Small Group 2019 Formulary Guide (List of Covered Prescription Medications)

Transcription

1 Small Group 2019 Formulary Guide (List of Covered Prescription Medications)

2 Pharmacy Benefits Management Table of Contents Overview... iii True Health New Mexico Customer Service... iii Understanding Coverage and Cost Sharing... iii Formulary... iii Tiers... iii Understanding Our Symbols... v Prior Authorization... v Step Therapy... v Quantity Limits... v About Generic Drugs... vi Short Term Medications... vi Long Term Medications... vi Specialty Medications... vii How to Fill Your Prescription Medications... vii Filling Your Prescription When Traveling... vii Medication Supplies Not Covered by the Health Plan... vii List of Abbreviations... viii ii

3 Pharmacy Benefits Management Overview This guide provides an overview of your pharmacy benefit. It explains the tiers for drug coverage, the process for getting certain drugs covered, your options for filling prescriptions, important phone numbers, and more. True Health New Mexico Customer Service: Hours of operation: 24 hours a day, 7 days a week. Understanding Coverage and Cost Sharing Formulary The Formulary, also known as your Preferred Drug List, is a list of prescription drugs that are covered under your plan. The inclusion of specific medications on the Health Plan formulary is based on the medication s effectiveness, safety, and value. The formulary offers a wide selection of generic and brand-name prescription drugs suggested by the Pharmacy and Therapeutics (P&T) Committee, a group of physicians and pharmacists who research and evaluate medications. The formulary is periodically reviewed and updated throughout the year in order to ensure that our benefits package consistently and adequately meets your needs. When you need a prescription medication, you and your doctor can choose from six different levels of the formulary. These are: Generics Tier 1 and Tier 2, Preferred Brands Tier 3, Non Preferred Brands Tier 4, Preferred Specialty Tier 5, and Non-Preferred Specialty Tier 6. Each level has a different cost-share, which could be a copay or coinsurance, depending on your plan. This gives you and your doctor the freedom to choose the medication that is right for you. At the same time, this will help you to better budget your health care dollars. Tiers Generic Medications Tier 1 and Tier 2 have the lowest copayment/coinsurance. Generic drugs offer the same level of safety and quality as their brand name equivalents. They have the same amount of active ingredients as brand name medications. You are required to use a generic version of the drug if one is available. Refer to the generic drugs section of your Summary of Benefits and Coverage for your plan s cost-share amount. Preferred-Brand Medications Tier 3 have the middle level copayment/coinsurance. These drugs are primarily brand medications and preferred because of their value and effectiveness. This tier may also include some generic medications. Refer to the preferred-brand drugs section of your Summary of Benefits and Coverage for your plan s cost-share amount. iii

4 Pharmacy Benefits Management Non Preferred Brand Medications Tier 4 have a higher copayment/coinsurance level. These medications are primarily brand drugs that are more expensive and have similar effectiveness as Tier 3 medications. This tier may also include higher cost generic medications. Refer to the non-preferred-brand drugs section of your Summary of Benefits and Coverage for your plan s cost-share amount. Preferred Specialty Medications Tier 5 have a higher copayment/coinsurance level. These also include Specialty medications, which usually treat complex and rare conditions. These drugs can be high cost medications and biologicals regardless of how they are administered (injectable, oral, transdermal, or inhalant). Non-Preferred Specialty Medications Tier 6 have the highest copayment/coinsurance level. These also include Specialty medications, which usually treat complex and rare conditions. These drugs can be high cost medications and biologicals regardless of how they are administered (injectable, oral, transdermal, or inhalant) and have similar effectiveness as Tier 5. Affordable Care Act/Zero Cost-Share Preventative Drugs Tier have a zero cost-share copay/co-insurance. These medications are brand and generic preventative drugs that may be covered at $0 copay provided that certain clinical conditions are met. $0 Generics for Several Chronic Conditions Generic drug coverage is provided at no cost for certain medications used to treat asthma, bipolar disorder, chronic obstructive pulmonary disease, congestive heart failure, coronary artery disease, depression, diabetes, hypercholesterolemia, and hypertension. This benefit does not apply to all plans; please refer to your Summary of Benefits and Coverage for your specific plan benefits. For a listing of these drugs, click <here>. Orally Administered Anti-Cancer Medications Coverage of these medications are subject to the same Prior Authorization requirements as intravenously administered injected cancer medications covered by the Health Plan. Orally administered medications cannot cost more than an intravenously injected equivalent. Intravenously injected medications cannot cost more than orally administered medications. Non Formulary Medications may be covered if the formulary medications do not work for you. If you require a Non Formulary medication, your doctor may request coverage for your Tier 4 (Non-Preferred Brand Medications) or your Tier 6 (Non-Preferred Specialty Medications) costshare by making a request for a coverage exception. iv

5 Pharmacy Benefits Management Understanding Our Symbols Prior Authorization You will see the symbol PA (Prior Authorization). Prior Authorization helps ensure that you re using the best drugs in the safest way. If you are currently taking or have recently been prescribed one of these drugs, please discuss possible alternatives or have your doctor request authorization by calling Drugs that require prior authorization are often: Newer drugs for which the Health Plan wants to track usage. Non formulary drugs that require the use of formulary drugs prior to coverage. These drugs are not used as a standard first option in treating a medical condition. Drugs with potential side effects that the Health Plan wants to monitor for patient safety. Drugs categorized as specialty medications. Step Therapy You will see the symbol ST (Step Therapy) next to certain drugs on the formulary tables in this booklet. Step Therapy ensures you are taking the most effective medication at the best cost. This means trying the least expensive medications usually generic medications or drugs that are considered as the standard first line treatment. How Step Therapy Works Step 1: When your prescribed drug is impacted by step therapy, first you will be asked to try generic or first line treatment drugs. The drug recommended will be approved by the Food and Drug Administration (FDA) as providing the same health benefit at a much lower cost. Step 2: If the generic drug in step 1 does not work for you, then you may be able to receive a brand name drug. For more information on Step Therapy, call Quantity Limits The symbol QL next to the drugs in this formulary booklet stands for Quantity Limits. To ensure you are getting the most cost effective dose for your medication, a quantity limit or dose duration may be placed on certain drugs. These limits are based on FDA guidelines, clinical literature, and manufacturer s instructions. Quantity limits promote appropriate use of the drug, prevent waste, and help control costs. v

6 Pharmacy Benefits Management For some drugs, the dosing guidelines may recommend that patients take the drug one time a day in a larger dose instead of several times a day in smaller doses. The quantity limits follow the guidelines and cover one larger dose per day. Prescriptions for specialty medications are limited to a 30 day supply. For more information on quantity limits or dose durations, call About Generic Drugs Generic drugs have the same active ingredients as their brand name equivalents, but cost significantly less. Not all drugs have a generic equivalent. Generally, new drugs receive patent protection for 20 years. Once the patent expires, other pharmaceutical companies can produce the same drug in a generic formulation. Companies that make generic drugs do not have to invest large amounts of money in research, since the company making the brand name equivalent has already done this. Also, generic companies do not need to advertise their drugs. As a result, generic drug makers can pass these savings on to you. Generic drugs have the same active ingredients as brand name drugs, but their inactive ingredients can vary. This is why the generic drug might look different from the brand name drug. Inactive ingredients can be dyes used to color the drug or powders used to shape the tablets. Inactive ingredients do not affect how the generic drug works. The FDA regulates generic drug manufacturers just as it regulates the makers of brand name medications. The generic drug must pass strict FDA measurements to ensure that it delivers the same amount of the active ingredient in the same time frame as its brand name counterpart. The manufacturer of the generic drug must prove that it produces its product under the same strict guidelines as the brand name drug. Short Term Medications These are drugs you need immediately. This includes medications used to treat short term infections, or to relieve pain temporarily. Locate the nearest retail network pharmacy by calling To fill your prescription, present your member ID card and written prescription and pay your copayment/co insurance as described above. Long Term Medications These are drugs you take on a regular basis. These could be drugs to treat asthma, high blood pressure, diabetes, etc. These medications can be mailed to your home for up to a 90 day supply. Please call to learn more about your mail-order options. vi

7 Pharmacy Benefits Management Specialty Medications Specialty medications treat specific medical conditions such as cancer, hemophilia, hepatitis, multiple sclerosis, psoriasis, pulmonary arterial hypertension, respiratory syncytial virus, rheumatoid arthritis, and more. You can fill these prescriptions through CVS Specialty Pharmacy. CVS Specialty Pharmacy is a pharmacy that provides specialty medications. Please call between the hours of 6:30 a.m. to 8 p.m. (CT) Monday through Friday to learn more about filling your specialty medication. How to Fill Your Prescription Medications Filling Your Prescription When Traveling When you travel outside of your local area, thousands of pharmacies across the country will honor your Health Plan member ID card. To locate a participating pharmacy, call Customer Service at To fill a prescription at a participating out of area pharmacy, present your Health Plan member ID card. Some pharmacies may ask you to pay the full price of the medication. If that happens: Submit a Direct Reimbursement Claim form to the Health Plan at: CVS Caremark RxClaim P.O Box Phoenix, AZ Or you may call for assistance. If your claim is approved, you will be reimbursed the amount that you paid for the medication, less the appropriate copayment. If you will be away from home for an extended period of time, or if you will be traveling outside of the country, you may want to use our mail order service so that you receive a 90 day supply before you leave home. Medication Supplies Not Covered by the Health Plan Medications received at no charge to the member (workers compensation, medications purchased with a manufacturer s coupon, etc.) will not be covered. Prescriptions that are written more than a year ago will not be covered. Your doctor will need to write a new prescription. vii

8 Pharmacy Benefits Management List of Abbreviations : Affordable Care Act. LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information, please call Customer Service at OTC: Over the Counter. An OTC drug is a non-prescription drug. PA: Prior Authorization. The Health Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don t get approval, we may not cover the drug. QL: Quantity Limit. For certain drugs, the Health Plan limits the amount of the drug that we will cover. ST: Step Therapy. In some cases, the Health Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. viii

9 True Health NM eff 01/01/2019 Drug Name ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS ANOREXIANTS NON-AMPHETAMINE phendimetrazine tartrate tab 35 mg Tier 4 PA phentermine hcl cap 15 mg Tier 4 PA ANTI-OBESITY AGENTS BELVIQ TAB 10MG Tier 4 PA STIMULANTS - MISC. armodafinil tab 50 mg Tier 5 PA; QL armodafinil tab 150 mg Tier 5 PA; QL armodafinil tab 200 mg Tier 5 PA; QL armodafinil tab 250 mg Tier 5 PA; QL ALLERGENIC EXTRACTS ALLERGENIC EXTRACTS GRASTEK SUB 2800BAU Tier 5 PA; QL RAGWITEK SUB Tier 5 PA; QL MIXED ALLERGENIC EXTRACTS ORALAIR SUB 300 IR Tier 5 PA; QL ALLERGENIC EXTRACTS/BIOLOGICALS MISC ALLERGENIC EXTRACTS ODACTRA SUB Tier 5 PA; QL ANABOLIC STEROIDS ANABOLIC STEROIDS ANADROL-50 TAB 50MG Tier 4 PA oxandrolone tab 2.5 mg Tier 2 PA oxandrolone tab 10 mg Tier 2 PA ANALGESICS COX-II INHIBITORS celecoxib cap 50 mg Tier 4 ST celecoxib cap 100 mg Tier 4 ST; QL celecoxib cap 200 mg Tier 4 ST; QL celecoxib cap 400 mg Tier 4 ST; QL GOUT allopurinol tab 100 mg Tier 2 allopurinol tab 300 mg Tier 2 COLCRYS TAB 0.6MG Tier 3 KRYSTEXXA INJ 8MG/ML Tier 5 PA; QL ULORIC TAB 40MG Tier 3 ST; QL ULORIC TAB 80MG Tier 3 ST LOCAL ANESTHETICS lidocaine hcl local inj 1% Tier 2 lidocaine hcl local inj 2% Tier 2 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 1

10 lidocaine hcl local preservative free (pf) inj Tier 2 0.5% lidocaine hcl local preservative free (pf) inj Tier 2 1% lidocaine hcl local preservative free (pf) inj Tier 2 2% lidocaine hcl local preservative free (pf) inj Tier 2 4% lidocaine inj 0.5% w/ epinephrine- Tier 2 1: lidocaine inj 1% w/ epinephrine-1: Tier 2 lidocaine inj 2% w/ epinephrine-1: Tier 2 NON-OPIOID ANALGESICS butalbital-acetaminophen tab mg Tier 2 butalbital-acetaminophen-caffeine cap 50- Tier mg butalbital-acetaminophen-caffeine tab 50- Tier mg butalbital-aspirin-caffeine cap Tier 2 mg NSAIDS aspirin chew tab 81 mg ASPIRIN TAB 81MG aspirin tab 325 mg aspirin tab delayed release 81 mg aspirin tab delayed release 325 mg CALDOLOR INJ 800/8ML Tier 4 choline & magnesium salicylates liq 500 Tier 2 mg/5ml diclofenac potassium tab 50 mg Tier 2 diclofenac sodium tab delayed release 25 Tier 2 mg diclofenac sodium tab delayed release 50 Tier 2 mg diclofenac sodium tab delayed release 75 Tier 2 mg diclofenac sodium tab er 24hr 100 mg Tier 2 diflunisal tab 500 mg Tier 2 etodolac cap 200 mg Tier 2 etodolac cap 300 mg Tier 2 etodolac tab 400 mg Tier 2 etodolac tab 500 mg Tier 2 etodolac tab er 24hr 400 mg Tier 2 etodolac tab er 24hr 500 mg Tier 2 etodolac tab er 24hr 600 mg Tier 2 fenoprofen calcium tab 600 mg Tier 4 PA flurbiprofen tab 50 mg Tier 2 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 2

11 flurbiprofen tab 100 mg Tier 2 HALFPRIN TAB 162MG EC ibuprofen tab 400 mg Tier 2 ibuprofen tab 600 mg Tier 2 ibuprofen tab 800 mg Tier 2 indomethacin cap 25 mg Tier 2 indomethacin cap 50 mg Tier 2 indomethacin cap er 75 mg Tier 2 ketoprofen cap 50 mg Tier 2 ketoprofen cap 75 mg Tier 2 ketorolac tromethamine im inj 60 mg/2ml Tier 2 QL (30 mg/ml) ketorolac tromethamine inj 15 mg/ml Tier 2 QL ketorolac tromethamine inj 30 mg/ml Tier 2 QL ketorolac tromethamine inj 300 mg/10ml Tier 2 QL (30 mg/ml) ketorolac tromethamine tab 10 mg Tier 2 QL meclofenamate sodium cap 50 mg Tier 4 PA mefenamic acid cap 250 mg Tier 4 PA meloxicam susp 7.5 mg/5ml Tier 4 meloxicam tab 7.5 mg Tier 1 meloxicam tab 15 mg Tier 1 nabumetone tab 500 mg Tier 2 nabumetone tab 750 mg Tier 2 naproxen sodium tab 275 mg Tier 2 naproxen sodium tab 550 mg Tier 2 naproxen susp 125 mg/5ml Tier 2 naproxen tab 250 mg Tier 2 naproxen tab 375 mg Tier 2 naproxen tab 500 mg Tier 2 naproxen tab ec 375 mg Tier 2 naproxen tab ec 500 mg Tier 2 oxaprozin tab 600 mg Tier 2 piroxicam cap 10 mg Tier 4 piroxicam cap 20 mg Tier 4 salsalate tab 500 mg Tier 2 salsalate tab 750 mg Tier 2 ST JOSEPH CHW 75MG ADU sulindac tab 150 mg Tier 2 sulindac tab 200 mg Tier 2 tolmetin sodium cap 400 mg Tier 2 tolmetin sodium tab 200 mg Tier 4 PA tolmetin sodium tab 600 mg Tier 2 NSAIDS, COMBINATIONS diclofenac w/ misoprostol tab delayed release mg Tier 2 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 3

12 diclofenac w/ misoprostol tab delayed Tier 2 release mg NSAIDS, TOPICAL diclofenac sodium gel 1% Tier 2 QL NOVOCLAIR CRE Tier 4 OPIOID ANALGESICS ABSTRAL SUB 100MCG Tier 6 PA, ST; QL ABSTRAL SUB 200MCG Tier 6 PA, ST; QL ABSTRAL SUB 300MCG Tier 6 PA, ST; QL ABSTRAL SUB 400MCG Tier 6 PA, ST; QL ABSTRAL SUB 600MCG Tier 6 PA, ST; QL ABSTRAL SUB 800MCG Tier 6 PA, ST; QL acetaminophen w/ codeine soln mg/5ml Tier 2 PA, ST acetaminophen w/ codeine tab mg Tier 2 PA, ST acetaminophen w/ codeine tab mg Tier 2 PA, ST acetaminophen w/ codeine tab mg Tier 2 PA, ST aspirin-caffeine-dihydrocodeine cap Tier 2 ST mg BUPRENEX INJ 0.3MG/ML Tier 4 ST; QL buprenorphine hcl inj 0.3 mg/ml (base Tier 2 ST; QL equiv) butalbital-acetaminophen-caff w/ cod cap Tier 2 PA, ST mg butalbital-acetaminophen-caff w/ cod cap Tier 2 PA, ST mg butalbital-aspirin-caff w/ codeine cap 50- Tier 2 PA, ST mg butorphanol tartrate inj 1 mg/ml Tier 2 ST butorphanol tartrate inj 2 mg/ml Tier 2 ST butorphanol tartrate nasal soln 10 mg/ml Tier 2 PA, ST; QL BUTRANS DIS 5MCG/HR Tier 4 PA, ST; QL BUTRANS DIS 7.5/HR Tier 4 PA, ST; QL BUTRANS DIS 10MCG/HR Tier 4 PA, ST; QL BUTRANS DIS 15MCG/HR Tier 4 PA, ST; QL BUTRANS DIS 20MCG/HR Tier 4 PA, ST; QL codeine sulfate tab 15 mg Tier 2 PA, ST codeine sulfate tab 30 mg Tier 2 PA, ST codeine sulfate tab 60 mg Tier 2 PA, ST DEMEROL INJ 25MG/0.5 Tier 4 ST DEMEROL INJ 75MG/1.5 Tier 4 ST DEMEROL INJ 75MG/ML Tier 4 ST DEMEROL INJ 100/2ML Tier 4 ST EMBEDA CAP MG Tier 4 PA, ST; QL EMBEDA CAP MG Tier 4 PA, ST; QL EMBEDA CAP 50-2MG Tier 4 PA, ST; QL EMBEDA CAP MG Tier 4 PA, ST; QL PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 4

13 EMBEDA CAP MG Tier 4 PA, ST; QL EMBEDA CAP 100-4MG Tier 4 PA, ST; QL EXALGO TAB 8MG Tier 4 PA, ST; QL EXALGO TAB 12MG Tier 4 PA, ST; QL EXALGO TAB 16MG Tier 4 PA, ST; QL EXALGO TAB 32MG Tier 4 PA, ST; QL fentanyl citrate lozenge on a handle 200 Tier 5 PA, ST; QL mcg fentanyl citrate lozenge on a handle 400 Tier 5 PA, ST; QL mcg fentanyl citrate lozenge on a handle 600 Tier 5 PA, ST; QL mcg fentanyl citrate lozenge on a handle 800 Tier 5 PA, ST; QL mcg fentanyl citrate lozenge on a handle 1200 Tier 5 PA, ST; QL mcg fentanyl citrate lozenge on a handle 1600 Tier 5 PA, ST; QL mcg fentanyl citrate pf soln cartridge 100 Tier 2 PA, ST mcg/2ml fentanyl td patch 72hr 12 mcg/hr Tier 2 PA, ST; QL fentanyl td patch 72hr 25 mcg/hr Tier 2 PA, ST; QL fentanyl td patch 72hr 50 mcg/hr Tier 2 PA, ST; QL fentanyl td patch 72hr 75 mcg/hr Tier 2 PA, ST; QL fentanyl td patch 72hr 100 mcg/hr Tier 2 PA, ST; QL FENTORA TAB 100MCG Tier 6 PA, ST; QL FENTORA TAB 200MCG Tier 6 PA, ST; QL FENTORA TAB 400MCG Tier 6 PA, ST; QL FENTORA TAB 600MCG Tier 6 PA, ST; QL FENTORA TAB 800MCG Tier 6 PA, ST; QL hydrocodone-acetaminophen soln Tier 2 PA, ST mg/15ml hydrocodone-acetaminophen soln Tier 2 ST mg/15ml hydrocodone-acetaminophen tab mg Tier 2 PA, ST hydrocodone-acetaminophen tab mg Tier 2 PA, ST hydrocodone-acetaminophen tab Tier 2 PA, ST mg hydrocodone-acetaminophen tab Tier 2 PA, ST mg hydrocodone-ibuprofen tab mg Tier 2 PA, ST hydrocodone-ibuprofen tab mg Tier 2 PA, ST; QL hydrocodone-ibuprofen tab mg Tier 2 PA, ST; QL hydrocodone-ibuprofen tab mg Tier 2 PA, ST; QL HYDROMORPHON SUP 3MG Tier 2 PA, ST hydromorphone hcl inj 1 mg/ml Tier 2 ST hydromorphone hcl inj 2 mg/ml Tier 2 ST PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 5

14 hydromorphone hcl inj 4 mg/ml Tier 2 ST hydromorphone hcl preservative free (pf) Tier 2 ST inj 10 mg/ml hydromorphone hcl tab 2 mg Tier 2 PA, ST hydromorphone hcl tab 4 mg Tier 2 PA, ST hydromorphone hcl tab 8 mg Tier 2 PA, ST hydromorphone hcl tab er 24hr deter 8 mg Tier 2 PA, ST; QL hydromorphone hcl tab er 24hr deter 12 Tier 2 PA, ST; QL mg hydromorphone hcl tab er 24hr deter 16 Tier 2 PA, ST; QL mg hydromorphone hcl tab er 24hr deter 32 Tier 2 PA, ST; QL mg LAZANDA SPR 100MCG Tier 6 PA, ST; QL LAZANDA SPR 400MCG Tier 6 PA, ST; QL levorphanol tartrate tab 2 mg Tier 2 PA, ST meperidine hcl inj 10 mg/ml Tier 2 ST meperidine hcl oral soln 50 mg/5ml Tier 2 PA, ST meperidine hcl tab 50 mg Tier 2 PA, ST meperidine hcl tab 100 mg Tier 2 PA, ST methadone hcl conc 10 mg/ml Tier 2 PA, ST methadone hcl soln 5 mg/5ml Tier 2 PA, ST methadone hcl soln 10 mg/5ml Tier 2 PA, ST methadone hcl tab 5 mg Tier 2 PA, ST methadone hcl tab 10 mg Tier 2 PA, ST methadone hcl tab for oral susp 40 mg Tier 2 PA, ST MORPHINE SUL INJ 2MG/ML Tier 2 ST MORPHINE SUL INJ 4MG/ML Tier 2 ST MORPHINE SUL INJ 5MG/ML Tier 2 ST MORPHINE SUL INJ 10/0.7ML Tier 2 ST MORPHINE SUL INJ 150/30ML Tier 2 ST MORPHINE SUL SUP 30MG Tier 2 PA, ST morphine sulfate inj 8 mg/ml Tier 2 ST morphine sulfate inj 10 mg/ml Tier 2 ST morphine sulfate inj 15 mg/ml Tier 2 ST morphine sulfate inj pf 0.5 mg/ml Tier 2 ST morphine sulfate inj pf 1 mg/ml Tier 2 ST morphine sulfate iv soln 1 mg/ml Tier 2 ST morphine sulfate iv soln 25 mg/ml Tier 2 ST morphine sulfate iv soln 50 mg/ml Tier 2 ST morphine sulfate iv soln pf 10 mg/ml Tier 2 ST morphine sulfate iv soln pf 15 mg/ml Tier 2 ST morphine sulfate oral soln 10 mg/5ml Tier 2 PA, ST morphine sulfate oral soln 20 mg/5ml Tier 2 PA, ST morphine sulfate oral soln 100 mg/5ml (20 Tier 2 PA, ST mg/ml) morphine sulfate suppos 5 mg Tier 2 PA, ST PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 6

15 morphine sulfate suppos 10 mg Tier 2 PA, ST morphine sulfate suppos 20 mg Tier 2 PA, ST morphine sulfate tab 15 mg Tier 2 PA, ST; QL morphine sulfate tab 30 mg Tier 2 PA, ST morphine sulfate tab er 15 mg Tier 2 PA, ST morphine sulfate tab er 15 mg Tier 2 PA, ST; QL morphine sulfate tab er 30 mg Tier 2 PA, ST; QL morphine sulfate tab er 60 mg Tier 2 PA, ST morphine sulfate tab er 60 mg Tier 2 PA, ST; QL morphine sulfate tab er 100 mg Tier 2 PA, ST morphine sulfate tab er 100 mg Tier 2 PA, ST; QL morphine sulfate tab er 200 mg Tier 2 PA, ST; QL nalbuphine hcl inj 10 mg/ml Tier 2 ST nalbuphine hcl inj 20 mg/ml Tier 2 ST NUCYNTA ER TAB 50MG Tier 4 PA, ST; QL NUCYNTA ER TAB 100MG Tier 4 PA, ST; QL NUCYNTA ER TAB 150MG Tier 4 PA, ST; QL NUCYNTA ER TAB 200MG Tier 4 PA, ST; QL NUCYNTA ER TAB 250MG Tier 4 PA, ST; QL NUCYNTA TAB 50MG Tier 4 PA, ST; QL NUCYNTA TAB 75MG Tier 4 PA, ST; QL NUCYNTA TAB 100MG Tier 4 PA, ST; QL oxycodone hcl cap 5 mg Tier 2 PA, ST oxycodone hcl conc 100 mg/5ml (20 Tier 2 PA, ST mg/ml) oxycodone hcl soln 5 mg/5ml Tier 2 PA, ST oxycodone hcl tab 5 mg Tier 2 PA, ST oxycodone hcl tab 10 mg Tier 2 PA, ST oxycodone hcl tab 15 mg Tier 2 PA, ST oxycodone hcl tab 20 mg Tier 2 PA, ST oxycodone hcl tab 30 mg Tier 2 PA, ST oxycodone hcl tab er 12hr deter 10 mg Tier 4 PA, ST; QL oxycodone hcl tab er 12hr deter 15 mg Tier 4 PA, ST; QL oxycodone hcl tab er 12hr deter 20 mg Tier 4 PA, ST; QL oxycodone hcl tab er 12hr deter 30 mg Tier 4 PA, ST; QL oxycodone hcl tab er 12hr deter 40 mg Tier 4 PA, ST; QL oxycodone hcl tab er 12hr deter 60 mg Tier 4 PA, ST; QL oxycodone hcl tab er 12hr deter 80 mg Tier 4 PA, ST; QL oxycodone w/ acetaminophen tab Tier 2 PA, ST mg oxycodone w/ acetaminophen tab mg Tier 2 PA, ST oxycodone w/ acetaminophen tab Tier 2 PA, ST mg oxycodone w/ acetaminophen tab Tier 2 PA, ST mg oxycodone-aspirin tab mg Tier 2 PA, ST PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 7

16 oxycodone-ibuprofen tab mg Tier 2 PA, ST; QL OXYCONTIN TAB 10MG CR Tier 4 PA, ST; QL OXYCONTIN TAB 15MG CR Tier 4 PA, ST; QL OXYCONTIN TAB 20MG CR Tier 4 PA, ST; QL OXYCONTIN TAB 30MG CR Tier 4 PA, ST; QL OXYCONTIN TAB 40MG CR Tier 4 PA, ST; QL OXYCONTIN TAB 60MG CR Tier 4 PA, ST; QL OXYCONTIN TAB 80MG CR Tier 4 PA, ST; QL oxymorphone hcl tab 5 mg Tier 2 PA, ST oxymorphone hcl tab 10 mg Tier 2 PA, ST oxymorphone hcl tab er 12hr 5 mg Tier 2 PA, ST; QL oxymorphone hcl tab er 12hr 7.5 mg Tier 2 PA, ST; QL oxymorphone hcl tab er 12hr 10 mg Tier 2 PA, ST; QL oxymorphone hcl tab er 12hr 15 mg Tier 2 PA, ST; QL oxymorphone hcl tab er 12hr 20 mg Tier 2 PA, ST; QL oxymorphone hcl tab er 12hr 30 mg Tier 2 PA, ST; QL oxymorphone hcl tab er 12hr 40 mg Tier 2 PA, ST; QL pentazocine w/ naloxone tab mg Tier 2 PA, ST REPREXAIN TAB Tier 2 ST; QL SUBSYS SPR 100MCG Tier 6 PA, ST; QL SUBSYS SPR 200MCG Tier 6 PA, ST; QL SUBSYS SPR 400MCG Tier 6 PA, ST; QL SUBSYS SPR 600MCG Tier 6 PA, ST; QL SUBSYS SPR 800MCG Tier 6 PA, ST; QL SUBSYS SPR 1200MCG Tier 6 PA, ST; QL SUBSYS SPR 1600MCG Tier 6 PA, ST; QL TALWIN INJ 30MG/ML Tier 4 ST tramadol hcl tab 50 mg Tier 2 PA, ST; QL tramadol hcl tab er 24hr 100 mg Tier 2 PA, ST; QL tramadol hcl tab er 24hr 200 mg Tier 2 PA, ST; QL tramadol hcl tab er 24hr 300 mg Tier 2 PA, ST; QL tramadol hcl tab er 24hr biphasic release Tier 2 PA, ST; QL 100 mg tramadol hcl tab er 24hr biphasic release Tier 2 PA, ST; QL 200 mg tramadol hcl tab er 24hr biphasic release 300 mg Tier 2 PA, ST; QL tramadol-acetaminophen tab mg Tier 2 PA, ST; QL XARTEMIS XR TAB Tier 4 PA, ST; QL VISCOSUPPLEMENTS EUFLEXXA INJ 10MG/ML Tier 5 PA; QL ANALGESICS - ANTI-INFLAMMATORY ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES HUMIRA INJ 10/0.1ML Tier 5 PA; QL HUMIRA INJ 20/0.2ML Tier 5 PA; QL HUMIRA INJ 40/0.4ML Tier 5 PA; QL PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 8

17 HUMIRA PEDIA INJ CROHNS Tier 5 PA; QL HUMIRA PEN INJ 40/0.4ML Tier 5 PA; QL HUMIRA PEN KIT CD/UC/HS Tier 5 PA; QL HUMIRA PEN KIT PS/UV Tier 5 PA; QL SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS ENBREL MINI INJ 50MG/ML Tier 5 PA; QL ANALGESICS - OPIOID OPIOID AGONISTS ZOHYDRO ER CAP 10MG Tier 4 PA, ST; QL ZOHYDRO ER CAP 15MG Tier 4 PA, ST; QL ZOHYDRO ER CAP 20MG Tier 4 PA, ST; QL ZOHYDRO ER CAP 30MG Tier 4 PA, ST; QL ZOHYDRO ER CAP 40MG Tier 4 PA, ST; QL ZOHYDRO ER CAP 50MG Tier 4 PA, ST; QL ANDROGENS-ANABOLIC ANDROGENS ANDROGEL GEL 1.62% Tier 3 PA ANTI-INFECTIVES AMINOGLYCOSIDES amikacin sulfate inj 1 gm/4ml (250 mg/ml) Tier 2 amikacin sulfate inj 500 mg/2ml (250 Tier 2 mg/ml) GENTAM/NACL INJ 0.9MG/ML Tier 2 GENTAM/NACL INJ 1.4MG/ML Tier 2 gentamicin in saline inj 0.8 mg/ml Tier 2 gentamicin in saline inj 1 mg/ml Tier 2 gentamicin in saline inj 1.2 mg/ml Tier 2 gentamicin in saline inj 1.6 mg/ml Tier 2 gentamicin in saline inj 2 mg/ml Tier 2 gentamicin sulfate inj 10 mg/ml Tier 2 gentamicin sulfate inj 40 mg/ml Tier 2 gentamicin sulfate iv soln 10 mg/ml Tier 2 neomycin sulfate tab 500 mg Tier 2 paromomycin sulfate cap 250 mg Tier 2 streptomycin sulfate for inj 1 gm Tier 4 tobramycin sulfate for inj 1.2 gm Tier 2 tobramycin sulfate inj 1.2 gm/30ml (40 Tier 2 mg/ml) (base equiv) tobramycin sulfate inj 2 gm/50ml (40 Tier 2 mg/ml) (base equiv) tobramycin sulfate inj 10 mg/ml (base Tier 2 equivalent) tobramycin sulfate inj 80 mg/2ml (40 Tier 2 mg/ml) (base equiv) ANTIBACTERIALS, CARBAPENEMS PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 9

18 imipenem-cilastatin intravenous for soln Tier mg imipenem-cilastatin intravenous for soln Tier mg INVANZ INJ 1GM Tier 4 meropenem iv for soln 1 gm Tier 2 meropenem iv for soln 500 mg Tier 2 ANTIBACTERIALS, CEPHALOSPORINS 1ST GEN cefadroxil cap 500 mg Tier 2 cefadroxil for susp 250 mg/5ml Tier 2 cefadroxil for susp 500 mg/5ml Tier 2 cefadroxil tab 1 gm Tier 2 CEFAZOL/DEX SOL 1GM Tier 2 CEFAZOL/DEX SOL 2GM Tier 2 CEFAZOLIN INJ 1GM/50ML Tier 2 CEFAZOLIN INJ 100GM Tier 2 CEFAZOLIN INJ 300GM Tier 2 cefazolin sodium for inj 1 gm Tier 2 cefazolin sodium for inj 10 gm Tier 2 cefazolin sodium for inj 20 gm Tier 2 cefazolin sodium for inj 500 mg Tier 2 cefazolin sodium for iv soln 1 gm Tier 2 cephalexin cap 250 mg Tier 1 cephalexin cap 500 mg Tier 1 cephalexin cap 750 mg Tier 2 cephalexin for susp 125 mg/5ml Tier 2 cephalexin for susp 250 mg/5ml Tier 2 cephalexin tab 250 mg Tier 2 cephalexin tab 500 mg Tier 2 ANTIBACTERIALS, CEPHALOSPORINS, 2ND GEN cefaclor cap 250 mg Tier 2 cefaclor cap 500 mg Tier 2 CEFACLOR ER TAB 500MG Tier 2 cefaclor for susp 250 mg/5ml Tier 2 cefaclor for susp 375 mg/5ml Tier 2 cefotetan disodium for inj 1 gm Tier 2 cefotetan disodium for inj 2 gm Tier 2 cefotetan disodium for inj 10 gm Tier 2 CEFOXITIN INJ 1GM Tier 2 CEFOXITIN INJ 2GM Tier 2 cefoxitin sodium for inj 10 gm Tier 2 cefoxitin sodium for iv soln 1 gm Tier 2 cefoxitin sodium for iv soln 2 gm Tier 2 cefprozil for susp 125 mg/5ml Tier 2 cefprozil for susp 250 mg/5ml Tier 2 cefprozil tab 250 mg Tier 2 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 10

19 cefprozil tab 500 mg Tier 2 CEFTIN SUS 125/5ML Tier 4 CEFTIN SUS 250/5ML Tier 4 cefuroxime axetil tab 250 mg Tier 2 cefuroxime axetil tab 500 mg Tier 2 cefuroxime sodium for inj 7.5 gm Tier 2 cefuroxime sodium for inj 750 mg Tier 2 cefuroxime sodium for iv soln 1.5 gm Tier 2 ZINACEF/H20 INJ 1.5GM PB Tier 4 ANTIBACTERIALS, CEPHALOSPORINS, 3RD GEN CEDAX CAP 400MG Tier 4 cefdinir cap 300 mg Tier 2 cefdinir for susp 125 mg/5ml Tier 2 cefdinir for susp 250 mg/5ml Tier 2 cefditoren pivoxil tab 200 mg (base Tier 2 equivalent) cefditoren pivoxil tab 400 mg (base Tier 2 equivalent) cefixime for susp 100 mg/5ml Tier 2 cefixime for susp 200 mg/5ml Tier 2 cefotaxime sodium for inj 1 gm Tier 2 cefotaxime sodium for inj 2 gm Tier 2 cefotaxime sodium for inj 10 gm Tier 2 cefotaxime sodium for inj 500 mg Tier 2 cefpodoxime proxetil for susp 50 mg/5ml Tier 2 cefpodoxime proxetil for susp 100 mg/5ml Tier 2 cefpodoxime proxetil tab 100 mg Tier 2 cefpodoxime proxetil tab 200 mg Tier 2 ceftazidime for inj 1 gm Tier 2 ceftazidime for inj 2 gm Tier 2 ceftazidime for inj 6 gm Tier 2 CEFTAZIDIME/ SOL D5W 1GM Tier 4 CEFTAZIDIME/ SOL D5W 2GM Tier 4 ceftibuten cap 400 mg Tier 2 ceftibuten for susp 180 mg/5ml Tier 2 CEFTRIAX/DEX INJ 1GM Tier 4 CEFTRIAX/DEX INJ 2GM Tier 4 ceftriaxone sodium for inj 1 gm Tier 2 ceftriaxone sodium for inj 2 gm Tier 2 ceftriaxone sodium for inj 10 gm Tier 2 ceftriaxone sodium for inj 250 mg Tier 2 ceftriaxone sodium for inj 500 mg Tier 2 ceftriaxone sodium for iv soln 1 gm Tier 2 ceftriaxone sodium for iv soln 2 gm Tier 2 ceftriaxone sodium in dextrose inj 20 Tier 2 mg/ml PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 11

20 ceftriaxone sodium in dextrose inj 40 Tier 2 mg/ml CLAFORAN INJ 1GM Tier 4 CLAFORAN INJ 2GM Tier 4 SPECTRACEF TAB 200MG Tier 4 SPECTRACEF TAB 400MG Tier 4 SUPRAX CAP 400MG Tier 4 SUPRAX CHW 100MG Tier 4 SUPRAX CHW 200MG Tier 4 SUPRAX SUS 100/5ML Tier 4 SUPRAX SUS 200/5ML Tier 4 SUPRAX SUS 500/5ML Tier 4 ANTIBACTERIALS, CEPHALOSPORINS, 4TH GEN cefepime hcl for inj 1 gm Tier 2 cefepime hcl for inj 2 gm Tier 2 CEFEPIME INJ 1GM Tier 2 CEFEPIME INJ 2GM Tier 2 CEFEPIME/DEX INJ 1GM Tier 4 CEFEPIME/DEX INJ 2GM Tier 2 MAXIPIME INJ 1GM Tier 4 MAXIPIME INJ 2GM Tier 4 ANTIBACTERIALS, CEPHALOSPORINS, 5TH GEN TEFLARO INJ 400MG Tier 4 TEFLARO INJ 600MG Tier 4 ANTIBACTERIALS, ERYTHROMYCINS/MACROLIDES azithromycin for susp 100 mg/5ml Tier 2 azithromycin for susp 200 mg/5ml Tier 2 azithromycin iv for soln 500 mg Tier 2 azithromycin powd pack for susp 1 gm Tier 2 azithromycin tab 250 mg Tier 2 azithromycin tab 500 mg Tier 2 azithromycin tab 600 mg Tier 2 clarithromycin for susp 125 mg/5ml Tier 2 clarithromycin for susp 250 mg/5ml Tier 2 clarithromycin tab 250 mg Tier 2 clarithromycin tab 500 mg Tier 2 clarithromycin tab er 24hr 500 mg Tier 2 DIFICID TAB 200MG Tier 5 ST; QL ERYPED SUS 200/5ML Tier 4 ERYPED SUS 400/5ML Tier 4 ERYTHROCIN INJ 500MG Tier 4 erythromycin ethylsuccinate tab 400 mg Tier 2 erythromycin stearate tab 250 mg Tier 2 erythromycin tab 250 mg Tier 2 erythromycin tab 500 mg Tier 2 erythromycin tab delayed release 250 mg Tier 2 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 12

21 erythromycin tab delayed release 333 mg Tier 2 erythromycin w/ delayed release particles Tier 2 cap 250 mg ANTIBACTERIALS, FLUOROQUINOLONES AVELOX TAB 400MG Tier 4 CIPRO (5%) SUS 250MG/5 Tier 4 CIPRO (10%) SUS 500MG/5 Tier 4 ciprofloxacin 200 mg/100ml in d5w Tier 2 ciprofloxacin 400 mg/200ml in d5w Tier 2 ciprofloxacin for oral susp 250 mg/5ml Tier 2 (5%) (5 gm/100ml) ciprofloxacin for oral susp 500 mg/5ml Tier 2 (10%) (10 gm/100ml) ciprofloxacin hcl tab 100 mg (base equiv) Tier 2 ciprofloxacin hcl tab 250 mg (base equiv) Tier 1 ciprofloxacin hcl tab 500 mg (base equiv) Tier 1 ciprofloxacin hcl tab 750 mg (base equiv) Tier 2 ciprofloxacin iv soln 200 mg/20ml (1%) Tier 2 ciprofloxacin iv soln 400 mg/40ml (1%) Tier 2 ciprofloxacin-ciprofloxacin hcl tab er 24hr Tier 2 QL 500 mg (base eq) ciprofloxacin-ciprofloxacin hcl tab er 24hr Tier 2 QL 1000 mg(base eq) FACTIVE TAB 320MG Tier 4 QL levofloxacin in d5w iv soln 250 mg/50ml Tier 2 levofloxacin in d5w iv soln 500 mg/100ml Tier 2 levofloxacin in d5w iv soln 750 mg/150ml Tier 2 levofloxacin iv soln 25 mg/ml Tier 2 levofloxacin oral soln 25 mg/ml Tier 2 levofloxacin tab 250 mg Tier 2 levofloxacin tab 500 mg Tier 2 levofloxacin tab 750 mg Tier 2 moxifloxacin hcl tab 400 mg (base equiv) Tier 2 MOXIFLOXACIN INJ Tier 4 NOROXIN TAB 400MG Tier 4 ofloxacin tab 400 mg Tier 2 ANTIBACTERIALS, KETOLIDES KETEK TAB 300MG Tier 4 QL KETEK TAB 400MG Tier 4 QL ANTIBACTERIALS, PENICILLINS amoxicillin & k clavulanate chew tab mg amoxicillin & k clavulanate chew tab mg amoxicillin & k clavulanate for susp mg/5ml Tier 2 Tier 2 Tier 2 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 13

22 amoxicillin & k clavulanate for susp 250- Tier mg/5ml amoxicillin & k clavulanate for susp Tier 2 mg/5ml amoxicillin & k clavulanate for susp 600- Tier mg/5ml amoxicillin & k clavulanate tab mg Tier 2 amoxicillin & k clavulanate tab mg Tier 2 amoxicillin & k clavulanate tab mg Tier 2 amoxicillin & k clavulanate tab er 12hr Tier mg amoxicillin (trihydrate) cap 250 mg Tier 1 amoxicillin (trihydrate) cap 500 mg Tier 1 amoxicillin (trihydrate) chew tab 125 mg Tier 2 amoxicillin (trihydrate) chew tab 250 mg Tier 2 amoxicillin (trihydrate) for susp 125 Tier 2 mg/5ml amoxicillin (trihydrate) for susp 200 Tier 2 mg/5ml amoxicillin (trihydrate) for susp 250 Tier 2 mg/5ml amoxicillin (trihydrate) for susp 400 Tier 2 mg/5ml amoxicillin (trihydrate) tab 500 mg Tier 2 amoxicillin (trihydrate) tab 875 mg Tier 2 ampicillin & sulbactam sodium for inj 1.5 Tier 2 (1-0.5) gm ampicillin & sulbactam sodium for inj 3 (2- Tier 2 1) gm ampicillin & sulbactam sodium for inj 15 Tier 2 (10-5) gm ampicillin & sulbactam sodium for iv soln Tier 2 15 (10-5) gm ampicillin cap 250 mg Tier 1 ampicillin cap 500 mg Tier 1 ampicillin for susp 125 mg/5ml Tier 2 ampicillin for susp 250 mg/5ml Tier 2 ampicillin sodium for inj 1 gm Tier 2 ampicillin sodium for inj 2 gm Tier 2 ampicillin sodium for inj 10 gm Tier 2 ampicillin sodium for inj 125 mg Tier 2 ampicillin sodium for inj 250 mg Tier 2 ampicillin sodium for inj 500 mg Tier 2 ampicillin sodium for iv soln 1 gm Tier 2 ampicillin sodium for iv soln 2 gm Tier 2 ampicillin sodium for iv soln 10 gm Tier 2 AUGMENTIN SUS 125/5ML Tier 4 BACTOCILL INJ DEX 1GM Tier 2 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 14

23 BACTOCILL INJ DEX 2GM Tier 2 BICILLIN C-R INJ 900/300 Tier 4 BICILLIN C-R INJ Tier 4 BICILLIN L-A INJ Tier 4 BICILLIN L-A INJ Tier 4 BICILLIN L-A INJ Tier 4 dicloxacillin sodium cap 250 mg Tier 2 dicloxacillin sodium cap 500 mg Tier 2 NAFCILLIN INJ 1GM/50ML Tier 2 NAFCILLIN INJ 2GM/100 Tier 2 nafcillin sodium for inj 1 gm Tier 2 nafcillin sodium for inj 2 gm Tier 2 nafcillin sodium for iv soln 1 gm Tier 2 nafcillin sodium for iv soln 2 gm Tier 2 nafcillin sodium for iv soln 10 gm Tier 2 oxacillin sodium for inj 1 gm (base Tier 2 equivalent) oxacillin sodium for inj 2 gm (base Tier 2 equivalent) oxacillin sodium for inj 10 gm (base Tier 2 equivalent) PEN G PROC INJ Tier 2 PENICILL GK/ INJ DEX 1MU Tier 4 PENICILL GK/ INJ DEX 2MU Tier 4 PENICILL GK/ INJ DEX 3MU Tier 4 penicillin g potassium for inj unit Tier 2 penicillin g potassium for inj unit Tier 2 penicillin g sodium for inj unit Tier 2 penicillin v potassium for soln 125 mg/5ml Tier 2 penicillin v potassium for soln 250 mg/5ml Tier 2 penicillin v potassium tab 250 mg Tier 1 penicillin v potassium tab 500 mg Tier 2 piperacillin sod-tazobactam na for inj Tier 2 gm ( gm) piperacillin sod-tazobactam sod for inj 2.25 Tier 2 gm ( gm) piperacillin sod-tazobactam sod for inj 4.5 Tier 2 gm (4-0.5 gm) piperacillin sod-tazobactam sod for inj 40.5 Tier 2 gm ( gm) ANTIBACTERIALS, SULFONAMIDES SULFADIAZINE TAB 500MG Tier 2 sulfamethoxazole-trimethoprim iv soln Tier mg/5ml sulfamethoxazole-trimethoprim susp 200- Tier 2 40 mg/5ml PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 15

24 sulfamethoxazole-trimethoprim tab Tier 2 mg sulfamethoxazole-trimethoprim tab 800- Tier mg ANTIBACTERIALS, TETRACYCLINES demeclocycline hcl tab 150 mg Tier 2 demeclocycline hcl tab 300 mg Tier 2 doxycycline hyclate cap 50 mg Tier 2 doxycycline hyclate cap 100 mg Tier 2 doxycycline hyclate for inj 100 mg Tier 2 doxycycline hyclate tab 20 mg Tier 2 doxycycline hyclate tab 100 mg Tier 2 doxycycline monohydrate cap 50 mg Tier 2 doxycycline monohydrate cap 100 mg Tier 2 doxycycline monohydrate for susp 25 Tier 2 mg/5ml doxycycline monohydrate tab 50 mg Tier 2 doxycycline monohydrate tab 75 mg Tier 2 doxycycline monohydrate tab 100 mg Tier 2 doxycycline monohydrate tab 150 mg Tier 2 MINOCIN INJ 100MG Tier 4 minocycline hcl cap 50 mg Tier 2 minocycline hcl cap 75 mg Tier 2 minocycline hcl cap 100 mg Tier 2 minocycline hcl tab 50 mg Tier 2 minocycline hcl tab 75 mg Tier 2 minocycline hcl tab 100 mg Tier 2 tetracycline hcl cap 250 mg Tier 2 tetracycline hcl cap 500 mg Tier 2 ANTIFUNGALS ABELCET INJ 5MG/ML Tier 4 AMBISOME INJ 50MG Tier 4 amphotericin b for inj 50 mg Tier 2 clotrimazole troche 10 mg Tier 2 CRESEMBA CAP 186 MG Tier 5 QL CRESEMBA INJ 372MG Tier 5 QL ERAXIS INJ 50MG Tier 4 ERAXIS INJ 100MG Tier 4 fluconazole for susp 10 mg/ml Tier 2 fluconazole for susp 40 mg/ml Tier 2 fluconazole in nacl 0.9% inj 200 mg/100ml Tier 2 fluconazole in nacl 0.9% inj 400 mg/200ml Tier 2 fluconazole tab 50 mg Tier 2 QL fluconazole tab 100 mg Tier 2 QL fluconazole tab 150 mg Tier 2 QL fluconazole tab 200 mg Tier 2 QL PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 16

25 FLUCONAZOLE/ INJ NACL 100 Tier 2 flucytosine cap 250 mg Tier 5 PA flucytosine cap 500 mg Tier 5 PA griseofulvin microsize susp 125 mg/5ml Tier 2 griseofulvin microsize tab 500 mg Tier 2 griseofulvin ultramicrosize tab 125 mg Tier 2 griseofulvin ultramicrosize tab 250 mg Tier 2 itraconazole cap 100 mg Tier 2 PA; QL ketoconazole tab 200 mg Tier 2 MYCAMINE INJ 50MG Tier 4 MYCAMINE INJ 100MG Tier 4 NOXAFIL SUS 40MG/ML Tier 5 PA NOXAFIL TAB 100MG Tier 5 PA; QL *nystatin oral powder* Tier 2 nystatin susp unit/ml Tier 2 nystatin tab unit Tier 2 ONMEL TAB 200MG Tier 4 PA; QL ORAVIG TAB 50MG Tier 4 PA; QL SPORANOX SOL 10MG/ML Tier 4 PA; QL terbinafine hcl tab 250 mg Tier 2 PA; QL voriconazole for inj 200 mg Tier 2 QL voriconazole for susp 40 mg/ml Tier 5 QL voriconazole tab 50 mg Tier 5 QL voriconazole tab 200 mg Tier 5 QL ANTIMALARIALS atovaquone-proguanil hcl tab mg Tier 2 PA atovaquone-proguanil hcl tab mg Tier 2 PA COARTEM TAB MG Tier 3 ANTIRETROVIRALS, ANTIRETROVIRAL ADJUVANTS TYBOST TAB 150MG Tier 3 QL ANTIRETROVIRALS, ANTIRETROVIRAL COMBINATIONS abacavir sulfate-lamivudine-zidovudine tab Tier 2 QL mg ATRIPLA TAB Tier 3 QL COMPLERA TAB Tier 3 QL EPZICOM TAB Tier 3 QL EVOTAZ TAB Tier 3 QL GENVOYA TAB Tier 3 QL lamivudine-zidovudine tab mg Tier 2 QL PREZCOBIX TAB Tier 3 QL STRIBILD TAB Tier 3 QL TRIUMEQ TAB Tier 3 QL TRIZIVIR TAB Tier 3 QL TRUVADA TAB Tier 3 QL ANTIRETROVIRALS, CHEMOKINE RECEPTOR ANTAGONISTS SELZENTRY SOL 20MG/ML Tier 3 PA; QL PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 17

26 SELZENTRY TAB 150MG Tier 3 PA; QL SELZENTRY TAB 300MG Tier 3 PA; QL ANTIRETROVIRALS, FUSION INHIBITORS FUZEON INJ 90MG Tier 3 QL ANTIRETROVIRALS, INTEGRASE INHIBITORS ISENTRESS CHW 25MG Tier 3 QL ISENTRESS CHW 100MG Tier 3 QL ISENTRESS HD TAB 600MG Tier 5 QL ISENTRESS POW 100MG Tier 3 QL ISENTRESS TAB 400MG Tier 3 QL TIVICAY TAB 50MG Tier 3 QL VITEKTA TAB 85MG Tier 3 QL VITEKTA TAB 150MG Tier 3 QL ANTIRETROVIRALS, PROTEASE INHIBITORS APTIVUS CAP 250MG Tier 3 QL APTIVUS SOL Tier 3 QL atazanavir sulfate cap 150 mg (base equiv) Tier 2 QL atazanavir sulfate cap 200 mg (base equiv) Tier 2 QL atazanavir sulfate cap 300 mg (base equiv) Tier 2 QL CRIXIVAN CAP 200MG Tier 3 QL CRIXIVAN CAP 400MG Tier 3 QL fosamprenavir calcium tab 700 mg (base Tier 2 QL equiv) INVIRASE CAP 200MG Tier 3 QL INVIRASE TAB 500MG Tier 3 QL KALETRA SOL Tier 6 QL KALETRA TAB MG Tier 3 QL KALETRA TAB MG Tier 3 QL LEXIVA SUS 50MG/ML Tier 3 QL LEXIVA TAB 700MG Tier 3 QL lopinavir-ritonavir soln mg/5ml Tier 2 QL (80-20 mg/ml) NORVIR CAP 100MG Tier 3 QL NORVIR SOL 80MG/ML Tier 3 QL NORVIR TAB 100MG Tier 3 QL PREZISTA SUS 100MG/ML Tier 3 QL PREZISTA TAB 75MG Tier 3 QL PREZISTA TAB 150MG Tier 3 QL PREZISTA TAB 600MG Tier 3 QL PREZISTA TAB 800MG Tier 3 QL REYATAZ CAP 150MG Tier 3 QL REYATAZ CAP 200MG Tier 3 QL REYATAZ CAP 300MG Tier 3 QL REYATAZ POW 50MG Tier 3 QL ritonavir tab 100 mg Tier 2 QL VIRACEPT TAB 250MG Tier 3 QL PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 18

27 VIRACEPT TAB 625MG Tier 3 QL ANTIRETROVIRALS, REVERSE TRANSCRIPTASE INHIBITORS - NON- NUCLEOSIDE EDURANT TAB 25MG Tier 3 QL INTELENCE TAB 25MG Tier 3 PA; QL INTELENCE TAB 100MG Tier 3 PA; QL INTELENCE TAB 200MG Tier 3 PA; QL nevirapine susp 50 mg/5ml Tier 2 QL nevirapine tab 200 mg Tier 2 QL nevirapine tab er 24hr 100 mg Tier 2 QL nevirapine tab er 24hr 400 mg Tier 2 QL RESCRIPTOR TAB 100 MG Tier 3 QL RESCRIPTOR TAB 200MG Tier 3 QL SUSTIVA CAP 50MG Tier 3 QL SUSTIVA CAP 200MG Tier 3 QL SUSTIVA TAB 600MG Tier 3 QL viramune sus 50mg/5ml Tier 3 QL VIRAMUNE XR TAB 100MG Tier 6 QL VIRAMUNE XR TAB 400MG Tier 6 QL ANTIRETROVIRALS, REVERSE TRANSCRIPTASE INHIBITORS - NUCLEOSIDE abacavir sulfate soln 20 mg/ml (base Tier 2 QL equiv) abacavir sulfate tab 300 mg (base equiv) Tier 2 QL didanosine delayed release capsule 125 mg Tier 2 QL didanosine delayed release capsule 200 mg Tier 2 QL didanosine delayed release capsule 250 mg Tier 2 QL didanosine delayed release capsule 400 mg Tier 2 QL EMTRIVA CAP 200MG Tier 3 QL EMTRIVA SOL 10MG/ML Tier 3 QL lamivudine oral soln 10 mg/ml Tier 2 QL lamivudine tab 150 mg Tier 2 QL lamivudine tab 300 mg Tier 2 QL RETROVIR INJ 10MG/ML Tier 3 stavudine cap 15 mg Tier 2 QL stavudine cap 20 mg Tier 2 QL stavudine cap 30 mg Tier 2 QL stavudine cap 40 mg Tier 2 QL stavudine for oral soln 1 mg/ml Tier 2 QL VIDEX SOL 2GM Tier 3 QL ZIAGEN SOL 20MG/ML Tier 4 QL zidovudine cap 100 mg Tier 2 QL zidovudine syrup 10 mg/ml Tier 2 QL zidovudine tab 300 mg Tier 2 QL ANTIRETROVIRALS, REVERSE TRANSCRIPTASE INHIBITORS - NUCLEOTIDE PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 19

28 VIREAD POW 40MG/GM Tier 3 QL VIREAD TAB 150MG Tier 3 QL VIREAD TAB 200MG Tier 3 QL VIREAD TAB 250MG Tier 3 QL VIREAD TAB 300MG Tier 3 QL ANTITUBERCULAR AGENTS CAPASTAT SUL INJ 1GM Tier 4 cycloserine cap 250 mg Tier 4 ethambutol hcl tab 100 mg Tier 2 ethambutol hcl tab 400 mg Tier 2 isoniazid inj 100 mg/ml Tier 2 isoniazid syrup 50 mg/5ml Tier 2 isoniazid tab 100 mg Tier 2 isoniazid tab 300 mg Tier 2 PASER GRA 4GM Tier 3 PRIFTIN TAB 150MG Tier 4 pyrazinamide tab 500 mg Tier 2 RIFAMATE CAP Tier 4 rifampin cap 150 mg Tier 2 rifampin cap 300 mg Tier 2 rifampin for inj 600 mg Tier 2 RIFATER TAB Tier 4 SIRTURO TAB 100MG Tier 5 PA TRECATOR TAB 250MG Tier 4 ANTIVIRALS, CMV AGENTS cidofovir iv inj 75 mg/ml Tier 2 ganciclovir sodium for inj 500 mg Tier 2 VALCYTE SOL 50MG/ML Tier 6 QL VALCYTE TAB 450MG Tier 4 valganciclovir hcl for soln 50 mg/ml (base Tier 4 QL equiv) valganciclovir hcl tab 450 mg (base Tier 2 equivalent) ANTIVIRALS, HEPATITIS AGENTS - HEPATITIS B adefovir dipivoxil tab 10 mg Tier 5 BARACLUDE SOL.05MG/ML Tier 5 PA entecavir tab 0.5 mg Tier 5 entecavir tab 1 mg Tier 5 EPIVIR HBV SOL 5MG/ML Tier 3 PA lamivudine tab 100 mg (hbv) Tier 2 TYZEKA TAB 600MG Tier 4 PA ANTIVIRALS, HEPATITIS AGENTS - HEPATITIS C DAKLINZA TAB 30MG Tier 6 PA; QL DAKLINZA TAB 60MG Tier 6 PA; QL EPCLUSA TAB Tier 5 PA; QL HARVONI TAB MG Tier 5 PA; QL PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 20

