Prescription Drug Formulary

Transcription

1 Prescription Drug Formulary 016 This formulary was updated on 07/6/016. For more recent information or other questions, please contact Essence Healthcare, Inc. Customer Service at (866) or, for TTY users, 711, 8:00 a.m. to 8:00 p.m., or visit You may receive a messaging service on weekends and holidays from February 15 through September 0. Please leave a message and your call will be returned the next business day. HPMS Approved Formulary File Submission ID 1608, Version 16 Y007_15-077_MM CMS Accepted 08/8/015

2 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means Essence Healthcare, Inc.. When it refers to plan or our plan, it means Essence Advantage (HMO)/Essence Platinum (HMO-POS). This document includes list of the drugs (formulary) for our plan which is current as of August 016. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or co-payments/co-insurance may change on January 1, 017, and from time to time during the year. Essence Healthcare is an HMO plan with a Medicare contract. Enrollment in Essence Healthcare depends on contract renewal. The formulary, pharmacy network and/or provider network may change at any time. You will receive notice when necessary. HPMS Approved Formulary File Submission ID: Version Number 16 Y007_16-015a_MM i

3 What is the Essence Advantage (HMO)/Essence Platinum (HMO-POS) Formulary? A formulary is a list of covered drugs selected by Essence in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Essence will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an Essence network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 016 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 016 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of August 016. To get updated information about the drugs covered by Essence, please contact us. Our contact information appears on the front and back cover pages. All mid-year changes in drug coverage are updated monthly with a Formulary Change Notice posted on our web site and available upon request from Customer Service. If we make mid-year nonmaintenance formulary changes, Essence will mail written notification to affected members in the form of Formulary Errata Sheets. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page I-1. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. ii

4 What are generic drugs? Essence covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: Essence requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Essence before you fill your prescriptions. If you don t get approval, Essence may not cover the drug. Quantity Limits: For certain drugs, Essence limits the amount of the drug that Essence will cover. For example, Essence provides eighteen per prescription for sumatriptan. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, Essence 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, Essence may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Essence will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask Essence to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the Essence formulary? on page iii for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered. If you learn that Essence does not cover your drug, you have two options: You can ask Customer Service for a list of similar drugs that are covered by Essence. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Essence. You can ask Essence to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the Essence Advantage (HMO)/Essence Platinum (HMO-POS) Formulary? You can ask Essence to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. iii

5 You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Essence limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, Essence will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 7 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 7 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 4 hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 0-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 0-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with at least 91and may be up to a 98-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 1-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. Members who have a change in level of care (setting) will be allowed up to a one-time 0-day transition supply per drug. For example, members who: Enter long-term care (LTC) facilities from hospitals are sometimes accompanied by a discharge list of medications from the hospital formulary, with very short term planning taken into account (often under 8 hours). iv

6 Are discharged from a hospital to a home. End their skilled nursing facility Medicare Part A stay (where payments include all pharmacy charges) and who need to revert to their Part D plan formulary. End a long-term care facility stay and return to the community. If a member has more than one change in level of care in a month, the pharmacy will have to call Essence to request an extension of the transition policy. For more information For more detailed information about your Essence prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Essence, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) 4 hours a day/7 days a week. TTY users should call Or, visit v

7 Essence Formulary The formulary that begins on the next page provides coverage information about the drugs covered by Essence. If you have trouble finding your drug in the list, turn to the Index that begins on page I-1. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., COUMADIN) and generic drugs are listed in lower-case italics (e.g., warfarin). The information in the Requirements/Limits column tells you if Essence has any special requirements for coverage of your drug. List of Abbreviations EX: Excluded Part D: This prescription drug is not normally covered in a Medicare Prescription Drug Plan. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. FF: Free First Fill. This prescription drug will be provided at zero/reduced cost-sharing the first time you fill it. GC: Gap Coverage. We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. HI: Home Infusion. This prescription drug may be covered under our medical benefit. For more information call Customer Service at or toll free , 7 days a week from 8:00 a.m. to 8:00 p.m. You may receive a messaging service on weekends and holidays from February 15 through September 0. Please leave a message and your call will be returned the next business day. TTY users should call 711. LA: Limited Access. This prescription may be available only at certain pharmacies. For more information call Customer Service at or toll free , 7 days a week from 8:00 a.m. to 8:00 p.m. You may receive a messaging service on weekends and holidays from February 15 through September 0. Please leave a message and your call will be returned the next business day. TTY users should call 711. NM: Non Mail Order. The prescription cannot be filled by an Essence network mail order pharmacy.] PA: Prior Authorization. Essence requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Essence before you fill your prescriptions. If you don't get approval, Essence may not cover the drug. PA BvD: Prior Authorization for Part B vs Part D Determination. This prescription drug has a Part B versus D administrative prior authorization requirement. You (or your physician) are required to get prior authorization from Essence to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, Essence may not cover this drug. PA-HRM: Prior Authorization, High Risk Medications. This prescription drug has been deemed by CMS to be potentially harmful and therefore, a High Risk Medication for Medicare beneficiaries 65 years of age or older. Members age 65 years or older are required to get prior approval from Essence before filling prescriptions for this drug. Without prior approval, Essence may not cover this drug. vi

8 PA_NSO: Prior Authorization, New Starts Only. If you are a new member or if you have not taken this drug before, you or your physician are required to get prior authorization from Essence before you fill your prescription for this drug. Without prior approval, Essence may not cover this drug. QL: Quantity Limit. For certain drugs, Essence limits the amount of the drug that Essence will cover. For example, Essence provides eighteen tablets per prescription for sumatriptan succinate. This may be in addition to a standard one-month or three-month supply. ST: Step Therapy. In some cases, Essence 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, Essence may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Essence will then cover Drug B. vii

9 Table of Contents Table of Contents Analgesics... Anesthetics... 9 Anti-Addiction/Substance Abuse Treatment Agents... 9 Antianxiety Agents Antibacterials... 1 Anticancer Agents... 1 Anticholinergic Agents... 0 Anticonvulsants... 0 Antidementia Agents... 4 Antidepressants... 5 Antidiabetic Agents... 7 Antifungals... 4 Antihistamines Anti-Infectives (Skin And Mucous Membrane) Antimigraine Agents Antimycobacterials Antinausea Agents Antiparasite Agents Antiparkinsonian Agents Antipsychotic Agents Antivirals (Systemic)... 5 Blood Products/Modifiers/Volume Expanders Caloric Agents Cardiovascular Agents Central Nervous System Agents Contraceptives Dental And Oral Agents Dermatological Agents Devices Enzyme Replacement/Modifiers Eye, Ear, Nose, Throat Agents Gastrointestinal Agents Genitourinary Agents Heavy Metal Antagonists Hormonal Agents, Stimulant/Replacement/Modifying Immunological Agents Inflammatory Bowel Disease Agents Irrigating Solutions Metabolic Bone Disease Agents Miscellaneous Therapeutic Agents Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

10 Table of Contents Ophthalmic Agents Replacement Preparations Respiratory Tract Agents Skeletal Muscle Relaxants Sleep Disorder Agents Vasodilating Agents Vitamins And Minerals Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

11 Analgesics Analgesics, Miscellaneous acetaminophen-codeine 10 mg-1 mg/5 ml QL (700 per 0 days) solution 10-1 mg/5 ml acetaminophen-codeine oral solution 00 mg-0 QL (700 per 0 days) mg /1.5 ml acetaminophen-codeine oral tablet mg, QL (60 per 0 days) 00-0 mg acetaminophen-codeine oral tablet mg QL (180 per 0 days) ALLZITAL ORAL TABLET 5-5 MG ascomp with codeine oral capsule PA-HRM; QL (180 per 0 days) mg BELBUCA BUCCAL FILM 150 MCG, 00 4 ST; QL (60 per 0 days) MCG, 450 MCG, 600 MCG, 75 MCG, 750 MCG, 900 MCG buprenorphine hcl injection syringe 0. mg/ml butalbital compound w/codeine oral capsule PA-HRM; QL (180 per 0 days) mg butalbital-acetaminop-caf-cod oral capsule PA-HRM; QL (180 per 0 days) mg, mg butalbital-acetaminophen oral tablet 50-5 mg PA-HRM; QL (180 per 0 days) butalbital-acetaminophen-caff oral capsule PA-HRM; QL (180 per 0 days) mg butalbital-acetaminophen-caff oral tablet PA-HRM; QL (180 per 0 days) mg butalbital-aspirin-caffeine oral capsule PA-HRM; QL (180 per 0 days) mg butorphanol tartrate nasal spray,non-aerosol 10 QL (5 per 8 days) mg/ml BUTRANS TRANSDERMAL PATCH QL (4 per 8 days) WEEKLY 10 MCG/HOUR, 15 MCG/HOUR, 0 MCG/HOUR, 5 MCG/HOUR, 7.5 MCG/HOUR capacet oral capsule mg PA-HRM; QL (180 per 0 days) codeine sulfate oral tablet 15 mg, 0 mg, 60 mg QL (180 per 0 days) Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

12 EMBEDA ORAL CAPSULE,ORAL 4 QL (60 per 0 days) ONLY,EXT.REL PELL MG, MG, 0-1. MG, 50- MG, MG, 80-. MG endocet oral tablet 10-5 mg,.5-5 mg, QL (60 per 0 days) 5-5 mg, mg endodan oral tablet mg QL (60 per 0 days) fentanyl citrate buccal lozenge on a handle 1,00 5 PA; NM; QL (10 per 0 days) mcg, 1,600 mcg, 00 mcg, 400 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 7 hour 100 mcg/hr, QL (10 per 0 days) 1 mcg/hr, 5 mcg/hr, 7.5 mcg/hour, 50 mcg/hr, 6.5 mcg/hour, 75 mcg/hr, 87.5 mcg/hour hydrocodone-acetaminophen oral solution QL (700 per 0 days) 10-5 mg/15 ml(15 ml), mg/5 ml, mg/15 ml hydrocodone-acetaminophen oral tablet mg, 5-00 mg, mg (includes Vicodin, Vicodin ES and Vicodin HP); QL (90 per 0 days) hydrocodone-acetaminophen oral tablet 10-5 QL (60 per 0 days) mg,.5-5 mg, 5-5 mg, mg hydrocodone-ibuprofen oral tablet mg, QL (150 per 0 days).5-00 mg, 5-00 mg, mg hydromorphone (pf) injection solution 10 mg/ml, 4 mg/ml hydromorphone injection solution mg/ml hydromorphone injection syringe mg/ml hydromorphone oral liquid 1 mg/ml QL (100 per 0 days) hydromorphone oral tablet mg, 4 mg QL (180 per 0 days) hydromorphone oral tablet 8 mg QL (40 per 0 days) HYSINGLA ER ORAL TABLET,ORAL QL (0 per 0 days) ONLY,EXT.REL.4 HR 100 MG, 10 MG, 0 MG, 0 MG, 40 MG, 60 MG, 80 MG LAZANDA NASAL 5 PA; NM; QL (0 per 0 days) SPRAY,NON-AEROSOL 100 MCG/SPRAY, 00 MCG/SPRAY, 400 MCG/SPRAY lorcet (hydrocodone) oral tablet 5-5 mg QL (60 per 0 days) 4 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

13 lorcet hd oral tablet 10-5 mg QL (60 per 0 days) lorcet plus oral tablet mg QL (60 per 0 days) margesic oral capsule mg PA-HRM; QL (180 per 0 days) methadone injection solution 10 mg/ml methadone oral solution 10 mg/5 ml, 5 mg/5 ml QL (1800 per 0 days) methadone oral tablet 10 mg, 5 mg QL (60 per 0 days) methadose oral tablet,soluble 40 mg QL (90 per 0 days) morphine (pf) in 0.9 % nacl intravenous pt controlled analgesia syring 50 mg/5 ml ( mg/ml) morphine 10 mg/ml carpuject 10 mg/ml morphine mg/ml carpuject mg/ml morphine 4 mg/ml carpuject 4 mg/ml morphine 8 mg/ml syringe 8 mg/ml morphine concentrate oral solution 100 mg/5 ml QL (00 per 0 days) (0 mg/ml) morphine concentrate oral syringe 0 mg/ml morphine in dextrose 5 % injection pt controlled analgesia syring 100 mg/50 ml ( mg/ml), 50 mg/5 ml ( mg/ml) morphine injection solution 15 mg/ml, 8 mg/ml morphine injection syringe 10 mg/ml morphine intramuscular pen injector 10 mg/0.7 ml morphine intravenous cartridge 15 mg/ml morphine intravenous solution 5 mg/ml, 50 mg/ml morphine intravenous syringe 10 mg/ml, mg/ml, 4 mg/ml, 8 mg/ml morphine oral solution 10 mg/5 ml QL (700 per 0 days) morphine oral solution 0 mg/5 ml (4 mg/ml) QL (00 per 0 days) MORPHINE ORAL TABLET 15 MG, 0 4 QL (180 per 0 days) MG morphine oral tablet extended release 100 mg, 0 mg, 60 mg QL (10 per 0 days) 5 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

14 morphine oral tablet extended release 15 mg, QL (180 per 0 days) 00 mg morphine rectal suppository 10 mg, 0 mg, 0 mg, 5 mg NUCYNTA ER ORAL TABLET QL (60 per 0 days) EXTENDED RELEASE 1 HR 100 MG, 150 MG, 00 MG, 50 MG, 50 MG NUCYNTA ORAL TABLET 100 MG, 50 QL (181 per 0 days) MG, 75 MG oxycodone oral capsule 5 mg QL (180 per 0 days) oxycodone oral concentrate 0 mg/ml QL (180 per 0 days) oxycodone oral solution 5 mg/5 ml QL (100 per 0 days) oxycodone oral tablet 10 mg, 15 mg, 0 mg, 0 QL (180 per 0 days) mg, 5 mg oxycodone oral tablet,oral only,ext.rel.1 hr 10 QL (60 per 0 days) mg, 15 mg, 0 mg, 0 mg, 40 mg, 60 mg oxycodone oral tablet,oral only,ext.rel.1 hr 80 5 NM; QL (10 per 0 days) mg oxycodone-acetaminophen oral solution 5-5 QL (1800 per 0 days) mg/5 ml oxycodone-acetaminophen oral tablet 10-5 QL (60 per 0 days) mg,.5-5 mg, 5-5 mg, mg oxycodone-acetaminophen oral tablet QL (180 per 0 days) mg oxycodone-acetaminophen oral tablet QL (40 per 0 days) mg oxycodone-aspirin oral tablet mg QL (60 per 0 days) OXYCONTIN ORAL TABLET,ORAL QL (60 per 0 days) ONLY,EXT.REL.1 HR 10 MG, 15 MG, 0 MG, 0 MG, 40 MG, 60 MG OXYCONTIN ORAL TABLET,ORAL QL (10 per 0 days) ONLY,EXT.REL.1 HR 80 MG oxymorphone oral tablet 10 mg, 5 mg QL (180 per 0 days) oxymorphone oral tablet extended release 1 hr 10 mg, 15 mg, 0 mg, 5 mg, 7.5 mg QL (60 per 0 days) 6 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

15 oxymorphone oral tablet extended release 1 hr QL (10 per 0 days) 0 mg, 40 mg reprexain oral tablet mg,.5-00 mg, QL (150 per 0 days) 5-00 mg roxicet oral solution 5-5 mg/5 ml QL (1800 per 0 days) tencon oral tablet 50-5 mg PA-HRM; QL (180 per 0 days) tramadol oral tablet 50 mg QL (40 per 0 days) tramadol-acetaminophen oral tablet QL (40 per 0 days) mg vicodin es oral tablet mg (includes Vicodin, Vicodin ES and Vicodin HP); QL (90 per 0 days) vicodin hp oral tablet mg (includes Vicodin, Vicodin ES and Vicodin HP); QL (90 per 0 days) vicodin oral tablet 5-00 mg (includes Vicodin, Vicodin ES and Vicodin HP); QL (90 per 0 days) XARTEMIS XR ORAL TAB,ORAL QL (60 per 0 days) ONLY,IR - ER, BIPHASE MG xylon 10 oral tablet mg QL (150 per 0 days) zebutal oral capsule mg PA-HRM; QL (180 per 0 days) ZOHYDRO ER ORAL CAPSULE, ORAL 4 QL (60 per 0 days) ONLY, ER 1HR 10 MG, 15 MG, 0 MG, 0 MG, 40 MG, 50 MG Nonsteroidal Anti-Inflammatory Agents CALDOLOR INTRAVENOUS RECON 4 SOLN 400 MG/4 ML (100 MG/ML) celecoxib oral capsule 100 mg, 00 mg, 400 mg, QL (60 per 0 days) 50 mg choline,magnesium salicylate oral liquid 500 mg/5 ml diclofenac potassium oral tablet 50 mg diclofenac sodium oral tablet extended release 4 hr 100 mg diclofenac sodium oral tablet,delayed release (dr/ec) 5 mg, 50 mg, 75 mg diclofenac sodium topical gel 1 % diclofenac sodium topical gel % 5 NM 7 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

16 diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic mg-mcg, mg-mcg diflunisal oral tablet 500 mg etodolac oral capsule 00 mg, 00 mg etodolac oral tablet 400 mg, 500 mg etodolac oral tablet extended release 4 hr 400 mg, 500 mg, 600 mg fenoprofen oral capsule 00 mg fenoprofen oral tablet 600 mg FLECTOR TRANSDERMAL PATCH 1 PA HOUR 1. % flurbiprofen oral tablet 100 mg, 50 mg ibuprofen oral suspension 100 mg/5 ml ibuprofen oral tablet 400 mg, 600 mg, 800 mg 1 indomethacin oral capsule 5 mg QL (40 per 0 days) indomethacin oral capsule 50 mg QL (10 per 0 days) indomethacin oral capsule, extended release 75 QL (60 per 0 days) mg indomethacin sodium intravenous recon soln 1 mg ketoprofen oral capsule 50 mg, 75 mg ketoprofen oral capsule,ext rel. pellets 4 hr 00 mg ketorolac 0 mg/ml carpuject luer lock, 10's,l/f 0 mg/ml ketorolac injection cartridge 15 mg/ml QL (40 per 0 days) ketorolac injection cartridge 0 mg/ml QL (0 per 0 days) ketorolac injection solution 15 mg/ml QL (40 per 0 days) ketorolac injection solution 0 mg/ml (1 ml) QL (0 per 0 days) ketorolac intramuscular solution 60 mg/ ml QL (0 per 0 days) ketorolac oral tablet 10 mg QL (0 per 0 days) mefenamic acid oral capsule 50 mg meloxicam oral suspension 7.5 mg/5 ml meloxicam oral tablet 15 mg, 7.5 mg 1 nabumetone oral tablet 500 mg, 750 mg 8 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

17 naproxen oral suspension 15 mg/5 ml naproxen oral tablet 50 mg, 75 mg, 500 mg 1 naproxen oral tablet,delayed release (dr/ec) 75 mg, 500 mg naproxen sodium oral tablet 75 mg, 550 mg 1 piroxicam oral capsule 10 mg, 0 mg sulindac oral tablet 150 mg, 00 mg tolmetin oral capsule 400 mg tolmetin oral tablet 00 mg, 600 mg VOLTAREN TOPICAL GEL 1 % Anesthetics Local Anesthetics glydo mucous membrane jelly in applicator % lidocaine (pf) injection solution 15 mg/ml (1.5 %), 40 mg/ml (4 %), 5 mg/ml (0.5 %) lidocaine (pf) intravenous syringe 100 mg/5 ml ( %) lidocaine % viscous soln % lidocaine hcl injection solution 10 mg/ml (1 %), 0 mg/ml ( %) lidocaine hcl laryngotracheal solution 4 % lidocaine hcl mucous membrane gel % lidocaine hcl mucous membrane solution %, 4 % (40 mg/ml) lidocaine topical adhesive patch,medicated 5 % PA lidocaine topical ointment 5 % lidocaine-prilocaine topical cream.5-.5 % Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed release (dr/ec) mg buprenorphine hcl sublingual tablet mg, 8 mg PA; QL (90 per 0 days) 9 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

18 buprenorphine-naloxone sublingual tablet -0.5 PA; QL (90 per 0 days) mg, 8- mg bupropion hcl (smoking deter) oral tablet extended release 150 mg CHANTIX CONTINUING MONTH BOX QL (168 per 84 days) ORAL TABLET 1 MG CHANTIX ORAL TABLET 0.5 MG, 1 MG QL (168 per 84 days) CHANTIX STARTING MONTH BOX QL (5 per 8 days) ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (4) disulfiram oral tablet 50 mg, 500 mg naloxone injection solution 0.4 mg/ml naloxone injection syringe 0.4 mg/ml, 1 mg/ml naltrexone oral tablet 50 mg NARCAN NASAL 4 QL (4 per 0 days) SPRAY,NON-AEROSOL 4 MG/ACTUATION NICOTROL INHALATION CARTRIDGE 4 QL (1008 per 90 days) 10 MG ZUBSOLV SUBLINGUAL TABLET PA; QL (90 per 0 days) MG, MG, MG, MG, MG Antianxiety Agents Benzodiazepines alprazolam oral tablet 0.5 mg, 0.5 mg, 1 mg, QL (10 per 0 days) mg alprazolam oral tablet extended release 4 hr QL (10 per 0 days) 0.5 mg, 1 mg, mg alprazolam oral tablet extended release 4 hr QL (90 per 0 days) mg chlordiazepoxide hcl oral capsule 10 mg, 5 mg, QL (10 per 0 days) 5 mg clonazepam oral tablet 0.5 mg, 1 mg QL (90 per 0 days) clonazepam oral tablet mg QL (00 per 0 days) clonazepam oral tablet,disintegrating 0.15 mg, 0.5 mg, 0.5 mg, 1 mg QL (90 per 0 days) 10 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

19 clonazepam oral tablet,disintegrating mg QL (00 per 0 days) clorazepate dipotassium oral tablet 15 mg QL (10 per 0 days) clorazepate dipotassium oral tablet.75 mg, 7.5 QL (60 per 0 days) mg diazepam injection syringe 5 mg/ml QL (10 per 8 days) diazepam intensol oral concentrate 5 mg/ml QL (100 per 0 days) diazepam oral solution 5 mg/5 ml (1 mg/ml) QL (100 per 0 days) diazepam oral tablet 10 mg, mg, 5 mg QL (10 per 0 days) diazepam rectal kit mg,.5 mg, mg estazolam oral tablet 1 mg PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (60 per 0 days) estazolam oral tablet mg PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (0 per 0 days) flurazepam oral capsule 15 mg PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (60 per 0 days) flurazepam oral capsule 0 mg PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (0 per 0 days) lorazepam intensol oral concentrate mg/ml QL (150 per 0 days) lorazepam oral tablet 0.5 mg, 1 mg, mg QL (90 per 0 days) midazolam oral syrup mg/ml QL (10 per 0 days) ONFI ORAL SUSPENSION.5 MG/ML 4 PA NSO; QL (480 per 0 days) 11 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

20 temazepam oral capsule 15 mg,.5 mg, 0 mg PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (0 per 0 days) temazepam oral capsule 7.5 mg PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (10 per 0 days) triazolam oral tablet 0.15 mg PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (10 per 0 days) triazolam oral tablet 0.5 mg PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (60 per 0 days) Antibacterials Aminoglycosides BETHKIS INHALATION SOLUTION FOR 5 PA BvD; NM NEBULIZATION 00 MG/4 ML gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 100 mg/50 ml, 60 mg/50 ml, 70 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml, 90 mg/100 ml gentamicin injection solution 40 mg/ml gentamicin ped 0 mg/ ml vial 5's,pedi,latex-free 0 mg/ ml gentamicin sulfate (pf) intravenous solution 80 mg/8 ml neomycin oral tablet 500 mg streptomycin intramuscular recon soln 1 gram 1 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

21 TOBI PODHALER INHALATION 5 NM; QL (4 per 8 days) CAPSULE, W/INHALATION DEVICE 8 MG tobramycin in 0.5 % nacl inhalation solution 5 PA BvD; NM for nebulization 00 mg/5 ml tobramycin in 0.9 % nacl intravenous piggyback 60 mg/50 ml, 80 mg/100 ml tobramycin sulfate injection solution 10 mg/ml, 40 mg/ml Antibacterials, Miscellaneous baciim intramuscular recon soln 50,000 unit bacitracin intramuscular recon soln 50,000 unit chloramphenicol sod succinate intravenous recon soln 1 gram clindamycin 75 mg/5 ml soln 75 mg/5 ml clindamycin hcl oral capsule 150 mg, 00 mg, 75 mg clindamycin in 5 % dextrose intravenous piggyback 00 mg/50 ml, 600 mg/50 ml, 900 mg/50 ml clindamycin pediatric oral recon soln 75 mg/5 ml clindamycin phosphate injection solution 150 mg/ml clindamycin phosphate intravenous solution 600 mg/4 ml colistin (colistimethate na) injection recon soln 5 NM 150 mg CUBICIN INTRAVENOUS RECON SOLN 5 NM 500 MG linezolid intravenous parenteral solution NM mg/00 ml linezolid oral suspension for reconstitution NM mg/5 ml linezolid oral tablet 600 mg 5 NM methenamine hippurate oral tablet 1 gram 1 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

22 metronidazole in nacl (iso-os) intravenous piggyback 500 mg/100 ml metronidazole oral capsule 75 mg metronidazole oral tablet 50 mg, 500 mg nitrofurantoin macrocrystal oral capsule 100 mg, 5 mg, 50 mg PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (10 per 0 days) nitrofurantoin monohyd/m-cryst oral capsule 100 mg nitrofurantoin monohyd/m-cryst oral capsule 100 mg (75/5) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (10 per 0 days) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (10 per 0 days) nitrofurantoin oral suspension 5 mg/5 ml PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (400 per 0 days) polymyxin b sulfate injection recon soln 500,000 unit SYNERCID INTRAVENOUS RECON 5 NM SOLN 500 MG trimethoprim oral tablet 100 mg vancomycin hcl 1g/00 ml bag 1 gram/00 ml vancomycin intravenous recon soln 1,000 mg, 10 gram, 500 mg, 750 mg vancomycin oral capsule 15 mg, 50 mg 5 NM XIFAXAN ORAL TABLET 00 MG 5 PA; NM; QL (9 per 0 days) XIFAXAN ORAL TABLET 550 MG 5 PA; NM ZYVOX ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML 5 NM 14 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

23 Cephalosporins cefaclor oral capsule 50 mg, 500 mg cefaclor oral suspension for reconstitution 15 mg/5 ml, 50 mg/5 ml, 75 mg/5 ml cefaclor oral tablet extended release 1 hr 500 mg cefadroxil oral capsule 500 mg cefadroxil oral suspension for reconstitution 50 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet 1 gram CEFAZOLIN IN DEXTROSE (ISO-OS) INTRAVENOUS PIGGYBACK 1 GRAM/50 ML cefazolin in dextrose (iso-os) intravenous piggyback gram/50 ml cefazolin injection recon soln 1 gram, 10 gram, 500 mg cefdinir oral capsule 00 mg cefdinir oral suspension for reconstitution 15 mg/5 ml, 50 mg/5 ml cefditoren pivoxil oral tablet 00 mg, 400 mg CEFEPIME GM INJECTION 4 GRAM/100 ML CEFEPIME IN DEXTROSE 5 % 4 INTRAVENOUS PIGGYBACK 1 GRAM/50 ML, GRAM/50 ML cefepime injection recon soln 1 gram, gram cefixime oral suspension for reconstitution 100 mg/5 ml, 00 mg/5 ml cefotaxime injection recon soln 1 gram, 10 gram, gram, 500 mg cefoxitin in dextrose, iso-osm intravenous piggyback gram/50 ml cefoxitin intravenous recon soln 1 gram, 10 gram, gram 15 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

24 cefpodoxime oral suspension for reconstitution 100 mg/5 ml, 50 mg/5 ml cefpodoxime oral tablet 100 mg, 00 mg cefprozil oral suspension for reconstitution 15 mg/5 ml, 50 mg/5 ml cefprozil oral tablet 50 mg, 500 mg ceftazidime injection recon soln gram, 6 gram ceftibuten oral capsule 400 mg ceftibuten oral suspension for reconstitution 180 mg/5 ml ceftriaxone 1 gm piggyback 50ml galaxycontainer 1 gram/50 ml ceftriaxone 1 gm vial 10's, fliptop,l/f 1 gram ceftriaxone gm piggyback 50ml galaxycontainer gram/50 ml ceftriaxone injection recon soln 10 gram, 50 mg, 500 mg ceftriaxone intravenous recon soln 1 gram, gram cefuroxime axetil oral tablet 50 mg, 500 mg cefuroxime sodium injection recon soln 1.5 gram, 750 mg cefuroxime sodium intravenous recon soln 7.5 gram cephalexin oral capsule 50 mg, 500 mg, 750 mg 1 cephalexin oral suspension for reconstitution 15 1 mg/5 ml, 50 mg/5 ml cephalexin oral tablet 50 mg, 500 mg 1 MEFOXIN IN DEXTROSE (ISO-OSM) 4 INTRAVENOUS PIGGYBACK 1 GRAM/50 ML, GRAM/50 ML SUPRAX ORAL SUSPENSION FOR 4 RECONSTITUTION 500 MG/5 ML SUPRAX ORAL TABLET,CHEWABLE MG, 00 MG tazicef injection recon soln gram, 6 gram 16 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

25 TEFLARO INTRAVENOUS RECON SOLN MG, 600 MG Macrolides azithromycin intravenous recon soln 500 mg azithromycin oral packet 1 gram azithromycin oral suspension for reconstitution 100 mg/5 ml, 00 mg/5 ml azithromycin oral tablet 50 mg, 50 mg (6 pack), 600 mg azithromycin oral tablet 500 mg clarithromycin oral suspension for reconstitution 15 mg/5 ml, 50 mg/5 ml clarithromycin oral tablet 50 mg, 500 mg clarithromycin oral tablet extended release 4 hr 500 mg DIFICID ORAL TABLET 00 MG 5 NM; QL (0 per 10 days) e.e.s. 400 oral tablet 400 mg e.e.s. granules oral suspension for reconstitution 00 mg/5 ml ery-tab oral tablet,delayed release (dr/ec) 50 mg, 500 mg ERY-TAB ORAL TABLET,DELAYED 4 RELEASE (DR/EC) MG erythrocin (as stearate) oral tablet 50 mg ERYTHROCIN INTRAVENOUS RECON 4 SOLN 1,000 MG, 500 MG erythromycin ethylsuccinate oral tablet 400 mg erythromycin oral capsule,delayed release(dr/ec) 50 mg erythromycin oral tablet 50 mg, 500 mg Miscellaneous B-Lactam Antibiotics aztreonam injection recon soln 1 gram CAYSTON INHALATION SOLUTION 5 NM; LA FOR NEBULIZATION 75 MG/ML imipenem-cilastatin intravenous recon soln 50 mg, 500 mg 17 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

26 INVANZ INJECTION RECON SOLN 1 4 GRAM meropenem intravenous recon soln 500 mg meropenem iv 1 gm vial outer, latex-free 1 gram Penicillins amoxicillin oral capsule 50 mg, 500 mg 1 amoxicillin oral suspension for reconstitution 1 15 mg/5 ml, 00 mg/5 ml, 50 mg/5 ml, 400 mg/5 ml amoxicillin oral tablet 500 mg, 875 mg 1 amoxicillin oral tablet,chewable 15 mg, 50 mg 1 amoxicillin-pot clavulanate oral suspension for reconstitution mg/5 ml, mg/5 ml, mg/5 ml, mg/5 ml amoxicillin-pot clavulanate oral tablet mg, mg, mg amoxicillin-pot clavulanate oral tablet extended release 1 hr 1, mg amoxicillin-pot clavulanate oral tablet,chewable mg, mg ampicillin gm vial 10's, latex-free gram ampicillin oral capsule 50 mg, 500 mg 1 ampicillin oral suspension for reconstitution 15 1 mg/5 ml, 50 mg/5 ml ampicillin sodium injection recon soln 1 gram, 10 gram, 15 mg ampicillin sodium intravenous recon soln gram ampicillin-sulbactam 1.5 gm vl p/f, latex-free 1.5 gram ampicillin-sulbactam injection recon soln 15 gram, gram ampicillin-sulbactam intravenous recon soln 1.5 gram 18 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

27 BICILLIN C-R INTRAMUSCULAR 4 SYRINGE 1,00,000 UNIT/ ML(600K/600K), 1,00,000 UNIT/ ML(900K/00K) BICILLIN L-A INTRAMUSCULAR 4 SYRINGE 1,00,000 UNIT/ ML,,400,000 UNIT/4 ML, 600,000 UNIT/ML dicloxacillin oral capsule 50 mg, 500 mg nafcillin gm vial sterile, latex-free gram nafcillin injection recon soln 1 gram, 10 gram nafcillin intravenous recon soln gram oxacillin 1 gm add-vantage vl add-vantage, inner 1 gram oxacillin in dextrose(iso-osm) intravenous piggyback 1 gram/50 ml, gram/50 ml oxacillin injection recon soln 10 gram oxacillin intravenous recon soln gram penicillin g pot in dextrose intravenous piggyback 1 million unit/50 ml, million unit/50 ml, million unit/50 ml penicillin g potassium injection recon soln 5 million unit penicillin g procaine intramuscular syringe 1. million unit/ ml, 600,000 unit/ml penicillin gk 0 million unit 0 million unit penicillin v potassium oral recon soln 15 mg/5 ml, 50 mg/5 ml penicillin v potassium oral tablet 50 mg, 500 mg pfizerpen-g injection recon soln 0 million unit piperacillin-tazobactam intravenous recon soln.5 gram,.75 gram, 4.5 gram piperacil-tazobact 40.5 gram p/f, latex-free 40.5 gram 19 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

