMAT - tiotropium bromide monohydrate inhal aerosol.5 mcg/act SYMBICORT - budesonideformoterol fumarate dihyd aerosol 80-.5 mcg/act SYMBICORT - budesonideformoterol fumarate dihyd aerosol 160-.5 mcg/act terbutaline sulfate tab.5 mg terbutaline sulfate tab 5 mg theophylline tab sr 1hr 100 mg 1 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 76

theophylline tab sr 1hr 00 mg theophylline tab sr 1hr 300 mg theophylline tab sr 1hr 50 mg theophylline tab sr hr 00 mg theophylline tab sr hr 600 mg tobramycin nebu soln 300 mg/5ml 5 X TRACLEER - bosentan tab 6.5 mg* TRACLEER - bosentan tab 15 mg* VENTOLIN HFA - albuterol sulfate inhal aero 108 mcg/act XOLAIR - omalizumab for inj 150 mg* zafirlukast tab 10 mg zafirlukast tab 0 mg Skeletal Muscle Relaxants cyclobenzaprine hcl tab 5 mg# cyclobenzaprine hcl tab 10 mg# methocarbamol tab 500 mg# methocarbamol tab 750 mg# Sleep Disorder Agents HETLIOZ - tasimelteon capsule 0 mg modafinil tab 100 mg modafinil tab 00 mg NUVIGIL - armodafinil tab 50 mg NUVIGIL - armodafinil tab 150 mg NUVIGIL - armodafinil tab 00 mg NUVIGIL - armodafinil tab 50 mg SILENOR - doxepin hcl tab 3 mg SILENOR - doxepin hcl tab 6 mg XYREM - sodium oxybate oral solution 500 mg/ml* zaleplon cap 5 mg# zaleplon cap 10 mg# zolpidem tartrate tab 5 mg# zolpidem tartrate tab 10 mg# Therapeutic Nutrients/Minerals/Electrolytes amino acid infusion 6% X amino acid infusion 8% X amino acid infusion 15% X CHEMET - succimer cap 100 mg DEPEN TITRATABS - penicillamine tab 50 mg dextrose inj 5% dextrose inj 10% dextrose 5% in lactated ringers dextrose.5% w/ sodium chloride 0.5% dextrose 5% w/ sodium chloride 0.% dextrose 5% w/ sodium chloride 0.33% dextrose 5% w/ sodium chloride 0.5% dextrose 5% w/ sodium chloride 0.9% electrolyte-m in d5w soln 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 77

EXJADE - deferasirox tab for oral 5 susp 15 mg* EXJADE - deferasirox tab for oral 5 susp 50 mg* EXJADE - deferasirox tab for oral 5 susp 500 mg* fat emulsion iv soln 0% X JADENU - deferasirox tab 90 mg 5 JADENU - deferasirox tab 180 mg 5 JADENU - deferasirox tab 360 mg 5 kcl 10 meq/l (0.075%) in dextrose 5% & nacl 0.5% inj kcl 0 meq/l (0.15%) in dextrose 5% & nacl 0.% inj kcl 0 meq/l (0.15%) in dextrose 5% & nacl 0.33% inj kcl 0 meq/l (0.15%) in dextrose 5% & nacl 0.5% inj kcl 30 meq/l (0.%) in dextrose 5% & nacl 0.5% inj kcl 0 meq/l (0.3%) in dextrose 5% & nacl 0.5% inj lactated ringer's solution levocarnitine oral soln 1 gm/10ml (10%) levocarnitine tab 330 mg potassium chloride cap cr 8 meq potassium chloride cap cr 10 meq potassium chloride microencapsulated crys cr tab 10 meq potassium chloride microencapsulated crys cr tab 0 meq potassium chloride tab cr 8 meq (600 mg) potassium chloride tab cr 10 meq potassium chloride 0 meq/l (0.15%) in dextrose 5% inj potassium chloride 0 meq/l (0.3%) in dextrose 5% inj potassium citrate tab cr 5 meq (50 mg) potassium citrate tab cr 10 meq (1080 mg) potassium citrate tab cr 15 meq (160 mg) sodium chloride inj 0.5% sodium chloride iv soln 0.9% sodium polystyrene sulfonate oral susp 15 gm/60ml sodium polystyrene sulfonate rectal susp 30 gm/10ml SYPRINE - trientine hcl cap 50 mg water for irrigation, sterile irrigation soln 5 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 78

015 Quantity abacavir 300 mg abacavir/lamivudine/zidovudine 300-150-300 mg ABILIFY MAINTENA 300 mg ABILIFY MAINTENA 00 mg ABILIFY 10 mg ABILIFY 15 mg ABILIFY mg ABILIFY 0 mg ABILIFY 30 mg ABILIFY 5 mg acarbose 100 mg acarbose 5 mg acarbose 50 mg acetaminophen/codeine 10-1 mg/5 ml soln acetaminophen/codeine 300-15 mg acetaminophen/codeine 300-30 mg acetaminophen/codeine 300-60 mg ADCIRCA 0 mg Monthly Limit (unless otherwise noted) 1 syringe or 1 vial < Applies to members age 65 and over. 79 1 vial 90 tablets 3 180 tablets 700 ml 3 3 180 tablets ADVAIR DISKUS 100/50 1 package of 60 ADVAIR DISKUS 50/50 1 package of 60 ADVAIR DISKUS 500/50 1 package of 60 ADVAIR HFA 115/1 ADVAIR HFA 30/1 ADVAIR HFA 5/1 AFINITOR DISPERZ mg AFINITOR DISPERZ 3 mg AFINITOR DISPERZ 5 mg AFINITOR 10 mg AFINITOR.5 mg AFINITOR 5 mg AFINITOR 7.5 mg alendronate 10 mg alendronate 35 mg alendronate 5 mg alendronate 70 mg amlodipine besylate/valsartan 10-160 mg amlodipine besylate/valsartan 10-30 mg amlodipine besylate/valsartan 5-160 mg 1 canister 1 canister 1 canister 90 tablets 10 tablets tablets per 8 days tablets per 8 days

amlodipine besylate/valsartan 5-30 mg amlodipine/valsartan/hydrochlorothiazide 10-160-1.5 mg amlodipine/valsartan/hydrochlorothiazide 10-160-5 mg amlodipine/valsartan/hydrochlorothiazide 10-30-5 mg amlodipine/valsartan/hydrochlorothiazide 5-160-1.5 mg amlodipine/valsartan/hydrochlorothiazide 5-160-5 mg amphetamine/dextroamphetamine ER 10 mg amphetamine/dextroamphetamine ER 15 mg amphetamine/dextroamphetamine ER 0 mg amphetamine/dextroamphetamine ER 5 mg amphetamine/dextroamphetamine ER 30 mg amphetamine/dextroamphetamine ER 5 mg ANDRODERM mg/ hour ANDRODERM mg/ hour ANDROGEL PUMP 1.6% ANDROGEL PUMP 1% ANDROGEL 1.6% (0.5 mg/ 1.5 gm) ANDROGEL 1.6% (0.5 mg/.5 gm) ANDROGEL 1% (5 mg/.5 gm) ANDROGEL 1% (50 mg/ 5 gm) ANORO ELLIPTA APTIVUS 100 mg/ml soln APTIVUS 50 mg ARIPIPRAZOLE ODT 10 mg ARIPIPRAZOLE ODT 15 mg aripiprazole 1 mg/ml oral soln aripiprazole 10 mg aripiprazole 15 mg aripiprazole mg aripiprazole 0 mg aripiprazole 30 mg aripiprazole 5 mg ARNUITY ELLIPTA inh 100 mcg ARNUITY ELLIPTA inh 00 mcg ascomp/codeine 30 mg ASMANEX HFA 100 mcg/act ASMANEX HFA 00 mcg/act ASMANEX TWISTHALER 10 (0 mcg) ASMANEX TWISTHALER 1 (0 mcg) ASMANEX TWISTHALER 30 (110 mcg) Monthly Limit (unless otherwise noted) 30 capsules 30 capsules 30 capsules 30 capsules 30 capsules 30 capsules 30 patches 30 patches pump bottles pump bottles 30 packets 60 packets 60 packets 60 packets 1 package 380 ml 10 capsules 750 ml 30 blisters 30 blisters 180 capsules 1 canister 1 canister 1 canister 1 canister 1 canister 80 < Applies to members age 65 and over.

ASMANEX TWISTHALER 30 (0 mcg) ASMANEX TWISTHALER 60 (0 mcg) ASMANEX TWISTHALER 7 (110 mcg) ASTEPRO 0.15% atorvastatin 10 mg atorvastatin 0 mg atorvastatin 0 mg atorvastatin 80 mg ATRIPLA 600-00-300 mg ATROVENT HFA 17 mcg AVODART 0.5 mg AVONEX KIT 30 mcg AVONEX PEN KIT 30 mcg azelastine 0.1% nasal spray azelastine 0.15% nasal spray AZOR 10-0 mg AZOR 10-0 mg AZOR 5-0 mg AZOR 5-0 mg BENICAR HCT 0-1.5 mg BENICAR HCT 0-1.5 mg BENICAR HCT 0-5 mg BENICAR 0 mg BENICAR 0 mg BENICAR 5 mg BETASERON 0.3 mg BOSULIF 100 mg BOSULIF 500 mg BREO ELLIPTA 100-5 mcg/inh BREO ELLIPTA 00-5 mcg/inh BRINTELLIX 10 mg BRINTELLIX 0 mg BRINTELLIX 5 mg budeprion SR 150 mg bupropion ER 100 mg bupropion ER 150 mg bupropion ER 00 mg bupropion SR 100 mg bupropion SR 150 mg Monthly Limit (unless otherwise noted) 1 canister 1 canister 1 canister bottles 5 tablets 5 tablets 5 tablets canisters 30 capsules 1 kit per 8 days 1 kit per 8 days bottles bottles 15 vials/syringes 10 tablets 1 package 1 package < Applies to members age 65 and over. 81

bupropion SR 00 mg bupropion XL 150 mg bupropion XL 300 mg bupropion 100 mg bupropion 75 mg butalbital/acetaminophen/caffeine w/ codeine 50-300-0-30 mg butalbital/acetaminophen/caffeine w/ codeine 50-35-0-30 mg butalbital/aspirin/caffeine w/ codeine 50-35-0-30 mg BYDUREON PEN mg BYDUREON mg CAPRELSA 100 mg CAPRELSA 300 mg CHANTIX PAK 0.5 mg & 1 mg CHANTIX PAK 1 mg CHANTIX 0.5 mg CHANTIX 1 mg CINRYZE citalopram 10 mg citalopram 10 mg/5 ml soln citalopram 0 mg citalopram 0 mg clonazepam ODT 0.15 mg clonazepam ODT 0.5 mg clonazepam ODT 0.5 mg clonazepam ODT 1 mg clonazepam ODT mg clonazepam 0.5 mg clonazepam 1 mg clonazepam mg clonidine ER 0.1 mg clorazepate dipotassium 15 mg clorazepate dipotassium 3.75 mg clorazepate dipotassium 7.5 mg Monthly Limit (unless otherwise noted) 10 tablets 180 capsules 180 capsules 180 capsules vials per 8 days vials per 8 days 336 tablets or amount dispensed up to 168 days of therapy per 365 days 336 tablets or amount dispensed up to 168 days of therapy per 365 days 336 tablets or amount dispensed up to 168 days of therapy per 365 days 336 tablets or amount dispensed up to 168 days of therapy per 365 days 0 vials or 100 ml 600 ml 90 tablets 90 tablets 90 tablets 90 tablets 300 tablets 90 tablets 90 tablets 300 tablets 10 tablets 180 tablets 90 tablets 90 tablets 8 < Applies to members age 65 and over.

clozapine 100 mg clozapine 00 mg clozapine 5 mg clozapine 50 mg COMETRIQ KIT 100 mg COMETRIQ KIT 10 mg COMETRIQ KIT 60 mg COMPLERA 00-5-300 mg COPAXONE soln prefilled syringe 0 mg/ml COPAXONE soln prefilled syringe 0 mg/ml CORLANOR 5 mg CORLANOR 7.5 mg CRESTOR 10 mg CRESTOR 0 mg CRESTOR 0 mg CRESTOR 5 mg CRIXIVAN 00 mg CRIXIVAN 00 mg CYCLOSET 0.8 mg DALIRESP 500 mcg dexedrine 10 mg dexedrine 5 mg dexmethylphenidate 10 mg dexmethylphenidate.5 mg dexmethylphenidate 5 mg dextroamphetamine 10 mg dextroamphetamine 5 mg DIAZEPAM 1 mg/ml soln diazepam 10 mg DIAZEPAM 10 mg gel diazepam mg DIAZEPAM.5 mg gel DIAZEPAM 0 mg gel diazepam 5 mg didanosine 15 mg didanosine 00 mg didanosine 50 mg didanosine 00 mg digox 0.15 mg Monthly Limit (unless otherwise noted) 70 tablets 10 tablets 90 tablets 90 tablets 56 capsules per 8 days 11 capsules per 8 days 8 capsules per 8 days 30 syringes 1 syringes per 8 days 5 tablets 5 tablets 5 tablets 70 capsules 180 capsules 180 tablets 180 tablets 90 tablets 180 tablets 90 tablets 100 ml 10 tablets 5 twin packs 10 tablets 5 twin packs 5 twin packs 10 tablets 30 capsules 30 capsules 30 capsules 30 capsules < Applies to members age 65 and over. 83

digox 0.5 mg digoxin 0.15 mg digoxin 0.5 mg DIGOXIN 50 mcg/ml soln doxazosin 1 mg doxazosin mg doxazosin mg doxazosin 8 mg DULERA 100-5 mcg DULERA 00-5 mcg duloxetine 0 mg duloxetine 30 mg duloxetine 60 mg EDURANT 5 mg EMTRIVA 10 mg/ml soln EMTRIVA 00 mg endocet 10-35 mg endocet.5-35 mg endocet 5-35 mg endocet 7.5-35 mg enoxaparin 100 mg/ml enoxaparin 10 mg/0.8 ml enoxaparin 150 mg/ml enoxaparin 30 mg/0.3 ml enoxaparin 300 mg/3 ml enoxaparin 0 mg/0. ml enoxaparin 60 mg/0.6 ml enoxaparin 80 mg/0.8 ml EPIVIR 10 mg/ml soln EPZICOM 600-300 mg ERIVEDGE 150 mg ESBRIET 67 mg escitalopram 10 mg escitalopram 0 mg escitalopram 5 mg escitalopram 5 mg/5 ml soln EVOTAZ 300-150 mg EXFORGE HCT 10-160-1.5 mg EXFORGE HCT 10-160-5 mg EXFORGE HCT 10-30-5 mg Monthly Limit (unless otherwise noted) 75 ml 1 canister 1 canister 60 capsules 60 capsules 60 capsules 850 ml 30 capsules 180 tablets 3 3 0 tablets 30 syringes per 90 days 30 syringes per 90 days 30 syringes per 90 days 30 syringes per 90 days 10 vials per 90 days 30 syringes per 90 days 30 syringes per 90 days 30 syringes per 90 days 960 ml 30 capsules 70 capsules 600 ml 8 < Applies to members age 65 and over.

EXFORGE HCT 5-160-1.5 mg EXFORGE HCT 5-160-5 mg EXFORGE 10-160 mg EXFORGE 10-30 mg EXFORGE 5-160 mg EXFORGE 5-30 mg FANAPT PAK FANAPT 1 mg FANAPT 10 mg FANAPT 1 mg FANAPT mg FANAPT mg FANAPT 6 mg FANAPT 8 mg FARYDAK 10 mg FARYDAK 15 mg FARYDAK 0 mg FAZACLO ODT 100 mg FAZACLO ODT 1.5 mg FAZACLO ODT 150 mg FAZACLO ODT 00 mg FAZACLO ODT 5 mg fenofibrate 13 mg fenofibrate 15 mg fenofibrate 160 mg fenofibrate 00 mg fenofibrate 8 mg fenofibrate 5 mg fenofibrate 67 mg fentanyl 100 mcg/hr transdermal patch fentanyl 1 mcg/hr transdermal patch fentanyl 100 mcg lozenge on a handle fentanyl 1600 mcg lozenge on a handle fentanyl 00 mcg lozenge on a handle fentanyl 5 mcg/hr transdermal patch fentanyl 00 mcg lozenge on a handle fentanyl 50 mcg/hr transdermal patch fentanyl 600 mcg lozenge on a handle fentanyl 75 mcg/hr transdermal patch Monthly Limit (unless otherwise noted) 7 packs (56 tablets) per 8 days 6 capsules per 1 days 6 capsules per 1 days 6 capsules per 1 days 90 tablets 90 tablets 180 tablets 10 tablets 70 tablets 30 capsules 30 capsules 30 capsules 15 patches 15 patches 10 lozenges 10 lozenges 10 lozenges 15 patches 10 lozenges 15 patches 10 lozenges 15 patches < Applies to members age 65 and over. 85

fentanyl 800 mcg lozenge on a handle FETZIMA TITRATION PACK FETZIMA 10 mg FETZIMA 0 mg FETZIMA 0 mg FETZIMA 80 mg finasteride 5 mg FIRAZYR 30 mg/3 ml FLOVENT DISKUS 100 mcg FLOVENT DISKUS 50 mcg FLOVENT DISKUS 50 mcg FLOVENT HFA 110 mcg FLOVENT HFA 0 mcg FLOVENT HFA mcg fluoxetine 10 mg capsule fluoxetine 10 mg tablet fluoxetine 0 mg capsule fluoxetine 0 mg tablet fluoxetine 0 mg/5 ml soln fluoxetine 0 mg capsule fluticasone 50 mcg nasal spray fluvoxamine 100 mg fluvoxamine 5 mg fluvoxamine 50 mg fondaparinux sodium subcutaneous inj 10 mg/0.8 ml fondaparinux sodium subcutaneous inj.5 mg/0.5 ml fondaparinux sodium subcutaneous inj 5 mg/0. ml fondaparinux sodium subcutaneous inj 7.5 mg/0.6 ml Monthly Limit (unless otherwise noted) 10 lozenges 8 capsules per 8 days 30 capsules 30 capsules 30 capsules 30 capsules 6 syringes 1 inhaler inhalers 1 inhaler 1 canister canisters 1 canister 30 capsules 10 capsules 10 tablets 600 ml 60 capsules 1 bottle 90 tablets 30 syringes per 90 days 30 syringes per 90 days 30 syringes per 90 days 30 syringes per 90 days FORADIL 1 package of 60 FUZEON 90 mg inj gemfibrozil 600 mg GEODON 0 mg inj GILOTRIF 0 mg GILOTRIF 30 mg GILOTRIF 0 mg glatopa 0 mg/ml inj GLEEVEC 100 mg GLEEVEC 00 mg glimepiride 1 mg glimepiride mg 60 vials 60 vials 30 syringes 90 tablets 0 tablets 10 tablets 86 < Applies to members age 65 and over.

