EXCHANGES_CVSC_NY3 eff 10/01/2015

EXCHANGES_CVSC_NY3 eff 10/01/2015 Drug Name ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS Amphetamines amphetamine-dextroamphetamine cap sr 1 QL (90 caps / 25 days) 24hr 5 amphetamine-dextroamphetamine cap sr 1 QL (90 caps / 25 days) 24hr 10 amphetamine-dextroamphetamine cap sr 1 QL (30 caps / 25 days) 24hr 15 amphetamine-dextroamphetamine cap sr 1 QL (30 caps / 25 days) 24hr 20 amphetamine-dextroamphetamine cap sr 1 QL (30 caps / 25 days) 24hr 25 amphetamine-dextroamphetamine cap sr 1 QL (30 caps / 25 days) 24hr 30 amphetamine-dextroamphetamine tab 5 1 QL (90 tabs / 25 days) amphetamine-dextroamphetamine tab 7.5 1 QL (90 tabs / 25 days) amphetamine-dextroamphetamine tab 10 1 QL (90 tabs / 25 days) amphetamine-dextroamphetamine tab 12.51 QL (90 tabs / 25 days) amphetamine-dextroamphetamine tab 15 1 QL (60 tabs / 25 days) amphetamine-dextroamphetamine tab 20 1 QL (60 tabs / 25 days) amphetamine-dextroamphetamine tab 30 1 QL (30 tabs / 25 days) dextroamphetamine sulfate cap sr 24hr 5 1 QL (120 caps / 25 days) dextroamphetamine sulfate cap sr 24hr 10 1 QL (120 caps / 25 days) dextroamphetamine sulfate cap sr 24hr 15 1 QL (60 caps / 25 days) dextroamphetamine sulfate oral solution 5 1 QL (1,200 ml / 25 days) /5ml dextroamphetamine sulfate tab 5 1 QL (120 tabs / 25 days) dextroamphetamine sulfate tab 10 1 QL (120 tabs / 25 days) methamphetamine hcl tab 5 1 QL (150 tabs / 25 days) VYVANSE CAP 10MG 3 QL (60 caps / 25 days), PA; PA applies for members age 19 and 1

VYVANSE CAP 20MG 3 QL (60 caps / 25 days), PA; PA applies for members age 19 and VYVANSE CAP 30MG 3 QL (60 caps / 25 days), PA; PA applies for members age 19 and VYVANSE CAP 40MG 3 QL (30 caps / 25 days), PA; PA applies for members age 19 and VYVANSE CAP 50MG 3 QL (30 caps / 25 days), PA; PA applies for members age 19 and VYVANSE CAP 60MG 3 QL (30 caps / 25 days), PA; PA applies for members age 19 and VYVANSE CAP 70MG 3 QL (30 caps / 25 days), PA; PA applies for members age 19 and zenzedi tab 2.5 1 QL (120 tabs / 25 days) zenzedi tab 7.5 1 QL (120 tabs / 25 days) zenzedi tab 15 1 QL (60 tabs / 25 days) zenzedi tab 20 1 QL (60 tabs / 25 days) zenzedi tab 30 1 QL (30 tabs / 25 days) Attention-Deficit/Hyperactivity Disorder (ADHD) Agents guanfacine hcl tab sr 24hr 1 (base 1 ST; PA** equiv) guanfacine hcl tab sr 24hr 2 (base 1 ST; PA** equiv) guanfacine hcl tab sr 24hr 3 (base 1 ST; PA** equiv) guanfacine hcl tab sr 24hr 4 (base 1 ST; PA** equiv) STRATTERA CAP 10MG 2 QL (120 caps / 25 days) STRATTERA CAP 18MG 2 QL (120 caps / 25 days) STRATTERA CAP 25MG 2 QL (120 caps / 25 days) STRATTERA CAP 40MG 2 QL (60 caps / 25 days) STRATTERA CAP 60MG 2 QL (30 caps / 25 days) STRATTERA CAP 80MG 2 QL (30 caps / 25 days) STRATTERA CAP 100MG 2 QL (30 caps / 25 days) Stimulants - Misc. dexmethylphenidate hcl cap sr 24 hr 5 1 dexmethylphenidate hcl cap sr 24 hr 10 1 QL (60 caps / 25 days) QL (60 caps / 25 days) 2

dexmethylphenidate hcl cap sr 24 hr 15 1 QL (60 caps / 25 days) dexmethylphenidate hcl cap sr 24 hr 30 1 QL (30 caps / 25 days) dexmethylphenidate hcl cap sr 24 hr 40 1 QL (30 caps / 25 days) dexmethylphenidate hcl tab 2.5 1 QL (120 tabs / 25 days) dexmethylphenidate hcl tab 5 1 QL (120 tabs / 25 days) dexmethylphenidate hcl tab 10 1 QL (60 tabs / 25 days) metadate tab 20 er 1 QL (90 tabs / 25 days) methylphenidate hcl cap cr 10 1 QL (60 caps / 25 days) methylphenidate hcl cap cr 20 1 QL (60 caps / 25 days) methylphenidate hcl cap cr 30 1 QL (60 caps / 25 days) methylphenidate hcl cap cr 40 1 QL (30 caps / 25 days) methylphenidate hcl cap cr 50 1 QL (30 caps / 25 days) methylphenidate hcl cap cr 60 1 QL (30 caps / 25 days) methylphenidate hcl cap sr 24hr 20 (la) 1 QL (60 caps / 25 days) methylphenidate hcl cap sr 24hr 30 (la) 1 QL (60 caps / 25 days) methylphenidate hcl cap sr 24hr 40 (la) 1 QL (30 caps / 25 days) methylphenidate hcl soln 5 /5ml 1 QL (1800 ml / 25 days) methylphenidate hcl soln 10 /5ml 1 QL (900 ml / 25 days) methylphenidate hcl tab 5 1 QL (180 tabs / 25 days) methylphenidate hcl tab 10 1 QL (180 tabs / 25 days) methylphenidate hcl tab 20 1 QL (90 tabs / 25 days) methylphenidate hcl tab cr 10 1 QL (90 tabs / 25 days) methylphenidate hcl tab cr 20 1 QL (90 tabs / 25 days) methylphenidate hcl tab sa osm 18 1 QL (60 tabs / 25 days) methylphenidate hcl tab sa osm 27 1 QL (60 tabs / 25 days) methylphenidate hcl tab sa osm 36 1 QL (60 tabs / 25 days) methylphenidate hcl tab sa osm 54 1 QL (30 tabs / 25 days) modafinil tab 100 1 PA modafinil tab 200 1 PA NUVIGIL TAB 50MG 2 PA NUVIGIL TAB 150MG 2 PA NUVIGIL TAB 200MG 2 PA NUVIGIL TAB 250MG 2 PA RITALIN LA CAP 10MG 2 QL (60 caps / 25 days) RITALIN LA CAP 60MG 2 QL (30 caps / 25 days) AMINOGLYCOSIDES Aminoglycosides streptomycin sulfate for inj 1 gm 1 tobramycin nebu soln 300 /5ml 1 PA ANALGESICS - ANTI-INFLAMMATORY Anti-TNF-alpha - Monoclonal Antibodies HUMIRA INJ 10MG/0.2 3 PA HUMIRA INJ 40MG/0.8 3 PA HUMIRA KIT 20MG/0.4 3 PA HUMIRA PEN INJ CROHNS 3 PA 3

Interleukin-1 Receptor Antagonist (IL-1Ra) KINERET INJ 3 PA, ST Interleukin-6 Receptor Inhibitors ACTEMRA INJ 80MG/4ML 3 PA, ST ACTEMRA INJ 162/0.9 3 PA, ST ACTEMRA INJ 200/10ML 3 PA, ST ACTEMRA INJ 400/20ML 3 PA, ST Nonsteroidal Anti-inflammatory Agents (NSAIDs) celecoxib cap 50 1 celecoxib cap 100 1 celecoxib cap 200 1 celecoxib cap 400 1 diclofenac potassium tab 50 1 diclofenac sodium tab delayed release 25 1 diclofenac sodium tab delayed release 50 1 diclofenac sodium tab delayed release 75 1 diclofenac sodium tab sr 24hr 100 1 diclofenac w/ misoprostol tab delayed 1 release 50-0.2 diclofenac w/ misoprostol tab delayed 1 release 75-0.2 etodolac cap 200 1 etodolac cap 300 1 etodolac tab 400 1 etodolac tab 500 1 fenoprofen calcium tab 600 1 flurbiprofen tab 50 1 flurbiprofen tab 100 1 ibuprofen susp 100 /5ml 1 ibuprofen tab 400 1 ibuprofen tab 600 1 ibuprofen tab 800 1 INDOCIN SUS 25MG/5ML 3 indomethacin cap 25 1 indomethacin cap 50 1 indomethacin cap cr 75 1 ketoprofen cap 50 1 ketoprofen cap 75 1 ketoprofen cap sr 24hr 200 1 ketorolac tromethamine im inj 60 /2ml 1 (30 /ml) ketorolac tromethamine inj 15 /ml 1 ketorolac tromethamine inj 30 /ml 1 4

ketorolac tromethamine inj 60 /2ml (30 1 /ml) ketorolac tromethamine inj 300 /10ml 1 (30 /ml) ketorolac tromethamine tab 10 1 QL (20 tabs / 25 days) meclofenamate sodium cap 50 1 meclofenamate sodium cap 100 1 mefenamic acid cap 250 1 meloxicam susp 7.5 /5ml 1 meloxicam tab 7.5 1 meloxicam tab 15 1 nabumetone tab 500 1 nabumetone tab 750 1 NALFON CAP 400MG 3 ST; PA** naproxen dr tab 375 1 naproxen dr tab 500 1 naproxen sodium tab 275 1 naproxen sodium tab 550 1 naproxen susp 125 /5ml 1 naproxen tab 250 1 naproxen tab 375 1 naproxen tab 500 1 oxaprozin tab 600 1 piroxicam cap 10 1 piroxicam cap 20 1 sulindac tab 150 1 sulindac tab 200 1 tolmetin sodium cap 400 1 tolmetin sodium tab 200 1 tolmetin sodium tab 600 1 Pyrimidine Synthesis Inhibitors leflunomide tab 10 1 leflunomide tab 20 1 Selective Costimulation Modulators ORENCIA INJ 125MG/ML 3 PA, ST ORENCIA INJ 250MG 3 PA, ST Soluble Tumor Necrosis Factor Receptor Agents ENBREL INJ 25/0.5ML 3 PA ENBREL INJ 25MG 3 PA ENBREL INJ 50MG/ML 3 PA ENBREL SRCLK INJ 50MG/ML 3 PA ANALGESICS - NonNarcotic Analgesics-Sedatives butalbital-acetaminophen-caffeine cap 50-300-40 1 QL (48 caps / 25 days) 5

butalbital-acetaminophen-caffeine cap 1 QL (48 caps / 25 days) 50-325-40 butalbital-acetaminophen-caffeine tab 1 QL (48 tabs / 25 days) 50-325-40 butalbital-aspirin-caffeine cap 50-325-40 1 QL (48 caps / 25 days) butalbital-aspirin-caffeine tab 50-325-40 1 QL (48 tabs / 25 days) margesic cap 1 QL (48 caps / 25 days) Salicylates aspirin chew tab 81 0 QL (100 tabs / 30 days); OTC; $0 copay for patients 12 and aspirin low tab 81 ec 0 QL (100 tabs / 30 days); OTC; $0 copay for patients 12 and ASPIRIN TAB 81 MG 0 QL (100 tabs / 30 days); OTC; $0 copay for patients 12 and aspirin tab 325 0 QL (100 tabs / 30 days); OTC; $0 copay for patients 45 and aspirin tab delayed release 325 0 QL (100 tabs / 30 days); OTC; $0 copay for patients 45 and diflunisal tab 500 1 ANALGESICS - OPIOID Opioid Agonists CODEINE SULF SOL 30MG/5ML 2 codeine sulfate tab 15 1 QL (42 tabs / 25 days) codeine sulfate tab 30 1 QL (42 tabs / 25 days) codeine sulfate tab 60 1 QL (42 tabs / 25 days) EMBEDA CAP 20-0.8MG 3 QL (60 caps / 25 days) EMBEDA CAP 30-1.2MG 3 QL (60 caps / 25 days) EMBEDA CAP 50-2MG 3 QL (60 caps / 25 days) EMBEDA CAP 60-2.4MG 3 QL (30 caps / 25 days) EMBEDA CAP 80-3.2MG 3 QL (30 caps / 25 days) EMBEDA CAP 100-4MG 3 QL (30 caps / 25 days) fentanyl citrate lozenge on a handle 200 mcg 1 QL (120 lozenges / 25 days), PA fentanyl citrate lozenge on a handle 400 mcg 1 QL (120 lozenges / 25 days), PA fentanyl citrate lozenge on a handle 600 mcg 1 QL (120 lozenges / 25 days), PA fentanyl citrate lozenge on a handle 800 mcg 1 QL (120 lozenges / 25 days), PA 6

fentanyl citrate lozenge on a handle 1200 mcg 1 QL (120 lozenges / 25 days), PA fentanyl citrate lozenge on a handle 1600 mcg 1 QL (120 lozenges / 25 days), PA fentanyl td patch 72hr 12 mcg/hr 1 QL (10 patches / 25 days) fentanyl td patch 72hr 25 mcg/hr 1 QL (10 patches / 25 days) fentanyl td patch 72hr 50 mcg/hr 1 QL (10 patches / 25 days) fentanyl td patch 72hr 75 mcg/hr 1 QL (10 patches / 25 days) fentanyl td patch 72hr 100 mcg/hr 1 QL (10 patches / 25 days) HYDROMORPHON SUP 3MG 3 QL (120 units / 25 days) hydromorphone hcl liqd 1 /ml 1 QL (600 ml / 25 days) hydromorphone hcl tab 2 1 QL (180 tabs / 25 days) hydromorphone hcl tab 4 1 QL (180 tabs / 25 days) hydromorphone hcl tab 8 1 QL (180 tabs / 25 days) hydromorphone hcl tab er 24hr deter 8 1 QL (30 tablets per 25 days) hydromorphone hcl tab er 24hr deter 12 1 QL (30 tablets per 25 days) hydromorphone hcl tab er 24hr deter 16 1 QL (30 tablets per 25 days) hydromorphone hcl tab er 24hr deter 32 1 QL (30 tablets per 25 days) levorphanol tartrate tab 2 1 QL (120 tabs / 25 days) methadone hcl conc 10 /ml 1 QL (30mL / 25 days) methadone hcl soln 5 /5ml 1 QL (600 ml / 25 days) methadone hcl soln 10 /5ml 1 QL (300 ml / 25 days) methadone hcl tab 5 1 QL (120 tabs / 25 days) methadone hcl tab 10 1 QL (60 tabs / 25 days) methadone hcl tab for oral susp 40 1 QL (9 tabs / 25 days) MORPHINE SUL SUP 30MG 2 QL (180 supp / 25 days) morphine sulfate (concentrate) oral soln 201 QL (180 ml / 25 days) /ml morphine sulfate beads cap sr 24hr 30 1 QL (60 caps / 25 days) morphine sulfate beads cap sr 24hr 45 1 QL (60 caps / 25 days) morphine sulfate beads cap sr 24hr 60 1 QL (60 caps / 25 days) morphine sulfate beads cap sr 24hr 75 1 QL (30 caps / 25 days) morphine sulfate beads cap sr 24hr 90 1 QL (30 caps / 25 days) morphine sulfate beads cap sr 24hr 120 1 QL (30 caps / 25 days) morphine sulfate oral soln 10 /5ml 1 QL (900 ml / 25 days) morphine sulfate oral soln 20 /5ml 1 QL (900 ml / 25 days) morphine sulfate suppos 5 1 QL (180 supp / 25 days) morphine sulfate suppos 10 1 QL (180 supp / 25 days) 7

morphine sulfate suppos 20 1 QL (180 supp / 25 days) morphine sulfate tab 15 1 QL (180 tabs / 25 days) morphine sulfate tab 30 1 QL (180 tabs / 25 days) morphine sulfate tab cr 15 1 QL (120 tabs / 25 days) morphine sulfate tab cr 30 1 QL (120 tabs / 25 days) morphine sulfate tab cr 60 1 QL (120 tabs / 25 days) morphine sulfate tab cr 100 1 QL (60 tabs / 25 days) morphine sulfate tab cr 200 1 QL (60 tabs / 25 days) NUCYNTA ER TAB 50MG 3 QL (120 tabs / 25 days) NUCYNTA ER TAB 100MG 3 QL (120 tabs / 25 days) NUCYNTA ER TAB 150MG 3 QL (60 tabs / 25 days) NUCYNTA ER TAB 200MG 3 QL (60 tabs / 25 days) NUCYNTA ER TAB 250MG 3 QL (60 tabs / 25 days) NUCYNTA TAB 50MG 3 QL (360 tabs / 25 days) NUCYNTA TAB 75MG 3 QL (240 tabs / 25 days) NUCYNTA TAB 100MG 3 QL (180 tabs / 25 days) OPANA ER TAB 5MG 3 QL (120 tabs / 25 days) OPANA ER TAB 7.5MG 3 QL (120 tabs / 25 days) OPANA ER TAB 10MG 3 QL (120 tabs / 25 days) OPANA ER TAB 15MG 3 QL (120 tabs / 25 days) OPANA ER TAB 20MG 3 QL (120 tabs / 25 days) OPANA ER TAB 30MG 3 QL (60 tabs / 25 days) OPANA ER TAB 40MG 3 QL (60 tabs / 25 days) oxycodone hcl cap 5 1 QL (180 caps / 25 days) oxycodone hcl conc 100 /5ml (20 /ml) 1 QL (180 ml / 25 days) oxycodone hcl soln 5 /5ml 1 QL (900 ml / 25 days) oxycodone hcl tab 5 1 QL (180 tabs / 25 days) oxycodone hcl tab 10 1 QL (180 tabs / 25 days) oxycodone hcl tab 15 1 QL (180 tabs / 25 days) oxycodone hcl tab 20 1 QL (180 tabs / 25 days) oxycodone hcl tab 30 1 QL (180 tabs / 25 days) oxycodone hcl tab er 12hr deter 10 1 QL (120 tabs / 25 days) oxycodone hcl tab er 12hr deter 20 1 QL (120 tabs / 25 days) oxycodone hcl tab er 12hr deter 40 1 QL (120 tabs / 25 days) oxycodone hcl tab er 12hr deter 80 1 QL (60 tabs / 25 days) OXYCONTIN TAB 10MG CR 2 QL (120 tabs / 25 days) OXYCONTIN TAB 15MG CR 2 QL (120 tabs / 25 days) OXYCONTIN TAB 20MG CR 2 QL (120 tabs / 25 days) OXYCONTIN TAB 30MG CR 2 QL (120 tabs / 25 days) OXYCONTIN TAB 40MG CR 2 QL (120 tabs / 25 days) OXYCONTIN TAB 60MG CR 2 QL (60 tabs / 25 days) OXYCONTIN TAB 80MG CR 2 QL (60 tabs / 25 days) oxymorphone hcl tab 5 1 QL (180 tabs / 25 days) oxymorphone hcl tab 10 1 QL (180 tabs / 25 days) oxymorphone hcl tab sr 12hr 5 1 QL (120 tabs / 25 days) oxymorphone hcl tab sr 12hr 7.5 1 QL (120 tabs / 25 days) 8

oxymorphone hcl tab sr 12hr 10 1 QL (120 tabs / 25 days) oxymorphone hcl tab sr 12hr 15 1 QL (120 tabs / 25 days) oxymorphone hcl tab sr 12hr 20 1 QL (120 tabs / 25 days) oxymorphone hcl tab sr 12hr 30 1 QL (120 tabs / 25 days) oxymorphone hcl tab sr 12hr 40 1 QL (120 tabs / 25 days) tramadol hcl tab 50 1 QL (240 tabs / 25 days) tramadol hcl tab sr 24hr 100 1 QL (30 tabs / 25 days) tramadol hcl tab sr 24hr 200 1 QL (30 tabs / 25 days) tramadol hcl tab sr 24hr 300 1 QL (30 tabs / 25 days) Opioid Combinations acetaminophen w/ codeine soln 120-12 1 QL (5000 ml / 25 days) /5ml acetaminophen w/ codeine tab 300-15 1 QL (400 tabs / 25 days) acetaminophen w/ codeine tab 300-30 1 QL (400 tabs / 25 days) acetaminophen w/ codeine tab 300-60 1 QL (400 tabs / 25 days) CAPITAL/COD SUS 120-12/5 3 QL (5000 ml / 25 days) endocet tab 5-325 1 QL (375 tabs / 25 days) endocet tab 7.5-325 1 QL (375 tabs / 25 days) endocet tab 10-325 1 QL (375 tabs / 25 days) hydrocodone-acetaminophen soln 7.5-325 1 QL (5540 ml / 25 days) /15ml HYDROCODONE-ACETAMINOPHEN SOLN 1 QL (5540 ml / 25 days) 10-325 MG/15ML hydrocodone-acetaminophen tab 2.5-325 1 QL (375 tabs / 25 days) hydrocodone-acetaminophen tab 5-300 1 QL (400 tabs / 25 days) hydrocodone-acetaminophen tab 5-325 1 QL (375 tabs / 25 days) hydrocodone-acetaminophen tab 7.5-300 1 QL (400 tabs / 25 days) hydrocodone-acetaminophen tab 7.5-325 1 QL (375 tabs / 25 days) hydrocodone-acetaminophen tab 10-300 1 QL (400 tabs / 25 days) hydrocodone-acetaminophen tab 10-325 1 QL (375 tabs / 25 days) oxycodone w/ acetaminophen tab 2.5-325 1 QL (375 tabs / 25 days) oxycodone w/ acetaminophen tab 5-325 1 QL (375 tabs / 25 days) oxycodone w/ acetaminophen tab 7.5-325 1 QL (375 tabs / 25 days) oxycodone w/ acetaminophen tab 10-325 1 QL (375 tabs / 25 days) oxycodone-aspirin tab 4.8355-325 1 QL (375 tabs / 25 days) oxycodone-ibuprofen tab 5-400 1 QL (28 tabs / 25 days) PRIMLEV TAB 5-300MG 3 QL (400 tabs / 25 days) PRIMLEV TAB 7.5-300 3 QL (400 tabs / 25 days) PRIMLEV TAB 10-300MG 3 QL (400 tabs / 25 days) 9

ROXICET SOL 5-325/5 3 QL (1850 ml / 25 days) roxicet tab 5-325 1 QL (375 tabs / 25 days) vicodin es tab 7.5-300 1 QL (400 tabs / 25 days) vicodin hp tab 10-300 1 QL (400 tabs / 25 days) vicodin tab 5-300 1 QL (400 tabs / 25 days) Opioid Partial Agonists buprenorphine hcl sl tab 2 (base equiv) 1 QL (120 tablets per 25 days), PA buprenorphine hcl sl tab 8 (base equiv) 1 QL (120 tablets per 25 days), PA buprenorphine hcl-naloxone hcl sl tab 2-0.51 QL (120 tablets per 25 (base equiv) days), PA buprenorphine hcl-naloxone hcl sl tab 8-2 (base equiv) 1 QL (120 tablets per 25 days), PA butorphanol tartrate nasal soln 10 /ml 1 QL (2 bottles / 25 days) nalbuphine hcl inj 10 /ml 1 nalbuphine hcl inj 20 /ml 1 SUBOXONE MIS 2-0.5MG 2 QL (120 units per 25 days), PA SUBOXONE MIS 4-1MG 2 QL (120 units per 25 days), PA SUBOXONE MIS 8-2MG 2 QL (120 units per 25 days), PA SUBOXONE MIS 12-3MG 2 QL (60 films per 25 days), PA ANDROGENS-ANABOLIC Anabolic Steroids ANADROL-50 TAB 50MG 3 PA oxandrolone tab 2.5 1 PA oxandrolone tab 10 1 PA Androgens ANDRODERM DIS 2MG/24HR 2 PA ANDRODERM DIS 4MG/24HR 2 PA android cap 10 1 PA AXIRON SOL 30MG/ACT 2 PA danazol cap 50 1 danazol cap 100 1 danazol cap 200 1 testosterone cypionate im inj in oil 100 1 PA /ml testosterone cypionate im inj in oil 200 1 PA /ml testosterone enanthate im inj in oil 200 1 PA /ml ANORECTAL AGENTS Intrarectal Steroids 10

colocort ene 100 1 Rectal Steroids proctosol hc cre 2.5% 1 Vasodilating Agents RECTIV OIN 0.4% 3 ANTHELMINTICS Anthelmintics ALBENZA TAB 200MG 2 BILTRICIDE TAB 600MG 3 ivermectin tab 3 1 ANTI-INFECTIVE AGENTS - MISC. Anti-infective Agents - Misc. aztreonam for inj 1 gm 1 aztreonam for inj 2 gm 1 metronidazole cap 375 1 metronidazole tab 250 1 metronidazole tab 500 1 NEBUPENT INH 300MG 3 PENTAM 300 INJ 300MG 3 PRIMSOL SOL 50MG/5ML 2 tinidazole tab 250 1 tinidazole tab 500 1 trimethoprim tab 100 1 vancomycin hcl cap 125 1 ST; PA** vancomycin hcl cap 250 1 ST; PA** VIBATIV INJ 250MG 3 VIBATIV INJ 750MG 3 XIFAXAN TAB 200MG 2 XIFAXAN TAB 550MG 2 PA Anti-infective Misc. - Combinations e.s.p. sus 200-600 1 sulfamethoxazole-trimethoprim susp 1 200-40 /5ml sulfamethoxazole-trimethoprim tab 400-80 1 sulfamethoxazole-trimethoprim tab 1 800-160 Antiprotozoal Agents ALINIA SUS 100/5ML 2 ALINIA TAB 500MG 2 Carbapenems DORIBAX INJ 250MG 3 DORIBAX INJ 500MG 3 Cyclic Lipopeptides CUBICIN SOL 500MG 3 11

Ketolides KETEK TAB 300MG 3 KETEK TAB 400MG 3 Leprostatics dapsone tab 25 1 dapsone tab 100 1 Lincosamides clindamycin hcl cap 75 1 clindamycin hcl cap 150 1 clindamycin hcl cap 300 1 Oxazolidinones SIVEXTRO INJ 200MG 3 PA ZYVOX SUS 100MG/5M 2 ZYVOX TAB 600MG 2 ANTIANGINAL AGENTS Antianginals-Other RANEXA TAB 500MG 2 ST; PA** RANEXA TAB 1000MG 2 ST; PA** Nitrates isoditrate tab 40 er 1 ISORDIL TAB 40MG 2 isosorbide dinitrate sl tab 2.5 1 isosorbide dinitrate tab 5 1 isosorbide dinitrate tab 10 1 isosorbide dinitrate tab 20 1 isosorbide dinitrate tab 30 1 isosorbide dinitrate tab cr 40 1 isosorbide mononitrate tab 10 1 isosorbide mononitrate tab 20 1 isosorbide mononitrate tab sr 24hr 30 1 isosorbide mononitrate tab sr 24hr 60 1 isosorbide mononitrate tab sr 24hr 120 1 minitran dis 0.1/hr 1 minitran dis 0.2/hr 1 minitran dis 0.4/hr 1 minitran dis 0.6/hr 1 NITRO-DUR DIS 0.3MG/HR 2 NITRO-DUR DIS 0.8MG/HR 2 nitroglycerin cap cr 2.5 1 nitroglycerin cap cr 6.5 1 nitroglycerin cap cr 9 1 nitroglycerin lingual aerosol 400 mcg/spray 1 nitroglycerin td patch 24hr 0.1 /hr 1 nitroglycerin td patch 24hr 0.2 /hr 1 nitroglycerin td patch 24hr 0.4 /hr 1 12

nitroglycerin td patch 24hr 0.6 /hr 1 NITROSTAT SUB 0.3MG 2 NITROSTAT SUB 0.4MG 2 NITROSTAT SUB 0.6MG 2 ANTIANXIETY AGENTS Antianxiety Agents - Misc. buspirone hcl tab 5 1 buspirone hcl tab 7.5 1 buspirone hcl tab 10 1 buspirone hcl tab 15 1 buspirone hcl tab 30 1 hydroxyzine hcl syrup 10 /5ml 1 PA; High Risk Medications require PA for members age 65 and hydroxyzine hcl tab 10 1 PA; High Risk Medications require PA for members age 65 and hydroxyzine hcl tab 25 1 PA; High Risk Medications require PA for members age 65 and hydroxyzine hcl tab 50 1 PA; High Risk Medications require PA for members age 65 and meprobamate tab 200 1 meprobamate tab 400 1 Benzodiazepines ALPRAZOLAM CON 1 MG/ML 2 QL (120 ml / 25 days) alprazolam orally disintegrating tab 0.5 1 QL (90 tabs / 25 days) alprazolam orally disintegrating tab 0.25 1 QL (90 tabs / 25 days) alprazolam orally disintegrating tab 1 1 QL (90 tabs / 25 days) alprazolam orally disintegrating tab 2 1 QL (60 tabs / 25 days) alprazolam tab 0.5 1 QL (90 tabs / 25 days) alprazolam tab 0.25 1 QL (90 tabs / 25 days) alprazolam tab 1 1 QL (90 tabs / 25 days) alprazolam tab 2 1 QL (60 tabs / 25 days) clorazepate dipotassium tab 3.75 1 QL (120 tabs / 25 days) clorazepate dipotassium tab 7.5 1 QL (120 tabs / 25 days) clorazepate dipotassium tab 15 1 QL (120 tabs / 25 days) DIAZEPAM CON 5MG/ML 1 QL (240 ml / 25 days) diazepam soln 1 /ml 1 QL (1200 ml / 25 days) diazepam tab 2 1 QL (120 tabs / 25 days) diazepam tab 5 1 QL (120 tabs / 25 days) diazepam tab 10 1 QL (120 tabs / 25 days) 13

lorazepam conc 2 /ml 1 QL (150 ml / 25 days) lorazepam tab 0.5 1 QL (150 tabs / 25 days) lorazepam tab 1 1 QL (150 tabs / 25 days) lorazepam tab 2 1 QL (150 tabs / 25 days) oxazepam cap 10 1 QL (120 caps / 25 days) oxazepam cap 15 1 QL (120 caps / 25 days) oxazepam cap 30 1 QL (120 caps / 25 days) ANTIARRHYTHMICS Antiarrhythmics Type I-A disopyramide phosphate cap 100 1 disopyramide phosphate cap 150 1 NORPACE CAP 100MG CR 2 NORPACE CAP 150MG CR 2 procainamide hcl inj 100 /ml 1 PROCAINAMIDE INJ 500MG/ML 3 Antiarrhythmics Type I-B mexiletine hcl cap 150 1 mexiletine hcl cap 200 1 mexiletine hcl cap 250 1 Antiarrhythmics Type I-C flecainide acetate tab 50 1 flecainide acetate tab 100 1 flecainide acetate tab 150 1 propafenone hcl cap sr 12hr 225 1 propafenone hcl cap sr 12hr 325 1 propafenone hcl cap sr 12hr 425 1 propafenone hcl tab 150 1 propafenone hcl tab 225 1 propafenone hcl tab 300 1 Antiarrhythmics Type III amiodarone hcl tab 200 1 amiodarone hcl tab 400 1 MULTAQ TAB 400MG 3 PA pacerone tab 100 1 pacerone tab 200 1 TIKOSYN CAP 125MCG 3 PA TIKOSYN CAP 250MCG 3 PA TIKOSYN CAP 500MCG 3 PA ANTIASTHMATIC AND BRONCHODILATOR AGENTS Anti-Inflammatory Agents cromolyn sodium soln nebu 20 /2ml 1 QL (2 boxes / 25 days) Bronchodilators - Anticholinergics ATROVENT HFA AER 17MCG 2 QL (2 inhalers / 25 days) ipratropium bromide inhal soln 0.02% 1 QL (5 boxes / 25 days) SPIRIVA CAP HANDIHLR 2 QL (30 caps / 25 days) 14

SPIRIVA SPR RESPIMAT 2 QL (1 inhaler / 25 days) Leukotriene Modulators montelukast sodium chew tab 4 (base 1 equiv) montelukast sodium chew tab 5 (base 1 equiv) montelukast sodium oral granules packet 4 1 (base equiv) montelukast sodium tab 10 (base equiv) 1 zafirlukast tab 10 1 zafirlukast tab 20 1 ZYFLO CR TAB 600MG 3 Selective Phosphodiesterase 4 (PDE4) Inhibitors DALIRESP TAB 500MCG 3 PA Steroid Inhalants ALVESCO AER 80MCG 3 QL (3 inhalers / 25 days), ST ALVESCO AER 160MCG 3 QL (2 inhalers / 25 days), ST ASMANEX 30 AER 110MCG 2 QL (2 inhalers / 25 days) ASMANEX 60 AER 220MCG 2 QL (2 inhalers per 25 days) ASMANEX 120 AER 220MCG 2 QL (1 inhaler per 25 days) ASMANEX HFA AER 100 MCG 2 QL (1 inhaler per 25 days) ASMANEX HFA AER 200 MCG 2 QL (1 inhaler per 25 days) budesonide inhalation susp 0.5 /2ml 1 QL (2 boxes / 25 days) budesonide inhalation susp 0.25 /2ml 1 QL (3 boxes / 25 days) PULMICORT INH 90MCG 3 QL (3 inhalers / 25 days), ST PULMICORT INH 180MCG 3 QL (2 inhalers / 25 days), ST PULMICORT SUS 1MG/2ML 3 QL (1 box / 25 days), ST QVAR AER 40MCG 2 QL (2 inhalers / 25 days) QVAR AER 80MCG 2 QL (2 inhalers / 25 days) Sympathomimetics ADVAIR DISKU AER 100/50 2 QL (1 inhaler / 25 days), ST; PA**; Covered for ages 4-11 albuterol sulfate soln nebu 0.5% (5 /ml) 1 QL (3 boxes / 25 days) albuterol sulfate soln nebu 0.5% (5 /ml) 1 QL (4 boxes / 25 days) albuterol sulfate soln nebu 0.63 /3ml (base equiv) 1 QL (5 boxes / 25 days) 15

albuterol sulfate soln nebu 0.083% (2.5 1 QL (5 boxes / 25 days) /3ml) albuterol sulfate soln nebu 1.25 /3ml 1 QL (5 boxes / 25 days) (base equiv) albuterol sulfate syrup 2 /5ml 1 albuterol sulfate tab 2 1 albuterol sulfate tab 4 1 albuterol sulfate tab sr 12hr 8 1 BREO ELLIPTA INH 100-25 3 QL (1 Package / 25 days), PA BROVANA NEB 15MCG 3 QL (2 boxes / 25 days) COMBIVENT AER RESPIMAT 2 QL (2 inhalers / 25 days) DULERA AER 100-5MCG 2 QL (1 inhaler / 25 days), ST; PA** DULERA AER 200-5MCG 2 QL (1 inhaler / 25 days), ST; PA** epinephrine hcl inj 1 /ml 1 epinephrine hcl soln prefilled syringe 0.1 1 /ml FORADIL CAP AEROLIZE 2 QL (60 caps / 25 days) ipratropium-albuterol nebu soln 0.5-2.5(3) 1 QL (6 boxes / 25 days) /3ml levalbuterol hcl soln nebu 0.31 /3ml 1 QL (4 boxes / 25 days) (base equiv) levalbuterol hcl soln nebu 0.63 /3ml 1 QL (4 boxes / 25 days) (base equiv) levalbuterol hcl soln nebu 1.25 /3ml 1 QL (4 boxes / 25 days) (base equiv) levalbuterol hcl soln nebu conc 1.25 1 QL (3 boxes / 25 days) /0.5ml (base equiv) metaproterenol sulfate syrup 10 /5ml 1 metaproterenol sulfate tab 10 1 metaproterenol sulfate tab 20 1 PERFOROMIST NEB 20MCG 2 QL (2 boxes / 25 days) PROAIR HFA AER 2 QL (2 inhalers / 25 days) SEREVENT DIS AER 50MCG 3 QL (1 inhaler / 25 days) SYMBICORT AER 80-4.5 2 QL (1 inhaler / 25 days), ST; PA** SYMBICORT AER 160-4.5 2 QL (1 inhaler / 25 days), ST; PA** terbutaline sulfate tab 2.5 1 terbutaline sulfate tab 5 1 Xanthines theochron tab 100 cr 1 theochron tab 200 cr 1 theochron tab 300 cr 1 theophylline tab sr 12hr 450 1 16

theophylline tab sr 24hr 400 1 theophylline tab sr 24hr 600 1 ANTICOAGULANTS Coumarin Anticoagulants jantoven tab 1 1 jantoven tab 2.5 1 jantoven tab 2 1 jantoven tab 3 1 jantoven tab 4 1 jantoven tab 5 1 jantoven tab 6 1 jantoven tab 7.5 1 jantoven tab 10 1 warfarin sodium tab 1 1 warfarin sodium tab 2 1 warfarin sodium tab 2.5 1 warfarin sodium tab 3 1 warfarin sodium tab 4 1 warfarin sodium tab 5 1 warfarin sodium tab 6 1 warfarin sodium tab 7.5 1 warfarin sodium tab 10 1 Direct Factor Xa Inhibitors ELIQUIS TAB 2.5MG 3 ELIQUIS TAB 5MG 3 XARELTO STAR TAB 15/20MG 2 XARELTO TAB 10MG 2 XARELTO TAB 15MG 2 XARELTO TAB 20MG 2 Heparins And Heparinoid-Like Agents enoxaparin sodium inj 30 /0.3ml 1 enoxaparin sodium inj 40 /0.4ml 1 enoxaparin sodium inj 60 /0.6ml 1 enoxaparin sodium inj 80 /0.8ml 1 enoxaparin sodium inj 100 /ml 1 enoxaparin sodium inj 120 /0.8ml 1 enoxaparin sodium inj 150 /ml 1 enoxaparin sodium inj 300 /3ml 1 fondaparinux sodium subcutaneous inj 2.5 1 /0.5ml fondaparinux sodium subcutaneous inj 5 1 /0.4ml fondaparinux sodium subcutaneous inj 7.5 1 /0.6ml fondaparinux sodium subcutaneous inj 10 1 /0.8ml 17

FRAGMIN INJ 2500/0.2 3 FRAGMIN INJ 5000/0.2 3 FRAGMIN INJ 7500/0.3 3 FRAGMIN INJ 10000/ML 3 FRAGMIN INJ 12500UNT 3 FRAGMIN INJ 15000UNT 3 FRAGMIN INJ 18000UNT 3 FRAGMIN INJ 25000/ML 3 FRAGMIN INJ 95000UNT 3 heparin sodium (porcine) inj 1000 unit/ml 1 heparin sodium (porcine) inj 5000 unit/ml 1 heparin sodium (porcine) inj 10000 unit/ml 1 heparin sodium (porcine) inj 20000 unit/ml 1 heparin sodium (porcine) pf inj 5000 1 unit/0.5ml Thrombin Inhibitors argatroban inj 100 /ml (concentrate for 1 iv infusion) ARGATROBAN INJ 125/125 3 ARGATROBAN INJ 250/250 3 PRADAXA CAP 75MG 2 PRADAXA CAP 150MG 2 ANTICONVULSANTS Anticonvulsants - Benzodiazepines clonazepam tab 0.5 1 clonazepam tab 1 1 clonazepam tab 2 1 ONFI SUS 2.5MG/ML 3 PA ONFI TAB 5MG 3 PA ONFI TAB 10MG 3 PA ONFI TAB 20MG 3 PA Anticonvulsants - Misc. BANZEL SUS 40MG/ML 3 PA BANZEL TAB 200MG 3 PA BANZEL TAB 400MG 3 PA carbamazepine chew tab 100 1 carbamazepine susp 100 /5ml 1 carbamazepine tab 200 1 carbamazepine tab sr 12hr 200 1 carbamazepine tab sr 12hr 400 1 epitol tab 200 1 gabapentin cap 100 1 gabapentin cap 300 1 gabapentin cap 400 1 gabapentin tab 600 1 gabapentin tab 800 1 18

LAMICTAL CHW 2MG 2 lamotrigine orally disintegrating tab 25 1 lamotrigine orally disintegrating tab 50 1 lamotrigine orally disintegrating tab 100 1 lamotrigine orally disintegrating tab 200 1 lamotrigine tab 25 1 lamotrigine tab 100 1 lamotrigine tab 150 1 lamotrigine tab 200 1 lamotrigine tab chewable dispersible 5 1 lamotrigine tab chewable dispersible 25 1 lamotrigine tab sr 24hr 25 1 lamotrigine tab sr 24hr 50 1 lamotrigine tab sr 24hr 100 1 lamotrigine tab sr 24hr 200 1 lamotrigine tab sr 24hr 250 1 lamotrigine tab sr 24hr 300 1 levetiracetam oral soln 100 /ml 1 levetiracetam tab 250 1 levetiracetam tab 500 1 levetiracetam tab 750 1 levetiracetam tab 1000 1 levetiracetam tab sr 24hr 500 1 levetiracetam tab sr 24hr 750 1 LYRICA CAP 25MG 3 ST; PA** LYRICA CAP 50MG 3 ST; PA** LYRICA CAP 75MG 3 ST; PA** LYRICA CAP 100MG 3 ST; PA** LYRICA CAP 150MG 3 ST; PA** LYRICA CAP 200MG 3 ST; PA** LYRICA CAP 225MG 3 ST; PA** LYRICA CAP 300MG 3 ST; PA** LYRICA SOL 20MG/ML 3 ST; PA** oxcarbazepine susp 300 /5ml (60 1 /ml) oxcarbazepine tab 150 1 oxcarbazepine tab 300 1 oxcarbazepine tab 600 1 POTIGA TAB 50MG 3 PA POTIGA TAB 200MG 3 PA POTIGA TAB 300MG 3 PA POTIGA TAB 400MG 3 PA primidone tab 50 1 primidone tab 250 1 TEGRETOL-XR TAB 100MG 2 topiramate sprinkle cap 15 1 19

topiramate sprinkle cap 25 1 topiramate tab 25 1 topiramate tab 50 1 topiramate tab 100 1 topiramate tab 200 1 VIMPAT SOL 10MG/ML 3 PA VIMPAT TAB 50MG 3 PA VIMPAT TAB 100MG 3 PA VIMPAT TAB 150MG 3 PA VIMPAT TAB 200MG 3 PA zonisamide cap 25 1 zonisamide cap 50 1 zonisamide cap 100 1 Carbamates felbamate susp 600 /5ml 1 felbamate tab 400 1 felbamate tab 600 1 GABA Modulators GABITRIL TAB 12MG 2 GABITRIL TAB 16MG 2 SABRIL POW 500MG 3 PA SABRIL TAB 500MG 3 PA tiagabine hcl tab 2 1 tiagabine hcl tab 4 1 Hydantoins phenytoin chew tab 50 1 phenytoin sodium extended cap 100 1 phenytoin sodium extended cap 200 1 phenytoin sodium extended cap 300 1 phenytoin susp 125 /5ml 1 Succinimides ethosuximide cap 250 1 ethosuximide soln 250 /5ml 1 Valproic Acid divalproex sodium cap sprinkle 125 1 divalproex sodium tab delayed release 125 1 divalproex sodium tab delayed release 250 1 divalproex sodium tab delayed release 500 1 divalproex sodium tab sr 24 hr 250 1 divalproex sodium tab sr 24 hr 500 1 valproate sodium syrup 250 /5ml (base 1 equiv) valproic acid cap 250 1 20

