PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

Transcription

1 2018 Formulary (List of Covered Drugs) PLEASE READ: TS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN TS PLAN Ally Rx (HMO SNP) This formulary was updated on July 27, For more recent information or other questions, please contact Security Health Plan Customer Service at or, for TTY users, 711, or visit We are open 7 days a week, 8 a.m. to 8 p.m., from Oct. 1-March 31; and Monday through Friday, 8 a.m. to 8 p.m., from April 1-Sept. 30. Y0117_MC C pending Effective date 8/1/2018 Updated 7/27/2018 Formulary ID , v.14

2 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 Security Health Plan. When it refers to plan or our plan, it means Ally Rx (HMO SNP). This document includes a list of the drugs (formulary) for our plan which is current as of August 1, 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 copayments/coinsurance may change on January 1, 2019, and from time to time during the year. Security Health Plan of Wisconsin, Inc., is an HMO, MSA and D-SNP plan with a Medicare contract and a contract with the Wisconsin Medicaid program. Enrollment in Security Health Plan depends on contract renewal. This document is available in alternate formats. Call Customer Service at the number on the covers for more information.

3 What is the Ally Rx (HMO SNP) Formulary? A formulary is a list of covered drugs selected by Security Health Plan 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. Security Health Plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Security Health Plan 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 2018 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2018 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, add prior authorization, quantity limits and/or step therapy restrictions on a drug, 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 1, To get updated information about the drugs covered by Security Health Plan, please contact us. Our contact information appears on the front and back cover pages. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page vii. 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 97. 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 i

4 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. What are generic drugs? Security Health Plan 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: Security Health Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Security Health Plan before you fill your prescriptions. If you don t get approval, Security Health Plan may not cover the drug. Quantity Limits: For certain drugs, Security Health Plan limits the amount of the drug that your Medicare Advantage plan will cover. For example, Security Health Plan provides 18 tablets per prescription for sumatriptan. This may be in addition to a standard 1-month or 3- month supply. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page vii. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online a document that explains our prior authorization restriction. 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 Security Health Plan to make an exception to these restrictions or limits or for a list of other drugs that may treat your health condition. See the section, How do I request an exception to Security Health Plan s 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 Security Health Plan does not cover your drug, you have two options: You can ask Customer Service for a list of similar drugs that are covered by Security Health Plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Security Health Plan. You can ask Security Health Plan to make an exception and cover your drug. See below for information about how to request an exception. ii

5 How do I request an exception to the Ally Rx (HMO SNP) Formulary? You can ask Security Health Plan to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. 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 waive coverage restrictions or limits on your drug. For example, for certain drugs, Security Health Plan 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, Security Health Plan will only approve your request for an exception if the alternative drugs included on the plan s formulary 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 or utilization restriction exception. When you request a formulary or utilization restriction exception, you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 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 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 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 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-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 a 93-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 iii

6 membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. There are times outside of your first 90 days of new membership when the prescription drug transition process will also apply. One of the more common examples would be if you experience a change in your level of care (for example, when you are discharged from a hospital to either your home or to a long-term care facility, or if you end your long-term care facility stay and return to your home). Security Health Plan will ensure you have an effective transition of care, including your medication therapy, anytime you experience a change in your level of care. For more information For more detailed information about your Security Health Plan prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Security Health Plan, 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 ( ) 24 hours a day/7 days a week. TTY users should call Or, visit iv

7 Notice of Nondiscrimination Discrimination is against the law Security Health Plan of Wisconsin, Inc., complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation or health status in the administration of the plan, including enrollment and benefit determinations. Security Health Plan does not exclude people or treat them differently because of race, color, national origin, disability, age, sex, gender identity, sexual orientation or health status. Security Health Plan: Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages If you need these services, contact Customer Service at (TTY: 711). If you believe that Security Health Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation or health status, you can file a grievance with: Security Health Plan Attn: Grievances 1515 North Saint Joseph Avenue Marshfield, WI Phone: (TTY: 711) Fax: shp.appeals.grievance@securityhealth.org You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, Security Health Plan can help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue SW. Room 509F, HHH Building Washington, DC Phone: or (TDD) Complaint forms are available at Language Assistance Services ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call (TTY: 711). Español (Spanish) ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). Hmoob (Hmong) LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau (TTY: 711). v

8 繁體中文 (Chinese) 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY: 711) Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: 711). (Arabic) ةيبرعلا ملحوظة: إذا كنت تتحدث اذكر اللغة فا ن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم (رقم ھاتف الصم والبكم: 117). Русский (Russian) ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 711). 한국어 (Korean) 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 711) 번으로전화해주십시오. Tiếng Việt (Vietnamese) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: 711). Deitsch (Pennsylvania Dutch) Wann du Deitsch schwetzscht, kannscht du mitaus Koschte ebber gricke, ass dihr helft mit die englisch Schprooch. Ruf selli Nummer uff: (TTY: 711). ພາສາລາວ (Lao) ໂປດຊາບ: ຖ າວ າ ທ ານເວ (TTY: 711). າພາສາ ລາວ, ການບ ລການຊ ວຍເຫ ອດ ານພາສາ, ໂດຍບ ເສ ຽຄ າ, ແ ມ ນ ມ ພ ອມໃຫ ທ ານ. ໂທຣ Français (French) ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS : 711). Polski (Polish) UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer (TTY: 711). ह द (Hindi) ध य न द : य द आप ह द ब लत ह त आपक लए म फ त म भ ष सह यत स व ए उपलब ध ह (TTY: 711) पर क ल कर Shqip (Albanian) KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në (TTY: 711). Tagalog (Filipino) PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: 711). Oroomiffa (Oromo/Somalia) XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa (TTY: 711). Large print If you require materials in large print, please call (TTY: 711). vi

9 Ally Rx (HMO SNP) Formulary The formulary that begins on the next page provides coverage information about the drugs covered by Security Health Plan. If you have trouble finding your drug in the list, turn to the index that begins on page 97. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., ZETIA) and generic drugs are listed in lower-case italics (e.g., amoxicillin). The information in the column tells you if Security Health Plan has any special requirements for coverage of your drug. key: PA = Prior authorization required PA NSO = Prior authorization required on new starts only PA B vs. D = Prior authorization required for Part B vs. Part D coverage = Home infusion coverage This prescription drug may be covered under our medical benefit. For more information call Customer Service at , Monday through Sunday from 8 a.m. to 8 p.m. TTY users should call 711. LA = Limited access This prescription may be available only at certain pharmacies. For more information, consult your Pharmacy Directory or call Customer Service at , Monday through Sunday from 8 a.m. 8 p.m. TTY users should call 711. QL = Quantity limit = Non-extended day supply (Limited to 30-day supply) vii

10 Table of Contents Analgesics... 3 Anesthetics... 6 Anti-Addiction/ Substance Abuse Treatment Agents... 6 Antibacterials... 7 Anticonvulsants Antidementia Agents Antidepressants Antiemetics Antifungals Antigout Agents Anti-Inflammatory Agents Antimigraine Agents Antimyasthenic Agents Antimycobacterials Antineoplastics Antiparasitics Antiparkinson Agents Antipsychotics Antispasticity Agents Antivirals Anxiolytics Bipolar Agents Blood Glucose Regulators Blood Products/ Modifiers/ Volume Expanders Cardiovascular Agents Central Nervous System Agents Dental And Oral Agents Dermatological Agents Electrolytes/Minerals/Metals/Vitamins Gastrointestinal Agents Genetic Or Enzyme Disorder: Replacement, Modifiers, Treatment Genitourinary Agents Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal) Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary) Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex Hormones/ Modifiers) Hormonal Agents, Stimulant/ Replacement/ Modifying (Thyroid)

11 Hormonal Agents, Suppressant (Adrenal) Hormonal Agents, Suppressant (Pituitary) Hormonal Agents, Suppressant (Thyroid) Immunological Agents Inflammatory Bowel Disease Agents Metabolic Bone Disease Agents Ophthalmic Agents Otic Agents Respiratory Tract/ Pulmonary Agents Skeletal Muscle Relaxants Sleep Disorder Agents

12 Analgesics Analgesics acetaminophen-codeine oral solution mg/5 ml acetaminophen-codeine oral tablet mg, mg, mg ascomp with codeine oral capsule mg butalbital compound w/codeine oral capsule mg butalbital-acetaminop-caf-cod oral capsule mg butalbital-acetaminop-caf-cod oral capsule mg butalbital-acetaminophen oral tablet mg butalbital-acetaminophen-caff oral capsule mg butalbital-acetaminophen-caff oral capsule mg butalbital-acetaminophen-caff oral tablet mg butalbital-aspirin-caffeine oral capsule mg butalbital-aspirin-caffeine oral tablet mg capacet oral capsule mg endocet oral tablet mg, mg, mg, mg hydrocodone-acetaminophen oral solution mg/15 ml hydrocodone-acetaminophen oral tablet mg, mg, mg, mg, mg, mg, mg hydrocodone-ibuprofen oral tablet mg, mg, mg lorcet (hydrocodone) oral tablet mg lorcet hd oral tablet mg lorcet plus oral tablet mg marten-tab oral tablet mg nalocet oral tablet mg oxycodone-acetaminophen oral tablet mg, mg, mg, mg oxycodone-aspirin oral tablet mg phrenilin forte(with caffeine) oral capsule mg reprexain oral tablet mg, mg, mg tencon oral tablet mg tramadol-acetaminophen oral tablet mg vicodin es oral tablet mg vicodin hp oral tablet mg vicodin oral tablet mg xylon 10 oral tablet mg QL (360 per 30 days) QL (360 per 30 days) QL (360 per 30 days) QL (180 per 30 days) QL (180 per 30 days) QL (180 per 30 days) QL (180 per 30 days) QL (180 per 30 days) QL (240 per 30 days) 3

13 Nonsteroidal Anti-Inflammatory Drugs celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg diclofenac sodium topical gel 3 % diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic mgmcg, mg-mcg diflunisal oral tablet 500 mg etodolac oral capsule 200 mg, 300 mg etodolac oral tablet 400 mg, 500 mg etodolac oral tablet extended release 24 hr 400 mg, 500 mg, 600 mg flurbiprofen oral tablet 100 mg, 50 mg ibu oral tablet 400 mg, 600 mg, 800 mg ibuprofen oral suspension 100 mg/5 ml ibuprofen oral tablet 400 mg, 600 mg, 800 mg indomethacin oral capsule 25 mg, 50 mg indomethacin oral capsule, extended release 75 mg ketorolac injection solution 15 mg/ml ketorolac injection solution 30 mg/ml (1 ml) ketorolac injection syringe 15 mg/ml ketorolac oral tablet 10 mg meloxicam oral tablet 15 mg meloxicam oral tablet 7.5 mg nabumetone oral tablet 500 mg, 750 mg sulindac oral tablet 150 mg, 200 mg Opioid Analgesics, Long-Acting ARYMO ER ORAL TABLET,ORAL ONLY,EXTND RELEASE 15 MG, 30 MG, 60 MG buprenorphine transdermal patch weekly 10 mcg/hour, 15 mcg/hour, 20 mcg/hour, 5 mcg/hour, 7.5 mcg/hour DURAMORPH (PF) INJECTION SOLUTION 0.5 MG/ML, 1 MG/ML fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 62.5 mcg/hour, 75 mcg/hr fentanyl transdermal patch 72 hour 25 mcg/hr hydromorphone (pf) injection solution 10 mg/ml hydromorphone oral tablet extended release 24 hr 12 mg, 16 mg, 32 mg, 8 mg levorphanol tartrate oral tablet 2 mg methadone injection solution 10 mg/ml PA QL (20 per 5 days) QL (20 per 5 days) QL (120 per 30 days) QL (20 per 30 days) QL (15 per 30 days) QL (180 per 30 days) QL (300 per 30 days) 4

14 methadone oral solution 10 mg/5 ml methadone oral solution 5 mg/5 ml methadone oral tablet 10 mg, 5 mg morphine concentrate oral solution 100 mg/5 ml (20 mg/ml) morphine oral solution 10 mg/5 ml, 20 mg/5 ml (4 mg/ml) MORPNE ORAL TABLET 15 MG, 30 MG morphine oral tablet extended release 100 mg, 15 mg, 30 mg, 60 mg morphine oral tablet extended release 200 mg NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR 100 MG, 150 MG, 200 MG, 250 MG, 50 MG OPANA ER ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 5 MG, 7.5 MG oxycodone oral tablet,oral only,ext.rel.12 hr 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 60 mg oxycodone oral tablet,oral only,ext.rel.12 hr 80 mg OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 80 MG tramadol hcl er 300 mg tablet 300 mg tramadol oral tablet extended release 24 hr 100 mg tramadol oral tablet extended release 24 hr 200 mg tramadol oral tablet, er multiphase 24 hr 300 mg Opioid Analgesics, Short-Acting butorphanol tartrate injection solution 1 mg/ml butorphanol tartrate injection solution 2 mg/ml butorphanol tartrate nasal spray,non-aerosol 10 mg/ml codeine sulfate oral tablet 15 mg, 30 mg, 60 mg fentanyl citrate buccal lozenge on a handle 1,200 mcg, 1,600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg hydromorphone oral liquid 1 mg/ml hydromorphone oral tablet 2 mg, 4 mg, 8 mg meperidine oral solution 50 mg/5 ml meperidine oral tablet 100 mg meperidine oral tablet 50 mg morphine 2 mg/ml syringe p/f, suv 2 mg/ml morphine injection solution 10 mg/ml QL (450 per 30 days) QL (900 per 30 days) QL (180 per 30 days) QL (180 per 30 days) QL (120 per 30 days) QL (180 per 30 days) QL (90 per 30 days) QL (120 per 30 days) QL (90 per 30 days) QL (120 per 30 days) QL (90 per 30 days) QL (960 per 30 days) QL (480 per 30 days) QL (5 per 28 days) PA; QL (120 per 30 days); QL (900 per 30 days) QL (180 per 30 days) 5

15 MORPNE INJECTION SOLUTION 2 MG/ML morphine injection syringe 5 mg/ml morphine intravenous cartridge 10 mg/ml, 2 mg/ml, 4 mg/ml, 8 mg/ml morphine intravenous solution 10 mg/ml, 4 mg/ml, 8 mg/ml morphine intravenous syringe 10 mg/ml, 2 mg/ml, 4 mg/ml, 8 mg/ml NUCYNTA ORAL TABLET 100 MG, 50 MG, 75 MG oxycodone oral concentrate 20 mg/ml oxycodone oral solution 5 mg/5 ml oxycodone oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 5 mg oxymorphone oral tablet 10 mg, 5 mg tramadol oral tablet 50 mg Anesthetics Local Anesthetics lidocaine (pf) injection solution 20 mg/ml (2 %), 5 mg/ml (0.5 %) lidocaine (pf) injection syringe 40 mg/2 ml (2%) lidocaine hcl injection solution 10 mg/ml (1 %), 20 mg/ml (2 %), 5 mg/ml (0.5 %) lidocaine hcl mucous membrane jelly 2 % lidocaine hcl mucous membrane solution 4 % (40 mg/ml) lidocaine hcl(pf) in 0.9% nacl injection syringe 100 mg/10 ml (1 %) lidocaine topical adhesive patch,medicated 5 % lidocaine topical ointment 5 % lidocaine viscous mucous membrane solution 2 % lidocaine-prilocaine topical cream % Anti-Addiction/ Substance Abuse Treatment Agents Alcohol Deterrents/Anti-Craving acamprosate oral tablet,delayed release (dr/ec) 333 mg disulfiram oral tablet 250 mg, 500 mg Opioid Dependence Treatments buprenorphine hcl injection syringe 0.3 mg/ml buprenorphine hcl sublingual tablet 2 mg, 8 mg buprenorphine-naloxone sublingual film 8-2 mg buprenorphine-naloxone sublingual tablet mg, 8-2 mg LUCEMYRA ORAL TABLET 0.18 MG naltrexone oral tablet 50 mg SUBOXONE SUBLINGUAL FILM 12-3 MG QL (180 per 30 days) QL (360 per 30 days) QL (7200 per 30 days) QL (360 per 30 days) QL (240 per 30 days) PA NSO; QL (90 per 30 days) QL (90 per 30 days) QL (90 per 30 days) QL (224 per 14 days) 6

16 SUBOXONE SUBLINGUAL FILM MG, 4-1 MG, 8-2 MG Opioid Reversal Agents naloxone injection solution 0.4 mg/ml naloxone injection syringe 1 mg/ml NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION Smoking Cessation Agents bupropion hcl (smoking deter) oral tablet extended release 12 hr 150 mg CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG CHANTIX ORAL TABLET 0.5 MG, 1 MG CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (42) NICOTROL INHALATION CARTRIDGE 10 MG NICOTROL NS NASAL SPRAY,NON-AEROSOL 10 MG/ML Antibacterials Aminoglycosides amikacin injection solution 1,000 mg/4 ml, 500 mg/2 ml BETHKIS INHALATION SOLUTION FOR NEBULIZATION 300 MG/4 ML gentak ophthalmic (eye) ointment 0.3 % (3 mg/gram) gentamicin 80 mg/2 ml vial 25's,mdv,latex-free 40 mg/ml gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 80 mg/100 ml, 80 mg/50 ml gentamicin in nacl (iso-osm) intravenous piggyback 60 mg/50 ml gentamicin injection solution 40 mg/ml gentamicin ophthalmic (eye) drops 0.3 % gentamicin ophthalmic (eye) ointment 0.3 % (3 mg/gram) gentamicin sulfate (ped) (pf) injection solution 20 mg/2 ml gentamicin sulfate (pf) intravenous solution 100 mg/10 ml, 60 mg/6 ml, 80 mg/8 ml gentamicin topical cream 0.1 % gentamicin topical ointment 0.1 % neomycin oral tablet 500 mg neomycin-polymyxin b gu irrigation solution 40 mg-200,000 unit/ml paromomycin oral capsule 250 mg streptomycin intramuscular recon soln 1 gram TOBRADEX OPHTHALMIC (EYE) OINTMENT % QL (90 per 30 days) PA; LA; QL (224 per 28 days); 7

17 tobramycin in % nacl inhalation solution for nebulization 300 mg/5 ml tobramycin ophthalmic (eye) drops 0.3 % tobramycin sulfate injection solution 10 mg/ml, 40 mg/ml TOBREX OPHTHALMIC (EYE) OINTMENT 0.3 % Antibacterials colistin (colistimethate na) injection recon soln 150 mg SYNERCID INTRAVENOUS RECON SOLN 500 MG Antibacterials, Other acetic acid irrigation solution 0.25 % acetic acid otic (ear) solution 2 % ALCOHOL PADS TOPICAL PADS, MEDICATED ALCOHOL PREP PADS aztreonam injection recon soln 2 gram baciim intramuscular recon soln 50,000 unit bacitracin intramuscular recon soln 50,000 unit bacitracin ophthalmic (eye) ointment 500 unit/gram BACTROBAN NASAL NASAL OINTMENT 2 % chloramphenicol sod succinate intravenous recon soln 1 gram clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg clindamycin in 5 % dextrose intravenous piggyback 300 mg/50 ml, 600 mg/50 ml, 900 mg/50 ml clindamycin palmitate hcl oral recon soln 75 mg/5 ml clindamycin phosphate injection solution 150 (mg/ml) (6 ml) clindamycin phosphate injection solution 150 mg/ml clindamycin phosphate intravenous solution 600 mg/4 ml 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 phosphate vaginal cream 2 % daptomycin intravenous recon soln 500 mg lincomycin injection solution 300 mg/ml linezolid 600 mg/300 ml-0.9% nacl 600 mg/300 ml PA; ; PA; ; 8

18 linezolid in dextrose 5% intravenous parenteral solution 600 mg/300 ml linezolid oral suspension for reconstitution 100 mg/5 ml linezolid oral tablet 600 mg mafenide acetate topical packet 50 gram methenamine hippurate oral tablet 1 gram metronidazole in nacl (iso-os) intravenous piggyback 500 mg/100 ml metronidazole oral capsule 375 mg metronidazole oral tablet 250 mg, 500 mg metronidazole topical cream 0.75 % metronidazole topical gel 0.75 %, 1 % metronidazole topical lotion 0.75 % metronidazole vaginal gel 0.75 % MONUROL ORAL PACKET 3 GRAM mupirocin calcium topical cream 2 % mupirocin topical ointment 2 % nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg nitrofurantoin monohyd/m-cryst oral capsule 100 mg nitrofurantoin oral suspension 25 mg/5 ml polymyxin b sulfate injection recon soln 500,000 unit rosadan topical cream 0.75 % SIVEXTRO INTRAVENOUS RECON SOLN 200 MG SIVEXTRO ORAL TABLET 200 MG SULFAMYLON TOPICAL CREAM 85 MG/G SULFAMYLON TOPICAL PACKET 50 GRAM tinidazole oral tablet 250 mg, 500 mg trimethoprim oral tablet 100 mg TRIMPEX ORAL SOLUTION 50 MG/5 ML TYGACIL INTRAVENOUS RECON SOLN 50 MG vancomycin intravenous recon soln 1,000 mg, 10 gram, 5 gram, 500 mg vancomycin intravenous recon soln 750 mg vancomycin oral capsule 125 mg, 250 mg XIFAXAN ORAL TABLET 200 MG XIFAXAN ORAL TABLET 550 MG Beta-Lactam, Cephalosporins PA; ; PA; PA; PA; ; QL (6 per 28 days); PA; QL (6 per 28 days); ; ; QL (9 per 30 days); QL (84 per 28 days); 9

19 cefaclor oral capsule 250 mg, 500 mg cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml cefadroxil oral capsule 500 mg cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet 1 gram cefazolin in 0.9% sod chloride intravenous solution 2 gram/100 ml cefazolin injection recon soln 1 gram, 10 gram, 500 mg cefdinir oral capsule 300 mg cefdinir oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml CEFEPIME 1 GM INJECTION 1 GRAM/50 ML CEFEPIME INJECTION RECON SOLN 1 GRAM, 2 GRAM CEFEPIME-DEXTROSE 2 GM/50 ML 2 GRAM/50 ML cefixime oral suspension for reconstitution 100 mg/5 ml, 200 mg/5 ml cefotaxime injection recon soln 1 gram, 2 gram cefotaxime injection recon soln 10 gram, 500 mg cefotetan injection recon soln 1 gram, 2 gram cefotetan-dextr 1 g duplex bag 1 gram/50 ml cefotetan-dextr 2 g duplex bag 2 gram/50 ml cefoxitin 2 gm piggyback bag 2 gram/50 ml cefoxitin intravenous recon soln 1 gram, 10 gram, 2 gram cefpodoxime oral suspension for reconstitution 100 mg/5 ml, 50 mg/5 ml cefpodoxime oral tablet 100 mg, 200 mg cefprozil oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml cefprozil oral tablet 250 mg, 500 mg ceftazidime injection recon soln 1 gram, 2 gram, 6 gram ceftriaxone 1 gm piggyback l/f, single use 1 gram/50 ml ceftriaxone 2 gm piggyback l/f, single use 2 gram/50 ml ceftriaxone injection recon soln 1 gram, 10 gram, 2 gram, 250 mg, 500 mg cefuroxime axetil oral tablet 250 mg, 500 mg cefuroxime sodium injection recon soln 750 mg cefuroxime sodium intravenous recon soln 1.5 gram cefuroxime sodium intravenous recon soln 7.5 gram cefuroxime-dextrose (iso-osm) intravenous piggyback 1.5 gram/50 ml 10

20 cephalexin oral capsule 250 mg, 500 mg cephalexin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml SUPRAX ORAL CAPSULE 400 MG TEFLARO INTRAVENOUS RECON SOLN 400 MG, 600 MG ZERBAXA INTRAVENOUS RECON SOLN 1.5 GRAM Beta-Lactam, Other aztreonam injection recon soln 1 gram imipenem-cilastatin intravenous recon soln 250 mg, 500 mg INVANZ INJECTION RECON SOLN 1 GRAM meropenem intravenous recon soln 1 gram, 500 mg Beta-Lactam, Penicillins amoxicillin oral capsule 250 mg, 500 mg amoxicillin oral suspension for reconstitution 125 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml amoxicillin oral tablet 500 mg, 875 mg amoxicillin oral tablet,chewable 125 mg, 250 mg 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,chewable mg, mg ampicillin oral capsule 250 mg, 500 mg ampicillin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml ampicillin sodium injection recon soln 1 gram, 10 gram, 125 mg, 250 mg, 500 mg ampicillin-sulbactam injection recon soln 1.5 gram, 15 gram, 3 gram BICILLIN C-R INTRAMUSCULAR SYRINGE 1,200,000 UNIT/ 2 ML(600K/600K), 1,200,000 UNIT/ 2 ML(900K/300K) BICILLIN L-A INTRAMUSCULAR SYRINGE 1,200,000 UNIT/2 ML, 2,400,000 UNIT/4 ML, 600,000 UNIT/ML dicloxacillin oral capsule 250 mg, 500 mg nafcillin 2 gm vial sterile, latex-free 2 gram nafcillin injection recon soln 1 gram, 10 gram penicillin g pot in dextrose intravenous piggyback 2 million unit/50 ml, 3 million unit/50 ml penicillin g potassium injection recon soln 20 million unit 11

21 penicillin v potassium oral recon soln 125 mg/5 ml, 250 mg/5 ml penicillin v potassium oral tablet 250 mg, 500 mg pfizerpen-g injection recon soln 20 million unit piperacillin-tazobactam intravenous recon soln 2.25 gram, gram, 4.5 gram piperacillin-tazobactam intravenous recon soln 40.5 gram Macrolides AZASITE OPHTHALMIC (EYE) DROPS 1 % azithromycin intravenous recon soln 500 mg azithromycin oral packet 1 gram azithromycin oral suspension for reconstitution 100 mg/5 ml, 200 mg/5 ml azithromycin oral tablet 250 mg, 250 mg (6 pack), 500 mg, 500 mg (3 pack), 600 mg clarithromycin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml clarithromycin oral tablet 250 mg, 500 mg clarithromycin oral tablet extended release 24 hr 500 mg DIFICID ORAL TABLET 200 MG ery pads topical swab 2 % ery-tab oral tablet,delayed release (dr/ec) 250 mg, 500 mg ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 333 MG ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG erythromycin ethylsuccinate oral suspension for reconstitution 200 mg/5 ml erythromycin ethylsuccinate oral tablet 400 mg erythromycin ophthalmic (eye) ointment 5 mg/gram (0.5 %) erythromycin oral tablet 250 mg, 500 mg erythromycin with ethanol topical gel 2 % erythromycin with ethanol topical solution 2 % erythromycin with ethanol topical swab 2 % Quinolones AVELOX IN NACL (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK 400 MG/250 ML BESIVANCE OPHTHALMIC (EYE) DROPS,SUSPENSION 0.6 % CILOXAN OPHTHALMIC (EYE) OINTMENT 0.3 % ciprofloxacin hcl ophthalmic (eye) drops 0.3 % PA; QL (20 per 10 days); 12

22 ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 mg ciprofloxacin lactate intravenous solution 200 mg/20 ml, 400 mg/40 ml ciprofloxacin oral suspension,microcapsule recon 250 mg/5 ml, 500 mg/5 ml gatifloxacin ophthalmic (eye) drops 0.5 % levofloxacin 750 mg/30 ml vial suv 25 mg/ml levofloxacin in d5w intravenous piggyback 500 mg/100 ml levofloxacin in d5w intravenous piggyback 750 mg/150 ml levofloxacin intravenous solution 25 mg/ml levofloxacin ophthalmic (eye) drops 0.5 % levofloxacin oral solution 250 mg/10 ml levofloxacin oral tablet 250 mg, 500 mg, 750 mg MOXEZA OPHTHALMIC (EYE) DROPS, VISCOUS 0.5 % moxifloxacin 400 mg/250 ml bag 400 mg/250 ml moxifloxacin in nacl (iso-osm) intravenous piggyback 400 mg/250 ml moxifloxacin ophthalmic (eye) drops 0.5 % moxifloxacin oral tablet 400 mg ofloxacin ophthalmic (eye) drops 0.3 % ofloxacin oral tablet 400 mg ofloxacin otic (ear) drops 0.3 % Sulfonamides bleph-10 ophthalmic (eye) drops 10 % silver sulfadiazine topical cream 1 % ssd topical cream 1 % sulfacetamide sodium (acne) topical suspension 10 % sulfacetamide sodium ophthalmic (eye) drops 10 % 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 sulfatrim oral suspension mg/5 ml Tetracyclines demeclocycline oral tablet 150 mg, 300 mg doxy-100 intravenous recon soln 100 mg doxycycline hyclate intravenous recon soln 100 mg doxycycline hyclate oral capsule 100 mg, 50 mg QL (2.5 per 25 days) 13