28 Quinolones ciprofloxacin (mixture) oral tablet, er multiphase 4 hr 1,000 mg, 500 mg ciprofloxacin 00 mg/0 ml vl sdv,latex-free 00 mg/0 ml ciprofloxacin hcl oral tablet 100 mg, 50 mg, mg, 750 mg ciprofloxacin in 5 % dextrose intravenous piggyback 00 mg/100 ml ciprofloxacin lactate intravenous solution 400 mg/40 ml ciprofloxacin oral suspension,microcapsule recon 50 mg/5 ml, 500 mg/5 ml ciprofloxacn-d5w 400 mg/00 ml p/f,latex/f, in d5w 400 mg/00 ml levofloxacin in d5w intravenous piggyback 500 mg/100 ml, 750 mg/150 ml levofloxacin intravenous solution 5 mg/ml levofloxacin oral solution 50 mg/10 ml levofloxacin oral tablet 50 mg, 500 mg, 750 mg 1 moxifloxacin oral tablet 400 mg ofloxacin oral tablet 400 mg Sulfonamides sulfadiazine oral tablet 500 mg sulfamethoxazole-trimethoprim intravenous solution mg/5 ml sulfamethoxazole-trimethoprim oral suspension mg/5 ml sulfamethoxazole-trimethoprim oral tablet mg, mg sulfasalazine oral tablet 500 mg sulfasalazine oral tablet,delayed release (dr/ec) 500 mg sulfatrim oral suspension mg/5 ml Tetracyclines demeclocycline oral tablet 150 mg, 00 mg 0 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

29 doxy 100 vial 10's, p/f 100 mg doxycycline hyclate intravenous recon soln 100 mg doxycycline hyclate oral capsule 100 mg doxycycline hyclate oral capsule 50 mg doxycycline hyclate oral tablet 100 mg doxycycline hyclate oral tablet 0 mg, 50 mg doxycycline hyclate oral tablet,delayed release (dr/ec) 100 mg, 150 mg, 00 mg, 50 mg, 75 mg doxycycline mono 100 mg cap 100 mg doxycycline mono 100 mg tablet f/c 100 mg doxycycline mono 50 mg tablet 50 mg doxycycline monohydrate oral capsule 150 mg, 50 mg, 75 mg doxycycline monohydrate oral suspension for reconstitution 5 mg/5 ml doxycycline monohydrate oral tablet 150 mg, 75 mg MINOCIN INTRAVENOUS RECON SOLN 5 NM 100 MG minocycline oral capsule 100 mg, 50 mg, 75 mg minocycline oral tablet 100 mg, 50 mg, 75 mg minocycline oral tablet extended release 4 hr 15 mg, 45 mg, 90 mg tetracycline oral capsule 50 mg, 500 mg TYGACIL INTRAVENOUS RECON SOLN 5 NM 50 MG Anticancer Agents Anticancer Agents ABRAXANE INTRAVENOUS 5 NM SUSPENSION FOR RECONSTITUTION 100 MG ADCETRIS INTRAVENOUS RECON 5 PA NSO; NM; QL (4 per 1 days) SOLN 50 MG adriamycin intravenous recon soln 10 mg, 0 mg, 50 mg PA BvD 1 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

30 adriamycin intravenous solution 10 mg/5 ml PA BvD adrucil,500 mg/50 ml vial outer, latex-free.5 PA BvD gram/50 ml adrucil intravenous solution 500 mg/10 ml PA BvD AFINITOR DISPERZ ORAL TABLET FOR 5 PA NSO; NM; QL (11 per 8 days) SUSPENSION MG, MG, 5 MG AFINITOR ORAL TABLET 10 MG 5 PA NSO; NM; QL (56 per 8 days) AFINITOR ORAL TABLET.5 MG, 5 MG, 5 PA NSO; NM; QL (8 per 8 days) 7.5 MG ALECENSA ORAL CAPSULE 150 MG 5 PA NSO; NM; QL (40 per 0 days) ALIMTA INTRAVENOUS RECON SOLN 5 NM 500 MG anastrozole oral tablet 1 mg AVASTIN INTRAVENOUS SOLUTION 5 5 PA NSO; NM MG/ML, 5 MG/ML (16 ML) azacitidine injection recon soln 100 mg 5 NM BELEODAQ INTRAVENOUS RECON 5 PA NSO; NM SOLN 500 MG BENDEKA INTRAVENOUS SOLUTION 5 PA NSO; NM 5 MG/ML bexarotene oral capsule 75 mg 5 PA NSO; NM; QL (40 per 0 days) bicalutamide oral tablet 50 mg bleomycin injection recon soln 0 unit PA BvD bleomycin sulfate 15 unit vial latex-free 15 unit PA BvD BLINCYTO INTRAVENOUS KIT 5 MCG 5 PA NSO; NM; QL (140 per 65 days) BOSULIF ORAL TABLET 100 MG 5 PA NSO; NM; QL (10 per 0 days) BOSULIF ORAL TABLET 500 MG 5 PA NSO; NM; QL (0 per 0 days) CABOMETYX ORAL TABLET 0 MG, 60 5 PA NSO; NM; QL (0 per 0 days) MG CABOMETYX ORAL TABLET 40 MG 5 PA NSO; NM; QL (60 per 0 days) CAPRELSA ORAL TABLET 100 MG 5 PA NSO; NM; QL (60 per 0 days) CAPRELSA ORAL TABLET 00 MG 5 PA NSO; NM; QL (0 per 0 days) carboplatin intravenous solution 10 mg/ml cladribine intravenous solution 10 mg/10 ml PA BvD Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

31 COMETRIQ ORAL CAPSULE PA NSO; NM; QL (11 per 8 days) MG/DAY(80 MG X1-0 MG X1), 140 MG/DAY(80 MG X1-0 MG X), 60 MG/DAY (0 MG X /DAY) COTELLIC ORAL TABLET 0 MG 5 PA NSO; NM; LA; QL (6 per 8 days) cyclophosphamide intravenous recon soln 1 PA BvD gram, gram, 500 mg CYCLOPHOSPHAMIDE ORAL CAPSULE 4 PA BvD; ST 5 MG, 50 MG cyclophosphamide oral tablet 5 mg, 50 mg PA BvD; ST CYRAMZA INTRAVENOUS SOLUTION 5 PA NSO; NM 10 MG/ML, 10 MG/ML (50 ML) dactinomycin intravenous recon soln 0.5 mg DARZALEX INTRAVENOUS SOLUTION 5 PA NSO; NM; LA 0 MG/ML DAUNOXOME INTRAVENOUS SOLUTION MG/ML decitabine intravenous recon soln 50 mg 5 NM docetaxel 160 mg/16 ml vial mdv 160 mg/16 ml 5 NM (10 mg/ml) docetaxel intravenous solution 0 mg/ ml 5 NM (final), 80 mg/4 ml (0 mg/ml), 80 mg/8 ml (10 mg/ml) doxorubicin, peg-liposomal intravenous 5 PA BvD; NM suspension mg/ml DROXIA ORAL CAPSULE 00 MG, 00 MG, 400 MG ELIGARD SUBCUTANEOUS SYRINGE 4 QL (1 per 84 days).5 MG ( MONTH) ELIGARD SUBCUTANEOUS SYRINGE 4 QL (1 per 11 days) 0 MG (4 MONTH) ELIGARD SUBCUTANEOUS SYRINGE 4 QL (1 per 168 days) 45 MG (6 MONTH) ELIGARD SUBCUTANEOUS SYRINGE MG (1 MONTH) EMCYT ORAL CAPSULE 140 MG Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

32 EMPLICITI INTRAVENOUS RECON 5 PA NSO; NM SOLN 00 MG, 400 MG ERIVEDGE ORAL CAPSULE 150 MG 5 PA NSO; NM; QL (0 per 0 days) ETOPOPHOS INTRAVENOUS RECON 4 SOLN 100 MG etoposide intravenous solution 0 mg/ml exemestane oral tablet 5 mg FARESTON ORAL TABLET 60 MG 5 NM FARYDAK ORAL CAPSULE 10 MG, 15 5 PA NSO; NM MG, 0 MG FASLODEX INTRAMUSCULAR 5 NM SYRINGE 50 MG/5 ML floxuridine injection recon soln 0.5 gram PA BvD fluorouracil 5,000 mg/100 ml latex-free 5 PA BvD gram/100 ml fluorouracil intravenous solution 1 gram/0 ml, PA BvD.5 gram/50 ml, 500 mg/10 ml flutamide oral capsule 15 mg GAZYVA INTRAVENOUS SOLUTION 5 PA NSO; NM 1,000 MG/40 ML gemcitabine intravenous recon soln 1 gram 5 NM GILOTRIF ORAL TABLET 0 MG, 0 MG, 5 PA NSO; NM; QL (0 per 0 days) 40 MG GLEOSTINE ORAL CAPSULE 10 MG, MG, 40 MG HERCEPTIN INTRAVENOUS RECON 5 PA NSO; NM SOLN 440 MG HEXALEN ORAL CAPSULE 50 MG 5 NM hydroxyurea oral capsule 500 mg IBRANCE ORAL CAPSULE 100 MG, 15 5 PA NSO; NM; QL (1 per 8 days) MG, 75 MG ICLUSIG ORAL TABLET 15 MG 5 PA NSO; NM; QL (60 per 0 days) ICLUSIG ORAL TABLET 45 MG 5 PA NSO; NM; QL (0 per 0 days) ifosfamide 1 gm/0 ml vial suv 1 gram/0 ml PA BvD ifosfamide intravenous recon soln 1 gram PA BvD 4 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

33 ifosfamide-mesna intravenous kit 1-1 gram, 5 PA BvD; NM,000-1,000 mg imatinib oral tablet 100 mg 5 PA NSO; NM; QL (90 per 0 days) imatinib oral tablet 400 mg 5 PA NSO; NM; QL (60 per 0 days) IMBRUVICA ORAL CAPSULE 140 MG 5 PA NSO; NM IMLYGIC INJECTION SUSPENSION 5 PA NSO; NM; QL (4 per 65 days) 10EXP6 (1 MILLION) PFU/ML IMLYGIC INJECTION SUSPENSION 5 PA NSO; NM; QL (8 per 8 days) 10EXP8 (100 MILLION) PFU/ML INLYTA ORAL TABLET 1 MG 5 PA NSO; NM; QL (180 per 0 days) INLYTA ORAL TABLET 5 MG 5 PA NSO; NM; QL (60 per 0 days) IRESSA ORAL TABLET 50 MG 5 PA NSO; NM; QL (60 per 0 days) irinotecan intravenous solution 100 mg/5 ml, 500 mg/5 ml IXEMPRA 15 MG KIT WITH DILUENT 15 5 NM MG IXEMPRA INTRAVENOUS RECON SOLN 5 NM 45 MG JAKAFI ORAL TABLET 10 MG, 15 MG, 0 5 PA NSO; NM; QL (60 per 0 days) MG, 5 MG, 5 MG KEYTRUDA INTRAVENOUS RECON 5 PA NSO; NM SOLN 50 MG KEYTRUDA INTRAVENOUS SOLUTION 5 PA NSO; NM 100 MG/4 ML (5 MG/ML) KYPROLIS INTRAVENOUS RECON 5 PA NSO; NM; QL (1 per 8 days) SOLN 0 MG KYPROLIS INTRAVENOUS RECON 5 PA NSO; NM; QL (6 per 8 days) SOLN 60 MG LENVIMA ORAL CAPSULE 10 MG/DAY 5 PA NSO; NM (10 MG X 1/DAY), 14 MG/DAY(10 MG X 1-4 MG X 1), 18 MG/DAY (10 MG X 1-4 MG X), 0 MG/DAY (10 MG X ), 4 MG/DAY(10 MG X -4 MG X 1), 8 MG/DAY (4 MG X ) letrozole oral tablet.5 mg LEUKERAN ORAL TABLET MG 4 5 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

34 leuprolide subcutaneous kit 1 mg/0. ml lipodox 50 intravenous suspension mg/ml 5 PA BvD; NM lipodox intravenous suspension mg/ml 5 PA BvD; NM lomustine oral capsule 10 mg, 100 mg, 40 mg LONSURF ORAL TABLET MG 5 PA NSO; NM; QL (100 per 8 days) LONSURF ORAL TABLET MG 5 PA NSO; NM; QL (80 per 8 days) LUPRON DEPOT ( MONTH) 5 NM; QL (1 per 84 days) INTRAMUSCULAR SYRINGE KIT 11.5 MG,.5 MG LUPRON DEPOT (4 MONTH) 5 NM; QL (1 per 84 days) INTRAMUSCULAR SYRINGE KIT 0 MG LUPRON DEPOT (6 MONTH) 5 NM; QL (1 per 168 days) INTRAMUSCULAR SYRINGE KIT 45 MG LUPRON DEPOT INTRAMUSCULAR 5 NM SYRINGE KIT.75 MG, 7.5 MG LYNPARZA ORAL CAPSULE 50 MG 5 PA NSO; NM; QL (480 per 0 days) LYSODREN ORAL TABLET 500 MG MARQIBO INTRAVENOUS KIT 5 MG/1 5 PA NSO; NM; QL (4 per 8 days) ML(0.16 MG/ML) FINAL MATULANE ORAL CAPSULE 50 MG 5 NM megestrol oral tablet 0 mg, 40 mg MEKINIST ORAL TABLET 0.5 MG 5 PA NSO; NM; QL (90 per 0 days) MEKINIST ORAL TABLET MG 5 PA NSO; NM; QL (0 per 0 days) melphalan hcl intravenous recon soln 50 mg 5 NM mercaptopurine oral tablet 50 mg methotrexate 50 mg/ ml vial latex-free, 5's, PA BvD mdv 5 mg/ml methotrexate sodium (pf) injection recon soln 1 PA BvD gram methotrexate sodium (pf) injection solution 5 PA BvD mg/ml methotrexate sodium oral tablet.5 mg PA BvD; ST mitoxantrone intravenous concentrate mg/ml NEXAVAR ORAL TABLET 00 MG 5 PA NSO; NM; QL (10 per 0 days) NILANDRON ORAL TABLET 150 MG 6 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

35 NINLARO ORAL CAPSULE. MG, 5 PA NSO; NM; QL ( per 8 days) MG, 4 MG ODOMZO ORAL CAPSULE 00 MG 5 PA NSO; NM; LA ONCASPAR INJECTION SOLUTION PA NSO; NM UNIT/ML onxol intravenous concentrate 6 mg/ml OPDIVO INTRAVENOUS SOLUTION 40 5 PA NSO; NM MG/4 ML oxaliplatin intravenous solution 100 mg/0 ml 5 NM paclitaxel intravenous concentrate 6 mg/ml PERJETA INTRAVENOUS SOLUTION 40 5 PA NSO; NM MG/14 ML (0 MG/ML) POMALYST ORAL CAPSULE 1 MG, 5 PA NSO; NM; QL (1 per 8 days) MG, MG, 4 MG PORTRAZZA INTRAVENOUS 5 PA NSO; NM; QL (100 per 1 days) SOLUTION 800 MG/50 ML (16 MG/ML) PROLEUKIN INTRAVENOUS RECON 5 NM SOLN MILLION UNIT PURIXAN ORAL SUSPENSION 0 5 NM MG/ML REVLIMID ORAL CAPSULE 10 MG, 15 5 PA NSO; NM; LA MG,.5 MG, 0 MG, 5 MG, 5 MG RITUXAN INTRAVENOUS 5 PA NSO; NM CONCENTRATE 10 MG/ML SOLTAMOX ORAL SOLUTION 10 MG/5 4 ML SPRYCEL ORAL TABLET 100 MG, PA NSO; NM; QL (0 per 0 days) MG, 50 MG, 70 MG, 80 MG SPRYCEL ORAL TABLET 0 MG 5 PA NSO; NM; QL (60 per 0 days) STIVARGA ORAL TABLET 40 MG 5 PA NSO; NM; QL (84 per 8 days) SUTENT ORAL CAPSULE 1.5 MG, 5 5 PA NSO; NM; QL (0 per 0 days) MG, 7.5 MG, 50 MG SYLVANT INTRAVENOUS RECON SOLN 5 PA NSO; NM 100 MG, 400 MG SYNRIBO SUBCUTANEOUS RECON SOLN.5 MG 5 PA NSO; NM; QL (8 per 8 days) 7 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

36 TABLOID ORAL TABLET 40 MG TAFINLAR ORAL CAPSULE 50 MG, 75 5 PA NSO; NM; QL (10 per 0 days) MG TAGRISSO ORAL TABLET 40 MG, 80 MG 5 PA NSO; NM; LA; QL (0 per 0 days) tamoxifen oral tablet 10 mg, 0 mg TARCEVA ORAL TABLET 100 MG, 5 MG 5 PA NSO; NM; QL (60 per 0 days) TARCEVA ORAL TABLET 150 MG 5 PA NSO; NM; QL (90 per 0 days) TARGRETIN ORAL CAPSULE 75 MG 5 PA NSO; NM; QL (40 per 0 days) TARGRETIN TOPICAL GEL 1 % 5 PA NSO; NM; QL (60 per 8 days) TASIGNA ORAL CAPSULE 150 MG, 00 5 PA NSO; NM; QL (11 per 8 days) MG TECENTRIQ INTRAVENOUS SOLUTION 5 PA NSO; NM; QL (0 per 1 days) 1,00 MG/0 ML (60 MG/ML) TEMODAR INTRAVENOUS RECON 5 PA NSO; NM; (vial only) SOLN 100 MG teniposide intravenous solution 50 mg/5 ml 5 NM thiotepa injection recon soln 15 mg 5 NM toposar intravenous solution 0 mg/ml topotecan hcl 4 mg/4 ml vial suv,latex-free 4 5 NM mg/4 ml (1 mg/ml) topotecan intravenous recon soln 4 mg 5 NM TORISEL INTRAVENOUS RECON SOLN 5 PA BvD; NM; QL (4 per 8 days) 0 MG/ ML (10 MG/ML) (FIRST) TREANDA 5 MG VIAL 5 MG 5 NM TREANDA INTRAVENOUS RECON 5 NM SOLN 100 MG TREANDA INTRAVENOUS SOLUTION 5 NM 180 MG/ ML, 45 MG/0.5 ML TRELSTAR.5 MG SYRINGE WITH 5 NM; QL (1 per 168 days) MIXJECT.5 MG/ ML TRELSTAR INTRAMUSCULAR 5 NM; QL (1 per 168 days) SUSPENSION FOR RECONSTITUTION.5 MG TRELSTAR INTRAMUSCULAR SYRINGE 11.5 MG/ ML 5 NM; QL (1 per 84 days) 8 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

37 TRELSTAR INTRAMUSCULAR 5 NM SYRINGE.75 MG/ ML tretinoin (chemotherapy) oral capsule 10 mg 5 NM; (capsule: 10mg) TREXALL ORAL TABLET 10 MG, 15 MG, 4 PA BvD; ST 5 MG, 7.5 MG TYKERB ORAL TABLET 50 MG 5 NM UNITUXIN INTRAVENOUS SOLUTION 5 PA NSO; NM.5 MG/ML VALSTAR INTRAVESICAL SOLUTION 40 5 NM MG/ML VECTIBIX INTRAVENOUS SOLUTION 5 PA NSO; NM 100 MG/5 ML (0 MG/ML) VELCADE INJECTION RECON SOLN.5 5 PA NSO; NM MG VENCLEXTA ORAL TABLET 10 MG, 50 4 PA NSO; LA MG VENCLEXTA ORAL TABLET 100 MG 5 PA NSO; NM; LA VENCLEXTA STARTING PACK ORAL 5 PA NSO; NM; LA TABLETS,DOSE PACK 10 MG-50 MG- 100 MG vinblastine intravenous solution 1 mg/ml PA BvD vincasar pfs mg/ ml vial mg/ ml PA BvD vincasar pfs intravenous solution 1 mg/ml PA BvD vincristine mg/ ml vial p/f, sdv mg/ ml PA BvD vincristine intravenous solution 1 mg/ml PA BvD vinorelbine intravenous solution 50 mg/5 ml VOTRIENT ORAL TABLET 00 MG 5 PA NSO; NM; QL (10 per 0 days) XALKORI ORAL CAPSULE 00 MG, 50 5 PA NSO; NM; QL (60 per 0 days) MG XTANDI ORAL CAPSULE 40 MG 5 PA NSO; NM; QL (10 per 0 days) YERVOY INTRAVENOUS SOLUTION 50 5 PA NSO; NM MG/10 ML (5 MG/ML) YONDELIS INTRAVENOUS RECON 5 PA NSO; NM SOLN 1 MG ZALTRAP INTRAVENOUS SOLUTION 100 MG/4 ML (5 MG/ML) 5 PA NSO; NM 9 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

38 ZELBORAF ORAL TABLET 40 MG 5 PA NSO; NM; QL (40 per 0 days) ZOLADEX SUBCUTANEOUS IMPLANT 4 QL (1 per 84 days) 10.8 MG ZOLADEX SUBCUTANEOUS IMPLANT 4 QL (1 per 8 days).6 MG ZOLINZA ORAL CAPSULE 100 MG 5 NM ZYDELIG ORAL TABLET 100 MG, PA NSO; NM; QL (60 per 0 days) MG ZYKADIA ORAL CAPSULE 150 MG 5 PA NSO; NM; QL (140 per 8 days) ZYTIGA ORAL TABLET 50 MG 5 PA NSO; NM; QL (10 per 0 days) Anticholinergic Agents Antimuscarinics/Antispasmodics atropine injection solution 0.4 mg/ml, 1 mg/ml atropine injection syringe 0.05 mg/ml, 0.1 mg/ml propantheline oral tablet 15 mg STIOLTO RESPIMAT INHALATION QL (4 per 8 days) MIST.5-.5 MCG/ACTUATION Anticonvulsants Anticonvulsants APTIOM ORAL TABLET 00 MG, 400 MG, MG, 800 MG BANZEL ORAL SUSPENSION 40 MG/ML 4 BANZEL ORAL TABLET 00 MG, 400 MG 4 BRIVIACT INTRAVENOUS SOLUTION 50 4 QL (80 per 0 days) MG/5 ML BRIVIACT ORAL SOLUTION 10 MG/ML 4 QL (600 per 0 days) BRIVIACT ORAL TABLET 10 MG, NM; QL (60 per 0 days) MG, 5 MG, 50 MG, 75 MG carbamazepine oral capsule, er multiphase 1 hr 100 mg, 00 mg, 00 mg carbamazepine oral suspension 100 mg/5 ml carbamazepine oral tablet 00 mg carbamazepine oral tablet extended release 1 hr 100 mg, 00 mg, 400 mg carbamazepine oral tablet,chewable 100 mg 0 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

39 CELONTIN ORAL CAPSULE 00 MG DILANTIN ORAL CAPSULE 0 MG divalproex oral capsule, sprinkle 15 mg divalproex oral tablet extended release 4 hr 50 mg, 500 mg divalproex oral tablet,delayed release (dr/ec) 15 mg, 50 mg, 500 mg epitol oral tablet 00 mg ethosuximide oral capsule 50 mg ethosuximide oral solution 50 mg/5 ml felbamate oral suspension 600 mg/5 ml felbamate oral tablet 400 mg, 600 mg fosphenytoin 500 mg pe/10 ml 10's,sdv,latex-free 500 mg pe/10 ml fosphenytoin injection solution 100 mg pe/ ml FYCOMPA ORAL SUSPENSION MG/ML FYCOMPA ORAL TABLET 10 MG, 1 MG, 4 MG, 4 MG, 6 MG, 8 MG gabapentin oral capsule 100 mg, 00 mg, 400 mg gabapentin oral solution 50 mg/5 ml gabapentin oral tablet 600 mg, 800 mg GABITRIL ORAL TABLET 1 MG, 16 MG GRALISE 0-DAY STARTER PACK 4 ST; QL (78 per 0 days) ORAL TABLET EXTENDED RELEASE 4 HR 00 MG (9)- 600 MG (69) GRALISE ORAL TABLET EXTENDED 4 ST; QL (90 per 0 days) RELEASE 4 HR 00 MG, 600 MG LAMICTAL ODT STARTER (BLUE) 4 ORAL TABLET DISINTEGRATING, DOSE PK 5 MG (1) -50 MG (7) LAMICTAL ODT STARTER (GREEN) ORAL TABLET DISINTEGRATING, DOSE PK 50 MG (4) -100 MG (14) 4 1 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

40 LAMICTAL ODT STARTER (ORANGE) 4 ORAL TABLET DISINTEGRATING, DOSE PK 5 MG(14)-50 MG (14)-100 MG (7) LAMICTAL ORAL TABLET, CHEWABLE 4 DISPERSIBLE MG lamotrigine oral tablet 100 mg, 150 mg, 00 mg, 5 mg lamotrigine oral tablet disintegrating, dose pk 5 mg (1) -50 mg (7), 5 mg(14)-50 mg (14)-100 mg (7), 50 mg (4) -100 mg (14) lamotrigine oral tablet extended release 4hr 100 mg, 00 mg, 5 mg, 50 mg, 00 mg, 50 mg lamotrigine oral tablet, chewable dispersible 5 mg, 5 mg lamotrigine oral tablet,disintegrating 100 mg, 00 mg, 5 mg, 50 mg lamotrigine oral tablets,dose pack 5 mg (5) levetiracetam in nacl (iso-os) intravenous piggyback 1,000 mg/100 ml, 1,500 mg/100 ml, 500 mg/100 ml levetiracetam intravenous solution 500 mg/5 ml levetiracetam oral solution 100 mg/ml levetiracetam oral tablet 1,000 mg, 50 mg, 500 mg, 750 mg levetiracetam oral tablet extended release 4 hr 500 mg, 750 mg LYRICA ORAL CAPSULE 100 MG, 150 QL (90 per 0 days) MG, 00 MG, 5 MG, 5 MG, 00 MG, 50 MG, 75 MG LYRICA ORAL SOLUTION 0 MG/ML QL (900 per 0 days) oxcarbazepine oral suspension 00 mg/5 ml oxcarbazepine oral tablet 150 mg, 00 mg, 600 mg OXTELLAR XR ORAL TABLET EXTENDED RELEASE 4 HR 150 MG, 00 MG, 600 MG 4 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

41 PEGANONE ORAL TABLET 50 MG phenobarbital oral elixir 0 mg/5 ml (4 mg/ml) QL (1500 per 0 days) phenobarbital oral tablet 100 mg, 15 mg, 16. QL (90 per 0 days) mg,.4 mg, 60 mg, 64.8 mg, 97. mg phenobarbital oral tablet 0 mg QL (00 per 0 days) phenobarbital sodium injection solution 10 QL ( per 0 days) mg/ml, 65 mg/ml phenytoin oral suspension 15 mg/5 ml phenytoin oral tablet,chewable 50 mg phenytoin sodium extended oral capsule 100 mg, 00 mg, 00 mg phenytoin sodium intravenous solution 50 mg/ml phenytoin sodium intravenous syringe 50 mg/ml POTIGA ORAL TABLET 00 MG, 00 MG, 4 QL (90 per 0 days) 400 MG POTIGA ORAL TABLET 50 MG 4 QL (70 per 0 days) primidone oral tablet 50 mg, 50 mg SABRIL ORAL POWDER IN PACKET NM MG SABRIL ORAL TABLET 500 MG 5 NM SPRITAM ORAL TABLET FOR 4 ST; QL (60 per 0 days) SUSPENSION 1,000 MG SPRITAM ORAL TABLET FOR 4 ST; QL (10 per 0 days) SUSPENSION 50 MG, 500 MG, 750 MG TEGRETOL XR ORAL TABLET EXTENDED RELEASE 1 HR 100 MG tiagabine oral tablet mg, 4 mg topiragen oral tablet 100 mg, 00 mg, 5 mg, 50 mg topiramate oral capsule, sprinkle 15 mg, 5 mg topiramate oral capsule,sprinkle,er 4hr 100 mg, 150 mg, 00 mg, 5 mg, 50 mg topiramate oral tablet 100 mg, 00 mg, 5 mg, 50 mg Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

42 TROKENDI XR ORAL 4 CAPSULE,EXTENDED RELEASE 4HR 100 MG, 00 MG, 5 MG, 50 MG valproate sodium intravenous solution 500 mg/5 ml (100 mg/ml) valproic acid (as sodium salt) oral solution 50 mg/5 ml valproic acid oral capsule 50 mg VIMPAT INTRAVENOUS SOLUTION 00 4 QL (00 per 5 days) MG/0 ML VIMPAT ORAL SOLUTION 10 MG/ML 4 QL (100 per 0 days) VIMPAT ORAL TABLET 100 MG, 150 MG, 4 QL (60 per 0 days) 00 MG, 50 MG zonisamide oral capsule 100 mg, 5 mg, 50 mg Antidementia Agents Antidementia Agents donepezil oral tablet 10 mg, mg, 5 mg QL (0 per 0 days) donepezil oral tablet,disintegrating 10 mg, 5 mg QL (0 per 0 days) galantamine oral capsule,ext rel. pellets 4 hr 16 QL (0 per 0 days) mg, 4 mg, 8 mg galantamine oral solution 4 mg/ml QL (00 per 0 days) galantamine oral tablet 1 mg, 4 mg, 8 mg QL (60 per 0 days) memantine oral solution mg/ml QL (60 per 0 days) memantine oral tablet 10 mg, 5 mg QL (60 per 0 days) memantine oral tablets,dose pack 5-10 mg QL (49 per 8 days) NAMENDA XR ORAL QL (8 per 8 days) CAP,SPRINKLE,ER 4HR DOSE PACK MG NAMENDA XR ORAL QL (0 per 0 days) CAPSULE,SPRINKLE,ER 4HR 14 MG, 1 MG, 8 MG, 7 MG NAMZARIC ORAL CAPSULE,SPRINKLE,ER 4HR MG, 8-10 MG rivastigmine tartrate oral capsule 1.5 mg, mg, 4.5 mg, 6 mg QL (60 per 0 days) 4 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

43 rivastigmine transdermal patch 4 hour 1. QL (0 per 0 days) mg/4 hour, 4.6 mg/4 hr, 9.5 mg/4 hr Antidepressants Antidepressants amitriptyline oral tablet 10 mg, 100 mg, 150 mg, PA NSO-HRM 5 mg, 50 mg, 75 mg amoxapine oral tablet 100 mg, 150 mg, 5 mg, 50 mg BRINTELLIX ORAL TABLET 10 MG, 0 4 MG, 5 MG buproban oral tablet extended release 150 mg bupropion hcl oral tablet 100 mg, 75 mg bupropion hcl oral tablet extended release 100 mg, 150 mg, 00 mg bupropion hcl oral tablet extended release 4 hr 150 mg, 00 mg citalopram oral solution 10 mg/5 ml citalopram oral tablet 10 mg, 0 mg, 40 mg 1 QL (0 per 0 days) clomipramine oral capsule 5 mg, 50 mg, 75 mg PA NSO-HRM desipramine oral tablet 10 mg, 100 mg, 150 mg, 5 mg, 50 mg, 75 mg DESVENLAFAXINE FUMARATE ORAL QL (0 per 0 days) TABLET EXTENDED RELEASE 4HR 100 MG, 50 MG doxepin oral capsule 10 mg, 100 mg, 150 mg, 5 PA NSO-HRM mg, 50 mg, 75 mg doxepin oral concentrate 10 mg/ml PA NSO-HRM duloxetine oral capsule,delayed release(dr/ec) (Cymbalta); QL (60 per 0 days) 0 mg, 60 mg duloxetine oral capsule,delayed release(dr/ec) (Cymbalta); QL (0 per 0 days) 0 mg duloxetine oral capsule,delayed release(dr/ec) (Irenka); QL (0 per 0 days) 40 mg EMSAM TRANSDERMAL PATCH 4 HOUR 1 MG/4 HR, 6 MG/4 HR, 9 MG/4 HR 4 QL (0 per 0 days) 5 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

44 escitalopram oxalate oral solution 5 mg/5 ml escitalopram oxalate oral tablet 10 mg, 0 mg, 5 mg FETZIMA ORAL CAPSULE,EXT REL 4 4HR DOSE PACK 0 MG ()- 40 MG (6) FETZIMA ORAL CAPSULE,EXTENDED 4 RELEASE 4 HR 10 MG, 0 MG, 40 MG, 80 MG fluoxetine oral capsule 10 mg, 0 mg, 40 mg 1 fluoxetine oral capsule,delayed release(dr/ec) 90 mg fluoxetine oral solution 0 mg/5 ml (4 mg/ml) fluoxetine oral tablet 10 mg, 0 mg FLUOXETINE ORAL TABLET 60 MG 4 fluvoxamine oral capsule,extended release 4hr 100 mg, 150 mg fluvoxamine oral tablet 100 mg, 5 mg, 50 mg imipramine hcl oral tablet 10 mg, 5 mg, 50 mg PA NSO-HRM imipramine pamoate oral capsule 100 mg, 15 PA NSO-HRM mg, 150 mg, 75 mg maprotiline oral tablet 5 mg, 50 mg, 75 mg MARPLAN ORAL TABLET 10 MG 4 mirtazapine oral tablet 15 mg, 0 mg, 45 mg, 7.5 mg mirtazapine oral tablet,disintegrating 15 mg, 0 mg, 45 mg nefazodone oral tablet 100 mg, 150 mg, 00 mg, 50 mg, 50 mg nortriptyline oral capsule 10 mg, 5 mg, 50 mg, 75 mg nortriptyline oral solution 10 mg/5 ml olanzapine-fluoxetine oral capsule 1-5 mg, 1-50 mg, -5 mg, 6-5 mg, 6-50 mg paroxetine hcl oral tablet 10 mg, 0 mg, 0 mg, 40 mg 6 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