ANTIDEPRESSANTS Alpha-2 Receptor Antagonists (Tetracyclics) mirtazapine orally disintegrating tab 15 1 mirtazapine orally disintegrating tab 30 1 mirtazapine orally disintegrating tab 45 1 mirtazapine tab 7.5 1 mirtazapine tab 15 1 mirtazapine tab 30 1 mirtazapine tab 45 1 Antidepressants - Misc. bupropion hcl tab 75 1 bupropion hcl tab 100 1 bupropion hcl tab sr 12hr 100 1 bupropion hcl tab sr 12hr 150 1 bupropion hcl tab sr 12hr 200 1 bupropion hcl tab sr 24hr 150 1 bupropion hcl tab sr 24hr 300 1 maprotiline hcl tab 25 1 maprotiline hcl tab 50 1 maprotiline hcl tab 75 1 Modified Cyclics nefazodone hcl tab 50 1 nefazodone hcl tab 100 1 nefazodone hcl tab 150 1 nefazodone hcl tab 200 1 nefazodone hcl tab 250 1 trazodone hcl tab 50 1 trazodone hcl tab 100 1 trazodone hcl tab 150 1 trazodone hcl tab 300 1 VIIBRYD KIT 3 ST; PA** VIIBRYD TAB 10MG 3 ST; PA** VIIBRYD TAB 20MG 3 ST; PA** VIIBRYD TAB 40MG 3 ST; PA** Monoamine Oxidase Inhibitors (MAOIs) EMSAM DIS 6MG/24HR 3 EMSAM DIS 9MG/24HR 3 EMSAM DIS 12MG/24H 3 MARPLAN TAB 10MG 3 phenelzine sulfate tab 15 1 tranylcypromine sulfate tab 10 1 Selective Serotonin Reuptake Inhibitors (SSRIs) citalopram hydrobromide oral soln 10 1 /5ml 21

citalopram hydrobromide tab 10 (base 1 equiv) citalopram hydrobromide tab 20 (base 1 equiv) citalopram hydrobromide tab 40 (base 1 equiv) escitalopram oxalate soln 5 /5ml (base 1 equiv) escitalopram oxalate tab 5 (base equiv) 1 escitalopram oxalate tab 10 (base 1 equiv) escitalopram oxalate tab 20 (base 1 equiv) fluoxetine hcl cap 10 1 fluoxetine hcl cap 20 1 fluoxetine hcl cap 40 1 fluoxetine hcl solution 20 /5ml 1 fluoxetine hcl tab 10 1 fluoxetine hcl tab 20 1 fluvoxamine maleate cap sr 24hr 100 1 fluvoxamine maleate cap sr 24hr 150 1 fluvoxamine maleate tab 25 1 fluvoxamine maleate tab 50 1 fluvoxamine maleate tab 100 1 paroxetine hcl tab 10 1 paroxetine hcl tab 20 1 paroxetine hcl tab 30 1 paroxetine hcl tab 40 1 paroxetine hcl tab sr 24hr 12.5 1 paroxetine hcl tab sr 24hr 25 1 paroxetine hcl tab sr 24hr 37.5 1 PAXIL SUS 10MG/5ML 2 PEXEVA TAB 10MG 3 ST; PA** PEXEVA TAB 20MG 3 ST; PA** PEXEVA TAB 30MG 3 ST; PA** PEXEVA TAB 40MG 3 ST; PA** sertraline hcl oral conc 20 /ml 1 sertraline hcl tab 25 1 sertraline hcl tab 50 1 sertraline hcl tab 100 1 Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) duloxetine hcl cap 20 1 duloxetine hcl cap 30 1 duloxetine hcl cap 60 1 PRISTIQ TAB 25MG 3 ST; PA** PRISTIQ TAB 50MG 3 ST; PA** 22

PRISTIQ TAB 100MG 3 ST; PA** venlafaxine hcl cap sr 24hr 37.5 (base 1 equivalent) venlafaxine hcl cap sr 24hr 75 (base 1 equivalent) venlafaxine hcl cap sr 24hr 150 (base 1 equivalent) venlafaxine hcl tab 25 1 venlafaxine hcl tab 37.5 1 venlafaxine hcl tab 50 1 venlafaxine hcl tab 75 1 venlafaxine hcl tab 100 1 venlafaxine hcl tab sr 24hr 37.5 (base 1 equivalent) venlafaxine hcl tab sr 24hr 75 (base 1 equivalent) venlafaxine hcl tab sr 24hr 150 (base 1 equivalent) venlafaxine hcl tab sr 24hr 225 (base 1 equivalent) Tricyclic Agents amitriptyline hcl tab 10 1 QL (150 tabs / 25 days); QL applies to members age 65 and amitriptyline hcl tab 25 1 QL (30 tabs / 25 days); QL applies to members age 65 and amitriptyline hcl tab 50 1 QL (30 tabs / 25 days); QL applies to members age 65 and amitriptyline hcl tab 75 1 Members 65 and subject to PA amitriptyline hcl tab 100 1 Members 65 and subject to PA amitriptyline hcl tab 150 1 Members 65 and subject to PA amoxapine tab 25 1 QL (90 tabs / 25 days); QL applies to members age 65 and amoxapine tab 50 1 QL (90 tabs / 25 days); QL applies to members age 65 and amoxapine tab 100 1 QL (90 tabs / 25 days); QL applies to members age 65 and 23

amoxapine tab 150 1 QL (60 tabs / 25 days); QL applies to members age 65 and regardles of QL clomipramine hcl cap 25 1 QL (150 caps / 25 days); QL applies to members age 65 and clomipramine hcl cap 50 1 QL (150 caps / 25 days); QL applies to members age 65 and clomipramine hcl cap 75 1 QL (90 caps / 25 days); QL applies to members age 65 and desipramine hcl tab 10 1 QL (90 tabs / 25 days); QL applies to members age 65 and desipramine hcl tab 25 1 QL (90 tabs / 25 days); QL applies to members age 65 and desipramine hcl tab 50 1 QL (90 tabs / 25 days); QL applies to members age 65 and desipramine hcl tab 75 1 QL (60 tabs / 25 days); QL applies to members age 65 and desipramine hcl tab 100 1 QL (30 tabs / 25 days); QL applies to members age 65 and desipramine hcl tab 150 1 QL (30 tabs / 25 days); QL applies to members age 65 and doxepin hcl cap 10 1 QL (90 caps / 25 days); QL applies to members age 65 and doxepin hcl cap 25 1 QL (90 caps / 25 days); QL applies to members age 65 and doxepin hcl cap 50 1 QL (90 caps / 25 days); QL applies to members age 65 and doxepin hcl cap 75 1 QL (60 caps / 25 days); QL applies to members age 65 and doxepin hcl cap 100 1 QL (30 caps / 25 days); QL applies to members age 65 and doxepin hcl cap 150 1 QL (30 caps / 25 days); QL applies to members age 65 and 24

doxepin hcl conc 10 /ml 1 QL (450 ml / 25 days); QL applies to members age 65 and imipramine hcl tab 10 1 QL (60 tabs / 25 days); QL applies to members age 65 and imipramine hcl tab 25 1 QL (60 tabs / 25 days); QL applies to members age 65 and imipramine hcl tab 50 1 QL (60 tabs / 25 days); QL applies to members age 65 and imipramine pamoate cap 75 1 QL (30 caps / 25 days); QL applies to members age 65 and imipramine pamoate cap 100 1 QL (30 caps / 25 days); QL applies to members age 65 and imipramine pamoate cap 125 1 Members 65 and subject to PA imipramine pamoate cap 150 1 Members 65 and subject to PA nortriptyline hcl cap 10 1 QL (150 caps / 25 days); QL applies to members age 65 and nortriptyline hcl cap 25 1 QL (60 caps / 25 days); QL applies to members age 65 and nortriptyline hcl cap 50 1 QL (30 caps / 25 days); QL applies to members age 65 and nortriptyline hcl cap 75 1 Members 65 and subject to PA nortriptyline hcl soln 10 /5ml 1 QL (750 ml / 25 days); QL applies to members age 65 and protriptyline hcl tab 5 1 QL (90 tabs / 25 days); QL applies to members age 65 and protriptyline hcl tab 10 1 QL (60 tabs / 25 days); QL applies to members age 65 and SURMONTIL CAP 25MG 3 QL (60 caps / 25 days); QL applies to members age 65 and SURMONTIL CAP 50MG 3 QL (60 caps / 25 days); QL applies to members age 65 and 25

SURMONTIL CAP 100MG 3 QL (30 caps / 25 days); QL applies to members age 65 and ANTIDIABETICS Alpha-Glucosidase Inhibitors acarbose tab 25 1 acarbose tab 50 1 acarbose tab 100 1 GLYSET TAB 25MG 3 GLYSET TAB 50MG 3 GLYSET TAB 100MG 3 Antidiabetic - Amylin Analogs SYMLINPEN 60 INJ 1000MCG 3 PA SYMLNPEN 120 INJ 1000MCG 3 PA Antidiabetic Combinations glipizide-metformin hcl tab 2.5-250 1 glipizide-metformin hcl tab 2.5-500 1 glipizide-metformin hcl tab 5-500 1 glyburide-metformin tab 1.25-250 1 PA; High Risk Medications require PA for members age 65 and glyburide-metformin tab 2.5-500 1 PA; High Risk Medications require PA for members age 65 and glyburide-metformin tab 5-500 1 PA; High Risk Medications require PA for members age 65 and JANUMET TAB 50-500MG 2 JANUMET TAB 50-1000 2 JANUMET XR TAB 50-500MG 2 JANUMET XR TAB 50-1000 2 JANUMET XR TAB 100-1000 2 JENTADUETO TAB 2.5-500 2 JENTADUETO TAB 2.5-850 2 JENTADUETO TAB 2.5-1000 2 pioglitazone hcl-glimepiride tab 30-2 1 pioglitazone hcl-glimepiride tab 30-4 1 pioglitazone hcl-metformin hcl tab 15-500 1 pioglitazone hcl-metformin hcl tab 15-850 1 Biguanides metformin hcl tab 500 1 26

metformin hcl tab 850 1 metformin hcl tab 1000 1 metformin hcl tab sr 24hr 500 1 metformin hcl tab sr 24hr 750 1 metformin hcl tab sr 24hr osmotic 500 1 metformin hcl tab sr 24hr osmotic 1000 1 Diabetic Other GLUCAGEN INJ HYPOKIT 2 GLUCAGON KIT 1MG 2 glucose gel/oral liquid/chew tab 2 PROGLYCEM SUS 50MG/ML 3 Dipeptidyl Peptidase-4 (DPP-4) Inhibitors JANUVIA TAB 25MG 2 JANUVIA TAB 50MG 2 JANUVIA TAB 100MG 2 ONGLYZA TAB 2.5MG 3 PA ONGLYZA TAB 5MG 3 PA TRADJENTA TAB 5MG 3 PA Dopamine Receptor Agonists - Antidiabetic CYCLOSET TAB 0.8MG 3 Incretin Mimetic Agents (GLP Receptor Agonists) BYDUREON INJ 2 BYETTA INJ 5MCG 3 QL (1 prefilled pen (60 doses) / 25 days), PA BYETTA INJ 10MCG 3 QL (1 prefilled pen (60 doses) / 25 days), PA VICTOZA INJ 18MG/3ML 3 PA Insulin APIDRA INJ SOLOSTAR 2 APIDRA INJ U-100 2 HUMALOG INJ 100/ML 3 HUMALOG KWIK INJ 100/ML 3 HUMALOG MIX INJ 50/50 3 HUMALOG MIX INJ 50/50KWP 3 HUMALOG MIX INJ 75/25KWP 3 HUMALOG MIX SUS 75/25 3 HUMULIN INJ 70/30 3 OTC HUMULIN INJ 70/30KWP 3 OTC HUMULIN N INJ U-100 3 OTC HUMULIN N INJ U-100KWP 3 OTC HUMULIN R INJ U-100 3 OTC HUMULIN R INJ U-500 2 LANTUS INJ 100/ML 2 LANTUS INJ SOLOSTAR 2 LEVEMIR INJ 2 27

LEVEMIR INJ FLEXTOUC 2 NOVOLIN INJ 70/30 2 OTC NOVOLIN N INJ U-100 2 OTC NOVOLIN R INJ U-100 2 OTC NOVOLOG INJ 100/ML 2 NOVOLOG INJ FLEXPEN 2 NOVOLOG INJ MIX FLEXPEN 2 NOVOLOG INJ PENFILL 2 NOVOLOG MIX INJ 70/30 2 Insulin Sensitizing Agents pioglitazone hcl tab 15 (base equiv) 1 pioglitazone hcl tab 30 (base equiv) 1 pioglitazone hcl tab 45 (base equiv) 1 Meglitinide Analogues nateglinide tab 60 1 nateglinide tab 120 1 repaglinide tab 0.5 1 repaglinide tab 1 1 repaglinide tab 2 1 Sulfonylureas chlorpropamide tab 100 1 chlorpropamide tab 250 1 glimepiride tab 1 1 glimepiride tab 2 1 glimepiride tab 4 1 glipizide tab 5 1 glipizide tab 10 1 glipizide tab sr 24hr 2.5 1 glipizide tab sr 24hr 5 1 glipizide tab sr 24hr 10 1 glyburide micronized tab 1.5 1 PA; High Risk Medications require PA for members age 65 and glyburide micronized tab 3 1 PA; High Risk Medications require PA for members age 65 and glyburide micronized tab 6 1 PA; High Risk Medications require PA for members age 65 and glyburide tab 1.25 1 PA; High Risk Medications require PA for members age 65 and 28

glyburide tab 2.5 1 PA; High Risk Medications require PA for members age 65 and glyburide tab 5 1 PA; High Risk Medications require PA for members age 65 and tolbutamide tab 500 1 ANTIDIARRHEALS Antiperistaltic Agents anti-diarrhe tab 2 1 diphenoxylate w/ atropine liq 2.5-0.025 1 /5ml diphenoxylate w/ atropine tab 2.5-0.025 1 loperamide hcl cap 2 1 MOTOFEN TAB 3 ANTIDOTES Antidotes - Chelating Agents CHEMET CAP 100MG 3 EXJADE TAB 125MG 3 PA EXJADE TAB 250MG 3 PA EXJADE TAB 500MG 3 PA FERRIPROX TAB 500MG 3 PA Opioid Antagonists naltrexone hcl tab 50 1 ANTIEMETICS 5-HT3 Receptor Antagonists ALOXI INJ 0.25MG/5 3 QL (5 ml / 15 days) granisetron hcl tab 1 1 QL (6 tabs / 15 days) ondansetron hcl oral soln 4 /5ml 1 QL (2 bottles / 15 days) ondansetron hcl tab 4 1 QL (12 tabs / 15 days) ondansetron hcl tab 8 1 QL (12 tabs / 15 days) ondansetron hcl tab 24 1 QL (1 tab / 15 days) ondansetron orally disintegrating tab 4 1 QL (12 tabs / 15 days) ondansetron orally disintegrating tab 8 1 QL (12 tabs / 15 days) SANCUSO DIS 3.1MG 3 QL (1 patch / 15 days) Antiemetics - Anticholinergic ANTIVERT TAB 50MG 2 meclizine hcl tab 12.5 1 meclizine hcl tab 25 1 TRANSDERM-SC DIS 1MG 3 trimethobenzamide hcl cap 300 1 PA; High Risk Medications require PA for members age 65 and 29

univert tab 32 1 Antiemetics - Miscellaneous dronabinol cap 2.5 1 QL (60 caps / 25 days) dronabinol cap 5 1 QL (60 caps / 25 days) dronabinol cap 10 1 QL (60 caps / 25 days) Substance P/Neurokinin 1 (NK1) Receptor Antagonists EMEND CAP 40MG 3 QL (3 caps / 180 days) EMEND CAP 80MG 3 QL (2 caps / 15 days) EMEND CAP 125MG 3 QL (1 cap / 15 days) EMEND PAK 80 & 125 3 QL (1 pack / 15 days) ANTIFUNGALS Antifungal - Glucan Synthesis Inhibitors (Echinocandins) CANCIDAS INJ 50MG 3 CANCIDAS INJ 70MG 3 ERAXIS INJ 50MG 3 ERAXIS INJ 100MG 3 Antifungals ABELCET INJ 5MG/ML 3 AMPHOTEC INJ 50MG 3 AMPHOTEC INJ 100MG 3 amphotericin b for inj 50 1 BIO-STATIN CAP 500000 2 BIO-STATIN CAP 1000000 2 griseofulvin microsize susp 125 /5ml 1 griseofulvin microsize tab 500 1 griseofulvin ultramicrosize tab 125 1 griseofulvin ultramicrosize tab 250 1 nystatin oral powder 1 nystatin tab 500000 unit 1 terbinafine hcl tab 250 1 PA Imidazole-Related Antifungals fluconazole for susp 10 /ml 1 fluconazole for susp 40 /ml 1 fluconazole tab 50 1 fluconazole tab 100 1 fluconazole tab 150 1 fluconazole tab 200 1 itraconazole cap 100 1 PA NOXAFIL SUS 40MG/ML 2 NOXAFIL TAB 100MG 2 SPORANOX SOL 10MG/ML 2 PA voriconazole for susp 40 /ml 1 PA voriconazole tab 50 1 PA voriconazole tab 200 1 PA ANTIHISTAMINES 30

Antihistamines - Alkylamines brompheniramine tannate chew tab 12 1 dexchlorpheniramine maleate syrup 2 1 /5ml Antihistamines - Ethanolamines carbinoxamine maleate tab 4 1 clemastine fumarate syrup 0.67 /5ml (0.5 /5ml base eq) 1 PA; High Risk Medications require PA for members age 65 and clemastine fumarate tab 2.68 1 PA; High Risk Medications require PA for members age 65 and diphenhydramine hcl cap 25 1 diphenhydramine hcl cap 50 1 diphenhydramine hcl elixir 12.5 /5ml 1 diphenhydramine hcl inj 50 /ml 1 Antihistamines - Non-Sedating all day allg cap 10 1 OTC all day allg chw 5 1 OTC all day allg chw 10 1 OTC allergy relf tab 10 1 OTC allergy tab 10 1 OTC cetirizine hcl tab 5 1 OTC cetirizine hcl tab 10 1 OTC cetirizine sol 1/ml 1 OTC CLARINEX SYP 0.5MG/ML 3 ST desloratadine tab 5 1 ST desloratadine tab orally disintegrating 2.5 1 ST desloratadine tab orally disintegrating 5 1 ST fexofenadine hcl tab 60 1 OTC fexofenadine hcl tab 180 1 OTC fexofenadine sus 30/5ml 1 OTC levocetirizine dihydrochloride soln 2.5 1 /5ml (0.5 /ml) levocetirizine dihydrochloride tab 5 1 loratadine syp 5/5ml 1 OTC Antihistamines - Phenothiazines promethazine hcl syrup 6.25 /5ml 1 PA; High Risk Medications require PA for members age 65 and 31

promethazine hcl tab 12.5 1 PA; High Risk Medications require PA for members age 65 and promethazine hcl tab 25 1 PA; High Risk Medications require PA for members age 65 and promethazine hcl tab 50 1 PA; High Risk Medications require PA for members age 65 and Antihistamines - Piperidines cyproheptadine hcl syrup 2 /5ml 1 cyproheptadine hcl tab 4 1 ANTIHYPERLIPIDEMICS Antihyperlipidemics - Combinations VYTORIN TAB 10-10MG 3 ST; PA** VYTORIN TAB 10-20MG 3 ST; PA** VYTORIN TAB 10-40MG 3 ST; PA** VYTORIN TAB 10-80MG 3 ST; PA** Antihyperlipidemics - Misc. omega-3-acid ethyl esters cap 1 gm 1 PA Bile Acid Sequestrants cholestyramine light powder 4 gm/dose 1 cholestyramine light powder packets 4 gm 1 cholestyramine powder 4 gm/dose 1 cholestyramine powder packets 4 gm 1 colestipol hcl granule packets 5 gm 1 colestipol hcl granules 5 gm 1 colestipol hcl tab 1 gm 1 prevalite pow 4gm 1 WELCHOL PAK 3.75GM 3 WELCHOL TAB 625MG 3 Fibric Acid Derivatives fenofibrate cap 50 1 fenofibrate cap 150 1 fenofibrate micronized cap 43 1 fenofibrate micronized cap 67 1 fenofibrate micronized cap 130 1 fenofibrate micronized cap 134 1 fenofibrate micronized cap 200 1 fenofibrate tab 48 1 fenofibrate tab 54 1 fenofibrate tab 145 1 fenofibrate tab 160 1 32

gemfibrozil tab 600 1 HMG CoA Reductase Inhibitors atorvastatin calcium tab 10 (base 1 equivalent) atorvastatin calcium tab 20 (base 1 equivalent) atorvastatin calcium tab 40 (base 1 equivalent) atorvastatin calcium tab 80 (base 1 equivalent) CRESTOR TAB 5MG 3 ST; PA** CRESTOR TAB 10MG 3 ST; PA** CRESTOR TAB 20MG 3 ST; PA** CRESTOR TAB 40MG 3 PA** fluvastatin sodium cap 20 1 fluvastatin sodium cap 40 1 LIVALO TAB 1MG 3 ST; PA** LIVALO TAB 2MG 3 ST; PA** LIVALO TAB 4MG 3 ST; PA** lovastatin tab 10 1 lovastatin tab 20 1 lovastatin tab 40 1 pravastatin sodium tab 10 1 pravastatin sodium tab 20 1 pravastatin sodium tab 40 1 pravastatin sodium tab 80 1 simvastatin tab 5 1 simvastatin tab 10 1 simvastatin tab 20 1 simvastatin tab 40 1 simvastatin tab 80 1 ST Intestinal Cholesterol Absorption Inhibitors ZETIA TAB 10MG 3 ST; PA** Nicotinic Acid Derivatives niacin tab cr 500 (antihyperlipidemic) 1 niacin tab cr 750 (antihyperlipidemic) 1 niacin tab cr 1000 (antihyperlipidemic) 1 ANTIHYPERTENSIVES ACE Inhibitors benazepril hcl tab 5 1 benazepril hcl tab 10 1 benazepril hcl tab 20 1 benazepril hcl tab 40 1 captopril tab 12.5 1 captopril tab 25 1 captopril tab 50 1 33

captopril tab 100 1 enalapril maleate tab 2.5 1 enalapril maleate tab 5 1 enalapril maleate tab 10 1 enalapril maleate tab 20 1 fosinopril sodium tab 10 1 fosinopril sodium tab 20 1 fosinopril sodium tab 40 1 lisinopril tab 2.5 1 lisinopril tab 5 1 lisinopril tab 10 1 lisinopril tab 20 1 lisinopril tab 30 1 lisinopril tab 40 1 moexipril hcl tab 7.5 1 moexipril hcl tab 15 1 perindopril erbumine tab 2 1 perindopril erbumine tab 4 1 perindopril erbumine tab 8 1 quinapril hcl tab 5 1 quinapril hcl tab 10 1 quinapril hcl tab 20 1 quinapril hcl tab 40 1 ramipril cap 1.25 1 ramipril cap 2.5 1 ramipril cap 5 1 ramipril cap 10 1 trandolapril tab 1 1 trandolapril tab 2 1 trandolapril tab 4 1 Agents for Pheochromocytoma DIBENZYLINE CAP 10MG 3 Angiotensin II Receptor Antagonists BENICAR TAB 5MG 3 ST; PA** BENICAR TAB 20MG 3 ST; PA** BENICAR TAB 40MG 3 ST; PA** candesartan cilexetil tab 4 1 candesartan cilexetil tab 8 1 candesartan cilexetil tab 16 1 candesartan cilexetil tab 32 1 EDARBI TAB 40MG 3 ST; PA** EDARBI TAB 80MG 3 ST; PA** eprosartan mesylate tab 600 1 irbesartan tab 75 1 irbesartan tab 150 1 irbesartan tab 300 1 34

losartan potassium tab 25 1 losartan potassium tab 50 1 losartan potassium tab 100 1 telmisartan tab 20 1 telmisartan tab 40 1 telmisartan tab 80 1 valsartan tab 40 1 valsartan tab 80 1 valsartan tab 160 1 valsartan tab 320 1 Antiadrenergic Antihypertensives clonidine hcl tab 0.1 1 clonidine hcl tab 0.2 1 clonidine hcl tab 0.3 1 clonidine hcl td patch weekly 0.1 /24hr 1 clonidine hcl td patch weekly 0.2 /24hr 1 clonidine hcl td patch weekly 0.3 /24hr 1 doxazosin mesylate tab 1 1 doxazosin mesylate tab 2 1 doxazosin mesylate tab 4 1 doxazosin mesylate tab 8 1 guanfacine hcl tab 1 1 guanfacine hcl tab 2 1 methyldopa tab 250 1 methyldopa tab 500 1 prazosin hcl cap 1 1 prazosin hcl cap 2 1 prazosin hcl cap 5 1 terazosin hcl cap 1 1 terazosin hcl cap 2 1 terazosin hcl cap 5 1 terazosin hcl cap 10 1 Antihypertensive Combinations amlodipine besylate-benazepril hcl cap 1 2.5-10 amlodipine besylate-benazepril hcl cap 5-101 amlodipine besylate-benazepril hcl cap 5-201 amlodipine besylate-benazepril hcl cap 5-401 amlodipine besylate-benazepril hcl cap 1 10-20 amlodipine besylate-benazepril hcl cap 1 10-40 35

amlodipine besylate-valsartan tab 5-160 1 amlodipine besylate-valsartan tab 5-320 1 amlodipine besylate-valsartan tab 10-160 1 amlodipine besylate-valsartan tab 10-320 1 amlodipine-valsartan-hydrochlorothiazide 1 tab 5-160-12.5 amlodipine-valsartan-hydrochlorothiazide 1 tab 5-160-25 amlodipine-valsartan-hydrochlorothiazide 1 tab 10-160-12.5 amlodipine-valsartan-hydrochlorothiazide 1 tab 10-160-25 amlodipine-valsartan-hydrochlorothiazide 1 tab 10-320-25 atenolol & chlorthalidone tab 50-25 1 atenolol & chlorthalidone tab 100-25 1 benazepril & hydrochlorothiazide tab 5-6.251 benazepril & hydrochlorothiazide tab 1 10-12.5 benazepril & hydrochlorothiazide tab 1 20-12.5 benazepril & hydrochlorothiazide tab 20-25 1 bisoprolol & hydrochlorothiazide tab 1 2.5-6.25 bisoprolol & hydrochlorothiazide tab 5-6.25 1 bisoprolol & hydrochlorothiazide tab 1 10-6.25 candesartan cilexetil-hydrochlorothiazide 1 tab 16-12.5 candesartan cilexetil-hydrochlorothiazide 1 tab 32-12.5 candesartan cilexetil-hydrochlorothiazide 1 tab 32-25 captopril & hydrochlorothiazide tab 25-15 1 captopril & hydrochlorothiazide tab 25-25 1 captopril & hydrochlorothiazide tab 50-15 1 captopril & hydrochlorothiazide tab 50-25 1 36

enalapril maleate & hydrochlorothiazide tab 1 5-12.5 enalapril maleate & hydrochlorothiazide tab 1 10-25 fosinopril sodium & hydrochlorothiazide tab 1 10-12.5 fosinopril sodium & hydrochlorothiazide tab 1 20-12.5 irbesartan-hydrochlorothiazide tab 1 150-12.5 irbesartan-hydrochlorothiazide tab 1 300-12.5 lisinopril & hydrochlorothiazide tab 10-12.5 1 lisinopril & hydrochlorothiazide tab 20-12.5 1 lisinopril & hydrochlorothiazide tab 20-25 1 losartan potassium & hydrochlorothiazide 1 tab 50-12.5 losartan potassium & hydrochlorothiazide 1 tab 100-12.5 losartan potassium & hydrochlorothiazide 1 tab 100-25 metoprolol & hydrochlorothiazide tab 50-251 metoprolol & hydrochlorothiazide tab 1 100-25 metoprolol & hydrochlorothiazide tab 1 100-50 moexipril-hydrochlorothiazide tab 7.5-12.5 1 moexipril-hydrochlorothiazide tab 15-12.5 1 moexipril-hydrochlorothiazide tab 15-25 1 nadolol & bendroflumethiazide tab 40-5 1 nadolol & bendroflumethiazide tab 80-5 1 propranolol & hydrochlorothiazide tab 40-251 propranolol & hydrochlorothiazide tab 80-251 quinapril-hydrochlorothiazide tab 10-12.5 1 quinapril-hydrochlorothiazide tab 20-12.5 1 quinapril-hydrochlorothiazide tab 20-25 1 telmisartan-amlodipine tab 40-5 1 telmisartan-amlodipine tab 40-10 1 37

telmisartan-amlodipine tab 80-5 1 telmisartan-amlodipine tab 80-10 1 telmisartan-hydrochlorothiazide tab 1 40-12.5 telmisartan-hydrochlorothiazide tab 1 80-12.5 telmisartan-hydrochlorothiazide tab 80-25 1 trandolapril-verapamil hcl tab cr 1-240 1 trandolapril-verapamil hcl tab cr 2-180 1 trandolapril-verapamil hcl tab cr 2-240 1 trandolapril-verapamil hcl tab cr 4-240 1 valsartan-hydrochlorothiazide tab 80-12.5 1 valsartan-hydrochlorothiazide tab 160-12.51 valsartan-hydrochlorothiazide tab 160-25 1 valsartan-hydrochlorothiazide tab 320-12.51 valsartan-hydrochlorothiazide tab 320-25 1 Direct Renin Inhibitors TEKTURNA TAB 150MG 3 ST; PA** TEKTURNA TAB 300MG 3 ST; PA** Selective Aldosterone Receptor Antagonists (SARAs) eplerenone tab 25 1 eplerenone tab 50 1 Vasodilators hydralazine hcl tab 10 1 hydralazine hcl tab 25 1 hydralazine hcl tab 50 1 hydralazine hcl tab 100 1 minoxidil tab 2.5 1 minoxidil tab 10 1 ANTIMALARIALS Antimalarial Combinations atovaquone-proguanil hcl tab 62.5-25 1 atovaquone-proguanil hcl tab 250-100 1 COARTEM TAB 20-120MG 3 Antimalarials chloroquine phosphate tab 250 1 chloroquine phosphate tab 500 1 DARAPRIM TAB 25MG 3 hydroxychloroquine sulfate tab 200 1 mefloquine hcl tab 250 1 38

PRIMAQUINE TAB 26.3MG 3 quinine sulfate cap 324 1 quinine sulfate tab 260 1 ANTIMYASTHENIC AGENTS Antimyasthenic Agents MESTINON SYP 60MG/5ML 2 MESTINON TAB TIMESPAN 3 pyridostigmine bromide tab 60 1 ANTIMYCOBACTERIAL AGENTS Anti TB Combinations RIFAMATE CAP 2 RIFATER TAB 2 Antimycobacterial Agents CAPASTAT SUL INJ 1GM 2 cycloserine cap 250 1 ethambutol hcl tab 100 1 ethambutol hcl tab 400 1 isoniazid syrup 50 /5ml 1 isoniazid tab 100 1 isoniazid tab 300 1 PRIFTIN TAB 150MG 2 pyrazinamide tab 500 1 rifabutin cap 150 1 rifampin cap 150 1 rifampin cap 300 1 TRECATOR TAB 250MG 2 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Alkylating Agents ALKERAN TAB 2MG 2 BICNU INJ 100MG 2 BUSULFEX INJ 6MG/ML 2 carboplatin iv for inj 150 1 carboplatin iv soln 50 /5ml 1 carboplatin iv soln 150 /15ml 1 carboplatin iv soln 450 /45ml 1 carboplatin iv soln 600 /60ml 1 cisplatin inj 50 /50ml (1 /ml) 1 cisplatin inj 100 /100ml (1 /ml) 1 cisplatin inj 200 /200ml (1 /ml) 1 CYCLOPHOSPH CAP 25MG 2 CYCLOPHOSPHAMIDE FOR INJ 1 GM 1 CYCLOPHOSPHAMIDE FOR INJ 2 GM 1 CYCLOPHOSPHAMIDE FOR INJ 500 MG 1 cyclophosphamide tab 25 1 cyclophosphamide tab 50 1 39

ELOXATIN INJ 200MG 2 GLIADEL WAF 7.7MG 2 HEXALEN CAP 50MG 2 ifosfamide for inj 1 gm 1 ifosfamide iv inj 1 gm/20ml (50 /ml) 1 ifosfamide iv inj 3 gm/60ml (50 /ml) 1 LEUKERAN TAB 2MG 2 lomustine cap 10 1 lomustine cap 40 1 lomustine cap 100 1 MYLERAN TAB 2MG 2 oxaliplatin for iv inj 50 1 oxaliplatin for iv inj 100 1 oxaliplatin iv soln 50 /10ml 1 oxaliplatin iv soln 100 /20ml 1 TEMODAR INJ 100MG 3 PA temozolomide cap 5 3 PA temozolomide cap 20 3 PA temozolomide cap 100 3 PA temozolomide cap 140 3 PA temozolomide cap 180 3 PA temozolomide cap 250 3 PA ZANOSAR INJ 1GM 2 Antimetabolites adrucil inj 2.5g/50m 1 adrucil inj 500/10ml 1 ALIMTA INJ 100MG 2 ALIMTA INJ 500MG 2 ARRANON INJ 5MG/ML 2 azacitidine for inj 100 3 PA capecitabine tab 150 3 PA capecitabine tab 500 3 PA cladribine inj 1 /ml 1 CLOLAR INJ 1MG/ML 2 cytarabine for inj 1 gm 1 cytarabine for inj 100 1 cytarabine for inj 500 1 cytarabine inj 20 /ml 1 cytarabine inj pf 20 /ml 1 cytarabine inj pf 100 /ml 1 decitabine for inj 50 3 PA DEPOCYT INJ 50MG/5ML 2 floxuridine for inj 0.5 gm 1 fludarabine phosphate for inj 50 1 fludarabine phosphate inj 25 /ml 1 fluorouracil inj 1 gm/20ml (50 /ml) 1 40

fluorouracil inj 2.5 gm/50ml (50 /ml) 1 fluorouracil inj 5 gm/100ml (50 /ml) 1 fluorouracil inj 500 /10ml (50 /ml) 1 gemcitabine hcl for inj 1 gm 1 gemcitabine hcl for inj 2 gm 1 gemcitabine hcl for inj 200 1 mercaptopurine tab 50 1 methotrexate sodium for inj 1 gm 1 methotrexate sodium inj 25 /ml 1 methotrexate sodium inj pf 25 /ml 1 methotrexate sodium tab 2.5 (base 1 equiv) TABLOID TAB 40MG 2 Antineoplastic - Antibodies ERBITUX INJ 100MG 3 PA ERBITUX INJ 200MG 3 PA GAZYVA INJ 25MG/ML 3 PA KEYTRUDA INJ 100MG/4M 3 PA KEYTRUDA SOL 50MG 3 PA RITUXAN INJ 100MG 3 PA YERVOY INJ 50MG 3 PA YERVOY INJ 200MG 3 PA Antineoplastic - Hedgehog Pathway Inhibitors ERIVEDGE CAP 150MG 3 PA Antineoplastic - Hormonal and Related Agents anastrozole tab 1 1 bicalutamide tab 50 1 EMCYT CAP 140MG 2 exemestane tab 25 1 FARESTON TAB 60MG 2 FASLODEX INJ 250MG 2 FIRMAGON INJ 80MG 3 PA FIRMAGON INJ 120MG 3 PA flutamide cap 125 1 letrozole tab 2.5 1 leuprolide acetate inj kit 5 /ml 3 PA LUPRON DEPOT INJ 3.75MG 3 PA LUPRON DEPOT INJ 7.5MG 3 PA LUPRON DEPOT INJ 11.25MG 3 PA LUPRON DEPOT INJ 22.5MG 3 PA LUPRON DEPOT INJ 30MG 3 PA LUPRON DEPOT INJ 45MG 3 PA LYSODREN TAB 500MG 2 megestrol acetate susp 40 /ml 1 megestrol acetate tab 20 1 megestrol acetate tab 40 1 41

NILANDRON TAB 150MG 2 tamoxifen citrate tab 10 (base equivalent) 1 $0 copay for women > 35 years for the primary prevention of breast cancer tamoxifen citrate tab 20 (base equivalent) XTANDI CAP 40MG 3 PA ZYTIGA TAB 250MG 3 PA Antineoplastic Antibiotics adriamycin inj 10 1 ADRIAMYCIN INJ 20MG 2 bleomycin sulfate for inj 15 unit 1 bleomycin sulfate for inj 30 unit 1 dactinomycin for inj 0.5 1 daunorubicin hcl for inj 20 1 daunorubicin hcl inj 5 /ml (base equiv) 1 DAUNOXOME INJ 2MG/ML 2 doxorubicin hcl for inj 10 1 doxorubicin hcl for inj 50 1 doxorubicin hcl inj 2 /ml 1 epirubicin hcl iv soln 50 /25ml (2 /ml) 1 epirubicin hcl iv soln 200 /100ml (2 1 /ml) EPIRUBICIN INJ 50MG 2 idarubicin hcl iv inj 5 /5ml (1 /ml) 1 idarubicin hcl iv inj 10 /10ml (1 /ml) 1 idarubicin hcl iv inj 20 /20ml (1 /ml) 1 lipodox inj 2/ml 1 mitomycin for iv soln 5 1 mitomycin for iv soln 20 1 mitomycin for iv soln 40 1 mitoxantrone hcl inj conc 20 /10ml (2 3 PA /ml) mitoxantrone hcl inj conc 25 /12.5ml (2 3 PA /ml) mitoxantrone hcl inj conc 30 /15ml (2 3 PA /ml) Antineoplastic Combinations ifosfamide & mesna inj kit 1000-1000 1 Antineoplastic Enzyme Inhibitors AFINITOR DIS TAB 2MG 3 PA AFINITOR DIS TAB 3MG 3 PA AFINITOR DIS TAB 5MG 3 PA 1 $0 copay for women > 35 years for the primary prevention of breast cancer 42

AFINITOR TAB 2.5MG 3 PA AFINITOR TAB 5MG 3 PA AFINITOR TAB 7.5MG 3 PA AFINITOR TAB 10MG 3 PA BOSULIF TAB 100MG 3 PA BOSULIF TAB 500MG 3 PA CAPRELSA TAB 100MG 3 PA CAPRELSA TAB 300MG 3 PA COMETRIQ KIT 60MG 3 PA COMETRIQ KIT 100MG 3 PA COMETRIQ KIT 140MG 3 PA GLEEVEC TAB 100MG 3 PA GLEEVEC TAB 400MG 3 PA IBRANCE CAP 75MG 3 PA IBRANCE CAP 100MG 3 PA IBRANCE CAP 125MG 3 PA ICLUSIG TAB 15MG 3 PA ICLUSIG TAB 45MG 3 PA IMBRUVICA CAP 140MG 3 PA INLYTA TAB 1MG 3 PA INLYTA TAB 5MG 3 PA JAKAFI TAB 5MG 3 PA JAKAFI TAB 10MG 3 PA JAKAFI TAB 15MG 3 PA JAKAFI TAB 20MG 3 PA JAKAFI TAB 25MG 3 PA KADCYLA INJ 100MG 3 PA KADCYLA INJ 160MG 3 PA LENVIMA CAP 10MG 3 PA LENVIMA CAP 14MG 3 PA LENVIMA CAP 20MG 3 PA LENVIMA CAP 24MG 3 PA LYNPARZA CAP 50MG 3 PA MEKINIST TAB 0.5MG 3 PA MEKINIST TAB 2MG 3 PA NEXAVAR TAB 200MG 3 PA SPRYCEL TAB 20MG 3 PA SPRYCEL TAB 50MG 3 PA SPRYCEL TAB 70MG 3 PA SPRYCEL TAB 80MG 3 PA SPRYCEL TAB 100MG 3 PA SPRYCEL TAB 140MG 3 PA STIVARGA TAB 40MG 3 PA SUTENT CAP 12.5MG 3 PA SUTENT CAP 25MG 3 PA SUTENT CAP 37.5MG 3 PA 43

SUTENT CAP 50MG 3 PA TAFINLAR CAP 50MG 3 PA TAFINLAR CAP 75MG 3 PA TARCEVA TAB 25MG 3 PA TARCEVA TAB 100MG 3 PA TARCEVA TAB 150MG 3 PA TASIGNA CAP 150MG 3 PA TASIGNA CAP 200MG 3 PA TORISEL SOL 25MG/ML 3 PA TYKERB TAB 250MG 3 PA VOTRIENT TAB 200MG 3 PA XALKORI CAP 200MG 3 PA XALKORI CAP 250MG 3 PA ZELBORAF TAB 240MG 3 PA ZOLINZA CAP 100MG 3 PA ZYDELIG TAB 100MG 3 PA ZYDELIG TAB 150MG 3 PA ZYKADIA CAP 150MG 3 PA Antineoplastic Enzymes ONCASPAR INJ 750/ML 3 PA Antineoplastic Radiopharmaceuticals QUADRAMET INJ 2 Antineoplastics - Immunomodulators POMALYST CAP 1MG 3 PA POMALYST CAP 2MG 3 PA POMALYST CAP 3MG 3 PA POMALYST CAP 4MG 3 PA Antineoplastics Misc. ALFERON N INJ 5MU/ML 3 PA dacarbazine for inj 100 1 dacarbazine for inj 200 1 hydroxyurea cap 500 1 INTRON-A INJ 10MU 3 PA INTRON-A INJ 18MU 3 PA INTRON-A INJ 25MU 3 PA INTRON-A INJ 50MU 3 PA MATULANE CAP 50MG 2 NIPENT INJ 10MG 2 PHOTOFRIN INJ 75MG 2 TARGRETIN CAP 75MG 3 PA THERACYS INJ 2 TICE BCG INJ 2 tretinoin cap 10 1 TRISENOX SOL 10MG/10M 2 UVADEX INJ 20MCG/ML 2 44

Chemotherapy Adjuncts KEPIVANCE INJ 6.25MG 2 Chemotherapy Rescue/Antidote Agents amifostine crystalline for inj 500 1 dexrazoxane for inj 250 1 dexrazoxane for inj 500 1 leucovorin calcium for inj 50 1 leucovorin calcium for inj 100 1 leucovorin calcium for inj 200 1 leucovorin calcium for inj 350 1 leucovorin calcium tab 5 1 leucovorin calcium tab 10 1 leucovorin calcium tab 15 1 leucovorin calcium tab 25 1 LEUCOVORIN INJ CALCIUM 2 mesna inj 100 /ml 1 MESNEX TAB 400MG 2 Mitotic Inhibitors ABRAXANE INJ 100MG 2 DOCEFREZ INJ 20MG 2 DOCEFREZ INJ 80MG 2 docetaxel for inj conc 20 /ml 1 docetaxel for inj conc 80 /4ml (20 1 /ml) DOCETAXEL INJ 20/0.5ML 2 DOCETAXEL INJ 20MG/2ML 2 DOCETAXEL INJ 80MG/2ML 2 DOCETAXEL INJ 80MG/8ML 2 DOCETAXEL INJ 140/7ML 2 DOCETAXEL INJ 160/8ML 2 DOCETAXEL INJ 160/16ML 2 DOCETAXEL INJ 200MG/20 2 ETOPOPHOS INJ 100MG 2 etoposide cap 50 1 etoposide inj 100/5ml (20 /ml) 1 paclitaxel iv conc 30 /5ml (6 /ml) 1 paclitaxel iv conc 100 /16.7ml (6 /ml) 1 paclitaxel iv conc 150 /25ml (6 /ml) 1 paclitaxel iv conc 300 /50ml (6 /ml) 1 TENIPOSIDE INJ 50MG/5ML 2 toposar inj 20/ml 1 toposar inj 100/5ml 1 VINBLASTINE INJ 10MG 2 vinblastine sulfate inj 1 /ml 1 vincasar pfs inj 1/ml 1 vincristine sulfate iv soln 1 /ml 1 45

vinorelbine tartrate inj 10 /ml (base 1 equiv) vinorelbine tartrate inj 50 /5ml (10 1 /ml) (base equiv) Topoisomerase I Inhibitors CAMPTOSAR INJ 300/15ML 2 HYCAMTIN CAP 0.25MG 3 PA HYCAMTIN CAP 1MG 3 PA irinotecan hcl inj 40 /2ml (20 /ml) 1 irinotecan hcl inj 100 /5ml (20 /ml) 1 irinotecan hcl inj 500 /25ml (20 /ml) 1 topotecan hcl for inj 4 1 TOPOTECAN INJ 4MG/4ML 2 ANTIPARKINSON AGENTS Antiparkinson Adjuvants carbidopa tab 25 1 Antiparkinson Anticholinergics benztropine mesylate tab 0.5 1 benztropine mesylate tab 1 1 benztropine mesylate tab 2 1 trihexyphenidyl hcl elixir 0.4 /ml 1 trihexyphenidyl hcl tab 2 1 trihexyphenidyl hcl tab 5 1 Antiparkinson COMT Inhibitors entacapone tab 200 1 tolcapone tab 100 1 Antiparkinson Dopaminergics amantadine hcl cap 100 1 amantadine hcl syrup 50 /5ml 1 amantadine hcl tab 100 1 APOKYN INJ 10MG/ML 3 PA bromocriptine mesylate cap 5 1 bromocriptine mesylate tab 2.5 1 carbidopa & levodopa orally disintegrating 1 tab 10-100 carbidopa & levodopa orally disintegrating 1 tab 25-100 carbidopa & levodopa orally disintegrating 1 tab 25-250 carbidopa & levodopa tab 10-100 1 carbidopa & levodopa tab 25-100 1 carbidopa & levodopa tab 25-250 1 carbidopa & levodopa tab cr 25-100 1 carbidopa & levodopa tab cr 50-200 1 carbidopa-levodopa-entacapone tabs 1 12.5-50-200 46

carbidopa-levodopa-entacapone tabs 1 18.75-75-200 carbidopa-levodopa-entacapone tabs 1 25-100-200 carbidopa-levodopa-entacapone tabs 1 31.25-125-200 carbidopa-levodopa-entacapone tabs 1 37.5-150-200 carbidopa-levodopa-entacapone tabs 1 50-200-200 MIRAPEX ER TAB 2.25MG 2 MIRAPEX ER TAB 3.75MG 2 MIRAPEX ER TAB 3MG 2 MIRAPEX ER TAB 4.5MG 2 pramipexole dihydrochloride tab 0.5 1 pramipexole dihydrochloride tab 0.25 1 pramipexole dihydrochloride tab 0.75 1 pramipexole dihydrochloride tab 0.125 1 pramipexole dihydrochloride tab 1 1 pramipexole dihydrochloride tab 1.5 1 pramipexole dihydrochloride tab sr 24hr 1 0.75 pramipexole dihydrochloride tab sr 24hr 1 0.375 pramipexole dihydrochloride tab sr 24hr 1.51 ropinirole hydrochloride tab 0.5 1 ropinirole hydrochloride tab 0.25 1 ropinirole hydrochloride tab 1 1 ropinirole hydrochloride tab 2 1 ropinirole hydrochloride tab 3 1 ropinirole hydrochloride tab 4 1 ropinirole hydrochloride tab 5 1 Antiparkinson Monoamine Oxidase Inhibitors AZILECT TAB 0.5MG 2 AZILECT TAB 1MG 2 selegiline hcl cap 5 1 selegiline hcl tab 5 1 ANTIPSYCHOTICS/ANTIMANIC AGENTS Antimanic Agents lithium carbonate cap 150 1 lithium carbonate cap 300 1 lithium carbonate cap 600 1 lithium carbonate tab 300 1 lithium carbonate tab cr 300 1 lithium carbonate tab cr 450 1 47

