(List of Covered Drugs)

2019 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Assurance Rx (HMO-POS) Essence Rx (HMO-POS) Esteem Rx (HMO-POS) Promise Rx (HMO-POS) Spirit Rx (HMO-POS) Surety Rx (HMO-POS) This formulary was updated on February 26, 2019. For more recent information or other questions, please contact Security Health Plan Customer Service at 1-877-998-0998 or, for TTY users, 711, or visit https://www.securityhealth.org/medicareformulary. 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-785-0395-C-03-19_C Effective date 3/1/2019 Updated 2/26/2019 Formulary ID 000191, v.12

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 Assurance Rx (HMO-POS), Essence Rx (HMO-POS), Esteem Rx (HMO-POS), Promise Rx (HMO-POS), Spirit Rx (HMO-POS) or Surety Rx (HMO-POS). This document includes a list of the drugs (formulary) for our plan which is current as of March 1, 2019. 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 Jan. 1, 2020, 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.

What is the Security Health Plan 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 2019 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2019 coverage year except when a new, less expensive generic drug becomes available, when new information about the safety or effectiveness of a drug is released, or the drug is removed from the market. (See bullets below for more information on changes that affect members currently taking the drug.) 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. Below are changes to the drug list that will also affect members currently taking a drug: New generic drugs. We may immediately remove a brand name drug on our Drug List if we are replacing it with a new generic drug that will appear on the same or lower cost sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our Drug List, but immediately move it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made. o If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on the steps you may take to request an exception, and you can also find information in the section below entitled How do I request an exception to the Security Health Plan Formulary? Drugs removed from the market. 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. Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a new generic drug to replace a brand name drug currently on the formulary or add new restrictions to the brand name drug or move it to a different cost-sharing tier. Or we may make changes based on new clinical guidelines. If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 30 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 31-day supply of the drug. i

The enclosed formulary is current as of January 1, 2019. 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 vi. 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 112. The index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the index. Look in the index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the index and find the name of your drug in the first column of the list. 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 vi. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online a document ii

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, similar drugs that may treat your health condition. See the section, How do I request an exception to Security Health Plan s formulary? below on this page 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. How do I request an exception to the Security Health Plan 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 cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, 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 drug is included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception, you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 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 2 hours after we get a supporting statement from your doctor or other prescriber. iii

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 31-day supply. If your prescription is written for fewer days, we ll allow refills to provide up to a maximum 31-day supply of medication. After your first 31-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 and you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug 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 1-800-MEDICARE (1-800-633-227) 2 hours a day/7 days a week. TTY users should call 1-877-86-208. Or, visit http://www.medicare.gov. iv

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 1-877-998-0998 (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 59-8000. Phone: 715-221-9596 (TTY: 711). Fax: 715-221-92. Email: shp.appeals.grievance@securityhealth.org. You can file a grievance in person or by mail, fax or email. 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 https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201. Phone: 1 800 368 1019 or 800 537 7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. Language assistance services ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call 1-877-998-0998 (TTY: 711). Español (Spanish) ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-877-998-0998 (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 1-877-998-0998 (TTY: 711). 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 1-877-998-0998 (TTY: 711) Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-877-998-0998 (TTY: 711). (Arabic) ةيبرعلا ملحوظة: إذا كنت تتحدث اذكر اللغة فا ن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم 8990-899-778-1 (رقم ھاتف الصم والبكم: 117). v

Русский (Russian) ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-877-998-0998 (телетайп: 711). 한국어 (Korean) 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다. 1-877-998-0998 (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 1-877-998-0998 (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: 1-877-998-0998 (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 1-877-998-0998 Français (French) ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-877-998-0998 (ATS : 711). Polski (Polish) UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-877-998-0998 (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 1-877-998-0998 (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 1-877-998-0998 (TTY: 711). Tagalog (Filipino) PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng a serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-877-998-0998 (TTY: 711). Oroomiffa (Oromo/Somalia) XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 1-877-998-0998 (TTY: 711). Large print If you require materials in large print, please call 1-877-998-0998 (TTY: 711). Security Health Plan 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 112. 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). vi

The information in the Requirements/Limits column tells you if Security Health Plan has any special requirements for coverage of your drug. Deductibles and initial coverage period copay amounts: (30-day supply) Tier Assurance Rx (HMO-POS) $330 deductible (Tiers 3-5 only) Essence Rx (HMO-POS) $330 deductible (Tiers 3-5 only) Esteem Rx (HMO-POS) $330 deductible (Tiers 3-5 only) Promise Rx (HMO-POS) $250 deductible (Tiers 3-5 only) Spirit Rx (HMO-POS) No deductible Surety Rx (HMO-POS) $330 deductible (Tiers 3-5 only) 1 Preferred generic drugs 2 Generic drugs 3 Preferred brand drugs Nonpreferred drugs $7 $7 $8 $7 $9 $8 $20 $16 $20 $20 $20 $20 $7 $7 $7 $7 $7 $7 $100 $100 $100 $100 $100 $100 5 Specialty drugs 26% of the cost 26% of the cost 26% of the cost 28% of the cost 33% of the cost 26% of the cost 6 All Part D vaccines $0 $0 $0 $0 $0 $0 Requirements/Limits 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 HI = Home infusion coverage This prescription drug may be covered under our medical benefit. For more information call Customer Service at 1-877-998-0998, 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 1-877-998-0998, Monday through Sunday from 8 a.m. 8 p.m. TTY users should call 711. QL = Quantity limit NDS = Non-extended day supply (Limited to 30-day supply) vii

Table of Contents Analgesics... 3 Anesthetics... 7 Anti-Addiction/Substance Abuse Treatment Agents... 8 Antianxiety Agents... 8 Antibacterials... 9 Anticancer Agents... 16 Anticholinergic Agents... 23 Anticonvulsants... 23 Antidementia Agents... 26 Antidepressants... 27 Antidiabetic Agents... 29 Antifungals... 33 Antigout Agents... 3 Antihistamines... 3 Anti-Infectives (Skin And Mucous Membrane)... 35 Antimigraine Agents... 35 Antimycobacterials... 36 Antinausea Agents... 36 Antiparasite Agents... 37 Antiparkinsonian Agents... 38 Antipsychotic Agents... 39 Antivirals (Systemic)... 2 Blood Products/Modifiers/Volume Expanders... 7 Caloric Agents... 50 Cardiovascular Agents... 53 Central Nervous System Agents... 62 Contraceptives... 65 1

Dental And Oral Agents... 71 Dermatological Agents... 71 Devices... 76 Enzyme Replacement/Modifiers... 77 Eye, Ear, Nose, Throat Agents... 78 Gastrointestinal Agents... 82 Genitourinary Agents... 85 Heavy Metal Antagonists... 86 Hormonal Agents, Stimulant/Replacement/Modifying... 86 Immunological Agents... 91 Inflammatory Bowel Disease Agents... 99 Irrigating Solutions... 99 Metabolic Bone Disease Agents... 100 Miscellaneous Therapeutic Agents... 101 Ophthalmic Agents... 102 Replacement Preparations... 103 Respiratory Tract Agents... 106 Skeletal Muscle Relaxants... 110 Sleep Disorder Agents... 110 Vasodilating Agents... 110 Vitamins And Minerals... 111 2

Analgesics Analgesics, Miscellaneous acetaminophen-codeine oral solution 120-12 3 /5 ml acetaminophen-codeine oral tablet 300-15, 3 300-30, 300-60 ascomp with codeine oral capsule 30-50-325-0 QL (360 per 30 days) astramorph-pf injection solution 0.5 /ml, 1 3 HI /ml buprenorphine hcl injection syringe 0.3 /ml buprenorphine transdermal patch weekly 10 mcg/hour, 15 mcg/hour, 20 mcg/hour, 5 mcg/hour, 7.5 mcg/hour butalbital compound w/codeine oral capsule 30- QL (360 per 30 days) 50-325-0 butalbital-acetaminop-caf-cod oral capsule 50- QL (360 per 30 days) 300-0-30 butalbital-acetaminop-caf-cod oral capsule 50-325-0-30 butalbital-acetaminophen oral tablet 50-325 QL (180 per 30 days) butalbital-acetaminophen-caff oral capsule 50- QL (180 per 30 days) 300-0 butalbital-acetaminophen-caff oral capsule 50-325-0 butalbital-acetaminophen-caff oral tablet 50-325- 0 butalbital-aspirin-caffeine oral capsule 50-325- 0 butalbital-aspirin-caffeine oral tablet 50-325-0 butorphanol 2 /ml vial latex-free, sdv 2 /ml butorphanol tartrate injection solution 1 /ml QL (960 per 30 days) butorphanol tartrate injection solution 2 /ml QL (80 per 30 days) butorphanol tartrate nasal spray,non-aerosol 10 QL (5 per 28 days) /ml capacet oral capsule 50-325-0 codeine sulfate oral tablet 15, 30, 60 3 DEMEROL (PF) INJECTION SOLUTION 100 MG/2 ML, 100 MG/ML, 25 MG/0.5 ML, 50 MG/ML, 75 MG/1.5 ML PA; HI; AGE (Max 6 Years) 3

DEMEROL (PF) INJECTION SYRINGE 100 PA; HI; AGE (Max 6 Years) MG/ML, 50 MG/ML, 75 MG/ML DEMEROL (PF) INJECTION SYRINGE 25 PA; AGE (Max 6 Years) MG/ML DEMEROL INJECTION SOLUTION 100 PA; HI; AGE (Max 6 Years) MG/ML, 50 MG/ML DILAUDID (PF) INJECTION SYRINGE 0.5 HI MG/0.5 ML, 1 MG/ML, 2 MG/ML, MG/ML endocet oral tablet 10-325, 2.5-325, 5-325 3, 7.5-325 fentanyl citrate (pf) intravenous syringe 100 HI mcg/2 ml (50 mcg/ml) fentanyl citrate buccal lozenge on a handle 1,200 5 PA; NDS; QL (120 per 30 days) mcg, 1,600 mcg, 200 mcg, 00 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 72 hour 100 mcg/hr, 3 QL (15 per 30 days) 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 62.5 mcg/hour, 75 mcg/hr fioricet oral capsule 50-300-0 hydrocodone-acetaminophen oral solution 7.5-3 325 /15 ml hydrocodone-acetaminophen oral tablet 10-300 3, 10-325, 2.5-325, 5-300, 5-325, 7.5-300, 7.5-325 hydrocodone-ibuprofen oral tablet 10-200, 5-3 200, 7.5-200 hydromorphone (pf) injection solution 10 (/ml) (5 ml), 10 /ml hydromorphone 2 /ml carpujct latexfree,inner,suv HI 2 /ml hydromorphone 500 /50 ml via sdv,p/f,latexfree HI 10 /ml hydromorphone injection solution 1 /ml, 2 HI /ml, /ml hydromorphone injection syringe 0.5 /0.5 ml, 1 HI /ml, /ml hydromorphone injection syringe 2 /ml hydromorphone oral liquid 1 /ml 3 hydromorphone oral tablet 2,, 8 3 hydromorphone oral tablet extended release 2 hr 12, 16, 32, 8 INFUMORPH P/F INJECTION SOLUTION 10 MG/ML, 25 MG/ML HI

levorphanol tartrate oral tablet 2 QL (180 per 30 days) lorcet (hydrocodone) oral tablet 5-325 3 lorcet hd oral tablet 10-325 3 lorcet plus oral tablet 7.5-325 3 marten-tab oral tablet 50-325 QL (180 per 30 days) meperidine (pf) injection solution 100 /ml, 25 3 PA; AGE (Max 6 Years) /ml, 50 /ml meperidine injection cartridge 10 /ml 3 PA; HI; AGE (Max 6 Years) methadone oral concentrate 10 /ml 3 methadone oral solution 10 /5 ml 3 QL (50 per 30 days) methadone oral solution 5 /5 ml 3 QL (900 per 30 days) methadone oral tablet 10, 5 3 QL (180 per 30 days) morphine (pf) injection solution 0.5 /ml, 1 3 HI /ml morphine (pf) intravenous patient 3 HI control.analgesia soln 150 /30 ml, 30 /30 ml morphine concentrate oral solution 100 /5 ml 3 (20 /ml) morphine injection solution 10 /ml 3 HI MORPHINE INJECTION SOLUTION 2 MG/ML morphine injection solution 5 /ml morphine injection syringe 10 /ml, 2 /ml, 3 HI /ml, 5 /ml, 8 /ml morphine intravenous solution 10 /ml, 3 HI /ml, 8 /ml morphine intravenous syringe 10 /ml, 2 /ml, 3 HI /ml, 8 /ml morphine oral solution 10 /5 ml, 20 /5 ml ( 3 /ml) MORPHINE ORAL TABLET 15 MG, 30 MG 3 QL (180 per 30 days) morphine oral tablet extended release 100, 15 3 QL (120 per 30 days), 30, 60 morphine oral tablet extended release 200 3 QL (180 per 30 days) nalocet oral tablet 2.5-300 3 oxycodone oral concentrate 20 /ml 3 QL (360 per 30 days) oxycodone oral solution 5 /5 ml 3 QL (7200 per 30 days) oxycodone oral tablet 10, 15, 20, 30 3 QL (360 per 30 days), 5 oxycodone oral tablet,oral only,ext.rel.12 hr 10, 15, 20, 30, 0, 60 3 QL (90 per 30 days) 5

oxycodone oral tablet,oral only,ext.rel.12 hr 80 3 QL (120 per 30 days) oxycodone-acetaminophen oral tablet 10-325, 3 2.5-325, 5-325, 7.5-325 oxycodone-aspirin oral tablet.8355-325 3 OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 0 MG, 60 MG, 80 MG oxymorphone oral tablet 10, 5 3 oxymorphone oral tablet extended release 12 hr 3 10, 15, 20, 30, 0, 5, 7.5 phrenilin forte(with caffeine) oral capsule 50- QL (180 per 30 days) 300-0 PRIALT INTRATHECAL SOLUTION 100 HI MCG/ML, 25 MCG/ML tencon oral tablet 50-325 QL (180 per 30 days) tramadol oral tablet 50 3 QL (20 per 30 days) tramadol oral tablet extended release 2 hr 100 QL (90 per 30 days) tramadol oral tablet extended release 2 hr 200 QL (60 per 30 days) tramadol oral tablet extended release 2 hr 300 QL (30 per 30 days) tramadol-acetaminophen oral tablet 37.5-325 3 QL (20 per 30 days) vicodin es oral tablet 7.5-300 3 vicodin hp oral tablet 10-300 3 vicodin oral tablet 5-300 3 xylon 10 oral tablet 10-200 3 zebutal oral capsule 50-325-0 Nonsteroidal Anti-Inflammatory Agents celecoxib oral capsule 100, 200, 00, 2 QL (60 per 30 days) 50 diclofenac potassium oral tablet 50 2 diclofenac sodium oral tablet extended release 2 2 hr 100 diclofenac sodium oral tablet,delayed release 2 (dr/ec) 25, 50, 75 diclofenac sodium topical gel 1 % 2 diclofenac sodium topical gel 3 % PA NSO diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic 50-200 -mcg, 75-200 -mcg diflunisal oral tablet 500 6

etodolac oral capsule 200, 300 2 etodolac oral tablet 00, 500 2 etodolac oral tablet extended release 2 hr 00, 500, 600 FLECTOR TRANSDERMAL PATCH 12 HOUR PA NSO; QL (60 per 30 days) 1.3 % flurbiprofen oral tablet 100, 50 2 ibu oral tablet 00, 600, 800 1 ibuprofen oral suspension 100 /5 ml 1 ibuprofen oral tablet 00, 600, 800 1 indomethacin oral capsule 25, 50 3 indomethacin oral capsule, extended release 75 3 ketoprofen oral capsule 25, 50, 75 2 ketorolac injection cartridge 15 /ml ketorolac intramuscular cartridge 60 /2 ml ketorolac intramuscular syringe 60 /2 ml ketorolac oral tablet 10 3 QL (120 per 30 days) meloxicam oral tablet 15 1 QL (30 per 30 days) meloxicam oral tablet 7.5 1 QL (60 per 30 days) nabumetone oral tablet 500, 750 2 naproxen oral suspension 125 /5 ml naproxen oral tablet 250, 375, 500 1 naproxen oral tablet,delayed release (dr/ec) 375 2, 500 naproxen sodium oral tablet 275, 550 3 naproxen sodium oral tablet, er multiphase 2 hr 375, 500 oxaprozin oral tablet 600 piroxicam oral capsule 10, 20 3 sulindac oral tablet 150, 200 2 Anesthetics Local Anesthetics lidocaine hcl mucous membrane jelly 2 % 3 lidocaine hcl mucous membrane solution % (0 2 /ml) lidocaine topical adhesive patch,medicated 5 % 3 PA NSO; QL (90 per 30 days) lidocaine topical ointment 5 % 3 lidocaine viscous mucous membrane solution 2 % 2 lidocaine-prilocaine topical cream 2.5-2.5 % 7

Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed release (dr/ec) 333 buprenorphine hcl sublingual tablet 2 2 QL (20 per 30 days) buprenorphine hcl sublingual tablet 8 2 QL (90 per 30 days) buprenorphine-naloxone sublingual film 8-2 3 QL (90 per 30 days) buprenorphine-naloxone sublingual tablet 2-0.5 2, 8-2 bupropion hcl (smoking deter) oral tablet 2 QL (60 per 30 days) extended release 12 hr 150 CHANTIX CONTINUING MONTH BOX QL (60 per 30 days) ORAL TABLET 1 MG CHANTIX ORAL TABLET 0.5 MG, 1 MG QL (60 per 30 days) CHANTIX STARTING MONTH BOX ORAL QL (60 per 30 days) TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (2) disulfiram oral tablet 250, 500 3 LUCEMYRA ORAL TABLET 0.18 MG QL (22 per 1 days) naloxone injection syringe 0. /ml, 1 /ml 2 naltrexone oral tablet 50 2 NARCAN NASAL SPRAY,NON-AEROSOL 3 MG/ACTUATION NICOTROL INHALATION CARTRIDGE 10 MG NICOTROL NS NASAL SPRAY,NON- AEROSOL 10 MG/ML SUBOXONE SUBLINGUAL FILM 12-3 MG 3 QL (60 per 30 days) SUBOXONE SUBLINGUAL FILM 2-0.5 MG, -1 MG, 8-2 MG 3 QL (90 per 30 days) Antianxiety Agents Benzodiazepines alprazolam oral tablet 0.25, 0.5, 1, 2 8 2 QL (120 per 30 days) buspirone oral tablet 10, 15, 30, 5, 2 7.5 chlordiazepoxide hcl oral capsule 10, 25, 3 5 clobazam oral suspension 2.5 /ml QL (80 per 30 days) clobazam oral tablet 10, 20 QL (60 per 30 days)

clonazepam oral tablet 0.5, 1, 2 3 clonazepam oral tablet,disintegrating 0.125, 0.25, 0.5, 1, 2 clorazepate dipotassium oral tablet 15, 3.75 3, 7.5 DIASTAT ACUDIAL RECTAL KIT 12.5-15- 17.5-20 MG, 5-7.5-10 MG DIASTAT RECTAL KIT 2.5 MG diazepam intensol oral concentrate 5 /ml 3 QL (20 per 30 days) diazepam oral solution 5 /5 ml (1 /ml) 3 QL (1200 per 30 days) diazepam oral tablet 10, 5 3 QL (120 per 30 days) diazepam oral tablet 2 3 QL (90 per 30 days) diazepam rectal kit 12.5-15-17.5-20, 2.5, 3 5-7.5-10 flurazepam oral capsule 15, 30 3 lorazepam oral concentrate 2 /ml 3 QL (150 per 30 days) lorazepam oral tablet 0.5, 1, 2 2 meprobamate oral tablet 200, 00 midazolam (pf) injection cartridge 2 /2 ml (1 /ml), 5 /ml midazolam (pf) injection solution 1 /ml, 5 /ml midazolam (pf) injection syringe 2 /2 ml (1 /ml), 5 /ml midazolam injection solution 1 /ml, 5 /ml ONFI ORAL SUSPENSION 2.5 MG/ML QL (80 per 30 days) ONFI ORAL TABLET 10 MG, 20 MG QL (60 per 30 days) oxazepam oral capsule 10, 15, 30 temazepam oral capsule 15 2 QL (60 per 30 days) temazepam oral capsule 30 2 QL (30 per 30 days) Antibacterials Aminoglycosides amikacin injection solution 1,000 / ml, 500 HI /2 ml BETHKIS INHALATION SOLUTION FOR 5 PA; LA; NDS; QL (22 per 28 days) NEBULIZATION 300 MG/ ML gentamicin in nacl (iso-osm) intravenous 3 HI piggyback 100 /100 ml, 100 /50 ml, 120 /100 ml, 60 /50 ml, 70 /50 ml, 80 /100 ml, 80 /50 ml, 90 /100 ml gentamicin injection solution 20 /2 ml, 0 /ml 3 HI 9

gentamicin sulfate (ped) (pf) injection solution 20 3 HI /2 ml gentamicin sulfate (pf) intravenous solution 100 3 HI /10 ml, 60 /6 ml, 80 /8 ml neomycin oral tablet 500 3 streptomycin intramuscular recon soln 1 gram TOBI PODHALER INHALATION CAPSULE, 5 PA; NDS; QL (22 per 28 days) W/INHALATION DEVICE 28 MG tobramycin in 0.225 % nacl inhalation solution 5 PA; NDS; QL (280 per 28 days) for nebulization 300 /5 ml tobramycin in 0.9 % nacl intravenous piggyback 3 HI 60 /50 ml tobramycin sulfate injection solution 10 /ml, 3 HI 0 /ml Antibacterials, Miscellaneous baciim intramuscular recon soln 50,000 unit bacitracin intramuscular recon soln 50,000 unit chloramphenicol sod succinate intravenous recon 3 HI soln 1 gram clindamycin hcl oral capsule 150, 300, 75 2 clindamycin in 5 % dextrose intravenous HI piggyback 300 /50 ml, 600 /50 ml, 900 /50 ml clindamycin palmitate hcl oral recon soln 75 /5 ml clindamycin phosphate injection solution 150 HI (/ml) (6 ml), 150 /ml clindamycin phosphate intravenous solution 600 HI / ml colistin (colistimethate na) injection recon soln HI 150 daptomycin intravenous recon soln 350, 500 HI lincomycin injection solution 300 /ml linezolid 600 /300 ml-0.9% nacl 600 /300 5 PA; HI; NDS ml linezolid in dextrose 5% intravenous piggyback 5 PA; HI; NDS 600 /300 ml linezolid oral suspension for reconstitution 100 5 PA; NDS; QL (1800 per 30 days) /5 ml linezolid oral tablet 600 5 PA; NDS; QL (60 per 30 days) 10

methenamine hippurate oral tablet 1 gram 2 metronidazole in nacl (iso-os) intravenous HI piggyback 500 /100 ml metronidazole oral capsule 375 metronidazole oral tablet 250, 500 2 MONUROL ORAL PACKET 3 GRAM nitrofurantoin macrocrystal oral capsule 100, 3 50 nitrofurantoin monohyd/m-cryst oral capsule 100 3 nitrofurantoin oral suspension 25 /5 ml 3 polymyxin b sulfate injection recon soln 500,000 3 HI unit SIVEXTRO INTRAVENOUS RECON SOLN 5 PA; HI; NDS; QL (6 per 28 days) 200 MG SIVEXTRO ORAL TABLET 200 MG 5 PA; NDS; QL (6 per 28 days) SYNERCID INTRAVENOUS RECON SOLN 5 NDS 500 MG trimethoprim oral tablet 100 2 TRIMPEX ORAL SOLUTION 50 MG/5 ML vancomycin in dextrose 5 % intravenous 3 HI piggyback 1 gram/200 ml, 500 /100 ml, 750 /150 ml vancomycin intravenous recon soln 1,000, 3 HI 1.25 gram, 10 gram, 5 gram, 500, 750 VANCOMYCIN INTRAVENOUS RECON 3 HI SOLN 1.5 GRAM vancomycin intravenous recon soln 250 3 vancomycin oral capsule 125, 250 3 QL (80 per 10 days) VIBATIV INTRAVENOUS RECON SOLN 750 HI MG XIFAXAN ORAL TABLET 200 MG QL (9 per 30 days) XIFAXAN ORAL TABLET 550 MG QL (8 per 28 days) ZYVOX INTRAVENOUS PIGGYBACK 200 5 HI; NDS MG/100 ML Cephalosporins AVYCAZ INTRAVENOUS RECON SOLN 2.5 GRAM cefaclor oral capsule 250, 500 3 cefaclor oral suspension for reconstitution 125 3 /5 ml, 250 /5 ml, 375 /5 ml cefadroxil oral capsule 500 2 11

cefadroxil oral suspension for reconstitution 250 2 /5 ml, 500 /5 ml cefadroxil oral tablet 1 gram 2 cefazolin in dextrose (iso-os) intravenous 3 HI piggyback 2 gram/50 ml cefazolin injection recon soln 1 gram, 10 gram, 3 HI 500 cefdinir oral capsule 300 2 cefdinir oral suspension for reconstitution 125 2 /5 ml, 250 /5 ml cefepime injection recon soln 1 gram, 2 gram HI cefixime oral suspension for reconstitution 100 3 /5 ml, 200 /5 ml cefotaxime injection recon soln 1 gram, 10 gram, HI 2 gram, 500 cefotetan injection recon soln 1 gram, 2 gram HI cefotetan intravenous recon soln 10 gram HI cefoxitin intravenous recon soln 1 gram, 10 gram, HI 2 gram cefpodoxime oral suspension for reconstitution 100 /5 ml, 50 /5 ml cefpodoxime oral tablet 100, 200 cefprozil oral suspension for reconstitution 125 3 /5 ml, 250 /5 ml cefprozil oral tablet 250, 500 3 ceftazidime injection recon soln 1 gram, 2 gram, HI 6 gram ceftriaxone injection recon soln 1 gram, 10 gram, 3 HI 2 gram, 250, 500 cefuroxime axetil oral tablet 250, 500 3 cefuroxime sodium injection recon soln 750 3 HI cefuroxime sodium intravenous recon soln 1.5 3 HI gram, 7.5 gram cephalexin oral capsule 250, 500 1 cephalexin oral suspension for reconstitution 125 1 /5 ml, 250 /5 ml CLAFORAN INTRAVENOUS RECON SOLN 1 HI GRAM, 2 GRAM FORTAZ INJECTION RECON SOLN 500 MG HI MAXIPIME 1 GM ADD-VANTAGE VL OUTER, LATEX-FREE 1 GRAM HI 12

MAXIPIME INJECTION RECON SOLN 1 HI GRAM SUPRAX ORAL CAPSULE 00 MG tazicef injection recon soln 1 gram, 2 gram, 6 HI gram TEFLARO INTRAVENOUS RECON SOLN HI 00 MG, 600 MG ZERBAXA INTRAVENOUS RECON SOLN 5 HI; NDS 1.5 GRAM Macrolides azithromycin intravenous recon soln 500 HI azithromycin oral packet 1 gram 3 azithromycin oral suspension for reconstitution 1 100 /5 ml, 200 /5 ml azithromycin oral tablet 250, 250 (6 1 pack), 500, 500 (3 pack), 600 clarithromycin oral suspension for reconstitution 3 125 /5 ml, 250 /5 ml clarithromycin oral tablet 250, 500 3 clarithromycin oral tablet extended release 2 hr 3 500 DIFICID ORAL TABLET 200 MG 5 PA; NDS; QL (20 per 10 days) ery-tab oral tablet,delayed release (dr/ec) 250, 500 ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 333 MG ERYTHROCIN INTRAVENOUS RECON 3 HI SOLN 1,000 MG, 500 MG erythromycin ethylsuccinate oral suspension for reconstitution 200 /5 ml erythromycin ethylsuccinate oral tablet 00 erythromycin oral tablet 250, 500 Miscellaneous B-Lactam Antibiotics AZACTAM INJECTION RECON SOLN 1 HI GRAM AZACTAM-ISO-OSMOT 1 GM/50 ML HI 2'S,SINGLE USE 1 GRAM/50 ML aztreonam injection recon soln 1 gram, 2 gram HI CAYSTON INHALATION SOLUTION FOR 5 PA; NDS; QL (8 per 28 days) NEBULIZATION 75 MG/ML ertapenem injection recon soln 1 gram HI 13

imipenem-cilastatin intravenous recon soln 250 HI imipenem-cilastatin intravenous recon soln 500 3 HI INVANZ INJECTION RECON SOLN 1 GRAM HI meropenem intravenous recon soln 1 gram, 500 HI Penicillins amoxicillin oral capsule 250, 500 1 amoxicillin oral suspension for reconstitution 125 1 /5 ml, 200 /5 ml, 250 /5 ml, 00 /5 ml amoxicillin oral tablet 500, 875 1 amoxicillin oral tablet,chewable 125, 250 1 amoxicillin-pot clavulanate oral suspension for 2 reconstitution 200-28.5 /5 ml, 250-62.5 /5 ml, 00-57 /5 ml, 600-2.9 /5 ml amoxicillin-pot clavulanate oral tablet 250-125 2, 500-125, 875-125 amoxicillin-pot clavulanate oral tablet,chewable 2 200-28.5, 00-57 ampicillin oral capsule 250, 500 2 ampicillin sodium injection recon soln 1 gram, 10 HI gram, 125, 2 gram, 250, 500 ampicillin sodium intravenous recon soln 2 gram HI ampicillin-sulbactam injection recon soln 1.5 HI gram, 15 gram, 3 gram BICILLIN L-A INTRAMUSCULAR SYRINGE 1,200,000 UNIT/2 ML, 2,00,000 UNIT/ ML, 600,000 UNIT/ML dicloxacillin oral capsule 250, 500 2 nafcillin 1 gm/ 50 ml inj 1 gram/50 ml HI nafcillin injection recon soln 1 gram, 10 gram, 2 HI gram nafcillin intravenous recon soln 2 gram HI oxacillin 1 gm add-vantage vl add-vantage, inner HI 1 gram oxacillin in dextrose(iso-osm) intravenous HI piggyback 1 gram/50 ml, 2 gram/50 ml oxacillin injection recon soln 1 gram, 10 gram, 2 HI gram penicillin g pot in dextrose intravenous piggyback 1 million unit/50 ml 1

penicillin g pot in dextrose intravenous piggyback HI 2 million unit/50 ml, 3 million unit/50 ml penicillin g potassium injection recon soln 20 HI million unit penicillin g procaine intramuscular syringe 1.2 million unit/2 ml, 600,000 unit/ml penicillin g sodium injection recon soln 5 million HI unit penicillin v potassium oral recon soln 125 /5 2 ml, 250 /5 ml penicillin v potassium oral tablet 250, 500 2 pfizerpen-g injection recon soln 20 million unit HI piperacillin-tazobactam intravenous recon soln HI 2.25 gram, 3.375 gram,.5 gram, 0.5 gram ZOSYN IN DEXTROSE (ISO-OSM) HI INTRAVENOUS PIGGYBACK 3.375 GRAM/50 ML,.5 GRAM/100 ML Quinolones ciprofloxacin hcl oral tablet 100, 250, 500 1, 750 ciprofloxacin in 5 % dextrose intravenous HI piggyback 200 /100 ml, 00 /200 ml ciprofloxacin oral suspension,microcapsule recon 2 250 /5 ml, 500 /5 ml levofloxacin in d5w intravenous piggyback 250 HI /50 ml, 500 /100 ml, 750 /150 ml levofloxacin intravenous solution 25 /ml HI levofloxacin oral solution 250 /10 ml 2 levofloxacin oral tablet 250, 500, 750 2 moxifloxacin 00 /250 ml bag 00 /250 ml HI moxifloxacin in nacl (iso-osm) intravenous HI piggyback 00 /250 ml moxifloxacin oral tablet 00 ofloxacin oral tablet 300, 00 3 Sulfonamides sulfadiazine oral tablet 500 sulfamethoxazole-trimethoprim intravenous HI solution 00-80 /5 ml sulfamethoxazole-trimethoprim oral suspension 3 200-0 /5 ml sulfamethoxazole-trimethoprim oral tablet 00-80, 800-160 1 15

sulfatrim oral suspension 200-0 /5 ml 3 Tetracyclines demeclocycline oral tablet 150, 300 doxy-100 intravenous recon soln 100 HI doxycycline hyclate intravenous recon soln 100 HI doxycycline hyclate oral capsule 100, 50 2 doxycycline hyclate oral tablet 100, 20 2 doxycycline monohydrate oral capsule 100, 1 QL (60 per 30 days) 50 doxycycline monohydrate oral tablet 100, 150, 50, 75 2 minocycline oral capsule 100, 50, 75 2 okebo oral capsule 100 1 QL (60 per 30 days) tetracycline oral capsule 250, 500 tigecycline intravenous recon soln 50 HI Anticancer Agents Anticancer Agents abiraterone oral tablet 250 5 PA NSO; NDS; QL (120 per 30 days) ABRAXANE INTRAVENOUS SUSPENSION 5 NDS FOR RECONSTITUTION 100 MG adriamycin intravenous solution 10 /5 ml, 2 HI /ml, 20 /10 ml, 50 /25 ml adrucil intravenous solution 2.5 gram/50 ml, 500 HI /10 ml AFINITOR DISPERZ ORAL TABLET FOR 5 PA NSO; NDS SUSPENSION 2 MG, 3 MG, 5 MG AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 5 PA NSO; NDS; QL (30 per 30 days) MG, 7.5 MG ALECENSA ORAL CAPSULE 150 MG 5 PA NSO; NDS ALIMTA INTRAVENOUS RECON SOLN 100 5 NDS MG, 500 MG ALIQOPA INTRAVENOUS RECON SOLN 60 5 PA BvD; NDS MG ALUNBRIG ORAL TABLET 180 MG, 90 MG 5 PA NSO; NDS; QL (30 per 30 days) ALUNBRIG ORAL TABLET 30 MG 5 PA NSO; NDS; QL (60 per 30 days) ALUNBRIG ORAL TABLETS,DOSE PACK 90 5 PA NSO; NDS; QL (30 per 180 days) MG (7)- 180 MG (23) anastrozole oral tablet 1 1 QL (30 per 30 days) arsenic trioxide intravenous solution 1 /ml AVASTIN INTRAVENOUS SOLUTION 25 MG/ML 5 NDS 16

azacitidine injection recon soln 100 5 NDS BAVENCIO INTRAVENOUS SOLUTION 20 5 PA BvD; NDS MG/ML BELEODAQ INTRAVENOUS RECON SOLN 5 NDS 500 MG BESPONSA INTRAVENOUS RECON SOLN 5 PA BvD; NDS 0.9 MG (0.25 MG/ML INITIAL) bexarotene oral capsule 75 5 PA NSO; NDS; QL (300 per 30 days) bicalutamide oral tablet 50 1 QL (30 per 30 days) BICNU INTRAVENOUS RECON SOLN 100 MG bleomycin injection recon soln 15 unit, 30 unit HI BORTEZOMIB INTRAVENOUS RECON 5 NDS SOLN 3.5 MG BOSULIF ORAL TABLET 100 MG 5 PA NSO; NDS; QL (120 per 30 days) BOSULIF ORAL TABLET 00 MG, 500 MG 5 PA NSO; NDS; QL (30 per 30 days) BRAFTOVI ORAL CAPSULE 50 MG 5 PA NSO; NDS; QL (120 per 30 days) BRAFTOVI ORAL CAPSULE 75 MG 5 PA NSO; NDS; QL (180 per 30 days) CABOMETYX ORAL TABLET 20 MG, 0 5 PA NSO; NDS; QL (30 per 30 days) MG, 60 MG CALQUENCE ORAL CAPSULE 100 MG 5 PA NSO; NDS; QL (2 per 1 day) CAPRELSA ORAL TABLET 100 MG 5 PA NSO; LA; NDS; QL (60 per 30 days) CAPRELSA ORAL TABLET 300 MG 5 PA NSO; LA; NDS; QL (30 per 30 days) carboplatin intravenous solution 10 /ml carmustine intravenous recon soln 100 cladribine intravenous solution 10 /10 ml HI COMETRIQ ORAL CAPSULE 100 5 PA NSO; LA; NDS; QL (56 per 28 days) MG/DAY(80 MG X1-20 MG X1) COMETRIQ ORAL CAPSULE 10 5 PA NSO; LA; NDS; QL (112 per 28 days) MG/DAY(80 MG X1-20 MG X3) COMETRIQ ORAL CAPSULE 60 MG/DAY (20 5 PA NSO; LA; NDS; QL (8 per 28 days) MG X 3/DAY) COPIKTRA ORAL CAPSULE 15 MG, 25 MG 5 PA NSO; NDS; QL (56 per 28 days) COTELLIC ORAL TABLET 20 MG 5 PA NSO; LA; NDS; QL (90 per 30 days) cyclophosphamide intravenous recon soln 1 HI gram, 2 gram, 500 CYCLOPHOSPHAMIDE ORAL CAPSULE 25 3 PA BvD MG, 50 MG CYRAMZA INTRAVENOUS SOLUTION 10 5 PA NSO; NDS; QL (200 per 28 days) MG/ML cytarabine (pf) injection solution 100 /5 ml (20 /ml), 2 gram/20 ml (100 /ml) HI 17

cytarabine injection solution 20 /ml HI DARZALEX INTRAVENOUS SOLUTION 20 5 PA NSO; LA; NDS; QL (00 per 30 days) MG/ML daunorubicin intravenous recon soln 20 HI daunorubicin intravenous solution 5 /ml HI DAURISMO ORAL TABLET 100 MG 5 PA NSO; NDS; QL (28 per 28 days) DAURISMO ORAL TABLET 25 MG 5 PA NSO; NDS; QL (8 per 28 days) doxorubicin intravenous recon soln 10, 50 HI doxorubicin intravenous solution 10 /5 ml, 2 HI /ml, 20 /10 ml, 50 /25 ml doxorubicin, peg-liposomal intravenous HI suspension 2 /ml DROXIA ORAL CAPSULE 200 MG, 300 MG, 00 MG EMCYT ORAL CAPSULE 10 MG EMPLICITI INTRAVENOUS RECON SOLN 5 PA NSO; NDS 300 MG, 00 MG epirubicin intravenous recon soln 200, 50 3 epirubicin intravenous solution 200 /100 ml, 3 50 /25 ml ERIVEDGE ORAL CAPSULE 150 MG 5 PA NSO; NDS; QL (30 per 30 days) ERLEADA ORAL TABLET 60 MG 5 PA NSO; NDS; QL (120 per 30 days) ETOPOPHOS INTRAVENOUS RECON SOLN HI 100 MG etoposide intravenous solution 20 /ml HI exemestane oral tablet 25 2 QL (60 per 30 days) FARESTON ORAL TABLET 60 MG 5 NDS; QL (30 per 30 days) FARYDAK ORAL CAPSULE 10 MG, 15 MG, 5 PA NSO; NDS; QL (6 per 21 days) 20 MG FASLODEX INTRAMUSCULAR SYRINGE 5 NDS; QL (30 per 30 days) 250 MG/5 ML FIRMAGON KIT W DILUENT SYRINGE 5 NDS SUBCUTANEOUS RECON SOLN 120 MG FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 80 MG fluorouracil intravenous solution 1 gram/20 ml, 5 HI gram/100 ml, 500 /10 ml flutamide oral capsule 125 2 GILOTRIF ORAL TABLET 20 MG, 30 MG, 0 5 PA NSO; NDS; QL (30 per 30 days) MG GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 0 MG, 5 MG PA NSO 18