23 doxycycline hyclate oral tablet 100 mg, 20 mg doxycycline monohydrate oral capsule 100 mg, 150 mg, 50 mg, 75 mg doxycycline monohydrate oral tablet 100 mg, 150 mg, 50 mg, 75 mg minocycline oral capsule 100 mg, 50 mg, 75 mg tetracycline oral capsule 250 mg, 500 mg Anticonvulsants Anticonvulsants, Other BRIVIACT INTRAVENOUS SOLUTION 50 MG/5 ML BRIVIACT ORAL SOLUTION 10 MG/ML BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 MG, 75 MG 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, 250 mg, 500 mg, 750 mg levetiracetam oral tablet extended release 24 hr 500 mg, 750 mg POTIGA ORAL TABLET 200 MG, 300 MG, 400 MG, 50 MG ROWEEPRA ORAL TABLET 1,000 MG, 750 MG ROWEEPRA XR ORAL TABLET EXTENDED RELEASE 24 HR 500 MG, 750 MG SPRITAM ORAL TABLET FOR SUSPENSION 1,000 MG SPRITAM ORAL TABLET FOR SUSPENSION 250 MG SPRITAM ORAL TABLET FOR SUSPENSION 500 MG SPRITAM ORAL TABLET FOR SUSPENSION 750 MG Calcium Channel Modifying Agents CELONTIN ORAL CAPSULE 300 MG ethosuximide oral capsule 250 mg ethosuximide oral solution 250 mg/5 ml LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 300 MG, 50 MG, 75 MG LYRICA ORAL CAPSULE 225 MG LYRICA ORAL CAPSULE 25 MG LYRICA ORAL SOLUTION 20 MG/ML zonisamide oral capsule 100 mg, 25 mg, 50 mg Gamma-Aminobutyric Acid (Gaba) Augmenting Agents QL (600 per 30 days); ; QL (90 per 30 days) QL (360 per 30 days) QL (180 per 30 days) QL (120 per 30 days) QL (90 per 30 days) QL (900 per 30 days) 14

24 DIASTAT ACUDIAL RECTAL KIT MG, MG DIASTAT RECTAL KIT 2.5 MG diazepam rectal kit 2.5 mg, mg divalproex oral capsule, delayed rel sprinkle 125 mg divalproex oral tablet extended release 24 hr 250 mg, 500 mg divalproex oral tablet,delayed release (dr/ec) 125 mg, 250 mg, 500 mg gabapentin oral capsule 100 mg, 300 mg, 400 mg gabapentin oral solution 250 mg/5 ml gabapentin oral tablet 600 mg, 800 mg GABITRIL ORAL TABLET 12 MG, 16 MG ONFI ORAL SUSPENSION 2.5 MG/ML ONFI ORAL TABLET 10 MG, 20 MG phenobarbital oral elixir 20 mg/5 ml (4 mg/ml) QL (270 per 30 days) QL (180 per 30 days) QL (480 per 30 days) QL (1500 per 30 days) phenobarbital oral tablet 100 mg, 16.2 mg, 32.4 mg, 64.8 mg, 97.2 mg QL (90 per 30 days) phenobarbital oral tablet 15 mg, 60 mg phenobarbital oral tablet 30 mg primidone oral tablet 250 mg, 50 mg SABRIL ORAL POWDER IN PACKET 500 MG SABRIL ORAL TABLET 500 MG tiagabine oral tablet 12 mg, 16 mg, 2 mg, 4 mg valproate sodium intravenous solution 500 mg/5 ml (100 mg/ml) valproic acid (as sodium salt) oral solution 500 mg/10 ml (10 ml) valproic acid 250 mg/5 ml soln 250 mg/5 ml valproic acid oral capsule 250 mg vigabatrin oral powder in packet 500 mg Glutamate Reducing Agents felbamate oral suspension 600 mg/5 ml felbamate oral tablet 400 mg, 600 mg FYCOMPA ORAL SUSPENSION 0.5 MG/ML FYCOMPA ORAL TABLET 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg lamotrigine oral tablet extended release 24hr 100 mg, 200 mg, 25 mg, 300 mg, 50 mg lamotrigine oral tablet, chewable dispersible 25 mg, 5 mg QL (120 per 30 days) QL (300 per 30 days) QL (180 per 30 days); QL (180 per 30 days); QL (680 per 28 days) 15

25 lamotrigine oral tablets,dose pack 25 mg (35), 25 mg (42) -100 mg (7), 25 mg (84) -100 mg (14) topiramate oral capsule, sprinkle 15 mg, 25 mg topiramate oral capsule,sprinkle,er 24hr 100 mg, 150 mg, 200 mg, 25 mg, 50 mg topiramate oral tablet 100 mg, 200 mg, 50 mg topiramate oral tablet 25 mg Sodium Channel Agents APTIOM ORAL TABLET 200 MG, 400 MG, 800 MG APTIOM ORAL TABLET 600 MG BANZEL ORAL SUSPENSION 40 MG/ML BANZEL ORAL TABLET 200 MG BANZEL ORAL TABLET 400 MG carbamazepine oral suspension 100 mg/5 ml carbamazepine oral tablet 200 mg carbamazepine oral tablet extended release 12 hr 100 mg, 200 mg, 400 mg carbamazepine oral tablet,chewable 100 mg DILANTIN EXTENDED ORAL CAPSULE 100 MG DILANTIN INFATABS ORAL TABLET,CHEWABLE 50 MG DILANTIN ORAL CAPSULE 30 MG DILANTIN-125 ORAL SUSPENSION 125 MG/5 ML epitol oral tablet 200 mg EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 100 MG, 200 MG, 300 MG fosphenytoin injection solution 100 mg pe/2 ml, 500 mg pe/10 ml oxcarbazepine oral suspension 300 mg/5 ml (60 mg/ml) oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg PEGANONE ORAL TABLET 250 MG PHENYTEK ORAL CAPSULE 200 MG, 300 MG phenytoin oral suspension 125 mg/5 ml phenytoin oral tablet,chewable 50 mg phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 mg phenytoin sodium intravenous solution 50 mg/ml TEGRETOL ORAL SUSPENSION 100 MG/5 ML TEGRETOL ORAL TABLET 200 MG VIMPAT INTRAVENOUS SOLUTION 200 MG/20 ML QL (120 per 30 days) QL (90 per 30 days) QL (2760 per 30 days); QL (480 per 30 days); QL (240 per 30 days); 16

26 VIMPAT ORAL SOLUTION 10 MG/ML VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG Antidementia Agents Antidementia Agents, Other ergoloid oral tablet 1 mg Cholinesterase Inhibitors donepezil oral tablet 10 mg donepezil oral tablet 23 mg, 5 mg donepezil oral tablet,disintegrating 10 mg, 5 mg galantamine oral capsule,ext rel. pellets 24 hr 16 mg, 24 mg, 8 mg galantamine oral solution 4 mg/ml galantamine oral tablet 12 mg, 4 mg, 8 mg rivastigmine tartrate oral capsule 1.5 mg, 3 mg rivastigmine tartrate oral capsule 4.5 mg, 6 mg rivastigmine transdermal patch 24 hour 13.3 mg/24 hour, 4.6 mg/24 hr, 9.5 mg/24 hr N-Methyl-D-Aspartate (Nmda) Receptor Antagonist memantine oral capsule,sprinkle,er 24hr 14 mg, 21 mg, 28 mg, 7 mg memantine oral solution 2 mg/ml memantine oral tablet 10 mg, 5 mg memantine oral tablets,dose pack 5-10 mg NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE PACK MG NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 24HR 14 MG, 21 MG, 28 MG, 7 MG NAMZARIC ORAL CAP,SPRINKLE,ER 24HR DOSE PACK 7/14/21/28 MG-10 MG NAMZARIC ORAL CAPSULE,SPRINKLE,ER 24HR MG, MG, MG, 7-10 MG Antidepressants Antidepressants amitriptyline-chlordiazepoxide oral tablet mg, mg perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4-10 mg, 4-25 mg, 4-50 mg Antidepressants, Other bupropion hcl oral tablet 100 mg bupropion hcl oral tablet 75 mg QL (1395 per 30 days) QL (200 per 30 days) QL (90 per 30 days) QL (360 per 30 days) QL (98 per 30 days) QL (28 per 30 days) QL (28 per 28 days) QL (180 per 30 days) 17

27 bupropion hcl oral tablet extended release 12 hr 100 mg bupropion hcl oral tablet extended release 12 hr 150 mg bupropion hcl oral tablet extended release 12 hr 200 mg bupropion hcl oral tablet extended release 24 hr 150 mg bupropion hcl oral tablet extended release 24 hr 300 mg maprotiline oral tablet 25 mg, 50 mg, 75 mg mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg mirtazapine oral tablet,disintegrating 15 mg, 30 mg, 45 mg nefazodone oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 mg trazodone oral tablet 100 mg, 150 mg, 300 mg, 50 mg Monoamine Oxidase Inhibitors EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG/24 HR, 6 MG/24 HR, 9 MG/24 HR MARPLAN ORAL TABLET 10 MG phenelzine oral tablet 15 mg tranylcypromine oral tablet 10 mg Ssris/ Snris citalopram oral solution 10 mg/5 ml citalopram oral tablet 10 mg, 40 mg citalopram oral tablet 20 mg desvenlafaxine succinate oral tablet extended release 24 hr 100 mg, 25 mg, 50 mg duloxetine oral capsule,delayed release(dr/ec) 20 mg, 30 mg, 40 mg, 60 mg escitalopram oxalate oral solution 5 mg/5 ml escitalopram oxalate oral tablet 10 mg escitalopram oxalate oral tablet 20 mg escitalopram oxalate oral tablet 5 mg FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK 20 MG (2)- 40 MG (26) FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 20 MG, 40 MG, 80 MG fluoxetine oral capsule 10 mg, 40 mg fluoxetine oral capsule 20 mg fluoxetine oral solution 20 mg/5 ml (4 mg/ml) fluvoxamine oral capsule,extended release 24hr 100 mg, 150 mg fluvoxamine oral tablet 100 mg, 25 mg, 50 mg QL (120 per 30 days) QL (90 per 30 days) QL (90 per 30 days) ; QL (600 per 30 days) QL (45 per 30 days) QL (90 per 30 days) QL (28 per 28 days) QL (120 per 30 days) QL (90 per 30 days) 18

28 paroxetine hcl oral tablet 10 mg, 20 mg paroxetine hcl oral tablet 30 mg, 40 mg PAXIL ORAL SUSPENSION 10 MG/5 ML sertraline oral concentrate 20 mg/ml sertraline oral tablet 100 mg sertraline oral tablet 25 mg, 50 mg TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG venlafaxine oral capsule,extended release 24hr 150 mg venlafaxine oral capsule,extended release 24hr 37.5 mg venlafaxine oral capsule,extended release 24hr 75 mg venlafaxine oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23), 10 MG (7)-20 MG (7)-40 MG (16) Tricyclics amitriptyline oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg clomipramine oral capsule 25 mg, 50 mg, 75 mg desipramine oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg doxepin oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg doxepin oral concentrate 10 mg/ml imipramine hcl oral tablet 10 mg, 25 mg, 50 mg imipramine pamoate oral capsule 100 mg, 125 mg, 150 mg, 75 mg nortriptyline oral capsule 10 mg, 25 mg, 50 mg, 75 mg nortriptyline oral solution 10 mg/5 ml protriptyline oral tablet 10 mg, 5 mg SILENOR ORAL TABLET 3 MG, 6 MG trimipramine oral capsule 100 mg, 25 mg, 50 mg Antiemetics Antiemetics, Other compro rectal suppository 25 mg diphenhydramine hcl injection solution 50 mg/ml diphenhydramine hcl injection syringe 50 mg/ml hydroxyzine hcl intramuscular solution 25 mg/ml hydroxyzine hcl oral solution 10 mg/5 ml hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg QL (300 per 30 days) QL (90 per 30 days) 19

29 hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg meclizine oral tablet 12.5 mg, 25 mg perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg phenadoz rectal suppository 12.5 mg, 25 mg prochlorperazine edisylate injection solution 10 mg/2 ml (5 mg/ml) prochlorperazine maleate oral tablet 10 mg, 5 mg prochlorperazine rectal suppository 25 mg promethazine injection solution 25 mg/ml, 50 mg/ml promethazine oral syrup 6.25 mg/5 ml promethazine oral tablet 12.5 mg, 25 mg, 50 mg promethazine rectal suppository 12.5 mg, 25 mg, 50 mg promethegan rectal suppository 12.5 mg, 25 mg, 50 mg scopolamine base transdermal patch 3 day 1 mg over 3 days TRANSDERM-SCOP TRANSDERMAL PATCH 3 DAY 1 MG OVER 3 DAYS Emetogenic Therapy Adjuncts AKYNZEO (NETUPITANT) ORAL CAPSULE MG ANZEMET ORAL TABLET 100 MG ANZEMET ORAL TABLET 50 MG aprepitant oral capsule 125 mg, 40 mg, 80 mg aprepitant oral capsule,dose pack 125 mg (1)- 80 mg (2) CESAMET ORAL CAPSULE 1 MG dronabinol oral capsule 10 mg, 2.5 mg, 5 mg granisetron (pf) intravenous solution 100 mcg/ml granisetron hcl intravenous solution 1 mg/ml, 1 mg/ml (1 ml) granisetron hcl oral tablet 1 mg ondansetron hcl (pf) injection solution 4 mg/2 ml ondansetron hcl (pf) injection syringe 4 mg/2 ml ondansetron hcl oral solution 4 mg/5 ml ondansetron hcl oral tablet 24 mg, 4 mg, 8 mg ondansetron oral tablet,disintegrating 4 mg, 8 mg Antifungals Antifungals ABELCET INTRAVENOUS SUSPENSION 5 MG/ML AMBISOME INTRAVENOUS SUSPENSION FOR RECONSTITUTION 50 MG QL (10 per 30 days) ; ; ; QL (120 per 30 days) ; QL (28 per 28 days) ; ; ; QL (450 per 30 days) ; QL (450 per 30 days) ; 20

30 amphotericin b injection recon soln 50 mg CANCIDAS INTRAVENOUS RECON SOLN 50 MG, 70 MG caspofungin intravenous recon 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 % clotrimazole mucous membrane troche 10 mg clotrimazole topical cream 1 % clotrimazole topical solution 1 % econazole topical cream 1 % fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/100 ml, 400 mg/200 ml fluconazole oral suspension for reconstitution 10 mg/ml, 40 mg/ml fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg fluconazole-dext 200 mg/100 ml inner, suv 200 mg/100 ml flucytosine oral capsule 250 mg, 500 mg griseofulvin microsize oral suspension 125 mg/5 ml griseofulvin microsize oral tablet 500 mg griseofulvin ultramicrosize oral tablet 125 mg, 250 mg itraconazole oral capsule 100 mg ketoconazole oral tablet 200 mg ketoconazole topical cream 2 % ketoconazole topical shampoo 2 % miconazole-3 vaginal suppository 200 mg naftifine topical cream 1 %, 2 % NAFTIN TOPICAL GEL 1 %, 2 % NATACYN OPHTHALMIC (EYE) DROPS,SUSPENSION 5 % NOXAFIL ORAL SUSPENSION 200 MG/5 ML (40 MG/ML) ; PA; QL (120 per 30 days) PA; QL (840 per 28 days); NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) 100 MG PA; QL (93 per 30 days); nyamyc topical powder 100,000 unit/gram nyata topical powder 100,000 unit/gram nystatin oral powder 500 million unit nystatin oral suspension 100,000 unit/ml nystatin oral tablet 500,000 unit 21

31 nystatin topical cream 100,000 unit/gram nystatin topical ointment 100,000 unit/gram nystatin topical powder 100,000 unit/gram nystop topical powder 100,000 unit/gram SPORANOX ORAL SOLUTION 10 MG/ML terbinafine hcl oral tablet 250 mg terconazole vaginal cream 0.4 %, 0.8 % terconazole vaginal suppository 80 mg voriconazole intravenous solution 200 mg voriconazole oral suspension for reconstitution 200 mg/5 ml (40 mg/ml) voriconazole oral tablet 200 mg, 50 mg Antigout Agents Antigout Agents allopurinol oral tablet 100 mg, 300 mg colchicine oral capsule 0.6 mg colchicine oral tablet 0.6 mg COLCRYS ORAL TABLET 0.6 MG probenecid oral tablet 500 mg probenecid-colchicine oral tablet mg ULORIC ORAL TABLET 40 MG, 80 MG Anti-Inflammatory Agents Glucocorticoids 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 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 % BLEPHAMIDE OPHTHALMIC (EYE) DROPS,SUSPENSION % BLEPHAMIDE S.O.P. OPHTHALMIC (EYE) OINTMENT % PA; QL (90 per 365 days) PA; QL (400 per 30 days); PA; QL (120 per 30 days); QL (120 per 30 days) 22

32 cortisone oral tablet 25 mg deltasone oral tablet 20 mg DEPO-MEDROL INJECTION SUSPENSION 20 MG/ML, 40 MG/ML, 80 MG/ML dexamethasone oral elixir 0.5 mg/5 ml dexamethasone oral tablet 0.5 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg dexamethasone oral tablet 0.75 mg dexamethasone sodium phos (pf) injection solution 10 mg/ml dexamethasone sodium phosphate injection solution 10 mg/ml, 4 mg/ml dexamethasone sodium phosphate injection syringe 4 mg/ml hydrocortisone oral tablet 20 mg, 5 mg methylprednisolone acetate injection suspension 40 mg/ml, 80 mg/ml methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg methylprednisolone sodium succ injection recon soln 40 mg methylprednisolone sodium succ intravenous recon soln 1,000 mg PRED MILD OPHTHALMIC (EYE) DROPS,SUSPENSION 0.12 % prednisolone 15 mg/5 ml soln a/f, d/f 15 mg/5 ml (3 mg/ml) prednisolone oral solution 15 mg/5 ml prednisone oral tablet 1 mg, 2.5 mg, 20 mg, 5 mg, 50 mg prednisone oral tablet 10 mg SOLU-CORTEF (PF) INJECTION RECON SOLN 1,000 MG/8 ML, 100 MG/2 ML, 250 MG/2 ML, 500 MG/4 ML SOLU-MEDROL (PF) INJECTION RECON SOLN 125 MG/2 ML, 40 MG/ML SOLU-MEDROL (PF) INTRAVENOUS RECON SOLN 1,000 MG/8 ML, 500 MG/4 ML SOLU-MEDROL INTRAVENOUS RECON SOLN 1,000 MG, 2 GRAM sulfacetamide-prednisolone ophthalmic (eye) drops 10 %-0.23 % (0.25 %) Nonsteroidal Anti-Inflammatory Drugs diclofenac potassium oral tablet 50 mg diclofenac sodium oral tablet extended release 24 hr 100 mg diclofenac sodium oral tablet,delayed release (dr/ec) 25 mg, 50 mg, 75 mg FLECTOR TRANSDERMAL PATCH 12 HOUR 1.3 % ketoprofen oral capsule 50 mg, 75 mg PA NSO; 23

33 naproxen oral suspension 125 mg/5 ml naproxen oral tablet 250 mg, 375 mg, 500 mg naproxen oral tablet,delayed release (dr/ec) 375 mg, 500 mg naproxen sodium oral tablet 275 mg, 550 mg naproxen sodium oral tablet, er multiphase 24 hr 375 mg, 500 mg oxaprozin oral tablet 600 mg piroxicam oral capsule 10 mg, 20 mg Antimigraine Agents Ergot Alkaloids dihydroergotamine injection solution 1 mg/ml dihydroergotamine nasal spray,non-aerosol 0.5 mg/pump act. (4 mg/ml) ergotamine-caffeine oral tablet mg MIGERGOT RECTAL SUPPOSITORY MG Serotonin (5-Ht) 1B/1D Receptor Agonists almotriptan malate oral tablet 12.5 mg, 6.25 mg eletriptan oral tablet 20 mg, 40 mg frovatriptan oral tablet 2.5 mg naratriptan oral tablet 1 mg, 2.5 mg rizatriptan oral tablet 10 mg, 5 mg rizatriptan oral tablet,disintegrating 10 mg, 5 mg sumatriptan nasal spray,non-aerosol 20 mg/actuation sumatriptan nasal spray,non-aerosol 5 mg/actuation sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg QL (12 per 30 days) QL (12 per 30 days) QL (12 per 30 days) QL (18 per 30 days) QL (18 per 30 days) QL (18 per 30 days) QL (12 per 30 days) QL (6 per 30 days) QL (18 per 30 days) sumatriptan succinate subcutaneous cartridge 4 mg/0.5 ml, 6 mg/0.5 ml QL (8 per 30 days) sumatriptan succinate subcutaneous pen injector 4 mg/0.5 ml, 6 mg/0.5 ml sumatriptan succinate subcutaneous solution 6 mg/0.5 ml sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml zolmitriptan oral tablet 2.5 mg, 5 mg zolmitriptan oral tablet,disintegrating 2.5 mg, 5 mg Antimyasthenic Agents Parasympathomimetics guanidine oral tablet 125 mg pyridostigmine bromide oral tablet 60 mg pyridostigmine bromide oral tablet extended release 180 mg QL (8 per 30 days) QL (8 per 30 days) QL (8 per 30 days) QL (12 per 30 days) QL (12 per 30 days) 24

34 Antimycobacterials Antimycobacterials, Other dapsone oral tablet 100 mg, 25 mg PRIFTIN ORAL TABLET 150 MG rifabutin oral capsule 150 mg Antituberculars CAPASTAT INJECTION RECON SOLN 1 GRAM ethambutol oral tablet 100 mg, 400 mg isoniazid injection solution 100 mg/ml isoniazid oral solution 50 mg/5 ml isoniazid oral tablet 100 mg, 300 mg PASER ORAL GRANULES DR FOR SUSP IN PACKET 4 GRAM pyrazinamide oral tablet 500 mg rifampin intravenous recon soln 600 mg rifampin oral capsule 150 mg, 300 mg RIFATER ORAL TABLET MG SIRTURO ORAL TABLET 100 MG TRECATOR ORAL TABLET 250 MG Antineoplastics Alkylating Agents CYCLOPHOSPHAMIDE ORAL CAPSULE 25 MG, 50 MG cyclophosphamide oral tablet 25 mg, 50 mg HEXALEN ORAL CAPSULE 50 MG LEUKERAN ORAL TABLET 2 MG MATULANE ORAL CAPSULE 50 MG VALCHLOR TOPICAL GEL % Antiandrogens bicalutamide oral tablet 50 mg ERLEADA ORAL TABLET 60 MG flutamide oral capsule 125 mg nilutamide oral tablet 150 mg XTANDI ORAL CAPSULE 40 MG ZYTIGA ORAL TABLET 250 MG ZYTIGA ORAL TABLET 500 MG Antiangiogenic Agents QL (68 per 28 days); LA; QL (60 per 28 days); PA NSO; QL (120 per 30 days); ; PA NSO; QL (120 per 30 days); PA NSO; QL (120 per 30 days); PA NSO; QL (2 per 1 day); 25

35 POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG REVLIMID ORAL CAPSULE 10 MG, 15 MG, 25 MG, 5 MG THALOMID ORAL CAPSULE 100 MG, 200 MG, 50 MG THALOMID ORAL CAPSULE 150 MG Antiestrogens/Modifiers EMCYT ORAL CAPSULE 140 MG FARESTON ORAL TABLET 60 MG SOLTAMOX ORAL SOLUTION 10 MG/5 ML tamoxifen oral tablet 10 mg, 20 mg Antimetabolites DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG hydroxyurea oral capsule 500 mg LONSURF ORAL TABLET MG LONSURF ORAL TABLET MG PURIXAN ORAL SUSPENSION 20 MG/ML TABLOID ORAL TABLET 40 MG Antineoplastics adrucil intravenous solution 2.5 gram/50 ml adrucil intravenous solution 500 mg/10 ml ALIMTA INTRAVENOUS RECON SOLN 100 MG, 500 MG AVASTIN INTRAVENOUS SOLUTION 25 MG/ML, 25 MG/ML (16 ML) azacitidine injection recon soln 100 mg BELEODAQ INTRAVENOUS RECON SOLN 500 MG BICNU INTRAVENOUS RECON SOLN 100 MG bleomycin injection recon soln 15 unit bleomycin injection recon soln 30 unit BORTEZOMIB INTRAVENOUS RECON SOLN 3.5 MG carboplatin intravenous solution 10 mg/ml dexrazoxane hcl intravenous recon soln 250 mg, 500 mg doxorubicin, peg-liposomal intravenous suspension 2 mg/ml ELITEK INTRAVENOUS RECON SOLN 1.5 MG epirubicin intravenous solution 200 mg/100 ml FASLODEX INTRAMUSCULAR SYRINGE 250 MG/5 ML PA NSO; LA; QL (21 per 28 days); PA NSO; LA; QL (28 per 28 days); PA NSO; ; PA NSO; ; ; PA NSO; QL (100 per 30 days); PA NSO; QL (80 per 30 days); QL (300 per 30 days); ; 26

36 GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG, 5 MG HERCEPTIN INTRAVENOUS RECON SOLN 150 MG, 440 MG KADCYLA INTRAVENOUS RECON SOLN 100 MG, 160 MG LEVOLEUCOVORIN INTRAVENOUS RECON SOLN 175 MG levoleucovorin intravenous recon soln 50 mg levoleucovorin intravenous solution 10 mg/ml LYNPARZA ORAL CAPSULE 50 MG LYNPARZA ORAL TABLET 100 MG, 150 MG mesna intravenous solution 100 mg/ml MESNEX INTRAVENOUS SOLUTION 100 MG/ML MESNEX ORAL TABLET 400 MG MUSTARGEN INJECTION RECON SOLN 10 MG NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG oxaliplatin intravenous recon soln 100 mg paclitaxel intravenous concentrate 6 mg/ml PERJETA INTRAVENOUS SOLUTION 420 MG/14 ML (30 MG/ML) PROLEUKIN INTRAVENOUS RECON SOLN 22 MILLION UNIT RUBRACA ORAL TABLET 200 MG, 300 MG RUBRACA ORAL TABLET 250 MG SYLVANT INTRAVENOUS RECON SOLN 100 MG, 400 MG TREANDA INTRAVENOUS RECON SOLN 100 MG, 25 MG TRISENOX INTRAVENOUS SOLUTION 10 MG/10 ML, 2 MG/ML VELCADE INJECTION RECON SOLN 3.5 MG VENCLEXTA ORAL TABLET 10 MG VENCLEXTA ORAL TABLET 100 MG VENCLEXTA ORAL TABLET 50 MG VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 10 MG-50 MG- 100 MG VYXEOS INTRAVENOUS RECON SOLN MG YONDELIS INTRAVENOUS RECON SOLN 1 MG ZEJULA ORAL CAPSULE 100 MG Antineoplastics, Other ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 100 MG leucovorin calcium 100 mg vial sdv,p/f,latex-free 100 mg PA NSO PA NSO; LA; QL (448 per 28 days); PA NSO; QL (4 per 1 day); PA NSO; QL (3 per 28 days); PA NSO PA NSO; PA NSO; PA NSO; ; PA NSO; PA NSO; PA NSO; QL (28 per 28 days) PA NSO; QL (120 per 30 days); PA NSO; QL (14 per 28 days) PA NSO; QL (42 per 28 days); ; PA NSO; PA NSO; 27

37 leucovorin calcium injection recon soln 100 mg, 200 mg leucovorin calcium injection solution 500 mg/50 ml leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg mitoxantrone intravenous concentrate 2 mg/ml NAVELBINE INTRAVENOUS SOLUTION 10 MG/ML, 50 MG/5 ML REVLIMID ORAL CAPSULE 2.5 MG, 20 MG SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG SYNRIBO SUBCUTANEOUS RECON SOLN 3.5 MG YERVOY INTRAVENOUS SOLUTION 50 MG/10 ML (5 MG/ML) Aromatase Inhibitors, 3Rd Generation anastrozole oral tablet 1 mg exemestane oral tablet 25 mg letrozole oral tablet 2.5 mg Enzyme Inhibitors ALIQOPA INTRAVENOUS RECON SOLN 60 MG ETOPOPHOS INTRAVENOUS RECON SOLN 100 MG etoposide intravenous solution 20 mg/ml FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG HYCAMTIN INTRAVENOUS RECON SOLN 4 MG IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG IDFA ORAL TABLET 100 MG, 50 MG KISQALI FEMARA CO-PACK ORAL TABLET 200 MG/DAY(200 MG X 1)-2.5 MG, 400 MG/DAY(200 MG X 2)-2.5 MG, 600 MG/DAY(200 MG X 3)-2.5 MG KISQALI ORAL TABLET 200 MG/DAY (200 MG X 1), 400 MG/DAY (200 MG X 2), 600 MG/DAY (200 MG X 3) toposar intravenous solution 20 mg/ml topotecan intravenous recon soln 4 mg topotecan intravenous solution 4 mg/4 ml (1 mg/ml) VERZENIO ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG YONSA ORAL TABLET 125 MG ZOLINZA ORAL CAPSULE 100 MG ZYDELIG ORAL TABLET 100 MG, 150 MG Molecular Target Inhibitors AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG PA NSO; LA; PA NSO; QL (4 per 28 days); PA NSO; QL (28 per 28 days); QL (250 per 21 days); ; PA NSO; QL (6 per 21 days); PA NSO; QL (21 per 28 days); PA NSO; QL (1 per 1 day); PA NSO; PA NSO; PA NSO; QL (56 per 28 days); PA NSO; QL (120 per 30 days); PA NSO; QL (120 per 30 days); PA NSO; ; PA NSO; ; 28

