Providence prescription drug coverage

Providence prescription drug coverage Providence Health Plan wants to help you to make the most of your prescription drug coverage. That s why we strive to provide you with the information you need to make smart decisions about medications. Know more, save more We encourage you to be knowledgeable about your prescription drug benefits. Information is available on your benefit summary, in your member handbook and on the Providence Health Plan website. When you require a prescription, be sure to let your doctor know cost matters to you. Choosing a generic when possible can help manage your costs. Retail pharmacies You have access to more than 25,000 participating pharmacies nationwide at discounted rates. Search the provider directory to locate participating pharmacies near you. Maintenance drugs Maintenance medications are those typically prescribed to treat long-term or chronic conditions, such as diabetes, high blood pressure and high cholesterol. A 90-day supply of maintenance medication is available through participating mail-order pharmacies, as well as through preferred retail pharmacies. Your 90-day supply copay or coinsurance applies. Not all covered prescription drugs are available in a 90-day supply. Learn more about mail-order pharmacies and preferred retail pharmacies. drugs drugs are prescriptions that require special delivery, handling, administration and monitoring by your pharmacist. These drugs are listed in the Providence formulary with a status of, and are available through Providence Pharmacy Services. Learn more about specialty drugs. drugs Making the switch from brand to generic medication can save you money. drugs, which are available only after the brand-name patent expires: Have the same active ingredient formula as the brand-name drug and Are tested by the Food and Drug Administration (FDA) to be as safe and effective as the brand-name drug. There are two types of generic drugs: equivalent - A generic equivalent is a generic drug that has the same active ingredient, dosage form and strength as its brand-name counterpart. The FDA assures i

sameness between brand-name and generic equivalent products. equivalents are an important option to brand-name prescription drugs because they cost less. Example: Zocor, a brand-name drug commonly used to treat high cholesterol, is now available in generic form under the name simvastatin. Zocor and simvastatin are identical drugs the only difference is that one costs more than the other. alternative - A generic alternative is a generic drug used to treat the same condition as a brand-name drug. It is not, however, the exact same medication as the brandname drug. According to clinical evidence, a generic alternative can be expected to treat the same condition as well as the brand-name option. Example: Simvastatin, the generic form of Zocor, may be prescribed instead of Crestor in the treatment of high cholesterol. alternatives are an important option for prescription drugs for which there is no generic available. Visit the Consumer Reports Best-Buy Drug website for more information regarding safe and effective drug treatment options. The Providence formulary Your prescription drug plan provides coverage for medications listed on the Providence formulary. Developed in collaboration with Providence Health Plans, physicians and pharmacists, the formulary includes FDA-approved prescription generic, brand-name and specialty medications. The formulary can help you and your physician choose effective, quality medications that minimize your out-ofpocket expense. Search the formulary There are two ways to search the formulary. They include: 1. By medical condition category (e.g., drugs used to treat heart conditions are listed under the category, Cardiovascular Agents); and 2. By index (provides an alphabetical listing of drugs included in the formulary). Formulary updates The formulary is updated every two months. Providence s Oregon Regional Pharmacy and Therapeutics committee (comprised of doctors and pharmacists who practice in the communities we serve) continuously reviews the latest evidence to identify opportunities to promote safe, effective and affordable drug therapy. Generally, the formulary status of a drug covered by your Providence Health Plan prescription drug coverage will not change during the year unless: The medication becomes available in generic form; There are safety or effectiveness concerns raised about the prescription drug; or The Pharmacy and Therapeutics committee determines that changes to the formulary would be in the best overall interest of Providence Health Plan members. ii

If a change to the formulary results in a reduction of benefits or an increase in member copay, affected individuals are notified in writing. Formulary brand-name drugs The Providence formulary includes prescription drugs that are proven safe, effective and that offer value. Refer to your benefit summary for your brand-name drug copay or coinsurance amount. Remember, even if a generic equivalent is not yet available, safe and effective generic alternatives may be available to treat most common conditions. Using these options can provide cost savings. Non-approved drugs Your prescription drug benefit covers only FDA-approved prescription drugs. It is possible for medications to be on the market without FDA approval. The FDA is taking action to ensure these drugs become approved or are removed from the market. In the meantime, many remain on pharmacy shelves. If the drug you are taking is not FDA approved, know that there are likely approved prescription drugs available to treat your condition. We encourage you to discuss alternative medications with your doctor. Should you and your doctor determine that there is no covered alternative and you choose to continue to take a medication that is not FDA approved, your health plan will not cover that expense. More information regarding medications that are not FDA approved can be found on our website, in the related article and in the FAQ document, which includes links to the FDA website. You may also call the Providence Health Plan pharmacy team for more information and to discuss potential alternatives. Prior authorization Prior authorization is a process to review a prescription drug for coverage before it is dispensed. The prior authorization process is initiated by the prescribing medical provider. Many factors including the potential for serious health risks, FDA-approved indications and costeffectiveness are considered before making the decision to require prior authorization of a prescription medication. A limited number of medications require prior authorization review; any medications requiring prior authorization are indicated as such in the Providence formulary. Keep in mind, the formulary may contain other suitable options. You and your doctor may wish to discuss the possibility of changing your prescription to an effective formulary alternative. Otherwise, your doctor may submit a prior authorization request on your behalf. Formulary exceptions There may be times that you require a medication that is not on the Providence formulary. If you currently take a prescription drug that is not on the formulary, contact customer service to confirm that drug is not covered. If the prescription drug is not covered, your doctor may request a formulary exception. iii

Step therapy Step therapy is a form of prior authorization. Its purpose is to confirm if drugs generally considered "first-line" therapy based on clinical evidence already have been tried. If they have, the drug requiring prior authorization will automatically be approved. In the event these drugs are not tried first, cannot be tried first or the individual s prescription medication history is not part of Providence Health Plan claims history, prior authorization is required. Quantity limit For certain drugs, Providence Health Plan limits the amount of the drug covered for a specified time frame [e.g., Providence Health Plan provides two inhalers per 30 days for Proair or Proventil HFA (albuterol HFA)]. Quantity limits are in place to ensure safe and appropriate use of a drug. Answers to frequently asked questions Learn more about your prescription drug coverage by reviewing answers to frequently asked questions. iv

Analgesics alagesic lq butalbital/acetaminophen butalbital/acetaminophen/caffeine (50-325-40 tablet, 50-500-40 tablet, 50-325-40 capsule) butalbital/aspirin/caffeine capacet tencon 50-325 mg tablet vanatol lq Nonsteroidal Anti-inflammatory Drugs celecoxib (50 mg capsule, 100 mg capsule, 200 mg capsule) PA, QL (2 PER DAY) celecoxib 400 mg capsule PA, QL (1 PER DAY) diclofenac potassium diclofenac sodium (25 mg tablet dr, 50 mg tablet dr, 75 mg tablet dr, 100 mg tab er 24h) diflunisal etodolac (200 mg capsule, 300 mg capsule, 400 mg tab er 24h, 400 mg tablet, 500 mg tablet, 500 mg tab er 24h, 600 mg tab er 24h) fenoprofen calcium 600 mg tablet flurbiprofen (50 mg tablet, 100 mg tablet) ibuprofen (400 mg tablet, 600 mg tablet, 800 mg tablet) ibuprofen/oxycodone hcl indomethacin (25 mg capsule, 50 mg capsule, 75 mg capsule er) 1 LAST UPDATE 08/2015

ketoprofen (50 mg capsule, 75 mg capsule, 200 mg cap24h pel) ketorolac tromethamine 10 mg tablet meclofenamate sodium (50 mg capsule, 100 mg capsule) meloxicam (7.5 mg tablet, 7.5 mg/5ml oral susp, 15 mg tablet) nabumetone (500 mg tablet, 750 mg tablet) NAPRELAN CR 500 MG TABLET naproxen (125 mg/5ml oral susp, 250 mg tablet, 375 mg tablet, 375 mg tablet dr, 500 mg tablet dr, 500 mg tablet) naproxen sodium (275 mg tablet, 550 mg tablet) naproxen sodium 500 mg tbmp 24hr oxaprozin piroxicam (10 mg capsule, 20 mg capsule) sulindac (150 mg tablet, 200 mg tablet) tolmetin sodium Opioid Analgesics, Long-acting fentanyl (12 mcg/hr patch td72, 25mcg/hr patch td72, 50mcg/hr patch td72, 75mcg/hr patch td72, 100 mcg/hr patch td72) levorphanol tartrate 2 mg tablet methadone hcl (5 mg/5 ml solution, 5 mg tablet, 10 mg/5 ml solution, 10 mg/ml oral conc, 10 mg tablet, 40 mg tablet sol) methadone intensol methadose 40 mg tablet dispr QL (15 PER 30 DAYS) 2 LAST UPDATE 08/2015

morphine sulfate (15 mg tablet er, 30 mg tablet er, 60 mg tablet er, 100 mg tablet er, 200 mg tablet er) oxycodone hcl (10 mg tab er 12h, 20 mg tab er 12h, 40 mg tab er 12h, 80 mg tab er 12h) PA, QL (90 PER 30 DAYS) OXYCONTIN PA, QL (90 PER 30 DAYS) tramadol hcl (100 mg tbmp 24hr, 100 mg tab er 24h, 200 mg tbmp 24hr, 200 mg tab er 24h, 300 mg tab er 24h, 300 mg tbmp 24hr) Opioid Analgesics, Short-acting acetaminophen with codeine phosphate (120-12mg/5 solution, 300mg/12.5 solution, 300mg-30mg tablet, 300mg- 60mg tablet, 300mg-15mg tablet) PA (For ages 5 and under) ascomp with codeine PA (For ages 5 and under) butalbit/acetamin/caff/codeine 50-325- 30 capsule butorphanol tartrate 10 mg/ml spray co-gesic codeine phosphate/butalbital/aspirin/caffeine PA (For ages 5 and under) PA (For ages 5 and under) codeine phosphate/carisoprodol/aspirin PA (For ages 5 and under) codeine sulfate (15 mg tablet, 30 mg tablet, 60 mg tablet) dihydrocodeine bitartrate/acetaminophen/caffeine endocet (5-325 tablet, 7.5-325 mg tablet, 7.5-500 mg tablet, 10-325 mg tablet, 10-650 mg tablet) endodan PA (For ages 5 and under) 3 LAST UPDATE 08/2015

hydrocodone bitartrate/acetaminophen (2.5-167/5 solution, 2.5-500 mg tablet, 5 mg-325mg tablet, 5 mg-500mg tablet, 5-334mg/10 solution, 7.5-500/15 solution, 7.5-750mg tablet, 7.5-325/15 solution, 7.5-325mg tablet, 7.5-650 mg tablet, 7.5-500mg tablet, 10-660mg tablet, 10-750mg tablet, 10mg- 650mg tablet, 10mg-500mg tablet, 10mg-325mg tablet) hydrocodone/ibuprofen hydromorphone hcl (1 mg/ml liquid, 2 mg tablet, 3 mg supp.rect, 4 mg tablet, 8 mg tablet) ibudone 5-200 mg tablet lorcet lorcet hd lorcet plus 7.5-325 mg tablet lortab (5-325 mg tablet, 5-500 tablet, 7.5-325 mg tablet, 10-325 mg tablet) meperidine hcl (50 mg tablet, 100 mg tablet) meperitab morphine sulfate (5 mg supp.rect, 10 mg supp.rect, 10 mg/5 ml solution, 15 mg tablet, 20 mg supp.rect, 20 mg/5 ml solution, 30 mg tablet, 30 mg supp.rect, 100 mg/5ml solution) oxycodone hcl (5 mg/5 ml solution, 5 mg capsule, 5 mg tablet, 10 mg tablet, 15 mg tablet, 20 mg/ml oral conc, 20 mg tablet, 30 mg tablet) oxycodone hcl/acetaminophen (5 mg- 500mg capsule, 5 mg-325mg tablet, 7.5-325mg tablet, 7.5-500mg tablet, 10mg-650mg tablet, 10mg-325mg tablet) oxycodone hcl/aspirin 4 LAST UPDATE 08/2015

oxymorphone hcl 10 mg tablet PA, QL (4 PER DAY) oxymorphone hcl 5 mg tablet PA, QL (8 PER DAY) reprexain 10-200 mg tablet ROXICET 5-325 ORAL SOLUTION roxicet 5-325 tablet stagesic tramadol hcl 50 mg tablet tramadol hcl/acetaminophen QL (240 PER 30 DAYS) xylon 10 Anesthetics Local Anesthetics glydo lidocaine 5 % oint. (g) lidocaine 5%(700mg) adh. patch PA, QL (90 PER 30 DAYS) lidocaine hcl (2 % solution, 2 % jel/pf app, 2 % jel (ml), 4 % solution, 40 mg/ml solution) lidocaine/prilocaine (2.5 %-2.5% cream (g), 2.5 %-2.5% kit) relador pak relador pak plus Anti-Addiction/Substance Abuse Treatment Agents Alcohol Deterrents/Anti-craving acamprosate calcium depade disulfiram (250 mg tablet, 500 mg tablet) naltrexone hcl 50 mg tablet 5 LAST UPDATE 08/2015

revia Opioid Antagonists buprenorphine hcl (2 mg tab subl, 8 mg tab subl) buprenorphine hcl/naloxone hcl SUBOXONE (2 MG-0.5 MG FILM, 8 MG- 2 MG FILM) Smoking Cessation Agents buproban CHANTIX Anti-inflammatory Agents Glucocorticoids alclometasone dipropionate amcinonide 0.1 % cream (g) anusol-hc 2.5% cream apexicon apexicon e betamethasone dipropionate (0.05 % lotion, 0.05 % gel (gram), 0.05 % cream (g), 0.05 % oint. (g)) betamethasone dipropionate/propylene glycol (0.05 % cream (g), 0.05 % oint. (g), 0.05 % lotion) betamethasone valerate (0.1 % cream (g), 0.1 % lotion, 0.1 % oint. (g)) clobetasol propionate (0.05 % solution, 0.05 % shampoo, 0.05 % cream (g), 0.05 % foam, 0.05 % oint. (g), 0.05 % gel (gram)) clobetasol propionate/emoll 0.05 % cream (g) QL (90 PER 30 DAYS) 6 LAST UPDATE 08/2015

clobetasol propionate/emoll 0.05 % foam clodan 0.05% shampoo cormax cortisone acetate 25 mg tablet desonide (0.05 % lotion, 0.05 % cream (g), 0.05 % oint. (g)) desoximetasone diflorasone diacetate fludrocortisone acetate 0.1 mg tablet fluocinolone acetonide (0.01 % cream (g), 0.01 % solution, 0.025 % oint. (g), 0.025 % cream (g)) fluocinonide (0.05 % gel (gram), 0.05 % solution, 0.05 % cream (g), 0.05 % oint. (g)) fluocinonide/emollient base fluticasone propionate (0.005 % oint. (g), 0.05 % lotion, 0.05 % cream (g)) halobetasol propionate hydrocortisone (2.5 % lotion, 2.5 % cream (g), 2.5 % oint. (g)) hydrocortisone butyrate 0.1 % cream (g) methylprednisolone millipred 5 mg tablet millipred dp neomycin sulfate/polymyxin b sulfate/hydrocortisone (drops susp, solution) nystatin/triamcinolone acetonide oralone PA 7 LAST UPDATE 08/2015

prednisolone 15 mg/5 ml solution prednisolone sod phosphate (5 mg/5 ml solution, 10 mg tab rapdis, 15 mg tab rapdis, 15 mg/5 ml solution, 30 mg tab rapdis) prednisone (1 mg tablet, 2.5 mg tablet, 5 mg tablet, 5 mg/5 ml solution, 5 mg tab ds pk, 10 mg tablet, 10 mg tab ds pk, 20 mg tablet, 50 mg tablet) prednisone intensol procto-pak proctocream-hc psorcon triamcinolone acetonide (0.025 % cream (g), 0.025 % oint. (g), 0.025 % lotion, 0.1 % lotion, 0.1 % oint. (g), 0.1 % cream (g), 0.1 % paste (g), 0.5 % oint. (g), 0.5 % cream (g)) triderm Antibacterials Aminoglycosides garamycin 0.3% eye drops gentak gentamicin sulfate (0.1 % oint. (g), 0.1 % cream (g), 0.3 % oint. (g), 0.3 % drops) neomycin sulfate 500 mg tablet TOBI PODHALER TOBRADEX EYE OINTMENT tobramycin 0.3 % drops tobramycin in 0.225 % sodium chloride LA TOBREX 0.3% EYE OINTMENT 8 LAST UPDATE 08/2015