LITHIUM SOL 8MEQ/5ML 3 Antipsychotics - Misc. LATUDA TAB 20MG 2 ST; PA** LATUDA TAB 40MG 2 ST; PA** LATUDA TAB 60MG 2 ST; PA** LATUDA TAB 80MG 2 ST; PA** LATUDA TAB 120MG 2 ST; PA** ziprasidone hcl cap 20 1 ziprasidone hcl cap 40 1 ziprasidone hcl cap 60 1 ziprasidone hcl cap 80 1 Benzisoxazoles FANAPT PAK 3 ST; PA** FANAPT TAB 1MG 3 ST; PA** FANAPT TAB 2MG 3 ST; PA** FANAPT TAB 4MG 3 ST; PA** FANAPT TAB 6MG 3 ST; PA** FANAPT TAB 8MG 3 ST; PA** FANAPT TAB 10MG 3 ST; PA** FANAPT TAB 12MG 3 ST; PA** INVEGA TAB 1.5MG 3 ST; PA** INVEGA TAB 3MG 3 ST; PA** INVEGA TAB 6MG 3 ST; PA** INVEGA TAB 9MG 3 ST; PA** RISPERDAL INJ 12.5MG 2 PA RISPERDAL INJ 25MG 2 PA RISPERDAL INJ 37.5MG 2 PA RISPERDAL INJ 50MG 2 PA risperidone orally disintegrating tab 0.5 1 risperidone orally disintegrating tab 0.25 1 risperidone orally disintegrating tab 1 1 risperidone orally disintegrating tab 2 1 risperidone orally disintegrating tab 3 1 risperidone orally disintegrating tab 4 1 risperidone soln 1 /ml 1 risperidone tab 0.5 1 risperidone tab 0.25 1 risperidone tab 1 1 risperidone tab 2 1 risperidone tab 3 1 risperidone tab 4 1 Butyrophenones haloperidol decanoate im soln 50 /ml 1 haloperidol decanoate im soln 100 /ml 1 haloperidol lactate oral conc 2 /ml 1 48

haloperidol tab 0.5 1 haloperidol tab 1 1 haloperidol tab 2 1 haloperidol tab 5 1 haloperidol tab 10 1 haloperidol tab 20 1 Dibenzapines clozapine tab 25 1 clozapine tab 50 1 clozapine tab 100 1 clozapine tab 200 1 loxapine succinate cap 5 1 loxapine succinate cap 10 1 loxapine succinate cap 25 1 loxapine succinate cap 50 1 olanzapine tab 2.5 1 olanzapine tab 5 1 olanzapine tab 7.5 1 olanzapine tab 10 1 olanzapine tab 15 1 olanzapine tab 20 1 quetiapine fumarate tab 25 1 quetiapine fumarate tab 50 1 quetiapine fumarate tab 100 1 quetiapine fumarate tab 200 1 quetiapine fumarate tab 300 1 quetiapine fumarate tab 400 1 SAPHRIS SUB 2.5MG 3 ST; PA** SAPHRIS SUB 5MG 3 ST; PA** SAPHRIS SUB 10MG 3 ST; PA** SEROQUEL XR TAB 50MG 2 ST; PA** SEROQUEL XR TAB 150MG 2 ST; PA** SEROQUEL XR TAB 200MG 2 ST; PA** SEROQUEL XR TAB 300MG 2 ST; PA** SEROQUEL XR TAB 400MG 2 ST; PA** Phenothiazines chlorpromazine hcl tab 10 1 chlorpromazine hcl tab 25 1 chlorpromazine hcl tab 50 1 chlorpromazine hcl tab 100 1 chlorpromazine hcl tab 200 1 compro sup 25 1 fluphenazine hcl elixir 2.5 /5ml 1 fluphenazine hcl oral conc 5 /ml 1 fluphenazine hcl tab 1 1 fluphenazine hcl tab 2.5 1 49

fluphenazine hcl tab 5 1 fluphenazine hcl tab 10 1 perphenazine tab 2 1 perphenazine tab 4 1 perphenazine tab 8 1 perphenazine tab 16 1 prochlorperazine maleate tab 5 (base 1 equivalent) prochlorperazine maleate tab 10 (base 1 equivalent) prochlorperazine suppos 25 1 thioridazine hcl tab 10 1 thioridazine hcl tab 25 1 thioridazine hcl tab 50 1 thioridazine hcl tab 100 1 trifluoperazine hcl tab 1 1 trifluoperazine hcl tab 2 1 trifluoperazine hcl tab 5 1 trifluoperazine hcl tab 10 1 Quinolinone Derivatives ABILIFY DISC TAB 10MG 2 ST; PA** ABILIFY DISC TAB 15MG 2 ST; PA** ABILIFY SOL 1MG/ML 2 ST; PA** aripiprazole tab 2 1 aripiprazole tab 5 1 aripiprazole tab 10 1 aripiprazole tab 15 1 aripiprazole tab 20 1 aripiprazole tab 30 1 Thioxanthenes thiothixene cap 1 1 thiothixene cap 2 1 thiothixene cap 5 1 thiothixene cap 10 1 ANTISEPTICS DISINFECTANTS Chlorine Antiseptics PHISOHEX LIQ 3% 3 ANTIVIRALS Antiretrovirals abacavir sulfate tab 300 (base equiv) 1 abacavir sulfate-lamivudine-zidovudine tab 1 300-150-300 APTIVUS CAP 250MG 2 APTIVUS SOL 2 ATRIPLA TAB 2 50

COMPLERA TAB 2 CRIXIVAN CAP 200MG 2 CRIXIVAN CAP 400MG 2 didanosine delayed release capsule 125 1 didanosine delayed release capsule 200 1 didanosine delayed release capsule 250 1 didanosine delayed release capsule 400 1 EDURANT TAB 25MG 2 EMTRIVA CAP 200MG 2 EMTRIVA SOL 10MG/ML 2 EPIVIR SOL 10MG/ML 2 EPZICOM TAB 600-300 2 EVOTAZ TAB 300-150 2 FUZEON INJ 90MG 3 PA INTELENCE TAB 25MG 2 INTELENCE TAB 100MG 2 INTELENCE TAB 200MG 2 INVIRASE CAP 200MG 2 INVIRASE TAB 500MG 2 ISENTRESS CHW 25MG 2 ISENTRESS CHW 100MG 2 ISENTRESS POW 100MG 2 ISENTRESS TAB 400MG 2 KALETRA SOL 2 KALETRA TAB 100-25MG 2 KALETRA TAB 200-50MG 2 lamivudine tab 150 1 lamivudine tab 300 1 lamivudine-zidovudine tab 150-300 1 LEXIVA SUS 50MG/ML 2 LEXIVA TAB 700MG 2 nevirapine susp 50 /5ml 1 nevirapine tab 200 1 nevirapine tab sr 24hr 400 1 NORVIR CAP 100MG 2 NORVIR SOL 80MG/ML 2 NORVIR TAB 100MG 2 PREZCOBIX TAB 800-150 2 PREZISTA SUS 100MG/ML 2 PREZISTA TAB 75MG 2 PREZISTA TAB 150MG 2 PREZISTA TAB 400MG 2 PREZISTA TAB 600MG 2 PREZISTA TAB 800MG 2 RESCRIPTOR TAB 100 MG 2 RESCRIPTOR TAB 200MG 2 51

REYATAZ CAP 100MG 2 REYATAZ CAP 150MG 2 REYATAZ CAP 200MG 2 REYATAZ CAP 300MG 2 REYATAZ POW 50MG 2 SELZENTRY TAB 150MG 2 SELZENTRY TAB 300MG 2 stavudine cap 15 1 stavudine cap 20 1 stavudine cap 30 1 stavudine cap 40 1 stavudine for oral soln 1 /ml 1 STRIBILD TAB 2 SUSTIVA CAP 50MG 2 SUSTIVA CAP 200MG 2 SUSTIVA TAB 600MG 2 TIVICAY TAB 50MG 2 TRIUMEQ TAB 2 TRUVADA TAB 200-300 2 TYBOST TAB 150MG 2 VIDEX SOL 2GM 2 VIDEX SOL 4GM 2 VIRACEPT TAB 250MG 2 VIRACEPT TAB 625MG 2 VIRAMUNE XR TAB 100MG 2 VIREAD POW 40MG/GM 2 VIREAD TAB 150MG 2 VIREAD TAB 200MG 2 VIREAD TAB 250MG 2 VIREAD TAB 300MG 2 VITEKTA TAB 85MG 2 VITEKTA TAB 150MG 2 ZIAGEN SOL 20MG/ML 2 zidovudine cap 100 1 zidovudine syrup 10 /ml 1 zidovudine tab 300 1 CMV Agents foscarnet sodium inj 24 /ml 1 VALCYTE SOL 50MG/ML 3 valganciclovir hcl tab 450 (base 1 equivalent) Hepatitis Agents adefovir dipivoxil tab 10 1 PA BARACLUDE SOL.05MG/ML 2 entecavir tab 0.5 1 entecavir tab 1 1 52

EPIVIR HBV SOL 5MG/ML 2 HARVONI TAB 90-400MG 3 PA INFERGEN INJ 9MCG 3 PA INFERGEN INJ 15MCG 3 PA lamivudine tab 100 (hbv) 1 PEG-INTRON KIT 50MCG RP 3 PA PEG-INTRON KIT 80MCG 3 PA PEG-INTRON KIT 120 RP 3 PA PEG-INTRON KIT 150MCG 3 PA PEGASYS INJ 3 PA PEGASYS INJ 180MCG/M 3 PA PEGASYS INJ PROCLICK 3 PA PEGASYS KIT 3 PA REBETOL SOL 40MG/ML 3 PA ribasphere cap 200 1 PA ribasphere tab 200 1 PA ribasphere tab 400 1 PA ribasphere tab 600 1 PA ribavirin cap 200 1 PA ribavirin tab 200 1 PA SOVALDI TAB 400MG 3 PA TYZEKA TAB 600MG 3 PA Herpes Agents acyclovir cap 200 1 acyclovir susp 200 /5ml 1 acyclovir tab 400 1 acyclovir tab 800 1 famciclovir tab 125 1 famciclovir tab 250 1 famciclovir tab 500 1 valacyclovir hcl tab 1 gm 1 valacyclovir hcl tab 500 1 Influenza Agents RELENZA MIS DISKHALE 2 QL (2 inhalers / 90 days) rimantadine hydrochloride tab 100 1 TAMIFLU CAP 30MG 2 QL (28 caps / 90 days) TAMIFLU CAP 45MG 2 QL (14 caps / 90 days) TAMIFLU CAP 75MG 2 QL (14 caps / 90 days) TAMIFLU SUS 6MG/ML 2 QL (180 ml / 90 days) ASSORTED CLASSES Chelating Agents DEPEN TITRA TAB 250MG 3 SYPRINE CAP 250MG 3 Immunomodulators REVLIMID CAP 2.5MG 3 PA 53

REVLIMID CAP 5MG 3 PA REVLIMID CAP 10MG 3 PA REVLIMID CAP 15MG 3 PA REVLIMID CAP 20MG 3 PA REVLIMID CAP 25MG 3 PA THALOMID CAP 50MG 3 PA THALOMID CAP 100MG 3 PA THALOMID CAP 150MG 3 PA THALOMID CAP 200MG 3 PA Immunosuppressive Agents azathioprine tab 50 1 cyclosporine modified cap 25 1 cyclosporine modified cap 50 1 cyclosporine modified cap 100 1 cyclosporine modified oral soln 100 /ml 1 gengraf cap 25 1 gengraf cap 100 1 gengraf sol 100/ml 1 mycophenolate mofetil cap 250 1 mycophenolate mofetil for oral susp 200 1 /ml mycophenolate mofetil tab 500 1 mycophenolate sodium tab dr 180 1 (mycophenolic acid equiv) mycophenolate sodium tab dr 360 1 (mycophenolic acid equiv) NULOJIX INJ 250MG 3 RAPAMUNE SOL 1MG/ML 2 SIMULECT INJ 10MG 3 SIMULECT INJ 20MG 3 sirolimus tab 0.5 1 sirolimus tab 1 1 sirolimus tab 2 1 tacrolimus cap 0.5 1 tacrolimus cap 1 1 tacrolimus cap 5 1 ZORTRESS TAB 0.5MG 2 ZORTRESS TAB 0.25MG 2 ZORTRESS TAB 0.75MG 2 Potassium Removing Resins kionex sus 15gm/60 1 sodium polystyrene sulfonate oral susp 15 1 gm/60ml sodium polystyrene sulfonate rectal susp 301 gm/120ml BETA BLOCKERS 54

Alpha-Beta Blockers carvedilol tab 3.125 1 carvedilol tab 6.25 1 carvedilol tab 12.5 1 carvedilol tab 25 1 labetalol hcl tab 100 1 labetalol hcl tab 200 1 labetalol hcl tab 300 1 Beta Blockers Cardio-Selective acebutolol hcl cap 200 1 acebutolol hcl cap 400 1 atenolol tab 25 1 atenolol tab 50 1 atenolol tab 100 1 betaxolol hcl tab 10 1 betaxolol hcl tab 20 1 bisoprolol fumarate tab 5 1 bisoprolol fumarate tab 10 1 BYSTOLIC TAB 2.5MG 3 BYSTOLIC TAB 5MG 3 BYSTOLIC TAB 10MG 3 BYSTOLIC TAB 20MG 3 metoprolol succinate tab sr 24hr 25 1 metoprolol succinate tab sr 24hr 50 1 metoprolol succinate tab sr 24hr 100 1 metoprolol succinate tab sr 24hr 200 1 metoprolol tartrate tab 25 1 metoprolol tartrate tab 50 1 metoprolol tartrate tab 100 1 Beta Blockers Non-Selective LEVATOL TAB 20MG 3 nadolol tab 20 1 nadolol tab 40 1 nadolol tab 80 1 pindolol tab 5 1 pindolol tab 10 1 propranolol hcl cap sr 24hr 60 1 propranolol hcl cap sr 24hr 80 1 propranolol hcl cap sr 24hr 120 1 propranolol hcl cap sr 24hr 160 1 propranolol hcl oral soln 20 /5ml 1 propranolol hcl oral soln 40 /5ml 1 propranolol hcl tab 10 1 propranolol hcl tab 20 1 propranolol hcl tab 40 1 propranolol hcl tab 60 1 55

propranolol hcl tab 80 1 sorine tab 80 1 sorine tab 120 1 sorine tab 160 1 sorine tab 240 1 sotalol hcl (afib/afl) tab 80 1 sotalol hcl (afib/afl) tab 120 1 sotalol hcl (afib/afl) tab 160 1 sotalol hcl tab 80 1 sotalol hcl tab 120 1 sotalol hcl tab 160 1 sotalol hcl tab 240 1 timolol maleate tab 5 1 timolol maleate tab 10 1 timolol maleate tab 20 1 CALCIUM CHANNEL BLOCKERS Calcium Channel Blockers afeditab tab 30 cr 1 afeditab tab 60 cr 1 amlodipine besylate tab 2.5 1 amlodipine besylate tab 5 1 amlodipine besylate tab 10 1 CARDIZEM LA TAB 120MG 2 cartia xt cap 120/24hr 1 cartia xt cap 180/24hr 1 cartia xt cap 240/24hr 1 cartia xt cap 300/24hr 1 diltiazem hcl cap sr 12hr 60 1 diltiazem hcl cap sr 12hr 90 1 diltiazem hcl cap sr 12hr 120 1 diltiazem hcl cap sr 24hr 120 1 diltiazem hcl cap sr 24hr 180 1 diltiazem hcl cap sr 24hr 240 1 diltiazem hcl coated beads cap sr 24hr 120 1 diltiazem hcl coated beads cap sr 24hr 180 1 diltiazem hcl coated beads cap sr 24hr 240 1 diltiazem hcl coated beads cap sr 24hr 300 1 diltiazem hcl coated beads cap sr 24hr 360 1 diltiazem hcl extended release beads cap sr 1 24hr 120 56

diltiazem hcl extended release beads cap sr 1 24hr 180 diltiazem hcl extended release beads cap sr 1 24hr 240 diltiazem hcl extended release beads cap sr 1 24hr 300 diltiazem hcl extended release beads cap sr 1 24hr 360 diltiazem hcl extended release beads cap sr 1 24hr 420 felodipine tab sr 24hr 2.5 1 felodipine tab sr 24hr 5 1 felodipine tab sr 24hr 10 1 isradipine cap 2.5 1 isradipine cap 5 1 matzim la tab 180/24 1 matzim la tab 240/24 1 matzim la tab 300/24 1 matzim la tab 360/24 1 matzim la tab 420/24 1 nicardipine hcl cap 20 1 nicardipine hcl cap 30 1 nifedical xl tab 30 1 nifedical xl tab 60 1 nifedipine tab sr 24hr 30 1 nifedipine tab sr 24hr 60 1 nifedipine tab sr 24hr 90 1 nifedipine tab sr 24hr osmotic 90 1 nimodipine cap 30 1 nisoldipine tab sr 24hr 8.5 1 nisoldipine tab sr 24hr 17 1 nisoldipine tab sr 24hr 20 1 nisoldipine tab sr 24hr 25.5 1 nisoldipine tab sr 24hr 30 1 nisoldipine tab sr 24hr 34 1 nisoldipine tab sr 24hr 40 1 taztia xt cap 120/24 1 taztia xt cap 180/24 1 taztia xt cap 240/24 1 taztia xt cap 300/24 1 taztia xt cap 360/24 1 verapamil hcl cap sr 24hr 100 1 verapamil hcl cap sr 24hr 120 1 verapamil hcl cap sr 24hr 180 1 verapamil hcl cap sr 24hr 200 1 verapamil hcl cap sr 24hr 240 1 57

verapamil hcl cap sr 24hr 300 1 verapamil hcl cap sr 24hr 360 1 verapamil hcl tab cr 120 1 verapamil hcl tab cr 180 1 verapamil hcl tab cr 240 1 CARDIOTONICS Cardiac Glycosides digoxin oral soln 0.05 /ml 1 digoxin tab 125 mcg (0.125 ) 1 digoxin tab 250 mcg (0.25 ) 1 LANOXIN TAB 0.0625MG 2 LANOXIN TAB 0.1875MG 2 CARDIOVASCULAR AGENTS - MISC. Cardiovascular Agents Misc. - Combinations amlodipine besylate-atorvastatin calcium 1 tab 2.5-10 amlodipine besylate-atorvastatin calcium 1 tab 2.5-20 amlodipine besylate-atorvastatin calcium 1 tab 2.5-40 amlodipine besylate-atorvastatin calcium 1 tab 5-10 amlodipine besylate-atorvastatin calcium 1 tab 5-20 amlodipine besylate-atorvastatin calcium 1 tab 5-40 amlodipine besylate-atorvastatin calcium 1 tab 5-80 amlodipine besylate-atorvastatin calcium 1 tab 10-10 amlodipine besylate-atorvastatin calcium 1 tab 10-20 amlodipine besylate-atorvastatin calcium 1 tab 10-40 amlodipine besylate-atorvastatin calcium 1 tab 10-80 Prostaglandin Vasodilators epoprostenol sodium for inj 0.5 3 PA epoprostenol sodium for inj 1.5 3 PA REMODULIN INJ 1MG/ML 3 PA REMODULIN INJ 2.5MG/ML 3 PA REMODULIN INJ 5MG/ML 3 PA REMODULIN INJ 10MG/ML 3 PA TYVASO START SOL 0.6MG/ML 3 PA Pulmonary Hypertension - Endothelin Receptor Antagonists LETAIRIS TAB 5MG 3 PA 58

LETAIRIS TAB 10MG 3 PA TRACLEER TAB 62.5MG 3 PA TRACLEER TAB 125MG 3 PA Pulmonary Hypertension - Phosphodiesterase Inhibitors ADCIRCA TAB 20MG 3 PA, ST REVATIO INJ 3 PA sildenafil citrate tab 20 3 PA CEPHALOSPORINS Cephalosporins - 1st Generation cefadroxil cap 500 1 cefadroxil for susp 250 /5ml 1 cefadroxil for susp 500 /5ml 1 cefadroxil tab 1 gm 1 cephalexin cap 250 1 cephalexin cap 500 1 cephalexin cap 750 1 cephalexin for susp 125 /5ml 1 cephalexin for susp 250 /5ml 1 cephalexin tab 250 1 cephalexin tab 500 1 Cephalosporins - 2nd Generation cefaclor cap 250 1 cefaclor cap 500 1 CEFACLOR ER TAB 500MG 2 cefaclor for susp 125 /5ml 1 cefaclor for susp 250 /5ml 1 cefaclor for susp 375 /5ml 1 cefprozil for susp 125 /5ml 1 cefprozil for susp 250 /5ml 1 cefprozil tab 250 1 cefprozil tab 500 1 CEFTIN SUS 250/5ML 2 cefuroxime axetil for susp 125 /5ml 1 cefuroxime axetil tab 250 1 cefuroxime axetil tab 500 1 Cephalosporins - 3rd Generation cefdinir cap 300 1 cefdinir for susp 125 /5ml 1 cefdinir for susp 250 /5ml 1 cefixime for susp 100 /5ml 1 cefixime for susp 200 /5ml 1 cefpodoxime proxetil for susp 50 /5ml 1 cefpodoxime proxetil for susp 100 /5ml 1 cefpodoxime proxetil tab 100 1 cefpodoxime proxetil tab 200 1 59

ceftazidime for inj 2 gm 1 CEFTAZIDIME INJ 100GM 3 ceftriaxone sodium for inj 1 gm 1 ceftriaxone sodium for inj 2 gm 1 ceftriaxone sodium for inj 10 gm 1 ceftriaxone sodium for inj 250 1 ceftriaxone sodium for inj 500 1 ceftriaxone sodium for iv soln 1 gm 1 ceftriaxone sodium for iv soln 2 gm 1 FORTAZ INJ 500MG 3 SUPRAX CAP 400MG 2 SUPRAX CHW 100MG 2 SUPRAX CHW 200MG 2 SUPRAX SUS 500/5ML 2 SUPRAX TAB 400MG 2 tazicef inj 1gm 1 tazicef inj 2gm 1 tazicef inj 6gm 1 Cephalosporins - 4th Generation cefepime hcl for inj 1 gm 1 cefepime hcl for inj 2 gm 1 CEFEPIME INJ 1GM 3 CEFEPIME INJ 2GM 3 MAXIPIME INJ 1GM 3 MAXIPIME INJ 2GM 3 CONTRACEPTIVES Combination Contraceptives - Oral altavera tab 0 alyacen tab 1/35 0 alyacen tab 7/7/7 0 amethia tab 0 amethyst tab 90-20mcg 0 apri tab 0 aranelle tab 0 aviane tab 0 azurette tab 28 day 0 caziant pak 0 cesia pak 0 chateal tab 0.15/30 0 cryselle-28 tab 28 tabs 0 cyclafem tab 1/35 0 cyclafem tab 7/7/7 0 dasetta tab 1/35 0 dasetta tab 7/7/7 0 drospirenone-ethinyl estradiol tab 3-0.03 0 60

elinest tab 0 emoquette tab 0 enpresse-28 tab 0 falmina tab 0 gianvi tab 3-0.02 0 gildess fe tab 1.5/30 0 gildess fe tab 1/20 0 gildess tab 1.5/30 0 gildess tab 1/20 0 introvale tab 0 jolessa tab 0 junel 1.5/30 tab 0 junel 1/20 tab 0 junel fe tab 1.5/30 0 junel fe tab 1/20 0 kariva tab 28 day 0 kelnor tab 1/35 0 kurvelo tab 0.15/30 0 leena tab 0 lessina tab 0 levonest tab 0 levonorg-eth est tab 0.1-0.02(84) & eth 0 est tab 0.01(7) levonorgestrel & ethinyl estradiol (91-day) 0 tab 0.15-0.03 levonorgestrel & ethinyl estradiol tab 0.15 0-30 mcg levora-28 tab 0.15/30 0 lomedia 24 tab fe 0 loryna tab 3-0.02 0 low-ogestrel tab 0 lutera tab 0 marlissa tab 0.15/30 0 mono-linyah tab 0.25-35 0 mononessa tab 0 myzilra tab 0 necon tab 0.5/35 0 necon tab 1/35 0 necon tab 1/50-28 0 necon tab 7/7/7 0 norethindrone & ethinyl estradiol-fe chew 0 tab 0.8-25 mcg norgestimate & ethinyl estradiol tab 0.25 0-35 mcg norgestimate-eth estrad tab 0 0.18-35/0.215-35/0.25-35 -mcg nortrel tab 0.5/35 0 61

nortrel tab 1/35 0 nortrel tab 7/7/7 0 ocella tab 3-0.03 0 ogestrel tab 0 orsythia tab 0 portia-28 tab 0 previfem tab 0 quasense tab 0 reclipsen tab 0 solia tab 0 sprintec 28 tab 28 day 0 sronyx tab 0 syeda tab 3-0.03 0 tilia fe tab 0 tri-linyah tab 0 tri-previfem tab 0 tri-sprintec tab 0 trinessa tab 0 trivora-28 tab 0 velivet pak 0 vestura tab 3-0.02 0 viorele tab 0 wera tab 0.5/35 0 zarah tab 3-0.03 0 zenchent fe chw 0.4-35 0 zenchent tab 0 zovia 1/35e tab 0 zovia 1/50e tab 0 Combination Contraceptives - Transdermal xulane dis 150-35 0 Combination Contraceptives - Vaginal NUVARING MIS 0 QL (13 / 300 days) Copper Contraceptives - IUD PARAGARD IUD T380A 0 QL (1 unit / 300 days) Emergency Contraceptives ELLA TAB 30MG 0 levonorgestrel tab 0.75 0 levonorgestrel tab 1.5 0 Progestin Contraceptives - Injectable DEPO-SQ PROV INJ 104 0 QL (1 inj / 75 days) medroxyprogesterone acetate im susp 150 0 QL (1 inj / 75 days) /ml Progestin Contraceptives - Oral camila tab 0.35 0 errin tab 0.35 0 62

heather tab 0.35 0 jolivette tab 0.35 0 nora-be tab 0.35 0 norethindrone tab 0.35 0 CORTICOSTEROIDS Glucocorticosteroids budesonide cap sr 24hr 3 1 cortisone acetate tab 25 1 DEXAMETHASON CON 1MG/ML 2 dexamethasone elixir 0.5 /5ml 1 dexamethasone soln 0.5 /5ml 1 dexamethasone tab 0.5 1 dexamethasone tab 0.75 1 dexamethasone tab 1 1 dexamethasone tab 1.5 1 dexamethasone tab 2 1 dexamethasone tab 4 1 dexamethasone tab 6 1 hydrocortisone tab 5 1 hydrocortisone tab 10 1 hydrocortisone tab 20 1 MEDROL TAB 2MG 2 methylprednisolone tab 4 1 methylprednisolone tab 4 dose pack 1 methylprednisolone tab 8 1 methylprednisolone tab 16 1 methylprednisolone tab 32 1 prednisolone sod phosph oral soln 6.7 1 /5ml (5 /5ml base) prednisolone sod phosphate oral soln 15 1 /5ml (base equiv) prednisolone sodium phosphate oral soln 251 /5ml (base eq) prednisolone syrup 15 /5ml (usp solution 1 equivalent) PREDNISONE CON 5MG/ML 2 prednisone oral soln 5 /5ml 1 prednisone tab 1 1 prednisone tab 2.5 1 prednisone tab 5 1 prednisone tab 5 dose pack 1 prednisone tab 10 1 prednisone tab 10 dose pack 1 prednisone tab 20 1 prednisone tab 50 1 Mineralocorticoids 63

fludrocortisone acetate tab 0.1 1 COUGH/COLD/ALLERGY Antitussives benzonatate cap 100 1 benzonatate cap 200 1 hydrocodone w/ homatropine syrup 5-1.5 1 /5ml hydrocodone w/ homatropine tab 5-1.5 1 tussigon tab 5 1 Cough/Cold/Allergy Combinations ALLFEN CDX LIQ 2 NORTUSS-EX LIQ 200-20/5 2 PHENYLHIST LIQ DH 3 prometh vc syp plain 1 prometh vc/ syp codeine 1 promethazine w/ codeine syrup 6.25-10 1 /5ml promethazine-dm syrup 6.25-15 /5ml 1 tgq 50pse/3 syp brm/30dm 1 TRICODE AR LIQ 3 Misc. Respiratory Inhalants sodium chloride soln nebu 0.9% 1 sodium chloride soln nebu 3% 1 sodium chloride soln nebu 7% 1 sodium chloride soln nebu 10% 1 Mucolytics acetylcysteine inhal soln 10% 1 acetylcysteine inhal soln 20% 1 DERMATOLOGICALS Acne Products ACANYA GEL 1.2-2.5% 3 ST; PA** acne medicat gel 5% 1 OTC ACNE MEDICAT LOT 5% 1 OTC ACNE MEDICAT LOT 10% 1 OTC adapalene cream 0.1% 1 PA; PA applies for members age 25 and adapalene gel 0.1% 1 PA; PA applies for members age 25 and adapalene gel 0.3% 1 PA; PA applies for members age 25 and amnesteem cap 10 1 PA amnesteem cap 20 1 PA amnesteem cap 40 1 PA 64

avar-e green cre 10-5% 1 avita cre 0.025% 1 PA; PA applies for members age 35 and avita gel 0.025% 1 PA; PA applies for members age 35 and AZELEX CRE 20% 3 ST; PA** BENZAMYCIN GEL PAK 2 ST benzashave cre 10% 1 ST benzepro aer 5.3% 1 ST benzepro sc aer 9.8% 1 ST BENZIQ GEL 5.25% 2 ST BENZIQ LS GEL 2.75% 2 ST BENZOYL PER GEL 2.5% 1 OTC benzoyl per gel 10% 1 OTC benzoyl per liq 5% wash 1 OTC benzoyl per liq 10% wash 1 OTC benzoyl per liq 10% wash 1 ST benzoyl per lot 4% 1 ST benzoyl per lot 6% 1 OTC benzoyl per lot 8% 1 ST benzoyl per lot 9% 1 ST benzoyl pero kit acne pck 1 OTC benzoyl pero kit acne pck 1 ST benzoyl peroxide foam 5.3% 1 ST benzoyl peroxide foam 9.8% 1 ST benzoyl peroxide gel 5% 1 OTC benzoyl peroxide-erythromycin gel 5-3% 1 bp gel gel 10% 1 OTC bp wash liq 2.5% 1 ST bp wash liq 5% 1 OTC bp wash liq 5.25% 1 OTC bp wash liq 7% 1 ST bp wash liq 10% 1 OTC BPO CLOTHS MIS 3% 2 ST BPO CLOTHS MIS 6% 1 ST BPO CLOTHS MIS 9% 2 ST bpo creamy kit 4% wash 1 OTC BPO GEL 4% 2 ST BPO GEL 8% 2 ST bpo-5 wash liq 5% 1 OTC bpo-10 wash liq 10% 1 OTC claravis cap 10 1 PA claravis cap 20 1 PA claravis cap 30 1 PA 65

claravis cap 40 1 PA clearplex x gel 10% 1 ST CLINAC BPO GEL 7% 2 ST CLINDACIN KIT PAC 1% 3 clindamycin phosph-benzoyl peroxide 1 (refrig) gel 1.2 (1)-5% clindamycin phosphate gel 1% 1 clindamycin phosphate lotion 1% 1 clindamycin phosphate soln 1% 1 clindamycin phosphate-benzoyl peroxide 1 gel 1-5% DIFFERIN LOT 0.1% 3 PA; PA applies for members age 25 and EPIDUO GEL 0.1-2.5% 3 ST erythromycin gel 2% 1 erythromycin soln 2% 1 lavoclen-4 kit acne wsh 1 ST LAVOCLEN-4 LIQ CREM WSH 2 ST lavoclen-8 kit acne wsh 1 ST LAVOCLEN-8 LIQ CREM WSH 2 ST myorisan cap 10 1 PA myorisan cap 20 1 PA myorisan cap 40 1 PA oscion clnsr lot 6% 1 ST oscion clnsr lot 9% 1 ST persa-gel xs gel 5% 1 OTC pr benzoyl liq 7% wash 1 ST sulfacetamide sodium lotion 10% (acne) 1 sulfacetamide sodium w/ sulfur cleansing 1 cloth 10-5% sulfacetamide sodium w/ sulfur cleansing 1 pad 10-4% sulfacetamide sodium w/ sulfur cream 1 10-5% sulfacetamide sodium w/ sulfur lotion 1 10-5% tretinoin cream 0.1% 1 PA; PA applies for members age 35 and tretinoin cream 0.05% 1 PA; PA applies for members age 35 and tretinoin cream 0.025% 1 PA; PA applies for members age 35 and 66

tretinoin gel 0.01% 1 PA; PA applies for members age 35 and tretinoin gel 0.025% 1 PA; PA applies for members age 35 and VELTIN GEL 3 PA; PA applies for members age 35 and ZIANA GEL 3 PA; PA applies for members age 35 and Agents for External Genital and Perianal Warts VEREGEN OIN 15% 3 Agents for Facial Wrinkles AVAGE CRE 0.1% 3 Anti-inflammatory Agents - Topical VOLTAREN GEL 1% 3 ST; PA** Antibiotics - Topical ALTABAX OIN 1% 3 ST bacitracin oin 500/gm 1 OTC CENTANY AT KIT 2% 3 ST CORTISPORIN CRE 0.5% 3 ST CORTISPORIN OIN 1% 3 ST gentamicin sulfate cream 0.1% 1 gentamicin sulfate oint 0.1% 1 mupirocin oint 2% 1 triple antib oin 1 OTC Antifungals - Topical anti-fungal pow 1% 1 OTC antifungal cre 1% 1 OTC antifungal cre 2% 1 OTC ath foot spr aer 1% 1 ciclopirox gel 0.77% 1 ST ciclopirox kit 8% 1 ST ciclopirox olamine cream 0.77% (base 1 ST equiv) ciclopirox olamine susp 0.77% (base equiv) 1 ST ciclopirox shampoo 1% 1 ST ciclopirox solution 8% 1 ST clotrimazole cre 1% 1 OTC clotrimazole cream 1% 1 ST CLOTRIMAZOLE CRY 3 clotrimazole soln 1% 1 clotrimazole soln 1% 1 OTC 67

clotrimazole w/ betamethasone cream 1 1-0.05% clotrimazole w/ betamethasone lotion 1 1-0.05% cruex aer 2% 1 desenex spry aer liquid 1 econazole nitrate cream 1% 1 ST ketoconazole cream 2% 1 ST ketoconazole shampoo 2% 1 ST ketodan aer 2% 1 LAMISIL ADV GEL 1% 1 OTC LAMISIL AT SPR 1% 1 OTC LOTRIMIN ULT CRE 1% 1 OTC mitrazol pow 2% 1 NAFTIN CRE 1% 3 ST NAFTIN CRE 2% 3 ST NAFTIN GEL 1% 3 ST NAFTIN GEL 2% 3 ST nyamyc pow 100000 1 ST nystatin cream 100000 unit/gm 1 ST nystatin oint 100000 unit/gm 1 ST nystatin-triamcinolone cream 100000-0.1 1 unit/gm-% nystatin-triamcinolone oint 100000-0.1 1 unit/gm-% nystop pow 100000 1 ST OXISTAT CRE 1% 3 ST OXISTAT LOT 1% 3 ST terbinafine cre 1% 1 OTC tolnaftate aerosol pow 1% 1 OTC tolnaftate soln 1% 1 OTC triple paste oin af 2% 1 Antineoplastic or Premalignant Lesion Agents - Topical FLUOROPLEX CRE 1% 3 fluorouracil cream 0.5% 1 fluorouracil cream 5% 1 fluorouracil soln 2% 1 fluorouracil soln 5% 1 PANRETIN GEL 0.1% 3 PICATO GEL 0.05% 3 PICATO GEL 0.015% 3 Antipruritics - Topical prudoxin cre 5% 1 Antipsoriatics acitretin cap 10 1 acitretin cap 17.5 1 68

acitretin cap 25 1 calcipotriene cream 0.005% 1 calcipotriene oint 0.005% 1 calcipotriene soln 0.005% (50 mcg/ml) 1 calcitriol oint 3 mcg/gm 1 methoxsalen rapid cap 10 1 8-MOP CAP 10MG 3 STELARA INJ 45MG/0.5 3 PA, ST STELARA INJ 90MG/ML 3 PA, ST TAZORAC CRE 0.1% 2 PA TAZORAC CRE 0.05% 2 PA TAZORAC GEL 0.1% 2 PA TAZORAC GEL 0.05% 2 PA Antiseborrheic Products selenium sulfide lotion 2.5% 1 SELENIUM SULFIDE-PYRITHIONE ZINC IN 1 UREA SHAMPOO 2.25% Antivirals - Topical ABREVA CRE 10% 1 OTC DENAVIR CRE 1% 3 ST Burn Products mafenide acetate packet for topical soln 5% 1 (50 gm) silver sulfadiazine cream 1% 1 ssd cre 1% 1 Corticosteroids - Topical alclometasone dipropionate cream 0.05% 1 alclometasone dipropionate oint 0.05% 1 alphatrex gel 0.05% 1 amcinonide cream 0.1% 1 amcinonide lotion 0.1% 1 AMCINONIDE OIN 0.1% 2 apexicon oin 0.05% 1 betamethasone dipropionate augmented 1 cream 0.05% betamethasone dipropionate augmented 1 lotion 0.05% betamethasone dipropionate augmented 1 oint 0.05% betamethasone dipropionate cream 0.05% 1 betamethasone dipropionate lotion 0.05% 1 betamethasone dipropionate oint 0.05% 1 betamethasone valerate aerosol foam 1 0.12% betamethasone valerate cream 0.1% 1 betamethasone valerate lotion 0.1% 1 69

betamethasone valerate oint 0.1% 1 calcipotriene-betamethasone dipropionate 1 oint 0.005-0.064% clobetasol propionate cream 0.05% 1 clobetasol propionate foam 0.05% 1 clobetasol propionate gel 0.05% 1 clobetasol propionate lotion 0.05% 1 clobetasol propionate oint 0.05% 1 clobetasol propionate shampoo 0.05% 1 clocortolone pivalate cream 0.1% 1 CORDRAN 24X3 TAP 4MCG/CM 3 CORDRAN CRE 0.05% 3 CORDRAN LOT 0.05% 3 cormax scalp sol 0.05% 1 desonide cream 0.05% 1 desonide lotion 0.05% 1 desonide oint 0.05% 1 desoximetasone cream 0.05% 1 desoximetasone cream 0.25% 1 desoximetasone gel 0.05% 1 desoximetasone oint 0.05% 1 desoximetasone oint 0.25% 1 diflorasone diacetate cream 0.05% 1 diflorasone diacetate oint 0.05% 1 fluocin acet oil 0.01% sc 1 fluocin acet oil body 1 fluocinolone acetonide cream 0.01% 1 fluocinolone acetonide cream 0.025% 1 fluocinolone acetonide oint 0.025% 1 fluocinolone acetonide soln 0.01% 1 fluocinonide cream 0.1% 1 fluocinonide cream 0.05% 1 fluocinonide gel 0.05% 1 fluocinonide oint 0.05% 1 fluocinonide soln 0.05% 1 fluticasone propionate cream 0.05% 1 fluticasone propionate lotion 0.05% 1 fluticasone propionate oint 0.005% 1 halobetasol propionate cream 0.05% 1 halobetasol propionate oint 0.05% 1 HALOG CRE 0.1% 3 HALOG OIN 0.1% 3 hydrocortisone butyrate cream 0.1% 1 hydrocortisone butyrate hydrophilic lipo 1 base cream 0.1% hydrocortisone butyrate oint 0.1% 1 70

hydrocortisone butyrate soln 0.1% 1 hydrocortisone cream 1% 1 hydrocortisone cream 2.5% 1 hydrocortisone lotion 2.5% 1 hydrocortisone oint 1% 1 hydrocortisone oint 2.5% 1 hydrocortisone valerate cream 0.2% 1 hydrocortisone valerate oint 0.2% 1 lokara lot 0.05% 1 mometasone furoate cream 0.1% 1 mometasone furoate oint 0.1% 1 mometasone furoate solution 0.1% (lotion) 1 scalacort lot 2% 1 TACLONEX SUS 3 triamcinolone acetonide cream 0.1% 1 triamcinolone acetonide cream 0.5% 1 triamcinolone acetonide cream 0.025% 1 triamcinolone acetonide lotion 0.1% 1 triamcinolone acetonide lotion 0.025% 1 triamcinolone acetonide oint 0.1% 1 triamcinolone acetonide oint 0.5% 1 triamcinolone acetonide oint 0.025% 1 triderm cre 0.1% 1 Emollients amlactin lot 12% 1 OTC laclotion lot 12% 1 lactic acid (ammonium lactate) cream 12% 1 lactic acid (ammonium lactate) lotion 10% 1 lactic acid (ammonium lactate) lotion 12% 1 Enzymes - Topical SANTYL OIN 250/GM 3 Immunomodulating Agents - Topical imiquimod cream 5% 1 ZYCLARA CRE 3.75% 3 ZYCLARA PUMP CRE 2.5% 3 Immunosuppressive Agents - Topical ELIDEL CRE 1% 2 ST; PA** tacrolimus oint 0.1% 1 ST; PA** tacrolimus oint 0.03% 1 ST; PA** Keratolytic/Antimitotic Agents CONDYLOX GEL 0.5% 3 podofilox soln 0.5% 1 Local Anesthetics - Topical lidocaine hcl cream 3% 1 lidocaine hcl gel 2% 1 71

lidocaine hcl lotion 3% 1 lidocaine hcl soln 4% 1 lidocaine-prilocaine cream 2.5-2.5% 1 lidocaine-prilocaine kit 2.5-2.5% 1 pramox gel 1% 1 SYNERA DIS 70-70MG 3 Pigmenting-Depigmenting Agents OXSORALEN LOT 1% 3 Rosacea Agents FINACEA GEL 15% 3 metronidazole cream 0.75% 1 metronidazole gel 0.75% 1 metronidazole gel 1% 1 metronidazole lotion 0.75% 1 rosadan cre 0.75% 1 Scabicides Pediculicides acticin cre 5% 1 EURAX CRE 10% 3 EURAX LOT 10% 3 malathion lotion 0.5% 1 permethrin cream 5% 1 permethrin lotion 1% 1 OTC SKLICE LOT 0.5% 3 ST spinosad susp 0.9% 1 ULESFIA LOT 5% 3 ST Wound Care Products REGRANEX GEL 0.01% 3 DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS Dietary Management Products folbic tab 1 DIGESTIVE AIDS Digestive Enzymes CREON CAP 3000UNIT 2 CREON CAP 6000UNIT 2 CREON CAP 12000UNT 2 CREON CAP 24000UNT 2 CREON CAP 36000UNT 2 pancrelipase (lip-prot-amyl) dr cap 1 5000-17000-27000 unit SUCRAID SOL 8500/ML 3 ULTRESA CAP 13800UNT 2 ULTRESA CAP 20700UNT 2 ULTRESA CAP 23000UNT 2 VIOKACE TAB 2 VIOKACE TAB 20880 2 72