HERCEPTIN INTRAVENOUS RECON SOLN 5 NDS 150 MG, 0 MG HEXALEN ORAL CAPSULE 50 MG 5 NDS hydroxyurea oral capsule 500 2 IBRANCE ORAL CAPSULE 100 MG, 125 MG, 5 PA NSO; NDS; QL (21 per 28 days) 75 MG ICLUSIG ORAL TABLET 15 MG, 5 MG 5 PA NSO; LA; NDS; QL (30 per 30 days) IDHIFA ORAL TABLET 100 MG, 50 MG 5 PA NSO; NDS; QL (30 per 30 days) imatinib oral tablet 100, 00 5 PA NSO; NDS IMBRUVICA ORAL CAPSULE 10 MG 5 PA NSO; NDS; QL (120 per 30 days) IMBRUVICA ORAL CAPSULE 70 MG 5 PA NSO; NDS; QL (30 per 30 days) IMBRUVICA ORAL TABLET 10 MG, 280 5 PA NSO; NDS; QL (30 per 30 days) MG, 20 MG, 560 MG IMFINZI INTRAVENOUS SOLUTION 50 5 PA BvD; NDS MG/ML INLYTA ORAL TABLET 1 MG 5 PA NSO; NDS; QL (180 per 30 days) INLYTA ORAL TABLET 5 MG 5 PA NSO; NDS; QL (60 per 30 days) IRESSA ORAL TABLET 250 MG 5 PA NSO; LA; NDS; QL (30 per 30 days) JAKAFI ORAL TABLET 10 MG, 15 MG, 20 5 PA NSO; NDS; QL (60 per 30 days) MG, 25 MG, 5 MG KADCYLA INTRAVENOUS RECON SOLN 5 NDS 100 MG, 160 MG KEYTRUDA INTRAVENOUS SOLUTION 25 5 PA NSO; NDS MG/ML KISQALI FEMARA CO-PACK ORAL 5 PA NSO; NDS TABLET 200 MG/DAY(200 MG X 1)-2.5 MG, 00 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 5 PA NSO; NDS MG X 1), 00 MG/DAY (200 MG X 2), 600 MG/DAY (200 MG X 3) LARTRUVO INTRAVENOUS SOLUTION 10 5 PA NSO; NDS MG/ML LENVIMA ORAL CAPSULE 10 MG/DAY (10 5 PA NSO; LA; NDS; QL (30 per 30 days) MG X 1) LENVIMA ORAL CAPSULE 12 MG/DAY ( 5 PA NSO; NDS; QL (30 per 30 days) MG X 3) LENVIMA ORAL CAPSULE 1 MG/DAY(10 5 PA NSO; LA; NDS; QL (60 per 30 days) MG X 1- MG X 1), 20 MG/DAY (10 MG X 2), 8 MG/DAY ( MG X 2) LENVIMA ORAL CAPSULE 18 MG/DAY (10 5 PA NSO; LA; NDS; QL (90 per 30 days) MG X 1- MG X2), 2 MG/DAY(10 MG X 2- MG X 1) 19

LENVIMA ORAL CAPSULE MG 5 PA NSO; NDS; QL (60 per 30 days) letrozole oral tablet 2.5 1 QL (30 per 30 days) LEUKERAN ORAL TABLET 2 MG leuprolide subcutaneous kit 1 /0.2 ml LONSURF ORAL TABLET 15-6.1 MG 5 PA NSO; NDS; QL (100 per 30 days) LONSURF ORAL TABLET 20-8.19 MG 5 PA NSO; NDS; QL (80 per 30 days) LORBRENA ORAL TABLET 100 MG 5 PA NSO; NDS; QL (30 per 30 days) LORBRENA ORAL TABLET 25 MG 5 PA NSO; NDS; QL (90 per 30 days) LUPRON DEPOT (3 MONTH) QL (1 per 90 days) INTRAMUSCULAR SYRINGE KIT 11.25 MG, 22.5 MG LUPRON DEPOT ( MONTH) QL (1 per 112 days) INTRAMUSCULAR SYRINGE KIT 30 MG LUPRON DEPOT (6 MONTH) 5 NDS; QL (1 per 168 days) INTRAMUSCULAR SYRINGE KIT 5 MG LUPRON DEPOT INTRAMUSCULAR QL (1 per 30 days) SYRINGE KIT 3.75 MG LUPRON DEPOT INTRAMUSCULAR 5 NDS; QL (1 per 30 days) SYRINGE KIT 7.5 MG LYNPARZA ORAL CAPSULE 50 MG 5 PA NSO; LA; NDS; QL (80 per 30 days) LYNPARZA ORAL TABLET 100 MG 5 PA NSO; NDS; QL (120 per 30 days) LYNPARZA ORAL TABLET 150 MG 5 PA NSO; NDS; QL (30 per 30 days) LYSODREN ORAL TABLET 500 MG 5 NDS MARQIBO INTRAVENOUS KIT 5 MG/31 5 HI; NDS ML(0.16 MG/ML) FINAL MATULANE ORAL CAPSULE 50 MG 5 LA; NDS megestrol oral tablet 20, 0 3 MEKINIST ORAL TABLET 0.5 MG 5 PA NSO; NDS; QL (90 per 30 days) MEKINIST ORAL TABLET 2 MG 5 PA NSO; NDS; QL (30 per 30 days) MEKTOVI ORAL TABLET 15 MG 5 PA NSO; NDS; QL (180 per 30 days) mercaptopurine oral tablet 50 3 methotrexate sodium (pf) injection recon soln 1 2 HI gram methotrexate sodium (pf) injection solution 25 2 HI /ml methotrexate sodium injection solution 25 /ml 2 HI methotrexate sodium oral tablet 2.5 1 PA BvD mitomycin intravenous recon soln 20, 0, HI 5 mitoxantrone intravenous concentrate 2 /ml HI MUSTARGEN INJECTION RECON SOLN 10 MG 20

mutamycin intravenous recon soln 20, 0, HI 5 MYLOTARG INTRAVENOUS RECON SOLN 5 PA BvD; NDS.5 MG (1 MG/ML INITIAL CONC) NERLYNX ORAL TABLET 0 MG 5 PA NSO; NDS; QL (180 per 30 days) NEXAVAR ORAL TABLET 200 MG 5 PA NSO; NDS; QL (120 per 30 days) nilutamide oral tablet 150 5 NDS; QL (60 per 30 days) NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 5 PA NSO; NDS; QL (3 per 28 days) MG ODOMZO ORAL CAPSULE 200 MG 5 PA NSO; LA; NDS; QL (30 per 30 days) OPDIVO INTRAVENOUS SOLUTION 100 5 NDS; QL (80 per 28 days) MG/10 ML, 20 MG/2 ML, 0 MG/ ML paclitaxel intravenous concentrate 6 /ml PERJETA INTRAVENOUS SOLUTION 20 5 PA NSO; NDS MG/1 ML (30 MG/ML) POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 5 PA NSO; LA; NDS; QL (21 per 28 days) MG, MG PROLEUKIN INTRAVENOUS RECON SOLN 5 NDS 22 MILLION UNIT PURIXAN ORAL SUSPENSION 20 MG/ML 5 NDS; QL (300 per 30 days) REVLIMID ORAL CAPSULE 10 MG, 5 MG 5 PA NSO; LA; NDS; QL (28 per 28 days) REVLIMID ORAL CAPSULE 15 MG, 20 MG, 5 PA NSO; LA; NDS; QL (21 per 28 days) 25 MG REVLIMID ORAL CAPSULE 2.5 MG 5 PA NSO; LA; NDS; QL (30 per 30 days) RITUXAN INTRAVENOUS CONCENTRATE 5 NDS 10 MG/ML RUBRACA ORAL TABLET 200 MG, 250 MG, 5 PA NSO; NDS; QL (120 per 30 days) 300 MG RYDAPT ORAL CAPSULE 25 MG 5 PA NSO; NDS SOLTAMOX ORAL SOLUTION 10 MG/5 ML SPRYCEL ORAL TABLET 100 MG, 10 MG, 5 PA NSO; NDS; QL (30 per 30 days) 50 MG, 70 MG SPRYCEL ORAL TABLET 20 MG 5 PA NSO; NDS; QL (90 per 30 days) SPRYCEL ORAL TABLET 80 MG 5 PA NSO; NDS; QL (60 per 30 days) STIVARGA ORAL TABLET 0 MG 5 PA NSO; NDS; QL (8 per 28 days) SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 5 PA NSO; NDS; QL (28 per 28 days) 37.5 MG, 50 MG SYLVANT INTRAVENOUS RECON SOLN 5 PA NSO; NDS 100 MG, 00 MG SYNRIBO SUBCUTANEOUS RECON SOLN 5 PA NSO; NDS; QL (28 per 28 days) 3.5 MG TABLOID ORAL TABLET 0 MG 21

TAFINLAR ORAL CAPSULE 50 MG 5 PA NSO; NDS; QL (180 per 30 days) TAFINLAR ORAL CAPSULE 75 MG 5 PA NSO; NDS; QL (120 per 30 days) TAGRISSO ORAL TABLET 0 MG, 80 MG 5 PA NSO; LA; NDS; QL (30 per 30 days) TALZENNA ORAL CAPSULE 0.25 MG 5 PA NSO; NDS; QL (90 per 30 days) TALZENNA ORAL CAPSULE 1 MG 5 PA NSO; NDS; QL (30 per 30 days) tamoxifen oral tablet 10, 20 1 TARCEVA ORAL TABLET 100 MG, 150 MG 5 PA NSO; NDS; QL (30 per 30 days) TARCEVA ORAL TABLET 25 MG 5 PA NSO; NDS; QL (90 per 30 days) TARGRETIN TOPICAL GEL 1 % 5 NDS TASIGNA ORAL CAPSULE 150 MG, 200 MG 5 PA NSO; NDS; QL (120 per 30 days) TASIGNA ORAL CAPSULE 50 MG 5 PA NSO; NDS; QL (20 per 30 days) TECENTRIQ INTRAVENOUS SOLUTION 5 PA NSO; NDS; QL (20 per 21 days) 1,200 MG/20 ML (60 MG/ML) TIBSOVO ORAL TABLET 250 MG 5 PA NSO; NDS; QL (60 per 30 days) toposar intravenous solution 20 /ml HI topotecan intravenous recon soln 5 NDS topotecan intravenous solution / ml (1 5 NDS /ml) TREANDA INTRAVENOUS RECON SOLN 5 PA NSO; NDS 100 MG, 25 MG tretinoin (chemotherapy) oral capsule 10 5 NDS TRISENOX INTRAVENOUS SOLUTION 2 MG/ML TYKERB ORAL TABLET 250 MG 5 PA NSO; NDS; QL (150 per 30 days) VELCADE INJECTION RECON SOLN 3.5 MG 5 NDS VENCLEXTA ORAL TABLET 10 MG PA NSO; QL (60 per 30 days) VENCLEXTA ORAL TABLET 100 MG 5 PA NSO; NDS; QL (120 per 30 days) VENCLEXTA ORAL TABLET 50 MG PA NSO; QL (30 per 30 days) VENCLEXTA STARTING PACK ORAL 5 PA NSO; NDS; QL (2 per 28 days) TABLETS,DOSE PACK 10 MG-50 MG- 100 MG VERZENIO ORAL TABLET 100 MG, 150 MG, 5 PA NSO; NDS; QL (60 per 30 days) 200 MG, 50 MG vinblastine intravenous solution 1 /ml HI vincasar pfs intravenous solution 1 /ml, 2 /2 HI ml vincristine intravenous solution 1 /ml, 2 /2 HI ml vinorelbine intravenous solution 10 /ml, 50 /5 ml VITRAKVI ORAL CAPSULE 100 MG 5 PA NSO; NDS; QL (60 per 30 days) VITRAKVI ORAL CAPSULE 25 MG 5 PA NSO; NDS; QL (180 per 30 days) 22

VITRAKVI ORAL SOLUTION 20 MG/ML 5 PA NSO; NDS; QL (300 per 30 days) VIZIMPRO ORAL TABLET 15 MG, 30 MG, 5 5 PA NSO; NDS; QL (30 per 30 days) MG VOTRIENT ORAL TABLET 200 MG 5 PA NSO; NDS; QL (120 per 30 days) VYXEOS INTRAVENOUS RECON SOLN - 5 PA BvD; HI; NDS 100 MG XALKORI ORAL CAPSULE 200 MG, 250 MG 5 PA NSO; NDS; QL (60 per 30 days) XATMEP ORAL SOLUTION 2.5 MG/ML 5 PA BvD; NDS XOSPATA ORAL TABLET 0 MG 5 PA NSO; NDS; QL (90 per 30 days) XTANDI ORAL CAPSULE 0 MG 5 PA NSO; NDS; QL (120 per 30 days) YERVOY INTRAVENOUS SOLUTION 200 5 NDS MG/0 ML (5 MG/ML) YERVOY INTRAVENOUS SOLUTION 50 5 NDS; QL (250 per 21 days) MG/10 ML (5 MG/ML) YONDELIS INTRAVENOUS RECON SOLN 1 5 PA NSO; NDS MG YONSA ORAL TABLET 125 MG 5 PA NSO; NDS; QL (120 per 30 days) ZANOSAR INTRAVENOUS RECON SOLN 1 GRAM 5 HI; NDS ZEJULA ORAL CAPSULE 100 MG 5 PA NSO; NDS ZELBORAF ORAL TABLET 20 MG 5 PA NSO; NDS; QL (20 per 30 days) ZOLINZA ORAL CAPSULE 100 MG 5 PA NSO; NDS; QL (120 per 30 days) ZYDELIG ORAL TABLET 100 MG, 150 MG 5 PA NSO; NDS; QL (60 per 30 days) ZYKADIA ORAL CAPSULE 150 MG 5 PA NSO; NDS; QL (150 per 30 days) ZYTIGA ORAL TABLET 250 MG 5 PA NSO; NDS; QL (120 per 30 days) ZYTIGA ORAL TABLET 500 MG 5 PA NSO; NDS; QL (60 per 30 days) Anticholinergic Agents Antimuscarinics/Antispasmodics chlordiazepoxide-clidinium oral capsule 5-2.5 QL (20 per 30 days) propantheline oral tablet 15 3 Anticonvulsants Anticonvulsants APTIOM ORAL TABLET 200 MG, 00 MG, 800 MG QL (30 per 30 days) APTIOM ORAL TABLET 600 MG QL (60 per 30 days) BANZEL ORAL SUSPENSION 0 MG/ML 5 NDS; QL (200 per 30 days) BANZEL ORAL TABLET 200 MG 5 NDS; QL (80 per 30 days) BANZEL ORAL TABLET 00 MG 5 NDS; QL (20 per 30 days) BRIVIACT INTRAVENOUS SOLUTION 50 MG/5 ML BRIVIACT ORAL SOLUTION 10 MG/ML 5 NDS; QL (600 per 30 days) 23

BRIVIACT ORAL TABLET 10 MG 5 NDS; QL (50 per 30 days) BRIVIACT ORAL TABLET 100 MG, 25 MG, 5 NDS; QL (60 per 30 days) 50 MG, 75 MG carbamazepine oral capsule, er multiphase 12 hr 3 100, 200, 300 carbamazepine oral suspension 100 /5 ml 3 carbamazepine oral tablet 200 2 carbamazepine oral tablet extended release 12 hr 3 100, 200, 00 carbamazepine oral tablet,chewable 100 2 CELONTIN ORAL CAPSULE 300 MG DILANTIN EXTENDED ORAL CAPSULE 100 3 MG DILANTIN INFATABS ORAL 3 TABLET,CHEWABLE 50 MG DILANTIN ORAL CAPSULE 30 MG 3 DILANTIN-125 ORAL SUSPENSION 125 3 MG/5 ML divalproex oral capsule, delayed rel sprinkle 125 2 divalproex oral tablet extended release 2 hr 250 2, 500 divalproex oral tablet,delayed release (dr/ec) 125 2, 250, 500 EPIDIOLEX ORAL SOLUTION 100 MG/ML PA NSO epitol oral tablet 200 2 EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 100 MG, 200 MG, 300 MG ethosuximide oral capsule 250 ethosuximide oral solution 250 /5 ml felbamate oral suspension 600 /5 ml 5 NDS felbamate oral tablet 00, 600 fosphenytoin injection solution 100 pe/2 ml, 2 500 pe/10 ml FYCOMPA ORAL SUSPENSION 0.5 MG/ML QL (680 per 28 days) FYCOMPA ORAL TABLET 10 MG, 12 MG, 2 QL (30 per 30 days) MG, MG, 6 MG, 8 MG gabapentin oral capsule 100, 300, 00 2 QL (270 per 30 days) gabapentin oral solution 250 /5 ml gabapentin oral tablet 600 2 QL (180 per 30 days) gabapentin oral tablet 800 2 QL (120 per 30 days) 2

lamotrigine oral tablet 100, 150, 200, 2 25 lamotrigine oral tablet extended release 2hr 100, 200, 25, 250, 300, 50 lamotrigine oral tablet, chewable dispersible 25 2, 5 lamotrigine oral tablets,dose pack 25 (35), 25 2 (2) -100 (7), 25 (8) -100 (1) levetiracetam in nacl (iso-os) intravenous piggyback 1,000 /100 ml, 1,500 /100 ml, 500 /100 ml levetiracetam intravenous solution 500 /5 ml levetiracetam oral solution 100 /ml 2 levetiracetam oral tablet 1,000, 250, 500 2, 750 levetiracetam oral tablet extended release 2 hr 3 500, 750 LYRICA ORAL CAPSULE 100 MG, 150 MG, 3 QL (90 per 30 days) 200 MG, 25 MG, 300 MG, 50 MG, 75 MG LYRICA ORAL CAPSULE 225 MG 3 QL (60 per 30 days) LYRICA ORAL SOLUTION 20 MG/ML 3 QL (900 per 30 days) oxcarbazepine oral suspension 300 /5 ml (60 /ml) oxcarbazepine oral tablet 150, 300, 600 3 PEGANONE ORAL TABLET 250 MG phenobarbital oral elixir 20 /5 ml ( /ml) QL (1500 per 30 days) phenobarbital oral tablet 100, 16.2, 32. 3 QL (90 per 30 days), 6.8, 97.2 phenobarbital oral tablet 15, 60 3 QL (120 per 30 days) phenobarbital oral tablet 30 3 QL (300 per 30 days) phenytoin oral suspension 125 /5 ml 2 phenytoin oral tablet,chewable 50 2 phenytoin sodium extended oral capsule 100, 2 200, 300 primidone oral tablet 250, 50 2 SABRIL ORAL TABLET 500 MG 5 NDS; QL (180 per 30 days) SPRITAM ORAL TABLET FOR SUSPENSION QL (90 per 30 days) 1,000 MG SPRITAM ORAL TABLET FOR SUSPENSION 250 MG QL (360 per 30 days) 25

SPRITAM ORAL TABLET FOR SUSPENSION QL (180 per 30 days) 500 MG SPRITAM ORAL TABLET FOR SUSPENSION QL (120 per 30 days) 750 MG tiagabine oral tablet 12, 16, 2, topiramate oral capsule, sprinkle 15, 25 2 topiramate oral capsule,sprinkle,er 2hr 100, 3 150, 200, 25, 50 topiramate oral tablet 100, 50 2 QL (120 per 30 days) topiramate oral tablet 200 2 QL (60 per 30 days) topiramate oral tablet 25 2 QL (90 per 30 days) valproate sodium intravenous solution 500 /5 ml (100 /ml) valproic acid (as sodium salt) oral solution 250 2 /5 ml valproic acid oral capsule 250 2 vigabatrin oral powder in packet 500 5 NDS vigabatrin oral tablet 500 5 NDS; QL (180 per 30 days) vigadrone oral powder in packet 500 5 NDS VIMPAT INTRAVENOUS SOLUTION 200 MG/20 ML VIMPAT ORAL SOLUTION 10 MG/ML QL (1395 per 30 days) VIMPAT ORAL TABLET 100 MG QL (90 per 30 days) VIMPAT ORAL TABLET 150 MG QL (60 per 30 days) VIMPAT ORAL TABLET 200 MG QL (120 per 30 days) VIMPAT ORAL TABLET 50 MG QL (210 per 30 days) zonisamide oral capsule 100, 25, 50 2 Antidementia Agents Antidementia Agents donepezil oral tablet 10, 5 1 QL (30 per 30 days) donepezil oral tablet 23 3 QL (30 per 30 days) donepezil oral tablet,disintegrating 10, 5 1 QL (30 per 30 days) galantamine oral capsule,ext rel. pellets 2 hr 16 QL (30 per 30 days), 2, 8 galantamine oral solution /ml QL (180 per 30 days) galantamine oral tablet 12,, 8 QL (60 per 30 days) memantine oral capsule,sprinkle,er 2hr 1, QL (30 per 30 days) 21, 28, 7 memantine oral solution 2 /ml 3 QL (300 per 30 days) memantine oral tablet 10 1 QL (60 per 30 days) memantine oral tablet 5 1 QL (90 per 30 days) 26

memantine oral tablets,dose pack 5-10 1 QL (98 per 30 days) NAMZARIC ORAL CAP,SPRINKLE,ER 2HR QL (28 per 28 days) DOSE PACK 7/1/21/28 MG-10 MG NAMZARIC ORAL CAPSULE,SPRINKLE,ER QL (30 per 30 days) 2HR 1-10 MG, 21-10 MG, 28-10 MG, 7-10 MG rivastigmine tartrate oral capsule 1.5, 3, QL (60 per 30 days).5, 6 rivastigmine transdermal patch 2 hour 13.3 QL (30 per 30 days) /2 hour,.6 /2 hr, 9.5 /2 hr Antidepressants Antidepressants amitriptyline oral tablet 10, 100, 150, 3 25, 50, 75 amitriptyline-chlordiazepoxide oral tablet 12.5-5 3, 25-10 amoxapine oral tablet 100, 150, 25, 50 bupropion hcl oral tablet 100 2 QL (120 per 30 days) bupropion hcl oral tablet 75 2 QL (180 per 30 days) bupropion hcl oral tablet extended release 2 hr 2 QL (90 per 30 days) 150 bupropion hcl oral tablet extended release 2 hr 2 QL (30 per 30 days) 300 bupropion hcl oral tablet sustained-release 12 hr 2 QL (90 per 30 days) 100, 150 bupropion hcl oral tablet sustained-release 12 hr 2 QL (60 per 30 days) 200 citalopram oral solution 10 /5 ml 3 citalopram oral tablet 10, 20 1 QL (5 per 30 days) citalopram oral tablet 0 1 QL (30 per 30 days) clomipramine oral capsule 25, 50, 75 desipramine oral tablet 10, 100, 150, 2 25, 50, 75 desvenlafaxine succinate oral tablet extended 2 release 2 hr 100, 25, 50 doxepin oral capsule 10, 100, 150, 25 3, 50, 75 doxepin oral concentrate 10 /ml 3 duloxetine oral capsule,delayed release(dr/ec) 20, 30, 60 2 QL (60 per 30 days) 27

duloxetine oral capsule,delayed release(dr/ec) 0 3 QL (60 per 30 days) EMSAM TRANSDERMAL PATCH 2 HOUR 5 NDS; QL (30 per 30 days) 12 MG/2 HR, 6 MG/2 HR, 9 MG/2 HR escitalopram oxalate oral solution 5 /5 ml QL (600 per 30 days) escitalopram oxalate oral tablet 10, 5 1 QL (5 per 30 days) escitalopram oxalate oral tablet 20 1 QL (90 per 30 days) FETZIMA ORAL CAPSULE,EXT REL 2HR QL (28 per 28 days) DOSE PACK 20 MG (2)- 0 MG (26) FETZIMA ORAL CAPSULE,EXTENDED QL (30 per 30 days) RELEASE 2 HR 120 MG, 0 MG, 80 MG FETZIMA ORAL CAPSULE,EXTENDED QL (150 per 30 days) RELEASE 2 HR 20 MG fluoxetine oral capsule 10 1 QL (150 per 30 days) fluoxetine oral capsule 20 1 QL (120 per 30 days) fluoxetine oral capsule 0 1 QL (60 per 30 days) fluoxetine oral solution 20 /5 ml ( /ml) 2 fluvoxamine oral capsule,extended release 2hr 100, 150 fluvoxamine oral tablet 100, 25, 50 3 QL (90 per 30 days) imipramine hcl oral tablet 10, 25, 50 3 imipramine pamoate oral capsule 100, 125, 150, 75 maprotiline oral tablet 25, 50, 75 MARPLAN ORAL TABLET 10 MG mirtazapine oral tablet 15, 30, 5, 7.5 2 QL (30 per 30 days) mirtazapine oral tablet,disintegrating 15, 30 QL (30 per 30 days), 5 nefazodone oral tablet 100, 150, 200, 250, 50 nortriptyline oral capsule 10, 25, 50, 1 75 nortriptyline oral solution 10 /5 ml paroxetine hcl oral tablet 10, 20 1 QL (90 per 30 days) paroxetine hcl oral tablet 30, 0 1 QL (60 per 30 days) PAXIL ORAL SUSPENSION 10 MG/5 ML perphenazine-amitriptyline oral tablet 2-10, 3 2-25, -10, -25, -50 phenelzine oral tablet 15 3 protriptyline oral tablet 10, 5 sertraline oral concentrate 20 /ml 3 QL (300 per 30 days) 28

sertraline oral tablet 100 1 QL (60 per 30 days) sertraline oral tablet 25 1 QL (20 per 30 days) sertraline oral tablet 50 1 QL (120 per 30 days) tranylcypromine oral tablet 10 trazodone oral tablet 100, 150, 50 1 trazodone oral tablet 300 2 trimipramine oral capsule 100, 25, 50 TRINTELLIX ORAL TABLET 10 MG QL (5 per 30 days) TRINTELLIX ORAL TABLET 20 MG QL (30 per 30 days) TRINTELLIX ORAL TABLET 5 MG QL (90 per 30 days) venlafaxine oral capsule,extended release 2hr 2 QL (60 per 30 days) 150 venlafaxine oral capsule,extended release 2hr 2 QL (90 per 30 days) 37.5, 75 venlafaxine oral tablet 100, 25, 37.5, 2 50, 75 VIIBRYD ORAL TABLET 10 MG, 20 MG, 0 QL (30 per 30 days) MG VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23), 10 MG (7)-20 MG (7)-0 MG (16) QL (30 per 30 days) Antidiabetic Agents Antidiabetic Agents, Miscellaneous acarbose oral tablet 100, 25, 50 2 ADLYXIN SUBCUTANEOUS PEN INJECTOR 10 MCG/0.2 ML- 20 MCG/0.2 ML, 20 MCG/0.2 ML PA; QL (6 per 28 days) alogliptin oral tablet 12.5, 25, 6.25 alogliptin-metformin oral tablet 12.5-1,000, 12.5-500 alogliptin-pioglitazone oral tablet 12.5-15, 12.5-30, 12.5-5, 25-15, 25-30, 25-5 AVANDIA ORAL TABLET 2 MG, MG QL (60 per 30 days) BYDUREON BCISE SUBCUTANEOUS PA; QL (3. per 28 days) AUTO-INJECTOR 2 MG/0.85 ML BYDUREON SUBCUTANEOUS PEN PA; QL ( per 28 days) INJECTOR 2 MG/0.65 ML BYDUREON SUBCUTANEOUS PA; QL ( per 28 days) SUSPENSION,EXTENDED REL RECON 2 MG BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2. ML PA; QL (2. per 30 days) 29

BYETTA SUBCUTANEOUS PEN INJECTOR 5 PA; QL (1.2 per 30 days) MCG/DOSE (250 MCG/ML) 1.2 ML CYCLOSET ORAL TABLET 0.8 MG QL (180 per 30 days) GLUCAGEN HYPOKIT INJECTION RECON 3 SOLN 1 MG GLUCAGON EMERGENCY KIT (HUMAN) 3 INJECTION RECON SOLN 1 MG GLYXAMBI ORAL TABLET 10-5 MG, 25-5 3 MG INVOKAMET ORAL TABLET 150-1,000 MG, 3 QL (60 per 30 days) 150-500 MG, 50-1,000 MG, 50-500 MG INVOKAMET XR ORAL TABLET, IR - ER, 3 QL (60 per 30 days) BIPHASIC 2HR 150-1,000 MG, 150-500 MG, 50-1,000 MG INVOKAMET XR ORAL TABLET, IR - ER, 3 QL (120 per 30 days) BIPHASIC 2HR 50-500 MG INVOKANA ORAL TABLET 100 MG, 300 MG 3 QL (30 per 30 days) JANUMET ORAL TABLET 50-1,000 MG, 50-3 QL (60 per 30 days) 500 MG JANUMET XR ORAL TABLET, ER 3 QL (30 per 30 days) MULTIPHASE 2 HR 100-1,000 MG JANUMET XR ORAL TABLET, ER 3 QL (60 per 30 days) MULTIPHASE 2 HR 50-1,000 MG, 50-500 MG JANUVIA ORAL TABLET 100 MG, 25 MG, 50 3 QL (30 per 30 days) MG JARDIANCE ORAL TABLET 10 MG, 25 MG 3 QL (30 per 30 days) JENTADUETO ORAL TABLET 2.5-1,000 MG, 3 QL (60 per 30 days) 2.5-500 MG, 2.5-850 MG JENTADUETO XR ORAL TABLET, IR - ER, 3 QL (60 per 30 days) BIPHASIC 2HR 2.5-1,000 MG JENTADUETO XR ORAL TABLET, IR - ER, 3 QL (30 per 30 days) BIPHASIC 2HR 5-1,000 MG KORLYM ORAL TABLET 300 MG 5 NDS; QL (120 per 30 days) metformin oral tablet 1,000, 500, 850 1 metformin oral tablet extended release 2 hr 500 1, 750 miglitol oral tablet 100, 25, 50 nateglinide oral tablet 120, 60 3 OZEMPIC SUBCUTANEOUS PEN INJECTOR 3 PA; QL (3 per 28 days) 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, 30, 5 1 QL (30 per 30 days) 30

pioglitazone-glimepiride oral tablet 30-2, 30- QL (30 per 30 days) pioglitazone-metformin oral tablet 15-500, QL (90 per 30 days) 15-850 QTERN ORAL TABLET 10-5 MG repaglinide oral tablet 0.5, 1, 2 3 SYMLINPEN 120 SUBCUTANEOUS PEN QL (10.8 per 30 days) INJECTOR 2,700 MCG/2.7 ML SYMLINPEN 60 SUBCUTANEOUS PEN QL (10.5 per 30 days) INJECTOR 1,500 MCG/1.5 ML SYNJARDY ORAL TABLET 12.5-1,000 MG, 3 QL (60 per 30 days) 12.5-500 MG, 5-1,000 MG, 5-500 MG SYNJARDY XR ORAL TABLET, IR - ER, 3 BIPHASIC 2HR 10-1,000 MG, 12.5-1,000 MG, 25-1,000 MG, 5-1,000 MG TANZEUM SUBCUTANEOUS PEN PA; QL ( per 28 days) INJECTOR 30 MG/0.5 ML, 50 MG/0.5 ML TRADJENTA ORAL TABLET 5 MG 3 QL (30 per 30 days) TRULICITY SUBCUTANEOUS PEN 3 PA; QL (2 per 28 days) INJECTOR 0.75 MG/0.5 ML, 1.5 MG/0.5 ML VICTOZA SUBCUTANEOUS PEN INJECTOR 3 PA; QL (9 per 30 days) 0.6 MG/0.1 ML (18 MG/3 ML) Insulins FIASP FLEXTOUCH U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) FIASP U-100 INSULIN SUBCUTANEOUS 3 SOLUTION 100 UNIT/ML LANTUS SOLOSTAR U-100 INSULIN 3 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) LANTUS U-100 INSULIN SUBCUTANEOUS 3 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) 3 31