Antibacterials, Other acetasol hc acetic acid/aluminum acetate acetic acid/hydrocortisone bacitracin 500 unit/g oint. (g) chlorhexidine gluconate 0.12 % mouthwash clindacin etz 1% pledget clindacin p clindamycin hcl (75 mg capsule, 150 mg capsule, 300 mg capsule) clindamycin palmitate hcl clindamycin phosphate (1 % foam, 1 % lotion, 1 % gel (gram), 1 % med. swab, 1 % solution, 2 % cream/appl) cycloserine 250 mg capsule erythromycin ethylsuccinate/sulfisoxazole acetyl linezolid 600 mg tablet methenamine hippurate metronidazole (0.75 % gel (gram), 0.75 % cream (g), 0.75 % gel w/appl, 0.75 % lotion, 250 mg tablet, 375 mg capsule, 500 mg tablet) MONUROL mupirocin 2 % oint. (g) nitrofurantoin 25 mg/5 ml oral susp nitrofurantoin macrocrystal (50 mg capsule, 100 mg capsule) nitrofurantoin monohydrate/macrocrystals paroex 9 LAST UPDATE 08/2015

periogard rosadan (0.75% gel, 0.75% cream) SIVEXTRO 200 MG TABLET PA tinidazole (250 mg tablet, 500 mg tablet) trimethoprim 100 mg tablet vancomycin hcl (125 mg capsule, 250 mg capsule) vandazole vitazol XIFAXAN 200 MG TABLET PA, QL (90 PER 30 DAYS) XIFAXAN 550 MG TABLET PA, QL (60 PER 30 DAYS) ZYVOX (100 MG/5 ML SUSPENSION, 600 MG TABLET) PA Beta-lactam, Cephalosporins cefaclor (125 mg/5ml susp recon, 250 mg/5ml susp recon, 250 mg capsule, 375 mg/5ml susp recon, 500 mg capsule) cefadroxil (1 g tablet, 250 mg/5ml susp recon, 500 mg capsule, 500 mg/5ml susp recon) cefdinir (125 mg/5ml susp recon, 250 mg/5ml susp recon, 300 mg capsule) cefpodoxime proxetil (50 mg/5 ml susp recon, 100 mg tablet, 100 mg/5ml susp recon, 200 mg tablet) cefprozil (125 mg/5ml susp recon, 250 mg tablet, 250 mg/5ml susp recon, 500 mg tablet) ceftibuten (180 mg/5ml susp recon, 400 mg capsule) CEFTIN (125 ML ORAL SUSP, 250 ML ORAL SUSP) 10 LAST UPDATE 08/2015

cefuroxime axetil cephalexin (125 mg/5ml susp recon, 250 mg tablet, 250 mg capsule, 250 mg/5ml susp recon, 500 mg tablet, 500 mg capsule) Beta-lactam, Penicillins amoxicillin (125 mg tab chew, 125 mg/5ml susp recon, 200 mg/5ml susp recon, 250 mg capsule, 250 mg tab chew, 250 mg/5ml susp recon, 400 mg/5ml susp recon, 500 mg tablet, 500 mg capsule, 875 mg tablet) amoxicillin/potassium clavulanate (200-28.5mg tab chew, 200-28.5/5 susp recon, 250-125 mg tablet, 250-62.5/5 susp recon, 400-57mg tab chew, 400-57mg/5 susp recon, 500-125 mg tablet, 600-42.9/5 susp recon, 875-125 mg tablet, 1000-62.5 tab er 12h) ampicillin trihydrate (250 mg capsule, 500 mg capsule) dicloxacillin sodium penicillin v potassium (125 mg/5ml soln recon, 250 mg tablet, 250 mg/5ml soln recon, 500 mg tablet) Macrolides AZASITE azithromycin (1 g packet, 100 mg/5ml susp recon, 200 mg/5ml susp recon, 250 mg tablet, 500 mg tablet, 600 mg tablet) clarithromycin (125 mg/5ml susp recon, 250 mg/5ml susp recon, 250 mg tablet, 500 mg tab er 24h, 500 mg tablet) DIFICID PA E.E.S. 200 11 LAST UPDATE 08/2015

ERY-TAB erygel ERYPED 200 erythromycin base (5 mg/g oint. (g), 250 mg tablet, 250 mg capsule dr, 500 mg tablet) erythromycin base/ethyl alcohol (2 % solution, 2 % gel (gram)) erythromycin ethylsuccinate 400 mg tablet Quinolones ciprofloxacin hcl (0.3 % drops, 100 mg tablet, 250 mg tablet, 500 mg tablet, 750 mg tablet) ciprofloxacin/ciprofloxa hcl 500 mg tbmp 24hr gatifloxacin levofloxacin (0.5 % drops, 250mg/10ml solution, 250 mg tablet, 500 mg tablet, 750 mg tablet) MOXEZA moxifloxacin hcl 400 mg tablet ofloxacin (0.3 % drops, 200 mg tablet, 300 mg tablet, 400 mg tablet) VIGAMOX Sulfonamides bleph-10 silver sulfadiazine 1 % cream (g) sulfacetamide sodium (10 % drops, 10 % suspension) sulfadiazine 500 mg tablet 12 LAST UPDATE 08/2015

sulfamethoxazole/trimethoprim (200-40mg/5 oral susp, 400mg-80mg tablet, 800-160/20 oral susp, 800-160 mg tablet) sulfamide Tetracyclines avidoxy demeclocycline hcl doxycycline hyclate (20 mg tablet, 50 mg capsule, 100 mg capsule, 100 mg tablet) doxycycline monohydrate (50 mg capsule, 50 mg tablet, 75 mg tablet, 100 mg tablet, 100 mg capsule, 150 mg tablet) dynacin 100 mg tablet minocycline hcl (50 mg capsule, 75 mg capsule, 100 mg capsule, 100 mg tablet) morgidox 100 mg capsule OCUDOX tetracycline hcl (250 mg capsule, 500 mg capsule) Anticonvulsants Anticonvulsants, Other acetazolamide (125 mg tablet, 250 mg tablet) levetiracetam (100 mg/ml solution, 250 mg tablet, 500 mg/5ml solution, 500 mg tablet, 750 mg tablet, 1000 mg tablet) primidone (50 mg tablet, 250 mg tablet) 13 LAST UPDATE 08/2015

Calcium Channel Modifying Agents CELONTIN ethosuximide (250 mg/5ml solution, 250 mg capsule) LYRICA (20 MG/ML ORAL SOLUTION, 25 MG CAPSULE, 50 MG CAPSULE, 75 MG CAPSULE, 100 MG CAPSULE, 150 MG CAPSULE, 200 MG CAPSULE, 225 MG CAPSULE, 300 MG CAPSULE) zonisamide (25 mg capsule, 50 mg capsule, 100 mg capsule) PA Gamma-aminobutyric Acid (GABA) Augmenting Agents DIASTAT diazepam (5-7.5-10mg kit, 12.5-15-20 kit) diazepam 2.5 mg kit divalproex sodium gabapentin (100 mg capsule, 250 mg/5ml solution, 300 mg capsule, 400 mg capsule, 600 mg tablet, 800 mg tablet) GABITRIL (12 MG TABLET, 16 MG TABLET) ONFI (5 MG TABLET, 10 MG TABLET, 20 MG TABLET) ONFI 2.5 MG/ML SUSPENSION PA phenobarbital (15 mg tablet, 16.2 mg tablet, 20 mg/5 ml elixir, 30 mg tablet, 32.4 mg tablet, 60 mg tablet, 64.8 mg tablet, 97.2mg tablet, 100 mg tablet) SABRIL LA tiagabine hcl valproic acid (as sodium salt) (valproate sodium) (250 mg/5ml solution, 500 mg/5ml vial, 500mg/10ml solution) PA, QL (60 PER 30 DAYS) 14 LAST UPDATE 08/2015

valproic acid 250 mg capsule Glutamate Reducing Agents felbamate (400 mg tablet, 600 mg tablet, 600 mg/5ml oral susp) lamotrigine (5 mg tb chw dsp, 25 mg tablet, 25mg (35) tab ds pk, 25 mg tb chw dsp, 100 mg tablet, 150 mg tablet, 200 mg tablet) topiragen topiramate (15 mg cap sprink, 25 mg cap sprink, 25 mg tablet, 50 mg tablet, 100 mg tablet, 200 mg tablet) topiramate (25 mg cap spr 24, 50 mg cap spr 24, 100 mg cap spr 24, 150 mg cap spr 24, 200 mg cap spr 24) PA Sodium Channel Agents APTIOM PA BANZEL (40 MG/ML SUSPENSION, 200 MG TABLET, 400 MG TABLET) carbamazepine (100 mg cpmp 12hr, 100 mg tab chew, 100 mg/5ml oral susp, 200 mg tablet, 200 mg tab er 12h, 200 mg cpmp 12hr, 300 mg cpmp 12hr, 400 mg tab er 12h) DILANTIN 30 MG CAPSULE epitol EQUETRO oxcarbazepine (150 mg tablet, 300 mg tablet, 300 mg/5ml oral susp, 600 mg tablet) phenytoin (50 mg tab chew, 100 mg/4ml oral susp, 125 mg/5ml oral susp) phenytoin sodium extended (100 mg capsule, 200 mg capsule) PA 15 LAST UPDATE 08/2015

VIMPAT (10 MG/ML SOLUTION, 50 MG TABLET, 100 MG TABLET, 150 MG TABLET, 200 MG TABLET) ziprasidone hcl 20 mg capsule PA Antidementia Agents Cholinesterase Inhibitors donepezil hcl (5 mg tab rapdis, 5 mg tablet, 10 mg tablet, 10 mg tab rapdis) EXELON (2 MG/ML ORAL SOLUTION, 4.6 MG/24HR PATCH, 9.5 MG/24HR PATCH, 13.3 MG/24HR PATCH) rivastigmine tartrate N-methyl-D-aspartate (NMDA) Receptor Antagonist memantine hcl (5 mg tablet, 10 mg tablet) memantine hcl 5 mg-10 mg tab ds pk PA PA, QL (60 PER 30 DAYS) NAMENDA 10 MG/5 ML SOLUTION PA, QL (360 ML PER 30 DAYS) Antidepressants Antidepressants, Other ABILIFY 1 MG/ML SOLUTION ABILIFY DISCMELT aripiprazole budeprion sr bupropion hcl (75 mg tablet, 100 mg tablet er, 100 mg tablet, 150 mg tab er 24h, 150 mg tablet er, 200 mg tablet er, 300 mg tab er 24h) maprotiline hcl 75 mg tablet mirtazapine (7.5 mg tablet, 15 mg tablet, 15 mg tab rapdis, 30 mg tablet, 30 mg tab rapdis, 45 mg tablet, 45 mg tab rapdis) 16 LAST UPDATE 08/2015

nefazodone hcl olanzapine/fluoxetine hcl perphenazine/amitriptyline hcl trazodone hcl (50 mg tablet, 100 mg tablet, 150 mg tablet, 300 mg tablet) Monoamine Oxidase Inhibitors MARPLAN phenelzine sulfate 15 mg tablet tranylcypromine sulfate Serotonin/Norepinephrine Reuptake Inhibitors citalopram hydrobromide (10 mg tablet, 10 mg/5 ml solution, 20 mg tablet, 40 mg tablet) duloxetine hcl (20 mg capsule dr, 30 mg capsule dr) QL (60 PER 30 DAYS) duloxetine hcl 60 mg capsule dr QL (30 PER 30 DAYS) escitalopram oxalate (5 mg tablet, 5 mg/5 ml solution, 10 mg tablet, 20 mg tablet) fluoxetine hcl (10 mg tablet, 10 mg capsule, 20 mg tablet, 20 mg/5 ml solution, 20 mg capsule, 40 mg capsule, 60 mg tablet, 90 mg capsule dr) fluvoxamine maleate (25 mg tablet, 50 mg tablet, 100 mg tablet) paroxetine hcl (10 mg tablet, 20 mg tablet, 30 mg tablet, 40 mg tablet) PAXIL 10 MG/5 ML SUSPENSION sertraline hcl (20 mg/ml oral conc, 25 mg tablet, 50 mg tablet, 100 mg tablet) 17 LAST UPDATE 08/2015

venlafaxine hcl (25 mg tablet, 37.5 mg cap er 24h, 37.5 mg tab er 24, 37.5 mg tablet, 50 mg tablet, 75 mg cap er 24h, 75 mg tab er 24, 75 mg tablet, 100 mg tablet, 150 mg cap er 24h, 150 mg tab er 24) venlafaxine hcl 225 mg tab er 24 Tricyclics amitriptyline hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 75 mg tablet, 100 mg tablet, 150 mg tablet) amoxapine clomipramine hcl (25 mg capsule, 50 mg capsule, 75 mg capsule) desipramine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 75 mg tablet, 100 mg tablet, 150 mg tablet) doxepin hcl (10 mg/ml oral conc, 10 mg capsule, 25 mg capsule, 50 mg capsule, 75 mg capsule, 100 mg capsule, 150 mg capsule) imipramine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet) imipramine pamoate nortriptyline hcl (10 mg/5 ml solution, 10 mg capsule, 25 mg capsule, 50 mg capsule, 75 mg capsule) protriptyline hcl trimipramine maleate (25 mg capsule, 50 mg capsule) Antiemetics Antiemetics, Other chlorpromazine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 100 mg tablet, 200 mg tablet) 18 LAST UPDATE 08/2015

compro DICLEGIS QL (60 PER 30 DAYS) hydroxyzine hcl (10 mg tablet, 10 mg/5 ml solution, 25 mg tablet, 50 mg tablet) hydroxyzine pamoate (25 mg capsule, 50 mg capsule, 100 mg capsule) metoclopramide hcl (5 mg tablet, 5 mg/5 ml solution, 10 mg tablet, 10 mg/10ml solution) perphenazine (2 mg tablet, 4 mg tablet, 8 mg tablet, 16 mg tablet) phenadoz prochlorperazine prochlorperazine maleate (5 mg tablet, 10 mg tablet) promethazine hcl (6.25mg/5ml syrup, 12.5 mg supp.rect, 12.5 mg tablet, 25 mg tablet, 25 mg supp.rect, 50 mg supp.rect, 50 mg tablet) promethegan TRANSDERM-SCOP trimethobenzamide hcl 300 mg capsule Emetogenic Therapy Adjuncts EMEND (80 MG CAPSULE, 125 MG CAPSULE, TRIFOLD PACK) QL (4 PER 30 DAYS) granisetron hcl 1 mg tablet PA, QL (8 PER 30 DAYS) ondansetron ondansetron hcl (4 mg/5 ml solution, 4 mg tablet, 8 mg tablet) Antifungals ciclodan 0.77% cream 19 LAST UPDATE 08/2015

ciclopirox (0.77 % gel (gram), 1 % shampoo) ciclopirox olamine (0.77 % cream (g), 0.77 % suspension) clotrimazole 10 mg troche econazole nitrate 1 % cream (g) fluconazole (10 mg/ml susp recon, 40 mg/ml susp recon, 50 mg tablet, 100 mg tablet, 150 mg tablet, 200 mg tablet) griseofulvin ultramicrosize 250 mg tablet griseofulvin, microsize (125 mg/5ml oral susp, 500 mg tablet) itraconazole 100 mg capsule PA ketoconazole (2 % cream (g), 2 % shampoo) LAMISIL 187.5 MG GRANULES PACK PA NATACYN NOXAFIL (40 MG/ML SUSPENSION, DR 100 MG TABLET) nyamyc nystatin (50mm unit powder(ea), 150mm unit powder(ea), 500mm unit powder(ea), 500k unit tablet, 100000/ml oral susp, 100000/g powder, 100000/g cream (g), 100000/g oint. (g)) nystop pedi-dri SPORANOX 10 MG/ML SOLUTION PA terbinafine hcl 250 mg tablet terconazole (0.4 % cream/appl, 0.8 % cream/appl, 80 mg supp.vag) voriconazole 200 mg/5ml susp recon 20 LAST UPDATE 08/2015

Antigout Agents allopurinol (100 mg tablet, 300 mg tablet) colchicine 0.6 mg tablet QL (60 PER 30 DAYS) colchicine/probenecid COLCRYS QL (60 PER 30 DAYS) probenecid Antimigraine Agents Ergot Alkaloids cafergot dihydroergotamine mesylate 0.5mg/spry spray/pump ergotamine tartrate/caffeine migergot QL (3.5 ML PER 30 DAYS) MIGRANAL QL (3.5 ML PER 30 DAYS) Prophylactic timolol maleate (5 mg tablet, 10 mg tablet, 20 mg tablet) Serotonin (5-HT) 1b/1d Receptor Agonists rizatriptan benzoate QL (24 PER 30 DAYS) sumatriptan (5 mg spray, 20 mg spray) QL (6 PER 30 DAYS) sumatriptan succinate (25 mg tablet, 50 mg tablet, 100 mg tablet) sumatriptan succinate (4 pen injctr, 4 cartridge, 6 pen injctr, 6 syringe, 6 cartridge, 6 vial) zolmitriptan (2.5 mg tab rapdis, 2.5 mg tablet, 5 mg tab rapdis, 5 mg tablet) QL (18 PER 30 DAYS) QL (2 ML PER 30 DAYS) QL (12 PER 30 DAYS) ZOMIG (2.5 MG SPRAY, 5 MG SPRAY) QL (12 PER 30 DAYS) 21 LAST UPDATE 08/2015

