Drug Name Drug Tier Requirements/Limits

EXCHANGES_MOLINA_WA ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS Amphetamines amphetamine cap 5mg er Tier 1 AGE amphetamine cap 10mg er Tier 1 AGE amphetamine cap 15mg er Tier 1 AGE amphetamine cap 20mg er Tier 1 AGE amphetamine cap 25mg er Tier 1 AGE amphetamine cap 30mg er Tier 1 AGE amphetamine tab 5mg Tier 1 AGE amphetamine tab 7.5mg Tier 1 AGE amphetamine tab 10mg Tier 1 AGE amphetamine tab 12.5mg Tier 1 AGE amphetamine tab 15mg Tier 1 AGE amphetamine tab 20mg Tier 1 AGE amphetamine tab 30mg Tier 1 AGE dextroamphet cap 5mg er Tier 1 AGE dextroamphet cap 10mg er Tier 1 AGE dextroamphet cap 15mg er Tier 1 AGE dextroamphet tab 5mg Tier 1 AGE dextroamphet tab 10mg Tier 1 AGE methamphetam tab 5mg Tier 1 AGE VYVANSE CAP 20MG Tier 3 AGE VYVANSE CAP 30MG Tier 3 AGE VYVANSE CAP 40MG Tier 3 AGE VYVANSE CAP 50MG Tier 3 AGE VYVANSE CAP 60MG Tier 3 AGE VYVANSE CAP 70MG Tier 3 AGE zenzedi tab 5mg Tier 1 AGE zenzedi tab 10mg Tier 1 AGE Analeptics caffeine cit sol 20mg/ml Tier 1 caffeine cit sol 60mg/3ml Tier 1 Attention-Deficit/Hyperactivity Disorder (ADHD) Agents INTUNIV TAB 1MG Tier 3 PA INTUNIV TAB 2MG Tier 3 PA INTUNIV TAB 3MG Tier 3 PA INTUNIV TAB 4MG Tier 3 PA STRATTERA CAP 10MG Tier 2 AGE STRATTERA CAP 18MG Tier 2 AGE STRATTERA CAP 25MG Tier 2 AGE 1

STRATTERA CAP 40MG Tier 2 AGE STRATTERA CAP 60MG Tier 2 AGE STRATTERA CAP 80MG Tier 2 AGE STRATTERA CAP 100MG Tier 2 AGE Stimulants - Misc. DAYTRANA DIS 10MG/9HR Tier 3 PA; AGE DAYTRANA DIS 15MG/9HR Tier 3 PA; AGE DAYTRANA DIS 20MG/9HR Tier 3 PA; AGE DAYTRANA DIS 30MG/9HR Tier 3 PA; AGE dexmethylph tab 2.5mg Tier 1 AGE dexmethylph tab 5mg Tier 1 AGE dexmethylph tab 10mg Tier 1 AGE FOCALIN XR CAP 5MG Tier 3 PA; AGE FOCALIN XR CAP 10MG Tier 3 PA; AGE FOCALIN XR CAP 15MG Tier 3 PA; AGE FOCALIN XR CAP 20MG Tier 3 PA; AGE FOCALIN XR CAP 25MG Tier 3 PA; AGE FOCALIN XR CAP 30MG Tier 3 PA; AGE FOCALIN XR CAP 35MG Tier 3 PA; AGE FOCALIN XR CAP 40MG Tier 3 PA; AGE metadate tab 20mg er Tier 1 AGE METHYLIN CHW 2.5MG Tier 2 AGE METHYLIN CHW 5MG Tier 2 AGE METHYLIN CHW 10MG Tier 2 AGE methylin tab 5mg Tier 1 AGE methylin tab 10mg Tier 1 AGE methylin tab 10mg er Tier 1 AGE methylin tab 20mg Tier 1 AGE methylin tab 20mg er Tier 1 AGE methylphenid cap 10mg Tier 1 AGE methylphenid cap 20mg Tier 1 AGE methylphenid cap 20mg er Tier 1 AGE methylphenid cap 30mg Tier 1 AGE methylphenid cap 30mg er Tier 1 AGE methylphenid cap 40mg Tier 1 AGE methylphenid cap 40mg er Tier 1 AGE methylphenid cap 50mg Tier 1 AGE methylphenid cap 60mg Tier 1 AGE methylphenid sol 5mg/5ml Tier 1 AGE methylphenid sol 10mg/5ml Tier 1 AGE methylphenid tab 5mg Tier 1 AGE methylphenid tab 10mg Tier 1 AGE methylphenid tab 10mg er Tier 1 AGE 2

methylphenid tab 18mg er Tier 1 AGE methylphenid tab 20mg Tier 1 AGE methylphenid tab 20mg er Tier 1 AGE methylphenid tab 20mg sr Tier 1 AGE methylphenid tab 27mg er Tier 1 AGE methylphenid tab 36mg er Tier 1 AGE methylphenid tab 54mg er Tier 1 AGE modafinil tab 100mg Tier 1 PA modafinil tab 200mg Tier 1 PA NUVIGIL TAB 50MG Tier 3 PA NUVIGIL TAB 150MG Tier 3 PA NUVIGIL TAB 250MG Tier 3 PA QUILLIVANT SUS XR Tier 3 PA RITALIN LA CAP 10MG Tier 3 PA; AGE AMEBICIDES Amebicides YODOXIN TAB 210MG Tier 2 YODOXIN TAB 650MG Tier 2 AMINOGLYCOSIDES Aminoglycosides NEO-FRADIN SOL 125/5ML Tier 2 neomycin tab 500mg Tier 1 paromomycin cap 250mg Tier 1 TOBI NEB 300/5ML Tier 4 PA ANALGESICS - ANTI-INFLAMMATORY Anti-TNF-alpha - Monoclonoal Antibodies HUMIRA KIT 20MG/0.4 Tier 4 PA HUMIRA KIT 40MG/0.8 Tier 4 PA HUMIRA PEN KIT 40MG/0.8 Tier 4 PA HUMIRA PEN KIT CROHNS Tier 4 PA HUMIRA PEN KIT PSORIASI Tier 4 PA Antirheumatic Antimetabolites RHEUMATREX TAB 2.5MG Tier 2 Gold Compounds RIDAURA CAP 3MG Tier 2 Interleukin-1 Blockers ARCALYST INJ 220MG Tier 4 PA Interleukin-1 Receptor Antagonist (IL-1Ra) KINERET INJ Tier 4 PA Interleukin-6 Receptor Inhibitors ACTEMRA INJ 80MG/4ML Tier 4 PA 3

ACTEMRA INJ 200/10ML Tier 4 PA ACTEMRA INJ 400/20ML Tier 4 PA Nonsteroidal Anti-inflammatory Agents (NSAIDs) all day pain tab 220mg Tier 1 all day relf tab 220mg Tier 1 CELEBREX CAP 50MG Tier 2 PA CELEBREX CAP 100MG Tier 2 PA CELEBREX CAP 200MG Tier 2 PA CELEBREX CAP 400MG Tier 2 PA diclofen pot tab 50mg Tier 1 diclofenac tab 25mg dr Tier 1 diclofenac tab 50mg dr Tier 1 diclofenac tab 75mg dr Tier 1 diclofenac tab 100mg er Tier 1 diclofenac tab 100mg xr Tier 1 etodolac cap 200mg Tier 1 etodolac cap 300mg Tier 1 etodolac er tab 400mg Tier 1 etodolac er tab 500mg Tier 1 etodolac er tab 600mg Tier 1 etodolac tab 400mg Tier 1 etodolac tab 500mg Tier 1 fenoprofen tab 600mg Tier 1 flanax pain tab 220mg Tier 1 flurbiprofen tab 50mg Tier 1 flurbiprofen tab 100mg Tier 1 ibuprofen tab 400mg Tier 1 ibuprofen tab 600mg Tier 1 ibuprofen tab 800mg Tier 1 INDOCIN SUP 50MG Tier 2 INDOCIN SUS 25MG/5ML Tier 2 indomethacin cap 25mg Tier 1 indomethacin cap 50mg Tier 1 indomethacin cap 75mg er Tier 1 ketoprofen cap 50mg Tier 1 ketoprofen cap 75mg Tier 1 ketoprofen cap 200mg er Tier 1 ketorolac tab 10mg Tier 1 kls naproxen tab 220mg Tier 1 meclofen sod cap 50mg Tier 1 meclofen sod cap 100mg Tier 1 mediproxen tab 220mg Tier 1 mefenam acid cap 250mg Tier 1 4

meloxicam sus 7.5/5ml Tier 1 meloxicam tab 7.5mg Tier 1 meloxicam tab 15mg Tier 1 midol extend tab 220mg Tier 1 nabumetone tab 500mg Tier 1 nabumetone tab 750mg Tier 1 naproxen dr tab 375mg Tier 1 naproxen dr tab 500mg Tier 1 naproxen sod tab 220mg Tier 1 naproxen sod tab 275mg Tier 1 naproxen sod tab 550mg Tier 1 naproxen sus 125/5ml Tier 1 naproxen tab 250mg Tier 1 naproxen tab 375mg Tier 1 naproxen tab 500mg Tier 1 oxaprozin tab 600mg Tier 1 pamprin tab 220mg Tier 1 piroxicam cap 10mg Tier 1 piroxicam cap 20mg Tier 1 SPRIX SPR 15.75MG Tier 3 PA sulindac tab 150mg Tier 1 sulindac tab 200mg Tier 1 th naproxen tab 220mg Tier 1 tolmetin sod cap 400mg Tier 1 tolmetin sod tab 200mg Tier 1 tolmetin sod tab 600mg Tier 1 wal-proxen tab 220mg Tier 1 Pyrimidine Synthesis Inhibitors leflunomide tab 10mg Tier 1 leflunomide tab 20mg Tier 1 Soluble Tumor Necrosis Factor Receptor Agents ENBREL INJ 25/0.5ML Tier 4 PA ENBREL INJ 25MG Tier 4 PA ENBREL INJ 50MG/ML Tier 4 PA ENBREL SRCLK INJ 50MG/ML Tier 4 PA ANALGESICS - NonNarcotic Analgesic Combinations alagesic cap Tier 1 anolor 300 cap Tier 1 bupap tab 50-650mg Tier 1 but/apap/caf cap Tier 1 but/apap/caf tab Tier 1 5

but/asa/caff cap Tier 1 but/asa/caff tab Tier 1 butal/apap tab 50-325mg Tier 1 butalbital tab cpd Tier 1 capacet cap Tier 1 cephadyn tab 50-650mg Tier 1 margesic cap Tier 1 marten-tab tab 50-325mg Tier 1 PHRENILIN CAP FORTE Tier 2 promacet tab 50-650mg Tier 1 repan tab Tier 1 Salicylates anacin tab 81mg ec Tier 0 aspir-81 tab 81mg ec Tier 0 aspir-low tab 81mg ec Tier 0 aspirin adlt tab 81mg Tier 0 aspirin chil chw 81mg Tier 0 aspirin chld chw 81mg Tier 0 aspirin chw 81mg Tier 0 aspirin low chw 81mg Tier 0 aspirin tab 5gr ec Tier 0 aspirin tab 81mg Tier 0 aspirin tab 81mg ec Tier 0 aspirin tab 325mg Tier 0 aspirin tab 325mg ec Tier 0 aspirtab tab 324mg ec Tier 0 bayer adv tab 325mg Tier 0 bayer asa tab 325mg Tier 0 bayer low chw 81mg Tier 0 bayer low tab 81mg ec Tier 0 child asa chw 81mg Tier 0 child asa ls chw 81mg Tier 0 cho mag tris liq 500/5ml Tier 1 cho mag tris tab 500mg Tier 1 cho mag tris tab 750mg Tier 1 cho mag tris tab 1000mg Tier 1 cvs aspirin tab 81mg ec Tier 0 cvs aspirin tab 325mg Tier 0 cvs aspirin tab 325mg ec Tier 0 cvs chld asa chw 81mg Tier 0 diflunisal tab 500mg Tier 1 ecotrin low tab 81mg ec Tier 0 ecpirin tab 325mg ec Tier 0 6

eq aspirin tab 325mg Tier 0 eq aspirin tab 325mg ec Tier 0 eq child asa chw 81mg Tier 0 eql aspirin tab 81mg ec Tier 0 eql aspirin tab 325mg Tier 0 eql aspirin tab 325mg ec Tier 0 eql chld asa chw 81mg Tier 0 gnp aspirin chw 81mg Tier 0 gnp aspirin tab 81mg ec Tier 0 gnp aspirin tab 325mg Tier 0 gnp aspirin tab 325mg ec Tier 0 halfprin tab 81mg ec Tier 0 hm aspirin chw 81mg Tier 0 hm aspirin tab 325mg Tier 0 kls aspirin tab 81mg ec Tier 0 kls aspirin tab 325mg ec Tier 0 kp aspirin tab 81mg ec Tier 0 miniprin low tab 81mg ec Tier 0 mm aspirin tab 325mg Tier 0 norwich asa tab 325mg Tier 0 px aspirin chw 81mg Tier 0 px aspirin tab 81mg ec Tier 0 px aspirin tab 325mg Tier 0 px aspirin tab 325mg ec Tier 0 qc aspirin tab 325mg Tier 0 qc aspirin tab 325mg ec Tier 0 qc child asa chw 81mg Tier 0 ra aspirin chw 81mg Tier 0 ra aspirin tab 81mg ec Tier 0 ra aspirin tab 325mg Tier 0 ra aspirin tab 325mg ec Tier 0 ra child asa chw 81mg Tier 0 salsalate tab 500mg Tier 1 salsalate tab 750mg Tier 1 sb aspirin tab 325mg Tier 0 sb aspirin tab 325mg ec Tier 0 sb child asa chw 81mg Tier 0 sm aspirin chw 81mg Tier 0 sm aspirin tab 81mg ec Tier 0 sm aspirin tab 325mg Tier 0 sm aspirin tab 325mg ec Tier 0 sm child asa chw 81mg Tier 0 st joseph as chw 81mg Tier 0 7

tgt aspirin chw 81mg Tier 0 tgt aspirin chw child Tier 0 tgt aspirin tab 81mg ec Tier 0 tgt aspirin tab 325mg Tier 0 th aspirin tab 81mg ec Tier 0 th aspirin tab 325mg Tier 0 th aspirin tab 325mg ec Tier 0 ANALGESICS - OPIOID Opioid Agonists ABSTRAL SUB 100MCG Tier 3 PA ABSTRAL SUB 200MCG Tier 3 PA ABSTRAL SUB 300MCG Tier 3 PA ABSTRAL SUB 400MCG Tier 3 PA ABSTRAL SUB 600MCG Tier 3 PA ABSTRAL SUB 800MCG Tier 3 PA codeine sulf tab 15mg Tier 1 codeine sulf tab 30mg Tier 1 codeine sulf tab 60mg Tier 1 fentanyl dis 12mcg/hr Tier 1 fentanyl dis 25mcg/hr Tier 1 fentanyl dis 50mcg/hr Tier 1 fentanyl dis 75mcg/hr Tier 1 fentanyl dis 100mcg/h Tier 1 fentanyl ot loz 200mcg Tier 1 PA fentanyl ot loz 400mcg Tier 1 PA fentanyl ot loz 600mcg Tier 1 PA fentanyl ot loz 800mcg Tier 1 PA fentanyl ot loz 1200mcg Tier 1 PA fentanyl ot loz 1600mcg Tier 1 PA FENTORA TAB 100MCG Tier 3 PA FENTORA TAB 200MCG Tier 3 PA FENTORA TAB 400MCG Tier 3 PA FENTORA TAB 600MCG Tier 3 PA FENTORA TAB 800MCG Tier 3 PA hydromorphon liq 1mg/ml Tier 1 hydromorphon tab 2mg Tier 1 hydromorphon tab 4mg Tier 1 hydromorphon tab 8mg Tier 1 KADIAN CAP 10MG CR Tier 3 PA KADIAN CAP 200MG CR Tier 3 PA LAZANDA SPR 100MCG Tier 3 PA LAZANDA SPR 400MCG Tier 3 PA 8

levorphanol tab 2mg Tier 1 meperidine tab 50mg Tier 1 meperidine tab 100mg Tier 1 meperitab tab 50mg Tier 1 meperitab tab 100mg Tier 1 methadone con 10mg/ml Tier 1 methadone sol 5mg/5ml Tier 1 methadone sol 10mg/5ml Tier 1 methadone tab 5mg Tier 1 methadone tab 10mg Tier 1 methadone tab 40mg Tier 1 methadose con 10mg/ml Tier 1 methadose sf con 10mg/ml Tier 1 methadose tab 5mg Tier 1 methadose tab 10mg Tier 1 methadose tab 40mg Tier 1 morphine sul cap 20mg er Tier 1 morphine sul cap 30mg er Tier 1 morphine sul cap 50mg er Tier 1 morphine sul cap 60mg er Tier 1 morphine sul cap 80mg er Tier 1 morphine sul cap 100mg er Tier 1 morphine sul tab 15mg Tier 1 morphine sul tab 15mg er Tier 1 morphine sul tab 30mg Tier 1 morphine sul tab 30mg er Tier 1 morphine sul tab 100mg er Tier 1 morphine sul tab 200mg er Tier 1 NUCYNTA ER TAB 50MG Tier 3 PA NUCYNTA ER TAB 100MG Tier 3 PA NUCYNTA ER TAB 150MG Tier 3 PA NUCYNTA ER TAB 200MG Tier 3 PA NUCYNTA ER TAB 250MG Tier 3 PA NUCYNTA TAB 50MG Tier 3 PA NUCYNTA TAB 75MG Tier 3 PA NUCYNTA TAB 100MG Tier 3 PA ONSOLIS MIS 200MCG Tier 3 PA ONSOLIS MIS 400MCG Tier 3 PA ONSOLIS MIS 600MCG Tier 3 PA ONSOLIS MIS 800MCG Tier 3 PA ONSOLIS MIS 1200MCG Tier 3 PA OXECTA TAB 5MG Tier 3 OXECTA TAB 7.5MG Tier 3 9

oxycodone cap 5mg Tier 1 oxycodone con 20mg/ml Tier 1 oxycodone con 100/5ml Tier 1 oxycodone sol 5mg/5ml Tier 1 oxycodone tab 5mg Tier 1 oxycodone tab 10mg Tier 1 oxycodone tab 15mg Tier 1 oxycodone tab 20mg Tier 1 oxycodone tab 30mg Tier 1 OXYCONTIN TAB 10MG CR Tier 3 PA OXYCONTIN TAB 15MG CR Tier 3 PA OXYCONTIN TAB 20MG CR Tier 3 PA OXYCONTIN TAB 30MG CR Tier 3 PA OXYCONTIN TAB 40MG CR Tier 3 PA OXYCONTIN TAB 60MG CR Tier 3 PA OXYCONTIN TAB 80MG CR Tier 3 PA oxymorphone tab 5mg er Tier 1 PA oxymorphone tab 7.5mg er Tier 1 PA oxymorphone tab 10mg er Tier 1 PA oxymorphone tab 15mg er Tier 1 PA oxymorphone tab 20mg er Tier 1 PA oxymorphone tab 30mg er Tier 1 PA oxymorphone tab 40mg er Tier 1 PA oxymorphone tab hcl 5mg Tier 1 PA oxymorphone tab hcl 10mg Tier 1 PA SUBSYS SPR 100MCG Tier 3 PA SUBSYS SPR 200MCG Tier 3 PA SUBSYS SPR 400MCG Tier 3 PA SUBSYS SPR 800MCG Tier 3 PA SUBSYS SPR 1200MCG Tier 3 PA tramadol hcl tab 50mg Tier 1 tramadol hcl tab 100mg er Tier 1 PA tramadol hcl tab 200mg er Tier 1 PA tramadol hcl tab 300mg er Tier 1 PA Opioid Combinations apap/codeine sol 120-12/5 Tier 1 apap/codeine tab 300-15mg Tier 1 apap/codeine tab 300-30mg Tier 1 apap/codeine tab 300-60mg Tier 1 ascomp/cod cap 30mg Tier 1 but/apap/caf cap codeine Tier 1 but/asa/caf/ cap cod 30mg Tier 1 co-gesic tab 5-500mg Tier 1 10

endodan tab Tier 1 hydroco/apap sol 7.5-325 Tier 1 hydroco/apap sol 7.5-500 Tier 1 hydroco/apap tab 2.5-500 Tier 1 hydroco/apap tab 5-325mg Tier 1 hydroco/apap tab 5-500mg Tier 1 hydroco/apap tab 7.5-325 Tier 1 hydroco/apap tab 7.5-500 Tier 1 hydroco/apap tab 7.5-650 Tier 1 hydroco/apap tab 7.5-750 Tier 1 hydroco/apap tab 10-325mg Tier 1 hydroco/apap tab 10-500mg Tier 1 hydroco/apap tab 10-650mg Tier 1 hydrocod/ibu tab 7.5-200 Tier 1 oxycod/apap cap 5-500mg Tier 1 oxycod/apap tab 5-325mg Tier 1 oxycod/asa tab Tier 1 oxycod/ibu tab 5-400mg Tier 1 ROXICET SOL 5-325/5 Tier 2 Opioid Partial Agonists bupren/nalox sub 2-0.5mg Tier 1 PA bupren/nalox sub 8-2mg Tier 1 PA buprenorphin sub 2mg Tier 1 PA buprenorphin sub 8mg Tier 1 PA butorphanol sol 10mg/ml Tier 1 BUTRANS DIS 5MCG/HR Tier 3 PA BUTRANS DIS 10MCG/HR Tier 3 PA BUTRANS DIS 20MCG/HR Tier 3 PA pentaz/nalox tab 50-0.5mg Tier 1 ANDROGENS-ANABOLIC Anabolic Steroids ANADROL-50 TAB 50MG Tier 3 PA oxandrolone tab 2.5mg Tier 1 PA oxandrolone tab 10mg Tier 1 PA Androgens ANDRODERM DIS 2.5MG/24 Tier 2 PA ANDRODERM DIS 5MG/24HR Tier 2 PA ANDROGEL GEL 1%(25MG) Tier 2 PA ANDROGEL GEL 1%(50MG) Tier 2 PA ANDROGEL GEL PUMP 1% Tier 2 PA android cap 10mg Tier 1 ANDROXY TAB 10MG Tier 2 11

danazol cap 50mg Tier 1 danazol cap 100mg Tier 1 danazol cap 200mg Tier 1 METHITEST TAB 10MG Tier 2 TESTIM GEL 1%(50MG) Tier 2 PA testost cyp inj 100mg/ml Tier 1 testost cyp inj 200mg/ml Tier 1 testost enan inj 200mg/ml Tier 1 ANORECTAL AGENTS Intrarectal Steroids CORTIFOAM AER 90MG Tier 2 Rectal Combinations hc pramoxine cre 1-1% Tier 1 hc pramoxine cre 2.5-1% Tier 1 PROCORT CRE Tier 2 PROCTOFOAM AER HC 1% Tier 2 Rectal Steroids anucort-hc sup 25mg Tier 1 hemril-30 sup 30mg Tier 1 hydrocort ac sup 25mg Tier 1 hydrocort ac sup 30mg Tier 1 procto-pak cre 1% Tier 1 proctocream cre hc 2.5% Tier 1 proctosol hc cre 2.5% Tier 1 proctozone cre -hc 2.5% Tier 1 rectacort-hc sup 25mg Tier 1 ANTHELMINTICS Anthelmintics ALBENZA TAB 200MG Tier 2 BILTRICIDE TAB 600MG Tier 2 mebendazole chw 100mg Tier 1 STROMECTOL TAB 3MG Tier 2 ANTI-INFECTIVE AGENTS - MISC. Anti-infective Agents - Misc. baciim inj 50000unt Tier 1 PA bacitracin inj 50000unt Tier 1 PA FLAGYL ER TAB 750MG Tier 3 metronidazol cap 375mg Tier 1 metronidazol tab 250mg Tier 1 metronidazol tab 500mg Tier 1 NEBUPENT INH 300MG Tier 3 PA 12

PENTAM 300 INJ 300MG Tier 4 PA trimethoprim tab 100mg Tier 1 vancomycin cap 125mg Tier 1 PA vancomycin cap 250mg Tier 1 PA XIFAXAN TAB 200MG Tier 3 XIFAXAN TAB 550MG Tier 3 Anti-infective Misc. - Combinations e.s.p. sus 200-600 Tier 1 ees/sulfisox sus 200-600 Tier 1 smz-tmp sus Tier 1 smz-tmp sus 200-40/5 Tier 1 smz-tmp tab 400-80mg Tier 1 smz/tmp ds tab 800-160 Tier 1 Antiprotozoal Agents ALINIA SUS 100MG/5M Tier 3 ALINIA TAB 500MG Tier 3 MEPRON SUS Tier 2 Carbapenems imipenem/cil inj 250mg Tier 4 PA imipenem/cil inj 500mg Tier 4 PA Chloramphenicols chloramphen inj 1gm Tier 1 PA Ketolides KETEK TAB 300MG Tier 3 PA KETEK TAB 400MG Tier 3 PA Leprostatics dapsone tab 25mg Tier 1 dapsone tab 100mg Tier 1 Lincosamides clindamycin cap 75mg Tier 1 clindamycin cap 150mg Tier 1 clindamycin cap 300mg Tier 1 PA Oxazolidinones ZYVOX SUS 100MG/5M Tier 3 PA ZYVOX TAB 600MG Tier 3 PA Polymyxins polymyxin b inj 500000 Tier 1 PA ANTIANGINAL AGENTS Antianginals-Other RANEXA TAB 500MG Tier 3 PA RANEXA TAB 1000MG Tier 3 PA Nitrates 13

DILATRATE SR CAP 40MG Tier 2 isochron tab 40mg cr Tier 1 isoditrate tab 40mg er Tier 1 ISORDIL TAB 40MG Tier 2 isosorb din tab 5mg Tier 1 isosorb din tab 10mg Tier 1 isosorb din tab 20mg Tier 1 isosorb din tab 30mg Tier 1 isosorb din tab 40mg er Tier 1 isosorb mono tab 30mg er Tier 1 isosorb mono tab 60mg er Tier 1 isosorb mono tab 120mg er Tier 1 minitran dis 0.1mg/hr Tier 1 minitran dis 0.2mg/hr Tier 1 minitran dis 0.4mg/hr Tier 1 minitran dis 0.6mg/hr Tier 1 NITRO-BID OIN 2% Tier 2 nitro-time cap 2.5mg cr Tier 1 nitro-time cap 6.5mg cr Tier 1 nitro-time cap 9mg cr Tier 1 nitroglycer aer 400mcg Tier 1 nitroglycer cap 2.5mg er Tier 1 nitroglycer cap 2.5mg sr Tier 1 nitroglycer cap 6.5mg cr Tier 1 nitroglycer cap 6.5mg er Tier 1 nitroglycer cap 9mg cr Tier 1 nitroglycer cap 9mg er Tier 1 nitroglycer dis 0.1mg/hr Tier 1 nitroglycer dis 0.2mg/hr Tier 1 nitroglycer dis 0.4mg/hr Tier 1 nitroglycer dis 0.6mg/hr Tier 1 nitroglyceri dis 0.6mg/hr Tier 1 nitroglycrn spr lingual Tier 1 NITROSTAT SUB 0.3MG Tier 2 NITROSTAT SUB 0.4MG Tier 2 NITROSTAT SUB 0.6MG Tier 2 ANTIANXIETY AGENTS Antianxiety Agents - Misc. buspirone tab 5mg Tier 1 buspirone tab 7.5mg Tier 1 buspirone tab 10mg Tier 1 buspirone tab 15mg Tier 1 14

buspirone tab 30mg Tier 1 hydroxyz hcl inj 25mg/ml Tier 1 PA hydroxyz hcl inj 50mg/ml Tier 1 PA hydroxyz hcl sol 10mg/5ml Tier 1 hydroxyz hcl syp 10mg/5ml Tier 1 hydroxyz hcl tab 10mg Tier 1 hydroxyz hcl tab 25mg Tier 1 hydroxyz hcl tab 50mg Tier 1 hydroxyz pam cap 25mg Tier 1 hydroxyz pam cap 50mg Tier 1 hydroxyz pam cap 100mg Tier 1 meprobamate tab 200mg Tier 1 meprobamate tab 400mg Tier 1 Benzodiazepines alprazolam tab 0.5mg Tier 1 alprazolam tab 0.25mg Tier 1 alprazolam tab 1mg Tier 1 alprazolam tab 2mg Tier 1 chlordiazep cap 5mg Tier 1 chlordiazep cap 10mg Tier 1 chlordiazep cap 25mg Tier 1 cloraz dipot tab 3.75mg Tier 1 cloraz dipot tab 7.5mg Tier 1 cloraz dipot tab 15mg Tier 1 diazepam sol 1mg/ml Tier 1 diazepam tab 2mg Tier 1 diazepam tab 5mg Tier 1 diazepam tab 10mg Tier 1 lorazepam tab 0.5mg Tier 1 lorazepam tab 1mg Tier 1 lorazepam tab 2mg Tier 1 oxazepam cap 10mg Tier 1 oxazepam cap 15mg Tier 1 oxazepam cap 30mg Tier 1 ANTIARRHYTHMICS Antiarrhythmics Type I-A disopyramide cap 100mg Tier 1 disopyramide cap 150mg Tier 1 NORPACE CAP 100MG CR Tier 2 NORPACE CAP 150MG CR Tier 2 procainamide inj 100mg/ml Tier 4 PA quinidine gl tab 324mg cr Tier 1 15

quinidine gl tab 324mg er Tier 1 quinidine su tab 200mg Tier 1 quinidine su tab 300mg Tier 1 quinidine su tab 300mg er Tier 1 Antiarrhythmics Type I-B mexiletine cap 150mg Tier 1 mexiletine cap 200mg Tier 1 mexiletine cap 250mg Tier 1 Antiarrhythmics Type I-C flecainide tab 50mg Tier 1 flecainide tab 100mg Tier 1 flecainide tab 150mg Tier 1 propafenone cap 225mg er Tier 1 propafenone cap 325mg er Tier 1 propafenone cap 425mg sr Tier 1 propafenone tab 150mg Tier 1 propafenone tab 225mg Tier 1 propafenone tab 300mg Tier 1 Antiarrhythmics Type III amiodarone inj 50mg/ml Tier 4 PA amiodarone inj 150mg/3m Tier 4 PA amiodarone tab 200mg Tier 1 amiodarone tab 400mg Tier 1 MULTAQ TAB 400MG Tier 3 PACERONE TAB 100MG Tier 2 pacerone tab 200mg Tier 1 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Anti-Inflammatory Agents cromolyn sod neb 20mg/2ml Tier 1 Bronchodilators - Anticholinergics ATROVENT HFA AER 17MCG Tier 2 ipratropium sol 0.02%inh Tier 1 SPIRIVA CAP HANDIHLR Tier 2 TUDORZA PRES AER 400/ACT Tier 2 Leukotriene Modulators montelukast chw 4mg Tier 1 montelukast chw 5mg Tier 1 montelukast gra 4mg Tier 1 montelukast tab 10mg Tier 1 zafirlukast tab 10mg Tier 1 zafirlukast tab 20mg Tier 1 ZYFLO CR TAB 600MG Tier 3 PA 16

ZYFLO TAB 600MG Tier 3 PA STEROID INHALANTS ASMANEX 7 AER 110MCG Tier 2 ASMANEX 30 AER 110MCG Tier 2 Steroid Inhalants ALVESCO AER 80MCG Tier 3 ALVESCO AER 160MCG Tier 3 ASMANEX 14 AER 220MCG Tier 2 ASMANEX 30 AER 220MCG Tier 2 ASMANEX 60 AER 220MCG Tier 2 ASMANEX 120 AER 220MCG Tier 2 budesonide sus 0.5mg/2 Tier 1 budesonide sus 0.25mg/2 Tier 1 FLOVENT DISK AER 50MCG Tier 2 FLOVENT DISK AER 100MCG Tier 2 FLOVENT DISK AER 250MCG Tier 2 FLOVENT HFA AER 44MCG Tier 2 FLOVENT HFA AER 110MCG Tier 2 FLOVENT HFA AER 220MCG Tier 2 PULMICORT INH 90MCG Tier 3 PULMICORT INH 180MCG Tier 3 PULMICORT SUS 1MG/2ML Tier 3 QVAR AER 40MCG Tier 2 QVAR AER 80MCG Tier 2 Sympathomimetics ADVAIR DISKU AER 100/50 Tier 2 ST ADVAIR DISKU AER 250/50 Tier 2 ST ADVAIR DISKU AER 500/50 Tier 2 ST ADVAIR HFA AER 45/21 Tier 2 ST ADVAIR HFA AER 115/21 Tier 2 ST ADVAIR HFA AER 230/21 Tier 2 ST albuterol neb 0.5% Tier 1 albuterol neb 0.63mg/3 Tier 1 albuterol neb 0.083% Tier 1 albuterol neb 1.25mg/3 Tier 1 albuterol syp 2mg/5ml Tier 1 albuterol tab 2mg Tier 1 albuterol tab 4mg Tier 1 albuterol tab 4mg er Tier 1 albuterol tab 8mg er Tier 1 ARCAPTA CAP 75MCG Tier 3 COMBIVENT AER Tier 2 DULERA AER 100-5MCG Tier 2 ST 17

DULERA AER 200-5MCG Tier 2 ST epinephrine inj 0.1mg/ml Tier 1 epinephrine inj 1mg/ml Tier 1 FORADIL CAP AEROLIZE Tier 2 ST levalbuterol neb 0.31mg Tier 1 PA levalbuterol neb 0.63mg Tier 1 PA levalbuterol neb 1.25/0.5 Tier 1 PA levalbuterol neb 1.25mg Tier 1 PA MAXAIR AUTOH AER 200MCG Tier 2 metaproteren syp 10mg/5ml Tier 1 metaproteren tab 10mg Tier 1 metaproteren tab 20mg Tier 1 PERFOROMIST NEB 20MCG Tier 3 PROAIR HFA AER Tier 2 SEREVENT DIS AER 50MCG Tier 2 ST SYMBICORT AER 80-4.5 Tier 2 ST SYMBICORT AER 160-4.5 Tier 2 ST terbutaline inj 1mg/ml Tier 1 terbutaline tab 2.5mg Tier 1 terbutaline tab 5mg Tier 1 VENTOLIN HFA AER Tier 2 XOPENEX HFA AER Tier 3 PA Xanthines aminophyllin tab 100mg Tier 1 aminophyllin tab 200mg Tier 1 ELIXOPHYLLIN ELX 80/15ML Tier 2 LUFYLLIN TAB 200MG Tier 2 LUFYLLIN TAB 400MG Tier 2 THEO-24 CAP 100MG CR Tier 2 THEO-24 CAP 200MG CR Tier 2 THEO-24 CAP 300MG CR Tier 2 THEO-24 CAP 400MG ER Tier 2 theochron tab 100mg cr Tier 1 theochron tab 200mg cr Tier 1 theochron tab 300mg cr Tier 1 theophylline sol 80/15ml Tier 1 theophylline tab 100mg cr Tier 1 theophylline tab 100mg er Tier 1 theophylline tab 200mg cr Tier 1 theophylline tab 200mg er Tier 1 theophylline tab 300mg er Tier 1 theophylline tab 400mg er Tier 1 theophylline tab 450mg er Tier 1 18

theophylline tab 600mg er Tier 1 ANTICOAGULANTS Coumarin Anticoagulants jantoven tab 1mg Tier 1 jantoven tab 2.5mg Tier 1 jantoven tab 2mg Tier 1 jantoven tab 3mg Tier 1 jantoven tab 4mg Tier 1 jantoven tab 5mg Tier 1 jantoven tab 6mg Tier 1 jantoven tab 7.5mg Tier 1 jantoven tab 10mg Tier 1 warfarin tab 1mg Tier 1 warfarin tab 2.5mg Tier 1 warfarin tab 2mg Tier 1 warfarin tab 3mg Tier 1 warfarin tab 4mg Tier 1 warfarin tab 5mg Tier 1 warfarin tab 6mg Tier 1 warfarin tab 7.5mg Tier 1 warfarin tab 10mg Tier 1 Direct Factor Xa Inhibitors XARELTO TAB 10MG Tier 3 PA XARELTO TAB 15MG Tier 3 PA XARELTO TAB 20MG Tier 3 PA Heparins And Heparinoid-Like Agents enoxaparin inj 30/0.3ml Tier 4 QL enoxaparin inj 40/0.4ml Tier 4 QL enoxaparin inj 60/0.6ml Tier 4 QL enoxaparin inj 80/0.8ml Tier 4 QL enoxaparin inj 100mg/ml Tier 4 QL enoxaparin inj 120/0.8 Tier 4 QL enoxaparin inj 150mg/ml Tier 4 QL enoxaparin inj 300/3ml Tier 4 QL fondaparinux sol 2.5/0.5 Tier 4 PA fondaparinux sol 5.0/0.4 Tier 4 PA fondaparinux sol 7.5/0.6 Tier 4 PA fondaparinux sol 10/0.8 Tier 4 PA FRAGMIN INJ 2500/0.2 Tier 4 PA FRAGMIN INJ 5000/0.2 Tier 4 PA FRAGMIN INJ 7500/0.3 Tier 4 PA FRAGMIN INJ 10000/ML Tier 4 PA 19

FRAGMIN INJ 12500UNT Tier 4 PA FRAGMIN INJ 15000UNT Tier 4 PA FRAGMIN INJ 18000UNT Tier 4 PA FRAGMIN INJ 25000/ML Tier 4 PA heparin sod inj 1000/ml Tier 1 heparin sod inj 10000/ml 10000unit/ml Tier 1 heparin sod inj 20000/ml Tier 1 INNOHEP INJ 20000/ML Tier 4 PA ANTICONVULSANTS Anticonvulsants - Benzodiazepines clonazepam tab 0.5mg Tier 1 clonazepam tab 1mg Tier 1 clonazepam tab 2mg Tier 1 Anticonvulsants - Misc. BANZEL SUS 40MG/ML Tier 3 PA BANZEL TAB 200MG Tier 3 PA BANZEL TAB 400MG Tier 3 PA carbamazepin cap 100mg er Tier 1 carbamazepin cap 200mg er Tier 1 carbamazepin cap 300mg er Tier 1 carbamazepin chw 100mg Tier 1 carbamazepin sus 100/5ml Tier 1 carbamazepin tab 200mg Tier 1 carbamazepin tab 200mg er Tier 1 carbamazepin tab 400mg er Tier 1 epitol tab 200mg Tier 1 gabapentin cap 100mg Tier 1 gabapentin cap 300mg Tier 1 gabapentin cap 400mg Tier 1 gabapentin tab 600mg Tier 1 gabapentin tab 800mg Tier 1 LAMICTAL CHW 2MG Tier 2 LAMICTAL KIT START 35 Tier 2 PA LAMICTAL KIT START 49 Tier 2 PA LAMICTAL KIT START 98 Tier 2 PA LAMICTAL ODT KIT Tier 2 PA LAMICTAL ODT TAB 25MG Tier 2 PA LAMICTAL ODT TAB 50MG Tier 2 PA LAMICTAL ODT TAB 100MG Tier 2 PA LAMICTAL ODT TAB 200MG Tier 2 PA LAMICTAL XR KIT Tier 2 PA lamotrigine chw 5mg Tier 1 20

lamotrigine chw 25mg Tier 1 lamotrigine tab 25mg Tier 1 lamotrigine tab 25mg er Tier 1 PA lamotrigine tab 50mg er Tier 1 PA lamotrigine tab 100mg Tier 1 lamotrigine tab 100mg er Tier 1 PA lamotrigine tab 150mg Tier 1 lamotrigine tab 200mg Tier 1 lamotrigine tab 200mg er Tier 1 PA lamotrigine tab 250mg er Tier 1 PA lamotrigine tab 300mg er Tier 1 PA levetiraceta sol 100mg/ml Tier 1 levetiraceta sol 500/5ml Tier 1 levetiraceta tab 250mg Tier 1 levetiraceta tab 500mg Tier 1 levetiraceta tab 750mg Tier 1 levetiraceta tab 1000mg Tier 1 LYRICA CAP 25MG Tier 3 LYRICA CAP 50MG Tier 3 LYRICA CAP 75MG Tier 3 LYRICA CAP 100MG Tier 3 LYRICA CAP 150MG Tier 3 LYRICA CAP 200MG Tier 3 LYRICA CAP 225MG Tier 3 LYRICA CAP 300MG Tier 3 oxcarbazepin sus 300mg/5m Tier 1 oxcarbazepin tab 150mg Tier 1 oxcarbazepin tab 300mg Tier 1 oxcarbazepin tab 600mg Tier 1 OXTELLAR XR TAB 150MG Tier 3 OXTELLAR XR TAB 300MG Tier 3 OXTELLAR XR TAB 600MG Tier 3 primidone tab 50mg Tier 1 primidone tab 250mg Tier 1 TEGRETOL XR TAB 100MG Tier 2 topiragen tab 25mg Tier 1 topiragen tab 50mg Tier 1 topiragen tab 100mg Tier 1 topiragen tab 200mg Tier 1 topiramate cap 15mg Tier 1 topiramate cap 25mg Tier 1 topiramate tab 25mg Tier 1 topiramate tab 50mg Tier 1 21

topiramate tab 100mg Tier 1 topiramate tab 200mg Tier 1 VIMPAT SOL 10MG/ML Tier 3 PA VIMPAT TAB 50MG Tier 3 PA VIMPAT TAB 100MG Tier 3 PA VIMPAT TAB 150MG Tier 3 PA VIMPAT TAB 200MG Tier 3 PA zonisamide cap 25mg Tier 1 zonisamide cap 50mg Tier 1 zonisamide cap 100mg Tier 1 Carbamates felbamate sus 600/5ml Tier 1 felbamate tab 400mg Tier 1 felbamate tab 600mg Tier 1 GABA Modulators GABITRIL TAB 12MG Tier 2 GABITRIL TAB 16MG Tier 2 SABRIL TAB 500MG Tier 3 PA tiagabine tab 2mg Tier 1 tiagabine tab 4mg Tier 1 Hydantoins DILANTIN CAP 30MG Tier 2 PEGANONE TAB 250MG Tier 2 phenytoin chw 50mg Tier 1 phenytoin ex cap 100mg Tier 1 phenytoin ex cap 200mg Tier 1 phenytoin ex cap 300mg Tier 1 phenytoin sus 125/5ml Tier 1 Succinimides CELONTIN CAP 300MG Tier 2 ethosuximide cap 250mg Tier 1 ethosuximide sol 250/5ml Tier 1 Valproic Acid divalproex cap 125mg Tier 1 divalproex tab 125mg dr Tier 1 divalproex tab 250mg dr Tier 1 divalproex tab 250mg er Tier 1 divalproex tab 500mg dr Tier 1 divalproex tab 500mg er Tier 1 valproic acd cap 250mg Tier 1 valproic acd sol 250/5ml Tier 1 valproic acd syp 250/5ml Tier 1 22

ANTIDEPRESSANTS Alpha-2 Receptor Antagonists (Tetracyclics) mirtazapine tab 7.5mg Tier 1 mirtazapine tab 15mg Tier 1 mirtazapine tab 15mg odt Tier 1 PA mirtazapine tab 30mg Tier 1 mirtazapine tab 30mg odt Tier 1 PA mirtazapine tab 45mg Tier 1 mirtazapine tab 45mg odt Tier 1 PA Antidepressants - Misc. APLENZIN TAB 174MG Tier 3 PA APLENZIN TAB 348MG Tier 3 PA APLENZIN TAB 522MG Tier 3 PA budeprion tab 100mg sr Tier 1 budeprion tab 150mg sr Tier 1 budeprion xl tab 150mg Tier 1 budeprion xl tab 300mg Tier 1 bupropion tab 75mg Tier 1 bupropion tab 100mg Tier 1 bupropion tab 100mg er Tier 1 bupropion tab 100mg sr Tier 1 bupropion tab 150mg er Tier 1 bupropion tab 150mg sr Tier 1 bupropion tab 200mg er Tier 1 bupropion tab 200mg sr Tier 1 bupropn hcl tab 150mg xl Tier 1 bupropn hcl tab 300mg xl Tier 1 maprotiline tab 25mg Tier 1 maprotiline tab 50mg Tier 1 maprotiline tab 75mg Tier 1 Modified Cyclics nefazodone tab 50mg Tier 1 nefazodone tab 100mg Tier 1 nefazodone tab 150mg Tier 1 nefazodone tab 200mg Tier 1 nefazodone tab 250mg Tier 1 OLEPTRO TAB 24HR150 Tier 3 PA OLEPTRO TAB 24HR300 Tier 3 PA trazodone tab 50mg Tier 1 trazodone tab 100mg Tier 1 trazodone tab 150mg Tier 1 trazodone tab 300mg Tier 1 23

VIIBRYD KIT Tier 3 PA VIIBRYD TAB 10MG Tier 3 PA VIIBRYD TAB 20MG Tier 3 PA VIIBRYD TAB 40MG Tier 3 PA Monoamine Oxidase Inhibitors (MAOIs) EMSAM DIS 6MG/24HR Tier 3 PA EMSAM DIS 9MG/24HR Tier 3 PA EMSAM DIS 12MG/24H Tier 3 PA MARPLAN TAB 10MG Tier 2 phenelzine tab 15mg Tier 1 tranylcyprom tab 10mg Tier 1 Selective Serotonin Reuptake Inhibitors (SSRIs) citalopram sol 10mg/5ml Tier 1 citalopram tab 10mg Tier 1 citalopram tab 20mg Tier 1 citalopram tab 40mg Tier 1 escitalopram sol 5mg/5ml Tier 1 PA escitalopram tab 5mg Tier 1 escitalopram tab 10mg Tier 1 escitalopram tab 20mg Tier 1 fluoxetine cap 10mg 10mg Tier 1 fluoxetine cap 20mg 20mg Tier 1 fluoxetine cap 40mg Tier 1 fluoxetine cap 90mg dr Tier 1 PA fluoxetine sol 20mg/5ml Tier 1 fluoxetine tab 10mg Tier 1 fluoxetine tab 20mg Tier 1 fluoxetine tab 60mg Tier 1 fluvoxamine tab 25mg Tier 1 fluvoxamine tab 50mg Tier 1 fluvoxamine tab 100mg Tier 1 paroxetin er tab 12.5mg Tier 1 PA paroxetin er tab 37.5mg Tier 1 PA paroxetine sus 10mg/5ml Tier 1 paroxetine tab 10mg Tier 1 paroxetine tab 20mg Tier 1 paroxetine tab 25mg er Tier 1 PA paroxetine tab 30mg Tier 1 paroxetine tab 40mg Tier 1 sertraline con 20mg/ml Tier 1 sertraline tab 25mg Tier 1 sertraline tab 50mg Tier 1 sertraline tab 100mg Tier 1 24