38 ALECENSA ORAL CAPSULE 150 MG ALUNBRIG ORAL TABLET 180 MG, 90 MG ALUNBRIG ORAL TABLET 30 MG ALUNBRIG ORAL TABLETS,DOSE PACK 90 MG (7)- 180 MG (23) BOSULIF ORAL TABLET 100 MG BOSULIF ORAL TABLET 400 MG BOSULIF ORAL TABLET 500 MG CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG CALQUENCE ORAL CAPSULE 100 MG CAPRELSA ORAL TABLET 100 MG CAPRELSA ORAL TABLET 300 MG COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1) COMETRIQ ORAL CAPSULE 140 MG/DAY(80 MG X1-20 MG X3) COMETRIQ ORAL CAPSULE 60 MG/DAY (20 MG X 3/DAY) COTELLIC ORAL TABLET 20 MG ERIVEDGE ORAL CAPSULE 150 MG GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG ICLUSIG ORAL TABLET 15 MG, 45 MG imatinib oral tablet 100 mg, 400 mg IMBRUVICA ORAL CAPSULE 140 MG IMBRUVICA ORAL CAPSULE 70 MG IMBRUVICA ORAL TABLET 140 MG, 280 MG, 420 MG, 560 MG INLYTA ORAL TABLET 1 MG INLYTA ORAL TABLET 5 MG IRESSA ORAL TABLET 250 MG JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1/DAY) PA NSO; PA NSO; ; PA NSO; PA NSO; ; PA NSO; QL (120 per 30 days); PA NSO; QL (1 per 1 day); PA NSO; ; PA NSO; ; PA NSO; QL (2 per 1 day); PA NSO; LA; ; PA NSO; LA; ; PA NSO; LA; QL (56 per 28 days); PA NSO; LA; QL (112 per 28 days); PA NSO; LA; QL (84 per 28 days); PA NSO; LA; QL (63 per 28 days); PA NSO; QL (28 per 28 days); PA NSO; ; PA NSO; LA; ; PA NSO; PA NSO; QL (120 per 30 days); PA NSO; ; PA NSO; ; PA NSO; QL (180 per 30 days); PA NSO; ; PA NSO; LA; ; PA NSO; ; PA NSO; LA; ; 29

39 LENVIMA ORAL CAPSULE 14 MG/DAY(10 MG X 1-4 MG X 1), 20 MG/DAY (10 MG X 2), 8 MG/DAY (4 MG X 2) LENVIMA ORAL CAPSULE 18 MG/DAY (10 MG X 1-4 MG X2), 24 MG/DAY(10 MG X 2-4 MG X 1) MEKINIST ORAL TABLET 0.5 MG MEKINIST ORAL TABLET 2 MG NERLYNX ORAL TABLET 40 MG NEXAVAR ORAL TABLET 200 MG ODOMZO ORAL CAPSULE 200 MG RYDAPT ORAL CAPSULE 25 MG SPRYCEL ORAL TABLET 100 MG, 50 MG, 70 MG, 80 MG SPRYCEL ORAL TABLET 140 MG SPRYCEL ORAL TABLET 20 MG STIVARGA ORAL TABLET 40 MG SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG TAFINLAR ORAL CAPSULE 50 MG TAFINLAR ORAL CAPSULE 75 MG TAGRISSO ORAL TABLET 40 MG, 80 MG TARCEVA ORAL TABLET 100 MG, 150 MG TARCEVA ORAL TABLET 25 MG TASIGNA ORAL CAPSULE 150 MG, 200 MG, 50 MG TYKERB ORAL TABLET 250 MG VOTRIENT ORAL TABLET 200 MG XALKORI ORAL CAPSULE 200 MG, 250 MG ZELBORAF ORAL TABLET 240 MG ZYKADIA ORAL CAPSULE 150 MG Monoclonal Antibody/Antibody-Drug Conjugate BAVENCIO INTRAVENOUS SOLUTION 20 MG/ML BESPONSA INTRAVENOUS RECON SOLN 0.9 MG (0.25 MG/ML INITIAL) CYRAMZA INTRAVENOUS SOLUTION 10 MG/ML, 10 MG/ML (50 ML) DARZALEX INTRAVENOUS SOLUTION 20 MG/ML EMPLICITI INTRAVENOUS RECON SOLN 300 MG, 400 MG PA NSO; LA; ; PA NSO; LA; QL (90 per 30 days); PA NSO; QL (120 per 30 days); PA NSO; ; PA NSO; QL (180 per 30 days); QL (120 per 30 days); PA NSO; LA; ; PA NSO; PA NSO; ; PA NSO; ; PA NSO; QL (90 per 30 days); PA NSO; QL (84 per 28 days); PA NSO; QL (28 per 28 days); PA NSO; QL (180 per 30 days); PA NSO; QL (120 per 30 days); PA NSO; LA; ; PA NSO; ; PA NSO; QL (90 per 30 days); PA NSO; PA NSO; QL (150 per 30 days); PA NSO; QL (120 per 30 days); PA NSO; ; PA NSO; QL (240 per 30 days); PA NSO; QL (150 per 30 days); ; ; PA NSO; QL (200 per 28 days); PA NSO; LA; QL (400 per 30 days); PA NSO; 30

40 IMFINZI INTRAVENOUS SOLUTION 50 MG/ML, 50 MG/ML (10 ML) KEYTRUDA INTRAVENOUS RECON SOLN 50 MG KEYTRUDA INTRAVENOUS SOLUTION 25 MG/ML LARTRUVO INTRAVENOUS SOLUTION 10 MG/ML, 10 MG/ML (19 ML) MYLOTARG INTRAVENOUS RECON SOLN 4.5 MG (1 MG/ML INITIAL CONC) OPDIVO INTRAVENOUS SOLUTION 100 MG/10 ML, 240 MG/24 ML, 40 MG/4 ML RITUXAN INTRAVENOUS CONCENTRATE 10 MG/ML, 10 MG/ML (10 ML) TECENTRIQ INTRAVENOUS SOLUTION 1,200 MG/20 ML (60 MG/ML) Retinoids bexarotene oral capsule 75 mg PANRETIN TOPICAL GEL 0.1 % TARGRETIN TOPICAL GEL 1 % tretinoin (chemotherapy) oral capsule 10 mg Antiparasitics Anthelmintics ALBENZA ORAL TABLET 200 MG BILTRICIDE ORAL TABLET 600 MG ivermectin oral tablet 3 mg praziquantel oral tablet 600 mg Antiprotozoals ALINIA ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML ALINIA ORAL TABLET 500 MG atovaquone oral suspension 750 mg/5 ml atovaquone-proguanil oral tablet mg, mg chloroquine phosphate oral tablet 250 mg, 500 mg COARTEM ORAL TABLET MG DARAPRIM ORAL TABLET 25 MG hydroxychloroquine oral tablet 200 mg mefloquine oral tablet 250 mg MEPRON ORAL SUSPENSION 750 MG/5 ML PA NSO; PA NSO; PA NSO; ; QL (80 per 28 days); PA NSO; QL (20 per 21 days); PA NSO; QL (300 per 30 days); QL (150 per 30 days) QL (40 per 30 days) QL (24 per 30 days) PA 31

41 NEBUPENT INHALATION RECON SOLN 300 MG PENTAM INJECTION RECON SOLN 300 MG PRIMAQUINE ORAL TABLET 26.3 MG quinine sulfate oral capsule 324 mg Pediculicides/Scabicides lindane topical shampoo 1 % malathion topical lotion 0.5 % permethrin topical cream 5 % Antiparkinson Agents Anticholinergics benztropine oral tablet 0.5 mg, 1 mg, 2 mg trihexyphenidyl oral elixir 0.4 mg/ml trihexyphenidyl oral tablet 2 mg, 5 mg Antiparkinson Agents carbidopa oral tablet 25 mg carbidopa-levodopa-entacapone oral tablet mg, mg, mg, mg, mg, mg RYTARY ORAL CAPSULE, EXTENDED RELEASE MG, MG, MG, MG Antiparkinson Agents, Other amantadine hcl oral capsule 100 mg amantadine hcl oral solution 50 mg/5 ml amantadine hcl oral tablet 100 mg entacapone oral tablet 200 mg tolcapone oral tablet 100 mg Dopamine Agonists APOKYN SUBCUTANEOUS CARTRIDGE 10 MG/ML bromocriptine oral capsule 5 mg bromocriptine oral tablet 2.5 mg NEUPRO TRANSDERMAL PATCH 24 HOUR 1 MG/24 HOUR, 2 MG/24 HOUR, 3 MG/24 HOUR, 4 MG/24 HOUR, 6 MG/24 HOUR, 8 MG/24 HOUR pramipexole oral tablet mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg pramipexole oral tablet extended release 24 hr mg, 0.75 mg, 1.5 mg, 2.25 mg, 3 mg, 3.75 mg, 4.5 mg PA; QL (42 per 7 days) QL (300 per 30 days) QL (300 per 30 days) QL (60 per 28 days); 32

42 ropinirole oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg ropinirole oral tablet extended release 24 hr 12 mg, 2 mg, 4 mg, 6 mg, 8 mg Dopamine Precursors/ L-Amino Acid Decarboxylase Inhibitors carbidopa-levodopa oral tablet mg, mg, mg carbidopa-levodopa oral tablet extended release mg, mg carbidopa-levodopa oral tablet,disintegrating mg, mg, mg Monoamine Oxidase B (Mao-B) Inhibitors rasagiline oral tablet 0.5 mg, 1 mg selegiline hcl oral capsule 5 mg selegiline hcl oral tablet 5 mg XADAGO ORAL TABLET 100 MG, 50 MG Antipsychotics 1St Generation/Typical chlorpromazine injection solution 25 mg/ml chlorpromazine oral tablet 10 mg, 100 mg, 200 mg, 25 mg, 50 mg fluphenazine decanoate injection solution 25 mg/ml fluphenazine hcl injection solution 2.5 mg/ml fluphenazine hcl oral concentrate 5 mg/ml fluphenazine hcl oral elixir 2.5 mg/5 ml fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg haloperidol decanoate intramuscular solution 100 mg/ml, 100 mg/ml (1 ml), 50 mg/ml haloperidol lactate injection solution 5 mg/ml haloperidol lactate intramuscular syringe 5 mg/ml haloperidol lactate oral concentrate 2 mg/ml haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg molindone oral tablet 10 mg molindone oral tablet 25 mg molindone oral tablet 5 mg pimozide oral tablet 1 mg, 2 mg thioridazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg QL (240 per 30 days) QL (270 per 30 days) QL (360 per 30 days) trifluoperazine oral tablet 1 mg, 10 mg, 2 mg, 5 mg 33

43 2Nd Generation/Atypical ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 300 MG ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 400 MG ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 300 MG, 400 MG aripiprazole oral solution 1 mg/ml aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 mg aripiprazole oral tablet,disintegrating 10 mg, 15 mg ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 1,064 MG/3.9 ML ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 441 MG/1.6 ML ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 662 MG/2.4 ML ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 882 MG/3.2 ML FANAPT ORAL TABLET 1 MG, 2 MG, 4 MG FANAPT ORAL TABLET 10 MG, 12 MG, 6 MG, 8 MG FANAPT ORAL TABLETS,DOSE PACK 1MG(2)-2MG(2)- 4MG(2)- 6MG(2) GEODON INTRAMUSCULAR RECON SOLN 20 MG/ML (FINAL CONC.) INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML, 234 MG/1.5 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 156 MG/ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 39 MG/0.25 ML, 78 MG/0.5 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 410 MG/1.315 ML QL (1 per 28 days); QL (1 per 28 days); QL (900 per 30 days) ; QL (1.6 per 28 days); QL (2.4 per 28 days); QL (3.2 per 28 days); ; QL (1.5 per 28 days); QL (1 per 28 days); QL (1.5 per 28 days) QL (0.87 per 28 days); QL (1.31 per 28 days); INVEGA TRINZA INTRAMUSCULAR SYRINGE 546 MG/1.75 ML QL (1.75 per 28 days); INVEGA TRINZA INTRAMUSCULAR SYRINGE 819 MG/2.625 ML LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG LATUDA ORAL TABLET 80 MG NUPLAZID ORAL TABLET 17 MG QL (2.62 per 28 days); ; ; ; 34

44 olanzapine intramuscular recon soln 10 mg olanzapine oral tablet 10 mg, 2.5 mg, 5 mg, 7.5 mg olanzapine oral tablet 15 mg, 20 mg olanzapine oral tablet,disintegrating 10 mg, 5 mg olanzapine oral tablet,disintegrating 15 mg, 20 mg paliperidone oral tablet extended release 24hr 1.5 mg, 3 mg, 9 mg paliperidone oral tablet extended release 24hr 6 mg quetiapine oral tablet 100 mg, 200 mg, 25 mg, 300 mg, 400 mg, 50 mg quetiapine oral tablet extended release 24 hr 150 mg quetiapine oral tablet extended release 24 hr 200 mg quetiapine oral tablet extended release 24 hr 300 mg, 400 mg quetiapine oral tablet extended release 24 hr 50 mg REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 12.5 MG/2 ML, 25 MG/2 ML, 37.5 MG/2 ML ; ; QL (90 per 30 days) QL (120 per 30 days) ; QL (2 per 28 days) RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 50 MG/2 ML QL (2 per 28 days); risperidone oral solution 1 mg/ml risperidone oral tablet 0.25 mg, 1 mg, 2 mg, 3 mg, 4 mg risperidone oral tablet 0.5 mg QL (240 per 30 days) QL (120 per 30 days) risperidone oral tablet,disintegrating 0.25 mg, 1 mg, 2 mg, 3 mg, 4 mg risperidone oral tablet,disintegrating 0.5 mg SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 10 MG SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 2.5 MG, 5 MG VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5 MG, 6 MG VRAYLAR ORAL CAPSULE,DOSE PACK 1.5 MG (1)- 3 MG (6) ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG, 300 MG, 405 MG Treatment-Resistant clozapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 150 mg, 200 mg, 25 mg FAZACLO ORAL TABLET,DISINTEGRATING 100 MG, 150 MG, 200 MG FAZACLO ORAL TABLET,DISINTEGRATING 12.5 MG, 25 MG QL (120 per 30 days) ; ; QL (4 per 28 days) 35

45 VERSACLOZ ORAL SUSPENSION 50 MG/ML Antispasticity Agents Antispasticity Agents baclofen oral tablet 10 mg, 20 mg dantrolene oral capsule 100 mg, 25 mg, 50 mg tizanidine oral tablet 2 mg, 4 mg Antivirals Anti-Cytomegalovirus (Cmv) Agents cidofovir intravenous solution 75 mg/ml ganciclovir sodium intravenous recon soln 500 mg ganciclovir sodium intravenous solution 50 mg/ml valganciclovir oral recon soln 50 mg/ml valganciclovir oral tablet 450 mg ZIRGAN OPHTHALMIC (EYE) GEL 0.15 % Anti-Hepatitis B (Hbv) Agents adefovir oral tablet 10 mg BARACLUDE ORAL SOLUTION 0.05 MG/ML entecavir oral tablet 0.5 mg, 1 mg EPIVIR HBV ORAL SOLUTION 25 MG/5 ML (5 MG/ML) INTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML) INTRON A INJECTION SOLUTION 6 MILLION UNIT/ML ribasphere oral capsule 200 mg ribasphere oral tablet 200 mg VEMLIDY ORAL TABLET 25 MG VIREAD ORAL TABLET 300 MG Anti-Hepatitis C (Hcv) Agents MAVYRET ORAL TABLET MG VOSEVI ORAL TABLET MG Anti-Hepatitis C (Hcv) Agents, Others EPCLUSA ORAL TABLET MG HARVONI ORAL TABLET MG INTRON A INJECTION RECON SOLN 18 MILLION UNIT (1 ML), 50 MILLION UNIT (1 ML) INTRON A INJECTION SOLUTION 10 MILLION UNIT/ML PEGASYS CONVENIENCE PACK SUBCUTANEOUS KIT 180 MCG/0.5 ML QL (540 per 30 days) ; QL (5 per 30 days) QL (630 per 30 days); ; PA NSO; PA NSO; QL (168 per 28 days) QL (168 per 28 days) ; PA; QL (84 per 28 days); PA; QL (1 per 1 day); PA; PA; QL (28 per 28 days); PA NSO; PA NSO; PA; QL (2 per 28 days); 36

46 PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 135 MCG/0.5 ML, 180 MCG/0.5 ML PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/ML PEGASYS SUBCUTANEOUS SYRINGE 180 MCG/0.5 ML PEGINTRON REDIPEN SUBCUTANEOUS PEN INJECTOR KIT 120 MCG/0.5 ML, 150 MCG/0.5 ML, 50 MCG/0.5 ML, 80 MCG/0.5 ML PEGINTRON SUBCUTANEOUS KIT 120 MCG/0.5 ML, 150 MCG/0.5 ML, 50 MCG/0.5 ML, 80 MCG/0.5 ML ribavirin oral capsule 200 mg ribavirin oral tablet 200 mg VIRAZOLE INHALATION RECON SOLN 6 GRAM ZEPATIER ORAL TABLET MG Antiherpetic Agents acyclovir 1,000 mg/20 ml vial 10's,latex-free,sdv 50 mg/ml acyclovir oral capsule 200 mg acyclovir oral suspension 200 mg/5 ml acyclovir oral tablet 400 mg, 800 mg acyclovir sodium intravenous recon soln 500 mg acyclovir sodium intravenous solution 50 mg/ml acyclovir topical ointment 5 % famciclovir oral tablet 125 mg, 250 mg, 500 mg trifluridine ophthalmic (eye) drops 1 % valacyclovir oral tablet 1 gram, 500 mg Anti-Hiv Agents, Integrase Inhibitors (Insti) GENVOYA ORAL TABLET MG ISENTRESS HD ORAL TABLET 600 MG ISENTRESS ORAL POWDER IN PACKET 100 MG ISENTRESS ORAL TABLET 400 MG ISENTRESS ORAL TABLET,CHEWABLE 100 MG ISENTRESS ORAL TABLET,CHEWABLE 25 MG STRIBILD ORAL TABLET MG TIVICAY ORAL TABLET 10 MG TIVICAY ORAL TABLET 25 MG, 50 MG Anti-Hiv Agents, Non-Nucleoside Reverse Transcriptase Inhibitors (Nnrti) COMPLERA ORAL TABLET MG PA; QL (2 per 28 days); PA; QL (4 per 28 days); PA; QL (2 per 28 days); PA; QL (4 per 28 days); PA; QL (4 per 28 days); QL (168 per 28 days) QL (168 per 28 days) PA; ; QL (90 per 30 days) QL (120 per 30 days) ; QL (300 per 30 days) QL (120 per 30 days); QL (180 per 30 days) QL (720 per 30 days) ; ; ; 37

47 EDURANT ORAL TABLET 25 MG efavirenz oral capsule 200 mg, 50 mg efavirenz oral tablet 600 mg INTELENCE ORAL TABLET 100 MG INTELENCE ORAL TABLET 200 MG INTELENCE ORAL TABLET 25 MG nevirapine oral suspension 50 mg/5 ml nevirapine oral tablet 200 mg nevirapine oral tablet extended release 24 hr 100 mg nevirapine oral tablet extended release 24 hr 400 mg RESCRIPTOR ORAL TABLET 200 MG RESCRIPTOR ORAL TABLET, DISPERSIBLE 100 MG SUSTIVA ORAL CAPSULE 200 MG SUSTIVA ORAL CAPSULE 50 MG SUSTIVA ORAL TABLET 600 MG VIRAMUNE ORAL SUSPENSION 50 MG/5 ML Anti-Hiv Agents, Nucleoside And Nucleotide Reverse Transcriptase Inhibitors (Nrti) abacavir oral solution 20 mg/ml abacavir oral tablet 300 mg abacavir-lamivudine oral tablet mg abacavir-lamivudine-zidovudine oral tablet mg ATRIPLA ORAL TABLET MG BIKTARVY ORAL TABLET MG CIMDUO ORAL TABLET MG DESCOVY ORAL TABLET MG didanosine oral capsule,delayed release(dr/ec) 125 mg didanosine oral capsule,delayed release(dr/ec) 200 mg didanosine oral capsule,delayed release(dr/ec) 250 mg, 400 mg EMTRIVA ORAL CAPSULE 200 MG EMTRIVA ORAL SOLUTION 10 MG/ML EPZICOM ORAL TABLET MG JULUCA ORAL TABLET MG lamivudine oral solution 10 mg/ml lamivudine oral tablet 100 mg, 300 mg lamivudine oral tablet 150 mg ; QL (120 per 30 days); ; QL (120 per 30 days) QL (1200 per 30 days) QL (120 per 30 days) QL (180 per 30 days) QL (360 per 30 days) QL (120 per 30 days); QL (480 per 30 days) ; QL (1200 per 30 days) ; ; ; ; ; ; QL (90 per 30 days) QL (680 per 28 days) ; QL (960 per 30 days) 38

48 lamivudine-zidovudine oral tablet mg ODEFSEY ORAL TABLET MG RETROVIR INTRAVENOUS SOLUTION 10 MG/ML stavudine oral capsule 15 mg, 20 mg stavudine oral capsule 30 mg, 40 mg SYMFI LO ORAL TABLET MG SYMFI ORAL TABLET MG tenofovir disoproxil fumarate oral tablet 300 mg TROGARZO INTRAVENOUS SOLUTION 200 MG/1.33 ML (150 MG/ML) TRUVADA ORAL TABLET MG, MG, MG, MG VIDEX 2 GM PEDIATRIC SOLN 10 MG/ML (FINAL) VIDEX 4 GRAM PEDIATRIC ORAL RECON SOLN 10 MG/ML (FINAL) VIDEX EC ORAL CAPSULE,DELAYED RELEASE(DR/EC) 125 MG VIREAD ORAL POWDER 40 MG/SCOOP (40 MG/GRAM) VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG ZERIT ORAL RECON SOLN 1 MG/ML ZIAGEN ORAL SOLUTION 20 MG/ML zidovudine oral capsule 100 mg zidovudine oral syrup 10 mg/ml zidovudine oral tablet 300 mg Anti-Hiv Agents, Other FUZEON SUBCUTANEOUS RECON SOLN 90 MG SELZENTRY ORAL SOLUTION 20 MG/ML SELZENTRY ORAL TABLET 150 MG SELZENTRY ORAL TABLET 25 MG SELZENTRY ORAL TABLET 300 MG SELZENTRY ORAL TABLET 75 MG TRIUMEQ ORAL TABLET MG TYBOST ORAL TABLET 150 MG Anti-Hiv Agents, Protease Inhibitors APTIVUS ORAL CAPSULE 250 MG APTIVUS ORAL SOLUTION 100 MG/ML atazanavir oral capsule 150 mg, 200 mg ; QL (120 per 30 days) ; ; ; QL (1200 per 30 days) QL (1200 per 30 days) QL (90 per 30 days) QL (240 per 30 days); ; QL (960 per 30 days) QL (180 per 30 days) QL (1680 per 28 days) ; QL (240 per 30 days); QL (120 per 30 days); ; QL (120 per 30 days); QL (285 per 28 days); ; 39

49 atazanavir oral capsule 300 mg CRIXIVAN ORAL CAPSULE 200 MG CRIXIVAN ORAL CAPSULE 400 MG EVOTAZ ORAL TABLET MG fosamprenavir oral tablet 700 mg INVIRASE ORAL CAPSULE 200 MG INVIRASE ORAL TABLET 500 MG KALETRA ORAL SOLUTION MG/5 ML KALETRA ORAL TABLET MG KALETRA ORAL TABLET MG LEXIVA ORAL SUSPENSION 50 MG/ML LEXIVA ORAL TABLET 700 MG lopinavir-ritonavir oral solution mg/5 ml NORVIR ORAL CAPSULE 100 MG NORVIR ORAL POWDER IN PACKET 100 MG NORVIR ORAL SOLUTION 80 MG/ML NORVIR ORAL TABLET 100 MG PREZCOBIX ORAL TABLET MG-MG PREZISTA ORAL SUSPENSION 100 MG/ML PREZISTA ORAL TABLET 150 MG PREZISTA ORAL TABLET 600 MG PREZISTA ORAL TABLET 75 MG PREZISTA ORAL TABLET 800 MG REYATAZ ORAL CAPSULE 150 MG, 200 MG REYATAZ ORAL CAPSULE 300 MG REYATAZ ORAL POWDER IN PACKET 50 MG ritonavir oral tablet 100 mg VIRACEPT ORAL TABLET 250 MG VIRACEPT ORAL TABLET 625 MG Anti-Influenza Agents oseltamivir oral capsule 30 mg, 45 mg, 75 mg oseltamivir oral suspension for reconstitution 6 mg/ml RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MG/ACTUATION rimantadine oral tablet 100 mg ; QL (450 per 30 days) QL (270 per 30 days) ; QL (300 per 30 days); QL (120 per 30 days); QL (600 per 30 days); QL (300 per 30 days) QL (150 per 30 days); QL (1575 per 28 days) QL (120 per 30 days); QL (360 per 30 days) QL (360 per 30 days) QL (480 per 30 days) QL (360 per 30 days) ; QL (360 per 30 days); QL (240 per 30 days) ; QL (480 per 30 days) ; ; ; QL (240 per 30 days); QL (360 per 30 days) QL (300 per 30 days); QL (120 per 30 days); QL (60 per 180 days) 40

50 TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION 6 MG/ML Anxiolytics Anxiolytics, Other buspirone oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg meprobamate oral tablet 200 mg, 400 mg oxazepam oral capsule 10 mg, 15 mg, 30 mg Benzodiazepines alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg chlordiazepoxide hcl oral capsule 10 mg, 25 mg, 5 mg clonazepam oral tablet 0.5 mg, 1 mg, 2 mg clonazepam oral tablet,disintegrating mg, 0.25 mg, 0.5 mg, 1 mg, 2 mg clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg diazepam intensol oral concentrate 5 mg/ml diazepam oral solution 5 mg/5 ml (1 mg/ml) diazepam oral tablet 10 mg diazepam oral tablet 2 mg, 5 mg diazepam rectal kit mg lorazepam oral concentrate 2 mg/ml lorazepam oral tablet 0.5 mg, 1 mg lorazepam oral tablet 2 mg Bipolar Agents Mood Stabilizers carbamazepine oral capsule, er multiphase 12 hr 100 mg, 200 mg, 300 mg lithium carbonate oral capsule 150 mg, 300 mg, 600 mg lithium carbonate oral tablet 300 mg lithium carbonate oral tablet extended release 300 mg, 450 mg lithium citrate oral solution 8 meq/5 ml Blood Glucose Regulators Antidiabetic Agents acarbose oral tablet 100 mg, 25 mg, 50 mg ADLYXIN SUBCUTANEOUS PEN INJECTOR 10 MCG/0.2 ML- 20 MCG/0.2 ML, 20 MCG/0.2 ML alogliptin oral tablet 12.5 mg, 25 mg, 6.25 mg QL (720 per 365 days) QL (120 per 30 days) QL (240 per 30 days) QL (1200 per 30 days) QL (120 per 30 days) QL (90 per 30 days) QL (150 per 30 days) QL (90 per 30 days) QL (150 per 30 days) 41