NOVOLIN 70-30 FLEXPEN U-100 3 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30) NOVOLIN N NPH U-100 INSULIN 3 SUBCUTANEOUS SUSPENSION 100 UNIT/ML NOVOLIN R REGULAR U-100 INSULN 3 INJECTION SOLUTION 100 UNIT/ML NOVOLOG FLEXPEN U-100 INSULIN 3 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML NOVOLOG MIX 70-30 U-100 INSULN 3 SUBCUTANEOUS SOLUTION 100 UNIT/ML (70-30) NOVOLOG MIX 70-30FLEXPEN U-100 3 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30) NOVOLOG PENFILL U-100 INSULIN 3 SUBCUTANEOUS CARTRIDGE 100 UNIT/ML NOVOLOG U-100 INSULIN ASPART 3 SUBCUTANEOUS SOLUTION 100 UNIT/ML SOLIQUA 100/33 SUBCUTANEOUS INSULIN QL (18 per 30 days) PEN 100 UNIT-33 MCG/ML TOUJEO MAX U-300 SOLOSTAR 3 SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (3 ML) TOUJEO SOLOSTAR U-300 INSULIN 3 SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (1.5 ML) TRESIBA FLEXTOUCH U-100 QL (30 per 30 days) SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) TRESIBA FLEXTOUCH U-200 QL (27 per 30 days) SUBCUTANEOUS INSULIN PEN 200 UNIT/ML (3 ML) TRESIBA U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML XULTOPHY 100/3.6 SUBCUTANEOUS QL (15 per 30 days) INSULIN PEN 100 UNIT-3.6 MG /ML (3 ML) Sulfonylureas glimepiride oral tablet 1, 2, 1 glipizide oral tablet 10, 5 1 32

glipizide oral tablet extended release 2hr 10, 1 2.5, 5 glipizide-metformin oral tablet 2.5-250, 2.5-1 500, 5-500 Antifungals Antifungals ABELCET INTRAVENOUS SUSPENSION 5 5 HI; NDS MG/ML AMBISOME INTRAVENOUS SUSPENSION HI FOR RECONSTITUTION 50 MG amphotericin b injection recon soln 50 HI caspofungin intravenous recon soln 50, 70 5 HI; NDS ciclopirox topical cream 0.77 % 2 ciclopirox topical gel 0.77 % 2 ciclopirox topical shampoo 1 % 2 ciclopirox topical solution 8 % 3 ciclopirox topical suspension 0.77 % 2 clotrimazole mucous membrane troche 10 2 clotrimazole topical cream 1 % 2 clotrimazole topical solution 1 % 2 clotrimazole-betamethasone topical cream 1-0.05 2 % clotrimazole-betamethasone topical lotion 1-0.05 3 % econazole topical cream 1 % ERAXIS(WATER DILUENT) INTRAVENOUS HI RECON SOLN 100 MG, 50 MG fluconazole in nacl (iso-osm) intravenous HI piggyback 100 /50 ml, 200 /100 ml, 00 /200 ml fluconazole oral suspension for reconstitution 10 2 /ml, 0 /ml fluconazole oral tablet 100, 150, 200, 2 50 flucytosine oral capsule 250, 500 5 NDS griseofulvin microsize oral suspension 125 /5 ml griseofulvin microsize oral tablet 500 griseofulvin ultramicrosize oral tablet 125, 250 itraconazole oral capsule 100 PA; QL (120 per 30 days) itraconazole oral solution 10 /ml PA 33

ketoconazole oral tablet 200 2 ketoconazole topical cream 2 % 2 ketoconazole topical shampoo 2 % 2 miconazole-3 vaginal suppository 200 2 MYCAMINE INTRAVENOUS RECON SOLN HI 100 MG, 50 MG naftifine topical cream 1 %, 2 % NOXAFIL INTRAVENOUS SOLUTION 300 HI MG/16.7 ML NOXAFIL ORAL SUSPENSION 200 MG/5 ML 5 PA; NDS; QL (80 per 28 days) (0 MG/ML) NOXAFIL ORAL TABLET,DELAYED 5 PA; NDS; QL (93 per 30 days) RELEASE (DR/EC) 100 MG nyamyc topical powder 100,000 unit/gram 2 nystatin oral powder 150 million unit 2 nystatin oral suspension 100,000 unit/ml 2 nystatin oral tablet 500,000 unit 3 nystatin topical cream 100,000 unit/gram 2 nystatin topical ointment 100,000 unit/gram 2 nystatin topical powder 100,000 unit/gram 2 nystatin-triamcinolone topical cream 100,000-0.1 unit/g-% nystatin-triamcinolone topical ointment 100,000-0.1 unit/gram-% nystop topical powder 100,000 unit/gram 2 oxiconazole topical cream 1 % SPORANOX ORAL SOLUTION 10 MG/ML 5 PA; NDS terbinafine hcl oral tablet 250 2 QL (90 per 365 days) voriconazole intravenous solution 200 HI voriconazole oral suspension for reconstitution 5 PA; NDS; QL (00 per 30 days) 200 /5 ml (0 /ml) voriconazole oral tablet 200, 50 5 PA; NDS; QL (120 per 30 days) Antigout Agents Antigout Agents, Other allopurinol oral tablet 100, 300 1 colchicine oral capsule 0.6 3 colchicine oral tablet 0.6 3 probenecid oral tablet 500 3 probenecid-colchicine oral tablet 500-0.5 3 ULORIC ORAL TABLET 0 MG, 80 MG 3 QL (30 per 30 days) Antihistamines 3

Antihistamines cetirizine oral solution 1 /ml 2 QL (300 per 30 days) clemastine oral tablet 2.68 cyproheptadine oral syrup 2 /5 ml 3 cyproheptadine oral tablet 3 desloratadine oral tablet 5 1 QL (30 per 30 days) hydroxyzine hcl oral solution 10 /5 ml 3 hydroxyzine hcl oral tablet 10, 25, 50 3 levocetirizine oral tablet 5 1 QL (30 per 30 days) promethazine oral syrup 6.25 /5 ml 3 Anti-Infectives (Skin And Mucous Membrane) Anti-Infectives (Skin And Mucous Membrane) clindamycin phosphate vaginal cream 2 % metronidazole vaginal gel 0.75 % 2 terconazole vaginal cream 0. %, 0.8 % 2 terconazole vaginal suppository 80 2 Antimigraine Agents Antimigraine Agents AIMOVIG 70 MG/ML AUTOINJECTOR 70 PA NSO; QL (2 per 28 days) MG/ML AIMOVIG AUTOINJECTOR (2 PACK) PA NSO; QL (2 per 28 days) SUBCUTANEOUS AUTO-INJECTOR 70 MG/ML almotriptan malate oral tablet 12.5, 6.25 QL (12 per 30 days) dihydroergotamine injection solution 1 /ml 3 dihydroergotamine nasal spray,non-aerosol 0.5 3 /pump act. ( /ml) eletriptan oral tablet 20, 0 QL (12 per 30 days) ergotamine-caffeine oral tablet 1-100 frovatriptan oral tablet 2.5 QL (12 per 30 days) MIGERGOT RECTAL SUPPOSITORY 2-100 MG naratriptan oral tablet 1, 2.5 3 QL (18 per 30 days) rizatriptan oral tablet 10, 5 2 QL (18 per 30 days) rizatriptan oral tablet,disintegrating 10, 5 2 QL (18 per 30 days) sumatriptan nasal spray,non-aerosol 20 QL (12 per 30 days) /actuation sumatriptan nasal spray,non-aerosol 5 /actuation QL (6 per 30 days) 35

sumatriptan succinate oral tablet 100, 25, 2 QL (18 per 30 days) 50 sumatriptan succinate subcutaneous cartridge QL (8 per 30 days) /0.5 ml, 6 /0.5 ml sumatriptan succinate subcutaneous pen injector QL (8 per 30 days) /0.5 ml, 6 /0.5 ml sumatriptan succinate subcutaneous solution 6 QL (8 per 30 days) /0.5 ml sumatriptan succinate subcutaneous syringe 6 QL (8 per 30 days) /0.5 ml zolmitriptan oral tablet 2.5, 5 3 QL (12 per 30 days) zolmitriptan oral tablet,disintegrating 2.5, 5 3 QL (12 per 30 days) Antimycobacterials Antimycobacterials CAPASTAT INJECTION RECON SOLN 1 GRAM dapsone oral tablet 100, 25 3 ethambutol oral tablet 100, 00 isoniazid injection solution 100 /ml 1 isoniazid oral solution 50 /5 ml isoniazid oral tablet 100, 300 1 PASER ORAL GRANULES DR FOR SUSP IN PACKET GRAM PRIFTIN ORAL TABLET 150 MG pyrazinamide oral tablet 500 rifabutin oral capsule 150 rifampin intravenous recon soln 600 3 rifampin oral capsule 150, 300 3 RIFATER ORAL TABLET 50-120-300 MG SIRTURO ORAL TABLET 100 MG 5 NDS; QL (68 per 28 days) TRECATOR ORAL TABLET 250 MG Antinausea Agents Antinausea Agents AKYNZEO (NETUPITANT) ORAL CAPSULE 300-0.5 MG 3 PA BvD ANZEMET ORAL TABLET 100 MG, 50 MG PA BvD aprepitant oral capsule 125, 0, 80 2 PA BvD aprepitant oral capsule,dose pack 125 (1)- 80 2 PA BvD (2) CESAMET ORAL CAPSULE 1 MG 5 PA BvD; NDS 36

compro rectal suppository 25 2 dronabinol oral capsule 10, 2.5, 5 PA BvD; QL (120 per 30 days) granisetron hcl oral tablet 1 3 PA BvD; QL (28 per 28 days) meclizine oral tablet 12.5, 25 2 ondansetron hcl (pf) injection solution /2 ml 2 HI ondansetron hcl (pf) injection syringe /2 ml 2 HI ondansetron hcl intravenous solution 2 /ml 2 HI ondansetron hcl oral solution /5 ml PA BvD; QL (50 per 30 days) ondansetron hcl oral tablet 2 2 PA BvD; QL (30 per 30 days) ondansetron hcl oral tablet, 8 2 PA BvD; QL (90 per 30 days) ondansetron oral tablet,disintegrating, 8 2 PA BvD; QL (90 per 30 days) PALONOSETRON INTRAVENOUS HI SOLUTION 0.25 MG/2 ML palonosetron intravenous solution 0.25 /5 ml HI phenadoz rectal suppository 12.5, 25 prochlorperazine maleate oral tablet 10, 5 1 prochlorperazine rectal suppository 25 3 promethazine injection solution 25 /ml, 50 3 /ml promethazine oral tablet 12.5, 25, 50 3 promethazine rectal suppository 12.5, 25, 3 50 promethegan rectal suppository 12.5, 25, 3 50 scopolamine base transdermal patch 3 day 1 over 3 days 2 Antiparasite Agents Antiparasite Agents albendazole oral tablet 200 ALBENZA ORAL TABLET 200 MG 5 NDS ALINIA ORAL SUSPENSION FOR QL (150 per 30 days) RECONSTITUTION 100 MG/5 ML ALINIA ORAL TABLET 500 MG QL (0 per 30 days) atovaquone oral suspension 750 /5 ml 5 NDS atovaquone-proguanil oral tablet 250-100, 3 62.5-25 chloroquine phosphate oral tablet 250, 500 3 COARTEM ORAL TABLET 20-120 MG QL (2 per 30 days) DARAPRIM ORAL TABLET 25 MG 5 PA; NDS 37

EMVERM ORAL TABLET,CHEWABLE 100 MG hydroxychloroquine oral tablet 200 2 ivermectin oral tablet 3 3 KRINTAFEL ORAL TABLET 150 MG mefloquine oral tablet 250 3 NEBUPENT INHALATION RECON SOLN 300 MG PA BvD paromomycin oral capsule 250 PENTAM INJECTION RECON SOLN 300 MG HI praziquantel oral tablet 600 PRIMAQUINE ORAL TABLET 26.3 MG 3 quinine sulfate oral capsule 32 PA; QL (2 per 7 days) tinidazole oral tablet 250, 500 3 Antiparkinsonian Agents Antiparkinsonian Agents amantadine hcl oral capsule 100 3 amantadine hcl oral solution 50 /5 ml 3 amantadine hcl oral tablet 100 3 APOKYN SUBCUTANEOUS CARTRIDGE 10 5 NDS; QL (60 per 28 days) MG/ML benztropine oral tablet 0.5, 1, 2 3 bromocriptine oral capsule 5 3 bromocriptine oral tablet 2.5 3 cabergoline oral tablet 0.5 3 QL (16 per 28 days) carbidopa oral tablet 25 carbidopa-levodopa oral tablet 10-100, 25-1 100, 25-250 carbidopa-levodopa oral tablet extended release 2 25-100, 50-200 carbidopa-levodopa oral tablet,disintegrating 10-2 100, 25-100, 25-250 carbidopa-levodopa-entacapone oral tablet 12.5-50-200, 18.75-75-200, 25-100-200, 31.25-125-200, 37.5-150-200, 50-200-200 entacapone oral tablet 200 QL (300 per 30 days) NEUPRO TRANSDERMAL PATCH 2 HOUR 1 MG/2 HOUR, 2 MG/2 HOUR, 3 MG/2 HOUR, MG/2 HOUR, 6 MG/2 HOUR, 8 MG/2 HOUR QL (30 per 30 days) 38

pramipexole oral tablet 0.125, 0.25, 0.5 2, 0.75, 1, 1.5 pramipexole oral tablet extended release 2 hr 0.375, 0.75, 1.5, 2.25, 3, 3.75,.5 rasagiline oral tablet 0.5, 1 3 ropinirole oral tablet 0.25, 0.5, 1, 2 2, 3,, 5 ropinirole oral tablet extended release 2 hr 12 3, 2,, 6, 8 RYTARY ORAL CAPSULE, EXTENDED RELEASE 23.75-95 MG, 36.25-15 MG, 8.75-195 MG, 61.25-25 MG selegiline hcl oral capsule 5 3 selegiline hcl oral tablet 5 3 tolcapone oral tablet 100 trihexyphenidyl oral elixir 0. /ml 3 trihexyphenidyl oral tablet 2, 5 3 XADAGO ORAL TABLET 100 MG, 50 MG Antipsychotic Agents Antipsychotic Agents ABILIFY MAINTENA INTRAMUSCULAR 5 NDS; QL (1 per 28 days) SUSPENSION,EXTENDED REL RECON 300 MG ABILIFY MAINTENA INTRAMUSCULAR 5 NDS SUSPENSION,EXTENDED REL RECON 00 MG ABILIFY MAINTENA INTRAMUSCULAR 5 NDS; QL (1 per 28 days) SUSPENSION,EXTENDED REL SYRING 300 MG, 00 MG aripiprazole oral solution 1 /ml QL (900 per 30 days) aripiprazole oral tablet 10, 15, 2, 20 2 QL (30 per 30 days), 30, 5 aripiprazole oral tablet,disintegrating 10, 15 5 NDS; QL (60 per 30 days) ARISTADA INTRAMUSCULAR 5 NDS SUSPENSION,EXTENDED REL SYRING 1,06 MG/3.9 ML ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 1 MG/1.6 ML 5 NDS; QL (1.6 per 28 days) 39

ARISTADA INTRAMUSCULAR 5 NDS; QL (2. per 28 days) SUSPENSION,EXTENDED REL SYRING 662 MG/2. ML ARISTADA INTRAMUSCULAR 5 NDS; QL (3.2 per 28 days) SUSPENSION,EXTENDED REL SYRING 882 MG/3.2 ML chlorpromazine injection solution 25 /ml chlorpromazine oral tablet 10, 100, 200, 25, 50 clozapine oral tablet 100, 200, 25, 50 3 clozapine oral tablet,disintegrating 100, 12.5, 150, 200, 25 FANAPT ORAL TABLET 1 MG, 2 MG, MG QL (60 per 30 days) FANAPT ORAL TABLET 10 MG, 12 MG, 6 5 NDS; QL (60 per 30 days) MG, 8 MG FANAPT ORAL TABLETS,DOSE PACK QL (60 per 30 days) 1MG(2)-2MG(2)- MG(2)-6MG(2) fluphenazine decanoate injection solution 25 /ml fluphenazine hcl injection solution 2.5 /ml fluphenazine hcl oral concentrate 5 /ml 3 fluphenazine hcl oral elixir 2.5 /5 ml 3 fluphenazine hcl oral tablet 1, 10, 2.5, 2 5 GEODON INTRAMUSCULAR RECON SOLN 20 MG/ML (FINAL CONC.) haloperidol decanoate intramuscular solution 100 /ml, 100 /ml (1 ml), 50 /ml haloperidol lactate intramuscular syringe 5 2 /ml haloperidol lactate oral concentrate 2 /ml haloperidol oral tablet 0.5, 1, 10, 2 2, 20, 5 INVEGA SUSTENNA INTRAMUSCULAR 5 NDS; QL (0.75 per 28 days) SYRINGE 117 MG/0.75 ML INVEGA SUSTENNA INTRAMUSCULAR 5 NDS; QL (1 per 28 days) SYRINGE 156 MG/ML INVEGA SUSTENNA INTRAMUSCULAR 5 NDS; QL (1.5 per 28 days) SYRINGE 23 MG/1.5 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 39 MG/0.25 ML QL (0.25 per 28 days) 0

INVEGA SUSTENNA INTRAMUSCULAR 5 NDS; QL (0.5 per 28 days) SYRINGE 78 MG/0.5 ML INVEGA TRINZA INTRAMUSCULAR 5 NDS; QL (0.87 per 28 days) SYRINGE 273 MG/0.875 ML INVEGA TRINZA INTRAMUSCULAR 5 NDS; QL (1.31 per 28 days) SYRINGE 10 MG/1.315 ML INVEGA TRINZA INTRAMUSCULAR 5 NDS; QL (1.75 per 28 days) SYRINGE 56 MG/1.75 ML INVEGA TRINZA INTRAMUSCULAR 5 NDS; QL (2.62 per 28 days) SYRINGE 819 MG/2.625 ML LATUDA ORAL TABLET 120 MG, 20 MG, 0 5 NDS; QL (30 per 30 days) MG, 60 MG LATUDA ORAL TABLET 80 MG 5 NDS; QL (60 per 30 days) loxapine succinate oral capsule 10, 25, 5 2, 50 molindone oral tablet 10 QL (20 per 30 days) molindone oral tablet 25 QL (270 per 30 days) molindone oral tablet 5 QL (360 per 30 days) NUPLAZID ORAL CAPSULE 3 MG 5 NDS; QL (30 per 30 days) NUPLAZID ORAL TABLET 10 MG 5 NDS NUPLAZID ORAL TABLET 17 MG 5 NDS; QL (60 per 30 days) olanzapine intramuscular recon soln 10 olanzapine oral tablet 10, 2.5, 20, 5 2 QL (30 per 30 days), 7.5 olanzapine oral tablet 15 2 QL (60 per 30 days) olanzapine oral tablet,disintegrating 10, 15 QL (30 per 30 days), 5 olanzapine oral tablet,disintegrating 20 QL (60 per 30 days) paliperidone oral tablet extended release 2hr 5 NDS; QL (120 per 30 days) 1.5, 3 paliperidone oral tablet extended release 2hr 6 5 NDS; QL (60 per 30 days) paliperidone oral tablet extended release 2hr 9 5 NDS; QL (30 per 30 days) perphenazine oral tablet 16, 2,, 8 3 pimozide oral tablet 1, 2 quetiapine oral tablet 100, 200, 25, 2 300, 00, 50 quetiapine oral tablet extended release 2 hr 150 2 QL (90 per 30 days) quetiapine oral tablet extended release 2 hr 200 2 QL (30 per 30 days) 1

quetiapine oral tablet extended release 2 hr 300 2 QL (60 per 30 days), 00 quetiapine oral tablet extended release 2 hr 50 2 QL (120 per 30 days) REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 5 NDS; QL (30 per 30 days) MG, 2 MG, 3 MG, MG RISPERDAL CONSTA INTRAMUSCULAR QL (2 per 28 days) SYRINGE 12.5 MG/2 ML, 25 MG/2 ML, 37.5 MG/2 ML RISPERDAL CONSTA INTRAMUSCULAR 5 NDS; QL (2 per 28 days) SYRINGE 50 MG/2 ML risperidone oral solution 1 /ml 2 QL (20 per 30 days) risperidone oral tablet 0.25, 1, 2, 3 1 QL (60 per 30 days), risperidone oral tablet 0.5 1 QL (120 per 30 days) risperidone oral tablet,disintegrating 0.25, 1 QL (60 per 30 days), 2, 3, risperidone oral tablet,disintegrating 0.5 QL (120 per 30 days) SAPHRIS SUBLINGUAL TABLET 10 MG, 5 5 NDS; QL (60 per 30 days) MG SAPHRIS SUBLINGUAL TABLET 2.5 MG 5 NDS; QL (180 per 30 days) thioridazine oral tablet 10, 100, 25, 50 3 thiothixene oral capsule 1, 10, 2, 5 trifluoperazine oral tablet 1, 10, 2, 5 3 VERSACLOZ ORAL SUSPENSION 50 MG/ML QL (50 per 30 days) VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 5 NDS; QL (30 per 30 days).5 MG, 6 MG VRAYLAR ORAL CAPSULE,DOSE PACK 1.5 MG (1)- 3 MG (6) ziprasidone hcl oral capsule 20, 0, 60 2 QL (60 per 30 days), 80 ZYPREXA RELPREVV INTRAMUSCULAR QL (2 per 28 days) SUSPENSION FOR RECONSTITUTION 210 MG, 300 MG ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 05 MG QL (1 per 28 days) Antivirals (Systemic) Antiretrovirals abacavir oral solution 20 /ml QL (960 per 30 days) 2

abacavir oral tablet 300 QL (60 per 30 days) abacavir-lamivudine oral tablet 600-300 5 NDS; QL (30 per 30 days) abacavir-lamivudine-zidovudine oral tablet 300-5 NDS; QL (60 per 30 days) 150-300 APTIVUS ORAL CAPSULE 250 MG 5 NDS; QL (120 per 30 days) APTIVUS ORAL SOLUTION 100 MG/ML 5 NDS; QL (285 per 28 days) atazanavir oral capsule 150, 200 5 NDS; QL (60 per 30 days) atazanavir oral capsule 300 5 NDS; QL (30 per 30 days) ATRIPLA ORAL TABLET 600-200-300 MG 5 NDS; QL (30 per 30 days) BIKTARVY ORAL TABLET 50-200-25 MG 5 NDS; QL (30 per 30 days) CIMDUO ORAL TABLET 300-300 MG 5 NDS; QL (30 per 30 days) COMPLERA ORAL TABLET 200-25-300 MG 5 NDS; QL (30 per 30 days) CRIXIVAN ORAL CAPSULE 200 MG QL (360 per 30 days) CRIXIVAN ORAL CAPSULE 00 MG QL (180 per 30 days) DELSTRIGO ORAL TABLET 100-300-300 MG 5 NDS; QL (30 per 30 days) DESCOVY ORAL TABLET 200-25 MG 5 NDS; QL (30 per 30 days) didanosine oral capsule,delayed release(dr/ec) QL (90 per 30 days) 125 didanosine oral capsule,delayed release(dr/ec) QL (60 per 30 days) 200 didanosine oral capsule,delayed release(dr/ec) QL (30 per 30 days) 250, 00 EDURANT ORAL TABLET 25 MG 5 NDS; QL (30 per 30 days) efavirenz oral capsule 200 3 QL (120 per 30 days) efavirenz oral capsule 50 3 QL (360 per 30 days) efavirenz oral tablet 600 3 QL (30 per 30 days) EMTRIVA ORAL CAPSULE 200 MG QL (30 per 30 days) EMTRIVA ORAL SOLUTION 10 MG/ML QL (850 per 30 days) EPIVIR HBV ORAL SOLUTION 25 MG/5 ML (5 MG/ML) EPZICOM ORAL TABLET 600-300 MG 3 QL (30 per 30 days) EVOTAZ ORAL TABLET 300-150 MG 5 NDS; QL (30 per 30 days) fosamprenavir oral tablet 700 QL (120 per 30 days) FUZEON SUBCUTANEOUS RECON SOLN 90 5 NDS; QL (60 per 30 days) MG GENVOYA ORAL TABLET 150-150-200-10 5 NDS; QL (30 per 30 days) MG INTELENCE ORAL TABLET 100 MG 5 NDS; QL (120 per 30 days) INTELENCE ORAL TABLET 200 MG 5 NDS; QL (60 per 30 days) INTELENCE ORAL TABLET 25 MG QL (120 per 30 days) INVIRASE ORAL CAPSULE 200 MG 5 NDS; QL (300 per 30 days) 3

INVIRASE ORAL TABLET 500 MG 5 NDS; QL (120 per 30 days) ISENTRESS HD ORAL TABLET 600 MG 3 QL (60 per 30 days) ISENTRESS ORAL POWDER IN PACKET 100 3 QL (300 per 30 days) MG ISENTRESS ORAL TABLET 00 MG 3 QL (120 per 30 days) ISENTRESS ORAL TABLET,CHEWABLE 100 3 QL (180 per 30 days) MG ISENTRESS ORAL TABLET,CHEWABLE 25 3 QL (720 per 30 days) MG JULUCA ORAL TABLET 50-25 MG 5 NDS; QL (30 per 30 days) KALETRA ORAL TABLET 100-25 MG QL (300 per 30 days) KALETRA ORAL TABLET 200-50 MG 5 NDS; QL (150 per 30 days) lamivudine oral solution 10 /ml QL (960 per 30 days) lamivudine oral tablet 100, 300 QL (30 per 30 days) lamivudine oral tablet 150 QL (60 per 30 days) lamivudine-zidovudine oral tablet 150-300 QL (60 per 30 days) LEXIVA ORAL SUSPENSION 50 MG/ML QL (1800 per 30 days) lopinavir-ritonavir oral solution 00-100 /5 ml QL (80 per 30 days) nevirapine oral suspension 50 /5 ml QL (1200 per 30 days) nevirapine oral tablet 200 2 QL (60 per 30 days) nevirapine oral tablet extended release 2 hr 100 QL (120 per 30 days) nevirapine oral tablet extended release 2 hr 00 QL (30 per 30 days) NORVIR ORAL CAPSULE 100 MG QL (360 per 30 days) NORVIR ORAL POWDER IN PACKET 100 QL (360 per 30 days) MG NORVIR ORAL SOLUTION 80 MG/ML QL (80 per 30 days) ODEFSEY ORAL TABLET 200-25-25 MG 5 NDS; QL (30 per 30 days) PIFELTRO ORAL TABLET 100 MG 5 NDS; QL (30 per 30 days) PREZCOBIX ORAL TABLET 800-150 MG-MG 5 NDS; QL (30 per 30 days) PREZISTA ORAL SUSPENSION 100 MG/ML 5 NDS; QL (360 per 30 days) PREZISTA ORAL TABLET 150 MG 5 NDS; QL (20 per 30 days) PREZISTA ORAL TABLET 600 MG 5 NDS; QL (60 per 30 days) PREZISTA ORAL TABLET 75 MG 5 NDS; QL (80 per 30 days) PREZISTA ORAL TABLET 800 MG 5 NDS; QL (30 per 30 days) RESCRIPTOR ORAL TABLET 200 MG QL (180 per 30 days) RESCRIPTOR ORAL TABLET, DISPERSIBLE QL (360 per 30 days) 100 MG RETROVIR INTRAVENOUS SOLUTION 10 MG/ML

REYATAZ ORAL POWDER IN PACKET 50 5 NDS; QL (20 per 30 days) MG ritonavir oral tablet 100 3 QL (360 per 30 days) SELZENTRY ORAL SOLUTION 20 MG/ML QL (180 per 30 days) SELZENTRY ORAL TABLET 150 MG 5 NDS; QL (20 per 30 days) SELZENTRY ORAL TABLET 25 MG QL (120 per 30 days) SELZENTRY ORAL TABLET 300 MG 5 NDS; QL (120 per 30 days) SELZENTRY ORAL TABLET 75 MG 5 NDS; QL (60 per 30 days) stavudine oral capsule 15, 20 3 QL (120 per 30 days) stavudine oral capsule 30, 0 3 QL (60 per 30 days) STRIBILD ORAL TABLET 150-150-200-300 5 NDS; QL (30 per 30 days) MG SYMFI LO ORAL TABLET 00-300-300 MG 5 NDS; QL (30 per 30 days) SYMFI ORAL TABLET 600-300-300 MG 5 NDS; QL (30 per 30 days) SYMTUZA ORAL TABLET 800-150-200-10 5 NDS; QL (30 per 30 days) MG tenofovir disoproxil fumarate oral tablet 300 QL (30 per 30 days) TIVICAY ORAL TABLET 10 MG QL (60 per 30 days) TIVICAY ORAL TABLET 25 MG, 50 MG 5 NDS; QL (60 per 30 days) TRIUMEQ ORAL TABLET 600-50-300 MG 5 NDS; QL (30 per 30 days) TRUVADA ORAL TABLET 100-150 MG, 133-5 NDS; QL (30 per 30 days) 200 MG, 167-250 MG, 200-300 MG VEMLIDY ORAL TABLET 25 MG 5 NDS VIDEX 2 GM PEDIATRIC SOLN 10 MG/ML QL (1200 per 30 days) (FINAL) VIDEX GRAM PEDIATRIC ORAL RECON QL (1200 per 30 days) SOLN 10 MG/ML (FINAL) VIDEX EC ORAL CAPSULE,DELAYED QL (90 per 30 days) RELEASE(DR/EC) 125 MG VIRACEPT ORAL TABLET 250 MG 5 NDS; QL (300 per 30 days) VIRACEPT ORAL TABLET 625 MG 5 NDS; QL (120 per 30 days) VIRAMUNE ORAL SUSPENSION 50 MG/5 ML VIREAD ORAL POWDER 0 MG/SCOOP (0 5 NDS; QL (20 per 30 days) MG/GRAM) VIREAD ORAL TABLET 150 MG, 200 MG, 5 NDS; QL (30 per 30 days) 250 MG ZERIT ORAL RECON SOLN 1 MG/ML QL (200 per 30 days) zidovudine oral capsule 100 2 QL (180 per 30 days) zidovudine oral syrup 10 /ml 2 QL (1680 per 28 days) zidovudine oral tablet 300 2 QL (60 per 30 days) Antivirals, Miscellaneous 5

foscarnet intravenous solution 2 /ml HI oseltamivir oral capsule 30, 5, 75 2 oseltamivir oral suspension for reconstitution 6 2 /ml RELENZA DISKHALER INHALATION 3 QL (60 per 180 days) BLISTER WITH DEVICE 5 MG/ACTUATION rimantadine oral tablet 100 XOFLUZA ORAL TABLET 20 MG, 0 MG 3 QL ( per 180 days) Hcv Antivirals EPCLUSA ORAL TABLET 00-100 MG 5 PA; NDS; QL (30 per 30 days) HARVONI ORAL TABLET 90-00 MG 5 PA; NDS; QL (28 per 28 days) MAVYRET ORAL TABLET 100-0 MG 5 PA; NDS; QL (8 per 28 days) VOSEVI ORAL TABLET 00-100-100 MG 5 PA; NDS; QL (30 per 30 days) Interferons INTRON A INJECTION RECON SOLN 10 5 PA NSO; NDS MILLION UNIT (1 ML), 18 MILLION UNIT (1 ML), 50 MILLION UNIT (1 ML) INTRON A INJECTION SOLUTION 10 5 PA NSO; NDS MILLION UNIT/ML, 6 MILLION UNIT/ML PEGASYS PROCLICK SUBCUTANEOUS PEN 5 NDS; QL (2 per 28 days) INJECTOR 135 MCG/0.5 ML, 180 MCG/0.5 ML PEGINTRON REDIPEN SUBCUTANEOUS 5 PA NSO; NDS; QL ( per 28 days) PEN INJECTOR KIT 150 MCG/0.5 ML, 50 MCG/0.5 ML, 80 MCG/0.5 ML PEGINTRON SUBCUTANEOUS KIT 120 5 PA NSO; NDS; QL ( per 28 days) MCG/0.5 ML, 150 MCG/0.5 ML, 50 MCG/0.5 ML, 80 MCG/0.5 ML SYLATRON SUBCUTANEOUS KIT 200 MCG, 5 PA NSO; NDS; QL ( per 28 days) 300 MCG, 600 MCG Nucleosides And Nucleotides acyclovir oral capsule 200 2 acyclovir oral suspension 200 /5 ml acyclovir oral tablet 00, 800 2 acyclovir sodium intravenous recon soln 500 HI acyclovir sodium intravenous solution 50 /ml HI adefovir oral tablet 10 5 NDS BARACLUDE ORAL SOLUTION 0.05 MG/ML 5 NDS; QL (630 per 30 days) entecavir oral tablet 0.5, 1 2 QL (30 per 30 days) famciclovir oral tablet 125, 250, 500 2 QL (90 per 30 days) ganciclovir sodium intravenous recon soln 500 HI 6

ganciclovir sodium intravenous solution 50 /ml HI ribasphere oral capsule 200 3 ribasphere oral tablet 200 3 ribavirin oral capsule 200 3 QL (168 per 28 days) ribavirin oral tablet 200 3 QL (168 per 28 days) valacyclovir oral tablet 1 gram, 500 2 QL (120 per 30 days) valganciclovir oral recon soln 50 /ml 5 NDS valganciclovir oral tablet 50 5 NDS Blood Products/Modifiers/Volume Expanders Anticoagulants COUMADIN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, MG, 5 MG, 6 MG, 7.5 MG ELIQUIS ORAL TABLET 2.5 MG 3 QL (60 per 30 days) ELIQUIS ORAL TABLET 5 MG 3 QL (7 per 30 days) ELIQUIS ORAL TABLETS,DOSE PACK 5 MG 3 QL (7 per 30 days) (7 TABS) enoxaparin subcutaneous solution 300 /3 ml QL (8 per 28 days) enoxaparin subcutaneous syringe 100 /ml, 150 QL (56 per 28 days) /ml enoxaparin subcutaneous syringe 120 /0.8 ml, QL (.8 per 28 days) 80 /0.8 ml enoxaparin subcutaneous syringe 30 /0.3 ml, QL (33.6 per 28 days) 60 /0.6 ml enoxaparin subcutaneous syringe 0 /0. ml QL (22. per 28 days) fondaparinux subcutaneous syringe 10 /0.8 ml QL (2 per 30 days) fondaparinux subcutaneous syringe 2.5 /0.5 ml QL (15 per 30 days) fondaparinux subcutaneous syringe 5 /0. ml QL (12 per 30 days) fondaparinux subcutaneous syringe 7.5 /0.6 ml QL (18 per 30 days) heparin (porcine) in 5 % dex intravenous parenteral solution 20,000 unit/500 ml (0 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) 3 HI 3 HI 3 HI 7

heparin (porcine) injection solution 1,000 3 HI unit/ml, 10,000 unit/ml, 20,000 unit/ml, 5,000 unit/ml heparin (porcine) injection syringe 5,000 unit/ml 3 HI HEPARIN(PORCINE) IN 0.5% NACL 3 HI INTRAVENOUS PARENTERAL SOLUTION 12,500 UNIT/250 ML heparin, porcine (pf) injection solution 1,000 3 HI unit/ml, 5,000 unit/0.5 ml heparin, porcine (pf) injection syringe 5,000 3 HI unit/0.5 ml jantoven oral tablet 1, 10, 2, 2.5, 3 1,, 5, 6, 7.5 warfarin oral tablet 1, 10, 2, 2.5, 3 1,, 5, 6, 7.5 XARELTO ORAL TABLET 10 MG, 20 MG 3 QL (30 per 30 days) XARELTO ORAL TABLET 15 MG 3 QL (2 per 21 days) XARELTO ORAL TABLET 2.5 MG 3 QL (60 per 30 days) XARELTO ORAL TABLETS,DOSE PACK 15 3 QL (51 per 30 days) MG (2)- 20 MG (9) Blood Formation Modifiers ARANESP (IN POLYSORBATE) INJECTION 5 PA BvD; NDS SOLUTION 100 MCG/ML, 150 MCG/0.75 ML, 200 MCG/ML, 300 MCG/ML, 60 MCG/ML ARANESP (IN POLYSORBATE) INJECTION PA BvD SOLUTION 25 MCG/ML, 0 MCG/ML ARANESP (IN POLYSORBATE) INJECTION PA BvD SYRINGE 10 MCG/0. ML, 25 MCG/0.2 ML, 0 MCG/0. ML ARANESP (IN POLYSORBATE) INJECTION 5 PA BvD; NDS SYRINGE 100 MCG/0.5 ML, 150 MCG/0.3 ML, 200 MCG/0. ML, 300 MCG/0.6 ML, 500 MCG/ML, 60 MCG/0.3 ML BERINERT INTRAVENOUS KIT 500 UNIT 5 HI; NDS (10 ML) CINRYZE INTRAVENOUS RECON SOLN 500 5 HI; NDS UNIT (5 ML) FULPHILA SUBCUTANEOUS SYRINGE 6 5 PA; NDS; QL (1.2 per 28 days) MG/0.6 ML GRANIX SUBCUTANEOUS SYRINGE 300 5 PA; NDS MCG/0.5 ML, 80 MCG/0.8 ML LEUKINE INJECTION RECON SOLN 250 MCG 5 PA; NDS 8