glimepiride mg glipizide ER 10 mg glipizide ER.5 mg glipizide ER 5 mg glipizide XL 10 mg glipizide XL.5 mg glipizide XL 5 mg glipizide 10 mg glipizide 5 mg glyburide micronized 1.5 mg glyburide micronized 3 mg glyburide micronized 6 mg glyburide 1.5 mg GLYBURIDE 1.5 mg GLYBURIDE.5 mg glyburide.5 mg GLYBURIDE 5 mg glyburide 5 mg GRASTEK HETLIOZ 0 mg hydrocodone/acetaminophen 10-300 mg hydrocodone/acetaminophen 10-35 mg hydrocodone/acetaminophen 5-300 mg hydrocodone/acetaminophen 5-35 mg hydrocodone/acetaminophen 7.5-300 mg hydrocodone/acetaminophen 7.5-35 mg hydrocodone/acetaminophen 7.5-35 mg soln hydromorphone 1 mg/ml liquid hydromorphone mg hydromorphone mg hydromorphone 8 mg ibandronate 150 mg IBRANCE 100 mg IBRANCE 15 mg IBRANCE 75 mg ICLUSIG 15 mg ICLUSIG 5 mg IMBRUVICA 10 mg INLYTA 1 mg Monthly Limit (unless otherwise noted) 0 tablets 10 tablets 0 tablets 10 tablets 10 tablets 0 tablets 0 tablets 10 tablets 80 tablets 80 tablets 0 tablets 0 tablets 10 tablets 10 tablets 30 capsules 180 tablets 180 tablets 3 3 180 tablets 180 tablets 3600 ml 10 ml 180 tablets 180 tablets 180 tablets 1 tablet per 8 days 1 capsules per 8 days 1 capsules per 8 days 1 capsules per 8 days 10 capsules 180 tablets < Applies to members age 65 and over. 87

INLYTA 5 mg INTELENCE 100 mg INTELENCE 00 mg INTELENCE 5 mg INVEGA SUSTENNA 117 mg/0.75 ml INVEGA SUSTENNA 156 mg/ml INVEGA SUSTENNA 3 mg/1.5 ml INVEGA SUSTENNA 39 mg/0.5 ml INVEGA SUSTENNA 78 mg/0.5 ml INVEGA TRINZA 73 mg INVEGA TRINZA 10 mg INVEGA TRINZA 56 mg INVEGA TRINZA 819 mg INVEGA 1.5 mg INVEGA 3 mg INVEGA 6 mg INVEGA 9 mg INVIRASE 00 mg INVIRASE 500 mg INVOKANA 100 mg INVOKANA 300 mg ipratropium 0.03% nasal spray ipratropium 0.06% nasal spray irbesartan 150 mg irbesartan 300 mg irbesartan 75 mg irbesartan/hydrochlorothiazide 150-1.5 mg irbesartan/hydrochlorothiazide 300-1.5 mg IRESSA 50 mg ISENTRESS 100 mg chewable tablet ISENTRESS 100 mg packet ISENTRESS 5 mg chewable tablet ISENTRESS 00 mg tablet JAKAFI 10 mg JAKAFI 15 mg JAKAFI 0 mg JAKAFI 5 mg JAKAFI 5 mg JANUMET XR 100-1000 mg JANUMET XR 50-1000 mg Monthly Limit (unless otherwise noted) 10 tablets 10 tablets 1 kit 1 kit 1 kit 1 kit 1 kit 1 kit per 90 days 1 kit per 90 days 1 kit per 90 days 1 kit per 90 days 300 capsules 10 tablets 90 tablets bottles 3 bottles 180 tablets 60 packets 180 tablets 88 < Applies to members age 65 and over.

JANUMET XR 50-500 mg JANUMET 50-1000 mg JANUMET 50-500 mg JANUVIA 100 mg JANUVIA 5 mg JANUVIA 50 mg JENTADUETO.5-1000 mg JENTADUETO.5-500 mg JENTADUETO.5-850 mg KALETRA soln KALETRA 100-5 mg KALETRA 00-50 mg KALYDECO packet 50 mg KALYDECO packet 75 mg KALYDECO 150 mg KOMBIGLYZE XR.5-1000 mg KOMBIGLYZE XR 5-1000 mg KOMBIGLYZE XR 5-500 mg lamivudine 10 mg/ml oral solution lamivudine 150 mg lamivudine 300 mg lamivudine/zidovudine 150-300 mg LATUDA 10 mg LATUDA 0 mg LATUDA 0 mg LATUDA 60 mg LATUDA 80 mg LAZANDA 100 mcg nasal spray LAZANDA 00 mcg nasal spray LENVIMA 10 mg DAILY DOSE LENVIMA 1 mg DAILY DOSE LENVIMA 0 mg DAILY DOSE LENVIMA mg DAILY DOSE LETAIRIS 10 mg LETAIRIS 5 mg LEXIVA 50 mg/ml susp LEXIVA 700 mg LONSURF 15-6.1 mg LONSURF 0-8.19 mg Monthly Limit (unless otherwise noted) 10 tablets 30 ml 300 tablets 10 tablets 60 packets 60 packets 960 ml 30 bottles 30 bottles 30 capsules 60 capsules 60 capsules 90 capsules 1800 ml 10 tablets 0 tablets per 8 days 80 tablets per 8 days < Applies to members age 65 and over. 89

lorazepam 0.5 mg lorazepam 1 mg lorazepam mg lorcet hd 10-35 mg lorcet plus 7.5-35 mg lorcet 5-35 mg lortab 10-35 mg lortab 5-35 mg lortab 7.5-35 mg losartan 100 mg losartan 5 mg losartan 50 mg losartan/hydrochlorothiazide 100-1.5 mg losartan/hydrochlorothiazide 100-5 mg losartan/hydrochlorothiazide 50-1.5 mg lovastatin 10 mg lovastatin 0 mg lovastatin 0 mg LYNPARZA 50 mg MAPROTILINE 5 mg MAPROTILINE 50 mg MAPROTILINE 75 mg MEKINIST 0.5 mg MEKINIST mg metadate ER 0 mg metformin ER 500 mg metformin ER 750 mg metformin 1000 mg metformin 500 mg metformin 850 mg methadone 10 mg methadone 5 mg methadose 10 mg methylphenidate ER 0 mg methylphenidate SR 0 mg methylphenidate 10 mg methylphenidate 0 mg methylphenidate 5 mg mirtazapine ODT 15 mg mirtazapine ODT 30 mg Monthly Limit (unless otherwise noted) 90 tablets 90 tablets 150 tablets 180 tablets 180 tablets 3 180 tablets 3 180 tablets 80 capsules 90 tablets 90 tablets 90 tablets 90 tablets 90 tablets 10 tablets 75 tablets 150 tablets 90 tablets 3 180 tablets 3 90 tablets 90 tablets 90 tablets 90 tablets 90 tablets 90 < Applies to members age 65 and over.

mirtazapine ODT 5 mg mirtazapine 15 mg mirtazapine 30 mg mirtazapine 5 mg mirtazapine 7.5 mg modafinil 100 mg modafinil 00 mg morphine sulfate ER 100 mg tablet morphine sulfate ER 15 mg tablet morphine sulfate ER 00 mg tablet morphine sulfate ER 30 mg tablet morphine sulfate ER 60 mg tablet MORPHINE SULFATE 15 mg tablet MORPHINE SULFATE 30 mg tablet MYRBETRIQ 5 mg MYRBETRIQ 50 mg naratriptan 1 mg naratriptan.5 mg NASONEX nateglinide 10 mg nateglinide 60 mg nevirapine ER 00 mg nevirapine 00 mg nevirapine 50 mg/5 ml susp NEXAVAR 00 mg NEXIUM 10 mg susp packet NEXIUM.5 mg susp packet NEXIUM 0 mg NEXIUM 0 mg susp packet NEXIUM 0 mg NEXIUM 0 mg susp packet NEXIUM 5 mg susp packet niacin ER 1000 mg niacin ER 500 mg niacin ER 750 mg nitrofurantoin macrocrystalline 100 mg< Monthly Limit (unless otherwise noted) 90 tablets 90 tablets 90 tablets 90 tablets 90 tablets 0 tablets 180 tablets 18 tablets 18 tablets bottles 90 tablets 180 tablets 100 ml 10 tablets 30 packets 30 packets 30 capsules 30 packets 30 capsules 30 packets 30 packets 360 capsules or amount dispensed up to 90 days of therapy per 365 days < Applies to members age 65 and over. 91

nitrofurantoin macrocrystalline 50 mg< nitrofurantoin monohydrate 100 mg< NORVIR 100 mg capsule NORVIR 100 mg tablet NORVIR 80 mg/ml soln NUVIGIL 150 mg NUVIGIL 00 mg NUVIGIL 50 mg NUVIGIL 50 mg ODOMZO 00 mg OFEV 100 mg OFEV 150 mg olanzapine ODT 10 mg olanzapine ODT 15 mg olanzapine ODT 0 mg olanzapine ODT 5 mg olanzapine 10 mg olanzapine 10 mg inj olanzapine 15 mg olanzapine.5 mg olanzapine 0 mg olanzapine 5 mg olanzapine 7.5 mg omeprazole 10 mg omeprazole 0 mg omeprazole 0 mg ONFI 10 mg ONFI.5 mg/ml susp ONFI 0 mg ONFI 5 mg ONGLYZA.5 mg ONGLYZA 5 mg OPSUMIT 10 mg ORKAMBI 00-15 mg oxybutynin 5 mg oxybutynin 5 mg/5 ml syrup Monthly Limit (unless otherwise noted) 360 capsules or amount dispensed up to 90 days of therapy per 365 days 180 capsules or amount dispensed up to 90 days of therapy per 365 days 360 capsules 3 80 ml 30 capsules 60 capsules 60 capsules 90 vials 30 capsules 30 capsules 30 capsules 80 ml 10 tablets 10 tablets 600 ml 9 < Applies to members age 65 and over.

oxycodone 10 mg oxycodone 15 mg oxycodone 0 mg oxycodone 30 mg oxycodone 5 mg oxycodone/acetaminophen 10-35 mg oxycodone/acetaminophen.5-35 mg oxycodone/acetaminophen 5-35 mg oxycodone/acetaminophen 7.5-35 mg paliperidone sr hr 1.5 mg paliperidone sr hr 3 mg paliperidone sr hr 6 mg paliperidone sr hr 9 mg pantoprazole 0 mg pantoprazole 0 mg paroxetine ER 1.5 mg paroxetine ER 5 mg paroxetine ER 37.5 mg paroxetine 10 mg paroxetine 0 mg paroxetine 30 mg paroxetine 0 mg PAXIL 10 mg/5 ml susp pioglitazone 15 mg pioglitazone 30 mg pioglitazone 5 mg PLEGRIDY inj PLEGRIDY inj STARTER PACK PLEGRIDY PEN PLEGRIDY PEN STARTER PACK POMALYST 1 mg POMALYST mg POMALYST 3 mg POMALYST mg PRADAXA 150 mg PRADAXA 75 mg pravastatin 10 mg pravastatin 0 mg pravastatin 0 mg Monthly Limit (unless otherwise noted) 180 tablets 180 tablets 180 tablets 180 tablets 3 180 tablets 3 3 0 tablets 900 ml 90 tablets syringes per 8 days syringes per 8 days syringes per 8 days syringes per 8 days 1 capsules per 8 days 1 capsules per 8 days 1 capsules per 8 days 1 capsules per 8 days 60 capsules 60 capsules 5 tablets 5 tablets 5 tablets < Applies to members age 65 and over. 93

pravastatin 80 mg PREZCOBIX 800-150 mg PREZISTA 100 mg/ml susp PREZISTA 150 mg PREZISTA 600 mg PREZISTA 75 mg PREZISTA 800 mg PRISTIQ 100 mg PRISTIQ 5 mg PRISTIQ 50 mg PROAIR HFA PROAIR RESPICLICK quetiapine 100 mg quetiapine 00 mg quetiapine 5 mg quetiapine 300 mg quetiapine 00 mg quetiapine 50 mg QVAR 0 mcg QVAR 80 mcg RAGWITEK RESCRIPTOR 100 mg RESCRIPTOR 00 mg REVLIMID 10 mg REVLIMID 15 mg REVLIMID.5 mg REVLIMID 0 mg REVLIMID 5 mg REVLIMID 5 mg REXULTI 0.5 mg REXULTI 0.5 mg REXULTI 1 mg REXULTI mg REXULTI 3 mg REXULTI mg REYATAZ 100 mg REYATAZ 150 mg REYATAZ 00 mg REYATAZ 300 mg REYATAZ 50 mg powder Monthly Limit (unless otherwise noted) 00 ml 180 tablets 300 tablets canisters canisters 90 tablets 90 tablets 90 tablets 90 tablets 1 canister canisters 3 180 tablets 30 capsules 1 capsules per 8 days 30 capsules 1 capsules per 8 days 1 capsules per 8 days 30 capsules 30 capsules 30 capsules 60 capsules 30 capsules 150 packets 9 < Applies to members age 65 and over.

RISPERDAL 1.5 mg inj RISPERDAL 5 mg inj RISPERDAL 37.5 mg inj RISPERDAL 50 mg inj risperidone ODT 0.5 mg risperidone ODT 0.5 mg risperidone ODT 1 mg risperidone ODT mg risperidone ODT 3 mg risperidone ODT mg risperidone 0.5 mg risperidone 0.5 mg risperidone 1 mg risperidone 1 mg/ml soln risperidone mg risperidone 3 mg risperidone mg rizatriptan ODT 10 mg rizatriptan ODT 5 mg rizatriptan 10 mg rizatriptan 5 mg roxicet 5-35 mg SAPHRIS 10 mg SAPHRIS.5 mg SAPHRIS 5 mg SELZENTRY 150 mg SELZENTRY 300 mg Monthly Limit (unless otherwise noted) vials per 8 days vials per 8 days vials per 8 days vials per 8 days 10 tablets 80 ml 10 tablets 18 tablets 18 tablets 18 tablets 18 tablets 3 10 tablets SEREVENT DISKUS 50 mcg 1 package of 60 SEROQUEL XR 150 mg SEROQUEL XR 00 mg SEROQUEL XR 300 mg SEROQUEL XR 00 mg SEROQUEL XR 50 mg sertraline 100 mg sertraline 0 mg/ml conc sertraline 5 mg sertraline 50 mg sildenafil 0 mg SILENOR 3 mg 300 ml 90 tablets < Applies to members age 65 and over. 95

SILENOR 6 mg simvastatin 10 mg simvastatin 0 mg simvastatin 0 mg simvastatin 5 mg simvastatin 80 mg SPIRIVA HANDIHALER SPIRIVA RESPIMAT.5 mcg/act SPRYCEL 100 mg SPRYCEL 10 mg SPRYCEL 0 mg SPRYCEL 50 mg SPRYCEL 70 mg SPRYCEL 80 mg stavudine 1 mg/ml soln stavudine 15 mg stavudine 0 mg stavudine 30 mg stavudine 0 mg STIVARGA 0 mg STRATTERA 10 mg STRATTERA 100 mg STRATTERA 18 mg STRATTERA 5 mg STRATTERA 0 mg STRATTERA 60 mg STRATTERA 80 mg STRIBILD 150-150-00-300 mg sumatriptan 100 mg SUMATRIPTAN 0 mg/act nasal spray sumatriptan 5 mg SUMATRIPTAN 5 mg/act nasal spray sumatriptan 50 mg SUSTIVA 00 mg capsule SUSTIVA 50 mg capsule SUSTIVA 600 mg tablet SUTENT 1.5 mg SUTENT 5 mg SUTENT 37.5 mg SUTENT 50 mg Monthly Limit (unless otherwise noted) 5 tablets 5 tablets 5 tablets 30 capsules 1 canister 00 ml 60 capsules 60 capsules 60 capsules 60 capsules 8 tablets per 8 days 60 capsules 30 capsules 60 capsules 60 capsules 60 capsules 30 capsules 30 capsules 18 tablets 1 units/ packages 18 tablets 1 units/ packages 18 tablets 60 capsules 90 capsules 90 capsules 30 capsules 30 capsules 30 capsules 96 < Applies to members age 65 and over.

SYMBICORT 160-.5 mcg/act SYMBICORT 80-.5 mcg/act TAFINLAR 50 mg TAFINLAR 75 mg tamsulosin 0. mg TARCEVA 100 mg TARCEVA 150 mg TARCEVA 5 mg TASIGNA 150 mg TASIGNA 00 mg TECFIDERA STARTER KIT TECFIDERA 10 mg TECFIDERA 0 mg TEKTURNA 150 mg TEKTURNA 300 mg telmisartan 0 mg telmisartan 0 mg telmisartan 80 mg telmisartan/hydrochlorothiazide 0-1.5 mg telmisartan/hydrochlorothiazide 80-1.5 mg telmisartan/hydrochlorothiazide 80-5 mg terazosin 1 mg terazosin 10 mg terazosin mg terazosin 5 mg tetrabenazine 1.5 mg tetrabenazine 5 mg THALOMID 100 mg THALOMID 150 mg THALOMID 00 mg THALOMID 50 mg TIVICAY 50 mg tolterodine ER mg tolterodine ER mg TOVIAZ mg TOVIAZ 8 mg TRACLEER 15 mg TRACLEER 6.5 mg TRADJENTA 5 mg Monthly Limit (unless otherwise noted) 1 canister 1 canister 10 capsules 10 capsules 60 capsules 10 capsules 10 capsules 60 capsules 60 capsules 60 capsules 30 capsules 60 capsules 30 capsules 30 capsules 0 tablets 10 tablets 30 capsules 60 capsules 60 capsules 30 capsules 30 capsules 30 capsules < Applies to members age 65 and over. 97

tramadol 50 mg TRIBENZOR 0-5-1.5 mg TRIBENZOR 0-10-1.5 mg TRIBENZOR 0-10-5 mg TRIBENZOR 0-5-1.5 mg TRIBENZOR 0-5-5 mg TRIUMEQ 600-50-300 mg TRUVADA 00-300 mg TYBOST 150 mg TYKERB 50 mg venlafaxine ER 150 mg capsule venlafaxine ER 37.5 mg capsule venlafaxine ER 75 mg capsule venlafaxine 100 mg tablet venlafaxine 5 mg tablet venlafaxine 37.5 mg tablet venlafaxine 50 mg tablet venlafaxine 75 mg tablet VENTOLIN HFA (18 grams) VENTOLIN HFA (8 grams) VERSACLOZ 50 mg/ml susp VESICARE 10 mg VESICARE 5 mg vicodin ES 7.5-300 mg vicodin HP 10-300 mg vicodin 5-300 mg VICTOZA 18 mg/3 ml inj VIDEX gm soln VIDEX gm soln VIIBRYD KIT VIIBRYD STARTER PACK VIIBRYD 10 mg VIIBRYD 0 mg VIIBRYD 0 mg VIRACEPT 50 mg VIRACEPT 65 mg VIRAMUNE XR 100 mg VIRAMUNE 50 mg/5 ml susp VIREAD 150 mg VIREAD 00 mg Monthly Limit (unless otherwise noted) 0 tablets 180 tablets 30 capsules 30 capsules 90 capsules 90 tablets 90 tablets 90 tablets 90 tablets 90 tablets canisters canisters 50 ml 180 tablets 180 tablets 3 1 package of 3 pens 100 ml 100 ml 1 kit per 30 days 1 kit per 30 days 70 tablets 10 tablets 10 tablets 100 ml 98 < Applies to members age 65 and over.

