Blue Cross of Idaho s Standard Six-Tier Prescription Drug Formulary

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1 Blue Cross of Idaho s Standard Six-Tier Prescription Drug Formulary This document is a searchable PDF. On your keyboard press Ctrl+F (Command+F for Mac) and a search field will open. Type in the name of the drug you are looking for in the search field, press enter and it will locate the name of the drug in the document. 017 Blue Cross of Idaho is an Independent Licensee of the Blue Cross and Blue Shield Association

2 Things to know about Blue Cross of Idaho s Standard Six-Tier Prescription Drug Formulary The Blue Cross of Idaho formulary is a list of drugs approved by Blue Cross of Idaho s Pharmacy and Therapeutics Committee for coverage under your pharmacy benefit. The formulary includes brand name as well as generic drugs that have undergone rigorous testing and are approved by the Food and Drug Administration (FDA). Not all drugs approved by the FDA are covered under the Blue Cross of Idaho formulary. The Multi-Tier Formulary In most cases you will be responsible for a portion of the cost of each prescription you have filled, and depending on the drug prescribed, your cost can vary. The Blue Cross of Idaho formulary has six tiers, with the first tier costing you the least and the sixth tier costing you the most. Asking your doctor to prescribe drugs listed in the first, second or third tier of the formulary can save you money. Tier Description 1 Preferred Generic Drugs are equivalent to brand-name drugs in dosage, safety, strength, method of administration, performance characteristics and intended use and Blue Cross of Idaho has rated as preferred due to their quality and costeffectiveness. Non-Preferred Generic Drugs are equivalent to brand-name drugs in dosage, safety, strength, method of administration, performance characteristics and intended use but come with an excessive cost compared to other alternatives within the same drug class. Preferred Brand-Name Drugs are drugs that Blue Cross of Idaho has rated as preferred due to their quality and costeffectiveness. Non-Preferred Brand-Name Drugs are clinically effective medications, but come with an excessive cost compared to other alternatives within the same drug class. 5 Preferred Specialty Drugs are medications used to treat complex conditions and Blue Cross of Idaho has rated as preferred due to their quality and cost-effectiveness. 6 Non-Preferred Specialty Drugs are medications used to treat complex conditions, but come with an excessive cost compared to other alternatives within the same drug class. ACA Affordable Care Act Drugs are drugs prescribed for covered preventive services that may be available at no cost to members under the regulations of the Affordable Care Act. Some plans grandfathered under the Affordable Care Act may not be eligible for the ACA preventive drugs at no cost.

3 Reading the Formulary On the following pages, you ll find a list of prescription drugs and columns that list the tier they each belong to and any specific requirements or limitations. Column Name Drug Reference Tier Notes What you will find in each column: Name of covered prescription drugs Brand name of the covered generic drug listed in the Drug column. *Please see information below regarding Mandatory Generic Substitution The tier assignment for the prescription drug listed in the Drug column Requirements and limitations, as well as indicating if drugs are part of the Preventive Drug List for HSA Plans. See Abbreviation Dictionary on the next page for definitions and more information about the abbreviations. Mandatory Generic Substitution Some Blue Cross of Idaho prescription drug plans include a mandatory generic substitution requirement. When a drug has both brand and generic forms available, the generic drug is listed under the Drug column as the covered option with the brand or trademark name listed under the Reference column. When you or your physician choose the brand name drug, in addition to any applicable cost share (deductible/coinsurance/copayments) for the brand name medication, you will pay the cost difference between the contracted cost of the generic drug and brand name drug. These cost difference amounts do not apply to your annual out of pocket maximum. Reference Specialty Drugs, designated by an SP in the Notes column, will apply a Tier 5 and 6 cost share prior to the cost difference calculation All other Reference brand name drugs will apply a Tier cost share prior to the cost difference calculation This formulary is subject to change as new products and information become available. Please refer to your contract for more information about the terms and conditions of your prescription drug benefit. If you have questions about any of your medications, please discuss them with your doctor or pharmacist.

4 Abbreviation Dictionary PA - Prior authorization Medications that list PA need prior authorization from Blue Cross of Idaho before we will cover the drug. Your provider must provide documentation showing that the prescription is medically necessary. If prior authorization is not obtained, you may be held responsible for the entire cost of the drug. Please refer to your policy (also called a member contract) for more information about prior authorization. You can find a copy of your policy and detailed information on the prior authorization process online by logging into members.bcidaho.com. PREV - Preventive Drugs for HSA Plans Some preventive drugs may be available at no cost to members of High Deductible Health Plans, also known as HSA plans. Preventive medications are prescribed for the prevention of conditions or illnesses when individuals may be at high risk. QL - Quantity Limits Some formulary drugs can only be filled in limited quantities. These prescriptions have been found to be less effective or even dangerous when taken at higher than normal doses. The limits on OL drugs are in line with manufacturer s recommendations regarding safety and effectiveness. SP - Specialty Drug Program Specialty medications are generally prescribed for treatment of complex, on-going medical conditions. These medications are generally high cost, and have specific handling requirements. All specialty drugs are limited to a 0 day supply per fill. ST - Step Therapy You may need to use one or more alternative medications before Blue Cross of Idaho can authorize benefits for the use of another medication. Blue Cross of Idaho wants to ensure providers are trying equally or more effective, low-cost options before recommending effective, but higher cost treatments. AL - Age Limitation Some drugs may be only be safe or recommended for certain age groups. Blue Cross of Idaho places age limitations to ensure drugs are not prescribed to individuals who are not of the recommended age.

5 *Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexiants* *Adhd Agent - Selective Alpha Adrenergic Agonists*** clonidine hcl er oral tablet extended release 1 hour guanfacine hcl er oral tablet extended release hour Kapvay Intuniv *Adhd Agent - Selective Norepinephrine Reuptake Inhibitor*** atomoxetine hcl oral capsule Strattera *Amphetamine Mixtures*** amphetamine-dextroamphet er oral capsule extended release hour amphetamine-dextroamphetamine oral tablet *Amphetamines*** ADZENYS XR-ODT ORAL TABLET EXTENDED RELEASE DISPERSIBLE Adderall XR Adderall DEXEDRINE ORAL TABLET Zenzedi dextroamphetamine sulfate er oral capsule extended release hour dextroamphetamine sulfate oral solution Dexedrine ProCentra dextroamphetamine sulfate oral tablet Zenzedi DYANAVEL XR ORAL SUSPENSION EXTENDED RELEASE methamphetamine hcl oral tablet Desoxyn VYVANSE ORAL CAPSULE VYVANSE ORAL TABLET CHEWABLE QL Effective as of /1/018 1

6 *Stimulants - Misc.*** armodafinil oral tablet 150 mg, 00 mg, 50 mg, 50 mg Nuvigil QL DAYTRANA TRANSDERMAL PATCH dexmethylphenidate hcl er oral capsule extended release hour Focalin XR dexmethylphenidate hcl oral tablet Focalin METADATE ER ORAL TABLET EXTENDED RELEASE 0 MG methylphenidate hcl er (cd) oral capsule extended release methylphenidate hcl er (la) oral capsule extended release hour methylphenidate hcl er oral tablet extended release 10 mg methylphenidate hcl er oral tablet extended release 18 mg, 7 mg, 6 mg, 5 mg methylphenidate hcl er oral tablet extended release 0 mg methylphenidate hcl er oral tablet extended release hour Metadate ER Ritalin LA Concerta Metadate ER methylphenidate hcl oral solution Methylin methylphenidate hcl oral tablet Ritalin methylphenidate hcl oral tablet chewable modafinil oral tablet Provigil QUILLICHEW ER ORAL TABLET CHEWABLE EXTENDED RELEASE 0 MG, 0 MG, 0 MG QUILLIVANT XR ORAL SUSPENSION RECONSTITUTED *Alternative Medicines* *Alternative Medicine - Eu*** ISCAR MALI SUBCUTANEOUS INJECTABLE 5 MG/ML QL Effective as of /1/018