ZENPEP CAP 3000UNIT 2 ZENPEP CAP 10000UNT 2 ZENPEP CAP 15000UNT 2 ZENPEP CAP 20000UNT 2 ZENPEP CAP 25000UNT 2 ZENPEP CAP 40000UNT 2 DIURETICS Carbonic Anhydrase Inhibitors acetazolamide sodium for inj 500 1 methazolamide tab 25 1 methazolamide tab 50 1 Diuretic Combinations ALDACTAZIDE TAB 50/50 2 amiloride & hydrochlorothiazide tab 5-50 1 spironolactone & hydrochlorothiazide tab 1 25-25 triamterene & hydrochlorothiazide cap 1 37.5-25 triamterene & hydrochlorothiazide cap 1 50-25 triamterene & hydrochlorothiazide tab 1 37.5-25 triamterene & hydrochlorothiazide tab 1 75-50 Loop Diuretics bumetanide tab 0.5 1 bumetanide tab 1 1 bumetanide tab 2 1 EDECRIN TAB 25MG 3 furosemide oral soln 10 /ml 1 FUROSEMIDE SOL 8MG/ML 2 furosemide tab 20 1 furosemide tab 40 1 furosemide tab 80 1 SOD EDECRIN INJ 50MG 3 torsemide tab 5 1 torsemide tab 10 1 torsemide tab 20 1 torsemide tab 100 1 Potassium Sparing Diuretics amiloride hcl tab 5 1 DYRENIUM CAP 50MG 3 DYRENIUM CAP 100MG 3 spironolactone tab 25 1 spironolactone tab 50 1 73

spironolactone tab 100 1 Thiazides and Thiazide-Like Diuretics chlorothiazide tab 250 1 chlorothiazide tab 500 1 chlorthalidone tab 25 1 chlorthalidone tab 50 1 chlorthalidone tab 100 1 DIURIL SUS 250/5ML 3 hydrochlorothiazide cap 12.5 1 hydrochlorothiazide tab 12.5 1 hydrochlorothiazide tab 25 1 hydrochlorothiazide tab 50 1 indapamide tab 1.25 1 indapamide tab 2.5 1 metolazone tab 2.5 1 metolazone tab 5 1 metolazone tab 10 1 ENDOCRINE AND METABOLIC AGENTS - MISC. Bone Density Regulators ACTONEL TAB 5MG 3 ST; PA** ACTONEL TAB 30MG 3 ST; PA** ACTONEL TAB 35MG 3 ST; PA** alendronate sodium oral soln 70 /75ml 1 alendronate sodium tab 5 1 alendronate sodium tab 10 1 alendronate sodium tab 35 1 alendronate sodium tab 40 1 alendronate sodium tab 70 1 calcitonin (salmon) nasal soln 200 unit/act 1 FORTEO SOL 600/2.4 3 PA ibandronate sodium tab 150 (base 1 equivalent) pamidronate disodium for inj 30 1 pamidronate disodium for inj 90 1 pamidronate disodium iv soln 3 /ml 1 pamidronate disodium iv soln 9 /ml 1 PAMIDRONATE INJ 6MG/ML 3 PROLIA SOL 60MG/ML 3 PA risedronate sodium tab 150 1 risedronate sodium tab delayed release 35 1 Fertility Regulators chorionic gonadotropin for inj 10000 unit 3 PA clomiphene citrate tab 50 1 novarel inj 10000unt 3 PA pregnyl inj 10000unt 3 PA 74

Growth Hormone Receptor Antagonists SOMAVERT INJ 10MG 3 PA SOMAVERT INJ 15MG 3 PA SOMAVERT INJ 20MG 3 PA SOMAVERT INJ 25MG 3 PA SOMAVERT INJ 30MG 3 PA Growth Hormones HUMATROPE INJ 5MG 3 PA HUMATROPE INJ 6MG 3 PA HUMATROPE INJ 12MG 3 PA HUMATROPE INJ 24MG 3 PA NORDITROPIN INJ 5/1.5ML 3 PA NORDITROPIN INJ 10/1.5ML 3 PA NORDITROPIN INJ 15/1.5ML 3 PA NORDITROPIN INJ 30/3ML 3 PA Hormone Receptor Modulators raloxifene hcl tab 60 1 $0 copay for women > 35 years for the primary prevention of breast cancer Insulin-Like Growth Factors (Somatomedins) INCRELEX INJ 40MG/4ML 3 PA LHRH/GnRH Agonist Analog Pituitary Suppressants LUPR DEP-PED INJ 7.5MG 3 PA LUPR DEP-PED INJ 11.25MG 3 PA LUPR DEP-PED INJ 15MG 3 PA LUPR DEP-PED INJ 30MG 3 PA SYNAREL SOL 2MG/ML 2 Metabolic Modifiers calcitriol cap 0.5 mcg 1 calcitriol cap 0.25 mcg 1 calcitriol oral soln 1 mcg/ml 1 CYSTADANE POW 3 doxercalciferol cap 0.5 mcg 1 doxercalciferol cap 1 mcg 1 doxercalciferol cap 2.5 mcg 1 FABRAZYME INJ 5MG 3 PA FABRAZYME INJ 35MG 3 PA MYOZYME INJ 50MG 3 PA paricalcitol cap 1 mcg 1 paricalcitol cap 2 mcg 1 paricalcitol cap 4 mcg 1 SENSIPAR TAB 30MG 3 PA SENSIPAR TAB 60MG 3 PA SENSIPAR TAB 90MG 3 PA 75

Posterior Pituitary Hormones desmopressin acetate nasal soln 0.01% 1 (refrigerated) desmopressin acetate nasal spray soln 1 0.01% desmopressin acetate nasal spray soln 1 0.01% (refrigerated) desmopressin acetate tab 0.1 1 desmopressin acetate tab 0.2 1 Prolactin Inhibitors cabergoline tab 0.5 1 Somatostatic Agents octreotide acetate inj 50 mcg/ml (0.05 3 PA /ml) octreotide acetate inj 100 mcg/ml (0.1 3 PA /ml) octreotide acetate inj 200 mcg/ml (0.2 3 PA /ml) octreotide acetate inj 500 mcg/ml (0.5 3 PA /ml) octreotide acetate inj 1000 mcg/ml (1 3 PA /ml) SOMATULINE INJ 60/0.2ML 3 PA SOMATULINE INJ 90/0.3ML 3 PA SOMATULINE INJ 120/.5ML 3 PA Vasopressin Receptor Antagonists SAMSCA TAB 15MG 3 PA SAMSCA TAB 30MG 3 PA ESTROGENS Estrogen Combinations CLIMARA PRO DIS WEEKLY 2 estradiol & norethindrone acetate tab 1 0.5-0.1 estradiol & norethindrone acetate tab 1-0.51 FEMHRT TAB 0.5-2.5 2 jinteli tab 1-5mcg 1 mimvey tab 1-0.5 1 Estrogens CENESTIN TAB 0.3MG 3 PA; High Risk Medications require PA for members age 65 and CENESTIN TAB 0.9MG 3 PA; High Risk Medications require PA for members age 65 and 76

CENESTIN TAB 0.45MG 3 PA; High Risk Medications require PA for members age 65 and CENESTIN TAB 0.625MG 3 PA; High Risk Medications require PA for members age 65 and CENESTIN TAB 1.25MG 3 PA; High Risk Medications require PA for members age 65 and ENJUVIA TAB 0.3MG 3 PA; High Risk Medications require PA for members age 65 and ENJUVIA TAB 0.9MG 3 PA; High Risk Medications require PA for members age 65 and ENJUVIA TAB 0.45MG 3 PA; High Risk Medications require PA for members age 65 and ENJUVIA TAB 0.625MG 3 PA; High Risk Medications require PA for members age 65 and ENJUVIA TAB 1.25MG 3 PA; High Risk Medications require PA for members age 65 and estradiol tab 0.5 1 PA; High Risk Medications require PA for members age 65 and estradiol tab 1 1 PA; High Risk Medications require PA for members age 65 and estradiol tab 2 1 PA; High Risk Medications require PA for members age 65 and estradiol td patch weekly 0.1 /24hr 1 PA; High Risk Medications require PA for members age 65 and 77

estradiol td patch weekly 0.05 /24hr 1 PA; High Risk Medications require PA for members age 65 and estradiol td patch weekly 0.06 /24hr 1 PA; High Risk Medications require PA for members age 65 and estradiol td patch weekly 0.025 /24hr 1 PA; High Risk Medications require PA for members age 65 and estradiol td patch weekly 0.075 /24hr 1 PA; High Risk Medications require PA for members age 65 and estradiol td patch weekly 0.0375 /24hr 1 PA; High Risk (37.5 mcg/24hr) Medications require PA for members age 65 and estropipate tab 0.75 1 PA; High Risk Medications require PA for members age 65 and estropipate tab 1.5 1 PA; High Risk Medications require PA for members age 65 and estropipate tab 3 1 PA; High Risk Medications require PA for members age 65 and MENEST TAB 0.3MG 3 PA; High Risk Medications require PA for members age 65 and MENEST TAB 0.625MG 3 PA; High Risk Medications require PA for members age 65 and MENEST TAB 1.25MG 3 PA; High Risk Medications require PA for members age 65 and MENEST TAB 2.5MG 3 PA; High Risk Medications require PA for members age 65 and 78

ortho-est tab 0.625 1 PA; High Risk Medications require PA for members age 65 and ortho-est tab 1.25 1 PA; High Risk Medications require PA for members age 65 and PREMARIN TAB 0.3MG 3 PA; High Risk Medications require PA for members age 65 and PREMARIN TAB 0.9MG 3 PA; High Risk Medications require PA for members age 65 and PREMARIN TAB 0.45MG 3 PA; High Risk Medications require PA for members age 65 and PREMARIN TAB 0.625MG 3 PA; High Risk Medications require PA for members age 65 and PREMARIN TAB 1.25MG 3 PA; High Risk Medications require PA for members age 65 and FLUOROQUINOLONES Fluoroquinolones ciprofloxacin for oral susp 250 /5ml (5%) 1 (5 gm/100ml) ciprofloxacin for oral susp 500 /5ml 1 (10%) (10 gm/100ml) ciprofloxacin hcl tab 100 (base equiv) 1 ciprofloxacin hcl tab 250 (base equiv) 1 ciprofloxacin hcl tab 500 (base equiv) 1 ciprofloxacin hcl tab 750 (base equiv) 1 ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1 500 (base eq) ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1 1000 (base eq) FACTIVE TAB 320MG 3 levofloxacin oral soln 25 /ml 1 levofloxacin tab 250 1 levofloxacin tab 500 1 levofloxacin tab 750 1 moxifloxacin hcl tab 400 (base equiv) 1 79

NOROXIN TAB 400MG 3 GASTROINTESTINAL AGENTS - MISC. Gallstone Solubilizing Agents ursodiol cap 300 1 ursodiol tab 250 1 ursodiol tab 500 1 Gastrointestinal Chloride Channel Activators AMITIZA CAP 8MCG 2 PA AMITIZA CAP 24MCG 2 PA Gastrointestinal Stimulants metoclopramide hcl soln 5 /5ml (10 1 /10ml) metoclopramide hcl tab 5 1 metoclopramide hcl tab 10 1 Inflammatory Bowel Agents APRISO CAP 0.375GM 2 balsalazide disodium cap 750 1 CANASA SUP 1000MG 2 DIPENTUM CAP 250MG 3 mesalamine enema 4 gm 1 mesalamine rectal enema 4 gm & cleanser 1 wipe kit sulfasalazine tab 500 1 sulfasalazine tab delayed release 500 1 Irritable Bowel Syndrome (IBS) Agents LOTRONEX TAB 0.5MG 3 PA LOTRONEX TAB 1MG 3 PA Phosphate Binder Agents calcium acetate (phosphate binder) cap 6671 (169 ca) calcium acetate (phosphate binder) tab 6671 FOSRENOL CHW 500MG 3 FOSRENOL CHW 750MG 3 FOSRENOL CHW 1000MG 3 FOSRENOL POW 750MG 3 FOSRENOL POW 1000MG 3 RENVELA PAK 0.8GM 2 RENVELA PAK 2.4GM 2 RENVELA TAB 800MG 2 GENITOURINARY AGENTS - MISCELLANEOUS Alkalinizers potassium citrate tab cr 5 meq (540 ) 1 potassium citrate tab cr 10 meq (1080 ) 1 potassium citrate tab cr 15 meq (1620 ) 1 80

Cystinosis Agents CYSTAGON CAP 50MG 3 PA CYSTAGON CAP 150MG 3 PA Genitourinary Irrigants sodium chloride irrigation soln 0.9% 1 Interstitial Cystitis Agents ELMIRON CAP 100MG 3 Prostatic Hypertrophy Agents alfuzosin hcl tab sr 24hr 10 1 AVODART CAP 0.5MG 3 ST; PA** CARDURA XL TAB 4MG 3 ST; PA** CARDURA XL TAB 8MG 3 ST; PA** CIALIS TAB 2.5MG 3 QL (30 tabs / 25 days), PA CIALIS TAB 5MG 3 QL (30 tabs / 25 days), PA finasteride tab 5 1 JALYN CAP 3 ST; PA** RAPAFLO CAP 4MG 3 ST; PA** RAPAFLO CAP 8MG 3 ST; PA** tamsulosin hcl cap 0.4 1 Urinary Analgesics phenazopyridine hcl tab 100 1 phenazopyridine hcl tab 200 1 GOUT AGENTS Gout Agent Combinations colchicine w/ probenecid tab 0.5-500 1 Gout Agents allopurinol tab 100 1 allopurinol tab 300 1 colchicine tab 0.6 1 ULORIC TAB 40MG 3 ST; PA** ULORIC TAB 80MG 3 ST; PA** Uricosurics probenecid tab 500 1 HEMATOLOGICAL AGENTS - MISC. Hematorheologic Agents pentoxifylline tab cr 400 1 Platelet Aggregation Inhibitors AGGRENOX CAP 25-200MG 2 anagrelide hcl cap 0.5 1 anagrelide hcl cap 1 1 BRILINTA TAB 90MG 2 cilostazol tab 50 1 81

cilostazol tab 100 1 clopidogrel bisulfate tab 75 (base equiv) 1 clopidogrel bisulfate tab 300 (base 1 equiv) dipyridamole tab 25 1 PA; High Risk Medications require PA for members age 65 and dipyridamole tab 50 1 PA; High Risk Medications require PA for members age 65 and dipyridamole tab 75 1 PA; High Risk Medications require PA for members age 65 and EFFIENT TAB 5MG 2 EFFIENT TAB 10MG 2 ZONTIVITY TAB 2.08MG 2 HEMATOPOIETIC AGENTS Agents for Gaucher Disease CEREZYME INJ 200UNIT 3 PA CEREZYME INJ 400UNIT 3 PA Agents for Sickle Cell Anemia DROXIA CAP 200MG 2 DROXIA CAP 300MG 2 DROXIA CAP 400MG 2 Cobalamins cyanocobalamin inj 1000 mcg/ml 1 Folic Acid/Folates folic acid tab 1 1 folic acid tab 400 mcg 0 QL (100 tabs / 30 days); OTC; $0 copay for women ages 55 and under folic acid tab 800 mcg 0 QL (100 tabs / 30 days); OTC; $0 copay for women ages 55 and under Hematopoietic Growth Factors ARANESP INJ 10MCG 3 PA ARANESP INJ 25MCG 3 PA ARANESP INJ 40MCG 3 PA ARANESP INJ 60MCG 3 PA ARANESP INJ 100MCG 3 PA ARANESP INJ 150MCG 3 PA ARANESP INJ 200MCG 3 PA 82

ARANESP INJ 300MCG 3 PA ARANESP INJ 500MCG 3 PA LEUKINE INJ 250MCG 3 PA LEUKINE INJ 500 MCG 3 PA NEULASTA INJ 6MG/0.6M 3 PA NEUPOGEN INJ 300/0.5 3 PA NEUPOGEN INJ 300MCG 3 PA NEUPOGEN INJ 480/0.8 3 PA NEUPOGEN INJ 480MCG 3 PA PROCRIT INJ 2000/ML 3 PA PROCRIT INJ 3000/ML 3 PA PROCRIT INJ 4000/ML 3 PA PROCRIT INJ 10000/ML 3 PA PROCRIT INJ 20000/ML 3 PA PROCRIT INJ 40000/ML 3 PA PROMACTA TAB 12.5MG 3 PA PROMACTA TAB 25MG 3 PA PROMACTA TAB 50MG 3 PA PROMACTA TAB 75MG 3 PA Iron FER-IN-SOL DRO 15MG/ML 0 OTC; $0 for ages 6-12 months FERROUS SUL LIQ 220/5ML 0 OTC; $0 for ages 6-12 months FERROUS SULF SYP 300/5ML 0 OTC; $0 for ages 6-12 months ferrous sulfate elixir 220 /5ml (44 /5ml elemental fe) 0 OTC; $0 for ages 6-12 months ferrous sulfate soln 75 /ml (15 /ml elemental fe) 0 OTC; $0 for ages 6-12 months ICAR PEDS SUS GRAPE 0 OTC; $0 for ages 6-12 months MYKIDZ IRON SUS 15/1.5ML 0 OTC; $0 for ages 6-12 months wee care sus 15/1.25 0 OTC; $0 for ages 6-12 months Stem Cell Mobilizers MOZOBIL INJ 3 PA HEMOSTATICS Hemostatics - Systemic tranexamic acid inj 100 /ml 1 tranexamic acid tab 650 1 HYPNOTICS Barbiturate Hypnotics phenobarbital elixir 20 /5ml 1 phenobarbital tab 15 1 83

phenobarbital tab 16.2 1 phenobarbital tab 30 1 phenobarbital tab 32.4 1 phenobarbital tab 60 1 phenobarbital tab 64.8 1 phenobarbital tab 97.2 1 phenobarbital tab 100 1 Non-Barbiturate Hypnotics eszopiclone tab 1 1 QL (15 tabs / 25 days) eszopiclone tab 2 1 QL (15 tabs / 25 days) eszopiclone tab 3 1 QL (15 tabs / 25 days) temazepam cap 7.5 1 QL (15 caps / 25 days) temazepam cap 15 1 QL (15 caps / 25 days) temazepam cap 22.5 1 QL (15 caps / 25 days) temazepam cap 30 1 QL (15 caps / 25 days) zaleplon cap 5 1 QL (15 caps / 25 days) zaleplon cap 10 1 QL (15 caps / 25 days) zolpidem tartrate tab 5 1 QL (15 tabs / 25 days) zolpidem tartrate tab 10 1 QL (15 tabs / 25 days) zolpidem tartrate tab cr 6.25 1 QL (15 tabs / 25 days) zolpidem tartrate tab cr 12.5 1 QL (15 tabs / 25 days) Selective Melatonin Receptor Agonists ROZEREM TAB 8MG 3 QL (15 tabs / 25 days), ST; PA** LAXATIVES Laxative Combinations COLYTE/FLAVR SOL PACKS 2 gavilyte-c sol 1 gavilyte-g sol 1 gavilyte-n sol flav pk 1 GOLYTELY SOL 2 MOVIPREP SOL 2 $0 copay for members age 50 through 74 peg 3350-kcl-na bicarb-nacl-na sulfate for 1 soln 236 gm peg 3350-kcl-na bicarb-nacl-na sulfate for 1 soln 240 gm peg 3350-kcl-sod bicarb-nacl for soln 420 1 gm PREPOPIK PAK 0 PA; $0 copay for members age 50 through 74 SUPREP BOWEL SOL PREP 3 $0 copay for members age 50 through 74 Laxatives - Miscellaneous lactulose solution 10 gm/15ml 1 84

polyethylene glycol 3350 oral packet 1 polyethylene glycol 3350 oral powder 1 Saline Laxatives OSMOPREP TAB 1.5GM 3 MACROLIDES Azithromycin azithromycin for susp 100 /5ml 1 azithromycin for susp 200 /5ml 1 azithromycin powd pack for susp 1 gm 1 azithromycin tab 250 1 azithromycin tab 500 1 azithromycin tab 600 1 Clarithromycin clarithromycin for susp 125 /5ml 1 clarithromycin for susp 250 /5ml 1 clarithromycin tab 250 1 clarithromycin tab 500 1 clarithromycin tab sr 24hr 500 1 Erythromycins e.e.s. 400 tab 400 1 E.E.S. GRAN SUS 200/5ML 2 ERY-TAB TAB 250MG EC 2 ERY-TAB TAB 333MG EC 2 ERY-TAB TAB 500MG EC 2 ERYPED SUS 200/5ML 2 ERYPED SUS 400/5ML 2 erythrocin tab 250 1 erythromycin ethylsuccinate tab 400 1 erythromycin tab 250 1 erythromycin tab 500 1 erythromycin w/ delayed release particles 1 cap 250 Fidaxomicin DIFICID TAB 200MG 2 PA MEDICAL DEVICES Contraceptives FC2 FEMALE MIS CONDOM 0 OTC FEMCAP MIS 22MM 0 QL (1 / 300 days) FEMCAP MIS 26MM 0 QL (1 / 300 days) FEMCAP MIS 30MM 0 QL (1 / 300 days) OMNIFLEX DPR 0 QL (1 / 300 days) ORTHO COIL DPR KIT 50 0 QL (1 / 300 days) ORTHO COIL DPR KIT 100 0 QL (1 / 300 days) ORTHO COIL DPR KIT 105 0 QL (1 / 300 days) ORTHO FLAT DPR KIT 55 0 QL (1 / 300 days) 85

ORTHO FLAT DPR KIT 60 0 QL (1 / 300 days) ORTHO FLAT DPR KIT 65 0 QL (1 / 300 days) ORTHO FLAT DPR KIT 70 0 QL (1 / 300 days) ORTHO FLAT DPR KIT 75 0 QL (1 / 300 days) ORTHO FLAT DPR KIT 80 0 QL (1 / 300 days) ORTHO FLAT DPR KIT 85 0 QL (1 / 300 days) ORTHO FLAT DPR KIT 90 0 QL (1 / 300 days) ORTHO FLAT DPR KIT 95 0 QL (1 / 300 days) ORTHO FLEX DPR 65MM 0 QL (1 / 300 days) ORTHO FLEX DPR 70MM 0 QL (1 / 300 days) ORTHO FLEX DPR 75MM 0 QL (1 / 300 days) ORTHO FLEX DPR 80MM 0 QL (1 / 300 days) PRENTIF MIS 22MM 0 QL (1 / 300 days) PRENTIF MIS 25MM 0 QL (1 / 300 days) PRENTIF MIS 28MM 0 QL (1 / 300 days) PRENTIF MIS 31MM 0 QL (1 / 300 days) PRENTIF MIS FITTING 0 QL (1 / 300 days) TODAY SPONGE MIS 0 OTC WIDE-SEAL DPR KIT 60 0 QL (1 / 300 days) WIDE-SEAL DPR KIT 65 0 QL (1 / 300 days) WIDE-SEAL DPR KIT 70 0 QL (1 / 300 days) WIDE-SEAL DPR KIT 75 0 QL (1 / 300 days) WIDE-SEAL DPR KIT 80 0 QL (1 / 300 days) WIDE-SEAL DPR KIT 85 0 QL (1 / 300 days) WIDE-SEAL DPR KIT 90 0 QL (1 / 300 days) WIDE-SEAL DPR KIT 95 0 QL (1 / 300 days) Diabetic Supplies ALCOHOL PREP WIPES AND SWABS 2 OTC BLOOD GLUCOSE CALIBRATION SOLUTION 2 OTC FREESTYLE BLOOD GLUCOSE TEST KITS 2 OTC FREESTYLE BLOOD GLUCOSE TEST STRIPS 2 OTC INSULIN INFUSION PUMP KIT 2 INSULIN PEN NEEDLES/SYRINGES 2 OTC LANCETS 2 OTC LANCING DEVICE 2 OTC URINE TEST STRIPS 2 OTC Respiratory Therapy Supplies ADULT RESPIRATORY MASK 2 PEDIATRIC RESPIRATORY MASK 2 MIGRAINE PRODUCTS Migraine Combinations CAFERGOT TAB 1-100MG 2 Migraine Products dihydroergotamine mesylate nasal spray 4 1 QL (8 kits / 25 days) /ml 86

Serotonin Agonists AXERT TAB 6.25MG 3 QL (12 tabs / 25 days), ST; PA** AXERT TAB 12.5MG 3 QL (12 tabs / 25 days), ST; PA** FROVA TAB 2.5MG 3 QL (18 tabs / 25 days), ST; PA** naratriptan hcl tab 1 (base equiv) 1 QL (12 tabs / 25 days) naratriptan hcl tab 2.5 (base equiv) 1 QL (12 tabs / 25 days) RELPAX TAB 20MG 3 QL (12 tabs / 25 days), ST; PA** RELPAX TAB 40MG 3 QL (12 tabs / 25 days), ST; PA** rizatriptan benzoate orally disintegrating 1 QL (18 tabs / 25 days) tab 5 rizatriptan benzoate orally disintegrating 1 QL (18 tabs / 25 days) tab 10 rizatriptan benzoate tab 5 1 QL (18 tabs / 25 days) rizatriptan benzoate tab 10 1 QL (18 tabs / 25 days) sumatriptan nasal spray 5 /act 1 QL (24 sprays / 25 days) sumatriptan nasal spray 20 /act 1 QL (12 sprays / 25 days) sumatriptan succinate inj 4 /0.5ml 1 QL (12 units / 25 days) sumatriptan succinate inj 6 /0.5ml 1 QL (6 kits / 25 days) sumatriptan succinate solution auto-injector 1 QL (6 kits / 25 days) 4 /0.5ml sumatriptan succinate solution auto-injector 1 QL (6 kits / 25 days) 6 /0.5ml sumatriptan succinate solution cartridge 4 1 QL (12 units / 25 days) /0.5ml sumatriptan succinate solution cartridge 6 1 QL (12 units / 25 days) /0.5ml sumatriptan succinate solution prefilled 1 QL (12 units / 25 days) syringe 6 /0.5ml sumatriptan succinate tab 25 1 QL (12 tabs / 25 days) sumatriptan succinate tab 50 1 QL (12 tabs / 25 days) sumatriptan succinate tab 100 1 QL (12 tabs / 25 days) zolmitriptan orally disintegrating tab 2.5 1 QL (12 tabs / 25 days) zolmitriptan orally disintegrating tab 5 1 QL (12 tabs / 25 days) zolmitriptan tab 2.5 1 QL (12 tabs / 25 days) zolmitriptan tab 5 1 QL (12 tabs / 25 days) ZOMIG NASAL SPR 5MG 3 QL (12 sprays / 25 days) ZOMIG SPR 2.5MG 3 QL (12 sprays / 25 days) MINERALS ELECTROLYTES Fluoride fluor-a-day dro 0.125 0 $0 applies for ages 5 and under 87

FLUORABON DRO 0 $0 applies for ages 5 and under fluoritab chw 0.5 f 0 $0 applies for ages 5 and under fluoritab chw 0.25 f 0 $0 applies for ages 5 and under fluoritab chw 2.2 1 flura-drops dro 0.25 f 0 $0 applies for ages 5 and under flura-drops dro 0.125 0 $0 applies for ages 5 and under ludent chw 0.5 f 0 $0 applies for ages 5 and under ludent chw 0.25 f 0 $0 applies for ages 5 and under ludent chw 1 f 1 LURIDE CHW 0.5MG F 0 $0 applies for ages 5 and under LURIDE CHW 0.25MG F 0 $0 applies for ages 5 and under LURIDE DRO 0.5MG/ML 0 $0 applies for ages 5 and under nafrinse chw 1 f 1 sodium fluoride chew tab 0.5 f (from 1.10 $0 applies for ages 5 and naf) under sodium fluoride chew tab 0.25 f (from 0.55 naf) 0 $0 applies for ages 5 and under sodium fluoride chew tab 1 f (from 2.2 1 naf) sodium fluoride soln 0.5 /ml f (from 1.1 0 $0 applies for ages 5 and /ml naf) under sodium fluoride tab 0.5 f (from 1.1 0 $0 applies for ages 5 and naf) under sodium fluoride tab 1 f (from 2.2 1 naf) Magnesium MAGNESIUM SU INJ 2/50ML 3 Potassium klor-con 8 tab 8meq er 1 klor-con 10 tab 10meq er 1 KLOR-CON M15 TAB 15MEQ ER 2 klor-con m20 tab 20meq er 1 potassium chloride cap cr 8 meq 1 potassium chloride cap cr 10 meq 1 potassium chloride microencapsulated crys 1 cr tab 10 meq potassium chloride microencapsulated crys 1 cr tab 20 meq 88

potassium chloride oral liq 10% (20 1 meq/15ml) potassium chloride oral liq 20% (40 1 meq/15ml) potassium chloride tab cr 8 meq (600 ) 1 potassium chloride tab cr 10 meq 1 POTASSIUM CHLORIDE TAB CR 20 MEQ 1 (1500 MG) Sodium sodium chloride flush iv soln 0.9% 1 sodium chloride inj 0.9% 1 sodium chloride inj 0.45% 1 sodium chloride inj 2.5 meq/ml (14.6%) 1 sodium chloride inj 3% 1 sodium chloride inj 4 meq/ml (23.4%) 1 sodium chloride inj 5% 1 sodium chloride iv soln 0.9% 1 MOUTH/THROAT/DENTAL AGENTS Anesthetics Topical Oral lidocaine hcl laryngotracheal soln 4% 1 lidocaine hcl viscous soln 2% 1 Anti-infectives - Throat clotrimazole troche 10 1 nystatin susp 100000 unit/ml 1 Antiseptics - Mouth/Throat chlorhexidine gluconate soln 0.12% 1 periogard sol 0.12% 1 Steroids - Mouth/Throat oralone pst 0.1% 1 triamcinolone acetonide dental paste 0.1% 1 Throat Products - Misc. cevimeline hcl cap 30 1 pilocarpine hcl tab 5 1 pilocarpine hcl tab 7.5 1 MULTIVITAMINS Ped MV w/ Fluoride acd/fluoride dro 0.25 1 multi-vit/fl dro 0.5/ml 1 multi-vit/fl dro 0.25 1 multivit/fl chw 0.5 1 multivit/fl chw 0.25 1 multivit/fl chw 1 1 mvc-fluoride chw 0.5 1 mvc-fluoride chw 1 1 tri-vit/fl dro 0.5 1 89

tri-vit/fl dro 0.25 1 Ped Multi Vitamins w/fl FE MULTI-VIT/FE DRO /FL 0.25 1 tri-vit/fe dro /fl 0.25 1 Prenatal Vitamins CITRANATAL CAP HARMONY 2 CITRANATAL MIS 90 DHA 2 CITRANATAL MIS B-CALM 2 CITRANATAL PAK ASSURE 2 CITRANATAL PAK DHA 2 CITRANATAL TAB RX 2 prenatabs rx tab 1 TARON-BC MIS 2 MUSCULOSKELETAL THERAPY AGENTS Central Muscle Relaxants baclofen tab 10 1 baclofen tab 20 1 carisoprodol tab 250 1 PA; High Risk Medications require PA for members age 65 and carisoprodol tab 350 1 PA; High Risk Medications require PA for members age 65 and chlorzoxazone tab 500 1 cyclobenzaprine hcl tab 5 1 PA; High Risk Medications require PA for members age 65 and cyclobenzaprine hcl tab 7.5 1 PA; High Risk Medications require PA for members age 65 and cyclobenzaprine hcl tab 10 1 PA; High Risk Medications require PA for members age 65 and metaxalone tab 400 1 PA; High Risk Medications require PA for members age 65 and metaxalone tab 800 1 PA; High Risk Medications require PA for members age 65 and 90

methocarbamol tab 500 1 PA; High Risk Medications require PA for members age 65 and methocarbamol tab 750 1 PA; High Risk Medications require PA for members age 65 and orphenadrine citrate inj 30 /ml 1 orphenadrine citrate tab sr 12hr 100 1 PA; High Risk Medications require PA for members age 65 and tizanidine hcl tab 2 (base equivalent) 1 tizanidine hcl tab 4 (base equivalent) 1 Direct Muscle Relaxants dantrolene sodium cap 25 1 dantrolene sodium cap 50 1 dantrolene sodium cap 100 1 Muscle Relaxant Combinations orphen cpd tab ds 1 PA; High Risk Medications require PA for members age 65 and orphenadrine w/ aspirin & caffeine tab 25-385-30 1 PA; High Risk Medications require PA for members age 65 and NASAL AGENTS - SYSTEMIC AND TOPICAL Nasal Antiallergy azelastine hcl nasal spray 0.1% (137 1 QL (2 bottles / 25 days) mcg/spray) azelastine hcl nasal spray 0.15% (205.5 1 QL (2 bottles / 25 days) mcg/spray) Nasal Anticholinergics ipratropium bromide nasal soln 0.03% (21 1 mcg/spray) ipratropium bromide nasal soln 0.06% (42 1 mcg/spray) Nasal Steroids flunisolide nasal soln 25 mcg/act (0.025%) 1 QL (3 containers / 25 days) fluticasone propionate nasal susp 50 mcg/act 1 QL (1 container / 25 days) triamcinolone acetonide nasal aerosol suspension 55 mcg/act Sympathomimetic Decongestants 1 QL (1 container / 25 days) 91

TYZINE PED DRO 0.05% 3 TYZINE SOL 0.1% 3 NEUROMUSCULAR AGENTS ALS Agents riluzole tab 50 1 OPHTHALMIC AGENTS Artificial Tears and Lubricants LACRISERT MIS 5MG OP 3 Beta-blockers - Ophthalmic betaxolol hcl ophth soln 0.5% 1 BETIMOL SOL 0.5% 3 BETIMOL SOL 0.25% 3 BETOPTIC-S SUS 0.25% OP 2 carteolol hcl ophth soln 1% 1 COMBIGAN SOL 0.2/0.5% 2 dorzolamide hcl-timolol maleate ophth soln 1 22.3-6.8 /ml levobunolol hcl ophth soln 0.5% 1 levobunolol hcl ophth soln 0.25% 1 metipranolol ophth soln 0.3% 1 timolol maleate ophth gel forming soln 0.5% 1 timolol maleate ophth gel forming soln 1 0.25% timolol maleate ophth soln 0.5% 1 timolol maleate ophth soln 0.25% 1 TIMOPTIC OCU SOL 0.5% OP 2 TIMOPTIC OCU SOL 0.25% OP 2 Cycloplegic Mydriatics atropine sulfate ophth soln 1% 1 homatropine hbr ophth soln 5% 1 ISO HOMATROP SOL 2% OP 3 tropicamide ophth soln 0.5% 1 tropicamide ophth soln 1% 1 Miotics PHOSPHOLINE SOL 0.125%OP 3 PILOPINE HS GEL 4% OP 3 Ophthalmic Adrenergic Agents brimonidine tartrate ophth soln 0.2% 1 brimonidine tartrate ophth soln 0.15% 1 Ophthalmic Anti-infectives bacitracin ophth oint 500 unit/gm 1 bacitracin-polymyxin b ophth oint 1 BESIVANCE SUS 0.6% 3 CILOXAN OIN 0.3% OP 2 ciprofloxacin hcl ophth soln 0.3% 1 92

erythromycin ophth oint 5 /gm 1 gatifloxacin ophth soln 0.5% 1 gentamicin sulfate ophth oint 0.3% 1 gentamicin sulfate ophth soln 0.3% 1 ilotycin oin op 1 NATACYN SUS 5% OP 2 neomycin-polymy-gramicid op sol 1 1.75-10000-0.025-unt-/ml ofloxacin ophth soln 0.3% 1 polycin oin op 1 polymyxin b-trimethoprim ophth soln 100001 unit/ml-0.1% romycin oin op 1 sulfacetamide sodium ophth soln 10% 1 tobramycin ophth soln 0.3% 1 TOBREX OIN 0.3% OP 2 trifluridine ophth soln 1% 1 VIGAMOX DRO 0.5% 2 ZIRGAN GEL 0.15% 3 Ophthalmic Decongestants naphazoline hcl ophth soln 0.1% 1 phenylephrine hcl ophth soln 2.5% 1 phenylephrine hcl ophth soln 10% 1 Ophthalmic Immunomodulators RESTASIS EMU 0.05% 3 Ophthalmic Steroids ALREX SUS 0.2% 3 bacitracin-polymyxin-neomycin-hc ophth 1 oint 1% BLEPHAMIDE OIN S.O.P. 2 BLEPHAMIDE SUS OP 2 dexamethasone sodium phosphate ophth 1 soln 0.1% DUREZOL EMU 0.05% 3 fluorometholone ophth susp 0.1% 1 LOTEMAX GEL 0.5% 3 LOTEMAX OIN 0.5% 3 LOTEMAX SUS 0.5% 3 neomycin-polymyxin-dexamethasone 1 ophth oint 0.1% neomycin-polymyxin-dexamethasone 1 ophth susp 0.1% neomycin-polymyxin-hc ophth susp 1 poly-dex oin 0.1% op 1 PRED MILD SUS 0.12% OP 2 PRED SOD PHO SOL 1% OP 2 93

prednisolone acetate ophth susp 1% 1 sulfacetamide sodium-prednisolone ophth 1 soln 10-0.23(0.25)% TOBRADEX OIN 0.3-0.1% 2 tobramycin-dexamethasone ophth susp 1 0.3-0.1% VEXOL SUS 1% OP 3 Ophthalmics - Misc. ALOCRIL SOL 2% 3 azelastine hcl ophth soln 0.05% 1 ST AZOPT SUS 1% OP 3 BEPREVE DRO 1.5% 3 ST bromfenac sodium ophth soln 0.09% (base 1 equiv) (once-daily) bromfenac sodium ophth soln 0.09% (base 1 equivalent) cromolyn sodium ophth soln 4% 1 diclofenac sodium ophth soln 0.1% 1 dorzolamide hcl ophth soln 2% 1 EMADINE SOL 0.05% OP 3 ST epinastine hcl ophth soln 0.05% 1 ST flurbiprofen sodium ophth soln 0.03% 1 ketorolac tromethamine ophth soln 0.4% 1 ketorolac tromethamine ophth soln 0.5% 1 ketotifen fumarate ophth soln 0.025% (base 1 OTC equiv) LASTACAFT SOL 0.25% 3 ST NEVANAC SUS 0.1% 3 PATADAY SOL 0.2% 3 ST PATANOL SOL 0.1% OP 3 ST Prostaglandins - Ophthalmic bimatoprost ophth soln 0.03% 1 latanoprost ophth soln 0.005% 1 LUMIGAN SOL 0.01% 3 ST; PA** TRAVATAN Z DRO 0.004% 3 ST; PA** ZIOPTAN DRO 0.0015% 3 ST; PA** OTIC AGENTS Otic Agents - Miscellaneous acetic acid 2% in aluminum acetate otic soln 1 acetic acid otic soln 2% 1 Otic Anti-infectives ofloxacin otic soln 0.3% 1 Otic Combinations CIPRO HC SUS OTIC 3 CIPRODEX SUS 0.3-0.1% 2 CORTISPORIN SUS -TC OTIC 3 94

neomycin-polymyxin-hc otic soln 1% 1 neomycin-polymyxin-hc otic susp 3.5 1 /ml-10000 unit/ml-1% Otic Steroids fluocinolone acetonide (otic) oil 0.01% 1 hydrocortisone w/ acetic acid otic soln 1-2% 1 PASSIVE IMMUNIZING AGENTS Immune Serums GAMASTAN S/D INJ 3 PA GAMMAGARD INJ 2.5GM/25 3 PA GAMMAGARD INJ 5GM/50ML 3 PA GAMMAGARD INJ 10GM/100 3 PA GAMMAGARD INJ 20GM/200 3 PA GAMMAKED INJ 1GM/10ML 3 PA PENICILLINS Aminopenicillins amoxicillin (trihydrate) cap 250 1 amoxicillin (trihydrate) cap 500 1 amoxicillin (trihydrate) chew tab 125 1 amoxicillin (trihydrate) chew tab 250 1 amoxicillin (trihydrate) for susp 125 /5ml 1 amoxicillin (trihydrate) for susp 200 /5ml 1 amoxicillin (trihydrate) for susp 250 /5ml 1 amoxicillin (trihydrate) for susp 400 /5ml 1 amoxicillin (trihydrate) tab 500 1 amoxicillin (trihydrate) tab 875 1 ampicillin cap 250 1 ampicillin cap 500 1 ampicillin for susp 125 /5ml 1 ampicillin for susp 250 /5ml 1 Natural Penicillins penicillin v potassium for soln 125 /5ml 1 penicillin v potassium for soln 250 /5ml 1 penicillin v potassium tab 250 1 penicillin v potassium tab 500 1 Penicillin Combinations amoxicillin & k clavulanate chew tab 1 200-28.5 amoxicillin & k clavulanate chew tab 400-571 amoxicillin & k clavulanate for susp 1 200-28.5 /5ml amoxicillin & k clavulanate for susp 1 250-62.5 /5ml amoxicillin & k clavulanate for susp 400-57 1 /5ml 95

amoxicillin & k clavulanate for susp 1 600-42.9 /5ml amoxicillin & k clavulanate tab 250-125 1 amoxicillin & k clavulanate tab 500-125 1 amoxicillin & k clavulanate tab 875-125 1 amoxicillin & k clavulanate tab sr 12hr 1 1000-62.5 AUGMENTIN SUS 125/5ML 2 Penicillinase-Resistant Penicillins dicloxacillin sodium cap 250 1 dicloxacillin sodium cap 500 1 PROGESTINS Progestins medroxyprogesterone acetate tab 2.5 1 medroxyprogesterone acetate tab 5 1 medroxyprogesterone acetate tab 10 1 norethindrone acetate tab 5 1 progesterone micronized cap 100 1 progesterone micronized cap 200 1 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. Agents for Chemical Dependency acamprosate calcium tab delayed release 1 PA 333 disulfiram tab 250 1 disulfiram tab 500 1 Anti-Cataplectic Agents XYREM SOL 500MG/ML 2 PA Antidementia Agents donepezil hydrochloride orally 1 disintegrating tab 5 donepezil hydrochloride orally 1 disintegrating tab 10 donepezil hydrochloride tab 5 1 donepezil hydrochloride tab 10 1 donepezil hydrochloride tab 23 1 EXELON SOL 2MG/ML 2 PA galantamine hydrobromide cap sr 24hr 8 1 galantamine hydrobromide cap sr 24hr 16 1 galantamine hydrobromide cap sr 24hr 24 1 galantamine hydrobromide oral soln 4 1 /ml galantamine hydrobromide tab 4 1 galantamine hydrobromide tab 8 1 96

galantamine hydrobromide tab 12 1 NAMENDA SOL 10MG/5ML 2 PA; PA applies for members age 30 and younger NAMENDA TAB 5-10MG 3 PA; PA applies for members age 30 and younger NAMENDA TAB 5MG 2 PA; PA applies for members age 30 and younger NAMENDA TAB 10MG 2 PA; PA applies for members age 30 and younger NAMENDA XR CAP 7MG 2 PA; PA applies for members age 30 and younger NAMENDA XR CAP 14MG 2 PA; PA applies for members age 30 and younger NAMENDA XR CAP 21MG 2 PA; PA applies for members age 30 and younger NAMENDA XR CAP 28MG 2 PA; PA applies for members age 30 and younger NAMENDA XR CAP TITRATIO 2 PA; PA applies for members age 30 and younger rivastigmine tartrate cap 1.5 1 PA rivastigmine tartrate cap 3 1 PA rivastigmine tartrate cap 4.5 1 PA rivastigmine tartrate cap 6 1 PA Fibromyalgia Agents SAVELLA MIS TITR PAK 3 SAVELLA TAB 12.5MG 3 SAVELLA TAB 25MG 3 SAVELLA TAB 50MG 3 SAVELLA TAB 100MG 3 Movement Disorder Drug Therapy XENAZINE TAB 12.5MG 3 PA XENAZINE TAB 25MG 3 PA Multiple Sclerosis Agents AUBAGIO TAB 7MG 3 PA, ST AUBAGIO TAB 14MG 3 PA, ST AVONEX KIT 30MCG 3 PA AVONEX PREFL KIT 30MCG 3 PA BETASERON INJ 0.3MG 3 PA 97