VIREAD 50 mg VIREAD 300 mg VIREAD 0 mg/gm oral powder VITEKTA 150 mg VITEKTA 85 mg VOTRIENT 00 mg VYTORIN 10-10 mg VYTORIN 10-0 mg VYTORIN 10-0 mg VYTORIN 10-80 mg XALKORI 00 mg XALKORI 50 mg XARELTO STARTER PACK XARELTO 10 mg XARELTO 15 mg XARELTO 0 mg XENAZINE 1.5 mg XENAZINE 5 mg XTANDI 0 mg XYREM 500 mg/ml soln zaleplon 10 mg< zaleplon 5 mg< ZELBORAF 0 mg zenzedi 10 mg zenzedi 5 mg ZETIA 10 mg ZIAGEN 0 mg/ml soln zidovudine 100 mg capsule zidovudine 300 mg tablet zidovudine 50 mg/ml syrup ziprasidone 0 mg ziprasidone 0 mg ziprasidone 60 mg ziprasidone 80 mg ZOHYDRO ER abuse-deterrent 10 mg ZOHYDRO ER abuse-deterrent 15 mg ZOHYDRO ER abuse-deterrent 0 mg ZOHYDRO ER abuse-deterrent 30 mg Monthly Limit (unless otherwise noted) 0 grams 10 tablets 60 capsules 60 capsules 51 tablets 35 tablets per 90 days 0 tablets 10 tablets 10 capsules 50 ml 90 capsules or amount dispensed up to 90 days of therapy per 365 days 90 capsules or amount dispensed up to 90 days of therapy per 365 days 0 tablets 180 tablets 90 tablets 960 ml 180 capsules 190 ml 60 capsules 60 capsules 60 capsules 60 capsules 60 capsules 60 capsules 60 capsules 60 capsules < Applies to members age 65 and over. 99

ZOHYDRO ER abuse-deterrent 0 mg ZOHYDRO ER abuse-deterrent 50 mg ZOHYDRO ER 10 mg ZOHYDRO ER 15 mg ZOHYDRO ER 0 mg ZOHYDRO ER 30 mg ZOHYDRO ER 0 mg ZOHYDRO ER 50 mg ZOLINZA 100 mg zolpidem 10 mg< zolpidem 5 mg< ZOSTAVAX inj ZYDELIG 100 mg ZYDELIG 150 mg ZYKADIA 150 mg ZYPREXA RELPREVV 10 mg ZYPREXA RELPREVV 300 mg ZYPREXA RELPREVV 05 mg ZYTIGA 50 mg Monthly Limit (unless otherwise noted) 60 capsules 60 capsules 60 capsules 60 capsules 60 capsules 60 capsules 60 capsules 60 capsules 10 capsules 90 tablets or amount dispensed up to 90 days of therapy per 365 days 90 tablets or amount dispensed up to 90 days of therapy per 365 days 1 vaccine per lifetime 150 capsules vials per 8 days vials per 8 days 1 vial per 8 days 10 tablets 100 < Applies to members age 65 and over.

INDEX A abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg...35 abacavir sulfate tab 300 mg...35 ABILIFY...13 ABILIFY...13 ABILIFY...13 ABILIFY...13 ABILIFY...13 ABILIFY...13 ABILIFY...30 ABILIFY...30 ABILIFY...30 ABILIFY...30 ABILIFY...30 ABILIFY...30 ABILIFY...0 ABILIFY...0 ABILIFY...0 ABILIFY...0 ABILIFY...1 ABILIFY...1 ABILIFY MAINTENA...13 ABILIFY MAINTENA...13 ABILIFY MAINTENA...30 ABILIFY MAINTENA...30 ABILIFY MAINTENA...1 ABILIFY MAINTENA...1 ABRAXANE...1 acamprosate calcium tab delayed release 333 mg...3 acarbose tab 100 mg... 3 acarbose tab 5 mg... 3 acarbose tab 50 mg... 3 acetaminophen w/ codeine soln 10-1 mg/5ml... 1 acetaminophen w/ codeine tab 300-15 mg...1 acetaminophen w/ codeine tab 300-30 mg...1 acetaminophen w/ codeine tab 300-60 mg...1 acetazolamide cap sr 1hr 500 mg... 7 acetazolamide tab 50 mg... 7 acetylcysteine inhal soln 10%... 73 acetylcysteine inhal soln 0%... 73 acitretin cap 10 mg...57 acitretin cap 17.5 mg...57 acitretin cap 5 mg...57 ACTHIB...67 ACTIMMUNE*...67 acyclovir cap 00 mg... 35 acyclovir sodium for inj 500 mg... 35 acyclovir sodium iv soln 50 mg/ml...35 acyclovir susp 00 mg/5ml...35 acyclovir tab 00 mg... 35 acyclovir tab 800 mg... 35 ADACEL... 67 ADAGEN*...58 ADASUVE... 30 ADCIRCA... 73 adefovir dipivoxil tab 10 mg...35 ADVAIR DISKUS...73 ADVAIR DISKUS...73 ADVAIR DISKUS...73 ADVAIR HFA...73 ADVAIR HFA...7 ADVAIR HFA...7 AFINITOR...1 AFINITOR...1 AFINITOR...1 AFINITOR...1 AFINITOR DISPERZ... 1 AFINITOR DISPERZ... 1 AFINITOR DISPERZ... 1 AGGRENOX... 5 ALBENZA... 9 albuterol sulfate soln nebu 0.083% (.5 mg/3ml)...7 albuterol sulfate soln nebu 0.5% (5 mg/ ml)...7 albuterol sulfate soln nebu 0.63 mg/3ml...7 albuterol sulfate soln nebu 1.5 mg/3ml...7 albuterol sulfate syrup mg/5ml...7 albuterol sulfate tab mg...7 albuterol sulfate tab mg...7 ALCOHOL SWABS...3 ALDURAZYME*...58 alendronate sodium tab 10 mg... 71 alendronate sodium tab 35 mg... 7 alendronate sodium tab 5 mg... 71 alendronate sodium tab 70 mg... 7 ALIMTA... 1 ALIMTA... 1 ALINIA...9 ALINIA...9 allopurinol tab 100 mg...18 allopurinol tab 300 mg...18 alosetron hcl tab 0.5 mg... 59 101

alosetron hcl tab 1 mg... 59 ALOXI...17 amantadine hcl cap 100 mg...9 amantadine hcl cap 100 mg...35 amantadine hcl syrup 50 mg/5ml...9 amantadine hcl syrup 50 mg/5ml...35 AMBISOME...18 amifostine crystalline for inj 500 mg... 1 amikacin sulfate inj 1 gm/ml (50 mg/ ml)... amikacin sulfate inj 500 mg/ml (50 mg/ ml)... amiloride hcl tab 5 mg...7 amino acid infusion 15%...77 amino acid infusion 6%...77 amino acid infusion 8%...77 amiodarone hcl tab 00 mg...7 amiodarone hcl tab 00 mg...7 AMITIZA...59 AMITIZA...59 amitriptyline hcl tab 100 mg... 13 amitriptyline hcl tab 10 mg...13 amitriptyline hcl tab 150 mg... 13 amitriptyline hcl tab 5 mg...13 amitriptyline hcl tab 50 mg...13 amitriptyline hcl tab 75 mg...13 amlodipine besylate tab 10 mg...7 amlodipine besylate tab.5 mg...7 amlodipine besylate tab 5 mg... 7 amlodipine besylate-valsartan tab 10-160 mg...7 amlodipine besylate-valsartan tab 10-30 mg...7 amlodipine besylate-valsartan tab 5-160 mg...7 amlodipine besylate-valsartan tab 5-30 mg...7 amlodipine-valsartan-hydrochlorothiazide tab 10-160-1.5 mg...7 amlodipine-valsartan-hydrochlorothiazide tab 10-160-5 mg...8 amlodipine-valsartan-hydrochlorothiazide tab 10-30-5 mg...8 amlodipine-valsartan-hydrochlorothiazide tab 5-160-1.5 mg...7 amlodipine-valsartan-hydrochlorothiazide tab 5-160-5 mg... 7 AMOXAPINE...13 AMOXAPINE...13 AMOXAPINE...13 AMOXAPINE...13 amoxicillin (trihydrate) cap 50 mg... amoxicillin (trihydrate) cap 500 mg... amoxicillin (trihydrate) for susp 15 mg/5ml... amoxicillin (trihydrate) for susp 00 mg/5ml... amoxicillin (trihydrate) for susp 50 mg/5ml... amoxicillin (trihydrate) for susp 00 mg/5ml... amoxicillin (trihydrate) tab 500 mg... amoxicillin (trihydrate) tab 875 mg... amoxicillin & k clavulanate chew tab 00-8.5 mg... amoxicillin & k clavulanate chew tab 00-57 mg... amoxicillin & k clavulanate tab 50-15 mg... amoxicillin & k clavulanate tab 500-15 mg... amoxicillin & k clavulanate tab 875-15 mg... amphetamine-dextroamphetamine cap sr hr 10 mg...55 amphetamine-dextroamphetamine cap sr hr 15 mg...55 amphetamine-dextroamphetamine cap sr hr 0 mg...55 amphetamine-dextroamphetamine cap sr hr 5 mg...55 amphetamine-dextroamphetamine cap sr hr 30 mg...55 amphetamine-dextroamphetamine cap sr hr 5 mg...5 AMPHOTERICIN B...18 AMPICILLIN... AMPICILLIN... ampicillin & sulbactam sodium for inj -1 gm... ampicillin cap 50 mg... ampicillin cap 500 mg... ampicillin sodium for inj 1 gm... ampicillin sodium for inj 50 mg... ampicillin sodium for inj gm... ampicillin sodium for inj 500 mg... AMPYRA*...55 anagrelide hcl cap 0.5 mg... 5 anagrelide hcl cap 1 mg... 5 anastrozole tab 1 mg...1 ANDRODERM... 63 ANDRODERM... 63 ANDROGEL...63 ANDROGEL...63 10

ANDROGEL...63 ANDROGEL...63 ANDROGEL PUMP... 63 ANDROGEL PUMP... 63 ANDROID...63 ANDROXY...63 ANORO ELLIPTA...7 APOKYN*... 9 APRISO... 71 APTIOM... 8 APTIOM... 8 APTIOM... 8 APTIOM... 8 APTIVUS... 35 APTIVUS... 35 ARCALYST*... 67 ARIPIPRAZOLE ODT...13 ARIPIPRAZOLE ODT...13 ARIPIPRAZOLE ODT...30 ARIPIPRAZOLE ODT...30 ARIPIPRAZOLE ODT...1 ARIPIPRAZOLE ODT...1 aripiprazole oral solution 1 mg/ml...13 aripiprazole oral solution 1 mg/ml...30 aripiprazole oral solution 1 mg/ml...1 aripiprazole tab 10 mg... 13 aripiprazole tab 10 mg... 31 aripiprazole tab 10 mg... 1 aripiprazole tab 15 mg... 13 aripiprazole tab 15 mg... 31 aripiprazole tab 15 mg... 1 aripiprazole tab 0 mg... 13 aripiprazole tab 0 mg... 31 aripiprazole tab 0 mg... 1 aripiprazole tab mg...13 aripiprazole tab mg...30 aripiprazole tab mg...1 aripiprazole tab 30 mg... 13 aripiprazole tab 30 mg... 31 aripiprazole tab 30 mg... 1 aripiprazole tab 5 mg...13 aripiprazole tab 5 mg...31 aripiprazole tab 5 mg...1 ARNUITY ELLIPTA...7 ARNUITY ELLIPTA...7 ARRANON... 1 ARZERRA*...1 ARZERRA*...1 ASMANEX HFA...7 ASMANEX HFA...7 ASMANEX TWISTHALER 10 METERED DOSES... 7 ASMANEX TWISTHALER 1 METERED DOSES... 7 ASMANEX TWISTHALER 30 METERED DOSES... 7 ASMANEX TWISTHALER 30 METERED DOSES... 7 ASMANEX TWISTHALER 60 METERED DOSES... 7 ASMANEX TWISTHALER 7 METERED DOSES... 7 ASTEPRO... 7 atenolol tab 100 mg...8 atenolol tab 5 mg...8 atenolol tab 50 mg...8 atorvastatin calcium tab 10 mg...8 atorvastatin calcium tab 0 mg...8 atorvastatin calcium tab 0 mg...8 atorvastatin calcium tab 80 mg...8 atovaquone-proguanil hcl tab 50-100 mg...9 atovaquone-proguanil hcl tab 6.5-5 mg...9 atovaquone susp 750 mg/5ml...9 ATRIPLA... 35 ATROVENT HFA...7 AVASTIN*... 1 AVASTIN*... 1 AVELOX... AVODART... 61 AVONEX... 55 AVONEX... 55 AVONEX PEN... 55 azacitidine for inj 100 mg...1 azathioprine tab 50 mg... 67 azelastine hcl nasal spray 0.1% (137 mcg/ spray)...7 azelastine hcl nasal spray 0.15% (05.5 mcg/ spray)...7 azelastine hcl ophth soln 0.05%... 7 AZILECT...9 AZILECT...9 azithromycin for susp 100 mg/5ml... azithromycin for susp 00 mg/5ml... azithromycin iv for soln 500 mg... azithromycin tab 50 mg... azithromycin tab 500 mg... azithromycin tab 600 mg... AZOR... 8 AZOR... 8 AZOR... 8 AZOR... 8 aztreonam for inj 1 gm... 103

aztreonam for inj gm... B BACITRACIN... 7 baclofen tab 10 mg...35 baclofen tab 0 mg...35 balsalazide disodium cap 750 mg... 71 BANZEL... 8 BANZEL... 8 BANZEL... 8 BARACLUDE...35 BARACLUDE...35 BARACLUDE...35 BCG VACCINE...67 BELEODAQ... 1 benazepril & hydrochlorothiazide tab 10-1.5 mg...8 benazepril & hydrochlorothiazide tab 0-1.5 mg...8 benazepril & hydrochlorothiazide tab 0-5 mg...8 benazepril & hydrochlorothiazide tab 5-6.5 mg...8 benazepril hcl tab 10 mg... 8 benazepril hcl tab 0 mg... 8 benazepril hcl tab 0 mg... 8 benazepril hcl tab 5 mg... 8 BENICAR...8 BENICAR...8 BENICAR...8 BENICAR HCT... 8 BENICAR HCT... 8 BENICAR HCT... 8 benzoyl peroxide-erythromycin gel 5-3%...57 benztropine mesylate tab 0.5 mg... 9 benztropine mesylate tab 1 mg...9 benztropine mesylate tab mg...9 BETASERON... 55 bethanechol chloride tab 10 mg...61 bethanechol chloride tab 5 mg...61 bethanechol chloride tab 50 mg...61 bethanechol chloride tab 5 mg...61 bexarotene cap 75 mg... 1 BEXSERO... 67 bicalutamide tab 50 mg...1 BICILLIN L-A... BICILLIN L-A... BICILLIN L-A... BICNU...1 BILTRICIDE...9 bleomycin sulfate for inj 15 unit... 1 bleomycin sulfate for inj 30 unit... 1 BLINCYTO...1 BOOSTRIX...67 BOSULIF... 1 BOSULIF... 1 BREO ELLIPTA... 75 BREO ELLIPTA... 75 BRILINTA...5 BRILINTA...5 brimonidine tartrate ophth soln 0.15%... 7 brimonidine tartrate ophth soln 0.%... 7 BRINTELLIX...13 BRINTELLIX...13 BRINTELLIX...13 budesonide cap sr hr 3 mg... 71 bumetanide inj 0.5 mg/ml... 8 bumetanide tab 0.5 mg... 8 bumetanide tab 1 mg... 8 bumetanide tab mg... 8 BUPHENYL...58 buprenorphine hcl-naloxone hcl sl tab -0.5 mg...3 buprenorphine hcl-naloxone hcl sl tab 8- mg...3 buprenorphine hcl sl tab mg...3 buprenorphine hcl sl tab 8 mg...3 bupropion hcl (smoking deterrent) tab sr 1hr 150 mg...3 bupropion hcl tab 100 mg...1 bupropion hcl tab 75 mg...1 bupropion hcl tab sr 1hr 100 mg...1 bupropion hcl tab sr 1hr 150 mg...1 bupropion hcl tab sr 1hr 00 mg...1 bupropion hcl tab sr hr 150 mg...1 bupropion hcl tab sr hr 300 mg...1 buspirone hcl tab 10 mg... 39 buspirone hcl tab 15 mg... 39 buspirone hcl tab 30 mg... 39 buspirone hcl tab 5 mg... 39 buspirone hcl tab 7.5 mg... 39 BUSULFEX... 1 butalbital-acetaminophen-caff w/ cod cap 50-300-0-30 mg... 19 butalbital-acetaminophen-caff w/ cod cap 50-35-0-30 mg... 19 butalbital-aspirin-caff w/ codeine cap 50-35-0-30 mg...19 butorphanol tartrate inj 1 mg/ml... 1 butorphanol tartrate inj mg/ml... 1 BYDUREON...3 BYDUREON...3 10

C cabergoline tab 0.5 mg... 66 caffeine citrate oral soln 60 mg/3ml...75 calcipotriene cream 0.005%...57 calcipotriene soln 0.005% (50 mcg/ml)...57 calcitonin (salmon) nasal soln 00 unit/ act...7 calcitriol cap 0.5 mcg... 7 calcitriol cap 0.5 mcg...7 calcitriol inj 1 mcg/ml...7 calcitriol oral soln 1 mcg/ml...7 calcium acetate cap 667 mg... 61 calcium acetate tab 667 mg... 61 CANASA...71 CANCIDAS...18 CANCIDAS...18 CAPASTAT SULFATE...0 CAPRELSA*...1 CAPRELSA*...1 captopril tab 100 mg...8 captopril tab 1.5 mg...8 captopril tab 5 mg...8 captopril tab 50 mg...8 carbamazepine cap sr 1hr 100 mg...8 carbamazepine cap sr 1hr 00 mg...8 carbamazepine cap sr 1hr 300 mg...9 carbamazepine chew tab 100 mg...9 carbamazepine susp 100 mg/5ml...9 carbamazepine tab 00 mg...9 carbamazepine tab sr 1hr 00 mg...9 carbamazepine tab sr 1hr 00 mg...9 carbidopa & levodopa orally disintegrating tab 10-100 mg...9 carbidopa & levodopa orally disintegrating tab 5-100 mg...9 carbidopa & levodopa orally disintegrating tab 5-50 mg...9 carbidopa & levodopa tab 10-100 mg... 9 carbidopa & levodopa tab 5-100 mg... 9 carbidopa & levodopa tab 5-50 mg... 30 carbidopa & levodopa tab cr 5-100 mg...9 carbidopa & levodopa tab cr 50-00 mg...9 carbidopa tab 5 mg... 30 carboplatin iv soln 150 mg/15ml... 1 carboplatin iv soln 50 mg/5ml... 1 carboplatin iv soln 50 mg/5ml... 1 carboplatin iv soln 600 mg/60ml... 1 carteolol hcl ophth soln 1%... 7 carvedilol tab 1.5 mg...9 carvedilol tab 5 mg...9 carvedilol tab 3.15 mg...8 carvedilol tab 6.5 mg...8 cefaclor cap 50 mg... cefaclor cap 500 mg... cefazolin sodium for inj 1 gm... 5 cefazolin sodium for inj 500 mg... 5 cefdinir cap 300 mg...5 cefdinir for susp 15 mg/5ml...5 cefdinir for susp 50 mg/5ml...5 cefepime hcl for inj 1 gm... 5 cefepime hcl for inj gm... 5 cefotaxime sodium for inj 10 gm...5 cefotaxime sodium for inj 1 gm... 5 cefotaxime sodium for inj gm... 5 cefotaxime sodium for inj 500 mg...5 cefoxitin sodium for iv soln 1 gm... 5 cefoxitin sodium for iv soln gm... 5 cefprozil tab 50 mg...5 cefprozil tab 500 mg...5 ceftazidime for inj 1 gm...5 ceftazidime for inj gm...5 ceftazidime for inj 6 gm...5 ceftazidime for iv soln 1 gm...5 ceftazidime for iv soln gm...5 ceftriaxone sodium for inj 10 gm...5 ceftriaxone sodium for inj 1 gm...5 ceftriaxone sodium for inj 50 mg...5 ceftriaxone sodium for inj gm...5 ceftriaxone sodium for inj 500 mg...5 ceftriaxone sodium for iv soln 1 gm...5 ceftriaxone sodium for iv soln gm...5 cefuroxime axetil tab 50 mg... 5 cefuroxime axetil tab 500 mg... 5 cefuroxime sodium for inj 1.5 gm...5 cefuroxime sodium for inj 7.5 gm...5 cefuroxime sodium for inj 750 mg...5 cefuroxime sodium for iv soln 1.5 gm...5 CELLCEPT...67 CELLCEPT INTRAVENOUS... 67 CELONTIN... 9 cephalexin cap 50 mg...5 cephalexin cap 500 mg...5 cephalexin for susp 15 mg/5ml...5 cephalexin for susp 50 mg/5ml...5 CEREZYME*...58 CERVARIX... 68 CHANTIX... 3 CHANTIX... 3 CHANTIX CONTINUING MONTH...3 CHANTIX STARTING MONTH PACK...3 CHEMET...77 105