MOZOBIL SUBCUTANEOUS SOLUTION 2 5 NDS; QL (9.6 per 30 days) MG/1.2 ML (20 MG/ML) NEULASTA SUBCUTANEOUS SYRINGE 6 5 PA; NDS; QL (1.2 per 28 days) MG/0.6ML NEUPOGEN INJECTION SOLUTION 300 5 PA; NDS MCG/ML, 80 MCG/1.6 ML NEUPOGEN INJECTION SYRINGE 300 5 PA; NDS MCG/0.5 ML, 80 MCG/0.8 ML NIVESTYM SUBCUTANEOUS SYRINGE 300 5 PA; NDS; QL (7 per 30 days) MCG/0.5 ML NIVESTYM SUBCUTANEOUS SYRINGE 80 5 PA; NDS; QL (11.2 per 30 days) MCG/0.8 ML PROCRIT INJECTION SOLUTION 10,000 PA BvD; QL (12 per 28 days) UNIT/ML, 2,000 UNIT/ML, 3,000 UNIT/ML,,000 UNIT/ML PROCRIT INJECTION SOLUTION 20,000 5 PA BvD; NDS; QL (12 per 28 days) UNIT/2 ML, 0,000 UNIT/ML PROCRIT INJECTION SOLUTION 20,000 5 PA BvD; NDS; QL (2 per 28 days) UNIT/ML PROMACTA ORAL POWDER IN PACKET 5 PA; NDS; QL (180 per 30 days) 12.5 MG PROMACTA ORAL TABLET 12.5 MG, 25 MG 5 PA; NDS; QL (30 per 30 days) PROMACTA ORAL TABLET 50 MG, 75 MG 5 PA; NDS; QL (60 per 30 days) RETACRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 3,000 UNIT/ML,,000 UNIT/ML, 0,000 UNIT/ML RUCONEST INTRAVENOUS RECON SOLN 5 HI; NDS 2,100 UNIT UDENYCA SUBCUTANEOUS SYRINGE 6 5 PA; NDS; QL (1.2 per 28 days) MG/0.6 ML ZARXIO INJECTION SYRINGE 300 MCG/0.5 5 PA; NDS; QL (7 per 30 days) ML ZARXIO INJECTION SYRINGE 80 MCG/0.8 5 PA; NDS; QL (11.2 per 30 days) ML Hematologic Agents, Miscellaneous aminocaproic acid intravenous solution 250 HI /ml anagrelide oral capsule 0.5, 1 3 tranexamic acid intravenous solution 1,000 /10 ml (100 /ml) tranexamic acid oral tablet 650 3 QL (30 per 5 days) Platelet-Aggregation Inhibitors 9

aspirin-dipyridamole oral capsule, er multiphase 12 hr 25-200 BRILINTA ORAL TABLET 60 MG, 90 MG 3 QL (60 per 30 days) cilostazol oral tablet 100, 50 2 clopidogrel oral tablet 300 2 clopidogrel oral tablet 75 1 QL (37 per 30 days) dipyridamole oral tablet 25, 50, 75 2 pentoxifylline oral tablet extended release 00 2 prasugrel oral tablet 10, 5 2 ZONTIVITY ORAL TABLET 2.08 MG Caloric Agents Caloric Agents AMINOSYN 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % AMINOSYN 7 % WITH ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN 8.5 % INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN 8.5 %-ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN II 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % AMINOSYN II 15 % INTRAVENOUS PARENTERAL SOLUTION 15 % AMINOSYN II 7 % INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN II 8.5 % INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN II 8.5 %-ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN M 3.5 % INTRAVENOUS PARENTERAL SOLUTION 3.5 % AMINOSYN-HBC 7% INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN-PF 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % AMINOSYN-PF 7 % (SULFITE-FREE) INTRAVENOUS PARENTERAL SOLUTION 7 % 50 3 HI PA BvD; HI PA BvD; HI PA BvD; HI PA BvD; HI PA BvD; HI PA BvD; HI PA BvD; HI PA BvD; HI HI PA BvD; HI PA BvD; HI PA BvD; HI

AMINOSYN-RF 5.2 % INTRAVENOUS PARENTERAL SOLUTION 5.2 % 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.25%/D10W SULF FREE INTRAVENOUS PARENTERAL SOLUTION.25 % CLINIMIX.25%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION.25 % CLINIMIX.25%-D20W SULF-FREE INTRAVENOUS PARENTERAL SOLUTION.25 % CLINIMIX.25%-D25W SULF-FREE INTRAVENOUS PARENTERAL SOLUTION.25 % CLINIMIX 5%-D20W(SULFITE-FREE) INTRAVENOUS PARENTERAL SOLUTION 5 % 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.25%/D10W SUL FREE INTRAVENOUS PARENTERAL SOLUTION.25 % CLINIMIX E.25%/D25W SUL FREE INTRAVENOUS PARENTERAL SOLUTION.25 % CLINIMIX E.25%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION.25 % PA BvD; HI PA BvD; HI PA BvD; HI PA BvD; HI PA BvD; HI PA BvD; HI PA BvD; HI PA BvD; HI PA BvD; HI PA BvD; HI PA BvD; HI PA BvD; HI PA BvD; HI PA BvD; HI 51

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 % CLINISOL SF 15 % INTRAVENOUS PARENTERAL SOLUTION 15 % dextrose 10 % in water (d10w) intravenous parenteral solution 10 % dextrose 20 % in water (d20w) intravenous parenteral solution 20 % dextrose 25 % in water (d25w) intravenous syringe dextrose 30 % in water (d30w) intravenous parenteral solution dextrose 0 % in water (d0w) intravenous parenteral solution 0 % dextrose 5 % in ringer's intravenous parenteral solution 5 % dextrose 5 % in water (d5w) intravenous parenteral solution dextrose 5 % in water (d5w) intravenous piggyback 5 % dextrose 50 % in water (d50w) intravenous parenteral solution dextrose 50 % in water (d50w) intravenous syringe dextrose 70 % in water (d70w) intravenous parenteral solution FREAMINE HBC 6.9 % INTRAVENOUS PARENTERAL SOLUTION 6.9 % FREAMINE III 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % HEPATAMINE 8% INTRAVENOUS PARENTERAL SOLUTION 8 % INTRALIPID INTRAVENOUS EMULSION 20 %, 30 % KABIVEN INTRAVENOUS EMULSION 3.31-9.8-3.9 % PA BvD; HI PA BvD; HI PA BvD; HI HI 2 HI 2 HI 2 HI 2 HI 2 HI 2 HI 2 HI 2 HI 2 HI 2 HI 2 HI PA BvD; HI HI PA BvD; HI PA BvD; HI HI 52

NEPHRAMINE 5. % INTRAVENOUS PARENTERAL SOLUTION 5. % NUTRILIPID INTRAVENOUS EMULSION 20 % PERIKABIVEN INTRAVENOUS EMULSION 2.36-6.8-3.5 % PLENAMINE INTRAVENOUS PARENTERAL SOLUTION 15 % PREMASOL 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % PREMASOL 6 % INTRAVENOUS PARENTERAL SOLUTION 6 % PROSOL 20 % INTRAVENOUS PARENTERAL SOLUTION TRAVASOL 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % TROPHAMINE 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % TROPHAMINE 6% INTRAVENOUS PARENTERAL SOLUTION 6 % Cardiovascular Agents Alpha-Adrenergic Agents PA BvD; HI PA BvD; HI HI PA BvD; HI PA BvD; HI PA BvD; HI PA BvD; HI PA BvD; HI PA BvD; HI PA BvD; HI clonidine hcl oral tablet 0.1, 0.2, 0.3 2 clonidine transdermal patch weekly 0.1 /2 hr, QL ( per 28 days) 0.2 /2 hr, 0.3 /2 hr clorpres oral tablet 0.1-15, 0.2-15, 0.3-15 doxazosin oral tablet 1, 2,, 8 2 guanfacine oral tablet 1, 2 2 methyldopa oral tablet 250, 500 3 methyldopa-hydrochlorothiazide oral tablet 250-3 15, 250-25 midodrine oral tablet 10, 2.5, 5 3 NORTHERA ORAL CAPSULE 100 MG, 200 5 NDS; QL (90 per 30 days) MG NORTHERA ORAL CAPSULE 300 MG 5 NDS; QL (180 per 30 days) phenoxybenzamine oral capsule 10 5 NDS prazosin oral capsule 1, 2, 5 2 Angiotensin Ii Receptor Antagonists candesartan oral tablet 16,, 8 3 QL (60 per 30 days) candesartan oral tablet 32 3 QL (30 per 30 days) 53

candesartan-hydrochlorothiazid oral tablet 16-3 QL (30 per 30 days) 12.5, 32-12.5, 32-25 ENTRESTO ORAL TABLET 2-26 MG, 9-51 3 QL (60 per 30 days) MG, 97-103 MG eprosartan oral tablet 600 2 irbesartan oral tablet 150, 75 1 QL (60 per 30 days) irbesartan oral tablet 300 1 QL (30 per 30 days) irbesartan-hydrochlorothiazide oral tablet 150-1 QL (30 per 30 days) 12.5, 300-12.5 losartan oral tablet 100, 25, 50 1 QL (60 per 30 days) losartan-hydrochlorothiazide oral tablet 100-12.5 1 QL (60 per 30 days), 100-25, 50-12.5 olmesartan oral tablet 20, 0, 5 2 QL (30 per 30 days) olmesartan-amlodipin-hcthiazid oral tablet 20-5- 2 QL (30 per 30 days) 12.5, 0-10-12.5, 0-10-25, 0-5-12.5, 0-5-25 olmesartan-hydrochlorothiazide oral tablet 20-2 QL (30 per 30 days) 12.5, 0-12.5, 0-25 telmisartan oral tablet 20, 0 2 QL (30 per 30 days) telmisartan oral tablet 80 2 QL (60 per 30 days) telmisartan-hydrochlorothiazid oral tablet 0- QL (30 per 30 days) 12.5, 80-25 telmisartan-hydrochlorothiazid oral tablet 80- QL (60 per 30 days) 12.5 valsartan oral tablet 160, 320, 0, 80 1 QL (60 per 30 days) valsartan-hydrochlorothiazide oral tablet 160-1 QL (30 per 30 days) 12.5, 160-25, 320-12.5, 320-25, 80-12.5 Angiotensin-Converting Enzyme Inhibitors benazepril oral tablet 10, 20, 0, 5 1 benazepril-hydrochlorothiazide oral tablet 10-2 12.5, 20-12.5, 20-25, 5-6.25 captopril oral tablet 100, 12.5, 25, 50 3 captopril-hydrochlorothiazide oral tablet 25-15 3, 25-25, 50-15, 50-25 enalapril maleate oral tablet 10, 2.5, 20 1, 5 enalapril-hydrochlorothiazide oral tablet 10-25 1, 5-12.5 fosinopril oral tablet 10, 20, 0 1 5

fosinopril-hydrochlorothiazide oral tablet 10-2 12.5, 20-12.5 lisinopril oral tablet 10, 2.5, 20, 30 1, 0, 5 lisinopril-hydrochlorothiazide oral tablet 10-12.5 1, 20-12.5, 20-25 moexipril oral tablet 15, 7.5 2 moexipril-hydrochlorothiazide oral tablet 15-12.5 2, 15-25, 7.5-12.5 perindopril erbumine oral tablet 2,, 8 2 quinapril oral tablet 10, 20, 0, 5 1 quinapril-hydrochlorothiazide oral tablet 10-12.5 2, 20-12.5, 20-25 ramipril oral capsule 1.25, 10, 2.5, 5 1 trandolapril oral tablet 1, 2, 1 Antiarrhythmic Agents amiodarone oral tablet 100, 00 amiodarone oral tablet 200 1 disopyramide phosphate oral capsule 100, 3 150 dofetilide oral capsule 125 mcg 2 QL (20 per 30 days) dofetilide oral capsule 250 mcg 2 QL (120 per 30 days) dofetilide oral capsule 500 mcg 2 QL (60 per 30 days) flecainide oral tablet 100, 150, 50 2 mexiletine oral capsule 150, 200, 250 MULTAQ ORAL TABLET 00 MG 3 QL (60 per 30 days) pacerone oral tablet 100, 00 pacerone oral tablet 200 1 propafenone oral capsule,extended release 12 hr 225, 325, 25 propafenone oral tablet 150, 225, 300 3 quinidine gluconate oral tablet extended release 32 quinidine sulfate oral tablet 200, 300 2 Beta-Adrenergic Blocking Agents acebutolol oral capsule 200, 00 2 atenolol oral tablet 100, 25, 50 1 atenolol-chlorthalidone oral tablet 100-25, 1 50-25 betaxolol oral tablet 10, 20 2 55

bisoprolol fumarate oral tablet 10, 5 1 bisoprolol-hydrochlorothiazide oral tablet 10-2 6.25, 2.5-6.25, 5-6.25 BYSTOLIC ORAL TABLET 10 MG QL (120 per 30 days) BYSTOLIC ORAL TABLET 2.5 MG, 5 MG QL (30 per 30 days) BYSTOLIC ORAL TABLET 20 MG QL (60 per 30 days) carvedilol oral tablet 12.5, 25, 3.125, 1 6.25 carvedilol phosphate oral capsule, er multiphase 3 QL (30 per 30 days) 2 hr 10, 20, 0, 80 labetalol oral tablet 100, 200, 300 2 metoprolol succinate oral tablet extended release 1 2 hr 100, 200, 25, 50 metoprolol ta-hydrochlorothiaz oral tablet 100-2 25, 100-50, 50-25 metoprolol tartrate oral tablet 100, 25, 50 1 nadolol oral tablet 20, 0, 80 3 pindolol oral tablet 10, 5 3 propranolol oral capsule,extended release 2 hr 2 120, 160, 60, 80 propranolol oral solution 20 /5 ml ( /ml), 2 0 /5 ml (8 /ml) propranolol oral tablet 10, 20, 0, 60 2, 80 propranolol-hydrochlorothiazid oral tablet 0-25 3, 80-25 sorine oral tablet 120, 160, 20, 80 2 sotalol af oral tablet 120, 160, 80 2 sotalol oral tablet 120, 160, 20, 80 2 timolol maleate oral tablet 10, 20, 5 Calcium-Channel Blocking Agents cartia xt oral capsule,extended release 2hr 120 2 QL (60 per 30 days), 180, 20 cartia xt oral capsule,extended release 2hr 300 2 QL (30 per 30 days) diltiazem hcl oral capsule,extended release 12 hr 2 120, 60, 90 diltiazem hcl oral capsule,extended release 2 hr 360 2 QL (30 per 30 days) 56

diltiazem hcl oral capsule,extended release 2 hr 2 20 diltiazem hcl oral capsule,extended release 2hr 2 QL (60 per 30 days) 120, 180, 20 diltiazem hcl oral capsule,extended release 2hr 2 300 diltiazem hcl oral tablet 120, 30, 60, 2 90 diltiazem hcl oral tablet extended release 2 hr 2 180, 300 diltiazem hcl oral tablet extended release 2 hr 2 QL (30 per 30 days) 20, 360, 20 dilt-xr oral capsule,ext.rel 2h degradable 120 2 QL (60 per 30 days), 180, 20 matzim la oral tablet extended release 2 hr 180 2, 20, 300, 360, 20 taztia xt oral capsule,extended release 2 hr 120 2 QL (60 per 30 days), 180, 20 taztia xt oral capsule,extended release 2 hr 300 2 QL (30 per 30 days), 360 verapamil oral capsule, 2 hr er pellet ct 100, 3 QL (30 per 30 days) 300 verapamil oral capsule, 2 hr er pellet ct 200 3 QL (60 per 30 days) verapamil oral capsule,ext rel. pellets 2 hr 120 3 QL (60 per 30 days), 180, 20, 360 verapamil oral tablet 120, 0, 80 1 verapamil oral tablet extended release 120, 2 180, 20 Cardiovascular Agents, Miscellaneous CORLANOR ORAL TABLET 5 MG, 7.5 MG 3 QL (60 per 30 days) DEMSER ORAL CAPSULE 250 MG 5 PA; NDS digitek oral tablet 125 mcg 2 QL (30 per 30 days) digitek oral tablet 250 mcg 2 digox oral tablet 125 mcg 2 QL (30 per 30 days) digox oral tablet 250 mcg 2 digoxin 125 mcg tablet 125 mcg 2 QL (30 per 30 days) digoxin injection syringe 250 mcg/ml DIGOXIN ORAL SOLUTION 50 MCG/ML 3 digoxin oral tablet 125 mcg 2 QL (30 per 30 days) digoxin oral tablet 250 mcg 2 57

dobutamine in d5w intravenous parenteral HI solution 1,000 /250 ml (,000 mcg/ml), 250 /250 ml (1 /ml), 500 /250 ml (2,000 mcg/ml) dobutamine intravenous solution 250 /20 ml HI (12.5 /ml), 500 /0 ml (12.5 /ml) dopamine in 5 % dextrose intravenous solution HI 200 /250 ml (800 mcg/ml), 00 /250 ml (1,600 mcg/ml), 00 /500 ml (800 mcg/ml), 800 /250 ml (3,200 mcg/ml), 800 /500 ml (1,600 mcg/ml) dopamine intravenous solution 200 /5 ml (0 HI /ml), 00 /10 ml (0 /ml), 00 /5 ml (80 /ml), 800 /10 ml (80 /ml), 800 /5 ml (160 /ml) epinephrine injection auto-injector 0.15 /0.15 3 ml, 0.15 /0.3 ml, 0.3 /0.3 ml FIRAZYR SUBCUTANEOUS SYRINGE 30 5 PA; NDS; QL (18 per 30 days) MG/3 ML hydralazine injection solution 20 /ml 2 hydralazine oral tablet 10, 100, 25, 50 2 LANOXIN INJECTION SOLUTION 250 MCG/ML LANOXIN ORAL TABLET 187.5 MCG, 62.5 QL (30 per 30 days) MCG milrinone in 5 % dextrose intravenous piggyback HI 20 /100 ml (200 mcg/ml), 0 /200 ml (200 mcg/ml) milrinone intravenous solution 1 /ml HI RANEXA ORAL TABLET EXTENDED 3 QL (120 per 30 days) RELEASE 12 HR 1,000 MG, 500 MG SYMJEPI INJECTION SYRINGE 0.3 MG/0.3 3 ML Dihydropyridines afeditab cr oral tablet extended release 30, 60 2 QL (60 per 30 days) amlodipine oral tablet 10, 2.5, 5 1 amlodipine-benazepril oral capsule 10-20, 2 QL (60 per 30 days) 2.5-10 amlodipine-benazepril oral capsule 10-0 2 QL (30 per 30 days) amlodipine-benazepril oral capsule 5-10, 5-20, 5-0 2 58

amlodipine-olmesartan oral tablet 10-20, 10- QL (30 per 30 days) 0, 5-20, 5-0 amlodipine-valsartan oral tablet 10-160, 10-2 QL (30 per 30 days) 320, 5-160 amlodipine-valsartan oral tablet 5-320 2 QL (60 per 30 days) amlodipine-valsartan-hcthiazid oral tablet 10-160-12.5, 10-160-25, 10-320-25, 5-160-12.5, 5-160-25 felodipine oral tablet extended release 2 hr 10 2 QL (30 per 30 days), 2.5, 5 nicardipine oral capsule 20, 30 nifedical xl oral tablet extended release 2hr 30 2 QL (60 per 30 days), 60 nifedipine oral tablet extended release 2hr 30 2 QL (60 per 30 days), 60, 90 nifedipine oral tablet extended release 30, 60 2 QL (60 per 30 days), 90 nimodipine oral capsule 30 nisoldipine oral tablet extended release 2 hr 17 QL (30 per 30 days), 20, 3, 0, 8.5 nisoldipine oral tablet extended release 2 hr QL (60 per 30 days) 25.5, 30 Diuretics amiloride oral tablet 5 1 amiloride-hydrochlorothiazide oral tablet 5-50 1 bumetanide injection solution 0.25 /ml 2 HI bumetanide oral tablet 0.5, 1, 2 2 chlorothiazide oral tablet 250, 500 2 chlorothiazide sodium intravenous recon soln 500 2 HI chlorthalidone oral tablet 25, 50 1 DYRENIUM ORAL CAPSULE 100 MG, 50 MG ethacrynic acid oral tablet 25 3 furosemide injection solution 10 /ml 1 HI furosemide injection syringe 10 /ml 1 HI furosemide oral solution 10 /ml, 0 /5 ml (8 1 /ml) furosemide oral tablet 20, 0, 80 1 hydrochlorothiazide oral capsule 12.5 1 hydrochlorothiazide oral tablet 12.5, 25, 50 1 59

indapamide oral tablet 1.25, 2.5 1 methyclothiazide oral tablet 5 3 metolazone oral tablet 10, 2.5, 5 2 SAMSCA ORAL TABLET 15 MG, 30 MG 5 PA; NDS spironolactone oral tablet 100, 25, 50 1 spironolacton-hydrochlorothiaz oral tablet 25-25 2 torsemide oral tablet 10, 100, 20, 5 2 triamterene-hydrochlorothiazid oral capsule 1 37.5-25 triamterene-hydrochlorothiazid oral capsule 50-2 25 triamterene-hydrochlorothiazid oral tablet 37.5-1 25, 75-50 Dyslipidemics amlodipine-atorvastatin oral tablet 10-10, 10- QL (30 per 30 days) 20, 10-0, 10-80, 2.5-20, 2.5-0, 5-10, 5-20, 5-0 amlodipine-atorvastatin oral tablet 2.5-10, 5-80 atorvastatin oral tablet 10, 20, 0 1 QL (60 per 30 days) atorvastatin oral tablet 80 1 QL (30 per 30 days) cholestyramine (with sugar) oral powder in 3 packet gram cholestyramine light oral powder gram 3 cholestyramine light packet gram 3 colesevelam oral powder in packet 3.75 gram 3 colesevelam oral tablet 625 3 QL (180 per 30 days) colestipol oral packet 5 gram 3 colestipol oral tablet 1 gram 3 ezetimibe oral tablet 10 1 ezetimibe-simvastatin oral tablet 10-10, 10-20 2, 10-0, 10-80 fenofibrate micronized oral capsule 13, 200 2 QL (30 per 30 days) fenofibrate micronized oral capsule 67 2 QL (60 per 30 days) fenofibrate nanocrystallized oral tablet 15 2 QL (30 per 30 days) fenofibrate nanocrystallized oral tablet 8 2 QL (60 per 30 days) fenofibrate oral tablet 160 2 QL (30 per 30 days) fenofibrate oral tablet 5 2 QL (60 per 30 days) fenofibric acid (choline) oral capsule,delayed release(dr/ec) 135, 5 2 QL (30 per 30 days) 60

fenofibric acid oral tablet 105, 35 2 fluvastatin oral capsule 20, 0 QL (60 per 30 days) gemfibrozil oral tablet 600 2 QL (60 per 30 days) lovastatin oral tablet 10, 20, 0 1 QL (60 per 30 days) niacin oral tablet extended release 2 hr 1,000, 500, 750 omega-3 acid ethyl esters oral capsule 1 gram QL (120 per 30 days) PRALUENT PEN SUBCUTANEOUS PEN 5 PA; NDS INJECTOR 150 MG/ML, 75 MG/ML pravastatin oral tablet 10, 20, 0, 80 2 QL (60 per 30 days) prevalite oral powder in packet gram 3 REPATHA PUSHTRONEX SUBCUTANEOUS 5 PA; NDS; QL (3.5 per 28 days) WEARABLE INJECTOR 20 MG/3.5 ML REPATHA SURECLICK SUBCUTANEOUS 5 PA; NDS; QL (3 per 28 days) PEN INJECTOR 10 MG/ML REPATHA SYRINGE SUBCUTANEOUS 5 PA; NDS; QL (3 per 28 days) SYRINGE 10 MG/ML rosuvastatin oral tablet 10, 20, 0, 5 1 QL (30 per 30 days) simvastatin oral tablet 10, 20, 0, 5 1 QL (60 per 30 days) simvastatin oral tablet 80 1 QL (30 per 30 days) VASCEPA ORAL CAPSULE 0.5 GRAM QL (20 per 30 days) VASCEPA ORAL CAPSULE 1 GRAM QL (120 per 30 days) WELCHOL ORAL POWDER IN PACKET 3.75 GRAM Renin-Angiotensin-Aldosterone System Inhibitors CAROSPIR ORAL SUSPENSION 25 MG/5 ML eplerenone oral tablet 25, 50 3 Vasodilators isosorbide dinitrate oral tablet 10, 20, 30, 5 isosorbide dinitrate oral tablet extended release 0 isosorbide mononitrate oral tablet 10, 20 2 isosorbide mononitrate oral tablet extended 2 release 2 hr 120, 30, 60 minitran transdermal patch 2 hour 0.1 /hr, 2 0.2 /hr, 0. /hr, 0.6 /hr minoxidil oral tablet 10, 2.5 2 61 2

NITRO-BID TRANSDERMAL OINTMENT 2 % nitroglycerin intravenous solution 50 /10 ml (5 /ml) nitroglycerin sublingual tablet 0.3, 0., 0.6 nitroglycerin transdermal patch 2 hour 0.1 /hr, 0.2 /hr, 0.6 /hr nitroglycerin transdermal patch 2 hour 0. /hr nitroglycerin translingual spray,non-aerosol 00 mcg/spray NITROSTAT SUBLINGUAL TABLET 0.3 MG, 0. MG, 0.6 MG Central Nervous System Agents Central Nervous System Agents AMPYRA ORAL TABLET EXTENDED 3 2 2 2 QL (30 per 30 days) 2 QL (60 per 30 days) 5 PA; LA; NDS RELEASE 12 HR 10 MG atomoxetine oral capsule 10, 100, 18, 3 25, 0, 60, 80 AUBAGIO ORAL TABLET 1 MG, 7 MG 5 PA; LA; NDS; QL (30 per 30 days) AUSTEDO ORAL TABLET 12 MG, 6 MG, 9 5 PA; NDS MG AVONEX (WITH ALBUMIN) 5 PA; NDS; QL ( per 28 days) INTRAMUSCULAR KIT 30 MCG AVONEX INTRAMUSCULAR PEN 5 PA; NDS; QL (1 per 28 days) INJECTOR KIT 30 MCG/0.5 ML AVONEX INTRAMUSCULAR SYRINGE KIT 5 PA; NDS; QL (1 per 28 days) 30 MCG/0.5 ML BETASERON SUBCUTANEOUS KIT 0.3 MG 5 PA; NDS; QL (15 per 30 days) clonidine hcl oral tablet extended release 12 hr QL (120 per 30 days) 0.1 COPAXONE SUBCUTANEOUS SYRINGE 20 5 PA; NDS; QL (30 per 30 days) MG/ML COPAXONE SUBCUTANEOUS SYRINGE 0 5 PA; NDS; QL (12 per 28 days) MG/ML dalfampridine oral tablet extended release 12 hr 5 PA; NDS; QL (60 per 30 days) 10 dexmethylphenidate oral capsule,er biphasic 50-50 10, 15, 20, 25, 30, 35, 0, 5 QL (30 per 30 days) 3 62

dexmethylphenidate oral tablet 10, 2.5, 5 3 QL (60 per 30 days) dextroamphetamine oral capsule, extended QL (180 per 30 days) release 10 dextroamphetamine oral capsule, extended QL (120 per 30 days) release 15 dextroamphetamine oral capsule, extended QL (60 per 30 days) release 5 dextroamphetamine oral tablet 10 3 QL (180 per 30 days) dextroamphetamine oral tablet 5 3 QL (150 per 30 days) dextroamphetamine-amphetamine oral QL (30 per 30 days) capsule,extended release 2hr 10, 15, 5 dextroamphetamine-amphetamine oral QL (60 per 30 days) capsule,extended release 2hr 20, 25, 30 dextroamphetamine-amphetamine oral tablet 10 3 QL (90 per 30 days), 12.5, 15, 20, 5, 7.5 dextroamphetamine-amphetamine oral tablet 30 3 QL (60 per 30 days) EXTAVIA SUBCUTANEOUS KIT 0.3 MG 5 PA; NDS; QL (15 per 30 days) GILENYA ORAL CAPSULE 0.25 MG, 0.5 MG 5 PA; NDS; QL (30 per 30 days) glatiramer subcutaneous syringe 20 /ml 5 PA; NDS; QL (30 per 30 days) glatiramer subcutaneous syringe 0 /ml 5 PA; NDS; QL (12 per 28 days) glatopa subcutaneous syringe 20 /ml 5 PA; NDS; QL (30 per 30 days) glatopa subcutaneous syringe 0 /ml 5 PA; NDS; QL (12 per 28 days) LEMTRADA INTRAVENOUS SOLUTION 12 5 HI; NDS MG/1.2 ML lithium carbonate oral capsule 150, 300, 2 600 lithium carbonate oral tablet 300 2 lithium carbonate oral tablet extended release 2 300, 50 lithium citrate oral solution 8 meq/5 ml 2 metadate er oral tablet extended release 20 methylphenidate hcl oral capsule, er biphasic 30-70 10, 20, 30, 0, 50, 60 methylphenidate hcl oral capsule,er biphasic 50-50 10 methylphenidate hcl oral capsule,er biphasic 50-50 20, 30, 0, 60 QL (30 per 30 days) 63

methylphenidate hcl oral solution 10 /5 ml, 5 /5 ml methylphenidate hcl oral tablet 10, 5 3 QL (90 per 30 days) methylphenidate hcl oral tablet 20 3 methylphenidate hcl oral tablet extended release QL (180 per 30 days) 10 methylphenidate hcl oral tablet extended release QL (90 per 30 days) 20 methylphenidate hcl oral tablet extended release 2hr 18, 27, 36, 5 methylphenidate hcl oral tablet extended release 2hr 72 methylphenidate la 0 cap 0 QL (30 per 30 days) NUEDEXTA ORAL CAPSULE 20-10 MG PA; QL (60 per 30 days) PLEGRIDY SUBCUTANEOUS PEN 5 PA; LA; NDS; QL (1 per 28 days) INJECTOR 125 MCG/0.5 ML PLEGRIDY SUBCUTANEOUS PEN 5 PA; LA; NDS; QL (2 per 365 days) INJECTOR 63 MCG/0.5 ML- 9 MCG/0.5 ML PLEGRIDY SUBCUTANEOUS SYRINGE 125 5 PA; LA; NDS; QL (1 per 28 days) MCG/0.5 ML PLEGRIDY SUBCUTANEOUS SYRINGE 63 5 PA; NDS; QL (2 per 365 days) MCG/0.5 ML- 9 MCG/0.5 ML RADICAVA INTRAVENOUS PIGGYBACK 30 5 HI; NDS MG/100 ML REBIF (WITH ALBUMIN) SUBCUTANEOUS 5 PA; NDS; QL (6 per 28 days) SYRINGE 22 MCG/0.5 ML, MCG/0.5 ML REBIF REBIDOSE SUBCUTANEOUS PEN 5 PA; NDS; QL (6 per 28 days) INJECTOR 22 MCG/0.5 ML, MCG/0.5 ML REBIF REBIDOSE SUBCUTANEOUS PEN 5 PA; NDS; QL (.2 per 28 days) INJECTOR 8.8MCG/0.2ML-22 MCG/0.5ML (6) REBIF TITRATION PACK SUBCUTANEOUS 5 PA; NDS; QL (.2 per 28 days) SYRINGE 8.8MCG/0.2ML-22 MCG/0.5ML (6) riluzole oral tablet 50 SAVELLA ORAL TABLET 100 MG, 12.5 MG, QL (60 per 30 days) 50 MG SAVELLA ORAL TABLET 25 MG QL (90 per 30 days) SAVELLA ORAL TABLETS,DOSE PACK 12.5 QL (60 per 30 days) MG (5)-25 MG(8)-50 MG(2) TECFIDERA ORAL CAPSULE,DELAYED 5 PA; LA; NDS; QL (60 per 30 days) RELEASE(DR/EC) 120 MG, 120 MG (1)- 20 MG (6), 20 MG tetrabenazine oral tablet 12.5 5 PA; NDS; QL (20 per 30 days) 6

tetrabenazine oral tablet 25 5 PA; NDS; QL (120 per 30 days) VYVANSE ORAL CAPSULE 10 MG, 20 MG, QL (30 per 30 days) 30 MG, 0 MG, 50 MG, 60 MG, 70 MG VYVANSE ORAL TABLET,CHEWABLE 10 MG, 20 MG, 30 MG, 0 MG, 50 MG, 60 MG zenzedi oral tablet 10 3 QL (180 per 30 days) zenzedi oral tablet 5 3 QL (150 per 30 days) Contraceptives Contraceptives altavera (28) oral tablet 0.15-0.03 alyacen 1/35 (28) oral tablet 1-35 -mcg alyacen 7/7/7 (28) oral tablet 0.5/0.75/1-35 mcg amethia lo oral tablets,dose pack,3 month 0.10 QL (91 per 90 days) -20 mcg (8)/10 mcg (7) amethia oral tablets,dose pack,3 month 0.15 - QL (91 per 90 days) 30 mcg (8)/10 mcg (7) amethyst (28) oral tablet 90-20 mcg (28) apri oral tablet 0.15-0.03 aranelle (28) oral tablet 0.5/1/0.5-35 -mcg ashlyna oral tablets,dose pack,3 month 0.15-30 mcg (8)/10 mcg (7) aubra oral tablet 0.1-20 -mcg aviane oral tablet 0.1-20 -mcg azurette (28) oral tablet 0.15-0.02 x21 /0.01 x 5 balziva (28) oral tablet 0.-35 -mcg bekyree (28) oral tablet 0.15-0.02 x21 /0.01 x 5 blisovi 2 fe oral tablet 1-20 mcg (2)/75 () blisovi fe 1.5/30 (28) oral tablet 1.5-30 mcg (21)/75 (7) blisovi fe 1/20 (28) oral tablet 1-20 mcg (21)/75 (7) brevicon (28) oral tablet 0.5-35 -mcg briellyn oral tablet 0.-35 -mcg camila oral tablet 0.35 camrese lo oral tablets,dose pack,3 month 0.10-20 mcg (8)/10 mcg (7) camrese oral tablets,dose pack,3 month 0.15-30 mcg (8)/10 mcg (7) QL (91 per 90 days) 65

caziant (28) oral tablet 0.1/.125/.15-25 -mcg chateal (28) oral tablet 0.15-0.03 cryselle (28) oral tablet 0.3-30 -mcg cyclafem 1/35 (28) oral tablet 1-35 -mcg cyclafem 7/7/7 (28) oral tablet 0.5/0.75/1-35 mcg cyred 28 day tablet outer 0.15-0.03 cyred eq oral tablet 0.15-0.03 dasetta 1/35 (28) oral tablet 1-35 -mcg dasetta 7/7/7 (28) oral tablet 0.5/0.75/1-35 mcg daysee oral tablets,dose pack,3 month 0.15-30 mcg (8)/10 mcg (7) deblitane oral tablet 0.35 delyla (28) oral tablet 0.1-20 -mcg desog-e.estradiol/e.estradiol oral tablet 0.15-0.02 x21 /0.01 x 5 desogestrel-ethinyl estradiol oral tablet 0.15-0.03 drospirenone-e.estradiol-lm.fa oral tablet 3-0.02-0.51 (2) (), 3-0.03-0.51 (21) (7) drospirenone-ethinyl estradiol oral tablet 3-0.02, 3-0.03 elinest oral tablet 0.3-30 -mcg emoquette oral tablet 0.15-0.03 enpresse oral tablet 50-30 (6)/75-0 (5)/125-30(10) enskyce oral tablet 0.15-0.03 errin oral tablet 0.35 estarylla oral tablet 0.25-35 -mcg ethynodiol diac-eth estradiol oral tablet 1-35 mcg, 1-50 -mcg falmina (28) oral tablet 0.1-20 -mcg fayosim oral tablets,dose pack,3 month 0.15-20 mcg/ 0.15-25 mcg femynor oral tablet 0.25-35 -mcg gianvi (28) oral tablet 3-0.02 gildess 1.5/30 (21) oral tablet 1.5-30 -mcg gildess 2 fe oral tablet 1-20 mcg (2)/75 () hailey 2 fe oral tablet 1-20 mcg (2)/75 () 66

heather oral tablet 0.35 incassia oral tablet 0.35 introvale oral tablets,dose pack,3 month 0.15 - QL (91 per 30 days) 30 mcg isibloom oral tablet 0.15-0.03 jencycla oral tablet 0.35 jolessa oral tablets,dose pack,3 month 0.15 - QL (91 per 90 days) 30 mcg jolivette oral tablet 0.35 juleber oral tablet 0.15-0.03 junel 1.5/30 (21) oral tablet 1.5-30 -mcg junel 1/20 (21) oral tablet 1-20 -mcg junel fe 1.5/30 (28) oral tablet 1.5-30 mcg (21)/75 (7) junel fe 1/20 (28) oral tablet 1-20 mcg (21)/75 (7) junel fe 2 oral tablet 1-20 mcg (2)/75 () kaitlib fe oral tablet,chewable 0.8-25mcg(2) and 75 () kariva (28) oral tablet 0.15-0.02 x21 /0.01 x 5 kelnor 1/35 (28) oral tablet 1-35 -mcg kelnor 1-50 oral tablet 1-50 -mcg kimidess (28) oral tablet 0.15-0.02 x21 /0.01 x 5 kurvelo (28) oral tablet 0.15-0.03 l norgest/e.estradiol-e.estrad oral tablets,dose QL (91 per 90 days) pack,3 month 0.10-20 mcg (8)/10 mcg (7) l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.15-20 mcg/ 0.15-25 mcg, 0.15-30 mcg (8)/10 mcg (7) larin 1.5/30 (21) oral tablet 1.5-30 -mcg larin 1/20 (21) oral tablet 1-20 -mcg larin 2 fe oral tablet 1-20 mcg (2)/75 () larin fe 1.5/30 (28) oral tablet 1.5-30 mcg (21)/75 (7) larin fe 1/20 (28) oral tablet 1-20 mcg (21)/75 (7) larissia oral tablet 0.1-20 -mcg 67

layolis fe oral tablet,chewable 0.8-25mcg(2) and 75 () leena 28 oral tablet 0.5/1/0.5-35 -mcg lessina oral tablet 0.1-20 -mcg levonest (28) oral tablet 50-30 (6)/75-0 (5)/125-30(10) levonorgestrel-ethinyl estrad oral tablet 0.1-20 -mcg, 0.15-0.03, 90-20 mcg (28) levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month 0.15-30 mcg levonorg-eth estrad triphasic oral tablet 50-30 (6)/75-0 (5)/125-30(10) levora-28 oral tablet 0.15-0.03 lillow (28) oral tablet 0.15-0.03 LO LOESTRIN FE ORAL TABLET 1 MG-10 MCG (2)/10 MCG (2) lomedia 2 fe oral tablet 1-20 mcg (2)/75 () loryna (28) oral tablet 3-0.02 low-ogestrel (28) oral tablet 0.3-30 -mcg lutera (28) oral tablet 0.1-20 -mcg lyza oral tablet 0.35 marlissa (28) oral tablet 0.15-0.03 melodetta 2 fe oral tablet,chewable 1-20 mcg(2) /75 () mibelas 2 fe oral tablet,chewable 1-20 mcg(2) /75 () microgestin 1.5/30 (21) oral tablet 1.5-30 mcg microgestin 1/20 (21) oral tablet 1-20 -mcg microgestin 2 fe oral tablet 1-20 mcg (2)/75 () microgestin fe 1.5/30 (28) oral tablet 1.5-30 mcg (21)/75 (7) microgestin fe 1/20 (28) oral tablet 1-20 mcg (21)/75 (7) mili oral tablet 0.25-35 -mcg mono-linyah oral tablet 0.25-35 -mcg mononessa (28) oral tablet 0.25-35 -mcg myzilra oral tablet 50-30 (6)/75-0 (5)/125-30(10) 68