45 paroxetine hcl oral tablet extended release 4 hr 1.5 mg, 5 mg, 7.5 mg PAXIL ORAL SUSPENSION 10 MG/5 ML 4 perphenazine-amitriptyline oral tablet -10 mg, PA NSO-HRM -5 mg, 4-10 mg, 4-5 mg, 4-50 mg phenelzine oral tablet 15 mg PRISTIQ ORAL TABLET EXTENDED 4 QL (0 per 0 days) RELEASE 4 HR 100 MG, 5 MG, 50 MG protriptyline oral tablet 10 mg, 5 mg sertraline oral concentrate 0 mg/ml sertraline oral tablet 100 mg, 5 mg, 50 mg 1 SILENOR ORAL TABLET MG, 6 MG QL (0 per 0 days) SURMONTIL ORAL CAPSULE 100 MG, 5 4 PA NSO-HRM MG, 50 MG tranylcypromine oral tablet 10 mg trazodone oral tablet 100 mg, 150 mg, 00 mg, 1 50 mg trimipramine oral capsule 100 mg, 5 mg, 50 mg PA NSO-HRM TRINTELLIX ORAL TABLET 10 MG, 0 4 MG, 5 MG venlafaxine oral capsule,extended release 4hr 150 mg, 7.5 mg, 75 mg venlafaxine oral tablet 100 mg, 5 mg, 7.5 mg, 50 mg, 75 mg venlafaxine oral tablet extended release 4hr 150 mg, 7.5 mg, 75 mg venlafaxine oral tablet extended release 4hr 5 mg VIIBRYD ORAL TABLET 10 MG, 0 MG, 4 40 MG VIIBRYD ORAL TABLETS,DOSE PACK 4 10 MG (7)- 0 MG (), 10 MG (7)-0 MG (7)-40 MG (16) Antidiabetic Agents Antidiabetic Agents, Miscellaneous acarbose oral tablet 100 mg, 5 mg, 50 mg QL (90 per 0 days) 7 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

46 ACTOPLUS MET XR ORAL TABLET, ER QL (60 per 0 days) MULTIPHASE 4 HR 15-1,000 MG, 0-1,000 MG alogliptin oral tablet 1.5 mg, 5 mg, 6.5 mg 4 QL (0 per 0 days) alogliptin-metformin oral tablet 1.5-1,000 mg, 4 QL (60 per 0 days) mg alogliptin-pioglitazone oral tablet mg, 4 QL (0 per 0 days) mg, mg, 5-15 mg, 5-0 mg, 5-45 mg CYCLOSET ORAL TABLET 0.8 MG 4 QL (180 per 0 days) GLYSET ORAL TABLET 100 MG, 5 MG, QL (90 per 0 days) 50 MG GLYXAMBI ORAL TABLET 10-5 MG, 5-5 ST MG INVOKAMET ORAL TABLET 150-1,000 ST MG, MG, 50-1,000 MG, MG INVOKANA ORAL TABLET 100 MG, 00 ST MG JANUMET ORAL TABLET 50-1,000 MG, MG JANUMET XR ORAL TABLET, ER MULTIPHASE 4 HR 100-1,000 MG, 50-1,000 MG, MG JANUVIA ORAL TABLET 100 MG, 5 MG, 50 MG JARDIANCE ORAL TABLET 10 MG, 5 ST MG JENTADUETO ORAL TABLET.5-1,000 MG, MG, MG JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 4HR.5-1,000 MG, 5-1,000 MG KAZANO ORAL TABLET 1.5-1,000 MG, 4 QL (60 per 0 days) MG KORLYM ORAL TABLET 00 MG 5 PA; NM; QL (11 per 8 days) metformin oral tablet 1,000 mg 1 QL (75 per 0 days) metformin oral tablet 500 mg 1 QL (150 per 0 days) 8 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

47 metformin oral tablet 850 mg 1 QL (90 per 0 days) metformin oral tablet extended release 4 hr 500 QL (10 per 0 days) mg metformin oral tablet extended release 4 hr 750 QL (90 per 0 days) mg metformin oral tablet extended release 4hr QL (60 per 0 days) 1,000 mg metformin oral tablet extended release 4hr 500 QL (150 per 0 days) mg miglitol oral tablet 100 mg, 5 mg, 50 mg QL (90 per 0 days) nateglinide oral tablet 10 mg, 60 mg QL (90 per 0 days) NESINA ORAL TABLET 1.5 MG, 5 MG, 4 QL (0 per 0 days) 6.5 MG OSENI ORAL TABLET MG, QL (0 per 0 days) MG, MG, 5-15 MG, 5-0 MG, 5-45 MG pioglitazone oral tablet 15 mg, 0 mg, 45 mg QL (0 per 0 days) pioglitazone-glimepiride oral tablet 0- mg, QL (0 per 0 days) 0-4 mg pioglitazone-metformin oral tablet mg, QL (90 per 0 days) mg repaglinide oral tablet 0.5 mg, 1 mg, mg QL (40 per 0 days) repaglinide-metformin oral tablet mg, QL (150 per 0 days) -500 mg SYMLINPEN 10 SUBCUTANEOUS PEN 4 QL (10.8 per 8 days) INJECTOR,700 MCG/.7 ML SYMLINPEN 60 SUBCUTANEOUS PEN 4 QL (6 per 8 days) INJECTOR 1,500 MCG/1.5 ML SYNJARDY ORAL TABLET 1.5-1,000 ST MG, MG, 5-1,000 MG, MG TRADJENTA ORAL TABLET 5 MG TRULICITY SUBCUTANEOUS PEN INJECTOR 0.75 MG/0.5 ML, 1.5 MG/0.5 ML VICTOZA -PAK SUBCUTANEOUS PEN INJECTOR 0.6 MG/0.1 ML (18 MG/ ML) 9 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

48 Insulins HUMALOG 100 UNITS/ML CARTRIDGE 5'S, OUTER 100 UNIT/ML HUMALOG KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML HUMALOG KWIKPEN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML ( ML) HUMALOG MIX KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (50-50) HUMALOG MIX SUBCUTANEOUS SUSPENSION 100 UNIT/ML (50-50) HUMALOG MIX 75-5 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (75-5) HUMALOG MIX 75-5 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (75-5) HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML (PREFILLED SYRINGE) HUMULIN 70/0 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-0) HUMULIN 70/0 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-0) HUMULIN N KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML ( ML) HUMULIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML HUMULIN R INJECTION SOLUTION 100 UNIT/ML HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN 500 UNIT/ML ( ML) QL (0 per 8 days) QL (0 per 8 days) QL (1 per 8 days) QL (0 per 8 days) QL (40 per 8 days) QL (0 per 8 days) QL (40 per 8 days) QL (40 per 8 days) QL (0 per 8 days) QL (0 per 8 days) QL (40 per 8 days) QL (0 per 8 days) QL (40 per 8 days) QL (40 per 8 days) QL (4 per 8 days) 40 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

49 HUMULIN R U-500 (CONCENTRATED) QL (40 per 8 days) SUBCUTANEOUS SOLUTION 500 UNIT/ML LANTUS SOLOSTAR SUBCUTANEOUS INSULIN PEN 100 UNIT/ML ( ML) LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML NOVOLIN 70/0 SUBCUTANEOUS QL (40 per 8 days) SUSPENSION 100 UNIT/ML (70-0) NOVOLIN N SUBCUTANEOUS QL (40 per 8 days) SUSPENSION 100 UNIT/ML NOVOLIN R INJECTION SOLUTION 100 QL (40 per 8 days) UNIT/ML NOVOLOG FLEXPEN SUBCUTANEOUS QL (0 per 8 days) INSULIN PEN 100 UNIT/ML NOVOLOG MIX 70-0 FLEXPEN QL (0 per 8 days) SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-0) NOVOLOG MIX 70-0 SUBCUTANEOUS QL (40 per 8 days) SOLUTION 100 UNIT/ML (70-0) NOVOLOG PENFILL SUBCUTANEOUS QL (0 per 8 days) CARTRIDGE 100 UNIT/ML NOVOLOG SUBCUTANEOUS SOLUTION QL (40 per 8 days) 100 UNIT/ML TOUJEO SOLOSTAR SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (1.5 ML) Sulfonylureas glimepiride oral tablet 1 mg, mg 1 QL (0 per 0 days) glimepiride oral tablet 4 mg 1 QL (60 per 0 days) glipizide oral tablet 10 mg 1 QL (10 per 0 days) glipizide oral tablet 5 mg 1 QL (60 per 0 days) glipizide oral tablet extended release 4hr 10 mg QL (60 per 0 days) glipizide oral tablet extended release 4hr.5 QL (0 per 0 days) mg, 5 mg glipizide-metformin oral tablet.5-50 mg QL (40 per 0 days) 41 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

50 glipizide-metformin oral tablet mg, QL (10 per 0 days) mg glyburide micronized oral tablet 1.5 mg PA-HRM; QL (400 per 0 days) glyburide micronized oral tablet mg PA-HRM; QL (180 per 0 days) glyburide micronized oral tablet 6 mg PA-HRM; QL (10 per 0 days) glyburide oral tablet 1.5 mg PA-HRM; QL (80 per 0 days) glyburide oral tablet.5 mg PA-HRM; QL (40 per 0 days) glyburide oral tablet 5 mg PA-HRM; QL (10 per 0 days) glyburide-metformin oral tablet mg PA-HRM; QL (40 per 0 days) glyburide-metformin oral tablet mg, PA-HRM; QL (10 per 0 days) mg tolazamide oral tablet 50 mg QL (10 per 0 days) tolazamide oral tablet 500 mg QL (60 per 0 days) tolbutamide oral tablet 500 mg QL (180 per 0 days) Antifungals Antifungals ABELCET INTRAVENOUS SUSPENSION 5 PA BvD; NM 5 MG/ML AMBISOME INTRAVENOUS 5 PA BvD; NM SUSPENSION FOR RECONSTITUTION 50 MG amphotericin b injection recon soln 50 mg PA BvD CANCIDAS INTRAVENOUS RECON 5 NM SOLN 50 MG, 70 MG ciclopirox topical cream 0.77 % ciclopirox topical gel 0.77 % ciclopirox topical shampoo 1 % ciclopirox topical solution 8 % ciclopirox topical suspension 0.77 % ciclopirox-ure-camph-menth-euc topical solution 8 % clotrimazole mucous membrane troche 10 mg clotrimazole topical cream 1 % clotrimazole topical solution 1 % 4 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

51 clotrimazole-betamethasone topical cream % clotrimazole-betamethasone topical lotion % econazole topical cream 1 % EXELDERM TOPICAL CREAM 1 % 4 EXELDERM TOPICAL SOLUTION 1 % 4 fluconazole in dextrose(iso-o) intravenous piggyback 400 mg/00 ml fluconazole in nacl (iso-osm) intravenous piggyback 100 mg/50 ml, 00 mg/100 ml fluconazole oral suspension for reconstitution 10 mg/ml, 40 mg/ml fluconazole oral tablet 100 mg, 150 mg, 00 mg, 50 mg fluconazole-nacl 400 mg/00 ml 10's,latex-free, p/f 400 mg/00 ml flucytosine oral capsule 50 mg, 500 mg 5 NM griseofulvin microsize oral suspension 15 mg/5 ml griseofulvin microsize oral tablet 500 mg griseofulvin ultramicrosize oral tablet 15 mg, 50 mg itraconazole oral capsule 100 mg ketoconazole oral tablet 00 mg ketoconazole topical cream % ketoconazole topical shampoo % miconazole- vaginal suppository 00 mg NOXAFIL INTRAVENOUS SOLUTION 5 NM 00 MG/16.7 ML NOXAFIL ORAL SUSPENSION 00 MG/5 5 NM ML (40 MG/ML) NOXAFIL ORAL TABLET,DELAYED 5 NM RELEASE (DR/EC) 100 MG nyamyc topical powder 100,000 unit/gram nystatin oral suspension 100,000 unit/ml 4 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

52 nystatin oral tablet 500,000 unit nystatin topical cream 100,000 unit/gram nystatin topical ointment 100,000 unit/gram nystatin topical powder 100,000 unit/gram nystatin-triamcinolone topical cream 100, unit/g-% nystatin-triamcinolone topical ointment 100, unit/gram-% nystop topical powder 100,000 unit/gram SPORANOX ORAL SOLUTION 10 MG/ML 4 terbinafine hcl oral tablet 50 mg voriconazole intravenous solution 00 mg voriconazole oral suspension for reconstitution 5 NM 00 mg/5 ml (40 mg/ml) voriconazole oral tablet 00 mg, 50 mg 5 NM Antihistamines Antihistamines carbinoxamine maleate oral liquid 4 mg/5 ml carbinoxamine maleate oral tablet 4 mg clemastine oral tablet.68 mg cyproheptadine oral syrup mg/5 ml cyproheptadine oral tablet 4 mg diphenhydramine hcl injection solution 50 mg/ml diphenhydramine hcl injection syringe 50 mg/ml levocetirizine oral solution.5 mg/5 ml levocetirizine oral tablet 5 mg promethazine oral syrup 6.5 mg/5 ml PA-HRM Anti-Infectives (Skin And Mucous Membrane) Anti-Infectives (Skin And Mucous Membrane) AVC VAGINAL VAGINAL CREAM 15 % clindamycin phosphate vaginal cream % metronidazole vaginal gel 0.75 % terconazole vaginal cream 0.4 %, 0.8 % 44 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

53 terconazole vaginal suppository 80 mg Antimigraine Agents Antimigraine Agents almotriptan malate oral tablet 1.5 mg, 6.5 mg QL (1 per 8 days) dihydroergotamine injection solution 1 mg/ml QL (0 per 8 days) dihydroergotamine nasal spray,non-aerosol 0.5 QL (8 per 8 days) mg/pump act. (4 mg/ml) ERGOMAR SUBLINGUAL TABLET MG 4 QL (40 per 8 days) naratriptan oral tablet 1 mg,.5 mg QL (18 per 8 days) rizatriptan oral tablet 10 mg, 5 mg QL (18 per 8 days) rizatriptan oral tablet,disintegrating 10 mg, 5 QL (18 per 8 days) mg sumatriptan 6 mg/0.5 ml syrng p/f,dehp/f,pvc/f 6 QL (4 per 8 days) mg/0.5 ml sumatriptan nasal spray,non-aerosol 0 QL (1 per 8 days) mg/actuation, 5 mg/actuation sumatriptan succinate oral tablet 100 mg, 5 QL (18 per 8 days) mg, 50 mg sumatriptan succinate subcutaneous cartridge 4 QL (4 per 8 days) mg/0.5 ml, 6 mg/0.5 ml sumatriptan succinate subcutaneous pen injector QL (4 per 8 days) 4 mg/0.5 ml sumatriptan succinate subcutaneous pen injector QL (4 per 8 days) 6 mg/0.5 ml, 6 mg/0.5 ml (auto-injector) sumatriptan succinate subcutaneous solution 6 QL (4 per 8 days) mg/0.5 ml zolmitriptan oral tablet.5 mg, 5 mg QL (1 per 8 days) zolmitriptan oral tablet,disintegrating.5 mg, 5 QL (1 per 8 days) mg Antimycobacterials Antimycobacterials CAPASTAT INJECTION RECON SOLN 1 4 GRAM dapsone oral tablet 100 mg, 5 mg ethambutol oral tablet 100 mg, 400 mg isoniazid oral solution 50 mg/5 ml 45 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

54 isoniazid oral tablet 100 mg, 00 mg 1 PASER ORAL GRANULES DR FOR SUSP 4 IN PACKET 4 GRAM PRIFTIN ORAL TABLET 150 MG 4 pyrazinamide oral tablet 500 mg rifabutin oral capsule 150 mg rifampin intravenous recon soln 600 mg rifampin oral capsule 150 mg, 00 mg RIFATER ORAL TABLET MG 4 SIRTURO ORAL TABLET 100 MG 5 PA; NM; QL (188 per 168 days) TRECATOR ORAL TABLET 50 MG 4 Antinausea Agents Antinausea Agents AKYNZEO ORAL CAPSULE MG PA BvD compro rectal suppository 5 mg dimenhydrinate injection solution 50 mg/ml dronabinol oral capsule 10 mg,.5 mg, 5 mg EMEND INTRAVENOUS RECON SOLN 4 QL ( per 8 days) 115 MG, 150 MG EMEND ORAL CAPSULE 15 MG, 80 MG 4 PA BvD EMEND ORAL CAPSULE 40 MG 4 EMEND ORAL CAPSULE,DOSE PACK 4 PA BvD 15 MG (1)- 80 MG () granisetron (pf) intravenous solution 100 mcg/ml granisetron hcl intravenous solution 1 mg/ml (1 ml) granisetron hcl oral tablet 1 mg PA BvD granisol oral solution 1 mg/5 ml PA BvD meclizine oral tablet 1.5 mg, 5 mg ondansetron hcl (pf) injection solution 4 mg/ ml ondansetron hcl (pf) injection syringe 4 mg/ ml ondansetron hcl oral solution 4 mg/5 ml PA BvD ondansetron hcl oral tablet 4 mg, 4 mg, 8 mg PA BvD 46 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

55 ondansetron oral tablet,disintegrating 4 mg, 8 PA BvD mg phenadoz rectal suppository 1.5 mg, 5 mg PA-HRM prochlorperazine edisylate injection solution 10 mg/ ml (5 mg/ml) prochlorperazine maleate oral tablet 10 mg, 5 1 mg prochlorperazine rectal suppository 5 mg promethazine oral tablet 1.5 mg, 5 mg, 50 mg PA-HRM promethazine rectal suppository 1.5 mg, 5 mg, PA-HRM 50 mg promethegan rectal suppository 1.5 mg, 5 mg, PA-HRM 50 mg TRANSDERM-SCOP TRANSDERMAL 4 QL (10 per 0 days) PATCH DAY 1.5 MG (1 MG OVER DAYS) Antiparasite Agents Antiparasite Agents ALBENZA ORAL TABLET 00 MG 4 ALINIA ORAL SUSPENSION FOR 4 RECONSTITUTION 100 MG/5 ML ALINIA ORAL TABLET 500 MG 4 atovaquone oral suspension 750 mg/5 ml 5 NM atovaquone-proguanil oral tablet mg, mg chloroquine phosphate oral tablet 50 mg, 500 mg COARTEM ORAL TABLET 0-10 MG 4 DARAPRIM ORAL TABLET 5 MG 4 EMVERM ORAL TABLET,CHEWABLE QL (6 per 1 days) 100 MG hydroxychloroquine oral tablet 00 mg ivermectin oral tablet mg mefloquine oral tablet 50 mg NEBUPENT INHALATION RECON SOLN 00 MG 4 PA BvD 47 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

56 paromomycin oral capsule 50 mg PENTAM INJECTION RECON SOLN 00 4 MG PRIMAQUINE ORAL TABLET 6. MG 4 QL (90 per 0 days) quinine sulfate oral capsule 4 mg PA; QL (4 per 7 days) tinidazole oral tablet 50 mg, 500 mg Antiparkinsonian Agents Antiparkinsonian Agents amantadine hcl oral capsule 100 mg amantadine hcl oral solution 50 mg/5 ml amantadine hcl oral tablet 100 mg APOKYN SUBCUTANEOUS 5 NM; QL (60 per 0 days) CARTRIDGE 10 MG/ML AZILECT ORAL TABLET 0.5 MG, 1 MG benztropine injection solution mg/ ml PA-HRM benztropine oral tablet 0.5 mg, 1 mg, mg PA-HRM bromocriptine oral capsule 5 mg bromocriptine oral tablet.5 mg cabergoline oral tablet 0.5 mg carbidopa oral tablet 5 mg carbidopa-levodopa oral tablet mg, mg, 5-50 mg carbidopa-levodopa oral tablet extended release mg, mg carbidopa-levodopa oral tablet,disintegrating mg, mg, 5-50 mg carbidopa-levodopa-entacapone oral tablet mg, mg, mg, mg, mg, mg entacapone oral tablet 00 mg NEUPRO TRANSDERMAL PATCH 4 HOUR 1 MG/4 HOUR, MG/4 HOUR, MG/4 HOUR, 4 MG/4 HOUR, 6 MG/4 HOUR, 8 MG/4 HOUR 48 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

57 pramipexole oral tablet 0.15 mg, 0.5 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg ropinirole oral tablet 0.5 mg, 0.5 mg, 1 mg, mg, mg, 4 mg, 5 mg ropinirole oral tablet extended release 4 hr 1 mg, mg, 4 mg, 6 mg, 8 mg selegiline hcl oral capsule 5 mg selegiline hcl oral tablet 5 mg trihexyphenidyl oral elixir 0.4 mg/ml PA-HRM trihexyphenidyl oral tablet mg, 5 mg PA-HRM Antipsychotic Agents Antipsychotic Agents ABILIFY MAINTENA 5 NM INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 00 MG ABILIFY MAINTENA 5 NM; QL (1 per 8 days) INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 400 MG ABILIFY MAINTENA 5 NM; QL (1 per 8 days) INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 00 MG, 400 MG aripiprazole oral solution 1 mg/ml QL (900 per 0 days) aripiprazole oral tablet 10 mg, 15 mg, 0 mg, 0 QL (0 per 0 days) mg, 5 mg aripiprazole oral tablet mg QL (60 per 0 days) aripiprazole oral tablet,disintegrating 10 mg QL (90 per 0 days) aripiprazole oral tablet,disintegrating 15 mg QL (60 per 0 days) ARISTADA INTRAMUSCULAR 5 NM; QL (1.6 per 8 days) SUSPENSION,EXTENDED REL SYRING 441 MG/1.6 ML ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 66 MG/.4 ML 5 NM; QL (.4 per 8 days) 49 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

58 ARISTADA INTRAMUSCULAR 5 NM; QL (. per 8 days) SUSPENSION,EXTENDED REL SYRING 88 MG/. ML chlorpromazine injection solution 5 mg/ml chlorpromazine oral tablet 10 mg, 100 mg, 00 mg, 5 mg, 50 mg clozapine oral tablet 100 mg QL (70 per 0 days) clozapine oral tablet 00 mg QL (15 per 0 days) clozapine oral tablet 5 mg, 50 mg QL (90 per 0 days) clozapine oral tablet,disintegrating 100 mg, 1.5 ST mg, 150 mg, 00 mg, 5 mg FANAPT ORAL TABLET 1 MG, 10 MG, 1 4 ST; QL (60 per 0 days) MG, MG, 4 MG, 6 MG, 8 MG FANAPT ORAL TABLETS,DOSE PACK 4 ST; QL (8 per 8 days) 1MG()-MG()- 4MG()-6MG() fluphenazine decanoate injection solution 5 mg/ml fluphenazine hcl injection solution.5 mg/ml fluphenazine hcl oral concentrate 5 mg/ml fluphenazine hcl oral elixir.5 mg/5 ml fluphenazine hcl oral tablet 1 mg, 10 mg,.5 mg, 5 mg GEODON INTRAMUSCULAR RECON 4 QL (6 per 8 days) SOLN 0 MG/ML (FINAL CONC.) haloperidol decanoate intramuscular solution 100 mg/ml, 50 mg/ml haloperidol lactate injection solution 5 mg/ml haloperidol lactate oral concentrate mg/ml haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, mg, 0 mg, 5 mg INVEGA SUSTENNA INTRAMUSCULAR 5 NM SYRINGE 117 MG/0.75 ML, 156 MG/ML, 4 MG/1.5 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 9 MG/0.5 ML, 78 MG/0.5 ML 50 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

59 INVEGA TRINZA INTRAMUSCULAR 5 NM SYRINGE 7 MG/0.875 ML, 410 MG/1.15 ML, 546 MG/1.75 ML, 819 MG/.65 ML LATUDA ORAL TABLET 10 MG, 0 MG, 4 40 MG, 60 MG, 80 MG loxapine succinate oral capsule 10 mg, 5 mg, 5 mg, 50 mg molindone oral tablet 10 mg QL (40 per 0 days) molindone oral tablet 5 mg QL (70 per 0 days) molindone oral tablet 5 mg QL (10 per 0 days) NUPLAZID ORAL TABLET 17 MG 5 PA NSO; NM; QL (60 per 0 days) olanzapine intramuscular recon soln 10 mg QL (0 per 0 days) olanzapine oral tablet 10 mg, 15 mg,.5 mg, 0 QL (0 per 0 days) mg, 5 mg, 7.5 mg olanzapine oral tablet,disintegrating 10 mg, 15 QL (0 per 0 days) mg, 5 mg olanzapine oral tablet,disintegrating 0 mg QL (1 per 0 days) paliperidone oral tablet extended release 4hr QL (0 per 0 days) 1.5 mg, mg, 9 mg paliperidone oral tablet extended release 4hr 6 QL (60 per 0 days) mg perphenazine oral tablet 16 mg, mg, 4 mg, 8 mg pimozide oral tablet 1 mg, mg quetiapine oral tablet 100 mg, 00 mg, 5 mg, QL (90 per 0 days) 00 mg, 400 mg, 50 mg REXULTI ORAL TABLET 0.5 MG 5 NM; QL (10 per 0 days) REXULTI ORAL TABLET 0.5 MG 5 NM; QL (60 per 0 days) REXULTI ORAL TABLET 1 MG, MG, 5 NM; QL (0 per 0 days) MG, 4 MG RISPERDAL CONSTA 4 QL (4 per 8 days) INTRAMUSCULAR SYRINGE 1.5 MG/ ML, 5 MG/ ML, 7.5 MG/ ML, 50 MG/ ML risperidone oral solution 1 mg/ml QL (480 per 0 days) 51 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

60 risperidone oral tablet 0.5 mg, 0.5 mg, 1 mg, QL (60 per 0 days) mg, mg, 4 mg risperidone oral tablet,disintegrating 0.5 mg, QL (60 per 0 days) 0.5 mg, 1 mg, mg risperidone oral tablet,disintegrating mg, 4 mg QL (10 per 0 days) SAPHRIS (BLACK CHERRY) 4 ST; QL (60 per 0 days) SUBLINGUAL TABLET 10 MG,.5 MG, 5 MG SEROQUEL XR ORAL TABLET 4 ST; QL (60 per 0 days) EXTENDED RELEASE 4 HR 150 MG, 00 MG, 400 MG, 50 MG SEROQUEL XR ORAL TABLET 4 ST; QL (0 per 0 days) EXTENDED RELEASE 4 HR 00 MG thioridazine oral tablet 10 mg, 100 mg, 5 mg, PA NSO-HRM 50 mg thiothixene oral capsule 1 mg, 10 mg, mg, 5 mg trifluoperazine oral tablet 1 mg, 10 mg, mg, 5 mg VERSACLOZ ORAL SUSPENSION 50 5 ST; NM; QL (540 per 0 days) MG/ML VRAYLAR ORAL CAPSULE 1.5 MG, 5 NM; QL (0 per 0 days) MG, 4.5 MG, 6 MG VRAYLAR ORAL CAPSULE,DOSE PACK 4 QL (7 per 0 days) 1.5 MG (1)- MG (6) ziprasidone hcl oral capsule 0 mg, 40 mg, 60 QL (60 per 0 days) mg, 80 mg ZYPREXA RELPREVV 405 MG VL KIT W/ 5 NM DILUENT, OUTER 405 MG ZYPREXA RELPREVV 5 NM INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 10 MG Antivirals (Systemic) Antiretrovirals abacavir oral tablet 00 mg 5 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

61 abacavir-lamivudine-zidovudine oral tablet 5 NM mg APTIVUS ORAL CAPSULE 50 MG 5 NM APTIVUS ORAL SOLUTION 100 MG/ML 4 ATRIPLA ORAL TABLET MG 5 NM COMPLERA ORAL TABLET NM MG CRIXIVAN ORAL CAPSULE 00 MG, MG DESCOVY ORAL TABLET 00-5 MG 5 NM didanosine oral capsule,delayed release(dr/ec) 15 mg, 00 mg, 50 mg, 400 mg EDURANT ORAL TABLET 5 MG 5 NM EMTRIVA ORAL CAPSULE 00 MG EMTRIVA ORAL SOLUTION 10 MG/ML EPIVIR HBV ORAL SOLUTION 5 MG/5 4 ML (5 MG/ML) EPZICOM ORAL TABLET MG 5 NM EVOTAZ ORAL TABLET MG 5 NM FUZEON SUBCUTANEOUS RECON 5 NM SOLN 90 MG GENVOYA ORAL TABLET NM MG INTELENCE ORAL TABLET 100 MG, 00 5 NM MG INTELENCE ORAL TABLET 5 MG INVIRASE ORAL CAPSULE 00 MG 5 NM INVIRASE ORAL TABLET 500 MG 5 NM ISENTRESS ORAL POWDER IN PACKET 100 MG ISENTRESS ORAL TABLET 400 MG 5 NM ISENTRESS ORAL TABLET,CHEWABLE 100 MG, 5 MG KALETRA ORAL SOLUTION NM MG/5 ML KALETRA ORAL TABLET MG 5 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

62 KALETRA ORAL TABLET MG 5 NM lamivudine oral solution 10 mg/ml lamivudine oral tablet 100 mg, 150 mg, 00 mg lamivudine-zidovudine oral tablet mg 5 NM LEXIVA ORAL SUSPENSION 50 MG/ML LEXIVA ORAL TABLET 700 MG 5 NM nevirapine oral suspension 50 mg/5 ml nevirapine oral tablet 00 mg nevirapine oral tablet extended release 4 hr 100 mg, 400 mg NORVIR ORAL CAPSULE 100 MG NORVIR ORAL SOLUTION 80 MG/ML NORVIR ORAL TABLET 100 MG ODEFSEY ORAL TABLET MG 5 NM PREZCOBIX ORAL TABLET NM MG-MG PREZISTA ORAL SUSPENSION MG/ML PREZISTA ORAL TABLET 150 MG, 75 MG PREZISTA ORAL TABLET 400 MG, NM MG, 800 MG RESCRIPTOR ORAL TABLET 00 MG 4 RESCRIPTOR ORAL TABLET, 4 DISPERSIBLE 100 MG RETROVIR INTRAVENOUS SOLUTION 10 MG/ML REYATAZ ORAL CAPSULE 150 MG, 00 5 NM MG, 00 MG REYATAZ ORAL POWDER IN PACKET 5 NM 50 MG SELZENTRY ORAL TABLET 150 MG, 00 5 NM MG stavudine oral capsule 15 mg, 0 mg, 0 mg, 40 mg stavudine oral recon soln 1 mg/ml 54 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

63 STRIBILD ORAL TABLET NM MG SUSTIVA ORAL CAPSULE 00 MG, 50 4 MG SUSTIVA ORAL TABLET 600 MG 4 TIVICAY ORAL TABLET 10 MG, 5 MG, 5 NM 50 MG TRIUMEQ ORAL TABLET MG 5 NM TRUVADA ORAL TABLET MG, 5 NM 1-00 MG, MG, MG VIDEX GRAM PEDIATRIC ORAL RECON SOLN 10 MG/ML (FINAL) VIDEX 4 GM PEDIATRIC SOLN 10 MG/ML (FINAL) VIRACEPT ORAL TABLET 50 MG, 65 4 MG VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 4 HR 100 MG VIREAD ORAL POWDER 40 MG/SCOOP 5 NM (40 MG/GRAM) VIREAD ORAL TABLET 150 MG, 00 MG, 5 NM 50 MG, 00 MG VITEKTA ORAL TABLET 150 MG, 85 MG 5 NM ZIAGEN ORAL SOLUTION 0 MG/ML 4 zidovudine oral capsule 100 mg zidovudine oral syrup 10 mg/ml zidovudine oral tablet 00 mg Antivirals, Miscellaneous foscarnet intravenous solution 4 mg/ml PA BvD RELENZA DISKHALER INHALATION 4 BLISTER WITH DEVICE 5 MG/ACTUATION rimantadine oral tablet 100 mg SYNAGIS 100 MG/1 ML VIAL 100 MG/ML 5 NM SYNAGIS INTRAMUSCULAR SOLUTION 50 MG/0.5 ML 5 NM 55 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

