(List of Covered Drugs)

(List of Covered Drugs) This formulary was updated on 8/19/2015. For more recent information or other questions, please contact Florida Health Care Plans Member Services at 1-877-615-4022 or, for TTY users, TRS Relay 711. Hours of operation are 7 days a week, 8 am 8 pm, or visit www.fhcp.com Note to Members: Please review this document to make sure that it contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means Florida Health Care Plans (FHCP). When it refers to plan or our plan, it means Florida Health Care Plans (FHCP). This document includes a list of the drugs (formulary) for our plan which is current as of 8/19/2015. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front cover page. Disclaimers: You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change upon renewal of your plan. This information is available for free in other languages. Please contact our Member Services number at 1-877-615-4022 for additional information. (TTY users should call TRS Relay 711). Hours are 8 am to 8 pm, 7 days a week. Member Services also has free language interpreter services available for non-english speakers. Esta informacion esta disponible gratis en otros lenguajes. Por favor pongase en contacto con nuestro Servicios de Miembros a 1-877-615-4022 para informacion adicional. Usuarios de TTY deben de llamar TRS Relay 711. Horas son de 8 am hasta 8 pm, 7 dias de la semana. Servicios de Miembros tambien tiene servicios de interpretacion de lenguajes gratis disponible para personas que no hablan ingles. Form#: 03-310-26

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

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

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

KEY FOR COVERAGE DETAILS COLUMN PA: Prior Authorization. - This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-877-615-4022, 7 days a week, 8 am 8 pm. TTY users should call TRS Relay 711. QL: Quantity Limit. ST: Step Therapy - This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-877-615-4022, 7 days a week, 8 am 8 pm. TTY users should call TRS Relay 711. * 75% Usage Rule Prescription refills will not be covered unless at least 75% of the previous prescription has been used by the Member (based on the dosage schedule prescribed by the physician). 90% Usage Rule Prescription refills for narcotics or controlled substances will not be covered unless at least 90% of the previous prescription has been used by the Member (based on the dosage schedule prescribed by the physician). HOW TO SEARCH FOR A DRUG IN THE FLORIDA HEALTH CARE PLAN PREFERRED DRUG LIST (FORMULARY) On the FHCP Website, click on the Members tab, click on Formulary http://www.fhcp.com/members/formulary/formulary.htm Click on Commercial Formulary http://www.fhcp.com/members/plansandbenefits/commercial%20formulary.pdf When the PDF file comes up, press Control F. A pop-up search text box will appear at the top of the page. Type the drug name for which you are searching and click the right arrow in the pop-up search text box to begin the search. To close the pop-up search text box, click on the x in the pop-up search text box. Page 5 of 88

Florida Health Care Plan- FHCP Commercial Formulary Effective 8-19-15 (10:00) Antineoplastic Agents 49884072401 HYDROXYUREA CAPS 500MG T2 (HYDREA) 00054458111 MERCAPTOPURINE TABS 50MG T2 (PURINETHOL) 00054455025 METHOTREXATE TABS 2.5MG T2 (TREXALL) 00054855025 METHOTREXATE TABS 2.5MG T2 (TREXALL) Tier: T6 61703035038 METHOTREXATE SODIUM SOLN 25MG/ML T6 (12:04) Autonomic Drugs» Parasympathomimetic (Cholinergic) Agents 64679096601 BETHANECHOL CHLORIDE TABS 10MG T2 (URECHOLINE) 64679096701 BETHANECHOL CHLORIDE TABS 25MG T2 (URECHOLINE) 65162057110 BETHANECHOL CHLORIDE TABS 5MG T2 (URECHOLINE) 65162057410 BETHANECHOL CHLORIDE TABS 50MG T2 (URECHOLINE) 13668010310 DONEPEZIL HCL TABS 10MG T2 not 23mg or XR, (ARICEPT) 64679031103 DONEPEZIL HCL TABS 5MG T2 not 23mg or XR, (ARICEPT) 68382034606 DONEPEZIL HCL TBDP 5MG T2 not 23mg or XR, (ARICEPT) 68382034706 DONEPEZIL HCL TBDP 10MG T2 not 23mg or XR, (ARICEPT) 00591349730 GALANTAMINE HYDROBROMIDE CP24 16MG T2 (RAZADYNE ER) 10147089103 GALANTAMINE HYDROBROMIDE CP24 8MG T2 (RAZADYNE ER) 10147089303 GALANTAMINE HYDROBROMIDE CP24 24MG T2 (RAZADYNE ER) 00054013749 GALANTAMINE HYDROBROMIDE SOLN 4MG/ML T2 (RAZADYNE) 00378272191 GALANTAMINE HYDROBROMIDE TABS 4MG T2 (RAZADYNE) 00378272291 GALANTAMINE HYDROBROMIDE TABS 8MG T2 (RAZADYNE) 00378272391 GALANTAMINE HYDROBROMIDE TABS 12MG T2 (RAZADYNE) 00228280111 PILOCARPINE HYDROCHLORIDE TABS 5MG T2 (SALAGEN) 00115351101 PYRIDOSTIGMINE BROMIDE TABS 60MG T2 (MESTINON) 00187301330 MESTINON TIMESPAN TBCR 180MG T3 Page 6 of 88

00085049201 GUANIDINE HCL TABS 125MG T4 (12:08.08) Autonomic Drugs» Anticholinergic Agents» Antimuscarinics/Antispasmodics 42192033601 CHLORDIAZEPOXIDE HCL/CLIDINIUM BROMIDE CAPS 5MG; 2.5MG T2 (LIBRAX) 00378161001 DICYCLOMINE HCL CAPS 10MG T2 (BENTYL) 00378162001 DICYCLOMINE HCL TABS 20MG T2 (BENTYL) 00603116158 DICYCLOMINE HCL SOLN 10MG/5ML T2 (BENTYL) 00603318021 GLYCOPYRROLATE TABS 1MG T2 (ROBINUL) 00603318121 GLYCOPYRROLATE TABS 2MG T2 (ROBINUL) 24486060110 HYOMAX-SL SUBL 0.125MG T2 (LEVSIN) 39328004816 HYOSCYAMINE SULFATE ELIX 0.125MG/5ML T2 60258080215 HYOSCYAMINE SULFATE SOLN 0.125MG/ML T2 QL 43199001301 HYOSCYAMINE SULFATE TABS 0.125MG T2 (LEVSIN) 50532011310 HYOSCYAMINE SULFATE SUBL 0.125MG T2 (LEVSIN) 43199001401 HYOSCYAMINE SULFATE ER TB12 0.375MG T2 (LEVBID) 54838051180 HYOSYNE ELIX 0.125MG/5ML T2 54838050615 HYOSYNE SOLN 0.125MG/ML T2 QL 00054004544 IPRATROPIUM BROMIDE SOLN 0.03% T2 QL (ATROVENT NASAL) 00054004641 IPRATROPIUM BROMIDE SOLN 0.06% T2 QL (ATROVENT NASAL) 00487980125 IPRATROPIUM BROMIDE SOLN 0.02% T2 QL (ATROVENT NEB) 68047025201 OSCIMIN TABS 0.125MG T2 (LEVSIN) 68047025501 OSCIMIN SR TB12 0.375MG T2 (LEVBID) 00054472125 PROPANTHELINE BROMIDE TABS 15MG T2 (PRO-BANTHINE) 00597008717 ATROVENT HFA AERS 17MCG/ACT T3 QL 00597007541 SPIRIVA HANDIHALER CAPS 18MCG T3 QL 00597010061 SPIRIVA RESPIMAT AERS 2.5MCG/ACT T3 QL (12:12.04) Autonomic Drugs» Sympathomimetic (Adrenergic) Agents» alpha- Adrenergic Agonists 00115421101 MIDODRINE HCL TABS 2.5MG T2 (PRO-AMATINE) 00115422201 MIDODRINE HCL TABS 5MG T2 (PRO-AMATINE) 00115423301 MIDODRINE HCL TABS 10MG T2 (PRO-AMATINE) Page 7 of 88

(12:12.08.12) Autonomic Drugs» Sympathomimetic (Adrenergic) Agents» beta- Adrenergic Agonists» Selective beta-2-adrenergic Agonists 00603100858 ALBUTEROL SULFATE SYRP 2MG/5ML T2 (VENTOLIN) 53489017601 ALBUTEROL SULFATE TABS 2MG T2 (VENTOLIN) 53489017701 ALBUTEROL SULFATE TABS 4MG T2 (VENTOLIN) 00487950125 ALBUTEROL SULFATE NEBU 0.083% T2 QL (VENTOLIN) 50383074120 ALBUTEROL SULFATE NEBU 0.5% T2 QL (VENTOLIN) 00487990401 ALBUTEROL SULFATE NEBU 1.25MG/3ML T2 QL Only for under 2 years old, (ACCUNEB) 00591346753 ALBUTEROL SULFATE NEBU 0.63MG/3ML T2 QL Only for under 2 years old, (ACCUNEB) 49884025801 METAPROTERENOL SULFATE TABS 10MG T2 (ALUPENT) 49884025901 METAPROTERENOL SULFATE TABS 20MG T2 (ALUPENT) 00527131101 TERBUTALINE SULFATE TABS 5MG T2 (BRETHINE) 00527131801 TERBUTALINE SULFATE TABS 2.5MG T2 (BRETHINE) 00173052100 SEREVENT DISKUS AEPB 50MCG/DOSE T3 QL 00597019231 STRIVERDI RESPIMAT AERS 2.5MCG/ACT T3 QL 00173068220 VENTOLIN HFA AERS 108MCG/ACT T3 QL 00173069500 ADVAIR DISKUS AEPB 100MCG/DOSE; T4 QL 50MCG/DOSE 00173069600 ADVAIR DISKUS AEPB 250MCG/DOSE; 50MCG/DOSE 00173069700 ADVAIR DISKUS AEPB 500MCG/DOSE; 50MCG/DOSE 00173071520 ADVAIR HFA AERO 45MCG/ACT; 21MCG/ACT 00173071620 ADVAIR HFA AERO 115MCG/ACT; 21MCG/ACT 00173071720 ADVAIR HFA AERO 230MCG/ACT; 21MCG/ACT T4 T4 T4 T4 T4 QL QL QL QL QL (12:12.12) Autonomic Drugs» Sympathomimetic (Adrenergic) Agents» alpha- and beta- Adrenergic Agonists 49502050002 EPIPEN 2-PAK SOAJ 0.3MG/0.3ML T3 QL one pen per copay 49502050102 EPIPEN-JR 2-PAK SOAJ 0.15MG/0.3ML T3 QL one pen per copay Page 8 of 88

(12:16.04.04) Autonomic Drugs» Sympatholytic (Adrenergic Blocking) Agents» alpha- Adrenergic Blocking Agents» Non-selective alpha-adrenergic Blocking Agents 53489028101 ERGOLOID MESYLATES TABS 1MG T2 (HYDERGINE) (12:16.04.12) Autonomic Drugs» Sympatholytic (Adrenergic Blocking) Agents» alpha- Adrenergic Blocking Agents» Selective alpha-1-adrenergic Blocking Agents 47335095688 ALFUZOSIN HCL ER TB24 10MG T2 (UROXATRAL) 57237001401 TAMSULOSIN HCL CAPS 0.4MG T2 (FLOMAX) (12:20.04) Autonomic Drugs» Skeletal Muscle Relaxants» Centrally Acting Skeletal Muscle Relaxants 00603258221 CARISOPRODOL TABS 350MG T2 not cmpd or cod or 250mg (SOMA) 00603307921 CYCLOBENZAPRINE HCL TABS 10MG T2 not 5mg, (FLEXERIL) 31722053301 METHOCARBAMOL TABS 500MG T2 (ROBAXIN) 31722053401 METHOCARBAMOL TABS 750MG T2 (ROBAXIN) 00185003451 TIZANIDINE HCL TABS 2MG T2 (ZANAFLEX) 57664050389 TIZANIDINE HCL TABS 4MG T2 (ZANAFLEX) (12:20.12) Autonomic Drugs» Skeletal Muscle Relaxants» GABA-derivative Skeletal Muscle Relaxants 00172409660 BACLOFEN TABS 10MG T2 (LIORESAL) 00172409760 BACLOFEN TABS 20MG T2 (LIORESAL) (12:92) Autonomic Drugs» Autonomic Drugs, Miscellaneous 00009540001 NICOTROL INHALER INHA 10MG T3 PA; QL 00069046856 CHANTIX TABS 0.5MG T4 Page 9 of 88

00069046956 CHANTIX TABS 1MG T4 00069046912 CHANTIX CONTINUING MONTH PAK TABS 1MG T4 00069047102 CHANTIX STARTING MONTH PAK TABS T4 (20:04.04) Blood Formation,Coagulation & Thrombosis» Antianemia Drugs» Iron Preparations 51991063501 FEROCON CAPS 75MG; 15MCG; T2 110MG; 0.5MG; 240MG 10267046401 FEROTRINSIC CAPS 75MG; 15MCG; 110MG; 0.5MG; 240MG 63044063510 TRICON CAPS 75MG; 15MCG; 110MG; 0.5MG; 240MG T2 T2 (20:12.04.08) Blood Formation,Coagulation & Thrombosis» Antithrombotic Agents» Anticoagulants» Coumarin Derivatives Tier: T1 00555083102 WARFARIN SODIUM TABS 1MG T1 (COUMADIN) 00555083202 WARFARIN SODIUM TABS 2.5MG T1 (COUMADIN) 00555083302 WARFARIN SODIUM TABS 5MG T1 (COUMADIN) 00555083402 WARFARIN SODIUM TABS 7.5MG T1 (COUMADIN) 00555083502 WARFARIN SODIUM TABS 10MG T1 (COUMADIN) 00555086902 WARFARIN SODIUM TABS 2MG T1 (COUMADIN) 00555087402 WARFARIN SODIUM TABS 4MG T1 (COUMADIN) 00555092502 WARFARIN SODIUM TABS 3MG T1 (COUMADIN) 00555092602 WARFARIN SODIUM TABS 6MG T1 (COUMADIN) (20:12.04.12) Blood Formation,Coagulation & Thrombosis» Antithrombotic Agents» Anticoagulants» Direct Thrombin Inhibitors 00597013554 PRADAXA CAPS 150MG T3 PA 00597014954 PRADAXA CAPS 75MG T3 PA (20:12.04.14) Blood Formation,Coagulation & Thrombosis» Antithrombotic Agents» Anticoagulants» Direct Factor Xa Inhibitors Page 10 of 88

00003089321 ELIQUIS TABS 2.5MG T3 PA 00003089421 ELIQUIS TABS 5MG T3 PA 50458057890 XARELTO TABS 15MG T3 ST 50458057930 XARELTO TABS 20MG T3 ST 50458058030 XARELTO TABS 10MG T3 ST Tier: T6 60505607804 FONDAPARINUX SODIUM SOLN 2.5MG/0.5ML T6 PA (ARIXTRA) 60505607904 FONDAPARINUX SODIUM SOLN 5MG/0.4ML T6 PA (ARIXTRA) 60505608004 FONDAPARINUX SODIUM SOLN 7.5MG/0.6ML T6 PA (ARIXTRA) 60505608104 FONDAPARINUX SODIUM SOLN 10MG/0.8ML T6 PA (ARIXTRA) (20:12.04.16) Blood Formation,Coagulation & Thrombosis» Antithrombotic Agents» Anticoagulants» Heparins Tier: T6 00781313363 ENOXAPARIN SODIUM SOLN 30MG/0.3ML T6 QL (LOVENOX) 00781322464 ENOXAPARIN SODIUM SOLN 40MG/0.4ML T6 QL (LOVENOX) 00781335666 ENOXAPARIN SODIUM SOLN 60MG/0.6ML T6 QL (LOVENOX) 00781342868 ENOXAPARIN SODIUM SOLN 80MG/0.8ML T6 QL (LOVENOX) 00781350069 ENOXAPARIN SODIUM SOLN 100MG/ML T6 QL (LOVENOX) 00781361268 ENOXAPARIN SODIUM SOLN 120MG/0.8ML T6 QL (LOVENOX) 00781365569 ENOXAPARIN SODIUM SOLN 150MG/ML T6 QL (LOVENOX) (20:12.14) Blood Formation,Coagulation & Thrombosis» Antithrombotic Agents» Platelet-reducing Agents 00172524060 ANAGRELIDE HYDROCHLORIDE CAPS 1MG T2 (AGRYLIN) 00172524160 ANAGRELIDE HYDROCHLORIDE CAPS 0.5MG T2 (AGRYLIN) (20:12.18) Blood Formation,Coagulation & Thrombosis» Antithrombotic Agents» Platelet-Aggregation Inhibitors 00093206406 CILOSTAZOL TABS 100MG T2 (PLETAL) 60505252101 CILOSTAZOL TABS 50MG T2 (PLETAL) 16729021815 CLOPIDOGREL TABS 75MG T2 (PLAVIX) 57664032786 TICLOPIDINE HCL TABS 250MG T2 for aspirin intolerant patients only, (TICLID) Page 11 of 88

00597000160 AGGRENOX CP12 25MG; 200MG T3 00186077739 BRILINTA TABS 90MG T4 PA (20:16) Blood Formation,Coagulation & Thrombosis» Hematopoietic Agents Tier: T5 55513000601 ARANESP ALBUMIN FREE SOLN 200MCG/ML T5 PA 55513011101 ARANESP ALBUMIN FREE SOLN 300MCG/0.6ML T5 PA 55513019001 NEULASTA SOLN 6MG/0.6ML T5 58394000408 NEUMEGA SOLR 5MG T5 55513053010 NEUPOGEN SOLN 300MCG/ML T5 55513054610 NEUPOGEN SOLN 480MCG/1.6ML T5 00007464013 PROMACTA TABS 25MG T5 PA 00007464113 PROMACTA TABS 50MG T5 PA 00007464213 PROMACTA TABS 75MG T5 PA 00007464313 PROMACTA TABS 12.5MG T5 PA Tier: T6 55513000304 ARANESP ALBUMIN FREE SOLN 40MCG/ML T6 PA 55513000404 ARANESP ALBUMIN FREE SOLN 60MCG/ML T6 PA 55513000504 ARANESP ALBUMIN FREE SOLN 100MCG/ML T6 PA 55513005704 ARANESP ALBUMIN FREE SOLN 25MCG/0.42ML T6 PA 59676030201 PROCRIT SOLN 2000UNIT/ML T6 PA 59676030301 PROCRIT SOLN 3000UNIT/ML T6 PA 59676030401 PROCRIT SOLN 4000UNIT/ML T6 PA 59676031001 PROCRIT SOLN 10000UNIT/ML T6 PA 59676032004 PROCRIT SOLN 20000UNIT/ML T6 PA 59676034001 PROCRIT SOLN 40000UNIT/ML T6 PA (20:24) Blood Formation,Coagulation & Thrombosis» Hemorrheologic Agents 00904544861 PENTOXIFYLLINE ER TBCR 400MG T2 (TRENTAL) Page 12 of 88

(20:28.16) Blood Formation,Coagulation & Thrombosis» Antihemorrhagic Agents» Hemostatics 61748004416 AMINOCAPROIC ACID SYRP 25% T2 (AMICAR) 61748004501 AMINOCAPROIC ACID TABS 500MG T2 (AMICAR) 61748004601 AMINOCAPROIC ACID TABS 1000MG T2 (AMICAR) (24:04.04.04) Cardiovascular Drugs» Cardiac Drugs» Antiarrhythmic Agents» Class Ia Antiarrhythmics 00093312701 DISOPYRAMIDE PHOSPHATE CAPS 100MG T2 (NORPACE) 00093312901 DISOPYRAMIDE PHOSPHATE CAPS 150MG T2 (NORPACE) 53489014101 QUINIDINE GLUCONATE CR TBCR 324MG T2 (QUINAGLUTE) 00185104701 QUINIDINE SULFATE TABS 300MG T2 00185434601 QUINIDINE SULFATE TABS 200MG T2 00093917501 QUINIDINE SULFATE ER TBCR 300MG T2 00025273231 NORPACE CR CP12 100MG T4 00025274231 NORPACE CR CP12 150MG T4 (24:04.04.08) Cardiovascular Drugs» Cardiac Drugs» Antiarrhythmic Agents» Class Ib Antiarrhythmics 00093873901 MEXILETINE HCL CAPS 150MG T2 (MEXITIL) 00093874001 MEXILETINE HCL CAPS 200MG T2 (MEXITIL) 00093874101 MEXILETINE HCL CAPS 250MG T2 (MEXITIL) (24:04.04.12) Cardiovascular Drugs» Cardiac Drugs» Antiarrhythmic Agents» Class Ic Antiarrhythmics 00054001021 FLECAINIDE ACETATE TABS 50MG T2 (TAMBOCOR) 00054001121 FLECAINIDE ACETATE TABS 100MG T2 (TAMBOCOR) 65162064310 FLECAINIDE ACETATE TABS 150MG T2 (TAMBOCOR) 00591058201 PROPAFENONE HCL TABS 150MG T2 not SR, (RYTHMOL) Page 13 of 88

00603545021 PROPAFENONE HCL TABS 300MG T2 not SR, (RYTHMOL) 53489055201 PROPAFENONE HCL TABS 225MG T2 not SR, (RYTHMOL) (24:04.04.20) Cardiovascular Drugs» Cardiac Drugs» Antiarrhythmic Agents» Class III Antiarrhythmics 00093913306 AMIODARONE HCL TABS 200MG T2 (CORDARONE) 00069580060 TIKOSYN CAPS 125MCG T4 00069581060 TIKOSYN CAPS 250MCG T4 00069582060 TIKOSYN CAPS 500MCG T4 (24:04.08) Cardiovascular Drugs» Cardiac Drugs» Cardiotonic Agents 00527132410 DIGOX TABS 125MCG T2 (LANOXIN) 00527132510 DIGOX TABS 250MCG T2 (LANOXIN) 00054005746 DIGOXIN SOLN 0.05MG/ML T2 (LANOXIN) (24:04.92) Cardiovascular Drugs» Cardiac Drugs» Cardiac Drugs, Miscellaneous 61958100301 RANEXA TB12 500MG T3 PA 61958100401 RANEXA TB12 1000MG T3 PA (24:06.04) Cardiovascular Drugs» Antilipemic Agents» Bile Acid Sequestrants 49884046565 CHOLESTYRAMINE PACK 4GM T2 QL (QUESTRAN) 49884046667 CHOLESTYRAMINE LIGHT POWD 4GM/DOSE T2 QL (QUESTRAN LITE) 65597070118 WELCHOL TABS 625MG T4 PA (24:06.05) Cardiovascular Drugs» Antilipemic Agents» Cholesterol Absorption Page 14 of 88

Inhibitors 66582041431 ZETIA TABS 10MG T3 (24:06.06) Cardiovascular Drugs» Antilipemic Agents» Fibric Acid Derivatives 00378306577 FENOFIBRATE TABS 48MG T2 (TRICOR) 00378306677 FENOFIBRATE TABS 145MG T2 (TRICOR) 00115145910 FENOFIBRIC ACID DR CPDR 45MG T2 (TRILIPIX) 00115146010 FENOFIBRIC ACID DR CPDR 135MG T2 (TRILIPIX) 31722022505 GEMFIBROZIL TABS 600MG T2 (LOPID) (24:06.08) Cardiovascular Drugs» Antilipemic Agents» HMG-CoA Reductase Inhibitors Tier: T1 45963063301 LOVASTATIN TABS 10MG T1 (MEVACOR) 45963063404 LOVASTATIN TABS 20MG T1 (MEVACOR) 45963063501 LOVASTATIN TABS 40MG T1 (MEVACOR) 00378395005 ATORVASTATIN CALCIUM TABS 10MG T2 (LIPITOR) 60505257908 ATORVASTATIN CALCIUM TABS 20MG T2 (LIPITOR) 60505258008 ATORVASTATIN CALCIUM TABS 40MG T2 (LIPITOR) 60505267109 ATORVASTATIN CALCIUM TABS 80MG T2 (LIPITOR) 42291066590 PRAVASTATIN SODIUM TABS 10MG T2 (PRAVACHOL) 42291066790 PRAVASTATIN SODIUM TABS 20MG T2 (PRAVACHOL) 42291066810 PRAVASTATIN SODIUM TABS 40MG T2 (PRAVACHOL) 68180048809 PRAVASTATIN SODIUM TABS 80MG T2 (PRAVACHOL) 16729000417 SIMVASTATIN TABS 10MG T2 (ZOCOR) 16729000517 SIMVASTATIN TABS 20MG T2 (ZOCOR) 16729000617 SIMVASTATIN TABS 40MG T2 (ZOCOR) 16729000715 SIMVASTATIN TABS 80MG T2 (ZOCOR) 55111019730 SIMVASTATIN TABS 5MG T2 (ZOCOR) 00310075190 CRESTOR TABS 10MG T3 00310075290 CRESTOR TABS 20MG T3 00310075430 CRESTOR TABS 40MG T3 Page 15 of 88