NATAZIA ORAL TABLET 3 MG/2 MG-2 MG/ 2 MG-3 MG/1 MG necon 0.5/35 (28) oral tablet 0.5-35 -mcg necon 7/7/7 (28) oral tablet 0.5/0.75/1-35 mcg nikki (28) oral tablet 3-0.02 nora-be oral tablet 0.35 noreth-ethinyl estradiol-iron oral tablet,chewable 0.-35mcg(21) and 75 (7), 0.8-25mcg(2) and 75 () norethindrone (contraceptive) oral tablet 0.35 norethindrone ac-eth estradiol oral tablet 1-20 -mcg norethindrone-e.estradiol-iron oral tablet 1-20 mcg (21)/75 (7), 1-20 mcg (2)/75 () norethindrone-e.estradiol-iron oral tablet,chewable 1-20 mcg(2) /75 () norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25-25 mcg, 0.18/0.215/0.25-35 mcg (28), 0.25-35 -mcg norlyda oral tablet 0.35 norlyroc oral tablet 0.35 nortrel 0.5/35 (28) oral tablet 0.5-35 -mcg nortrel 1/35 (21) oral tablet 1-35 -mcg nortrel 1/35 (28) oral tablet 1-35 -mcg nortrel 7/7/7 (28) oral tablet 0.5/0.75/1-35 mcg ocella oral tablet 3-0.03 ogestrel (28) oral tablet 0.5-50 -mcg orsythia oral tablet 0.1-20 -mcg philith oral tablet 0.-35 -mcg pimtrea (28) oral tablet 0.15-0.02 x21 /0.01 x 5 pirmella oral tablet 0.5/0.75/1-35 mcg, 1-35 -mcg portia 28 oral tablet 0.15-0.03 previfem oral tablet 0.25-35 -mcg quasense oral tablets,dose pack,3 month 0.15-30 mcg rajani oral tablet 3-0.02-0.51 (2) () reclipsen (28) oral tablet 0.15-0.03 69

rivelsa oral tablets,dose pack,3 month 0.15-20 mcg/ 0.15-25 mcg setlakin oral tablets,dose pack,3 month 0.15 - QL (91 per 90 days) 30 mcg sharobel oral tablet 0.35 sprintec (28) oral tablet 0.25-35 -mcg sronyx oral tablet 0.1-20 -mcg syeda oral tablet 3-0.03 tarina fe 1/20 (28) oral tablet 1-20 mcg (21)/75 (7) tilia fe oral tablet 1-20(5)/1-30(7) /1-35mcg (9) tri femynor oral tablet 0.18/0.215/0.25-35 mcg (28) tri-estarylla oral tablet 0.18/0.215/0.25-35 mcg (28) tri-legest fe oral tablet 1-20(5)/1-30(7) /1-35mcg (9) tri-linyah oral tablet 0.18/0.215/0.25-35 mcg (28) tri-lo-estarylla oral tablet 0.18/0.215/0.25-25 mcg tri-lo-marzia oral tablet 0.18/0.215/0.25-25 mcg tri-lo-sprintec oral tablet 0.18/0.215/0.25-25 mcg tri-mili oral tablet 0.18/0.215/0.25-35 mcg (28) trinessa (28) oral tablet 0.18/0.215/0.25-35 mcg (28) trinessa lo oral tablet 0.18/0.215/0.25-25 mcg tri-previfem (28) oral tablet 0.18/0.215/0.25-35 mcg (28) tri-sprintec (28) oral tablet 0.18/0.215/0.25-35 mcg (28) trivora (28) oral tablet 50-30 (6)/75-0 (5)/125-30(10) tri-vylibra lo oral tablet 0.18/0.215/0.25-25 mcg tri-vylibra oral tablet 0.18/0.215/0.25-35 mcg (28) tulana oral tablet 0.35 70

tydemy oral tablet 3-0.03-0.51 (21) (7) velivet triphasic regimen (28) oral tablet 0.1/.125/.15-25 -mcg vestura (28) oral tablet 3-0.02 vienva oral tablet 0.1-20 -mcg viorele (28) oral tablet 0.15-0.02 x21 /0.01 x 5 vyfemla (28) oral tablet 0.-35 -mcg vylibra oral tablet 0.25-35 -mcg wera (28) oral tablet 0.5-35 -mcg wymzya fe oral tablet,chewable 0.-35mcg(21) and 75 (7) xulane transdermal patch weekly 150-35 mcg/2 hr QL (3 per 28 days) zarah oral tablet 3-0.03 zenchent (28) oral tablet 0.-35 -mcg zovia 1/35e (28) oral tablet 1-35 -mcg Dental And Oral Agents Dental And Oral Agents cevimeline oral capsule 30 chlorhexidine gluconate mucous membrane 1 mouthwash 0.12 % denta 5000 plus dental cream 1.1 % 2 dentagel dental gel 1.1 % 2 oralone dental paste 0.1 % 2 paroex oral rinse mucous membrane mouthwash 0.12 % periogard mucous membrane mouthwash 0.12 % 1 pilocarpine hcl oral tablet 5, 7.5 3 sf 5000 plus dental cream 1.1 % 2 triamcinolone acetonide dental paste 0.1 % 2 Dermatological Agents Dermatological Agents, Other acitretin oral capsule 10, 17.5, 25 5 NDS acyclovir topical ointment 5 % ALCOHOL PADS TOPICAL PADS, 1 MEDICATED ammonium lactate topical cream 12 % 2 ammonium lactate topical lotion 12 % 2 amnesteem oral capsule 10, 20, 0 azelaic acid topical gel 15 % 3 71 1

AZELEX TOPICAL CREAM 20 % calcipotriene scalp solution 0.005 % QL (60 per 30 days) calcipotriene topical cream 0.005 % QL (120 per 30 days) calcipotriene topical ointment 0.005 % 3 QL (120 per 30 days) calcitrene topical ointment 0.005 % 3 calcitriol topical ointment 3 mcg/gram claravis oral capsule 10, 20, 30, 0 COSENTYX (2 SYRINGES) 5 PA; LA; NDS; QL (2 per 28 days) SUBCUTANEOUS SYRINGE 150 MG/ML COSENTYX PEN (2 PENS) SUBCUTANEOUS 5 PA; LA; NDS; QL (2 per 28 days) PEN INJECTOR 150 MG/ML dapsone topical gel 5 % DUPIXENT SUBCUTANEOUS SYRINGE 300 5 NDS MG/2 ML FINACEA TOPICAL FOAM 15 % FINACEA TOPICAL GEL 15 % fluorouracil topical cream 0.5 % fluorouracil topical cream 5 % 3 fluorouracil topical solution 2 %, 5 % 3 imiquimod topical cream in metered-dose pump QL (28 per 28 days) 3.75 % imiquimod topical cream in packet 5 % 3 QL (12 per 30 days) isotretinoin oral capsule 10, 20, 30, 0 mafenide acetate topical packet 50 gram 3 methoxsalen oral capsule,liqd-filled,rapid rel 10 5 NDS MIRVASO TOPICAL GEL WITH PUMP 0.33 % myorisan oral capsule 10, 20, 30, 0 PANRETIN TOPICAL GEL 0.1 % 5 NDS PICATO TOPICAL GEL 0.015 % QL (3 per 30 days) PICATO TOPICAL GEL 0.05 % QL (2 per 30 days) podofilox topical solution 0.5 % REGRANEX TOPICAL GEL 0.01 % 5 PA; NDS SANTYL TOPICAL OINTMENT 250 UNIT/GRAM SILIQ SUBCUTANEOUS SYRINGE 210 5 PA; NDS MG/1.5 ML SULFAMYLON TOPICAL CREAM 85 MG/G SULFAMYLON TOPICAL PACKET 50 GRAM 72

TALTZ AUTOINJECTOR SUBCUTANEOUS 5 PA; LA; NDS AUTO-INJECTOR 80 MG/ML TALTZ SYRINGE SUBCUTANEOUS 5 PA; LA; NDS SYRINGE 80 MG/ML TOLAK TOPICAL CREAM % VALCHLOR TOPICAL GEL 0.016 % 5 NDS; QL (60 per 28 days) zenatane oral capsule 10, 20, 30, 0 ZYCLARA TOPICAL CREAM IN METERED- QL (7.5 per 28 days) DOSE PUMP 2.5 % ZYCLARA TOPICAL CREAM IN METERED- QL (28 per 28 days) DOSE PUMP 3.75 % Dermatological Antibacterials BACTROBAN NASAL NASAL OINTMENT 2 % clindamycin phosphate topical foam 1 % clindamycin phosphate topical gel 1 % clindamycin phosphate topical lotion 1 % clindamycin phosphate topical solution 1 % 3 clindamycin phosphate topical swab 1 % 2 clindamycin-benzoyl peroxide topical gel 1-5 %, 1.2 %(1 % base) -5 % CORTISPORIN TOPICAL CREAM 3.5-10,000-0.5 MG/G-UNIT/G-% CORTISPORIN TOPICAL OINTMENT 1 % ery pads topical swab 2 % 3 erythromycin with ethanol topical gel 2 % 3 erythromycin with ethanol topical solution 2 % 3 erythromycin with ethanol topical swab 2 % 3 erythromycin-benzoyl peroxide topical gel 3-5 % gentamicin topical cream 0.1 % 2 gentamicin topical ointment 0.1 % 2 metronidazole topical cream 0.75 % 2 metronidazole topical gel 0.75 %, 1 % 2 metronidazole topical lotion 0.75 % 3 mupirocin calcium topical cream 2 % mupirocin topical ointment 2 % 2 neomycin-polymyxin b gu irrigation solution 0 3-200,000 unit/ml neuac topical gel 1.2 %(1 % base) -5 % rosadan topical cream 0.75 % 3 selenium sulfide topical lotion 2.5 % 2 73

silver sulfadiazine topical cream 1 % 2 ssd topical cream 1 % 2 sulfacetamide sodium (acne) topical suspension 3 10 % Dermatological Anti-Inflammatory Agents ala-cort topical cream 1 %, 2.5 % 2 alclometasone topical cream 0.05 % 3 alclometasone topical ointment 0.05 % 3 ANALPRAM-HC RECTAL CREAM 1-1 % ANALPRAM-HC TOPICAL LOTION 2.5-1 % betamethasone dipropionate topical cream 0.05 2 % betamethasone dipropionate topical lotion 0.05 2 % betamethasone dipropionate topical ointment 2 0.05 % betamethasone valerate topical cream 0.1 % 2 betamethasone valerate topical lotion 0.1 % 2 betamethasone valerate topical ointment 0.1 % 2 betamethasone, augmented topical cream 0.05 % 2 betamethasone, augmented topical gel 0.05 % 2 betamethasone, augmented topical lotion 0.05 % 2 betamethasone, augmented topical ointment 0.05 2 % clobetasol scalp solution 0.05 % 3 clobetasol topical cream 0.05 % 3 clobetasol topical foam 0.05 % 3 clobetasol topical gel 0.05 % 3 clobetasol topical lotion 0.05 % 3 clobetasol topical ointment 0.05 % 3 clobetasol topical shampoo 0.05 % 3 clobetasol topical spray,non-aerosol 0.05 % 3 clobetasol-emollient topical cream 0.05 % 3 clobetasol-emollient topical foam 0.05 % 3 CORDRAN TAPE LARGE ROLL TOPICAL TAPE MCG/CM2 cormax scalp solution 0.05 % 3 desonide topical cream 0.05 % 3 desonide topical lotion 0.05 % 3 desonide topical ointment 0.05 % 3 desoximetasone topical cream 0.05 % 7

desoximetasone topical cream 0.25 % 3 desoximetasone topical gel 0.05 % desoximetasone topical ointment 0.05 % desoximetasone topical ointment 0.25 % 3 ELIDEL TOPICAL CREAM 1 % fluocinolone 0.01% body oil 0.01 % fluocinolone and shower cap scalp oil 0.01 % fluocinolone topical cream 0.01 %, 0.025 % fluocinolone topical ointment 0.025 % fluocinolone topical solution 0.01 % fluocinonide topical cream 0.05 %, 0.1 % fluocinonide topical gel 0.05 % fluocinonide topical ointment 0.05 % fluocinonide topical solution 0.05 % fluocinonide-e topical cream 0.05 % fluticasone topical cream 0.05 % 2 fluticasone topical ointment 0.005 % 2 halobetasol propionate topical cream 0.05 % halobetasol propionate topical ointment 0.05 % hydrocort buty 0.1% lipo cream 0.1 % hydrocortisone butyrate topical cream 0.1 % hydrocortisone butyrate topical lotion 0.1 % hydrocortisone butyrate topical ointment 0.1 % hydrocortisone butyrate topical solution 0.1 % hydrocortisone topical cream 1 %, 2.5 % 2 hydrocortisone topical lotion 2.5 % 2 hydrocortisone topical ointment 1 %, 2.5 % 2 hydrocortisone valerate topical cream 0.2 % hydrocortisone valerate topical ointment 0.2 % hydrocortisone-pramoxine rectal cream 1-1 % 3 mometasone topical cream 0.1 % 2 mometasone topical ointment 0.1 % 2 mometasone topical solution 0.1 % 2 pimecrolimus topical cream 1 % 3 PRAMOSONE TOPICAL CREAM 1-1 % PRAMOSONE TOPICAL LOTION 1-1 %, 2.5-1 % prednicarbate topical cream 0.1 % prednicarbate topical ointment 0.1 % procto-med hc topical cream with perineal 2 applicator 2.5 % 75

procto-pak topical cream with perineal 2 applicator 1 % proctosol hc topical cream with perineal 2 applicator 2.5 % proctozone-hc topical cream with perineal 2 applicator 2.5 % tacrolimus topical ointment 0.03 %, 0.1 % triamcinolone acetonide topical cream 0.025 %, 2 0.1 %, 0.5 % triamcinolone acetonide topical lotion 0.025 %, 2 0.1 % triamcinolone acetonide topical ointment 0.025 2 %, 0.1 %, 0.5 % triderm topical cream 0.1 %, 0.5 % 2 tridesilon topical cream 0.05 % 3 Dermatological Retinoids adapalene 0.3% gel pump 0.3 % 3 PA adapalene topical cream 0.1 % 3 PA adapalene topical gel 0.1 %, 0.3 % 3 PA avita topical cream 0.025 % PA avita topical gel 0.025 % PA tazarotene topical cream 0.1 % 3 PA TAZORAC TOPICAL CREAM 0.05 % PA TAZORAC TOPICAL GEL 0.05 %, 0.1 % PA tretinoin topical cream 0.025 %, 0.05 %, 0.1 % 3 PA tretinoin topical gel 0.01 %, 0.025 % 3 PA Scabicides And Pediculicides lindane topical shampoo 1 % malathion topical lotion 0.5 % permethrin topical cream 5 % 2 spinosad topical suspension 0.9 % Devices Devices ASSURE ID INSULIN SAFETY SYRINGE 1 1 ML 29 GAUGE X 1/2" BD UF NANO PEN NEEDLE MMX32G 32 1 GAUGE X 5/32" BD VEO INS 0.3 ML 6MMX31G (1/2) 0.3 ML 1 31 GAUGE X 15/6" BD VEO INS SYRING 1 ML 6MMX31G 1 ML 31 GAUGE X 15/6" 1 76

BD VEO INS SYRN 0.5 ML 6MMX31G 1/2 ML 1 31 GAUGE X 15/6" GAUZE PAD TOPICAL BANDAGE 2 X 2 " 1 INSULIN SYRINGE-NEEDLE U-100 1 SYRINGE 0.3 ML 29 GAUGE, 1 ML 29 GAUGE X 1/2", 1/2 ML 28 GAUGE PEN NEEDLE, DIABETIC NEEDLE 29 1 GAUGE X 1/2" SURE COMFORT 0.5 ML SYRINGE 0.5 ML 29 1 GAUGE X 1/2" Enzyme Replacement/Modifiers Enzyme Replacement/Modifiers ADAGEN INTRAMUSCULAR SOLUTION 250 UNIT/ML ALDURAZYME INTRAVENOUS SOLUTION 2.9 MG/5 ML CEREZYME INTRAVENOUS RECON SOLN 00 UNIT CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 12,000-38,000-60,000 UNIT, 2,000-76,000-120,000 UNIT, 3,000-9,500-15,000 UNIT, 36,000-11,000-180,000 UNIT, 6,000-19,000-30,000 UNIT 5 NDS 5 HI; NDS 5 HI; NDS ELAPRASE INTRAVENOUS SOLUTION 6 5 HI; NDS MG/3 ML ELELYSO INTRAVENOUS RECON SOLN 200 5 HI; NDS UNIT FABRAZYME INTRAVENOUS RECON SOLN 5 HI; NDS 35 MG, 5 MG KRYSTEXXA INTRAVENOUS SOLUTION 8 5 HI; NDS MG/ML KUVAN ORAL POWDER IN PACKET 100 5 PA; NDS MG, 500 MG KUVAN ORAL TABLET,SOLUBLE 100 MG 5 PA; NDS LUMIZYME INTRAVENOUS RECON SOLN 5 HI; NDS 50 MG miglustat oral capsule 100 5 NDS; QL (90 per 30 days) NAGLAZYME INTRAVENOUS SOLUTION 5 MG/5 ML 5 HI; NDS 3 77

PANCREAZE ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,500-35,500-61,500 UNIT, 16,800-56,800-98,00 UNIT, 2,600-6,200-10,850 UNIT, 21,000-5,700-83,900 UNIT,,200-1,200-2,600 UNIT PERTZYE ORAL CAPSULE,DELAYED RELEASE(DR/EC) 16,000-57,500-60,500 UNIT, 2,000-86,250-90,750 UNIT,,000-1,375-15,125 UNIT, 8,000-28,750-30,250 UNIT PULMOZYME INHALATION SOLUTION 1 MG/ML STRENSIQ 28 MG/0.7 ML VIAL OUTER, L/F, P/F, SUV 0 MG/ML STRENSIQ SUBCUTANEOUS SOLUTION 100 MG/ML, 0 MG/ML VIOKACE ORAL TABLET 10,0-39,150-39,150 UNIT, 20,880-78,300-78,300 UNIT VPRIV INTRAVENOUS RECON SOLN 00 UNIT ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,000-32,000-2,000 UNIT, 10,000-3,000-55,000 UNIT, 15,000-7,000-63,000 UNIT, 15,000-51,000-82,000 UNIT, 20,000-63,000-8,000 UNIT, 25,000-79,000-105,000 UNIT, 25,000-85,000-136,000 UNIT, 3,000-10,000-1,000-UNIT, 3,000-10,000-16,000 UNIT, 0,000-126,000-168,000 UNIT, 5,000-17,000-27,000 UNIT, 5,000-17,000-2,000 UNIT Eye, Ear, Nose, Throat Agents Eye, Ear, Nose, Throat Agents, Miscellaneous apraclonidine ophthalmic (eye) drops 0.5 % atropine ophthalmic (eye) drops 1 % 2 78 5 PA; NDS; QL (150 per 30 days) 5 NDS 5 PA; NDS 5 HI; NDS azelastine nasal aerosol,spray 137 mcg (0.1 %) 3 QL (30 per 25 days) azelastine nasal spray,non-aerosol 0.15 % (205.5 QL (30 per 25 days) mcg) azelastine ophthalmic (eye) drops 0.05 % 3 BEPREVE OPHTHALMIC (EYE) DROPS 1.5 % cromolyn ophthalmic (eye) drops % 2 cyclopentolate ophthalmic (eye) drops 0.5 %, 1 %, 2 % 2 3

DYMISTA NASAL SPRAY,NON-AEROSOL 137-50 MCG/SPRAY epinastine ophthalmic (eye) drops 0.05 % 3 ipratropium bromide nasal spray,non-aerosol 2 QL (30 per 30 days) 0.03 % ipratropium bromide nasal spray,non-aerosol 2 2 QL (5 per 30 days) mcg (0.06 %) LACRISERT OPHTHALMIC (EYE) INSERT 5 QL (120 per 30 days) MG LASTACAFT OPHTHALMIC (EYE) DROPS 0.25 % naphazoline ophthalmic (eye) drops 0.1 % 2 olopatadine nasal spray,non-aerosol 0.6 % QL (30.5 per 30 days) olopatadine ophthalmic (eye) drops 0.1 %, 0.2 % proparacaine ophthalmic (eye) drops 0.5 % 1 tropicamide ophthalmic (eye) drops 0.5 %, 1 % 2 Eye, Ear, Nose, Throat Anti-Infectives Agents acetic acid otic (ear) solution 2 % 2 AZASITE OPHTHALMIC (EYE) DROPS 1 % bacitracin ophthalmic (eye) ointment 500 2 unit/gram bacitracin-polymyxin b ophthalmic (eye) ointment 2 500-10,000 unit/gram BESIVANCE OPHTHALMIC (EYE) DROPS,SUSPENSION 0.6 % bleph-10 ophthalmic (eye) drops 10 % 2 BLEPHAMIDE OPHTHALMIC (EYE) 3 DROPS,SUSPENSION 10-0.2 % BLEPHAMIDE S.O.P. OPHTHALMIC (EYE) 3 OINTMENT 10-0.2 % CILOXAN OPHTHALMIC (EYE) OINTMENT 3 0.3 % CIPRO HC OTIC (EAR) DROPS,SUSPENSION 0.2-1 % CIPRODEX OTIC (EAR) 3 DROPS,SUSPENSION 0.3-0.1 % ciprofloxacin hcl ophthalmic (eye) drops 0.3 % 1 COLY-MYCIN S OTIC (EAR) 3 DROPS,SUSPENSION 3.3-3-10-0.5 MG/ML erythromycin ophthalmic (eye) ointment 5 2 /gram (0.5 %) gatifloxacin ophthalmic (eye) drops 0.5 % QL (2.5 per 25 days) 79

gentak ophthalmic (eye) ointment 0.3 % (3 2 /gram) gentamicin ophthalmic (eye) drops 0.3 % 2 hydrocortisone-acetic acid otic (ear) drops 1-2 % levofloxacin ophthalmic (eye) drops 0.5 % 3 MOXEZA OPHTHALMIC (EYE) DROPS, VISCOUS 0.5 % moxifloxacin ophthalmic (eye) drops 0.5 % 2 NATACYN OPHTHALMIC (EYE) DROPS,SUSPENSION 5 % neomycin-bacitracin-poly-hc ophthalmic (eye) 3 ointment 3.5-00-10,000 -unit/g-1% neomycin-bacitracin-polymyxin ophthalmic (eye) 3 ointment 3.5-00-10,000 -unit-unit/g neomycin-polymyxin b-dexameth ophthalmic 2 (eye) drops,suspension 3.5/ml-10,000 unit/ml- 0.1 % neomycin-polymyxin b-dexameth ophthalmic 2 (eye) ointment 3.5 /g-10,000 unit/g-0.1 % neomycin-polymyxin-gramicidin ophthalmic (eye) 2 drops 1.75-10,000 unit-0.025/ml neomycin-polymyxin-hc ophthalmic (eye) drops,suspension 3.5-10,000-10 -unit-/ml neomycin-polymyxin-hc otic (ear) 2 drops,suspension 3.5-10,000-1 /ml-unit/ml-% neomycin-polymyxin-hc otic (ear) solution 3.5-3 10,000-1 /ml-unit/ml-% neo-polycin hc ophthalmic (eye) ointment 3.5-3 00-10,000 -unit/g-1% neo-polycin ophthalmic (eye) ointment 3.5-00- 3 10,000 -unit-unit/g ofloxacin ophthalmic (eye) drops 0.3 % 2 ofloxacin otic (ear) drops 0.3 % 3 polycin ophthalmic (eye) ointment 500-10,000 2 unit/gram polymyxin b sulf-trimethoprim ophthalmic (eye) 1 drops 10,000 unit- 1 /ml sulfacetamide sodium ophthalmic (eye) drops 10 2 % sulfacetamide sodium ophthalmic (eye) ointment 2 10 % sulfacetamide-prednisolone ophthalmic (eye) 2 drops 10 %-0.23 % (0.25 %) 80

TOBRADEX OPHTHALMIC (EYE) OINTMENT 0.3-0.1 % TOBRADEX ST OPHTHALMIC (EYE) DROPS,SUSPENSION 0.3-0.05 % tobramycin ophthalmic (eye) drops 0.3 % 1 tobramycin-dexamethasone ophthalmic (eye) 2 drops,suspension 0.3-0.1 % TOBREX OPHTHALMIC (EYE) OINTMENT 3 0.3 % trifluridine ophthalmic (eye) drops 1 % 3 ZIRGAN OPHTHALMIC (EYE) GEL 0.15 % QL (5 per 30 days) ZYLET OPHTHALMIC (EYE) DROPS,SUSPENSION 0.3-0.5 % Eye, Ear, Nose, Throat Anti-Inflammatory Agents ACUVAIL (PF) OPHTHALMIC (EYE) 3 DROPPERETTE 0.5 % ALOCRIL OPHTHALMIC (EYE) DROPS 2 % ALREX OPHTHALMIC (EYE) DROPS,SUSPENSION 0.2 % bromfenac ophthalmic (eye) drops 0.09 % 3 dexamethasone sodium phosphate ophthalmic 2 (eye) drops 0.1 % diclofenac sodium ophthalmic (eye) drops 0.1 % 2 DUREZOL OPHTHALMIC (EYE) DROPS 0.05 3 % FLAREX OPHTHALMIC (EYE) 3 DROPS,SUSPENSION 0.1 % flunisolide nasal spray,non-aerosol 25 mcg 2 QL (50 per 30 days) (0.025 %) fluocinolone acetonide oil otic (ear) drops 0.01 % 3 fluorometholone ophthalmic (eye) 3 drops,suspension 0.1 % flurbiprofen sodium ophthalmic (eye) drops 0.03 2 % fluticasone nasal spray,suspension 50 1 QL (16 per 30 days) mcg/actuation FML FORTE OPHTHALMIC (EYE) 3 DROPS,SUSPENSION 0.25 % FML S.O.P. OPHTHALMIC (EYE) OINTMENT 0.1 % 3 81

ILEVRO OPHTHALMIC (EYE) DROPS,SUSPENSION 0.3 % INVELTYS OPHTHALMIC (EYE) DROPS,SUSPENSION 1 % ketorolac ophthalmic (eye) drops 0. %, 0.5 % 2 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 % mometasone nasal spray,non-aerosol 50 2 QL (3 per 30 days) mcg/actuation NEVANAC OPHTHALMIC (EYE) DROPS,SUSPENSION 0.1 % PRED MILD OPHTHALMIC (EYE) 3 DROPS,SUSPENSION 0.12 % prednisolone acetate ophthalmic (eye) 2 drops,suspension 1 % prednisolone sodium phosphate ophthalmic (eye) 2 drops 1 % QNASL NASAL HFA AEROSOL INHALER 0 MCG/ACTUATION QNASL NASAL HFA AEROSOL INHALER 80 3 MCG/ACTUATION RESTASIS OPHTHALMIC (EYE) 3 QL (60 per 30 days) DROPPERETTE 0.05 % XIIDRA OPHTHALMIC (EYE) DROPPERETTE 5 % Gastrointestinal Agents Antiulcer Agents And Acid Suppressants amoxicil-clarithromy-lansopraz oral combo pack 500-500-30 CARAFATE ORAL SUSPENSION 100 MG/ML cimetidine hcl oral solution 300 /5 ml cimetidine oral tablet 200, 300, 00, 800 esomeprazole magnesium oral capsule,delayed 2 QL (30 per 30 days) release(dr/ec) 20, 0 famotidine oral suspension 0 /5 ml (8 /ml) 82

famotidine oral tablet 20, 0 1 lansoprazole oral capsule,delayed release(dr/ec) 2 QL (60 per 30 days) 15 lansoprazole oral capsule,delayed release(dr/ec) 2 QL (30 per 30 days) 30 lansoprazole oral tablet,disintegrat, delay rel 15 QL (60 per 30 days) lansoprazole oral tablet,disintegrat, delay rel 30 QL (30 per 30 days) misoprostol oral tablet 100 mcg, 200 mcg 2 nizatidine oral capsule 150, 300 3 nizatidine oral solution 150 /10 ml 3 omeprazole oral capsule,delayed release(dr/ec) 1 QL (60 per 30 days) 10, 20, 0 pantoprazole oral tablet,delayed release (dr/ec) 1 QL (60 per 30 days) 20, 0 rabeprazole oral tablet,delayed release (dr/ec) 20 2 QL (60 per 30 days) ranitidine hcl injection solution 50 /2 ml (25 2 /ml) ranitidine hcl oral syrup 15 /ml 1 ranitidine hcl oral tablet 150, 300 1 sucralfate oral tablet 1 gram 2 Gastrointestinal Agents, Other AMITIZA ORAL CAPSULE 2 MCG, 8 MCG QL (60 per 30 days) CARBAGLU ORAL TABLET, DISPERSIBLE 5 PA; NDS 200 MG CHOLBAM ORAL CAPSULE 250 MG, 50 MG 5 PA; NDS constulose oral solution 10 gram/15 ml 2 cromolyn oral concentrate 100 /5 ml dicyclomine oral capsule 10 2 dicyclomine oral solution 10 /5 ml 3 dicyclomine oral tablet 20 2 diphenoxylate-atropine oral liquid 2.5-0.025 3 /5 ml diphenoxylate-atropine oral tablet 2.5-0.025 3 enulose oral solution 10 gram/15 ml 2 GATTEX 30-VIAL SUBCUTANEOUS KIT 5 5 PA; NDS MG generlac oral solution 10 gram/15 ml 2 glycopyrrolate oral tablet 1, 2 83

kionex (with sorbitol) oral suspension 15-19.3 2 gram/60 ml lactulose oral packet 10 gram 2 lactulose oral solution 10 gram/15 ml 2 LINZESS ORAL CAPSULE 15 MCG, 290 3 QL (30 per 30 days) MCG, 72 MCG loperamide oral capsule 2 2 methscopolamine oral tablet 2.5, 5 metoclopramide hcl injection solution 5 /ml 2 HI metoclopramide hcl injection syringe 5 /ml 2 HI metoclopramide hcl oral solution 5 /5 ml 2 metoclopramide hcl oral tablet 10, 5 2 RAVICTI ORAL LIQUID 1.1 GRAM/ML 5 PA; NDS RELISTOR ORAL TABLET 150 MG 5 NDS; QL (90 per 30 days) RELISTOR SUBCUTANEOUS SOLUTION 12 5 NDS; QL (18 per 30 days) MG/0.6 ML RELISTOR SUBCUTANEOUS SYRINGE 12 5 NDS; QL (18 per 30 days) MG/0.6 ML RELISTOR SUBCUTANEOUS SYRINGE 8 5 NDS; QL (12 per 30 days) MG/0. ML sod polystyren sulf 15 g/60 ml sorbitol free 15 3 gram/60 ml sodium phenylbutyrate oral powder 0.9 5 NDS gram/gram sodium polystyrene sulfonate oral powder 3 sps (with sorbitol) oral suspension 15-20 gram/60 2 ml TRULANCE ORAL TABLET 3 MG QL (30 per 30 days) ursodiol oral capsule 300 3 ursodiol oral tablet 250, 500 3 VELTASSA ORAL POWDER IN PACKET 16.8 GRAM, 25.2 GRAM, 8. GRAM VIBERZI ORAL TABLET 100 MG, 75 MG 5 NDS; QL (60 per 30 days) Laxatives COLYTE WITH FLAVOR PACKS ORAL RECON SOLN 227.1-21.5-6.36 GRAM, 20-22.72-6.72-5.8 GRAM gavilyte-c oral recon soln 20-22.72-6.72-5.8 2 gram gavilyte-g oral recon soln 236-22.7-6.7-5.86 2 gram gavilyte-n oral recon soln 20 gram 2 8

GOLYTELY ORAL POWDER IN PACKET 227.1-21.5-6.36 GRAM GOLYTELY ORAL RECON SOLN 236-22.7-6.7-5.86 GRAM peg 3350-electrolytes oral recon soln 236-22.7-2 6.7-5.86 gram, 20-22.72-6.72-5.8 gram peg-electrolyte soln oral recon soln 20 gram 2 polyethylene glycol 3350 oral powder 17 2 gram/dose SUPREP BOWEL PREP KIT ORAL RECON 3 SOLN 17.5-3.13-1.6 GRAM trilyte with flavor packets oral recon soln 20 2 gram Phosphate Binders calcium acetate oral capsule 667 2 calcium acetate oral tablet 667 2 eliphos oral tablet 667 2 lanthanum oral tablet,chewable 1,000, 500 2, 750 PHOSLYRA ORAL SOLUTION 667 MG (169 3 MG CALCIUM)/5 ML sevelamer carbonate oral powder in packet 0.8 gram, 2. gram sevelamer carbonate oral tablet 800 2 VELPHORO ORAL TABLET,CHEWABLE 500 3 MG Genitourinary Agents Antispasmodics, Urinary bethanechol chloride oral tablet 10, 25, 5 2, 50 darifenacin oral tablet extended release 2 hr 15 3 QL (30 per 30 days), 7.5 flavoxate oral tablet 100 3 MYRBETRIQ ORAL TABLET EXTENDED QL (30 per 30 days) RELEASE 2 HR 25 MG, 50 MG oxybutynin chloride oral syrup 5 /5 ml 2 oxybutynin chloride oral tablet 5 2 oxybutynin chloride oral tablet extended release 2 QL (60 per 30 days) 2hr 10, 15 oxybutynin chloride oral tablet extended release 2hr 5 2 QL (30 per 30 days) 85

tolterodine oral capsule,extended release 2hr 2 2 QL (30 per 30 days), tolterodine oral tablet 1, 2 2 QL (60 per 30 days) TOVIAZ ORAL TABLET EXTENDED 3 QL (30 per 30 days) RELEASE 2 HR MG, 8 MG trospium oral capsule,extended release 2hr 60 3 QL (30 per 30 days) trospium oral tablet 20 3 QL (60 per 30 days) VESICARE ORAL TABLET 10 MG, 5 MG QL (30 per 30 days) Genitourinary Agents, Miscellaneous alfuzosin oral tablet extended release 2 hr 10 2 QL (30 per 30 days) dutasteride oral capsule 0.5 2 QL (30 per 30 days) dutasteride-tamsulosin oral capsule, er QL (30 per 30 days) multiphase 2 hr 0.5-0. finasteride oral tablet 5 1 QL (30 per 30 days) RAPAFLO ORAL CAPSULE MG, 8 MG QL (30 per 30 days) silodosin oral capsule, 8 3 QL (30 per 30 days) tamsulosin oral capsule 0. 1 QL (60 per 30 days) terazosin oral capsule 1, 10, 2, 5 1 Heavy Metal Antagonists Heavy Metal Antagonists deferoxamine injection recon soln 2 gram, 500 HI DEPEN TITRATABS ORAL TABLET 250 MG 5 NDS EXJADE ORAL TABLET, DISPERSIBLE 125 5 PA; LA; NDS MG, 250 MG, 500 MG FERRIPROX ORAL SOLUTION 100 MG/ML 5 PA; NDS FERRIPROX ORAL TABLET 500 MG 5 PA; NDS JADENU ORAL TABLET 180 MG, 360 MG, 90 5 PA; NDS MG JADENU SPRINKLE ORAL GRANULES IN PACKET 180 MG, 360 MG, 90 MG 5 PA; NDS trientine oral capsule 250 5 NDS Hormonal Agents, Stimulant/Replacement/Modifying Androgens ANADROL-50 ORAL TABLET 50 MG 5 NDS ANDRODERM TRANSDERMAL PATCH 2 PA NSO; QL (60 per 30 days) HOUR 2 MG/2 HOUR 86