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) CYMBALTA CAP 20MG Tier 2 PA CYMBALTA CAP 30MG Tier 2 PA CYMBALTA CAP 60MG Tier 2 PA PRISTIQ TAB 50MG Tier 3 PA PRISTIQ TAB 100MG Tier 3 PA venlafaxine cap 37.5mg Tier 1 venlafaxine cap 75mg er Tier 1 venlafaxine cap 150mg er Tier 1 venlafaxine tab 25mg Tier 1 venlafaxine tab 37.5 er Tier 1 PA venlafaxine tab 37.5mg Tier 1 venlafaxine tab 50mg Tier 1 venlafaxine tab 75mg Tier 1 venlafaxine tab 75mg er Tier 1 PA venlafaxine tab 100mg Tier 1 venlafaxine tab 150mg er Tier 1 PA venlafaxine tab 225mg er Tier 1 PA Tricyclic Agents amitriptylin tab 10mg Tier 1 amitriptylin tab 25mg Tier 1 amitriptylin tab 50mg Tier 1 amitriptylin tab 75mg Tier 1 amitriptylin tab 100mg Tier 1 amitriptylin tab 150mg Tier 1 amoxapine tab 25mg Tier 1 amoxapine tab 50mg Tier 1 amoxapine tab 100mg Tier 1 amoxapine tab 150mg Tier 1 clomipramine cap 25mg Tier 1 clomipramine cap 50mg Tier 1 clomipramine cap 75mg Tier 1 desipramine tab 10mg Tier 1 desipramine tab 25mg Tier 1 desipramine tab 50mg Tier 1 desipramine tab 75mg Tier 1 desipramine tab 100mg Tier 1 desipramine tab 150mg Tier 1 doxepin hcl cap 10mg Tier 1 doxepin hcl cap 25mg Tier 1 doxepin hcl cap 50mg Tier 1 doxepin hcl cap 75mg Tier 1 doxepin hcl cap 100mg Tier 1 25

doxepin hcl cap 150mg Tier 1 doxepin hcl con 10mg/ml Tier 1 imipram hcl tab 10mg Tier 1 imipram hcl tab 25mg Tier 1 imipram hcl tab 50mg Tier 1 imipram pam cap 75mg Tier 1 imipram pam cap 100mg Tier 1 imipram pam cap 125mg Tier 1 imipram pam cap 150mg Tier 1 nortriptylin cap 10mg Tier 1 nortriptylin cap 25mg Tier 1 nortriptylin cap 50mg Tier 1 nortriptylin cap 75mg Tier 1 nortriptylin sol 10mg/5ml Tier 1 protriptylin tab 5mg Tier 1 protriptylin tab 10mg Tier 1 trimipramine cap 25mg Tier 1 trimipramine cap 50mg Tier 1 trimipramine cap 100mg Tier 1 ANTIDIABETICS Alpha-Glucosidase Inhibitors acarbose tab 25mg Tier 1 acarbose tab 50mg Tier 1 acarbose tab 100mg Tier 1 GLYSET TAB 25MG Tier 2 GLYSET TAB 50MG Tier 2 GLYSET TAB 100MG Tier 2 Antidiabetic - Amylin Analogs SYMLIN INJ 600MCG Tier 3 PA SYMLINPEN 60 INJ 1000MCG Tier 3 PA SYMLNPEN 120 INJ 1000MCG Tier 3 PA Antidiabetic Combinations ACTOPLUS MET TAB XR Tier 2 AVANDAMET TAB 2-500MG Tier 2 PA AVANDAMET TAB 2-1000MG Tier 2 PA AVANDAMET TAB 4-500MG Tier 2 PA AVANDAMET TAB 4-1000MG Tier 2 PA Biguanides GLUMETZA TAB 500MG Tier 3 GLUMETZA TAB 1000MG Tier 3 metformin er tab 1000mg Tier 1 metformin tab 500mg Tier 1 26

metformin tab 500mg er Tier 1 metformin tab 750mg er Tier 1 metformin tab 850mg Tier 1 metformin tab 1000mg Tier 1 RIOMET SOL Tier 3 Diabetic Other GLUCAGEN INJ 1MG Tier 2 GLUCAGEN INJ HYPOKIT Tier 2 GLUCAGON KIT 1MG Tier 2 Dipeptidyl Peptidase-4 (DPP-4) Inhibitors JANUVIA TAB 25MG Tier 2 ST JANUVIA TAB 50MG Tier 2 ST JANUVIA TAB 100MG Tier 2 ST ONGLYZA TAB 2.5MG Tier 3 ST ONGLYZA TAB 5MG Tier 3 ST TRADJENTA TAB 5MG Tier 2 ST Dopamine Receptor Agonists - Antidiabetic CYCLOSET TAB 0.8MG Tier 2 Incretin Mimetic Agents (GLP-1 Receptor Agonists) BYETTA INJ 5MCG Tier 3 PA BYETTA INJ 10MCG Tier 3 PA VICTOZA INJ 18MG/3ML Tier 3 PA Insulin APIDRA INJ SOLOSTAR Tier 2 APIDRA INJ U-100 Tier 2 HUMALOG INJ 100/ML Tier 2 HUMALOG KWIK INJ 100/ML Tier 2 HUMALOG MIX INJ 50/50 Tier 2 HUMALOG MIX INJ 50/50KWP Tier 2 HUMALOG MIX INJ 75/25KWP Tier 2 HUMALOG MIX SUS 75/25 Tier 2 HUMULIN INJ 70/30 Tier 2 HUMULIN N INJ U-100 Tier 2 HUMULIN N PN INJ U-100 Tier 2 HUMULIN PEN INJ 70/30 Tier 2 HUMULIN R INJ U-100 Tier 2 HUMULIN R INJ U-500 Tier 2 LANTUS INJ 100/ML Tier 2 LANTUS INJ SOLOSTAR Tier 2 LEVEMIR INJ Tier 2 LEVEMIR INJ FLEXPEN Tier 2 NOVOLIN70/30 INJ RELION Tier 1 NOVOLIN INJ 70/30 Tier 1 27

NOVOLIN N INJ RELION Tier 1 NOVOLIN N INJ U-100 Tier 1 NOVOLIN R INJ RELION Tier 1 NOVOLIN R INJ U-100 Tier 1 NOVOLOG INJ 100/ML Tier 1 NOVOLOG INJ FLEXPEN Tier 2 NOVOLOG INJ PENFILL Tier 2 NOVOLOG MIX INJ 70/30 Tier 1 NOVOLOG MIX INJ FLEXPEN Tier 2 Insulin Sensitizing Agents AVANDIA TAB 2MG Tier 2 PA AVANDIA TAB 4MG Tier 2 PA AVANDIA TAB 8MG Tier 2 PA pioglitazone tab 15mg Tier 1 pioglitazone tab 30mg Tier 1 pioglitazone tab 45mg Tier 1 Meglitinide Analogues nateglinide tab 60mg Tier 1 nateglinide tab 120mg Tier 1 PRANDIN TAB 0.5MG Tier 2 PRANDIN TAB 1MG Tier 2 PRANDIN TAB 2MG Tier 2 Sulfonylureas chlorpropam tab 100mg Tier 1 chlorpropam tab 250mg Tier 1 glimepiride tab 1mg Tier 1 glimepiride tab 2mg Tier 1 glimepiride tab 4mg Tier 1 glipizide er tab 2.5mg Tier 1 glipizide er tab 5mg Tier 1 glipizide er tab 10mg Tier 1 glipizide tab 5mg Tier 1 glipizide tab 10mg Tier 1 glipizide xl tab 2.5mg Tier 1 glipizide xl tab 5mg Tier 1 glipizide xl tab 10mg Tier 1 glyburid mcr tab 1.5mg Tier 1 glyburid mcr tab 3mg Tier 1 glyburid mcr tab 6mg Tier 1 glyburide tab 1.25mg Tier 1 glyburide tab 2.5mg Tier 1 glyburide tab 5mg Tier 1 tolazamide tab 250mg Tier 1 28

tolazamide tab 500mg Tier 1 tolbutamide tab 500mg Tier 1 ANTIDIARRHEALS Antiperistaltic Agents anti-diarrhe cap 2mg Tier 1 anti-diarrhe tab 2mg Tier 1 diamode tab 2mg Tier 1 diphen/atrop liq 2.5/5 Tier 1 diphen/atrop tab 2.5mg Tier 1 imperim tab 2mg Tier 1 kls anti-dia tab 2mg Tier 1 lofene tab 2.5mg Tier 1 lonox tab 2.5mg Tier 1 loperamide cap 2mg Tier 1 loperamide tab 2mg Tier 1 MOTOFEN TAB Tier 2 sm anti-diar tab 2mg Tier 1 ANTIDOTES Antidotes IPECAC SYP Tier 2 SM IPECAC SYP Tier 2 Antidotes - Chelating Agents CHEMET CAP 100MG Tier 2 EXJADE TAB 125MG Tier 4 PA EXJADE TAB 250MG Tier 4 PA EXJADE TAB 500MG Tier 4 PA FERRIPROX TAB 500MG Tier 4 PA Opioid Antagonists depade tab 50mg Tier 1 naltrexone tab 50mg Tier 1 ANTIEMETICS 5-HT3 Receptor Antagonists ANZEMET TAB 50MG Tier 3 PA ANZEMET TAB 100MG Tier 3 PA granisetron tab 1mg Tier 1 PA GRANISOL SOL 2MG/10ML Tier 2 PA ondansetron inj 32/50ml Tier 1 PA ondansetron sol 4mg/5ml Tier 1 PA ondansetron tab 4mg Tier 1 ondansetron tab 4mg odt Tier 1 ondansetron tab 8mg Tier 1 29

ondansetron tab 8mg odt Tier 1 ondansetron tab 24mg Tier 1 ZUPLENZ MIS 4MG Tier 2 PA ZUPLENZ MIS 8MG Tier 2 PA Antiemetics - Anticholinergic ANTIVERT TAB 50MG Tier 2 dimenhydrin tab 50mg Tier 1 dramamine tab 25mg Tier 1 driminate tab 50mg Tier 1 meclizine tab 12.5mg Tier 1 meclizine tab 25mg Tier 1 medi-meclizi tab 25mg Tier 1 motion relf tab 25mg Tier 1 motion sick tab 25mg Tier 1 motion sick tab 50mg Tier 1 SCOPACE TAB 0.4MG Tier 2 TRANSDERM-SC DIS 1.5MG Tier 2 trav-tabs tab 50mg Tier 1 travel sick tab 50mg Tier 1 trimethobenz cap 300mg Tier 1 triptone tab 50mg Tier 1 wal-dram ii tab 25mg Tier 1 wal-dram tab 50mg Tier 1 Antiemetics - Miscellaneous CESAMET CAP 1MG Tier 3 PA dronabinol cap 2.5mg Tier 1 PA dronabinol cap 5mg Tier 1 PA dronabinol cap 10mg Tier 1 PA Substance P/Neurokinin 1 (NK1) Receptor Antagonists EMEND CAP 40MG Tier 3 PA EMEND CAP 80MG Tier 3 PA EMEND CAP 125MG Tier 3 PA ANTIFUNGALS Antifungals bio-statin pow Tier 1 flucytosine cap 250mg Tier 1 flucytosine cap 500mg Tier 1 griseofulvin sus 125/5ml Tier 1 griseofulvin tab micr 500 Tier 1 griseofulvin tab ultr 125 Tier 1 griseofulvin tab ultr 250 Tier 1 nystatin pow Tier 1 30

nystatin tab 500000 Tier 1 terbinafine tab 250mg Tier 1 Imidazole-Related Antifungals fluconazole sus 10mg/ml Tier 1 fluconazole sus 40mg/ml Tier 1 fluconazole tab 50mg Tier 1 fluconazole tab 100mg Tier 1 fluconazole tab 150mg Tier 1 fluconazole tab 200mg Tier 1 itraconazole cap 100mg Tier 1 PA ketoconazole tab 200mg Tier 1 SPORANOX SOL 10MG/ML Tier 2 PA voriconazole tab 50mg Tier 1 PA voriconazole tab 200mg Tier 1 PA ANTIHISTAMINES Antihistamines - Alkylamines dexchlorphen syp 2mg/5ml Tier 1 dexchlorphen tab 4mg cr Tier 1 Antihistamines - Ethanolamines af-diphedryl elx 12.5/5ml Tier 1 aler-cap cap 25mg Tier 1 allergy cap 25mg Tier 1 allergy med cap 25mg Tier 1 allergy rel elx 12.5/5ml Tier 1 allergy relf cap 25mg Tier 1 altaryl elx 12.5/5ml Tier 1 altaryl syp 12.5/5ml Tier 1 anti-hist cap 25mg Tier 1 antihistamin cap 25mg Tier 1 arbinoxa liq 4mg/5ml Tier 1 arbinoxa tab 4mg Tier 1 banophen cap 25mg Tier 1 banophen cap 50mg Tier 1 carbinoxamin liq 4mg/5ml Tier 1 carbinoxamin tab 4mg Tier 1 clemastine syp 0.5/5ml Tier 1 clemastine tab 2.68mg Tier 1 comp allergy cap 25mg Tier 1 cvs allergy cap 25mg Tier 1 diphenhist cap 25mg Tier 1 diphenhydram cap 25mg Tier 1 diphenhydram cap 50mg Tier 1 31

diphenhydram elx 12.5/5ml Tier 1 diphenhydram inj 50mg/ml Tier 1 PA dormin cap 25mg Tier 1 dytuss syp 12.5/5ml Tier 1 eq allergy cap 25mg Tier 1 eql allergy cap 25mg Tier 1 genahist cap 25mg Tier 1 geri-dryl cap 25mg Tier 1 gnp allergy cap 25mg Tier 1 medi-phedryl cap 25mg Tier 1 medi-phedryl elx 12.5/5ml Tier 1 mp aller med cap 25mg Tier 1 pharbedryl cap 25mg Tier 1 pharbedryl cap 50mg Tier 1 px allergy cap 25mg Tier 1 q-dryl cap 25mg Tier 1 quenalin syp 12.5/5ml Tier 1 silphen coug syp 12.5/5ml Tier 1 wal-dryl cap 25mg Tier 1 Antihistamines - Non-Sedating all day allg sol 1mg/ml Tier 1 all day allg sol 5mg/5ml Tier 1 all day allg syp 1mg/ml Tier 1 all day allg syp 5mg/5ml Tier 1 aller-ease tab 60mg Tier 1 aller-ease tab 180mg Tier 1 aller-fex tab 180mg Tier 1 aller-tec sol 1mg/ml Tier 1 allergy chld sol 1mg/ml Tier 1 allergy comp sol 1mg/ml Tier 1 allergy rel sol 1mg/ml Tier 1 allergy relf sol 5mg/5ml Tier 1 allergy relf tab 60mg Tier 1 allergy relf tab 180mg Tier 1 cetirizine sol 1mg/ml Tier 1 cetirizine sol 5mg/5ml Tier 1 cetirizine syp 1mg/ml Tier 1 cetirizine syp 5mg/5ml Tier 1 cvs allergy tab 180mg Tier 1 desloratadin tab 2.5 odt Tier 1 PA desloratadin tab 5mg Tier 1 PA desloratadin tab 5mg odt Tier 1 PA fexofenadine tab 30mg Tier 1 32

fexofenadine tab 60mg Tier 1 fexofenadine tab 180mg Tier 1 gnp allergy tab 180mg Tier 1 levocetirizi sol 2.5/5ml Tier 1 PA levocetirizi tab 5mg Tier 1 PA wal-fex allr tab 180mg Tier 1 wal-fex alrg tab 60mg Tier 1 wal-zyr sol 1mg/ml Tier 1 wal-zyr sol 5mg/5ml Tier 1 Antihistamines - Phenothiazines phenadoz sup 12.5mg Tier 1 phenadoz sup 25mg Tier 1 promethazine sol 6.25/5ml Tier 1 promethazine sup 12.5mg Tier 1 promethazine sup 25mg Tier 1 promethazine syp 6.25/5ml Tier 1 promethazine tab 12.5mg Tier 1 promethazine tab 25mg Tier 1 promethazine tab 50mg Tier 1 promethegan sup 12.5mg Tier 1 promethegan sup 25mg Tier 1 promethegan sup 50mg Tier 1 Antihistamines - Piperidines cyproheptad syp 2mg/5ml Tier 1 cyproheptad tab 4mg Tier 1 ANTIHYPERLIPIDEMICS Antihyperlipidemics - Combinations VYTORIN TAB 10-10MG Tier 3 PA VYTORIN TAB 10-20MG Tier 3 PA VYTORIN TAB 10-40MG Tier 3 PA VYTORIN TAB 10-80MG Tier 3 PA Antihyperlipidemics - Misc. LOVAZA CAP 1GM Tier 3 PA Bile Acid Sequestrants cholestyram pow 4gm Tier 1 cholestyram pow 4gm lite Tier 1 colestipol gra 5gm Tier 1 colestipol tab 1gm Tier 1 prevalite pow 4gm Tier 1 prevalite pow 4gm pk Tier 1 WELCHOL PAK 3.75GM Tier 3 ST WELCHOL TAB 625MG Tier 3 ST 33

Fibric Acid Derivatives fenofibrate cap 67mg Tier 1 fenofibrate cap 134mg Tier 1 fenofibrate cap 200mg Tier 1 fenofibrate tab 48mg Tier 1 fenofibrate tab 54mg Tier 1 fenofibrate tab 145mg Tier 1 fenofibrate tab 160mg Tier 1 gemfibrozil tab 600mg Tier 1 HMG CoA Reductase Inhibitors atorvastatin tab 10mg Tier 1 ST atorvastatin tab 20mg Tier 1 ST atorvastatin tab 40mg Tier 1 ST atorvastatin tab 80mg Tier 1 ST CRESTOR TAB 5MG Tier 3 PA CRESTOR TAB 10MG Tier 3 PA CRESTOR TAB 20MG Tier 3 PA CRESTOR TAB 40MG Tier 3 PA fluvastatin cap 20mg Tier 1 PA fluvastatin cap 40mg Tier 1 PA FLUVASTATIN TAB 80MG ER Tier 3 PA LESCOL XL TAB 80MG Tier 3 PA LIVALO TAB 1MG Tier 3 PA LIVALO TAB 2MG Tier 3 PA LIVALO TAB 4MG Tier 3 PA lovastatin tab 10mg Tier 1 lovastatin tab 20mg Tier 1 lovastatin tab 40mg Tier 1 pravastatin tab 10mg Tier 1 pravastatin tab 20mg Tier 1 pravastatin tab 40mg Tier 1 pravastatin tab 80mg Tier 1 simvastatin tab 5mg Tier 1 simvastatin tab 10mg Tier 1 simvastatin tab 20mg Tier 1 simvastatin tab 40mg Tier 1 simvastatin tab 80mg Tier 1 Intestinal Cholesterol Absorption Inhibitors ZETIA TAB 10MG Tier 2 PA Nicotinic Acid Derivatives niacor tab 500mg Tier 1 NIASPAN TAB 500MG ER Tier 2 NIASPAN TAB 750MG ER Tier 2 34

NIASPAN TAB 1000 ER Tier 2 ANTIHYPERTENSIVES ACE Inhibitors benazepril tab 5mg Tier 1 benazepril tab 10mg Tier 1 benazepril tab 20mg Tier 1 benazepril tab 40mg Tier 1 captopril tab 12.5mg Tier 1 captopril tab 25mg Tier 1 captopril tab 50mg Tier 1 captopril tab 100mg Tier 1 enalapril tab 2.5mg Tier 1 enalapril tab 5mg Tier 1 enalapril tab 10mg Tier 1 enalapril tab 20mg Tier 1 fosinopril tab 10mg Tier 1 fosinopril tab 20mg Tier 1 fosinopril tab 40mg Tier 1 lisinopril tab 2.5mg Tier 1 lisinopril tab 5mg Tier 1 lisinopril tab 10mg Tier 1 lisinopril tab 20mg Tier 1 lisinopril tab 30mg Tier 1 lisinopril tab 40mg Tier 1 moexipril tab 7.5mg Tier 1 moexipril tab 15mg Tier 1 perindopril tab 2mg Tier 1 perindopril tab 4mg Tier 1 perindopril tab 8mg Tier 1 quinapril tab 5mg Tier 1 quinapril tab 10mg Tier 1 quinapril tab 20mg Tier 1 quinapril tab 40mg Tier 1 ramipril cap 1.25mg Tier 1 ramipril cap 2.5mg Tier 1 ramipril cap 5mg Tier 1 ramipril cap 10mg Tier 1 trandolapril tab 1mg Tier 1 trandolapril tab 2mg Tier 1 trandolapril tab 4mg Tier 1 Agents for Pheochromocytoma DIBENZYLINE CAP 10MG Tier 2 35

Angiotensin II Receptor Antagonists BENICAR TAB 5MG Tier 3 PA BENICAR TAB 20MG Tier 3 PA BENICAR TAB 40MG Tier 3 PA candesartan tab 4mg Tier 3 ST candesartan tab 8mg Tier 3 ST candesartan tab 16mg Tier 3 ST candesartan tab 32mg Tier 3 ST DIOVAN TAB 40MG Tier 2 PA DIOVAN TAB 80MG Tier 2 PA DIOVAN TAB 160MG Tier 2 PA DIOVAN TAB 320MG Tier 2 PA EDARBI TAB 40MG Tier 3 PA EDARBI TAB 80MG Tier 3 PA eprosart mes tab 600mg Tier 1 PA irbesartan tab 75mg Tier 1 ST irbesartan tab 150mg Tier 1 ST irbesartan tab 300mg Tier 1 ST losartan pot tab 25mg Tier 1 ST losartan pot tab 50mg Tier 1 ST losartan pot tab 100mg Tier 1 ST MICARDIS TAB 20MG Tier 3 PA MICARDIS TAB 40MG Tier 3 PA MICARDIS TAB 80MG Tier 3 PA TEVETEN TAB 400MG Tier 3 PA Antiadrenergic Antihypertensives clonidine dis 0.1/24hr Tier 1 PA clonidine dis 0.2/24hr Tier 1 PA clonidine dis 0.3/24hr Tier 1 PA clonidine tab 0.1mg Tier 1 clonidine tab 0.2mg Tier 1 clonidine tab 0.3mg Tier 1 doxazosin tab 1mg Tier 1 doxazosin tab 2mg Tier 1 doxazosin tab 4mg Tier 1 doxazosin tab 8mg Tier 1 guanfacine tab 1mg Tier 1 guanfacine tab 2mg Tier 1 methyldopa tab 250mg Tier 1 methyldopa tab 500mg Tier 1 prazosin hcl cap 1mg Tier 1 prazosin hcl cap 2mg Tier 1 prazosin hcl cap 5mg Tier 1 36

reserpine tab 0.1mg Tier 1 reserpine tab 0.25mg Tier 1 terazosin cap 1mg Tier 1 terazosin cap 2mg Tier 1 terazosin cap 5mg Tier 1 terazosin cap 10mg Tier 1 Antihypertensive Combinations amlod/benazp cap 2.5-10mg Tier 1 amlod/benazp cap 5-10mg Tier 1 amlod/benazp cap 5-20mg Tier 1 amlod/benazp cap 5-40mg Tier 1 amlod/benazp cap 10-20mg Tier 1 amlod/benazp cap 10-40mg Tier 1 atenol/chlor tab 50-25mg Tier 1 atenol/chlor tab 100-25mg Tier 1 AVALIDE TAB 300-25MG Tier 3 ST benazep/hctz tab 5-6.25 Tier 1 benazep/hctz tab 10-12.5 Tier 1 benazep/hctz tab 20-12.5 Tier 1 benazep/hctz tab 20-25mg Tier 1 BENICAR HCT TAB 20-12.5 Tier 3 PA BENICAR HCT TAB 40-12.5 Tier 3 PA BENICAR HCT TAB 40-25MG Tier 3 PA bisoprl/hctz tab 2.5/6.25 Tier 1 bisoprl/hctz tab 5-6.25mg Tier 1 bisoprl/hctz tab 10/6.25 Tier 1 captopr/hctz tab 25-15mg Tier 1 captopr/hctz tab 25-25mg Tier 1 captopr/hctz tab 50-15mg Tier 1 captopr/hctz tab 50-25mg Tier 1 irbesar/hctz tab 150-12.5 Tier 1 ST irbesar/hctz tab 300-12.5 Tier 1 ST lisinop/hctz tab 10-12.5 Tier 1 lisinop/hctz tab 20-12.5 Tier 1 lisinop/hctz tab 20-25mg Tier 1 losartan/hct tab 50-12.5 Tier 1 ST losartan/hct tab 100-12.5 Tier 1 ST losartan/hct tab 100-25 Tier 1 ST propran/hctz tab 40/25 Tier 1 propran/hctz tab 80/25 Tier 1 TARKA TAB 1-240 CR Tier 2 PA TARKA TAB 2-180 CR Tier 2 PA TARKA TAB 2-240 CR Tier 2 PA 37

TARKA TAB 4-240 CR Tier 2 PA valsart/hctz tab 80-12.5 Tier 1 ST valsart/hctz tab 160-12.5 Tier 1 ST valsart/hctz tab 160-25mg Tier 1 ST valsart/hctz tab 320-12.5 Tier 1 ST valsart/hctz tab 320-25mg Tier 1 ST Direct Renin Inhibitors TEKTURNA TAB 150MG Tier 3 PA TEKTURNA TAB 300MG Tier 3 PA Selective Aldosterone Receptor Antagonists (SARAs) eplerenone tab 25mg Tier 1 PA eplerenone tab 50mg Tier 1 PA Vasodilators hydralazine tab 10mg Tier 1 hydralazine tab 25mg Tier 1 hydralazine tab 50mg Tier 1 hydralazine tab 100mg Tier 1 minoxidil tab 2.5mg Tier 1 minoxidil tab 10mg Tier 1 ANTIMALARIALS Antimalarial Combinations atovaq/progu tab 62.5-25 Tier 1 atovaq/progu tab 250-100 Tier 1 COARTEM TAB 20-120MG Tier 3 Antimalarials chloroquine tab 250mg Tier 1 chloroquine tab 500mg Tier 1 DARAPRIM TAB 25MG Tier 2 hydroxychlor tab 200mg Tier 1 mefloquine tab 250mg Tier 1 PRIMAQUINE TAB 26.3MG Tier 2 quinine sulf cap 324mg Tier 1 ANTIMYASTHENIC AGENTS Antimyasthenic Agents GUANIDINE TAB 125MG Tier 3 MESTINON SYP 60MG/5ML Tier 2 MYTELASE TAB 10MG Tier 3 PROSTIGMIN TAB 15MG Tier 2 pyridostigm tab 60mg Tier 1 ANTIMYCOBACTERIAL AGENTS Anti TB Combinations 38

isonarif cap Tier 1 RIFATER TAB Tier 2 Antimycobacterial Agents ethambutol tab 100mg Tier 1 ethambutol tab 400mg Tier 1 isoniazid syp 50mg/5ml Tier 1 isoniazid tab 100mg Tier 1 isoniazid tab 300mg Tier 1 MYCOBUTIN CAP 150MG Tier 2 PASER GRA 4GM Tier 3 PRIFTIN TAB 150MG Tier 3 pyrazinamide tab 500mg Tier 1 rifampin cap 150mg Tier 1 rifampin cap 300mg Tier 1 TRECATOR TAB 250MG Tier 3 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Alkylating Agents ALKERAN TAB 2MG Tier 2 CEENU CAP 10MG Tier 2 CEENU CAP 40MG Tier 2 CEENU CAP 100MG Tier 2 cyclophosph tab 25mg Tier 1 cyclophosph tab 50mg Tier 1 GLIADEL WAF 7.7MG Tier 4 PA HEXALEN CAP 50MG Tier 2 LEUKERAN TAB 2MG Tier 2 melphalan inj 50mg Tier 4 PA MYLERAN TAB 2MG Tier 2 TEMODAR CAP 5MG Tier 4 PA TEMODAR CAP 20MG Tier 4 PA TEMODAR CAP 100MG Tier 4 PA TEMODAR CAP 140MG Tier 4 PA TEMODAR CAP 180MG Tier 4 PA TEMODAR CAP 250MG Tier 4 PA Antimetabolites adrucil inj 2.5g/50m Tier 4 PA adrucil inj 5gm/100m Tier 4 PA adrucil inj 500/10ml Tier 4 PA fluorouracil inj 1gm/20ml Tier 4 PA fluorouracil inj 2.5g/50m Tier 4 PA fluorouracil inj 5gm/100m Tier 4 PA fluorouracil inj 500/10ml Tier 4 PA 39

mercaptopur tab 50mg Tier 1 methotrexate tab 2.5mg Tier 1 OFORTA TAB 10MG Tier 4 PA TABLOID TAB 40MG Tier 2 TREXALL TAB 5MG Tier 2 TREXALL TAB 7.5MG Tier 2 TREXALL TAB 10MG Tier 2 TREXALL TAB 15MG Tier 2 XELODA TAB 150MG Tier 4 PA XELODA TAB 500MG Tier 4 PA Antineoplastic - Antibodies RITUXAN INJ 100MG Tier 4 PA RITUXAN INJ 500MG Tier 4 PA Antineoplastic - Hedgehog Pathway Inhibitors ERIVEDGE CAP 150MG Tier 4 PA Antineoplastic - Hormonal and Related Agents anastrozole tab 1mg Tier 1 bicalutamide tab 50mg Tier 1 DEPO-PROVERA INJ 400/ML Tier 2 ELIGARD INJ 7.5MG Tier 4 PA ELIGARD INJ 22.5MG Tier 4 PA ELIGARD INJ 30MG Tier 4 PA ELIGARD INJ 45MG Tier 4 PA EMCYT CAP 140MG Tier 2 exemestane tab 25mg Tier 1 FARESTON TAB 60MG Tier 2 flutamide cap 125mg Tier 1 letrozole tab 2.5mg Tier 1 leuprolide inj 1mg/0.2 Tier 4 PA LUPRON DEPOT INJ 3.75MG Tier 4 PA LUPRON DEPOT INJ 7.5MG Tier 4 PA LUPRON DEPOT INJ 11.25MG Tier 4 PA LUPRON DEPOT INJ 22.5MG Tier 4 PA LUPRON DEPOT INJ 30MG Tier 4 PA LYSODREN TAB 500MG Tier 2 megestrol ac sus 40mg/ml Tier 1 megestrol ac sus 400mg/10 Tier 1 megestrol ac tab 20mg Tier 1 megestrol ac tab 40mg Tier 1 NILANDRON TAB 150MG Tier 2 SOLTAMOX SOL 10MG/5ML Tier 2 tamoxifen tab 10mg Tier 1 tamoxifen tab 20mg Tier 1 40

XTANDI CAP 40MG Tier 4 PA ZYTIGA TAB 250MG Tier 4 PA Antineoplastic Antibiotics VALSTAR SOL 40MG/ML Tier 4 PA Antineoplastic Enzyme Inhibitors AFINITOR TAB 2.5MG Tier 4 PA AFINITOR TAB 5MG Tier 4 PA AFINITOR TAB 7.5MG Tier 4 PA AFINITOR TAB 10MG Tier 4 PA BOSULIF TAB 100MG Tier 4 PA BOSULIF TAB 500MG Tier 4 PA CAPRELSA TAB 100MG Tier 4 PA CAPRELSA TAB 300MG Tier 4 PA COMETRIQ KIT 60MG Tier 4 PA COMETRIQ KIT 100MG Tier 4 PA COMETRIQ KIT 140MG Tier 4 PA GLEEVEC TAB 100MG Tier 4 PA GLEEVEC TAB 400MG Tier 4 PA ICLUSIG TAB 15MG Tier 4 PA ICLUSIG TAB 45MG Tier 4 PA INLYTA TAB 1MG Tier 4 PA INLYTA TAB 5MG Tier 4 PA IRESSA TAB 250MG Tier 4 PA JAKAFI TAB 5MG Tier 4 PA JAKAFI TAB 10MG Tier 4 PA JAKAFI TAB 15MG Tier 4 PA JAKAFI TAB 20MG Tier 4 PA JAKAFI TAB 25MG Tier 4 PA NEXAVAR TAB 200MG Tier 4 PA SPRYCEL TAB 20MG Tier 4 PA SPRYCEL TAB 50MG Tier 4 PA SPRYCEL TAB 70MG Tier 4 PA SPRYCEL TAB 80MG Tier 4 PA SPRYCEL TAB 100MG Tier 4 PA SPRYCEL TAB 140MG Tier 4 PA STIVARGA TAB 40MG Tier 4 PA SUTENT CAP 12.5MG Tier 4 PA SUTENT CAP 25MG Tier 4 PA SUTENT CAP 50MG Tier 4 PA TARCEVA TAB 25MG Tier 4 PA TARCEVA TAB 100MG Tier 4 PA TARCEVA TAB 150MG Tier 4 PA TASIGNA CAP 150MG Tier 4 PA 41

TASIGNA CAP 200MG Tier 4 PA TORISEL SOL 25MG/ML Tier 4 PA TYKERB TAB 250MG Tier 4 PA VANDETANIB TAB 100MG Tier 4 PA VANDETANIB TAB 300MG Tier 4 PA VOTRIENT TAB 200MG Tier 4 PA XALKORI CAP 200MG Tier 4 PA XALKORI CAP 250MG Tier 4 PA ZELBORAF TAB 240MG Tier 4 PA ZOLINZA CAP 100MG Tier 4 PA Antineoplastic Enzymes ELSPAR INJ 10000UNT Tier 4 PA Antineoplastics Misc. ACTIMMUNE INJ 2MU/0.5 Tier 4 PA ALFERON N INJ 5MU/ML Tier 4 PA hydroxyurea cap 500mg Tier 1 INTRON-A INJ 3MU PEN Tier 4 PA INTRON-A INJ 5MU PEN Tier 4 PA INTRON-A INJ 10MU Tier 4 PA INTRON-A INJ 10MU PEN Tier 4 PA INTRON-A INJ 18MU Tier 4 PA INTRON-A INJ 25MU Tier 4 PA INTRON-A INJ 50MU Tier 4 PA MATULANE CAP 50MG Tier 2 PA TARGRETIN CAP 75MG Tier 4 PA tretinoin cap 10mg Tier 1 Chemotherapy Adjuncts KEPIVANCE INJ 6.25MG Tier 4 PA Chemotherapy Rescue/Antidote Agents leucovor ca tab 5mg Tier 1 leucovor ca tab 10mg Tier 1 leucovor ca tab 15mg Tier 1 leucovor ca tab 25mg Tier 1 MESNEX TAB 400MG Tier 3 PA Mitotic Inhibitors etoposide cap 50mg Tier 1 PA etoposide inj 20mg/ml Tier 4 PA toposar inj 1gm/50ml Tier 4 PA toposar inj 20mg/ml Tier 4 PA toposar inj 100/5ml Tier 4 PA toposar inj 500/25ml Tier 4 PA Topoisomerase I Inhibitors HYCAMTIN CAP 0.25MG Tier 4 PA 42

HYCAMTIN CAP 1MG Tier 4 PA ANTIPARKINSON AGENTS Antiparkinson Adjuvants LODOSYN TAB 25MG Tier 2 Antiparkinson Anticholinergics benztropine tab 0.5mg Tier 1 benztropine tab 1mg Tier 1 benztropine tab 2mg Tier 1 trihexyphen elx 0.4mg/ml Tier 1 trihexyphen tab 2mg Tier 1 trihexyphen tab 5mg Tier 1 Antiparkinson COMT Inhibitors entacapone tab 200mg Tier 1 TASMAR TAB 100MG Tier 2 Antiparkinson Dopaminergics amantadine cap 100mg Tier 1 amantadine syp 50mg/5ml Tier 1 amantadine tab 100mg Tier 1 APOKYN INJ Tier 4 PA APOKYN INJ 10MG/ML Tier 4 PA bromocriptin cap 5mg Tier 1 bromocriptin tab 2.5mg Tier 1 carb/levo er tab 25-100mg Tier 1 carb/levo er tab 50-200mg Tier 1 carb/levo sr tab 25-100mg Tier 1 carb/levo sr tab 50-200mg Tier 1 carb/levo tab 10-100mg Tier 1 carb/levo tab 25-100mg Tier 1 carb/levo tab 25-250mg Tier 1 pramipexole tab 0.5mg Tier 1 pramipexole tab 0.25mg Tier 1 pramipexole tab 0.75mg Tier 1 pramipexole tab 0.125mg Tier 1 pramipexole tab 1.5mg Tier 1 pramipexole tab 1mg Tier 1 ropinirole tab 0.5mg Tier 1 ropinirole tab 0.25mg Tier 1 ropinirole tab 1mg Tier 1 ropinirole tab 2mg Tier 1 ropinirole tab 2mg er Tier 1 PA ropinirole tab 3mg Tier 1 ropinirole tab 4mg Tier 1 43

ropinirole tab 4mg er Tier 1 PA ropinirole tab 5mg Tier 1 ropinirole tab 6mg er Tier 1 PA ropinirole tab 8mg er Tier 1 PA ropinirole tab 12mg er Tier 1 PA Antiparkinson Monoamine Oxidase Inhibitors AZILECT TAB 0.5MG Tier 3 AZILECT TAB 1MG Tier 3 selegiline cap 5mg Tier 1 selegiline tab 5mg Tier 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Antimanic Agents lithium carb cap 150mg Tier 1 lithium carb cap 300mg Tier 1 lithium carb cap 600mg Tier 1 lithium carb tab 300mg Tier 1 lithium carb tab 300mg er Tier 1 lithium carb tab 450mg er Tier 1 LITHIUM CITR SOL 8MEQ/5ML Tier 2 Antipsychotics - Misc. EQUETRO CAP 100MG Tier 3 EQUETRO CAP 200MG Tier 3 EQUETRO CAP 300MG Tier 3 LATUDA TAB 20MG Tier 2 ST LATUDA TAB 40MG Tier 2 ST LATUDA TAB 80MG Tier 2 ST ziprasidone cap 20mg Tier 1 ST ziprasidone cap 40mg Tier 1 ST ziprasidone cap 60mg Tier 1 ST ziprasidone cap 80mg Tier 1 ST Benzisoxazoles FANAPT PAK Tier 3 PA FANAPT TAB 1MG Tier 3 PA FANAPT TAB 2MG Tier 3 PA FANAPT TAB 4MG Tier 3 PA FANAPT TAB 6MG Tier 3 PA FANAPT TAB 8MG Tier 3 PA FANAPT TAB 10MG Tier 3 PA FANAPT TAB 12MG Tier 3 PA INVEGA SUST INJ 39/0.25 Tier 3 PA INVEGA SUST INJ 78/0.5ML Tier 3 PA INVEGA SUST INJ 117/0.75 Tier 3 PA 44

INVEGA SUST INJ 156MG/ML Tier 3 PA INVEGA SUST INJ 234/1.5 Tier 3 PA INVEGA TAB 1.5MG Tier 3 PA INVEGA TAB 3MG Tier 3 PA INVEGA TAB 6MG Tier 3 PA INVEGA TAB 9MG Tier 3 PA RISPERDAL INJ 12.5MG Tier 3 PA RISPERDAL INJ 25MG Tier 3 PA RISPERDAL INJ 37.5MG Tier 3 PA RISPERDAL INJ 50MG Tier 3 PA risperidone sol 1mg/ml Tier 1 risperidone tab 0.5mg Tier 1 risperidone tab 0.5mg od Tier 1 risperidone tab 0.25 odt Tier 1 risperidone tab 0.25mg Tier 1 risperidone tab 1mg Tier 1 risperidone tab 1mg odt Tier 1 risperidone tab 2mg Tier 1 risperidone tab 2mg odt Tier 1 risperidone tab 3mg Tier 1 risperidone tab 3mg odt Tier 1 risperidone tab 4mg Tier 1 risperidone tab 4mg odt Tier 1 Butyrophenones haloperidol con 2mg/ml Tier 1 haloperidol tab 0.5mg Tier 1 haloperidol tab 1mg Tier 1 haloperidol tab 2mg Tier 1 haloperidol tab 5mg Tier 1 haloperidol tab 10mg Tier 1 haloperidol tab 20mg Tier 1 Dibenzapines clozapine tab 12.5/odt Tier 1 ST clozapine tab 25mg Tier 1 ST clozapine tab 25mg odt Tier 1 ST clozapine tab 50mg Tier 1 ST clozapine tab 100/odt Tier 1 ST clozapine tab 100mg Tier 1 ST clozapine tab 200mg Tier 1 ST FAZACLO TAB 150MG Tier 3 PA FAZACLO TAB 200MG Tier 3 PA loxapine cap 5mg Tier 1 loxapine cap 10mg Tier 1 45

loxapine cap 25mg Tier 1 loxapine cap 50mg Tier 1 olanzapine tab 2.5mg Tier 1 ST olanzapine tab 5mg Tier 1 ST olanzapine tab 5mg odt Tier 1 ST olanzapine tab 7.5mg Tier 1 ST olanzapine tab 10mg Tier 1 ST olanzapine tab 10mg odt Tier 1 ST olanzapine tab 15mg Tier 1 ST olanzapine tab 15mg odt Tier 1 ST olanzapine tab 20mg Tier 1 ST olanzapine tab 20mg odt Tier 1 ST quetiapine tab 25mg Tier 1 ST quetiapine tab 50mg Tier 1 ST quetiapine tab 100mg Tier 1 ST quetiapine tab 200mg Tier 1 ST quetiapine tab 300mg Tier 1 ST quetiapine tab 400mg Tier 1 ST SAPHRIS SUB 5MG Tier 3 PA SAPHRIS SUB 10MG Tier 3 PA SEROQUEL XR TAB 50MG Tier 2 ST SEROQUEL XR TAB 150MG Tier 2 ST SEROQUEL XR TAB 200MG Tier 2 ST SEROQUEL XR TAB 300MG Tier 2 ST SEROQUEL XR TAB 400MG Tier 2 ST ZYPREXA RELP INJ 210MG Tier 3 PA ZYPREXA RELP INJ 300MG Tier 3 PA ZYPREXA RELP INJ 405MG Tier 3 PA Phenothiazines chlorpromaz tab 10mg Tier 1 chlorpromaz tab 25mg Tier 1 chlorpromaz tab 50mg Tier 1 chlorpromaz tab 100mg Tier 1 chlorpromaz tab 200mg Tier 1 compro sup 25mg Tier 1 fluphenaz de inj 25mg/ml Tier 1 PA fluphenazine con 5mg/ml Tier 1 fluphenazine elx 2.5/5ml Tier 1 fluphenazine tab 1mg Tier 1 fluphenazine tab 2.5mg Tier 1 fluphenazine tab 5mg Tier 1 fluphenazine tab 10mg Tier 1 perphenazine tab 2mg Tier 1 46

perphenazine tab 4mg Tier 1 perphenazine tab 8mg Tier 1 perphenazine tab 16mg Tier 1 prochlorper sup 25mg Tier 1 prochlorper tab 5mg Tier 1 prochlorper tab 10mg Tier 1 thioridazine tab 10mg Tier 1 thioridazine tab 25mg Tier 1 thioridazine tab 50mg Tier 1 thioridazine tab 100mg Tier 1 trifluoperaz tab 1mg Tier 1 trifluoperaz tab 2mg Tier 1 trifluoperaz tab 5mg Tier 1 trifluoperaz tab 10mg Tier 1 Quinolinone Derivatives ABILIFY DISC TAB 10MG Tier 2 ST ABILIFY DISC TAB 15MG Tier 2 ST ABILIFY MAIN INJ 300MG Tier 3 PA ABILIFY MAIN INJ 400MG Tier 3 PA ABILIFY SOL 1MG/ML Tier 2 ST ABILIFY TAB 2MG Tier 2 ST ABILIFY TAB 5MG Tier 2 ST ABILIFY TAB 10MG Tier 2 ST ABILIFY TAB 15MG Tier 2 ST ABILIFY TAB 20MG Tier 2 ST ABILIFY TAB 30MG Tier 2 ST Thioxanthenes NAVANE CAP 20MG Tier 2 thiothixene cap 1mg Tier 1 thiothixene cap 2mg Tier 1 thiothixene cap 5mg Tier 1 thiothixene cap 10mg Tier 1 ANTISEPTICS DISINFECTANTS Chlorine Antiseptics CHLORHEX DIG SOL 20% Tier 2 CHLORHEX GLU SOL 20% Tier 2 PHISOHEX LIQ 3% Tier 2 ANTIVIRALS Antiretrovirals abacavir tab 300mg Tier 1 APTIVUS CAP 250MG Tier 2 APTIVUS SOL Tier 2 47

ATRIPLA TAB Tier 2 COMPLERA TAB Tier 2 CRIXIVAN CAP 100MG Tier 2 CRIXIVAN CAP 200MG Tier 2 CRIXIVAN CAP 400MG Tier 2 didanosine cap 125mg Tier 1 didanosine cap 200mg Tier 1 didanosine cap 250mg Tier 1 didanosine cap 400mg Tier 1 EDURANT TAB 25MG Tier 2 EMTRIVA CAP 200MG Tier 2 EMTRIVA SOL 10MG/ML Tier 2 EPIVIR HBV SOL 5MG/ML Tier 2 EPIVIR HBV TAB 100MG Tier 2 EPIVIR SOL 10MG/ML Tier 2 EPZICOM TAB 600-300 Tier 2 FUZEON INJ 90MG Tier 4 PA FUZEON KIT Tier 4 PA INTELENCE TAB 25MG Tier 4 INTELENCE TAB 100MG Tier 4 INTELENCE TAB 200MG Tier 4 INVIRASE CAP 200MG Tier 2 INVIRASE TAB 500MG Tier 2 ISENTRESS CHW 25MG Tier 2 ISENTRESS CHW 100MG Tier 2 ISENTRESS TAB 400MG Tier 2 KALETRA SOL Tier 2 KALETRA TAB 100-25MG Tier 2 KALETRA TAB 200-50MG Tier 2 lamivud/zido tab 150-300 Tier 1 lamivudine tab 150mg Tier 1 lamivudine tab 300mg Tier 1 LEXIVA SUS 50MG/ML Tier 2 LEXIVA TAB 700MG Tier 2 nevirapine sus 50mg/5ml Tier 1 nevirapine tab 200mg Tier 1 NORVIR CAP 100MG Tier 2 NORVIR SOL 80MG/ML Tier 2 NORVIR TAB 100MG Tier 2 PREZISTA TAB 75MG Tier 2 PREZISTA TAB 150MG Tier 2 PREZISTA TAB 400MG Tier 2 PREZISTA TAB 600MG Tier 2 48

PREZISTA TAB 800MG Tier 2 RESCRIPTOR TAB 100 MG Tier 2 RESCRIPTOR TAB 200MG Tier 2 REYATAZ CAP 100MG Tier 2 REYATAZ CAP 150MG Tier 2 REYATAZ CAP 200MG Tier 2 REYATAZ CAP 300MG Tier 2 SELZENTRY TAB 150MG Tier 2 SELZENTRY TAB 300MG Tier 2 stavudine cap 15mg Tier 1 stavudine cap 20mg Tier 1 stavudine cap 30mg Tier 1 stavudine cap 40mg Tier 1 stavudine sol 1mg/ml Tier 1 STRIBILD TAB Tier 2 PA SUSTIVA CAP 50MG Tier 2 SUSTIVA CAP 200MG Tier 2 SUSTIVA TAB 600MG Tier 2 TRIZIVIR TAB Tier 2 TRUVADA TAB 200-300 Tier 2 VIDEX SOL 2GM Tier 2 VIDEX SOL 4GM Tier 2 VIRACEPT POW 50MG/GM Tier 2 VIRACEPT TAB 250MG Tier 2 VIRACEPT TAB 625MG Tier 2 VIRAMUNE XR TAB 400MG Tier 2 VIREAD POW 40MG/GM Tier 2 VIREAD TAB 150MG Tier 2 VIREAD TAB 200MG Tier 2 VIREAD TAB 250MG Tier 2 VIREAD TAB 300MG Tier 2 ZIAGEN SOL 20MG/ML Tier 2 zidovudine cap 100mg Tier 1 zidovudine syp 50mg/5ml Tier 1 zidovudine tab 300mg Tier 1 CMV Agents ganciclovir cap 250mg Tier 1 PA ganciclovir cap 500mg Tier 1 PA VALCYTE TAB 450MG Tier 2 PA Hepatitis Agents BARACLUDE SOL.05MG/ML Tier 3 BARACLUDE TAB 0.5MG Tier 3 BARACLUDE TAB 1MG Tier 3 49

HEPSERA TAB 10MG Tier 3 INCIVEK TAB 375MG Tier 4 PA INFERGEN INJ 9MCG Tier 4 PA INFERGEN INJ 15MCG Tier 4 PA PEG-INTRON KIT 50MCG Tier 4 PA PEG-INTRON KIT 50MCG RP Tier 4 PA PEG-INTRON KIT 80MCG Tier 4 PA PEG-INTRON KIT 80MCG RP Tier 4 PA PEG-INTRON KIT 120 RP Tier 4 PA PEG-INTRON KIT 120MCG Tier 4 PA PEG-INTRON KIT 150 RP Tier 4 PA PEG-INTRON KIT 150MCG Tier 4 PA PEGASYS INJ Tier 4 PA PEGASYS INJ PROCLICK 180mcg/0.5ml Tier 4 PA PEGASYS KIT Tier 4 PA RIBAPAK PAK 800/DAY Tier 4 PA RIBAPAK PAK 1200/DAY Tier 4 PA ribasphere cap 200mg Tier 4 PA ribasphere tab 200mg Tier 4 PA ribasphere tab 400mg Tier 4 PA ribasphere tab 600mg Tier 4 PA RIBATAB TAB 800/DAY Tier 4 PA RIBATAB TAB 1200/DAY Tier 4 PA ribavirin cap 200mg Tier 4 PA ribavirin tab 200mg Tier 4 PA TYZEKA TAB 600MG Tier 3 VICTRELIS CAP 200MG Tier 4 PA Herpes Agents acyclovir cap 200mg Tier 1 acyclovir sus 200/5ml Tier 1 acyclovir tab 400mg Tier 1 acyclovir tab 800mg Tier 1 famciclovir tab 125mg Tier 1 famciclovir tab 250mg Tier 1 famciclovir tab 500mg Tier 1 valacyclovir tab 1gm Tier 1 valacyclovir tab 500mg Tier 1 Influenza Agents RELENZA MIS DISKHALE Tier 3 rimantadine tab 100mg Tier 1 TAMIFLU CAP 30MG Tier 2 TAMIFLU CAP 45MG Tier 2 TAMIFLU CAP 75MG Tier 2 50