7 *Aminoglycosides* *Aminoglycosides*** neomycin sulfate oral tablet paromomycin sulfate oral capsule TOBI PODHALER INHALATION CAPSULE tobramycin inhalation nebulization solution *Analgesics - Anti-Inflammatory* *Antirheumatic - Janus Kinase (Jak) Inhibitors*** 5 SP; QL Kitabis Pak 5 SP XELJANZ ORAL TABLET 6 PA; SP; QL XELJANZ XR ORAL TABLET EXTENDED RELEASE HOUR *Antirheumatic Antimetabolites*** RHEUMATREX ORAL TABLET.5 MG *Anti-Tnf-Alpha - Monoclonal Antibodies*** HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 0 MG/0.8ML HUMIRA PEN SUBCUTANEOUS PEN- INJECTOR KIT HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS PEN-INJECTOR KIT HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS PEN-INJECTOR KIT HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR 100 MG/ML, 50 MG/0.5ML SIMPONI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/ML, 50 MG/0.5ML 6 PA; SP; QL 5 PA; SP 5 PA; SP 5 PA; SP 5 PA; SP 5 PA; SP 6 PA; SP; QL 6 PA; SP; QL Effective as of /1/018

8 *Anti-Tnf-Alpha - Monoclonoal Antibodies*** HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 0 MG/0.8ML HUMIRA PEN SUBCUTANEOUS PEN- INJECTOR KIT HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS PEN-INJECTOR KIT HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS PEN-INJECTOR KIT HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR 100 MG/ML, 50 MG/0.5ML SIMPONI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/ML, 50 MG/0.5ML *Cyclooxygenase (Cox-) Inhibitors*** celecoxib oral capsule 100 mg, 00 mg, 00 mg, 50 mg *Gold Compounds*** 5 PA; SP 5 PA; SP 5 PA; SP 5 PA; SP 5 PA; SP 6 PA; SP; QL 6 PA; SP; QL CeleBREX QL RIDAURA ORAL CAPSULE *Interleukin-1 Blockers*** ARCALYST SUBCUTANEOUS SOLUTION RECONSTITUTED *Interleukin-1 Receptor Antagonist (Il-1Ra)*** KINERET SUBCUTANEOUS SOLUTION PREFILLED SYRINGE *Interleukin-1Beta Blockers*** ILARIS (150MG DELIVERED) SUBCUTANEOUS SOLUTION RECONSTITUTED 6 PA; SP 6 PA; SP 6 PA; SP ILARIS SUBCUTANEOUS SOLUTION 6 PA; SP *Interleukin-6 Receptor Inhibitors*** ACTEMRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 6 PA; SP Effective as of /1/018

9 KEVZARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE *Nonsteroidal Anti-Inflammatory Agent Combinations*** diclofenac-misoprostol oral tablet delayed release Arthrotec *Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** diclofenac potassium oral tablet diclofenac sodium er oral tablet extended release hour diclofenac sodium oral tablet delayed release etodolac er oral tablet extended release hour etodolac oral capsule etodolac oral tablet Lodine fenoprofen calcium oral tablet ProFeno flurbiprofen oral tablet ibuprofen oral tablet 00 mg, 600 mg, 800 mg indomethacin er oral capsule extended release IBU indomethacin oral capsule ketoprofen er oral capsule extended release hour ketoprofen oral capsule 6 PA; SP ketorolac tromethamine oral tablet QL meclofenamate sodium oral capsule mefenamic acid oral capsule Ponstel meloxicam oral suspension meloxicam oral tablet Mobic nabumetone oral tablet naproxen dr oral tablet delayed release EC-Naprosyn naproxen oral suspension Naprosyn naproxen oral tablet Naprosyn naproxen sodium oral tablet 75 mg naproxen sodium oral tablet 550 mg Anaprox DS Effective as of /1/018 5

10 oxaprozin oral tablet Daypro piroxicam oral capsule Feldene sulindac oral tablet tolmetin sodium oral capsule tolmetin sodium oral tablet *Pyrimidine Synthesis Inhibitors*** leflunomide oral tablet Arava QL *Selective Costimulation Modulators*** ORENCIA CLICKJECT SUBCUTANEOUS SOLUTION AUTO- INJECTOR ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE *Soluble Tumor Necrosis Factor Receptor Agents*** ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO- INJECTOR *Analgesics - Nonnarcotic* *Analgesic Combinations*** duraxin oral capsule LEVACET ORAL TABLET *Analgesics-Sedatives*** BUPAP ORAL TABLET MG butalbital-acetaminophen oral tablet 50-5 mg Tencon butalbital-apap-caffeine oral capsule Fioricet butalbital-apap-caffeine oral tablet mg Esgic butalbital-aspirin-caffeine oral capsule Fiorinal CAPACET ORAL CAPSULE Esgic 6 PA; SP 6 PA; SP 5 PA; SP 5 PA; SP 5 PA; SP 5 PA; SP 6 Effective as of /1/018

11 ESGIC ORAL CAPSULE Esgic margesic oral capsule Esgic marten-tab oral tablet Tencon TENCON ORAL TABLET 50-5 MG Tencon ZEBUTAL ORAL CAPSULE MG *Salicylate Combinations*** Esgic choline-mag trisalicylate oral liquid *Salicylates*** adult aspirin ec low strength oral tablet delayed release Aspir-Low ACA AL; QL aspir-81 oral tablet delayed release Aspir-Low ACA AL; QL aspirin adult low dose oral tablet delayed release aspirin adult low strength oral tablet chewable Aspir-Low ACA AL; QL Bayer Low Dose ACA AL; QL aspirin childrens oral tablet chewable Bayer Low Dose ACA AL; QL aspirin ec oral tablet delayed release 5 mg Bayer Aspirin Regimen ACA AL; QL aspirin low dose oral tablet chewable Bayer Low Dose ACA AL; QL aspirin oral tablet delayed release 81 mg ASPIR-LOW ORAL TABLET DELAYED RELEASE BAYER ASPIRIN EC LOW DOSE ORAL TABLET DELAYED RELEASE BAYER LOW DOSE ORAL TABLET CHEWABLE BAYER LOW DOSE ORAL TABLET DELAYED RELEASE childrens aspirin low strength oral tablet chewable Aspir-Low ACA AL; QL Aspir-Low ACA AL; QL Aspir-Low ACA AL; QL Bayer Low Dose ACA AL; QL Aspir-Low ACA AL; QL Bayer Low Dose ACA AL; QL childrens aspirin oral tablet chewable Bayer Low Dose ACA AL; QL cvs aspirin child oral tablet chewable Bayer Low Dose ACA QL cvs childrens aspirin oral tablet chewable Bayer Low Dose ACA QL diflunisal oral tablet Effective as of /1/018 7

12 ECOTRIN LOW STRENGTH ORAL TABLET DELAYED RELEASE eq childrens aspirin oral tablet chewable gnp adult aspirin low strength oral tablet chewable gnp aspirin oral tablet delayed release 81 mg goodsense aspirin oral tablet Aspir-Low ACA AL; QL Bayer Low Dose ACA AL; QL Bayer Low Dose ACA AL; QL Aspir-Low ACA AL; QL Bayer Advanced Aspirin Reg St ACA AL; QL goodsense aspirin oral tablet chewable Bayer Low Dose ACA AL; QL kls aspirin low dose oral tablet delayed release Aspir-Low ACA AL; QL kp aspirin oral tablet delayed release Aspir-Low ACA AL; QL MINIPRIN LOW DOSE ORAL TABLET DELAYED RELEASE Aspir-Low ACA AL; QL px aspirin oral tablet chewable Bayer Low Dose ACA AL; QL px enteric aspirin oral tablet delayed release 81 mg qc childrens aspirin oral tablet chewable ra aspirin adult low strength oral tablet chewable ra aspirin ec adult low st oral tablet delayed release ra aspirin ec oral tablet delayed release 81 mg ra childrens aspirin oral tablet chewable Aspir-Low ACA AL; QL Bayer Low Dose ACA AL; QL Bayer Low Dose ACA AL; QL Aspir-Low ACA AL; QL Aspir-Low ACA AL; QL Bayer Low Dose ACA AL; QL salsalate oral tablet sb childrens aspirin oral tablet chewable ST JOSEPH LOW DOSE ORAL TABLET CHEWABLE tgt aspirin low dose oral tablet delayed release Bayer Low Dose ACA AL; QL Bayer Low Dose ACA AL; QL Aspir-Low ACA AL; QL tgt aspirin oral tablet chewable Bayer Low Dose ACA AL; QL tgt aspirin oral tablet delayed release Aspir-Low ACA AL; QL 8 Effective as of /1/018