64 TAMIFLU ORAL CAPSULE 0 MG, 45 MG, 75 MG TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION 6 MG/ML Hcv Antivirals DAKLINZA ORAL TABLET 0 MG, 60 5 PA; NM; QL (8 per 8 days) MG, 90 MG HARVONI ORAL TABLET MG 5 PA; NM; QL (0 per 0 days) OLYSIO ORAL CAPSULE 150 MG 5 PA; NM; QL (8 per 8 days) SOVALDI ORAL TABLET 400 MG 5 PA; NM; QL (8 per 8 days) TECHNIVIE ORAL TABLET PA; NM; QL (56 per 8 days) MG VIEKIRA PAK ORAL TABLETS,DOSE 5 PA; NM; QL (11 per 8 days) PACK 1.5 MG-75 MG -50 MG/50 MG ZEPATIER ORAL TABLET MG 5 PA; NM; QL (0 per 0 days) Interferons INTRON A 5 MILLION UNIT/.5 ML 10 4 PA NSO MILLION UNIT/ML INTRON A INJECTION RECON SOLN 10 4 PA NSO MILLION UNIT (1 ML) INTRON A INJECTION RECON SOLN 18 4 PA NSO MILLION UNIT (1 ML), 50 MILLION UNIT (1 ML) INTRON A INJECTION SOLUTION 6 4 PA NSO MILLION UNIT/ML PEGASYS PROCLICK SUBCUTANEOUS 5 PA; NM PEN INJECTOR 15 MCG/0.5 ML, 180 MCG/0.5 ML PEGASYS SUBCUTANEOUS SOLUTION 5 PA; NM 180 MCG/ML PEGASYS SUBCUTANEOUS SYRINGE 5 PA; NM 180 MCG/0.5 ML PEGINTRON SUBCUTANEOUS KIT 10 5 PA; NM MCG/0.5 ML, 150 MCG/0.5 ML, 50 MCG/0.5 ML, 80 MCG/0.5 ML SYLATRON SUBCUTANEOUS KIT 00 MCG, 00 MCG, 600 MCG 5 PA NSO; NM; QL (4 per 8 days) 56 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

65 Nucleosides And Nucleotides acyclovir oral capsule 00 mg acyclovir oral suspension 00 mg/5 ml acyclovir oral tablet 400 mg, 800 mg acyclovir sodium intravenous solution 50 mg/ml PA BvD adefovir oral tablet 10 mg 5 NM BARACLUDE ORAL SOLUTION MG/ML cidofovir intravenous solution 75 mg/ml 5 NM entecavir oral tablet 0.5 mg, 1 mg 5 NM famciclovir oral tablet 15 mg, 50 mg, 500 mg ganciclovir sodium intravenous recon soln 500 PA BvD mg ribasphere oral capsule 00 mg ribasphere oral tablet 00 mg, 400 mg, 600 mg ribasphere ribapak oral tablets,dose pack 00 5 NM mg (7)- 400 mg (7), mg (8)-mg (8), mg (8)-mg (8), mg (8)-mg (8) ribavirin oral capsule 00 mg ribavirin oral tablet 00 mg TYZEKA ORAL TABLET 600 MG 5 NM valacyclovir oral tablet 1 gram, 500 mg VALCYTE ORAL RECON SOLN 50 4 MG/ML valganciclovir oral tablet 450 mg 5 NM VIRAZOLE INHALATION RECON SOLN 5 PA BvD; NM 6 GRAM Blood Products/Modifiers/Volume Expanders Anticoagulants CEPROTIN (BLUE BAR) INTRAVENOUS 5 NM RECON SOLN 500 UNIT ELIQUIS ORAL TABLET.5 MG, 5 MG enoxaparin subcutaneous solution 00 mg/ ml 57 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

66 enoxaparin subcutaneous syringe 100 mg/ml, 5 NM 10 mg/0.8 ml, 150 mg/ml enoxaparin subcutaneous syringe 0 mg/0. ml, 40 mg/0.4 ml, 60 mg/0.6 ml, 80 mg/0.8 ml fondaparinux subcutaneous syringe 10 mg/0.8 QL (4 per 0 days) ml fondaparinux subcutaneous syringe.5 mg/0.5 QL (15 per 0 days) ml fondaparinux subcutaneous syringe 5 mg/0.4 ml QL (1 per 0 days) fondaparinux subcutaneous syringe 7.5 mg/0.6 QL (18 per 0 days) ml heparin (porcine) in 5 % dex intravenous parenteral solution 1,500 unit/50 ml, 0,000 unit/500 ml (40 unit/ml), 5,000 unit/50 ml(100 unit/ml), 5,000 unit/500 ml (50 unit/ml) heparin (porcine) in nacl (pf) intravenous parenteral solution 1,000 unit/500 ml heparin (porcine) injection solution 1,000 unit/ml, 10,000 unit/ml, 0,000 unit/ml, 5,000 unit/ml heparin, porcine (pf) injection solution 5,000 unit/0.5 ml heparin, porcine (pf) injection syringe 5,000 unit/0.5 ml heparin-0.45% nacl 5,000 units/50 ml (100 units/ml) bag latex-free, inner 5,000 unit/50 ml IPRIVASK SUBCUTANEOUS RECON 5 PA; NM; QL (4 per 8 days) SOLN 15 MG jantoven oral tablet 1 mg, 10 mg, mg,.5 mg, 1 mg, 4 mg, 5 mg, 6 mg, 7.5 mg PRADAXA ORAL CAPSULE 110 MG, ST; QL (60 per 0 days) MG, 75 MG SAVAYSA ORAL TABLET 15 MG, 0 MG, 60 MG 4 58 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

67 warfarin oral tablet 1 mg, 10 mg, mg,.5 mg, mg, 4 mg, 5 mg, 6 mg, 7.5 mg XARELTO ORAL TABLET 10 MG, 15 MG, 0 MG XARELTO ORAL TABLETS,DOSE PACK 15 MG (4)- 0 MG (9) Blood Formation Modifiers CINRYZE INTRAVENOUS RECON SOLN 500 UNIT (5 ML) EPOGEN 10,000 UNITS/ML VIAL SDV, P/F, OUTER 10,000 UNIT/ML EPOGEN INJECTION SOLUTION,000 UNIT/ML, 0,000 UNIT/ ML, 0,000 UNIT/ML,,000 UNIT/ML, 4,000 UNIT/ML GRANIX SUBCUTANEOUS SYRINGE 00 MCG/0.5 ML, 480 MCG/0.8 ML LEUKINE INJECTION RECON SOLN 50 MCG MIRCERA INJECTION SYRINGE 100 MCG/0. ML, 00 MCG/0. ML, 50 MCG/0. ML, 75 MCG/0. ML MOZOBIL SUBCUTANEOUS SOLUTION 4 MG/1. ML (0 MG/ML) NEULASTA SUBCUTANEOUS SYRINGE 6 MG/0.6ML NEULASTA SUBCUTANEOUS SYRINGE, W/ WEARABLE INJECTOR 6 MG/0.6 ML NEUMEGA SUBCUTANEOUS RECON SOLN 5 MG NEUPOGEN INJECTION SOLUTION 00 MCG/ML, 480 MCG/1.6 ML NEUPOGEN INJECTION SYRINGE 00 MCG/0.5 ML, 480 MCG/0.8 ML PROCRIT 10,000 UNITS/ML VIAL 4'S, MDV, OUTER 0,000 UNIT/ ML 1 5 PA; NM PA; QL (1 per 8 days) PA; QL (1 per 8 days) 5 NM 5 NM 4 PA; QL (0.6 per 8 days) 5 NM 5 NM 5 NM 5 NM 5 NM 5 NM PA; QL (1 per 8 days) 59 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

68 PROCRIT INJECTION SOLUTION 10,000 PA; QL (1 per 8 days) UNIT/ML,,000 UNIT/ML,,000 UNIT/ML, 4,000 UNIT/ML PROCRIT INJECTION SOLUTION 0,000 5 PA; NM; QL (1 per 8 days) UNIT/ML PROCRIT INJECTION SOLUTION 40,000 5 PA; NM; QL (6 per 8 days) UNIT/ML PROMACTA ORAL TABLET 1.5 MG, 5 5 PA; NM; QL (0 per 0 days) MG, 50 MG, 75 MG ZARXIO INJECTION SYRINGE 00 5 NM MCG/0.5 ML, 480 MCG/0.8 ML Hematologic Agents, Miscellaneous aminocaproic acid oral solution 50 mg/ml (5 %) aminocaproic acid oral tablet 1,000 mg, 500 mg anagrelide oral capsule 0.5 mg, 1 mg protamine intravenous solution 10 mg/ml tranexamic acid intravenous solution 1,000 mg/10 ml (100 mg/ml) tranexamic acid oral tablet 650 mg QL (0 per 0 days) Platelet-Aggregation Inhibitors aspirin-dipyridamole oral capsule, er multiphase 1 hr 5-00 mg BRILINTA ORAL TABLET 60 MG, 90 MG cilostazol oral tablet 100 mg, 50 mg clopidogrel oral tablet 00 mg, 75 mg dipyridamole oral tablet 5 mg, 50 mg, 75 mg EFFIENT ORAL TABLET 10 MG, 5 MG QL (0 per 0 days) pentoxifylline oral tablet extended release 400 mg Caloric Agents Caloric Agents AMINO ACIDS 15 % INTRAVENOUS 4 PA BvD PARENTERAL SOLUTION 15 % AMINOSYN 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % 4 PA BvD 60 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

69 AMINOSYN.5 % INTRAVENOUS PARENTERAL SOLUTION.5 % AMINOSYN 7 % INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN 7 % WITH ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN 8.5 % INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN 8.5 %-ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN II 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % AMINOSYN II 15 % INTRAVENOUS PARENTERAL SOLUTION 15 % AMINOSYN II 7 % INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN II 8.5 % INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN II 8.5 %-ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN M.5 % INTRAVENOUS PARENTERAL SOLUTION.5 % AMINOSYN-HBC 7% INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN-PF 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % AMINOSYN-PF 7 % (SULFITE-FREE) INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN-RF 5. % INTRAVENOUS PARENTERAL SOLUTION 5. % CLINIMIX 5%/D15W SULFITE FREE INTRAVENOUS PARENTERAL SOLUTION 5 % 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 61 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

70 CLINIMIX 5%/D5W SULFITE-FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX.75%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION.75 % CLINIMIX 4.5%/D10W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 4.5 % CLINIMIX 4.5%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 4.5 % CLINIMIX 4.5%-D0W SULF-FREE INTRAVENOUS PARENTERAL SOLUTION 4.5 % CLINIMIX 4.5%-D5W SULF-FREE INTRAVENOUS PARENTERAL SOLUTION 4.5 % CLINIMIX 5%-D0W(SULFITE-FREE) INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E.75%/D10W SUL FREE INTRAVENOUS PARENTERAL SOLUTION.75 % CLINIMIX E.75%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION.75 % CLINIMIX E 4.5%/D10W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 4.5 % CLINIMIX E 4.5%/D5W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 4.5 % CLINIMIX E 4.5%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 4.5 % 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 6 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

71 CLINIMIX E 5%/D15W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 5%/D0W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 5%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINISOL SF 15 % INTRAVENOUS PARENTERAL SOLUTION 15 % cysteine (l-cysteine) intravenous solution 50 mg/ml dextrose 10 % in water (d10w) intravenous parenteral solution 10 % dextrose 0 % in water (d0w) intravenous parenteral solution 0 % dextrose 5 % in water (d5w) intravenous syringe dextrose 40 % in water (d40w) intravenous parenteral solution 40 % dextrose 5 % in ringers intravenous parenteral solution 5 % dextrose 5 % in water (d5w) intravenous parenteral solution dextrose 50 % in water (d50w) intravenous parenteral solution dextrose 50 % in water (d50w) intravenous syringe dextrose 70 % in water (d70w) intravenous parenteral solution FREAMINE HBC 6.9 % INTRAVENOUS PARENTERAL SOLUTION 6.9 % FREAMINE III 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % HEPATAMINE 8% INTRAVENOUS PARENTERAL SOLUTION 8 % 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 6 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

72 HEPATASOL 8 % INTRAVENOUS 4 PA BvD PARENTERAL SOLUTION 8 % INTRALIPID INTRAVENOUS 4 PA BvD EMULSION 0 %, 0 % KABIVEN INTRAVENOUS EMULSION 4 PA BvD % NEPHRAMINE 5.4 % INTRAVENOUS 4 PA BvD PARENTERAL SOLUTION 5.4 % NUTRILIPID INTRAVENOUS 4 PA BvD EMULSION 0 % PERIKABIVEN INTRAVENOUS 4 PA BvD EMULSION % PREMASOL 10 % INTRAVENOUS 4 PA BvD PARENTERAL SOLUTION 10 % PREMASOL 6 % INTRAVENOUS 4 PA BvD PARENTERAL SOLUTION 6 % PROCALAMINE % INTRAVENOUS 4 PA BvD PARENTERAL SOLUTION % PROSOL 0 % INTRAVENOUS 4 PA BvD PARENTERAL SOLUTION TRAVASOL 10 % INTRAVENOUS 4 PA BvD PARENTERAL SOLUTION 10 % TROPHAMINE 10 % INTRAVENOUS 4 PA BvD PARENTERAL SOLUTION 10 % TROPHAMINE 6% INTRAVENOUS 4 PA BvD PARENTERAL SOLUTION 6 % Cardiovascular Agents Alpha-Adrenergic Agents clonidine hcl oral tablet 0.1 mg, 0. mg, 0. mg 1 clonidine transdermal patch weekly 0.1 mg/4 QL (4 per 8 days) hr, 0. mg/4 hr clonidine transdermal patch weekly 0. mg/4 hr QL (8 per 8 days) clorpres oral tablet mg, mg, mg doxazosin oral tablet 1 mg, mg, 4 mg, 8 mg guanfacine oral tablet 1 mg, mg PA-HRM 64 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

73 midodrine oral tablet 10 mg,.5 mg, 5 mg NORTHERA ORAL CAPSULE 100 MG, 5 PA; NM; QL (180 per 0 days) 00 MG, 00 MG phenylephrine hcl injection solution 10 mg/ml prazosin oral capsule 1 mg, mg, 5 mg Angiotensin Ii Receptor Antagonists BENICAR HCT ORAL TABLET MG, MG, 40-5 MG BENICAR ORAL TABLET 0 MG, 40 MG, 5 MG candesartan oral tablet 16 mg, mg, 4 mg, 8 mg candesartan-hydrochlorothiazid oral tablet mg, -1.5 mg, -5 mg EDARBI ORAL TABLET 40 MG, 80 MG 4 ST EDARBYCLOR ORAL TABLET ST MG, 40-5 MG ENTRESTO ORAL TABLET 4-6 MG, PA; QL (60 per 0 days) MG, MG eprosartan oral tablet 600 mg irbesartan oral tablet 150 mg, 00 mg, 75 mg irbesartan-hydrochlorothiazide oral tablet mg, mg losartan oral tablet 100 mg, 5 mg, 50 mg 1 losartan-hydrochlorothiazide oral tablet mg, mg, mg telmisartan oral tablet 0 mg, 40 mg, 80 mg telmisartan-hydrochlorothiazid oral tablet mg, mg, 80-5 mg TEVETEN HCT ORAL TABLET ST MG, MG TRIBENZOR ORAL TABLET ST MG, MG, MG, MG, MG valsartan oral tablet 160 mg, 0 mg, 40 mg, 80 mg 65 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

74 valsartan-hydrochlorothiazide oral tablet mg, mg, mg, 0-5 mg, mg Angiotensin-Converting Enzyme Inhibitors benazepril oral tablet 10 mg, 0 mg, 40 mg, 5 1 mg benazepril-hydrochlorothiazide oral tablet mg, mg, 0-5 mg, mg captopril oral tablet 100 mg, 1.5 mg, 5 mg, 50 mg captopril-hydrochlorothiazide oral tablet 5-15 mg, 5-5 mg, mg, 50-5 mg enalapril maleate oral tablet 10 mg,.5 mg, 0 1 mg, 5 mg enalaprilat intravenous solution 1.5 mg/ml enalapril-hydrochlorothiazide oral tablet 10-5 mg, mg fosinopril oral tablet 10 mg, 0 mg, 40 mg fosinopril-hydrochlorothiazide oral tablet mg, mg lisinopril oral tablet 10 mg,.5 mg, 0 mg, 0 1 mg, 40 mg, 5 mg lisinopril-hydrochlorothiazide oral tablet mg, mg, 0-5 mg moexipril oral tablet 15 mg, 7.5 mg moexipril-hydrochlorothiazide oral tablet mg, 15-5 mg, mg perindopril erbumine oral tablet mg, 4 mg, 8 mg quinapril oral tablet 10 mg, 0 mg, 40 mg, 5 mg quinapril-hydrochlorothiazide oral tablet mg, mg, 0-5 mg ramipril oral capsule 1.5 mg, 10 mg,.5 mg, 5 mg trandolapril oral tablet 1 mg, mg, 4 mg 66 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

75 Antiarrhythmic Agents amiodarone intravenous solution 50 mg/ml amiodarone intravenous syringe 150 mg/ ml amiodarone oral tablet 100 mg, 00 mg, 400 mg disopyramide phosphate oral capsule 100 mg, 150 mg dofetilide oral capsule 15 mcg, 50 mcg, 500 mcg flecainide oral tablet 100 mg, 150 mg, 50 mg lidocaine (pf) intravenous syringe 50 mg/5 ml (1 %) lidocaine in 5 % dextrose (pf) intravenous parenteral solution 8 mg/ml (0.8 %) mexiletine oral capsule 150 mg, 00 mg, 50 mg MULTAQ ORAL TABLET 400 MG pacerone oral tablet 100 mg, 00 mg, 400 mg procainamide injection solution 100 mg/ml, 500 mg/ml propafenone oral capsule,extended release 1 hr 5 mg, 5 mg, 45 mg propafenone oral tablet 150 mg, 5 mg, 00 mg quinidine gluconate oral tablet extended release 4 mg quinidine sulfate oral tablet 00 mg, 00 mg quinidine sulfate oral tablet extended release 00 mg TIKOSYN ORAL CAPSULE 15 MCG, 50 MCG, 500 MCG Beta-Adrenergic Blocking Agents acebutolol oral capsule 00 mg, 400 mg atenolol oral tablet 100 mg, 5 mg, 50 mg 1 atenolol-chlorthalidone oral tablet mg, mg betaxolol oral tablet 10 mg, 0 mg bisoprolol fumarate oral tablet 10 mg, 5 mg 67 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

76 bisoprolol-hydrochlorothiazide oral tablet mg, mg, mg BYSTOLIC ORAL TABLET 10 MG,.5 MG, 0 MG, 5 MG carvedilol oral tablet 1.5 mg, 5 mg,.15 mg, mg esmolol intravenous solution 100 mg/10 ml (10 PA BvD mg/ml) labetalol intravenous solution 5 mg/ml labetalol oral tablet 100 mg, 00 mg, 00 mg metoprolol succinate oral tablet extended release 4 hr 100 mg, 00 mg, 5 mg, 50 mg metoprolol ta-hydrochlorothiaz oral tablet mg, mg, 50-5 mg metoprolol tartrate intravenous solution 5 mg/5 ml metoprolol tartrate oral tablet 100 mg, 5 mg, 1 50 mg metoprolol tartrate oral tablet 7.5 mg, 75 mg nadolol oral tablet 0 mg, 40 mg, 80 mg pindolol oral tablet 10 mg, 5 mg propranolol intravenous solution 1 mg/ml propranolol oral capsule,extended release 4 hr 10 mg, 160 mg, 60 mg, 80 mg propranolol oral solution 0 mg/5 ml (4 mg/ml), 40 mg/5 ml (8 mg/ml) propranolol oral tablet 10 mg, 0 mg, 40 mg, 60 mg, 80 mg propranolol-hydrochlorothiazid oral tablet 40-5 mg, 80-5 mg sorine oral tablet 10 mg, 160 mg, 40 mg, 80 mg sotalol 10 mg tablet 10 mg sotalol af oral tablet 10 mg sotalol oral tablet 160 mg, 40 mg, 80 mg timolol maleate oral tablet 10 mg, 0 mg, 5 mg 68 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

77 Calcium-Channel Blocking Agents cartia xt oral capsule,extended release 4hr 10 mg, 180 mg, 40 mg, 00 mg diltiazem 4hr er 180 mg cap 180 mg diltiazem 4hr er 60 mg cap once a day dosage 60 mg diltiazem hcl intravenous recon soln 100 mg diltiazem hcl intravenous solution 5 mg/ml diltiazem hcl oral capsule, extended release 180 mg, 60 mg, 40 mg diltiazem hcl oral capsule,extended release 1 hr 10 mg, 60 mg, 90 mg diltiazem hcl oral capsule,extended release 4hr 10 mg, 40 mg, 00 mg diltiazem hcl oral tablet 10 mg, 0 mg, 60 mg, 1 90 mg diltiazem hcl oral tablet extended release 4 hr 180 mg, 40 mg, 00 mg, 60 mg, 40 mg dilt-xr oral capsule,ext release degradable 10 mg, 180 mg, 40 mg matzim la oral tablet extended release 4 hr 180 mg, 40 mg, 00 mg, 60 mg, 40 mg taztia xt oral capsule, extended release 10 mg, 180 mg, 40 mg, 00 mg, 60 mg verapamil intravenous syringe.5 mg/ml verapamil oral capsule, 4 hr er pellet ct 100 mg, 00 mg, 00 mg verapamil oral capsule,ext rel. pellets 4 hr 10 mg, 180 mg, 40 mg, 60 mg verapamil oral tablet 10 mg, 40 mg, 80 mg 1 verapamil oral tablet extended release 10 mg, 180 mg, 40 mg Cardiovascular Agents, Miscellaneous CORLANOR ORAL TABLET 5 MG, 7.5 ST MG DEMSER ORAL CAPSULE 50 MG 5 NM 69 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

78 digitek oral tablet 15 mcg (High Risk Med for Ages 65 and Older and Dose is Greater Than 15mcg Per Day); QL (0 per 0 days) digitek oral tablet 50 mcg PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 15mcg Per Day); QL (0 per 0 days) digox 15 mcg tablet 15 mcg (High Risk Med for Ages 65 and Older and Dose is Greater Than 15mcg Per Day); QL (0 per 0 days) digox 50 mcg tablet 50 mcg PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 15mcg Per Day); QL (0 per 0 days) digoxin 0.5 mg/ml syringe 50 mcg/ml PA-HRM digoxin injection solution 50 mcg/ml PA-HRM DIGOXIN ORAL SOLUTION 50 MCG/ML PA-HRM; QL (00 per 0 days) digoxin oral tablet 15 mcg (High Risk Med for Ages 65 and Older and Dose is Greater Than 15mcg Per Day); QL (0 per 0 days) digoxin oral tablet 50 mcg PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 15mcg Per Day); QL (0 per 0 days) dobutamine in d5w intravenous parenteral PA BvD solution 1,000 mg/50 ml (4,000 mcg/ml), 50 mg/50 ml (1 mg/ml), 500 mg/50 ml (,000 mcg/ml) dobutamine intravenous solution 50 mg/0 ml PA BvD (1.5 mg/ml) dopamine in 5 % dextrose intravenous solution PA BvD 00 mg/50 ml (800 mcg/ml), 400 mg/50 ml (1,600 mcg/ml), 800 mg/50 ml (,00 mcg/ml) dopamine intravenous solution 00 mg/5 ml (40 PA BvD mg/ml), 400 mg/5 ml (80 mg/ml), 800 mg/10 ml (80 mg/ml), 800 mg/5 ml (160 mg/ml) ephedrine sulfate injection solution 50 mg/ml epinephrine hcl (pf) intravenous solution 1 mg/ml (1 ml) 70 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

79 epinephrine injection auto-injector 0.15 mg/0.15 ml, 0. mg/0. ml epinephrine injection solution 1 mg/ml (1 ml) epinephrine injection syringe 0.1 mg/ml EPIPEN -PAK INJECTION AUTO-INJECTOR 0. MG/0. ML EPIPEN JR -PAK INJECTION AUTO-INJECTOR 0.15 MG/0. ML ethamolin intravenous solution 5 % FIRAZYR SUBCUTANEOUS SYRINGE 0 5 NM MG/ ML hydralazine injection solution 0 mg/ml hydralazine oral tablet 10 mg, 100 mg, 5 mg, 50 mg LANOXIN ORAL TABLET MCG 4 PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 15mcg Per Day); QL (0 per 0 days) LANOXIN ORAL TABLET 6.5 MCG 4 (High Risk Med for Ages 65 and Older and Dose is Greater Than 15mcg Per Day); QL (0 per 0 days) milrinone in 5 % dextrose intravenous piggyback 5 PA BvD; NM 0 mg/100 ml (00 mcg/ml), 40 mg/00 ml (00 mcg/ml) milrinone intravenous solution 1 mg/ml 5 PA BvD; NM norepinephrine bitartrate intravenous solution 1 PA BvD mg/ml papaverine injection solution 0 mg/ml PA papaverine oral capsule, extended release 150 PA mg RANEXA ORAL TABLET EXTENDED RELEASE 1 HR 1,000 MG, 500 MG Dihydropyridines afeditab cr oral tablet extended release 0 mg, 60 mg amlodipine oral tablet 10 mg,.5 mg, 5 mg 1 71 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

80 amlodipine-benazepril oral capsule 10-0 mg, mg,.5-10 mg, 5-10 mg, 5-0 mg, 5-40 mg amlodipine-valsartan oral tablet mg, 10-0 mg, mg, 5-0 mg amlodipine-valsartan-hcthiazid oral tablet mg, mg, mg, mg, mg AZOR ORAL TABLET 10-0 MG, ST MG, 5-0 MG, 5-40 MG CLEVIPREX INTRAVENOUS EMULSION 4 50 MG/100 ML felodipine oral tablet extended release 4 hr 10 mg,.5 mg, 5 mg isradipine oral capsule.5 mg, 5 mg nicardipine oral capsule 0 mg, 0 mg nifedical xl oral tablet extended release 4hr 0 mg, 60 mg nifedipine er 0 mg tablet f/c 0 mg nifedipine oral tablet extended release 4hr 0 mg, 60 mg, 90 mg Diuretics amiloride oral tablet 5 mg amiloride-hydrochlorothiazide oral tablet 5-50 mg bumetanide injection solution 0.5 mg/ml bumetanide oral tablet 0.5 mg, 1 mg, mg chlorothiazide oral tablet 50 mg, 500 mg 1 chlorothiazide sodium intravenous recon soln 500 mg chlorthalidone oral tablet 5 mg, 50 mg 1 DYRENIUM ORAL CAPSULE 100 MG, 50 4 MG furosemide injection solution 10 mg/ml furosemide injection syringe 10 mg/ml 7 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

81 furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml) furosemide oral tablet 0 mg, 40 mg, 80 mg 1 hydrochlorothiazide oral capsule 1.5 mg 1 hydrochlorothiazide oral tablet 1.5 mg, 5 mg, 1 50 mg indapamide oral tablet 1.5 mg,.5 mg 1 methyclothiazide oral tablet 5 mg metolazone oral tablet 10 mg,.5 mg, 5 mg torsemide oral tablet 10 mg, 100 mg, 0 mg, 5 mg triamterene-hydrochlorothiazid oral capsule mg, 50-5 mg triamterene-hydrochlorothiazid oral tablet mg, mg Dyslipidemics ALTOPREV ORAL TABLET EXTENDED 4 RELEASE 4 HR 0 MG, 40 MG, 60 MG amlodipine-atorvastatin oral tablet mg, 10-0 mg, mg, mg,.5-10 mg,.5-0 mg,.5-40 mg, 5-10 mg, 5-0 mg, 5-40 mg, 5-80 mg atorvastatin oral tablet 10 mg, 0 mg, 40 mg, 80 1 mg cholestyramine light oral powder in packet 4 gram cholestyramine packet 4 gram colestipol hcl granules packet 5 gram colestipol oral granules 5 gram colestipol oral tablet 1 gram CRESTOR ORAL TABLET 10 MG, 0 MG, 40 MG, 5 MG fenofibrate micronized oral capsule 10 mg, 14 mg, 00 mg, 4 mg, 67 mg fenofibrate nanocrystallized oral tablet 145 mg, 48 mg 7 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

82 fenofibrate oral tablet 10 mg, 160 mg, 40 mg, 54 mg fenofibric acid (choline) oral capsule,delayed release(dr/ec) 15 mg, 45 mg fenofibric acid oral tablet 105 mg, 5 mg fluvastatin oral capsule 0 mg, 40 mg gemfibrozil oral tablet 600 mg JUXTAPID ORAL CAPSULE 10 MG, 0 5 PA; NM MG, 0 MG, 40 MG, 5 MG, 60 MG KYNAMRO SUBCUTANEOUS SYRINGE 5 PA; NM; QL (4 per 8 days) 00 MG/ML lovastatin oral tablet 10 mg, 0 mg, 40 mg 1 niacin oral tablet extended release 4 hr 1,000 mg, 500 mg, 750 mg niacor oral tablet 500 mg omega- acid ethyl esters oral capsule 1 gram PRALUENT PEN SUBCUTANEOUS PEN 5 PA; NM; QL ( per 8 days) INJECTOR 150 MG/ML, 75 MG/ML PRALUENT SYRINGE SUBCUTANEOUS 5 PA; NM; QL ( per 8 days) SYRINGE 150 MG/ML, 75 MG/ML pravastatin oral tablet 10 mg, 0 mg, 40 mg, 80 1 mg prevalite oral powder 4 gram prevalite packet outer 4 gram REPATHA SURECLICK 5 PA; NM; QL ( per 8 days) SUBCUTANEOUS PEN INJECTOR 140 MG/ML REPATHA SYRINGE SUBCUTANEOUS 5 PA; NM; QL ( per 8 days) SYRINGE 140 MG/ML rosuvastatin oral tablet 10 mg, 0 mg, 40 mg, 5 mg simvastatin oral tablet 10 mg, 0 mg, 40 mg, 5 1 mg simvastatin oral tablet 80 mg 1 QL (0 per 0 days) VASCEPA ORAL CAPSULE 1 GRAM VYTORIN ORAL TABLET MG 4 74 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

83 VYTORIN 10-0 ORAL TABLET 10-0 MG 4 VYTORIN ORAL TABLET MG 4 VYTORIN ORAL TABLET MG 4 WELCHOL ORAL POWDER IN PACKET.75 GRAM WELCHOL ORAL TABLET 65 MG ZETIA ORAL TABLET 10 MG 4 Renin-Angiotensin-Aldosterone System Inhibitors eplerenone oral tablet 5 mg, 50 mg spironolactone oral tablet 100 mg, 5 mg, 50 mg spironolacton-hydrochlorothiaz oral tablet 5-5 mg Vasodilators BIDIL ORAL TABLET MG isosorbide dinitrate oral tablet 10 mg, 0 mg, 0 mg, 5 mg isosorbide dinitrate oral tablet extended release 40 mg isosorbide dinitrate sublingual tablet.5 mg, 5 1 mg isosorbide mononitrate oral tablet 10 mg, 0 mg isosorbide mononitrate oral tablet extended release 4 hr 10 mg, 0 mg, 60 mg minitran transdermal patch 4 hour 0.1 mg/hr, QL (0 per 0 days) 0. mg/hr, 0.6 mg/hr minitran transdermal patch 4 hour 0.4 mg/hr QL (60 per 0 days) minoxidil oral tablet 10 mg,.5 mg NITRO-BID TRANSDERMAL OINTMENT % nitroglycerin in 5 % dextrose intravenous solution 100 mg/50 ml (400 mcg/ml), 5 mg/50 ml (100 mcg/ml), 50 mg/50 ml (00 mcg/ml) nitroglycerin intravenous solution 50 mg/10 ml (5 mg/ml) 75 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

84 nitroglycerin transdermal patch 4 hour 0.1 QL (0 per 0 days) mg/hr, 0. mg/hr, 0.6 mg/hr nitroglycerin transdermal patch 4 hour 0.4 QL (60 per 0 days) mg/hr NITROSTAT SUBLINGUAL TABLET 0. MG, 0.4 MG, 0.6 MG PROGLYCEM ORAL SUSPENSION 50 4 MG/ML Central Nervous System Agents Central Nervous System Agents AMPYRA ORAL TABLET EXTENDED 5 PA; NM; QL (60 per 0 days) RELEASE 1 HR 10 MG caffeine citrated intravenous solution 60 mg/ ml (0 mg/ml) caffeine citrated oral solution 60 mg/ ml (0 mg/ml) caffeine-sodium benzoate injection solution 50 mg/ml (15 mg/ml caffeine) clonidine hcl oral tablet extended release 1 hr 0.1 mg dexmethylphenidate oral tablet 10 mg,.5 mg, 5 QL (60 per 0 days) mg dextroamphetamine oral capsule, extended QL (10 per 0 days) release 10 mg, 15 mg, 5 mg dextroamphetamine oral tablet 10 mg, 5 mg QL (180 per 0 days) dextroamphetamine-amphetamine oral QL (0 per 0 days) capsule,extended release 4hr 10 mg, 15 mg, 5 mg dextroamphetamine-amphetamine oral QL (60 per 0 days) capsule,extended release 4hr 0 mg, 5 mg, 0 mg dextroamphetamine-amphetamine oral tablet 10 QL (60 per 0 days) mg, 1.5 mg, 15 mg, 0 mg, 0 mg, 5 mg, 7.5 mg flumazenil intravenous solution 0.1 mg/ml guanfacine oral tablet extended release 4 hr 1 mg, mg, mg, 4 mg 76 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