00310075590 CRESTOR TABS 5MG T3 (24:06.92) Cardiovascular Drugs» Antilipemic Agents» Antilipemic Agents, Miscellaneous 00093739298 NIACIN ER TBCR 500MG T2 (NIASPAN) 00093739398 NIACIN ER TBCR 750MG T2 (NIASPAN) 00093739498 NIACIN ER TBCR 1000MG T2 (NIASPAN) 00093540189 OMEGA-3-ACID ETHYL ESTERS CAPS 375MG; 465MG; 1GM T2 (LOVAZA) (24:08.16) Cardiovascular Drugs» Hypotensive Agents» Central Alpha-Agonists Tier: T1 00228212850 CLONIDINE HCL TABS 0.2MG T1 (CATAPRES) not ER 00378015210 CLONIDINE HCL TABS 0.1MG T1 (CATAPRES) not ER 00228212910 CLONIDINE HCL TABS 0.3MG T2 (CATAPRES) not ER 00378116001 GUANFACINE HCL TABS 1MG T2 (TENEX) 00378119001 GUANFACINE HCL TABS 2MG T2 (TENEX) 00093293101 METHYLDOPA TABS 250MG T2 (ALDOMET) 16729003101 METHYLDOPA TABS 500MG T2 (ALDOMET) (24:08.20) Cardiovascular Drugs» Hypotensive Agents» Direct Vasodilators 23155000101 HYDRALAZINE HCL TABS 10MG T2 (APRESOLINE) 23155000201 HYDRALAZINE HCL TABS 25MG T2 (APRESOLINE) 50111032701 HYDRALAZINE HCL TABS 25MG T2 (APRESOLINE) 50111032801 HYDRALAZINE HCL TABS 50MG T2 (APRESOLINE) 49884025601 MINOXIDIL TABS 2.5MG T2 (LONITEN) 49884025701 MINOXIDIL TABS 10MG T2 (LONITEN) (24:08.32) Cardiovascular Drugs» Hypotensive Agents» Peripheral Adrenergic Inhibitors Page 16 of 88

00185003201 RESERPINE TABS 0.1MG T2 00185013401 RESERPINE TABS 0.25MG T2 (24:12.08) Cardiovascular Drugs» Vasodilating Agents» Nitrates and Nitrites 00143176901 ISOSORBIDE DINITRATE TABS 5MG T2 (ISORDIL) 00143177101 ISOSORBIDE DINITRATE TABS 10MG T2 (ISORDIL) 00143177201 ISOSORBIDE DINITRATE TABS 20MG T2 (ISORDIL) 49884000901 ISOSORBIDE DINITRATE TABS 30MG T2 (ISORDIL) 57664060088 ISOSORBIDE DINITRATE ER TBCR 40MG T2 (SORBITRATE) 00143223001 ISOSORBIDE MONONITRATE ER TB24 30MG T2 (IMDUR) 00143226001 ISOSORBIDE MONONITRATE ER TB24 60MG T2 (IMDUR) 13668010601 ISOSORBIDE MONONITRATE ER TB24 120MG T2 (IMDUR) 00281032630 NITRO-BID OINT 2% T2 QL 49730011130 NITROGLYCERIN PT24 0.2MG/HR T2 (MINITRAN) 49730011230 NITROGLYCERIN PT24 0.4MG/HR T2 (MINITRAN) 49730011330 NITROGLYCERIN PT24 0.6MG/HR T2 (MINITRAN) 00904064352 NITROGLYCERIN ER CPCR 2.5MG T2 00904064452 NITROGLYCERIN ER CPCR 6.5MG T2 00904064752 NITROGLYCERIN ER CPCR 9MG T2 00378910293 NITROGLYCERIN TRANSDERMAL PT24 0.1MG/HR T2 (MINITRAN) 00071041724 NITROSTAT SUBL 0.3MG T3 00071041824 NITROSTAT SUBL 0.4MG T3 00071041924 NITROSTAT SUBL 0.6MG T3 (24:12.12) Cardiovascular Drugs» Vasodilating Agents» Phosphodiesterase Type 5 Inhibitors 59762003301 SILDENAFIL CITRATE TABS 20MG T2 PA (REVATIO) (24:12.92) Cardiovascular Drugs» Vasodilating Agents» Vasodilating Agents, Miscellaneous 68382018701 DIPYRIDAMOLE TABS 25MG T2 (PERSANTINE) 68382018801 DIPYRIDAMOLE TABS 50MG T2 (PERSANTINE) Page 17 of 88

68382018901 DIPYRIDAMOLE TABS 75MG T2 (PERSANTINE) (24:20) Cardiovascular Drugs» alpha-adrenergic Blocking Agents Tier: T1 59746038306 TERAZOSIN HCL CAPS 1MG T1 (HYTRIN) 59746038406 TERAZOSIN HCL CAPS 2MG T1 (HYTRIN) 59746038506 TERAZOSIN HCL CAPS 5MG T1 (HYTRIN) 59746038606 TERAZOSIN HCL CAPS 10MG T1 (HYTRIN) 00378402101 DOXAZOSIN MESYLATE TABS 1MG T2 not XL, (CARDURA) 00378402201 DOXAZOSIN MESYLATE TABS 2MG T2 not XL, (CARDURA) 00378402401 DOXAZOSIN MESYLATE TABS 4MG T2 not XL, (CARDURA) 00378402801 DOXAZOSIN MESYLATE TABS 8MG T2 not XL, (CARDURA) 00378110101 PRAZOSIN HCL CAPS 1MG T2 (MINIPRESS) 00378230201 PRAZOSIN HCL CAPS 2MG T2 (MINIPRESS) 00378320501 PRAZOSIN HCL CAPS 5MG T2 (MINIPRESS) (24:24) Cardiovascular Drugs» beta-adrenergic Blocking Agents Tier: T1 16571043011 ATENOLOL TABS 25MG T1 (TENORMIN) 16571043111 ATENOLOL TABS 50MG T1 (TENORMIN) 16571044111 ATENOLOL TABS 100MG T1 (TENORMIN) 42291019910 CARVEDILOL TABS 25MG T1 (COREG) 43547025410 CARVEDILOL TABS 3.125MG T1 (COREG) 43547025510 CARVEDILOL TABS 6.25MG T1 (COREG) 43547025650 CARVEDILOL TABS 12.5MG T1 (COREG) 00093073310 METOPROLOL TARTRATE TABS 50MG T1 not HCT, (LOPRESSOR) 00378004710 METOPROLOL TARTRATE TABS 100MG T1 not HCT, (LOPRESSOR) 50742010701 METOPROLOL TARTRATE TABS 25MG T1 not HCT, (LOPRESSOR) 23155011001 PROPRANOLOL HCL TABS 10MG T1 not LA, (INDERAL) 23155011101 PROPRANOLOL HCL TABS 20MG T1 not LA, (INDERAL) 23155011201 PROPRANOLOL HCL TABS 40MG T1 not LA, (INDERAL) 23155011301 PROPRANOLOL HCL TABS 60MG T1 not LA, (INDERAL) 23155011401 PROPRANOLOL HCL TABS 80MG T1 not LA, (INDERAL) Page 18 of 88

65162066910 ACEBUTOLOL HCL CAPS 200MG T2 (SECTRAL) 65162067010 ACEBUTOLOL HCL CAPS 400MG T2 (SECTRAL) 00185001001 LABETALOL HCL TABS 100MG T2 (TRANDATE) 00185011701 LABETALOL HCL TABS 200MG T2 (TRANDATE) 00185011801 LABETALOL HCL TABS 300MG T2 (TRANDATE) 00054372763 PROPRANOLOL HCL SOLN 20MG/5ML T2 (INDERAL) 00054373063 PROPRANOLOL HCL SOLN 40MG/5ML T2 (INDERAL) 00093106201 SOTALOL HCL TABS 160MG T2 (BETAPACE) 00603576921 SOTALOL HCL TABS 80MG T2 (BETAPACE) 00603577021 SOTALOL HCL TABS 120MG T2 (BETAPACE) 60505008200 SOTALOL HCL TABS 240MG T2 (BETAPACE) 00007337013 COREG CR CP24 10MG T3 00007337113 COREG CR CP24 20MG T3 00007337213 COREG CR CP24 40MG T3 00007337313 COREG CR CP24 80MG T3 (24:28.08) Cardiovascular Drugs» Calcium-Channel Blocking Agents» Dihydropyridines 00591319301 AFEDITAB CR TB24 30MG T2 (ADALAT CC) 00591319401 AFEDITAB CR TB24 60MG T2 (ADALAT CC) 00378520877 AMLODIPINE BESYLATE TABS 2.5MG T2 (NORVASC) 29300024210 AMLODIPINE BESYLATE TABS 5MG T2 (NORVASC) 31722023910 AMLODIPINE BESYLATE TABS 10MG T2 (NORVASC) 00228253010 NIFEDIPINE CAPS 20MG T2 not XL, (PROCARDIA) 43386044024 NIFEDIPINE CAPS 10MG T2 not XL, (PROCARDIA) 00378039001 NIFEDIPINE ER TB24 90MG T2 (ADALAT CC) 49884067701 NIFEDIPINE ER TB24 30MG T2 (ADALAT CC) 49884067801 NIFEDIPINE ER TB24 60MG T2 (ADALAT CC) 23155010830 NIMODIPINE CAPS 30MG T4 (NIMOTOP) (24:28.92) Cardiovascular Drugs» Calcium-Channel Blocking Agents» Calcium-Channel Blocking Agents, Misc Page 19 of 88

49884082909 DILTIAZEM CD CP24 120MG T2 not 360, (CARDIZEM CD) 49884083005 DILTIAZEM CD CP24 180MG T2 not 360, (CARDIZEM CD) 49884083109 DILTIAZEM CD CP24 240MG T2 not 360, (CARDIZEM CD) 49884083209 DILTIAZEM CD CP24 300MG T2 not 360, (CARDIZEM CD) 00093031801 DILTIAZEM HCL TABS 30MG T2 not SR, (CARDIZEM) 00093031901 DILTIAZEM HCL TABS 60MG T2 not SR, (CARDIZEM) 00093032001 DILTIAZEM HCL TABS 90MG T2 not SR, (CARDIZEM) 00093032101 DILTIAZEM HCL TABS 120MG T2 not SR, (CARDIZEM) 00591034301 VERAPAMIL HCL TABS 80MG T2 (CALAN) 00591034501 VERAPAMIL HCL TABS 120MG T2 (CALAN) 00591040401 VERAPAMIL HCL TABS 40MG T2 (CALAN) 00093304401 VERAPAMIL HCL ER TBCR 180MG T2 (CALAN-SR) 60505274205 VERAPAMIL HCL ER TBCR 240MG T2 (CALAN-SR) 68462029201 VERAPAMIL HCL ER TBCR 120MG T2 (CALAN-SR) (24:32.04) Cardiovascular Drugs» Renin-Angiotensin-Aldosterone Sys Inhib» Angiotensin-Converting Enzyme Inhibitors Tier: T1 43547033710 BENAZEPRIL HCL TABS 20MG T1 not HCT, (LOTENSIN) 65162075110 BENAZEPRIL HCL TABS 5MG T1 not HCT, (LOTENSIN) 65162075210 BENAZEPRIL HCL TABS 10MG T1 not HCT, (LOTENSIN) 65162075410 BENAZEPRIL HCL TABS 40MG T1 not HCT, (LOTENSIN) 00603420921 LISINOPRIL TABS 2.5MG T1 (PRINIVIL) 00603421032 LISINOPRIL TABS 5MG T1 (PRINIVIL) 00603421132 LISINOPRIL TABS 10MG T1 (PRINIVIL) 00603421232 LISINOPRIL TABS 20MG T1 (PRINIVIL) 00603421432 LISINOPRIL TABS 40MG T1 (PRINIVIL) 68180051801 LISINOPRIL/HYDROCHLOROTHIAZIDE TABS 12.5MG; 10MG T1 (ZESTORETIC) 68180051901 LISINOPRIL/HYDROCHLOROTHIAZIDE TABS 12.5MG; 20MG T1 (ZESTORETIC) 68180052001 LISINOPRIL/HYDROCHLOROTHIAZIDE TABS 25MG; 20MG T1 (ZESTORETIC) 00093002601 ENALAPRIL MALEATE TABS 2.5MG T2 (VASOTEC) 00378105210 ENALAPRIL MALEATE TABS 5MG T2 (VASOTEC) 64679092503 ENALAPRIL MALEATE TABS 10MG T2 (VASOTEC) 64679092602 ENALAPRIL MALEATE TABS 20MG T2 (VASOTEC) 31722020090 FOSINOPRIL SODIUM TABS 10MG T2 not HCT, (MONOPRIL) 31722020190 FOSINOPRIL SODIUM TABS 20MG T2 not HCT, (MONOPRIL) 31722020290 FOSINOPRIL SODIUM TABS 40MG T2 not HCT, Page 20 of 88

(MONOPRIL) 00603421321 LISINOPRIL TABS 30MG T2 (ZESTRIL) 16252057030 RAMIPRIL CAPS 1.25MG T2 (ALTACE) 16252057101 RAMIPRIL CAPS 2.5MG T2 (ALTACE) 16252057201 RAMIPRIL CAPS 5MG T2 (ALTACE) 16252057301 RAMIPRIL CAPS 10MG T2 (ALTACE) (24:32.08) Cardiovascular Drugs» Renin-Angiotensin-Aldosterone Sys Inhib» Angiotensin II Receptor Antagonists 00603422402 LOSARTAN POTASSIUM TABS 25MG T2 (COZAAR) 00603422532 LOSARTAN POTASSIUM TABS 50MG T2 (COZAAR) 00603422602 LOSARTAN POTASSIUM TABS 100MG T2 (COZAAR) 00603422632 LOSARTAN POTASSIUM TABS 100MG T2 (COZAAR) 00781520492 LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE TABS 12.5MG; 100MG T2 (HYZAAR) 00781520692 LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE TABS 12.5MG; 50MG T2 (HYZAAR) 00781520792 LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE TABS 25MG; 100MG T2 (HYZAAR) 00054054318 TELMISARTAN TABS 40MG T2 (MICARDIS) not HCT 00378292277 TELMISARTAN TABS 80MG T2 (MICARDIS) not HCT 00054054218 TELMISARTAN TABS 20MG T2 not HCT 51660014030 VALSARTAN TABS 40MG T2 not HCT 51660014190 VALSARTAN TABS 80MG T2 not HCT 51660014290 VALSARTAN TABS 160MG T2 not HCT 51660014390 VALSARTAN TABS 320MG T2 not HCT (24:32.20) Cardiovascular Drugs» Renin-Angiotensin-Aldosterone Sys Inhib» Mineralocorticoid (Aldost) Recept Antag 53746051110 SPIRONOLACTONE TABS 25MG T2 (ALDACTONE) 53746051401 SPIRONOLACTONE TABS 50MG T2 (ALDACTONE) 00378014101 SPIRONOLACTONE/HYDROCHLOROTHIAZIDE TABS 25MG; 25MG T2 (ALDACTAZIDE) (24:32.40) Cardiovascular Drugs» Renin-Angiotensin-Aldosterone Sys Inhib» Renin Inhibitors 00078048515 TEKTURNA TABS 150MG T4 ST 00078048615 TEKTURNA TABS 300MG T4 ST Page 21 of 88

(28:08.04.24) Central Nervous System Agents» Analgesics and Antipyretics» Nonsteroidal Anti-inflammatory Agents» Salicylates 42192036510 SALSALATE TABS 500MG T2 (DISALCID) 42192036610 SALSALATE TABS 750MG T2 (DISALCID) (28:08.04.92) Central Nervous System Agents» Analgesics and Antipyretics» Nonsteroidal Anti-inflammatory Agents» Other Nonsteroidal Anti-inflammatory Agents Tier: T1 53746046405 IBUPROFEN TABS 400MG T1 (MOTRIN) 53746046601 IBUPROFEN TABS 800MG T1 (MOTRIN) 67877029505 IBUPROFEN TABS 600MG T1 (MOTRIN) 68180050103 MELOXICAM TABS 7.5MG T1 (MOBIC) 68180050203 MELOXICAM TABS 15MG T1 (MOBIC) 53746018901 NAPROXEN TABS 375MG T1 (NAPROSYN) 53746019001 NAPROXEN TABS 500MG T1 (NAPROSYN) 00378628001 DICLOFENAC SODIUM DR TBEC 50MG T2 not XR, (VOLTAREN) 16571020111 DICLOFENAC SODIUM DR TBEC 75MG T2 not XR, (VOLTAREN) 16571020310 DICLOFENAC SODIUM DR TBEC 25MG T2 not XR, (VOLTAREN) 00093089201 ETODOLAC TABS 400MG T2 (LODINE) 00093189301 ETODOLAC TABS 500MG T2 (LODINE) 51672401601 ETODOLAC CAPS 200MG T2 (LODINE) 51672401701 ETODOLAC CAPS 300MG T2 (LODINE) 00093111801 ETODOLAC ER TB24 600MG T2 (LODINE XL) 00093717201 ETODOLAC ER TB24 500MG T2 (LODINE XL) 51672405101 ETODOLAC ER TB24 400MG T2 (LODINE XL) 00378047101 FENOPROFEN CALCIUM TABS 600MG T2 (NALFON) 00093402901 INDOMETHACIN CAPS 25MG T2 (INDOCIN) 00093403001 INDOMETHACIN CAPS 50MG T2 (INDOCIN) 10702001601 INDOMETHACIN ER CPCR 75MG T2 (INDOCIN-SR) 00093319301 KETOPROFEN CAPS 50MG T2 not 25mg or ER 200mg, (ORUDIS) 00093319501 KETOPROFEN CAPS 75MG T2 not 25mg or ER 200mg, (ORUDIS) 00093031401 KETOROLAC TROMETHAMINE TABS 10MG T2 QL (TORADOL) 20 tabs per 31 days 00378215001 MECLOFENAMATE SODIUM CAPS 50MG T2 (MECLOMEN) 00378300001 MECLOFENAMATE SODIUM CAPS 100MG T2 (MECLOMEN) Page 22 of 88

00054022849 MELOXICAM SUSP 7.5MG/5ML T2 QL (MOBIC) 00185014501 NABUMETONE TABS 500MG T2 (RELAFEN) 00185014601 NABUMETONE TABS 750MG T2 (RELAFEN) 53746018801 NAPROXEN TABS 250MG T2 (NAPROSYN) 53746019401 NAPROXEN SODIUM TABS 550MG T2 (ANAPROX-DS) 00093075601 PIROXICAM CAPS 10MG T2 (FELDENE) 00093075701 PIROXICAM CAPS 20MG T2 (FELDENE) 42806001101 SULINDAC TABS 200MG T2 (CLINORIL) 42806001801 SULINDAC TABS 150MG T2 (CLINORIL) (28:08.08) Central Nervous System Agents» Analgesics and Antipyretics» Opiate Agonists 00093005001 ACETAMINOPHEN/CODEINE TABS 300MG; 15MG T2 (TYLENOL W/CODEINE) 00093035001 ACETAMINOPHEN/CODEINE TABS 300MG; 60MG T2 (TYLENOL W/CODEINE) 50383007916 ACETAMINOPHEN/CODEINE SOLN 120MG/5ML; 12MG/5ML T2 (TYLENOL W/CODEINE) 00093015001 ACETAMINOPHEN/CODEINE #3 TABS 300MG; 30MG T2 (TYLENOL W/CODEINE) 51991007401 ASCOMP/CODEINE CAPS 325MG; 50MG; 40MG; 30MG T2 (FIORINAL W/CODEINE) 00527131201 BUTALBITAL/ASPIRIN/CAFFEINE/CODEINE CAPS 325MG; 50MG; 40MG; 30MG 00054024324 CODEINE SULFATE TABS 15MG T2 00054024425 CODEINE SULFATE TABS 30MG T2 T2 (FIORINAL W/CODEINE) 00591319872 FENTANYL PT72 25MCG/HR T2 PA (DURAGESIC) 00591321272 FENTANYL PT72 50MCG/HR T2 PA (DURAGESIC) 00591321372 FENTANYL PT72 75MCG/HR T2 PA (DURAGESIC) 00591321472 FENTANYL PT72 100MCG/HR T2 PA (DURAGESIC) 00781724055 FENTANYL PT72 12MCG/HR T2 PA (DURAGESIC) 00121077216 HYDROCODONE BITARTRATE/ACETAMINOPHEN SOLN 325MG/15ML; 7.5MG/15ML 00406036501 HYDROCODONE/ACETAMINOPHEN TABS 325MG; 5MG T2 (NORCO) 00406036601 HYDROCODONE/ACETAMINOPHEN TABS 325MG; 7.5MG T2 (NORCO) 00406036701 HYDROCODONE/ACETAMINOPHEN TABS 325MG; 10MG T2 (NORCO) 00406324401 HYDROMORPHONE HCL TABS 4MG T2 (DILAUDID) 00527135301 HYDROMORPHONE HCL TABS 2MG T2 (DILAUDID) 42858030301 HYDROMORPHONE HCL TABS 8MG T2 (DILAUDID) 42858030416 HYDROMORPHONE HCL LIQD 1MG/ML T2 (DILAUDID) 00054459625 MEPERIDINE HCL TABS 100MG T2 (DEMEROL) 00555038102 MEPERIDINE HCL TABS 50MG T2 (DEMEROL) 00054355563 METHADONE HCL SOLN 5MG/5ML T2 (DOLOPHINE) 00054457025 METHADONE HCL TABS 5MG T2 (DOLOPHINE) 00054457125 METHADONE HCL TABS 10MG T2 (DOLOPHINE) 00054023525 MORPHINE SULFATE TABS 15MG T2 (MSIR) T2 QL Page 23 of 88

00054023625 MORPHINE SULFATE TABS 30MG T2 (MSIR) 00054023763 MORPHINE SULFATE SOLN 10MG/5ML T2 (ROXANOL) 00054023863 MORPHINE SULFATE SOLN 20MG/5ML T2 (ROXANOL) 00054040444 MORPHINE SULFATE SOLN 20MG/ML T2 (ROXANOL) 00574015312 MORPHINE SULFATE SOLN 100MG/5ML T2 (ROXANOL) 00378266001 MORPHINE SULFATE ER TBCR 60MG T2 (MS CONTIN) 00378266101 MORPHINE SULFATE ER TBCR 100MG T2 (MS CONTIN) 00406831501 MORPHINE SULFATE ER TBCR 15MG T2 (MS CONTIN) 42858080201 MORPHINE SULFATE ER TBCR 30MG T2 (MS CONTIN) 42858080501 MORPHINE SULFATE ER TBCR 200MG T2 (MS CONTIN) 00228287811 OXYCODONE HCL TABS 15MG T2 IR only 00378611201 OXYCODONE HCL TABS 5MG T2 IR only 00378611401 OXYCODONE HCL TABS 30MG T2 IR only 10702005601 OXYCODONE HCL TABS 10MG T2 IR only 68382079601 OXYCODONE HCL TABS 20MG T2 IR only 00406051201 OXYCODONE/ACETAMINOPHEN TABS 325MG; 5MG T2 (PERCOCET) 5mg/325mg only 00054368663 ROXICET SOLN 325MG/5ML; 5MG/5ML T2 00054465025 ROXICET TABS 325MG; 5MG T2 (PERCOCET) 5mg/325mg only 57664037718 TRAMADOL HCL TABS 50MG T2 (ULTRAM) not ER (28:08.12) Central Nervous System Agents» Analgesics and Antipyretics» Opiate Partial Agonists 00054017613 BUPRENORPHINE HCL SUBL 2MG T2 PA (SUBUTEX) 00054017713 BUPRENORPHINE HCL SUBL 8MG T2 PA (SUBUTEX) 65162041503 BUPRENORPHINE HCL/NALOXONE HCL SUBL 8MG; 2MG T2 PA (SUBOXONE) 65162041603 BUPRENORPHINE HCL/NALOXONE HCL SUBL 2MG; 0.5MG T2 PA (SUBOXONE) 12496120203 SUBOXONE FILM 2MG; 0.5MG T4 PA 12496120403 SUBOXONE FILM 4MG; 1MG T4 PA 12496120803 SUBOXONE FILM 8MG; 2MG T4 PA 12496121203 SUBOXONE FILM 12MG; 3MG T4 PA (28:08.92) Central Nervous System Agents» Analgesics and Antipyretics» Analgesics and Antipyretics, Misc 00527169501 BUTALBITAL/ACETAMINOPHEN/CAFFEINE TABS 325MG; 50MG; T2 40MG not Capsules, (FIORICET) Page 24 of 88