TAMIFLU SUS 6MG/ML Tier 2 TAMIFLU SUS 12MG/ML Tier 2 ASSORTED CLASSES Chelating Agents CUPRIMINE CAP 250MG Tier 2 DEPEN TITRA TAB 250MG Tier 3 PA SYPRINE CAP 250MG Tier 3 PA Immunomodulators REVLIMID CAP 5MG Tier 4 PA REVLIMID CAP 10MG Tier 4 PA REVLIMID CAP 15MG Tier 4 PA REVLIMID CAP 25MG Tier 4 PA THALOMID CAP 50MG Tier 4 PA THALOMID CAP 100MG Tier 4 PA THALOMID CAP 150MG Tier 4 PA THALOMID CAP 200MG Tier 4 PA Immunosuppressive Agents AZASAN TAB 75 MG Tier 2 AZASAN TAB 100MG Tier 2 azathioprine inj 100mg Tier 1 PA azathioprine tab 50mg Tier 1 CELLCEPT SUS 200MG/ML Tier 2 cyclosporine cap 25mg Tier 1 cyclosporine cap 25mg mod Tier 1 cyclosporine cap 50mg mod Tier 1 cyclosporine cap 100mg Tier 1 cyclosporine cap 100mg md Tier 1 cyclosporine sol modified Tier 1 gengraf cap 25mg Tier 1 gengraf cap 100mg Tier 1 gengraf sol 100mg/ml Tier 1 hecoria cap 0.5mg Tier 1 hecoria cap 1mg Tier 1 hecoria cap 5mg Tier 1 mycophenolat cap 250mg Tier 1 mycophenolat tab 500mg Tier 1 MYFORTIC TAB 180MG Tier 3 MYFORTIC TAB 360MG Tier 3 RAPAMUNE SOL 1MG/ML Tier 3 RAPAMUNE TAB 1MG Tier 3 RAPAMUNE TAB 2MG Tier 3 SANDIMMUNE SOL 100MG/ML Tier 2 51

tacrolimus cap 0.5mg Tier 1 tacrolimus cap 1mg Tier 1 tacrolimus cap 5mg Tier 1 Irrigation Solutions ringers irr sol Tier 1 PA tis-u-sol sol Tier 1 PA Potassium Removing Resins kalexate pow Tier 1 kionex pow usp Tier 1 kionex sus 15gm/60 Tier 1 sod poly sul pow Tier 1 sod poly sul sus 15gm/60 Tier 1 sps sus 15gm/60 Tier 1 BETA BLOCKERS Alpha-Beta Blockers carvedilol tab 3.125mg Tier 1 carvedilol tab 6.25mg Tier 1 carvedilol tab 12.5mg Tier 1 carvedilol tab 25mg Tier 1 labetalol tab 100mg Tier 1 labetalol tab 200mg Tier 1 labetalol tab 300mg Tier 1 Beta Blockers Cardio-Selective acebutolol cap 200mg Tier 1 acebutolol cap 400mg Tier 1 atenolol tab 25mg Tier 1 atenolol tab 50mg Tier 1 atenolol tab 100mg Tier 1 betaxolol tab 10mg Tier 1 betaxolol tab 20mg Tier 1 bisoprol fum tab 5mg Tier 1 bisoprol fum tab 10mg Tier 1 BYSTOLIC TAB 2.5MG Tier 3 BYSTOLIC TAB 5MG Tier 3 BYSTOLIC TAB 10MG Tier 3 BYSTOLIC TAB 20MG Tier 3 metoprol tar tab 25mg Tier 1 metoprol tar tab 50mg Tier 1 metoprol tar tab 100mg Tier 1 metoprolol tab 25mg er Tier 1 metoprolol tab 50mg er Tier 1 metoprolol tab 100mg er Tier 1 52

metoprolol tab 200mg er Tier 1 Beta Blockers Non-Selective INNOPRAN XL CAP 80MG Tier 3 INNOPRAN XL CAP 120MG Tier 3 LEVATOL TAB 20MG Tier 2 nadolol tab 20mg Tier 1 nadolol tab 40mg Tier 1 nadolol tab 80mg Tier 1 pindolol tab 5mg Tier 1 pindolol tab 10mg Tier 1 propranolol cap 60mg er Tier 1 propranolol cap 80mg er Tier 1 propranolol cap 120mg er Tier 1 propranolol cap 160mg er Tier 1 propranolol sol 20mg/5ml Tier 1 propranolol sol 40mg/5ml Tier 1 propranolol tab 10mg Tier 1 propranolol tab 20mg Tier 1 propranolol tab 40mg Tier 1 propranolol tab 60mg Tier 1 propranolol tab 80mg Tier 1 sorine tab 80mg Tier 1 sorine tab 120mg Tier 1 sorine tab 160mg Tier 1 sorine tab 240mg Tier 1 sotalol af tab 80mg Tier 1 sotalol af tab 120mg Tier 1 sotalol af tab 160mg Tier 1 sotalol hcl tab 80mg Tier 1 sotalol hcl tab 120mg Tier 1 sotalol hcl tab 160mg Tier 1 sotalol hcl tab 240mg Tier 1 timolol mal tab 5mg Tier 1 timolol mal tab 10mg Tier 1 timolol mal tab 20mg Tier 1 CALCIUM CHANNEL BLOCKERS Calcium Channel Blockers afeditab tab 30mg cr Tier 1 afeditab tab 60mg cr Tier 1 amlodipine tab 2.5mg Tier 1 amlodipine tab 5mg Tier 1 amlodipine tab 10mg Tier 1 53

CARDENE SR CAP 30MG Tier 2 CARDENE SR CAP 45MG Tier 2 CARDENE SR CAP 60MG Tier 2 cartia xt cap 120/24hr Tier 1 cartia xt cap 180/24hr Tier 1 cartia xt cap 240/24hr Tier 1 cartia xt cap 300/24hr Tier 1 COVERA-HS TAB 180MG Tier 3 COVERA-HS TAB 240MG Tier 3 dilt-cd cap 120mg Tier 1 dilt-cd cap 180mg Tier 1 dilt-cd cap 240mg Tier 1 dilt-cd cap 300mg Tier 1 dilt-xr cap 120mg Tier 1 dilt-xr cap 180mg Tier 1 dilt-xr cap 240mg Tier 1 diltiazem cap 60mg er Tier 1 diltiazem cap 90mg er Tier 1 diltiazem cap 120mg cd Tier 1 diltiazem cap 120mg er Tier 1 diltiazem cap 120mg/24 Tier 1 diltiazem cap 180mg cd Tier 1 diltiazem cap 180mg er Tier 1 diltiazem cap 180mg/24 Tier 1 diltiazem cap 240mg cd Tier 1 diltiazem cap 240mg er Tier 1 diltiazem cap 240mg/24 Tier 1 diltiazem cap 300mg cd Tier 1 diltiazem cap 300mg er Tier 1 diltiazem cap 300mg/24 Tier 1 diltiazem cap 360mg cd Tier 1 diltiazem cap 360mg er Tier 1 diltiazem cap 360mg/24 Tier 1 diltiazem cap 420mg/24 Tier 1 diltiazem tab 30mg Tier 1 diltiazem tab 60mg Tier 1 diltiazem tab 90mg Tier 1 diltiazem tab 120mg Tier 1 diltzac cap 120mg/24 Tier 1 diltzac cap 180mg/24 Tier 1 diltzac cap 240mg/24 Tier 1 diltzac cap 300mg/24 Tier 1 diltzac cap 360mg/24 Tier 1 54

DYNACIRC CR TAB 5MG Tier 2 DYNACIRC CR TAB 10MG Tier 2 felodipine tab 2.5mg er Tier 1 felodipine tab 5mg er Tier 1 felodipine tab 10mg er Tier 1 isradipine cap 2.5mg Tier 1 isradipine cap 5mg Tier 1 nicardipine cap 20mg Tier 1 nicardipine cap 30mg Tier 1 nifediac cc tab 30mg er Tier 1 nifediac cc tab 60mg er Tier 1 nifediac cc tab 90mg er Tier 1 nifedical xl tab 30mg Tier 1 nifedical xl tab 60mg Tier 1 nifedipine cap 10mg Tier 1 nifedipine cap 20mg Tier 1 nifedipine tab 30mg er Tier 1 nifedipine tab 60mg er Tier 1 nifedipine tab 90mg er Tier 1 nimodipine cap 30mg Tier 1 PA nisoldipine tab 8.5mg er Tier 1 nisoldipine tab 17mg er Tier 1 nisoldipine tab 20mg Tier 1 nisoldipine tab 25.5mg Tier 1 nisoldipine tab 30mg Tier 1 nisoldipine tab 34mg er Tier 1 nisoldipine tab 40mg Tier 1 taztia xt cap 120mg/24 Tier 1 taztia xt cap 180mg/24 Tier 1 taztia xt cap 240mg/24 Tier 1 taztia xt cap 300mg/24 Tier 1 taztia xt cap 360mg/24 Tier 1 verapamil cap 120mg er Tier 1 verapamil cap 120mg sr Tier 1 verapamil cap 180mg er Tier 1 verapamil cap 180mg sr Tier 1 verapamil cap 240mg er Tier 1 verapamil cap 240mg sr Tier 1 verapamil cap 360mg sr Tier 1 verapamil tab 40mg Tier 1 verapamil tab 80mg Tier 1 verapamil tab 120mg Tier 1 verapamil tab 120mg er Tier 1 55

verapamil tab 120mg sr Tier 1 verapamil tab 180mg er Tier 1 verapamil tab 180mg sr Tier 1 verapamil tab 240mg er Tier 1 verapamil tab 240mg sr Tier 1 CARDIOTONICS Cardiac Glycosides digoxin sol 50mcg/ml Tier 1 digoxin tab 0.25mg Tier 1 digoxin tab 0.125mg Tier 1 CARDIOVASCULAR AGENTS - MISC. Impotence Agents CAVERJECT INJ 20MCG Tier 3 PA; QL CAVERJECT INJ 40MCG Tier 3 PA; QL CAVERJECT KIT 10MCG Tier 3 PA; QL CAVERJECT KIT 20MCG Tier 3 PA; QL CIALIS TAB 2.5MG Tier 3 PA; QL CIALIS TAB 5MG Tier 3 PA; QL CIALIS TAB 10MG Tier 3 PA; QL CIALIS TAB 20MG Tier 3 PA; QL EDEX KIT 10MCG Tier 3 PA; QL EDEX KIT 20MCG Tier 3 PA; QL EDEX KIT 40MCG Tier 3 PA; QL LEVITRA TAB 2.5MG Tier 3 PA; QL LEVITRA TAB 5MG Tier 3 PA; QL LEVITRA TAB 10MG Tier 3 PA; QL LEVITRA TAB 20MG Tier 3 PA; QL MUSE SUP 125MCG Tier 3 PA; QL MUSE SUP 250MCG Tier 3 PA; QL MUSE SUP 500MCG Tier 3 PA; QL MUSE SUP 1000MCG Tier 3 PA; QL STAXYN TAB 10MG Tier 3 PA; QL VIAGRA TAB 25MG Tier 3 PA; QL VIAGRA TAB 50MG Tier 3 PA; QL VIAGRA TAB 100MG Tier 3 PA; QL yohimbine tab 5.4mg Tier 1 QL Prostaglandin Vasodilators REMODULIN INJ 1MG/ML Tier 4 PA REMODULIN INJ 2.5MG/ML Tier 4 PA REMODULIN INJ 5MG/ML Tier 4 PA REMODULIN INJ 10MG/ML Tier 4 PA VENTAVIS SOL 10MCG/ML Tier 4 PA 56

Pulmonary Hypertension - Endothelin Receptor Antagonists LETAIRIS TAB 5MG Tier 4 PA LETAIRIS TAB 10MG Tier 4 PA TRACLEER TAB 62.5MG Tier 4 PA TRACLEER TAB 125MG Tier 4 PA Pulmonary Hypertension - Phosphodiesterase Inhibitors ADCIRCA TAB 20MG Tier 4 PA sildenafil tab 20mg Tier 4 PA CEPHALOSPORINS Cephalosporins - 1st Generation cefadroxil cap 500mg Tier 1 cefadroxil sus 250/5ml Tier 1 cefadroxil sus 500/5ml Tier 1 cefadroxil tab 1gm Tier 1 cephalexin cap 250mg Tier 1 cephalexin cap 500mg Tier 1 cephalexin cap 750mg Tier 1 cephalexin sus 125/5ml Tier 1 cephalexin sus 250/5ml Tier 1 cephalexin tab 250mg Tier 1 cephalexin tab 500mg Tier 1 KEFLEX CAP 750MG Tier 1 Cephalosporins - 2nd Generation cefaclor cap 250mg Tier 1 cefaclor cap 500mg Tier 1 cefaclor sus 125/5ml Tier 1 cefaclor sus 250/5ml Tier 1 cefaclor sus 375/5ml Tier 1 cefprozil sus 125/5ml Tier 1 cefprozil sus 250/5ml Tier 1 cefprozil tab 250mg Tier 1 cefprozil tab 500mg Tier 1 CEFTIN SUS 250/5ML Tier 2 cefuroxime sus 125/5ml Tier 1 cefuroxime tab 250mg Tier 1 cefuroxime tab 500mg Tier 1 Cephalosporins - 3rd Generation CEDAX CAP 400MG Tier 2 cefdinir cap 300mg Tier 1 cefdinir sus 125/5ml Tier 1 cefdinir sus 250/5ml Tier 1 cefditoren tab 200mg Tier 1 57

cefditoren tab 400mg Tier 1 cefpodo prox sus 50mg/5ml Tier 1 cefpodo prox sus 100/5ml Tier 1 cefpodoxime tab 100mg Tier 1 cefpodoxime tab 200mg Tier 1 SUPRAX SUS 100/5ML Tier 2 SUPRAX SUS 200/5ML Tier 2 SUPRAX TAB 400MG Tier 2 CONTRACEPTIVES Combination Contraceptives - Oral altavera tab Tier 0 alyacen tab 1/35 Tier 0 alyacen tab 7/7/7 Tier 0 amethyst tab 90-20mcg Tier 0 apri tab Tier 0 aranelle tab Tier 0 aviane tab Tier 0 azurette tab 28 day Tier 0 balziva tab Tier 0 briellyn tab Tier 0 caziant pak Tier 0 cesia pak Tier 0 chateal tab 0.15/30 Tier 0 cryselle-28 tab 28 tabs Tier 0 cyclafem tab 1/35 Tier 0 cyclafem tab 7/7/7 Tier 0 dasetta tab 1/35 Tier 0 dasetta tab 7/7/7 Tier 0 drospir/ethi tab 3-0.03mg Tier 0 elinest tab Tier 0 emoquette tab Tier 0 enpresse-28 tab Tier 0 enskyce tab Tier 0 estarylla tab 0.25-35 Tier 0 falmina tab Tier 0 gianvi tab 3-0.02mg Tier 0 gildagia tab 0.4-35 Tier 0 gildess fe tab 1.5/30 Tier 0 gildess fe tab 1/20 Tier 0 gildess tab 1.5/30 Tier 0 gildess tab 1/20 Tier 0 junel 1.5/30 tab Tier 0 58

junel 1/20 tab Tier 0 junel fe tab 1.5/30 Tier 0 junel fe tab 1/20 Tier 0 kariva tab 28 day Tier 0 kelnor tab 1/35 Tier 0 kurvelo tab 0.15/30 Tier 0 leena tab Tier 0 lessina tab Tier 0 levonest tab Tier 0 levonor/ethi tab 0.1-0.02 Tier 0 levonor/ethi tab estradio Tier 0 levora-28 tab 0.15/30 Tier 0 loryna tab 3-0.02mg Tier 0 low-ogestrel tab Tier 0 lutera tab Tier 0 marlissa tab 0.15/30 Tier 0 microgestin tab 1.5/30 Tier 0 microgestin tab 1/20 Tier 0 microgestin tab fe1.5/30 Tier 0 microgestin tab fe 1/20 Tier 0 mono-linyah tab 0.25-35 Tier 0 mononessa tab Tier 0 myzilra tab Tier 0 necon tab 0.5/35 Tier 0 necon tab 1/35 Tier 0 necon tab 1/50-28 Tier 0 necon tab 7/7/7 Tier 0 norgest/eth tab estrad Tier 0 norgest/ethi tab 0.25/35 Tier 0 norgest/ethi tab estradio Tier 0 nortrel tab 0.5/35 Tier 0 nortrel tab 1/35 Tier 0 nortrel tab 7/7/7 Tier 0 ocella tab 3-0.03mg Tier 0 ogestrel tab Tier 0 orsythia tab Tier 0 philith tab 0.4-35 Tier 0 portia-28 tab Tier 0 previfem tab Tier 0 reclipsen tab Tier 0 solia tab Tier 0 sprintec 28 tab 28 day Tier 0 sronyx tab Tier 0 59

syeda tab 3-0.03mg Tier 0 tilia fe tab Tier 0 tri-estaryll tab Tier 0 tri-legest tab fe Tier 0 tri-linyah tab Tier 0 tri-previfem tab Tier 0 tri-sprintec tab Tier 0 trinessa tab Tier 0 trivora-28 tab Tier 0 velivet pak Tier 0 vestura tab 3-0.02mg Tier 0 viorele tab Tier 0 wera tab 0.5/35 Tier 0 wymzya fe chw 0.4mg-35 Tier 0 zarah tab 3-0.03mg Tier 0 zenchent fe chw Tier 0 zenchent fe chw 0.4mg-35 Tier 0 zenchent tab Tier 0 zeosa chw Tier 0 zovia 1/35e tab Tier 0 zovia 1/50e tab Tier 0 Combination Contraceptives - Transdermal ORTHO EVRA DIS WEEK Tier 0 Combination Contraceptives - Vaginal NUVARING MIS Tier 0 Emergency Contraceptives ELLA TAB 30MG Tier 0 levonorgestr tab 0.75mg Tier 0 my way tab 1.5mg Tier 0 next choice tab 0.75mg Tier 0 next choice tab 1.5mg Tier 0 Progestin Contraceptives - IUD MIRENA IUD SYSTEM Tier 0 PA SKYLA IUD 13.5MG Tier 0 PA Progestin Contraceptives - Implants IMPLANON IMP 68MG Tier 0 PA NEXPLANON IMP 68MG Tier 0 PA Progestin Contraceptives - Injectable DEPO-SQ PROV INJ 104 Tier 2 medroxypr ac inj 150mg/ml Tier 0 Progestin Contraceptives - Oral camila tab 0.35mg Tier 0 errin tab 0.35mg Tier 0 60

heather tab 0.35mg Tier 0 jencycla tab 0.35mg Tier 0 jolivette tab 0.35mg Tier 0 nora-be tab 0.35mg Tier 0 norethindron tab 0.35mg Tier 0 CORTICOSTEROIDS Glucocorticosteroids asmalpred sol 15mg/5ml Tier 1 asmalpred sol plus Tier 1 baycadron elx 0.5/5ml Tier 1 budesonide cap 3mg/24hr Tier 1 PA cortisone ac tab 25mg Tier 1 dexamethason con 1mg/ml Tier 1 dexamethason elx 0.5/5ml Tier 1 dexamethason sol 0.5/5ml Tier 1 dexamethason tab 0.5mg Tier 1 dexamethason tab 0.75mg Tier 1 dexamethason tab 1.5mg Tier 1 dexamethason tab 1mg Tier 1 dexamethason tab 2mg Tier 1 dexamethason tab 4mg Tier 1 dexamethason tab 6mg Tier 1 hydrocort tab 5mg Tier 1 hydrocort tab 10mg Tier 1 hydrocort tab 20mg Tier 1 methylpred pak 4mg Tier 1 methylpred tab 4mg Tier 1 methylpred tab 8mg Tier 1 methylpred tab 16mg Tier 1 methylpred tab 32mg Tier 1 MILLIPRED SOL 10MG/5ML Tier 2 MILLIPRED TAB 5MG Tier 2 pred sod pho sol 5mg/5ml Tier 1 pred sod pho sol 6.7/5ml Tier 1 prednisolone sol 15mg/5ml Tier 1 prednisolone sol 25mg/5ml Tier 1 prednisone pak 5mg Tier 1 prednisone pak 10mg Tier 1 prednisone sol 5mg/5ml Tier 1 prednisone tab 1mg Tier 1 prednisone tab 2.5mg Tier 1 prednisone tab 5mg Tier 1 61

prednisone tab 10mg Tier 1 prednisone tab 20mg Tier 1 prednisone tab 50mg Tier 1 VERIPRED 20 SOL 20MG/5ML Tier 2 Mineralocorticoids fludrocort tab 0.1mg Tier 1 COUGH/COLD/ALLERGY Antitussives benzonatate cap 100mg Tier 1 benzonatate cap 200mg Tier 1 hydrocod/hom syp 5-1.5/5 Tier 1 hydromet syp 5-1.5/5 Tier 1 Cough/Cold/Allergy Combinations biocotron liq 100-10/5 Tier 1 broncotron liq 10-100/5 Tier 1 c-phen dm syp Tier 1 ceron-dm syp Tier 1 cheratussin sol dac Tier 1 cheratussin syp ac Tier 1 diabetic tus liq children Tier 1 diabetic tus liq dm Tier 1 dm/gg sol Tier 1 dm/gg sol 10-100/5 Tier 1 g-tron liq 10-100/5 Tier 1 gani-tuss dm liq 100-10/5 Tier 1 gani-tuss nr liq 100-10/5 Tier 1 gg/codeine sol 100-10/5 Tier 1 gnp tussin liq dm Tier 1 gnp tussin liq dm cough Tier 1 guaiasorb dm liq 100-10/5 Tier 1 guaiatussin syp ac Tier 1 guaifenesin sol dac Tier 1 guaifenesin syp ac Tier 1 hm tussin liq adlt dm Tier 1 iophen c-nr liq 100-10/5 Tier 1 iophen dm-nr liq 100-10/5 Tier 1 medi-tuss dm liq diabetic Tier 1 myci-gc sol 100-10/5 Tier 1 mytussin ac syp 100-10/5 Tier 1 mytussin dac sol Tier 1 novagest/cod sol expect Tier 1 ped formula liq 100-10/5 Tier 1 62

prometh vc syp 6.25-5/5 Tier 1 prometh vc syp plain Tier 1 prometh vc/ syp codeine Tier 1 prometh/cod syp 6.25-10 Tier 1 promethazine syp dm Tier 1 px tussin dm liq 100-10/5 Tier 1 ra tussin dm liq 100-10/5 Tier 1 robafen ac syp 100-10/5 Tier 1 robitussin liq cgh/cong Tier 1 robitussin liq to go dm Tier 1 romilar ac sol 100-10/5 Tier 1 safe tussin liq 10-100/5 Tier 1 sb cgh contr liq dm Tier 1 sildec pe-dm syp Tier 1 siltussin dm liq das Tier 1 siltussin-dm liq diabetic Tier 1 tgt cough liq form dm Tier 1 tolu-sed dm liq 100-10/5 Tier 1 tusnel diabt liq 10-100/5 Tier 1 tussin adult liq cgh/cong Tier 1 tussin cough liq 10-100/5 Tier 1 tussin cough liq congesti Tier 1 tussin dm liq Tier 1 tussin dm liq 100-10/5 Tier 1 tussin dm liq clear Tier 1 wal-tussin liq dm Tier 1 Expectorants buckleys liq chest Tier 1 chest conges liq child Tier 1 chest conges liq childrns Tier 1 coughtab tab 200mg Tier 1 diabetic tus liq 100/5ml Tier 1 eq tussin liq 100/5ml Tier 1 ganidin-nr liq 100/5ml Tier 1 guaifenesin liq nr Tier 1 guaifenesin sol 100/5ml Tier 1 guaifenesin sol 200/10ml Tier 1 guaifenesin sol 300/15ml Tier 1 guaifenesin tab 200mg Tier 1 iophen-nr liq 100/5ml Tier 1 mucinex chld liq 100/5ml Tier 1 mucinex/kids liq 100/5ml Tier 1 mucus relief liq 100/5ml Tier 1 63

mucus relief liq 400/20ml Tier 1 mucus+chst liq 100/5ml Tier 1 organ-i nr tab 200mg Tier 1 px tussin sol 100/5ml Tier 1 qc medifin liq mucus rl Tier 1 qc medifin tab 200mg Tier 1 ra tussin liq 100/5ml Tier 1 refenesen tab 200mg Tier 1 sb coughtab tab 200mg Tier 1 scot-tussin liq expct sf Tier 1 siltuss das liq 100/5ml Tier 1 th tussin liq 100/5ml Tier 1 tussin adult liq 100/5ml Tier 1 Misc. Respiratory Inhalants sod chloride neb 0.9% Tier 1 sodium chlor neb 7% Tier 1 Mucolytics acetylcyst sol 10% Tier 1 acetylcyst sol 20% Tier 1 DERMATOLOGICALS Acne Products acne medicat gel 10% Tier 1 acne treatmn gel 10% Tier 1 acne-clear gel 10% Tier 1 adapalene cre 0.1% Tier 1 PA adapalene gel 0.1% Tier 1 PA amnesteem cap 10mg Tier 1 PA amnesteem cap 20mg Tier 1 PA amnesteem cap 40mg Tier 1 PA ATRALIN GEL 0.05% Tier 2 PA; AGE avita cre 0.025% Tier 1 AGE avita gel 0.025% Tier 1 AGE AZELEX CRE 20% Tier 3 benzoyl per gel 5% Tier 1 benzoyl per gel 10% Tier 1 benzoyl per liq 5% wash Tier 1 benzoyl per liq 10% wash Tier 1 bp gel gel 5% Tier 1 bp gel gel 10% Tier 1 bp wash liq 5% Tier 1 bp wash liq 10% Tier 1 bpo-5 wash liq 5% Tier 1 64

bpo-10 wash liq 10% Tier 1 claravis cap 10mg Tier 1 PA claravis cap 20mg Tier 1 PA claravis cap 30mg Tier 1 PA claravis cap 40mg Tier 1 PA clearplex v gel 5% Tier 1 clearplex x gel 10% Tier 1 clindacin-p pad 1% Tier 1 clindamax gel 1% Tier 1 clindamax lot 10mg/ml Tier 1 clindamy/ben gel 1-5% Tier 1 clindamy/ben gel 1.2-5% Tier 1 clindamycin aer 1% Tier 1 PA clindamycin gel 1% Tier 1 clindamycin lot 1% Tier 1 clindamycin lot 10mg/ml Tier 1 clindamycin pad 1% Tier 1 clindamycin sol 1% Tier 1 DIFFERIN GEL 0.3% Tier 2 PA EPIDUO GEL 0.1-2.5% Tier 3 PA ery pad 2% Tier 1 PA erythromycin gel 2% Tier 1 erythromycin gel /benzoyl Tier 1 erythromycin pad 2% Tier 1 PA erythromycin sol 2% Tier 1 foaming face liq wsh 10% Tier 1 myorisan cap 10mg Tier 1 PA myorisan cap 20mg Tier 1 PA myorisan cap 40mg Tier 1 PA panoxyl wash liq 10% Tier 1 persa-gel gel 10% Tier 1 persa-gel xs gel 5% Tier 1 ra renewal gel 10% Tier 1 sotret cap 10mg Tier 1 PA sotret cap 20mg Tier 1 PA sotret cap 30mg Tier 1 PA TRETIN-X CRE 0.0375% Tier 2 AGE tretinoin cre 0.1% Tier 1 AGE tretinoin cre 0.05% Tier 1 AGE tretinoin cre 0.025% Tier 1 AGE tretinoin gel 0.01% Tier 1 AGE tretinoin gel 0.025% Tier 1 AGE VELTIN GEL Tier 3 65

zenatane cap 10mg Tier 1 PA zenatane cap 20mg Tier 1 PA zenatane cap 40mg Tier 1 PA ZIANA GEL Tier 3 Agents for External Genital and Perianal Warts VEREGEN OIN 15% Tier 3 Agents for Facial Wrinkles refissa cre 0.05% Tier 1 tretinoin em cre 0.05% Tier 1 Anti-inflammatory Agents - Topical VOLTAREN GEL 1% Tier 2 Antibiotics - Topical ALTABAX OIN 1% Tier 3 centany oin 2% Tier 1 CORTISPORIN CRE 0.5% Tier 2 CORTISPORIN OIN 1% Tier 2 gentamicin cre 0.1% Tier 1 gentamicin oin 0.1% Tier 1 mupirocin ca cre 2% Tier 1 mupirocin cre 2% Tier 1 mupirocin oin 2% Tier 1 Antifungals - Topical antifungal cre 1% Tier 1 antifungal cre 2% Tier 1 athlete foot cre 1% Tier 1 baza antifun cre 2% Tier 1 ciclodan cre 0.77% Tier 1 ciclopirox cre 0.77% Tier 1 ciclopirox gel 0.77% Tier 1 ciclopirox sus 0.77% Tier 1 clotrim/beta cre 1-0.05% Tier 1 clotrim/beta cre diprop Tier 1 clotrim/beta lot diprop Tier 1 clotrimazole cre 1% Tier 1 clotrimazole sol 1% Tier 1 desenex cre 1% Tier 1 econazole cre 1% Tier 1 ERTACZO CRE 2% Tier 3 EXELDERM CRE 1% Tier 2 EXELDERM SOL 1% Tier 2 fungicure spr intens Tier 1 jock itch cre 1% Tier 1 ketoconazole aer 2% Tier 1 66

ketoconazole cre 2% Tier 1 ketoconazole sha 2% Tier 1 ketodan aer 2% Tier 1 LAMISIL AT SPR 1% Tier 2 LAMISIL SPR 1% Tier 2 LOTRIMIN ULT CRE 1% Tier 2 MENTAX CRE 1% Tier 2 micaderm cre 2% Tier 1 miconazole cre 2% Tier 1 MICONAZOLE POW NITRATE Tier 2 micro guard cre 2% Tier 1 mp clotrimaz cre 1% Tier 1 NAFTIN CRE 1% Tier 2 NAFTIN CRE 2% Tier 2 NAFTIN GEL 1% Tier 2 neosporin af cre 2% jock Tier 1 nuzole cre 2% Tier 1 nyamyc pow 100000 Tier 1 nystat/triam cre Tier 1 nystat/triam oin Tier 1 nystatin cre 100000 Tier 1 nystatin oin 100000 Tier 1 nystatin pow 100000 Tier 1 nystop pow 100000 Tier 1 OXISTAT CRE 1% Tier 3 PA OXISTAT LOT 1% Tier 3 PA pedi-dri pow 100000 Tier 1 podactin cre 2% Tier 1 remedy cre antifung Tier 1 ringworm cre 1% Tier 1 sm antifungl cre 2% Tier 1 soothe&cool cre inzo 2% Tier 1 Antineoplastic or Premalignant Lesion Agents - Topical fluorouracil cre 5% Tier 1 fluorouracil dro 2% Tier 1 fluorouracil dro 5% Tier 1 fluorouracil sol 2% Tier 1 fluorouracil sol 5% Tier 1 PANRETIN GEL 0.1% Tier 4 PICATO GEL 0.05% Tier 3 PICATO GEL 0.015% Tier 3 Antipruritics - Topical prudoxin cre 5% Tier 1 67

Antipsoriatics calcipotrien cre 0.005% Tier 1 calcipotrien oin 0.005% Tier 1 calcipotrien sol 0.005% Tier 1 calcitrene oin 0.005% Tier 1 calcitriol oin 3mcg/gm Tier 1 OXSORALEN-UL CAP 10MG Tier 3 PA SORIATANE CAP 10MG Tier 3 SORIATANE CAP 17.5MG Tier 3 SORIATANE CAP 25MG Tier 3 STELARA INJ 45MG/0.5 Tier 4 PA STELARA INJ 90MG/ML Tier 4 PA TAZORAC CRE 0.1% Tier 2 TAZORAC CRE 0.05% Tier 2 TAZORAC GEL 0.1% Tier 2 TAZORAC GEL 0.05% Tier 2 Antiseborrheic Products selenium sul lot 2.5% Tier 1 selenium sul sha 2.5% Tier 1 Antivirals - Topical DENAVIR CRE 1% Tier 2 Burn Products silver sulfa cre 1% Tier 1 ssd af cre 1% Tier 1 ssd cre 1% Tier 1 SULFAMYLON CRE 85MG/GM Tier 2 thermazene cre 1% Tier 1 Corticosteroids - Topical ala cort cre 1% Tier 1 ala-cort lot 1% Tier 1 alclometason cre 0.05% Tier 1 alclometason oin 0.05% Tier 1 amcinonide cre 0.1% Tier 1 amcinonide lot 0.1% Tier 1 AMCINONIDE OIN 0.1% Tier 2 anti-itch cre 1% Tier 1 anti-itch cre 1%pls 10 Tier 1 anti-itch cre /aloe/e Tier 1 anti-itch cre /oatmeal Tier 1 anti-itch lot 1% Tier 1 anti-itch oin 1% Tier 1 anti-itch oin max st Tier 1 apexicon oin 0.05% Tier 1 68

aquanil hc lot 1% Tier 1 aug betamet cre 0.05% Tier 1 aug betamet oin 0.05% Tier 1 aveeno cre 1% Tier 1 beta hc lot 1% Tier 1 betameth dip cre 0.05% Tier 1 betameth dip oin 0.05% Tier 1 betameth val cre 0.1% Tier 1 betameth val lot 0.1% Tier 1 betameth val oin 0.1% Tier 1 caldecort cre 1% Tier 1 clobetasol cre 0.05% Tier 1 clobetasol gel 0.05% Tier 1 clobetasol oin 0.05% Tier 1 clobetasol sol 0.05% Tier 1 CLODERM CRE 0.1% Tier 3 CLODERM CRE 0.1% PMP Tier 3 CORDRAN LOT 0.05% Tier 2 CORDRAN SP CRE 0.05% Tier 2 cormax oin 0.05% Tier 1 cormax scalp sol 0.05% Tier 1 cormax sol 0.05% Tier 1 cort intense cre heal 1% Tier 1 cortaid adv cre 1% 12 hr Tier 1 cortaid cre 1% Tier 1 cortisone + cre 1% Tier 1 cortisone cre 1% Tier 1 cortisone lot 1% Tier 1 cortisone oin 1%max st Tier 1 cortizone-10 lot eczema Tier 1 cortizone-10 lot hydraten Tier 1 cortizone-10 oin 1% Tier 1 cvs cort int cre heal 1% Tier 1 desonide cre 0.05% Tier 1 desonide lot 0.05% Tier 1 desonide oin 0.05% Tier 1 desoximetas cre 0.05% Tier 1 desoximetas cre 0.25% Tier 1 desoximetas gel 0.05% Tier 1 desoximetas oin 0.05% Tier 1 desoximetas oin 0.25% Tier 1 diflorasone cre 0.05% Tier 1 diflorasone oin 0.05% Tier 1 69

eq hydrocort cre 1% Tier 1 fluocin acet cre 0.01% Tier 1 fluocin acet cre 0.025% Tier 1 fluocin acet oin 0.025% Tier 1 fluocin acet sol 0.01% Tier 1 fluocinonide cre 0.05% Tier 1 fluocinonide gel 0.05% Tier 1 fluocinonide oin 0.05% Tier 1 fluocinonide sol 0.05% Tier 1 fluticasone cre 0.05% Tier 1 fluticasone oin 0.005% Tier 1 gnp hydrocor cre 1% plus Tier 1 halobetasol cre 0.05% Tier 1 halobetasol oin 0.05% Tier 1 HALOG CRE 0.1% Tier 2 HALOG OIN 0.1% Tier 2 hc pramoxine cre 1-2.5% Tier 1 hc valerate cre 0.2% Tier 1 hc valerate oin 0.2% Tier 1 hydro-lotion lot 1% Tier 1 hydrocort cre 1% Tier 1 hydrocort cre 1% plus Tier 1 hydrocort cre 1%pls 10 Tier 1 hydrocort cre 1%pls 12 Tier 1 hydrocort cre 2.5% Tier 1 hydrocort lot 1% Tier 1 hydrocort lot 2.5% Tier 1 hydrocort oin 1% Tier 1 hydrocort oin 2.5% Tier 1 hydrocort/ab oin 1% Tier 1 hydrocream cre 1% Tier 1 hydroskin cre 1% Tier 1 itch-x lot 1% Tier 1 kericort 10 cre 1% Tier 1 lokara lot 0.05% Tier 1 med-derm hc cre 1% Tier 1 mometasone cre 0.1% Tier 1 mometasone oin 0.1% Tier 1 mometasone sol 0.1% Tier 1 mp hydrocort cre 1% Tier 1 mp hydrocort oin 1% Tier 1 neosporin cre eczema Tier 1 noble formul cre hc 1% Tier 1 70

pramcort cre 1-1% Tier 1 prednicarbat cre 0.1% Tier 1 prednicarbat oin 0.1% Tier 1 prep h hc cre 1% Tier 1 qc hydrocort cre 1% Tier 1 ra anti-itch cre 1% Tier 1 ra anti-itch oin 1% Tier 1 ra hydrocort cre 1% Tier 1 ra hydrocort cre 1%pls 12 Tier 1 recort plus cre 1% Tier 1 rederm lot 1% Tier 1 sarnol-hc lot 1% Tier 1 sb hydrocort cre 1% Tier 1 sb hydrocort oin 1% Tier 1 scalacort lot 2% Tier 1 sm hydrocort cre 1% Tier 1 sm hydrocort oin 1% Tier 1 TACLONEX OIN Tier 3 TACLONEX SUS Tier 3 th hydrocort cre 1% Tier 1 theracort lot 1% Tier 1 triamcinolon cre 0.1% Tier 1 triamcinolon cre 0.5% Tier 1 triamcinolon cre 0.025% Tier 1 triamcinolon lot 0.1% Tier 1 triamcinolon oin 0.1% Tier 1 triamcinolon oin 0.5% Tier 1 triamcinolon oin 0.05% Tier 1 triamcinolon oin 0.025% Tier 1 triderm cre 0.1% Tier 1 VANOS CRE 0.1% Tier 2 Emollients al12 lot 12% Tier 1 amlactin cre 12% Tier 1 amlactin lot 12% Tier 1 ammonium lac cre 12% Tier 1 ammonium lac lot 12% Tier 1 geri-hydrola cre 12% Tier 1 geri-hydrola lot 12% Tier 1 laclotion lot 12% Tier 1 moist skin cre 12% Tier 1 moist skin lot 12% Tier 1 skin trtment lot 12% Tier 1 71

Enzymes - Topical SANTYL OIN 250/GM Tier 2 Hair Growth Agents finasteride tab 1mg Tier 1 Immunomodulating Agents - Topical imiquimod cre 5% Tier 1 ZYCLARA CRE 3.75% Tier 2 ZYCLARA PUMP CRE 2.5% Tier 2 ZYCLARA PUMP CRE 3.75% Tier 2 Immunosuppressive Agents - Topical ELIDEL CRE 1% Tier 2 PROTOPIC OIN 0.1% Tier 2 PROTOPIC OIN 0.03% Tier 2 Keratolytic/Antimitotic Agents CONDYLOX GEL 0.5% Tier 2 podofilox sol 0.5% Tier 1 Local Anesthetics - Topical lido/prilocn cre 2.5-2.5% Tier 1 lidocaine gel 2% Tier 1 lidocaine gel 2% jelly Tier 1 lidocaine oin 5% Tier 1 lidocaine sol 4% Tier 1 LIDODERM DIS 5% Tier 2 regenecare gel ha 2% Tier 1 SYNERA DIS 70-70MG Tier 3 Misc. Topical hypercare sol 20% Tier 1 Pigmenting-Depigmenting Agents OXSORALEN LOT 1% Tier 3 Rosacea Agents FINACEA GEL 15% Tier 3 METROGEL GEL 1% Tier 2 metronidazol cre 0.75% Tier 1 metronidazol gel 0.75% Tier 1 metronidazol lot 0.75% Tier 1 NORITATE CRE 1% Tier 2 rosadan cre 0.75% Tier 1 rosadan gel 0.75% Tier 1 vitazol cre 0.75% Tier 1 Scabicides Pediculicides A-200 GEL 0.33-4% Tier 2 acticin cre 5% Tier 1 72

BARC LIQ Tier 2 EURAX CRE 10% Tier 2 EURAX LOT 10% Tier 2 gnp lice egg gel remover Tier 2 lice egg gel remover Tier 2 lice md gel Tier 2 LICE TRTMNT KIT MAX-STR Tier 2 liceout gel Tier 2 liceout gel /comb Tier 2 LICIDE TREAT KIT Tier 2 lindane lot 1% Tier 1 lindane sha 1% Tier 1 LYCELLE GEL Tier 2 malathion lot 0.5% Tier 1 ST med-lice gel combing Tier 2 nix combing gel Tier 2 NIX LICE SPR CONTROL Tier 2 permethrin cre 5% Tier 1 PRONTO AER 0.4% Tier 2 PYRE/PIPERON LIQ Tier 2 ra lice egg gel remover Tier 2 RID LICE KIL AER MOUSSE Tier 2 spinosad sus 0.9% Tier 3 PA stop lice gel step 2 Tier 2 SULF LIME SOL USP Tier 2 TEGRIN-LT KIT Tier 2 ULESFIA LOT 5% Tier 3 PA Wound Care Products REGRANEX GEL 0.01% Tier 3 PA DIAGNOSTIC PRODUCTS Diagnostic Tests ASCENSIA MIS AUTODISC Tier 2 BAYER BREEZE MIS 2 TEST Tier 2 CLINISTIX TES STRIPS Tier 2 DIASTIX TES STRIPS Tier 2 TRUETEST TES Tier 2 DIGESTIVE AIDS Digestive Enzymes CREON CAP 6000UNIT Tier 2 CREON CAP 12000UNT Tier 2 CREON CAP 24000UNT Tier 2 PANCREAZE CAP 4200UNIT Tier 2 73

PANCREAZE CAP 10500UNT Tier 2 PANCREAZE CAP 16800UNT Tier 2 PANCREAZE CAP 21000UNT Tier 2 pancrelipase cap 5000unit Tier 2 ZENPEP CAP 10000UNT Tier 2 ZENPEP CAP 15000UNT Tier 2 ZENPEP CAP 20000UNT Tier 2 DIURETICS Carbonic Anhydrase Inhibitors acetazolamid cap 500mg er Tier 1 acetazolamid tab 125mg Tier 1 acetazolamid tab 250mg Tier 1 methazolamid tab 25mg Tier 1 methazolamid tab 50mg Tier 1 Diuretic Combinations ALDACTAZIDE TAB 50/50 Tier 2 amilor/hctz tab 5-50 Tier 1 spirono/hctz tab 25/25 Tier 1 triamt/hctz cap 37.5-25 Tier 1 triamt/hctz tab 37.5-25 Tier 1 triamt/hctz tab 75-50mg Tier 1 Loop Diuretics bumetanide tab 0.5mg Tier 1 bumetanide tab 1mg Tier 1 bumetanide tab 2mg Tier 1 EDECRIN TAB 25MG Tier 2 furosemide sol 10mg/ml Tier 1 furosemide tab 20mg Tier 1 furosemide tab 40mg Tier 1 furosemide tab 80mg Tier 1 torsemide tab 5mg Tier 1 torsemide tab 10mg Tier 1 torsemide tab 20mg Tier 1 torsemide tab 100mg Tier 1 Potassium Sparing Diuretics amiloride tab 5mg Tier 1 DYRENIUM CAP 50MG Tier 2 DYRENIUM CAP 100MG Tier 2 spironolact tab 25mg Tier 1 spironolact tab 50mg Tier 1 spironolact tab 100mg Tier 1 Thiazides and Thiazide-Like Diuretics 74

chlorothiaz tab 250mg Tier 1 chlorothiaz tab 500mg Tier 1 chlorthalid tab 25mg Tier 1 chlorthalid tab 50mg Tier 1 chlorthalid tab 100mg Tier 1 hydrochlorot cap 12.5mg Tier 1 hydrochlorot tab 12.5mg Tier 1 hydrochlorot tab 25mg Tier 1 hydrochlorot tab 50mg Tier 1 indapamide tab 1.25mg Tier 1 indapamide tab 2.5mg Tier 1 methyclothia tab 5mg Tier 1 metolazone tab 2.5mg Tier 1 metolazone tab 5mg Tier 1 metolazone tab 10mg Tier 1 THALITONE TAB 15MG Tier 3 ENDOCRINE AND METABOLIC AGENTS - MISC. Bone Density Regulators ACTONEL TAB 5MG Tier 2 ST ACTONEL TAB 30MG Tier 2 ST ACTONEL TAB 35MG Tier 2 ST ACTONEL TAB 150MG Tier 2 ST alendronate tab 5mg Tier 1 alendronate tab 10mg Tier 1 alendronate tab 35mg Tier 1 alendronate tab 40mg Tier 1 alendronate tab 70mg Tier 1 calcitonin spr 200/act Tier 1 etidron disd tab 200mg Tier 1 etidron disd tab 400mg Tier 1 FORTEO SOL 600/2.4 Tier 4 PA FOSAMAX + D TAB 70-2800 Tier 3 FOSAMAX + D TAB 70-5600 Tier 3 ibandronate tab 150mg Tier 1 PA pamidronate inj 30/10ml Tier 4 PA pamidronate inj 30mg Tier 4 PA pamidronate inj 90/10ml Tier 4 PA pamidronate inj 90mg Tier 4 PA SKELID TAB 200MG Tier 2 PA Fertility Regulators chor gonadot inj 10000unt Tier 4 PA novarel inj 10000unt Tier 4 PA 75

pregnyl inj 10000unt Tier 4 PA Growth Hormone Receptor Antagonists SOMAVERT INJ 10MG Tier 4 PA SOMAVERT INJ 15MG Tier 4 PA SOMAVERT INJ 20MG Tier 4 PA Growth Hormones TEV-TROPIN INJ 5MG Tier 4 PA Hormone Receptor Modulators EVISTA TAB 60MG Tier 2 LHRH/GnRH Agonist Analog Pituitary Suppressants LUPR DEP-PED INJ 7.5MG Tier 4 PA LUPR DEP-PED INJ 11.25MG Tier 4 PA LUPR DEP-PED INJ 15MG Tier 4 PA LUPR DEP-PED INJ 30MG Tier 4 PA SYNAREL SOL 2MG/ML Tier 4 PA Metabolic Modifiers BUPHENYL TAB 500MG Tier 4 PA calcitriol cap 0.5mcg Tier 1 calcitriol cap 0.25mcg Tier 1 calcitriol sol 1mcg/ml Tier 1 FABRAZYME INJ 5MG Tier 4 PA HECTOROL CAP 0.5MCG Tier 2 HECTOROL CAP 1MCG Tier 2 HECTOROL CAP 2.5MCG Tier 2 levocarnitin sol 1gm/10ml Tier 1 levocarnitin tab 330mg Tier 1 LUMIZYME INJ 50MG Tier 4 PA MYOZYME INJ 50MG Tier 4 PA ORFADIN CAP 2MG Tier 4 PA ORFADIN CAP 5MG Tier 4 PA ORFADIN CAP 10MG Tier 4 PA SENSIPAR TAB 30MG Tier 4 PA SENSIPAR TAB 60MG Tier 4 PA SENSIPAR TAB 90MG Tier 4 PA Posterior Pituitary Hormones desmopressin inj 4mcg/ml Tier 4 PA desmopressin sol 0.01% Tier 1 PA desmopressin tab 0.1mg Tier 1 desmopressin tab 0.2mg Tier 1 STIMATE SOL 1.5MG/ML Tier 4 PA Prolactin Inhibitors cabergoline tab 0.5mg Tier 1 76

Somatostatic Agents octreotide inj 50mcg/ml Tier 4 PA octreotide inj 100mcg Tier 4 PA octreotide inj 200mcg Tier 4 PA octreotide inj 500mcg Tier 4 PA octreotide inj 1000mcg Tier 4 PA SANDOSTATIN KIT LAR 10MG Tier 4 PA SANDOSTATIN KIT LAR 20MG Tier 4 PA SANDOSTATIN KIT LAR 30MG Tier 4 PA SOMATULINE INJ 60/0.2ML Tier 4 PA SOMATULINE INJ 90/0.3ML Tier 4 PA SOMATULINE INJ 120/.5ML Tier 4 PA Vasopressin Receptor Antagonists SAMSCA TAB 15MG Tier 4 PA SAMSCA TAB 30MG Tier 4 PA ESTROGENS Estrogen Combinations covaryx hs tab Tier 1 covaryx tab Tier 1 eemt hs tab Tier 1 eemt tab Tier 1 essian h.s. tab Tier 1 essian tab Tier 1 est estrogen tab mtest Tier 1 est estrogen tab mtest ds Tier 1 est estrogen tab mtest hs Tier 1 mtest hs/est tab estrogen Tier 1 mtest/est tab estrogen Tier 1 PREMPHASE TAB Tier 2 PREMPRO TAB 0.3-1.5 Tier 2 PREMPRO TAB 0.45-1.5 Tier 2 PREMPRO TAB 0.625-5 Tier 2 PREMPRO TAB.625-2.5 Tier 2 Estrogens ALORA DIS 0.1MG Tier 2 ALORA DIS 0.05MG Tier 2 ALORA DIS 0.025MG Tier 2 ALORA DIS 0.075MG Tier 2 CENESTIN TAB 0.3MG Tier 3 CENESTIN TAB 0.9MG Tier 3 CENESTIN TAB 0.45MG Tier 3 CENESTIN TAB 0.625MG Tier 3 77