COPAXONE INJ 20MG/ML 3 PA COPAXONE INJ 40MG/ML 3 PA EXTAVIA INJ 0.3MG 3 PA GILENYA CAP 0.5MG 3 PA TECFIDERA CAP 120MG 3 PA TECFIDERA CAP 240MG 3 PA TECFIDERA MIS STARTER 3 PA TYSABRI INJ 300/15ML 3 PA, ST Pseudobulbar Affect (PBA) Agents NUEDEXTA CAP 20-10MG 3 Psychotherapeutic and Neurological Agents - Misc. ergoloid mesylates tab 1 1 ORAP TAB 1MG 3 ORAP TAB 2MG 3 Restless Leg Syndrome (RLS) Agents HORIZANT TAB 300MG 3 ST; PA** HORIZANT TAB 600MG 3 ST; PA** Smoking Deterrents buproban tab 150 0 $0 limited to 2 treatment cycles/year CHANTIX PAK 0.5& 1MG 0 $0 limited to 2 treatment cycles/year CHANTIX PAK 1MG 0 $0 limited to 2 treatment cycles/year CHANTIX TAB 0.5MG 0 $0 limited to 2 treatment cycles/year nicotine polacrilex gum 2 0 OTC; $0 limited to 2 treatment cycles/year nicotine polacrilex gum 4 0 OTC; $0 limited to 2 treatment cycles/year nicotine polacrilex lozenge 2 0 OTC; $0 limited to 2 treatment cycles/year nicotine polacrilex lozenge 4 0 OTC; $0 limited to 2 treatment cycles/year nicotine td patch 24hr 7 /24hr 0 OTC; $0 limited to 2 treatment cycles/year nicotine td patch 24hr 14 /24hr 0 OTC; $0 limited to 2 treatment cycles/year nicotine td patch 24hr 21 /24hr 0 OTC; $0 limited to 2 treatment cycles/year NICOTROL INH 0 QL (max 168 days per year); OTC; $0 limited to 2 treatment cycles/year NICOTROL NS SPR 10MG/ML 0 QL (max 168 days per year); OTC; $0 limited to 2 treatment cycles/year 98

sm nicotine dis 7/24hr 0 OTC; $0 limited to 2 treatment cycles/year sm nicotine dis 14/24h 0 OTC; $0 limited to 2 treatment cycles/year sm nicotine dis 21 0 OTC; $0 limited to 2 treatment cycles/year thrive gum 4 mint 0 OTC; $0 limited to 2 treatment cycles/year RESPIRATORY AGENTS - MISC. Alpha-Proteinase Inhibitor (Human) ARALAST NP INJ 400MG 3 PA ARALAST NP INJ 500MG 3 PA ARALAST NP INJ 800MG 3 PA GLASSIA INJ 3 PA PROLASTIN-C INJ 1000MG 3 PA ZEMAIRA INJ 1000MG 3 PA SULFONAMIDES Sulfonamides SULFADIAZINE TAB 500MG 3 TETRACYCLINES Tetracyclines avidoxy tab 100 1 demeclocycline hcl tab 150 1 demeclocycline hcl tab 300 1 doxycycline hyclate cap 50 1 doxycycline hyclate cap 100 1 doxycycline hyclate tab 20 1 doxycycline hyclate tab 100 1 doxycycline monohydrate cap 50 1 doxycycline monohydrate cap 75 1 doxycycline monohydrate cap 100 1 doxycycline monohydrate cap 150 1 doxycycline monohydrate for susp 25 1 /5ml doxycycline monohydrate tab 50 1 doxycycline monohydrate tab 75 1 doxycycline monohydrate tab 150 1 minocycline hcl cap 50 1 minocycline hcl cap 75 1 minocycline hcl cap 100 1 minocycline hcl tab 50 1 minocycline hcl tab 75 1 minocycline hcl tab 100 1 minocycline hcl tab sr 24hr 45 1 minocycline hcl tab sr 24hr 90 1 minocycline hcl tab sr 24hr 135 1 99

morgidox cap 1x100 1 tetracycline hcl cap 250 1 tetracycline hcl cap 500 1 THYROID AGENTS Antithyroid Agents methimazole tab 5 1 methimazole tab 10 1 propylthiouracil tab 50 1 Thyroid Hormones levothyroxine sodium tab 25 mcg 1 levothyroxine sodium tab 50 mcg 1 levothyroxine sodium tab 75 mcg 1 levothyroxine sodium tab 88 mcg 1 levothyroxine sodium tab 100 mcg 1 levothyroxine sodium tab 112 mcg 1 levothyroxine sodium tab 125 mcg 1 levothyroxine sodium tab 137 mcg 1 levothyroxine sodium tab 150 mcg 1 levothyroxine sodium tab 175 mcg 1 levothyroxine sodium tab 200 mcg 1 levothyroxine sodium tab 300 mcg 1 levoxyl tab 25mcg 1 levoxyl tab 50mcg 1 levoxyl tab 75mcg 1 levoxyl tab 88mcg 1 levoxyl tab 100mcg 1 levoxyl tab 112mcg 1 levoxyl tab 125mcg 1 levoxyl tab 137mcg 1 levoxyl tab 150mcg 1 levoxyl tab 175mcg 1 levoxyl tab 200mcg 1 liothyronine sodium tab 5 mcg 1 liothyronine sodium tab 25 mcg 1 liothyronine sodium tab 50 mcg 1 SYNTHROID TAB 25MCG 2 SYNTHROID TAB 50MCG 2 SYNTHROID TAB 75MCG 2 SYNTHROID TAB 88MCG 2 SYNTHROID TAB 100MCG 2 SYNTHROID TAB 112MCG 2 SYNTHROID TAB 125MCG 2 SYNTHROID TAB 137MCG 2 SYNTHROID TAB 150MCG 2 SYNTHROID TAB 175MCG 2 SYNTHROID TAB 200MCG 2 100

SYNTHROID TAB 300MCG 2 unithroid tab 25mcg 1 unithroid tab 50mcg 1 unithroid tab 75mcg 1 unithroid tab 88mcg 1 unithroid tab 100mcg 1 unithroid tab 112mcg 1 unithroid tab 125mcg 1 unithroid tab 200mcg 1 unithroid tab 300mcg 1 TOXOIDS Toxoid Combinations ADACEL INJ 0 BOOSTRIX INJ 0 DAPTACEL INJ 0 $0 copay for members age 18 and younger DIP/TET PED INJ 25-5LFU 0 $0 copay for members age 18 and younger INFANRIX INJ 0 $0 copay for members age 18 and younger KINRIX INJ 0 $0 copay for members age 18 and younger PEDIARIX INJ 0.5ML 0 $0 copay for members age 18 and younger PENTACEL INJ 0 $0 copay for members age 18 and younger TENIVAC INJ 5-2LF 0 TET/DIP TOX INJ 2-2 LF 0 TRIPEDIA SUS P/F 0 $0 copay for members age 18 and younger ULCER DRUGS Antispasmodics chlordiazepoxide hcl-clidinium bromide cap 1 5-2.5 CUVPOSA SOL 1MG/5ML 2 dicyclomine hcl cap 10 1 dicyclomine hcl oral soln 10 /5ml 1 dicyclomine hcl tab 20 1 ed-spaz tab 0.125 1 hyomax-sl sub 0.125 1 hyoscyamine sulfate tab 0.125 1 hyoscyamine sulfate tab disp 0.125 1 hyoscyamine sulfate tab sl 0.125 1 hyoscyamine sulfate tab sr 12hr 0.375 1 methscopolamine bromide tab 2.5 1 methscopolamine bromide tab 5 1 101

nulev tab 0.125 1 oscimin sr tab 0.375 1 oscimin sub 0.125 1 oscimin tab 0.125 1 symax fastab tab 0.125 1 symax-sl sub 0.125 1 H-2 Antagonists cimetidine hcl soln 300 /5ml 1 cimetidine tab 200 1 cimetidine tab 300 1 cimetidine tab 400 1 cimetidine tab 800 1 famotidine for susp 40 /5ml 1 famotidine tab 20 1 famotidine tab 40 1 nizatidine cap 150 1 nizatidine cap 300 1 nizatidine oral soln 15 /ml 1 ranitidine hcl cap 150 1 ranitidine hcl cap 300 1 ranitidine hcl syrup 15 /ml (75 /5ml) 1 ranitidine hcl tab 150 1 ranitidine hcl tab 300 1 Misc. Anti-Ulcer CARAFATE SUS 1GM/10ML 3 sucralfate tab 1 gm 1 Proton Pump Inhibitors DEXILANT CAP 30MG DR 3 QL (90 caps / 365 days), ST; PA** DEXILANT CAP 60MG DR 3 QL (90 caps / 365 days), ST; PA** esomeprazole magnesium cap delayed 1 QL (90 caps / 365 days) release 20 (base eq) esomeprazole magnesium cap delayed 1 QL (90 caps / 365 days) release 40 (base eq) lansoprazole cap 15 dr 1 QL (90 caps / 365 days); OTC lansoprazole cap delayed release 15 1 QL (90 caps / 365 days) lansoprazole cap delayed release 30 1 QL (90 caps / 365 days) NEXIUM 24HR CAP 20MG 1 QL (90 caps / 365 days); OTC NEXIUM CAP 20MG 3 QL (90 caps / 365 days), ST NEXIUM CAP 40MG 3 QL (90 caps / 365 days), ST 102

NEXIUM GRA 2.5MG DR 3 QL (90 packets / 365 days), ST NEXIUM GRA 5MG DR 3 QL (90 packets / 365 days), ST NEXIUM GRA 10MG DR 3 QL (90 packets / 365 days), ST NEXIUM GRA 20MG DR 3 QL (90 packets / 365 days), ST NEXIUM GRA 40MG DR 3 QL (90 packets / 365 days), ST omeprazole cap delayed release 10 1 QL (90 caps / 365 days) omeprazole cap delayed release 20 1 QL (90 caps / 365 days) omeprazole cap delayed release 40 1 QL (90 caps / 365 days) omeprazole magnesium cap dr 20.6 (201 QL (90 caps / 365 days); base equiv) OTC OMEPRAZOLE TAB 20MG 1 QL (90 tabs / 365 days); OTC pantoprazole sodium ec tab 20 (base 1 QL (90 tabs / 365 days) equiv) pantoprazole sodium ec tab 40 (base 1 QL (90 tabs / 365 days) equiv) rabeprazole sodium ec tab 20 1 QL (90 tabs / 365 days) Ulcer Drugs - Prostaglandins misoprostol tab 100 mcg 1 misoprostol tab 200 mcg 1 Ulcer Therapy Combinations omeprazole-sodium bicarbonate cap 1 QL (90 caps / 365 days) 20-1100 omeprazole-sodium bicarbonate cap 1 QL (90 caps / 365 days) 40-1100 URINARY ANTI-INFECTIVES Urinary Anti-infectives MACRODANTIN CAP 25MG 2 PA; High Risk Medications require PA for members age 65 and ; PA applies to greater than cumulative 90 days of therapy per year methenamine hippurate tab 1 gm 1 MONUROL PAK GRANULES 3 nitrofurantoin macrocrystalline cap 50 1 PA; High Risk Medications require PA for members age 65 and ; PA applies to greater than cumulative 90 days of therapy per year 103

nitrofurantoin macrocrystalline cap 100 1 PA; High Risk Medications require PA for members age 65 and ; PA applies to greater than cumulative 90 days of therapy per year nitrofurantoin monohydrate macrocrystalline cap 100 1 PA; High Risk Medications require PA for members age 65 and ; PA applies to greater than cumulative 90 days of therapy per year URINARY ANTISPASMODICS Beta-3 Adrenergic Agonists MYRBETRIQ TAB 25MG 3 ST; PA** MYRBETRIQ TAB 50MG 3 ST; PA** Urinary Antispasmodics bethanechol chloride tab 5 1 bethanechol chloride tab 10 1 bethanechol chloride tab 25 1 bethanechol chloride tab 50 1 ENABLEX TAB 7.5MG 3 ST; PA** ENABLEX TAB 15MG 3 ST; PA** flavoxate hcl tab 100 1 GELNIQUE GEL 3% 3 ST; PA** oxybutynin chloride syrup 5 /5ml 1 oxybutynin chloride tab 5 1 oxybutynin chloride tab sr 24hr 5 1 oxybutynin chloride tab sr 24hr 10 1 oxybutynin chloride tab sr 24hr 15 1 OXYTROL DIS 3.9MG/24 3 ST; PA** tolterodine tartrate cap sr 24hr 2 1 tolterodine tartrate cap sr 24hr 4 1 tolterodine tartrate tab 1 1 tolterodine tartrate tab 2 1 TOVIAZ TAB 4MG 3 ST; PA** TOVIAZ TAB 8MG 3 ST; PA** trospium chloride cap sr 24hr 60 1 trospium chloride tab 20 1 VESICARE TAB 5MG 3 ST; PA** VESICARE TAB 10MG 3 ST; PA** VACCINES Bacterial Vaccines 104

ACTHIB INJ 0 $0 copay for members age 18 and younger BEXSERO INJ 0 HIBERIX SOL 10MCG 0 $0 copay for members age 18 and younger MENACTRA INJ 0 MENHIBRIX INJ 0 MENOMUNE INJ A/C/Y/W 0 MENVEO INJ 0 PEDVAX HIB INJ 0 $0 copay for members age 18 and younger PNEUMOVAX 23 INJ 25/0.5 0 PREVNAR 13 INJ 0 TRUMENBA INJ 0 Mixed Vaccine Combinations COMVAX INJ 0 $0 copay for members age 18 and younger Viral Vaccines AFLURIA INJ 2014-15 0 CERVARIX INJ 0 ENGERIX-B INJ 10/0.5ML 0 ENGERIX-B INJ 20MCG/ML 0 FLUBLOK SOL 2014-15 0 FLUCELVAX INJ 2014-15 0 FLULAVAL QUA INJ 2014-15 0 FLUMIST QUAD SUS 2014-15 0 FLUZONE INJ INTRADRM 0 FLUZONE QUAD INJ 14-15 0 GARDASIL 9 INJ 0 GARDASIL INJ 0 HAVRIX INJ 720UNIT 0 HAVRIX INJ 1440UNIT 0 INFLUENZA A SPR 09 H1N1 0 IPOL INJ INACTIVE 0 $0 copay for members age 18 and younger M-M-R II INJ LIVE 0 PROQUAD INJ 0 RECOMBIVA HB INJ 5MCG/0.5 0 RECOMBIVA HB INJ 10MCG/ML 0 RECOMBIVA-HB INJ 40MCG/ML 0 ROTARIX SUS 0 $0 copay for members age 18 and younger ROTATEQ SOL 0 $0 copay for members age 18 and younger TWINRIX INJ 0 VAQTA INJ 25/0.5ML 0 105

VAQTA INJ 50UNT/ML 0 VARIVAX INJ 0 ZOSTAVAX INJ 0 $0 copay for members age 19 and VAGINAL PRODUCTS Spermicides CONCEPTROL GEL 4% 0 OTC ENCARE SUP 100MG 0 OTC GYNOL II GEL 3% 0 OTC SHUR-SEAL GEL 2% 0 OTC VCF VAGINAL AER CONTRACP 0 OTC VCF VAGINAL MIS CONTRACP 0 OTC Vaginal Anti-infectives CLEOCIN SUP 100MG 2 clindamycin phosphate vaginal cream 2% 1 metronidazole vaginal gel 0.75% 1 miconazole 3 kit combo pk 1 miconazole 3 sup 200 1 terconazole vaginal cream 0.4% 1 terconazole vaginal suppos 80 1 vandazole gel 0.75% 1 zazole cre 0.4% 1 zazole cre 0.8% 1 zazole sup 80 1 Vaginal Estrogens ESTRACE VAG CRE 0.1MG/GM 2 PREMARIN VAG CRE 0.625MG 3 Vaginal Progestins CRINONE GEL 4% VAG 2 CRINONE GEL 8% VAG 2 VASOPRESSORS Anaphylaxis Therapy Agents epinephrine solution auto-injector 0.3 1 /0.3ml (1:1000) epinephrine solution auto-injector 0.15 1 /0.15ml (1:1000) EPIPEN 2-PAK INJ 0.3MG 2 EPIPEN-JR INJ 2-PAK 2 Vasopressors midodrine hcl tab 2.5 1 midodrine hcl tab 5 1 midodrine hcl tab 10 1 VITAMINS Oil Soluble Vitamins 106

bio-d-mulsio liq 400unit 0 OTC; $0 applies for ages 65 and child vit d chw 400unit 0 OTC; $0 applies for ages 65 and CHOLECALCIFEROL CAP 400 UNIT 0 OTC; $0 applies for ages 65 and D-VI-SOL LIQ 400UNIT 0 OTC; $0 applies for ages 65 and ergocalciferol cap 50000 unit 1 MEPHYTON TAB 5MG 2 pedia d-vite dro 400unit 0 OTC; $0 applies for ages 65 and sm vitamin d tab 400unit 0 OTC; $0 applies for ages 65 and VITAMIN D2 TAB 400UNIT 0 OTC; $0 applies for ages 65 and VITAMIN D3 LIQ 1000UNIT 0 OTC; $0 applies for ages 65 and 107

Index 8 8-MOP CAP 10MG... 69 A abacavir sulfate tab 300 (base equiv)... 51 abacavir sulfate-lamivudine-zidovudine tab 300-150-300... 51 ABELCET INJ 5MG/ML... 30 ABILIFY DISC TAB 10MG... 50 ABILIFY DISC TAB 15MG... 51 ABILIFY SOL 1MG/ML... 51 ABRAXANE INJ 100MG... 45 ABREVA CRE 10%... 69 acamprosate calcium tab delayed release 333... 97 ACANYA GEL 1.2-2.5%... 65 acarbose tab 100... 26 acarbose tab 25... 26 acarbose tab 50... 26 acd/fluoride dro 0.25... 90 acebutolol hcl cap 200... 55 acebutolol hcl cap 400... 55 acetaminophen w/ codeine soln 120-12 /5ml... 9 acetaminophen w/ codeine tab 300-15... 9 acetaminophen w/ codeine tab 300-30... 9 acetaminophen w/ codeine tab 300-60... 9 acetazolamide sodium for inj 500.. 73 acetic acid 2% in aluminum acetate otic soln... 95 acetic acid otic soln 2%... 95 acetylcysteine inhal soln 10%... 65 acetylcysteine inhal soln 20%... 65 acitretin cap 10... 69 acitretin cap 17.5... 69 acitretin cap 25... 69 acne medicat gel 5%... 65 ACNE MEDICAT LOT 10%... 65 ACNE MEDICAT LOT 5%... 65 ACTEMRA INJ 162/0.9... 4 ACTEMRA INJ 200/10ML... 4 ACTEMRA INJ 400/20ML... 4 ACTEMRA INJ 80MG/4ML... 4 ACTHIB INJ... 106 acticin cre 5%... 72 ACTONEL TAB 30MG... 75 ACTONEL TAB 35MG... 75 ACTONEL TAB 5MG... 75 acyclovir cap 200... 54 acyclovir susp 200 /5ml... 54 acyclovir tab 400... 54 acyclovir tab 800... 54 ADACEL INJ... 102 adapalene cream 0.1%... 65 adapalene gel 0.1%... 65 adapalene gel 0.3%... 65 ADCIRCA TAB 20MG... 59 adefovir dipivoxil tab 10... 53 adriamycin inj 10... 42 ADRIAMYCIN INJ 20MG... 42 adrucil inj 2.5g/50m... 41 adrucil inj 500/10ml... 41 ADULT RESPIRATORY MASK... 87 ADVAIR DISKU AER 100/50... 16 afeditab tab 30 cr... 56 afeditab tab 60 cr... 56 AFINITOR DIS TAB 2MG... 43 AFINITOR DIS TAB 3MG... 43 AFINITOR DIS TAB 5MG... 43 AFINITOR TAB 10MG... 43 AFINITOR TAB 2.5MG... 43 AFINITOR TAB 5MG... 43 AFINITOR TAB 7.5MG... 43 AFLURIA INJ 2014-15... 106 AGGRENOX CAP 25-200MG... 82 ALBENZA TAB 200MG... 11 albuterol sulfate soln nebu 0.083% (2.5 /3ml)... 16 albuterol sulfate soln nebu 0.5% (5 /ml)... 16 albuterol sulfate soln nebu 0.63 /3ml (base equiv)... 16 albuterol sulfate soln nebu 1.25 /3ml (base equiv)... 16 albuterol sulfate syrup 2 /5ml... 16 albuterol sulfate tab 2... 16 albuterol sulfate tab 4... 16 albuterol sulfate tab sr 12hr 8... 16 alclometasone dipropionate cream 0.05%... 70 alclometasone dipropionate oint 0.05% 108

... 70 ALCOHOL PREP WIPES AND SWABS... 87 ALDACTAZIDE TAB 50/50... 73 alendronate sodium oral soln 70 /75ml... 75 alendronate sodium tab 10... 75 alendronate sodium tab 35... 75 alendronate sodium tab 40... 75 alendronate sodium tab 5... 75 alendronate sodium tab 70... 75 ALFERON N INJ 5MU/ML... 45 alfuzosin hcl tab sr 24hr 10... 81 ALIMTA INJ 100MG... 41 ALIMTA INJ 500MG... 41 ALINIA SUS 100/5ML... 12 ALINIA TAB 500MG... 12 ALKERAN TAB 2MG... 40 all day allg cap 10... 31 all day allg chw 10... 31 all day allg chw 5... 31 allergy relf tab 10... 32 allergy tab 10... 32 ALLFEN CDX LIQ... 64 allopurinol tab 100... 82 allopurinol tab 300... 82 ALOCRIL SOL 2%... 95 ALOXI INJ 0.25MG/5... 30 alphatrex gel 0.05%... 70 ALPRAZOLAM CON 1 MG/ML... 13 alprazolam orally disintegrating tab 0.25... 13 alprazolam orally disintegrating tab 0.5... 13 alprazolam orally disintegrating tab 1... 13 alprazolam orally disintegrating tab 2... 13 alprazolam tab 0.25... 14 alprazolam tab 0.5... 13 alprazolam tab 1... 14 alprazolam tab 2... 14 ALREX SUS 0.2%... 94 ALTABAX OIN 1%... 67 altavera tab... 61 ALVESCO AER 160MCG... 15 ALVESCO AER 80MCG... 15 alyacen tab 1/35... 61 alyacen tab 7/7/7... 61 amantadine hcl cap 100... 47 amantadine hcl syrup 50 /5ml... 47 amantadine hcl tab 100... 47 amcinonide cream 0.1%... 70 amcinonide lotion 0.1%... 70 AMCINONIDE OIN 0.1%... 70 amethia tab... 61 amethyst tab 90-20mcg... 61 amifostine crystalline for inj 500... 45 amiloride & hydrochlorothiazide tab 5-50... 73 amiloride hcl tab 5... 74 amiodarone hcl tab 200... 14 amiodarone hcl tab 400... 14 AMITIZA CAP 24MCG... 80 AMITIZA CAP 8MCG... 80 amitriptyline hcl tab 10... 23 amitriptyline hcl tab 100... 24 amitriptyline hcl tab 150... 24 amitriptyline hcl tab 25... 23 amitriptyline hcl tab 50... 24 amitriptyline hcl tab 75... 24 amlactin lot 12%... 72 amlodipine besylate tab 10... 57 amlodipine besylate tab 2.5... 57 amlodipine besylate tab 5... 57 amlodipine besylate-atorvastatin calcium tab 10-10... 59 amlodipine besylate-atorvastatin calcium tab 10-20... 59 amlodipine besylate-atorvastatin calcium tab 10-40... 59 amlodipine besylate-atorvastatin calcium tab 10-80... 59 amlodipine besylate-atorvastatin calcium tab 2.5-10... 58 amlodipine besylate-atorvastatin calcium tab 2.5-20... 58 amlodipine besylate-atorvastatin calcium tab 2.5-40... 58 amlodipine besylate-atorvastatin calcium tab 5-10... 59 amlodipine besylate-atorvastatin calcium tab 5-20... 59 amlodipine besylate-atorvastatin calcium tab 5-40... 59 amlodipine besylate-atorvastatin calcium tab 5-80... 59 109

amlodipine besylate-benazepril hcl cap 10-20... 36 amlodipine besylate-benazepril hcl cap 10-40... 36 amlodipine besylate-benazepril hcl cap 2.5-10... 36 amlodipine besylate-benazepril hcl cap 5-10... 36 amlodipine besylate-benazepril hcl cap 5-20... 36 amlodipine besylate-benazepril hcl cap 5-40... 36 amlodipine besylate-valsartan tab 10-160... 36 amlodipine besylate-valsartan tab 10-320... 36 amlodipine besylate-valsartan tab 5-160... 36 amlodipine besylate-valsartan tab 5-320... 36 amlodipine-valsartan-hydrochlorothiazide tab 10-160-12.5... 36 amlodipine-valsartan-hydrochlorothiazide tab 10-160-25... 36 amlodipine-valsartan-hydrochlorothiazide tab 10-320-25... 36 amlodipine-valsartan-hydrochlorothiazide tab 5-160-12.5... 36 amlodipine-valsartan-hydrochlorothiazide tab 5-160-25... 36 amnesteem cap 10... 65 amnesteem cap 20... 65 amnesteem cap 40... 65 amoxapine tab 100... 24 amoxapine tab 150... 24 amoxapine tab 25... 24 amoxapine tab 50... 24 amoxicillin & k clavulanate chew tab 200-28.5... 96 amoxicillin & k clavulanate chew tab 400-57... 96 amoxicillin & k clavulanate for susp 200-28.5 /5ml... 96 amoxicillin & k clavulanate for susp 250-62.5 /5ml... 97 amoxicillin & k clavulanate for susp 400-57 /5ml... 97 amoxicillin & k clavulanate for susp 600-42.9 /5ml... 97 amoxicillin & k clavulanate tab 250-125... 97 amoxicillin & k clavulanate tab 500-125... 97 amoxicillin & k clavulanate tab 875-125... 97 amoxicillin & k clavulanate tab sr 12hr 1000-62.5... 97 amoxicillin (trihydrate) cap 250... 96 amoxicillin (trihydrate) cap 500... 96 amoxicillin (trihydrate) chew tab 125... 96 amoxicillin (trihydrate) chew tab 250... 96 amoxicillin (trihydrate) for susp 125 /5ml... 96 amoxicillin (trihydrate) for susp 200 /5ml... 96 amoxicillin (trihydrate) for susp 250 /5ml... 96 amoxicillin (trihydrate) for susp 400 /5ml... 96 amoxicillin (trihydrate) tab 500... 96 amoxicillin (trihydrate) tab 875... 96 amphetamine-dextroamphetamine cap sr 24hr 10... 1 amphetamine-dextroamphetamine cap sr 24hr 15... 1 amphetamine-dextroamphetamine cap sr 24hr 20... 1 amphetamine-dextroamphetamine cap sr 24hr 25... 1 amphetamine-dextroamphetamine cap sr 24hr 30... 1 amphetamine-dextroamphetamine cap sr 24hr 5... 1 amphetamine-dextroamphetamine tab 10... 1 amphetamine-dextroamphetamine tab 12.5... 1 amphetamine-dextroamphetamine tab 15... 1 amphetamine-dextroamphetamine tab 20... 1 amphetamine-dextroamphetamine tab 30... 1 amphetamine-dextroamphetamine tab 5 110

... 1 amphetamine-dextroamphetamine tab 7.5... 1 AMPHOTEC INJ 100MG... 30 AMPHOTEC INJ 50MG... 30 amphotericin b for inj 50... 30 ampicillin cap 250... 96 ampicillin cap 500... 96 ampicillin for susp 125 /5ml... 96 ampicillin for susp 250 /5ml... 96 ANADROL-50 TAB 50MG... 10 anagrelide hcl cap 0.5... 82 anagrelide hcl cap 1... 82 anastrozole tab 1... 42 ANDRODERM DIS 2MG/24HR... 10 ANDRODERM DIS 4MG/24HR... 10 android cap 10... 10 anti-diarrhe tab 2... 29 antifungal cre 1%... 68 antifungal cre 2%... 68 anti-fungal pow 1%... 68 ANTIVERT TAB 50MG... 30 apexicon oin 0.05%... 70 APIDRA INJ SOLOSTAR... 28 APIDRA INJ U-100... 28 APOKYN INJ 10MG/ML... 47 apri tab... 61 APRISO CAP 0.375GM... 81 APTIVUS CAP 250MG... 51 APTIVUS SOL... 51 ARALAST NP INJ 400MG... 100 ARALAST NP INJ 500MG... 100 ARALAST NP INJ 800MG... 100 aranelle tab... 61 ARANESP INJ 100MCG... 83 ARANESP INJ 10MCG... 83 ARANESP INJ 150MCG... 83 ARANESP INJ 200MCG... 83 ARANESP INJ 25MCG... 83 ARANESP INJ 300MCG... 83 ARANESP INJ 40MCG... 83 ARANESP INJ 500MCG... 83 ARANESP INJ 60MCG... 83 argatroban inj 100 /ml (concentrate for iv infusion)... 18 ARGATROBAN INJ 125/125... 18 ARGATROBAN INJ 250/250... 18 aripiprazole tab 10... 51 aripiprazole tab 15... 51 aripiprazole tab 2... 51 aripiprazole tab 20... 51 aripiprazole tab 30... 51 aripiprazole tab 5... 51 ARRANON INJ 5MG/ML... 41 ASMANEX 120 AER 220MCG... 15 ASMANEX 30 AER 110MCG... 15 ASMANEX 60 AER 220MCG... 15 ASMANEX HFA AER 100 MCG... 15 ASMANEX HFA AER 200 MCG... 15 aspirin chew tab 81... 6 aspirin low tab 81 ec... 6 aspirin tab 325... 6 ASPIRIN TAB 81 MG... 6 aspirin tab delayed release 325... 6 atenolol & chlorthalidone tab 100-25... 36 atenolol & chlorthalidone tab 50-25... 36 atenolol tab 100... 55 atenolol tab 25... 55 atenolol tab 50... 55 ath foot spr aer 1%... 68 atorvastatin calcium tab 10 (base equivalent)... 33 atorvastatin calcium tab 20 (base equivalent)... 33 atorvastatin calcium tab 40 (base equivalent)... 33 atorvastatin calcium tab 80 (base equivalent)... 33 atovaquone-proguanil hcl tab 250-100... 39 atovaquone-proguanil hcl tab 62.5-25... 39 ATRIPLA TAB... 51 atropine sulfate ophth soln 1%... 93 ATROVENT HFA AER 17MCG... 15 AUBAGIO TAB 14MG... 99 AUBAGIO TAB 7MG... 98 AUGMENTIN SUS 125/5ML... 97 AVAGE CRE 0.1%... 67 avar-e green cre 10-5%... 65 aviane tab... 61 avidoxy tab 100... 100 avita cre 0.025%... 65 avita gel 0.025%... 65 111

AVODART CAP 0.5MG... 81 AVONEX KIT 30MCG... 99 AVONEX PREFL KIT 30MCG... 99 AXERT TAB 12.5MG... 87 AXERT TAB 6.25MG... 87 AXIRON SOL 30MG/ACT... 10 azacitidine for inj 100... 41 azathioprine tab 50... 54 azelastine hcl nasal spray 0.1% (137 mcg/spray)... 92 azelastine hcl nasal spray 0.15% (205.5 mcg/spray)... 92 azelastine hcl ophth soln 0.05%... 95 AZELEX CRE 20%... 65 AZILECT TAB 0.5MG... 48 AZILECT TAB 1MG... 48 azithromycin for susp 100 /5ml... 85 azithromycin for susp 200 /5ml... 85 azithromycin powd pack for susp 1 gm 85 azithromycin tab 250... 85 azithromycin tab 500... 85 azithromycin tab 600... 86 AZOPT SUS 1% OP... 95 aztreonam for inj 1 gm... 11 aztreonam for inj 2 gm... 11 azurette tab 28 day... 61 B bacitracin oin 500/gm... 67 bacitracin ophth oint 500 unit/gm... 93 bacitracin-polymyxin b ophth oint... 93 bacitracin-polymyxin-neomycin-hc ophth oint 1%... 94 baclofen tab 10... 91 baclofen tab 20... 91 balsalazide disodium cap 750... 81 BANZEL SUS 40MG/ML... 19 BANZEL TAB 200MG... 19 BANZEL TAB 400MG... 19 BARACLUDE SOL.05MG/ML... 53 benazepril & hydrochlorothiazide tab 10-12.5... 36 benazepril & hydrochlorothiazide tab 20-12.5... 37 benazepril & hydrochlorothiazide tab 20-25... 37 benazepril & hydrochlorothiazide tab 5-6.25... 36 benazepril hcl tab 10... 34 benazepril hcl tab 20... 34 benazepril hcl tab 40... 34 benazepril hcl tab 5... 34 BENICAR TAB 20MG... 35 BENICAR TAB 40MG... 35 BENICAR TAB 5MG... 35 BENZAMYCIN GEL PAK... 65 benzashave cre 10%... 65 benzepro aer 5.3%... 65 benzepro sc aer 9.8%... 65 BENZIQ GEL 5.25%... 65 BENZIQ LS GEL 2.75%... 65 benzonatate cap 100... 64 benzonatate cap 200... 64 benzoyl per gel 10%... 65 BENZOYL PER GEL 2.5%... 65 benzoyl per liq 10% wash... 65 benzoyl per liq 5% wash... 65 benzoyl per lot 4%... 65 benzoyl per lot 6%... 65 benzoyl per lot 8%... 66 benzoyl per lot 9%... 66 benzoyl pero kit acne pck... 66 benzoyl peroxide foam 5.3%... 66 benzoyl peroxide foam 9.8%... 66 benzoyl peroxide gel 5%... 66 benzoyl peroxide-erythromycin gel 5-3%... 66 benztropine mesylate tab 0.5... 46 benztropine mesylate tab 1... 46 benztropine mesylate tab 2... 46 BEPREVE DRO 1.5%... 95 BESIVANCE SUS 0.6%... 93 betamethasone dipropionate augmented cream 0.05%... 70 betamethasone dipropionate augmented lotion 0.05%... 70 betamethasone dipropionate augmented oint 0.05%... 70 betamethasone dipropionate cream 0.05%... 70 betamethasone dipropionate lotion 0.05%... 70 betamethasone dipropionate oint 0.05%... 70 betamethasone valerate aerosol foam 0.12%... 70 betamethasone valerate cream 0.1%. 70 112

betamethasone valerate lotion 0.1%... 70 betamethasone valerate oint 0.1%... 70 BETASERON INJ 0.3MG... 99 betaxolol hcl ophth soln 0.5%... 93 betaxolol hcl tab 10... 55 betaxolol hcl tab 20... 55 bethanechol chloride tab 10... 105 bethanechol chloride tab 25... 105 bethanechol chloride tab 5... 105 bethanechol chloride tab 50... 105 BETIMOL SOL 0.25%... 93 BETIMOL SOL 0.5%... 93 BETOPTIC-S SUS 0.25% OP... 93 BEXSERO INJ... 106 bicalutamide tab 50... 42 BICNU INJ 100MG... 40 BILTRICIDE TAB 600MG... 11 bimatoprost ophth soln 0.03%... 95 bio-d-mulsio liq 400unit... 108 BIO-STATIN CAP 1000000... 31 BIO-STATIN CAP 500000... 31 bisoprolol & hydrochlorothiazide tab 10-6.25... 37 bisoprolol & hydrochlorothiazide tab 2.5-6.25... 37 bisoprolol & hydrochlorothiazide tab 5-6.25... 37 bisoprolol fumarate tab 10... 55 bisoprolol fumarate tab 5... 55 bleomycin sulfate for inj 15 unit... 42 bleomycin sulfate for inj 30 unit... 42 BLEPHAMIDE OIN S.O.P.... 94 BLEPHAMIDE SUS OP... 94 BLOOD GLUCOSE CALIBRATION SOLUTION... 87 BOOSTRIX INJ... 102 BOSULIF TAB 100MG... 43 BOSULIF TAB 500MG... 43 bp gel gel 10%... 66 bp wash liq 10%... 66 bp wash liq 2.5%... 66 bp wash liq 5%... 66 bp wash liq 5.25%... 66 bp wash liq 7%... 66 BPO CLOTHS MIS 3%... 66 BPO CLOTHS MIS 6%... 66 BPO CLOTHS MIS 9%... 66 bpo creamy kit 4% wash... 66 BPO GEL 4%... 66 BPO GEL 8%... 66 bpo-10 wash liq 10%... 66 bpo-5 wash liq 5%... 66 BREO ELLIPTA INH 100-25... 16 BRILINTA TAB 90MG... 82 brimonidine tartrate ophth soln 0.15% 93 brimonidine tartrate ophth soln 0.2%. 93 bromfenac sodium ophth soln 0.09% (base equiv) (once-daily)... 95 bromfenac sodium ophth soln 0.09% (base equivalent)... 95 bromocriptine mesylate cap 5... 47 bromocriptine mesylate tab 2.5... 47 brompheniramine tannate chew tab 12... 31 BROVANA NEB 15MCG... 16 budesonide cap sr 24hr 3... 63 budesonide inhalation susp 0.25 /2ml... 15 budesonide inhalation susp 0.5 /2ml... 15 bumetanide tab 0.5... 74 bumetanide tab 1... 74 bumetanide tab 2... 74 buprenorphine hcl sl tab 2 (base equiv)... 10 buprenorphine hcl sl tab 8 (base equiv)... 10 buprenorphine hcl-naloxone hcl sl tab 2-0.5 (base equiv)... 10 buprenorphine hcl-naloxone hcl sl tab 8-2 (base equiv)... 10 buproban tab 150... 99 bupropion hcl tab 100... 21 bupropion hcl tab 75... 21 bupropion hcl tab sr 12hr 100... 21 bupropion hcl tab sr 12hr 150... 21 bupropion hcl tab sr 12hr 200... 21 bupropion hcl tab sr 24hr 150... 21 bupropion hcl tab sr 24hr 300... 21 buspirone hcl tab 10... 13 buspirone hcl tab 15... 13 buspirone hcl tab 30... 13 buspirone hcl tab 5... 13 buspirone hcl tab 7.5... 13 BUSULFEX INJ 6MG/ML... 40 butalbital-acetaminophen-caffeine cap 113

50-300-40... 6 butalbital-acetaminophen-caffeine cap 50-325-40... 6 butalbital-acetaminophen-caffeine tab 50-325-40... 6 butalbital-aspirin-caffeine cap 50-325-40... 6 butalbital-aspirin-caffeine tab 50-325-40... 6 butorphanol tartrate nasal soln 10 /ml... 10 BYDUREON INJ... 28 BYETTA INJ 10MCG... 28 BYETTA INJ 5MCG... 28 BYSTOLIC TAB 10MG... 56 BYSTOLIC TAB 2.5MG... 55 BYSTOLIC TAB 20MG... 56 BYSTOLIC TAB 5MG... 56 C cabergoline tab 0.5... 76 CAFERGOT TAB 1-100MG... 87 calcipotriene cream 0.005%... 69 calcipotriene oint 0.005%... 69 calcipotriene soln 0.005% (50 mcg/ml)... 69 calcipotriene-betamethasone dipropionate oint 0.005-0.064%... 70 calcitonin (salmon) nasal soln 200 unit/act... 75 calcitriol cap 0.25 mcg... 76 calcitriol cap 0.5 mcg... 76 calcitriol oint 3 mcg/gm... 69 calcitriol oral soln 1 mcg/ml... 76 calcium acetate (phosphate binder) cap 667 (169 ca)... 81 calcium acetate (phosphate binder) tab 667... 81 camila tab 0.35... 63 CAMPTOSAR INJ 300/15ML... 46 CANASA SUP 1000MG... 81 CANCIDAS INJ 50MG... 30 CANCIDAS INJ 70MG... 30 candesartan cilexetil tab 16... 35 candesartan cilexetil tab 32... 35 candesartan cilexetil tab 4... 35 candesartan cilexetil tab 8... 35 candesartan cilexetil-hydrochlorothiazide tab 16-12.5... 37 candesartan cilexetil-hydrochlorothiazide tab 32-12.5... 37 candesartan cilexetil-hydrochlorothiazide tab 32-25... 37 CAPASTAT SUL INJ 1GM... 39 capecitabine tab 150... 41 capecitabine tab 500... 41 CAPITAL/COD SUS 120-12/5... 9 CAPRELSA TAB 100MG... 43 CAPRELSA TAB 300MG... 43 captopril & hydrochlorothiazide tab 25-15... 37 captopril & hydrochlorothiazide tab 25-25... 37 captopril & hydrochlorothiazide tab 50-15... 37 captopril & hydrochlorothiazide tab 50-25... 37 captopril tab 100... 34 captopril tab 12.5... 34 captopril tab 25... 34 captopril tab 50... 34 CARAFATE SUS 1GM/10ML... 103 carbamazepine chew tab 100... 19 carbamazepine susp 100 /5ml... 19 carbamazepine tab 200... 19 carbamazepine tab sr 12hr 200... 19 carbamazepine tab sr 12hr 400... 19 carbidopa & levodopa orally disintegrating tab 10-100... 47 carbidopa & levodopa orally disintegrating tab 25-100... 47 carbidopa & levodopa orally disintegrating tab 25-250... 47 carbidopa & levodopa tab 10-100. 47 carbidopa & levodopa tab 25-100. 47 carbidopa & levodopa tab 25-250. 47 carbidopa & levodopa tab cr 25-100... 47 carbidopa & levodopa tab cr 50-200... 47 carbidopa tab 25... 46 carbidopa-levodopa-entacapone tabs 12.5-50-200... 47 carbidopa-levodopa-entacapone tabs 18.75-75-200... 47 carbidopa-levodopa-entacapone tabs 25-100-200... 47 114

carbidopa-levodopa-entacapone tabs 31.25-125-200... 47 carbidopa-levodopa-entacapone tabs 37.5-150-200... 47 carbidopa-levodopa-entacapone tabs 50-200-200... 47 carbinoxamine maleate tab 4... 31 carboplatin iv for inj 150... 40 carboplatin iv soln 150 /15ml... 40 carboplatin iv soln 450 /45ml... 40 carboplatin iv soln 50 /5ml... 40 carboplatin iv soln 600 /60ml... 40 CARDIZEM LA TAB 120MG... 57 CARDURA XL TAB 4MG... 81 CARDURA XL TAB 8MG... 81 carisoprodol tab 250... 91 carisoprodol tab 350... 91 carteolol hcl ophth soln 1%... 93 cartia xt cap 120/24hr... 57 cartia xt cap 180/24hr... 57 cartia xt cap 240/24hr... 57 cartia xt cap 300/24hr... 57 carvedilol tab 12.5... 55 carvedilol tab 25... 55 carvedilol tab 3.125... 55 carvedilol tab 6.25... 55 caziant pak... 61 cefaclor cap 250... 60 cefaclor cap 500... 60 CEFACLOR ER TAB 500MG... 60 cefaclor for susp 125 /5ml... 60 cefaclor for susp 250 /5ml... 60 cefaclor for susp 375 /5ml... 60 cefadroxil cap 500... 59 cefadroxil for susp 250 /5ml... 59 cefadroxil for susp 500 /5ml... 59 cefadroxil tab 1 gm... 59 cefdinir cap 300... 60 cefdinir for susp 125 /5ml... 60 cefdinir for susp 250 /5ml... 60 cefepime hcl for inj 1 gm... 60 cefepime hcl for inj 2 gm... 60 CEFEPIME INJ 1GM... 61 CEFEPIME INJ 2GM... 61 cefixime for susp 100 /5ml... 60 cefixime for susp 200 /5ml... 60 cefpodoxime proxetil for susp 100 /5ml... 60 cefpodoxime proxetil for susp 50 /5ml... 60 cefpodoxime proxetil tab 100... 60 cefpodoxime proxetil tab 200... 60 cefprozil for susp 125 /5ml... 60 cefprozil for susp 250 /5ml... 60 cefprozil tab 250... 60 cefprozil tab 500... 60 ceftazidime for inj 2 gm... 60 CEFTAZIDIME INJ 100GM... 60 CEFTIN SUS 250/5ML... 60 ceftriaxone sodium for inj 1 gm... 60 ceftriaxone sodium for inj 10 gm... 60 ceftriaxone sodium for inj 2 gm... 60 ceftriaxone sodium for inj 250... 60 ceftriaxone sodium for inj 500... 60 ceftriaxone sodium for iv soln 1 gm... 60 ceftriaxone sodium for iv soln 2 gm... 60 cefuroxime axetil for susp 125 /5ml 60 cefuroxime axetil tab 250... 60 cefuroxime axetil tab 500... 60 celecoxib cap 100... 4 celecoxib cap 200... 4 celecoxib cap 400... 4 celecoxib cap 50... 4 CENESTIN TAB 0.3MG... 77 CENESTIN TAB 0.45MG... 77 CENESTIN TAB 0.625MG... 77 CENESTIN TAB 0.9MG... 77 CENESTIN TAB 1.25MG... 77 CENTANY AT KIT 2%... 67 cephalexin cap 250... 59 cephalexin cap 500... 59 cephalexin cap 750... 59 cephalexin for susp 125 /5ml... 59 cephalexin for susp 250 /5ml... 59 cephalexin tab 250... 59 cephalexin tab 500... 59 CEREZYME INJ 200UNIT... 83 CEREZYME INJ 400UNIT... 83 CERVARIX INJ... 106 cesia pak... 61 cetirizine hcl tab 10... 32 cetirizine hcl tab 5... 32 cetirizine sol 1/ml... 32 cevimeline hcl cap 30... 90 CHANTIX PAK 0.5& 1MG... 99 CHANTIX PAK 1MG... 99 115