00527169505 BUTALBITAL/ACETAMINOPHEN/CAFFEINE TABS 325MG; 50MG; 40MG T2 not Capsules, (FIORICET) (28:10) Central Nervous System Agents» Opiate Antagonists 16729008101 NALTREXONE HCL TABS 50MG T2 tabs only, (REVIA) (28:12.04) Central Nervous System Agents» Anticonvulsants» Barbiturates 00527123101 PRIMIDONE TABS 250MG T2 (MYSOLINE) 00527130101 PRIMIDONE TABS 50MG T2 (MYSOLINE) (28:12.08) Central Nervous System Agents» Anticonvulsants» Benzodiazepines 00185006301 CLONAZEPAM TABS 0.5MG T2 (KLONOPIN) 00185006405 CLONAZEPAM TABS 1MG T2 (KLONOPIN) 00228300550 CLONAZEPAM TABS 2MG T2 (KLONOPIN) 00555009496 CLONAZEPAM ODT TBDP 0.125MG T2 (KLONOPIN) 00555009596 CLONAZEPAM ODT TBDP 0.25MG T2 (KLONOPIN) 49884030802 CLONAZEPAM ODT TBDP 0.5MG T2 (KLONOPIN) 67386031001 ONFI TABS 5MG T4 PA 67386031401 ONFI TABS 10MG T4 PA 67386031501 ONFI TABS 20MG T4 PA 67386031321 ONFI SUSP 2.5MG/ML T4 QL (28:12.12) Central Nervous System Agents» Anticonvulsants» Hydantoins 60432013108 PHENYTOIN SUSP 125MG/5ML T2 (DILANTIN) 59762521001 PHENYTOIN INFATABS CHEW 50MG T2 (DILANTIN) 00378156010 PHENYTOIN SODIUM EXTENDED CAPS 100MG T2 (DILANTIN) Page 25 of 88

00071374066 DILANTIN CAPS 30MG T3 (28:12.20) Central Nervous System Agents» Anticonvulsants» Succinimides 50111090101 ETHOSUXIMIDE CAPS 250MG T2 (ZARONTIN) 61748002416 ETHOSUXIMIDE SOLN 250MG/5ML T2 (ZARONTIN) 00071052524 CELONTIN CAPS 300MG T4 (28:12.92) Central Nervous System Agents» Anticonvulsants» Anticonvulsants, Miscellaneous 51672400501 CARBAMAZEPINE TABS 200MG T2 not XR (TEGRETOL) 51672404101 CARBAMAZEPINE CHEW 100MG T2 not XR (TEGRETOL) 51672404709 CARBAMAZEPINE SUSP 100MG/5ML T2 not XR (TEGRETOL) 55111053201 DIVALPROEX SODIUM CPSP 125MG T2 (DEPAKOTE SPRINKLES) 00245018011 DIVALPROEX SODIUM DR TBEC 125MG T2 (DEPAKOTE) 00245018111 DIVALPROEX SODIUM DR TBEC 250MG T2 (DEPAKOTE) 00245018211 DIVALPROEX SODIUM DR TBEC 500MG T2 (DEPAKOTE) 00378047205 DIVALPROEX SODIUM ER TB24 250MG T2 (DEPAKOTE ER) 10370051110 DIVALPROEX SODIUM ER TB24 500MG T2 (DEPAKOTE ER) 51525044208 FELBAMATE SUSP 600MG/5ML T2 (FELBATOL) 65162073409 FELBAMATE TABS 400MG T2 (FELBATOL) 65162073509 FELBAMATE TABS 600MG T2 (FELBATOL) 31722022101 GABAPENTIN CAPS 100MG T2 (NEURONTIN) 31722022201 GABAPENTIN CAPS 300MG T2 (NEURONTIN) 31722022305 GABAPENTIN CAPS 400MG T2 (NEURONTIN) 31722040505 GABAPENTIN TABS 600MG T2 (NEURONTIN) 31722040605 GABAPENTIN TABS 800MG T2 (NEURONTIN) 50383031147 GABAPENTIN SOLN 250MG/5ML T2 (NEURONTIN) 51672413001 LAMOTRIGINE TABS 25MG T2 not XR or ODT, (LAMICTAL) 51672413101 LAMOTRIGINE TABS 100MG T2 not XR or ODT, (LAMICTAL) 51672413204 LAMOTRIGINE TABS 150MG T2 not XR or ODT, (LAMICTAL) 51672413304 LAMOTRIGINE TABS 200MG T2 not XR or ODT, (LAMICTAL) 68382010801 LAMOTRIGINE CHEW 5MG T2 not XR or ODT, (LAMICTAL) 68382010901 LAMOTRIGINE CHEW 25MG T2 not XR or ODT, (LAMICTAL) Page 26 of 88

00054022463 LEVETIRACETAM SOLN 100MG/ML T2 (KEPPRA) 31722053612 LEVETIRACETAM TABS 250MG T2 (KEPPRA) 31722053712 LEVETIRACETAM TABS 500MG T2 (KEPPRA) 31722053960 LEVETIRACETAM TABS 1000MG T2 (KEPPRA) 68180011416 LEVETIRACETAM TABS 750MG T2 (KEPPRA) 00603418620 LEVETIRACETAM ER TB24 500MG T2 (KEPPRA ER) 68001011406 LEVETIRACETAM ER TB24 750MG T2 (KEPPRA ER) 00054009725 OXCARBAZEPINE TABS 150MG T2 (TRILEPTAL) 00054009925 OXCARBAZEPINE TABS 600MG T2 (TRILEPTAL) 51991029301 OXCARBAZEPINE TABS 300MG T2 (TRILEPTAL) 65162064978 OXCARBAZEPINE SUSP 300MG/5ML T2 (TRILEPTAL) 55253060030 TIAGABINE HYDROCHLORIDE TABS 2MG T2 (GABITRIL) 55253060130 TIAGABINE HYDROCHLORIDE TABS 4MG T2 (GABITRIL) 00093733506 TOPIRAMATE CPSP 15MG T2 (TOPAMAX) 00093733606 TOPIRAMATE CPSP 25MG T2 (TOPAMAX) 00378610591 TOPIRAMATE TABS 200MG T2 (TOPAMAX) 31722027860 TOPIRAMATE TABS 25MG T2 (TOPAMAX) 31722027960 TOPIRAMATE TABS 50MG T2 (TOPAMAX) 31722028060 TOPIRAMATE TABS 100MG T2 (TOPAMAX) 00603184158 VALPROIC ACID SYRP 250MG/5ML T2 (DEPAKENE) 50111085201 VALPROIC ACID CAPS 250MG T2 (DEPAKENE) 00378672501 ZONISAMIDE CAPS 25MG T2 (ZONEGRAN) 64679094601 ZONISAMIDE CAPS 50MG T2 (ZONEGRAN) 64679099001 ZONISAMIDE CAPS 100MG T2 (ZONEGRAN) 62856058352 BANZEL TABS 400MG T4 PA 62856058446 BANZEL SUSP 40MG/ML T4 PA 63459041630 GABITRIL TABS 16MG T4 00071102001 LYRICA SOLN 20MG/ML T4 ST 00071101268 LYRICA CAPS 25MG T4 ST; QL 00071101368 LYRICA CAPS 50MG T4 ST; QL 00071101468 LYRICA CAPS 75MG T4 ST; QL 00071101568 LYRICA CAPS 100MG T4 ST; QL 00071101668 LYRICA CAPS 150MG T4 ST; QL 00071101768 LYRICA CAPS 200MG T4 ST; QL 00071101868 LYRICA CAPS 300MG T4 ST; QL 00071101968 LYRICA CAPS 225MG T4 ST; QL 00173081059 POTIGA TABS 50MG T4 00173081259 POTIGA TABS 200MG T4 00173081359 POTIGA TABS 300MG T4 00173081459 POTIGA TABS 400MG T4 67386011101 SABRIL TABS 500MG T4 PA Page 27 of 88

67386021165 SABRIL PACK 500MG T4 PA 00131247735 VIMPAT TABS 50MG T4 PA 00131247835 VIMPAT TABS 100MG T4 PA 00131247935 VIMPAT TABS 150MG T4 PA 00131248035 VIMPAT TABS 200MG T4 PA 00131541070 VIMPAT SOLN 10MG/ML T4 PA (28:16.04.12) Central Nervous System Agents» Psychotherapeutic Agents» Antidepressants» Monoamine Oxidase Inhibitors 43386036021 PHENELZINE SULFATE TABS 15MG T2 (NARDIL) 49884003201 TRANYLCYPROMINE SULFATE TABS 10MG T2 (PARNATE) 30698003201 MARPLAN TABS 10MG T4 (28:16.04.16) Central Nervous System Agents» Psychotherapeutic Agents» Antidepressants» Selective Serotonin- and Norepinephrine-reuptake Inhibitors 63304019130 DESVENLAFAXINE ER TB24 50MG T2 63304019230 DESVENLAFAXINE ER TB24 100MG T2 13668010960 DULOXETINE HCL CPEP 20MG T2 (CYMBALTA) 13668011030 DULOXETINE HCL CPEP 30MG T2 (CYMBALTA) 13668011130 DULOXETINE HCL CPEP 60MG T2 (CYMBALTA) 23155024901 VENLAFAXINE HCL TABS 75MG T2 (EFFEXOR) 23155025001 VENLAFAXINE HCL TABS 100MG T2 (EFFEXOR) 68382001801 VENLAFAXINE HCL TABS 25MG T2 (EFFEXOR) 68382001901 VENLAFAXINE HCL TABS 37.5MG T2 (EFFEXOR) 68382002001 VENLAFAXINE HCL TABS 50MG T2 (EFFEXOR) 68382003416 VENLAFAXINE HCL ER CP24 37.5MG T2 (EFFEXOR) 68382003516 VENLAFAXINE HCL ER CP24 75MG T2 (EFFEXOR) 68382003616 VENLAFAXINE HCL ER CP24 150MG T2 (EFFEXOR) 00008121130 PRISTIQ TB24 50MG T3 00008122230 PRISTIQ TB24 100MG T3 Page 28 of 88

(28:16.04.20) Central Nervous System Agents» Psychotherapeutic Agents» Antidepressants» Selective Serotonin-reuptake Inhibitors Tier: T1 00054006258 CITALOPRAM HYDROBROMIDE SOLN 10MG/5ML T1 (CELEXA) 00378623101 CITALOPRAM HYDROBROMIDE TABS 10MG T1 (CELEXA) 00378623201 CITALOPRAM HYDROBROMIDE TABS 20MG T1 (CELEXA) 00378623301 CITALOPRAM HYDROBROMIDE TABS 40MG T1 (CELEXA) 50111064701 FLUOXETINE HCL CAPS 10MG T1 not 40mg, (PROZAC) 50111064802 FLUOXETINE HCL CAPS 20MG T1 not 40mg, (PROZAC) 00093585001 ESCITALOPRAM OXALATE TABS 5MG T2 (LEXAPRO) 00093585101 ESCITALOPRAM OXALATE TABS 10MG T2 (LEXAPRO) 00093585201 ESCITALOPRAM OXALATE TABS 20MG T2 (LEXAPRO) 54838055170 ESCITALOPRAM OXALATE SOLN 5MG/5ML T2 (LEXAPRO) 54838052340 FLUOXETINE HCL SOLN 20MG/5ML T2 (PROZAC) 62559015801 FLUVOXAMINE MALEATE TABS 25MG T2 not CR, (LUVOX) 62559015901 FLUVOXAMINE MALEATE TABS 50MG T2 not CR, (LUVOX) 62559016001 FLUVOXAMINE MALEATE TABS 100MG T2 not CR, (LUVOX) 00378700193 PAROXETINE HCL TABS 10MG T2 (PAXIL) 00378700293 PAROXETINE HCL TABS 20MG T2 (PAXIL) 00378700493 PAROXETINE HCL TABS 40MG T2 (PAXIL) 68382009906 PAROXETINE HCL TABS 30MG T2 (PAXIL) 00378200393 PAROXETINE HCL ER TB24 12.5MG T2 (PAXIL CR) 00378200493 PAROXETINE HCL ER TB24 25MG T2 (PAXIL CR) 00378200593 PAROXETINE HCL ER TB24 37.5MG T2 (PAXIL CR) 59762494001 SERTRALINE HCL CONC 20MG/ML T2 (ZOLOFT) 68180035109 SERTRALINE HCL TABS 25MG T2 not 50mg, (ZOLOFT) 68180035302 SERTRALINE HCL TABS 100MG T2 not 50mg, (ZOLOFT) 60505040205 PAXIL SUSP 10MG/5ML T4 (28:16.04.24) Central Nervous System Agents» Psychotherapeutic Agents» Antidepressants» Serotonin Modulators Tier: T1 50111043301 TRAZODONE HCL TABS 50MG T1 not 300mg, (DESYREL) 50111043402 TRAZODONE HCL TABS 100MG T1 not 300mg, (DESYREL) Page 29 of 88

00093102406 NEFAZODONE HCL TABS 100MG T2 (SERZONE) 00093102506 NEFAZODONE HCL TABS 200MG T2 (SERZONE) 00093102606 NEFAZODONE HCL TABS 250MG T2 (SERZONE) 00093711306 NEFAZODONE HCL TABS 150MG T2 (SERZONE) 00093717801 NEFAZODONE HCL TABS 50MG T2 (SERZONE) 50111044101 TRAZODONE HCL TABS 150MG T2 not 300mg, (DESYREL) 64764055030 BRINTELLIX TABS 5MG T4 PA 64764056030 BRINTELLIX TABS 10MG T4 PA 64764058030 BRINTELLIX TABS 20MG T4 PA 00456111030 VIIBRYD TABS 10MG T4 00456112030 VIIBRYD TABS 20MG T4 00456114030 VIIBRYD TABS 40MG T4 (28:16.04.28) Central Nervous System Agents» Psychotherapeutic Agents» Antidepressants» Tricyclics and Other Norepinephrine-reuptake Inhibitors Tier: T1 00603221232 AMITRIPTYLINE HCL TABS 10MG T1 (ELAVIL) 00603221321 AMITRIPTYLINE HCL TABS 25MG T1 (ELAVIL) 00603221421 AMITRIPTYLINE HCL TABS 50MG T1 (ELAVIL) 00603221521 AMITRIPTYLINE HCL TABS 75MG T1 (ELAVIL) 00603221621 AMITRIPTYLINE HCL TABS 100MG T1 (ELAVIL) 00093081001 NORTRIPTYLINE HCL CAPS 10MG T1 (PAMELOR) 00093081101 NORTRIPTYLINE HCL CAPS 25MG T1 (PAMELOR) 00603221721 AMITRIPTYLINE HCL TABS 150MG T2 (ELAVIL) 00591571301 AMOXAPINE TABS 25MG T2 (ASENDIN) 00591571401 AMOXAPINE TABS 50MG T2 (ASENDIN) 00591571501 AMOXAPINE TABS 100MG T2 (ASENDIN) 00591571630 AMOXAPINE TABS 150MG T2 (ASENDIN) 51672401106 CLOMIPRAMINE HCL CAPS 25MG T2 (ANAFRANIL) 51672401206 CLOMIPRAMINE HCL CAPS 50MG T2 (ANAFRANIL) 51672401306 CLOMIPRAMINE HCL CAPS 75MG T2 (ANAFRANIL) 00781197101 DESIPRAMINE HCL TABS 10MG T2 (NORPRAMIN) 00781197201 DESIPRAMINE HCL TABS 25MG T2 (NORPRAMIN) Page 30 of 88

00781197301 DESIPRAMINE HCL TABS 50MG T2 (NORPRAMIN) 00781197401 DESIPRAMINE HCL TABS 75MG T2 (NORPRAMIN) 00781197501 DESIPRAMINE HCL TABS 100MG T2 (NORPRAMIN) 00781197650 DESIPRAMINE HCL TABS 150MG T2 (NORPRAMIN) 00378104901 DOXEPIN HCL CAPS 10MG T2 (SINEQUAN) 00378312501 DOXEPIN HCL CAPS 25MG T2 (SINEQUAN) 00378425001 DOXEPIN HCL CAPS 50MG T2 (SINEQUAN) 00378537501 DOXEPIN HCL CAPS 75MG T2 (SINEQUAN) 00378641001 DOXEPIN HCL CAPS 100MG T2 (SINEQUAN) 49884022203 DOXEPIN HCL CAPS 150MG T2 (SINEQUAN) 54838051240 DOXEPIN HCL CONC 10MG/ML T2 (SINEQUAN) 68180031101 IMIPRAMINE HCL TABS 10MG T2 not PM, (TOFRANIL) 68180031201 IMIPRAMINE HCL TABS 25MG T2 not PM, (TOFRANIL) 68180031301 IMIPRAMINE HCL TABS 50MG T2 not PM, (TOFRANIL) 00378006001 MAPROTILINE HCL TABS 25MG T2 (LUDIOMIL) 00378008701 MAPROTILINE HCL TABS 50MG T2 (LUDIOMIL) 00378009201 MAPROTILINE HCL TABS 75MG T2 (LUDIOMIL) 00093081201 NORTRIPTYLINE HCL CAPS 50MG T2 (PAMELOR) 00093081301 NORTRIPTYLINE HCL CAPS 75MG T2 (PAMELOR) 00121067816 NORTRIPTYLINE HCL SOLN 10MG/5ML T2 (PAMELOR) 00054021025 PROTRIPTYLINE HCL TABS 5MG T2 (VIVACTIL) 00054021125 PROTRIPTYLINE HCL TABS 10MG T2 (VIVACTIL) (28:16.04.92) Central Nervous System Agents» Psychotherapeutic Agents» Antidepressants» Miscellaneous Antidepressants 00093570301 BUPROBAN TB12 150MG T2 (ZYBAN) 00378043301 BUPROPION HCL TABS 75MG T2 (WELLBUTRIN) 00378043501 BUPROPION HCL TABS 100MG T2 (WELLBUTRIN) 00185041060 BUPROPION HCL SR TB12 100MG T2 not 200mg (WELLBUTRIN SR) 00185041560 BUPROPION HCL SR TB12 150MG T2 not 200mg (WELLBUTRIN SR) 00115681108 BUPROPION HCL XL TB24 150MG T2 (WELLBUTRIN XL) 10370010203 BUPROPION HCL XL TB24 300MG T2 (WELLBUTRIN XL) 00093720656 MIRTAZAPINE TABS 15MG T2 (REMERON) 00093720756 MIRTAZAPINE TABS 30MG T2 (REMERON) 13107000130 MIRTAZAPINE TABS 7.5MG T2 (REMERON) 13107003234 MIRTAZAPINE TABS 45MG T2 (REMERON) 65862002106 MIRTAZAPINE TBDP 15MG T2 (REMERON) 65862002206 MIRTAZAPINE ODT TBDP 30MG T2 (REMERON) 65862002306 MIRTAZAPINE ODT TBDP 45MG T2 (REMERON) Page 31 of 88

(28:16.08.04) Central Nervous System Agents» Psychotherapeutic Agents» Antipsychotics» Atypical Antipsychotics 13668021630 ARIPIPRAZOLE TABS 2MG T2 PA 13668021730 ARIPIPRAZOLE TABS 5MG T2 PA (ABILIFY) 13668021890 ARIPIPRAZOLE TABS 10MG T2 PA (ABILIFY) 13668021930 ARIPIPRAZOLE TABS 15MG T2 PA (ABILIFY) 13668022030 ARIPIPRAZOLE TABS 20MG T2 PA (ABILIFY) 13668022130 ARIPIPRAZOLE TABS 30MG T2 PA (ABILIFY) 00093435901 CLOZAPINE TABS 25MG T2 (CLOZARIL) 00093440401 CLOZAPINE TABS 50MG T2 (CLOZARIL) 00093440501 CLOZAPINE TABS 200MG T2 (CLOZARIL) 00093777201 CLOZAPINE TABS 100MG T2 (CLOZARIL) 55111016330 OLANZAPINE TABS 2.5MG T2 PA (ZYPREXA) 55111016430 OLANZAPINE TABS 5MG T2 PA (ZYPREXA) 55111016530 OLANZAPINE TABS 7.5MG T2 PA (ZYPREXA) 55111016630 OLANZAPINE TABS 10MG T2 PA (ZYPREXA) 55111016730 OLANZAPINE TABS 15MG T2 PA (ZYPREXA) 55111016830 OLANZAPINE TABS 20MG T2 PA (ZYPREXA) 00093524565 OLANZAPINE ODT TBDP 5MG T2 PA 66993046930 OLANZAPINE ODT TBDP 20MG T2 (ZYPREXA ODT) 00093524665 OLANZAPINE ODT TBDP 10MG T2 PA (ZYPREXA ODT) 00378551293 OLANZAPINE ODT TBDP 15MG T2 PA (ZYPREXA ODT) 00054022125 QUETIAPINE FUMARATE TABS 100MG T2 (SEROQUEL) 00054022225 QUETIAPINE FUMARATE TABS 200MG T2 (SEROQUEL) 00054022321 QUETIAPINE FUMARATE TABS 300MG T2 (SEROQUEL) 60505313201 QUETIAPINE FUMARATE TABS 50MG T2 (SEROQUEL) 68001018100 QUETIAPINE FUMARATE TABS 400MG T2 (SEROQUEL) 68001018500 QUETIAPINE FUMARATE TABS 25MG T2 (SEROQUEL) 00603568320 RISPERIDONE TABS 0.25MG T2 (RISPERDAL) 00603568420 RISPERIDONE TABS 0.5MG T2 (RISPERDAL) 00603568520 RISPERIDONE TABS 1MG T2 (RISPERDAL) 00603568620 RISPERIDONE TABS 2MG T2 (RISPERDAL) 00603568820 RISPERIDONE TABS 4MG T2 (RISPERDAL) 00603568920 RISPERIDONE TABS 3MG T2 (RISPERDAL) 65162067384 RISPERIDONE SOLN 1MG/ML T2 (RISPERDAL) 50458060128 RISPERIDONE M-TAB TBDP 0.5MG T2 (RISPERDAL-M) 50458060228 RISPERIDONE M-TAB TBDP 1MG T2 (RISPERDAL-M) 50458060328 RISPERIDONE M-TAB TBDP 2MG T2 (RISPERDAL-M) 59762200101 ZIPRASIDONE HCL CAPS 20MG T2 PA (GEODON) 59762200201 ZIPRASIDONE HCL CAPS 40MG T2 PA (GEODON) 59762200301 ZIPRASIDONE HCL CAPS 60MG T2 PA (GEODON) 59762200401 ZIPRASIDONE HCL CAPS 80MG T2 PA (GEODON) Page 32 of 88