29 MAVYRET TAB MG Tier 5 PA; QL moderiba pak 800/day Tier 6 QL moderiba pak 1200/day Tier 6 QL OLYSIO CAP 150MG Tier 6 PA; QL REBETOL SOL 40MG/ML Tier 5 RIBAPAK PAK 1000/DAY Tier 5 ribavirin cap 200 mg Tier 5 QL ribavirin tab 200 mg Tier 5 QL ribavirin tab 400 mg Tier 5 QL ribavirin tab 600 mg Tier 5 QL SOVALDI TAB 400MG Tier 5 PA; QL TECHNIVIE TAB Tier 6 PA; QL VIEKIRA PAK TAB Tier 6 PA; QL VOSEVI TAB Tier 5 PA; QL ANTIVIRALS, HERPES AGENTS acyclovir cap 200 mg Tier 2 acyclovir sodium for inj 500 mg Tier 2 acyclovir sodium for inj 1000 mg Tier 2 acyclovir sodium iv soln 50 mg/ml Tier 2 acyclovir susp 200 mg/5ml Tier 2 acyclovir tab 400 mg Tier 2 acyclovir tab 800 mg Tier 2 famciclovir tab 125 mg Tier 2 QL famciclovir tab 250 mg Tier 2 QL famciclovir tab 500 mg Tier 2 QL valacyclovir hcl tab 1 gm Tier 2 QL valacyclovir hcl tab 500 mg Tier 2 QL ANTIVIRALS, INFLUENZA AGENTS oseltamivir phosphate cap 30 mg (base Tier 2 QL equiv) oseltamivir phosphate cap 45 mg (base Tier 2 QL equiv) oseltamivir phosphate cap 75 mg (base Tier 2 QL equiv) RELENZA MIS DISKHALE Tier 4 QL rimantadine hydrochloride tab 100 mg Tier 2 TAMIFLU CAP 30MG Tier 4 QL TAMIFLU CAP 45MG Tier 4 QL TAMIFLU CAP 75MG Tier 4 QL TAMIFLU SUS 6MG/ML Tier 4 QL MISCELLANEOUS ALBENZA TAB 200MG Tier 3 ALINIA SUS 100/5ML Tier 3 ALINIA TAB 500MG Tier 3 atovaquone susp 750 mg/5ml Tier 2 AZACTAM/DEX INJ 1GM Tier 4 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 21

30 AZACTAM/DEX INJ 2GM Tier 4 aztreonam for inj 1 gm Tier 2 aztreonam for inj 2 gm Tier 2 bacitracin intramuscular for soln Tier 2 unit BILTRICIDE TAB 600MG Tier 3 chloramphenicol sodium succinate for iv inj Tier 2 1 gm clindamycin hcl cap 75 mg Tier 2 clindamycin hcl cap 150 mg Tier 2 clindamycin hcl cap 300 mg Tier 2 clindamycin palmitate hcl for soln 75 Tier 2 mg/5ml (base equiv) clindamycin phosphate in d5w iv soln 300 Tier 2 mg/50ml clindamycin phosphate in d5w iv soln 600 Tier 2 mg/50ml clindamycin phosphate in d5w iv soln 900 Tier 2 mg/50ml clindamycin phosphate inj 300 mg/2ml Tier 2 clindamycin phosphate inj 600 mg/4ml Tier 2 clindamycin phosphate iv soln 300 mg/2ml Tier 2 colistimethate sod for inj 150 mg (colistin Tier 2 base activity) dapsone tab 25 mg Tier 2 dapsone tab 100 mg Tier 2 ivermectin tab 3 mg Tier 2 linezolid for susp 100 mg/5ml Tier 4 QL linezolid in sodium chloride iv soln 600 Tier 2 mg/300ml-0.9% linezolid tab 600 mg Tier 4 QL METRONIDAZOL INJ 5MG/ML Tier 2 metronidazole cap 375 mg Tier 2 metronidazole in nacl 0.79% iv soln 500 Tier 2 mg/100ml metronidazole tab 250 mg Tier 2 metronidazole tab 500 mg Tier 2 NEBUPENT INH 300MG Tier 3 nitrofurantoin macrocrystalline cap 50 mg Tier 2 nitrofurantoin macrocrystalline cap 100 mg Tier 2 nitrofurantoin monohydrate Tier 2 macrocrystalline cap 100 mg PENTAM 300 INJ 300MG Tier 4 polymyxin b sulfate for inj unit Tier 2 rifabutin cap 150 mg Tier 2 SIVEXTRO INJ 200MG Tier 5 QL SIVEXTRO TAB 200MG Tier 5 QL STROMECTOL TAB 3MG Tier 3 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 22

31 tinidazole tab 250 mg Tier 2 tinidazole tab 500 mg Tier 2 trimethoprim tab 100 mg Tier 2 VANCOMYC/DEX INJ 500MG Tier 4 VANCOMYC/DEX INJ 750MG Tier 4 vancomycin hcl cap 125 mg Tier 5 vancomycin hcl cap 250 mg Tier 5 vancomycin hcl for inj 1000 mg Tier 2 vancomycin hcl for iv soln 5 gm (base Tier 2 equivalent) vancomycin hcl for iv soln 10 gm (base Tier 2 equivalent) vancomycin hcl for iv soln 500 mg (base Tier 2 equivalent) VANCOMYCIN INJ 750MG Tier 2 VIBATIV INJ 250MG Tier 4 VIBATIV INJ 750MG Tier 4 XIFAXAN TAB 200MG Tier 4 QL XIFAXAN TAB 550MG Tier 5 PA; QL ZYVOX SOL 2MG/ML Tier 4 ANTIASTHMATIC AND BRONCHODILATOR AGENTS BRONCHODILATORS - ANTICHOLINERGICS INCRUSE ELPT INH 62.5MCG Tier 3 LEUKOTRIENE MODULATORS zileuton tab er 12hr 600 mg Tier 5 ST; QL STEROID INHALANTS QVAR REDIHA AER 80MCG Tier 3 QVAR REDIHAL AER 40MCG Tier 3 SYMPATHOMIMETICS levalbuterol tartrate inhal aerosol 45 Tier 4 mcg/act (base equiv) MAXAIR AUTOH AER 200MCG Tier 4 ANTICOAGULANTS DIRECT FACTOR XA INHIBITORS SAVAYSA TAB 15MG Tier 4 ST SAVAYSA TAB 30MG Tier 4 ST SAVAYSA TAB 60MG Tier 4 ST ANTICONVULSANTS ANTICONVULSANTS - MISC. carbamazepine tab er 12hr 100 mg Tier 2 LAMICTAL CHW 2MG Tier 2 lamotrigine orally disintegrating tab 25 mg Tier 4 lamotrigine orally disintegrating tab 50 mg Tier 4 lamotrigine orally disintegrating tab 100 Tier 4 mg PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 23

32 lamotrigine orally disintegrating tab 200 Tier 4 mg lamotrigine tab er 24hr 50 mg Tier 2 lamotrigine tab er 24hr 250 mg Tier 2 ANTIDIABETICS ANTIDIABETIC COMBINATIONS INVOKAMET XR TAB MG Tier 3 QL INVOKAMET XR TAB Tier 3 QL INVOKAMET XR TAB Tier 3 QL INVOKAMET XR TAB Tier 3 QL JENTADUETO TAB XR Tier 3 SOLIQUA INJ 100/33 Tier 4 ST; QL SYNJARDY XR TAB Tier 3 QL SYNJARDY XR TAB MG Tier 3 QL SYNJARDY XR TAB Tier 3 QL SYNJARDY XR TAB Tier 3 QL XULTOPHY INJ 100/3.6 Tier 4 ST; QL DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS alogliptin benzoate tab 6.25 mg (base Tier 4 equiv) alogliptin benzoate tab 25 mg (base equiv) Tier 4 ANTIEMETICS SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS aprepitant capsule 40 mg Tier 3 QL aprepitant capsule 80 mg Tier 3 QL aprepitant capsule 125 mg Tier 3 QL aprepitant capsule therapy pack 80 & 125 Tier 3 QL mg ANTIHYPERTENSIVES ANGIOTENSIN II RECEPTOR ANTAGONISTS olmesartan medoxomil tab 5 mg Tier 4 olmesartan medoxomil tab 20 mg Tier 4 olmesartan medoxomil tab 40 mg Tier 4 ANTIMALARIALS ANTIMALARIALS chloroquine phosphate tab 250 mg Tier 2 PA chloroquine phosphate tab 500 mg Tier 2 PA DARAPRIM TAB 25MG Tier 4 PA mefloquine hcl tab 250 mg Tier 2 PA PRIMAQUINE TAB 26.3MG Tier 4 PA quinine sulfate cap 324 mg Tier 2 PA ANTINEOPLASTIC AGENTS ALKYLATING AGENTS ALKERAN TAB 2MG Tier 6 BICNU INJ 100MG Tier 5 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 24

33 carboplatin iv soln 600 mg/60ml Tier 5 cisplatin inj 50 mg/50ml (1 mg/ml) Tier 5 CYCLOPHOSPH CAP 25MG Tier 5 CYCLOPHOSPH CAP 50MG Tier 5 cyclophosphamide for inj 1 gm Tier 5 cyclophosphamide for inj 2 gm Tier 5 cyclophosphamide for inj 500 mg Tier 5 dacarbazine for inj 100 mg Tier 5 dacarbazine for inj 200 mg Tier 5 EMCYT CAP 140MG Tier 5 PA GLEOSTINE CAP 5MG Tier 5 PA GLEOSTINE CAP 10MG Tier 5 PA GLEOSTINE CAP 40MG Tier 5 PA GLEOSTINE CAP 100MG Tier 5 PA HEXALEN CAP 50MG Tier 5 ifosfamide for inj 1 gm Tier 5 IFOSFAMIDE INJ 3GM Tier 5 ifosfamide iv inj 1 gm/20ml (50 mg/ml) Tier 5 ifosfamide iv inj 3 gm/60ml (50 mg/ml) Tier 5 LEUKERAN TAB 2MG Tier 5 melphalan hcl for inj 50 mg (base equiv) Tier 5 melphalan tab 2 mg Tier 5 MUSTARGEN INJ 10MG Tier 5 MYLERAN TAB 2MG Tier 5 oxaliplatin for iv inj 50 mg Tier 5 oxaliplatin for iv inj 100 mg Tier 5 oxaliplatin iv soln 50 mg/10ml Tier 5 oxaliplatin iv soln 100 mg/20ml Tier 5 TEMODAR INJ 100MG Tier 5 temozolomide cap 5 mg Tier 5 PA temozolomide cap 20 mg Tier 5 PA temozolomide cap 100 mg Tier 5 PA temozolomide cap 140 mg Tier 5 PA temozolomide cap 180 mg Tier 5 PA temozolomide cap 250 mg Tier 5 PA TREANDA INJ 25MG Tier 5 TREANDA INJ 45/0.5ML Tier 5 TREANDA INJ 100MG Tier 5 TREANDA INJ 180/2ML Tier 5 VALCHLOR GEL 0.016% Tier 5 PA ZANOSAR INJ 1GM Tier 5 ANTIMETABOLITES ALIMTA INJ 100MG Tier 5 ALIMTA INJ 500MG Tier 5 capecitabine tab 150 mg Tier 5 PA capecitabine tab 500 mg Tier 5 PA PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 25

34 cladribine iv soln 10 mg/10ml (1 mg/ml) Tier 5 cytarabine inj 20 mg/ml Tier 5 cytarabine inj pf 20 mg/ml Tier 5 cytarabine inj pf 100 mg/ml Tier 5 floxuridine for inj 0.5 gm Tier 5 fludarabine phosphate for inj 50 mg Tier 5 fludarabine phosphate inj 25 mg/ml Tier 5 fluorouracil iv soln 1 gm/20ml (50 mg/ml) Tier 5 fluorouracil iv soln 2.5 gm/50ml (50 Tier 5 mg/ml) fluorouracil iv soln 5 gm/100ml (50 mg/ml) Tier 5 fluorouracil iv soln 500 mg/10ml (50 Tier 5 mg/ml) gemcitabine hcl for inj 1 gm Tier 5 gemcitabine hcl for inj 2 gm Tier 5 gemcitabine hcl for inj 200 mg Tier 5 gemcitabine hcl inj 1 gm/26.3ml (38 Tier 5 mg/ml) (base equiv) gemcitabine hcl inj 2 gm/52.6ml (38 Tier 5 mg/ml) (base equiv) gemcitabine hcl inj 200 mg/5.26ml (38 Tier 5 mg/ml) (base equiv) mercaptopurine tab 50 mg Tier 2 methotrexate sodium for inj 1 gm Tier 5 methotrexate sodium inj 50 mg/2ml (25 Tier 5 mg/ml) methotrexate sodium inj pf 50 mg/2ml (25 Tier 5 mg/ml) methotrexate sodium tab 2.5 mg (base Tier 2 equiv) TABLOID TAB 40MG Tier 5 PA HORMONAL ANTINEOPLASTICS, ANTIANDROGENS bicalutamide tab 50 mg Tier 2 FARESTON TAB 60MG Tier 5 PA flutamide cap 125 mg Tier 2 nilutamide tab 150 mg Tier 2 PA tamoxifen citrate tab 10 mg (base PA equivalent) tamoxifen citrate tab 20 mg (base PA equivalent) XTANDI CAP 40MG Tier 5 PA; QL HORMONAL ANTINEOPLASTICS, ANTIESTROGENS FASLODEX INJ 250/5ML Tier 5 HORMONAL ANTINEOPLASTICS, AROMATASE INHIBITORS anastrozole tab 1 mg Tier 2 exemestane tab 25 mg Tier 2 letrozole tab 2.5 mg Tier 2 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 26

35 HORMONAL ANTINEOPLASTICS, GONADOTROPIN RELEASING HORMONE ANTAGONISTS FIRMAGON INJ 80MG Tier 5 PA; QL FIRMAGON INJ 120MG Tier 5 PA; QL ZYTIGA TAB 250MG Tier 5 PA; QL ZYTIGA TAB 500MG Tier 5 PA; QL HORMONAL ANTINEOPLASTICS, LUTEINIZING HORMONE- RELEASING HORMONE (LHRH) AGONISTS ELIGARD INJ 7.5MG Tier 5 PA; QL ELIGARD INJ 22.5MG Tier 5 PA; QL ELIGARD INJ 30MG Tier 5 PA; QL ELIGARD INJ 45MG Tier 5 PA; QL leuprolide acetate inj kit 5 mg/ml Tier 5 PA; QL LUPRON DEPOT INJ 3.75MG Tier 5 PA; QL LUPRON DEPOT INJ 7.5MG Tier 5 PA; QL LUPRON DEPOT INJ 11.25MG Tier 5 PA; QL LUPRON DEPOT INJ 22.5MG Tier 5 PA; QL LUPRON DEPOT INJ 30MG Tier 5 PA; QL LUPRON DEPOT INJ 45MG Tier 5 PA; QL TRELSTAR INJ 3.75MG Tier 5 PA; QL TRELSTAR INJ 11.25MG Tier 5 PA; QL TRELSTAR MIX INJ 22.5MG Tier 5 PA; QL VANTAS KIT 50MG Tier 5 PA; QL ZOLADEX IMP 3.6MG Tier 5 PA; QL ZOLADEX IMP 10.8MG Tier 5 PA; QL HORMONAL ANTINEOPLASTICS, PROGESTINS megestrol acetate susp 40 mg/ml Tier 2 megestrol acetate tab 20 mg Tier 2 megestrol acetate tab 40 mg Tier 2 IMMUNOMODULATORS POMALYST CAP 1MG Tier 5 PA; QL POMALYST CAP 2MG Tier 5 PA; QL POMALYST CAP 3MG Tier 5 PA; QL POMALYST CAP 4MG Tier 5 PA; QL REVLIMID CAP 2.5MG Tier 5 PA; QL REVLIMID CAP 5MG Tier 5 PA; QL REVLIMID CAP 10MG Tier 5 PA; QL REVLIMID CAP 15MG Tier 5 PA; QL REVLIMID CAP 20MG Tier 5 PA; QL REVLIMID CAP 25MG Tier 5 PA; QL THALOMID CAP 50MG Tier 5 PA; QL THALOMID CAP 100MG Tier 5 PA; QL THALOMID CAP 150MG Tier 5 PA; QL THALOMID CAP 200MG Tier 5 PA; QL KINASE INHIBITORS PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 27

36 AFINITOR DIS TAB 2MG Tier 5 PA; QL AFINITOR DIS TAB 3MG Tier 5 PA; QL AFINITOR DIS TAB 5MG Tier 5 PA; QL AFINITOR TAB 2.5MG Tier 5 PA; QL AFINITOR TAB 5MG Tier 5 PA; QL AFINITOR TAB 7.5MG Tier 5 PA; QL AFINITOR TAB 10MG Tier 5 PA; QL ALECENSA CAP 150MG Tier 5 PA; QL BOSULIF TAB 100MG Tier 5 PA; QL BOSULIF TAB 500MG Tier 5 PA; QL CAPRELSA TAB 100MG Tier 5 PA; QL CAPRELSA TAB 300MG Tier 5 PA; QL COMETRIQ KIT 60MG Tier 5 PA; QL COMETRIQ KIT 100MG Tier 5 PA; QL COMETRIQ KIT 140MG Tier 5 PA; QL COTELLIC TAB 20MG Tier 5 PA; QL GILOTRIF TAB 20MG Tier 5 PA; QL GILOTRIF TAB 30MG Tier 5 PA; QL GILOTRIF TAB 40MG Tier 5 PA; QL IBRANCE CAP 75MG Tier 5 PA; QL IBRANCE CAP 100MG Tier 5 PA; QL IBRANCE CAP 125MG Tier 5 PA; QL ICLUSIG TAB 15MG Tier 5 PA; QL ICLUSIG TAB 45MG Tier 5 PA; QL IMBRUVICA CAP 140MG Tier 5 PA; QL IMBRUVICA TAB 140MG Tier 5 PA; QL IMBRUVICA TAB 280MG Tier 5 PA; QL IMBRUVICA TAB 420MG Tier 5 PA; QL IMBRUVICA TAB 560MG Tier 5 PA; QL INLYTA TAB 1MG Tier 5 PA; QL INLYTA TAB 5MG Tier 5 PA; QL IRESSA TAB 250MG Tier 5 PA; QL JAKAFI TAB 5MG Tier 5 PA; QL JAKAFI TAB 10MG Tier 5 PA; QL JAKAFI TAB 15MG Tier 5 PA; QL JAKAFI TAB 20MG Tier 5 PA; QL JAKAFI TAB 25MG Tier 5 PA; QL KISQALI 200 PAK FEMARA Tier 5 PA; QL KISQALI 400 PAK FEMARA Tier 5 PA; QL KISQALI 600 PAK FEMARA Tier 5 PA; QL KISQALI TAB 200DOSE Tier 5 PA; QL KISQALI TAB 400DOSE Tier 5 PA; QL KISQALI TAB 600DOSE Tier 5 PA; QL LENVIMA CAP 10 MG Tier 5 PA; QL LENVIMA CAP 14 MG Tier 5 PA; QL LENVIMA CAP 20 MG Tier 5 PA; QL PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 28

37 LENVIMA CAP 24 MG Tier 5 PA; QL MEKINIST TAB 0.5MG Tier 5 PA; QL MEKINIST TAB 2MG Tier 5 PA; QL NEXAVAR TAB 200MG Tier 5 PA; QL SPRYCEL TAB 20MG Tier 5 PA; QL SPRYCEL TAB 50MG Tier 5 PA; QL SPRYCEL TAB 70MG Tier 5 PA; QL SPRYCEL TAB 80MG Tier 5 PA; QL SPRYCEL TAB 100MG Tier 5 PA; QL SPRYCEL TAB 140MG Tier 5 PA; QL STIVARGA TAB 40MG Tier 5 PA; QL SUTENT CAP 12.5MG Tier 5 PA; QL SUTENT CAP 25MG Tier 5 PA; QL SUTENT CAP 37.5MG Tier 5 PA; QL SUTENT CAP 50MG Tier 5 PA; QL TAFINLAR CAP 50MG Tier 5 PA; QL TAFINLAR CAP 75MG Tier 5 PA; QL TAGRISSO TAB 40MG Tier 5 PA; QL TAGRISSO TAB 80MG Tier 5 PA; QL TARCEVA TAB 25MG Tier 5 PA TARCEVA TAB 100MG Tier 5 PA; QL TARCEVA TAB 150MG Tier 5 PA; QL TASIGNA CAP 150MG Tier 5 PA; QL TASIGNA CAP 200MG Tier 5 PA; QL TORISEL SOL 25MG/ML Tier 5 TYKERB TAB 250MG Tier 5 PA; QL VOTRIENT TAB 200MG Tier 5 PA; QL XALKORI CAP 200MG Tier 5 PA; QL XALKORI CAP 250MG Tier 5 PA; QL ZELBORAF TAB 240MG Tier 5 PA; QL ZYDELIG TAB 100MG Tier 5 PA; QL ZYDELIG TAB 150MG Tier 5 PA; QL ZYKADIA CAP 150MG Tier 5 PA; QL MISCELLANEOUS ABRAXANE INJ 100MG Tier 5 amifostine for inj 500 mg Tier 5 ARRANON INJ 5MG/ML Tier 5 ARZERRA CON 100/5ML Tier 5 PA AVASTIN INJ Tier 5 bexarotene cap 75 mg Tier 5 PA bleomycin sulfate for inj 15 unit Tier 5 bleomycin sulfate for inj 30 unit Tier 5 daunorubicin hcl iv soln 20 mg/4ml (base Tier 5 equiv) DAUNOXOME INJ 2MG/ML Tier 5 dexrazoxane for inj 250 mg Tier 5 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 29

38 dexrazoxane for inj 500 mg Tier 5 doxorubicin hcl for inj 10 mg Tier 5 doxorubicin hcl for inj 50 mg Tier 5 doxorubicin hcl inj 2 mg/ml Tier 5 ELITEK INJ 1.5MG Tier 5 ELITEK INJ 7.5MG Tier 5 epirubicin hcl iv soln 50 mg/25ml (2 Tier 5 mg/ml) epirubicin hcl iv soln 200 mg/100ml (2 Tier 5 mg/ml) ERBITUX INJ 100MG Tier 5 ERBITUX INJ 200MG Tier 5 ERIVEDGE CAP 150MG Tier 5 PA; QL ETOPOPHOS INJ 100MG Tier 5 etoposide cap 50 mg Tier 5 PA etoposide inj 1 gm/50ml (20 mg/ml) Tier 5 etoposide inj 100 mg/5ml (20 mg/ml) Tier 5 PA etoposide inj 500 mg/25ml (20 mg/ml) Tier 5 PA FARYDAK CAP 10MG Tier 5 PA; QL FARYDAK CAP 15MG Tier 5 PA; QL FARYDAK CAP 20MG Tier 5 PA; QL FLUORAC CRE 5-1% Tier 4 HERCEPTIN INJ 150MG Tier 5 HERCEPTIN INJ 440MG Tier 5 hydroxyurea cap 500 mg Tier 2 idarubicin hcl iv inj 5 mg/5ml (1 mg/ml) Tier 5 IXEMPRA KIT INJ 15MG Tier 5 IXEMPRA KIT INJ 45MG Tier 5 leucovorin calcium tab 5 mg Tier 5 leucovorin calcium tab 10 mg Tier 5 leucovorin calcium tab 15 mg Tier 5 leucovorin calcium tab 25 mg Tier 5 LONSURF TAB Tier 5 PA LONSURF TAB Tier 5 PA LYNPARZA CAP 50MG Tier 5 PA; QL LYSODREN TAB 500MG Tier 5 PA MATULANE CAP 50MG Tier 5 mesna inj 100 mg/ml Tier 5 MESNEX TAB 400MG Tier 5 mitomycin for iv soln 5 mg Tier 5 mitomycin for iv soln 20 mg Tier 5 mitomycin for iv soln 40 mg Tier 5 mitoxantrone hcl inj conc 25 mg/12.5ml (2 Tier 5 mg/ml) NINLARO CAP 2.3MG Tier 5 PA; QL NINLARO CAP 3MG Tier 5 PA; QL NINLARO CAP 4MG Tier 5 PA; QL PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 30

39 ODOMZO CAP 200MG Tier 5 PA; QL ONCASPAR INJ 750/ML Tier 5 paclitaxel iv conc 30 mg/5ml (6 mg/ml) Tier 5 PHOTOFRIN INJ 75MG Tier 5 PROLEUKIN INJ 22MU Tier 5 RITUXAN INJ 100MG Tier 5 PA; QL TARGRETIN CAP 75MG Tier 5 PA TARGRETIN GEL 1% Tier 5 PA tretinoin cap 10 mg Tier 5 TRISENOX SOL 10MG/10M Tier 5 UVADEX INJ 20MCG/ML Tier 4 VENCLEXTA TAB 10MG Tier 5 PA; QL VENCLEXTA TAB 50MG Tier 5 PA; QL VENCLEXTA TAB 100MG Tier 5 PA; QL vinblastine sulfate inj 1 mg/ml Tier 5 vincristine sulfate iv soln 1 mg/ml Tier 5 vinorelbine tartrate inj 10 mg/ml (base Tier 5 equiv) vinorelbine tartrate inj 50 mg/5ml (10 Tier 5 mg/ml) (base equiv) VORAXAZE INJ 1000UNIT Tier 5 PA ZOLINZA CAP 100MG Tier 5 PA; QL TOPOISOMERASE INHIBITORS HYCAMTIN CAP 0.25MG Tier 5 PA HYCAMTIN CAP 1MG Tier 5 PA irinotecan hcl inj 40 mg/2ml (20 mg/ml) Tier 5 irinotecan hcl inj 100 mg/5ml (20 mg/ml) Tier 5 irinotecan hcl inj 500 mg/25ml (20 mg/ml) Tier 5 TOPOTECAN INJ 4MG/4ML Tier 5 ANTINEOPLASTIC ENZYME INHIBITORS POLY (ADP-RIBOSE) POLYMERASE (PARP) INHIBITORS RUBR TAB 200MG Tier 5 PA; QL RUBR TAB 250MG Tier 5 PA; QL RUBR TAB 300MG Tier 5 PA; QL ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ANTINEOPLASTIC - BCL-2 INHIBITORS VENCLEXTA TAB 10MG Tier 5 PA; QL VENCLEXTA TAB 50MG Tier 5 PA; QL VENCLEXTA TAB 100MG Tier 5 PA; QL VENCLEXTA TAB START PK Tier 5 PA; QL ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS ERLEADA TAB 60MG Tier 5 PA; QL ANTINEOPLASTIC ENZYME INHIBITORS ALUNBRIG PAK Tier 5 PA; QL ALUNBRIG TAB 30MG Tier 5 PA; QL ALUNBRIG TAB 90MG Tier 5 PA; QL PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 31

40 ALUNBRIG TAB 180MG Tier 5 PA; QL CABOMETYX TAB 20MG Tier 5 PA; QL CABOMETYX TAB 40MG Tier 5 PA; QL CABOMETYX TAB 60MG Tier 5 PA; QL CALQUENCE CAP 100MG Tier 5 PA; QL IDHIFA TAB 50MG Tier 5 PA; QL IDHIFA TAB 100MG Tier 5 PA; QL imatinib mesylate tab 100 mg (base Tier 5 PA; QL equivalent) imatinib mesylate tab 400 mg (base Tier 5 PA; QL equivalent) LENVIMA CAP 8 MG Tier 5 PA; QL LENVIMA CAP 18 MG Tier 5 PA; QL NERLYNX TAB 40MG Tier 5 PA; QL RYDAPT CAP 25MG Tier 5 PA; QL TASIGNA CAP 50MG Tier 5 PA; QL VERZENIO TAB 50MG Tier 5 PA; QL VERZENIO TAB 100MG Tier 5 PA; QL VERZENIO TAB 150MG Tier 5 PA; QL VERZENIO TAB 200MG Tier 5 PA; QL ZEJULA CAP 100MG Tier 5 PA; QL ANTIPARKINSON AND RELATED THERAPY AGENTS ANTIPARKINSON MONOAMINE OXIDASE INHIBITORS rasagiline mesylate tab 0.5 mg (base Tier 2 equiv) rasagiline mesylate tab 1 mg (base equiv) Tier 2 ANTIPSYCHOTICS/ANTIMANIC AGENTS DIBENZAPINES quetiapine fumarate tab er 24hr 50 mg Tier 2 QL quetiapine fumarate tab er 24hr 150 mg Tier 2 QL quetiapine fumarate tab er 24hr 200 mg Tier 2 QL quetiapine fumarate tab er 24hr 300 mg Tier 2 QL quetiapine fumarate tab er 24hr 400 mg Tier 2 QL DIHYDROINDOLONES molindone hcl tab 5 mg Tier 2 molindone hcl tab 10 mg Tier 2 molindone hcl tab 25 mg Tier 2 ANTIVIRALS ANTIRETROVIRALS abacavir sulfate-lamivudine tab Tier 2 QL mg BIKTARVY TAB Tier 5 QL efavirenz cap 50 mg Tier 2 QL efavirenz cap 200 mg Tier 2 QL efavirenz tab 600 mg Tier 2 QL tenofovir disoproxil fumarate tab 300 mg Tier 2 QL PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 32

41 INFLUENZA AGENTS oseltamivir phosphate for susp 6 mg/ml Tier 2 (base equiv) BACTERIAL VACCINES BACTERIAL VACCINE COMBINATIONS MENHIBRIX INJ BACTERIAL VACCINES ACTHIB INJ BEXSERO INJ HIBERIX SOL 10MCG MENACTRA INJ MENOMUNE INJ A/C/Y/W MENVEO INJ PEDVAX HIB INJ PNEUMOVAX 23 INJ 25/0.5 PREVNAR 13 INJ TRUMENBA INJ CALCIUM CHANNEL BLOCKERS CALCIUM CHANNEL BLOCKERS diltiazem hcl cap er 24hr 120 mg Tier 2 diltiazem hcl cap er 24hr 180 mg Tier 2 diltiazem hcl cap er 24hr 240 mg Tier 2 diltiazem hcl coated beads cap er 24hr 120 Tier 2 mg diltiazem hcl coated beads cap er 24hr 180 Tier 2 mg diltiazem hcl coated beads cap er 24hr 240 Tier 2 mg diltiazem hcl coated beads cap er 24hr 300 Tier 2 mg diltiazem hcl extended release beads cap Tier 2 er 24hr 120 mg diltiazem hcl extended release beads cap Tier 2 er 24hr 180 mg diltiazem hcl extended release beads cap Tier 2 er 24hr 240 mg diltiazem hcl extended release beads cap Tier 2 er 24hr 300 mg diltiazem hcl extended release beads cap Tier 2 er 24hr 360 mg diltiazem hcl extended release beads cap Tier 2 er 24hr 420 mg diltiazem hcl tab 30 mg Tier 2 diltiazem hcl tab 60 mg Tier 2 diltiazem hcl tab 90 mg Tier 2 diltiazem hcl tab 120 mg Tier 2 CARDIOVASCULAR PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 33 QL

42 ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS amlodipine besylate-benazepril hcl cap 2.5-Tier 2 10 mg amlodipine besylate-benazepril hcl cap 5- Tier 2 10 mg amlodipine besylate-benazepril hcl cap 5- Tier 2 20 mg amlodipine besylate-benazepril hcl cap 5- Tier 2 40 mg amlodipine besylate-benazepril hcl cap 10- Tier 2 20 mg amlodipine besylate-benazepril hcl cap 10- Tier 2 40 mg trandolapril-verapamil hcl tab er mg Tier 2 trandolapril-verapamil hcl tab er mg Tier 2 trandolapril-verapamil hcl tab er mg Tier 2 trandolapril-verapamil hcl tab er mg Tier 2 ACE INHIBITOR/DIURETIC COMBINATIONS benazepril & hydrochlorothiazide tab 5- Tier mg benazepril & hydrochlorothiazide tab 10- Tier mg benazepril & hydrochlorothiazide tab 20- Tier mg benazepril & hydrochlorothiazide tab Tier 4 mg captopril & hydrochlorothiazide tab Tier 4 mg captopril & hydrochlorothiazide tab Tier 4 mg captopril & hydrochlorothiazide tab Tier 4 mg captopril & hydrochlorothiazide tab Tier 4 mg enalapril maleate & hydrochlorothiazide tab Tier mg enalapril maleate & hydrochlorothiazide tab Tier mg fosinopril sodium & hydrochlorothiazide tab Tier mg fosinopril sodium & hydrochlorothiazide tab Tier mg lisinopril & hydrochlorothiazide tab Tier 1 mg lisinopril & hydrochlorothiazide tab Tier 1 mg lisinopril & hydrochlorothiazide tab Tier 1 mg PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 34

43 moexipril-hydrochlorothiazide tab Tier 2 mg moexipril-hydrochlorothiazide tab Tier 2 mg moexipril-hydrochlorothiazide tab Tier 2 mg quinapril-hydrochlorothiazide tab Tier 2 mg quinapril-hydrochlorothiazide tab Tier 2 mg quinapril-hydrochlorothiazide tab mg Tier 2 ACE INHIBITORS benazepril hcl tab 5 mg Tier 1 benazepril hcl tab 10 mg Tier 1 benazepril hcl tab 20 mg Tier 1 benazepril hcl tab 40 mg Tier 1 captopril tab 12.5 mg Tier 4 captopril tab 25 mg Tier 4 captopril tab 50 mg Tier 4 captopril tab 100 mg Tier 4 enalapril maleate tab 2.5 mg Tier 2 enalapril maleate tab 5 mg Tier 2 enalapril maleate tab 10 mg Tier 2 enalapril maleate tab 20 mg Tier 2 enalaprilat iv inj 1.25 mg/ml Tier 2 fosinopril sodium tab 10 mg Tier 2 fosinopril sodium tab 20 mg Tier 2 fosinopril sodium tab 40 mg Tier 2 lisinopril tab 2.5 mg Tier 1 lisinopril tab 5 mg Tier 1 lisinopril tab 10 mg Tier 1 lisinopril tab 20 mg Tier 1 lisinopril tab 30 mg Tier 1 lisinopril tab 40 mg Tier 1 moexipril hcl tab 7.5 mg Tier 2 moexipril hcl tab 15 mg Tier 2 perindopril erbumine tab 2 mg Tier 2 perindopril erbumine tab 4 mg Tier 2 perindopril erbumine tab 8 mg Tier 2 quinapril hcl tab 5 mg Tier 2 quinapril hcl tab 10 mg Tier 2 quinapril hcl tab 20 mg Tier 2 quinapril hcl tab 40 mg Tier 2 ramipril cap 1.25 mg Tier 2 ramipril cap 2.5 mg Tier 2 ramipril cap 5 mg Tier 2 ramipril cap 10 mg Tier 2 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 35

44 trandolapril tab 1 mg Tier 2 trandolapril tab 2 mg Tier 2 trandolapril tab 4 mg Tier 2 ADRENOLYTICS, CENTRAL clonidine hcl tab 0.1 mg Tier 2 clonidine hcl tab 0.2 mg Tier 2 clonidine hcl tab 0.3 mg Tier 2 clonidine td patch weekly 0.1 mg/24hr Tier 2 clonidine td patch weekly 0.2 mg/24hr Tier 2 clonidine td patch weekly 0.3 mg/24hr Tier 2 guanfacine hcl tab 1 mg Tier 2 guanfacine hcl tab 2 mg Tier 2 AGENTS FOR PHEOCHROMOCYTOMA DEMSER CAP 250MG Tier 6 PA DIBENZYLINE CAP 10MG Tier 6 PA phenoxybenzamine hcl cap 10 mg Tier 6 PA PHENTOLAMINE INJ 5MG Tier 2 ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone tab 25 mg Tier 2 eplerenone tab 50 mg Tier 2 spironolactone tab 25 mg Tier 1 spironolactone tab 50 mg Tier 2 spironolactone tab 100 mg Tier 2 ALPHA BLOCKERS doxazosin mesylate tab 1 mg Tier 2 doxazosin mesylate tab 2 mg Tier 2 doxazosin mesylate tab 4 mg Tier 2 doxazosin mesylate tab 8 mg Tier 2 prazosin hcl cap 1 mg Tier 2 prazosin hcl cap 2 mg Tier 2 prazosin hcl cap 5 mg Tier 2 terazosin hcl cap 1 mg (base equivalent) Tier 2 terazosin hcl cap 2 mg (base equivalent) Tier 2 terazosin hcl cap 5 mg (base equivalent) Tier 2 terazosin hcl cap 10 mg (base equivalent) Tier 2 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS EDARBYCLOR TAB Tier 4 ST EDARBYCLOR TAB 40-25MG Tier 4 ST telmisartan-amlodipine tab 40-5 mg Tier 2 telmisartan-amlodipine tab mg Tier 2 telmisartan-amlodipine tab 80-5 mg Tier 2 telmisartan-amlodipine tab mg Tier 2 ANGIOTENSIN II RECEPTOR ANTAGONIST/DIURETIC COMBINATIONS PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 36

45 candesartan cilexetil-hydrochlorothiazide Tier 2 tab mg candesartan cilexetil-hydrochlorothiazide Tier 2 tab mg candesartan cilexetil-hydrochlorothiazide Tier 2 tab mg irbesartan-hydrochlorothiazide tab 150- Tier mg irbesartan-hydrochlorothiazide tab 300- Tier mg losartan potassium & hydrochlorothiazide Tier 2 tab mg losartan potassium & hydrochlorothiazide Tier 2 tab mg losartan potassium & hydrochlorothiazide Tier 2 tab mg telmisartan-hydrochlorothiazide tab 40- Tier mg telmisartan-hydrochlorothiazide tab 80- Tier mg telmisartan-hydrochlorothiazide tab Tier 2 mg valsartan-hydrochlorothiazide tab Tier 2 mg valsartan-hydrochlorothiazide tab Tier 2 mg valsartan-hydrochlorothiazide tab Tier 2 mg valsartan-hydrochlorothiazide tab Tier 2 mg valsartan-hydrochlorothiazide tab Tier 2 mg ANGIOTENSIN II RECEPTOR ANTAGONISTS candesartan cilexetil tab 4 mg Tier 2 candesartan cilexetil tab 8 mg Tier 2 candesartan cilexetil tab 16 mg Tier 2 candesartan cilexetil tab 32 mg Tier 2 EDARBI TAB 40MG Tier 4 ST EDARBI TAB 80MG Tier 4 ST eprosartan mesylate tab 600 mg Tier 2 irbesartan tab 75 mg Tier 2 irbesartan tab 150 mg Tier 2 irbesartan tab 300 mg Tier 2 losartan potassium tab 25 mg Tier 2 losartan potassium tab 50 mg Tier 2 losartan potassium tab 100 mg Tier 2 telmisartan tab 20 mg Tier 2 telmisartan tab 40 mg Tier 2 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 37

46 telmisartan tab 80 mg Tier 2 valsartan tab 40 mg Tier 2 valsartan tab 80 mg Tier 2 valsartan tab 160 mg Tier 2 valsartan tab 320 mg Tier 2 ANTIARRHYTHMICS amiodarone hcl tab 100 mg Tier 2 amiodarone hcl tab 200 mg Tier 2 amiodarone hcl tab 400 mg Tier 2 disopyramide phosphate cap 100 mg Tier 2 disopyramide phosphate cap 150 mg Tier 2 dofetilide cap 125 mcg (0.125 mg) Tier 2 QL dofetilide cap 250 mcg (0.25 mg) Tier 2 QL dofetilide cap 500 mcg (0.5 mg) Tier 2 QL flecainide acetate tab 50 mg Tier 2 flecainide acetate tab 100 mg Tier 2 flecainide acetate tab 150 mg Tier 2 mexiletine hcl cap 150 mg Tier 2 mexiletine hcl cap 200 mg Tier 2 mexiletine hcl cap 250 mg Tier 2 MULTAQ TAB 400MG Tier 3 procainamide hcl inj 100 mg/ml Tier 2 PROCAINAMIDE INJ 500MG/ML Tier 2 propafenone hcl cap er 12hr 225 mg Tier 2 propafenone hcl cap er 12hr 325 mg Tier 2 propafenone hcl cap er 12hr 425 mg Tier 2 propafenone hcl tab 150 mg Tier 2 propafenone hcl tab 225 mg Tier 2 propafenone hcl tab 300 mg Tier 2 QUINIDINE GL INJ 80MG/ML Tier 2 quinidine gluconate tab er 324 mg Tier 2 quinidine sulfate tab 200 mg Tier 2 quinidine sulfate tab 300 mg Tier 2 quinidine sulfate tab er 300 mg Tier 2 sotalol hcl (afib/afl) tab 80 mg Tier 2 sotalol hcl (afib/afl) tab 120 mg Tier 2 sotalol hcl (afib/afl) tab 160 mg Tier 2 SOTALOL HCL INJ 150/10ML Tier 4 sotalol hcl tab 80 mg Tier 2 sotalol hcl tab 120 mg Tier 2 sotalol hcl tab 160 mg Tier 2 sotalol hcl tab 240 mg Tier 2 ANTILIPEMICS, BILE ACID RESINS cholestyramine light powder 4 gm/dose Tier 4 cholestyramine light powder packets 4 gm Tier 4 cholestyramine powder 4 gm/dose Tier 4 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 38

47 cholestyramine powder packets 4 gm Tier 4 colesevelam hcl tab 625 mg Tier 2 colestipol hcl granule packets 5 gm Tier 4 colestipol hcl granules 5 gm Tier 4 colestipol hcl tab 1 gm Tier 4 WELCHOL PAK 3.75GM Tier 3 WELCHOL TAB 625MG Tier 3 ANTILIPEMICS, CHOLESTEROL ABSORPTION INHIBITORS ezetimibe tab 10 mg Tier 2 ANTILIPEMICS, FIBRATES choline fenofibrate cap dr 45 mg (fenofibric Tier 4 acid equiv) choline fenofibrate cap dr 135 mg Tier 4 (fenofibric acid equiv) fenofibrate micronized cap 43 mg Tier 2 fenofibrate micronized cap 67 mg Tier 2 fenofibrate micronized cap 134 mg Tier 2 fenofibrate micronized cap 200 mg Tier 4 fenofibrate tab 48 mg Tier 2 fenofibrate tab 54 mg Tier 2 fenofibrate tab 145 mg Tier 2 fenofibrate tab 160 mg Tier 2 fenofibric acid tab 35 mg Tier 4 fenofibric acid tab 105 mg Tier 4 gemfibrozil tab 600 mg Tier 2 ANTILIPEMICS, HMG-COA REDUCTASE INHIBITORS/COMBINATIONS atorvastatin calcium tab 10 mg (base Tier 2 equivalent) atorvastatin calcium tab 20 mg (base Tier 2 equivalent) atorvastatin calcium tab 40 mg (base Tier 2 equivalent) atorvastatin calcium tab 80 mg (base Tier 2 equivalent) fluvastatin sodium cap 20 mg Tier 4 fluvastatin sodium cap 40 mg Tier 4 LIVALO TAB 1MG Tier 4 PA LIVALO TAB 2MG Tier 4 PA LIVALO TAB 4MG Tier 4 PA lovastatin tab 10 mg Tier 1 lovastatin tab 20 mg Tier 1 lovastatin tab 40 mg Tier 1 pravastatin sodium tab 10 mg Tier 2 pravastatin sodium tab 20 mg Tier 2 pravastatin sodium tab 40 mg Tier 2 pravastatin sodium tab 80 mg Tier 2 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 39

48 rosuvastatin calcium tab 5 mg Tier 2 rosuvastatin calcium tab 10 mg Tier 2 rosuvastatin calcium tab 20 mg Tier 2 rosuvastatin calcium tab 40 mg Tier 2 simvastatin tab 5 mg Tier 1 simvastatin tab 10 mg Tier 1 simvastatin tab 20 mg Tier 1 simvastatin tab 40 mg Tier 1 simvastatin tab 80 mg Tier 1 ANTILIPEMICS, MISCELLANEOUS JUXTAPID CAP 5MG Tier 6 PA; QL JUXTAPID CAP 10MG Tier 6 PA; QL JUXTAPID CAP 20MG Tier 6 PA; QL JUXTAPID CAP 30MG Tier 6 PA; QL JUXTAPID CAP 40MG Tier 6 PA; QL JUXTAPID CAP 60MG Tier 6 PA; QL KYNAMRO INJ 200MG/ML Tier 6 PA; QL ANTILIPEMICS, NIACINS/COMBINATIONS niacin tab er 500 mg (antihyperlipidemic) Tier 4 niacin tab er 750 mg (antihyperlipidemic) Tier 4 niacin tab er 1000 mg (antihyperlipidemic) Tier 4 ANTILIPEMICS, OMEGA-3 FATTY ACIDS omega-3-acid ethyl esters cap 1 gm Tier 3 VASCEPA CAP 1GM Tier 3 ANTILIPEMICS, PCSK9 INHIBITORS PRALUENT INJ 75MG/ML Tier 5 PA; QL PRALUENT INJ 150MG/ML Tier 5 PA; QL REPATHA INJ 140MG/ML Tier 5 PA; QL REPATHA SURE INJ 140MG/ML Tier 5 PA; QL BETA-BLOCKER/DIURETIC COMBINATIONS atenolol & chlorthalidone tab mg Tier 1 atenolol & chlorthalidone tab mg Tier 1 bisoprolol & hydrochlorothiazide tab 2.5- Tier mg bisoprolol & hydrochlorothiazide tab Tier 1 mg bisoprolol & hydrochlorothiazide tab 10- Tier mg metoprolol & hydrochlorothiazide tab 50- Tier 2 25 mg metoprolol & hydrochlorothiazide tab 100- Tier 2 25 mg metoprolol & hydrochlorothiazide tab 100- Tier 2 50 mg nadolol & bendroflumethiazide tab 40-5 mg Tier 2 nadolol & bendroflumethiazide tab 80-5 mg Tier 2 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 40

49 propranolol & hydrochlorothiazide tab 40- Tier 2 25 mg propranolol & hydrochlorothiazide tab 80- Tier 2 25 mg BETA-BLOCKERS acebutolol hcl cap 200 mg Tier 2 acebutolol hcl cap 400 mg Tier 2 atenolol tab 25 mg Tier 1 atenolol tab 50 mg Tier 1 atenolol tab 100 mg Tier 1 betaxolol hcl tab 10 mg Tier 2 betaxolol hcl tab 20 mg Tier 2 bisoprolol fumarate tab 5 mg Tier 2 bisoprolol fumarate tab 10 mg Tier 2 BYSTOLIC TAB 2.5MG Tier 4 ST BYSTOLIC TAB 5MG Tier 4 ST BYSTOLIC TAB 10MG Tier 4 ST BYSTOLIC TAB 20MG Tier 4 ST carvedilol tab mg Tier 1 carvedilol tab 6.25 mg Tier 1 carvedilol tab 12.5 mg Tier 1 carvedilol tab 25 mg Tier 1 esmolol hcl inj 100 mg/10ml Tier 2 HEMANGEOL SOL 4.28/ML Tier 4 PA; QL labetalol hcl iv soln 5 mg/ml Tier 2 labetalol hcl tab 100 mg Tier 2 labetalol hcl tab 200 mg Tier 2 labetalol hcl tab 300 mg Tier 2 LEVATOL TAB 20MG Tier 4 ST metoprolol succinate tab er 24hr 25 mg Tier 2 (tartrate equiv) metoprolol succinate tab er 24hr 50 mg Tier 2 (tartrate equiv) metoprolol succinate tab er 24hr 100 mg Tier 2 (tartrate equiv) metoprolol succinate tab er 24hr 200 mg Tier 2 (tartrate equiv) metoprolol tartrate iv soln 5 mg/5ml Tier 2 metoprolol tartrate tab 25 mg Tier 1 metoprolol tartrate tab 50 mg Tier 1 metoprolol tartrate tab 100 mg Tier 1 nadolol tab 20 mg Tier 2 nadolol tab 40 mg Tier 2 nadolol tab 80 mg Tier 2 pindolol tab 5 mg Tier 2 pindolol tab 10 mg Tier 2 propranolol hcl cap er 24hr 60 mg Tier 2 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 41

50 propranolol hcl cap er 24hr 80 mg Tier 2 propranolol hcl cap er 24hr 120 mg Tier 2 propranolol hcl cap er 24hr 160 mg Tier 2 propranolol hcl inj 1 mg/ml Tier 2 propranolol hcl oral soln 20 mg/5ml Tier 2 propranolol hcl oral soln 40 mg/5ml Tier 2 propranolol hcl tab 10 mg Tier 1 propranolol hcl tab 20 mg Tier 1 propranolol hcl tab 40 mg Tier 1 propranolol hcl tab 60 mg Tier 2 propranolol hcl tab 80 mg Tier 1 timolol maleate tab 5 mg Tier 2 timolol maleate tab 10 mg Tier 2 timolol maleate tab 20 mg Tier 2 CALCIUM CHANNEL BLOCKERS, DIHYDROPYRIDINES amlodipine besylate tab 2.5 mg (base Tier 1 equivalent) amlodipine besylate tab 5 mg (base Tier 1 equivalent) amlodipine besylate tab 10 mg (base Tier 1 equivalent) CLEVIPREX EMU 50/100ML Tier 4 felodipine tab er 24hr 2.5 mg Tier 2 felodipine tab er 24hr 5 mg Tier 2 felodipine tab er 24hr 10 mg Tier 2 isradipine cap 2.5 mg Tier 2 isradipine cap 5 mg Tier 2 nicardipine hcl cap 20 mg Tier 2 nicardipine hcl cap 30 mg Tier 2 nicardipine hcl iv soln 2.5 mg/ml Tier 2 nifedipine cap 10 mg Tier 2 nifedipine cap 20 mg Tier 2 nifedipine tab er 24hr 30 mg Tier 2 nifedipine tab er 24hr 60 mg Tier 2 nifedipine tab er 24hr 90 mg Tier 2 nifedipine tab er 24hr osmotic release 30 Tier 2 mg nifedipine tab er 24hr osmotic release 60 Tier 2 mg nifedipine tab er 24hr osmotic release 90 Tier 2 mg nimodipine cap 30 mg Tier 2 nisoldipine tab er 24hr 8.5 mg Tier 2 ST nisoldipine tab er 24hr 17 mg Tier 2 ST nisoldipine tab er 24hr 20 mg Tier 2 ST nisoldipine tab er 24hr 25.5 mg Tier 2 ST nisoldipine tab er 24hr 30 mg Tier 2 ST PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 42

51 nisoldipine tab er 24hr 34 mg Tier 2 ST nisoldipine tab er 24hr 40 mg Tier 2 ST CALCIUM CHANNEL BLOCKERS, NON DIHYDROPYRIDINES diltiazem hcl coated beads cap er 24hr 120 Tier 2 mg verapamil hcl cap er 24hr 120 mg Tier 2 verapamil hcl cap er 24hr 180 mg Tier 2 verapamil hcl cap er 24hr 240 mg Tier 2 verapamil hcl iv soln 2.5 mg/ml Tier 2 verapamil hcl tab 40 mg Tier 2 verapamil hcl tab 80 mg Tier 2 verapamil hcl tab 120 mg Tier 2 verapamil hcl tab er 120 mg Tier 2 verapamil hcl tab er 180 mg Tier 2 verapamil hcl tab er 240 mg Tier 2 DIGITALIS GLYCOSIDES digoxin inj 0.25 mg/ml Tier 2 digoxin oral soln 0.05 mg/ml Tier 2 digoxin tab 125 mcg (0.125 mg) Tier 2 digoxin tab 250 mcg (0.25 mg) Tier 2 DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS TEKTURNA HCT TAB Tier 3 ST TEKTURNA HCT TAB MG Tier 3 ST TEKTURNA HCT TAB Tier 3 ST TEKTURNA HCT TAB MG Tier 3 ST TEKTURNA TAB 150MG Tier 3 ST TEKTURNA TAB 300MG Tier 3 ST DIURETICS amiloride & hydrochlorothiazide tab 5-50 Tier 2 mg amiloride hcl tab 5 mg Tier 2 bumetanide inj 0.25 mg/ml Tier 2 bumetanide tab 0.5 mg Tier 1 bumetanide tab 1 mg Tier 1 bumetanide tab 2 mg Tier 2 chlorothiazide sodium for inj 500 mg Tier 2 chlorothiazide tab 250 mg Tier 2 chlorothiazide tab 500 mg Tier 2 chlorthalidone tab 25 mg Tier 2 chlorthalidone tab 50 mg Tier 2 DIURIL SUS 250/5ML Tier 4 DYRENIUM CAP 50MG Tier 4 DYRENIUM CAP 100MG Tier 4 ethacrynate sodium for inj 50 mg Tier 5 furosemide inj 10 mg/ml Tier 2 furosemide oral soln 8 mg/ml Tier 2 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 43

52 furosemide oral soln 10 mg/ml Tier 2 furosemide tab 20 mg Tier 1 furosemide tab 40 mg Tier 1 furosemide tab 80 mg Tier 1 hydrochlorothiazide cap 12.5 mg Tier 1 hydrochlorothiazide tab 12.5 mg Tier 2 hydrochlorothiazide tab 25 mg Tier 1 hydrochlorothiazide tab 50 mg Tier 1 indapamide tab 1.25 mg Tier 2 indapamide tab 2.5 mg Tier 2 methyclothiazide tab 5 mg Tier 2 metolazone tab 2.5 mg Tier 2 metolazone tab 5 mg Tier 2 metolazone tab 10 mg Tier 2 spironolactone & hydrochlorothiazide tab Tier mg torsemide tab 5 mg Tier 2 torsemide tab 10 mg Tier 2 torsemide tab 20 mg Tier 2 torsemide tab 100 mg Tier 2 triamterene & hydrochlorothiazide cap Tier mg triamterene & hydrochlorothiazide cap 50- Tier 2 25 mg triamterene & hydrochlorothiazide tab Tier mg triamterene & hydrochlorothiazide tab 75- Tier 1 50 mg MISCELLANEOUS atropine sulfate inj 0.4 mg/ml Tier 2 atropine sulfate inj 1 mg/ml Tier 2 atropine sulfate soln prefill syr 0.25 Tier 2 mg/5ml (0.05 mg/ml) atropine sulfate soln prefill syr 1 mg/10ml Tier 2 (0.1 mg/ml) CORLANOR TAB 5MG Tier 4 PA; QL CORLANOR TAB 7.5MG Tier 4 PA; QL hydralazine hcl inj 20 mg/ml Tier 2 hydralazine hcl tab 10 mg Tier 2 hydralazine hcl tab 25 mg Tier 2 hydralazine hcl tab 50 mg Tier 2 hydralazine hcl tab 100 mg Tier 2 isoxsuprine hcl tab 10 mg Tier 2 isoxsuprine hcl tab 20 mg Tier 2 methyldopa & hydrochlorothiazide tab 250-Tier 2 15 mg PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 44

53 methyldopa & hydrochlorothiazide tab 250-Tier 2 25 mg methyldopa tab 250 mg Tier 2 methyldopa tab 500 mg Tier 2 methyldopate hcl inj 250 mg/5ml Tier 2 midodrine hcl tab 2.5 mg Tier 2 midodrine hcl tab 5 mg Tier 2 midodrine hcl tab 10 mg Tier 2 minoxidil tab 2.5 mg Tier 2 minoxidil tab 10 mg Tier 2 NORTHERA CAP 100MG Tier 5 PA; QL NORTHERA CAP 200MG Tier 5 PA; QL NORTHERA CAP 300MG Tier 5 PA; QL papaverine hcl inj 30 mg/ml Tier 2 RANEXA TAB 500MG Tier 3 RANEXA TAB 1000MG Tier 3 reserpine tab 0.1 mg Tier 2 reserpine tab 0.25 mg Tier 2 NEPRILYSIN INHIBITOR / ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS ENTRESTO TAB 24-26MG Tier 3 PA; QL ENTRESTO TAB 49-51MG Tier 3 PA; QL ENTRESTO TAB MG Tier 3 PA; QL NITRATES, INJECTABLE NITROGLYCER INJ 5MG/ML Tier 2 nitroglycerin iv soln 100 mcg/ml in d5w Tier 2 nitroglycerin iv soln 200 mcg/ml in d5w Tier 2 nitroglycerin iv soln 400 mcg/ml in d5w Tier 2 NITRATES, ORAL isosorbide dinitrate tab 5 mg Tier 2 isosorbide dinitrate tab 10 mg Tier 2 isosorbide dinitrate tab 20 mg Tier 2 isosorbide dinitrate tab 30 mg Tier 2 isosorbide dinitrate tab er 40 mg Tier 2 isosorbide mononitrate tab 10 mg Tier 2 isosorbide mononitrate tab 20 mg Tier 2 isosorbide mononitrate tab er 24hr 30 mg Tier 2 isosorbide mononitrate tab er 24hr 60 mg Tier 2 isosorbide mononitrate tab er 24hr 120 mg Tier 2 nitroglycerin cap er 2.5 mg Tier 2 nitroglycerin cap er 6.5 mg Tier 2 nitroglycerin cap er 9 mg Tier 2 NITRATES, SUBLINGUAL/TRANSLINGUAL nitroglycerin lingual aerosol 400 mcg/spray Tier 2 nitroglycerin sl tab 0.3 mg Tier 2 nitroglycerin sl tab 0.4 mg Tier 2 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 45

54 nitroglycerin sl tab 0.6 mg Tier 2 nitroglycerin tl soln 0.4 mg/spray (400 Tier 2 mcg/spray) NITROSTAT SUB 0.3MG Tier 4 NITROSTAT SUB 0.4MG Tier 4 NITROSTAT SUB 0.6MG Tier 4 NITRATES, TRANSDERMAL NITRO-BID OIN 2% Tier 2 NITRO-DUR DIS 0.3MG/HR Tier 4 NITRO-DUR DIS 0.8MG/HR Tier 4 nitroglycerin td patch 24hr 0.1 mg/hr Tier 2 nitroglycerin td patch 24hr 0.2 mg/hr Tier 2 nitroglycerin td patch 24hr 0.4 mg/hr Tier 2 nitroglycerin td patch 24hr 0.6 mg/hr Tier 2 PULMONARY ARTERIAL HYPERTENSION, ENDOTHELIN RECEPTOR ANTAGONIST LETAIRIS TAB 5MG Tier 5 PA; QL LETAIRIS TAB 10MG Tier 5 PA; QL OPSUMIT TAB 10MG Tier 5 PA; QL TRACLEER TAB 62.5MG Tier 5 PA; QL TRACLEER TAB 125MG Tier 5 PA; QL PULMONARY ARTERIAL HYPERTENSION, PHOSPHODIESTERASE INHIBITOR sildenafil citrate tab 20 mg Tier 5 PA; QL PULMONARY ARTERIAL HYPERTENSION, PROSTAGLANDIN VASODILATORS epoprostenol sodium for inj 0.5 mg Tier 5 PA epoprostenol sodium for inj 1.5 mg Tier 5 PA ORENITRAM TAB 0.25MG Tier 6 PA ORENITRAM TAB 0.125MG Tier 6 PA ORENITRAM TAB 1MG Tier 6 PA ORENITRAM TAB 2.5MG Tier 6 PA ORENITRAM TAB 5MG Tier 6 PA REMODULIN INJ 1MG/ML Tier 5 PA REMODULIN INJ 2.5MG/ML Tier 5 PA REMODULIN INJ 5MG/ML Tier 5 PA REMODULIN INJ 10MG/ML Tier 5 PA TYVASO START SOL 0.6MG/ML Tier 5 PA VELETRI INJ 0.5MG Tier 6 PA VELETRI INJ 1.5MG Tier 6 PA VENTAVIS SOL 10MCG/ML Tier 6 PA VENTAVIS SOL 20MCG/ML Tier 6 PA PULMONARY ARTERIAL HYPERTENSION, SOLUBLE GUANYLATE CYCLASE STIMULATORS ADEMPAS TAB 0.5MG Tier 5 PA; QL PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 46