Antimyasthenic Agents Parasympathomimetics guanidine hcl MESTINON 60 MG/5 ML SYRUP pyridostigmine bromide (60 mg tablet, 180 mg tablet er) Antimycobacterials Antimycobacterials, Other dapsone (25 mg tablet, 100 mg tablet) rifabutin Antituberculars ethambutol hcl isoniazid (50 mg/5 ml solution, 100 mg tablet, 300 mg tablet) PRIFTIN RIFAMATE rifampin (150 mg capsule, 300 mg capsule) RIFATER SIRTURO LA TRECATOR Antineoplastics Alkylating Agents ALKERAN 2 MG TABLET PA CEENU CYCLOPHOSPHAMIDE CAPSULES 22 LAST UPDATE 08/2015

cyclophosphamide tablets GLEOSTINE LEUKERAN lomustine MATULANE temozolomide PA VALCHLOR LA Antiangiogenic Agents POMALYST PA REVLIMID PA, LA THALOMID Antiestrogens/Modifiers EMCYT FARESTON SOLTAMOX tamoxifen citrate (10 mg tablet, 20 mg tablet) Antimetabolites capecitabine DROXIA hydroxyurea 500 mg capsule mercaptopurine 50 mg tablet methotrexate sodium (2.5 mg tablet, 25 mg/ml vial) methotrexate sodium/pf (1 g vial, 25 mg/ml vial) PURIXAN RHEUMATREX 23 LAST UPDATE 08/2015

Antineoplastics, Other ALFERON N FARYDAK PA, QL (6 PER 21 DAYS) HEXALEN imiquimod 5 % cream pack INTRON A (6 MILLION UNIT/ML VL, 10 MILLION UNIT/ML, 10 MILLION UNITS VIL, 18 MILLION UNITS VIL, 50 MILLION UNITS VIL) IRESSA PA leucovorin calcium (5 mg tablet, 10 mg tablet, 15 mg tablet, 25 mg tablet) MESNEX 400 MG TABLET SYLATRON PA SYLATRON 4-PACK PA SYNRIBO PA Aromatase Inhibitors, 3rd Generation anastrozole 1 mg tablet exemestane letrozole 2.5 mg tablet Enzyme Inhibitors BOSULIF PA GILOTRIF PA HYCAMTIN (0.25 MG CAPSULE, 1 MG CAPSULE) IMBRUVICA PA INLYTA PA, LA JAKAFI PA, LA LYNPARZA PA, LA PA 24 LAST UPDATE 08/2015

MEKINIST PA TAFINLAR PA VOTRIENT PA ZELBORAF PA ZYTIGA PA Molecular Target Inhibitors AFINITOR PA AFINITOR DISPERZ PA CAPRELSA PA COMETRIQ PA, LA ERIVEDGE PA GLEEVEC PA IBRANCE PA ICLUSIG PA LENVIMA PA, LA NEXAVAR PA SPRYCEL PA STIVARGA PA SUTENT PA TARCEVA PA TASIGNA PA TYKERB PA vandetanib PA XALKORI PA, LA ZOLINZA PA ZYDELIG PA, QL (60 PER 30 DAYS) ZYKADIA PA 25 LAST UPDATE 08/2015

Retinoids bexarotene PA PANRETIN TARGRETIN 1% GEL PA tretinoin 10 mg capsule PA Antiparasitics Anthelmintics ALBENZA ivermectin 3 mg tablet SOOLANTRA ST, QL (30 GM PER 30 DAYS) Antiprotozoals ALINIA (100 MG/5 ML SUSPENSION, 500 MG TABLET) atovaquone PA chloroquine phosphate (250 mg tablet, 500 mg tablet) DARAPRIM PA hydroxychloroquine sulfate 200 mg tablet mefloquine hcl PA primaquine phosphate PA PA Pediculicides/Scabicides elimite lindane permethrin 5 % cream (g) ULESFIA 26 LAST UPDATE 08/2015

Antiparkinson Agents Anticholinergics benztropine mesylate (0.5 mg tablet, 1 mg tablet, 2 mg tablet) trihexyphenidyl hcl (2 mg tablet, 5 mg tablet) Antiparkinson Agents, Other amantadine hcl (50 mg/5 ml solution, 100 mg tablet, 100 mg capsule) carbidopa/levodopa/entacapone entacapone Dopamine Agonists bromocriptine mesylate (2.5 mg tablet, 5 mg capsule) pramipexole di-hcl (0.125 mg tablet, 0.25 mg tablet, 0.5 mg tablet, 0.75 mg tablet, 1 mg tablet, 1.5 mg tablet) ropinirole hcl (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet, 2 mg tablet, 3 mg tablet, 4 mg tablet, 5 mg tablet) Dopamine Precursors/ L-Amino Acid Decarboxylase Inhibitors carbidopa 25 mg tablet carbidopa/levodopa (10mg-100mg tablet, 25mg-250mg tablet, 25mg- 100mg tablet er, 25mg-100mg tablet, 50mg-200mg tablet er) Monoamine Oxidase B (MAO-B) Inhibitors AZILECT selegiline hcl (5 mg tablet, 5 mg capsule) 27 LAST UPDATE 08/2015

Antipsychotics 1st Generation/Typical fluphenazine hcl (1 mg tablet, 2.5 mg tablet, 5 mg tablet, 10 mg tablet) haloperidol (0.5 mg tablet, 1 mg tablet, 2 mg tablet, 5 mg tablet, 10 mg tablet, 20 mg tablet) haloperidol lactate 2 mg/ml oral conc loxapine succinate ORAP thioridazine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 100 mg tablet) thiothixene trifluoperazine hcl 2nd Generation/Atypical INVEGA LATUDA PA, QL (30 PER 30 DAYS) olanzapine (2.5 mg tablet, 5 mg tablet, 5 mg tab rapdis, 7.5 mg tablet, 10 mg tab rapdis, 10 mg tablet, 15 mg tab rapdis, 15 mg tablet, 20 mg tablet, 20 mg tab rapdis) quetiapine fumarate RISPERDAL CONSTA 12.5 MG SYR risperidone (0.25 mg tablet, 0.5 mg tablet, 1 mg/ml solution, 1 mg tablet, 2 mg tablet, 3 mg tab rapdis, 3 mg tablet, 4 mg tablet) SAPHRIS PA ziprasidone hcl (40 mg capsule, 60 mg capsule, 80 mg capsule) 28 LAST UPDATE 08/2015

Treatment-Resistant clozapine VERSACLOZ Antispasticity Agents baclofen (10 mg tablet, 20 mg tablet) dantrolene sodium (25 mg capsule, 50 mg capsule) MYRBETRIQ PA tizanidine hcl (2 mg tablet, 4 mg tablet) Antivirals Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors EDURANT INTELENCE nevirapine (200 mg tablet, 400 mg tab er 24h) SUSTIVA VIRAMUNE XR 100 MG TABLET Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors abacavir sulfate abacavir sulfate/lamivudine/zidovudine COMPLERA didanosine EMTRIVA (10 MG/ML SOLUTION, 200 MG CAPSULE) EPZICOM lamivudine (10 mg/ml solution, 150 mg tablet, 300 mg tablet) 29 LAST UPDATE 08/2015

lamivudine/zidovudine stavudine (20 mg capsule, 30 mg capsule, 40 mg capsule) TRUVADA VIREAD (150 MG TABLET, 200 MG TABLET, 250 MG TABLET, 300 MG TABLET, POWDER) zidovudine (100 mg capsule, 300 mg tablet) Anti-HIV Agents, Other ATRIPLA FUZEON ISENTRESS (100 MG POWDER PACKET, 400 MG TABLET) SELZENTRY STRIBILD TIVICAY TRIUMEQ TYBOST VITEKTA Anti-HIV Agents, Protease Inhibitors APTIVUS (100 MG/ML SOLUTION, 250 MG CAPSULE) CRIXIVAN 400 MG CAPSULE EVOTAZ INVIRASE KALETRA (100-25 MG TABLET, 200-50 MG TABLET) LEXIVA (50 MG/ML SUSPENSION, 700 MG TABLET) NORVIR (100 MG TABLET, 100 MG SOFTGEL CAP) 30 LAST UPDATE 08/2015

PREZCOBIX PREZISTA (75 MG TABLET, 100 MG/ML SUSPENSION, 150 MG TABLET, 400 MG TABLET, 600 MG TABLET, 800 MG TABLET) REYATAZ VIRACEPT Anti-cytomegalovirus (CMV) Agents VALCYTE 50 MG/ML SOLUTION valganciclovir hcl QL (60 PER 30 DAYS) ZIRGAN Anti-influenza Agents rimantadine hcl TAMIFLU (6 MG/ML SUSPENSION, 30 MG CAPSULE, 45 MG CAPSULE, 75 MG CAPSULE) Antihepatitis Agents adefovir dipivoxil BARACLUDE 0.05 MG/ML SOLUTION entecavir EPIVIR HBV 25 MG/5 ML SOLN HARVONI PA, QL (28 PER 28 DAYS) INCIVEK INFERGEN lamivudine 100 mg tablet MODERIBA OLYSIO PA, QL (28 PER 28 DAYS) PEGASYS (180 MCG/ML VIAL, 180 MCG/0.5 ML SYRINGE) PEGASYS PROCLICK 31 LAST UPDATE 08/2015

PEGINTRON PEGINTRON REDIPEN REBETOL 40 MG/ML SOLUTION RIBAPAK RIBASPHERE RIBASPHERE RIBAPAK RIBATAB ribavirin (200 mg capsule, 200 mg tablet, 400 mg tablet, 600 mg tablet) SOVALDI PA, QL (28 PER 28 DAYS) TYZEKA VICTRELIS PA VIEKIRA PAK PA, QL (112 PER 28 DAYS) Antiherpetic Agents acyclovir (200 mg capsule, 200 mg/5ml oral susp, 400 mg tablet, 800 mg tablet) DENAVIR PA famciclovir trifluridine 1 % drops valacyclovir hcl (500 mg tablet, 1000 mg tablet) Anxiolytics Anxiolytics, Other alprazolam (0.25 mg tablet, 0.5 mg tab er 24h, 0.5 mg tablet, 1 mg tablet, 1 mg tab er 24h, 2 mg tablet, 2 mg tab er 24h, 3 mg tab er 24h) buspirone hcl (5 mg tablet, 7.5 mg tablet, 10 mg tablet, 15 mg tablet, 30 mg tablet) 32 LAST UPDATE 08/2015

chlordiazepoxide hcl clonazepam (0.125 mg tab rapdis, 0.25 mg tab rapdis, 0.5 mg tablet, 0.5 mg tab rapdis, 1 mg tab rapdis, 1 mg tablet, 2 mg tab rapdis, 2 mg tablet) clorazepate dipotassium diazepam (2 mg tablet, 5 mg/5 ml solution, 5 mg tablet, 10 mg tablet) lorazepam (0.5 mg tablet, 1 mg tablet, 2 mg tablet, 2 mg/ml oral conc) lorazepam intensol meprobamate 400 mg tablet oxazepam Bipolar Agents Mood Stabilizers lithium carbonate (150 mg capsule, 300 mg tablet er, 300 mg tablet, 300 mg capsule, 450 mg tablet er, 600 mg capsule) lithium citrate Blood Glucose Regulators Antidiabetic Agents acarbose ACTOPLUS MET XR BYDUREON ST BYDUREON PEN ST BYETTA ST chlorpropamide FARXIGA PA 33 LAST UPDATE 08/2015

glimepiride glipizide (2.5 mg tab er 24, 5 mg tablet, 5 mg tab er 24, 10 mg tab er 24, 10 mg tablet) glipizide/metformin hcl glyburide glyburide,micronized glyburide/metformin hcl INVOKAMET PA INVOKANA PA JANUMET PA JANUMET XR PA JANUVIA PA JARDIANCE PA JENTADUETO PA KAZANO PA KOMBIGLYZE XR PA metformin hcl (500 mg tablet, 500 mg tab er 24h, 750 mg tab er 24h, 850 mg tablet, 1000 mg tablet) nateglinide NESINA PA ONGLYZA PA OSENI PA pioglitazone hcl pioglitazone hcl/glimepiride pioglitazone hcl/metformin hcl RIOMET SYMLINPEN 120 PA SYMLINPEN 60 PA 34 LAST UPDATE 08/2015

TRADJENTA PA VICTOZA 2-PAK ST VICTOZA 3-PAK ST XIGDUO XR PA Glycemic Agents GLUCAGEN 1MG HYPOKIT GLUCAGON EMERGENCY KIT PROGLYCEM Insulins APIDRA APIDRA SOLOSTAR HUMALOG HUMALOG KWIKPEN HUMALOG MIX 50-50 HUMALOG MIX 50-50 KWIKPEN HUMALOG MIX 75-25 HUMALOG MIX 75-25 KWIKPEN HUMULIN 70-30 HUMULIN 70/30 KWIKPEN HUMULIN N HUMULIN N KWIKPEN HUMULIN R HUMULIN R U-500 LANTUS LANTUS SOLOSTAR LEVEMIR LEVEMIR FLEXPEN LEVEMIR FLEXTOUCH 35 LAST UPDATE 08/2015

NOVOLIN 70-30 NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX 70-30 NOVOLOG MIX 70-30 FLEXPEN TOUJEO SOLOSTAR Blood Products/Modifiers/ Volume Expanders Anticoagulants ELIQUIS enoxaparin sodium (30mg/0.3ml syringe, 40mg/0.4ml syringe, 60mg/0.6ml syringe, 80mg/0.8ml syringe, 100 mg/ml syringe, 120mg/.8ml syringe, 150 mg/ml syringe) fondaparinux sodium FRAGMIN jantoven PRADAXA SAVAYSA warfarin sodium (1 mg tablet, 2 mg tablet, 2.5 mg tablet, 3 mg tablet, 4 mg tablet, 5 mg tablet, 6 mg tablet, 7.5 mg tablet, 10 mg tablet) XARELTO Blood Formation Modifiers anagrelide hcl ARANESP PA 36 LAST UPDATE 08/2015

EPOGEN PA GRANIX LEUKINE (250 MCG VIAL, 500 MCG/ML VIAL) NEULASTA NEUMEGA NEUPOGEN PROCRIT PA PROMACTA PA Coagulants tranexamic acid 650 mg tablet Platelet Modifying Agents AGGRENOX aspirin/dipyridamole BRILINTA cilostazol clopidogrel bisulfate 75 mg tablet dipyridamole (25 mg tablet, 50 mg tablet, 75 mg tablet) EFFIENT ticlopidine hcl Cardiovascular Agents Alpha-adrenergic Agonists clonidine clonidine hcl (0.1 mg tablet, 0.2 mg tablet, 0.3 mg tablet) guanfacine hcl (1 mg tablet, 2 mg tablet) 37 LAST UPDATE 08/2015

methyldopa midodrine hcl Alpha-adrenergic Blocking Agents doxazosin mesylate (1 mg tablet, 2 mg tablet, 4 mg tablet, 8 mg tablet) prazosin hcl (1 mg capsule, 2 mg capsule, 5 mg capsule) terazosin hcl Angiotensin II Receptor Antagonists candesartan cilexetil irbesartan losartan potassium valsartan Angiotensin-converting Enzyme (ACE) Inhibitors benazepril hcl (5 mg tablet, 10 mg tablet, 20 mg tablet, 40 mg tablet) captopril (12.5 mg tablet, 25 mg tablet, 50 mg tablet, 100 mg tablet) enalapril maleate (2.5 mg tablet, 5 mg tablet, 10 mg tablet, 20 mg tablet) EPANED fosinopril sodium lisinopril (2.5 mg tablet, 5 mg tablet, 10 mg tablet, 20 mg tablet, 30 mg tablet, 40 mg tablet) moexipril hcl perindopril erbumine quinapril hcl ramipril trandolapril 38 LAST UPDATE 08/2015

Antiarrhythmics amiodarone hcl (100 mg tablet, 200 mg tablet, 400 mg tablet) disopyramide phosphate flecainide acetate mexiletine hcl (150 mg capsule, 200 mg capsule, 250 mg capsule) MULTAQ NORPACE CR pacerone 200 mg tablet propafenone hcl quinidine gluconate 324 mg tablet er quinidine sulfate (200 mg tablet, 300 mg tablet er, 300 mg tablet) sorine sotalol hcl (80 mg tablet, 120 mg tablet, 160 mg tablet, 240 mg tablet) TIKOSYN verapamil hcl (40 mg tablet, 80 mg tablet, 120 mg tablet) Beta-adrenergic Blocking Agents acebutolol hcl (200 mg capsule, 400 mg capsule) atenolol (25 mg tablet, 50 mg tablet, 100 mg tablet) betaxolol hcl (10 mg tablet, 20 mg tablet) bisoprolol fumarate carvedilol COREG CR labetalol hcl (100 mg tablet, 200 mg tablet, 300 mg tablet) 39 LAST UPDATE 08/2015