ANDRODERM TRANSDERMAL PATCH 2 PA NSO; QL (30 per 30 days) HOUR MG/2 HR ANDROGEL TRANSDERMAL GEL IN PA NSO; QL (150 per 30 days) METERED-DOSE PUMP 20.25 MG/1.25 GRAM (1.62 %) ANDROGEL TRANSDERMAL GEL IN PA NSO; QL (112.5 per 30 days) PACKET 1.62 % (20.25 MG/1.25 GRAM) ANDROGEL TRANSDERMAL GEL IN PA NSO; QL (150 per 30 days) PACKET 1.62 % (0.5 MG/2.5 GRAM) danazol oral capsule 100, 200, 50 DEPO-TESTOSTERONE INTRAMUSCULAR PA NSO OIL 200 MG/ML oxandrolone oral tablet 10 5 NDS; QL (60 per 30 days) oxandrolone oral tablet 2.5 QL (180 per 30 days) testosterone cyp 200 /ml sdv, latex-free 200 3 PA NSO /ml testosterone cypionate intramuscular oil 100 3 /ml testosterone cypionate intramuscular oil 200 3 PA NSO /ml testosterone enanthate intramuscular oil 200 3 PA NSO; QL (.5 per 30 days) /ml testosterone transdermal gel in metered-dose 3 PA NSO; QL (300 per 30 days) pump 12.5 / 1.25 gram (1 %) testosterone transdermal gel in metered-dose 3 PA NSO; QL (150 per 30 days) pump 20.25 /1.25 gram (1.62 %) testosterone transdermal gel in packet 1 % (25 3 PA NSO; QL (300 per 30 days) /2.5gram), 1 % (50 /5 gram) testosterone transdermal gel in packet 1.62 % 3 PA NSO; QL (37.5 per 30 days) (20.25 /1.25 gram) testosterone transdermal gel in packet 1.62 % 3 PA NSO; QL (150 per 30 days) (0.5 /2.5 gram) Estrogens And Antiestrogens ALORA TRANSDERMAL PATCH QL (8 per 28 days) SEMIWEEKLY 0.025 MG/2 HR, 0.05 MG/2 HR, 0.075 MG/2 HR, 0.1 MG/2 HR amabelz oral tablet 0.5-0.1, 1-0.5 CLIMARA PRO TRANSDERMAL PATCH WEEKLY 0.05-0.015 MG/2 HR DUAVEE ORAL TABLET 0.5-20 MG estradiol oral tablet 0.5, 1, 2 3 estradiol transdermal patch semiweekly 0.025 3 /2 hr 87

estradiol transdermal patch semiweekly 0.0375 3 QL (8 per 28 days) /2 hr, 0.05 /2 hr, 0.075 /2 hr, 0.1 /2 hr estradiol transdermal patch weekly 0.025 /2 3 QL ( per 28 days) hr, 0.0375 /2 hr, 0.05 /2 hr, 0.06 /2 hr, 0.075 /2 hr, 0.1 /2 hr estradiol vaginal cream 0.01 % (0.1 /gram) 2 estradiol vaginal tablet 10 mcg 2 estradiol-norethindrone acet oral tablet 0.5-0.1, 1-0.5 ESTRING VAGINAL RING 2 MG (7.5 MCG QL (1 per 90 days) /2 HOUR) estropipate oral tablet 0.75, 1.5, 3 3 fyavolv oral tablet 0.5-2.5 -mcg, 1-5 -mcg IMVEXXY MAINTENANCE PACK VAGINAL QL (18 per 28 days) INSERT 10 MCG, MCG IMVEXXY STARTER PACK VAGINAL QL (18 per 28 days) INSERT, DOSE PACK 10 MCG, MCG jinteli oral tablet 1-5 -mcg lopreeza oral tablet 0.5-0.1, 1-0.5 MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG, 2.5 MG mimvey lo oral tablet 0.5-0.1 mimvey oral tablet 1-0.5 norethindrone ac-eth estradiol oral tablet 0.5-2.5 -mcg, 1-5 -mcg PREMARIN ORAL TABLET 0.3 MG, 0.5 MG, 3 0.625 MG, 0.9 MG, 1.25 MG PREMARIN VAGINAL CREAM 0.625 3 MG/GRAM PREMPHASE ORAL TABLET 0.625 MG (1)/ 3 0.625MG-5MG(1) PREMPRO ORAL TABLET 0.3-1.5 MG, 0.5-3 1.5 MG, 0.625-2.5 MG, 0.625-5 MG raloxifene oral tablet 60 3 QL (30 per 30 days) yuvafem vaginal tablet 10 mcg 2 Glucocorticoids/Mineralocorticoids cortisone oral tablet 25 3 deltasone oral tablet 20 1 PA BvD DEPO-MEDROL INJECTION SUSPENSION 2 HI 20 MG/ML dexamethasone oral elixir 0.5 /5 ml 2 PA BvD 88

dexamethasone oral tablet 0.5, 0.75, 1, 2 PA BvD 1.5, 2,, 6 dexamethasone sodium phos (pf) injection 2 HI solution 10 /ml dexamethasone sodium phosphate injection 2 HI solution 10 /ml, /ml dexamethasone sodium phosphate injection 2 HI syringe /ml EMFLAZA ORAL SUSPENSION 22.75 5 PA; NDS MG/ML EMFLAZA ORAL TABLET 18 MG, 30 MG, 36 5 PA; NDS MG, 6 MG fludrocortisone oral tablet 0.1 2 hydrocortisone oral tablet 10, 20, 5 2 methylprednisolone acetate injection suspension 2 HI 0 /ml, 80 /ml methylprednisolone oral tablet 16, 32, 2, 8 methylprednisolone oral tablets,dose pack 2 methylprednisolone sodium succ injection recon HI soln 125, 0 methylprednisolone sodium succ intravenous HI recon soln 1,000 prednisolone 15 /5 ml soln a/f, d/f 15 /5 ml 2 PA BvD (3 /ml) prednisolone oral solution 15 /5 ml 2 PA BvD prednisolone sodium phosphate oral solution 25 PA BvD /5 ml (5 /ml), 5 base/5 ml (6.7 /5 ml) prednisone oral solution 5 /5 ml 3 PA BvD prednisone oral tablet 1, 2.5, 20, 5, 1 PA BvD 50 prednisone oral tablet 10 1 PA BvD SOLU-CORTEF (PF) INJECTION RECON SOLN 1,000 MG/8 ML, 100 MG/2 ML, 250 MG/2 ML, 500 MG/ ML SOLU-MEDROL (PF) INJECTION RECON HI SOLN 125 MG/2 ML, 0 MG/ML SOLU-MEDROL (PF) INTRAVENOUS HI RECON SOLN 1,000 MG/8 ML, 500 MG/ ML SOLU-MEDROL INTRAVENOUS RECON HI SOLN 2 GRAM triamcinolone acetonide injection suspension 0 /ml 89

Pituitary desmopressin 10 mcg/0.1 ml spr 10 mcg/spray 3 (0.1 ml) desmopressin injection solution mcg/ml HI desmopressin nasal solution 0.1 /ml 3 (refrigerate) desmopressin nasal spray,non-aerosol 10 3 mcg/spray (0.1 ml) desmopressin oral tablet 0.1, 0.2 3 EGRIFTA SUBCUTANEOUS RECON SOLN 1 5 PA; LA; NDS; QL (60 per 30 days) MG INCRELEX SUBCUTANEOUS SOLUTION 10 5 PA; NDS MG/ML NORDITROPIN FLEXPRO SUBCUTANEOUS 5 PA; NDS 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) octreotide acetate injection solution 1,000 PA mcg/ml, 100 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml octreotide acetate injection syringe 100 mcg/ml PA (1 ml), 50 mcg/ml (1 ml), 500 mcg/ml (1 ml) OMNITROPE SUBCUTANEOUS CARTRIDGE 5 PA; NDS 10 MG/1.5 ML (6.7 MG/ML), 5 MG/1.5 ML (3.3 MG/ML) OMNITROPE SUBCUTANEOUS RECON 5 PA; NDS SOLN 5.8 MG SANDOSTATIN LAR DEPOT 5 PA; NDS INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 10 MG, 20 MG, 30 MG SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 5 NDS; QL (60 per 30 days) MG/ML (1 ML), 0.6 MG/ML (1 ML), 0.9 MG/ML (1 ML) SOMATULINE DEPOT SUBCUTANEOUS 5 PA NSO; NDS SYRINGE 120 MG/0.5 ML, 60 MG/0.2 ML, 90 MG/0.3 ML SOMAVERT SUBCUTANEOUS RECON 5 NDS; QL (60 per 30 days) SOLN 15 MG, 20 MG SOMAVERT SUBCUTANEOUS RECON 5 NDS; QL (30 per 30 days) SOLN 25 MG, 30 MG STIMATE NASAL SPRAY,NON-AEROSOL 150 MCG/SPRAY (0.1 ML) 90

Progestins DEPO-SUBQ PROVERA 10 QL (0.65 per 90 days) SUBCUTANEOUS SYRINGE 10 MG/0.65 ML medroxyprogesterone intramuscular suspension 150 /ml medroxyprogesterone oral tablet 10, 2.5, 2 5 megestrol oral suspension 00 /10 ml (0 3 /ml), 625 /5 ml norethindrone acetate oral tablet 5 3 progesterone micronized oral capsule 100, 2 200 Thyroid And Antithyroid Agents levothyroxine oral tablet 100 mcg, 112 mcg, 125 1 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 3 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG liothyronine oral tablet 25 mcg, 5 mcg, 50 mcg 3 methimazole oral tablet 10, 5 2 propylthiouracil oral tablet 50 3 SYNTHROID ORAL TABLET 100 MCG, 112 3 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 12.5-50 MCG 3 THYROLAR-1/2 ORAL TABLET 6.25-25 MCG 3 THYROLAR-1/ ORAL TABLET 3.1-12.5 MCG 3 THYROLAR-2 ORAL TABLET 25-100 MCG 3 THYROLAR-3 ORAL TABLET 37.5-150 MCG 3 Immunological Agents Immunological Agents ACTEMRA ACTPEN SUBCUTANEOUS PEN INJECTOR 162 MG/0.9 ML ACTEMRA INTRAVENOUS SOLUTION 200 MG/10 ML (20 MG/ML), 00 MG/20 ML (20 MG/ML), 80 MG/ ML (20 MG/ML) ACTEMRA SUBCUTANEOUS SYRINGE 162 MG/0.9 ML 5 PA; NDS 5 HI; NDS 5 PA; NDS 91

ATGAM INTRAVENOUS SOLUTION 50 5 HI; NDS MG/ML azathioprine oral tablet 50 1 PA BvD azathioprine sodium injection recon soln 100 PA BvD BIVIGAM INTRAVENOUS SOLUTION 10 % 5 PA BvD; HI; NDS CARIMUNE NF NANOFILTERED 5 PA BvD; HI; NDS INTRAVENOUS RECON SOLN 12 GRAM, 6 GRAM CIMZIA POWDER FOR RECONST 5 PA; NDS SUBCUTANEOUS KIT 00 MG (200 MG X 2 VIALS) CIMZIA SUBCUTANEOUS SYRINGE KIT 00 5 PA; NDS MG/2 ML (200 MG/ML X 2) cyclosporine intravenous solution 250 /5 ml PA BvD; HI cyclosporine modified oral capsule 100, 25 3 PA BvD, 50 cyclosporine modified oral solution 100 /ml 3 PA BvD cyclosporine oral capsule 100, 25 3 PA BvD CYTOGAM INTRAVENOUS SOLUTION 50 5 HI; NDS MG/ML ENBREL SUBCUTANEOUS RECON SOLN 25 5 PA; NDS; QL (8 per 28 days) MG (1 ML) ENBREL SUBCUTANEOUS SYRINGE 25 5 PA; NDS; QL (.08 per 28 days) MG/0.5ML (0.51) ENBREL SUBCUTANEOUS SYRINGE 50 5 PA; NDS; QL (8 per 28 days) MG/ML (0.98 ML) ENBREL SURECLICK SUBCUTANEOUS 5 PA; NDS; QL (8 per 28 days) PEN INJECTOR 50 MG/ML (0.98 ML) ENVARSUS XR ORAL TABLET EXTENDED PA BvD RELEASE 2 HR 0.75 MG, 1 MG, MG FLEBOGAMMA DIF INTRAVENOUS 5 PA BvD; HI; NDS SOLUTION 10 %, 5 % GAMASTAN S/D INTRAMUSCULAR 5 HI; NDS SOLUTION 15-18 % RANGE GAMASTAN S-D VIAL P/F, L/F, OUTER, 5 PA BvD; HI; NDS SDV 15-18 % RANGE GAMMAGARD LIQUID INJECTION 5 PA BvD; HI; NDS SOLUTION 10 % GAMMAGARD S-D (IGA < 1 MCG/ML) INTRAVENOUS RECON SOLN 10 GRAM, 5 GRAM 5 PA BvD; HI; NDS 92

GAMMAKED INJECTION SOLUTION 1 5 PA BvD; HI; NDS GRAM/10 ML (10 %), 10 GRAM/100 ML (10 %), 2.5 GRAM/25 ML (10 %), 20 GRAM/200 ML (10 %), 5 GRAM/50 ML (10 %) GAMMAPLEX (WITH SORBITOL) 5 PA BvD; HI; NDS INTRAVENOUS SOLUTION 5 % GAMMAPLEX INTRAVENOUS SOLUTION 5 PA BvD; HI; NDS 10 %, 10 % (100 ML), 10 % (200 ML) GAMUNEX-C INJECTION SOLUTION 1 5 PA BvD; HI; NDS GRAM/10 ML (10 %) GAMUNEX-C INJECTION SOLUTION 10 5 HI; NDS GRAM/100 ML (10 %), 2.5 GRAM/25 ML (10 %), 20 GRAM/200 ML (10 %), 0 GRAM/00 ML (10 %), 5 GRAM/50 ML (10 %) gengraf oral capsule 100, 25, 50 3 PA BvD gengraf oral solution 100 /ml 3 PA BvD HEPAGAM B INJECTION SOLUTION >312 HI UNIT/ML, GREATR THAN 312 UNIT/ML (5 ML) HIZENTRA SUBCUTANEOUS SOLUTION 1 5 HI; NDS GRAM/5 ML (20 %), 10 GRAM/50 ML (20 %), 2 GRAM/10 ML (20 %), GRAM/20 ML (20 %) HUMIRA PEDIATRIC CROHNS START 5 PA; NDS; QL (6 per 28 days) SUBCUTANEOUS SYRINGE KIT 0 MG/0.8 ML HUMIRA PEN CROHNS-UC-HS START 5 PA; NDS; QL (6 per 28 days) SUBCUTANEOUS PEN INJECTOR KIT 0 MG/0.8 ML HUMIRA PEN PSOR-UVEITS-ADOL HS 5 PA; NDS; QL (6 per 28 days) SUBCUTANEOUS PEN INJECTOR KIT 0 MG/0.8 ML HUMIRA PEN SUBCUTANEOUS PEN 5 PA; NDS; QL (6 per 28 days) INJECTOR KIT 0 MG/0.8 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 10 5 PA; NDS; QL (2 per 28 days) MG/0.2 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 20 5 PA; NDS; QL (6 per 28 days) MG/0. ML, 0 MG/0.8 ML HUMIRA(CF) PEDI CROHNS STARTER 5 PA; NDS; QL (3 per 28 days) SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML-0 MG/0. ML 5 PA; NDS; QL (2 per 28 days) 93

HUMIRA(CF) PEN CROHNS-UC-HS 5 PA; NDS; QL (3 per 28 days) SUBCUTANEOUS PEN INJECTOR KIT 80 MG/0.8 ML HUMIRA(CF) PEN PSOR-UV-ADOL HS 5 PA; NDS; QL (3 per 28 days) SUBCUTANEOUS PEN INJECTOR KIT 80 MG/0.8 ML-0 MG/0. ML HUMIRA(CF) PEN SUBCUTANEOUS PEN 5 PA; NDS; QL (6 per 28 days) INJECTOR KIT 0 MG/0. ML HUMIRA(CF) SUBCUTANEOUS SYRINGE 5 PA; NDS; QL (2 per 28 days) KIT 10 MG/0.1 ML, 20 MG/0.2 ML HUMIRA(CF) SUBCUTANEOUS SYRINGE 5 PA; NDS; QL (6 per 28 days) KIT 0 MG/0. ML HYPERHEP B S/D INTRAMUSCULAR HI SOLUTION 220 UNIT/ML, 220 UNIT/ML (5 ML) HYPERHEP B S/D INTRAMUSCULAR HI SYRINGE 220 UNIT/ML HYPERHEP B S-D NEONATAL HI INTRAMUSCULAR SYRINGE 110 UNIT/0.5 ML HYQVIA SUBCUTANEOUS SOLUTION 10 5 HI; NDS GRAM /100 ML (10 %), 2.5 GRAM /25 ML (10 %), 20 GRAM /200 ML (10 %), 30 GRAM /300 ML (10 %), 5 GRAM /50 ML (10 %) ILARIS (PF) SUBCUTANEOUS RECON SOLN 5 PA; NDS 150 MG/ML ILARIS (PF) SUBCUTANEOUS SOLUTION 5 PA; NDS 150 MG/ML INFLECTRA INTRAVENOUS RECON SOLN 5 HI; NDS 100 MG KEDRAB (PF) INTRAMUSCULAR 3 SOLUTION 150 UNIT/ML KINERET SUBCUTANEOUS SYRINGE 100 5 PA; NDS MG/0.67 ML leflunomide oral tablet 10, 20 2 QL (30 per 30 days) mycophenolate mofetil hcl intravenous recon soln PA BvD 500 mycophenolate mofetil oral capsule 250 2 PA BvD mycophenolate mofetil oral suspension for 2 PA BvD reconstitution 200 /ml mycophenolate mofetil oral tablet 500 2 PA BvD mycophenolate sodium oral tablet,delayed release (dr/ec) 180, 360 PA BvD 9

NABI-HB INTRAMUSCULAR SOLUTION HI GREATER THAN 1,560 UNIT/5 ML, GREATR THAN 312 UNIT/ML NULOJIX INTRAVENOUS RECON SOLN 250 5 PA BvD; NDS; QL (20 per 30 days) MG OCTAGAM INTRAVENOUS SOLUTION 10 5 PA BvD; HI; NDS %, 5 % ORENCIA CLICKJECT SUBCUTANEOUS 5 PA; NDS AUTO-INJECTOR 125 MG/ML ORENCIA SUBCUTANEOUS SYRINGE 125 5 PA; NDS MG/ML, 50 MG/0. ML, 87.5 MG/0.7 ML OTEZLA ORAL TABLET 30 MG 5 PA; NDS OTEZLA STARTER ORAL TABLETS,DOSE 5 PA; NDS PACK 10 MG ()-20 MG ()-30 MG (7), 10 MG ()-20 MG ()-30 MG(19) PRIVIGEN INTRAVENOUS SOLUTION 10 % 5 PA BvD; HI; NDS PROGRAF INTRAVENOUS SOLUTION 5 PA BvD MG/ML RAPAMUNE ORAL SOLUTION 1 MG/ML PA BvD REMICADE INTRAVENOUS RECON SOLN 5 HI; NDS 100 MG RHOPHYLAC INJECTION SYRINGE 1,500 5 HI; NDS UNIT (300 MCG)/2 ML RIDAURA ORAL CAPSULE 3 MG 5 NDS SANDIMMUNE ORAL SOLUTION 100 PA BvD MG/ML SIMPONI ARIA INTRAVENOUS SOLUTION 5 PA; HI; NDS 12.5 MG/ML SIMPONI SUBCUTANEOUS PEN INJECTOR 5 PA; NDS; QL (1 per 30 days) 100 MG/ML, 50 MG/0.5 ML SIMPONI SUBCUTANEOUS SYRINGE 100 5 PA; NDS MG/ML SIMPONI SUBCUTANEOUS SYRINGE 50 5 PA; NDS; QL (1 per 30 days) MG/0.5 ML sirolimus oral tablet 0.5, 1, 2 PA BvD STELARA INTRAVENOUS SOLUTION 130 5 HI; NDS MG/26 ML STELARA SUBCUTANEOUS SOLUTION 5 5 PA; NDS MG/0.5 ML STELARA SUBCUTANEOUS SYRINGE 5 5 PA; NDS MG/0.5 ML, 90 MG/ML tacrolimus oral capsule 0.5, 1, 5 3 PA BvD 95

THYMOGLOBULIN INTRAVENOUS RECON 5 HI; NDS SOLN 25 MG TYSABRI INTRAVENOUS SOLUTION 300 5 PA; HI; NDS MG/15 ML WINRHO SDF INJECTION SOLUTION 1,500 5 HI; NDS UNIT (300 MCG)/1.3 ML, 15000 UNIT(3000 MCG)/13 ML, 2,500 UNIT (500 MCG)/2.2 ML, 5,000 UNIT(1000 MCG)/. ML XELJANZ ORAL TABLET 10 MG, 5 MG 5 PA; NDS; QL (60 per 30 days) XELJANZ XR ORAL TABLET EXTENDED 5 PA; NDS; QL (30 per 30 days) RELEASE 2 HR 11 MG ZORTRESS ORAL TABLET 0.25 MG, 0.75 PA BvD; QL (60 per 30 days) MG, 1 MG ZORTRESS ORAL TABLET 0.5 MG PA BvD; QL (120 per 30 days) Vaccines ACTHIB (PF) INTRAMUSCULAR RECON 6 SOLN 10 MCG/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) 6 INTRAMUSCULAR SUSPENSION 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) 6 INTRAMUSCULAR SYRINGE 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML BCG VACCINE, LIVE (PF) PERCUTANEOUS 6 SUSPENSION FOR RECONSTITUTION 50 MG BEXSERO INTRAMUSCULAR SYRINGE 50-6 50-50-25 MCG/0.5 ML BOOSTRIX TDAP INTRAMUSCULAR 6 SUSPENSION 2.5-8-5 LF-MCG-LF/0.5ML BOOSTRIX TDAP INTRAMUSCULAR 6 SYRINGE 2.5-8-5 LF-MCG-LF/0.5ML DAPTACEL (DTAP PEDIATRIC) (PF) 6 INTRAMUSCULAR SUSPENSION 15-10-5 LF-MCG-LF/0.5ML ENGERIX-B (PF) INTRAMUSCULAR 6 PA BvD SUSPENSION 20 MCG/ML ENGERIX-B (PF) INTRAMUSCULAR 6 PA BvD SYRINGE 20 MCG/ML ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE 10 MCG/0.5 ML 6 PA BvD 96

GARDASIL (PF) INTRAMUSCULAR SYRINGE 20-0-0-20 MCG/0.5 ML GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION 0.5 ML GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 0.5 ML HAVRIX (PF) INTRAMUSCULAR SUSPENSION 1,0 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML HAVRIX (PF) INTRAMUSCULAR SYRINGE 1,0 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML HIBERIX (PF) INTRAMUSCULAR RECON SOLN 10 MCG/0.5 ML IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN 2.5 UNIT INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION 25-58-10 LF-MCG-LF/0.5ML INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE 25-58-10 LF-MCG-LF/0.5ML IPOL INJECTION SUSPENSION 0-8-32 UNIT/0.5 ML IPOL INJECTION SYRINGE 0-8-32 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 MCG/0.5 ML 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 HIB (PF) INTRAMUSCULAR SOLUTION 7.5 MCG/0.5 ML PENTACEL (PF) INTRAMUSCULAR KIT 15 LF UNIT-20 MCG-5 LF/0.5 ML 97 6 6 QL (1.5 per 365 days) 6 QL (1.5 per 365 days) 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6

PENTACEL DTAP-IPV COMPNT (PF) 6 INTRAMUSCULAR SUSPENSION 15 LF-8 MCG- 5 LF UNIT/0.5ML PROQUAD (PF) SUBCUTANEOUS 6 SUSPENSION FOR RECONSTITUTION 10EXP3-.3-3- 3.99 TCID50/0.5 QUADRACEL (PF) INTRAMUSCULAR 6 SUSPENSION 15 LF-8 MCG- 5 LF UNIT/0.5ML RABAVERT (PF) INTRAMUSCULAR 6 SUSPENSION FOR RECONSTITUTION 2.5 UNIT RECOMBIVAX HB (PF) INTRAMUSCULAR 6 PA BvD SUSPENSION 10 MCG/ML, 0 MCG/ML, 5 MCG/0.5 ML RECOMBIVAX HB (PF) INTRAMUSCULAR 6 PA BvD SYRINGE 10 MCG/ML, 5 MCG/0.5 ML ROTARIX ORAL SUSPENSION FOR 6 RECONSTITUTION 10EXP6 CCID50/ML ROTATEQ VACCINE ORAL SOLUTION 2 ML 6 SHINGRIX (PF) INTRAMUSCULAR 6 QL (2 per 365 days); AGE (Min 50 Years) SUSPENSION FOR RECONSTITUTION 50 MCG/0.5 ML TENIVAC (PF) INTRAMUSCULAR 6 SUSPENSION 5 LF UNIT- 2 LF UNIT/0.5ML TENIVAC (PF) INTRAMUSCULAR SYRINGE 6 5-2 LF UNIT/0.5 ML TETANUS,DIPHTHERIA TOX PED(PF) 6 INTRAMUSCULAR SUSPENSION 5-25 LF UNIT/0.5 ML TETANUS-DIPHTHERIA TOXOIDS-TD 6 INTRAMUSCULAR SUSPENSION 2-2 LF UNIT/0.5 ML TICE BCG INTRAVESICAL SUSPENSION 6 FOR RECONSTITUTION 50 MG TRUMENBA INTRAMUSCULAR SYRINGE 6 120 MCG/0.5 ML TWINRIX (PF) INTRAMUSCULAR SYRINGE 6 720 ELISA UNIT- 20 MCG/ML TYPHIM VI INTRAMUSCULAR SOLUTION 6 25 MCG/0.5 ML TYPHIM VI INTRAMUSCULAR SYRINGE 25 MCG/0.5 ML 6 98

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 EXP.7 UNIT/0.5 ML ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 19,00 UNIT/0.65 ML 6 6 6 6 6 QL (1 per 365 days); AGE (Min 9 Years) Inflammatory Bowel Disease Agents Inflammatory Bowel Disease Agents alosetron oral tablet 0.5, 1 5 NDS; QL (60 per 30 days) balsalazide oral capsule 750 2 budesonide oral capsule,delayed,extend.release 3 budesonide oral tablet,delayed and ext.release 9 QL (30 per 30 days) CANASA RECTAL SUPPOSITORY 1,000 MG 3 QL (30 per 30 days) colocort rectal enema 100 /60 ml 3 DELZICOL ORAL CAPSULE (WITH DEL REL 3 TABLETS) 00 MG GIAZO ORAL TABLET 1.1 GRAM 5 NDS hydrocortisone rectal enema 100 /60 ml 3 mesalamine oral tablet,delayed release (dr/ec) 3 1.2 gram, 800 mesalamine rectal enema gram/60 ml mesalamine rectal suppository 1,000 3 QL (30 per 30 days) PENTASA ORAL CAPSULE, EXTENDED QL (150 per 30 days) RELEASE 250 MG PENTASA ORAL CAPSULE, EXTENDED QL (300 per 30 days) RELEASE 500 MG sulfasalazine oral tablet 500 1 sulfasalazine oral tablet,delayed release (dr/ec) 500 1 Irrigating Solutions Irrigating Solutions acetic acid irrigation solution 0.25 % 3 99

LACTATED RINGERS IRRIGATION SOLUTION PHYSIOSOL IRRIGATION IRRIGATION SOLUTION 10-5-3-98 MEQ/L ringer's irrigation solution 1 sodium chloride irrigation solution 0.9 % 2 water for irrigation, sterile irrigation solution 2 Metabolic Bone Disease Agents Metabolic Bone Disease Agents alendronate oral solution 70 /75 ml alendronate oral tablet 10, 0, 5 1 QL (30 per 30 days) alendronate oral tablet 35, 70 1 QL ( per 28 days) calcitonin (salmon) nasal spray,non-aerosol 200 3 QL (3.7 per 28 days) unit/actuation calcitriol intravenous solution 1 mcg/ml 2 calcitriol oral capsule 0.25 mcg, 0.5 mcg 2 calcitriol oral solution 1 mcg/ml 2 cinacalcet oral tablet 30, 90 PA BvD; QL (120 per 30 days) cinacalcet oral tablet 60 PA BvD; QL (90 per 30 days) doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5 3 mcg etidronate disodium oral tablet 200, 00 FORTEO SUBCUTANEOUS PEN INJECTOR PA NSO; QL (2. per 28 days) 20 MCG/DOSE - 600 MCG/2. ML ibandronate oral tablet 150 1 QL (1 per 28 days) MIACALCIN INJECTION SOLUTION 200 UNIT/ML NATPARA SUBCUTANEOUS CARTRIDGE 100 MCG/DOSE, 25 MCG/DOSE, 50 MCG/DOSE, 75 MCG/DOSE 5 NDS; QL (2 per 28 days) pamidronate intravenous recon soln 30, 90 pamidronate intravenous solution 30 /10 ml (3 /ml), 60 /10 ml (6 /ml), 90 /10 ml (9 /ml) paricalcitol hemodialysis port injection solution 2 mcg/ml PARICALCITOL HEMODIALYSIS PORT INJECTION SOLUTION 5 MCG/ML paricalcitol oral capsule 1 mcg, 2 mcg, mcg PROLIA SUBCUTANEOUS SYRINGE 60 MG/ML PA; QL (2 per 365 days) 100 3 3 3

RAYALDEE ORAL CAPSULE,EXTENDED 5 NDS RELEASE 2 HR 30 MCG risedronate oral tablet 150 QL (1 per 30 days) risedronate oral tablet 30, 5 QL (30 per 30 days) risedronate oral tablet 35, 35 (12 pack), QL ( per 28 days) 35 ( pack) risedronate oral tablet,delayed release (dr/ec) 35 QL ( per 28 days) SENSIPAR ORAL TABLET 30 MG, 90 MG 5 PA BvD; NDS; QL (120 per 30 days) SENSIPAR ORAL TABLET 60 MG 5 PA BvD; NDS; QL (90 per 30 days) TYMLOS SUBCUTANEOUS PEN INJECTOR 3 PA NSO; QL (1.56 per 30 days) 80 MCG (3,120 MCG/1.56 ML) XGEVA SUBCUTANEOUS SOLUTION 120 5 PA; NDS; QL (1.7 per 28 days) MG/1.7 ML (70 MG/ML) zoledronic acid intravenous recon soln HI; QL (15 per 21 days) zoledronic acid intravenous solution /5 ml HI; QL (15 per 21 days) zoledronic acid-mannitol-water intravenous HI; QL (100 per 365 days) piggyback 5 /100 ml zoledronic ac-mannitol-0.9nacl intravenous HI piggyback /100 ml ZOMETA INTRAVENOUS PIGGYBACK MG/100 ML HI Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents ACTIMMUNE SUBCUTANEOUS SOLUTION 5 NDS 100 MCG/0.5 ML BENLYSTA INTRAVENOUS RECON SOLN 5 HI; NDS; QL (20 per 28 days) 120 MG BENLYSTA INTRAVENOUS RECON SOLN 5 HI; NDS; QL (6 per 28 days) 00 MG BENLYSTA SUBCUTANEOUS AUTO- 5 NDS; QL ( per 28 days) INJECTOR 200 MG/ML BENLYSTA SUBCUTANEOUS SYRINGE 200 5 NDS; QL ( per 28 days) MG/ML ELMIRON ORAL CAPSULE 100 MG ENTYVIO INTRAVENOUS RECON SOLN 300 5 HI; NDS MG ergoloid oral tablet 1 3 EXONDYS 51 INTRAVENOUS SOLUTION 50 5 HI; NDS MG/ML hydroxyzine pamoate oral capsule 100, 25, 50 3 101

leucovorin calcium injection recon soln 100, 200, 350, 50, 500 leucovorin calcium oral tablet 10, 15, 25 3, 5 levocarnitine (with sugar) oral solution 100 3 /ml levocarnitine oral tablet 330 3 levoleucovorin calcium intravenous solution 10 5 NDS /ml mesna intravenous solution 100 /ml MESNEX ORAL TABLET 00 MG METHERGINE ORAL TABLET 0.2 MG methylergonovine oral tablet 0.2 3 MYALEPT SUBCUTANEOUS RECON SOLN 5 PA; NDS; QL (30 per 30 days) 5 MG/ML (FINAL CONC.) PROGLYCEM ORAL SUSPENSION 50 MG/ML pyridostigmine bromide oral tablet 60 3 pyridostigmine bromide oral tablet extended 3 release 180 RENFLEXIS INTRAVENOUS RECON SOLN 5 HI; NDS 100 MG SIMULECT INTRAVENOUS RECON SOLN 5 HI; NDS 10 MG, 20 MG SOLIRIS INTRAVENOUS SOLUTION 300 5 HI; NDS MG/30 ML THALOMID ORAL CAPSULE 100 MG 5 PA NSO; NDS; QL (90 per 30 days) THALOMID ORAL CAPSULE 150 MG, 200 MG 5 PA NSO; NDS; QL (60 per 30 days) THALOMID ORAL CAPSULE 50 MG 5 PA NSO; NDS; QL (30 per 30 days) TYBOST ORAL TABLET 150 MG QL (30 per 30 days) Ophthalmic Agents Antiglaucoma Agents acetazolamide oral capsule, extended release 500 acetazolamide oral tablet 125, 250 3 ALPHAGAN P OPHTHALMIC (EYE) DROPS 3 0.1 % AZOPT OPHTHALMIC (EYE) DROPS,SUSPENSION 1 % betaxolol ophthalmic (eye) drops 0.5 % 3 102

BETOPTIC S OPHTHALMIC (EYE) DROPS,SUSPENSION 0.25 % bimatoprost ophthalmic (eye) drops 0.03 % 3 brimonidine ophthalmic (eye) drops 0.15 % 3 brimonidine ophthalmic (eye) drops 0.2 % 2 carteolol ophthalmic (eye) drops 1 % 2 COMBIGAN OPHTHALMIC (EYE) DROPS 3 0.2-0.5 % COSOPT (PF) OPHTHALMIC (EYE) QL (60 per 30 days) DROPPERETTE 2-0.5 % COSOPT OPHTHALMIC (EYE) DROPS 22.3-3 QL (10 per 30 days) 6.8 MG/ML dorzolamide ophthalmic (eye) drops 2 % 2 QL (10 per 30 days) dorzolamide-timolol (pf) ophthalmic (eye) 3 QL (60 per 30 days) dropperette 2-0.5 % dorzolamide-timolol ophthalmic (eye) drops 22.3-2 QL (10 per 30 days) 6.8 /ml latanoprost ophthalmic (eye) drops 0.005 % 1 QL (5 per 25 days) levobunolol ophthalmic (eye) drops 0.5 % 2 LUMIGAN OPHTHALMIC (EYE) DROPS 0.01 QL (2.5 per 25 days) % methazolamide oral tablet 25, 50 metipranolol ophthalmic (eye) drops 0.3 % 2 PHOSPHOLINE IODIDE OPHTHALMIC (EYE) DROPS 0.125 % pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %, 2 % RHOPRESSA OPHTHALMIC (EYE) DROPS 0.02 % SIMBRINZA OPHTHALMIC (EYE) 3 DROPS,SUSPENSION 1-0.2 % timolol maleate ophthalmic (eye) drops 0.25 %, 1 0.5 % timolol maleate ophthalmic (eye) drops, once 1 daily 0.5 % timolol maleate ophthalmic (eye) gel forming 2 solution 0.25 %, 0.5 % TRAVATAN Z OPHTHALMIC (EYE) DROPS 3 0.00 % travoprost (benzalkonium) ophthalmic (eye) drops 0.00 % 3 Replacement Preparations 103