55 ADEMPAS TAB 1.5MG Tier 5 PA; QL ADEMPAS TAB 1MG Tier 5 PA; QL ADEMPAS TAB 2.5MG Tier 5 PA; QL ADEMPAS TAB 2MG Tier 5 PA; QL CARDIOVASCULAR AGENTS - MISC. PULMONARY HYPERTENSION - PROSTACYCLIN RECEPTOR AGONIST UPTRAVI TAB 200/800 Tier 5 PA; QL UPTRAVI TAB 200MCG Tier 5 PA; QL UPTRAVI TAB 400MCG Tier 5 PA; QL UPTRAVI TAB 600MCG Tier 5 PA; QL UPTRAVI TAB 800MCG Tier 5 PA; QL UPTRAVI TAB 1000MCG Tier 5 PA; QL UPTRAVI TAB 1200MCG Tier 5 PA; QL UPTRAVI TAB 1400MCG Tier 5 PA; QL UPTRAVI TAB 1600MCG Tier 5 PA; QL CENTRAL NERVOUS SYSTEM ANTI-OBESITY CONTRAVE TAB 8-90MG Tier 4 PA; QL ANTIANXIETY, BENZODIAZEPINES ALPRAZOLAM CON 1 MG/ML Tier 2 alprazolam orally disintegrating tab 0.5 mg Tier 2 ST alprazolam orally disintegrating tab 0.25 Tier 2 ST mg alprazolam orally disintegrating tab 1 mg Tier 2 ST alprazolam orally disintegrating tab 2 mg Tier 2 ST alprazolam tab 0.5 mg Tier 2 alprazolam tab 0.25 mg Tier 2 alprazolam tab 1 mg Tier 2 alprazolam tab 2 mg Tier 2 alprazolam tab er 24hr 0.5 mg Tier 2 alprazolam tab er 24hr 1 mg Tier 2 alprazolam tab er 24hr 2 mg Tier 2 alprazolam tab er 24hr 3 mg Tier 2 chlordiazepoxide hcl cap 5 mg Tier 2 chlordiazepoxide hcl cap 10 mg Tier 2 chlordiazepoxide hcl cap 25 mg Tier 2 clonazepam orally disintegrating tab 0.5 Tier 2 mg clonazepam orally disintegrating tab 0.25 mg Tier 2 clonazepam orally disintegrating tab Tier 2 mg clonazepam orally disintegrating tab 1 mg Tier 2 clonazepam orally disintegrating tab 2 mg Tier 2 clonazepam tab 0.5 mg Tier 2 clonazepam tab 1 mg Tier 2 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 47

56 clonazepam tab 2 mg Tier 2 clorazepate dipotassium tab 3.75 mg Tier 2 clorazepate dipotassium tab 7.5 mg Tier 2 clorazepate dipotassium tab 15 mg Tier 2 diazepam conc 5 mg/ml Tier 2 diazepam inj 5 mg/ml Tier 2 DIAZEPAM INJ 10MG/2ML Tier 2 diazepam oral soln 1 mg/ml Tier 2 diazepam tab 2 mg Tier 2 diazepam tab 5 mg Tier 2 diazepam tab 10 mg Tier 2 lorazepam conc 2 mg/ml Tier 2 lorazepam inj 2 mg/ml Tier 2 lorazepam inj 4 mg/ml Tier 2 lorazepam tab 0.5 mg Tier 2 lorazepam tab 1 mg Tier 2 lorazepam tab 2 mg Tier 2 oxazepam cap 10 mg Tier 2 oxazepam cap 15 mg Tier 2 oxazepam cap 30 mg Tier 2 ANTIANXIETY, MISCELLANEOUS buspirone hcl tab 5 mg Tier 2 buspirone hcl tab 7.5 mg Tier 2 buspirone hcl tab 10 mg Tier 2 buspirone hcl tab 15 mg Tier 2 buspirone hcl tab 30 mg Tier 2 clomipramine hcl cap 25 mg Tier 2 clomipramine hcl cap 50 mg Tier 2 clomipramine hcl cap 75 mg Tier 2 fluvoxamine maleate tab 25 mg Tier 2 fluvoxamine maleate tab 50 mg Tier 2 fluvoxamine maleate tab 100 mg Tier 2 meprobamate tab 200 mg Tier 2 meprobamate tab 400 mg Tier 2 ANTICONVULSANTS APTIOM TAB 200MG Tier 4 PA; QL APTIOM TAB 400MG Tier 4 PA; QL APTIOM TAB 600MG Tier 4 PA; QL APTIOM TAB 800MG Tier 4 PA; QL BANZEL SUS 40MG/ML Tier 4 PA BANZEL TAB 200MG Tier 4 PA BANZEL TAB 400MG Tier 4 PA carbamazepine cap er 12hr 100 mg Tier 2 carbamazepine cap er 12hr 200 mg Tier 2 carbamazepine cap er 12hr 300 mg Tier 2 carbamazepine chew tab 100 mg Tier 2 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 48

57 carbamazepine susp 100 mg/5ml Tier 2 carbamazepine tab 200 mg Tier 2 carbamazepine tab er 12hr 200 mg Tier 2 carbamazepine tab er 12hr 400 mg Tier 2 CELONTIN CAP 300MG Tier 3 diazepam rectal gel delivery system 2.5 Tier 2 mg diazepam rectal gel delivery system 10 mg Tier 2 diazepam rectal gel delivery system 20 mg Tier 2 QL DILANTIN CAP 30MG Tier 3 divalproex sodium cap delayed release Tier 2 sprinkle 125 mg divalproex sodium tab delayed release 125 Tier 2 mg divalproex sodium tab delayed release 250 Tier 2 mg divalproex sodium tab delayed release 500 Tier 2 mg divalproex sodium tab er 24 hr 250 mg Tier 2 divalproex sodium tab er 24 hr 500 mg Tier 2 ethosuximide cap 250 mg Tier 2 ethosuximide soln 250 mg/5ml Tier 2 felbamate susp 600 mg/5ml Tier 2 felbamate tab 400 mg Tier 2 felbamate tab 600 mg Tier 2 fosphenytoin sodium inj 100 mg/2ml Tier 2 (phenytoin equiv) fosphenytoin sodium inj 500 mg/10ml Tier 2 (phenytoin equiv) FYCOMPA SUS 0.5MG/ML Tier 4 QL FYCOMPA TAB 2MG Tier 4 PA; QL FYCOMPA TAB 4MG Tier 4 PA; QL FYCOMPA TAB 6MG Tier 4 PA; QL FYCOMPA TAB 8MG Tier 4 PA; QL FYCOMPA TAB 10MG Tier 4 PA; QL FYCOMPA TAB 12MG Tier 4 PA; QL gabapentin cap 100 mg Tier 2 gabapentin cap 300 mg Tier 2 gabapentin cap 400 mg Tier 2 gabapentin oral soln 250 mg/5ml Tier 2 gabapentin tab 600 mg Tier 2 gabapentin tab 800 mg Tier 2 lamotrigine tab 25 mg Tier 2 lamotrigine tab 100 mg Tier 2 lamotrigine tab 150 mg Tier 2 lamotrigine tab 200 mg Tier 2 lamotrigine tab chewable dispersible 5 mg Tier 2 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 49

58 lamotrigine tab chewable dispersible 25 mg Tier 2 levetiracetam inj 500 mg/5ml (100 mg/ml) Tier 2 levetiracetam oral soln 100 mg/ml Tier 2 levetiracetam tab 250 mg Tier 2 levetiracetam tab 500 mg Tier 2 levetiracetam tab 750 mg Tier 2 levetiracetam tab 1000 mg Tier 2 levetiracetam tab er 24hr 500 mg Tier 2 QL levetiracetam tab er 24hr 750 mg Tier 2 QL ONFI SUS 2.5MG/ML Tier 4 PA; QL ONFI TAB 10MG Tier 4 PA; QL ONFI TAB 20MG Tier 4 PA; QL oxcarbazepine susp 300 mg/5ml (60 Tier 2 mg/ml) oxcarbazepine tab 150 mg Tier 2 oxcarbazepine tab 300 mg Tier 2 oxcarbazepine tab 600 mg Tier 2 PEGANONE TAB 250MG Tier 4 PA phenobarbital elixir 20 mg/5ml Tier 2 phenobarbital tab 15 mg Tier 2 phenobarbital tab 16.2 mg Tier 2 phenobarbital tab 30 mg Tier 2 phenobarbital tab 32.4 mg Tier 2 phenobarbital tab 60 mg Tier 2 phenobarbital tab 64.8 mg Tier 2 phenobarbital tab 97.2 mg Tier 2 phenobarbital tab 100 mg Tier 2 phenytoin chew tab 50 mg Tier 2 phenytoin sodium extended cap 100 mg Tier 2 phenytoin sodium extended cap 200 mg Tier 2 phenytoin sodium extended cap 300 mg Tier 2 phenytoin sodium inj 50 mg/ml Tier 2 phenytoin susp 125 mg/5ml Tier 2 POTIGA TAB 50MG Tier 4 PA; QL POTIGA TAB 200MG Tier 4 PA; QL POTIGA TAB 300MG Tier 4 PA; QL POTIGA TAB 400MG Tier 4 PA; QL primidone tab 50 mg Tier 2 primidone tab 250 mg Tier 2 SABRIL TAB 500MG Tier 5 PA; QL tiagabine hcl tab 2 mg Tier 2 tiagabine hcl tab 4 mg Tier 2 tiagabine hcl tab 12 mg Tier 2 tiagabine hcl tab 16 mg Tier 2 topiramate cap er 24hr sprinkle 25 mg Tier 2 topiramate cap er 24hr sprinkle 50 mg Tier 2 topiramate cap er 24hr sprinkle 100 mg Tier 2 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 50

59 topiramate cap er 24hr sprinkle 150 mg Tier 2 topiramate cap er 24hr sprinkle 200 mg Tier 2 topiramate sprinkle cap 15 mg Tier 2 QL topiramate sprinkle cap 25 mg Tier 2 QL topiramate tab 25 mg Tier 2 topiramate tab 25 mg Tier 2 QL topiramate tab 50 mg Tier 2 topiramate tab 100 mg Tier 2 topiramate tab 200 mg Tier 2 valproate sodium inj 100 mg/ml Tier 2 valproate sodium oral soln 250 mg/5ml Tier 2 (base equiv) valproic acid cap 250 mg Tier 2 vigabatrin powd pack 500 mg Tier 5 PA; QL VIMPAT INJ 200MG/20 Tier 4 PA VIMPAT SOL 10MG/ML Tier 4 PA VIMPAT TAB 50MG Tier 4 PA VIMPAT TAB 100MG Tier 4 PA VIMPAT TAB 150MG Tier 4 PA VIMPAT TAB 200MG Tier 4 PA zonisamide cap 25 mg Tier 2 zonisamide cap 50 mg Tier 2 zonisamide cap 100 mg Tier 2 ANTIDEMENTIA donepezil hydrochloride orally Tier 2 disintegrating tab 5 mg donepezil hydrochloride orally Tier 2 disintegrating tab 10 mg donepezil hydrochloride tab 5 mg Tier 2 donepezil hydrochloride tab 10 mg Tier 2 galantamine hydrobromide cap er 24hr 8 Tier 2 mg galantamine hydrobromide cap er 24hr 16 Tier 2 mg galantamine hydrobromide cap er 24hr 24 Tier 2 mg galantamine hydrobromide oral soln 4 Tier 2 mg/ml galantamine hydrobromide tab 4 mg Tier 2 galantamine hydrobromide tab 8 mg Tier 2 galantamine hydrobromide tab 12 mg Tier 2 memantine hcl oral solution 2 mg/ml Tier 2 memantine hcl tab 5 mg Tier 2 memantine hcl tab 5 mg (28) & 10 mg Tier 2 (21) titration pak memantine hcl tab 10 mg Tier 2 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 51

60 rivastigmine tartrate cap 1.5 mg (base Tier 2 equivalent) rivastigmine tartrate cap 3 mg (base Tier 2 equivalent) rivastigmine tartrate cap 4.5 mg (base Tier 2 equivalent) rivastigmine tartrate cap 6 mg (base Tier 2 equivalent) rivastigmine td patch 24hr 4.6 mg/24hr Tier 2 rivastigmine td patch 24hr 9.5 mg/24hr Tier 2 rivastigmine td patch 24hr 13.3 mg/24hr Tier 2 ANTIDEPRESSANTS, MAOIS EMSAM DIS 6MG/24HR Tier 4 PA; QL EMSAM DIS 9MG/24HR Tier 4 PA; QL EMSAM DIS 12MG/24H Tier 4 PA; QL MARPLAN TAB 10MG Tier 4 phenelzine sulfate tab 15 mg Tier 2 tranylcypromine sulfate tab 10 mg Tier 2 ANTIDEPRESSANTS, MISCELLANEOUS bupropion hcl tab 75 mg Tier 2 bupropion hcl tab 100 mg Tier 2 bupropion hcl tab er 12hr 100 mg Tier 2 bupropion hcl tab er 12hr 150 mg Tier 2 bupropion hcl tab er 12hr 200 mg Tier 2 bupropion hcl tab er 24hr 150 mg Tier 2 QL bupropion hcl tab er 24hr 300 mg Tier 2 QL chlordiazepoxide-amitriptyline tab Tier 2 mg chlordiazepoxide-amitriptyline tab Tier 2 mg maprotiline hcl tab 25 mg Tier 2 maprotiline hcl tab 50 mg Tier 2 maprotiline hcl tab 75 mg Tier 2 mirtazapine orally disintegrating tab 15 mg Tier 2 mirtazapine orally disintegrating tab 30 mg Tier 2 mirtazapine orally disintegrating tab 45 mg Tier 2 mirtazapine tab 7.5 mg Tier 2 mirtazapine tab 15 mg Tier 2 mirtazapine tab 30 mg Tier 2 mirtazapine tab 45 mg Tier 2 nefazodone hcl tab 50 mg Tier 2 nefazodone hcl tab 100 mg Tier 2 nefazodone hcl tab 150 mg Tier 2 nefazodone hcl tab 200 mg Tier 2 nefazodone hcl tab 250 mg Tier 2 trazodone hcl tab 50 mg Tier 2 trazodone hcl tab 100 mg Tier 2 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 52

61 trazodone hcl tab 150 mg Tier 2 trazodone hcl tab 300 mg Tier 2 ANTIDEPRESSANTS, SNRIS DESVENLAFAX TAB 50MG ER Tier 4 ST; QL DESVENLAFAX TAB 100MG ER Tier 4 ST; QL desvenlafaxine succinate tab er 24hr 25 Tier 4 QL mg (base equiv) desvenlafaxine succinate tab er 24hr 50 Tier 4 QL mg (base equiv) desvenlafaxine succinate tab er 24hr 100 mg (base equiv) Tier 4 QL duloxetine hcl enteric coated pellets cap 20 Tier 2 QL mg (base eq) duloxetine hcl enteric coated pellets cap 30 Tier 2 QL mg (base eq) duloxetine hcl enteric coated pellets cap 60 Tier 2 QL mg (base eq) FETZIMA CAP 20MG Tier 4 PA; QL FETZIMA CAP 40MG Tier 4 PA; QL FETZIMA CAP 80MG Tier 4 PA; QL FETZIMA CAP 120MG Tier 4 PA; QL FETZIMA CAP TITRATIO Tier 4 PA; QL PRISTIQ TAB 25MG Tier 4 ST; QL PRISTIQ TAB 50MG Tier 4 ST; QL PRISTIQ TAB 100MG Tier 4 ST; QL venlafaxine hcl cap er 24hr 37.5 mg (base Tier 2 QL equivalent) venlafaxine hcl cap er 24hr 75 mg (base Tier 2 QL equivalent) venlafaxine hcl cap er 24hr 150 mg (base Tier 2 QL equivalent) venlafaxine hcl tab 25 mg Tier 2 venlafaxine hcl tab 37.5 mg Tier 2 venlafaxine hcl tab 50 mg Tier 2 venlafaxine hcl tab 75 mg Tier 2 venlafaxine hcl tab 100 mg Tier 2 ANTIDEPRESSANTS, SSRIS citalopram hydrobromide oral soln 10 mg/5ml Tier 2 citalopram hydrobromide tab 10 mg (base Tier 1 QL equiv) citalopram hydrobromide tab 20 mg (base Tier 1 QL equiv) citalopram hydrobromide tab 40 mg (base Tier 1 QL equiv) escitalopram oxalate soln 5 mg/5ml (base Tier 2 QL equiv) PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 53

62 escitalopram oxalate tab 5 mg (base Tier 2 QL equiv) escitalopram oxalate tab 10 mg (base Tier 2 QL equiv) escitalopram oxalate tab 20 mg (base Tier 2 QL equiv) fluoxetine hcl (pmdd) cap 10 mg Tier 1 fluoxetine hcl (pmdd) cap 20 mg Tier 1 fluoxetine hcl cap 10 mg Tier 1 fluoxetine hcl cap 20 mg Tier 1 fluoxetine hcl cap 40 mg Tier 2 fluoxetine hcl solution 20 mg/5ml Tier 2 fluoxetine hcl tab 10 mg Tier 2 ST fluoxetine hcl tab 20 mg Tier 2 ST paroxetine hcl tab 10 mg Tier 1 QL paroxetine hcl tab 20 mg Tier 1 QL paroxetine hcl tab 30 mg Tier 2 QL paroxetine hcl tab 40 mg Tier 2 QL sertraline hcl oral concentrate for solution Tier 2 20 mg/ml sertraline hcl tab 25 mg Tier 1 sertraline hcl tab 50 mg Tier 1 sertraline hcl tab 100 mg Tier 1 TRINTELLIX TAB 5MG Tier 4 PA; QL TRINTELLIX TAB 10MG Tier 4 PA; QL TRINTELLIX TAB 20MG Tier 4 PA; QL VIIBRYD KIT STARTER Tier 4 PA; QL VIIBRYD TAB 10MG Tier 4 PA; QL VIIBRYD TAB 20MG Tier 4 PA; QL VIIBRYD TAB 40MG Tier 4 PA; QL ANTIDEPRESSANTS, TCAS amitriptyline hcl tab 10 mg Tier 2 amitriptyline hcl tab 25 mg Tier 2 amitriptyline hcl tab 50 mg Tier 2 amitriptyline hcl tab 75 mg Tier 2 amitriptyline hcl tab 100 mg Tier 2 amitriptyline hcl tab 150 mg Tier 2 amoxapine tab 25 mg Tier 2 amoxapine tab 50 mg Tier 2 amoxapine tab 100 mg Tier 2 amoxapine tab 150 mg Tier 2 desipramine hcl tab 10 mg Tier 2 desipramine hcl tab 25 mg Tier 2 desipramine hcl tab 50 mg Tier 2 desipramine hcl tab 75 mg Tier 2 desipramine hcl tab 100 mg Tier 2 desipramine hcl tab 150 mg Tier 2 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 54

63 doxepin hcl cap 10 mg Tier 2 doxepin hcl cap 25 mg Tier 2 doxepin hcl cap 50 mg Tier 2 doxepin hcl cap 75 mg Tier 2 doxepin hcl cap 100 mg Tier 2 doxepin hcl cap 150 mg Tier 2 doxepin hcl conc 10 mg/ml Tier 2 imipramine hcl tab 10 mg Tier 2 imipramine hcl tab 25 mg Tier 2 imipramine hcl tab 50 mg Tier 2 imipramine pamoate cap 75 mg Tier 2 imipramine pamoate cap 100 mg Tier 2 imipramine pamoate cap 125 mg Tier 2 imipramine pamoate cap 150 mg Tier 2 nortriptyline hcl cap 10 mg Tier 2 nortriptyline hcl cap 25 mg Tier 2 nortriptyline hcl cap 50 mg Tier 2 nortriptyline hcl cap 75 mg Tier 2 nortriptyline hcl soln 10 mg/5ml Tier 2 protriptyline hcl tab 5 mg Tier 2 protriptyline hcl tab 10 mg Tier 2 trimipramine maleate cap 25 mg Tier 2 trimipramine maleate cap 50 mg Tier 2 trimipramine maleate cap 100 mg Tier 2 ANTIPARKINSONIAN AGENTS amantadine hcl cap 100 mg Tier 2 amantadine hcl syrup 50 mg/5ml Tier 2 amantadine hcl tab 100 mg Tier 2 APOKYN INJ 10MG/ML Tier 5 PA; QL benztropine mesylate inj 1 mg/ml Tier 2 benztropine mesylate tab 0.5 mg Tier 2 benztropine mesylate tab 1 mg Tier 2 benztropine mesylate tab 2 mg Tier 2 bromocriptine mesylate cap 5 mg (base Tier 2 equivalent) bromocriptine mesylate tab 2.5 mg (base equivalent) Tier 2 carbidopa & levodopa orally disintegrating Tier 2 tab mg carbidopa & levodopa orally disintegrating Tier 2 tab mg carbidopa & levodopa orally disintegrating Tier 2 tab mg carbidopa & levodopa tab mg Tier 2 carbidopa & levodopa tab mg Tier 2 carbidopa & levodopa tab mg Tier 2 carbidopa & levodopa tab er mg Tier 2 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 55

64 carbidopa & levodopa tab er mg Tier 2 carbidopa tab 25 mg Tier 2 carbidopa-levodopa-entacapone tabs Tier mg carbidopa-levodopa-entacapone tabs Tier mg carbidopa-levodopa-entacapone tabs 25- Tier mg carbidopa-levodopa-entacapone tabs Tier mg carbidopa-levodopa-entacapone tabs Tier mg carbidopa-levodopa-entacapone tabs 50- Tier mg DUOPA SUS Tier 5 PA entacapone tab 200 mg Tier 2 pramipexole dihydrochloride tab 0.5 mg Tier 2 pramipexole dihydrochloride tab 0.25 mg Tier 2 pramipexole dihydrochloride tab 0.75 mg Tier 2 pramipexole dihydrochloride tab mg Tier 2 pramipexole dihydrochloride tab 1 mg Tier 2 pramipexole dihydrochloride tab 1.5 mg Tier 2 ropinirole hydrochloride tab 0.5 mg Tier 2 ropinirole hydrochloride tab 0.25 mg Tier 2 ropinirole hydrochloride tab 1 mg Tier 2 ropinirole hydrochloride tab 2 mg Tier 2 ropinirole hydrochloride tab 3 mg Tier 2 ropinirole hydrochloride tab 4 mg Tier 2 ropinirole hydrochloride tab 5 mg Tier 2 ropinirole hydrochloride tab er 24hr 2 mg Tier 2 ST (base equivalent) ropinirole hydrochloride tab er 24hr 4 mg Tier 2 ST (base equivalent) ropinirole hydrochloride tab er 24hr 6 mg Tier 2 ST (base equivalent) ropinirole hydrochloride tab er 24hr 8 mg (base equivalent) Tier 2 ST ropinirole hydrochloride tab er 24hr 12 mg Tier 2 ST (base equivalent) selegiline hcl cap 5 mg Tier 2 selegiline hcl tab 5 mg Tier 2 tolcapone tab 100 mg Tier 2 ST trihexyphenidyl hcl elixir 0.4 mg/ml Tier 2 trihexyphenidyl hcl tab 2 mg Tier 2 trihexyphenidyl hcl tab 5 mg Tier 2 ANTIPSYCHOTICS, ATYPICALS ABILIFY MAIN INJ 300MG Tier 5 PA; QL ABILIFY MAIN INJ 400MG Tier 5 PA; QL PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 56

65 aripiprazole oral solution 1 mg/ml Tier 4 QL aripiprazole orally disintegrating tab 10 mg Tier 2 QL aripiprazole orally disintegrating tab 15 mg Tier 2 QL aripiprazole tab 2 mg Tier 2 QL aripiprazole tab 5 mg Tier 2 QL aripiprazole tab 10 mg Tier 2 QL aripiprazole tab 15 mg Tier 2 QL aripiprazole tab 20 mg Tier 2 QL aripiprazole tab 30 mg Tier 2 QL clozapine orally disintegrating tab 12.5 mg Tier 2 QL clozapine orally disintegrating tab 25 mg Tier 2 QL clozapine orally disintegrating tab 100 mg Tier 2 QL clozapine orally disintegrating tab 150 mg Tier 4 QL clozapine orally disintegrating tab 200 mg Tier 4 QL clozapine tab 25 mg Tier 2 clozapine tab 50 mg Tier 2 clozapine tab 100 mg Tier 2 clozapine tab 200 mg Tier 2 FANAPT TAB 1MG Tier 4 PA; QL FANAPT TAB 2MG Tier 4 PA; QL FANAPT TAB 4MG Tier 4 PA; QL FANAPT TAB 6MG Tier 4 PA; QL FANAPT TAB 8MG Tier 4 PA; QL FANAPT TAB 10MG Tier 4 PA; QL FANAPT TAB 12MG Tier 4 PA; QL GEODON INJ 20MG Tier 4 PA INVEGA SUST INJ 39/0.25 Tier 5 PA; QL INVEGA SUST INJ 78/0.5ML Tier 5 PA; QL INVEGA SUST INJ 117/0.75 Tier 5 PA; QL INVEGA SUST INJ 156MG/ML Tier 5 PA; QL INVEGA SUST INJ 234/1.5 Tier 5 PA; QL INVEGA TRINZ INJ 273MG Tier 5 PA; QL INVEGA TRINZ INJ 410MG Tier 5 PA; QL INVEGA TRINZ INJ 546MG Tier 5 PA; QL INVEGA TRINZ INJ 819MG Tier 5 PA; QL LATUDA TAB 20MG Tier 4 ST; QL LATUDA TAB 40MG Tier 4 ST; QL LATUDA TAB 60MG Tier 4 ST; QL LATUDA TAB 80MG Tier 4 ST; QL LATUDA TAB 120MG Tier 4 ST; QL loxapine succinate cap 5 mg Tier 2 loxapine succinate cap 10 mg Tier 2 loxapine succinate cap 25 mg Tier 2 loxapine succinate cap 50 mg Tier 2 NUPLAZID TAB 17MG Tier 5 PA; QL olanzapine for im inj 10 mg Tier 2 PA; QL PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 57

66 olanzapine orally disintegrating tab 5 mg Tier 2 QL olanzapine orally disintegrating tab 10 mg Tier 2 QL olanzapine orally disintegrating tab 15 mg Tier 2 QL olanzapine orally disintegrating tab 20 mg Tier 2 QL olanzapine tab 2.5 mg Tier 2 QL olanzapine tab 5 mg Tier 2 QL olanzapine tab 7.5 mg Tier 2 QL olanzapine tab 10 mg Tier 2 QL olanzapine tab 15 mg Tier 2 QL olanzapine tab 20 mg Tier 2 QL paliperidone tab er 24hr 1.5 mg Tier 4 QL paliperidone tab er 24hr 3 mg Tier 4 QL paliperidone tab er 24hr 6 mg Tier 4 QL paliperidone tab er 24hr 9 mg Tier 4 QL quetiapine fumarate tab 25 mg Tier 2 QL quetiapine fumarate tab 50 mg Tier 2 QL quetiapine fumarate tab 100 mg Tier 2 QL quetiapine fumarate tab 200 mg Tier 2 QL quetiapine fumarate tab 300 mg Tier 2 QL quetiapine fumarate tab 400 mg Tier 2 QL REXULTI TAB 0.5MG Tier 4 ST; QL REXULTI TAB 0.25MG Tier 4 ST; QL REXULTI TAB 1MG Tier 4 ST; QL REXULTI TAB 2MG Tier 4 ST; QL REXULTI TAB 3MG Tier 4 ST; QL REXULTI TAB 4MG Tier 4 ST; QL RISPERDAL INJ 12.5MG Tier 5 PA; QL RISPERDAL INJ 25MG Tier 5 PA; QL RISPERDAL INJ 37.5MG Tier 5 PA; QL RISPERDAL INJ 50MG Tier 5 PA; QL risperidone orally disintegrating tab 0.5 mg Tier 2 QL risperidone orally disintegrating tab 0.25 Tier 2 QL mg risperidone orally disintegrating tab 1 mg Tier 2 QL risperidone orally disintegrating tab 2 mg Tier 2 QL risperidone orally disintegrating tab 3 mg Tier 2 QL risperidone orally disintegrating tab 4 mg Tier 2 QL risperidone soln 1 mg/ml Tier 2 QL risperidone tab 0.5 mg Tier 2 QL risperidone tab 0.25 mg Tier 2 QL risperidone tab 1 mg Tier 2 QL risperidone tab 2 mg Tier 2 QL risperidone tab 3 mg Tier 2 QL risperidone tab 4 mg Tier 2 QL SAPHRIS SUB 2.5MG Tier 4 ST; QL SAPHRIS SUB 5MG Tier 4 ST; QL ziprasidone hcl cap 20 mg Tier 2 QL PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 58

67 ziprasidone hcl cap 40 mg Tier 2 QL ziprasidone hcl cap 60 mg Tier 2 QL ziprasidone hcl cap 80 mg Tier 2 QL ZYPREXA RELP INJ 210MG Tier 5 PA; QL ZYPREXA RELP INJ 300MG Tier 5 PA; QL ZYPREXA RELP INJ 405MG Tier 5 PA; QL ANTIPSYCHOTICS, MISCELLANEOUS CHLORPROMAZ INJ 25MG/ML Tier 2 chlorpromazine hcl tab 10 mg Tier 2 chlorpromazine hcl tab 25 mg Tier 2 chlorpromazine hcl tab 50 mg Tier 2 chlorpromazine hcl tab 100 mg Tier 2 chlorpromazine hcl tab 200 mg Tier 2 fluphenazine decanoate inj 25 mg/ml Tier 2 fluphenazine hcl elixir 2.5 mg/5ml Tier 2 fluphenazine hcl inj 2.5 mg/ml Tier 2 fluphenazine hcl oral conc 5 mg/ml Tier 2 fluphenazine hcl tab 1 mg Tier 2 fluphenazine hcl tab 2.5 mg Tier 2 fluphenazine hcl tab 5 mg Tier 2 fluphenazine hcl tab 10 mg Tier 2 haloperidol decanoate im soln 50 mg/ml Tier 5 haloperidol decanoate im soln 100 mg/ml Tier 5 haloperidol lactate inj 5 mg/ml Tier 2 haloperidol lactate oral conc 2 mg/ml Tier 2 haloperidol tab 0.5 mg Tier 2 haloperidol tab 1 mg Tier 2 haloperidol tab 2 mg Tier 2 haloperidol tab 5 mg Tier 2 haloperidol tab 10 mg Tier 2 haloperidol tab 20 mg Tier 2 olanzapine-fluoxetine hcl cap 3-25 mg Tier 4 PA; QL olanzapine-fluoxetine hcl cap 6-25 mg Tier 4 PA; QL olanzapine-fluoxetine hcl cap 6-50 mg Tier 4 PA; QL olanzapine-fluoxetine hcl cap mg Tier 4 PA; QL olanzapine-fluoxetine hcl cap mg Tier 4 PA; QL perphenazine tab 2 mg Tier 2 perphenazine tab 4 mg Tier 2 perphenazine tab 8 mg Tier 2 perphenazine tab 16 mg Tier 2 perphenazine-amitriptyline tab 2-10 mg Tier 2 perphenazine-amitriptyline tab 2-25 mg Tier 2 perphenazine-amitriptyline tab 4-10 mg Tier 2 perphenazine-amitriptyline tab 4-25 mg Tier 2 perphenazine-amitriptyline tab 4-50 mg Tier 2 pimozide tab 1 mg Tier 2 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 59

68 pimozide tab 2 mg Tier 2 thioridazine hcl tab 10 mg Tier 2 thioridazine hcl tab 25 mg Tier 2 thioridazine hcl tab 50 mg Tier 2 thioridazine hcl tab 100 mg Tier 2 thiothixene cap 1 mg Tier 2 thiothixene cap 2 mg Tier 2 thiothixene cap 5 mg Tier 2 thiothixene cap 10 mg Tier 2 trifluoperazine hcl tab 1 mg (base Tier 2 equivalent) trifluoperazine hcl tab 2 mg (base Tier 2 equivalent) trifluoperazine hcl tab 5 mg (base Tier 2 equivalent) trifluoperazine hcl tab 10 mg (base Tier 2 equivalent) ATTENTION DEFICIT HYPERACTIVITY DISORDER ADDERALL XR CAP 5MG Tier 4 QL ADDERALL XR CAP 10MG Tier 4 QL ADDERALL XR CAP 15MG Tier 4 QL ADDERALL XR CAP 20MG Tier 4 QL ADDERALL XR CAP 25MG Tier 4 QL ADDERALL XR CAP 30MG Tier 4 QL amphetamine-dextroamphetamine cap er Tier 2 QL 24hr 5 mg amphetamine-dextroamphetamine cap er Tier 2 QL 24hr 10 mg amphetamine-dextroamphetamine cap er Tier 2 QL 24hr 15 mg amphetamine-dextroamphetamine cap er Tier 2 QL 24hr 20 mg amphetamine-dextroamphetamine cap er Tier 2 QL 24hr 25 mg amphetamine-dextroamphetamine cap er Tier 2 QL 24hr 30 mg amphetamine-dextroamphetamine tab 5 mg Tier 2 QL amphetamine-dextroamphetamine tab 7.5 Tier 2 QL mg amphetamine-dextroamphetamine tab 10 Tier 2 QL mg amphetamine-dextroamphetamine tab Tier 2 QL 12.5 mg amphetamine-dextroamphetamine tab 15 Tier 2 QL mg amphetamine-dextroamphetamine tab 20 mg Tier 2 QL PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 60

69 amphetamine-dextroamphetamine tab 30 Tier 2 QL mg atomoxetine hcl cap 10 mg (base equiv) Tier 2 QL atomoxetine hcl cap 18 mg (base equiv) Tier 2 QL atomoxetine hcl cap 25 mg (base equiv) Tier 2 QL atomoxetine hcl cap 40 mg (base equiv) Tier 2 QL atomoxetine hcl cap 60 mg (base equiv) Tier 2 QL atomoxetine hcl cap 80 mg (base equiv) Tier 2 QL atomoxetine hcl cap 100 mg (base equiv) Tier 2 QL clonidine hcl tab er 12hr 0.1 mg Tier 2 QL dexmethylphenidate hcl cap er 24 hr 5 mg Tier 4 QL dexmethylphenidate hcl cap er 24 hr 10 Tier 4 QL mg dexmethylphenidate hcl cap er 24 hr 15 Tier 4 QL mg dexmethylphenidate hcl cap er 24 hr 20 Tier 4 QL mg dexmethylphenidate hcl cap er 24 hr 30 Tier 4 QL mg dexmethylphenidate hcl cap er 24 hr 40 Tier 4 QL mg dexmethylphenidate hcl tab 2.5 mg Tier 2 QL dexmethylphenidate hcl tab 5 mg Tier 2 QL dexmethylphenidate hcl tab 10 mg Tier 2 QL dextroamphetamine sulfate cap er 24hr 5 mg Tier 4 QL dextroamphetamine sulfate cap er 24hr 10 Tier 4 QL mg dextroamphetamine sulfate cap er 24hr 15 Tier 4 QL mg dextroamphetamine sulfate tab 5 mg Tier 2 dextroamphetamine sulfate tab 5 mg Tier 2 QL dextroamphetamine sulfate tab 10 mg Tier 2 QL guanfacine hcl tab er 24hr 1 mg (base Tier 2 QL equiv) guanfacine hcl tab er 24hr 2 mg (base Tier 2 QL equiv) guanfacine hcl tab er 24hr 3 mg (base Tier 2 QL equiv) guanfacine hcl tab er 24hr 4 mg (base Tier 2 QL equiv) methamphetamine hcl tab 5 mg Tier 4 QL methylphenidate hcl cap er 10 mg (cd) Tier 2 QL methylphenidate hcl cap er 20 mg (cd) Tier 2 QL methylphenidate hcl cap er 24hr 20 mg Tier 2 QL (la) methylphenidate hcl cap er 24hr 30 mg (la) Tier 2 QL PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 61

70 methylphenidate hcl cap er 24hr 40 mg Tier 2 QL (la) methylphenidate hcl cap er 30 mg (cd) Tier 2 QL methylphenidate hcl cap er 40 mg (cd) Tier 2 QL methylphenidate hcl cap er 50 mg (cd) Tier 2 QL methylphenidate hcl cap er 60 mg (cd) Tier 2 QL methylphenidate hcl chew tab 2.5 mg Tier 2 QL methylphenidate hcl chew tab 5 mg Tier 2 QL methylphenidate hcl chew tab 10 mg Tier 2 QL methylphenidate hcl soln 5 mg/5ml Tier 4 QL methylphenidate hcl soln 10 mg/5ml Tier 4 QL methylphenidate hcl tab 5 mg Tier 2 QL methylphenidate hcl tab 10 mg Tier 2 QL methylphenidate hcl tab 20 mg Tier 2 QL methylphenidate hcl tab er 10 mg Tier 4 QL methylphenidate hcl tab er 20 mg Tier 2 methylphenidate hcl tab er 20 mg Tier 2 QL methylphenidate hcl tab er 24hr 27 mg Tier 4 QL methylphenidate hcl tab er 24hr 36 mg Tier 4 QL methylphenidate hcl tab er 24hr 54 mg Tier 4 QL methylphenidate hcl tab er osmotic release Tier 4 QL (osm) 18 mg methylphenidate hcl tab er osmotic release Tier 4 QL (osm) 27 mg methylphenidate hcl tab er osmotic release Tier 4 QL (osm) 36 mg methylphenidate hcl tab er osmotic release Tier 4 QL (osm) 54 mg STRATTERA CAP 10MG Tier 4 QL STRATTERA CAP 18MG Tier 4 QL STRATTERA CAP 25MG Tier 4 QL STRATTERA CAP 40MG Tier 4 QL STRATTERA CAP 60MG Tier 4 QL STRATTERA CAP 80MG Tier 4 QL STRATTERA CAP 100MG Tier 4 QL VYVANSE CAP 10MG Tier 4 PA; QL VYVANSE CAP 20MG Tier 4 PA; QL VYVANSE CAP 30MG Tier 4 PA; QL VYVANSE CAP 40MG Tier 4 PA; QL VYVANSE CAP 50MG Tier 4 PA; QL VYVANSE CAP 60MG Tier 4 PA; QL VYVANSE CAP 70MG Tier 4 PA; QL FIBROMYALGIA LYRICA CAP 25MG Tier 4 PA; QL LYRICA CAP 50MG Tier 4 PA; QL LYRICA CAP 75MG Tier 4 PA; QL LYRICA CAP 100MG Tier 4 PA; QL PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 62

71 LYRICA CAP 150MG Tier 4 PA; QL LYRICA CAP 200MG Tier 4 PA; QL LYRICA CAP 225MG Tier 4 PA; QL LYRICA CAP 300MG Tier 4 PA; QL LYRICA SOL 20MG/ML Tier 4 PA; QL SAVELLA MIS TITR PAK Tier 4 PA; QL SAVELLA TAB 12.5MG Tier 4 PA; QL SAVELLA TAB 25MG Tier 4 PA; QL SAVELLA TAB 50MG Tier 4 PA; QL SAVELLA TAB 100MG Tier 4 PA; QL HUNTINGTON'S DISEASE AGENTS tetrabenazine tab 12.5 mg Tier 5 PA; QL tetrabenazine tab 25 mg Tier 5 PA; QL XENAZINE TAB 12.5MG Tier 5 PA; QL XENAZINE TAB 25MG Tier 5 PA; QL HYPNOTICS, BENZODIAZEPINES estazolam tab 1 mg Tier 2 estazolam tab 2 mg Tier 2 flurazepam hcl cap 15 mg Tier 2 flurazepam hcl cap 30 mg Tier 2 midazolam hcl syrup 2 mg/ml (base Tier 2 equivalent) temazepam cap 15 mg Tier 2 temazepam cap 30 mg Tier 2 triazolam tab 0.25 mg Tier 2 triazolam tab mg Tier 2 HYPNOTICS, NON-BENZODIAZEPINES eszopiclone tab 1 mg Tier 2 QL eszopiclone tab 2 mg Tier 2 QL eszopiclone tab 3 mg Tier 2 QL HETLIOZ CAP 20MG Tier 6 PA; QL zaleplon cap 5 mg Tier 2 QL zaleplon cap 10 mg Tier 2 QL zolpidem tartrate tab 5 mg Tier 2 QL zolpidem tartrate tab 10 mg Tier 2 QL MIGRAINE, ERGOTAMINE DERIVATIVES dihydroergotamine mesylate inj 1 mg/ml Tier 4 dihydroergotamine mesylate nasal spray 4 Tier 4 mg/ml ERGOMAR SUB 2MG Tier 4 PA; QL MIGRAINE, MISCELLANEOUS isometheptene-dichloral-acetaminophen Tier 2 cap mg MIGRAINE, SELECTIVE SEROTONIN AGONISTS almotriptan malate tab 6.25 mg Tier 4 ST; QL almotriptan malate tab 12.5 mg Tier 4 ST; QL PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 63

72 naratriptan hcl tab 1 mg (base equiv) Tier 4 QL naratriptan hcl tab 2.5 mg (base equiv) Tier 4 QL rizatriptan benzoate oral disintegrating tab Tier 4 QL 5 mg (base eq) rizatriptan benzoate oral disintegrating tab Tier 2 QL 10 mg (base eq) rizatriptan benzoate tab 5 mg (base Tier 4 QL equivalent) rizatriptan benzoate tab 10 mg (base Tier 4 QL equivalent) sumatriptan nasal spray 5 mg/act Tier 4 QL sumatriptan nasal spray 20 mg/act Tier 4 QL sumatriptan succinate inj 6 mg/0.5ml Tier 3 QL sumatriptan succinate solution autoinjector Tier 3 QL 4 mg/0.5ml sumatriptan succinate solution autoinjector 6 mg/0.5ml Tier 3 QL sumatriptan succinate solution cartridge 4 Tier 3 QL mg/0.5ml sumatriptan succinate solution cartridge 6 Tier 3 QL mg/0.5ml sumatriptan succinate solution prefilled Tier 3 QL syringe 6 mg/0.5ml sumatriptan succinate tab 25 mg Tier 2 QL sumatriptan succinate tab 50 mg Tier 2 QL sumatriptan succinate tab 100 mg Tier 2 QL zolmitriptan orally disintegrating tab 2.5 mg Tier 4 QL zolmitriptan orally disintegrating tab 5 mg Tier 4 QL zolmitriptan tab 2.5 mg Tier 4 QL zolmitriptan tab 5 mg Tier 4 QL ZOMIG SPR 2.5MG Tier 4 QL ZOMIG SPR 5MG Tier 4 QL MISCELLANEOUS BOTOX INJ 100UNIT Tier 5 PA; QL BOTOX INJ 200UNIT Tier 5 PA; QL DYSPORT INJ 500UNIT Tier 5 PA; QL ergoloid mesylates tab 1 mg Tier 2 GUANIDINE TAB 125MG Tier 2 MYOBLOC INJ 2500/0.5 Tier 5 PA; QL MYOBLOC INJ 5000/ML Tier 5 PA; QL MYOBLOC INJ 10000/2 Tier 5 PA; QL REGONOL INJ 5MG/ML Tier 2 riluzole tab 50 mg Tier 5 PA; QL XEOMIN INJ 50 UNIT Tier 5 PA; QL XEOMIN INJ 100UNIT Tier 5 PA; QL MOOD STABILIZERS PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 64

73 lithium carbonate cap 150 mg Tier 1 lithium carbonate cap 300 mg Tier 1 lithium carbonate cap 600 mg Tier 2 lithium carbonate tab 300 mg Tier 2 lithium carbonate tab er 300 mg Tier 2 lithium carbonate tab er 450 mg Tier 2 LITHIUM SOL 8MEQ/5ML Tier 2 MULTIPLE SCLEROSIS AMPYRA TAB 10MG Tier 5 PA; QL AUBAGIO TAB 7MG Tier 5 PA; QL AUBAGIO TAB 14MG Tier 5 PA; QL BETASERON INJ 0.3MG Tier 5 QL COPAXONE INJ 20MG/ML Tier 5 QL COPAXONE INJ 40MG/ML Tier 5 QL GILENYA CAP 0.5MG Tier 5 PA; QL LEMTRADA INJ 12/1.2ML Tier 5 PA REBIF INJ 22/0.5 Tier 5 PA; QL REBIF INJ 44/0.5 Tier 5 PA; QL REBIF REBIDO INJ 22/0.5 Tier 5 PA; QL REBIF REBIDO INJ 44/0.5 Tier 5 PA; QL REBIF REBIDO INJ TITRATN Tier 5 PA; QL REBIF TITRTN INJ PACK Tier 5 PA; QL TECFIDERA CAP 120MG Tier 5 PA; QL TECFIDERA CAP 240MG Tier 5 PA; QL TECFIDERA MIS STARTER Tier 5 PA; QL TYSABRI INJ 300/15ML Tier 5 PA; QL MUSCULOSKELETAL THERAPY AGENTS baclofen tab 10 mg Tier 2 baclofen tab 20 mg Tier 2 carisoprodol tab 350 mg Tier 2 QL carisoprodol w/ aspirin tab mg Tier 4 chlorzoxazone tab 500 mg Tier 2 cyclobenzaprine hcl tab 5 mg Tier 2 cyclobenzaprine hcl tab 10 mg Tier 2 dantrolene sodium cap 25 mg Tier 2 dantrolene sodium cap 50 mg Tier 2 dantrolene sodium cap 100 mg Tier 2 metaxalone tab 800 mg Tier 4 PA; QL methocarbamol tab 500 mg Tier 2 methocarbamol tab 750 mg Tier 2 orphenadrine citrate inj 30 mg/ml Tier 2 orphenadrine citrate tab er 12hr 100 mg Tier 2 tizanidine hcl cap 2 mg (base equivalent) Tier 2 ST tizanidine hcl cap 4 mg (base equivalent) Tier 2 ST tizanidine hcl cap 6 mg (base equivalent) Tier 2 ST tizanidine hcl tab 2 mg (base equivalent) Tier 2 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 65

74 tizanidine hcl tab 4 mg (base equivalent) Tier 2 MYASTHENIA GRAVIS pyridostigmine bromide tab 60 mg Tier 2 NARCOLEPSY/CATAPLEXY modafinil tab 100 mg Tier 4 PA; QL modafinil tab 200 mg Tier 4 PA; QL NUVIGIL TAB 50MG Tier 6 PA; QL NUVIGIL TAB 150MG Tier 6 PA; QL NUVIGIL TAB 200MG Tier 6 PA; QL NUVIGIL TAB 250MG Tier 6 PA; QL XYREM SOL 500MG/ML Tier 5 PA; QL POSTHERPETIC NEURALGIA GRALISE STAR MIS 300/600 Tier 4 PA; QL GRALISE TAB 300MG Tier 4 PA; QL GRALISE TAB 600MG Tier 4 PA; QL PSYCHOTHERAPEUTIC-MISC, ALCOHOL DETERRENTS acamprosate calcium tab delayed release Tier mg CAMPRAL TAB 333MG Tier 2 disulfiram tab 250 mg Tier 2 disulfiram tab 500 mg Tier 2 VIVITROL INJ 380MG Tier 5 PSYCHOTHERAPEUTIC-MISC, OPIOID ANTAGONIST EVZIO INJ Tier 5 PA; QL naloxone hcl inj 0.4 mg/ml Tier 2 naloxone hcl soln prefilled syringe 2 Tier 2 mg/2ml naltrexone hcl tab 50 mg NARCAN SPR Tier 4 QL PSYCHOTHERAPEUTIC-MISC, PARTIAL OPIOID AGONIST/OPIOID ANTAGONIST COMBINATIONS BUNAVAIL MIS Tier 4 QL BUNAVAIL MIS Tier 4 QL BUNAVAIL MIS 6.3-1MG Tier 4 QL buprenorphine hcl-naloxone hcl sl tab 2- QL 0.5 mg (base equiv) buprenorphine hcl-naloxone hcl sl tab 8-2 QL mg (base equiv) SUBOXONE MIS 2-0.5MG Tier 3 QL SUBOXONE MIS 4-1MG Tier 3 QL SUBOXONE MIS 8-2MG Tier 3 QL SUBOXONE MIS 12-3MG Tier 3 QL ZUBSOLV SUB Tier 3 QL ZUBSOLV SUB Tier 3 QL PSYCHOTHERAPEUTIC-MISC, PARTIAL OPIOID AGONISTS buprenorphine hcl sl tab 2 mg (base equiv) QL PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 66

75 buprenorphine hcl sl tab 8 mg (base equiv) QL PSYCHOTHERAPEUTIC-MISC, PSEUDOBULBAR AFFECT NUEDEXTA CAP 20-10MG Tier 5 PA; QL PSYCHOTHERAPEUTIC-MISC, SMOKING DETERRENTS bupropion hcl (smoking deterrent) tab er QL 12hr 150 mg CHANTIX PAK 0.5& 1MG QL CHANTIX PAK 1MG QL CHANTIX TAB 0.5MG QL nicotine polacrilex gum 2 mg nicotine polacrilex gum 4 mg nicotine polacrilex lozenge 2 mg nicotine polacrilex lozenge 4 mg NICOTINE SYS KIT TRANSDER QL nicotine td patch 24hr 7 mg/24hr nicotine td patch 24hr 14 mg/24hr nicotine td patch 24hr 21 mg/24hr NICOTROL INH QL NICOTROL NS SPR 10MG/ML QL RESTLESS LEG SYNDROME (RLS) AGENTS HORIZANT TAB 300MG ER Tier 4 PA; QL HORIZANT TAB 600MG ER Tier 4 PA; QL COMBINATION CONTRACEPTIVES - ORAL BIPHASIC CONTRACEPTIVES - ORAL desogest-eth estrad & eth estrad tab /0.01 mg(21/5) LO LOESTRIN TAB NECON TAB 10/11-28 COMBINATION CONTRACEPTIVES - ORAL desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg drospirenone-ethinyl estrad-levomefolate tab mg drospirenone-ethinyl estradiol tab mg drospirenone-ethinyl estradiol tab mg ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg ethynodiol diacetate & ethinyl estradiol tab 1 mg-50 mcg FALESSA KIT GENERESS FE CHW levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 67

76 norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg norethindrone & ethinyl estradiol tab 1 mg- 35 mcg norethindrone & ethinyl estradiol-fe chew tab 0.4 mg-35 mcg norethindrone & ethinyl estradiol-fe chew tab 0.8 mg-25 mcg norethindrone & mestranol tab 1 mg-50 mcg norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg norethindrone ace-eth estradiol-fe chew tab 1 mg-20 mcg (24) norethindrone ace-ethinyl estradiol-fe tab 1 mg-20 mcg (24) norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg norgestrel & ethinyl estradiol tab 0.3 mg- 30 mcg norgestrel & ethinyl estradiol tab 0.5 mg- 50 mcg NORINYL TAB SAFYRAL TAB TAYTULLA CAP 1MG/20MC CONTINUOUS CONTRACEPTIVES - ORAL levonorgestrel-ethinyl estradiol (continuous) tab mcg EXTENDED-CYCLE CONTRACEPTIVES - ORAL levonorg-eth est tab mg(84) & eth Tier 4 est tab 0.01mg(7) levonorg-eth est tab mg(84) & Tier 4 eth est tab 0.01mg(7) levonorgestrel & ethinyl estradiol (91-day) Tier 4 tab mg QUARTETTE TAB Tier 4 FOUR PHASE CONTRACEPTIVES - ORAL NATAZIA TAB TRIPHASIC CONTRACEPTIVES - ORAL PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 68

77 desogest-ethin est tab / / mg-mg levonorgestrel-eth estra tab / / mg-mcg norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35 mg-mcg norethindrone-eth estradiol tab / /1-35 mg-mcg norethindrone-eth estradiol tab /1-35/ mg-mcg norgestimate-eth estrad tab / / mg-mcg norgestimate-eth estrad tab / / mg-mcg COMBINATION CONTRACEPTIVES - TRANSDERMAL COMBINATION CONTRACEPTIVES - TRANSDERMAL norelgestromin-ethinyl estradiol td ptwk mcg/24hr QL COMBINATION CONTRACEPTIVES - VAGINAL COMBINATION CONTRACEPTIVES - VAGINAL NUVARING MIS QL CONTRACEPTIVES CERVICAL CAPS FEMCAP MIS 26MM FEMCAP MIS 30MM PRENTIF MIS 22MM PRENTIF MIS 25MM PRENTIF MIS 28MM PRENTIF MIS 31MM PRENTIF MIS FITTING CONDOMS - FEMALE FC FEMALE MIS CONDOM DIAPHRAGMS CAYA DPR OMNIFLEX DPR ORTHO COIL DPR KIT 50 ORTHO COIL DPR KIT 100 ORTHO COIL DPR KIT 105 ORTHO FLAT DPR KIT 55 ORTHO FLAT DPR KIT 60 ORTHO FLAT DPR KIT 65 ORTHO FLAT DPR KIT 70 ORTHO FLAT DPR KIT 75 ORTHO FLAT DPR KIT 80 ORTHO FLAT DPR KIT 85 ORTHO FLAT DPR KIT 90 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 69

78 ORTHO FLAT DPR KIT 95 WIDE-SEAL DPR KIT 60 WIDE-SEAL DPR KIT 65 WIDE-SEAL DPR KIT 70 WIDE-SEAL DPR KIT 75 WIDE-SEAL DPR KIT 80 WIDE-SEAL DPR KIT 85 WIDE-SEAL DPR KIT 90 WIDE-SEAL DPR KIT 95 COPPER CONTRACEPTIVES - IUD COPPER CONTRACEPTIVES - IUD PARAGARD IUD T380A CORTICOSTEROIDS GLUCOCORTICOSTEROIDS methylprednisolone acetate inj susp 40 Tier 4 mg/ml COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COMBINATIONS TUZISTRA XR SUS Tier 4 DERMATOLOGICALS ACNE PRODUCTS ACZONE GEL 7.5% Tier 4 PA dapsone gel 5% Tier 2 PA FABIOR AER 0.1% Tier 4 PA ANTIFUNGALS - TOPICAL JUBLIA SOL 10% Tier 4 PA, ST ANTINEOPLASTIC OR PREMALIGNANT LESION AGENTS - TOPICAL PICATO GEL 0.05% Tier 5 PA PICATO GEL 0.015% Tier 5 PA ANTIPSORIATICS tazarotene cream 0.1% Tier 2 PA CORTICOSTEROIDS - TOPICAL clocortolone pivalate cream 0.1% Tier 4 CORDRAN OIN 0.025% Tier 4 HALOG OIN 0.1% Tier 4 LOCAL ANESTHETICS - TOPICAL lidocaine hcl gel 2% Tier 2 QL SCABICIDES & PEDICULICIDES ULESFIA LOT 5% Tier 4 DIURETICS LOOP DIURETICS ethacrynic acid tab 25 mg Tier 2 PA; QL EMERGENCY CONTRACEPTIVES EMERGENCY CONTRACEPTIVES PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 70

79 ELLA TAB 30MG levonorgestrel tab 0.75 mg levonorgestrel tab 1.5 mg levonorgestrel tab 1.5 mg ENDOCRINE AND METABOLIC ANDROGENS ANDRODERM DIS 2MG/24HR Tier 3 PA ANDRODERM DIS 4MG/24HR Tier 3 PA ANDROGEL GEL 1%(25MG) Tier 4 PA ANDROGEL GEL PUMP 1% Tier 4 ANDROXY TAB 10MG Tier 2 PA AVEED INJ 750/3ML Tier 4 PA AXIRON SOL 30MG/ACT Tier 3 PA METHITEST TAB 10MG Tier 4 PA methyltestosterone cap 10 mg Tier 5 PA STRIANT MIS 30MG Tier 4 PA testosterone cypionate im inj in oil 100 Tier 2 mg/ml testosterone cypionate im inj in oil 200 Tier 2 mg/ml testosterone enanthate im inj in oil 200 Tier 2 mg/ml testosterone td gel 10mg/act (2%) Tier 2 testosterone td gel 12.5 mg/act (1%) Tier 2 testosterone td gel 25 mg/2.5gm (1%) Tier 2 PA testosterone td gel 50 mg/5gm (1%) Tier 2 PA ANTIDIABETICS, ALPHA-GLUCOSIDASE INHIBITOR acarbose tab 25 mg Tier 2 acarbose tab 50 mg Tier 2 acarbose tab 100 mg Tier 2 MIGLITOL TAB 25 MG Tier 2 MIGLITOL TAB 50 MG Tier 2 MIGLITOL TAB 100 MG Tier 2 ANTIDIABETICS, AMYLIN ANALOGS SYMLINPEN 60 INJ 1000MCG Tier 3 ST; QL SYMLNPEN 120 INJ 1000MCG Tier 3 ST; QL ANTIDIABETICS, BIGUANIDE/SULFONYLUREA COMBINATIONS glipizide-metformin hcl tab mg Tier 2 glipizide-metformin hcl tab mg Tier 2 glipizide-metformin hcl tab mg Tier 2 glyburide-metformin tab mg Tier 2 glyburide-metformin tab mg Tier 2 glyburide-metformin tab mg Tier 2 ANTIDIABETICS, BIGUANIDES metformin hcl tab 500 mg Tier 1 metformin hcl tab 850 mg Tier 2 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 71

80 metformin hcl tab 1000 mg Tier 1 metformin hcl tab er 24hr 500 mg Tier 2 metformin hcl tab er 24hr 750 mg Tier 2 metformin hcl tab er 24hr osmotic 500 mg Tier 5 PA metformin hcl tab er 24hr osmotic 1000 mg Tier 5 PA ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS JANUVIA TAB 25MG Tier 3 JANUVIA TAB 50MG Tier 3 JANUVIA TAB 100MG Tier 3 TRADJENTA TAB 5MG Tier 3 QL ANTIDIABETICS, DPP-4 INHIBITOR COMBINATIONS JANUMET TAB MG Tier 3 JANUMET TAB Tier 3 JANUMET XR TAB MG Tier 3 JANUMET XR TAB Tier 3 JANUMET XR TAB Tier 3 JENTADUETO TAB Tier 3 JENTADUETO TAB Tier 3 JENTADUETO TAB Tier 3 ANTIDIABETICS, INCRETIN MIMETIC AGENTS BYDUREON INJ 2MG Tier 4 QL BYDUREON PEN INJ 2MG Tier 4 QL BYETTA INJ 5MCG Tier 4 ST; QL BYETTA INJ 10MCG Tier 4 ST; QL TRULICITY INJ 0.75/0.5 Tier 3 QL TRULICITY INJ 1.5/0.5 Tier 3 QL VICTOZA INJ 18MG/3ML Tier 3 VICTOZA INJ 18MG/3ML Tier 3 QL ANTIDIABETICS, INSULIN SENSITIZER/BIGUANIDE COMBINATION AVANDAMET TAB 2-500MG Tier 5 AVANDAMET TAB MG Tier 5 AVANDAMET TAB 4-500MG Tier 5 pioglitazone hcl-metformin hcl tab Tier 2 mg pioglitazone hcl-metformin hcl tab Tier 2 mg ANTIDIABETICS, INSULIN SENSITIZERS AVANDIA TAB 2MG Tier 6 AVANDIA TAB 4MG Tier 6 AVANDIA TAB 8MG Tier 5 pioglitazone hcl tab 15 mg (base equiv) Tier 2 pioglitazone hcl tab 30 mg (base equiv) Tier 2 pioglitazone hcl tab 45 mg (base equiv) Tier 2 ANTIDIABETICS, INSULINS HUMULIN R INJ U-500 Tier 3 QL PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 72