CHENODAL*...59 CHLORAMPHENICOL SODIUM SUCCINATE...5 chlorhexidine gluconate soln 0.1%...56 chloroquine phosphate tab 50 mg...9 chloroquine phosphate tab 500 mg...9 CHLORPROMAZINE HCL...17 CHLORPROMAZINE HCL...17 CHLORPROMAZINE HCL...31 CHLORPROMAZINE HCL...31 chlorpromazine hcl tab 100 mg...17 chlorpromazine hcl tab 100 mg...31 chlorpromazine hcl tab 10 mg...17 chlorpromazine hcl tab 10 mg...31 chlorpromazine hcl tab 00 mg...17 chlorpromazine hcl tab 00 mg...31 chlorpromazine hcl tab 5 mg...17 chlorpromazine hcl tab 5 mg...31 chlorpromazine hcl tab 50 mg...17 chlorpromazine hcl tab 50 mg...31 CHLORTHALIDONE...9 cholestyramine light powder gm/ dose... 9 cholestyramine light powder packets gm...9 cholestyramine powder gm/dose...9 cholestyramine powder packets gm...9 chorionic gonadotropin for inj 10000 unit...63 ciclopirox solution 8%...57 cilostazol tab 100 mg... 5 cilostazol tab 50 mg... 5 CINRYZE*... 68 ciprofloxacin 00 mg/100ml in d5w... 5 ciprofloxacin 00 mg/00ml in d5w... 5 ciprofloxacin hcl ophth soln 0.3%... 7 ciprofloxacin hcl tab 100 mg...5 ciprofloxacin hcl tab 50 mg...5 ciprofloxacin hcl tab 500 mg...5 ciprofloxacin hcl tab 750 mg...5 ciprofloxacin iv soln 00 mg/0ml (1%)... 5 ciprofloxacin iv soln 00 mg/0ml (1%)... 5 CISPLATIN... 1 cisplatin inj 100 mg/100ml (1 mg/ml)...1 cisplatin inj 50 mg/50ml (1 mg/ml)...1 citalopram hydrobromide oral soln 10 mg/5ml...1 citalopram hydrobromide tab 10 mg...1 citalopram hydrobromide tab 0 mg...1 citalopram hydrobromide tab 0 mg...1 cladribine inj 1 mg/ml... 1 clarithromycin for susp 15 mg/5ml...5 clarithromycin for susp 50 mg/5ml...5 clarithromycin tab 50 mg... 5 clarithromycin tab 500 mg... 6 clemastine fumarate tab.68 mg... 75 clindamycin hcl cap 150 mg... 6 clindamycin hcl cap 300 mg... 6 clindamycin hcl cap 75 mg... 6 clindamycin phosphate inj 300 mg/ml... 6 clindamycin phosphate inj 600 mg/ml... 6 clindamycin phosphate inj 900 mg/6ml... 6 clindamycin phosphate inj 9 gm/60ml... 6 clindamycin phosphate iv soln 600 mg/ml... 6 clindamycin phosphate iv soln 900 mg/6ml... 6 clindamycin phosphate vaginal cream %...6 clobetasol propionate cream 0.05%...57 clobetasol propionate emollient base cream 0.05%...57 clobetasol propionate gel 0.05%...57 clobetasol propionate oint 0.05%... 57 clobetasol propionate soln 0.05%...57 CLOLAR... clomipramine hcl cap 5 mg... 1 clomipramine hcl cap 50 mg... 1 clomipramine hcl cap 75 mg... 1 clonazepam orally disintegrating tab 0.15 mg...9 clonazepam orally disintegrating tab 0.15 mg...39 clonazepam orally disintegrating tab 0.5 mg...9 clonazepam orally disintegrating tab 0.5 mg...39 clonazepam orally disintegrating tab 0.5 mg...9 clonazepam orally disintegrating tab 0.5 mg...39 clonazepam orally disintegrating tab 1 mg...9 clonazepam orally disintegrating tab 1 mg...39 clonazepam orally disintegrating tab mg...9 clonazepam orally disintegrating tab mg...39 clonazepam tab 0.5 mg...9 clonazepam tab 0.5 mg... 39 clonazepam tab 1 mg...9 clonazepam tab 1 mg...39 clonazepam tab mg...9 106

clonazepam tab mg...39 clonidine hcl tab 0.1 mg...9 clonidine hcl tab 0. mg...9 clonidine hcl tab 0.3 mg...9 clonidine hcl tab sr 1hr 0.1 mg...55 clopidogrel bisulfate tab 75 mg...5 clorazepate dipotassium tab 15 mg...9 clorazepate dipotassium tab 15 mg...0 clorazepate dipotassium tab 3.75 mg... 9 clorazepate dipotassium tab 3.75 mg... 39 clorazepate dipotassium tab 7.5 mg...9 clorazepate dipotassium tab 7.5 mg... 0 clotrimazole troche 10 mg... 18 clozapine tab 100 mg...31 clozapine tab 00 mg...31 clozapine tab 5 mg...31 clozapine tab 50 mg...31 COARTEM...9 colchicine w/ probenecid tab 0.5-500 mg...18 COLCRYS... 18 colestipol hcl granule packets 5 gm... 9 colestipol hcl granules 5 gm...9 colestipol hcl tab 1 gm... 9 colistimethate sodium for inj 150 mg...6 COMETRIQ*... COMETRIQ*... COMETRIQ*... COMPLERA...35 COMVAX... 68 COPAXONE... 55 COPAXONE... 55 CORLANOR...9 CORLANOR...9 CORTISONE ACETATE...6 COSMEGEN... CREON...58 CREON...58 CREON...58 CREON...58 CREON...58 CRESEMBA...18 CRESEMBA...18 CRESTOR...9 CRESTOR...9 CRESTOR...9 CRESTOR...9 CRIXIVAN...35 CRIXIVAN...35 cromolyn sodium ophth soln %...7 cromolyn sodium soln nebu 0 mg/ml... 75 cyclobenzaprine hcl tab 10 mg... 77 cyclobenzaprine hcl tab 5 mg... 77 CYCLOPHOSPHAMIDE... CYCLOPHOSPHAMIDE... cyclophosphamide for inj 1 gm... cyclophosphamide for inj gm... cyclophosphamide for inj 500 mg... CYCLOSET...3 cyclosporine cap 100 mg...68 cyclosporine cap 5 mg...68 cyclosporine iv soln 50 mg/ml...68 CYCLOSPORINE MODIFIED... 68 cyclosporine modified cap 100 mg...68 cyclosporine modified cap 5 mg... 68 cyclosporine modified oral soln 100 mg/ ml...68 CYRAMZA... CYRAMZA... CYSTADANE... 58 CYSTAGON*...58 CYSTAGON*...58 cytarabine inj 0 mg/ml... cytarabine inj pf 100 mg/ml... cytarabine inj pf 0 mg/ml... D DACARBAZINE... dacarbazine for inj 00 mg... DAKLINZA...35 DAKLINZA...35 DALIRESP...75 DALVANCE...6 danazol cap 100 mg...63 danazol cap 00 mg...63 danazol cap 50 mg...63 DAPSONE...0 DAPSONE...0 DAPTACEL...68 DARAPRIM... 9 daunorubicin hcl for inj 0 mg... daunorubicin hcl inj 5 mg/ml... DAUNOXOME... decitabine for inj 50 mg... DEMSER... 9 DEPEN TITRATABS...61 DEPEN TITRATABS...68 DEPEN TITRATABS...77 DEPO-PROVERA... 63 desipramine hcl tab 100 mg...1 desipramine hcl tab 10 mg... 1 desipramine hcl tab 150 mg...1 desipramine hcl tab 5 mg... 1 desipramine hcl tab 50 mg... 1 107

desipramine hcl tab 75 mg... 1 desmopressin acetate inj mcg/ml...63 desmopressin acetate nasal soln 0.01% (refrigerated)... 63 desmopressin acetate nasal spray soln 0.01%...63 desmopressin acetate nasal spray soln 0.01% (refrigerated)... 63 desmopressin acetate tab 0.1 mg... 63 desmopressin acetate tab 0. mg... 63 desogest-eth estrad & eth estrad tab 0.15-0.0/0.01 mg(1/5)... 63 desogest-ethin est tab 0.1-0.05/0.15-0.05/0.15-0.05mgmg...63 desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg...63 dexamethasone elixir 0.5 mg/5ml...6 dexamethasone sodium phosphate inj 10 mg/30ml...6 dexamethasone sodium phosphate inj 0 mg/5ml...6 dexamethasone sodium phosphate inj mg/ ml...6 dexamethasone sodium phosphate ophth soln 0.1%...7 dexamethasone tab 0.5 mg...6 dexamethasone tab 0.75 mg...6 dexamethasone tab 1.5 mg...6 dexamethasone tab mg...6 dexamethasone tab 6 mg...6 dexmethylphenidate hcl tab 10 mg...55 dexmethylphenidate hcl tab.5 mg...55 dexmethylphenidate hcl tab 5 mg...55 dexrazoxane for inj 50 mg... dexrazoxane for inj 500 mg... dextroamphetamine sulfate tab 10 mg...55 dextroamphetamine sulfate tab 5 mg...55 dextrose.5% w/ sodium chloride 0.5%...77 dextrose 5% in lactated ringers... 77 dextrose 5% w/ sodium chloride 0.%...77 dextrose 5% w/ sodium chloride 0.33%...77 dextrose 5% w/ sodium chloride 0.5%...77 dextrose 5% w/ sodium chloride 0.9%...77 dextrose inj 10%... 77 dextrose inj 5%...77 DIAZEPAM...9 DIAZEPAM...9 DIAZEPAM...9 DIAZEPAM...9 DIAZEPAM... 0 diazepam tab 10 mg...9 diazepam tab 10 mg...0 diazepam tab mg...9 diazepam tab mg...0 diazepam tab 5 mg...9 diazepam tab 5 mg...0 DIBENZYLINE... 9 diclofenac potassium tab 50 mg... 1 diclofenac potassium tab 50 mg... 19 diclofenac sodium tab delayed release 5 mg...1 diclofenac sodium tab delayed release 5 mg...19 diclofenac sodium tab delayed release 50 mg...1 diclofenac sodium tab delayed release 50 mg...19 diclofenac sodium tab delayed release 75 mg...1 diclofenac sodium tab delayed release 75 mg...19 diclofenac sodium tab sr hr 100 mg... 1 diclofenac sodium tab sr hr 100 mg...19 dicloxacillin sodium cap 50 mg... 6 dicloxacillin sodium cap 500 mg... 6 dicyclomine hcl tab 0 mg...59 didanosine delayed release capsule 15 mg...35 didanosine delayed release capsule 00 mg...35 didanosine delayed release capsule 50 mg...35 didanosine delayed release capsule 00 mg...35 DIGOXIN...9 digoxin tab 15 mcg (0.15 mg)...9 digoxin tab 50 mcg (0.5 mg)... 9 DILANTIN... 9 diltiazem hcl cap sr 1hr 10 mg...9 diltiazem hcl cap sr 1hr 60 mg...9 diltiazem hcl cap sr 1hr 90 mg...9 diltiazem hcl cap sr hr 10 mg...9 diltiazem hcl cap sr hr 180 mg...9 diltiazem hcl cap sr hr 0 mg...9 diltiazem hcl coated beads cap sr hr 10 mg...9 diltiazem hcl coated beads cap sr hr 180 mg...9 diltiazem hcl coated beads cap sr hr 0 mg...9 108

diltiazem hcl coated beads cap sr hr 300 mg...9 diltiazem hcl coated beads cap sr hr 360 mg...9 diltiazem hcl extended release beads cap sr hr 10 mg... 9 diltiazem hcl extended release beads cap sr hr 180 mg... 9 diltiazem hcl extended release beads cap sr hr 0 mg... 9 diltiazem hcl extended release beads cap sr hr 300 mg... 50 diltiazem hcl extended release beads cap sr hr 360 mg... 50 diltiazem hcl extended release beads cap sr hr 0 mg... 50 diltiazem hcl tab 10 mg...50 diltiazem hcl tab 30 mg...50 diltiazem hcl tab 60 mg...50 diltiazem hcl tab 90 mg...50 DIPENTUM...71 diphenhydramine hcl inj 50 mg/ml...17 diphenhydramine hcl inj 50 mg/ml...30 DIPHTHERIA/TETANUS TOXOID...68 disulfiram tab 50 mg...3 disulfiram tab 500 mg...3 divalproex sodium cap sprinkle 15 mg...9 divalproex sodium cap sprinkle 15 mg...19 divalproex sodium cap sprinkle 15 mg...1 divalproex sodium tab delayed release 15 mg...9 divalproex sodium tab delayed release 15 mg...19 divalproex sodium tab delayed release 15 mg...1 divalproex sodium tab delayed release 50 mg...9 divalproex sodium tab delayed release 50 mg...19 divalproex sodium tab delayed release 50 mg...1 divalproex sodium tab delayed release 500 mg...9 divalproex sodium tab delayed release 500 mg...19 divalproex sodium tab delayed release 500 mg...1 divalproex sodium tab sr hr 50 mg...9 divalproex sodium tab sr hr 50 mg...19 divalproex sodium tab sr hr 50 mg...1 divalproex sodium tab sr hr 500 mg...9 divalproex sodium tab sr hr 500 mg...19 divalproex sodium tab sr hr 500 mg...1 DIVIGEL...63 DIVIGEL...63 DIVIGEL...6 DOCETAXEL... DOCETAXEL... DOCETAXEL... DOCETAXEL... DOCETAXEL... DOCETAXEL... DOCETAXEL... docetaxel for inj conc 0 mg/ml... docetaxel for inj conc 80 mg/ml (0 mg/ ml)... donepezil hydrochloride orally disintegrating tab 10 mg...1 donepezil hydrochloride orally disintegrating tab 5 mg...1 donepezil hydrochloride tab 10 mg... 1 donepezil hydrochloride tab 3 mg... 1 donepezil hydrochloride tab 5 mg...1 dorzolamide hcl ophth soln %...7 doxazosin mesylate tab 1 mg... 50 doxazosin mesylate tab 1 mg... 61 doxazosin mesylate tab mg... 50 doxazosin mesylate tab mg... 61 doxazosin mesylate tab mg... 50 doxazosin mesylate tab mg... 61 doxazosin mesylate tab 8 mg... 50 doxazosin mesylate tab 8 mg... 61 doxepin hcl cap 100 mg...1 doxepin hcl cap 100 mg...0 doxepin hcl cap 10 mg...1 doxepin hcl cap 10 mg...0 doxepin hcl cap 150 mg...1 doxepin hcl cap 150 mg...0 doxepin hcl cap 5 mg...1 doxepin hcl cap 5 mg...0 doxepin hcl cap 50 mg...1 doxepin hcl cap 50 mg...0 doxepin hcl conc 10 mg/ml...1 doxepin hcl conc 10 mg/ml...0 DOXIL... doxorubicin hcl for inj 10 mg... doxorubicin hcl for inj 50 mg... doxorubicin hcl inj mg/ml... doxorubicin hcl liposomal inj (for iv infusion) mg/ ml... doxycycline hyclate cap 100 mg...6 doxycycline hyclate cap 100 mg...56 109

doxycycline hyclate cap 50 mg... 6 doxycycline hyclate cap 50 mg...56 doxycycline hyclate for inj 100 mg...6 doxycycline hyclate for inj 100 mg...56 doxycycline hyclate tab 100 mg...6 doxycycline hyclate tab 100 mg...56 dronabinol cap 10 mg... 17 dronabinol cap.5 mg... 17 dronabinol cap 5 mg...17 drospirenone-ethinyl estradiol tab 3-0.0 mg...6 drospirenone-ethinyl estradiol tab 3-0.03 mg...6 DULERA... 75 DULERA... 75 duloxetine hcl enteric coated pellets cap 0 mg...1 duloxetine hcl enteric coated pellets cap 0 mg...0 duloxetine hcl enteric coated pellets cap 0 mg...55 duloxetine hcl enteric coated pellets cap 30 mg...1 duloxetine hcl enteric coated pellets cap 30 mg...0 duloxetine hcl enteric coated pellets cap 30 mg...55 duloxetine hcl enteric coated pellets cap 60 mg...1 duloxetine hcl enteric coated pellets cap 60 mg...0 duloxetine hcl enteric coated pellets cap 60 mg...55 E EDURANT... 35 EFFIENT...5 EFFIENT...6 ELAPRASE... 58 electrolyte-m in d5w soln... 77 ELELYSO*...58 ELIDEL...57 ELIDEL...68 ELIGARD...66 ELIGARD...66 ELIGARD...66 ELIGARD...66 ELITEK... ELITEK...3 ELLA...6 EMCYT... 3 EMEND...17 EMEND...17 EMEND...17 EMEND...17 EMEND...17 EMSAM...1 EMSAM...1 EMSAM...1 EMTRIVA...35 EMTRIVA...35 enalapril maleate & hydrochlorothiazide tab 10-5 mg...50 enalapril maleate & hydrochlorothiazide tab 5-1.5 mg...50 enalapril maleate tab 10 mg...50 enalapril maleate tab.5 mg...50 enalapril maleate tab 0 mg...50 enalapril maleate tab 5 mg...50 ENBREL... 68 ENBREL... 68 ENBREL... 68 ENBREL SURECLICK... 68 ENGERIX-B... 68 ENGERIX-B... 68 enoxaparin sodium inj 100 mg/ml...6 enoxaparin sodium inj 10 mg/0.8ml... 6 enoxaparin sodium inj 150 mg/ml...6 enoxaparin sodium inj 300 mg/3ml...6 enoxaparin sodium inj 30 mg/0.3ml...6 enoxaparin sodium inj 0 mg/0.ml...6 enoxaparin sodium inj 60 mg/0.6ml...6 enoxaparin sodium inj 80 mg/0.8ml...6 entacapone tab 00 mg...30 entecavir tab 0.5 mg...35 entecavir tab 1 mg...35 EPIPEN -PAK... 75 EPIPEN-JR -PAK...75 epirubicin hcl iv soln 00 mg/100ml ( mg/ ml)...3 epirubicin hcl iv soln 50 mg/5ml ( mg/ ml)...3 EPIVIR... 35 EPIVIR HBV...36 EPOGEN... 6 EPOGEN... 6 EPOGEN... 6 EPOGEN... 6 EPOGEN... 6 EPZICOM... 36 EQUETRO...1 EQUETRO...1 EQUETRO...1 ERBITUX... 3 110