51 alogliptin-metformin oral tablet ,000 mg, mg alogliptin-pioglitazone oral tablet mg, mg, mg, mg, mg, mg AVANDIA ORAL TABLET 2 MG, 4 MG BYDUREON BCISE SUBCUTANEOUS AUTO-INJECTOR 2 MG/0.85 ML BYDUREON SUBCUTANEOUS PEN INJECTOR 2 MG/0.65 ML BYDUREON SUBCUTANEOUS SUSPENSION,EXTENDED REL RECON 2 MG BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML, 5 MCG/DOSE (250 MCG/ML) 1.2 ML CYCLOSET ORAL TABLET 0.8 MG FARXIGA ORAL TABLET 10 MG, 5 MG glimepiride oral tablet 1 mg, 2 mg, 4 mg glipizide oral tablet 10 mg, 5 mg glipizide oral tablet extended release 24hr 10 mg, 2.5 mg, 5 mg GLYXAMBI ORAL TABLET 10-5 MG, 25-5 MG INVOKAMET ORAL TABLET 150-1,000 MG, MG, 50-1,000 MG, MG INVOKAMET XR ORAL TABLET, IR - ER, BIPHASIC 24HR 150-1,000 MG, MG, 50-1,000 MG INVOKAMET XR ORAL TABLET, IR - ER, BIPHASIC 24HR MG INVOKANA ORAL TABLET 100 MG, 300 MG JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG JARDIANCE ORAL TABLET 10 MG, 25 MG JENTADUETO ORAL TABLET 2.5-1,000 MG, MG, MG JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 5-1,000 MG metformin oral tablet 1,000 mg, 500 mg, 850 mg metformin oral tablet extended release 24 hr 500 mg metformin oral tablet extended release 24 hr 750 mg miglitol oral tablet 100 mg, 25 mg, 50 mg nateglinide oral tablet 120 mg, 60 mg ONGLYZA ORAL TABLET 2.5 MG, 5 MG QL (3.4 per 28 days) QL (4 per 28 days) QL (4 per 28 days) QL (2.4 per 30 days) QL (180 per 30 days) QL (120 per 30 days) QL (120 per 30 days) QL (75 per 30 days) 42

52 OZEMPIC SUBCUTANEOUS PEN INJECTOR 0.25 MG OR 0.5 MG(2 MG/1.5 ML), 1 MG/0.75 ML (2 MG/1.5 ML) pioglitazone oral tablet 15 mg, 30 mg, 45 mg QTERN ORAL TABLET 10-5 MG repaglinide oral tablet 0.5 mg, 1 mg, 2 mg SOLIQUA 100/33 SUBCUTANEOUS INSULIN PEN 100 UNIT-33 MCG/ML SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR 2,700 MCG/2.7 ML SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR 1,500 MCG/1.5 ML SYNJARDY ORAL TABLET ,000 MG, MG, 5-1,000 MG, MG SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, ,000 MG, 5-1,000 MG SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 25-1,000 MG TANZEUM SUBCUTANEOUS PEN INJECTOR 30 MG/0.5 ML, 50 MG/0.5 ML TRADJENTA ORAL TABLET 5 MG TRULICITY SUBCUTANEOUS PEN INJECTOR 0.75 MG/0.5 ML, 1.5 MG/0.5 ML VICTOZA SUBCUTANEOUS PEN INJECTOR 0.6 MG/0.1 ML (18 MG/3 ML) XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, MG, 5-1,000 MG XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG, MG XULTOPHY 100/3.6 SUBCUTANEOUS INSULIN PEN 100 UNIT- 3.6 MG /ML (3 ML) Blood Glucose Regulators glipizide-metformin oral tablet mg, mg, mg JANUMET ORAL TABLET 50-1,000 MG, MG JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-1,000 MG, MG KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 24 HR 2.5-1,000 MG PA; QL (3 per 28 days) QL (18 per 30 days) QL (10.8 per 30 days) QL (10.5 per 30 days) PA PA; QL (2 per 28 days) QL (9 per 30 days) QL (15 per 30 days) 43

53 KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 24 HR 5-1,000 MG, MG pioglitazone-glimepiride oral tablet 30-2 mg, 30-4 mg pioglitazone-metformin oral tablet mg, mg Glycemic Agents GLUCAGEN HYPOKIT INJECTION RECON SOLN 1 MG GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT 1 MG KORLYM ORAL TABLET 300 MG PROGLYCEM ORAL SUSPENSION 50 MG/ML Insulins ASSURE ID INSULIN SAFETY SYRINGE 1 ML 29 GAUGE X 1/2" BD UF NANO PEN NEEDLE 4MMX32G 32 GAUGE X 5/32" BD VEO INS SYRING 1 ML 6MMX31G 1 ML 31 GAUGE X 15/64" BD VEO INS SYRN 0.3 ML 6MMX31G 0.3 ML 31 GAUGE X 15/64" BD VEO INS SYRN 0.5 ML 6MMX31G 1/2 ML 31 GAUGE X 15/64" FIASP FLEXTOUCH U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) FIASP U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML GAUZE PAD TOPICAL BANDAGE 2 X 2 " HUMALOG KWIKPEN INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML, 200 UNIT/ML (3 ML) HUMALOG MIX INSULN U-100 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (50-50) HUMALOG MIX KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (50-50) HUMALOG MIX KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (75-25) HUMALOG MIX 75-25(U-100)INSULN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (75-25) HUMALOG U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNIT/ML HUMALOG U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML HUMULIN 70/30 U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30) QL (90 per 30 days) QL (120 per 30 days); 44

54 HUMULIN 70/30 U-100 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30) HUMULIN N NPH INSULIN KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) HUMULIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML HUMULIN R REGULAR U-100 INSULN INJECTION SOLUTION 100 UNIT/ML HUMULIN R U-500 (CONC) INSULIN SUBCUTANEOUS SOLUTION 500 UNIT/ML HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN 500 UNIT/ML (3 ML) INSULIN SYRINGE-NEEDLE U-100 SYRINGE 0.3 ML 29 GAUGE, 1 ML 29 GAUGE X 1/2", 1/2 ML 28 GAUGE LANTUS SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) LANTUS U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML LEVEMIR FLEXTOUCH U-100 INSULN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) LEVEMIR U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML NOVOLIN 70/30 U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30) NOVOLIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML NOVOLIN R REGULAR U-100 INSULN INJECTION SOLUTION 100 UNIT/ML NOVOLOG FLEXPEN U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML NOVOLOG MIX U-100 INSULN SUBCUTANEOUS SOLUTION 100 UNIT/ML (70-30) NOVOLOG MIX 70-30FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30) NOVOLOG PENFILL U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNIT/ML NOVOLOG U-100 INSULIN ASPART SUBCUTANEOUS SOLUTION 100 UNIT/ML PEN NEEDLE, DIABETIC NEEDLE 29 GAUGE X 1/2" STERILE PADS 2" X 2" 2 X 2 " 45

55 TOUJEO MAX SOLOSTAR SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (3 ML) TOUJEO SOLOSTAR U-300 INSULIN SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (1.5 ML) TRESIBA FLEXTOUCH U-100 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) TRESIBA FLEXTOUCH U-200 SUBCUTANEOUS INSULIN PEN 200 UNIT/ML (3 ML) VGO 40 DISPOSABLE DEVICE Blood Products/ Modifiers/ Volume Expanders Anticoagulants COUMADIN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG ELIQUIS ORAL TABLET 2.5 MG ELIQUIS ORAL TABLET 5 MG ELIQUIS ORAL TABLETS,DOSE PACK 5 MG (74 TABS) enoxaparin subcutaneous solution 300 mg/3 ml enoxaparin subcutaneous syringe 100 mg/ml, 150 mg/ml enoxaparin subcutaneous syringe 120 mg/0.8 ml, 80 mg/0.8 ml enoxaparin subcutaneous syringe 30 mg/0.3 ml, 60 mg/0.6 ml enoxaparin subcutaneous syringe 40 mg/0.4 ml fondaparinux subcutaneous syringe 10 mg/0.8 ml fondaparinux subcutaneous syringe 2.5 mg/0.5 ml fondaparinux subcutaneous syringe 5 mg/0.4 ml fondaparinux subcutaneous syringe 7.5 mg/0.6 ml heparin (porcine) in 5 % dex intravenous parenteral solution 20,000 unit/500 ml (40 unit/ml), 25,000 unit/250 ml(100 unit/ml), 25,000 unit/500 ml (50 unit/ml) heparin (porcine) in nacl (pf) intravenous parenteral solution 1,000 unit/500 ml, 2,000 unit/1,000 ml heparin (porcine) injection cartridge 5,000 unit/ml (1 ml) heparin (porcine) injection solution 1,000 unit/ml heparin (porcine) injection solution 10,000 unit/ml, 20,000 unit/ml, 5,000 unit/ml heparin (porcine) injection syringe 5,000 unit/ml heparin 25,000 unit/250 ml (100 unit/ml)-0.45% nacl bag l/f,inner,single-use 25,000 unit/250 ml heparin sodium 10,000 unit/ml vial 25's,mdv, latex-free 10,000 unit/ml QL (27 per 30 days) QL (74 per 30 days) QL (74 per 30 days) QL (84 per 28 days) QL (56 per 28 days) QL (33.6 per 28 days) QL (22.4 per 28 days) QL (24 per 30 days); QL (15 per 30 days) QL (12 per 30 days); QL (18 per 30 days); 46

56 HEPARIN(PORCINE) IN 0.45% NACL INTRAVENOUS PARENTERAL SOLUTION 12,500 UNIT/250 ML heparin, porcine (pf) injection solution 1,000 unit/ml, 5,000 unit/0.5 ml heparin-0.45% nacl 25,000 units/500 ml (50 units/ml) bag l/f,outer,single-use 25,000 unit/500 ml jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG warfarin oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg XARELTO ORAL TABLET 10 MG, 20 MG XARELTO ORAL TABLET 15 MG XARELTO ORAL TABLETS,DOSE PACK 15 MG (42)- 20 MG (9) Blood Formation Modifiers anagrelide oral capsule 0.5 mg, 1 mg ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, 150 MCG/0.75 ML, 200 MCG/ML, 300 MCG/ML, 60 MCG/ML ARANESP (IN POLYSORBATE) INJECTION SOLUTION 25 MCG/ML, 40 MCG/ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG/0.4 ML, 25 MCG/0.42 ML, 40 MCG/0.4 ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 100 MCG/0.5 ML, 150 MCG/0.3 ML, 200 MCG/0.4 ML, 300 MCG/0.6 ML, 500 MCG/ML, 60 MCG/0.3 ML GRANIX SUBCUTANEOUS SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML LEUKINE INJECTION RECON SOLN 250 MCG MOZOBIL SUBCUTANEOUS SOLUTION 24 MG/1.2 ML (20 MG/ML) NEULASTA SUBCUTANEOUS SYRINGE 6 MG/0.6ML NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6 ML NEUPOGEN INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML PROCRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML PROCRIT INJECTION SOLUTION 20,000 UNIT/2 ML PROCRIT INJECTION SOLUTION 20,000 UNIT/ML, 40,000 UNIT/ML QL (51 per 30 days) PA; PA; QL (9.6 per 30 days); PA; QL (1.2 per 28 days); PA; PA; QL (14 per 30 days) QL (14 per 30 days); 47

57 PROMACTA ORAL TABLET 12.5 MG, 75 MG PROMACTA ORAL TABLET 25 MG PROMACTA ORAL TABLET 50 MG RETACRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML, 40,000 UNIT/ML ZARXIO INJECTION SYRINGE 300 MCG/0.5 ML ZARXIO INJECTION SYRINGE 480 MCG/0.8 ML Hemostasis Agents tranexamic acid intravenous solution 1,000 mg/10 ml (100 mg/ml) tranexamic acid oral tablet 650 mg Platelet Modifying Agents aspirin-dipyridamole oral capsule, er multiphase 12 hr mg BRILINTA ORAL TABLET 60 MG, 90 MG cilostazol oral tablet 100 mg, 50 mg clopidogrel oral tablet 300 mg clopidogrel oral tablet 75 mg dipyridamole oral tablet 25 mg, 50 mg, 75 mg prasugrel oral tablet 10 mg, 5 mg ZONTIVITY ORAL TABLET 2.08 MG Cardiovascular Agents Alpha-Adrenergic Agonists clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg clonidine transdermal patch weekly 0.1 mg/24 hr, 0.2 mg/24 hr, 0.3 mg/24 hr clorpres oral tablet mg, mg, mg guanfacine oral tablet 1 mg, 2 mg methyldopa oral tablet 250 mg, 500 mg midodrine oral tablet 10 mg, 2.5 mg, 5 mg NORTHERA ORAL CAPSULE 100 MG, 200 MG NORTHERA ORAL CAPSULE 300 MG Alpha-Adrenergic Blocking Agents doxazosin oral tablet 1 mg, 2 mg, 4 mg, 8 mg phenoxybenzamine oral capsule 10 mg prazosin oral capsule 1 mg, 2 mg, 5 mg terazosin oral capsule 1 mg, 10 mg, 2 mg, 5 mg Angiotensin Ii Receptor Antagonists PA; ; PA; ; PA; QL (90 per 30 days); PA; QL (7 per 30 days); PA; QL (11.2 per 30 days); QL (30 per 5 days) QL (4 per 28 days) QL (90 per 30 days); QL (180 per 30 days); 48

58 candesartan oral tablet 16 mg, 4 mg, 8 mg candesartan oral tablet 32 mg ENTRESTO ORAL TABLET MG, MG, MG eprosartan oral tablet 600 mg irbesartan oral tablet 150 mg, 300 mg, 75 mg losartan oral tablet 100 mg, 25 mg, 50 mg olmesartan oral tablet 20 mg, 40 mg, 5 mg olmesartan-hydrochlorothiazide oral tablet mg, mg, mg telmisartan oral tablet 20 mg, 40 mg telmisartan oral tablet 80 mg valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg Angiotensin-Converting Enzyme (Ace) Inhibitors benazepril oral tablet 10 mg, 20 mg, 40 mg, 5 mg captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg fosinopril oral tablet 10 mg, 20 mg, 40 mg lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg moexipril oral tablet 15 mg, 7.5 mg perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg quinapril oral tablet 10 mg, 20 mg, 40 mg, 5 mg ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg trandolapril oral tablet 1 mg, 2 mg, 4 mg Antiarrhythmics amiodarone oral tablet 100 mg, 200 mg, 400 mg disopyramide phosphate oral capsule 100 mg, 150 mg dofetilide oral capsule 125 mcg dofetilide oral capsule 250 mcg dofetilide oral capsule 500 mcg flecainide oral tablet 100 mg, 150 mg, 50 mg mexiletine oral capsule 150 mg, 200 mg, 250 mg MULTAQ ORAL TABLET 400 MG pacerone oral tablet 100 mg, 200 mg, 400 mg propafenone oral capsule,extended release 12 hr 225 mg, 325 mg, 425 mg propafenone oral tablet 150 mg, 225 mg, 300 mg QL (240 per 30 days) QL (120 per 30 days) 49

59 quinidine gluconate oral tablet extended release 324 mg quinidine sulfate oral tablet 200 mg, 300 mg sorine oral tablet 120 mg, 160 mg, 240 mg, 80 mg sotalol 120 mg tablet 120 mg sotalol af oral tablet 120 mg sotalol oral tablet 160 mg, 240 mg, 80 mg Beta-Adrenergic Blocking Agents acebutolol oral capsule 200 mg, 400 mg atenolol oral tablet 100 mg, 25 mg, 50 mg betaxolol oral tablet 10 mg, 20 mg bisoprolol fumarate oral tablet 10 mg, 5 mg BYSTOLIC ORAL TABLET 10 MG BYSTOLIC ORAL TABLET 2.5 MG, 5 MG BYSTOLIC ORAL TABLET 20 MG carvedilol oral tablet 12.5 mg, 25 mg, mg, 6.25 mg carvedilol phosphate oral capsule, er multiphase 24 hr 10 mg, 20 mg, 40 mg, 80 mg COREG CR ORAL CAPSULE, ER MULTIPHASE 24 HR 10 MG, 20 MG, 40 MG, 80 MG labetalol oral tablet 100 mg, 200 mg, 300 mg metoprolol succinate oral tablet extended release 24 hr 100 mg, 200 mg, 25 mg, 50 mg metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg nadolol oral tablet 20 mg, 40 mg, 80 mg pindolol oral tablet 10 mg, 5 mg propranolol oral capsule,extended release 24 hr 120 mg, 160 mg, 60 mg, 80 mg propranolol oral solution 20 mg/5 ml (4 mg/ml), 40 mg/5 ml (8 mg/ml) propranolol oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg timolol maleate oral tablet 10 mg, 20 mg, 5 mg Calcium Channel Blocking Agents afeditab cr oral tablet extended release 30 mg, 60 mg amlodipine oral tablet 10 mg, 2.5 mg, 5 mg cartia xt oral capsule,extended release 24hr 120 mg, 180 mg, 240 mg cartia xt oral capsule,extended release 24hr 300 mg diltiazem hcl intravenous recon soln 100 mg diltiazem hcl intravenous solution 5 mg/ml QL (120 per 30 days) 50

60 diltiazem hcl oral capsule,extended release 12 hr 120 mg, 60 mg, 90 mg diltiazem hcl oral capsule,extended release 24 hr 360 mg diltiazem hcl oral capsule,extended release 24 hr 420 mg diltiazem hcl oral capsule,extended release 24hr 120 mg, 180 mg, 240 mg diltiazem hcl oral capsule,extended release 24hr 300 mg diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg diltiazem hcl oral tablet extended release 24 hr 240 mg, 360 mg, 420 mg dilt-xr oral capsule,ext.rel 24h degradable 120 mg, 180 mg, 240 mg felodipine oral tablet extended release 24 hr 10 mg, 2.5 mg, 5 mg matzim la oral tablet extended release 24 hr 240 mg, 360 mg, 420 mg nicardipine oral capsule 20 mg, 30 mg nifedical xl oral tablet extended release 24hr 30 mg, 60 mg nifedipine oral tablet extended release 24hr 30 mg, 60 mg, 90 mg nifedipine oral tablet extended release 30 mg, 60 mg, 90 mg nimodipine oral capsule 30 mg nisoldipine oral tablet extended release 24 hr 17 mg, 20 mg, 34 mg, 40 mg, 8.5 mg nisoldipine oral tablet extended release 24 hr 25.5 mg, 30 mg taztia xt oral capsule,extended release 24 hr 120 mg, 180 mg, 240 mg taztia xt oral capsule,extended release 24 hr 300 mg, 360 mg verapamil intravenous solution 2.5 mg/ml verapamil oral capsule, 24 hr er pellet ct 100 mg, 300 mg verapamil oral capsule, 24 hr er pellet ct 200 mg verapamil oral capsule,ext rel. pellets 24 hr 120 mg, 180 mg, 240 mg, 360 mg verapamil oral tablet 120 mg, 40 mg, 80 mg verapamil oral tablet extended release 120 mg, 180 mg, 240 mg Cardiovascular Agents amiloride-hydrochlorothiazide oral tablet 5-50 mg amlodipine-atorvastatin oral tablet mg, mg, mg, mg, mg, mg, 5-10 mg, 5-20 mg, 5-40 mg amlodipine-atorvastatin oral tablet mg, 5-80 mg amlodipine-benazepril oral capsule mg, mg amlodipine-benazepril oral capsule mg 51

61 amlodipine-benazepril oral capsule 5-10 mg, 5-20 mg, 5-40 mg amlodipine-olmesartan oral tablet mg, mg, 5-20 mg, 5-40 mg amlodipine-valsartan oral tablet mg, mg, mg amlodipine-valsartan oral tablet mg atenolol-chlorthalidone oral tablet mg, mg benazepril-hydrochlorothiazide oral tablet mg, mg, mg, mg bisoprolol-hydrochlorothiazide oral tablet mg, mg, mg candesartan-hydrochlorothiazid oral tablet mg, mg, mg captopril-hydrochlorothiazide oral tablet mg, mg, mg, mg DEMSER ORAL CAPSULE 250 MG enalapril-hydrochlorothiazide oral tablet mg, mg ezetimibe-simvastatin oral tablet mg, mg, mg, mg fosinopril-hydrochlorothiazide oral tablet mg, mg irbesartan-hydrochlorothiazide oral tablet mg, mg lisinopril-hydrochlorothiazide oral tablet mg, mg, mg losartan-hydrochlorothiazide oral tablet mg, mg, mg methyldopa-hydrochlorothiazide oral tablet mg, mg metoprolol ta-hydrochlorothiaz oral tablet mg, mg, mg moexipril-hydrochlorothiazide oral tablet mg, mg, mg nadolol-bendroflumethiazide oral tablet 40-5 mg, 80-5 mg olmesartan-amlodipin-hcthiazid oral tablet mg, mg, mg, mg, mg propranolol-hydrochlorothiazid oral tablet mg, mg quinapril-hydrochlorothiazide oral tablet mg, mg, mg spironolacton-hydrochlorothiaz oral tablet mg telmisartan-hydrochlorothiazid oral tablet mg, mg telmisartan-hydrochlorothiazid oral tablet mg triamterene-hydrochlorothiazid oral capsule mg, mg 52

62 triamterene-hydrochlorothiazid oral tablet mg, mg valsartan-hydrochlorothiazide oral tablet mg, mg, mg, mg, mg Cardiovascular Agents, Other CORLANOR ORAL TABLET 5 MG, 7.5 MG digitek oral tablet 125 mcg digitek oral tablet 250 mcg digox oral tablet 125 mcg digox oral tablet 250 mcg digoxin 0.25 mg/ml syringe 250 mcg/ml digoxin injection solution 250 mcg/ml DIGOXIN ORAL SOLUTION 50 MCG/ML digoxin oral tablet 125 mcg digoxin oral tablet 250 mcg LANOXIN INJECTION SOLUTION 250 MCG/ML LANOXIN ORAL TABLET MCG, 62.5 MCG pentoxifylline oral tablet extended release 400 mg RANEXA ORAL TABLET EXTENDED RELEASE 12 HR 1,000 MG, 500 MG UPTRAVI ORAL TABLET 1,000 MCG, 1,200 MCG, 1,400 MCG, 1,600 MCG, 800 MCG UPTRAVI ORAL TABLET 200 MCG, 400 MCG, 600 MCG UPTRAVI ORAL TABLETS,DOSE PACK 200 MCG (140)- 800 MCG (60) Diuretics, Carbonic Anhydrase Inhibitors acetazolamide oral capsule, extended release 500 mg acetazolamide oral tablet 125 mg, 250 mg methazolamide oral tablet 25 mg, 50 mg Diuretics, Loop bumetanide injection solution 0.25 mg/ml bumetanide oral tablet 0.5 mg, 1 mg, 2 mg ethacrynic acid oral tablet 25 mg furosemide injection solution 10 mg/ml furosemide injection syringe 10 mg/ml furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml) furosemide oral tablet 20 mg, 40 mg, 80 mg torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg QL (120 per 30 days) PA; ; PA; PA; 53

63 Diuretics, Potassium-Sparing amiloride oral tablet 5 mg eplerenone oral tablet 25 mg, 50 mg spironolactone oral tablet 100 mg, 25 mg, 50 mg Diuretics, Thiazide chlorothiazide oral tablet 250 mg, 500 mg chlorothiazide sodium intravenous recon soln 500 mg chlorthalidone oral tablet 25 mg, 50 mg DIURIL ORAL SUSPENSION 250 MG/5 ML hydrochlorothiazide oral capsule 12.5 mg hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg indapamide oral tablet 1.25 mg, 2.5 mg methyclothiazide oral tablet 5 mg metolazone oral tablet 10 mg, 2.5 mg, 5 mg Dyslipidemics, Fibric Acid Derivatives fenofibrate micronized oral capsule 134 mg, 200 mg fenofibrate micronized oral capsule 67 mg fenofibrate nanocrystallized oral tablet 145 mg fenofibrate nanocrystallized oral tablet 48 mg fenofibrate oral tablet 160 mg fenofibrate oral tablet 54 mg fenofibric acid (choline) oral capsule,delayed release(dr/ec) 135 mg, 45 mg fenofibric acid oral tablet 35 mg gemfibrozil oral tablet 600 mg Dyslipidemics, Hmg Coa Reductase Inhibitors atorvastatin oral tablet 10 mg, 20 mg, 40 mg atorvastatin oral tablet 80 mg fluvastatin oral capsule 20 mg, 40 mg lovastatin oral tablet 10 mg, 20 mg, 40 mg pravastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg rosuvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg simvastatin oral tablet 80 mg Dyslipidemics, Other cholestyramine (with sugar) oral powder in packet 4 gram 54

64 cholestyramine light oral powder 4 gram cholestyramine light packet 4 gram colesevelam oral tablet 625 mg colestipol oral packet 5 gram colestipol oral tablet 1 gram ezetimibe oral tablet 10 mg niacin oral tablet extended release 24 hr 1,000 mg, 500 mg, 750 mg omega-3 acid ethyl esters oral capsule 1 gram PRALUENT PEN SUBCUTANEOUS PEN INJECTOR 150 MG/ML, 75 MG/ML prevalite oral powder in packet 4 gram REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE INJECTOR 420 MG/3.5 ML REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR 140 MG/ML REPATHA SYRINGE SUBCUTANEOUS SYRINGE 140 MG/ML VASCEPA ORAL CAPSULE 0.5 GRAM VASCEPA ORAL CAPSULE 1 GRAM WELCHOL ORAL POWDER IN PACKET 3.75 GRAM WELCHOL ORAL TABLET 625 MG Vasodilators, Direct-Acting Arterial hydralazine injection solution 20 mg/ml hydralazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg minoxidil oral tablet 10 mg, 2.5 mg Vasodilators, Direct-Acting Arterial/ Venous isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg isosorbide dinitrate oral tablet extended release 40 mg isosorbide mononitrate oral tablet 10 mg, 20 mg isosorbide mononitrate oral tablet extended release 24 hr 120 mg, 30 mg, 60 mg NITRO-BID TRANSDERMAL OINTMENT 2 % nitroglycerin intravenous solution 50 mg/10 ml (5 mg/ml) nitroglycerin sublingual tablet 0.3 mg, 0.4 mg, 0.6 mg nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.6 mg/hr nitroglycerin transdermal patch 24 hour 0.4 mg/hr nitroglycerin translingual spray,non-aerosol 400 mcg/spray QL (180 per 30 days) QL (120 per 30 days) PA; PA; QL (3.5 per 28 days); PA; QL (3 per 28 days); PA; QL (3 per 28 days); QL (240 per 30 days) QL (120 per 30 days) 55

65 NITROSTAT SUBLINGUAL TABLET 0.3 MG, 0.4 MG, 0.6 MG Central Nervous System Agents Attention Deficit Hyperactivity Disorder Agents, Amphetamines dextroamphetamine oral capsule, extended release 10 mg dextroamphetamine oral capsule, extended release 15 mg dextroamphetamine oral capsule, extended release 5 mg dextroamphetamine oral tablet 10 mg dextroamphetamine oral tablet 5 mg dextroamphetamine-amphetamine oral capsule,extended release 24hr 10 mg, 15 mg, 5 mg dextroamphetamine-amphetamine oral capsule,extended release 24hr 20 mg, 25 mg, 30 mg dextroamphetamine-amphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 5 mg, 7.5 mg dextroamphetamine-amphetamine oral tablet 30 mg VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG VYVANSE ORAL TABLET,CHEWABLE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG zenzedi oral tablet 10 mg zenzedi oral tablet 5 mg Attention Deficit Hyperactivity Disorder Agents, Non- Amphetamines atomoxetine oral capsule 10 mg, 100 mg, 18 mg, 25 mg, 40 mg, 60 mg, 80 mg clonidine hcl oral tablet extended release 12 hr 0.1 mg dexmethylphenidate oral capsule,er biphasic mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg, 5 mg dexmethylphenidate oral tablet 10 mg, 2.5 mg, 5 mg metadate er oral tablet extended release 20 mg methylphenidate hcl oral capsule, er biphasic mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg methylphenidate hcl oral capsule,er biphasic mg methylphenidate hcl oral capsule,er biphasic mg, 30 mg, 40 mg, 60 mg methylphenidate hcl oral solution 10 mg/5 ml, 5 mg/5 ml methylphenidate hcl oral tablet 10 mg, 5 mg methylphenidate hcl oral tablet 20 mg QL (180 per 30 days) QL (120 per 30 days) QL (180 per 30 days) QL (150 per 30 days) QL (90 per 30 days) QL (180 per 30 days) QL (150 per 30 days) QL (120 per 30 days) QL (90 per 30 days) 56