81 LANTUS INJ 100/ML Tier 3 QL LANTUS INJ SOLOSTAR Tier 3 QL LEVEMIR INJ Tier 3 QL LEVEMIR INJ FLEXTOUC Tier 3 QL NOVOLIN INJ 70/30 Tier 3 QL NOVOLIN N INJ U-100 Tier 3 QL NOVOLIN R INJ U-100 Tier 3 QL NOVOLOG INJ 100/ML Tier 3 QL NOVOLOG INJ FLEXPEN Tier 3 QL NOVOLOG INJ PENFILL Tier 3 QL NOVOLOG MIX INJ 70/30 Tier 3 QL NOVOLOG MIX INJ FLEXPEN Tier 3 QL ANTIDIABETICS, MEGLITINIDE nateglinide tab 60 mg Tier 2 nateglinide tab 120 mg Tier 2 repaglinide tab 0.5 mg Tier 2 repaglinide tab 1 mg Tier 2 repaglinide tab 2 mg Tier 2 ANTIDIABETICS, MEGLITINIDE/BIGUANIDE COMBINATIONS repaglinide-metformin hcl tab mg Tier 2 repaglinide-metformin hcl tab mg Tier 2 ANTIDIABETICS, MISCELLANEOUS CYCLOSET TAB 0.8MG Tier 4 ANTIDIABETICS, SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITOR/BIGUANIDE COMBINATIONS INVOKAMET TAB MG Tier 3 QL INVOKAMET TAB Tier 3 QL INVOKAMET TAB Tier 3 QL INVOKAMET TAB Tier 3 QL SYNJARDY TAB Tier 3 QL SYNJARDY TAB 5-500MG Tier 3 QL SYNJARDY TAB MG Tier 3 QL SYNJARDY TAB Tier 3 QL ANTIDIABETICS, SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS INVOKANA TAB 100MG Tier 3 QL INVOKANA TAB 300MG Tier 3 QL JARDIANCE TAB 10MG Tier 3 QL JARDIANCE TAB 25MG Tier 3 QL ANTIDIABETICS, SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR/DPP-4 INHIBITOR COMBINATIONS GLYXAMBI TAB 10-5 MG Tier 3 QL GLYXAMBI TAB 25-5 MG Tier 3 QL ANTIDIABETICS, SULFONYLUREAS chlorpropamide tab 100 mg Tier 2 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 73

82 chlorpropamide tab 250 mg Tier 2 glimepiride tab 1 mg Tier 2 glimepiride tab 2 mg Tier 2 glimepiride tab 4 mg Tier 2 glipizide tab 5 mg Tier 2 glipizide tab 10 mg Tier 2 glipizide tab er 24hr 2.5 mg Tier 2 glipizide tab er 24hr 5 mg Tier 2 glipizide tab er 24hr 10 mg Tier 2 glyburide micronized tab 1.5 mg Tier 2 glyburide micronized tab 3 mg Tier 2 glyburide micronized tab 6 mg Tier 2 glyburide tab 1.25 mg Tier 2 glyburide tab 2.5 mg Tier 2 glyburide tab 5 mg Tier 2 tolazamide tab 250 mg Tier 2 tolazamide tab 500 mg Tier 2 tolbutamide tab 500 mg Tier 2 ANTIDIABETICS, SUPPLIES ADVOCATE MIS LANCETS Tier 3 QL AUTOSHIELD MIS 29X3/16" Tier 3 AUTOSHIELD MIS 29X5/16" Tier 3 AUTOSHIELD MIS 30GX3/16 Tier 3 BD NEEDLES MIS 18GX1.5" Tier 3 COMFORT EZ MIS 33GX5MM Tier 3 COMFORT EZ MIS 33GX6MM Tier 3 COMFORT EZ MIS 33GX8MM Tier 3 FINGERSTIX MIS LANCETS Tier 3 QL GLUCOLET 2 MIS LANCING Tier 3 QL HYPO NEEDLE MIS 18GX1" Tier 3 HYPO NEEDLE MIS 18GX1.5" Tier 3 INSUPEN MIS 33GX4MM Tier 3 INSUPEN SENS MIS 32GX8MM Tier 3 MONOJECTOR MIS END CAPS Tier 3 QL NOVOFINE MIS 32GX6MM Tier 3 NOVOFINE PLS MIS 32GX4MM Tier 3 NOVOTWIST MIS 30GX8MM Tier 3 NOVOTWIST MIS 32GX5MM Tier 3 ONE TCH SLVR KIT ULT MINI Tier 3 ONETOUCH KIT ULT MINI Tier 3 ONETOUCH KIT ULTRA 2 Tier 3 ONETOUCH KIT ULTRALNK Tier 3 ONETOUCH KIT VERIO Tier 3 ONETOUCH KIT VERIO IQ Tier 3 ONETOUCH TES ULTRA BL Tier 3 ONETOUCH TES ULTRA BL Tier 3 QL PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 74

83 ONETOUCH TES VERIO Tier 3 QL ONETOUCH VER KIT SYNC Tier 3 PEN NEEDLES MIS 29GX12.7 Tier 3 SYMPATH NDL MIS 18GX6" Tier 3 TECHLITE MIS LANCETS Tier 3 QL UNIFINE PNTP MIS 29GX12MM Tier 3 UNIFINE PNTP MIS 31GX5MM Tier 3 UNIFINE PNTP MIS 31GX6MM Tier 3 UNIFINE PNTP MIS 31GX8MM Tier 3 ANTIDOTES flumazenil iv soln 1 mg/10ml (0.1 mg/ml) Tier 2 CALCIUM RECEPTOR ANTAGONISTS SENSIPAR TAB 30MG Tier 5 SENSIPAR TAB 60MG Tier 5 SENSIPAR TAB 90MG Tier 5 CALCIUM REGULATORS, BISPHOSPHONATES alendronate sodium oral soln 70 mg/75ml Tier 2 QL alendronate sodium tab 5 mg Tier 2 alendronate sodium tab 10 mg Tier 2 alendronate sodium tab 35 mg Tier 1 alendronate sodium tab 40 mg Tier 2 alendronate sodium tab 70 mg Tier 1 BONIVA INJ 3MG/3ML Tier 6 QL etidronate disodium tab 200 mg Tier 2 etidronate disodium tab 400 mg Tier 2 FOSAMAX + D TAB Tier 4 PA; QL FOSAMAX + D TAB Tier 4 PA; QL ibandronate sodium iv soln 3 mg/3ml Tier 4 QL (base equivalent) ibandronate sodium tab 150 mg (base Tier 2 QL equivalent) pamidronate disodium for inj 30 mg Tier 5 pamidronate disodium for inj 90 mg Tier 5 pamidronate disodium iv soln 3 mg/ml Tier 5 pamidronate disodium iv soln 9 mg/ml Tier 5 PAMIDRONATE INJ 6MG/ML Tier 5 risedronate sodium tab 5 mg Tier 4 QL risedronate sodium tab 30 mg Tier 4 QL risedronate sodium tab 35 mg Tier 4 QL risedronate sodium tab 150 mg Tier 4 QL risedronate sodium tab delayed release 35 Tier 4 QL mg zoledronic acid inj conc for iv infusion 4 Tier 5 QL mg/5ml zoledronic acid iv soln 5 mg/100ml Tier 5 QL ZOLEDRONIC INJ 4MG Tier 5 QL PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 75

84 ZOMETA INJ 4MG/100 Tier 5 QL CALCIUM REGULATORS, CALCITONINS calcitonin (salmon) nasal soln 200 unit/act Tier 2 FORTICAL SPR 200/ACT Tier 2 CALCIUM REGULATORS, PARATHYROID HORMONES FORTEO SOL 600/2.4 Tier 5 QL NATPARA INJ 25MCG Tier 5 PA; QL NATPARA INJ 50MCG Tier 5 PA; QL NATPARA INJ 75MCG Tier 5 PA; QL NATPARA INJ 100MCG Tier 5 PA; QL CALCIUM REGULATORS, RANK LIGAND INHIBITORS PROLIA SOL 60MG/ML Tier 5 PA; QL XGEVA INJ Tier 5 PA; QL ENDOMETRIOSIS danazol cap 50 mg Tier 2 PA danazol cap 100 mg Tier 2 PA danazol cap 200 mg Tier 2 PA LUPANETA KIT Tier 5 PA; QL LUPANETA KIT Tier 5 PA; QL SYNAREL SOL 2MG/ML Tier 5 PA; QL ESTROGEN/PROGESTIN, ORAL estradiol & norethindrone acetate tab mg Tier 2 estradiol & norethindrone acetate tab Tier 2 mg norethindrone acetate-ethinyl estradiol tab Tier mg-2.5 mcg norethindrone acetate-ethinyl estradiol tab Tier 2 1 mg-5 mcg PREMPHASE TAB Tier 3 PREMPRO TAB Tier 3 PREMPRO TAB Tier 3 PREMPRO TAB Tier 3 PREMPRO TAB Tier 3 ESTROGEN/PROGESTIN, TRANSDERMAL COMBIPATCH DIS.05/.14 Tier 4 QL COMBIPATCH DIS.05/.25 Tier 4 QL ESTROGEN/SELECTIVE ESTROGEN RECEPTOR MODULATOR COMBINATIONS DUAVEE TAB Tier 3 ESTROGENS, INJECTABLE DEPO-ESTRADI INJ 5MG/ML Tier 4 estradiol valerate im in oil 20 mg/ml Tier 2 estradiol valerate im in oil 40 mg/ml Tier 2 PREMARIN INJ 25MG Tier 4 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 76

85 ESTROGENS, ORAL ENJUVIA TAB 0.3MG Tier 4 ST ENJUVIA TAB 0.9MG Tier 4 ST ENJUVIA TAB 0.45MG Tier 4 ST ENJUVIA TAB 0.625MG Tier 4 ST ENJUVIA TAB 1.25MG Tier 4 ST esterified estrogens & methyltestosterone Tier 2 tab mg esterified estrogens & methyltestosterone Tier 2 tab mg estradiol tab 0.5 mg Tier 2 estradiol tab 1 mg Tier 2 estradiol tab 2 mg Tier 2 estropipate tab 0.75 mg Tier 2 estropipate tab 1.5 mg Tier 2 estropipate tab 3 mg Tier 2 MENEST TAB 0.3MG Tier 4 MENEST TAB 0.625MG Tier 4 MENEST TAB 1.25MG Tier 4 MENEST TAB 2.5MG Tier 4 PREMARIN TAB 0.3MG Tier 3 PREMARIN TAB 0.9MG Tier 3 PREMARIN TAB 0.45MG Tier 3 PREMARIN TAB 0.625MG Tier 3 PREMARIN TAB 1.25MG Tier 3 ESTROGENS, TRANSDERMAL estradiol td patch twice weekly 0.1 Tier 2 QL mg/24hr estradiol td patch twice weekly 0.05 Tier 2 QL mg/24hr estradiol td patch twice weekly Tier 2 QL mg/24hr estradiol td patch twice weekly Tier 2 QL mg/24hr estradiol td patch twice weekly Tier 2 QL mg/24hr estradiol td patch weekly 0.1 mg/24hr Tier 2 QL estradiol td patch weekly 0.05 mg/24hr Tier 2 QL estradiol td patch weekly 0.06 mg/24hr Tier 2 QL estradiol td patch weekly mg/24hr Tier 2 QL estradiol td patch weekly mg/24hr Tier 2 QL estradiol td patch weekly mg/24hr Tier 2 QL (37.5 mcg/24hr) ESTROGEL GEL Tier 4 QL MENOSTAR DIS 14MCG Tier 4 QL ESTROGENS, VAGINAL ESTRACE VAG CRE 0.01% Tier 4 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 77

86 FEMRING MIS 0.1MG/24 Tier 4 FEMRING MIS 0.05/24H Tier 4 PREMARIN VAG CRE 0.625MG Tier 3 VAGIFEM TAB 10MCG Tier 4 GLUCOCORTICOIDS cortisone acetate tab 25 mg Tier 2 DEXAMETHASON CON 1MG/ML Tier 2 dexamethasone elixir 0.5 mg/5ml Tier 2 dexamethasone soln 0.5 mg/5ml Tier 2 dexamethasone tab 0.5 mg Tier 2 dexamethasone tab 0.75 mg Tier 2 dexamethasone tab 1 mg Tier 2 dexamethasone tab 1.5 mg Tier 2 dexamethasone tab 2 mg Tier 2 dexamethasone tab 4 mg Tier 2 dexamethasone tab 6 mg Tier 2 fludrocortisone acetate tab 0.1 mg Tier 2 hydrocortisone tab 5 mg Tier 2 hydrocortisone tab 10 mg Tier 2 hydrocortisone tab 20 mg Tier 2 methylprednisolone tab 4 mg Tier 2 methylprednisolone tab 8 mg Tier 2 methylprednisolone tab 16 mg Tier 2 methylprednisolone tab 32 mg Tier 2 methylprednisolone tab therapy pack 4 mg Tier 2 (21) prednisolone sod phosph oral soln 6.7 Tier 2 mg/5ml (5 mg/5ml base) prednisolone sod phosphate oral soln 15 Tier 2 mg/5ml (base equiv) prednisolone sodium phosphate oral soln Tier 2 25 mg/5ml (base eq) prednisolone syrup 15 mg/5ml (usp Tier 2 solution equivalent) PREDNISONE CON 5MG/ML Tier 2 prednisone oral soln 5 mg/5ml Tier 2 prednisone tab 1 mg Tier 2 prednisone tab 2.5 mg Tier 2 prednisone tab 5 mg Tier 2 prednisone tab 10 mg Tier 2 prednisone tab 20 mg Tier 2 prednisone tab 50 mg Tier 2 prednisone tab therapy pack 5 mg (21) Tier 2 prednisone tab therapy pack 10 mg (21) Tier 2 GLUCOSE ELEVATING AGENT GLUCAGEN INJ 1MG Tier 3 QL GLUCAGEN INJ HYPOKIT Tier 3 QL PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 78

87 GLUCAGON KIT 1MG Tier 3 QL PROGLYCEM SUS 50MG/ML Tier 4 HUMAN GROWTH HORMONES NORDITROPIN INJ 5/1.5ML Tier 5 PA NORDITROPIN INJ 10/1.5ML Tier 5 PA NORDITROPIN INJ 15/1.5ML Tier 5 PA NORDITROPIN INJ 30/3ML Tier 5 PA SEROSTIM INJ 4MG Tier 6 PA SEROSTIM INJ 5MG Tier 6 PA SEROSTIM INJ 6MG Tier 6 PA ZORBTIVE INJ 8.8MG Tier 6 PA HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS calcitriol cap 0.5 mcg Tier 2 calcitriol cap 0.25 mcg Tier 2 calcitriol inj 1 mcg/ml Tier 2 calcitriol oral soln 1 mcg/ml Tier 2 doxercalciferol cap 0.5 mcg Tier 2 doxercalciferol cap 1 mcg Tier 2 doxercalciferol cap 2.5 mcg Tier 2 doxercalciferol inj 4 mcg/2ml (2 mcg/ml) Tier 2 HECTOROL INJ 2MCG/ML Tier 4 paricalcitol cap 1 mcg Tier 2 paricalcitol cap 2 mcg Tier 2 paricalcitol cap 4 mcg Tier 2 INSULIN-LIKE GROWTH FACTOR INCRELEX INJ 40MG/4ML Tier 5 PA LYSOSOMAL STORAGE DISORDERS ALDURAZYME INJ 2.9MG/5M Tier 5 PA CERDELGA CAP 84MG Tier 5 PA; QL CEREZYME INJ 400UNIT Tier 5 PA ELAPRASE INJ 6MG/3ML Tier 5 PA ELELYSO INJ 200UNIT Tier 5 PA FABRAZYME INJ 5MG Tier 5 PA FABRAZYME INJ 35MG Tier 5 PA MYOZYME INJ 50MG Tier 5 PA NAGLAZYME INJ 1MG/ML Tier 5 PA VIMIZIM INJ 5MG/5ML Tier 5 PA VPRIV INJ 400UNIT Tier 5 PA ZAVESCA CAP 100MG Tier 6 PA MISCELLANEOUS ADAGEN INJ 250/ML Tier 5 PA cabergoline tab 0.5 mg Tier 2 CARBAGLU TAB 200MG Tier 5 PA chorionic gonadotropin for im inj unit Tier 5 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 79

88 chorionic gonadotropin for im inj Tier 5 PA unit CYSTADANE POW Tier 5 PA H.P. ACTHAR INJ 80UNIT Tier 5 PA; QL KORLYM TAB 300MG Tier 6 PA; QL levocarnitine inj 200 mg/ml Tier 2 levocarnitine oral soln 1 gm/10ml (10%) Tier 2 levocarnitine tab 330 mg Tier 2 LUPR DEP-PED INJ 3M 30MG Tier 5 PA; QL LUPR DEP-PED INJ 7.5MG Tier 5 PA; QL LUPR DEP-PED INJ 11.25MG Tier 5 PA; QL LUPR DEP-PED INJ 15MG Tier 5 PA; QL methergine tab 0.2mg Tier 2 MYALEPT INJ 11.3MG Tier 5 PA; QL octreotide acetate inj 50 mcg/ml (0.05 Tier 5 mg/ml) octreotide acetate inj 100 mcg/ml (0.1 Tier 5 mg/ml) octreotide acetate inj 200 mcg/ml (0.2 Tier 5 mg/ml) octreotide acetate inj 500 mcg/ml (0.5 Tier 5 mg/ml) octreotide acetate inj 1000 mcg/ml (1 Tier 5 mg/ml) ORFADIN CAP 2MG Tier 5 PA ORFADIN CAP 5MG Tier 5 PA ORFADIN CAP 10MG Tier 5 PA OSPHENA TAB 60MG Tier 4 PA; QL raloxifene hcl tab 60 mg PA RAVICTI LIQ 1.1GM/ML Tier 6 PA; QL SANDOSTATIN KIT LAR 10MG Tier 6 PA; QL SANDOSTATIN KIT LAR 20MG Tier 6 PA; QL SANDOSTATIN KIT LAR 30MG Tier 6 PA; QL SIGNIFOR INJ 0.3MG/ML Tier 6 PA; QL SIGNIFOR INJ 0.6MG/ML Tier 6 PA; QL SIGNIFOR INJ 0.9MG/ML Tier 6 PA; QL SIGNIFOR LAR INJ 20MG Tier 6 PA; QL SIGNIFOR LAR INJ 40MG Tier 6 PA; QL SIGNIFOR LAR INJ 60MG Tier 6 PA; QL SOMATULINE INJ 60/0.2ML Tier 6 PA; QL SOMATULINE INJ 90/0.3ML Tier 6 PA; QL SOMATULINE INJ 120/.5ML Tier 6 PA; QL SOMAVERT INJ 10MG Tier 5 PA; QL SOMAVERT INJ 15MG Tier 5 PA; QL SOMAVERT INJ 20MG Tier 5 PA; QL SOMAVERT INJ 25MG Tier 5 PA; QL SOMAVERT INJ 30MG Tier 5 PA; QL PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 80

89 SUPPRELIN LA KIT 50MG Tier 5 PA; QL SYPRINE CAP 250MG Tier 6 PA trientine hcl cap 250 mg Tier 5 PA PHENYLKETONURIA TREATMENT AGENTS KUVAN POW 500MG Tier 5 PA KUVAN TAB 100MG Tier 5 PA PHOSPHATE BINDER AGENTS AURYXIA TAB 210MG Tier 3 calcium acetate (phosphate binder) cap Tier mg (169 mg ca) calcium acetate (phosphate binder) tab Tier mg ELIPHOS TAB 667MG Tier 2 FOSRENOL POW 750MG Tier 4 ST FOSRENOL POW 1000MG Tier 4 ST lanthanum carbonate chew tab 500 mg Tier 2 (elemental) lanthanum carbonate chew tab 750 mg Tier 2 (elemental) lanthanum carbonate chew tab 1000 mg Tier 2 (elemental) RENAGEL TAB 400MG Tier 3 RENAGEL TAB 800MG Tier 3 sevelamer carbonate packet 0.8 gm Tier 2 sevelamer carbonate packet 2.4 gm Tier 2 VELPHORO CHW 500MG Tier 4 ST PROGESTINS, INJECTABLE MAKENA INJ 250MG/ML Tier 5 PA PROGESTINS, ORAL medroxyprogesterone acetate tab 2.5 mg Tier 2 medroxyprogesterone acetate tab 5 mg Tier 2 medroxyprogesterone acetate tab 10 mg Tier 2 norethindrone acetate tab 5 mg Tier 2 progesterone micronized cap 100 mg Tier 2 progesterone micronized cap 200 mg Tier 2 PROGESTINS, VAGINAL CRINONE GEL 4% VAG Tier 4 THYROID AGENTS, ANTITHYROID AGENTS methimazole tab 5 mg Tier 2 methimazole tab 10 mg Tier 2 propylthiouracil tab 50 mg Tier 2 SSKI SOL 1GM/ML Tier 4 THYROID SUPPLEMENTS ARMOUR THYRO TAB 15MG Tier 4 ARMOUR THYRO TAB 30MG Tier 4 ARMOUR THYRO TAB 60MG Tier 4 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 81

90 ARMOUR THYRO TAB 90MG Tier 4 ARMOUR THYRO TAB 120MG Tier 4 ARMOUR THYRO TAB 180MG Tier 4 ARMOUR THYRO TAB 240MG Tier 4 ARMOUR THYRO TAB 300MG Tier 4 LEVOTHYROXIN INJ 200MCG Tier 2 levothyroxine sodium for iv inj 100 mcg Tier 2 levothyroxine sodium for iv inj 500 mcg Tier 2 levothyroxine sodium tab 25 mcg Tier 2 levothyroxine sodium tab 50 mcg Tier 2 levothyroxine sodium tab 75 mcg Tier 2 levothyroxine sodium tab 88 mcg Tier 2 levothyroxine sodium tab 100 mcg Tier 2 levothyroxine sodium tab 112 mcg Tier 2 levothyroxine sodium tab 125 mcg Tier 2 levothyroxine sodium tab 137 mcg Tier 2 levothyroxine sodium tab 150 mcg Tier 2 levothyroxine sodium tab 175 mcg Tier 2 levothyroxine sodium tab 200 mcg Tier 2 levothyroxine sodium tab 300 mcg Tier 2 liothyronine sodium iv soln 10 mcg/ml Tier 2 liothyronine sodium tab 5 mcg Tier 2 liothyronine sodium tab 25 mcg Tier 2 liothyronine sodium tab 50 mcg Tier 2 NATURE THROI TAB 162.5MG Tier 2 NATURE-THROI TAB 16.25MG Tier 2 NATURE-THROI TAB 32.5MG Tier 2 NATURE-THROI TAB 48.75MG Tier 2 NATURE-THROI TAB 65MG Tier 2 NATURE-THROI TAB 81.25MG Tier 2 NATURE-THROI TAB 97.5MG Tier 2 NATURE-THROI TAB MG Tier 2 NATURE-THROI TAB 130MG Tier 2 NATURE-THROI TAB MG Tier 2 NATURE-THROI TAB 195MG Tier 2 NATURE-THROI TAB 260MG Tier 2 NATURE-THROI TAB 325MG Tier 2 SYNTHROID TAB 25MCG Tier 4 SYNTHROID TAB 50MCG Tier 4 SYNTHROID TAB 75MCG Tier 4 SYNTHROID TAB 88MCG Tier 4 SYNTHROID TAB 100MCG Tier 4 SYNTHROID TAB 112MCG Tier 4 SYNTHROID TAB 125MCG Tier 4 SYNTHROID TAB 137MCG Tier 4 SYNTHROID TAB 150MCG Tier 4 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 82

91 SYNTHROID TAB 175MCG Tier 4 SYNTHROID TAB 200MCG Tier 4 SYNTHROID TAB 300MCG Tier 4 thyroid tab 30 mg (1/2 grain) Tier 2 thyroid tab 60 mg (1 grain) Tier 2 thyroid tab 90 mg (1 1/2 grain) Tier 2 THYROLAR-1 TAB 60MG Tier 4 THYROLAR-1/2 TAB 30MG Tier 4 THYROLAR-1/4 TAB 15MG Tier 4 THYROLAR-2 TAB 120MG Tier 4 THYROLAR-3 TAB 180MG Tier 4 TIROSINT CAP 13MCG Tier 4 TIROSINT CAP 25MCG Tier 4 TIROSINT CAP 50MCG Tier 4 TIROSINT CAP 75MCG Tier 4 TIROSINT CAP 88MCG Tier 4 TIROSINT CAP 100MCG Tier 4 TIROSINT CAP 112MCG Tier 4 TIROSINT CAP 125MCG Tier 4 TIROSINT CAP 137MCG Tier 4 TIROSINT CAP 150MCG Tier 4 WESTHROID TAB 16.25MG Tier 2 WESTHROID TAB 32.5MG Tier 2 WESTHROID TAB 48.75MG Tier 2 WESTHROID TAB 65MG Tier 2 WESTHROID TAB 81.25MG Tier 2 WESTHROID TAB 97.5MG Tier 2 WESTHROID TAB MG Tier 2 WESTHROID TAB 130MG Tier 2 VASOPRESSIN RECEPTOR ANTAGONISTS SAMSCA TAB 15MG Tier 5 PA; QL SAMSCA TAB 30MG Tier 5 PA; QL VASOPRESSINS desmopressin acetate nasal soln 0.01% Tier 2 (refrigerated) desmopressin acetate nasal spray soln Tier % (refrigerated) desmopressin acetate tab 0.1 mg Tier 2 desmopressin acetate tab 0.2 mg Tier 2 ENDOCRINE AND METABOLIC AGENTS - MISC. METABOLIC MODIFIERS PALYNZIQ INJ 2.5/0.5 Tier 5 PA; QL PALYNZIQ INJ 10/0.5ML Tier 5 PA; QL PALYNZIQ INJ 20MG/ML Tier 5 PA; QL sodium phenylbutyrate tab 500 mg Tier 5 PA; QL VASOPRESSIN RECEPTOR ANTAGONISTS PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 83

92 JYNARQUE PAK 45-15MG Tier 5 PA; QL JYNARQUE PAK 60-30MG Tier 5 PA; QL JYNARQUE PAK 90-30MG Tier 5 PA; QL ENZYMES ENZYMES VITRASE INJ 200/ML Tier 4 ESTROGENS ESTROGENS CENESTIN TAB 0.3MG Tier 4 GASTROINTESTINAL ANTIDIARRHEALS diphenoxylate w/ atropine liq Tier 2 mg/5ml diphenoxylate w/ atropine tab Tier 2 mg FULYZAQ TAB 125MG Tier 5 PA; QL loperamide hcl cap 2 mg Tier 2 paregoric tincture 2 mg/5ml (morphine Tier 2 equivalent) ANTIEMETICS AKYNZEO CAP Tier 4 QL ALOXI INJ 0.25MG/5 Tier 4 ST ANZEMET INJ 20MG/ML Tier 4 ST ANZEMET TAB 50MG Tier 4 ST; QL ANZEMET TAB 100MG Tier 4 ST; QL CESAMET CAP 1MG Tier 4 ST DIMENHYDRIN INJ 50MG/ML Tier 2 dronabinol cap 2.5 mg Tier 4 dronabinol cap 5 mg Tier 4 dronabinol cap 10 mg Tier 4 droperidol inj 2.5 mg/ml Tier 2 EMEND SOL 150MG Tier 4 QL granisetron hcl inj 0.1 mg/ml Tier 2 QL granisetron hcl inj 1 mg/ml Tier 2 QL granisetron hcl inj 4 mg/4ml (1 mg/ml) Tier 2 QL granisetron hcl tab 1 mg Tier 4 QL meclizine hcl tab 12.5 mg Tier 2 meclizine hcl tab 25 mg Tier 2 metoclopramide hcl inj 5 mg/ml (base Tier 2 equivalent) metoclopramide hcl soln 5 mg/5ml (10 Tier 2 mg/10ml) (base equiv) metoclopramide hcl tab 5 mg (base Tier 1 equivalent) metoclopramide hcl tab 10 mg (base equivalent) Tier 1 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 84

93 ondansetron hcl inj 4 mg/2ml (2 mg/ml) Tier 2 ondansetron hcl inj 40 mg/20ml (2 mg/ml) Tier 2 ondansetron hcl oral soln 4 mg/5ml Tier 2 ondansetron hcl tab 4 mg Tier 2 QL ondansetron hcl tab 8 mg Tier 2 QL ondansetron hcl tab 24 mg Tier 2 QL ondansetron orally disintegrating tab 4 mg Tier 2 QL ondansetron orally disintegrating tab 8 mg Tier 2 QL prochlorperazine edisylate inj 5 mg/ml Tier 2 prochlorperazine maleate tab 5 mg (base Tier 2 equivalent) prochlorperazine maleate tab 10 mg (base Tier 2 equivalent) prochlorperazine suppos 25 mg Tier 2 promethazine hcl inj 25 mg/ml Tier 2 promethazine hcl inj 50 mg/ml Tier 2 promethazine hcl suppos 12.5 mg Tier 2 promethazine hcl suppos 25 mg Tier 2 promethazine hcl suppos 50 mg Tier 4 promethazine hcl syrup 6.25 mg/5ml Tier 2 promethazine hcl tab 12.5 mg Tier 2 promethazine hcl tab 25 mg Tier 2 promethazine hcl tab 50 mg Tier 2 SANCUSO DIS 3.1MG Tier 4 ST; QL scopolamine td patch 72hr 1 mg/3days Tier 2 TIGAN INJ 100MG/ML Tier 4 trimethobenzamide hcl cap 300 mg Tier 2 ANTISPASMODICS BELLA/OPIUM SUP Tier 2 ST BELLA/OPIUM SUP Tier 2 ST CANTIL TAB 25MG Tier 4 chlordiazepoxide hcl-clidinium bromide cap Tier mg CUVPOSA SOL 1MG/5ML Tier 5 PA dicyclomine hcl cap 10 mg Tier 2 dicyclomine hcl oral soln 10 mg/5ml Tier 2 dicyclomine hcl tab 20 mg Tier 2 glycopyrrolate inj 1 mg/5ml (0.2 mg/ml) Tier 2 glycopyrrolate tab 1 mg Tier 2 glycopyrrolate tab 2 mg Tier 2 hyoscyamine sulfate elixir mg/5ml Tier 2 hyoscyamine sulfate sl tab mg Tier 2 hyoscyamine sulfate soln mg/ml Tier 2 hyoscyamine sulfate tab mg Tier 2 hyoscyamine sulfate tab disint mg Tier 2 hyoscyamine sulfate tab er 12hr mg Tier 2 LEVSIN INJ 0.5MG/ML Tier 4 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 85

94 methscopolamine bromide tab 2.5 mg Tier 2 methscopolamine bromide tab 5 mg Tier 2 pb-hyoscy-atrop-scopol tab Tier mg propantheline bromide tab 15 mg Tier 2 CHOLELITHOLYTICS ursodiol cap 300 mg Tier 2 ursodiol tab 250 mg Tier 2 ursodiol tab 500 mg Tier 2 H2-RECEPTOR ANTAGONISTS cimetidine hcl soln 300 mg/5ml Tier 2 cimetidine tab 300 mg Tier 2 cimetidine tab 400 mg Tier 2 cimetidine tab 800 mg Tier 2 famotidine for susp 40 mg/5ml Tier 2 famotidine in nacl 0.9% iv soln 20 Tier 2 mg/50ml famotidine inj 20 mg/2ml Tier 2 famotidine inj 40 mg/4ml Tier 2 famotidine tab 40 mg Tier 2 nizatidine cap 150 mg Tier 2 nizatidine cap 300 mg Tier 2 nizatidine oral soln 15 mg/ml Tier 2 ranitidine hcl cap 150 mg Tier 4 ranitidine hcl cap 300 mg Tier 4 ranitidine hcl inj 50 mg/2ml (25 mg/ml) Tier 2 ranitidine hcl inj 150 mg/6ml (25 mg/ml) Tier 2 ranitidine hcl syrup 15 mg/ml (75 mg/5ml) Tier 2 ranitidine hcl tab 150 mg Tier 1 ranitidine hcl tab 300 mg Tier 1 INFLAMMATORY BOWEL DISEASE, INJECTABLE AGENTS ENTYVIO INJ 300MG Tier 6 PA; QL INFLAMMATORY BOWEL DISEASE, ORAL AGENTS APRISO CAP 0.375GM Tier 3 ASACOL HD TAB 800MG Tier 3 balsalazide disodium cap 750 mg Tier 2 budesonide delayed release particles cap 3 Tier 2 mg DELZICOL CAP 400MG Tier 3 DIPENTUM CAP 250MG Tier 4 ST *mesalamine rectal enema 4 gm & Tier 2 cleanser wipe kit** PENTASA CAP 250MG CR Tier 4 PENTASA CAP 500MG CR Tier 4 sulfasalazine tab 500 mg Tier 2 sulfasalazine tab delayed release 500 mg Tier 2 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 86

95 UCERIS TAB 9MG Tier 5 PA INFLAMMATORY BOWEL DISEASE, RECTAL AGENTS CANASA SUP 1000MG Tier 4 hydrocortisone enema 100 mg/60ml Tier 2 mesalamine enema 4 gm Tier 2 IRRITABLE BOWEL SYNDROME WITH CONSTIPATION AMITIZA CAP 8MCG Tier 4 ST; QL AMITIZA CAP 24MCG Tier 4 ST; QL LINZESS CAP 145MCG Tier 3 QL LINZESS CAP 290MCG Tier 3 QL IRRITABLE BOWEL SYNDROME WITH DIARRHEA alosetron hcl tab 0.5 mg (base equiv) Tier 5 PA; QL alosetron hcl tab 1 mg (base equiv) Tier 5 PA; QL VIBERZI TAB 75MG Tier 5 PA; QL VIBERZI TAB 100MG Tier 5 PA; QL LAXATIVES/STOOL SOFTENERS bisacodyl tab & peg 3350-kcl-sod bicarbnacl for soln kit bisacodyl tab delayed release 5 mg lactulose solution 10 gm/15ml Tier 2 MILK OF MAGN SUS 2400MG MOVIPREP SOL PA OSMOPREP TAB 1.5GM Tier 4 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm peg 3350-kcl-sod bicarb-nacl for soln 420 gm polyethylene glycol 3350 oral powder PREPOPIK PAK SUCLEAR KIT SUPREP BOWEL SOL PREP KIT PA MISCELLANEOUS BUPHENYL POW Tier 5 PA CARAFATE SUS 1GM/10ML Tier 2 cromolyn sodium oral conc 100 mg/5ml Tier 2 GATTEX KIT 5MG Tier 5 PA; QL KEPIVANCE INJ 6.25MG Tier 5 lactulose (encephalopathy) solution 10 Tier 2 gm/15ml RECTIV OIN 0.4% Tier 4 PA sodium phenylbutyrate oral powder 3 Tier 5 PA gm/teaspoonful SUCRAID SOL 8500/ML Tier 5 PA sucralfate tab 1 gm Tier 2 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 87

96 OPIOID-INDUCED CONSTIPATION MOVANTIK TAB 12.5MG Tier 3 QL MOVANTIK TAB 25MG Tier 3 QL PANCREATIC ENZYMES CREON CAP 3000UNIT Tier 3 CREON CAP 6000UNIT Tier 3 CREON CAP 12000UNT Tier 3 CREON CAP 24000UNT Tier 3 CREON CAP 36000UNT Tier 3 ZENPEP CAP 3000UNIT Tier 4 ST ZENPEP CAP 10000UNT Tier 4 ST ZENPEP CAP 15000UNT Tier 4 ST ZENPEP CAP 20000UNT Tier 4 ST ZENPEP CAP 25000UNT Tier 4 ST ZENPEP CAP 40000UNT Tier 4 ST PROSTAGLANDINS misoprostol tab 100 mcg Tier 2 misoprostol tab 200 mcg Tier 2 PROTON PUMP INHIBITORS (PPI) DEXILANT CAP 30MG DR Tier 4 PA, ST; QL DEXILANT CAP 60MG DR Tier 4 PA, ST; QL esomeprazole magnesium cap delayed Tier 2 PA, ST; QL release 20 mg (base eq) esomeprazole magnesium cap delayed release 40 mg (base eq) Tier 2 PA, ST; QL esomeprazole sodium for intravenous soln Tier 2 QL 20 mg (base equiv) esomeprazole sodium for intravenous soln Tier 2 QL 40 mg (base equiv) lansoprazole cap delayed release 15 mg Tier 2 QL lansoprazole cap delayed release 30 mg Tier 2 QL omeprazole cap delayed release 10 mg Tier 2 QL omeprazole cap delayed release 20 mg Tier 2 QL omeprazole cap delayed release 40 mg Tier 2 QL pantoprazole sodium ec tab 20 mg (base Tier 2 QL equiv) pantoprazole sodium ec tab 40 mg (base Tier 2 QL equiv) rabeprazole sodium ec tab 20 mg Tier 2 PA; QL SALIVA STIMULANTS cevimeline hcl cap 30 mg Tier 2 pilocarpine hcl tab 5 mg Tier 2 pilocarpine hcl tab 7.5 mg Tier 2 STEROIDS, RECTAL hydrocortisone acetate suppos 25 mg Tier 2 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 88

97 hydrocortisone acetate w/ pramoxine rectal Tier 2 cream 1-1% hydrocortisone acetate w/ pramoxine rectal Tier 2 cream 2.5-1% hydrocortisone rectal cream 2.5% Tier 2 lidocaine-hydrocortisone acetate rectal Tier 2 cream 3-0.5% ULCER THERAPY COMBINATION amoxicillin cap-clarithro tab-lansopraz cap Tier 4 dr therapy pack omeprazole-sodium bicarbonate cap 20- Tier 2 PA, ST; QL 1100 mg omeprazole-sodium bicarbonate cap 40- Tier 2 PA, ST; QL 1100 mg GASTROINTESTINAL AGENTS - MISC. INFLAMMATORY BOWEL AGENTS mesalamine tab delayed release 1.2 gm Tier 2 IRRITABLE BOWEL SYNDROME (IBS) AGENTS LINZESS CAP 72MCG Tier 3 PHOSPHATE BINDER AGENTS sevelamer carbonate tab 800 mg Tier 2 GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl tab er 24hr 10 mg Tier 2 AVODART CAP 0.5MG Tier 6 dutasteride cap 0.5 mg Tier 4 dutasteride-tamsulosin hcl cap mg Tier 2 finasteride tab 5 mg Tier 2 RAPAFLO CAP 4MG Tier 3 ST RAPAFLO CAP 8MG Tier 3 ST tamsulosin hcl cap 0.4 mg Tier 2 GENITOURINARY IRRIGANTS acetic acid irrigation soln 0.25% Tier 2 neomycin-polymyxin b gu irrigation soln Tier 2 MISCELLANEOUS bethanechol chloride tab 5 mg Tier 2 bethanechol chloride tab 10 mg Tier 2 bethanechol chloride tab 25 mg Tier 2 bethanechol chloride tab 50 mg Tier 2 CYSTAGON CAP 50MG Tier 5 CYSTAGON CAP 150MG Tier 5 ELMIRON CAP 100MG Tier 4 methenamine hippurate tab 1 gm Tier 2 methenamine mandelate tab 0.5 gm Tier 2 methenamine mandelate tab 1 gm Tier 2 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 89

98 *methenamine-hyos-meth blue-sod phosphen Tier 2 sal tab 81.6 mg*** methenamine-hyosc-meth blue-benz acidphenyl Tier 2 sal tab 81.6mg *methenamine-hyoscamine-meth blue-sod Tier 2 phos tab 81.6 mg*** MONUROL PAK GRANULES Tier 4 PA nitrofurantoin macrocrystalline cap 25 mg Tier 2 phenazopyridine hcl tab 100 mg Tier 2 phenazopyridine hcl tab 200 mg Tier 2 pot & sod citrates w/ cit ac soln Tier mg/5ml pot & sod citrates w/ cit ac syrup Tier mg/5ml potassium citrate & citric acid powder pack Tier mg potassium citrate & citric acid soln Tier mg/5ml potassium citrate tab er 5 meq (540 mg) Tier 2 potassium citrate tab er 10 meq (1080 mg) Tier 2 potassium citrate tab er 15 meq (1620 mg) Tier 2 PROCYSBI CAP 25MG Tier 5 PA; QL PROCYSBI CAP 75MG Tier 5 PA; QL sodium citrate & citric acid soln Tier 2 mg/5ml THIOLA TAB 100MG Tier 4 URINARY ANTISPASMODICS flavoxate hcl tab 100 mg Tier 2 MYRBETRIQ TAB 25MG Tier 3 QL MYRBETRIQ TAB 50MG Tier 3 QL oxybutynin chloride syrup 5 mg/5ml Tier 2 oxybutynin chloride tab 5 mg Tier 2 oxybutynin chloride tab er 24hr 5 mg Tier 2 oxybutynin chloride tab er 24hr 10 mg Tier 2 oxybutynin chloride tab er 24hr 15 mg Tier 2 tolterodine tartrate cap er 24hr 2 mg Tier 2 tolterodine tartrate cap er 24hr 4 mg Tier 2 tolterodine tartrate tab 1 mg Tier 2 tolterodine tartrate tab 2 mg Tier 2 TOVIAZ TAB 4MG Tier 4 ST TOVIAZ TAB 8MG Tier 4 ST trospium chloride cap er 24hr 60 mg Tier 4 trospium chloride tab 20 mg Tier 2 VESICARE TAB 5MG Tier 3 VESICARE TAB 10MG Tier 3 VAGINAL ANTI-INFECTIVES clindamycin phosphate vaginal cream 2% Tier 2 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 90

99 GYNAZOLE-1 CRE 2% Tier 4 metronidazole vaginal gel 0.75% Tier 2 terconazole vaginal cream 0.4% Tier 2 terconazole vaginal cream 0.8% Tier 2 terconazole vaginal suppos 80 mg Tier 2 GENITOURINARY AGENTS - MISCELLANEOUS PROSTATIC HYPERTROPHY AGENTS CARDURA XL TAB 4MG Tier 3 ST CARDURA XL TAB 8MG Tier 3 ST GOUT AGENT COMBINATIONS GOUT AGENT COMBINATIONS colchicine w/ probenecid tab mg Tier 2 HEMATOLOGIC ANTICOAGULANTS, INJECTABLE ARGATROBAN INJ 50MG/50M Tier 4 bivalirudin trifluoroacetate for iv soln 250 Tier 2 mg (base equiv) enoxaparin sodium inj 30 mg/0.3ml Tier 5 enoxaparin sodium inj 40 mg/0.4ml Tier 5 enoxaparin sodium inj 60 mg/0.6ml Tier 5 enoxaparin sodium inj 80 mg/0.8ml Tier 5 enoxaparin sodium inj 100 mg/ml Tier 5 enoxaparin sodium inj 120 mg/0.8ml Tier 5 enoxaparin sodium inj 150 mg/ml Tier 5 enoxaparin sodium inj 300 mg/3ml Tier 5 fondaparinux sodium subcutaneous inj 2.5 Tier 5 QL mg/0.5ml fondaparinux sodium subcutaneous inj 5 mg/0.4ml Tier 5 QL fondaparinux sodium subcutaneous inj 7.5 Tier 5 QL mg/0.6ml fondaparinux sodium subcutaneous inj 10 Tier 5 QL mg/0.8ml FRAGMIN INJ 2500/0.2 Tier 5 QL FRAGMIN INJ 5000/0.2 Tier 5 QL FRAGMIN INJ 7500/0.3 Tier 5 QL FRAGMIN INJ 10000/ML Tier 5 QL FRAGMIN INJ 12500UNT Tier 5 QL FRAGMIN INJ 15000UNT Tier 5 QL FRAGMIN INJ 18000UNT Tier 5 QL FRAGMIN INJ 95000UNT Tier 5 QL heparin sodium (porcine) inj 1000 unit/ml Tier 2 heparin sodium (porcine) inj 5000 unit/ml Tier 2 heparin sodium (porcine) inj unit/ml Tier 2 heparin sodium (porcine) inj unit/ml Tier 2 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 91

100 heparin sodium (porcine) pf inj 5000 Tier 2 unit/0.5ml ANTICOAGULANTS, ORAL ELIQUIS TAB 2.5MG Tier 3 QL ELIQUIS TAB 5MG Tier 3 QL warfarin sodium tab 1 mg Tier 2 warfarin sodium tab 2 mg Tier 2 warfarin sodium tab 2.5 mg Tier 2 warfarin sodium tab 3 mg Tier 2 warfarin sodium tab 4 mg Tier 2 warfarin sodium tab 5 mg Tier 2 warfarin sodium tab 6 mg Tier 2 warfarin sodium tab 7.5 mg Tier 2 warfarin sodium tab 10 mg Tier 2 XARELTO STAR TAB 15/20MG Tier 3 QL XARELTO TAB 10MG Tier 3 QL XARELTO TAB 15MG Tier 3 QL XARELTO TAB 20MG Tier 3 QL HEMATOPOIETIC GROWTH FACTORS ARANESP INJ 10MCG Tier 5 PA ARANESP INJ 25MCG Tier 5 PA ARANESP INJ 40MCG Tier 5 PA ARANESP INJ 60MCG Tier 5 PA ARANESP INJ 100MCG Tier 5 PA ARANESP INJ 150MCG Tier 5 PA ARANESP INJ 200MCG Tier 5 PA ARANESP INJ 300MCG Tier 5 PA ARANESP INJ 500MCG Tier 5 PA EPOGEN INJ 2000/ML Tier 6 PA EPOGEN INJ 3000/ML Tier 6 PA EPOGEN INJ 4000/ML Tier 6 PA EPOGEN INJ 10000/ML Tier 6 PA EPOGEN INJ 20000/ML Tier 6 PA GRANIX INJ 300/0.5 Tier 5 PA GRANIX INJ 480/0.8 Tier 5 PA LEUKINE INJ 250MCG Tier 5 NEULASTA INJ 6MG/0.6M Tier 5 PA NEULASTA KIT 6MG/0.6M Tier 5 PA NEUPOGEN INJ 300/0.5 Tier 5 PA NEUPOGEN INJ 300MCG Tier 5 PA NEUPOGEN INJ 480/0.8 Tier 5 PA NEUPOGEN INJ 480MCG Tier 5 PA PROCRIT INJ 40000/ML Tier 5 PA ZARXIO INJ 300/0.5 Tier 5 PA ZARXIO INJ 480/0.8 Tier 5 PA HEMOSTATICS, SYSTEMIC PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 92

101 aminocaproic acid inj 250 mg/ml Tier 2 tranexamic acid iv soln 1000 mg/10ml Tier 2 (100 mg/ml) tranexamic acid tab 650 mg Tier 2 QL HEREDITARY ANGIOEDEMA AGENTS BERINERT INJ 500UNIT Tier 5 PA; QL CINRYZE SOL 500 UNIT Tier 5 PA; QL FIRAZYR INJ 30MG/3ML Tier 5 PA; QL KALBITOR INJ 10MG/ML Tier 5 PA RUCONEST INJ 2100UNIT Tier 5 PA IDIOPATHIC THROMBOCYTOPENIC PURPURA NPLATE INJ 250MCG Tier 5 PA NPLATE INJ 500MCG Tier 5 PA PROMACTA TAB 12.5MG Tier 5 PA; QL PROMACTA TAB 25MG Tier 5 PA; QL PROMACTA TAB 50MG Tier 5 PA; QL PROMACTA TAB 75MG Tier 5 PA; QL MISCELLANEOUS CHEMET CAP 100MG Tier 4 PA cilostazol tab 50 mg Tier 2 cilostazol tab 100 mg Tier 2 EXJADE TAB 125MG Tier 5 PA EXJADE TAB 250MG Tier 5 PA EXJADE TAB 500MG Tier 5 PA FERRIPROX SOL 100MG/ML Tier 5 PA FERRIPROX TAB 500MG Tier 5 PA JADENU TAB 90MG Tier 5 PA JADENU TAB 180MG Tier 5 PA JADENU TAB 360MG Tier 5 PA pentoxifylline tab er 400 mg Tier 2 protamine sulfate inj 10 mg/ml Tier 2 PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS SOLIRIS INJ 10MG/ML Tier 5 PA PLATELET AGGREGATION INHIBITORS aspirin-dipyridamole cap er 12hr Tier 2 mg BRILINTA TAB 60MG Tier 3 QL BRILINTA TAB 90MG Tier 3 QL clopidogrel bisulfate tab 75 mg (base Tier 2 equiv) clopidogrel bisulfate tab 300 mg (base Tier 2 equiv) dipyridamole tab 25 mg Tier 2 dipyridamole tab 50 mg Tier 2 dipyridamole tab 75 mg Tier 2 ticlopidine hcl tab 250 mg Tier 2 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 93

102 ZONTIVITY TAB 2.08MG Tier 4 PA; QL PLATELET SYNTHESIS INHIBITOR anagrelide hcl cap 0.5 mg Tier 2 anagrelide hcl cap 1 mg Tier 2 STEM CELL MOBILIZERS MOZOBIL INJ Tier 5 PA; QL HEMATOLOGICAL AGENTS - MISC. PLATELET AGGREGATION INHIBITORS prasugrel hcl tab 5 mg (base equiv) Tier 2 QL prasugrel hcl tab 10 mg (base equiv) Tier 2 QL HEMATOPOIETIC AGENTS HEMATOPOIETIC GROWTH FACTORS DOPTELET TAB 20MG Tier 5 PA; QL HYPOACTIVE SEXUAL DESIRE DISORDER (HSDD) AGENTS SEROTONIN 1A RECEPT AGONIST/SEROTONIN 2A RECEPT ANTAG ADDYI TAB 100MG Tier 5 PA IMMUNOLOGIC AGENTS BIOLOGIC DISEASE-MODIFYING AGENTS ENBREL INJ 25/0.5ML Tier 5 PA; QL ENBREL INJ 25MG Tier 5 PA; QL ENBREL INJ 50MG/ML Tier 5 PA; QL ENBREL SRCLK INJ 50MG/ML Tier 5 PA; QL HUMIRA INJ 10MG/0.2 Tier 5 PA; QL HUMIRA KIT 20MG/0.4 Tier 5 PA; QL HUMIRA KIT 40MG/0.8 Tier 5 PA; QL HUMIRA PEN INJ 40MG/0.8 Tier 5 PA; QL DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDS) CUPRIMINE CAP 250MG Tier 6 PA DEPEN TITRA TAB 250MG Tier 5 PA hydroxychloroquine sulfate tab 200 mg Tier 2 leflunomide tab 10 mg Tier 2 leflunomide tab 20 mg Tier 2 OTREXUP INJ 7.5/0.4 Tier 5 PA; QL OTREXUP INJ 10MG Tier 5 PA; QL OTREXUP INJ 15MG Tier 5 PA; QL OTREXUP INJ 20MG Tier 5 PA; QL OTREXUP INJ 25MG Tier 5 PA; QL PENICILLAMIN POW Tier 5 RASUVO INJ 7.5MG Tier 5 PA; QL RASUVO INJ 10MG Tier 5 PA; QL RASUVO INJ 12.5MG Tier 5 PA; QL RASUVO INJ 15MG Tier 5 PA; QL RASUVO INJ 17.5MG Tier 5 PA; QL RASUVO INJ 22.5MG Tier 5 PA; QL RASUVO INJ 25MG Tier 5 PA; QL PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 94

103 RASUVO INJ 27.5MG Tier 5 PA; QL RASUVO INJ 30MG Tier 5 PA; QL RIDAURA CAP 3MG Tier 5 IMMUNE GLOBULINS ATGAM INJ 250MG Tier 5 CARIMUNE NF INJ 6GM Tier 6 PA CARIMUNE NF INJ 12GM Tier 6 PA CUVITRU INJ 2GM/10ML Tier 6 PA CUVITRU INJ 4GM/20ML Tier 6 PA CUVITRU SOL 1GM/5ML Tier 6 PA FLEBOGAMMA INJ 20/400ML Tier 6 PA GAMASTAN S/D INJ Tier 6 PA GAMMAGARD INJ 1GM/10ML Tier 6 PA GAMMAGARD INJ 2.5GM/25 Tier 6 PA GAMMAGARD INJ 5GM/50ML Tier 6 PA GAMMAGARD INJ 10GM/100 Tier 6 PA GAMMAGARD INJ 20GM/200 Tier 6 PA GAMMAGARD SD INJ 5GM HU Tier 6 PA GAMMAGARD SD INJ 10GM HU Tier 6 PA GAMUNEX-C INJ 40/400ML Tier 6 PA HIZENTRA INJ 10/50ML Tier 6 PA OCTAGAM INJ 1GM Tier 6 PA OCTAGAM INJ 2GM/20ML Tier 6 PA PRIVIGEN INJ 5 GRAMS Tier 6 PA THYMOGLOBULN INJ 25MG Tier 5 IMMUNOMODULATORS, INTERFERONS ACTIMMUNE INJ 2MU/0.5 Tier 5 PA ALFERON N INJ 5MU/ML Tier 5 PA INTRON A INJ 10MU Tier 5 PA INTRON A INJ 18MU Tier 5 PA INTRON A INJ 25MU Tier 5 PA INTRON A INJ 50MU Tier 5 PA PEG-INTRON KIT 50MCG RP Tier 5 PA; QL PEG-INTRON KIT 80MCG Tier 5 PA; QL PEG-INTRON KIT 120 RP Tier 5 PA; QL PEG-INTRON KIT 150MCG Tier 5 PA; QL PEGASYS INJ Tier 5 PA; QL PEGASYS INJ 180MCG/M Tier 5 PA; QL PEGASYS INJ PROCLICK Tier 5 PA; QL SYLATRON KIT 200MCG Tier 5 PA SYLATRON KIT 300MCG Tier 5 PA SYLATRON KIT 600MCG Tier 5 PA IMMUNOMODULATORS, MISCELLANEOUS ARCALYST INJ 220MG Tier 5 PA; QL ILARIS INJ 150MG Tier 6 PA; QL OTEZLA TAB 10/20/30 Tier 5 PA; QL PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 95

104 OTEZLA TAB 30MG Tier 5 PA; QL IMMUNOSUPPRESSANTS, ANTIMETABOLITES azathioprine tab 50 mg Tier 2 CELLCEPT SUS 200MG/ML Tier 5 mycophenolate mofetil cap 250 mg Tier 2 mycophenolate mofetil for oral susp 200 Tier 5 mg/ml mycophenolate mofetil tab 500 mg Tier 2 mycophenolate sodium tab dr 180 mg Tier 2 (mycophenolic acid equiv) mycophenolate sodium tab dr 360 mg Tier 2 (mycophenolic acid equiv) MYFORTIC TAB 180MG Tier 6 MYFORTIC TAB 360MG Tier 6 IMMUNOSUPPRESSANTS, CALCINEURIN INHIBITORS cyclosporine cap 25 mg Tier 2 cyclosporine cap 100 mg Tier 2 cyclosporine iv soln 50 mg/ml Tier 5 cyclosporine modified cap 25 mg Tier 2 cyclosporine modified cap 50 mg Tier 2 cyclosporine modified cap 100 mg Tier 2 cyclosporine modified oral soln 100 mg/ml Tier 2 PROGRAF INJ 5MG/ML Tier 5 tacrolimus cap 0.5 mg Tier 2 tacrolimus cap 1 mg Tier 2 tacrolimus cap 5 mg Tier 2 IMMUNOSUPPRESSANTS, MISCELLANEOUS BENLYSTA INJ 120MG Tier 5 PA BENLYSTA INJ 200MG/ML Tier 5 PA BENLYSTA INJ 400MG Tier 5 PA NULOJIX INJ 250MG Tier 5 PA SIMULECT INJ 10MG Tier 5 SIMULECT INJ 20MG Tier 5 IMMUNOSUPPRESSANTS, RAPAMYCIN DERIVATIVE RAPAMUNE SOL 1MG/ML Tier 5 PA sirolimus tab 0.5 mg Tier 2 PA sirolimus tab 1 mg Tier 2 PA sirolimus tab 2 mg Tier 2 PA ZORTRESS TAB 0.5MG Tier 5 PA ZORTRESS TAB 0.25MG Tier 5 PA ZORTRESS TAB 0.75MG Tier 5 PA MONOCLONAL ANTIBODIES SYNAGIS INJ 50MG Tier 5 PA; QL SYNAGIS INJ 100MG/ML Tier 5 PA; QL INSULIN HUMAN INSULIN PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 96

105 TOUJEO SOLO INJ 300IU/ML Tier 3 QL TRESIBA FLEX INJ 100UNIT Tier 3 TRESIBA FLEX INJ 200UNIT Tier 3 LYMPHATIC AGENTS INTERLEUKIN-6 (IL-6) ANTAGONISTS SYLVANT SOL 100MG Tier 5 PA SYLVANT SOL 400MG Tier 5 PA MACROLIDES ERYTHROMYCINS erythromycin ethylsuccinate for susp 200 Tier 4 mg/5ml MEDICAL DEVICES AND SUPPLIES PARENTERAL THERAPY SUPPLIES INSULIN PEN MIS 31GX4MM Tier 3 PEN NEEDLES MIS 29GX10MM Tier 3 MIGRAINE PRODUCTS SEROTONIN AGONISTS eletriptan hydrobromide tab 20 mg (base Tier 2 QL equivalent) eletriptan hydrobromide tab 40 mg (base Tier 2 QL equivalent) frovatriptan succinate tab 2.5 mg (base Tier 4 ST; QL equivalent) MISCELLANEOUS DIAGNOSTIC AGENTS GLUCAGON INJ 1MG Tier 3 QL INFUSION SUPPLIES HEP SOD/NACL INJ 25000UNT Tier 2 heparin sodium (porcine) 40 unit/ml in Tier 2 d5w heparin sodium (porcine) 50 unit/ml in Tier 2 d5w heparin sodium (porcine) 100 unit/ml in Tier 2 d5w OTHER NEXAVIR INJ Tier 4 MISCELLANEOUS THERAPEUTIC CLASSES IRRIGATION SOLUTIONS *irrigation solution, physiological** Tier 4 POTASSIUM REMOVING AGENTS LOKELMA PAK 5GM Tier 5 PA; QL LOKELMA PAK 10GM Tier 5 PA; QL MIXED VACCINE COMBINATIONS MIXED VACCINE COMBINATIONS COMVAX INJ PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 97