13 tgt childrens aspirin oral tablet chewable *Analgesics - Opioid* *Codeine Combinations*** Bayer Low Dose ACA AL; QL acetaminophen-codeine # oral tablet acetaminophen-codeine # oral tablet Tylenol with Codeine # acetaminophen-codeine # oral tablet Tylenol with Codeine # acetaminophen-codeine oral solution ASCOMP-CODEINE ORAL CAPSULE Ascomp-Codeine butalbital-apap-caff-cod oral capsule Fioricet/Codeine butalbital-asa-caff-codeine oral capsule Ascomp-Codeine CAPITAL/CODEINE ORAL SUSPENSION *Dihydrocodeine Combinations*** aspirin-caff-dihydrocodeine oral capsule *Hydrocodone Combinations*** hydrocodone-acetaminophen oral solution 10-5 mg/15ml hydrocodone-acetaminophen oral solution mg/15ml hydrocodone-acetaminophen oral tablet mg hydrocodone-acetaminophen oral tablet 10-5 mg hydrocodone-acetaminophen oral tablet.5-5 mg hydrocodone-acetaminophen oral tablet 5-00 mg hydrocodone-acetaminophen oral tablet 5-5 mg hydrocodone-acetaminophen oral tablet mg hydrocodone-acetaminophen oral tablet mg Hycet Vicodin HP Lorcet HD Verdrocet Vicodin Lorcet Vicodin ES Lorcet Plus hydrocodone-ibuprofen oral tablet Ibudone IBUDONE ORAL TABLET Ibudone Effective as of /1/018 9

14 LORCET HD ORAL TABLET Lorcet HD LORCET ORAL TABLET Lorcet LORCET PLUS ORAL TABLET MG LORTAB ORAL ELIXIR MG/15ML Lorcet Plus LORTAB ORAL TABLET 10-5 MG Lorcet HD LORTAB ORAL TABLET 5-5 MG Lorcet LORTAB ORAL TABLET MG Lorcet Plus REPREXAIN ORAL TABLET MG Ibudone VERDROCET ORAL TABLET Verdrocet VICODIN ES ORAL TABLET MG VICODIN HP ORAL TABLET MG Vicodin ES Vicodin HP VICODIN ORAL TABLET 5-00 MG Vicodin XYLON ORAL TABLET Ibudone ZAMICET ORAL SOLUTION *Opioid Agonists*** ABSTRAL SUBLINGUAL TABLET SUBLINGUAL ARYMO ER ORAL TABLET EXTENDED RELEASE ABUSE- DETERRENT codeine sulfate oral tablet EMBEDA ORAL CAPSULE EXTENDED RELEASE fentanyl citrate buccal lozenge on a handle fentanyl transdermal patch 7 hour 100 mcg/hr fentanyl transdermal patch 7 hour 1 mcg/hr fentanyl transdermal patch 7 hour 5 mcg/hr fentanyl transdermal patch 7 hour 50 mcg/hr 10 PA PA Actiq PA Duragesic-100 Duragesic-1 Duragesic-5 Duragesic-50 Effective as of /1/018

15 fentanyl transdermal patch 7 hour 75 mcg/hr FENTORA BUCCAL TABLET 100 MCG, 00 MCG, 00 MCG, 600 MCG, 800 MCG hydromorphone hcl er oral tablet er hour abuse-deterrent hydromorphone hcl injection solution mg/ml Duragesic-75 Exalgo Dilaudid hydromorphone hcl oral liquid Dilaudid hydromorphone hcl oral tablet Dilaudid hydromorphone hcl rectal suppository KADIAN ORAL CAPSULE EXTENDED RELEASE HOUR 00 MG, 0 MG levorphanol tartrate oral tablet meperidine hcl oral solution meperidine hcl oral tablet Demerol methadone hcl oral concentrate Methadone HCl Intensol methadone hcl oral solution methadone hcl oral tablet Dolophine methadone hcl oral tablet soluble Methadose METHADOSE ORAL TABLET SOLUBLE MORPHABOND ER ORAL TABLET ER 1 HOUR ABUSE-DETERRENT morphine sulfate (concentrate) oral solution 100 mg/5ml morphine sulfate er beads oral capsule extended release hour morphine sulfate er oral capsule extended release hour morphine sulfate er oral tablet extended release Methadose Kadian MS Contin morphine sulfate oral solution morphine sulfate oral tablet morphine sulfate rectal suppository 10 mg, 0 mg, 5 mg PA PA Effective as of /1/018 11

16 morphine sulfate rectal suppository 0 mg NUCYNTA ER ORAL TABLET EXTENDED RELEASE 1 HOUR NUCYNTA ORAL TABLET OPANA ER ORAL TABLET ER 1 HOUR ABUSE-DETERRENT OXAYDO ORAL TABLET ABUSE- DETERRENT oxycodone hcl er oral tablet er 1 hour abuse-deterrent OxyCONTIN QL oxycodone hcl oral capsule oxycodone hcl oral concentrate 100 mg/5ml oxycodone hcl oral solution oxycodone hcl oral tablet OXYCONTIN ORAL TABLET ER 1 HOUR ABUSE-DETERRENT oxymorphone hcl er oral tablet extended release 1 hour OxyCONTIN QL oxymorphone hcl oral tablet Opana tramadol hcl er oral tablet extended release hour tramadol hcl oral tablet Ultram XTAMPZA ER ORAL CAPSULE ER 1 HOUR ABUSE-DETERRENT *Opioid Combinations*** ENDOCET ORAL TABLET 10-5 MG,.5-5 MG, 5-5 MG, MG Endocet oxycodone-acetaminophen oral solution oxycodone-acetaminophen oral tablet 10-5 mg,.5-5 mg, 5-5 mg, mg oxycodone-aspirin oral tablet mg Endocet oxycodone-ibuprofen oral tablet *Opioid Partial Agonists*** BUNAVAIL BUCCAL FILM 1 Effective as of /1/018

17 buprenorphine hcl sublingual tablet sublingual buprenorphine hcl-naloxone hcl sublingual tablet sublingual buprenorphine transdermal patch weekly 10 mcg/hr, 15 mcg/hr, 0 mcg/hr, 5 mcg/hr Butrans butorphanol tartrate nasal solution BUTRANS TRANSDERMAL PATCH WEEKLY Butrans pentazocine-naloxone hcl oral tablet SUBOXONE SUBLINGUAL FILM *Tramadol Combinations*** tramadol-acetaminophen oral tablet Ultracet *Androgens-Anabolic* *Anabolic Steroids*** ANADROL-50 ORAL TABLET oxandrolone oral tablet Oxandrin *Androgens*** ANDRODERM TRANSDERMAL PATCH HOUR ANDROXY ORAL TABLET danazol oral capsule methitest oral tablet methyltestosterone oral capsule Android STRIANT BUCCAL testosterone cypionate intramuscular solution 100 mg/ml, 00 mg/ml testosterone enanthate intramuscular solution testosterone transdermal gel 10 mg/act (%) testosterone transdermal gel 1.5 mg/act (1%) testosterone transdermal gel 5 mg/.5gm (1%), 50 mg/5gm (1%) Depo-Testosterone Fortesta Vogelxo Pump AndroGel testosterone transdermal solution Effective as of /1/018 1