CENESTIN TAB 1.25MG Tier 3 DEPO-ESTRADI INJ 5MG/ML Tier 2 PA DIVIGEL GEL 0.5MG Tier 2 PA DIVIGEL GEL 0.25MG Tier 2 PA DIVIGEL GEL 1MG/GM Tier 2 PA ELESTRIN GEL 0.06% Tier 2 PA ENJUVIA TAB 0.3MG Tier 2 ENJUVIA TAB 0.9MG Tier 2 ENJUVIA TAB 0.45MG Tier 2 ENJUVIA TAB 0.625MG Tier 2 ENJUVIA TAB 1.25MG Tier 2 estrad val inj 10mg/ml Tier 1 PA estrad val inj 20mg/ml Tier 1 PA estrad val inj 40mg/ml Tier 1 PA estrad val inj 200mg/5 Tier 1 PA ESTRADERM DIS 0.1MG Tier 2 ESTRADERM DIS 0.05MG Tier 2 estradiol dis 0.1mg Tier 1 estradiol dis 0.05mg Tier 1 estradiol dis 0.06mg Tier 1 estradiol dis 0.025mg Tier 1 estradiol dis 0.075mg Tier 1 estradiol dis 0.0375mg Tier 1 estradiol tab 0.5mg Tier 1 estradiol tab 1mg Tier 1 estradiol tab 2mg Tier 1 ESTRASORB EMU Tier 2 PA ESTROGEL GEL Tier 2 PA estropipate tab 0.75mg Tier 1 estropipate tab 1.5mg Tier 1 estropipate tab 3mg Tier 1 EVAMIST SPR 1.53MG Tier 2 PA FEMTRACE TAB 0.9MG Tier 2 FEMTRACE TAB 0.45MG Tier 2 FEMTRACE TAB 1.8MG Tier 2 MENEST TAB 0.3MG Tier 2 MENEST TAB 0.625MG Tier 2 MENEST TAB 1.25MG Tier 2 MENEST TAB 2.5MG Tier 2 MENOSTAR DIS 14MCG Tier 2 MINIVELLE DIS 0.1MG Tier 2 MINIVELLE DIS 0.05MG Tier 2 MINIVELLE DIS 0.075MG Tier 2 78

MINIVELLE DIS 0.0375MG Tier 2 ortho-est tab 0.625 Tier 1 ortho-est tab 1.25 Tier 1 PREMARIN TAB 0.3MG Tier 2 PREMARIN TAB 0.9MG Tier 2 PREMARIN TAB 0.45MG Tier 2 PREMARIN TAB 0.625MG Tier 2 PREMARIN TAB 1.25MG Tier 2 VIVELLE-DOT DIS 0.1MG Tier 2 VIVELLE-DOT DIS 0.05MG Tier 2 VIVELLE-DOT DIS 0.025MG Tier 2 VIVELLE-DOT DIS 0.075MG Tier 2 VIVELLE-DOT DIS 0.0375MG Tier 2 FLUOROQUINOLONES Fluoroquinolones AVELOX ABC TAB 400MG Tier 3 AVELOX TAB 400MG Tier 3 CIPRO (5%) SUS 250MG/5 Tier 2 CIPRO (10%) SUS 500MG/5 Tier 2 ciprofloxacn tab 100mg Tier 1 ciprofloxacn tab 250mg Tier 1 ciprofloxacn tab 500mg Tier 1 ciprofloxacn tab 750mg Tier 1 FACTIVE TAB 320MG Tier 3 PA levofloxacin sol 25mg/ml Tier 1 levofloxacin tab 250mg Tier 1 levofloxacin tab 500mg Tier 1 levofloxacin tab 750mg Tier 1 NOROXIN TAB 400MG Tier 2 ofloxacin tab 200mg Tier 1 ofloxacin tab 300mg Tier 1 ofloxacin tab 400mg Tier 1 GASTROINTESTINAL AGENTS - MISC. Gallstone Solubilizing Agents ursodiol cap 300mg Tier 1 ursodiol tab 250mg Tier 1 ursodiol tab 500mg Tier 1 Gastrointestinal Chloride Channel Activators AMITIZA CAP 8MCG Tier 3 PA AMITIZA CAP 24MCG Tier 3 PA Gastrointestinal Stimulants metoclopram sol 5mg/5ml Tier 1 79

metoclopram sol 10/10ml Tier 1 metoclopram tab 5mg Tier 1 metoclopram tab 10mg Tier 1 Inflammatory Bowel Agents APRISO CAP 0.375GM Tier 2 ASACOL HD TAB 800MG Tier 2 ASACOL TAB 400MG DR Tier 2 balsalazide cap 750mg Tier 1 CANASA SUP 1000MG Tier 2 CIMZIA KIT Tier 4 PA DIPENTUM CAP 250MG Tier 2 LIALDA TAB 1.2GM Tier 2 mesalamine ene 4gm Tier 1 mesalamine kit 4gm Tier 1 PENTASA CAP 250MG CR Tier 2 PENTASA CAP 500MG CR Tier 2 REMICADE INJ 100MG Tier 4 PA SFROWASA ENE 4GM Tier 3 sulfasalazin tab 500mg Tier 1 sulfasalazin tab 500mg dr Tier 1 sulfazine ec tab 500mg Tier 1 sulfazine tab 500mg Tier 1 Intestinal Acidifiers enulose sol 10gm/15 Tier 1 generlac sol 10gm/15 Tier 1 lactulose sol 10gm/15 10gm/15ml Tier 1 Irritable Bowel Syndrome (IBS) Agents LOTRONEX TAB 0.5MG Tier 3 PA LOTRONEX TAB 1MG Tier 3 PA Peripheral Opioid Receptor Antagonists RELISTOR KIT 12/0.6ML Tier 4 PA Phosphate Binder Agents calc acetate cap 667mg Tier 1 calc acetate tab 667mg Tier 1 FOSRENOL CHW 500MG Tier 3 PA FOSRENOL CHW 750MG Tier 3 PA FOSRENOL CHW 1000MG Tier 3 PA RENAGEL TAB 400MG Tier 2 ST RENAGEL TAB 800MG Tier 2 ST RENVELA PAK 0.8GM Tier 2 ST RENVELA PAK 2.4GM Tier 2 ST RENVELA TAB 800MG Tier 2 ST 80

GENITOURINARY AGENTS - MISCELLANEOUS Alkalinizers cytra-k sol Tier 1 k citrate sol citr acd Tier 1 pot citrate tab 540mg Tier 1 pot citrate tab 1080mg Tier 1 UROCIT-K 15 TAB Tier 2 Cystinosis Agents CYSTAGON CAP 50MG Tier 3 PA CYSTAGON CAP 150MG Tier 3 PA Genitourinary Irrigants argyl saline sol 0.9% Tier 1 PA curity salin sol 0.9% irr Tier 1 PA sodium chlor sol 0.9% irr Tier 1 PA Interstitial Cystitis Agents ELMIRON CAP 100MG Tier 3 Prostatic Hypertrophy Agents alfuzosin tab 10mg Tier 1 AVODART CAP 0.5MG Tier 2 finasteride tab 5mg Tier 1 RAPAFLO CAP 4MG Tier 3 RAPAFLO CAP 8MG Tier 3 tamsulosin cap 0.4mg Tier 1 Urinary Analgesics phenazo tab 200mg Tier 1 phenazopyrid tab 100mg Tier 1 phenazopyrid tab 200mg Tier 1 GOUT AGENTS Gout Agent Combinations proben/colch tab 500-0.5 Tier 1 Gout Agents allopurinol tab 100mg Tier 1 allopurinol tab 300mg Tier 1 COLCRYS TAB 0.6MG Tier 3 ULORIC TAB 40MG Tier 3 PA ULORIC TAB 80MG Tier 3 PA Uricosurics probenecid tab 500mg Tier 1 HEMATOLOGICAL AGENTS - MISC. Hematorheologic Agents pentoxifylli tab 400mg er Tier 1 81

Platelet Aggregation Inhibitors AGGRENOX CAP 25-200MG Tier 2 anagrelide cap 0.5mg Tier 1 anagrelide cap 1mg Tier 1 cilostazol tab 50mg Tier 1 cilostazol tab 100mg Tier 1 clopidogrel tab 75mg Tier 1 clopidogrel tab 300mg Tier 1 dipyridamole tab 25mg Tier 1 dipyridamole tab 50mg Tier 1 dipyridamole tab 75mg Tier 1 EFFIENT TAB 5MG Tier 3 PA EFFIENT TAB 10MG Tier 3 PA ticlopidine tab 250mg Tier 1 HEMATOPOIETIC AGENTS Agents for Gaucher Disease ELELYSO INJ 200UNIT Tier 4 PA VPRIV INJ 400UNIT Tier 4 PA ZAVESCA CAP 100MG Tier 4 PA Folic Acid/Folates fa-8 tab 0.8mg Tier 0 folic acid tab 1mg Tier 1 folic acid tab 400mcg Tier 0 folic acid tab 800mcg Tier 0 folic acid tab 1000mcg Tier 1 sm folic acd tab 400mcg Tier 0 yl folic aci tab 400mcg Tier 0 Hematopoietic Growth Factors EPOGEN INJ 2000/ML Tier 4 PA EPOGEN INJ 3000/ML Tier 4 PA EPOGEN INJ 4000/ML Tier 4 PA EPOGEN INJ 10000/ML Tier 4 PA EPOGEN INJ 20000/ML Tier 4 PA LEUKINE INJ 250MCG Tier 4 PA NEUPOGEN INJ 300/0.5 Tier 4 PA NEUPOGEN INJ 300MCG Tier 4 PA NEUPOGEN INJ 480/0.8 Tier 4 PA NEUPOGEN INJ 480MCG Tier 4 PA PROCRIT INJ 2000/ML Tier 4 PA PROCRIT INJ 3000/ML Tier 4 PA PROCRIT INJ 4000/ML Tier 4 PA PROCRIT INJ 10000/ML Tier 4 PA 82

PROCRIT INJ 20000/ML Tier 4 PA PROCRIT INJ 40000/ML Tier 4 PA Hematopoietic Mixtures ferrocite tab plus Tier 1 hematinic pl tab vit/min Tier 1 hematinic/fa tab Tier 1 hemocyte tab -plus Tier 1 hemocyte-f tab Tier 1 Iron fer-iron dro 15mg/ml Tier 0 ferrous dro 15mg/ml Tier 0 ferrous sulf dro 15mg/ml Tier 0 ferrous sulf elx 220/5ml Tier 0 iron supplmt dro 15mg/ml Tier 0 wee care sus 15/1.25 Tier 0 HEMOSTATICS Hemostatics - Systemic aminocapr ac syp 25% Tier 1 aminocapr ac tab 500mg Tier 1 aminocapr ac tab 1000mg Tier 1 tranexamic inj acid Tier 4 PA HYPNOTICS Barbiturate Hypnotics phenobarb elx 20mg/5ml Tier 1 phenobarb sol 20mg/5ml Tier 1 phenobarb tab 15mg Tier 1 phenobarb tab 16.2mg Tier 1 phenobarb tab 30mg Tier 1 phenobarb tab 32.4mg Tier 1 phenobarb tab 60mg Tier 1 phenobarb tab 64.8mg Tier 1 phenobarb tab 97.2mg Tier 1 phenobarb tab 100mg Tier 1 Non-Barbiturate Hypnotics chloral hydr syp 500/5ml Tier 1 DORAL TAB 15MG Tier 2 estazolam tab 1mg Tier 1 estazolam tab 2mg Tier 1 flurazepam cap 15mg Tier 1 flurazepam cap 30mg Tier 1 LUNESTA TAB 1MG Tier 3 PA LUNESTA TAB 2MG Tier 3 PA 83

LUNESTA TAB 3MG Tier 3 PA SOMNOTE CAP 500MG Tier 2 temazepam cap 7.5mg Tier 1 PA temazepam cap 15mg Tier 1 temazepam cap 30mg Tier 1 triazolam tab 0.25mg Tier 1 triazolam tab 0.125mg Tier 1 zaleplon cap 5mg Tier 1 zaleplon cap 10mg Tier 1 zolpidem tab 5mg Tier 1 zolpidem tab 10mg Tier 1 Selective Melatonin Receptor Agonists ROZEREM TAB 8MG Tier 3 PA LAXATIVES Laxative Combinations COLYTE/FLAVR SOL PACKS Tier 2 gavilyte-c sol Tier 1 gavilyte-g sol Tier 1 gavilyte-n sol flav pk Tier 1 MOVIPREP SOL Tier 2 peg 3350 sol electrol Tier 1 peg-3350 sol electrol Tier 1 peg-3350/kcl sol /sodium Tier 1 PREPOPIK PAK Tier 2 trilyte sol Tier 1 Laxatives - Miscellaneous clearlax pow Tier 1 constulose sol 10gm/15 Tier 1 cvs purelax pow Tier 1 cvs purelax pow 3350 nf Tier 1 dulcolax pow balance Tier 1 eql clearlax pow Tier 1 gavilax pow Tier 1 gentlelax pow Tier 1 glycolax pow 3350 nf Tier 1 gnp clearlax pow Tier 1 healthylax pow Tier 1 hm clearlax pow Tier 1 lactulose sol 10gm/15 10gm/15ml Tier 1 lactulose sol 20gm/30 Tier 1 laxaclear pow Tier 1 natura-lax pow 3350 nf Tier 1 84

peg 3350 pow Tier 1 polyeth glyc pow 3350 nf Tier 1 polyeth glyc pow 3350-grx Tier 1 ra laxative pow Tier 1 sm clearlax pow Tier 1 smooth lax pow Tier 1 smooth lax pow 3350 nf Tier 1 sw clearlax pow Tier 1 Saline Laxatives OSMOPREP TAB 1.5GM Tier 2 VISICOL TAB 1.5GM Tier 2 MACROLIDES Azithromycin azithromycin pow 1gm pak Tier 1 azithromycin sus 100/5ml Tier 1 azithromycin sus 200/5ml Tier 1 azithromycin tab 250mg Tier 1 azithromycin tab 500mg Tier 1 azithromycin tab 600mg Tier 1 ZMAX SUS 2GM Tier 2 PA Clarithromycin clarithromyc sus 125/5ml Tier 1 clarithromyc sus 250/5ml Tier 1 clarithromyc tab 250mg Tier 1 clarithromyc tab 500mg Tier 1 Erythromycins e.e.s. 400 tab 400mg Tier 1 E.E.S. GRAN SUS 200/5ML Tier 2 ERY-TAB TAB 250MG EC Tier 2 ERY-TAB TAB 333MG EC Tier 2 ERY-TAB TAB 500MG EC Tier 2 ERYPED SUS 200/5ML Tier 2 ERYPED SUS 400/5ML Tier 2 erythrocin tab 250mg Tier 1 erythrom eth tab 400mg Tier 1 erythromycin cap 250mg ec Tier 1 erythromycin tab 250mg bs Tier 1 erythromycin tab 500mg bs Tier 1 PCE TAB 333MG EC Tier 2 PCE TAB 500MG EC Tier 2 Fidaxomicin DIFICID TAB 200MG Tier 3 PA 85

MEDICAL DEVICES Contraceptives CONDOMS MIS Tier 2 FC2 FEMALE MIS CONDOM Tier 0 FC FEMALE MIS CONDOM Tier 0 FEMCAP MIS 22MM Tier 0 FEMCAP MIS 26MM Tier 0 FEMCAP MIS 30MM Tier 0 LIFESTYLES MIS COLORS Tier 2 LIFESTYLES MIS EXT STR Tier 2 LIFESTYLES MIS FORM FIT Tier 2 LIFESTYLES MIS LUBRICAT Tier 2 LIFESTYLES MIS RIBBED Tier 2 LIFESTYLES MIS SPERM/LU Tier 2 LIFESTYLES MIS STUDDED Tier 2 LIFESTYLES MIS ULT/SENS Tier 2 LIFESTYLES MIS VIBRA-RI Tier 2 LIFESTYLES MIS XPLEASUR Tier 2 OMNIFLEX DPR Tier 0 ORTHO COIL DPR KIT 50 Tier 0 ORTHO COIL DPR KIT 100 Tier 0 ORTHO COIL DPR KIT 105 Tier 0 ORTHO FLAT DPR KIT 55 Tier 0 ORTHO FLAT DPR KIT 60 Tier 0 ORTHO FLAT DPR KIT 65 Tier 0 ORTHO FLAT DPR KIT 70 Tier 0 ORTHO FLAT DPR KIT 75 Tier 0 ORTHO FLAT DPR KIT 80 Tier 0 ORTHO FLAT DPR KIT 85 Tier 0 ORTHO FLAT DPR KIT 90 Tier 0 ORTHO FLAT DPR KIT 95 Tier 0 ORTHO FLEX DPR 65MM Tier 0 ORTHO FLEX DPR 70MM Tier 0 ORTHO FLEX DPR 75MM Tier 0 ORTHO FLEX DPR 80MM Tier 0 PARAGARD IUD T380A Tier 0 PRENTIF MIS 22MM Tier 0 PRENTIF MIS 25MM Tier 0 PRENTIF MIS 28MM Tier 0 PRENTIF MIS 31MM Tier 0 PRENTIF MIS FITTING Tier 0 TODAY SPONGE MIS Tier 0 86

TROJAN MIS NAT LAMB Tier 2 WIDE-SEAL DPR KIT 60 Tier 0 WIDE-SEAL DPR KIT 65 Tier 0 WIDE-SEAL DPR KIT 70 Tier 0 WIDE-SEAL DPR KIT 75 Tier 0 WIDE-SEAL DPR KIT 80 Tier 0 WIDE-SEAL DPR KIT 85 Tier 0 WIDE-SEAL DPR KIT 90 Tier 0 WIDE-SEAL DPR KIT 95 Tier 0 Diabetic Supplies LANCETS DME TRUERESULT KIT DME Misc. Devices ALCOHOL SWABS Tier 2 Parenteral Therapy Supplies BD NEEDLE MIS 27GX1.25 DME BD NEEDLES MIS 27GX1/2" DME HYPO NEEDLE MIS 27GX1.5" DME HYPO NEEDLE MIS 27GX1.25 DME HYPO NEEDLE MIS 27GX1/2" DME INSULIN PEN NEEDLES DME INSULIN SYRINGES DME POLY HUB MIS 27GX1.25 DME POLY HUB MIS 27GX1/2" DME PRECISIONGLI MIS 27GX1.5" DME SAFETYGLIDE MIS 27GX5/8" DME SURGUARD2 MIS 27GX1/2" DME Respiratory Therapy Supplies AEROCHAMBER KIT ACTION Tier 2 INSPIREASE MIS BAGS Tier 2 INSPIREASE MIS MOUTHPCE Tier 2 QL INSPIREASE MIS REP MOUT Tier 2 QL INSPIREASE MIS RES BAG Tier 2 SPACERS DEVI Tier 2 SPACERS DEVI Tier 2 QL SPACERS MISC Tier 2 SPACERS MISC Tier 2 QL MIGRAINE PRODUCTS Migraine Combinations epidrin cap Tier 1 isometh/apap cap dichlor Tier 1 MIGERGOT SUP 2/100 Tier 2 87

migragesic cap ida Tier 1 nodolor cap Tier 1 Migraine Products dihydroergot inj 1mg/ml Tier 1 PA ERGOMAR SUB 2MG Tier 2 Serotonin Agonists AXERT TAB 6.25MG Tier 3 PA AXERT TAB 12.5MG Tier 3 PA FROVA TAB 2.5MG Tier 3 PA naratriptan tab 1mg Tier 1 ST; QL naratriptan tab 2.5mg Tier 1 ST; QL RELPAX TAB 20MG Tier 2 ST; QL RELPAX TAB 40MG Tier 2 ST; QL rizatriptan tab 5mg Tier 1 ST; QL rizatriptan tab 10mg Tier 1 ST; QL sumatriptan inj 4mg/0.5 Tier 1 PA sumatriptan inj 6mg/0.5 Tier 1 PA; QL sumatriptan spr 5mg/act Tier 1 QL sumatriptan spr 20mg/act Tier 1 QL sumatriptan tab 25mg Tier 1 QL sumatriptan tab 50mg Tier 1 QL sumatriptan tab 100mg Tier 1 QL zolmitriptan tab 2.5 mg Tier 2 ST; QL zolmitriptan tab 2.5mg Tier 2 ST; QL zolmitriptan tab 5mg Tier 2 ST; QL ZOMIG SPR 5MG Tier 2 ST MINERALS ELECTROLYTES Electrolyte Mixtures baby darlng sol ped elec Tier 1 cvs electrol sol Tier 1 gnp pediatri sol electrol Tier 1 naturalyte sol bubblegm Tier 1 naturalyte sol fruit Tier 1 naturalyte sol grape Tier 1 naturalyte sol unflavor Tier 1 oralyte sol Tier 1 oralyte sol freeze Tier 1 pc ped elect sol fruit Tier 1 pc ped elect sol grape Tier 1 pc pediatric sol electrol Tier 1 ped elctrlyt sol Tier 1 ped elctrlyt sol /zinc Tier 1 88

ped elctrlyt sol apple Tier 1 ped elctrlyt sol bubblegm Tier 1 ped elctrlyt sol bubblgum Tier 1 ped elctrlyt sol freeze Tier 1 ped elctrlyt sol freezer Tier 1 ped elctrlyt sol freezpop Tier 1 ped elctrlyt sol fruit Tier 1 ped elctrlyt sol grape Tier 1 ped elctrlyt sol mango Tier 1 ped elctrlyt sol strawbry Tier 1 ped elctrlyt sol unflavor Tier 1 ped elctrlyt sol unflavrd Tier 1 pedia vance sol apple Tier 1 pedia vance sol grape Tier 1 ra pediatric sol electrol Tier 1 rehydralyte sol Tier 1 revital frzr sol pops Tier 1 revital jell sol cups Tier 1 revital lqd sol squeezer Tier 1 Fluoride epiflur chw 0.5mg f Tier 0 epiflur chw 0.25mg f Tier 0 epiflur chw 1mg f Tier 1 fluor-a-day dro 0.125mg Tier 0 fluoride chw 0.5mg f Tier 0 fluoride chw 0.25mg f Tier 0 fluoride chw 1mg f Tier 1 fluoritab chw 0.5mg f Tier 0 fluoritab chw 0.25mg f Tier 0 fluoritab chw 1mg f Tier 1 fluoritab chw 2.2mg Tier 1 fluoritab dro 0.125mg Tier 0 flura-drops dro 0.25mg f Tier 0 flura-drops dro 0.125mg Tier 0 karidium dro 0.125mg Tier 0 ludent chw 0.5mg f Tier 0 ludent chw 0.25mg f Tier 0 ludent chw 1mg f Tier 1 nafrinse chw 1mg f Tier 1 nafrinse dro 0.125mg Tier 0 sod fluoride chw 0.5mg f Tier 0 sod fluoride chw 0.25mg f Tier 0 sod fluoride chw 1.1mg Tier 0 89

sod fluoride chw 1mg f Tier 1 sod fluoride chw 2.2mg Tier 1 sod fluoride dro 0.5mg/ml Tier 0 sod fluoride tab 0.5mg f Tier 0 sod fluoride tab 1mg f Tier 1 Iodine Products SSKI SOL 1GM/ML Tier 2 Magnesium magnesium su inj 50% Tier 1 PA Phosphate phospha 250 tab neutral Tier 1 Potassium effer-k tab 25meq ef Tier 1 epiklor pow 20meq Tier 1 epiklor/25 pow 25meq Tier 1 k-effervesce tab 25meq ef Tier 1 k-prime tab 25meq ef Tier 1 k-vescent pow 20meq Tier 1 k-vescent tab 25meq ef Tier 1 klor-con 8 tab 8meq er Tier 1 klor-con 10 tab 10meq er Tier 1 klor-con m10 tab 10meq er Tier 1 KLOR-CON M15 TAB Tier 2 klor-con m20 tab 20meq er Tier 1 klor-con pow 20meq Tier 1 klor-con/ef tab 25meq fr Tier 1 pot bicarbon tab 25meq ef Tier 1 pot chloride cap 8meq er Tier 1 pot chloride cap 10meq er Tier 1 pot chloride liq 10% Tier 1 pot chloride liq 20% Tier 1 pot chloride liq 20% sf Tier 1 pot chloride sol 10% sf Tier 1 pot chloride tab 8meq er Tier 1 pot chloride tab 8meq sr Tier 1 pot chloride tab 10meq cr Tier 1 pot chloride tab 10meq er Tier 1 pot cl micro tab 10meq cr Tier 1 pot cl micro tab 10meq er Tier 1 pot cl micro tab 20meq er Tier 1 potassium tab 25meq ef Tier 1 Sodium flush syring inj 0.9% Tier 1 PA 90

sod chloride inj 0.9% Tier 1 PA sod chloride inj 0.45% Tier 1 PA sod chloride inj 2.5/ml Tier 1 PA sod chloride inj 3% Tier 1 PA sod chloride inj 5% Tier 1 PA Zinc orazinc cap 220mg Tier 1 zinc sulfate cap 220mg Tier 1 zinc-220 cap Tier 1 zincate cap 220mg Tier 1 MOUTH/THROAT/DENTAL AGENTS Anesthetics Topical Oral lidocaine sol 2% visc Tier 1 Anti-infectives - Throat clotrimazole loz 10mg Tier 1 clotrimazole tro 10mg Tier 1 nystatin sus 100000 Tier 1 ORAVIG TAB 50MG Tier 3 Antiallergy Agents - Mouth/Throat APHTHASOL PST 5% Tier 2 Antiseptics - Mouth/Throat chlorhex glu sol 0.12% Tier 1 periogard sol 0.12% Tier 1 Steroids - Mouth/Throat oralone pst 0.1% Tier 1 triamcin/ora pst 0.1% Tier 1 triamcinolon pst 0.1% Tier 1 Throat Products - Misc. cevimeline cap 30mg Tier 1 pilocarpine tab 5mg Tier 1 pilocarpine tab 7.5mg Tier 1 MULTIVITAMINS B-Complex w/ Folic Acid BIOTIN FORTE TAB Tier 1 dialyvite tab Tier 1 dialyvite tab 800 Tier 1 folbee plus tab Tier 1 FULL SPECT TAB B/ VIT C Tier 1 nephronex tab 1mg Tier 1 rena-vite rx tab Tier 1 rena-vite tab Tier 1 renal tab multivit Tier 1 91

virt-vite tab plus Tier 1 vol-care rx tab Tier 1 Multivitamins anti-oxidant tab Tier 1 cvs daily tab multiple Tier 1 daily multi tab vitamin Tier 1 daily multi tab vitamins Tier 1 daily tab vitamin Tier 1 daily value tab multivit Tier 1 daily vit tab Tier 1 daily vite tab Tier 1 daily-vitamn tab Tier 1 e/c/beta car tab Tier 1 eql one dail tab essentia Tier 1 essentl one tab daily Tier 1 mult vitamin tab daily Tier 1 mult vitamin tab essent Tier 1 mult vitamin tab mens Tier 1 multi-day tab Tier 1 multi-vit tab Tier 1 multi-vitamn tab Tier 1 multiple vit tab Tier 1 multiple vit tab folic Tier 1 once daily tab Tier 1 one daily tab Tier 1 one daily tab essent Tier 1 one daily tab essentl Tier 1 one-daily tab mult vit Tier 1 qc essential tab Tier 1 ra one daily tab essentia Tier 1 ra one daily tab multivit Tier 1 renal/zinc tab multivit Tier 1 sigtab tab Tier 1 sm multiple tab vitamins Tier 1 stress form tab Tier 1 stress form tab 500/biot Tier 1 stress formu tab Tier 1 tab-a-vite tab Tier 1 tab-a-vite tab beta car Tier 1 thera tab Tier 1 thera-mill tab Tier 1 thera-tabs tab Tier 1 therapeutic tab Tier 1 92

therems tab Tier 1 vigomar tab Tier 1 vimar hp tab Tier 1 vitalee tab Tier 1 Ped MV w/ Fluoride acd/fluoride dro 0.25mg Tier 1 mult-vit/fl chw 0.5mg Tier 1 multi-vit/fl chw 0.5mg Tier 1 multi-vit/fl chw 0.25mg Tier 1 multi-vit/fl chw 1mg Tier 1 multi-vit/fl dro 0.5mg/ml Tier 1 multi-vit/fl dro 0.25mg Tier 1 multivit/fl chw 0.5mg Tier 1 multivit/fl chw 0.25mg Tier 1 multivit/fl chw 1mg Tier 1 mvc-fluoride chw 0.5mg Tier 1 mvc-fluoride chw 0.25mg Tier 1 mvc-fluoride chw 1mg Tier 1 poly-vi-flor chw 0.5mg Tier 1 poly-vi-flor chw 0.25mg Tier 1 poly-vi-flor chw 1mg Tier 1 poly-vit/fl dro 0.25mg Tier 1 polyvit/fl dro 0.5mg/ml Tier 1 tri-vit/fl dro 0.5mg Tier 1 tri-vit/fl dro 0.25mg Tier 1 tri-vit/fluo dro 0.5mg Tier 1 tri-vit/fluo dro 0.25mg Tier 1 tri-vita/fl dro 0.25mg Tier 1 Ped Multi Vitamins w/fl FE multi-vit/fe dro /fl 0.25 Tier 1 multi-vit/fl dro /fe 0.25 Tier 1 POLY-VI-FLOR CHW W/IRON Tier 2 poly-vit/fe dro /fl 0.5 Tier 1 poly-vit/fe dro /fl 0.25 Tier 1 tri-vit/fe dro /fl 0.25 Tier 1 Prenatal Vitamins CL PRENATAL TAB 28-0.8MG Tier 2 COMPLETE-RF TAB PRENATAL Tier 2 COMPLETENATE CHW Tier 2 CONCEPT DHA CAP Tier 2 CONCEPT OB CAP Tier 2 CVS PRENATAL TAB Tier 2 CVS PRENATAL TAB 28-0.8MG Tier 2 93

EQL PRENATAL TAB FORMULA Tier 2 FOLIVANE-OB CAP Tier 2 GNP PRENATAL TAB 28-0.8MG Tier 2 HM PRENATAL TAB Tier 2 KP PRENATAL TAB MULTIVIT Tier 2 M-VIT TAB 27-1MG Tier 2 MULTI PRENAT TAB Tier 2 NATAL-V RX TAB 29-1MG Tier 2 O-CAL FA TAB Tier 2 PNV FOLIC AC TAB + IRON Tier 2 PNV PRENATAL TAB PLUS Tier 2 prenaplus tab Tier 1 prenatabs rx tab Tier 1 PRENATAL 19 CHW 29-1MG Tier 2 prenatal 19 chw tab Tier 1 prenatal 19 tab Tier 1 PRENATAL 19 TAB 29-1MG Tier 2 PRENATAL ONE TAB DAILY Tier 2 PRENATAL TAB Tier 2 PRENATAL TAB 27-0.8MG Tier 2 PRENATAL TAB 27-1MG Tier 2 PRENATAL TAB 28-0.8MG Tier 2 PRENATAL TAB COMPLETE Tier 2 PRENATAL TAB FORMULA Tier 2 PRENATAL TAB LOW IRON Tier 2 PRENATAL TAB PLUS Tier 2 prenatal tab plus fe Tier 1 PRENATAL VIT TAB PLUS Tier 2 PRENATAL+DHA MIS Tier 2 PRENATAL+DHA MIS WOMENS Tier 2 PRENATAL+FE TAB 29-1MG Tier 2 PRENATAL-U CAP Tier 2 PX PRENATAL TAB MULTIVIT Tier 2 QC PRENATAL TAB 28-0.8MG Tier 2 RA PRENATAL TAB 28-0.8MG Tier 2 RA PRENATAL TAB FORMULA Tier 2 RIGHT STEP TAB PRENATAL Tier 2 SE-NATAL 19 CHW Tier 2 SE-NATAL 19 TAB Tier 2 SE-NATAL ONE TAB Tier 2 SM PRENATAL TAB VITAMINS Tier 2 STUART PREN TAB Tier 2 TARON-C DHA CAP Tier 2 94

TH PRENATAL TAB VITAMINS Tier 2 THERANATAL TAB 27-1 Tier 2 TRICARE TAB PRENATAL Tier 2 TRINATAL RX TAB 1 Tier 2 TRIVEEN-U CAP Tier 2 VINATE AZ EX TAB Tier 2 VINATE II TAB Tier 2 VINATE ONE TAB Tier 2 VOL-PLUS TAB Tier 2 VOL-TAB RX TAB Tier 2 MUSCULOSKELETAL THERAPY AGENTS Central Muscle Relaxants baclofen tab 10mg Tier 1 baclofen tab 20mg Tier 1 carisoprodol tab 350mg Tier 1 chlorzoxazon tab 500mg Tier 1 cyclobenzapr tab 5mg Tier 1 cyclobenzapr tab 10mg Tier 1 ed baclofen tab 10mg Tier 1 LORZONE TAB 375MG Tier 2 LORZONE TAB 750MG Tier 2 metaxalone tab 800mg Tier 1 methocarbam tab 500mg Tier 1 methocarbam tab 750mg Tier 1 orphenadrine tab 100mg er Tier 1 ROBAXIN INJ 100MG/ML Tier 4 PA tizanidine cap 2mg Tier 1 tizanidine cap 4mg Tier 1 tizanidine cap 6mg Tier 1 tizanidine tab 2mg Tier 1 tizanidine tab 4mg Tier 1 Direct Muscle Relaxants dantrolene cap 25mg Tier 1 dantrolene cap 50mg Tier 1 dantrolene cap 100mg Tier 1 Muscle Relaxant Combinations carisopr/asa tab 200-325 Tier 1 carisoprodol tab asa/cod Tier 1 orph/asa/caf tab Tier 1 orphen cpd tab ds Tier 1 NASAL AGENTS - SYSTEMIC AND TOPICAL Nasal Anti-infectives 95

BACTROBAN OIN NASAL 2% Tier 2 Nasal Antiallergy ASTEPRO SPR 0.15% Tier 2 azelastine spr 0.1% Tier 1 Nasal Steroids flunisolide spr 0.025% Tier 1 flunisolide spr 29mcg Tier 1 fluticasone spr 50mcg Tier 1 NASONEX SPR 50MCG/AC Tier 2 ST triamcinolon spr 55mcg/ac Tier 1 Sympathomimetic Decongestants congest aid tab 30mg Tier 1 congestion tab 30mg Tier 1 decongestant tab 30mg Tier 1 decongestant tab 60mg Tier 1 eq suphedrin tab 30mg Tier 1 genaphed tab 30mg Tier 1 medi-phedrin tab 30mg Tier 1 nasal decon syp 30mg/5ml Tier 1 nasal decong tab 30mg Tier 1 NEO-SYNEPHRI SPR 0.5% Tier 2 pseudoephedr syp 30mg/5ml Tier 1 pseudoephedr tab 30mg Tier 1 pseudoephedr tab 60mg Tier 1 psudatabs tab 30mg Tier 1 ra suphedrin tab 30mg Tier 1 sb pseudophe tab 30mg Tier 1 simply stuff tab 30mg Tier 1 sm nasal dec tab 30mg Tier 1 sudanyl tab 30mg Tier 1 sudogest tab 30mg Tier 1 sudogest tab 60mg Tier 1 sudophed tab 30mg Tier 1 suphedrine tab 30mg Tier 1 sw nasal dec tab 30mg Tier 1 TYZINE PED DRO 0.05% Tier 2 TYZINE SOL 0.1% Tier 2 wal-phed tab 30mg Tier 1 NEUROMUSCULAR AGENTS ALS Agents RILUTEK TAB 50MG Tier 2 riluzole tab 50mg Tier 2 96

OPHTHALMIC AGENTS Artificial Tears and Lubricants LACRISERT MIS 5MG OP Tier 3 PA Beta-blockers - Ophthalmic betaxolol sol 0.5% op Tier 1 BETIMOL SOL 0.5% Tier 2 BETIMOL SOL 0.25% Tier 2 BETOPTIC-S SUS 0.25% OP Tier 2 carteolol sol 1% op Tier 1 COMBIGAN SOL 0.2/0.5% Tier 2 COSOPT PF SOL Tier 2 dorzol/timol sol 2-0.5%op Tier 1 ISTALOL SOL 0.5% OP Tier 2 levobunolol sol 0.5% op Tier 1 levobunolol sol 0.25% op Tier 1 metipranolol sol 0.3% Tier 1 metipranolol sol 0.3% oph Tier 1 timolol gel sol 0.5% op Tier 1 timolol gel sol 0.25% op Tier 1 timolol mal sol 0.5% op Tier 1 timolol mal sol 0.25% op Tier 1 TIMOPTIC OCU SOL 0.5% OP Tier 2 TIMOPTIC OCU SOL 0.25% OP Tier 2 Cycloplegic Mydriatics ak-pentolate sol 1% op Tier 1 atropin-care sol 1% op Tier 1 ATROPINE SUL OIN 1% OP Tier 2 atropine sul sol 1% op Tier 1 CYCLOGYL SOL 0.5% OP Tier 2 cyclopentol sol 1% op Tier 1 cyclopentol sol 2% op Tier 1 cylate sol 1% op Tier 1 homatropaire sol 5% op Tier 1 homatropine sol 5% op Tier 1 ISO HOMATROP SOL 2% OP Tier 2 ISO HYOSCINE SOL 0.25% OP Tier 2 mydral sol 0.5% op Tier 1 mydral sol 1% op Tier 1 tropicamide sol 0.5% op Tier 1 tropicamide sol 1% op Tier 1 Miotics ISO CARBACHO SOL 1.5% OP Tier 2 97

ISO CARBACHO SOL 3% OP Tier 2 PHOSPHOLINE SOL 0.125%OP Tier 2 pilocarpine sol 1% op Tier 1 pilocarpine sol 2% op Tier 1 pilocarpine sol 4% op Tier 1 PILOPINE HS GEL 4% OP Tier 2 Ophthalmic Adrenergic Agents ALPHAGAN P SOL 0.1% Tier 2 apraclonidin sol 0.5% op Tier 1 brimonidine sol 0.2% op Tier 1 brimonidine sol 0.15% Tier 1 IOPIDINE SOL 1% OP Tier 2 Ophthalmic Anti-infectives ak-poly-bac oin op Tier 1 bacit/polymy oin op Tier 1 bacitracin oin op Tier 1 BESIVANCE SUS 0.6% Tier 3 PA BETADINE SOL 5% OP Tier 2 ciprofloxacn sol 0.3% op Tier 1 erythromycin oin 5mg/gm Tier 1 erythromycin oin op Tier 1 garamycin oin 0.3% op Tier 1 gentak oin 0.3% op Tier 1 gentak sol 0.3% op Tier 1 gentamicin oin 0.3% op Tier 1 gentamicin sol 0.3% op Tier 1 gentasol sol 0.3% op Tier 1 ilotycin oin op Tier 1 levofloxacin sol 0.5% Tier 1 NATACYN SUS 5% OP Tier 2 neo-polycin oin op Tier 1 neo/bac/poly oin op Tier 1 neo/poly/gra sol op Tier 1 ofloxacin dro 0.3% op Tier 1 polycin b oin op Tier 1 polycin oin op Tier 1 polymyxin b/ sol trimethp Tier 1 romycin oin op Tier 1 sod sulfacet sol 10% op Tier 1 sulfacet sod oin 10% op Tier 1 sulfacet sod sol 10% op Tier 1 tobramycin sol 0.3% op Tier 1 tobrasol sol 0.3% op Tier 1 98

TOBREX OIN 0.3% OP Tier 2 trifluridine sol 1% op Tier 1 trimethoprim sol polymyxn Tier 1 ZIRGAN GEL 0.15% Tier 3 PA ZYMAXID SOL 0.5% Tier 3 PA Ophthalmic Decongestants naphazoline sol 0.1% op Tier 1 Ophthalmic Immunomodulators RESTASIS EMU 0.05% Tier 3 PA Ophthalmic Local Anesthetics parcaine sol 0.5% op Tier 1 proparacaine sol 0.5% op Tier 1 Ophthalmic Steroids ALREX SUS 0.2% Tier 3 BLEPHAMIDE OIN S.O.P. Tier 2 BLEPHAMIDE SUS OP Tier 2 dexameth pho sol 0.1% op Tier 1 DUREZOL EMU 0.05% Tier 2 FLAREX SUS 0.1% OP Tier 2 fluor-op sus 0.1% op Tier 1 fluoromethol sus 0.1% op Tier 1 FML FORTE SUS 0.25% OP Tier 2 FML OIN 0.1% OP Tier 2 LOTEMAX SUS 0.5% Tier 3 MAXIDEX SUS 0.1% OP Tier 2 neo-polycin oin hc 1%op Tier 1 neo/poly/bac oin /hc 1%op Tier 1 neo/poly/dex oin 0.1% op Tier 1 neo/poly/dex sus 0.1% op Tier 1 neo/poly/hc sus op Tier 1 poly-dex oin 0.1% op Tier 1 PRED MILD SUS 0.12% OP Tier 2 PRED SOD PHO SOL 1% OP Tier 2 prednisolone sus 1% op Tier 1 sulf/pred na sol op Tier 1 tobra/dexame sus 0.3-0.1% Tier 1 TOBRADEX OIN 0.3-0.1% Tier 2 TOBRADEX ST SUS 0.3-0.05 Tier 2 VEXOL SUS 1% OP Tier 2 Ophthalmics - Misc. ACUVAIL SOL 0.45% Tier 2 ALAMAST DRO 0.1% Tier 3 alaway child dro 0.025%op Tier 1 99

alaway dro 0.025%op Tier 1 allergy eye dro 0.025%op Tier 1 ALOCRIL SOL 2% Tier 3 ALOMIDE SOL 0.1% OP Tier 2 antihistamin dro 0.025%op Tier 1 azelastine dro 0.05% Tier 1 AZOPT SUS 1% OP Tier 2 BEPREVE DRO 1.5% Tier 3 bromfenac sol 0.09% Tier 1 claritin eye dro 0.025%op Tier 1 cromolyn sod sol 4% op Tier 1 cvs allergy dro 0.025%op Tier 1 diclofenac sol 0.1% op Tier 1 dorzolamide sol 2% op Tier 1 EMADINE SOL 0.05% OP Tier 2 epinastine dro 0.05% Tier 1 eq itchy eye dro 0.025%op Tier 1 eye itch rel dro 0.025%op Tier 1 flurbiprofen sol 0.03% op Tier 1 itchy eye dro 0.025%op Tier 1 ketorolac sol 0.4% Tier 1 ketorolac sol 0.5% Tier 1 ketotif fum dro 0.025%op Tier 1 NEVANAC SUS 0.1% Tier 2 PATADAY SOL 0.2% Tier 3 PA PATANOL SOL 0.1% OP Tier 2 ST wal-zyr dro 0.025%op Tier 1 zyrtec itchy dro 0.025%op Tier 1 Prostaglandins - Ophthalmic latanoprost sol 0.005% Tier 1 LUMIGAN SOL 0.03% Tier 2 TRAVATAN Z DRO 0.004% Tier 2 travoprost dro 0.004% Tier 2 OTIC AGENTS Otic Agents - Miscellaneous ace acd/alum sol 2% otic Tier 1 acetic acid sol 2% otic Tier 1 Otic Anti-infectives ofloxacin dro 0.3%otic Tier 1 Otic Combinations antipy/benzo sol otic Tier 1 aurax sol 5.5-1.4% Tier 1 100

aurodex sol otic Tier 1 CIPRO HC SUS OTIC Tier 2 CIPRODEX SUS 0.3-0.1% Tier 2 COLY-MYCIN S SUS OTIC Tier 2 CORTISPORIN SUS -TC OTIC Tier 2 neo/poly/hc sol 1% otic Tier 1 neo/poly/hc sus 1% otic Tier 1 Otic Steroids acetasol hc sol otic Tier 1 fluocin acet oil 0.01% Tier 1 hc/acet acid sol otic Tier 1 OXYTOCICS Oxytocics methylergon tab 0.2mg Tier 1 PASSIVE IMMUNIZING AGENTS Immune Serums BIVIGAM INJ 10% Tier 4 PA CARIMUNE NF INJ 3GM Tier 4 PA CARIMUNE NF INJ 6GM Tier 4 PA CARIMUNE NF INJ 12GM Tier 4 PA FLEBOGAMMA INJ 5% Tier 4 PA FLEBOGAMMA INJ 10% Tier 4 PA FLEBOGAMMA INJ DIF 5% Tier 4 PA GAMASTAN S/D INJ Tier 4 PA GAMMAGARD INJ 1GM/10ML Tier 4 PA GAMMAGARD INJ 2.5GM/25 Tier 4 PA GAMMAGARD INJ 5GM/50ML Tier 4 PA GAMMAGARD INJ 10GM/100 Tier 4 PA GAMMAGARD INJ 20GM/200 Tier 4 PA GAMMAGARD INJ 30GM/300 Tier 4 PA GAMMAGARD SD INJ 2.5GM HU Tier 4 PA GAMMAGARD SD INJ 5GM HU Tier 4 PA GAMMAGARD SD INJ 10GM HU Tier 4 PA GAMMAKED INJ 1GM/10ML Tier 4 PA GAMMAKED INJ 2.5GM/25 Tier 4 PA GAMMAKED INJ 5GM/50ML Tier 4 PA GAMMAKED INJ 10GM/100 Tier 4 PA GAMMAKED INJ 20GM/200 Tier 4 PA GAMMAPLEX INJ 2.5GM Tier 4 PA GAMMAPLEX INJ 5GM Tier 4 PA GAMMAPLEX INJ 10GM Tier 4 PA GAMUNEX INJ 10% Tier 4 PA 101

GAMUNEX-C INJ 1GM/10ML Tier 4 PA GAMUNEX-C INJ 2.5GM/25 Tier 4 PA GAMUNEX-C INJ 5GM/50ML Tier 4 PA GAMUNEX-C INJ 10GM/100 Tier 4 PA GAMUNEX-C INJ 20GM/200 Tier 4 PA OCTAGAM INJ 1GM Tier 4 PA OCTAGAM INJ 2.5GM Tier 4 PA OCTAGAM INJ 5GM Tier 4 PA OCTAGAM INJ 10GM Tier 4 PA OCTAGAM INJ 25GM Tier 4 PA PRIVIGEN INJ 5 GRAMS Tier 4 PA PRIVIGEN INJ 10GRAMS Tier 4 PA PRIVIGEN INJ 20GRAMS Tier 4 PA VIVAGLOBIN SOL 160MG/ML Tier 4 PA PENICILLINS Aminopenicillins amoxicillin cap 250mg Tier 1 amoxicillin cap 500mg Tier 1 amoxicillin chw 125mg Tier 1 amoxicillin chw 250mg Tier 1 amoxicillin sus 125/5ml Tier 1 amoxicillin sus 200/5ml Tier 1 amoxicillin sus 250/5ml Tier 1 amoxicillin sus 400/5ml Tier 1 amoxicillin tab 500mg Tier 1 amoxicillin tab 875mg Tier 1 ampicillin cap 250mg Tier 1 ampicillin cap 500mg Tier 1 ampicillin sus 125/5ml Tier 1 ampicillin sus 250/5ml Tier 1 MOXATAG TAB 775MG Tier 2 Natural Penicillins penicilln vk sol 125/5ml Tier 1 penicilln vk sol 250/5ml Tier 1 penicilln vk tab 250mg Tier 1 penicilln vk tab 500mg Tier 1 Penicillin Combinations amox/k clav chw 200mg Tier 1 amox/k clav chw 400mg Tier 1 amox/k clav sus 200/5ml Tier 1 amox/k clav sus 250/5ml Tier 1 amox/k clav sus 400/5ml Tier 1 102

amox/k clav sus 600/5ml Tier 1 amox/k clav tab 250mg Tier 1 amox/k clav tab 500mg Tier 1 amox/k clav tab 875mg Tier 1 AUGMENTIN SUS 125/5ML Tier 2 Penicillinase-Resistant Penicillins BACTOCILL INJ DEX 1GM Tier 4 PA BACTOCILL INJ DEX 2GM Tier 4 PA dicloxacill cap 250mg Tier 1 dicloxacill cap 500mg Tier 1 oxacillin inj 1gm Tier 4 PA oxacillin inj 2gm Tier 4 PA oxacillin inj 10gm Tier 4 PA PROGESTINS Progestins medroxypr ac tab 2.5mg Tier 1 medroxypr ac tab 5mg Tier 1 medroxypr ac tab 10mg Tier 1 norethin ace tab 5mg Tier 1 progesterone cap 100mg Tier 1 progesterone cap 200mg Tier 1 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. Agents for Chemical Dependency CAMPRAL TAB 333MG Tier 3 PA disulfiram tab 250mg Tier 1 disulfiram tab 500mg Tier 1 Anti-Cataplectic Agents XYREM SOL 500MG/ML Tier 4 Antidementia Agents ARICEPT TAB 23MG Tier 2 PA donepezil tab 5mg Tier 1 donepezil tab 5mg odt Tier 1 donepezil tab 10mg Tier 1 donepezil tab 10mg odt Tier 1 galantamine cap 8mg er Tier 1 galantamine cap 16mg er Tier 1 galantamine cap 24mg er Tier 1 galantamine tab 4mg Tier 1 galantamine tab 8mg Tier 1 galantamine tab 12mg Tier 1 NAMENDA SOL 10MG/5ML Tier 3 PA NAMENDA TAB 5MG Tier 3 PA 103