106 MOUTH/THROAT/DENTAL AGENTS ANTISEPTICS - MOUTH/THROAT DEBACTEROL SOL 30-50% Tier 4 MUSCULOSKELETAL THERAPY AGENTS CENTRAL MUSCLE RELAXANTS GABLOFEN INJ 50MCG/ML Tier 5 GABLOFEN INJ 20000/20 Tier 5 NASAL AGENTS - SYSTEMIC AND TOPICAL NASAL AGENT COMBINATIONS DYMISTA SPR Tier 3 NASAL STEROIDS OMNARIS SPR Tier 4 ST triamcinolone acetonide nasal aerosol Tier 4 suspension 55 mcg/act NUTRITIONAL / SUPPLEMENTS DIETARY MANAGEMENT PRODUCTS CEREFOLIN TAB Tier 2 folic acid-pyridoxine-cyanocobalamin tab Tier mg L-METHYL- TAB B6-B12 Tier 2 L-METHYL-MC TAB Tier 2 L-METHYL-MC TAB NAC Tier 2 METAFOLBIC TAB Tier 2 METAFOLBIC TAB PLUS Tier 2 ELECTROLYTES, MISCELLANEOUS pot phos monobasic w/sod phos di & Tier 2 monobas tab mg ELECTROLYTES, POTASSIUM KLOR-CON M15 TAB 15MEQ ER Tier 2 pot bicarbonate & chloride effer tab 25 Tier 2 meq potassium bicarbonate effer tab 25 meq Tier 2 potassium chloride cap er 8 meq Tier 2 potassium chloride cap er 10 meq Tier 2 potassium chloride microencapsulated crys Tier 2 er tab 10 meq potassium chloride microencapsulated crys Tier 2 er tab 20 meq potassium chloride oral soln 10% (20 Tier 2 meq/15ml) potassium chloride oral soln 20% (40 Tier 2 meq/15ml) potassium chloride powder packet 20 meq Tier 2 potassium chloride tab er 8 meq (600 mg) Tier 2 potassium chloride tab er 10 meq Tier 2 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 98

107 potassium chloride tab er 20 meq (1500 Tier 2 mg) ELECTROLYTES, POTASSIUM-REMOVING AGENTS sodium polystyrene sulfonate oral susp 15 Tier 2 gm/60ml *sodium polystyrene sulfonate powder** Tier 2 sodium polystyrene sulfonate rectal susp Tier 2 30 gm/120ml VELTASSA POW 8.4GM Tier 5 PA; QL VELTASSA POW 16.8GM Tier 5 PA; QL VELTASSA POW 25.2GM Tier 5 PA; QL VITAMINS AND MINERALS, FOLIC ACID / COMBINATIONS BP VIT 3 CAP Tier 2 folic acid cap 0.8 mg folic acid tab 1 mg Tier 2 folic acid tab 400 mcg folic acid tab 800 mcg folic acid-vitamin b6-vitamin b12 tab 2.2- Tier mg folic acid-vitamin b6-vitamin b12 tab 2.2- Tier mg folic acid-vitamin b6-vitamin b12 tab 2.5- Tier mg VITAMINS AND MINERALS, MISCELLANEOUS *b-complex vitamin tab** *b-complex w/ c & folic acid cap 1 mg*** Tier 2 *b-complex w/ c & folic acid tab 1 mg*** Tier 2 *b-complex w/ c & folic acid tab 5 mg*** Tier 2 *b-complex w/ c & folic acid tab*** *b-complex w/ c cap** *b-complex w/ folic acid tab** *b-complex w/biotin & folic acid tab*** BAL-CARE MIS DHA Tier 2 C-NATE DHA CAP Tier 2 calcium citrate-vitamin d tab 315 mg-200 unit (elemental ca) calcium citrate-vitamin d tab 1500 mg-200 unit CALCIUM PNV CAP Tier 2 CALCIUM-FA WAF PLUS D Tier 2 carbonyl iron susp 15 mg/1.25ml (elemental iron) cholecalciferol cap unit Tier 4 CL PRENATAL TAB MG COMPLETE NAT PAK DHA Tier 2 COMPLETENATE CHW Tier 2 CVS PRENATAL TAB PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 99

108 CVS PRENATAL TAB MG DIALYVITE/ TAB ZINC Tier 2 EQL PRENATAL TAB FORMULA ergocalciferol cap unit Tier 2 EXTRA-VIRT CAP PLUS DHA Tier 4 *fe asp gly-fe polysacch-succ ac-c-threon Tier 2 ac-b12-fa cap*** *fe asparto gly-fe fum-b12-fa-c-succinic ac Tier 2 tab ther pack** *fe fum-iron polysacch complex-fa-b Tier 2 cmplx-c-zn-mn-cu cap*** fe fumarate w/ b12-vit c-fa-ifc cap 110- Tier mg fe fumarate-vit c-vit b12-fa cap 460 (151 Tier 2 fe) mg FER-IN-SOL DRO 15MG/ML FERRALET 90 TAB Tier 2 FERRAPLUS 90 TAB Tier 2 ferrous fumarate-folic acid tab mg Tier 2 FERROUS SUL LIQ 220/5ML FERROUS SULF SYP 300/5ML ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental fe) ferrous sulfate soln 75 mg/ml (15 mg/ml elemental fe) FLUOR-A-DAY CHW 0.5MG F FLUOR-A-DAY CHW 0.25MG F FLUOR-A-DAY CHW 1MG F Tier 2 FLUORABON DRO FOCALGIN 90 MIS DHA Tier 2 FOCALGIN CA MIS Tier 2 FOCALGIN DSS TAB 90-1MG Tier 2 FOLIVANE-F CAP Tier 2 FOLIVANE-OB CAP Tier 2 FOLIVANE-PLS CAP Tier 2 FULL SPECT TAB B/ VIT C FUSION PLUS CAP Tier 4 GALZIN CAP 25MG Tier 4 PA GALZIN CAP 50MG Tier 4 PA HEMATOGEN FA CAP Tier 2 HEMENATAL OB MIS + DHA Tier 2 HEMENATAL OB TAB MG Tier 2 ICAR PEDS SUS GRAPE INATAL ULTRA TAB Tier 2 INFANATE CAP BALANCE Tier 2 *iron combination cap*** Tier 2 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 100

109 iron polysacch complex-vit b12-fa cap 150-Tier mg *iron-docusate-b12-folic acid-c-e-cu-biotin Tier 2 tab mg*** iron-folic acid-vit c-vit b6-vit b12-zinc tab Tier mg iron-vit c-vit b12-folic acid tab Tier mg LEVOMEFOLATE CAP DHA Tier 2 LOZI-FLUR LOZ 1MG F Tier 2 LURIDE CHW 0.5MG F LURIDE CHW 0.25MG F LURIDE DRO 0.5MG/ML MULTIGEN PLS TAB Tier 2 MULTIGEN TAB Tier 2 MULTIGEN TAB FOLIC Tier 2 *multiple vitamin tab** MYKIDZ IRON SUS 15/1.5ML MYNATAL CAP Tier 2 MYNATAL TAB Tier 2 MYNATAL TAB ADVANCE Tier 2 MYNATE 90 TAB PLUS Tier 2 NATELLE ONE CAP Tier 2 NEWGEN TAB 32-1MG Tier 2 NEXA PLUS CAP Tier 4 O-CAL FA TAB Tier 2 OBSTETRIX PAK DHA Tier 2 *pediatric multiple vitamins w/ fl-fe drops mg/ml** *pediatric multiple vitamins w/ fluoride chew tab 0.5 mg*** *pediatric multiple vitamins w/ fluoride chew tab 0.25 mg*** *pediatric multiple vitamins w/ fluoride Tier 2 chew tab 1 mg*** *pediatric multiple vitamins w/ fluoride soln 0.5 mg/ml*** *pediatric multiple vitamins w/ fluoride soln 0.25 mg/ml*** *pediatric multiple vitamins w/ iron drops 10 mg/ml** *pediatric vitamins acd fluoride & fe drops mg/ml*** *pediatric vitamins acd w/ fluoride soln 0.5 mg/ml*** *pediatric vitamins acd w/ fluoride soln 0.25 mg/ml*** PERRY PRENAT CAP PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 101

110 PNV FOLIC AC TAB + IRON Tier 2 PNV OB+DHA PAK Tier 2 PNV PRENATAL TAB PLUS Tier 2 PNV PRENATAL TAB PLUS Tier 2 PNV-DHA CAP DOCUSATE Tier 2 PR NATAL 400 PAK EC Tier 2 PR NATAL 430 PAK Tier 2 PR NATAL 430 PAK EC Tier 2 PRENA1 CHW Tier 2 PRENAISSANCE CAP Tier 2 PRENAISSANCE CAP BALANCE Tier 2 PRENAISSANCE CAP PLUS Tier 2 PRENAISSANCE PAK 90 DHA Tier 2 PRENAISSANCE PAK DHA Tier 2 PRENAISSANCE PAK PROMISE Tier 2 PRENAISSANCE TAB NEXT Tier 2 PRENAT PLUS TAB 27-1MG Tier 2 *prenat w/o a w/fefum-methfol-fa-dha cap Tier mg** PRENATAL ONE TAB DAILY PRENATAL TAB PRENATAL TAB MG PRENATAL TAB 27-1MG Tier 2 PRENATAL TAB MG PRENATAL TAB COMPLETE PRENATAL TAB FORMULA Tier 2 PRENATAL TAB FORMULA PRENATAL TAB LOW IRON Tier 2 PRENATAL TAB PLUS/FE Tier 2 *prenatal vit w/ dss-iron carbonyl-fa tab Tier mg*** *prenatal vit w/ fe fum-methylfolate-fa tab Tier mg*** *prenatal vit w/ fe fumarate-fa tab 27-1 Tier 2 mg*** *prenatal vit w/ fe fumarate-fa tab 28-1 Tier 2 mg*** *prenatal vit w/ fe fumarate-fa tab 29-1 Tier 2 mg*** *prenatal vit w/ iron carbonyl-fa tab 29-1 Tier 2 mg*** *prenatal vit w/ iron carbonyl-fa tab 50- Tier mg*** PRENATAL-U CAP Tier 2 PREPLUS TAB 27-1MG Tier 2 PRETAB TAB 29-1MG Tier 2 RA ONE DAILY MIS PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 102

111 REDICHEW RX CHW Tier 2 RELNATE DHA CAP Tier 2 SE-NATAL 19 TAB Tier 2 SE-TAN DHA CAP Tier 2 sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf) sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf) sodium fluoride chew tab 1 mg f (from 2.2 Tier 2 mg naf) sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf) sodium fluoride soln 0.25 mg/drop f (from 0.55 mg/drop naf) sodium fluoride soln mg/drop f (0.275 mg/drop naf) sodium fluoride tab 0.5 mg f (from 1.1 mg naf) TARON FORTE CAP Tier 2 TARON-C DHA CAP Tier 2 TARON-PREX CAP Tier 2 THERANATAL TAB 27-1 Tier 2 TL-SELECT CAP Tier 2 TRI-TABS DHA MIS Tier 2 TRINATAL GT TAB Tier 2 TRINATAL RX TAB 1 Tier 2 TRIVEEN-DUO PAK DHA Tier 2 ULTIMATECARE CAP ONE Tier 2 ULTIMATECARE CAP ONE NF Tier 2 VEMAVITE- CAP PRX 2 Tier 2 VENA-BAL MIS DHA Tier 2 VINATE CARE CHW 40-1MG Tier 2 VINATE II TAB Tier 2 VINATE M TAB Tier 2 VINATE ULTRA TAB Tier 2 VIRT-ADVANCE TAB 90-1MG Tier 2 VIRT-C DHA CAP Tier 2 VIRT-CARE CAP ONE Tier 2 VIRT-SELECT CAP Tier 2 VIRT-VITE GT TAB 90-1MG Tier 2 VITAFOL-OB TAB 65-1MG Tier 2 VOL-NATE TAB Tier 2 VOL-PLUS TAB Tier 2 VOL-TAB RX TAB Tier 2 VP-CH PLUS CAP Tier 2 VP-HEME OB MIS + DHA Tier 2 VP-HEME ONE CAP Tier 2 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 103

112 VP-HEME-OB TAB MG Tier 2 ZATEAN-CH CAP Tier 2 ZATEAN-PN CAP DHA Tier 2 ZATEAN-PN CAP PLUS Tier 2 ZATEAN-PN TAB Tier 2 OPHTHALMIC AGENTS BETA-BLOCKERS - OPHTHALMIC BETIMOL SOL 0.5% Tier 4 BETIMOL SOL 0.25% Tier 4 OPHTHALMIC ANTI-INFECTIVES moxifloxacin hcl ophth soln 0.5% (base Tier 2 equiv) OPHTHALMIC KINASE INHIBITORS RHOPRESSA SOL 0.02% Tier 4 ST OPHTHALMICS - MISC. olopatadine hcl ophth soln 0.2% (base Tier 2 equivalent) PASSIVE IMMUNIZING AGENTS - COMBINATIONS PASSIVE IMMUNIZING AGENTS - COMBINATIONS HYQVIA INJ Tier 6 PA HYQVIA INJ Tier 6 PA HYQVIA INJ Tier 6 PA HYQVIA INJ Tier 6 PA HYQVIA INJ Tier 6 PA PROGESTIN CONTRACEPTIVES - IMPLANTS PROGESTIN CONTRACEPTIVES - IMPLANTS IMPLANON IMP 68MG PROGESTIN CONTRACEPTIVES - INJECTABLE PROGESTIN CONTRACEPTIVES - INJECTABLE DEPO-SQ PROV INJ 104 QL KYLEENA IUD 19.5MG QL medroxyprogesterone acetate im susp 150 QL mg/ml medroxyprogesterone acetate im susp QL prefilled syr 150 mg/ml SKYLA IUD 13.5MG PROGESTIN CONTRACEPTIVES - IUD PROGESTIN CONTRACEPTIVES - IUD LILETTA IUD 52MG MIRENA IUD SYSTEM PROGESTIN CONTRACEPTIVES - ORAL PROGESTIN CONTRACEPTIVES - ORAL norethindrone tab 0.35 mg PROGESTINS PROGESTINS PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 104

113 progesterone im in oil 50 mg/ml Tier 2 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. AGENTS FOR CHEMICAL DEPENDENCY LUCEMYRA TAB 0.18MG Tier 4 PA; QL MULTIPLE SCLEROSIS AGENTS AVONEX KIT 30MCG Tier 5 PA; QL AVONEX PEN KIT 30MCG Tier 5 PA; QL AVONEX PREFL KIT 30MCG Tier 5 PA; QL PLEGRIDY INJ Tier 5 PA; QL PLEGRIDY INJ PEN Tier 5 PA; QL PLEGRIDY INJ STARTER Tier 5 PA; QL PLEGRIDY PEN INJ STARTER Tier 5 PA; QL PULMONARY FIBROSIS AGENTS PULMONARY FIBROSIS AGENTS ESBRIET CAP 267MG Tier 5 PA; QL PULMONARY FIBROSIS AGENTS - KINASE INHIBITORS OFEV CAP 100MG Tier 5 PA; QL OFEV CAP 150MG Tier 5 PA; QL RESPIRATORY ANAPHYLAXIS TREATMENT AGENTS ADRENACLICK INJ 0.3MG Tier 3 QL ADRENALIN INJ 1MG/ML Tier 2 ADRENALIN INJ 30/30ML Tier 2 AUVI-Q INJ 0.3MG Tier 3 QL epinephrine pf inj 1 mg/ml Tier 2 epinephrine pf soln prefilled syringe 1 Tier 2 mg/10ml (0.1 mg/ml) epinephrine solution auto-injector 0.3 Tier 4 QL mg/0.3ml (1:1000) epinephrine solution auto-injector 0.15 Tier 4 mg/0.15ml (1:1000) EPIPEN 2-PAK INJ 0.3MG Tier 3 QL EPIPEN-JR INJ 2-PAK Tier 3 QL ANTICHOLINERGIC/BETA AGONIST COMBINATIONS, LONG ACTING ANORO ELLIPT AER Tier 3 STIOLTO AER Tier 3 ANTICHOLINERGIC/BETA AGONIST COMBINATIONS, SHORT ACTING COMBIVENT AER Tier 3 ipratropium-albuterol nebu soln (3) Tier 2 mg/3ml ANTICHOLINERGICS ATROVENT HFA AER 17MCG Tier 4 ipratropium bromide inhal soln 0.02% Tier 2 SPIRIVA AER 1.25MCG Tier 3 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 105

114 SPIRIVA CAP HANDIHLR Tier 3 SPIRIVA SPR 2.5MCG Tier 3 ANTIHISTAMINE/DECONGESTANT COMBINATIONS promethazine & phenylephrine syrup Tier 2 5 mg/5ml ANTIHISTAMINES, LOW-SEDATING cetirizine hcl oral soln 1 mg/ml (5 mg/5ml) Tier 2 desloratadine tab 5 mg Tier 4 levocetirizine dihydrochloride soln 2.5 Tier 2 mg/5ml (0.5 mg/ml) levocetirizine dihydrochloride tab 5 mg Tier 2 ANTIHISTAMINES, SEDATING carbinoxamine maleate soln 4 mg/5ml Tier 2 carbinoxamine maleate tab 4 mg Tier 2 clemastine fumarate tab 2.68 mg Tier 2 cyproheptadine hcl syrup 2 mg/5ml Tier 2 cyproheptadine hcl tab 4 mg Tier 2 dexchlorpheniramine maleate syrup 2 Tier 4 mg/5ml diphenhydramine hcl inj 50 mg/ml Tier 2 hydroxyzine hcl im soln 25 mg/ml Tier 2 hydroxyzine hcl im soln 50 mg/ml Tier 2 hydroxyzine hcl syrup 10 mg/5ml Tier 2 hydroxyzine hcl tab 10 mg Tier 2 hydroxyzine hcl tab 25 mg Tier 2 hydroxyzine hcl tab 50 mg Tier 2 hydroxyzine pamoate cap 25 mg Tier 2 hydroxyzine pamoate cap 50 mg Tier 2 hydroxyzine pamoate cap 100 mg Tier 2 ANTITUSSIVE COMBINATIONS, NON-OPIOID phenylephrine-guaifenesin liqd Tier 2 mg/5ml ( mg/ml) promethazine-dm syrup mg/5ml Tier 2 pseudoephed-bromphen-dm syrup Tier 2 mg/5ml ANTITUSSIVE COMBINATIONS, OPIOID FLOWTUSS SOL Tier 4 guaifenesin-codeine soln mg/5ml Tier 2 guaifenesin-codeine soln mg/5ml Tier 2 hydrocod polst-chlorphen polst er susp 10- Tier 2 QL 8 mg/5ml hydrocodone w/ homatropine syrup mg/5ml Tier 2 ST hydrocodone w/ homatropine tab mg Tier 2 ST LORTUSS EX LIQ Tier 2 PHENHIST DH LIQ Tier 2 ST PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 106

115 phenylephrine w/ dm-gg tab Tier 2 mg promethazine w/ codeine syrup mg/5ml Tier 2 ST promethazine-phenylephrine-codeine syrup Tier 2 ST mg/5ml pseudoephedrine w/ cod-gg soln Tier mg/5ml RYDEX LIQ Tier 2 ST ANTITUSSIVES benzonatate cap 100 mg Tier 2 benzonatate cap 200 mg Tier 2 BETA AGONISTS, INHALANTS, LONG ACTING, Hand-held Active Inhalation ARCAPTA CAP 75MCG Tier 4 ST FORADIL CAP AEROLIZE Tier 3 SEREVENT DIS AER 50MCG Tier 3 STRIVERDI AER 2.5MCG Tier 4 BETA AGONISTS, INHALANTS, LONG ACTING, Nebulized Passive Inhalation BROVANA NEB 15MCG Tier 4 PERFOROMIST NEB 20MCG Tier 4 BETA AGONISTS, INHALANTS, SHORT ACTING albuterol sulfate soln nebu 0.5% (5 mg/ml) Tier 2 albuterol sulfate soln nebu 0.63 mg/3ml Tier 2 (base equiv) albuterol sulfate soln nebu 0.083% (2.5 Tier 2 mg/3ml) albuterol sulfate soln nebu 1.25 mg/3ml Tier 2 (base equiv) levalbuterol hcl soln nebu 0.31 mg/3ml Tier 2 (base equiv) levalbuterol hcl soln nebu 0.63 mg/3ml Tier 2 (base equiv) levalbuterol hcl soln nebu 1.25 mg/3ml Tier 2 (base equiv) levalbuterol hcl soln nebu conc 1.25 Tier 2 mg/0.5ml (base equiv) metaproterenol sulfate syrup 10 mg/5ml Tier 2 metaproterenol sulfate tab 10 mg Tier 2 metaproterenol sulfate tab 20 mg Tier 2 PROAIR HFA AER Tier 3 PA; QL PROVENTIL AER HFA Tier 3 PA; QL VENTOLIN HFA AER Tier 3 QL XOPENEX HFA AER Tier 4 BETA AGONISTS, INJECTABLE terbutaline sulfate inj 1 mg/ml Tier 2 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 107

116 BETA AGONISTS, ORAL AGENTS albuterol sulfate syrup 2 mg/5ml Tier 2 albuterol sulfate tab 2 mg Tier 2 albuterol sulfate tab 4 mg Tier 2 albuterol sulfate tab er 12hr 4 mg Tier 2 albuterol sulfate tab er 12hr 8 mg Tier 2 terbutaline sulfate tab 2.5 mg Tier 2 terbutaline sulfate tab 5 mg Tier 2 CYSTIC FIBROSIS BETHKIS NEB 300/4ML Tier 5 QL CAYSTON INH 75MG Tier 5 QL KALYDECO PAK 50MG Tier 5 PA; QL KALYDECO PAK 75MG Tier 5 PA; QL KALYDECO TAB 150MG Tier 5 PA; QL ORKAMBI TAB Tier 5 PA; QL PULMOZYME SOL 1MG/ML Tier 5 PA; QL TOBI NEB 300/5ML Tier 5 QL TOBI PODHALR CAP 28MG Tier 5 QL tobramycin nebu soln 300 mg/5ml Tier 5 QL LEUKOTRIENE MODIFIERS montelukast sodium chew tab 4 mg (base Tier 2 QL equiv) montelukast sodium chew tab 5 mg (base Tier 2 QL equiv) montelukast sodium oral granules packet 4 Tier 2 QL mg (base equiv) montelukast sodium tab 10 mg (base Tier 2 QL equiv) zafirlukast tab 10 mg Tier 2 zafirlukast tab 20 mg Tier 2 ZYFLO TAB 600MG Tier 6 MAST CELL STABILIZERS cromolyn sodium soln nebu 20 mg/2ml Tier 2 MISCELLANEOUS acetylcysteine inhal soln 10% Tier 2 acetylcysteine inhal soln 20% Tier 2 ARALAST NP INJ 400MG Tier 5 PA ARALAST NP INJ 500MG Tier 5 ARALAST NP INJ 800MG Tier 5 PA GLASSIA INJ Tier 5 PA ipratropium bromide nasal soln 0.03% (21 Tier 2 mcg/spray) ipratropium bromide nasal soln 0.06% (42 Tier 2 mcg/spray) NEBUSAL NEB 6% Tier 3 NUCALA INJ 100MG Tier 6 PA; QL PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 108

117 PROLASTIN-C INJ 1000MG Tier 5 PA sodium chloride soln nebu 3% Tier 2 sodium chloride soln nebu 7% Tier 2 sodium chloride soln nebu 10% Tier 2 XOLAIR SOL 150MG Tier 5 PA; QL ZEMAIRA INJ 1000MG Tier 5 PA NASAL ANTIHISTAMINES azelastine hcl nasal spray 0.1% (137 Tier 2 mcg/spray) azelastine hcl nasal spray 0.15% (205.5 Tier 2 mcg/spray) olopatadine hcl nasal soln 0.6% Tier 2 ST NASAL STEROIDS / COMBINATIONS budesonide nasal susp 32 mcg/act Tier 2 flunisolide nasal soln 25 mcg/act (0.025%) Tier 2 fluticasone propionate nasal susp 50 Tier 2 mcg/act VERAMYST SPR 27.5MCG Tier 3 PHOSPHODIESTERASE-4 INHIBITORS DALIRESP TAB 500MCG Tier 4 PA STEROID INHALANTS ARNUITY ELPT INH 100MCG Tier 3 ARNUITY ELPT INH 200MCG Tier 3 ASMANEX 30 AER 110MCG Tier 3 ASMANEX 120 AER 220MCG Tier 3 ASMANEX HFA AER 100 MCG Tier 3 ASMANEX HFA AER 200 MCG Tier 3 budesonide inhalation susp 0.5 mg/2ml Tier 2 budesonide inhalation susp 0.25 mg/2ml Tier 2 budesonide inhalation susp 1 mg/2ml Tier 2 FLOVENT DISK AER 50MCG Tier 3 FLOVENT DISK AER 100MCG Tier 3 FLOVENT DISK AER 250MCG Tier 3 FLOVENT HFA AER 44MCG Tier 3 FLOVENT HFA AER 110MCG Tier 3 FLOVENT HFA AER 220MCG Tier 3 PULMICORT INH 90MCG Tier 3 PULMICORT INH 180MCG Tier 3 QVAR AER 40MCG Tier 3 QVAR AER 80MCG Tier 3 STEROID/BETA AGONIST COMBINATIONS ADVAIR DISKU AER 100/50 Tier 3 ADVAIR DISKU AER 250/50 Tier 3 ADVAIR DISKU AER 500/50 Tier 3 ADVAIR HFA AER 45/21 Tier 3 ADVAIR HFA AER 115/21 Tier 3 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 109

118 ADVAIR HFA AER 230/21 Tier 3 BREO ELLIPTA INH Tier 3 BREO ELLIPTA INH Tier 3 SYMBICORT AER Tier 3 SYMBICORT AER Tier 3 TOPICAL DECONGESTANTS ADRENALIN SOL 1:1000 Tier 2 XANTHINES aminophylline inj 25 mg/ml Tier 2 theophylline soln 80 mg/15ml Tier 2 theophylline tab er 12hr 100 mg Tier 2 theophylline tab er 12hr 200 mg Tier 2 theophylline tab er 12hr 300 mg Tier 2 theophylline tab er 12hr 450 mg Tier 2 theophylline tab er 24hr 400 mg Tier 2 theophylline tab er 24hr 600 mg Tier 2 RESPIRATORY AGENTS - MISC. CYSTIC FIBROSIS AGENTS SYMDEKO TAB Tier 5 PA; QL SELECTIVE CGMP PHOSPHODIESTERASE TYPE 5 INHIBITORS SELECTIVE CGMP PHOSPHODIESTERASE TYPE 5 INHIBITORS CIALIS TAB 2.5MG Tier 4 PA; QL CIALIS TAB 5MG Tier 4 PA; QL CIALIS TAB 10MG Tier 4 PA; QL CIALIS TAB 20MG Tier 4 PA; QL SPERMICIDES SPERMICIDES CONCEPTROL GEL 4% ENCARE SUP 100MG GYNOL II GEL 3% nonoxynol-9 gel 4% SHUR-SEAL GEL 2% TODAY SPONGE MIS VCF VAGINAL AER CONTRACP VCF VAGINAL MIS CONTRACP TOPICAL DERMATOLOGY, ACNE: ORAL CLARAVIS Tier 4 DERMATOLOGY, ACNE: TOPICAL adapalene cream 0.1% Tier 2 PA AVAR LS PAD 10-2% Tier 4 PA AVAR PAD 9.5-5% Tier 4 PA clindamycin phosphate gel 1% Tier 2 clindamycin phosphate lotion 1% Tier 2 clindamycin phosphate soln 1% Tier 2 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 110

119 clindamycin phosphate swab 1% Tier 2 clindamycin phosphate-benzoyl peroxide Tier 4 PA gel 1-5% clindamycin phosphate-tretinoin gel 1.2- Tier 2 PA 0.025% clindamycin phosphate-tretinoin gel 1.2- Tier % CLINDAP-T CRE Tier 4 erythromycin gel 2% Tier 4 erythromycin pads 2% Tier 2 erythromycin soln 2% Tier 2 *sulfacetamide sod-sulfur wash 9-4.5% & Tier 2 sunscreen kit*** sulfacetamide sodium lotion 10% (acne) Tier 2 sulfacetamide sodium w/ sulfur emulsion Tier % sulfacetamide sodium w/ sulfur emulsion Tier % TAZORAC CRE 0.05% Tier 4 PA TAZORAC GEL 0.1% Tier 4 PA TAZORAC GEL 0.05% Tier 4 PA tretinoin cream 0.1% Tier 2 tretinoin cream 0.05% Tier 2 tretinoin cream 0.025% Tier 2 tretinoin gel 0.01% Tier 2 tretinoin gel 0.025% Tier 2 ZIANA GEL Tier 4 PA DERMATOLOGY, ACTINIC KERATOSIS fluorouracil cream 5% Tier 2 fluorouracil soln 2% Tier 2 fluorouracil soln 5% Tier 2 DERMATOLOGY, ANTI-INFECTIVE/ANTI-INFLAMMATORY COMBINATIONS CORTISPORIN CRE 0.5% Tier 4 CORTISPORIN OIN 1% Tier 4 NEO-SYNALAR CRE Tier 4 PA DERMATOLOGY, ANTIBIOTICS ALTABAX OIN 1% Tier 4 gentamicin sulfate cream 0.1% Tier 2 gentamicin sulfate oint 0.1% Tier 2 mupirocin calcium cream 2% Tier 2 ST mupirocin oint 2% Tier 2 silver sulfadiazine cream 1% Tier 2 DERMATOLOGY, ANTIFUNGALS ciclopirox olamine cream 0.77% (base Tier 2 equiv) ciclopirox solution 8% Tier 2 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 111

120 clotrimazole w/ betamethasone cream 1- Tier % clotrimazole w/ betamethasone lotion 1- Tier % econazole nitrate cream 1% Tier 4 ERTACZO CRE 2% Tier 4 PA EXELDERM CRE 1% Tier 4 EXELDERM SOL 1% Tier 4 KERYDIN SOL 5% Tier 5 PA ketoconazole cream 2% Tier 2 ketoconazole shampoo 2% Tier 2 LUZU CRE 1% Tier 4 PA MENTAX CRE 1% Tier 4 PA NAFTIN GEL 1% Tier 4 PA nystatin cream unit/gm Tier 2 nystatin oint unit/gm Tier 2 nystatin topical powder unit/gm Tier 2 nystatin-triamcinolone cream Tier 2 unit/gm-% nystatin-triamcinolone oint Tier 2 unit/gm-% oxiconazole nitrate cream 1% Tier 2 PA; QL DERMATOLOGY, ANTIPSORIATICS, INJECTABLE COSENTYX INJ 150MG/ML Tier 5 PA; QL COSENTYX PEN INJ 300DOSE Tier 5 PA; QL STELARA INJ 45MG/0.5 Tier 5 PA; QL STELARA INJ 90MG/ML Tier 5 PA; QL DERMATOLOGY, ANTIPSORIATICS, ORAL acitretin cap 10 mg Tier 5 ST acitretin cap 17.5 mg Tier 5 ST acitretin cap 25 mg Tier 5 ST methoxsalen rapid cap 10 mg Tier 5 PA 8-MOP CAP 10MG Tier 5 PA OXSORALEN-UL CAP 10MG Tier 5 PA DERMATOLOGY, ANTIPSORIATICS, TOPICAL calcipotriene cream 0.005% Tier 4 QL calcipotriene oint 0.005% Tier 4 QL calcipotriene soln 0.005% (50 mcg/ml) Tier 4 QL calcitriol oint 3 mcg/gm Tier 4 QL DRITHO-CREME CRE HP 1% Tier 2 DERMATOLOGY, ANTISEBORRHEICS selenium sulfide lotion 2.5% Tier 2 selenium sulfide shampoo 2.25% Tier 2 sulfacetamide sodium liquid 10% Tier 2 DERMATOLOGY, CORTICOSTEROIDS: HIGH POTENCY amcinonide cream 0.1% Tier 4 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 112

121 amcinonide lotion 0.1% Tier 4 AMCINONIDE OIN 0.1% Tier 4 betamethasone dipropionate augmented Tier 2 cream 0.05% betamethasone dipropionate augmented Tier 4 lotion 0.05% betamethasone dipropionate cream 0.05% Tier 2 betamethasone dipropionate lotion 0.05% Tier 2 betamethasone dipropionate oint 0.05% Tier 2 desoximetasone cream 0.25% Tier 4 desoximetasone gel 0.05% Tier 4 desoximetasone oint 0.25% Tier 4 diflorasone diacetate cream 0.05% Tier 4 fluocinonide cream 0.05% Tier 2 QL fluocinonide emulsified base cream 0.05% Tier 2 fluocinonide gel 0.05% Tier 2 fluocinonide oint 0.05% Tier 4 fluocinonide soln 0.05% Tier 2 DERMATOLOGY, CORTICOSTEROIDS: LOW POTENCY alclometasone dipropionate cream 0.05% Tier 2 alclometasone dipropionate oint 0.05% Tier 2 desonide cream 0.05% Tier 4 desonide oint 0.05% Tier 4 fluocinolone acetonide cream 0.01% Tier 2 fluocinolone acetonide oil 0.01% (body oil) Tier 2 fluocinolone acetonide oil 0.01% (scalp oil) Tier 2 fluocinolone acetonide soln 0.01% Tier 2 hydrocortisone butyrate oint 0.1% Tier 2 hydrocortisone butyrate soln 0.1% Tier 2 hydrocortisone cream 2.5% Tier 2 hydrocortisone lotion 2.5% Tier 2 hydrocortisone oint 1% Tier 2 hydrocortisone oint 2.5% Tier 2 hydrocortisone valerate cream 0.2% Tier 2 hydrocortisone valerate oint 0.2% Tier 2 mometasone furoate cream 0.1% Tier 2 mometasone furoate oint 0.1% Tier 2 mometasone furoate solution 0.1% (lotion) Tier 2 pramoxine-hc cream 1-2.5% Tier 2 prednicarbate cream 0.1% Tier 2 prednicarbate oint 0.1% Tier 2 TACLONEX SUS Tier 4 PA triamcinolone acetonide aerosol soln Tier 2 mg/gm triamcinolone acetonide cream 0.1% Tier 1 triamcinolone acetonide cream 0.5% Tier 2 triamcinolone acetonide cream 0.025% Tier 2 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 113

122 triamcinolone acetonide lotion 0.1% Tier 2 triamcinolone acetonide lotion 0.025% Tier 2 triamcinolone acetonide oint 0.1% Tier 2 triamcinolone acetonide oint 0.5% Tier 2 triamcinolone acetonide oint 0.025% Tier 2 TRIDERMA CRE FORTE Tier 4 DERMATOLOGY, CORTICOSTEROIDS: MEDIUM POTENCY betamethasone valerate cream 0.1% (base Tier 2 equivalent) betamethasone valerate lotion 0.1% (base Tier 2 equivalent) betamethasone valerate oint 0.1% (base Tier 2 equivalent) desoximetasone cream 0.05% Tier 4 desoximetasone oint 0.05% Tier 4 fluocinolone acetonide cream 0.025% Tier 2 fluocinolone acetonide oint 0.025% Tier 2 fluticasone propionate cream 0.05% Tier 2 fluticasone propionate oint 0.005% Tier 2 DERMATOLOGY, CORTICOSTEROIDS: VERY HIGH POTENCY betamethasone dipropionate augmented Tier 4 gel 0.05% betamethasone dipropionate augmented Tier 4 oint 0.05% clobetasol propionate cream 0.05% Tier 2 QL clobetasol propionate gel 0.05% Tier 2 QL clobetasol propionate oint 0.05% Tier 2 QL clobetasol propionate soln 0.05% Tier 2 QL diflorasone diacetate oint 0.05% Tier 4 halobetasol propionate cream 0.05% Tier 2 QL halobetasol propionate oint 0.05% Tier 4 QL DERMATOLOGY, EMOLLIENTS lactic acid (ammonium lactate) cream 12% Tier 2 lactic acid (ammonium lactate) lotion 10% Tier 2 lactic acid (ammonium lactate) lotion 12% Tier 2 lactic acid (ammonium lactate) lotion 12% Tier 2 lactic acid w/ vitamin e cream 10%-3500 Tier 2 unit/30gm urea cream 40% Tier 2 urea cream 50% Tier 2 urea lotion 40% Tier 2 DERMATOLOGY, IMMUNOMODULATORS ELIDEL CRE 1% Tier 4 PA tacrolimus oint 0.1% Tier 4 PA; QL tacrolimus oint 0.03% Tier 4 PA; QL DERMATOLOGY, LOCAL ANALGESIC PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 114

123 lidocaine patch 5% Tier 4 PA; QL DERMATOLOGY, LOCAL ANESTHETICS lidocaine hcl gel 2% Tier 2 lidocaine hcl soln 4% Tier 2 PA; QL lidocaine oint 5% Tier 4 PA; QL lidocaine-prilocaine cream % Tier 2 PA; QL lidocaine-prilocaine cream kit % Tier 2 QUTENZA KIT 8% 1-PCH Tier 6 PA; QL SYNERA DIS 70-70MG Tier 4 PA DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE acyclovir oint 5% Tier 4 DENAVIR CRE 1% Tier 4 ethyl chloride aerosol spray Tier 2 imiquimod cream 5% Tier 2 PANRETIN GEL 0.1% Tier 5 PA podofilox soln 0.5% Tier 2 SALICYLIC AC LIQ 26% Tier 2 salicylic acid cream 6% Tier 2 salicylic acid film forming liquid 27.5% Tier 2 salicylic acid lotion 6% Tier 2 salicylic acid shampoo 6% Tier 2 SANTYL OIN 250/GM Tier 4 PA SILVER NITRA SOL 10% Tier 2 silver nitrate-potassium nitrate applicator Tier % SULFAMYLON CRE 85MG/GM Tier 4 trypsin w/ castor oil & peruvian balsam Tier 2 spray VEREGEN OIN 15% Tier 4 ZOVIRAX CRE 5% Tier 4 DERMATOLOGY, ROSACEA FINACEA GEL 15% Tier 4 PA metronidazole cream 0.75% Tier 2 metronidazole gel 0.75% Tier 2 metronidazole gel 1% Tier 2 metronidazole lotion 0.75% Tier 2 MIRVASO GEL 0.33% Tier 4 PA DERMATOLOGY, SCABICIDES AND PEDICULICIDES EURAX CRE 10% Tier 4 EURAX LOT 10% Tier 4 lindane lotion 1% Tier 2 lindane shampoo 1% Tier 4 malathion lotion 0.5% Tier 4 permethrin cream 5% Tier 4 SKLICE LOT 0.5% Tier 4 PA spinosad susp 0.9% Tier 2 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 115

124 DERMATOLOGY, WOUND CARE PRODUCTS AVO CREAM EMU Tier 2 BIAFINE EMU Tier 2 PRUTECT EMU Tier 2 REGRANEX GEL 0.01% Tier 4 QL IRRIGATION SOLUTIONS lactated ringer's for irrigation Tier 2 ringer's solution for irrigation Tier 2 water for irrigation, sterile irrigation soln Tier 2 MOUTH/THROAT/DENTAL AGENTS, MISCELLANEOUS chlorhexidine gluconate soln 0.12% Tier 2 GELCLAIR GEL Tier 4 lidocaine hcl viscous soln 2% Tier 2 sodium fluoride cream 1.1% Tier 2 sodium fluoride gel 1.1% (0.5% f) Tier 2 sodium fluoride rinse 0.2% Tier 2 sodium fluoride rinse 0.2% Tier 2 triamcinolone acetonide dental paste 0.1% Tier 2 MOUTH/THROAT/DENTAL AGENTS, PROTECTANTS ORAMAGICRX SUS Tier 4 SALICEPT SUS Tier 4 OPHTHALMIC, ANTI-INFECTIVE/ANTI-INFLAMMATORY COMBINATIONS bacitracin-polymyxin-neomycin-hc ophth Tier 2 oint 1% BLEPHAMIDE OIN S.O.P. Tier 4 BLEPHAMIDE SUS OP Tier 4 neomycin-polymyxin-dexamethasone Tier 2 ophth oint 0.1% neomycin-polymyxin-dexamethasone Tier 2 ophth susp 0.1% neomycin-polymyxin-hc ophth susp Tier 2 PRED-G S.O.P OIN OP Tier 4 PRED-G SUS OP Tier 4 sulfacetamide sodium-prednisolone ophth Tier 2 soln (0.25)% TOBRADEX OIN % Tier 4 TOBRADEX ST SUS Tier 4 tobramycin-dexamethasone ophth susp Tier % ZYLET SUS % Tier 4 OPHTHALMIC, ANTI-INFECTIVES AZASITE SOL 1% Tier 4 bacitracin ophth oint 500 unit/gm Tier 2 bacitracin-polymyxin b ophth oint Tier 2 BESIVANCE SUS 0.6% Tier 4 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 116

125 BETADINE SOL 5% OP Tier 4 CILOXAN OIN 0.3% OP Tier 4 ciprofloxacin hcl ophth soln 0.3% Tier 2 erythromycin ophth oint 5 mg/gm Tier 2 gatifloxacin ophth soln 0.5% Tier 2 gentamicin sulfate ophth oint 0.3% Tier 2 gentamicin sulfate ophth soln 0.3% Tier 2 levofloxacin ophth soln 0.5% Tier 2 MOXEZA SOL 0.5% Tier 4 neomycin-bacitrac zn-polymyx 5(3.5)mg- Tier 2 400unt-10000unt op oin neomycin-polymy-gramicid op sol Tier mg-unt-mg/ml ofloxacin ophth soln 0.3% Tier 2 polymyxin b-trimethoprim ophth soln Tier unit/ml-0.1% sulfacetamide sodium ophth oint 10% Tier 2 sulfacetamide sodium ophth soln 10% Tier 2 tobramycin ophth soln 0.3% Tier 2 TOBREX OIN 0.3% OP Tier 4 VIGAMOX DRO 0.5% Tier 4 OPHTHALMIC, ANTI-INFLAMMATORY: NONSTEROIDAL ACUVAIL SOL 0.45% Tier 4 QL bromfenac sodium ophth soln 0.09% (base Tier 2 equivalent) diclofenac sodium ophth soln 0.1% Tier 2 flurbiprofen sodium ophth soln 0.03% Tier 2 ILEVRO DRO 0.3% OP Tier 4 ketorolac tromethamine ophth soln 0.4% Tier 2 QL ketorolac tromethamine ophth soln 0.5% Tier 2 QL NEVANAC SUS 0.1% Tier 4 PROLENSA SOL 0.07% Tier 4 OPHTHALMIC, ANTI-INFLAMMATORY: STEROIDAL ALREX SUS 0.2% Tier 4 dexamethasone sodium phosphate ophth Tier 2 soln 0.1% DUREZOL EMU 0.05% Tier 3 FLAREX SUS 0.1% OP Tier 4 fluorometholone ophth susp 0.1% Tier 2 FML FORTE SUS 0.25% OP Tier 4 FML OIN 0.1% OP Tier 4 ILUVIEN IMP 0.19MG Tier 6 PA; QL LOTEMAX GEL 0.5% Tier 4 LOTEMAX OIN 0.5% Tier 4 LOTEMAX SUS 0.5% Tier 4 MAXIDEX SUS 0.1% OP Tier 4 PRED MILD SUS 0.12% OP Tier 4 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 117

126 PRED SOD PHO SOL 1% OP Tier 2 prednisolone acetate ophth susp 1% Tier 2 TRIESENCE INJ 40MG/ML Tier 4 VEXOL SUS 1% OP Tier 4 OPHTHALMIC, ANTIALLERGICS ALOCRIL SOL 2% Tier 4 ST ALOMIDE SOL 0.1% OP Tier 4 ST azelastine hcl ophth soln 0.05% Tier 2 BEPREVE DRO 1.5% Tier 4 ST cromolyn sodium ophth soln 4% Tier 2 EMADINE SOL 0.05% OP Tier 4 ST epinastine hcl ophth soln 0.05% Tier 2 LASTFT SOL 0.25% Tier 4 ST olopatadine hcl ophth soln 0.1% (base Tier 2 ST equivalent) PATADAY SOL 0.2% Tier 3 PATANOL SOL 0.1% OP Tier 4 ST PAZEO DRO 0.7% Tier 3 OPHTHALMIC, ANTIFUNGALS NATACYN SUS 5% OP Tier 4 OPHTHALMIC, ANTIVIRAL trifluridine ophth soln 1% Tier 2 ZIRGAN GEL 0.15% Tier 3 OPHTHALMIC, BETA-BLOCKERS: NONSELECTIVE carteolol hcl ophth soln 1% Tier 2 levobunolol hcl ophth soln 0.5% Tier 2 metipranolol ophth soln 0.3% Tier 2 timolol maleate ophth gel forming soln Tier 4 0.5% timolol maleate ophth gel forming soln Tier % timolol maleate ophth soln 0.5% Tier 2 timolol maleate ophth soln 0.25% Tier 2 OPHTHALMIC, BETA-BLOCKERS: SELECTIVE betaxolol hcl ophth soln 0.5% Tier 2 BETOPTIC-S SUS 0.25% OP Tier 3 OPHTHALMIC, CARBONIC ANHYDRASE INHIBITOR/BETA-BLOCKER COMBINATIONS COSOPT PF SOL Tier 4 dorzolamide hcl-timolol maleate ophth soln Tier mg/ml OPHTHALMIC, CARBONIC ANHYDRASE INHIBITOR/SYMPATHOMIMETIC COMBINATIONS SIMBRINZA SUS 1-0.2% Tier 3 OPHTHALMIC, CARBONIC ANHYDRASE INHIBITORS, INJECTABLE PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 118

127 acetazolamide sodium for inj 500 mg Tier 2 KEVEYIS TAB 50MG Tier 6 PA; QL OPHTHALMIC, CARBONIC ANHYDRASE INHIBITORS: ORAL acetazolamide cap er 12hr 500 mg Tier 2 acetazolamide tab 125 mg Tier 2 acetazolamide tab 250 mg Tier 2 methazolamide tab 25 mg Tier 2 methazolamide tab 50 mg Tier 2 OPHTHALMIC, CARBONIC ANHYDRASE INHIBITORS: TOPICAL AZOPT SUS 1% OP Tier 3 dorzolamide hcl ophth soln 2% Tier 2 OPHTHALMIC, DIAGNOSTIC PRODUCTS fluorescein w/ benoxinate ophth soln Tier 2 0.4% fluorescein w/ proparacaine ophth soln Tier % OPHTHALMIC, DRY EYE DISEASE RESTASIS EMU 0.05% Tier 3 QL OPHTHALMIC, MISCELLANEOUS CYSTARAN SOL 0.44% Tier 5 PA; QL EYLEA INJ 2/0.05ML Tier 5 PA JETREA INJ 2.5MG/ML Tier 5 PA; QL LUCENTIS SOL 0.3MG Tier 5 PA LUCENTIS SOL 0.5MG Tier 5 PA MACUGEN INJ Tier 5 PA naphazoline hcl ophth soln 0.1% Tier 2 phenylephrine hcl ophth soln 2.5% Tier 2 phenylephrine hcl ophth soln 10% Tier 2 proparacaine hcl ophth soln 0.5% Tier 2 tetracaine hcl ophth soln 0.5% Tier 2 OPHTHALMIC, MYDRIATICS ATROPINE SUL OIN 1% OP Tier 2 atropine sulfate ophth soln 1% Tier 2 cyclopentolate hcl ophth soln 1% Tier 2 cyclopentolate hcl ophth soln 2% Tier 2 homatropine hbr ophth soln 5% Tier 2 tropicamide ophth soln 0.5% Tier 2 tropicamide ophth soln 1% Tier 2 OPHTHALMIC, PARASYMPATHOMIMETICS MIOSTAT INJ 0.01% OP Tier 2 pilocarpine hcl ophth soln 1% Tier 2 pilocarpine hcl ophth soln 2% Tier 2 pilocarpine hcl ophth soln 4% Tier 2 OPHTHALMIC, PROSTAGLANDINS bimatoprost ophth soln 0.03% Tier 3 PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 119

128 latanoprost ophth soln 0.005% Tier 2 LUMIGAN SOL 0.01% Tier 3 RESCULA SOL 0.15% Tier 4 TRAVATAN Z DRO 0.004% Tier 4 travoprost ophth soln 0.004% Tier 3 ZIOPTAN DRO % Tier 4 OPHTHALMIC, SYMPATHOMIMETIC/BETA-BLOCKER COMBINATIONS COMBIGAN SOL 0.2/0.5% Tier 3 OPHTHALMIC, SYMPATHOMIMETICS ALPHAGAN P SOL 0.1% Tier 3 apraclonidine hcl ophth soln 0.5% (base Tier 2 equivalent) brimonidine tartrate ophth soln 0.2% Tier 2 brimonidine tartrate ophth soln 0.15% Tier 3 PHOSPHOLINE SOL 0.125%OP Tier 4 OTIC ANALGESIC COMBINATIONS pramoxine-hc-chloroxylenol otic soln 10- Tier mg/ml OTIC, ANTI-INFECTIVE/ANTI-INFLAMMATORY COMBINATIONS CIPRO HC SUS OTIC Tier 3 CIPRODEX SUS % Tier 3 COLY-MYCIN S SUS OTIC Tier 4 hydrocortisone w/ acetic acid otic soln 1- Tier 2 2% neomycin-polymyxin-hc otic soln 1% Tier 2 neomycin-polymyxin-hc otic susp 3.5 Tier 2 mg/ml unit/ml-1% OTIC, ANTI-INFECTIVES acetic acid 2% in aluminum acetate otic Tier 2 soln acetic acid otic soln 2% Tier 2 ciprofloxacin hcl otic soln 0.2% (base Tier 2 equivalent) ofloxacin otic soln 0.3% Tier 2 OTIC, MISCELLANEOUS fluocinolone acetonide (otic) oil 0.01% Tier 2 TOXOID COMBINATIONS TOXOID COMBINATIONS ADACEL INJ BOOSTRIX INJ DAPTACEL INJ DIP/TET PED INJ 25-5LFU INFANRIX INJ PEDIARIX INJ 0.5ML PENTACEL INJ QUADRACEL INJ PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 120

129 TENIVAC INJ 5-2LF TET/DIP TOX INJ 2-2 LF TOXOIDS TOXOIDS TETANUS TOX INJ 5LF ADS ULCER DRUGS H-2 ANTAGONISTS famotidine tab 20 mg Tier 2 URICOSURICS URICOSURICS probenecid tab 500 mg Tier 2 URINARY ANTISPASMODICS URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC) darifenacin hydrobromide tab er 24hr 7.5 Tier 2 mg (base equiv) darifenacin hydrobromide tab er 24hr 15 Tier 2 mg (base equiv) VAGINAL PRODUCTS MISCELLANEOUS VAGINAL PRODUCTS acetic acid-oxyquinoline vaginal gel 0.9- Tier % VAGINAL ESTROGENS estradiol vaginal cream 0.1 mg/gm Tier 2 estradiol vaginal tab 10 mcg Tier 2 VIRAL VACCINES VIRAL VACCINE COMBINATIONS M-M-R II INJ PROQUAD INJ TWINRIX INJ VIRAL VACCINES AFLURIA INJ PF CERVARIX INJ ENGERIX-B INJ 10/0.5ML ENGERIX-B INJ 20MCG/ML EZ FLU SHOT INJ EZ FLU SHOT INJ PF EZ FLU SHOT KIT EZ FLU SHOT KIT FLUAD INJ FLUBLOK SOL FLUCELVAX INJ FLUCLVX QUAD INJ FLULAVAL INJ FLULAVAL QUA INJ PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 121

130 FLUMIST QUAD SUS FLUVIRIN INJ FLUVIRIN INJ FLUVIRIN PF INJ FLUZONE HD INJ PF FLUZONE INJ INTRADRM FLUZONE QUAD INJ FLUZONE QUAD INJ GARDASIL 9 INJ GARDASIL INJ HAVRIX INJ 720UNIT HAVRIX INJ 1440UNIT IPOL INJ INACTIVE RECOMBIVA HB INJ 5MCG/0.5 RECOMBIVA HB INJ 10MCG/ML RECOMBIVA-HB INJ 40MCG/ML ROTARIX SUS ROTATEQ SOL VAQTA INJ 25/0.5ML VAQTA INJ 50UNT/ML VARIVAX INJ ZOSTAVAX INJ PA - Prior Authorization ST - Step Therapy QL - Quantity Limits 122

131 Index * *b-complex vitamin tab** *b-complex w/ c & folic acid cap 1 mg*** *b-complex w/ c & folic acid tab 1 mg*** *b-complex w/ c & folic acid tab 5 mg*** *b-complex w/ c & folic acid tab*** *b-complex w/ c cap** *b-complex w/ folic acid tab** *b-complex w/biotin & folic acid tab*** *fe asp gly-fe polysacch-succ ac-c-threon ac-b12-fa cap*** *fe asparto gly-fe fum-b12-fa-c-succinic ac tab ther pack** *fe fum-iron polysacch complex-fa-b cmplx-c-zn-mn-cu cap*** *iron combination cap*** *iron-docusate-b12-folic acid-c-e-cubiotin tab mg*** *irrigation solution, physiological** *mesalamine rectal enema 4 gm & cleanser wipe kit** *methenamine-hyoscamine-meth bluesod phos tab 81.6 mg*** *methenamine-hyos-meth blue-sod phos-phen sal tab 81.6 mg*** *multiple vitamin tab** *nystatin oral powder* *pediatric multiple vitamins w/ fl-fe drops mg/ml** *pediatric multiple vitamins w/ fluoride chew tab 0.25 mg*** *pediatric multiple vitamins w/ fluoride chew tab 0.5 mg*** *pediatric multiple vitamins w/ fluoride chew tab 1 mg*** *pediatric multiple vitamins w/ fluoride soln 0.25 mg/ml*** *pediatric multiple vitamins w/ fluoride soln 0.5 mg/ml*** *pediatric multiple vitamins w/ iron drops 10 mg/ml** *pediatric vitamins acd fluoride & fe drops mg/ml*** *pediatric vitamins acd w/ fluoride soln 0.25 mg/ml*** *pediatric vitamins acd w/ fluoride soln 0.5 mg/ml*** *prenat w/o a w/fefum-methfol-fa-dha cap mg** *prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg*** *prenatal vit w/ fe fumarate-fa tab 27-1 mg*** *prenatal vit w/ fe fumarate-fa tab 28-1 mg*** *prenatal vit w/ fe fumarate-fa tab 29-1 mg*** *prenatal vit w/ fe fum-methylfolate-fa tab mg*** *prenatal vit w/ iron carbonyl-fa tab 29-1 mg*** *prenatal vit w/ iron carbonyl-fa tab mg*** *sodium polystyrene sulfonate powder** *sulfacetamide sod-sulfur wash 9-4.5% & sunscreen kit*** MOP CAP 10MG A abacavir sulfate soln 20 mg/ml (base equiv) abacavir sulfate tab 300 mg (base equiv) abacavir sulfate-lamivudine tab mg abacavir sulfate-lamivudine-zidovudine tab mg ABELCET INJ 5MG/ML ABILIFY MAIN INJ 300MG ABILIFY MAIN INJ 400MG ABRAXANE INJ 100MG ABSTRAL SUB 100MCG... 4 ABSTRAL SUB 200MCG... 4 ABSTRAL SUB 300MCG... 4 ABSTRAL SUB 400MCG... 4 ABSTRAL SUB 600MCG... 4 ABSTRAL SUB 800MCG

132 acamprosate calcium tab delayed release 333 mg acarbose tab 100 mg acarbose tab 25 mg acarbose tab 50 mg acebutolol hcl cap 200 mg acebutolol hcl cap 400 mg acetaminophen w/ codeine soln mg/5ml... 4 acetaminophen w/ codeine tab mg... 4 acetaminophen w/ codeine tab mg... 4 acetaminophen w/ codeine tab mg... 4 acetazolamide cap er 12hr 500 mg acetazolamide sodium for inj 500 mg 118 acetazolamide tab 125 mg acetazolamide tab 250 mg acetic acid 2% in aluminum acetate otic soln acetic acid irrigation soln 0.25% acetic acid otic soln 2% acetic acid-oxyquinoline vaginal gel % acetylcysteine inhal soln 10% acetylcysteine inhal soln 20% acitretin cap 10 mg acitretin cap 17.5 mg acitretin cap 25 mg ACTHIB INJ ACTIMMUNE INJ 2MU/ ACUVAIL SOL 0.45% acyclovir cap 200 mg acyclovir oint 5% acyclovir sodium for inj 1000 mg acyclovir sodium for inj 500 mg acyclovir sodium iv soln 50 mg/ml acyclovir susp 200 mg/5ml acyclovir tab 400 mg acyclovir tab 800 mg ACZONE GEL 7.5% ADACEL INJ ADAGEN INJ 250/ML adapalene cream 0.1% ADDERALL XR CAP 10MG ADDERALL XR CAP 15MG ADDERALL XR CAP 20MG ADDERALL XR CAP 25MG ADDERALL XR CAP 30MG ADDERALL XR CAP 5MG ADDYI TAB 100MG adefovir dipivoxil tab 10 mg ADEMPAS TAB 0.5MG ADEMPAS TAB 1.5MG ADEMPAS TAB 1MG ADEMPAS TAB 2.5MG ADEMPAS TAB 2MG ADRENACLICK INJ 0.3MG ADRENALIN INJ 1MG/ML ADRENALIN INJ 30/30ML ADRENALIN SOL 1: ADVAIR DISKU AER 100/ ADVAIR DISKU AER 250/ ADVAIR DISKU AER 500/ ADVAIR HFA AER 115/ ADVAIR HFA AER 230/ ADVAIR HFA AER 45/ ADVOCATE MIS LANCETS AFINITOR DIS TAB 2MG AFINITOR DIS TAB 3MG AFINITOR DIS TAB 5MG AFINITOR TAB 10MG AFINITOR TAB 2.5MG AFINITOR TAB 5MG AFINITOR TAB 7.5MG AFLURIA INJ PF AKYNZEO CAP ALBENZA TAB 200MG albuterol sulfate soln nebu 0.083% (2.5 mg/3ml) albuterol sulfate soln nebu 0.5% (5 mg/ml) albuterol sulfate soln nebu 0.63 mg/3ml (base equiv) albuterol sulfate soln nebu 1.25 mg/3ml (base equiv) albuterol sulfate syrup 2 mg/5ml albuterol sulfate tab 2 mg albuterol sulfate tab 4 mg albuterol sulfate tab er 12hr 4 mg albuterol sulfate tab er 12hr 8 mg alclometasone dipropionate cream 0.05% alclometasone dipropionate oint 0.05%