18 *Anorectal Agents* *Intrarectal Steroids*** COLOCORT RECTAL ENEMA Colocort CORTIFOAM RECTAL FOAM hydrocortisone rectal enema Colocort *Nitrate Vasodilating Agents*** RECTIV RECTAL OINTMENT *Rectal Anesthetic/Steroids*** ANALPRAM-HC RECTAL LOTION 1-.5 % hydrocortisone ace-pramoxine rectal cream 1-1 % Analpram-HC pramcort rectal cream Analpram-HC PROCTOFOAM HC RECTAL FOAM *Rectal Steroids*** hydrocortisone rectal cream Anusol-HC PROCTO-MED HC RECTAL CREAM Anusol-HC PROCTO-PAK RECTAL CREAM Procto-Pak PROCTOSOL HC RECTAL CREAM Anusol-HC PROCTOZONE-HC RECTAL CREAM Anusol-HC *Anthelmintics* *Anthelmintics*** ALBENZA ORAL TABLET BILTRICIDE ORAL TABLET EMVERM ORAL TABLET CHEWABLE ivermectin oral tablet Stromectol *Antianginal Agents* *Antianginals-Other*** RANEXA ORAL TABLET EXTENDED RELEASE 1 HOUR *Nitrates*** DILATRATE-SR ORAL CAPSULE EXTENDED RELEASE QL 1 Effective as of /1/018

19 ISORDIL TITRADOSE ORAL TABLET 0 MG isosorbide dinitrate er oral tablet extended release isosorbide dinitrate oral tablet Isordil Titradose 1 isosorbide mononitrate er oral tablet extended release hour isosorbide mononitrate oral tablet 1 MINITRAN TRANSDERMAL PATCH HOUR NITRO-BID TRANSDERMAL OINTMENT NITRO-DUR TRANSDERMAL PATCH HOUR 0. MG/HR, 0.8 MG/HR nitroglycerin er oral capsule extended release nitroglycerin sublingual tablet sublingual nitroglycerin transdermal patch hour nitroglycerin translingual aerosol solution Minitran Nitro-Time Nitrostat Minitran NitroMist nitroglycerin translingual solution Nitrolingual NITRO-TIME ORAL CAPSULE EXTENDED RELEASE *Antianxiety Agents* *Antianxiety Agents - Misc.*** Nitro-Time buspirone hcl oral tablet hydroxyzine hcl oral syrup 1 hydroxyzine hcl oral tablet hydroxyzine pamoate oral capsule meprobamate oral tablet *Benzodiazepines*** ALPRAZOLAM INTENSOL ORAL CONCENTRATE alprazolam oral tablet Xanax alprazolam oral tablet dispersible 1 1 Effective as of /1/018 15

20 chlordiazepoxide hcl oral capsule clorazepate dipotassium oral tablet Tranxene-T DIAZEPAM INTENSOL ORAL CONCENTRATE diazepam oral solution 1 mg/ml diazepam oral tablet Valium LORAZEPAM INTENSOL ORAL CONCENTRATE lorazepam oral tablet Ativan oxazepam oral capsule *Antiarrhythmics* *Antiarrhythmics Type I-A*** disopyramide phosphate oral capsule Norpace NORPACE CR ORAL CAPSULE EXTENDED RELEASE 1 HOUR quinidine gluconate er oral tablet extended release quinidine sulfate er oral tablet extended release quinidine sulfate oral tablet 1 *Antiarrhythmics Type I-B*** mexiletine hcl oral capsule *Antiarrhythmics Type I-C*** flecainide acetate oral tablet propafenone hcl er oral capsule extended release 1 hour Rythmol SR propafenone hcl oral tablet *Antiarrhythmics Type Iii*** amiodarone hcl oral tablet Pacerone dofetilide oral capsule Tikosyn MULTAQ ORAL TABLET PACERONE ORAL TABLET 100 MG, 00 MG, 00 MG Pacerone 1 16 Effective as of /1/018

21 *Antiasthmatic And Bronchodilator Agents* *5-Lipoxygenase Inhibitors*** zileuton er oral tablet extended release 1 hour *Adrenergic Combinations*** ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED ADVAIR HFA INHALATION AEROSOL ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED BREO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION Zyflo CR DULERA INHALATION AEROSOL fluticasone-salmeterol inhalation aerosol powder breath activated ipratropium-albuterol inhalation solution STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION AirDuo RespiClick /1 PREV PREV PREV PREV PREV SYMBICORT INHALATION AEROSOL PREV TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED *Anti-Ige Monoclonal Antibodies*** XOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTED *Anti-Inflammatory Agents*** cromolyn sodium inhalation nebulization solution *Beta Adrenergics*** albuterol sulfate er oral tablet extended release 1 hour ST 5 PA; SP PREV Effective as of /1/018 17

22 albuterol sulfate inhalation nebulization solution albuterol sulfate oral syrup albuterol sulfate oral tablet BROVANA INHALATION NEBULIZATION SOLUTION levalbuterol hcl inhalation nebulization solution 0.1 mg/ml, 0.6 mg/ml, 1.5 mg/ml levalbuterol hcl inhalation nebulization solution 1.5 mg/0.5ml Xopenex PREV Xopenex Concentrate PREV levalbuterol tartrate inhalation aerosol Xopenex HFA metaproterenol sulfate oral syrup PREV metaproterenol sulfate oral tablet PREV PERFOROMIST INHALATION NEBULIZATION SOLUTION PROAIR HFA INHALATION AEROSOL SOLUTION PROAIR RESPICLICK INHALATION AEROSOL POWDER BREATH ACTIVATED PROVENTIL HFA INHALATION AEROSOL SOLUTION SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED PREV terbutaline sulfate oral tablet PREV VENTOLIN HFA INHALATION AEROSOL SOLUTION *Bronchodilators - Anticholinergics*** ATROVENT HFA INHALATION AEROSOL SOLUTION ipratropium bromide inhalation solution SPIRIVA HANDIHALER INHALATION CAPSULE SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION PREV PREV PREV 18 Effective as of /1/018

23 TUDORZA PRESSAIR INHALATION AEROSOL POWDER BREATH ACTIVATED *Leukotriene Receptor Antagonists*** montelukast sodium oral packet Singulair PREV montelukast sodium oral tablet Singulair PREV montelukast sodium oral tablet chewable Singulair PREV zafirlukast oral tablet Accolate PREV *Selective Phosphodiesterase (Pde) Inhibitors*** DALIRESP ORAL TABLET 500 MCG *Steroid Inhalants*** ALVESCO INHALATION AEROSOL SOLUTION ASMANEX 10 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED ASMANEX 1 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED ASMANEX 0 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 110 MCG/INH ASMANEX 0 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 0 MCG/INH ASMANEX 60 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED ASMANEX 7 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED ASMANEX HFA INHALATION AEROSOL PREV PREV PREV budesonide inhalation suspension Pulmicort PREV FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED PREV Effective as of /1/018 19