66 methylphenidate hcl oral tablet extended release 10 mg methylphenidate hcl oral tablet extended release 20 mg methylphenidate hcl oral tablet extended release 24hr 18 mg, 27 mg, 36 mg, 54 mg methylphenidate hcl oral tablet extended release 24hr 72 mg STRATTERA ORAL CAPSULE 10 MG, 100 MG, 18 MG, 25 MG, 40 MG, 60 MG, 80 MG Central Nervous System, Other AUSTEDO ORAL TABLET 12 MG, 6 MG, 9 MG NUEDEXTA ORAL CAPSULE MG riluzole oral tablet 50 mg tetrabenazine oral tablet 12.5 mg tetrabenazine oral tablet 25 mg Fibromyalgia Agents SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG SAVELLA ORAL TABLETS,DOSE PACK 12.5 MG (5)-25 MG(8)- 50 MG(42) Multiple Sclerosis Agents AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR 10 MG AUBAGIO ORAL TABLET 14 MG, 7 MG AVONEX (WITH ALBUMIN) INTRAMUSCULAR KIT 30 MCG AVONEX INTRAMUSCULAR PEN INJECTOR KIT 30 MCG/0.5 ML AVONEX INTRAMUSCULAR SYRINGE KIT 30 MCG/0.5 ML BETASERON SUBCUTANEOUS KIT 0.3 MG COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML EXTAVIA SUBCUTANEOUS KIT 0.3 MG GILENYA ORAL CAPSULE 0.25 MG, 0.5 MG glatiramer subcutaneous syringe 20 mg/ml, 40 mg/ml glatopa subcutaneous syringe 20 mg/ml, 40 mg/ml PLEGRIDY SUBCUTANEOUS PEN INJECTOR 125 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML PLEGRIDY SUBCUTANEOUS SYRINGE 125 MCG/0.5 ML PLEGRIDY SUBCUTANEOUS SYRINGE 63 MCG/0.5 ML- 94 MCG/0.5 ML REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE 22 MCG/0.5 ML, 44 MCG/0.5 ML QL (180 per 30 days) QL (90 per 30 days) PA; PA; QL (60 per 28 days) PA; QL (240 per 30 days); PA; QL (120 per 30 days); PA; LA; PA; LA; QL (4 per 28 days); QL (1 per 28 days); QL (1 per 28 days); PA; QL (15 per 30 days); QL (12 per 28 days); ; PA; LA; PA; LA; PA; PA; QL (6 per 28 days); 57

67 REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 8.8MCG/0.2ML-22 MCG/0.5ML (6) REBIF TITRATION PACK SUBCUTANEOUS SYRINGE 8.8MCG/0.2ML-22 MCG/0.5ML (6) TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG, 120 MG (14)- 240 MG (46), 240 MG TYSABRI INTRAVENOUS SOLUTION 300 MG/15 ML ZINBRYTA SUBCUTANEOUS SYRINGE 150 MG/ML Dental And Oral Agents Dental And Oral Agents cevimeline oral capsule 30 mg chlorhexidine gluconate mucous membrane mouthwash 0.12 % denta 5000 plus dental cream 1.1 % dentagel dental gel 1.1 % oralone dental paste 0.1 % paroex oral rinse mucous membrane mouthwash 0.12 % periogard mucous membrane mouthwash 0.12 % pilocarpine hcl oral tablet 5 mg, 7.5 mg sf 5000 plus dental cream 1.1 % triamcinolone acetonide dental paste 0.1 % Dermatological Agents Dermatological Agents acitretin oral capsule 10 mg, 17.5 mg, 25 mg adapalene topical cream 0.1 % adapalene topical gel 0.1 %, 0.3 % ammonium lactate topical cream 12 % ammonium lactate topical lotion 12 % amnesteem oral capsule 10 mg, 20 mg, 40 mg avita topical cream % avita topical gel % AZELEX TOPICAL CREAM 20 % calcipotriene scalp solution % calcipotriene topical cream % calcipotriene topical ointment % PA; QL (6 per 28 days); PA; QL (4.2 per 28 days); PA; QL (4.2 per 28 days); LA; PA; PA; QL (1 per 30 days); PA PA PA PA QL (120 per 30 days) QL (120 per 30 days) 58

68 calcitriol topical ointment 3 mcg/gram claravis oral capsule 10 mg, 20 mg, 30 mg, 40 mg clindamycin-benzoyl peroxide topical gel 1-5 %, 1.2 %(1 % base) -5 % clobetasol topical spray,non-aerosol 0.05 % clotrimazole-betamethasone topical cream % clotrimazole-betamethasone topical lotion % CORTISPORIN TOPICAL CREAM , MG/G-UNIT/G-% CORTISPORIN TOPICAL OINTMENT 1 % COSENTYX (2 SYRINGES) SUBCUTANEOUS SYRINGE 150 MG/ML COSENTYX PEN (2 PENS) SUBCUTANEOUS PEN INJECTOR 150 MG/ML dapsone topical gel 5 % diclofenac sodium topical gel 1 % ELIDEL TOPICAL CREAM 1 % erythromycin-benzoyl peroxide topical gel 3-5 % FINACEA TOPICAL FOAM 15 % FINACEA TOPICAL GEL 15 % fluocinonide topical cream 0.1 % fluorouracil topical cream 0.5 %, 5 % fluorouracil topical solution 2 %, 5 % fluticasone topical cream 0.05 % fluticasone topical ointment % imiquimod topical cream in packet 5 % isotretinoin oral capsule 10 mg, 20 mg, 30 mg, 40 mg methoxsalen oral capsule,liqd-filled,rapid rel 10 mg myorisan oral capsule 10 mg, 20 mg, 30 mg, 40 mg neuac topical gel 1.2 %(1 % base) -5 % nystatin-triamcinolone topical cream 100, unit/g-% nystatin-triamcinolone topical ointment 100, unit/gram-% oxiconazole topical cream 1 % PICATO TOPICAL GEL % PICATO TOPICAL GEL 0.05 % podofilox topical solution 0.5 % prednicarbate topical cream 0.1 % REGRANEX TOPICAL GEL 0.01 % PA; LA; QL (32 per 365 days); PA; LA; QL (32 per 365 days); QL (12 per 30 days) QL (3 per 30 days) QL (2 per 30 days) PA; 59

69 SANTYL TOPICAL OINTMENT 250 UNIT/GRAM selenium sulfide topical lotion 2.5 % SILIQ SUBCUTANEOUS SYRINGE 210 MG/1.5 ML STELARA SUBCUTANEOUS SOLUTION 45 MG/0.5 ML STELARA SUBCUTANEOUS SYRINGE 45 MG/0.5 ML, 90 MG/ML tacrolimus topical ointment 0.03 %, 0.1 % TALTZ AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 80 MG/ML TALTZ SYRINGE SUBCUTANEOUS SYRINGE 80 MG/ML tazarotene topical cream 0.1 % TAZORAC TOPICAL CREAM 0.05 %, 0.1 % TAZORAC TOPICAL GEL 0.05 %, 0.1 % TOLAK TOPICAL CREAM 4 % tretinoin topical cream %, 0.05 %, 0.1 % tretinoin topical gel 0.01 %, % zenatane oral capsule 10 mg, 20 mg, 30 mg, 40 mg ZYCLARA TOPICAL CREAM IN METERED-DOSE PUMP 2.5 % PA; PA; PA; PA; LA; PA; LA; PA PA PA PA QL (7.5 per 28 days) ZYCLARA TOPICAL CREAM IN METERED-DOSE PUMP 3.75 % QL (28 per 28 days) Electrolytes/Minerals/Metals/Vitamins Electrolyte/ Mineral Replacement CARBAGLU ORAL TABLET, DISPERSIBLE 200 MG fluoride (sodium) oral tablet 1 mg (2.2 mg sod. fluoride) KLOR-CON 10 ORAL TABLET EXTENDED RELEASE 10 MEQ KLOR-CON 8 ORAL TABLET EXTENDED RELEASE 8 MEQ klor-con m10 oral tablet,er particles/crystals 10 meq klor-con m15 oral tablet,er particles/crystals 15 meq klor-con m20 oral tablet,er particles/crystals 20 meq klor-con sprinkle oral capsule, extended release 10 meq, 8 meq K-SOL ORAL LIQUID 40 MEQ/15 ML K-TAB ORAL TABLET EXTENDED RELEASE 10 MEQ, 20 MEQ, 8 MEQ magnesium sulfate injection solution 4 meq/ml (50 %) magnesium sulfate injection syringe 4 meq/ml PHYSIOSOL IRRIGATION IRRIGATION SOLUTION MEQ/L PA; 60

70 potassium chloride in water intravenous piggyback 20 meq/100 ml, 40 meq/100 ml potassium chloride intravenous solution 2 meq/ml potassium chloride oral capsule, extended release 10 meq, 8 meq potassium chloride oral liquid 20 meq/15 ml, 40 meq/15 ml potassium chloride oral packet 20 meq potassium chloride oral tablet extended release 10 meq, 20 meq, 8 meq potassium chloride oral tablet,er particles/crystals 10 meq, 20 meq sodium chloride 0.45 % intravenous parenteral solution 0.45 % sodium chloride 0.45 % intravenous piggyback 0.45 % sodium chloride 0.9 % intravenous parenteral solution sodium chloride 3 % intravenous parenteral solution 3 % sodium chloride 5 % intravenous parenteral solution 5 % sodium chloride intravenous parenteral solution 2.5 meq/ml sodium chloride irrigation solution 0.9 % sodium fluoride 0.5 mg/ml drop d/f, s/f,gluten-free (otc) 0.5 mg (1.1 mg sod.fluorid)/ml SUPREP BOWEL PREP KIT ORAL RECON SOLN GRAM Electrolyte/Mineral/Metal Modifiers AMINOSYN 7 % WITH ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN-RF 5.2 % INTRAVENOUS PARENTERAL SOLUTION 5.2 % DEPEN TITRATABS ORAL TABLET 250 MG EXJADE ORAL TABLET, DISPERSIBLE 125 MG, 250 MG, 500 MG FERRIPROX ORAL SOLUTION 100 MG/ML FERRIPROX ORAL TABLET 500 MG FREAMINE HBC 6.9 % INTRAVENOUS PARENTERAL SOLUTION 6.9 % JADENU ORAL TABLET 180 MG, 360 MG, 90 MG JADENU SPRINKLE ORAL GRANULES IN PACKET 180 MG, 360 MG, 90 MG kionex (with sorbitol) oral suspension gram/60 ml PLENAMINE INTRAVENOUS PARENTERAL SOLUTION 15 % SAMSCA ORAL TABLET 15 MG, 30 MG sod polystyren sulf 15 g/60 ml sorbitol free 15 gram/60 ml ; ; PA; LA; PA; PA; ; PA; PA; PA; 61

71 sodium polystyrene sulfonate oral powder sps (with sorbitol) oral suspension gram/60 ml SYPRINE ORAL CAPSULE 250 MG Electrolytes/Minerals/Metals/Vitamins 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-HBC 7% INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN-PF 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % AMINOSYN-PF 7 % (SULFITE-FREE) INTRAVENOUS PARENTERAL SOLUTION 7 % CLINIMIX 5%/D15W SULFITE FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX 5%/D25W SULFITE-FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX 2.75%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 % CLINIMIX 4.25%/D10W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 4.25%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 4.25%-D20W SULF-FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 4.25%-D25W SULF-FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 5%-D20W(SULFITE-FREE) INTRAVENOUS PARENTERAL SOLUTION 5 % ; ; ; ; ; ; ; ; ; 62

72 CLINIMIX E 2.75%/D10W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 % CLINIMIX E 2.75%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 % CLINIMIX E 4.25%/D10W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 4.25%/D25W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 4.25%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 5%/D15W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 5%/D20W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 5%/D25W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % d10 %-0.45 % sodium chloride intravenous parenteral solution d2.5 %-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 0.2 % nacl intravenous parenteral solution dextrose 10 % in water (d10w) intravenous parenteral solution 10 % dextrose 5 % in water (d5w) intravenous parenteral solution dextrose 5 % in water (d5w) intravenous piggyback 5 % dextrose 5 %-lactated ringers intravenous parenteral solution dextrose 5%-0.2 % sod chloride intravenous parenteral solution dextrose 5%-0.3 % sod.chloride intravenous parenteral solution HEPATAMINE 8% INTRAVENOUS PARENTERAL SOLUTION 8 % INTRALIPID INTRAVENOUS EMULSION 20 %, 30 % LACTATED RINGERS INTRAVENOUS PARENTERAL SOLUTION LACTATED RINGERS IRRIGATION SOLUTION levocarnitine (with sugar) oral solution 100 mg/ml levocarnitine oral tablet 330 mg NEPHRAMINE 5.4 % INTRAVENOUS PARENTERAL SOLUTION 5.4 % NUTRILIPID INTRAVENOUS EMULSION 20 % ; ; ; ; 63

73 pnv prenatal plus multivit tab s/f, gluten-free 27 mg iron- 1 mg potassium chlorid-d5-0.45%nacl intravenous parenteral solution 10 meq/l, 20 meq/l, 30 meq/l potassium chloride in lr-d5 intravenous parenteral solution 40 meq/l potassium chloride intravenous solution 2 meq/ml potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.9%nacl intravenous parenteral solution 20 meq/l PREMASOL 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % ; PREMASOL 6 % INTRAVENOUS PARENTERAL SOLUTION 6 % ; prenatal vitamin plus low iron oral tablet 27 mg iron- 1 mg PROSOL 20 % INTRAVENOUS PARENTERAL SOLUTION ringer's irrigation solution sodium chloride 100 meq/40 ml 25's, sdv 2.5 meq/ml TPN ELECTROLYTES II IV SOLN 25'S,20ML/50ML FTV MEQ/20 ML TPN ELECTROLYTES INTRAVENOUS SOLUTION MEQ/20 ML TRAVASOL 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % trientine oral capsule 250 mg TROPHAMINE 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % TROPHAMINE 6% INTRAVENOUS PARENTERAL SOLUTION 6 % water for irrigation, sterile irrigation solution Gastrointestinal Agents Antispasmodics, Gastrointestinal chlordiazepoxide-clidinium oral capsule mg dicyclomine oral capsule 10 mg dicyclomine oral solution 10 mg/5 ml dicyclomine oral tablet 20 mg glycopyrrolate oral tablet 1 mg, 2 mg methscopolamine oral tablet 2.5 mg, 5 mg propantheline oral tablet 15 mg Gastrointestinal Agents ; ; ; ; QL (240 per 30 days) 64

74 amoxicil-clarithromy-lansopraz oral combo pack mg UCERIS ORAL TABLET,DELAYED AND EXT.RELEASE 9 MG UCERIS RECTAL FOAM 2 MG/ACTUATION Gastrointestinal Agents, Other CHOLBAM ORAL CAPSULE 250 MG, 50 MG diphenoxylate-atropine oral liquid mg/5 ml diphenoxylate-atropine oral tablet mg GATTEX 30-VIAL SUBCUTANEOUS KIT 5 MG loperamide oral capsule 2 mg metoclopramide hcl injection solution 5 mg/ml metoclopramide hcl injection syringe 5 mg/ml metoclopramide hcl oral solution 5 mg/5 ml metoclopramide hcl oral tablet 10 mg, 5 mg MOVANTIK ORAL TABLET 12.5 MG, 25 MG RELISTOR ORAL TABLET 150 MG RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6 ML RELISTOR SUBCUTANEOUS SYRINGE 12 MG/0.6 ML RELISTOR SUBCUTANEOUS SYRINGE 8 MG/0.4 ML ursodiol oral capsule 300 mg ursodiol oral tablet 250 mg, 500 mg Histamine2 (H2) Receptor Antagonists cimetidine hcl oral solution 300 mg/5 ml cimetidine oral tablet 200 mg, 300 mg, 400 mg, 800 mg famotidine (pf) intravenous solution 20 mg/2 ml famotidine (pf)-nacl (iso-os) intravenous piggyback 20 mg/50 ml famotidine oral suspension 40 mg/5 ml (8 mg/ml) famotidine oral tablet 20 mg, 40 mg nizatidine oral capsule 300 mg nizatidine oral solution 150 mg/10 ml ranitidine hcl injection solution 50 mg/2 ml (25 mg/ml) ranitidine hcl oral syrup 15 mg/ml ranitidine hcl oral tablet 150 mg, 300 mg Irritable Bowel Syndrome Agents alosetron oral tablet 0.5 mg, 1 mg AMITIZA ORAL CAPSULE 24 MCG, 8 MCG DELZICOL ORAL CAPSULE (WITH DEL REL TABLETS) 400 MG PA; PA; QL (90 per 30 days); QL (36 per 28 days); QL (36 per 28 days); QL (12 per 30 days); ; 65

75 GIAZO ORAL TABLET 1.1 GRAM LINZESS ORAL CAPSULE 145 MCG, 290 MCG, 72 MCG VIBERZI ORAL TABLET 100 MG, 75 MG Laxatives COLYTE WITH FLAVOR PACKS ORAL RECON SOLN GRAM constulose oral solution 10 gram/15 ml enulose oral solution 10 gram/15 ml gavilyte-c oral recon soln gram gavilyte-g oral recon soln gram gavilyte-h and bisacodyl oral kit mg-gram gavilyte-n oral recon soln 420 gram generlac oral solution 10 gram/15 ml GOLYTELY ORAL POWDER IN PACKET GRAM GOLYTELY ORAL RECON SOLN GRAM lactulose oral solution 10 gram/15 ml peg 3350-electrolytes oral recon soln gram, gram peg-electrolyte soln oral recon soln 420 gram polyethylene glycol 3350 oral powder 17 gram/dose trilyte with flavor packets oral recon soln 420 gram Protectants CARAFATE ORAL SUSPENSION 100 MG/ML misoprostol oral tablet 100 mcg, 200 mcg sucralfate oral tablet 1 gram Proton Pump Inhibitors esomeprazole magnesium oral capsule,delayed release(dr/ec) 20 mg, 40 mg lansoprazole oral capsule,delayed release(dr/ec) 15 mg lansoprazole oral capsule,delayed release(dr/ec) 30 mg lansoprazole oral tablet,disintegrat, delay rel 15 mg lansoprazole oral tablet,disintegrat, delay rel 30 mg omeprazole oral capsule,delayed release(dr/ec) 10 mg, 20 mg, 40 mg pantoprazole oral tablet,delayed release (dr/ec) 20 mg, 40 mg rabeprazole oral tablet,delayed release (dr/ec) 20 mg 66

76 Genetic Or Enzyme Disorder: Replacement, Modifiers, Treatment Genetic Or Enzyme Disorder: Replacement, Modifiers, Treatment ADAGEN INTRAMUSCULAR SOLUTION 250 UNIT/ML CEREZYME INTRAVENOUS RECON SOLN 400 UNIT CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 12,000-38,000-60,000 UNIT, 24,000-76, ,000 UNIT, 3,000-9,500-15,000 UNIT, 36, , ,000 UNIT, 6,000-19,000-30,000 UNIT CYSTADANE ORAL POWDER 1 GRAM/1.7 ML FABRAZYME INTRAVENOUS RECON SOLN 35 MG KUVAN ORAL POWDER IN PACKET 100 MG, 500 MG KUVAN ORAL TABLET,SOLUBLE 100 MG miglustat oral capsule 100 mg NAGLAZYME INTRAVENOUS SOLUTION 5 MG/5 ML PANCREAZE ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,500-35,500-61,500 UNIT, 16,800-56,800-98,400 UNIT, 2,600-6,200-10,850 UNIT, 21,000-54,700-83,900 UNIT, 4,200-14,200-24,600 UNIT PROCYSBI ORAL CAPSULE, DELAYED REL SPRINKLE 25 MG, 75 MG RAVICTI ORAL LIQUID 1.1 GRAM/ML PA; PA; QL (90 per 30 days); PA; STRENSIQ SUBCUTANEOUS SOLUTION 100 MG/ML, 40 MG/ML PA; SUCRAID ORAL SOLUTION 8,500 UNIT/ML VPRIV INTRAVENOUS RECON SOLN 400 UNIT ZAVESCA ORAL CAPSULE 100 MG ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,000-32,000-42,000 UNIT, 15,000-47,000-63,000 UNIT, 20,000-63,000-84,000 UNIT, 20,000-68, ,000 UNIT, 25,000-79, ,000 UNIT, 3,000-10,000-14,000-UNIT, 40, , ,000 UNIT, 40, , ,000 UNIT, 5,000-17,000-24,000 UNIT ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,000-34,000-55,000 UNIT, 15,000-51,000-82,000 UNIT, 25,000-85, ,000 UNIT, 3,000-10,000-16,000 UNIT, 5,000-17,000-27,000 UNIT Genitourinary Agents Antispasmodics, Urinary darifenacin oral tablet extended release 24 hr 15 mg, 7.5 mg flavoxate oral tablet 100 mg QL (90 per 30 days); 67

77 MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG, 50 MG oxybutynin chloride oral syrup 5 mg/5 ml oxybutynin chloride oral tablet 5 mg oxybutynin chloride oral tablet extended release 24hr 10 mg, 15 mg, 5 mg tolterodine oral capsule,extended release 24hr 2 mg, 4 mg tolterodine oral tablet 1 mg, 2 mg TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HR 4 MG, 8 MG trospium oral capsule,extended release 24hr 60 mg trospium oral tablet 20 mg VESICARE ORAL TABLET 10 MG, 5 MG Benign Prostatic Hypertrophy Agents alfuzosin oral tablet extended release 24 hr 10 mg CIALIS ORAL TABLET 2.5 MG, 5 MG dutasteride oral capsule 0.5 mg dutasteride-tamsulosin oral capsule, er multiphase 24 hr mg finasteride oral tablet 5 mg RAPAFLO ORAL CAPSULE 4 MG, 8 MG tamsulosin oral capsule 0.4 mg Genitourinary Agents, Other bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg ELMIRON ORAL CAPSULE 100 MG potassium citrate oral tablet extended release 10 meq (1,080 mg), 15 meq, 5 meq (540 mg) sodium phenylbutyrate oral powder 0.94 gram/gram Phosphate Binders calcium acetate oral capsule 667 mg calcium acetate oral tablet 667 mg eliphos oral tablet 667 mg FOSRENOL ORAL POWDER IN PACKET 1,000 MG, 750 MG FOSRENOL ORAL TABLET,CHEWABLE 1,000 MG, 500 MG, 750 MG lanthanum oral tablet,chewable 1,000 mg, 500 mg, 750 mg PHOSLYRA ORAL SOLUTION 667 MG (169 MG CALCIUM)/5 ML RENAGEL ORAL TABLET 400 MG, 800 MG PA 68

78 RENVELA ORAL POWDER IN PACKET 0.8 GRAM RENVELA ORAL POWDER IN PACKET 2.4 GRAM RENVELA ORAL TABLET 800 MG sevelamer carbonate oral powder in packet 0.8 gram, 2.4 gram sevelamer carbonate oral tablet 800 mg Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal) Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal) ala-cort topical cream 1 %, 2.5 % alclometasone topical cream 0.05 % alclometasone topical ointment 0.05 % ANALPRAM-HC RECTAL CREAM 1-1 % ANALPRAM-HC TOPICAL LOTION % 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 % clobetasol-emollient topical foam 0.05 % CORDRAN TAPE LARGE ROLL TOPICAL TAPE 4 MCG/CM2 cormax scalp solution 0.05 % desonide topical cream 0.05 % desonide topical lotion 0.05 % desonide topical ointment 0.05 % desoximetasone topical cream 0.05 %, 0.25 % desoximetasone topical gel 0.05 % desoximetasone topical ointment 0.05 %, 0.25 % EMFLAZA ORAL SUSPENSION MG/ML EMFLAZA ORAL TABLET 18 MG, 30 MG, 36 MG, 6 MG fludrocortisone oral tablet 0.1 mg fluocinolone 0.01% body oil 0.01 % fluocinolone acetonide oil otic (ear) drops 0.01 % fluocinolone and shower cap scalp oil 0.01 % QL (540 per 30 days) QL (180 per 30 days) QL (540 per 30 days) PA; PA; 69

79 fluocinolone topical cream 0.01 %, % fluocinolone topical ointment % fluocinolone topical solution 0.01 % fluocinonide topical cream 0.05 % fluocinonide topical gel 0.05 % fluocinonide topical ointment 0.05 % fluocinonide topical solution 0.05 % fluocinonide-e topical cream 0.05 % halobetasol propionate topical cream 0.05 % halobetasol propionate topical ointment 0.05 % hydrocortisone butyrate topical cream 0.1 % hydrocortisone butyrate topical ointment 0.1 % hydrocortisone butyrate topical solution 0.1 % hydrocortisone oral tablet 10 mg hydrocortisone topical cream 1 %, 2.5 % hydrocortisone topical lotion 2.5 % hydrocortisone topical ointment 1 %, 2.5 % hydrocortisone valerate topical cream 0.2 % hydrocortisone valerate topical ointment 0.2 % hydrocortisone-pramoxine rectal cream 1-1 % methylprednisolone oral tablets,dose pack 4 mg methylprednisolone sodium succ injection recon soln 125 mg mometasone topical cream 0.1 % mometasone topical ointment 0.1 % mometasone topical solution 0.1 % PRAMOSONE TOPICAL CREAM 1-1 % PRAMOSONE TOPICAL LOTION 1-1 % prednicarbate topical ointment 0.1 % prednisolone sodium phosphate oral solution 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) prednisone oral solution 5 mg/5 ml procto-pak topical cream with perineal applicator 1 % proctozone-hc topical cream with perineal applicator 2.5 % triamcinolone acetonide topical cream %, 0.1 %, 0.5 % triamcinolone acetonide topical lotion %, 0.1 % triamcinolone acetonide topical ointment %, 0.1 %, 0.5 % 70

80 triderm topical cream 0.1 %, 0.5 % tridesilon topical cream 0.05 % Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary) Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary) desmopressin 10 mcg/0.1 ml spr 10 mcg/spray (0.1 ml) desmopressin injection solution 4 mcg/ml desmopressin nasal solution 0.1 mg/ml (refrigerate) desmopressin nasal spray,non-aerosol 10 mcg/spray (0.1 ml) desmopressin oral tablet 0.1 mg, 0.2 mg EGRIFTA SUBCUTANEOUS RECON SOLN 1 MG INCRELEX SUBCUTANEOUS SOLUTION 10 MG/ML methylergonovine oral tablet 0.2 mg MYALEPT SUBCUTANEOUS RECON SOLN 5 MG/ML (FINAL CONC.) NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 10 MG/1.5 ML (6.7 MG/ML), 15 MG/1.5 ML (10 MG/ML), 30 MG/3 ML (10 MG/ML), 5 MG/1.5 ML (3.3 MG/ML) STIMATE NASAL SPRAY,NON-AEROSOL 150 MCG/SPRAY (0.1 ML) Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex Hormones/ Modifiers) Anabolic Steroids ANADROL-50 ORAL TABLET 50 MG oxandrolone oral tablet 10 mg oxandrolone oral tablet 2.5 mg Androgens ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 MG/24 HOUR ANDRODERM TRANSDERMAL PATCH 24 HOUR 4 MG/24 HR ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP MG/1.25 GRAM (1.62 %) ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM) ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (40.5 MG/2.5 GRAM) danazol oral capsule 100 mg, 200 mg, 50 mg DEPO-TESTOSTERONE INTRAMUSCULAR OIL 200 MG/ML PA; LA; ; PA; PA; ; PA; ; QL (120 per 30 days) PA NSO; PA NSO; PA NSO; QL (150 per 30 days) PA NSO; QL (37.5 per 30 days) PA NSO; QL (150 per 30 days) PA NSO 71

81 testosterone cypionate intramuscular oil 100 mg/ml testosterone cypionate intramuscular oil 200 mg/ml testosterone enanthate intramuscular oil 200 mg/ml testosterone transdermal gel in metered-dose pump 12.5 mg/ 1.25 gram (1 %) testosterone transdermal gel in packet 1 % (25 mg/2.5gram), 1 % (50 mg/5 gram) Estrogens ALORA TRANSDERMAL PATCH SEMIWEEKLY MG/24 HR, 0.05 MG/24 HR, MG/24 HR, 0.1 MG/24 HR ESTRACE VAGINAL CREAM 0.01 % (0.1 MG/GRAM) estradiol oral tablet 0.5 mg, 1 mg, 2 mg estradiol transdermal patch semiweekly mg/24 hr estradiol transdermal patch semiweekly mg/24 hr, 0.05 mg/24 hr, mg/24 hr, 0.1 mg/24 hr estradiol transdermal patch weekly mg/24 hr, mg/24 hr, 0.05 mg/24 hr, 0.06 mg/24 hr, mg/24 hr, 0.1 mg/24 hr estradiol vaginal cream 0.01 % (0.1 mg/gram) ESTRING VAGINAL RING 2 MG (7.5 MCG /24 HOUR) estropipate oral tablet 0.75 mg, 1.5 mg, 3 mg MENEST ORAL TABLET 0.3 MG, MG, 1.25 MG PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, MG, 0.9 MG, 1.25 MG PREMARIN VAGINAL CREAM MG/GRAM yuvafem vaginal tablet 10 mcg Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex Hormones/ Modifiers) altavera (28) oral tablet mg alyacen 1/35 (28) oral tablet 1-35 mg-mcg alyacen 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg amabelz oral tablet mg, mg amethia lo oral tablets,dose pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7) amethia oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (7) amethyst oral tablet mcg apri oral tablet mg aranelle (28) oral tablet 0.5/1/ mg-mcg PA NSO PA NSO; QL (4.5 per 30 days) PA NSO; QL (300 per 30 days) PA NSO; QL (300 per 30 days) QL (8 per 28 days) QL (8 per 28 days) QL (4 per 28 days) QL (1 per 90 days) QL (91 per 90 days) QL (91 per 90 days) 72