133 ALDURAZYME INJ 2.9MG/5M ALECENSA CAP 150MG alendronate sodium oral soln 70 mg/75ml alendronate sodium tab 10 mg alendronate sodium tab 35 mg alendronate sodium tab 40 mg alendronate sodium tab 5 mg alendronate sodium tab 70 mg ALFERON N INJ 5MU/ML alfuzosin hcl tab er 24hr 10 mg ALIMTA INJ 100MG ALIMTA INJ 500MG ALINIA SUS 100/5ML ALINIA TAB 500MG ALKERAN TAB 2MG allopurinol tab 100 mg... 1 allopurinol tab 300 mg... 1 almotriptan malate tab 12.5 mg almotriptan malate tab 6.25 mg ALOCRIL SOL 2% alogliptin benzoate tab 25 mg (base equiv) alogliptin benzoate tab 6.25 mg (base equiv) ALOMIDE SOL 0.1% OP alosetron hcl tab 0.5 mg (base equiv). 87 alosetron hcl tab 1 mg (base equiv) ALOXI INJ 0.25MG/ ALPHAGAN P SOL 0.1% ALPRAZOLAM CON 1 MG/ML alprazolam orally disintegrating tab 0.25 mg alprazolam orally disintegrating tab 0.5 mg alprazolam orally disintegrating tab 1 mg alprazolam orally disintegrating tab 2 mg alprazolam tab 0.25 mg alprazolam tab 0.5 mg alprazolam tab 1 mg alprazolam tab 2 mg alprazolam tab er 24hr 0.5 mg alprazolam tab er 24hr 1 mg alprazolam tab er 24hr 2 mg alprazolam tab er 24hr 3 mg ALREX SUS 0.2% ALTABAX OIN 1% ALUNBRIG PAK ALUNBRIG TAB 180MG ALUNBRIG TAB 30MG ALUNBRIG TAB 90MG amantadine hcl cap 100 mg amantadine hcl syrup 50 mg/5ml amantadine hcl tab 100 mg AMBISOME INJ 50MG amcinonide cream 0.1% amcinonide lotion 0.1% AMCINONIDE OIN 0.1% amifostine for inj 500 mg amikacin sulfate inj 1 gm/4ml (250 mg/ml)... 9 amikacin sulfate inj 500 mg/2ml (250 mg/ml)... 9 amiloride & hydrochlorothiazide tab 5-50 mg amiloride hcl tab 5 mg aminocaproic acid inj 250 mg/ml aminophylline inj 25 mg/ml amiodarone hcl tab 100 mg amiodarone hcl tab 200 mg amiodarone hcl tab 400 mg AMITIZA CAP 24MCG AMITIZA CAP 8MCG amitriptyline hcl tab 10 mg amitriptyline hcl tab 100 mg amitriptyline hcl tab 150 mg amitriptyline hcl tab 25 mg amitriptyline hcl tab 50 mg amitriptyline hcl tab 75 mg amlodipine besylate tab 10 mg (base equivalent) amlodipine besylate tab 2.5 mg (base equivalent) amlodipine besylate tab 5 mg (base equivalent) amlodipine besylate-benazepril hcl cap mg amlodipine besylate-benazepril hcl cap mg amlodipine besylate-benazepril hcl cap mg amlodipine besylate-benazepril hcl cap 5-10 mg amlodipine besylate-benazepril hcl cap 5-125

134 20 mg amlodipine besylate-benazepril hcl cap 5-40 mg amoxapine tab 100 mg amoxapine tab 150 mg amoxapine tab 25 mg amoxapine tab 50 mg amoxicillin & k clavulanate chew tab mg amoxicillin & k clavulanate chew tab mg amoxicillin & k clavulanate for susp mg/5ml amoxicillin & k clavulanate for susp mg/5ml amoxicillin & k clavulanate for susp mg/5ml amoxicillin & k clavulanate for susp mg/5ml amoxicillin & k clavulanate tab mg amoxicillin & k clavulanate tab mg amoxicillin & k clavulanate tab mg amoxicillin & k clavulanate tab er 12hr mg amoxicillin (trihydrate) cap 250 mg amoxicillin (trihydrate) cap 500 mg amoxicillin (trihydrate) chew tab 125 mg amoxicillin (trihydrate) chew tab 250 mg amoxicillin (trihydrate) for susp 125 mg/5ml amoxicillin (trihydrate) for susp 200 mg/5ml amoxicillin (trihydrate) for susp 250 mg/5ml amoxicillin (trihydrate) for susp 400 mg/5ml amoxicillin (trihydrate) tab 500 mg amoxicillin (trihydrate) tab 875 mg amoxicillin cap-clarithro tab-lansopraz cap dr therapy pack amphetamine-dextroamphetamine cap er 24hr 10 mg amphetamine-dextroamphetamine cap er 24hr 15 mg amphetamine-dextroamphetamine cap er 24hr 20 mg amphetamine-dextroamphetamine cap er 24hr 25 mg amphetamine-dextroamphetamine cap er 24hr 30 mg amphetamine-dextroamphetamine cap er 24hr 5 mg amphetamine-dextroamphetamine tab 10 mg amphetamine-dextroamphetamine tab 12.5 mg amphetamine-dextroamphetamine tab 15 mg amphetamine-dextroamphetamine tab 20 mg amphetamine-dextroamphetamine tab 30 mg amphetamine-dextroamphetamine tab 5 mg amphetamine-dextroamphetamine tab 7.5 mg amphotericin b for inj 50 mg ampicillin & sulbactam sodium for inj 1.5 (1-0.5) gm ampicillin & sulbactam sodium for inj 15 (10-5) gm ampicillin & sulbactam sodium for inj 3 (2-1) gm ampicillin & sulbactam sodium for iv soln 15 (10-5) gm ampicillin cap 250 mg ampicillin cap 500 mg ampicillin for susp 125 mg/5ml ampicillin for susp 250 mg/5ml ampicillin sodium for inj 1 gm ampicillin sodium for inj 10 gm ampicillin sodium for inj 125 mg ampicillin sodium for inj 2 gm ampicillin sodium for inj 250 mg ampicillin sodium for inj 500 mg ampicillin sodium for iv soln 1 gm ampicillin sodium for iv soln 10 gm ampicillin sodium for iv soln 2 gm AMPYRA TAB 10MG ANADROL-50 TAB 50MG... 1 anagrelide hcl cap 0.5 mg

135 anagrelide hcl cap 1 mg anastrozole tab 1 mg ANDRODERM DIS 2MG/24HR ANDRODERM DIS 4MG/24HR ANDROGEL GEL 1%(25MG) ANDROGEL GEL 1.62%... 9 ANDROGEL GEL PUMP 1% ANDROXY TAB 10MG ANORO ELLIPT AER ANZEMET INJ 20MG/ML ANZEMET TAB 100MG ANZEMET TAB 50MG APOKYN INJ 10MG/ML apraclonidine hcl ophth soln 0.5% (base equivalent) aprepitant capsule 125 mg aprepitant capsule 40 mg aprepitant capsule 80 mg aprepitant capsule therapy pack 80 & 125 mg APRISO CAP 0.375GM APTIOM TAB 200MG APTIOM TAB 400MG APTIOM TAB 600MG APTIOM TAB 800MG APTIVUS CAP 250MG APTIVUS SOL ARALAST NP INJ 400MG ARALAST NP INJ 500MG ARALAST NP INJ 800MG ARANESP INJ 100MCG ARANESP INJ 10MCG ARANESP INJ 150MCG ARANESP INJ 200MCG ARANESP INJ 25MCG ARANESP INJ 300MCG ARANESP INJ 40MCG ARANESP INJ 500MCG ARANESP INJ 60MCG ARCALYST INJ 220MG ARCAPTA CAP 75MCG ARGATROBAN INJ 50MG/50M aripiprazole oral solution 1 mg/ml aripiprazole orally disintegrating tab 10 mg aripiprazole orally disintegrating tab 15 mg aripiprazole tab 10 mg aripiprazole tab 15 mg aripiprazole tab 2 mg aripiprazole tab 20 mg aripiprazole tab 30 mg aripiprazole tab 5 mg armodafinil tab 150 mg... 1 armodafinil tab 200 mg... 1 armodafinil tab 250 mg... 1 armodafinil tab 50 mg... 1 ARMOUR THYRO TAB 120MG ARMOUR THYRO TAB 15MG ARMOUR THYRO TAB 180MG ARMOUR THYRO TAB 240MG ARMOUR THYRO TAB 300MG ARMOUR THYRO TAB 30MG ARMOUR THYRO TAB 60MG ARMOUR THYRO TAB 90MG ARNUITY ELPT INH 100MCG ARNUITY ELPT INH 200MCG ARRANON INJ 5MG/ML ARZERRA CON 100/5ML ASACOL HD TAB 800MG ASMANEX 120 AER 220MCG ASMANEX 30 AER 110MCG ASMANEX HFA AER 100 MCG ASMANEX HFA AER 200 MCG aspirin chew tab 81 mg... 2 aspirin tab 325 mg... 2 ASPIRIN TAB 81MG... 2 aspirin tab delayed release 325 mg... 2 aspirin tab delayed release 81 mg... 2 aspirin-caffeine-dihydrocodeine cap mg... 4 aspirin-dipyridamole cap er 12hr mg atazanavir sulfate cap 150 mg (base equiv) atazanavir sulfate cap 200 mg (base equiv) atazanavir sulfate cap 300 mg (base equiv) atenolol & chlorthalidone tab mg atenolol & chlorthalidone tab mg atenolol tab 100 mg atenolol tab 25 mg atenolol tab 50 mg

136 ATGAM INJ 250MG atomoxetine hcl cap 10 mg (base equiv) atomoxetine hcl cap 100 mg (base equiv) atomoxetine hcl cap 18 mg (base equiv) atomoxetine hcl cap 25 mg (base equiv) atomoxetine hcl cap 40 mg (base equiv) atomoxetine hcl cap 60 mg (base equiv) atomoxetine hcl cap 80 mg (base equiv) atorvastatin calcium tab 10 mg (base equivalent) atorvastatin calcium tab 20 mg (base equivalent) atorvastatin calcium tab 40 mg (base equivalent) atorvastatin calcium tab 80 mg (base equivalent) atovaquone susp 750 mg/5ml atovaquone-proguanil hcl tab mg atovaquone-proguanil hcl tab mg ATRIPLA TAB ATROPINE SUL OIN 1% OP atropine sulfate inj 0.4 mg/ml atropine sulfate inj 1 mg/ml atropine sulfate ophth soln 1% atropine sulfate soln prefill syr 0.25 mg/5ml (0.05 mg/ml) atropine sulfate soln prefill syr 1 mg/10ml (0.1 mg/ml) ATROVENT HFA AER 17MCG AUBAGIO TAB 14MG AUBAGIO TAB 7MG AUGMENTIN SUS 125/5ML AURYXIA TAB 210MG AUTOSHIELD MIS 29X3/ AUTOSHIELD MIS 29X5/ AUTOSHIELD MIS 30GX3/ AUVI-Q INJ 0.3MG AVANDAMET TAB MG AVANDAMET TAB 2-500MG AVANDAMET TAB 4-500MG AVANDIA TAB 2MG AVANDIA TAB 4MG AVANDIA TAB 8MG AVAR LS PAD 10-2% AVAR PAD 9.5-5% AVASTIN INJ AVEED INJ 750/3ML AVELOX TAB 400MG AVO CREAM EMU AVODART CAP 0.5MG AVONEX KIT 30MCG AVONEX PEN KIT 30MCG AVONEX PREFL KIT 30MCG AXIRON SOL 30MG/ACT AZACTAM/DEX INJ 1GM AZACTAM/DEX INJ 2GM AZASITE SOL 1% azathioprine tab 50 mg azelastine hcl nasal spray 0.1% (137 mcg/spray) azelastine hcl nasal spray 0.15% (205.5 mcg/spray) azelastine hcl ophth soln 0.05% azithromycin for susp 100 mg/5ml azithromycin for susp 200 mg/5ml azithromycin iv for soln 500 mg azithromycin powd pack for susp 1 gm 12 azithromycin tab 250 mg azithromycin tab 500 mg azithromycin tab 600 mg AZOPT SUS 1% OP aztreonam for inj 1 gm aztreonam for inj 2 gm B bacitracin intramuscular for soln unit bacitracin ophth oint 500 unit/gm bacitracin-polymyxin b ophth oint bacitracin-polymyxin-neomycin-hc ophth oint 1% baclofen tab 10 mg baclofen tab 20 mg BACTOCILL INJ DEX 1GM BACTOCILL INJ DEX 2GM BAL-CARE MIS DHA balsalazide disodium cap 750 mg BANZEL SUS 40MG/ML

137 BANZEL TAB 200MG BANZEL TAB 400MG BARACLUDE SOL.05MG/ML BD NEEDLES MIS 18GX BELLA/OPIUM SUP BELLA/OPIUM SUP BELVIQ TAB 10MG... 1 benazepril & hydrochlorothiazide tab mg benazepril & hydrochlorothiazide tab mg benazepril & hydrochlorothiazide tab mg benazepril & hydrochlorothiazide tab mg benazepril hcl tab 10 mg benazepril hcl tab 20 mg benazepril hcl tab 40 mg benazepril hcl tab 5 mg BENLYSTA INJ 120MG BENLYSTA INJ 200MG/ML BENLYSTA INJ 400MG benzonatate cap 100 mg benzonatate cap 200 mg benztropine mesylate inj 1 mg/ml benztropine mesylate tab 0.5 mg benztropine mesylate tab 1 mg benztropine mesylate tab 2 mg BEPREVE DRO 1.5% BERINERT INJ 500UNIT BESIVANCE SUS 0.6% BETADINE SOL 5% OP betamethasone dipropionate augmented cream 0.05% betamethasone dipropionate augmented gel 0.05% betamethasone dipropionate augmented lotion 0.05% betamethasone dipropionate augmented oint 0.05% betamethasone dipropionate cream 0.05% betamethasone dipropionate lotion 0.05% betamethasone dipropionate oint 0.05% betamethasone valerate cream 0.1% (base equivalent) betamethasone valerate lotion 0.1% (base equivalent) betamethasone valerate oint 0.1% (base equivalent) BETASERON INJ 0.3MG betaxolol hcl ophth soln 0.5% betaxolol hcl tab 10 mg betaxolol hcl tab 20 mg bethanechol chloride tab 10 mg bethanechol chloride tab 25 mg bethanechol chloride tab 5 mg bethanechol chloride tab 50 mg BETHKIS NEB 300/4ML BETIMOL SOL 0.25% BETIMOL SOL 0.5% BETOPTIC-S SUS 0.25% OP bexarotene cap 75 mg BEXSERO INJ BIAFINE EMU bicalutamide tab 50 mg BICILLIN C-R INJ BICILLIN C-R INJ 900/ BICILLIN L-A INJ BICILLIN L-A INJ BICILLIN L-A INJ BICNU INJ 100MG BIKTARVY TAB BILTRICIDE TAB 600MG bimatoprost ophth soln 0.03% bisacodyl tab & peg 3350-kcl-sod bicarbnacl for soln kit bisacodyl tab delayed release 5 mg bisoprolol & hydrochlorothiazide tab mg bisoprolol & hydrochlorothiazide tab mg bisoprolol & hydrochlorothiazide tab mg bisoprolol fumarate tab 10 mg bisoprolol fumarate tab 5 mg bivalirudin trifluoroacetate for iv soln 250 mg (base equiv) bleomycin sulfate for inj 15 unit bleomycin sulfate for inj 30 unit BLEPHAMIDE OIN S.O.P BLEPHAMIDE SUS OP BONIVA INJ 3MG/3ML BOOSTRIX INJ

138 BOSULIF TAB 100MG BOSULIF TAB 500MG BOTOX INJ 100UNIT BOTOX INJ 200UNIT BP VIT 3 CAP BREO ELLIPTA INH BREO ELLIPTA INH BRILINTA TAB 60MG BRILINTA TAB 90MG brimonidine tartrate ophth soln 0.15% brimonidine tartrate ophth soln 0.2% 120 bromfenac sodium ophth soln 0.09% (base equivalent) bromocriptine mesylate cap 5 mg (base equivalent) bromocriptine mesylate tab 2.5 mg (base equivalent) BROVANA NEB 15MCG budesonide delayed release particles cap 3 mg budesonide inhalation susp 0.25 mg/2ml budesonide inhalation susp 0.5 mg/2ml budesonide inhalation susp 1 mg/2ml 109 budesonide nasal susp 32 mcg/act bumetanide inj 0.25 mg/ml bumetanide tab 0.5 mg bumetanide tab 1 mg bumetanide tab 2 mg BUNAVAIL MIS BUNAVAIL MIS BUNAVAIL MIS 6.3-1MG BUPHENYL POW BUPRENEX INJ 0.3MG/ML... 4 buprenorphine hcl inj 0.3 mg/ml (base equiv)... 4 buprenorphine hcl sl tab 2 mg (base equiv) buprenorphine hcl sl tab 8 mg (base equiv) buprenorphine hcl-naloxone hcl sl tab mg (base equiv) buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv) bupropion hcl (smoking deterrent) tab er 12hr 150 mg bupropion hcl tab 100 mg bupropion hcl tab 75 mg bupropion hcl tab er 12hr 100 mg bupropion hcl tab er 12hr 150 mg bupropion hcl tab er 12hr 200 mg bupropion hcl tab er 24hr 150 mg bupropion hcl tab er 24hr 300 mg buspirone hcl tab 10 mg buspirone hcl tab 15 mg buspirone hcl tab 30 mg buspirone hcl tab 5 mg buspirone hcl tab 7.5 mg butalbital-acetaminophen tab mg... 2 butalbital-acetaminophen-caff w/ cod cap mg... 4 butalbital-acetaminophen-caff w/ cod cap mg... 4 butalbital-acetaminophen-caffeine cap mg... 2 butalbital-acetaminophen-caffeine tab mg... 2 butalbital-aspirin-caff w/ codeine cap mg... 4 butalbital-aspirin-caffeine cap mg... 2 butorphanol tartrate inj 1 mg/ml... 4 butorphanol tartrate inj 2 mg/ml... 4 butorphanol tartrate nasal soln 10 mg/ml... 4 BUTRANS DIS 10MCG/HR... 4 BUTRANS DIS 15MCG/HR... 4 BUTRANS DIS 20MCG/HR... 4 BUTRANS DIS 5MCG/HR... 4 BUTRANS DIS 7.5/HR... 4 BYDUREON INJ 2MG BYDUREON PEN INJ 2MG BYETTA INJ 10MCG BYETTA INJ 5MCG BYSTOLIC TAB 10MG BYSTOLIC TAB 2.5MG BYSTOLIC TAB 20MG BYSTOLIC TAB 5MG C cabergoline tab 0.5 mg CABOMETYX TAB 20MG CABOMETYX TAB 40MG CABOMETYX TAB 60MG

139 calcipotriene cream 0.005% calcipotriene oint 0.005% calcipotriene soln 0.005% (50 mcg/ml) calcitonin (salmon) nasal soln 200 unit/act calcitriol cap 0.25 mcg calcitriol cap 0.5 mcg calcitriol inj 1 mcg/ml calcitriol oint 3 mcg/gm calcitriol oral soln 1 mcg/ml calcium acetate (phosphate binder) cap 667 mg (169 mg ca) calcium acetate (phosphate binder) tab 667 mg calcium citrate-vitamin d tab 1500 mg- 200 unit calcium citrate-vitamin d tab 315 mg- 200 unit (elemental ca) CALCIUM PNV CAP CALCIUM-FA WAF PLUS D CALDOLOR INJ 800/8ML... 2 CALQUENCE CAP 100MG CAMPRAL TAB 333MG CANASA SUP 1000MG candesartan cilexetil tab 16 mg candesartan cilexetil tab 32 mg candesartan cilexetil tab 4 mg candesartan cilexetil tab 8 mg candesartan cilexetil-hydrochlorothiazide tab mg candesartan cilexetil-hydrochlorothiazide tab mg candesartan cilexetil-hydrochlorothiazide tab mg CANTIL TAB 25MG CAPASTAT SUL INJ 1GM capecitabine tab 150 mg capecitabine tab 500 mg CAPRELSA TAB 100MG CAPRELSA TAB 300MG captopril & hydrochlorothiazide tab mg captopril & hydrochlorothiazide tab mg captopril & hydrochlorothiazide tab mg captopril & hydrochlorothiazide tab mg captopril tab 100 mg captopril tab 12.5 mg captopril tab 25 mg captopril tab 50 mg CARAFATE SUS 1GM/10ML CARBAGLU TAB 200MG carbamazepine cap er 12hr 100 mg carbamazepine cap er 12hr 200 mg carbamazepine cap er 12hr 300 mg carbamazepine chew tab 100 mg carbamazepine susp 100 mg/5ml carbamazepine tab 200 mg carbamazepine tab er 12hr 100 mg carbamazepine tab er 12hr 200 mg carbamazepine tab er 12hr 400 mg carbidopa & levodopa orally disintegrating tab mg carbidopa & levodopa orally disintegrating tab mg carbidopa & levodopa orally disintegrating tab mg carbidopa & levodopa tab mg. 55 carbidopa & levodopa tab mg. 55 carbidopa & levodopa tab mg. 55 carbidopa & levodopa tab er mg carbidopa & levodopa tab er mg carbidopa tab 25 mg carbidopa-levodopa-entacapone tabs mg carbidopa-levodopa-entacapone tabs mg carbidopa-levodopa-entacapone tabs mg carbidopa-levodopa-entacapone tabs mg carbidopa-levodopa-entacapone tabs mg carbidopa-levodopa-entacapone tabs mg carbinoxamine maleate soln 4 mg/5ml carbinoxamine maleate tab 4 mg carbonyl iron susp 15 mg/1.25ml (elemental iron) carboplatin iv soln 600 mg/60ml

140 CARDURA XL TAB 4MG CARDURA XL TAB 8MG CARIMUNE NF INJ 12GM CARIMUNE NF INJ 6GM carisoprodol tab 350 mg carisoprodol w/ aspirin tab mg carteolol hcl ophth soln 1% carvedilol tab 12.5 mg carvedilol tab 25 mg carvedilol tab mg carvedilol tab 6.25 mg CAYA DPR CAYSTON INH 75MG CEDAX CAP 400MG cefaclor cap 250 mg cefaclor cap 500 mg CEFACLOR ER TAB 500MG cefaclor for susp 250 mg/5ml cefaclor for susp 375 mg/5ml cefadroxil cap 500 mg cefadroxil for susp 250 mg/5ml cefadroxil for susp 500 mg/5ml cefadroxil tab 1 gm CEFAZOL/DEX SOL 1GM CEFAZOL/DEX SOL 2GM CEFAZOLIN INJ 100GM CEFAZOLIN INJ 1GM/50ML CEFAZOLIN INJ 300GM cefazolin sodium for inj 1 gm cefazolin sodium for inj 10 gm cefazolin sodium for inj 20 gm cefazolin sodium for inj 500 mg cefazolin sodium for iv soln 1 gm cefdinir cap 300 mg cefdinir for susp 125 mg/5ml cefdinir for susp 250 mg/5ml cefditoren pivoxil tab 200 mg (base equivalent) cefditoren pivoxil tab 400 mg (base equivalent) cefepime hcl for inj 1 gm cefepime hcl for inj 2 gm CEFEPIME INJ 1GM CEFEPIME INJ 2GM CEFEPIME/DEX INJ 1GM CEFEPIME/DEX INJ 2GM cefixime for susp 100 mg/5ml cefixime for susp 200 mg/5ml cefotaxime sodium for inj 1 gm cefotaxime sodium for inj 10 gm cefotaxime sodium for inj 2 gm cefotaxime sodium for inj 500 mg cefotetan disodium for inj 1 gm cefotetan disodium for inj 10 gm cefotetan disodium for inj 2 gm CEFOXITIN INJ 1GM CEFOXITIN INJ 2GM cefoxitin sodium for inj 10 gm cefoxitin sodium for iv soln 1 gm cefoxitin sodium for iv soln 2 gm cefpodoxime proxetil for susp 100 mg/5ml cefpodoxime proxetil for susp 50 mg/5ml cefpodoxime proxetil tab 100 mg cefpodoxime proxetil tab 200 mg cefprozil for susp 125 mg/5ml cefprozil for susp 250 mg/5ml cefprozil tab 250 mg cefprozil tab 500 mg ceftazidime for inj 1 gm ceftazidime for inj 2 gm ceftazidime for inj 6 gm CEFTAZIDIME/ SOL D5W 1GM CEFTAZIDIME/ SOL D5W 2GM ceftibuten cap 400 mg ceftibuten for susp 180 mg/5ml CEFTIN SUS 125/5ML CEFTIN SUS 250/5ML CEFTRIAX/DEX INJ 1GM CEFTRIAX/DEX INJ 2GM ceftriaxone sodium for inj 1 gm ceftriaxone sodium for inj 10 gm ceftriaxone sodium for inj 2 gm ceftriaxone sodium for inj 250 mg ceftriaxone sodium for inj 500 mg ceftriaxone sodium for iv soln 1 gm ceftriaxone sodium for iv soln 2 gm ceftriaxone sodium in dextrose inj 20 mg/ml ceftriaxone sodium in dextrose inj 40 mg/ml cefuroxime axetil tab 250 mg cefuroxime axetil tab 500 mg cefuroxime sodium for inj 7.5 gm

141 cefuroxime sodium for inj 750 mg cefuroxime sodium for iv soln 1.5 gm.. 11 celecoxib cap 100 mg... 1 celecoxib cap 200 mg... 1 celecoxib cap 400 mg... 1 celecoxib cap 50 mg... 1 CELLCEPT SUS 200MG/ML CELONTIN CAP 300MG CENESTIN TAB 0.3MG cephalexin cap 250 mg cephalexin cap 500 mg cephalexin cap 750 mg cephalexin for susp 125 mg/5ml cephalexin for susp 250 mg/5ml cephalexin tab 250 mg cephalexin tab 500 mg CERDELGA CAP 84MG CEREFOLIN TAB CEREZYME INJ 400UNIT CERVARIX INJ CESAMET CAP 1MG cetirizine hcl oral soln 1 mg/ml (5 mg/5ml) cevimeline hcl cap 30 mg CHANTIX PAK 0.5& 1MG CHANTIX PAK 1MG CHANTIX TAB 0.5MG CHEMET CAP 100MG chloramphenicol sodium succinate for iv inj 1 gm chlordiazepoxide hcl cap 10 mg chlordiazepoxide hcl cap 25 mg chlordiazepoxide hcl cap 5 mg chlordiazepoxide hcl-clidinium bromide cap mg chlordiazepoxide-amitriptyline tab mg chlordiazepoxide-amitriptyline tab mg chlorhexidine gluconate soln 0.12% chloroquine phosphate tab 250 mg chloroquine phosphate tab 500 mg chlorothiazide sodium for inj 500 mg chlorothiazide tab 250 mg chlorothiazide tab 500 mg CHLORPROMAZ INJ 25MG/ML chlorpromazine hcl tab 10 mg chlorpromazine hcl tab 100 mg chlorpromazine hcl tab 200 mg chlorpromazine hcl tab 25 mg chlorpromazine hcl tab 50 mg chlorpropamide tab 100 mg chlorpropamide tab 250 mg chlorthalidone tab 25 mg chlorthalidone tab 50 mg chlorzoxazone tab 500 mg cholecalciferol cap unit cholestyramine light powder 4 gm/dose cholestyramine light powder packets 4 gm cholestyramine powder 4 gm/dose cholestyramine powder packets 4 gm. 38 choline & magnesium salicylates liq 500 mg/5ml... 2 choline fenofibrate cap dr 135 mg (fenofibric acid equiv) choline fenofibrate cap dr 45 mg (fenofibric acid equiv) chorionic gonadotropin for im inj unit CIALIS TAB 10MG CIALIS TAB 2.5MG CIALIS TAB 20MG CIALIS TAB 5MG ciclopirox olamine cream 0.77% (base equiv) ciclopirox solution 8% cidofovir iv inj 75 mg/ml cilostazol tab 100 mg cilostazol tab 50 mg CILOXAN OIN 0.3% OP cimetidine hcl soln 300 mg/5ml cimetidine tab 300 mg cimetidine tab 400 mg cimetidine tab 800 mg CINRYZE SOL 500 UNIT CIPRO (10%) SUS 500MG/ CIPRO (5%) SUS 250MG/ CIPRO HC SUS OTIC CIPRODEX SUS % ciprofloxacin 200 mg/100ml in d5w ciprofloxacin 400 mg/200ml in d5w ciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml) ciprofloxacin for oral susp 500 mg/5ml 133

142 (10%) (10 gm/100ml) ciprofloxacin hcl ophth soln 0.3% ciprofloxacin hcl otic soln 0.2% (base equivalent) ciprofloxacin hcl tab 100 mg (base equiv) ciprofloxacin hcl tab 250 mg (base equiv) ciprofloxacin hcl tab 500 mg (base equiv) ciprofloxacin hcl tab 750 mg (base equiv) ciprofloxacin iv soln 200 mg/20ml (1%) ciprofloxacin iv soln 400 mg/40ml (1%) ciprofloxacin-ciprofloxacin hcl tab er 24hr 1000 mg(base eq) ciprofloxacin-ciprofloxacin hcl tab er 24hr 500 mg (base eq) cisplatin inj 50 mg/50ml (1 mg/ml) citalopram hydrobromide oral soln 10 mg/5ml citalopram hydrobromide tab 10 mg (base equiv) citalopram hydrobromide tab 20 mg (base equiv) citalopram hydrobromide tab 40 mg (base equiv) CL PRENATAL TAB MG cladribine iv soln 10 mg/10ml (1 mg/ml) CLAFORAN INJ 1GM CLAFORAN INJ 2GM CLARAVIS clarithromycin for susp 125 mg/5ml clarithromycin for susp 250 mg/5ml clarithromycin tab 250 mg clarithromycin tab 500 mg clarithromycin tab er 24hr 500 mg clemastine fumarate tab 2.68 mg CLEVIPREX EMU 50/100ML clindamycin hcl cap 150 mg clindamycin hcl cap 300 mg clindamycin hcl cap 75 mg clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) clindamycin phosphate gel 1% clindamycin phosphate in d5w iv soln 300 mg/50ml clindamycin phosphate in d5w iv soln 600 mg/50ml clindamycin phosphate in d5w iv soln 900 mg/50ml clindamycin phosphate inj 300 mg/2ml 22 clindamycin phosphate inj 600 mg/4ml 22 clindamycin phosphate iv soln 300 mg/2ml clindamycin phosphate lotion 1% clindamycin phosphate soln 1% clindamycin phosphate swab 1% clindamycin phosphate vaginal cream 2% clindamycin phosphate-benzoyl peroxide gel 1-5% clindamycin phosphate-tretinoin gel % CLINDAP-T CRE clobetasol propionate cream 0.05% clobetasol propionate gel 0.05% clobetasol propionate oint 0.05% clobetasol propionate soln 0.05% clocortolone pivalate cream 0.1% clomipramine hcl cap 25 mg clomipramine hcl cap 50 mg clomipramine hcl cap 75 mg clonazepam orally disintegrating tab mg clonazepam orally disintegrating tab 0.25 mg clonazepam orally disintegrating tab 0.5 mg clonazepam orally disintegrating tab 1 mg clonazepam orally disintegrating tab 2 mg clonazepam tab 0.5 mg clonazepam tab 1 mg clonazepam tab 2 mg clonidine hcl tab 0.1 mg clonidine hcl tab 0.2 mg clonidine hcl tab 0.3 mg clonidine hcl tab er 12hr 0.1 mg clonidine td patch weekly 0.1 mg/24hr 36 clonidine td patch weekly 0.2 mg/24hr 36 clonidine td patch weekly 0.3 mg/24hr

143 clopidogrel bisulfate tab 300 mg (base equiv) clopidogrel bisulfate tab 75 mg (base equiv) clorazepate dipotassium tab 15 mg clorazepate dipotassium tab 3.75 mg.. 47 clorazepate dipotassium tab 7.5 mg clotrimazole troche 10 mg clotrimazole w/ betamethasone cream % clotrimazole w/ betamethasone lotion % clozapine orally disintegrating tab 100 mg clozapine orally disintegrating tab 12.5 mg clozapine orally disintegrating tab 150 mg clozapine orally disintegrating tab 200 mg clozapine orally disintegrating tab 25 mg clozapine tab 100 mg clozapine tab 200 mg clozapine tab 25 mg clozapine tab 50 mg C-NATE DHA CAP COARTEM TAB MG codeine sulfate tab 15 mg... 4 codeine sulfate tab 30 mg... 4 codeine sulfate tab 60 mg... 4 colchicine w/ probenecid tab mg COLCRYS TAB 0.6MG... 1 colesevelam hcl tab 625 mg colestipol hcl granule packets 5 gm colestipol hcl granules 5 gm colestipol hcl tab 1 gm colistimethate sod for inj 150 mg (colistin base activity) COLY-MYCIN S SUS OTIC COMBIGAN SOL 0.2/0.5% COMBIPATCH DIS.05/ COMBIPATCH DIS.05/ COMBIVENT AER COMETRIQ KIT 100MG COMETRIQ KIT 140MG COMETRIQ KIT 60MG COMFORT EZ MIS 33GX5MM COMFORT EZ MIS 33GX6MM COMFORT EZ MIS 33GX8MM COMPLERA TAB COMPLETE NAT PAK DHA COMPLETENATE CHW COMVAX INJ CONCEPTROL GEL 4% CONTRAVE TAB 8-90MG COPAXONE INJ 20MG/ML COPAXONE INJ 40MG/ML CORDRAN OIN 0.025% CORLANOR TAB 5MG CORLANOR TAB 7.5MG cortisone acetate tab 25 mg CORTISPORIN CRE 0.5% CORTISPORIN OIN 1% COSENTYX INJ 150MG/ML COSENTYX PEN INJ 300DOSE COSOPT PF SOL COTELLIC TAB 20MG CREON CAP 12000UNT CREON CAP 24000UNT CREON CAP 3000UNIT CREON CAP 36000UNT CREON CAP 6000UNIT CRESEMBA CAP 186 MG CRESEMBA INJ 372MG CRINONE GEL 4% VAG CRIXIVAN CAP 200MG CRIXIVAN CAP 400MG cromolyn sodium ophth soln 4% cromolyn sodium oral conc 100 mg/5ml cromolyn sodium soln nebu 20 mg/2ml CUPRIMINE CAP 250MG CUVITRU INJ 2GM/10ML CUVITRU INJ 4GM/20ML CUVITRU SOL 1GM/5ML CUVPOSA SOL 1MG/5ML CVS PRENATAL TAB CVS PRENATAL TAB MG cyclobenzaprine hcl tab 10 mg cyclobenzaprine hcl tab 5 mg cyclopentolate hcl ophth soln 1% cyclopentolate hcl ophth soln 2% CYCLOPHOSPH CAP 25MG

144 CYCLOPHOSPH CAP 50MG cyclophosphamide for inj 1 gm cyclophosphamide for inj 2 gm cyclophosphamide for inj 500 mg cycloserine cap 250 mg CYCLOSET TAB 0.8MG cyclosporine cap 100 mg cyclosporine cap 25 mg cyclosporine iv soln 50 mg/ml cyclosporine modified cap 100 mg cyclosporine modified cap 25 mg cyclosporine modified cap 50 mg cyclosporine modified oral soln 100 mg/ml cyproheptadine hcl syrup 2 mg/5ml cyproheptadine hcl tab 4 mg CYSTADANE POW CYSTAGON CAP 150MG CYSTAGON CAP 50MG CYSTARAN SOL 0.44% cytarabine inj 20 mg/ml cytarabine inj pf 100 mg/ml cytarabine inj pf 20 mg/ml D dacarbazine for inj 100 mg dacarbazine for inj 200 mg DAKLINZA TAB 30MG DAKLINZA TAB 60MG DALIRESP TAB 500MCG danazol cap 100 mg danazol cap 200 mg danazol cap 50 mg dantrolene sodium cap 100 mg dantrolene sodium cap 25 mg dantrolene sodium cap 50 mg dapsone gel 5% dapsone tab 100 mg dapsone tab 25 mg DAPTACEL INJ DARAPRIM TAB 25MG darifenacin hydrobromide tab er 24hr 15 mg (base equiv) darifenacin hydrobromide tab er 24hr 7.5 mg (base equiv) daunorubicin hcl iv soln 20 mg/4ml (base equiv) DAUNOXOME INJ 2MG/ML DEBACTEROL SOL 30-50% DELZICOL CAP 400MG demeclocycline hcl tab 150 mg demeclocycline hcl tab 300 mg DEMEROL INJ 100/2ML... 4 DEMEROL INJ 25MG/ DEMEROL INJ 75MG/ DEMEROL INJ 75MG/ML... 4 DEMSER CAP 250MG DENAVIR CRE 1% DEPEN TITRA TAB 250MG DEPO-ESTRADI INJ 5MG/ML DEPO-SQ PROV INJ desipramine hcl tab 10 mg desipramine hcl tab 100 mg desipramine hcl tab 150 mg desipramine hcl tab 25 mg desipramine hcl tab 50 mg desipramine hcl tab 75 mg desloratadine tab 5 mg desmopressin acetate nasal soln 0.01% (refrigerated) desmopressin acetate nasal spray soln 0.01% (refrigerated) desmopressin acetate tab 0.1 mg desmopressin acetate tab 0.2 mg desogest-eth estrad & eth estrad tab /0.01 mg(21/5) desogest-ethin est tab / / mg-mg desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg desonide cream 0.05% desonide oint 0.05% desoximetasone cream 0.05% desoximetasone cream 0.25% desoximetasone gel 0.05% desoximetasone oint 0.05% desoximetasone oint 0.25% DESVENLAFAX TAB 100MG ER DESVENLAFAX TAB 50MG ER desvenlafaxine succinate tab er 24hr 100 mg (base equiv) desvenlafaxine succinate tab er 24hr 25 mg (base equiv) desvenlafaxine succinate tab er 24hr 50 mg (base equiv) DEXAMETHASON CON 1MG/ML dexamethasone elixir 0.5 mg/5ml

145 dexamethasone sodium phosphate ophth soln 0.1% dexamethasone soln 0.5 mg/5ml dexamethasone tab 0.5 mg dexamethasone tab 0.75 mg dexamethasone tab 1 mg dexamethasone tab 1.5 mg dexamethasone tab 2 mg dexamethasone tab 4 mg dexamethasone tab 6 mg dexchlorpheniramine maleate syrup 2 mg/5ml DEXILANT CAP 30MG DR DEXILANT CAP 60MG DR dexmethylphenidate hcl cap er 24 hr 10 mg dexmethylphenidate hcl cap er 24 hr 15 mg dexmethylphenidate hcl cap er 24 hr 20 mg dexmethylphenidate hcl cap er 24 hr 30 mg dexmethylphenidate hcl cap er 24 hr 40 mg dexmethylphenidate hcl cap er 24 hr 5 mg dexmethylphenidate hcl tab 10 mg dexmethylphenidate hcl tab 2.5 mg dexmethylphenidate hcl tab 5 mg dexrazoxane for inj 250 mg dexrazoxane for inj 500 mg dextroamphetamine sulfate cap er 24hr 10 mg dextroamphetamine sulfate cap er 24hr 15 mg dextroamphetamine sulfate cap er 24hr 5 mg dextroamphetamine sulfate tab 10 mg 61 dextroamphetamine sulfate tab 5 mg.. 61 DIALYVITE/ TAB ZINC diazepam conc 5 mg/ml DIAZEPAM INJ 10MG/2ML diazepam inj 5 mg/ml diazepam oral soln 1 mg/ml diazepam rectal gel delivery system 10 mg diazepam rectal gel delivery system 2.5 mg diazepam rectal gel delivery system 20 mg diazepam tab 10 mg diazepam tab 2 mg diazepam tab 5 mg DIBENZYLINE CAP 10MG diclofenac potassium tab 50 mg... 2 diclofenac sodium gel 1%... 4 diclofenac sodium ophth soln 0.1% diclofenac sodium tab delayed release 25 mg... 2 diclofenac sodium tab delayed release 50 mg... 2 diclofenac sodium tab delayed release 75 mg... 2 diclofenac sodium tab er 24hr 100 mg.. 2 diclofenac w/ misoprostol tab delayed release mg... 3 diclofenac w/ misoprostol tab delayed release mg... 4 dicloxacillin sodium cap 250 mg dicloxacillin sodium cap 500 mg dicyclomine hcl cap 10 mg dicyclomine hcl oral soln 10 mg/5ml dicyclomine hcl tab 20 mg didanosine delayed release capsule 125 mg didanosine delayed release capsule 200 mg didanosine delayed release capsule 250 mg didanosine delayed release capsule 400 mg DIFICID TAB 200MG diflorasone diacetate cream 0.05% diflorasone diacetate oint 0.05% diflunisal tab 500 mg... 2 digoxin inj 0.25 mg/ml digoxin oral soln 0.05 mg/ml digoxin tab 125 mcg (0.125 mg) digoxin tab 250 mcg (0.25 mg) dihydroergotamine mesylate inj 1 mg/ml dihydroergotamine mesylate nasal spray 4 mg/ml DILANTIN CAP 30MG diltiazem hcl cap er 24hr 120 mg diltiazem hcl cap er 24hr 180 mg

146 diltiazem hcl cap er 24hr 240 mg diltiazem hcl coated beads cap er 24hr 120 mg... 33, 43 diltiazem hcl coated beads cap er 24hr 180 mg diltiazem hcl coated beads cap er 24hr 240 mg diltiazem hcl coated beads cap er 24hr 300 mg diltiazem hcl extended release beads cap er 24hr 120 mg diltiazem hcl extended release beads cap er 24hr 180 mg diltiazem hcl extended release beads cap er 24hr 240 mg diltiazem hcl extended release beads cap er 24hr 300 mg diltiazem hcl extended release beads cap er 24hr 360 mg diltiazem hcl extended release beads cap er 24hr 420 mg diltiazem hcl tab 120 mg diltiazem hcl tab 30 mg diltiazem hcl tab 60 mg diltiazem hcl tab 90 mg DIMENHYDRIN INJ 50MG/ML DIP/TET PED INJ 25-5LFU DIPENTUM CAP 250MG diphenhydramine hcl inj 50 mg/ml diphenoxylate w/ atropine liq mg/5ml diphenoxylate w/ atropine tab mg dipyridamole tab 25 mg dipyridamole tab 50 mg dipyridamole tab 75 mg disopyramide phosphate cap 100 mg.. 38 disopyramide phosphate cap 150 mg.. 38 disulfiram tab 250 mg disulfiram tab 500 mg DIURIL SUS 250/5ML divalproex sodium cap delayed release sprinkle 125 mg divalproex sodium tab delayed release 125 mg divalproex sodium tab delayed release 250 mg divalproex sodium tab delayed release 500 mg divalproex sodium tab er 24 hr 250 mg divalproex sodium tab er 24 hr 500 mg dofetilide cap 125 mcg (0.125 mg) dofetilide cap 250 mcg (0.25 mg) dofetilide cap 500 mcg (0.5 mg) donepezil hydrochloride orally disintegrating tab 10 mg donepezil hydrochloride orally disintegrating tab 5 mg donepezil hydrochloride tab 10 mg donepezil hydrochloride tab 5 mg DOPTELET TAB 20MG dorzolamide hcl ophth soln 2% dorzolamide hcl-timolol maleate ophth soln mg/ml doxazosin mesylate tab 1 mg doxazosin mesylate tab 2 mg doxazosin mesylate tab 4 mg doxazosin mesylate tab 8 mg doxepin hcl cap 10 mg doxepin hcl cap 100 mg doxepin hcl cap 150 mg doxepin hcl cap 25 mg doxepin hcl cap 50 mg doxepin hcl cap 75 mg doxepin hcl conc 10 mg/ml doxercalciferol cap 0.5 mcg doxercalciferol cap 1 mcg doxercalciferol cap 2.5 mcg doxercalciferol inj 4 mcg/2ml (2 mcg/ml) doxorubicin hcl for inj 10 mg doxorubicin hcl for inj 50 mg doxorubicin hcl inj 2 mg/ml doxycycline hyclate cap 100 mg doxycycline hyclate cap 50 mg doxycycline hyclate for inj 100 mg doxycycline hyclate tab 100 mg doxycycline hyclate tab 20 mg doxycycline monohydrate cap 100 mg 16 doxycycline monohydrate cap 50 mg.. 16 doxycycline monohydrate for susp 25 mg/5ml doxycycline monohydrate tab 100 mg. 16 doxycycline monohydrate tab 150 mg

147 doxycycline monohydrate tab 50 mg doxycycline monohydrate tab 75 mg DRITHO-CREME CRE HP 1% dronabinol cap 10 mg dronabinol cap 2.5 mg dronabinol cap 5 mg droperidol inj 2.5 mg/ml drospirenone-ethinyl estradiol tab mg drospirenone-ethinyl estradiol tab mg drospirenone-ethinyl estrad-levomefolate tab mg DUAVEE TAB duloxetine hcl enteric coated pellets cap 20 mg (base eq) duloxetine hcl enteric coated pellets cap 30 mg (base eq) duloxetine hcl enteric coated pellets cap 60 mg (base eq) DUOPA SUS DUREZOL EMU 0.05% dutasteride cap 0.5 mg dutasteride-tamsulosin hcl cap mg DYMISTA SPR DYRENIUM CAP 100MG DYRENIUM CAP 50MG DYSPORT INJ 500UNIT E econazole nitrate cream 1% EDARBI TAB 40MG EDARBI TAB 80MG EDARBYCLOR TAB EDARBYCLOR TAB 40-25MG EDURANT TAB 25MG efavirenz cap 200 mg efavirenz cap 50 mg efavirenz tab 600 mg ELAPRASE INJ 6MG/3ML ELELYSO INJ 200UNIT eletriptan hydrobromide tab 20 mg (base equivalent) eletriptan hydrobromide tab 40 mg (base equivalent) ELIDEL CRE 1% ELIGARD INJ 22.5MG ELIGARD INJ 30MG ELIGARD INJ 45MG ELIGARD INJ 7.5MG ELIPHOS TAB 667MG ELIQUIS TAB 2.5MG ELIQUIS TAB 5MG ELITEK INJ 1.5MG ELITEK INJ 7.5MG ELLA TAB 30MG ELMIRON CAP 100MG EMADINE SOL 0.05% OP EMBEDA CAP 100-4MG... 5 EMBEDA CAP MG... 4 EMBEDA CAP MG... 4 EMBEDA CAP 50-2MG... 4 EMBEDA CAP MG... 4 EMBEDA CAP MG... 5 EMCYT CAP 140MG EMEND SOL 150MG EMSAM DIS 12MG/24H EMSAM DIS 6MG/24HR EMSAM DIS 9MG/24HR EMTRIVA CAP 200MG EMTRIVA SOL 10MG/ML enalapril maleate & hydrochlorothiazide tab mg enalapril maleate & hydrochlorothiazide tab mg enalapril maleate tab 10 mg enalapril maleate tab 2.5 mg enalapril maleate tab 20 mg enalapril maleate tab 5 mg enalaprilat iv inj 1.25 mg/ml ENBREL INJ 25/0.5ML ENBREL INJ 25MG ENBREL INJ 50MG/ML ENBREL MINI INJ 50MG/ML... 9 ENBREL SRCLK INJ 50MG/ML ENCARE SUP 100MG ENGERIX-B INJ 10/0.5ML ENGERIX-B INJ 20MCG/ML ENJUVIA TAB 0.3MG ENJUVIA TAB 0.45MG ENJUVIA TAB 0.625MG ENJUVIA TAB 0.9MG ENJUVIA TAB 1.25MG enoxaparin sodium inj 100 mg/ml enoxaparin sodium inj 120 mg/0.8ml.. 91 enoxaparin sodium inj 150 mg/ml

148 enoxaparin sodium inj 30 mg/0.3ml enoxaparin sodium inj 300 mg/3ml enoxaparin sodium inj 40 mg/0.4ml enoxaparin sodium inj 60 mg/0.6ml enoxaparin sodium inj 80 mg/0.8ml entacapone tab 200 mg entecavir tab 0.5 mg entecavir tab 1 mg ENTRESTO TAB 24-26MG ENTRESTO TAB 49-51MG ENTRESTO TAB MG ENTYVIO INJ 300MG EPCLUSA TAB epinastine hcl ophth soln 0.05% epinephrine pf inj 1 mg/ml epinephrine pf soln prefilled syringe 1 mg/10ml (0.1 mg/ml) epinephrine solution auto-injector 0.15 mg/0.15ml (1:1000) epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000) EPIPEN 2-PAK INJ 0.3MG EPIPEN-JR INJ 2-PAK epirubicin hcl iv soln 200 mg/100ml (2 mg/ml) epirubicin hcl iv soln 50 mg/25ml (2 mg/ml) EPIVIR HBV SOL 5MG/ML eplerenone tab 25 mg eplerenone tab 50 mg EPOGEN INJ 10000/ML EPOGEN INJ 2000/ML EPOGEN INJ 20000/ML EPOGEN INJ 3000/ML EPOGEN INJ 4000/ML epoprostenol sodium for inj 0.5 mg epoprostenol sodium for inj 1.5 mg eprosartan mesylate tab 600 mg EPZICOM TAB EQL PRENATAL TAB FORMULA ERAXIS INJ 100MG ERAXIS INJ 50MG ERBITUX INJ 100MG ERBITUX INJ 200MG ergocalciferol cap unit ergoloid mesylates tab 1 mg ERGOMAR SUB 2MG ERIVEDGE CAP 150MG ERLEADA TAB 60MG ERTACZO CRE 2% ERYPED SUS 200/5ML ERYPED SUS 400/5ML ERYTHROCIN INJ 500MG erythromycin ethylsuccinate for susp 200 mg/5ml erythromycin ethylsuccinate tab 400 mg erythromycin gel 2% erythromycin ophth oint 5 mg/gm erythromycin pads 2% erythromycin soln 2% erythromycin stearate tab 250 mg erythromycin tab 250 mg erythromycin tab 500 mg erythromycin tab delayed release 250 mg erythromycin tab delayed release 333 mg erythromycin w/ delayed release particles cap 250 mg ESBRIET CAP 267MG escitalopram oxalate soln 5 mg/5ml (base equiv) escitalopram oxalate tab 10 mg (base equiv) escitalopram oxalate tab 20 mg (base equiv) escitalopram oxalate tab 5 mg (base equiv) esmolol hcl inj 100 mg/10ml esomeprazole magnesium cap delayed release 20 mg (base eq) esomeprazole magnesium cap delayed release 40 mg (base eq) esomeprazole sodium for intravenous soln 20 mg (base equiv) esomeprazole sodium for intravenous soln 40 mg (base equiv) estazolam tab 1 mg estazolam tab 2 mg esterified estrogens & methyltestosterone tab mg 77 esterified estrogens & methyltestosterone tab mg.. 77 ESTRACE VAG CRE 0.01% estradiol & norethindrone acetate tab 140

149 mg estradiol & norethindrone acetate tab mg estradiol tab 0.5 mg estradiol tab 1 mg estradiol tab 2 mg estradiol td patch twice weekly mg/24hr estradiol td patch twice weekly mg/24hr estradiol td patch twice weekly 0.05 mg/24hr estradiol td patch twice weekly mg/24hr estradiol td patch twice weekly 0.1 mg/24hr estradiol td patch weekly mg/24hr estradiol td patch weekly mg/24hr (37.5 mcg/24hr) estradiol td patch weekly 0.05 mg/24hr estradiol td patch weekly 0.06 mg/24hr estradiol td patch weekly mg/24hr estradiol td patch weekly 0.1 mg/24hr 77 estradiol vaginal cream 0.1 mg/gm estradiol vaginal tab 10 mcg estradiol valerate im in oil 20 mg/ml estradiol valerate im in oil 40 mg/ml ESTROGEL GEL estropipate tab 0.75 mg estropipate tab 1.5 mg estropipate tab 3 mg eszopiclone tab 1 mg eszopiclone tab 2 mg eszopiclone tab 3 mg ethacrynate sodium for inj 50 mg ethacrynic acid tab 25 mg ethambutol hcl tab 100 mg ethambutol hcl tab 400 mg ethosuximide cap 250 mg ethosuximide soln 250 mg/5ml ethyl chloride aerosol spray ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg ethynodiol diacetate & ethinyl estradiol tab 1 mg-50 mcg etidronate disodium tab 200 mg etidronate disodium tab 400 mg etodolac cap 200 mg... 2 etodolac cap 300 mg... 2 etodolac tab 400 mg... 2 etodolac tab 500 mg... 2 etodolac tab er 24hr 400 mg... 2 etodolac tab er 24hr 500 mg... 2 etodolac tab er 24hr 600 mg... 2 ETOPOPHOS INJ 100MG etoposide cap 50 mg etoposide inj 1 gm/50ml (20 mg/ml).. 30 etoposide inj 100 mg/5ml (20 mg/ml) 30 etoposide inj 500 mg/25ml (20 mg/ml) EUFLEXXA INJ 10MG/ML... 8 EURAX CRE 10% EURAX LOT 10% EVOTAZ TAB EVZIO INJ EXALGO TAB 12MG... 5 EXALGO TAB 16MG... 5 EXALGO TAB 32MG... 5 EXALGO TAB 8MG... 5 EXELDERM CRE 1% EXELDERM SOL 1% exemestane tab 25 mg EXJADE TAB 125MG EXJADE TAB 250MG EXJADE TAB 500MG EXTRA-VIRT CAP PLUS DHA EYLEA INJ 2/0.05ML EZ FLU SHOT INJ EZ FLU SHOT INJ PF EZ FLU SHOT KIT EZ FLU SHOT KIT ezetimibe tab 10 mg F FABIOR AER 0.1% FABRAZYME INJ 35MG FABRAZYME INJ 5MG FACTIVE TAB 320MG FALESSA KIT famciclovir tab 125 mg famciclovir tab 250 mg famciclovir tab 500 mg famotidine for susp 40 mg/5ml

150 famotidine in nacl 0.9% iv soln 20 mg/50ml famotidine inj 20 mg/2ml famotidine inj 40 mg/4ml famotidine tab 20 mg famotidine tab 40 mg FANAPT TAB 10MG FANAPT TAB 12MG FANAPT TAB 1MG FANAPT TAB 2MG FANAPT TAB 4MG FANAPT TAB 6MG FANAPT TAB 8MG FARESTON TAB 60MG FARYDAK CAP 10MG FARYDAK CAP 15MG FARYDAK CAP 20MG FASLODEX INJ 250/5ML FC FEMALE MIS CONDOM fe fumarate w/ b12-vit c-fa-ifc cap mg fe fumarate-vit c-vit b12-fa cap 460 (151 fe) mg felbamate susp 600 mg/5ml felbamate tab 400 mg felbamate tab 600 mg felodipine tab er 24hr 10 mg felodipine tab er 24hr 2.5 mg felodipine tab er 24hr 5 mg FEMCAP MIS 26MM FEMCAP MIS 30MM FEMRING MIS 0.05/24H FEMRING MIS 0.1MG/ fenofibrate micronized cap 134 mg fenofibrate micronized cap 200 mg fenofibrate micronized cap 43 mg fenofibrate micronized cap 67 mg fenofibrate tab 145 mg fenofibrate tab 160 mg fenofibrate tab 48 mg fenofibrate tab 54 mg fenofibric acid tab 105 mg fenofibric acid tab 35 mg fenoprofen calcium tab 600 mg... 2 fentanyl citrate lozenge on a handle 1200 mcg... 5 fentanyl citrate lozenge on a handle 1600 mcg... 5 fentanyl citrate lozenge on a handle 200 mcg... 5 fentanyl citrate lozenge on a handle 400 mcg... 5 fentanyl citrate lozenge on a handle 600 mcg... 5 fentanyl citrate lozenge on a handle 800 mcg... 5 fentanyl citrate pf soln cartridge 100 mcg/2ml... 5 fentanyl td patch 72hr 100 mcg/hr... 5 fentanyl td patch 72hr 12 mcg/hr... 5 fentanyl td patch 72hr 25 mcg/hr... 5 fentanyl td patch 72hr 50 mcg/hr... 5 fentanyl td patch 72hr 75 mcg/hr... 5 FENTORA TAB 100MCG... 5 FENTORA TAB 200MCG... 5 FENTORA TAB 400MCG... 5 FENTORA TAB 600MCG... 5 FENTORA TAB 800MCG... 5 FER-IN-SOL DRO 15MG/ML FERRALET 90 TAB FERRAPLUS 90 TAB FERRIPROX SOL 100MG/ML FERRIPROX TAB 500MG ferrous fumarate-folic acid tab mg FERROUS SUL LIQ 220/5ML FERROUS SULF SYP 300/5ML ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental fe) ferrous sulfate soln 75 mg/ml (15 mg/ml elemental fe) FETZIMA CAP 120MG FETZIMA CAP 20MG FETZIMA CAP 40MG FETZIMA CAP 80MG FETZIMA CAP TITRATIO FINACEA GEL 15% finasteride tab 5 mg FINGERSTIX MIS LANCETS FIRAZYR INJ 30MG/3ML FIRMAGON INJ 120MG FIRMAGON INJ 80MG FLAREX SUS 0.1% OP flavoxate hcl tab 100 mg FLEBOGAMMA INJ 20/400ML flecainide acetate tab 100 mg

151 flecainide acetate tab 150 mg flecainide acetate tab 50 mg FLOVENT DISK AER 100MCG FLOVENT DISK AER 250MCG FLOVENT DISK AER 50MCG FLOVENT HFA AER 110MCG FLOVENT HFA AER 220MCG FLOVENT HFA AER 44MCG FLOWTUSS SOL floxuridine for inj 0.5 gm FLUAD INJ FLUBLOK SOL FLUCELVAX INJ FLUCLVX QUAD INJ fluconazole for susp 10 mg/ml fluconazole for susp 40 mg/ml fluconazole in nacl 0.9% inj 200 mg/100ml fluconazole in nacl 0.9% inj 400 mg/200ml fluconazole tab 100 mg fluconazole tab 150 mg fluconazole tab 200 mg fluconazole tab 50 mg FLUCONAZOLE/ INJ NACL flucytosine cap 250 mg flucytosine cap 500 mg fludarabine phosphate for inj 50 mg fludarabine phosphate inj 25 mg/ml fludrocortisone acetate tab 0.1 mg FLULAVAL INJ FLULAVAL QUA INJ flumazenil iv soln 1 mg/10ml (0.1 mg/ml) FLUMIST QUAD SUS flunisolide nasal soln 25 mcg/act (0.025%) fluocinolone acetonide (otic) oil 0.01% fluocinolone acetonide cream 0.01%. 113 fluocinolone acetonide cream 0.025% 114 fluocinolone acetonide oil 0.01% (body oil) fluocinolone acetonide oil 0.01% (scalp oil) fluocinolone acetonide oint 0.025% fluocinolone acetonide soln 0.01% fluocinonide cream 0.05% fluocinonide emulsified base cream 0.05% fluocinonide gel 0.05% fluocinonide oint 0.05% fluocinonide soln 0.05% FLUORABON DRO FLUORAC CRE 5-1% FLUOR-A-DAY CHW 0.25MG F FLUOR-A-DAY CHW 0.5MG F FLUOR-A-DAY CHW 1MG F fluorescein w/ benoxinate ophth soln % fluorescein w/ proparacaine ophth soln % fluorometholone ophth susp 0.1% fluorouracil cream 5% fluorouracil iv soln 1 gm/20ml (50 mg/ml) fluorouracil iv soln 2.5 gm/50ml (50 mg/ml) fluorouracil iv soln 5 gm/100ml (50 mg/ml) fluorouracil iv soln 500 mg/10ml (50 mg/ml) fluorouracil soln 2% fluorouracil soln 5% fluoxetine hcl (pmdd) cap 10 mg fluoxetine hcl (pmdd) cap 20 mg fluoxetine hcl cap 10 mg fluoxetine hcl cap 20 mg fluoxetine hcl cap 40 mg fluoxetine hcl solution 20 mg/5ml fluoxetine hcl tab 10 mg fluoxetine hcl tab 20 mg fluphenazine decanoate inj 25 mg/ml. 59 fluphenazine hcl elixir 2.5 mg/5ml fluphenazine hcl inj 2.5 mg/ml fluphenazine hcl oral conc 5 mg/ml fluphenazine hcl tab 1 mg fluphenazine hcl tab 10 mg fluphenazine hcl tab 2.5 mg fluphenazine hcl tab 5 mg flurazepam hcl cap 15 mg flurazepam hcl cap 30 mg flurbiprofen sodium ophth soln 0.03% flurbiprofen tab 100 mg... 3 flurbiprofen tab 50 mg