85 lithium carbonate oral capsule 150 mg, 00 mg, 600 mg lithium carbonate oral tablet 00 mg lithium carbonate oral tablet extended release 00 mg, 450 mg lithium citrate oral solution 8 meq/5 ml methylphenidate cd 0 mg cap 0 mg QL (0 per 0 days) methylphenidate cd 40 mg cap 40 mg QL (0 per 0 days) methylphenidate oral capsule, er biphasic 0-70 QL (0 per 0 days) 10 mg, 50 mg, 60 mg methylphenidate oral capsule, er biphasic 0-70 QL (60 per 0 days) 0 mg methylphenidate oral capsule,er biphasic QL (0 per 0 days) 0 mg, 40 mg methylphenidate oral solution 10 mg/5 ml, 5 QL (900 per 0 days) mg/5 ml methylphenidate oral tablet 10 mg, 0 mg, 5 mg QL (90 per 0 days) methylphenidate oral tablet extended release 10 QL (90 per 0 days) mg, 0 mg methylphenidate oral tablet extended release QL (0 per 0 days) 4hr 18 mg, 7 mg, 54 mg methylphenidate oral tablet extended release QL (60 per 0 days) 4hr 6 mg NUEDEXTA ORAL CAPSULE 0-10 MG QL (60 per 0 days) QUILLIVANT XR ORAL SUSPENSION,EXT REL 4HR,RECON 5 MG/ML (5 MG/5 ML) riluzole oral tablet 50 mg SAVELLA ORAL TABLET 100 MG, 1.5 QL (60 per 0 days) MG, 5 MG, 50 MG SAVELLA ORAL TABLETS,DOSE PACK QL (60 per 0 days) 1.5 MG (5)-5 MG(8)-50 MG(4) STRATTERA ORAL CAPSULE 10 MG, 100 MG, 18 MG, 5 MG, 40 MG, 60 MG, 80 MG tetrabenazine oral tablet 1.5 mg, 5 mg 5 PA; NM; QL (11 per 8 days) 77 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

86 Contraceptives Contraceptives altavera (8) oral tablet mg alyacen 1/5 (8) oral tablet 1-5 mg-mcg alyacen 7/7/7 (8) oral tablet 0.5/0.75/1 mg- 5 mcg amethia lo oral tablets,dose pack, month 0.10 QL (91 per 84 days) mg-0 mcg (84)/10 mcg (7) amethia oral tablets,dose pack, month 0.15 QL (91 per 84 days) mg-0 mcg (84)/10 mcg (7) apri oral tablet mg aranelle (8) oral tablet 0.5/1/0.5-5 mg-mcg ashlyna oral tablets,dose pack, month 0.15 mg-0 mcg (84)/10 mcg (7) aubra oral tablet mg-mcg aviane oral tablet mg-mcg azurette (8) oral tablet mgx1 /0.01 mg x 5 balziva (8) oral tablet mg-mcg bekyree (8) oral tablet mgx1 /0.01 mg x 5 blisovi 4 fe oral tablet 1 mg-0 mcg (4)/75 mg (4) blisovi fe 1.5/0 (8) oral tablet 1.5 mg-0 mcg (1)/75 mg (7) blisovi fe 1/0 (8) oral tablet 1 mg-0 mcg (1)/75 mg (7) briellyn oral tablet mg-mcg camila oral tablet 0.5 mg camrese lo oral tablets,dose pack, month 0.10 QL (91 per 84 days) mg-0 mcg (84)/10 mcg (7) camrese oral tablets,dose pack, month 0.15 QL (91 per 84 days) mg-0 mcg (84)/10 mcg (7) caziant (8) oral tablet 0.1/.15/.15-5 mg-mcg cryselle (8) oral tablet 0.-0 mg-mcg cyclafem 1/5 (8) oral tablet 1-5 mg-mcg 78 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

87 cyclafem 7/7/7 (8) oral tablet 0.5/0.75/1 mg- 5 mcg cyred oral tablet mg dasetta 1/5 (8) oral tablet 1-5 mg-mcg dasetta 7/7/7 (8) oral tablet 0.5/0.75/1 mg- 5 mcg daysee oral tablets,dose pack, month 0.15 QL (91 per 84 days) mg-0 mcg (84)/10 mcg (7) deblitane oral tablet 0.5 mg delyla (8) oral tablet mg-mcg desog-e.estradiol/e.estradiol oral tablet mgx1 /0.01 mg x 5 desogestrel-ethinyl estradiol oral tablet mg drospirenone-ethinyl estradiol oral tablet -0.0 mg, -0.0 mg elinest oral tablet 0.-0 mg-mcg ELLA ORAL TABLET 0 MG 4 QL (6 per 65 days) emoquette oral tablet mg enpresse oral tablet 50-0 (6)/75-40 (5)/15-0(10) enskyce oral tablet mg errin oral tablet 0.5 mg estarylla oral tablet mg-mcg falmina (8) oral tablet mg-mcg gianvi (8) oral tablet -0.0 mg gildagia oral tablet mg-mcg gildess 1.5/0 (1) oral tablet mg-mcg gildess 1/0 (1) oral tablet 1-0 mg-mcg gildess 4 fe oral tablet 1 mg-0 mcg (4)/75 mg (4) gildess fe 1.5/0 (8) oral tablet 1.5 mg-0 mcg (1)/75 mg (7) gildess fe 1/0 (8) oral tablet 1 mg-0 mcg (1)/75 mg (7) heather oral tablet 0.5 mg 79 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

88 introvale oral tablets,dose pack, month QL (91 per 84 days) mg-mcg jencycla oral tablet 0.5 mg jolessa oral tablets,dose pack, month QL (91 per 84 days) mg-mcg jolivette oral tablet 0.5 mg juleber oral tablet mg junel 1.5/0 (1) oral tablet mg-mcg junel 1/0 (1) oral tablet 1-0 mg-mcg junel fe 1.5/0 (8) oral tablet 1.5 mg-0 mcg (1)/75 mg (7) junel fe 1/0 (8) oral tablet 1 mg-0 mcg (1)/75 mg (7) junel fe 4 oral tablet 1 mg-0 mcg (4)/75 mg (4) kariva (8) oral tablet mgx1 /0.01 mg x 5 kelnor 1/5 (8) oral tablet 1-5 mg-mcg kimidess (8) oral tablet mgx1 /0.01 mg x 5 kurvelo oral tablet mg l norgest/e.estradiol-e.estrad oral tablets,dose QL (91 per 84 days) pack, month 0.10 mg-0 mcg (84)/10 mcg (7), 0.15 mg-0 mcg (84)/10 mcg (7) larin 1.5/0 (1) oral tablet mg-mcg larin 1/0 (1) oral tablet 1-0 mg-mcg larin 4 fe oral tablet 1 mg-0 mcg (4)/75 mg (4) larin fe 1.5/0 (8) oral tablet 1.5 mg-0 mcg (1)/75 mg (7) larin fe 1/0 (8) oral tablet 1 mg-0 mcg (1)/75 mg (7) leena 8 oral tablet 0.5/1/0.5-5 mg-mcg lessina oral tablet mg-mcg levonest (8) oral tablet 50-0 (6)/75-40 (5)/15-0(10) 80 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

89 levonor-eth estrad outer mg QL (91 per 84 days) levonorgestrel oral tablet 0.75 mg QL (1 per 65 days) levonorgestrel oral tablet 1.5 mg QL (6 per 65 days) levonorgestrel-ethinyl estrad oral tablet mg-mcg levonorgestrel-ethinyl estrad oral tablets,dose QL (91 per 84 days) pack, month mg-mcg levonorg-eth estrad triphasic oral tablet 50-0 QL (91 per 84 days) (6)/75-40 (5)/15-0(10) levora-8 oral tablet mg lomedia 4 fe oral tablet 1 mg-0 mcg (4)/75 mg (4) loryna (8) oral tablet -0.0 mg low-ogestrel (8) oral tablet 0.-0 mg-mcg lutera (8) oral tablet mg-mcg lyza oral tablet 0.5 mg marlissa oral tablet mg microgestin 1.5/0 (1) oral tablet mg-mcg microgestin 1/0 (1) oral tablet 1-0 mg-mcg microgestin fe 1.5/0 (8) oral tablet 1.5 mg-0 mcg (1)/75 mg (7) microgestin fe 1/0 (8) oral tablet 1 mg-0 mcg (1)/75 mg (7) mono-linyah oral tablet mg-mcg mononessa (8) oral tablet mg-mcg myzilra oral tablet 50-0 (6)/75-40 (5)/15-0(10) necon 0.5/5 (8) oral tablet mg-mcg necon 1/5 (8) oral tablet 1-5 mg-mcg necon 1/50 (8) oral tablet 1-50 mg-mcg necon 10/11 (8) oral tablet 0.5-5/1-5 mg-mcg/mg-mcg necon 7/7/7 (8) oral tablet 0.5/0.75/1 mg- 5 mcg next choice one dose oral tablet 1.5 mg QL (6 per 65 days) 81 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

90 nikki (8) oral tablet -0.0 mg nora-be oral tablet 0.5 mg norethindrone (contraceptive) oral tablet 0.5 mg norethindrone ac-eth estradiol oral tablet 1-0 mg-mcg norethindrone-e.estradiol-iron oral tablet 1 mg-0 mcg (4)/75 mg (4) norg-ee / /0.15/0.5 mg-5 mcg (8) norgestimate-ethinyl estradiol oral tablet 0.18/0.15/0.5 mg-5 mcg, mg-mcg norlyroc oral tablet 0.5 mg nortrel 0.5/5 (8) oral tablet mg-mcg nortrel 1/5 (1) oral tablet 1-5 mg-mcg nortrel 1/5 (8) oral tablet 1-5 mg-mcg nortrel 7/7/7 (8) oral tablet 0.5/0.75/1 mg- 5 mcg NUVARING VAGINAL RING QL (1 per 8 days) MG/4 HR ocella oral tablet -0.0 mg ogestrel (8) oral tablet mg-mcg orsythia oral tablet mg-mcg philith oral tablet mg-mcg pimtrea (8) oral tablet mgx1 /0.01 mg x 5 pirmella oral tablet 0.5/0.75/1 mg- 5 mcg, 1-5 mg-mcg portia oral tablet mg previfem oral tablet mg-mcg quasense oral tablets,dose pack, month QL (91 per 84 days) mg-mcg reclipsen (8) oral tablet mg setlakin oral tablets,dose pack, month QL (91 per 84 days) mg-mcg sharobel oral tablet 0.5 mg 8 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

91 sprintec (8) oral tablet mg-mcg sronyx oral tablet mg-mcg syeda oral tablet -0.0 mg tarina fe 1/0 (8) oral tablet 1 mg-0 mcg (1)/75 mg (7) tilia fe oral tablet 1-0(5)/1-0(7) /1mg-5mcg (9) tri-estarylla oral tablet 0.18/0.15/0.5 mg-5 mcg (8) tri-legest fe oral tablet 1-0(5)/1-0(7) /1mg-5mcg (9) tri-linyah oral tablet 0.18/0.15/0.5 mg-5 mcg (8) tri-lo-estarylla oral tablet 0.18/0.15/0.5 mg-5 mcg tri-lo-marzia oral tablet 0.18/0.15/0.5 mg-5 mcg tri-lo-sprintec oral tablet 0.18/0.15/0.5 mg-5 mcg trinessa (8) oral tablet 0.18/0.15/0.5 mg-5 mcg (8) tri-previfem (8) oral tablet 0.18/0.15/0.5 mg-5 mcg (8) tri-sprintec (8) oral tablet 0.18/0.15/0.5 mg-5 mcg (8) trivora (8) oral tablet 50-0 (6)/75-40 (5)/15-0(10) velivet triphasic regimen (8) oral tablet 0.1/.15/.15-5 mg-mcg vestura (8) oral tablet -0.0 mg vienva oral tablet mg-mcg viorele (8) oral tablet mgx1 /0.01 mg x 5 vyfemla (8) oral tablet mg-mcg wera (8) oral tablet mg-mcg 8 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

92 wymzya fe oral tablet,chewable 0.4mg-5mcg(1) and 75 mg (7) xulane transdermal patch weekly mcg/4 QL ( per 8 days) hr zarah oral tablet -0.0 mg zenchent (8) oral tablet mg-mcg zenchent fe oral tablet,chewable 0.4mg-5mcg(1) and 75 mg (7) zeosa oral tablet,chewable 0.4mg-5mcg(1) and 75 mg (7) zovia 1/5e (8) oral tablet 1-5 mg-mcg zovia 1/50e (8) oral tablet 1-50 mg-mcg Dental And Oral Agents Dental And Oral Agents cevimeline oral capsule 0 mg chlorhexidine gluconate mucous membrane mouthwash 0.1 % oralone dental paste 0.1 % periogard mucous membrane mouthwash 0.1 % pilocarpine hcl oral tablet 5 mg, 7.5 mg sodium fluoride oral tablet,chewable 0.5 mg fluorid (0.55 mg) triamcinolone acetonide dental paste 0.1 % Dermatological Agents Dermatological Agents, Other 8-MOP ORAL CAPSULE 10 MG 4 acitretin oral capsule 10 mg, 17.5 mg, 5 mg 5 NM acyclovir topical ointment 5 % QL (0 per 0 days) ALCOHOL PADS TOPICAL PADS, 1 MEDICATED ALCOHOL PREP PADS 1 ammonium lactate topical cream 1 % ammonium lactate topical lotion 1 % ANACAINE TOPICAL OINTMENT 10 % 4 calcipotriene scalp solution % 84 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

93 calcipotriene topical cream % calcipotriene topical ointment % calcitrene topical ointment % calcitriol topical ointment mcg/gram CONDYLOX TOPICAL GEL 0.5 % 4 COSENTYX (150 MG/ML) 00 MG DOSE- 5 PA; NM PENS 150 MG/ML COSENTYX (150 MG/ML) 00 MG DOSE- 5 PA; NM SYRINGES 150 MG/ML COSENTYX PEN SUBCUTANEOUS PEN 5 PA; NM INJECTOR 150 MG/ML COSENTYX SUBCUTANEOUS SYRINGE 5 PA; NM 150 MG/ML DENAVIR TOPICAL CREAM 1 % 4 fluorouracil topical cream 0.5 %, 5 % fluorouracil topical solution %, 5 % imiquimod topical cream in packet 5 % PA NSO; QL (4 per 0 days) methoxsalen rapid oral capsule 10 mg 5 NM PANRETIN TOPICAL GEL 0.1 % 5 NM PICATO TOPICAL GEL % QL ( per 56 days) PICATO TOPICAL GEL 0.05 % QL ( per 56 days) podocon topical liquid 5 % podofilox topical solution 0.5 % potassium hydroxide topical solution 5 % REGRANEX TOPICAL GEL 0.01 % 4 PA; QL (0 per 0 days) SANTYL TOPICAL OINTMENT 50 4 UNIT/GRAM TALTZ AUTOINJECTOR 5 PA; NM SUBCUTANEOUS AUTO-INJECTOR 80 MG/ML TALTZ SYRINGE SUBCUTANEOUS 5 PA; NM SYRINGE 80 MG/ML TOLAK TOPICAL CREAM 4 % 4 VALCHLOR TOPICAL GEL % 5 NM VEREGEN TOPICAL OINTMENT 15 % 4 85 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

94 zenatane oral capsule 10 mg, 0 mg, 0 mg, 40 mg ZOVIRAX TOPICAL CREAM 5 % QL (15 per 0 days) Dermatological Antibacterials clindamycin phosphate topical foam 1 % clindamycin phosphate topical gel 1 % clindamycin phosphate topical lotion 1 % clindamycin phosphate topical solution 1 % clindamycin phosphate topical swab 1 % clindamycin-benzoyl peroxide topical gel 1-5 %, 1. %(1 % base) -5 % ery pads topical swab % erythromycin with ethanol topical gel % erythromycin with ethanol topical solution % erythromycin with ethanol topical swab % erythromycin-benzoyl peroxide topical gel -5 % gentamicin topical cream 0.1 % gentamicin topical ointment 0.1 % metronidazole topical cream 0.75 % metronidazole topical gel 0.75 %, 1 % metronidazole topical lotion 0.75 % mupirocin calcium topical cream % mupirocin topical ointment % neomycin-polymyxin b gu irrigation solution 40 mg-00,000 unit/ml neuac topical gel 1. %(1 % base) -5 % rosadan topical cream 0.75 % selenium sulfide topical lotion.5 % selenium sulfide topical shampoo.5 % silver nitrate topical ointment 10 % silver nitrate topical solution 0.5 %, 10 %, 5 %, 50 % silver sulfadiazine topical cream 1 % ssd topical cream 1 % 86 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

95 sulfacetamide sodium (acne) topical suspension 10 % Dermatological Anti-Inflammatory Agents ala-cort topical cream 1 % ala-scalp topical lotion % alclometasone topical cream 0.05 % alclometasone topical ointment 0.05 % betamethasone dipropionate topical cream 0.05 % betamethasone dipropionate topical lotion 0.05 % betamethasone dipropionate topical ointment 0.05 % betamethasone valerate topical cream 0.1 % betamethasone valerate topical foam 0.1 % betamethasone valerate topical lotion 0.1 % betamethasone valerate topical ointment 0.1 % betamethasone, augmented topical cream 0.05 % betamethasone, augmented topical gel 0.05 % betamethasone, augmented topical lotion 0.05 % betamethasone, augmented topical ointment 0.05 % clobetasol 0.05% cream 0.05 % clobetasol scalp solution 0.05 % clobetasol topical foam 0.05 % clobetasol topical gel 0.05 % clobetasol topical lotion 0.05 % clobetasol topical ointment 0.05 % clobetasol topical shampoo 0.05 % clobetasol-emollient topical cream 0.05 % clocortolone pivalate topical cream 0.1 % colocort rectal enema 100 mg/60 ml cormax scalp solution 0.05 % desonide topical cream 0.05 % 87 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

96 desonide topical lotion 0.05 % desonide topical ointment 0.05 % desoximetasone topical cream 0.05 %, 0.5 % desoximetasone topical gel 0.05 % desoximetasone topical ointment 0.05 %, 0.5 % diflorasone topical cream 0.05 % diflorasone topical ointment 0.05 % ELIDEL TOPICAL CREAM 1 % fluocinonide 0.05% cream 0.05 % fluocinonide topical gel 0.05 % fluocinonide topical ointment 0.05 % fluocinonide topical solution 0.05 % fluocinonide-e topical cream 0.05 % fluticasone topical cream 0.05 % fluticasone topical ointment % halobetasol propionate topical cream 0.05 % halobetasol propionate topical ointment 0.05 % hydrocortisone 1% ointment carton (otc) 1 % hydrocortisone acet-aloe vera topical gel % hydrocortisone buty 0.1% cream 0.1 % hydrocortisone butyrate topical ointment 0.1 % hydrocortisone butyrate topical solution 0.1 % hydrocortisone butyr-emollient topical cream 0.1 % hydrocortisone rectal enema 100 mg/60 ml hydrocortisone topical cream 1 %,.5 % hydrocortisone topical lotion.5 % hydrocortisone topical ointment 1 %,.5 % hydrocortisone valerate topical cream 0. % hydrocortisone valerate topical ointment 0. % mometasone topical cream 0.1 % mometasone topical ointment 0.1 % mometasone topical solution 0.1 % ONFI ORAL TABLET 10 MG, 0 MG 4 PA NSO; QL (60 per 0 days) prednicarbate topical cream 0.1 % 88 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

97 prednicarbate topical ointment 0.1 % procto-med hc rectal cream.5 % procto-pak rectal cream 1 % proctosol hc rectal cream.5 % proctozone-hc rectal cream.5 % tacrolimus topical ointment 0.0 %, 0.1 % triamcinolone acetonide topical cream 0.05 %, 0.1 %, 0.5 % triamcinolone acetonide topical lotion 0.05 %, 0.1 % triamcinolone acetonide topical ointment 0.05 %, 0.1 %, 0.5 % trianex topical ointment 0.05 % u-cort topical cream 1-10 % Dermatological Retinoids adapalene topical cream 0.1 % adapalene topical gel 0.1 % TAZORAC TOPICAL CREAM 0.05 %, % tretinoin gel micro 0.04% tube 0.04 % PA tretinoin gel micro 0.1% tube 0.1 % PA tretinoin microspheres topical gel with pump PA 0.04 %, 0.1 % tretinoin topical cream 0.05 %, 0.05 %, 0.1 % PA tretinoin topical gel 0.01 %, 0.05 %, 0.05 % PA Scabicides And Pediculicides EURAX TOPICAL CREAM 10 % EURAX TOPICAL LOTION 10 % malathion topical lotion 0.5 % permethrin topical cream 5 % spinosad topical suspension 0.9 % Devices Devices ASSURE ID INSULIN SAFETY SYRINGE 1 ML 9 GAUGE X 1/" 89 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

98 BD INSULIN SYR 0. ML 1GX5/16 0. ML 1 GAUGE X 5/16 BD INSULIN SYR 0.5 ML 1GX5/16" 0.5 ML 1 GAUGE X 5/16 BD INSULIN SYR 1 ML 1GX5/16" 1 ML 1 GAUGE X 5/16 BD ULTRA-FINE PEN NDL 8MMX1G SHORT 1 GAUGE X 5/16" INSULIN SYRINGE-NEEDLE U-100 SYRINGE 0. ML 9, 1 ML 9 GAUGE X 1/", 1/ ML 8 GAUGE PEN NEEDLE, DIABETIC NEEDLE 9 GAUGE X 1/ " VGO 40 DISPOSABLE DEVICE Enzyme Replacement/Modifiers Enzyme Replacement/Modifiers ADAGEN INTRAMUSCULAR 5 NM SOLUTION 50 UNIT/ML ALDURAZYME INTRAVENOUS 5 NM SOLUTION.9 MG/5 ML CEREZYME INTRAVENOUS RECON 5 NM SOLN 400 UNIT CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 1,000-8,000-60,000 UNIT, 4,000-76,000-10,000 UNIT,,000-9,500-15,000 UNIT, 6, , ,000 UNIT, 6,000-19,000-0,000 UNIT ELAPRASE INTRAVENOUS SOLUTION 6 5 NM MG/ ML ELITEK INTRAVENOUS RECON SOLN 5 NM 1.5 MG, 7.5 MG FABRAZYME INTRAVENOUS RECON 5 NM SOLN 5 MG KANUMA INTRAVENOUS SOLUTION 5 PA; NM MG/ML KRYSTEXXA INTRAVENOUS SOLUTION 8 MG/ML 5 NM 90 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

99 KUVAN ORAL TABLET,SOLUBLE NM MG MYOZYME INTRAVENOUS RECON 5 NM SOLN 50 MG NAGLAZYME INTRAVENOUS 5 NM SOLUTION 5 MG/5 ML ORFADIN ORAL CAPSULE 10 MG, MG, 5 NM 5 MG pancrelipase 5000 oral capsule,delayed release(dr/ec) 5,000-17,000-7,000 unit PERTZYE ORAL CAPSULE,DELAYED 4 RELEASE(DR/EC) 16,000-57,500-60,500 UNIT, 8,000-8,750-0,50 UNIT PULMOZYME INHALATION SOLUTION 5 PA BvD; NM 1 MG/ML STRENSIQ SUBCUTANEOUS SOLUTION 5 PA; NM; LA 100 MG/ML, 40 MG/ML VIMIZIM INTRAVENOUS SOLUTION 5 5 PA; NM MG/5 ML (1 MG/ML) VPRIV INTRAVENOUS RECON SOLN NM UNIT ZAVESCA ORAL CAPSULE 100 MG 5 NM; QL (90 per 0 days) ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,000-4,000-55,000 UNIT, 15,000-51,000-8,000 UNIT, 0,000-68, ,000 UNIT, 5,000-85,000-16,000 UNIT,,000-10,000-16,000 UNIT, 40,000-16,000-18,000 UNIT, 5,000-17,000-7,000 UNIT Eye, Ear, Nose, Throat Agents Eye, Ear, Nose, Throat Agents, Miscellaneous AKTEN (PF) OPHTHALMIC GEL.5 % 4 alcaine ophthalmic drops 0.5 % altacaine ophthalmic drops 0.5 % apraclonidine ophthalmic drops 0.5 % 91 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

100 atropine ophthalmic drops 1 % atropine ophthalmic ointment 1 % atropine-care ophthalmic drops 1 % azelastine nasal aerosol,spray 17 mcg (0.1 %) QL (0 per 5 days) azelastine nasal spray,non-aerosol 0.15 % QL (0 per 5 days) (05.5 mcg) azelastine ophthalmic drops 0.05 % BEPREVE OPHTHALMIC DROPS 1.5 % 4 ST carteolol ophthalmic drops 1 % cromolyn ophthalmic drops 4 % cyclopentolate ophthalmic drops 0.5 %, 1 %, % CYSTARAN OPHTHALMIC DROPS NM % epinastine ophthalmic drops 0.05 % flucaine ophthalmic drops % homatropaire ophthalmic drops 5 % homatropine hbr ophthalmic drops 5 % ipratropium bromide nasal spray,non-aerosol QL (0 per 8 days) 0.0 % ipratropium bromide nasal spray,non-aerosol QL (15 per 10 days) 0.06 % LACRISERT OPHTHALMIC INSERT 5 MG naphazoline ophthalmic drops 0.1 % 1 olopatadine nasal spray,non-aerosol 0.6 % QL (0.5 per 0 days) olopatadine ophthalmic drops 0.1 % PATADAY OPHTHALMIC DROPS 0. % 4 ST phenylephrine hcl ophthalmic drops 10 %,.5 % proparacaine ophthalmic drops 0.5 % tetracaine hcl (pf) ophthalmic drops 0.5 % TYZINE NASAL DROPS 0.1 % 4 TYZINE NASAL SPRAY,NON-AEROSOL 0.1 % 4 9 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

101 Eye, Ear, Nose, Throat Anti-Infectives Agents acetasol hc otic drops 1- % acetic acid otic solution % bacitracin ophthalmic ointment 500 unit/gram bacitracin-polymyxin b ophthalmic ointment ,000 unit/gram bleph-10 ophthalmic drops 10 % BLEPHAMIDE OPHTHALMIC DROPS,SUSPENSION % BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT % CILOXAN OPHTHALMIC OINTMENT 0. 4 % CIPRODEX OTIC DROPS,SUSPENSION % ciprofloxacin hcl ophthalmic drops 0. % ciprofloxacin hcl otic dropperette 0. % COLY-MYCIN S OTIC 4 DROPS,SUSPENSION MG/ML CORTISPORIN-TC OTIC DROPS,SUSPENSION MG/ML erythromycin ophthalmic ointment 5 mg/gram (0.5 %) gatifloxacin ophthalmic drops 0.5 % gentak ophthalmic ointment 0. % ( mg/gram) gentamicin ophthalmic drops 0. % gentamicin ophthalmic ointment 0. % ( mg/gram) hydrocortisone-acetic acid otic drops 1- % levofloxacin ophthalmic drops 0.5 % MOXEZA OPHTHALMIC DROPS, VISCOUS 0.5 % NATACYN OPHTHALMIC DROPS,SUSPENSION 5 % 9 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

102 neomycin-bacitracin-poly-hc ophthalmic ointment ,000 mg-unit/g-1% neomycin-bacitracin-polymyxin ophthalmic ointment ,000 mg-unit-unit/g neomycin-polymyxin b-dexameth ophthalmic drops,suspension.5mg/ml-10,000 unit/ml-0.1 % neomycin-polymyxin b-dexameth ophthalmic ointment.5 mg/g-10,000 unit/g-0.1 % neomycin-polymyxin-gramicidin ophthalmic drops 1.75 mg-10,000 unit-0.05mg/ml neomycin-polymyxin-hc ophthalmic drops,suspension.5-10, mg-unit-mg/ml neomycin-polymyxin-hc otic drops,suspension.5-10,000-1 mg/ml-unit/ml-% neomycin-polymyxin-hc otic solution.5-10,000-1 mg/ml-unit/ml-% neo-polycin hc ophthalmic ointment ,000 mg-unit/g-1% neo-polycin ophthalmic ointment ,000 mg-unit-unit/g ofloxacin ophthalmic drops 0. % ofloxacin otic drops 0. % polymyxin b sulf-trimethoprim ophthalmic drops 10,000 unit- 1 mg/ml sulfacetamide sodium ophthalmic drops 10 % sulfacetamide sodium ophthalmic ointment 10 % sulfacetamide-prednisolone ophthalmic drops 10 %-0. % (0.5 %) TOBRADEX OPHTHALMIC OINTMENT % TOBRADEX ST OPHTHALMIC DROPS,SUSPENSION % tobramycin ophthalmic drops 0. % tobramycin-dexamethasone ophthalmic drops,suspension % trifluridine ophthalmic drops 1 % 94 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

103 VIGAMOX OPHTHALMIC DROPS 0.5 % ZIRGAN OPHTHALMIC GEL 0.15 % 4 ZYLET OPHTHALMIC DROPS,SUSPENSION % Eye, Ear, Nose, Throat Anti-Inflammatory Agents ALREX OPHTHALMIC ST DROPS,SUSPENSION 0. % bromfenac ophthalmic drops 0.09 % dexamethasone sodium phosphate ophthalmic drops 0.1 % diclofenac sodium ophthalmic drops 0.1 % DUREZOL OPHTHALMIC DROPS 0.05 % flunisolide nasal spray,non-aerosol 5 mcg QL (50 per 5 days) (0.05 %) fluocinolone acetonide oil otic drops 0.01 % fluorometholone ophthalmic drops,suspension 0.1 % flurbiprofen sodium ophthalmic drops 0.0 % fluticasone nasal spray,suspension 50 1 mcg/actuation ILEVRO OPHTHALMIC DROPS,SUSPENSION 0. % ketorolac ophthalmic drops 0.4 %, 0.5 % LOTEMAX OPHTHALMIC DROPS,GEL 0.5 % LOTEMAX OPHTHALMIC DROPS,SUSPENSION 0.5 % LOTEMAX OPHTHALMIC OINTMENT 0.5 % NEVANAC OPHTHALMIC DROPS,SUSPENSION 0.1 % prednisolone acetate ophthalmic drops,suspension 1 % prednisolone sodium phosphate ophthalmic drops 1 % 95 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

104 PROLENSA OPHTHALMIC DROPS 0.07 % RESTASIS OPHTHALMIC QL (60 per 0 days) DROPPERETTE 0.05 % triamcinolone acetonide nasal aerosol,spray 55 QL (16.5 per 0 days) mcg Gastrointestinal Agents Antiulcer Agents And Acid Suppressants amoxicil-clarithromy-lansopraz oral combo pack mg CARAFATE ORAL SUSPENSION 100 MG/ML cimetidine hcl oral solution 00 mg/5 ml cimetidine oral tablet 00 mg, 00 mg, 400 mg, (Rx Product Only) 800 mg DEXILANT ORAL CAPSULE,BIPHASE ST DELAYED RELEAS 0 MG, 60 MG esomeprazole sodium intravenous recon soln 0 mg, 40 mg famotidine (pf) intravenous solution 0 mg/ ml famotidine (pf)-nacl (iso-os) intravenous piggyback 0 mg/50 ml famotidine 40 mg/4 ml vial 5's,outer 10 mg/ml famotidine oral suspension 40 mg/5 ml (8 (Rx Product Only) mg/ml) famotidine oral tablet 0 mg, 40 mg 1 (Rx Product Only) lansoprazole oral capsule,delayed release(dr/ec) (Rx Product Only) 15 mg, 0 mg misoprostol oral tablet 100 mcg, 00 mcg nizatidine oral capsule 150 mg, 00 mg nizatidine oral solution 150 mg/10 ml omeprazole oral capsule,delayed release(dr/ec) 10 mg, 0 mg, 40 mg pantoprazole oral tablet,delayed release (dr/ec) 0 mg, 40 mg ranitidine hcl 50 mg/ ml vial sdv 50 mg/ ml (5 mg/ml) (Rx Product Only) 96 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

105 ranitidine hcl injection solution 5 mg/ml (Rx Product Only) ranitidine hcl oral capsule 150 mg, 00 mg (Rx Product Only) ranitidine hcl oral syrup 15 mg/ml (Rx Product Only) ranitidine hcl oral tablet 150 mg, 00 mg 1 (Rx Product Only) sucralfate oral suspension 100 mg/ml sucralfate oral tablet 1 gram Gastrointestinal Agents, Other AMITIZA ORAL CAPSULE 4 MCG, 8 QL (60 per 0 days) MCG BUPHENYL ORAL TABLET 500 MG 5 NM CARBAGLU ORAL TABLET, 5 NM DISPERSIBLE 00 MG constulose oral solution 10 gram/15 ml cromolyn oral concentrate 100 mg/5 ml 5 NM dicyclomine oral capsule 10 mg dicyclomine oral solution 10 mg/5 ml dicyclomine oral tablet 0 mg diphenoxylate-atropine oral liquid mg/5 ml diphenoxylate-atropine oral tablet mg enulose oral solution 10 gram/15 ml GATTEX 5 MG 0-VIAL KIT 5 MG 5 PA; NM GATTEX ONE-VIAL SUBCUTANEOUS 5 PA; NM KIT 5 MG generlac oral solution 10 gram/15 ml glycopyrrolate injection solution 0. mg/ml glycopyrrolate oral tablet 1 mg, mg kionex 15 gm/60 ml suspension 15 gram/60 ml kionex oral powder lactulose oral solution 10 gram/15 ml LINZESS ORAL CAPSULE 145 MCG, 90 QL (0 per 0 days) MCG loperamide oral capsule mg LOTRONEX ORAL TABLET 0.5 MG, 1 MG 5 NM 97 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