82 ashlyna oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (7) aubra oral tablet mg-mcg aviane oral tablet mg-mcg azurette (28) oral tablet mgx21 /0.01 mg x 5 balziva (28) oral tablet mg-mcg bekyree (28) oral tablet mgx21 /0.01 mg x 5 blisovi 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4) blisovi fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) blisovi fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7) brevicon (28) oral tablet mg-mcg briellyn oral tablet mg-mcg camrese lo oral tablets,dose pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7) camrese oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (7) caziant (28) oral tablet 0.1/.125/ mg-mcg chateal oral tablet mg CLIMARA PRO TRANSDERMAL PATCH WEEKLY MG/24 HR cryselle (28) oral tablet mg-mcg cyclafem 1/35 (28) oral tablet 1-35 mg-mcg cyclafem 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg cyred oral tablet mg dasetta 1/35 (28) oral tablet 1-35 mg-mcg dasetta 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg deblitane oral tablet 0.35 mg delyla (28) oral tablet mg-mcg desog-e.estradiol/e.estradiol oral tablet mgx21 /0.01 mg x 5 desogestrel-ethinyl estradiol oral tablet mg drospirenone-e.estradiol-lm.fa oral tablet mg (24) (4), mg (21) (7) drospirenone-ethinyl estradiol oral tablet mg, mg elinest oral tablet mg-mcg emoquette oral tablet mg enpresse oral tablet (6)/75-40 (5)/125-30(10) enskyce oral tablet mg QL (91 per 90 days) 73

83 estarylla oral tablet mg-mcg estradiol vaginal tablet 10 mcg estradiol-norethindrone acet oral tablet mg, mg ethynodiol diac-eth estradiol oral tablet 1-35 mg-mcg, 1-50 mg-mcg falmina (28) oral tablet mg-mcg fayosim oral tablets,dose pack,3 month 0.15 mg-20 mcg/ 0.15 mg-25 mcg femynor oral tablet mg-mcg fyavolv oral tablet mg-mcg, 1-5 mg-mcg gianvi (28) oral tablet mg gildagia oral tablet mg-mcg gildess 1.5/30 (21) oral tablet mg-mcg gildess 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4) heather oral tablet 0.35 mg introvale oral tablets,dose pack,3 month 0.15 mg-30 mcg isibloom oral tablet mg jencycla oral tablet 0.35 mg jinteli oral tablet 1-5 mg-mcg jolessa oral tablets,dose pack,3 month 0.15 mg-30 mcg juleber oral tablet mg junel 1.5/30 (21) oral tablet mg-mcg junel 1/20 (21) oral tablet 1-20 mg-mcg junel fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) junel fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7) junel fe 24 oral tablet 1 mg-20 mcg (24)/75 mg (4) kaitlib fe oral tablet,chewable 0.8mg-25mcg(24) and 75 mg (4) kariva (28) oral tablet mgx21 /0.01 mg x 5 kelnor 1/35 (28) oral tablet 1-35 mg-mcg kelnor 1-50 oral tablet 1-50 mg-mcg kimidess (28) oral tablet mgx21 /0.01 mg x 5 kurvelo oral tablet mg l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.10 mg- 20 mcg (84)/10 mcg (7) l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.15 mg- 20 mcg/ 0.15 mg-25 mcg, 0.15 mg-30 mcg (84)/10 mcg (7) larin 1.5/30 (21) oral tablet mg-mcg QL (91 per 30 days) QL (91 per 90 days) QL (91 per 90 days) 74

84 larin 1/20 (21) oral tablet 1-20 mg-mcg larin 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4) larin fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) larin fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7) larissia oral tablet mg-mcg layolis fe oral tablet,chewable 0.8mg-25mcg(24) and 75 mg (4) leena 28 oral tablet 0.5/1/ mg-mcg lessina oral tablet mg-mcg levonest (28) oral tablet (6)/75-40 (5)/125-30(10) levonorgestrel-ethinyl estrad oral tablet mg-mcg, mg, mcg levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month 0.15 mg- 30 mcg levonorg-eth estrad triphasic oral tablet (6)/75-40 (5)/125-30(10) levora-28 oral tablet mg lillow oral tablet mg lomedia 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4) lopreeza oral tablet mg, mg loryna (28) oral tablet mg low-ogestrel (28) oral tablet mg-mcg lutera (28) oral tablet mg-mcg marlissa oral tablet mg melodetta 24 fe oral tablet,chewable 1 mg-20 mcg(24) /75 mg (4) mibelas 24 fe oral tablet,chewable 1 mg-20 mcg(24) /75 mg (4) microgestin 1.5/30 (21) oral tablet mg-mcg microgestin 1/20 (21) oral tablet 1-20 mg-mcg microgestin 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4) microgestin fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) microgestin fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7) mili oral tablet mg-mcg mimvey lo oral tablet mg mimvey oral tablet mg mono-linyah oral tablet mg-mcg mononessa (28) oral tablet mg-mcg myzilra oral tablet (6)/75-40 (5)/125-30(10) 75

85 NATAZIA ORAL TABLET 3 MG/2 MG-2 MG/ 2 MG-3 MG/1 MG necon 0.5/35 (28) oral tablet mg-mcg necon 1/50 (28) oral tablet 1-50 mg-mcg necon 10/11 (28) oral tablet /1-35 mg-mcg/mg-mcg necon 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg nikki (28) oral tablet mg nora-be oral tablet 0.35 mg noreth-ethinyl estradiol-iron oral tablet,chewable 0.4mg-35mcg(21) and 75 mg (7), 0.8mg-25mcg(24) and 75 mg (4) norethindrone ac-eth estradiol oral tablet mg-mcg, 1-20 mgmcg, 1-5 mg-mcg norethindrone-e.estradiol-iron oral tablet 1 mg-20 mcg (21)/75 mg (7), 1 mg-20 mcg (24)/75 mg (4) norethindrone-e.estradiol-iron oral tablet,chewable 1 mg-20 mcg(24) /75 mg (4) norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 mg-25 mcg, 0.18/0.215/0.25 mg-35 mcg (28), mg-mcg norinyl 1/35 (28) oral tablet 1-35 mg-mcg norlyda oral tablet 0.35 mg norlyroc oral tablet 0.35 mg nortrel 0.5/35 (28) oral tablet mg-mcg nortrel 1/35 (21) oral tablet 1-35 mg-mcg nortrel 1/35 (28) oral tablet 1-35 mg-mcg nortrel 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg ocella oral tablet mg ogestrel (28) oral tablet mg-mcg orsythia oral tablet mg-mcg philith oral tablet mg-mcg pimtrea (28) oral tablet mgx21 /0.01 mg x 5 pirmella oral tablet 0.5/0.75/1 mg- 35 mcg, 1-35 mg-mcg portia oral tablet mg PREMPHASE ORAL TABLET MG (14)/ 0.625MG-5MG(14) PREMPRO ORAL TABLET MG, MG, MG, MG previfem oral tablet mg-mcg quasense oral tablets,dose pack,3 month 0.15 mg-30 mcg rajani oral tablet mg (24) (4) 76

86 reclipsen (28) oral tablet mg rivelsa oral tablets,dose pack,3 month 0.15 mg-20 mcg/ 0.15 mg-25 mcg setlakin oral tablets,dose pack,3 month 0.15 mg-30 mcg sharobel oral tablet 0.35 mg sprintec (28) oral tablet mg-mcg sronyx oral tablet mg-mcg syeda oral tablet mg tarina fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7) tilia fe oral tablet 1-20(5)/1-30(7) /1mg-35mcg (9) tri femynor oral tablet 0.18/0.215/0.25 mg-35 mcg (28) tri-estarylla oral tablet 0.18/0.215/0.25 mg-35 mcg (28) tri-legest fe oral tablet 1-20(5)/1-30(7) /1mg-35mcg (9) tri-linyah oral tablet 0.18/0.215/0.25 mg-35 mcg (28) tri-lo-estarylla oral tablet 0.18/0.215/0.25 mg-25 mcg tri-lo-sprintec oral tablet 0.18/0.215/0.25 mg-25 mcg tri-mili oral tablet 0.18/0.215/0.25 mg-35 mcg (28) trinessa (28) oral tablet 0.18/0.215/0.25 mg-35 mcg (28) trinessa lo oral tablet 0.18/0.215/0.25 mg-25 mcg tri-previfem (28) oral tablet 0.18/0.215/0.25 mg-35 mcg (28) tri-sprintec (28) oral tablet 0.18/0.215/0.25 mg-35 mcg (28) trivora (28) oral tablet (6)/75-40 (5)/125-30(10) tri-vylibra oral tablet 0.18/0.215/0.25 mg-35 mcg (28) tydemy oral tablet mg (21) (7) velivet triphasic regimen (28) oral tablet 0.1/.125/ mg-mcg vestura (28) oral tablet mg vienva oral tablet mg-mcg vyfemla (28) oral tablet mg-mcg vylibra oral tablet mg-mcg wera (28) oral tablet mg-mcg wymzya fe oral tablet,chewable 0.4mg-35mcg(21) and 75 mg (7) xulane transdermal patch weekly mcg/24 hr zarah oral tablet mg zenchent (28) oral tablet mg-mcg zenchent fe oral tablet,chewable 0.4mg-35mcg(21) and 75 mg (7) zovia 1/35e (28) oral tablet 1-35 mg-mcg QL (91 per 90 days) QL (3 per 28 days) 77

87 zovia 1/50e (28) oral tablet 1-50 mg-mcg Progestins camila oral tablet 0.35 mg DEPO-PROVERA INTRAMUSCULAR SUSPENSION 150 MG/ML, 400 MG/ML DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SYRINGE 104 MG/0.65 ML errin oral tablet 0.35 mg jolivette oral tablet 0.35 mg lyza oral tablet 0.35 mg medroxyprogesterone intramuscular suspension 150 mg/ml medroxyprogesterone oral tablet 10 mg, 2.5 mg, 5 mg megestrol oral suspension 400 mg/10 ml (40 mg/ml), 625 mg/5 ml megestrol oral tablet 20 mg, 40 mg norethindrone (contraceptive) oral tablet 0.35 mg norethindrone acetate oral tablet 5 mg progesterone micronized oral capsule 100 mg, 200 mg tulana oral tablet 0.35 mg Selective Estrogen Receptor Modifying Agents raloxifene oral tablet 60 mg Hormonal Agents, Stimulant/ Replacement/ Modifying (Thyroid) Hormonal Agents, Stimulant/ Replacement/ Modifying (Thyroid) levothyroxine intravenous recon soln 100 mcg levothyroxine oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg LEVOXYL ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG liothyronine intravenous solution 10 mcg/ml liothyronine oral tablet 25 mcg, 5 mcg, 50 mcg SYNTHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG THYROLAR-1 ORAL TABLET MCG THYROLAR-1/2 ORAL TABLET MCG THYROLAR-1/4 ORAL TABLET MCG QL (0.65 per 90 days) 78

88 THYROLAR-2 ORAL TABLET MCG THYROLAR-3 ORAL TABLET MCG Hormonal Agents, Suppressant (Adrenal) Hormonal Agents, Suppressant (Adrenal) LYSODREN ORAL TABLET 500 MG Hormonal Agents, Suppressant (Pituitary) Hormonal Agents, Suppressant (Pituitary) cabergoline oral tablet 0.5 mg FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 120 MG FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 80 MG leuprolide subcutaneous kit 1 mg/0.2 ml LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT MG, 22.5 MG LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 45 MG LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 7.5 MG octreotide acetate injection solution 1,000 mcg/ml, 100 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml octreotide acetate injection syringe 100 mcg/ml (1 ml), 50 mcg/ml (1 ml), 500 mcg/ml (1 ml) SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 10 MG, 20 MG, 30 MG SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML (1 ML), 0.6 MG/ML (1 ML), 0.9 MG/ML (1 ML) SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 120 MG/0.5 ML, 60 MG/0.2 ML, 90 MG/0.3 ML SOMAVERT SUBCUTANEOUS RECON SOLN 10 MG, 15 MG, 20 MG SOMAVERT SUBCUTANEOUS RECON SOLN 25 MG, 30 MG SYNAREL NASAL SPRAY,NON-AEROSOL 2 MG/ML Hormonal Agents, Suppressant (Thyroid) Antithyroid Agents methimazole oral tablet 10 mg, 5 mg QL (16 per 28 days) QL (1 per 90 days) QL (1 per 112 days) QL (1 per 168 days); QL (1 per 30 days) QL (1 per 30 days); PA PA PA; ; PA NSO; ; ; 79

89 propylthiouracil oral tablet 50 mg Immunological Agents Angioedema Agents CINRYZE INTRAVENOUS RECON SOLN 500 UNIT (5 ML) FIRAZYR SUBCUTANEOUS SYRINGE 30 MG/3 ML Immune Suppressants ACTEMRA SUBCUTANEOUS SYRINGE 162 MG/0.9 ML AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, 3 MG, 5 MG ATGAM INTRAVENOUS SOLUTION 50 MG/ML azathioprine oral tablet 50 mg azathioprine sodium injection recon soln 100 mg BENLYSTA INTRAVENOUS RECON SOLN 120 MG BENLYSTA INTRAVENOUS RECON SOLN 400 MG BENLYSTA SUBCUTANEOUS AUTO-INJECTOR 200 MG/ML BENLYSTA SUBCUTANEOUS SYRINGE 200 MG/ML CELLCEPT ORAL CAPSULE 250 MG CELLCEPT ORAL SUSPENSION FOR RECONSTITUTION 200 MG/ML CELLCEPT ORAL TABLET 500 MG CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT 400 MG (200 MG X 2 VIALS) CIMZIA SUBCUTANEOUS SYRINGE KIT 400 MG/2 ML (200 MG/ML X 2) cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg cyclosporine modified oral solution 100 mg/ml cyclosporine oral capsule 100 mg, 25 mg ENBREL SUBCUTANEOUS RECON SOLN 25 MG (1 ML) ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5ML (0.51) ENBREL SUBCUTANEOUS SYRINGE 50 MG/ML (0.98 ML) ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MG/ML (0.98 ML) ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HR 0.75 MG, 1 MG, 4 MG gengraf oral capsule 100 mg, 25 mg, 50 mg gengraf oral solution 100 mg/ml PA; QL (20 per 30 days); PA; QL (18 per 30 days); PA; PA NSO; ; QL (20 per 28 days); ; QL (6 per 28 days); ; ; PA; PA; PA; QL (8 per 28 days); PA; QL (4.08 per 28 days); PA; QL (7.84 per 28 days); PA; QL (7.84 per 28 days); 80

90 HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML-40 MG/0.4 ML HUMIRA PEN CROHN'S-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA PEN PSORIASIS-UVEITIS SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.4 ML, 40 MG/0.8 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.1 ML, 10 MG/0.2 ML, 20 MG/0.2 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 20 MG/0.4 ML, 40 MG/0.4 ML, 40 MG/0.8 ML KEVZARA SUBCUTANEOUS SYRINGE 150 MG/1.14 ML, 200 MG/1.14 ML KINERET SUBCUTANEOUS SYRINGE 100 MG/0.67 ML mercaptopurine oral tablet 50 mg methotrexate sodium (pf) injection recon soln 1 gram methotrexate sodium (pf) injection solution 25 mg/ml, 25 mg/ml (10 ml) methotrexate sodium injection solution 25 mg/ml methotrexate sodium oral tablet 2.5 mg mycophenolate mofetil hcl intravenous recon soln 500 mg mycophenolate mofetil oral capsule 250 mg mycophenolate mofetil oral suspension for reconstitution 200 mg/ml mycophenolate mofetil oral tablet 500 mg mycophenolate sodium oral tablet,delayed release (dr/ec) 180 mg, 360 mg NULOJIX INTRAVENOUS RECON SOLN 250 MG ORENCIA CLICKJECT SUBCUTANEOUS AUTO-INJECTOR 125 MG/ML ORENCIA SUBCUTANEOUS SYRINGE 125 MG/ML, 50 MG/0.4 ML, 87.5 MG/0.7 ML OTEZLA ORAL TABLET 30 MG OTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG (4)-20 MG (4)-30 MG (47), 10 MG (4)-20 MG (4)-30 MG(19) PROGRAF INTRAVENOUS SOLUTION 5 MG/ML PA; QL (6 per 28 days); PA; QL (3 per 28 days); PA; QL (2 per 28 days); PA; QL (6 per 28 days); PA; QL (6 per 28 days); PA; QL (6 per 28 days); PA; QL (2 per 28 days); PA; QL (6 per 28 days); PA; PA; ; QL (20 per 30 days); PA; PA; PA; PA; 81

91 RAPAMUNE ORAL SOLUTION 1 MG/ML RAPAMUNE ORAL TABLET 0.5 MG, 1 MG, 2 MG REMICADE INTRAVENOUS RECON SOLN 100 MG RENFLEXIS INTRAVENOUS RECON SOLN 100 MG SANDIMMUNE INTRAVENOUS SOLUTION 250 MG/5 ML SANDIMMUNE ORAL SOLUTION 100 MG/ML SIMPONI ARIA INTRAVENOUS SOLUTION 12.5 MG/ML SIMPONI SUBCUTANEOUS PEN INJECTOR 100 MG/ML, 50 MG/0.5 ML SIMPONI SUBCUTANEOUS SYRINGE 50 MG/0.5 ML sirolimus oral tablet 0.5 mg, 1 mg, 2 mg tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG XATMEP ORAL SOLUTION 2.5 MG/ML XELJANZ ORAL TABLET 10 MG, 5 MG XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR 11 MG ZORTRESS ORAL TABLET 0.25 MG, 0.75 MG ZORTRESS ORAL TABLET 0.5 MG Immunizing Agents, Passive CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN 12 GRAM, 6 GRAM GAMASTAN S/D INTRAMUSCULAR SOLUTION % RANGE GAMASTAN S/D INTRAMUSCULAR SOLUTION % RANGE (2 ML) GAMMAGARD LIQUID INJECTION SOLUTION 10 % GAMMAPLEX (WITH SORBITOL) INTRAVENOUS SOLUTION 5 % GAMMAPLEX INTRAVENOUS SOLUTION 10 %, 10 % (100 ML), 10 % (200 ML) GAMUNEX-C INJECTION SOLUTION 1 GRAM/10 ML (10 %) PRIVIGEN INTRAVENOUS SOLUTION 10 % THYMOGLOBULIN INTRAVENOUS RECON SOLN 25 MG Immunological Agents leflunomide oral tablet 10 mg, 20 mg SYNAGIS INTRAMUSCULAR SOLUTION 100 MG/ML PA; PA; QL (1 per 30 days); PA; QL (1 per 30 days); PA; ; PA; ; ; ; QL (120 per 30 days) ; ; ; ; ; ; QL (4 per 28 days); 82

92 SYNAGIS INTRAMUSCULAR SOLUTION 50 MG/0.5 ML Immunomodulators ACTIMMUNE SUBCUTANEOUS SOLUTION 100 MCG/0.5 ML ARCALYST SUBCUTANEOUS RECON SOLN 220 MG ILARIS (PF) SUBCUTANEOUS RECON SOLN 180 MG/1.2 ML (150 MG/ML) RIDAURA ORAL CAPSULE 3 MG SIMPONI SUBCUTANEOUS SYRINGE 100 MG/ML Vaccines ACTB (PF) INTRAMUSCULAR RECON SOLN 10 MCG/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION 2 LF-( MCG)-5LF/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE 2 LF-( MCG)-5LF/0.5 ML BCG VACCINE, LIVE (PF) PERCUTANEOUS SUSPENSION FOR RECONSTITUTION 50 MG BEXSERO INTRAMUSCULAR SYRINGE MCG/0.5 ML BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION LF- MCG-LF/0.5ML BOOSTRIX TDAP INTRAMUSCULAR SYRINGE LF- MCG-LF/0.5ML DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION LF-MCG-LF/0.5ML ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION 20 MCG/ML ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 20 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 9 (PF) INTRAMUSCULAR SUSPENSION 0.5 ML GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 0.5 ML HAVRIX (PF) INTRAMUSCULAR SUSPENSION 1,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML HAVRIX (PF) INTRAMUSCULAR SYRINGE 1,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML BERIX (PF) INTRAMUSCULAR RECON SOLN 10 MCG/0.5 ML PA; PA; QL (1.5 per 365 days) QL (1.5 per 365 days) QL (1.5 per 365 days) 83

93 IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN 2.5 UNIT INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION LF-MCG-LF/0.5ML INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE 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 25 LF-58 MCG-10 LF/0.5 ML KINRIX (PF) INTRAMUSCULAR SYRINGE 25 LF-58 MCG-10 LF/0.5 ML MENACTRA (PF) INTRAMUSCULAR SOLUTION 4 MCG/0.5 ML MENBRIX (PF) INTRAMUSCULAR RECON SOLN MCG/0.5 ML MENOMUNE - A/C/Y/W-135 (PF) SUBCUTANEOUS RECON SOLN 50 MCG MENOMUNE - A/C/Y/W-135 SUBCUTANEOUS RECON SOLN 50 MCG MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT 10-5 MCG/0.5 ML M-M-R II (PF) SUBCUTANEOUS RECON SOLN 1,000-12,500 TCID50/0.5 ML PEDIARIX (PF) INTRAMUSCULAR SYRINGE 10 MCG-25LF-25 MCG-10LF/0.5 ML PEDVAX B (PF) INTRAMUSCULAR SOLUTION 7.5 MCG/0.5 ML PENTACEL (PF) INTRAMUSCULAR KIT 15 LF UNIT-20 MCG-5 LF/0.5 ML PENTACEL DTAP-IPV COMPNT (PF) INTRAMUSCULAR SUSPENSION 15 LF-48 MCG- 5 LF UNIT/0.5ML 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 2.5 UNIT RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCG/ML, 40 MCG/ML, 5 MCG/0.5 ML 84

94 RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCG/ML, 5 MCG/0.5 ML ROTARIX ORAL SUSPENSION FOR RECONSTITUTION 10EXP6 CCID50/ML ROTATEQ VACCINE ORAL SOLUTION 2 ML SNGRIX (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 50 MCG/0.5 ML TENIVAC (PF) INTRAMUSCULAR SUSPENSION 5 LF UNIT- 2 LF UNIT/0.5ML TENIVAC (PF) INTRAMUSCULAR SYRINGE 5-2 LF UNIT/0.5 ML TETANUS,DIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION 5-25 LF UNIT/0.5 ML TETANUS-DIPHTHERIA TOXOIDS-TD INTRAMUSCULAR SUSPENSION 2-2 LF UNIT/0.5 ML TRUMENBA INTRAMUSCULAR SYRINGE 120 MCG/0.5 ML TWINRIX (PF) INTRAMUSCULAR SUSPENSION 720 ELISA UNIT- 20 MCG/ML TWINRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT- 20 MCG/ML TYPM VI INTRAMUSCULAR SOLUTION 25 MCG/0.5 ML TYPM VI INTRAMUSCULAR SYRINGE 25 MCG/0.5 ML VAQTA (PF) INTRAMUSCULAR SUSPENSION 25 UNIT/0.5 ML, 50 UNIT/ML VAQTA (PF) INTRAMUSCULAR SYRINGE 25 UNIT/0.5 ML, 50 UNIT/ML VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1,350 UNIT/0.5 ML YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10 EXP4.74 UNIT/0.5 ML ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 19,400 UNIT/0.65 ML Inflammatory Bowel Disease Agents Aminosalicylates balsalazide oral capsule 750 mg CANASA RECTAL SUPPOSITORY 1,000 MG LIALDA ORAL TABLET,DELAYED RELEASE (DR/EC) 1.2 GRAM mesalamine oral tablet,delayed release (dr/ec) 1.2 gram, 800 mg mesalamine rectal enema 4 gram/60 ml QL (2 per 365 days); AGE (Min 50 Years) QL (1 per 365 days); AGE (Min 49 Years) QL (120 per 30 days) 85

95 PENTASA ORAL CAPSULE, EXTENDED RELEASE 250 MG PENTASA ORAL CAPSULE, EXTENDED RELEASE 500 MG Glucocorticoids budesonide oral capsule,delayed,extend.release 3 mg colocort rectal enema 100 mg/60 ml hydrocortisone rectal enema 100 mg/60 ml procto-med hc topical cream with perineal applicator 2.5 % proctosol hc topical cream with perineal applicator 2.5 % Sulfonamides sulfasalazine oral tablet 500 mg sulfasalazine oral tablet,delayed release (dr/ec) 500 mg Metabolic Bone Disease Agents Metabolic Bone Disease Agents alendronate oral solution 70 mg/75 ml alendronate oral tablet 10 mg, 40 mg, 5 mg alendronate oral tablet 35 mg, 70 mg calcitonin (salmon) nasal spray,non-aerosol 200 unit/actuation calcitriol intravenous solution 1 mcg/ml calcitriol oral capsule 0.25 mcg, 0.5 mcg calcitriol oral solution 1 mcg/ml doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5 mcg etidronate disodium oral tablet 200 mg, 400 mg FORTEO SUBCUTANEOUS PEN INJECTOR 20 MCG/DOSE MCG/2.4 ML ibandronate oral tablet 150 mg MIACALCIN INJECTION SOLUTION 200 UNIT/ML NATPARA SUBCUTANEOUS CARTRIDGE 100 MCG/DOSE, 25 MCG/DOSE, 50 MCG/DOSE, 75 MCG/DOSE pamidronate intravenous recon soln 30 mg, 90 mg pamidronate intravenous solution 30 mg/10 ml (3 mg/ml), 60 mg/10 ml (6 mg/ml), 90 mg/10 ml (9 mg/ml) paricalcitol 2 mcg/ml vial sdv,inner,latex-free 2 mcg/ml PARICALCITOL HEMODIALYSIS PORT INJECTION SOLUTION 5 MCG/ML paricalcitol intravenous solution 2 mcg/ml PARICALCITOL INTRAVENOUS SOLUTION 5 MCG/ML QL (150 per 30 days) QL (300 per 30 days) QL (12 per 84 days) QL (3.7 per 28 days) PA; QL (2.4 per 28 days) QL (1 per 28 days) QL (2 per 28 days); paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg 86

96 PROLIA SUBCUTANEOUS SYRINGE 60 MG/ML RAYALDEE ORAL CAPSULE,EXTENDED RELEASE 24 HR 30 MCG risedronate oral tablet 150 mg risedronate oral tablet 30 mg, 5 mg risedronate oral tablet 35 mg (12 pack) risedronate oral tablet 35 mg, 35 mg (4 pack) risedronate oral tablet,delayed release (dr/ec) 35 mg SENSIPAR ORAL TABLET 30 MG, 60 MG SENSIPAR ORAL TABLET 90 MG TYMLOS SUBCUTANEOUS PEN INJECTOR 80 MCG (3,120 MCG/1.56 ML) XGEVA SUBCUTANEOUS SOLUTION 120 MG/1.7 ML (70 MG/ML) zoledronic acid intravenous recon soln 4 mg zoledronic acid intravenous solution 4 mg/5 ml zoledronic acid-mannitol-water intravenous piggyback 5 mg/100 ml zoledronic ac-mannitol-0.9nacl intravenous piggyback 4 mg/100 ml Ophthalmic Agents Ophthalmic Agents bacitracin-polymyxin b ophthalmic (eye) ointment ,000 unit/gram naphazoline ophthalmic (eye) drops 0.1 % neomycin-bacitracin-poly-hc ophthalmic (eye) ointment ,000 mg-unit/g-1% neomycin-bacitracin-polymyxin ophthalmic (eye) ointment ,000 mg-unit-unit/g neomycin-polymyxin b-dexameth ophthalmic (eye) drops,suspension 3.5mg/ml-10,000 unit/ml-0.1 % neomycin-polymyxin b-dexameth ophthalmic (eye) ointment 3.5 mg/g- 10,000 unit/g-0.1 % neomycin-polymyxin-gramicidin ophthalmic (eye) drops 1.75 mg- 10,000 unit-0.025mg/ml neomycin-polymyxin-hc ophthalmic (eye) drops,suspension , mg-unit-mg/ml neo-polycin hc ophthalmic (eye) ointment ,000 mg-unit/g- 1% neo-polycin ophthalmic (eye) ointment ,000 mg-unit-unit/g PA; QL (1 per 180 days) QL (1 per 30 days) QL (12 per 84 days) QL (4 per 28 days) QL (4 per 28 days) ; QL (120 per 30 days) PA; PA; QL (1.7 per 28 days); QL (15 per 21 days) QL (15 per 21 days) QL (100 per 365 days) 87