50458055001 INVEGA TB24 3MG T3 50458055101 INVEGA TB24 6MG T3 50458055201 INVEGA TB24 9MG T3 59148001315 ABILIFY SOLN 1MG/ML T4 PA 59148064023 ABILIFY DISCMELT TBDP 10MG T4 PA 59148064123 ABILIFY DISCMELT TBDP 15MG T4 PA 00078059520 FANAPT TABS 1MG T4 PA 00078059620 FANAPT TABS 2MG T4 PA 00078059720 FANAPT TABS 4MG T4 PA 00078059820 FANAPT TABS 6MG T4 PA 00078059920 FANAPT TABS 8MG T4 PA 00078060020 FANAPT TABS 10MG T4 PA 00078060120 FANAPT TABS 12MG T4 PA 63402030230 LATUDA TABS 20MG T4 PA 63402030430 LATUDA TABS 40MG T4 PA 63402030630 LATUDA TABS 60MG T4 PA 63402030830 LATUDA TABS 80MG T4 PA 63402031230 LATUDA TABS 120MG T4 PA 00052213903 SAPHRIS SUBL 5MG T4 PA 00052214203 SAPHRIS SUBL 10MG T4 PA 00456240260 SAPHRIS SUBL 2.5MG T4 PA 00310028060 SEROQUEL XR TB24 50MG T4 PA 00310028160 SEROQUEL XR TB24 150MG T4 PA 00310028260 SEROQUEL XR TB24 200MG T4 PA 00310028360 SEROQUEL XR TB24 300MG T4 PA 00310028460 SEROQUEL XR TB24 400MG T4 PA Tier: T6 59148004580 ABILIFY MAINTENA SUSR 300MG T6 PA 59148007280 ABILIFY MAINTENA SUSR 400MG T6 PA (28:16.08.08) Central Nervous System Agents» Psychotherapeutic Agents» Antipsychotics» Butyrophenones 00378021401 HALOPERIDOL TABS 2MG T2 (HALDOL) 00378025701 HALOPERIDOL TABS 1MG T2 (HALDOL) Page 33 of 88

00378032701 HALOPERIDOL TABS 5MG T2 (HALDOL) 00378035101 HALOPERIDOL TABS 0.5MG T2 (HALDOL) 54838050140 HALOPERIDOL CONC 2MG/ML T2 (HALDOL) 68382008001 HALOPERIDOL TABS 10MG T2 (HALDOL) 68382008101 HALOPERIDOL TABS 20MG T2 (HALDOL) (28:16.08.24) Central Nervous System Agents» Psychotherapeutic Agents» Antipsychotics» Phenothiazines 00781591401 CHLORPROMAZINE HCL TABS 25MG T2 (THORAZINE) 00781591501 CHLORPROMAZINE HCL TABS 50MG T2 (THORAZINE) 00832030000 CHLORPROMAZINE HCL TABS 10MG T2 (THORAZINE) 00832030300 CHLORPROMAZINE HCL TABS 100MG T2 (THORAZINE) 00832030400 CHLORPROMAZINE HCL TABS 200MG T2 (THORAZINE) 00574722612 COMPRO SUPP 25MG T2 QL (COMPAZINE SUPPOSITORIES) 00121065304 FLUPHENAZINE HCL CONC 5MG/ML T2 (PROLIXIN) 00121065402 FLUPHENAZINE HCL ELIX 2.5MG/5ML T2 (PROLIXIN) 00378600401 FLUPHENAZINE HCL TABS 1MG T2 (PROLIXIN) 00527178901 FLUPHENAZINE HCL TABS 2.5MG T2 (PROLIXIN) 00527179001 FLUPHENAZINE HCL TABS 5MG T2 (PROLIXIN) 00527179101 FLUPHENAZINE HCL TABS 10MG T2 (PROLIXIN) 00781104601 PERPHENAZINE TABS 2MG T2 (TRILAFON) 00781104701 PERPHENAZINE TABS 4MG T2 (TRILAFON) 00781104801 PERPHENAZINE TABS 8MG T2 (TRILAFON) 00781104901 PERPHENAZINE TABS 16MG T2 (TRILAFON) 00713013512 PROCHLORPERAZINE SUPP 25MG T2 QL (COMPAZINE SUPPOSITORIES) 00093964301 PROCHLORPERAZINE MALEATE TABS 5MG T2 (COMPAZINE) 00781502101 PROCHLORPERAZINE MALEATE TABS 10MG T2 (COMPAZINE) 00378061201 THIORIDAZINE HCL TABS 10MG T2 (MELLARIL) 00378061401 THIORIDAZINE HCL TABS 25MG T2 (MELLARIL) 00378061601 THIORIDAZINE HCL TABS 50MG T2 (MELLARIL) 00378061801 THIORIDAZINE HCL TABS 100MG T2 (MELLARIL) 00378240101 TRIFLUOPERAZINE HCL TABS 1MG T2 (STELAZINE) 00378240201 TRIFLUOPERAZINE HCL TABS 2MG T2 (STELAZINE) 00378240501 TRIFLUOPERAZINE HCL TABS 5MG T2 (STELAZINE) 00378241001 TRIFLUOPERAZINE HCL TABS 10MG T2 (STELAZINE) (28:16.08.32) Central Nervous System Agents» Psychotherapeutic Agents» Antipsychotics» Thioxanthenes Page 34 of 88

00378100101 THIOTHIXENE CAPS 1MG T2 (NAVANE) 00378200201 THIOTHIXENE CAPS 2MG T2 (NAVANE) 00378300501 THIOTHIXENE CAPS 5MG T2 (NAVANE) 00378501001 THIOTHIXENE CAPS 10MG T2 (NAVANE) (28:16.08.92) Central Nervous System Agents» Psychotherapeutic Agents» Antipsychotics» Miscellaneous Antipsychotics 00527139401 LOXAPINE CAPS 5MG T2 (LOXITANE) 00527139501 LOXAPINE CAPS 10MG T2 (LOXITANE) 00527139601 LOXAPINE CAPS 25MG T2 (LOXITANE) 00527139701 LOXAPINE CAPS 50MG T2 (LOXITANE) 57844015101 ORAP TABS 1MG T4 57844018701 ORAP TABS 2MG T4 (28:20.04) Central Nervous System Agents» Anorexigenic Agents and Respiratory and CNS Stimulants» Amphetamines 54092038101 ADDERALL XR CP24 1.25MG; 1.25MG; 1.25MG; 1.25MG T2 QL (ADDERALL XR) 54092038301 ADDERALL XR CP24 2.5MG; 2.5MG; 2.5MG; 2.5MG 54092038501 ADDERALL XR CP24 3.75MG; 3.75MG; 3.75MG; 3.75MG T2 QL (ADDERALL XR) T2 QL (ADDERALL XR) 54092038701 ADDERALL XR CP24 5MG; 5MG; 5MG; 5MG 54092038901 ADDERALL XR CP24 6.25MG; 6.25MG; 6.25MG; 6.25MG 54092039101 ADDERALL XR CP24 7.5MG; 7.5MG; 7.5MG; 7.5MG T2 QL (ADDERALL XR) T2 QL (ADDERALL XR) T2 QL (ADDERALL XR) 00555095202 DEXTROAMPHETAMINE SULFATE TABS 5MG T2 (DEXTROSTAT) 00555095302 DEXTROAMPHETAMINE SULFATE TABS 10MG T2 (DEXTROSTAT) 00406896101 DEXTROAMPHETAMINE SULFATE ER CP24 10MG T2 (DEXEDRINE CR) 00406896201 DEXTROAMPHETAMINE SULFATE ER CP24 15MG T2 (DEXEDRINE CR) 00555095402 DEXTROAMPHETAMINE SULFATE ER CP24 5MG T2 (DEXEDRINE CR) Page 35 of 88

59417010210 VYVANSE CAPS 20MG T3 QL 59417010310 VYVANSE CAPS 30MG T3 QL 59417010410 VYVANSE CAPS 40MG T3 QL 59417010510 VYVANSE CAPS 50MG T3 QL 59417010610 VYVANSE CAPS 60MG T3 QL 59417010710 VYVANSE CAPS 70MG T3 QL (28:20.32) Central Nervous System Agents» Anorexigenic Agents and Respiratory and CNS Stimulants» Respiratory and CNS Stimulants 53014059407 METADATE ER TBCR 20MG T2 (RITALIN SR) 00406114201 METHYLPHENIDATE HCL TABS 5MG T2 (RITALIN) 00406114401 METHYLPHENIDATE HCL TABS 10MG T2 (RITALIN) 00406114601 METHYLPHENIDATE HCL TABS 20MG T2 (RITALIN) 00093529201 METHYLPHENIDATE HCL CD CPCR 50MG T2 QL (METADATE CD) 00093529301 METHYLPHENIDATE HCL CD CPCR 60MG T2 QL (METADATE CD) 00093529501 METHYLPHENIDATE HCL CD CPCR 10MG T2 QL (METADATE CD) 00093529601 METHYLPHENIDATE HCL CD CPCR 20MG T2 QL (METADATE CD) 00093529701 METHYLPHENIDATE HCL CD CPCR 30MG T2 QL (METADATE CD) 00093529801 METHYLPHENIDATE HCL CD CPCR 40MG T2 QL (METADATE CD) 00591271501 METHYLPHENIDATE HCL ER TBCR 18MG T2 QL (CONCERTA) 00591271601 METHYLPHENIDATE HCL ER TBCR 27MG T2 QL (CONCERTA) 00591271701 METHYLPHENIDATE HCL ER TBCR 36MG T2 QL (CONCERTA) 00591271801 METHYLPHENIDATE HCL ER TBCR 54MG T2 QL (CONCERTA) 00406147301 METHYLPHENIDATE HCL ER TBCR 20MG T2 (RITALIN SR) 00781575401 METHYLPHENIDATE HCL SR TBCR 20MG T2 (RITALIN SR) 51991071250 METHYLPHENIDATE HYDROCHLORIDE SOLN 5MG/5ML T2 (METHYLIN) 51991071350 METHYLPHENIDATE HYDROCHLORIDE SOLN 10MG/5ML T2 (METHYLIN) (28:20.80) Central Nervous System Agents» Anorexigenic Agents and Respiratory and CNS Stimulants» Wakefulness-promoting Agents 55253080130 MODAFINIL TABS 100MG T2 PA; QL (PROVIGIL) 55253080230 MODAFINIL TABS 200MG T2 PA; QL (PROVIGIL) (28:24.04) Central Nervous System Agents» Anxiolytics, Sedatives, and Hypnotics» Barbiturates Page 36 of 88

00603516521 PHENOBARBITAL TABS 16.2MG T2 00603516621 PHENOBARBITAL TABS 32.4MG T2 00603516721 PHENOBARBITAL TABS 64.8MG T2 00603516821 PHENOBARBITAL TABS 97.2MG T2 16571033016 PHENOBARBITAL SOLN 20MG/5ML T2 (28:24.08) Central Nervous System Agents» Anxiolytics, Sedatives, and Hypnotics» Benzodiazepines 59762371901 ALPRAZOLAM TABS 0.25MG T2 not XR, (XANAX) 59762372004 ALPRAZOLAM TABS 0.5MG T2 not XR, (XANAX) 59762372103 ALPRAZOLAM TABS 1MG T2 not XR, (XANAX) 59762372203 ALPRAZOLAM TABS 2MG T2 not XR, (XANAX) 00555003302 CHLORDIAZEPOXIDE HCL CAPS 10MG T2 (LIBRIUM) 00555015802 CHLORDIAZEPOXIDE HCL CAPS 5MG T2 (LIBRIUM) 00555015902 CHLORDIAZEPOXIDE HCL CAPS 25MG T2 (LIBRIUM) 00378003001 CLORAZEPATE DIPOTASSIUM TABS 3.75MG T2 (TRANXENE) 00378004001 CLORAZEPATE DIPOTASSIUM TABS 7.5MG T2 (TRANXENE) 00378007001 CLORAZEPATE DIPOTASSIUM TABS 15MG T2 (TRANXENE) 00054318863 DIAZEPAM SOLN 1MG/ML T2 (VALIUM) 00172392570 DIAZEPAM TABS 2MG T2 (VALIUM) 00172392670 DIAZEPAM TABS 5MG T2 (VALIUM) 00172392770 DIAZEPAM TABS 10MG T2 (VALIUM) 00378441501 FLURAZEPAM HCL CAPS 15MG T2 (DALMANE) 00378443001 FLURAZEPAM HCL CAPS 30MG T2 (DALMANE) 00591024010 LORAZEPAM TABS 0.5MG T2 (ATIVAN) 00591024101 LORAZEPAM TABS 1MG T2 (ATIVAN) 00591024210 LORAZEPAM TABS 2MG T2 (ATIVAN) 00121077001 LORAZEPAM CONC 2MG/ML T2 QL (ATIVAN) 00378401001 TEMAZEPAM CAPS 15MG T2 not 7.5mg, (RESTORIL) 00378505001 TEMAZEPAM CAPS 30MG T2 not 7.5mg, (RESTORIL) 00093613732 DIAZEPAM GEL 2.5MG T4 PA; QL (DIASTAT) 00093613832 DIAZEPAM GEL 10MG T4 PA; QL (DIASTAT) 00093613932 DIAZEPAM GEL 20MG T4 PA; QL (DIASTAT) (28:24.92) Central Nervous System Agents» Anxiolytics, Sedatives, and Hypnotics» Page 37 of 88

Anxiolytics, Sedatives, & Hypnotics Misc 00093520006 BUSPIRONE HCL TABS 30MG T2 (BUSPAR) 00378114001 BUSPIRONE HCL TABS 5MG T2 (BUSPAR) 00378116591 BUSPIRONE HCL TABS 15MG T2 (BUSPAR) 00591065801 BUSPIRONE HCL TABS 10MG T2 (BUSPAR) 10702005216 HYDROXYZINE HCL SYRP 10MG/5ML T2 (ATARAX) 23155010501 HYDROXYZINE HCL TABS 10MG T2 (ATARAX) 23155010610 HYDROXYZINE HCL TABS 25MG T2 (ATARAX) 23155010701 HYDROXYZINE HCL TABS 50MG T2 (ATARAX) 50383079616 HYDROXYZINE HCL SOLN 10MG/5ML T2 (ATARAX) 00185061301 HYDROXYZINE PAMOATE CAPS 25MG T2 (VISTARIL) 00185061501 HYDROXYZINE PAMOATE CAPS 50MG T2 (VISTARIL) 00555032402 HYDROXYZINE PAMOATE CAPS 100MG T2 (VISTARIL) 23155012901 MEPROBAMATE TABS 400MG T2 (EQUANIL) 55111064001 MEPROBAMATE TABS 200MG T2 (EQUANIL) 00093526801 ZALEPLON CAPS 5MG T2 (SONATA) 00093526901 ZALEPLON CAPS 10MG T2 (SONATA) 00378530501 ZOLPIDEM TARTRATE TABS 5MG T2 (AMBIEN) 00603646921 ZOLPIDEM TARTRATE TABS 10MG T2 (AMBIEN) (28:28) Central Nervous System Agents» Antimanic Agents Tier: T1 31722054501 LITHIUM CARBONATE CAPS 300MG T1 (ESKALITH) 00054352763 LITHIUM SOLN 8MEQ/5ML T2 PA 00054252625 LITHIUM CARBONATE CAPS 150MG T2 (ESKALITH) 00054002025 LITHIUM CARBONATE ER TBCR 450MG T2 (ESKALITH-CR) 00378130001 LITHIUM CARBONATE ER TBCR 300MG T2 (LITHOBID) (28:32.28) Central Nervous System Agents» Antimigraine Agents» Selective Serotonin Agonists 00093747143 RIZATRIPTAN BENZOATE TABS 5MG T2 QL (MAXALT) 00093747243 RIZATRIPTAN BENZOATE TABS 10MG T2 QL (MAXALT) 51991036278 RIZATRIPTAN BENZOATE ODT TBDP 5MG T2 QL (MAXALT) 51991036378 RIZATRIPTAN BENZOATE ODT TBDP 10MG T2 QL (MAXALT) Page 38 of 88

00781652386 SUMATRIPTAN SOLN 20MG/ACT T2 QL (IMITREX) 00781652486 SUMATRIPTAN SOLN 5MG/ACT T2 QL (IMITREX) 00781316907 SUMATRIPTAN SUCCINATE SOAJ 4MG/0.5ML T2 QL (IMITREX) 00781317207 SUMATRIPTAN SUCCINATE SOAJ 6MG/0.5ML T2 QL (IMITREX) 55111029309 SUMATRIPTAN SUCCINATE TABS 100MG T2 QL (IMITREX) 63304009719 SUMATRIPTAN SUCCINATE TABS 25MG T2 QL (IMITREX) 63304009819 SUMATRIPTAN SUCCINATE TABS 50MG T2 QL (IMITREX) (28:32.92) Central Nervous System Agents» Antimigraine Agents» Antimigraine Agents, Miscellaneous 44183044001 ISOMETHEPTENE/DICHLORALPHENAZONE/ACETAMINOPHEN CAPS 325MG; 100MG; T2 65MG (MIDRIN) 00713016612 MIGERGOT SUPP 100MG; 2MG T2 QL (CAFERGOT) (28:36.04) Central Nervous System Agents» Antiparkinsonian Agents» Adamantanes 00121064616 AMANTADINE HCL SYRP 50MG/5ML T2 (SYMMETREL) 00832101500 AMANTADINE HCL CAPS 100MG T2 (SYMMETREL) (28:36.08) Central Nervous System Agents» Antiparkinsonian Agents» Anticholinergic Agents 00832108000 BENZTROPINE MESYLATE TABS 0.5MG T2 (COGENTIN) 00832108100 BENZTROPINE MESYLATE TABS 1MG T2 (COGENTIN) 00832108200 BENZTROPINE MESYLATE TABS 2MG T2 (COGENTIN) 00121065816 TRIHEXYPHENIDYL HCL ELIX 0.4MG/ML T2 (ARTANE) 00591533501 TRIHEXYPHENIDYL HCL TABS 2MG T2 (ARTANE) 00591533701 TRIHEXYPHENIDYL HCL TABS 5MG T2 (ARTANE) (28:36.12) Central Nervous System Agents» Antiparkinsonian Agents» COMT Inhibitors 00378908001 ENTACAPONE TABS 200MG T2 (COMTAN) (28:36.16) Central Nervous System Agents» Antiparkinsonian Agents» Dopamine Precursors Page 39 of 88

00228253810 CARBIDOPA/LEVODOPA TABS 10MG; 100MG T2 (SINEMET) 00228253950 CARBIDOPA/LEVODOPA TABS 25MG; 100MG T2 (SINEMET) 00228253996 CARBIDOPA/LEVODOPA TABS 25MG; 100MG T2 (SINEMET) 00228254010 CARBIDOPA/LEVODOPA TABS 25MG; 250MG T2 (SINEMET) 00378009401 CARBIDOPA/LEVODOPA ER TBCR 50MG; 200MG T2 (SINEMET CR) (28:36.20.04) Central Nervous System Agents» Antiparkinsonian Agents» Dopamine Receptor Agonists» Ergot-derivative Dopamine Receptor Agonists 00378709693 BROMOCRIPTINE MESYLATE CAPS 5MG T2 (PARLODEL) 00574010601 BROMOCRIPTINE MESYLATE TABS 2.5MG T2 (PARLODEL) 00093542088 CABERGOLINE TABS 0.5MG T2 (DOSTINEX) (28:36.20.08) Central Nervous System Agents» Antiparkinsonian Agents» Dopamine Receptor Agonists» Nonergot-derivative Dopamine Receptor Agonists 13668009190 PRAMIPEXOLE DIHYDROCHLORIDE TABS 0.125MG T2 not ER, (MIRAPEX) 13668009290 PRAMIPEXOLE DIHYDROCHLORIDE TABS 0.25MG T2 not ER, (MIRAPEX) 13668009390 PRAMIPEXOLE DIHYDROCHLORIDE TABS 0.5MG T2 not ER, (MIRAPEX) 13668009490 PRAMIPEXOLE DIHYDROCHLORIDE TABS 1MG T2 not ER, (MIRAPEX) 13668009590 PRAMIPEXOLE DIHYDROCHLORIDE TABS 1.5MG T2 not ER, (MIRAPEX) 13668018490 PRAMIPEXOLE DIHYDROCHLORIDE TABS 0.75MG T2 not ER, (MIRAPEX) 13811064330 ROPINIROLE ER TB24 12MG T2 (REQUIP-XL) 55111065930 ROPINIROLE ER TB24 2MG T2 (REQUIP-XL) 55111066130 ROPINIROLE ER TB24 4MG T2 (REQUIP-XL) 55111066230 ROPINIROLE ER TB24 8MG T2 (REQUIP-XL) 55111072730 ROPINIROLE ER TB24 6MG T2 (REQUIP-XL) 43547026810 ROPINIROLE HCL TABS 0.25MG T2 (REQUIP) 43547026910 ROPINIROLE HCL TABS 0.5MG T2 (REQUIP) 43547027010 ROPINIROLE HCL TABS 1MG T2 (REQUIP) 43547027110 ROPINIROLE HCL TABS 2MG T2 (REQUIP) 43547027210 ROPINIROLE HCL TABS 3MG T2 (REQUIP) 43547027310 ROPINIROLE HCL TABS 4MG T2 (REQUIP) 43547027410 ROPINIROLE HCL TABS 5MG T2 (REQUIP) (28:36.32) Central Nervous System Agents» Antiparkinsonian Agents» Monoamine Oxidase B Inhibitors Page 40 of 88

00378929091 SELEGILINE HCL TABS 5MG T2 (ELDEPRYL) 60505005501 SELEGILINE HCL CAPS 5MG T2 (ELDEPRYL) 49502090030 EMSAM PT24 6MG/24HR T4 PA; QL 49502090130 EMSAM PT24 9MG/24HR T4 PA; QL (28:40) Central Nervous System Agents» Fibromyalgia Agents 00456151060 SAVELLA TABS 100MG T3 PA 00456151260 SAVELLA TABS 12.5MG T3 PA 00456152560 SAVELLA TABS 25MG T3 PA 00456155060 SAVELLA TABS 50MG T3 PA 00456150055 SAVELLA TITRATION PACK MISC T3 PA; QL (28:92) Central Nervous System Agents» Central Nervous System Agents, Misc 00258400060 ACAMPROSATE CALCIUM DR TBEC 333MG T2 (CAMPRAL) 00228285011 GUANFACINE ER TB24 1MG T2 PA; QL (INTUNIV) 00228285111 GUANFACINE ER TB24 2MG T2 PA; QL (INTUNIV) 00228285311 GUANFACINE ER TB24 3MG T2 PA; QL (INTUNIV) 00228285511 GUANFACINE ER TB24 4MG T2 PA; QL (INTUNIV) 00456320212 NAMENDA SOLN 10MG/5ML T3 00456320560 NAMENDA TABS 5MG T3 not XR 00456321060 NAMENDA TABS 10MG T3 not XR 00456320014 NAMENDA TITRATION PAK TABS T3 00002322730 STRATTERA CAPS 10MG T3 00002322830 STRATTERA CAPS 25MG T3 00002322930 STRATTERA CAPS 40MG T3 00002323830 STRATTERA CAPS 18MG T3 00002323930 STRATTERA CAPS 60MG T3 00002325030 STRATTERA CAPS 80MG T3 00002325130 STRATTERA CAPS 100MG T3 Page 41 of 88

68727010001 XYREM SOLN 500MG/ML T4 Tier: T5 67386042201 XENAZINE TABS 25MG T5 PA (36:26) Diagnostic Agents» Diabetes Mellitus 00193146550 BAYER BREEZE 2 TEST DISC DISK T2 1 box per copay (TEST STRIPS) 00193708050 BAYER CONTOUR BLOOD GLUCOSE TEST STRIPS STRP T2 1 box per copay (TEST STRIPS) 00193731150 BAYER CONTOUR NEXT BLOOD GLUCOSE TEST STRP T2 1 box per copay (TEST STRIPS) 99073070822 FREESTYLE LITE TEST STRIPS STRP T2 1 box per copay (TEST STRIPS) (4:04.04) Antihistamine Drugs» First Generation Antihistamines» Ethanolamine Derivatives 00093030912 CLEMASTINE FUMARATE SYRP 0.67MG/5ML T2 QL syrup only, (TAVIST) (4:04.12) Antihistamine Drugs» First Generation Antihistamines» Phenothiazine Derivatives 65162052110 PROMETHAZINE HCL TABS 25MG T2 (PHENERGAN) 68001016300 PROMETHAZINE HCL TABS 50MG T2 (PHENERGAN) 68382004001 PROMETHAZINE HCL TABS 12.5MG T2 (PHENERGAN) 45802075830 PROMETHAZINE HCL SUPP 12.5MG T2 QL (PHENERGAN) 45802075930 PROMETHAZINE HCL SUPP 25MG T2 QL (PHENERGAN) 00603158458 PROMETHAZINE HCL PLAIN SYRP 6.25MG/5ML T2 QL (PHENERGAN) 00603158758 PROMETHAZINE VC PLAIN SYRP 5MG/5ML; 6.25MG/5ML T2 QL (PHENERGAN) 00713013212 PROMETHEGAN SUPP 50MG T2 QL (PHENERGAN) 00713052612 PROMETHEGAN SUPP 25MG T2 QL (PHENERGAN) 00713053612 PROMETHEGAN SUPP 12.5MG T2 QL (PHENERGAN) (4:04.92) Antihistamine Drugs» First Generation Antihistamines» Derivatives, Page 42 of 88