LEVATOL metoprolol succinate metoprolol tartrate (25 mg tablet, 50 mg tablet, 100 mg tablet) nadolol (20 mg tablet, 40 mg tablet, 80 mg tablet) pindolol propranolol hcl (10 mg tablet, 20 mg tablet, 40 mg tablet, 40mg/5ml solution, 60 mg cap sa 24h, 60 mg tablet, 80 mg tablet, 80 mg cap sa 24h, 120 mg cap sa 24h, 160 mg cap sa 24h) Calcium Channel Blocking Agents afeditab cr amlodipine besylate (2.5 mg tablet, 5 mg tablet, 10 mg tablet) CARDIZEM LA 120 MG TABLET cartia xt dilt-cd dilt-xr diltia xt 40 LAST UPDATE 08/2015

diltiazem hcl (30 mg tablet, 60 mg cap er 12h, 60 mg tablet, 90 mg cap er 12h, 90 mg tablet, 120 mg cap er 12h, 120 mg cap er 24h, 120 mg cap er deg, 120 mg capsule er, 120 mg tablet, 180 mg cap er 24h, 180 mg tab er 24h, 180 mg capsule er, 180 mg cap er deg, 240 mg tab er 24h, 240 mg cap er deg, 240 mg cap er 24h, 240 mg capsule er, 300 mg capsule er, 300 mg tab er 24h, 300 mg cap er 24h, 360 mg cap er 24h, 360 mg capsule er, 360 mg tab er 24h, 420mg tab er 24h, 420mg capsule er) diltzac er felodipine isradipine matzim la nicardipine hcl (20 mg capsule, 30 mg capsule) nifediac cc nifedical xl nifedipine (30 mg tab er 24, 30 mg tablet er, 60 mg tablet er, 60 mg tab er 24, 90 mg tab er 24, 90 mg tablet er) nimodipine 30 mg capsule nisoldipine taztia xt verapamil hcl (100 mg cap24h pct, 120 mg tablet er, 120 mg cap24h pel, 180 mg tablet er, 180 mg cap24h pel, 200 mg cap24h pct, 240 mg cap24h pel, 240 mg tablet er, 300 mg cap24h pct, 360 mg cap24h pel) Cardiovascular Agents, Other amiloride hcl/hydrochlorothiazide amlodipine besylate/atorvastatin calcium 41 LAST UPDATE 08/2015

amlodipine besylate/benazepril hcl atenolol/chlorthalidone benazepril hcl/hydrochlorothiazide bisoprolol fumarate/hydrochlorothiazide captopril/hydrochlorothiazide digitek digox digoxin (50 mcg/ml solution, 125 mcg tablet, 250 mcg tablet) enalapril maleate/hydrochlorothiazide fosinopril sodium/hydrochlorothiazide irbesartan/hydrochlorothiazide LANOXIN (62.5 MCG TABLET, 187.5 MCG TABLET) lisinopril/hydrochlorothiazide losartan potassium/hydrochlorothiazide methyldopa/hydrochlorothiazide metoprolol tartrate/hydrochlorothiazide moexipril hcl/hydrochlorothiazide nadolol/bendroflumethiazide pentoxifylline 400 mg tablet er propranolol hcl/hydrochlorothiazide quinapril hcl/hydrochlorothiazide RANEXA spironolactone/hydrochlorothiazide triamterene/hydrochlorothiazide valsartan/hydrochlorothiazide 42 LAST UPDATE 08/2015

Diuretics, Carbonic Anhydrase Inhibitors acetazolamide 500 mg capsule er methazolamide (25 mg tablet, 50 mg tablet) Diuretics, Loop bumetanide (0.5 mg tablet, 1 mg tablet, 2 mg tablet) EDECRIN furosemide (10 mg/ml solution, 20 mg tablet, 40 mg tablet, 80 mg tablet) torsemide (5 mg tablet, 10 mg tablet, 20 mg tablet, 100 mg tablet) Diuretics, Potassium-sparing amiloride hcl DYRENIUM eplerenone spironolactone (25 mg tablet, 50 mg tablet, 100 mg tablet) Diuretics, Thiazide chlorothiazide chlorthalidone hydrochlorothiazide (12.5 mg capsule, 12.5 mg tablet, 25 mg tablet, 50 mg tablet) indapamide methyclothiazide metolazone Dyslipidemics, Fibric Acid Derivatives fenofibrate (54 mg tablet, 160 mg tablet) 43 LAST UPDATE 08/2015

fenofibrate nanocrystallized fenofibrate,micronized (67 mg capsule, 134mg capsule, 200 mg capsule) fenofibric acid fenofibric acid (choline) gemfibrozil 600 mg tablet lofibra TRIGLIDE Dyslipidemics, HMG CoA Reductase Inhibitors atorvastatin calcium CRESTOR fluvastatin sodium lovastatin pravastatin sodium simvastatin (5 mg tablet, 10 mg tablet, 20 mg tablet, 40 mg tablet) Dyslipidemics, Other cholestyramine (with sugar) (4 g powder, 4 g powd pack) cholestyramine/aspartame (4 g powd pack, 4 g powder) COLESTID FLAVORED GRANULES colestid granules colestipol hcl (1 g tablet, 5 g packet, 5 g granules) JUXTAPID PA, LA KYNAMRO PA, LA prevalite (packet, powder) ZETIA PA 44 LAST UPDATE 08/2015

Vasodilators, Direct-acting Arterial hydralazine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 100 mg tablet) minoxidil (2.5 mg tablet, 10 mg tablet) RECTIV Vasodilators, Direct-acting Arterial/Venous DILATRATE-SR isochron isosorbide dinitrate isosorbide mononitrate minitran NITRO-BID NITRO-DUR (0.3 PATCH, 0.8 PATCH) nitro-time nitroglycerin (0.1mg/hr patch td24, 0.2mg/hr patch td24, 0.4mg/hr patch td24, 0.6mg/hr patch td24, 2.5 mg capsule er, 6.5 mg capsule er, 9 mg capsule er, 400mcg/spr spray) NITROSTAT Central Nervous System Agents Attention Deficit Hyperactivity Disorder Agents, Amphetamines dextroamphetamine sulfsaccharate/amphetamine sulfaspartate dextroamphetamine sulfate (5 mg tablet, 5 mg capsule er, 10 mg tablet, 10 mg capsule er, 15 mg capsule er) VYVANSE zenzedi (5 mg tablet, 10 mg tablet) 45 LAST UPDATE 08/2015

Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines DAYTRANA PA, QL (30 PER 30 DAYS) dexmethylphenidate hcl (2.5 mg tablet, 5 mg tablet, 10 mg tablet) dexmethylphenidate hcl (5 mg cpbp 50-50, 10 mg cpbp 50-50, 15 mg cpbp 50-50, 20 mg cpbp 50-50, 30 mg cpbp 50-50, 40 mg cpbp 50-50) FOCALIN XR (25 MG CAPSULE, 35 MG CAPSULE) guanfacine hcl (1 mg tab er 24h, 2 mg tab er 24h, 3 mg tab er 24h, 4 mg tab er 24h) metadate er methylphenidate hcl (5 mg tablet, 5 mg/5 ml solution, 10 mg tablet, 10 mg tablet er, 10 mg/5 ml solution, 10 mg cpbp 30-70, 18 mg tab er 24, 20 mg cpbp 30-70, 20 mg tablet, 20 mg cpbp 50-50, 20 mg tablet er, 27 mg tab er 24, 30 mg cpbp 50-50, 30 mg cpbp 30-70, 36 mg tab er 24, 40 mg cpbp 50-50, 40 mg cpbp 30-70, 50 mg cpbp 30-70, 54 mg tab er 24, 60 mg cpbp 30-70) RITALIN LA (10 MG CAPSULE, 60 MG CAPSULE) PA PA PA, QL (30 PER 30 DAYS) STRATTERA PA, QL (30 PER 30 DAYS) Central Nervous System Agents, Other NUEDEXTA PA riluzole XENAZINE PA Fibromyalgia Agents SAVELLA (12.5 MG TABLET, 25 MG TABLET, 50 MG TABLET, 100 MG TABLET) PA, QL (60 PER 30 DAYS) 46 LAST UPDATE 08/2015

SAVELLA TITRATION PACK PA, QL (55 PER 30 DAYS) Multiple Sclerosis Agents AMPYRA PA, LA, QL (60 PER 30 DAYS) AUBAGIO PA, LA, QL (30 PER 30 DAYS) AVONEX (SYR 30 MCG, SYR 30 MCG KT) AVONEX ADMINISTRATION PACK AVONEX PEN BETASERON 0.3 MG KIT PA, QL (14 PER 30 DAYS) BETASERON 0.3 MG VIAL PA, QL (15 PER 30 DAYS) COPAXONE 20 MG/ML SYRINGE QL (30 ML PER 30 DAYS) COPAXONE 40 MG/ML SYRINGE QL (12 ML PER 28 DAYS) EXTAVIA 0.3 MG KIT PA, QL (14 PER 30 DAYS) EXTAVIA 0.3 MG VIAL PA, QL (15 PER 30 DAYS) GILENYA PA, QL (30 PER 30 DAYS) GLATOPA QL (30 ML PER 30 DAYS) PLEGRIDY QL (1 ML PER 28 DAYS) PLEGRIDY PEN QL (1 ML PER 28 DAYS) REBIF (22 ML SYRINGE, 44 ML SYRINGE) QL (6 ML PER 30 DAYS) REBIF REBIDOSE (22 ML, 44 ML) QL (6 ML PER 30 DAYS) REBIF REBIDOSE TITRATION PACK QL (4.2 ML PER 30 DAYS) REBIF TITRATION PACK QL (4.2 ML PER 30 DAYS) TECFIDERA QL (60 PER 30 DAYS) Dental and Oral Agents FLUOR-A-DAY (0.25 MG TAB CHEW, 0.5 MG TAB CHEW, 1 MG TABLET CHEW) pilocarpine hcl (5 mg tablet, 7.5 mg tablet) 47 LAST UPDATE 08/2015

Dermatological Agents acitretin adapalene (0.1 % gel (gram), 0.1 % cream (g), 0.3 % gel w/pump) adapalene 0.3 % gel (gram) amnesteem avita 0.025% cream calcipotriene (0.005 % cream (g), 0.005 % solution) CARAC claravis clindamycin phos/benzoyl perox 1 %-5 % gel (gram) clotrimazole/betamethasone dipropionate (1 %-0.05 % lotion, 1 %- 0.05 % cream (g)) cyclosporine, modified (25 mg capsule, 50 mg capsule, 100 mg/ml solution) DIFFERIN 0.3% GEL ELIDEL PA erythromycin base/benzoyl peroxide FINACEA PA FLUOROPLEX fluorouracil (2 % solution, 5 % solution, 5 % cream (g)) fluorouracil 0.5 % cream (g) gengraf (25 mg capsule, 100 mg/ml solution, 100 mg capsule) hypercare methoxsalen, rapid 48 LAST UPDATE 08/2015

mometasone furoate (0.1 % cream (g), 0.1 % oint. (g), 0.1 % solution) myorisan OXSORALEN PICATO podofilox 0.5 % solution refissa REGRANEX PA SANTYL QL (30 GM PER 30 DAYS) STELARA 45 MG/0.5 ML SYRINGE QL (0.5 ML PER 90 DAYS) STELARA 90 MG/ML SYRINGE QL (1 ML PER 90 DAYS) tacrolimus (0.03 % oint. (g), 0.1 % oint. (g)) TAZORAC tretinoin (0.01 % gel (gram), 0.025 % gel (gram), 0.025 % cream (g), 0.05 % cream (g), 0.1 % cream (g)) tretinoin/emollient base trianex VOLTAREN zenatane Enzyme Replacement/ Modifiers PA ADAGEN BUPHENYL 500 MG TABLET CARBAGLU CERDELGA CEREZYME 400 UNITS VIAL CREON ELELYSO 49 LAST UPDATE 08/2015

KUVAN PA, LA ORFADIN pancrelipase 5,000 RAVICTI LA sodium phenylbutyrate 0.94 g/g powder SUCRAID ZAVESCA ZENPEP (DR 3,000 CAPSULE, DR 10,000 CAPSULE, DR 15,000 CAPSULE, DR 20,000 CAPSULE, DR 25,000 CAPSULE, DR 40,000 CAPSULE) Gastrointestinal Agents Antispasmodics, Gastrointestinal CUVPOSA PA dicyclomine hcl (10 mg capsule, 10 mg/5 ml solution, 20 mg tablet) glycopyrrolate (1 mg tablet, 2 mg tablet) Gastrointestinal Agents, Other APRISO ASACOL HD CANASA CHENODAL PA, LA DELZICOL diphenoxylate hcl/atropine sulfate (2.5-.025mg tablet, 2.5-.025/5 liquid) FULYZAQ PA GATTEX PA lansoprazole/amoxicillin trihydrate/clarithromycin 50 LAST UPDATE 08/2015

LIALDA mesalamine 4 g/60 ml enema mesalamine with cleansing wipes PENTASA PROCTOFOAM-HC propantheline bromide 15 mg tablet PYLERA sulfasalazine (500 mg tablet, 500 mg tablet dr) sulfazine sulfazine ec ursodiol (250 mg tablet, 300 mg capsule, 500 mg tablet) Histamine2 (H2) Receptor Antagonists cimetidine (300 mg tablet, 400 mg tablet, 800 mg tablet) cimetidine hcl famotidine 40 mg tablet nizatidine (150 mg capsule, 300 mg capsule) ranitidine hcl (15 mg/ml syrup, 300 mg tablet) Irritable Bowel Syndrome Agents alosetron hcl PA Laxatives constulose enulose gavilyte-c gavilyte-g 51 LAST UPDATE 08/2015

gavilyte-n generlac GOLYTELY PACKET lactulose MOVIPREP nulytely with flavor packs peg 3350/sod sulf/sod bicarbonate/sod chloride/potassium chl sodium chloride/sodium bicarbonate/potassium chloride/peg SUPREP trilyte with flavor packets Protectants CARAFATE 1 GM/10 ML SUSP misoprostol (100 mcg tablet, 200 mcg tablet) sucralfate 1 g tablet Proton Pump Inhibitors lansoprazole 30 mg capsule dr omeprazole (10 mg capsule dr, 20 mg capsule dr, 40 mg capsule dr) pantoprazole sodium (20 mg tablet dr, 40 mg tablet dr) PROTONIX 40 MG SUSPENSION rabeprazole sodium Genitourinary Agents Antispasmodics, Urinary flavoxate hcl oxybutynin chloride (5 mg/5 ml syrup, 5 mg tablet, 5 mg tab er 24, 10 mg tab er 24, 15 mg tab er 24) 52 LAST UPDATE 08/2015

OXYTROL tolterodine tartrate trospium chloride 20 mg tablet Benign Prostatic Hypertrophy Agents alfuzosin hcl finasteride 5 mg tablet tamsulosin hcl Genitourinary Agents, Other bethanechol chloride (5 mg tablet, 10 mg tablet, 25 mg tablet, 50 mg tablet) CUPRIMINE CYSTAGON PA DEPEN ELMIRON PROCYSBI PA, LA THIOLA Phosphate Binders AURYXIA PA calcium acetate 667 mg capsule RENAGEL PA RENVELA PA sevelamer carbonate PA Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal) Glucocorticoids/Mineralocorticoids betamethasone acetate/betamethasone sodium phosphate budesonide 3 mg capdr - er 53 LAST UPDATE 08/2015