24 FLOVENT HFA INHALATION AEROSOL PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED QVAR INHALATION AEROSOL SOLUTION *Xanthine-Expectorants*** DIFIL-G FORTE ORAL LIQUID *Xanthines*** ELIXOPHYLLIN ORAL ELIXIR THEO- ORAL CAPSULE EXTENDED RELEASE HOUR THEOCHRON ORAL TABLET EXTENDED RELEASE 1 HOUR 100 MG, 00 MG, 00 MG theophylline er oral tablet extended release 1 hour theophylline er oral tablet extended release hour PREV PREV PREV Theochron PREV Theochron PREV PREV theophylline oral solution PREV *Anticoagulants* *Coumarin Anticoagulants*** COUMADIN ORAL TABLET Coumadin PREV JANTOVEN ORAL TABLET Coumadin PREV warfarin sodium oral tablet Coumadin PREV *Direct Factor Xa Inhibitors*** ELIQUIS ORAL TABLET XARELTO ORAL TABLET XARELTO STARTER PACK ORAL TABLET THERAPY PACK *Heparins And Heparinoid-Like Agents*** heparin (porcine) in nacl injection solution unit/ml-%, unit/ml-% heparin (porcine) in nacl injection solution -0.9 unit/ml-% 0 Effective as of /1/018

25 *Low Molecular Weight Heparins*** enoxaparin sodium injection solution Lovenox enoxaparin sodium subcutaneous solution FRAGMIN SUBCUTANEOUS SOLUTION UNIT/ML, 1500 UNIT/0.5ML, UNIT/0.6ML, UNT/0.7ML, 500 UNIT/0.ML, 5000 UNIT/0.ML, 7500 UNIT/0.ML, UNIT/.8ML *Synthetic Heparinoid-Like Agents*** fondaparinux sodium subcutaneous solution Lovenox Arixtra *Thrombin Inhibitors - Selective Direct & Reversible*** PRADAXA ORAL CAPSULE QL *Anticonvulsants* *Ampa Glutamate Receptor Antagonists*** FYCOMPA ORAL SUSPENSION PA FYCOMPA ORAL TABLET PA *Anticonvulsants - Benzodiazepines*** clonazepam oral tablet KlonoPIN clonazepam oral tablet dispersible diazepam rectal gel Diastat AcuDial ONFI ORAL SUSPENSION PA ONFI ORAL TABLET 10 MG, 0 MG PA *Anticonvulsants - Misc.*** APTIOM ORAL TABLET PA BANZEL ORAL SUSPENSION BANZEL ORAL TABLET BRIVIACT ORAL SOLUTION PA BRIVIACT ORAL TABLET PA carbamazepine er oral capsule extended release 1 hour carbamazepine er oral tablet extended release 1 hour Carbatrol TEGretol-XR carbamazepine oral suspension TEGretol Effective as of /1/018 1

26 carbamazepine oral tablet Epitol carbamazepine oral tablet chewable CARBATROL ORAL CAPSULE EXTENDED RELEASE 1 HOUR Carbatrol EPITOL ORAL TABLET Epitol gabapentin oral capsule Neurontin gabapentin oral solution Neurontin gabapentin oral tablet Neurontin LAMICTAL ODT ORAL KIT LaMICtal ODT LAMICTAL ODT ORAL TABLET DISPERSIBLE LaMICtal ODT LAMICTAL ORAL TABLET LaMICtal LAMICTAL ORAL TABLET CHEWABLE 5 MG, 5 MG LaMICtal LAMICTAL XR ORAL KIT LAMICTAL XR ORAL TABLET EXTENDED RELEASE HOUR lamotrigine er oral tablet extended release hour lamotrigine oral kit 5 & 50 & 100 mg, 5 (1)-50 (7) mg, 50 ()-100(1) mg LaMICtal XR LaMICtal XR LaMICtal ODT lamotrigine oral tablet LaMICtal lamotrigine oral tablet chewable LaMICtal lamotrigine oral tablet dispersible LaMICtal ODT lamotrigine starter kit-blue oral kit LaMICtal Starter lamotrigine starter kit-green oral kit LaMICtal Starter lamotrigine starter kit-orange oral kit LaMICtal Starter levetiracetam er oral tablet extended release hour Keppra XR levetiracetam oral solution Keppra levetiracetam oral tablet Keppra LYRICA ORAL CAPSULE LYRICA ORAL SOLUTION oxcarbazepine oral suspension Trileptal oxcarbazepine oral tablet Trileptal Effective as of /1/018

27 OXTELLAR XR ORAL TABLET EXTENDED RELEASE HOUR POTIGA ORAL TABLET primidone oral tablet Mysoline ROWEEPRA ORAL TABLET 500 MG Keppra SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE TEGRETOL ORAL SUSPENSION TEGretol TEGRETOL ORAL TABLET Epitol TEGRETOL-XR ORAL TABLET EXTENDED RELEASE 1 HOUR 00 MG, 00 MG TEGretol-XR TOPAMAX ORAL TABLET Topamax TOPAMAX SPRINKLE ORAL CAPSULE SPRINKLE Topamax Sprinkle topiramate oral capsule sprinkle Topamax Sprinkle topiramate oral tablet Topamax TRILEPTAL ORAL SUSPENSION Trileptal TRILEPTAL ORAL TABLET Trileptal VIMPAT ORAL SOLUTION VIMPAT ORAL TABLET ZONEGRAN ORAL CAPSULE Zonegran zonisamide oral capsule Zonegran *Carbamates*** felbamate oral suspension Felbatol felbamate oral tablet Felbatol *Gaba Modulators*** GABITRIL ORAL TABLET 1 MG, 16 MG SABRIL ORAL PACKET Sabril 5 PA; SP SABRIL ORAL TABLET 5 PA; SP tiagabine hcl oral tablet mg, mg Gabitril vigabatrin oral packet Sabril 5 PA; SP *Hydantoins*** DILANTIN INFATABS ORAL TABLET CHEWABLE Dilantin Infatabs Effective as of /1/018

28 DILANTIN ORAL CAPSULE Dilantin DILANTIN ORAL SUSPENSION Dilantin PEGANONE ORAL TABLET PHENYTEK ORAL CAPSULE Phenytek phenytoin oral suspension 15 mg/5ml Dilantin phenytoin oral tablet chewable Dilantin Infatabs phenytoin sodium extended oral capsule Dilantin *Succinimides*** CELONTIN ORAL CAPSULE ethosuximide oral capsule Zarontin ethosuximide oral solution Zarontin ZARONTIN ORAL CAPSULE Zarontin ZARONTIN ORAL SOLUTION Zarontin *Valproic Acid*** DEPAKENE ORAL CAPSULE Depakene DEPAKENE ORAL SOLUTION Depakene DEPAKOTE ER ORAL TABLET EXTENDED RELEASE HOUR DEPAKOTE ORAL TABLET DELAYED RELEASE DEPAKOTE SPRINKLES ORAL CAPSULE DELAYED RELEASE SPRINKLE divalproex sodium er oral tablet extended release hour divalproex sodium oral capsule delayed release sprinkle divalproex sodium oral tablet delayed release Depakote ER Depakote Depakote Sprinkles Depakote ER Depakote Sprinkles Depakote valproate sodium oral solution Depakene valproic acid oral capsule Depakene valproic acid oral solution Depakene *Antidepressants* *Alpha- Receptor Antagonists (Tetracyclics)*** mirtazapine oral tablet Remeron 1 mirtazapine oral tablet dispersible Remeron SolTab 1 Effective as of /1/018

29 *Antidepressants - Misc.*** APLENZIN ORAL TABLET EXTENDED RELEASE HOUR bupropion hcl er (sr) oral tablet extended release 1 hour bupropion hcl er (xl) oral tablet extended release hour Wellbutrin SR 1 Wellbutrin XL 1 bupropion hcl oral tablet 1 FORFIVO XL ORAL TABLET EXTENDED RELEASE HOUR maprotiline hcl oral tablet 1 *Modified Cyclics*** nefazodone hcl oral tablet 1 trazodone hcl oral tablet 1 TRINTELLIX ORAL TABLET PA VIIBRYD ORAL KIT PA; ST; QL VIIBRYD ORAL TABLET PA; ST; QL *Monoamine Oxidase Inhibitors (Maois)*** EMSAM TRANSDERMAL PATCH HOUR MARPLAN ORAL TABLET phenelzine sulfate oral tablet Nardil 1 tranylcypromine sulfate oral tablet Parnate 1 *Selective Serotonin Reuptake Inhibitors (Ssris)*** citalopram hydrobromide oral solution 1 citalopram hydrobromide oral tablet CeleXA 1 escitalopram oxalate oral solution 1 escitalopram oxalate oral tablet Lexapro 1 fluoxetine hcl oral capsule PROzac 1 fluoxetine hcl oral capsule delayed release fluoxetine hcl oral solution 1 fluoxetine hcl oral tablet 10 mg, 0 mg 1 fluoxetine hcl oral tablet 60 mg fluvoxamine maleate er oral capsule extended release hour 1 QL Effective as of /1/