Miscellaneous 60258085001 CYPROHEPTADINE HCL TABS 4MG T2 (PERIACTIN) 00472140016 CYPROHEPTADINE HCL SYRP 2MG/5ML T2 QL (PERIACTIN) (4:08) Antihistamine Drugs» Second Generation Antihistamines 00955102590 LEVOCETIRIZINE DIHYDROCHLORIDE TABS 5MG T2 (XYZAL) (40:08) Electrolytic, Caloric, and Water Balance» Alkalinizing Agents 60258000316 CYTRA-K SOLN 334MG/5ML; T2 1100MG/5ML 44523041501 POTASSIUM CITRATE ER TBCR 15MEQ T2 00245007011 POTASSIUM CITRATE ER TBCR 540MG T2 (UROCIT-K) 00245007111 POTASSIUM CITRATE ER TBCR 1080MG T2 (UROCIT-K) (40:10) Electrolytic, Caloric, and Water Balance» Ammonia Detoxicants 60432003816 GENERLAC SOLN 10GM/15ML T2 QL limit 1pt/31days, (CEPHULAC) 00054348663 LACTULOSE SOLN 10GM/15ML T2 QL limit 1pt/31days, (CEPHULAC) 50383079516 LACTULOSE SOLN 10GM/15ML T2 QL limit 1pt/31days, (CEPHULAC) 62592049603 BUPHENYL TABS 500MG T4 PA (40:12) Electrolytic, Caloric, and Water Balance» Replacement Preparations 00054008826 CALCIUM ACETATE CAPS 667MG T2 (PHOSLO) 00603417016 K-EFFERVESCENT TBEF 25MEQ T2 (K-LYTE) 00904272046 K-VESCENT TBEF 25MEQ T2 (K-LYTE) 00245003530 KLOR-CON PACK 20MEQ T2 00245004011 KLOR-CON 8 TBCR 8MEQ T2 (SLOW-K) Page 43 of 88

64980010401 PHOSPHA 250 NEUTRAL TABS 155MG; 852MG; 130MG T2 00395230016 POTASSIUM CHLORIDE LIQD 10% T2 00603153658 POTASSIUM CHLORIDE LIQD 20% T2 00904100716 POTASSIUM CHLORIDE SOLN 10% T2 76439034330 POTASSIUM CHLORIDE PACK 20MEQ T2 00781152601 POTASSIUM CHLORIDE CR TBCR 10MEQ T2 (K-TAB) 00781151601 POTASSIUM CHLORIDE SR TBCR 8MEQ T2 (SLOW-K) 00486111101 K-PHOS TABS 500MG T4 (40:18.18) Electrolytic, Caloric, and Water Balance» Ion-removing Agents» Potassiumremoving Agents 00574200416 KIONEX POWD T2 (KAYEXELATE) 46287000601 SPS SUSP 15GM/60ML T2 (KAYEXALATE) (40:18.19) Electrolytic, Caloric, and Water Balance» Ion-removing Agents» Phosphateremoving Agents 54092025290 FOSRENOL CHEW 500MG T4 PA 54092025390 FOSRENOL CHEW 750MG T4 PA 54092025490 FOSRENOL CHEW 1000MG T4 PA (40:28.08) Electrolytic, Caloric, and Water Balance» Diuretics» Loop Diuretics Tier: T1 00093423201 BUMETANIDE TABS 0.5MG T1 (BUMEX) 00093423301 BUMETANIDE TABS 1MG T1 (BUMEX) 00603373921 FUROSEMIDE TABS 20MG T1 (LASIX) 00603374021 FUROSEMIDE TABS 40MG T1 (LASIX) 00603374128 FUROSEMIDE TABS 80MG T1 (LASIX) 00093423401 BUMETANIDE TABS 2MG T2 (BUMEX) 00054329450 FUROSEMIDE SOLN 10MG/ML T2 (LASIX) Page 44 of 88

00054329863 FUROSEMIDE SOLN 8MG/ML T2 (LASIX) 25010021515 EDECRIN TABS 25MG T3 sulfa allergic pts (40:28.16) Electrolytic, Caloric, and Water Balance» Diuretics» Potassium-sparing Diuretics Tier: T1 00378253710 TRIAMTERENE/HYDROCHLOROTHIAZIDE CAPS 25MG; 37.5MG T1 (DYAZIDE) 00378135505 TRIAMTERENE/HYDROCHLOROTHIAZIDE TABS 50MG; 75MG T1 (MAXZIDE) 60505265605 TRIAMTERENE/HYDROCHLOROTHIAZIDE TABS 25MG; 37.5MG T1 (MAXZIDE) 00574029201 AMILORIDE HCL TABS 5MG T2 (MIDAMOR) (40:28.20) Electrolytic, Caloric, and Water Balance» Diuretics» Thiazide Diuretics Tier: T1 29300012810 HYDROCHLOROTHIAZIDE TABS 25MG T1 (HYDRODIURIL) 29300012901 HYDROCHLOROTHIAZIDE TABS 50MG T1 (HYDRODIURIL) 00143121001 CHLOROTHIAZIDE TABS 500MG T2 (DIURIL) 00378015001 CHLOROTHIAZIDE TABS 250MG T2 (DIURIL) 00378016001 METHYCLOTHIAZIDE TABS 5MG T2 (ENDURON) 65649031112 DIURIL SUSP 250MG/5ML T4 (40:28.24) Electrolytic, Caloric, and Water Balance» Diuretics» Thiazide-like Diuretics 00378021301 CHLORTHALIDONE TABS 50MG T2 (HYGROTON) 00378022201 CHLORTHALIDONE TABS 25MG T2 (HYGROTON) 00378617201 METOLAZONE TABS 2.5MG T2 (ZAROXOLYN) Page 45 of 88

00378617401 METOLAZONE TABS 10MG T2 (ZAROXOLYN) 65580064471 METOLAZONE TABS 5MG T2 (ZAROXOLYN) (40:40) Electrolytic, Caloric, and Water Balance» Uricosuric Agents 00378015601 PROBENECID TABS 500MG T2 (BENEMID) 64980014901 PROBENECID/COLCHICINE TABS 0.5MG; 500MG T2 (COLBENEMID) (48:08) Respiratory Tract Agents» Antitussives 67877010501 BENZONATATE CAPS 100MG T2 (TESSALON PERLES) 67877010601 BENZONATATE CAPS 200MG T2 (TESSALON PERLES) 00603107558 CHERATUSSIN AC SYRP 10MG/5ML; 100MG/5ML 00603107858 CHERATUSSIN DAC SOLN 10MG/5ML; 100MG/5ML; 30MG/5ML 16571030116 GUAIFENESIN DAC SOLN 10MG/5ML; 100MG/5ML; 30MG/5ML 00121077516 GUAIFENESIN/CODEINE SOLN 10MG/5ML; 100MG/5ML 50383004316 HYDROCODONE BITARTRATE/HOMATROPINE METHYLBROMIDE SYRP 1.5MG/5ML; 5MG/5ML T2 QL (ROBITUSSIN AC) T2 QL (ROBITUSSIN DAC) T2 QL (ROBITUSSIN DAC) T2 QL (ROBITUSSIN AC) T2 QL (HYCODAN) 00472103016 HYDROMET SYRP 1.5MG/5ML; 5MG/5ML 00603158858 PROMETHAZINE VC/CODEINE SYRP 10MG/5ML; 5MG/5ML; 6.25MG/5ML 00603158658 PROMETHAZINE-DM SYRP 15MG/5ML; 6.25MG/5ML 00603158558 PROMETHAZINE/CODEINE SYRP 10MG/5ML; 6.25MG/5ML T2 QL (HYCODAN) T2 QL (PHENERGAN) T2 QL (PHENERGAN) T2 QL (PHENERGAN) (48:10.24) Respiratory Tract Agents» Anti-inflammatory Agents» Leukotriene Modifiers 00054025913 MONTELUKAST SODIUM TABS 10MG T2 (SINGULAIR) 00093742456 MONTELUKAST SODIUM CHEW 4MG T2 (SINGULAIR) 00093742556 MONTELUKAST SODIUM CHEW 5MG T2 (SINGULAIR) 55111076303 MONTELUKAST SODIUM PACK 4MG T2 (SINGULAIR) 10122090212 ZYFLO CR TB12 600MG T4 Page 46 of 88

(48:10.32) Respiratory Tract Agents» Anti-inflammatory Agents» Mast-cell Stabilizers 66993047096 CROMOLYN SODIUM CONC 100MG/5ML T2 (GASTROCROM) 00172640649 CROMOLYN SODIUM NEBU 20MG/2ML T2 (INTAL NEB) (48:24) Respiratory Tract Agents» Mucolytic Agents Tier: T6 50242010040 PULMOZYME SOLN 1MG/ML T6 PA; QL (48:48) Respiratory Tract Agents» Vasodilating Agents Tier: T5 66215010106 TRACLEER TABS 62.5MG T5 PA 66215010206 TRACLEER TABS 125MG T5 PA (48:92) Respiratory Tract Agents» Respiratory Tract Agents, Miscellaneous Tier: T5 50242004062 XOLAIR SOLR 150MG T5 PA (52:02) Eye, Ear, Nose & Throat Preparations» Antiallergic Agents 51525029403 AZELASTINE HCL SOLN 0.1% T2 QL (ASTELIN) 61314023710 CROMOLYN SODIUM SOLN 4% T2 QL (CROLOM) 60505084505 OLOPATADINE HCL SOLN 0.6% T2 QL (PATANASE) 00065034510 ALOMIDE SOLN 0.1% T3 QL (52:04.04) Eye, Ear, Nose & Throat Preparations» Anti-infectives» Antibacterials 48102000735 BACITRACIN OINT 500UNIT/GM T2 QL (POLYSPORIN Page 47 of 88

OPHTHALMIC) 24208055555 BACITRACIN/POLYMYXIN B OINT 500UNIT/GM; 10000UNIT/GM T2 QL (POLYSPORIN OPHTHALMIC) 61314065605 CIPROFLOXACIN HCL SOLN 0.3% T2 QL (CILOXAN) 00574402435 ERYTHROMYCIN OINT 5MG/GM T2 QL (ILOTYCIN) 17478007035 ERYTHROMYCIN OINT 5MG/GM T2 QL (ILOTYCIN) 17478028435 GENTAK OINT 0.3% T2 QL (GARAMYCIN) 00574410235 GENTAMICIN SULFATE OINT 0.3% T2 QL (GARAMYCIN) 24208058060 GENTAMICIN SULFATE SOLN 0.3% T2 QL (GARAMYCIN) 16571015050 LEVOFLOXACIN SOLN 0.5% T2 QL (LEVAQUIN) 48102000635 NEO-POLYCIN OINT 400UNIT/GM; 3.5MG/GM; 10000UNIT/GM T2 QL (NEOSPORIN OPHTH OINT) 24208078055 NEOMYCIN/BACITRACIN/POLYMYXIN OINT 400UNIT/GM; 5MG/GM; 10000UNIT/GM T2 QL (NEOSPORIN OPHTH OINT) 24208079062 NEOMYCIN/POLYMYXIN/GRAMICIDIN SOLN 0.025MG/ML; 1.75MG/ML; 10000UNIT/ML T2 QL (NEOSPORIN OPHTH SOLN) 24208041005 OFLOXACIN SOLN 0.3% T2 QL (FLOXIN) 24208043405 OFLOXACIN SOLN 0.3% T2 QL (OCUFLOX) 60758090810 POLYMYXIN B SULFATE/TRIMETHOPRIM SULFATE SOLN 10000UNIT/ML; 0.1% T2 QL (POLYTRIM) 24208067004 SODIUM SULFACETAMIDE SOLN 10% T2 QL (BLEPH-10) 61314070101 SULFACETAMIDE SODIUM SOLN 10% T2 QL (BLEPH-10) 17478029010 TOBRAMYCIN SULFATE SOLN 0.3% T2 QL (TOBREX) 00065065435 CILOXAN OINT 0.3% T3 QL 00065000603 MOXEZA SOLN 0.5% T3 QL 00065064435 TOBREX OINT 0.3% T3 QL 00065401303 VIGAMOX SOLN 0.5% T3 QL (52:04.16) Eye, Ear, Nose & Throat Preparations» Anti-infectives» Antifungals 00065064515 NATACYN SUSP 5% T3 QL (52:04.20) Eye, Ear, Nose & Throat Preparations» Anti-infectives» Antivirals 61314004475 TRIFLURIDINE SOLN 1% T2 QL (VIROPTIC) Page 48 of 88

24208053535 ZIRGAN GEL 0.15% T4 QL (52:04.92) Eye, Ear, Nose & Throat Preparations» Anti-infectives» EENT Anti-infectives, Miscellaneous 00116200116 CHLORHEXIDINE GLUCONATE SOLN 0.12% T2 QL (PERIDEX) (52:08.08) Eye, Ear, Nose & Throat Preparations» Anti-inflammatory Agents» Corticosteroids 24208072002 DEXAMETHASONE SODIUM PHOSPHATE SOLN 0.1% T2 QL (DECADRON OPHTH) 24208034425 FLUNISOLIDE SOLN 0.025% T2 QL (NASALIDE) 65162070294 FLUOCINOLONE ACETONIDE OIL 0.01% T2 QL (DERMOTIC) 60758088005 FLUOROMETHOLONE SUSP 0.1% T2 QL (FML) 00054327099 FLUTICASONE PROPIONATE SUSP 50MCG/ACT T2 QL (FLONASE) 48102000535 NEO-POLYCIN HC OINT 400UNIT/GM; 1%; 3.5MG/GM; 10000UNIT/GM T2 QL (CORTISPORIN) 24208078555 NEOMYCIN/POLYMYXIN/BACITRACIN/HYDROCORTISONE OINT 400UNIT/GM; 1%; 0.5%; 10000UNIT/GM T2 QL (CORTISPORIN) 24208079535 NEOMYCIN/POLYMYXIN/DEXAMETHASONE OINT 0.1%; 3.5MG/GM; 10000UNIT/GM T2 QL (MAXITROL) 24208083060 NEOMYCIN/POLYMYXIN/DEXAMETHASONE SUSP 0.1%; 3.5MG/ML; 10000UNIT/ML 24208063110 NEOMYCIN/POLYMYXIN/HC SOLN 1%; 3.5MG/ML; 10000UNIT/ML 61314064175 NEOMYCIN/POLYMYXIN/HYDROCORTISONE SUSP 1%; 3.5MG/ML; 10000UNIT/ML T2 QL (MAXITROL) T2 QL (CORTISPORIN) T2 QL (CORTISPORIN) 60758011905 PREDNISOLONE ACETATE SUSP 1% T2 QL (PRED-FORTE) 24208071510 PREDNISOLONE SODIUM PHOSPHATE SOLN 1% T2 QL (INFLAMASE FORTE) 24208031705 SULFACETAMIDE SODIUM/PREDNISOLONE SODIUM PHOSPHATE SOLN 0.23%; 10% T2 QL (VASOCIDIN) 24208029505 TOBRAMYCIN/DEXAMETHASONE SUSP 0.1%; 0.3% T2 QL (TOBRADEX) 11980002205 BLEPHAMIDE SUSP 0.2%; 10% T3 QL Page 49 of 88

00023031304 BLEPHAMIDE S.O.P. OINT 0.2%; 10% T3 QL 00065853302 CIPRODEX SUSP 0.3%; 0.1% T3 QL 00023031604 FML OINT 0.1% T3 QL 11980022805 FML FORTE SUSP 0.25% T3 QL 11980017405 PRED MILD SUSP 0.12% T3 QL 00023010605 PRED-G SUSP 0.3%; 1% T3 QL 00023006604 PRED-G S.O.P. OINT 0.3%; 0.6% T3 QL 00065064835 TOBRADEX OINT 0.1%; 0.3% T3 QL 24208035305 ALREX SUSP 0.2% T4 QL 24208029905 LOTEMAX SUSP 0.5% T4 QL 24208044335 LOTEMAX OINT 0.5% T4 QL 24208050307 LOTEMAX GEL 0.5% T4 QL (52:08.20) Eye, Ear, Nose & Throat Preparations» Anti-inflammatory Agents» Nonsteroidal Anti-inflammatory Agents 16571010150 DICLOFENAC SODIUM SOLN 0.1% T2 QL (VOLTAREN) 24208031425 FLURBIPROFEN SODIUM SOLN 0.03% T2 QL (OCUFEN) 17478020810 KETOROLAC TROMETHAMINE SOLN 0.4% T2 QL (ACULAR LS) 17478020910 KETOROLAC TROMETHAMINE SOLN 0.5% T2 QL (ACULAR) 00065175007 ILEVRO SUSP 0.3% T3 QL 00065000203 NEVANAC SUSP 0.1% T3 QL (52:08.92) Eye, Ear, Nose & Throat Preparations» Anti-inflammatory Agents» EENT Anti-inflammatory Agents, Misc 00023916330 RESTASIS EMUL 0.05% T3 QL (52:16) Eye, Ear, Nose & Throat Preparations» Local Anesthetics 24208056162 ANTIPYRINE/BENZOCAINE SOLN 5.4%; 1.4% T2 QL (AURALGAN) 00603139364 LIDOCAINE VISCOUS SOLN 2% T2 QL (XYLOCAINE) Page 50 of 88

17478026312 PROPARACAINE HCL SOLN 0.5% T2 QL (ALCAINE) (52:24) Eye, Ear, Nose & Throat Preparations» Mydriatics 24208075006 ATROPINE SULFATE SOLN 1% T2 QL 24208082555 ATROPINE SULFATE OINT 1% T2 QL 24208073506 CYCLOPENTOLATE HCL SOLN 1% T2 QL (CYCLOGYL) 59390019205 HOMATROPAIRE SOLN 5% T2 (ISOPTO HOMATROPINE) 17478010112 TROPICAMIDE SOLN 0.5% T2 QL 24208058564 TROPICAMIDE SOLN 1% T2 QL 00065039515 CYCLOGYL SOLN 0.5% T3 QL 00998031105 ISOPTO HOMATROPINE SOLN 2% T3 QL (52:40.04) Eye, Ear, Nose & Throat Preparations» Antiglaucoma Agents» alpha- Adrenergic Agonists 24208041105 BRIMONIDINE TARTRATE SOLN 0.2% T2 QL not P, (ALPHAGAN) (52:40.08) Eye, Ear, Nose & Throat Preparations» Antiglaucoma Agents» beta- Adrenergic Blocking Agents Tier: T1 24208050505 LEVOBUNOLOL HCL SOLN 0.5% T1 QL (BETAGAN) 60758080105 TIMOLOL MALEATE SOLN 0.5% T1 QL not XE, (TIMOPTIC) 60758080205 TIMOLOL MALEATE SOLN 0.25% T1 QL not XE, (TIMOPTIC) 61314024501 BETAXOLOL HCL SOLN 0.5% T2 QL (KERLONE) 24208036705 CARTEOLOL HCL SOLN 1% T2 QL (OCUPRESS) 60758006305 LEVOBUNOLOL HCL SOLN 0.25% T2 QL (BETAGAN) 00065024610 BETOPTIC-S SUSP 0.25% T3 QL Page 51 of 88

(52:40.12) Eye, Ear, Nose & Throat Preparations» Antiglaucoma Agents» Carbonic Anhydrase Inhibitors 00527105001 ACETAZOLAMIDE TABS 250MG T2 (DIAMOX) 51672402201 ACETAZOLAMIDE TABS 125MG T2 (DIAMOX) 23155012001 ACETAZOLAMIDE ER CP12 500MG T2 (DIAMOX CR) 50383023210 DORZOLAMIDE HCL SOLN 2% T2 QL (TRUSOPT) 50383023310 DORZOLAMIDE HCL/TIMOLOL MALEATE SOLN 22.3MG/ML; 6.8MG/ML T2 QL (COSOPT) 00781107101 METHAZOLAMIDE TABS 50MG T2 (NEPTAZANE) 48102010001 METHAZOLAMIDE TABS 25MG T2 (NEPTAZANE) (52:40.20) Eye, Ear, Nose & Throat Preparations» Antiglaucoma Agents» Miotics 61314020315 PILOCARPINE HCL SOLN 1% T2 QL 61314020415 PILOCARPINE HCL SOLN 2% T2 QL 61314020615 PILOCARPINE HCL SOLN 4% T2 QL 00998022315 ISOPTO CARBACHOL SOLN 1.5% T3 QL 00998022515 ISOPTO CARBACHOL SOLN 3% T3 QL 00046106505 PHOSPHOLINE IODIDE SOLR 0.125% T3 (52:40.28) Eye, Ear, Nose & Throat Preparations» Antiglaucoma Agents» Prostaglandin Analogs 17478062512 LATANOPROST SOLN 0.005% T2 QL (XALATAN) 00065026025 TRAVATAN Z SOLN 0.004% T3 QL (52:92) Eye, Ear, Nose & Throat Preparations» EENT Drugs, Miscellaneous Page 52 of 88

50383088915 ACETIC ACID SOLN 2% T2 QL (VOSOL) 24208061577 ACETIC ACID/ALUMINUM ACETATE SOLN 2% T2 QL (DOMBORO OTIC) 17478071610 APRACLONIDINE SOLN 0.5% T2 QL (IOPIDINE) (56:08) Gastrointestinal Drugs» Antidiarrhea Agents 00054319446 DIPHENOXYLATE/ATROPINE LIQD 0.025MG/5ML; T2 2.5MG/5ML (LOMOTIL) 00378041501 DIPHENOXYLATE/ATROPINE TABS 0.025MG; 2.5MG T2 (LOMOTIL) 00093031101 LOPERAMIDE HCL CAPS 2MG T2 (IMODIUM) (56:12) Gastrointestinal Drugs» Cathartics and Laxatives 52268010001 GOLYTELY SOLR 236GM; 2.97GM; T2 QL 6.74GM; 5.86GM; 22.74GM (56:14) Gastrointestinal Drugs» Cholelitholytic Agents 00527132601 URSODIOL CAPS 300MG T2 (ACTIGALL) (56:16) Gastrointestinal Drugs» Digestants 39822020501 PANCRELIPASE CPEP 27000UNIT; T2 5000UNIT; 17000UNIT 00032120370 CREON CPEP 15000UNIT; T3 3000UNIT; 9500UNIT 00032120601 CREON CPEP 30000UNIT; 6000UNIT; 19000UNIT 00032121201 CREON CPEP 60000UNIT; 12000UNIT; 38000UNIT T3 T3 Page 53 of 88

00032122401 CREON CPEP 120000UNIT; 24000UNIT; 76000UNIT 00032301613 CREON CPEP 180000UNIT; 36000UNIT; 114000UNIT 50458034260 PANCREAZE CPEP 43750UNIT; 10500UNIT; 25000UNIT 50458034360 PANCREAZE CPEP 70000UNIT; 16800UNIT; 40000UNIT 50458034660 PANCREAZE CPEP 61000UNIT; 21000UNIT; 37000UNIT T3 T3 T3 T3 T3 42865010002 ZENPEP CPEP 27000UNIT; T4 5000UNIT; 17000UNIT 42865010102 ZENPEP CPEP 55000UNIT; 10000UNIT; 34000UNIT 42865010202 ZENPEP CPEP 82000UNIT; 15000UNIT; 51000UNIT 42865010302 ZENPEP CPEP 109000UNIT; 20000UNIT; 68000UNIT 42865010502 ZENPEP CPEP 136000UNIT; 25000UNIT; 85000UNIT T4 T4 T4 T4 (56:22.08) Gastrointestinal Drugs» Antiemetics» Antihistamines 53489037601 TRIMETHOBENZAMIDE HCL CAPS 300MG T2 (TIGAN) (56:22.20) Gastrointestinal Drugs» Antiemetics» 5-HT3 Receptor Antagonists 45963053830 ONDANSETRON HCL TABS 4MG T2 QL (ZOFRAN) 45963053930 ONDANSETRON HCL TABS 8MG T2 QL (ZOFRAN) 65162069179 ONDANSETRON HCL SOLN 4MG/5ML T2 QL (ZOFRAN) 00781523864 ONDANSETRON ODT TBDP 4MG T2 QL (ZOFRAN) 00781523964 ONDANSETRON ODT TBDP 8MG T2 QL (ZOFRAN) (56:22.92) Gastrointestinal Drugs» Antiemetics» Antiemetics, Miscellaneous Page 54 of 88