CHANTIX TAB 0.5MG... 99 chateal tab 0.15/30... 61 CHEMET CAP 100MG... 29 child vit d chw 400unit... 108 chlordiazepoxide hcl-clidinium bromide cap 5-2.5... 102 chlorhexidine gluconate soln 0.12%... 90 chloroquine phosphate tab 250... 39 chloroquine phosphate tab 500... 39 chlorothiazide tab 250... 74 chlorothiazide tab 500... 74 chlorpromazine hcl tab 10... 50 chlorpromazine hcl tab 100... 50 chlorpromazine hcl tab 200... 50 chlorpromazine hcl tab 25... 50 chlorpromazine hcl tab 50... 50 chlorpropamide tab 100... 28 chlorpropamide tab 250... 28 chlorthalidone tab 100... 74 chlorthalidone tab 25... 74 chlorthalidone tab 50... 74 chlorzoxazone tab 500... 91 CHOLECALCIFEROL CAP 400 UNIT... 108 cholestyramine light powder 4 gm/dose... 33 cholestyramine light powder packets 4 gm... 33 cholestyramine powder 4 gm/dose... 33 cholestyramine powder packets 4 gm.. 33 chorionic gonadotropin for inj 10000 unit... 75 CIALIS TAB 2.5MG... 81 CIALIS TAB 5MG... 82 ciclopirox gel 0.77%... 68 ciclopirox kit 8%... 68 ciclopirox olamine cream 0.77% (base equiv)... 68 ciclopirox olamine susp 0.77% (base equiv)... 68 ciclopirox shampoo 1%... 68 ciclopirox solution 8%... 68 cilostazol tab 100... 82 cilostazol tab 50... 82 CILOXAN OIN 0.3% OP... 93 cimetidine hcl soln 300 /5ml... 103 cimetidine tab 200... 103 cimetidine tab 300... 103 cimetidine tab 400... 103 cimetidine tab 800... 103 CIPRO HC SUS OTIC... 95 CIPRODEX SUS 0.3-0.1%... 95 ciprofloxacin for oral susp 250 /5ml (5%) (5 gm/100ml)... 80 ciprofloxacin for oral susp 500 /5ml (10%) (10 gm/100ml)... 80 ciprofloxacin hcl ophth soln 0.3%... 93 ciprofloxacin hcl tab 100 (base equiv)... 80 ciprofloxacin hcl tab 250 (base equiv)... 80 ciprofloxacin hcl tab 500 (base equiv)... 80 ciprofloxacin hcl tab 750 (base equiv)... 80 ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000 (base eq)... 80 ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 (base eq)... 80 cisplatin inj 100 /100ml (1 /ml). 40 cisplatin inj 200 /200ml (1 /ml). 40 cisplatin inj 50 /50ml (1 /ml)... 40 citalopram hydrobromide oral soln 10 /5ml... 22 citalopram hydrobromide tab 10 (base equiv)... 22 citalopram hydrobromide tab 20 (base equiv)... 22 citalopram hydrobromide tab 40 (base equiv)... 22 CITRANATAL CAP HARMONY... 91 CITRANATAL MIS 90 DHA... 91 CITRANATAL MIS B-CALM... 91 CITRANATAL PAK ASSURE... 91 CITRANATAL PAK DHA... 91 CITRANATAL TAB RX... 91 cladribine inj 1 /ml... 41 claravis cap 10... 66 claravis cap 20... 66 claravis cap 30... 66 claravis cap 40... 66 CLARINEX SYP 0.5MG/ML... 32 clarithromycin for susp 125 /5ml... 86 clarithromycin for susp 250 /5ml... 86 clarithromycin tab 250... 86 clarithromycin tab 500... 86 clarithromycin tab sr 24hr 500... 86 116

clearplex x gel 10%... 66 clemastine fumarate syrup 0.67 /5ml (0.5 /5ml base eq)... 31 clemastine fumarate tab 2.68... 31 CLEOCIN SUP 100MG... 107 CLIMARA PRO DIS WEEKLY... 77 CLINAC BPO GEL 7%... 66 CLINDACIN KIT PAC 1%... 66 clindamycin hcl cap 150... 12 clindamycin hcl cap 300... 12 clindamycin hcl cap 75... 12 clindamycin phosphate gel 1%... 66 clindamycin phosphate lotion 1%... 66 clindamycin phosphate soln 1%... 66 clindamycin phosphate vaginal cream 2%... 107 clindamycin phosphate-benzoyl peroxide gel 1-5%... 66 clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5%... 66 clobetasol propionate cream 0.05%... 70 clobetasol propionate foam 0.05%... 70 clobetasol propionate gel 0.05%... 70 clobetasol propionate lotion 0.05%... 70 clobetasol propionate oint 0.05%... 70 clobetasol propionate shampoo 0.05% 70 clocortolone pivalate cream 0.1%... 70 CLOLAR INJ 1MG/ML... 41 clomiphene citrate tab 50... 75 clomipramine hcl cap 25... 24 clomipramine hcl cap 50... 24 clomipramine hcl cap 75... 24 clonazepam tab 0.5... 18 clonazepam tab 1... 18 clonazepam tab 2... 18 clonidine hcl tab 0.1... 35 clonidine hcl tab 0.2... 35 clonidine hcl tab 0.3... 35 clonidine hcl td patch weekly 0.1 /24hr... 35 clonidine hcl td patch weekly 0.2 /24hr... 35 clonidine hcl td patch weekly 0.3 /24hr... 35 clopidogrel bisulfate tab 300 (base equiv)... 82 clopidogrel bisulfate tab 75 (base equiv)... 82 clorazepate dipotassium tab 15... 14 clorazepate dipotassium tab 3.75.. 14 clorazepate dipotassium tab 7.5... 14 clotrimazole cre 1%... 68 clotrimazole cream 1%... 68 CLOTRIMAZOLE CRY... 68 clotrimazole soln 1%... 68 clotrimazole troche 10... 90 clotrimazole w/ betamethasone cream 1-0.05%... 68 clotrimazole w/ betamethasone lotion 1-0.05%... 68 clozapine tab 100... 49 clozapine tab 200... 49 clozapine tab 25... 49 clozapine tab 50... 49 COARTEM TAB 20-120MG... 39 CODEINE SULF SOL 30MG/5ML... 6 codeine sulfate tab 15... 6 codeine sulfate tab 30... 6 codeine sulfate tab 60... 6 colchicine tab 0.6... 82 colchicine w/ probenecid tab 0.5-500... 82 colestipol hcl granule packets 5 gm... 33 colestipol hcl granules 5 gm... 33 colestipol hcl tab 1 gm... 33 colocort ene 100... 11 COLYTE/FLAVR SOL PACKS... 85 COMBIGAN SOL 0.2/0.5%... 93 COMBIVENT AER RESPIMAT... 16 COMETRIQ KIT 100MG... 43 COMETRIQ KIT 140MG... 43 COMETRIQ KIT 60MG... 43 COMPLERA TAB... 51 compro sup 25... 50 COMVAX INJ... 106 CONCEPTROL GEL 4%... 107 CONDYLOX GEL 0.5%... 72 COPAXONE INJ 20MG/ML... 99 COPAXONE INJ 40MG/ML... 99 CORDRAN 24X3 TAP 4MCG/CM... 70 CORDRAN CRE 0.05%... 70 CORDRAN LOT 0.05%... 70 cormax scalp sol 0.05%... 70 cortisone acetate tab 25... 63 CORTISPORIN CRE 0.5%... 68 CORTISPORIN OIN 1%... 68 117

CORTISPORIN SUS -TC OTIC... 95 CREON CAP 12000UNT... 73 CREON CAP 24000UNT... 73 CREON CAP 3000UNIT... 73 CREON CAP 36000UNT... 73 CREON CAP 6000UNIT... 73 CRESTOR TAB 10MG... 33 CRESTOR TAB 20MG... 33 CRESTOR TAB 40MG... 33 CRESTOR TAB 5MG... 33 CRINONE GEL 4% VAG... 107 CRINONE GEL 8% VAG... 107 CRIXIVAN CAP 200MG... 51 CRIXIVAN CAP 400MG... 51 cromolyn sodium ophth soln 4%... 95 cromolyn sodium soln nebu 20 /2ml... 15 cruex aer 2%... 68 cryselle-28 tab 28 tabs... 61 CUBICIN SOL 500MG... 12 CUVPOSA SOL 1MG/5ML... 102 cyanocobalamin inj 1000 mcg/ml... 83 cyclafem tab 1/35... 61 cyclafem tab 7/7/7... 61 cyclobenzaprine hcl tab 10... 91 cyclobenzaprine hcl tab 5... 91 cyclobenzaprine hcl tab 7.5... 91 CYCLOPHOSPH CAP 25MG... 40 CYCLOPHOSPHAMIDE FOR INJ 1 GM... 40 CYCLOPHOSPHAMIDE FOR INJ 2 GM... 40 CYCLOPHOSPHAMIDE FOR INJ 500 MG 40 cyclophosphamide tab 25... 40 cyclophosphamide tab 50... 40 cycloserine cap 250... 39 CYCLOSET TAB 0.8MG... 27 cyclosporine modified cap 100... 54 cyclosporine modified cap 25... 54 cyclosporine modified cap 50... 54 cyclosporine modified oral soln 100 /ml... 54 cyproheptadine hcl syrup 2 /5ml... 32 cyproheptadine hcl tab 4... 32 CYSTADANE POW... 76 CYSTAGON CAP 150MG... 81 CYSTAGON CAP 50MG... 81 cytarabine for inj 1 gm... 41 cytarabine for inj 100... 41 cytarabine for inj 500... 41 cytarabine inj 20 /ml... 41 cytarabine inj pf 100 /ml... 41 cytarabine inj pf 20 /ml... 41 D dacarbazine for inj 100... 45 dacarbazine for inj 200... 45 dactinomycin for inj 0.5... 42 DALIRESP TAB 500MCG... 15 danazol cap 100... 11 danazol cap 200... 11 danazol cap 50... 10 dantrolene sodium cap 100... 92 dantrolene sodium cap 25... 92 dantrolene sodium cap 50... 92 dapsone tab 100... 12 dapsone tab 25... 12 DAPTACEL INJ... 102 DARAPRIM TAB 25MG... 39 dasetta tab 1/35... 61 dasetta tab 7/7/7... 61 daunorubicin hcl for inj 20... 42 daunorubicin hcl inj 5 /ml (base equiv)... 42 DAUNOXOME INJ 2MG/ML... 42 decitabine for inj 50... 41 demeclocycline hcl tab 150... 100 demeclocycline hcl tab 300... 100 DENAVIR CRE 1%... 69 DEPEN TITRA TAB 250MG... 54 DEPOCYT INJ 50MG/5ML... 41 DEPO-SQ PROV INJ 104... 63 desenex spry aer liquid... 68 desipramine hcl tab 10... 24 desipramine hcl tab 100... 24 desipramine hcl tab 150... 25 desipramine hcl tab 25... 24 desipramine hcl tab 50... 24 desipramine hcl tab 75... 24 desloratadine tab 5... 32 desloratadine tab orally disintegrating 2.5... 32 desloratadine tab orally disintegrating 5... 32 desmopressin acetate nasal soln 0.01% (refrigerated)... 76 desmopressin acetate nasal spray soln 0.01%... 76 desmopressin acetate nasal spray soln 118

0.01% (refrigerated)... 76 desmopressin acetate tab 0.1... 76 desmopressin acetate tab 0.2... 76 desonide cream 0.05%... 70 desonide lotion 0.05%... 70 desonide oint 0.05%... 70 desoximetasone cream 0.05%... 70 desoximetasone cream 0.25%... 70 desoximetasone gel 0.05%... 70 desoximetasone oint 0.05%... 71 desoximetasone oint 0.25%... 71 DEXAMETHASON CON 1MG/ML... 63 dexamethasone elixir 0.5 /5ml... 63 dexamethasone sodium phosphate ophth soln 0.1%... 94 dexamethasone soln 0.5 /5ml... 63 dexamethasone tab 0.5... 63 dexamethasone tab 0.75... 63 dexamethasone tab 1... 63 dexamethasone tab 1.5... 63 dexamethasone tab 2... 63 dexamethasone tab 4... 63 dexamethasone tab 6... 63 dexchlorpheniramine maleate syrup 2 /5ml... 31 DEXILANT CAP 30MG DR... 103 DEXILANT CAP 60MG DR... 103 dexmethylphenidate hcl cap sr 24 hr 10... 3 dexmethylphenidate hcl cap sr 24 hr 15... 3 dexmethylphenidate hcl cap sr 24 hr 30... 3 dexmethylphenidate hcl cap sr 24 hr 40... 3 dexmethylphenidate hcl cap sr 24 hr 5... 2 dexmethylphenidate hcl tab 10... 3 dexmethylphenidate hcl tab 2.5... 3 dexmethylphenidate hcl tab 5... 3 dexrazoxane for inj 250... 45 dexrazoxane for inj 500... 45 dextroamphetamine sulfate cap sr 24hr 10... 1 dextroamphetamine sulfate cap sr 24hr 15... 1 dextroamphetamine sulfate cap sr 24hr 5... 1 dextroamphetamine sulfate oral solution 5 /5ml... 1 dextroamphetamine sulfate tab 10.. 1 dextroamphetamine sulfate tab 5... 1 DIAZEPAM CON 5MG/ML... 14 diazepam soln 1 /ml... 14 diazepam tab 10... 14 diazepam tab 2... 14 diazepam tab 5... 14 DIBENZYLINE CAP 10MG... 35 diclofenac potassium tab 50... 4 diclofenac sodium ophth soln 0.1%... 95 diclofenac sodium tab delayed release 25... 4 diclofenac sodium tab delayed release 50... 4 diclofenac sodium tab delayed release 75... 4 diclofenac sodium tab sr 24hr 100.. 4 diclofenac w/ misoprostol tab delayed release 50-0.2... 4 diclofenac w/ misoprostol tab delayed release 75-0.2... 4 dicloxacillin sodium cap 250... 97 dicloxacillin sodium cap 500... 97 dicyclomine hcl cap 10... 102 dicyclomine hcl oral soln 10 /5ml. 102 dicyclomine hcl tab 20... 102 didanosine delayed release capsule 125... 51 didanosine delayed release capsule 200... 51 didanosine delayed release capsule 250... 51 didanosine delayed release capsule 400... 51 DIFFERIN LOT 0.1%... 66 DIFICID TAB 200MG... 86 diflorasone diacetate cream 0.05%... 71 diflorasone diacetate oint 0.05%... 71 diflunisal tab 500... 6 digoxin oral soln 0.05 /ml... 58 digoxin tab 125 mcg (0.125 )... 58 digoxin tab 250 mcg (0.25 )... 58 dihydroergotamine mesylate nasal spray 4 /ml... 87 diltiazem hcl cap sr 12hr 120... 57 diltiazem hcl cap sr 12hr 60... 57 119

diltiazem hcl cap sr 12hr 90... 57 diltiazem hcl cap sr 24hr 120... 57 diltiazem hcl cap sr 24hr 180... 57 diltiazem hcl cap sr 24hr 240... 57 diltiazem hcl coated beads cap sr 24hr 120... 57 diltiazem hcl coated beads cap sr 24hr 180... 57 diltiazem hcl coated beads cap sr 24hr 240... 57 diltiazem hcl coated beads cap sr 24hr 300... 57 diltiazem hcl coated beads cap sr 24hr 360... 57 diltiazem hcl extended release beads cap sr 24hr 120... 57 diltiazem hcl extended release beads cap sr 24hr 180... 57 diltiazem hcl extended release beads cap sr 24hr 240... 57 diltiazem hcl extended release beads cap sr 24hr 300... 57 diltiazem hcl extended release beads cap sr 24hr 360... 57 diltiazem hcl extended release beads cap sr 24hr 420... 57 DIP/TET PED INJ 25-5LFU... 102 DIPENTUM CAP 250MG... 81 diphenhydramine hcl cap 25... 31 diphenhydramine hcl cap 50... 31 diphenhydramine hcl elixir 12.5 /5ml... 31 diphenhydramine hcl inj 50 /ml... 31 diphenoxylate w/ atropine liq 2.5-0.025 /5ml... 29 diphenoxylate w/ atropine tab 2.5-0.025... 29 dipyridamole tab 25... 82 dipyridamole tab 50... 82 dipyridamole tab 75... 83 disopyramide phosphate cap 100.. 14 disopyramide phosphate cap 150.. 14 disulfiram tab 250... 97 disulfiram tab 500... 97 DIURIL SUS 250/5ML... 74 divalproex sodium cap sprinkle 125... 21 divalproex sodium tab delayed release 125... 21 divalproex sodium tab delayed release 250... 21 divalproex sodium tab delayed release 500... 21 divalproex sodium tab sr 24 hr 250 21 divalproex sodium tab sr 24 hr 500 21 DOCEFREZ INJ 20MG... 45 DOCEFREZ INJ 80MG... 45 docetaxel for inj conc 20 /ml... 45 docetaxel for inj conc 80 /4ml (20 /ml)... 46 DOCETAXEL INJ 140/7ML... 46 DOCETAXEL INJ 160/16ML... 46 DOCETAXEL INJ 160/8ML... 46 DOCETAXEL INJ 20/0.5ML... 46 DOCETAXEL INJ 200MG/20... 46 DOCETAXEL INJ 20MG/2ML... 46 DOCETAXEL INJ 80MG/2ML... 46 DOCETAXEL INJ 80MG/8ML... 46 donepezil hydrochloride orally disintegrating tab 10... 97 donepezil hydrochloride orally disintegrating tab 5... 97 donepezil hydrochloride tab 10... 97 donepezil hydrochloride tab 23... 97 donepezil hydrochloride tab 5... 97 DORIBAX INJ 250MG... 12 DORIBAX INJ 500MG... 12 dorzolamide hcl ophth soln 2%... 95 dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 /ml... 93 doxazosin mesylate tab 1... 35 doxazosin mesylate tab 2... 35 doxazosin mesylate tab 4... 35 doxazosin mesylate tab 8... 35 doxepin hcl cap 10... 25 doxepin hcl cap 100... 25 doxepin hcl cap 150... 25 doxepin hcl cap 25... 25 doxepin hcl cap 50... 25 doxepin hcl cap 75... 25 doxepin hcl conc 10 /ml... 25 doxercalciferol cap 0.5 mcg... 76 doxercalciferol cap 1 mcg... 76 doxercalciferol cap 2.5 mcg... 76 doxorubicin hcl for inj 10... 42 doxorubicin hcl for inj 50... 42 120

doxorubicin hcl inj 2 /ml... 42 doxycycline hyclate cap 100... 100 doxycycline hyclate cap 50... 100 doxycycline hyclate tab 100... 100 doxycycline hyclate tab 20... 100 doxycycline monohydrate cap 100... 100 doxycycline monohydrate cap 150... 100 doxycycline monohydrate cap 50. 100 doxycycline monohydrate cap 75. 100 doxycycline monohydrate for susp 25 /5ml... 100 doxycycline monohydrate tab 150 100 doxycycline monohydrate tab 50. 100 doxycycline monohydrate tab 75. 100 dronabinol cap 10... 30 dronabinol cap 2.5... 30 dronabinol cap 5... 30 drospirenone-ethinyl estradiol tab 3-0.03... 61 DROXIA CAP 200MG... 83 DROXIA CAP 300MG... 83 DROXIA CAP 400MG... 83 DULERA AER 100-5MCG... 16 DULERA AER 200-5MCG... 16 duloxetine hcl cap 20... 23 duloxetine hcl cap 30... 23 duloxetine hcl cap 60... 23 DUREZOL EMU 0.05%... 94 D-VI-SOL LIQ 400UNIT... 108 DYRENIUM CAP 100MG... 74 DYRENIUM CAP 50MG... 74 E e.e.s. 400 tab 400... 86 E.E.S. GRAN SUS 200/5ML... 86 e.s.p. sus 200-600... 11 econazole nitrate cream 1%... 68 EDARBI TAB 40MG... 35 EDARBI TAB 80MG... 35 EDECRIN TAB 25MG... 74 ed-spaz tab 0.125... 103 EDURANT TAB 25MG... 51 EFFIENT TAB 10MG... 83 EFFIENT TAB 5MG... 83 ELIDEL CRE 1%... 72 elinest tab... 61 ELIQUIS TAB 2.5MG... 17 ELIQUIS TAB 5MG... 17 ELLA TAB 30MG... 63 ELMIRON CAP 100MG... 81 ELOXATIN INJ 200MG... 40 EMADINE SOL 0.05% OP... 95 EMBEDA CAP 100-4MG... 6 EMBEDA CAP 20-0.8MG... 6 EMBEDA CAP 30-1.2MG... 6 EMBEDA CAP 50-2MG... 6 EMBEDA CAP 60-2.4MG... 6 EMBEDA CAP 80-3.2MG... 6 EMCYT CAP 140MG... 42 EMEND CAP 125MG... 30 EMEND CAP 40MG... 30 EMEND CAP 80MG... 30 EMEND PAK 80 & 125... 30 emoquette tab... 61 EMSAM DIS 12MG/24H... 22 EMSAM DIS 6MG/24HR... 22 EMSAM DIS 9MG/24HR... 22 EMTRIVA CAP 200MG... 51 EMTRIVA SOL 10MG/ML... 51 ENABLEX TAB 15MG... 105 ENABLEX TAB 7.5MG... 105 enalapril maleate & hydrochlorothiazide tab 10-25... 37 enalapril maleate & hydrochlorothiazide tab 5-12.5... 37 enalapril maleate tab 10... 34 enalapril maleate tab 2.5... 34 enalapril maleate tab 20... 34 enalapril maleate tab 5... 34 ENBREL INJ 25/0.5ML... 5 ENBREL INJ 25MG... 5 ENBREL INJ 50MG/ML... 6 ENBREL SRCLK INJ 50MG/ML... 6 ENCARE SUP 100MG... 107 endocet tab 10-325... 9 endocet tab 5-325... 9 endocet tab 7.5-325... 9 ENGERIX-B INJ 10/0.5ML... 106 ENGERIX-B INJ 20MCG/ML... 106 ENJUVIA TAB 0.3MG... 77 ENJUVIA TAB 0.45MG... 78 ENJUVIA TAB 0.625MG... 78 ENJUVIA TAB 0.9MG... 78 ENJUVIA TAB 1.25MG... 78 enoxaparin sodium inj 100 /ml... 18 121

enoxaparin sodium inj 120 /0.8ml.. 18 enoxaparin sodium inj 150 /ml... 18 enoxaparin sodium inj 30 /0.3ml... 18 enoxaparin sodium inj 300 /3ml... 18 enoxaparin sodium inj 40 /0.4ml... 18 enoxaparin sodium inj 60 /0.6ml... 18 enoxaparin sodium inj 80 /0.8ml... 18 enpresse-28 tab... 61 entacapone tab 200... 47 entecavir tab 0.5... 53 entecavir tab 1... 53 EPIDUO GEL 0.1-2.5%... 66 epinastine hcl ophth soln 0.05%... 95 epinephrine hcl inj 1 /ml... 16 epinephrine hcl soln prefilled syringe 0.1 /ml... 16 epinephrine solution auto-injector 0.15 /0.15ml (1:1000)... 107 epinephrine solution auto-injector 0.3 /0.3ml (1:1000)... 107 EPIPEN 2-PAK INJ 0.3MG... 107 EPIPEN-JR INJ 2-PAK... 107 epirubicin hcl iv soln 200 /100ml (2 /ml)... 43 epirubicin hcl iv soln 50 /25ml (2 /ml)... 43 EPIRUBICIN INJ 50MG... 43 epitol tab 200... 19 EPIVIR HBV SOL 5MG/ML... 53 EPIVIR SOL 10MG/ML... 51 eplerenone tab 25... 39 eplerenone tab 50... 39 epoprostenol sodium for inj 0.5... 59 epoprostenol sodium for inj 1.5... 59 eprosartan mesylate tab 600... 35 EPZICOM TAB 600-300... 51 ERAXIS INJ 100MG... 30 ERAXIS INJ 50MG... 30 ERBITUX INJ 100MG... 41 ERBITUX INJ 200MG... 41 ergocalciferol cap 50000 unit... 108 ergoloid mesylates tab 1... 99 ERIVEDGE CAP 150MG... 42 errin tab 0.35... 63 ERYPED SUS 200/5ML... 86 ERYPED SUS 400/5ML... 86 ERY-TAB TAB 250MG EC... 86 ERY-TAB TAB 333MG EC... 86 ERY-TAB TAB 500MG EC... 86 erythrocin tab 250... 86 erythromycin ethylsuccinate tab 400... 86 erythromycin gel 2%... 66 erythromycin ophth oint 5 /gm... 93 erythromycin soln 2%... 66 erythromycin tab 250... 86 erythromycin tab 500... 86 erythromycin w/ delayed release particles cap 250... 86 escitalopram oxalate soln 5 /5ml (base equiv)... 22 escitalopram oxalate tab 10 (base equiv)... 22 escitalopram oxalate tab 20 (base equiv)... 22 escitalopram oxalate tab 5 (base equiv)... 22 esomeprazole magnesium cap delayed release 20 (base eq)... 103 esomeprazole magnesium cap delayed release 40 (base eq)... 103 ESTRACE VAG CRE 0.1MG/GM... 107 estradiol & norethindrone acetate tab 0.5-0.1... 77 estradiol & norethindrone acetate tab 1-0.5... 77 estradiol tab 0.5... 78 estradiol tab 1... 78 estradiol tab 2... 78 estradiol td patch weekly 0.025 /24hr... 78 estradiol td patch weekly 0.0375 /24hr (37.5 mcg/24hr)... 79 estradiol td patch weekly 0.05 /24hr... 78 estradiol td patch weekly 0.06 /24hr... 78 estradiol td patch weekly 0.075 /24hr... 78 estradiol td patch weekly 0.1 /24hr 78 estropipate tab 0.75... 79 estropipate tab 1.5... 79 estropipate tab 3... 79 eszopiclone tab 1... 84 eszopiclone tab 2... 84 eszopiclone tab 3... 84 122

ethambutol hcl tab 100... 39 ethambutol hcl tab 400... 39 ethosuximide cap 250... 21 ethosuximide soln 250 /5ml... 21 etodolac cap 200... 4 etodolac cap 300... 4 etodolac tab 400... 4 etodolac tab 500... 4 ETOPOPHOS INJ 100MG... 46 etoposide cap 50... 46 etoposide inj 100/5ml (20 /ml).. 46 EURAX CRE 10%... 72 EURAX LOT 10%... 72 EVOTAZ TAB 300-150... 51 EXELON SOL 2MG/ML... 97 exemestane tab 25... 42 EXJADE TAB 125MG... 29 EXJADE TAB 250MG... 29 EXJADE TAB 500MG... 30 EXTAVIA INJ 0.3MG... 99 F FABRAZYME INJ 35MG... 76 FABRAZYME INJ 5MG... 76 FACTIVE TAB 320MG... 80 falmina tab... 61 famciclovir tab 125... 54 famciclovir tab 250... 54 famciclovir tab 500... 54 famotidine for susp 40 /5ml... 103 famotidine tab 20... 103 famotidine tab 40... 103 FANAPT PAK... 48 FANAPT TAB 10MG... 48 FANAPT TAB 12MG... 48 FANAPT TAB 1MG... 48 FANAPT TAB 2MG... 48 FANAPT TAB 4MG... 48 FANAPT TAB 6MG... 48 FANAPT TAB 8MG... 48 FARESTON TAB 60MG... 42 FASLODEX INJ 250MG... 42 FC2 FEMALE MIS CONDOM... 86 felbamate susp 600 /5ml... 20 felbamate tab 400... 20 felbamate tab 600... 20 felodipine tab sr 24hr 10... 57 felodipine tab sr 24hr 2.5... 57 felodipine tab sr 24hr 5... 57 FEMCAP MIS 22MM... 86 FEMCAP MIS 26MM... 86 FEMCAP MIS 30MM... 86 FEMHRT TAB 0.5-2.5... 77 fenofibrate cap 150... 33 fenofibrate cap 50... 33 fenofibrate micronized cap 130... 33 fenofibrate micronized cap 134... 33 fenofibrate micronized cap 200... 33 fenofibrate micronized cap 43... 33 fenofibrate micronized cap 67... 33 fenofibrate tab 145... 33 fenofibrate tab 160... 33 fenofibrate tab 48... 33 fenofibrate tab 54... 33 fenoprofen calcium tab 600... 4 fentanyl citrate lozenge on a handle 1200 mcg... 7 fentanyl citrate lozenge on a handle 1600 mcg... 7 fentanyl citrate lozenge on a handle 200 mcg... 6 fentanyl citrate lozenge on a handle 400 mcg... 7 fentanyl citrate lozenge on a handle 600 mcg... 7 fentanyl citrate lozenge on a handle 800 mcg... 7 fentanyl td patch 72hr 100 mcg/hr... 7 fentanyl td patch 72hr 12 mcg/hr... 7 fentanyl td patch 72hr 25 mcg/hr... 7 fentanyl td patch 72hr 50 mcg/hr... 7 fentanyl td patch 72hr 75 mcg/hr... 7 FER-IN-SOL DRO 15MG/ML... 84 FERRIPROX TAB 500MG... 30 FERROUS SUL LIQ 220/5ML... 84 FERROUS SULF SYP 300/5ML... 84 ferrous sulfate elixir 220 /5ml (44 /5ml elemental fe)... 84 ferrous sulfate soln 75 /ml (15 /ml elemental fe)... 84 fexofenadine hcl tab 180... 32 fexofenadine hcl tab 60... 32 fexofenadine sus 30/5ml... 32 FINACEA GEL 15%... 72 finasteride tab 5... 82 FIRMAGON INJ 120MG... 42 FIRMAGON INJ 80MG... 42 123

flavoxate hcl tab 100... 105 flecainide acetate tab 100... 14 flecainide acetate tab 150... 14 flecainide acetate tab 50... 14 floxuridine for inj 0.5 gm... 41 FLUBLOK SOL 2014-15... 106 FLUCELVAX INJ 2014-15... 106 fluconazole for susp 10 /ml... 31 fluconazole for susp 40 /ml... 31 fluconazole tab 100... 31 fluconazole tab 150... 31 fluconazole tab 200... 31 fluconazole tab 50... 31 fludarabine phosphate for inj 50... 41 fludarabine phosphate inj 25 /ml... 41 fludrocortisone acetate tab 0.1... 64 FLULAVAL QUA INJ 2014-15... 106 FLUMIST QUAD SUS 2014-15... 106 flunisolide nasal soln 25 mcg/act (0.025%)... 92 fluocin acet oil 0.01% sc... 71 fluocin acet oil body... 71 fluocinolone acetonide (otic) oil 0.01% 96 fluocinolone acetonide cream 0.01%... 71 fluocinolone acetonide cream 0.025%. 71 fluocinolone acetonide oint 0.025%... 71 fluocinolone acetonide soln 0.01%... 71 fluocinonide cream 0.05%... 71 fluocinonide cream 0.1%... 71 fluocinonide gel 0.05%... 71 fluocinonide oint 0.05%... 71 fluocinonide soln 0.05%... 71 FLUORABON DRO... 88 fluor-a-day dro 0.125... 88 fluoritab chw 0.25 f... 88 fluoritab chw 0.5 f... 88 fluoritab chw 2.2... 88 fluorometholone ophth susp 0.1%... 94 FLUOROPLEX CRE 1%... 69 fluorouracil cream 0.5%... 69 fluorouracil cream 5%... 69 fluorouracil inj 1 gm/20ml (50 /ml). 41 fluorouracil inj 2.5 gm/50ml (50 /ml)... 41 fluorouracil inj 5 gm/100ml (50 /ml)... 41 fluorouracil inj 500 /10ml (50 /ml)... 41 fluorouracil soln 2%... 69 fluorouracil soln 5%... 69 fluoxetine hcl cap 10... 22 fluoxetine hcl cap 20... 22 fluoxetine hcl cap 40... 22 fluoxetine hcl solution 20 /5ml... 22 fluoxetine hcl tab 10... 22 fluoxetine hcl tab 20... 22 fluphenazine hcl elixir 2.5 /5ml... 50 fluphenazine hcl oral conc 5 /ml... 50 fluphenazine hcl tab 1... 50 fluphenazine hcl tab 10... 50 fluphenazine hcl tab 2.5... 50 fluphenazine hcl tab 5... 50 flura-drops dro 0.125... 89 flura-drops dro 0.25 f... 89 flurbiprofen sodium ophth soln 0.03% 95 flurbiprofen tab 100... 4 flurbiprofen tab 50... 4 flutamide cap 125... 42 fluticasone propionate cream 0.05%... 71 fluticasone propionate lotion 0.05%... 71 fluticasone propionate nasal susp 50 mcg/act... 92 fluticasone propionate oint 0.005%... 71 fluvastatin sodium cap 20... 33 fluvastatin sodium cap 40... 33 fluvoxamine maleate cap sr 24hr 100... 22 fluvoxamine maleate cap sr 24hr 150... 22 fluvoxamine maleate tab 100... 22 fluvoxamine maleate tab 25... 22 fluvoxamine maleate tab 50... 22 FLUZONE INJ INTRADRM... 106 FLUZONE QUAD INJ 14-15... 106 folbic tab... 73 folic acid tab 1... 83 folic acid tab 400 mcg... 83 folic acid tab 800 mcg... 83 fondaparinux sodium subcutaneous inj 10 /0.8ml... 18 fondaparinux sodium subcutaneous inj 2.5 /0.5ml... 18 fondaparinux sodium subcutaneous inj 5 /0.4ml... 18 fondaparinux sodium subcutaneous inj 7.5 /0.6ml... 18 124

FORADIL CAP AEROLIZE... 16 FORTAZ INJ 500MG... 60 FORTEO SOL 600/2.4... 75 foscarnet sodium inj 24 /ml... 53 fosinopril sodium & hydrochlorothiazide tab 10-12.5... 37 fosinopril sodium & hydrochlorothiazide tab 20-12.5... 37 fosinopril sodium tab 10... 34 fosinopril sodium tab 20... 34 fosinopril sodium tab 40... 34 FOSRENOL CHW 1000MG... 81 FOSRENOL CHW 500MG... 81 FOSRENOL CHW 750MG... 81 FOSRENOL POW 1000MG... 81 FOSRENOL POW 750MG... 81 FRAGMIN INJ 10000/ML... 18 FRAGMIN INJ 12500UNT... 18 FRAGMIN INJ 15000UNT... 18 FRAGMIN INJ 18000UNT... 18 FRAGMIN INJ 2500/0.2... 18 FRAGMIN INJ 25000/ML... 18 FRAGMIN INJ 5000/0.2... 18 FRAGMIN INJ 7500/0.3... 18 FRAGMIN INJ 95000UNT... 18 FREESTYLE BLOOD GLUCOSE TEST KITS... 87 FREESTYLE BLOOD GLUCOSE TEST STRIPS... 87 FROVA TAB 2.5MG... 87 furosemide oral soln 10 /ml... 74 FUROSEMIDE SOL 8MG/ML... 74 furosemide tab 20... 74 furosemide tab 40... 74 furosemide tab 80... 74 FUZEON INJ 90MG... 51 G gabapentin cap 100... 19 gabapentin cap 300... 19 gabapentin cap 400... 19 gabapentin tab 600... 19 gabapentin tab 800... 19 GABITRIL TAB 12MG... 20 GABITRIL TAB 16MG... 20 galantamine hydrobromide cap sr 24hr 16... 97 galantamine hydrobromide cap sr 24hr 24... 97 galantamine hydrobromide cap sr 24hr 8... 97 galantamine hydrobromide oral soln 4 /ml... 98 galantamine hydrobromide tab 12 98 galantamine hydrobromide tab 4.. 98 galantamine hydrobromide tab 8.. 98 GAMASTAN S/D INJ... 96 GAMMAGARD INJ 10GM/100... 96 GAMMAGARD INJ 2.5GM/25... 96 GAMMAGARD INJ 20GM/200... 96 GAMMAGARD INJ 5GM/50ML... 96 GAMMAKED INJ 1GM/10ML... 96 GARDASIL 9 INJ... 106 GARDASIL INJ... 106 gatifloxacin ophth soln 0.5%... 93 gavilyte-c sol... 85 gavilyte-g sol... 85 gavilyte-n sol flav pk... 85 GAZYVA INJ 25MG/ML... 41 GELNIQUE GEL 3%... 105 gemcitabine hcl for inj 1 gm... 41 gemcitabine hcl for inj 2 gm... 41 gemcitabine hcl for inj 200... 41 gemfibrozil tab 600... 33 gengraf cap 100... 54 gengraf cap 25... 54 gengraf sol 100/ml... 54 gentamicin sulfate cream 0.1%... 68 gentamicin sulfate oint 0.1%... 68 gentamicin sulfate ophth oint 0.3%... 93 gentamicin sulfate ophth soln 0.3%... 94 gianvi tab 3-0.02... 61 gildess fe tab 1.5/30... 61 gildess fe tab 1/20... 61 gildess tab 1.5/30... 61 gildess tab 1/20... 61 GILENYA CAP 0.5MG... 99 GLASSIA INJ... 100 GLEEVEC TAB 100MG... 43 GLEEVEC TAB 400MG... 43 GLIADEL WAF 7.7MG... 40 glimepiride tab 1... 29 glimepiride tab 2... 29 glimepiride tab 4... 29 glipizide tab 10... 29 glipizide tab 5... 29 glipizide tab sr 24hr 10... 29 125

glipizide tab sr 24hr 2.5... 29 glipizide tab sr 24hr 5... 29 glipizide-metformin hcl tab 2.5-250... 26 glipizide-metformin hcl tab 2.5-500... 26 glipizide-metformin hcl tab 5-500.. 26 GLUCAGEN INJ HYPOKIT... 27 GLUCAGON KIT 1MG... 27 glucose gel/oral liquid/chew tab... 27 glyburide micronized tab 1.5... 29 glyburide micronized tab 3... 29 glyburide micronized tab 6... 29 glyburide tab 1.25... 29 glyburide tab 2.5... 29 glyburide tab 5... 29 glyburide-metformin tab 1.25-250. 26 glyburide-metformin tab 2.5-500.. 27 glyburide-metformin tab 5-500... 27 GLYSET TAB 100MG... 26 GLYSET TAB 25MG... 26 GLYSET TAB 50MG... 26 GOLYTELY SOL... 85 granisetron hcl tab 1... 30 griseofulvin microsize susp 125 /5ml... 31 griseofulvin microsize tab 500... 31 griseofulvin ultramicrosize tab 125 31 griseofulvin ultramicrosize tab 250 31 guanfacine hcl tab 1... 35 guanfacine hcl tab 2... 36 guanfacine hcl tab sr 24hr 1 (base equiv)... 2 guanfacine hcl tab sr 24hr 2 (base equiv)... 2 guanfacine hcl tab sr 24hr 3 (base equiv)... 2 guanfacine hcl tab sr 24hr 4 (base equiv)... 2 GYNOL II GEL 3%... 107 H halobetasol propionate cream 0.05%.. 71 halobetasol propionate oint 0.05%... 71 HALOG CRE 0.1%... 71 HALOG OIN 0.1%... 71 haloperidol decanoate im soln 100 /ml... 49 haloperidol decanoate im soln 50 /ml... 49 haloperidol lactate oral conc 2 /ml. 49 haloperidol tab 0.5... 49 haloperidol tab 1... 49 haloperidol tab 10... 49 haloperidol tab 2... 49 haloperidol tab 20... 49 haloperidol tab 5... 49 HARVONI TAB 90-400MG... 53 HAVRIX INJ 1440UNIT... 106 HAVRIX INJ 720UNIT... 106 heather tab 0.35... 63 heparin sodium (porcine) inj 1000 unit/ml... 18 heparin sodium (porcine) inj 10000 unit/ml... 18 heparin sodium (porcine) inj 20000 unit/ml... 18 heparin sodium (porcine) inj 5000 unit/ml... 18 heparin sodium (porcine) pf inj 5000 unit/0.5ml... 18 HEXALEN CAP 50MG... 40 HIBERIX SOL 10MCG... 106 homatropine hbr ophth soln 5%... 93 HORIZANT TAB 300MG... 99 HORIZANT TAB 600MG... 99 HUMALOG INJ 100/ML... 28 HUMALOG KWIK INJ 100/ML... 28 HUMALOG MIX INJ 50/50... 28 HUMALOG MIX INJ 50/50KWP... 28 HUMALOG MIX INJ 75/25KWP... 28 HUMALOG MIX SUS 75/25... 28 HUMATROPE INJ 12MG... 75 HUMATROPE INJ 24MG... 75 HUMATROPE INJ 5MG... 75 HUMATROPE INJ 6MG... 75 HUMIRA INJ 10MG/0.2... 4 HUMIRA INJ 40MG/0.8... 4 HUMIRA KIT 20MG/0.4... 4 HUMIRA PEN INJ CROHNS... 4 HUMULIN INJ 70/30... 28 HUMULIN INJ 70/30KWP... 28 HUMULIN N INJ U-100... 28 HUMULIN N INJ U-100KWP... 28 HUMULIN R INJ U-100... 28 HUMULIN R INJ U-500... 28 HYCAMTIN CAP 0.25MG... 46 126