30 fluvoxamine maleate oral tablet 1 paroxetine hcl er oral tablet extended release hour Paxil CR 1 paroxetine hcl oral tablet Paxil 1 PAXIL ORAL SUSPENSION PEXEVA ORAL TABLET sertraline hcl oral concentrate Zoloft 1 sertraline hcl oral tablet Zoloft 1 *Serotonin-Norepinephrine Reuptake Inhibitors (Snris)*** desvenlafaxine fumarate er oral tablet extended release hour desvenlafaxine succinate er oral tablet extended release hour duloxetine hcl oral capsule delayed release particles venlafaxine hcl er oral capsule extended release hour venlafaxine hcl er oral tablet extended release hour Pristiq 1 Cymbalta 1 Effexor XR 1 venlafaxine hcl oral tablet 1 *Tricyclic Agents*** amitriptyline hcl oral tablet 1 amoxapine oral tablet 1 clomipramine hcl oral capsule Anafranil 1 desipramine hcl oral tablet 1 doxepin hcl oral capsule 1 doxepin hcl oral concentrate 1 imipramine hcl oral tablet Tofranil 1 imipramine pamoate oral capsule 1 nortriptyline hcl oral capsule Pamelor 1 nortriptyline hcl oral solution 1 protriptyline hcl oral tablet 1 trimipramine maleate oral capsule Surmontil Effective as of /1/018

31 *Antidiabetics* *Alpha-Glucosidase Inhibitors*** acarbose oral tablet Precose PREV miglitol oral tablet Glyset *Antidiabetic - Amylin Analogs*** SYMLINPEN 10 SUBCUTANEOUS SOLUTION PEN-INJECTOR SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN-INJECTOR *Biguanides*** metformin hcl er oral tablet extended release hour PREV PREV Glucophage XR 1 PREV metformin hcl oral tablet Glucophage 1 PREV RIOMET ORAL SOLUTION *Diabetic Other*** GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED GLUCAGON EMERGENCY INJECTION KIT PROGLYCEM ORAL SUSPENSION *Dipeptidyl Peptidase- (Dpp-) Inhibitors*** JANUVIA ORAL TABLET TRADJENTA ORAL TABLET *Dipeptidyl Peptidase- Inhibitor-Biguanide Combinations*** JANUMET ORAL TABLET JANUMET XR ORAL TABLET EXTENDED RELEASE HOUR JENTADUETO ORAL TABLET JENTADUETO XR ORAL TABLET EXTENDED RELEASE HOUR *Dopamine Receptor Agonists - Ergot Derivatives*** CYCLOSET ORAL TABLET Effective as of /1/018 7

32 *Human Insulin*** FIASP FLEXTOUCH SUBCUTANEOUS SOLUTION PEN- INJECTOR PREV FIASP SUBCUTANEOUS SOLUTION PREV HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION PEN- INJECTOR LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN- INJECTOR LANTUS SUBCUTANEOUS SOLUTION LEVEMIR FLEXTOUCH SUBCUTANEOUS SOLUTION PEN- INJECTOR LEVEMIR SUBCUTANEOUS SOLUTION NOVOLIN 70/0 SUBCUTANEOUS SUSPENSION NOVOLIN N SUBCUTANEOUS SUSPENSION PREV PREV PREV PREV PREV PREV PREV PREV NOVOLIN R INJECTION SOLUTION PREV NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN- INJECTOR NOVOLOG MIX 70/0 FLEXPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR NOVOLOG MIX 70/0 SUBCUTANEOUS SUSPENSION NOVOLOG PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE NOVOLOG SUBCUTANEOUS SOLUTION PREV PREV PREV PREV PREV 8 Effective as of /1/018

33 TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTION PEN- INJECTOR TRESIBA FLEXTOUCH SUBCUTANEOUS SOLUTION PEN- INJECTOR *Incretin Mimetic Agents (Glp-1 Receptor Agonists)*** BYDUREON SUBCUTANEOUS PEN- INJECTOR BYDUREON SUBCUTANEOUS SUSPENSION RECONSTITUTED ER BYETTA 10 MCG PEN SUBCUTANEOUS SOLUTION PEN- INJECTOR BYETTA 5 MCG PEN SUBCUTANEOUS SOLUTION PEN- INJECTOR TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR VICTOZA SUBCUTANEOUS SOLUTION PEN-INJECTOR *Meglitinide Analogues*** PREV PREV PA; ST PA; ST PA; ST; QL PA; ST; QL PA; ST; PREV; QL PA; ST; PREV nateglinide oral tablet Starlix 1 PREV repaglinide oral tablet Prandin 1 PREV *Meglitinide-Biguanide Combinations*** repaglinide-metformin hcl oral tablet 1 *Progesterone Receptor Antagonists*** KORLYM ORAL TABLET 6 PA; SP *Sodium-Glucose Co-Transporter (Sglt) Inhibitors*** FARXIGA ORAL TABLET PA JARDIANCE ORAL TABLET PA *Sulfonylurea-Biguanide Combinations*** glipizide-metformin hcl oral tablet 1 PREV glyburide-metformin oral tablet 1 PREV *Sulfonylureas*** chlorpropamide oral tablet PREV Effective as of /1/018 9

34 glimepiride oral tablet Amaryl 1 PREV glipizide er oral tablet extended release hour Glucotrol XL 1 PREV glipizide oral tablet Glucotrol 1 PREV glipizide xl oral tablet extended release hour Glucotrol XL 1 PREV glyburide micronized oral tablet Glynase 1 PREV glyburide oral tablet 1 PREV tolazamide oral tablet PREV tolbutamide oral tablet *Sulfonylurea-Thiazolidinedione Combinations*** pioglitazone hcl-glimepiride oral tablet Duetact 1 PREV *Thiazolidinedione-Biguanide Combinations*** ACTOPLUS MET XR ORAL TABLET EXTENDED RELEASE HOUR pioglitazone hcl-metformin hcl oral tablet *Thiazolidinediones*** Actoplus Met 1 PREV AVANDIA ORAL TABLET pioglitazone hcl oral tablet Actos 1 PREV *Antidiarrheals* *Antidiarrheal Combinations*** RESTORA RX ORAL CAPSULE *Antiperistaltic Agents*** diphenoxylate-atropine oral liquid diphenoxylate-atropine oral tablet Lomotil opium oral tincture paregoric oral tincture *Antidotes And Specific Antagonists* *Antidotes And Specific Antagonists*** VISTOGARD ORAL PACKET 5 SP *Antidotes* *Antidotes - Chelating Agents*** CHEMET ORAL CAPSULE PA 0 Effective as of /1/018