NAMENDA TAB 10MG Tier 3 PA rivastigmine cap 1.5mg Tier 1 rivastigmine cap 3mg Tier 1 rivastigmine cap 4.5mg Tier 1 rivastigmine cap 6mg Tier 1 Combination Psychotherapeutics perphen/amit tab 2-10mg Tier 1 perphen/amit tab 2-25mg Tier 1 perphen/amit tab 4-10mg Tier 1 perphen/amit tab 4-25mg Tier 1 perphen/amit tab 4-50mg Tier 1 Fibromyalgia Agents SAVELLA TAB 12.5MG Tier 3 PA SAVELLA TAB 25MG Tier 3 PA SAVELLA TAB 50MG Tier 3 PA SAVELLA TAB 100MG Tier 3 PA Movement Disorder Drug Therapy XENAZINE TAB 12.5MG Tier 3 PA XENAZINE TAB 25MG Tier 3 PA Multiple Sclerosis Agents AMPYRA TAB 10MG Tier 4 PA AVONEX KIT 30MCG Tier 4 PA AVONEX PEN KIT 30MCG Tier 4 PA AVONEX PREFL KIT 30MCG Tier 4 PA BETASERON INJ 0.3MG Tier 4 PA COPAXONE KIT 20MG/ML Tier 4 PA EXTAVIA INJ 0.3MG Tier 4 PA REBIF INJ 22/0.5 Tier 4 PA REBIF INJ 44/0.5 Tier 4 PA REBIF REBIDO INJ 22/0.5 Tier 4 PA REBIF REBIDO INJ 44/0.5 Tier 4 PA REBIF REBIDO SOL TITRATN Tier 4 PA REBIF TITRTN SOL PACK Tier 4 PA TYSABRI INJ Tier 4 PA Premenstrual Dysphoric Disorder (PMDD) Agents fluoxetine cap 10mg 10mg Tier 1 fluoxetine cap 20mg 20mg Tier 1 Pseudobulbar Affect (PBA) Agents NUEDEXTA CAP 20-10MG Tier 3 PA Psychotherapeutic and Neurological Agents - Misc. ergoloid mes tab 1mg oral Tier 1 ORAP TAB 1MG Tier 2 ORAP TAB 2MG Tier 2 104

Restless Leg Syndrome (RLS) Agents HORIZANT TAB 600MG Tier 3 PA Smoking Deterrents buproban tab 150mg Tier 0 bupropion tab 150mg Tier 0 CHANTIX PAK 0.5& 1MG Tier 0 CHANTIX PAK 1MG Tier 0 CHANTIX TAB 0.5MG Tier 0 CHANTIX TAB 1MG Tier 0 cvs nicotine dis 7mg/24hr Tier 0 cvs nicotine dis 14mg/24h Tier 0 cvs nicotine dis 21mg/24h Tier 0 cvs nicotine gum 2mg cinn Tier 0 cvs nicotine gum 2mg mint Tier 0 cvs nicotine gum 2mg orig Tier 0 cvs nicotine gum 2mgfruit Tier 0 cvs nicotine gum 4mg cinn Tier 0 cvs nicotine gum 4mg mint Tier 0 cvs nicotine gum 4mg orig Tier 0 cvs nicotine gum 4mgfruit Tier 0 cvs nicotine loz 2mg mint Tier 0 cvs nicotine loz 4mg mint Tier 0 cvs nts dis step 1 Tier 0 eq nicotine dis 7mg/24hr Tier 0 eq nicotine dis 14mg/24h Tier 0 eq nicotine dis 21mg/24h Tier 0 eq nicotine gum 2mg cinn Tier 0 eq nicotine gum 2mg mint Tier 0 eq nicotine gum 2mg orig Tier 0 eq nicotine gum 2mgfruit Tier 0 eq nicotine gum 4mg cinn Tier 0 eq nicotine gum 4mg mint Tier 0 eq nicotine gum 4mg orig Tier 0 eq nicotine gum 4mg ref Tier 0 eq nicotine gum 4mg strt Tier 0 eq nicotine gum 4mgfruit Tier 0 eq nicotine loz 2mg cher Tier 0 eq nicotine loz 2mg mint Tier 0 eq nicotine loz 4mg chry Tier 0 eq nicotine loz 4mg mint Tier 0 eql nicotine dis 7mg/24hr Tier 0 eql nicotine dis 14mg/24h Tier 0 eql nicotine dis 21mg/24h Tier 0 105

eql nicotine gum 2mg Tier 0 eql nicotine gum 2mg ref Tier 0 eql nicotine gum 2mg strt Tier 0 eql nicotine gum 4mg Tier 0 eql nicotine gum 4mg ref Tier 0 eql nicotine gum 4mg strt Tier 0 eql nicotine loz 2mg mint Tier 0 eql nicotine loz 4mg mint Tier 0 gnp nicotine gum 2mg mint Tier 0 gnp nicotine gum 2mg orig Tier 0 gnp nicotine gum 4mg mint Tier 0 gnp nicotine gum 4mg orig Tier 0 gnp nicotine loz 2mg mint Tier 0 gnp nicotine loz 4mg mint Tier 0 hm nicotine dis 14mg/24h Tier 0 hm nicotine dis 21mg/24h Tier 0 hm nicotine gum 2mg mint Tier 0 hm nicotine gum 4mg mint Tier 0 hm nicotine loz 2mg mint Tier 0 hm nicotine loz 4mg mint Tier 0 kls quit2 gum 2mg Tier 0 kls quit4 gum 4mg Tier 0 nicorelief gum 2mg mint Tier 0 nicorelief gum 2mg orig Tier 0 nicorelief gum 4mg mint Tier 0 nicorelief gum 4mg orig Tier 0 nicorelief loz 2mg mint Tier 0 nicorelief loz 4mg mint Tier 0 nicotine dis 7mg/24hr Tier 0 nicotine dis 14mg/24h Tier 0 nicotine dis 21mg/24h Tier 0 nicotine dis step 1 Tier 0 nicotine dis step 2 Tier 0 nicotine dis step 3 Tier 0 nicotine gum 2mg Tier 0 nicotine gum 2mgfruit Tier 0 nicotine gum 4mg Tier 0 nicotine loz 2mg chry Tier 0 nicotine loz 2mg mint Tier 0 nicotine loz 4mg chry Tier 0 nicotine loz 4mg cinn Tier 0 nicotine loz 4mg mint Tier 0 nicotine pol gum 2mg Tier 0 106

nicotine pol gum 2mg cinn Tier 0 nicotine pol gum 2mg mint Tier 0 nicotine pol gum 2mg orig Tier 0 nicotine pol gum 2mg ref Tier 0 nicotine pol gum 2mg strt Tier 0 nicotine pol gum 2mgfruit Tier 0 nicotine pol gum 4mg Tier 0 nicotine pol gum 4mg mint Tier 0 nicotine pol gum 4mg orig Tier 0 nicotine pol gum 4mg ref Tier 0 nicotine pol gum 4mg strt Tier 0 nicotine pol gum 4mgfruit Tier 0 nicotine pol loz 2mg cinn Tier 0 nicotine pol loz 2mg mint Tier 0 nicotine pol loz 4mg chry Tier 0 nicotine pol loz 4mg mint Tier 0 NICOTINE SYS KIT TRANSDER Tier 0 PA nicotine td dis 7mg/24hr Tier 0 nicotine td dis 14mg/24h Tier 0 nicotine td dis 21mg/24h Tier 0 NICOTROL INH Tier 0 PA NICOTROL NS SPR 10MG/ML Tier 0 PA ra nicotine dis 7mg/24hr Tier 0 ra nicotine dis 14mg/24h Tier 0 ra nicotine dis 21mg/24h Tier 0 ra nicotine gum 2mg Tier 0 ra nicotine gum 2mg cinn Tier 0 ra nicotine gum 2mg mint Tier 0 ra nicotine gum 2mgfruit Tier 0 ra nicotine gum 4mg Tier 0 ra nicotine gum 4mg frut Tier 0 ra nicotine gum 4mg mint Tier 0 ra nicotine loz 2mg mint Tier 0 ra nicotine loz 4mg mint Tier 0 sm nicotine dis 7mg/24hr Tier 0 sm nicotine dis 14mg/24h Tier 0 sm nicotine dis 21mg Tier 0 sm nicotine gum 2mg Tier 0 sm nicotine gum 2mg mint Tier 0 sm nicotine gum 4mg Tier 0 sm nicotine gum 4mg mint Tier 0 sm nicotine loz 2mg mint Tier 0 sm nicotine loz 4mg mint Tier 0 107

stop smoking gum 2mg mint Tier 0 stop smoking gum 2mg orig Tier 0 stop smoking gum 4mg Tier 0 stop smoking loz 2mg mint Tier 0 stop smoking loz 4mg mint Tier 0 sw nicotine gum 2mg mint Tier 0 sw nicotine gum 4mg Tier 0 sw nicotine loz 2mg mint Tier 0 sw nicotine loz 4mg mint Tier 0 tgt nicotine dis 7mg/24hr Tier 0 tgt nicotine dis 14mg/24h Tier 0 tgt nicotine dis 21mg/24h Tier 0 tgt nicotine gum 2mg mint Tier 0 tgt nicotine gum 2mg orig Tier 0 tgt nicotine gum 2mgfruit Tier 0 tgt nicotine gum 4mg Tier 0 tgt nicotine gum 4mg mint Tier 0 tgt nicotine gum 4mg orig Tier 0 tgt nicotine loz 2mg chry Tier 0 tgt nicotine loz 2mg mint Tier 0 tgt nicotine loz 4mg chry Tier 0 tgt nicotine loz 4mg mint Tier 0 thrive gum 2mg mint Tier 0 thrive gum 4mg mint Tier 0 RESPIRATORY AGENTS - MISC. Alpha-Proteinase Inhibitor (Human) ARALAST NP INJ 400MG Tier 4 PA ARALAST NP INJ 500MG Tier 4 PA ARALAST NP INJ 800MG Tier 4 PA ARALAST NP INJ 1000MG Tier 4 PA GLASSIA INJ Tier 4 PA PROLASTIN INJ 500MG Tier 4 PA PROLASTIN INJ 1000MG Tier 4 PA PROLASTIN-C INJ 1000MG Tier 4 PA ZEMAIRA INJ 1000MG Tier 4 PA Cystic Fibrosis Agents PULMOZYME SOL 1MG/ML Tier 4 PA SULFONAMIDES Sulfonamides SULFADIAZINE TAB 500MG Tier 2 TETRACYCLINES 108

Tetracyclines demeclocycl tab 150mg Tier 1 demeclocycl tab 300mg Tier 1 doxycyc mono cap 50mg Tier 1 doxycyc mono cap 100mg Tier 1 doxycycl hyc cap 50mg Tier 1 DOXYCYCL HYC CAP 75MG Tier 2 doxycycl hyc cap 100mg CAPS Tier 1 DOXYCYCL HYC CAP 100MG CPEP Tier 2 doxycycl hyc tab 100mg Tier 1 doxycycline cap 75mg Tier 1 doxycycline cap 150mg Tier 1 doxycycline sus 25mg/5ml Tier 2 doxycycline tab 20mg Tier 1 minocycline cap 50mg Tier 1 minocycline cap 75mg Tier 1 minocycline cap 100mg Tier 1 morgidox cap 1x100mg Tier 1 morgidox cap 2x100mg Tier 1 ORAXYL CAP 20MG Tier 3 tetracycline cap 250mg Tier 1 tetracycline cap 500mg Tier 1 VIBRAMYCIN SYP 50MG/5ML Tier 2 THYROID AGENTS Antithyroid Agents methimazole tab 5mg Tier 1 methimazole tab 10mg Tier 1 propylthiour tab 50mg Tier 1 Thyroid Hormones ARMOUR THYRO TAB 15MG Tier 2 ARMOUR THYRO TAB 120MG Tier 2 ARMOUR THYRO TAB 180MG Tier 2 ARMOUR THYRO TAB 240MG Tier 2 ARMOUR THYRO TAB 300MG Tier 2 levothroid tab 25mcg Tier 1 levothroid tab 50mcg Tier 1 levothroid tab 75mcg Tier 1 levothroid tab 88mcg Tier 1 levothroid tab 100mcg Tier 1 levothroid tab 112mcg Tier 1 levothroid tab 125mcg Tier 1 levothroid tab 137mcg Tier 1 109

levothroid tab 150mcg Tier 1 levothroid tab 175mcg Tier 1 levothroid tab 200mcg Tier 1 levothroid tab 300mcg Tier 1 levothyroxin tab 25mcg Tier 1 levothyroxin tab 50mcg Tier 1 levothyroxin tab 75mcg Tier 1 levothyroxin tab 88mcg Tier 1 levothyroxin tab 100mcg Tier 1 levothyroxin tab 112mcg Tier 1 levothyroxin tab 125mcg Tier 1 levothyroxin tab 137mcg Tier 1 levothyroxin tab 150mcg Tier 1 levothyroxin tab 175mcg Tier 1 levothyroxin tab 200mcg Tier 1 levothyroxin tab 300mcg Tier 1 levoxyl tab 25mcg Tier 1 levoxyl tab 50mcg Tier 1 levoxyl tab 75mcg Tier 1 levoxyl tab 88mcg Tier 1 levoxyl tab 100mcg Tier 1 levoxyl tab 112mcg Tier 1 levoxyl tab 125mcg Tier 1 levoxyl tab 137mcg Tier 1 levoxyl tab 150mcg Tier 1 levoxyl tab 175mcg Tier 1 levoxyl tab 200mcg Tier 1 liothyronine tab 5mcg Tier 1 liothyronine tab 25mcg Tier 1 liothyronine tab 50mcg Tier 1 np thyroid tab 30mg Tier 1 np thyroid tab 60mg Tier 1 np thyroid tab 90mg Tier 1 THYROLAR-1 TAB 60MG Tier 2 THYROLAR-1/2 TAB 30MG Tier 2 THYROLAR-1/4 TAB 15MG Tier 2 THYROLAR-2 TAB 120MG Tier 2 THYROLAR-3 TAB 180MG Tier 2 unith direct tab 25mcg Tier 1 unith direct tab 50mcg Tier 1 unith direct tab 75mcg Tier 1 unith direct tab 88mcg Tier 1 unith direct tab 100mcg Tier 1 110

unith direct tab 112mcg Tier 1 unith direct tab 125mcg Tier 1 unith direct tab 150mcg Tier 1 unith direct tab 175mcg Tier 1 unith direct tab 200mcg Tier 1 unith direct tab 300mcg Tier 1 unithroid tab 25mcg Tier 1 unithroid tab 50mcg Tier 1 unithroid tab 75mcg Tier 1 unithroid tab 88mcg Tier 1 unithroid tab 100mcg Tier 1 unithroid tab 112mcg Tier 1 unithroid tab 125mcg Tier 1 unithroid tab 137mcg Tier 1 unithroid tab 150mcg Tier 1 unithroid tab 175mcg Tier 1 unithroid tab 200mcg Tier 1 unithroid tab 300mcg Tier 1 ULCER DRUGS Antispasmodics ATROPEN INJ 0.5MG Tier 1 PA ATROPEN INJ 0.25MG Tier 1 PA ATROPEN INJ 1MG Tier 1 PA ATROPEN INJ 2MG Tier 1 PA atropine sul inj 0.1mg/ml Tier 1 PA atropine sul inj 0.4/0.5 Tier 1 PA atropine sul inj 0.4mg/ml Tier 1 PA atropine sul inj 0.05mg/1 Tier 1 PA atropine sul inj 1mg/ml Tier 1 PA bella alk/pb tab 16.2mg Tier 1 belladonna tin 30/100ml Tier 1 chlord/clidi cap 5-2.5mg Tier 1 colidrops dro 0.125/ml Tier 1 dicyclomine cap 10mg Tier 1 dicyclomine sol 10mg/5ml Tier 1 dicyclomine tab 20mg Tier 1 ed-spaz tab 0.125mg Tier 1 glycopyrrol tab 1mg Tier 1 glycopyrrol tab 2mg Tier 1 hyomax tab 0.125mg Tier 1 hyomax-ft tab 0.125mg Tier 1 hyomax-sl sub 0.125mg Tier 1 111

hyomax-sr tab 0.375mg Tier 1 hyoscyamine dro 0.125/ml Tier 1 hyoscyamine elx 0.125/5 Tier 1 hyoscyamine sub 0.125mg Tier 1 hyoscyamine tab 0.125mg Tier 1 hyoscyamine tab 0.375 er Tier 1 hyoscyamine tab 0.375 sr Tier 1 hyosyne dro 0.125/ml Tier 1 hyosyne elx 0.125/5 Tier 1 methscopolam tab 2.5mg Tier 1 nulev tab 0.125mg Tier 1 oscimin sr tab 0.375mg Tier 1 oscimin sub 0.125mg Tier 1 oscimin tab 0.125mg Tier 1 propanthelin tab 15mg Tier 1 quadrapax elx Tier 1 SAL-TROPINE TAB 0.4MG Tier 2 se-donna elx pb hyos Tier 1 symax fastab tab 0.125mg Tier 1 symax-sl sub 0.125mg Tier 1 symax-sr tab 0.375mg Tier 1 H-2 Antagonists acid control tab 20mg Tier 1 acid control tab 150mg Tier 1 acid reducer tab 20mg Tier 1 acid reducer tab 150mg Tier 1 acid reducer tab 200mg Tier 1 acid relief tab 200mg Tier 1 cimetidine sol 300/5ml Tier 1 cimetidine tab 200mg Tier 1 cimetidine tab 300mg Tier 1 cimetidine tab 400mg Tier 1 cimetidine tab 800mg Tier 1 eq heartburn tab relief Tier 1 famotidine sus 40mg/5ml Tier 1 famotidine tab 20mg Tier 1 famotidine tab 40mg Tier 1 heartbrn rel tab 200mg Tier 1 heartburn tab 20mg Tier 1 heartburn tab 150mg Tier 1 heartburn tab 200mg Tier 1 heartburn tab relief 200mg Tier 1 nizatidine cap 150mg Tier 1 112

nizatidine cap 300mg Tier 1 qc heartburn tab 200mg Tier 1 ranitidine cap 150mg Tier 1 ranitidine cap 300mg Tier 1 ranitidine syp 15mg/ml Tier 1 ranitidine syp 75mg/5ml Tier 1 ranitidine syp 150/10ml Tier 1 ranitidine tab 150mg Tier 1 ranitidine tab 300mg Tier 1 sm acid redu tab 200mg Tier 1 wal-zan tab 150mg Tier 1 Misc. Anti-Ulcer sucralfate tab 1gm Tier 1 Proton Pump Inhibitors ACIPHEX TAB 20MG Tier 3 PA DEXILANT CAP 30MG DR Tier 3 PA DEXILANT CAP 60MG DR Tier 3 PA hrtbrn rel cap 15mg dr Tier 1 lansoprazole cap 15mg dr Tier 1 lansoprazole cap 30mg dr Tier 1 LANSOPRAZOLE SUS 3MG/ML Tier 3 PA lansoprazole tab 15mg odt Tier 1 lansoprazole tab 30mg odt Tier 1 NEXIUM CAP 20MG Tier 3 PA NEXIUM CAP 40MG Tier 3 PA omeprazole cap 10mg Tier 1 omeprazole cap 20mg Tier 1 omeprazole cap 40mg Tier 1 PA pantoprazole tab 20mg Tier 1 pantoprazole tab 40mg Tier 1 Ulcer Drugs - Prostaglandins misoprostol tab 100mcg Tier 1 misoprostol tab 200mcg Tier 1 Ulcer Therapy Combinations HELIDAC MIS Tier 3 PREVPAC MIS Tier 3 URINARY ANTI-INFECTIVES Urinary Anti-infectives MACRODANTIN CAP 25MG Tier 2 methenam hip tab 1gm Tier 1 nitrofur mac cap 50mg Tier 1 nitrofur mac cap 100mg Tier 1 113

nitrofurantn cap 100mg Tier 1 nitrofurantn sus 25mg/5ml Tier 1 URINARY ANTISPASMODICS Urinary Antispasmodics bethanechol tab 5mg Tier 1 bethanechol tab 10mg Tier 1 bethanechol tab 25mg Tier 1 bethanechol tab 50mg Tier 1 DETROL LA CAP 2MG Tier 3 ST ENABLEX TAB 7.5MG Tier 3 PA flavoxate tab 100mg Tier 1 oxybutynin syp 5mg/5ml Tier 1 oxybutynin tab 5mg Tier 1 oxybutynin tab 5mg er Tier 1 oxybutynin tab 10mg er Tier 1 oxybutynin tab 15mg er Tier 1 tolterodine tab 1mg Tier 1 ST tolterodine tab 2mg Tier 1 ST TOVIAZ TAB 4MG Tier 2 ST TOVIAZ TAB 8MG Tier 2 ST trospium chl cap 60mg er Tier 1 ST VESICARE TAB 5MG Tier 3 PA VACCINES Viral Vaccines AFLURIA INJ 2011-12 Tier 0 AFLURIA INJ 2012-13 Tier 0 AFLURIA INJ PF 10-11 Tier 0 AFLURIA INJ PF 11-12 Tier 0 AFLURIA INJ PF 12-13 Tier 0 AGRIFLU INJ PF 10-11 Tier 0 EZ USE FLU KIT 2012-13 Tier 0 FLUARIX INJ PF 10-11 Tier 0 FLUARIX INJ PF 11-12 Tier 0 FLUARIX INJ PF 12-13 Tier 0 FLULAVAL INJ 2010-11 Tier 0 FLULAVAL INJ 2011-12 Tier 0 FLULAVAL INJ 2012-13 Tier 0 FLUVIRIN INJ 2011-12 Tier 0 FLUVIRIN INJ 2012-13 Tier 0 FLUVIRIN INJ PF 11-12 Tier 0 FLUVIRIN INJ PF 12-13 Tier 0 FLUZONE INJ INTRADRM Tier 0 114

FLUZONE INJ PF 11-12 Tier 0 FLUZONE INJ PF 12-13 Tier 0 FLUZONE PED/ INJ PF 11-12 Tier 0 FLUZONE PED/ INJ PF 12-13 Tier 0 FLUZONE QUAD INJ 13-14 Tier 0 FLUZONE SPLT INJ 2011-12 Tier 0 FLUZONE SPLT INJ 2012-13 Tier 0 INFLUENZA A INJ PF09H1N1 Tier 0 VAGINAL PRODUCTS Spermicides encare gel 4% Tier 0 Vaginal Anti-infectives clindamycin cre 2% vag Tier 1 metronidazol gel 0.75%vag Tier 1 miconazole 1 kit Tier 2 miconazole 1 kit 1200-2% Tier 2 miconazole 1 kit 1200mg2% Tier 2 miconazole 3 kit combo pk Tier 1 miconazole 3 sup 200mg Tier 1 NYSTATIN VAG TAB 100000 Tier 2 terconazole cre 0.4% Tier 1 terconazole cre 0.8% Tier 1 terconazole sup 80mg Tier 1 vagistat-3 kit combo pk Tier 1 vandazole gel 0.75% Tier 1 zazole cre 0.4% Tier 1 zazole cre 0.8% Tier 1 zazole sup 80mg Tier 1 Vaginal Estrogens ESTRACE VAG CRE 0.1MG/GM Tier 2 ESTRING MIS 2MG Tier 3 PREMARIN VAG CRE 0.625MG Tier 2 VASOPRESSORS Anaphylaxis Therapy Agents ADRENACLICK INJ 0.3MG Tier 2 ADRENACLICK INJ 0.15MG Tier 2 AUVI-Q INJ 0.3MG Tier 2 AUVI-Q INJ 0.15MG Tier 2 epinephrine inj 0.3mg Tier 1 epinephrine inj 0.15mg Tier 1 EPIPEN 2-PAK INJ 0.3MG Tier 2 EPIPEN INJ 0.3MG Tier 2 115

EPIPEN-JR INJ 0.15MG Tier 2 EPIPEN-JR INJ 2-PAK Tier 2 TWINJECT INJ 0.3MG Tier 2 TWINJECT INJ 0.15MG Tier 2 VITAMINS Oil Soluble Vitamins A-25 CAP 25000UNT Tier 2 bio-d-mulsio liq 400unit Tier 0 child vit d chw 400unit Tier 0 d3 kids chw 400unit Tier 0 d-3 gummy chw 400unit Tier 0 d-400 tab 400unit Tier 0 d-vita liq 400unit Tier 0 DECARA CAP 25000UNT Tier 2 delta d3 tab 400unit Tier 0 ergocalcifer cap 50000unt Tier 1 gnp vit d tab 400unit Tier 0 just d liq 400unit Tier 0 MEPHYTON TAB 5MG Tier 2 sm vitamin d tab 400unit Tier 0 vit d gummie chw 400unit Tier 0 VITAMIN A CAP 25000UNT Tier 2 vitamin d3 chw 400unit Tier 0 vitamin d3 dro 400unit Tier 0 vitamin d3 tab 400unit Tier 0 vitamin d cap 50000unt Tier 1 vitamin d chw 400unit Tier 0 vitamin d dro 400unit Tier 0 vitamin d tab 400unit Tier 0 116

Index A A-200 GEL 0.33-4% 72 A-25 CAP 25000UNT 116 abacavir tab 300mg 47 ABILIFY DISC TAB 10MG 47 ABILIFY DISC TAB 15MG 47 ABILIFY MAIN INJ 300MG 47 ABILIFY MAIN INJ 400MG 47 ABILIFY SOL 1MG/ML 47 ABILIFY TAB 10MG 47 ABILIFY TAB 15MG 47 ABILIFY TAB 20MG 47 ABILIFY TAB 2MG 47 ABILIFY TAB 30MG 47 ABILIFY TAB 5MG 47 ABSTRAL SUB 100MCG 8 ABSTRAL SUB 200MCG 8 ABSTRAL SUB 300MCG 8 ABSTRAL SUB 400MCG 8 ABSTRAL SUB 600MCG 8 ABSTRAL SUB 800MCG 8 acarbose tab 100mg 26 acarbose tab 25mg 26 acarbose tab 50mg 26 acd/fluoride dro 0.25mg 93 ace acd/alum sol 2% otic 100 acebutolol cap 200mg 52 acebutolol cap 400mg 52 acetasol hc sol otic 101 acetazolamid cap 500mg er 74 acetazolamid tab 125mg 74 acetazolamid tab 250mg 74 acetic acid sol 2% otic 100 acetylcyst sol 10% 64 acetylcyst sol 20% 64 acid control tab 150mg 112 acid control tab 20mg 112 acid reducer tab 150mg 112 acid reducer tab 200mg 112 acid reducer tab 20mg 112 acid relief tab 200mg 112 ACIPHEX TAB 20MG 113 acne medicat gel 10% 64 acne treatmn gel 10% 64 acne-clear gel 10% 64 ACTEMRA INJ 200/10ML 4 ACTEMRA INJ 400/20ML 4 ACTEMRA INJ 80MG/4ML 3 acticin cre 5% 72 ACTIMMUNE INJ 2MU/0.5 42 ACTONEL TAB 150MG 75 ACTONEL TAB 30MG 75 ACTONEL TAB 35MG 75 ACTONEL TAB 5MG 75 ACTOPLUS MET TAB XR 26 ACUVAIL SOL 0.45% 99 acyclovir cap 200mg 50 acyclovir sus 200/5ml 50 acyclovir tab 400mg 50 acyclovir tab 800mg 50 adapalene cre 0.1% 64 adapalene gel 0.1% 64 ADCIRCA TAB 20MG 57 ADRENACLICK INJ 0.15MG 115 ADRENACLICK INJ 0.3MG 115 adrucil inj 2.5g/50m 39 adrucil inj 500/10ml 39 adrucil inj 5gm/100m 39 ADVAIR DISKU AER 100/50 17 ADVAIR DISKU AER 250/50 17 ADVAIR DISKU AER 500/50 17 ADVAIR HFA AER 115/21 17 ADVAIR HFA AER 230/21 17 ADVAIR HFA AER 45/21 17 AEROCHAMBER KIT ACTION 87 af-diphedryl elx 12.5/5ml 31 afeditab tab 30mg cr 53 afeditab tab 60mg cr 53 AFINITOR TAB 10MG 41 AFINITOR TAB 2.5MG 41 AFINITOR TAB 5MG 41 AFINITOR TAB 7.5MG 41 AFLURIA INJ 2011-12 114 AFLURIA INJ 2012-13 114 AFLURIA INJ PF 10-11 114 AFLURIA INJ PF 11-12 114 AFLURIA INJ PF 12-13 114 AGGRENOX CAP 25-200MG 82 AGRIFLU INJ PF 10-11 114 ak-pentolate sol 1% op 97 ak-poly-bac oin op 98 al12 lot 12% 71 ala cort cre 1% 68 ala-cort lot 1% 68 alagesic cap 5 ALAMAST DRO 0.1% 99 alaway child dro 0.025%op 99 alaway dro 0.025%op 100 ALBENZA TAB 200MG 12 albuterol neb 0.083% 17 albuterol neb 0.5% 17 albuterol neb 0.63mg/3 17 albuterol neb 1.25mg/3 17 albuterol syp 2mg/5ml 17 albuterol tab 2mg 17 albuterol tab 4mg 17 albuterol tab 4mg er 17 albuterol tab 8mg er 17 alclometason cre 0.05% 68 alclometason oin 0.05% 68 ALCOHOL SWABS 87 ALDACTAZIDE TAB 50/50 74 alendronate tab 10mg 75 alendronate tab 35mg 75 alendronate tab 40mg 75 alendronate tab 5mg 75 alendronate tab 70mg 75 117

aler-cap cap 25mg 31 ALFERON N INJ 5MU/ML 42 alfuzosin tab 10mg 81 ALINIA SUS 100MG/5M 13 ALINIA TAB 500MG 13 ALKERAN TAB 2MG 39 all day allg sol 1mg/ml 32 all day allg sol 5mg/5ml 32 all day allg syp 1mg/ml 32 all day allg syp 5mg/5ml 32 all day pain tab 220mg 4 all day relf tab 220mg 4 aller-ease tab 180mg 32 aller-ease tab 60mg 32 aller-fex tab 180mg 32 aller-tec sol 1mg/ml 32 allergy cap 25mg 31 allergy chld sol 1mg/ml 32 allergy comp sol 1mg/ml 32 allergy eye dro 0.025%op 100 allergy med cap 25mg 31 allergy rel elx 12.5/5ml 31 allergy rel sol 1mg/ml 32 allergy relf cap 25mg 31 allergy relf sol 5mg/5ml 32 allergy relf tab 180mg 32 allergy relf tab 60mg 32 allopurinol tab 100mg 81 allopurinol tab 300mg 81 ALOCRIL SOL 2% 100 ALOMIDE SOL 0.1% OP 100 ALORA DIS 0.025MG 77 ALORA DIS 0.05MG 77 ALORA DIS 0.075MG 77 ALORA DIS 0.1MG 77 ALPHAGAN P SOL 0.1% 98 alprazolam tab 0.25mg 15 alprazolam tab 0.5mg 15 alprazolam tab 1mg 15 alprazolam tab 2mg 15 ALREX SUS 0.2% 99 ALTABAX OIN 1% 66 altaryl elx 12.5/5ml 31 altaryl syp 12.5/5ml 31 altavera tab 58 ALVESCO AER 160MCG 17 ALVESCO AER 80MCG 17 alyacen tab 1/35 58 alyacen tab 7/7/7 58 amantadine cap 100mg 43 amantadine syp 50mg/5ml 43 amantadine tab 100mg 43 amcinonide cre 0.1% 68 amcinonide lot 0.1% 68 AMCINONIDE OIN 0.1% 68 amethyst tab 90-20mcg 58 amilor/hctz tab 5-50 74 amiloride tab 5mg 74 aminocapr ac syp 25% 83 aminocapr ac tab 1000mg 83 aminocapr ac tab 500mg 83 aminophyllin tab 100mg 18 aminophyllin tab 200mg 18 amiodarone inj 150mg/3m 16 amiodarone inj 50mg/ml 16 amiodarone tab 200mg 16 amiodarone tab 400mg 16 AMITIZA CAP 24MCG 79 AMITIZA CAP 8MCG 79 amitriptylin tab 100mg 25 amitriptylin tab 10mg 25 amitriptylin tab 150mg 25 amitriptylin tab 25mg 25 amitriptylin tab 50mg 25 amitriptylin tab 75mg 25 amlactin cre 12% 71 amlactin lot 12% 71 amlod/benazp cap 10-20mg 37 amlod/benazp cap 10-40mg 37 amlod/benazp cap 2.5-10mg 37 amlod/benazp cap 5-10mg 37 amlod/benazp cap 5-20mg 37 amlod/benazp cap 5-40mg 37 amlodipine tab 10mg 53 amlodipine tab 2.5mg 53 amlodipine tab 5mg 53 ammonium lac cre 12% 71 ammonium lac lot 12% 71 amnesteem cap 10mg 64 amnesteem cap 20mg 64 amnesteem cap 40mg 64 amox/k clav chw 200mg 102 amox/k clav chw 400mg 102 amox/k clav sus 200/5ml 102 amox/k clav sus 250/5ml 102 amox/k clav sus 400/5ml 102 amox/k clav sus 600/5ml 103 amox/k clav tab 250mg 103 amox/k clav tab 500mg 103 amox/k clav tab 875mg 103 amoxapine tab 100mg 25 amoxapine tab 150mg 25 amoxapine tab 25mg 25 amoxapine tab 50mg 25 amoxicillin cap 250mg 102 amoxicillin cap 500mg 102 amoxicillin chw 125mg 102 amoxicillin chw 250mg 102 amoxicillin sus 125/5ml 102 amoxicillin sus 200/5ml 102 amoxicillin sus 250/5ml 102 amoxicillin sus 400/5ml 102 amoxicillin tab 500mg 102 amoxicillin tab 875mg 102 amphetamine cap 10mg er 1 amphetamine cap 15mg er 1 amphetamine cap 20mg er 1 amphetamine cap 25mg er 1 amphetamine cap 30mg er 1 amphetamine cap 5mg er 1 118

amphetamine tab 10mg 1 amphetamine tab 12.5mg 1 amphetamine tab 15mg 1 amphetamine tab 20mg 1 amphetamine tab 30mg 1 amphetamine tab 5mg 1 amphetamine tab 7.5mg 1 ampicillin cap 250mg 102 ampicillin cap 500mg 102 ampicillin sus 125/5ml 102 ampicillin sus 250/5ml 102 AMPYRA TAB 10MG 104 anacin tab 81mg ec 6 ANADROL-50 TAB 50MG 11 anagrelide cap 0.5mg 82 anagrelide cap 1mg 82 anastrozole tab 1mg 40 ANDRODERM DIS 2.5MG/24 11 ANDRODERM DIS 5MG/24HR 11 ANDROGEL GEL 1%(25MG) 11 ANDROGEL GEL 1%(50MG) 11 ANDROGEL GEL PUMP 1% 11 android cap 10mg 11 ANDROXY TAB 10MG 11 anolor 300 cap 5 anti-diarrhe cap 2mg 29 anti-diarrhe tab 2mg 29 anti-hist cap 25mg 31 anti-itch cre /aloe/e 68 anti-itch cre /oatmeal 68 anti-itch cre 1% 68 anti-itch cre 1%pls 10 68 anti-itch lot 1% 68 anti-itch oin 1% 68 anti-itch oin max st 68 anti-oxidant tab 92 antifungal cre 1% 66 antifungal cre 2% 66 antihistamin cap 25mg 31 antihistamin dro 0.025%op 100 antipy/benzo sol otic 100 ANTIVERT TAB 50MG 30 anucort-hc sup 25mg 12 ANZEMET TAB 100MG 29 ANZEMET TAB 50MG 29 apap/codeine sol 120-12/5 10 apap/codeine tab 300-15mg 10 apap/codeine tab 300-30mg 10 apap/codeine tab 300-60mg 10 apexicon oin 0.05% 68 APHTHASOL PST 5% 91 APIDRA INJ SOLOSTAR 27 APIDRA INJ U-100 27 APLENZIN TAB 174MG 23 APLENZIN TAB 348MG 23 APLENZIN TAB 522MG 23 APOKYN INJ 43 APOKYN INJ 10MG/ML 43 apraclonidin sol 0.5% op 98 apri tab 58 APRISO CAP 0.375GM 80 APTIVUS CAP 250MG 47 APTIVUS SOL 47 aquanil hc lot 1% 69 ARALAST NP INJ 1000MG 108 ARALAST NP INJ 400MG 108 ARALAST NP INJ 500MG 108 ARALAST NP INJ 800MG 108 aranelle tab 58 arbinoxa liq 4mg/5ml 31 arbinoxa tab 4mg 31 ARCALYST INJ 220MG 3 ARCAPTA CAP 75MCG 17 argyl saline sol 0.9% 81 ARICEPT TAB 23MG 103 ARMOUR THYRO TAB 120MG 109 ARMOUR THYRO TAB 15MG 109 ARMOUR THYRO TAB 180MG 109 ARMOUR THYRO TAB 240MG 109 ARMOUR THYRO TAB 300MG 109 ASACOL HD TAB 800MG 80 ASACOL TAB 400MG DR 80 ASCENSIA MIS AUTODISC 73 ascomp/cod cap 30mg 10 asmalpred sol 15mg/5ml 61 asmalpred sol plus 61 ASMANEX 120 AER 220MCG 17 ASMANEX 14 AER 220MCG 17 ASMANEX 30 AER 110MCG 17 ASMANEX 30 AER 220MCG 17 ASMANEX 60 AER 220MCG 17 ASMANEX 7 AER 110MCG 17 aspir-81 tab 81mg ec 6 aspir-low tab 81mg ec 6 aspirin adlt tab 81mg 6 aspirin chil chw 81mg 6 aspirin chld chw 81mg 6 aspirin chw 81mg 6 aspirin low chw 81mg 6 aspirin tab 325mg 6 aspirin tab 325mg ec 6 aspirin tab 5gr ec 6 aspirin tab 81mg 6 aspirin tab 81mg ec 6 aspirtab tab 324mg ec 6 ASTEPRO SPR 0.15% 96 atenol/chlor tab 100-25mg 37 atenol/chlor tab 50-25mg 37 atenolol tab 100mg 52 atenolol tab 25mg 52 atenolol tab 50mg 52 athlete foot cre 1% 66 atorvastatin tab 10mg 34 atorvastatin tab 20mg 34 atorvastatin tab 40mg 34 atorvastatin tab 80mg 34 atovaq/progu tab 250-100 38 atovaq/progu tab 62.5-25 38 ATRALIN GEL 0.05% 64 ATRIPLA TAB 48 119

ATROPEN INJ 0.25MG 111 ATROPEN INJ 0.5MG 111 ATROPEN INJ 1MG 111 ATROPEN INJ 2MG 111 atropin-care sol 1% op 97 atropine sul inj 0.05mg/1 111 atropine sul inj 0.1mg/ml 111 atropine sul inj 0.4/0.5 111 atropine sul inj 0.4mg/ml 111 atropine sul inj 1mg/ml 111 ATROPINE SUL OIN 1% OP 97 atropine sul sol 1% op 97 ATROVENT HFA AER 17MCG 16 aug betamet cre 0.05% 69 aug betamet oin 0.05% 69 AUGMENTIN SUS 125/5ML 103 aurax sol 5.5-1.4% 100 aurodex sol otic 101 AUVI-Q INJ 0.15MG 115 AUVI-Q INJ 0.3MG 115 AVALIDE TAB 300-25MG 37 AVANDAMET TAB 2-1000MG 26 AVANDAMET TAB 2-500MG 26 AVANDAMET TAB 4-1000MG 26 AVANDAMET TAB 4-500MG 26 AVANDIA TAB 2MG 28 AVANDIA TAB 4MG 28 AVANDIA TAB 8MG 28 aveeno cre 1% 69 AVELOX ABC TAB 400MG 79 AVELOX TAB 400MG 79 aviane tab 58 avita cre 0.025% 64 avita gel 0.025% 64 AVODART CAP 0.5MG 81 AVONEX KIT 30MCG 104 AVONEX PEN KIT 30MCG 104 AVONEX PREFL KIT 30MCG 104 AXERT TAB 12.5MG 88 AXERT TAB 6.25MG 88 AZASAN TAB 100MG 51 AZASAN TAB 75 MG 51 azathioprine inj 100mg 51 azathioprine tab 50mg 51 azelastine dro 0.05% 100 azelastine spr 0.1% 96 AZELEX CRE 20% 64 AZILECT TAB 0.5MG 44 AZILECT TAB 1MG 44 azithromycin pow 1gm pak 85 azithromycin sus 100/5ml 85 azithromycin sus 200/5ml 85 azithromycin tab 250mg 85 azithromycin tab 500mg 85 azithromycin tab 600mg 85 AZOPT SUS 1% OP 100 azurette tab 28 day 58 B baby darlng sol ped elec 88 baciim inj 50000unt 12 bacit/polymy oin op 98 bacitracin inj 50000unt 12 bacitracin oin op 98 baclofen tab 10mg 95 baclofen tab 20mg 95 BACTOCILL INJ DEX 1GM 103 BACTOCILL INJ DEX 2GM 103 BACTROBAN OIN NASAL 2% 96 balsalazide cap 750mg 80 balziva tab 58 banophen cap 25mg 31 banophen cap 50mg 31 BANZEL SUS 40MG/ML 20 BANZEL TAB 200MG 20 BANZEL TAB 400MG 20 BARACLUDE SOL.05MG/ML 49 BARACLUDE TAB 0.5MG 49 BARACLUDE TAB 1MG 49 BARC LIQ 73 baycadron elx 0.5/5ml 61 bayer adv tab 325mg 6 bayer asa tab 325mg 6 BAYER BREEZE MIS 2 TEST 73 bayer low chw 81mg 6 bayer low tab 81mg ec 6 baza antifun cre 2% 66 BD NEEDLE MIS 27GX1.25 87 BD NEEDLES MIS 27GX1/2" 87 bella alk/pb tab 16.2mg 111 belladonna tin 30/100ml 111 benazep/hctz tab 10-12.5 37 benazep/hctz tab 20-12.5 37 benazep/hctz tab 20-25mg 37 benazep/hctz tab 5-6.25 37 benazepril tab 10mg 35 benazepril tab 20mg 35 benazepril tab 40mg 35 benazepril tab 5mg 35 BENICAR HCT TAB 20-12.5 37 BENICAR HCT TAB 40-12.5 37 BENICAR HCT TAB 40-25MG 37 BENICAR TAB 20MG 36 BENICAR TAB 40MG 36 BENICAR TAB 5MG 36 benzonatate cap 100mg 62 benzonatate cap 200mg 62 benzoyl per gel 10% 64 benzoyl per gel 5% 64 benzoyl per liq 10% wash 64 benzoyl per liq 5% wash 64 benztropine tab 0.5mg 43 benztropine tab 1mg 43 benztropine tab 2mg 43 BEPREVE DRO 1.5% 100 BESIVANCE SUS 0.6% 98 beta hc lot 1% 69 BETADINE SOL 5% OP 98 betameth dip cre 0.05% 69 120

betameth dip oin 0.05% 69 betameth val cre 0.1% 69 betameth val lot 0.1% 69 betameth val oin 0.1% 69 BETASERON INJ 0.3MG 104 betaxolol sol 0.5% op 97 betaxolol tab 10mg 52 betaxolol tab 20mg 52 bethanechol tab 10mg 114 bethanechol tab 25mg 114 bethanechol tab 50mg 114 bethanechol tab 5mg 114 BETIMOL SOL 0.25% 97 BETIMOL SOL 0.5% 97 BETOPTIC-S SUS 0.25% OP 97 bicalutamide tab 50mg 40 BILTRICIDE TAB 600MG 12 bio-d-mulsio liq 400unit 116 bio-statin pow 30 biocotron liq 100-10/5 62 BIOTIN FORTE TAB 91 bisoprl/hctz tab 10/6.25 37 bisoprl/hctz tab 2.5/6.25 37 bisoprl/hctz tab 5-6.25mg 37 bisoprol fum tab 10mg 52 bisoprol fum tab 5mg 52 BIVIGAM INJ 10% 101 BLEPHAMIDE OIN S.O.P. 99 BLEPHAMIDE SUS OP 99 BOSULIF TAB 100MG 41 BOSULIF TAB 500MG 41 bp gel gel 10% 64 bp gel gel 5% 64 bp wash liq 10% 64 bp wash liq 5% 64 bpo-10 wash liq 10% 65 bpo-5 wash liq 5% 64 briellyn tab 58 brimonidine sol 0.15% 98 brimonidine sol 0.2% op 98 bromfenac sol 0.09% 100 bromocriptin cap 5mg 43 bromocriptin tab 2.5mg 43 broncotron liq 10-100/5 62 buckleys liq chest 63 budeprion tab 100mg sr 23 budeprion tab 150mg sr 23 budeprion xl tab 150mg 23 budeprion xl tab 300mg 23 budesonide cap 3mg/24hr 61 budesonide sus 0.25mg/2 17 budesonide sus 0.5mg/2 17 bumetanide tab 0.5mg 74 bumetanide tab 1mg 74 bumetanide tab 2mg 74 bupap tab 50-650mg 5 BUPHENYL TAB 500MG 76 bupren/nalox sub 2-0.5mg 11 bupren/nalox sub 8-2mg 11 buprenorphin sub 2mg 11 buprenorphin sub 8mg 11 buproban tab 150mg 105 bupropion tab 100mg 23 bupropion tab 100mg er 23 bupropion tab 100mg sr 23 bupropion tab 150mg 105 bupropion tab 150mg er 23 bupropion tab 150mg sr 23 bupropion tab 200mg er 23 bupropion tab 200mg sr 23 bupropion tab 75mg 23 bupropn hcl tab 150mg xl 23 bupropn hcl tab 300mg xl 23 buspirone tab 10mg 14 buspirone tab 15mg 14 buspirone tab 30mg 15 buspirone tab 5mg 14 buspirone tab 7.5mg 14 but/apap/caf cap 5 but/apap/caf cap codeine 10 but/apap/caf tab 5 but/asa/caf/ cap cod 30mg 10 but/asa/caff cap 6 but/asa/caff tab 6 butal/apap tab 50-325mg 6 butalbital tab cpd 6 butorphanol sol 10mg/ml 11 BUTRANS DIS 10MCG/HR 11 BUTRANS DIS 20MCG/HR 11 BUTRANS DIS 5MCG/HR 11 BYETTA INJ 10MCG 27 BYETTA INJ 5MCG 27 BYSTOLIC TAB 10MG 52 BYSTOLIC TAB 2.5MG 52 BYSTOLIC TAB 20MG 52 BYSTOLIC TAB 5MG 52 C c-phen dm syp 62 cabergoline tab 0.5mg 76 caffeine cit sol 20mg/ml 1 caffeine cit sol 60mg/3ml 1 calc acetate cap 667mg 80 calc acetate tab 667mg 80 calcipotrien cre 0.005% 68 calcipotrien oin 0.005% 68 calcipotrien sol 0.005% 68 calcitonin spr 200/act 75 calcitrene oin 0.005% 68 calcitriol cap 0.25mcg 76 calcitriol cap 0.5mcg 76 calcitriol oin 3mcg/gm 68 calcitriol sol 1mcg/ml 76 caldecort cre 1% 69 camila tab 0.35mg 60 CAMPRAL TAB 333MG 103 CANASA SUP 1000MG 80 candesartan tab 16mg 36 candesartan tab 32mg 36 121