ERBITUX... 3 ergoloid mesylates tab 1 mg... 1 ERIVEDGE*... 3 ERWINAZE... 3 ERY-TAB...6 ERY-TAB...6 ERY-TAB...6 ERYTHROCIN LACTOBIONATE...6 ERYTHROCIN LACTOBIONATE...6 ERYTHROMYCIN BASE...6 ERYTHROMYCIN BASE...6 erythromycin ophth oint 5 mg/gm... 7 ESBRIET... 75 escitalopram oxalate soln 5 mg/5ml...1 escitalopram oxalate soln 5 mg/5ml...0 escitalopram oxalate tab 10 mg...1 escitalopram oxalate tab 10 mg...0 escitalopram oxalate tab 0 mg...1 escitalopram oxalate tab 0 mg...0 escitalopram oxalate tab 5 mg...1 escitalopram oxalate tab 5 mg...0 esomeprazole sodium for intravenous soln 0 mg...59 esomeprazole sodium for intravenous soln 0 mg...59 ESTRACE...6 estradiol tab 0.5 mg...6 estradiol tab 1 mg...6 estradiol tab mg...6 estradiol td patch weekly 0.05 mg/hr... 6 estradiol td patch weekly 0.0375 mg/hr (37.5 mcg/hr)... 6 estradiol td patch weekly 0.05 mg/hr... 6 estradiol td patch weekly 0.06 mg/hr... 6 estradiol td patch weekly 0.075 mg/hr... 6 estradiol td patch weekly 0.1 mg/hr... 6 estropipate tab 0.75 mg...6 estropipate tab 1.5 mg... 6 ethambutol hcl tab 100 mg...0 ethambutol hcl tab 00 mg...0 ethosuximide cap 50 mg...9 ethosuximide soln 50 mg/5ml...9 ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg...6 etodolac cap 00 mg...1 etodolac cap 00 mg...19 etodolac cap 300 mg...1 etodolac cap 300 mg...19 etodolac tab 00 mg...1 etodolac tab 00 mg...19 etodolac tab 500 mg...1 etodolac tab 500 mg...19 ETOPOPHOS... 3 etoposide inj 100 mg/5ml (0 mg/ml)...3 etoposide inj 1 gm/50ml (0 mg/ml)... 3 etoposide inj 500 mg/5ml (0 mg/ml)...3 EVOTAZ...36 EXELON... 1 EXELON... 1 EXELON... 1 exemestane tab 5 mg... 3 EXFORGE...50 EXFORGE...50 EXFORGE...50 EXFORGE...50 EXFORGE HCT... 50 EXFORGE HCT... 50 EXFORGE HCT... 50 EXFORGE HCT... 50 EXFORGE HCT... 50 EXJADE*... 78 EXJADE*... 78 EXJADE*... 78 F FABRAZYME*...58 FABRAZYME*...58 famotidine inj 00 mg/0ml... 59 famotidine inj 0 mg/ml...59 famotidine inj 0 mg/ml...59 famotidine tab 0 mg...59 famotidine tab 0 mg...59 FANAPT...31 FANAPT...31 FANAPT...31 FANAPT...31 FANAPT...31 FANAPT...31 FANAPT...31 FANAPT TITRATION PACK... 31 FARESTON...3 FARYDAK...3 FARYDAK...3 FARYDAK...3 FASLODEX... 3 fat emulsion iv soln 0%...78 FAZACLO... 31 FAZACLO... 31 FAZACLO... 31 FAZACLO... 31 FAZACLO... 31 felbamate susp 600 mg/5ml... 9 felbamate tab 00 mg... 9 111

felbamate tab 600 mg... 9 fenofibrate micronized cap 13 mg... 50 fenofibrate micronized cap 00 mg... 50 fenofibrate micronized cap 67 mg... 50 fenofibrate tab 15 mg...50 fenofibrate tab 160 mg...50 fenofibrate tab 8 mg... 50 fenofibrate tab 5 mg... 50 fentanyl citrate lozenge on a handle 100 mcg...1 fentanyl citrate lozenge on a handle 1600 mcg...1 fentanyl citrate lozenge on a handle 00 mcg...1 fentanyl citrate lozenge on a handle 00 mcg...1 fentanyl citrate lozenge on a handle 600 mcg...1 fentanyl citrate lozenge on a handle 800 mcg...1 fentanyl td patch 7hr 100 mcg/hr...1 fentanyl td patch 7hr 1 mcg/hr... 1 fentanyl td patch 7hr 5 mcg/hr... 1 fentanyl td patch 7hr 50 mcg/hr... 1 fentanyl td patch 7hr 75 mcg/hr... 1 FETZIMA... 1 FETZIMA... 1 FETZIMA... 1 FETZIMA... 1 FETZIMA TITRATION PACK...1 FINACEA... 57 FINACEA... 57 finasteride tab 5 mg...61 FIRAZYR... 68 FIRMAGON...66 FIRMAGON...66 flecainide acetate tab 100 mg...50 flecainide acetate tab 150 mg...50 flecainide acetate tab 50 mg... 50 FLOVENT DISKUS...75 FLOVENT DISKUS...75 FLOVENT DISKUS...75 FLOVENT HFA...75 FLOVENT HFA...75 FLOVENT HFA...75 fluconazole for susp 10 mg/ml... 18 fluconazole for susp 0 mg/ml... 18 fluconazole in dextrose inj 00 mg/100ml...18 fluconazole in dextrose inj 00 mg/00ml...18 fluconazole in nacl 0.9% inj 00 mg/100ml...18 fluconazole in nacl 0.9% inj 00 mg/00ml...18 fluconazole tab 100 mg...18 fluconazole tab 150 mg...18 fluconazole tab 00 mg...18 fluconazole tab 50 mg...18 flucytosine cap 50 mg... 18 flucytosine cap 500 mg... 18 FLUDARABINE PHOSPHATE... 3 fludarabine phosphate for inj 50 mg...3 fludarabine phosphate inj 5 mg/ml... 3 fludrocortisone acetate tab 0.1 mg...6 fluocinolone acetonide (otic) oil 0.01%... 73 fluocinonide cream 0.05%... 57 fluocinonide emulsified base cream 0.05%...57 fluocinonide gel 0.05%...57 fluorometholone ophth susp 0.1%...7 fluorouracil cream 5%... 57 fluorouracil inj 1 gm/0ml (50 mg/ml)...3 fluorouracil inj.5 gm/50ml (50 mg/ml)...3 fluorouracil inj 500 mg/10ml (50 mg/ ml)...3 fluorouracil inj 5 gm/100ml (50 mg/ml)...3 fluoxetine hcl cap 10 mg...1 fluoxetine hcl cap 0 mg...1 fluoxetine hcl cap 0 mg...1 fluoxetine hcl solution 0 mg/5ml... 15 fluoxetine hcl tab 10 mg...15 fluoxetine hcl tab 0 mg...15 fluphenazine decanoate inj 5 mg/ml...31 FLUPHENAZINE HCL...31 FLUPHENAZINE HCL...31 FLUPHENAZINE HCL...31 fluphenazine hcl tab 10 mg... 31 fluphenazine hcl tab 1 mg... 31 fluphenazine hcl tab.5 mg... 31 fluphenazine hcl tab 5 mg... 31 flurbiprofen sodium ophth soln 0.03%...7 flutamide cap 15 mg...3 fluticasone propionate nasal susp 50 mcg/ act...75 fluvoxamine maleate tab 100 mg...15 fluvoxamine maleate tab 5 mg...15 fluvoxamine maleate tab 50 mg...15 FOLOTYN...3 FOLOTYN...3 fondaparinux sodium subcutaneous inj 10 mg/0.8ml...6 11

fondaparinux sodium subcutaneous inj.5 mg/0.5ml...6 fondaparinux sodium subcutaneous inj 5 mg/0.ml...6 fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml...6 FORADIL AEROLIZER... 75 FORTEO...7 fosinopril sodium tab 10 mg... 50 fosinopril sodium tab 0 mg... 50 fosinopril sodium tab 0 mg... 51 fosphenytoin sodium inj 100 mg/ml...9 fosphenytoin sodium inj 500 mg/10ml...10 FOSRENOL... 61 FOSRENOL... 61 FOSRENOL... 61 FOSRENOL... 61 FOSRENOL... 61 furosemide inj 10 mg/ml...51 furosemide oral soln 10 mg/ml...51 furosemide tab 0 mg... 51 furosemide tab 0 mg... 51 furosemide tab 80 mg... 51 FUZEON...36 FYCOMPA...10 FYCOMPA...10 FYCOMPA...10 FYCOMPA...10 FYCOMPA...10 FYCOMPA...10 G gabapentin cap 100 mg... 10 gabapentin cap 300 mg... 10 gabapentin cap 00 mg... 10 gabapentin oral soln 50 mg/5ml... 10 gabapentin tab 600 mg... 10 gabapentin tab 800 mg... 10 galantamine hydrobromide cap sr hr 16 mg...1 galantamine hydrobromide cap sr hr mg...1 galantamine hydrobromide cap sr hr 8 mg...1 galantamine hydrobromide oral soln mg/ ml...1 galantamine hydrobromide tab 1 mg... 1 galantamine hydrobromide tab mg...1 galantamine hydrobromide tab 8 mg...1 GAMMAPLEX... 68 GAMMAPLEX... 68 GAMMAPLEX... 68 GAMMAPLEX... 68 GAMUNEX-C...68 GAMUNEX-C...68 GAMUNEX-C...68 GAMUNEX-C...69 GAMUNEX-C...69 GAMUNEX-C...69 ganciclovir sodium for inj 500 mg... 36 GARDASIL... 69 GARDASIL 9...69 GARDASIL 9...69 GAUZE PADS " X "...3 GAZYVA...3 gemcitabine hcl for inj 1 gm... 3 gemcitabine hcl for inj 00 mg...3 gemcitabine hcl for inj gm... 3 gemfibrozil tab 600 mg... 51 GENTAMICIN SULFATE...57 GENTAMICIN SULFATE...57 gentamicin sulfate inj 10 mg/ml...6 gentamicin sulfate inj 0 mg/ml...6 gentamicin sulfate iv soln 10 mg/ml... 6 gentamicin sulfate ophth oint 0.3%... 7 gentamicin sulfate ophth soln 0.3%...7 GEODON...31 GILOTRIF...3 GILOTRIF... GILOTRIF... Glatopa - glatiramer acetate soln prefilled syringe 0 mg/ml... 55 GLEEVEC... GLEEVEC... GLEOSTINE... GLEOSTINE... GLEOSTINE... glimepiride tab 1 mg...3 glimepiride tab mg...3 glimepiride tab mg...3 glipizide tab 10 mg... 3 glipizide tab 5 mg...3 glipizide tab sr hr 10 mg...3 glipizide tab sr hr.5 mg...3 glipizide tab sr hr 5 mg...3 GLUCAGEN HYPOKIT... 3 GLYBURIDE...3 GLYBURIDE...3 GLYBURIDE...3 glyburide micronized tab 1.5 mg...3 glyburide micronized tab 3 mg...3 glyburide micronized tab 6 mg...3 glyburide tab 1.5 mg... 3 glyburide tab.5 mg...3 113

glyburide tab 5 mg...3 glycopyrrolate tab 1 mg... 59 glycopyrrolate tab mg... 60 GRANIX... 6 GRANIX... 6 GRASTEK... 75 griseofulvin microsize susp 15 mg/5ml...18 GUANIDINE HCL...0 H HALAVEN... haloperidol decanoate im soln 100 mg/ ml...31 haloperidol decanoate im soln 50 mg/ ml...31 haloperidol lactate inj 5 mg/ml... 31 haloperidol lactate oral conc mg/ml...3 haloperidol tab 0.5 mg... 3 haloperidol tab 10 mg... 3 haloperidol tab 1 mg...3 haloperidol tab 0 mg... 3 haloperidol tab mg...3 haloperidol tab 5 mg...3 HARVONI... 36 HAVRIX...69 HAVRIX...69 heparin sodium (porcine) 0 unit/ml in d5w...6 heparin sodium (porcine) inj 10000 unit/ ml...6 heparin sodium (porcine) inj 1000 unit/ ml...6 heparin sodium (porcine) inj 0000 unit/ ml...6 heparin sodium (porcine) inj 5000 unit/ ml...6 heparin sodium (porcine) pf inj 5000 unit/0.5ml...6 HERCEPTIN... HETLIOZ...77 HEXALEN... HIBERIX... 69 HUMALOG... 3 HUMALOG... 3 HUMALOG KWIKPEN...3 HUMALOG KWIKPEN... HUMALOG MIX 50/50... HUMALOG MIX 50/50 KWIKPEN... HUMALOG MIX 75/5... HUMALOG MIX 75/5 KWIKPEN... HUMAPEN LUXURA HD... HUMIRA...69 HUMIRA...69 HUMIRA...69 HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK...69 HUMIRA PEN...69 HUMIRA PEN-CROHNS DISEASE STARTER...69 HUMIRA PEN-PSORIASIS STARTER... 69 HUMULIN 70/30... HUMULIN 70/30 KWIKPEN... HUMULIN 70/30 PEN... HUMULIN N... HUMULIN N KWIKPEN... HUMULIN N U-100 PEN... HUMULIN R... HUMULIN R U-500 (CONCENTRATE)... hydralazine hcl tab 100 mg... 51 hydralazine hcl tab 10 mg... 51 hydralazine hcl tab 5 mg... 51 hydralazine hcl tab 50 mg... 51 hydrochlorothiazide cap 1.5 mg...51 hydrochlorothiazide tab 1.5 mg...51 hydrochlorothiazide tab 5 mg...51 hydrochlorothiazide tab 50 mg...51 hydrocodone-acetaminophen soln 7.5-35 mg/15ml...1 hydrocodone-acetaminophen tab 10-300 mg...1 hydrocodone-acetaminophen tab 10-35 mg...1 hydrocodone-acetaminophen tab 5-300 mg...1 hydrocodone-acetaminophen tab 5-35 mg...1 hydrocodone-acetaminophen tab 7.5-300 mg...1 hydrocodone-acetaminophen tab 7.5-35 mg...1 hydrocortisone cream 1%...57 hydrocortisone cream.5%...57 hydrocortisone enema 100 mg/60ml...71 hydrocortisone lotion.5%... 57 hydrocortisone oint 1%... 57 hydrocortisone oint.5%... 57 hydrocortisone rectal cream.5%...71 hydrocortisone w/ acetic acid otic soln 1-%...73 hydromorphone hcl liqd 1 mg/ml...1 hydromorphone hcl preservative free (pf) inj 10 mg/ ml... 1 hydromorphone hcl tab mg... 1 11

hydromorphone hcl tab mg... 1 hydromorphone hcl tab 8 mg... 1 hydroxychloroquine sulfate tab 00 mg... 9 hydroxyurea cap 500 mg... I ibandronate sodium iv soln 3 mg/3ml...7 ibandronate sodium tab 150 mg... 7 IBRANCE... IBRANCE... IBRANCE... ibuprofen tab 00 mg... 1 ibuprofen tab 00 mg... 19 ibuprofen tab 600 mg... 1 ibuprofen tab 600 mg... 19 ibuprofen tab 800 mg... ibuprofen tab 800 mg... 19 ICLUSIG... ICLUSIG... idarubicin hcl iv inj 10 mg/10ml (1 mg/ ml)... idarubicin hcl iv inj 0 mg/0ml (1 mg/ ml)... idarubicin hcl iv inj 5 mg/5ml (1 mg/ml)... IFOSFAMIDE... ifosfamide for inj 1 gm... ILARIS*... 69 IMBRUVICA... imipenem-cilastatin intravenous for soln 50 mg...6 imipenem-cilastatin intravenous for soln 500 mg...6 imipramine hcl tab 10 mg... 15 imipramine hcl tab 5 mg... 15 imipramine hcl tab 50 mg... 15 imiquimod cream 5%...57 IMOVAX RABIES (H.D.C.V.)... 69 INCRELEX*...63 INFANRIX...69 INLYTA*... INLYTA*... INSULIN SYRINGE/NEEDLE... INTELENCE...36 INTELENCE...36 INTELENCE...36 INTRON A...36 INTRON A...36 INTRON A W/DILUENT...36 INTRON A W/DILUENT...36 INTRON A W/DILUENT...36 INVEGA... 3 INVEGA... 3 INVEGA... 3 INVEGA... 3 INVEGA SUSTENNA... 3 INVEGA SUSTENNA... 3 INVEGA SUSTENNA... 3 INVEGA SUSTENNA... 3 INVEGA SUSTENNA... 3 INVEGA TRINZA...3 INVEGA TRINZA...3 INVEGA TRINZA...3 INVEGA TRINZA...3 INVIRASE...36 INVIRASE...36 INVOKANA... INVOKANA... IPOL INACTIVATED IPV...69 ipratropium bromide nasal soln 0.03% (1 mcg/ spray)...75 ipratropium bromide nasal soln 0.06% ( mcg/ spray)...75 irbesartan-hydrochlorothiazide tab 150-1.5 mg...51 irbesartan-hydrochlorothiazide tab 300-1.5 mg...51 irbesartan tab 150 mg...51 irbesartan tab 300 mg...51 irbesartan tab 75 mg... 51 IRESSA... IRINOTECAN... irinotecan hcl inj 100 mg/5ml (0 mg/ ml)... irinotecan hcl inj 0 mg/ml (0 mg/ml)... ISENTRESS...36 ISENTRESS...36 ISENTRESS...36 ISENTRESS...36 ISONIAZID... 0 isoniazid tab 100 mg... 0 isoniazid tab 300 mg... 0 isosorbide dinitrate tab 10 mg...51 isosorbide dinitrate tab 0 mg...51 isosorbide dinitrate tab 5 mg...51 isosorbide mononitrate tab sr hr 10 mg...51 isosorbide mononitrate tab sr hr 30 mg...51 isosorbide mononitrate tab sr hr 60 mg...51 isotretinoin cap 10 mg...57 isotretinoin cap 0 mg...57 isotretinoin cap 30 mg...57 isotretinoin cap 0 mg...57 115