CELESTONE 0.6 MG/5 ML SOLUTION dexamethasone (0.5 mg tablet, 0.5 mg/5ml elixir, 0.5 mg/5ml solution, 0.75 mg tablet, 1 mg tablet, 1.5 mg tablet, 2 mg tablet, 4 mg tablet, 6 mg tablet) dexamethasone sod phosphate 0.1 % drops diclofenac sodium 0.1 % drops EPIFOAM FLAREX FLOVENT DISKUS FLOVENT HFA fluocinolone acetonide oil fluorometholone fluticasone propionate 50 mcg spray susp FML FORTE FML S.O.P. hydrocortisone (5 mg tablet, 10 mg tablet, 20 mg tablet) hydrocortisone butyrate (0.1 % oint. (g), 0.1 % solution) hydrocortisone valerate prednisolone acetate triamcinolone acetonide 55 mcg spray Hormonal Agents, Stimulant/Replacement/Modifying (Other) MYALEPT PA Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) desmopressin acetate (0.1 mg tablet, 0.1 mg/ml solution, 0.2 mg tablet, 4mcg/ml ampul, 4mcg/ml vial, 10/spray spray/pump) PA 54 LAST UPDATE 08/2015

desmopressin acetate (nonrefrigerated) PA EGRIFTA PA GENOTROPIN PA HUMATROPE PA INCRELEX PA, LA NORDITROPIN PA NORDITROPIN FLEXPRO (5, 10, 15) PA NORDITROPIN NORDIFLEX (NORDIFLEX 5, NORDIFLX 10, NORDIFLX 15) PA NUTROPIN PA NUTROPIN AQ PA NUTROPIN AQ NUSPIN PA OMNITROPE (5 ML, 10 ML) PA OMNITROPE 5.8 MG VIAL PA SAIZEN PA SEROSTIM PA STIMATE TEV-TROPIN PA ZOMACTON PA ZORBTIVE PA Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) Anabolic Steroids ANADROL-50 oxandrolone 10 mg tablet Androgens ANDROGEL (1.62%(1.25G) GEL PCKT, 1.62% GEL PUMP, 1.62%(2.5G) GEL PCKT) 55 LAST UPDATE 08/2015

danazol (50 mg capsule, 100 mg capsule, 200 mg capsule) testosterone (1.25g (1%) gel md pmp, 25mg(1%) gel packet, 50 mg (1%) gel (gram), 50 mg (1%) gel packet) testosterone cypionate (100 mg/ml vial, 200 mg/ml vial) testosterone enanthate 200 mg/ml vial Estrogens altavera alyacen amethia amethia lo amethyst apri aranelle ashlyna aubra aviane azurette balziva briellyn camrese camrese lo caziant chateal COMBIPATCH cryselle cyclafem 56 LAST UPDATE 08/2015

dasetta daysee delyla desogestrel-ethinyl estradiol desogestrel-ethinyl estradiol/ethinyl estradiol DUAVEE elinest emoquette enpresse enskyce estarylla ESTRACE 0.01% CREAM estradiol (.025mg/24h patch tdsw,.025mg/24h patch tdwk,.0375mg/24 patch tdwk,.0375mg/24 patch tdsw, 0.05mg/24h patch tdsw, 0.05mg/24h patch tdwk, 0.06mg/24h patch tdwk,.075mg/24h patch tdwk,.075mg/24h patch tdsw, 0.1mg/24hr patch tdwk, 0.1mg/24hr patch tdsw, 0.5 mg tablet, 1 mg tablet, 2 mg tablet) estradiol/norethindrone acetate ESTRING estropipate ethinyl estradiol/drospirenone falmina gianvi gildagia gildess gildess 24 fe gildess fe 57 LAST UPDATE 08/2015

introvale jolessa junel junel fe junel fe 24 kariva kelnor 1-35 kimidess kurvelo larin larin 24 fe larin fe leena lessina levonest levonorgestrel-ethinyl estradiol levonorgestrel/ethinyl estradiol and ethinyl estradiol levora-28 lomedia 24 fe lopreeza loryna low-ogestrel lutera marlissa microgestin microgestin fe mimvey 58 LAST UPDATE 08/2015

mimvey lo mono-linyah mononessa myzilra necon nikki norethindrone ac-eth estradiol 1mg- 20mcg tablet norethindrone acetate-ethinyl estradiol/ferrous fumarate norgestimate-ethinyl estradiol nortrel NUVARING ocella ogestrel orsythia ORTHO TRI-CYCLEN LO philith pimtrea pirmella portia PREMARIN (0.3 MG TABLET, 0.45 MG TABLET, 0.625 MG TABLET, 0.9 MG TABLET, 1.25 MG TABLET, VAGINAL CREAM-APPL) PREMPHASE PREMPRO previfem quasense reclipsen 59 LAST UPDATE 08/2015

sprintec sronyx syeda tarina fe tilia fe tri-estarylla tri-legest fe tri-linyah tri-previfem tri-sprintec trinessa trivora-28 VAGIFEM velivet vestura viorele vyfemla wera xulane zarah zenchent zovia 1-35e zovia 1-50e Progestins camila deblitane DEPO-SUBQ PROVERA 104 errin 60 LAST UPDATE 08/2015

heather jencycla jolivette lyza medroxyprogesterone acetate (2.5 mg tablet, 5 mg tablet, 10 mg tablet, 150 mg/ml vial, 150 mg/ml syringe) megestrol acetate (20 mg tablet, 40 mg tablet, 400mg/10ml oral susp) nora-be norethindrone 0.35 mg tablet norethindrone acetate 5 mg tablet norlyroc progesterone,micronized (100 mg capsule, 200 mg capsule) sharobel Selective Estrogen Receptor Modifying Agents raloxifene hcl Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) levothyroxine sodium (25 mcg tablet, 50 mcg tablet, 75 mcg tablet, 88 mcg tablet, 100 mcg tablet, 112 mcg tablet, 125 mcg tablet, 137 mcg tablet, 150 mcg tablet, 175mcg tablet, 200 mcg tablet, 300 mcg tablet) levoxyl liothyronine sodium (5 mcg tablet, 25 mcg tablet, 50 mcg tablet) 61 LAST UPDATE 08/2015

unithroid (25 mcg tablet, 50 mcg tablet, 75 mcg tablet, 88 mcg tablet, 100 mcg tablet, 112 mcg tablet, 125 mcg tablet, 150 mcg tablet, 175 mcg tablet, 200 mcg tablet, 300 mcg tablet) Hormonal Agents, Suppressant (Adrenal) LYSODREN SIGNIFOR PA, LA Hormonal Agents, Suppressant (Parathyroid) calcitriol (0.25 mcg capsule, 0.5 mcg capsule, 1 mcg/ml solution) paricalcitol (1 mcg capsule, 2 mcg capsule, 4mcg capsule) SENSIPAR (30 MG TABLET, 60 MG TABLET) SENSIPAR 90 MG TABLET ST QL (60 PER 30 DAYS) Hormonal Agents, Suppressant (Pituitary) cabergoline ELIGARD PA leuprolide acetate 1 mg/0.2ml kit PA octreotide acetate PA SOMAVERT PA, LA Hormonal Agents, Suppressant (Sex Hormones/Modifiers) Antiandrogens bicalutamide NILANDRON XTANDI PA 62 LAST UPDATE 08/2015

Hormonal Agents, Suppressant (Thyroid) Antithyroid Agents methimazole (5 mg tablet, 10 mg tablet) propylthiouracil 50 mg tablet Immunological Agents Angioedema (HAE) Agents BERINERT PA, QL (3 PER 30 DAYS) Immune Suppressants ASTAGRAF XL azathioprine 50 mg tablet cyclosporine (25 mg capsule, 100 mg capsule) cyclosporine, modified 100 mg capsule ENBREL (50 MG/ML SYRINGE, 50 MG/ML SURECLICK SYR) QL (3.92 ML PER 28 DAYS) ENBREL 25 MG KIT QL (8 PER 28 DAYS) ENBREL 25 MG/0.5 ML SYRINGE QL (4.08 ML PER 28 DAYS) hecoria HUMIRA QL (2 PER 28 DAYS) HUMIRA CROHN'S QL (6 PER 28 DAYS) HUMIRA PEDIATRIC CROHN'S QL (6 PER 28 DAYS) HUMIRA PSORIASIS QL (4 PER 28 DAYS) mycophenolate mofetil (200 mg/ml susp recon, 250 mg capsule, 500 mg tablet) mycophenolate sodium PROGRAF 5 MG/ML AMPULE 63 LAST UPDATE 08/2015

RAPAMUNE 1 MG/ML ORAL SOLN RESTASIS QL (60 PER 30 DAYS) SANDIMMUNE 100 MG/ML SOLN SIMPONI (100 MG/ML PEN INJECTOR, 100 MG/ML SYRINGE) SIMPONI (50 ML SYRINGE, 50 ML PEN INJEC) sirolimus (0.5 mg tablet, 1 mg tablet, 2 mg tablet) tacrolimus (0.5 mg capsule, 1 mg capsule, 5 mg capsule) ZORTRESS Immunizing Agents, Passive GAMMAKED PA GAMUNEX-C PA HIZENTRA PA HYQVIA PA Immunomodulators ACTIMMUNE PA QL (1 ML PER 30 DAYS) QL (0.5 ML PER 30 DAYS) FIRAZYR PA, QL (9 ML PER 30 DAYS) leflunomide OTEZLA (28 DAY PACK, PACK) PA OTEZLA 30 MG TABLET PA, QL (2 PER DAY) Inflammatory Bowel Disease Agents Aminosalicylates balsalazide disodium DIPENTUM 64 LAST UPDATE 08/2015

Glucocorticoids proctosol-hc proctozone-hc UCERIS 9 MG ER TABLET PA Metabolic Bone Disease Agents alendronate sodium (5 mg tablet, 10 mg tablet, 35 mg tablet, 40 mg tablet, 70 mg/75ml solution, 70 mg tablet) BINOSTO calcitonin,salmon,synthetic doxercalciferol (0.5 mcg capsule, 1 mcg capsule, 2.5 mcg capsule) etidronate disodium FORTEO PA fortical ibandronate sodium 150 mg tablet risedronate sodium Miscellaneous Glucose Testing ACCU-CHECK (METERS & TEST STRIPS) DME Benefit QL LIFESCAN (METERS & TEST STRIPS) DME Benefit QL Ophthalmic Agents Ophthalmic Prostaglandin and Prostamide Analogs bimatoprost ST, QL (2.5 ML PER 30 DAYS) latanoprost 0.005 % drops LUMIGAN ST, QL (2.5 ML PER 30 DAYS) ST 65 LAST UPDATE 08/2015

TRAVATAN Z travoprost (benzalkonium) Ophthalmic Agents, Other ak-poly-bac bacitracin/polymyxin b sulfate 500-10k/g oint. (g) BLEPHAMIDE BLEPHAMIDE S.O.P. CYSTARAN PA, LA, QL (60 ML PER 30 DAYS) LACRISERT naphazoline hcl neo-polycin neo-polycin hc neomycin sulfate/bacitracin zinc/polymyxin b/hydrocortisone neomycin sulfate/bacitracin/polymyxin b neomycin sulfate/polymyxin b sulfate/gramicidin d neomycin/polymyxin b sulf/hc 3.5-10k- 10 drops susp neomycin/polymyxin b sulfate/dexamethasone (0.1 % drops susp, 3.5-10k-.1 oint. (g)) neosporin eye drops polycin polymyxin b sulfate/trimethoprim sulfacetamide sodium/prednisolone sodium phosphate TOBRADEX ST tobramycin/dexamethasone 66 LAST UPDATE 08/2015

tropicamide (0.5 % drops, 1 % drops) ZYLET Ophthalmic Anti-allergy Agents ALOMIDE azelastine hcl 0.05 % drops cromolyn sodium 4 % drops PATANOL PA Ophthalmic Anti-inflammatories ALREX bromfenac sodium flurbiprofen sodium ketorolac tromethamine (0.4 % drops, 0.5 % drops) LOTEMAX (0.5% EYE DROPS, 0.5% OPHTHALMIC GEL, 0.5% EYE OINTMENT) prednisolone sod phosphate 1 % drops VEXOL Ophthalmic Antiglaucoma Agents ALPHAGAN P 0.1% DROPS AZOPT betaxolol hcl 0.5 % drops BETIMOL BETOPTIC S brimonidine tartrate (0.15 % drops, 0.2 % drops) carteolol hcl dorzolamide hcl dorzolamide hcl/timolol maleate 67 LAST UPDATE 08/2015

ISTALOL levobunolol hcl metipranolol pilocarpine hcl (1 % drops, 2 % drops, 4 % drops) PILOPINE HS timolol maleate (0.25 % drops, 0.25 % sol-gel, 0.5 % drops, 0.5 % sol-gel) Otic Agents CIPRO HC CIPRODEX ciprofloxacin hcl 0.2 % droperette Respiratory Tract Agents Anti-inflammatories, Inhaled Corticosteroids AEROSPAN ALVESCO ARNUITY ELLIPTA ASMANEX ASMANEX HFA BREO ELLIPTA 100-25 MCG INH budesonide (0.25mg/2ml ampul-neb, 0.5 mg/2ml ampul-neb, 1 mg/2 ml ampul-neb, 32mcg spray/pump) flunisolide (25 mcg spray, 29mcg spray) NASONEX QL (17 GM PER 30 DAYS) PULMICORT FLEXHALER QVAR 68 LAST UPDATE 08/2015

Antihistamines azelastine hcl 137 mcg spray/pump clemastine fumarate (0.67mg/5ml syrup, 2.68 mg tablet) cyproheptadine hcl (2 mg/5 ml syrup, 4 mg tablet) levocetirizine dihydrochloride (2.5 mg/5ml solution, 5 mg tablet) Antileukotrienes montelukast sodium (4 mg gran pack, 4 mg tab chew, 5 mg tab chew, 10 mg tablet) zafirlukast QL (60 PER 30 DAYS) ZYFLO CR PA Bronchodilators, Anticholinergic ATROVENT HFA INCRUSE ELLIPTA ipratropium bromide (0.2 mg/ml solution, 21 mcg spray, 42mcg spray) SPIRIVA SPIRIVA RESPIMAT Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) theochron theophylline anhydrous (100 mg tab er 12h, 200 mg tab er 12h, 300 mg tab er 12h, 400 mg tablet er, 450 mg tab er 12h, 600 mg tablet er) Bronchodilators, Sympathomimetic ADVAIR DISKUS ADVAIR HFA 69 LAST UPDATE 08/2015

albuterol sulfate (0.63mg/3ml vial-neb, 1.25mg/3ml vial-neb, 2 mg/5 ml syrup, 2 mg tablet, 2.5 mg/3ml vial-neb, 2.5 mg/0.5 vial-neb, 4 mg tab er 12h, 4 mg tablet, 5 mg/ml solution, 8 mg tab er 12h) ANORO ELLIPTA BREO ELLIPTA 200-25 MCG INH COMBIVENT QL (14.7 GM PER 30 DAYS) COMBIVENT RESPIMAT QL (4 GM PER 30 DAYS) EPIPEN 2-PAK EPIPEN JR 2-PAK FORADIL ipratropium bromide/albuterol sulfate levalbuterol hcl (0.31mg/3ml vial-neb, 0.63mg/3ml vial-neb, 1.25mg/0.5 vialneb, 1.25mg/3ml vial-neb) proair hfa QL (17 GM PER 30 DAYS) proair respiclick QL (2 PER 30 DAYS) SEREVENT DISKUS SYMBICORT terbutaline sulfate (2.5 mg tablet, 5 mg tablet) ventolin hfa QL (36 GM PER 30 DAYS) XOPENEX HFA Mast Cell Stabilizers cromolyn sodium (20 mg/ml oral conc, 20 mg/2 ml ampul-neb) Pulmonary Antihypertensives ADCIRCA PA, QL (60 PER 30 DAYS) ADEMPAS PA 70 LAST UPDATE 08/2015

LETAIRIS PA OPSUMIT PA, LA ORENITRAM ER PA, LA REVATIO 10 MG/ML ORAL SUSP PA sildenafil citrate 20 mg tablet PA, QL (90 PER 30 DAYS) TRACLEER PA, LA VENTAVIS PA Respiratory Tract Agents, Other ambitussin ac PA (For ages 5 and under) benzonatate cheratussin ac PA (For ages 5 and under) cheratussin dac PA (For ages 5 and under) ESBRIET PA, LA GRASTEK PA guaiatussin ac PA (For ages 5 and under) guaifenesin ac PA (For ages 5 and under) guaifenesin dac PA (For ages 5 and under) guaifenesin/codeine phosphate PA (For ages 5 and under) hydrocodone bit/homatrop me-br 5-1.5 mg/5 syrup hydromet HYPER-SAL 3.5% VIAL iophen-c nr PA (For ages 5 and under) KALYDECO (50 MG GRANULES PACKET, 75 MG GRANULES PACKET) PA, LA, QL (60 PER 30 DAYS) KALYDECO 150 MG TABLET PA, LA, QL (60 PER 30 DAYS) lortuss ex PA (For ages 5 and under) OFEV PA ORALAIR PA, LA 71 LAST UPDATE 08/2015

phenylephrine hcl/promethazine hcl promethazine hcl/codeine PA (For ages 5 and under) promethazine hcl/dextromethorphan hbr promethazine/phenylephrine hcl/codeine pulmosal PULMOZYME RAGWITEK PA sodium chloride for inhalation 7 % vialneb PA (For ages 5 and under) tusnel c PA (For ages 5 and under) TYZINE virtussin ac PA (For ages 5 and under) virtussin dac PA (For ages 5 and under) Skeletal Muscle Relaxants carisoprodol (250 mg tablet, 350 mg tablet) carisoprodol/aspirin chlorzoxazone cyclobenzaprine hcl (5 mg tablet, 7.5 mg tablet, 10 mg tablet) metaxalone 800 mg tablet methocarbamol (500 mg tablet, 750 mg tablet) orphenadrine citrate 100 mg tablet er orphenadrine/aspirin/caffeine 50-770- 60 tablet 72 LAST UPDATE 08/2015