00591359160 DRONABINOL CAPS 2.5MG T2 PA; QL (MARINOL) 00591359260 DRONABINOL CAPS 5MG T2 PA; QL (MARINOL) 49884086902 DRONABINOL CAPS 10MG T2 PA; QL (MARINOL) Tier: T6 00006046102 EMEND CAPS 80MG T6 PA 00006046410 EMEND CAPS 40MG T6 PA 00006386203 EMEND CAPS T6 PA (56:28.12) Gastrointestinal Drugs» Antiulcer Agents and Acid Suppressants» Histamine H2-Antagonists Tier: T1 53746025301 RANITIDINE HCL TABS 150MG T1 (ZANTAC) 53746025401 RANITIDINE HCL TABS 300MG T1 (ZANTAC) 00093819201 CIMETIDINE TABS 300MG T2 (TAGAMET) 00093820401 CIMETIDINE TABS 400MG T2 (TAGAMET) 00378054101 CIMETIDINE TABS 800MG T2 (TAGAMET) 50383005008 CIMETIDINE HCL SOLN 300MG/5ML T2 (TAGAMET) 00121072716 RANITIDINE HCL SYRP 75MG/5ML T2 (ZANTAC) 50383005116 RANITIDINE HCL SYRP 15MG/ML T2 (ZANTAC) (56:28.28) Gastrointestinal Drugs» Antiulcer Agents and Acid Suppressants» Prostaglandins 59762500701 MISOPROSTOL TABS 100MCG T2 (CYTOTEC) 59762500801 MISOPROSTOL TABS 200MCG T2 (CYTOTEC) (56:28.32) Gastrointestinal Drugs» Antiulcer Agents and Acid Suppressants» Protectants 00093221001 SUCRALFATE TABS 1GM T2 (CARAFATE) Page 55 of 88

58914017014 CARAFATE SUSP 1GM/10ML T3 (56:28.36) Gastrointestinal Drugs» Antiulcer Agents and Acid Suppressants» Protonpump Inhibitors 00781214731 LANSOPRAZOLE CPDR 15MG T2 not Solutab,(PREVACID) 55111039990 LANSOPRAZOLE CPDR 30MG T2 not Solutab,(PREVACID) 55111015810 OMEPRAZOLE CPDR 20MG T2 (PRILOSEC) 62175011432 OMEPRAZOLE CPDR 10MG T2 (PRILOSEC) 00008060601 PANTOPRAZOLE SODIUM TBEC 20MG T2 (PROTONIX) 00008060701 PANTOPRAZOLE SODIUM TBEC 40MG T2 (PROTONIX) 00008084402 PROTONIX PACK 40MG T3 (56:32) Gastrointestinal Drugs» Prokinetic Agents Tier: T1 00093220310 METOCLOPRAMIDE HCL TABS 10MG T1 (REGLAN) 00093220401 METOCLOPRAMIDE HCL TABS 5MG T2 (REGLAN) 00121057616 METOCLOPRAMIDE HCL SOLN 5MG/5ML T2 (REGLAN) (56:36) Gastrointestinal Drugs» Anti-inflammatory Agents 00054029513 ALOSETRON HYDROCHLORIDE TABS 0.5MG T2 PA 00054029613 ALOSETRON HYDROCHLORIDE TABS 1MG T2 PA 00054007928 BALSALAZIDE DISODIUM CAPS 750MG T2 (COLAZAL) 45802009851 MESALAMINE ENEM 4GM T2 QL (ROWASA) 00430078327 ASACOL HD TBEC 800MG T3 58914050156 CANASA SUPP 1000MG T3 QL Page 56 of 88

68220016010 DIPENTUM CAPS 250MG T4 (56:92) Gastrointestinal Drugs» GI Drugs, Miscellaneous 00456120130 LINZESS CAPS 145MCG T3 PA 00456120230 LINZESS CAPS 290MCG T3 PA 00310196930 MOVANTIK TABS 12.5MG T3 PA 00310197030 MOVANTIK TABS 25MG T3 PA 64764008060 AMITIZA CAPS 8MCG T4 PA 64764024060 AMITIZA CAPS 24MCG T4 PA (64:00) Heavy Metal Antagonists 25010070515 CUPRIMINE CAPS 250MG T3 Tier: T5 00078046815 EXJADE TBSO 125MG T5 PA 00078046915 EXJADE TBSO 250MG T5 PA 00078047015 EXJADE TBSO 500MG T5 PA (68:04) Hormones and Synthetic Substitutes» Adrenals 00378715501 BUDESONIDE CP24 3MG T2 PA (ENTOCORT EC) 00093681573 BUDESONIDE SUSP 0.25MG/2ML T2 PA; QL (PULMICORT RESPULES) 00093681673 BUDESONIDE SUSP 0.5MG/2ML T2 PA; QL (PULMICORT RESPULES) 00143120201 CORTISONE ACETATE TABS 25MG T2 (CORTONE) 00054317763 DEXAMETHASONE SOLN 0.5MG/5ML T2 (DECADRON) 00054417925 DEXAMETHASONE TABS 0.5MG T2 (DECADRON) 00054418025 DEXAMETHASONE TABS 0.75MG T2 (DECADRON) 00054418125 DEXAMETHASONE TABS 1MG T2 (DECADRON) Page 57 of 88

00054418225 DEXAMETHASONE TABS 1.5MG T2 (DECADRON) 00054418425 DEXAMETHASONE TABS 4MG T2 (DECADRON) 00054418625 DEXAMETHASONE TABS 6MG T2 (DECADRON) 60432046608 DEXAMETHASONE ELIX 0.5MG/5ML T2 (DECADRON) 00054317644 DEXAMETHASONE INTENSOL CONC 1MG/ML T2 QL (DECADRON) 00115703301 FLUDROCORTISONE ACETATE TABS 0.1MG T2 (FLORINEF) 00603389919 HYDROCORTISONE TABS 5MG T2 (CORTEF) 00603390021 HYDROCORTISONE TABS 10MG T2 (CORTEF) 54505033310 HYDROCORTISONE TABS 20MG T2 (CORTEF) 00603459321 METHYLPREDNISOLONE TABS 4MG T2 (MEDROL) 59746000314 METHYLPREDNISOLONE TABS 16MG T2 (MEDROL) 00603459315 METHYLPREDNISOLONE DOSE PACK TABS 4MG T2 (MEDROL) 00093611887 PREDNISOLONE SOLN 15MG/5ML T2 (PRELONE) 50383004004 PREDNISOLONE SODIUM PHOSPHATE SOLN 5MG/5ML T2 (ORAPRED) 00054001729 PREDNISONE TABS 10MG T2 (DELTASONE) 00054001829 PREDNISONE TABS 20MG T2 (DELTASONE) 00054001925 PREDNISONE TABS 50MG T2 (DELTASONE) 00054372263 PREDNISONE SOLN 5MG/5ML T2 (DELTASONE) 00054472825 PREDNISONE TABS 5MG T2 (DELTASONE) 00054474125 PREDNISONE TABS 1MG T2 (DELTASONE) 00054474225 PREDNISONE TABS 2.5MG T2 (DELTASONE) 00173087410 ARNUITY ELLIPTA AEPB 100MCG/ACT T3 00173087610 ARNUITY ELLIPTA AEPB 200MCG/ACT T3 00085433301 ASMANEX HFA AERO 100MCG/ACT T3 00085433401 ASMANEX HFA AERO 200MCG/ACT T3 00085134101 ASMANEX TWISTHALER 120 METERED DOSES AEPB 220MCG/INH T3 QL 00085134103 ASMANEX TWISTHALER 30 METERED DOSES AEPB 220MCG/INH T3 QL 00085146102 ASMANEX TWISTHALER 30 METERED DOSES AEPB 110MCG/INH T3 QL 00085134102 ASMANEX TWISTHALER 60 METERED DOSES AEPB 220MCG/INH T3 QL 00173060002 FLOVENT DISKUS AEPB 50MCG/BLIST T3 QL 00173060102 FLOVENT DISKUS AEPB 250MCG/BLIST T3 QL 00173060202 FLOVENT DISKUS AEPB 100MCG/BLIST T3 QL 00173071820 FLOVENT HFA AERO 44MCG/ACT T3 QL 00173071920 FLOVENT HFA AERO 110MCG/ACT T3 QL 00173072020 FLOVENT HFA AERO 220MCG/ACT T3 QL 00186199004 PULMICORT SUSP 1MG/2ML T3 PA; QL Page 58 of 88

00173085910 BREO ELLIPTA AEPB 100MCG/INH; 25MCG/INH 00085461001 DULERA AERO 5MCG/ACT; 200MCG/ACT 00085720601 DULERA AERO 5MCG/ACT; 100MCG/ACT 59310020240 QVAR AERS 40MCG/ACT T4 QL 59310020480 QVAR AERS 80MCG/ACT T4 QL T4 T4 T4 QL QL 00186037020 SYMBICORT AERO 160MCG/ACT; 4.5MCG/ACT 00186037220 SYMBICORT AERO 80MCG/ACT; 4.5MCG/ACT T4 T4 QL QL (68:08) Hormones and Synthetic Substitutes» Androgens 00832008600 ANDROXY TABS 10MG T2 (HALOTESTIN) 00527136801 DANAZOL CAPS 100MG T2 (DANOCRINE) 00527136906 DANAZOL CAPS 200MG T2 (DANOCRINE) 00527139201 DANAZOL CAPS 50MG T2 (DANOCRINE) 00591354401 OXANDROLONE TABS 2.5MG T2 PA (OXANDRIN) 00832112005 TESTOSTERONE GEL 1% T2 QL (TESTIM) 68220005510 ANADROL-50 TABS 50MG T4 PA 00051846230 ANDROGEL GEL 40.5MG/2.5GM T4 QL only 1.62% Tier: T6 00143972601 TESTOSTERONE CYPIONATE SOLN 200MG/ML T6 QL (68:12) Hormones and Synthetic Substitutes» Contraceptives 00555904358 APRI TABS 0.15MG; 30MCG T2 (DESOGEN) 00555071558 CAMILA TABS 0.35MG T2 (MICRONOR) 00555904958 CRYSELLE-28 TABS 30MCG; 0.3MG T2 (LO-OVRAL) 00603752117 CYCLAFEM 1/35 TABS 35MCG; 1MG T2 not 7/7/7, (ORTHO NOVUM) 00555904758 ENPRESSE-28 TABS T2 (TRIPHASIL) 00555034458 ERRIN TABS 0.35MG T2 (MICRONOR) 00093542358 GIANVI TABS 3MG; 0.02MG T2 (YAZ) 00603760817 GILDESS FE 1.5/30 TABS 30MCG; 75MG; 1.5MG 00603760917 GILDESS FE 1/20 TABS 20MCG; 75MG; 1MG Page 59 of 88 T2 T2 (LOESTRIN-FE) (LOESTRIN-FE)

00555902858 JUNEL FE 1.5/30 TABS 30MCG; 75MG; 1.5MG 00555902658 JUNEL FE 1/20 TABS 20MCG; 75MG; 1MG T2 T2 (LOESTRIN-FE) (LOESTRIN-FE) 00555906458 KELNOR 1/35 TABS 35MCG; 1MG T2 (DEMULEN) 52544027928 LEVORA 0.15/30-28 TABS 30MCG; 0.15MG T2 (NORDETTE) 52544084728 LOW-OGESTREL TABS 30MCG; 0.3MG T2 (LO-OVRAL) 52544024728 MONONESSA TABS 35MCG; 0.25MG T2 not LO, (ORTHO CYCLEN) 00603762517 MYZILRA TABS T2 (TRIPHASIL) 52544055228 NECON 1/35 TABS 35MCG; 1MG T2 not 7/7/7, (ORTHO NOVUM) 52544024531 NECON 1/50-28 TABS 50MCG; 1MG T2 not 7/7/7, (ORTHO NOVUM) 52544055428 NECON 10/11-28 TABS 35MCG T2 not 7/7/7, (ORTHO NOVUM) 68180087613 NORETHINDRONE TABS 0.35MG T2 (MICRONOR) 00555900867 NORTREL 0.5/35 (28) TABS 35MCG; 0.5MG T2 not 7/7/7, (ORTHO NOVUM) 00555901058 NORTREL 1/35 TABS 35MCG; 1MG T2 not 7/7/7, (ORTHO NOVUM) 52544084828 OGESTREL TABS 50MCG; 0.5MG T2 (OVRAL) 00603763417 ORSYTHIA TABS 20MCG; 0.1MG T2 (ALESSE) 00555902058 PORTIA-28 TABS 0.03MG; 0.15MG T2 (NORDETTE) 00603764217 PREVIFEM TABS 35MCG; 0.25MG T2 not LO, (ORTHO CYCLEN) 52544095428 RECLIPSEN TABS 0.15MG; 30MCG T2 (DESOGEN) 00555901658 SPRINTEC 28 TABS 35MCG; 0.25MG T2 not LO, (ORTHO CYCLEN) 00555901858 TRI-SPRINTEC TABS T2 not LO, (ORTHO TRICYCLEN) 52544024828 TRINESSA TABS T2 not LO, (ORTHO TRICYCLEN) 52544029128 TRIVORA-28 TABS T2 (TRIPHASIL) 52544038328 ZOVIA 1/35E TABS 35MCG; 1MG T2 (DEMULEN) 52544038428 ZOVIA 1/50E TABS 50MCG; 1MG T2 (DEMULEN) (68:16.04) Hormones and Synthetic Substitutes» Estrogens and Antiestrogens» Estrogens Tier: T1 00555088702 ESTRADIOL TABS 2MG T1 (ESTRACE) 00591048705 ESTRADIOL TABS 1MG T1 (ESTRACE) 00591052801 ESTRADIOL TABS 0.5MG T1 (ESTRACE) 15310001001 EEMT TABS 1.25MG; 2.5MG T2 (ESTRATEST) 62559014901 ESTERIFIED ESTROGENS/METHYLTESTOSTERONE TABS 1.25MG; 2.5MG T2 (ESTRATEST) Page 60 of 88

62559015001 ESTERIFIED ESTROGENS/METHYLTESTOSTERONE HS TABS 0.625MG; 1.25MG T2 (ESTRATEST HS) 47781020404 ESTRADIOL PTWK 0.025MG/24HR T2 not PRO, (CLIMARA) 47781020504 ESTRADIOL PTWK 37.5MCG/24HR T2 not PRO, (CLIMARA) 47781020604 ESTRADIOL PTWK 0.05MG/24HR T2 not PRO, (CLIMARA) 47781020704 ESTRADIOL PTWK 0.06MG/24HR T2 not PRO, (CLIMARA) 47781020804 ESTRADIOL PTWK 0.075MG/24HR T2 not PRO, (CLIMARA) 47781020904 ESTRADIOL PTWK 0.1MG/24HR T2 not PRO, (CLIMARA) 00591041401 ESTROPIPATE TABS 0.75MG T2 (OGEN) 00591041501 ESTROPIPATE TABS 1.5MG T2 (OGEN) 00591041601 ESTROPIPATE TABS 3MG T2 (OGEN) 00046110081 PREMARIN TABS 0.3MG T3 00046110181 PREMARIN TABS 0.45MG T3 00046110281 PREMARIN TABS 0.625MG T3 00046110381 PREMARIN TABS 0.9MG T3 00046110481 PREMARIN TABS 1.25MG T3 00046087221 PREMARIN CREA 0.625MG/GM T3 QL 00046257512 PREMPHASE TABS 0.625MG; 5MG T3 00046110511 PREMPRO TABS 0.3MG; 1.5MG T3 00046110611 PREMPRO TABS 0.45MG; 1.5MG T3 00046110711 PREMPRO TABS 0.625MG; 2.5MG T3 00046110811 PREMPRO TABS 0.625MG; 5MG T3 00430375414 ESTRACE CREA 0.1MG/GM T4 QL 61570007201 MENEST TABS 0.3MG T4 PA 61570007301 MENEST TABS 0.625MG T4 PA 61570007401 MENEST TABS 1.25MG T4 PA 61570007550 MENEST TABS 2.5MG T4 PA (68:16.12) Hormones and Synthetic Substitutes» Estrogens and Antiestrogens» Estrogen Agonist-Antagonists 66993041730 RALOXIFENE HYDROCHLORIDE TABS 60MG T2 (EVISTA) Page 61 of 88

00008112312 DUAVEE TABS 20MG; 0.45MG T3 (68:18) Hormones and Synthetic Substitutes» Gonadotropins 00025016608 SYNAREL SOLN 2MG/ML T4 PA; QL (68:20.02) Hormones and Synthetic Substitutes» Antidiabetic Agents» Alpha- Glucosidase Inhibitors 23155014701 ACARBOSE TABS 25MG T2 (PRECOSE) 23155014801 ACARBOSE TABS 50MG T2 (PRECOSE) 23155014901 ACARBOSE TABS 100MG T2 (PRECOSE) (68:20.03) Hormones and Synthetic Substitutes» Antidiabetic Agents» Amylinomimetics 66780012102 SYMLINPEN 120 SOPN 2700MCG/2.7ML T3 PA 66780011502 SYMLINPEN 60 SOPN 1500MCG/1.5ML T3 PA (68:20.04) Hormones and Synthetic Substitutes» Antidiabetic Agents» Biguanides Tier: T1 23155010210 METFORMIN HCL TABS 500MG T1 (GLUCOPHAGE) 23155010405 METFORMIN HCL TABS 1000MG T1 (GLUCOPHAGE) 65162021911 METFORMIN HCL TABS 850MG T1 (GLUCOPHAGE) 53746017801 METFORMIN HCL ER TB24 500MG T2 (GLUCOPHAGE) 53746017901 METFORMIN HCL ER TB24 750MG T2 (GLUCOPHAGE) (68:20.05) Hormones and Synthetic Substitutes» Antidiabetic Agents» Dipeptidyl Peptidase-4 (DPP-4) Inhibitors Page 62 of 88

00597014660 JENTADUETO TABS 2.5MG; 500MG T3 ST 00597014760 JENTADUETO TABS 2.5MG; 850MG T3 ST 00597014860 JENTADUETO TABS 2.5MG; 1000MG T3 ST 00597014030 TRADJENTA TABS 5MG T3 ST 00006011231 JANUVIA TABS 50MG T4 PA; QL 00006022131 JANUVIA TABS 25MG T4 PA; QL 00006027731 JANUVIA TABS 100MG T4 PA; QL 00003421411 ONGLYZA TABS 2.5MG T4 PA; QL 00003421511 ONGLYZA TABS 5MG T4 PA; QL (68:20.06) Hormones and Synthetic Substitutes» Antidiabetic Agents» Incretin Mimetics 66780021007 BYETTA SOPN 5MCG/0.02ML T3 PA; QL 66780021201 BYETTA SOPN 10MCG/0.04ML T3 PA; QL 00173086635 TANZEUM PEN 30MG T3 ST 00173086735 TANZEUM PEN 50MG T3 ST 66780021904 BYDUREON SUSR 2MG T4 PA; QL (68:20.08) Hormones and Synthetic Substitutes» Antidiabetic Agents» Insulins 00002850101 HUMULIN R U-500 (CONCENTRATED) SOLN 500UNIT/ML T3 QL no Pens 00169368712 LEVEMIR SOLN 100UNIT/ML T3 QL no Pens 00169183711 NOVOLIN 70/30 SUSP 30UNIT/ML; 70UNIT/ML T3 QL no Pens 00169183411 NOVOLIN N SUSP 100UNIT/ML T3 QL no Pens 00169183311 NOVOLIN R SOLN 100UNIT/ML T3 QL no Pens 00169750111 NOVOLOG SOLN 100UNIT/ML T3 QL no Pens 00169368512 NOVOLOG MIX 70/30 SUSP 30UNIT/ML; 70UNIT/ML T3 QL no Pens 00088222033 LANTUS SOLN 100UNIT/ML T4 QL no Pens Page 63 of 88

(68:20.16) Hormones and Synthetic Substitutes» Antidiabetic Agents» Meglitinides 49884098401 NATEGLINIDE TABS 60MG T2 (STARLIX) 49884098501 NATEGLINIDE TABS 120MG T2 (STARLIX) (68:20.18) Hormones and Synthetic Substitutes» Antidiabetic Agents» Sodium-glucose Cotransporter 2 (SGLT2) Inhibitors 00003142711 FARXIGA TABS 5MG T3 ST 00003142811 FARXIGA TABS 10MG T3 ST 00597015230 JARDIANCE TABS 10MG T3 ST 00597015330 JARDIANCE TABS 25MG T3 ST (68:20.20) Hormones and Synthetic Substitutes» Antidiabetic Agents» Sulfonylureas Tier: T1 00603374421 GLIMEPIRIDE TABS 1MG T1 (AMARYL) 16729000201 GLIMEPIRIDE TABS 2MG T1 (AMARYL) 16729000301 GLIMEPIRIDE TABS 4MG T1 (AMARYL) 00781145310 GLIPIZIDE TABS 10MG T1 not XL, (GLUCOTROL) 60505014101 GLIPIZIDE TABS 5MG T1 not XL, (GLUCOTROL) 00093834301 GLYBURIDE TABS 2.5MG T1 (DIABETA) 23155005810 GLYBURIDE TABS 5MG T1 (DIABETA) 00378019701 CHLORPROPAMIDE TABS 100MG T2 (DIABINESE) 00378021001 CHLORPROPAMIDE TABS 250MG T2 (DIABINESE) 23155005601 GLYBURIDE TABS 1.25MG T2 (DIABETA) 00093803501 GLYBURIDE MICRONIZED TABS 3MG T2 (MICRONASE) 00378021701 TOLAZAMIDE TABS 250MG T2 (TOLINASE) 00378055101 TOLAZAMIDE TABS 500MG T2 (TOLINASE) 00378021501 TOLBUTAMIDE TABS 500MG T2 (TOLINASE) (68:20.28) Hormones and Synthetic Substitutes» Antidiabetic Agents» Thiazolidinediones Page 64 of 88

00093204698 PIOGLITAZONE HCL TABS 45MG T2 ST (ACTOS) 00093204798 PIOGLITAZONE HCL TABS 30MG T2 ST (ACTOS) 00093204856 PIOGLITAZONE HCL TABS 15MG T2 ST (ACTOS) (68:22.12) Hormones and Synthetic Substitutes» Antihypoglycemic Agents» Glycogenolytic Agents 00002803101 GLUCAGON EMERGENCY KIT KIT 1MG T3 QL (68:22.92) Hormones and Synthetic Substitutes» Antihypoglycemic Agents» Antihypoglycemic Agents, Miscellaneous 00575620030 PROGLYCEM SUSP 50MG/ML T4 (68:24) Hormones and Synthetic Substitutes» Parathyroid 49884016111 CALCITONIN SALMON SOLN 200UNIT/ACT T2 QL (MIACALCIN) Tier: T5 00002840001 FORTEO SOLN 600MCG/2.4ML T5 PA (68:28) Hormones and Synthetic Substitutes» Pituitary 00093731701 DESMOPRESSIN ACETATE TABS 0.2MG T2 (DDAVP) 00591246401 DESMOPRESSIN ACETATE TABS 0.1MG T2 (DDAVP) 24208034205 DESMOPRESSIN ACETATE SOLN 0.01% T2 QL (DDAVP) (68:30.04) Hormones and Synthetic Substitutes» Somatotropin Agonists and Antagonists» Somatotropin Agonists Tier: T6 00781300107 OMNITROPE SOLN 5MG/1.5ML T6 PA Page 65 of 88