ISTODAX... itraconazole cap 100 mg... 18 ivermectin tab 3 mg...9 IXEMPRA KIT... IXEMPRA KIT... IXIARO...69 J JADENU... 78 JADENU... 78 JADENU... 78 JAKAFI*... JAKAFI*... JAKAFI*... JAKAFI*... JAKAFI*... 5 JANUMET... JANUMET... JANUMET XR... JANUMET XR... JANUMET XR... JANUVIA... JANUVIA... JANUVIA... JENTADUETO... JENTADUETO... 5 JENTADUETO... 5 JEVTANA...5 K KADCYLA...5 KADCYLA...5 KALETRA... 36 KALETRA... 36 KALETRA... 36 KALYDECO...75 KALYDECO...75 KALYDECO...75 kcl 10 meq/l (0.075%) in dextrose 5% & nacl 0.5% inj... 78 kcl 0 meq/l (0.15%) in dextrose 5% & nacl 0.% inj... 78 kcl 0 meq/l (0.15%) in dextrose 5% & nacl 0.33% inj... 78 kcl 0 meq/l (0.15%) in dextrose 5% & nacl 0.5% inj... 78 kcl 30 meq/l (0.%) in dextrose 5% & nacl 0.5% inj... 78 kcl 0 meq/l (0.3%) in dextrose 5% & nacl 0.5% inj... 78 KEPIVANCE...56 ketoconazole cream %...57 ketoconazole shampoo %... 57 ketoconazole tab 00 mg... 18 ketorolac tromethamine ophth soln 0.%...7 ketorolac tromethamine ophth soln 0.5%...7 ketorolac tromethamine tab 10 mg... KEYTRUDA...5 KEYTRUDA...5 KINERET... 69 KINRIX... 69 KOMBIGLYZE XR...5 KOMBIGLYZE XR...5 KOMBIGLYZE XR...5 KUVAN*... 59 KUVAN*... 59 KUVAN*... 59 L labetalol hcl tab 100 mg...51 labetalol hcl tab 00 mg...51 labetalol hcl tab 300 mg...51 LACRISERT... 7 lactated ringer's solution... 78 lactic acid (ammonium lactate) cream 1%... 57 lactic acid (ammonium lactate) lotion 1%... 57 lactulose (encephalopathy) solution 10 gm/15ml...60 lactulose solution 10 gm/15ml...60 LAMICTAL ODT... 10 LAMICTAL ODT... 10 LAMICTAL ODT... 10 LAMICTAL ODT... 10 LAMICTAL ODT... 1 LAMICTAL ODT... 1 LAMICTAL ODT... 1 LAMICTAL ODT... 1 lamivudine oral soln 10 mg/ml... 36 lamivudine tab 100 mg (hbv)...36 lamivudine tab 150 mg...36 lamivudine tab 300 mg...36 lamivudine-zidovudine tab 150-300 mg... 36 lamotrigine orally disintegrating tab 100 mg...10 lamotrigine orally disintegrating tab 100 mg...1 lamotrigine orally disintegrating tab 00 mg...10 lamotrigine orally disintegrating tab 00 mg...1 116

lamotrigine orally disintegrating tab 5 mg...10 lamotrigine orally disintegrating tab 5 mg...1 lamotrigine orally disintegrating tab 50 mg...10 lamotrigine orally disintegrating tab 50 mg...1 lamotrigine tab 100 mg... 10 lamotrigine tab 100 mg... 1 lamotrigine tab 150 mg... 10 lamotrigine tab 150 mg... 1 lamotrigine tab 00 mg... 10 lamotrigine tab 00 mg... 1 lamotrigine tab 5 mg... 10 lamotrigine tab 5 mg... 1 lamotrigine tab chewable dispersible 5 mg...10 lamotrigine tab chewable dispersible 5 mg...1 lamotrigine tab chewable dispersible 5 mg...10 lamotrigine tab chewable dispersible 5 mg...1 LANTUS...5 LANTUS SOLOSTAR...5 latanoprost ophth soln 0.005%... 73 LATUDA...3 LATUDA...3 LATUDA...3 LATUDA...3 LATUDA...3 LAZANDA... LAZANDA... leflunomide tab 10 mg...69 leflunomide tab 0 mg...69 LENVIMA 10MG DAILY DOSE...5 LENVIMA 1MG DAILY DOSE...5 LENVIMA 0MG DAILY DOSE...5 LENVIMA MG DAILY DOSE...5 LETAIRIS*... 75 LETAIRIS*... 75 letrozole tab.5 mg...5 LEUCOVORIN CALCIUM...5 LEUCOVORIN CALCIUM...5 leucovorin calcium for inj 100 mg... 5 leucovorin calcium for inj 00 mg... 5 leucovorin calcium for inj 350 mg... 5 leucovorin calcium for inj 50 mg... 5 leucovorin calcium tab 5 mg... 5 leucovorin calcium tab 5 mg...5 LEUKERAN...5 LEUKINE... 6 leuprolide acetate inj kit 5 mg/ml... 66 levetiracetam inj 500 mg/5ml (100 mg/ ml)...10 levetiracetam oral soln 100 mg/ml...10 levetiracetam tab 1000 mg...10 levetiracetam tab 50 mg... 10 levetiracetam tab 500 mg... 10 levetiracetam tab 750 mg... 10 levocarnitine oral soln 1 gm/10ml (10%)... 78 levocarnitine tab 330 mg... 78 levocetirizine dihydrochloride tab 5 mg...76 levofloxacin in d5w iv soln 50 mg/50ml...6 levofloxacin in d5w iv soln 500 mg/100ml...6 levofloxacin in d5w iv soln 750 mg/150ml...6 levofloxacin iv soln 5 mg/ml... 6 levofloxacin oral soln 5 mg/ml...6 levofloxacin tab 50 mg... 6 levofloxacin tab 500 mg... 6 levofloxacin tab 750 mg... 7 levonorgestrel & ethinyl estradiol (91-day) tab 0.15-0.03 mg... 6 levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg...6 levonorgestrel & ethinyl estradiol tab 0.1 mg-0 mcg...6 levonorgestrel-eth estra tab 0.05-30/0.075-0/0.15-30mg-mcg...6 levonorgestrel-ethinyl estradiol (continuous) tab 90-0 mcg...6 levonorg-eth est tab 0.1-0.0mg(8) & eth est tab 0.01mg(7)...6 levonorg-eth est tab 0.15-0.03mg(8) & eth est tab 0.01mg(7)...6 levothyroxine sodium tab 100 mcg...65 levothyroxine sodium tab 11 mcg... 65 levothyroxine sodium tab 15 mcg...65 levothyroxine sodium tab 137 mcg...66 levothyroxine sodium tab 150 mcg...66 levothyroxine sodium tab 175 mcg...66 levothyroxine sodium tab 00 mcg...66 levothyroxine sodium tab 5 mcg...65 levothyroxine sodium tab 300 mcg...66 levothyroxine sodium tab 50 mcg...65 levothyroxine sodium tab 75 mcg...65 levothyroxine sodium tab 88 mcg...65 LEXIVA...36 LEXIVA...36 LIALDA...71 117

lidocaine hcl gel %...3 lidocaine hcl local inj 1%...3 lidocaine hcl local preservative free (pf) inj 1%...3 lidocaine hcl soln %...3 lidocaine hcl viscous soln %...3 lidocaine patch 5%...3 lidocaine-prilocaine cream.5-.5%... 3 linezolid iv soln mg/ml...7 linezolid tab 600 mg... 7 LINZESS...60 LINZESS...60 liothyronine sodium tab 5 mcg...66 liothyronine sodium tab 50 mcg...66 liothyronine sodium tab 5 mcg... 66 lisinopril & hydrochlorothiazide tab 10-1.5 mg...51 lisinopril & hydrochlorothiazide tab 0-1.5 mg...51 lisinopril & hydrochlorothiazide tab 0-5 mg...51 lisinopril tab 10 mg... 51 lisinopril tab.5 mg... 51 lisinopril tab 0 mg... 51 lisinopril tab 30 mg... 51 lisinopril tab 0 mg... 51 lisinopril tab 5 mg...51 LITHIUM... lithium carbonate cap 150 mg... lithium carbonate cap 300 mg... lithium carbonate cap 600 mg... lithium carbonate tab 300 mg... lithium carbonate tab cr 300 mg... lithium carbonate tab cr 50 mg... LOMUSTINE... 5 LOMUSTINE... 5 LOMUSTINE... 5 LONSURF... 5 LONSURF... 5 loperamide hcl cap mg... 60 lorazepam tab 0.5 mg... 0 lorazepam tab 1 mg... 0 lorazepam tab mg... 0 losartan potassium & hydrochlorothiazide tab 100-1.5 mg... 51 losartan potassium & hydrochlorothiazide tab 100-5 mg...51 losartan potassium & hydrochlorothiazide tab 50-1.5 mg...51 losartan potassium tab 100 mg...51 losartan potassium tab 5 mg...51 losartan potassium tab 50 mg...51 LOTRONEX... 60 LOTRONEX... 60 lovastatin tab 10 mg...51 lovastatin tab 0 mg...51 lovastatin tab 0 mg...5 loxapine succinate cap 10 mg...3 loxapine succinate cap 5 mg...3 loxapine succinate cap 50 mg...3 loxapine succinate cap 5 mg...3 LUPRON DEPOT...66 LUPRON DEPOT...66 LUPRON DEPOT...66 LUPRON DEPOT...66 LUPRON DEPOT...66 LUPRON DEPOT...66 LYNPARZA...5 LYRICA... 10 LYRICA... 10 LYRICA... 10 LYRICA... 10 LYRICA... 10 LYRICA... 10 LYRICA... 10 LYRICA... 10 LYRICA... 10 LYRICA... 55 LYRICA... 55 LYRICA... 55 LYRICA... 55 LYRICA... 55 LYRICA... 55 LYRICA... 55 LYRICA... 55 LYRICA... 55 LYSODREN...66 M MAPROTILINE HCL... 15 MAPROTILINE HCL... 15 MAPROTILINE HCL... 15 MARPLAN... 15 MATULANE*... 5 meclizine hcl tab 1.5 mg...17 medroxyprogesterone acetate im susp 150 mg/ ml...6 medroxyprogesterone acetate tab 10 mg...6 medroxyprogesterone acetate tab.5 mg...6 medroxyprogesterone acetate tab 5 mg...6 mefloquine hcl tab 50 mg... 9 megestrol acetate susp 0 mg/ml...6 118

megestrol acetate tab 0 mg... 6 megestrol acetate tab 0 mg... 6 MEKINIST...5 MEKINIST...5 meloxicam tab 15 mg... meloxicam tab 15 mg...19 meloxicam tab 7.5 mg... meloxicam tab 7.5 mg...19 melphalan hcl for inj 50 mg... 5 memantine hcl oral solution mg/ml...1 memantine hcl tab 10 mg...1 memantine hcl tab 5 mg... 1 memantine hcl tab 5 mg (8) & 10 mg (1) titration pak...1 MENACTRA...70 MENEST...6 MENEST...6 MENEST...65 MENEST...65 MENOMUNE-A/C/Y/W-135... 70 MENVEO... 70 mercaptopurine tab 50 mg... 5 meropenem iv for soln 1 gm...7 meropenem iv for soln 500 mg... 7 mesalamine enema gm... 71 mesna inj 100 mg/ml...5 MESNEX...5 MESTINON... 0 metformin hcl tab 1000 mg...5 metformin hcl tab 500 mg...5 metformin hcl tab 850 mg...5 metformin hcl tab sr hr 500 mg...5 metformin hcl tab sr hr 750 mg...5 methadone hcl tab 10 mg... methadone hcl tab 5 mg... methazolamide tab 5 mg... 5 methazolamide tab 50 mg... 5 methimazole tab 10 mg... 67 methimazole tab 5 mg...67 methocarbamol tab 500 mg...77 methocarbamol tab 750 mg...77 methotrexate sodium for inj 1 gm... 5 methotrexate sodium for inj 1 gm... 70 methotrexate sodium inj 5 mg/ml... 5 methotrexate sodium inj 5 mg/ml... 70 methotrexate sodium inj pf 5 mg/ml... 5 methotrexate sodium inj pf 5 mg/ml... 70 methotrexate sodium tab.5 mg...5 methotrexate sodium tab.5 mg...70 methoxsalen rapid cap 10 mg...57 methscopolamine bromide tab.5 mg...60 methscopolamine bromide tab 5 mg...60 methylergonovine maleate tab 0. mg...61 methylphenidate hcl tab 10 mg...55 methylphenidate hcl tab 0 mg...55 methylphenidate hcl tab 5 mg...55 methylphenidate hcl tab cr 0 mg... 55 methylprednisolone sodium succinate for inj 1000 mg...6 methylprednisolone sodium succinate for inj 15 mg...6 methylprednisolone sodium succinate for inj 0 mg...6 methylprednisolone tab 16 mg...6 methylprednisolone tab 3 mg...6 methylprednisolone tab mg...6 methylprednisolone tab mg dose pack...6 methylprednisolone tab 8 mg...6 methyltestosterone cap 10 mg...65 metoclopramide hcl soln 5 mg/5ml (10 mg/10ml)...17 metoclopramide hcl soln 5 mg/5ml (10 mg/10ml)...60 metoclopramide hcl tab 10 mg...17 metoclopramide hcl tab 10 mg...60 metoclopramide hcl tab 5 mg...17 metoclopramide hcl tab 5 mg...60 metoprolol succinate tab sr hr 100 mg...5 metoprolol succinate tab sr hr 00 mg...5 metoprolol succinate tab sr hr 5 mg...5 metoprolol succinate tab sr hr 50 mg...5 metoprolol tartrate tab 100 mg...5 metoprolol tartrate tab 5 mg...5 metoprolol tartrate tab 50 mg...5 metronidazole cream 0.75%...57 metronidazole gel 0.75%... 57 metronidazole in nacl 0.79% iv soln 500 mg/100ml...7 metronidazole lotion 0.75%... 57 metronidazole tab 50 mg...7 metronidazole tab 500 mg...7 metronidazole vaginal gel 0.75%...7 mexiletine hcl cap 150 mg...5 mexiletine hcl cap 00 mg...5 mexiletine hcl cap 50 mg...5 MIACALCIN...7 midodrine hcl tab 10 mg... 5 midodrine hcl tab.5 mg... 5 midodrine hcl tab 5 mg... 5 119

MIGERGOT...19 MIGRANAL...19 minocycline hcl cap 100 mg... 7 minocycline hcl cap 50 mg... 7 minocycline hcl cap 75 mg... 7 minoxidil tab 10 mg... 5 minoxidil tab.5 mg... 5 mirtazapine orally disintegrating tab 15 mg...15 mirtazapine orally disintegrating tab 30 mg...15 mirtazapine orally disintegrating tab 5 mg...15 mirtazapine tab 15 mg... 15 mirtazapine tab 30 mg... 15 mirtazapine tab 5 mg... 15 mirtazapine tab 7.5 mg... 15 misoprostol tab 100 mcg... 60 misoprostol tab 00 mcg... 60 mitomycin for iv soln 0 mg... 6 mitomycin for iv soln 0 mg... 6 mitomycin for iv soln 5 mg...6 mitoxantrone hcl inj conc 0 mg/10ml ( mg/ ml)...6 mitoxantrone hcl inj conc 0 mg/10ml ( mg/ ml)...56 mitoxantrone hcl inj conc 5 mg/1.5ml ( mg/ ml)...6 mitoxantrone hcl inj conc 5 mg/1.5ml ( mg/ ml)...56 mitoxantrone hcl inj conc 30 mg/15ml ( mg/ ml)...6 mitoxantrone hcl inj conc 30 mg/15ml ( mg/ ml)...56 M-M-R II... 69 modafinil tab 100 mg...77 modafinil tab 00 mg...77 montelukast sodium chew tab mg...76 montelukast sodium chew tab 5 mg...76 montelukast sodium oral granules packet mg...76 montelukast sodium tab 10 mg...76 MORPHINE SULFATE... MORPHINE SULFATE... morphine sulfate inj pf 0.5 mg/ml... morphine sulfate inj pf 1 mg/ml... morphine sulfate tab cr 100 mg... morphine sulfate tab cr 15 mg... morphine sulfate tab cr 00 mg... morphine sulfate tab cr 30 mg... morphine sulfate tab cr 60 mg... MOZOBIL... 6 MULTAQ... 5 mupirocin oint %... 57 MUSTARGEN... 6 MYALEPT... 6 MYCAMINE...18 MYCAMINE...18 mycophenolate mofetil cap 50 mg...70 mycophenolate mofetil for oral susp 00 mg/ ml...70 mycophenolate mofetil tab 500 mg... 70 MYOZYME... 59 MYRBETRIQ...61 MYRBETRIQ...61 N nabumetone tab 500 mg... nabumetone tab 500 mg...19 nabumetone tab 750 mg... nabumetone tab 750 mg...19 NAFCILLIN SODIUM...7 NAFCILLIN SODIUM...7 nafcillin sodium for inj 10 gm...7 nafcillin sodium for inj 1 gm...7 nafcillin sodium for inj gm...7 NAGLAZYME*... 59 naloxone hcl inj 0. mg/ml...3 naloxone hcl inj 1 mg/ml... 3 naltrexone hcl tab 50 mg... 3 NAMENDA... 1 NAMENDA... 1 NAMENDA... 1 NAMENDA TITRATION PAK...1 NAMENDA XR...1 NAMENDA XR...1 NAMENDA XR...1 NAMENDA XR...13 NAMENDA XR TITRATION PACK... 13 NAPHAZOLINE HCL...73 naproxen tab 50 mg... naproxen tab 50 mg... 19 naproxen tab 375 mg... naproxen tab 375 mg... 19 naproxen tab 500 mg... naproxen tab 500 mg... 19 naratriptan hcl tab 1 mg...19 naratriptan hcl tab.5 mg...19 NASONEX...76 NATACYN...73 nateglinide tab 10 mg... 5 nateglinide tab 60 mg...5 NEBUPENT...9 NEFAZODONE HCL...15 10