HYCAMTIN CAP 1MG... 46 hydralazine hcl tab 10... 39 hydralazine hcl tab 100... 39 hydralazine hcl tab 25... 39 hydralazine hcl tab 50... 39 hydrochlorothiazide cap 12.5... 74 hydrochlorothiazide tab 12.5... 74 hydrochlorothiazide tab 25... 74 hydrochlorothiazide tab 50... 74 hydrocodone w/ homatropine syrup 5-1.5 /5ml... 64 hydrocodone w/ homatropine tab 5-1.5... 64 HYDROCODONE-ACETAMINOPHEN SOLN 10-325 MG/15ML... 9 hydrocodone-acetaminophen soln 7.5-325 /15ml... 9 hydrocodone-acetaminophen tab 10-300... 9 hydrocodone-acetaminophen tab 10-325... 9 hydrocodone-acetaminophen tab 2.5-325... 9 hydrocodone-acetaminophen tab 5-300... 9 hydrocodone-acetaminophen tab 5-325... 9 hydrocodone-acetaminophen tab 7.5-300... 9 hydrocodone-acetaminophen tab 7.5-325... 9 hydrocortisone butyrate cream 0.1%... 71 hydrocortisone butyrate hydrophilic lipo base cream 0.1%... 71 hydrocortisone butyrate oint 0.1%... 71 hydrocortisone butyrate soln 0.1%... 71 hydrocortisone cream 1%... 71 hydrocortisone cream 2.5%... 71 hydrocortisone lotion 2.5%... 71 hydrocortisone oint 1%... 71 hydrocortisone oint 2.5%... 71 hydrocortisone tab 10... 63 hydrocortisone tab 20... 63 hydrocortisone tab 5... 63 hydrocortisone valerate cream 0.2%... 71 hydrocortisone valerate oint 0.2%... 71 hydrocortisone w/ acetic acid otic soln 1-2%... 96 HYDROMORPHON SUP 3MG... 7 hydromorphone hcl liqd 1 /ml... 7 hydromorphone hcl tab 2... 7 hydromorphone hcl tab 4... 7 hydromorphone hcl tab 8... 7 hydromorphone hcl tab er 24hr deter 12... 7 hydromorphone hcl tab er 24hr deter 16... 7 hydromorphone hcl tab er 24hr deter 32... 7 hydromorphone hcl tab er 24hr deter 8... 7 hydroxychloroquine sulfate tab 200... 39 hydroxyurea cap 500... 45 hydroxyzine hcl syrup 10 /5ml... 13 hydroxyzine hcl tab 10... 13 hydroxyzine hcl tab 25... 13 hydroxyzine hcl tab 50... 13 hyomax-sl sub 0.125... 103 hyoscyamine sulfate tab 0.125... 103 hyoscyamine sulfate tab disp 0.125... 103 hyoscyamine sulfate tab sl 0.125 103 hyoscyamine sulfate tab sr 12hr 0.375... 103 I ibandronate sodium tab 150 (base equivalent)... 75 IBRANCE CAP 100MG... 43 IBRANCE CAP 125MG... 43 IBRANCE CAP 75MG... 43 ibuprofen susp 100 /5ml... 4 ibuprofen tab 400... 4 ibuprofen tab 600... 4 ibuprofen tab 800... 4 ICAR PEDS SUS GRAPE... 84 ICLUSIG TAB 15MG... 43 ICLUSIG TAB 45MG... 43 idarubicin hcl iv inj 10 /10ml (1 /ml)... 43 idarubicin hcl iv inj 20 /20ml (1 /ml)... 43 idarubicin hcl iv inj 5 /5ml (1 /ml)... 43 ifosfamide & mesna inj kit 1000-1000... 43 127

ifosfamide for inj 1 gm... 40 ifosfamide iv inj 1 gm/20ml (50 /ml)... 40 ifosfamide iv inj 3 gm/60ml (50 /ml)... 40 ilotycin oin op... 94 IMBRUVICA CAP 140MG... 43 imipramine hcl tab 10... 25 imipramine hcl tab 25... 25 imipramine hcl tab 50... 25 imipramine pamoate cap 100... 25 imipramine pamoate cap 125... 25 imipramine pamoate cap 150... 25 imipramine pamoate cap 75... 25 imiquimod cream 5%... 72 INCRELEX INJ 40MG/4ML... 76 indapamide tab 1.25... 74 indapamide tab 2.5... 74 INDOCIN SUS 25MG/5ML... 4 indomethacin cap 25... 4 indomethacin cap 50... 4 indomethacin cap cr 75... 4 INFANRIX INJ... 102 INFERGEN INJ 15MCG... 53 INFERGEN INJ 9MCG... 53 INFLUENZA A SPR 09 H1N1... 106 INLYTA TAB 1MG... 43 INLYTA TAB 5MG... 43 INSULIN INFUSION PUMP KIT... 87 INSULIN PEN NEEDLES/SYRINGES... 87 INTELENCE TAB 100MG... 51 INTELENCE TAB 200MG... 51 INTELENCE TAB 25MG... 51 INTRON-A INJ 10MU... 45 INTRON-A INJ 18MU... 45 INTRON-A INJ 25MU... 45 INTRON-A INJ 50MU... 45 introvale tab... 61 INVEGA TAB 1.5MG... 48 INVEGA TAB 3MG... 49 INVEGA TAB 6MG... 49 INVEGA TAB 9MG... 49 INVIRASE CAP 200MG... 51 INVIRASE TAB 500MG... 51 IPOL INJ INACTIVE... 106 ipratropium bromide inhal soln 0.02%. 15 ipratropium bromide nasal soln 0.03% (21 mcg/spray)... 92 ipratropium bromide nasal soln 0.06% (42 mcg/spray)... 92 ipratropium-albuterol nebu soln 0.5-2.5(3) /3ml... 16 irbesartan tab 150... 35 irbesartan tab 300... 35 irbesartan tab 75... 35 irbesartan-hydrochlorothiazide tab 150-12.5... 37 irbesartan-hydrochlorothiazide tab 300-12.5... 37 irinotecan hcl inj 100 /5ml (20 /ml)... 46 irinotecan hcl inj 40 /2ml (20 /ml)... 46 irinotecan hcl inj 500 /25ml (20 /ml)... 46 ISENTRESS CHW 100MG... 51 ISENTRESS CHW 25MG... 51 ISENTRESS POW 100MG... 52 ISENTRESS TAB 400MG... 52 ISO HOMATROP SOL 2% OP... 93 isoditrate tab 40 er... 12 isoniazid syrup 50 /5ml... 39 isoniazid tab 100... 39 isoniazid tab 300... 39 ISORDIL TAB 40MG... 12 isosorbide dinitrate sl tab 2.5... 12 isosorbide dinitrate tab 10... 12 isosorbide dinitrate tab 20... 12 isosorbide dinitrate tab 30... 12 isosorbide dinitrate tab 5... 12 isosorbide dinitrate tab cr 40... 12 isosorbide mononitrate tab 10... 12 isosorbide mononitrate tab 20... 12 isosorbide mononitrate tab sr 24hr 120... 12 isosorbide mononitrate tab sr 24hr 30... 12 isosorbide mononitrate tab sr 24hr 60... 12 isradipine cap 2.5... 57 isradipine cap 5... 57 itraconazole cap 100... 31 ivermectin tab 3... 11 J JAKAFI TAB 10MG... 44 JAKAFI TAB 15MG... 44 128

JAKAFI TAB 20MG... 44 JAKAFI TAB 25MG... 44 JAKAFI TAB 5MG... 43 JALYN CAP... 82 jantoven tab 10... 17 jantoven tab 1... 17 jantoven tab 2.5... 17 jantoven tab 2... 17 jantoven tab 3... 17 jantoven tab 4... 17 jantoven tab 5... 17 jantoven tab 6... 17 jantoven tab 7.5... 17 JANUMET TAB 50-1000... 27 JANUMET TAB 50-500MG... 27 JANUMET XR TAB 100-1000... 27 JANUMET XR TAB 50-1000... 27 JANUMET XR TAB 50-500MG... 27 JANUVIA TAB 100MG... 27 JANUVIA TAB 25MG... 27 JANUVIA TAB 50MG... 27 JENTADUETO TAB 2.5-1000... 27 JENTADUETO TAB 2.5-500... 27 JENTADUETO TAB 2.5-850... 27 jinteli tab 1-5mcg... 77 jolessa tab... 61 jolivette tab 0.35... 63 junel 1.5/30 tab... 61 junel 1/20 tab... 61 junel fe tab 1.5/30... 61 junel fe tab 1/20... 61 K KADCYLA INJ 100MG... 44 KADCYLA INJ 160MG... 44 KALETRA SOL... 52 KALETRA TAB 100-25MG... 52 KALETRA TAB 200-50MG... 52 kariva tab 28 day... 61 kelnor tab 1/35... 61 KEPIVANCE INJ 6.25MG... 45 KETEK TAB 300MG... 12 KETEK TAB 400MG... 12 ketoconazole cream 2%... 68 ketoconazole shampoo 2%... 68 ketodan aer 2%... 68 ketoprofen cap 50... 5 ketoprofen cap 75... 5 ketoprofen cap sr 24hr 200... 5 ketorolac tromethamine im inj 60 /2ml (30 /ml)... 5 ketorolac tromethamine inj 15 /ml... 5 ketorolac tromethamine inj 30 /ml... 5 ketorolac tromethamine inj 300 /10ml (30 /ml)... 5 ketorolac tromethamine inj 60 /2ml (30 /ml)... 5 ketorolac tromethamine ophth soln 0.4%... 95 ketorolac tromethamine ophth soln 0.5%... 95 ketorolac tromethamine tab 10... 5 ketotifen fumarate ophth soln 0.025% (base equiv)... 95 KEYTRUDA INJ 100MG/4M... 41 KEYTRUDA SOL 50MG... 41 KINERET INJ... 4 KINRIX INJ... 102 kionex sus 15gm/60... 55 klor-con 10 tab 10meq er... 89 klor-con 8 tab 8meq er... 89 KLOR-CON M15 TAB 15MEQ ER... 89 klor-con m20 tab 20meq er... 89 kurvelo tab 0.15/30... 61 L labetalol hcl tab 100... 55 labetalol hcl tab 200... 55 labetalol hcl tab 300... 55 laclotion lot 12%... 72 LACRISERT MIS 5MG OP... 93 lactic acid (ammonium lactate) cream 12%... 72 lactic acid (ammonium lactate) lotion 10%... 72 lactic acid (ammonium lactate) lotion 12%... 72 lactulose solution 10 gm/15ml... 85 LAMICTAL CHW 2MG... 19 LAMISIL ADV GEL 1%... 68 LAMISIL AT SPR 1%... 68 lamivudine tab 100 (hbv)... 53 lamivudine tab 150... 52 lamivudine tab 300... 52 lamivudine-zidovudine tab 150-300... 52 lamotrigine orally disintegrating tab 100... 19 129

lamotrigine orally disintegrating tab 200... 19 lamotrigine orally disintegrating tab 25... 19 lamotrigine orally disintegrating tab 50... 19 lamotrigine tab 100... 19 lamotrigine tab 150... 19 lamotrigine tab 200... 19 lamotrigine tab 25... 19 lamotrigine tab chewable dispersible 25... 19 lamotrigine tab chewable dispersible 5... 19 lamotrigine tab sr 24hr 100... 19 lamotrigine tab sr 24hr 200... 19 lamotrigine tab sr 24hr 25... 19 lamotrigine tab sr 24hr 250... 19 lamotrigine tab sr 24hr 300... 19 lamotrigine tab sr 24hr 50... 19 LANCETS... 87 LANCING DEVICE... 87 LANOXIN TAB 0.0625MG... 58 LANOXIN TAB 0.1875MG... 58 lansoprazole cap 15 dr... 103 lansoprazole cap delayed release 15... 103 lansoprazole cap delayed release 30... 104 LANTUS INJ 100/ML... 28 LANTUS INJ SOLOSTAR... 28 LASTACAFT SOL 0.25%... 95 latanoprost ophth soln 0.005%... 95 LATUDA TAB 120MG... 48 LATUDA TAB 20MG... 48 LATUDA TAB 40MG... 48 LATUDA TAB 60MG... 48 LATUDA TAB 80MG... 48 lavoclen-4 kit acne wsh... 66 LAVOCLEN-4 LIQ CREM WSH... 66 lavoclen-8 kit acne wsh... 66 LAVOCLEN-8 LIQ CREM WSH... 66 leena tab... 61 leflunomide tab 10... 5 leflunomide tab 20... 5 LENVIMA CAP 10MG... 44 LENVIMA CAP 14MG... 44 LENVIMA CAP 20MG... 44 LENVIMA CAP 24MG... 44 lessina tab... 61 LETAIRIS TAB 10MG... 59 LETAIRIS TAB 5MG... 59 letrozole tab 2.5... 42 leucovorin calcium for inj 100... 45 leucovorin calcium for inj 200... 45 leucovorin calcium for inj 350... 45 leucovorin calcium for inj 50... 45 leucovorin calcium tab 10... 45 leucovorin calcium tab 15... 45 leucovorin calcium tab 25... 45 leucovorin calcium tab 5... 45 LEUCOVORIN INJ CALCIUM... 45 LEUKERAN TAB 2MG... 40 LEUKINE INJ 250MCG... 83 LEUKINE INJ 500 MCG... 83 leuprolide acetate inj kit 5 /ml... 42 levalbuterol hcl soln nebu 0.31 /3ml (base equiv)... 16 levalbuterol hcl soln nebu 0.63 /3ml (base equiv)... 16 levalbuterol hcl soln nebu 1.25 /3ml (base equiv)... 16 levalbuterol hcl soln nebu conc 1.25 /0.5ml (base equiv)... 16 LEVATOL TAB 20MG... 56 LEVEMIR INJ... 28 LEVEMIR INJ FLEXTOUC... 28 levetiracetam oral soln 100 /ml... 19 levetiracetam tab 1000... 19 levetiracetam tab 250... 19 levetiracetam tab 500... 19 levetiracetam tab 750... 19 levetiracetam tab sr 24hr 500... 19 levetiracetam tab sr 24hr 750... 19 levobunolol hcl ophth soln 0.25%... 93 levobunolol hcl ophth soln 0.5%... 93 levocetirizine dihydrochloride soln 2.5 /5ml (0.5 /ml)... 32 levocetirizine dihydrochloride tab 5 32 levofloxacin oral soln 25 /ml... 80 levofloxacin tab 250... 80 levofloxacin tab 500... 80 levofloxacin tab 750... 80 levonest tab... 61 levonorgestrel & ethinyl estradiol (91-day) tab 0.15-0.03... 62 130

levonorgestrel & ethinyl estradiol tab 0.15-30 mcg... 62 levonorgestrel tab 0.75... 63 levonorgestrel tab 1.5... 63 levonorg-eth est tab 0.1-0.02(84) & eth est tab 0.01(7)... 62 levora-28 tab 0.15/30... 62 levorphanol tartrate tab 2... 7 levothyroxine sodium tab 100 mcg... 101 levothyroxine sodium tab 112 mcg... 101 levothyroxine sodium tab 125 mcg... 101 levothyroxine sodium tab 137 mcg... 101 levothyroxine sodium tab 150 mcg... 101 levothyroxine sodium tab 175 mcg... 101 levothyroxine sodium tab 200 mcg... 101 levothyroxine sodium tab 25 mcg... 101 levothyroxine sodium tab 300 mcg... 101 levothyroxine sodium tab 50 mcg... 101 levothyroxine sodium tab 75 mcg... 101 levothyroxine sodium tab 88 mcg... 101 levoxyl tab 100mcg... 101 levoxyl tab 112mcg... 101 levoxyl tab 125mcg... 101 levoxyl tab 137mcg... 101 levoxyl tab 150mcg... 101 levoxyl tab 175mcg... 101 levoxyl tab 200mcg... 101 levoxyl tab 25mcg... 101 levoxyl tab 50mcg... 101 levoxyl tab 75mcg... 101 levoxyl tab 88mcg... 101 LEXIVA SUS 50MG/ML... 52 LEXIVA TAB 700MG... 52 lidocaine hcl cream 3%... 72 lidocaine hcl gel 2%... 72 lidocaine hcl laryngotracheal soln 4%.. 90 lidocaine hcl lotion 3%... 72 lidocaine hcl soln 4%... 72 lidocaine hcl viscous soln 2%... 90 lidocaine-prilocaine cream 2.5-2.5%... 72 lidocaine-prilocaine kit 2.5-2.5%... 72 liothyronine sodium tab 25 mcg... 101 liothyronine sodium tab 5 mcg... 101 liothyronine sodium tab 50 mcg... 101 lipodox inj 2/ml... 43 lisinopril & hydrochlorothiazide tab 10-12.5... 37 lisinopril & hydrochlorothiazide tab 20-12.5... 37 lisinopril & hydrochlorothiazide tab 20-25... 37 lisinopril tab 10... 34 lisinopril tab 2.5... 34 lisinopril tab 20... 34 lisinopril tab 30... 34 lisinopril tab 40... 34 lisinopril tab 5... 34 lithium carbonate cap 150... 48 lithium carbonate cap 300... 48 lithium carbonate cap 600... 48 lithium carbonate tab 300... 48 lithium carbonate tab cr 300... 48 lithium carbonate tab cr 450... 48 LITHIUM SOL 8MEQ/5ML... 48 LIVALO TAB 1MG... 33 LIVALO TAB 2MG... 33 LIVALO TAB 4MG... 33 lokara lot 0.05%... 71 lomedia 24 tab fe... 62 lomustine cap 10... 40 lomustine cap 100... 40 lomustine cap 40... 40 loperamide hcl cap 2... 29 loratadine syp 5/5ml... 32 lorazepam conc 2 /ml... 14 lorazepam tab 0.5... 14 lorazepam tab 1... 14 lorazepam tab 2... 14 loryna tab 3-0.02... 62 losartan potassium & hydrochlorothiazide tab 100-12.5... 37 losartan potassium & hydrochlorothiazide tab 100-25... 37 losartan potassium & hydrochlorothiazide tab 50-12.5... 37 losartan potassium tab 100... 35 losartan potassium tab 25... 35 losartan potassium tab 50... 35 LOTEMAX GEL 0.5%... 94 LOTEMAX OIN 0.5%... 94 LOTEMAX SUS 0.5%... 94 LOTRIMIN ULT CRE 1%... 68 LOTRONEX TAB 0.5MG... 81 LOTRONEX TAB 1MG... 81 lovastatin tab 10... 33 lovastatin tab 20... 33 131

lovastatin tab 40... 33 low-ogestrel tab... 62 loxapine succinate cap 10... 49 loxapine succinate cap 25... 49 loxapine succinate cap 5... 49 loxapine succinate cap 50... 49 ludent chw 0.25 f... 89 ludent chw 0.5 f... 89 ludent chw 1 f... 89 LUMIGAN SOL 0.01%... 95 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 LUPRON DEPOT INJ 11.25MG... 42 LUPRON DEPOT INJ 22.5MG... 42 LUPRON DEPOT INJ 3.75MG... 42 LUPRON DEPOT INJ 30MG... 42 LUPRON DEPOT INJ 45MG... 42 LUPRON DEPOT INJ 7.5MG... 42 LURIDE CHW 0.25MG F... 89 LURIDE CHW 0.5MG F... 89 LURIDE DRO 0.5MG/ML... 89 lutera tab... 62 LYNPARZA CAP 50MG... 44 LYRICA CAP 100MG... 20 LYRICA CAP 150MG... 20 LYRICA CAP 200MG... 20 LYRICA CAP 225MG... 20 LYRICA CAP 25MG... 19 LYRICA CAP 300MG... 20 LYRICA CAP 50MG... 19 LYRICA CAP 75MG... 19 LYRICA SOL 20MG/ML... 20 LYSODREN TAB 500MG... 42 M MACRODANTIN CAP 25MG... 104 mafenide acetate packet for topical soln 5% (50 gm)... 70 MAGNESIUM SU INJ 2/50ML... 89 malathion lotion 0.5%... 72 maprotiline hcl tab 25... 21 maprotiline hcl tab 50... 21 maprotiline hcl tab 75... 21 margesic cap... 6 marlissa tab 0.15/30... 62 MARPLAN TAB 10MG... 22 MATULANE CAP 50MG... 45 matzim la tab 180/24... 57 matzim la tab 240/24... 57 matzim la tab 300/24... 57 matzim la tab 360/24... 57 matzim la tab 420/24... 57 MAXIPIME INJ 1GM... 61 MAXIPIME INJ 2GM... 61 meclizine hcl tab 12.5... 30 meclizine hcl tab 25... 30 meclofenamate sodium cap 100... 5 meclofenamate sodium cap 50... 5 MEDROL TAB 2MG... 64 medroxyprogesterone acetate im susp 150 /ml... 63 medroxyprogesterone acetate tab 10... 97 medroxyprogesterone acetate tab 2.5... 97 medroxyprogesterone acetate tab 5... 97 mefenamic acid cap 250... 5 mefloquine hcl tab 250... 39 megestrol acetate susp 40 /ml... 42 megestrol acetate tab 20... 42 megestrol acetate tab 40... 42 MEKINIST TAB 0.5MG... 44 MEKINIST TAB 2MG... 44 meloxicam susp 7.5 /5ml... 5 meloxicam tab 15... 5 meloxicam tab 7.5... 5 MENACTRA INJ... 106 MENEST TAB 0.3MG... 79 MENEST TAB 0.625MG... 79 MENEST TAB 1.25MG... 79 MENEST TAB 2.5MG... 79 MENHIBRIX INJ... 106 MENOMUNE INJ A/C/Y/W... 106 MENVEO INJ... 106 MEPHYTON TAB 5MG... 108 meprobamate tab 200... 13 meprobamate tab 400... 13 mercaptopurine tab 50... 41 mesalamine enema 4 gm... 81 mesalamine rectal enema 4 gm & cleanser wipe kit... 81 mesna inj 100 /ml... 45 MESNEX TAB 400MG... 45 MESTINON SYP 60MG/5ML... 39 132

MESTINON TAB TIMESPAN... 39 metadate tab 20 er... 3 metaproterenol sulfate syrup 10 /5ml... 16 metaproterenol sulfate tab 10... 17 metaproterenol sulfate tab 20... 17 metaxalone tab 400... 91 metaxalone tab 800... 91 metformin hcl tab 1000... 27 metformin hcl tab 500... 27 metformin hcl tab 850... 27 metformin hcl tab sr 24hr 500... 27 metformin hcl tab sr 24hr 750... 27 metformin hcl tab sr 24hr osmotic 1000... 27 metformin hcl tab sr 24hr osmotic 500... 27 methadone hcl conc 10 /ml... 7 methadone hcl soln 10 /5ml... 7 methadone hcl soln 5 /5ml... 7 methadone hcl tab 10... 7 methadone hcl tab 5... 7 methadone hcl tab for oral susp 40. 7 methamphetamine hcl tab 5... 1 methazolamide tab 25... 73 methazolamide tab 50... 73 methenamine hippurate tab 1 gm... 104 methimazole tab 10... 101 methimazole tab 5... 101 methocarbamol tab 500... 91 methocarbamol tab 750... 92 methotrexate sodium for inj 1 gm... 41 methotrexate sodium inj 25 /ml... 41 methotrexate sodium inj pf 25 /ml. 41 methotrexate sodium tab 2.5 (base equiv)... 41 methoxsalen rapid cap 10... 69 methscopolamine bromide tab 2.5... 103 methscopolamine bromide tab 5.. 103 methyldopa tab 250... 36 methyldopa tab 500... 36 methylphenidate hcl cap cr 10... 3 methylphenidate hcl cap cr 20... 3 methylphenidate hcl cap cr 30... 3 methylphenidate hcl cap cr 40... 3 methylphenidate hcl cap cr 50... 3 methylphenidate hcl cap cr 60... 3 methylphenidate hcl cap sr 24hr 20 (la)... 3 methylphenidate hcl cap sr 24hr 30 (la)... 3 methylphenidate hcl cap sr 24hr 40 (la)... 3 methylphenidate hcl soln 10 /5ml... 3 methylphenidate hcl soln 5 /5ml... 3 methylphenidate hcl tab 10... 3 methylphenidate hcl tab 20... 3 methylphenidate hcl tab 5... 3 methylphenidate hcl tab cr 10... 3 methylphenidate hcl tab cr 20... 3 methylphenidate hcl tab sa osm 18. 3 methylphenidate hcl tab sa osm 27. 3 methylphenidate hcl tab sa osm 36. 3 methylphenidate hcl tab sa osm 54. 3 methylprednisolone tab 16... 64 methylprednisolone tab 32... 64 methylprednisolone tab 4... 64 methylprednisolone tab 4 dose pack... 64 methylprednisolone tab 8... 64 metipranolol ophth soln 0.3%... 93 metoclopramide hcl soln 5 /5ml (10 /10ml)... 80 metoclopramide hcl tab 10... 80 metoclopramide hcl tab 5... 80 metolazone tab 10... 74 metolazone tab 2.5... 74 metolazone tab 5... 74 metoprolol & hydrochlorothiazide tab 100-25... 38 metoprolol & hydrochlorothiazide tab 100-50... 38 metoprolol & hydrochlorothiazide tab 50-25... 38 metoprolol succinate tab sr 24hr 100... 56 metoprolol succinate tab sr 24hr 200... 56 metoprolol succinate tab sr 24hr 25... 56 metoprolol succinate tab sr 24hr 50... 56 metoprolol tartrate tab 100... 56 metoprolol tartrate tab 25... 56 metoprolol tartrate tab 50... 56 133

metronidazole cap 375... 11 metronidazole cream 0.75%... 72 metronidazole gel 0.75%... 72 metronidazole gel 1%... 72 metronidazole lotion 0.75%... 72 metronidazole tab 250... 11 metronidazole tab 500... 11 metronidazole vaginal gel 0.75%... 107 mexiletine hcl cap 150... 14 mexiletine hcl cap 200... 14 mexiletine hcl cap 250... 14 miconazole 3 kit combo pk... 107 miconazole 3 sup 200... 107 midodrine hcl tab 10... 108 midodrine hcl tab 2.5... 108 midodrine hcl tab 5... 108 mimvey tab 1-0.5... 77 minitran dis 0.1/hr... 12 minitran dis 0.2/hr... 12 minitran dis 0.4/hr... 12 minitran dis 0.6/hr... 13 minocycline hcl cap 100... 101 minocycline hcl cap 50... 100 minocycline hcl cap 75... 101 minocycline hcl tab 100... 101 minocycline hcl tab 50... 101 minocycline hcl tab 75... 101 minocycline hcl tab sr 24hr 135... 101 minocycline hcl tab sr 24hr 45... 101 minocycline hcl tab sr 24hr 90... 101 minoxidil tab 10... 39 minoxidil tab 2.5... 39 MIRAPEX ER TAB 2.25MG... 47 MIRAPEX ER TAB 3.75MG... 47 MIRAPEX ER TAB 3MG... 47 MIRAPEX ER TAB 4.5MG... 47 mirtazapine orally disintegrating tab 15... 21 mirtazapine orally disintegrating tab 30... 21 mirtazapine orally disintegrating tab 45... 21 mirtazapine tab 15... 21 mirtazapine tab 30... 21 mirtazapine tab 45... 21 mirtazapine tab 7.5... 21 misoprostol tab 100 mcg... 104 misoprostol tab 200 mcg... 104 mitomycin for iv soln 20... 43 mitomycin for iv soln 40... 43 mitomycin for iv soln 5... 43 mitoxantrone hcl inj conc 20 /10ml (2 /ml)... 43 mitoxantrone hcl inj conc 25 /12.5ml (2 /ml)... 43 mitoxantrone hcl inj conc 30 /15ml (2 /ml)... 43 mitrazol pow 2%... 68 M-M-R II INJ LIVE... 106 modafinil tab 100... 3 modafinil tab 200... 3 moexipril hcl tab 15... 34 moexipril hcl tab 7.5... 34 moexipril-hydrochlorothiazide tab 15-12.5... 38 moexipril-hydrochlorothiazide tab 15-25... 38 moexipril-hydrochlorothiazide tab 7.5-12.5... 38 mometasone furoate cream 0.1%... 71 mometasone furoate oint 0.1%... 71 mometasone furoate solution 0.1% (lotion)... 71 mono-linyah tab 0.25-35... 62 mononessa tab... 62 montelukast sodium chew tab 4 (base equiv)... 15 montelukast sodium chew tab 5 (base equiv)... 15 montelukast sodium oral granules packet 4 (base equiv)... 15 montelukast sodium tab 10 (base equiv)... 15 MONUROL PAK GRANULES... 105 morgidox cap 1x100... 101 MORPHINE SUL SUP 30MG... 7 morphine sulfate (concentrate) oral soln 20 /ml... 7 morphine sulfate beads cap sr 24hr 120... 8 morphine sulfate beads cap sr 24hr 30... 7 morphine sulfate beads cap sr 24hr 45... 7 morphine sulfate beads cap sr 24hr 60... 7 134

morphine sulfate beads cap sr 24hr 75... 7 morphine sulfate beads cap sr 24hr 90... 7 morphine sulfate oral soln 10 /5ml.. 8 morphine sulfate oral soln 20 /5ml.. 8 morphine sulfate suppos 10... 8 morphine sulfate suppos 20... 8 morphine sulfate suppos 5... 8 morphine sulfate tab 15... 8 morphine sulfate tab 30... 8 morphine sulfate tab cr 100... 8 morphine sulfate tab cr 15... 8 morphine sulfate tab cr 200... 8 morphine sulfate tab cr 30... 8 morphine sulfate tab cr 60... 8 MOTOFEN TAB... 29 MOVIPREP SOL... 85 moxifloxacin hcl tab 400 (base equiv)... 80 MOZOBIL INJ... 84 MULTAQ TAB 400MG... 14 MULTI-VIT/FE DRO /FL 0.25... 90 multivit/fl chw 0.25... 90 multivit/fl chw 0.5... 90 multivit/fl chw 1... 90 multi-vit/fl dro 0.25... 90 multi-vit/fl dro 0.5/ml... 90 mupirocin oint 2%... 68 mvc-fluoride chw 0.5... 90 mvc-fluoride chw 1... 90 mycophenolate mofetil cap 250... 54 mycophenolate mofetil for oral susp 200 /ml... 55 mycophenolate mofetil tab 500... 55 mycophenolate sodium tab dr 180 (mycophenolic acid equiv)... 55 mycophenolate sodium tab dr 360 (mycophenolic acid equiv)... 55 MYKIDZ IRON SUS 15/1.5ML... 84 MYLERAN TAB 2MG... 40 myorisan cap 10... 67 myorisan cap 20... 67 myorisan cap 40... 67 MYOZYME INJ 50MG... 76 MYRBETRIQ TAB 25MG... 105 MYRBETRIQ TAB 50MG... 105 myzilra tab... 62 N nabumetone tab 500... 5 nabumetone tab 750... 5 nadolol & bendroflumethiazide tab 40-5... 38 nadolol & bendroflumethiazide tab 80-5... 38 nadolol tab 20... 56 nadolol tab 40... 56 nadolol tab 80... 56 nafrinse chw 1 f... 89 NAFTIN CRE 1%... 68 NAFTIN CRE 2%... 68 NAFTIN GEL 1%... 68 NAFTIN GEL 2%... 68 nalbuphine hcl inj 10 /ml... 10 nalbuphine hcl inj 20 /ml... 10 NALFON CAP 400MG... 5 naltrexone hcl tab 50... 30 NAMENDA SOL 10MG/5ML... 98 NAMENDA TAB 10MG... 98 NAMENDA TAB 5-10MG... 98 NAMENDA TAB 5MG... 98 NAMENDA XR CAP 14MG... 98 NAMENDA XR CAP 21MG... 98 NAMENDA XR CAP 28MG... 98 NAMENDA XR CAP 7MG... 98 NAMENDA XR CAP TITRATIO... 98 naphazoline hcl ophth soln 0.1%... 94 naproxen dr tab 375... 5 naproxen dr tab 500... 5 naproxen sodium tab 275... 5 naproxen sodium tab 550... 5 naproxen susp 125 /5ml... 5 naproxen tab 250... 5 naproxen tab 375... 5 naproxen tab 500... 5 naratriptan hcl tab 1 (base equiv). 87 naratriptan hcl tab 2.5 (base equiv)... 87 NATACYN SUS 5% OP... 94 nateglinide tab 120... 28 nateglinide tab 60... 28 NEBUPENT INH 300MG... 11 necon tab 0.5/35... 62 necon tab 1/35... 62 necon tab 1/50-28... 62 necon tab 7/7/7... 62 135

nefazodone hcl tab 100... 21 nefazodone hcl tab 150... 21 nefazodone hcl tab 200... 21 nefazodone hcl tab 250... 21 nefazodone hcl tab 50... 21 neomycin-polymy-gramicid op sol 1.75-10000-0.025-unt-/ml... 94 neomycin-polymyxin-dexamethasone ophth oint 0.1%... 94 neomycin-polymyxin-dexamethasone ophth susp 0.1%... 94 neomycin-polymyxin-hc ophth susp... 94 neomycin-polymyxin-hc otic soln 1%.. 95 neomycin-polymyxin-hc otic susp 3.5 /ml-10000 unit/ml-1%... 96 NEULASTA INJ 6MG/0.6M... 83 NEUPOGEN INJ 300/0.5... 83 NEUPOGEN INJ 300MCG... 83 NEUPOGEN INJ 480/0.8... 83 NEUPOGEN INJ 480MCG... 83 NEVANAC SUS 0.1%... 95 nevirapine susp 50 /5ml... 52 nevirapine tab 200... 52 nevirapine tab sr 24hr 400... 52 NEXAVAR TAB 200MG... 44 NEXIUM 24HR CAP 20MG... 104 NEXIUM CAP 20MG... 104 NEXIUM CAP 40MG... 104 NEXIUM GRA 10MG DR... 104 NEXIUM GRA 2.5MG DR... 104 NEXIUM GRA 20MG DR... 104 NEXIUM GRA 40MG DR... 104 NEXIUM GRA 5MG DR... 104 niacin tab cr 1000 (antihyperlipidemic)... 34 niacin tab cr 500 (antihyperlipidemic)... 34 niacin tab cr 750 (antihyperlipidemic)... 34 nicardipine hcl cap 20... 57 nicardipine hcl cap 30... 58 nicotine polacrilex gum 2... 99 nicotine polacrilex gum 4... 99 nicotine polacrilex lozenge 2... 99 nicotine polacrilex lozenge 4... 99 nicotine td patch 24hr 14 /24hr... 99 nicotine td patch 24hr 21 /24hr... 99 nicotine td patch 24hr 7 /24hr... 99 NICOTROL INH... 100 NICOTROL NS SPR 10MG/ML... 100 nifedical xl tab 30... 58 nifedical xl tab 60... 58 nifedipine tab sr 24hr 30... 58 nifedipine tab sr 24hr 60... 58 nifedipine tab sr 24hr 90... 58 nifedipine tab sr 24hr osmotic 90.. 58 NILANDRON TAB 150MG... 42 nimodipine cap 30... 58 NIPENT INJ 10MG... 45 nisoldipine tab sr 24hr 17... 58 nisoldipine tab sr 24hr 20... 58 nisoldipine tab sr 24hr 25.5... 58 nisoldipine tab sr 24hr 30... 58 nisoldipine tab sr 24hr 34... 58 nisoldipine tab sr 24hr 40... 58 nisoldipine tab sr 24hr 8.5... 58 NITRO-DUR DIS 0.3MG/HR... 13 NITRO-DUR DIS 0.8MG/HR... 13 nitrofurantoin macrocrystalline cap 100... 105 nitrofurantoin macrocrystalline cap 50... 105 nitrofurantoin monohydrate macrocrystalline cap 100... 105 nitroglycerin cap cr 2.5... 13 nitroglycerin cap cr 6.5... 13 nitroglycerin cap cr 9... 13 nitroglycerin lingual aerosol 400 mcg/spray... 13 nitroglycerin td patch 24hr 0.1 /hr. 13 nitroglycerin td patch 24hr 0.2 /hr. 13 nitroglycerin td patch 24hr 0.4 /hr. 13 nitroglycerin td patch 24hr 0.6 /hr. 13 NITROSTAT SUB 0.3MG... 13 NITROSTAT SUB 0.4MG... 13 NITROSTAT SUB 0.6MG... 13 nizatidine cap 150... 103 nizatidine cap 300... 103 nizatidine oral soln 15 /ml... 103 nora-be tab 0.35... 63 NORDITROPIN INJ 10/1.5ML... 75 NORDITROPIN INJ 15/1.5ML... 75 NORDITROPIN INJ 30/3ML... 75 NORDITROPIN INJ 5/1.5ML... 75 norethindrone & ethinyl estradiol-fe chew tab 0.8-25 mcg... 62 136

norethindrone acetate tab 5... 97 norethindrone tab 0.35... 63 norgestimate & ethinyl estradiol tab 0.25-35 mcg... 62 norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 -mcg... 62 NOROXIN TAB 400MG... 80 NORPACE CAP 100MG CR... 14 NORPACE CAP 150MG CR... 14 nortrel tab 0.5/35... 62 nortrel tab 1/35... 62 nortrel tab 7/7/7... 62 nortriptyline hcl cap 10... 25 nortriptyline hcl cap 25... 26 nortriptyline hcl cap 50... 26 nortriptyline hcl cap 75... 26 nortriptyline hcl soln 10 /5ml... 26 NORTUSS-EX LIQ 200-20/5... 64 NORVIR CAP 100MG... 52 NORVIR SOL 80MG/ML... 52 NORVIR TAB 100MG... 52 novarel inj 10000unt... 75 NOVOLIN INJ 70/30... 28 NOVOLIN N INJ U-100... 28 NOVOLIN R INJ U-100... 28 NOVOLOG INJ 100/ML... 28 NOVOLOG INJ FLEXPEN... 28 NOVOLOG INJ MIX FLEXPEN... 28 NOVOLOG INJ PENFILL... 28 NOVOLOG MIX INJ 70/30... 28 NOXAFIL SUS 40MG/ML... 31 NOXAFIL TAB 100MG... 31 NUCYNTA ER TAB 100MG... 8 NUCYNTA ER TAB 150MG... 8 NUCYNTA ER TAB 200MG... 8 NUCYNTA ER TAB 250MG... 8 NUCYNTA ER TAB 50MG... 8 NUCYNTA TAB 100MG... 8 NUCYNTA TAB 50MG... 8 NUCYNTA TAB 75MG... 8 NUEDEXTA CAP 20-10MG... 99 nulev tab 0.125... 103 NULOJIX INJ 250MG... 55 NUVARING MIS... 63 NUVIGIL TAB 150MG... 3 NUVIGIL TAB 200MG... 3 NUVIGIL TAB 250MG... 3 NUVIGIL TAB 50MG... 3 nyamyc pow 100000... 68 nystatin cream 100000 unit/gm... 68 nystatin oint 100000 unit/gm... 68 nystatin oral powder... 31 nystatin susp 100000 unit/ml... 90 nystatin tab 500000 unit... 31 nystatin-triamcinolone cream 100000-0.1 unit/gm-%... 69 nystatin-triamcinolone oint 100000-0.1 unit/gm-%... 69 nystop pow 100000... 69 O ocella tab 3-0.03... 62 octreotide acetate inj 100 mcg/ml (0.1 /ml)... 76 octreotide acetate inj 1000 mcg/ml (1 /ml)... 77 octreotide acetate inj 200 mcg/ml (0.2 /ml)... 77 octreotide acetate inj 50 mcg/ml (0.05 /ml)... 76 octreotide acetate inj 500 mcg/ml (0.5 /ml)... 77 ofloxacin ophth soln 0.3%... 94 ofloxacin otic soln 0.3%... 95 ogestrel tab... 62 olanzapine tab 10... 49 olanzapine tab 15... 49 olanzapine tab 2.5... 49 olanzapine tab 20... 49 olanzapine tab 5... 49 olanzapine tab 7.5... 49 omega-3-acid ethyl esters cap 1 gm... 32 omeprazole cap delayed release 10... 104 omeprazole cap delayed release 20... 104 omeprazole cap delayed release 40... 104 omeprazole magnesium cap dr 20.6 (20 base equiv)... 104 OMEPRAZOLE TAB 20MG... 104 omeprazole-sodium bicarbonate cap 20-1100... 104 omeprazole-sodium bicarbonate cap 40-1100... 104 OMNIFLEX DPR... 86 ONCASPAR INJ 750/ML... 44 137

ondansetron hcl oral soln 4 /5ml... 30 ondansetron hcl tab 24... 30 ondansetron hcl tab 4... 30 ondansetron hcl tab 8... 30 ondansetron orally disintegrating tab 4... 30 ondansetron orally disintegrating tab 8... 30 ONFI SUS 2.5MG/ML... 18 ONFI TAB 10MG... 19 ONFI TAB 20MG... 19 ONFI TAB 5MG... 18 ONGLYZA TAB 2.5MG... 27 ONGLYZA TAB 5MG... 27 OPANA ER TAB 10MG... 8 OPANA ER TAB 15MG... 8 OPANA ER TAB 20MG... 8 OPANA ER TAB 30MG... 8 OPANA ER TAB 40MG... 8 OPANA ER TAB 5MG... 8 OPANA ER TAB 7.5MG... 8 oralone pst 0.1%... 90 ORAP TAB 1MG... 99 ORAP TAB 2MG... 99 ORENCIA INJ 125MG/ML... 5 ORENCIA INJ 250MG... 5 orphen cpd tab ds... 92 orphenadrine citrate inj 30 /ml... 92 orphenadrine citrate tab sr 12hr 100... 92 orphenadrine w/ aspirin & caffeine tab 25-385-30... 92 orsythia tab... 62 ORTHO COIL DPR KIT 100... 86 ORTHO COIL DPR KIT 105... 86 ORTHO COIL DPR KIT 50... 86 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... 87 ortho-est tab 0.625... 79 ortho-est tab 1.25... 79 oscimin sr tab 0.375... 103 oscimin sub 0.125... 103 oscimin tab 0.125... 103 oscion clnsr lot 6%... 67 oscion clnsr lot 9%... 67 OSMOPREP TAB 1.5GM... 85 oxaliplatin for iv inj 100... 40 oxaliplatin for iv inj 50... 40 oxaliplatin iv soln 100 /20ml... 40 oxaliplatin iv soln 50 /10ml... 40 oxandrolone tab 10... 10 oxandrolone tab 2.5... 10 oxaprozin tab 600... 5 oxazepam cap 10... 14 oxazepam cap 15... 14 oxazepam cap 30... 14 oxcarbazepine susp 300 /5ml (60 /ml)... 20 oxcarbazepine tab 150... 20 oxcarbazepine tab 300... 20 oxcarbazepine tab 600... 20 OXISTAT CRE 1%... 69 OXISTAT LOT 1%... 69 OXSORALEN LOT 1%... 72 oxybutynin chloride syrup 5 /5ml. 105 oxybutynin chloride tab 5... 105 oxybutynin chloride tab sr 24hr 10... 105 oxybutynin chloride tab sr 24hr 15... 105 oxybutynin chloride tab sr 24hr 5 105 oxycodone hcl cap 5... 8 oxycodone hcl conc 100 /5ml (20 /ml)... 8 oxycodone hcl soln 5 /5ml... 8 oxycodone hcl tab 10... 8 oxycodone hcl tab 15... 8 oxycodone hcl tab 20... 8 oxycodone hcl tab 30... 8 oxycodone hcl tab 5... 8 oxycodone hcl tab er 12hr deter 10. 8 oxycodone hcl tab er 12hr deter 20. 8 oxycodone hcl tab er 12hr deter 40. 8 oxycodone hcl tab er 12hr deter 80. 8 oxycodone w/ acetaminophen tab 10-325 138