97 NEOSPORIN (NEO-POLYM-GRAMICID) OPHTHALMIC (EYE) DROPS 1.75 MG-10,000 UNIT-0.025MG/ML polycin ophthalmic (eye) ointment ,000 unit/gram polymyxin b sulf-trimethoprim ophthalmic (eye) drops 10,000 unit- 1 mg/ml RHOPRESSA OPHTHALMIC (EYE) DROPS 0.02 % TOBRADEX ST OPHTHALMIC (EYE) DROPS,SUSPENSION % tobramycin-dexamethasone ophthalmic (eye) drops,suspension % ZYLET OPHTHALMIC (EYE) DROPS,SUSPENSION % Ophthalmic Agents, Other atropine ophthalmic (eye) drops 1 % CYSTARAN OPHTHALMIC (EYE) DROPS 0.44 % proparacaine ophthalmic (eye) drops 0.5 % RESTASIS OPHTHALMIC (EYE) DROPPERETTE 0.05 % sulfacetamide sodium ophthalmic (eye) ointment 10 % Ophthalmic Anti-Allergy Agents ALOCRIL OPHTHALMIC (EYE) DROPS 2 % ALOMIDE OPHTHALMIC (EYE) DROPS 0.1 % azelastine ophthalmic (eye) drops 0.05 % BEPREVE OPHTHALMIC (EYE) DROPS 1.5 % cromolyn ophthalmic (eye) drops 4 % epinastine ophthalmic (eye) drops 0.05 % LASTACAFT OPHTHALMIC (EYE) DROPS 0.25 % olopatadine ophthalmic (eye) drops 0.1 %, 0.2 % PATADAY OPHTHALMIC (EYE) DROPS 0.2 % Ophthalmic Antiglaucoma Agents ALPHAGAN P OPHTHALMIC (EYE) DROPS 0.1 % apraclonidine ophthalmic (eye) drops 0.5 % AZOPT OPHTHALMIC (EYE) DROPS,SUSPENSION 1 % betaxolol ophthalmic (eye) drops 0.5 % BETOPTIC S OPHTHALMIC (EYE) DROPS,SUSPENSION 0.25 % bimatoprost ophthalmic (eye) drops 0.03 % brimonidine ophthalmic (eye) drops 0.15 %, 0.2 % carteolol ophthalmic (eye) drops 1 % COMBIGAN OPHTHALMIC (EYE) DROPS % QL (60 per 28 days); 88

98 COSOPT (PF) OPHTHALMIC (EYE) DROPPERETTE % COSOPT OPHTHALMIC (EYE) DROPS MG/ML cyclopentolate ophthalmic (eye) drops 0.5 %, 1 %, 2 % dorzolamide ophthalmic (eye) drops 2 % dorzolamide-timolol ophthalmic (eye) drops mg/ml levobunolol ophthalmic (eye) drops 0.5 % metipranolol ophthalmic (eye) drops 0.3 % PHOSPHOLINE IODIDE OPHTHALMIC (EYE) DROPS % pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %, 4 % SIMBRINZA OPHTHALMIC (EYE) DROPS,SUSPENSION % timolol maleate ophthalmic (eye) drops 0.25 %, 0.5 % timolol maleate ophthalmic (eye) drops, once daily 0.5 % timolol maleate ophthalmic (eye) gel forming solution 0.25 %, 0.5 % TRAVATAN Z OPHTHALMIC (EYE) DROPS % TRUSOPT OPHTHALMIC (EYE) DROPS 2 % Ophthalmic Anti-Inflammatories ACUVAIL (PF) OPHTHALMIC (EYE) DROPPERETTE 0.45 % ALREX OPHTHALMIC (EYE) DROPS,SUSPENSION 0.2 % bromfenac ophthalmic (eye) drops 0.09 % dexamethasone sodium phosphate ophthalmic (eye) drops 0.1 % diclofenac sodium ophthalmic (eye) drops 0.1 % DUREZOL OPHTHALMIC (EYE) DROPS 0.05 % FLAREX OPHTHALMIC (EYE) DROPS,SUSPENSION 0.1 % fluorometholone ophthalmic (eye) drops,suspension 0.1 % flurbiprofen sodium ophthalmic (eye) drops 0.03 % FML FORTE OPHTHALMIC (EYE) DROPS,SUSPENSION 0.25 % FML LIQUIFILM OPHTHALMIC (EYE) DROPS,SUSPENSION 0.1 % FML S.O.P. OPHTHALMIC (EYE) OINTMENT 0.1 % ILEVRO OPHTHALMIC (EYE) DROPS,SUSPENSION 0.3 % ketorolac ophthalmic (eye) drops 0.4 %, 0.5 % LOTEMAX OPHTHALMIC (EYE) DROPS,GEL 0.5 % LOTEMAX OPHTHALMIC (EYE) DROPS,SUSPENSION 0.5 % LOTEMAX OPHTHALMIC (EYE) OINTMENT 0.5 % MAXIDEX OPHTHALMIC (EYE) DROPS,SUSPENSION 0.1 % NEVANAC OPHTHALMIC (EYE) DROPS,SUSPENSION 0.1 % QL (10 per 30 days) QL (10 per 30 days) QL (10 per 30 days) 89

99 prednisolone acetate ophthalmic (eye) drops,suspension 1 % prednisolone sodium phosphate ophthalmic (eye) drops 1 % XIIDRA OPHTHALMIC (EYE) DROPPERETTE 5 % Ophthalmic Prostaglandin And Prostamide Analogs latanoprost ophthalmic (eye) drops % LUMIGAN OPHTHALMIC (EYE) DROPS 0.01 % travoprost (benzalkonium) ophthalmic (eye) drops % ZIOPTAN (PF) OPHTHALMIC (EYE) DROPPERETTE % Otic Agents Otic Agents acetasol hc otic (ear) drops 1-2 % CETRAXAL OTIC (EAR) DROPPERETTE 0.2 % CIPRO HC OTIC (EAR) DROPS,SUSPENSION % CIPRODEX OTIC (EAR) DROPS,SUSPENSION % COLY-MYCIN S OTIC (EAR) DROPS,SUSPENSION MG/ML hydrocortisone-acetic acid otic (ear) drops 1-2 % neomycin-polymyxin-hc otic (ear) drops,suspension ,000-1 mg/ml-unit/ml-% neomycin-polymyxin-hc otic (ear) solution ,000-1 mg/ml-unit/ml- % ofloxacin oral tablet 300 mg Respiratory Tract/ Pulmonary Agents Antihistamines azelastine nasal aerosol,spray 137 mcg (0.1 %) azelastine nasal spray,non-aerosol 0.15 % (205.5 mcg) cetirizine oral solution 1 mg/ml clemastine oral tablet 2.68 mg cyproheptadine oral syrup 2 mg/5 ml cyproheptadine oral tablet 4 mg desloratadine oral tablet 5 mg levocetirizine oral tablet 5 mg olopatadine nasal spray,non-aerosol 0.6 % Anti-Inflammatories, Inhaled Corticosteroids ADVAIR DISKUS INHALATION BLISTER WITH DEVICE MCG/DOSE, MCG/DOSE, MCG/DOSE QL (5 per 25 days) QL (2.5 per 25 days) QL (30 per 25 days) QL (30 per 25 days) QL (300 per 30 days) QL (30.5 per 30 days) 90

100 ADVAIR HFA INHALATION HFA AEROSOL INHALER MCG/ACTUATION, MCG/ACTUATION, MCG/ACTUATION AEROSPAN INHALATION HFA AEROSOL INHALER 80 MCG/ACTUATION ALVESCO INHALATION HFA AEROSOL INHALER 160 MCG/ACTUATION, 80 MCG/ACTUATION ARMONAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED 113 MCG/ACTUATION, 232 MCG/ACTUATION, 55 MCG/ACTUATION ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 200 MCG/ACTUATION, 50 MCG/ACTUATION ASMANEX HFA INHALATION HFA AEROSOL INHALER 100 MCG/ACTUATION, 200 MCG/ACTUATION ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (30 DOSES), 220 MCG (120 DOSES), 220 MCG (14 DOSES), 220 MCG (30 DOSES), 220 MCG (60 DOSES) BECONASE AQ NASAL SPRAY,NON-AEROSOL 42 MCG (0.042 %) budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml, 1 mg/2 ml FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 250 MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION, 220 MCG/ACTUATION, 44 MCG/ACTUATION flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) fluticasone nasal spray,suspension 50 mcg/actuation mometasone nasal spray,non-aerosol 50 mcg/actuation OMNARIS NASAL SPRAY,NON-AEROSOL 50 MCG PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 180 MCG/ACTUATION, 90 MCG/ACTUATION QNASL NASAL HFA AEROSOL INHALER 40 MCG/ACTUATION, 80 MCG/ACTUATION Antileukotrienes montelukast oral granules in packet 4 mg QL (12 per 30 days) QL (24 per 30 days) QL (50 per 30 days) QL (16 per 30 days) QL (34 per 30 days) QL (12.5 per 30 days) 91

101 montelukast oral tablet 10 mg montelukast oral tablet,chewable 4 mg, 5 mg zafirlukast oral tablet 10 mg, 20 mg zileuton oral tablet, er multiphase 12 hr 600 mg ZYFLO ORAL TABLET 600 MG Bronchodilators, Anticholinergic ATROVENT HFA INHALATION HFA AEROSOL INHALER 17 MCG/ACTUATION INCRUSE ELLIPTA INHALATION BLISTER WITH DEVICE 62.5 MCG/ACTUATION ipratropium bromide inhalation solution 0.02 % ipratropium bromide nasal spray,non-aerosol 0.03 % ipratropium bromide nasal spray,non-aerosol 42 mcg (0.06 %) SPIRIVA RESPIMAT INHALATION MIST 1.25 MCG/ACTUATION QL (25.8 per 30 days) QL (45 per 30 days) QL (4 per 28 days) SPIRIVA RESPIMAT INHALATION MIST 2.5 MCG/ACTUATION QL (4 per 28 days) SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE 18 MCG TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED 400 MCG/ACTUATION, 400 MCG/ACTUATION (30 ACTUAT) Bronchodilators, Sympathomimetic albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 5 mg/ml albuterol sulfate oral syrup 2 mg/5 ml albuterol sulfate oral tablet 2 mg, 4 mg albuterol sulfate oral tablet extended release 12 hr 4 mg, 8 mg ARCAPTA NEOHALER INHALATION CAPSULE, W/INHALATION DEVICE 75 MCG BREO ELLIPTA INHALATION BLISTER WITH DEVICE MCG/DOSE, MCG/DOSE BROVANA INHALATION SOLUTION FOR NEBULIZATION 15 MCG/2 ML DULERA INHALATION HFA AEROSOL INHALER MCG/ACTUATION, MCG/ACTUATION epinephrine injection auto-injector 0.15 mg/0.15 ml, 0.15 mg/0.3 ml, 0.3 mg/0.3 ml fluticasone-salmeterol inhalation aerosol powdr breath activated mcg/actuation, mcg/actuation, mcg/actuation QL (1 per 30 days) ; QL (120 per 30 days) 92

102 levalbuterol hcl inhalation solution for nebulization 0.31 mg/3 ml, 0.63 mg/3 ml, 1.25 mg/0.5 ml levalbuterol tartrate inhalation hfa aerosol inhaler 45 mcg/actuation metaproterenol oral syrup 10 mg/5 ml metaproterenol oral tablet 10 mg, 20 mg PERFOROMIST INHALATION SOLUTION FOR NEBULIZATION 20 MCG/2 ML 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 STRIVERDI RESPIMAT INHALATION MIST 2.5 MCG/ACTUATION terbutaline oral tablet 2.5 mg, 5 mg terbutaline subcutaneous solution 1 mg/ml VENTOLIN HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION Cystic Fibrosis Agents CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML KALYDECO ORAL GRANULES IN PACKET 50 MG, 75 MG KALYDECO ORAL TABLET 150 MG ORKAMBI ORAL TABLET MG, MG PULMOZYME INHALATION SOLUTION 1 MG/ML SYMDEKO ORAL TABLETS, SEQUENTIAL MG (D)/ 150 MG (N) TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE 28 MG Mast Cell Stabilizers cromolyn inhalation solution for nebulization 20 mg/2 ml cromolyn oral concentrate 100 mg/5 ml Phosphodiesterase Inhibitors, Airways Disease DALIRESP ORAL TABLET 250 MCG, 500 MCG theophylline oral tablet extended release 12 hr 100 mg, 200 mg, 450 mg theophylline oral tablet extended release 12 hr 300 mg ; QL (120 per 30 days) QL (36 per 30 days) PA; QL (84 per 28 days); PA; QL (56 per 28 days); PA; ; PA; LA; QL (112 per 28 days); PA; QL (150 per 30 days); PA; ; PA; QL (224 per 28 days); 93

103 theophylline oral tablet extended release 24 hr 400 mg, 600 mg Pulmonary Antihypertensives ADCIRCA ORAL TABLET 20 MG ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, 2.5 MG LETAIRIS ORAL TABLET 10 MG, 5 MG OPSUMIT ORAL TABLET 10 MG ORENITRAM ORAL TABLET EXTENDED RELEASE MG ORENITRAM ORAL TABLET EXTENDED RELEASE 0.25 MG, 1 MG, 2.5 MG, 5 MG REVATIO ORAL SUSPENSION FOR RECONSTITUTION 10 MG/ML sildenafil (antihypertensive) oral tablet 20 mg TRACLEER ORAL TABLET 125 MG, 62.5 MG VENTAVIS INHALATION SOLUTION FOR NEBULIZATION 10 MCG/ML VENTAVIS INHALATION SOLUTION FOR NEBULIZATION 20 MCG/ML Respiratory Tract Agents, Other acetylcysteine solution 100 mg/ml (10 %), 200 mg/ml (20 %) ANORO ELLIPTA INHALATION BLISTER WITH DEVICE MCG/ACTUATION ARALAST NP INTRAVENOUS RECON SOLN 1,000 MG BEVESPI AEROSPHERE INHALATION HFA AEROSOL INHALER MCG GLASSIA INTRAVENOUS SOLUTION 1 GRAM/50 ML (2 %) LUMIZYME INTRAVENOUS RECON SOLN 50 MG PROLASTIN-C INTRAVENOUS RECON SOLN 1,000 MG STIOLTO RESPIMAT INHALATION MIST MCG/ACTUATION TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE MCG ZEMAIRA INTRAVENOUS RECON SOLN 1,000 MG Respiratory Tract/ Pulmonary Agents COMBIVENT RESPIMAT INHALATION MIST MCG/ACTUATION DYMISTA NASAL SPRAY,NON-AEROSOL MCG/SPRAY ESBRIET ORAL CAPSULE 267 MG ESBRIET ORAL TABLET 267 MG, 801 MG PA; ; PA; QL (90 per 30 days); ; PA; QL (30 per 28 days); PA PA; PA; QL (180 per 30 days); PA; QL (90 per 30 days) LA; ; ; QL (270 per 30 days); ; QL (90 per 30 days); PA; PA; PA; QL (4 per 28 days) PA; QL (4 per 20 days) PA; QL (270 per 30 days); PA; 94

104 ipratropium-albuterol inhalation solution for nebulization 0.5 mg-3 mg(2.5 mg base)/3 ml OFEV ORAL CAPSULE 100 MG, 150 MG SYMBICORT MCG INHALER 60 INHALATIONS MCG/ACTUATION SYMBICORT MCG INHALER 60 INHALATIONS MCG/ACTUATION SYMBICORT INHALATION HFA AEROSOL INHALER MCG/ACTUATION, MCG/ACTUATION XOLAIR SUBCUTANEOUS RECON SOLN 150 MG Skeletal Muscle Relaxants Skeletal Muscle Relaxants carisoprodol oral tablet 250 mg, 350 mg chlorzoxazone oral tablet 250 mg, 500 mg cyclobenzaprine oral tablet 10 mg, 5 mg metaxall oral tablet 800 mg metaxalone oral tablet 400 mg metaxalone oral tablet 800 mg methocarbamol oral tablet 500 mg, 750 mg orphenadrine citrate oral tablet extended release 100 mg Sleep Disorder Agents Gaba Receptor Modulators eszopiclone oral tablet 1 mg, 2 mg, 3 mg flurazepam oral capsule 15 mg, 30 mg temazepam oral capsule 15 mg, 30 mg zaleplon oral capsule 10 mg, 5 mg zolpidem oral tablet 10 mg zolpidem oral tablet 5 mg zolpidem oral tablet,ext release multiphase 12.5 mg zolpidem oral tablet,ext release multiphase 6.25 mg Sleep Disorders, Other armodafinil oral tablet 150 mg, 200 mg, 250 mg armodafinil oral tablet 50 mg BELSOMRA ORAL TABLET 10 MG, 15 MG, 20 MG, 5 MG HETLIOZ ORAL CAPSULE 20 MG modafinil oral tablet 100 mg, 200 mg PA; ; QL (12 per 30 days) QL (13.8 per 30 days) QL (10.2 per 30 days) QL (6 per 28 days); PA; AGE (Max 64 Years) PA; AGE (Max 64 Years) QL (120 per 30 days) QL (120 per 30 days) PA; PA; PA; QL (30 per 28 days); PA; 95

105 ROZEREM ORAL TABLET 8 MG XYREM ORAL SOLUTION 500 MG/ML PA; LA; QL (540 per 30 days); 96

106 INDEX A abacavir abacavir-lamivudine abacavir-lamivudine-zidovudine ABELCET ABILIFY MAINTENA ABRAXANE acamprosate... 6 acarbose acebutolol acetaminophen-codeine... 3 acetasol hc acetazolamide acetic acid... 8 acetylcysteine acitretin ACTEMRA ACTB (PF) ACTIMMUNE ACUVAIL (PF) acyclovir acyclovir sodium ADACEL(TDAP ADOLESN/ADULT)(PF).. 83 ADAGEN adapalene ADCIRCA adefovir ADEMPAS ADLYXIN adrucil ADVAIR DISKUS ADVAIR HFA AEROSPAN afeditab cr AFINITOR AFINITOR DISPERZ AKYNZEO (NETUPITANT) 20 ala-cort ALBENZA albuterol sulfate alclometasone ALCOHOL PADS... 8 ALCOHOL PREP PADS... 8 ALECENSA alendronate alfuzosin ALIMTA ALINIA ALIQOPA allopurinol almotriptan malate ALOCRIL alogliptin alogliptin-metformin alogliptin-pioglitazone ALOMIDE ALORA alosetron ALPHAGAN P alprazolam ALREX altavera (28) ALUNBRIG ALVESCO alyacen 1/35 (28) alyacen 7/7/7 (28) amabelz amantadine hcl AMBISOME amethia amethia lo amethyst amikacin... 7 amiloride amiloride-hydrochlorothiazide51 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-HBC 7% AMINOSYN-PF 10 % AMINOSYN-PF 7 % (SULFITE-FREE) AMINOSYN-RF 5.2 % amiodarone AMITIZA amitriptyline amitriptyline-chlordiazepoxide amlodipine amlodipine-atorvastatin amlodipine-benazepril... 51, 52 amlodipine-olmesartan amlodipine-valsartan ammonium lactate amnesteem amoxapine amoxicil-clarithromy-lansopraz amoxicillin amoxicillin-pot clavulanate amphotericin b ampicillin ampicillin sodium ampicillin-sulbactam AMPYRA ANADROL anagrelide ANALPRAM-HC anastrozole ANDRODERM ANDROGEL ANORO ELLIPTA ANZEMET APOKYN apraclonidine aprepitant apri APTIOM APTIVUS ARALAST NP aranelle (28) ARANESP (IN POLYSORBATE) ARCALYST ARCAPTA NEOHALER aripiprazole ARISTADA armodafinil ARMONAIR RESPICLICK.. 91 ARNUITY ELLIPTA ARYMO ER... 4 ascomp with codeine... 3 ashlyna ASMANEX HFA ASMANEX TWISTHALER.. 91 aspirin-dipyridamole ASSURE ID INSULIN SAFETY atazanavir... 39, 40 atenolol

107 atenolol-chlorthalidone ATGAM atomoxetine atorvastatin atovaquone atovaquone-proguanil ATRIPLA atropine ATROVENT HFA AUBAGIO aubra AUSTEDO AVANDIA AVASTIN AVELOX IN NACL (ISO- OSMOTIC) aviane avita AVONEX AVONEX (WITH ALBUMIN) azacitidine AZASITE azathioprine azathioprine sodium azelastine... 88, 90 AZELEX azithromycin AZOPT aztreonam... 8, 11 azurette (28) B baciim... 8 bacitracin... 8 bacitracin-polymyxin b baclofen BACTROBAN NASAL... 8 balsalazide balziva (28) BANZEL BARACLUDE BAVENCIO BCG VACCINE, LIVE (PF).. 83 BD ULTRA-FINE NANO PEN NEEDLE BD VEO INSULIN SYRINGE UF BECONASE AQ bekyree (28) BELEODAQ BELSOMRA benazepril benazepril-hydrochlorothiazide BENLYSTA benztropine BEPREVE BESIVANCE BESPONSA betamethasone dipropionate betamethasone valerate betamethasone, augmented BETASERON betaxolol... 50, 88 bethanechol chloride BETHKIS... 7 BETOPTIC S BEVESPI AEROSPHERE bexarotene BEXSERO bicalutamide BICILLIN C-R BICILLIN L-A BICNU BIKTARVY BILTRICIDE bimatoprost bisoprolol fumarate bisoprolol-hydrochlorothiazide bleomycin bleph BLEPHAMIDE BLEPHAMIDE S.O.P blisovi 24 fe blisovi fe 1.5/30 (28) blisovi fe 1/20 (28) BOOSTRIX TDAP BORTEZOMIB BOSULIF BREO ELLIPTA brevicon (28) briellyn BRILINTA brimonidine BRIVIACT bromfenac bromocriptine BROVANA budesonide... 86, 91 bumetanide buprenorphine... 4 buprenorphine hcl... 6 buprenorphine-naloxone... 6 bupropion hcl... 17, 18 bupropion hcl (smoking deter). 7 buspirone butalbital compound w/codeine 3 butalbital-acetaminop-caf-cod.. 3 butalbital-acetaminophen... 3 butalbital-acetaminophen-caff.. 3 butalbital-aspirin-caffeine... 3 butorphanol tartrate... 5 BYDUREON BYDUREON BCISE BYETTA BYSTOLIC C cabergoline CABOMETYX calcipotriene calcitonin (salmon) calcitriol... 59, 86 calcium acetate CALQUENCE camila camrese camrese lo CANASA CANCIDAS candesartan candesartan-hydrochlorothiazid capacet... 3 CAPASTAT CAPRELSA captopril captopril-hydrochlorothiazide 52 CARAFATE CARBAGLU carbamazepine... 16, 41 carbidopa carbidopa-levodopa carbidopa-levodopa-entacapone carboplatin CARIMUNE NF NANOFILTERED carisoprodol carteolol cartia xt carvedilol carvedilol phosphate

108 caspofungin CAYSTON caziant (28) cefaclor cefadroxil cefazolin cefazolin in 0.9% sod chloride10 cefdinir CEFEPIME CEFEPIME IN DEXTROSE 5 % CEFEPIME IN DEXTROSE,ISO-OSM cefixime cefotaxime cefotetan cefotetan in dextrose, iso-osm 10 cefoxitin cefoxitin in dextrose, iso-osm 10 cefpodoxime cefprozil ceftazidime ceftriaxone ceftriaxone in dextrose,iso-os. 10 cefuroxime axetil cefuroxime sodium cefuroxime-dextrose (iso-osm) celecoxib... 4 CELLCEPT CELONTIN cephalexin CEREZYME CESAMET cetirizine CETRAXAL cevimeline CHANTIX... 7 CHANTIX CONTINUING MONTH BOX... 7 CHANTIX STARTING MONTH BOX... 7 chateal chloramphenicol sod succinate. 8 chlordiazepoxide hcl chlordiazepoxide-clidinium chlorhexidine gluconate chloroquine phosphate chlorothiazide chlorothiazide sodium chlorpromazine chlorthalidone chlorzoxazone CHOLBAM cholestyramine (with sugar) cholestyramine light CIALIS ciclopirox cidofovir cilostazol CILOXAN CIMDUO cimetidine cimetidine hcl CIMZIA CIMZIA POWDER FOR RECONST CINRYZE CIPRO HC CIPRODEX ciprofloxacin ciprofloxacin hcl... 12, 13 ciprofloxacin lactate citalopram claravis clarithromycin clemastine CLIMARA PRO clindamycin hcl... 8 clindamycin in 5 % dextrose... 8 clindamycin palmitate hcl... 8 clindamycin phosphate... 8 clindamycin-benzoyl peroxide59 CLINIMIX 5%/D15W SULFITE FREE CLINIMIX 5%/D25W SULFITE-FREE CLINIMIX 2.75%/D5W SULFIT FREE CLINIMIX 4.25%/D10W SULF FREE CLINIMIX 4.25%/D5W SULFIT FREE CLINIMIX 4.25%-D20W SULF-FREE CLINIMIX 4.25%-D25W SULF-FREE CLINIMIX 5%- D20W(SULFITE-FREE) CLINIMIX E 2.75%/D10W SUL FREE CLINIMIX E 2.75%/D5W SULF FREE CLINIMIX E 4.25%/D10W SUL FREE CLINIMIX E 4.25%/D25W SUL FREE CLINIMIX E 4.25%/D5W SULF FREE CLINIMIX E 5%/D15W SULFIT FREE CLINIMIX E 5%/D20W SULFIT FREE CLINIMIX E 5%/D25W SULFIT FREE clobetasol... 59, 69 clobetasol-emollient clomipramine clonazepam clonidine clonidine hcl... 48, 56 clopidogrel clorazepate dipotassium clorpres clotrimazole clotrimazole-betamethasone clozapine COARTEM codeine sulfate... 5 colchicine COLCRYS colesevelam colestipol colistin (colistimethate na)... 8 colocort COLY-MYCIN S COLYTE WITH FLAVOR PACKS COMBIGAN COMBIVENT RESPIMAT COMETRIQ COMPLERA compro constulose COPAXONE CORDRAN TAPE LARGE ROLL COREG CR CORLANOR cormax cortisone CORTISPORIN

109 COSENTYX (2 SYRINGES) 59 COSENTYX PEN (2 PENS).. 59 COSOPT COSOPT (PF) COTELLIC COUMADIN CREON CRIXIVAN cromolyn... 88, 93 cryselle (28) cyclafem 1/35 (28) cyclafem 7/7/7 (28) cyclobenzaprine cyclopentolate cyclophosphamide CYCLOPHOSPHAMIDE CYCLOSET cyclosporine cyclosporine modified cyproheptadine CYRAMZA cyred CYSTADANE CYSTARAN D d10 %-0.45 % sodium chloride d2.5 %-0.45 % sodium chloride d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride 63 DALIRESP danazol dantrolene dapsone... 25, 59 DAPTACEL (DTAP PEDIATRIC) (PF) daptomycin... 8 DARAPRIM darifenacin DARZALEX dasetta 1/35 (28) dasetta 7/7/7 (28) deblitane deltasone delyla (28) DELZICOL demeclocycline DEMSER denta 5000 plus dentagel DEPEN TITRATABS DEPO-MEDROL DEPO-PROVERA DEPO-SUBQ PROVERA DEPO-TESTOSTERONE DESCOVY desipramine desloratadine desmopressin desog-e.estradiol/e.estradiol desogestrel-ethinyl estradiol desonide desoximetasone desvenlafaxine succinate dexamethasone dexamethasone sodium phos (pf) dexamethasone sodium phosphate... 23, 89 dexmethylphenidate dexrazoxane hcl dextroamphetamine dextroamphetamineamphetamine dextrose 10 % and 0.2 % nacl 63 dextrose 10 % in water (d10w) dextrose 5 % in water (d5w) dextrose 5 %-lactated ringers. 63 dextrose 5%-0.2 % sod chloride dextrose 5%-0.3 % sod.chloride DIASTAT DIASTAT ACUDIAL diazepam... 15, 41 diazepam intensol diclofenac potassium diclofenac sodium... 4, 23, 59, 89 diclofenac-misoprostol... 4 dicloxacillin dicyclomine didanosine DIFICID diflunisal... 4 digitek digox digoxin DIGOXIN dihydroergotamine DILANTIN DILANTIN EXTENDED DILANTIN INFATABS DILANTIN diltiazem hcl... 50, 51 dilt-xr diphenhydramine hcl diphenoxylate-atropine dipyridamole disopyramide phosphate disulfiram... 6 DIURIL divalproex dofetilide donepezil dorzolamide dorzolamide-timolol doxazosin doxepin doxercalciferol doxorubicin, peg-liposomal doxy doxycycline hyclate... 13, 14 doxycycline monohydrate dronabinol drospirenone-e.estradiol-lm.fa 73 drospirenone-ethinyl estradiol 73 DROXIA DULERA duloxetine DURAMORPH (PF)... 4 DUREZOL dutasteride dutasteride-tamsulosin DYMISTA E econazole EDURANT efavirenz EGRIFTA eletriptan ELIDEL elinest eliphos ELIQUIS ELITEK ELMIRON EMCYT EMFLAZA emoquette