00781300407 OMNITROPE SOLN 10MG/1.5ML T6 PA 00781400436 OMNITROPE SOLR 5.8MG T6 PA (68:32) Hormones and Synthetic Substitutes» Progestins Tier: T1 00555077902 MEDROXYPROGESTERONE ACETATE TABS 10MG T1 (PROVERA) 00555087202 MEDROXYPROGESTERONE ACETATE TABS 2.5MG T1 (PROVERA) 00555087302 MEDROXYPROGESTERONE ACETATE TABS 5MG T1 (PROVERA) 59762453701 MEDROXYPROGESTERONE ACETATE SUSP 150MG/ML T2 QL (DEPO-PROVERA) 68462030450 NORETHINDRONE ACETATE TABS 5MG T2 (AYGESTIN) (68:36.04) Hormones and Synthetic Substitutes» Thyroid and Antithyroid Agents» Thyroid Agents Tier: T1 00378180010 LEVOTHYROXINE SODIUM TABS 25MCG T1 (SYNTHROID, LEVOXYL, LEVOTHROID, UNITHROID 00378180301 LEVOTHYROXINE SODIUM TABS 50MCG T1 (SYNTHROID, LEVOXYL, LEVOTHROID, UNITHROID 00378180501 LEVOTHYROXINE SODIUM TABS 75MCG T1 (SYNTHROID, LEVOXYL, LEVOTHROID, UNITHROID 00378180701 LEVOTHYROXINE SODIUM TABS 88MCG T1 (SYNTHROID, LEVOXYL, LEVOTHROID, UNITHROID 00378180910 LEVOTHYROXINE SODIUM TABS 100MCG T1 (SYNTHROID, LEVOXYL, LEVOTHROID, UNITHROID 00378181110 LEVOTHYROXINE SODIUM TABS 112MCG T1 (SYNTHROID, LEVOXYL, LEVOTHROID, UNITHROID 00378181310 LEVOTHYROXINE SODIUM TABS 125MCG T1 (SYNTHROID, LEVOXYL, LEVOTHROID, UNITHROID 00378181501 LEVOTHYROXINE SODIUM TABS 150MCG T1 (SYNTHROID, LEVOXYL, LEVOTHROID, UNITHROID 00378181701 LEVOTHYROXINE SODIUM TABS 175MCG T1 (SYNTHROID, LEVOXYL, LEVOTHROID, UNITHROID Page 66 of 88

00378181901 LEVOTHYROXINE SODIUM TABS 200MCG T1 (SYNTHROID, LEVOXYL, LEVOTHROID, UNITHROID 00378182101 LEVOTHYROXINE SODIUM TABS 300MCG T1 (SYNTHROID, LEVOXYL, LEVOTHROID, UNITHROID 00378182301 LEVOTHYROXINE SODIUM TABS 137MCG T1 (SYNTHROID, LEVOXYL, LEVOTHROID, UNITHROID 00574022001 LIOTHYRONINE SODIUM TABS 5MCG T2 (CYTOMEL) 00574022201 LIOTHYRONINE SODIUM TABS 25MCG T2 (CYTOMEL) 00574022301 LIOTHYRONINE SODIUM TABS 50MCG T2 (CYTOMEL) (68:36.08) Hormones and Synthetic Substitutes» Thyroid and Antithyroid Agents» Antithyroid Agents 49884064001 METHIMAZOLE TABS 5MG T2 (TAPAZOLE) 49884064101 METHIMAZOLE TABS 10MG T2 (TAPAZOLE) 00228234810 PROPYLTHIOURACIL TABS 50MG T2 (PTU) (76:00) Oxytocics 43386014028 METHYLERGONOVINE MALEATE TABS 0.2MG T2 (METHERGINE) (8:08) Anti-infective Agents» Anthelmintics 42799080601 IVERMECTIN TABS 3MG T2 (STROMECTOL) 52054055022 ALBENZA TABS 200MG T4 (8:12.02) Anti-infective Agents» Antibacterials» Aminoglycosides Page 67 of 88

50383056510 NEOMYCIN SULFATE TABS 500MG T2 Tier: T5 00078049471 TOBI NEBU 300MG/5ML T5 (8:12.06.04) Anti-infective Agents» Antibacterials» Cephalosporins» First Generation Cephalosporins 68180018102 CEFADROXIL SUSR 250MG/5ML T2 QL Susp Only (DURICEF) 68180018202 CEFADROXIL SUSR 500MG/5ML T2 QL Susp Only (DURICEF) 00093314501 CEPHALEXIN CAPS 250MG T2 (KEFLEX) 68180012202 CEPHALEXIN CAPS 500MG T2 (KEFLEX) 00093417573 CEPHALEXIN SUSR 125MG/5ML T2 QL (KEFLEX) 00093417773 CEPHALEXIN SUSR 250MG/5ML T2 QL (KEFLEX) (8:12.06.08) Anti-infective Agents» Antibacterials» Cephalosporins» Second Generation Cephalosporins 61442017130 CEFACLOR CAPS 250MG T2 (CECLOR) 61442017230 CEFACLOR CAPS 500MG T2 (CECLOR) 00093107701 CEFPROZIL TABS 250MG T2 (CEFZIL) 00093107853 CEFPROZIL TABS 500MG T2 (CEFZIL) 68180040101 CEFPROZIL SUSR 125MG/5ML T2 QL (CEFZIL) 68180040201 CEFPROZIL SUSR 250MG/5ML T2 QL (CEFZIL) 64679092101 CEFUROXIME AXETIL TABS 250MG T2 tabs only, (CEFTIN) 64679092201 CEFUROXIME AXETIL TABS 500MG T2 tabs only, (CEFTIN) (8:12.06.12) Anti-infective Agents» Antibacterials» Cephalosporins» Third Generation Cephalosporins 00781217660 CEFDINIR CAPS 300MG T2 (OMNICEF) 00781607861 CEFDINIR SUSR 250MG/5ML T2 QL (OMNICEF) 68180072210 CEFDINIR SUSR 125MG/5ML T2 QL (OMNICEF) 65862075150 CEFIXIME SUSR 100MG/5ML T2 QL 65862075250 CEFIXIME SUSR 200MG/5ML T2 QL (SUPRAX) Page 68 of 88

27437020108 SUPRAX TABS 400MG T4 27437020811 SUPRAX CAPS 400MG T4 (8:12.12.04) Anti-infective Agents» Antibacterials» Macrolides» Erythromycins 51285044521 E.S.P. SUSR 200MG/5ML; 600MG/5ML T2 QL (PEDIAZOLE) 24338010013 E.E.S. 400 TABS 400MG T3 24338010620 ERYTHROCIN STEARATE TABS 250MG T3 24338012013 ERYTHROMYCIN CPEP 250MG T3 24338011013 ERYTHROMYCIN ETHYLSUCCINATE TABS 400MG T3 (8:12.12.92) Anti-infective Agents» Antibacterials» Macrolides» Other Macrolides 00781149731 AZITHROMYCIN TABS 600MG T2 (ZITHROMAX) 59762306001 AZITHROMYCIN TABS 250MG T2 (ZITHROMAX) 59762307001 AZITHROMYCIN TABS 500MG T2 (ZITHROMAX) 00093202623 AZITHROMYCIN SUSR 200MG/5ML T2 QL (ZITHROMAX) 00093202723 AZITHROMYCIN SUSR 100MG/5ML T2 QL (ZITHROMAX) 00781602246 CLARITHROMYCIN SUSR 125MG/5ML T2 QL (BIAXIN) 00781602346 CLARITHROMYCIN SUSR 250MG/5ML T2 QL (BIAXIN) 00781196260 CLARITHROMYCIN TABS 500MG T2 not XL, (BIAXIN) 68382076114 CLARITHROMYCIN TABS 250MG T2 not XL, (BIAXIN) (8:12.16.04) Anti-infective Agents» Antibacterials» Penicillins» Natural Penicillins 00781120501 PENICILLIN V POTASSIUM TABS 250MG T2 (PEN VEE K) 00781165501 PENICILLIN V POTASSIUM TABS 500MG T2 (PEN VEE K) 00093412573 PENICILLIN V POTASSIUM SOLR 125MG/5ML T2 QL (PEN VEE K) 00093412773 PENICILLIN V POTASSIUM SOLR 250MG/5ML T2 QL (PEN VEE K) (8:12.16.08) Anti-infective Agents» Antibacterials» Penicillins» Aminopenicillins Page 69 of 88

00093226701 AMOXICILLIN CHEW 125MG T2 (AMOXIL) 00093226801 AMOXICILLIN CHEW 250MG T2 (AMOXIL) 00143995101 AMOXICILLIN TABS 875MG T2 (AMOXIL) 00781202005 AMOXICILLIN CAPS 250MG T2 (AMOXIL) 00781261301 AMOXICILLIN CAPS 500MG T2 (AMOXIL) 00093415573 AMOXICILLIN SUSR 250MG/5ML T2 QL (AMOXIL) 00143988601 AMOXICILLIN SUSR 200MG/5ML T2 QL (AMOXIL) 00143988701 AMOXICILLIN SUSR 400MG/5ML T2 QL (AMOXIL) 00143988801 AMOXICILLIN SUSR 125MG/5ML T2 QL (AMOXIL) 00093227034 AMOXICILLIN/CLAVULANATE POTASSIUM CHEW 200MG; 28.5MG T2 (AUGMENTIN) 00781164366 AMOXICILLIN/CLAVULANATE POTASSIUM CHEW 400MG; 57MG T2 (AUGMENTIN) 00781187431 AMOXICILLIN/CLAVULANATE POTASSIUM TABS 250MG; 125MG T2 (AUGMENTIN) 66685100100 AMOXICILLIN/CLAVULANATE POTASSIUM TABS 875MG; 125MG T2 (AUGMENTIN) 66685100200 AMOXICILLIN/CLAVULANATE POTASSIUM TABS 500MG; 125MG T2 (AUGMENTIN) 00143985375 AMOXICILLIN/CLAVULANATE POTASSIUM SUSR 600MG/5ML; 42.9MG/5ML 60432006500 AMOXICILLIN/CLAVULANATE POTASSIUM SUSR 250MG/5ML; 62.5MG/5ML 66685101100 AMOXICILLIN/CLAVULANATE POTASSIUM SUSR 200MG/5ML; 28.5MG/5ML 66685101200 AMOXICILLIN/CLAVULANATE POTASSIUM SUSR 400MG/5ML; 57MG/5ML T2 QL (AUGMENTIN) T2 QL (AUGMENTIN) T2 QL (AUGMENTIN) T2 QL (AUGMENTIN) 00781194382 AMOXICILLIN/CLAVULANATE POTASSIUM ER TB12 1000MG; 62.5MG T2 (AUGMENTIN XR) 67253018010 AMPICILLIN CAPS 250MG T2 (PRINCIPEN, OMNIPEN, POLYCILLIN) 67253018110 AMPICILLIN CAPS 500MG T2 (PRINCIPEN, OMNIPEN, POLYCILLIN) 67253018210 AMPICILLIN SUSR 125MG/5ML T2 QL (PRINCIPEN, OMNIPEN, POLYCILLIN) 67253018310 AMPICILLIN SUSR 250MG/5ML T2 QL (PRINCIPEN, OMNIPEN, POLYCILLIN) (8:12.16.12) Anti-infective Agents» Antibacterials» Penicillins» Penicillinase-resistant Penicillins 00093312301 DICLOXACILLIN SODIUM CAPS 250MG T2 caps only (DYCILL) 00093312501 DICLOXACILLIN SODIUM CAPS 500MG T2 caps only (DYCILL) (8:12.18) Anti-infective Agents» Antibacterials» Quinolones Page 70 of 88

16571041110 CIPROFLOXACIN HCL TABS 250MG T2 not Susp or XR, (CIPRO) 55111012701 CIPROFLOXACIN HCL TABS 500MG T2 not Susp or XR, (CIPRO) 55111012850 CIPROFLOXACIN HCL TABS 750MG T2 not Susp or XR, (CIPRO) 50383028616 LEVOFLOXACIN SOLN 25MG/ML T2 (LEVAQUIN) 55111027950 LEVOFLOXACIN TABS 250MG T2 (LEVAQUIN) 55111028050 LEVOFLOXACIN TABS 500MG T2 (LEVAQUIN) 55111028130 LEVOFLOXACIN TABS 750MG T2 (LEVAQUIN) (8:12.20) Anti-infective Agents» Antibacterials» Sulfonamides 00185075701 SULFADIAZINE TABS 500MG T2 50383082316 SULFAMETHOXAZOLE/TRIMETHOPRIM SUSP 200MG/5ML; 40MG/5ML T2 (BACTRIM, SEPTRA) 53746027101 SULFAMETHOXAZOLE/TRIMETHOPRIM TABS 400MG; 80MG T2 (BACTRIM, SEPTRA) 53746027205 SULFAMETHOXAZOLE/TRIMETHOPRIM DS TABS 800MG; 160MG T2 (BACTRIM DS, SEPTRA DS) 00591079601 SULFASALAZINE TABS 500MG T2 not EN, (AZULFIDINE) 00603580121 SULFAZINE TABS 500MG T2 not EN, (AZULFIDINE) (8:12.24) Anti-infective Agents» Antibacterials» Tetracyclines 53489064701 DOXYCYCLINE HYCLATE TABS 20MG T2 (PERIOSTAT) 00143314150 DOXYCYCLINE HYCLATE CAPS 50MG T2 (VIBRAMYCIN) 00143314205 DOXYCYCLINE HYCLATE CAPS 100MG T2 (VIBRAMYCIN) 00143211250 DOXYCYCLINE HYCLATE TABS 100MG T2 (VIBRATABS) 49884072601 DOXYCYCLINE MONOHYDRATE CAPS 50MG T2 (MONODOX) 49884072703 DOXYCYCLINE MONOHYDRATE CAPS 100MG T2 (MONODOX) 00093316501 MINOCYCLINE HCL CAPS 50MG T2 (MINOCIN) 00093316753 MINOCYCLINE HCL CAPS 100MG T2 (MINOCIN) 23155001701 TETRACYCLINE HCL CAPS 250MG T2 (SUMYCIN) 23155001801 TETRACYCLINE HCL CAPS 500MG T2 (SUMYCIN) (8:12.28.20) Anti-infective Agents» Antibacterials» Antibacterials, Miscellaneous» Lincomycins 00093317101 CLINDAMYCIN HCL CAPS 150MG T2 150mg caps and Suspension only, (CLEOCIN) 00574012901 CLINDAMYCIN PALMITATE HCL SOLR 75MG/5ML T2 (CLEOCIN) Page 71 of 88

64980051110 CLINDAMYCIN PALMITATE HCL SOLR 75MG/5ML T2 (CLEOCIN) (8:12.28.24) Anti-infective Agents» Antibacterials» Antibacterials, Miscellaneous» Oxazolidinones 00009513502 ZYVOX TABS 600MG T3 PA 00009513601 ZYVOX SUSR 100MG/5ML T3 PA (8:14.04) Anti-infective Agents» Antifungals» Allylamines 31722020930 TERBINAFINE HCL TABS 250MG T2 (LAMISIL) (8:14.08) Anti-infective Agents» Antifungals» Azoles 68001025104 FLUCONAZOLE TABS 50MG T2 (DIFLUCAN) 68001025204 FLUCONAZOLE TABS 100MG T2 (DIFLUCAN) 68462010430 FLUCONAZOLE TABS 200MG T2 (DIFLUCAN) 59762502901 FLUCONAZOLE SUSR 10MG/ML T2 QL (DIFLUCAN) 59762503001 FLUCONAZOLE SUSR 40MG/ML T2 QL (DIFLUCAN) 68001025320 FLUCONAZOLE TABS 150MG T2 QL (DIFLUCAN) 10147170003 ITRACONAZOLE CAPS 100MG T2 PA (SPORONOX) 00093090001 KETOCONAZOLE TABS 200MG T2 not shampoo, (NIZORAL) 00378627045 VORICONAZOLE SUSR 40MG/ML T2 QL (VFEND) 50458029515 SPORANOX SOLN 10MG/ML T4 PA (8:14.28) Anti-infective Agents» Antifungals» Polyenes 00603148149 NYSTATIN SUSP 100000UNIT/ML T2 not Powder 23155005101 NYSTATIN TABS 500000UNIT T2 not PWD (8:14.32) Anti-infective Agents» Antifungals» Pyrimidines Page 72 of 88

64980017901 FLUCYTOSINE CAPS 250MG T2 (ANCOBON) 64980018001 FLUCYTOSINE CAPS 500MG T2 (ANCOBON) (8:14.92) Anti-infective Agents» Antifungals» Antifungals, Miscellaneous 00603917154 GRISEOFULVIN MICROSIZE SUSP 125MG/5ML T2 suspension only, (GRIFULVIN V SUSP) (8:16.04) Anti-infective Agents» Antimycobacterials» Antituberculosis Agents 54879000101 ETHAMBUTOL HCL TABS 100MG T2 (MYAMBUTAL) 54879000201 ETHAMBUTOL HCL TABS 400MG T2 (MYAMBUTAL) 00555006602 ISONIAZID TABS 100MG T2 (LANIAZID) 00555007102 ISONIAZID TABS 300MG T2 (LANIAZID) 61748001206 PYRAZINAMIDE TABS 500MG T2 68180028501 RIFABUTIN CAPS 150MG T2 00527131506 RIFAMPIN CAPS 300MG T2 (RIFADIN) 00527139330 RIFAMPIN CAPS 150MG T2 (RIFADIN) 49938010704 PASER PACK 4GM T4 00088210003 PRIFTIN TABS 150MG T4 00008411701 TRECATOR TABS 250MG T4 (8:16.92) Anti-infective Agents» Antimycobacterials» Antimycobacterials, Miscellaneous 49938010130 DAPSONE TABS 100MG T4 49938010230 DAPSONE TABS 25MG T4 (8:18.04) Anti-infective Agents» Antivirals» Adamantanes 00115191101 RIMANTADINE HCL TABS 100MG T2 (FLUMADINE) Page 73 of 88

(8:18.20) Anti-infective Agents» Antivirals» Interferons Tier: T5 00085127901 PEG-INTRON KIT 150MCG/0.5ML T5 PA 00085129101 PEG-INTRON KIT 80MCG/0.5ML T5 PA 00085130401 PEG-INTRON KIT 120MCG/0.5ML T5 PA 00085136801 PEG-INTRON KIT 50MCG/0.5ML T5 PA 00085129701 PEG-INTRON REDIPEN KIT 120MCG/0.5ML T5 PA 00085131601 PEG-INTRON REDIPEN KIT 80MCG/0.5ML T5 PA 00085137001 PEG-INTRON REDIPEN KIT 150MCG/0.5ML T5 PA 00004035730 PEGASYS SOLN 180MCG/0.5ML T5 PA (8:18.28) Anti-infective Agents» Antivirals» Neuraminidase Inhibitors 00173068101 RELENZA DISKHALER AEPB 5MG/BLISTER T4 00004082205 TAMIFLU SUSR 6MG/ML T4 QL under 2 years of age only, susp. only (8:18.32) Anti-infective Agents» Antivirals» Nucleosides and Nucleotides 00093894001 ACYCLOVIR CAPS 200MG T2 (ZOVIRAX) 00093894301 ACYCLOVIR TABS 400MG T2 (ZOVIRAX) 00093894701 ACYCLOVIR TABS 800MG T2 (ZOVIRAX) 50383081016 ACYCLOVIR SUSP 200MG/5ML T2 (ZOVIRAX) 00093578656 ENTECAVIR TABS 0.5MG T2 00093578756 ENTECAVIR TABS 1MG T2 00378427577 VALACYCLOVIR HCL TABS 500MG T2 (VALTREX) 00378427677 VALACYCLOVIR HCL TABS 1GM T2 (VALTREX) 00603633020 VALGANCICLOVIR TABS 450MG T2 00004003909 VALCYTE SOLR 50MG/ML T3 00078053815 TYZEKA TABS 600MG T4 PA Page 74 of 88

Tier: T5 42794000308 ADEFOVIR DIPIVOXIL TABS 10MG T5 PA Tier: T6 68382026012 RIBAVIRIN CAPS 200MG T6 (8:18.40.16) Anti-infective Agents» Antivirals» HCV Antivirals» HCV Polymerase Inhibitors Tier: T5 61958150101 SOVALDI TABS 400MG T5 PA (8:18.40.20) Anti-infective Agents» Antivirals» HCV Antivirals» HCV Protease Inhibitors Tier: T5 59676022528 OLYSIO CAPS 150MG T5 PA 00085031402 VICTRELIS CAPS 200MG T5 PA (8:18.40.24) Anti-infective Agents» Antivirals» HCV Antivirals» HCV Replication Complex Inhibitors Tier: T5 00074309328 VIEKIRA PAK TBPK 250MG; 12.5MG; T5 PA 75MG; 50MG (8:30.04) Anti-infective Agents» Antiprotozoals» Amebicides 57664017508 PAROMOMYCIN SULFATE CAPS 250MG T3 (8:30.08) Anti-infective Agents» Antiprotozoals» Antimalarials 66993006002 ATOVAQUONE/PROGUANIL HCL TABS 250MG; 100MG T2 (MALARONE) 68462056301 ATOVAQUONE/PROGUANIL HCL TABS 62.5MG; 25MG T2 (MALARONE) Page 75 of 88

64980017750 CHLOROQUINE PHOSPHATE TABS 250MG T2 (ARALEN) 64980017802 CHLOROQUINE PHOSPHATE TABS 500MG T2 (ARALEN) 00781140705 HYDROXYCHLOROQUINE SULFATE TABS 200MG T2 (PLAQUENIL) 00054002511 MEFLOQUINE HCL TABS 250MG T2 (LARIAM) 52054033010 DARAPRIM TABS 25MG T4 (8:30.92) Anti-infective Agents» Antiprotozoals» Antiprotozoals, Miscellaneous 66993006272 ATOVAQUONE SUSP 750MG/5ML T2 (MEPRON) 23155006401 METRONIDAZOLE TABS 250MG T2 (FLAGYL) 23155006501 METRONIDAZOLE TABS 500MG T2 (FLAGYL) 67546011112 ALINIA TABS 500MG T3 (8:36) Anti-infective Agents» Urinary Anti-infectives 00093213001 NITROFURANTOIN MACROCRYSTALS CAPS 50MG T2 (MACRODANTIN) 00093213101 NITROFURANTOIN MACROCRYSTALS CAPS 100MG T2 (MACRODANTIN) 00378342201 NITROFURANTOIN MONOHYDRATE CAPS 100MG T2 (MACROBID) 43386033001 TRIMETHOPRIM TABS 100MG T2 (TRIMPEX) 00486111401 UROQID #2 TABS 500MG; 500MG T3 (84:04.04) Skin and Mucous Membrane Preparations» Anti-infectives» Antibacterials 00168027740 CLINDAMYCIN PHOSPHATE CREA 2% T2 QL Vaginal only (CLEOCIN) 00168021560 ERYTHROMYCIN SOLN 2% T2 QL (A/T/S) 45802004611 GENTAMICIN SULFATE OINT 0.1% T2 QL (GARAMYCIN) 45802005611 GENTAMICIN SULFATE CREA 0.1% T2 QL (GARAMYCIN) 00168032346 METRONIDAZOLE CREA 0.75% T2 QL (METROCREAM) Page 76 of 88