candesartan tab 4mg 36 candesartan tab 8mg 36 capacet cap 6 CAPRELSA TAB 100MG 41 CAPRELSA TAB 300MG 41 captopr/hctz tab 25-15mg 37 captopr/hctz tab 25-25mg 37 captopr/hctz tab 50-15mg 37 captopr/hctz tab 50-25mg 37 captopril tab 100mg 35 captopril tab 12.5mg 35 captopril tab 25mg 35 captopril tab 50mg 35 carb/levo er tab 25-100mg 43 carb/levo er tab 50-200mg 43 carb/levo sr tab 25-100mg 43 carb/levo sr tab 50-200mg 43 carb/levo tab 10-100mg 43 carb/levo tab 25-100mg 43 carb/levo tab 25-250mg 43 carbamazepin cap 100mg er 20 carbamazepin cap 200mg er 20 carbamazepin cap 300mg er 20 carbamazepin chw 100mg 20 carbamazepin sus 100/5ml 20 carbamazepin tab 200mg 20 carbamazepin tab 200mg er 20 carbamazepin tab 400mg er 20 carbinoxamin liq 4mg/5ml 31 carbinoxamin tab 4mg 31 CARDENE SR CAP 30MG 54 CARDENE SR CAP 45MG 54 CARDENE SR CAP 60MG 54 CARIMUNE NF INJ 12GM 101 CARIMUNE NF INJ 3GM 101 CARIMUNE NF INJ 6GM 101 carisopr/asa tab 200-325 95 carisoprodol tab 350mg 95 carisoprodol tab asa/cod 95 carteolol sol 1% op 97 cartia xt cap 120/24hr 54 cartia xt cap 180/24hr 54 cartia xt cap 240/24hr 54 cartia xt cap 300/24hr 54 carvedilol tab 12.5mg 52 carvedilol tab 25mg 52 carvedilol tab 3.125mg 52 carvedilol tab 6.25mg 52 CAVERJECT INJ 20MCG 56 CAVERJECT INJ 40MCG 56 CAVERJECT KIT 10MCG 56 CAVERJECT KIT 20MCG 56 caziant pak 58 CEDAX CAP 400MG 57 CEENU CAP 100MG 39 CEENU CAP 10MG 39 CEENU CAP 40MG 39 cefaclor cap 250mg 57 cefaclor cap 500mg 57 cefaclor sus 125/5ml 57 cefaclor sus 250/5ml 57 cefaclor sus 375/5ml 57 cefadroxil cap 500mg 57 cefadroxil sus 250/5ml 57 cefadroxil sus 500/5ml 57 cefadroxil tab 1gm 57 cefdinir cap 300mg 57 cefdinir sus 125/5ml 57 cefdinir sus 250/5ml 57 cefditoren tab 200mg 57 cefditoren tab 400mg 58 cefpodo prox sus 100/5ml 58 cefpodo prox sus 50mg/5ml 58 cefpodoxime tab 100mg 58 cefpodoxime tab 200mg 58 cefprozil sus 125/5ml 57 cefprozil sus 250/5ml 57 cefprozil tab 250mg 57 cefprozil tab 500mg 57 CEFTIN SUS 250/5ML 57 cefuroxime sus 125/5ml 57 cefuroxime tab 250mg 57 cefuroxime tab 500mg 57 CELEBREX CAP 100MG 4 CELEBREX CAP 200MG 4 CELEBREX CAP 400MG 4 CELEBREX CAP 50MG 4 CELLCEPT SUS 200MG/ML 51 CELONTIN CAP 300MG 22 CENESTIN TAB 0.3MG 77 CENESTIN TAB 0.45MG 77 CENESTIN TAB 0.625MG 77 CENESTIN TAB 0.9MG 77 CENESTIN TAB 1.25MG 78 centany oin 2% 66 cephadyn tab 50-650mg 6 cephalexin cap 250mg 57 cephalexin cap 500mg 57 cephalexin cap 750mg 57 cephalexin sus 125/5ml 57 cephalexin sus 250/5ml 57 cephalexin tab 250mg 57 cephalexin tab 500mg 57 ceron-dm syp 62 CESAMET CAP 1MG 30 cesia pak 58 cetirizine sol 1mg/ml 32 cetirizine sol 5mg/5ml 32 cetirizine syp 1mg/ml 32 cetirizine syp 5mg/5ml 32 cevimeline cap 30mg 91 CHANTIX PAK 0.5& 1MG 105 CHANTIX PAK 1MG 105 CHANTIX TAB 0.5MG 105 CHANTIX TAB 1MG 105 chateal tab 0.15/30 58 CHEMET CAP 100MG 29 cheratussin sol dac 62 cheratussin syp ac 62 chest conges liq child 63 122

chest conges liq childrns 63 child asa chw 81mg 6 child asa ls chw 81mg 6 child vit d chw 400unit 116 chloral hydr syp 500/5ml 83 chloramphen inj 1gm 13 chlord/clidi cap 5-2.5mg 111 chlordiazep cap 10mg 15 chlordiazep cap 25mg 15 chlordiazep cap 5mg 15 CHLORHEX DIG SOL 20% 47 chlorhex glu sol 0.12% 91 CHLORHEX GLU SOL 20% 47 chloroquine tab 250mg 38 chloroquine tab 500mg 38 chlorothiaz tab 250mg 75 chlorothiaz tab 500mg 75 chlorpromaz tab 100mg 46 chlorpromaz tab 10mg 46 chlorpromaz tab 200mg 46 chlorpromaz tab 25mg 46 chlorpromaz tab 50mg 46 chlorpropam tab 100mg 28 chlorpropam tab 250mg 28 chlorthalid tab 100mg 75 chlorthalid tab 25mg 75 chlorthalid tab 50mg 75 chlorzoxazon tab 500mg 95 cho mag tris liq 500/5ml 6 cho mag tris tab 1000mg 6 cho mag tris tab 500mg 6 cho mag tris tab 750mg 6 cholestyram pow 4gm 33 cholestyram pow 4gm lite 33 chor gonadot inj 10000unt 75 CIALIS TAB 10MG 56 CIALIS TAB 2.5MG 56 CIALIS TAB 20MG 56 CIALIS TAB 5MG 56 ciclodan cre 0.77% 66 ciclopirox cre 0.77% 66 ciclopirox gel 0.77% 66 ciclopirox sus 0.77% 66 cilostazol tab 100mg 82 cilostazol tab 50mg 82 cimetidine sol 300/5ml 112 cimetidine tab 200mg 112 cimetidine tab 300mg 112 cimetidine tab 400mg 112 cimetidine tab 800mg 112 CIMZIA KIT 80 CIPRO (10%) SUS 500MG/5 79 CIPRO (5%) SUS 250MG/5 79 CIPRO HC SUS OTIC 101 CIPRODEX SUS 0.3-0.1% 101 ciprofloxacn sol 0.3% op 98 ciprofloxacn tab 100mg 79 ciprofloxacn tab 250mg 79 ciprofloxacn tab 500mg 79 ciprofloxacn tab 750mg 79 citalopram sol 10mg/5ml 24 citalopram tab 10mg 24 citalopram tab 20mg 24 citalopram tab 40mg 24 CL PRENATAL TAB 28-0.8MG 93 claravis cap 10mg 65 claravis cap 20mg 65 claravis cap 30mg 65 claravis cap 40mg 65 clarithromyc sus 125/5ml 85 clarithromyc sus 250/5ml 85 clarithromyc tab 250mg 85 clarithromyc tab 500mg 85 claritin eye dro 0.025%op 100 clearlax pow 84 clearplex v gel 5% 65 clearplex x gel 10% 65 clemastine syp 0.5/5ml 31 clemastine tab 2.68mg 31 clindacin-p pad 1% 65 clindamax gel 1% 65 clindamax lot 10mg/ml 65 clindamy/ben gel 1-5% 65 clindamy/ben gel 1.2-5% 65 clindamycin aer 1% 65 clindamycin cap 150mg 13 clindamycin cap 300mg 13 clindamycin cap 75mg 13 clindamycin cre 2% vag 115 clindamycin gel 1% 65 clindamycin lot 1% 65 clindamycin lot 10mg/ml 65 clindamycin pad 1% 65 clindamycin sol 1% 65 CLINISTIX TES STRIPS 73 clobetasol cre 0.05% 69 clobetasol gel 0.05% 69 clobetasol oin 0.05% 69 clobetasol sol 0.05% 69 CLODERM CRE 0.1% 69 CLODERM CRE 0.1% PMP 69 clomipramine cap 25mg 25 clomipramine cap 50mg 25 clomipramine cap 75mg 25 clonazepam tab 0.5mg 20 clonazepam tab 1mg 20 clonazepam tab 2mg 20 clonidine dis 0.1/24hr 36 clonidine dis 0.2/24hr 36 clonidine dis 0.3/24hr 36 clonidine tab 0.1mg 36 clonidine tab 0.2mg 36 clonidine tab 0.3mg 36 clopidogrel tab 300mg 82 clopidogrel tab 75mg 82 cloraz dipot tab 15mg 15 cloraz dipot tab 3.75mg 15 cloraz dipot tab 7.5mg 15 clotrim/beta cre 1-0.05% 66 clotrim/beta cre diprop 66 123

clotrim/beta lot diprop 66 clotrimazole cre 1% 66 clotrimazole loz 10mg 91 clotrimazole sol 1% 66 clotrimazole tro 10mg 91 clozapine tab 100/odt 45 clozapine tab 100mg 45 clozapine tab 12.5/odt 45 clozapine tab 200mg 45 clozapine tab 25mg 45 clozapine tab 25mg odt 45 clozapine tab 50mg 45 co-gesic tab 5-500mg 10 COARTEM TAB 20-120MG 38 codeine sulf tab 15mg 8 codeine sulf tab 30mg 8 codeine sulf tab 60mg 8 COLCRYS TAB 0.6MG 81 colestipol gra 5gm 33 colestipol tab 1gm 33 colidrops dro 0.125/ml 111 COLY-MYCIN S SUS OTIC 101 COLYTE/FLAVR SOL PACKS 84 COMBIGAN SOL 0.2/0.5% 97 COMBIVENT AER 17 COMETRIQ KIT 100MG 41 COMETRIQ KIT 140MG 41 COMETRIQ KIT 60MG 41 comp allergy cap 25mg 31 COMPLERA TAB 48 COMPLETE-RF TAB PRENATAL 93 COMPLETENATE CHW 93 compro sup 25mg 46 CONCEPT DHA CAP 93 CONCEPT OB CAP 93 CONDOMS MIS 86 CONDYLOX GEL 0.5% 72 congest aid tab 30mg 96 congestion tab 30mg 96 constulose sol 10gm/15 84 COPAXONE KIT 20MG/ML 104 CORDRAN LOT 0.05% 69 CORDRAN SP CRE 0.05% 69 cormax oin 0.05% 69 cormax scalp sol 0.05% 69 cormax sol 0.05% 69 cort intense cre heal 1% 69 cortaid adv cre 1% 12 hr 69 cortaid cre 1% 69 CORTIFOAM AER 90MG 12 cortisone + cre 1% 69 cortisone ac tab 25mg 61 cortisone cre 1% 69 cortisone lot 1% 69 cortisone oin 1%max st 69 CORTISPORIN CRE 0.5% 66 CORTISPORIN OIN 1% 66 CORTISPORIN SUS -TC OTIC 101 cortizone-10 lot eczema 69 cortizone-10 lot hydraten 69 cortizone-10 oin 1% 69 COSOPT PF SOL 97 coughtab tab 200mg 63 covaryx hs tab 77 covaryx tab 77 COVERA-HS TAB 180MG 54 COVERA-HS TAB 240MG 54 CREON CAP 12000UNT 73 CREON CAP 24000UNT 73 CREON CAP 6000UNIT 73 CRESTOR TAB 10MG 34 CRESTOR TAB 20MG 34 CRESTOR TAB 40MG 34 CRESTOR TAB 5MG 34 CRIXIVAN CAP 100MG 48 CRIXIVAN CAP 200MG 48 CRIXIVAN CAP 400MG 48 cromolyn sod neb 20mg/2ml 16 cromolyn sod sol 4% op 100 cryselle-28 tab 28 tabs 58 CUPRIMINE CAP 250MG 51 curity salin sol 0.9% irr 81 cvs allergy cap 25mg 31 cvs allergy dro 0.025%op 100 cvs allergy tab 180mg 32 cvs aspirin tab 325mg 6 cvs aspirin tab 325mg ec 6 cvs aspirin tab 81mg ec 6 cvs chld asa chw 81mg 6 cvs cort int cre heal 1% 69 cvs daily tab multiple 92 cvs electrol sol 88 cvs nicotine dis 14mg/24h 105 cvs nicotine dis 21mg/24h 105 cvs nicotine dis 7mg/24hr 105 cvs nicotine gum 2mg cinn 105 cvs nicotine gum 2mg mint 105 cvs nicotine gum 2mg orig 105 cvs nicotine gum 2mgfruit 105 cvs nicotine gum 4mg cinn 105 cvs nicotine gum 4mg mint 105 cvs nicotine gum 4mg orig 105 cvs nicotine gum 4mgfruit 105 cvs nicotine loz 2mg mint 105 cvs nicotine loz 4mg mint 105 cvs nts dis step 1 105 CVS PRENATAL TAB 93 CVS PRENATAL TAB 28-0.8MG 93 cvs purelax pow 84 cvs purelax pow 3350 nf 84 cyclafem tab 1/35 58 cyclafem tab 7/7/7 58 cyclobenzapr tab 10mg 95 cyclobenzapr tab 5mg 95 CYCLOGYL SOL 0.5% OP 97 cyclopentol sol 1% op 97 cyclopentol sol 2% op 97 cyclophosph tab 25mg 39 cyclophosph tab 50mg 39 CYCLOSET TAB 0.8MG 27 124

cyclosporine cap 100mg 51 cyclosporine cap 100mg md 51 cyclosporine cap 25mg 51 cyclosporine cap 25mg mod 51 cyclosporine cap 50mg mod 51 cyclosporine sol modified 51 cylate sol 1% op 97 CYMBALTA CAP 20MG 25 CYMBALTA CAP 30MG 25 CYMBALTA CAP 60MG 25 cyproheptad syp 2mg/5ml 33 cyproheptad tab 4mg 33 CYSTAGON CAP 150MG 81 CYSTAGON CAP 50MG 81 cytra-k sol 81 D d-3 gummy chw 400unit 116 d-400 tab 400unit 116 d-vita liq 400unit 116 d3 kids chw 400unit 116 daily multi tab vitamin 92 daily multi tab vitamins 92 daily tab vitamin 92 daily value tab multivit 92 daily vit tab 92 daily vite tab 92 daily-vitamn tab 92 danazol cap 100mg 12 danazol cap 200mg 12 danazol cap 50mg 12 dantrolene cap 100mg 95 dantrolene cap 25mg 95 dantrolene cap 50mg 95 dapsone tab 100mg 13 dapsone tab 25mg 13 DARAPRIM TAB 25MG 38 dasetta tab 1/35 58 dasetta tab 7/7/7 58 DAYTRANA DIS 10MG/9HR 2 DAYTRANA DIS 15MG/9HR 2 DAYTRANA DIS 20MG/9HR 2 DAYTRANA DIS 30MG/9HR 2 DECARA CAP 25000UNT 116 decongestant tab 30mg 96 decongestant tab 60mg 96 delta d3 tab 400unit 116 demeclocycl tab 150mg 109 demeclocycl tab 300mg 109 DENAVIR CRE 1% 68 depade tab 50mg 29 DEPEN TITRA TAB 250MG 51 DEPO-ESTRADI INJ 5MG/ML 78 DEPO-PROVERA INJ 400/ML 40 DEPO-SQ PROV INJ 104 60 desenex cre 1% 66 desipramine tab 100mg 25 desipramine tab 10mg 25 desipramine tab 150mg 25 desipramine tab 25mg 25 desipramine tab 50mg 25 desipramine tab 75mg 25 desloratadin tab 2.5 odt 32 desloratadin tab 5mg 32 desloratadin tab 5mg odt 32 desmopressin inj 4mcg/ml 76 desmopressin sol 0.01% 76 desmopressin tab 0.1mg 76 desmopressin tab 0.2mg 76 desonide cre 0.05% 69 desonide lot 0.05% 69 desonide oin 0.05% 69 desoximetas cre 0.05% 69 desoximetas cre 0.25% 69 desoximetas gel 0.05% 69 desoximetas oin 0.05% 69 desoximetas oin 0.25% 69 DETROL LA CAP 2MG 114 dexameth pho sol 0.1% op 99 dexamethason con 1mg/ml 61 dexamethason elx 0.5/5ml 61 dexamethason sol 0.5/5ml 61 dexamethason tab 0.5mg 61 dexamethason tab 0.75mg 61 dexamethason tab 1.5mg 61 dexamethason tab 1mg 61 dexamethason tab 2mg 61 dexamethason tab 4mg 61 dexamethason tab 6mg 61 dexchlorphen syp 2mg/5ml 31 dexchlorphen tab 4mg cr 31 DEXILANT CAP 30MG DR 113 DEXILANT CAP 60MG DR 113 dexmethylph tab 10mg 2 dexmethylph tab 2.5mg 2 dexmethylph tab 5mg 2 dextroamphet cap 10mg er 1 dextroamphet cap 15mg er 1 dextroamphet cap 5mg er 1 dextroamphet tab 10mg 1 dextroamphet tab 5mg 1 diabetic tus liq 100/5ml 63 diabetic tus liq children 62 diabetic tus liq dm 62 dialyvite tab 91 dialyvite tab 800 91 diamode tab 2mg 29 DIASTIX TES STRIPS 73 diazepam sol 1mg/ml 15 diazepam tab 10mg 15 diazepam tab 2mg 15 diazepam tab 5mg 15 DIBENZYLINE CAP 10MG 35 diclofen pot tab 50mg 4 diclofenac sol 0.1% op 100 diclofenac tab 100mg er 4 diclofenac tab 100mg xr 4 diclofenac tab 25mg dr 4 diclofenac tab 50mg dr 4 125

diclofenac tab 75mg dr 4 dicloxacill cap 250mg 103 dicloxacill cap 500mg 103 dicyclomine cap 10mg 111 dicyclomine sol 10mg/5ml 111 dicyclomine tab 20mg 111 didanosine cap 125mg 48 didanosine cap 200mg 48 didanosine cap 250mg 48 didanosine cap 400mg 48 DIFFERIN GEL 0.3% 65 DIFICID TAB 200MG 85 diflorasone cre 0.05% 69 diflorasone oin 0.05% 69 diflunisal tab 500mg 6 digoxin sol 50mcg/ml 56 digoxin tab 0.125mg 56 digoxin tab 0.25mg 56 dihydroergot inj 1mg/ml 88 DILANTIN CAP 30MG 22 DILATRATE SR CAP 40MG 14 dilt-cd cap 120mg 54 dilt-cd cap 180mg 54 dilt-cd cap 240mg 54 dilt-cd cap 300mg 54 dilt-xr cap 120mg 54 dilt-xr cap 180mg 54 dilt-xr cap 240mg 54 diltiazem cap 120mg cd 54 diltiazem cap 120mg er 54 diltiazem cap 120mg/24 54 diltiazem cap 180mg cd 54 diltiazem cap 180mg er 54 diltiazem cap 180mg/24 54 diltiazem cap 240mg cd 54 diltiazem cap 240mg er 54 diltiazem cap 240mg/24 54 diltiazem cap 300mg cd 54 diltiazem cap 300mg er 54 diltiazem cap 300mg/24 54 diltiazem cap 360mg cd 54 diltiazem cap 360mg er 54 diltiazem cap 360mg/24 54 diltiazem cap 420mg/24 54 diltiazem cap 60mg er 54 diltiazem cap 90mg er 54 diltiazem tab 120mg 54 diltiazem tab 30mg 54 diltiazem tab 60mg 54 diltiazem tab 90mg 54 diltzac cap 120mg/24 54 diltzac cap 180mg/24 54 diltzac cap 240mg/24 54 diltzac cap 300mg/24 54 diltzac cap 360mg/24 54 dimenhydrin tab 50mg 30 DIOVAN TAB 160MG 36 DIOVAN TAB 320MG 36 DIOVAN TAB 40MG 36 DIOVAN TAB 80MG 36 DIPENTUM CAP 250MG 80 diphen/atrop liq 2.5/5 29 diphen/atrop tab 2.5mg 29 diphenhist cap 25mg 31 diphenhydram cap 25mg 31 diphenhydram cap 50mg 31 diphenhydram elx 12.5/5ml 32 diphenhydram inj 50mg/ml 32 dipyridamole tab 25mg 82 dipyridamole tab 50mg 82 dipyridamole tab 75mg 82 disopyramide cap 100mg 15 disopyramide cap 150mg 15 disulfiram tab 250mg 103 disulfiram tab 500mg 103 divalproex cap 125mg 22 divalproex tab 125mg dr 22 divalproex tab 250mg dr 22 divalproex tab 250mg er 22 divalproex tab 500mg dr 22 divalproex tab 500mg er 22 DIVIGEL GEL 0.25MG 78 DIVIGEL GEL 0.5MG 78 DIVIGEL GEL 1MG/GM 78 dm/gg sol 62 dm/gg sol 10-100/5 62 donepezil tab 10mg 103 donepezil tab 10mg odt 103 donepezil tab 5mg 103 donepezil tab 5mg odt 103 DORAL TAB 15MG 83 dormin cap 25mg 32 dorzol/timol sol 2-0.5%op 97 dorzolamide sol 2% op 100 doxazosin tab 1mg 36 doxazosin tab 2mg 36 doxazosin tab 4mg 36 doxazosin tab 8mg 36 doxepin hcl cap 100mg 25 doxepin hcl cap 10mg 25 doxepin hcl cap 150mg 26 doxepin hcl cap 25mg 25 doxepin hcl cap 50mg 25 doxepin hcl cap 75mg 25 doxepin hcl con 10mg/ml 26 doxycyc mono cap 100mg 109 doxycyc mono cap 50mg 109 DOXYCYCL HYC CAP 100MG 109 doxycycl hyc cap 100mg 109 doxycycl hyc cap 50mg 109 DOXYCYCL HYC CAP 75MG 109 doxycycl hyc tab 100mg 109 doxycycline cap 150mg 109 doxycycline cap 75mg 109 doxycycline sus 25mg/5ml 109 doxycycline tab 20mg 109 dramamine tab 25mg 30 driminate tab 50mg 30 dronabinol cap 10mg 30 dronabinol cap 2.5mg 30 126

dronabinol cap 5mg 30 drospir/ethi tab 3-0.03mg 58 dulcolax pow balance 84 DULERA AER 100-5MCG 17 DULERA AER 200-5MCG 18 DUREZOL EMU 0.05% 99 DYNACIRC CR TAB 10MG 55 DYNACIRC CR TAB 5MG 55 DYRENIUM CAP 100MG 74 DYRENIUM CAP 50MG 74 dytuss syp 12.5/5ml 32 E e.e.s. 400 tab 400mg 85 E.E.S. GRAN SUS 200/5ML 85 e.s.p. sus 200-600 13 e/c/beta car tab 92 econazole cre 1% 66 ecotrin low tab 81mg ec 6 ecpirin tab 325mg ec 6 ed baclofen tab 10mg 95 ed-spaz tab 0.125mg 111 EDARBI TAB 40MG 36 EDARBI TAB 80MG 36 EDECRIN TAB 25MG 74 EDEX KIT 10MCG 56 EDEX KIT 20MCG 56 EDEX KIT 40MCG 56 EDURANT TAB 25MG 48 eemt hs tab 77 eemt tab 77 ees/sulfisox sus 200-600 13 effer-k tab 25meq ef 90 EFFIENT TAB 10MG 82 EFFIENT TAB 5MG 82 ELELYSO INJ 200UNIT 82 ELESTRIN GEL 0.06% 78 ELIDEL CRE 1% 72 ELIGARD INJ 22.5MG 40 ELIGARD INJ 30MG 40 ELIGARD INJ 45MG 40 ELIGARD INJ 7.5MG 40 elinest tab 58 ELIXOPHYLLIN ELX 80/15ML 18 ELLA TAB 30MG 60 ELMIRON CAP 100MG 81 ELSPAR INJ 10000UNT 42 EMADINE SOL 0.05% OP 100 EMCYT CAP 140MG 40 EMEND CAP 125MG 30 EMEND CAP 40MG 30 EMEND CAP 80MG 30 emoquette tab 58 EMSAM DIS 12MG/24H 24 EMSAM DIS 6MG/24HR 24 EMSAM DIS 9MG/24HR 24 EMTRIVA CAP 200MG 48 EMTRIVA SOL 10MG/ML 48 ENABLEX TAB 7.5MG 114 enalapril tab 10mg 35 enalapril tab 2.5mg 35 enalapril tab 20mg 35 enalapril tab 5mg 35 ENBREL INJ 25/0.5ML 5 ENBREL INJ 25MG 5 ENBREL INJ 50MG/ML 5 ENBREL SRCLK INJ 50MG/ML 5 encare gel 4% 115 endodan tab 11 ENJUVIA TAB 0.3MG 78 ENJUVIA TAB 0.45MG 78 ENJUVIA TAB 0.625MG 78 ENJUVIA TAB 0.9MG 78 ENJUVIA TAB 1.25MG 78 enoxaparin inj 100mg/ml 19 enoxaparin inj 120/0.8 19 enoxaparin inj 150mg/ml 19 enoxaparin inj 30/0.3ml 19 enoxaparin inj 300/3ml 19 enoxaparin inj 40/0.4ml 19 enoxaparin inj 60/0.6ml 19 enoxaparin inj 80/0.8ml 19 enpresse-28 tab 58 enskyce tab 58 entacapone tab 200mg 43 enulose sol 10gm/15 80 epidrin cap 87 EPIDUO GEL 0.1-2.5% 65 epiflur chw 0.25mg f 89 epiflur chw 0.5mg f 89 epiflur chw 1mg f 89 epiklor pow 20meq 90 epiklor/25 pow 25meq 90 epinastine dro 0.05% 100 epinephrine inj 0.15mg 115 epinephrine inj 0.1mg/ml 18 epinephrine inj 0.3mg 115 epinephrine inj 1mg/ml 18 EPIPEN 2-PAK INJ 0.3MG 115 EPIPEN INJ 0.3MG 115 EPIPEN-JR INJ 0.15MG 116 EPIPEN-JR INJ 2-PAK 116 epitol tab 200mg 20 EPIVIR HBV SOL 5MG/ML 48 EPIVIR HBV TAB 100MG 48 EPIVIR SOL 10MG/ML 48 eplerenone tab 25mg 38 eplerenone tab 50mg 38 EPOGEN INJ 10000/ML 82 EPOGEN INJ 2000/ML 82 EPOGEN INJ 20000/ML 82 EPOGEN INJ 3000/ML 82 EPOGEN INJ 4000/ML 82 eprosart mes tab 600mg 36 EPZICOM TAB 600-300 48 eq allergy cap 25mg 32 eq aspirin tab 325mg 7 eq aspirin tab 325mg ec 7 eq child asa chw 81mg 7 127

eq heartburn tab relief 112 eq hydrocort cre 1% 70 eq itchy eye dro 0.025%op 100 eq nicotine dis 14mg/24h 105 eq nicotine dis 21mg/24h 105 eq nicotine dis 7mg/24hr 105 eq nicotine gum 2mg cinn 105 eq nicotine gum 2mg mint 105 eq nicotine gum 2mg orig 105 eq nicotine gum 2mgfruit 105 eq nicotine gum 4mg cinn 105 eq nicotine gum 4mg mint 105 eq nicotine gum 4mg orig 105 eq nicotine gum 4mg ref 105 eq nicotine gum 4mg strt 105 eq nicotine gum 4mgfruit 105 eq nicotine loz 2mg cher 105 eq nicotine loz 2mg mint 105 eq nicotine loz 4mg chry 105 eq nicotine loz 4mg mint 105 eq suphedrin tab 30mg 96 eq tussin liq 100/5ml 63 eql allergy cap 25mg 32 eql aspirin tab 325mg 7 eql aspirin tab 325mg ec 7 eql aspirin tab 81mg ec 7 eql chld asa chw 81mg 7 eql clearlax pow 84 eql nicotine dis 14mg/24h 105 eql nicotine dis 21mg/24h 105 eql nicotine dis 7mg/24hr 105 eql nicotine gum 2mg 106 eql nicotine gum 2mg ref 106 eql nicotine gum 2mg strt 106 eql nicotine gum 4mg 106 eql nicotine gum 4mg ref 106 eql nicotine gum 4mg strt 106 eql nicotine loz 2mg mint 106 eql nicotine loz 4mg mint 106 eql one dail tab essentia 92 EQL PRENATAL TAB FORMULA 94 EQUETRO CAP 100MG 44 EQUETRO CAP 200MG 44 EQUETRO CAP 300MG 44 ergocalcifer cap 50000unt 116 ergoloid mes tab 1mg oral 104 ERGOMAR SUB 2MG 88 ERIVEDGE CAP 150MG 40 errin tab 0.35mg 60 ERTACZO CRE 2% 66 ery pad 2% 65 ERY-TAB TAB 250MG EC 85 ERY-TAB TAB 333MG EC 85 ERY-TAB TAB 500MG EC 85 ERYPED SUS 200/5ML 85 ERYPED SUS 400/5ML 85 erythrocin tab 250mg 85 erythrom eth tab 400mg 85 erythromycin cap 250mg ec 85 erythromycin gel /benzoyl 65 erythromycin gel 2% 65 erythromycin oin 5mg/gm 98 erythromycin oin op 98 erythromycin pad 2% 65 erythromycin sol 2% 65 erythromycin tab 250mg bs 85 erythromycin tab 500mg bs 85 escitalopram sol 5mg/5ml 24 escitalopram tab 10mg 24 escitalopram tab 20mg 24 escitalopram tab 5mg 24 essentl one tab daily 92 essian h.s. tab 77 essian tab 77 est estrogen tab mtest 77 est estrogen tab mtest ds 77 est estrogen tab mtest hs 77 estarylla tab 0.25-35 58 estazolam tab 1mg 83 estazolam tab 2mg 83 ESTRACE VAG CRE 0.1MG/GM 115 estrad val inj 10mg/ml 78 estrad val inj 200mg/5 78 estrad val inj 20mg/ml 78 estrad val inj 40mg/ml 78 ESTRADERM DIS 0.05MG 78 ESTRADERM DIS 0.1MG 78 estradiol dis 0.025mg 78 estradiol dis 0.0375mg 78 estradiol dis 0.05mg 78 estradiol dis 0.06mg 78 estradiol dis 0.075mg 78 estradiol dis 0.1mg 78 estradiol tab 0.5mg 78 estradiol tab 1mg 78 estradiol tab 2mg 78 ESTRASORB EMU 78 ESTRING MIS 2MG 115 ESTROGEL GEL 78 estropipate tab 0.75mg 78 estropipate tab 1.5mg 78 estropipate tab 3mg 78 ethambutol tab 100mg 39 ethambutol tab 400mg 39 ethosuximide cap 250mg 22 ethosuximide sol 250/5ml 22 etidron disd tab 200mg 75 etidron disd tab 400mg 75 etodolac cap 200mg 4 etodolac cap 300mg 4 etodolac er tab 400mg 4 etodolac er tab 500mg 4 etodolac er tab 600mg 4 etodolac tab 400mg 4 etodolac tab 500mg 4 etoposide cap 50mg 42 etoposide inj 20mg/ml 42 EURAX CRE 10% 73 EURAX LOT 10% 73 EVAMIST SPR 1.53MG 78 128

EVISTA TAB 60MG 76 EXELDERM CRE 1% 66 EXELDERM SOL 1% 66 exemestane tab 25mg 40 EXJADE TAB 125MG 29 EXJADE TAB 250MG 29 EXJADE TAB 500MG 29 EXTAVIA INJ 0.3MG 104 eye itch rel dro 0.025%op 100 EZ USE FLU KIT 2012-13 114 F fa-8 tab 0.8mg 82 FABRAZYME INJ 5MG 76 FACTIVE TAB 320MG 79 falmina tab 58 famciclovir tab 125mg 50 famciclovir tab 250mg 50 famciclovir tab 500mg 50 famotidine sus 40mg/5ml 112 famotidine tab 20mg 112 famotidine tab 40mg 112 FANAPT PAK 44 FANAPT TAB 10MG 44 FANAPT TAB 12MG 44 FANAPT TAB 1MG 44 FANAPT TAB 2MG 44 FANAPT TAB 4MG 44 FANAPT TAB 6MG 44 FANAPT TAB 8MG 44 FARESTON TAB 60MG 40 FAZACLO TAB 150MG 45 FAZACLO TAB 200MG 45 FC FEMALE MIS CONDOM 86 FC2 FEMALE MIS CONDOM 86 felbamate sus 600/5ml 22 felbamate tab 400mg 22 felbamate tab 600mg 22 felodipine tab 10mg er 55 felodipine tab 2.5mg er 55 felodipine tab 5mg er 55 FEMCAP MIS 22MM 86 FEMCAP MIS 26MM 86 FEMCAP MIS 30MM 86 FEMTRACE TAB 0.45MG 78 FEMTRACE TAB 0.9MG 78 FEMTRACE TAB 1.8MG 78 fenofibrate cap 134mg 34 fenofibrate cap 200mg 34 fenofibrate cap 67mg 34 fenofibrate tab 145mg 34 fenofibrate tab 160mg 34 fenofibrate tab 48mg 34 fenofibrate tab 54mg 34 fenoprofen tab 600mg 4 fentanyl dis 100mcg/h 8 fentanyl dis 12mcg/hr 8 fentanyl dis 25mcg/hr 8 fentanyl dis 50mcg/hr 8 fentanyl dis 75mcg/hr 8 fentanyl ot loz 1200mcg 8 fentanyl ot loz 1600mcg 8 fentanyl ot loz 200mcg 8 fentanyl ot loz 400mcg 8 fentanyl ot loz 600mcg 8 fentanyl ot loz 800mcg 8 FENTORA TAB 100MCG 8 FENTORA TAB 200MCG 8 FENTORA TAB 400MCG 8 FENTORA TAB 600MCG 8 FENTORA TAB 800MCG 8 fer-iron dro 15mg/ml 83 FERRIPROX TAB 500MG 29 ferrocite tab plus 83 ferrous dro 15mg/ml 83 ferrous sulf dro 15mg/ml 83 ferrous sulf elx 220/5ml 83 fexofenadine tab 180mg 33 fexofenadine tab 30mg 32 fexofenadine tab 60mg 33 FINACEA GEL 15% 72 finasteride tab 1mg 72 finasteride tab 5mg 81 FLAGYL ER TAB 750MG 12 flanax pain tab 220mg 4 FLAREX SUS 0.1% OP 99 flavoxate tab 100mg 114 FLEBOGAMMA INJ 10% 101 FLEBOGAMMA INJ 5% 101 FLEBOGAMMA INJ DIF 5% 101 flecainide tab 100mg 16 flecainide tab 150mg 16 flecainide tab 50mg 16 FLOVENT DISK AER 100MCG 17 FLOVENT DISK AER 250MCG 17 FLOVENT DISK AER 50MCG 17 FLOVENT HFA AER 110MCG 17 FLOVENT HFA AER 220MCG 17 FLOVENT HFA AER 44MCG 17 FLUARIX INJ PF 10-11 114 FLUARIX INJ PF 11-12 114 FLUARIX INJ PF 12-13 114 fluconazole sus 10mg/ml 31 fluconazole sus 40mg/ml 31 fluconazole tab 100mg 31 fluconazole tab 150mg 31 fluconazole tab 200mg 31 fluconazole tab 50mg 31 flucytosine cap 250mg 30 flucytosine cap 500mg 30 fludrocort tab 0.1mg 62 FLULAVAL INJ 2010-11 114 FLULAVAL INJ 2011-12 114 FLULAVAL INJ 2012-13 114 flunisolide spr 0.025% 96 flunisolide spr 29mcg 96 fluocin acet cre 0.01% 70 fluocin acet cre 0.025% 70 fluocin acet oil 0.01% 101 129

fluocin acet oin 0.025% 70 fluocin acet sol 0.01% 70 fluocinonide cre 0.05% 70 fluocinonide gel 0.05% 70 fluocinonide oin 0.05% 70 fluocinonide sol 0.05% 70 fluor-a-day dro 0.125mg 89 fluor-op sus 0.1% op 99 fluoride chw 0.25mg f 89 fluoride chw 0.5mg f 89 fluoride chw 1mg f 89 fluoritab chw 0.25mg f 89 fluoritab chw 0.5mg f 89 fluoritab chw 1mg f 89 fluoritab chw 2.2mg 89 fluoritab dro 0.125mg 89 fluoromethol sus 0.1% op 99 fluorouracil cre 5% 67 fluorouracil dro 2% 67 fluorouracil dro 5% 67 fluorouracil inj 1gm/20ml 39 fluorouracil inj 2.5g/50m 39 fluorouracil inj 500/10ml 39 fluorouracil inj 5gm/100m 39 fluorouracil sol 2% 67 fluorouracil sol 5% 67 fluoxetine cap 10mg 24, 104 fluoxetine cap 20mg 24, 104 fluoxetine cap 40mg 24 fluoxetine cap 90mg dr 24 fluoxetine sol 20mg/5ml 24 fluoxetine tab 10mg 24 fluoxetine tab 20mg 24 fluoxetine tab 60mg 24 fluphenaz de inj 25mg/ml 46 fluphenazine con 5mg/ml 46 fluphenazine elx 2.5/5ml 46 fluphenazine tab 10mg 46 fluphenazine tab 1mg 46 fluphenazine tab 2.5mg 46 fluphenazine tab 5mg 46 flura-drops dro 0.125mg 89 flura-drops dro 0.25mg f 89 flurazepam cap 15mg 83 flurazepam cap 30mg 83 flurbiprofen sol 0.03% op 100 flurbiprofen tab 100mg 4 flurbiprofen tab 50mg 4 flush syring inj 0.9% 90 flutamide cap 125mg 40 fluticasone cre 0.05% 70 fluticasone oin 0.005% 70 fluticasone spr 50mcg 96 fluvastatin cap 20mg 34 fluvastatin cap 40mg 34 FLUVASTATIN TAB 80MG ER 34 FLUVIRIN INJ 2011-12 114 FLUVIRIN INJ 2012-13 114 FLUVIRIN INJ PF 11-12 114 FLUVIRIN INJ PF 12-13 114 fluvoxamine tab 100mg 24 fluvoxamine tab 25mg 24 fluvoxamine tab 50mg 24 FLUZONE INJ INTRADRM 114 FLUZONE INJ PF 11-12 115 FLUZONE INJ PF 12-13 115 FLUZONE PED/ INJ PF 11-12 115 FLUZONE PED/ INJ PF 12-13 115 FLUZONE QUAD INJ 13-14 115 FLUZONE SPLT INJ 2011-12 115 FLUZONE SPLT INJ 2012-13 115 FML FORTE SUS 0.25% OP 99 FML OIN 0.1% OP 99 foaming face liq wsh 10% 65 FOCALIN XR CAP 10MG 2 FOCALIN XR CAP 15MG 2 FOCALIN XR CAP 20MG 2 FOCALIN XR CAP 25MG 2 FOCALIN XR CAP 30MG 2 FOCALIN XR CAP 35MG 2 FOCALIN XR CAP 40MG 2 FOCALIN XR CAP 5MG 2 folbee plus tab 91 folic acid tab 1000mcg 82 folic acid tab 1mg 82 folic acid tab 400mcg 82 folic acid tab 800mcg 82 FOLIVANE-OB CAP 94 fondaparinux sol 10/0.8 19 fondaparinux sol 2.5/0.5 19 fondaparinux sol 5.0/0.4 19 fondaparinux sol 7.5/0.6 19 FORADIL CAP AEROLIZE 18 FORTEO SOL 600/2.4 75 FOSAMAX + D TAB 70-2800 75 FOSAMAX + D TAB 70-5600 75 fosinopril tab 10mg 35 fosinopril tab 20mg 35 fosinopril tab 40mg 35 FOSRENOL CHW 1000MG 80 FOSRENOL CHW 500MG 80 FOSRENOL CHW 750MG 80 FRAGMIN INJ 10000/ML 19 FRAGMIN INJ 12500UNT 20 FRAGMIN INJ 15000UNT 20 FRAGMIN INJ 18000UNT 20 FRAGMIN INJ 2500/0.2 19 FRAGMIN INJ 25000/ML 20 FRAGMIN INJ 5000/0.2 19 FRAGMIN INJ 7500/0.3 19 FROVA TAB 2.5MG 88 FULL SPECT TAB B/ VIT C 91 fungicure spr intens 66 furosemide sol 10mg/ml 74 furosemide tab 20mg 74 furosemide tab 40mg 74 furosemide tab 80mg 74 FUZEON INJ 90MG 48 FUZEON KIT 48 130

G g-tron liq 10-100/5 62 gabapentin cap 100mg 20 gabapentin cap 300mg 20 gabapentin cap 400mg 20 gabapentin tab 600mg 20 gabapentin tab 800mg 20 GABITRIL TAB 12MG 22 GABITRIL TAB 16MG 22 galantamine cap 16mg er 103 galantamine cap 24mg er 103 galantamine cap 8mg er 103 galantamine tab 12mg 103 galantamine tab 4mg 103 galantamine tab 8mg 103 GAMASTAN S/D INJ 101 GAMMAGARD INJ 10GM/100 101 GAMMAGARD INJ 1GM/10ML 101 GAMMAGARD INJ 2.5GM/25 101 GAMMAGARD INJ 20GM/200 101 GAMMAGARD INJ 30GM/300 101 GAMMAGARD INJ 5GM/50ML 101 GAMMAGARD SD INJ 10GM HU 101 GAMMAGARD SD INJ 2.5GM HU 101 GAMMAGARD SD INJ 5GM HU 101 GAMMAKED INJ 10GM/100 101 GAMMAKED INJ 1GM/10ML 101 GAMMAKED INJ 2.5GM/25 101 GAMMAKED INJ 20GM/200 101 GAMMAKED INJ 5GM/50ML 101 GAMMAPLEX INJ 10GM 101 GAMMAPLEX INJ 2.5GM 101 GAMMAPLEX INJ 5GM 101 GAMUNEX INJ 10% 101 GAMUNEX-C INJ 10GM/100 102 GAMUNEX-C INJ 1GM/10ML 102 GAMUNEX-C INJ 2.5GM/25 102 GAMUNEX-C INJ 20GM/200 102 GAMUNEX-C INJ 5GM/50ML 102 ganciclovir cap 250mg 49 ganciclovir cap 500mg 49 gani-tuss dm liq 100-10/5 62 gani-tuss nr liq 100-10/5 62 ganidin-nr liq 100/5ml 63 garamycin oin 0.3% op 98 gavilax pow 84 gavilyte-c sol 84 gavilyte-g sol 84 gavilyte-n sol flav pk 84 gemfibrozil tab 600mg 34 genahist cap 25mg 32 genaphed tab 30mg 96 generlac sol 10gm/15 80 gengraf cap 100mg 51 gengraf cap 25mg 51 gengraf sol 100mg/ml 51 gentak oin 0.3% op 98 gentak sol 0.3% op 98 gentamicin cre 0.1% 66 gentamicin oin 0.1% 66 gentamicin oin 0.3% op 98 gentamicin sol 0.3% op 98 gentasol sol 0.3% op 98 gentlelax pow 84 geri-dryl cap 25mg 32 geri-hydrola cre 12% 71 geri-hydrola lot 12% 71 gg/codeine sol 100-10/5 62 gianvi tab 3-0.02mg 58 gildagia tab 0.4-35 58 gildess fe tab 1.5/30 58 gildess fe tab 1/20 58 gildess tab 1.5/30 58 gildess tab 1/20 58 GLASSIA INJ 108 GLEEVEC TAB 100MG 41 GLEEVEC TAB 400MG 41 GLIADEL WAF 7.7MG 39 glimepiride tab 1mg 28 glimepiride tab 2mg 28 glimepiride tab 4mg 28 glipizide er tab 10mg 28 glipizide er tab 2.5mg 28 glipizide er tab 5mg 28 glipizide tab 10mg 28 glipizide tab 5mg 28 glipizide xl tab 10mg 28 glipizide xl tab 2.5mg 28 glipizide xl tab 5mg 28 GLUCAGEN INJ 1MG 27 GLUCAGEN INJ HYPOKIT 27 GLUCAGON KIT 1MG 27 GLUMETZA TAB 1000MG 26 GLUMETZA TAB 500MG 26 glyburid mcr tab 1.5mg 28 glyburid mcr tab 3mg 28 glyburid mcr tab 6mg 28 glyburide tab 1.25mg 28 glyburide tab 2.5mg 28 glyburide tab 5mg 28 glycolax pow 3350 nf 84 glycopyrrol tab 1mg 111 glycopyrrol tab 2mg 111 GLYSET TAB 100MG 26 GLYSET TAB 25MG 26 GLYSET TAB 50MG 26 gnp allergy cap 25mg 32 gnp allergy tab 180mg 33 gnp aspirin chw 81mg 7 gnp aspirin tab 325mg 7 gnp aspirin tab 325mg ec 7 gnp aspirin tab 81mg ec 7 gnp clearlax pow 84 gnp hydrocor cre 1% plus 70 gnp lice egg gel remover 73 gnp nicotine gum 2mg mint 106 gnp nicotine gum 2mg orig 106 gnp nicotine gum 4mg mint 106 gnp nicotine gum 4mg orig 106 131

gnp nicotine loz 2mg mint 106 gnp nicotine loz 4mg mint 106 gnp pediatri sol electrol 88 GNP PRENATAL TAB 28-0.8MG 94 gnp tussin liq dm 62 gnp tussin liq dm cough 62 gnp vit d tab 400unit 116 granisetron tab 1mg 29 GRANISOL SOL 2MG/10ML 29 griseofulvin sus 125/5ml 30 griseofulvin tab micr 500 30 griseofulvin tab ultr 125 30 griseofulvin tab ultr 250 30 guaiasorb dm liq 100-10/5 62 guaiatussin syp ac 62 guaifenesin liq nr 63 guaifenesin sol 100/5ml 63 guaifenesin sol 200/10ml 63 guaifenesin sol 300/15ml 63 guaifenesin sol dac 62 guaifenesin syp ac 62 guaifenesin tab 200mg 63 guanfacine tab 1mg 36 guanfacine tab 2mg 36 GUANIDINE TAB 125MG 38 H halfprin tab 81mg ec 7 halobetasol cre 0.05% 70 halobetasol oin 0.05% 70 HALOG CRE 0.1% 70 HALOG OIN 0.1% 70 haloperidol con 2mg/ml 45 haloperidol tab 0.5mg 45 haloperidol tab 10mg 45 haloperidol tab 1mg 45 haloperidol tab 20mg 45 haloperidol tab 2mg 45 haloperidol tab 5mg 45 hc pramoxine cre 1-1% 12 hc pramoxine cre 1-2.5% 70 hc pramoxine cre 2.5-1% 12 hc valerate cre 0.2% 70 hc valerate oin 0.2% 70 hc/acet acid sol otic 101 healthylax pow 84 heartbrn rel tab 200mg 112 heartburn tab 150mg 112 heartburn tab 200mg 112 heartburn tab 20mg 112 heartburn tab relief 112 heather tab 0.35mg 61 hecoria cap 0.5mg 51 hecoria cap 1mg 51 hecoria cap 5mg 51 HECTOROL CAP 0.5MCG 76 HECTOROL CAP 1MCG 76 HECTOROL CAP 2.5MCG 76 HELIDAC MIS 113 hematinic pl tab vit/min 83 hematinic/fa tab 83 hemocyte tab -plus 83 hemocyte-f tab 83 hemril-30 sup 30mg 12 heparin sod inj 1000/ml 20 heparin sod inj 10000/ml 20 heparin sod inj 20000/ml 20 HEPSERA TAB 10MG 50 HEXALEN CAP 50MG 39 hm aspirin chw 81mg 7 hm aspirin tab 325mg 7 hm clearlax pow 84 hm nicotine dis 14mg/24h 106 hm nicotine dis 21mg/24h 106 hm nicotine gum 2mg mint 106 hm nicotine gum 4mg mint 106 hm nicotine loz 2mg mint 106 hm nicotine loz 4mg mint 106 HM PRENATAL TAB 94 hm tussin liq adlt dm 62 homatropaire sol 5% op 97 homatropine sol 5% op 97 HORIZANT TAB 600MG 105 hrtbrn rel cap 15mg dr 113 HUMALOG INJ 100/ML 27 HUMALOG KWIK INJ 100/ML 27 HUMALOG MIX INJ 50/50 27 HUMALOG MIX INJ 50/50KWP 27 HUMALOG MIX INJ 75/25KWP 27 HUMALOG MIX SUS 75/25 27 HUMIRA KIT 20MG/0.4 3 HUMIRA KIT 40MG/0.8 3 HUMIRA PEN KIT 40MG/0.8 3 HUMIRA PEN KIT CROHNS 3 HUMIRA PEN KIT PSORIASI 3 HUMULIN INJ 70/30 27 HUMULIN N INJ U-100 27 HUMULIN N PN INJ U-100 27 HUMULIN PEN INJ 70/30 27 HUMULIN R INJ U-100 27 HUMULIN R INJ U-500 27 HYCAMTIN CAP 0.25MG 42 HYCAMTIN CAP 1MG 43 hydralazine tab 100mg 38 hydralazine tab 10mg 38 hydralazine tab 25mg 38 hydralazine tab 50mg 38 hydro-lotion lot 1% 70 hydrochlorot cap 12.5mg 75 hydrochlorot tab 12.5mg 75 hydrochlorot tab 25mg 75 hydrochlorot tab 50mg 75 hydroco/apap sol 7.5-325 11 hydroco/apap sol 7.5-500 11 hydroco/apap tab 10-325mg 11 hydroco/apap tab 10-500mg 11 hydroco/apap tab 10-650mg 11 hydroco/apap tab 2.5-500 11 hydroco/apap tab 5-325mg 11 132

hydroco/apap tab 5-500mg 11 hydroco/apap tab 7.5-325 11 hydroco/apap tab 7.5-500 11 hydroco/apap tab 7.5-650 11 hydroco/apap tab 7.5-750 11 hydrocod/hom syp 5-1.5/5 62 hydrocod/ibu tab 7.5-200 11 hydrocort ac sup 25mg 12 hydrocort ac sup 30mg 12 hydrocort cre 1% 70 hydrocort cre 1% plus 70 hydrocort cre 1%pls 10 70 hydrocort cre 1%pls 12 70 hydrocort cre 2.5% 70 hydrocort lot 1% 70 hydrocort lot 2.5% 70 hydrocort oin 1% 70 hydrocort oin 2.5% 70 hydrocort tab 10mg 61 hydrocort tab 20mg 61 hydrocort tab 5mg 61 hydrocort/ab oin 1% 70 hydrocream cre 1% 70 hydromet syp 5-1.5/5 62 hydromorphon liq 1mg/ml 8 hydromorphon tab 2mg 8 hydromorphon tab 4mg 8 hydromorphon tab 8mg 8 hydroskin cre 1% 70 hydroxychlor tab 200mg 38 hydroxyurea cap 500mg 42 hydroxyz hcl inj 25mg/ml 15 hydroxyz hcl inj 50mg/ml 15 hydroxyz hcl sol 10mg/5ml 15 hydroxyz hcl syp 10mg/5ml 15 hydroxyz hcl tab 10mg 15 hydroxyz hcl tab 25mg 15 hydroxyz hcl tab 50mg 15 hydroxyz pam cap 100mg 15 hydroxyz pam cap 25mg 15 hydroxyz pam cap 50mg 15 hyomax tab 0.125mg 111 hyomax-ft tab 0.125mg 111 hyomax-sl sub 0.125mg 111 hyomax-sr tab 0.375mg 112 hyoscyamine dro 0.125/ml 112 hyoscyamine elx 0.125/5 112 hyoscyamine sub 0.125mg 112 hyoscyamine tab 0.125mg 112 hyoscyamine tab 0.375 er 112 hyoscyamine tab 0.375 sr 112 hyosyne dro 0.125/ml 112 hyosyne elx 0.125/5 112 hypercare sol 20% 72 HYPO NEEDLE MIS 27GX1.25 87 HYPO NEEDLE MIS 27GX1.5" 87 HYPO NEEDLE MIS 27GX1/2" 87 I ibandronate tab 150mg 75 ibuprofen tab 400mg 4 ibuprofen tab 600mg 4 ibuprofen tab 800mg 4 ICLUSIG TAB 15MG 41 ICLUSIG TAB 45MG 41 ilotycin oin op 98 imipenem/cil inj 250mg 13 imipenem/cil inj 500mg 13 imipram hcl tab 10mg 26 imipram hcl tab 25mg 26 imipram hcl tab 50mg 26 imipram pam cap 100mg 26 imipram pam cap 125mg 26 imipram pam cap 150mg 26 imipram pam cap 75mg 26 imiquimod cre 5% 72 imperim tab 2mg 29 IMPLANON IMP 68MG 60 INCIVEK TAB 375MG 50 indapamide tab 1.25mg 75 indapamide tab 2.5mg 75 INDOCIN SUP 50MG 4 INDOCIN SUS 25MG/5ML 4 indomethacin cap 25mg 4 indomethacin cap 50mg 4 indomethacin cap 75mg er 4 INFERGEN INJ 15MCG 50 INFERGEN INJ 9MCG 50 INFLUENZA A INJ PF09H1N1 115 INLYTA TAB 1MG 41 INLYTA TAB 5MG 41 INNOHEP INJ 20000/ML 20 INNOPRAN XL CAP 120MG 53 INNOPRAN XL CAP 80MG 53 INSPIREASE MIS BAGS 87 INSPIREASE MIS MOUTHPCE 87 INSPIREASE MIS REP MOUT 87 INSPIREASE MIS RES BAG 87 INSULIN PEN NEEDLES 87 INSULIN SYRINGES 87 INTELENCE TAB 100MG 48 INTELENCE TAB 200MG 48 INTELENCE TAB 25MG 48 INTRON-A INJ 10MU 42 INTRON-A INJ 10MU PEN 42 INTRON-A INJ 18MU 42 INTRON-A INJ 25MU 42 INTRON-A INJ 3MU PEN 42 INTRON-A INJ 50MU 42 INTRON-A INJ 5MU PEN 42 INTUNIV TAB 1MG 1 INTUNIV TAB 2MG 1 INTUNIV TAB 3MG 1 INTUNIV TAB 4MG 1 INVEGA SUST INJ 117/0.75 44 INVEGA SUST INJ 156MG/ML 45 INVEGA SUST INJ 234/1.5 45 INVEGA SUST INJ 39/0.25 44 INVEGA SUST INJ 78/0.5ML 44 133