110 EMPLICITI EMSAM EMTRIVA enalapril maleate enalapril-hydrochlorothiazide 52 ENBREL ENBREL SURECLICK endocet... 3 ENGERIX-B (PF) ENGERIX-B PEDIATRIC (PF) enoxaparin enpresse enskyce entacapone entecavir ENTRESTO enulose ENVARSUS XR EPCLUSA epinastine epinephrine epirubicin epitol EPIVIR HBV eplerenone eprosartan EPZICOM EQUETRO ergoloid ergotamine-caffeine ERIVEDGE ERLEADA errin ery pads ery-tab ERY-TAB ERYTHROCIN erythromycin erythromycin ethylsuccinate.. 12 erythromycin with ethanol erythromycin-benzoyl peroxide ESBRIET escitalopram oxalate esomeprazole magnesium estarylla ESTRACE estradiol... 72, 74 estradiol-norethindrone acet ESTRING estropipate eszopiclone ethacrynic acid ethambutol ethosuximide ethynodiol diac-eth estradiol.. 74 etidronate disodium etodolac... 4 ETOPOPHOS etoposide EVOTAZ exemestane EXJADE EXTAVIA ezetimibe ezetimibe-simvastatin F FABRAZYME falmina (28) famciclovir famotidine famotidine (pf) famotidine (pf)-nacl (iso-os). 65 FANAPT FARESTON FARXIGA FARYDAK FASLODEX fayosim FAZACLO felbamate felodipine femynor fenofibrate fenofibrate micronized fenofibrate nanocrystallized fenofibric acid fenofibric acid (choline) fentanyl... 4 fentanyl citrate... 5 FERRIPROX FETZIMA FIASP FLEXTOUCH U-100 INSULIN FIASP U-100 INSULIN FINACEA finasteride FIRAZYR FIRMAGON KIT W DILUENT SYRINGE FLAREX flavoxate flecainide FLECTOR FLOVENT DISKUS FLOVENT HFA fluconazole fluconazole in dextrose(iso-o) 21 fluconazole in nacl (iso-osm). 21 flucytosine fludrocortisone flunisolide fluocinolone... 69, 70 fluocinolone acetonide oil fluocinolone and shower cap.. 69 fluocinonide... 59, 70 fluocinonide-e fluoride (sodium)... 60, 61 fluorometholone fluorouracil fluoxetine fluphenazine decanoate fluphenazine hcl flurazepam flurbiprofen... 4 flurbiprofen sodium flutamide fluticasone... 59, 91 fluticasone-salmeterol fluvastatin fluvoxamine FML FORTE FML LIQUIFILM FML S.O.P fondaparinux FORTEO fosamprenavir fosinopril fosinopril-hydrochlorothiazide fosphenytoin FOSRENOL FREAMINE HBC 6.9 % frovatriptan furosemide FUZEON fyavolv FYCOMPA G gabapentin GABITRIL galantamine

111 GAMASTAN S/D GAMMAGARD LIQUID GAMMAPLEX GAMMAPLEX (WITH SORBITOL) GAMUNEX-C ganciclovir sodium GARDASIL (PF) GARDASIL 9 (PF) gatifloxacin GATTEX 30-VIAL GAUZE PAD gavilyte-c gavilyte-g gavilyte-h and bisacodyl gavilyte-n gemfibrozil generlac gengraf gentak... 7 gentamicin... 7 gentamicin in nacl (iso-osm)... 7 gentamicin sulfate (ped) (pf)... 7 gentamicin sulfate (pf)... 7 GENVOYA GEODON gianvi (28) GIAZO gildagia gildess 1.5/30 (21) gildess 24 fe GILENYA GILOTRIF GLASSIA glatiramer glatopa GLEOSTINE glimepiride glipizide glipizide-metformin GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) glycopyrrolate GLYXAMBI GOLYTELY granisetron (pf) granisetron hcl GRANIX griseofulvin microsize griseofulvin ultramicrosize guanfacine guanidine H halobetasol propionate haloperidol haloperidol decanoate haloperidol lactate HARVONI HAVRIX (PF) heather heparin (porcine) heparin (porcine) in 5 % dex.. 46 heparin (porcine) in nacl (pf).. 46 heparin(porcine) in 0.45% nacl... 46, 47 HEPARIN(PORCINE) IN 0.45% NACL heparin, porcine (pf) HEPATAMINE 8% HERCEPTIN HETLIOZ HEXALEN BERIX (PF) HUMALOG KWIKPEN INSULIN HUMALOG MIX INSULN U HUMALOG MIX KWIKPEN HUMALOG MIX KWIKPEN HUMALOG MIX 75-25(U- 100)INSULN HUMALOG U-100 INSULIN 44 HUMIRA HUMIRA PEDIATRIC CROHN'S START HUMIRA PEN HUMIRA PEN CROHN'S-UC- HS START HUMIRA PEN PSORIASIS- UVEITIS HUMULIN 70/30 U-100 INSULIN HUMULIN 70/30 U-100 KWIKPEN HUMULIN N NPH INSULIN KWIKPEN HUMULIN N NPH U-100 INSULIN HUMULIN R REGULAR U- 100 INSULN HUMULIN R U-500 (CONC) INSULIN HUMULIN R U-500 (CONC) KWIKPEN HYCAMTIN hydralazine hydrochlorothiazide hydrocodone-acetaminophen... 3 hydrocodone-ibuprofen... 3 hydrocortisone... 23, 70, 86 hydrocortisone butyrate hydrocortisone valerate hydrocortisone-acetic acid hydrocortisone-pramoxine hydromorphone... 4, 5 hydromorphone (pf)... 4 hydroxychloroquine hydroxyurea hydroxyzine hcl hydroxyzine pamoate I ibandronate IBRANCE ibu... 4 ibuprofen... 4 ICLUSIG IDFA ILARIS (PF) ILEVRO imatinib IMBRUVICA IMFINZI imipenem-cilastatin imipramine hcl imipramine pamoate imiquimod IMOVAX RABIES VACCINE (PF) INCRELEX INCRUSE ELLIPTA indapamide indomethacin... 4 INFANRIX (DTAP) (PF) INLYTA INSULIN SYRINGE-NEEDLE U INTELENCE INTRALIPID INTRON A

112 introvale INVANZ INVEGA SUSTENNA INVEGA TRINZA INVIRASE INVOKAMET INVOKAMET XR INVOKANA IPOL ipratropium bromide ipratropium-albuterol irbesartan irbesartan-hydrochlorothiazide IRESSA ISENTRESS ISENTRESS HD isibloom isoniazid isosorbide dinitrate isosorbide mononitrate isotretinoin itraconazole ivermectin IXIARO (PF) J JADENU JADENU SPRINKLE JAKAFI jantoven JANUMET JANUMET XR JANUVIA JARDIANCE jencycla JENTADUETO JENTADUETO XR jinteli jolessa jolivette juleber JULUCA junel 1.5/30 (21) junel 1/20 (21) junel fe 1.5/30 (28) junel fe 1/20 (28) junel fe K KADCYLA kaitlib fe KALETRA KALYDECO kariva (28) kelnor 1/35 (28) kelnor ketoconazole ketoprofen ketorolac... 4, 89 KEVZARA KEYTRUDA kimidess (28) KINERET KINRIX (PF) kionex (with sorbitol) KISQALI KISQALI FEMARA CO-PACK KLOR-CON KLOR-CON klor-con m klor-con m klor-con m klor-con sprinkle KOMBIGLYZE XR... 43, 44 KORLYM K-SOL K-TAB kurvelo KUVAN L l norgest/e.estradiol-e.estrad labetalol LACTATED RINGERS lactulose lamivudine lamivudine-zidovudine lamotrigine... 15, 16 LANOXIN lansoprazole lanthanum LANTUS SOLOSTAR U-100 INSULIN LANTUS U-100 INSULIN larin 1.5/30 (21) larin 1/20 (21) larin 24 fe larin fe 1.5/30 (28) larin fe 1/20 (28) larissia LARTRUVO LASTACAFT latanoprost LATUDA layolis fe leena leflunomide LENVIMA... 29, 30 lessina LETAIRIS letrozole leucovorin calcium... 27, 28 LEUKERAN LEUKINE leuprolide levalbuterol hcl levalbuterol tartrate LEVEMIR FLEXTOUCH U- 100 INSULN LEVEMIR U-100 INSULIN.. 45 levetiracetam levetiracetam in nacl (iso-os).. 14 levobunolol levocarnitine levocarnitine (with sugar) levocetirizine levofloxacin levofloxacin in d5w levoleucovorin LEVOLEUCOVORIN levonest (28) levonorgestrel-ethinyl estrad.. 75 levonorg-eth estrad triphasic.. 75 levora levorphanol tartrate... 4 levothyroxine LEVOXYL LEXIVA LIALDA lidocaine... 6 lidocaine (pf)... 6 lidocaine hcl... 6 lidocaine hcl(pf) in 0.9% nacl.. 6 lidocaine viscous... 6 lidocaine-prilocaine... 6 lillow lincomycin... 8 lindane linezolid... 9 linezolid in dextrose 5%... 9 linezolid-0.9% sodium chloride 8 LINZESS liothyronine lisinopril

113 lisinopril-hydrochlorothiazide 52 lithium carbonate lithium citrate lomedia 24 fe LONSURF loperamide lopinavir-ritonavir lopreeza lorazepam lorcet (hydrocodone)... 3 lorcet hd... 3 lorcet plus... 3 loryna (28) losartan losartan-hydrochlorothiazide.. 52 LOTEMAX lovastatin low-ogestrel (28) loxapine succinate LUCEMYRA... 6 LUMIGAN LUMIZYME LUPRON DEPOT LUPRON DEPOT (3 MONTH) LUPRON DEPOT (4 MONTH) LUPRON DEPOT (6 MONTH) lutera (28) LYNPARZA LYRICA LYSODREN lyza M mafenide acetate... 9 magnesium sulfate malathion maprotiline marlissa MARPLAN marten-tab... 3 MATULANE matzim la MAVYRET MAXIDEX meclizine medroxyprogesterone mefloquine megestrol MEKINIST melodetta 24 fe meloxicam... 4 memantine MENACTRA (PF) MENEST MENBRIX (PF) MENOMUNE - A/C/Y/W MENOMUNE - A/C/Y/W-135 (PF) MENVEO A-C-Y-W-135-DIP (PF) meperidine... 5 meprobamate MEPRON mercaptopurine meropenem mesalamine mesna MESNEX metadate er metaproterenol metaxall metaxalone metformin methadone... 4, 5 methazolamide methenamine hippurate... 9 methimazole methocarbamol methotrexate sodium methotrexate sodium (pf) methoxsalen methscopolamine methyclothiazide methyldopa methyldopa-hydrochlorothiazide methylergonovine methylphenidate hcl... 56, 57 methylprednisolone... 23, 70 methylprednisolone acetate methylprednisolone sodium succ... 23, 70 metipranolol metoclopramide hcl metolazone metoprolol succinate metoprolol ta-hydrochlorothiaz metoprolol tartrate metronidazole... 9 metronidazole in nacl (iso-os).. 9 mexiletine MIACALCIN mibelas 24 fe miconazole microgestin 1.5/30 (21) microgestin 1/20 (21) microgestin 24 fe microgestin fe 1.5/30 (28) microgestin fe 1/20 (28) midodrine MIGERGOT miglitol miglustat mili mimvey mimvey lo minocycline minoxidil mirtazapine misoprostol mitoxantrone M-M-R II (PF) modafinil moexipril moexipril-hydrochlorothiazide molindone mometasone... 70, 91 mono-linyah mononessa (28) montelukast... 91, 92 MONUROL... 9 morphine... 5, 6 MORPNE... 5, 6 morphine concentrate... 5 MOVANTIK MOXEZA moxifloxacin moxifloxacin in nacl (iso-osm) moxifloxacin-sod.ace,sul-water MOZOBIL MULTAQ mupirocin... 9 mupirocin calcium... 9 MUSTARGEN MYALEPT mycophenolate mofetil

114 mycophenolate mofetil hcl mycophenolate sodium MYLOTARG myorisan MYRBETRIQ myzilra N nabumetone... 4 nadolol nadolol-bendroflumethiazide. 52 nafcillin naftifine NAFTIN NAGLAZYME nalocet... 3 naloxone... 7 naltrexone... 6 NAMENDA XR NAMZARIC naphazoline naproxen naproxen sodium naratriptan NARCAN... 7 NATACYN NATAZIA nateglinide NATPARA NAVELBINE NEBUPENT necon 0.5/35 (28) necon 1/50 (28) necon 10/11 (28) necon 7/7/7 (28) nefazodone neomycin... 7 neomycin-bacitracin-poly-hc. 87 neomycin-bacitracin-polymyxin neomycin-polymyxin b gu... 7 neomycin-polymyxin b- dexameth neomycin-polymyxingramicidin neomycin-polymyxin-hc.. 87, 90 neo-polycin neo-polycin hc NEOSPORIN (NEO-POLYM- GRAMICID) NEPHRAMINE 5.4 % NERLYNX neuac NEULASTA NEUPOGEN NEUPRO NEVANAC nevirapine NEXAVAR niacin nicardipine NICOTROL... 7 NICOTROL NS... 7 nifedical xl nifedipine nikki (28) nilutamide nimodipine NINLARO nisoldipine NITRO-BID nitrofurantoin... 9 nitrofurantoin macrocrystal... 9 nitrofurantoin monohyd/m-cryst... 9 nitroglycerin NITROSTAT nizatidine nora-be NORDITROPIN FLEXPRO.. 71 noreth-ethinyl estradiol-iron norethindrone (contraceptive) 78 norethindrone acetate norethindrone ac-eth estradiol 76 norethindrone-e.estradiol-iron 76 norgestimate-ethinyl estradiol 76 norinyl 1/35 (28) norlyda norlyroc NORTHERA nortrel 0.5/35 (28) nortrel 1/35 (21) nortrel 1/35 (28) nortrel 7/7/7 (28) nortriptyline NORVIR NOVOLIN 70/30 U-100 INSULIN NOVOLIN N NPH U-100 INSULIN NOVOLIN R REGULAR U- 100 INSULN NOVOLOG FLEXPEN U-100 INSULIN NOVOLOG MIX U-100 INSULN NOVOLOG MIX 70-30FLEXPEN U NOVOLOG PENFILL U-100 INSULIN NOVOLOG U-100 INSULIN ASPART NOXAFIL NUCYNTA... 6 NUCYNTA ER... 5 NUEDEXTA NULOJIX NUPLAZID NUTRILIPID nyamyc nyata nystatin... 21, 22 nystatin-triamcinolone nystop O ocella octreotide acetate ODEFSEY ODOMZO OFEV ofloxacin... 13, 90 ogestrel (28) olanzapine olmesartan olmesartan-amlodipin-hcthiazid olmesartan-hydrochlorothiazide olopatadine... 88, 90 omega-3 acid ethyl esters omeprazole OMNARIS ondansetron ondansetron hcl ondansetron hcl (pf) ONFI ONGLYZA OPANA ER... 5 OPDIVO OPSUMIT oralone ORENCIA ORENCIA CLICKJECT

115 ORENITRAM ORKAMBI orphenadrine citrate orsythia oseltamivir OTEZLA OTEZLA STARTER oxaliplatin oxandrolone oxaprozin oxazepam oxcarbazepine oxiconazole oxybutynin chloride oxycodone... 5, 6 oxycodone-acetaminophen... 3 oxycodone-aspirin... 3 OXYCONTIN... 5 oxymorphone... 6 OZEMPIC P pacerone paclitaxel paliperidone pamidronate PANCREAZE PANRETIN pantoprazole paricalcitol PARICALCITOL paroex oral rinse paromomycin... 7 paroxetine hcl PASER PATADAY PAXIL PEDIARIX (PF) PEDVAX B (PF) peg 3350-electrolytes PEGANONE PEGASYS PEGASYS CONVENIENCE PACK PEGASYS PROCLICK peg-electrolyte soln PEGINTRON PEGINTRON REDIPEN PEN NEEDLE, DIABETIC penicillin g pot in dextrose penicillin g potassium penicillin v potassium PENTACEL (PF) PENTACEL DTAP-IPV COMPNT (PF) PENTAM PENTASA pentoxifylline PERFOROMIST perindopril erbumine periogard PERJETA permethrin perphenazine perphenazine-amitriptyline pfizerpen-g phenadoz phenelzine phenobarbital phenoxybenzamine PHENYTEK phenytoin phenytoin sodium phenytoin sodium extended philith PHOSLYRA PHOSPHOLINE IODIDE phrenilin forte(with caffeine)... 3 PHYSIOSOL IRRIGATION.. 60 PICATO pilocarpine hcl... 58, 89 pimozide pimtrea (28) pindolol pioglitazone pioglitazone-glimepiride pioglitazone-metformin piperacillin-tazobactam pirmella piroxicam PLEGRIDY PLENAMINE podofilox polycin polyethylene glycol polymyxin b sulfate... 9 polymyxin b sulf-trimethoprim POMALYST portia potassium chlorid-d5-0.45%nacl potassium chloride... 61, 64 potassium chloride in lr-d potassium chloride in water potassium chloride-d5-0.3%nacl potassium chloride-d5-0.9%nacl potassium citrate POTIGA PRADAXA PRALUENT PEN pramipexole PRAMOSONE prasugrel pravastatin praziquantel prazosin PRED MILD prednicarbate... 59, 70 prednisolone prednisolone acetate prednisolone sodium phosphate... 23, 70, 90 prednisone... 23, 70 PREMARIN PREMASOL 10 % PREMASOL 6 % PREMPHASE PREMPRO prenatal plus (calcium carb) prenatal vitamin plus low iron 64 prevalite previfem PREZCOBIX PREZISTA PRIFTIN PRIMAQUINE primidone PRIVIGEN PROAIR HFA PROAIR RESPICLICK probenecid probenecid-colchicine prochlorperazine prochlorperazine edisylate prochlorperazine maleate PROCRIT procto-med hc procto-pak proctosol hc proctozone-hc PROCYSBI

116 progesterone micronized PROGLYCEM PROGRAF PROLASTIN-C PROLEUKIN PROLIA PROMACTA promethazine promethegan propafenone propantheline proparacaine propranolol propranolol-hydrochlorothiazid propylthiouracil PROQUAD (PF) PROSOL 20 % protriptyline PULMICORT FLEXHALER 91 PULMOZYME PURIXAN pyrazinamide pyridostigmine bromide Q QNASL QTERN QUADRACEL (PF) quasense quetiapine quinapril quinapril-hydrochlorothiazide 52 quinidine gluconate quinidine sulfate quinine sulfate R RABAVERT (PF) rabeprazole rajani raloxifene ramipril RANEXA ranitidine hcl RAPAFLO RAPAMUNE rasagiline RAVICTI RAYALDEE REBIF (WITH ALBUMIN) REBIF REBIDOSE REBIF TITRATION PACK.. 58 reclipsen (28) RECOMBIVAX HB (PF) 84, 85 REGRANEX RELENZA DISKHALER RELISTOR REMICADE RENAGEL RENFLEXIS RENVELA repaglinide REPATHA PUSHTRONEX.. 55 REPATHA SURECLICK REPATHA SYRINGE reprexain... 3 RESCRIPTOR RESTASIS RETACRIT RETROVIR REVATIO REVLIMID... 26, 28 REXULTI REYATAZ RHOPRESSA ribasphere ribavirin RIDAURA rifabutin rifampin RIFATER riluzole rimantadine ringer's risedronate RISPERDAL CONSTA risperidone ritonavir RITUXAN rivastigmine rivastigmine tartrate rivelsa rizatriptan ropinirole rosadan... 9 rosuvastatin ROTARIX ROTATEQ VACCINE ROWEEPRA ROWEEPRA XR ROZEREM RUBRACA RYDAPT RYTARY S SABRIL SAMSCA SANDIMMUNE SANDOSTATIN LAR DEPOT SANTYL SAPHRIS (BLACK CHERRY) SAVELLA scopolamine base selegiline hcl selenium sulfide SELZENTRY SENSIPAR SEREVENT DISKUS sertraline setlakin sevelamer carbonate sf 5000 plus sharobel SNGRIX (PF) SIGNIFOR sildenafil (antihypertensive) SILENOR SILIQ silver sulfadiazine SIMBRINZA SIMPONI... 82, 83 SIMPONI ARIA simvastatin sirolimus SIRTURO SIVEXTRO... 9 sodium chloride... 61, 64 sodium chloride 0.45 % sodium chloride 0.9 % sodium chloride 3 % sodium chloride 5 % sodium phenylbutyrate sodium polystyrene (sorb free) sodium polystyrene sulfonate. 62 SOLIQUA 100/ SOLTAMOX SOLU-CORTEF (PF) SOLU-MEDROL SOLU-MEDROL (PF) SOMATULINE DEPOT SOMAVERT

117 sorine sotalol sotalol af SPIRIVA RESPIMAT SPIRIVA WITH HANDIHALER spironolactone spironolacton-hydrochlorothiaz SPORANOX sprintec (28) SPRITAM SPRYCEL sps (with sorbitol) sronyx ssd stavudine STELARA STERILE PADS STIMATE STIOLTO RESPIMAT STIVARGA STRATTERA STRENSIQ streptomycin... 7 STRIBILD STRIVERDI RESPIMAT SUBOXONE... 6, 7 SUCRAID sucralfate sulfacetamide sodium... 13, 88 sulfacetamide sodium (acne).. 13 sulfacetamide-prednisolone sulfadiazine sulfamethoxazole-trimethoprim SULFAMYLON... 9 sulfasalazine sulfatrim sulindac... 4 sumatriptan sumatriptan succinate SUPRAX SUPREP BOWEL PREP KIT 61 SUSTIVA SUTENT syeda SYLATRON SYLVANT SYMBICORT SYMDEKO SYMFI SYMFI LO SYMLINPEN SYMLINPEN SYNAGIS... 82, 83 SYNAREL SYNERCID... 8 SYNJARDY SYNJARDY XR SYNRIBO SYNTHROID SYPRINE T TABLOID tacrolimus... 60, 82 TAFINLAR TAGRISSO TALTZ AUTOINJECTOR TALTZ SYRINGE TAMIFLU tamoxifen tamsulosin TANZEUM TARCEVA TARGRETIN tarina fe 1/20 (28) TASIGNA tazarotene TAZORAC taztia xt TECENTRIQ TECFIDERA TEFLARO TEGRETOL telmisartan telmisartan-hydrochlorothiazid temazepam tencon... 3 TENIVAC (PF) tenofovir disoproxil fumarate. 39 terazosin terbinafine hcl terbutaline terconazole testosterone testosterone cypionate testosterone enanthate TETANUS,DIPHTHERIA TOX PED(PF) TETANUS-DIPHTHERIA TOXOIDS-TD tetrabenazine tetracycline THALOMID theophylline... 93, 94 thioridazine thiothixene THYMOGLOBULIN THYROLAR THYROLAR-1/ THYROLAR-1/ THYROLAR THYROLAR tiagabine tilia fe timolol maleate... 50, 89 tinidazole... 9 TIVICAY tizanidine TOBI PODHALER TOBRADEX... 7 TOBRADEX ST tobramycin... 8 tobramycin in % nacl... 8 tobramycin sulfate... 8 tobramycin-dexamethasone TOBREX... 8 TOLAK tolcapone tolterodine topiramate toposar topotecan torsemide TOUJEO MAX SOLOSTAR. 46 TOUJEO SOLOSTAR U-300 INSULIN TOVIAZ TPN ELECTROLYTES TPN ELECTROLYTES II TRACLEER TRADJENTA tramadol... 5, 6 tramadol-acetaminophen... 3 trandolapril tranexamic acid TRANSDERM-SCOP tranylcypromine TRAVASOL 10 % TRAVATAN Z

118 travoprost (benzalkonium) trazodone TREANDA TRECATOR TRELEGY ELLIPTA TRESIBA FLEXTOUCH U TRESIBA FLEXTOUCH U tretinoin tretinoin (chemotherapy) TREXALL tri femynor triamcinolone acetonide... 58, 70 triamterene-hydrochlorothiazid... 52, 53 triderm tridesilon trientine tri-estarylla trifluoperazine trifluridine trihexyphenidyl tri-legest fe tri-linyah tri-lo-estarylla tri-lo-sprintec trilyte with flavor packets trimethoprim... 9 tri-mili trimipramine TRIMPEX... 9 trinessa (28) trinessa lo TRINTELLIX tri-previfem (28) TRISENOX tri-sprintec (28) TRIUMEQ trivora (28) tri-vylibra TROGARZO TROPHAMINE 10 % TROPHAMINE 6% trospium TRULICITY TRUMENBA TRUSOPT TRUVADA TUDORZA PRESSAIR tulana TWINRIX (PF) TYBOST tydemy TYGACIL... 9 TYKERB TYMLOS TYPM VI TYSABRI U UCERIS ULORIC UPTRAVI ursodiol V valacyclovir VALCHLOR valganciclovir valproate sodium valproic acid valproic acid (as sodium salt). 15 valsartan valsartan-hydrochlorothiazide 53 vancomycin... 9 VAQTA (PF) VARIVAX (PF) VASCEPA VELCADE velivet triphasic regimen (28). 77 VEMLIDY VENCLEXTA VENCLEXTA STARTING PACK venlafaxine VENTAVIS VENTOLIN HFA verapamil VERSACLOZ VERZENIO VESICARE vestura (28) VGO VIBERZI vicodin... 3 vicodin es... 3 vicodin hp... 3 VICTOZA VIDEX 2 GRAM PEDIATRIC VIDEX 4 GRAM PEDIATRIC VIDEX EC vienva vigabatrin VIIBRYD VIMPAT... 16, 17 VIRACEPT VIRAMUNE VIRAZOLE VIREAD... 36, 39 voriconazole VOSEVI VOTRIENT VPRIV VRAYLAR vyfemla (28) vylibra VYVANSE VYXEOS W warfarin water for irrigation, sterile WELCHOL wera (28) wymzya fe X XADAGO XALKORI XARELTO XATMEP XELJANZ XELJANZ XR XGEVA XIFAXAN... 9 XIGDUO XR XIIDRA XOLAIR XTANDI xulane XULTOPHY 100/ xylon XYREM Y YERVOY YF-VAX (PF) YONDELIS YONSA yuvafem Z zafirlukast zaleplon zarah ZARXIO

119 ZAVESCA ZEJULA ZELBORAF ZEMAIRA zenatane zenchent (28) zenchent fe ZENPEP zenzedi ZEPATIER ZERBAXA ZERIT ZIAGEN zidovudine zileuton ZINBRYTA ZIOPTAN (PF) ziprasidone hcl ZIRGAN zoledronic acid zoledronic acid-mannitol-water zoledronic ac-mannitol-0.9nacl ZOLINZA zolmitriptan zolpidem zonisamide ZONTIVITY ZORTRESS ZOSTAVAX (PF) zovia 1/35e (28) zovia 1/50e (28) ZYCLARA ZYDELIG ZYFLO ZYKADIA ZYLET ZYPREXA RELPREVV ZYTIGA

120 1515 North Saint Joseph Avenue PO Box 8000 Marshfield, WI TTY: 711 Fax a.m. 8 p.m., 7 days a week This formulary was updated on June 26, For more recent information or other questions please contact Security Health Plan Customer Service at or, for TTY users, 711, or visit We are open 7 days a week, 8 a.m. to 8 p.m., from Oct. 1-March 31; and Monday through Friday, 8 a.m. to 8 p.m., from April 1-Sept Security Health Plan of Wisconsin, Inc.