35 EXJADE ORAL TABLET SOLUBLE 6 PA; SP FERRIPROX ORAL SOLUTION 6 PA; SP FERRIPROX ORAL TABLET 6 PA; SP JADENU ORAL TABLET 6 PA; SP JADENU SPRINKLE ORAL PACKET 6 PA; SP *Antidotes*** VISTOGARD ORAL PACKET 5 SP *Opioid Antagonists*** EVZIO INJECTION SOLUTION AUTO- INJECTOR naloxone hcl injection solution 0. mg/ml, mg/10ml naloxone hcl injection solution cartridge naltrexone hcl oral tablet PA; ST; QL QL QL NARCAN NASAL LIQUID QL VIVITROL INTRAMUSCULAR SUSPENSION RECONSTITUTED *Antiemetics* *5-Ht Receptor Antagonists*** 6 SP; QL ANZEMET ORAL TABLET QL granisetron hcl oral tablet QL ondansetron hcl oral solution Zofran ondansetron hcl oral tablet QL ondansetron oral tablet dispersible Zofran ODT QL SANCUSO TRANSDERMAL PATCH QL ZUPLENZ ORAL FILM QL *Antiemetics - Anticholinergic*** meclizine hcl oral tablet Dramamine Less Drowsy scopolamine transdermal patch 7 hour Transderm-Scop (1.5 MG) trimethobenzamide hcl oral capsule Tigan *Antiemetics - Miscellaneous*** CESAMET ORAL CAPSULE QL dronabinol oral capsule Marinol QL 1 Effective as of /1/018 1

36 SYNDROS ORAL SOLUTION QL *Substance P/Neurokinin 1 (Nk1) Receptor Antagonists*** aprepitant oral capsule Emend QL EMEND ORAL SUSPENSION RECONSTITUTED QL VARUBI ORAL TABLET PA; QL *Antifungals* *Antifungals*** bio-statin oral capsule bio-statin oral powder flucytosine oral capsule Ancobon griseofulvin microsize oral suspension griseofulvin microsize oral tablet griseofulvin ultramicrosize oral tablet Gris-PEG LAMISIL ORAL PACKET nystatin oral tablet terbinafine hcl oral tablet LamISIL *Imidazoles*** ketoconazole oral tablet *Triazoles*** CRESEMBA ORAL CAPSULE PA fluconazole oral suspension reconstituted Diflucan fluconazole oral tablet Diflucan itraconazole oral capsule Sporanox NOXAFIL ORAL SUSPENSION PA NOXAFIL ORAL TABLET DELAYED RELEASE ONMEL ORAL TABLET SPORANOX ORAL SOLUTION voriconazole oral suspension reconstituted Vfend voriconazole oral tablet Vfend PA Effective as of /1/018

37 *Antihistamines* *Antihistamines - Alkylamines*** brompheniramine tannate oral tablet chewable RESPA-BR ORAL TABLET EXTENDED RELEASE 1 HOUR *Antihistamines - Ethanolamines*** ARBINOXA ORAL SOLUTION ARBINOXA ORAL TABLET carbinoxamine maleate oral solution carbinoxamine maleate oral tablet mg clemastine fumarate oral syrup clemastine fumarate oral tablet.68 mg diphenhydramine hcl oral elixir pharbedryl oral capsule 50 mg Banophen *Antihistamines - Phenothiazines*** PHENADOZ RECTAL SUPPOSITORY Phenadoz PHENERGAN RECTAL SUPPOSITORY Phenergan promethazine hcl oral solution promethazine hcl oral syrup promethazine hcl oral tablet promethazine hcl rectal suppository Phenadoz PROMETHEGAN RECTAL SUPPOSITORY *Antihistamines - Piperidines*** Phenadoz cyproheptadine hcl oral syrup cyproheptadine hcl oral tablet *Antihyperlipidemics* *Bile Acid Sequestrants*** cholestyramine light oral packet Prevalite 1 PREV cholestyramine light oral powder Prevalite 1 PREV cholestyramine oral packet Questran 1 PREV cholestyramine oral powder Questran 1 PREV colestipol hcl oral granules Colestid PREV Effective as of /1/018

38 colestipol hcl oral packet Colestid PREV colestipol hcl oral tablet Colestid PREV PREVALITE ORAL PACKET Prevalite 1 PREV PREVALITE ORAL POWDER Prevalite 1 PREV WELCHOL ORAL PACKET WELCHOL ORAL TABLET *Fibric Acid Derivatives*** ANTARA ORAL CAPSULE 0 MG, 90 MG fenofibrate micronized oral capsule PREV fenofibrate oral capsule Lipofen PREV fenofibrate oral tablet Lofibra PREV fenofibric acid oral capsule delayed release Trilipix PREV fenofibric acid oral tablet Fibricor PREV gemfibrozil oral tablet Lopid 1 PREV *Hmg Coa Reductase Inhibitors*** ALTOPREV ORAL TABLET EXTENDED RELEASE HOUR atorvastatin calcium oral tablet 10 mg, 0 mg atorvastatin calcium oral tablet 0 mg, 80 mg fluvastatin sodium er oral tablet extended release hour Lipitor ACA PREV Lipitor 1 PREV Lescol XL ACA fluvastatin sodium oral capsule ACA PREV lovastatin oral tablet Mevacor ACA PREV pravastatin sodium oral tablet Pravachol ACA PREV rosuvastatin calcium oral tablet 10 mg, 5 mg rosuvastatin calcium oral tablet 0 mg, 0 mg simvastatin oral tablet 10 mg, 0 mg, 0 mg, 5 mg Crestor ACA PREV Crestor 1 PREV Zocor ACA PREV simvastatin oral tablet 80 mg Zocor 1 PREV Effective as of /1/018

39 *Intest Cholest Absorp Inhib-Hmg Coa Reductase Inhib Comb*** ezetimibe-simvastatin oral tablet Vytorin PREV *Intestinal Cholesterol Absorption Inhibitors*** ezetimibe oral tablet Zetia PREV *Nicotinic Acid Derivatives*** niacin er (antihyperlipidemic) oral tablet extended release Niaspan NIACOR ORAL TABLET *Antihypertensives* *Ace Inhibitor & Calcium Channel Blocker Combinations*** amlodipine besy-benazepril hcl oral capsule trandolapril-verapamil hcl er oral tablet extended release *Ace Inhibitors & Thiazide/Thiazide-Like*** benazepril-hydrochlorothiazide oral tablet captopril-hydrochlorothiazide oral tablet enalapril-hydrochlorothiazide oral tablet Lotrel 1 PREV Tarka 1 PREV Lotensin HCT 1 PREV 1 PREV 1 PREV fosinopril sodium-hctz oral tablet 1 PREV lisinopril-hydrochlorothiazide oral tablet moexipril-hydrochlorothiazide oral tablet quinapril-hydrochlorothiazide oral tablet *Ace Inhibitors*** Zestoretic 1 PREV 1 PREV Accuretic 1 PREV benazepril hcl oral tablet 1 PREV captopril oral tablet 1 PREV enalapril maleate oral tablet Vasotec 1 PREV EPANED ORAL SOLUTION EPANED ORAL SOLUTION RECONSTITUTED fosinopril sodium oral tablet 1 PREV Effective as of /1/018 5

40 lisinopril oral tablet Zestril 1 PREV moexipril hcl oral tablet 1 PREV perindopril erbumine oral tablet 1 PREV quinapril hcl oral tablet Accupril 1 PREV ramipril oral capsule Altace 1 PREV trandolapril oral tablet 1 PREV *Adrenolytics-Central & Thiazide/Thiazide-Like Comb*** CLORPRES ORAL TABLET PREV methyldopa-hydrochlorothiazide oral tablet *Agents For Pheochromocytoma*** DEMSER ORAL CAPSULE phenoxybenzamine hcl oral capsule Dibenzyline *Angiotensin Ii Receptor Antag & Ca Channel Blocker Comb*** amlodipine besylate-valsartan oral tablet PREV Exforge 1 PREV amlodipine-olmesartan oral tablet Azor 1 telmisartan-amlodipine oral tablet Twynsta 1 PREV *Angiotensin Ii Receptor Antag & Thiazide/Thiazide-Like*** candesartan cilexetil-hctz oral tablet Atacand HCT 1 PREV EDARBYCLOR ORAL TABLET irbesartan-hydrochlorothiazide oral tablet Avalide 1 PREV losartan potassium-hctz oral tablet Hyzaar 1 PREV olmesartan medoxomil-hctz oral tablet Benicar HCT 1 PREV telmisartan-hctz oral tablet Micardis HCT 1 PREV valsartan-hydrochlorothiazide oral tablet *Angiotensin Ii Receptor Antagonists*** Diovan HCT 1 PREV candesartan cilexetil oral tablet Atacand 1 PREV EDARBI ORAL TABLET eprosartan mesylate oral tablet 1 PREV irbesartan oral tablet Avapro 1 PREV losartan potassium oral tablet Cozaar 1 PREV olmesartan medoxomil oral tablet Benicar 1 PREV 6 Effective as of /1/018