Replacement Preparations d10 %-0.5 % sodium chloride intravenous 2 HI parenteral solution d2.5 %-0.5 % sodium chloride intravenous 2 HI parenteral solution d5 % and 0.9 % sodium chloride intravenous 2 HI parenteral solution d5 %-0.5 % sodium chloride intravenous 2 HI parenteral solution dextrose 10 % and 0.2 % nacl intravenous 2 HI parenteral solution dextrose 5 %-lactated ringers intravenous 2 HI parenteral solution dextrose 5%-0.2 % sod chloride intravenous 2 HI parenteral solution dextrose 5%-0.3 % sod.chloride intravenous 2 HI parenteral solution dextrose with sodium chloride intravenous 2 HI parenteral solution 5-0.2 % KLOR-CON 10 ORAL TABLET EXTENDED 3 RELEASE 10 MEQ KLOR-CON 8 ORAL TABLET EXTENDED 3 RELEASE 8 MEQ klor-con m10 oral tablet,er particles/crystals 10 2 meq klor-con m15 oral tablet,er particles/crystals 15 2 meq klor-con m20 oral tablet,er particles/crystals 20 2 meq KLOR-CON ORAL PACKET 20 MEQ klor-con sprinkle oral capsule, extended release 2 10 meq, 8 meq K-TAB ORAL TABLET EXTENDED RELEASE 10 MEQ, 20 MEQ, 8 MEQ LACTATED RINGERS INTRAVENOUS 3 PARENTERAL SOLUTION magnesium sulfate in d5w intravenous piggyback 2 HI 1 gram/100 ml magnesium sulfate in water intravenous parenteral solution 20 gram/500 ml ( %), 0 gram/1,000 ml ( %) 2 HI 10

magnesium sulfate in water intravenous 2 HI piggyback 2 gram/50 ml ( %), gram/100 ml ( %), gram/50 ml (8 %) magnesium sulfate injection solution meq/ml 2 HI (50 %) magnesium sulfate injection syringe meq/ml 2 HI potassium chlorid-d5-0.5%nacl intravenous HI parenteral solution 10 meq/l, 30 meq/l, 0 meq/l potassium chlorid-d5-0.5%nacl intravenous HI parenteral solution 20 meq/l potassium chloride in 0.9%nacl intravenous HI parenteral solution 20 meq/l, 0 meq/l potassium chloride in 5 % dex intravenous HI parenteral solution 20 meq/l, 30 meq/l, 0 meq/l potassium chloride in lr-d5 intravenous HI parenteral solution 20 meq/l, 0 meq/l potassium chloride in water intravenous HI piggyback 10 meq/100 ml, 10 meq/50 ml, 20 meq/100 ml, 20 meq/50 ml, 30 meq/100 ml, 0 meq/100 ml potassium chloride intravenous solution 2 meq/ml HI potassium chloride intravenous solution 2 meq/ml HI (20 ml) potassium chloride oral capsule, extended release 2 10 meq, 8 meq potassium chloride oral liquid 20 meq/15 ml, 0 meq/15 ml potassium chloride oral packet 20 meq potassium chloride oral tablet extended release 2 10 meq, 20 meq, 8 meq potassium chloride oral tablet,er 2 particles/crystals 10 meq, 20 meq potassium chloride-0.5 % nacl intravenous HI parenteral solution 20 meq/l potassium chloride-d5-0.2%nacl intravenous HI parenteral solution 10 meq/l, 20 meq/l, 30 meq/l, 0 meq/l potassium chloride-d5-0.3%nacl intravenous HI parenteral solution 20 meq/l potassium chloride-d5-0.9%nacl intravenous HI parenteral solution 20 meq/l, 0 meq/l potassium citrate oral tablet extended release 10 meq (1,080 ), 15 meq, 5 meq (50 ) 3 105

ringer's intravenous parenteral solution 1 sodium chloride 0.5 % intravenous parenteral 2 HI solution 0.5 % sodium chloride 0.5 % intravenous piggyback 2 HI 0.5 % sodium chloride 0.9 % intravenous parenteral 2 HI solution sodium chloride 3 % intravenous parenteral 2 HI solution 3 % sodium chloride 5 % intravenous parenteral 2 HI solution 5 % sodium chloride intravenous parenteral solution 2 HI 2.5 meq/ml TPN ELECTROLYTES II IV SOLN 25'S,20ML/50ML FTV 18-18-5-.5-35 MEQ/20 ML TPN ELECTROLYTES INTRAVENOUS SOLUTION 35-20-5 MEQ/20 ML Respiratory Tract Agents Anti-Inflammatories, Inhaled Corticosteroids ADVAIR DISKUS INHALATION BLISTER WITH DEVICE 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE ADVAIR HFA INHALATION HFA AEROSOL INHALER 115-21 MCG/ACTUATION, 230-21 MCG/ACTUATION, 5-21 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 BREO ELLIPTA INHALATION BLISTER WITH DEVICE 100-25 MCG/DOSE, 200-25 MCG/DOSE budesonide inhalation suspension for nebulization 0.25 /2 ml, 0.5 /2 ml, 1 /2 ml FLOVENT 100 MCG DISKUS 100 MCG/ACTUATION FLOVENT 250 MCG DISKUS 250 MCG/ACTUATION 3 QL (60 per 30 days) 3 QL (12 per 30 days) 106 3 QL (30 per 30 days) 3 QL (60 per 30 days) 3 PA BvD 3 QL (60 per 30 days) 3 QL (20 per 30 days)

FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION, 220 MCG/ACTUATION, MCG/ACTUATION fluticasone-salmeterol inhalation aerosol powdr breath activated 113-1 mcg/actuation, 232-1 mcg/actuation, 55-1 mcg/actuation QVAR INHALATION AEROSOL 0 MCG/ACTUATION, 80 MCG/ACTUATION QVAR REDIHALER INHALATION HFA AEROSOL BREATH ACTIVATED 0 MCG/ACTUATION, 80 MCG/ACTUATION SYMBICORT 160-.5 MCG INHALER 60 INHALATIONS 160-.5 MCG/ACTUATION SYMBICORT 80-.5 MCG INHALER 60 INHALATIONS 80-.5 MCG/ACTUATION SYMBICORT INHALATION HFA AEROSOL INHALER 160-.5 MCG/ACTUATION, 80-.5 MCG/ACTUATION 3 QL (60 per 30 days) 3 QL (20 per 30 days) 3 QL (2 per 30 days) 2 3 3 3 QL (12 per 30 days) 3 QL (13.8 per 30 days) 3 QL (10.2 per 30 days) Antileukotrienes montelukast oral tablet 10 1 QL (30 per 30 days) montelukast oral tablet,chewable, 5 1 QL (30 per 30 days) zafirlukast oral tablet 10, 20 2 QL (60 per 30 days) zileuton oral tablet, er multiphase 12 hr 600 5 NDS ZYFLO ORAL TABLET 600 MG 5 NDS Bronchodilators albuterol sulfate inhalation solution for nebulization 0.63 /3 ml, 1.25 /3 ml, 2.5 /3 ml (0.083 %), 5 /ml 1 PA BvD albuterol sulfate oral syrup 2 /5 ml 2 albuterol sulfate oral tablet 2, albuterol sulfate oral tablet extended release 12 hr, 8 aminophylline intravenous solution 250 /10 HI ml, 500 /20 ml ANORO ELLIPTA INHALATION BLISTER WITH DEVICE 62.5-25 MCG/ACTUATION 3 QL (60 per 30 days) 107

ARCAPTA NEOHALER INHALATION CAPSULE, W/INHALATION DEVICE 75 MCG ATROVENT HFA INHALATION HFA QL (25.8 per 30 days) AEROSOL INHALER 17 MCG/ACTUATION BROVANA INHALATION SOLUTION FOR PA BvD; QL (120 per 30 days) NEBULIZATION 15 MCG/2 ML COMBIVENT RESPIMAT INHALATION 3 QL ( per 20 days) MIST 20-100 MCG/ACTUATION INCRUSE ELLIPTA INHALATION BLISTER 3 QL (30 per 30 days) WITH DEVICE 62.5 MCG/ACTUATION ipratropium bromide inhalation solution 0.02 % 2 PA BvD ipratropium-albuterol inhalation solution for 1 PA BvD nebulization 0.5-3 (2.5 base)/3 ml levalbuterol hcl inhalation solution for PA BvD nebulization 0.31 /3 ml, 0.63 /3 ml, 1.25 /0.5 ml levalbuterol tartrate inhalation hfa aerosol QL (30 per 30 days) inhaler 5 mcg/actuation metaproterenol oral syrup 10 /5 ml metaproterenol oral tablet 10, 20 PERFOROMIST INHALATION SOLUTION PA BvD; QL (120 per 30 days) FOR NEBULIZATION 20 MCG/2 ML SEREVENT DISKUS 50 MCG 50 MCG/DOSE 3 SEREVENT DISKUS INHALATION BLISTER 3 QL (60 per 30 days) WITH DEVICE 50 MCG/DOSE SPIRIVA RESPIMAT INHALATION MIST 3 QL ( per 28 days) 1.25 MCG/ACTUATION SPIRIVA RESPIMAT INHALATION MIST 2.5 3 QL ( per 28 days) MCG/ACTUATION SPIRIVA WITH HANDIHALER INHALATION 3 QL (30 per 30 days) CAPSULE, W/INHALATION DEVICE 18 MCG STIOLTO RESPIMAT INHALATION MIST 3 QL ( per 28 days) 2.5-2.5 MCG/ACTUATION STRIVERDI RESPIMAT INHALATION MIST 3 2.5 MCG/ACTUATION terbutaline oral tablet 2.5, 5 theophylline oral tablet extended release 12 hr 100, 200, 300, 50 theophylline oral tablet extended release 2 hr 00, 600 TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE 100-62.5-25 MCG QL (60 per 30 days) 108

VENTOLIN HFA 90 MCG INHALER 60 3 ACTUATIONS 90 MCG/ACTUATION VENTOLIN HFA INHALATION HFA 3 QL (36 per 30 days) AEROSOL INHALER 90 MCG/ACTUATION YUPELRI INHALATION SOLUTION FOR PA BvD; QL (90 per 30 days) NEBULIZATION 175 MCG/3 ML Respiratory Tract Agents, Other acetylcysteine intravenous solution 200 /ml 3 (20 %) acetylcysteine solution 100 /ml (10 %), 200 3 PA BvD /ml (20 %) ARALAST NP INTRAVENOUS RECON SOLN 5 HI; NDS 1,000 MG CINQAIR INTRAVENOUS SOLUTION 10 5 HI; NDS MG/ML cromolyn inhalation solution for nebulization 20 3 PA BvD /2 ml DALIRESP ORAL TABLET 250 MCG, 500 3 QL (30 per 30 days) MCG ESBRIET ORAL CAPSULE 267 MG 5 PA; NDS; QL (270 per 30 days) ESBRIET ORAL TABLET 267 MG, 801 MG 5 PA; NDS FASENRA SUBCUTANEOUS SYRINGE 30 5 NDS MG/ML GLASSIA INTRAVENOUS SOLUTION 1 5 HI; NDS GRAM/50 ML (2 %) KALYDECO ORAL GRANULES IN PACKET 5 PA; NDS; QL (56 per 28 days) 50 MG, 75 MG KALYDECO ORAL TABLET 150 MG 5 PA; NDS; QL (60 per 30 days) NUCALA SUBCUTANEOUS RECON SOLN 5 NDS 100 MG OFEV ORAL CAPSULE 100 MG, 150 MG 5 PA; NDS; QL (60 per 30 days) ORKAMBI ORAL GRANULES IN PACKET 5 PA; NDS; QL (56 per 28 days) 100-125 MG, 150-188 MG ORKAMBI ORAL TABLET 100-125 MG, 200-5 PA; LA; NDS; QL (112 per 28 days) 125 MG PROLASTIN-C INTRAVENOUS RECON 5 HI; NDS SOLN 1,000 MG SYMDEKO ORAL TABLETS, SEQUENTIAL 5 PA; NDS; QL (60 per 30 days) 100-150 MG (D)/ 150 MG (N) XOLAIR SUBCUTANEOUS RECON SOLN 5 NDS; QL (6 per 28 days) 150 MG XOLAIR SUBCUTANEOUS SYRINGE 150 5 NDS; QL ( per 28 days) MG/ML 109

XOLAIR SUBCUTANEOUS SYRINGE 75 MG/0.5 ML ZEMAIRA INTRAVENOUS RECON SOLN 1,000 MG 5 NDS; QL (2 per 28 days) 5 HI; NDS Skeletal Muscle Relaxants Skeletal Muscle Relaxants baclofen oral tablet 10, 20 1 carisoprodol oral tablet 250, 350 3 PA; AGE (Max 6 Years) chlorzoxazone oral tablet 250, 500 3 PA; AGE (Max 6 Years) cyclobenzaprine oral tablet 10, 5 3 PA; AGE (Max 6 Years) dantrolene oral capsule 100, 25, 50 3 metaxall oral tablet 800 metaxalone oral tablet 00, 800 methocarbamol oral tablet 500, 750 3 PA; AGE (Max 6 Years) orphenadrine citrate oral tablet extended release 3 100 tizanidine oral tablet 2, 1 Sleep Disorder Agents Sleep Disorder Agents armodafinil oral tablet 150, 200, 250 PA; QL (30 per 30 days) armodafinil oral tablet 50 PA; QL (60 per 30 days) BELSOMRA ORAL TABLET 10 MG, 15 MG, QL (30 per 30 days) 20 MG, 5 MG eszopiclone oral tablet 1, 2, 3 3 QL (30 per 30 days) HETLIOZ ORAL CAPSULE 20 MG 5 PA; NDS; QL (30 per 30 days) modafinil oral tablet 100 3 PA; QL (90 per 30 days) modafinil oral tablet 200 3 PA; QL (60 per 30 days) ROZEREM ORAL TABLET 8 MG QL (30 per 30 days) XYREM ORAL SOLUTION 500 MG/ML 5 PA; LA; NDS; QL (50 per 30 days) zaleplon oral capsule 10, 5 3 QL (30 per 30 days) zolpidem oral tablet 10 3 QL (30 per 30 days) zolpidem oral tablet 5 3 QL (60 per 30 days) zolpidem oral tablet,ext release multiphase 12.5 zolpidem oral tablet,ext release multiphase 6.25 Vasodilating Agents Vasodilating Agents QL (30 per 30 days) QL (60 per 30 days) ADCIRCA ORAL TABLET 20 MG 5 PA; NDS; QL (60 per 30 days) ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 5 PA; NDS; QL (90 per 30 days) MG, 2 MG, 2.5 MG 110

CIALIS ORAL TABLET 2.5 MG, 5 MG PA epoprostenol (glycine) intravenous recon soln 0.5 5 HI; NDS, 1.5 LETAIRIS ORAL TABLET 10 MG, 5 MG 5 NDS; QL (30 per 30 days) OPSUMIT ORAL TABLET 10 MG 5 PA; NDS; QL (30 per 30 days) ORENITRAM ORAL TABLET EXTENDED PA RELEASE 0.125 MG ORENITRAM ORAL TABLET EXTENDED 5 PA; NDS RELEASE 0.25 MG, 1 MG, 2.5 MG, 5 MG REMODULIN INJECTION SOLUTION 1 5 HI; NDS MG/ML, 10 MG/ML, 2.5 MG/ML, 5 MG/ML REVATIO ORAL SUSPENSION FOR 5 PA; NDS; QL (180 per 30 days) RECONSTITUTION 10 MG/ML sildenafil (antihypertensive) oral tablet 20 2 PA; QL (90 per 30 days) tadalafil (antihypertensive) oral tablet 20 3 PA; QL (60 per 30 days) tadalafil oral tablet 2.5, 5 3 PA; QL (30 per 30 days) TRACLEER ORAL TABLET 125 MG, 62.5 MG 5 LA; NDS; QL (60 per 30 days) UPTRAVI ORAL TABLET 1,000 MCG, 1,200 5 PA; NDS; QL (60 per 30 days) MCG, 1,00 MCG, 1,600 MCG, 800 MCG UPTRAVI ORAL TABLET 200 MCG, 00 5 PA; NDS MCG, 600 MCG UPTRAVI ORAL TABLETS,DOSE PACK 200 5 PA; NDS MCG (10)- 800 MCG (60) VELETRI INTRAVENOUS RECON SOLN 0.5 5 HI; NDS MG, 1.5 MG VENTAVIS INHALATION SOLUTION FOR NEBULIZATION 10 MCG/ML, 20 MCG/ML 5 PA BvD; NDS; QL (270 per 30 days) Vitamins And Minerals Vitamins And Minerals FLUORIDE (SODIUM) ORAL TABLET 1 MG (2.2 MG SOD. FLUORIDE) LUDENT FLUORIDE 1 MG TAB CHEW D/F, S/F, CHEWABLE (OTC) 1 MG (2.2 MG SOD. FLUORIDE) pnv prenatal plus multivit tab s/f, gluten-free 27 iron- 1 prenatal vitamin plus low iron oral tablet 27 iron- 1 3 3 2 2 111

INDEX A abacavir... 2, 3 abacavir-lamivudine... 3 abacavir-lamivudine-zidovudine... 3 ABELCET... 33 ABILIFY MAINTENA... 39 abiraterone... 16 ABRAXANE... 16 acamprosate... 8 acarbose... 29 acebutolol... 55 acetaminophen-codeine... 3 acetazolamide... 102 acetic acid... 79, 99 acetylcysteine... 109 acitretin... 71 ACTEMRA... 91 ACTEMRA ACTPEN... 91 ACTHIB (PF)... 96 ACTIMMUNE... 101 ACUVAIL (PF)... 81 acyclovir... 6, 71 acyclovir sodium... 6 ADACEL(TDAP ADOLESN/ADULT)(PF).. 96 ADAGEN... 77 adapalene... 76 ADCIRCA... 110 adefovir... 6 ADEMPAS... 110 ADLYXIN... 29 adriamycin... 16 adrucil... 16 ADVAIR DISKUS... 106 ADVAIR HFA... 106 afeditab cr... 58 AFINITOR... 16 AFINITOR DISPERZ... 16 AIMOVIG AUTOINJECTOR35 AIMOVIG AUTOINJECTOR (2 PACK)... 35 AKYNZEO (NETUPITANT) 36 ala-cort... 7 albendazole... 37 ALBENZA... 37 albuterol sulfate... 107 alclometasone... 7 ALCOHOL PADS... 71 ALDURAZYME... 77 ALECENSA... 16 alendronate... 100 alfuzosin... 86 ALIMTA... 16 ALINIA... 37 ALIQOPA... 16 allopurinol... 3 almotriptan malate... 35 ALOCRIL... 81 alogliptin... 29 alogliptin-metformin... 29 alogliptin-pioglitazone... 29 ALORA... 87 alosetron... 99 ALPHAGAN P... 102 alprazolam... 8 ALREX... 81 altavera (28)... 65 ALUNBRIG... 16 alyacen 1/35 (28)... 65 alyacen 7/7/7 (28)... 65 amabelz... 87 amantadine hcl... 38 AMBISOME... 33 amethia... 65 amethia lo... 65 amethyst (28)... 65 amikacin... 9 amiloride... 59 amiloride-hydrochlorothiazide59 aminocaproic acid... 9 aminophylline... 107 AMINOSYN 10 %... 50 AMINOSYN 7 % WITH ELECTROLYTES... 50 AMINOSYN 8.5 %... 50 AMINOSYN 8.5 %- ELECTROLYTES... 50 AMINOSYN II 10 %... 50 AMINOSYN II 15 %... 50 AMINOSYN II 7 %... 50 AMINOSYN II 8.5 %... 50 AMINOSYN II 8.5 %- ELECTROLYTES... 50 AMINOSYN M 3.5 %... 50 AMINOSYN-HBC 7%... 50 AMINOSYN-PF 10 %... 50 AMINOSYN-PF 7 % (SULFITE-FREE)... 50 AMINOSYN-RF 5.2 %... 51 amiodarone... 55 AMITIZA... 83 amitriptyline... 27 amitriptyline-chlordiazepoxide... 27 amlodipine... 58 amlodipine-atorvastatin... 60 amlodipine-benazepril... 58 amlodipine-olmesartan... 59 amlodipine-valsartan... 59 amlodipine-valsartan-hcthiazid... 59 ammonium lactate... 71 amnesteem... 71 112

amoxapine... 27 amoxicil-clarithromy-lansopraz... 82 amoxicillin... 1 amoxicillin-pot clavulanate... 1 amphotericin b... 33 ampicillin... 1 ampicillin sodium... 1 ampicillin-sulbactam... 1 AMPYRA... 62 ANADROL-50... 86 anagrelide... 9 ANALPRAM-HC... 7 anastrozole... 16 ANDRODERM... 86, 87 ANDROGEL... 87 ANORO ELLIPTA... 107 ANZEMET... 36 APOKYN... 38 apraclonidine... 78 aprepitant... 36 apri... 65 APTIOM... 23 APTIVUS... 3 ARALAST NP... 109 aranelle (28)... 65 ARANESP (IN POLYSORBATE)... 8 ARCAPTA NEOHALER... 108 aripiprazole... 39 ARISTADA... 39, 0 armodafinil... 110 ARMONAIR RESPICLICK 106 ARNUITY ELLIPTA... 106 arsenic trioxide... 16 ascomp with codeine... 3 ashlyna... 65 aspirin-dipyridamole... 50 ASSURE ID INSULIN SAFETY... 76 astramorph-pf... 3 atazanavir... 3 atenolol... 55 atenolol-chlorthalidone... 55 ATGAM... 92 atomoxetine... 62 atorvastatin... 60 atovaquone... 37 atovaquone-proguanil... 37 ATRIPLA... 3 atropine... 78 ATROVENT HFA... 108 AUBAGIO... 62 aubra... 65 AUSTEDO... 62 AVANDIA... 29 AVASTIN... 16 aviane... 65 avita... 76 AVONEX... 62 AVONEX (WITH ALBUMIN)... 62 AVYCAZ... 11 azacitidine... 17 AZACTAM... 13 AZACTAM IN DEXTROSE (ISO-OSM)... 13 AZASITE... 79 azathioprine... 92 azathioprine sodium... 92 azelaic acid... 71 azelastine... 78 AZELEX... 72 azithromycin... 13 AZOPT... 102 aztreonam... 13 azurette (28)... 65 B baciim... 10 bacitracin... 10, 79 bacitracin-polymyxin b... 79 baclofen... 110 BACTROBAN NASAL... 73 balsalazide... 99 balziva (28)... 65 BANZEL... 23 BARACLUDE... 6 BAVENCIO... 17 BCG VACCINE, LIVE (PF).. 96 BD ULTRA-FINE NANO PEN NEEDLE... 76 BD VEO INSULIN SYR HALF UNIT... 76 BD VEO INSULIN SYRINGE UF... 76, 77 bekyree (28)... 65 BELEODAQ... 17 BELSOMRA... 110 benazepril... 5 benazepril-hydrochlorothiazide... 5 BENLYSTA... 101 benztropine... 38 BEPREVE... 78 BERINERT... 8 BESIVANCE... 79 BESPONSA... 17 betamethasone dipropionate... 7 betamethasone valerate... 7 betamethasone, augmented... 7 BETASERON... 62 betaxolol... 55, 102 bethanechol chloride... 85 BETHKIS... 9 BETOPTIC S... 103 bexarotene... 17 BEXSERO... 96 bicalutamide... 17 BICILLIN L-A... 1 BICNU... 17 BIKTARVY... 3 bimatoprost... 103 bisoprolol fumarate... 56 bisoprolol-hydrochlorothiazide... 56 BIVIGAM... 92 113

bleomycin... 17 bleph-10... 79 BLEPHAMIDE... 79 BLEPHAMIDE S.O.P.... 79 blisovi 2 fe... 65 blisovi fe 1.5/30 (28)... 65 blisovi fe 1/20 (28)... 65 BOOSTRIX TDAP... 96 BORTEZOMIB... 17 BOSULIF... 17 BRAFTOVI... 17 BREO ELLIPTA... 106 brevicon (28)... 65 briellyn... 65 BRILINTA... 50 brimonidine... 103 BRIVIACT... 23, 2 bromfenac... 81 bromocriptine... 38 BROVANA... 108 budesonide... 99, 106 bumetanide... 59 buprenorphine... 3 buprenorphine hcl... 3, 8 buprenorphine-naloxone... 8 bupropion hcl... 27 bupropion hcl (smoking deter). 8 buspirone... 8 butalbital compound w/codeine 3 butalbital-acetaminop-caf-cod.. 3 butalbital-acetaminophen... 3 butalbital-acetaminophen-caff.. 3 butalbital-aspirin-caffeine... 3 butorphanol tartrate... 3 BYDUREON... 29 BYDUREON BCISE... 29 BYETTA... 29, 30 BYSTOLIC... 56 C cabergoline... 38 CABOMETYX... 17 calcipotriene... 72 calcitonin (salmon)... 100 calcitrene... 72 calcitriol... 72, 100 calcium acetate... 85 CALQUENCE... 17 camila... 65 camrese... 65 camrese lo... 65 CANASA... 99 candesartan... 53 candesartan-hydrochlorothiazid... 5 capacet... 3 CAPASTAT... 36 CAPRELSA... 17 captopril... 5 captopril-hydrochlorothiazide 5 CARAFATE... 82 CARBAGLU... 83 carbamazepine... 2 carbidopa... 38 carbidopa-levodopa... 38 carbidopa-levodopa-entacapone... 38 carboplatin... 17 CARIMUNE NF NANOFILTERED... 92 carisoprodol... 110 carmustine... 17 CAROSPIR... 61 carteolol... 103 cartia xt... 56 carvedilol... 56 carvedilol phosphate... 56 caspofungin... 33 CAYSTON... 13 caziant (28)... 66 cefaclor... 11 cefadroxil... 11, 12 cefazolin... 12 cefazolin in dextrose (iso-os). 12 cefdinir... 12 cefepime... 12 cefixime... 12 cefotaxime... 12 cefotetan... 12 cefoxitin... 12 cefpodoxime... 12 cefprozil... 12 ceftazidime... 12 ceftriaxone... 12 cefuroxime axetil... 12 cefuroxime sodium... 12 celecoxib... 6 CELONTIN... 2 cephalexin... 12 CEREZYME... 77 CESAMET... 36 cetirizine... 35 cevimeline... 71 CHANTIX... 8 CHANTIX CONTINUING MONTH BOX... 8 CHANTIX STARTING MONTH BOX... 8 chateal (28)... 66 chloramphenicol sod succinate... 10 chlordiazepoxide hcl... 8 chlordiazepoxide-clidinium... 23 chlorhexidine gluconate... 71 chloroquine phosphate... 37 chlorothiazide... 59 chlorothiazide sodium... 59 chlorpromazine... 0 chlorthalidone... 59 chlorzoxazone... 110 CHOLBAM... 83 cholestyramine (with sugar)... 60 cholestyramine light... 60 CIALIS... 111 ciclopirox... 33 cilostazol... 50 CILOXAN... 79 11

CIMDUO... 3 cimetidine... 82 cimetidine hcl... 82 CIMZIA... 92 CIMZIA POWDER FOR RECONST... 92 cinacalcet... 100 CINQAIR... 109 CINRYZE... 8 CIPRO HC... 79 CIPRODEX... 79 ciprofloxacin... 15 ciprofloxacin hcl... 15, 79 ciprofloxacin in 5 % dextrose. 15 citalopram... 27 cladribine... 17 CLAFORAN... 12 claravis... 72 clarithromycin... 13 clemastine... 35 CLIMARA PRO... 87 clindamycin hcl... 10 clindamycin in 5 % dextrose.. 10 clindamycin palmitate hcl... 10 clindamycin phosphate... 10, 35, 73 clindamycin-benzoyl peroxide73 CLINIMIX 5%/D15W SULFITE FREE... 51 CLINIMIX 5%/D25W SULFITE-FREE... 51 CLINIMIX 2.75%/D5W SULFIT FREE... 51 CLINIMIX.25%/D10W SULF FREE... 51 CLINIMIX.25%/D5W SULFIT FREE... 51 CLINIMIX.25%-D20W SULF-FREE... 51 CLINIMIX.25%-D25W SULF-FREE... 51 CLINIMIX 5%- D20W(SULFITE-FREE)... 51 CLINIMIX E 2.75%/D10W SUL FREE... 51 CLINIMIX E 2.75%/D5W SULF FREE... 51 CLINIMIX E.25%/D10W SUL FREE... 51 CLINIMIX E.25%/D25W SUL FREE... 51 CLINIMIX E.25%/D5W SULF FREE... 51 CLINIMIX E 5%/D15W SULFIT FREE... 52 CLINIMIX E 5%/D20W SULFIT FREE... 52 CLINIMIX E 5%/D25W SULFIT FREE... 52 CLINISOL SF 15 %... 52 clobazam... 8 clobetasol... 7 clobetasol-emollient... 7 clomipramine... 27 clonazepam... 9 clonidine... 53 clonidine hcl... 53, 62 clopidogrel... 50 clorazepate dipotassium... 9 clorpres... 53 clotrimazole... 33 clotrimazole-betamethasone... 33 clozapine... 0 COARTEM... 37 codeine sulfate... 3 colchicine... 3 colesevelam... 60 colestipol... 60 colistin (colistimethate na)... 10 colocort... 99 COLY-MYCIN S... 79 COLYTE WITH FLAVOR PACKS... 8 COMBIGAN... 103 COMBIVENT RESPIMAT.. 108 COMETRIQ... 17 COMPLERA... 3 compro... 37 constulose... 83 COPAXONE... 62 COPIKTRA... 17 CORDRAN TAPE LARGE ROLL... 7 CORLANOR... 57 cormax... 7 cortisone... 88 CORTISPORIN... 73 COSENTYX (2 SYRINGES). 72 COSENTYX PEN (2 PENS).. 72 COSOPT... 103 COSOPT (PF)... 103 COTELLIC... 17 COUMADIN... 7 CREON... 77 CRIXIVAN... 3 cromolyn... 78, 83, 109 cryselle (28)... 66 cyclafem 1/35 (28)... 66 cyclafem 7/7/7 (28)... 66 cyclobenzaprine... 110 cyclopentolate... 78 cyclophosphamide... 17 CYCLOPHOSPHAMIDE... 17 CYCLOSET... 30 cyclosporine... 92 cyclosporine modified... 92 cyproheptadine... 35 CYRAMZA... 17 cyred... 66 cyred eq... 66 cytarabine... 18 cytarabine (pf)... 17 CYTOGAM... 92 115

D d10 %-0.5 % sodium chloride... 10 d2.5 %-0.5 % sodium chloride... 10 d5 % and 0.9 % sodium chloride... 10 d5 %-0.5 % sodium chloride... 10 dalfampridine... 62 DALIRESP... 109 danazol... 87 dantrolene... 110 dapsone... 36, 72 DAPTACEL (DTAP PEDIATRIC) (PF)... 96 daptomycin... 10 DARAPRIM... 37 darifenacin... 85 DARZALEX... 18 dasetta 1/35 (28)... 66 dasetta 7/7/7 (28)... 66 daunorubicin... 18 DAURISMO... 18 daysee... 66 deblitane... 66 deferoxamine... 86 DELSTRIGO... 3 deltasone... 88 delyla (28)... 66 DELZICOL... 99 demeclocycline... 16 DEMEROL... DEMEROL (PF)... 3, DEMSER... 57 denta 5000 plus... 71 dentagel... 71 DEPEN TITRATABS... 86 DEPO-MEDROL... 88 DEPO-SUBQ PROVERA 10... 91 DEPO-TESTOSTERONE... 87 DESCOVY... 3 desipramine... 27 desloratadine... 35 desmopressin... 90 desog-e.estradiol/e.estradiol... 66 desogestrel-ethinyl estradiol... 66 desonide... 7 desoximetasone... 7, 75 desvenlafaxine succinate... 27 dexamethasone... 88, 89 dexamethasone sodium phos (pf)... 89 dexamethasone sodium phosphate... 81, 89 dexmethylphenidate... 62, 63 dextroamphetamine... 63 dextroamphetamineamphetamine... 63 dextrose 10 % and 0.2 % nacl... 10 dextrose 10 % in water (d10w)... 52 dextrose 20 % in water (d20w)... 52 dextrose 25 % in water (d25w)... 52 dextrose 30 % in water (d30w)... 52 dextrose 0 % in water (d0w)... 52 dextrose 5 % in ringer's... 52 dextrose 5 % in water (d5w)... 52 dextrose 5 %-lactated ringers10 dextrose 5%-0.2 % sod chloride... 10 dextrose 5%-0.3 % sod.chloride... 10 dextrose 50 % in water (d50w)... 52 dextrose 70 % in water (d70w)... 52 dextrose with sodium chloride... 10 DIASTAT... 9 DIASTAT ACUDIAL... 9 diazepam... 9 diazepam intensol... 9 diclofenac potassium... 6 diclofenac sodium... 6, 81 diclofenac-misoprostol... 6 dicloxacillin... 1 dicyclomine... 83 didanosine... 3 DIFICID... 13 diflunisal... 6 digitek... 57 digox... 57 digoxin... 57 DIGOXIN... 57 dihydroergotamine... 35 DILANTIN... 2 DILANTIN EXTENDED... 2 DILANTIN INFATABS... 2 DILANTIN-125... 2 DILAUDID (PF)... diltiazem hcl... 56, 57 dilt-xr... 57 diphenoxylate-atropine... 83 dipyridamole... 50 disopyramide phosphate... 55 disulfiram... 8 divalproex... 2 dobutamine... 58 dobutamine in d5w... 58 dofetilide... 55 donepezil... 26 dopamine... 58 dopamine in 5 % dextrose... 58 dorzolamide... 103 dorzolamide-timolol... 103 dorzolamide-timolol (pf)... 103 doxazosin... 53 doxepin... 27 116

doxercalciferol... 100 doxorubicin... 18 doxorubicin, peg-liposomal... 18 doxy-100... 16 doxycycline hyclate... 16 doxycycline monohydrate... 16 dronabinol... 37 drospirenone-e.estradiol-lm.fa 66 drospirenone-ethinyl estradiol 66 DROXIA... 18 DUAVEE... 87 duloxetine... 27, 28 DUPIXENT... 72 DUREZOL... 81 dutasteride... 86 dutasteride-tamsulosin... 86 DYMISTA... 79 DYRENIUM... 59 E econazole... 33 EDURANT... 3 efavirenz... 3 EGRIFTA... 90 ELAPRASE... 77 ELELYSO... 77 eletriptan... 35 ELIDEL... 75 elinest... 66 eliphos... 85 ELIQUIS... 7 ELMIRON... 101 EMCYT... 18 EMFLAZA... 89 emoquette... 66 EMPLICITI... 18 EMSAM... 28 EMTRIVA... 3 EMVERM... 38 enalapril maleate... 5 enalapril-hydrochlorothiazide 5 ENBREL... 92 ENBREL SURECLICK... 92 endocet... ENGERIX-B (PF)... 96 ENGERIX-B PEDIATRIC (PF)... 96 enoxaparin... 7 enpresse... 66 enskyce... 66 entacapone... 38 entecavir... 6 ENTRESTO... 5 ENTYVIO... 101 enulose... 83 ENVARSUS XR... 92 EPCLUSA... 6 EPIDIOLEX... 2 epinastine... 79 epinephrine... 58 epirubicin... 18 epitol... 2 EPIVIR HBV... 3 eplerenone... 61 epoprostenol (glycine)... 111 eprosartan... 5 EPZICOM... 3 EQUETRO... 2 ERAXIS(WATER DILUENT)... 33 ergoloid... 101 ergotamine-caffeine... 35 ERIVEDGE... 18 ERLEADA... 18 errin... 66 ertapenem... 13 ery pads... 73 ery-tab... 13 ERY-TAB... 13 ERYTHROCIN... 13 erythromycin... 13, 79 erythromycin ethylsuccinate... 13 erythromycin with ethanol... 73 erythromycin-benzoyl peroxide... 73 ESBRIET... 109 escitalopram oxalate... 28 esomeprazole magnesium... 82 estarylla... 66 estradiol... 87, 88 estradiol-norethindrone acet... 88 ESTRING... 88 estropipate... 88 eszopiclone... 110 ethacrynic acid... 59 ethambutol... 36 ethosuximide... 2 ethynodiol diac-eth estradiol.. 66 etidronate disodium... 100 etodolac... 7 ETOPOPHOS... 18 etoposide... 18 EVOTAZ... 3 exemestane... 18 EXJADE... 86 EXONDYS 51... 101 EXTAVIA... 63 ezetimibe... 60 ezetimibe-simvastatin... 60 F FABRAZYME... 77 falmina (28)... 66 famciclovir... 6 famotidine... 82, 83 FANAPT... 0 FARESTON... 18 FARYDAK... 18 FASENRA... 109 FASLODEX... 18 fayosim... 66 felbamate... 2 felodipine... 59 femynor... 66 fenofibrate... 60 fenofibrate micronized... 60 fenofibrate nanocrystallized... 60 fenofibric acid... 61 117

fenofibric acid (choline)... 60 fentanyl... fentanyl citrate... fentanyl citrate (pf)... FERRIPROX... 86 FETZIMA... 28 FIASP FLEXTOUCH U-100 INSULIN... 31 FIASP U-100 INSULIN... 31 FINACEA... 72 finasteride... 86 fioricet... FIRAZYR... 58 FIRMAGON KIT W DILUENT SYRINGE... 18 FLAREX... 81 flavoxate... 85 FLEBOGAMMA DIF... 92 flecainide... 55 FLECTOR... 7 FLOVENT DISKUS... 106, 107 FLOVENT HFA... 107 fluconazole... 33 fluconazole in nacl (iso-osm). 33 flucytosine... 33 fludrocortisone... 89 flunisolide... 81 fluocinolone... 75 fluocinolone acetonide oil... 81 fluocinolone and shower cap.. 75 fluocinonide... 75 fluocinonide-e... 75 FLUORIDE (SODIUM)... 111 fluorometholone... 81 fluorouracil... 18, 72 fluoxetine... 28 fluphenazine decanoate... 0 fluphenazine hcl... 0 flurazepam... 9 flurbiprofen... 7 flurbiprofen sodium... 81 flutamide... 18 fluticasone... 75, 81 fluticasone-salmeterol... 107 fluvastatin... 61 fluvoxamine... 28 FML FORTE... 81 FML S.O.P.... 81 fondaparinux... 7 FORTAZ... 12 FORTEO... 100 fosamprenavir... 3 foscarnet... 6 fosinopril... 5 fosinopril-hydrochlorothiazide... 55 fosphenytoin... 2 FREAMINE HBC 6.9 %... 52 FREAMINE III 10 %... 52 frovatriptan... 35 FULPHILA... 8 furosemide... 59 FUZEON... 3 fyavolv... 88 FYCOMPA... 2 G gabapentin... 2 galantamine... 26 GAMASTAN S/D... 92 GAMMAGARD LIQUID... 92 GAMMAGARD S-D (IGA < 1 MCG/ML)... 92 GAMMAKED... 93 GAMMAPLEX... 93 GAMMAPLEX (WITH SORBITOL)... 93 GAMUNEX-C... 93 ganciclovir sodium... 6, 7 GARDASIL (PF)... 97 GARDASIL 9 (PF)... 97 gatifloxacin... 79 GATTEX 30-VIAL... 83 GAUZE PAD... 77 gavilyte-c... 8 gavilyte-g... 8 gavilyte-n... 8 gemfibrozil... 61 generlac... 83 gengraf... 93 gentak... 80 gentamicin... 9, 73, 80 gentamicin in nacl (iso-osm)... 9 gentamicin sulfate (ped) (pf).. 10 gentamicin sulfate (pf)... 10 GENVOYA... 3 GEODON... 0 gianvi (28)... 66 GIAZO... 99 gildess 1.5/30 (21)... 66 gildess 2 fe... 66 GILENYA... 63 GILOTRIF... 18 GLASSIA... 109 glatiramer... 63 glatopa... 63 GLEOSTINE... 18 glimepiride... 32 glipizide... 32, 33 glipizide-metformin... 33 GLUCAGEN HYPOKIT... 30 GLUCAGON EMERGENCY KIT (HUMAN)... 30 glycopyrrolate... 83 GLYXAMBI... 30 GOLYTELY... 85 granisetron hcl... 37 GRANIX... 8 griseofulvin microsize... 33 griseofulvin ultramicrosize... 33 guanfacine... 53 H hailey 2 fe... 66 halobetasol propionate... 75 haloperidol... 0 haloperidol decanoate... 0 haloperidol lactate... 0 118