152 flutamide cap 125 mg fluticasone propionate cream 0.05%. 114 fluticasone propionate nasal susp 50 mcg/act fluticasone propionate oint 0.005% fluvastatin sodium cap 20 mg fluvastatin sodium cap 40 mg FLUVIRIN INJ FLUVIRIN INJ FLUVIRIN PF INJ fluvoxamine maleate tab 100 mg fluvoxamine maleate tab 25 mg fluvoxamine maleate tab 50 mg FLUZONE HD INJ PF FLUZONE INJ INTRADRM FLUZONE QUAD INJ FLUZONE QUAD INJ FML FORTE SUS 0.25% OP FML OIN 0.1% OP FOCALGIN 90 MIS DHA FOCALGIN CA MIS FOCALGIN DSS TAB 90-1MG folic acid cap 0.8 mg folic acid tab 1 mg folic acid tab 400 mcg folic acid tab 800 mcg folic acid-pyridoxine-cyanocobalamin tab mg folic acid-vitamin b6-vitamin b12 tab mg folic acid-vitamin b6-vitamin b12 tab mg folic acid-vitamin b6-vitamin b12 tab mg FOLIVANE-F CAP FOLIVANE-OB CAP FOLIVANE-PLS CAP fondaparinux sodium subcutaneous inj 10 mg/0.8ml fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml fondaparinux sodium subcutaneous inj 5 mg/0.4ml fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml FORADIL CAP AEROLIZE FORTEO SOL 600/ FORTICAL SPR 200/ACT FOSAMAX + D TAB FOSAMAX + D TAB fosamprenavir calcium tab 700 mg (base equiv) fosinopril sodium & hydrochlorothiazide tab mg fosinopril sodium & hydrochlorothiazide tab mg fosinopril sodium tab 10 mg fosinopril sodium tab 20 mg fosinopril sodium tab 40 mg fosphenytoin sodium inj 100 mg/2ml (phenytoin equiv) fosphenytoin sodium inj 500 mg/10ml (phenytoin equiv) FOSRENOL POW 1000MG FOSRENOL POW 750MG FRAGMIN INJ 10000/ML FRAGMIN INJ 12500UNT FRAGMIN INJ 15000UNT FRAGMIN INJ 18000UNT FRAGMIN INJ 2500/ FRAGMIN INJ 5000/ FRAGMIN INJ 7500/ FRAGMIN INJ 95000UNT frovatriptan succinate tab 2.5 mg (base equivalent) FULL SPECT TAB B/ VIT C FULYZAQ TAB 125MG furosemide inj 10 mg/ml furosemide oral soln 10 mg/ml furosemide oral soln 8 mg/ml furosemide tab 20 mg furosemide tab 40 mg furosemide tab 80 mg FUSION PLUS CAP FUZEON INJ 90MG FYCOMPA SUS 0.5MG/ML FYCOMPA TAB 10MG FYCOMPA TAB 12MG FYCOMPA TAB 2MG FYCOMPA TAB 4MG FYCOMPA TAB 6MG FYCOMPA TAB 8MG G gabapentin cap 100 mg gabapentin cap 300 mg gabapentin cap 400 mg

153 gabapentin oral soln 250 mg/5ml gabapentin tab 600 mg gabapentin tab 800 mg GABLOFEN INJ 20000/ GABLOFEN INJ 50MCG/ML galantamine hydrobromide cap er 24hr 16 mg galantamine hydrobromide cap er 24hr 24 mg galantamine hydrobromide cap er 24hr 8 mg galantamine hydrobromide oral soln 4 mg/ml galantamine hydrobromide tab 12 mg. 51 galantamine hydrobromide tab 4 mg galantamine hydrobromide tab 8 mg GALZIN CAP 25MG GALZIN CAP 50MG GAMASTAN S/D INJ GAMMAGARD INJ 10GM/ GAMMAGARD INJ 1GM/10ML GAMMAGARD INJ 2.5GM/ GAMMAGARD INJ 20GM/ GAMMAGARD INJ 5GM/50ML GAMMAGARD SD INJ 10GM HU GAMMAGARD SD INJ 5GM HU GAMUNEX-C INJ 40/400ML ganciclovir sodium for inj 500 mg GARDASIL 9 INJ GARDASIL INJ gatifloxacin ophth soln 0.5% GATTEX KIT 5MG GELCLAIR GEL gemcitabine hcl for inj 1 gm gemcitabine hcl for inj 2 gm gemcitabine hcl for inj 200 mg gemcitabine hcl inj 1 gm/26.3ml (38 mg/ml) (base equiv) gemcitabine hcl inj 2 gm/52.6ml (38 mg/ml) (base equiv) gemcitabine hcl inj 200 mg/5.26ml (38 mg/ml) (base equiv) gemfibrozil tab 600 mg GENERESS FE CHW GENTAM/NACL INJ 0.9MG/ML... 9 GENTAM/NACL INJ 1.4MG/ML... 9 gentamicin in saline inj 0.8 mg/ml... 9 gentamicin in saline inj 1 mg/ml... 9 gentamicin in saline inj 1.2 mg/ml... 9 gentamicin in saline inj 1.6 mg/ml... 9 gentamicin in saline inj 2 mg/ml... 9 gentamicin sulfate cream 0.1% gentamicin sulfate inj 10 mg/ml... 9 gentamicin sulfate inj 40 mg/ml... 9 gentamicin sulfate iv soln 10 mg/ml... 9 gentamicin sulfate oint 0.1% gentamicin sulfate ophth oint 0.3% gentamicin sulfate ophth soln 0.3% GENVOYA TAB GEODON INJ 20MG GILENYA CAP 0.5MG GILOTRIF TAB 20MG GILOTRIF TAB 30MG GILOTRIF TAB 40MG GLASSIA INJ GLEOSTINE CAP 100MG GLEOSTINE CAP 10MG GLEOSTINE CAP 40MG GLEOSTINE CAP 5MG glimepiride tab 1 mg glimepiride tab 2 mg glimepiride tab 4 mg glipizide tab 10 mg glipizide tab 5 mg glipizide tab er 24hr 10 mg glipizide tab er 24hr 2.5 mg glipizide tab er 24hr 5 mg glipizide-metformin hcl tab mg glipizide-metformin hcl tab mg glipizide-metformin hcl tab mg. 71 GLUCAGEN INJ 1MG GLUCAGEN INJ HYPOKIT GLUCAGON INJ 1MG GLUCAGON KIT 1MG GLUCOLET 2 MIS LANCING glyburide micronized tab 1.5 mg glyburide micronized tab 3 mg glyburide micronized tab 6 mg glyburide tab 1.25 mg glyburide tab 2.5 mg glyburide tab 5 mg glyburide-metformin tab mg 71 glyburide-metformin tab mg.. 71 glyburide-metformin tab mg

154 glycopyrrolate inj 1 mg/5ml (0.2 mg/ml) glycopyrrolate tab 1 mg glycopyrrolate tab 2 mg GLYXAMBI TAB 10-5 MG GLYXAMBI TAB 25-5 MG GRALISE STAR MIS 300/ GRALISE TAB 300MG GRALISE TAB 600MG granisetron hcl inj 0.1 mg/ml granisetron hcl inj 1 mg/ml granisetron hcl inj 4 mg/4ml (1 mg/ml) granisetron hcl tab 1 mg GRANIX INJ 300/ GRANIX INJ 480/ GRASTEK SUB 2800BAU... 1 griseofulvin microsize susp 125 mg/5ml griseofulvin microsize tab 500 mg griseofulvin ultramicrosize tab 125 mg 17 griseofulvin ultramicrosize tab 250 mg 17 guaifenesin-codeine soln mg/5ml guaifenesin-codeine soln mg/5ml guanfacine hcl tab 1 mg guanfacine hcl tab 2 mg guanfacine hcl tab er 24hr 1 mg (base equiv) guanfacine hcl tab er 24hr 2 mg (base equiv) guanfacine hcl tab er 24hr 3 mg (base equiv) guanfacine hcl tab er 24hr 4 mg (base equiv) GUANIDINE TAB 125MG GYNAZOLE-1 CRE 2% GYNOL II GEL 3% H H.P. ACTHAR INJ 80UNIT HALFPRIN TAB 162MG EC... 3 halobetasol propionate cream 0.05% 114 halobetasol propionate oint 0.05% HALOG OIN 0.1% haloperidol decanoate im soln 100 mg/ml haloperidol decanoate im soln 50 mg/ml haloperidol lactate inj 5 mg/ml haloperidol lactate oral conc 2 mg/ml. 59 haloperidol tab 0.5 mg haloperidol tab 1 mg haloperidol tab 10 mg haloperidol tab 2 mg haloperidol tab 20 mg haloperidol tab 5 mg HARVONI TAB MG HAVRIX INJ 1440UNIT HAVRIX INJ 720UNIT HECTOROL INJ 2MCG/ML HEMANGEOL SOL 4.28/ML HEMATOGEN FA CAP HEMENATAL OB MIS + DHA HEMENATAL OB TAB MG HEP SOD/NACL INJ 25000UNT heparin sodium (porcine) 100 unit/ml in d5w heparin sodium (porcine) 40 unit/ml in d5w heparin sodium (porcine) 50 unit/ml in d5w heparin sodium (porcine) inj 1000 unit/ml heparin sodium (porcine) inj unit/ml heparin sodium (porcine) inj unit/ml heparin sodium (porcine) inj 5000 unit/ml heparin sodium (porcine) pf inj 5000 unit/0.5ml HERCEPTIN INJ 150MG HERCEPTIN INJ 440MG HETLIOZ CAP 20MG HEXALEN CAP 50MG HIBERIX SOL 10MCG HIZENTRA INJ 10/50ML homatropine hbr ophth soln 5% HORIZANT TAB 300MG ER HORIZANT TAB 600MG ER HUMIRA INJ 10/0.1ML... 8 HUMIRA INJ 10MG/ HUMIRA INJ 20/0.2ML... 8 HUMIRA INJ 40/0.4ML... 8 HUMIRA KIT 20MG/

155 HUMIRA KIT 40MG/ HUMIRA PEDIA INJ CROHNS... 9 HUMIRA PEN INJ 40/0.4ML... 9 HUMIRA PEN INJ 40MG/ HUMIRA PEN KIT CD/UC/HS... 9 HUMIRA PEN KIT PS/UV... 9 HUMULIN R INJ U HYCAMTIN CAP 0.25MG HYCAMTIN CAP 1MG hydralazine hcl inj 20 mg/ml hydralazine hcl tab 10 mg hydralazine hcl tab 100 mg hydralazine hcl tab 25 mg hydralazine hcl tab 50 mg hydrochlorothiazide cap 12.5 mg hydrochlorothiazide tab 12.5 mg hydrochlorothiazide tab 25 mg hydrochlorothiazide tab 50 mg hydrocod polst-chlorphen polst er susp 10-8 mg/5ml hydrocodone w/ homatropine syrup mg/5ml hydrocodone w/ homatropine tab mg hydrocodone-acetaminophen soln mg/15ml... 5 hydrocodone-acetaminophen soln mg/15ml... 5 hydrocodone-acetaminophen tab mg... 5 hydrocodone-acetaminophen tab mg... 5 hydrocodone-acetaminophen tab mg... 5 hydrocodone-acetaminophen tab mg... 5 hydrocodone-ibuprofen tab mg. 5 hydrocodone-ibuprofen tab mg... 5 hydrocodone-ibuprofen tab mg 5 hydrocortisone acetate suppos 25 mg.. 88 hydrocortisone acetate w/ pramoxine rectal cream 1-1% hydrocortisone acetate w/ pramoxine rectal cream 2.5-1% hydrocortisone butyrate oint 0.1% hydrocortisone butyrate soln 0.1% hydrocortisone cream 2.5% hydrocortisone enema 100 mg/60ml hydrocortisone lotion 2.5% hydrocortisone oint 1% hydrocortisone oint 2.5% hydrocortisone rectal cream 2.5% hydrocortisone tab 10 mg hydrocortisone tab 20 mg hydrocortisone tab 5 mg hydrocortisone valerate cream 0.2% 113 hydrocortisone valerate oint 0.2% hydrocortisone w/ acetic acid otic soln 1-2% HYDROMORPHON SUP 3MG... 5 hydromorphone hcl inj 1 mg/ml... 5 hydromorphone hcl inj 2 mg/ml... 5 hydromorphone hcl inj 4 mg/ml... 6 hydromorphone hcl preservative free (pf) inj 10 mg/ml... 6 hydromorphone hcl tab 2 mg... 6 hydromorphone hcl tab 4 mg... 6 hydromorphone hcl tab 8 mg... 6 hydromorphone hcl tab er 24hr deter 12 mg... 6 hydromorphone hcl tab er 24hr deter 16 mg... 6 hydromorphone hcl tab er 24hr deter 32 mg... 6 hydromorphone hcl tab er 24hr deter 8 mg... 6 hydroxychloroquine sulfate tab 200 mg hydroxyurea cap 500 mg hydroxyzine hcl im soln 25 mg/ml hydroxyzine hcl im soln 50 mg/ml hydroxyzine hcl syrup 10 mg/5ml hydroxyzine hcl tab 10 mg hydroxyzine hcl tab 25 mg hydroxyzine hcl tab 50 mg hydroxyzine pamoate cap 100 mg hydroxyzine pamoate cap 25 mg hydroxyzine pamoate cap 50 mg hyoscyamine sulfate elixir mg/5ml hyoscyamine sulfate sl tab mg.. 85 hyoscyamine sulfate soln mg/ml 85 hyoscyamine sulfate tab mg hyoscyamine sulfate tab disint mg hyoscyamine sulfate tab er 12hr

156 mg HYPO NEEDLE MIS 18GX HYPO NEEDLE MIS 18GX HYQVIA INJ HYQVIA INJ HYQVIA INJ HYQVIA INJ HYQVIA INJ I ibandronate sodium iv soln 3 mg/3ml (base equivalent) ibandronate sodium tab 150 mg (base equivalent) IBRANCE CAP 100MG IBRANCE CAP 125MG IBRANCE CAP 75MG ibuprofen tab 400 mg... 3 ibuprofen tab 600 mg... 3 ibuprofen tab 800 mg... 3 ICAR PEDS SUS GRAPE ICLUSIG TAB 15MG ICLUSIG TAB 45MG idarubicin hcl iv inj 5 mg/5ml (1 mg/ml) IDHIFA TAB 100MG IDHIFA TAB 50MG ifosfamide for inj 1 gm IFOSFAMIDE INJ 3GM ifosfamide iv inj 1 gm/20ml (50 mg/ml) ifosfamide iv inj 3 gm/60ml (50 mg/ml) ILARIS INJ 150MG ILEVRO DRO 0.3% OP ILUVIEN IMP 0.19MG imatinib mesylate tab 100 mg (base equivalent) imatinib mesylate tab 400 mg (base equivalent) IMBRUVICA CAP 140MG IMBRUVICA TAB 140MG IMBRUVICA TAB 280MG IMBRUVICA TAB 420MG IMBRUVICA TAB 560MG imipenem-cilastatin intravenous for soln 250 mg imipenem-cilastatin intravenous for soln 500 mg imipramine hcl tab 10 mg imipramine hcl tab 25 mg imipramine hcl tab 50 mg imipramine pamoate cap 100 mg imipramine pamoate cap 125 mg imipramine pamoate cap 150 mg imipramine pamoate cap 75 mg imiquimod cream 5% IMPLANON IMP 68MG INATAL ULTRA TAB INCRELEX INJ 40MG/4ML INCRUSE ELPT INH 62.5MCG indapamide tab 1.25 mg indapamide tab 2.5 mg indomethacin cap 25 mg... 3 indomethacin cap 50 mg... 3 indomethacin cap er 75 mg... 3 INFANATE CAP BALANCE INFANRIX INJ INLYTA TAB 1MG INLYTA TAB 5MG INSULIN PEN MIS 31GX4MM INSUPEN MIS 33GX4MM INSUPEN SENS MIS 32GX8MM INTELENCE TAB 100MG INTELENCE TAB 200MG INTELENCE TAB 25MG INTRON A INJ 10MU INTRON A INJ 18MU INTRON A INJ 25MU INTRON A INJ 50MU INVANZ INJ 1GM INVEGA SUST INJ 117/ INVEGA SUST INJ 156MG/ML INVEGA SUST INJ 234/ INVEGA SUST INJ 39/ INVEGA SUST INJ 78/0.5ML INVEGA TRINZ INJ 273MG INVEGA TRINZ INJ 410MG INVEGA TRINZ INJ 546MG INVEGA TRINZ INJ 819MG INVIRASE CAP 200MG INVIRASE TAB 500MG INVOKAMET TAB INVOKAMET TAB INVOKAMET TAB INVOKAMET TAB MG INVOKAMET XR TAB

157 INVOKAMET XR TAB INVOKAMET XR TAB INVOKAMET XR TAB MG INVOKANA TAB 100MG INVOKANA TAB 300MG IPOL INJ INACTIVE ipratropium bromide inhal soln 0.02% ipratropium bromide nasal soln 0.03% (21 mcg/spray) ipratropium bromide nasal soln 0.06% (42 mcg/spray) ipratropium-albuterol nebu soln (3) mg/3ml irbesartan tab 150 mg irbesartan tab 300 mg irbesartan tab 75 mg irbesartan-hydrochlorothiazide tab mg irbesartan-hydrochlorothiazide tab mg IRESSA TAB 250MG irinotecan hcl inj 100 mg/5ml (20 mg/ml) irinotecan hcl inj 40 mg/2ml (20 mg/ml) irinotecan hcl inj 500 mg/25ml (20 mg/ml) iron polysacch complex-vit b12-fa cap mg iron-folic acid-vit c-vit b6-vit b12-zinc tab mg iron-vit c-vit b12-folic acid tab mg ISENTRESS CHW 100MG ISENTRESS CHW 25MG ISENTRESS HD TAB 600MG ISENTRESS POW 100MG ISENTRESS TAB 400MG isometheptene-dichloral-acetaminophen cap mg isoniazid inj 100 mg/ml isoniazid syrup 50 mg/5ml isoniazid tab 100 mg isoniazid tab 300 mg isosorbide dinitrate tab 10 mg isosorbide dinitrate tab 20 mg isosorbide dinitrate tab 30 mg isosorbide dinitrate tab 5 mg isosorbide dinitrate tab er 40 mg isosorbide mononitrate tab 10 mg isosorbide mononitrate tab 20 mg isosorbide mononitrate tab er 24hr 120 mg isosorbide mononitrate tab er 24hr 30 mg isosorbide mononitrate tab er 24hr 60 mg isoxsuprine hcl tab 10 mg isoxsuprine hcl tab 20 mg isradipine cap 2.5 mg isradipine cap 5 mg itraconazole cap 100 mg ivermectin tab 3 mg IXEMPRA KIT INJ 15MG IXEMPRA KIT INJ 45MG J JADENU TAB 180MG JADENU TAB 360MG JADENU TAB 90MG JAKAFI TAB 10MG JAKAFI TAB 15MG JAKAFI TAB 20MG JAKAFI TAB 25MG JAKAFI TAB 5MG JANUMET TAB JANUMET TAB MG JANUMET XR TAB JANUMET XR TAB JANUMET XR TAB MG JANUVIA TAB 100MG JANUVIA TAB 25MG JANUVIA TAB 50MG JARDIANCE TAB 10MG JARDIANCE TAB 25MG JENTADUETO TAB JENTADUETO TAB JENTADUETO TAB JENTADUETO TAB XR JETREA INJ 2.5MG/ML JUBLIA SOL 10% JUXTAPID CAP 10MG JUXTAPID CAP 20MG JUXTAPID CAP 30MG JUXTAPID CAP 40MG JUXTAPID CAP 5MG

158 JUXTAPID CAP 60MG JYNARQUE PAK 45-15MG JYNARQUE PAK 60-30MG JYNARQUE PAK 90-30MG K KALBITOR INJ 10MG/ML KALETRA SOL KALETRA TAB MG KALETRA TAB MG KALYDECO PAK 50MG KALYDECO PAK 75MG KALYDECO TAB 150MG KEPIVANCE INJ 6.25MG KERYDIN SOL 5% KETEK TAB 300MG KETEK TAB 400MG ketoconazole cream 2% ketoconazole shampoo 2% ketoconazole tab 200 mg ketoprofen cap 50 mg... 3 ketoprofen cap 75 mg... 3 ketorolac tromethamine im inj 60 mg/2ml (30 mg/ml)... 3 ketorolac tromethamine inj 15 mg/ml... 3 ketorolac tromethamine inj 30 mg/ml... 3 ketorolac tromethamine inj 300 mg/10ml (30 mg/ml)... 3 ketorolac tromethamine ophth soln 0.4% ketorolac tromethamine ophth soln 0.5% ketorolac tromethamine tab 10 mg... 3 KEVEYIS TAB 50MG KISQALI 200 PAK FEMARA KISQALI 400 PAK FEMARA KISQALI 600 PAK FEMARA KISQALI TAB 200DOSE KISQALI TAB 400DOSE KISQALI TAB 600DOSE KLOR-CON M15 TAB 15MEQ ER KORLYM TAB 300MG KRYSTEXXA INJ 8MG/ML... 1 KUVAN POW 500MG KUVAN TAB 100MG KYLEENA IUD 19.5MG KYNAMRO INJ 200MG/ML L labetalol hcl iv soln 5 mg/ml labetalol hcl tab 100 mg labetalol hcl tab 200 mg labetalol hcl tab 300 mg lactated ringer's for irrigation lactic acid (ammonium lactate) cream 12% lactic acid (ammonium lactate) lotion 10% lactic acid (ammonium lactate) lotion 12% lactic acid w/ vitamin e cream 10%-3500 unit/30gm lactulose (encephalopathy) solution 10 gm/15ml lactulose solution 10 gm/15ml LAMICTAL CHW 2MG lamivudine oral soln 10 mg/ml lamivudine tab 100 mg (hbv) lamivudine tab 150 mg lamivudine tab 300 mg lamivudine-zidovudine tab mg lamotrigine orally disintegrating tab 100 mg lamotrigine orally disintegrating tab 200 mg lamotrigine orally disintegrating tab 25 mg lamotrigine orally disintegrating tab 50 mg lamotrigine tab 100 mg lamotrigine tab 150 mg lamotrigine tab 200 mg lamotrigine tab 25 mg lamotrigine tab chewable dispersible 25 mg lamotrigine tab chewable dispersible 5 mg lamotrigine tab er 24hr 250 mg lamotrigine tab er 24hr 50 mg lansoprazole cap delayed release 15 mg lansoprazole cap delayed release 30 mg lanthanum carbonate chew tab 1000 mg (elemental) lanthanum carbonate chew tab 500 mg (elemental)

159 lanthanum carbonate chew tab 750 mg (elemental) LANTUS INJ 100/ML LANTUS INJ SOLOSTAR LASTFT SOL 0.25% latanoprost ophth soln 0.005% LATUDA TAB 120MG LATUDA TAB 20MG LATUDA TAB 40MG LATUDA TAB 60MG LATUDA TAB 80MG LAZANDA SPR 100MCG... 6 LAZANDA SPR 400MCG... 6 leflunomide tab 10 mg leflunomide tab 20 mg LEMTRADA INJ 12/1.2ML LENVIMA CAP 10 MG LENVIMA CAP 14 MG LENVIMA CAP 18 MG LENVIMA CAP 20 MG LENVIMA CAP 24 MG LENVIMA CAP 8 MG LETAIRIS TAB 10MG LETAIRIS TAB 5MG letrozole tab 2.5 mg leucovorin calcium tab 10 mg leucovorin calcium tab 15 mg leucovorin calcium tab 25 mg leucovorin calcium tab 5 mg LEUKERAN TAB 2MG LEUKINE INJ 250MCG leuprolide acetate inj kit 5 mg/ml levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv) levalbuterol hcl soln nebu 0.63 mg/3ml (base equiv) levalbuterol hcl soln nebu 1.25 mg/3ml (base equiv) levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base equiv) levalbuterol tartrate inhal aerosol 45 mcg/act (base equiv) LEVATOL TAB 20MG LEVEMIR INJ LEVEMIR INJ FLEXTOUC levetiracetam inj 500 mg/5ml (100 mg/ml) levetiracetam oral soln 100 mg/ml levetiracetam tab 1000 mg levetiracetam tab 250 mg levetiracetam tab 500 mg levetiracetam tab 750 mg levetiracetam tab er 24hr 500 mg levetiracetam tab er 24hr 750 mg levobunolol hcl ophth soln 0.5% levocarnitine inj 200 mg/ml levocarnitine oral soln 1 gm/10ml (10%) levocarnitine tab 330 mg levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/ml) levocetirizine dihydrochloride tab 5 mg levofloxacin in d5w iv soln 250 mg/50ml levofloxacin in d5w iv soln 500 mg/100ml levofloxacin in d5w iv soln 750 mg/150ml levofloxacin iv soln 25 mg/ml levofloxacin ophth soln 0.5% levofloxacin oral soln 25 mg/ml levofloxacin tab 250 mg levofloxacin tab 500 mg levofloxacin tab 750 mg LEVOMEFOLATE CAP DHA levonorgestrel & ethinyl estradiol (91- day) tab mg levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg levonorgestrel tab 0.75 mg levonorgestrel tab 1.5 mg levonorgestrel-eth estra tab / / mg-mcg levonorgestrel-ethinyl estradiol (continuous) tab mcg levonorg-eth est tab mg(84) & eth est tab 0.01mg(7) levonorg-eth est tab mg(84) & eth est tab 0.01mg(7) levorphanol tartrate tab 2 mg... 6 LEVOTHYROXIN INJ 200MCG levothyroxine sodium for iv inj 100 mcg

160 levothyroxine sodium for iv inj 500 mcg levothyroxine sodium tab 100 mcg levothyroxine sodium tab 112 mcg levothyroxine sodium tab 125 mcg levothyroxine sodium tab 137 mcg levothyroxine sodium tab 150 mcg levothyroxine sodium tab 175 mcg levothyroxine sodium tab 200 mcg levothyroxine sodium tab 25 mcg levothyroxine sodium tab 300 mcg levothyroxine sodium tab 50 mcg levothyroxine sodium tab 75 mcg levothyroxine sodium tab 88 mcg LEVSIN INJ 0.5MG/ML LEXIVA SUS 50MG/ML LEXIVA TAB 700MG lidocaine hcl gel 2%... 70, 114 lidocaine hcl local inj 1%... 1 lidocaine hcl local inj 2%... 1 lidocaine hcl local preservative free (pf) inj 0.5%... 2 lidocaine hcl local preservative free (pf) inj 1%... 2 lidocaine hcl local preservative free (pf) inj 2%... 2 lidocaine hcl local preservative free (pf) inj 4%... 2 lidocaine hcl soln 4% lidocaine hcl viscous soln 2% lidocaine inj 0.5% w/ epinephrine- 1: lidocaine inj 1% w/ epinephrine- 1: lidocaine inj 2% w/ epinephrine- 1: lidocaine oint 5% lidocaine patch 5% lidocaine-hydrocortisone acetate rectal cream 3-0.5% lidocaine-prilocaine cream %. 114 lidocaine-prilocaine cream kit % LILETTA IUD 52MG lindane lotion 1% lindane shampoo 1% linezolid for susp 100 mg/5ml linezolid in sodium chloride iv soln 600 mg/300ml-0.9% linezolid tab 600 mg LINZESS CAP 145MCG LINZESS CAP 290MCG LINZESS CAP 72MCG liothyronine sodium iv soln 10 mcg/ml 82 liothyronine sodium tab 25 mcg liothyronine sodium tab 5 mcg liothyronine sodium tab 50 mcg lisinopril & hydrochlorothiazide tab mg lisinopril & hydrochlorothiazide tab mg lisinopril & hydrochlorothiazide tab mg lisinopril tab 10 mg lisinopril tab 2.5 mg lisinopril tab 20 mg lisinopril tab 30 mg lisinopril tab 40 mg lisinopril tab 5 mg lithium carbonate cap 150 mg lithium carbonate cap 300 mg lithium carbonate cap 600 mg lithium carbonate tab 300 mg lithium carbonate tab er 300 mg lithium carbonate tab er 450 mg LITHIUM SOL 8MEQ/5ML LIVALO TAB 1MG LIVALO TAB 2MG LIVALO TAB 4MG L-METHYL- TAB B6-B L-METHYL-MC TAB L-METHYL-MC TAB NAC LO LOESTRIN TAB LOKELMA PAK 10GM LOKELMA PAK 5GM LONSURF TAB LONSURF TAB loperamide hcl cap 2 mg lopinavir-ritonavir soln mg/5ml (80-20 mg/ml) lorazepam conc 2 mg/ml lorazepam inj 2 mg/ml lorazepam inj 4 mg/ml lorazepam tab 0.5 mg lorazepam tab 1 mg lorazepam tab 2 mg

161 LORTUSS EX LIQ losartan potassium & hydrochlorothiazide tab mg losartan potassium & hydrochlorothiazide tab mg losartan potassium & hydrochlorothiazide tab mg losartan potassium tab 100 mg losartan potassium tab 25 mg losartan potassium tab 50 mg LOTEMAX GEL 0.5% LOTEMAX OIN 0.5% LOTEMAX SUS 0.5% lovastatin tab 10 mg lovastatin tab 20 mg lovastatin tab 40 mg loxapine succinate cap 10 mg loxapine succinate cap 25 mg loxapine succinate cap 5 mg loxapine succinate cap 50 mg LOZI-FLUR LOZ 1MG F LUCEMYRA TAB 0.18MG LUCENTIS SOL 0.3MG LUCENTIS SOL 0.5MG LUMIGAN SOL 0.01% LUPANETA KIT LUPANETA KIT LUPR DEP-PED INJ 11.25MG LUPR DEP-PED INJ 15MG LUPR DEP-PED INJ 3M 30MG LUPR DEP-PED INJ 7.5MG LUPRON DEPOT INJ 11.25MG LUPRON DEPOT INJ 22.5MG LUPRON DEPOT INJ 3.75MG LUPRON DEPOT INJ 30MG LUPRON DEPOT INJ 45MG LUPRON DEPOT INJ 7.5MG LURIDE CHW 0.25MG F LURIDE CHW 0.5MG F LURIDE DRO 0.5MG/ML LUZU CRE 1% LYNPARZA CAP 50MG LYRICA CAP 100MG LYRICA CAP 150MG LYRICA CAP 200MG LYRICA CAP 225MG LYRICA CAP 25MG LYRICA CAP 300MG LYRICA CAP 50MG LYRICA CAP 75MG LYRICA SOL 20MG/ML LYSODREN TAB 500MG M MACUGEN INJ MAKENA INJ 250MG/ML malathion lotion 0.5% maprotiline hcl tab 25 mg maprotiline hcl tab 50 mg maprotiline hcl tab 75 mg MARPLAN TAB 10MG MATULANE CAP 50MG MAVYRET TAB MG MAXAIR AUTOH AER 200MCG MAXIDEX SUS 0.1% OP MAXIPIME INJ 1GM MAXIPIME INJ 2GM meclizine hcl tab 12.5 mg meclizine hcl tab 25 mg meclofenamate sodium cap 50 mg... 3 medroxyprogesterone acetate im susp 150 mg/ml medroxyprogesterone acetate im susp prefilled syr 150 mg/ml medroxyprogesterone acetate tab 10 mg medroxyprogesterone acetate tab 2.5 mg medroxyprogesterone acetate tab 5 mg mefenamic acid cap 250 mg... 3 mefloquine hcl tab 250 mg megestrol acetate susp 40 mg/ml megestrol acetate tab 20 mg megestrol acetate tab 40 mg MEKINIST TAB 0.5MG MEKINIST TAB 2MG meloxicam susp 7.5 mg/5ml... 3 meloxicam tab 15 mg... 3 meloxicam tab 7.5 mg... 3 melphalan hcl for inj 50 mg (base equiv) melphalan tab 2 mg memantine hcl oral solution 2 mg/ml.. 51 memantine hcl tab 10 mg memantine hcl tab 5 mg memantine hcl tab 5 mg (28) & 10 mg 153

162 (21) titration pak MENACTRA INJ MENEST TAB 0.3MG MENEST TAB 0.625MG MENEST TAB 1.25MG MENEST TAB 2.5MG MENHIBRIX INJ MENOMUNE INJ A/C/Y/W MENOSTAR DIS 14MCG MENTAX CRE 1% MENVEO INJ meperidine hcl inj 10 mg/ml... 6 meperidine hcl oral soln 50 mg/5ml... 6 meperidine hcl tab 100 mg... 6 meperidine hcl tab 50 mg... 6 meprobamate tab 200 mg meprobamate tab 400 mg mercaptopurine tab 50 mg meropenem iv for soln 1 gm meropenem iv for soln 500 mg mesalamine enema 4 gm mesalamine tab delayed release 1.2 gm mesna inj 100 mg/ml MESNEX TAB 400MG METAFOLBIC TAB METAFOLBIC TAB PLUS metaproterenol sulfate syrup 10 mg/5ml metaproterenol sulfate tab 10 mg metaproterenol sulfate tab 20 mg metaxalone tab 800 mg metformin hcl tab 1000 mg metformin hcl tab 500 mg metformin hcl tab 850 mg metformin hcl tab er 24hr 500 mg metformin hcl tab er 24hr 750 mg metformin hcl tab er 24hr osmotic 1000 mg metformin hcl tab er 24hr osmotic 500 mg methadone hcl conc 10 mg/ml... 6 methadone hcl soln 10 mg/5ml... 6 methadone hcl soln 5 mg/5ml... 6 methadone hcl tab 10 mg... 6 methadone hcl tab 5 mg... 6 methadone hcl tab for oral susp 40 mg. 6 methamphetamine hcl tab 5 mg methazolamide tab 25 mg methazolamide tab 50 mg methenamine hippurate tab 1 gm methenamine mandelate tab 0.5 gm.. 89 methenamine mandelate tab 1 gm methenamine-hyosc-meth blue-benz acid-phenyl sal tab 81.6mg methergine tab 0.2mg methimazole tab 10 mg methimazole tab 5 mg METHITEST TAB 10MG methocarbamol tab 500 mg methocarbamol tab 750 mg methotrexate sodium for inj 1 gm methotrexate sodium inj 50 mg/2ml (25 mg/ml) methotrexate sodium inj pf 50 mg/2ml (25 mg/ml) methotrexate sodium tab 2.5 mg (base equiv) methoxsalen rapid cap 10 mg methscopolamine bromide tab 2.5 mg 85 methscopolamine bromide tab 5 mg methyclothiazide tab 5 mg methyldopa & hydrochlorothiazide tab mg methyldopa & hydrochlorothiazide tab mg methyldopa tab 250 mg methyldopa tab 500 mg methyldopate hcl inj 250 mg/5ml methylphenidate hcl cap er 10 mg (cd) 61 methylphenidate hcl cap er 20 mg (cd) 61 methylphenidate hcl cap er 24hr 20 mg (la) methylphenidate hcl cap er 24hr 30 mg (la) methylphenidate hcl cap er 24hr 40 mg (la) methylphenidate hcl cap er 30 mg (cd) 61 methylphenidate hcl cap er 40 mg (cd) 62 methylphenidate hcl cap er 50 mg (cd) 62 methylphenidate hcl cap er 60 mg (cd) 62 methylphenidate hcl chew tab 10 mg.. 62 methylphenidate hcl chew tab 2.5 mg. 62 methylphenidate hcl chew tab 5 mg methylphenidate hcl soln 10 mg/5ml.. 62 methylphenidate hcl soln 5 mg/5ml

163 methylphenidate hcl tab 10 mg methylphenidate hcl tab 20 mg methylphenidate hcl tab 5 mg methylphenidate hcl tab er 10 mg methylphenidate hcl tab er 20 mg methylphenidate hcl tab er 24hr 27 mg methylphenidate hcl tab er 24hr 36 mg methylphenidate hcl tab er 24hr 54 mg methylphenidate hcl tab er osmotic release (osm) 18 mg methylphenidate hcl tab er osmotic release (osm) 27 mg methylphenidate hcl tab er osmotic release (osm) 36 mg methylphenidate hcl tab er osmotic release (osm) 54 mg methylprednisolone acetate inj susp 40 mg/ml methylprednisolone tab 16 mg methylprednisolone tab 32 mg methylprednisolone tab 4 mg methylprednisolone tab 8 mg methylprednisolone tab therapy pack 4 mg (21) methyltestosterone cap 10 mg metipranolol ophth soln 0.3% metoclopramide hcl inj 5 mg/ml (base equivalent) metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) (base equiv) metoclopramide hcl tab 10 mg (base equivalent) metoclopramide hcl tab 5 mg (base equivalent) metolazone tab 10 mg metolazone tab 2.5 mg metolazone tab 5 mg metoprolol & hydrochlorothiazide tab mg metoprolol & hydrochlorothiazide tab mg metoprolol & hydrochlorothiazide tab mg metoprolol succinate tab er 24hr 100 mg (tartrate equiv) metoprolol succinate tab er 24hr 200 mg (tartrate equiv) metoprolol succinate tab er 24hr 25 mg (tartrate equiv) metoprolol succinate tab er 24hr 50 mg (tartrate equiv) metoprolol tartrate iv soln 5 mg/5ml.. 41 metoprolol tartrate tab 100 mg metoprolol tartrate tab 25 mg metoprolol tartrate tab 50 mg METRONIDAZOL INJ 5MG/ML metronidazole cap 375 mg metronidazole cream 0.75% metronidazole gel 0.75% metronidazole gel 1% metronidazole in nacl 0.79% iv soln 500 mg/100ml metronidazole lotion 0.75% metronidazole tab 250 mg metronidazole tab 500 mg metronidazole vaginal gel 0.75% mexiletine hcl cap 150 mg mexiletine hcl cap 200 mg mexiletine hcl cap 250 mg midazolam hcl syrup 2 mg/ml (base equivalent) midodrine hcl tab 10 mg midodrine hcl tab 2.5 mg midodrine hcl tab 5 mg MIGLITOL TAB 100 MG MIGLITOL TAB 25 MG MIGLITOL TAB 50 MG MILK OF MAGN SUS 2400MG MINOCIN INJ 100MG minocycline hcl cap 100 mg minocycline hcl cap 50 mg minocycline hcl cap 75 mg minocycline hcl tab 100 mg minocycline hcl tab 50 mg minocycline hcl tab 75 mg minoxidil tab 10 mg minoxidil tab 2.5 mg MIOSTAT INJ 0.01% OP MIRENA IUD SYSTEM mirtazapine orally disintegrating tab 15 mg mirtazapine orally disintegrating tab 30 mg

164 mirtazapine orally disintegrating tab 45 mg mirtazapine tab 15 mg mirtazapine tab 30 mg mirtazapine tab 45 mg mirtazapine tab 7.5 mg MIRVASO GEL 0.33% misoprostol tab 100 mcg misoprostol tab 200 mcg mitomycin for iv soln 20 mg mitomycin for iv soln 40 mg mitomycin for iv soln 5 mg mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/ml) M-M-R II INJ modafinil tab 100 mg modafinil tab 200 mg moderiba pak 1200/day moderiba pak 800/day moexipril hcl tab 15 mg moexipril hcl tab 7.5 mg moexipril-hydrochlorothiazide tab mg moexipril-hydrochlorothiazide tab mg moexipril-hydrochlorothiazide tab mg molindone hcl tab 10 mg molindone hcl tab 25 mg molindone hcl tab 5 mg mometasone furoate cream 0.1% mometasone furoate oint 0.1% mometasone furoate solution 0.1% (lotion) MONOJECTOR MIS END CAPS montelukast sodium chew tab 4 mg (base equiv) montelukast sodium chew tab 5 mg (base equiv) montelukast sodium oral granules packet 4 mg (base equiv) montelukast sodium tab 10 mg (base equiv) MONUROL PAK GRANULES MORPHINE SUL INJ 10/0.7ML... 6 MORPHINE SUL INJ 150/30ML... 6 MORPHINE SUL INJ 2MG/ML... 6 MORPHINE SUL INJ 4MG/ML... 6 MORPHINE SUL INJ 5MG/ML... 6 MORPHINE SUL SUP 30MG... 6 morphine sulfate inj 10 mg/ml... 6 morphine sulfate inj 15 mg/ml... 6 morphine sulfate inj 8 mg/ml... 6 morphine sulfate inj pf 0.5 mg/ml... 6 morphine sulfate inj pf 1 mg/ml... 6 morphine sulfate iv soln 1 mg/ml... 6 morphine sulfate iv soln 25 mg/ml... 6 morphine sulfate iv soln 50 mg/ml... 6 morphine sulfate iv soln pf 10 mg/ml... 6 morphine sulfate iv soln pf 15 mg/ml... 6 morphine sulfate oral soln 10 mg/5ml... 6 morphine sulfate oral soln 100 mg/5ml (20 mg/ml)... 6 morphine sulfate oral soln 20 mg/5ml... 6 morphine sulfate suppos 10 mg... 7 morphine sulfate suppos 20 mg... 7 morphine sulfate suppos 5 mg... 6 morphine sulfate tab 15 mg... 7 morphine sulfate tab 30 mg... 7 morphine sulfate tab er 100 mg... 7 morphine sulfate tab er 15 mg... 7 morphine sulfate tab er 200 mg... 7 morphine sulfate tab er 30 mg... 7 morphine sulfate tab er 60 mg... 7 MOVANTIK TAB 12.5MG MOVANTIK TAB 25MG MOVIPREP SOL MOXEZA SOL 0.5% moxifloxacin hcl ophth soln 0.5% (base equiv) moxifloxacin hcl tab 400 mg (base equiv) MOXIFLOXACIN INJ MOZOBIL INJ MULTAQ TAB 400MG MULTIGEN PLS TAB MULTIGEN TAB MULTIGEN TAB FOLIC mupirocin calcium cream 2% mupirocin oint 2% MUSTARGEN INJ 10MG MYALEPT INJ 11.3MG MYCAMINE INJ 100MG MYCAMINE INJ 50MG mycophenolate mofetil cap 250 mg mycophenolate mofetil for oral susp

165 mg/ml mycophenolate mofetil tab 500 mg mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv) mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv) MYFORTIC TAB 180MG MYFORTIC TAB 360MG MYKIDZ IRON SUS 15/1.5ML MYLERAN TAB 2MG MYNATAL CAP MYNATAL TAB MYNATAL TAB ADVANCE MYNATE 90 TAB PLUS MYOBLOC INJ 10000/ MYOBLOC INJ 2500/ MYOBLOC INJ 5000/ML MYOZYME INJ 50MG MYRBETRIQ TAB 25MG MYRBETRIQ TAB 50MG N nabumetone tab 500 mg... 3 nabumetone tab 750 mg... 3 nadolol & bendroflumethiazide tab 40-5 mg nadolol & bendroflumethiazide tab 80-5 mg nadolol tab 20 mg nadolol tab 40 mg nadolol tab 80 mg NAFCILLIN INJ 1GM/50ML NAFCILLIN INJ 2GM/ nafcillin sodium for inj 1 gm nafcillin sodium for inj 2 gm nafcillin sodium for iv soln 1 gm nafcillin sodium for iv soln 10 gm nafcillin sodium for iv soln 2 gm NAFTIN GEL 1% NAGLAZYME INJ 1MG/ML nalbuphine hcl inj 10 mg/ml... 7 nalbuphine hcl inj 20 mg/ml... 7 naloxone hcl inj 0.4 mg/ml naloxone hcl soln prefilled syringe 2 mg/2ml naltrexone hcl tab 50 mg naphazoline hcl ophth soln 0.1% naproxen sodium tab 275 mg... 3 naproxen sodium tab 550 mg... 3 naproxen susp 125 mg/5ml... 3 naproxen tab 250 mg... 3 naproxen tab 375 mg... 3 naproxen tab 500 mg... 3 naproxen tab ec 375 mg... 3 naproxen tab ec 500 mg... 3 naratriptan hcl tab 1 mg (base equiv). 63 naratriptan hcl tab 2.5 mg (base equiv) NARCAN SPR NATACYN SUS 5% OP NATAZIA TAB nateglinide tab 120 mg nateglinide tab 60 mg NATELLE ONE CAP NATPARA INJ 100MCG NATPARA INJ 25MCG NATPARA INJ 50MCG NATPARA INJ 75MCG NATURE THROI TAB 162.5MG NATURE-THROI TAB MG NATURE-THROI TAB 130MG NATURE-THROI TAB MG NATURE-THROI TAB 16.25MG NATURE-THROI TAB 195MG NATURE-THROI TAB 260MG NATURE-THROI TAB 32.5MG NATURE-THROI TAB 325MG NATURE-THROI TAB 48.75MG NATURE-THROI TAB 65MG NATURE-THROI TAB 81.25MG NATURE-THROI TAB 97.5MG NEBUPENT INH 300MG NEBUSAL NEB 6% NECON TAB 10/ nefazodone hcl tab 100 mg nefazodone hcl tab 150 mg nefazodone hcl tab 200 mg nefazodone hcl tab 250 mg nefazodone hcl tab 50 mg neomycin sulfate tab 500 mg... 9 neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin neomycin-polymy-gramicid op sol mg-unt-mg/ml neomycin-polymyxin b gu irrigation soln neomycin-polymyxin-dexamethasone 157

166 ophth oint 0.1% neomycin-polymyxin-dexamethasone ophth susp 0.1% neomycin-polymyxin-hc ophth susp neomycin-polymyxin-hc otic soln 1% 120 neomycin-polymyxin-hc otic susp 3.5 mg/ml unit/ml-1% NEO-SYNALAR CRE NERLYNX TAB 40MG NEULASTA INJ 6MG/0.6M NEULASTA KIT 6MG/0.6M NEUPOGEN INJ 300/ NEUPOGEN INJ 300MCG NEUPOGEN INJ 480/ NEUPOGEN INJ 480MCG NEVANAC SUS 0.1% nevirapine susp 50 mg/5ml nevirapine tab 200 mg nevirapine tab er 24hr 100 mg nevirapine tab er 24hr 400 mg NEWGEN TAB 32-1MG NEXA PLUS CAP NEXAVAR TAB 200MG NEXAVIR INJ niacin tab er 1000 mg (antihyperlipidemic) niacin tab er 500 mg (antihyperlipidemic) niacin tab er 750 mg (antihyperlipidemic) nicardipine hcl cap 20 mg nicardipine hcl cap 30 mg nicardipine hcl iv soln 2.5 mg/ml nicotine polacrilex gum 2 mg nicotine polacrilex gum 4 mg nicotine polacrilex lozenge 2 mg nicotine polacrilex lozenge 4 mg NICOTINE SYS KIT TRANSDER nicotine td patch 24hr 14 mg/24hr nicotine td patch 24hr 21 mg/24hr nicotine td patch 24hr 7 mg/24hr NICOTROL INH NICOTROL NS SPR 10MG/ML nifedipine cap 10 mg nifedipine cap 20 mg nifedipine tab er 24hr 30 mg nifedipine tab er 24hr 60 mg nifedipine tab er 24hr 90 mg nifedipine tab er 24hr osmotic release 30 mg nifedipine tab er 24hr osmotic release 60 mg nifedipine tab er 24hr osmotic release 90 mg nilutamide tab 150 mg nimodipine cap 30 mg NINLARO CAP 2.3MG NINLARO CAP 3MG NINLARO CAP 4MG nisoldipine tab er 24hr 17 mg nisoldipine tab er 24hr 20 mg nisoldipine tab er 24hr 25.5 mg nisoldipine tab er 24hr 30 mg nisoldipine tab er 24hr 34 mg nisoldipine tab er 24hr 40 mg nisoldipine tab er 24hr 8.5 mg NITRO-BID OIN 2% NITRO-DUR DIS 0.3MG/HR NITRO-DUR DIS 0.8MG/HR nitrofurantoin macrocrystalline cap 100 mg nitrofurantoin macrocrystalline cap 25 mg nitrofurantoin macrocrystalline cap 50 mg nitrofurantoin monohydrate macrocrystalline cap 100 mg NITROGLYCER INJ 5MG/ML nitroglycerin cap er 2.5 mg nitroglycerin cap er 6.5 mg nitroglycerin cap er 9 mg nitroglycerin iv soln 100 mcg/ml in d5w nitroglycerin iv soln 200 mcg/ml in d5w nitroglycerin iv soln 400 mcg/ml in d5w nitroglycerin lingual aerosol 400 mcg/spray nitroglycerin sl tab 0.3 mg nitroglycerin sl tab 0.4 mg nitroglycerin sl tab 0.6 mg nitroglycerin td patch 24hr 0.1 mg/hr. 46 nitroglycerin td patch 24hr 0.2 mg/hr. 46 nitroglycerin td patch 24hr 0.4 mg/hr. 46 nitroglycerin td patch 24hr 0.6 mg/hr

167 nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray) NITROSTAT SUB 0.3MG NITROSTAT SUB 0.4MG NITROSTAT SUB 0.6MG nizatidine cap 150 mg nizatidine cap 300 mg nizatidine oral soln 15 mg/ml nonoxynol-9 gel 4% NORDITROPIN INJ 10/1.5ML NORDITROPIN INJ 15/1.5ML NORDITROPIN INJ 30/3ML NORDITROPIN INJ 5/1.5ML norelgestromin-ethinyl estradiol td ptwk mcg/24hr norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg norethindrone & ethinyl estradiol tab 1 mg-35 mcg norethindrone & ethinyl estradiol-fe chew tab 0.4 mg-35 mcg norethindrone & ethinyl estradiol-fe chew tab 0.8 mg-25 mcg norethindrone & mestranol tab 1 mg-50 mcg norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg norethindrone ace-eth estradiol-fe chew tab 1 mg-20 mcg (24) norethindrone ace-ethinyl estradiol-fe tab 1 mg-20 mcg (24) norethindrone acetate tab 5 mg norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5 mcg norethindrone acetate-ethinyl estradiol tab 1 mg-5 mcg norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35 mg-mcg norethindrone tab 0.35 mg norethindrone-eth estradiol tab / /1-35 mg-mcg norethindrone-eth estradiol tab /1-35/ mg-mcg norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg norgestimate-eth estrad tab / / mg-mcg norgestimate-eth estrad tab / / mg-mcg norgestrel & ethinyl estradiol tab 0.3 mg- 30 mcg norgestrel & ethinyl estradiol tab 0.5 mg- 50 mcg NORINYL TAB NOROXIN TAB 400MG NORTHERA CAP 100MG NORTHERA CAP 200MG NORTHERA CAP 300MG nortriptyline hcl cap 10 mg nortriptyline hcl cap 25 mg nortriptyline hcl cap 50 mg nortriptyline hcl cap 75 mg nortriptyline hcl soln 10 mg/5ml NORVIR CAP 100MG NORVIR SOL 80MG/ML NORVIR TAB 100MG NOVOCLAIR CRE... 4 NOVOFINE MIS 32GX6MM NOVOFINE PLS MIS 32GX4MM NOVOLIN INJ 70/ NOVOLIN N INJ U NOVOLIN R INJ U NOVOLOG INJ 100/ML NOVOLOG INJ FLEXPEN NOVOLOG INJ PENFILL NOVOLOG MIX INJ 70/ NOVOLOG MIX INJ FLEXPEN NOVOTWIST MIS 30GX8MM NOVOTWIST MIS 32GX5MM NOXAFIL SUS 40MG/ML NOXAFIL TAB 100MG NPLATE INJ 250MCG NPLATE INJ 500MCG NUCALA INJ 100MG NUCYNTA ER TAB 100MG... 7 NUCYNTA ER TAB 150MG... 7 NUCYNTA ER TAB 200MG... 7 NUCYNTA ER TAB 250MG

168 NUCYNTA ER TAB 50MG... 7 NUCYNTA TAB 100MG... 7 NUCYNTA TAB 50MG... 7 NUCYNTA TAB 75MG... 7 NUEDEXTA CAP 20-10MG NULOJIX INJ 250MG NUPLAZID TAB 17MG NUVARING MIS NUVIGIL TAB 150MG NUVIGIL TAB 200MG NUVIGIL TAB 250MG NUVIGIL TAB 50MG nystatin cream unit/gm nystatin oint unit/gm nystatin susp unit/ml nystatin tab unit nystatin topical powder unit/gm nystatin-triamcinolone cream unit/gm-% nystatin-triamcinolone oint unit/gm-% O OBSTETRIX PAK DHA O-CAL FA TAB OCTAGAM INJ 1GM OCTAGAM INJ 2GM/20ML octreotide acetate inj 100 mcg/ml (0.1 mg/ml) octreotide acetate inj 1000 mcg/ml (1 mg/ml) octreotide acetate inj 200 mcg/ml (0.2 mg/ml) octreotide acetate inj 50 mcg/ml (0.05 mg/ml) octreotide acetate inj 500 mcg/ml (0.5 mg/ml) ODACTRA SUB... 1 ODOMZO CAP 200MG OFEV CAP 100MG OFEV CAP 150MG ofloxacin ophth soln 0.3% ofloxacin otic soln 0.3% ofloxacin tab 400 mg olanzapine for im inj 10 mg olanzapine orally disintegrating tab 10 mg olanzapine orally disintegrating tab 15 mg olanzapine orally disintegrating tab 20 mg olanzapine orally disintegrating tab 5 mg olanzapine tab 10 mg olanzapine tab 15 mg olanzapine tab 2.5 mg olanzapine tab 20 mg olanzapine tab 5 mg olanzapine tab 7.5 mg olanzapine-fluoxetine hcl cap mg olanzapine-fluoxetine hcl cap mg olanzapine-fluoxetine hcl cap 3-25 mg 59 olanzapine-fluoxetine hcl cap 6-25 mg 59 olanzapine-fluoxetine hcl cap 6-50 mg 59 olmesartan medoxomil tab 20 mg olmesartan medoxomil tab 40 mg olmesartan medoxomil tab 5 mg olopatadine hcl nasal soln 0.6% olopatadine hcl ophth soln 0.1% (base equivalent) olopatadine hcl ophth soln 0.2% (base equivalent) OLYSIO CAP 150MG omega-3-acid ethyl esters cap 1 gm omeprazole cap delayed release 10 mg88 omeprazole cap delayed release 20 mg88 omeprazole cap delayed release 40 mg88 omeprazole-sodium bicarbonate cap mg omeprazole-sodium bicarbonate cap mg OMNARIS SPR OMNIFLEX DPR ONCASPAR INJ 750/ML ondansetron hcl inj 4 mg/2ml (2 mg/ml) ondansetron hcl inj 40 mg/20ml (2 mg/ml) ondansetron hcl oral soln 4 mg/5ml ondansetron hcl tab 24 mg ondansetron hcl tab 4 mg ondansetron hcl tab 8 mg ondansetron orally disintegrating tab 4 mg

169 ondansetron orally disintegrating tab 8 mg ONE TCH SLVR KIT ULT MINI ONETOUCH KIT ULT MINI ONETOUCH KIT ULTRA ONETOUCH KIT ULTRALNK ONETOUCH KIT VERIO ONETOUCH KIT VERIO IQ ONETOUCH TES ULTRA BL ONETOUCH TES VERIO ONETOUCH VER KIT SYNC ONFI SUS 2.5MG/ML ONFI TAB 10MG ONFI TAB 20MG ONMEL TAB 200MG OPSUMIT TAB 10MG ORALAIR SUB 300 IR... 1 ORAMAGICRX SUS ORAVIG TAB 50MG ORENITRAM TAB 0.125MG ORENITRAM TAB 0.25MG ORENITRAM TAB 1MG ORENITRAM TAB 2.5MG ORENITRAM TAB 5MG ORFADIN CAP 10MG ORFADIN CAP 2MG ORFADIN CAP 5MG ORKAMBI TAB orphenadrine citrate inj 30 mg/ml orphenadrine citrate tab er 12hr 100 mg ORTHO COIL DPR KIT ORTHO COIL DPR KIT ORTHO COIL DPR KIT ORTHO FLAT DPR KIT ORTHO FLAT DPR KIT ORTHO FLAT DPR KIT ORTHO FLAT DPR KIT ORTHO FLAT DPR KIT ORTHO FLAT DPR KIT ORTHO FLAT DPR KIT ORTHO FLAT DPR KIT ORTHO FLAT DPR KIT oseltamivir phosphate cap 30 mg (base equiv) oseltamivir phosphate cap 45 mg (base equiv) oseltamivir phosphate cap 75 mg (base equiv) oseltamivir phosphate for susp 6 mg/ml (base equiv) OSMOPREP TAB 1.5GM OSPHENA TAB 60MG OTEZLA TAB 10/20/ OTEZLA TAB 30MG OTREXUP INJ 10MG OTREXUP INJ 15MG OTREXUP INJ 20MG OTREXUP INJ 25MG OTREXUP INJ 7.5/ oxacillin sodium for inj 1 gm (base equivalent) oxacillin sodium for inj 10 gm (base equivalent) oxacillin sodium for inj 2 gm (base equivalent) oxaliplatin for iv inj 100 mg oxaliplatin for iv inj 50 mg oxaliplatin iv soln 100 mg/20ml oxaliplatin iv soln 50 mg/10ml oxandrolone tab 10 mg... 1 oxandrolone tab 2.5 mg... 1 oxaprozin tab 600 mg... 3 oxazepam cap 10 mg oxazepam cap 15 mg oxazepam cap 30 mg oxcarbazepine susp 300 mg/5ml (60 mg/ml) oxcarbazepine tab 150 mg oxcarbazepine tab 300 mg oxcarbazepine tab 600 mg oxiconazole nitrate cream 1% OXSORALEN-UL CAP 10MG oxybutynin chloride syrup 5 mg/5ml oxybutynin chloride tab 5 mg oxybutynin chloride tab er 24hr 10 mg 90 oxybutynin chloride tab er 24hr 15 mg 90 oxybutynin chloride tab er 24hr 5 mg. 90 oxycodone hcl cap 5 mg... 7 oxycodone hcl conc 100 mg/5ml (20 mg/ml)... 7 oxycodone hcl soln 5 mg/5ml... 7 oxycodone hcl tab 10 mg... 7 oxycodone hcl tab 15 mg... 7 oxycodone hcl tab 20 mg... 7 oxycodone hcl tab 30 mg