00168027545 METRONIDAZOLE GEL 0.75% T2 QL (METROGEL) 00781708035 METRONIDAZOLE GEL 1% T2 QL (METROGEL) 00168038360 METRONIDAZOLE LOTN 0.75% T2 QL (METROLOTION) 00781707787 METRONIDAZOLE VAGINAL GEL 0.75% T2 QL (METROGEL) 45802011222 MUPIROCIN OINT 2% T2 QL (BACTROBAN) 68462056435 MUPIROCIN CREA 2% T2 QL (BACTROBAN) 00245086070 VANDAZOLE GEL 0.75% T2 QL (METROGEL) (84:04.06) Skin and Mucous Membrane Preparations» Anti-infectives» Antivirals 00378870006 ACYCLOVIR OINT 5% T2 QL not crm 00067602415 DENAVIR CREA 1% T4 QL (84:04.08.08) Skin and Mucous Membrane Preparations» Anti-infectives» Antifungals» Azoles 00054414623 CLOTRIMAZOLE TROC 10MG T2 PA; QL (MYCELEX TROCHES) 00574010770 CLOTRIMAZOLE LOZG 10MG T2 PA; QL (MYCELEX TROCHES) 51672130803 CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE LOTN 0.05%; 1% T2 QL (LOTRISONE) 66993089815 CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE CREA 0.05%; 1% T2 QL (LOTRISONE) 66993089845 CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE CREA 0.05%; 1% T2 QL (LOTRISONE) 51672130302 ECONAZOLE NITRATE CREA 1% T2 QL (SPECTAZOLE) 00168009960 KETOCONAZOLE CREA 2% T2 QL not shampoo, (NIZORAL) 00591319689 TERCONAZOLE CREA 0.4% T2 QL (TERAZOL) 00591319752 TERCONAZOLE CREA 0.8% T2 QL (TERAZOL) 45802071708 TERCONAZOLE SUPP 80MG T2 QL (TERAZOL) 00462034646 ZAZOLE CREA 0.4% T2 QL (TERAZOL) 10337035830 OXISTAT CREA 1% T3 QL 10337035930 OXISTAT LOTN 1% T3 QL (84:04.08.20) Skin and Mucous Membrane Preparations» Anti-infectives» Antifungals» Page 77 of 88

Hydroxypyridones 00168040730 CICLOPIROX GEL 0.77% T2 QL not Shampoo, (LOPROX) 45802040049 CICLOPIROX SUSP 0.77% T2 QL not Shampoo, (LOPROX) 00713031788 CICLOPIROX NAIL LACQUER SOLN 8% T2 QL (PENLAC) 45802013818 CICLOPIROX OLAMINE CREA 0.77% T2 QL not Shampoo, (LOPROX) (84:04.08.28) Skin and Mucous Membrane Preparations» Anti-infectives» Antifungals» Polyenes 00168000730 NYSTATIN OINT 100000UNIT/GM T2 QL not PWD 45802005911 NYSTATIN CREA 100000UNIT/GM T2 QL not PWD (84:04.12) Skin and Mucous Membrane Preparations» Anti-infectives» Scabicides and Pediculicides 51672527704 MALATHION LOTN 0.5% T2 QL (OVIDE) 00472024260 PERMETHRIN CREA 5% T2 QL (ELIMITE) (84:04.92) Skin and Mucous Membrane Preparations» Anti-infectives» Local Antiinfectives, Miscellaneous 45802004064 SELENIUM SULFIDE LOTN 2.5% T2 QL (SELSUN) 43598021040 SSD CREA 1% T2 QL (SILVADENE) (84:06) Skin and Mucous Membrane Preparations» Anti-inflammatory Agents 00168005546 BETAMETHASONE DIPROPIONATE CREA 0.05% T2 QL (DIPROSONE) 00168005646 BETAMETHASONE DIPROPIONATE OINT 0.05% T2 QL (DIPROSONE) 00168005760 BETAMETHASONE DIPROPIONATE LOTN 0.05% T2 QL (DIPROSONE) 00168003346 BETAMETHASONE VALERATE OINT 0.1% T2 QL (VALISONE) 00168004046 BETAMETHASONE VALERATE CREA 0.1% T2 QL (VALISONE) 00168004160 BETAMETHASONE VALERATE LOTN 0.1% T2 QL (VALISONE) Page 78 of 88

00168029360 CLOBETASOL PROPIONATE GEL 0.05% T2 QL (TEMOVATE) 50383026650 CLOBETASOL PROPIONATE SOLN 0.05% T2 QL (TEMOVATE) 50383026760 CLOBETASOL PROPIONATE CREA 0.05% T2 QL (TEMOVATE) 50383026860 CLOBETASOL PROPIONATE OINT 0.05% T2 QL (TEMOVATE) 51672135004 CLOBETASOL PROPIONATE LOTN 0.05% T2 QL (TEMOVATE) 51672129703 CLOBETASOL PROPIONATE E CREA 0.05% T2 QL (TEMOVATE) 00574202007 COLOCORT ENEM 100MG/60ML T2 QL (CORTENEMA) 00168031002 DESONIDE LOTN 0.05% T2 QL (TRIDESILON) 45802042237 DESONIDE CREA 0.05% T2 QL (TRIDESILON) 45802042337 DESONIDE OINT 0.05% T2 QL (TRIDESILON) 45802049537 DESOXIMETASONE CREA 0.25% T2 QL not spray, (TOPICORT) 51672126207 DESOXIMETASONE OINT 0.25% T2 QL not spray, (TOPICORT) 51672127107 DESOXIMETASONE CREA 0.05% T2 QL not spray, (TOPICORT) 51672135207 DESOXIMETASONE OINT 0.05% T2 QL not spray, (TOPICORT) 61748020560 DESOXIMETASONE GEL 0.05% T2 QL not spray, (TOPICORT) 51672129503 DIFLORASONE DIACETATE OINT 0.05% T2 QL (MAXIFLOR) 51672129603 DIFLORASONE DIACETATE CREA 0.05% T2 QL (MAXIFLOR) 00713022460 FLUOCINOLONE ACETONIDE OINT 0.025% T2 QL (SYNALAR) 00713032460 FLUOCINOLONE ACETONIDE CREA 0.025% T2 QL (SYNALAR) 51672136504 FLUOCINOLONE ACETONIDE SOLN 0.01% T2 QL (SYNALAR) 52565003160 FLUOCINOLONE ACETONIDE CREA 0.01% T2 QL (SYNALAR) 00168013560 FLUOCINONIDE GEL 0.05% T2 QL (LIDEX) 00168014060 FLUOCINONIDE OINT 0.05% T2 QL (LIDEX) 00472390160 FLUOCINONIDE CREA 0.05% T2 QL (LIDEX) 51672127304 FLUOCINONIDE SOLN 0.05% T2 QL (LIDEX) 00093026392 FLUOCINONIDE-E CREA 0.05% T2 QL (LIDEX-E) 00168043460 FLUTICASONE PROPIONATE LOTN 0.05% T2 QL (CUTIVATE) 45802022111 FLUTICASONE PROPIONATE OINT 0.005% T2 QL (CUTIVATE) 45802022211 FLUTICASONE PROPIONATE CREA 0.05% T2 QL (CUTIVATE) 51991072867 HYDROCORTISONE ENEM 100MG/60ML T2 QL (CORTENEMA) 00168008031 HYDROCORTISONE CREA 2.5% T2 QL (HYTONE) 00168014630 HYDROCORTISONE OINT 2.5% T2 QL (HYTONE) 00168028802 HYDROCORTISONE LOTN 2.5% T2 QL (HYTONE) 00574709012 HYDROCORTISONE ACETATE SUPP 25MG T2 QL (ANUSOL HC) 43478027045 HYDROCORTISONE BUTYRATE CREA 0.1% T2 QL (LOCOID) 43478027361 HYDROCORTISONE BUTYRATE SOLN 0.1% T2 QL (LOCOID) 51672408306 HYDROCORTISONE BUTYRATE OINT 0.1% T2 QL (LOCOID) 00115147046 MOMETASONE FUROATE CREA 0.1% T2 QL (ELOCON) 00115147155 MOMETASONE FUROATE SOLN 0.1% T2 QL (ELOCON) 45802011942 MOMETASONE FUROATE OINT 0.1% T2 QL (ELOCON) 00168008160 NYSTATIN/TRIAMCINOLONE CREA 100000UNIT/GM; 1MG/GM 51672127201 NYSTATIN/TRIAMCINOLONE OINT 100000UNIT/GM; 0.1% T2 QL not PWD, (MYCOLOG) T2 QL not PWD, (MYCOLOG) 64980030130 PROCTOZONE-HC CREA 2.5% T2 QL (ANUSOL HC) Page 79 of 88

00168000215 TRIAMCINOLONE ACETONIDE CREA 0.5% T2 QL (ARISTOCORT) 00168000380 TRIAMCINOLONE ACETONIDE CREA 0.025% T2 QL (ARISTOCORT) 00168033760 TRIAMCINOLONE ACETONIDE LOTN 0.1% T2 QL (ARISTOCORT) 45802004935 TRIAMCINOLONE ACETONIDE OINT 0.5% T2 QL (ARISTOCORT) 45802005436 TRIAMCINOLONE ACETONIDE OINT 0.025% T2 QL (ARISTOCORT) 45802005505 TRIAMCINOLONE ACETONIDE OINT 0.1% T2 QL (ARISTOCORT) 60432056060 TRIAMCINOLONE ACETONIDE LOTN 0.025% T2 QL (ARISTOCORT) 67877025145 TRIAMCINOLONE ACETONIDE CREA 0.1% T2 QL (ARISTOCORT) 64980032005 TRIAMCINOLONE ACETONIDE PSTE 0.1% T2 QL (KENALOG ORABASE) 51672126705 TRIAMCINOLONE IN ORABASE PSTE 0.1% T2 QL (KENALOG ORABASE) 52544004424 CORDRAN TAPE TAPE 4MCG/SQCM T3 QL 52544004480 CORDRAN TAPE TAPE 4MCG/SQCM T3 QL 61570003150 CORTISPORIN OINT 400UNIT/GM; 1%; 0.5%; 5000UNIT/GM 61570003275 CORTISPORIN CREA 0.5%; 0.5%; 10000UNIT/GM T3 T3 QL QL (84:08) Skin and Mucous Membrane Preparations» Antipruritics and Local Anesthetics 00591352530 LIDOCAINE PTCH 5% T2 PA (LIDODERM) 51672300803 LIDOCAINE OINT 5% T2 QL oint only, (XYLOCAINE) 00115146845 LIDOCAINE/PRILOCAINE CREA 2.5%; 2.5% T2 QL (EMLA) 65162052010 PHENAZOPYRIDINE HCL TABS 200MG T2 not 100mg, (PYRIDIUM) 00064360045 PRUDOXIN CREA 5% T2 QL (84:16) Skin and Mucous Membrane Preparations» Cell Stimulants and Proliferants 00472011720 TRETINOIN CREA 0.025% T2 PA; QL (RETIN-A) No PA required for 19 and under 43478024120 TRETINOIN CREA 0.1% T2 PA; QL (RETIN-A) No PA required for 19 and under 43478024220 TRETINOIN CREA 0.05% T2 PA; QL (RETIN-A) No PA required for 19 and under 43478024320 TRETINOIN CREA 0.025% T2 PA; QL (RETIN-A) No PA required for 19 and under 43478024415 TRETINOIN GEL 0.025% T2 PA; QL (RETIN-A) No PA required for 19 and Page 80 of 88

43478024515 TRETINOIN GEL 0.01% T2 PA; QL (RETIN-A) No PA required for 19 and under under (84:28) Skin and Mucous Membrane Preparations» Keratolytic Agents 58980062380 X-VIATE LOTN 40% T2 QL 58980062530 X-VIATE CREA 40% T2 QL (84:50.06) Skin and Mucous Membrane Preparations» Depigmenting and Pigmenting Agents» Pigmenting Agents 00187040231 OXSORALEN LOTN 1% T3 QL 00187065042 OXSORALEN ULTRA CAPS 10MG T3 (84:92) Skin and Mucous Membrane Preparations» Skin and Mucous Membrane Agents, Misc 00115147555 CALCIPOTRIENE SOLN 0.005% T2 QL (DOVONEX) 00781711735 CALCIPOTRIENE CREA 0.005% T2 QL (DOVONEX) 51672415403 CALCIPOTRIENE OINT 0.005% T2 QL (DOVONEX) 00168080301 DICLOFENAC SODIUM GEL 3% T2 PA; QL (SOLARAZE) 51672406201 FLUOROURACIL SOLN 2% T2 QL (EFUDEX) 51672406301 FLUOROURACIL SOLN 5% T2 QL (EFUDEX) 51672411806 FLUOROURACIL CREA 5% T2 QL (EFUDEX) 45802036862 IMIQUIMOD CREA 5% T2 QL (ALDARA) 00591320413 PODOFILOX SOLN 0.5% T2 QL (CONDYLOX) 58980079011 VASOLEX OINT 788MG/GM; 87MG/GM; 90UNIT/GM T2 QL 62856060122 PANRETIN GEL 0.1% T3 00187510001 ELIDEL CREA 1% T4 QL 00064501030 SANTYL OINT 250UNIT/GM T4 QL Page 81 of 88

00023004203 TAZORAC GEL 0.1% T4 PA; QL 00023833503 TAZORAC GEL 0.05% T4 PA; QL 00023915530 TAZORAC CREA 0.05% T4 PA; QL 00023915630 TAZORAC CREA 0.1% T4 PA; QL 63481068447 VOLTAREN GEL 1% T4 PA Tier: T5 00093113556 ACITRETIN CAPS 10MG T5 PA (SORIATANE) 00093113656 ACITRETIN CAPS 25MG T5 PA (SORIATANE) 00093113856 ACITRETIN CAPS 17.5MG T5 PA (SORIATANE) 62856060422 TARGRETIN GEL 1% T5 QL (86:12.04) Smooth Muscle Relaxants» Genitourinary Smooth Muscle Relaxants» Antimuscarinics 00574011501 FLAVOXATE HCL TABS 100MG T2 (URISPAS) 00603497532 OXYBUTYNIN CHLORIDE TABS 5MG T2 (DITROPAN) 60432009216 OXYBUTYNIN CHLORIDE SYRP 5MG/5ML T2 (DITROPAN) 00069024230 TOVIAZ TB24 4MG T3 00069024430 TOVIAZ TB24 8MG T3 (86:16) Smooth Muscle Relaxants» Respiratory Smooth Muscle Relaxants 50111048201 THEOPHYLLINE CR TB12 200MG T2 (THEO-DUR) 50111048301 THEOPHYLLINE CR TB12 100MG T2 (THEO-DUR) 23155006301 THEOPHYLLINE ER TB12 450MG T2 (THEO-DUR) 50111045901 THEOPHYLLINE ER TB12 300MG T2 (THEO-DUR) (88:08) Vitamins» Vitamin B Complex 00603316232 FOLIC ACID TABS 1MG T2 (88:16) Vitamins» Vitamin D Page 82 of 88

00054312041 CALCITRIOL SOLN 1MCG/ML T2 (ROCALTROL) 23155011801 CALCITRIOL CAPS 0.25MCG T2 (ROCALTROL) 63304024001 CALCITRIOL CAPS 0.5MCG T2 (ROCALTROL) 10888500102 PARICALCITOL CAPS 1MCG T2 PA 10888500202 PARICALCITOL CAPS 2MCG T2 PA 10888500302 PARICALCITOL CAPS 4MCG T2 PA (ZEMPLAR) 51991060401 VITAMIN D CAPS 50000UNIT T2 (88:24) Vitamins» Vitamin K Activity 00187170405 MEPHYTON TABS 5MG T3 (88:28) Vitamins» Multivitamin Preparations 00603144947 MULTI-VIT/FLUORIDE SOLN 35MG/ML; T2 QL 400UNIT/ML; 2MCG/ML; 8MG/ML; 0.4MG/ML; 0.6MG/ML; 0.25MG/ML; 0.5MG/ML; 5UNIT/ML; 1500UNIT/ML 00603145047 MULTI-VIT/FLUORIDE SOLN 35MG/ML; 400UNIT/ML; 2MCG/ML; 8MG/ML; 0.4MG/ML; 0.6MG/ML; 0.5MG/ML; 0.5MG/ML; 5UNIT/ML; 1500UNIT/ML 00603145247 MULTI-VIT/IRON/FLUORIDE SOLN 35MG/ML; 400UNIT/ML; 10MG/ML; 8MG/ML; 0.4MG/ML; 0.6MG/ML; 0.25MG/ML; 0.5MG/ML; 5UNIT/ML; 1500UNIT/ML T2 T2 QL QL Page 83 of 88

44946102301 MULTIVITAMIN WITH FLUORIDE CHEW 60MG; 4.5MCG; 0.3MG; 13.5MG; 1.05MG; 1.2MG; 0.25MG; 1.05MG; 2500UNIT; 400UNIT; 15UNIT T2 65162066810 PRENATAL PLUS TABS 120MG; 0; 200MG; 400UNIT; 2MG; 12MCG; 27MG; 1MG; 20MG; 10MG; 3MG; 1.84MG; 22MG; 4000UNIT; 25MG T2 (STUARTNATAL PLUS) 00603178547 TRI-VIT/FLUORIDE SOLN 35MG/ML; 400UNIT/ML; 0.25MG/ML; 1500UNIT/ML 00603178647 TRI-VIT/FLUORIDE SOLN 35MG/ML; 400UNIT/ML; 0.5MG/ML; 1500UNIT/ML 00603178747 TRI-VIT/FLUORIDE/IRON SOLN 35MG/ML; 0.25MG/ML; 10MG/ML; 1500UNIT/ML; 400UNIT/ML 60258019201 TRINATE TABS 120MG; 3000UNIT; 200MG; 400UNIT; 2MG; 12MCG; 28MG; 1MG; 25MG; 20MG; 25MG; 4MG; 1.8MG; 22MG; 25MG T2 QL (TRI-VI-FLOR) T2 QL (TRI-VI-FLOR) T2 QL (TRI-VI-FLOR W/IRON) T2 (STUARTNATAL PLUS-3) (92:04) Miscellaneous Therapeutic Agents» Alcohol Deterrents 64980017101 DISULFIRAM TABS 250MG T2 (ANTABUSE) 64980017201 DISULFIRAM TABS 500MG T2 (ANTABUSE) (92:08) Miscellaneous Therapeutic Agents» 5-alpha-Reductase Inhibitors 16729009015 FINASTERIDE TABS 5MG T2 (PROSCAR) Page 84 of 88

00173071204 AVODART CAPS 0.5MG T3 (92:12) Miscellaneous Therapeutic Agents» Antidotes 00409330703 ACETYLCYSTEINE SOLN 10% T2 (MUCOMYST) 00409330803 ACETYLCYSTEINE SOLN 20% T2 (MUCOMYST) 00054449613 LEUCOVORIN CALCIUM TABS 5MG T2 (WELLCOVORIN) 00054449710 LEUCOVORIN CALCIUM TABS 10MG T2 (WELLCOVORIN) 00054449810 LEUCOVORIN CALCIUM TABS 15MG T2 (WELLCOVORIN) (92:16) Miscellaneous Therapeutic Agents» Antigout Agents Tier: T1 00378018105 ALLOPURINOL TABS 300MG T1 (ZYLOPRIM) 00603211521 ALLOPURINOL TABS 100MG T1 (ZYLOPRIM) 66993016502 COLCHICINE TABS 0.6MG T2 (COLCRYS) (92:20) Miscellaneous Therapeutic Agents» Immunomodulatory Agents 59572020594 THALOMID CAPS 50MG T3 PA 59572021095 THALOMID CAPS 100MG T3 PA 59572021513 THALOMID CAPS 150MG T3 PA 59572022096 THALOMID CAPS 200MG T3 PA Tier: T5 59627000103 AVONEX KIT 30MCG/VIAL T5 59627000205 AVONEX KIT 30MCG/0.5ML T5 59627000304 AVONEX PEN KIT 30MCG/0.5ML T5 50419052335 BETASERON KIT 0.3MG T5 68546031730 COPAXONE SOSY 20MG/ML T5 00078060751 GILENYA CAPS 0.5MG T5 PA; QL 44087002203 REBIF SOLN 22MCG/0.5ML T5 44087004403 REBIF SOLN 44MCG/0.5ML T5 Page 85 of 88

44087882201 REBIF TITRATION PACK SOLN T5 (92:24) Miscellaneous Therapeutic Agents» Bone Resorption Inhibitors Tier: T1 41616063868 ALENDRONATE SODIUM TABS 70MG T1 QL (FOSAMAX) 00093514056 ALENDRONATE SODIUM TABS 5MG T2 (FOSAMAX) 00093514156 ALENDRONATE SODIUM TABS 10MG T2 (FOSAMAX) 00093517244 ALENDRONATE SODIUM TABS 35MG T2 QL (FOSAMAX) Tier: T6 62756021840 IBANDRONATE SODIUM SOLN 3MG/3ML T6 PA; QL 55513071001 PROLIA SOLN 60MG/ML T6 PA 23155018631 ZOLEDRONIC ACID SOLN 5MG/100ML T6 (RECLAST) (92:28) Miscellaneous Therapeutic Agents» Cariostatic Agents 60258015101 SF GEL 1.1% T2 QL (PREVIDENT) 60258014520 SODIUM FLUORIDE CHEW 0.25MG T2 (LURIDE) 60258014620 SODIUM FLUORIDE CHEW 1.1MG T2 (LURIDE) 60258014720 SODIUM FLUORIDE CHEW 1MG T2 (LURIDE) 44946103208 SODIUM FLUORIDE SOLN 0.5MG/ML T2 QL (LURIDE) (92:36) Miscellaneous Therapeutic Agents» Disease-modifying Antirheumatic Drugs 13811067730 LEFLUNOMIDE TABS 10MG T2 (ARAVA) 23155004403 LEFLUNOMIDE TABS 20MG T2 (ARAVA) Tier: T5 58406042534 ENBREL KIT 25MG T5 PA 58406043504 ENBREL SOSY 50MG/ML T5 PA 58406045504 ENBREL SOSY 25MG/0.5ML T5 PA 58406044504 ENBREL SURECLICK SOAJ 50MG/ML T5 PA 00074379902 HUMIRA PSKT 40MG/0.8ML T5 PA Page 86 of 88

00074433902 HUMIRA PEN PNKT 40MG/0.8ML T5 PA 00074433906 HUMIRA PEN-CROHNS DISEASESTARTER PNKT 40MG/0.8ML T5 PA 00069100101 XELJANZ TABS 5MG T5 PA (92:44) Miscellaneous Therapeutic Agents» Immunosuppressive Agents 00054408425 AZATHIOPRINE TABS 50MG T2 (IMURAN) 00172731046 CYCLOSPORINE MODIFIED CAPS 25MG T2 (NEORAL) 00172731146 CYCLOSPORINE MODIFIED CAPS 50MG T2 (NEORAL) 00172731246 CYCLOSPORINE MODIFIED CAPS 100MG T2 (NEORAL) 00172731320 CYCLOSPORINE MODIFIED SOLN 100MG/ML T2 (NEORAL) 16729001901 MYCOPHENOLATE MOFETIL TABS 500MG T2 (CELLCEPT) 16729009401 MYCOPHENOLATE MOFETIL CAPS 250MG T2 (CELLCEPT) 67877023022 MYCOPHENOLATE MOFETIL SUSR 200MG/ML T2 (CELLCEPT) Tier: T6 00378420178 MYCOPHENOLIC ACID DR TBEC 180MG T6 00378420278 MYCOPHENOLIC ACID DR TBEC 360MG T6 59762100101 SIROLIMUS TABS 0.5MG T6 59762100201 SIROLIMUS TABS 1MG T6 59762100301 SIROLIMUS TABS 2MG T6 00378204501 TACROLIMUS CAPS 0.5MG T6 (PROGRAF) 00781210301 TACROLIMUS CAPS 1MG T6 (PROGRAF) 00781210401 TACROLIMUS CAPS 5MG T6 (PROGRAF) 00078041420 ZORTRESS TABS 0.5MG T6 00078041520 ZORTRESS TABS 0.75MG T6 00078041720 ZORTRESS TABS 0.25MG T6 (92:56) Miscellaneous Therapeutic Agents» Protective Agents 67108356509 MESNEX TABS 400MG T4 (92:92) Miscellaneous Therapeutic Agents» Other Miscellaneous Therapeutic Agents 55513007330 SENSIPAR TABS 30MG T3 PA 55513007430 SENSIPAR TABS 60MG T3 PA 55513007530 SENSIPAR TABS 90MG T3 PA Page 87 of 88

50458009801 ELMIRON CAPS 100MG T4 PA 66215020190 ZAVESCA CAPS 100MG T4 PA Tier: T5 68135030002 KUVAN TBSO 100MG T5 PA 66621101006 ORFADIN CAPS 10MG T5 PA (94:00) Devices 08271087100 FINE 30 MISC T2 Page 88 of 88