41 telmisartan oral tablet Micardis 1 PREV valsartan oral tablet Diovan 1 PREV *Angiotensin Ii Receptor Ant-Ca Channel Blocker-Thiazides*** amlodipine-valsartan-hctz oral tablet Exforge HCT 1 PREV olmesartan-amlodipine-hctz oral tablet Tribenzor *Antiadrenergics - Centrally Acting*** clonidine hcl oral tablet Catapres PREV clonidine hcl transdermal patch weekly Catapres-TTS- PREV guanfacine hcl oral tablet 1 PREV methyldopa oral tablet 1 PREV *Antiadrenergics - Peripherally Acting*** doxazosin mesylate oral tablet Cardura 1 prazosin hcl oral capsule Minipress 1 terazosin hcl oral capsule 1 *Antihypertensives - Misc.*** VECAMYL ORAL TABLET *Beta Blocker & Diuretic Combinations*** atenolol-chlorthalidone oral tablet Tenoretic PREV bisoprolol-hydrochlorothiazide oral tablet metoprolol-hydrochlorothiazide oral tablet Ziac 1 PREV 1 PREV nadolol-bendroflumethiazide oral tablet Corzide PREV propranolol-hctz oral tablet 1 PREV *Direct Renin Inhibitors & Thiazide/Thiazide-Like Comb*** TEKTURNA HCT ORAL TABLET *Direct Renin Inhibitors*** TEKTURNA ORAL TABLET *Selective Aldosterone Receptor Antagonists (Saras)*** eplerenone oral tablet Inspra PREV *Vasodilators*** hydralazine hcl oral tablet 1 PREV minoxidil oral tablet 1 PREV Effective as of /1/018 7

42 *Anti-Infective Agents - Misc.* *Anti-Infective Agents - Misc.*** CAYSTON INHALATION SOLUTION RECONSTITUTED FIRST-VANCOMYCIN 5 ORAL SOLUTION FIRST-VANCOMYCIN 50 ORAL SOLUTION metronidazole oral capsule Flagyl metronidazole oral tablet Flagyl NEBUPENT INHALATION SOLUTION RECONSTITUTED PRIMSOL ORAL SOLUTION tinidazole oral tablet trimethoprim oral tablet vancomycin hcl oral capsule Vancocin HCl XIFAXAN ORAL TABLET *Anti-Infective Misc. - Combinations*** sulfamethoxazole-trimethoprim oral suspension 00-0 mg/5ml sulfamethoxazole-trimethoprim oral tablet SULFATRIM PEDIATRIC ORAL SUSPENSION *Antiprotozoal Agents*** ALINIA ORAL SUSPENSION RECONSTITUTED Sulfatrim Pediatric Bactrim Sulfatrim Pediatric ALINIA ORAL TABLET atovaquone oral suspension Mepron *Ketolides*** KETEK ORAL TABLET *Leprostatics*** dapsone oral tablet *Lincosamides*** clindamycin hcl oral capsule Cleocin 6 SP 8 Effective as of /1/018

43 clindamycin palmitate hcl oral solution reconstituted *Oxazolidinones*** Cleocin linezolid oral suspension reconstituted Zyvox linezolid oral tablet Zyvox *Antimalarials* *Antimalarial Combinations*** atovaquone-proguanil hcl oral tablet Malarone COARTEM ORAL TABLET *Antimalarials*** chloroquine phosphate oral tablet DARAPRIM ORAL TABLET hydroxychloroquine sulfate oral tablet Plaquenil mefloquine hcl oral tablet QL primaquine phosphate oral tablet quinine sulfate oral capsule Qualaquin *Antimyasthenic Agents* *Antimyasthenic Agents*** guanidine hcl oral tablet MESTINON ORAL SYRUP pyridostigmine bromide er oral tablet extended release Mestinon pyridostigmine bromide oral tablet Mestinon *Antimyasthenic/Cholinergic Agents*** guanidine hcl oral tablet MESTINON ORAL SYRUP pyridostigmine bromide er oral tablet extended release Mestinon pyridostigmine bromide oral tablet Mestinon *Antimyasthenic/Cholinergic Agents* guanidine hcl oral tablet MESTINON ORAL SYRUP pyridostigmine bromide er oral tablet extended release Mestinon Effective as of /1/018 9

44 pyridostigmine bromide oral tablet Mestinon *Antimycobacterial Agents* *Anti Tb Combinations*** RIFAMATE ORAL CAPSULE RIFATER ORAL TABLET *Antimycobacterial Agents*** cycloserine oral capsule Seromycin ethambutol hcl oral tablet Myambutol isoniazid oral syrup isoniazid oral tablet PASER ORAL PACKET PRIFTIN ORAL TABLET pyrazinamide oral tablet rifabutin oral capsule Mycobutin rifampin oral capsule Rifadin TRECATOR ORAL TABLET *Antineoplastic - Bcl- Inhibitors*** *Antineoplastic - Bcl- Inhibitors*** VENCLEXTA ORAL TABLET 6 PA; SP VENCLEXTA STARTING PACK ORAL TABLET THERAPY PACK *Antineoplastics And Adjunctive Therapies* *Alkylating Agents*** HEXALEN ORAL CAPSULE MYLERAN ORAL TABLET *Androgen Biosynthesis Inhibitors*** 6 PA; SP ZYTIGA ORAL TABLET 6 PA; SP *Antiadrenals*** LYSODREN ORAL TABLET *Antiandrogens*** bicalutamide oral tablet Casodex flutamide oral capsule nilutamide oral tablet Nilandron 0 Effective as of /1/018

45 XTANDI ORAL CAPSULE 6 PA; SP *Antiestrogens*** FARESTON ORAL TABLET SOLTAMOX ORAL SOLUTION tamoxifen citrate oral tablet ACA AL; PREV *Antimetabolites*** capecitabine oral tablet Xeloda 5 PA; SP mercaptopurine oral tablet methotrexate oral tablet methotrexate sodium (pf) injection solution 50 mg/ml methotrexate sodium injection solution 50 mg/ml PURIXAN ORAL SUSPENSION 6 SP TABLOID ORAL TABLET *Antineoplastic - Braf Kinase Inhibitors*** TAFINLAR ORAL CAPSULE 6 PA; SP ZELBORAF ORAL TABLET 6 PA; SP *Antineoplastic - Hedgehog Pathway Inhibitors*** ERIVEDGE ORAL CAPSULE 6 PA; SP ODOMZO ORAL CAPSULE 6 PA; SP *Antineoplastic - Histone Deacetylase Inhibitors*** FARYDAK ORAL CAPSULE 6 PA; SP ZOLINZA ORAL CAPSULE 5 PA; SP *Antineoplastic - Immunomodulators*** POMALYST ORAL CAPSULE 6 PA; SP *Antineoplastic - Mek Inhibitors*** COTELLIC ORAL TABLET 6 PA; SP MEKINIST ORAL TABLET 6 PA; SP *Antineoplastic - Mtor Kinase Inhibitors*** AFINITOR DISPERZ ORAL TABLET SOLUBLE 5 PA; SP AFINITOR ORAL TABLET 5 PA; SP Effective as of /1/018 1

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