106 methscopolamine oral tablet.5 mg, 5 mg metoclopramide hcl injection solution 5 mg/ml metoclopramide hcl oral solution 5 mg/5 ml metoclopramide hcl oral tablet 10 mg, 5 mg 1 MOVANTIK ORAL TABLET 1.5 MG, 5 MG NUTRESTORE ORAL POWDER IN 4 PACKET 5 GRAM OCALIVA ORAL TABLET 10 MG, 5 MG 5 PA; NM; QL (0 per 0 days) RAVICTI ORAL LIQUID 1.1 GRAM/ML 5 PA; NM RELISTOR SUBCUTANEOUS SOLUTION 4 PA; QL (8 per 8 days) 1 MG/0.6 ML RELISTOR SUBCUTANEOUS SYRINGE 4 PA; QL (8 per 8 days) 1 MG/0.6 ML, 8 MG/0.4 ML sodium polystyrene (sorb free) oral suspension 15 gram/60 ml sodium polystyrene sulfonate rectal enema 0 gram/10 ml sps 15 gm/60 ml suspension 15 gram/60 ml ursodiol oral capsule 00 mg ursodiol oral tablet 50 mg, 500 mg VELPHORO ORAL TABLET,CHEWABLE MG VIBERZI ORAL TABLET 100 MG, 75 MG 5 ST; NM; QL (60 per 0 days) Laxatives gavilyte-c oral recon soln gram gavilyte-g oral recon soln gram gavilyte-n oral recon soln 40 gram MOVIPREP ORAL POWDER IN PACKET GRAM peg 50-electrolytes oral recon soln gram, gram peg-electrolyte soln oral recon soln 40 gram 98 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

107 polyethylene glycol 50 oral powder 17 gram/dose polyethylene glycol 50 oral powder in packet 17 gram PREPOPIK ORAL POWDER IN PACKET 4 10 MG-.5 GRAM-1 GRAM trilyte with flavor packets oral recon soln 40 gram Phosphate Binders AURYXIA ORAL TABLET 10 MG IRON 4 calcium acetate oral capsule 667 mg calcium acetate oral tablet 667 mg eliphos oral tablet 667 mg FOSRENOL ORAL POWDER IN PACKET 4 1,000 MG, 750 MG FOSRENOL ORAL TABLET,CHEWABLE 4 1,000 MG, 500 MG, 750 MG magnebind 400 oral tablet mg PHOSLYRA ORAL SOLUTION 667 MG 4 (169 MG CALCIUM)/5 ML RENAGEL ORAL TABLET 400 MG, 800 MG RENVELA ORAL POWDER IN PACKET 0.8 GRAM,.4 GRAM RENVELA ORAL TABLET 800 MG Genitourinary Agents Antispasmodics, Urinary flavoxate oral tablet 100 mg MYRBETRIQ ORAL TABLET EXTENDED RELEASE 4 HR 5 MG, 50 MG oxybutynin chloride oral syrup 5 mg/5 ml oxybutynin chloride oral tablet 5 mg oxybutynin chloride oral tablet extended release 4hr 10 mg, 15 mg, 5 mg 99 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

108 tolterodine oral capsule,extended release 4hr mg, 4 mg tolterodine oral tablet 1 mg, mg TOVIAZ ORAL TABLET EXTENDED RELEASE 4 HR 4 MG, 8 MG trospium oral capsule,extended release 4hr 60 mg trospium oral tablet 0 mg VESICARE ORAL TABLET 10 MG, 5 MG Genitourinary Agents, Miscellaneous alfuzosin oral tablet extended release 4 hr 10 mg tamsulosin oral capsule,extended release 4hr 0.4 mg terazosin oral capsule 1 mg, 10 mg, mg, 5 mg 1 Heavy Metal Antagonists Heavy Metal Antagonists deferoxamine injection recon soln gram, 500 PA BvD mg DEPEN TITRATABS ORAL TABLET 50 5 NM MG EXJADE ORAL TABLET, DISPERSIBLE 4 15 MG EXJADE ORAL TABLET, DISPERSIBLE 5 NM 50 MG, 500 MG FERRIPROX ORAL SOLUTION NM MG/ML FERRIPROX ORAL TABLET 500 MG 5 NM sodium thiosulfate intravenous solution 1 gram/10 ml (100 mg/ml), 1.5 gram/50 ml (50 mg/ml) SYPRINE ORAL CAPSULE 50 MG 5 NM 100 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

109 Hormonal Agents, Stimulant/Replacement/Modifying Androgens ANDRODERM TRANSDERMAL PATCH PA; QL (0 per 0 days) 4 HOUR MG/4 HOUR, 4 MG/4 HR ANDROGEL TRANSDERMAL GEL IN PA; QL (150 per 0 days) METERED-DOSE PUMP 0.5 MG/1.5 GRAM (1.6 %) ANDROGEL TRANSDERMAL GEL IN PA; QL (150 per 0 days) PACKET 1.6 % (0.5 MG/1.5 GRAM), 1.6 % (40.5 MG/.5 GRAM) androxy oral tablet 10 mg AXIRON TRANSDERMAL SOLUTION IN PA; QL (180 per 8 days) METERED PUMP W/APP 0 MG/ACTUATION (1.5 ML) danazol oral capsule 100 mg, 00 mg, 50 mg oxandrolone oral tablet 10 mg,.5 mg testosterone cypionate intramuscular oil 100 PA mg/ml, 00 mg/ml testosterone enanthate intramuscular oil 00 PA; QL (5 per 8 days) mg/ml testosterone transdermal gel 50 mg/5 gram (1 PA; QL (00 per 0 days) %) testosterone transdermal gel in metered-dose PA; QL (00 per 0 days) pump 1.5 gram/ actuation (1 %) testosterone transdermal gel in packet 1 % (5 PA; QL (00 per 0 days) mg/.5gram), 1 % (50 mg/5 gram) Estrogens And Antiestrogens COMBIPATCH TRANSDERMAL PATCH PA-HRM; QL (8 per 8 days) SEMIWEEKLY MG/4 HR, MG/4 HR DUAVEE ORAL TABLET MG PA-HRM ESTRACE VAGINAL CREAM 0.01 % (0.1 MG/GRAM) estradiol oral tablet 0.5 mg, 1 mg, mg PA-HRM 101 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

110 estradiol transdermal patch semiweekly 0.05 PA-HRM; QL (8 per 8 days) mg/4 hr, mg/4 hr, 0.05 mg/4 hr, mg/4 hr, 0.1 mg/4 hr estradiol transdermal patch weekly 0.05 mg/4 PA-HRM; QL (4 per 8 days) hr, mg/4 hr, 0.05 mg/4 hr, 0.06 mg/4 hr, mg/4 hr, 0.1 mg/4 hr estradiol valerate intramuscular oil 10 mg/ml, 0 mg/ml, 40 mg/ml estradiol-norethindrone acet oral tablet PA-HRM mg, mg ESTRING VAGINAL RING MG 4 QL (1 per 84 days) estropipate oral tablet 0.75 mg, 1.5 mg, mg PA-HRM FEMRING VAGINAL RING 0.05 MG/4 4 QL (1 per 84 days) HR, 0.1 MG/4 HR fyavolv oral tablet 1-5 mg-mcg PA-HRM jinteli oral tablet 1-5 mg-mcg PA-HRM MENEST ORAL TABLET 0. MG, PA-HRM MG, 1.5 MG,.5 MG mimvey lo oral tablet mg PA-HRM mimvey oral tablet mg PA-HRM norethindrone ac-eth estradiol oral tablet 1-5 PA-HRM mg-mcg PREMARIN INJECTION RECON SOLN 5 MG PREMARIN ORAL TABLET 0. MG, 0.45 PA-HRM MG, 0.65 MG, 0.9 MG, 1.5 MG PREMARIN VAGINAL CREAM 0.65 MG/GRAM PREMPHASE ORAL TABLET 0.65 MG PA-HRM (14)/ 0.65MG-5MG(14) PREMPRO ORAL TABLET MG, PA-HRM MG, MG, MG raloxifene oral tablet 60 mg VAGIFEM VAGINAL TABLET 10 MCG QL (18 per 8 days) Glucocorticoids/Mineralocorticoids a-hydrocort injection recon soln 100 mg 10 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

111 betamethasone acet,sod phos injection suspension 6 mg/ml cortisone oral tablet 5 mg PA BvD dexamethasone oral elixir 0.5 mg/5 ml PA BvD dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 1 PA BvD mg, 1.5 mg, mg, 4 mg, 6 mg dexamethasone sodium phosphate injection solution 10 mg/ml, 4 mg/ml fludrocortisone oral tablet 0.1 mg hydrocortisone oral tablet 10 mg, 0 mg, 5 mg PA BvD methylprednisolone 15 mg vial ml sdv, 5's,l/f 15 mg methylprednisolone acetate injection suspension 40 mg/ml, 80 mg/ml methylprednisolone oral tablet 16 mg, mg, 4 PA BvD mg, 8 mg methylprednisolone oral tablets,dose pack 4 mg PA BvD methylprednisolone sodium succ injection recon soln 15 mg, 40 mg methylprednisolone ss 1 gm vl mdv,latex-free 1,000 mg prednisolone sodium phosphate oral solution 15 PA BvD mg/5 ml ( mg/ml), 5 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) PREDNISONE INTENSOL ORAL PA BvD CONCENTRATE 5 MG/ML prednisone oral solution 5 mg/5 ml PA BvD prednisone oral tablet 1 mg,.5 mg, 0 mg, 5 1 PA BvD mg, 50 mg prednisone oral tablet 10 mg 1 PA BvD prednisone oral tablets,dose pack 10 mg, 5 mg PA BvD SOLU-CORTEF (PF) INJECTION RECON 4 SOLN 100 MG/ ML, 50 MG/ ML triamcinolone acetonide injection suspension 10 mg/ml, 40 mg/ml 10 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

112 Pituitary desmopressin injection solution 4 mcg/ml desmopressin nasal solution 0.1 mg/ml QL (15 per 0 days) (refrigerate) desmopressin nasal spray,non-aerosol 10 QL (15 per 0 days) mcg/spray (0.1 ml) desmopressin oral tablet 0.1 mg, 0. mg GENOTROPIN MINIQUICK 4 PA SUBCUTANEOUS SYRINGE 0. MG/0.5 ML GENOTROPIN MINIQUICK 5 PA; NM SUBCUTANEOUS SYRINGE 0.4 MG/0.5 ML, 0.6 MG/0.5 ML, 0.8 MG/0.5 ML, 1 MG/0.5 ML, 1. MG/0.5 ML, 1.4 MG/0.5 ML, 1.6 MG/0.5 ML, 1.8 MG/0.5 ML, MG/0.5 ML GENOTROPIN SUBCUTANEOUS 5 PA; NM CARTRIDGE 1 MG/ML (6 UNIT/ML), 5 MG/ML (15 UNIT/ML) INCRELEX SUBCUTANEOUS 5 NM SOLUTION 10 MG/ML LUPRON DEPOT-PED ( MONTH) 5 NM; QL (1 per 84 days) INTRAMUSCULAR SYRINGE KIT 0 MG LUPRON DEPOT-PED 5 NM INTRAMUSCULAR KIT 11.5 MG, 15 MG, 7.5 MG (PED) NORDITROPIN FLEXPRO 5 PA; NM SUBCUTANEOUS PEN INJECTOR 10 MG/1.5 ML (6.7 MG/ML), 15 MG/1.5 ML (10 MG/ML), 0 MG/ ML (10 MG/ML), 5 MG/1.5 ML (. MG/ML) octreotide acet 50 mcg/ml syr outer,single-dose,10 50 mcg/ml (1 ml) octreotide acetate injection solution 1,000 5 NM mcg/ml octreotide acetate injection solution 100 mcg/ml, 00 mcg/ml, 50 mcg/ml, 500 mcg/ml 104 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

113 SAIZEN CLICK.EASY SUBCUTANEOUS 5 PA; NM CARTRIDGE 8.8 MG/1.5 ML (FNL) SAIZEN SUBCUTANEOUS RECON SOLN 5 PA; NM 5 MG, 8.8 MG SANDOSTATIN LAR 10 MG KIT 10 MG 5 NM SANDOSTATIN LAR 0 MG KIT 0 MG 5 NM SANDOSTATIN LAR 0 MG KIT 0 MG 5 NM SANDOSTATIN LAR DEPOT 5 NM INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 10 MG, 0 MG, 0 MG SEROSTIM SUBCUTANEOUS RECON 5 PA; NM SOLN 4 MG, 5 MG, 6 MG SOMATULINE DEPOT SUBCUTANEOUS 5 NM; QL (1 per 8 days) SYRINGE 10 MG/0.5 ML, 60 MG/0. ML, 90 MG/0. ML SOMAVERT SUBCUTANEOUS RECON 5 NM SOLN 10 MG, 15 MG, 0 MG, 5 MG, 0 MG STIMATE NASAL 4 SPRAY,NON-AEROSOL 150 MCG/SPRAY (0.1 ML) SUPPRELIN LA IMPLANT KIT 50 MG (65 5 NM; QL (1 per 60 days) MCG/DAY) Progestins DEPO-PROVERA INTRAMUSCULAR 4 QL (10 per 8 days) SOLUTION 400 MG/ML hydroxyprogesterone caproate intramuscular oil 5 PA NSO; NM 50 mg/ml medroxyprogesterone intramuscular suspension QL (1 per 84 days) 150 mg/ml medroxyprogesterone intramuscular syringe 150 QL (1 per 84 days) mg/ml medroxyprogesterone oral tablet 10 mg,.5 mg, 5 mg MEGACE ES ORAL SUSPENSION 65 MG/5 ML 5 NM 105 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

114 megestrol oral suspension 400 mg/10 ml (40 mg/ml), 65 mg/5 ml norethindrone acetate oral tablet 5 mg progesterone in oil intramuscular oil 50 mg/ml progesterone micronized oral capsule 100 mg, 00 mg Thyroid And Antithyroid Agents levothyroxine intravenous recon soln 100 mcg, 00 mcg, 500 mcg levothyroxine oral tablet 100 mcg, 11 mcg, 15 1 mcg, 17 mcg, 150 mcg, 175 mcg, 00 mcg, 5 mcg, 00 mcg, 50 mcg, 75 mcg, 88 mcg liothyronine intravenous solution 10 mcg/ml liothyronine oral tablet 5 mcg, 5 mcg, 50 mcg methimazole oral tablet 10 mg, 5 mg propylthiouracil oral tablet 50 mg Immunological Agents Immunological Agents ARCALYST SUBCUTANEOUS RECON 5 NM SOLN 0 MG ASTAGRAF XL ORAL 4 PA BvD CAPSULE,EXTENDED RELEASE 4HR 0.5 MG, 1 MG, 5 MG AUBAGIO ORAL TABLET 14 MG, 7 MG 5 PA; NM; QL (8 per 8 days) azathioprine oral tablet 50 mg PA BvD azathioprine sodium injection recon soln 100 mg PA BvD CARIMUNE NF NANOFILTERED 5 PA BvD; NM INTRAVENOUS RECON SOLN 6 GRAM CELLCEPT INTRAVENOUS 4 PA BvD INTRAVENOUS RECON SOLN 500 MG CIMZIA POWDER FOR RECONST 5 PA; NM SUBCUTANEOUS KIT 400 MG (00 MG X VIALS) CIMZIA SUBCUTANEOUS SYRINGE KIT 5 PA; NM 400 MG/ ML (00 MG/ML X ) cyclosporine intravenous solution 50 mg/5 ml PA BvD 106 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

115 cyclosporine modified oral capsule 100 mg, 5 PA BvD mg, 50 mg cyclosporine modified oral solution 100 mg/ml PA BvD cyclosporine oral capsule 100 mg, 5 mg PA BvD ENBREL SUBCUTANEOUS RECON 5 PA; NM SOLN 5 MG (1 ML) ENBREL SUBCUTANEOUS SYRINGE 5 5 PA; NM MG/0.5ML (0.51), 50 MG/ML (0.98 ML) ENBREL SURECLICK SUBCUTANEOUS 5 PA; NM PEN INJECTOR 50 MG/ML (0.98 ML) ENVARSUS XR ORAL TABLET 4 PA BvD EXTENDED RELEASE 4 HR 0.75 MG, 1 MG, 4 MG FLEBOGAMMA DIF INTRAVENOUS 5 PA BvD; NM SOLUTION 10 %, 5 % GAMASTAN S/D INTRAMUSCULAR PA BvD SOLUTION % RANGE GAMMAGARD LIQUID INJECTION 5 PA BvD; NM SOLUTION 10 % GAMMAPLEX INTRAVENOUS 5 PA BvD; NM SOLUTION 5 % GAMUNEX-C 0 GRAM/00 ML VIAL 5 PA BvD; NM P/F,LTX-FR,SUV,OUTER 0 GRAM/00 ML (10 %) GAMUNEX-C INJECTION SOLUTION 1 5 PA BvD; NM GRAM/10 ML (10 %) gengraf oral capsule 100 mg, 5 mg PA BvD gengraf oral solution 100 mg/ml PA BvD HUMIRA PEN CROHN'S-UC-HS START 5 PA; NM SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA PEN SUBCUTANEOUS PEN 5 PA; NM INJECTOR KIT 40 MG/0.8 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0. ML, 0 MG/0.4 ML, 40 MG/0.8 ML 5 PA; NM 107 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

116 HYPERRAB S/D (PF) INTRAMUSCULAR 4 SOLUTION 150 UNIT/ML, 150 UNIT/ML (10 ML) HYQVIA IG COMPONENT 5 PA BvD; NM SUBCUTANEOUS SOLUTION.5 GRAM/5 ML (10 %) HYQVIA SUBCUTANEOUS SOLUTION 5 PA BvD; NM 10 GRAM /100 ML (10 %),.5 GRAM /5 ML (10 %), 0 GRAM /00 ML (10 %), 0 GRAM /00 ML (10 %), 5 GRAM /50 ML (10 %) ILARIS (PF) SUBCUTANEOUS RECON 5 PA; NM SOLN 180 MG/1. ML (150 MG/ML) IMOGAM RABIES-HT (PF) 4 INTRAMUSCULAR SOLUTION 150 UNIT/ML KINERET SUBCUTANEOUS SYRINGE 5 PA; NM; QL (18.76 per 8 days) 100 MG/0.67 ML leflunomide oral tablet 10 mg, 0 mg mycophenolate mofetil oral capsule 50 mg PA BvD mycophenolate mofetil oral suspension for 5 PA BvD; NM reconstitution 00 mg/ml mycophenolate mofetil oral tablet 500 mg PA BvD mycophenolate sodium oral tablet,delayed PA BvD release (dr/ec) 180 mg, 60 mg NULOJIX INTRAVENOUS RECON SOLN 5 PA BvD; NM 50 MG OCTAGAM INTRAVENOUS SOLUTION 5 PA BvD; NM 10 %, 5 % ORENCIA (WITH MALTOSE) 5 PA; NM INTRAVENOUS RECON SOLN 50 MG ORENCIA SUBCUTANEOUS SYRINGE 5 PA; NM 15 MG/ML PRIVIGEN INTRAVENOUS SOLUTION 5 PA BvD; NM 10 % PROGRAF INTRAVENOUS SOLUTION 5 MG/ML 4 PA BvD 108 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

117 RAPAMUNE ORAL SOLUTION 1 MG/ML 5 PA BvD; NM RIDAURA ORAL CAPSULE MG 5 NM sirolimus oral tablet 0.5 mg, 1 mg PA BvD sirolimus oral tablet mg 5 PA BvD; NM tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg PA BvD TYSABRI INTRAVENOUS SOLUTION 00 5 PA; NM; LA; QL (15 per 8 days) MG/15 ML ZORTRESS ORAL TABLET 0.5 MG 4 PA BvD; QL (10 per 0 days) ZORTRESS ORAL TABLET 0.5 MG, PA BvD; NM; QL (10 per 0 days) MG Vaccines ACTHIB (PF) INTRAMUSCULAR RECON SOLN 10 MCG/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION LF-( MCG)-5LF/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE LF-( MCG)-5LF/0.5 ML BCG (TICE STRAIN) VIAL 50 MG PA BvD BCG VACCINE, LIVE (PF) PA BvD PERCUTANEOUS SUSPENSION FOR RECONSTITUTION 50 MG BEXSERO (PF) INTRAMUSCULAR SYRINGE MCG/0.5 ML BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION LF-MCG-LF/0.5ML BOOSTRIX TDAP INTRAMUSCULAR SYRINGE LF-MCG-LF/0.5ML CERVARIX VACCINE (PF) INTRAMUSCULAR SYRINGE 0-0 MCG/0.5 ML COMVAX (PF) INTRAMUSCULAR SUSPENSION MCG/0.5 ML DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION LF-MCG-LF/0.5ML 109 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

118 ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 0 MCG/ML ENGERIX-B 0 MCG/ML VIAL 10'S,ADULT,P/F,OUTER 0 MCG/ML ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SUSPENSION 10 MCG/0.5 ML ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE 10 MCG/0.5 ML GARDASIL (PF) INTRAMUSCULAR SUSPENSION MCG/0.5 ML GARDASIL (PF) INTRAMUSCULAR SYRINGE MCG/0.5 ML GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION 0.5 ML GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 0.5 ML HAVRIX (PF) INTRAMUSCULAR SUSPENSION 1,440 ELISA UNIT/ML HAVRIX (PF) INTRAMUSCULAR SYRINGE 1,440 ELISA UNIT/ML, 70 ELISA UNIT/0.5 ML IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN.5 UNIT INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION LF-MCG-LF/0.5ML IPOL INJECTION SUSPENSION UNIT/0.5 ML IPOL INJECTION SYRINGE UNIT/0.5 ML IXIARO (PF) INTRAMUSCULAR SYRINGE 6 MCG/0.5 ML KINRIX (PF) INTRAMUSCULAR SUSPENSION 5 LF-58 MCG-10 LF/0.5 ML PA BvD; QL ( per 65 days) PA BvD; QL ( per 65 days) PA BvD; QL ( per 65 days) PA BvD; QL ( per 65 days) QL (1.5 per 65 days) QL (1.5 per 65 days) QL (1.5 per 65 days) QL (1.5 per 65 days) PA BvD 110 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

119 KINRIX (PF) INTRAMUSCULAR SYRINGE 5 LF-58 MCG-10 LF/0.5 ML MENACTRA (PF) INTRAMUSCULAR SOLUTION 4 MCG/0.5 ML MENHIBRIX (PF) INTRAMUSCULAR RECON SOLN 5-.5 MCG/0.5 ML MENOMUNE - A/C/Y/W-15 (PF) SUBCUTANEOUS RECON SOLN 50 MCG MENVEO A-C-Y-W-15-DIP (PF) INTRAMUSCULAR KIT 10-5 MCG/0.5 ML MENVEO MENA COMPONENT (PF) INTRAMUSCULAR RECON SOLN 10 MCG /0.5 ML (FINAL) MENVEO MENCYW-15 COMPNT (PF) INTRAMUSCULAR RECON SOLN 5 MCG X / 0.5 ML (FINAL) M-M-R II (PF) SUBCUTANEOUS RECON SOLN 1,000-1,500 TCID50/0.5 ML PEDIARIX (PF) INTRAMUSCULAR SYRINGE 10 MCG-5LF-5 MCG-10LF/0.5 ML PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION 7.5 MCG/0.5 ML PENTACEL (PF) INTRAMUSCULAR KIT 15 LF UNIT-0 MCG-5 LF/0.5 ML PENTACEL ACTHIB COMPONENT (PF) INTRAMUSCULAR RECON SOLN 10 MCG/0.5 ML PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10EXP TCID50/0.5 QUADRACEL (PF) INTRAMUSCULAR SUSPENSION 15 LF-48 MCG- 5 LF UNIT/0.5ML RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION.5 UNIT QL ( per 65 days) QL ( per 65 days) PA BvD 111 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

120 RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCG/ML, 40 MCG/ML RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCG/ML, 5 MCG/0.5 ML ROTARIX ORAL SUSPENSION FOR RECONSTITUTION 10EXP6 CCID50/ML ROTATEQ VACCINE ORAL SUSPENSION ML TENIVAC (PF) INTRAMUSCULAR SYRINGE 5- LF UNIT/0.5 ML TETANUS TOXOID,ADSORBED (PF) INTRAMUSCULAR SUSPENSION 5 LF UNIT/0.5 ML TETANUS,DIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION 5-5 LF UNIT/0.5 ML tetanus-diphtheria toxoids-td intramuscular suspension - lf unit/0.5 ml TRUMENBA INTRAMUSCULAR SYRINGE 10 MCG/0.5 ML TWINRIX (PF) INTRAMUSCULAR SUSPENSION 70 ELISA UNIT -0 MCG/ML TWINRIX (PF) INTRAMUSCULAR SYRINGE 70 ELISA UNIT -0 MCG/ML TYPHIM VI INTRAMUSCULAR SOLUTION 5 MCG/0.5 ML TYPHIM VI INTRAMUSCULAR SYRINGE 5 MCG/0.5 ML VAQTA (PF) INTRAMUSCULAR SUSPENSION 50 UNIT/ML VAQTA (PF) INTRAMUSCULAR SYRINGE 5 UNIT/0.5 ML, 50 UNIT/ML VAQTA 5 UNITS/0.5 ML VIAL SDV, OUTER 5 UNIT/0.5 ML PA BvD; QL ( per 65 days) PA BvD; QL ( per 65 days) PA BvD 11 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

121 VARIVAX (PF) SUBCUTANEOUS QL ( per 65 days) SUSPENSION FOR RECONSTITUTION 1,50 UNIT/0.5 ML YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10 EXP4.74 UNIT/0.5 ML ZOSTAVAX (PF) SUBCUTANEOUS QL (1 per 65 days) SUSPENSION FOR RECONSTITUTION 19,400 UNIT/0.65 ML Inflammatory Bowel Disease Agents Inflammatory Bowel Disease Agents alosetron oral tablet 0.5 mg, 1 mg 5 NM APRISO ORAL CAPSULE,EXTENDED RELEASE 4HR 0.75 GRAM ASACOL HD ORAL TABLET,DELAYED RELEASE (DR/EC) 800 MG balsalazide oral capsule 750 mg budesonide oral capsule,delayed,extend.release 5 NM mg DELZICOL ORAL CAPSULE,DELAYED RELEASE(DR/EC) 400 MG DIPENTUM ORAL CAPSULE 50 MG 4 ST Irrigating Solutions Irrigating Solutions acetic acid irrigation solution 0.5 % LACTATED RINGERS IRRIGATION SOLUTION ringers irrigation solution sodium chloride irrigation solution 0.9 % sorbitol irrigation solution %,. % sorbitol-mannitol urethral solution g/100 ml water for irrigation, sterile irrigation solution Metabolic Bone Disease Agents Metabolic Bone Disease Agents alendronate oral solution 70 mg/75 ml QL (00 per 8 days) 11 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

122 alendronate oral tablet 10 mg, 40 mg, 5 mg 1 alendronate oral tablet 5 mg, 70 mg 1 QL (4 per 8 days) calcitonin (salmon) nasal spray,non-aerosol 00 QL (.7 per 8 days) unit/actuation calcitriol intravenous solution 1 mcg/ml calcitriol oral capsule 0.5 mcg, 0.5 mcg calcitriol oral solution 1 mcg/ml doxercalciferol intravenous solution 4 mcg/ ml doxercalciferol oral capsule 0.5 mcg, 1 mcg,.5 mcg etidronate disodium oral tablet 00 mg, 400 mg FORTEO SUBCUTANEOUS PEN 4 QL (.4 per 8 days) INJECTOR 0 MCG/DOSE MCG/.4 ML FORTICAL NASAL 4 QL (.7 per 8 days) SPRAY,NON-AEROSOL 00 UNIT/ACTUATION ibandronate intravenous solution mg/ ml QL ( per 84 days) ibandronate intravenous syringe mg/ ml QL ( per 84 days) ibandronate oral tablet 150 mg QL (1 per 8 days) MIACALCIN INJECTION SOLUTION 00 UNIT/ML NATPARA SUBCUTANEOUS 5 PA; NM; QL ( per 8 days) CARTRIDGE 100 MCG/DOSE, 5 MCG/DOSE, 50 MCG/DOSE, 75 MCG/DOSE pamidronate intravenous solution 0 mg/10 ml ( mg/ml), 60 mg/10 ml (6 mg/ml), 90 mg/10 ml (9 mg/ml) paricalcitol oral capsule 1 mcg, mcg, 4 mcg PROLIA SUBCUTANEOUS SYRINGE 60 QL (1 per 180 days) MG/ML risedronate oral tablet 150 mg QL (1 per 8 days) risedronate oral tablet 0 mg, 5 mg QL (0 per 8 days) risedronate oral tablet 5 mg (1 pack), 5 mg (4 pack) QL (4 per 8 days) 114 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

123 risedronate sodium 5 mg tab f/c, once-a-week QL (4 per 8 days) 5 mg XGEVA SUBCUTANEOUS SOLUTION 5 PA; NM 10 MG/1.7 ML (70 MG/ML) ZEMPLAR INTRAVENOUS SOLUTION MCG/ML, 5 MCG/ML zoledronic acid intravenous solution 4 mg/5 ml zoledronic acid-mannitol-water intravenous piggyback 4 mg/100 ml zoledronic acid-mannitol-water intravenous QL (100 per 00 days) solution 5 mg/100 ml ZOMETA INTRAVENOUS SOLUTION 4 5 NM MG/100 ML Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents ACTEMRA INTRAVENOUS SOLUTION 5 PA; NM 00 MG/10 ML (0 MG/ML), 400 MG/0 ML (0 MG/ML), 80 MG/4 ML (0 MG/ML) ACTEMRA SUBCUTANEOUS SYRINGE 5 PA; NM 16 MG/0.9 ML ACTIMMUNE SUBCUTANEOUS 5 NM SOLUTION 100 MCG/0.5 ML allopurinol oral tablet 100 mg, 00 mg allopurinol sodium intravenous recon soln 500 mg amifostine crystalline intravenous recon soln 500 mg ammonium chloride intravenous solution 5 meq/ml anticoag citrate phos dextrose solution.6- gram-mg/100ml AVONEX (WITH ALBUMIN) 5 ST; NM INTRAMUSCULAR KIT 0 MCG AVONEX INTRAMUSCULAR PEN INJECTOR KIT 0 MCG/0.5 ML 5 ST; NM 115 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

124 AVONEX INTRAMUSCULAR SYRINGE 5 ST; NM KIT 0 MCG/0.5 ML BENLYSTA INTRAVENOUS RECON 5 PA; NM SOLN 10 MG, 400 MG BETASERON SUBCUTANEOUS KIT 0. 5 ST; NM MG bethanechol chloride oral tablet 10 mg, 5 mg, 5 mg, 50 mg BOTOX INJECTION RECON SOLN 100 PA; QL (4 per 90 days) UNIT BOTOX INJECTION RECON SOLN 00 PA; QL (1 per 90 days) UNIT buspirone oral tablet 10 mg, 15 mg, 0 mg, 5 mg, 7.5 mg CERDELGA ORAL CAPSULE 84 MG 5 PA; NM colchicine oral tablet 0.6 mg colchicine-probenecid oral tablet mg COPAXONE SUBCUTANEOUS SYRINGE 5 NM 0 MG/ML, 40 MG/ML CYSTADANE ORAL POWDER 1 5 NM GRAM/1.7 ML dexrazoxane hcl intravenous recon soln 50 mg droperidol injection solution.5 mg/ml dutasteride oral capsule 0.5 mg dutasteride-tamsulosin oral capsule, er QL (0 per 0 days) multiphase 4 hr mg ELMIRON ORAL CAPSULE 100 MG 4 ergoloid oral tablet 1 mg EXTAVIA SUBCUTANEOUS KIT 0. MG 5 ST; NM finasteride oral tablet 5 mg fomepizole intravenous solution 1 gram/ml 5 NM FUSILEV INTRAVENOUS RECON SOLN 5 NM 50 MG GAUZE PAD TOPICAL BANDAGE X " 1 GILENYA ORAL CAPSULE 0.5 MG 5 NM; QL (8 per 8 days) glatopa subcutaneous syringe 0 mg/ml 5 NM 116 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

125 GLUCAGEN HYPOKIT INJECTION RECON SOLN 1 MG GLUCAGON EMERGENCY KIT 4 (HUMAN) INJECTION KIT 1 MG guanidine oral tablet 15 mg hydroxyzine hcl intramuscular solution 5 PA-HRM mg/ml, 50 mg/ml hydroxyzine hcl oral solution 10 mg/5 ml PA-HRM hydroxyzine hcl oral tablet 10 mg, 5 mg, 50 mg PA-HRM hydroxyzine pamoate oral capsule 100 mg, 5 PA-HRM mg, 50 mg KEVEYIS ORAL TABLET 50 MG 5 PA NSO; NM; QL (10 per 0 days) LEMTRADA INTRAVENOUS SOLUTION 5 PA; NM 1 MG/1. ML leucovorin calcium 00 mg vial sdv, p/f, latex-free 00 mg leucovorin calcium injection recon soln 100 mg, 50 mg leucovorin calcium oral tablet 10 mg, 15 mg, 5 mg, 5 mg levocarnitine (with sugar) oral solution 100 mg/ml levocarnitine intravenous solution 00 mg/ml levocarnitine oral tablet 0 mg mesna intravenous solution 100 mg/ml MESNEX ORAL TABLET 400 MG 5 NM MESTINON ORAL SYRUP 60 MG/5 ML 4 MESTINON TIMESPAN ORAL TABLET 4 EXTENDED RELEASE 180 MG methylergonovine injection solution 0. mg/ml (1 ml) methylergonovine oral tablet 0. mg morrhuate sodium intravenous solution 5 % MYOBLOC INTRAMUSCULAR SOLUTION 10,000 UNIT/ ML,,500 UNIT/0.5 ML, 5,000 UNIT/ML 4 QL (1 per 90 days) 117 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