Sleep Disorder Agents GABA Receptor Modulators estazolam eszopiclone QL (30 PER 30 DAYS) flurazepam hcl temazepam triazolam zaleplon QL (30 PER 30 DAYS) zolpidem tartrate (5 mg tablet, 10 mg tablet) Sleep Disorders, Other QL (30 PER 30 DAYS) modafinil PA, QL (30 PER 30 DAYS) ROZEREM PA, QL (30 PER 30 DAYS) XYREM PA, LA, QL (540 ML PER 30 DAYS) Therapeutic Nutrients/ Minerals/ Electrolytes Electrolyte/Mineral Modifiers EXJADE kionex 15 gm/60 ml suspension levocarnitine 330 mg tablet sodium polystyrene sulfonate (15 g/60 ml oral susp, 30g/120ml enema, 50g/200ml enema) sps 15 gm/60 ml suspension SYPRINE Electrolyte/Mineral Replacement cyanocobalamin (vitamin b-12) 1000mcg/ml vial 73 LAST UPDATE 08/2015

ergocalciferol (vitamin d2) 50000 unit capsule fluoride/iron/vitamins a,c,and d fluoritab 0.5 mg tablet chew flura-drops klor-con 10 klor-con 8 klor-con m10 klor-con m20 ludent fluoride niva-plus pediatric multivitamin combination no.2/sodium fluoride pediatric multivitamins a,c,& d3 no.21 with sodium fluoride pediatric multivitamins no.16 with sodium fluoride pediatric multivitamins no.17 with sodium fluoride pediatric multivitamins no.82 with sodium fluoride pnv-vp-u POLY-VI-SOL WITH IRON potassium chloride (8 capsule er, 8 tablet er, 10 tab er prt, 10 tablet er, 10 capsule er, 20 tablet er, 20 tab er prt) potassium citrate (5 tablet er, 10 tablet er, 15 tablet er) prenaplus prenatal vitamins comb no.115/iron fumarate/folic acid prenatal vitamins comb no.115/iron fumarate/folic acid/dss 74 LAST UPDATE 08/2015

prenatal vitamins combo no.60/ferrous fumarate/folic acid prenatal vits with calcium #72/ferrous fumarate/folic acid prenatal vits with calcium #72/iron,carbonyl/folic acid prenatal vits with calcium #74/ferrous fumarate/folic acid prenatal vits without calc no5/ferrous fumarate/folic acid preplus QUFLORA (0.25 MG/ML DROP, 0.5 MG/ML DROP) sodium fluoride (0.25(0.55) tab chew, 0.5(1.1)mg tab chew, 0.5 mg/ml drops, 1mg(2.2mg) tab chew) sski TL FOLATE tl-fluorivite TRICARE trinatal rx 1 triveen-u vinate one vinate-m vol-plus 75 LAST UPDATE 08/2015

Non-Formulary Drugs That Require Prior Authorization ABSTRAL ACANYA ACIPHEX SPRINKLE ACTEMRA 162 MG/0.9 ML SYRINGE ACTICLATE ACTIQ ACYCLOVIR 5% OINTMENT ACZONE ADAPALENE 0.1% LOTION ADOXA ALTABAX AMBIEN CR AMITIZA AMRIX ANZEMET 50 MG TABLET ANZEMET 100 MG TABLET APLENZIN APOKYN ARCALYST ARICEPT 23 MG TABLET ARTHROTEC 50 ARTHROTEC 75 ASTEPRO ATOVAQUONE-PROGUANIL HCL ATRALIN AVINZA AZELASTINE 0.15% NASAL SPRAY BENICAR BENICAR HCT BENZACLIN GEL 35G PUMP BENZACLIN GEL 50G PUMP BEPREVE BIDIL BRINTELLIX BRISDELLE BUTALB-ACETAMINOPH-CAFF-CODEIN BUTALB-ACETAMIN-CAFF 50-300-40 BUTRANS BYSTOLIC CALCIPOTRIENE-BETAMETHASONE DP CALCITRIOL 3 MCG/G OINTMENT CAMBIA CAPITAL W-CODEINE CARDURA XL CENTANY AT CESAMET CHORIONIC GONAD 10,000 UNIT VL CIALIS CIMZIA 200 MG/ML SYRINGE KIT CIMZIA 200 MG/ML STARTER KIT CLARINEX CLARINEX-D 12 HOUR CLARINEX-D 24 HOUR CLOBETASOL PROP 0.05% SPRAY CLOBEX 0.05% SPRAY CLODAN 0.05% KIT CLOMIPHENE CITRATE 50 MG TAB CLONIDINE HCL ER COARTEM CODEINE SULFATE 30 MG/5 ML SOL COMBIGAN CONZIP COSENTYX (2 SYRINGES) COSENTYX PEN COSENTYX PEN (2 PENS) COSENTYX SYRINGE COTABFLU CRINONE DALIRESP DERMASORB HC DERMASORB TA DESLORATADINE DESONATE DESVENLAFAXINE FUMARATE ER DEXILANT DICLOFENAC SODIUM 3% GEL DICLOFENAC 1.5% TOPICAL SOLN DICLOFENAC SODIUM-MISOPROSTOL DIFFERIN 0.1% LOTION DONEPEZIL HCL 23 MG TABLET DORYX 76

DOXYCYCLINE HYC DR 75 MG TAB DOXYCYCLINE HYC DR 150 MG TAB DOXYCYCLINE HYC DR 100 MG TAB DOXYCYCLINE IR-DR DOXYCYCLINE MONO 150 MG CAP DOXYCYCLINE MONO 75 MG CAPSULE DRONABINOL DUEXIS ECOZA EDARBI EDARBYCLOR EDLUAR EMBEDA ENABLEX ENDACOF-C ENDOMETRIN EPIDUO EPIDUO FORTE EPROSARTAN MESYLATE ESOMEPRAZOLE MAGNESIUM ESOMEPRAZOLE STRONTIUM EVEKEO EXALGO FASLODEX FENOFIBRATE 50 MG CAPSULE FENOFIBRATE 150 MG CAPSULE FENTANYL CIT OTFC 1,600 MCG FENTANYL CIT OTFC 1,200 MCG FENTANYL CITRATE OTFC 600 MCG FENTANYL CITRATE OTFC 800 MCG FENTANYL CITRATE OTFC 200 MCG FENTANYL CITRATE OTFC 400 MCG FENTORA FETZIMA FIORICET FIORICET WITH CODEINE FLECTOR FLO-PRED FLUOCINONIDE 0.1% CREAM FLUVOXAMINE MALEATE ER FOLLISTIM AQ FORFIVO XL FORTAMET FOSAMAX PLUS D FOSRENOL FYCOMPA GIAZO GLUMETZA GONAL-F GONAL-F RFF GONAL-F RFF REDI-JECT GRALISE H.P. ACTHAR HETLIOZ HORIZANT HYDROMORPHONE ER HYSINGLA ER INTERMEZZO INTUNIV IXEMPRA JALYN KAPVAY KETOCONAZOLE 200 MG TABLET KINERET KITABIS PAK KORLYM LAMICTAL ODT LAMICTAL ODT (BLUE) LAMICTAL ODT (GREEN) LAMICTAL ODT (ORANGE) LAMOTRIGINE ODT LASTACAFT LAZANDA LINZESS LIPOFEN LIPTRUZET LIVALO LOCOID 0.1% LOTION LOVAZA LUVOX CR MALARONE MARINOL 77

MAXIFLU CD MAXIFLU CDX MENOPUR METFORMIN HCL ER 500 MG OSM-TB METFORMIN ER 1,000 MG OSM-TAB METOCLOPRAMIDE HCL ODT METOZOLV ODT METROGEL METRONIDAZOLE TOPICAL 1% GEL MICARDIS MICARDIS HCT MIRAPEX ER MIRCERA MONODOX 75 MG CAPSULE MORGIDOX 2X100 MG KIT MORGIDOX 1X100 MG KIT MORPHINE SULFATE ER 30 MG CAP MORPHINE SULFATE ER 75 MG CAP MORPHINE SULFATE ER 120 MG CAP MORPHINE SULFATE ER 60 MG CAP MORPHINE SULFATE ER 90 MG CAP MORPHINE SULFATE ER 45 MG CAP NAMENDA XR NATROBA NEO-SYNALAR NEUAC 1.2-5% KIT NEXIUM NIACIN ER NIASPAN NORDITROPIN FLEXPRO 30 MG/3 ML NORDITROPIN NORDIFLEX 30 MG/3 NORTHERA 100 MG CAPSULE NORTHERA 200 MG CAPSULE NOVAREL NUCYNTA NUCYNTA ER NUVIGIL OLEPTRO ER OLOPATADINE HCL OMEGA-3 ACID ETHYL ESTERS OMNARIS ONEXTON OPANA ER ORACEA ORENCIA 125 MG/ML SYRINGE OVIDREL OXECTA OXTELLAR XR OXYMORPHONE HCL ER PAROXETINE ER 37.5 MG TABLET PAROXETINE CR 37.5 MG TABLET PAROXETINE CR 12.5 MG TABLET PAROXETINE CR 25 MG TABLET PATADAY PATANASE PAXIL CR PENNSAID PEXEVA PHENFLU CD PHENFLU CDX POTIGA PRAMIPEXOLE ER PREGNYL PRISTIQ ER QNASL QNASL CHILDREN QUALAQUIN QUININE SULFATE 324 MG CAPSULE RAPAFLO RELISTOR RENOVA RENOVA PUMP REPRONEX REQUIP XL RETIN-A MICRO RETIN-A MICRO PUMP ROPINIROLE HCL ER 2 MG TABLET ROPINIROLE HCL ER 12 MG TABLET ROPINIROLE HCL ER 8 MG TABLET ROPINIROLE HCL ER 6 MG TABLET ROPINIROLE HCL ER 4 MG TABLET ROSADAN 0.75% GEL KIT 78

RUCONEST SANCTURA XR SANCUSO SEROPHENE SEROQUEL XR SILENOR SIMVASTATIN 80 MG TABLET SITAVIG SOLARAZE SOLODYN ER 55 MG TABLET SOLODYN ER 65 MG TABLET SOLODYN ER 115 MG TABLET SOLODYN ER 80 MG TABLET SOLODYN ER 105 MG TABLET SORILUX SPINOSAD STAVZOR SUBSYS SUMAVEL DOSEPRO SYNALAR 0.025% OINTMENT KIT SYNALAR 0.025% CREAM KIT SYNALAR TS TACLONEX TANZEUM TELMISARTAN TELMISARTAN-AMLODIPINE TELMISARTAN-HYDROCHLOROTHIAZID TEVETEN TEVETEN HCT TIZANIDINE HCL 4 MG CAPSULE TIZANIDINE HCL 2 MG CAPSULE TIZANIDINE HCL 6 MG CAPSULE TOPICORT 0.25% SPRAY TOVIAZ TRAMADOL HCL ER 150 MG CAPSULE TRAMADOL HCL ER 100 MG CAPSULE TRAMADOL HCL ER 200 MG CAPSULE TRAMADOL HCL ER 300 MG CAPSULE TRETIN-X TRETINOIN MICROSPHERE TREXIMET TRIBENZOR TROSPIUM CHLORIDE ER TRULICITY TUZISTRA XR TWYNSTA TYVASO ULORIC ULTRAVATE X CREAM COMBO PACK VANACOF CD VANOS VASCEPA VECTICAL VELPHORO VELTIN VERAMYST VERDESO VESICARE VIIBRYD VIMOVO VYTORIN WELCHOL XARTEMIS XR XELJANZ XERESE XOLEGEL ZANAFLEX 4 MG CAPSULE ZANAFLEX 2 MG CAPSULE ZANAFLEX 6 MG CAPSULE ZELAPAR ZENZEDI 2.5 MG TABLET ZENZEDI 15 MG TABLET ZENZEDI 7.5 MG TABLET ZENZEDI 20 MG TABLET ZENZEDI 30 MG TABLET ZETONNA ZIANA ZIPSOR ZMAX ZOCOR 80 MG TABLET ZOHYDRO ER ZOLPIDEM TARTRATE ER 79

ZOLPIMIST ZORVOLEX ZOVIRAX 5% CREAM ZOVIRAX 5% OINTMENT ZUPLENZ ZYCLARA 80

Alphabetical Listing A abacavir sulfate 29 abacavir sulfate/lamivudine/zidovudine 29 ABILIFY 16 ABILIFY DISCMELT 16 acamprosate calcium 5 acarbose 33 acebutolol hcl 39 acetaminophen with codeine phosphate 3 acetasol hc 9 acetazolamide 13,43 acetic acid/aluminum acetate 9 acetic acid/hydrocortisone 9 acitretin 48 ACTIMMUNE 64 ACTOPLUS MET XR 33 acyclovir 32 ADAGEN 49 adapalene 48 ADCIRCA 70 adefovir dipivoxil 31 ADEMPAS 70 ADVAIR DISKUS 69 ADVAIR HFA 69 AEROSPAN 68 afeditab cr 40 AFINITOR 25 AFINITOR DISPERZ 25 AGGRENOX 37 ak-poly-bac 66 alagesic lq 1 ALBENZA 26 albuterol sulfate 70 alclometasone dipropionate 6 alendronate sodium 65 ALFERON N 24 alfuzosin hcl 53 ALINIA 26 ALKERAN 22 allopurinol 21 ALOMIDE 67 alosetron hcl 51 ALPHAGAN P 67 alprazolam 32 ALREX 67 altavera 56 ALVESCO 68 alyacen 56 amantadine hcl 27 ambitussin ac 71 amcinonide 6 amethia 56 amethia lo 56 amethyst 56 amiloride hcl 43 amiloride hcl/hydrochlorothiazide 41 amiodarone hcl 39 amitriptyline hcl 18 amlodipine besylate 40 amlodipine besylate/atorvastatin calcium 41 amlodipine besylate/benazepril hcl 42 amnesteem 48 amoxapine 18 amoxicillin 11 amoxicillin/potassium clavulanate 11 ampicillin trihydrate 11 AMPYRA 47 ANADROL-50 55 anagrelide hcl 36 anastrozole 24 ANDROGEL 55 ANORO ELLIPTA 70 anusol-hc 6 apexicon 6 apexicon e 6 APIDRA 35 APIDRA SOLOSTAR 35 apri 56 APRISO 50 APTIOM 15 APTIVUS 30 81

aranelle 56 ARANESP 36 aripiprazole 16 ARNUITY ELLIPTA 68 ASACOL HD 50 ascomp with codeine 3 ashlyna 56 ASMANEX 68 ASMANEX HFA 68 aspirin/dipyridamole 37 ASTAGRAF XL 63 atenolol 39 atenolol/chlorthalidone 42 atorvastatin calcium 44 atovaquone 26 ATRIPLA 30 ATROVENT HFA 69 AUBAGIO 47 aubra 56 AURYXIA 53 aviane 56 avidoxy 13 avita 48 AVONEX 47 AVONEX ADMINISTRATION PACK 47 AVONEX PEN 47 AZASITE 11 azathioprine 63 azelastine hcl 67,69 AZILECT 27 azithromycin 11 AZOPT 67 azurette 56 B bacitracin 9 bacitracin/polymyxin b sulfate 66 baclofen 29 balsalazide disodium 64 balziva 56 BANZEL 15 BARACLUDE 31 benazepril hcl 38 benazepril hcl/hydrochlorothiazide 42 benzonatate 71 benztropine mesylate 27 BERINERT 63 betamethasone acetate/betamethasone sodium phosphate 53 betamethasone dipropionate 6 betamethasone dipropionate/propylene glycol 6 betamethasone valerate 6 BETASERON 47 betaxolol hcl 39,67 bethanechol chloride 53 BETIMOL 67 BETOPTIC S 67 bexarotene 26 bicalutamide 62 bimatoprost 65 BINOSTO 65 bisoprolol fumarate 39 bisoprolol fumarate/hydrochlorothiazide 42 bleph-10 12 BLEPHAMIDE 66 BLEPHAMIDE S.O.P. 66 blood sugar diagnostic 65 BOSULIF 24 BREO ELLIPTA 68,70 briellyn 56 BRILINTA 37 brimonidine tartrate 67 bromfenac sodium 67 bromocriptine mesylate 27 budeprion sr 16 budesonide 53,68 bumetanide 43 BUPHENYL 49 buprenorphine hcl 6 buprenorphine hcl/naloxone hcl 6 buproban 6 bupropion hcl 16 82