INVEGA TAB 1.5MG 45 INVEGA TAB 3MG 45 INVEGA TAB 6MG 45 INVEGA TAB 9MG 45 INVIRASE CAP 200MG 48 INVIRASE TAB 500MG 48 iophen c-nr liq 100-10/5 62 iophen dm-nr liq 100-10/5 62 iophen-nr liq 100/5ml 63 IOPIDINE SOL 1% OP 98 IPECAC SYP 29 ipratropium sol 0.02%inh 16 irbesar/hctz tab 150-12.5 37 irbesar/hctz tab 300-12.5 37 irbesartan tab 150mg 36 irbesartan tab 300mg 36 irbesartan tab 75mg 36 IRESSA TAB 250MG 41 iron supplmt dro 15mg/ml 83 ISENTRESS CHW 100MG 48 ISENTRESS CHW 25MG 48 ISENTRESS TAB 400MG 48 ISO CARBACHO SOL 1.5% OP 97 ISO CARBACHO SOL 3% OP 98 ISO HOMATROP SOL 2% OP 97 ISO HYOSCINE SOL 0.25% OP 97 isochron tab 40mg cr 14 isoditrate tab 40mg er 14 isometh/apap cap dichlor 87 isonarif cap 39 isoniazid syp 50mg/5ml 39 isoniazid tab 100mg 39 isoniazid tab 300mg 39 ISORDIL TAB 40MG 14 isosorb din tab 10mg 14 isosorb din tab 20mg 14 isosorb din tab 30mg 14 isosorb din tab 40mg er 14 isosorb din tab 5mg 14 isosorb mono tab 120mg er 14 isosorb mono tab 30mg er 14 isosorb mono tab 60mg er 14 isradipine cap 2.5mg 55 isradipine cap 5mg 55 ISTALOL SOL 0.5% OP 97 itch-x lot 1% 70 itchy eye dro 0.025%op 100 itraconazole cap 100mg 31 J JAKAFI TAB 10MG 41 JAKAFI TAB 15MG 41 JAKAFI TAB 20MG 41 JAKAFI TAB 25MG 41 JAKAFI TAB 5MG 41 jantoven tab 10mg 19 jantoven tab 1mg 19 jantoven tab 2.5mg 19 jantoven tab 2mg 19 jantoven tab 3mg 19 jantoven tab 4mg 19 jantoven tab 5mg 19 jantoven tab 6mg 19 jantoven tab 7.5mg 19 JANUVIA TAB 100MG 27 JANUVIA TAB 25MG 27 JANUVIA TAB 50MG 27 jencycla tab 0.35mg 61 jock itch cre 1% 66 jolivette tab 0.35mg 61 junel 1.5/30 tab 58 junel 1/20 tab 59 junel fe tab 1.5/30 59 junel fe tab 1/20 59 just d liq 400unit 116 K k citrate sol citr acd 81 k-effervesce tab 25meq ef 90 k-prime tab 25meq ef 90 k-vescent pow 20meq 90 k-vescent tab 25meq ef 90 KADIAN CAP 10MG CR 8 KADIAN CAP 200MG CR 8 KALETRA SOL 48 KALETRA TAB 100-25MG 48 KALETRA TAB 200-50MG 48 kalexate pow 52 karidium dro 0.125mg 89 kariva tab 28 day 59 KEFLEX CAP 750MG 57 kelnor tab 1/35 59 KEPIVANCE INJ 6.25MG 42 kericort 10 cre 1% 70 KETEK TAB 300MG 13 KETEK TAB 400MG 13 ketoconazole aer 2% 66 ketoconazole cre 2% 67 ketoconazole sha 2% 67 ketoconazole tab 200mg 31 ketodan aer 2% 67 ketoprofen cap 200mg er 4 ketoprofen cap 50mg 4 ketoprofen cap 75mg 4 ketorolac sol 0.4% 100 ketorolac sol 0.5% 100 ketorolac tab 10mg 4 ketotif fum dro 0.025%op 100 KINERET INJ 3 kionex pow usp 52 kionex sus 15gm/60 52 klor-con 10 tab 10meq er 90 klor-con 8 tab 8meq er 90 klor-con m10 tab 10meq er 90 KLOR-CON M15 TAB 90 klor-con m20 tab 20meq er 90 klor-con pow 20meq 90 klor-con/ef tab 25meq fr 90 134

kls anti-dia tab 2mg 29 kls aspirin tab 325mg ec 7 kls aspirin tab 81mg ec 7 kls naproxen tab 220mg 4 kls quit2 gum 2mg 106 kls quit4 gum 4mg 106 kp aspirin tab 81mg ec 7 KP PRENATAL TAB MULTIVIT 94 kurvelo tab 0.15/30 59 L labetalol tab 100mg 52 labetalol tab 200mg 52 labetalol tab 300mg 52 laclotion lot 12% 71 LACRISERT MIS 5MG OP 97 lactulose sol 10gm/15 80, 84 lactulose sol 20gm/30 84 LAMICTAL CHW 2MG 20 LAMICTAL KIT START 35 20 LAMICTAL KIT START 49 20 LAMICTAL KIT START 98 20 LAMICTAL ODT KIT 20 LAMICTAL ODT TAB 100MG 20 LAMICTAL ODT TAB 200MG 20 LAMICTAL ODT TAB 25MG 20 LAMICTAL ODT TAB 50MG 20 LAMICTAL XR KIT 20 LAMISIL AT SPR 1% 67 LAMISIL SPR 1% 67 lamivud/zido tab 150-300 48 lamivudine tab 150mg 48 lamivudine tab 300mg 48 lamotrigine chw 25mg 21 lamotrigine chw 5mg 20 lamotrigine tab 100mg 21 lamotrigine tab 100mg er 21 lamotrigine tab 150mg 21 lamotrigine tab 200mg 21 lamotrigine tab 200mg er 21 lamotrigine tab 250mg er 21 lamotrigine tab 25mg 21 lamotrigine tab 25mg er 21 lamotrigine tab 300mg er 21 lamotrigine tab 50mg er 21 LANCETS 87 lansoprazole cap 15mg dr 113 lansoprazole cap 30mg dr 113 LANSOPRAZOLE SUS 3MG/ML 113 lansoprazole tab 15mg odt 113 lansoprazole tab 30mg odt 113 LANTUS INJ 100/ML 27 LANTUS INJ SOLOSTAR 27 latanoprost sol 0.005% 100 LATUDA TAB 20MG 44 LATUDA TAB 40MG 44 LATUDA TAB 80MG 44 laxaclear pow 84 LAZANDA SPR 100MCG 8 LAZANDA SPR 400MCG 8 leena tab 59 leflunomide tab 10mg 5 leflunomide tab 20mg 5 LESCOL XL TAB 80MG 34 lessina tab 59 LETAIRIS TAB 10MG 57 LETAIRIS TAB 5MG 57 letrozole tab 2.5mg 40 leucovor ca tab 10mg 42 leucovor ca tab 15mg 42 leucovor ca tab 25mg 42 leucovor ca tab 5mg 42 LEUKERAN TAB 2MG 39 LEUKINE INJ 250MCG 82 leuprolide inj 1mg/0.2 40 levalbuterol neb 0.31mg 18 levalbuterol neb 0.63mg 18 levalbuterol neb 1.25/0.5 18 levalbuterol neb 1.25mg 18 LEVATOL TAB 20MG 53 LEVEMIR INJ 27 LEVEMIR INJ FLEXPEN 27 levetiraceta sol 100mg/ml 21 levetiraceta sol 500/5ml 21 levetiraceta tab 1000mg 21 levetiraceta tab 250mg 21 levetiraceta tab 500mg 21 levetiraceta tab 750mg 21 LEVITRA TAB 10MG 56 LEVITRA TAB 2.5MG 56 LEVITRA TAB 20MG 56 LEVITRA TAB 5MG 56 levobunolol sol 0.25% op 97 levobunolol sol 0.5% op 97 levocarnitin sol 1gm/10ml 76 levocarnitin tab 330mg 76 levocetirizi sol 2.5/5ml 33 levocetirizi tab 5mg 33 levofloxacin sol 0.5% 98 levofloxacin sol 25mg/ml 79 levofloxacin tab 250mg 79 levofloxacin tab 500mg 79 levofloxacin tab 750mg 79 levonest tab 59 levonor/ethi tab 0.1-0.02 59 levonor/ethi tab estradio 59 levonorgestr tab 0.75mg 60 levora-28 tab 0.15/30 59 levorphanol tab 2mg 9 levothroid tab 100mcg 109 levothroid tab 112mcg 109 levothroid tab 125mcg 109 levothroid tab 137mcg 109 levothroid tab 150mcg 110 levothroid tab 175mcg 110 levothroid tab 200mcg 110 levothroid tab 25mcg 109 levothroid tab 300mcg 110 levothroid tab 50mcg 109 135

levothroid tab 75mcg 109 levothroid tab 88mcg 109 levothyroxin tab 100mcg 110 levothyroxin tab 112mcg 110 levothyroxin tab 125mcg 110 levothyroxin tab 137mcg 110 levothyroxin tab 150mcg 110 levothyroxin tab 175mcg 110 levothyroxin tab 200mcg 110 levothyroxin tab 25mcg 110 levothyroxin tab 300mcg 110 levothyroxin tab 50mcg 110 levothyroxin tab 75mcg 110 levothyroxin tab 88mcg 110 levoxyl tab 100mcg 110 levoxyl tab 112mcg 110 levoxyl tab 125mcg 110 levoxyl tab 137mcg 110 levoxyl tab 150mcg 110 levoxyl tab 175mcg 110 levoxyl tab 200mcg 110 levoxyl tab 25mcg 110 levoxyl tab 50mcg 110 levoxyl tab 75mcg 110 levoxyl tab 88mcg 110 LEXIVA SUS 50MG/ML 48 LEXIVA TAB 700MG 48 LIALDA TAB 1.2GM 80 lice egg gel remover 73 lice md gel 73 LICE TRTMNT KIT MAX-STR 73 liceout gel 73 liceout gel /comb 73 LICIDE TREAT KIT 73 lido/prilocn cre 2.5-2.5% 72 lidocaine gel 2% 72 lidocaine gel 2% jelly 72 lidocaine oin 5% 72 lidocaine sol 2% visc 91 lidocaine sol 4% 72 LIDODERM DIS 5% 72 LIFESTYLES MIS COLORS 86 LIFESTYLES MIS EXT STR 86 LIFESTYLES MIS FORM FIT 86 LIFESTYLES MIS LUBRICAT 86 LIFESTYLES MIS RIBBED 86 LIFESTYLES MIS SPERM/LU 86 LIFESTYLES MIS STUDDED 86 LIFESTYLES MIS ULT/SENS 86 LIFESTYLES MIS VIBRA-RI 86 LIFESTYLES MIS XPLEASUR 86 lindane lot 1% 73 lindane sha 1% 73 liothyronine tab 25mcg 110 liothyronine tab 50mcg 110 liothyronine tab 5mcg 110 lisinop/hctz tab 10-12.5 37 lisinop/hctz tab 20-12.5 37 lisinop/hctz tab 20-25mg 37 lisinopril tab 10mg 35 lisinopril tab 2.5mg 35 lisinopril tab 20mg 35 lisinopril tab 30mg 35 lisinopril tab 40mg 35 lisinopril tab 5mg 35 lithium carb cap 150mg 44 lithium carb cap 300mg 44 lithium carb cap 600mg 44 lithium carb tab 300mg 44 lithium carb tab 300mg er 44 lithium carb tab 450mg er 44 LITHIUM CITR SOL 8MEQ/5ML 44 LIVALO TAB 1MG 34 LIVALO TAB 2MG 34 LIVALO TAB 4MG 34 LODOSYN TAB 25MG 43 lofene tab 2.5mg 29 lokara lot 0.05% 70 lonox tab 2.5mg 29 loperamide cap 2mg 29 loperamide tab 2mg 29 lorazepam tab 0.5mg 15 lorazepam tab 1mg 15 lorazepam tab 2mg 15 loryna tab 3-0.02mg 59 LORZONE TAB 375MG 95 LORZONE TAB 750MG 95 losartan pot tab 100mg 36 losartan pot tab 25mg 36 losartan pot tab 50mg 36 losartan/hct tab 100-12.5 37 losartan/hct tab 100-25 37 losartan/hct tab 50-12.5 37 LOTEMAX SUS 0.5% 99 LOTRIMIN ULT CRE 1% 67 LOTRONEX TAB 0.5MG 80 LOTRONEX TAB 1MG 80 lovastatin tab 10mg 34 lovastatin tab 20mg 34 lovastatin tab 40mg 34 LOVAZA CAP 1GM 33 low-ogestrel tab 59 loxapine cap 10mg 45 loxapine cap 25mg 46 loxapine cap 50mg 46 loxapine cap 5mg 45 ludent chw 0.25mg f 89 ludent chw 0.5mg f 89 ludent chw 1mg f 89 LUFYLLIN TAB 200MG 18 LUFYLLIN TAB 400MG 18 LUMIGAN SOL 0.03% 100 LUMIZYME INJ 50MG 76 LUNESTA TAB 1MG 83 LUNESTA TAB 2MG 83 LUNESTA TAB 3MG 84 LUPR DEP-PED INJ 11.25MG 76 LUPR DEP-PED INJ 15MG 76 LUPR DEP-PED INJ 30MG 76 LUPR DEP-PED INJ 7.5MG 76 136

LUPRON DEPOT INJ 11.25MG 40 LUPRON DEPOT INJ 22.5MG 40 LUPRON DEPOT INJ 3.75MG 40 LUPRON DEPOT INJ 30MG 40 LUPRON DEPOT INJ 7.5MG 40 lutera tab 59 LYCELLE GEL 73 LYRICA CAP 100MG 21 LYRICA CAP 150MG 21 LYRICA CAP 200MG 21 LYRICA CAP 225MG 21 LYRICA CAP 25MG 21 LYRICA CAP 300MG 21 LYRICA CAP 50MG 21 LYRICA CAP 75MG 21 LYSODREN TAB 500MG 40 M M-VIT TAB 27-1MG 94 MACRODANTIN CAP 25MG 113 magnesium su inj 50% 90 malathion lot 0.5% 73 maprotiline tab 25mg 23 maprotiline tab 50mg 23 maprotiline tab 75mg 23 margesic cap 6 marlissa tab 0.15/30 59 MARPLAN TAB 10MG 24 marten-tab tab 50-325mg 6 MATULANE CAP 50MG 42 MAXAIR AUTOH AER 200MCG 18 MAXIDEX SUS 0.1% OP 99 mebendazole chw 100mg 12 meclizine tab 12.5mg 30 meclizine tab 25mg 30 meclofen sod cap 100mg 4 meclofen sod cap 50mg 4 med-derm hc cre 1% 70 med-lice gel combing 73 medi-meclizi tab 25mg 30 medi-phedrin tab 30mg 96 medi-phedryl cap 25mg 32 medi-phedryl elx 12.5/5ml 32 medi-tuss dm liq diabetic 62 mediproxen tab 220mg 4 medroxypr ac inj 150mg/ml 60 medroxypr ac tab 10mg 103 medroxypr ac tab 2.5mg 103 medroxypr ac tab 5mg 103 mefenam acid cap 250mg 4 mefloquine tab 250mg 38 megestrol ac sus 400mg/10 40 megestrol ac sus 40mg/ml 40 megestrol ac tab 20mg 40 megestrol ac tab 40mg 40 meloxicam sus 7.5/5ml 5 meloxicam tab 15mg 5 meloxicam tab 7.5mg 5 melphalan inj 50mg 39 MENEST TAB 0.3MG 78 MENEST TAB 0.625MG 78 MENEST TAB 1.25MG 78 MENEST TAB 2.5MG 78 MENOSTAR DIS 14MCG 78 MENTAX CRE 1% 67 meperidine tab 100mg 9 meperidine tab 50mg 9 meperitab tab 100mg 9 meperitab tab 50mg 9 MEPHYTON TAB 5MG 116 meprobamate tab 200mg 15 meprobamate tab 400mg 15 MEPRON SUS 13 mercaptopur tab 50mg 40 mesalamine ene 4gm 80 mesalamine kit 4gm 80 MESNEX TAB 400MG 42 MESTINON SYP 60MG/5ML 38 metadate tab 20mg er 2 metaproteren syp 10mg/5ml 18 metaproteren tab 10mg 18 metaproteren tab 20mg 18 metaxalone tab 800mg 95 metformin er tab 1000mg 26 metformin tab 1000mg 27 metformin tab 500mg 26 metformin tab 500mg er 27 metformin tab 750mg er 27 metformin tab 850mg 27 methadone con 10mg/ml 9 methadone sol 10mg/5ml 9 methadone sol 5mg/5ml 9 methadone tab 10mg 9 methadone tab 40mg 9 methadone tab 5mg 9 methadose con 10mg/ml 9 methadose sf con 10mg/ml 9 methadose tab 10mg 9 methadose tab 40mg 9 methadose tab 5mg 9 methamphetam tab 5mg 1 methazolamid tab 25mg 74 methazolamid tab 50mg 74 methenam hip tab 1gm 113 methimazole tab 10mg 109 methimazole tab 5mg 109 METHITEST TAB 10MG 12 methocarbam tab 500mg 95 methocarbam tab 750mg 95 methotrexate tab 2.5mg 40 methscopolam tab 2.5mg 112 methyclothia tab 5mg 75 methyldopa tab 250mg 36 methyldopa tab 500mg 36 methylergon tab 0.2mg 101 METHYLIN CHW 10MG 2 METHYLIN CHW 2.5MG 2 METHYLIN CHW 5MG 2 methylin tab 10mg 2 137

methylin tab 10mg er 2 methylin tab 20mg 2 methylin tab 20mg er 2 methylin tab 5mg 2 methylphenid cap 10mg 2 methylphenid cap 20mg 2 methylphenid cap 20mg er 2 methylphenid cap 30mg 2 methylphenid cap 30mg er 2 methylphenid cap 40mg 2 methylphenid cap 40mg er 2 methylphenid cap 50mg 2 methylphenid cap 60mg 2 methylphenid sol 10mg/5ml 2 methylphenid sol 5mg/5ml 2 methylphenid tab 10mg 2 methylphenid tab 10mg er 2 methylphenid tab 18mg er 3 methylphenid tab 20mg 3 methylphenid tab 20mg er 3 methylphenid tab 20mg sr 3 methylphenid tab 27mg er 3 methylphenid tab 36mg er 3 methylphenid tab 54mg er 3 methylphenid tab 5mg 2 methylpred pak 4mg 61 methylpred tab 16mg 61 methylpred tab 32mg 61 methylpred tab 4mg 61 methylpred tab 8mg 61 metipranolol sol 0.3% 97 metipranolol sol 0.3% oph 97 metoclopram sol 10/10ml 80 metoclopram sol 5mg/5ml 79 metoclopram tab 10mg 80 metoclopram tab 5mg 80 metolazone tab 10mg 75 metolazone tab 2.5mg 75 metolazone tab 5mg 75 metoprol tar tab 100mg 52 metoprol tar tab 25mg 52 metoprol tar tab 50mg 52 metoprolol tab 100mg er 52 metoprolol tab 200mg er 53 metoprolol tab 25mg er 52 metoprolol tab 50mg er 52 METROGEL GEL 1% 72 metronidazol cap 375mg 12 metronidazol cre 0.75% 72 metronidazol gel 0.75% 72 metronidazol gel 0.75%vag 115 metronidazol lot 0.75% 72 metronidazol tab 250mg 12 metronidazol tab 500mg 12 mexiletine cap 150mg 16 mexiletine cap 200mg 16 mexiletine cap 250mg 16 micaderm cre 2% 67 MICARDIS TAB 20MG 36 MICARDIS TAB 40MG 36 MICARDIS TAB 80MG 36 miconazole 1 kit 115 miconazole 1 kit 1200-2% 115 miconazole 1 kit 1200mg2% 115 miconazole 3 kit combo pk 115 miconazole 3 sup 200mg 115 miconazole cre 2% 67 MICONAZOLE POW NITRATE 67 micro guard cre 2% 67 microgestin tab 1.5/30 59 microgestin tab 1/20 59 microgestin tab fe 1/20 59 microgestin tab fe1.5/30 59 midol extend tab 220mg 5 MIGERGOT SUP 2/100 87 migragesic cap ida 88 MILLIPRED SOL 10MG/5ML 61 MILLIPRED TAB 5MG 61 miniprin low tab 81mg ec 7 minitran dis 0.1mg/hr 14 minitran dis 0.2mg/hr 14 minitran dis 0.4mg/hr 14 minitran dis 0.6mg/hr 14 MINIVELLE DIS 0.0375MG 79 MINIVELLE DIS 0.05MG 78 MINIVELLE DIS 0.075MG 78 MINIVELLE DIS 0.1MG 78 minocycline cap 100mg 109 minocycline cap 50mg 109 minocycline cap 75mg 109 minoxidil tab 10mg 38 minoxidil tab 2.5mg 38 MIRENA IUD SYSTEM 60 mirtazapine tab 15mg 23 mirtazapine tab 15mg odt 23 mirtazapine tab 30mg 23 mirtazapine tab 30mg odt 23 mirtazapine tab 45mg 23 mirtazapine tab 45mg odt 23 mirtazapine tab 7.5mg 23 misoprostol tab 100mcg 113 misoprostol tab 200mcg 113 mm aspirin tab 325mg 7 modafinil tab 100mg 3 modafinil tab 200mg 3 moexipril tab 15mg 35 moexipril tab 7.5mg 35 moist skin cre 12% 71 moist skin lot 12% 71 mometasone cre 0.1% 70 mometasone oin 0.1% 70 mometasone sol 0.1% 70 mono-linyah tab 0.25-35 59 mononessa tab 59 montelukast chw 4mg 16 montelukast chw 5mg 16 montelukast gra 4mg 16 montelukast tab 10mg 16 morgidox cap 1x100mg 109 morgidox cap 2x100mg 109 138

morphine sul cap 100mg er 9 morphine sul cap 20mg er 9 morphine sul cap 30mg er 9 morphine sul cap 50mg er 9 morphine sul cap 60mg er 9 morphine sul cap 80mg er 9 morphine sul tab 100mg er 9 morphine sul tab 15mg 9 morphine sul tab 15mg er 9 morphine sul tab 200mg er 9 morphine sul tab 30mg 9 morphine sul tab 30mg er 9 motion relf tab 25mg 30 motion sick tab 25mg 30 motion sick tab 50mg 30 MOTOFEN TAB 29 MOVIPREP SOL 84 MOXATAG TAB 775MG 102 mp aller med cap 25mg 32 mp clotrimaz cre 1% 67 mp hydrocort cre 1% 70 mp hydrocort oin 1% 70 mtest hs/est tab estrogen 77 mtest/est tab estrogen 77 mucinex chld liq 100/5ml 63 mucinex/kids liq 100/5ml 63 mucus relief liq 100/5ml 63 mucus relief liq 400/20ml 64 mucus+chst liq 100/5ml 64 mult vitamin tab daily 92 mult vitamin tab essent 92 mult vitamin tab mens 92 mult-vit/fl chw 0.5mg 93 MULTAQ TAB 400MG 16 MULTI PRENAT TAB 94 multi-day tab 92 multi-vit tab 92 multi-vit/fe dro /fl 0.25 93 multi-vit/fl chw 0.25mg 93 multi-vit/fl chw 0.5mg 93 multi-vit/fl chw 1mg 93 multi-vit/fl dro /fe 0.25 93 multi-vit/fl dro 0.25mg 93 multi-vit/fl dro 0.5mg/ml 93 multi-vitamn tab 92 multiple vit tab 92 multiple vit tab folic 92 multivit/fl chw 0.25mg 93 multivit/fl chw 0.5mg 93 multivit/fl chw 1mg 93 mupirocin ca cre 2% 66 mupirocin cre 2% 66 mupirocin oin 2% 66 MUSE SUP 1000MCG 56 MUSE SUP 125MCG 56 MUSE SUP 250MCG 56 MUSE SUP 500MCG 56 mvc-fluoride chw 0.25mg 93 mvc-fluoride chw 0.5mg 93 mvc-fluoride chw 1mg 93 my way tab 1.5mg 60 myci-gc sol 100-10/5 62 MYCOBUTIN CAP 150MG 39 mycophenolat cap 250mg 51 mycophenolat tab 500mg 51 mydral sol 0.5% op 97 mydral sol 1% op 97 MYFORTIC TAB 180MG 51 MYFORTIC TAB 360MG 51 MYLERAN TAB 2MG 39 myorisan cap 10mg 65 myorisan cap 20mg 65 myorisan cap 40mg 65 MYOZYME INJ 50MG 76 MYTELASE TAB 10MG 38 mytussin ac syp 100-10/5 62 mytussin dac sol 62 myzilra tab 59 N nabumetone tab 500mg 5 nabumetone tab 750mg 5 nadolol tab 20mg 53 nadolol tab 40mg 53 nadolol tab 80mg 53 nafrinse chw 1mg f 89 nafrinse dro 0.125mg 89 NAFTIN CRE 1% 67 NAFTIN CRE 2% 67 NAFTIN GEL 1% 67 naltrexone tab 50mg 29 NAMENDA SOL 10MG/5ML 103 NAMENDA TAB 10MG 104 NAMENDA TAB 5MG 103 naphazoline sol 0.1% op 99 naproxen dr tab 375mg 5 naproxen dr tab 500mg 5 naproxen sod tab 220mg 5 naproxen sod tab 275mg 5 naproxen sod tab 550mg 5 naproxen sus 125/5ml 5 naproxen tab 250mg 5 naproxen tab 375mg 5 naproxen tab 500mg 5 naratriptan tab 1mg 88 naratriptan tab 2.5mg 88 nasal decon syp 30mg/5ml 96 nasal decong tab 30mg 96 NASONEX SPR 50MCG/AC 96 NATACYN SUS 5% OP 98 NATAL-V RX TAB 29-1MG 94 nateglinide tab 120mg 28 nateglinide tab 60mg 28 natura-lax pow 3350 nf 84 naturalyte sol bubblegm 88 naturalyte sol fruit 88 naturalyte sol grape 88 naturalyte sol unflavor 88 NAVANE CAP 20MG 47 139

NEBUPENT INH 300MG 12 necon tab 0.5/35 59 necon tab 1/35 59 necon tab 1/50-28 59 necon tab 7/7/7 59 nefazodone tab 100mg 23 nefazodone tab 150mg 23 nefazodone tab 200mg 23 nefazodone tab 250mg 23 nefazodone tab 50mg 23 NEO-FRADIN SOL 125/5ML 3 neo-polycin oin hc 1%op 99 neo-polycin oin op 98 NEO-SYNEPHRI SPR 0.5% 96 neo/bac/poly oin op 98 neo/poly/bac oin /hc 1%op 99 neo/poly/dex oin 0.1% op 99 neo/poly/dex sus 0.1% op 99 neo/poly/gra sol op 98 neo/poly/hc sol 1% otic 101 neo/poly/hc sus 1% otic 101 neo/poly/hc sus op 99 neomycin tab 500mg 3 neosporin af cre 2% jock 67 neosporin cre eczema 70 nephronex tab 1mg 91 NEUPOGEN INJ 300/0.5 82 NEUPOGEN INJ 300MCG 82 NEUPOGEN INJ 480/0.8 82 NEUPOGEN INJ 480MCG 82 NEVANAC SUS 0.1% 100 nevirapine sus 50mg/5ml 48 nevirapine tab 200mg 48 NEXAVAR TAB 200MG 41 NEXIUM CAP 20MG 113 NEXIUM CAP 40MG 113 NEXPLANON IMP 68MG 60 next choice tab 0.75mg 60 next choice tab 1.5mg 60 niacor tab 500mg 34 NIASPAN TAB 1000 ER 35 NIASPAN TAB 500MG ER 34 NIASPAN TAB 750MG ER 34 nicardipine cap 20mg 55 nicardipine cap 30mg 55 nicorelief gum 2mg mint 106 nicorelief gum 2mg orig 106 nicorelief gum 4mg mint 106 nicorelief gum 4mg orig 106 nicorelief loz 2mg mint 106 nicorelief loz 4mg mint 106 nicotine dis 14mg/24h 106 nicotine dis 21mg/24h 106 nicotine dis 7mg/24hr 106 nicotine dis step 1 106 nicotine dis step 2 106 nicotine dis step 3 106 nicotine gum 2mg 106 nicotine gum 2mgfruit 106 nicotine gum 4mg 106 nicotine loz 2mg chry 106 nicotine loz 2mg mint 106 nicotine loz 4mg chry 106 nicotine loz 4mg cinn 106 nicotine loz 4mg mint 106 nicotine pol gum 2mg 106 nicotine pol gum 2mg cinn 107 nicotine pol gum 2mg mint 107 nicotine pol gum 2mg orig 107 nicotine pol gum 2mg ref 107 nicotine pol gum 2mg strt 107 nicotine pol gum 2mgfruit 107 nicotine pol gum 4mg 107 nicotine pol gum 4mg mint 107 nicotine pol gum 4mg orig 107 nicotine pol gum 4mg ref 107 nicotine pol gum 4mg strt 107 nicotine pol gum 4mgfruit 107 nicotine pol loz 2mg cinn 107 nicotine pol loz 2mg mint 107 nicotine pol loz 4mg chry 107 nicotine pol loz 4mg mint 107 NICOTINE SYS KIT TRANSDER 107 nicotine td dis 14mg/24h 107 nicotine td dis 21mg/24h 107 nicotine td dis 7mg/24hr 107 NICOTROL INH 107 NICOTROL NS SPR 10MG/ML 107 nifediac cc tab 30mg er 55 nifediac cc tab 60mg er 55 nifediac cc tab 90mg er 55 nifedical xl tab 30mg 55 nifedical xl tab 60mg 55 nifedipine cap 10mg 55 nifedipine cap 20mg 55 nifedipine tab 30mg er 55 nifedipine tab 60mg er 55 nifedipine tab 90mg er 55 NILANDRON TAB 150MG 40 nimodipine cap 30mg 55 nisoldipine tab 17mg er 55 nisoldipine tab 20mg 55 nisoldipine tab 25.5mg 55 nisoldipine tab 30mg 55 nisoldipine tab 34mg er 55 nisoldipine tab 40mg 55 nisoldipine tab 8.5mg er 55 NITRO-BID OIN 2% 14 nitro-time cap 2.5mg cr 14 nitro-time cap 6.5mg cr 14 nitro-time cap 9mg cr 14 nitrofur mac cap 100mg 113 nitrofur mac cap 50mg 113 nitrofurantn cap 100mg 114 nitrofurantn sus 25mg/5ml 114 nitroglycer aer 400mcg 14 nitroglycer cap 2.5mg er 14 nitroglycer cap 2.5mg sr 14 nitroglycer cap 6.5mg cr 14 nitroglycer cap 6.5mg er 14 140

nitroglycer cap 9mg cr 14 nitroglycer cap 9mg er 14 nitroglycer dis 0.1mg/hr 14 nitroglycer dis 0.2mg/hr 14 nitroglycer dis 0.4mg/hr 14 nitroglycer dis 0.6mg/hr 14 nitroglyceri dis 0.6mg/hr 14 nitroglycrn spr lingual 14 NITROSTAT SUB 0.3MG 14 NITROSTAT SUB 0.4MG 14 NITROSTAT SUB 0.6MG 14 nix combing gel 73 NIX LICE SPR CONTROL 73 nizatidine cap 150mg 112 nizatidine cap 300mg 113 noble formul cre hc 1% 70 nodolor cap 88 nora-be tab 0.35mg 61 norethin ace tab 5mg 103 norethindron tab 0.35mg 61 norgest/eth tab estrad 59 norgest/ethi tab 0.25/35 59 norgest/ethi tab estradio 59 NORITATE CRE 1% 72 NOROXIN TAB 400MG 79 NORPACE CAP 100MG CR 15 NORPACE CAP 150MG CR 15 nortrel tab 0.5/35 59 nortrel tab 1/35 59 nortrel tab 7/7/7 59 nortriptylin cap 10mg 26 nortriptylin cap 25mg 26 nortriptylin cap 50mg 26 nortriptylin cap 75mg 26 nortriptylin sol 10mg/5ml 26 NORVIR CAP 100MG 48 NORVIR SOL 80MG/ML 48 NORVIR TAB 100MG 48 norwich asa tab 325mg 7 novagest/cod sol expect 62 novarel inj 10000unt 75 NOVOLIN INJ 70/30 27 NOVOLIN N INJ RELION 28 NOVOLIN N INJ U-100 28 NOVOLIN R INJ RELION 28 NOVOLIN R INJ U-100 28 NOVOLIN70/30 INJ RELION 27 NOVOLOG INJ 100/ML 28 NOVOLOG INJ FLEXPEN 28 NOVOLOG INJ PENFILL 28 NOVOLOG MIX INJ 70/30 28 NOVOLOG MIX INJ FLEXPEN 28 np thyroid tab 30mg 110 np thyroid tab 60mg 110 np thyroid tab 90mg 110 NUCYNTA ER TAB 100MG 9 NUCYNTA ER TAB 150MG 9 NUCYNTA ER TAB 200MG 9 NUCYNTA ER TAB 250MG 9 NUCYNTA ER TAB 50MG 9 NUCYNTA TAB 100MG 9 NUCYNTA TAB 50MG 9 NUCYNTA TAB 75MG 9 NUEDEXTA CAP 20-10MG 104 nulev tab 0.125mg 112 NUVARING MIS 60 NUVIGIL TAB 150MG 3 NUVIGIL TAB 250MG 3 NUVIGIL TAB 50MG 3 nuzole cre 2% 67 nyamyc pow 100000 67 nystat/triam cre 67 nystat/triam oin 67 nystatin cre 100000 67 nystatin oin 100000 67 nystatin pow 30 nystatin pow 100000 67 nystatin sus 100000 91 nystatin tab 500000 31 NYSTATIN VAG TAB 100000 115 nystop pow 100000 67 O O-CAL FA TAB 94 ocella tab 3-0.03mg 59 OCTAGAM INJ 10GM 102 OCTAGAM INJ 1GM 102 OCTAGAM INJ 2.5GM 102 OCTAGAM INJ 25GM 102 OCTAGAM INJ 5GM 102 octreotide inj 1000mcg 77 octreotide inj 100mcg 77 octreotide inj 200mcg 77 octreotide inj 500mcg 77 octreotide inj 50mcg/ml 77 ofloxacin dro 0.3% op 98 ofloxacin dro 0.3%otic 100 ofloxacin tab 200mg 79 ofloxacin tab 300mg 79 ofloxacin tab 400mg 79 OFORTA TAB 10MG 40 ogestrel tab 59 olanzapine tab 10mg 46 olanzapine tab 10mg odt 46 olanzapine tab 15mg 46 olanzapine tab 15mg odt 46 olanzapine tab 2.5mg 46 olanzapine tab 20mg 46 olanzapine tab 20mg odt 46 olanzapine tab 5mg 46 olanzapine tab 5mg odt 46 olanzapine tab 7.5mg 46 OLEPTRO TAB 24HR150 23 OLEPTRO TAB 24HR300 23 omeprazole cap 10mg 113 omeprazole cap 20mg 113 omeprazole cap 40mg 113 OMNIFLEX DPR 86 once daily tab 92 141

ondansetron inj 32/50ml 29 ondansetron sol 4mg/5ml 29 ondansetron tab 24mg 30 ondansetron tab 4mg 29 ondansetron tab 4mg odt 29 ondansetron tab 8mg 29 ondansetron tab 8mg odt 30 one daily tab 92 one daily tab essent 92 one daily tab essentl 92 one-daily tab mult vit 92 ONGLYZA TAB 2.5MG 27 ONGLYZA TAB 5MG 27 ONSOLIS MIS 1200MCG 9 ONSOLIS MIS 200MCG 9 ONSOLIS MIS 400MCG 9 ONSOLIS MIS 600MCG 9 ONSOLIS MIS 800MCG 9 oralone pst 0.1% 91 oralyte sol 88 oralyte sol freeze 88 ORAP TAB 1MG 104 ORAP TAB 2MG 104 ORAVIG TAB 50MG 91 ORAXYL CAP 20MG 109 orazinc cap 220mg 91 ORFADIN CAP 10MG 76 ORFADIN CAP 2MG 76 ORFADIN CAP 5MG 76 organ-i nr tab 200mg 64 orph/asa/caf tab 95 orphen cpd tab ds 95 orphenadrine tab 100mg er 95 orsythia tab 59 ORTHO COIL DPR KIT 100 86 ORTHO COIL DPR KIT 105 86 ORTHO COIL DPR KIT 50 86 ORTHO EVRA DIS WEEK 60 ORTHO FLAT DPR KIT 55 86 ORTHO FLAT DPR KIT 60 86 ORTHO FLAT DPR KIT 65 86 ORTHO FLAT DPR KIT 70 86 ORTHO FLAT DPR KIT 75 86 ORTHO FLAT DPR KIT 80 86 ORTHO FLAT DPR KIT 85 86 ORTHO FLAT DPR KIT 90 86 ORTHO FLAT DPR KIT 95 86 ORTHO FLEX DPR 65MM 86 ORTHO FLEX DPR 70MM 86 ORTHO FLEX DPR 75MM 86 ORTHO FLEX DPR 80MM 86 ortho-est tab 0.625 79 ortho-est tab 1.25 79 oscimin sr tab 0.375mg 112 oscimin sub 0.125mg 112 oscimin tab 0.125mg 112 OSMOPREP TAB 1.5GM 85 oxacillin inj 10gm 103 oxacillin inj 1gm 103 oxacillin inj 2gm 103 oxandrolone tab 10mg 11 oxandrolone tab 2.5mg 11 oxaprozin tab 600mg 5 oxazepam cap 10mg 15 oxazepam cap 15mg 15 oxazepam cap 30mg 15 oxcarbazepin sus 300mg/5m 21 oxcarbazepin tab 150mg 21 oxcarbazepin tab 300mg 21 oxcarbazepin tab 600mg 21 OXECTA TAB 5MG 9 OXECTA TAB 7.5MG 9 OXISTAT CRE 1% 67 OXISTAT LOT 1% 67 OXSORALEN LOT 1% 72 OXSORALEN-UL CAP 10MG 68 OXTELLAR XR TAB 150MG 21 OXTELLAR XR TAB 300MG 21 OXTELLAR XR TAB 600MG 21 oxybutynin syp 5mg/5ml 114 oxybutynin tab 10mg er 114 oxybutynin tab 15mg er 114 oxybutynin tab 5mg 114 oxybutynin tab 5mg er 114 oxycod/apap cap 5-500mg 11 oxycod/apap tab 5-325mg 11 oxycod/asa tab 11 oxycod/ibu tab 5-400mg 11 oxycodone cap 5mg 10 oxycodone con 100/5ml 10 oxycodone con 20mg/ml 10 oxycodone sol 5mg/5ml 10 oxycodone tab 10mg 10 oxycodone tab 15mg 10 oxycodone tab 20mg 10 oxycodone tab 30mg 10 oxycodone tab 5mg 10 OXYCONTIN TAB 10MG CR 10 OXYCONTIN TAB 15MG CR 10 OXYCONTIN TAB 20MG CR 10 OXYCONTIN TAB 30MG CR 10 OXYCONTIN TAB 40MG CR 10 OXYCONTIN TAB 60MG CR 10 OXYCONTIN TAB 80MG CR 10 oxymorphone tab 10mg er 10 oxymorphone tab 15mg er 10 oxymorphone tab 20mg er 10 oxymorphone tab 30mg er 10 oxymorphone tab 40mg er 10 oxymorphone tab 5mg er 10 oxymorphone tab 7.5mg er 10 oxymorphone tab hcl 10mg 10 oxymorphone tab hcl 5mg 10 P PACERONE TAB 100MG 16 pacerone tab 200mg 16 pamidronate inj 30/10ml 75 pamidronate inj 30mg 75 142

pamidronate inj 90/10ml 75 pamidronate inj 90mg 75 pamprin tab 220mg 5 PANCREAZE CAP 10500UNT 74 PANCREAZE CAP 16800UNT 74 PANCREAZE CAP 21000UNT 74 PANCREAZE CAP 4200UNIT 73 pancrelipase cap 5000unit 74 panoxyl wash liq 10% 65 PANRETIN GEL 0.1% 67 pantoprazole tab 20mg 113 pantoprazole tab 40mg 113 PARAGARD IUD T380A 86 parcaine sol 0.5% op 99 paromomycin cap 250mg 3 paroxetin er tab 12.5mg 24 paroxetin er tab 37.5mg 24 paroxetine sus 10mg/5ml 24 paroxetine tab 10mg 24 paroxetine tab 20mg 24 paroxetine tab 25mg er 24 paroxetine tab 30mg 24 paroxetine tab 40mg 24 PASER GRA 4GM 39 PATADAY SOL 0.2% 100 PATANOL SOL 0.1% OP 100 pc ped elect sol fruit 88 pc ped elect sol grape 88 pc pediatric sol electrol 88 PCE TAB 333MG EC 85 PCE TAB 500MG EC 85 ped elctrlyt sol 88 ped elctrlyt sol /zinc 88 ped elctrlyt sol apple 89 ped elctrlyt sol bubblegm 89 ped elctrlyt sol bubblgum 89 ped elctrlyt sol freeze 89 ped elctrlyt sol freezer 89 ped elctrlyt sol freezpop 89 ped elctrlyt sol fruit 89 ped elctrlyt sol grape 89 ped elctrlyt sol mango 89 ped elctrlyt sol strawbry 89 ped elctrlyt sol unflavor 89 ped elctrlyt sol unflavrd 89 ped formula liq 100-10/5 62 pedi-dri pow 100000 67 pedia vance sol apple 89 pedia vance sol grape 89 peg 3350 pow 85 peg 3350 sol electrol 84 peg-3350 sol electrol 84 peg-3350/kcl sol /sodium 84 PEG-INTRON KIT 120 RP 50 PEG-INTRON KIT 120MCG 50 PEG-INTRON KIT 150 RP 50 PEG-INTRON KIT 150MCG 50 PEG-INTRON KIT 50MCG 50 PEG-INTRON KIT 50MCG RP 50 PEG-INTRON KIT 80MCG 50 PEG-INTRON KIT 80MCG RP 50 PEGANONE TAB 250MG 22 PEGASYS INJ 50 PEGASYS INJ PROCLICK 50 PEGASYS KIT 50 penicilln vk sol 125/5ml 102 penicilln vk sol 250/5ml 102 penicilln vk tab 250mg 102 penicilln vk tab 500mg 102 PENTAM 300 INJ 300MG 13 PENTASA CAP 250MG CR 80 PENTASA CAP 500MG CR 80 pentaz/nalox tab 50-0.5mg 11 pentoxifylli tab 400mg er 81 PERFOROMIST NEB 20MCG 18 perindopril tab 2mg 35 perindopril tab 4mg 35 perindopril tab 8mg 35 periogard sol 0.12% 91 permethrin cre 5% 73 perphen/amit tab 2-10mg 104 perphen/amit tab 2-25mg 104 perphen/amit tab 4-10mg 104 perphen/amit tab 4-25mg 104 perphen/amit tab 4-50mg 104 perphenazine tab 16mg 47 perphenazine tab 2mg 46 perphenazine tab 4mg 47 perphenazine tab 8mg 47 persa-gel gel 10% 65 persa-gel xs gel 5% 65 pharbedryl cap 25mg 32 pharbedryl cap 50mg 32 phenadoz sup 12.5mg 33 phenadoz sup 25mg 33 phenazo tab 200mg 81 phenazopyrid tab 100mg 81 phenazopyrid tab 200mg 81 phenelzine tab 15mg 24 phenobarb elx 20mg/5ml 83 phenobarb sol 20mg/5ml 83 phenobarb tab 100mg 83 phenobarb tab 15mg 83 phenobarb tab 16.2mg 83 phenobarb tab 30mg 83 phenobarb tab 32.4mg 83 phenobarb tab 60mg 83 phenobarb tab 64.8mg 83 phenobarb tab 97.2mg 83 phenytoin chw 50mg 22 phenytoin ex cap 100mg 22 phenytoin ex cap 200mg 22 phenytoin ex cap 300mg 22 phenytoin sus 125/5ml 22 philith tab 0.4-35 59 PHISOHEX LIQ 3% 47 phospha 250 tab neutral 90 PHOSPHOLINE SOL 0.125%OP 98 PHRENILIN CAP FORTE 6 PICATO GEL 0.015% 67 143