170 oxycodone hcl tab 5 mg... 7 oxycodone hcl tab er 12hr deter 10 mg 7 oxycodone hcl tab er 12hr deter 15 mg 7 oxycodone hcl tab er 12hr deter 20 mg 7 oxycodone hcl tab er 12hr deter 30 mg 7 oxycodone hcl tab er 12hr deter 40 mg 7 oxycodone hcl tab er 12hr deter 60 mg 7 oxycodone hcl tab er 12hr deter 80 mg 7 oxycodone w/ acetaminophen tab mg... 7 oxycodone w/ acetaminophen tab mg... 7 oxycodone w/ acetaminophen tab mg... 7 oxycodone w/ acetaminophen tab mg... 7 oxycodone-aspirin tab mg. 7 oxycodone-ibuprofen tab mg... 8 OXYCONTIN TAB 10MG CR... 8 OXYCONTIN TAB 15MG CR... 8 OXYCONTIN TAB 20MG CR... 8 OXYCONTIN TAB 30MG CR... 8 OXYCONTIN TAB 40MG CR... 8 OXYCONTIN TAB 60MG CR... 8 OXYCONTIN TAB 80MG CR... 8 oxymorphone hcl tab 10 mg... 8 oxymorphone hcl tab 5 mg... 8 oxymorphone hcl tab er 12hr 10 mg... 8 oxymorphone hcl tab er 12hr 15 mg... 8 oxymorphone hcl tab er 12hr 20 mg... 8 oxymorphone hcl tab er 12hr 30 mg... 8 oxymorphone hcl tab er 12hr 40 mg... 8 oxymorphone hcl tab er 12hr 5 mg... 8 oxymorphone hcl tab er 12hr 7.5 mg... 8 P paclitaxel iv conc 30 mg/5ml (6 mg/ml) paliperidone tab er 24hr 1.5 mg paliperidone tab er 24hr 3 mg paliperidone tab er 24hr 6 mg paliperidone tab er 24hr 9 mg PALYNZIQ INJ 10/0.5ML PALYNZIQ INJ 2.5/ PALYNZIQ INJ 20MG/ML pamidronate disodium for inj 30 mg pamidronate disodium for inj 90 mg pamidronate disodium iv soln 3 mg/ml 75 pamidronate disodium iv soln 9 mg/ml 75 PAMIDRONATE INJ 6MG/ML PANRETIN GEL 0.1% pantoprazole sodium ec tab 20 mg (base equiv) pantoprazole sodium ec tab 40 mg (base equiv) papaverine hcl inj 30 mg/ml PARAGARD IUD T380A paregoric tincture 2 mg/5ml (morphine equivalent) paricalcitol cap 1 mcg paricalcitol cap 2 mcg paricalcitol cap 4 mcg paromomycin sulfate cap 250 mg... 9 paroxetine hcl tab 10 mg paroxetine hcl tab 20 mg paroxetine hcl tab 30 mg paroxetine hcl tab 40 mg PASER GRA 4GM PATADAY SOL 0.2% PATANOL SOL 0.1% OP PAZEO DRO 0.7% pb-hyoscy-atrop-scopol tab mg PEDIARIX INJ 0.5ML PEDVAX HIB INJ peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm peg 3350-kcl-sod bicarb-nacl for soln 420 gm PEGANONE TAB 250MG PEGASYS INJ PEGASYS INJ 180MCG/M PEGASYS INJ PROCLICK PEG-INTRON KIT 120 RP PEG-INTRON KIT 150MCG PEG-INTRON KIT 50MCG RP PEG-INTRON KIT 80MCG PEN G PROC INJ PEN NEEDLES MIS 29GX10MM PEN NEEDLES MIS 29GX PENICILL GK/ INJ DEX 1MU PENICILL GK/ INJ DEX 2MU PENICILL GK/ INJ DEX 3MU PENICILLAMIN POW penicillin g potassium for inj

171 unit penicillin g potassium for inj unit penicillin g sodium for inj unit penicillin v potassium for soln 125 mg/5ml penicillin v potassium for soln 250 mg/5ml penicillin v potassium tab 250 mg penicillin v potassium tab 500 mg PENTACEL INJ PENTAM 300 INJ 300MG PENTASA CAP 250MG CR PENTASA CAP 500MG CR pentazocine w/ naloxone tab mg 8 pentoxifylline tab er 400 mg PERFOROMIST NEB 20MCG perindopril erbumine tab 2 mg perindopril erbumine tab 4 mg perindopril erbumine tab 8 mg permethrin cream 5% perphenazine tab 16 mg perphenazine tab 2 mg perphenazine tab 4 mg perphenazine tab 8 mg perphenazine-amitriptyline tab 2-10 mg perphenazine-amitriptyline tab 2-25 mg perphenazine-amitriptyline tab 4-10 mg perphenazine-amitriptyline tab 4-25 mg perphenazine-amitriptyline tab 4-50 mg PERRY PRENAT CAP phenazopyridine hcl tab 100 mg phenazopyridine hcl tab 200 mg phendimetrazine tartrate tab 35 mg... 1 phenelzine sulfate tab 15 mg PHENHIST DH LIQ phenobarbital elixir 20 mg/5ml phenobarbital tab 100 mg phenobarbital tab 15 mg phenobarbital tab 16.2 mg phenobarbital tab 30 mg phenobarbital tab 32.4 mg phenobarbital tab 60 mg phenobarbital tab 64.8 mg phenobarbital tab 97.2 mg phenoxybenzamine hcl cap 10 mg phentermine hcl cap 15 mg... 1 PHENTOLAMINE INJ 5MG phenylephrine hcl ophth soln 10% phenylephrine hcl ophth soln 2.5% phenylephrine w/ dm-gg tab mg phenylephrine-guaifenesin liqd mg/5ml ( mg/ml) phenytoin chew tab 50 mg phenytoin sodium extended cap 100 mg phenytoin sodium extended cap 200 mg phenytoin sodium extended cap 300 mg phenytoin sodium inj 50 mg/ml phenytoin susp 125 mg/5ml PHOSPHOLINE SOL 0.125%OP PHOTOFRIN INJ 75MG PICATO GEL 0.015% PICATO GEL 0.05% pilocarpine hcl ophth soln 1% pilocarpine hcl ophth soln 2% pilocarpine hcl ophth soln 4% pilocarpine hcl tab 5 mg pilocarpine hcl tab 7.5 mg pimozide tab 1 mg pimozide tab 2 mg pindolol tab 10 mg pindolol tab 5 mg pioglitazone hcl tab 15 mg (base equiv) pioglitazone hcl tab 30 mg (base equiv) pioglitazone hcl tab 45 mg (base equiv) pioglitazone hcl-metformin hcl tab mg pioglitazone hcl-metformin hcl tab mg piperacillin sod-tazobactam na for inj gm ( gm) piperacillin sod-tazobactam sod for inj 2.25 gm ( gm)

172 piperacillin sod-tazobactam sod for inj 4.5 gm (4-0.5 gm) piperacillin sod-tazobactam sod for inj 40.5 gm ( gm) piroxicam cap 10 mg... 3 piroxicam cap 20 mg... 3 PLEGRIDY INJ PLEGRIDY INJ PEN PLEGRIDY INJ STARTER PLEGRIDY PEN INJ STARTER PNEUMOVAX 23 INJ 25/ PNV FOLIC AC TAB + IRON PNV OB+DHA PAK PNV PRENATAL TAB PLUS PNV-DHA CAP DOCUSATE podofilox soln 0.5% polyethylene glycol 3350 oral powder.. 87 polymyxin b sulfate for inj unit 22 polymyxin b-trimethoprim ophth soln unit/ml-0.1% POMALYST CAP 1MG POMALYST CAP 2MG POMALYST CAP 3MG POMALYST CAP 4MG pot & sod citrates w/ cit ac soln mg/5ml pot & sod citrates w/ cit ac syrup mg/5ml pot bicarbonate & chloride effer tab 25 meq pot phos monobasic w/sod phos di & monobas tab mg potassium bicarbonate effer tab 25 meq potassium chloride cap er 10 meq potassium chloride cap er 8 meq potassium chloride microencapsulated crys er tab 10 meq potassium chloride microencapsulated crys er tab 20 meq potassium chloride oral soln 10% (20 meq/15ml) potassium chloride oral soln 20% (40 meq/15ml) potassium chloride powder packet 20 meq potassium chloride tab er 10 meq potassium chloride tab er 20 meq (1500 mg) potassium chloride tab er 8 meq (600 mg) potassium citrate & citric acid powder pack mg potassium citrate & citric acid soln mg/5ml potassium citrate tab er 10 meq (1080 mg) potassium citrate tab er 15 meq (1620 mg) potassium citrate tab er 5 meq (540 mg) POTIGA TAB 200MG POTIGA TAB 300MG POTIGA TAB 400MG POTIGA TAB 50MG PR NATAL 400 PAK EC PR NATAL 430 PAK PR NATAL 430 PAK EC PRALUENT INJ 150MG/ML PRALUENT INJ 75MG/ML pramipexole dihydrochloride tab mg pramipexole dihydrochloride tab 0.25 mg pramipexole dihydrochloride tab 0.5 mg pramipexole dihydrochloride tab 0.75 mg pramipexole dihydrochloride tab 1 mg 56 pramipexole dihydrochloride tab 1.5 mg pramoxine-hc cream 1-2.5% pramoxine-hc-chloroxylenol otic soln mg/ml prasugrel hcl tab 10 mg (base equiv).. 94 prasugrel hcl tab 5 mg (base equiv) pravastatin sodium tab 10 mg pravastatin sodium tab 20 mg pravastatin sodium tab 40 mg pravastatin sodium tab 80 mg prazosin hcl cap 1 mg prazosin hcl cap 2 mg prazosin hcl cap 5 mg PRED MILD SUS 0.12% OP PRED SOD PHO SOL 1% OP PRED-G S.O.P OIN OP

173 PRED-G SUS OP prednicarbate cream 0.1% prednicarbate oint 0.1% prednisolone acetate ophth susp 1%. 117 prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base) prednisolone sod phosphate oral soln 15 mg/5ml (base equiv) prednisolone sodium phosphate oral soln 25 mg/5ml (base eq) prednisolone syrup 15 mg/5ml (usp solution equivalent) PREDNISONE CON 5MG/ML prednisone oral soln 5 mg/5ml prednisone tab 1 mg prednisone tab 10 mg prednisone tab 2.5 mg prednisone tab 20 mg prednisone tab 5 mg prednisone tab 50 mg prednisone tab therapy pack 10 mg (21) prednisone tab therapy pack 5 mg (21) PREMARIN INJ 25MG PREMARIN TAB 0.3MG PREMARIN TAB 0.45MG PREMARIN TAB 0.625MG PREMARIN TAB 0.9MG PREMARIN TAB 1.25MG PREMARIN VAG CRE 0.625MG PREMPHASE TAB PREMPRO TAB PREMPRO TAB PREMPRO TAB PREMPRO TAB PRENA1 CHW PRENAISSANCE CAP PRENAISSANCE CAP BALANCE PRENAISSANCE CAP PLUS PRENAISSANCE PAK 90 DHA PRENAISSANCE PAK DHA PRENAISSANCE PAK PROMISE PRENAISSANCE TAB NEXT PRENAT PLUS TAB 27-1MG PRENATAL ONE TAB DAILY PRENATAL TAB PRENATAL TAB MG PRENATAL TAB 27-1MG PRENATAL TAB MG PRENATAL TAB COMPLETE PRENATAL TAB FORMULA PRENATAL TAB LOW IRON PRENATAL TAB PLUS/FE PRENATAL-U CAP PRENTIF MIS 22MM PRENTIF MIS 25MM PRENTIF MIS 28MM PRENTIF MIS 31MM PRENTIF MIS FITTING PREPLUS TAB 27-1MG PREPOPIK PAK PRETAB TAB 29-1MG PREVNAR 13 INJ PREZCOBIX TAB PREZISTA SUS 100MG/ML PREZISTA TAB 150MG PREZISTA TAB 600MG PREZISTA TAB 75MG PREZISTA TAB 800MG PRIFTIN TAB 150MG PRIMAQUINE TAB 26.3MG primidone tab 250 mg primidone tab 50 mg PRISTIQ TAB 100MG PRISTIQ TAB 25MG PRISTIQ TAB 50MG PRIVIGEN INJ 5 GRAMS PROAIR HFA AER probenecid tab 500 mg procainamide hcl inj 100 mg/ml PROCAINAMIDE INJ 500MG/ML prochlorperazine edisylate inj 5 mg/ml 85 prochlorperazine maleate tab 10 mg (base equivalent) prochlorperazine maleate tab 5 mg (base equivalent) prochlorperazine suppos 25 mg PROCRIT INJ 40000/ML PROCYSBI CAP 25MG PROCYSBI CAP 75MG progesterone im in oil 50 mg/ml progesterone micronized cap 100 mg. 81 progesterone micronized cap 200 mg. 81 PROGLYCEM SUS 50MG/ML PROGRAF INJ 5MG/ML

174 PROLASTIN-C INJ 1000MG PROLENSA SOL 0.07% PROLEUKIN INJ 22MU PROLIA SOL 60MG/ML PROMACTA TAB 12.5MG PROMACTA TAB 25MG PROMACTA TAB 50MG PROMACTA TAB 75MG promethazine & phenylephrine syrup mg/5ml promethazine hcl inj 25 mg/ml promethazine hcl inj 50 mg/ml promethazine hcl suppos 12.5 mg promethazine hcl suppos 25 mg promethazine hcl suppos 50 mg promethazine hcl syrup 6.25 mg/5ml.. 85 promethazine hcl tab 12.5 mg promethazine hcl tab 25 mg promethazine hcl tab 50 mg promethazine w/ codeine syrup mg/5ml promethazine-dm syrup mg/5ml promethazine-phenylephrine-codeine syrup mg/5ml propafenone hcl cap er 12hr 225 mg propafenone hcl cap er 12hr 325 mg propafenone hcl cap er 12hr 425 mg propafenone hcl tab 150 mg propafenone hcl tab 225 mg propafenone hcl tab 300 mg propantheline bromide tab 15 mg proparacaine hcl ophth soln 0.5% propranolol & hydrochlorothiazide tab mg propranolol & hydrochlorothiazide tab mg propranolol hcl cap er 24hr 120 mg propranolol hcl cap er 24hr 160 mg propranolol hcl cap er 24hr 60 mg propranolol hcl cap er 24hr 80 mg propranolol hcl inj 1 mg/ml propranolol hcl oral soln 20 mg/5ml propranolol hcl oral soln 40 mg/5ml propranolol hcl tab 10 mg propranolol hcl tab 20 mg propranolol hcl tab 40 mg propranolol hcl tab 60 mg propranolol hcl tab 80 mg propylthiouracil tab 50 mg PROQUAD INJ protamine sulfate inj 10 mg/ml protriptyline hcl tab 10 mg protriptyline hcl tab 5 mg PROVENTIL AER HFA PRUTECT EMU pseudoephed-bromphen-dm syrup mg/5ml pseudoephedrine w/ cod-gg soln mg/5ml PULMICORT INH 180MCG PULMICORT INH 90MCG PULMOZYME SOL 1MG/ML pyrazinamide tab 500 mg pyridostigmine bromide tab 60 mg Q QUADRACEL INJ QUARTETTE TAB quetiapine fumarate tab 100 mg quetiapine fumarate tab 200 mg quetiapine fumarate tab 25 mg quetiapine fumarate tab 300 mg quetiapine fumarate tab 400 mg quetiapine fumarate tab 50 mg quetiapine fumarate tab er 24hr 150 mg quetiapine fumarate tab er 24hr 200 mg quetiapine fumarate tab er 24hr 300 mg quetiapine fumarate tab er 24hr 400 mg quetiapine fumarate tab er 24hr 50 mg quinapril hcl tab 10 mg quinapril hcl tab 20 mg quinapril hcl tab 40 mg quinapril hcl tab 5 mg quinapril-hydrochlorothiazide tab mg quinapril-hydrochlorothiazide tab mg quinapril-hydrochlorothiazide tab mg QUINIDINE GL INJ 80MG/ML quinidine gluconate tab er 324 mg

175 quinidine sulfate tab 200 mg quinidine sulfate tab 300 mg quinidine sulfate tab er 300 mg quinine sulfate cap 324 mg QUTENZA KIT 8% 1-PCH QVAR AER 40MCG QVAR AER 80MCG QVAR REDIHA AER 80MCG QVAR REDIHAL AER 40MCG R RA ONE DAILY MIS rabeprazole sodium ec tab 20 mg RAGWITEK SUB... 1 raloxifene hcl tab 60 mg ramipril cap 1.25 mg ramipril cap 10 mg ramipril cap 2.5 mg ramipril cap 5 mg RANEXA TAB 1000MG RANEXA TAB 500MG ranitidine hcl cap 150 mg ranitidine hcl cap 300 mg ranitidine hcl inj 150 mg/6ml (25 mg/ml) ranitidine hcl inj 50 mg/2ml (25 mg/ml) ranitidine hcl syrup 15 mg/ml (75 mg/5ml) ranitidine hcl tab 150 mg ranitidine hcl tab 300 mg RAPAFLO CAP 4MG RAPAFLO CAP 8MG RAPAMUNE SOL 1MG/ML rasagiline mesylate tab 0.5 mg (base equiv) rasagiline mesylate tab 1 mg (base equiv) RASUVO INJ 10MG RASUVO INJ 12.5MG RASUVO INJ 15MG RASUVO INJ 17.5MG RASUVO INJ 22.5MG RASUVO INJ 25MG RASUVO INJ 27.5MG RASUVO INJ 30MG RASUVO INJ 7.5MG RAVICTI LIQ 1.1GM/ML REBETOL SOL 40MG/ML REBIF INJ 22/ REBIF INJ 44/ REBIF REBIDO INJ 22/ REBIF REBIDO INJ 44/ REBIF REBIDO INJ TITRATN REBIF TITRTN INJ PACK RECOMBIVA HB INJ 10MCG/ML RECOMBIVA HB INJ 5MCG/ RECOMBIVA-HB INJ 40MCG/ML RECTIV OIN 0.4% REDICHEW RX CHW REGONOL INJ 5MG/ML REGRANEX GEL 0.01% RELENZA MIS DISKHALE RELNATE DHA CAP REMODULIN INJ 10MG/ML REMODULIN INJ 1MG/ML REMODULIN INJ 2.5MG/ML REMODULIN INJ 5MG/ML RENAGEL TAB 400MG RENAGEL TAB 800MG repaglinide tab 0.5 mg repaglinide tab 1 mg repaglinide tab 2 mg repaglinide-metformin hcl tab mg repaglinide-metformin hcl tab mg REPATHA INJ 140MG/ML REPATHA SURE INJ 140MG/ML REPREXAIN TAB RESCRIPTOR TAB 100 MG RESCRIPTOR TAB 200MG RESCULA SOL 0.15% reserpine tab 0.1 mg reserpine tab 0.25 mg RESTASIS EMU 0.05% RETROVIR INJ 10MG/ML REVLIMID CAP 10MG REVLIMID CAP 15MG REVLIMID CAP 2.5MG REVLIMID CAP 20MG REVLIMID CAP 25MG REVLIMID CAP 5MG REXULTI TAB 0.25MG REXULTI TAB 0.5MG REXULTI TAB 1MG REXULTI TAB 2MG

176 REXULTI TAB 3MG REXULTI TAB 4MG REYATAZ CAP 150MG REYATAZ CAP 200MG REYATAZ CAP 300MG REYATAZ POW 50MG RHOPRESSA SOL 0.02% RIBAPAK PAK 1000/DAY ribavirin cap 200 mg ribavirin tab 200 mg ribavirin tab 400 mg ribavirin tab 600 mg RIDAURA CAP 3MG rifabutin cap 150 mg RIFAMATE CAP rifampin cap 150 mg rifampin cap 300 mg rifampin for inj 600 mg RIFATER TAB riluzole tab 50 mg rimantadine hydrochloride tab 100 mg 21 ringer's solution for irrigation risedronate sodium tab 150 mg risedronate sodium tab 30 mg risedronate sodium tab 35 mg risedronate sodium tab 5 mg risedronate sodium tab delayed release 35 mg RISPERDAL INJ 12.5MG RISPERDAL INJ 25MG RISPERDAL INJ 37.5MG RISPERDAL INJ 50MG risperidone orally disintegrating tab 0.25 mg risperidone orally disintegrating tab 0.5 mg risperidone orally disintegrating tab 1 mg risperidone orally disintegrating tab 2 mg risperidone orally disintegrating tab 3 mg risperidone orally disintegrating tab 4 mg risperidone soln 1 mg/ml risperidone tab 0.25 mg risperidone tab 0.5 mg risperidone tab 1 mg risperidone tab 2 mg risperidone tab 3 mg risperidone tab 4 mg ritonavir tab 100 mg RITUXAN INJ 100MG rivastigmine tartrate cap 1.5 mg (base equivalent) rivastigmine tartrate cap 3 mg (base equivalent) rivastigmine tartrate cap 4.5 mg (base equivalent) rivastigmine tartrate cap 6 mg (base equivalent) rivastigmine td patch 24hr 13.3 mg/24hr rivastigmine td patch 24hr 4.6 mg/24hr rivastigmine td patch 24hr 9.5 mg/24hr rizatriptan benzoate oral disintegrating tab 10 mg (base eq) rizatriptan benzoate oral disintegrating tab 5 mg (base eq) rizatriptan benzoate tab 10 mg (base equivalent) rizatriptan benzoate tab 5 mg (base equivalent) ropinirole hydrochloride tab 0.25 mg.. 56 ropinirole hydrochloride tab 0.5 mg ropinirole hydrochloride tab 1 mg ropinirole hydrochloride tab 2 mg ropinirole hydrochloride tab 3 mg ropinirole hydrochloride tab 4 mg ropinirole hydrochloride tab 5 mg ropinirole hydrochloride tab er 24hr 12 mg (base equivalent) ropinirole hydrochloride tab er 24hr 2 mg (base equivalent) ropinirole hydrochloride tab er 24hr 4 mg (base equivalent) ropinirole hydrochloride tab er 24hr 6 mg (base equivalent) ropinirole hydrochloride tab er 24hr 8 mg (base equivalent) rosuvastatin calcium tab 10 mg rosuvastatin calcium tab 20 mg rosuvastatin calcium tab 40 mg rosuvastatin calcium tab 5 mg

177 ROTARIX SUS ROTATEQ SOL RUBR TAB 200MG RUBR TAB 250MG RUBR TAB 300MG RUCONEST INJ 2100UNIT RYDAPT CAP 25MG RYDEX LIQ S SABRIL TAB 500MG SAFYRAL TAB SALICEPT SUS SALICYLIC AC LIQ 26% salicylic acid cream 6% salicylic acid film forming liquid 27.5% salicylic acid lotion 6% salicylic acid shampoo 6% salsalate tab 500 mg... 3 salsalate tab 750 mg... 3 SAMSCA TAB 15MG SAMSCA TAB 30MG SANCUSO DIS 3.1MG SANDOSTATIN KIT LAR 10MG SANDOSTATIN KIT LAR 20MG SANDOSTATIN KIT LAR 30MG SANTYL OIN 250/GM SAPHRIS SUB 2.5MG SAPHRIS SUB 5MG SAVAYSA TAB 15MG SAVAYSA TAB 30MG SAVAYSA TAB 60MG SAVELLA MIS TITR PAK SAVELLA TAB 100MG SAVELLA TAB 12.5MG SAVELLA TAB 25MG SAVELLA TAB 50MG scopolamine td patch 72hr 1 mg/3days selegiline hcl cap 5 mg selegiline hcl tab 5 mg selenium sulfide lotion 2.5% selenium sulfide shampoo 2.25% SELZENTRY SOL 20MG/ML SELZENTRY TAB 150MG SELZENTRY TAB 300MG SE-NATAL 19 TAB SENSIPAR TAB 30MG SENSIPAR TAB 60MG SENSIPAR TAB 90MG SEREVENT DIS AER 50MCG SEROSTIM INJ 4MG SEROSTIM INJ 5MG SEROSTIM INJ 6MG sertraline hcl oral concentrate for solution 20 mg/ml sertraline hcl tab 100 mg sertraline hcl tab 25 mg sertraline hcl tab 50 mg SE-TAN DHA CAP sevelamer carbonate packet 0.8 gm sevelamer carbonate packet 2.4 gm sevelamer carbonate tab 800 mg SHUR-SEAL GEL 2% SIGNIFOR INJ 0.3MG/ML SIGNIFOR INJ 0.6MG/ML SIGNIFOR INJ 0.9MG/ML SIGNIFOR LAR INJ 20MG SIGNIFOR LAR INJ 40MG SIGNIFOR LAR INJ 60MG sildenafil citrate tab 20 mg SILVER NITRA SOL 10% silver nitrate-potassium nitrate applicator 75-25% silver sulfadiazine cream 1% SIMBRINZA SUS 1-0.2% SIMULECT INJ 10MG SIMULECT INJ 20MG simvastatin tab 10 mg simvastatin tab 20 mg simvastatin tab 40 mg simvastatin tab 5 mg simvastatin tab 80 mg sirolimus tab 0.5 mg sirolimus tab 1 mg sirolimus tab 2 mg SIRTURO TAB 100MG SIVEXTRO INJ 200MG SIVEXTRO TAB 200MG SKLICE LOT 0.5% SKYLA IUD 13.5MG sodium chloride soln nebu 10% sodium chloride soln nebu 3% sodium chloride soln nebu 7% sodium citrate & citric acid soln mg/5ml

178 sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf) sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf) sodium fluoride chew tab 1 mg f (from 2.2 mg naf) sodium fluoride cream 1.1% sodium fluoride gel 1.1% (0.5% f) sodium fluoride rinse 0.2% sodium fluoride soln mg/drop f (0.275 mg/drop naf) sodium fluoride soln 0.25 mg/drop f (from 0.55 mg/drop naf) sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf) sodium fluoride tab 0.5 mg f (from 1.1 mg naf) sodium phenylbutyrate oral powder 3 gm/teaspoonful sodium phenylbutyrate tab 500 mg sodium polystyrene sulfonate oral susp 15 gm/60ml sodium polystyrene sulfonate rectal susp 30 gm/120ml SOLIQUA INJ 100/ SOLIRIS INJ 10MG/ML SOMATULINE INJ 120/.5ML SOMATULINE INJ 60/0.2ML SOMATULINE INJ 90/0.3ML SOMAVERT INJ 10MG SOMAVERT INJ 15MG SOMAVERT INJ 20MG SOMAVERT INJ 25MG SOMAVERT INJ 30MG sotalol hcl (afib/afl) tab 120 mg sotalol hcl (afib/afl) tab 160 mg sotalol hcl (afib/afl) tab 80 mg SOTALOL HCL INJ 150/10ML sotalol hcl tab 120 mg sotalol hcl tab 160 mg sotalol hcl tab 240 mg sotalol hcl tab 80 mg SOVALDI TAB 400MG SPECTRACEF TAB 200MG SPECTRACEF TAB 400MG spinosad susp 0.9% SPIRIVA AER 1.25MCG SPIRIVA CAP HANDIHLR SPIRIVA SPR 2.5MCG spironolactone & hydrochlorothiazide tab mg spironolactone tab 100 mg spironolactone tab 25 mg spironolactone tab 50 mg SPORANOX SOL 10MG/ML SPRYCEL TAB 100MG SPRYCEL TAB 140MG SPRYCEL TAB 20MG SPRYCEL TAB 50MG SPRYCEL TAB 70MG SPRYCEL TAB 80MG SSKI SOL 1GM/ML ST JOSEPH CHW 75MG ADU... 3 stavudine cap 15 mg stavudine cap 20 mg stavudine cap 30 mg stavudine cap 40 mg stavudine for oral soln 1 mg/ml STELARA INJ 45MG/ STELARA INJ 90MG/ML STIOLTO AER STIVARGA TAB 40MG STRATTERA CAP 100MG STRATTERA CAP 10MG STRATTERA CAP 18MG STRATTERA CAP 25MG STRATTERA CAP 40MG STRATTERA CAP 60MG STRATTERA CAP 80MG streptomycin sulfate for inj 1 gm... 9 STRIANT MIS 30MG STRIBILD TAB STRIVERDI AER 2.5MCG STROMECTOL TAB 3MG SUBOXONE MIS 12-3MG SUBOXONE MIS 2-0.5MG SUBOXONE MIS 4-1MG SUBOXONE MIS 8-2MG SUBSYS SPR 100MCG... 8 SUBSYS SPR 1200MCG... 8 SUBSYS SPR 1600MCG... 8 SUBSYS SPR 200MCG... 8 SUBSYS SPR 400MCG... 8 SUBSYS SPR 600MCG... 8 SUBSYS SPR 800MCG... 8 SUCLEAR KIT

179 SUCRAID SOL 8500/ML sucralfate tab 1 gm sulfacetamide sodium liquid 10% sulfacetamide sodium lotion 10% (acne) sulfacetamide sodium ophth oint 10% sulfacetamide sodium ophth soln 10% sulfacetamide sodium w/ sulfur emulsion 10-1% sulfacetamide sodium w/ sulfur emulsion 10-5% sulfacetamide sodium-prednisolone ophth soln (0.25)% SULFADIAZINE TAB 500MG sulfamethoxazole-trimethoprim iv soln mg/5ml sulfamethoxazole-trimethoprim susp mg/5ml sulfamethoxazole-trimethoprim tab mg sulfamethoxazole-trimethoprim tab mg SULFAMYLON CRE 85MG/GM sulfasalazine tab 500 mg sulfasalazine tab delayed release 500 mg sulindac tab 150 mg... 3 sulindac tab 200 mg... 3 sumatriptan nasal spray 20 mg/act sumatriptan nasal spray 5 mg/act sumatriptan succinate inj 6 mg/0.5ml. 64 sumatriptan succinate solution autoinjector 4 mg/0.5ml sumatriptan succinate solution autoinjector 6 mg/0.5ml sumatriptan succinate solution cartridge 4 mg/0.5ml sumatriptan succinate solution cartridge 6 mg/0.5ml sumatriptan succinate solution prefilled syringe 6 mg/0.5ml sumatriptan succinate tab 100 mg sumatriptan succinate tab 25 mg sumatriptan succinate tab 50 mg SUPPRELIN LA KIT 50MG SUPRAX CAP 400MG SUPRAX CHW 100MG SUPRAX CHW 200MG SUPRAX SUS 100/5ML SUPRAX SUS 200/5ML SUPRAX SUS 500/5ML SUPREP BOWEL SOL PREP KIT SUSTIVA CAP 200MG SUSTIVA CAP 50MG SUSTIVA TAB 600MG SUTENT CAP 12.5MG SUTENT CAP 25MG SUTENT CAP 37.5MG SUTENT CAP 50MG SYLATRON KIT 200MCG SYLATRON KIT 300MCG SYLATRON KIT 600MCG SYLVANT SOL 100MG SYLVANT SOL 400MG SYMBICORT AER SYMBICORT AER SYMDEKO TAB SYMLINPEN 60 INJ 1000MCG SYMLNPEN 120 INJ 1000MCG SYMPATH NDL MIS 18GX SYNAGIS INJ 100MG/ML SYNAGIS INJ 50MG SYNAREL SOL 2MG/ML SYNERA DIS 70-70MG SYNJARDY TAB SYNJARDY TAB SYNJARDY TAB MG SYNJARDY TAB 5-500MG SYNJARDY XR TAB SYNJARDY XR TAB SYNJARDY XR TAB SYNJARDY XR TAB MG SYNTHROID TAB 100MCG SYNTHROID TAB 112MCG SYNTHROID TAB 125MCG SYNTHROID TAB 137MCG SYNTHROID TAB 150MCG SYNTHROID TAB 175MCG SYNTHROID TAB 200MCG SYNTHROID TAB 25MCG SYNTHROID TAB 300MCG SYNTHROID TAB 50MCG SYNTHROID TAB 75MCG SYNTHROID TAB 88MCG

180 SYPRINE CAP 250MG T TABLOID TAB 40MG TACLONEX SUS tacrolimus cap 0.5 mg tacrolimus cap 1 mg tacrolimus cap 5 mg tacrolimus oint 0.03% tacrolimus oint 0.1% TAFINLAR CAP 50MG TAFINLAR CAP 75MG TAGRISSO TAB 40MG TAGRISSO TAB 80MG TALWIN INJ 30MG/ML... 8 TAMIFLU CAP 30MG TAMIFLU CAP 45MG TAMIFLU CAP 75MG TAMIFLU SUS 6MG/ML tamoxifen citrate tab 10 mg (base equivalent) tamoxifen citrate tab 20 mg (base equivalent) tamsulosin hcl cap 0.4 mg TARCEVA TAB 100MG TARCEVA TAB 150MG TARCEVA TAB 25MG TARGRETIN CAP 75MG TARGRETIN GEL 1% TARON FORTE CAP TARON-C DHA CAP TARON-PREX CAP TASIGNA CAP 150MG TASIGNA CAP 200MG TASIGNA CAP 50MG TAYTULLA CAP 1MG/20MC tazarotene cream 0.1% TAZORAC CRE 0.05% TAZORAC GEL 0.05% TAZORAC GEL 0.1% TECFIDERA CAP 120MG TECFIDERA CAP 240MG TECFIDERA MIS STARTER TECHLITE MIS LANCETS TECHNIVIE TAB TEFLARO INJ 400MG TEFLARO INJ 600MG TEKTURNA HCT TAB TEKTURNA HCT TAB MG TEKTURNA HCT TAB TEKTURNA HCT TAB MG TEKTURNA TAB 150MG TEKTURNA TAB 300MG telmisartan tab 20 mg telmisartan tab 40 mg telmisartan tab 80 mg telmisartan-amlodipine tab mg. 36 telmisartan-amlodipine tab 40-5 mg telmisartan-amlodipine tab mg. 36 telmisartan-amlodipine tab 80-5 mg telmisartan-hydrochlorothiazide tab mg telmisartan-hydrochlorothiazide tab mg telmisartan-hydrochlorothiazide tab mg temazepam cap 15 mg temazepam cap 30 mg TEMODAR INJ 100MG temozolomide cap 100 mg temozolomide cap 140 mg temozolomide cap 180 mg temozolomide cap 20 mg temozolomide cap 250 mg temozolomide cap 5 mg TENIVAC INJ 5-2LF tenofovir disoproxil fumarate tab 300 mg terazosin hcl cap 1 mg (base equivalent) terazosin hcl cap 10 mg (base equivalent) terazosin hcl cap 2 mg (base equivalent) terazosin hcl cap 5 mg (base equivalent) terbinafine hcl tab 250 mg terbutaline sulfate inj 1 mg/ml terbutaline sulfate tab 2.5 mg terbutaline sulfate tab 5 mg terconazole vaginal cream 0.4% terconazole vaginal cream 0.8% terconazole vaginal suppos 80 mg testosterone cypionate im inj in oil 100 mg/ml testosterone cypionate im inj in oil 200 mg/ml

181 testosterone enanthate im inj in oil 200 mg/ml testosterone td gel 10mg/act (2%) testosterone td gel 12.5 mg/act (1%). 71 testosterone td gel 25 mg/2.5gm (1%)71 testosterone td gel 50 mg/5gm (1%).. 71 TET/DIP TOX INJ 2-2 LF TETANUS TOX INJ 5LF ADS tetrabenazine tab 12.5 mg tetrabenazine tab 25 mg tetracaine hcl ophth soln 0.5% tetracycline hcl cap 250 mg tetracycline hcl cap 500 mg THALOMID CAP 100MG THALOMID CAP 150MG THALOMID CAP 200MG THALOMID CAP 50MG theophylline soln 80 mg/15ml theophylline tab er 12hr 100 mg theophylline tab er 12hr 200 mg theophylline tab er 12hr 300 mg theophylline tab er 12hr 450 mg theophylline tab er 24hr 400 mg theophylline tab er 24hr 600 mg THERANATAL TAB THIOLA TAB 100MG thioridazine hcl tab 10 mg thioridazine hcl tab 100 mg thioridazine hcl tab 25 mg thioridazine hcl tab 50 mg thiothixene cap 1 mg thiothixene cap 10 mg thiothixene cap 2 mg thiothixene cap 5 mg THYMOGLOBULN INJ 25MG thyroid tab 30 mg (1/2 grain) thyroid tab 60 mg (1 grain) thyroid tab 90 mg (1 1/2 grain) THYROLAR-1 TAB 60MG THYROLAR-1/2 TAB 30MG THYROLAR-1/4 TAB 15MG THYROLAR-2 TAB 120MG THYROLAR-3 TAB 180MG tiagabine hcl tab 12 mg tiagabine hcl tab 16 mg tiagabine hcl tab 2 mg tiagabine hcl tab 4 mg ticlopidine hcl tab 250 mg TIGAN INJ 100MG/ML timolol maleate ophth gel forming soln 0.25% timolol maleate ophth gel forming soln 0.5% timolol maleate ophth soln 0.25% timolol maleate ophth soln 0.5% timolol maleate tab 10 mg timolol maleate tab 20 mg timolol maleate tab 5 mg tinidazole tab 250 mg tinidazole tab 500 mg TIROSINT CAP 100MCG TIROSINT CAP 112MCG TIROSINT CAP 125MCG TIROSINT CAP 137MCG TIROSINT CAP 13MCG TIROSINT CAP 150MCG TIROSINT CAP 25MCG TIROSINT CAP 50MCG TIROSINT CAP 75MCG TIROSINT CAP 88MCG TIVICAY TAB 50MG tizanidine hcl cap 2 mg (base equivalent) tizanidine hcl cap 4 mg (base equivalent) tizanidine hcl cap 6 mg (base equivalent) tizanidine hcl tab 2 mg (base equivalent) tizanidine hcl tab 4 mg (base equivalent) TL-SELECT CAP TOBI NEB 300/5ML TOBI PODHALR CAP 28MG TOBRADEX OIN % TOBRADEX ST SUS tobramycin nebu soln 300 mg/5ml tobramycin ophth soln 0.3% tobramycin sulfate for inj 1.2 gm... 9 tobramycin sulfate inj 1.2 gm/30ml (40 mg/ml) (base equiv)... 9 tobramycin sulfate inj 10 mg/ml (base equivalent)... 9 tobramycin sulfate inj 2 gm/50ml (40 mg/ml) (base equiv)... 9 tobramycin sulfate inj 80 mg/2ml (40 173

182 mg/ml) (base equiv)... 9 tobramycin-dexamethasone ophth susp % TOBREX OIN 0.3% OP TODAY SPONGE MIS tolazamide tab 250 mg tolazamide tab 500 mg tolbutamide tab 500 mg tolcapone tab 100 mg tolmetin sodium cap 400 mg... 3 tolmetin sodium tab 200 mg... 3 tolmetin sodium tab 600 mg... 3 tolterodine tartrate cap er 24hr 2 mg.. 90 tolterodine tartrate cap er 24hr 4 mg.. 90 tolterodine tartrate tab 1 mg tolterodine tartrate tab 2 mg topiramate cap er 24hr sprinkle 100 mg topiramate cap er 24hr sprinkle 150 mg topiramate cap er 24hr sprinkle 200 mg topiramate cap er 24hr sprinkle 25 mg 50 topiramate cap er 24hr sprinkle 50 mg 50 topiramate sprinkle cap 15 mg topiramate sprinkle cap 25 mg topiramate tab 100 mg topiramate tab 200 mg topiramate tab 25 mg topiramate tab 50 mg TOPOTECAN INJ 4MG/4ML TORISEL SOL 25MG/ML torsemide tab 10 mg torsemide tab 100 mg torsemide tab 20 mg torsemide tab 5 mg TOUJEO SOLO INJ 300IU/ML TOVIAZ TAB 4MG TOVIAZ TAB 8MG TRACLEER TAB 125MG TRACLEER TAB 62.5MG TRADJENTA TAB 5MG tramadol hcl tab 50 mg... 8 tramadol hcl tab er 24hr 100 mg... 8 tramadol hcl tab er 24hr 200 mg... 8 tramadol hcl tab er 24hr 300 mg... 8 tramadol hcl tab er 24hr biphasic release 100 mg... 8 tramadol hcl tab er 24hr biphasic release 200 mg... 8 tramadol hcl tab er 24hr biphasic release 300 mg... 8 tramadol-acetaminophen tab mg... 8 trandolapril tab 1 mg trandolapril tab 2 mg trandolapril tab 4 mg trandolapril-verapamil hcl tab er mg trandolapril-verapamil hcl tab er mg trandolapril-verapamil hcl tab er mg trandolapril-verapamil hcl tab er mg tranexamic acid iv soln 1000 mg/10ml (100 mg/ml) tranexamic acid tab 650 mg tranylcypromine sulfate tab 10 mg TRAVATAN Z DRO 0.004% travoprost ophth soln 0.004% trazodone hcl tab 100 mg trazodone hcl tab 150 mg trazodone hcl tab 300 mg trazodone hcl tab 50 mg TREANDA INJ 100MG TREANDA INJ 180/2ML TREANDA INJ 25MG TREANDA INJ 45/0.5ML TRECATOR TAB 250MG TRELSTAR INJ 11.25MG TRELSTAR INJ 3.75MG TRELSTAR MIX INJ 22.5MG TRESIBA FLEX INJ 100UNIT TRESIBA FLEX INJ 200UNIT tretinoin cap 10 mg tretinoin cream 0.025% tretinoin cream 0.05% tretinoin cream 0.1% tretinoin gel 0.01% tretinoin gel 0.025% triamcinolone acetonide aerosol soln mg/gm triamcinolone acetonide cream 0.025% triamcinolone acetonide cream 0.1%

183 triamcinolone acetonide cream 0.5%. 113 triamcinolone acetonide dental paste 0.1% triamcinolone acetonide lotion 0.025% triamcinolone acetonide lotion 0.1% triamcinolone acetonide nasal aerosol suspension 55 mcg/act triamcinolone acetonide oint 0.025%. 113 triamcinolone acetonide oint 0.1% triamcinolone acetonide oint 0.5% triamterene & hydrochlorothiazide cap mg triamterene & hydrochlorothiazide cap mg triamterene & hydrochlorothiazide tab mg triamterene & hydrochlorothiazide tab mg triazolam tab mg triazolam tab 0.25 mg TRIDERMA CRE FORTE trientine hcl cap 250 mg TRIESENCE INJ 40MG/ML trifluoperazine hcl tab 1 mg (base equivalent) trifluoperazine hcl tab 10 mg (base equivalent) trifluoperazine hcl tab 2 mg (base equivalent) trifluoperazine hcl tab 5 mg (base equivalent) trifluridine ophth soln 1% trihexyphenidyl hcl elixir 0.4 mg/ml trihexyphenidyl hcl tab 2 mg trihexyphenidyl hcl tab 5 mg trimethobenzamide hcl cap 300 mg trimethoprim tab 100 mg trimipramine maleate cap 100 mg trimipramine maleate cap 25 mg trimipramine maleate cap 50 mg TRINATAL GT TAB TRINATAL RX TAB TRINTELLIX TAB 10MG TRINTELLIX TAB 20MG TRINTELLIX TAB 5MG TRISENOX SOL 10MG/10M TRI-TABS DHA MIS TRIUMEQ TAB TRIVEEN-DUO PAK DHA TRIZIVIR TAB tropicamide ophth soln 0.5% tropicamide ophth soln 1% trospium chloride cap er 24hr 60 mg.. 90 trospium chloride tab 20 mg TRULICITY INJ 0.75/ TRULICITY INJ 1.5/ TRUMENBA INJ TRUVADA TAB trypsin w/ castor oil & peruvian balsam spray TUZISTRA XR SUS TWINRIX INJ TYBOST TAB 150MG TYKERB TAB 250MG TYSABRI INJ 300/15ML TYVASO START SOL 0.6MG/ML TYZEKA TAB 600MG U UCERIS TAB 9MG ULESFIA LOT 5% ULORIC TAB 40MG... 1 ULORIC TAB 80MG... 1 ULTIMATECARE CAP ONE ULTIMATECARE CAP ONE NF UNIFINE PNTP MIS 29GX12MM UNIFINE PNTP MIS 31GX5MM UNIFINE PNTP MIS 31GX6MM UNIFINE PNTP MIS 31GX8MM UPTRAVI TAB 1000MCG UPTRAVI TAB 1200MCG UPTRAVI TAB 1400MCG UPTRAVI TAB 1600MCG UPTRAVI TAB 200/ UPTRAVI TAB 200MCG UPTRAVI TAB 400MCG UPTRAVI TAB 600MCG UPTRAVI TAB 800MCG urea cream 40% urea cream 50% urea lotion 40% ursodiol cap 300 mg ursodiol tab 250 mg ursodiol tab 500 mg UVADEX INJ 20MCG/ML

184 V VAGIFEM TAB 10MCG valacyclovir hcl tab 1 gm valacyclovir hcl tab 500 mg VALCHLOR GEL 0.016% VALCYTE SOL 50MG/ML VALCYTE TAB 450MG valganciclovir hcl for soln 50 mg/ml (base equiv) valganciclovir hcl tab 450 mg (base equivalent) valproate sodium inj 100 mg/ml valproate sodium oral soln 250 mg/5ml (base equiv) valproic acid cap 250 mg valsartan tab 160 mg valsartan tab 320 mg valsartan tab 40 mg valsartan tab 80 mg valsartan-hydrochlorothiazide tab mg valsartan-hydrochlorothiazide tab mg valsartan-hydrochlorothiazide tab mg valsartan-hydrochlorothiazide tab mg valsartan-hydrochlorothiazide tab mg VANCOMYC/DEX INJ 500MG VANCOMYC/DEX INJ 750MG vancomycin hcl cap 125 mg vancomycin hcl cap 250 mg vancomycin hcl for inj 1000 mg vancomycin hcl for iv soln 10 gm (base equivalent) vancomycin hcl for iv soln 5 gm (base equivalent) vancomycin hcl for iv soln 500 mg (base equivalent) VANCOMYCIN INJ 750MG VANTAS KIT 50MG VAQTA INJ 25/0.5ML VAQTA INJ 50UNT/ML VARIVAX INJ VASCEPA CAP 1GM VCF VAGINAL AER CONTRACP VCF VAGINAL MIS CONTRACP VELETRI INJ 0.5MG VELETRI INJ 1.5MG VELPHORO CHW 500MG VELTASSA POW 16.8GM VELTASSA POW 25.2GM VELTASSA POW 8.4GM VEMAVITE- CAP PRX VENA-BAL MIS DHA VENCLEXTA TAB 100MG VENCLEXTA TAB 10MG VENCLEXTA TAB 50MG VENCLEXTA TAB START PK venlafaxine hcl cap er 24hr 150 mg (base equivalent) venlafaxine hcl cap er 24hr 37.5 mg (base equivalent) venlafaxine hcl cap er 24hr 75 mg (base equivalent) venlafaxine hcl tab 100 mg venlafaxine hcl tab 25 mg venlafaxine hcl tab 37.5 mg venlafaxine hcl tab 50 mg venlafaxine hcl tab 75 mg VENTAVIS SOL 10MCG/ML VENTAVIS SOL 20MCG/ML VENTOLIN HFA AER VERAMYST SPR 27.5MCG verapamil hcl cap er 24hr 120 mg verapamil hcl cap er 24hr 180 mg verapamil hcl cap er 24hr 240 mg verapamil hcl iv soln 2.5 mg/ml verapamil hcl tab 120 mg verapamil hcl tab 40 mg verapamil hcl tab 80 mg verapamil hcl tab er 120 mg verapamil hcl tab er 180 mg verapamil hcl tab er 240 mg VEREGEN OIN 15% VERZENIO TAB 100MG VERZENIO TAB 150MG VERZENIO TAB 200MG VERZENIO TAB 50MG VESICARE TAB 10MG VESICARE TAB 5MG VEXOL SUS 1% OP VIBATIV INJ 250MG VIBATIV INJ 750MG VIBERZI TAB 100MG

185 VIBERZI TAB 75MG VICTOZA INJ 18MG/3ML VIDEX SOL 2GM VIEKIRA PAK TAB vigabatrin powd pack 500 mg VIGAMOX DRO 0.5% VIIBRYD KIT STARTER VIIBRYD TAB 10MG VIIBRYD TAB 20MG VIIBRYD TAB 40MG VIMIZIM INJ 5MG/5ML VIMPAT INJ 200MG/ VIMPAT SOL 10MG/ML VIMPAT TAB 100MG VIMPAT TAB 150MG VIMPAT TAB 200MG VIMPAT TAB 50MG VINATE CARE CHW 40-1MG VINATE II TAB VINATE M TAB VINATE ULTRA TAB vinblastine sulfate inj 1 mg/ml vincristine sulfate iv soln 1 mg/ml vinorelbine tartrate inj 10 mg/ml (base equiv) vinorelbine tartrate inj 50 mg/5ml (10 mg/ml) (base equiv) VIRACEPT TAB 250MG VIRACEPT TAB 625MG viramune sus 50mg/5ml VIRAMUNE XR TAB 100MG VIRAMUNE XR TAB 400MG VIREAD POW 40MG/GM VIREAD TAB 150MG VIREAD TAB 200MG VIREAD TAB 250MG VIREAD TAB 300MG VIRT-ADVANCE TAB 90-1MG VIRT-C DHA CAP VIRT-CARE CAP ONE VIRT-SELECT CAP VIRT-VITE GT TAB 90-1MG VITAFOL-OB TAB 65-1MG VITEKTA TAB 150MG VITEKTA TAB 85MG VITRASE INJ 200/ML VIVITROL INJ 380MG VOL-NATE TAB VOL-PLUS TAB VOL-TAB RX TAB VORAXAZE INJ 1000UNIT voriconazole for inj 200 mg voriconazole for susp 40 mg/ml voriconazole tab 200 mg voriconazole tab 50 mg VOSEVI TAB VOTRIENT TAB 200MG VP-CH PLUS CAP VP-HEME OB MIS + DHA VP-HEME ONE CAP VP-HEME-OB TAB MG VPRIV INJ 400UNIT VYVANSE CAP 10MG VYVANSE CAP 20MG VYVANSE CAP 30MG VYVANSE CAP 40MG VYVANSE CAP 50MG VYVANSE CAP 60MG VYVANSE CAP 70MG W warfarin sodium tab 1 mg warfarin sodium tab 10 mg warfarin sodium tab 2 mg warfarin sodium tab 2.5 mg warfarin sodium tab 3 mg warfarin sodium tab 4 mg warfarin sodium tab 5 mg warfarin sodium tab 6 mg warfarin sodium tab 7.5 mg water for irrigation, sterile irrigation soln WELCHOL PAK 3.75GM WELCHOL TAB 625MG WESTHROID TAB MG WESTHROID TAB 130MG WESTHROID TAB 16.25MG WESTHROID TAB 32.5MG WESTHROID TAB 48.75MG WESTHROID TAB 65MG WESTHROID TAB 81.25MG WESTHROID TAB 97.5MG WIDE-SEAL DPR KIT WIDE-SEAL DPR KIT WIDE-SEAL DPR KIT WIDE-SEAL DPR KIT WIDE-SEAL DPR KIT

186 WIDE-SEAL DPR KIT WIDE-SEAL DPR KIT WIDE-SEAL DPR KIT X XALKORI CAP 200MG XALKORI CAP 250MG XARELTO STAR TAB 15/20MG XARELTO TAB 10MG XARELTO TAB 15MG XARELTO TAB 20MG XARTEMIS XR TAB XENAZINE TAB 12.5MG XENAZINE TAB 25MG XEOMIN INJ 100UNIT XEOMIN INJ 50 UNIT XGEVA INJ XIFAXAN TAB 200MG XIFAXAN TAB 550MG XOLAIR SOL 150MG XOPENEX HFA AER XTANDI CAP 40MG XULTOPHY INJ 100/ XYREM SOL 500MG/ML Z zafirlukast tab 10 mg zafirlukast tab 20 mg zaleplon cap 10 mg zaleplon cap 5 mg ZANOSAR INJ 1GM ZARXIO INJ 300/ ZARXIO INJ 480/ ZATEAN-CH CAP ZATEAN-PN CAP DHA ZATEAN-PN CAP PLUS ZATEAN-PN TAB ZAVESCA CAP 100MG ZEJULA CAP 100MG ZELBORAF TAB 240MG ZEMAIRA INJ 1000MG ZENPEP CAP 10000UNT ZENPEP CAP 15000UNT ZENPEP CAP 20000UNT ZENPEP CAP 25000UNT ZENPEP CAP 3000UNIT ZENPEP CAP 40000UNT ZIAGEN SOL 20MG/ML ZIANA GEL zidovudine cap 100 mg zidovudine syrup 10 mg/ml zidovudine tab 300 mg zileuton tab er 12hr 600 mg ZINACEF/H20 INJ 1.5GM PB ZIOPTAN DRO % ziprasidone hcl cap 20 mg ziprasidone hcl cap 40 mg ziprasidone hcl cap 60 mg ziprasidone hcl cap 80 mg ZIRGAN GEL 0.15% ZOHYDRO ER CAP 10MG... 9 ZOHYDRO ER CAP 15MG... 9 ZOHYDRO ER CAP 20MG... 9 ZOHYDRO ER CAP 30MG... 9 ZOHYDRO ER CAP 40MG... 9 ZOHYDRO ER CAP 50MG... 9 ZOLADEX IMP 10.8MG ZOLADEX IMP 3.6MG zoledronic acid inj conc for iv infusion 4 mg/5ml zoledronic acid iv soln 5 mg/100ml ZOLEDRONIC INJ 4MG ZOLINZA CAP 100MG zolmitriptan orally disintegrating tab 2.5 mg zolmitriptan orally disintegrating tab 5 mg zolmitriptan tab 2.5 mg zolmitriptan tab 5 mg zolpidem tartrate tab 10 mg zolpidem tartrate tab 5 mg ZOMETA INJ 4MG/ ZOMIG SPR 2.5MG ZOMIG SPR 5MG zonisamide cap 100 mg zonisamide cap 25 mg zonisamide cap 50 mg ZONTIVITY TAB 2.08MG ZORBTIVE INJ 8.8MG ZORTRESS TAB 0.25MG ZORTRESS TAB 0.5MG ZORTRESS TAB 0.75MG ZOSTAVAX INJ ZOVIRAX CRE 5% ZUBSOLV SUB ZUBSOLV SUB ZYDELIG TAB 100MG ZYDELIG TAB 150MG

187 ZYFLO TAB 600MG ZYKADIA CAP 150MG ZYLET SUS % ZYPREXA RELP INJ 210MG ZYPREXA RELP INJ 300MG ZYPREXA RELP INJ 405MG ZYTIGA TAB 250MG ZYTIGA TAB 500MG ZYVOX SOL 2MG/ML

188 Language Assistance Services Servicios de acceso al idioma English ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call (TTY: 711). Spanish ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). Navajo D77 baa ak0 n7n7zin: D77 saad bee y1n7[ti go Diné Bizaad, saad bee 1k1 1n7da 1wo d66, t 11 jiik eh, 47 n1 h0l=, koj8 h0d77lnih (TTY: 711.) Vietnamese CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: 711). German ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: 711). Chinese 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY:711) Arabic ملحوظة: إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم )رقم هاتف الصم والبكم: 711 (. Korean 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 711) 번으로전화해주십시오. Tagalog- Filipino PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: 711). Japanese 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます (TTY: 711) まで お電話にてご連絡ください French ATTENTION: Si vous parlez français, des services d aide linguistique vous sont proposés gratuitement. Appelez le (ATS : 711). Italian ATTENZIONE: In caso la lingua parlata sia l italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (TTY: 711). Russian ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 711). Hindi ध य न द : यदद आप ह द ब लत ह त आपक ललए म फ त म भ ष सह यत स व ए उपलब ध ह (TTY: 711) पर क ल कर Farsi توجه : اگر به زبان فارسی گفتگو می کنید تسهیالت زبانی بصورت رایگان برای شما فراهم می باشد. با (711 (TTY: تماس بگیرید. Thai เร ยน: ถ าค ณพ ดภาษาไทยค ณสามารถใช บร การช วยเหล อทางภาษาได ฟร โทร (TTY: 711(. THNM-ID

189 Notice of Non-Discrimination and Accessibility Aviso de no discriminación y accesibilidad The following is a statement describing nondiscrimination for True Health New Mexico and the services it provides to its clients and members. We do not discriminate on the basis of race, color, national origin, age, disability, or gender in our health programs or activities. We provide help free of charge to people with disabilities or whose primary language is not English. To ask for a document in another format such as large print, or to get language help such as a qualified interpreter, please call True Health New Mexico Customer Service at , Monday through Friday, 8:00 a.m. to 5:00 p.m. TTY: If you believe that we have failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or gender, you can send a complaint to: True Health New Mexico Compliance Hotline, 2440 Louisiana Blvd. NE, Suite 601, Albuquerque, NM Phone: Fax: You also have the right to file a complaint directly with the U.S. Dept. of Health and Human Services online, by phone, or by mail: Online: Complaint forms are available at Phone: Toll-free: , TDD: Mail: U.S. Dept. of Health & Human Services, 200 Independence Ave. SW, Room 509F, HHH Bldg., Washington, DC Aviso de no discriminación y accesibilidad A continuación presentamos una declaración que resume la norma de no discriminación de True Health New Mexico y los servicios que prestamos a nuestros clientes y asegurados. No discriminamos por la raza, el color, el origen nacional, la edad, las discapacidades o el sexo en nuestras actividades o programas de salud. Ayudamos gratuitamente a las personas que tienen discapacidades o cuyo idioma nativo no es el inglés. Para pedir un documento en otro formato, como en letra grande, o para recibir la ayuda de un intérprete calificado, favor de llamar al Centro de Atención al Cliente de True Health New Mexico al , para los servicios TTY llame al , de lunes a viernes, de las 8:00 de la mañana a las 5:00 de la tarde. Si usted cree que no hemos prestado estos servicios o que le hemos discriminado de alguna otra manera por su raza, color, origen nacional, edad, discapacidad o sexo, puede enviar una queja a: True Health New Mexico Compliance Hotline, 2440 Louisiana Blvd. NE, Suite 601, Albuquerque, NM Teléfono: Fax: Además tiene derecho a presentar una queja directamente al Departamento de Salud y Servicios Humanos de los EE. UU. [U.S. Dept. of Health and Human Services] ya sea en línea, por teléfono o por correo: En línea: Los formularios de queja están a su disposición en: Por teléfono: Línea telefónica gratis: , TDD: Por correo: U.S. Dept. of Health & Human Services, 200 Independence Ave. SW, Room 509F, HHH Bldg., Washington, DC THNM-ID