buspirone hcl 32 butalbital/acetaminophen 1 butalbital/acetaminophen/caffeine 1 butalbital/acetaminophen/caffeine/codeine phosphate 3 butalbital/aspirin/caffeine 1 butorphanol tartrate 3 BYDUREON 33 BYDUREON PEN 33 BYETTA 33 C cabergoline 62 cafergot 21 calcipotriene 48 calcitonin,salmon,synthetic 65 calcitriol 62 calcium acetate 53 camila 60 camrese 56 camrese lo 56 CANASA 50 candesartan cilexetil 38 capacet 1 capecitabine 23 CAPRELSA 25 captopril 38 captopril/hydrochlorothiazide 42 CARAC 48 CARAFATE 52 CARBAGLU 49 carbamazepine 15 carbidopa 27 carbidopa/levodopa 27 carbidopa/levodopa/entacapone 27 CARDIZEM LA 40 carisoprodol 72 carisoprodol/aspirin 72 carteolol hcl 67 cartia xt 40 carvedilol 39 caziant 56 CEENU 22 cefaclor 10 cefadroxil 10 cefdinir 10 cefpodoxime proxetil 10 cefprozil 10 ceftibuten 10 CEFTIN 10 cefuroxime axetil 11 celecoxib 1 CELESTONE 54 CELONTIN 14 cephalexin 11 CERDELGA 49 CEREZYME 49 CHANTIX 6 chateal 56 CHENODAL 50 cheratussin ac 71 cheratussin dac 71 chlordiazepoxide hcl 33 chlorhexidine gluconate 9 chloroquine phosphate 26 chlorothiazide 43 chlorpromazine hcl 18 chlorpropamide 33 chlorthalidone 43 chlorzoxazone 72 cholestyramine (with sugar) 44 cholestyramine/aspartame 44 ciclodan 19 ciclopirox 20 ciclopirox olamine 20 cilostazol 37 cimetidine 51 cimetidine hcl 51 CIPRO HC 68 CIPRODEX 68 ciprofloxacin hcl 12,68 ciprofloxacin/ciprofloxacin hcl 12 citalopram hydrobromide 17 83

claravis 48 clarithromycin 11 clemastine fumarate 69 clindacin etz 9 clindacin p 9 clindamycin hcl 9 clindamycin palmitate hcl 9 clindamycin phosphate 9 clindamycin phosphate/benzoyl peroxide 48 clobetasol propionate 6 clobetasol propionate/emollient base 6,7 clodan 7 clomipramine hcl 18 clonazepam 33 clonidine 37 clonidine hcl 37 clopidogrel bisulfate 37 clorazepate dipotassium 33 clotrimazole 20 clotrimazole/betamethasone dipropionate 48 clozapine 29 co-gesic 3 codeine phosphate/butalbital/aspirin/caffeine 3 codeine phosphate/carisoprodol/aspirin 3 codeine sulfate 3 colchicine 21 colchicine/probenecid 21 COLCRYS 21 COLESTID 44 colestid 44 colestipol hcl 44 COMBIPATCH 56 COMBIVENT 70 COMBIVENT RESPIMAT 70 COMETRIQ 25 COMPLERA 29 compro 19 constulose 51 COPAXONE 47 COREG CR 39 cormax 7 cortisone acetate 7 CREON 49 CRESTOR 44 CRIXIVAN 30 cromolyn sodium 67,70 cryselle 56 CUPRIMINE 53 CUVPOSA 50 cyanocobalamin (vitamin b-12) 73 cyclafem 56 cyclobenzaprine hcl 72 CYCLOPHOSPHAMIDE CAPSULES 22 cyclophosphamide tablets 23 cycloserine 9 cyclosporine 63 cyclosporine, modified 48,63 cyproheptadine hcl 69 CYSTAGON 53 CYSTARAN 66 D danazol 56 dantrolene sodium 29 dapsone 22 DARAPRIM 26 dasetta 57 daysee 57 DAYTRANA 46 deblitane 60 delyla 57 DELZICOL 50 demeclocycline hcl 13 DENAVIR 32 depade 5 DEPEN 53 DEPO-SUBQ PROVERA 104 60 desipramine hcl 18 desmopressin acetate 54 desmopressin acetate (non-refrigerated) 55 desogestrel-ethinyl estradiol 57 desogestrel-ethinyl estradiol/ethinyl estradiol 57 84

desonide 7 desoximetasone 7 dexamethasone 54 dexamethasone sod phosphate 54 dexmethylphenidate hcl 46 dextroamphetamine sulf-saccharate/amphetamine sulfaspartate 45 dextroamphetamine sulfate 45 DIASTAT 14 diazepam 14,33 DICLEGIS 19 diclofenac potassium 1 diclofenac sodium 1,54 dicloxacillin sodium 11 dicyclomine hcl 50 didanosine 29 DIFFERIN 48 DIFICID 11 diflorasone diacetate 7 diflunisal 1 digitek 42 digox 42 digoxin 42 dihydrocodeine bitartrate/acetaminophen/caffeine 3 dihydroergotamine mesylate 21 DILANTIN 15 DILATRATE-SR 45 dilt-cd 40 dilt-xr 40 diltia xt 40 diltiazem hcl 41 diltzac er 41 DIPENTUM 64 diphenoxylate hcl/atropine sulfate 50 dipyridamole 37 disopyramide phosphate 39 disulfiram 5 divalproex sodium 14 donepezil hcl 16 dorzolamide hcl 67 dorzolamide hcl/timolol maleate 67 doxazosin mesylate 38 doxepin hcl 18 doxercalciferol 65 doxycycline hyclate 13 doxycycline monohydrate 13 DROXIA 23 DUAVEE 57 duloxetine hcl 17 dynacin 13 DYRENIUM 43 E E.E.S. 200 11 econazole nitrate 20 EDECRIN 43 EDURANT 29 EFFIENT 37 EGRIFTA 55 ELELYSO 49 ELIDEL 48 ELIGARD 62 elimite 26 elinest 57 ELIQUIS 36 ELMIRON 53 EMCYT 23 EMEND 19 emoquette 57 EMTRIVA 29 enalapril maleate 38 enalapril maleate/hydrochlorothiazide 42 ENBREL 63 endocet 3 endodan 3 enoxaparin sodium 36 enpresse 57 enskyce 57 entacapone 27 entecavir 31 enulose 51 EPANED 38 85

EPIFOAM 54 EPIPEN 2-PAK 70 EPIPEN JR 2-PAK 70 epitol 15 EPIVIR HBV 31 eplerenone 43 EPOGEN 37 EPZICOM 29 EQUETRO 15 ergocalciferol (vitamin d2) 74 ergotamine tartrate/caffeine 21 ERIVEDGE 25 errin 60 ERY-TAB 12 erygel 12 ERYPED 200 12 erythromycin base 12 erythromycin base/benzoyl peroxide 48 erythromycin base/ethyl alcohol 12 erythromycin ethylsuccinate 12 erythromycin ethylsuccinate/sulfisoxazole acetyl 9 ESBRIET 71 escitalopram oxalate 17 estarylla 57 estazolam 73 ESTRACE 57 estradiol 57 estradiol/norethindrone acetate 57 ESTRING 57 estropipate 57 eszopiclone 73 ethambutol hcl 22 ethinyl estradiol/drospirenone 57 ethosuximide 14 etidronate disodium 65 etodolac 1 EVOTAZ 30 EXELON 16 exemestane 24 EXJADE 73 EXTAVIA 47 F falmina 57 famciclovir 32 famotidine 51 FARESTON 23 FARXIGA 33 FARYDAK 24 felbamate 15 felodipine 41 fenofibrate 43 fenofibrate nanocrystallized 44 fenofibrate,micronized 44 fenofibric acid 44 fenofibric acid (choline) 44 fenoprofen calcium 1 fentanyl 2 FINACEA 48 finasteride 53 FIRAZYR 64 FLAREX 54 flavoxate hcl 52 flecainide acetate 39 FLOVENT DISKUS 54 FLOVENT HFA 54 fluconazole 20 fludrocortisone acetate 7 flunisolide 68 fluocinolone acetonide 7 fluocinolone acetonide oil 54 fluocinonide 7 fluocinonide/emollient base 7 FLUOR-A-DAY 47 fluoride/iron/vitamins a,c,and d 74 fluoritab 74 fluorometholone 54 FLUOROPLEX 48 fluorouracil 48 fluoxetine hcl 17 fluphenazine hcl 28 flura-drops 74 86

flurazepam hcl 73 flurbiprofen 1 flurbiprofen sodium 67 fluticasone propionate 7,54 fluvastatin sodium 44 fluvoxamine maleate 17 FML FORTE 54 FML S.O.P. 54 FOCALIN XR 46 fondaparinux sodium 36 FORADIL 70 FORTEO 65 fortical 65 fosinopril sodium 38 fosinopril sodium/hydrochlorothiazide 42 FRAGMIN 36 FULYZAQ 50 furosemide 43 FUZEON 30 G gabapentin 14 GABITRIL 14 GAMMAKED 64 GAMUNEX-C 64 garamycin 8 gatifloxacin 12 GATTEX 50 gavilyte-c 51 gavilyte-g 51 gavilyte-n 52 gemfibrozil 44 generlac 52 gengraf 48 GENOTROPIN 55 gentak 8 gentamicin sulfate 8 gianvi 57 gildagia 57 gildess 57 gildess 24 fe 57 gildess fe 57 GILENYA 47 GILOTRIF 24 GLATOPA 47 GLEEVEC 25 GLEOSTINE 23 glimepiride 34 glipizide 34 glipizide/metformin hcl 34 GLUCAGEN 1MG HYPOKIT 35 GLUCAGON EMERGENCY KIT 35 glyburide 34 glyburide,micronized 34 glyburide/metformin hcl 34 glycopyrrolate 50 glydo 5 GOLYTELY 52 granisetron hcl 19 GRANIX 37 GRASTEK 71 griseofulvin ultramicrosize 20 griseofulvin, microsize 20 guaiatussin ac 71 guaifenesin ac 71 guaifenesin dac 71 guaifenesin/codeine phosphate 71 guanfacine hcl 37,46 guanidine hcl 22 H halobetasol propionate 7 haloperidol 28 haloperidol lactate 28 HARVONI 31 heather 61 hecoria 63 HEXALEN 24 HIZENTRA 64 HUMALOG 35 HUMALOG KWIKPEN 35 HUMALOG MIX 50-50 35 87

HUMALOG MIX 50-50 KWIKPEN 35 HUMALOG MIX 75-25 35 HUMALOG MIX 75-25 KWIKPEN 35 HUMATROPE 55 HUMIRA 63 HUMIRA CROHN'S 63 HUMIRA PEDIATRIC CROHN'S 63 HUMIRA PSORIASIS 63 HUMULIN 70-30 35 HUMULIN 70/30 KWIKPEN 35 HUMULIN N 35 HUMULIN N KWIKPEN 35 HUMULIN R 35 HUMULIN R U-500 35 HYCAMTIN 24 hydralazine hcl 45 hydrochlorothiazide 43 hydrocodone bitartrate/acetaminophen 4 hydrocodone bitartrate/homatropine methylbromide 71 hydrocodone/ibuprofen 4 hydrocortisone 7,54 hydrocortisone butyrate 7,54 hydrocortisone valerate 54 hydromet 71 hydromorphone hcl 4 hydroxychloroquine sulfate 26 hydroxyurea 23 hydroxyzine hcl 19 hydroxyzine pamoate 19 HYPER-SAL 71 hypercare 48 HYQVIA 64 I ibandronate sodium 65 IBRANCE 25 ibudone 4 ibuprofen 1 ibuprofen/oxycodone hcl 1 ICLUSIG 25 IMBRUVICA 24 imipramine hcl 18 imipramine pamoate 18 imiquimod 24 INCIVEK 31 INCRELEX 55 INCRUSE ELLIPTA 69 indapamide 43 indomethacin 1 INFERGEN 31 INLYTA 24 INTELENCE 29 INTRON A 24 introvale 58 INVEGA 28 INVIRASE 30 INVOKAMET 34 INVOKANA 34 iophen-c nr 71 ipratropium bromide 69 ipratropium bromide/albuterol sulfate 70 irbesartan 38 irbesartan/hydrochlorothiazide 42 IRESSA 24 ISENTRESS 30 isochron 45 isoniazid 22 isosorbide dinitrate 45 isosorbide mononitrate 45 isradipine 41 ISTALOL 68 itraconazole 20 ivermectin 26 J JAKAFI 24 jantoven 36 JANUMET 34 JANUMET XR 34 JANUVIA 34 JARDIANCE 34 jencycla 61 88

JENTADUETO 34 jolessa 58 jolivette 61 junel 58 junel fe 58 junel fe 24 58 JUXTAPID 44 K KALETRA 30 KALYDECO 71 kariva 58 KAZANO 34 kelnor 1-35 58 ketoconazole 20 ketoprofen 2 ketorolac tromethamine 2,67 kimidess 58 kionex 73 klor-con 10 74 klor-con 8 74 klor-con m10 74 klor-con m20 74 KOMBIGLYZE XR 34 kurvelo 58 KUVAN 50 KYNAMRO 44 L labetalol hcl 39 LACRISERT 66 lactulose 52 LAMISIL 20 lamivudine 29,31 lamivudine/zidovudine 30 lamotrigine 15 LANOXIN 42 lansoprazole 52 lansoprazole/amoxicillin trihydrate/clarithromycin 50 LANTUS 35 LANTUS SOLOSTAR 35 larin 58 larin 24 fe 58 larin fe 58 latanoprost 65 LATUDA 28 leena 58 leflunomide 64 LENVIMA 25 lessina 58 LETAIRIS 71 letrozole 24 leucovorin calcium 24 LEUKERAN 23 LEUKINE 37 leuprolide acetate 62 levalbuterol hcl 70 LEVATOL 40 LEVEMIR 35 LEVEMIR FLEXPEN 35 LEVEMIR FLEXTOUCH 35 levetiracetam 13 levobunolol hcl 68 levocarnitine 73 levocetirizine dihydrochloride 69 levofloxacin 12 levonest 58 levonorgestrel-ethinyl estradiol 58 levonorgestrel/ethinyl estradiol and ethinyl estradiol 58 levora-28 58 levorphanol tartrate 2 levothyroxine sodium 61 levoxyl 61 LEXIVA 30 LIALDA 51 lidocaine 5 lidocaine hcl 5 lidocaine/prilocaine 5 lindane 26 linezolid 9 liothyronine sodium 61 lisinopril 38 89

lisinopril/hydrochlorothiazide 42 lithium carbonate 33 lithium citrate 33 lofibra 44 lomedia 24 fe 58 lomustine 23 lopreeza 58 lorazepam 33 lorazepam intensol 33 lorcet 4 lorcet hd 4 lorcet plus 4 lortab 4 lortuss ex 71 loryna 58 losartan potassium 38 losartan potassium/hydrochlorothiazide 42 LOTEMAX 67 lovastatin 44 low-ogestrel 58 loxapine succinate 28 ludent fluoride 74 LUMIGAN 65 lutera 58 LYNPARZA 24 LYRICA 14 LYSODREN 62 lyza 61 M maprotiline hcl 16 marlissa 58 MARPLAN 17 MATULANE 23 matzim la 41 meclofenamate sodium 2 medroxyprogesterone acetate 61 mefloquine hcl 26 megestrol acetate 61 MEKINIST 25 meloxicam 2 memantine hcl 16 meperidine hcl 4 meperitab 4 meprobamate 33 mercaptopurine 23 mesalamine 51 mesalamine with cleansing wipes 51 MESNEX 24 MESTINON 22 metadate er 46 metaxalone 72 metformin hcl 34 methadone hcl 2 methadone intensol 2 methadose 2 methazolamide 43 methenamine hippurate 9 methimazole 63 methocarbamol 72 methotrexate sodium 23 methotrexate sodium/pf 23 methoxsalen, rapid 48 methyclothiazide 43 methyldopa 38 methyldopa/hydrochlorothiazide 42 methylphenidate hcl 46 methylprednisolone 7 metipranolol 68 metoclopramide hcl 19 metolazone 43 metoprolol succinate 40 metoprolol tartrate 40 metoprolol tartrate/hydrochlorothiazide 42 metronidazole 9 mexiletine hcl 39 microgestin 58 microgestin fe 58 midodrine hcl 38 migergot 21 MIGRANAL 21 millipred 7 90

millipred dp 7 mimvey 58 mimvey lo 59 minitran 45 minocycline hcl 13 minoxidil 45 mirtazapine 16 misoprostol 52 modafinil 73 MODERIBA 31 moexipril hcl 38 moexipril hcl/hydrochlorothiazide 42 mometasone furoate 49 mono-linyah 59 mononessa 59 montelukast sodium 69 MONUROL 9 morgidox 13 morphine sulfate 3,4 MOVIPREP 52 MOXEZA 12 moxifloxacin hcl 12 MULTAQ 39 mupirocin 9 MYALEPT 54 mycophenolate mofetil 63 mycophenolate sodium 63 myorisan 49 MYRBETRIQ 29 myzilra 59 N nabumetone 2 nadolol 40 nadolol/bendroflumethiazide 42 naltrexone hcl 5 NAMENDA 16 naphazoline hcl 66 NAPRELAN 2 naproxen 2 naproxen sodium 2 NASONEX 68 NATACYN 20 nateglinide 34 necon 59 nefazodone hcl 17 neo-polycin 66 neo-polycin hc 66 neomycin sulfate 8 neomycin sulfate/bacitracin zinc/polymyxin b/hydrocortisone 66 neomycin sulfate/bacitracin/polymyxin b 66 neomycin sulfate/polymyxin b sulfate/gramicidin d 66 neomycin sulfate/polymyxin b sulfate/hydrocortisone 7,66 neomycin/polymyxin b sulfate/dexamethasone 66 neosporin 66 NESINA 34 NEULASTA 37 NEUMEGA 37 NEUPOGEN 37 nevirapine 29 NEXAVAR 25 nicardipine hcl 41 nifediac cc 41 nifedical xl 41 nifedipine 41 nikki 59 NILANDRON 62 nimodipine 41 nisoldipine 41 NITRO-BID 45 NITRO-DUR 45 nitro-time 45 nitrofurantoin 9 nitrofurantoin macrocrystal 9 nitrofurantoin monohydrate/macrocrystals 9 nitroglycerin 45 NITROSTAT 45 niva-plus 74 nizatidine 51 nora-be 61 91