126 NPLATE SUBCUTANEOUS RECON 5 PA; NM; QL (8 per 8 days) SOLN 50 MCG, 500 MCG ORENCIA CLICKJECT SUBCUTANEOUS 5 PA; NM AUTO-INJECTOR 15 MG/ML ORFADIN ORAL SUSPENSION 4 MG/ML 5 NM OTEZLA ORAL TABLET 0 MG 5 PA; NM; QL (60 per 0 days) OTEZLA STARTER ORAL 5 PA; NM; QL (60 per 0 days) TABLETS,DOSE PACK 10 MG (4)-0 MG (4)-0 MG (47), 10 MG (4)-0 MG (4)-0 MG(19) OTREXUP (PF) SUBCUTANEOUS AUTO-INJECTOR 10 MG/0.4 ML, 15 MG/0.4 ML, 17.5 MG/0.4 ML, 0 MG/0.4 ML,.5 MG/0.4 ML, 5 MG/0.4 ML, 7.5 MG/0.4 ML PLEGRIDY SUBCUTANEOUS PEN 5 ST; NM INJECTOR 15 MCG/0.5 ML, 6 MCG/0.5 ML- 94 MCG/0.5 ML PLEGRIDY SUBCUTANEOUS SYRINGE 5 ST; NM 15 MCG/0.5 ML, 6 MCG/0.5 ML- 94 MCG/0.5 ML probenecid oral tablet 500 mg PROCYSBI ORAL CAPSULE, DELAYED 5 NM REL SPRINKLE 5 MG, 75 MG pyridostigmine bromide oral tablet 60 mg pyridostigmine bromide oral tablet extended release 180 mg RASUVO (PF) SUBCUTANEOUS AUTO-INJECTOR 10 MG/0. ML, 1.5 MG/0.5 ML, 15 MG/0. ML, 17.5 MG/0.5 ML, 0 MG/0.4 ML,.5 MG/0.45 ML, 5 MG/0.5 ML, 7.5 MG/0.55 ML, 0 MG/0.6 ML, 7.5 MG/0.15 ML REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE MCG/0.5 ML, 44 MCG/0.5 ML 5 NM 118 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

127 REBIF REBIDOSE SUBCUTANEOUS PEN 5 NM INJECTOR MCG/0.5 ML, 44 MCG/0.5 ML, 8.8MCG/0.ML- MCG/0.5ML (6) REBIF TITRATION PACK 5 NM SUBCUTANEOUS SYRINGE 8.8MCG/0.ML- MCG/0.5ML (6) REMICADE INTRAVENOUS RECON 5 PA; NM SOLN 100 MG SENSIPAR ORAL TABLET 0 MG SENSIPAR ORAL TABLET 60 MG, 90 MG 5 NM SIGNIFOR SUBCUTANEOUS SOLUTION 5 NM; QL (60 per 0 days) 0. MG/ML (1 ML), 0.6 MG/ML (1 ML), 0.9 MG/ML (1 ML) SIMPONI ARIA INTRAVENOUS 5 PA; NM SOLUTION 1.5 MG/ML SIMPONI SUBCUTANEOUS PEN 5 PA; NM INJECTOR 100 MG/ML, 50 MG/0.5 ML SIMPONI SUBCUTANEOUS SYRINGE 5 PA; NM 100 MG/ML, 50 MG/0.5 ML STELARA SUBCUTANEOUS SYRINGE 45 5 PA; NM MG/0.5 ML, 90 MG/ML STERILE PADS " X " X " 1 SYNAREL NASAL 5 NM SPRAY,NON-AEROSOL MG/ML TECFIDERA ORAL CAPSULE,DELAYED 5 NM; QL (14 per 0 days) RELEASE(DR/EC) 10 MG TECFIDERA ORAL CAPSULE,DELAYED 5 NM; QL (60 per 0 days) RELEASE(DR/EC) 10 MG (14)- 40 MG (46), 40 MG THALOMID ORAL CAPSULE 100 MG, PA NSO; NM; QL (60 per 0 days) MG, 00 MG, 50 MG TYBOST ORAL TABLET 150 MG 4 QL (0 per 0 days) ULORIC ORAL TABLET 40 MG, 80 MG QL (0 per 0 days) XELJANZ ORAL TABLET 5 MG 5 PA; NM; QL (60 per 0 days) XELJANZ XR ORAL TABLET EXTENDED RELEASE 4 HR 11 MG 5 PA; NM; QL (0 per 0 days) 119 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

128 Ophthalmic Agents Antiglaucoma Agents acetazolamide oral capsule, extended release 500 mg acetazolamide oral tablet 15 mg, 50 mg acetazolamide sodium injection recon soln 500 mg ALPHAGAN P OPHTHALMIC DROPS 0.1 % AZOPT OPHTHALMIC DROPS,SUSPENSION 1 % betaxolol ophthalmic drops 0.5 % BETOPTIC S OPHTHALMIC 4 DROPS,SUSPENSION 0.5 % bimatoprost ophthalmic drops 0.0 % brimonidine ophthalmic drops 0.15 %, 0. % (drops: 0.15%, 0.0%) COMBIGAN OPHTHALMIC DROPS % dorzolamide ophthalmic drops % dorzolamide-timolol ophthalmic drops.-6.8 mg/ml latanoprost ophthalmic drops % levobunolol ophthalmic drops 0.5 %, 0.5 % LUMIGAN OPHTHALMIC DROPS 0.01 % QL (.5 per 5 days) methazolamide oral tablet 5 mg, 50 mg metipranolol ophthalmic drops 0. % PHOSPHOLINE IODIDE OPHTHALMIC DROPS 0.15 % pilocarpine hcl ophthalmic drops 1 %, %, 4 % SIMBRINZA OPHTHALMIC DROPS,SUSPENSION 1-0. % timolol maleate ophthalmic drops 0.5 %, 0.5 % timolol maleate ophthalmic gel forming solution 0.5 %, 0.5 % TRAVATAN Z OPHTHALMIC DROPS % QL (.5 per 5 days) 10 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

129 travoprost (benzalkonium) ophthalmic drops QL (.5 per 5 days) % ZIOPTAN (PF) OPHTHALMIC 4 QL (0 per 0 days) DROPPERETTE % Replacement Preparations Replacement Preparations calcium chloride intravenous solution 100 mg/ml (10 %) calcium chloride intravenous syringe 100 mg/ml (10 %) calcium gluconate intravenous solution 100 mg/ml (10%) d10 %-0.45 % sodium chloride intravenous parenteral solution d.5 %-0.45 % sodium chloride intravenous parenteral solution d5 % and 0.9 % sodium chloride intravenous parenteral solution d5 %-0.45 % sodium chloride intravenous parenteral solution dextrose 10 % and 0. % nacl intravenous parenteral solution dextrose 5 %-lactated ringers intravenous parenteral solution dextrose 5%-0. % sod chloride intravenous parenteral solution dextrose 5%-0. % sod.chloride intravenous parenteral solution dextrose with sodium chloride intravenous parenteral solution 5-0. % dextrose-kcl-nacl intravenous solution % effer-k oral tablet, effervescent 5 meq electrolyte-48 in d5w intravenous parenteral solution 11 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

130 HYPERLYTE CR INTRAVENOUS 4 SOLUTION MEQ/0 ML IONOSOL-B IN D5W INTRAVENOUS 4 PARENTERAL SOLUTION 5 % IONOSOL-MB IN D5W INTRAVENOUS 4 PARENTERAL SOLUTION 5 % ISOLYTE M IN 5 % DEXTROSE 4 INTRAVENOUS PARENTERAL SOLUTION ISOLYTE-H IN 5 % DEXTROSE 4 INTRAVENOUS PARENTERAL SOLUTION 5 % ISOLYTE-P IN 5 % DEXTROSE 4 INTRAVENOUS PARENTERAL SOLUTION 5 % ISOLYTE-S INTRAVENOUS 4 PARENTERAL SOLUTION k-effervescent oral tablet, effervescent 5 meq klor-con 10 oral tablet extended release 10 meq klor-con m10 tablet 10 meq klor-con m15 oral tablet,er particles/crystals 15 meq klor-con m0 oral tablet,er particles/crystals 0 meq klor-con sprinkle oral capsule, extended release 10 meq, 8 meq magnesium chloride injection solution 00 mg/ml (0 %) magnesium sulf in 0.45% nacl intravenous solution 0 gram/500 ml (40 mg/ml) magnesium sulfate in d5w intravenous piggyback 1 gram/100 ml, 4 gram/100 ml magnesium sulfate in water intravenous parenteral solution 0 gram/500 ml (4 %), 40 gram/1,000 ml (4 %) 1 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

131 magnesium sulfate in water intravenous piggyback gram/50 ml (4 %), 4 gram/100 ml (4 %), 4 gram/50 ml (8 %) magnesium sulfate injection solution 4 meq/ml (50 %) magnesium sulfate injection syringe 4 meq/ml NORMOSOL-M IN 5 % DEXTROSE 4 INTRAVENOUS PARENTERAL SOLUTION NORMOSOL-R PH 7.4 INTRAVENOUS 4 PARENTERAL SOLUTION NUTRILYTE II INTRAVENOUS 4 SOLUTION MEQ/0 ML NUTRILYTE INTRAVENOUS SOLUTION MEQ/0 ML phospha 50 neutral oral tablet 50 mg PLASMA-LYTE 148 INTRAVENOUS 4 PARENTERAL SOLUTION PLASMA-LYTE A INTRAVENOUS 4 PARENTERAL SOLUTION PLASMA-LYTE-56 IN 5 % DEXTROSE 4 INTRAVENOUS PARENTERAL SOLUTION 5 % potassium acetate intravenous solution meq/ml, 4 meq/ml potassium bicarb and chloride oral tablet, effervescent 5 meq potassium bicarb-citric acid oral tablet, effervescent 5 meq potassium chlorid-d5-0.45%nacl intravenous parenteral solution 10 meq/l, 0 meq/l, 0 meq/l, 40 meq/l potassium chloride in 0.9%nacl intravenous parenteral solution 0 meq/l, 40 meq/l potassium chloride in 5 % dex intravenous parenteral solution 0 meq/l, 0 meq/l, 40 meq/l 1 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

132 potassium chloride in lr-d5 intravenous parenteral solution 0 meq/l potassium chloride intravenous piggyback 10 meq/100 ml, 0 meq/100 ml, 0 meq/100 ml, 40 meq/100 ml potassium chloride intravenous solution meq/ml potassium chloride oral capsule, extended release 10 meq, 8 meq potassium chloride oral liquid 0 meq/15 ml, 40 meq/15 ml potassium chloride oral packet 0 meq potassium chloride oral tablet extended release 8 meq potassium chloride oral tablet,er particles/crystals 10 meq, 0 meq potassium chloride-0.45 % nacl intravenous parenteral solution 0 meq/l potassium chloride-d5-0.%nacl intravenous parenteral solution 10 meq/l, 0 meq/l, 0 meq/l, 40 meq/l potassium chloride-d5-0.%nacl intravenous parenteral solution 0 meq/l potassium chloride-d5-0.9%nacl intravenous parenteral solution 0 meq/l, 40 meq/l potassium citrate oral tablet extended release 10 meq (1,080 mg), 15 meq, 5 meq (540 mg) potassium citrate-citric acid oral packet,00-1,00 mg potassium cl 10 meq/50 ml sol 10 meq/50 ml potassium cl 0 meq/50 ml sol 0 meq/50 ml potassium cl er 10 meq tablet f/c 10 meq potassium phosphate m-/d-basic intravenous solution mmol/ml ringers intravenous parenteral solution 14 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

133 sodium acetate intravenous solution meq/ml, 4 meq/ml sodium bicarbonate intravenous solution 1 meq/ml (8.4 %) sodium bicarbonate intravenous syringe 10 meq/10 ml (8.4 %), 4. % (0.5 meq/ml), 7.5 % (0.9 meq/ml), 8.4 % (1 meq/ml) sodium chloride 0.45 % intravenous parenteral solution 0.45 % sodium chloride 0.9 % intravenous parenteral solution 0.9 % sodium chloride % intravenous parenteral solution % sodium chloride 5 % intravenous parenteral solution 5 % sodium chloride intravenous parenteral solution.5 meq/ml, 4 meq/ml sodium lactate intravenous parenteral solution 167 meq/l sodium lactate intravenous solution 5 meq/ml sodium phosphate intravenous solution mmol/ml TPN ELECTROLYTES II IV SOLN 4 5'S,0ML/50ML FTV MEQ/0 ML TPN ELECTROLYTES INTRAVENOUS 4 SOLUTION MEQ/0 ML virt-phos 50 neutral oral tablet 50 mg Respiratory Tract Agents Anti-Inflammatories, Inhaled Corticosteroids ADVAIR DISKUS INHALATION BLISTER WITH DEVICE MCG/DOSE, MCG/DOSE, MCG/DOSE QL (60 per 0 days) 15 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

134 ADVAIR HFA INHALATION HFA QL (1 per 8 days) AEROSOL INHALER MCG/ACTUATION, 0-1 MCG/ACTUATION, 45-1 MCG/ACTUATION BREO ELLIPTA INHALATION BLISTER QL (60 per 0 days) WITH DEVICE MCG/DOSE, 00-5 MCG/DOSE DULERA INHALATION HFA AEROSOL QL (1 per 8 days) INHALER MCG/ACTUATION, 00-5 MCG/ACTUATION FLOVENT DISKUS INHALATION QL (60 per 0 days) BLISTER WITH DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION FLOVENT DISKUS INHALATION QL (10 per 0 days) BLISTER WITH DEVICE 50 MCG/ACTUATION FLOVENT HFA INHALATION HFA QL (1 per 8 days) AEROSOL INHALER 110 MCG/ACTUATION FLOVENT HFA INHALATION HFA QL (4 per 8 days) AEROSOL INHALER 0 MCG/ACTUATION FLOVENT HFA INHALATION HFA QL (1. per 8 days) AEROSOL INHALER 44 MCG/ACTUATION QVAR INHALATION AEROSOL 40 QL (17.4 per 5 days) MCG/ACTUATION, 80 MCG/ACTUATION Antileukotrienes montelukast oral granules in packet 4 mg montelukast oral tablet 10 mg montelukast oral tablet,chewable 4 mg, 5 mg zafirlukast oral tablet 10 mg, 0 mg 16 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

135 Bronchodilators albuterol sulfate inhalation solution for PA BvD nebulization 0.6 mg/ ml, 1.5 mg/ ml,.5 mg / ml (0.08 %), 5 mg/ml albuterol sulfate oral syrup mg/5 ml albuterol sulfate oral tablet mg, 4 mg albuterol sulfate oral tablet extended release 1 hr 4 mg, 8 mg ATROVENT HFA INHALATION HFA QL (5.8 per 8 days) AEROSOL INHALER 17 MCG/ACTUATION COMBIVENT RESPIMAT INHALATION QL (8 per 0 days) MIST MCG/ACTUATION elixophyllin oral elixir 80 mg/15 ml FORADIL AEROLIZER INHALATION CAPSULE, W/INHALATION DEVICE 1 MCG ipratropium bromide inhalation solution 0.0 % PA BvD ipratropium-albuterol inhalation solution for PA BvD nebulization 0.5 mg- mg(.5 mg base)/ ml metaproterenol oral syrup 10 mg/5 ml metaproterenol oral tablet 10 mg, 0 mg PROAIR HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED 90 MCG/ACTUATION SEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCG/DOSE SPIRIVA RESPIMAT INHALATION MIST 1.5 MCG/ACTUATION,.5 MCG/ACTUATION SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE 18 MCG 17 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

136 STRIVERDI RESPIMAT INHALATION MIST.5 MCG/ACTUATION terbutaline oral tablet.5 mg, 5 mg terbutaline subcutaneous solution 1 mg/ml theochron oral tablet extended release 1 hr 100 mg, 00 mg, 00 mg theophylline in dextrose 5 % intravenous parenteral solution 00 mg/100 ml, 00 mg/50 ml, 400 mg/50 ml, 400 mg/500 ml, 800 mg/50 ml theophylline oral solution 80 mg/15 ml theophylline oral tablet extended release 1 hr 100 mg, 00 mg, 00 mg, 450 mg theophylline oral tablet extended release 400 mg, 600 mg TUDORZA PRESSAIR INHALATION QL ( per 8 days) AEROSOL POWDR BREATH ACTIVATED 400 MCG/ACTUATION, 400 MCG/ACTUATION (0 ACTUAT) VENTOLIN HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION Respiratory Tract Agents, Other acetylcysteine intravenous solution 00 mg/ml PA BvD (0 %) acetylcysteine solution 100 mg/ml (10 %), 00 PA BvD mg/ml (0 %) CINQAIR INTRAVENOUS SOLUTION 10 5 PA; NM MG/ML cromolyn inhalation solution for nebulization 0 PA BvD mg/ ml DALIRESP ORAL TABLET 500 MCG QL (0 per 0 days) ESBRIET ORAL CAPSULE 67 MG 5 PA; NM; QL (70 per 0 days) KALYDECO ORAL GRANULES IN 5 PA; NM; QL (60 per 0 days) PACKET 50 MG, 75 MG KALYDECO ORAL TABLET 150 MG 5 PA; NM; QL (60 per 0 days) 18 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

137 NUCALA SUBCUTANEOUS RECON 5 PA; NM; LA; QL (1 per 8 days) SOLN 100 MG OFEV ORAL CAPSULE 100 MG, 150 MG 5 PA; NM ORKAMBI ORAL TABLET MG 5 PA; NM; QL (10 per 0 days) PROLASTIN-C INTRAVENOUS RECON 5 NM SOLN 1,000 MG XOLAIR SUBCUTANEOUS RECON 5 PA; NM SOLN 150 MG Skeletal Muscle Relaxants Skeletal Muscle Relaxants baclofen oral tablet 10 mg, 0 mg carisoprodol oral tablet 50 mg, 50 mg PA-HRM; QL (10 per 0 days) chlorzoxazone oral tablet 500 mg PA-HRM cyclobenzaprine oral tablet 10 mg, 5 mg, 7.5 mg PA-HRM dantrolene oral capsule 100 mg, 5 mg, 50 mg metaxall oral tablet 800 mg PA-HRM metaxalone oral tablet 400 mg, 800 mg PA-HRM methocarbamol oral tablet 500 mg, 750 mg PA-HRM revonto intravenous recon soln 0 mg tizanidine oral capsule mg, 4 mg, 6 mg tizanidine oral tablet mg, 4 mg Sleep Disorder Agents Sleep Disorder Agents armodafinil oral tablet 150 mg, 00 mg, 50 mg, PA 50 mg BELSOMRA ORAL TABLET 10 MG, 15 QL (0 per 0 days) MG, 0 MG, 5 MG eszopiclone oral tablet 1 mg, mg, mg PA-HRM; QL (0 per 0 days) HETLIOZ ORAL CAPSULE 0 MG 5 PA; NM NUVIGIL ORAL TABLET 150 MG, 00 PA MG, 50 MG, 50 MG ROZEREM ORAL TABLET 8 MG XYREM ORAL SOLUTION 500 MG/ML 5 NM; LA 19 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

138 zaleplon oral capsule 10 mg, 5 mg PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (60 per 0 days) zolpidem oral tablet 10 mg, 5 mg PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (0 per 0 days) zolpidem oral tablet,ext release multiphase 1.5 mg, 6.5 mg PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (0 per 0 days) Vasodilating Agents Vasodilating Agents ADCIRCA ORAL TABLET 0 MG 5 PA; NM; QL (60 per 0 days) ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 5 PA; NM; QL (90 per 0 days) 1.5 MG, MG,.5 MG CIALIS ORAL TABLET.5 MG, 5 MG PA; QL (0 per 0 days) epoprostenol (glycine) intravenous recon soln PA BvD 0.5 mg epoprostenol (glycine) intravenous recon soln 5 PA BvD; NM 1.5 mg LETAIRIS ORAL TABLET 10 MG, 5 MG 5 PA; NM; QL (0 per 0 days) OPSUMIT ORAL TABLET 10 MG 5 PA; NM; QL (0 per 0 days) ORENITRAM ORAL TABLET PA EXTENDED RELEASE 0.15 MG ORENITRAM ORAL TABLET 5 PA; NM EXTENDED RELEASE 0.5 MG, 1 MG,.5 MG REMODULIN INJECTION SOLUTION 1 5 PA BvD; NM MG/ML, 10 MG/ML,.5 MG/ML, 5 MG/ML sildenafil intravenous solution 10 mg/1.5 ml 5 PA; NM; QL (7.5 per 1 day) sildenafil oral tablet 0 mg PA; QL (90 per 0 days) 10 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

139 TRACLEER ORAL TABLET 15 MG, PA; NM; LA; QL (60 per 0 days) MG TYVASO INHALATION SOLUTION FOR 5 PA BvD; NM NEBULIZATION 1.74 MG/.9 ML (0.6 MG/ML) TYVASO REFILL KIT INHALATION 5 PA BvD; NM SOLUTION FOR NEBULIZATION 1.74 MG/.9 ML (0.6 MG/ML) TYVASO STARTER KIT INHALATION 5 PA BvD; NM SOLUTION FOR NEBULIZATION 1.74 MG/.9 ML UPTRAVI ORAL TABLET 1,000 MCG, 5 PA; NM; QL (60 per 0 days) 1,00 MCG, 1,400 MCG, 1,600 MCG, 400 MCG, 600 MCG, 800 MCG UPTRAVI ORAL TABLET 00 MCG 5 PA; NM; QL (40 per 0 days) UPTRAVI ORAL TABLETS,DOSE PACK 5 PA; NM; QL (00 per 65 days) 00 MCG (140)- 800 MCG (60) Vitamins And Minerals Vitamins And Minerals multivit-fluor 0.5 mg tab chew chewable, d/f, s/f 0.5 mg pnv prenatal plus multivit tab s/f, gluten-free 7 (All Rx Prenatal Vitamins Covered) mg iron- 1 mg prenatal vitamin plus low iron oral tablet 7 mg (All Rx Prenatal Vitamins Covered) iron- 1 mg sodium fluoride oral tablet 1 mg fluoride (. mg) VITAFOL FE+ (WITH DOCUSATE) ORAL CAPSULE 90 MG IRON-1 MG -50 MG-00 MG 11 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

140 1 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

141 Index 8-MOP abacavir... 5 abacavir-lamivudine-zidovudine... 5 ABELCET... 4 ABILIFY MAINTENA ABRAXANE... 1 acamprosate... 9 acarbose... 7 acebutolol acetaminophen-codeine... acetasol hc... 9 acetazolamide acetazolamide sodium acetic acid... 9, 11 acetylcysteine acitretin ACTEMRA ACTHIB (PF) ACTIMMUNE ACTOPLUS MET XR... 8 acyclovir... 57, 84 acyclovir sodium ADACEL(TDAP ADOLESN/ADULT)(PF) ADAGEN adapalene ADCETRIS... 1 ADCIRCA adefovir ADEMPAS adriamycin... 1, adrucil... ADVAIR DISKUS ADVAIR HFA afeditab cr AFINITOR... AFINITOR DISPERZ... a-hydrocort AKTEN (PF) AKYNZEO ala-cort INDEX Index ala-scalp ALBENZA albuterol sulfate alcaine alclometasone ALCOHOL PADS ALCOHOL PREP PADS ALDURAZYME ALECENSA... alendronate... 11, 114 alfuzosin ALIMTA... ALINIA allopurinol allopurinol sodium ALLZITAL... almotriptan malate alogliptin... 8 alogliptin-metformin... 8 alogliptin-pioglitazone... 8 alosetron ALPHAGAN P alprazolam ALREX altacaine altavera (8) ALTOPREV... 7 alyacen 1/5 (8) alyacen 7/7/7 (8) amantadine hcl AMBISOME... 4 amethia amethia lo amifostine crystalline amiloride... 7 amiloride-hydrochlorothiazide... 7 AMINO ACIDS 15 % aminocaproic acid AMINOSYN 10 % AMINOSYN.5 % AMINOSYN 7 % Index AMINOSYN 7 % WITH ELECTROLYTES AMINOSYN 8.5 % AMINOSYN 8.5 %-ELECTROLYTES AMINOSYN II 10 % AMINOSYN II 15 % AMINOSYN II 7 % AMINOSYN II 8.5 % AMINOSYN II 8.5 %-ELECTROLYTES AMINOSYN M.5 % AMINOSYN-HBC 7% AMINOSYN-PF 10 % AMINOSYN-PF 7 % (SULFITE-FREE) AMINOSYN-RF 5. % amiodarone AMITIZA amitriptyline... 5 amlodipine amlodipine-atorvastatin... 7 amlodipine-benazepril... 7 amlodipine-valsartan... 7 amlodipine-valsartan-hcthiazid... 7 ammonium chloride ammonium lactate amoxapine... 5 amoxicil-clarithromy-lansopraz amoxicillin amoxicillin-pot clavulanate amphotericin b... 4 ampicillin ampicillin sodium ampicillin-sulbactam AMPYRA ANACAINE anagrelide anastrozole... ANDRODERM I-1 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

142 Index ANDROGEL androxy anticoag citrate phos dextrose APOKYN apraclonidine apri APRISO APTIOM... 0 APTIVUS... 5 aranelle (8) ARCALYST aripiprazole ARISTADA... 49, 50 armodafinil ASACOL HD ascomp with codeine... ashlyna aspirin-dipyridamole ASSURE ID INSULIN SAFETY ASTAGRAF XL atenolol atenolol-chlorthalidone atorvastatin... 7 atovaquone atovaquone-proguanil ATRIPLA... 5 atropine... 0, 9 atropine-care... 9 ATROVENT HFA AUBAGIO aubra AURYXIA AVASTIN... AVC VAGINAL aviane AVONEX , 116 AVONEX (WITH ALBUMIN) AXIRON azacitidine... azathioprine azathioprine sodium azelastine... 9 Index AZILECT azithromycin AZOPT AZOR... 7 aztreonam azurette (8) baciim... 1 bacitracin... 1, 9 bacitracin-polymyxin b... 9 baclofen balsalazide balziva (8) BANZEL... 0 BARACLUDE BCG VACCINE, LIVE (PF) BD INSULIN PEN NEEDLE UF SHORT BD INSULIN SYRINGE ULTRA-FINE bekyree (8) BELBUCA... BELEODAQ... BELSOMRA benazepril benazepril-hydrochlorothiazide BENDEKA... BENICAR BENICAR HCT BENLYSTA benztropine BEPREVE... 9 betamethasone acet,sod phos betamethasone dipropionate betamethasone valerate betamethasone, augmented BETASERON betaxolol... 67, 10 bethanechol chloride BETHKIS... 1 BETOPTIC S bexarotene... BEXSERO (PF) bicalutamide... Index BICILLIN C-R BICILLIN L-A BIDIL bimatoprost bisoprolol fumarate bisoprolol-hydrochlorothiazide bleomycin... bleph BLEPHAMIDE... 9 BLEPHAMIDE S.O.P BLINCYTO... blisovi 4 fe blisovi fe 1.5/0 (8) blisovi fe 1/0 (8) BOOSTRIX TDAP BOSULIF... BOTOX BREO ELLIPTA briellyn BRILINTA brimonidine BRINTELLIX... 5 BRIVIACT... 0 bromfenac bromocriptine budesonide bumetanide... 7 BUPHENYL buprenorphine hcl..., 9 buprenorphine-naloxone buproban... 5 bupropion hcl... 5 bupropion hcl (smoking deter) buspirone butalbital compound w/codeine... butalbital-acetaminop-caf-cod... butalbital-acetaminophen... butalbital-acetaminophen-caff... butalbital-aspirin-caffeine... butorphanol tartrate... BUTRANS... BYSTOLIC cabergoline I- Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

143 Index CABOMETYX... caffeine citrated caffeine-sodium benzoate calcipotriene... 84, 85 calcitonin (salmon) calcitrene calcitriol... 85, 114 calcium acetate calcium chloride calcium gluconate CALDOLOR... 7 camila camrese camrese lo CANCIDAS... 4 candesartan candesartan-hydrochlorothiazid capacet... CAPASTAT CAPRELSA... captopril captopril-hydrochlorothiazide CARAFATE CARBAGLU carbamazepine... 0 carbidopa carbidopa-levodopa carbidopa-levodopa-entacapone carbinoxamine maleate carboplatin... CARIMUNE NF NANOFILTERED carisoprodol carteolol... 9 cartia xt carvedilol CAYSTON caziant (8) cefaclor cefadroxil cefazolin CEFAZOLIN IN DEXTROSE (ISO-OS) Index cefazolin in dextrose (iso-os) cefdinir cefditoren pivoxil cefepime CEFEPIME IN DEXTROSE 5 % CEFEPIME IN DEXTROSE,ISO-OSM cefixime cefotaxime cefoxitin cefoxitin in dextrose, iso-osm cefpodoxime cefprozil ceftazidime ceftibuten ceftriaxone ceftriaxone in dextrose,iso-os cefuroxime axetil cefuroxime sodium celecoxib... 7 CELLCEPT INTRAVENOUS CELONTIN... 1 cephalexin CEPROTIN (BLUE BAR) CERDELGA CEREZYME CERVARIX VACCINE (PF) cevimeline CHANTIX CHANTIX CONTINUING MONTH BOX CHANTIX STARTING MONTH BOX chloramphenicol sod succinate... 1 chlordiazepoxide hcl chlorhexidine gluconate chloroquine phosphate chlorothiazide... 7 chlorothiazide sodium... 7 chlorpromazine chlorthalidone... 7 Index chlorzoxazone cholestyramine (with sugar)... 7 cholestyramine light... 7 choline,magnesium salicylate... 7 CIALIS ciclopirox... 4 ciclopirox-ure-camph-menth-euc... 4 cidofovir cilostazol CILOXAN... 9 cimetidine cimetidine hcl CIMZIA CIMZIA POWDER FOR RECONST CINQAIR CINRYZE CIPRODEX... 9 ciprofloxacin... 0 ciprofloxacin (mixture)... 0 ciprofloxacin hcl... 0, 9 ciprofloxacin in 5 % dextrose... 0 ciprofloxacin lactate... 0 citalopram... 5 cladribine... clarithromycin clemastine CLEVIPREX... 7 clindamycin hcl... 1 clindamycin in 5 % dextrose... 1 clindamycin palmitate hcl... 1 clindamycin pediatric... 1 clindamycin phosphate... 1, 44, 86 clindamycin-benzoyl peroxide CLINIMIX 5%/D15W SULFITE FREE CLINIMIX 5%/D5W SULFITE-FREE... 6 CLINIMIX.75%/D5W SULFIT FREE... 6 CLINIMIX 4.5%/D10W SULF FREE... 6 CLINIMIX 4.5%/D5W SULFIT FREE... 6 I- Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

144 Index CLINIMIX 4.5%-D0W SULF-FREE... 6 CLINIMIX 4.5%-D5W SULF-FREE... 6 CLINIMIX 5%-D0W(SULFITE-FREE)... 6 CLINIMIX E.75%/D10W SUL FREE... 6 CLINIMIX E.75%/D5W SULF FREE... 6 CLINIMIX E 4.5%/D10W SUL FREE... 6 CLINIMIX E 4.5%/D5W SUL FREE... 6 CLINIMIX E 4.5%/D5W SULF FREE... 6 CLINIMIX E 5%/D15W SULFIT FREE... 6 CLINIMIX E 5%/D0W SULFIT FREE... 6 CLINIMIX E 5%/D5W SULFIT FREE... 6 CLINISOL SF 15 %... 6 clobetasol clobetasol-emollient clocortolone pivalate clomipramine... 5 clonazepam... 10, 11 clonidine clonidine hcl... 64, 76 clopidogrel clorazepate dipotassium clorpres clotrimazole... 4 clotrimazole-betamethasone... 4 clozapine COARTEM codeine sulfate... colchicine colchicine-probenecid colestipol... 7 colistin (colistimethate na)... 1 colocort COLY-MYCIN S... 9 Index COMBIGAN COMBIPATCH COMBIVENT RESPIMAT COMETRIQ... COMPLERA... 5 compro COMVAX (PF) CONDYLOX constulose COPAXONE CORLANOR cormax cortisone CORTISPORIN-TC... 9 COSENTYX COSENTYX ( SYRINGES) COSENTYX PEN COSENTYX PEN ( PENS) COTELLIC... CREON CRESTOR... 7 CRIXIVAN... 5 cromolyn... 9, 97, 18 cryselle (8) CUBICIN... 1 cyclafem 1/5 (8) cyclafem 7/7/7 (8) cyclobenzaprine cyclopentolate... 9 cyclophosphamide... CYCLOPHOSPHAMIDE... CYCLOSET... 8 cyclosporine , 107 cyclosporine modified cyproheptadine CYRAMZA... cyred CYSTADANE CYSTARAN... 9 cysteine (l-cysteine)... 6 d10 %-0.45 % sodium chloride Index d.5 %-0.45 % sodium chloride d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride dactinomycin... DAKLINZA DALIRESP danazol dantrolene dapsone DAPTACEL (DTAP PEDIATRIC) (PF) DARAPRIM DARZALEX... dasetta 1/5 (8) dasetta 7/7/7 (8) DAUNOXOME... daysee deblitane decitabine... deferoxamine delyla (8) DELZICOL demeclocycline... 0 DEMSER DENAVIR DEPEN TITRATABS DEPO-PROVERA DESCOVY... 5 desipramine... 5 desmopressin desog-e.estradiol/e.estradiol desogestrel-ethinyl estradiol desonide... 87, 88 desoximetasone DESVENLAFAXINE FUMARATE... 5 dexamethasone dexamethasone sodium phosphate... 95, 10 DEXILANT dexmethylphenidate dexrazoxane hcl I-4 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