... 10 oxycodone w/ acetaminophen tab 2.5-325... 9 oxycodone w/ acetaminophen tab 5-325... 10 oxycodone w/ acetaminophen tab 7.5-325... 10 oxycodone-aspirin tab 4.8355-325 10 oxycodone-ibuprofen tab 5-400... 10 OXYCONTIN TAB 10MG CR... 8 OXYCONTIN TAB 15MG CR... 9 OXYCONTIN TAB 20MG CR... 9 OXYCONTIN TAB 30MG CR... 9 OXYCONTIN TAB 40MG CR... 9 OXYCONTIN TAB 60MG CR... 9 OXYCONTIN TAB 80MG CR... 9 oxymorphone hcl tab 10... 9 oxymorphone hcl tab 5... 9 oxymorphone hcl tab sr 12hr 10... 9 oxymorphone hcl tab sr 12hr 15... 9 oxymorphone hcl tab sr 12hr 20... 9 oxymorphone hcl tab sr 12hr 30... 9 oxymorphone hcl tab sr 12hr 40... 9 oxymorphone hcl tab sr 12hr 5... 9 oxymorphone hcl tab sr 12hr 7.5... 9 OXYTROL DIS 3.9MG/24... 105 P pacerone tab 100... 14 pacerone tab 200... 15 paclitaxel iv conc 100 /16.7ml (6 /ml)... 46 paclitaxel iv conc 150 /25ml (6 /ml)... 46 paclitaxel iv conc 30 /5ml (6 /ml)... 46 paclitaxel iv conc 300 /50ml (6 /ml)... 46 pamidronate disodium for inj 30... 75 pamidronate disodium for inj 90... 75 pamidronate disodium iv soln 3 /ml 75 pamidronate disodium iv soln 9 /ml 75 PAMIDRONATE INJ 6MG/ML... 75 pancrelipase (lip-prot-amyl) dr cap 5000-17000-27000 unit... 73 PANRETIN GEL 0.1%... 69 pantoprazole sodium ec tab 20 (base equiv)... 104 pantoprazole sodium ec tab 40 (base equiv)... 104 PARAGARD IUD T380A... 63 paricalcitol cap 1 mcg... 76 paricalcitol cap 2 mcg... 76 paricalcitol cap 4 mcg... 76 paroxetine hcl tab 10... 22 paroxetine hcl tab 20... 22 paroxetine hcl tab 30... 22 paroxetine hcl tab 40... 23 paroxetine hcl tab sr 24hr 12.5... 23 paroxetine hcl tab sr 24hr 25... 23 paroxetine hcl tab sr 24hr 37.5... 23 PATADAY SOL 0.2%... 95 PATANOL SOL 0.1% OP... 95 PAXIL SUS 10MG/5ML... 23 pedia d-vite dro 400unit... 108 PEDIARIX INJ 0.5ML... 102 PEDIATRIC RESPIRATORY MASK... 87 PEDVAX HIB INJ... 106 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm... 85 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm... 85 peg 3350-kcl-sod bicarb-nacl for soln 420 gm... 85 PEGASYS INJ... 53 PEGASYS INJ 180MCG/M... 53 PEGASYS INJ PROCLICK... 53 PEGASYS KIT... 53 PEG-INTRON KIT 120 RP... 53 PEG-INTRON KIT 150MCG... 53 PEG-INTRON KIT 50MCG RP... 53 PEG-INTRON KIT 80MCG... 53 penicillin v potassium for soln 125 /5ml... 96 penicillin v potassium for soln 250 /5ml... 96 penicillin v potassium tab 250... 96 penicillin v potassium tab 500... 96 PENTACEL INJ... 102 PENTAM 300 INJ 300MG... 11 pentoxifylline tab cr 400... 82 PERFOROMIST NEB 20MCG... 17 perindopril erbumine tab 2... 34 perindopril erbumine tab 4... 34 perindopril erbumine tab 8... 34 periogard sol 0.12%... 90 permethrin cream 5%... 73 139

permethrin lotion 1%... 73 perphenazine tab 16... 50 perphenazine tab 2... 50 perphenazine tab 4... 50 perphenazine tab 8... 50 persa-gel xs gel 5%... 67 PEXEVA TAB 10MG... 23 PEXEVA TAB 20MG... 23 PEXEVA TAB 30MG... 23 PEXEVA TAB 40MG... 23 phenazopyridine hcl tab 100... 82 phenazopyridine hcl tab 200... 82 phenelzine sulfate tab 15... 22 phenobarbital elixir 20 /5ml... 84 phenobarbital tab 100... 84 phenobarbital tab 15... 84 phenobarbital tab 16.2... 84 phenobarbital tab 30... 84 phenobarbital tab 32.4... 84 phenobarbital tab 60... 84 phenobarbital tab 64.8... 84 phenobarbital tab 97.2... 84 phenylephrine hcl ophth soln 10%... 94 phenylephrine hcl ophth soln 2.5%... 94 PHENYLHIST LIQ DH... 64 phenytoin chew tab 50... 20 phenytoin sodium extended cap 100... 20 phenytoin sodium extended cap 200... 21 phenytoin sodium extended cap 300... 21 phenytoin susp 125 /5ml... 21 PHISOHEX LIQ 3%... 51 PHOSPHOLINE SOL 0.125%OP... 93 PHOTOFRIN INJ 75MG... 45 PICATO GEL 0.015%... 69 PICATO GEL 0.05%... 69 pilocarpine hcl tab 5... 90 pilocarpine hcl tab 7.5... 90 PILOPINE HS GEL 4% OP... 93 pindolol tab 10... 56 pindolol tab 5... 56 pioglitazone hcl tab 15 (base equiv)... 28 pioglitazone hcl tab 30 (base equiv)... 28 pioglitazone hcl tab 45 (base equiv)... 28 pioglitazone hcl-glimepiride tab 30-2... 27 pioglitazone hcl-glimepiride tab 30-4... 27 pioglitazone hcl-metformin hcl tab 15-500... 27 pioglitazone hcl-metformin hcl tab 15-850... 27 piroxicam cap 10... 5 piroxicam cap 20... 5 PNEUMOVAX 23 INJ 25/0.5... 106 podofilox soln 0.5%... 72 polycin oin op... 94 poly-dex oin 0.1% op... 94 polyethylene glycol 3350 oral packet.. 85 polyethylene glycol 3350 oral powder. 85 polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1%... 94 POMALYST CAP 1MG... 45 POMALYST CAP 2MG... 45 POMALYST CAP 3MG... 45 POMALYST CAP 4MG... 45 portia-28 tab... 62 potassium chloride cap cr 10 meq... 89 potassium chloride cap cr 8 meq... 89 potassium chloride microencapsulated crys cr tab 10 meq... 89 potassium chloride microencapsulated crys cr tab 20 meq... 89 potassium chloride oral liq 10% (20 meq/15ml)... 89 potassium chloride oral liq 20% (40 meq/15ml)... 89 potassium chloride tab cr 10 meq... 89 POTASSIUM CHLORIDE TAB CR 20 MEQ (1500 MG)... 90 potassium chloride tab cr 8 meq (600 )... 89 potassium citrate tab cr 10 meq (1080 )... 81 potassium citrate tab cr 15 meq (1620 )... 81 potassium citrate tab cr 5 meq (540 )... 81 POTIGA TAB 200MG... 20 POTIGA TAB 300MG... 20 POTIGA TAB 400MG... 20 140

POTIGA TAB 50MG... 20 pr benzoyl liq 7% wash... 67 PRADAXA CAP 150MG... 18 PRADAXA CAP 75MG... 18 pramipexole dihydrochloride tab 0.125... 47 pramipexole dihydrochloride tab 0.25... 47 pramipexole dihydrochloride tab 0.5... 47 pramipexole dihydrochloride tab 0.75... 47 pramipexole dihydrochloride tab 1. 47 pramipexole dihydrochloride tab 1.5... 47 pramipexole dihydrochloride tab sr 24hr 0.375... 48 pramipexole dihydrochloride tab sr 24hr 0.75... 47 pramipexole dihydrochloride tab sr 24hr 1.5... 48 pramox gel 1%... 72 pravastatin sodium tab 10... 33 pravastatin sodium tab 20... 33 pravastatin sodium tab 40... 34 pravastatin sodium tab 80... 34 prazosin hcl cap 1... 36 prazosin hcl cap 2... 36 prazosin hcl cap 5... 36 PRED MILD SUS 0.12% OP... 94 PRED SOD PHO SOL 1% OP... 94 prednisolone acetate ophth susp 1%... 94 prednisolone sod phosph oral soln 6.7 /5ml (5 /5ml base)... 64 prednisolone sod phosphate oral soln 15 /5ml (base equiv)... 64 prednisolone sodium phosphate oral soln 25 /5ml (base eq)... 64 prednisolone syrup 15 /5ml (usp solution equivalent)... 64 PREDNISONE CON 5MG/ML... 64 prednisone oral soln 5 /5ml... 64 prednisone tab 1... 64 prednisone tab 10... 64 prednisone tab 10 dose pack... 64 prednisone tab 2.5... 64 prednisone tab 20... 64 prednisone tab 5... 64 prednisone tab 5 dose pack... 64 prednisone tab 50... 64 pregnyl inj 10000unt... 75 PREMARIN TAB 0.3MG... 79 PREMARIN TAB 0.45MG... 80 PREMARIN TAB 0.625MG... 80 PREMARIN TAB 0.9MG... 79 PREMARIN TAB 1.25MG... 80 PREMARIN VAG CRE 0.625MG... 107 prenatabs rx tab... 91 PRENTIF MIS 22MM... 87 PRENTIF MIS 25MM... 87 PRENTIF MIS 28MM... 87 PRENTIF MIS 31MM... 87 PRENTIF MIS FITTING... 87 PREPOPIK PAK... 85 prevalite pow 4gm... 33 previfem tab... 62 PREVNAR 13 INJ... 106 PREZCOBIX TAB 800-150... 52 PREZISTA SUS 100MG/ML... 52 PREZISTA TAB 150MG... 52 PREZISTA TAB 400MG... 52 PREZISTA TAB 600MG... 52 PREZISTA TAB 75MG... 52 PREZISTA TAB 800MG... 52 PRIFTIN TAB 150MG... 39 PRIMAQUINE TAB 26.3MG... 39 primidone tab 250... 20 primidone tab 50... 20 PRIMLEV TAB 10-300MG... 10 PRIMLEV TAB 5-300MG... 10 PRIMLEV TAB 7.5-300... 10 PRIMSOL SOL 50MG/5ML... 11 PRISTIQ TAB 100MG... 23 PRISTIQ TAB 25MG... 23 PRISTIQ TAB 50MG... 23 PROAIR HFA AER... 17 probenecid tab 500... 82 procainamide hcl inj 100 /ml... 14 PROCAINAMIDE INJ 500MG/ML... 14 prochlorperazine maleate tab 10 (base equivalent)... 50 prochlorperazine maleate tab 5 (base equivalent)... 50 prochlorperazine suppos 25... 50 PROCRIT INJ 10000/ML... 84 PROCRIT INJ 2000/ML... 83 141

PROCRIT INJ 20000/ML... 84 PROCRIT INJ 3000/ML... 83 PROCRIT INJ 4000/ML... 84 PROCRIT INJ 40000/ML... 84 proctosol hc cre 2.5%... 11 progesterone micronized cap 100.. 97 progesterone micronized cap 200.. 97 PROGLYCEM SUS 50MG/ML... 27 PROLASTIN-C INJ 1000MG... 100 PROLIA SOL 60MG/ML... 75 PROMACTA TAB 12.5MG... 84 PROMACTA TAB 25MG... 84 PROMACTA TAB 50MG... 84 PROMACTA TAB 75MG... 84 prometh vc syp plain... 64 prometh vc/ syp codeine... 64 promethazine hcl syrup 6.25 /5ml.. 32 promethazine hcl tab 12.5... 32 promethazine hcl tab 25... 32 promethazine hcl tab 50... 32 promethazine w/ codeine syrup 6.25-10 /5ml... 64 promethazine-dm syrup 6.25-15 /5ml... 64 propafenone hcl cap sr 12hr 225... 14 propafenone hcl cap sr 12hr 325... 14 propafenone hcl cap sr 12hr 425... 14 propafenone hcl tab 150... 14 propafenone hcl tab 225... 14 propafenone hcl tab 300... 14 propranolol & hydrochlorothiazide tab 40-25... 38 propranolol & hydrochlorothiazide tab 80-25... 38 propranolol hcl cap sr 24hr 120... 56 propranolol hcl cap sr 24hr 160... 56 propranolol hcl cap sr 24hr 60... 56 propranolol hcl cap sr 24hr 80... 56 propranolol hcl oral soln 20 /5ml... 56 propranolol hcl oral soln 40 /5ml... 56 propranolol hcl tab 10... 56 propranolol hcl tab 20... 56 propranolol hcl tab 40... 56 propranolol hcl tab 60... 56 propranolol hcl tab 80... 56 propylthiouracil tab 50... 101 PROQUAD INJ... 106 protriptyline hcl tab 10... 26 protriptyline hcl tab 5... 26 prudoxin cre 5%... 69 PULMICORT INH 180MCG... 16 PULMICORT INH 90MCG... 15 PULMICORT SUS 1MG/2ML... 16 pyrazinamide tab 500... 39 pyridostigmine bromide tab 60... 39 Q QUADRAMET INJ... 44 quasense tab... 62 quetiapine fumarate tab 100... 50 quetiapine fumarate tab 200... 50 quetiapine fumarate tab 25... 50 quetiapine fumarate tab 300... 50 quetiapine fumarate tab 400... 50 quetiapine fumarate tab 50... 50 quinapril hcl tab 10... 34 quinapril hcl tab 20... 34 quinapril hcl tab 40... 34 quinapril hcl tab 5... 34 quinapril-hydrochlorothiazide tab 10-12.5... 38 quinapril-hydrochlorothiazide tab 20-12.5... 38 quinapril-hydrochlorothiazide tab 20-25... 38 quinine sulfate cap 324... 39 quinine sulfate tab 260... 39 QVAR AER 40MCG... 16 QVAR AER 80MCG... 16 R rabeprazole sodium ec tab 20... 104 raloxifene hcl tab 60... 76 ramipril cap 1.25... 35 ramipril cap 10... 35 ramipril cap 2.5... 35 ramipril cap 5... 35 RANEXA TAB 1000MG... 12 RANEXA TAB 500MG... 12 ranitidine hcl cap 150... 103 ranitidine hcl cap 300... 103 ranitidine hcl syrup 15 /ml (75 /5ml)... 103 ranitidine hcl tab 150... 103 ranitidine hcl tab 300... 103 RAPAFLO CAP 4MG... 82 RAPAFLO CAP 8MG... 82 RAPAMUNE SOL 1MG/ML... 55 142

REBETOL SOL 40MG/ML... 53 reclipsen tab... 62 RECOMBIVA HB INJ 10MCG/ML... 106 RECOMBIVA HB INJ 5MCG/0.5... 106 RECOMBIVA-HB INJ 40MCG/ML... 106 RECTIV OIN 0.4%... 11 REGRANEX GEL 0.01%... 73 RELENZA MIS DISKHALE... 54 RELPAX TAB 20MG... 87 RELPAX TAB 40MG... 88 REMODULIN INJ 10MG/ML... 59 REMODULIN INJ 1MG/ML... 59 REMODULIN INJ 2.5MG/ML... 59 REMODULIN INJ 5MG/ML... 59 RENVELA PAK 0.8GM... 81 RENVELA PAK 2.4GM... 81 RENVELA TAB 800MG... 81 repaglinide tab 0.5... 28 repaglinide tab 1... 28 repaglinide tab 2... 28 RESCRIPTOR TAB 100 MG... 52 RESCRIPTOR TAB 200MG... 52 RESTASIS EMU 0.05%... 94 REVATIO INJ... 59 REVLIMID CAP 10MG... 54 REVLIMID CAP 15MG... 54 REVLIMID CAP 2.5MG... 54 REVLIMID CAP 20MG... 54 REVLIMID CAP 25MG... 54 REVLIMID CAP 5MG... 54 REYATAZ CAP 100MG... 52 REYATAZ CAP 150MG... 52 REYATAZ CAP 200MG... 52 REYATAZ CAP 300MG... 52 REYATAZ POW 50MG... 52 ribasphere cap 200... 53 ribasphere tab 200... 53 ribasphere tab 400... 53 ribasphere tab 600... 53 ribavirin cap 200... 53 ribavirin tab 200... 53 rifabutin cap 150... 40 RIFAMATE CAP... 39 rifampin cap 150... 40 rifampin cap 300... 40 RIFATER TAB... 39 riluzole tab 50... 93 rimantadine hydrochloride tab 100 54 risedronate sodium tab 150... 75 risedronate sodium tab delayed release 35... 75 RISPERDAL INJ 12.5MG... 49 RISPERDAL INJ 25MG... 49 RISPERDAL INJ 37.5MG... 49 RISPERDAL INJ 50MG... 49 risperidone orally disintegrating tab 0.25... 49 risperidone orally disintegrating tab 0.5... 49 risperidone orally disintegrating tab 1... 49 risperidone orally disintegrating tab 2... 49 risperidone orally disintegrating tab 3... 49 risperidone orally disintegrating tab 4... 49 risperidone soln 1 /ml... 49 risperidone tab 0.25... 49 risperidone tab 0.5... 49 risperidone tab 1... 49 risperidone tab 2... 49 risperidone tab 3... 49 risperidone tab 4... 49 RITALIN LA CAP 10MG... 3 RITALIN LA CAP 60MG... 3 RITUXAN INJ 100MG... 41 rivastigmine tartrate cap 1.5... 98 rivastigmine tartrate cap 3... 98 rivastigmine tartrate cap 4.5... 98 rivastigmine tartrate cap 6... 98 rizatriptan benzoate orally disintegrating tab 10... 88 rizatriptan benzoate orally disintegrating tab 5... 88 rizatriptan benzoate tab 10... 88 rizatriptan benzoate tab 5... 88 romycin oin op... 94 ropinirole hydrochloride tab 0.25.. 48 ropinirole hydrochloride tab 0.5... 48 ropinirole hydrochloride tab 1... 48 ropinirole hydrochloride tab 2... 48 ropinirole hydrochloride tab 3... 48 ropinirole hydrochloride tab 4... 48 ropinirole hydrochloride tab 5... 48 rosadan cre 0.75%... 72 143

ROTARIX SUS... 107 ROTATEQ SOL... 107 ROXICET SOL 5-325/5... 10 roxicet tab 5-325... 10 ROZEREM TAB 8MG... 85 S SABRIL POW 500MG... 20 SABRIL TAB 500MG... 20 SAMSCA TAB 15MG... 77 SAMSCA TAB 30MG... 77 SANCUSO DIS 3.1MG... 30 SANTYL OIN 250/GM... 72 SAPHRIS SUB 10MG... 50 SAPHRIS SUB 2.5MG... 50 SAPHRIS SUB 5MG... 50 SAVELLA MIS TITR PAK... 98 SAVELLA TAB 100MG... 98 SAVELLA TAB 12.5MG... 98 SAVELLA TAB 25MG... 98 SAVELLA TAB 50MG... 98 scalacort lot 2%... 71 selegiline hcl cap 5... 48 selegiline hcl tab 5... 48 selenium sulfide lotion 2.5%... 69 SELENIUM SULFIDE-PYRITHIONE ZINC IN UREA SHAMPOO 2.25%... 69 SELZENTRY TAB 150MG... 52 SELZENTRY TAB 300MG... 52 SENSIPAR TAB 30MG... 76 SENSIPAR TAB 60MG... 76 SENSIPAR TAB 90MG... 76 SEREVENT DIS AER 50MCG... 17 SEROQUEL XR TAB 150MG... 50 SEROQUEL XR TAB 200MG... 50 SEROQUEL XR TAB 300MG... 50 SEROQUEL XR TAB 400MG... 50 SEROQUEL XR TAB 50MG... 50 sertraline hcl oral conc 20 /ml... 23 sertraline hcl tab 100... 23 sertraline hcl tab 25... 23 sertraline hcl tab 50... 23 SHUR-SEAL GEL 2%... 107 sildenafil citrate tab 20... 59 silver sulfadiazine cream 1%... 70 SIMULECT INJ 10MG... 55 SIMULECT INJ 20MG... 55 simvastatin tab 10... 34 simvastatin tab 20... 34 simvastatin tab 40... 34 simvastatin tab 5... 34 simvastatin tab 80... 34 sirolimus tab 0.5... 55 sirolimus tab 1... 55 sirolimus tab 2... 55 SIVEXTRO INJ 200MG... 12 SKLICE LOT 0.5%... 73 sm nicotine dis 14/24h... 100 sm nicotine dis 21... 100 sm nicotine dis 7/24hr... 100 sm vitamin d tab 400unit... 108 SOD EDECRIN INJ 50MG... 74 sodium chloride flush iv soln 0.9%... 90 sodium chloride inj 0.45%... 90 sodium chloride inj 0.9%... 90 sodium chloride inj 2.5 meq/ml (14.6%)... 90 sodium chloride inj 3%... 90 sodium chloride inj 4 meq/ml (23.4%) 90 sodium chloride inj 5%... 90 sodium chloride irrigation soln 0.9%... 81 sodium chloride iv soln 0.9%... 90 sodium chloride soln nebu 0.9%... 65 sodium chloride soln nebu 10%... 65 sodium chloride soln nebu 3%... 65 sodium chloride soln nebu 7%... 65 sodium fluoride chew tab 0.25 f (from 0.55 naf)... 89 sodium fluoride chew tab 0.5 f (from 1.1 naf)... 89 sodium fluoride chew tab 1 f (from 2.2 naf)... 89 sodium fluoride soln 0.5 /ml f (from 1.1 /ml naf)... 89 sodium fluoride tab 0.5 f (from 1.1 naf)... 89 sodium fluoride tab 1 f (from 2.2 naf)... 89 sodium polystyrene sulfonate oral susp 15 gm/60ml... 55 sodium polystyrene sulfonate rectal susp 30 gm/120ml... 55 solia tab... 62 SOMATULINE INJ 120/.5ML... 77 SOMATULINE INJ 60/0.2ML... 77 SOMATULINE INJ 90/0.3ML... 77 SOMAVERT INJ 10MG... 75 144

SOMAVERT INJ 15MG... 75 SOMAVERT INJ 20MG... 75 SOMAVERT INJ 25MG... 75 SOMAVERT INJ 30MG... 75 sorine tab 120... 56 sorine tab 160... 56 sorine tab 240... 56 sorine tab 80... 56 sotalol hcl (afib/afl) tab 120... 56 sotalol hcl (afib/afl) tab 160... 56 sotalol hcl (afib/afl) tab 80... 56 sotalol hcl tab 120... 56 sotalol hcl tab 160... 56 sotalol hcl tab 240... 56 sotalol hcl tab 80... 56 SOVALDI TAB 400MG... 53 spinosad susp 0.9%... 73 SPIRIVA CAP HANDIHLR... 15 SPIRIVA SPR RESPIMAT... 15 spironolactone & hydrochlorothiazide tab 25-25... 73 spironolactone tab 100... 74 spironolactone tab 25... 74 spironolactone tab 50... 74 SPORANOX SOL 10MG/ML... 31 sprintec 28 tab 28 day... 62 SPRYCEL TAB 100MG... 44 SPRYCEL TAB 140MG... 44 SPRYCEL TAB 20MG... 44 SPRYCEL TAB 50MG... 44 SPRYCEL TAB 70MG... 44 SPRYCEL TAB 80MG... 44 sronyx tab... 62 ssd cre 1%... 70 stavudine cap 15... 52 stavudine cap 20... 52 stavudine cap 30... 52 stavudine cap 40... 52 stavudine for oral soln 1 /ml... 52 STELARA INJ 45MG/0.5... 69 STELARA INJ 90MG/ML... 69 STIVARGA TAB 40MG... 44 STRATTERA CAP 100MG... 2 STRATTERA CAP 10MG... 2 STRATTERA CAP 18MG... 2 STRATTERA CAP 25MG... 2 STRATTERA CAP 40MG... 2 STRATTERA CAP 60MG... 2 STRATTERA CAP 80MG... 2 streptomycin sulfate for inj 1 gm... 3 STRIBILD TAB... 52 SUBOXONE MIS 12-3MG... 10 SUBOXONE MIS 2-0.5MG... 10 SUBOXONE MIS 4-1MG... 10 SUBOXONE MIS 8-2MG... 10 SUCRAID SOL 8500/ML... 73 sucralfate tab 1 gm... 103 sulfacetamide sodium lotion 10% (acne)... 67 sulfacetamide sodium ophth soln 10% 94 sulfacetamide sodium w/ sulfur cleansing cloth 10-5%... 67 sulfacetamide sodium w/ sulfur cleansing pad 10-4%... 67 sulfacetamide sodium w/ sulfur cream 10-5%... 67 sulfacetamide sodium w/ sulfur lotion 10-5%... 67 sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)%... 94 SULFADIAZINE TAB 500MG... 100 sulfamethoxazole-trimethoprim susp 200-40 /5ml... 11 sulfamethoxazole-trimethoprim tab 400-80... 11 sulfamethoxazole-trimethoprim tab 800-160... 12 sulfasalazine tab 500... 81 sulfasalazine tab delayed release 500... 81 sulindac tab 150... 5 sulindac tab 200... 5 sumatriptan nasal spray 20 /act... 88 sumatriptan nasal spray 5 /act... 88 sumatriptan succinate inj 4 /0.5ml. 88 sumatriptan succinate inj 6 /0.5ml. 88 sumatriptan succinate solution auto-injector 4 /0.5ml... 88 sumatriptan succinate solution auto-injector 6 /0.5ml... 88 sumatriptan succinate solution cartridge 4 /0.5ml... 88 sumatriptan succinate solution cartridge 6 /0.5ml... 88 sumatriptan succinate solution prefilled syringe 6 /0.5ml... 88 145

sumatriptan succinate tab 100... 88 sumatriptan succinate tab 25... 88 sumatriptan succinate tab 50... 88 SUPRAX CAP 400MG... 60 SUPRAX CHW 100MG... 60 SUPRAX CHW 200MG... 60 SUPRAX SUS 500/5ML... 60 SUPRAX TAB 400MG... 60 SUPREP BOWEL SOL PREP... 85 SURMONTIL CAP 100MG... 26 SURMONTIL CAP 25MG... 26 SURMONTIL CAP 50MG... 26 SUSTIVA CAP 200MG... 52 SUSTIVA CAP 50MG... 52 SUSTIVA TAB 600MG... 52 SUTENT CAP 12.5MG... 44 SUTENT CAP 25MG... 44 SUTENT CAP 37.5MG... 44 SUTENT CAP 50MG... 44 syeda tab 3-0.03... 62 symax fastab tab 0.125... 103 symax-sl sub 0.125... 103 SYMBICORT AER 160-4.5... 17 SYMBICORT AER 80-4.5... 17 SYMLINPEN 60 INJ 1000MCG... 26 SYMLNPEN 120 INJ 1000MCG... 26 SYNAREL SOL 2MG/ML... 76 SYNERA DIS 70-70MG... 72 SYNTHROID TAB 100MCG... 102 SYNTHROID TAB 112MCG... 102 SYNTHROID TAB 125MCG... 102 SYNTHROID TAB 137MCG... 102 SYNTHROID TAB 150MCG... 102 SYNTHROID TAB 175MCG... 102 SYNTHROID TAB 200MCG... 102 SYNTHROID TAB 25MCG... 101 SYNTHROID TAB 300MCG... 102 SYNTHROID TAB 50MCG... 101 SYNTHROID TAB 75MCG... 101 SYNTHROID TAB 88MCG... 102 SYPRINE CAP 250MG... 54 T TABLOID TAB 40MG... 41 TACLONEX SUS... 71 tacrolimus cap 0.5... 55 tacrolimus cap 1... 55 tacrolimus cap 5... 55 tacrolimus oint 0.03%... 72 tacrolimus oint 0.1%... 72 TAFINLAR CAP 50MG... 44 TAFINLAR CAP 75MG... 44 TAMIFLU CAP 30MG... 54 TAMIFLU CAP 45MG... 54 TAMIFLU CAP 75MG... 54 TAMIFLU SUS 6MG/ML... 54 tamoxifen citrate tab 10 (base equivalent)... 42 tamoxifen citrate tab 20 (base equivalent)... 42 tamsulosin hcl cap 0.4... 82 TARCEVA TAB 100MG... 44 TARCEVA TAB 150MG... 44 TARCEVA TAB 25MG... 44 TARGRETIN CAP 75MG... 45 TARON-BC MIS... 91 TASIGNA CAP 150MG... 44 TASIGNA CAP 200MG... 44 tazicef inj 1gm... 60 tazicef inj 2gm... 60 tazicef inj 6gm... 60 TAZORAC CRE 0.05%... 69 TAZORAC CRE 0.1%... 69 TAZORAC GEL 0.05%... 69 TAZORAC GEL 0.1%... 69 taztia xt cap 120/24... 58 taztia xt cap 180/24... 58 taztia xt cap 240/24... 58 taztia xt cap 300/24... 58 taztia xt cap 360/24... 58 TECFIDERA CAP 120MG... 99 TECFIDERA CAP 240MG... 99 TECFIDERA MIS STARTER... 99 TEGRETOL-XR TAB 100MG... 20 TEKTURNA TAB 150MG... 39 TEKTURNA TAB 300MG... 39 telmisartan tab 20... 35 telmisartan tab 40... 35 telmisartan tab 80... 35 telmisartan-amlodipine tab 40-10. 38 telmisartan-amlodipine tab 40-5... 38 telmisartan-amlodipine tab 80-10. 38 telmisartan-amlodipine tab 80-5... 38 telmisartan-hydrochlorothiazide tab 40-12.5... 38 telmisartan-hydrochlorothiazide tab 80-12.5... 38 146

telmisartan-hydrochlorothiazide tab 80-25... 38 temazepam cap 15... 85 temazepam cap 22.5... 85 temazepam cap 30... 85 temazepam cap 7.5... 85 TEMODAR INJ 100MG... 40 temozolomide cap 100... 40 temozolomide cap 140... 40 temozolomide cap 180... 40 temozolomide cap 20... 40 temozolomide cap 250... 40 temozolomide cap 5... 40 TENIPOSIDE INJ 50MG/5ML... 46 TENIVAC INJ 5-2LF... 102 terazosin hcl cap 1... 36 terazosin hcl cap 10... 36 terazosin hcl cap 2... 36 terazosin hcl cap 5... 36 terbinafine cre 1%... 69 terbinafine hcl tab 250... 31 terbutaline sulfate tab 2.5... 17 terbutaline sulfate tab 5... 17 terconazole vaginal cream 0.4%... 107 terconazole vaginal suppos 80... 107 testosterone cypionate im inj in oil 100 /ml... 11 testosterone cypionate im inj in oil 200 /ml... 11 testosterone enanthate im inj in oil 200 /ml... 11 TET/DIP TOX INJ 2-2 LF... 102 tetracycline hcl cap 250... 101 tetracycline hcl cap 500... 101 tgq 50pse/3 syp brm/30dm... 64 THALOMID CAP 100MG... 54 THALOMID CAP 150MG... 54 THALOMID CAP 200MG... 54 THALOMID CAP 50MG... 54 theochron tab 100 cr... 17 theochron tab 200 cr... 17 theochron tab 300 cr... 17 theophylline tab sr 12hr 450... 17 theophylline tab sr 24hr 400... 17 theophylline tab sr 24hr 600... 17 THERACYS INJ... 45 thioridazine hcl tab 10... 50 thioridazine hcl tab 100... 50 thioridazine hcl tab 25... 50 thioridazine hcl tab 50... 50 thiothixene cap 1... 51 thiothixene cap 10... 51 thiothixene cap 2... 51 thiothixene cap 5... 51 thrive gum 4 mint... 100 tiagabine hcl tab 2... 20 tiagabine hcl tab 4... 20 TICE BCG INJ... 45 TIKOSYN CAP 125MCG... 15 TIKOSYN CAP 250MCG... 15 TIKOSYN CAP 500MCG... 15 tilia fe tab... 62 timolol maleate ophth gel forming soln 0.25%... 93 timolol maleate ophth gel forming soln 0.5%... 93 timolol maleate ophth soln 0.25%... 93 timolol maleate ophth soln 0.5%... 93 timolol maleate tab 10... 56 timolol maleate tab 20... 56 timolol maleate tab 5... 56 TIMOPTIC OCU SOL 0.25% OP... 93 TIMOPTIC OCU SOL 0.5% OP... 93 tinidazole tab 250... 11 tinidazole tab 500... 11 TIVICAY TAB 50MG... 52 tizanidine hcl tab 2 (base equivalent)... 92 tizanidine hcl tab 4 (base equivalent)... 92 TOBRADEX OIN 0.3-0.1%... 95 tobramycin nebu soln 300 /5ml... 4 tobramycin ophth soln 0.3%... 94 tobramycin-dexamethasone ophth susp 0.3-0.1%... 95 TOBREX OIN 0.3% OP... 94 TODAY SPONGE MIS... 87 tolbutamide tab 500... 29 tolcapone tab 100... 47 tolmetin sodium cap 400... 5 tolmetin sodium tab 200... 5 tolmetin sodium tab 600... 5 tolnaftate aerosol pow 1%... 69 tolnaftate soln 1%... 69 tolterodine tartrate cap sr 24hr 2 105 tolterodine tartrate cap sr 24hr 4 105 147

tolterodine tartrate tab 1... 105 tolterodine tartrate tab 2... 105 topiramate sprinkle cap 15... 20 topiramate sprinkle cap 25... 20 topiramate tab 100... 20 topiramate tab 200... 20 topiramate tab 25... 20 topiramate tab 50... 20 toposar inj 100/5ml... 46 toposar inj 20/ml... 46 topotecan hcl for inj 4... 46 TOPOTECAN INJ 4MG/4ML... 46 TORISEL SOL 25MG/ML... 44 torsemide tab 10... 74 torsemide tab 100... 74 torsemide tab 20... 74 torsemide tab 5... 74 TOVIAZ TAB 4MG... 105 TOVIAZ TAB 8MG... 105 TRACLEER TAB 125MG... 59 TRACLEER TAB 62.5MG... 59 TRADJENTA TAB 5MG... 27 tramadol hcl tab 50... 9 tramadol hcl tab sr 24hr 100... 9 tramadol hcl tab sr 24hr 200... 9 tramadol hcl tab sr 24hr 300... 9 trandolapril tab 1... 35 trandolapril tab 2... 35 trandolapril tab 4... 35 trandolapril-verapamil hcl tab cr 1-240... 38 trandolapril-verapamil hcl tab cr 2-180... 38 trandolapril-verapamil hcl tab cr 2-240... 38 trandolapril-verapamil hcl tab cr 4-240... 38 tranexamic acid inj 100 /ml... 84 tranexamic acid tab 650... 84 TRANSDERM-SC DIS 1MG... 30 tranylcypromine sulfate tab 10... 22 TRAVATAN Z DRO 0.004%... 95 trazodone hcl tab 100... 22 trazodone hcl tab 150... 22 trazodone hcl tab 300... 22 trazodone hcl tab 50... 22 TRECATOR TAB 250MG... 40 tretinoin cap 10... 45 tretinoin cream 0.025%... 67 tretinoin cream 0.05%... 67 tretinoin cream 0.1%... 67 tretinoin gel 0.01%... 67 tretinoin gel 0.025%... 67 triamcinolone acetonide cream 0.025%... 71 triamcinolone acetonide cream 0.1%.. 71 triamcinolone acetonide cream 0.5%.. 71 triamcinolone acetonide dental paste 0.1%... 90 triamcinolone acetonide lotion 0.025% 71 triamcinolone acetonide lotion 0.1%... 71 triamcinolone acetonide nasal aerosol suspension 55 mcg/act... 92 triamcinolone acetonide oint 0.025%.. 72 triamcinolone acetonide oint 0.1%... 71 triamcinolone acetonide oint 0.5%... 72 triamterene & hydrochlorothiazide cap 37.5-25... 73 triamterene & hydrochlorothiazide cap 50-25... 74 triamterene & hydrochlorothiazide tab 37.5-25... 74 triamterene & hydrochlorothiazide tab 75-50... 74 TRICODE AR LIQ... 64 triderm cre 0.1%... 72 trifluoperazine hcl tab 1... 50 trifluoperazine hcl tab 10... 50 trifluoperazine hcl tab 2... 50 trifluoperazine hcl tab 5... 50 trifluridine ophth soln 1%... 94 trihexyphenidyl hcl elixir 0.4 /ml... 46 trihexyphenidyl hcl tab 2... 47 trihexyphenidyl hcl tab 5... 47 tri-linyah tab... 62 trimethobenzamide hcl cap 300... 30 trimethoprim tab 100... 11 trinessa tab... 62 TRIPEDIA SUS P/F... 102 triple antib oin... 68 triple paste oin af 2%... 69 tri-previfem tab... 62 TRISENOX SOL 10MG/10M... 45 tri-sprintec tab... 62 TRIUMEQ TAB... 52 tri-vit/fe dro /fl 0.25... 90 148

tri-vit/fl dro 0.25... 90 tri-vit/fl dro 0.5... 90 trivora-28 tab... 62 tropicamide ophth soln 0.5%... 93 tropicamide ophth soln 1%... 93 trospium chloride cap sr 24hr 60. 106 trospium chloride tab 20... 106 TRUMENBA INJ... 106 TRUVADA TAB 200-300... 52 tussigon tab 5... 64 TWINRIX INJ... 107 TYBOST TAB 150MG... 52 TYKERB TAB 250MG... 44 TYSABRI INJ 300/15ML... 99 TYVASO START SOL 0.6MG/ML... 59 TYZEKA TAB 600MG... 54 TYZINE PED DRO 0.05%... 92 TYZINE SOL 0.1%... 92 U ULESFIA LOT 5%... 73 ULORIC TAB 40MG... 82 ULORIC TAB 80MG... 82 ULTRESA CAP 13800UNT... 73 ULTRESA CAP 20700UNT... 73 ULTRESA CAP 23000UNT... 73 unithroid tab 100mcg... 102 unithroid tab 112mcg... 102 unithroid tab 125mcg... 102 unithroid tab 200mcg... 102 unithroid tab 25mcg... 102 unithroid tab 300mcg... 102 unithroid tab 50mcg... 102 unithroid tab 75mcg... 102 unithroid tab 88mcg... 102 univert tab 32... 30 URINE TEST STRIPS... 87 ursodiol cap 300... 80 ursodiol tab 250... 80 ursodiol tab 500... 80 UVADEX INJ 20MCG/ML... 45 V valacyclovir hcl tab 1 gm... 54 valacyclovir hcl tab 500... 54 VALCYTE SOL 50MG/ML... 53 valganciclovir hcl tab 450 (base equivalent)... 53 valproate sodium syrup 250 /5ml (base equiv)... 21 valproic acid cap 250... 21 valsartan tab 160... 35 valsartan tab 320... 35 valsartan tab 40... 35 valsartan tab 80... 35 valsartan-hydrochlorothiazide tab 160-12.5... 38 valsartan-hydrochlorothiazide tab 160-25... 38 valsartan-hydrochlorothiazide tab 320-12.5... 38 valsartan-hydrochlorothiazide tab 320-25... 38 valsartan-hydrochlorothiazide tab 80-12.5... 38 vancomycin hcl cap 125... 11 vancomycin hcl cap 250... 11 vandazole gel 0.75%... 107 VAQTA INJ 25/0.5ML... 107 VAQTA INJ 50UNT/ML... 107 VARIVAX INJ... 107 VCF VAGINAL AER CONTRACP... 107 VCF VAGINAL MIS CONTRACP... 107 velivet pak... 62 VELTIN GEL... 67 venlafaxine hcl cap sr 24hr 150 (base equivalent)... 23 venlafaxine hcl cap sr 24hr 37.5 (base equivalent)... 23 venlafaxine hcl cap sr 24hr 75 (base equivalent)... 23 venlafaxine hcl tab 100... 23 venlafaxine hcl tab 25... 23 venlafaxine hcl tab 37.5... 23 venlafaxine hcl tab 50... 23 venlafaxine hcl tab 75... 23 venlafaxine hcl tab sr 24hr 150 (base equivalent)... 23 venlafaxine hcl tab sr 24hr 225 (base equivalent)... 23 venlafaxine hcl tab sr 24hr 37.5 (base equivalent)... 23 venlafaxine hcl tab sr 24hr 75 (base equivalent)... 23 verapamil hcl cap sr 24hr 100... 58 verapamil hcl cap sr 24hr 120... 58 verapamil hcl cap sr 24hr 180... 58 verapamil hcl cap sr 24hr 200... 58 149

verapamil hcl cap sr 24hr 240... 58 verapamil hcl cap sr 24hr 300... 58 verapamil hcl cap sr 24hr 360... 58 verapamil hcl tab cr 120... 58 verapamil hcl tab cr 180... 58 verapamil hcl tab cr 240... 58 VEREGEN OIN 15%... 67 VESICARE TAB 10MG... 106 VESICARE TAB 5MG... 106 vestura tab 3-0.02... 62 VEXOL SUS 1% OP... 95 VIBATIV INJ 250MG... 11 VIBATIV INJ 750MG... 11 vicodin es tab 7.5-300... 10 vicodin hp tab 10-300... 10 vicodin tab 5-300... 10 VICTOZA INJ 18MG/3ML... 28 VIDEX SOL 2GM... 52 VIDEX SOL 4GM... 53 VIGAMOX DRO 0.5%... 94 VIIBRYD KIT... 22 VIIBRYD TAB 10MG... 22 VIIBRYD TAB 20MG... 22 VIIBRYD TAB 40MG... 22 VIMPAT SOL 10MG/ML... 20 VIMPAT TAB 100MG... 20 VIMPAT TAB 150MG... 20 VIMPAT TAB 200MG... 20 VIMPAT TAB 50MG... 20 VINBLASTINE INJ 10MG... 46 vinblastine sulfate inj 1 /ml... 46 vincasar pfs inj 1/ml... 46 vincristine sulfate iv soln 1 /ml... 46 vinorelbine tartrate inj 10 /ml (base equiv)... 46 vinorelbine tartrate inj 50 /5ml (10 /ml) (base equiv)... 46 VIOKACE TAB... 73 VIOKACE TAB 20880... 73 viorele tab... 63 VIRACEPT TAB 250MG... 53 VIRACEPT TAB 625MG... 53 VIRAMUNE XR TAB 100MG... 53 VIREAD POW 40MG/GM... 53 VIREAD TAB 150MG... 53 VIREAD TAB 200MG... 53 VIREAD TAB 250MG... 53 VIREAD TAB 300MG... 53 VITAMIN D2 TAB 400UNIT... 108 VITAMIN D3 LIQ 1000UNIT... 108 VITEKTA TAB 150MG... 53 VITEKTA TAB 85MG... 53 VOLTAREN GEL 1%... 67 voriconazole for susp 40 /ml... 31 voriconazole tab 200... 31 voriconazole tab 50... 31 VOTRIENT TAB 200MG... 44 VYTORIN TAB 10-10MG... 32 VYTORIN TAB 10-20MG... 32 VYTORIN TAB 10-40MG... 32 VYTORIN TAB 10-80MG... 32 VYVANSE CAP 10MG... 1 VYVANSE CAP 20MG... 2 VYVANSE CAP 30MG... 2 VYVANSE CAP 40MG... 2 VYVANSE CAP 50MG... 2 VYVANSE CAP 60MG... 2 VYVANSE CAP 70MG... 2 W warfarin sodium tab 1... 17 warfarin sodium tab 10... 17 warfarin sodium tab 2... 17 warfarin sodium tab 2.5... 17 warfarin sodium tab 3... 17 warfarin sodium tab 4... 17 warfarin sodium tab 5... 17 warfarin sodium tab 6... 17 warfarin sodium tab 7.5... 17 wee care sus 15/1.25... 84 WELCHOL PAK 3.75GM... 33 WELCHOL TAB 625MG... 33 wera tab 0.5/35... 63 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 X XALKORI CAP 200MG... 44 XALKORI CAP 250MG... 44 XARELTO STAR TAB 15/20MG... 17 XARELTO TAB 10MG... 17 XARELTO TAB 15MG... 17 150

XARELTO TAB 20MG... 17 XENAZINE TAB 12.5MG... 98 XENAZINE TAB 25MG... 98 XIFAXAN TAB 200MG... 11 XIFAXAN TAB 550MG... 11 XTANDI CAP 40MG... 42 xulane dis 150-35... 63 XYREM SOL 500MG/ML... 97 Y YERVOY INJ 200MG... 41 YERVOY INJ 50MG... 41 Z zafirlukast tab 10... 15 zafirlukast tab 20... 15 zaleplon cap 10... 85 zaleplon cap 5... 85 ZANOSAR INJ 1GM... 40 zarah tab 3-0.03... 63 zazole cre 0.4%... 107 zazole cre 0.8%... 107 zazole sup 80... 107 ZELBORAF TAB 240MG... 44 ZEMAIRA INJ 1000MG... 100 zenchent fe chw 0.4-35... 63 zenchent tab... 63 ZENPEP CAP 10000UNT... 73 ZENPEP CAP 15000UNT... 73 ZENPEP CAP 20000UNT... 73 ZENPEP CAP 25000UNT... 73 ZENPEP CAP 3000UNIT... 73 ZENPEP CAP 40000UNT... 73 zenzedi tab 15... 2 zenzedi tab 2.5... 2 zenzedi tab 20... 2 zenzedi tab 30... 2 zenzedi tab 7.5... 2 ZETIA TAB 10MG... 34 ZIAGEN SOL 20MG/ML... 53 ZIANA GEL... 67 zidovudine cap 100... 53 zidovudine syrup 10 /ml... 53 zidovudine tab 300... 53 ZIOPTAN DRO 0.0015%... 95 ziprasidone hcl cap 20... 48 ziprasidone hcl cap 40... 48 ziprasidone hcl cap 60... 48 ziprasidone hcl cap 80... 48 ZIRGAN GEL 0.15%... 94 ZOLINZA CAP 100MG... 44 zolmitriptan orally disintegrating tab 2.5... 88 zolmitriptan orally disintegrating tab 5... 88 zolmitriptan tab 2.5... 88 zolmitriptan tab 5... 88 zolpidem tartrate tab 10... 85 zolpidem tartrate tab 5... 85 zolpidem tartrate tab cr 12.5... 85 zolpidem tartrate tab cr 6.25... 85 ZOMIG NASAL SPR 5MG... 88 ZOMIG SPR 2.5MG... 88 zonisamide cap 100... 20 zonisamide cap 25... 20 zonisamide cap 50... 20 ZONTIVITY TAB 2.08MG... 83 ZORTRESS TAB 0.25MG... 55 ZORTRESS TAB 0.5MG... 55 ZORTRESS TAB 0.75MG... 55 ZOSTAVAX INJ... 107 zovia 1/35e tab... 63 zovia 1/50e tab... 63 ZYCLARA CRE 3.75%... 72 ZYCLARA PUMP CRE 2.5%... 72 ZYDELIG TAB 100MG... 44 ZYDELIG TAB 150MG... 44 ZYFLO CR TAB 600MG... 15 ZYKADIA CAP 150MG... 44 ZYTIGA TAB 250MG... 42 ZYVOX SUS 100MG/5M... 12 ZYVOX TAB 600MG... 12 151