NORDITROPIN 55 NORDITROPIN FLEXPRO 55 NORDITROPIN NORDIFLEX 55 norethindrone 61 norethindrone acetate 61 norethindrone acetate-ethinyl estradiol 59 norethindrone acetate-ethinyl estradiol/ferrous fumarate 59 norgestimate-ethinyl estradiol 59 norlyroc 61 NORPACE CR 39 nortrel 59 nortriptyline hcl 18 NORVIR 30 NOVOLIN 70-30 36 NOVOLIN N 36 NOVOLIN R 36 NOVOLOG 36 NOVOLOG FLEXPEN 36 NOVOLOG MIX 70-30 36 NOVOLOG MIX 70-30 FLEXPEN 36 NOXAFIL 20 NUEDEXTA 46 nulytely with flavor packs 52 NUTROPIN 55 NUTROPIN AQ 55 NUTROPIN AQ NUSPIN 55 NUVARING 59 nyamyc 20 nystatin 20 nystatin/triamcinolone acetonide 7 nystop 20 O ocella 59 octreotide acetate 62 OCUDOX 13 OFEV 71 ofloxacin 12 ogestrel 59 olanzapine 28 olanzapine/fluoxetine hcl 17 OLYSIO 31 omeprazole 52 OMNITROPE 55 ondansetron 19 ondansetron hcl 19 ONFI 14 ONGLYZA 34 OPSUMIT 71 ORALAIR 71 oralone 7 ORAP 28 ORENITRAM ER 71 ORFADIN 50 orphenadrine citrate 72 orphenadrine citrate/aspirin/caffeine 72 orsythia 59 ORTHO TRI-CYCLEN LO 59 OSENI 34 OTEZLA 64 oxandrolone 55 oxaprozin 2 oxazepam 33 oxcarbazepine 15 OXSORALEN 49 oxybutynin chloride 52 oxycodone hcl 3,4 oxycodone hcl/acetaminophen 4 oxycodone hcl/aspirin 4 OXYCONTIN 3 oxymorphone hcl 5 OXYTROL 53 P pacerone 39 pancrelipase 5,000 50 PANRETIN 26 pantoprazole sodium 52 paricalcitol 62 paroex 9 paroxetine hcl 17 92

PATANOL 67 PAXIL 17 pedi-dri 20 pediatric multivitamin combination no.2/sodium fluoride 74 pediatric multivitamins a,c,& d3 no.21 with sodium fluoride 74 pediatric multivitamins no.16 with sodium fluoride 74 pediatric multivitamins no.17 with sodium fluoride 74 pediatric multivitamins no.82 with sodium fluoride 74 peg 3350/sod sulf/sod bicarbonate/sod chloride/potassium chl 52 PEGASYS 31 PEGASYS PROCLICK 31 PEGINTRON 32 PEGINTRON REDIPEN 32 penicillin v potassium 11 PENTASA 51 pentoxifylline 42 perindopril erbumine 38 periogard 10 permethrin 26 perphenazine 19 perphenazine/amitriptyline hcl 17 phenadoz 19 phenelzine sulfate 17 phenobarbital 14 phenylephrine hcl/promethazine hcl 72 phenytoin 15 phenytoin sodium extended 15 philith 59 PICATO 49 pilocarpine hcl 47,68 PILOPINE HS 68 pimtrea 59 pindolol 40 pioglitazone hcl 34 pioglitazone hcl/glimepiride 34 pioglitazone hcl/metformin hcl 34 pirmella 59 piroxicam 2 PLEGRIDY 47 PLEGRIDY PEN 47 pnv-vp-u 74 podofilox 49 POLY-VI-SOL WITH IRON 74 polycin 66 polymyxin b sulfate/trimethoprim 66 POMALYST 23 portia 59 potassium chloride 74 potassium citrate 74 PRADAXA 36 pramipexole di-hcl 27 pravastatin sodium 44 prazosin hcl 38 prednisolone 8 prednisolone acetate 54 prednisolone sod phosphate 8,67 prednisone 8 prednisone intensol 8 PREMARIN 59 PREMPHASE 59 PREMPRO 59 prenaplus 74 prenatal vitamins comb no.115/iron fumarate/folic acid 74 prenatal vitamins comb no.115/iron fumarate/folic acid/dss 74 prenatal vitamins combo no.60/ferrous fumarate/folic acid 75 prenatal vits with calcium #72/ferrous fumarate/folic acid 75 prenatal vits with calcium #72/iron,carbonyl/folic acid 75 prenatal vits with calcium #74/ferrous fumarate/folic acid 75 prenatal vits without calc no5/ferrous fumarate/folic acid 75 preplus 75 prevalite 44 previfem 59 PREZCOBIX 31 93

PREZISTA 31 PRIFTIN 22 primaquine phosphate 26 primidone 13 proair hfa 70 proair respiclick 70 probenecid 21 prochlorperazine 19 prochlorperazine maleate 19 PROCRIT 37 procto-pak 8 proctocream-hc 8 PROCTOFOAM-HC 51 proctosol-hc 65 proctozone-hc 65 PROCYSBI 53 progesterone,micronized 61 PROGLYCEM 35 PROGRAF 63 PROMACTA 37 promethazine hcl 19 promethazine hcl/codeine 72 promethazine hcl/dextromethorphan hbr 72 promethazine/phenylephrine hcl/codeine 72 promethegan 19 propafenone hcl 39 propantheline bromide 51 propranolol hcl 40 propranolol hcl/hydrochlorothiazide 42 propylthiouracil 63 PROTONIX 52 protriptyline hcl 18 psorcon 8 PULMICORT FLEXHALER 68 pulmosal 72 PULMOZYME 72 PURIXAN 23 PYLERA 51 pyridostigmine bromide 22 Q quasense 59 quetiapine fumarate 28 QUFLORA 75 quinapril hcl 38 quinapril hcl/hydrochlorothiazide 42 quinidine gluconate 39 quinidine sulfate 39 QVAR 68 R rabeprazole sodium 52 RAGWITEK 72 raloxifene hcl 61 ramipril 38 RANEXA 42 ranitidine hcl 51 RAPAMUNE 64 RAVICTI 50 REBETOL 32 REBIF 47 REBIF REBIDOSE 47 reclipsen 59 RECTIV 45 refissa 49 REGRANEX 49 relador pak 5 relador pak plus 5 RENAGEL 53 RENVELA 53 reprexain 5 RESTASIS 64 REVATIO 71 revia 6 REVLIMID 23 REYATAZ 31 RHEUMATREX 23 RIBAPAK 32 RIBASPHERE 32 RIBASPHERE RIBAPAK 32 94

RIBATAB 32 ribavirin 32 rifabutin 22 RIFAMATE 22 rifampin 22 RIFATER 22 riluzole 46 rimantadine hcl 31 RIOMET 34 risedronate sodium 65 RISPERDAL CONSTA 28 risperidone 28 RITALIN LA 46 rivastigmine tartrate 16 rizatriptan benzoate 21 ropinirole hcl 27 rosadan 10 ROXICET 5 roxicet 5 ROZEREM 73 S SABRIL 14 SAIZEN 55 SANDIMMUNE 64 SANTYL 49 SAPHRIS 28 SAVAYSA 36 SAVELLA 46,47 selegiline hcl 27 SELZENTRY 30 SENSIPAR 62 SEREVENT DISKUS 70 SEROSTIM 55 sertraline hcl 17 sevelamer carbonate 53 sharobel 61 SIGNIFOR 62 sildenafil citrate 71 silver sulfadiazine 12 SIMPONI 64 simvastatin 44 sirolimus 64 SIRTURO 22 SIVEXTRO 10 sodium chloride for inhalation 72 sodium chloride/sodium bicarbonate/potassium chloride/peg 52 sodium fluoride 75 sodium phenylbutyrate 50 sodium polystyrene sulfonate 73 SOLTAMOX 23 SOMAVERT 62 SOOLANTRA 26 sorine 39 sotalol hcl 39 SOVALDI 32 SPIRIVA 69 SPIRIVA RESPIMAT 69 spironolactone 43 spironolactone/hydrochlorothiazide 42 SPORANOX 20 sprintec 60 SPRYCEL 25 sps 73 sronyx 60 sski 75 stagesic 5 stavudine 30 STELARA 49 STIMATE 55 STIVARGA 25 STRATTERA 46 STRIBILD 30 SUBOXONE 6 SUCRAID 50 sucralfate 52 sulfacetamide sodium 12 sulfacetamide sodium/prednisolone sodium phosphate 66 sulfadiazine 12 sulfamethoxazole/trimethoprim 13 95

sulfamide 13 sulfasalazine 51 sulfazine 51 sulfazine ec 51 sulindac 2 sumatriptan 21 sumatriptan succinate 21 SUPREP 52 SUSTIVA 29 SUTENT 25 syeda 60 SYLATRON 24 SYLATRON 4-PACK 24 SYMBICORT 70 SYMLINPEN 120 34 SYMLINPEN 60 34 SYNRIBO 24 SYPRINE 73 T tacrolimus 49,64 TAFINLAR 25 TAMIFLU 31 tamoxifen citrate 23 tamsulosin hcl 53 TARCEVA 25 TARGRETIN 26 tarina fe 60 TASIGNA 25 TAZORAC 49 taztia xt 41 TECFIDERA 47 temazepam 73 temozolomide 23 tencon 1 terazosin hcl 38 terbinafine hcl 20 terbutaline sulfate 70 terconazole 20 testosterone 56 testosterone cypionate 56 testosterone enanthate 56 tetracycline hcl 13 TEV-TROPIN 55 THALOMID 23 theochron 69 theophylline anhydrous 69 THIOLA 53 thioridazine hcl 28 thiothixene 28 tiagabine hcl 14 ticlopidine hcl 37 TIKOSYN 39 tilia fe 60 timolol maleate 21,68 tinidazole 10 TIVICAY 30 tizanidine hcl 29 TL FOLATE 75 tl-fluorivite 75 TOBI PODHALER 8 TOBRADEX 8 TOBRADEX ST 66 tobramycin 8 tobramycin in 0.225 % sodium chloride 8 tobramycin/dexamethasone 66 TOBREX 8 tolmetin sodium 2 tolterodine tartrate 53 topiragen 15 topiramate 15 torsemide 43 TOUJEO SOLOSTAR 36 TRACLEER 71 TRADJENTA 35 tramadol hcl 3,5 tramadol hcl/acetaminophen 5 trandolapril 38 tranexamic acid 37 TRANSDERM-SCOP 19 tranylcypromine sulfate 17 TRAVATAN Z 66 96

travoprost (benzalkonium) 66 trazodone hcl 17 TRECATOR 22 tretinoin 26,49 tretinoin/emollient base 49 tri-estarylla 60 tri-legest fe 60 tri-linyah 60 tri-previfem 60 tri-sprintec 60 triamcinolone acetonide 8,54 triamterene/hydrochlorothiazide 42 trianex 49 triazolam 73 TRICARE 75 triderm 8 trifluoperazine hcl 28 trifluridine 32 TRIGLIDE 44 trihexyphenidyl hcl 27 trilyte with flavor packets 52 trimethobenzamide hcl 19 trimethoprim 10 trimipramine maleate 18 trinatal rx 1 75 trinessa 60 TRIUMEQ 30 triveen-u 75 trivora-28 60 tropicamide 67 trospium chloride 53 TRUVADA 30 tusnel c 72 TYBOST 30 TYKERB 25 TYZEKA 32 TYZINE 72 U UCERIS 65 ULESFIA 26 unithroid 62 ursodiol 51 V VAGIFEM 60 valacyclovir hcl 32 VALCHLOR 23 VALCYTE 31 valganciclovir hcl 31 valproic acid 15 valproic acid (as sodium salt) (valproate sodium) 14 valsartan 38 valsartan/hydrochlorothiazide 42 vanatol lq 1 vancomycin hcl 10 vandazole 10 vandetanib 25 velivet 60 venlafaxine hcl 18 VENTAVIS 71 ventolin hfa 70 verapamil hcl 39,41 VERSACLOZ 29 vestura 60 VEXOL 67 VICTOZA 2-PAK 35 VICTOZA 3-PAK 35 VICTRELIS 32 VIEKIRA PAK 32 VIGAMOX 12 VIMPAT 16 vinate one 75 vinate-m 75 viorele 60 VIRACEPT 31 VIRAMUNE XR 29 VIREAD 30 virtussin ac 72 virtussin dac 72 vitazol 10 VITEKTA 30 97

vol-plus 75 VOLTAREN 49 voriconazole 20 VOTRIENT 25 vyfemla 60 VYVANSE 45 W warfarin sodium 36 wera 60 X XALKORI 25 XARELTO 36 XENAZINE 46 XIFAXAN 10 XIGDUO XR 35 XOPENEX HFA 70 XTANDI 62 xulane 60 xylon 10 5 XYREM 73 ZOMIG 21 zonisamide 14 ZORBTIVE 55 ZORTRESS 64 zovia 1-35e 60 zovia 1-50e 60 ZYDELIG 25 ZYFLO CR 69 ZYKADIA 25 ZYLET 67 ZYTIGA 25 ZYVOX 10 Z zafirlukast 69 zaleplon 73 zarah 60 ZAVESCA 50 ZELBORAF 25 zenatane 49 zenchent 60 ZENPEP 50 zenzedi 45 ZETIA 44 zidovudine 30 ziprasidone hcl 16,28 ZIRGAN 31 ZOLINZA 25 zolmitriptan 21 zolpidem tartrate 73 ZOMACTON 55 98

Category Listing Analgesics 1 Anesthetics 5 Anti-Addiction/Substance Abuse Treatment Agents 5 Anti-inflammatory Agents 6 Antibacterials 8 Anticonvulsants 13 Antidementia Agents 16 Antidepressants 16 Antiemetics 18 Antifungals 19 Antigout Agents 21 Antimigraine Agents 21 Antimyasthenic Agents 22 Antimycobacterials 22 Antineoplastics 22 Antiparasitics 26 Antiparkinson Agents 27 Antipsychotics 28 Antispasticity Agents 29 Antivirals 29 Anxiolytics 32 Bipolar Agents 33 Blood Glucose Regulators 33 Blood Products/Modifiers/ Volume Expanders 36 Cardiovascular Agents 37 Central Nervous System Agents 45 Dental and Oral Agents 47 Dermatological Agents 48 Enzyme Replacement/ Modifiers 49 Gastrointestinal Agents 50 Genitourinary Agents 52 Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal) 53 Hormonal Agents, Stimulant/Replacement/Modifying (Other) 54 Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) 54 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) 55 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) 61 Hormonal Agents, Suppressant (Adrenal) 62 Hormonal Agents, Suppressant (Parathyroid) 62 Hormonal Agents, Suppressant (Pituitary) 62 Hormonal Agents, Suppressant (Sex Hormones/Modifiers) 62 Hormonal Agents, Suppressant (Thyroid) 63 Immunological Agents 63 Inflammatory Bowel Disease Agents 64 Metabolic Bone Disease Agents 65 Miscellaneous 65 99

Ophthalmic Agents 65 Otic Agents 68 Respiratory Tract Agents 68 Skeletal Muscle Relaxants 72 Sleep Disorder Agents 73 Therapeutic Nutrients/ Minerals/ Electrolytes 73 100