145 Index dextroamphetamine dextroamphetamine-amphetamine dextrose 10 % and 0. % nacl dextrose 10 % in water (d10w)... 6 dextrose 0 % in water (d0w)... 6 dextrose 5 % in water (d5w)... 6 dextrose 40 % in water (d40w)... 6 dextrose 5 % in ringers... 6 dextrose 5 % in water (d5w)... 6 dextrose 5 %-lactated ringers dextrose 5%-0. % sod chloride dextrose 5%-0. % sod.chloride dextrose 50 % in water (d50w)... 6 dextrose 70 % in water (d70w)... 6 dextrose with sodium chloride dextrose-kcl-nacl diazepam diazepam intensol diclofenac potassium... 7 diclofenac sodium... 7, 95 diclofenac-misoprostol... 8 dicloxacillin dicyclomine didanosine... 5 DIFICID diflorasone diflunisal... 8 digitek digox digoxin DIGOXIN dihydroergotamine DILANTIN... 1 Index diltiazem hcl dilt-xr dimenhydrinate DIPENTUM diphenhydramine hcl diphenoxylate-atropine dipyridamole disopyramide phosphate disulfiram divalproex... 1 dobutamine dobutamine in d5w docetaxel... dofetilide donepezil... 4 dopamine dopamine in 5 % dextrose dorzolamide dorzolamide-timolol doxazosin doxepin... 5 doxercalciferol doxorubicin, peg-liposomal... doxy doxycycline hyclate... 1 doxycycline monohydrate... 1 dronabinol droperidol drospirenone-ethinyl estradiol DROXIA... DUAVEE DULERA duloxetine... 5 DUREZOL dutasteride dutasteride-tamsulosin DYRENIUM... 7 e.e.s e.e.s. granules econazole... 4 EDARBI EDARBYCLOR EDURANT... 5 effer-k EFFIENT Index ELAPRASE electrolyte-48 in d5w ELIDEL ELIGARD... elinest eliphos ELIQUIS ELITEK elixophyllin ELLA ELMIRON EMBEDA... 4 EMCYT... EMEND emoquette EMPLICITI... 4 EMSAM... 5 EMTRIVA... 5 EMVERM enalapril maleate enalaprilat enalapril-hydrochlorothiazide ENBREL ENBREL SURECLICK endocet... 4 endodan... 4 ENGERIX-B (PF) ENGERIX-B PEDIATRIC (PF) enoxaparin... 57, 58 enpresse enskyce entacapone entecavir ENTRESTO enulose ENVARSUS XR ephedrine sulfate epinastine... 9 epinephrine epinephrine hcl (pf) EPIPEN -PAK EPIPEN JR -PAK epitol... 1 EPIVIR HBV... 5 I-5 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

146 Index eplerenone EPOGEN epoprostenol (glycine) eprosartan EPZICOM... 5 ergoloid ERGOMAR ERIVEDGE... 4 errin ery pads ery-tab ERY-TAB ERYTHROCIN erythrocin (as stearate) erythromycin... 17, 9 erythromycin ethylsuccinate erythromycin with ethanol erythromycin-benzoyl peroxide ESBRIET escitalopram oxalate... 6 esmolol esomeprazole sodium estarylla estazolam ESTRACE estradiol , 10 estradiol valerate estradiol-norethindrone acet ESTRING estropipate eszopiclone ethambutol ethamolin ethosuximide... 1 etidronate disodium etodolac... 8 ETOPOPHOS... 4 etoposide... 4 EURAX EVOTAZ... 5 EXELDERM... 4 exemestane... 4 EXJADE EXTAVIA Index FABRAZYME falmina (8) famciclovir famotidine famotidine (pf) famotidine (pf)-nacl (iso-os) FANAPT FARESTON... 4 FARYDAK... 4 FASLODEX... 4 felbamate... 1 felodipine... 7 FEMRING fenofibrate fenofibrate micronized... 7 fenofibrate nanocrystallized... 7 fenofibric acid fenofibric acid (choline) fenoprofen... 8 fentanyl... 4 fentanyl citrate... 4 FERRIPROX FETZIMA... 6 finasteride FIRAZYR flavoxate FLEBOGAMMA DIF flecainide FLECTOR... 8 FLOVENT DISKUS FLOVENT HFA floxuridine... 4 flucaine... 9 fluconazole... 4 fluconazole in dextrose(iso-o)... 4 fluconazole in nacl (iso-osm)... 4 flucytosine... 4 fludrocortisone flumazenil flunisolide fluocinolone acetonide oil fluocinonide fluocinonide-e fluorometholone Index fluorouracil... 4, 85 fluoxetine... 6 FLUOXETINE... 6 fluphenazine decanoate fluphenazine hcl flurazepam flurbiprofen... 8 flurbiprofen sodium flutamide... 4 fluticasone... 88, 95 fluvastatin fluvoxamine... 6 fomepizole fondaparinux FORADIL AEROLIZER FORTEO FORTICAL foscarnet fosinopril fosinopril-hydrochlorothiazide fosphenytoin... 1 FOSRENOL FREAMINE HBC 6.9 %... 6 FREAMINE III 10 %... 6 furosemide... 7, 7 FUSILEV FUZEON... 5 fyavolv FYCOMPA... 1 gabapentin... 1 GABITRIL... 1 galantamine... 4 GAMASTAN S/D GAMMAGARD LIQUID GAMMAPLEX GAMUNEX-C ganciclovir sodium GARDASIL (PF) GARDASIL 9 (PF) gatifloxacin... 9 GATTEX 0-VIAL GATTEX ONE-VIAL GAUZE PAD gavilyte-c I-6 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

147 Index gavilyte-g gavilyte-n GAZYVA... 4 gemcitabine... 4 gemfibrozil generlac gengraf GENOTROPIN GENOTROPIN MINIQUICK gentak... 9 gentamicin... 1, 86, 9 gentamicin in nacl (iso-osm)... 1 gentamicin sulfate (ped) (pf)... 1 gentamicin sulfate (pf)... 1 GENVOYA... 5 GEODON gianvi (8) gildagia gildess 1.5/0 (1) gildess 1/0 (1) gildess 4 fe gildess fe 1.5/0 (8) gildess fe 1/0 (8) GILENYA GILOTRIF... 4 glatopa GLEOSTINE... 4 glimepiride glipizide glipizide-metformin... 41, 4 GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) glyburide... 4 glyburide micronized... 4 glyburide-metformin... 4 glycopyrrolate glydo... 9 GLYSET... 8 GLYXAMBI... 8 GRALISE... 1 GRALISE 0-DAY STARTER PACK... 1 granisetron (pf) Index granisetron hcl granisol GRANIX griseofulvin microsize... 4 griseofulvin ultramicrosize... 4 guanfacine... 64, 76 guanidine halobetasol propionate haloperidol haloperidol decanoate haloperidol lactate HARVONI HAVRIX (PF) heather heparin (porcine) heparin (porcine) in 5 % dex heparin (porcine) in nacl (pf) heparin(porcine) in 0.45% nacl heparin, porcine (pf) HEPATAMINE 8%... 6 HEPATASOL 8 % HERCEPTIN... 4 HETLIOZ HEXALEN... 4 homatropaire... 9 homatropine hbr... 9 HUMALOG HUMALOG KWIKPEN HUMALOG MIX HUMALOG MIX KWIKPEN HUMALOG MIX HUMALOG MIX 75-5 KWIKPEN HUMIRA HUMIRA PEN HUMIRA PEN CROHN'S-UC-HS START HUMULIN 70/ HUMULIN 70/0 KWIKPEN HUMULIN N HUMULIN N KWIKPEN HUMULIN R Index HUMULIN R U-500 (CONC) KWIKPEN HUMULIN R U-500 (CONCENTRATED) hydralazine hydrochlorothiazide... 7 hydrocodone-acetaminophen... 4 hydrocodone-ibuprofen... 4 hydrocortisone... 88, 10 hydrocortisone acet-aloe vera hydrocortisone butyrate hydrocortisone butyr-emollient hydrocortisone valerate hydrocortisone-acetic acid... 9 hydromorphone... 4 hydromorphone (pf)... 4 hydroxychloroquine hydroxyprogesterone caproate hydroxyurea... 4 hydroxyzine hcl hydroxyzine pamoate HYPERLYTE CR... 1 HYPERRAB S/D (PF) HYQVIA HYQVIA IG COMPONENT HYSINGLA ER... 4 ibandronate IBRANCE... 4 ibuprofen... 8 ICLUSIG... 4 ifosfamide... 4 ifosfamide-mesna... 5 ILARIS (PF) ILEVRO imatinib... 5 IMBRUVICA... 5 imipenem-cilastatin imipramine hcl... 6 imipramine pamoate... 6 imiquimod IMLYGIC... 5 I-7 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

148 Index IMOGAM RABIES-HT (PF) IMOVAX RABIES VACCINE (PF) INCRELEX indapamide... 7 indomethacin... 8 indomethacin sodium... 8 INFANRIX (DTAP) (PF) INLYTA... 5 INSULIN SYRINGE-NEEDLE U INTELENCE... 5 INTRALIPID INTRON A introvale INVANZ INVEGA SUSTENNA INVEGA TRINZA INVIRASE... 5 INVOKAMET... 8 INVOKANA... 8 IONOSOL-B IN D5W... 1 IONOSOL-MB IN D5W... 1 IPOL ipratropium bromide... 9, 17 ipratropium-albuterol IPRIVASK irbesartan irbesartan-hydrochlorothiazide IRESSA... 5 irinotecan... 5 ISENTRESS... 5 ISOLYTE M IN 5 % DEXTROSE... 1 ISOLYTE-H IN 5 % DEXTROSE... 1 ISOLYTE-P IN 5 % DEXTROSE... 1 ISOLYTE-S... 1 isoniazid... 45, 46 isosorbide dinitrate isosorbide mononitrate isradipine... 7 Index itraconazole... 4 ivermectin IXEMPRA... 5 IXIARO (PF) JAKAFI... 5 jantoven JANUMET... 8 JANUMET XR... 8 JANUVIA... 8 JARDIANCE... 8 jencycla JENTADUETO... 8 JENTADUETO XR... 8 jinteli jolessa jolivette juleber junel 1.5/0 (1) junel 1/0 (1) junel fe 1.5/0 (8) junel fe 1/0 (8) junel fe JUXTAPID KABIVEN KALETRA... 5, 54 KALYDECO KANUMA kariva (8) KAZANO... 8 k-effervescent... 1 kelnor 1/5 (8) ketoconazole... 4 ketoprofen... 8 ketorolac... 8, 95 KEVEYIS KEYTRUDA... 5 kimidess (8) KINERET KINRIX (PF) , 111 kionex klor-con klor-con m klor-con m klor-con m klor-con sprinkle... 1 Index KORLYM... 8 KRYSTEXXA kurvelo KUVAN KYNAMRO KYPROLIS... 5 l norgest/e.estradiol-e.estrad labetalol LACRISERT... 9 LACTATED RINGERS lactulose LAMICTAL... LAMICTAL ODT STARTER (BLUE)... 1 LAMICTAL ODT STARTER (GREEN)... 1 LAMICTAL ODT STARTER (ORANGE)... lamivudine lamivudine-zidovudine lamotrigine... LANOXIN lansoprazole LANTUS LANTUS SOLOSTAR larin 1.5/0 (1) larin 1/0 (1) larin 4 fe larin fe 1.5/0 (8) larin fe 1/0 (8) latanoprost LATUDA LAZANDA... 4 leena leflunomide LEMTRADA LENVIMA... 5 lessina LETAIRIS letrozole... 5 leucovorin calcium LEUKERAN... 5 LEUKINE leuprolide... 6 levetiracetam... I-8 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

149 Index levetiracetam in nacl (iso-os)... levobunolol levocarnitine levocarnitine (with sugar) levocetirizine levofloxacin... 0, 9 levofloxacin in d5w... 0 levonest (8) levonorgestrel levonorgestrel-ethinyl estrad levonorg-eth estrad triphasic levora levothyroxine LEXIVA lidocaine... 9 lidocaine (pf)... 9, 67 lidocaine hcl... 9 lidocaine in 5 % dextrose (pf) lidocaine viscous... 9 lidocaine-prilocaine... 9 linezolid... 1 LINZESS liothyronine lipodox... 6 lipodox lisinopril lisinopril-hydrochlorothiazide lithium carbonate lithium citrate lomedia 4 fe lomustine... 6 LONSURF... 6 loperamide lorazepam lorazepam intensol lorcet (hydrocodone)... 4 lorcet hd... 5 lorcet plus... 5 loryna (8) losartan losartan-hydrochlorothiazide LOTEMAX LOTRONEX lovastatin low-ogestrel (8) Index loxapine succinate LUMIGAN LUPRON DEPOT... 6 LUPRON DEPOT ( MONTH)... 6 LUPRON DEPOT (4 MONTH)... 6 LUPRON DEPOT (6 MONTH)... 6 LUPRON DEPOT-PED LUPRON DEPOT-PED ( MONTH) lutera (8) LYNPARZA... 6 LYRICA... LYSODREN... 6 lyza magnebind magnesium chloride... 1 magnesium sulf in 0.45% nacl... 1 magnesium sulfate... 1 magnesium sulfate in d5w... 1 magnesium sulfate in water... 1, 1 malathion maprotiline... 6 margesic... 5 marlissa MARPLAN... 6 MARQIBO... 6 MATULANE... 6 matzim la meclizine medroxyprogesterone mefenamic acid... 8 mefloquine MEFOXIN IN DEXTROSE (ISO-OSM) MEGACE ES megestrol... 6, 106 MEKINIST... 6 meloxicam... 8 melphalan hcl... 6 memantine... 4 Index MENACTRA (PF) MENEST MENHIBRIX (PF) MENOMUNE - A/C/Y/W-15 (PF) MENVEO A-C-Y-W-15-DIP (PF) MENVEO MENA COMPONENT (PF) MENVEO MENCYW-15 COMPNT (PF) mercaptopurine... 6 meropenem mesna MESNEX MESTINON MESTINON TIMESPAN metaproterenol metaxall metaxalone metformin... 8, 9 methadone... 5 methadose... 5 methazolamide methenamine hippurate... 1 methimazole methocarbamol methotrexate sodium... 6 methotrexate sodium (pf)... 6 methoxsalen rapid methscopolamine methyclothiazide... 7 methylergonovine methylphenidate methylprednisolone methylprednisolone acetate methylprednisolone sodium succ metipranolol metoclopramide hcl metolazone... 7 metoprolol succinate metoprolol ta-hydrochlorothiaz metoprolol tartrate I-9 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

150 Index metronidazole... 14, 44, 86 metronidazole in nacl (iso-os) mexiletine MIACALCIN miconazole microgestin 1.5/0 (1) microgestin 1/0 (1) microgestin fe 1.5/0 (8) microgestin fe 1/0 (8) midazolam midodrine miglitol... 9 milrinone milrinone in 5 % dextrose mimvey mimvey lo minitran MINOCIN... 1 minocycline... 1 minoxidil MIRCERA mirtazapine... 6 misoprostol mitoxantrone... 6 M-M-R II (PF) moexipril moexipril-hydrochlorothiazide molindone mometasone mono-linyah mononessa (8) montelukast morphine... 5, 6 MORPHINE... 5 morphine (pf) in 0.9 % nacl... 5 morphine concentrate... 5 morphine in dextrose 5 %... 5 morrhuate sodium MOVANTIK MOVIPREP MOXEZA... 9 moxifloxacin... 0 MOZOBIL Index MULTAQ multivitamin with fluoride mupirocin mupirocin calcium mycophenolate mofetil mycophenolate sodium MYOBLOC MYOZYME MYRBETRIQ myzilra nabumetone... 8 nadolol nafcillin NAGLAZYME naloxone naltrexone NAMENDA XR... 4 NAMZARIC... 4 naphazoline... 9 naproxen... 9 naproxen sodium... 9 naratriptan NARCAN NATACYN... 9 nateglinide... 9 NATPARA NEBUPENT necon 0.5/5 (8) necon 1/5 (8) necon 1/50 (8) necon 10/11 (8) necon 7/7/7 (8) nefazodone... 6 neomycin... 1 neomycin-bacitracin-poly-hc neomycin-bacitracin-polymyxin neomycin-polymyxin b gu neomycin-polymyxin b-dexameth neomycin-polymyxin-gramicidin neomycin-polymyxin-hc neo-polycin neo-polycin hc Index NEPHRAMINE 5.4 % NESINA... 9 neuac NEULASTA NEUMEGA NEUPOGEN NEUPRO NEVANAC nevirapine NEXAVAR... 6 next choice one dose niacin niacor nicardipine... 7 NICOTROL nifedical xl... 7 nifedipine... 7 nikki (8)... 8 NILANDRON... 6 NINLARO... 7 NITRO-BID nitrofurantoin nitrofurantoin macrocrystal nitrofurantoin monohyd/m-cryst nitroglycerin... 75, 76 nitroglycerin in 5 % dextrose NITROSTAT nizatidine nora-be... 8 NORDITROPIN FLEXPRO norepinephrine bitartrate norethindrone (contraceptive)... 8 norethindrone acetate norethindrone ac-eth estradiol... 8, 10 norethindrone-e.estradiol-iron... 8 norgestimate-ethinyl estradiol... 8 norlyroc... 8 NORMOSOL-M IN 5 % DEXTROSE... 1 NORMOSOL-R PH NORTHERA I-10 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

151 Index nortrel 0.5/5 (8)... 8 nortrel 1/5 (1)... 8 nortrel 1/5 (8)... 8 nortrel 7/7/7 (8)... 8 nortriptyline... 6 NORVIR NOVOLIN 70/ NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX NOVOLOG MIX 70-0 FLEXPEN NOVOLOG PENFILL NOXAFIL... 4 NPLATE NUCALA NUCYNTA... 6 NUCYNTA ER... 6 NUEDEXTA NULOJIX NUPLAZID NUTRESTORE NUTRILIPID NUTRILYTE... 1 NUTRILYTE II... 1 NUVARING... 8 NUVIGIL nyamyc... 4 nystatin... 4, 44 nystatin-triamcinolone nystop OCALIVA ocella... 8 OCTAGAM octreotide acetate ODEFSEY ODOMZO... 7 OFEV ofloxacin... 0, 94 ogestrel (8)... 8 olanzapine olanzapine-fluoxetine... 6 olopatadine... 9 Index OLYSIO omega- acid ethyl esters omeprazole ONCASPAR... 7 ondansetron ondansetron hcl ondansetron hcl (pf) ONFI... 11, 88 onxol... 7 OPDIVO... 7 OPSUMIT oralone ORENCIA ORENCIA (WITH MALTOSE) ORENCIA CLICKJECT ORENITRAM ORFADIN... 91, 118 ORKAMBI orsythia... 8 OSENI... 9 OTEZLA OTEZLA STARTER OTREXUP (PF) oxacillin oxacillin in dextrose(iso-osm) oxaliplatin... 7 oxandrolone oxcarbazepine... OXTELLAR XR... oxybutynin chloride oxycodone... 6 oxycodone-acetaminophen... 6 oxycodone-aspirin... 6 OXYCONTIN... 6 oxymorphone... 6, 7 pacerone paclitaxel... 7 paliperidone pamidronate pancrelipase PANRETIN pantoprazole papaverine Index paricalcitol paromomycin paroxetine hcl... 6, 7 PASER PATADAY... 9 PAXIL... 7 PEDIARIX (PF) PEDVAX HIB (PF) peg 50-electrolytes PEGANONE... PEGASYS PEGASYS PROCLICK peg-electrolyte soln PEGINTRON PEN NEEDLE, DIABETIC penicillin g pot in dextrose penicillin g potassium penicillin g procaine penicillin v potassium PENTACEL (PF) PENTACEL ACTHIB COMPONENT (PF) PENTAM pentoxifylline PERIKABIVEN perindopril erbumine periogard PERJETA... 7 permethrin perphenazine perphenazine-amitriptyline... 7 PERTZYE pfizerpen-g phenadoz phenelzine... 7 phenobarbital... phenobarbital sodium... phenylephrine hcl... 65, 9 phenytoin... phenytoin sodium... phenytoin sodium extended... philith... 8 PHOSLYRA phospha 50 neutral... 1 PHOSPHOLINE IODIDE I-11 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

152 Index PICATO pilocarpine hcl... 84, 10 pimozide pimtrea (8)... 8 pindolol pioglitazone... 9 pioglitazone-glimepiride... 9 pioglitazone-metformin... 9 piperacillin-tazobactam pirmella... 8 piroxicam... 9 PLASMA-LYTE PLASMA-LYTE A... 1 PLASMA-LYTE-56 IN 5 % DEXTROSE... 1 PLEGRIDY podocon podofilox polyethylene glycol polymyxin b sulfate polymyxin b sulf-trimethoprim POMALYST... 7 portia... 8 PORTRAZZA... 7 potassium acetate... 1 potassium bicarb and chloride... 1 potassium bicarb-citric acid... 1 potassium chlorid-d5-0.45%nacl... 1 potassium chloride potassium chloride in 0.9%nacl... 1 potassium chloride in 5 % dex... 1 potassium chloride in lr-d potassium chloride-0.45 % nacl potassium chloride-d5-0.%nacl potassium chloride-d5-0.%nacl potassium chloride-d5-0.9%nacl Index potassium citrate potassium citrate-citric acid potassium hydroxide potassium phosphate m-/d-basic POTIGA... PRADAXA PRALUENT PEN PRALUENT SYRINGE pramipexole pravastatin prazosin prednicarbate... 88, 89 prednisolone acetate prednisolone sodium phosphate... 95, 10 prednisone PREDNISONE INTENSOL PREMARIN PREMASOL 10 % PREMASOL 6 % PREMPHASE PREMPRO prenatal plus (calcium carb) prenatal vitamin plus low iron PREPOPIK prevalite previfem... 8 PREZCOBIX PREZISTA PRIFTIN PRIMAQUINE primidone... PRISTIQ... 7 PRIVIGEN PROAIR HFA PROAIR RESPICLICK probenecid procainamide PROCALAMINE % prochlorperazine prochlorperazine edisylate prochlorperazine maleate Index PROCRIT... 59, 60 procto-med hc procto-pak proctosol hc proctozone-hc PROCYSBI progesterone in oil progesterone micronized PROGLYCEM PROGRAF PROLASTIN-C PROLENSA PROLEUKIN... 7 PROLIA PROMACTA promethazine... 44, 47 promethegan propafenone propantheline... 0 proparacaine... 9 propranolol propranolol-hydrochlorothiazid propylthiouracil PROQUAD (PF) PROSOL 0 % protamine protriptyline... 7 PULMOZYME PURIXAN... 7 pyrazinamide pyridostigmine bromide QUADRACEL (PF) quasense... 8 quetiapine QUILLIVANT XR quinapril quinapril-hydrochlorothiazide quinidine gluconate quinidine sulfate quinine sulfate QVAR RABAVERT (PF) raloxifene ramipril I-1 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

153 Index RANEXA ranitidine hcl... 96, 97 RAPAMUNE RASUVO (PF) RAVICTI REBIF (WITH ALBUMIN) REBIF REBIDOSE REBIF TITRATION PACK reclipsen (8)... 8 RECOMBIVAX HB (PF) REGRANEX RELENZA DISKHALER RELISTOR REMICADE REMODULIN RENAGEL RENVELA repaglinide... 9 repaglinide-metformin... 9 REPATHA SURECLICK REPATHA SYRINGE reprexain... 7 RESCRIPTOR RESTASIS RETROVIR REVLIMID... 7 revonto REXULTI REYATAZ ribasphere ribasphere ribapak ribavirin RIDAURA rifabutin rifampin RIFATER riluzole rimantadine ringers... 11, 14 risedronate , 115 RISPERDAL CONSTA risperidone... 51, 5 RITUXAN... 7 Index rivastigmine... 5 rivastigmine tartrate... 4 rizatriptan ropinirole rosadan rosuvastatin ROTARIX ROTATEQ VACCINE roxicet... 7 ROZEREM SABRIL... SAIZEN SAIZEN CLICK.EASY SANDOSTATIN LAR DEPOT SANTYL SAPHRIS (BLACK CHERRY)... 5 SAVAYSA SAVELLA selegiline hcl selenium sulfide SELZENTRY SENSIPAR SEREVENT DISKUS SEROQUEL XR... 5 SEROSTIM sertraline... 7 setlakin... 8 sharobel... 8 SIGNIFOR sildenafil SILENOR... 7 silver nitrate silver sulfadiazine SIMBRINZA SIMPONI SIMPONI ARIA simvastatin sirolimus SIRTURO sodium acetate sodium bicarbonate sodium chloride... 11, 15 sodium chloride 0.45 % Index sodium chloride 0.9 % sodium chloride % sodium chloride 5 % sodium fluoride... 84, 11 sodium lactate sodium phosphate sodium polystyrene (sorb free) sodium polystyrene sulfonate sodium thiosulfate SOLTAMOX... 7 SOLU-CORTEF (PF) SOMATULINE DEPOT SOMAVERT sorbitol sorbitol-mannitol sorine sotalol sotalol af SOVALDI spinosad SPIRIVA RESPIMAT SPIRIVA WITH HANDIHALER spironolactone spironolacton-hydrochlorothiaz SPORANOX sprintec (8)... 8 SPRITAM... SPRYCEL... 7 sps sronyx... 8 ssd stavudine STELARA STERILE PADS STIMATE STIOLTO RESPIMAT... 0 STIVARGA... 7 STRATTERA STRENSIQ streptomycin... 1 STRIBILD STRIVERDI RESPIMAT I-1 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

154 Index sucralfate sulfacetamide sodium sulfacetamide sodium (acne) sulfacetamide-prednisolone sulfadiazine... 0 sulfamethoxazole-trimethoprim... 0 sulfasalazine... 0 sulfatrim... 0 sulindac... 9 sumatriptan sumatriptan succinate SUPPRELIN LA SUPRAX SURMONTIL... 7 SUSTIVA SUTENT... 7 syeda... 8 SYLATRON SYLVANT... 7 SYMLINPEN SYMLINPEN SYNAGIS SYNAREL SYNERCID SYNJARDY... 9 SYNRIBO... 7 SYPRINE TABLOID... 8 tacrolimus... 89, 109 TAFINLAR... 8 TAGRISSO... 8 TALTZ AUTOINJECTOR TALTZ SYRINGE TAMIFLU tamoxifen... 8 tamsulosin TARCEVA... 8 TARGRETIN... 8 tarina fe 1/0 (8)... 8 TASIGNA... 8 tazicef TAZORAC taztia xt TECENTRIQ... 8 Index TECFIDERA TECHNIVIE TEFLARO TEGRETOL XR... telmisartan telmisartan-hydrochlorothiazid temazepam... 1 TEMODAR... 8 tencon... 7 teniposide... 8 TENIVAC (PF) terazosin terbinafine hcl terbutaline terconazole... 44, 45 testosterone testosterone cypionate testosterone enanthate TETANUS TOXOID,ADSORBED (PF) TETANUS,DIPHTHERIA TOX PED(PF) tetanus-diphtheria toxoids-td tetrabenazine tetracaine hcl (pf)... 9 tetracycline... 1 TEVETEN HCT THALOMID theochron theophylline theophylline in dextrose 5 % thioridazine... 5 thiotepa... 8 thiothixene... 5 tiagabine... TICE BCG TIKOSYN tilia fe... 8 timolol maleate... 68, 10 tinidazole TIVICAY tizanidine Index TOBI PODHALER... 1 TOBRADEX TOBRADEX ST tobramycin tobramycin in 0.5 % nacl... 1 tobramycin in 0.9 % nacl... 1 tobramycin sulfate... 1 tobramycin-dexamethasone TOLAK tolazamide... 4 tolbutamide... 4 tolmetin... 9 tolterodine topiragen... topiramate... toposar... 8 topotecan... 8 TORISEL... 8 torsemide... 7 TOUJEO SOLOSTAR TOVIAZ TPN ELECTROLYTES TPN ELECTROLYTES II TRACLEER TRADJENTA... 9 tramadol... 7 tramadol-acetaminophen... 7 trandolapril tranexamic acid TRANSDERM-SCOP tranylcypromine... 7 TRAVASOL 10 % TRAVATAN Z travoprost (benzalkonium) trazodone... 7 TREANDA... 8 TRECATOR TRELSTAR... 8, 9 tretinoin tretinoin (chemotherapy)... 9 tretinoin microspheres TREXALL... 9 triamcinolone acetonide... 84, 89, 96, 10 I-14 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

155 Index triamterene-hydrochlorothiazid... 7 trianex triazolam... 1 TRIBENZOR tri-estarylla... 8 trifluoperazine... 5 trifluridine trihexyphenidyl tri-legest fe... 8 tri-linyah... 8 tri-lo-estarylla... 8 tri-lo-marzia... 8 tri-lo-sprintec... 8 trilyte with flavor packets trimethoprim trimipramine... 7 trinessa (8)... 8 TRINTELLIX... 7 tri-previfem (8)... 8 tri-sprintec (8)... 8 TRIUMEQ trivora (8)... 8 TROKENDI XR... 4 TROPHAMINE 10 % TROPHAMINE 6% trospium TRULICITY... 9 TRUMENBA TRUVADA TUDORZA PRESSAIR TWINRIX (PF) TYBOST TYGACIL... 1 TYKERB... 9 TYPHIM VI TYSABRI TYVASO TYVASO REFILL KIT TYVASO STARTER KIT TYZEKA TYZINE... 9 u-cort ULORIC UNITUXIN... 9 Index UPTRAVI ursodiol VAGIFEM valacyclovir VALCHLOR VALCYTE valganciclovir valproate sodium... 4 valproic acid... 4 valproic acid (as sodium salt)... 4 valsartan valsartan-hydrochlorothiazide VALSTAR... 9 vancomycin vancomycin in dextrose 5 % VAQTA (PF) VARIVAX (PF) VASCEPA VECTIBIX... 9 VELCADE... 9 velivet triphasic regimen (8)... 8 VELPHORO VENCLEXTA... 9 VENCLEXTA STARTING PACK... 9 venlafaxine... 7 VENTOLIN HFA verapamil VEREGEN VERSACLOZ... 5 VESICARE vestura (8)... 8 VGO VIBERZI vicodin... 7 vicodin es... 7 vicodin hp... 7 VICTOZA -PAK... 9 VIDEX GRAM PEDIATRIC VIDEX 4 GRAM PEDIATRIC VIEKIRA PAK vienva... 8 VIGAMOX Index VIIBRYD... 7 VIMIZIM VIMPAT... 4 vinblastine... 9 vincasar pfs... 9 vincristine... 9 vinorelbine... 9 viorele (8)... 8 VIRACEPT VIRAMUNE XR VIRAZOLE VIREAD virt-phos 50 neutral VITAFOL FE+ (WITH DOCUSATE) VITEKTA VOLTAREN... 9 voriconazole VOTRIENT... 9 VPRIV VRAYLAR... 5 vyfemla (8)... 8 VYTORIN VYTORIN VYTORIN VYTORIN warfarin water for irrigation, sterile WELCHOL wera (8)... 8 wymzya fe XALKORI... 9 XARELTO XARTEMIS XR... 7 XELJANZ XELJANZ XR XGEVA XIFAXAN XOLAIR XTANDI... 9 xulane xylon XYREM YERVOY... 9 YF-VAX (PF) I-15 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

156 Index YONDELIS... 9 zafirlukast zaleplon ZALTRAP... 9 zarah ZARXIO ZAVESCA zebutal... 7 ZELBORAF... 0 ZEMPLAR zenatane zenchent (8) zenchent fe ZENPEP zeosa ZEPATIER ZETIA ZIAGEN zidovudine ZIOPTAN (PF) ziprasidone hcl... 5 ZIRGAN ZOHYDRO ER... 7 ZOLADEX... 0 zoledronic acid zoledronic acid-mannitol-water ZOLINZA... 0 zolmitriptan zolpidem ZOMETA zonisamide... 4 ZORTRESS ZOSTAVAX (PF) zovia 1/5e (8) zovia 1/50e (8) ZOVIRAX ZUBSOLV ZYDELIG... 0 ZYKADIA... 0 ZYLET ZYPREXA RELPREVV... 5 ZYTIGA... 0 ZYVOX I-16 Essence Advantage (HMO)/Essence Platinum (HMO-POS) 016 Effective: August 01, 016

157 1900 Riverport Drive Maryland Heights, MO Local: (14) Toll-free: (866) TTY users dial: a.m. to 8 p.m. seven days a week This formulary was updated on 07/6/016. For more recent information or other questions, please contact Essence Healthcare, Inc. Customer Service at (866) or, for TTY users, 711, 8:00 a.m. to 8:00 p.m., or visit You may receive a messaging service on weekends and holidays from February 15 through September 0. Please leave a message and your call will be returned the next business day. HPMS Approved Formulary File Submission ID 1608, Version 16 Formulary - 005, 006, 011 & 014