NEFAZODONE HCL...15 NEFAZODONE HCL...15 nefazodone hcl tab 50 mg...15 nefazodone hcl tab 50 mg...15 neomycin-polymy-gramicid op sol 1.75-10000-0.05mg-unt-mg/ml... 73 neomycin-polymyxin-dexamethasone ophth oint 0.1%...73 neomycin-polymyxin-dexamethasone ophth susp 0.1%...73 neomycin-polymyxin-hc otic soln 1%... 73 neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1%... 73 neomycin sulfate tab 500 mg... 7 NEUMEGA... 6 NEUPRO... 30 NEUPRO... 30 NEUPRO... 30 NEUPRO... 30 NEUPRO... 30 NEUPRO... 30 NEVIRAPINE... 36 nevirapine tab 00 mg... 36 nevirapine tab sr hr 00 mg...36 NEXAVAR*... 6 NEXIUM...60 NEXIUM...60 NEXIUM...60 NEXIUM...60 NEXIUM...60 NEXIUM...60 NEXIUM...60 niacin tab cr 1000 mg... 5 niacin tab cr 500 mg...5 niacin tab cr 750 mg...5 NICOTROL INHALER... 3 NICOTROL NS...3 nifedipine tab sr hr 30 mg... 5 nifedipine tab sr hr 60 mg... 5 nifedipine tab sr hr 90 mg... 5 nifedipine tab sr hr osmotic release 30 mg...5 nifedipine tab sr hr osmotic release 60 mg...5 nifedipine tab sr hr osmotic release 90 mg...5 NILANDRON...6 NIPENT...6 nitrofurantoin macrocrystalline cap 100 mg...7 nitrofurantoin macrocrystalline cap 50 mg...7 nitrofurantoin monohydrate macrocrystalline cap 100 mg...7 nitroglycerin td patch hr 0.1 mg/hr...5 nitroglycerin td patch hr 0. mg/hr...5 nitroglycerin td patch hr 0. mg/hr...5 nitroglycerin td patch hr 0.6 mg/hr...5 NITROSTAT... 5 NITROSTAT... 5 NITROSTAT... 5 nizatidine cap 150 mg...60 nizatidine cap 300 mg...60 norethindrone & ethinyl estradiol-fe chew tab 0. mg-35 mcg...65 norethindrone & ethinyl estradiol-fe chew tab 0.8 mg-5 mcg...65 norethindrone & ethinyl estradiol tab 0. mg-35 mcg...65 norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg...65 norethindrone & ethinyl estradiol tab 1 mg-35 mcg...65 norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg...65 norethindrone ace & ethinyl estradiol-fe tab 1 mg-0 mcg...65 norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg...65 norethindrone ace & ethinyl estradiol tab 1 mg-0 mcg...65 norethindrone ace-ethinyl estradiol-fe tab 1 mg-0 mcg ()...65 norethindrone acetate tab 5 mg...65 norethindrone ac-ethinyl estrad-fe tab 1-0/1-30/1-35 mg-mcg...65 norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg-mcg...65 norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg-mcg...65 norethindrone tab 0.35 mg... 65 norgestimate & ethinyl estradiol tab 0.5 mg-35 mcg...65 norgestimate-eth estrad tab 0.18-35/0.15-35/0.5-35 mg-mcg...65 norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg...65 NORTHERA... 5 NORTHERA... 5 NORTHERA... 5 NORTRIPTYLINE HCL... 15 nortriptyline hcl cap 10 mg... 15 nortriptyline hcl cap 5 mg... 15 nortriptyline hcl cap 50 mg... 15 11

nortriptyline hcl cap 75 mg... 15 NORVIR...37 NORVIR...37 NORVIR...37 NOXAFIL... 18 NOXAFIL... 18 NUEDEXTA...56 NUVIGIL... 77 NUVIGIL... 77 NUVIGIL... 77 NUVIGIL... 77 nystatin cream 100000 unit/gm...57 nystatin oint 100000 unit/gm... 57 nystatin susp 100000 unit/ml...18 nystatin topical powder... 57 nystatin-triamcinolone cream 100000-0.1 unit/gm- %...57 O octreotide acetate inj 1000 mcg/ml (1 mg/ ml)...67 octreotide acetate inj 100 mcg/ml (0.1 mg/ ml)...66 octreotide acetate inj 00 mcg/ml (0. mg/ ml)...66 octreotide acetate inj 500 mcg/ml (0.5 mg/ ml)...67 octreotide acetate inj 50 mcg/ml (0.05 mg/ ml)...66 ODOMZO... 6 OFEV... 76 OFEV... 76 ofloxacin ophth soln 0.3%...73 ofloxacin otic soln 0.3%... 73 olanzapine for im inj 10 mg... 3 olanzapine for im inj 10 mg... olanzapine orally disintegrating tab 10 mg...33 olanzapine orally disintegrating tab 10 mg... olanzapine orally disintegrating tab 15 mg...33 olanzapine orally disintegrating tab 15 mg... olanzapine orally disintegrating tab 0 mg...33 olanzapine orally disintegrating tab 0 mg... olanzapine orally disintegrating tab 5 mg...33 olanzapine orally disintegrating tab 5 mg... olanzapine tab 10 mg...33 olanzapine tab 10 mg... olanzapine tab 15 mg...33 olanzapine tab 15 mg... olanzapine tab.5 mg...33 olanzapine tab.5 mg... olanzapine tab 0 mg...33 olanzapine tab 0 mg... olanzapine tab 5 mg...33 olanzapine tab 5 mg... olanzapine tab 7.5 mg...33 olanzapine tab 7.5 mg... OLYSIO...37 omega-3-acid ethyl esters cap 1 gm...5 omeprazole cap delayed release 10 mg...60 omeprazole cap delayed release 0 mg...60 omeprazole cap delayed release 0 mg...60 OMNITROPE... 63 OMNITROPE... 63 OMNITROPE... 63 ONCASPAR... 6 ondansetron hcl inj 0 mg/0ml ( mg/ ml)...17 ondansetron hcl inj mg/ml ( mg/ ml)...17 ondansetron orally disintegrating tab mg...17 ondansetron orally disintegrating tab 8 mg...17 ONFI...11 ONFI...11 ONFI...11 ONFI...11 ONGLYZA...5 ONGLYZA...5 OPDIVO...6 OPDIVO...6 OPSUMIT*...76 ORAP... 33 ORAP... 33 ORFADIN*... 59 ORFADIN*... 59 ORFADIN*... 59 ORKAMBI...76 oxaliplatin for iv inj 100 mg...6 oxaliplatin for iv inj 50 mg...6 oxaliplatin iv soln 100 mg/0ml...6 oxaliplatin iv soln 50 mg/10ml...6 oxandrolone tab 10 mg... 65 1

oxandrolone tab.5 mg...65 oxcarbazepine susp 300 mg/5ml (60 mg/ ml)...11 oxcarbazepine tab 150 mg...11 oxcarbazepine tab 300 mg...11 oxcarbazepine tab 600 mg...11 oxybutynin chloride syrup 5 mg/5ml...61 oxybutynin chloride tab 5 mg... 61 oxycodone hcl tab 10 mg... oxycodone hcl tab 15 mg... oxycodone hcl tab 0 mg... oxycodone hcl tab 30 mg... oxycodone hcl tab 5 mg... oxycodone w/ acetaminophen tab 10-35 mg... oxycodone w/ acetaminophen tab.5-35 mg... oxycodone w/ acetaminophen tab 5-35 mg... oxycodone w/ acetaminophen tab 7.5-35 mg... P paclitaxel iv conc 100 mg/16.7ml (6 mg/ ml)...6 paclitaxel iv conc 300 mg/50ml (6 mg/ ml)...6 paclitaxel iv conc 30 mg/5ml (6 mg/ml)...6 paliperidone tab sr hr 1.5 mg...33 paliperidone tab sr hr 3 mg...33 paliperidone tab sr hr 6 mg...33 paliperidone tab sr hr 9 mg...33 PANRETIN...6 pantoprazole sodium ec tab 0 mg... 60 pantoprazole sodium ec tab 0 mg... 60 paricalcitol cap 1 mcg... 7 paricalcitol cap mcg... 7 paricalcitol cap mcg... 7 paricalcitol iv soln mcg/ml... 7 paricalcitol iv soln 5 mcg/ml... 7 paromomycin sulfate cap 50 mg...7 paroxetine hcl tab 10 mg... 15 paroxetine hcl tab 10 mg... 0 paroxetine hcl tab 0 mg... 15 paroxetine hcl tab 0 mg... 0 paroxetine hcl tab 30 mg... 15 paroxetine hcl tab 30 mg... 0 paroxetine hcl tab 0 mg... 15 paroxetine hcl tab 0 mg... 0 paroxetine hcl tab sr hr 1.5 mg...15 paroxetine hcl tab sr hr 1.5 mg...0 paroxetine hcl tab sr hr 5 mg...15 paroxetine hcl tab sr hr 5 mg...0 paroxetine hcl tab sr hr 37.5 mg...15 paroxetine hcl tab sr hr 37.5 mg...0 PASER... 0 PAXIL... 15 PAXIL... 0 PEDVAX HIB... 70 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 36 gm...60 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 0 gm...60 peg 3350-kcl-sod bicarb-nacl for soln 0 gm...60 PEGANONE...11 PEGASYS... 37 PEGASYS... 37 PEGASYS PROCLICK...37 PEGASYS PROCLICK...37 PEG-INTRON... 37 PEG-INTRON... 37 PEG-INTRON... 37 PEG-INTRON... 37 PEG-INTRON REDIPEN... 37 PEG-INTRON REDIPEN... 37 PEG-INTRON REDIPEN... 37 PEG-INTRON REDIPEN... 37 PEG-INTRON REDIPEN PAK... 37 PEG-INTRON REDIPEN PAK... 37 PEG-INTRON REDIPEN PAK... 37 PEG-INTRON REDIPEN PAK... 37 penicillin g potassium for inj 5000000 unit...7 PENICILLIN G POTASSIUM IN DEXTROSE... 7 PENICILLIN G POTASSIUM IN DEXTROSE... 7 PENICILLIN G POTASSIUM IN DEXTROSE... 7 penicillin v potassium for soln 15 mg/5ml... 7 penicillin v potassium for soln 50 mg/5ml... 7 penicillin v potassium tab 50 mg...7 penicillin v potassium tab 500 mg...7 PENTACEL...70 PENTAM 300...9 pentoxifylline tab cr 00 mg... 5 PERJETA*... 6 permethrin cream 5%...9 perphenazine tab 16 mg...17 perphenazine tab 16 mg...33 perphenazine tab mg... 17 13

perphenazine tab mg... 33 perphenazine tab mg... 17 perphenazine tab mg... 33 perphenazine tab 8 mg... 17 perphenazine tab 8 mg... 33 phenelzine sulfate tab 15 mg...15 PHENOBARBITAL... 11 PHENOBARBITAL... 11 PHENOBARBITAL... 11 PHENOBARBITAL... 11 phenobarbital elixir 0 mg/5ml...11 PHENOBARBITAL SODIUM... 11 phenobarbital sodium inj 130 mg/ml... 11 phenobarbital tab 16. mg...11 phenobarbital tab 3. mg...11 phenobarbital tab 6.8 mg...11 phenobarbital tab 97. mg...11 phenoxybenzamine hcl cap 10 mg...5 phenytoin chew tab 50 mg... 11 phenytoin sodium extended cap 100 mg...11 phenytoin sodium extended cap 00 mg...11 phenytoin sodium extended cap 300 mg...11 phenytoin susp 15 mg/5ml... 11 PHOSPHOLINE IODIDE...73 pilocarpine hcl tab 5 mg...56 pilocarpine hcl tab 7.5 mg... 56 pimozide tab 1 mg...33 pimozide tab mg...33 pindolol tab 10 mg...53 pindolol tab 5 mg... 53 pioglitazone hcl tab 15 mg...5 pioglitazone hcl tab 30 mg...5 pioglitazone hcl tab 5 mg...5 piperacillin sodium-tazobactam sodium for inj -0.5 gm...7 piperacillin sodium-tazobactam sodium for inj 3-0.375 gm...7 piperacillin sodium-tazobactam sodium for inj -0.5 gm...7 PLEGRIDY... 56 PLEGRIDY... 56 PLEGRIDY STARTER PACK... 56 PLEGRIDY STARTER PACK... 56 polyethylene glycol 3350 oral packet... 60 polyethylene glycol 3350 oral powder...61 polymyxin b-trimethoprim ophth soln 10000 unit/ ml-0.1%... 73 POMALYST*... 6 POMALYST*... 6 POMALYST*... 6 POMALYST*... 6 potassium chloride 0 meq/l (0.15%) in dextrose 5% inj... 78 potassium chloride 0 meq/l (0.3%) in dextrose 5% inj... 78 potassium chloride cap cr 10 meq...78 potassium chloride cap cr 8 meq...78 potassium chloride microencapsulated crys cr tab 10 meq... 78 potassium chloride microencapsulated crys cr tab 0 meq... 78 potassium chloride tab cr 10 meq... 78 potassium chloride tab cr 8 meq (600 mg)... 78 potassium citrate tab cr 10 meq (1080 mg)... 78 potassium citrate tab cr 15 meq (160 mg)... 78 potassium citrate tab cr 5 meq (50 mg)... 78 POTIGA... 11 POTIGA... 11 POTIGA... 11 POTIGA... 11 PRADAXA... 6 PRADAXA... 6 pramipexole dihydrochloride tab 0.15 mg...30 pramipexole dihydrochloride tab 0.5 mg...30 pramipexole dihydrochloride tab 0.5 mg...30 pramipexole dihydrochloride tab 0.75 mg...30 pramipexole dihydrochloride tab 1.5 mg...30 pramipexole dihydrochloride tab 1 mg...30 pravastatin sodium tab 10 mg...53 pravastatin sodium tab 0 mg...53 pravastatin sodium tab 0 mg...53 pravastatin sodium tab 80 mg...53 prazosin hcl cap 1 mg...53 prazosin hcl cap 1 mg...61 prazosin hcl cap mg...53 prazosin hcl cap mg...61 prazosin hcl cap 5 mg...53 prazosin hcl cap 5 mg...61 prednisolone acetate ophth susp 1%...73 PREDNISONE... 6 PREDNISONE... 6 PREDNISONE... 6 1

PREDNISONE... 6 prednisone tab 10 mg... 6 prednisone tab 1 mg... 6 prednisone tab.5 mg... 6 prednisone tab 0 mg... 6 prednisone tab 5 mg... 6 PREMARIN... 65 PREZCOBIX... 37 PREZISTA... 37 PREZISTA... 37 PREZISTA... 37 PREZISTA... 37 PREZISTA... 37 PRIFTIN...0 PRIMAQUINE PHOSPHATE...9 primidone tab 50 mg... 11 primidone tab 50 mg... 11 PRISTIQ... 15 PRISTIQ... 15 PRISTIQ... 15 PROAIR HFA...76 PROAIR RESPICLICK... 76 probenecid tab 500 mg... 18 prochlorperazine edisylate inj 5 mg/ml...17 prochlorperazine edisylate inj 5 mg/ml...33 prochlorperazine maleate tab 10 mg...17 prochlorperazine maleate tab 10 mg...33 prochlorperazine maleate tab 5 mg...17 prochlorperazine maleate tab 5 mg...33 prochlorperazine suppos 5 mg... 17 prochlorperazine suppos 5 mg... 33 PROCRIT... 6 PROCRIT... 6 PROCRIT... 7 PROCRIT... 7 PROCRIT... 7 PROCRIT... 7 PROGLYCEM... 5 PROLASTIN-C*... 76 PROLEUKIN... 6 PROLIA...7 PROMACTA*...7 PROMACTA*...7 PROMACTA*...7 PROMACTA*...7 promethazine hcl syrup 6.5 mg/5ml... 17 promethazine hcl syrup 6.5 mg/5ml... 76 propafenone hcl cap sr 1hr 5 mg... 53 propafenone hcl cap sr 1hr 35 mg... 53 propafenone hcl cap sr 1hr 5 mg... 53 propafenone hcl tab 150 mg... 53 propafenone hcl tab 5 mg... 53 propafenone hcl tab 300 mg... 53 propranolol hcl inj 1 mg/ml... 19 propranolol hcl inj 1 mg/ml... 53 propranolol hcl tab 10 mg...19 propranolol hcl tab 10 mg...53 propranolol hcl tab 0 mg...19 propranolol hcl tab 0 mg...53 propranolol hcl tab 0 mg...19 propranolol hcl tab 0 mg...53 propranolol hcl tab 80 mg...19 propranolol hcl tab 80 mg...53 propylthiouracil tab 50 mg... 67 PROQUAD... 70 protriptyline hcl tab 10 mg... 15 protriptyline hcl tab 5 mg... 15 PULMOZYME... 76 PURIXAN...6 pyrazinamide tab 500 mg... 0 pyridostigmine bromide tab 60 mg... 0 Q QUADRACEL...70 quetiapine fumarate tab 100 mg...16 quetiapine fumarate tab 100 mg...33 quetiapine fumarate tab 100 mg... quetiapine fumarate tab 00 mg...16 quetiapine fumarate tab 00 mg...33 quetiapine fumarate tab 00 mg... quetiapine fumarate tab 5 mg...16 quetiapine fumarate tab 5 mg...33 quetiapine fumarate tab 5 mg... quetiapine fumarate tab 300 mg...16 quetiapine fumarate tab 300 mg...33 quetiapine fumarate tab 300 mg... quetiapine fumarate tab 00 mg...16 quetiapine fumarate tab 00 mg...33 quetiapine fumarate tab 00 mg... quetiapine fumarate tab 50 mg...16 quetiapine fumarate tab 50 mg...33 quetiapine fumarate tab 50 mg... quinapril hcl tab 10 mg... 53 quinapril hcl tab 0 mg... 53 quinapril hcl tab 0 mg... 53 quinapril hcl tab 5 mg...53 QUINIDINE SULFATE... 53 quinidine sulfate tab 300 mg... 53 QVAR... 76 QVAR... 76 R RABAVERT... 70 RAGWITEK... 76 raloxifene hcl tab 60 mg... 65 15

ramipril cap 1.5 mg...53 ramipril cap 10 mg...53 ramipril cap.5 mg...53 ramipril cap 5 mg...53 RANEXA...53 RANEXA...53 ranitidine hcl syrup 15 mg/ml (75 mg/5ml)...61 ranitidine hcl tab 150 mg... 61 ranitidine hcl tab 300 mg... 61 RAPAMUNE... 70 RECOMBIVAX HB... 70 RECOMBIVAX HB... 70 RECOMBIVAX HB... 70 RELISTOR...61 RELISTOR...61 RELISTOR...61 REMICADE... 70 REMODULIN*...76 REMODULIN*...76 REMODULIN*...76 REMODULIN*...76 RENVELA...61 RENVELA...61 RENVELA...61 RESCRIPTOR... 37 RESCRIPTOR... 37 RESTASIS...73 RETROVIR IV INFUSION...38 REVLIMID*...6 REVLIMID*...6 REVLIMID*...6 REVLIMID*...6 REVLIMID*...6 REVLIMID*...6 REXULTI...16 REXULTI...16 REXULTI...16 REXULTI...16 REXULTI...16 REXULTI...16 REXULTI...33 REXULTI...33 REXULTI...33 REXULTI...33 REXULTI...33 REXULTI...33 REYATAZ...38 REYATAZ...38 REYATAZ...38 REYATAZ...38 REYATAZ...38 ribavirin cap 00 mg...38 ribavirin tab 00 mg...38 rifabutin cap 150 mg...0 rifampin cap 150 mg...0 rifampin cap 300 mg...0 rifampin for inj 600 mg... 0 riluzole tab 50 mg... 56 rimantadine hydrochloride tab 100 mg...38 RISPERDAL CONSTA... 33 RISPERDAL CONSTA... 33 RISPERDAL CONSTA... 33 RISPERDAL CONSTA... 3 RISPERDAL CONSTA... RISPERDAL CONSTA... RISPERDAL CONSTA... RISPERDAL CONSTA... risperidone orally disintegrating tab 0.5 mg...3 risperidone orally disintegrating tab 0.5 mg... risperidone orally disintegrating tab 0.5 mg...3 risperidone orally disintegrating tab 0.5 mg... risperidone orally disintegrating tab 1 mg...3 risperidone orally disintegrating tab 1 mg... risperidone orally disintegrating tab mg...3 risperidone orally disintegrating tab mg... risperidone orally disintegrating tab 3 mg...3 risperidone orally disintegrating tab 3 mg... risperidone orally disintegrating tab mg...3 risperidone orally disintegrating tab mg... risperidone soln 1 mg/ml... 3 risperidone soln 1 mg/ml... risperidone tab 0.5 mg...3 risperidone tab 0.5 mg... risperidone tab 0.5 mg... 3 risperidone tab 0.5 mg... risperidone tab 1 mg... 3 risperidone tab 1 mg... risperidone tab mg... 3 risperidone tab mg... risperidone tab 3 mg... 3 risperidone tab 3 mg... 16