HARVONI... 6 HAVRIX (PF)... 97 heather... 67 HEPAGAM B... 93 heparin (porcine)... 7, 8 heparin (porcine) in 5 % dex.. 7 heparin (porcine) in nacl (pf). 7 HEPARIN(PORCINE) IN 0.5% NACL... 8 heparin, porcine (pf)... 8 HEPATAMINE 8%... 52 HERCEPTIN... 19 HETLIOZ... 110 HEXALEN... 19 HIBERIX (PF)... 97 HIZENTRA... 93 HUMIRA... 93 HUMIRA PEDIATRIC CROHNS START... 93 HUMIRA PEN... 93 HUMIRA PEN CROHNS-UC- HS START... 93 HUMIRA PEN PSOR-UVEITS- ADOL HS... 93 HUMIRA(CF)... 9 HUMIRA(CF) PEDI CROHNS STARTER... 93 HUMIRA(CF) PEN... 9 HUMIRA(CF) PEN CROHNS- UC-HS... 9 HUMIRA(CF) PEN PSOR-UV- ADOL HS... 9 hydralazine... 58 hydrochlorothiazide... 59 hydrocodone-acetaminophen... hydrocodone-ibuprofen... hydrocortisone... 75, 89, 99 hydrocortisone butyrate... 75 hydrocortisone butyr-emollient... 75 hydrocortisone valerate... 75 hydrocortisone-acetic acid... 80 hydrocortisone-pramoxine... 75 hydromorphone... hydromorphone (pf)... hydroxychloroquine... 38 hydroxyurea... 19 hydroxyzine hcl... 35 hydroxyzine pamoate... 101 HYPERHEP B S/D... 9 HYPERHEP B S-D NEONATAL... 9 HYQVIA... 9 I ibandronate... 100 IBRANCE... 19 ibu... 7 ibuprofen... 7 ICLUSIG... 19 IDHIFA... 19 ILARIS (PF)... 9 ILEVRO... 82 imatinib... 19 IMBRUVICA... 19 IMFINZI... 19 imipenem-cilastatin... 1 imipramine hcl... 28 imipramine pamoate... 28 imiquimod... 72 IMOVAX RABIES VACCINE (PF)... 97 IMVEXXY MAINTENANCE PACK... 88 IMVEXXY STARTER PACK... 88 incassia... 67 INCRELEX... 90 INCRUSE ELLIPTA... 108 indapamide... 60 indomethacin... 7 INFANRIX (DTAP) (PF)... 97 INFLECTRA... 9 INFUMORPH P/F... INLYTA... 19 INSULIN SYRINGE-NEEDLE U-100... 77 INTELENCE... 3 INTRALIPID... 52 INTRON A... 6 introvale... 67 INVANZ... 1 INVEGA SUSTENNA... 0, 1 INVEGA TRINZA... 1 INVELTYS... 82 INVIRASE... 3, INVOKAMET... 30 INVOKAMET XR... 30 INVOKANA... 30 IPOL... 97 ipratropium bromide... 79, 108 ipratropium-albuterol... 108 irbesartan... 5 irbesartan-hydrochlorothiazide... 5 IRESSA... 19 ISENTRESS... ISENTRESS HD... isibloom... 67 isoniazid... 36 isosorbide dinitrate... 61 isosorbide mononitrate... 61 isotretinoin... 72 itraconazole... 33 ivermectin... 38 IXIARO (PF)... 97 J JADENU... 86 JADENU SPRINKLE... 86 JAKAFI... 19 jantoven... 8 JANUMET... 30 JANUMET XR... 30 JANUVIA... 30 JARDIANCE... 30 jencycla... 67 JENTADUETO... 30 119

JENTADUETO XR... 30 jinteli... 88 jolessa... 67 jolivette... 67 juleber... 67 JULUCA... junel 1.5/30 (21)... 67 junel 1/20 (21)... 67 junel fe 1.5/30 (28)... 67 junel fe 1/20 (28)... 67 junel fe 2... 67 K KABIVEN... 52 KADCYLA... 19 kaitlib fe... 67 KALETRA... KALYDECO... 109 kariva (28)... 67 KEDRAB (PF)... 9 kelnor 1/35 (28)... 67 kelnor 1-50... 67 ketoconazole... 3 ketoprofen... 7 ketorolac... 7, 82 KEYTRUDA... 19 kimidess (28)... 67 KINERET... 9 KINRIX (PF)... 97 kionex (with sorbitol)... 8 KISQALI... 19 KISQALI FEMARA CO-PACK... 19 KLOR-CON... 10 KLOR-CON 10... 10 KLOR-CON 8... 10 klor-con m10... 10 klor-con m15... 10 klor-con m20... 10 klor-con sprinkle... 10 KORLYM... 30 KRINTAFEL... 38 KRYSTEXXA... 77 K-TAB... 10 kurvelo (28)... 67 KUVAN... 77 L l norgest/e.estradiol-e.estrad... 67 labetalol... 56 LACRISERT... 79 LACTATED RINGERS... 100, 10 lactulose... 8 lamivudine... lamivudine-zidovudine... lamotrigine... 25 LANOXIN... 58 lansoprazole... 83 lanthanum... 85 LANTUS SOLOSTAR U-100 INSULIN... 31 LANTUS U-100 INSULIN... 31 larin 1.5/30 (21)... 67 larin 1/20 (21)... 67 larin 2 fe... 67 larin fe 1.5/30 (28)... 67 larin fe 1/20 (28)... 67 larissia... 67 LARTRUVO... 19 LASTACAFT... 79 latanoprost... 103 LATUDA... 1 layolis fe... 68 leena 28... 68 leflunomide... 9 LEMTRADA... 63 LENVIMA... 19, 20 lessina... 68 LETAIRIS... 111 letrozole... 20 leucovorin calcium... 102 LEUKERAN... 20 LEUKINE... 8 leuprolide... 20 levalbuterol hcl... 108 levalbuterol tartrate... 108 LEVEMIR FLEXTOUCH U- 100 INSULN... 31 LEVEMIR U-100 INSULIN.. 31 levetiracetam... 25 levetiracetam in nacl (iso-os).. 25 levobunolol... 103 levocarnitine... 102 levocarnitine (with sugar)... 102 levocetirizine... 35 levofloxacin... 15, 80 levofloxacin in d5w... 15 levoleucovorin calcium... 102 levonest (28)... 68 levonorgestrel-ethinyl estrad.. 68 levonorg-eth estrad triphasic.. 68 levora-28... 68 levorphanol tartrate... 5 levothyroxine... 91 LEVOXYL... 91 LEXIVA... lidocaine... 7 lidocaine hcl... 7 lidocaine viscous... 7 lidocaine-prilocaine... 7 lillow (28)... 68 lincomycin... 10 lindane... 76 linezolid... 10 linezolid in dextrose 5%... 10 linezolid-0.9% sodium chloride... 10 LINZESS... 8 liothyronine... 91 lisinopril... 55 lisinopril-hydrochlorothiazide 55 lithium carbonate... 63 lithium citrate... 63 LO LOESTRIN FE... 68 lomedia 2 fe... 68 LONSURF... 20 loperamide... 8 120

lopinavir-ritonavir... lopreeza... 88 lorazepam... 9 LORBRENA... 20 lorcet (hydrocodone)... 5 lorcet hd... 5 lorcet plus... 5 loryna (28)... 68 losartan... 5 losartan-hydrochlorothiazide.. 5 LOTEMAX... 82 lovastatin... 61 low-ogestrel (28)... 68 loxapine succinate... 1 LUCEMYRA... 8 LUDENT FLUORIDE... 111 LUMIGAN... 103 LUMIZYME... 77 LUPRON DEPOT... 20 LUPRON DEPOT (3 MONTH)... 20 LUPRON DEPOT ( MONTH)... 20 LUPRON DEPOT (6 MONTH)... 20 lutera (28)... 68 LYNPARZA... 20 LYRICA... 25 LYSODREN... 20 lyza... 68 M mafenide acetate... 72 magnesium sulfate... 105 magnesium sulfate in d5w... 10 magnesium sulfate in water. 10, 105 malathion... 76 maprotiline... 28 marlissa (28)... 68 MARPLAN... 28 MARQIBO... 20 marten-tab... 5 MATULANE... 20 matzim la... 57 MAVYRET... 6 MAXIDEX... 82 MAXIPIME... 12, 13 meclizine... 37 medroxyprogesterone... 91 mefloquine... 38 megestrol... 20, 91 MEKINIST... 20 MEKTOVI... 20 melodetta 2 fe... 68 meloxicam... 7 memantine... 26, 27 MENACTRA (PF)... 97 MENEST... 88 MENVEO A-C-Y-W-135-DIP (PF)... 97 meperidine... 5 meperidine (pf)... 5 meprobamate... 9 mercaptopurine... 20 meropenem... 1 mesalamine... 99 mesna... 102 MESNEX... 102 metadate er... 63 metaproterenol... 108 metaxall... 110 metaxalone... 110 metformin... 30 methadone... 5 methazolamide... 103 methenamine hippurate... 11 METHERGINE... 102 methimazole... 91 methocarbamol... 110 methotrexate sodium... 20 methotrexate sodium (pf)... 20 methoxsalen... 72 methscopolamine... 8 methyclothiazide... 60 methyldopa... 53 methyldopa-hydrochlorothiazide... 53 methylergonovine... 102 methylphenidate hcl... 63, 6 methylprednisolone... 89 methylprednisolone acetate... 89 methylprednisolone sodium succ... 89 metipranolol... 103 metoclopramide hcl... 8 metolazone... 60 metoprolol succinate... 56 metoprolol ta-hydrochlorothiaz... 56 metoprolol tartrate... 56 metronidazole... 11, 35, 73 metronidazole in nacl (iso-os) 11 mexiletine... 55 MIACALCIN... 100 mibelas 2 fe... 68 miconazole-3... 3 microgestin 1.5/30 (21)... 68 microgestin 1/20 (21)... 68 microgestin 2 fe... 68 microgestin fe 1.5/30 (28)... 68 microgestin fe 1/20 (28)... 68 midazolam... 9 midazolam (pf)... 9 midodrine... 53 MIGERGOT... 35 miglitol... 30 miglustat... 77 mili... 68 milrinone... 58 milrinone in 5 % dextrose... 58 mimvey... 88 mimvey lo... 88 minitran... 61 minocycline... 16 minoxidil... 61 mirtazapine... 28 121

MIRVASO... 72 misoprostol... 83 mitomycin... 20 mitoxantrone... 20 M-M-R II (PF)... 97 modafinil... 110 moexipril... 55 moexipril-hydrochlorothiazide... 55 molindone... 1 mometasone... 75, 82 mono-linyah... 68 mononessa (28)... 68 montelukast... 107 MONUROL... 11 morphine... 5 MORPHINE... 5 morphine (pf)... 5 morphine concentrate... 5 MOXEZA... 80 moxifloxacin... 15, 80 moxifloxacin in nacl (iso-osm)... 15 moxifloxacin-sod.ace,sul-water... 15 MOZOBIL... 9 MULTAQ... 55 mupirocin... 73 mupirocin calcium... 73 MUSTARGEN... 20 mutamycin... 21 MYALEPT... 102 MYCAMINE... 3 mycophenolate mofetil... 9 mycophenolate mofetil hcl... 9 mycophenolate sodium... 9 MYLOTARG... 21 myorisan... 72 MYRBETRIQ... 85 myzilra... 68 N NABI-HB... 95 nabumetone... 7 nadolol... 56 nafcillin... 1 nafcillin in dextrose iso-osm.. 1 naftifine... 3 NAGLAZYME... 77 nalocet... 5 naloxone... 8 naltrexone... 8 NAMZARIC... 27 naphazoline... 79 naproxen... 7 naproxen sodium... 7 naratriptan... 35 NARCAN... 8 NATACYN... 80 NATAZIA... 69 nateglinide... 30 NATPARA... 100 NEBUPENT... 38 necon 0.5/35 (28)... 69 necon 7/7/7 (28)... 69 nefazodone... 28 neomycin... 10 neomycin-bacitracin-poly-hc.. 80 neomycin-bacitracin-polymyxin... 80 neomycin-polymyxin b gu... 73 neomycin-polymyxin b- dexameth... 80 neomycin-polymyxingramicidin... 80 neomycin-polymyxin-hc... 80 neo-polycin... 80 neo-polycin hc... 80 NEPHRAMINE 5. %... 53 NERLYNX... 21 neuac... 73 NEULASTA... 9 NEUPOGEN... 9 NEUPRO... 38 NEVANAC... 82 nevirapine... NEXAVAR... 21 niacin... 61 nicardipine... 59 NICOTROL... 8 NICOTROL NS... 8 nifedical xl... 59 nifedipine... 59 nikki (28)... 69 nilutamide... 21 nimodipine... 59 NINLARO... 21 nisoldipine... 59 NITRO-BID... 62 nitrofurantoin... 11 nitrofurantoin macrocrystal... 11 nitrofurantoin monohyd/m-cryst... 11 nitroglycerin... 62 NITROSTAT... 62 NIVESTYM... 9 nizatidine... 83 nora-be... 69 NORDITROPIN FLEXPRO.. 90 noreth-ethinyl estradiol-iron... 69 norethindrone (contraceptive) 69 norethindrone acetate... 91 norethindrone ac-eth estradiol... 69, 88 norethindrone-e.estradiol-iron 69 norgestimate-ethinyl estradiol 69 norlyda... 69 norlyroc... 69 NORTHERA... 53 nortrel 0.5/35 (28)... 69 nortrel 1/35 (21)... 69 nortrel 1/35 (28)... 69 nortrel 7/7/7 (28)... 69 nortriptyline... 28 NORVIR... NOVOLIN 70/30 U-100 INSULIN... 31 122

NOVOLIN 70-30 FLEXPEN U- 100... 32 NOVOLIN N NPH U-100 INSULIN... 32 NOVOLIN R REGULAR U- 100 INSULN... 32 NOVOLOG FLEXPEN U-100 INSULIN... 32 NOVOLOG MIX 70-30 U-100 INSULN... 32 NOVOLOG MIX 70-30FLEXPEN U-100... 32 NOVOLOG PENFILL U-100 INSULIN... 32 NOVOLOG U-100 INSULIN ASPART... 32 NOXAFIL... 3 NUCALA... 109 NUEDEXTA... 6 NULOJIX... 95 NUPLAZID... 1 NUTRILIPID... 53 nyamyc... 3 nystatin... 3 nystatin-triamcinolone... 3 nystop... 3 O ocella... 69 OCTAGAM... 95 octreotide acetate... 90 ODEFSEY... ODOMZO... 21 OFEV... 109 ofloxacin... 15, 80 ogestrel (28)... 69 okebo... 16 olanzapine... 1 olmesartan... 5 olmesartan-amlodipin-hcthiazid... 5 olmesartan-hydrochlorothiazide... 5 olopatadine... 79 omega-3 acid ethyl esters... 61 omeprazole... 83 OMNITROPE... 90 ondansetron... 37 ondansetron hcl... 37 ondansetron hcl (pf)... 37 ONFI... 9 OPDIVO... 21 OPSUMIT... 111 oralone... 71 ORENCIA... 95 ORENCIA CLICKJECT... 95 ORENITRAM... 111 ORKAMBI... 109 orphenadrine citrate... 110 orsythia... 69 oseltamivir... 6 OTEZLA... 95 OTEZLA STARTER... 95 oxacillin... 1 oxacillin in dextrose(iso-osm) 1 oxandrolone... 87 oxaprozin... 7 oxazepam... 9 oxcarbazepine... 25 oxiconazole... 3 oxybutynin chloride... 85 oxycodone... 5, 6 oxycodone-acetaminophen... 6 oxycodone-aspirin... 6 OXYCONTIN... 6 oxymorphone... 6 OZEMPIC... 30 P pacerone... 55 paclitaxel... 21 paliperidone... 1 palonosetron... 37 PALONOSETRON... 37 pamidronate... 100 PANCREAZE... 78 PANRETIN... 72 pantoprazole... 83 paricalcitol... 100 PARICALCITOL... 100 paroex oral rinse... 71 paromomycin... 38 paroxetine hcl... 28 PASER... 36 PAXIL... 28 PEDIARIX (PF)... 97 PEDVAX HIB (PF)... 97 peg 3350-electrolytes... 85 PEGANONE... 25 PEGASYS PROCLICK... 6 peg-electrolyte soln... 85 PEGINTRON... 6 PEGINTRON REDIPEN... 6 PEN NEEDLE, DIABETIC... 77 penicillin g pot in dextrose1, 15 penicillin g potassium... 15 penicillin g procaine... 15 penicillin g sodium... 15 penicillin v potassium... 15 PENTACEL (PF)... 97 PENTACEL DTAP-IPV COMPNT (PF)... 98 PENTAM... 38 PENTASA... 99 pentoxifylline... 50 PERFOROMIST... 108 PERIKABIVEN... 53 perindopril erbumine... 55 periogard... 71 PERJETA... 21 permethrin... 76 perphenazine... 1 perphenazine-amitriptyline... 28 PERTZYE... 78 pfizerpen-g... 15 phenadoz... 37 phenelzine... 28 phenobarbital... 25 123

phenoxybenzamine... 53 phenytoin... 25 phenytoin sodium extended... 25 philith... 69 PHOSLYRA... 85 PHOSPHOLINE IODIDE... 103 phrenilin forte(with caffeine)... 6 PHYSIOSOL IRRIGATION 100 PICATO... 72 PIFELTRO... pilocarpine hcl... 71, 103 pimecrolimus... 75 pimozide... 1 pimtrea (28)... 69 pindolol... 56 pioglitazone... 30 pioglitazone-glimepiride... 31 pioglitazone-metformin... 31 piperacillin-tazobactam... 15 pirmella... 69 piroxicam... 7 PLEGRIDY... 6 PLENAMINE... 53 podofilox... 72 polycin... 80 polyethylene glycol 3350... 85 polymyxin b sulfate... 11 polymyxin b sulf-trimethoprim... 80 POMALYST... 21 portia 28... 69 potassium chlorid-d5-0.5%nacl... 105 potassium chloride... 105 potassium chloride in 0.9%nacl... 105 potassium chloride in 5 % dex... 105 potassium chloride in lr-d5... 105 potassium chloride in water.. 105 potassium chloride-0.5 % nacl... 105 potassium chloride-d5-0.2%nacl... 105 potassium chloride-d5-0.3%nacl... 105 potassium chloride-d5-0.9%nacl... 105 potassium citrate... 105 PRALUENT PEN... 61 pramipexole... 39 PRAMOSONE... 75 prasugrel... 50 pravastatin... 61 praziquantel... 38 prazosin... 53 PRED MILD... 82 prednicarbate... 75 prednisolone... 89 prednisolone acetate... 82 prednisolone sodium phosphate... 82, 89 prednisone... 89 PREMARIN... 88 PREMASOL 10 %... 53 PREMASOL 6 %... 53 PREMPHASE... 88 PREMPRO... 88 prenatal plus (calcium carb). 111 prenatal vitamin plus low iron... 111 prevalite... 61 previfem... 69 PREZCOBIX... PREZISTA... PRIALT... 6 PRIFTIN... 36 PRIMAQUINE... 38 primidone... 25 PRIVIGEN... 95 probenecid... 3 probenecid-colchicine... 3 prochlorperazine... 37 prochlorperazine maleate... 37 PROCRIT... 9 procto-med hc... 75 procto-pak... 76 proctosol hc... 76 proctozone-hc... 76 progesterone micronized... 91 PROGLYCEM... 102 PROGRAF... 95 PROLASTIN-C... 109 PROLEUKIN... 21 PROLIA... 100 PROMACTA... 9 promethazine... 35, 37 promethegan... 37 propafenone... 55 propantheline... 23 proparacaine... 79 propranolol... 56 propranolol-hydrochlorothiazid... 56 propylthiouracil... 91 PROQUAD (PF)... 98 PROSOL 20 %... 53 protriptyline... 28 PULMOZYME... 78 PURIXAN... 21 pyrazinamide... 36 pyridostigmine bromide... 102 Q QNASL... 82 QTERN... 31 QUADRACEL (PF)... 98 quasense... 69 quetiapine... 1, 2 quinapril... 55 quinapril-hydrochlorothiazide 55 quinidine gluconate... 55 quinidine sulfate... 55 quinine sulfate... 38 QVAR... 107 QVAR REDIHALER... 107 12

R RABAVERT (PF)... 98 rabeprazole... 83 RADICAVA... 6 rajani... 69 raloxifene... 88 ramipril... 55 RANEXA... 58 ranitidine hcl... 83 RAPAFLO... 86 RAPAMUNE... 95 rasagiline... 39 RAVICTI... 8 RAYALDEE... 101 REBIF (WITH ALBUMIN)... 6 REBIF REBIDOSE... 6 REBIF TITRATION PACK.. 6 reclipsen (28)... 69 RECOMBIVAX HB (PF)... 98 REGRANEX... 72 RELENZA DISKHALER... 6 RELISTOR... 8 REMICADE... 95 REMODULIN... 111 RENFLEXIS... 102 repaglinide... 31 REPATHA PUSHTRONEX.. 61 REPATHA SURECLICK... 61 REPATHA SYRINGE... 61 RESCRIPTOR... RESTASIS... 82 RETACRIT... 9 RETROVIR... REVATIO... 111 REVLIMID... 21 REXULTI... 2 REYATAZ... 5 RHOPHYLAC... 95 RHOPRESSA... 103 ribasphere... 7 ribavirin... 7 RIDAURA... 95 rifabutin... 36 rifampin... 36 RIFATER... 36 riluzole... 6 rimantadine... 6 ringer's... 100, 106 risedronate... 101 RISPERDAL CONSTA... 2 risperidone... 2 ritonavir... 5 RITUXAN... 21 rivastigmine... 27 rivastigmine tartrate... 27 rivelsa... 70 rizatriptan... 35 ropinirole... 39 rosadan... 73 rosuvastatin... 61 ROTARIX... 98 ROTATEQ VACCINE... 98 ROZEREM... 110 RUBRACA... 21 RUCONEST... 9 RYDAPT... 21 RYTARY... 39 S SABRIL... 25 SAMSCA... 60 SANDIMMUNE... 95 SANDOSTATIN LAR DEPOT... 90 SANTYL... 72 SAPHRIS... 2 SAVELLA... 6 scopolamine base... 37 selegiline hcl... 39 selenium sulfide... 73 SELZENTRY... 5 SENSIPAR... 101 SEREVENT DISKUS... 108 sertraline... 28, 29 setlakin... 70 sevelamer carbonate... 85 sf 5000 plus... 71 sharobel... 70 SHINGRIX (PF)... 98 SIGNIFOR... 90 sildenafil (antihypertensive). 111 SILIQ... 72 silodosin... 86 silver sulfadiazine... 7 SIMBRINZA... 103 SIMPONI... 95 SIMPONI ARIA... 95 SIMULECT... 102 simvastatin... 61 sirolimus... 95 SIRTURO... 36 SIVEXTRO... 11 sodium chloride... 100, 106 sodium chloride 0.5 %... 106 sodium chloride 0.9 %... 106 sodium chloride 3 %... 106 sodium chloride 5 %... 106 sodium phenylbutyrate... 8 sodium polystyrene (sorb free)... 8 sodium polystyrene sulfonate. 8 SOLIQUA 100/33... 32 SOLIRIS... 102 SOLTAMOX... 21 SOLU-CORTEF (PF)... 89 SOLU-MEDROL... 89 SOLU-MEDROL (PF)... 89 SOMATULINE DEPOT... 90 SOMAVERT... 90 sorine... 56 sotalol... 56 sotalol af... 56 spinosad... 76 SPIRIVA RESPIMAT... 108 SPIRIVA WITH HANDIHALER... 108 spironolactone... 60 125

spironolacton-hydrochlorothiaz... 60 SPORANOX... 3 sprintec (28)... 70 SPRITAM... 25, 26 SPRYCEL... 21 sps (with sorbitol)... 8 sronyx... 70 ssd... 7 stavudine... 5 STELARA... 95 STIMATE... 90 STIOLTO RESPIMAT... 108 STIVARGA... 21 STRENSIQ... 78 streptomycin... 10 STRIBILD... 5 STRIVERDI RESPIMAT... 108 SUBOXONE... 8 sucralfate... 83 sulfacetamide sodium... 80 sulfacetamide sodium (acne).. 7 sulfacetamide-prednisolone... 80 sulfadiazine... 15 sulfamethoxazole-trimethoprim... 15 SULFAMYLON... 72 sulfasalazine... 99 sulfatrim... 16 sulindac... 7 sumatriptan... 35 sumatriptan succinate... 36 SUPRAX... 13 SUPREP BOWEL PREP KIT 85 SURE COMFORT INS. SYR. U-100... 77 SUTENT... 21 syeda... 70 SYLATRON... 6 SYLVANT... 21 SYMBICORT... 107 SYMDEKO... 109 SYMFI... 5 SYMFI LO... 5 SYMJEPI... 58 SYMLINPEN 120... 31 SYMLINPEN 60... 31 SYMTUZA... 5 SYNERCID... 11 SYNJARDY... 31 SYNJARDY XR... 31 SYNRIBO... 21 SYNTHROID... 91 T TABLOID... 21 tacrolimus... 76, 95 tadalafil... 111 tadalafil (antihypertensive)... 111 TAFINLAR... 22 TAGRISSO... 22 TALTZ AUTOINJECTOR... 73 TALTZ SYRINGE... 73 TALZENNA... 22 tamoxifen... 22 tamsulosin... 86 TANZEUM... 31 TARCEVA... 22 TARGRETIN... 22 tarina fe 1/20 (28)... 70 TASIGNA... 22 tazarotene... 76 tazicef... 13 TAZORAC... 76 taztia xt... 57 TECENTRIQ... 22 TECFIDERA... 6 TEFLARO... 13 telmisartan... 5 telmisartan-hydrochlorothiazid... 5 temazepam... 9 tencon... 6 TENIVAC (PF)... 98 tenofovir disoproxil fumarate. 5 terazosin... 86 terbinafine hcl... 3 terbutaline... 108 terconazole... 35 testosterone... 87 testosterone cypionate... 87 testosterone enanthate... 87 TETANUS,DIPHTHERIA TOX PED(PF)... 98 TETANUS-DIPHTHERIA TOXOIDS-TD... 98 tetrabenazine... 6, 65 tetracycline... 16 THALOMID... 102 theophylline... 108 thioridazine... 2 thiothixene... 2 THYMOGLOBULIN... 96 THYROLAR-1... 91 THYROLAR-1/2... 91 THYROLAR-1/... 91 THYROLAR-2... 91 THYROLAR-3... 91 tiagabine... 26 TIBSOVO... 22 TICE BCG... 98 tigecycline... 16 tilia fe... 70 timolol maleate... 56, 103 tinidazole... 38 TIVICAY... 5 tizanidine... 110 TOBI PODHALER... 10 TOBRADEX... 81 TOBRADEX ST... 81 tobramycin... 81 tobramycin in 0.225 % nacl... 10 tobramycin in 0.9 % nacl... 10 tobramycin sulfate... 10 tobramycin-dexamethasone... 81 TOBREX... 81 TOLAK... 73 126

tolcapone... 39 tolterodine... 86 topiramate... 26 toposar... 22 topotecan... 22 torsemide... 60 TOUJEO MAX U-300 SOLOSTAR... 32 TOUJEO SOLOSTAR U-300 INSULIN... 32 TOVIAZ... 86 TPN ELECTROLYTES... 106 TPN ELECTROLYTES II... 106 TRACLEER... 111 TRADJENTA... 31 tramadol... 6 tramadol-acetaminophen... 6 trandolapril... 55 tranexamic acid... 9 tranylcypromine... 29 TRAVASOL 10 %... 53 TRAVATAN Z... 103 travoprost (benzalkonium)... 103 trazodone... 29 TREANDA... 22 TRECATOR... 36 TRELEGY ELLIPTA... 108 TRESIBA FLEXTOUCH U-100... 32 TRESIBA FLEXTOUCH U-200... 32 TRESIBA U-100 INSULIN... 32 tretinoin... 76 tretinoin (chemotherapy)... 22 tri femynor... 70 triamcinolone acetonide.. 71, 76, 89 triamterene-hydrochlorothiazid... 60 triderm... 76 tridesilon... 76 trientine... 86 tri-estarylla... 70 trifluoperazine... 2 trifluridine... 81 trihexyphenidyl... 39 tri-legest fe... 70 tri-linyah... 70 tri-lo-estarylla... 70 tri-lo-marzia... 70 tri-lo-sprintec... 70 trilyte with flavor packets... 85 trimethoprim... 11 tri-mili... 70 trimipramine... 29 TRIMPEX... 11 trinessa (28)... 70 trinessa lo... 70 TRINTELLIX... 29 tri-previfem (28)... 70 TRISENOX... 22 tri-sprintec (28)... 70 TRIUMEQ... 5 trivora (28)... 70 tri-vylibra... 70 tri-vylibra lo... 70 TROPHAMINE 10 %... 53 TROPHAMINE 6%... 53 tropicamide... 79 trospium... 86 TRULANCE... 8 TRULICITY... 31 TRUMENBA... 98 TRUVADA... 5 tulana... 70 TWINRIX (PF)... 98 TYBOST... 102 tydemy... 71 TYKERB... 22 TYMLOS... 101 TYPHIM VI... 98 TYSABRI... 96 U UDENYCA... 9 ULORIC... 3 UPTRAVI... 111 ursodiol... 8 V valacyclovir... 7 VALCHLOR... 73 valganciclovir... 7 valproate sodium... 26 valproic acid... 26 valproic acid (as sodium salt). 26 valsartan... 5 valsartan-hydrochlorothiazide 5 vancomycin... 11 VANCOMYCIN... 11 vancomycin in dextrose 5 %... 11 VAQTA (PF)... 99 VARIVAX (PF)... 99 VASCEPA... 61 VELCADE... 22 VELETRI... 111 velivet triphasic regimen (28). 71 VELPHORO... 85 VELTASSA... 8 VEMLIDY... 5 VENCLEXTA... 22 VENCLEXTA STARTING PACK... 22 venlafaxine... 29 VENTAVIS... 111 VENTOLIN HFA... 109 verapamil... 57 VERSACLOZ... 2 VERZENIO... 22 VESICARE... 86 vestura (28)... 71 VIBATIV... 11 VIBERZI... 8 vicodin... 6 vicodin es... 6 vicodin hp... 6 VICTOZA... 31 127

VIDEX 2 GRAM PEDIATRIC... 5 VIDEX GRAM PEDIATRIC... 5 VIDEX EC... 5 vienva... 71 vigabatrin... 26 vigadrone... 26 VIIBRYD... 29 VIMPAT... 26 vinblastine... 22 vincasar pfs... 22 vincristine... 22 vinorelbine... 22 VIOKACE... 78 viorele (28)... 71 VIRACEPT... 5 VIRAMUNE... 5 VIREAD... 5 VITRAKVI... 22, 23 VIZIMPRO... 23 voriconazole... 3 VOSEVI... 6 VOTRIENT... 23 VPRIV... 78 VRAYLAR... 2 vyfemla (28)... 71 vylibra... 71 VYVANSE... 65 VYXEOS... 23 W warfarin... 8 water for irrigation, sterile... 100 WELCHOL... 61 wera (28)... 71 WINRHO SDF... 96 wymzya fe... 71 X XADAGO... 39 XALKORI... 23 XARELTO... 8 XATMEP... 23 XELJANZ... 96 XELJANZ XR... 96 XGEVA... 101 XIFAXAN... 11 XIIDRA... 82 XOFLUZA... 6 XOLAIR... 109, 110 XOSPATA... 23 XTANDI... 23 xulane... 71 XULTOPHY 100/3.6... 32 xylon 10... 6 XYREM... 110 Y YERVOY... 23 YF-VAX (PF)... 99 YONDELIS... 23 YONSA... 23 YUPELRI... 109 yuvafem... 88 Z zafirlukast... 107 zaleplon... 110 ZANOSAR... 23 zarah... 71 ZARXIO... 9 zebutal... 6 ZEJULA... 23 ZELBORAF... 23 ZEMAIRA... 110 zenatane... 73 zenchent (28)... 71 ZENPEP... 78 zenzedi... 65 ZERBAXA... 13 ZERIT... 5 zidovudine... 5 zileuton... 107 ziprasidone hcl... 2 ZIRGAN... 81 zoledronic acid... 101 zoledronic acid-mannitol-water... 101 zoledronic ac-mannitol-0.9nacl... 101 ZOLINZA... 23 zolmitriptan... 36 zolpidem... 110 ZOMETA... 101 zonisamide... 26 ZONTIVITY... 50 ZORTRESS... 96 ZOSTAVAX (PF)... 99 ZOSYN IN DEXTROSE (ISO- OSM)... 15 zovia 1/35e (28)... 71 ZYCLARA... 73 ZYDELIG... 23 ZYFLO... 107 ZYKADIA... 23 ZYLET... 81 ZYPREXA RELPREVV... 2 ZYTIGA... 23 ZYVOX... 11 128

1515 North Saint Joseph Avenue PO Box 8000 Marshfield, WI 59-8000 1-877-998-0998 715-221-9897 TTY 711 Fax 715-221-9500 8 a.m. 8 p.m., 7 days a week https://www.securityhealth.org/medicareadvantage This formulary was updated on February 26, 2019. For more recent information or other questions, please contact Security Health Plan Customer Service at 1-877-998-0998 or, for TTY users, 711, or visit https://www.securityhealth.org/medicareformulary. 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. 2017-2018 Security Health Plan of Wisconsin, Inc.