PICATO GEL 0.05% 67 pilocarpine sol 1% op 98 pilocarpine sol 2% op 98 pilocarpine sol 4% op 98 pilocarpine tab 5mg 91 pilocarpine tab 7.5mg 91 PILOPINE HS GEL 4% OP 98 pindolol tab 10mg 53 pindolol tab 5mg 53 pioglitazone tab 15mg 28 pioglitazone tab 30mg 28 pioglitazone tab 45mg 28 piroxicam cap 10mg 5 piroxicam cap 20mg 5 PNV FOLIC AC TAB + IRON 94 PNV PRENATAL TAB PLUS 94 podactin cre 2% 67 podofilox sol 0.5% 72 POLY HUB MIS 27GX1.25 87 POLY HUB MIS 27GX1/2" 87 poly-dex oin 0.1% op 99 poly-vi-flor chw 0.25mg 93 poly-vi-flor chw 0.5mg 93 poly-vi-flor chw 1mg 93 POLY-VI-FLOR CHW W/IRON 93 poly-vit/fe dro /fl 0.25 93 poly-vit/fe dro /fl 0.5 93 poly-vit/fl dro 0.25mg 93 polycin b oin op 98 polycin oin op 98 polyeth glyc pow 3350 nf 85 polyeth glyc pow 3350-grx 85 polymyxin b inj 500000 13 polymyxin b/ sol trimethp 98 polyvit/fl dro 0.5mg/ml 93 portia-28 tab 59 pot bicarbon tab 25meq ef 90 pot chloride cap 10meq er 90 pot chloride cap 8meq er 90 pot chloride liq 10% 90 pot chloride liq 20% 90 pot chloride liq 20% sf 90 pot chloride sol 10% sf 90 pot chloride tab 10meq cr 90 pot chloride tab 10meq er 90 pot chloride tab 8meq er 90 pot chloride tab 8meq sr 90 pot citrate tab 1080mg 81 pot citrate tab 540mg 81 pot cl micro tab 10meq cr 90 pot cl micro tab 10meq er 90 pot cl micro tab 20meq er 90 potassium tab 25meq ef 90 pramcort cre 1-1% 71 pramipexole tab 0.125mg 43 pramipexole tab 0.25mg 43 pramipexole tab 0.5mg 43 pramipexole tab 0.75mg 43 pramipexole tab 1.5mg 43 pramipexole tab 1mg 43 PRANDIN TAB 0.5MG 28 PRANDIN TAB 1MG 28 PRANDIN TAB 2MG 28 pravastatin tab 10mg 34 pravastatin tab 20mg 34 pravastatin tab 40mg 34 pravastatin tab 80mg 34 prazosin hcl cap 1mg 36 prazosin hcl cap 2mg 36 prazosin hcl cap 5mg 36 PRECISIONGLI MIS 27GX1.5" 87 PRED MILD SUS 0.12% OP 99 PRED SOD PHO SOL 1% OP 99 pred sod pho sol 5mg/5ml 61 pred sod pho sol 6.7/5ml 61 prednicarbat cre 0.1% 71 prednicarbat oin 0.1% 71 prednisolone sol 15mg/5ml 61 prednisolone sol 25mg/5ml 61 prednisolone sus 1% op 99 prednisone pak 10mg 61 prednisone pak 5mg 61 prednisone sol 5mg/5ml 61 prednisone tab 10mg 62 prednisone tab 1mg 61 prednisone tab 2.5mg 61 prednisone tab 20mg 62 prednisone tab 50mg 62 prednisone tab 5mg 61 pregnyl inj 10000unt 76 PREMARIN TAB 0.3MG 79 PREMARIN TAB 0.45MG 79 PREMARIN TAB 0.625MG 79 PREMARIN TAB 0.9MG 79 PREMARIN TAB 1.25MG 79 PREMARIN VAG CRE 0.625MG 115 PREMPHASE TAB 77 PREMPRO TAB.625-2.5 77 PREMPRO TAB 0.3-1.5 77 PREMPRO TAB 0.45-1.5 77 PREMPRO TAB 0.625-5 77 prenaplus tab 94 prenatabs rx tab 94 PRENATAL 19 CHW 29-1MG 94 prenatal 19 chw tab 94 prenatal 19 tab 94 PRENATAL 19 TAB 29-1MG 94 PRENATAL ONE TAB DAILY 94 PRENATAL TAB 94 PRENATAL TAB 27-0.8MG 94 PRENATAL TAB 27-1MG 94 PRENATAL TAB 28-0.8MG 94 PRENATAL TAB COMPLETE 94 PRENATAL TAB FORMULA 94 PRENATAL TAB LOW IRON 94 PRENATAL TAB PLUS 94 prenatal tab plus fe 94 PRENATAL VIT TAB PLUS 94 PRENATAL+DHA MIS 94 PRENATAL+DHA MIS WOMENS 94 144

PRENATAL+FE TAB 29-1MG 94 PRENATAL-U CAP 94 PRENTIF MIS 22MM 86 PRENTIF MIS 25MM 86 PRENTIF MIS 28MM 86 PRENTIF MIS 31MM 86 PRENTIF MIS FITTING 86 prep h hc cre 1% 71 PREPOPIK PAK 84 prevalite pow 4gm 33 prevalite pow 4gm pk 33 previfem tab 59 PREVPAC MIS 113 PREZISTA TAB 150MG 48 PREZISTA TAB 400MG 48 PREZISTA TAB 600MG 48 PREZISTA TAB 75MG 48 PREZISTA TAB 800MG 49 PRIFTIN TAB 150MG 39 PRIMAQUINE TAB 26.3MG 38 primidone tab 250mg 21 primidone tab 50mg 21 PRISTIQ TAB 100MG 25 PRISTIQ TAB 50MG 25 PRIVIGEN INJ 10GRAMS 102 PRIVIGEN INJ 20GRAMS 102 PRIVIGEN INJ 5 GRAMS 102 PROAIR HFA AER 18 proben/colch tab 500-0.5 81 probenecid tab 500mg 81 procainamide inj 100mg/ml 15 prochlorper sup 25mg 47 prochlorper tab 10mg 47 prochlorper tab 5mg 47 PROCORT CRE 12 PROCRIT INJ 10000/ML 82 PROCRIT INJ 2000/ML 82 PROCRIT INJ 20000/ML 83 PROCRIT INJ 3000/ML 82 PROCRIT INJ 4000/ML 82 PROCRIT INJ 40000/ML 83 procto-pak cre 1% 12 proctocream cre hc 2.5% 12 PROCTOFOAM AER HC 1% 12 proctosol hc cre 2.5% 12 proctozone cre -hc 2.5% 12 progesterone cap 100mg 103 progesterone cap 200mg 103 PROLASTIN INJ 1000MG 108 PROLASTIN INJ 500MG 108 PROLASTIN-C INJ 1000MG 108 promacet tab 50-650mg 6 prometh vc syp 6.25-5/5 63 prometh vc syp plain 63 prometh vc/ syp codeine 63 prometh/cod syp 6.25-10 63 promethazine sol 6.25/5ml 33 promethazine sup 12.5mg 33 promethazine sup 25mg 33 promethazine syp 6.25/5ml 33 promethazine syp dm 63 promethazine tab 12.5mg 33 promethazine tab 25mg 33 promethazine tab 50mg 33 promethegan sup 12.5mg 33 promethegan sup 25mg 33 promethegan sup 50mg 33 PRONTO AER 0.4% 73 propafenone cap 225mg er 16 propafenone cap 325mg er 16 propafenone cap 425mg sr 16 propafenone tab 150mg 16 propafenone tab 225mg 16 propafenone tab 300mg 16 propanthelin tab 15mg 112 proparacaine sol 0.5% op 99 propran/hctz tab 40/25 37 propran/hctz tab 80/25 37 propranolol cap 120mg er 53 propranolol cap 160mg er 53 propranolol cap 60mg er 53 propranolol cap 80mg er 53 propranolol sol 20mg/5ml 53 propranolol sol 40mg/5ml 53 propranolol tab 10mg 53 propranolol tab 20mg 53 propranolol tab 40mg 53 propranolol tab 60mg 53 propranolol tab 80mg 53 propylthiour tab 50mg 109 PROSTIGMIN TAB 15MG 38 PROTOPIC OIN 0.03% 72 PROTOPIC OIN 0.1% 72 protriptylin tab 10mg 26 protriptylin tab 5mg 26 prudoxin cre 5% 67 pseudoephedr syp 30mg/5ml 96 pseudoephedr tab 30mg 96 pseudoephedr tab 60mg 96 psudatabs tab 30mg 96 PULMICORT INH 180MCG 17 PULMICORT INH 90MCG 17 PULMICORT SUS 1MG/2ML 17 PULMOZYME SOL 1MG/ML 108 px allergy cap 25mg 32 px aspirin chw 81mg 7 px aspirin tab 325mg 7 px aspirin tab 325mg ec 7 px aspirin tab 81mg ec 7 PX PRENATAL TAB MULTIVIT 94 px tussin dm liq 100-10/5 63 px tussin sol 100/5ml 64 pyrazinamide tab 500mg 39 PYRE/PIPERON LIQ 73 pyridostigm tab 60mg 38 Q q-dryl cap 25mg 32 qc aspirin tab 325mg 7 145

qc aspirin tab 325mg ec 7 qc child asa chw 81mg 7 qc essential tab 92 qc heartburn tab 200mg 113 qc hydrocort cre 1% 71 qc medifin liq mucus rl 64 qc medifin tab 200mg 64 QC PRENATAL TAB 28-0.8MG 94 quadrapax elx 112 quenalin syp 12.5/5ml 32 quetiapine tab 100mg 46 quetiapine tab 200mg 46 quetiapine tab 25mg 46 quetiapine tab 300mg 46 quetiapine tab 400mg 46 quetiapine tab 50mg 46 QUILLIVANT SUS XR 3 quinapril tab 10mg 35 quinapril tab 20mg 35 quinapril tab 40mg 35 quinapril tab 5mg 35 quinidine gl tab 324mg cr 15 quinidine gl tab 324mg er 16 quinidine su tab 200mg 16 quinidine su tab 300mg 16 quinidine su tab 300mg er 16 quinine sulf cap 324mg 38 QVAR AER 40MCG 17 QVAR AER 80MCG 17 R ra anti-itch cre 1% 71 ra anti-itch oin 1% 71 ra aspirin chw 81mg 7 ra aspirin tab 325mg 7 ra aspirin tab 325mg ec 7 ra aspirin tab 81mg ec 7 ra child asa chw 81mg 7 ra hydrocort cre 1% 71 ra hydrocort cre 1%pls 12 71 ra laxative pow 85 ra lice egg gel remover 73 ra nicotine dis 14mg/24h 107 ra nicotine dis 21mg/24h 107 ra nicotine dis 7mg/24hr 107 ra nicotine gum 2mg 107 ra nicotine gum 2mg cinn 107 ra nicotine gum 2mg mint 107 ra nicotine gum 2mgfruit 107 ra nicotine gum 4mg 107 ra nicotine gum 4mg frut 107 ra nicotine gum 4mg mint 107 ra nicotine loz 2mg mint 107 ra nicotine loz 4mg mint 107 ra one daily tab essentia 92 ra one daily tab multivit 92 ra pediatric sol electrol 89 RA PRENATAL TAB 28-0.8MG 94 RA PRENATAL TAB FORMULA 94 ra renewal gel 10% 65 ra suphedrin tab 30mg 96 ra tussin dm liq 100-10/5 63 ra tussin liq 100/5ml 64 ramipril cap 1.25mg 35 ramipril cap 10mg 35 ramipril cap 2.5mg 35 ramipril cap 5mg 35 RANEXA TAB 1000MG 13 RANEXA TAB 500MG 13 ranitidine cap 150mg 113 ranitidine cap 300mg 113 ranitidine syp 150/10ml 113 ranitidine syp 15mg/ml 113 ranitidine syp 75mg/5ml 113 ranitidine tab 150mg 113 ranitidine tab 300mg 113 RAPAFLO CAP 4MG 81 RAPAFLO CAP 8MG 81 RAPAMUNE SOL 1MG/ML 51 RAPAMUNE TAB 1MG 51 RAPAMUNE TAB 2MG 51 REBIF INJ 22/0.5 104 REBIF INJ 44/0.5 104 REBIF REBIDO INJ 22/0.5 104 REBIF REBIDO INJ 44/0.5 104 REBIF REBIDO SOL TITRATN 104 REBIF TITRTN SOL PACK 104 reclipsen tab 59 recort plus cre 1% 71 rectacort-hc sup 25mg 12 rederm lot 1% 71 refenesen tab 200mg 64 refissa cre 0.05% 66 regenecare gel ha 2% 72 REGRANEX GEL 0.01% 73 rehydralyte sol 89 RELENZA MIS DISKHALE 50 RELISTOR KIT 12/0.6ML 80 RELPAX TAB 20MG 88 RELPAX TAB 40MG 88 remedy cre antifung 67 REMICADE INJ 100MG 80 REMODULIN INJ 10MG/ML 56 REMODULIN INJ 1MG/ML 56 REMODULIN INJ 2.5MG/ML 56 REMODULIN INJ 5MG/ML 56 rena-vite rx tab 91 rena-vite tab 91 RENAGEL TAB 400MG 80 RENAGEL TAB 800MG 80 renal tab multivit 91 renal/zinc tab multivit 92 RENVELA PAK 0.8GM 80 RENVELA PAK 2.4GM 80 RENVELA TAB 800MG 80 repan tab 6 RESCRIPTOR TAB 100 MG 49 RESCRIPTOR TAB 200MG 49 reserpine tab 0.1mg 37 146

reserpine tab 0.25mg 37 RESTASIS EMU 0.05% 99 revital frzr sol pops 89 revital jell sol cups 89 revital lqd sol squeezer 89 REVLIMID CAP 10MG 51 REVLIMID CAP 15MG 51 REVLIMID CAP 25MG 51 REVLIMID CAP 5MG 51 REYATAZ CAP 100MG 49 REYATAZ CAP 150MG 49 REYATAZ CAP 200MG 49 REYATAZ CAP 300MG 49 RHEUMATREX TAB 2.5MG 3 RIBAPAK PAK 1200/DAY 50 RIBAPAK PAK 800/DAY 50 ribasphere cap 200mg 50 ribasphere tab 200mg 50 ribasphere tab 400mg 50 ribasphere tab 600mg 50 RIBATAB TAB 1200/DAY 50 RIBATAB TAB 800/DAY 50 ribavirin cap 200mg 50 ribavirin tab 200mg 50 RID LICE KIL AER MOUSSE 73 RIDAURA CAP 3MG 3 rifampin cap 150mg 39 rifampin cap 300mg 39 RIFATER TAB 39 RIGHT STEP TAB PRENATAL 94 RILUTEK TAB 50MG 96 riluzole tab 50mg 96 rimantadine tab 100mg 50 ringers irr sol 52 ringworm cre 1% 67 RIOMET SOL 27 RISPERDAL INJ 12.5MG 45 RISPERDAL INJ 25MG 45 RISPERDAL INJ 37.5MG 45 RISPERDAL INJ 50MG 45 risperidone sol 1mg/ml 45 risperidone tab 0.25 odt 45 risperidone tab 0.25mg 45 risperidone tab 0.5mg 45 risperidone tab 0.5mg od 45 risperidone tab 1mg 45 risperidone tab 1mg odt 45 risperidone tab 2mg 45 risperidone tab 2mg odt 45 risperidone tab 3mg 45 risperidone tab 3mg odt 45 risperidone tab 4mg 45 risperidone tab 4mg odt 45 RITALIN LA CAP 10MG 3 RITUXAN INJ 100MG 40 RITUXAN INJ 500MG 40 rivastigmine cap 1.5mg 104 rivastigmine cap 3mg 104 rivastigmine cap 4.5mg 104 rivastigmine cap 6mg 104 rizatriptan tab 10mg 88 rizatriptan tab 5mg 88 robafen ac syp 100-10/5 63 ROBAXIN INJ 100MG/ML 95 robitussin liq cgh/cong 63 robitussin liq to go dm 63 romilar ac sol 100-10/5 63 romycin oin op 98 ropinirole tab 0.25mg 43 ropinirole tab 0.5mg 43 ropinirole tab 12mg er 44 ropinirole tab 1mg 43 ropinirole tab 2mg 43 ropinirole tab 2mg er 43 ropinirole tab 3mg 43 ropinirole tab 4mg 43 ropinirole tab 4mg er 44 ropinirole tab 5mg 44 ropinirole tab 6mg er 44 ropinirole tab 8mg er 44 rosadan cre 0.75% 72 rosadan gel 0.75% 72 ROXICET SOL 5-325/5 11 ROZEREM TAB 8MG 84 S SABRIL TAB 500MG 22 safe tussin liq 10-100/5 63 SAFETYGLIDE MIS 27GX5/8" 87 SAL-TROPINE TAB 0.4MG 112 salsalate tab 500mg 7 salsalate tab 750mg 7 SAMSCA TAB 15MG 77 SAMSCA TAB 30MG 77 SANDIMMUNE SOL 100MG/ML 51 SANDOSTATIN KIT LAR 10MG 77 SANDOSTATIN KIT LAR 20MG 77 SANDOSTATIN KIT LAR 30MG 77 SANTYL OIN 250/GM 72 SAPHRIS SUB 10MG 46 SAPHRIS SUB 5MG 46 sarnol-hc lot 1% 71 SAVELLA TAB 100MG 104 SAVELLA TAB 12.5MG 104 SAVELLA TAB 25MG 104 SAVELLA TAB 50MG 104 sb aspirin tab 325mg 7 sb aspirin tab 325mg ec 7 sb cgh contr liq dm 63 sb child asa chw 81mg 7 sb coughtab tab 200mg 64 sb hydrocort cre 1% 71 sb hydrocort oin 1% 71 sb pseudophe tab 30mg 96 scalacort lot 2% 71 SCOPACE TAB 0.4MG 30 scot-tussin liq expct sf 64 se-donna elx pb hyos 112 SE-NATAL 19 CHW 94 147

SE-NATAL 19 TAB 94 SE-NATAL ONE TAB 94 selegiline cap 5mg 44 selegiline tab 5mg 44 selenium sul lot 2.5% 68 selenium sul sha 2.5% 68 SELZENTRY TAB 150MG 49 SELZENTRY TAB 300MG 49 SENSIPAR TAB 30MG 76 SENSIPAR TAB 60MG 76 SENSIPAR TAB 90MG 76 SEREVENT DIS AER 50MCG 18 SEROQUEL XR TAB 150MG 46 SEROQUEL XR TAB 200MG 46 SEROQUEL XR TAB 300MG 46 SEROQUEL XR TAB 400MG 46 SEROQUEL XR TAB 50MG 46 sertraline con 20mg/ml 24 sertraline tab 100mg 24 sertraline tab 25mg 24 sertraline tab 50mg 24 SFROWASA ENE 4GM 80 sigtab tab 92 sildec pe-dm syp 63 sildenafil tab 20mg 57 silphen coug syp 12.5/5ml 32 siltuss das liq 100/5ml 64 siltussin dm liq das 63 siltussin-dm liq diabetic 63 silver sulfa cre 1% 68 simply stuff tab 30mg 96 simvastatin tab 10mg 34 simvastatin tab 20mg 34 simvastatin tab 40mg 34 simvastatin tab 5mg 34 simvastatin tab 80mg 34 SKELID TAB 200MG 75 skin trtment lot 12% 71 SKYLA IUD 13.5MG 60 sm acid redu tab 200mg 113 sm anti-diar tab 2mg 29 sm antifungl cre 2% 67 sm aspirin chw 81mg 7 sm aspirin tab 325mg 7 sm aspirin tab 325mg ec 7 sm aspirin tab 81mg ec 7 sm child asa chw 81mg 7 sm clearlax pow 85 sm folic acd tab 400mcg 82 sm hydrocort cre 1% 71 sm hydrocort oin 1% 71 SM IPECAC SYP 29 sm multiple tab vitamins 92 sm nasal dec tab 30mg 96 sm nicotine dis 14mg/24h 107 sm nicotine dis 21mg 107 sm nicotine dis 7mg/24hr 107 sm nicotine gum 2mg 107 sm nicotine gum 2mg mint 107 sm nicotine gum 4mg 107 sm nicotine gum 4mg mint 107 sm nicotine loz 2mg mint 107 sm nicotine loz 4mg mint 107 SM PRENATAL TAB VITAMINS 94 sm vitamin d tab 400unit 116 smooth lax pow 85 smooth lax pow 3350 nf 85 smz-tmp sus 13 smz-tmp sus 200-40/5 13 smz-tmp tab 400-80mg 13 smz/tmp ds tab 800-160 13 sod chloride inj 0.45% 91 sod chloride inj 0.9% 91 sod chloride inj 2.5/ml 91 sod chloride inj 3% 91 sod chloride inj 5% 91 sod chloride neb 0.9% 64 sod fluoride chw 0.25mg f 89 sod fluoride chw 0.5mg f 89 sod fluoride chw 1.1mg 89 sod fluoride chw 1mg f 90 sod fluoride chw 2.2mg 90 sod fluoride dro 0.5mg/ml 90 sod fluoride tab 0.5mg f 90 sod fluoride tab 1mg f 90 sod poly sul pow 52 sod poly sul sus 15gm/60 52 sod sulfacet sol 10% op 98 sodium chlor neb 7% 64 sodium chlor sol 0.9% irr 81 solia tab 59 SOLTAMOX SOL 10MG/5ML 40 SOMATULINE INJ 120/.5ML 77 SOMATULINE INJ 60/0.2ML 77 SOMATULINE INJ 90/0.3ML 77 SOMAVERT INJ 10MG 76 SOMAVERT INJ 15MG 76 SOMAVERT INJ 20MG 76 SOMNOTE CAP 500MG 84 soothe&cool cre inzo 2% 67 SORIATANE CAP 10MG 68 SORIATANE CAP 17.5MG 68 SORIATANE CAP 25MG 68 sorine tab 120mg 53 sorine tab 160mg 53 sorine tab 240mg 53 sorine tab 80mg 53 sotalol af tab 120mg 53 sotalol af tab 160mg 53 sotalol af tab 80mg 53 sotalol hcl tab 120mg 53 sotalol hcl tab 160mg 53 sotalol hcl tab 240mg 53 sotalol hcl tab 80mg 53 sotret cap 10mg 65 sotret cap 20mg 65 sotret cap 30mg 65 SPACERS 87 spinosad sus 0.9% 73 SPIRIVA CAP HANDIHLR 16 148

spirono/hctz tab 25/25 74 spironolact tab 100mg 74 spironolact tab 25mg 74 spironolact tab 50mg 74 SPORANOX SOL 10MG/ML 31 sprintec 28 tab 28 day 59 SPRIX SPR 15.75MG 5 SPRYCEL TAB 100MG 41 SPRYCEL TAB 140MG 41 SPRYCEL TAB 20MG 41 SPRYCEL TAB 50MG 41 SPRYCEL TAB 70MG 41 SPRYCEL TAB 80MG 41 sps sus 15gm/60 52 sronyx tab 59 ssd af cre 1% 68 ssd cre 1% 68 SSKI SOL 1GM/ML 90 st joseph as chw 81mg 7 stavudine cap 15mg 49 stavudine cap 20mg 49 stavudine cap 30mg 49 stavudine cap 40mg 49 stavudine sol 1mg/ml 49 STAXYN TAB 10MG 56 STELARA INJ 45MG/0.5 68 STELARA INJ 90MG/ML 68 STIMATE SOL 1.5MG/ML 76 STIVARGA TAB 40MG 41 stop lice gel step 2 73 stop smoking gum 2mg mint 108 stop smoking gum 2mg orig 108 stop smoking gum 4mg 108 stop smoking loz 2mg mint 108 stop smoking loz 4mg mint 108 STRATTERA CAP 100MG 2 STRATTERA CAP 10MG 1 STRATTERA CAP 18MG 1 STRATTERA CAP 25MG 1 STRATTERA CAP 40MG 2 STRATTERA CAP 60MG 2 STRATTERA CAP 80MG 2 stress form tab 92 stress form tab 500/biot 92 stress formu tab 92 STRIBILD TAB 49 STROMECTOL TAB 3MG 12 STUART PREN TAB 94 SUBSYS SPR 100MCG 10 SUBSYS SPR 1200MCG 10 SUBSYS SPR 200MCG 10 SUBSYS SPR 400MCG 10 SUBSYS SPR 800MCG 10 sucralfate tab 1gm 113 sudanyl tab 30mg 96 sudogest tab 30mg 96 sudogest tab 60mg 96 sudophed tab 30mg 96 SULF LIME SOL USP 73 sulf/pred na sol op 99 sulfacet sod oin 10% op 98 sulfacet sod sol 10% op 98 SULFADIAZINE TAB 500MG 108 SULFAMYLON CRE 85MG/GM 68 sulfasalazin tab 500mg 80 sulfasalazin tab 500mg dr 80 sulfazine ec tab 500mg 80 sulfazine tab 500mg 80 sulindac tab 150mg 5 sulindac tab 200mg 5 sumatriptan inj 4mg/0.5 88 sumatriptan inj 6mg/0.5 88 sumatriptan spr 20mg/act 88 sumatriptan spr 5mg/act 88 sumatriptan tab 100mg 88 sumatriptan tab 25mg 88 sumatriptan tab 50mg 88 suphedrine tab 30mg 96 SUPRAX SUS 100/5ML 58 SUPRAX SUS 200/5ML 58 SUPRAX TAB 400MG 58 SURGUARD2 MIS 27GX1/2" 87 SUSTIVA CAP 200MG 49 SUSTIVA CAP 50MG 49 SUSTIVA TAB 600MG 49 SUTENT CAP 12.5MG 41 SUTENT CAP 25MG 41 SUTENT CAP 50MG 41 sw clearlax pow 85 sw nasal dec tab 30mg 96 sw nicotine gum 2mg mint 108 sw nicotine gum 4mg 108 sw nicotine loz 2mg mint 108 sw nicotine loz 4mg mint 108 syeda tab 3-0.03mg 60 symax fastab tab 0.125mg 112 symax-sl sub 0.125mg 112 symax-sr tab 0.375mg 112 SYMBICORT AER 160-4.5 18 SYMBICORT AER 80-4.5 18 SYMLIN INJ 600MCG 26 SYMLINPEN 60 INJ 1000MCG 26 SYMLNPEN 120 INJ 1000MCG 26 SYNAREL SOL 2MG/ML 76 SYNERA DIS 70-70MG 72 SYPRINE CAP 250MG 51 T tab-a-vite tab 92 tab-a-vite tab beta car 92 TABLOID TAB 40MG 40 TACLONEX OIN 71 TACLONEX SUS 71 tacrolimus cap 0.5mg 52 tacrolimus cap 1mg 52 tacrolimus cap 5mg 52 TAMIFLU CAP 30MG 50 TAMIFLU CAP 45MG 50 TAMIFLU CAP 75MG 50 149

TAMIFLU SUS 12MG/ML 51 TAMIFLU SUS 6MG/ML 51 tamoxifen tab 10mg 40 tamoxifen tab 20mg 40 tamsulosin cap 0.4mg 81 TARCEVA TAB 100MG 41 TARCEVA TAB 150MG 41 TARCEVA TAB 25MG 41 TARGRETIN CAP 75MG 42 TARKA TAB 1-240 CR 37 TARKA TAB 2-180 CR 37 TARKA TAB 2-240 CR 37 TARKA TAB 4-240 CR 38 TARON-C DHA CAP 94 TASIGNA CAP 150MG 41 TASIGNA CAP 200MG 42 TASMAR TAB 100MG 43 TAZORAC CRE 0.05% 68 TAZORAC CRE 0.1% 68 TAZORAC GEL 0.05% 68 TAZORAC GEL 0.1% 68 taztia xt cap 120mg/24 55 taztia xt cap 180mg/24 55 taztia xt cap 240mg/24 55 taztia xt cap 300mg/24 55 taztia xt cap 360mg/24 55 TEGRETOL XR TAB 100MG 21 TEGRIN-LT KIT 73 TEKTURNA TAB 150MG 38 TEKTURNA TAB 300MG 38 temazepam cap 15mg 84 temazepam cap 30mg 84 temazepam cap 7.5mg 84 TEMODAR CAP 100MG 39 TEMODAR CAP 140MG 39 TEMODAR CAP 180MG 39 TEMODAR CAP 20MG 39 TEMODAR CAP 250MG 39 TEMODAR CAP 5MG 39 terazosin cap 10mg 37 terazosin cap 1mg 37 terazosin cap 2mg 37 terazosin cap 5mg 37 terbinafine tab 250mg 31 terbutaline inj 1mg/ml 18 terbutaline tab 2.5mg 18 terbutaline tab 5mg 18 terconazole cre 0.4% 115 terconazole cre 0.8% 115 terconazole sup 80mg 115 TESTIM GEL 1%(50MG) 12 testost cyp inj 100mg/ml 12 testost cyp inj 200mg/ml 12 testost enan inj 200mg/ml 12 tetracycline cap 250mg 109 tetracycline cap 500mg 109 TEV-TROPIN INJ 5MG 76 TEVETEN TAB 400MG 36 tgt aspirin chw 81mg 8 tgt aspirin chw child 8 tgt aspirin tab 325mg 8 tgt aspirin tab 81mg ec 8 tgt cough liq form dm 63 tgt nicotine dis 14mg/24h 108 tgt nicotine dis 21mg/24h 108 tgt nicotine dis 7mg/24hr 108 tgt nicotine gum 2mg mint 108 tgt nicotine gum 2mg orig 108 tgt nicotine gum 2mgfruit 108 tgt nicotine gum 4mg 108 tgt nicotine gum 4mg mint 108 tgt nicotine gum 4mg orig 108 tgt nicotine loz 2mg chry 108 tgt nicotine loz 2mg mint 108 tgt nicotine loz 4mg chry 108 tgt nicotine loz 4mg mint 108 th aspirin tab 325mg 8 th aspirin tab 325mg ec 8 th aspirin tab 81mg ec 8 th hydrocort cre 1% 71 th naproxen tab 220mg 5 TH PRENATAL TAB VITAMINS 95 th tussin liq 100/5ml 64 THALITONE TAB 15MG 75 THALOMID CAP 100MG 51 THALOMID CAP 150MG 51 THALOMID CAP 200MG 51 THALOMID CAP 50MG 51 THEO-24 CAP 100MG CR 18 THEO-24 CAP 200MG CR 18 THEO-24 CAP 300MG CR 18 THEO-24 CAP 400MG ER 18 theochron tab 100mg cr 18 theochron tab 200mg cr 18 theochron tab 300mg cr 18 theophylline sol 80/15ml 18 theophylline tab 100mg cr 18 theophylline tab 100mg er 18 theophylline tab 200mg cr 18 theophylline tab 200mg er 18 theophylline tab 300mg er 18 theophylline tab 400mg er 18 theophylline tab 450mg er 18 theophylline tab 600mg er 19 thera tab 92 thera-mill tab 92 thera-tabs tab 92 theracort lot 1% 71 THERANATAL TAB 27-1 95 therapeutic tab 92 therems tab 93 thermazene cre 1% 68 thioridazine tab 100mg 47 thioridazine tab 10mg 47 thioridazine tab 25mg 47 thioridazine tab 50mg 47 thiothixene cap 10mg 47 thiothixene cap 1mg 47 thiothixene cap 2mg 47 thiothixene cap 5mg 47 150

thrive gum 2mg mint 108 thrive gum 4mg mint 108 THYROLAR-1 TAB 60MG 110 THYROLAR-1/2 TAB 30MG 110 THYROLAR-1/4 TAB 15MG 110 THYROLAR-2 TAB 120MG 110 THYROLAR-3 TAB 180MG 110 tiagabine tab 2mg 22 tiagabine tab 4mg 22 ticlopidine tab 250mg 82 tilia fe tab 60 timolol gel sol 0.25% op 97 timolol gel sol 0.5% op 97 timolol mal sol 0.25% op 97 timolol mal sol 0.5% op 97 timolol mal tab 10mg 53 timolol mal tab 20mg 53 timolol mal tab 5mg 53 TIMOPTIC OCU SOL 0.25% OP 97 TIMOPTIC OCU SOL 0.5% OP 97 tis-u-sol sol 52 tizanidine cap 2mg 95 tizanidine cap 4mg 95 tizanidine cap 6mg 95 tizanidine tab 2mg 95 tizanidine tab 4mg 95 TOBI NEB 300/5ML 3 tobra/dexame sus 0.3-0.1% 99 TOBRADEX OIN 0.3-0.1% 99 TOBRADEX ST SUS 0.3-0.05 99 tobramycin sol 0.3% op 98 tobrasol sol 0.3% op 98 TOBREX OIN 0.3% OP 99 TODAY SPONGE MIS 86 tolazamide tab 250mg 28 tolazamide tab 500mg 29 tolbutamide tab 500mg 29 tolmetin sod cap 400mg 5 tolmetin sod tab 200mg 5 tolmetin sod tab 600mg 5 tolterodine tab 1mg 114 tolterodine tab 2mg 114 tolu-sed dm liq 100-10/5 63 topiragen tab 100mg 21 topiragen tab 200mg 21 topiragen tab 25mg 21 topiragen tab 50mg 21 topiramate cap 15mg 21 topiramate cap 25mg 21 topiramate tab 100mg 22 topiramate tab 200mg 22 topiramate tab 25mg 21 topiramate tab 50mg 21 toposar inj 100/5ml 42 toposar inj 1gm/50ml 42 toposar inj 20mg/ml 42 toposar inj 500/25ml 42 TORISEL SOL 25MG/ML 42 torsemide tab 100mg 74 torsemide tab 10mg 74 torsemide tab 20mg 74 torsemide tab 5mg 74 TOVIAZ TAB 4MG 114 TOVIAZ TAB 8MG 114 TRACLEER TAB 125MG 57 TRACLEER TAB 62.5MG 57 TRADJENTA TAB 5MG 27 tramadol hcl tab 100mg er 10 tramadol hcl tab 200mg er 10 tramadol hcl tab 300mg er 10 tramadol hcl tab 50mg 10 trandolapril tab 1mg 35 trandolapril tab 2mg 35 trandolapril tab 4mg 35 tranexamic inj acid 83 TRANSDERM-SC DIS 1.5MG 30 tranylcyprom tab 10mg 24 trav-tabs tab 50mg 30 TRAVATAN Z DRO 0.004% 100 travel sick tab 50mg 30 travoprost dro 0.004% 100 trazodone tab 100mg 23 trazodone tab 150mg 23 trazodone tab 300mg 23 trazodone tab 50mg 23 TRECATOR TAB 250MG 39 TRETIN-X CRE 0.0375% 65 tretinoin cap 10mg 42 tretinoin cre 0.025% 65 tretinoin cre 0.05% 65 tretinoin cre 0.1% 65 tretinoin em cre 0.05% 66 tretinoin gel 0.01% 65 tretinoin gel 0.025% 65 TREXALL TAB 10MG 40 TREXALL TAB 15MG 40 TREXALL TAB 5MG 40 TREXALL TAB 7.5MG 40 tri-estaryll tab 60 tri-legest tab fe 60 tri-linyah tab 60 tri-previfem tab 60 tri-sprintec tab 60 tri-vit/fe dro /fl 0.25 93 tri-vit/fl dro 0.25mg 93 tri-vit/fl dro 0.5mg 93 tri-vit/fluo dro 0.25mg 93 tri-vit/fluo dro 0.5mg 93 tri-vita/fl dro 0.25mg 93 triamcin/ora pst 0.1% 91 triamcinolon cre 0.025% 71 triamcinolon cre 0.1% 71 triamcinolon cre 0.5% 71 triamcinolon lot 0.1% 71 triamcinolon oin 0.025% 71 triamcinolon oin 0.05% 71 triamcinolon oin 0.1% 71 triamcinolon oin 0.5% 71 triamcinolon pst 0.1% 91 triamcinolon spr 55mcg/ac 96 151

triamt/hctz cap 37.5-25 74 triamt/hctz tab 37.5-25 74 triamt/hctz tab 75-50mg 74 triazolam tab 0.125mg 84 triazolam tab 0.25mg 84 TRICARE TAB PRENATAL 95 triderm cre 0.1% 71 trifluoperaz tab 10mg 47 trifluoperaz tab 1mg 47 trifluoperaz tab 2mg 47 trifluoperaz tab 5mg 47 trifluridine sol 1% op 99 trihexyphen elx 0.4mg/ml 43 trihexyphen tab 2mg 43 trihexyphen tab 5mg 43 trilyte sol 84 trimethobenz cap 300mg 30 trimethoprim sol polymyxn 99 trimethoprim tab 100mg 13 trimipramine cap 100mg 26 trimipramine cap 25mg 26 trimipramine cap 50mg 26 TRINATAL RX TAB 1 95 trinessa tab 60 triptone tab 50mg 30 TRIVEEN-U CAP 95 trivora-28 tab 60 TRIZIVIR TAB 49 TROJAN MIS NAT LAMB 87 tropicamide sol 0.5% op 97 tropicamide sol 1% op 97 trospium chl cap 60mg er 114 TRUERESULT KIT 87 TRUETEST TES 73 TRUVADA TAB 200-300 49 TUDORZA PRES AER 400/ACT 16 tusnel diabt liq 10-100/5 63 tussin adult liq 100/5ml 64 tussin adult liq cgh/cong 63 tussin cough liq 10-100/5 63 tussin cough liq congesti 63 tussin dm liq 63 tussin dm liq 100-10/5 63 tussin dm liq clear 63 TWINJECT INJ 0.15MG 116 TWINJECT INJ 0.3MG 116 TYKERB TAB 250MG 42 TYSABRI INJ 104 TYZEKA TAB 600MG 50 TYZINE PED DRO 0.05% 96 TYZINE SOL 0.1% 96 U ULESFIA LOT 5% 73 ULORIC TAB 40MG 81 ULORIC TAB 80MG 81 unith direct tab 100mcg 110 unith direct tab 112mcg 111 unith direct tab 125mcg 111 unith direct tab 150mcg 111 unith direct tab 175mcg 111 unith direct tab 200mcg 111 unith direct tab 25mcg 110 unith direct tab 300mcg 111 unith direct tab 50mcg 110 unith direct tab 75mcg 110 unith direct tab 88mcg 110 unithroid tab 100mcg 111 unithroid tab 112mcg 111 unithroid tab 125mcg 111 unithroid tab 137mcg 111 unithroid tab 150mcg 111 unithroid tab 175mcg 111 unithroid tab 200mcg 111 unithroid tab 25mcg 111 unithroid tab 300mcg 111 unithroid tab 50mcg 111 unithroid tab 75mcg 111 unithroid tab 88mcg 111 UROCIT-K 15 TAB 81 ursodiol cap 300mg 79 ursodiol tab 250mg 79 ursodiol tab 500mg 79 V vagistat-3 kit combo pk 115 valacyclovir tab 1gm 50 valacyclovir tab 500mg 50 VALCYTE TAB 450MG 49 valproic acd cap 250mg 22 valproic acd sol 250/5ml 22 valproic acd syp 250/5ml 22 valsart/hctz tab 160-12.5 38 valsart/hctz tab 160-25mg 38 valsart/hctz tab 320-12.5 38 valsart/hctz tab 320-25mg 38 valsart/hctz tab 80-12.5 38 VALSTAR SOL 40MG/ML 41 vancomycin cap 125mg 13 vancomycin cap 250mg 13 vandazole gel 0.75% 115 VANDETANIB TAB 100MG 42 VANDETANIB TAB 300MG 42 VANOS CRE 0.1% 71 velivet pak 60 VELTIN GEL 65 venlafaxine cap 150mg er 25 venlafaxine cap 37.5mg 25 venlafaxine cap 75mg er 25 venlafaxine tab 100mg 25 venlafaxine tab 150mg er 25 venlafaxine tab 225mg er 25 venlafaxine tab 25mg 25 venlafaxine tab 37.5 er 25 venlafaxine tab 37.5mg 25 venlafaxine tab 50mg 25 venlafaxine tab 75mg 25 venlafaxine tab 75mg er 25 152

VENTAVIS SOL 10MCG/ML 56 VENTOLIN HFA AER 18 verapamil cap 120mg er 55 verapamil cap 120mg sr 55 verapamil cap 180mg er 55 verapamil cap 180mg sr 55 verapamil cap 240mg er 55 verapamil cap 240mg sr 55 verapamil cap 360mg sr 55 verapamil tab 120mg 55 verapamil tab 120mg er 55 verapamil tab 120mg sr 56 verapamil tab 180mg er 56 verapamil tab 180mg sr 56 verapamil tab 240mg er 56 verapamil tab 240mg sr 56 verapamil tab 40mg 55 verapamil tab 80mg 55 VEREGEN OIN 15% 66 VERIPRED 20 SOL 20MG/5ML 62 VESICARE TAB 5MG 114 vestura tab 3-0.02mg 60 VEXOL SUS 1% OP 99 VIAGRA TAB 100MG 56 VIAGRA TAB 25MG 56 VIAGRA TAB 50MG 56 VIBRAMYCIN SYP 50MG/5ML 109 VICTOZA INJ 18MG/3ML 27 VICTRELIS CAP 200MG 50 VIDEX SOL 2GM 49 VIDEX SOL 4GM 49 vigomar tab 93 VIIBRYD KIT 24 VIIBRYD TAB 10MG 24 VIIBRYD TAB 20MG 24 VIIBRYD TAB 40MG 24 vimar hp tab 93 VIMPAT SOL 10MG/ML 22 VIMPAT TAB 100MG 22 VIMPAT TAB 150MG 22 VIMPAT TAB 200MG 22 VIMPAT TAB 50MG 22 VINATE AZ EX TAB 95 VINATE II TAB 95 VINATE ONE TAB 95 viorele tab 60 VIRACEPT POW 50MG/GM 49 VIRACEPT TAB 250MG 49 VIRACEPT TAB 625MG 49 VIRAMUNE XR TAB 400MG 49 VIREAD POW 40MG/GM 49 VIREAD TAB 150MG 49 VIREAD TAB 200MG 49 VIREAD TAB 250MG 49 VIREAD TAB 300MG 49 virt-vite tab plus 92 VISICOL TAB 1.5GM 85 vit d gummie chw 400unit 116 vitalee tab 93 VITAMIN A CAP 25000UNT 116 vitamin d cap 50000unt 116 vitamin d chw 400unit 116 vitamin d dro 400unit 116 vitamin d tab 400unit 116 vitamin d3 chw 400unit 116 vitamin d3 dro 400unit 116 vitamin d3 tab 400unit 116 vitazol cre 0.75% 72 VIVAGLOBIN SOL 160MG/ML 102 VIVELLE-DOT DIS 0.025MG 79 VIVELLE-DOT DIS 0.0375MG 79 VIVELLE-DOT DIS 0.05MG 79 VIVELLE-DOT DIS 0.075MG 79 VIVELLE-DOT DIS 0.1MG 79 vol-care rx tab 92 VOL-PLUS TAB 95 VOL-TAB RX TAB 95 VOLTAREN GEL 1% 66 voriconazole tab 200mg 31 voriconazole tab 50mg 31 VOTRIENT TAB 200MG 42 VPRIV INJ 400UNIT 82 VYTORIN TAB 10-10MG 33 VYTORIN TAB 10-20MG 33 VYTORIN TAB 10-40MG 33 VYTORIN TAB 10-80MG 33 VYVANSE CAP 20MG 1 VYVANSE CAP 30MG 1 VYVANSE CAP 40MG 1 VYVANSE CAP 50MG 1 VYVANSE CAP 60MG 1 VYVANSE CAP 70MG 1 W wal-dram ii tab 25mg 30 wal-dram tab 50mg 30 wal-dryl cap 25mg 32 wal-fex allr tab 180mg 33 wal-fex alrg tab 60mg 33 wal-phed tab 30mg 96 wal-proxen tab 220mg 5 wal-tussin liq dm 63 wal-zan tab 150mg 113 wal-zyr dro 0.025%op 100 wal-zyr sol 1mg/ml 33 wal-zyr sol 5mg/5ml 33 warfarin tab 10mg 19 warfarin tab 1mg 19 warfarin tab 2.5mg 19 warfarin tab 2mg 19 warfarin tab 3mg 19 warfarin tab 4mg 19 warfarin tab 5mg 19 warfarin tab 6mg 19 warfarin tab 7.5mg 19 wee care sus 15/1.25 83 WELCHOL PAK 3.75GM 33 WELCHOL TAB 625MG 33 wera tab 0.5/35 60 153

WIDE-SEAL DPR KIT 60 87 WIDE-SEAL DPR KIT 65 87 WIDE-SEAL DPR KIT 70 87 WIDE-SEAL DPR KIT 75 87 WIDE-SEAL DPR KIT 80 87 WIDE-SEAL DPR KIT 85 87 WIDE-SEAL DPR KIT 90 87 WIDE-SEAL DPR KIT 95 87 wymzya fe chw 0.4mg-35 60 X XALKORI CAP 200MG 42 XALKORI CAP 250MG 42 XARELTO TAB 10MG 19 XARELTO TAB 15MG 19 XARELTO TAB 20MG 19 XELODA TAB 150MG 40 XELODA TAB 500MG 40 XENAZINE TAB 12.5MG 104 XENAZINE TAB 25MG 104 XIFAXAN TAB 200MG 13 XIFAXAN TAB 550MG 13 XOPENEX HFA AER 18 XTANDI CAP 40MG 41 XYREM SOL 500MG/ML 103 Y yl folic aci tab 400mcg 82 YODOXIN TAB 210MG 3 YODOXIN TAB 650MG 3 yohimbine tab 5.4mg 56 Z zafirlukast tab 10mg 16 zafirlukast tab 20mg 16 zaleplon cap 10mg 84 zaleplon cap 5mg 84 zarah tab 3-0.03mg 60 ZAVESCA CAP 100MG 82 zazole cre 0.4% 115 zazole cre 0.8% 115 zazole sup 80mg 115 ZELBORAF TAB 240MG 42 ZEMAIRA INJ 1000MG 108 zenatane cap 10mg 66 zenatane cap 20mg 66 zenatane cap 40mg 66 zenchent fe chw 60 zenchent fe chw 0.4mg-35 60 zenchent tab 60 ZENPEP CAP 10000UNT 74 ZENPEP CAP 15000UNT 74 ZENPEP CAP 20000UNT 74 zenzedi tab 10mg 1 zenzedi tab 5mg 1 zeosa chw 60 ZETIA TAB 10MG 34 ZIAGEN SOL 20MG/ML 49 ZIANA GEL 66 zidovudine cap 100mg 49 zidovudine syp 50mg/5ml 49 zidovudine tab 300mg 49 zinc sulfate cap 220mg 91 zinc-220 cap 91 zincate cap 220mg 91 ziprasidone cap 20mg 44 ziprasidone cap 40mg 44 ziprasidone cap 60mg 44 ziprasidone cap 80mg 44 ZIRGAN GEL 0.15% 99 ZMAX SUS 2GM 85 ZOLINZA CAP 100MG 42 zolmitriptan tab 2.5 mg 88 zolmitriptan tab 2.5mg 88 zolmitriptan tab 5mg 88 zolpidem tab 10mg 84 zolpidem tab 5mg 84 ZOMIG SPR 5MG 88 zonisamide cap 100mg 22 zonisamide cap 25mg 22 zonisamide cap 50mg 22 zovia 1/35e tab 60 zovia 1/50e tab 60 ZUPLENZ MIS 4MG 30 ZUPLENZ MIS 8MG 30 ZYCLARA CRE 3.75% 72 ZYCLARA PUMP CRE 2.5% 72 ZYCLARA PUMP CRE 3.75% 72 ZYFLO CR TAB 600MG 16 ZYFLO TAB 600MG 17 ZYMAXID SOL 0.5% 99 ZYPREXA RELP INJ 210MG 46 ZYPREXA RELP INJ 300MG 46 ZYPREXA RELP INJ 405MG 46 zyrtec itchy dro 0.025%op 100 ZYTIGA TAB 250MG 41 ZYVOX SUS 100MG/5M 13 ZYVOX TAB 600MG 13 154