risperidone tab mg... 3 risperidone tab mg... RITUXAN*... 7 RITUXAN*... 7 rivastigmine tartrate cap 1.5 mg... 13 rivastigmine tartrate cap 3 mg...13 rivastigmine tartrate cap.5 mg... 13 rivastigmine tartrate cap 6 mg...13 rivastigmine td patch hr 13.3 mg/hr... 13 rivastigmine td patch hr.6 mg/hr...13 rivastigmine td patch hr 9.5 mg/hr...13 rizatriptan benzoate orally disintegrating tab 10 mg...0 rizatriptan benzoate orally disintegrating tab 5 mg...19 rizatriptan benzoate tab 10 mg... 0 rizatriptan benzoate tab 5 mg... 0 ropinirole hydrochloride tab 0.5 mg...30 ropinirole hydrochloride tab 0.5 mg...30 ropinirole hydrochloride tab 1 mg... 30 ropinirole hydrochloride tab mg... 30 ropinirole hydrochloride tab 3 mg... 30 ropinirole hydrochloride tab mg... 30 ropinirole hydrochloride tab 5 mg... 30 ROTARIX...70 ROTATEQ...70 S SABRIL... 11 SABRIL... 11 SANDIMMUNE... 70 SANTYL...57 SAPHRIS...3 SAPHRIS...3 SAPHRIS...3 selegiline hcl tab 5 mg... 30 selenium sulfide lotion.5%...57 SELZENTRY...38 SELZENTRY...38 SENSIPAR...66 SENSIPAR...66 SENSIPAR...66 SEREVENT DISKUS...76 SEROMYCIN... 0 SEROQUEL XR... 16 SEROQUEL XR... 16 SEROQUEL XR... 16 SEROQUEL XR... 16 SEROQUEL XR... 16 SEROQUEL XR... 3 SEROQUEL XR... 3 SEROQUEL XR... 3 SEROQUEL XR... 3 SEROQUEL XR... 3 SEROQUEL XR... 3 SEROQUEL XR... 3 SEROQUEL XR... 3 SEROQUEL XR... 3 SEROQUEL XR... 3 sertraline hcl oral conc 0 mg/ml...16 sertraline hcl oral conc 0 mg/ml...0 sertraline hcl tab 100 mg... 16 sertraline hcl tab 100 mg... 0 sertraline hcl tab 5 mg... 16 sertraline hcl tab 5 mg... 0 sertraline hcl tab 50 mg... 16 sertraline hcl tab 50 mg... 0 sildenafil citrate tab 0 mg...76 SILENOR...77 SILENOR...77 silver sulfadiazine cream 1%...58 simvastatin tab 10 mg...53 simvastatin tab 0 mg...53 simvastatin tab 0 mg...53 simvastatin tab 5 mg... 53 simvastatin tab 80 mg...53 sirolimus tab 0.5 mg...70 sirolimus tab 1 mg... 70 sirolimus tab mg... 70 SIVEXTRO... 7 SIVEXTRO... 7 sodium chloride inj 0.5%...78 sodium chloride iv soln 0.9%... 78 sodium phenylbutyrate oral powder 3 gm/ teaspoonful...59 sodium polystyrene sulfonate oral susp 15 gm/60ml...78 sodium polystyrene sulfonate rectal susp 30 gm/10ml...78 SOLTAMOX...7 SOMATULINE DEPOT...67 SOMATULINE DEPOT...67 SOMATULINE DEPOT...67 SOMAVERT*...67 SOMAVERT*...67 SOMAVERT*...67 SOMAVERT*...67 SOMAVERT*...67 sotalol hcl (afib/afl) tab 10 mg...53 sotalol hcl (afib/afl) tab 160 mg...53 sotalol hcl (afib/afl) tab 80 mg...53 sotalol hcl tab 10 mg...53 sotalol hcl tab 160 mg...53 17

sotalol hcl tab 0 mg...53 sotalol hcl tab 80 mg...53 SOVALDI... 38 SPIRIVA HANDIHALER... 76 SPIRIVA RESPIMAT...76 spironolactone tab 100 mg...53 spironolactone tab 5 mg... 53 spironolactone tab 50 mg... 53 SPRYCEL...7 SPRYCEL...7 SPRYCEL...7 SPRYCEL...7 SPRYCEL...7 SPRYCEL...7 stavudine cap 15 mg...38 stavudine cap 0 mg...38 stavudine cap 30 mg...38 stavudine cap 0 mg...38 stavudine for oral soln 1 mg/ml...38 STIMATE... 63 STIVARGA*...7 STRATTERA...56 STRATTERA...56 STRATTERA...56 STRATTERA...56 STRATTERA...56 STRATTERA...56 STRATTERA...56 STREPTOMYCIN SULFATE... 7 STRIBILD... 38 STROMECTOL...9 SUBOXONE...3 SUBOXONE...3 SUBOXONE...3 SUBOXONE...3 sucralfate tab 1 gm...61 sulfacetamide sodium lotion 10%...58 sulfacetamide sodium ophth soln 10%... 73 sulfacetamide sodium-prednisolone ophth soln 10-0.3(0.5)%...73 SULFADIAZINE... 7 SULFAMETHOXAZOLE/ TRIMETHOPRIM...8 sulfamethoxazole-trimethoprim susp 00-0 mg/5ml... 8 sulfamethoxazole-trimethoprim tab 00-80 mg...8 sulfamethoxazole-trimethoprim tab 800-160 mg...8 sulfasalazine tab 500 mg...71 sulindac tab 150 mg... sulindac tab 150 mg...19 sulindac tab 00 mg... sulindac tab 00 mg...19 SUMATRIPTAN... 0 SUMATRIPTAN... 0 SUMATRIPTAN SUCCINATE...0 sumatriptan succinate inj 6 mg/0.5ml...0 sumatriptan succinate solution auto-injector mg/0.5ml...0 sumatriptan succinate solution auto-injector 6 mg/0.5ml...0 sumatriptan succinate solution cartridge mg/0.5ml...0 sumatriptan succinate solution cartridge 6 mg/0.5ml...0 sumatriptan succinate tab 100 mg... 0 sumatriptan succinate tab 5 mg...0 sumatriptan succinate tab 50 mg...0 SUPRAX... 8 SUPRAX... 8 SUPRAX... 8 SURMONTIL...16 SURMONTIL...16 SURMONTIL...16 SUSTIVA...38 SUSTIVA...38 SUSTIVA...38 SUTENT... 7 SUTENT... 7 SUTENT... 7 SUTENT... 7 SYLATRON... 7 SYLATRON... 7 SYLATRON... 7 SYLATRON... 7 SYLATRON... 7 SYLATRON... 7 SYLATRON... 38 SYLATRON... 38 SYLATRON... 38 SYLATRON... 38 SYLATRON... 38 SYLATRON... 38 SYLVANT...7 SYLVANT...7 SYMBICORT...76 SYMBICORT...76 SYMLINPEN 10... 5 SYMLINPEN 60...5 SYNAGIS...70 SYNAGIS...70 SYNAREL...67 SYNERCID...8 18

SYNRIBO... 7 SYPRINE...78 T TABLOID...7 tacrolimus cap 0.5 mg...70 tacrolimus cap 1 mg...70 tacrolimus cap 5 mg...70 TAFINLAR... 7 TAFINLAR... 7 TAMIFLU...38 TAMIFLU...38 TAMIFLU...38 TAMIFLU...38 tamoxifen citrate tab 10 mg...7 tamoxifen citrate tab 0 mg...7 tamsulosin hcl cap 0. mg...6 TARCEVA... 7 TARCEVA... 7 TARCEVA... 7 TARGRETIN...7 TARGRETIN...7 TASIGNA... 7 TASIGNA... 7 TAZORAC...58 TAZORAC...58 TAZORAC...58 TAZORAC...58 TECFIDERA...56 TECFIDERA...56 TECFIDERA STARTER PACK...56 TECHNIVIE... 38 TEFLARO... 8 TEFLARO... 8 TEGRETOL-XR... 11 TEKTURNA...53 TEKTURNA...53 telmisartan-hydrochlorothiazide tab 0-1.5 mg...5 telmisartan-hydrochlorothiazide tab 80-1.5 mg...5 telmisartan-hydrochlorothiazide tab 80-5 mg...5 telmisartan tab 0 mg... 53 telmisartan tab 0 mg... 5 telmisartan tab 80 mg... 5 TEMODAR... 7 TENIVAC... 71 terazosin hcl cap 10 mg...5 terazosin hcl cap 10 mg...6 terazosin hcl cap 1 mg...5 terazosin hcl cap 1 mg...6 terazosin hcl cap mg...5 terazosin hcl cap mg...6 terazosin hcl cap 5 mg...5 terazosin hcl cap 5 mg...6 terbinafine hcl tab 50 mg...18 terbutaline sulfate tab.5 mg...76 terbutaline sulfate tab 5 mg...76 terconazole vaginal cream 0.%...18 terconazole vaginal cream 0.8%...18 testosterone cypionate im inj in oil 100 mg/ ml...65 testosterone cypionate im inj in oil 00 mg/ ml...65 TETANUS/DIPHTHERIA TOXOID...71 tetrabenazine tab 1.5 mg*... 56 tetrabenazine tab 5 mg*... 56 TETRACYCLINE HCL...8 TETRACYCLINE HCL...8 THALOMID...7 THALOMID...8 THALOMID...8 THALOMID...8 THALOMID...71 THALOMID...71 THALOMID...71 THALOMID...71 theophylline tab sr 1hr 100 mg... 76 theophylline tab sr 1hr 00 mg... 77 theophylline tab sr 1hr 300 mg... 77 theophylline tab sr 1hr 50 mg... 77 theophylline tab sr hr 00 mg... 77 theophylline tab sr hr 600 mg... 77 thioridazine hcl tab 100 mg... 3 thioridazine hcl tab 10 mg... 3 thioridazine hcl tab 5 mg... 3 thioridazine hcl tab 50 mg... 3 THIOTEPA...8 thiothixene cap 10 mg...3 thiothixene cap 1 mg...3 thiothixene cap mg...3 thiothixene cap 5 mg...3 THYMOGLOBULIN...71 tiagabine hcl tab mg...11 tiagabine hcl tab mg...11 TIKOSYN...5 TIKOSYN...5 TIKOSYN...5 timolol maleate ophth gel forming soln 0.5%...73 timolol maleate ophth gel forming soln 0.5%...73 timolol maleate ophth soln 0.5%...73 19

timolol maleate ophth soln 0.5%...73 TIVICAY... 38 tizanidine hcl tab mg...35 tizanidine hcl tab mg...35 tobramycin nebu soln 300 mg/5ml... 77 tobramycin ophth soln 0.3%...73 tobramycin sulfate inj 1. gm/30ml (0 mg/ ml)...8 tobramycin sulfate inj 10 mg/ml... 8 tobramycin sulfate inj gm/50ml (0 mg/ ml)...8 tobramycin sulfate inj 80 mg/ml (0 mg/ ml)...8 tolterodine tartrate cap sr hr mg...6 tolterodine tartrate cap sr hr mg...6 topiramate sprinkle cap 15 mg...11 topiramate sprinkle cap 15 mg...0 topiramate sprinkle cap 5 mg...11 topiramate sprinkle cap 5 mg...0 topiramate tab 100 mg...11 topiramate tab 100 mg...0 topiramate tab 00 mg...11 topiramate tab 00 mg...0 topiramate tab 5 mg... 11 topiramate tab 5 mg... 0 topiramate tab 50 mg... 11 topiramate tab 50 mg... 0 topotecan hcl for inj mg... 8 TORISEL... 8 TOUJEO SOLOSTAR...5 TOVIAZ...6 TOVIAZ...6 TRACLEER*...77 TRACLEER*...77 TRADJENTA... 5 tramadol hcl tab 50 mg... tranexamic acid inj 100 mg/ml... 7 tranexamic acid tab 650 mg...7 tranylcypromine sulfate tab 10 mg... 16 TRAVATAN Z... 73 trazodone hcl tab 100 mg...16 trazodone hcl tab 150 mg...16 trazodone hcl tab 300 mg...16 trazodone hcl tab 50 mg...16 TREANDA... 8 TREANDA... 8 TREANDA... 8 TREANDA... 8 TRECATOR...0 TRELSTAR...67 TRELSTAR...67 TRELSTAR MIXJECT...67 TRELSTAR MIXJECT...67 TRELSTAR MIXJECT...67 tretinoin cap 10 mg...8 TRIAMCINOLONE ACETONIDE...58 triamcinolone acetonide cream 0.05%...58 triamcinolone acetonide cream 0.1%...58 triamcinolone acetonide cream 0.5%...58 triamcinolone acetonide oint 0.05%... 58 triamcinolone acetonide oint 0.1%...58 triamterene & hydrochlorothiazide cap 37.5-5 mg...5 triamterene & hydrochlorothiazide tab 37.5-5 mg...5 triamterene & hydrochlorothiazide tab 75-50 mg...5 TRIBENZOR... 5 TRIBENZOR... 5 TRIBENZOR... 5 TRIBENZOR... 5 TRIBENZOR... 5 trifluoperazine hcl tab 10 mg...3 trifluoperazine hcl tab 1 mg...3 trifluoperazine hcl tab mg...3 trifluoperazine hcl tab 5 mg...3 trifluridine ophth soln 1%... 73 trimethoprim tab 100 mg...8 trimipramine maleate cap 100 mg... 16 trimipramine maleate cap 5 mg... 16 trimipramine maleate cap 50 mg... 16 TRISENOX...8 TRIUMEQ...38 TRUMENBA...71 TRUVADA...38 TWINRIX...71 TYBOST... 38 TYGACIL...8 TYKERB*...8 TYPHIM VI... 71 TYSABRI*...56 TYSABRI*...71 TYZEKA...39 U ULORIC... 18 ULORIC... 18 UNITUXIN...8 ursodiol cap 300 mg...61 UVADEX... 8 UVADEX... 58 V VAGIFEM...65 130

valacyclovir hcl tab 1 gm... 39 valacyclovir hcl tab 500 mg...39 VALCHLOR*...58 VALCYTE...39 VALCYTE...39 valganciclovir hcl tab 50 mg...39 valproate sodium inj 100 mg/ml...11 valproate sodium syrup 50 mg/5ml... 11 valproic acid cap 50 mg...11 valproic acid cap 50 mg...3 vancomycin hcl cap 15 mg...8 vancomycin hcl cap 50 mg...8 vancomycin hcl for inj 1000 mg... 8 vancomycin hcl for inj 10 gm...8 vancomycin hcl for inj 5000 mg... 8 vancomycin hcl for inj 500 mg...8 VAQTA... 71 VAQTA... 71 VARIVAX...71 VECTIBIX... 8 VECTIBIX... 8 VELCADE...8 venlafaxine hcl cap sr hr 150 mg... 16 venlafaxine hcl cap sr hr 150 mg... 0 venlafaxine hcl cap sr hr 37.5 mg... 16 venlafaxine hcl cap sr hr 37.5 mg... 0 venlafaxine hcl cap sr hr 75 mg...16 venlafaxine hcl cap sr hr 75 mg...0 venlafaxine hcl tab 100 mg... 16 venlafaxine hcl tab 100 mg... 0 venlafaxine hcl tab 5 mg...16 venlafaxine hcl tab 5 mg...0 venlafaxine hcl tab 37.5 mg... 16 venlafaxine hcl tab 37.5 mg... 0 venlafaxine hcl tab 50 mg...16 venlafaxine hcl tab 50 mg...0 venlafaxine hcl tab 75 mg...16 venlafaxine hcl tab 75 mg...0 VENTOLIN HFA... 77 verapamil hcl tab 10 mg... 5 verapamil hcl tab 80 mg... 5 verapamil hcl tab cr 10 mg...5 verapamil hcl tab cr 180 mg...5 verapamil hcl tab cr 0 mg...5 VERSACLOZ... 3 VESICARE... 6 VESICARE... 6 VICTOZA... 5 VIDEX... 39 VIDEX... 39 VIEKIRA PAK...39 VIIBRYD...16 VIIBRYD...16 VIIBRYD...17 VIIBRYD...17 VIIBRYD STARTER PACK... 17 VIMPAT... 1 VIMPAT... 1 VIMPAT... 1 VIMPAT... 1 VIMPAT... 1 VIMPAT... 1 VINBLASTINE SULFATE...8 vincristine sulfate iv soln 1 mg/ml...8 vinorelbine tartrate inj 10 mg/ml...8 vinorelbine tartrate inj 50 mg/5ml (10 mg/ ml)...8 VIRACEPT... 39 VIRACEPT... 39 VIRAMUNE... 39 VIRAMUNE XR... 39 VIRAZOLE...39 VIREAD...39 VIREAD...39 VIREAD...39 VIREAD...39 VIREAD...39 VITEKTA... 39 VITEKTA... 39 VOLTAREN... VOLTAREN...19 VOLTAREN...58 voriconazole for inj 00 mg... 18 voriconazole for susp 0 mg/ml...18 voriconazole tab 00 mg... 18 voriconazole tab 50 mg...18 VOTRIENT*...8 VPRIV... 59 VYTORIN...5 VYTORIN...5 VYTORIN...5 VYTORIN...5 W warfarin sodium tab 10 mg...7 warfarin sodium tab 1 mg...7 warfarin sodium tab.5 mg...7 warfarin sodium tab mg...7 warfarin sodium tab 3 mg...7 warfarin sodium tab mg...7 warfarin sodium tab 5 mg...7 warfarin sodium tab 6 mg...7 warfarin sodium tab 7.5 mg...7 131

water for irrigation, sterile irrigation soln...78 WELCHOL...5 WELCHOL...5 WELCHOL...5 WELCHOL...5 X XALKORI*...8 XALKORI*...8 XARELTO... 7 XARELTO... 7 XARELTO... 7 XARELTO STARTER PACK...7 XENAZINE*...56 XENAZINE*...56 XGEVA...7 XIFAXAN...8 XIFAXAN...61 XOLAIR*... 77 XTANDI*...8 XYREM*...77 Y YERVOY*... 8 YERVOY*... 8 YF-VAX... 71 Z zafirlukast tab 10 mg...77 zafirlukast tab 0 mg...77 zaleplon cap 10 mg... 77 zaleplon cap 5 mg... 77 ZALTRAP...8 ZALTRAP...8 ZANOSAR... 8 ZAVESCA*...59 ZELBORAF*...8 ZEMPLAR...7 ZEMPLAR...7 ZENPEP... 59 ZENPEP... 59 ZENPEP... 59 ZENPEP... 59 ZENPEP... 59 ZENPEP... 59 ZENPEP... 59 ZETIA... 5 ZIAGEN...39 zidovudine cap 100 mg...39 zidovudine syrup 10 mg/ml...39 zidovudine tab 300 mg...39 ziprasidone hcl cap 0 mg...3 ziprasidone hcl cap 0 mg...3 ziprasidone hcl cap 0 mg...3 ziprasidone hcl cap 0 mg...3 ziprasidone hcl cap 60 mg...3 ziprasidone hcl cap 60 mg...3 ziprasidone hcl cap 80 mg...3 ziprasidone hcl cap 80 mg...3 ZOHYDRO ER... ZOHYDRO ER... ZOHYDRO ER... ZOHYDRO ER... ZOHYDRO ER... ZOHYDRO ER...3 ZOHYDRO ER...3 ZOHYDRO ER...3 ZOHYDRO ER...3 ZOHYDRO ER...3 ZOHYDRO ER...3 ZOHYDRO ER...3 zoledronic acid inj conc for iv infusion mg/5ml...7 zoledronic acid iv soln 5 mg/100ml... 7 ZOLINZA...8 zolpidem tartrate tab 10 mg... 77 zolpidem tartrate tab 5 mg...77 ZOMETA... 7 zonisamide cap 100 mg...1 zonisamide cap 5 mg...1 zonisamide cap 50 mg...1 ZORTRESS...71 ZORTRESS...71 ZORTRESS...71 ZOSTAVAX...71 ZYDELIG... 8 ZYDELIG... 8 ZYKADIA... 8 ZYPREXA RELPREVV... 3 ZYPREXA RELPREVV... 3 ZYPREXA RELPREVV... 35 ZYTIGA*... 9 ZYVOX... 8 ZYVOX... 8 ZYVOX... 8 13

For more information, please contact Blue Medicare Rx Customer Services, at 1-888-7-1 or, for TTY users, 1-888-7-15, 8 a.m. to 8 p.m. daily, or visit www.bcbsnc.com/member/medicare. This Formulary was updated on 1/01/015., SM Marks of the Blue Cross and Blue Shield Association. Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association. U338, 8/13